Major adverse cardiovascular events in older emergency department patients presenting with non-cardiac medical complaints.

OBJECTIVE: The risk of major adverse cardiovascular events (MACE) for older emergency department (ED) patients presenting with non-cardiac medical complaints is unknown. To apply preventive measures timely, early identification of high-risk patients is incredibly important. We aimed at investigating the incidence of MACE within one year after their ED visit and the predictive value of high-sensitivity cardiac troponin T (hs-cTnT) and N­terminal pro-B-type natriuretic peptide (NT-proBNP) for subsequent MACE. METHODS: This is a substudy of a Dutch prospective cohort study (RISE UP study) in older (≥ 65 years) medical ED patients who presented with non-cardiac complaints. Biomarkers were measured upon ED arrival. Cox-regression analysis was used to determine the predictive value of the biomarkers, when corrected for other possible predictors of MACE, and area under the curves (AUCs) were calculated. RESULTS: Of 431 patients with a median age of 79 years, 86 (20.0%) developed MACE within 1 year. Both hs-cTnT and NT-proBNP were predictive of MACE with an AUC of 0.74 (95% CI 0.68-0.80) for both, and a hazard ratio (HR) of 2.00 (95% CI 1.68-2.39) and 1.82 (95% CI 1.57-2.11) respectively. Multivariate analysis correcting for other possible predictors of MACE revealed NT-proBNP as an independent predictor of MACE. CONCLUSION: Older medical ED patients are at high risk of subsequent MACE within 1 year after their ED visit. While both hs-cTnT and NT-proBNP are predictive, only NT-proBNP is an independent predictor of MACE. It is likely that early identification of those at risk offers a window of opportunity for prevention.

New diagnostic and treatment strategies in renal artery stenosis: a promising pursuit or disappointment foretold?

Clinical management of renal artery stenosis has seen a major shift, after randomised clinical trials have shown no group benefit of endovascular intervention relative to optimal medical control. However, the inclusion criteria of these trials have been criticised for focusing on a subset of patients with atherosclerotic renal artery stenosis where intervention was unlikely to be beneficial. Moreover, new imaging and computational techniques have become available, which have the potential to improve identification of patients that will respond to interventional treatment. This review addresses the challenges associated with clinical decision making in patients with renal artery stenosis. Opportunities for novel diagnostic techniques to improve patient selection are discussed, along with ongoing Dutch studies and network initiatives that investigate these strategies.

Spontaneous coronary artery dissections and associated predisposing factors: a narrative review.

Spontaneous coronary artery dissection (SCAD) represents around 25% of cases of acute coronary syndromes (ACS) in women aged 40-65 years who have few or no traditional cardiovascular risk factors. It is assumed that the incidence is underestimated, as the angiographic appearance of SCAD may often mimic atherosclerosis. This review aims to examine SCAD by focusing on the associated predisposing factors and precipitating stressors in this heterogeneous patient population, as well as the best treatment approach and the prognosis. Progressive knowledge has improved our current understanding of SCAD, but more awareness among clinicians is necessary. Recently, two position papers from the European Society of Cardiology (ESC) and the American Heart Association (AHA) have been released, which will be summarised in brief.

Metabolic syndrome and pre-eclampsia.

