Zika Virus May Harm the Heart

As the Zika virus continues to spread globally, new evidence has emerged about the virus’s potentially detrimental effects on the heart, according to the first study to report Zika-related heart troubles following infection. The investigation included adult patients with no prior history of cardiovascular disease who were treated at the Institute of Tropical Medicine in Caracas, Venezuela, one of the epicenters of the Zika virus outbreak. All but one patient developed a dangerous heart rhythm problem, and two-thirds had evidence of heart failure.

“Our report provides clear evidence that there is a relationship between the Zika virus infection and cardiovascular complications,” said Karina Gonzalez Carta, MD, a cardiologist and research fellow at the department of cardiovascular diseases at Mayo Clinic in Rochester, Minnesota, and the study’s lead author. “Based on these initial results, people need to be aware that if they travel to or live in a place with known Zika virus and develop a rash, fever, or conjunctivitis, and within a short timeframe also feel other symptoms such as fatigue, shortness of breath, or their heart skipping beats, they should see their doctor.”

Dr. Carta and her team were not entirely surprised by their findings, as they follow trends seen with other mosquito-borne diseases known to affect the heart, including the dengue and Chikungunya viruses. However, she noted that the burden and severity of heart problems, including rapidly progressive heart failure and potentially life-threatening arrhythmias, among these patients was unexpected.

Nine patients who were seen in the clinic in Caracas within one week of having Zika-type symptoms and who subsequently reported common symptoms of heart problems, most commonly palpitations followed by shortness of breath and fatigue, were included in this small, prospective case report. One patient had previous cardiovascular problems (ie, well-controlled high blood pressure), and laboratory tests confirmed that all had active Zika infection. Patients were asked to fill out a form to record their symptoms and underwent an initial ECG. These findings prompted researchers to perform a full cardiovascular work up using an echocardiogram, 24-hour Holter monitor, and a cardiac MRI study. Of the nine patients, six were female, with a mean age of 47. They were followed for an average of six months, beginning in July 2016.

Dangerous arrhythmias were detected in eight of the nine patients: three cases of atrial fibrillation, two cases of nonsustained atrial tachycardia, and two cases of ventricular arrhythmias, which can be deadly. Heart failure was present in six cases. Of these, five patients had heart failure with low ejection fraction, and one had heart failure with preserved ejection fraction along with pre-eclampsia and a moderate to severe amount of pericardial effusion. So far, none of the patients’ cardiac issues have resolved, though symptoms are much improved due to guideline-directed treatment for heart failure or atrial fibrillation. Cardiovascular symptoms tend to manifest later in the process. Data show an average lag of 10 days from patients’ initial complaints of Zika symptoms to reports of symptoms suggestive of heart problems.

“Since the majority of people with Zika virus infections present with mild or nonspecific symptoms, and symptoms of cardiovascular complications may not occur right away, we need to raise awareness about the possible association,” Dr. Carta said.

Serum Ceramide Levels Predict Cardiovascular Events

Measuring concentrations of a class of lipids known as ceramides in the blood may help clinicians identify individuals with suspected coronary heart disease who need treatment or should be followed more closely, according to research. Although previous research conducted outside the US has shown elevated ceramide levels among people with confirmed heart disease or post heart attack, this is the first study to show its predictive power among people with no blockages and in those with low levels of low-density lipoprotein (LDL).

Study data show that ceramides were able to predict major cardiovascular events (ie, heart attack, stroke, revascularization, and death) among patients with and without evidence of blockages and in those with low LDL. In fact, individuals with the highest levels of blood ceramides had a threefold to fourfold greater risk of having a cardiovascular event, compared with those with the lowest ceramide score, regardless of their LDL cholesterol level or the presence of a blockage in the heart’s arteries.

“Based on our findings, measuring ceramides in the blood appears to be a new, potentially better marker than LDL in predicting first and repeat cardiac events in both patients with and without established coronary blockages,” said Jeff Meeusen, PhD, a clinical chemist and codirector of Cardiovascular Laboratory Medicine at Mayo Clinic in Rochester, Minnesota, and the study’s lead author. “Heart disease remains the number one killer in the United States. Measuring ceramides offers another piece of information to help identify individuals who might need a little more attention, guide treatment decisions, and keep patients motivated to [live heart healthier].”

Unlike cholesterol, which is fairly inert, acting like a clog in the arteries, ceramides play an active role in the cardiovascular disease process by attracting and drawing inflammatory cells and promoting clotting. All cells have the ability to make ceramides; however, ceramide levels tend to accumulate in the blood when one has too much fat or consumes excess calories.

The study included 499 patients at Mayo Clinic who were referred for coronary angiography to check for possible blockages in the heart’s arteries. About 46% of participants had evidence of a blockage. Coronary artery disease was defined as 50% stenosis in one or more artery. Patients were similar in age and with regard to blood pressure, smoking status, and high-density lipoprotein (HDL). Those who had diabetes or a previous heart attack, stroke, or procedure to open narrowed coronary arteries were excluded. Researchers measured four types of ceramides in the blood at baseline and combined the values into a 12-point scale. Patients were grouped into the following four risk categories according to their ceramide levels: low (0–2), intermediate (3–6), moderate (7–9), and high (10–12).

Researchers prospectively followed study participants for an average of eight years and recorded occurrences of heart attack, stroke, revascularization, and death. Overall, 5.1% of patients had a major cardiovascular event during the study. The risk of having an event increased as the level of ceramides in the blood increased; for each one-point increase in the ceramide risk score, the risk rose by 9%—a trend that remained even after fully adjusting for other risk factors, including age, sex, high blood pressure, smoking, total cholesterol, HDL, and markers of inflammation. In fact, the rate of events was double among people with the highest ceramide score, compared with those with the lowest (8.1% vs 4.1%). Total cholesterol also increased with rising ceramide scores, and males were less likely to have high levels of ceramides.

Among those without coronary artery disease upon angiography, the rate of cardiovascular events was 3.1%, which was lower than the average. But when researchers examined cardiovascular disease in this population by ceramide scores, people with the highest levels of ceramides were four times more likely to have an event, compared with those with the lowest (7.8% vs 2.2%). A similar trend was seen among people with low LDL levels (<100 mg/dL). In this group, the rate of heart attack, stroke and revascularization, and death was 3.7% among those with a low ceramide score, but increased to 16.4% in people with the highest ceramide levels.

“Ceramides continued to be significant and independently associated with disease even after adjusting for traditional and novel cardiovascular risk factors,” said Dr. Meeusen. “[Based on what we are seeing,] ceramides appear to be much more important than previously recognized.”

Marijuana Increases Risks of Stroke and Heart Failure

Using marijuana increases the risk of stroke and heart failure, even after accounting for demographic factors, other health conditions, and lifestyle risk factors such as smoking and alcohol use, researchers reported. Coming at a time when marijuana, medically known as cannabis, soon may become legal for medical or recreational use in more than half of US states, this study sheds new light on how the drug affects cardiovascular health. While previous marijuana research has focused mostly on pulmonary and psychiatric complications, the new study is one of only a handful to investigate cardiovascular outcomes.

“Like all other drugs, whether they are prescribed or not prescribed, we want to know the effects and side effects of this drug,” said Aditi Kalla, MD, Cardiology Fellow at the Einstein Medical Center in Philadelphia and the study’s lead author. “It is important for physicians to know these effects so we can better educate patients, such as those who are inquiring about the safety of cannabis or even asking for a prescription for cannabis.”

The study drew data from the Nationwide Inpatient Sample, which includes the health records of patients admitted at more than 1,000 hospitals comprising about 20% of US medical centers. Researchers extracted records from young and middle-aged patients—ages 18 to 55—who were discharged from hospitals in 2009 and 2010, when marijuana use was illegal in most states.

Marijuana use was diagnosed in about 1.5% (316,000) of more than 20 million health records included in the analysis. Comparing cardiovascular disease rates in these patients to disease rates in patients not reporting marijuana use, researchers found that marijuana use was associated with a significantly increased risk for stroke, heart failure, coronary artery disease, and sudden cardiac death.

Marijuana use was also linked with various factors known to increase cardiovascular risk, such as obesity, high blood pressure, smoking, and alcohol use. After researchers adjusted the analysis to account for these factors, marijuana use was independently associated with a 26% increase in the risk of stroke and a 10% increase in the risk of developing heart failure.

“Even when we corrected for known risk factors, we still found a higher rate of both stroke and heart failure in these patients, so that leads us to believe that there is something else going on besides just obesity or diet-related cardiovascular side effects,” said Dr. Kalla. “More research will be needed to understand the pathophysiology behind this effect.”

Research in cell cultures shows that heart muscle cells have cannabis receptors relevant to contractility, thus suggesting that those receptors might be one mechanism through which marijuana use could affect the cardiovascular system. It is possible that other compounds could be developed to counteract that mechanism and reduce cardiovascular risk, said Dr. Kalla.

Because the study was based on hospital discharge records, the findings may not reflect the general population. The study was also limited by the researchers’ inability to account for quantity or frequency of marijuana use, purpose of use (ie, recreational or medical), or delivery mechanism (eg, smoking or ingestion).

The growing trend toward legalization of marijuana could mean that patients and doctors will become more comfortable speaking openly about marijuana use, which could allow for better data collection and further insights into the drug’s effects and side effects, said Dr. Kalla.

Study Examines Best Time to Screen for Sleep Apnea After Heart Attack

Conducting a diagnostic sleep test shortly after a heart attack can help doctors rule out sleep apnea in patients, but tests conducted in the immediate aftermath of a heart attack are somewhat unreliable for positively diagnosing sleep apnea, according to results from a single-center study. As a result, it may be best to repeat the test after a few months or to delay initial testing before making a definitive diagnosis and initiating treatment.

“In view of the strong association between sleep disordered breathing and heart attack and the established negative prognostic implications of untreated sleep apnea in these patients, cardiologists are becoming increasingly aware of the importance of screening for sleep disorders in their daily practice,” said Jeanette Ting, MBChB, senior resident at National University Heart Centre in Singapore, the study’s lead author. “Our aim was to determine if the screening should be performed during the acute phase soon after a heart attack or after a period of stabilization.”

Sleep apnea is thought to contribute to cardiovascular disease by increasing stress on the heart and blood vessels, causing inflammation, reducing available oxygen, and affecting hormones. Doctors can use questionnaires to identify patients who might have sleep apnea, but the only definitive test is an overnight sleep study, in which a specialist uses electrodes and sensors to monitor how often the patient stops breathing during sleep and the length of each pause.

