Heart Failure Outcomes and Benefits of NT-proBNP-Guided Management in the Elderly: Results From the Prospective, Randomized ProBNP Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) Study

BackgroundElderly patients with heart failure (HF) have a worse prognosis than younger patients. We wished to study whether elders benefit from natriuretic peptide-guided HF care in this single-center study.Methods and ResultsA total of 151 patients with HF resulting from left ventricular systolic dysfunction (LVSD) were treated with HF treatment by standard-of-care (SOC) management or guided by N-terminal pro-B type natriuretic peptide (NT-proBNP) values (with a goal to lower NT-proBNP ≤1000 pg/mL) over 10 months. The primary end point for this post-hoc analysis was total cardiovascular events in 2 age categories (<75 and ≥75 years). In those ≥75 years of age (n = 38), NT-proBNP values increased in the SOC arm (2570 to 3523 pg/mL, P = .01), but decreased in the NT-proBNP–guided arm (2664 to 1418 pg/mL, P = .001). Elderly patients treated with SOC management had the highest rate of cardiovascular events, whereas the elderly with NT-proBNP management had the lowest rate of cardiovascular events (1.76 events per patient versus 0.71 events per patient, P = .03); the adjusted logistic odds for cardiovascular events related to NT-proBNP–guided care for elders was 0.24 (P = .008), whereas in those <75 years (n = 113), the adjusted logistic odds for events following NT-proBNP–guided care was 0.61 (P = .10).ConclusionsNatriuretic peptide–guided HF care was well tolerated and resulted in substantial improvement in cardiovascular event rates in elders (Clinical Trials.Gov #00351390).     

Bariatric surgery in Asia in the last 5 years (2005-2009)

Obesity is a major public health concern around the world, including Asia. Bariatric surgery has grown in popularity to combat this rising trend. An e-mail questionnaire survey was sent to all the representative Asia-Pacific Metabolic and Bariatric Surgery Society (APMBSS) members of 12 leading Asian countries to provide bariatric surgery data for the last 5?years (2005-2009). The data provided by representative members were discussed at the 6th International APMBSS Congress held at Singapore between 21st and 23rd October 2010. Eleven nations except China responded. Between 2005 and 2009, a total of 6,598 bariatric procedures were performed on 2,445 men and 4,153 women with a mean age of 35.5?years (range, 18-69years) and mean BMI of 44.27?kg/m(2) (range, 31.4-73?kg/m(2)) by 155 practicing surgeons. Almost all of the operations were performed laparoscopically (99.8%). For combined years 2005-2009, the four most commonly performed procedures were laparoscopic adjustable gastric banding (LAGB, 35.9%), laparoscopic standard Roux-en-Y gastric bypass (LRYGB, 24.3%), laparoscopic sleeve gastrectomy (LSG, 19.5%), and laparoscopic mini gastric bypass (15.4%). Comparing the 5-year trend from 2004 to 2009, the absolute numbers of bariatric surgery procedures in Asia increased from 381 to 2,091, an increase of 5.5 times. LSG increased from 1% to 24.8% and LRYGB from 12% to 27.7%, a relative increase of 24.8 and 2.3 times, whereas LAGB and mini gastric bypass decreased from 44.6% to 35.6% and 41.7% to 6.7%, respectively. The absolute growth rate of bariatric surgery in Asia over the last 5?years was 449%.     

Novel Biomarkers: Utility in Patients with Acute Chest Pain and Relationship to Coronary Artery Disease on Coronary CT Angiography

Acute chest pain remains one of the most common patient presentations encountered in the emergency department. With the evolution of biomarkers and improvement in cardiac imaging there has been advancement in risk stratification of patients, but millions of dollars continue to be spent in the assessment of chest pain. Investigators have explored possible comparative alternatives to the traditional work up of chest pain. In this review, we will discuss the current state of biomarker use in the evaluation of acute chest pain. We will review established and emerging circulating biomarkers and their addition to cardiac CT for appropriate diagnosis of coronary artery disease.     

