MRI after removal of central venous access device reveals a high number of asymptomatic thromboses in children with haemophilia

Central venous access devices (CVADs) are often required in children with haemophilia to secure venous access for prophylactic treatment or immune tolerance therapy. Complications of CVADs include infections, thrombosis and mechanical problems. This study sought to determine the outcome of the vessels by magnetic resonance imaging (MRI) in children with haemophilia and to assess risk factors for development of catheter-related deep venous thrombosis (DVT). After the removal of CVAD an MRI of the chest and neck was performed to 20 boys with haemophilia who each had 1-3 (total number 27) CVADs placed. MRI revealed DVT in five children (25%). As their CVADs were functional at the time of the removal, the DVTs were clinically silent. However, there had been suspicion of DVT leading to replacement of the CVAD in one case. All the children with DVT had their CVADs inserted initially below the age of 1 year. The clinical signs of mild post-thrombotic syndrome (PTS) were common: dilated chest wall veins were observed in 11 (55%) children and were associated with DVT in three cases. Arm circumference discrepancy was observed in one child with DVT. No correlation between the duration or number of CVADs and DVT was detected. None of the patients had subjective symptoms of PTS. Silent DVT is a common complication of CVAD. Catheter insertion at a young age seems to predispose to thrombosis. The long-term consequences of the DVTs remain unknown.     

Cutting seton for anal fistulas

PURPOSE: Long-term results of cutting seton in the treatment of anal fistulas were studied. METHODS: Of the 44 patients with anal fistulas, mainly of the high variety, managed with this method, 35 (25 men) attended a clinical and manometric follow-up examination on average 70 (range, 28–184) months after operation. Fistula distribution was high transsphincteric (25), low transsphincteric (5), extrasphincteric (3), and suprasphincteric (2). The seton was tightened at one-week to two-week intervals to achieve gradual sphincter division. RESULTS: Time required to achieve complete fistula healing ranged from 37 to 557 (mean, 151) days. Two (6 percent) of the 35 patients reexamined had recurrence of fistula and 22 (63 percent) reported symptoms of minor impairment in anal control, which in four patients had existed already before operation. Anal resting pressures were similar for defective and normal control, but other manometric variables were inferior in incontinence, although total squeeze pressure only showed statistically significant difference from normal continence ( P =0.0345). Incontinence was likely associated with hard and gutter-shaped operation scars in the anal canal, but the difference from normal continence was not statistically significant. CONCLUSION: Cutting seton yields fairly good results in regard to cure of fistula, but the risk of anal incontinence, despite its minor degree, seems to be too high to recommend its routine use for all high fistulas. The suprasphincteric fistulas and some extrasphincteric fistulas are difficult to treat otherwise, but especially for high transsphincteric fistulas, other methods of treatment (preferably those in which sphincter division can be avoided and the risk of anal canal deformity and incontinence are minimized) are advocated.No reprints are available.     

Long‐Term Follow‐Up of Coronary Venous Bypass Graft Lesions Treated with a New Generation Drug‐Eluting Stent with Bioabsorbable Polymer

Background

To date, no published data are available regarding long‐term follow‐up of new generation DES implanted in coronary artery bypass graft (CABG) lesions.

Objectives

To assess the long‐term clinical outcome of patients receiving the new generation Biolimus A9‐coated drug‐eluting stent (DES) with biodegradable polymer in saphenous vein grafts (SVG).

Methods

Three thousand sixty‐seven patients were included in the NOBORI 2 registry: 71 patients with a total of 117 lesions received at least 1 biolimus A9 DES in SVG lesions and 2,959 patients received percutaneous coronary intervention in other lesions. Clinical follow‐up was performed at 1, 6, and 12 months, and annually up to 3 years.

Results

Compared to the non‐CABG group, patients with CABG lesions were older (P < 0.001), had a higher Charlson Comorbidity Index (P = 0.004), and presented more often with acute coronary syndrome (P = 0.02). At 3‐year follow‐up, cardiac death occurred in 9.7% versus 2.1% (P < 0.001), myocardial infarction (MI) in 8.3% versus 3.0% (P = 0.02), target lesion failure in 13.9% versus 6.4% (P = 0.03), and major adverse cardiac event in 18.1% versus 8.6% (P = 0.01). No differences were observed in TV‐MI and TLR, nor stent thrombosis (ST) which was generally low in both groups (1.4% vs 0.8%, P = NS).

