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Aim In patients with prior myocardial infarction (MI) on aspirin, the addition of ticagrelor reduces ischaemic risk but increases bleeding risk. The simultaneous assessment of baseline ischaemic and bleeding risk may assist clinicians in selecting patients who are most likely to have a favourable risk/benefit profile with long-term ticagrelor. Methods and results PEGASUS-TIMI 54 randomized 21 162 prior MI patients, 13 956 of which to the approved 60 mg dose or placebo and who had all necessary data. The primary efficacy endpoint was cardiovascular death, MI, or stroke, and the primary safety outcome was TIMI major bleeding; differences in Kaplan–Meier event rates at 3 years are presented. Post-hoc subgroups based on predictors of bleeding and ischaemic risk were merged into a selection algorithm. Patients were divided into four groups: those with a bleeding predictor (n = 2721, 19%) and then those without a bleeding predictor and either 0–1 ischaemic risk factor (IRF; n = 3004, 22%), 2 IRF (n = 4903, 35%), or ≥3 IRF (n = 3328, 24%). In patients at high bleeding risk, ticagrelor increased bleeding [absolute risk difference (ARD) +2.3%, 95% confidence interval (CI) 0.6, 3.9] and did not reduce the primary efficacy endpoint (ARD +0.08%, 95% CI −2.4 to 2.5). In patients at low bleeding risk, the ARDs in the primary efficacy endpoint with ticagrelor were −0.5% (−2.2, 1.3), −1.5% (−3.1, 0.02), and −2.6% (−5.0, −0.24, P = 0.03) in those with ≤1, 2, and 3 risk factors, respectively (P = 0.076 for trend across groups). There were significant trends for greater absolute risk reductions for cardiovascular death (P -trend 0.018), all-cause mortality (P -trend 0.027), and net outcomes (P -trend 0.037) with ticagrelor across these risk groups. Conclusion In a post-hoc exploratory analysis of patients with prior MI, long-term ticagrelor therapy appears to be best suited for those with prior MI with multiple IRFs at low bleeding risk. Clinical Trial Registration NCT01225562 ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

Objective: Heart failure (HF) is an impactful complication of type 2 diabetes mellitus (T2DM). We aimed to develop and validate a risk score for hospitalization for HF (HHF) incorporating biomarkers and clinical factor(s) in patients with T2DM.Research Design and Methods: We derived a risk score for HHF using clinical data, high-sensitivity troponin T (hsTnT), and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) from 6,106 placebo-treated patients with T2DM in SAVOR-TIMI 53 (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53). Candidate variables were assessed using Cox regression. The strongest indicators of HHF risk were included in the score using integer weights. The score was externally validated in 7,251 placebo-treated patients in DECLARE-TIMI 58 (Dapagliflozin Effect on CardiovascuLAR Events-Thrombolysis in Myocardial Infarction 58). The effect of dapagliflozin on HHF was assessed by risk category in DECLARE-TIMI 58.Results: The strongest indicators of HHF risk were NT-proBNP, prior HF, and hsTnT (each P < 0.001). A risk score using these three variables identified a gradient of HHF risk (P-trend <0.001) in the derivation and validation cohorts, with C-indices of 0.87 (95% CI, 0.84-0.89) and 0.84 (0.81-0.86), respectively. Whereas there was no significant effect of dapagliflozin versus placebo on HHF in the low-risk group (hazard ratio [HR] 0.98 [95% CI 0.50-1.92]), dapagliflozin significantly reduced HHF in the intermediate-, high-, and very-high-risk groups (HR 0.64 [0.43-0.95], 0.63 [0.43-0.94], and 0.72 [0.54-0.96], respectively). Correspondingly, absolute risk reductions (95% CI) increased across these latter 3 groups: 1.0% (0.0-1.9), 3.0% (0.7-5.3), and 4.4% (-0.2 to 8.9) (P-trend <0.001).Conclusions: We developed and validated a risk score for HHF in T2DM that incorporated NT-proBNP, prior HF, and hsTnT. The risk score identifies patients at higher risk of HHF who derive greater absolute benefit from dapagliflozin. [ABSTRACT FROM AUTHOR]