For the study, researchers performed an overnight sleep test in 397 patients treated for heart attack at Singapore’s National University Heart Center. This initial test was conducted within five days of hospital admission. A subgroup of 102 patients underwent a second sleep test at home six months later.

In all, 52% of patients tested positive for sleep apnea in the initial test. Forty-two percent had obstructive sleep apnea, the most common form of the disorder. In addition, 10% had central sleep apnea.

About one-quarter of the patients underwent a second sleep study after six months. A majority of the patients initially found to have sleep apnea showed a change of status in the follow-up sleep study. Among those initially diagnosed with obstructive sleep apnea, 46% no longer had sleep apnea at the six-month test. Among those initially diagnosed with central sleep apnea, 83% were found to have obstructive sleep apnea at the six-month test. The vast majority (93%) of those initially found to have no sleep apnea remained apnea-free at six months.

Overall, patients with sleep apnea were older, had a higher BMI, and more often had high blood pressure, compared with those without sleep apnea. Patients showed no significant change in BMI between the first and second sleep tests.

Zika Virus May Harm the Heart

As the Zika virus continues to spread globally, new evidence has emerged about the virus’s potentially detrimental effects on the heart, according to the first study to report Zika-related heart troubles following infection. The investigation included adult patients with no prior history of cardiovascular disease who were treated at the Institute of Tropical Medicine in Caracas, Venezuela, one of the epicenters of the Zika virus outbreak. All but one patient developed a dangerous heart rhythm problem, and two-thirds had evidence of heart failure.

“Our report provides clear evidence that there is a relationship between the Zika virus infection and cardiovascular complications,” said Karina Gonzalez Carta, MD, a cardiologist and research fellow at the department of cardiovascular diseases at Mayo Clinic in Rochester, Minnesota, and the study’s lead author. “Based on these initial results, people need to be aware that if they travel to or live in a place with known Zika virus and develop a rash, fever, or conjunctivitis, and within a short timeframe also feel other symptoms such as fatigue, shortness of breath, or their heart skipping beats, they should see their doctor.”

Dr. Carta and her team were not entirely surprised by their findings, as they follow trends seen with other mosquito-borne diseases known to affect the heart, including the dengue and Chikungunya viruses. However, she noted that the burden and severity of heart problems, including rapidly progressive heart failure and potentially life-threatening arrhythmias, among these patients was unexpected.

Nine patients who were seen in the clinic in Caracas within one week of having Zika-type symptoms and who subsequently reported common symptoms of heart problems, most commonly palpitations followed by shortness of breath and fatigue, were included in this small, prospective case report. One patient had previous cardiovascular problems (ie, well-controlled high blood pressure), and laboratory tests confirmed that all had active Zika infection. Patients were asked to fill out a form to record their symptoms and underwent an initial ECG. These findings prompted researchers to perform a full cardiovascular work up using an echocardiogram, 24-hour Holter monitor, and a cardiac MRI study. Of the nine patients, six were female, with a mean age of 47. They were followed for an average of six months, beginning in July 2016.

Dangerous arrhythmias were detected in eight of the nine patients: three cases of atrial fibrillation, two cases of nonsustained atrial tachycardia, and two cases of ventricular arrhythmias, which can be deadly. Heart failure was present in six cases. Of these, five patients had heart failure with low ejection fraction, and one had heart failure with preserved ejection fraction along with pre-eclampsia and a moderate to severe amount of pericardial effusion. So far, none of the patients’ cardiac issues have resolved, though symptoms are much improved due to guideline-directed treatment for heart failure or atrial fibrillation. Cardiovascular symptoms tend to manifest later in the process. Data show an average lag of 10 days from patients’ initial complaints of Zika symptoms to reports of symptoms suggestive of heart problems.

“Since the majority of people with Zika virus infections present with mild or nonspecific symptoms, and symptoms of cardiovascular complications may not occur right away, we need to raise awareness about the possible association,” Dr. Carta said.

Serum Ceramide Levels Predict Cardiovascular Events

Measuring concentrations of a class of lipids known as ceramides in the blood may help clinicians identify individuals with suspected coronary heart disease who need treatment or should be followed more closely, according to research. Although previous research conducted outside the US has shown elevated ceramide levels among people with confirmed heart disease or post heart attack, this is the first study to show its predictive power among people with no blockages and in those with low levels of low-density lipoprotein (LDL).

Study data show that ceramides were able to predict major cardiovascular events (ie, heart attack, stroke, revascularization, and death) among patients with and without evidence of blockages and in those with low LDL. In fact, individuals with the highest levels of blood ceramides had a threefold to fourfold greater risk of having a cardiovascular event, compared with those with the lowest ceramide score, regardless of their LDL cholesterol level or the presence of a blockage in the heart’s arteries.

“Based on our findings, measuring ceramides in the blood appears to be a new, potentially better marker than LDL in predicting first and repeat cardiac events in both patients with and without established coronary blockages,” said Jeff Meeusen, PhD, a clinical chemist and codirector of Cardiovascular Laboratory Medicine at Mayo Clinic in Rochester, Minnesota, and the study’s lead author. “Heart disease remains the number one killer in the United States. Measuring ceramides offers another piece of information to help identify individuals who might need a little more attention, guide treatment decisions, and keep patients motivated to [live heart healthier].”

Unlike cholesterol, which is fairly inert, acting like a clog in the arteries, ceramides play an active role in the cardiovascular disease process by attracting and drawing inflammatory cells and promoting clotting. All cells have the ability to make ceramides; however, ceramide levels tend to accumulate in the blood when one has too much fat or consumes excess calories.

The study included 499 patients at Mayo Clinic who were referred for coronary angiography to check for possible blockages in the heart’s arteries. About 46% of participants had evidence of a blockage. Coronary artery disease was defined as 50% stenosis in one or more artery. Patients were similar in age and with regard to blood pressure, smoking status, and high-density lipoprotein (HDL). Those who had diabetes or a previous heart attack, stroke, or procedure to open narrowed coronary arteries were excluded. Researchers measured four types of ceramides in the blood at baseline and combined the values into a 12-point scale. Patients were grouped into the following four risk categories according to their ceramide levels: low (0–2), intermediate (3–6), moderate (7–9), and high (10–12).

Researchers prospectively followed study participants for an average of eight years and recorded occurrences of heart attack, stroke, revascularization, and death. Overall, 5.1% of patients had a major cardiovascular event during the study. The risk of having an event increased as the level of ceramides in the blood increased; for each one-point increase in the ceramide risk score, the risk rose by 9%—a trend that remained even after fully adjusting for other risk factors, including age, sex, high blood pressure, smoking, total cholesterol, HDL, and markers of inflammation. In fact, the rate of events was double among people with the highest ceramide score, compared with those with the lowest (8.1% vs 4.1%). Total cholesterol also increased with rising ceramide scores, and males were less likely to have high levels of ceramides.

Among those without coronary artery disease upon angiography, the rate of cardiovascular events was 3.1%, which was lower than the average. But when researchers examined cardiovascular disease in this population by ceramide scores, people with the highest levels of ceramides were four times more likely to have an event, compared with those with the lowest (7.8% vs 2.2%). A similar trend was seen among people with low LDL levels (<100 mg/dL). In this group, the rate of heart attack, stroke and revascularization, and death was 3.7% among those with a low ceramide score, but increased to 16.4% in people with the highest ceramide levels.

“Ceramides continued to be significant and independently associated with disease even after adjusting for traditional and novel cardiovascular risk factors,” said Dr. Meeusen. “[Based on what we are seeing,] ceramides appear to be much more important than previously recognized.”

Marijuana Increases Risks of Stroke and Heart Failure

Using marijuana increases the risk of stroke and heart failure, even after accounting for demographic factors, other health conditions, and lifestyle risk factors such as smoking and alcohol use, researchers reported. Coming at a time when marijuana, medically known as cannabis, soon may become legal for medical or recreational use in more than half of US states, this study sheds new light on how the drug affects cardiovascular health. While previous marijuana research has focused mostly on pulmonary and psychiatric complications, the new study is one of only a handful to investigate cardiovascular outcomes.

“Like all other drugs, whether they are prescribed or not prescribed, we want to know the effects and side effects of this drug,” said Aditi Kalla, MD, Cardiology Fellow at the Einstein Medical Center in Philadelphia and the study’s lead author. “It is important for physicians to know these effects so we can better educate patients, such as those who are inquiring about the safety of cannabis or even asking for a prescription for cannabis.”

The study drew data from the Nationwide Inpatient Sample, which includes the health records of patients admitted at more than 1,000 hospitals comprising about 20% of US medical centers. Researchers extracted records from young and middle-aged patients—ages 18 to 55—who were discharged from hospitals in 2009 and 2010, when marijuana use was illegal in most states.

Marijuana use was diagnosed in about 1.5% (316,000) of more than 20 million health records included in the analysis. Comparing cardiovascular disease rates in these patients to disease rates in patients not reporting marijuana use, researchers found that marijuana use was associated with a significantly increased risk for stroke, heart failure, coronary artery disease, and sudden cardiac death.

Marijuana use was also linked with various factors known to increase cardiovascular risk, such as obesity, high blood pressure, smoking, and alcohol use. After researchers adjusted the analysis to account for these factors, marijuana use was independently associated with a 26% increase in the risk of stroke and a 10% increase in the risk of developing heart failure.

“Even when we corrected for known risk factors, we still found a higher rate of both stroke and heart failure in these patients, so that leads us to believe that there is something else going on besides just obesity or diet-related cardiovascular side effects,” said Dr. Kalla. “More research will be needed to understand the pathophysiology behind this effect.”

Research in cell cultures shows that heart muscle cells have cannabis receptors relevant to contractility, thus suggesting that those receptors might be one mechanism through which marijuana use could affect the cardiovascular system. It is possible that other compounds could be developed to counteract that mechanism and reduce cardiovascular risk, said Dr. Kalla.

Because the study was based on hospital discharge records, the findings may not reflect the general population. The study was also limited by the researchers’ inability to account for quantity or frequency of marijuana use, purpose of use (ie, recreational or medical), or delivery mechanism (eg, smoking or ingestion).

