Atraumatic Fractures of the Humerus Associated With Throwing Whilst Playing Dodgeball: A Case Series and Review of the Literature

Introduction: Five patients presented to the emergency department of a tertiary referral teaching hospital with atraumatic fractures of their humerus sustained during a recreational dodgeball tournament. Case Presentation: The patients were young healthy individuals that described the fracture occurring during the act of throwing. Conclusions: The causes leading to fracture of the humerus during the act of a throw are discussed and the management strategies utilized

Left Atrial Appendage Closure: Initial Experience with the Watchman Device

We herein present the first left atrial appendage (LAA) percutaneous closure procedure performed in our Institution with use of the Watchman device in an 82-year old woman with atrial fibrillation, unable to continue receiving anticoagulation therapy due to bleeding complications. A propos with this case, we discuss the data related to this therapeutic approach geared to prevent thromboembolism in patients with atrial fibrillation and contraindications to treatment with anticoagulants

Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement

BackgroundImpingement is a common cause of shoulder pain. Impingement mechanisms may occur subacromially (under the coraco-acromial arch) or internally (within the shoulder joint), and a number of secondary pathologies may be associated. These include subacromial-subdeltoid bursitis (inflammation of the subacromial portion of the bursa, the subdeltoid portion, or both), tendinopathy or tears affecting the rotator cuff or the long head of biceps tendon, and glenoid labral damage. Accurate diagnosis based on physical tests would facilitate early optimisation of the clinical management approach. Most people with shoulder pain are diagnosed and managed in the primary care setting.ObjectivesTo evaluate the diagnostic accuracy of physical tests for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders.Search methodsWe searched electronic databases for primary studies in two stages. in the first stage, we searched MEDLINE, EMBASE, CINAHL, AMED and DARE (all from inception to November 2005). in the second stage, we searched MEDLINE, EMBASE and AMED(2005 to 15 February 2010). Searches were delimited to articles written in English.Selection criteriaWe considered for inclusion diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test in any clinical setting. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials.Data collection and analysisTwo pairs of review authors independently performed study selection, assessed the study quality using QUADAS, and extracted data onto a purpose-designed form, noting patient characteristics (including care setting), study design, index tests and reference standard, and the diagnostic 2 x 2 table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for the index tests. Meta-analysis was not performed.Main resultsWe included 33 studies involving 4002 shoulders in 3852 patients. Although 28 studies were prospective, study quality was still generally poor. Mainly reflecting the use of surgery as a reference test in most studies, all but two studies were judged as not meeting the criteria for having a representative spectrum of patients. However, even these two studies only partly recruited from primary care.The target conditions assessed in the 33 studies were grouped under five main categories: subacromial or internal impingement, rotator cuff tendinopathy or tears, long head of biceps tendinopathy or tears, glenoid labral lesions and multiple undifferentiated target conditions. the majority of studies used arthroscopic surgery as the reference standard. Eight studies utilised reference standards which were potentially applicable to primary care (local anaesthesia, one study; ultrasound, three studies) or the hospital outpatient setting (magnetic resonance imaging, four studies). One study used a variety of reference standards, some applicable to primary care or the hospital outpatient setting. in two of these studies the reference standard used was acceptable for identifying the target condition, but in six it was only partially so. the studies evaluated numerous standard, modified, or combination index tests and 14 novel index tests. There were 170 target condition/index test combinations, but only six instances of any index test being performed and interpreted similarly in two studies. Only two studies of a modified empty can test for full thickness tear of the rotator cuff, and two studies of a modified anterior slide test for type II superior labrum anterior to posterior (SLAP) lesions, were clinically homogenous. Due to the limited number of studies, meta-analyses were considered inappropriate. Sensitivity and specificity estimates from each study are presented on forest plots for the 170 target condition/index test combinations grouped according to target condition.Authors' conclusionsThere is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. the large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.University of Teesside, Middlesbrough, UKDepartment of Health, UKUniv Teesside, Hlth & Social Care Inst, Middlesbrough TS1 3BA, Tees Valley, EnglandUniversidade Federal de São Paulo, Dept Orthopaed & Traumatol, São Paulo, BrazilUniv Birmingham, Birmingham, W Midlands, EnglandUniversidade Federal de São Paulo, Dept Orthopaed & Traumatol, São Paulo, BrazilWeb of Scienc

Investigation of the use of dual antiplatelet therapy in coronary artery patients undergoing angioplasty, patient compliance and complications