OBJECTIVE: To evaluate the association between different pre-eclampsia (PE) phenotypes and the development of metabolic syndrome postpartum, in order to identify the subgroup of formerly pre-eclamptic women with a worse cardiovascular risk profile requiring tailored postpartum follow-up. METHODS: This was a cohort study of 1102 formerly pre-eclamptic women in whom cardiovascular and cardiometabolic evaluation was performed at least 3 months postpartum. Women were divided into four subgroups based on PE resulting in delivery before 34 weeks (early-onset (EO)) or at or after 34 weeks (late onset (LO)) of gestation and whether they delivered a small-for-gestational-age (SGA) neonate. Metabolic syndrome was diagnosed as the presence of hyperinsulinemia along with two or more of: body mass index ≥ 30 kg/m2 ; dyslipidemia; hypertension; and microalbuminuria or proteinuria. Data were compared between groups using ANOVA after Bonferroni correction. Odds ratios (OR) were calculated using logistic regression to determine the association between metabolic syndrome and the four subgroups. We constructed receiver-operating characteristics curves and computed the area under the curve (AUC) to quantify the ability of different obstetric variables to distinguish between women who developed metabolic syndrome and those who did not. RESULTS: The prevalence of metabolic syndrome was higher in women with EO-PE and SGA (25.8%) than in those with EO-PE without SGA (14.7%) (OR 2.01 (95% CI, 1.34-3.03)) and approximately five-fold higher than in women with LO-PE with SGA (5.6%) (OR 5.85 (95% CI, 2.60-13.10)). In women with LO-PE, the prevalence of metabolic syndrome did not differ significantly between women with and those without SGA. Multivariate analysis revealed that a history of SGA, a history of EO-PE and systolic blood pressure at the time of screening are the best predictors of developing metabolic syndrome postpartum. The AUC of the model combining these three variables was 74.6% (95% CI, 70.7-78.5%). The probability of the presence of metabolic syndrome was calculated as: P = 1/(1 + e-LP ), where LP is linear predictor = -8.693 + (0.312 × SGA (yes = 1)) + (0.507 × EO-PE (yes = 1)) + (0.053 × systolic blood pressure). CONCLUSIONS: The incidence of metabolic syndrome postpartum was associated more strongly with EO-PE in combination with SGA as compared with LO-PE or EO-PE without SGA. Both time of onset of PE and fetal growth affect the risk of metabolic syndrome after a pre-eclamptic pregnancy. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Chronic meningococcemia presenting with recurrent painful rash and poly-arthralgia without fever.

Chronic meningococcemia is an uncommon disorder, representing a diagnostic challenge. Classically, this pathology would be considered in young adults with a history of episodes of fever, disseminated cutaneous vasculitis and arthralgia. Exact and rapid diagnosis is often further challenged by the fact that routine microbiological investigations frequently failed to identify incriminated micro-organism, Neisseria meningitidis. Here we present the case of a young man not presenting with the classical triad.

Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.

PURPOSE: The purpose of this study was to describe the short-term clinical outcome of a new arthroscopic fixation technique for primary osteochondral talar defects: lift, drill, fill and fix (LDFF). METHODS: Seven patients underwent an arthroscopic LDFF surgery for osteochondral talar defects, the mean follow-up was 12 months (SD 0.6). Pre- and postoperative clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS) and the numeric rating scales (NRS) of pain at rest and during walking. Remodelling and bone ingrowth after LDFF were analysed on weight-bearing radiographs during follow-up. RESULTS: In all patients, LDFF led to an improvement of the AOFAS and NRS of pain. The AOFAS significantly improved from 63 to 99 (p < 0.001). The NRS of pain at rest significantly improved from 2.9 to 0.1 (p = 0.004), and pain with walking significantly improved from 7.6 to 0.1 (p < 0.001). On the final radiographs, five of seven patients showed remodelling and bone ingrowth after LDFF. CONCLUSIONS: The LDFF of an osteochondral talar defect appears to be a promising arthroscopic treatment option for primary talar osteochondral defects. Although the clinical and radiological results of 1-year follow-up are encouraging, more patients and longer follow-up are needed to draw any firm conclusions and determine whether the results stand the test of time. LEVEL OF EVIDENCE: Prospective case series. Therapeutic, Level IV.

A SpoT polymorphism correlates with chill stress survival and is prevalent in clinical isolates of Campylobacter jejuni.

