Treatment strategies and survival of patients with connective tissue disease and pulmonary arterial hypertension: a COMPERA analysis.

OBJECTIVES: Pulmonary arterial hypertension (PAH) occurs in various connective tissue diseases (CTDs). We sought to assess contemporary treatment patterns and survival of patients with various forms of CTD-PAH. METHODS: We analysed data from COMPERA, a European pulmonary hypertension registry, to describe treatment strategies and survival in patients with newly diagnosed PAH associated with SSc, SLE, MCTD, UCTD and other types of CTD. All-cause mortality was analysed according to the underlying CTD. For patients with SSc-PAH, we also assessed survival according to initial therapy with endothelin receptor antagonists (ERAs), phosphodiesterase type 5 inhibitors (PDE5is) or a combination of these two drug classes. RESULTS: This analysis included 607 patients with CTD-PAH. Survival estimates at 1, 3 and 5 years for SSc-PAH (n = 390) were 85%, 59% and 42%; for SLE-PAH (n = 34) they were 97%, 77% and 61%; for MCTD-PAH (n = 33) they were 97%, 70% and 59%; for UCTD-PAH (n = 60) they were 88%, 67% and 52%; and for other CTD-PAH (n = 90) they were 92%, 69% and 55%, respectively. After multivariable adjustment, the survival of patients with SSc-PAH was significantly worse compared with the other conditions (P = 0.001). In these patients, the survival estimates were significantly better with initial ERA-PDE5i combination therapy than with initial ERA or PDE5i monotherapy (P = 0.016 and P = 0.012, respectively). CONCLUSIONS: Mortality remains high in patients with CTD-PAH, especially for patients with SSc-PAH. However, for patients with SSc-PAH, our results suggest that long-term survival may be improved with initial ERA-PDE5i combination therapy compared with initial monotherapy.

Quantifying cup overhang after total hip arthroplasty: standardized measurement using reformatted computed tomography and association of overhang distance with iliopsoas impingement.

OBJECTIVES: Currently, there is no standardized measurement method for evaluating cup overhang (CO) in patients undergoing total hip arthroplasty (THA). We propose a novel, standardized method of measuring overhang distance in patients following primary total hip arthroplasty (THA) on computed tomography (CT) images after multiplanar reformation and compare it to a previously proposed measurement method on sagittal CT images. MATERIALS AND METHODS: This retrospective study included patients who underwent primary THA with an anterior approach. Patients with cup overhang (CO) and iliopsoas impingement (IPI) were identified by clinical and imaging data. Uncorrected overhang distance (ODu) was evaluated on orthogonal sagittal CT images while corrected overhang distance (ODc) was evaluated on reformatted sagittal CT images corrected for pelvic rotation and aligned with the plane of the cup face. RESULTS: Out of 220 patients with THA, 23 patients (10.4%) with CO and 16 patients (7.3%) with IPI were identified. CO was significantly associated to IPI (p < 0.001). The inter- and intrareader agreement was almost perfect for ODc (κ = 0.822, κ = 0.850), whereas it was fair and moderate for ODu (κ = 0.391, κ = 0.455), respectively. The discriminative ability of ODc was excellent (area under the curve (AUC) = 0.909 (95% confidence interval (CI) 0.784-1.000)) in the receiver operating characteristic analysis. Conversely, AUC for ODu was poor, measuring 0.677 (95% CI 0.433-0.921). CONCLUSION: We implemented a novel measurement method for CT images reformatted at the plane of the cup face to assess overhang distance in patients with CO following THA. CLINICAL RELEVANCE STATEMENT: While further validation is necessary, the proposed method is characterized by its high reproducibility and might be used to predict the occurrence of iliopsoas impingement in patients with cup overhang following total hip arthroplasty. KEY POINTS: • A novel, standardized method of measuring cup overhang distance in patients following primary total hip arthroplasty on CT images is proposed. • Cup overhang was associated to iliopsoas impingement. The proposed method was reproducible and showed excellent prediction of iliopsoas impingement in patients with cup overhang. • This method can be implemented in clinical practice when assessing CT images of patients with cup overhang for iliopsoas impingement.

The effect of nonsteroidal anti-inflammatory drugs on bone healing in humans: A qualitative, systematic review.

STUDY OBJECTIVE: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in postoperative pain management. While an increasing number of in vitro and animal studies point toward an inhibitory effect of NSAIDs on bone healing process, the few existing retro- and prospective clinical studies present conflicting data. DESIGN: The aim of this qualitative, systematic review was to investigate the impact of perioperative use of NSAIDs in humans on postoperative fracture/spinal fusion healing compared to other used analgesics measured as fracture nonunion with radiological control. PATIENTS/INTERVENTIONS: We performed a systematic literature search of the last 38 years using PubMed Embase and the Cochrane Controlled Trials Register including retro- and prospective clinical, human trials assessing the effect of NSAIDs on postoperative fracture/spinal fusion healing when used for perioperative pain management with a radiological follow up to assess eventual nonunion. Due to different study designs, drugs, dosages/exposition times and different methods to assess fracture nonunion, these studies were not pooled for a meta-analysis. A descriptive summary of all studies, level of evidence, study quality and study bias assessment using different scores were used. MAIN RESULTS: Three prospective randomized controlled studies and thirteen retrospective cohort human studies were identified for a total of 12'895 patients. The overall study quality was low according to Jadad and Oxford Levels of Evidence scores. CONCLUSIONS: Published results of human trials did not show strong evidence that NDAIDs for pain therapy after fracture osteosynthesis or spinal fusion lead to an increased nonunion rate. Reviewed studies present such conflicting data, that no clinical recommendation can be made regarding the appropriate use of NSAIDs in this context. Considering laboratory data of animal, human tissue research and recommendation of clinical reviews, a short perioperative exposition to NSAIDs is most likely not deleterious. However, randomized, controlled studies are warranted to support or refute this hypothesis.