No influence of immigrant background on the outcome of total hip arthroplasty. 140,299 patients born in Sweden and 11,539 immigrants in the Swedish Hip Arthroplasty Register.

BACKGROUND AND PURPOSE: Total Hip Replacement (THA) is one of the most successful and cost-effective operations. Despite its benefits, marked ethnic differences in the utilization of THA are well documented. However, very little has been published on the influence of ethnicity on outcome. We investigate whether the outcome-in terms of reoperation within 2 years or revision up to 14 years after the primary operation-varies depending on ethnic background. METHODS: Records of total hip arthroplasties performed between 1992 and 2007 were retrieved from the Swedish Hip Arthropalsty Registry and integrated with data on ethnicity of patients from 2 demographical databases (i.e. Patient Register and Statistics Sweden). The first operated side in patients with THA recorded in the Swedish Hip Arthroplasty Register (SHAR) between 1992 and 2007 were generally included. We excluded patients with 1 Swedish and 1 non-Swedish parent and patients born abroad with 2 Swedish parents. After these exclusions 151,838 patients were left for analysis. There were 11,539 Swedish patients born outside Sweden. We used a Cox regression model including age, sex, diagnosis, type of fixation, whether or not there was comorbidity according to Elixhauser or not, marital status and educational level. RESULTS: The mean age was lowest in the group of patient coming from outside Europe including the former Soviet Union (61 years), and highest in the Swedish population (70 years). Before adjustment, for covariates, patients born in Europe outside the Nordic countries showed a lower risk to undergo early reoperation (HR = 0.73, 95% CI: 0.56-0.97), which increased after adjustment to (HR = 0.76, 95% CI: 0.58-1.01). Before adjustment, patients born in the Nordic countries outside Sweden and those born outside Europe (including the former Soviet Union) showed a higher risk to undergo revision than patients born in Sweden (HR = 1.14, 95% CI: 1.02-1.27; HR = 1.49, 95% CI: 1.2-1.9), but this difference disappeared after adjustment for covariates. CONCLUSION: We did not find any certain differences in reoperation within 2 years, or revision within 14 years, between patients born in Sweden and immigrants. Further studies are needed to determine whether our observations are biased by the attitude of health providers regarding performance of these procedures, or by a reluctance of certain patient groups to seek medical attention should any complications requiring reoperation or revision occur.

Fatality, morbidity and quality of life in patients with refractory angina pectoris.

BACKGROUND: Refractory angina pectoris has been defined as coronary artery disease and severe angina, not available for further conventional pharmacological treatment or for revascularization procedures. The aim of the study was to assess fatality, morbidity and quality of life in patients with refractory angina. METHODS: Patients with refractory angina were prospectively identified at seven centres and were compared with an age and gender matched group of patients accepted for revascularization due to severe angina. RESULTS: Over three years, 139 patients with refractory angina were identified. The refractory group had more pronounced cardiac disease in terms of more previous myocardial infarctions (p < 0.05), more previous revascularization procedures (p < 0.0001), more severely impaired left ventricular ejection fraction (p < 0.001) as well as higher prevalence of renal dysfunction (p < 0.001) and insulin treated diabetes (p < 0.01) compared to the controls. The refractory patients had a higher one year fatality rate than the control group (10% vs. 0.7%; p < 0.001). Compared to the controls, the refractory group had significantly more impaired quality of life according to the Short Form 36 and the Seattle Angina Questionnaire with regard to physical function, physical well-being and impact of angina symptoms, but there were no differences with regard to mental health and emotional function. CONCLUSIONS: Patients with refractory angina pectoris have severe angina symptoms, a more pronounced cardiac disease, a higher fatality rate and a markedly impaired quality of life compared with patients who undergo revascularization procedures due to symptomatic coronary artery disease. Additional symptomatic treatment modalities are highly warranted for this patient group.

White matter disease in magnetic resonance imaging predicts cerebral complications after coronary artery bypass grafting.