Conclusion

Albeit 3‐year outcomes were less favorable in the CABG group, the higher cardiac mortality was apparently not driven by ST, target vessel MI, or TLR, but is likely due to advanced disease and age as well as comorbidity. The low TLR rate as well as the absence of late and very late ST suggest that BES are safe and effective for the treatment of CABG lesions. (J Interven Cardiol 2013;26:425‐433)

     

Favorable Long‐Term Survival in Patients Undergoing Multivessel‐PCI Compared to Predicted Prognosis of CABG Estimated by EuroSCORE: Procedural and Clinical Determinants of Long‐Term Outcome

Aims/Methods: Treatment of patients with multivessel coronary artery disease (CAD) has been an ongoing focus of recent clinical studies, questioning the ideal treatment. Randomized trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have so far only included a minority of screened patients. Therefore, we analyzed data from 679 consecutive “all‐comer” patients, who underwent PCI in at least two main vessels. Expected in‐hospital mortality for CABG was calculated using the EuroSCORE and compared to the observed mortality rate during in‐hospital as well as long‐term follow‐up. Results: The patients were suffering from 2.5 ± 0.6 diseased vessels, and 2.8 ± 1.0 lesions were stented (32% of patients received at least one drug‐eluting stent [DES]; 20% of lesions were treated with DES). Forty‐seven percent of patients were treated for acute coronary syndrome (ACS) ( N = 176 ST‐elevation myocardial infarction [STEMI]; N = 140 non‐ST‐elevation myocardial infarction [NSTEMI]). The EuroSCORE was significantly higher in ACS patients compared to stable patients (logistic: STEMI 16.3 ± 17.2; NSTEMI 13.6 ± 13.0; stable CAD 3.9 ± 4.2). The observed in‐hospital mortality (STEMI 13.0%; NSTEMI 2.9%; stable CAD 1.7%, P < 0.001) was far lower than the estimated 30‐day mortality. Cox regression analysis identified an elevated logistic EuroSCORE (HR per quartile 2.7, P = 0.003), severely reduced left ventricular ejection fraction (HR 2.7, P < 0.001), elevated C‐reactive protein (HR 1.8, P = 0.012), and chronic renal failure (HR 2.8, P = 0.001) as independent predictors of long‐term mortality. Conclusions: The EuroSCORE, which is routinely used to estimate the perioperative risk of patients undergoing CABG, also predicts short‐ and long‐term prognosis of patients undergoing MV‐PCI. The observed mortality of patients undergoing MV‐PCI seems to be much lower than the estimated mortality of CABG.     

Does NIDDM increase the risk for coronary heart disease similarly in both low- and high-risk populations?

Summary Finland has marked regional differences in the occurrence of coronary heart disease (CHD). Although the causes for these differences in CHD mortality and morbidity in the Finnish population are unknown, it offers an excellent opportunity to investigate the effects of non-insulin-dependent diabetes mellitus (NIDDM) on CHD risk in two populations differing significantly with respect to the occurrence of CHD. Therefore, we carried out a 7-year prospective population-based study including a large number of patients with NIDDM (East Finland: 253 men and 257 women; West Finland: 328 men, 221 women) and corresponding non-diabetic subjects (East Finland: 313 men, 336 women; West Finland: 325 men, 399 women). In both study populations the presence of NIDDM increased significantly the risk for CHD events (CHD mortality or all CHD events including CHD mortality or non-fatal myocardial infarction). Diabetic men had 3–4 fold higher and diabetic women 8–11-fold higher risk for CHD than corresponding non-diabetic subjects. Both non-diabetic and diabetic subjects had odds ratios (East vs West) for CHD events of about 2 indicating a similar East-West difference in the CHD risk. Regional difference was quite similar in men and women. These results imply that factors related to NIDDM, independently of conventional risk factors and the occurrence of atherothrombosis in the background population, must play a major role in the pathogenesis of atherosclerotic vascular disease in NIDDM diabetes.Abbreviations CHD Coronary heart disease - NIDDM non-insulin dependent diabetes mellitus - MI myocardial infarction     

