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NT-proBNP for heart failure diagnosis in Primary Care: Costs or savings? A budget impact study. Rev Port Cardiol 2021; 41:183-193. [DOI: 10.1016/j.repc.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/16/2021] [Accepted: 03/26/2021] [Indexed: 11/22/2022] Open
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Jovic A, Brkic K, Krstacic G. Detection of congestive heart failure from short-term heart rate variability segments using hybrid feature selection approach. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2019.101583] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Limkakeng Jr AT, Leahy JC, Griffin SM, Lokhnygina Y, Jaffa E, Christenson RH, Newby LK. Provocative biomarker stress test: stress-delta N-terminal pro-B type natriuretic peptide. Open Heart 2018; 5:e000847. [PMID: 30364466 PMCID: PMC6196976 DOI: 10.1136/openhrt-2018-000847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/30/2018] [Accepted: 08/31/2018] [Indexed: 11/04/2022] Open
Abstract
Objective Stress testing is commonly performed in emergency department (ED) patients with suspected acute coronary syndrome (ACS). We hypothesised that changes in N-terminal pro-B type natriuretic peptide (NT-proBNP) concentrations from baseline to post-stress testing (stress-delta values) differentiate patients with ischaemic stress tests from controls. Methods We prospectively enrolled 320 adult patients with suspected ACS in an ED-based observation unit who were undergoing exercise stress echocardiography. We measured plasma NT-proBNP concentrations at baseline and at 2 and 4 hours post-stress and compared stress-delta NT-proBNP between patients with abnormal stress tests versus controls using non-parametric statistics (Wilcoxon test) due to skew. We calculated the diagnostic test characteristics of stress-delta NT-proBNP for myocardial ischaemia on imaging. Results Among 320 participants, the median age was 51 (IQR 44-59) years, 147 (45.9%) were men, and 122 (38.1%) were African-American. Twenty-six (8.1%) had myocardial ischaemia. Static and stress-deltas NT-proBNP differed at all time points between groups. The median stress-deltas at 2 hours were 10.4 (IQR 6.0-51.7) ng/L vs 1.7 (IQR -0.4 to 8.7) ng/L, and at 4 hours were 14.8 (IQR 5.0-22.3) ng/L vs 1.0 (-2.0 to 10.3) ng/L for patients with ischaemia versus those without. Areas under the receiver operating curves were 0.716 and 0.719 for 2-hour and 4-hour stress-deltas, respectively. After adjusting for baseline NT-proBNP levels, the 4-hour stress-delta NT-proBNP remained significantly different between the groups (p=0.009). Conclusion Among patients with ischaemic stress tests, static and 4-hour stress-delta NT-proBNP values were significantly higher. Further study is needed to determine if stress-delta NT-proBNP is a useful adjunct to stress testing.
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Affiliation(s)
| | - J Clancy Leahy
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - S Michelle Griffin
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Yuliya Lokhnygina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Elias Jaffa
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, USA
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina, USA
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Hex C, Smeets M, Penders J, Van Hoof V, Verbakel J, Buntinx F, Vaes B. Accuracy, user-friendliness and usefulness of the Cobas h232 point-of-care test for NT-proBNP in primary care. J Clin Pathol 2017; 71:539-545. [DOI: 10.1136/jclinpath-2017-204746] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 11/03/2022]
Abstract
AimsN-terminal pro-B-type natriuretic peptide (NT-proBNP) has been shown to be useful for ruling out heart failure in primary care. In this study, we examined the accuracy of the Cobas h232 point-of-care (POC) instrument in primary care compared with an in-hospital measurement. Furthermore, we investigated the user-friendliness and usefulness of the POC device.MethodsFive general practitioner (GP) groups were asked to evaluate adult patients who were suspected of having heart failure and to test NT-proBNP with the Cobas h232. The samples were subsequently delivered to and analysed at a central hospital laboratory by the Cobas e602 using conventional transport and storage. Difference between the paired measurements was analysed using a percentage difference plot, and correlation was assessed using Passing-Bablok linear regression analysis. User-friendliness and usefulness were assessed using semistructured questionnaires.ResultsNineteen GPs studied 94 patients. Passing-Bablok analysis showed a slope of 1.05 (95% CI 1.00 to 1.11) (R2=0.97). The percentage difference plot showed a mean difference of 15.7% (95% CI −46.0% to –77.4%). User-friendliness and usefulness had median scores of 4 or 5 on a five-point Likert scale. Eighteen out of 19 GPs confirmed that the device influenced their clinical practice. During the study, GPs’ confidence in using NT-proBNP increased significantly from a mean score of 4.4 (95% CI 3.2 to 5.6) to 7.6 out of 10 (95% CI 7.1 to 8.2).ConclusionsThe Cobas h232 NT-proBNP POC test proved to be an accurate, user-friendly and useful test in primary care. Nearly all participating GPs were convinced that the test could benefit clinical decision making.