Resistance of Campylobacter jejuni to environmental stress is regarded as a risk factor for the transmission of C. jejuni from poultry or poultry products to humans. So far, the mechanisms underlying the capacity of C. jejuni to survive environmental stress conditions are not fully understood. In this study, we searched for polymorphisms in C. jejuni genes, potentially involved in resistance to chill stress. To this end, we assessed 3 groups of C. jejuni isolates (clinical, retail chicken meat, and feces) for survival of experimentally induced chill stress. For each isolate we sequenced 3 genes encoding the C. jejuni sigma factors FliA, RpoD, and RpoN as well as the genes for the transcriptional regulator SpoT and the periplasmic protein HtrA. Data suggest a higher prevalence of a specific polymorphism in spoT in clinical isolates compared with poultry meat or farm isolates. Moreover, this genotype correlated with enhanced survival of chill stress. The observation that the prevalence of this SNP is relatively high in clinical isolates, which most likely have been exposed to multiple forms of stress, suggest that this SNP may be a biomarker for enhanced survival of stress.

European Society of Hypertension practice guidelines for home blood pressure monitoring.

Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners.

No effect of rosuvastatin on left ventricular hypertrophy in patients with hypertension: a prospective randomised open-label study with blinded endpoint assessment.

BACKGROUND: This study tested the hypothesis that statins may reduce left ventricular hypertrophy (LVH) in patients with hypertension and LVH. METHOD: A prospective randomised open-label study with blinded endpoints assessment was performed in 142 patients. Inclusion criteria were hypertension, left ventricular ejection fraction ≥50% and echocardiographic determined LVH, defined as a left ventricular mass index (LVMI) of ≥ 100 g/m(2) in women and ≥ 116 g/m(2) in males. Patients were randomised between rosuvastatin 20mg once daily vs control. For each patient an echocardiogram and blood samples were obtained. These tests were repeated after 6 months. RESULTS: Baseline characteristics: mean age was 62 ± 11year and 62 (44%) were male. In both groups, there was a non-significant reduction in LVMI: 118 ± 22 to 111 ± 19 g/m(2) in the control group and 118 ± 21 to 114 ± 22 in the rosuvastatin group (p=0.376 for the comparison between rosuvastatin and control after 6 months). After six months, LDL-cholesterol was reduced from 3.5 ± 1.0 to 2.1 ± 1.2 mmol/L (40% reduction) in the rosuvastatin group and remained unchanged in the control group (3.5 ± 0.9 vs 3.6 ± 0.9 mmol/L. Hs-CRP decreased more with rosuvastatin compared to control (-38% vs -15%, p=0.006) There was no significant reduction in NT-pro-BNP levels after 6 months. CONCLUSION: Rosuvastatin does not reduce LVH despite a large LDL reduction in patients with hypertension and LVH.

Hindfoot endoscopy for posterior ankle impingement. Surgical technique.

BACKGROUND: The surgical treatment of posterior ankle impingement is associated with a high rate of complications and a substantial time to recover. An endoscopic approach to the posterior ankle (hindfoot endoscopy) may lack these disadvantages. We hypothesized that hindfoot endoscopy causes less morbidity and facilitates a quick recovery compared with open surgery. METHODS: Fifty-five consecutive patients with posterior ankle impingement were treated with an endoscopic removal of bone fragments and/or scar tissue. The symptoms were caused by trauma (65%) or overuse (35%). All patients were enrolled in a prospective protocol. At baseline, the age, sex, work and sports activities, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, and preinjury Tegner scores were determined for all patients. At the time of follow-up, AOFAS hindfoot scores and Tegner scores were assessed and the time to return to work and sports activities was determined. Complications were recorded. Patients scored the overall result as poor, fair, good, or excellent by means of a 4-point Likert scale. RESULTS: The median duration of follow-up was thirty-six months, and no patient was lost to follow-up. The median AOFAS hindfoot score increased from 75 points preoperatively to 90 points at the time of final follow-up. The median time to return to work and sports activities was two and eight weeks, respectively. At the time of follow-up, patients in the overuse group were more satisfied than those in the posttraumatic group, and the AOFAS hindfoot scores were higher in patients in the overuse group (median, 100 points) compared with patients in the posttraumatic group (median, 90 points). A complication occurred in one patient who had a temporary loss of sensation of the posteromedial aspect of the heel. CONCLUSIONS: The outcome after endoscopic treatment of posterior ankle impingement compares favorably with the results of open surgery reported in the literature. Hindfoot endoscopy appears to cause less morbidity than open ankle surgery and facilitates a quick recovery. Patients treated for posterior ankle impingement caused by overuse have better results than those treated following trauma.

