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BMJ 2008; 336 doi: (Published 07 February 2008) Cite this as: BMJ 2008;336:300

Football world cup linked to sharp rise in cardiac emergencies

The incidence of cardiac emergencies around Munich in Germany more than doubled during the 2006 football world cup, a study has found. On the days when the Germany team was playing, 2.66 times more cardiac emergencies (95% CI 2.33 to 3.04), 2.49 (1.47 to 4.23) times more heart attacks with ST elevation, and 3.07 (2.32 to 4.06) times more serious arrhythmias occurred in the area than had occurred during control periods before and after the competition. Germany played seven matches during the 2006 world cup. Six of them were associated with an increase in cardiac emergencies. The quarter final match against Argentina, which Germany won after a penalty shoot out, and the semi-final match against Italy, which the home team lost, seem to have been the most stressful. Germany eventually came third after beating Portugal in a match that had no discernible effect on cardiac events.

The link between football and cardiac emergencies was stronger for men than for women, although it was significant for both. It was strongest for people with known heart disease. The first two hours after the start of a match was the riskiest period, so the authors suspect that the emotional stress of watching crucial games triggered many of the extra events. Their analysis included only Germans, so the incidence wasn’t inflated by the influx of excitable foreign fans.

Still no conclusive evidence favouring one drug eluting stent over another

Paclitaxel eluting stents and sirolimus eluting stents both reduce the risk of serious cardiac events in eligible patients with ischaemic heart disease. It is proving harder than expected to find out which one works best, however. The latest and largest trial to date reported no difference between the two, but the authors and an editorial agree that it isn’t the final word (p 454). The participants had fewer cardiac events than anticipated, so the trial was weaker than it should have been. In the end, the authors had only a 30% chance of finding a small but meaningful difference between the stents, if one existed. One stent could still be better than the other, and previous meta-analyses have hinted that sirolimus eluting stents might be superior, says the editorial.

The Danish trial was designed to evaluate the two stents in real world practice. Any adult needing a stent was eligible, and more than 2000 people were eventually randomised. During a follow-up of 18 months, 9.3% of the sirolimus group and 11.2% of the paclitaxel group had a major cardiac event or needed revascularisation (hazard ratio 0.83, 95% confidence interval, 0.63 to 1.08). The two stents had comparable rates of thrombosis (2.5% v 2.9%, 0.87, 0.52 to 1.46).

Survey finds serious shortfall in prophylaxis against venous thromboembolism

Worldwide, only half of all eligible inpatients receive prophylaxis against venous thromboembolism, according to a major international survey. A single chart review of nearly 70 000 inpatients in 32 countries found that 35 329 (51.8%, 95% CI 51.4% to 52.2%) were at risk of deep vein thrombosis or pulmonary embolism on the appointed day. Just under 60% of at risk surgical patients and just under 40% of at risk medical patients were prescribed prophylaxis as recommended by the American College of Chest Physicians.

Some countries did better than others. German doctors, for example, gave the right medical or mechanical treatment to 92% of surgical and 70% of medical inpatients. Use of prophylaxis also varied between patient groups. Most of those having a hip or knee replacement received prophylaxis, compared with only a third of patients with cancer or ischaemic stroke—two high risk conditions.

Doctors seem no better than they were five or 10 years ago at protecting inpatients from lethal blood clots, says an editorial (p 361), probably because they don’t always agree who should be treated and how. American guidelines on heart failure don’t include prophylaxis against venous thromboembolism, nor do some stroke guidelines. Things won’t improve until specialists reach consensus about the risk-benefit balance of commonly used agents, such as heparins.

Neonates are vulnerable to iatrogenic harm

Between January and September 2005, 388 babies were admitted to one tertiary care neonatology centre in southern France. Nearly a third (116) of them experienced at least one adverse event caused entirely by their health care, not their illness. Doctors and nurses at the centre recorded 267 iatrogenic incidents during the eight month study period. Skin injuries—from intravenous lines for example—were common (94/267) but usually minor. Hospital acquired infections were also common (62/267) and more likely to be severe. Staff recorded 38 vascular events such as blocked lines and 26 respiratory events including unplanned extubations. In nine of the 19 drug errors, staff gave babies doses that were 10 times too high or too low, almost always because of a wrongly programmed pump. Overall, 29% (78/267) of events resulted in clinically important injury. A third of all events were preventable.

