Diagnosing ventilator-associated pneumonia (VAP) in UK NHS ICUs: the perceived value and role of a novel optical technology.

BACKGROUND: Diagnosing ventilator-associated pneumonia (VAP) in an intensive care unit (ICU) is a complex process. Our aim was to collect, evaluate and represent the information relating to current clinical practice for the diagnosis of VAP in UK NHS ICUs, and to explore the potential value and role of a novel diagnostic for VAP, which uses optical molecular alveoscopy to visualise the alveolar space. METHODS: Qualitative study performing semi-structured interviews with clinical experts. Interviews were recorded, transcribed, and thematically analysed. A flow diagram of the VAP patient pathway was elicited and validated with the expert interviewees. Fourteen clinicians were interviewed from a range of UK NHS hospitals: 12 ICU consultants, 1 professor of respiratory medicine and 1 professor of critical care. RESULTS: Five themes were identified, relating to [1] current practice for the diagnosis of VAP, [2] current clinical need in VAP diagnostics, [3] the potential value and role of the technology, [4] the barriers to adoption and [5] the evidence requirements for the technology, to help facilitate a successful adoption. These themes indicated that diagnosis of VAP is extremely difficult, as is the decision to stop antibiotic treatment. The analysis revealed that there is a clinical need for a diagnostic that provides an accurate and timely diagnosis of the causative pathogen, without the long delays associated with return of culture results, and which is not dangerous to the patient. It was determined that the technology would satisfy important aspects of this clinical need for diagnosing VAP (and pneumonia, more generally), but would require further evidence on safety and efficacy in the patient population to facilitate adoption. CONCLUSIONS: Care pathway analysis performed in this study was deemed accurate and representative of current practice for diagnosing VAP in a UK ICU as determined by relevant clinical experts, and explored the value and role of a novel diagnostic, which uses optical technology, and could streamline the diagnostic pathway for VAP and other pneumonias.

[Adults with congenital heart disease presenting to the emergency department : Potential pitfalls]. / Erwachsene mit angeborenen Herzfehlern im Notaufnahmedienst : Was ist zu beachten?

The number of adults with congenital heart disease (ACHD) already exceeds the number of children with congenital heart disease in the industrialized world. ACHD patients often show complex pathophysiology and anatomy even after reparative cardiac surgery. In case of complications patients may rapidly deteriorate and become unstable, even when they were asymptomatic or had only mild symptoms before the onset of the complication. Compared to all patients seen by emergency physicians, emergencies in ACHD patients are still rare. This review is aimed to guide management in ACHD emergency situations. Approximately two-thirds of all emergency admissions are caused by arrhythmias or acute heart failure. Sustained arrhythmias may rapidly lead to acute cardiac decompensation in ACHD patients. If medical treatment fails or patients present in hemodynamically unstable conditions, prompt electrical cardioversion is mandatory. Symptomatic bradycardia may require urgent pacemaker implantation. Depending on the underlying heart defect, placement of temporary transvenous pacemaker leads may be impossible. Acute heart failure in ACHD patients is often caused by acute right heart failure. Other more frequent emergencies are infections, syncope, thromboembolic events, and aortic dissection. It is highly recommended to contact the tertiary care center that follows the patient regularly early in case of patient presentation to the emergency room.

Exercise training comprising of single 20-s cycle sprints does not provide a sufficient stimulus for improving maximal aerobic capacity in sedentary individuals.

PURPOSE: Sprint interval training (SIT) provides a potent stimulus for improving maximal aerobic capacity ([Formula: see text]), which is among the strongest markers for future cardiovascular health and premature mortality. Cycling-based SIT protocols involving six or more 'all-out' 30-s Wingate sprints per training session improve [Formula: see text], but we have recently demonstrated that similar improvements in [Formula: see text] can be achieved with as few as two 20-s sprints. This suggests that the volume of sprint exercise has limited influence on subsequent training adaptations. Therefore, the aim of the present study was to examine whether a single 20-s cycle sprint per training session can provide a sufficient stimulus for improving [Formula: see text]. METHODS: Thirty sedentary or recreationally active participants (10 men/20 women; mean ± SD age: 24 ± 6 years, BMI: 22.6 ± 4.0 kg m(-2), [Formula: see text]: 33 ± 7 mL kg(-1) min(-1)) were randomised to a training group or a no-intervention control group. Training involved three exercise sessions per week for 4 weeks, consisting of a single 20-s Wingate sprint (no warm-up or cool-down). [Formula: see text] was determined prior to training and 3 days following the final training session. RESULTS: Mean [Formula: see text] did not significantly change in the training group (2.15 ± 0.62 vs. 2.22 ± 0.64 L min(-1)) or the control group (2.07 ± 0.69 vs. 2.08 ± 0.68 L min(-1); effect of time: P = 0.17; group × time interaction effect: P = 0.26). CONCLUSION: Although we have previously demonstrated that regularly performing two repeated 20-s 'all-out' cycle sprints provides a sufficient training stimulus for a robust increase in [Formula: see text], our present study suggests that this is not the case when training sessions are limited to a single sprint.