The growing trend toward legalization of marijuana could mean that patients and doctors will become more comfortable speaking openly about marijuana use, which could allow for better data collection and further insights into the drug’s effects and side effects, said Dr. Kalla.

Study Examines Best Time to Screen for Sleep Apnea After Heart Attack

Conducting a diagnostic sleep test shortly after a heart attack can help doctors rule out sleep apnea in patients, but tests conducted in the immediate aftermath of a heart attack are somewhat unreliable for positively diagnosing sleep apnea, according to results from a single-center study. As a result, it may be best to repeat the test after a few months or to delay initial testing before making a definitive diagnosis and initiating treatment.

“In view of the strong association between sleep disordered breathing and heart attack and the established negative prognostic implications of untreated sleep apnea in these patients, cardiologists are becoming increasingly aware of the importance of screening for sleep disorders in their daily practice,” said Jeanette Ting, MBChB, senior resident at National University Heart Centre in Singapore, the study’s lead author. “Our aim was to determine if the screening should be performed during the acute phase soon after a heart attack or after a period of stabilization.”

Sleep apnea is thought to contribute to cardiovascular disease by increasing stress on the heart and blood vessels, causing inflammation, reducing available oxygen, and affecting hormones. Doctors can use questionnaires to identify patients who might have sleep apnea, but the only definitive test is an overnight sleep study, in which a specialist uses electrodes and sensors to monitor how often the patient stops breathing during sleep and the length of each pause.

For the study, researchers performed an overnight sleep test in 397 patients treated for heart attack at Singapore’s National University Heart Center. This initial test was conducted within five days of hospital admission. A subgroup of 102 patients underwent a second sleep test at home six months later.

In all, 52% of patients tested positive for sleep apnea in the initial test. Forty-two percent had obstructive sleep apnea, the most common form of the disorder. In addition, 10% had central sleep apnea.

About one-quarter of the patients underwent a second sleep study after six months. A majority of the patients initially found to have sleep apnea showed a change of status in the follow-up sleep study. Among those initially diagnosed with obstructive sleep apnea, 46% no longer had sleep apnea at the six-month test. Among those initially diagnosed with central sleep apnea, 83% were found to have obstructive sleep apnea at the six-month test. The vast majority (93%) of those initially found to have no sleep apnea remained apnea-free at six months.

Overall, patients with sleep apnea were older, had a higher BMI, and more often had high blood pressure, compared with those without sleep apnea. Patients showed no significant change in BMI between the first and second sleep tests.

Zika Virus May Harm the Heart

As the Zika virus continues to spread globally, new evidence has emerged about the virus’s potentially detrimental effects on the heart, according to the first study to report Zika-related heart troubles following infection. The investigation included adult patients with no prior history of cardiovascular disease who were treated at the Institute of Tropical Medicine in Caracas, Venezuela, one of the epicenters of the Zika virus outbreak. All but one patient developed a dangerous heart rhythm problem, and two-thirds had evidence of heart failure.

“Our report provides clear evidence that there is a relationship between the Zika virus infection and cardiovascular complications,” said Karina Gonzalez Carta, MD, a cardiologist and research fellow at the department of cardiovascular diseases at Mayo Clinic in Rochester, Minnesota, and the study’s lead author. “Based on these initial results, people need to be aware that if they travel to or live in a place with known Zika virus and develop a rash, fever, or conjunctivitis, and within a short timeframe also feel other symptoms such as fatigue, shortness of breath, or their heart skipping beats, they should see their doctor.”

Dr. Carta and her team were not entirely surprised by their findings, as they follow trends seen with other mosquito-borne diseases known to affect the heart, including the dengue and Chikungunya viruses. However, she noted that the burden and severity of heart problems, including rapidly progressive heart failure and potentially life-threatening arrhythmias, among these patients was unexpected.

Nine patients who were seen in the clinic in Caracas within one week of having Zika-type symptoms and who subsequently reported common symptoms of heart problems, most commonly palpitations followed by shortness of breath and fatigue, were included in this small, prospective case report. One patient had previous cardiovascular problems (ie, well-controlled high blood pressure), and laboratory tests confirmed that all had active Zika infection. Patients were asked to fill out a form to record their symptoms and underwent an initial ECG. These findings prompted researchers to perform a full cardiovascular work up using an echocardiogram, 24-hour Holter monitor, and a cardiac MRI study. Of the nine patients, six were female, with a mean age of 47. They were followed for an average of six months, beginning in July 2016.

Dangerous arrhythmias were detected in eight of the nine patients: three cases of atrial fibrillation, two cases of nonsustained atrial tachycardia, and two cases of ventricular arrhythmias, which can be deadly. Heart failure was present in six cases. Of these, five patients had heart failure with low ejection fraction, and one had heart failure with preserved ejection fraction along with pre-eclampsia and a moderate to severe amount of pericardial effusion. So far, none of the patients’ cardiac issues have resolved, though symptoms are much improved due to guideline-directed treatment for heart failure or atrial fibrillation. Cardiovascular symptoms tend to manifest later in the process. Data show an average lag of 10 days from patients’ initial complaints of Zika symptoms to reports of symptoms suggestive of heart problems.

“Since the majority of people with Zika virus infections present with mild or nonspecific symptoms, and symptoms of cardiovascular complications may not occur right away, we need to raise awareness about the possible association,” Dr. Carta said.

Serum Ceramide Levels Predict Cardiovascular Events

Measuring concentrations of a class of lipids known as ceramides in the blood may help clinicians identify individuals with suspected coronary heart disease who need treatment or should be followed more closely, according to research. Although previous research conducted outside the US has shown elevated ceramide levels among people with confirmed heart disease or post heart attack, this is the first study to show its predictive power among people with no blockages and in those with low levels of low-density lipoprotein (LDL).

Study data show that ceramides were able to predict major cardiovascular events (ie, heart attack, stroke, revascularization, and death) among patients with and without evidence of blockages and in those with low LDL. In fact, individuals with the highest levels of blood ceramides had a threefold to fourfold greater risk of having a cardiovascular event, compared with those with the lowest ceramide score, regardless of their LDL cholesterol level or the presence of a blockage in the heart’s arteries.

“Based on our findings, measuring ceramides in the blood appears to be a new, potentially better marker than LDL in predicting first and repeat cardiac events in both patients with and without established coronary blockages,” said Jeff Meeusen, PhD, a clinical chemist and codirector of Cardiovascular Laboratory Medicine at Mayo Clinic in Rochester, Minnesota, and the study’s lead author. “Heart disease remains the number one killer in the United States. Measuring ceramides offers another piece of information to help identify individuals who might need a little more attention, guide treatment decisions, and keep patients motivated to [live heart healthier].”

Unlike cholesterol, which is fairly inert, acting like a clog in the arteries, ceramides play an active role in the cardiovascular disease process by attracting and drawing inflammatory cells and promoting clotting. All cells have the ability to make ceramides; however, ceramide levels tend to accumulate in the blood when one has too much fat or consumes excess calories.

The study included 499 patients at Mayo Clinic who were referred for coronary angiography to check for possible blockages in the heart’s arteries. About 46% of participants had evidence of a blockage. Coronary artery disease was defined as 50% stenosis in one or more artery. Patients were similar in age and with regard to blood pressure, smoking status, and high-density lipoprotein (HDL). Those who had diabetes or a previous heart attack, stroke, or procedure to open narrowed coronary arteries were excluded. Researchers measured four types of ceramides in the blood at baseline and combined the values into a 12-point scale. Patients were grouped into the following four risk categories according to their ceramide levels: low (0–2), intermediate (3–6), moderate (7–9), and high (10–12).

Researchers prospectively followed study participants for an average of eight years and recorded occurrences of heart attack, stroke, revascularization, and death. Overall, 5.1% of patients had a major cardiovascular event during the study. The risk of having an event increased as the level of ceramides in the blood increased; for each one-point increase in the ceramide risk score, the risk rose by 9%—a trend that remained even after fully adjusting for other risk factors, including age, sex, high blood pressure, smoking, total cholesterol, HDL, and markers of inflammation. In fact, the rate of events was double among people with the highest ceramide score, compared with those with the lowest (8.1% vs 4.1%). Total cholesterol also increased with rising ceramide scores, and males were less likely to have high levels of ceramides.

Among those without coronary artery disease upon angiography, the rate of cardiovascular events was 3.1%, which was lower than the average. But when researchers examined cardiovascular disease in this population by ceramide scores, people with the highest levels of ceramides were four times more likely to have an event, compared with those with the lowest (7.8% vs 2.2%). A similar trend was seen among people with low LDL levels (<100 mg/dL). In this group, the rate of heart attack, stroke and revascularization, and death was 3.7% among those with a low ceramide score, but increased to 16.4% in people with the highest ceramide levels.

“Ceramides continued to be significant and independently associated with disease even after adjusting for traditional and novel cardiovascular risk factors,” said Dr. Meeusen. “[Based on what we are seeing,] ceramides appear to be much more important than previously recognized.”

Marijuana Increases Risks of Stroke and Heart Failure

Using marijuana increases the risk of stroke and heart failure, even after accounting for demographic factors, other health conditions, and lifestyle risk factors such as smoking and alcohol use, researchers reported. Coming at a time when marijuana, medically known as cannabis, soon may become legal for medical or recreational use in more than half of US states, this study sheds new light on how the drug affects cardiovascular health. While previous marijuana research has focused mostly on pulmonary and psychiatric complications, the new study is one of only a handful to investigate cardiovascular outcomes.

“Like all other drugs, whether they are prescribed or not prescribed, we want to know the effects and side effects of this drug,” said Aditi Kalla, MD, Cardiology Fellow at the Einstein Medical Center in Philadelphia and the study’s lead author. “It is important for physicians to know these effects so we can better educate patients, such as those who are inquiring about the safety of cannabis or even asking for a prescription for cannabis.”

The study drew data from the Nationwide Inpatient Sample, which includes the health records of patients admitted at more than 1,000 hospitals comprising about 20% of US medical centers. Researchers extracted records from young and middle-aged patients—ages 18 to 55—who were discharged from hospitals in 2009 and 2010, when marijuana use was illegal in most states.

Marijuana use was diagnosed in about 1.5% (316,000) of more than 20 million health records included in the analysis. Comparing cardiovascular disease rates in these patients to disease rates in patients not reporting marijuana use, researchers found that marijuana use was associated with a significantly increased risk for stroke, heart failure, coronary artery disease, and sudden cardiac death.

