Prevalence, clinical phenotype, and outcomes associated with normal B-type natriuretic Peptide levels in heart failure with preserved ejection fraction

B-type natriuretic peptide (BNP) is used widely to exclude heart failure (HF) in patients with dyspnea. However, most studies of BNP have focused on diagnosing HF with reduced ejection fraction (EF). The aim of this study was to test the hypothesis that a normal BNP level (≤100 pg/ml) is relatively common in HF with preserved EF (HFpEF), a heterogenous disorder commonly associated with obesity. A total of 159 consecutive patients enrolled in the Northwestern University HFpEF Program were prospectively studied. All subjects had symptomatic HF with EF >50% and elevated pulmonary capillary wedge pressure. BNP was tested at baseline in all subjects. Clinical characteristics, echocardiographic parameters, invasive hemodynamics, and outcomes were compared among patients with HFpEF with normal (≤100 pg/ml) versus elevated (>100 pg/ml) BNP. Of the 159 patients with HFpEF, 46 (29%) had BNP ≤100 pg/ml. Subjects with normal BNP were younger, were more often women, had higher rates of obesity and higher body mass index, and less commonly had chronic kidney disease and atrial fibrillation. EFs and pulmonary capillary wedge pressures were similar in the normal and elevated BNP groups (62 ± 7% vs 61 ± 7%, p = 0.67, and 25 ± 8 vs 27 ± 9 mm Hg, p = 0.42, respectively). Elevated BNP was associated with enlarged left atrial volume, worse diastolic function, abnormal right ventricular structure and function, and worse outcomes (e.g., adjusted hazard ratio for HF hospitalization 4.0, 95% confidence interval 1.6 to 9.7, p = 0.003). In conclusion, normal BNP levels were present in 29% of symptomatic outpatients with HFpEF who had elevated pulmonary capillary wedge pressures, and although BNP is useful as a prognostic marker in HFpEF, normal BNP does not exclude the outpatient diagnosis of HFpEF.     

Direct Metal Laser Sintering: A Digitised Metal Casting Technology

Dental technology is undergoing advancements at a fast pace and technology is being imported from various other fields. One such imported technology is direct metal laser sintering technology for casting metal crowns. This article will discuss the process of laser sintering for making metal crowns and fixed partial dentures with a understanding of their pros and cons.     

Sexual Risk Behaviors Among HIV-Infected South African Men and Women with Their Partners in a Primary Care Program: Implications for Couples-Based Prevention

We studied 1163 sexually-active HIV-infected South African men and women in an urban primary care program to understand patterns of sexual behaviors and whether these behaviors differed by partner HIV status. Overall, 40% reported a HIV-positive partner and 60% a HIV-negative or status unknown partner; and 17.5% reported >2 sex acts in the last 2 weeks, 16.4% unprotected sex in the last 6 months, and 3.7% >1 sex partner in the last 6 months. Antiretroviral therapy (ART) was consistently associated with decreased sexual risk behaviors, as well as with reporting a HIV-negative or status unknown partner. The odds of sexual risk behaviors differed by sex; and were generally higher among participants reporting a HIV-positive partner, but continued among those with a HIV-negative or status unknown partner. These data support ART as a means of HIV prevention. Engaging in sexual risk behaviors primarily with HIV-positive partners was not widely practiced in this setting, emphasizing the need for couples-based prevention.     

Ultra-wide field retinal imaging: A wider clinical perspective

The peripheral retina is affected in a variety of retinal disorders. Traditional fundus cameras capture only a part of the fundus even when montaging techniques are used. Ultra-wide field imaging enables us to delve into the retinal periphery in greater detail. It not only facilitates assessing color images of the fundus, but also fluorescein angiography, indocyanine green angiography, fundus autofluorescence, and red and green free images. In this review, a literature search using the keywords “ultra-widefield imaging”, “widefield imaging”, and “peripheral retinal imaging” in English and non-English languages was done and the relevant articles were included. Ultra-wide field imaging has made new observations in the normal population as well as in eyes with retinal disorders including vascular diseases, degenerative diseases, uveitis, age-related macular degeneration, retinal and choroidal tumors and hereditary retinal dystrophies. This review aims to describe the utility of ultra-wide field imaging in various retinal disorders.     

Morphological Differences between Ruptured and Unruptured Basilar Bifurcation Aneurysms

Background Aspect ratio (AP), daughter artery ratio (DA), and lateral angle ratio (LA) have been reported in middle cerebral artery bifurcation aneurysms to correlate with rupture status.Objective To study the differences in AP, DA, LA, and aneurysm orientation between ruptured and unruptured basilar bifurcation aneurysms.Methods Three-dimensional (3D) angiograms of patients with basilar bifurcation aneurysms were analyzed for AP, DA, and LA. Aneurysm projection was classified as type A if the long axis of aneurysm was along basilar artery and type-B if otherwise.Results Thirty-one ruptured and 17 unruptured aneurysms were analyzed. The APs were significantly different (p = 0.008), 2.63 ± 1.1 for ruptured aneurysms and 1.7 ± 0.55 for unruptured aneurysms. AP ≥ 1.9 correlated with rupture status with 68% sensitivity and 70% specificity. Type-A configuration was significantly associated with ruptured aneurysms with an odds ratio (OR) of 5.9. LAs were 0.9 ± 0.4 and 1.4 ± 0.8 for ruptured and unruptured aneurysms, respectively, and the difference tended to be significant (p = 0.56). DAs were 1.25 ± 0.22 and 1.21 ± 0.19 for ruptured and unruptured aneurysms without any statistical difference.Conclusion AP > 1.9, type-A configuration, and lower LA is associated with ruptured basilar bifurcation aneurysms. DA did not differ between ruptured and unruptured aneurysms