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Monahan M, Barton P, Taylor CJ, Roalfe AK, Hobbs FDR, Cowie M, Davis R, Deeks J, Mant J, McCahon D, McDonagh T, Sutton G, Tait L. MICE or NICE? An economic evaluation of clinical decision rules in the diagnosis of heart failure in primary care. Int J Cardiol 2017; 241:255-261. [PMID: 28366472 PMCID: PMC5483229 DOI: 10.1016/j.ijcard.2017.02.149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Detection and treatment of heart failure (HF) can improve quality of life and reduce premature mortality. However, symptoms such as breathlessness are common in primary care, have a variety of causes and not all patients require cardiac imaging. In systems where healthcare resources are limited, ensuring those patients who are likely to have HF undergo appropriate and timely investigation is vital. DESIGN A decision tree was developed to assess the cost-effectiveness of using the MICE (Male, Infarction, Crepitations, Edema) decision rule compared to other diagnostic strategies to identify HF patients presenting to primary care. METHODS Data from REFER (REFer for EchocaRdiogram), a HF diagnostic accuracy study, was used to determine which patients received the correct diagnosis decision. The model adopted a UK National Health Service (NHS) perspective. RESULTS The current recommended National Institute for Health and Care Excellence (NICE) guidelines for identifying patients with HF was the most cost-effective option with a cost of £4400 per quality adjusted life year (QALY) gained compared to a "do nothing" strategy. That is, patients presenting with symptoms suggestive of HF should be referred straight for echocardiography if they had a history of myocardial infarction or if their NT-proBNP level was ≥400pg/ml. The MICE rule was more expensive and less effective than the other comparators. Base-case results were robust to sensitivity analyses. CONCLUSIONS This represents the first cost-utility analysis comparing HF diagnostic strategies for symptomatic patients. Current guidelines in England were the most cost-effective option for identifying patients for confirmatory HF diagnosis. The low number of HF with Reduced Ejection Fraction patients (12%) in the REFER patient population limited the benefits of early detection.
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Affiliation(s)
- Mark Monahan
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Pelham Barton
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, OX2 6GG, United Kingdom
| | - Andrea K Roalfe
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, OX2 6GG, United Kingdom.
| | - Martin Cowie
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Russell Davis
- Department of Cardiology, Sandwell and West Birmingham Hospitals, Lyndon, West Bromwich, West Midlands B71 4HJ, United Kingdom
| | - Jon Deeks
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Jonathan Mant
- Department of Public Health & Primary Care, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge CB1 8RN, United Kingdom
| | - Deborah McCahon
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Theresa McDonagh
- Department of Cardiology, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - George Sutton
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Lynda Tait
- School of Health Sciences, University of Nottingham, B Floor, South Block Link, Queen's Medical Centre, Nottingham NG7 2HA, United Kingdom
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Chrysant SG. The Clinical Significance of N-terminal Pro-brain Natriuretic Peptide in Detecting the Residual Cardiovascular Risk in Hypertension and Other Clinical Conditions and in Predicting Future Cardiovascular Events. J Clin Hypertens (Greenwich) 2016; 18:718-20. [PMID: 27507775 PMCID: PMC8031586 DOI: 10.1111/jch.12785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Athanasakis K, Arista I, Balasopoulos T, Boubouchairopoulou N, Kyriopoulos J. How peptide technology has improved costs and outcomes in patients with heart failure. Expert Rev Pharmacoecon Outcomes Res 2016; 16:371-82. [PMID: 27160541 DOI: 10.1080/14737167.2016.1187066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Heart failure (HF) is characterized by substantial health and economic burden, mainly attributed to increased hospitalizations and readmissions. Its diagnosis remains challenging due to the non-specific nature of the initial symptoms of the disease. Recently, scientific evidence has highlighted the potential of natriuretic peptides (NP) in improving the diagnosis and prognosis of HF and, by extension, in restraining healthcare costs. The present review aimed at providing evidence of their optimal use in terms of economic and health outcomes. AREAS COVERED Systematic literature research limited to studies published from February 2006 to February 2016 was performed with the aim of identifying and analyzing all cost-effectiveness and other economic evaluation studies that investigated the economic and health outcomes of NPs use as screening and management tools for HF. Expert commentary: NP testing either added in the standard of care, or substituting frequently used diagnostic procedures for the diagnosis and management of HF, regardless of the healthcare setting of interest, was proved to be a valid tool for clinical decision-making. Moreover it was associated with improved patient outcomes and important cost-savings mainly attributed to lower admission and readmission rates, shorter hospitalization length and improved health-related quality of life.