Very premature and very small babies were most likely to experience an iatrogenic event. The odds ratio for babies born before 28 weeks was 24.1 (95% CI 10.0 to 57.6) compared with those born at term. Mechanical ventilation and central lines also increased the risk.

These authors hope their reporting system—which was anonymous, voluntary, and completely non-judgemental—will help target initiatives on patient safety where they are needed most. An editorial encourages other centres to do the same (p 364).

Small RNA molecule linked to poor prognosis in colon cancer

Small RNA molecules that regulate genes, known as microRNAs, are emerging as potential prognostic markers for cancer. Researchers investigating the role of microRNAs in colon cancer found one, miR-21, that was linked to poor prognosis in two independent cohorts of adults from opposite sides of the world. High levels of miR-21 in tumour samples were associated with more than double the risk of death in patients in Hong Kong (2.4, 95% CI 1.4 to 3.9) and the US (2.5, 1.2 to 5.2), independent of tumour stage. High levels of miR-21 were also associated with a poor response to chemotherapy for colon cancer.

Expression of this particular microRNA seemed to have a dose response effect, with higher levels of expression in higher stage tumours. The effect was evident even in adenomas, which expressed higher levels of miR-21 than healthy tissue from the same patients in a small substudy.

It is too early to say from these preliminary observations whether miR-21 causes or promotes colon cancer in humans, say the authors. But it is a distinct possibility. Experiments in mice and in human cell lines suggest that miR-21 delays apoptosis. Suppressing it inhibits the growth of cells in vitro and tumours in mice.

One in six US foot soldiers get concussion in Iraq

When researchers interviewed 2525 US infantry a few months after their return from Iraq, more than one in six reported sustaining a mild head injury during the year long tour of duty. Nearly 5% (124/2525) said they had been knocked out briefly, and another 10% (260/2525) reported head injuries resulting in an altered mental state but no loss of consciousness. Both groups had worse mental and physical health than the 17% (435/2525) that had injured other parts of the body. The difference was almost entirely accounted for by high rates of post-traumatic stress disorder (PTSD) and depression in soldiers with mild head injury. In this survey, 44% (54/123) of the soldiers who had been knocked out and 27% (71/260) of those with altered mental state had PTSD, compared with 16% (70/433) of those with other injuries (P<0.001 for both comparisons). Loss of consciousness was an independent predictor of PTSD and depression. Altered mental state was a weaker but still significant predictor of PTSD.

The survey included two brigades of infantry and had a response rate of 59%. Most of the non-responders were away on training or transfers. Selection bias is unlikely, say the authors.

Eligible patients survive longer after endovascular repair of abdominal aortic aneurysm

More than 40% of abdominal aortic aneurysms are now repaired with endovascular stent grafts inserted through the femoral arteries. The technique is much less invasive than open repair, and patients treated this way are more likely to survive the procedure and the postoperative period. To find out more about what happens to them long term, researchers analysed data on Medicare claims for two cohorts of US adults—22 830 who had an endovascular repair and the same number who had an open repair, matched as closely as possible using a propensity score.

As expected the endovascular cohort had fewer complications than the open repair cohort and left hospital significantly sooner. They also had better survival for at least three years after surgery. The survival advantage lasted longest (more than four years) in people aged 85 or over.

In the long run, people who had an endovascular repair were more likely to need another vascular intervention, such as a repeat repair or angioplasty. But people who had an open repair were more likely to need treatment for complications of laparotomy, such as bowel obstruction. The two sets of risks roughly balanced each other out. The long term risk of rupture was small, but significantly higher after endovascular repair (1.8% v 0.5%, P<0.001).

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