Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry

Background: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p <.001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01–1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90 ml/min/1.73 m2). Conclusion: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

Background: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients\u2019 clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward\u2019s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients\u2019 prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27\u20133.62; HR 3.42, 95%CI 2.72\u20134.31; HR 2.79, 95%CI 2.32\u20133.35), and Cluster 1 (HR 1.88, 95%CI 1.48\u20132.38; HR 2.50, 95%CI 1.98\u20133.15; HR 2.09, 95%CI 1.74\u20132.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

Empfehlungen zur Sexualtität nach Hüfttotalprothesen-Implantation (Ein Kamasutra für Patienten nach Hüfttotalendoprothese?)

Population is getting older and arthroplasty is getting more common. And the evolution of implants and their better longevity enables arthroplasty to be done for younger patients too. Therefore sexual activity with hip prosthesis is more common. Literature demonstrates a positive effect of total hip arthroplasty for sexual activity. Despite the euphoria due to painfree movement of the joint, the risk of a luxation of prosthesis should not be underestimated. Especially during the first three months after surgery this risk is relatively high. This also makes sexual activity - not only in this time period, a potential risk for hip dislocation. We do recommend written guidelines for patients to be given to them preoperatively. This will allow some privacy

Intra-operative femoral condylar stress during arthroscopy : an in vivo biomechanical assessment

PURPOSE: Excessive varus and valgus stress forces during arthroscopy might exceed minimal compressive strength of cancellous bone. In extreme cases, this could lead to post-arthroscopic osteonecrosis. It was our purpose to measure the valgus and varus stress forces during arthroscopy and draw conclusions on the development of osteonecrosis. METHODS: On 24 consecutive patients undergoing arthroscopy, the maximum varus and valgus stress forces (N) were measured in vivo using a strain gauge mounted to a leg holder. The forces (N) and contact stresses (kPa) on the femoral condyles were calculated based on the measured acting lateral force at the femur fixation based on the lever principle. RESULTS: The maximum contact stress during varus on the medial condyle was significantly lower in patients with intact meniscus (mean ± standard error of the mean: 243 ± 29 kPa) than in patients with meniscus-deficient knees (520 ± 61 kPa; P > 0.01). A similar finding was obtained for the maximum contact stress during valgus on the lateral condyle: 630 ± 72 kPa in patients with intact meniscus compared to 2,173 ± 159 kPa in patients with meniscus-deficient knees (P > 0.01). In 19 patients (79%), the maximum contact stress was higher during valgus than during varus. The maximum contact stress on the lateral condyle during valgus was significantly higher for more experienced surgeons (P = 0.01). CONCLUSION: The maximum contact stresses in knees with intact menisci did not exceed the critical threshold of the compressive strength in cancellous bone. However, the maximum contact stresses in meniscus-deficient knees were frequently higher than the threshold. However, these stresses were much lower than those during daily activities and therefore unlikely to lead to post-arthroscopic osteonecrosis. LEVEL OF EVIDENCE: Diagnostic study, Level II

