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.

Randomized, comparative study of interferon beta-1a treatment regimens in MS: The EVIDENCE Trial

BACKGROUND

Interferon beta (IFNbeta) reduces relapses and MRI activity in relapsing-remitting MS (RRMS), with variable effects on disability. The most effective dose regimen remains controversial.

METHODS

This randomized, controlled, multicenter trial compared the efficacy and safety of IFNbeta-1a (Rebif) 44 micro g subcutaneously three times weekly (tiw), and IFNbeta-1a (Avonex) 30 micro g IM once weekly (qw) in 677 patients with RRMS. Assessors blinded to treatment performed neurologic and MRI evaluations. The primary endpoint was the proportion of patients who were relapse free at 24 weeks; the principal MRI endpoint was the number of active lesions per patient per scan at 24 weeks.

RESULTS

After 24 weeks, 74.9% (254/339) of patients receiving IFNbeta-1a 44 micro g tiw remained relapse free compared with 63.3% (214/338) of those given 30 micro g qw. The odds ratio for remaining relapse free was 1.9 (95% CI, 1.3 to 2.6; p = 0.0005) at 24 weeks and 1.5 (95% CI, 1.1 to 2.1; p = 0.009) at 48 weeks, favoring 44 micro g tiw. Patients receiving 44 micro g tiw had fewer active MRI lesions (p < 0.001 at 24 and 48 weeks) compared with those receiving 30 micro g qw. Injection-site reactions were more frequent with 44 micro g tiw (83% vs 28%, p < 0.001), as were asymptomatic abnormalities of liver enzymes (18% vs 9%, p = 0.002) and altered leukocyte counts (11% vs 5%, p = 0.003) compared with the 30 micro g qw dosage. Neutralizing antibodies developed in 25% of 44 micro g tiw patients and in 2% of patients receiving 30 micro g qw.

CONCLUSIONS

IFNbeta-1a 44 micro g subcutaneously tiw was more effective than IFNbeta-1a 30 micro g IM qw on all primary and secondary outcomes investigated after 24 and 48 weeks of treatment.

A new cell line-based neutralization assay for primary HIV type 1 isolates

Simple and standardized assays for detection and quantification of neutralizing antibodies to primary HIV-1 isolates are needed in research on HIV-1 vaccines and pathogenesis. Here we describe a new HIV-1 neutralization assay that is based on plaque formation in U87.CD4-CCR5 and U87.CD4-CXCR4 cells, which is an attractive alternative to peripheral blood mononuclear cell-based assays. Infected cells form syncytia, that is, plaques, that can be stained with hematoxylin and enumerated by light microscopy. Neutralization is determined by the ability of a serum to reduce the number of plaque-forming units (PFU) relative to controls exposed to medium or negative serum. The intraassay variation of the plaque-forming unit determinations was tested with 15 serum-virus combinations and showed good reproducibility. The differences ranged from -19 to +27% and had a standard deviation of +/- 9.1%. On the basis of these data the cutoff for neutralization (i.e., plaque reduction) was set to 30% (3.3 standard deviations). Virus titration experiments showed that neutralization results were dependent on virus dose and therefore the neutralization assays should be performed with a virus dose of 10-100 PFU/well. The reproducibility of the new neutralization assay was tested with 4 primary viruses and 9 sera for a total of 20 virus-serum combinations. The mean difference in neutralization (i.e. plaque reduction) determinations performed on different days was as small as 11%. None of 10 Swedish sera and 1 Ugandan plasma pool from HIV-1-uninfected subjects were positive for neutralization, indicating that the assay has high specificity. In summary, the new U87.CD4 cell line-based neutralization assay for primary HIV-1 isolates is a highly reproducible, sensitive, and high-throughput assay that is well suited for large-scale HIV-1 neutralization studies.

The efficacy of lidocaine administered via the LITA tracheal tube in attenuating the extubation response in beta-blocked patients following craniotomy

The Laryngotracheal Instillation of Topical Anaesthetic (LITA) tracheal tube has an additional pilot tube through which local anaesthetic can be instilled into the larynx via 10 small holes above and below the cuff We studied 40 patients undergoing supratentorial craniotomy. They were premedicated with two oral doses of propranolol 1 mg.kg(-1). The anaesthetic consisted of infusions of remifentanil, propofol and vecuronium. On insertion of the first skin clip at the end of surgery, 5 ml of either saline or 2% lidocaine was injected into the appropriate lumen of the tracheal tube. There was no difference between the groups in the degree of coughing or the haemodynamic response to tracheal extubation.

