A 52-year-old male developed subcutaneous nodules and polyarthritis in association with an acinar cell carcinoma of the pancreas. The arthritis did not respond to aspirin, phenylbutazone, indomethacin or corticosteroid therapy. Typical changes of pancreatic enzyme-induced injuries in the subcutaneous nodules and around the joints were found at autopsy.Inflammatory polyarthritis may be a manifestation of systemic disease. O n e of the more unusual examples of this is the arthritis associated with pancreatic disease. T h e association of subcutaneous fat necrosis with pancreatitis was first reported by Chiari in 1883 ( I ) and Hansemann in 1889 (2). In 1914 .Jenckel (3) reported an articular component as part of this syndrome. In 1908 ;I similar syndrome associated with pancreatic malignancy was reported by Berner (4). T h e following is the fourteenth reported case of polyarthritis associated with acinar cell Carcinoma of the pancreas (4, 14, 1-5. 17-26). CASE REPORTW W , a 52-year-old black male was admitted for the second time to the Washington VA Hospital in June 1971 with chronic complaints of lethargy and weakness. and a Iweek history of painful swelling of his right elbow and left pretibial area. T h e patient had a history of chronic alcoholism and the diagnosis of chronic pancreatitis with pseudo- cyst was made on his first admission 3 months earlier, but the patient refused exploratory surgery at that time. At the time of his present admission he was extremely cachectic with a pulse rate of 108 he;its/min. blood pressure 116/78. respiration 24/min and a tempewture of 101" F. A left upper quadrant nontender mass previously felt to he a pancreatic pseudocyst was still present. There was fluctuant swelling, tenderness and m;irked heat over his right elhow. There was a swollen warm nodule distal to the left knee. T w o days later he was noted to have swellinq. warmth and tenderness around his left second and third metacarpophalangeal (.M<:P) joints. Aspiration of the right elbow yielded purulent fluid, leading to an initial diagnosis of septic arthritis. Antibiotic (Keflin", later ampicillin) and antiinflammatory agents (phenylbutamne, later indomethacin) were instituted and there was gradual improvement in his articular symptoms and fever over the following 2 weeks. T h e nodule on the left leg developed spontaneous purulent drainage which persisted over the ensuing 8 months. Initial laboratory data included: hematorrit 20%, WBC 2O,OOO/cu mm, rheumatoid factor-negative.erythrocyte sedimentation rate (ESR) Westergren 77 mm/hr, uric acid 6.9 mg%, calcium 10.8 mg%, phosphorus 4.2 mg%, amylase 150 and 300 Somogyi Units on two determinations and lipase 26.9 TietzBorden Units (normal: < 2). Routine bacteriologic. acidfast and fungal cultures of .joint fluid were negative. T w o months after admission the patient had an exploratory laparotomy at which time a pancreatic carcinoma with hepatic metastases was discovered. T h e patient remained in the hospital over the next 4 months receiving only supportive care. Six...

Background Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients.

Aims The 4S-AF classification scheme comprises of four domains: stroke risk (St), symptoms (Sy), severity of atrial fibrillation (AF) burden (Sb), and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and compare outcomes in AF patients according to the 4S-AF-led decision-making process. Methods and results  Atrial fibrillation patients from 250 centres across 27 European countries were included. A 4S-AF score was calculated as the sum of each domain with a maximum score of 9. Of 6321 patients, 8.4% had low (St), 47.5% EHRA I (Sy), 40.5% newly diagnosed or paroxysmal AF (Sb), and 5.1% no cardiovascular risk factors or left atrial enlargement (Su). Median follow-up was 24 months. Using multivariable Cox regression analysis, independent predictors of all-cause mortality were (St) [adjusted hazard ratio (aHR) 8.21, 95% confidence interval (CI): 2.60–25.9], (Sb) (aHR 1.21, 95% CI: 1.08–1.35), and (Su) (aHR 1.27, 95% CI: 1.14–1.41). For CV mortality and any thromboembolic event, only (Su) (aHR 1.73, 95% CI: 1.45–2.06) and (Sy) (aHR 1.29, 95% CI: 1.00–1.66) were statistically significant, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding. Higher 4S-AF score was related to a significant increase in all-cause mortality, CV mortality, any thromboembolic event, and ischaemic stroke but not major bleeding. Treatment of all 4S-AF domains was associated with an independent decrease in all-cause mortality (aHR 0.71, 95% CI: 0.55–0.92). For each 4S-AF domain left untreated, the risk of all-cause mortality increased substantially (aHR 1.35, 95% CI: 1.16–1.56). Conclusion  Implementation of the novel 4S-AF scheme is feasible, and treatment decisions based on this scheme improve mortality rates in AF.

Background Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent. Objectives We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients. Methods A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined. Results Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55–0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty. Conclusions In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

The removal of proteins from the knee joints of patients with rheumatoid and osteoarthritis was studied. IgG is removed at the same rate as albumin. Reduction of IgG with 2-mercaptoethanol does not alter this rate. Heat aggregation of reduced IgG enhances, rather than re-UM SPECULATION has arisen concem-