Determinants of DNA yield and purity collected with buccal cell samples.

Buccal cells are an important source of DNA in epidemiological studies, but little is known about factors that influence amount and purity of DNA. We assessed these factors in a self-administered buccal cell collection procedure, obtained with three cotton swabs. In 2,451 patients DNA yield and in 1,033 patients DNA purity was assessed. Total DNA yield ranged from 0.08 to 1078.0 microg (median 54.3 microg; mean 82.2 microg +/- SD 92.6). The median UV 260:280 ratio, was 1.95. Samples from men yielded significantly more DNA (median 58.7 microg) than those from women (median 44.2 microg). Diuretic drug users had significantly lower purity (median 1.92) compared to other antihypertensive drug users (1.95). One technician obtained significantly lower DNA yields. Older age was associated with lower DNA purity. In conclusion, DNA yield from buccal swabs was higher in men and DNA purity was associated with age and the use of diuretics.

Vascular calcifications as a marker of increased cardiovascular risk: a meta-analysis.

BACKGROUND: Several imaging techniques may reveal calcification of the arterial wall or cardiac valves. Many studies indicate that the risk for cardiovascular disease is increased when calcification is present. Recent meta-analyses on coronary calcification and cardiovascular risk may be confounded by indication. Therefore, this meta-analysis was performed with extensive subgroup analysis to assess the overall cardiovascular risk of finding calcification in any arterial wall or cardiac valve when using different imaging techniques. METHODS AND RESULTS: A meta-analysis of prospective studies reporting calcifications and cardiovascular end-points was performed. Thirty articles were selected. The overall odds ratios (95% confidence interval [CI]) for calcifications versus no calcifications in 218,080 subjects after a mean follow-up of 10.1 years amounted to 4.62 (CI 2.24 to 9.53) for all cause mortality, 3.94 (CI 2.39 to 6.50) for cardiovascular mortality, 3.74 (CI 2.56 to 5.45) for coronary events, 2.21 (CI 1.81 to 2.69) for stroke, and 3.41 (CI 2.71 to 4.30) for any cardiovascular event. Heterogeneity was largely explained by length of follow up and sort of imaging technique. Subgroup analysis of patients with end stage renal disease revealed a much higher odds ratio for any event of 6.22 (CI 2.73 to 14.14). CONCLUSION: The presence of calcification in any arterial wall is associated with a 3-4-fold higher risk for mortality and cardiovascular events. Interpretation of the pooled estimates has to be done with caution because of heterogeneity across studies.

Systemic inflammatory responses in dogs experimentally infected with Babesia canis; a haematological study.

A detailed haematological study of dogs that were infected with low, moderate or high numbers of Babesia canis-infected red blood cells was performed in an attempt to elucidate the pathogenesis early after B. canis infection. Results showed that upon infection the C-reactive protein (CRP) level in plasma increased prior to the detection of parasites in the blood indicative of an acute phase reaction. The response was further characterised by fever, fibrinogenaemia, thrombocytopenia and leucopoenia. Thrombocytopenia was associated with increased coagulation time. Infected dogs also developed life threatening hypotension, and dogs that were infected with the highest dose of B. canis-infected red blood cells had to be treated chemotherapeutically. Hypotension was associated with a reduced packed cell volume (PCV). This reduction of PCV correlated with reduced plasma creatinin concentration, suggesting that the plasma volume was increased, affecting both the erythrocyte and creatinin concentration in the plasma. Importantly, the onset of the response but not the dynamics of the response was dependent on the infectious dose i.e. curves obtained with different doses of infected erythrocytes appeared to be shifted in time but had a similar shape. This indicates that infection triggered a preset inflammatory response.

The contribution of six polymorphisms to cardiovascular risk in a Dutch high-risk primary care population: the HIPPOCRATES project.