Radiostereometric analysis (RSA) has evolved as gold standard in the evaluation of wear and especially as regards novel hip implant materials. However, several cup shell materials and articulation types used in total hip arthroplasty (THA) cannot be studied due to poor radiographic visibility of the femoral head (FH). We addressed this problem with use of a point transfer function in the RSA software to indirectly measure FH translations with use of stem markers. In a base examination, the stem marker segment and cup center, as an approximation for the FH center position, were mathematically coupled. Thereafter, in subsequent examinations, we used the point transfer function to calculate FH positions from stem marker positions. To determine the variance of the difference of directly and indirectly measured FH positions, four stem marker configurations were studied in THAs with radiographically visible FHs. For the axis with least variance we also compared directly and indirectly measured translation up to 7 years. Finally, we applied the method in a ceramic‐on‐ceramic (COC) articulation and measured proximal translation up to 7 years and also estimated precision. Vertical translations had the smallest variation between measured and calculated FH position. Directly and indirectly measured vertical FH translation correlated well but indirect measurements had increased variance. Proximal steady‐state penetration rate in uncemented COC THA was −0.003 (SD 0.021) mm/year with 99% precision along the vertical axis measuring 0.34 mm. The point transfer function can be used to measure proximal FH penetration, but with less precision than direct RSA. [ABSTRACT FROM AUTHOR]

Aims PEGASUS-TIMI 54 demonstrated that long-term dual antiplatelet therapy (DAPT) with aspirin and ticagrelor reduced the risk of major adverse cardiovascular events (MACE), with an acceptable increase in bleeding, in patients with prior myocardial infarction (MI). While much of the discussion around prolonged DAPT has been focused on stented patients, patients with prior MI without prior coronary stenting comprise a clinically important subgroup. Methods and results This was a pre-specified analysis from PEGASUS-TIMI 54, which randomized 21 162 patients with prior MI (1–3 years) and additional high-risk features to ticagrelor 60 mg, 90 mg, or placebo twice daily in addition to aspirin. A total of 4199 patients had no history of coronary stenting at baseline. The primary efficacy outcome (MACE) was the composite of cardiovascular death, MI, or stroke. Patients without history of coronary stenting had higher baseline risk of MACE [13.2% vs. 8.0%, adjusted hazard ratio (HR) 1.41, 95% confidence interval (CI) 1.15–1.73, in the placebo arm]. The relative risk reduction in MACE with ticagrelor (pooled doses) was similar in patients without (HR 0.82, 95% CI 0.68–0.99) and with prior stenting (HR 0.85, 95% CI 0.75–0.96; P for interaction = 0.76). Conclusion Long-term ticagrelor reduces thrombotic events in patients with prior MI regardless of whether they had prior coronary stenting. These data highlight the benefits of DAPT in prevention of spontaneous atherothrombotic events and indicate that long-term ticagrelor may be considered in high-risk patients with prior MI even if they have not been treated with stenting. ClinicalTrials.gov Identifier NCT01225562. Open in new tab Download slide Open in new tab Download slide [ABSTRACT FROM AUTHOR]

Background and Objective: Ticagrelor is a P2Y12 receptor inhibitor approved as an antiplatelet drug for patients with acute coronary syndrome or a history of myocardial infarction. Ticagrelor is also being investigated for the reduction of vaso-occlusive crises in pediatric patients with sickle cell disease. A pediatric formulation suitable for this age range was developed; the development strategy is described. Primary objectives were determining the relative bioavailability of ticagrelor pediatric tablets and granules for oral suspension to the adult immediate-release tablet, and the pediatric tablets taken whole and dispersed/suspended in water to the granules for oral suspension. Bioequivalence between the pediatric tablet taken whole or suspended in water was also assessed. Secondary objectives were comparing the formulations' safety and tolerability. Methods: We conducted a randomized, four-period, cross-over, single-dose study. Pharmacokinetic parameters were assessed for ticagrelor and its active metabolite AR-C124910XX. Bioequivalence was concluded if the 90% confidence intervals of the maximum plasma concentration and area under the plasma concentration–time curve ratios were contained completely within the 80.00–125.00% limits for ticagrelor/AR-C124910XX. Results: Forty-four healthy adults (95% white; 57% male) were included. Similar bioavailability of ticagrelor (and AR-C124910XX) was demonstrated for all comparisons tested. Ticagrelor pediatric tablets taken whole were bioequivalent to pediatric tablets suspended in water. The plasma concentration–time profiles for ticagrelor and AR-C124910XX were similar, showing rapid ticagrelor absorption and AR-C124910XX formation. All formulations were well tolerated. Conclusion: Similar bioavailability of a new pediatric dispersible tablet formulation of ticagrelor for use across a wide age range of pediatric patients was demonstrated compared with other oral ticagrelor formulations. ClinicalTrials.gov Identifier: NCT03126695. EudraCT: 2017-000371-93. [ABSTRACT FROM AUTHOR]