Marijuana use was also linked with various factors known to increase cardiovascular risk, such as obesity, high blood pressure, smoking, and alcohol use. After researchers adjusted the analysis to account for these factors, marijuana use was independently associated with a 26% increase in the risk of stroke and a 10% increase in the risk of developing heart failure.

“Even when we corrected for known risk factors, we still found a higher rate of both stroke and heart failure in these patients, so that leads us to believe that there is something else going on besides just obesity or diet-related cardiovascular side effects,” said Dr. Kalla. “More research will be needed to understand the pathophysiology behind this effect.”

Research in cell cultures shows that heart muscle cells have cannabis receptors relevant to contractility, thus suggesting that those receptors might be one mechanism through which marijuana use could affect the cardiovascular system. It is possible that other compounds could be developed to counteract that mechanism and reduce cardiovascular risk, said Dr. Kalla.

Because the study was based on hospital discharge records, the findings may not reflect the general population. The study was also limited by the researchers’ inability to account for quantity or frequency of marijuana use, purpose of use (ie, recreational or medical), or delivery mechanism (eg, smoking or ingestion).

The growing trend toward legalization of marijuana could mean that patients and doctors will become more comfortable speaking openly about marijuana use, which could allow for better data collection and further insights into the drug’s effects and side effects, said Dr. Kalla.

Study Examines Best Time to Screen for Sleep Apnea After Heart Attack

Conducting a diagnostic sleep test shortly after a heart attack can help doctors rule out sleep apnea in patients, but tests conducted in the immediate aftermath of a heart attack are somewhat unreliable for positively diagnosing sleep apnea, according to results from a single-center study. As a result, it may be best to repeat the test after a few months or to delay initial testing before making a definitive diagnosis and initiating treatment.

“In view of the strong association between sleep disordered breathing and heart attack and the established negative prognostic implications of untreated sleep apnea in these patients, cardiologists are becoming increasingly aware of the importance of screening for sleep disorders in their daily practice,” said Jeanette Ting, MBChB, senior resident at National University Heart Centre in Singapore, the study’s lead author. “Our aim was to determine if the screening should be performed during the acute phase soon after a heart attack or after a period of stabilization.”

Sleep apnea is thought to contribute to cardiovascular disease by increasing stress on the heart and blood vessels, causing inflammation, reducing available oxygen, and affecting hormones. Doctors can use questionnaires to identify patients who might have sleep apnea, but the only definitive test is an overnight sleep study, in which a specialist uses electrodes and sensors to monitor how often the patient stops breathing during sleep and the length of each pause.

For the study, researchers performed an overnight sleep test in 397 patients treated for heart attack at Singapore’s National University Heart Center. This initial test was conducted within five days of hospital admission. A subgroup of 102 patients underwent a second sleep test at home six months later.

In all, 52% of patients tested positive for sleep apnea in the initial test. Forty-two percent had obstructive sleep apnea, the most common form of the disorder. In addition, 10% had central sleep apnea.

About one-quarter of the patients underwent a second sleep study after six months. A majority of the patients initially found to have sleep apnea showed a change of status in the follow-up sleep study. Among those initially diagnosed with obstructive sleep apnea, 46% no longer had sleep apnea at the six-month test. Among those initially diagnosed with central sleep apnea, 83% were found to have obstructive sleep apnea at the six-month test. The vast majority (93%) of those initially found to have no sleep apnea remained apnea-free at six months.

Overall, patients with sleep apnea were older, had a higher BMI, and more often had high blood pressure, compared with those without sleep apnea. Patients showed no significant change in BMI between the first and second sleep tests.

“This is one of the most vexing issues in vascular neurology nowadays, because we know [that] … patients in atrial fibrillation are at exceedingly high risk for one or more strokes, especially recurrent strokes,” said Mark J. Alberts, MD, Chief of Neurology at Hartford Hospital in Connecticut. Dr. Alberts did not participate in the study.

Although ICH location (ie, lobar vs nonlobar) provides information about etiology and the risk of ICH recurrence, previous studies have not examined the effect of ICH location on oral anticoagulation resumption. Previous studies also have not examined functional outcome following resumption of oral anticoagulation after ICH.

Meta-Analysis Included Three Trials

To address these questions, Dr. Biffi and colleagues conducted a meta-analysis of patient data from three studies of ICH. The studies were a German investigation that included 542 patients, an American investigation of 268 patients, and another American study of 217 patients. Eligible participants were 18 or older, had a diagnosis of acute ICH confirmed by CT, and were taking oral anticoagulants to prevent cardioembolic stroke resulting from nonvalvular atrial fibrillation. Patients with a history of prior ICH were excluded.

Dr. Biffi and colleagues assessed whether, at one year after ICH, resumption of oral anticoagulation was associated with mortality, favorable functional outcome (defined as modified Rankin Scale [mRS] score of 0 to 3), or recurrent ICH and ischemic stroke. They used multivariable Cox regression models to analyze nonlobar and lobar ICH cases separately.

Anticoagulation Resumption Reduced Mortality

In all, 641 patients had nonlobar ICH at baseline, and 386 participants had lobar ICH. Among patients with nonlobar ICH, 179 (28%) resumed oral anticoagulation therapy. Eighty-eight (23%) of patients with lobar ICH resumed anticoagulation therapy. ICH volume and CHADS2 and HAS-BLED scores were not associated with oral anticoagulation resumption in either lobar or nonlobar ICH. Discharge mRS was associated with oral anticoagulation resumption in lobar ICH only.

In multivariable analyses, resumption of oral anticoagulation after nonlobar ICH was associated with decreased mortality (hazard ratio [HR], 0.22) and improved functional outcome (HR, 5.12) at one year. Oral anticoagulation resumption after lobar ICH was associated with decreased mortality (HR, 0.25) and favorable functional outcome (HR, 4.89).

One limitation of the meta-analysis is that it examined observational studies, which are susceptible to ascertainment bias. “Physicians are going to do what they think is in the best interest of the patients, so you have bias in terms of who gets started and does not get started [on oral anticoagulation therapy],” said Dr. Alberts. Another limitation is that few patients in the meta-analysis used a new oral anticoagulant.

Many variables influence the decision about whether a patient should resume oral anticoagulation, including the severity of the initial stroke, the patient’s risk profile, and the size of the patient’s left atrium. “We need data from prospective randomized trials to figure out what the best approach is,” Dr. Alberts concluded.

Dr. Biffi’s meta-analysis was funded by a grant from the NIH.

—Erik Greb

Suggested Reading

Goldstein JN, Greenberg SM. Should anticoagulation be resumed after intracerebral hemorrhage? Cleve Clin J Med. 2010;77(11):791-799.

Nielsen PB, Larsen TB, Skjøth F, Lip GY. Outcomes associated with resuming warfarin treatment after hemorrhagic stroke or traumatic intracranial hemorrhage in patients with atrial fibrillation. JAMA Intern Med. 2017 Feb 20 [Epub ahead of print].

Poli D, Antonucci E, Dentali F, et al. Recurrence of ICH after resumption of anticoagulation with VK antagonists: CHIRONE study. Neurology. 2014;82(12):1020-1026.

“This is one of the most vexing issues in vascular neurology nowadays, because we know [that] … patients in atrial fibrillation are at exceedingly high risk for one or more strokes, especially recurrent strokes,” said Mark J. Alberts, MD, Chief of Neurology at Hartford Hospital in Connecticut. Dr. Alberts did not participate in the study.

Although ICH location (ie, lobar vs nonlobar) provides information about etiology and the risk of ICH recurrence, previous studies have not examined the effect of ICH location on oral anticoagulation resumption. Previous studies also have not examined functional outcome following resumption of oral anticoagulation after ICH.

Meta-Analysis Included Three Trials

To address these questions, Dr. Biffi and colleagues conducted a meta-analysis of patient data from three studies of ICH. The studies were a German investigation that included 542 patients, an American investigation of 268 patients, and another American study of 217 patients. Eligible participants were 18 or older, had a diagnosis of acute ICH confirmed by CT, and were taking oral anticoagulants to prevent cardioembolic stroke resulting from nonvalvular atrial fibrillation. Patients with a history of prior ICH were excluded.

Dr. Biffi and colleagues assessed whether, at one year after ICH, resumption of oral anticoagulation was associated with mortality, favorable functional outcome (defined as modified Rankin Scale [mRS] score of 0 to 3), or recurrent ICH and ischemic stroke. They used multivariable Cox regression models to analyze nonlobar and lobar ICH cases separately.

Anticoagulation Resumption Reduced Mortality

In all, 641 patients had nonlobar ICH at baseline, and 386 participants had lobar ICH. Among patients with nonlobar ICH, 179 (28%) resumed oral anticoagulation therapy. Eighty-eight (23%) of patients with lobar ICH resumed anticoagulation therapy. ICH volume and CHADS2 and HAS-BLED scores were not associated with oral anticoagulation resumption in either lobar or nonlobar ICH. Discharge mRS was associated with oral anticoagulation resumption in lobar ICH only.

In multivariable analyses, resumption of oral anticoagulation after nonlobar ICH was associated with decreased mortality (hazard ratio [HR], 0.22) and improved functional outcome (HR, 5.12) at one year. Oral anticoagulation resumption after lobar ICH was associated with decreased mortality (HR, 0.25) and favorable functional outcome (HR, 4.89).

One limitation of the meta-analysis is that it examined observational studies, which are susceptible to ascertainment bias. “Physicians are going to do what they think is in the best interest of the patients, so you have bias in terms of who gets started and does not get started [on oral anticoagulation therapy],” said Dr. Alberts. Another limitation is that few patients in the meta-analysis used a new oral anticoagulant.

Many variables influence the decision about whether a patient should resume oral anticoagulation, including the severity of the initial stroke, the patient’s risk profile, and the size of the patient’s left atrium. “We need data from prospective randomized trials to figure out what the best approach is,” Dr. Alberts concluded.

Dr. Biffi’s meta-analysis was funded by a grant from the NIH.

—Erik Greb

Suggested Reading

Goldstein JN, Greenberg SM. Should anticoagulation be resumed after intracerebral hemorrhage? Cleve Clin J Med. 2010;77(11):791-799.