Reducing the risk of aviator-multifunction display interface problems with human factor models and optimization design methods

Multifunction display and control systems (MFDCSs) in modern cockpits use computer-generated graphics and symbology that have integrated and largely replaced the myriad discrete electromechanical flight instruments found in older aircraft. While much is known about the physical and visual properties of MFDCSs, less is known about which human factors are the most important for optimum design and use. Reports in the literature indicate that poor MFDCS design can adversely influence flight performance. However, current MFDCS content design methods do not quantify the relative importance of different cognitive and psychomotor factors. This article discusses the need for practical human factors-oriented MFDCS design tools to optimize the distribution of systems information and functionality. Such advances may lead to better designed MFDCSs that reduce aircrew workload and stress and improve flight performance during both routine and emergency procedures.

Genetic susceptibility to MS: a second stage analysis in Canadian MS families

Four published genome screens have identified a number of markers with increased sharing in multiple sclerosis (MS) families, although none has reached statistical significance. One hundred and five markers previously identified as showing increased sharing in Canadian, British, Finnish, and American genome screens were genotyped in 219 sibling pairs ascertained from the database of the Canadian Collaborative Project on Genetic Susceptibility to MS (CCPGSMS). No markers examined met criteria for significant linkage. Markers located at 5p14 and 17q22 were analyzed in a total of 333 sibling pairs and attained mlod scores of 2.27 and 1.14, respectively. The known HLA Class II DRB1 association with MS was confirmed (P<0.0001). Significant transmission disequilibrium was also observed for D17S789 at 17q22 (P=0.0015). This study highlights the difficulty of searching for genes with only mild-to-moderate effects on susceptibility, although large effects of specific loci may still be present in individual families. Future progress in the genetics of this complex trait may be helped by (1) focussing on more ethnically homogeneous samples, (2) using an increased number of MS families, and (3) using transmission disequilibrium analysis in candidate regions rather than the affected relative pair linkage analysis.

Effects of Quillaja saponins on growth, metabolism, egg production and muscle cholesterol in individually reared Nile tilapia (Oreochromis niloticus)

The effects of supplementation of a Quillaja saponin (QS) mixture in the diets of tilapia have been studied using a respirometer system that allowed feeding and continuous measurement of oxygen consumption of individual fish. Five fish each were given control diet (C group) and control diet supplemented with 150 mg kg(-1) (S150 group) or 300 mg kg(-1) (S300 group) QS. At the end of 14 weeks the weight gain of the S300 group was significantly higher than control (P<0.05) whereas that of the S150 group had an intermediate value. The S150 group had a higher growth rate (P=0.05) after the first 3 weeks of feeding with the experimental diets, compared to the other two groups. At the end of the experiment the S300 group had significantly higher (P<0.05) average values for energy retention, apparent lipid conversion, carcass fat, energy and significantly lower (P<0.05) average values for apparently unutilised energy and carcass ash content compared to the C group. The corresponding values of the S150 group were intermediate between the C and S300 groups. One out of two female fish in the S150 group and both female fish in the S300 group never produced eggs during the entire 14-week experimental period. Contrarily, all three female fish in the control group and one out of the two female fish in the S150 group regularly produced eggs, at a rate of approximately once in every 14 days. The muscle cholesterol level in the S300 group was significantly higher than that of the C group. Possible mechanisms of action of the dietary saponins are discussed.

The RAFFT as a screening tool for adolescent substance use disorders

The objective of this study was to measure the sensitivity and specificity of the RAFFT, a screening instrument for problematic adolescent substance use. Two hundred and twenty-six adolescent patients, aged 13 to 18, who were referred to an emergency room or an ambulatory evaluation clinic were included. Patients answered the five questions of the RAFFT before a comprehensive psychiatric assessment was completed. Diagnoses were made according to DSM-IV. The best results were obtained with two positive answers on the RAFFT: a sensitivity of 89% and a specificity of 69% in the screening for substance abuse or dependence. The RAFFT performed well in this highly selected patient population.