Acute pontine infarction after percutaneous coronary intervention: a very rare but devastating complication.

A 64-year-old man suffering from an acute posterior wall myocardial infarction underwent primary percutaneous coronary intervention. After several aspiration attempts, tirofiban infusion and pre- and post-dilatation, a bare-metal stent was successfully implanted in the culprit right coronary artery. While the patient did not show any neurological symptoms before or during the procedure, he exhibited hemiplegia and loss of spontaneous speech. Additional magnetic resonance imaging showed an extensive brain stem infarction. This is the first report of a brain stem infarction as a complication of percutaneous coronary intervention.

Stenting for Emergency Colorectal Obstruction: An Analysis of 204 Patients in Relation to Predictors of Failure and Complications.

BACKGROUND AND AIMS: Self-expanding metallic stents are increasingly used in the management of malignant and benign colorectal obstructions. We aimed to identify relevant predictive factors for stent failure and stent-related complications. MATERIAL AND METHODS: We conducted a retrospective single-center analysis of 204 consecutive patients who underwent emergency colorectal stenting procedures because of symptomatic bowel obstructions from 1996 to 2011 at the Sisters of Charity Hospital Linz, Austria. RESULTS: A total of 204 patients (median age 74 years) with 36 (17.7%) benign and 168 (82.3%) malignant obstructions were included in the study. Technical success was achieved in 92.5% and clinical success in 86.8% of the cases. Major complications occurred in 2.9% and minor ones in 19.6%. Overall mortality during a median follow-up period of 4.3 years was 73% (149 patients). Relevant predictors of increased risk of complications were extracolonic obstruction (p = 0.001), complete obstruction (p = 0.066), and inflammatory bowel disease (p = 0.05). Stent localization at the splenic flexure, a stenosis of >8 cm in length, and the need for endoscopic guidance were associated with higher rates of technical and/or clinical stenting failure. CONCLUSION: Colorectal stenting is less invasive than other means of emergency treatment for large bowel obstruction; it is generally safe and effective in different types of colorectal obstruction. However, relevant rates of failure and complications were recorded and predictors could be determined.

Association of aortic stiffness with biomarkers of myocardial wall stress after myocardial infarction.

BACKGROUND: Aortic pulse wave velocity (PWV) was linked to LV-geometry and -function in patients with kidney disease and non-ischemic cardiomyopathy. The role of aortic compliance after acute STEMI is so far unknown. In the present study, we prospectively investigated the relationship of increased aortic stiffness with biomarkers of myocardial wall stress 4 months after STEMI. METHODS: 48 STEMI patients who were reperfused by primary coronary angioplasty underwent cardiovascular magnetic resonance (CMR) at baseline and at 4-month follow-up. The CMR protocol comprised cine-CMR as well as gadolinium contrast-enhanced CMR. Aortic PWV was determined by velocity-encoded, phase-contrast CMR. Blood samples were routinely drawn at baseline and follow-up to determine N-terminal pro-B-type natriuretic peptide (NT-proBNP). In a subgroup of patients, mid-regional pro-adrenomedullin (MR-proADM) and mid-regional pro-A-type natriuretic peptide (MR-proANP) levels were determined. RESULTS: Patients with a PWV above median (>7.0m/s) had significantly higher NT-proBNP, MR-proADM and MR-proANP concentrations at 4-month follow-up than patients with a PWV below median (all p<0.02). PWV showed moderate to good correlation with NT-proBNP, MR-proAMD and MR-proANP levels 4 months after STEMI (all p<0.05). Multivariate analysis revealed PWV, beside myocardial infarct size, as an independent predictor of 4-month NT-proBNP levels after correction for age, creatinine and LV ejection fraction (model r: 0.781, p<0.001). CONCLUSION: Aortic stiffness is directly associated with biomarkers of myocardial wall stress 4 months after reperfused STEMI, suggesting a role for aortic stiffness in chronic LV-remodelling.