Nielsen PB, Larsen TB, Skjøth F, Lip GY. Outcomes associated with resuming warfarin treatment after hemorrhagic stroke or traumatic intracranial hemorrhage in patients with atrial fibrillation. JAMA Intern Med. 2017 Feb 20 [Epub ahead of print].

Poli D, Antonucci E, Dentali F, et al. Recurrence of ICH after resumption of anticoagulation with VK antagonists: CHIRONE study. Neurology. 2014;82(12):1020-1026.

“This is one of the most vexing issues in vascular neurology nowadays, because we know [that] … patients in atrial fibrillation are at exceedingly high risk for one or more strokes, especially recurrent strokes,” said Mark J. Alberts, MD, Chief of Neurology at Hartford Hospital in Connecticut. Dr. Alberts did not participate in the study.

Although ICH location (ie, lobar vs nonlobar) provides information about etiology and the risk of ICH recurrence, previous studies have not examined the effect of ICH location on oral anticoagulation resumption. Previous studies also have not examined functional outcome following resumption of oral anticoagulation after ICH.

Meta-Analysis Included Three Trials

To address these questions, Dr. Biffi and colleagues conducted a meta-analysis of patient data from three studies of ICH. The studies were a German investigation that included 542 patients, an American investigation of 268 patients, and another American study of 217 patients. Eligible participants were 18 or older, had a diagnosis of acute ICH confirmed by CT, and were taking oral anticoagulants to prevent cardioembolic stroke resulting from nonvalvular atrial fibrillation. Patients with a history of prior ICH were excluded.

Dr. Biffi and colleagues assessed whether, at one year after ICH, resumption of oral anticoagulation was associated with mortality, favorable functional outcome (defined as modified Rankin Scale [mRS] score of 0 to 3), or recurrent ICH and ischemic stroke. They used multivariable Cox regression models to analyze nonlobar and lobar ICH cases separately.

Anticoagulation Resumption Reduced Mortality

In all, 641 patients had nonlobar ICH at baseline, and 386 participants had lobar ICH. Among patients with nonlobar ICH, 179 (28%) resumed oral anticoagulation therapy. Eighty-eight (23%) of patients with lobar ICH resumed anticoagulation therapy. ICH volume and CHADS2 and HAS-BLED scores were not associated with oral anticoagulation resumption in either lobar or nonlobar ICH. Discharge mRS was associated with oral anticoagulation resumption in lobar ICH only.

In multivariable analyses, resumption of oral anticoagulation after nonlobar ICH was associated with decreased mortality (hazard ratio [HR], 0.22) and improved functional outcome (HR, 5.12) at one year. Oral anticoagulation resumption after lobar ICH was associated with decreased mortality (HR, 0.25) and favorable functional outcome (HR, 4.89).

One limitation of the meta-analysis is that it examined observational studies, which are susceptible to ascertainment bias. “Physicians are going to do what they think is in the best interest of the patients, so you have bias in terms of who gets started and does not get started [on oral anticoagulation therapy],” said Dr. Alberts. Another limitation is that few patients in the meta-analysis used a new oral anticoagulant.

Many variables influence the decision about whether a patient should resume oral anticoagulation, including the severity of the initial stroke, the patient’s risk profile, and the size of the patient’s left atrium. “We need data from prospective randomized trials to figure out what the best approach is,” Dr. Alberts concluded.

Dr. Biffi’s meta-analysis was funded by a grant from the NIH.

—Erik Greb

Suggested Reading

Goldstein JN, Greenberg SM. Should anticoagulation be resumed after intracerebral hemorrhage? Cleve Clin J Med. 2010;77(11):791-799.

Nielsen PB, Larsen TB, Skjøth F, Lip GY. Outcomes associated with resuming warfarin treatment after hemorrhagic stroke or traumatic intracranial hemorrhage in patients with atrial fibrillation. JAMA Intern Med. 2017 Feb 20 [Epub ahead of print].

Poli D, Antonucci E, Dentali F, et al. Recurrence of ICH after resumption of anticoagulation with VK antagonists: CHIRONE study. Neurology. 2014;82(12):1020-1026.

PHILADELPHIA – The main lesson for discordant data regarding the benefit of corticosteroids for alcoholic hepatitis is that mortality reductions accrue only to those patients who have advanced hepatitis but have not yet developed end-stage disease, according to a detailed look at published studies presented at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.

The relative benefit even in appropriate candidates is modest, according to Kevin Mullen, MD, chief of digestive diseases, West Virginia University, Morgantown. By his calculations, there is a survival benefit for one of every five to seven patients treated, and that survival benefit endures only 6-12 months.

PHILADELPHIA – The main lesson for discordant data regarding the benefit of corticosteroids for alcoholic hepatitis is that mortality reductions accrue only to those patients who have advanced hepatitis but have not yet developed end-stage disease, according to a detailed look at published studies presented at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.

The relative benefit even in appropriate candidates is modest, according to Kevin Mullen, MD, chief of digestive diseases, West Virginia University, Morgantown. By his calculations, there is a survival benefit for one of every five to seven patients treated, and that survival benefit endures only 6-12 months.

PHILADELPHIA – The main lesson for discordant data regarding the benefit of corticosteroids for alcoholic hepatitis is that mortality reductions accrue only to those patients who have advanced hepatitis but have not yet developed end-stage disease, according to a detailed look at published studies presented at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.

The relative benefit even in appropriate candidates is modest, according to Kevin Mullen, MD, chief of digestive diseases, West Virginia University, Morgantown. By his calculations, there is a survival benefit for one of every five to seven patients treated, and that survival benefit endures only 6-12 months.

NATIONAL HARBOR, MD – A large hereditary cancer study supports National Comprehensive Cancer Network guidance to consider risk-reducing salpingo-oophorectomy (RRSO) between ages 45 and 50 years for women with BRIP1, RAD51C, or RAD51D mutations, Lydia Usha, MD, said at the annual meeting of the Society of Gynecologic Oncology.

The average ages for an ovarian cancer diagnosis were 56 years for women with RAD51D mutations, 61 years for RAD51C mutations, and 64 years for BRIP1 mutations, said Dr. Usha of Rush Medical College, Chicago. When appropriate, delaying RRSO “avoids the psychosocial and medical complications of premature menopause,” she said.

Amy Karon/Frontline Medical News

NATIONAL HARBOR, MD – A large hereditary cancer study supports National Comprehensive Cancer Network guidance to consider risk-reducing salpingo-oophorectomy (RRSO) between ages 45 and 50 years for women with BRIP1, RAD51C, or RAD51D mutations, Lydia Usha, MD, said at the annual meeting of the Society of Gynecologic Oncology.

The average ages for an ovarian cancer diagnosis were 56 years for women with RAD51D mutations, 61 years for RAD51C mutations, and 64 years for BRIP1 mutations, said Dr. Usha of Rush Medical College, Chicago. When appropriate, delaying RRSO “avoids the psychosocial and medical complications of premature menopause,” she said.

Amy Karon/Frontline Medical News

NATIONAL HARBOR, MD – A large hereditary cancer study supports National Comprehensive Cancer Network guidance to consider risk-reducing salpingo-oophorectomy (RRSO) between ages 45 and 50 years for women with BRIP1, RAD51C, or RAD51D mutations, Lydia Usha, MD, said at the annual meeting of the Society of Gynecologic Oncology.

The average ages for an ovarian cancer diagnosis were 56 years for women with RAD51D mutations, 61 years for RAD51C mutations, and 64 years for BRIP1 mutations, said Dr. Usha of Rush Medical College, Chicago. When appropriate, delaying RRSO “avoids the psychosocial and medical complications of premature menopause,” she said.

Amy Karon/Frontline Medical News

Dupilumab, a monoclonal antibody that targets both interleukin-4 and interleukin-13, has been approved for the treatment of moderate to severe atopic dermatitis in adults not adequately controlled with topical prescription therapies or for whom topicals are not appropriate.

The approval marks the first biologic approved for treating AD, according to a March 28 announcement from the Food and Drug Administration.

The FDA approval announcement noted that the safety and efficacy of dupilumab had not been established in patients with asthma. 

Dupilumab currently is being studied for children with AD in phase II studies and is being studied for other indications: eosinophilic esophagitis in phase II studies, and asthma and nasal polyps in phase III studies.

Dupilumab will be marketed as Dupixent by Regeneron.

emechcatie@frontlinemedcom.com

Dupilumab, a monoclonal antibody that targets both interleukin-4 and interleukin-13, has been approved for the treatment of moderate to severe atopic dermatitis in adults not adequately controlled with topical prescription therapies or for whom topicals are not appropriate.

The approval marks the first biologic approved for treating AD, according to a March 28 announcement from the Food and Drug Administration.

The FDA approval announcement noted that the safety and efficacy of dupilumab had not been established in patients with asthma. 

Dupilumab currently is being studied for children with AD in phase II studies and is being studied for other indications: eosinophilic esophagitis in phase II studies, and asthma and nasal polyps in phase III studies.

Dupilumab will be marketed as Dupixent by Regeneron.

emechcatie@frontlinemedcom.com

Dupilumab, a monoclonal antibody that targets both interleukin-4 and interleukin-13, has been approved for the treatment of moderate to severe atopic dermatitis in adults not adequately controlled with topical prescription therapies or for whom topicals are not appropriate.

The approval marks the first biologic approved for treating AD, according to a March 28 announcement from the Food and Drug Administration.

The FDA approval announcement noted that the safety and efficacy of dupilumab had not been established in patients with asthma. 

Dupilumab currently is being studied for children with AD in phase II studies and is being studied for other indications: eosinophilic esophagitis in phase II studies, and asthma and nasal polyps in phase III studies.

Dupilumab will be marketed as Dupixent by Regeneron.

emechcatie@frontlinemedcom.com

PHILADELPHIA – There is a long list of benefits from bariatric surgery in the morbidly obese, but prevention of end-stage liver disease and the need for a first or second liver transplant is likely to grow as an indication, according to an overview of weight loss surgery at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.

“Bariatric surgery is associated with significant improvement not just in diabetes, dyslipidemia, hypertension, and other complications of metabolic disorders but for me more interestingly, it is effective for treating fatty liver disease where you can see a 90% improvement in steatosis,” reported Subhashini Ayloo, MD, chief of minimally invasive robotic hepato-pancreato-biliary surgery and liver transplantation at New Jersey Medical School, Newark.

