N-terminal pro-B-type natriuretic peptide concentrations and long-term outcome after cardiac surgery: a prospective cohort study.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations predict cardiovascular outcome in many settings. There are very few data assessing the utility of NT-proBNP concentrations in the prediction of long-term outcome after cardiac surgery. We assessed the ability of NT-proBNP to predict 3 yr mortality compared with validated clinical risk prediction tools. METHODS: A secondary analysis of a prospectively recruited patient cohort of 1010 patients undergoing cardiac surgery. Baseline clinical details were obtained including EuroSCORE. Multi-variable modelling, area under the receiver operating characteristic curves (AUCs), and net reclassification improvement were utilized. RESULTS: NT-proBNP was a univariable predictor of 3 yr mortality but was no longer a significant predictor in a multivariable model (hazard ratio 1.00 per 250 ng litre(-1), 95% confidence interval 0.98-1.02, P=0.80). The relative and additive predictive values of the preoperative EuroSCORE (both additive and logistic versions) and NT-proBNP concentrations were compared. All were predictive of 3 yr mortality (P<0.001) with almost identical AUCs (0.71 for EuroSCORE, 0.70 for NT-proBNP). When either the EuroSCORE or NT-proBNP concentrations are known, the addition of the other does not improve the ability to predict 3 yr mortality. CONCLUSIONS: Preoperative NT-proBNP concentrations and the EuroSCORE have equivalent, and moderate, predictive accuracy for mortality 3 yr after cardiac surgery. EuroSCORE uses clinical data but is not routinely used for individual clinical risk prediction. NT-proBNP measurement would incur additional costs but can be measured quickly and objectively. With such similar predictive accuracy, factors such as the ease of calculation and cost will likely determine their use in clinical practice.

Bilateral hip replacement in three patients with lysosomal storage disease: Mucopolysaccharidosis type IV and Mucolipidosis type III.

The management of joint replacement in lysosomal storage diseases has not been well reported. We present three patients with progressive degenerative changes of the hips who required bilateral total hip replacement in early childhood. The stature of the patients make it essential to have access to appropriately scaled prostheses. Consideration has to be given to associated disorders of the skeleton which must be carefully screened to ensure safety in providing appropriate anaesthesia as well as ensuring that there is no cardiac abnormality. In one patient, a periprosthetic fracture was sustained in one hip in the early post-operative course requiring internal fixation. The patient made a full recovery and all six hips were clinically and radiologically satisfactory at mid-term review.

N-terminal pro-B-type natriuretic peptide levels and early outcome after cardiac surgery: a prospective cohort study.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a powerful predictor of cardiovascular outcome in many circumstances. There are, however, limited data regarding the utility of NT-proBNP or BNP levels in patients undergoing cardiac surgery. The current study assesses the ability of NT-proBNP to predict early outcome in this setting. METHODS: One thousand and ten patients undergoing non-emergent cardiac surgery were recruited prospectively. Baseline clinical details were obtained and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Parsonnet score were calculated. Preoperative NT-proBNP levels were measured using the Roche Elecsys assay. The primary endpoint was 30 day mortality. RESULTS: Median NT-proBNP levels were 624 ng litre(-1) among patients who died within 30 days of surgery (n=29), compared with 279 ng litre(-1) in survivors [odds ratio (OR) 1.03 per 250 ng litre(-1), 95% confidence interval 1.01-1.05, P=0.001). NT-proBNP levels remained predictors of 30 day mortality in models including either the additive EuroSCORE (OR 1.03 per 250 ng litre(-1), P=0.01), the logistic EuroSCORE (OR 1.03 per 250 ng litre(-1), P=0.004), or the Parsonnet score (OR 1.02 per 250 ng litre(-1), P=0.04). Levels of NT-proBNP were also predictors of prolonged (>1 day) stay in the intensive care unit (OR 1.03 per 250 ng litre(-1), P<0.001) and of a hospital stay >1 week (OR 1.07 per 250 ng litre(-1), P<0.001). They remained predictive of these outcomes in regression models that included either the EuroSCORE or the Parsonnet score and in a model that included all study variables. CONCLUSIONS: NT-proBNP levels predict early outcome after cardiac surgery. Their prognostic utility is modest-but is independent of traditional indicators and conventional risk prediction scores.