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Affiliation(s)
- Kostas Athanasakis
- a Department of Health Economics , National School of Public Health , Athens , Greece
| | - Ioli Arista
- b Health Economist, Independent Researcher , Athens , Greece
| | - Thanos Balasopoulos
- a Department of Health Economics , National School of Public Health , Athens , Greece
| | | | - John Kyriopoulos
- a Department of Health Economics , National School of Public Health , Athens , Greece
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Collerton J, Kingston A, Yousaf F, Davies K, Kenny A, Neely D, Martin-Ruiz C, MacGowan G, Robinson L, Kirkwood TBL, Keavney B. Utility of NT-proBNP as a rule-out test for left ventricular dysfunction in very old people with limiting dyspnoea: the Newcastle 85+ Study. BMC Cardiovasc Disord 2014; 14:128. [PMID: 25257704 PMCID: PMC4189162 DOI: 10.1186/1471-2261-14-128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 09/18/2014] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Guidelines advocate using B-type natriuretic peptides in the diagnostic work-up of suspected heart failure (HF). Their main role is to limit echocardiography rates by ruling out HF/LV dysfunction where peptide level is low. Recommended rule-out cut points vary between guidelines. The utility of B-type natriuretic peptides in the very old (85+) requires further investigation, with optimal cut points yet to be established. We examined NT-proBNP's utility, alone and in combination with history of myocardial infarction (MI), as a rule-out test for LV dysfunction in very old people with limiting dyspnoea. METHODS DESIGN Cross-sectional analysis. SETTING Population-based sample; North-East England. PARTICIPANTS 155 people (aged 87-89) with limiting dyspnoea. MEASURES Dyspnoea assessed by questionnaire. Domiciliary echocardiography performed; LV systolic/diastolic function graded. NT-proBNP measured (Roche Diagnostics). Receiver operating characteristic analyses examined NT-proBNP's diagnostic accuracy for LV dysfunction. RESULTS AUC for LVEF less than or equal to 50% was poor (0.58, 95% CI 0.49-0.65), but good for LVEF less than or equal to 40% (0.80, 95% CI 0.73-0.86). At ESC cut point (125 ng/l), few cases of systolic dysfunction were missed (NPV 94-100%, depending on severity), but echocardiography (88%) and false positive rates (56-81 per 100 screened) were high. At NICE cut point (400 ng/l), echocardiography (51%) and false positive rates (33-45) were lower; exclusionary performance was good for LVEF less than or equal to 40% (1 case missed per 100 screened, 15% of cases; NPV 97%), but poor for LVEF less than or equal to 50% (16 cases missed per 100 screened, 45% of cases; NPV 68%). Incorporating isolated moderate/severe diastolic dysfunction into target condition increased the proportion of cases missed (lower NPV), whilst improving case detection. Incorporating MI history as an additional referral prompt slightly reduced the number of cases missed at expense of higher echocardiography and false positive rates. CONCLUSIONS High echocardiography rates and poor exclusionary performance for mild degrees of systolic dysfunction and for diastolic dysfunction limit NT-proBNP's utility as a rule-out test for LV dysfunction in very old people with limiting dyspnoea. Incorporating MI history as an additional echocardiography prompt yields no overall benefit compared to using NT-proBNP level alone.