Trained in both bariatric surgery and liver transplant, Dr. Ayloo predicts that these fields will become increasingly connected because of the obesity epidemic and the related rise in nonalcoholic fatty liver disease (NAFLD). Dr. Ayloo reported that bariatric surgery is already being used in her center to avoid a second liver transplant in obese patients who are unable to lose sufficient weight to prevent progressive NAFLD after a first transplant.

Courtesy of Wikimedia / Nephron / Creative Commons License

Global Academy and this news organization are owned by the same company. Dr. Ayloo reports no relevant financial relationships.

PHILADELPHIA – There is a long list of benefits from bariatric surgery in the morbidly obese, but prevention of end-stage liver disease and the need for a first or second liver transplant is likely to grow as an indication, according to an overview of weight loss surgery at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.

“Bariatric surgery is associated with significant improvement not just in diabetes, dyslipidemia, hypertension, and other complications of metabolic disorders but for me more interestingly, it is effective for treating fatty liver disease where you can see a 90% improvement in steatosis,” reported Subhashini Ayloo, MD, chief of minimally invasive robotic hepato-pancreato-biliary surgery and liver transplantation at New Jersey Medical School, Newark.

Trained in both bariatric surgery and liver transplant, Dr. Ayloo predicts that these fields will become increasingly connected because of the obesity epidemic and the related rise in nonalcoholic fatty liver disease (NAFLD). Dr. Ayloo reported that bariatric surgery is already being used in her center to avoid a second liver transplant in obese patients who are unable to lose sufficient weight to prevent progressive NAFLD after a first transplant.

Courtesy of Wikimedia / Nephron / Creative Commons License

Global Academy and this news organization are owned by the same company. Dr. Ayloo reports no relevant financial relationships.

PHILADELPHIA – There is a long list of benefits from bariatric surgery in the morbidly obese, but prevention of end-stage liver disease and the need for a first or second liver transplant is likely to grow as an indication, according to an overview of weight loss surgery at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.

“Bariatric surgery is associated with significant improvement not just in diabetes, dyslipidemia, hypertension, and other complications of metabolic disorders but for me more interestingly, it is effective for treating fatty liver disease where you can see a 90% improvement in steatosis,” reported Subhashini Ayloo, MD, chief of minimally invasive robotic hepato-pancreato-biliary surgery and liver transplantation at New Jersey Medical School, Newark.

Trained in both bariatric surgery and liver transplant, Dr. Ayloo predicts that these fields will become increasingly connected because of the obesity epidemic and the related rise in nonalcoholic fatty liver disease (NAFLD). Dr. Ayloo reported that bariatric surgery is already being used in her center to avoid a second liver transplant in obese patients who are unable to lose sufficient weight to prevent progressive NAFLD after a first transplant.

Courtesy of Wikimedia / Nephron / Creative Commons License

Global Academy and this news organization are owned by the same company. Dr. Ayloo reports no relevant financial relationships.

ORLANDO—A high-salt diet might be a key environmental risk factor for multiple sclerosis (MS), according to an overview presented at the ACTRIMS 2017 Forum. Since most research has been performed in vitro and in animal models, it remains unclear how a high-salt diet affects patients with MS. Researchers have found in experimental models, however, that salt induces inflammation by several mechanisms: it increases frequency of inflammatory TH17 cells, decreases function of suppressor cells, and increases inflammation of antigen-presenting cells.

“There’s been an epidemic of human autoimmune disease over the past 70 years,” said Dr. Hafler. Researchers are working to discover why there has been such a significant rise in cases. “Genetics cannot allow this to happen. There must be something in the environment,” said Dr. Hafler. He and his colleagues sought to understand how a high-salt diet affects MS.

“What we found is if you added sodium chloride to cultures of T cells, you have autoimmune increases in the frequency of TH17 cells,” he said. In addition, salt decreases function of suppressor cells, the Tregs, and increases inflammation of antigen-presenting cells of the immune system, said Dr. Hafler.

Previous research found that mice fed a high-salt diet were more prone to severe experimental autoimmune encephalomyelitis. When the mice were given a high-salt, high-fat diet that mimicked fast food and probiotics, researchers observed a decrease in inflammation.

“It is really surprising to me how diet can really influence the degree of inflammation in these animals,” said Dr. Hafler. “We do not know if this will work in humans, but probiotics may decrease inflammation. We have no information [on] whether a diet with a probiotic would help prevent or treat MS.”

According to Farez et al, a higher sodium intake is associated with increased clinical and radiological disease activity in patients with MS. Other studies have found that environmental factors such as smoking and low vitamin D levels are associated with MS risk, and the risk is genetically mediated. What may be an environmental risk for one individual may not be a risk for another individual, said Dr. Hafler. “It is unlikely that any of these factors by themselves—smoking, vitamin D, fat, and salt—would be critically important, but together, they might have a strong effect,” he said.

Since there is limited research on a high-salt diet in humans, Dr. Hafler does not recommend his patients with MS go on a strict low-salt diet. However, he does advise patients to stay away from processed foods and fast food. He also encourages patients to get most of their calories from fruits and vegetables.

“We are now doing studies in which we put patients and control subjects on a high-salt diet and low[-salt] diet to observe the direct effect in those individuals,” said Dr. Hafler.

—Erica Tricarico

Suggested Reading

Farez MF, Fiol MP, Gaitán MI, et al. Sodium intake is associated with increased disease activity in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2015;86(1):26-31.

Jörg S, Kissel J, Manzel A, et al. High salt drives Th17 responses in experimental autoimmune encephalomyelitis without impacting myeloid dendritic cells. Exp Neurol. 2016;279:212-222.

Kleinewietfeld M, Manzel A, Tize J, et al. Sodium chloride drives autoimmune disease by the induction of pathogenic TH17 cells. Nature. 2013;496(7446):518-522.

Paling D, Solanky BS, Riemer F, et al. Sodium accumulation is associated with disability and a progressive course in multiple sclerosis. Brain. 2013;136(Pt 7):2305-2317.

ORLANDO—A high-salt diet might be a key environmental risk factor for multiple sclerosis (MS), according to an overview presented at the ACTRIMS 2017 Forum. Since most research has been performed in vitro and in animal models, it remains unclear how a high-salt diet affects patients with MS. Researchers have found in experimental models, however, that salt induces inflammation by several mechanisms: it increases frequency of inflammatory TH17 cells, decreases function of suppressor cells, and increases inflammation of antigen-presenting cells.

“There’s been an epidemic of human autoimmune disease over the past 70 years,” said Dr. Hafler. Researchers are working to discover why there has been such a significant rise in cases. “Genetics cannot allow this to happen. There must be something in the environment,” said Dr. Hafler. He and his colleagues sought to understand how a high-salt diet affects MS.

“What we found is if you added sodium chloride to cultures of T cells, you have autoimmune increases in the frequency of TH17 cells,” he said. In addition, salt decreases function of suppressor cells, the Tregs, and increases inflammation of antigen-presenting cells of the immune system, said Dr. Hafler.

Previous research found that mice fed a high-salt diet were more prone to severe experimental autoimmune encephalomyelitis. When the mice were given a high-salt, high-fat diet that mimicked fast food and probiotics, researchers observed a decrease in inflammation.

“It is really surprising to me how diet can really influence the degree of inflammation in these animals,” said Dr. Hafler. “We do not know if this will work in humans, but probiotics may decrease inflammation. We have no information [on] whether a diet with a probiotic would help prevent or treat MS.”

According to Farez et al, a higher sodium intake is associated with increased clinical and radiological disease activity in patients with MS. Other studies have found that environmental factors such as smoking and low vitamin D levels are associated with MS risk, and the risk is genetically mediated. What may be an environmental risk for one individual may not be a risk for another individual, said Dr. Hafler. “It is unlikely that any of these factors by themselves—smoking, vitamin D, fat, and salt—would be critically important, but together, they might have a strong effect,” he said.

Since there is limited research on a high-salt diet in humans, Dr. Hafler does not recommend his patients with MS go on a strict low-salt diet. However, he does advise patients to stay away from processed foods and fast food. He also encourages patients to get most of their calories from fruits and vegetables.

“We are now doing studies in which we put patients and control subjects on a high-salt diet and low[-salt] diet to observe the direct effect in those individuals,” said Dr. Hafler.

—Erica Tricarico

Suggested Reading

Farez MF, Fiol MP, Gaitán MI, et al. Sodium intake is associated with increased disease activity in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2015;86(1):26-31.

Jörg S, Kissel J, Manzel A, et al. High salt drives Th17 responses in experimental autoimmune encephalomyelitis without impacting myeloid dendritic cells. Exp Neurol. 2016;279:212-222.

Kleinewietfeld M, Manzel A, Tize J, et al. Sodium chloride drives autoimmune disease by the induction of pathogenic TH17 cells. Nature. 2013;496(7446):518-522.

Paling D, Solanky BS, Riemer F, et al. Sodium accumulation is associated with disability and a progressive course in multiple sclerosis. Brain. 2013;136(Pt 7):2305-2317.

ORLANDO—A high-salt diet might be a key environmental risk factor for multiple sclerosis (MS), according to an overview presented at the ACTRIMS 2017 Forum. Since most research has been performed in vitro and in animal models, it remains unclear how a high-salt diet affects patients with MS. Researchers have found in experimental models, however, that salt induces inflammation by several mechanisms: it increases frequency of inflammatory TH17 cells, decreases function of suppressor cells, and increases inflammation of antigen-presenting cells.

“There’s been an epidemic of human autoimmune disease over the past 70 years,” said Dr. Hafler. Researchers are working to discover why there has been such a significant rise in cases. “Genetics cannot allow this to happen. There must be something in the environment,” said Dr. Hafler. He and his colleagues sought to understand how a high-salt diet affects MS.

“What we found is if you added sodium chloride to cultures of T cells, you have autoimmune increases in the frequency of TH17 cells,” he said. In addition, salt decreases function of suppressor cells, the Tregs, and increases inflammation of antigen-presenting cells of the immune system, said Dr. Hafler.

Previous research found that mice fed a high-salt diet were more prone to severe experimental autoimmune encephalomyelitis. When the mice were given a high-salt, high-fat diet that mimicked fast food and probiotics, researchers observed a decrease in inflammation.

“It is really surprising to me how diet can really influence the degree of inflammation in these animals,” said Dr. Hafler. “We do not know if this will work in humans, but probiotics may decrease inflammation. We have no information [on] whether a diet with a probiotic would help prevent or treat MS.”