Performance evaluation of diverse T-wave alternans estimators under variety of noise characterizations and alternans distributions

Prognostic significance of microvolt T-wave alternans (TWA) has been established since their inclusion among important risk stratifiers for sudden cardiac death. Signal processing schemes employed for TWA estimation have their peculiar theoretical assumptions and reported statistics. An unbiased comparison of all these techniques is still a challenge. Choosing three classical schemes, this study aims to achieve holistic performance evaluation of diverse TWA estimators from a three dimensional standpoint, i.e., estimation statistics, alternan distribution and ECG signal quality. Three performance indices called average deviation (? _L ), moment of deviation (? _m ) and coefficient of deviation ( $\varphi$ ) are devised to quantify estimator performance and consistency. Both synthetic and real physiological noises, as well as variety of temporal distributions of alternan waveforms are simulated to evaluate estimators’ responses. Results show that modification of original estimation statistics, consideration of relevant noise models and a priori knowledge of alternan distribution is necessary for an unbiased performance comparison. Spectral method proves to be the most accurate for stationary TWA, even at SNRs as low as 5 dB. Correlation method’s strength lies in accurately detecting temporal origins of multiple alternan episodes within a single analysis window. Modified moving average method gives best estimation at lower noise levels (SNR >25 dB) for non-stationary TWA. Estimation of both MMAM and CM is adversely effected by even small baseline drifts due to respiration, although CM gives considerably higher deviation levels than MMAM. Performance of SM is only effected when fundamental frequency of baseline drift due to respiration falls within the estimation band around 0.5 cpb.     

Cardiovascular risk factors among adolescent secondary school boys in Ahad Rufeida, southwestern Saudi Arabia

A cross-sectional stratified sample of 1249 adolescent secondary school boys was studied. More than 25% of boys did not practice any physical exercise. More than half of the parents (54.5%) were consanguineous. High prevalence of parental history of hypertension, diabetes and high blood lipids was found. Smoking amounted to 11.8%. The prevalence of obesity was 23.3%. The study showed that 6.8% had a high systolic blood pressure and 13.0% (162) had high diastolic blood pressure. There is a need for a national programme to prevent and control cardiovascular risk factors among adolescents.     

A nomogram for estimating the probability of ovarian cancer

Objective

Accurate preoperative estimates of the probability of malignancy in women with adnexal masses are essential for ensuring optimal care. This study presents a new statistical model for combining predictive information and a graphic decision support tool for calculating risk of malignancy.

Methods

The study included 153 women treated with definitive surgery for adnexal mass between 2001 and 2007 with preoperative ultrasound testing and a serum CA125. Multivariable logistic regression was used to develop a statistical model for estimating the probability of ovarian cancer as a function of age, ultrasound score, and CA125 value, with adjustments for nonlinear and interactive relationships.

Results

A total of 20 cases of pathologically confirmed cancer (13 invasive malignancies, and 7 tumors of low malignant potential) were identified (20/153 = 13%). The model obtained excellent discrimination (ROC area = 0.87), explained nearly half of the observed variation in the risk of malignancy (R² = 0.43), and was well calibrated across the full range of malignancy probabilities. The model equation is represented in the form of a nomogram, which can be used to calculate preoperative probability of malignancy. At a 5% risk of malignancy threshold, the model has a sensitivity of 90% and a specificity of 73%.

Conclusions

Statistical models for estimating the probability of adnexal mass malignancy are substantially improved by including adjustments for non-linear relationships among key variables. A clinically relevant nomogram provides an objective tool to further aid clinicians in counseling patients and ensuring proper referral to surgical sub-specialists when indicated.     

Atypical presentations of rhinosporidiosis: a clinical dilemma?

Rhinosporidiosis is a chronic inflammatory disease common in India and Sri Lanka. Its manifestations are mostly nasal, though extranasal ones in head and neck region are not rare. Occasionally these presentations lead to diagnostic dilemma. Here we present some cases with its associated confusions if any. In this study thirty five patients were included. Extranasal manifestations were noted in nine cases. Two patients attended with laryngopharyngeal and one with lacrimal sac presentation-subsequent nasal endoscopic examination revealed presence of nasal masses, too. Other six cases presented with polypoidal mass hanging from nasopharynx into oropharynx. One of them was confused with nasopharyngeal angiofibroma. Two laryngopharyngeal masses were removed successfully with rigid laryngoscope followed by cauterisation of the base. The solitary lacrimal sac mass was excised by external approach combined with nasal endoscope guided excision of nasal mass. The other six cases with nasopharyngeal attachment were subjected to nasal endoscope guided removal. In all these cases, the base of the lesions was cauterised. The experience about the various manifestations and diagnostic problems is discussed here.