Perceived motion in orientational afterimages: direction and speed

Two sets of experiments demonstrate new properties of motion in orientational after-effects. In a previous report, we showed that when observers adapted to a static bar grating whose elements varied in size or intensity from one side to the other, offset of the grating resulted in a motion after-effect, with the perceived motion in the direction of the largest or most intense bar. In the first new experiment, we show that similar results can be produced by varying the duration of the bar elements, with the direction of the motion after-effect toward the bar with the longest duration. In the second new experiment we demonstrate that the perceived speed of the motion after-effect is influenced by the spatial extent of the after-effect, with larger extents corresponding to faster speeds. The experimental findings are discussed in the context of a neural network theory of visual perception. In this theory, a moving oriented contour leaves a trail of activity among cortical cells tuned to orthogonal orientations. We hypothesize that the grating stimuli produce after-effects that mimic the pattern of oriented responses produced by a true moving contour, and the visual system interprets this pattern as a cue for motion. We also show how the model connects the properties of these motion after-effects to properties of visual persistence.

Working patterns of trainee anaesthetists in the UK: results of a national postal survey

The 'New Deal' restrictions on junior doctors' hours have major implications for the staffing of anaesthetic departments and the provision of adequate training. The results of a national postal survey demonstrate a decline in traditional on-call arrangements, especially in hard-pressed work sectors such as intensive care. A substantial number of anaesthetic departments have still completely to satisfy the hours restrictions in many work sectors. Many departments experience recruitment difficulties and express concern about both service and training issues.

Quantitative theories of metacontrast masking

In metacontrast masking, the effect of a visual mask stimulus on the perceptual strength of a target stimulus varies with the stimulus-onset asynchrony (SOA) between them. As SOA increases, the target percept first becomes weaker, bottoms out at an intermediate SOA, and then increases for still larger SOAs. As a result, a plot of target percept strength against SOA produces a U-shaped masking curve. Theories have proposed special mechanisms to account for this curve, but new mathematical analyses indicate that it is a robust characteristic of a large class of neurally plausible systems. The author describes 3 quantitative methods of accounting for the U-shaped masking effect and analyzes 4 previously published mathematical models of masking. The models produce the masking curve through mask blocking, whereby a strong internal representation of the target blocks the mask's effects.

Cost and health related quality of life consequences of multiple sclerosis

OBJECTIVES

To (i) quantify the cost of multiple sclerosis (MS) to the Canadian health care system and society; (ii) measure health utility in MS patients, and (iii) examine the influence of disability on patient utility and health care costs.

MATERIALS AND METHODS

A comprehensive patient survey and chart review of relapsing MS patients in remission, relapse and recalling a relapse.

RESULTS

Annual remission costs increased with EDSS level ($7596 at EDSS 1, $33 206 at EDSS 6). At all EDSS levels the largest costs were due to inability to work, which increased with EDSS. The average relapse cost for all EDSS levels was $1367. An inverse correlation was found between EDSS level and patient utility for patients in remission and relapse. The decrease in remission health utility from EDSS 1 to 6 was 0.24, which is 25% greater than the difference in health status between an average 25 and 85 year-old.

CONCLUSIONS

This study demonstrates that MS produces substantial health care costs and reductions in patient quality of life and ability to work, losses that can be avoided or delayed if disease progression is slowed. These data provide health-care decision-makers with the opportunity to consider the full impact of MS when faced with budget allocation decisions.

Treatment of acute disseminated encephalomyelitis with intravenous immunoglobulin

Acute disseminated encephalomyelitis (ADEM) is a presumed immune-mediated, demyelinating disease of the CNS for which the standard treatment is high-dose steroids. We describe two patients with ADEM in whom treatment with IV methylprednisolone coincided with deterioration in their clinical status. They were subsequently treated with IV immunoglobulin and exhibited dramatic clinical improvement, with return to their previous level of functioning.

Motion parallel to line orientation: disambiguation of motion percepts

Four experiments demonstrate that lines indicating path of movement can generate rotational percepts in a multistable motion display that usually produces only horizontal or vertical motion percepts. The properties of the path-of-movement lines are predicted by a neural-network theory of visual perception. Experimental results validate the theory's predictions by demonstrating that movement of the display elements seems to follow an increasing luminance gradient in lines but not bars, and that illusory contours have similar effects. Experimental results also demonstrate that, in a choice between movement along lines drawn parallel or orthogonal to possible motion paths, observers more often see movement along the lines parallel to the motion path. These results suggest modifications to current computational and neurophysiological theories of motion perception.