According to Farez et al, a higher sodium intake is associated with increased clinical and radiological disease activity in patients with MS. Other studies have found that environmental factors such as smoking and low vitamin D levels are associated with MS risk, and the risk is genetically mediated. What may be an environmental risk for one individual may not be a risk for another individual, said Dr. Hafler. “It is unlikely that any of these factors by themselves—smoking, vitamin D, fat, and salt—would be critically important, but together, they might have a strong effect,” he said.

Since there is limited research on a high-salt diet in humans, Dr. Hafler does not recommend his patients with MS go on a strict low-salt diet. However, he does advise patients to stay away from processed foods and fast food. He also encourages patients to get most of their calories from fruits and vegetables.

“We are now doing studies in which we put patients and control subjects on a high-salt diet and low[-salt] diet to observe the direct effect in those individuals,” said Dr. Hafler.

—Erica Tricarico

Suggested Reading

Farez MF, Fiol MP, Gaitán MI, et al. Sodium intake is associated with increased disease activity in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2015;86(1):26-31.

Jörg S, Kissel J, Manzel A, et al. High salt drives Th17 responses in experimental autoimmune encephalomyelitis without impacting myeloid dendritic cells. Exp Neurol. 2016;279:212-222.

Kleinewietfeld M, Manzel A, Tize J, et al. Sodium chloride drives autoimmune disease by the induction of pathogenic TH17 cells. Nature. 2013;496(7446):518-522.

Paling D, Solanky BS, Riemer F, et al. Sodium accumulation is associated with disability and a progressive course in multiple sclerosis. Brain. 2013;136(Pt 7):2305-2317.

Your colleagues have a lot to say! Here are the top discussion threads in ACS Communities in March (all of these threads are from the General Surgery community):

1. Sully

Your colleagues have a lot to say! Here are the top discussion threads in ACS Communities in March (all of these threads are from the General Surgery community):

1. Sully

Your colleagues have a lot to say! Here are the top discussion threads in ACS Communities in March (all of these threads are from the General Surgery community):

1. Sully

HOUSTON—Hemorrhagic stroke sharply increases the risk of new-onset depression which, in turn, is associated with a 30% increased risk of dementia within five years, according to research presented at the International Stroke Conference 2017.

“This is of great importance from a research and clinical standpoint, as it may represent a marker of ongoing cognitive deterioration,” said Dr. Biffi.

Hemorrhagic Stroke and Mood Disorders

Previous studies have found that patients with ICH have a significantly increased risk of mood disorders and cognitive decline. “There is probably a link between mood disorders and cognition after ICH, as is the case for a number of other neurologic conditions,” said Dr. Biffi. “Cerebrovascular small-vessel disease is likely to be involved in the underlying pathogenesis for these disorders, as it is also a risk factor for late-life depression in the general population. Therefore, depression and dementia after ICH may share some etiologic connections.”

Dr. Biffi and his colleagues enrolled 695 patients with ICH into their study and followed them for a mean of five years. None of the subjects had ever been diagnosed with a mood disorder or cognitive decline. The researchers conducted telephone interviews with patients every six months.

At baseline, investigators collected CT and MRI imaging data, epidemiologic exposure data, and apolipoprotein E4 genotype. The outcomes were new-onset depression and incident dementia.

Subjects had a mean age of 74 at baseline. In addition, approximately 70% of patients had hypertension, and 15% had heart disease. Less than 1% of the cohort was positive for the APOE e4 gene. Imaging-confirmed white matter disease was present in 65% of participants. During the follow-up period, new-onset depression developed in 278 (40%) patients. The temporal incidence of this outcome was consistent at about 7% per year.

Factors That Influenced Risk of Dementia

Researchers discovered that having more than a single copy of the APOE e4 allele at baseline (hazard ratio [HR], 1.7) and the presence of white matter disease at baseline (HR, 1.82), were significantly associated with new-onset depression. Having had at least 10 years of school protected against depression (HR, 0.75), as did functional independence (HR, 0.52). By the end of the follow-up period, dementia had developed in 80% of individuals with depression (220). In 81% of cases, depression preceded dementia, with an average time lag of 1.5 years, said Dr. Biffi.

In a multivariate analysis, several factors were significantly associated with incident dementia. Higher education reduced the risk by 40% (HR, 0.60). Factors that increased the risk of dementia were black race (HR, 1.48), APOE e4 gene (HR, 2.12), white matter disease (HR, 1.7), and poststroke new-onset depression (HR, 1.29). The study shows only association, said Dr. Biffi. “No causal relationship can be inferred by this study. We also cannot capture the severity of the mood symptoms, and we are unable to examine the relationship between cognition and apathy, which is another highly relevant neuropsychiatric manifestation of small-vessel disease,” he said.

—Michelle G. Sullivan

HOUSTON—Hemorrhagic stroke sharply increases the risk of new-onset depression which, in turn, is associated with a 30% increased risk of dementia within five years, according to research presented at the International Stroke Conference 2017.

“This is of great importance from a research and clinical standpoint, as it may represent a marker of ongoing cognitive deterioration,” said Dr. Biffi.

Hemorrhagic Stroke and Mood Disorders

Previous studies have found that patients with ICH have a significantly increased risk of mood disorders and cognitive decline. “There is probably a link between mood disorders and cognition after ICH, as is the case for a number of other neurologic conditions,” said Dr. Biffi. “Cerebrovascular small-vessel disease is likely to be involved in the underlying pathogenesis for these disorders, as it is also a risk factor for late-life depression in the general population. Therefore, depression and dementia after ICH may share some etiologic connections.”

Dr. Biffi and his colleagues enrolled 695 patients with ICH into their study and followed them for a mean of five years. None of the subjects had ever been diagnosed with a mood disorder or cognitive decline. The researchers conducted telephone interviews with patients every six months.

At baseline, investigators collected CT and MRI imaging data, epidemiologic exposure data, and apolipoprotein E4 genotype. The outcomes were new-onset depression and incident dementia.

Subjects had a mean age of 74 at baseline. In addition, approximately 70% of patients had hypertension, and 15% had heart disease. Less than 1% of the cohort was positive for the APOE e4 gene. Imaging-confirmed white matter disease was present in 65% of participants. During the follow-up period, new-onset depression developed in 278 (40%) patients. The temporal incidence of this outcome was consistent at about 7% per year.

Factors That Influenced Risk of Dementia

Researchers discovered that having more than a single copy of the APOE e4 allele at baseline (hazard ratio [HR], 1.7) and the presence of white matter disease at baseline (HR, 1.82), were significantly associated with new-onset depression. Having had at least 10 years of school protected against depression (HR, 0.75), as did functional independence (HR, 0.52). By the end of the follow-up period, dementia had developed in 80% of individuals with depression (220). In 81% of cases, depression preceded dementia, with an average time lag of 1.5 years, said Dr. Biffi.

In a multivariate analysis, several factors were significantly associated with incident dementia. Higher education reduced the risk by 40% (HR, 0.60). Factors that increased the risk of dementia were black race (HR, 1.48), APOE e4 gene (HR, 2.12), white matter disease (HR, 1.7), and poststroke new-onset depression (HR, 1.29). The study shows only association, said Dr. Biffi. “No causal relationship can be inferred by this study. We also cannot capture the severity of the mood symptoms, and we are unable to examine the relationship between cognition and apathy, which is another highly relevant neuropsychiatric manifestation of small-vessel disease,” he said.

—Michelle G. Sullivan

HOUSTON—Hemorrhagic stroke sharply increases the risk of new-onset depression which, in turn, is associated with a 30% increased risk of dementia within five years, according to research presented at the International Stroke Conference 2017.

“This is of great importance from a research and clinical standpoint, as it may represent a marker of ongoing cognitive deterioration,” said Dr. Biffi.

Hemorrhagic Stroke and Mood Disorders

Previous studies have found that patients with ICH have a significantly increased risk of mood disorders and cognitive decline. “There is probably a link between mood disorders and cognition after ICH, as is the case for a number of other neurologic conditions,” said Dr. Biffi. “Cerebrovascular small-vessel disease is likely to be involved in the underlying pathogenesis for these disorders, as it is also a risk factor for late-life depression in the general population. Therefore, depression and dementia after ICH may share some etiologic connections.”

Dr. Biffi and his colleagues enrolled 695 patients with ICH into their study and followed them for a mean of five years. None of the subjects had ever been diagnosed with a mood disorder or cognitive decline. The researchers conducted telephone interviews with patients every six months.

At baseline, investigators collected CT and MRI imaging data, epidemiologic exposure data, and apolipoprotein E4 genotype. The outcomes were new-onset depression and incident dementia.

Subjects had a mean age of 74 at baseline. In addition, approximately 70% of patients had hypertension, and 15% had heart disease. Less than 1% of the cohort was positive for the APOE e4 gene. Imaging-confirmed white matter disease was present in 65% of participants. During the follow-up period, new-onset depression developed in 278 (40%) patients. The temporal incidence of this outcome was consistent at about 7% per year.

Factors That Influenced Risk of Dementia

Researchers discovered that having more than a single copy of the APOE e4 allele at baseline (hazard ratio [HR], 1.7) and the presence of white matter disease at baseline (HR, 1.82), were significantly associated with new-onset depression. Having had at least 10 years of school protected against depression (HR, 0.75), as did functional independence (HR, 0.52). By the end of the follow-up period, dementia had developed in 80% of individuals with depression (220). In 81% of cases, depression preceded dementia, with an average time lag of 1.5 years, said Dr. Biffi.

In a multivariate analysis, several factors were significantly associated with incident dementia. Higher education reduced the risk by 40% (HR, 0.60). Factors that increased the risk of dementia were black race (HR, 1.48), APOE e4 gene (HR, 2.12), white matter disease (HR, 1.7), and poststroke new-onset depression (HR, 1.29). The study shows only association, said Dr. Biffi. “No causal relationship can be inferred by this study. We also cannot capture the severity of the mood symptoms, and we are unable to examine the relationship between cognition and apathy, which is another highly relevant neuropsychiatric manifestation of small-vessel disease,” he said.

—Michelle G. Sullivan

Take-Home Points

• Nail breakage is a known complication of intramedullary nail (IMN) fixation of tibial fractures.
• Several techniques have been described for broken IMN extraction.

