Complications following implant removal in patients with proximal femur fractures - an observational study over 16 years.

BACKGROUND: Fractures of the proximal femur commonly occur but the majority of orthopaedic surgeons do not consider general hardware removal as a routine necessity. Indications and time interval for hardware removal in this special selected patient group is still controversial. Therefore we performed a retrospective study to address the following questions: 1) Is there a difference between the medically- (infection, mechanical problems, implant failure) and non-medically indicated group (patients demand, meteoro-sensitivity, foreign body sensation) in relation to complications? 2) Is there a correlation regarding time interval between implantation and removal comparing these two groups? 3) Is there a context related refracture rate? 4) Should non-medically indicated implant removal (IR) be performed due to persistent pressure from the patient? HYPOTHESIS: We hypothesized that non-medically indicated implant removals should be avoided due to a significantly higher number of associated complications. PATIENTS AND METHODS: A total of 371 consecutive patients with 424 hardware removal procedures following a proximal femur fracture, between 08/1992 and 11/2008, have been included. Study population was divided into two groups according to their indication for implant removal: medically indicated group (MIR) consisted of 299 patients (80.59%) and 72 patients (19.41%) were assigned to the non-medically indicated (NMIR) group. RESULTS: In the NMIR subgroup a total of (n = 21) 28% complications occurred compared to 11.46% in the MIR subgroup; (P < 0.005), 86.51% of IR in the MIR group were performed within 1.5 years, compared to 79.17% in the NMIR group after 2 to 3.5 years (NS). In the MIR group 1 refracture occurred, compared to 4 in the NMIR group (NS). CONCLUSION: Non-medically indicated implant removal should be avoided due to the higher complication rate of 28%. Surgeons and patients should be aware of the imminent complications and therefore implant removal should only be performed for good medical reasons. LEVEL OF EVIDENCE: Level IV. Historical case study.

Monitoring the efficacy of ADP inhibitor treatment in patients with acute STEMI post-PCI by VASP-P flow cytometry assay.

INTRODUCTION: Dual antiplatelet treatment (DAPT) with clopidogrel and aspirin represents common approach in prevention of thromboembolic events in patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI). The drawback of clopidogrel treatment is large interindividual variability in response. AIM: Our article aims to suggesting the most convenient method in monitoring the DAPT of post-PCI patients. METHODS: We analyzed the on-treatment platelet reactivity by light transmission aggregometry and vasodilator-stimulated phosphoprotein (VASP) flow cytometric assay. Samples were obtained in 3 intervals: first prior to PCI, then 1, and 30 days after PCI. RESULTS: Based on VASP-platelet reactivity index (PRI), we observed 100% response rate in prasugrel-treated patients and 62% to 73 % in the clopidogrel group. Overall, only 2 (7%) patients with the VASP-PRI value in therapeutic range had major adverse cardiovascular events. CONCLUSION: Our results hint VASP-phosphorylation assay as a relevant method for guiding and tailoring DAPT.

The detection of early myocardial changes in asymptomatic diabetic individuals by 99mTc - Myoview gated-SPET and heart rate variability measurement.

AIMS: Incidence of early myocardial changes in asymptomatic diabetic individuals is not clearly documented. In the present study, we examined diabetic patients without a history of cardiovascular disease with negative treadmill test and no signs of systolic dysfunction for presence of cardiac autonomic neuropathy established by measurement of heart rate variability (HRV) and (99m)Tc - Myoview gated-SPET. MATERIALS AND METHODS: 47 type I and type II diabetic patients were subjected to prospective study including echocardiography and HRV measurement using the combination of Ewing´s testing and spectral analysis. Subsequently, patients underwent treadmill test and stress myocardial perfusion scintigraphy. Additionally, vascular and metabolic parameters were collected. RESULTS: Treadmill test was negative in all patients. Diastolic dysfunction was found in 10 % of T1DM and 11 % of T2DM patients by echocardiography, whereas none of the patients had systolic dysfunction. SPET confirmed hypoperfusion in 35 % T1DM (p=0.01) and in 60 % T2DM (p=0.001). Diagnosis of cardiac autonomic neuropathy based on Ewing´s testing and HRV examination was established in 60 % of T1DM patients (p=0.001) and 77 % of T2DM patients (p=0.001). In T1DM group, significant association was found between cardiac autonomic neuropathy (CAN) and frequency of hypoglycaemia (p=0.04). No such correlations were found in patients with T2DM. CONCLUSION: The results of the present study show high incidence of myocardial hypoperfusion and cardiac autonomic neuropathy among asymptomatic diabetic patients, whereas the standard diagnostic approaches including treadmill test and echocardiography failed to show any changes. Therefore, we conclude that diabetic heart disease remains underdiagnosed by standard approaches, but could be detected in asymptomatic patients by more sensitive methods, such as HRV measurement and myocardial scintigraphy (Tab. 2, Fig. 2, Ref. 26).

