Abdominal aortic aneurysm in women: prevalence, risk factors, and implications for screening

OBJECTIVE: Accurate data regarding the prevalence and associated risk factors for aneurysmal disease is essential when determining the appropriateness of screening for abdominal aortic aneurysms (AAA). Although women are poorly represented in most large studies of AAA prevalence, the US Preventative Services Task Force recently recommended against primary screening for AAA in women. The purpose of this analysis was to define the prevalence and risk factors associated with the development of AAA in women. METHODS: A free duplex ultrasound screening was offered to men and women with cardiovascular risk factors or a family history of AAA. Patients were recruited through advertising at local screening centers and screenings were performed between 2004 and 2006. Demographic information and cardiovascular and aneurysmal disease risk factors were obtained for each patient through a questionnaire. A total of 17,540 subjects were screened for AAA, including 10,012 women (mean age 69.6 years) and 7528 men (mean age 70.0 years). Univariate and multivariable logistic regression analysis was performed on the subset of women that were screened to determine risk factors for and prevalence of AAA. RESULTS: Seventy-four aneurysms were detected in women (including four aneurysms >5 cm diameter and 70 aneurysms 3 to 5 cm diameter) while 291 were detected in men, resulting in prevalence rates of 0.7% and 3.9%, respectively. Increasing age (odds ratio [OR]= 4.57, 95% confidence interval [CI] 1.98 to 10.54, P < .0001), history of tobacco use (OR = 3.29, 95% CI 1.86 to 5.80, P < .0001), and cardiovascular disease (OR= 3.57, 95% CI 2.19 to 5.84, P < .0001) were independently associated with AAA in women on univariate and multivariable analysis. Women with multiple atherosclerotic risk factors were more commonly found to have AAAs and had a prevalence rate of AAA as high as 6.4%. CONCLUSION: Although the medical literature suggests a low prevalence rate of AAA in women in the general population, specific risk factors are associated with the development of AAA, and subgroups of women can be identified that are at a substantially increased risk of aneurysmal disease. In particular, elevated rates of AAA were found among women of advanced age (> or =65 years) with a history of smoking or heart disease. These data support the notion that women with such risk factors should be considered for AAA screening.     

Maintenance of reduction of pediatric distal radius fractures with a sugar-tong splint

Distal radius fractures are common injuries in children. Displaced fractures have traditionally been treated with closed reduction followed by immobilization in a long arm cast. Because of variable success rates with this technique, a trend in the literature is toward operative fixation of these fractures. A popular alternative practice involves temporary immobilization in a sugar-tong splint, though we are unaware of any studies demonstrating the efficacy of this technique in children. We present our experience in treating these injuries initially with a sugar-tong splint and then with a short arm cast. We retrospectively reviewed the cases of 53 patients (age range, 2-12 years) treated with closed reduction and a sugar-tong splint followed by conversion to a short arm cast after 2 to 3 weeks. In 51 (96%) of 53 fractures, reduction was maintained without more aggressive intervention. The sugar-tong splint is effective in maintaining reductions in pediatric distal radius fractures and has none of the added risks associated with current alternative methods.     

Atubular glomeruli in a rat model of polycystic kidney disease

BACKGROUND: Autosomal-dominant polycystic kidney disease (ADPKD) is associated with a progressive decline in glomerular filtration rate (GFR) that often leads to end-stage renal disease. The basis for this decline in GFR is poorly understood. METHODS: Glomeruli in heterozygous Han:SPRD rats with ADPKD and their normal litter mates were studied by light microscopy, using serial sectioning techniques. The connections of the renal corpuscles to proximal tubules were classified as normal, atrophied, or absent (atubular glomerulus). Renal corpuscles also were examined by scanning electron microscopy. Single nephron glomerular blood flows were determined using microspheres. RESULTS: In the kidneys of six-month-old rats with ADPKD, 50% of the glomeruli were atubular and another 26% were associated with atrophied neck segments; these glomeruli were most often smaller in size than normal. About 16% of the glomeruli were hypertrophied and had normal connections to proximal tubules. Sclerotic changes in cystic kidney glomeruli were usually mild or moderate, and belied the failure of glomerular function. Glomerular blood flow in the cystic kidneys averaged half of normal and was markedly heterogeneous; the majority of small glomeruli displayed very low blood flows and a few showed relatively high blood flows. Fewer glomerular abnormalities were found in rats treated for five months with potassium citrate in their drinking water. CONCLUSIONS: The diminished GFR in the rat with ADPKD can be accounted for largely by the formation of atubular glomeruli. Compensatory glomerular hypertrophy also is present and may contribute to the progression of the renal disease.     

