Key PointsQuestionIs transcatheter aortic valve implantation (TAVI) noninferior to surgical aortic valve replacement (surgery) in patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk?FindingsIn this randomized clinical trial that included 913 patients at moderately increased operative risk due to age or comorbidity, all-cause mortality at 1 year was 4.6% with TAVI vs 6.6% with surgery, a difference that met the prespecified noninferiority margin of 5%.MeaningAmong patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, treatment with TAVI was noninferior to surgery with respect to all-cause mortality at 1 year.
The Nexplanon® implant is a commonly used radiopaque contraceptive device that contains progestogen associated with an ethylene vinyl-acetate copolymer resulting in a slow release of the active hormonal ingredient. It is inserted into the subdermal connective tissue and provides contraceptive efficacy for up to 3 years. Device removal for clinical, personal or device “end-of-life span” reasons is straightforward. In rare cases, implant migration can occur locally within centimeters of the insertion site. Distant device embolization is extremely rare and can result in complications including chest pain, dyspnoea, pneumothorax and thrombosis or prevent conception until the active ingredient is depleted. We present one such case, where a Nexplanon® implant embolized into the pulmonary artery of a young female patient. We describe the initial “missed” diagnosis of embolized device on a chest radiograph and subsequent successful percutaneous removal once distant embolization was diagnosed.
This study was performed to assess the incidence of generalised ligament laxity in patients presented with shoulder dislocations. Prospective data were collected for patients presented with shoulder dislocations between August 2008 and August 2009 under the care of a specialist shoulder surgeon including demographic details, types of dislocation, mechanism of injury and generalised ligament laxity. Clinical examination was used to assess the ligament laxity using the Beighton score. Laxity is scored on a 0-9 scale. Scores of 4 or above are indicative of generalised ligament laxity. Brighton criteria is used to diagnose benign joint hypermobility syndrome (BJHS) and use signs and symptoms along with Beighton score. There were 82 patients with a mean age of 30 years. There were 77 male (94%) and 5 (6%) female patients. 34 patients (41%) attended after first time shoulder dislocation, 37 (45%) after recurrent shoulder dislocations and 11 (13%) for revision shoulder stabilisation. The most common cause of shoulder dislocation was sports related injuries in 48 patients (68%). The most common sports involved was rugby in 22 (46%) patients followed by football in 15 (31%) patients. 75 (91%) patients had anterior shoulder dislocations and 6 (7%) had multidirectional instability. The average Beighton score for these patients was 3.1 with a range from 0 to 9. 35 patients (43%) in this group had a Beighton score of 4 or more indicating generalised ligament laxity. 15 patients (18%) fulfilled the Brighton criteria for BJHS. 12 patients (15%) had a first degree relative with generalised ligament laxity. The authors found that there is a high incidence (43%) of generalised ligament laxity in patients with shoulder dislocations after sports injuries. Appropriate advice should be given about the risk of shoulder dislocations in patients with generalised ligament laxity.
The aim of this study was to compare cardiovascular autonomic function of Hyperadrenergic PoTS, defined as a plasma norepinephrine >; 600 ng/mol during orthostasis, to PoTS due to other causes. Clinical cardiovascular autonomic function test results were reviewed. 50 PoTS patients were identified; 18 with Hyperadrenergic PoTS. Plasma norepinephrine was higher while upright (383 ± 99 vs 726 ± 112 ng/mol, p<0.05) and supine (233 ± 58 vs 422 ± 128 ng/mol, p<0.05) in Hyperadrenergic PoTS. There were no differences in heart rate or blood pressure during cold pressor challenge, mental stress, isometric exercise, deep breathing and short‐term (9 min) head‐up tilting, between groups (all p>;0.05). Valsalva manoeuvre derived Valsalva ratio, blood pressure recovery time and vagal baroreflex sensitivity were not different (all p>;0.05), whereas adrenergic baroreflex sensitivity was lower in Hyperadrenergic PoTS (p<0.05). Hyperadrenergic PoTS had lower prolonged (60 min or less) head‐up tilt tolerance (p<0.05); termination was predominantly due to patient request not differences in heart rate or blood pressure. These findings suggest that, 1) Hyperadrenergic PoTS have elevated supine and upright, plasma norepinephrine levels and 2) Hyperadrenergic PoTS do not have distinctive cardiovascular autonomic function except for decreased adrenergic baroreflex sensitivity and reduced prolonged orthostatic tolerance.
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