Statins and Angiotensin‐Converting Enzyme Inhibitors are Associated with Reduced Mortality and Morbidity in Chronic Liver Disease

Liver fibrosis is a common response to many chronic liver diseases. The aim of our study was to explore whether pharmacotherapy for concurrent diseases affects overall mortality, liver‐related mortality and liver‐related morbidity in patients with chronic liver disease. We performed a register‐based cohort study of all patients with a first‐time diagnosis of chronic liver disease between 2005 and 2012 in Sweden (n = 70 546). Data from the Patient Register, the Prescribed Drug Register and the Death Certificate Register were linked . We studied whether the use of statins, angiotensin‐converting enzyme inhibitors, angiotensin receptor blockers and antibiotics affected the risk of total mortality, liver‐specific mortality and morbidity. We found a reduction in mortality risk for statin users (n = 11,245) with hazard ratios from 0.57 (95% CI: 0.32–0.99) for patients with autoimmune hepatitis to 0.84 (95% CI: 0.75–0.95) for patients with alcoholic liver disease. There was a significantly reduced liver‐related mortality for patients with alcoholic liver disease who used angiotensin‐converting enzyme inhibitors, 0.85 (95% CI: 0.65–0.96). There were increased overall mortality risks for antibiotic users (n = 44,572), with hazard ratios up to 1.67 (95% CI, 1.55–1.80) for viral hepatitis. Statin use was associated with decreased risks of liver‐specific mortality and morbidity, and reduced total mortality foremost among patients with alcoholic liver disease. Angiotensin ‐converting enzyme inhibitors was associated with reduced liver‐related mortality among patients with alcoholic liver disease.     

Effect of reverse total shoulder arthroplasty humeral inclination on glenohumeral range of motion,deltoid force,and glenoid strain: a biomechanical study

BackgroundReverse total shoulder arthroplasty (RSA) primarily varies between 2 implant design options: a 135 humeral stem inclination that closely resembles anatomic orientation, versus the Grammont-style 155 humeral stem inclination that further medializes and distalizes the center of rotation (COR). The purpose of this study was to compare deltoid force, glenoid strain, and simulated glenohumeral range of motion (ROM) between RSA 135 and RSA 155 designs, with a series of standardized permutations of glenosphere offset and rotator cuff pathology.MethodsTwelve fresh-frozen cadaveric shoulder specimens were studied using a shoulder simulator. Native shoulder motion profiles for reproducible abduction range of motion were established using a customized testing device. Optical 3-dimensional tracking and pressure sensors were used to accurately record glenohumeral range of motion (ROM), deltoid force, and glenoid strain for RSA 135 and RSA 155 designs. For each cohort, all combinations of glenosphere offsets and rotator cuff tendon involvement were evaluated.ResultsThere was no significant difference in the overall abduction ROM between the 155 and the 135 humeral stem implants (P = .75). Resting abduction angle and maximum abduction angle were significantly greater with a 155 + STD (standard offset) construct than with a 135 + STD construct (P < .001 and P = .01, respectively). Both stem inclinations decreased combined deltoid force requirements as compared the native shoulder with a massive cuff tear. Effective glenoid strain did not vary significantly between 135 + STD and 155 + STD constructs (P = .66).ConclusionOverall, range of motion between the 135 and the 155 humeral stem inclinations was not significantly different. The cumulative deltoid force was lower in RSA shoulders when compared to native shoulders with massive rotator cuff tears, highlighting the utility of both implant designs. The Grammont-style 155 stem coupled with a 2.5 mm inferior offset glenosphere required less deltoid force to reach maximum abduction than did the more anatomic, lateralized 135 stem coupled with a 4 mm lateral offset glenosphere.Level of EvidenceBasic Science, Biomechanics Controlled Laboratory Study     

Flexions- und Extensionsosteotomien der proximalen Tibia

Background

Isolated deviations in flexion and extension of the leg axis are rare. These deviations can be corrected if necessary by osteotomy and the range of motion (ROM) of the knee joint can be optimized. In addition to correction in the frontal plane, the tibial slope (i.e. inclination of the surface of the tibial joint) can also be influenced by osteotomy and therefore osteotomy can also be utilized to optimize the biomechanical stability of the knee joint.

Method

Careful planning taking all three spatial planes and torsion into consideration is the foundation of a successful operation. A controlled surgical technique based on careful planning and some basic principles allows the alteration of the three dimensional alignment of the tibia.     

Psychotropic medication in geriatric psychiatric patients: use and unreported use in relation to serum concentrations

Purpose

The aim of this observational study was to describe the type, number, and serum concentration levels of psychotropic drugs in elderly patients, on admission to a geriatric psychiatric inpatient unit. We further wanted to investigate the use and unreported use of psychotropic drugs by analyzing for a broad spectrum of drugs in the serum samples.

Methods

A total of 236 patients were included. Drug use, patient characteristics, and diagnoses were recorded, and serum analysis was performed for a total of 56 psychotropic drugs in 233 of the patients.

Results

Nine out of ten patients (88 %) used one or more psychotropic drugs on admission to hospital; the mean use was 2.8 (95 % confidence interval (CI) 2.6–2.9) drugs. In 25 patients (11 %), drugs reported used were not detected in serum. Unreported use of drugs (serum analysis revealing one or more drugs not reported) was found in 100 patients (43 %). This was more common in younger patients. Psychotropic polypharmacy (use of three or more psychotropic drugs) was found in 109 patients (47 %). Patients with a main diagnosis of affective disorder used the most psychotropic drugs.