Background: In an earlier study with a 2-year follow-up of uncemented cups, we had reported low femoral-head penetration of vitamin E-infused highly cross-linked polyethylene liners (E1) compared with highly cross-linked liners without vitamin E (ArComXL). We studied the penetration rate of E1 compared with that of ArComXL, with a focus on changes occurring between 2 and 5 years after total hip arthroplasty.Methods: In this randomized controlled study, we performed radiostereometric analysis of the penetration rate up to 5 years in 63 hips.Results: During the total period of observation, the median proximal penetration for E1, 0.13 mm (mean, 0.11 mm [95% confidence interval (CI), 0.08 to 0.14 mm]), was lower than that for ArComXL, 0.20 mm (mean, 0.22 mm [95% CI, 0.17 to 0.26 mm]). The median proximal penetration rate between 2 and 5 years was 0.02 mm/yr (mean, 0.01 mm/yr [95% CI, 0.01 to 0.02 mm/yr]) for E1 and 0.04 mm/yr (mean, 0.04 mm/yr [95% CI, 0.03 to 0.05 mm/yr) for ArComXL. The corresponding median total (i.e., 3-dimensional resultant) penetration rates were 0.04 mm/yr (mean, 0.04 mm/yr [95% CI, 0.03 to 0.05 mm/yr]) for E1 and 0.07 mm/yr (mean, 0.08 mm/yr [95% CI, 0.06 to 0.10 mm/yr]) for ArComXL.Conclusions: From years 2 to 5, we observed increased penetration in both groups. The penetration rate was higher for ArComXL, resulting in more proximal and total penetration at 5 years than for E1.Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background and purpose — Most registry studies regarding highly crosslinked polyethylene (XLPE) have focused on the overall revision risk. We compared the risk of cup and/or liner revision for specific cup and liner designs made of either XLPE or conventional polyethylene (CPE), regarding revision for any reason and revision due to aseptic loosening and/or osteolysis. Patients and methods — Using the Nordic Arthroplasty Register Association (NARA) database, we identified cup and liner designs where either XLPE or CPE had been used in more than 500 THAs performed for primary hip osteoarthritis. We assessed risk of revision for any reason and for aseptic loosening using Cox regression adjusted for age, sex, femoral head material and size, surgical approach, stem fixation, and presence of hydroxyapatite coating (uncemented cups). Results — The CPE version of the ZCA cup had a risk of revision for any reason similar to that of the XLPE version (p = 0.09), but showed a 6-fold higher risk of revision for aseptic loosening (p < 0.001). The CPE version of the Reflection All Poly cup had an 8-fold elevated risk of revision for any reason (p < 0.001) and a 5-fold increased risk of revision for aseptic loosening (p < 0.001). The Charnley Elite Ogee/Marathon cup and the Trilogy cup did not show such differences. Interpretation — Whether XLPE has any advantage over CPE regarding revision risk may depend on the properties of the polyethylene materials being compared, as well as the respective cup designs, fixation type, and follow-up times. Further research is needed to elucidate how cup design factors interact with polyethylene type to affect the risk of revision. [ABSTRACT FROM PUBLISHER]