Socio-economic status and early outcome from coronary artery bypass grafting.

OBJECTIVE: To determine the effects of socio-economic status (SES) on the outcome of coronary artery bypass grafting (CABG). DESIGN: Prospective cohort study. SETTING: Regional cardiac surgical unit. PATIENTS: 1994 consecutive patients undergoing non-emergency CABG. MEASURES: SES was determined from the patient's postcode using Carstairs tables. The primary end-point was all-cause mortality at 30 days. RESULTS: There were 50 deaths (2.5%) within 30 days of surgery. A higher Carstairs score demonstrated a trend towards increased 30-day mortality (odds ratio (OR) 1.09 per unit, 95% CI 1.00 to 1.20, p = 0.06). In a backward conditional model, including other predictors of early mortality, Carstairs scores were independently predictive (OR 1.12 per unit, 95% CI 1.01 to 1.24, p = 0.02). In a model including only Carstairs scores and the EuroSCORE, both were independent predictors of this outcome (OR for Carstairs score 1.11 per unit, 95% CI 1.00 to 1.22, p = 0.04). The 30-day mortality increases in each quartile of Carstairs scores, with patients in quartile 4 (most deprived) at significantly higher risk compared with quartile 1 (uncorrected OR 2.53 per unit, 95% CI 1.04 to 6.15; OR corrected for EuroSCORE, 2.56 per unit, 95% CI 1.03 to 6.34, p = 0.04 for both). Similarly, patients in the least affluent quartile were twice as likely to suffer a serious complication as those in the most affluent quartile (OR 2.14 per unit, 95% CI 1.32 to 3.46, p = 0.002). This increased risk was also independent of the EuroSCORE. CONCLUSIONS: Lower SES is associated with a poorer early outcome following CABG and is independent of other recognised risk factors.

Simultaneous bilateral avulsion fractures of the tibial tuberosity in adolescence: A case report and review of over 50 years of literature.

Simultaneous bilateral avulsion fractures of the tibial tuberosity is a rare injury. Since it was first described in 1955, there have been eight similar cases. We have reviewed each of these reports and describe an additional case of a 13-year-old boy, who sustained simultaneous bilateral avulsion fractures of the tibial tuberosity from jumping while playing soccer. Like the previous reports, our patient had a satisfactory result from open reduction and internal fixation of both fractures. Despite being bilateral, these injuries have a low complication rate and good outcome comparable with that of unilateral avulsion fractures of the tibial tuberosity.

Bilateral, asymmetrical congenital dislocation of the radial heads in trisomy 8 syndrome.

Congenital radial head dislocation (CRHD) can occur as an isolated abnormality, as part of an upper-limb anomaly or as a feature of at least fourteen syndromes. The dislocation may be unilateral or bilateral, and rarely can be bilaterally asymmetrical. CRHD is often asymptomatic, and may go undiagnosed and remain undetected until after a radiography has been obtained for an incidental injury. It is therefore important to be able to differentiate congenital from traumatic dislocation of the radial head. We report a mentally retarded female, known to have trisomy 8, who presented with stiffness of her elbow joints and no history of preceding trauma. Radiographs confirmed bilateral asymmetrical radial head dislocation. This combination of anterior and posterior CRHD co-existing in the same patient has not been described previously with trisomy 8 syndrome.

Miniature angled sub-selective guiding catheter aids in placing guidewire through difficult anatomy.

A method for fabricating and using a "mini" guiding catheter is presented. Use of the mini guiding catheter provides the back up support necessary to enable a guidewire to traverse difficult anatomy. Use of this device to cross a lesion in an acutely angulated circumflex artery is presented.

Clenbuterol, a beta-adrenoceptor agonist, increases relative muscle strength in orthopaedic patients.

1. The sympathomimetic agent clenbuterol has a muscle-specific anabolic effect in normal and wasted muscles from animals. This trial was designed to examine the effect of the drug on the recovery of muscle strength and area after open medial meniscectomy. 2. A double-blind, completely randomized, placebo-controlled study was carried out on 20 healthy male patients. Muscle strength and cross-sectional area were determined before and after surgery. Patients were treated with drug or placebo for 4 weeks postoperatively and there was a 2 week washout period. 3. The results suggest that, in the operated leg, clenbuterol treatment is associated with a more rapid rehabilitation of strength in knee extensor muscles; in the unoperated leg, knee extensor strength increased above the initial values after 6 weeks (P = 0.01). However, in terms of absolute strength the differences were not significant between the two groups. 4. It is concluded that the data lend support to the proposition that clenbuterol has therapeutic potential in the treatment of muscle-wasting conditions.