Roles for primary cilia in gonadotrophin-releasing hormone neurones in the mouse.

During embryonic development, gonadotrophin-releasing hormone (GnRH) neurones make an extraordinary migration out of the nose and into the brain where, in adulthood, they drive the pituitary regulation of gonadal function and fertility. Primary cilia are antennae-like, immotile organelles that project from the surface of nearly all cells, including GnRH neurones. Links between defects in primary cilia and a variety of human pathologies have been discovered that suggest a role for primary cilia in embryogenesis and reproductive function. The present study aimed to investigate whether GnRH neurone primary cilia are critical for their embryonic migration and the adult control of fertility. To achieve this, we used a Cre-loxP strategy to selectively disrupt primary cilia by deleting Kif3a, an intraflagellar transport protein family member essential for primary cilia assembly and function, specifically in GnRH neurones. Confocal analysis revealed that, in Kif3a(fl/fl) (WT-Kif3a) controls, all GnRH neurones possessed primary cilia, whereas, in GnRH-Cre(+/-) ;Kif3a(fl/fl) (GnRH-Kif3aKO) mice, 60% of GnRH neurones lacked any evidence of primary cilia and the remaining 40% possessed only stunted primary cilia (< 2 µm). Despite abolishing normal primary cilia assembly in GnRH neurones from embryogenesis, adult GnRH neurone distribution and reproductive function was remarkably normal. The total number of GnRH neurones was the same in GnRH-Kif3aKO and WT-Kif3a controls; however, a significant increase (25%) was identified in the number of GnRH neurones sampled through the midpoint of the rostral pre-optic area in GnRH-Kif3aKO mice (P < 0.05). The time to vaginal opening was not different in GnRH-Kif3aKO mice, although they displayed significantly advanced first oestrus (P < 0.05), and oestrous cycle length was increased (P < 0.05). However, females displayed normal basal levels of luteinising hormone, responded normally to oestrogen-induced negative- and positive-feedback, and displayed normal fecundity. Taken together, these data suggest that primary cilia and associated signal transduction pathways play a role in the topographical distribution and specific functions of GnRH neurones; however, they are not essential for fertility.

Relation of plasma adiponectin levels and aortic stiffness after acute ST-segment elevation myocardial infarction.

BACKGROUND: Pulse wave velocity is a measure of aortic stiffness and an independent predictor of cardiovascular morbidity and mortality. Adiponectin is involved in atherosclerosis and inflammation. In the present study we aimed to explore the association between plasma adiponectin concentrations and pulse wave velocity in the acute phase after ST-segment elevation myocardial infarction (STEMI). METHODS: Forty-six consecutive STEMI patients (mean age 57 ± 11 years) treated with primary percutaneous coronary intervention (PCI) were enrolled in this cross-sectional study. Plasma adiponectin was measured 2 days after index event by enzyme-linked immunosorbent assay. Aortic pulse wave velocity (PWV) was calculated by the transit-time method with the use of a velocity-encoded, phase-contrast cardiac magnetic resonance protocol. RESULTS: Median plasma adiponectin concentration was 2385 ng/ml (interquartile range 1735-5403). Males had lower plasma adiponectin values than females and current smokers had lower values than non-smokers (all p<0.02). Adiponectin was significantly associated with PWV (r=0.505, p<0.001), age (r=0.437, p=0.002), and total cholesterol (r=0.468, p=0.001). Multiple linear regression analysis revealed adiponectin as a predictor of PWV independently of age, sex, smoking status, total cholesterol, and N-terminal pro-B-type natriuretic peptide (p=0.027). CONCLUSIONS: Plasma adiponectin concentrations are strongly associated with aortic stiffness in patients after acute STEMI treated with primary PCI. Our data support a possible role for adiponectin as an independent risk marker for increased aortic stiffness in STEMI patients.

Large intestinal mast cell count and proteinase expression is associated with larval burden in cyathostomin-infected horses.

