Electrocardiographic predictors of out-of-hospital sudden cardiac arrest in patients with coronary artery disease

Sudden cardiac arrest (SCA), due mainly to coronary artery disease (CAD), is a leading cause of death. To identify electrocardiographic and clinical differences between patients with CAD with and without SCA, 87 victims of SCA with CAD were compared with 131 patients with CAD without SCA. Patients' latest routine electrocardiograms and clinical variables were compared. Patients with CAD with and without previous myocardial infarctions (MIs) were included. Patients with SCA had a higher incidence of echocardiographic evidence of left ventricular hypertrophy and/or heart failure than controls. The median left ventricular ejection fractions for patients with SCA with and without previous MIs were 0.30 (interquartile range 0.24 to 0.41) and 0.41 (interquartile range 0.25 to 0.56). The median time between the last electrocardiographic assessment and SCA was 59 days (interquartile range 29 to 137). Regarding electrocardiographic characteristics, in patients with and without previous MIs, QRS width (odds ratio 1.032, 95% confidence interval 1.012 to 1.053, p = 0.002, and odds ratio 1.035, 95% confidence interval 1.015 to 1.056, p = 0.001) was the only significant predictor of SCA. In conclusion, in patients with CAD, regardless of a previous MI, a longer QRS width and echocardiographic parameters consistent with heart failure are associated with SCA, even in patients with ischemic cardiomyopathy currently not eligible for an implantable cardioverter-defibrillator.     

Differences in outcomes of oesophageal and gastric cancer surgery across Europe

Background:

In several European countries, centralization of oesophagogastric cancer surgery has been realized and clinical audits initiated. The present study was designed to evaluate differences in resection rates, outcomes and annual hospital volumes between these countries, and to analyse the relationship between hospital volume and outcomes.

Methods:

National data were obtained from cancer registries or clinical audits in the Netherlands, Sweden, Denmark and England. Differences in outcomes were analysed between countries and between hospital volume categories, adjusting for available case‐mix factors.

Results:

Between 2004 and 2009, 10 854 oesophagectomies and 9010 gastrectomies were registered. Resection rates in England were 18·2 and 21·6 per cent for oesophageal and gastric cancer respectively, compared with 28·5–29·9 and 41·4–41·9 per cent in the Netherlands and Denmark (P < 0·001). The adjusted 30‐day mortality rate after oesophagectomy was lowest in Sweden (1·9 per cent). After gastrectomy, the adjusted 30‐day mortality rate was significantly higher in the Netherlands (6·9 per cent) than in Sweden (3·5 per cent; P = 0·017) and Denmark (4·3 per cent; P = 0·029). Increasing hospital volume was associated with a lower 30‐day mortality rate after oesophagectomy (odds ratio 0·55 (95 per cent confidence interval 0·42 to 0·72) for at least 41 versus 1–10 procedures per year) and gastrectomy (odds ratio 0·64 (0·41 to 0·99) for at least 21 versus 1–10 procedures per year).

Conclusion:

Hospitals performing larger numbers of oesophagogastric cancer resections had a lower 30‐day mortality rate. Differences in outcomes between several European countries could not be explained by differences in hospital volumes. To understand these differences in outcomes and resection rates, with reliable case‐mix adjustments, a uniform European upper gastrointestinal cancer audit with recording of standardized data is warranted. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Dynamic adaptation of the peripheral circulation to cold exposure

Humans residing or working in cold environments exhibit a stronger cold-induced vasodilation (CIVD) reaction in the peripheral microvasculature than those living in warm regions of the world, leading to a general assumption that thermal responses to local cold exposure can be systematically improved by natural acclimatization or specific acclimation. However, it remains unclear whether this improved tolerance is actually due to systematic acclimatization, or alternately due to the genetic pre-disposition or self-selection for such occupations. Longitudinal studies of repeated extremity exposure to cold demonstrate only ambiguous adaptive responses. In field studies, general cold acclimation may lead to increased sympathetic activity that results in reduced finger blood flow. Laboratory studies offer more control over confounding parameters, but in most studies, no consistent changes in peripheral blood flow occur even after repeated exposure for several weeks. Most studies are performed on a limited amount of subjects only, and the variability of the CIVD response demands more subjects to obtain significant results. This review systematically surveys the trainability of CIVD, concluding that repeated local cold exposure does not alter circulatory dynamics in the peripheries, and that humans remain at risk of cold injuries even after extended stays in cold environments.     

