ImportanceMost epidemiological studies of heart failure (HF) have been conducted in high-income countries with limited comparable data from middle- or low-income countries.ObjectiveTo examine differences in HF etiology, treatment, and outcomes between groups of countries at different levels of economic development.Design, Setting, and ParticipantsMultinational HF registry of 23 341 participants in 40 high-income, upper–middle-income, lower–middle-income, and low-income countries, followed up for a median period of 2.0 years.Main Outcomes and MeasuresHF cause, HF medication use, hospitalization, and death.ResultsMean (SD) age of participants was 63.1 (14.9) years, and 9119 (39.1%) were female. The most common cause of HF was ischemic heart disease (38.1%) followed by hypertension (20.2%). The proportion of participants with HF with reduced ejection fraction taking the combination of a β-blocker, renin-angiotensin system inhibitor, and mineralocorticoid receptor antagonist was highest in upper–middle-income (61.9%) and high-income countries (51.1%), and it was lowest in low-income (45.7%) and lower–middle-income countries (39.5%) (P < .001). The age- and sex- standardized mortality rate per 100 person-years was lowest in high-income countries (7.8 [95% CI, 7.5-8.2]), 9.3 (95% CI, 8.8-9.9) in upper–middle-income countries, 15.7 (95% CI, 15.0-16.4) in lower–middle-income countries, and it was highest in low-income countries (19.1 [95% CI, 17.6-20.7]). Hospitalization rates were more frequent than death rates in high-income countries (ratio = 3.8) and in upper–middle-income countries (ratio = 2.4), similar in lower–middle-income countries (ratio = 1.1), and less frequent in low-income countries (ratio = 0.6). The 30-day case-fatality rate after first hospital admission was lowest in high-income countries (6.7%), followed by upper–middle-income countries (9.7%), then lower–middle-income countries (21.1%), and highest in low-income countries (31.6%). The proportional risk of death within 30 days of a first hospital admission was 3- to 5-fold higher in lower–middle-income countries and low-income countries compared with high-income countries after adjusting for patient characteristics and use of long-term HF therapies.Conclusions and RelevanceThis study of HF patients from 40 different countries and derived from 4 different economic levels demonstrated differences in HF etiologies, management, and outcomes. These data may be useful in planning approaches to improve HF prevention and treatment globally.

Vertical shear pelvic ring fractures are rare and account for less than 1% of all fractures. Unlike severely displaced antero-posterior compression and lateral compression pelvic fractures, patients' mortality is lower. Nevertheless, patients must be managed acutely using well-defined ATLS protocols and institution-specific protocols for haemodynamically unstable pelvic ring fractures. The definitive treatment of vertical shear pelvic fractures is however more controversial with a paucity of literature to recommend the ideal reduction and fixation strategy. While the majority of injuries can be reduced and fixed in a closed manner, orthopaedic traumatologists should be familiar with the contraindications to those techniques as well as options such as tension band plating and lumbo pelvic fixation. Our paper reviews the acute management, associated injuries and definitive reduction and fixation strategies of vertical shear pelvic fractures. In addition, we propose a treatment algorithm for the selection of the most appropriate fixation technique.

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Purpose To determine the most common injury patterns, root cause, and the frequency with which unrecognized contralateral posterior ring injury occurs in patients presenting with surgically treated pelvic fractures. Methods The medical records of 73 patients presenting to our level I trauma center (52 male and 21 female patients; mean age 41.8 years; range 18-89 years) with surgically treated pelvic ring fractures between January 1, 2016 and January 1, 2018 were reviewed. Patient demographics, mechanism of injury, associated injuries, imaging prior to binder or external fixation, use of temporary stabilization with pre-peritoneal pelvic packing (PPP) and anterior pelvic external fixation, and fracture pattern were recorded and analyzed to identify independent risk factors contributing to occult contralateral missed posterior ring injury. Results Occult contralateral pelvic ring injuries occurred in 6/72 patients (8.2% incidence). Pelvis fractures in multiply traumatized patients with associated orthopaedic injuries were associated with higher prevalence of occult contralateral pelvic ring injury (relative risk 1.85, 95% CI 1.13-3.02) as compared to patients with isolated pelvic fractures. Conclusions There is an 8.2% incidence of unrecognized contralateral SI joint instability in patients presenting with unstable pelvic ring injuries. Multiply traumatized patients with multiple orthopaedic injuries were an independent risk factor for this injury pattern.

Clinical Question.