Increased arterial stiffness in women,but not in men,with IDDM

Summary For unknown reasons, there is a greater increase in the risk for cardiovascular complications in diabetic women than in diabetic men. Our aim was to study gender-related differences in the mechanical properties of the great arteries in patients with insulin-dependent diabetes mellitus (IDDM) but free from known cardiovascular and cerebrovascular complications. We measured arterial stiffness (, inversely related to arterial compliance) in the abdominal aorta and the common carotid artery non-invasively using echo-tracking sonography in 30 women (mean age 34 years, range 20–61) and 26 men (mean age 38 years, range 22–56) with IDDM. The results were compared with those of healthy individuals of corresponding age and gender. The results showed a marked gender-difference in changes of arterial stiffness. Arterial stiffness was increased in both the abdominal aorta and the common carotid artery in diabetic women compared to control women (p=0.0001 and p=0.0076, respectively). In contrast, there was no significant difference in stiffness of the abdominal aorta or the common carotid artery between the diabetic men and the control men (p=0.69 and p=0.39, respectively). In conclusion, this study has shown that stiffness of the aorta and the common carotid artery is increased in diabetic women but not in diabetic men. Increased arterial stiffness in diabetic women may be a pathogenic factor which could help to explain the gender-related differences in the risk for cardiovascular and cerebrovascular complications in diabetic subjects.Abbreviations IDDM Insulin-dependent diabetes mellitus - arterial stiffness - MAP mean arterial blood pressure - AGE advanced glycation end products     

Caries risk profiles in schoolchildren over 2 years assessed by Cariogram

International Journal of Paediatric Dentistry 2010; 20: 341–346 Background. Caries risk assessment is an important tool in clinical decision making. Aim. To evaluate longitudinal changes in caries risk profiles in a group of schoolchildren in relation to caries development. Design. The Cariogram model was used to create caries risk profiles and to identify risk factors in 438 children being 10–11 years at baseline. The assessment was repeated after 2 years and the caries increment was recorded. The frequency of unfavourable risk factors were compared between those considered at the lowest and the highest risk. Results. Fifty percent of the children remained in the same risk category after 2 years. One third of the children were assessed in a higher‐risk category while 18.4% showed a lower risk. Those with increased risk compared with baseline developed significantly more caries than those with an unchanged risk category. The most frequent unfavourable risk factors among those with high risk at baseline were high‐salivary mutans streptococci and lactobacilli counts as well as frequent meals. Conclusion. Half of the children showed a changed risk category after 2 years, for better or for worse, which suggests that regular risk assessments are needed in order to make appropriate decisions on targeted preventive care and recall intervals.     

Dysregulated microRNA expression in rheumatoid arthritis families—a comparison between rheumatoid arthritis patients,their first-degree relatives,and healthy controls

Objective

Recent studies have demonstrated an altered expression of certain microRNAs in patients with rheumatoid arthritis (RA) as well as their first-degree relatives (FDRs) compared to healthy controls (HCs), suggesting a role of microRNA in the progression of the disease. To corroborate this, a set of well-characterized RA families originating from northern Sweden were analyzed for differential expression of a selected set of microRNAs.

Method

MicroRNA was isolated from frozen peripheral blood cells obtained from 21 different families and included 26 RA patients, 22 FDRs, and 21 HCs. Expression of the selected microRNAs miR-22-3p, miR-26b-5p, miR-34a-3p, miR-103a-3p, miR-142-3p, miR-146a-5p, miR-155, miR-346, and miR-451a was determined by a two-step quantitative real-time polymerase chain reaction (qRT-PCR). Statistical analysis including clinical variables was applied.

Results

Out of the nine selected microRNAs that previously have been linked to RA, we confirmed four after adjusting for age and gender, i.e., miR-22-3p (p?=?0.020), miR-26b-5p (p?=?0.018), miR-142-3p (p?=?0.005), and miR-155 (p?=?0.033). Moreover, a significant trend with an intermediate microRNA expression in FDR was observed for the same four microRNAs. In addition, analysis of the effect of corticosteroid use showed modulation of miR-103a-3p expression.

Conclusions

We confirm that microRNAs seem to be involved in the development of RA, and that the expression pattern in FDR is partly overlapping with RA patients. The contribution of single microRNAs in relation to the complex network including all microRNAs and other molecules is still to be revealed.