How Knee Replacements May Impact Heart Attacks and Strokes

Last week's articles on rheumatology topics in the major non-rheumatology journals.

The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysisBMJ, October 30, 2013

Editorial: Can joint replacement reduce cardiovascular risk? BMJ, November 20, 2013

An observational study found that that patients with moderate to severe hip or knee osteoarthritis who had total joint arthroplasty had a lower risk of cardiovascular disease, when compared with a group of patients matched by a propensity score.

In the editorial, a statistician explains how this study used propensity score matching and landmark analysis to overcome the limitations of observational designs.

Randomized trials are best, this editorial concedes, but observational designs can also provide useful information.

Interspinous process device versus standard conventional surgical decompression for lumbar spinal stenosis: randomized controlled trialBMJ, November 14, 2013

Editorial: Surgery for neurogenic claudication and spinal stenosisBMJ, November 20, 2013

A report last week found that the interspinous process device, a minimally invasive spacer, was no better than standard bony decompression for intermittent neurogenic claudication due to lumbar spinal stenosis. In addition, the repeat surgery rate was much higher for the interspinous process device.

This editorial gives the rationale for the spacer device, and suggests reasons why the spacer devices may be appropriate for selected patients, especially if they become less costly than their present price of £1,000 ($1,600).

Also, some patients may prefer a high revision rate for a less invasive procedure.
 

Case Reports:Case 36-2013 - A 38-Year-Old Woman with Anemia and ThrombocytopeniaNEJM, November 21, 2013

Anemia and Thrombocytopenia
Now@NEJM, November 21, 2013

This case describes a woman, age 38, with autoimmune hemolytic anemia and thrombocytopenia (Evans syndrome) due to systemic lupus erythematosus (SLE).

Diagnosing SLE was difficult because she did not initially meet four American College of Rheumatology criteria. But rising antiphospholipid antibodies, hypocomplementemia, and antibodies to double-stranded DNA confirm the diagnosis.

The patient history is noteworthy for episodes of epistaxis, metrorrhagia that required hysterectomy, and dramatic weight loss.

Treatments including glucocorticoids (standard for Evans syndrome despite lack of support from randomized trials), intravenous immune globulin, rituximab, and splenectomy all failed. She was stabilized on azathioprine and hydroxychloroquine.

Images in Clinical Medicine: Endocardial Calcification in Behet's DiseaseNEJM, November 21, 2013

A 60-year-old man with Behet's disease presents with progressive leg edema, dyspnea, and varices of the chest and abdominal wall, caused by collateral circulation associated with obstruction of the superior vena cava.

Restrictive cardiomyopathy with endomyocardial fibrosis is diagnosed. 

After diuresis, the edema and dyspnea improve, but the varices remain.