Bone impaction grafting is a biologically and mechanically appealing option in acetabular revision surgery, allowing restitution of the bone stock and restoration of the biomechanics. We analysed differences in proximal migration of the revision acetabular components when bone impaction grafting is used together with a cemented or an uncemented cup.~Background~Background~43 patients (47 hips), revised due to acetabular loosening and judged to have less than 50% host bone-implant contact were included. The hips were randomised to either an uncemented (n = 20) or a cemented (n = 27) revision cup. Radiostereometry and radiography was performed postoperatively, at 3 and 6 months, 1, 2, 3, 5, 7, 10 and 13 and 17 years postoperatively. Clinical follow-up was performed at 1, 2 and 5 years postoperatively and thereafter at the same interval as in the radiographic follow-up.~Patients and Methods~Methods~There were no differences in the base line demographic data between the 2 groups. At the last follow-up (17 years) 14 hips (10 cemented, 4 uncemented) had been re-revised due to loosening. 3 additional cups (1 uncemented and 2 cemented) were radiographically loose. There was a higher early proximal migration in the cemented cups.~Results~Results~Cups operated on with cement showed a higher early migration measured with RSA and also a higher number of late revisions. The reason for this is not known, but factors such as inclusion of cases with severe bone defects, use of smaller bone chips and issues related to the impaction technique might have had various degrees of influence.~Discussion~Conclusions [ABSTRACT FROM AUTHOR]

ABSTRACT In conventional Radiostereometric analysis (RSA) implants with attached tantalum markers are frequently used, which may be difficult to visualize. This problem can be avoided with model-based RSA (MBRSA), but it is uncertain if this method has the same precision as marker-based RSA. We evaluated the influence of cup design for the precision of MBRSA in four uncemented cups to study if the design had any influence on the precision. Stereo radiographs were analyzed postoperatively (double-examinations) and after 2 years (single examinations). The difference between the double-examinations was used to compute the precision for the methods and for each type of implant. Femoral head penetration and cup translation up to 2 years were compared using marker-based RSA as reference. The precision of proximal penetration and migration measurements did not differ between the methods for Trilogy, TMT and ABG. For Ringloc design a poorer precision was observed using MBRSA. Comparison between the methods regarding proximal penetration and cup migration at 2 years did not differ for three of the designs ( p = 0.12-0.91). However, for the group with porous plasma sprayed surface (Ringloc) a significant difference between the methods was observed ( ppenetration <0.01 and pmigration <0.01). Poorer precision, different penetration and migration values at 2 years for one of the designs indicate that the resolution of MBRSA might vary depending on surface coating and implant geometry. Therefore, we conclude that the resolution of MBRSA has to be studied for each type of basic cup design. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:760-767, 2017. [ABSTRACT FROM AUTHOR]

