Long-term survival of proximal humerus allografts for reconstruction following resection of malignant bone tumours.

We previously reported early favourable results concerning allograft use in proximal humerus reconstruction following malignancy. We now present the long-term follow-up of patients who underwent tumour resection with massive humeral allograft reconstruction. This is a retrospective review of 8 consecutive patients who underwent massive proximal humeral allograft for primary or secondary bone tumours. The median age at first surgery was 41 years; the median followup is 11.1 years. The overall revision rate of the allografts was 75%. A total of 10 revision procedures were required in this cohort. Five-year survival for implants was 44%; at ten years no implants were intact. Five-year survival for patients was 88%; it was 60% at ten years. In our experience, proximal humerus allograft reconstruction was associated with a high complication rate and resulted in multiple revision procedures in the long-term. We no longer perform or recommend this procedure.

Clinical associations with stage B heart failure in adults with type 2 diabetes.

BACKGROUND: There is a high prevalence of asymptomatic (American Heart Association Stage B) heart failure (SBHF) in people with type 2 diabetes (T2D). We aimed to identify associations between clinical characteristics and markers of SBHF in adults with T2D, which may allow therapeutic interventions prior to symptom onset. METHODS: Adults with T2D from a multi-ethnic population with no prevalent cardiovascular disease [n = 247, age 52 ± 12 years, glycated haemoglobin A1c (HbA1c) 7.4 ± 1.1% (57 ± 12 mmol/mol), duration of diabetes 61 (32, 120) months] underwent echocardiography and adenosine stress perfusion cardiovascular magnetic resonance imaging. Multivariable linear regression analyses were performed to identify independent associations between clinical characteristics and markers of SBHF. RESULTS: In a series of multivariable linear regression models containing age, sex, ethnicity, smoking history, number of glucose-lowering agents, systolic blood pressure (BP) duration of diabetes, body mass index (BMI), HbA1c, serum creatinine, and low-density lipoprotein (LDL)-cholesterol, independent associations with: left ventricular mass:volume were age (ß = 0.024), number of glucose-lowering agents (ß = 0.022) and systolic BP (ß = 0.027); global longitudinal strain were never smoking (ß = -1.196), systolic BP (ß = 0.328), and BMI (ß = -0.348); myocardial perfusion reserve were age (ß = -0.364) and male sex (ß = 0.458); and aortic distensibility were age (ß = -0.629) and systolic BP (ß = -0.348). HbA1c was not independently associated with any marker of SBHF. CONCLUSIONS: In asymptomatic adults with T2D, age, systolic BP, BMI, and smoking history, but not glycaemic control, are the major determinants of SBHF. Given BP and BMI are modifiable, these may be important targets to reduce the development of symptomatic heart failure.

First reported case of lead-related infective endocarditis secondary to Capnocytophaga canimorsus: 'Dog Scratch' endocarditis.

A 76-year-old woman presented with a 6-week history of malaise, night sweats and recurrent fever. She had a background of dilated cardiomyopathy for which she had a cardiac resynchronisation device in situ. She had several hospital admissions across this time with differing diagnoses offered. She received multiple courses of antibiotics with short-term symptom resolution. Blood cultures grew Gram-negative rods and samples were sent to a specialist centre for subtype analysis. A transthoracic echocardiogram revealed thickening of the distal right ventricular lead. A transoesophageal echocardiogram demonstrated a clearer vegetation on this lead. It transpired that she had been scratched by her dog a fortnight before symptom onset. The causal bacterium was reported as Capnocytophaga canimorsus, a bacterium that exists almost exclusively in the saliva and claws of dogs and cats. She received an extended course of antibiotics with eventual removal of the infected device.

Effects of Low-Energy Diet or Exercise on Cardiovascular Function in Working-Age Adults With Type 2 Diabetes: A Prospective, Randomized, Open-Label, Blinded End Point Trial.

OBJECTIVE: To confirm the presence of subclinical cardiovascular dysfunction in working-age adults with type 2 diabetes (T2D) and determine whether this is improved by a low-energy meal replacement diet (MRP) or exercise training. RESEARCH DESIGN AND METHODS: This article reports on a prospective, randomized, open-label, blinded end point trial with nested case-control study. Asymptomatic younger adults with T2D were randomized 1:1:1 to a 12-week intervention of 1) routine care, 2) supervised aerobic exercise training, or 3) a low-energy (∼810 kcal/day) MRP. Participants underwent echocardiography, cardiopulmonary exercise testing, and cardiac magnetic resonance (CMR) at baseline and 12 weeks. The primary outcome was change in left ventricular (LV) peak early diastolic strain rate (PEDSR) as measured by CMR. Healthy volunteers were enrolled for baseline case-control comparison. RESULTS: Eighty-seven participants with T2D (age 51 ± 7 years, HbA1c 7.3 ± 1.1%) and 36 matched control participants were included. At baseline, those with T2D had evidence of diastolic dysfunction (PEDSR 1.01 ± 0.19 vs. 1.10 ± 0.16 s-1, P = 0.02) compared with control participants. Seventy-six participants with T2D completed the trial (30 routine care, 22 exercise, and 24 MRP). The MRP arm lost 13 kg in weight and had improved blood pressure, glycemia, LV mass/volume, and aortic stiffness. The exercise arm had negligible weight loss but increased exercise capacity. PEDSR increased in the exercise arm versus routine care (ß = 0.132, P = 0.002) but did not improve with the MRP (ß = 0.016, P = 0.731). CONCLUSIONS: In asymptomatic working-age adults with T2D, exercise training improved diastolic function. Despite beneficial effects of weight loss on glycemic control, concentric LV remodeling, and aortic stiffness, a low-energy MRP did not improve diastolic function.

'Hearing hooves, finding zebras': the differential diagnosis of cardiac arrest precipitated by chest pain in the postpartum woman.

We describe the case of a 3-week postpartum 27-year-old woman who presented with chest pain to the emergency department shortly before developing cardiac arrest with refractory ventricular fibrillation. She was initially misdiagnosed and treated for presumed pulmonary embolism (PE) with thrombolysis. A total of 14 direct current cardioversion shocks were given and return of spontaneous circulation (ROSC) was achieved post thrombolysis. Subsequent CT pulmonary angiography excluded PE. A post-ROSC ECG demonstrated anterolateral ST elevation and she was transferred to the local cardiac unit for angiography. This revealed extensive dissection of the left anterior descending artery (LAD) with proximal occlusion. The diagnosis therefore was pregnancy-associated spontaneous artery dissection, a type of acute coronary syndrome. She received percutaneous intervention to her LAD with five drug-eluting stents. The patient survived and was discharged 5 days later. Her ventricular function is now grossly impaired, and had the correct diagnosis been arrived at sooner, this loss of function would have been less severe.