REASONS FOR PERFORMING STUDY: Cyathostomins are the principal pathogenic nematode of equidae worldwide. In other species mast cell (MC) proteinases, in particular chymases, appear to have protective roles. Knowledge of the equine intestinal immune response to cyathostomins is limited. OBJECTIVE: To investigate MC numbers and proteinase expression in equine cyathostomin-infected large intestine. HYPOTHESIS: MC populations in the large intestine are positively associated with cyathostomin burden and predominantly express chymase. METHODS: The caecal cyathostomin burden of naturally infected horses (n = 25) was determined by luminal counts and pepsin digest (mural count). MC were identified and enumerated in caecal tissue using toluidine blue (TB). Immunofluorescent labelling with polyclonal rabbit antibodies was used to demonstrate expression of equine tryptase and the chymase equine mast cell proteinase-1 (eqMCP-1) in Carnoy's fixed caecal sections. RESULTS: Significant positive linear relationships were found between TB-stained mucosal and submucosal MC counts and total cyathostomin burden (P<0.001, r² >36%), and both luminal (P<0.010, r² >25%) and mural (P<0.001, r² >36%) larval counts. Similar relationships were found with mucosal and submucosal chymase and tryptase-labelled MC counts (total: P<0.004, r² >29%; luminal: P<0.004, r² >30%; and mural: P<0.030, r² >19%). With all three MC labels, mean MC counts were higher in the submucosa compared to the mucosa (P<0.001). All caecal MC appeared to express chymase, with a small number of MC expressing both tryptase and chymase. CONCLUSIONS AND POTENTIAL RELEVANCE: Large intestinal MC counts are significantly associated with cyathostomin burden, with a predominance of chymase-positive MC. The burden is significantly associated with expression of MC proteinases, supporting their likely involvement in the intestinal immune response to cyathostomin infection. Further work to investigate the kinetics of proteinase expression, the possibility of differential proteinase expression and the role of these MC proteinases is warranted.

Limited utilities of N-terminal pro B-type natriuretic peptide and other newer risk markers compared with traditional risk factors for prediction of significant angiographic lesions in stable coronary artery disease.

OBJECTIVE: To investigate the usefulness of N-terminal pro-brain natriuretic peptide (NT-proBNP) as a predictive marker for angiographically significant coronary artery disease (CAD) and CAD severity compared with other newer biochemical risk markers and classic risk factors in patients with clinically suspected CAD. DESIGN: Cross-sectional evaluation of NT-proBNP in a large consecutive series of patients without a history of myocardial infarction referred for elective coronary angiography (CAG) between March 2004 and January 2005. The value of NT-proBNP for predicting CAD was assessed and compared with high sensitivity C-reactive protein (hs-CRP), gamma-glutamyltransferase (GGT) and traditional risk factors. SETTING: Tertiary care centre, Department of Cardiology, Innsbruck Medical University, Austria. PATIENTS: 561 men and 287 women aged between 20-86 years (median 65 years). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Association of NT-proBNP with the severity of CAD, left ventricular dysfunction and comparison of predictive values of NT-proBNP, hs-CRP, GGT and traditional CAD risk factors. RESULTS: Of all tested newer biochemical risk markers NT-proBNP performed best. In a multinomial logistic regression model NT-proBNP but not hs-CRP or GGT was significantly associated with three-vessel CAD adjusted for age, sex, ventricular, renal function and classic risk factors (odds ratio = 1.667; 95% CI 1.003 to 2.772; p = 0.049). However, NT-proBNP had no additive predictive value to traditional cardiovascular risk factors for the prediction of angiographically significant CAD in a binary logistic regression model. CONCLUSIONS: The predictive value of NT-proBNP for CAD severity is better than that of hs-CRP or GGT. However, NT-proBNP is also of limited value compared with traditional risk factors for predicting significant CAD.

Inmate-made weapons in prison facilities: assessing the injury risk.

More than 2400 correctional workers in the United States required medical attention in 1999 following assaults by inmates, often with unconventional "homemade" weapons. Little information is available about these weapons. The authors surveyed 101 state prisons for a 12 month period within 2002-03, and 70 responded. A total of 1326 weapons were either confiscated (1086) or used to injure inmates (203) or staff (37). Staff were most often attacked with clubs. The prison store was the most common source of materials used to make confiscated weapons. Issued items were the most common source of materials used to make weapons to injure staff. The injury rate for staff was 1.0/1000 workers per year. The annual cost of injuries for time lost and medical care for staff was estimated at $1,125,000 in these 70 prisons. Results identify materials that should be redesigned to prevent modifications to make weapons. Prison stores and issued items deserve special attention.

