Exercise oscillatory breathing and NT-proBNP levels in stable heart failure provide the strongest prediction of cardiac outcome when combining biomarkers with cardiopulmonary exercise testing

BackgroundN-Terminal pro–brain natriuretic peptide (NT-proBNP) and cardiopulmonary exercise testing (CPET)–derived variables are gold standards for assessing prognosis in heart failure (HF) patients. We sought to refine cardiac events prediction by performing a combined analysis of NT-proBNP with markers of exercise ventilatory efficiency.Methods and ResultsA total of 260 stable HF patients underwent measurements of plasma NT-proBNP levels before, at peak exercise, and at 1-minute CPET recovery phase along with peak oxygen uptake (VO₂), ventilation to CO₂ production (VE/VCO₂) slope, and exercise periodic breathing (EPB) determinations. After a median follow-up period of 20.6 months, there were 54 cardiac-related deaths. Univariate analysis including NT-proBNP at rest, at peak exercise, and at 1 minute recovery, peak VO₂, VE/VCO₂ slope, and EPB showed NT-proBNP to be the strongest independent predictor with equivalent performance for rest, peak, and recovery levels. Thus, only NT-proBNP at rest was considered (Harrel C 0.783, 95% confidence interval [CI] 0.722–0.844) with VE/VCO₂ slope (Harrel C 0.720, 95% CI 0.646–0.794), EPB (Harrel C 0.685, 95% CI 0.619–0.751), and peak VO₂ (Harrel C 0.618, 95% CI 0.533–0.704). With bivariate stepwise analyses, NT-proBNP along with EPB emerged as the strongest prognosticators (Harrel C 0.800, 95% CI 0.737–0.862).ConclusionsIn the refinement for robust outcome predictors in HF patients, NT-proBNP levels together with EPB led to the most powerful definition. VE/VCO₂ slope and peak VO₂ did not provide any prognostic adjunct. A biomarker/CPET approach seems very promising to warrant the continuous implementation in the prognostic work-up of HF patients.     

MAASH Technique for Total Hip Arthroplasty: A Capsular Work

Background

Dislocation and leg length discrepancy are major complications following total hip arthroplasty (THA). Many surgical approaches for THA have been described, but none suggest a capsular incision that assures good exposure while maintaining adequate capsule integrity in closure.

Purposes

Modified anterolateral approach for stable hip (MAASH) is a modification of the classical Hardinge approach, but specifically preserves the anterior iliofemoral lateral ligament and pubofemoral ligament excising the “weak area” of the capsule, in the so called “internervous safe zone” and introducing the “box concept” for the anterior approach to the hip. This is the main difference of the MAASH approach. This technique can be used as a standard for all THA standard models, but we introduce new devices to make it easier.

Methods

From November 2007 to May 2012, data were collected for this observational retrospective consecutive case study. We report the results of 100 THA cases corresponding to the development curve of this new concept in THA technique.

Results

MAASH technique offers to hip surgeons, a reliable and reproducible THA anterolateral technique assuring accurate reconstruction of leg length and a low rate of dislocation. Only one dislocation and six major complications are reported, but most of them occurred at the early stages of technique development.

Conclusion

MAASH technique proposes a novel concept on working with the anterior capsule of the hip for the anterolateral approach in total hip arthroplasty, as well as for hemiarthroplasty in the elderly population with high dislocation risk factors. MAASH offers maximal stability and the ability to restore leg length accurately.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9332-1) contains supplementary material, which is available to authorized users.     

Transcatheter closure of secundum atrial septal defect

Since the introduction of transcatheter closure of atrial septal defect, device closure has become the alternative treatment of selected atrial defects. Although excellent results have been reported for transcatheter closure, concerns have arisen regarding complications, including residual shunt, systemic or pulmonary embolization of the device, and erosion and perforation of the cardiac chamber. Those complications are rare but potentially serious adverse events that may require immediate surgical intervention. This review summarizes the current trends in patient selection, result of device closure and typical complications. Comparison between transcatheter device closure and surgical closure is also made.     

Diving-related fatalities: multidisciplinary,experience-based investigation

Forensic Science, Medicine and Pathology - To describe the technical characteristics of fatal diving mishaps and to elucidate the causes of death using a sequence analysis and a multidisciplinary...     