Cardiovascular diseases are the first cause of death in western societies and are now the biggest problem for public health and also the leading cause of death in the European Union, with over 2 million deaths per year. Men prevail over the incidence of cardiovascular disease up to about 70 years of age.Different risk levels of ACS patients create difficulties in treating them evenly. Thus, therapeutic interventions in the individual patient should be guided by the so-called ischemic risk of this patient. A second risk that should be considered in these patients is the hemorrhagic risk due to the frequent use of intense antithrombotic therapy. Purpose: The aim of the study was to study the ischemic prognostic scores GRACE and CHA2DS2-VASc, as well as the HAS-BLED and CRUSADE hemorrhagic prognostic scores in patients underwent angioplasty to highlight which is best predicting the ischemic and hemorrhagic Risk.The compliance with the use of dual antiplatelet therapy and the occurrence of complications, was also studied.Results: The patients who participated in the study were a total of 667 with an average age of 61 ± 11 years and were followed-up for a period of 2 years. The GRACE score and its predicted incidence at 3 years, was compared to the CHA2DS2-VASc score, which predicts the annual probability of ischemic. This is the first time that the two scores are compared in a group of patients with coronary artery disease. In the limited study population (n = 667), the CHA2DS2-VASc score was able to show a marginally better prognosis of future ischemic events, with an area under the curve (AUC) of 0.624 vs 0.608 of the GRACE score. On the contrary, the predictive capacity of the haemorrhagic scores was not able to be shown in this sample of patients due to the limited number of the sample but also to the limited number of the occured bleedings (CRUCADE vs. HAS-BLED: AUC = 0.526 for both). Patient compliance for DAPT for at least one year was 79%, with the main cause of cessation being the financial crisis and bleeding. Regarding the correlation of the occurrence of the various complications with the educational level of the patients, there appeared to be a slight tendency for more hemorrhages in the patients who had higher education than in the secondary ones (10% vs. 5.2%, p = 0.102) . The first population group had a tendency for more frequent MACCE (12% vs. 6.9%, p = 0.128). Conclusions: In the specific population of this study, the CHA2DS2-VASc score was able to show a marginally higher predictive value in the emergence of future ischemic (MACCE) than the GRACE score (the predicted incidence in 3 years), in patients with angioplasty. In contrast, the hemorrhagic risk scores CRUSADE and HAS-BLED, failed to predict the observed bleeding due to a small number of these. Finally, the financial crisis played an important role in halting dual antiplatelet education before the year.Τα καρδιαγγειακά νοσήματα είναι η πρώτη αιτία θανάτου, στις δυτικές κοινωνίες και αποτελούν πλέον το μεγαλύτερο πρόβλημα για την δημόσια υγεία. Ο καρδιαγγειακός θάνατος ανέρχεται σε περισσότερους από 2.000.000 ετησίως στην Ευρωπαϊκή ένωση. Οι άνδρες υπερτερούν στη συχνότητα εμφάνισης της καρδιαγγειακής νόσου μέχρι περίπου την ηλικία των 70 ετών. Τα διαφορετικά επίπεδα κινδύνου των ασθε¬νών με ΟΣΣ δημιουργούν δυσκολίες στην ομοιόμορφη θεραπευτική τους αντιμετώπιση. Έτσι, οι θεραπευτικές παρεμβάσεις στον εκάστοτε ασθε¬νή θα πρέπει να καθοδηγούνται με βάση τον λεγό-μενο ισχαιμικό κίνδυνο του ασθενούς αυτού, δηλα¬δή τον κίνδυνο που διατρέχει να εμφανίσει ανε¬πιθύμητα καρδιαγγειακά συμβάματα (θάνατο, ΕΜ, επανέμφραγμα). Ταυτόχρονα, θα πρέπει να συνεκτιμάται στους ασθενείς αυτούς είναι και ο αιμορραγικός κίνδυνος, λόγω της συχνά χορηγούμενης έντονης αντιθρομβωτικής αγωγής. Σκοπός: Ο σκοπός της εργασίας ήταν να μελετηθούν τα ισχαιμικά προγνωστικά scores GRACE και CHA2DS2-VASc, καθώς και τα αιμορραγικά προγνωστικά scores HAS-BLED και CRUSADE, σε ασθενείς οι οποίοι υποβλήθησαν σε αγγειοπλαστική, για την ανάδειξη αυτού που καλύτερα προβλέπει τον ισχαιμικό και αιμορραγικό κίνδυνο, και την συμμόρφωση τους στην χρήση της διπλής αντιαιμοπεταλειακής αγωγής και της εμφάνισης επιπλοκών. Αποτελέσματα: Οι ασθενείς που έλαβαν μέρος στην μελέτη ήταν συνολικά 667 με μέση ηλικία 61±11ετών και μελετήθησαν παρακολουθήθηκαν για χρονικό διαστημα 2 ετών. Έγινε σύγκριση του GRACE score στην προβλεπόμενη επίπτωση του στην 3ετία και του CHA2DS2-VASc score, το οποίο προβλέπει την ετήσια πιθανότητα εμφάνισης ισχαιμικού. Είναι η πρώτη φορά που γίνεται η σύγκριση των δύο scores σε ομάδα ασθενών με στεφανιαία νόσο. Στον συγκεκριμένο περιορισμένο πληθυσμό της μελέτης (n=667), το CHA2DS2-VASc score κατάφερε να δείξει οριακά καλύτερη ικανότητα πρόβλεψης των μελλοντικών ισχαιμικών, με Area Under the Curve (AUC) 0,624 vs 0,608 του GRACE score. Αντίθετα η προβλεπτική ικανότητα των αιμορραγικών scores δεν μπόρεσε να αναδειχθεί στο δείγμα των ασθενών, λόγω του αριθμού του δείγματος, αλλά και του περιορισμένου αριθμού των αιμορραγιών που συνέβησαν (CRUCADE vs HAS-BLED: AUC= 0,526 και για τα δύο). Η συμμόρφωση των ασθενών στην DAPT για τουλάχιστον ένα έτος ήταν 79%, με κύρια αιτία διακοπής την οικονομική κρίση και τις αιμορραγίες. Όσον αφορά στην συσχέτιση της εμφάνισης των διαφόρων επιπλοκών με το μορφωτικό επίπεδο των ασθενών, φάνηκε πως υπήρξε μία μικρή τάση για περισσότερες αιμορραγίες στους ασθενείς που είχαν τριτοβάθμια εκπαίδευση σε σχέση με αυτούς της δευτεροβάθμιας (10% vs 5,2%, p=0,102). Η πρώτη πληθυσμιακή ομάδα είχε και μία τάση για συχνότερη εμφάνιση MACCE (12% vs 6,9%, p=0,128).Συμπεράσματα: Στον συγκεκριμένο πληθυσμό της εργασίας, το CHA2DS2-VASc score κατάφερε να εμφανίσει οριακά μεγαλύτερη προβλεπτική αξία στην ανάδειξη των μελλοντικών ισχαιμικών (MACCE), σε σχέση με το GRACE score (την προβλεπόμενη επίπτωση του στην 3ετία) (σε ασθενείς με αγγειοπλαστική). Αντίθετα, τα αιμορραγικά scores κινδύνου CRUSADE και HAS-BLED, δεν κατάφεραν να προβλέψουν τις παρατηρηθείσες αιμορραγίες, λόγω του μικρού αριθμού αυτών. Τέλος, η οικονομική κρίση, διαδραμάτισε σημαντικό ρόλο στην διακοπή της διπλής ανιτιαιμοπεταλειακής αγωγής προ του έτους

