Dilated cardiomyopathy and chronic cardiac inflammation: Pathogenesis, diagnosis and therapy.

Dilated cardiomyopathy (DCM) is typically defined by left ventricular dilation and systolic dysfunction in the absence of a clear precipitant. Idiopathic disease is common; up to 50% of patients with DCM have no cause found despite imaging, genetic and biopsy assessments. Treatment remains focused on managing symptoms, reducing the risk of sudden cardiac death and ameliorating the structural and electrical complications of disease progression. In the absence of aetiology-specific treatments, the condition remains associated with a poor prognosis; mortality is approximately 40% at 10 years. The role of immune-mediated inflammatory injury in the development and progression of DCM was first proposed over 30 years ago. Despite the subsequent failures of three large clinical trials of immunosuppressive treatment (ATTACH, RENEWAL and the Myocarditis Treatment Trial), evidence for an abnormal adaptive immune response in DCM remains significant. In this review, we summarise and discuss available evidence supporting immune dysfunction in DCM, with a specific focus on cellular immunity. We also highlight current clinical and experimental treatments. We propose that the success of future immunosuppressive treatment trials in DCM will be dependent on the deep immunophenotyping of patients, to identify those with active inflammation and/or an abnormal immune response who are most likely to respond to therapy.

Cardiac MRI in cardiomyopathies.

Heart failure affects 1-2% of the adult population and one of the main contributors to its development is cardiomyopathy. Assessing a patient's risk for adverse events in heart failure is challenging and made more difficult by the heterogenous phenotypic expression of the disease. Cardiac MRI has long been a gold standard measure of myocardial function and anatomy due to its high spatial and temporal resolution. More recently, it has been posited to play a more critical role in the diagnosis and prognosis of cardiomyopathy-related heart failure. Given the limitations of more commonly used imaging modalities, increasing the clinical use of cardiac magnetic resonance imaging could potentially improve the prognosis of specific subgroups of patients at risk of adverse cardiac events.

Lay abstract Heart failure is a condition where the heart is unable to pump out enough blood to meet the body's daily needs. It can affect up to 2% of the adult population. One of the causes of heart failure is an intrinsic disease of the heart muscle, called cardiomyopathy. Assessing a patient's risk for events such as hospitalization and death in heart failure is challenging, and made more difficult by the wide variety of ways a patient can present with heart failure clinically. Cardiac MRI has long been a highly regarded imaging technique for heart function and shape due to the high level of detail it can show. More recently, it has been thought to play a more important role in investigating and predicting the course of cardiomyopathy-related heart failure. Given the limitations of more commonly used measurement techniques, increasing the clinical use of cardiac magnetic resonance imaging would potentially improve the outcomes and quality of life for patients suffering with cardiomyopathy.

Capsulorrhaphy using suture anchors in open reduction of developmental dislocation of hip: technical note.

We describe a new technique of using titanium alloy anchors to perform internally rotating capsulorrhaphy during open reduction and stabilization procedure and obliteration of pseudoacetabulum when one exists. We routinely use anterior approach via bikini incision (modified Smith-Peterson approach) to perform open reduction and internally rotating capsulorrhaphy. We describe the technique of using barbed titanium alloy anchors preloaded with nonabsorbable sutures and two needles, to accomplish a secure and easy capsulorrhaphy, in selected cases. We have used this technique in 21 hips, since 2008. None of the hips redislocated and hip movements were symmetrical in most cases at 6 months after surgery. One anchor appeared 5 mm away from the pubic ramus on first radiograph at 6 months without any adverse effect on the outcome. It did not migrate any further on follow up radiographs. MRI scan of hip obtained for another purpose confirmed that it was not intra-articular. Capsulorrhaphy using barbed titanium anchors with nonabsorbable ethibond sutures is an effective, safe and technically easy alternative to standard capsulorrhaphy using needles and sutures in selected cases.

Population Study of Ovarian Cancer Risk Prediction for Targeted Screening and Prevention.

Unselected population-based personalised ovarian cancer (OC) risk assessment combining genetic/epidemiology/hormonal data has not previously been undertaken. We aimed to perform a feasibility study of OC risk stratification of general population women using a personalised OC risk tool followed by risk management. Volunteers were recruited through London primary care networks. INCLUSION CRITERIA: women ≥18 years. EXCLUSION CRITERIA: prior ovarian/tubal/peritoneal cancer, previous genetic testing for OC genes. Participants accessed an online/web-based decision aid along with optional telephone helpline use. Consenting individuals completed risk assessment and underwent genetic testing (BRCA1/BRCA2/RAD51C/RAD51D/BRIP1, OC susceptibility single-nucleotide polymorphisms). A validated OC risk prediction algorithm provided a personalised OC risk estimate using genetic/lifestyle/hormonal OC risk factors. Population genetic testing (PGT)/OC risk stratification uptake/acceptability, satisfaction, decision aid/telephone helpline use, psychological health and quality of life were assessed using validated/customised questionnaires over six months. Linear-mixed models/contrast tests analysed impact on study outcomes. MAIN OUTCOMES: feasibility/acceptability, uptake, decision aid/telephone helpline use, satisfaction/regret, and impact on psychological health/quality of life. In total, 123 volunteers (mean age = 48.5 (SD = 15.4) years) used the decision aid, 105 (85%) consented. None fulfilled NHS genetic testing clinical criteria. OC risk stratification revealed 1/103 at ≥10% (high), 0/103 at ≥5%-<10% (intermediate), and 100/103 at <5% (low) lifetime OC risk. Decision aid satisfaction was 92.2%. The telephone helpline use rate was 13% and the questionnaire response rate at six months was 75%. Contrast tests indicated that overall depression (p = 0.30), anxiety (p = 0.10), quality-of-life (p = 0.99), and distress (p = 0.25) levels did not jointly change, while OC worry (p = 0.021) and general cancer risk perception (p = 0.015) decreased over six months. In total, 85.5-98.7% were satisfied with their decision. Findings suggest population-based personalised OC risk stratification is feasible and acceptable, has high satisfaction, reduces cancer worry/risk perception, and does not negatively impact psychological health/quality of life.