Minimum clinically significant VAS differences for simultaneous (paired) interval serial pain assessments

We conducted two studies to determine whether the minimum clinically significant difference in the visual analog scale (VAS) for nearly simultaneous and brief-interval serial assessments of pain is less than that for pain assessment at 20- to 30-minute intervals, using a 10-cm VAS. The first study was a blinded, randomized, placebo-controlled paired trial comparing the pain of intravenous cannulation in both hands (20-minute application of a eutectic mixture of local anesthetics v placebo) of study subjects. The second study was a non-blinded, randomized, paired trial of different treatments for jellyfish stings. In the first study, 37 of 40 subjects indicated that one hand experienced more pain than the other. Eleven of these 37 subjects (30%) indicated differences in VAS values of 1.0 cm or less, with a minimum value of 0.5 cm. In the second study, for all the VAS-based pain comparisons, VAS differences of 相似文献   

Epidemiological and clinical characteristics of community‐acquired and nosocomial influenza cases and risk factors associated with complications: A four season analysis of all adult patients admitted in a tertiary hospital

BackgroundInformation on the characteristics of patients with nosocomial influenza and associated complications is scarce. This study compared epidemiological and clinical characteristics of patients admitted with hospital‐acquired influenza (HAI) to those with community‐acquired influenza (CAI) and analyzed risk factors associated with complications.MethodsThis retrospective, observational study included all adult patients with confirmed influenza virus infection admitted to Son Espases University Hospital during the influenza season in Spain (October to May) from 2012‐2013 to 2015‐2016. Symptom onset before admission was included as CAI, and 2 days after admission or within 48 hours after previous discharge were considered as HAI.ResultsOverall, 666 patients with laboratory‐confirmed influenza were included; 590 (88.6%) and 76 (11.4%) had CAI and HAI, respectively. Baseline characteristics and vaccination rates were similar in both groups. Patients with HAI had significantly fewer symptoms, less radiological alterations, and earlier microbiological diagnosis than those with CAI. Eighty‐five (14.4%) and 20 (27.6%) CAI and HAI patients, respectively, experienced at least one complication, including septic shock, admission to the intensive care unit, mechanical ventilation or evolution to death (any one, P = .003). Univariate and multivariate binary logistic regression was performed to assess independent risk factors associated with the occurrence of complications: nosocomial infection, diabetes, oseltamivir treatment, having received no vaccination, microbiological delay, dyspnea, and the state of confusion were the most important significant factors.ConclusionsOur study shows the need to implement microbiological diagnostic measures in the first 48 hours to reduce HAI frequency and associated complications.     

Bone loss following hypogonadism in men with prostate cancer treated with GnRH analogs

It is known that bone mineral density (BMD) is low in men who are hypogonadal. However, the rate and sites of bone loss following testosterone deficiency are not known. The resulting hypogonadism after GnRH analog therapy for the treatment of prostate cancer allows us to examine bone loss and bone resorption immediately after testosterone withdrawal. Therefore, we examined the effects of GnRH analog treatment on bone loss and bone resorption in men with prostate cancer. BMD and serum and urine concentrations of markers of bone turnover were determined in men with prostate cancer and in age-matched controls. Measurements were taken before GnRH therapy and 6 and 12 months after instituting therapy. After 12 months of GnRH therapy, the BMD of the total hip and ultra distal radius decreased significantly (P < 0.001) in men with prostate cancer compared with the controls. The mean bone loss was 3.3% and 5.3%, respectively. The observed reduction in BMD in the spine (2.8%) and the femoral neck (2.3%) did not reach statistical significance. No significant bone loss was observed in the control subjects. The concentration of the urine marker of bone resorption, N-telopeptide, was significantly increased from baseline and from controls at both 6 and 12 months in patients treated with GnRH analog therapy compared with control subjects (P < 0.05). The concentration of a serum marker of bone formation, bone-specific alkaline phosphatase, was not significantly different from baseline or from controls at 6 and 12 months. Thus, the decreased total hip and ultra distal radius BMD and increased urinary N-telopeptide concentration after testosterone withdrawal demonstrate an increase in trabecular bone loss and enhanced bone resorption. These findings demonstrate a significant loss of bone in men with prostate cancer after receiving GnRH therapy and suggest that the total hip and radius are the preferred sites for monitoring bone loss in older men. In addition, markers of bone resorption may be helpful.