[The arrhytmias in patients with diabetes mellitus]. / Poruchy srdcového rytmu u pacientov s diabetes mellitus.

Cardiovascular disorders are the most common reason of morbidity and mortality worldwide. The prevalence of diabetes mellitus, which is strongly associated with cardiac and cerebrovascular events, is increasing during the last decades. Based on the results of clinical studies we summarize in the review article the risk factors and patomechanisms connecting diabetes mellitus to incidence of arrhythmias and sudden cardiac death. The paper analyzes influence of diabetes mellitus on atrial fibrillation and arrhythmogenic effect of antidiabetic drugs.

[Syncope as first and only sign of left atrial myxoma]. / Synkopa ako prvý a jediný príznak myxómu lavej predsiene.

Myxoma is the most frequent primary heart tumor. It is localised in the left atrium in majority of cases, but each of heart chambers may be affected. Left atrial myxoma becomes symptomatic in case it leads into mitral valve obstruction, systemic embolisation or it manifests with unspecific systemic symptoms. Echocardiography is a golden standard of myxoma diagnostics. We present a case of 61-years old woman patient in whom exercise induced syncope was the first and only sign of far gone left atrial myxoma with left ventricle inflow tract obstruction, leading to mitral pseudostenosis.

Prevalence of metabolic syndrome, insulin resistance, and microvascular angina pectoris in 500 consecutive patients referred to coronarography.

OBJECTIVE: This work was aimed to evaluate the prevalence of insulin resistance (IR) and metabolic syndrome in a large cohort of 40-60 years old patients with cardiovascular symptoms. METHODS: A total of 500 consecutive males and females referred to coronarography and coronary catheterization, because of spontaneous or after load precordial pain plus denivelisation of ST segment by electrocardiography, were included. Besides standard clinical examinations, ergometry, echocardiography, fundamental laboratory tests, and several other laboratory examinations were also performed, including oral glucose toleration test (OGTT), total and high-density lipoprotein (HDL) cholesterol, triglycerides, apoprotein A1 and B, apolipoprotein (a), uric acid, fibrinogen, plasminogen activator inhibitor-1 (PAI-1), cytokines (tumor necrosis factor α, TNFα, interleukin-1, IL-1, interleukin-6, IL-6), endothelin-1, as well as hormones (insulin, C peptide, leptin, growth hormone, cortisol). RESULTS: In 81.6% of patients, IR syndrome with compensatory hyperinsulinemia was found in a positive correlation with various symptoms of metabolic syndrome, including abdominal obesity, increased body mass index (BMI), dysglycemia, dyslipoproteinemia, coronary stenosis, decreased HDL level, and hypertension. Hirsutism with polycystic ovarian syndrome was found in 52% of examined women with IR. However, a normal coronary angiogram, called as a microvascular form of the angina pectoris (MIV-AP), was found in 14% of predominantly periclimacteric and benign hirsutic females with long-term disorders of menstrual cycle. Since these patients showed the same symptoms as their gender, age, BMI, and degree of coronary stenoses adjusted pairs with the macrovascular form (such as the same levels of several lipids, hormones and obesity measures), our data strongly support the view that MIV-AP might belong to the IR syndrome. CONCLUSIONS: Hyperinsulinemia and high prevalence of various symptoms of metabolic syndrome (MS) were found in high percentage of patients with after load precordial pain who were referred to coronarography. Similarly, in several women, MIV-AP was detected and its affiliation to MS suggested.

[Dehydrdoepiandrosterone, dehydroepiandrosteron-sulfate and insulin in acute myocardial infarct]. / Dehydroepiandrosterón, dehydroepiandrosterón-sulfát a inzulín u akútneho infarktu myokardu.

The authors discuss the relationship between dehydroepiandsoterone, its sulphate conjugate and insulin and ischaemic heart disease in patients with acute myocardial infarction. In the examined group of patients they found lower values of dehydroepiandosterone and its sulphate in men, lower values of dehydroepiandosterone in women as compared with mean values with regard to age and a close inverse correlation of insulin and dehydroepiandrosterone and insulin and dehydroepiandrosterone sulphate. Whether dehydroepiandosterone is the "missing link" of hyperinsulinaemia and arterosclerosis is so far only a theoretical issue.