BACKGROUND: The aim of the present study was to assess neurologic and neuropsychologic complications in 104 patients randomized to coronary artery bypass grafting or spinal cord stimulation. An additional objective of the study was to assess whether preoperative white matter disease might predict cerebral complications, as previous studies have shown that there is a relationship between white matter disease and neuropsychologic decline after coronary artery bypass grafting. METHODS: The patients were subjected to neurologic examination before and six months after intervention. The patients underwent a cerebral magnetic resonance imaging before intervention and the presence of white matter disease was related to development of cerebral complications. RESULTS: More patients in the bypass group than in the spinal cord stimulation group developed focal cerebral ischemia (p < 0.05) and astheno-emotional disorder (p < 0.001). More patients with white matter disease undergoing bypass were affected by focal cerebral ischemia (p < 0.01) and astheno-emotional disorder (p < 0.001) after the intervention compared to patients with white matter disease undergoing spinal cord stimulation. In patients with no white matter disease there were no differences between the bypass group and spinal cord stimulation group with regard to cerebral complications. CONCLUSIONS: Patients undergoing bypass had more neurologic and neuropsychologic complications than patients undergoing spinal cord stimulation. Furthermore, patients with white matter disease were affected by cerebral complications in a higher extent after bypass than after spinal cord stimulation. Thus, preoperative assessment of white matter disease before undergoing coronary artery bypass grafting might predict the patient's risk of developing cerebral injury.

Feasibility of spinal cord stimulation in angina pectoris in patients with chronic pacemaker treatment for cardiac arrhythmias.

Spinal cord stimulation (SCS) has been used since 1985 as additional symptom-relieving treatment for patients with severe angina pectoris despite optimal conventional medical and invasive treatment. SCS has antiischemic effects and is safe and effective in long-term use. Several patients with coronary artery disease also suffer from disorders that necessitate the use of a cardiac permanent pacemaker (PPM). The combination of SCS and PPM has previously been considered hazardous because of possible false inhibition of the PPM. To assess if thoracic SCS and PPM can be safely combined in patients with refractory angina pectoris, 18 patients treated with both SCS and PPM were tested. The PPM settings were temporarily modified to increase the probability of interference, while the SCS intensity (used in bipolar mode) was increased to the maximum level tolerated by the patient. Any sign of inhibition of the ventricular pacing was recorded by continuous ECG monitoring. With the aid of a questionnaire, symptoms of interference during long-term treatment were evaluated. No patient had signs of inhibition during the tests. Reprogramming of the pacemaker because of the test results was not needed in any of the patients. The long-term follow-up data revealed no serious events. This study indicates that bipolar SCS and PPM can be safely combined in patients with refractory angina pectoris. However, individual testing is mandatory to ascertain safety in each patient. A testing procedure for patients in need of SCS and PPM is suggested in this article.

Temporary cessation of spinal cord stimulation in angina pectoris-effects on symptoms and evaluation of long-term effect determinants.

BACKGROUND: Spinal cord stimulation (SCS) has been used since 1985 for patients with refractory angina pectoris. Spinal cord stimulation has anti-ischaemic effects and reduces angina effectively. After long-term treatment, temporary cessation of stimulation may occur due to SCS battery depletion or electrode fracture. The aim of the present study was to assess anginal symptoms and functional status during SCS dysfunction and after its restitution. DESIGN: A prospective follow-up study of angina patients treated with SCS, where temporary SCS dysfunction had occurred. METHODS: Thirty-two patients treated with SCS for angina pectoris over 65 months, on average (range 14-181 months), were included. Complete stimulator dysfunction had occurred due to battery depletion (n=25) or electrode fracture (n=7). The number of anginal attacks and the amount of short-acting nitrates consumed were assessed during dysfunction and after restitution of SCS function. The Seattle Angina Questionnaire (SAQ) was used to assess functional status. RESULTS: The anginal frequency increased during dysfunction (18.9 per week) and decreased after restitution of SCS function (7.6 episodes per week; p<0.001). The consumption of short-acting nitrates decreased as well (21.7 versus 7.1 tablets per week; p<0.01). The functional status according to the SAQ also improved with regard to anginal stability, anginal frequency, and disease perception. No evidence of tolerance development to SCS was found. CONCLUSION: This study indicates that SCS relieves angina effectively also after long-term treatment, without development of tolerance. The findings suggest that mechanisms other than placebo and spontaneous variation of symptoms are responsible for the improvement in angina during SCS.

Pain as presenting symptom in Lyme neuroborreliosis.

Neurogenic pain with radiculitis is often the starting symptom in adult patients with tick-borne Lyme neuroborreliosis and in some cases the only clinical manifestation. Cranial paresis and other neurologic signs usually occur after the onset of pain. The present paper describes four patients who had severe pain as the main presenting symptom of Lyme neuroborreliosis. Opioids had good short-term effect in two of the cases. Oral doxycycline treatment was used successfully to eliminate the infection.