Intramedullary nail (IMN) fixation is reliably used to manage tibial fractures and has become very popular for managing fractures of varying complexity.^1-4 An occasional complication of intramedullary nailing is nail breakage,^5-7 which can result from a fatigue fracture (from excessive fracture site instability caused by inadequate nail diameter, delayed fracture healing, or fracture nonunion) and direct traumatic impact.^5-7 Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from tibias and femurs.^4,8-16 In this article, we describe an efficient technique for extracting broken tibial IMNs—a technique that can be used before attempting more invasive extraction methods. The patient provided written informed consent for print and electronic publication of this case report.

Case Report and Surgical Technique

A 34-year-old male logger presented to our facility (Department of Orthopaedics, Warren Alpert School of Medicine, Brown University) with a new fracture of the left tibia and fibula with an associated broken IMN after a tree fell on his leg at work (Figures 1A, 1B).

The original IMN had been placed through a paramedian incision, with lateral to medial distal locking screws. The tibial shaft fracture and broken nail were displaced in the coronal plane (Figures 1A, 1B). For restoration of the central canal of the nail, closed reduction was performed in the operating room (Figure 2A). Once the fracture was reduced, the more proximal of the 2 distal interlocking screws was partially backed out so the extraction hook could be passed antegrade into the distal segment of the nail (Figure 2A).

Discussion

IMN fixation of tibial fractures is reliable.^1-4 An occasional complication of intramedullary nailing is nail breakage. Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from knees and femurs.^4,8-16

Our patient’s case involved a cannulated tibial IMN that broke secondary to an acute traumatic event. Several techniques have been used to remove the distal segment of broken cannulated tibial IMNs.^8,9,14,17 Abdelgawad and Kanlic⁸ described a technique in which a small distractor hook was introduced past the distal end of the broken distal piece, and a small (~2 in) piece of flexible nail was introduced into the slot of the distal interlocking screw hole. The hook was pulled back and became incarcerated in the nail by the flexible nail piece, allowing the hook to extract the distal segment of the nail.

Charnley and Farrington⁹ used Petelin laparoscopic grasping forceps to extract the distal segment of a broken cannulated tibial IMN under fluoroscopic guidance. This tibial canal was initially reamed before inserting the instrument and removing the distal segment of the nail.

Levine and Georgiadis¹⁴ used a 4.5-mm bit to drill a hole in the distal aspect of the medial malleolus. A smooth Steinmann pin was used to engage the tip of the IMN. The nail was hammered several centimeters up the medullary canal of the tibia. A 3.0-mm ball-tipped guide wire was inserted in the hole in the medial malleolus and advanced through the distal aspect of the nail under fluoroscopic guidance. The guide wire was advanced through the extent of the nail proximally until it emerged through the knee incision. The distal segment of the broken nail was extracted with the guide wire; the end of the guide wire with the ball engaged the distal aspect of the nail.

Our technique allowed us to use a nail extraction device to extract the distal segment of a broken tibial IMN. This device is usually on hand for routine nail extraction. We used the more distal of the 2 distal interlocking screws to push the extraction hook over the distal lip of the nail, allowing for extraction without additional incisions or additional drill holes in bone. Our technique was efficient in this particular situation and avoided more time-consuming extraction methods. In cases in which the extraction hook does not engage the distal aspect of the nail secondary to bone ingrowth, our technique should be used before attempting other extraction methods.

Am J Orthop. 2017;46(2):E112-E115. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Nail breakage is a known complication of intramedullary nail (IMN) fixation of tibial fractures.
• Several techniques have been described for broken IMN extraction.

Intramedullary nail (IMN) fixation is reliably used to manage tibial fractures and has become very popular for managing fractures of varying complexity.^1-4 An occasional complication of intramedullary nailing is nail breakage,^5-7 which can result from a fatigue fracture (from excessive fracture site instability caused by inadequate nail diameter, delayed fracture healing, or fracture nonunion) and direct traumatic impact.^5-7 Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from tibias and femurs.^4,8-16 In this article, we describe an efficient technique for extracting broken tibial IMNs—a technique that can be used before attempting more invasive extraction methods. The patient provided written informed consent for print and electronic publication of this case report.

Case Report and Surgical Technique

A 34-year-old male logger presented to our facility (Department of Orthopaedics, Warren Alpert School of Medicine, Brown University) with a new fracture of the left tibia and fibula with an associated broken IMN after a tree fell on his leg at work (Figures 1A, 1B).

The original IMN had been placed through a paramedian incision, with lateral to medial distal locking screws. The tibial shaft fracture and broken nail were displaced in the coronal plane (Figures 1A, 1B). For restoration of the central canal of the nail, closed reduction was performed in the operating room (Figure 2A). Once the fracture was reduced, the more proximal of the 2 distal interlocking screws was partially backed out so the extraction hook could be passed antegrade into the distal segment of the nail (Figure 2A).

Discussion

IMN fixation of tibial fractures is reliable.^1-4 An occasional complication of intramedullary nailing is nail breakage. Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from knees and femurs.^4,8-16

Our patient’s case involved a cannulated tibial IMN that broke secondary to an acute traumatic event. Several techniques have been used to remove the distal segment of broken cannulated tibial IMNs.^8,9,14,17 Abdelgawad and Kanlic⁸ described a technique in which a small distractor hook was introduced past the distal end of the broken distal piece, and a small (~2 in) piece of flexible nail was introduced into the slot of the distal interlocking screw hole. The hook was pulled back and became incarcerated in the nail by the flexible nail piece, allowing the hook to extract the distal segment of the nail.

Charnley and Farrington⁹ used Petelin laparoscopic grasping forceps to extract the distal segment of a broken cannulated tibial IMN under fluoroscopic guidance. This tibial canal was initially reamed before inserting the instrument and removing the distal segment of the nail.

Levine and Georgiadis¹⁴ used a 4.5-mm bit to drill a hole in the distal aspect of the medial malleolus. A smooth Steinmann pin was used to engage the tip of the IMN. The nail was hammered several centimeters up the medullary canal of the tibia. A 3.0-mm ball-tipped guide wire was inserted in the hole in the medial malleolus and advanced through the distal aspect of the nail under fluoroscopic guidance. The guide wire was advanced through the extent of the nail proximally until it emerged through the knee incision. The distal segment of the broken nail was extracted with the guide wire; the end of the guide wire with the ball engaged the distal aspect of the nail.

Our technique allowed us to use a nail extraction device to extract the distal segment of a broken tibial IMN. This device is usually on hand for routine nail extraction. We used the more distal of the 2 distal interlocking screws to push the extraction hook over the distal lip of the nail, allowing for extraction without additional incisions or additional drill holes in bone. Our technique was efficient in this particular situation and avoided more time-consuming extraction methods. In cases in which the extraction hook does not engage the distal aspect of the nail secondary to bone ingrowth, our technique should be used before attempting other extraction methods.

Am J Orthop. 2017;46(2):E112-E115. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Nail breakage is a known complication of intramedullary nail (IMN) fixation of tibial fractures.
• Several techniques have been described for broken IMN extraction.

Intramedullary nail (IMN) fixation is reliably used to manage tibial fractures and has become very popular for managing fractures of varying complexity.^1-4 An occasional complication of intramedullary nailing is nail breakage,^5-7 which can result from a fatigue fracture (from excessive fracture site instability caused by inadequate nail diameter, delayed fracture healing, or fracture nonunion) and direct traumatic impact.^5-7 Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from tibias and femurs.^4,8-16 In this article, we describe an efficient technique for extracting broken tibial IMNs—a technique that can be used before attempting more invasive extraction methods. The patient provided written informed consent for print and electronic publication of this case report.

Case Report and Surgical Technique

A 34-year-old male logger presented to our facility (Department of Orthopaedics, Warren Alpert School of Medicine, Brown University) with a new fracture of the left tibia and fibula with an associated broken IMN after a tree fell on his leg at work (Figures 1A, 1B).

The original IMN had been placed through a paramedian incision, with lateral to medial distal locking screws. The tibial shaft fracture and broken nail were displaced in the coronal plane (Figures 1A, 1B). For restoration of the central canal of the nail, closed reduction was performed in the operating room (Figure 2A). Once the fracture was reduced, the more proximal of the 2 distal interlocking screws was partially backed out so the extraction hook could be passed antegrade into the distal segment of the nail (Figure 2A).

Discussion

IMN fixation of tibial fractures is reliable.^1-4 An occasional complication of intramedullary nailing is nail breakage. Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from knees and femurs.^4,8-16

Our patient’s case involved a cannulated tibial IMN that broke secondary to an acute traumatic event. Several techniques have been used to remove the distal segment of broken cannulated tibial IMNs.^8,9,14,17 Abdelgawad and Kanlic⁸ described a technique in which a small distractor hook was introduced past the distal end of the broken distal piece, and a small (~2 in) piece of flexible nail was introduced into the slot of the distal interlocking screw hole. The hook was pulled back and became incarcerated in the nail by the flexible nail piece, allowing the hook to extract the distal segment of the nail.

Charnley and Farrington⁹ used Petelin laparoscopic grasping forceps to extract the distal segment of a broken cannulated tibial IMN under fluoroscopic guidance. This tibial canal was initially reamed before inserting the instrument and removing the distal segment of the nail.

Levine and Georgiadis¹⁴ used a 4.5-mm bit to drill a hole in the distal aspect of the medial malleolus. A smooth Steinmann pin was used to engage the tip of the IMN. The nail was hammered several centimeters up the medullary canal of the tibia. A 3.0-mm ball-tipped guide wire was inserted in the hole in the medial malleolus and advanced through the distal aspect of the nail under fluoroscopic guidance. The guide wire was advanced through the extent of the nail proximally until it emerged through the knee incision. The distal segment of the broken nail was extracted with the guide wire; the end of the guide wire with the ball engaged the distal aspect of the nail.

Our technique allowed us to use a nail extraction device to extract the distal segment of a broken tibial IMN. This device is usually on hand for routine nail extraction. We used the more distal of the 2 distal interlocking screws to push the extraction hook over the distal lip of the nail, allowing for extraction without additional incisions or additional drill holes in bone. Our technique was efficient in this particular situation and avoided more time-consuming extraction methods. In cases in which the extraction hook does not engage the distal aspect of the nail secondary to bone ingrowth, our technique should be used before attempting other extraction methods.

Am J Orthop. 2017;46(2):E112-E115. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.