Clinical evaluation of 2 flowable composites.

OBJECTIVE: This study evaluated the clinical efficacy of 2 flowable resin composites used to restore occlusal carious lesions. Tetric Flow (Vivadent) and Esthet-X Flow (Dentsply/Caulk) are resin composites with decreased filler loading and lower viscosity compared to conventional resin composites. METHOD AND MATERIALS: Sixty occlusal restorations (30 of each material) were placed. After tooth preparation and caries removal, each material was inserted with rubber dam isolation. Prime & Bond NT (Dentsply/Caulk) was used to bond both flowable composites, which were incrementally placed and light-cured for 20 seconds. Each restoration was evaluated at baseline (1 week after restoration placement), 3 months, 6 months, and 1 year for marginal discoloration, secondary caries, anatomic form, retention, polishability, marginal adaptation, and color match. Groups were compared at 1 year and the data analyzed statistically with a .05 level of significance. RESULTS: A marginally significant difference in color match was observed at 1 year (favoring Esthet-X Flow). No other differences were observed between materials. Marginal discoloration significantly worsened for all restorations at 6 months and 1 year, and marginal adaptation significantly worsened at 1 year for all restorations. A positive association between preparation size and sensitivity was detected at 3 months; no association was found at 6 months and 1 year. At 1 year, restoration size was positively associated with marginal adaptation. Despite some changes from baseline, all restorations were clinically acceptable at 1 year. CONCLUSION: Although flowable resin composites are advocated for occlusal restorations, it is recommended that they be limited to small and moderate-sized restorations.

[Technical feasibility of the implantation of a monorail stent system into the renal arteries without pre-dilatation]. / Technische Machbarkeit der Implantation eines Monorail-Stent-Systems in die Nierenarterien ohne vorherige Dilatation.

PURPOSE: To evaluate the technical feasibility of the implantation of the monorail RX Herculink system into the renal arteries without pre-dilatation. MATERIALS AND METHODS: Forty-two patients (mean age 71 years) from four centers with a total of 44 renal artery stenoses underwent implantation of the RX Herculink stent. The mean grade of the stenosis was 83.8 %, the mean length 7.5 mm. The stenoses were ostial in 38 cases and in immediate proximity to the ostium in 6 cases. The mean follow-up-period was 57 weeks (24 - 176 weeks). RESULTS: In 42 cases, the implantation was successful without pre-dilatation. In 2 cases, pre-dilatation was carried out. In none of the cases, detachment of the stent from the balloon was observed. In one stenosis with a length of 17 mm, implantation of two stents was performed. In 9 cases, post-dilatation with a larger balloon or higher balloon pressure was necessary. Residual stenoses exceeding 30 % were not observed. Two patients developed local bleeding at the puncture site. During the follow-up, restenoses were observed in 5 stents after 26 to 126 weeks, which necessitated a second intervention in 3 cases (PTA in 2 cases, re-stenting in 1 case). The primary patency rate after 6 and 12 months was 0.92 +/- 0.056 according to Kaplan-Meier, the secondary patency rate after 6 and 12 months was 1.0 +/- 0.0. CONCLUSION: Implantation of the RX Herculink stent system into the renal arteries without pre-dilatation is technically feasible and safe. Even without pre-dilatation, the stent-system can be advanced through the stenosis without detachment. The complication rate is low. Our clinical results are comparable to previous studies.

Clinical applications of B-type natriuretic peptide (BNP) testing.

Many claims have been made in recent years regarding the utility of plasma B-type natriuretic peptide (BNP) concentration measurements in the diagnosis, risk stratification and monitoring of patients with heart failure. This paper summarizes the current evidence and provides guidance for practising clinicians. Overall, plasma BNP testing appears to be of most value in the diagnostic arena, where it is likely to improve the performance of non-specialist physicians in diagnosing heart failure. In clinical practice, BNP testing is best used as a 'rule out' test for suspected cases of new heart failure in breathless patients presenting to either the outpatient or emergency care settings; it is not a replacement for echocardiography and full cardiological assessment, which will be required for patients with an elevated BNP concentration. Although work is ongoing in establishing the 'normal' values of BNP, heart failure appears to be highly unlikely below a plasma concentration of 100 pg/ml. However, as BNP levels rise with age and are affected by gender, comorbidity and drug therapy, the plasma BNP measurement should not be used in isolation from the clinical context.