Acute calcification and carpal tunnel syndrome.

Carpal tunnel syndrome is a common diagnosis, and often there is no identifiable cause. We describe the case of a patient who developed acute symptoms secondary to calcification in the carpal tunnel. The patient was treated by decompression, and made a slow, but uneventful recovery.

Transient synovitis of the hip joint.

A review of 286 children who presented with transient synovitis of the hip over a 6-year period shows that the condition remains a benign disease of the paediatric hip which settles quickly with simple symptomatic treatment. We have not found any obvious causal agent for the condition despite intensive laboratory investigation. There was only one subsequent case of Perthes' disease in association with transient synovitis, causing doubt on any relationship between the two conditions. The need for extensive investigation and long-term follow-up seems to be unnecessary in transient synovitis of the hip.

Structural and biochemical evidence that scrapie-associated fibrils assemble in vivo.

Scrapie-associated fibrils (SAF) are a ubiquitous pathological feature of brains affected by scrapie and the other scrapie-like agents. They are composed of PrP, a heterogeneous glycoprotein which is also present in normal brain but not as SAF. The PrP protein associated with SAF is partially resistant to proteinase K, whereas the soluble form is not. It has been proposed that SAF do not exist as such in vivo, but rather self-assemble from subunit structures liberated from membranes by detergent extraction during purification. We have purified SAF by a method that does not employ proteinase K. We show that the PrP protein from infected but not uninfected brain is partially resistant to protease digestion before and after detergent extraction. Likewise, SAF can be sheared by sonication before or after detergent extraction. In addition, SAF from mice infected with different strains of scrapie have different sedimentation properties. Since SAF-dependent properties exist before detergent extraction, then so must SAF. They are therefore not a detergent-induced artefact but most probably assemble in vivo.

An electron microscopic study of inclusion bodies in synaptic terminals of scrapie-infected animals.

Inclusion bodies consisting of vesicles of about 25 nm diameter and occurring in the synaptic terminals of scrapie-infected animals have been described by a number of people. In the present study these inclusion bodies were looked for in the neocortex, hippocampus and corpus callosum in a variety of strains of mice (C3H, LM, RIII, IM, VL) infected with different strains of scrapie agent (22C, 79A, ME7, 87V) after intracerebral inoculation. In plaque-bearing models of scrapie, terminals containing synaptic inclusion bodies were frequently found surrounding the amyloid plaque cores in the neocortex but not in the corpus callosum. In non-plaque-bearing models, terminals containing synaptic inclusion bodies were found in the neuropil of the neocortex and hippocampus. For all models, these bodies were either presynaptic or postsynaptic but were not, as a rule, found on both sides of the same synapse. Fibrillary material was frequently seen in the postsynaptic terminals containing the inclusion bodies in both the plaque- and non-plaque-bearing models. On one occasion fibrillary material was seen, together with the inclusion bodies, in a neuron cell body. Inclusion bodies were also seen in the neocortex of hamsters infected with the 263K strain of scrapie agent and a Cheviot sheep infected with the ME7 strain of agent. The inclusion bodies and the fibrillary material were thought to be derived from the breakdown of neurotubules.

Prevention of haematogenous infection in prosthetic joints.

A survey was conducted to identify the attitude of consultant orthopaedic surgeons and rheumatologists in Scotland, North East England and Ireland, to the prevention of blood-borne infection in prosthetic joints. Of the 61% who completed the questionnaire, 65% gave advice about intercurrent infection, a similar number gave advice about the use of prophylactic antibiotics before certain surgical procedures, with less than half of the patients receiving any written instructions about inter-current infection, and less than a quarter of the patients receiving any written instructions about antibiotic prophylaxis. 36% of the respondents were confused as to what to advise or ignored the problem. The reality of late infection is discussed and a policy to minimise the risk of late infection in prosthetic joints is presented for consideration.