Background: Radiostereometry (RSA) measurements of early micromotion can predict later failure in hip and knee prostheses. In hip implants, RSA has been particularly helpful in the evaluation of composite-beam stem designs. The Spectron EF Primary stem (Smith & Nephew, London, UK) has shown inferior performance compared with its predecessors in both clinical studies and registry reports. Early RSA studies have shown somewhat greater subsidence for the Spectron EF Primary stem compared with the earlier Spectron EF, but still within boundaries considered to be safe.Questions/purposes: Our primary research question was whether stem subsidence and rotation for this stem design measured with RSA at 2 years can predict later stem failure. A secondary question was whether high femoral stem offset and small stem sizes, both features specific to the Spectron EF Primary stem compared with its predecessors, are associated with stem failure rate.Methods: Two hundred forty-seven hips (209 patients with median age 63 years [range, 29-80 years], 65% female, and 77% primary osteoarthritis) with a valid RSA examination at 2 years were selected from four different RSA studies (totaling 279 hips in 236 patients) in our department. The studies were primarily aimed at evaluating cup fixation, bone cement, and polyethylene types. All study patients received a cemented Spectron EF Primary stem. The selected hips had complete followup until stem failure, death, or the end of the followup period. Stem failure was defined as revision of a loose femoral stem or radiological failure with significant osteolysis in Gruen zones 2 to 6. Cox regression analyses were performed to evaluate if stem subsidence and rotation after 2 years, adjusted for age, sex, stem size, standard/high stem offset, and conventional/highly crosslinked polyethylene, could predict later clinical aseptic failure of the stem. We identified 32 stem failures (27 revisions, five radiological failures) at 14 years median followup (range, 3-18 years). Ten-year stem survival was 94% (95% confidence interval [CI], 90%-96%).Results: Stem subsidence at 2 years (adjusted hazard ratio [HR], 6.0; 95% CI, 2.5-15; p < 0.001) and retrotorsion of the stem (adjusted HR, 1.7; 95% CI, 1.1-2.5; p = 0.018) were associated with later stem failure. Further risk factors were male sex (subsidence analysis HR, 6.9; p > 0.001), use of the two smallest stem sizes (HRsize 1, 8.0; p > 0.001, HRsize 2, 1 [reference], HRsize 3+, 0.06; p = 0.035), and the high offset option (HR, 3.1; p = 0.005).Conclusions: Stem subsidence and retrotorsion at 2 years can predict later failure in the Spectron EF Primary stem, consistent with earlier findings on composite-beam cemented stems. Small stem size and high-offset stems comprise the main group of underperforming stems. We recommend that premarket small-scale RSA studies be performed after any design change to a THA femoral component, because even seemingly minor design changes may unexpectedly result in inferior performance.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate 90-day cardiovascular outcome in patients after myocardial infarction (MI) in relation to different subtypes of atrial fibrillation (AF) and MI.Methods: We studied 155 071 hospital survivors of MI between 2000 and 2009 in Swedish registries. AF subtypes were defined according to history of AF and in-hospital ECG recordings. Clinical outcomes were evaluated with multivariable Cox models.Results: AF was documented in 24 023 (15.5%) cases. The AF subtypes were new-onset AF with sinus rhythm at discharge (3.7%), new-onset AF with AF at discharge (3.9%), paroxysmal AF (4.9%) and chronic AF (3.0%). The event rate per 100 person-years for the composite cardiovascular outcome (all-cause mortality, MI or ischaemic stroke) was 90.9 in patients with any type of AF versus 45.2 in patients with sinus rhythm, adjusted hazard ratio with 95% CI (HR) 1.28 (1.19 to 1.37). There were no significant differences in the composite cardiovascular outcome between AF subtypes. AF was associated with higher risk of mortality, HR 1.59 (1.41 to 1.80), reinfarction, HR 1.14 (1.05 to 1.24), and ischaemic stroke, HR 2.29 (1.92 to 2.74), respectively. In subgroup analysis, AF was associated with a higher risk of composite cardiovascular outcome in the non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) cohort, HR 1.24 (1.13 to 1.36) and HR 1.34 (1.21 to 1.48), respectively, with p value for interaction=0.23.Conclusions: AF is common in the setting of MI and is associated with a higher risk of composite cardiovascular outcome and the individual components; mortality, reinfarction and ischaemic stroke, respectively. No major difference in outcome was observed between AF subtypes. No difference in outcome for AF was observed between the NSTEMI and STEMI cohort. [ABSTRACT FROM AUTHOR]

Background: Highly cross-linked polyethylene infused with vitamin E (E-poly) was developed to increase oxidative resistance without affecting mechanical properties. We evaluated this type of polyethylene in a randomized clinical study that used radiostereometric analysis. Our objective was to compare the early-term femoral head penetration of an E-poly liner with that of a heat-treated polyethylene liner, ArComXL. We hypothesized that the clinical outcome at two years following total hip arthroplasty would be unaffected by the choice of polyethylene.Methods: In this prospective study, sixty-one patients (seventy hips) with noninflammatory hip osteoarthritis and a median age of fifty-eight years were randomized to receive either an implant with an E-Poly or a heat-treated highly cross-linked polyethylene liner. The patients were followed for two years and evaluated at three time points (three months, one year, and two years).Results: The median proximal penetration in the E-poly group increased from 0.04 mm at three months to 0.06 mm at two years of follow-up. Corresponding values for the ArComXL group were 0.03 mm and 0.10 mm. In both groups, significantly increased penetration was observed between three months and two years (E-poly, p = 0.02; ArComXL, p < 0.001), but between one and two years, the increase was significant only in the control group (E-poly, p = 0.23; ArComXL, p = 0.002).Conclusions: The femoral head penetration of E-poly was very low at two years. Whether the increase observed between three months and two years was caused by creep, deformation, wear, or a combination of these cannot be determined by our study. There were no significant differences observed in femoral head penetration rates between E-poly and ArComXL. Currently, the theoretical advantages of E-poly remain to be confirmed. [ABSTRACT FROM AUTHOR]

