BackgroundAtrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all‐cause mortality may guide interventions.Methods and ResultsIn the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose‐adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all‐cause mortality in the 14 171 participants in the intention‐to‐treat population. The median age was 73 years, and the mean CHADS 2 score was 3.5. Over 1.9 years of median follow‐up, 1214 (8.6%) patients died. Kaplan–Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all‐cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33–1.70, P<0.0001) and age ≥75 years (hazard ratio 1.69, 95% CI 1.51–1.90, P<0.0001) were associated with higher all‐cause mortality. Multiple additional characteristics were independently associated with higher mortality, with decreasing creatinine clearance, chronic obstructive pulmonary disease, male sex, peripheral vascular disease, and diabetes being among the most strongly associated (model C‐index 0.677).ConclusionsIn a large population of patients anticoagulated for nonvalvular atrial fibrillation, ≈7 in 10 deaths were cardiovascular, whereas <1 in 10 deaths were caused by nonhemorrhagic stroke or systemic embolism. Optimal prevention and treatment of heart failure, renal impairment, chronic obstructive pulmonary disease, and diabetes may improve survival.Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00403767.

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Scapula winging is an uncommon condition but one which may be underdiagnosed. Four patients with scapula winging referred to a sports injury clinic are presented. None of the patients was aware of any trauma and a traction injury to the long thoracic nerve is proposed as the aetiology of this condition. These case reports emphasize the importance of excluding winging of the scapula in patients who present to sports injury clinics with shoulder pain. Keywords: Scapula winging, sports injury clinic Four patients from a variety of sports attended the clinic with scapula winging over an 18-month period and are presented below. Case reports Case 1A 23-year-old right-handed boxer was referred with pain in the right shoulder of 8-10 weeks' duration. He had been training normally but there was no history of particular trauma. On examination he had winging of the right scapula. The winging recovered spontaneously over an 18-month period.Case 2 A 50-year-old weightlifter presented with 1 year's history of an abnormal appearance of the right shoulder. There was no history of trauma. On examination he had winging of the right scapula.Electromyographic (EMG) studies demonstrated a neurogenic lesion of the serratus anterior in isolation. No recovery occurred over 1 year and he was discharged from follow-up. Case 3A 27-year-old right-handed squash player presented 6 months after a sudden onset of aching in the right shoulder and a loss of power in the right arm while playing squash. On examination (Figure 1) he had winging of the right scapula. This recovered spontaneously over a 6-month period.Case 4 A 38-year-old right-handed rugby player experienced a sudden onset of pain in the right shoulder after a game of rugby, although he was unaware of injury during the game. Examination demonstrated scapula winging which recovered spontaneously over the next 6 months. DiscussionFour cases of scapula winging were detected in a sports injury clinic over an 18-month period. Scapula winging is said to be a rare condition, the subject of some 250 case reports since first described in 18251. The incidence among sportsmen may be higher, Gregg et al.l detecting ten cases in a sports injury clinic over a 3-year period. Trauma has been the precipitating factor in many of the previous case reports2.Scapula winging has been classified into static or dynamic types, and of bone, joint, muscle or nerve aetiology3. The cadaveric studies of Gregg et al.' suggested that the most likely aetiology in the

In order to assess the management of knee injuries in a sports medicine clinic, an audit was performed of all new patients who attended the clinic over a 12-month period. Of the 167 new patients seen, 76 (46%) had sustained knee injuries. Of these, 43 (57%) were treated in the sports medicine clinic and 33 (43%) were referred for arthroscopic assessment. The maximum waiting time from the time of referral was 3 weeks, with 85% of patients seen within 1 week and 92% within 2 weeks. Arthroscopy was performed on 28 (85%) of the 33 patients referred, and the positive correlation between the sports clinic diagnosis and the arthroscopic diagnosis was 64%. Of the 33 patients referred for arthroscopy, 28 (85%) had sustained acute knee injuries while five (15%) had been treated at other hospitals before referral to the sports medicine clinic. A National Health Service sports medicine clinic is an effective means of treating knee injuries, provided that access to arthroscopy is readily available.

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