Assessment of the aesthetic quality of a selection of beaches in the Firth of Forth, Scotland.

The aesthetic quality of fourteen beaches in the Firth of Forth, Scotland was surveyed between May and July 2002 using a protocol designed by the UK's National Aquatic Litter Group (NALG). Local authority beach cleaning regimes influence the amount of litter found on beaches. Frequent and thorough beach cleaning is necessary to maintain high aesthetic standards. Bathing and amenity beaches achieved higher aesthetic quality than non-bathing and non-amenity beaches. The aesthetic quality of rural and urban beaches was very similar. The NALG protocol appears more complicated to use than other beach litter surveys. However, the classification system generates results that are easily interpreted by the general public. Furthermore, the NALG protocol could be combined with coastal zone management plans as a useful environmental performance indicator.

Calpain, calpastatin activities and ratios during myocardial ischemia-reperfusion.

The purpose of this study was to test the hypothesis that myocardial ischemia-reperfusion (I/R) is accompanied by an early burst in calpain activity, resulting in decreased calpastatin activity and an increased calpain/calpastatin ratio, thereby promoting increased protein release. To determine the possibility of a 'calpain burst' impacting cardiac calpastatin inhibitory activity, rat hearts were subjected (Langendorff) to either 45 or 60 min of ischemia followed by 30 min of reperfusion with and without pre-administration (s.c.) of a cysteine protease inhibitor (E-64c). Myocardial function, calpain activities (casein release assay), calpastatin inhibitory activity and release of CK, LDH, cTnI and cTnT were determined (n = 8 for all groups). No detectable changes in calpain activities were observed following I/R with and without E-64c (p > 0.05). Both I/R conditions reduced calpastatin activity (p < 0.05) while E-64c pre-treatment was without effect, implicating a non-proteolytic event underlying the calpastatin changes. A similar result was noted for calpain-calpastatin ratios and the release of all marker proteins (p < 0.05). In regard to cardiac function, E-64c resulted in transient improvements (15 min) for left ventricular developed pressure (LVDP) and rate of pressure development (p < 0.05). E-64c had no effect on end diastolic pressure (LVEDP) or coronary pressure (CP) during I/R. These findings demonstrate that restricting the putative early burst in calpain activity, suggested for I/R, by pre-treatment of rats with E-64c does not prevent downregulation of calpastatin inhibitory activity and/or protein release despite a transient improvement in cardiac function. It is concluded that increases in calpain isoform activities are not a primary feature of l/R changes, although the role of calpastatin downregulation remains to be elucidated.

The impact of cardiac natriuretic peptide determination on the diagnosis and management of heart failure.

The long-predicted endocrine function of the heart has been proven by the discovery of atrial natriuretic peptide (atrial natriuretic factor, A-type natriuretic peptide; ANP) 20 years ago. This subsequently led to the description of a whole family of structurally similar but genetically distinct peptides, the natriuretic peptide family, which contributes to cardiovascular homeostasis. These looped peptides promote natriuresis and diuresis, act as vasodilators, and exert antimitogenic effects on cardiovascular tissues. Two members, ANP and brain natriuretic peptide (B-type natriuretic peptide; BNP) are secreted by the heart mainly in response to myocardial stretch induced by volume load. The natriuretic peptides are synthesized as preprohormones. The C-terminal endocrinological active peptides (ANP, BNP) and their N-terminal prohormone fragments are found in plasma. The natriuretic peptide system is activated to its highest degree in ventricular dysfunction. However, natriuretic peptides are increased in all patients with edematous disorders which lead to an increase in atrial tension or central blood volume, such as renal failure or ascitic liver cirrhosis. It could be demonstrated that in chronic heart failure patients and during the subacute phase of myocardial infarction, of all tested neurohormones, the cardiac natriuretic peptides were best markers to identify heart failure and the most powerful predictors of morbidity and mortality. Natriuretic peptides are independent markers for risk assessment. In comparative studies BNP was superior to ANP and its N-terminal prohormone fragments in myocardial infarction as well as in chronic heart failure patients. Less data on N-terminal proBNP (NT-proBNP) is available, but BNP and NT-proBNP appear to be equivalent markers. For primary care physicians natriuretic peptide measurement is useful to decide which patient with suspected heart failure warrants further investigation, particularly when assessment of left ventricular function is not readily available. Natriuretic peptides have an excellent negative predictive value, particularly in high risk patients. An increase in BNP is serious enough to warrant follow-up examinations. For the cardiologists the natriuretic peptides are helpful for guidance of therapy and monitoring disease course in heart failure patients and for risk stratification in heart failure and myocardial infarction.