Outcome of Debridement,Antibiotics, and Implant Retention With Modular Component Exchange in Acute Culture-Negative Periprosthetic Joint Infections

BackgroundModular component exchange and culture-directed antibiotic treatment is routinely employed for acute periprosthetic joint infection (PJI). However, as many as 7%-23% of PJIs have been reported to yield negative culture results. The efficacy of debridement, antibiotics, and implant retention (DAIR) with modular component exchange in the setting of acute culture negative PJI remains largely unknown. The aim of our study is to evaluate the outcomes of DAIR with modular component exchange in acute culture-positive and culture-negative PJI.MethodsA total of 149 consecutive patients with primary total joint replacements (90 total knee arthroplasties and 59 total hip arthroplasties) who underwent DAIR with modular component exchange for acute PJI with at least 3 years of follow-up were evaluated: (1) 46 culture-negative PJI patients and (2) 103 culture-positive PJI patients. Reinfection and aseptic revision rates along with complication rates were compared.ResultsThe reinfection rate for DAIR in acute culture-negative PJI was 13.0% compared to 19.4% in culture-positive PJI (P = .48). Mean survival time from reinfection between culture-negative (7.7 ± 0.4 years) and culture-positive (7.4 ± 0.3 years) PJI groups did not differ significantly (P = .40). Aseptic revision rates were 8.7% and 4.9% (P = .46), respectively, with loosening being the primary reason for implant failure in both cohorts.ConclusionsDespite lack of an identifying organism to guide postoperative antibiotic therapy, DAIR with modular component exchange for acute culture-negative PJI was associated with similar reinfection rates compared to acute culture-positive PJI, suggesting that culture negativity may not be a contraindication to DAIR in patients with acute PJI.     

Utility and Prognostic Ability of a Diagnostic Injection Before Revision Total Knee Arthroplasty

BackgroundDiagnostic injections are commonly utilized in the workup of painful total knee arthroplasties (TKA), particularly when the diagnosis remains unclear. However, current literature provides limited evidence regarding the utility and prognostic capability of anesthetic injections in this scenario. This study sought to establish the role of diagnostic injections in predicting successful revision TKA.MethodsA retrospective review was conducted on 144 consecutive aseptic revision TKAs receiving diagnostic anesthetic injections. Instability (57.6%) and aseptic loosening (33.3%) comprised most revision etiologies. Patient-reported percentage pain relief after the injection was statistically correlated with KOOS JR, Knee Society Score, UCLA Activity Level, and satisfaction scores.ResultsAbout 74.3% (107/144) of revision TKAs reported >50% pain relief after injection. There were no differences in pain relief based on revision indication (P = .841). Improvement from preoperative activity level was greater in the >50% pain relief group (P = .024). Four-month patient satisfaction did not differ between patients who reported >50% and ≤50% pain relief (67% vs. 66%, P = .130). About 64% of patients who reported >50% pain relief were satisfied at minimum 1-year follow-up, compared with only 47% of those who reported ≤50% pain relief after diagnostic injection (P < .001).ConclusionStudy results show that patients reporting >50% pain relief after diagnostic injection have improvements in activity level and maintain greater satisfaction at minimum 1-year than those reporting ≤50% pain relief. Expectations for improvement after revision TKA should be tempered if diagnostic anesthetic injection yields minimal subjective pain relief.     

Reduced renal function and benefits of treatment in cystinuria vs other forms of nephrolithiasis