Conclusions

Psychotropic drugs are commonly used among geriatric psychiatric patients on admission to hospital. Psychotropic polypharmacy is a major concern among these patients. There was considerable unreported use of drugs within this population, and a low threshold for a broader serum analysis for psychotropic drugs appears indicated.     

Heart transplantation for end-stage heart failure caused by iron overload

Few reports exist concerning heart transplantation in recipients with end-stage myocardiopathy-associated heart failure caused by iron overload occurring with β-thalassaemia, Diamond-Blackfan syndrome or haemochromatosis. Seven potential transplant candidates (six male, one female, mean age 26 years) with such heart failure, following desferrioxamine application subcutaneously over a number of years, and intravenously during their hospitalization before transplantation, were retrospectively analysed. Five were New York Heart Association (NYHA) class IV, three experienced one or more resuscitations immediately before transplantation could be performed. Continuous, high-volume, veno-venous haemofiltration was necessary in two patients. One of these two candidates additionally had to be bridged, first with a right ventricular, then with a biventricular assist device. Five of the seven patients survived, two with haemochromatosis, one with β-thalassaemia major and one with Diamond-Blackfan syndrome following transplantation. One non-transplanted candidate with β-thalassaemia major has been recompensated for 5 years. Survival was 14–74 months. Our results demonstrate the feasibility and indication of transplantation in patients with such heart failure and the satisfying outcome of immunosuppression is described.     

Transcapillary fluid balance in immature rats. Interstitial fluid pressure,serum and interstitial protein concentration,and colloid osmotic pressure

Several of the factors governing transcapillary fluid balance were studied in anesthetized rats from the age of 1 to 60 days. Serum albumin and total protein concentrations rose from 1.7 and 2.4 g/100 ml at birth to 4.1 and 6.2 g/100 ml in adult rats, while colloid osmotic pressure rose from 5.3 to about 20 mm Hg. Interstitial fluid collected from subcutis by the wick technique showed protein concentrations of approximately 60% of serum values in all age groups, and its colloid osmotic pressure rose from about 3 to 10 mm Hg during maturation. Arterial pressure rose from about 50 mm Hg in newborn rats to 120 mm Hg in adult animals. Iliac venous pressure was only 0.5–1 mm Hg in 10-day-old rats compared to 3 mm Hg in adult animals. Interstitial fluid pressures of 0 to ?1 mm Hg were obtained in all age groups with the “wick-in-needle” technique. The data suggest an average capillary pressure of less than 5 mm Hg in newborn animals and a pre- to postcapillary resistance ratio similar to that of adult animals. The safety factors against edema formation seem to be small in immature rats.     

Post-challenge hyperglycaemia is associated with premature death and macrovascular complications

Unravelling the precise association between cardiovascular disease and Type II (non-insulin-dependent) diabetes mellitus has proved problematic, largely as a result of the confusing variety of diagnostic criteria and methodologies used in previous studies of disease-associated risk. More recently, improved standardization and continuing refinements to risk analyses have begun to clarify the relative importance of individual risk factors for macrovascular complications and progression to cardiovascular disease. The evidence accumulated from several large-scale epidemiological and intervention studies strongly indicates that hyperglycaemia and specifically the post-load hyperglycaemia resulting from postprandial glucose excursions is the main factor associated with increasing the risks of morbidity and mortality in Type II diabetes. The DECODE study has de-emphasized the importance of fasting glucose, in contrast to post-load hyperglycaemia, as the principal measurable determinant of exposure to the risk of cardiovascular disease in Type II diabetes. Similarly, the Diabetes Intervention Study identified mealtime hyperglycaemia as an independent risk factor for myocardial infarction and all-cause mortality, while several other studies have also shown that such mortality is better predicted from post-challenge measurement criteria rather than from fasting-glucose criteria. It is likely that postprandial hyperglycaemia is an independent risk factor for atherosclerosis and is also exerting an atherogenic effect indirectly through the clustering of a number of risk factors for atherosclerosis. Whether the relation between post-load hyperglycaemia and the risk of cardiovascular events is causal is still not known.     

Prevalence of hypertension in Type 1 (insulin-dependent) diabetes mellitus

Summary The prevalence of hypertension in a representative sample (n=10202) of the Danish general population aged 16–59 years was assessed to 4.4% based on three blood pressure readings. In Type 1 (insulin-dependent) diabetic patients of similar age (n=1703) the prevalence was determined in a similar way to 14.7% (p<0.00001). The excess prevalence in Type 1 diabetic patients was due to hypertension in patients with incipient and clinical nephropathy as the prevalence of hypertension among diabetic patients with normal urinary albumin excretion (essential hypertension) was 3.9%, similar to that observed in the general population. The patients with Type 1 diabetes and essential hypertension had higher systolic (146±19 vs 133±18 mmHg, p<0.00001) and diastolic blood pressure (87±12 vs 79±7mmHg, p<0.00001), but less changes in the eye background than patients with incipient nephropathy (urinary albumin excretion 30–300 mg/24 h) (p<0.03), indicating that the two groups were also different with respect to other microangiopathic lesions. Patients with essential hypertension were defined as having a normal urinary albumin excretion before and during antihypertensive treatment (if any). They were followed-up for a 58 (6–234) month period. We confirmed that hypertension is more common among Type 1 diabetic patients than in the general population and found the prevalence of essential hypertension similar in Type 1 diabetic patients to the non-diabetic population. This supports our hypothesis that hypertension is very unlikely to be the cause of diabetic nephropathy.