[Insulin resistance and the coronary syndrome]. / Inzulínová rezistencia a koronárny syndróm.

The different diseases associated with the insulin resistance syndrome--diabetes mellitus or impaired carbohydrate tolerance, atherogenic lipoprotein phenotype, arterial hypertension and central type of obesity are the main risk factors of atherosclerosis. The reduced sensitivity of target tissues to the metabolic action of insulin (insulin resistance) is considered at present a separate risk factor. The authors analyze on the basis of a group of 210 coronarographic patients the influence of insulin resistance and associated etiopathogenetic risk factors on coronary lesions evaluated by the method of quantitative coronarography. From the results of the investigation ensues that insulin resistance is the most frequent metabolic deviation in patients with coronary disease whereby in the macrovascular group it was found in 74.3% and in the group with microvascular angina pectoris in 64.3% of the patients. Changes in the lipoprotein spectrum were a more frequent and earlier manifestation of insulin resistance than impaired carbohydrate metabolism. The change from functional changes of the vascular wall (impaired endothelium-dependent vasodilatation) to the development of an atheromatous plaque depends on the total number of cholesterol conveying lipoproteins assessed by means of the apoprotein B level and on the capacity of the reverse cholesterol transport, whereby both mechanisms are greatly influenced by insulin sensitivity. The degree of coronary affection evaluated by means of a coronary score, is in patients with manifest diabetes comparable with the affection in patients with insulin resistance without manifest diabetes and these two groups differ very significantly as to the extent and degree of affection from patients with a normal sensitivity to the effect of insulin.

[Percutaneous transluminal coronary angioplasty in the treatment of acute myocardial infarct]. / Perkutánní transluminální koronární angioplastika v lécbe akutního infarktu myokardu.

A patient with acute myocardial infarction can undergo at present one of the following reperfusion therapies: 1. Primary PTCA (as an alternative to thrombolytic treatment), 2. Emergency PTCA (when thrombolysis fails), 3. Elective PTCA (in spontaneous or post-exercise myocardial ischaemia). 4. Empirical PTCA (as prophylaxis of recurrent myocardial ischaemia). The authors submit their initial experience with the use of PTCA in the treatment of acute myocardial infarction. In a group of eight patients (5 men and 3 women), age 33-72 years (mean 51 years) where primary PTCA (5 patients) and emergency PTCA (3 patients) was used.

[Dispersion of the Q-T interval after myocardial infarct]. / Disperzia intervalov Q-T po infarkte myokardu.

Non-homogenity of ventricular myocardial repolarization is a substrate for the reentry mechanism of ventricular arrhythmias. It is manifestant by dispersion of Q-T and Q-Tc intervals on the standard ECG curve. The authors studied the possibility of using the dispersity of Q-T and Q-Tc intervals in clinical practice. They evaluated the dispersion of these intervals within the set of 21 patients after myocardial infarction with sustained ventricular tachycardia, and compared it with the dispersion within the control set of 17 patients after myocardial infarction without an arrhythmic episode. By means of comparison, they have discovered that: 1) the dispersion of Q-T and Q-Tc intervals is significantly higher in patients with ventricular tachycardia: Q-T (mean +/- SE) 82.8 +/- 7.8 msec vs 42.2 +/- 4.8 msec, Q-Tc 93.0 +/- 10.2 msec vs 47.1 +/- 4.8 msec, p > 0.001, 2) the dispersion of Q-Tc when higher than 60 msec is an optimum discrimination value for the prognosis of sudden arrhythmic death after myocardial infarction (sensitivity 81%, specificity 76%) and 3) the dispersion of Q-T and Q-Tc intervals has no relation to the function of the left ventricle. Therefore the authors consider the dispersion of Q-T and Q-Tc intervals as being a useful marker of malignant ventricular arrhythmia which could be included into the algorithm of assessment of the risk of sudden arrhythmic death after myocardial infarction.

[Diagnosis of acute dissection of the aorta]. / Diagnostika akutní disekce aorty.

The authors present a group of 14 patients (9 men and 5 women) aged 38-76 years (mean age 59 years) who were hospitalized during the five-year period between 1984 and 1988 at the medical department A of the Regional Institute of National Health in Banská Bystrica on account of acute dissection of the aorta. The authors describe clinical manifestations which can lead to suspicion of this serious disease. They make the readers familiar with their experience with ultrasonic and X-ray examination (in particular aortography and computed tomography). They analyze their contribution to the diagnosis of acute dissection of the aorta.