Aortic valve: anatomy and structure and the role of vasculature in the degenerative process

Aortic valve stenosis is a degenerative disease affecting increasing number of individuals and characterised by thickening, calcification and fibrosis of the valve resulting in restricted valve motion. Degeneration of the aortic valve is no longer considered a passive deposition of calcium, but an active process that involves certain mechanisms, that is endothelial dysfunction, inflammation, increased oxidative stress, calcification, bone formation, lipid deposition, extracellular matrix (ECM) remodelling and neoangiogenesis. Accumulating evidence indicates an important role for neoangiogenesis (i.e. formation of new vessels) in the pathogenesis of aortic valve stenosis. The normal aortic valve is generally an avascular tissue supplied with oxygen and nutrients via diffusion from the circulating blood. In contrast, presence of intrinsic micro-vasculature has been demonstrated in stenotic and calcified valves. Importantly, presence and density of neovessels have been associated with inflammation, calcification and bone formation. It remains unclear whether neoangiogenesis is a compensatory mechanism aiming to counteract hypoxia and increased metabolic demands of the thickened tissue or represents an active contributor to disease progression. Data extracted mainly from animal studies are supportive of a direct detrimental effect of neoangiogenesis, however, robust evidence from human studies is lacking. Thus, there is inadequate knowledge to assess whether neoangiogenesis could serve as a future therapeutic target for a disease that no effective medical therapy exists. In this review, we present basic aspects of anatomy and structure of the normal and stenotic aortic valve and we focus on the role of valve vasculature in the natural course of valve calcification and stenosis. © 2020 Belgian Society of Cardiology