Keeping an Eye on Iris: Risk and Income Solidarity in OECD Healthcare Systems

In most wealthy democracies as represented by long-term OECD-members, healthcare systems have been established which guarantee access to a broad package of health services. However, healthcare financing involves varying distributive effects and builds on different concepts of solidarity. Healthcare researchers have examined these equity issues in healthcare financing measuring the progressivity of healthcare financing using micro-level data. Most notably, the ECuity-project published progressivity indices in some European countries and the US for the late 1980s and early 1990s. Not least due to the rather complex procedure involved with the evaluation of income and expenditure surveys, such indices have been rarely calculated since. From these studies on redistributive effects, we know that the main modes of financing quite consistently correspond to different levels of progressivity. Moreover, financing modes reflect different concepts of solidarity. Therefore, we suggest an alternative indicator to explore equity issues in healthcare financing using aggregate spending and revenue data. The Index of Risk and Income Solidarity (IRIS) is based on the respective share of distinct modes of financing. We distinguish modes of financing which involve ex-ante redistribution of health risks from those which entail only ex-post redistribution or none at all. Further, we differentiate financing modes which are related to personal or household income from those which involve no income redistribution. We assume an increase of risk solidarity as well as a decline of income solidarity in the OECD-world. First of all, new and costly medical technologies drive the demand for ex-ante redistribution of health risks. At the same time, hopes to increase efficiency of healthcare provision through forms of co-payments have been disappointed. The decline of income solidarity is expected as a result of global competition. In order to reduce labour costs, OECD countries substitute social security contributions by flat-rate premiums or general taxes. In the light of global competition, governments also tend to strengthen indirect taxes since it is far more difficult to shift consumption abroad. Finally, we assume that it is easier to legitimize rising tobacco or alcohol taxes if they are ear-marked for healthcare financing. We examine these assumptions presenting time series of risk and income solidarity based on OECD health data, OECD revenue statistics and national aggregate data on healthcare financing. We cover eleven OECD countries: Australia, Belgium, Canada, Denmark, France, Germany, Japan, the Netherlands, Switzerland, the UK and the US. These countries reflect a broad spectrum of healthcare system types in the OECD-world. The observation period starts at the eve of the first oil crisis in the 1970s and ends at the onset of the Great Recession in 2009.In den meisten OECD-Ländern haben sich Gesundheitssysteme etabliert, die den allgemeinen Zugang zu umfassender medizinischer Versorgung sicherstellen. Die Finanzierung dieser Gesundheitssysteme hat unterschiedliche distributive Effekte zur Folge. Damit verbundene Gerechtigkeitsfragen wurden über die Messung des Progressivitätsgrades der Finanzierungs-instrumente erforscht. Insbesondere das ECuity-Project hat Progressivitätsindizes von einigen europäischen Staaten und den USA für die späten 1980er und die frühen 1990er Jahre veröffentlicht. Aufgrund der aufwändigen Berechnungsweise mit verschiedenen Individualdatensätzen wurden solche Indizes seither selten veröffentlicht. Auf Grundlage dieser Studien ist dokumentiert, dass die Finanzierungsquellen der Gesundheitssysteme mit unterschiedlichen redistributiven Effekten verbunden sind. Wir nutzen diese Informationen, um aus Aggregatdaten einen Indikator zu bilden, der Umverteilungswirkungen in der Finanzierungsdimension des Gesundheitssystems abbildet. Dabei unterscheiden wir auf der einen Seite Finanzierungsformen, die eine Umverteilung des Krankheitsrisikos bedeuten und auf der anderen Seite Finanzierungsformen, die eine Einkommensumverteilung einschließen, indem sie höhere Einkommen zumindest proportional stärker belasten. Aus dem Anteil der so charakterisierten Finanzierungsformen entwickeln wir einen Index der Risiko- und Einkommenssolidarität (IRIS). Ausgehend von einer starken Nachfrage nach Risikoumverteilung, um den Zugang zum Gesundheitssystem bei steigenden Kosten und Bedarfen zu gewährleisten, vermuten wir einen langfristigen Anstieg der Risikosolidarität. Dahingegen könnte die Einkommenssolidarität aufgrund von internationalem Wettbewerb um Investitionskapital schwächer werden. Diese Annahmen werden für 11 OECD-Länder (Australien, Belgien, Dänemark, Deutschland, Frankreich, Japan, die Niederlande, Kanada, die Schweiz, das UK und die USA) und einen Beobachtungszeitraum von 1970 bis 2009 untersucht

Diversity and community structure of rapids-dwelling fishes of the Xingu River: Implications for conservation amid large-scale hydroelectric development

A recent boom in hydroelectric development in the world's most diverse tropical river basins is currently threatening aquatic biodiversity on an unprecedented scale. Among the most controversial of these projects is the Belo Monte Hydroelectric Complex (BMHC) on the Xingu River, the Amazon's largest clear-water tributary. The design of the BMHC creates three distinctly altered segments: a flooded section upstream of the main dam, a middle section between the dam and the main powerhouse that will be dewatered, and a downstream section subject to flow alteration from powerhouse discharge. This region of the Xingu is notable for an extensive series of rapids known as the Volta Grande that hosts exceptional levels of endemic aquatic biodiversity; yet, patterns of temporal and spatial variation in community composition within this highly threatened habitat are not well documented. We surveyed fish assemblages within rapids in the three segments impacted by the BMHC prior to hydrologic alteration, and tested for differences in assemblage structure between segments and seasons. Fish species richness varied only slightly between segments, but there were significant differences in assemblage structure between segments and seasons. Most of the species thought to be highly dependent on rapids habitat, including several species listed as threatened in Brazil, were either restricted to or much more abundant within the upstream and middle segments. Our analysis identified the middle section of the Volta Grande as critically important for the conservation of this diverse, endemic fish fauna. Additional research is urgently needed to determine dam operations that may optimize energy production with an environmental flow regime that conserves the river's unique habitat and biodiversity. © 2018 Elsevier Lt