Alcohol and Drug Abuse Among U.S. Veterans: Comparing Associations With Intimate Partner Substance Abuse and Veteran Psychopathology

This study examined the relative influences of posttraumatic stress disorder (PTSD), other psychopathology, and intimate partner alcohol and drug use on substance‐related problems in U.S. veterans (242 couples, N = 484). Hierarchical regression analyses revealed that partner alcohol and drug use severity explained more variance in veteran alcohol use and drug use (20% and 13%, respectively) than did veteran PTSD, adult antisocial behavior, or depression symptoms combined (6% for veteran alcohol use; 7% for veteran drug use). Findings shed new light on the influence of relationship factors on veteran alcohol and drug use and underscore the importance of couples‐oriented approaches to treating veterans with comorbid PTSD and substance abuse.     

Early conversion to below-elbow cast for non-reduced diaphyseal both-bone forearm fractures in children is safe: preliminary results of a multicentre randomised controlled trial

Introduction

This multicentre randomised controlled trial was designed to explore whether 6 weeks above-elbow cast (AEC) or 3 weeks AEC followed by 3 weeks below-elbow cast (BEC) cause similar limitation of pronation and supination in non-reduced diaphyseal both-bone forearm fractures in children.

Materials and methods

Children were randomly allocated to 6 weeks AEC or to 3 weeks AEC followed by 3 weeks BEC. The primary outcome was limitation of pronation and supination after 6 months. The secondary outcomes were re-displacement of the fracture, complication rate, limitation of flexion and extension of wrist and elbow, cast comfort, cosmetics, complaints in daily life and assessment of radiographs.

Results

A group of 23 children was treated with 6 weeks AEC and 24 children with 3 weeks AEC and 3 weeks BEC. The follow-up rate was 98 % with a mean follow-up of 7.0 months. The mean limitation of pronation and supination was 23.3 ± 22.0 for children treated with AEC and 18.0 ± 16.9 for children treated with AEC and BEC. The other study outcomes were similar in both groups.

Conclusions

Early conversion to BEC is safe in the treatment of non-reduced diaphyseal both-bone forearm fractures in children.

Level of evidence

Multicentre randomised controlled trial, Level II.     

Surgical treatment of acute pancreatitis

Background

Acute pancreatitis remains an unpredictable, potentially lethal disease with significant morbidity and mortality rates. New insights in the pathophysiology of acute pancreatitis have changed management concepts. In the first phase, characterized by a systemic inflammatory response syndrome, organ failure, not related to infection but rather to severe inflammation, dominates the focus of treatment. In the second phase, secondary infectious complications largely determine the clinical outcome. As infection is associated with increased mortality in acute pancreatitis, numerous prophylactic strategies have been explored in the past two decades.

Purpose

This review describes the strategies that have been developed to lower the infection rate, in an attempt to lower mortality. Antibiotic prophylaxis has been the subject of many RCT’s without showing convincing evidence of their efficacy. Probiotics, although theoretically capable of lowering the rate of infection, also had no effect on infectious complications, and consequently, no effective strategy to lower the rate of infectious complications is currently available. In the second part of this review, new approaches for necrosectomy that have been designed by different centers around the world are discussed. All the interventional techniques have in common their aim to lower the invasive character, hypothesizing that lowering the surgical trauma will improve survival and lower complication rates. Recent advances include postponing intervention as a strategy to facilitate necrosectomy and improve prognosis and the “step-up approach” in case of infected necrosis. The step-up approach includes percutaneous catheter drainage as the first step, to be followed by necrosectomy, either through a minimally invasive approach or by open necrosectomy, as the next step.

Conclusions

All attempts to develop treatment strategies to lower the infection rate in acute pancreatitis have failed. Accumulating evidence is emerging to show that the combination of centralization, the use of catheter drainage as the first step of invasive treatment, and the development of minimally invasive techniques, improve the outlook for patients with infected necrosis. It is uncertain at this point in time as to which of the three effects is dominant in the improvement of prognosis.