Perceived motion in complementary afterimages: verification of a neural network theory

Steady fixation of a regular pattern like a bar grating or concentric circles leads to a complementary afterimage at pattern offset. The afterimage has the appearance of shimmering lines that are locally orthogonal to the orientations of the inducing image. Additionally, the afterimage includes motion running parallel to the orientation of the afterimage lines. We argue that this afterimage motion supports the existence of a cue to motion that is based on the spatial organization of oriented responses. This cue was previously proposed after analysis of a neural network model of visual perception. We test predictions of the model on various types of complementary afterimage inducing stimuli. When a contrast or size gradient is included in the inducing image, the afterimage motion moves toward the higher part of the gradient, in agreement with the model. Implications of this cue for computational and neurophysiological theories of motion perception are discussed.

Ambulatory ventricular arrhythmias in patients with heart failure do not specifically predict an increased risk of sudden death. PROMISE (Prospective Randomized Milrinone Survival Evaluation) Investigators

BACKGROUND

Ventricular arrhythmias are a frequent finding in congestive heart failure (CHF) patients and a cause of concern for physicians caring for them. Previous studies have reached conflicting conclusions regarding the importance of ventricular arrhythmias as predictors of sudden death in patients with CHF. This study examined the independent predictive value of ventricular arrhythmias for sudden death and all-cause mortality in PROMISE (Prospective Randomized Milrinone Survival Evaluation).

METHODS AND RESULTS

Ventricular arrhythmias were analyzed and quantified by use of prespecified criteria on baseline ambulatory ECGs from 1080 patients with New York Heart Association (NYHA) class III/IV symptoms and a left ventricular ejection fraction </=35% enrolled in PROMISE. The relationship of ventricular arrhythmias and other clinical parameters to overall mortality and sudden death classified by an independent, blinded mortality committee was determined. There were 290 deaths, of which 139 were classified as sudden. Of the several measures of ventricular ectopy that were univariate predictors, the frequency of nonsustained ventricular tachycardia (NSVT) was the most powerful predictor and remained a significant independent predictor when included with other clinical variables in multivariate models of both sudden death mortality and non-sudden death mortality. However, multiple logistic analysis with models including the clinical variables with and without the NSVT variable demonstrated that the frequency of NSVT did not add significant information beyond the clinical variables.

CONCLUSIONS

This study demonstrates that ventricular arrhythmias do not specifically predict sudden death in patients with moderate-to-severe heart failure. Thus, the finding of asymptomatic NSVT on ambulatory ECG does not identify specific candidates for antiarrhythmic or device therapy.

Ventilatory and heart rate responses to exercise : better predictors of heart failure mortality than peak oxygen consumption

BACKGROUND

An abnormally low chronotropic response and an abnormally high ventilatory response (V(E)/V(CO2)) to exercise are common in patients with severe heart failure, but their relative prognostic impacts have not been well explored.

METHODS AND RESULTS

Consecutive patients with heart failure referred for metabolic stress testing who were not taking beta-blockers or intravenous inotropes (n=470) were followed for 1.5 years. The chronotropic index was calculated while peak V(O2) and V(E)/V(CO2) were directly measured. Chronotropic index and peak V(O2) were considered abnormal if in the lowest 25th percentiles of the patient cohort, whereas V(E)/V(CO2) was considered abnormal if in the highest 25th percentile. For comparative purposes, a group of 17 healthy controls underwent metabolic testing as well. Compared with controls, heart failure patients had markedly abnormal ventilatory and chronotropic responses to exercise. In the heart failure cohort, there were 71 deaths. In univariate analyses, predictors of death included high V(E)/V(CO2) low chronotropic index, low V(O2), low resting systolic blood pressure, and older age. Nonparametric Kaplan-Meier plots demonstrated that by dividing the population according to peak V(E)/V(CO2) and peak V(O2), it is possible to identify low, intermediate, and very high risk groups. In multivariate analyses, the only independent predictors of death were high V(E)/V(CO2) (adjusted relative risk [RR] 3.20, 95% CI 1.95 to 5.26, P<0.0001) and low chronotropic index (adjusted RR 1.94, 95% CI 1.18 to 3.19, P=0.0009).

CONCLUSIONS

The ventilatory and chronotropic responses to exercise are powerful and independent predictors of heart failure mortality.