Creatine kinase, myosin heavy chains and magnetic resonance imaging after eccentric exercise.

The aim of this study was to examine the relationship between myosin heavy chain (MHC) release as a specific marker of slow-twitch muscle fibre breakdown and magnetic resonance imaging (MRI) of skeletal muscle injury after eccentric exercise. The effects of a single series of 70 high-intensity eccentric contractions of the quadriceps femoris muscle group (single leg) on plasma concentrations of creatine kinase and MHC fragments were assessed in 10 young male sport education trainees before and 1 and 4 days after exercise. To visualize muscle injury, MRI of the loaded thigh was performed before and 4 days after the eccentric exercise. All participants recorded an increase (P < 0.05) in creatine kinase after exercise. In five participants, T2 signal intensity was unchanged post-exercise compared with pre-exercise and MHC plasma concentration was normal; however, they showed an increase (P < 0.05) in creatine kinase after exercise. For the remaining five participants, there was an increase in T2 signal intensity of the loaded vastus intermedius and vastus lateralis. These changes in MRI were accompanied by an increase in MHC plasma concentration (P< 0.01) as well as an increase in creatine kinase (P < 0.01). We suggest that changes in MRI T, signal intensity after muscle damage induced by eccentric exercise are closely related to damage to structurally bound contractile filaments of some muscle fibres. Additionally, MHC plasma release indicates that this damage affects not only fast-twitch fibres but also some slow-twitch fibres.

School attendance and school performance: a population-based study of children with asthma.

OBJECTIVE: To analyze school attendance and school achievement as outcomes of the care of children with asthma. METHODS: A previously identified Rochester, Minnesota, cohort of children with asthma and age- and sex-matched children without asthma were studied. School attendance, standardized achievement test scores, grade point average, grade promotion, and class rank of graduating students for children with asthma and control subjects were obtained from the Rochester Public School system. RESULTS: Children with asthma (n = 92) and age- and sex-matched non-asthmatic control subjects with 640 school-years of observation were studied. Children with asthma had 2.21 (95% CI, 1.41 to 3.01) more days absent than children without asthma. There was no significant difference in standardized achievement test scores (reading percentile difference 1.22% [95% CI, -3.68 to 6.12], mathematics percentile difference 2.36% [95% CI, -2.89 to 7.60], language percentile difference 2.96% [95% CI, -4.03 to 7.15]). There was no significant difference in grade point average, grade promotion, or class rank of graduating students. CONCLUSION: In this community, although children with asthma had 2 excess days of absenteeism, the school performance of children with asthma was similar to that of children without asthma.

Head-to-head comparison of N-terminal pro-brain natriuretic peptide, brain natriuretic peptide and N-terminal pro-atrial natriuretic peptide in diagnosing left ventricular dysfunction.

Brain natriuretic peptide (BNP), NT-proBNP and NT-pro-atrial natriuretic peptide (NT-proANP) were measured in blood samples from 57 patients using immunoassays and immunoradiometric assays to evaluate the usefulness as diagnostic markers for the detection of heart failure. For the detection of impaired left ventricular ejection fraction (LVEF), receiver operating characteristic curves showed that BNP had the best diagnostic performance with an area under curve (AUC) of 0.75+/-0.06. However, NT-proBNP (AUC: 0.67+/-0.07) and NT-proANP (AUC: 0.69+/-0.08) showed no significant difference to BNP. In a further analysis for the detection of resting LVEF <40%, BNP again was the best marker with an AUC of 0.83+/-0.06. NT-proBNP showed only a slightly smaller AUC (0.79+/-0.07). The AUC for NT-proANP was significantly smaller (0.65+/-0.08) compared to BNP. Additionally, BNP and NT-proBNP correlated negatively with the resting LVEF (BNP: -0.472, p<0.001; NT-proBNP: -0.306, p=0.026), whereas NT-proANP showed no significant correlation. In summary, BNP was the best marker to detect patients with impaired LVEF compared to NT-proBNP and NT-proANP. However, NT-proBNP showed no significant differences to BNP and it is therefore a new promising alternative marker for the detection of left ventricular dysfunction.