Background: Highly cross-linked polyethylene infused with vitamin E (E-poly) was developed to increase oxidative resistance without affecting mechanical properties. We evaluated this type of polyethylene in a randomized clinical study that used radiostereometric analysis. Our objective was to compare the early-term femoral head penetration of an E-poly liner with that of a heat-treated polyethylene liner, ArComXL. We hypothesized that the clinical outcome at two years following total hip arthroplasty would be unaffected by the choice of polyethylene. Methods: In this prospective study, sixty-one patients (seventy hips) with noninflammatory hip osteoarthritis and a median age of fifty-eight years were randomized to receive either an implant with an E-Poly or a heat-treated highly crosslinked polyethylene liner. The patients were followed for two years and evaluated at three time points (three months, one year, and two years). Results: The median proximal penetration in the E-poly group increased from 0.04 mm at three months to 0.06 mm at two years of follow-up. Corresponding values for the ArComXL group were 0.03 mm and 0.10 mm. In both groups, significantly increased penetration was observed between three months and two years (E-poly, p = 0.02; ArComXL, p < 0.001), but between one and two years, the increase was significant only in the control group (E-poly, p = 0.23; ArComXL, p = 0.002). Conclusions: The femoral head penetration of E-poly was very low at two years. Whether the increase observed between three months and two years was caused by creep, deformation, wear, or a combination of these cannot be determined by our study. There were no significant differences observed in femoral head penetration rates between E-poly and ArComXL. Currently, the theoretical advantages of E-poly remain to be confirmed. [ABSTRACT FROM AUTHOR]

Background: Polyethylene (PE) wear particles are believed to cause aseptic loosening and thereby impair function in hip arthroplasty. Highly crosslinked polyethylene (XLPE) has low short- and medium-term wear rates. However, the long-term wear characteristics are unknown and it is unclear whether reduced wear particle burden improves function and survival of cemented hip arthroplasty. Questions/purposes: We asked whether XLPE wear rates remain low up to 10 years and whether this leads to improved implant fixation, periprosthetic bone quality, and clinical function compared to conventional PE. Methods: We randomized 60 patients (61 hips) to receive either PE or XLPE cemented cups combined with a cemented stem. At 10 years postoperatively, 51 patients (52 hips) were evaluated for polyethylene wear and component migration estimation by radiostereometry, for radiolucent lines, bone densitometry, and Harris hip and pain scores. Revisions were recorded. Results: XLPE cups had a lower mean three-dimensional wear rate between 2 and 10 years compared to conventional PE hips: 0.005 mm/year versus 0.056 mm/year. We found no differences in cup migration, bone mineral density, radiolucencies, functional scores, and revision rate. There was a trend toward improved stem fixation in the XLPE group. The overall stem failure rate was comparably high, without influencing wear rate in XLPE hips. Conclusions: XLPE displayed a low wear rate up to 10 years when used in cemented THA, but we found no clear benefits in any other parameters. Further research is needed to determine whether cemented THA designs with XLPE are less prone to stem loosening. Level of Evidence: Level I, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article discusses a study on the relationship between the adoption of evidence-based treatment and survival of patients with ST-elevation myocardial infarction (STEMI). The study involves the use of mortality data from the Register of Information and Knowledge About Swedish Heart Intensive Admissions (RIKS-HIA) database in Sweden. Analysis of evidence-based in-hospital treatments shows that reperfusion treatment posted an increase to 79% while primary percutaneous coronary intervention (PCI) rose to 61%. Results indicate that the implementation of new treatment strategies on STEMI patients supported by the registry leads to an increased use of evidence-based treatments, better adherence to treatment guidelines and a decrease in variation across hospitals.

Background and purpose The reported outcomes of hip resurfacing arthroplasty (HRA) vary. The frequency of this procedure in Denmark, Norway, and Sweden is low. We therefore determined the outcome of HRA in the NARA database, which is common to all 3 countries, and compared it to the outcome of conventional total hip arthroplasty (THA). Methods The risk of non-septic revision within 2 years was analyzed in 1,638 HRAs and compared to that for 172,554 conventional total hip arthroplasties (THAs), using Cox regression models. We calculated relative risk (RR) of revision and 95% confidence interval. Results HRA had an almost 3-fold increased revision risk compared to THA (RR = 2.7, 95% CI: 1.9-3.7). The difference was even greater when HRA was compared to the THA subgroup of cemented THAs (RR = 3.8, CI: 2.7-5.3). For men below 50 years of age, this difference was less pronounced (HRA vs. THA: RR = 1.9, CI: 1.0-3.9; HRA vs. cemented THA: RR = 2.4, CI: 1.1-5.3), but it was even more pronounced in women of the same age group (HRA vs. THA: RR = 4.7, CI: 2.6-8.5; HRA vs. cemented THA: RR = 7.4, CI: 3.7-15). Within the HRA group, risk of non-septic revision was reduced in hospitals performing ≥ 70 HRAs annually (RR = 0.3, CI: 0.1-0.7) and with use of Birmingham hip resurfacing (BHR) rather than the other designs as a group (RR = 0.3, CI: 0.1-0.7). Risk of early revision was also reduced in males (RR = 0.5, CI: 0.2-0.9). The femoral head diameter alone had no statistically significant influence on the early revision rate, but it eliminated the significance of male sex in a combined analysis. Interpretation In general, our results do not support continued use of hip resurfacing arthroplasty. Men had a lower early revision rate, which was still higher than observed for all-cemented hips. Further follow-up is necessary to determine whether HRA might be useful as an alternative in males. [ABSTRACT FROM AUTHOR]