This study was designed to examine the contribution of six polymorphisms to the occurrence of cardiovascular disease (CVD) in a Dutch primary care population with a high prevalence of cardiovascular risk factors. In this cross-sectional case-control study, 232 patients with CVD and 571 event-free controls were studied. Patients were genotyped for the AGTR1 (A1166C), AGT (M235T), ACE (4656rpt), NOS3 (E298D), GNB3 (C825T) and ADD1 (G460W) polymorphisms. Univariate and multivariate odds ratios (ORs) were calculated to assess the relationship between genotypes and CVD. Receiver operating characteristic (ROC) analysis was used to quantify the contribution of the polymorphisms to the prediction of CVD. No differences in either genotype or allele frequencies were found between CVD cases and controls. Multivariate analyses, corrected for multiple testing according to Bonferroni, showed significant protective associations for the T-allele of AGT (OR=0.55 (0.34-0.84)) and for the T-allele of ADD1 (OR=0.52 (0.31-0.82)). ROC analysis showed only a very small improvement of CVD risk prediction by adding the six polymorphisms to a model with traditional risk factors. Our data suggest that a major attribution of the six polymorphisms to the cardiovascular risk prediction in a primary care population such as HIPPOCRATES is unlikely.

Treatment of osteochondral defects of the talus.

This review article provides a current concepts overview of osteochondral defects of the talus, with special emphasis on treatment options, their indications and future developments. Osteochondral defects of the talar dome are mostly caused by a traumatic event. They may lead to deep ankle pain on weight-bearing, prolonged swelling, diminished range of motion and synovitis. Plain radiographs may disclose the lesion. For further diagnostic evaluation, computed tomography (CT) and magnetic resonance imaging (MRI) have demonstrated similar accuracy. Computed tomography is preferred for preoperative planning. Treatment options are diverse and up to the present there is no consensus. Based on the current literature, we present a treatment algorithm that is mainly guided by the size of the lesion. Asymptomatic or low-symptomatic lesions are treated nonoperatively. The primary surgical treatment of defects up to 15 mm in diameter consists of arthroscopic debridement and bone marrow stimulation. For large cystic talar lesions, retrograde drilling combined with a bone graft is an important alternative. In adolescents or in (sub)acute situations, in which the fragment is 15 mm or larger, fixation of the fragment is preferred. Osteochondral autograft transfer and autologous chondrocyte implantation (ACI), with or without a cancellous bone graft, are recommended for secondary cases as well as large lesions.

[Two-thirds of doctors are female, but ever still behind]. / Twee derde van de artsen vrouw, maar nog steeds op achterstand.

At present, two-thirds of the medical students in The Netherlands are women. However, the problems of combining a medical education with the responsibilities of motherhood, and the inaccessibility of medical top positions for women, are as serious as they were ten years ago at the 65th anniversary of the Dutch Association of Medical Women (VNVA). There is a serious need for medical education to become more 'woman-friendly'--and 'man-friendly' for that matter. For healthcare workers, it should be feasible to combine having children with a career. In addition, research into gender-specific health differences should be facilitated. Women, in particular, should take their responsibility in this respect, and be aware of the achievements of their pioneering predecessors. Last but not least: the Dutch Journal of Medicine needs to adapt. It needs to address a new audience, in which the male readers aged 50 and over have been largely replaced by female physicians in their thirties with children.

[The dawn of a smoke-free leisure industry in The Nederlands]. / Aan de vooravond van een rookvrije horeca in Nederland.

From the 1st of July 2008 the Dutch smoking ban for public spaces will be extended to hotels, restaurants and bars. The ban is a result of a 2003 Health Council report in which it was concluded that the annual incidence of deaths due to passive smoking is considerable. Based on these numbers, smoking in public spaces is prohibited since 2004. In a society where smoking in public spaces is prohibited, the harm of passive smoking will decrease. In this issue of The Nederlands Tijdschrit voor Geneeskunde (Dutch Journal of Medicine) a number of articles are dedicated to the subject of smoking.