A significant study from the USA compares cystine stone formers and routine stone formers; the former group had a higher requirement for therapeutic procedures, but this was less if they took chelating agents, although remaining higher than in the latter group. Other interesting findings are also presented. OBJECTIVE: First, to compare two types of stone formers (SF), those with cystinuria and those without, for effects of treatments for stones, as cystinuria leads to recurrent stones that are difficult to fragment with shock-wave lithotripsy, and there is disagreement about the efficacy of current treatments. Second, to compare these two groups with respect to blood pressure (BP) and renal function, as cystine stones may be associated with more morbidity than are routine stones. PATIENTS AND METHODS: Fifty-two cystinuric patients (cystine SF) entering our programme since 1970 were compared with 3215 SF without cystinuria (routine SF), of whom 114 had a single functioning kidney (routine SF + nephrectomy). All patients had three 24-h urine and blood samples taken to determine the risk of stones before their first clinic visit; these studies were repeated after therapy was initiated, and at regular intervals to monitor therapy. Cystine was measured in the urine samples of the cystine SF. All stone-related procedures were recorded, and BP measured at clinic visits. Creatinine clearances (CCr) were calculated from each set of serum and urine values. Cystine supersaturation (SS) was directly measured in 16 urine samples collected before treatment and 13 afterward. RESULTS: Patients were treated with increased fluid intake, potassium alkali and chelating agents such as alpha-mercapto-propionyl-glycine, as needed. The mean (sd) CCr, corrected for age and gender, was significantly lower at entry in cystine SF than in routine SF, at 91 (6) vs 160 (1) L/day, respectively (P < 0.001), and remained so at the last CCr. Neither systolic nor diastolic BP, similarly corrected, differed between the groups, but cystine SF had significantly more procedures, corrected for time at risk, before treatment than did routine SF, at 4.0 (0.4) vs 1.86 (0.06), respectively (P < 0.001); time-adjusted procedures decreased significantly in both groups during treatment, but remained higher in cystine SF, at 0.88 (0.14) vs 0.23 (0.02), respectively, (P < 0.001). Urine volume and pH were significantly higher in cystine SF than in routine SF, both before and during treatment. Cystine SS decreased during treatment, consistent with the increase in urine volume and decline in procedure rates during treatment. CONCLUSION: Cystine SF have significantly higher procedure rates than routine SF, but procedure rates decline during therapy, although they remain higher than in routine SF. The lower CCr in cystinurics suggests that treatment to prevent stone recurrence and the need for procedures is particularly important, and emphasizes the need for a close follow-up. Use of cystine SS measurements may allow closer monitoring of the effect of treatment on the risk of stone recurrence.     

Influence of hypothermic cardiopulmonary bypass on atrial natriuretic factor levels

Atrial natriuretic factor (ANF) is a peptide released from the heart in response to atrial distension. This peptide causes diuresis, vasodilatation, decreased blood pressure, and antagonizes the renin-aldosterone and antidiuretic hormone neuraxes. The influence of cardiopulmonary bypass and cardiac surgery on the circulation and release of ANF is unknown. Plasma ANF concentrations were therefore determined in patients undergoing coronary artery revascularization (CABG) and mitral valve replacement (MVR). Peptide levels were unchanged following anaesthetic induction. Plasma ANF concentrations decreased significantly during hypothermic (less than or equal to 28 degrees C) cardiopulmonary bypass in both patient groups. After 60 minutes of cardiac bypass, ANF declined from (mean +/- SEM) 512 +/- 132 to 20 +/- 6 pg.ml-1 (P less than 0.05) during MVR, and from 178 +/- 41 to 110 +/- 48 pg.ml-1 during CABG (P less than 0.05). Rewarming during bypass was associated with an increase in ANF concentration in both groups. Heparin anticoagulation and protamine reversal had no effect on immunoreactive ANF levels. In patients undergoing CABG, there was a linear relationship between plasma ANF concentration (pg.ml-1) and right atrial pressure (mmHg) prior to cardiopulmonary bypass (r = 0.86, P less than 0.005). However, one and three hours after cardiopulmonary bypass there was no significant relationship between right atrial pressure and ANF plasma levels. These results suggest that reduction in plasma ANF concentration occurs during hypothermic cardiopulmonary bypass. Furthermore, the proportional relationship between atrial distension and circulating ANF concentration was altered following cardiac surgery.     

Recent Developments in the Role of Coenzyme Q10 for Coronary Heart Disease: a Systematic Review

Purpose of Review

This review examines recent randomized clinical trials evaluating the role of coenzyme Q10 (CoQ10) in the management of coronary heart disease.

Recent Findings

CoQ10 is one of the most commonly used dietary supplements in the USA. Due to its antioxidant and anti-inflammatory effects, CoQ10 has been studied extensively for possible use in managing coronary heart disease. One of the most common applications of CoQ10 is to mitigate statin-associated muscle symptoms (SAMS) based on the theory that SAMS are caused by statin depletion of CoQ10 in the muscle. Although previous studies of CoQ10 for SAMS have produced mixed results, CoQ10 appears to be safe. Because CoQ10 is a cofactor in the generation of adenosine triphosphate, supplementation has also recently been studied in patients with heart failure, which is inherently an energy deprived state. The Q-SYMBIO trial found that CoQ10 supplementation in patients with heart failure not only improved functional capacity, but also significantly reduced cardiovascular events and mortality. Despite these positive findings, a larger prospective trial is warranted to support routine use of CoQ10. Less impressive are the effects of CoQ10 on specific cardiovascular risk factors such as blood pressure, dyslipidemia, and glycemic control.

Summary

Current evidence does not support routine use of CoQ10 in patients with coronary heart disease. Additional studies are warranted to fully determine the benefit of CoQ10 in patients with heart failure before including it in guideline-directed medical therapy.