Aims Serial forecasts of final myocardial infarct (MI) size during fibrinolytic treatment (Rx) of ST-elevation MI would allow the identification of high-risk patients with a predicted major loss of viable myocardium, at a point when treatment may still be modified. We investigated a model for such forecasting, using time and the ECG. [ABSTRACT FROM PUBLISHER]

ST-segment analyses from electrocardiograms during acute coronary syndromes (ACS) have repeatedly shown strong mechanistic links to coronary artery patency and myocardial reperfusion. In these patients, such analyses have also consistently been reported to have close correlations with outcome—correlations superior even to those reported for invasive coronary flow measurements and outcome. Continuous multilead ST-monitoring of patients with ACS provides accurate and noninvasive information on the dynamics of the myocardial reperfusion process over time. This information can be used for improved early diagnostic accuracy, evaluation of treatment efficacy, early risk-stratification, and can be supportive in clinical decision making regarding these patients. Continuous multilead ST-monitoring during ACS is no longer a cumbersome source of more nuisance than benefit, but can be an accurate and useful tool in multicenter clinical trials, as well as in clinical medicine. [ABSTRACT FROM AUTHOR]

Aims Analyses of ST-segment resolution during acute myocardial infarction has, during recent years, challenged coronary angiography as gold-standard for predictingmyocardial reflow and future risk. We have previously reported that continuous ST-monitoring can be done accurately in the clinical setting. We now set out to compare the prognostic value of previously suggested cut-offs for ST-segmentresolution, and determine the times to measure these.Methods and results We analysed 752 patients with ST-elevation infarction, from the second Assessment of Safety and Efficacy of a New Thrombolytic (ASSENT 2) and ASSENT-PLUS studies, either with vectorcardiography or continuous 12-lead ST-monitoring. All analyses were made blindly by two independent observers. Times to 20, 30, 50 and 70% ST-segment resolution were examined in relation to 30-day mortality.The optimal cut-off for ST-segment resolution analyses was found to be 50%, measured at 60min. We could hereby identify a large low-risk group, 40% of the population, with only 1.4% 30-day mortality. Furthermore, 88% of deaths were correctly predicted within 1h of observation and treatment.Conclusion Continuous ST-monitoring of patients with acute myocardial infarction yields important prognostic information after 60min of observation and should be used for very early-risk stratification in these patients. [ABSTRACT FROM PUBLISHER]

Background: Early and complete myocardial reperfusion is the goal when treating a patient with acute myocardial infarction. To achieve this in each individual, an on-line, accurate, easily handled and preferably noninvasive technique to monitor flow alterations is needed. Recurrent ST-segment elevation has been shown to reflect cyclic disturbances in perfusion.Methods: We have retrospectively analyzed ST variability in 102 patients with acute myocardial infarction randomized to 100 mg of rt-Pa or placebo. Patients were monitored for 24 hours using vectorcardiography.Results: Patients alive at one year (86%) had significantly less ST variability during the first four hours: 4.3 versus 7.1 episodes, P = 0.007. Patients having six or more ST episodes showed a 31.3% one-year mortality as compared to no mortality in patients having no ST variability. Furthermore ST variability was reduced by fibrinolysis.Conclusion: Early ST variability detectable in real time is associated with worse outcome. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Association Between Adoption of Evidence-Based Treatment and Survival for Patients With ST-Elevation Myocardial Infarction," by Tomas Jernberg and colleagues which appeared in a previous issue.