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Affiliation(s)
- Joanna Collerton
- Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, UK.
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Booth RA, Hill SA, Don-Wauchope A, Santaguida PL, Oremus M, McKelvie R, Balion C, Brown JA, Ali U, Bustamam A, Sohel N, Raina P. Performance of BNP and NT-proBNP for diagnosis of heart failure in primary care patients: a systematic review. Heart Fail Rev 2014; 19:439-51. [PMID: 24969534 DOI: 10.1007/s10741-014-9445-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
National and international guidelines have been published recommending the use of natriuretic peptides as an aid to the diagnosis of heart failure (HF) in acute settings; however, few specific recommendations exist for governing the use of these peptides in primary care populations. To summarize the available data relevant to the diagnosis of HF in primary care patient population, we systematically reviewed the literature to identify original articles that investigated the diagnostic accuracy of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in primary care settings. The search yielded 25,864 articles in total: 12 investigating BNP and 20 investigating NT-proBNP were relevant to our objective and included in the review. QUADAS-2 and GRADE were used to assess the quality of the included articles. Diagnostic data were pooled based on three cutpoints: lowest and optimal, as chosen by study authors, and manufacturers' suggested. The effect of various determinants (e.g., age, gender, BMI, and renal function) on diagnostic performance was also investigated. Pooled sensitivity and specificity of BNP and NT-proBNP using the lowest [0.85 (sensitivity) and 0.54 (specificity)], optimal (0.80 and 0.61), and manufacturers' (0.74 and 0.67) cutpoints showed good performance for diagnosing HF. Similar performance was seen for NT-proBNP: lowest (0.90 and 0.50), optimal (0.86 and 0.58), and manufacturers' (0.82 and 0.58) cutpoints. Overall, we rated the strength of evidence as high because further studies will be unlikely to change the estimates diagnostic performance.
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Affiliation(s)
- Ronald A Booth
- Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada
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Verdú JM, Comín-Colet J, Domingo M, Lupón J, Gómez M, Molina L, Casacuberta JM, Muñoz MA, Mena A, Bruguera-Cortada J. Rapid point-of-care NT-proBNP optimal cut-off point for heart failure diagnosis in primary care. Rev Esp Cardiol 2012; 65:613-9. [PMID: 22541282 DOI: 10.1016/j.recesp.2012.01.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 01/11/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES Measurement of natriuretic peptides may be recommended prior to echocardiography in patients with suspected heart failure. Cut-off point for heart failure diagnosis in primary care is not well established. We aimed to assess the optimal diagnostic cut-off value of N-terminal pro-B-type natriuretic peptide on a community population attended in primary care. METHODS Prospective diagnostic accuracy study of a rapid point-of-care N-terminal pro-B-type natriuretic peptide test in a primary healthcare centre. Consecutive patients referred by their general practitioners to echocardiography due to suspected heart failure were included. Clinical history and physical examination based on Framingham criteria, electrocardiogram, chest X-ray, N-terminal pro-B-type natriuretic peptide measurement and echocardiogram were performed. Heart failure diagnosis was made by a cardiologist blinded to N-terminal pro-B-type natriuretic peptide value, using the European Society of Cardiology diagnosis criteria (clinical and echocardiographic data). RESULTS Of 220 patients evaluated (65.5% women; median 74 years [interquartile range 67-81]). Heart failure diagnosis was confirmed in 52 patients (23.6%), 16 (30.8%) with left ventricular ejection fraction <50% (39.6 [5.1]%). Median values of N-terminal pro-B-type natriuretic peptide were 715 pg/mL [interquartile range 510.5-1575] and 77.5 pg/mL [interquartile range 58-179.75] for patients with and without heart failure respectively. The best cut-off point was 280 pg/mL, with a receiver operating characteristic curve of 0.94 (95% confidence interval, 0.91-0.97). Six patients with heart failure diagnosis (11.5%) had N-terminal pro-B-type natriuretic peptide values <400 pg/mL. Measurement of natriuretic peptides would avoid 67% of requested echocardiograms. CONCLUSIONS In a community population attended in primary care, the best cut-off point of N-terminal pro-B-type natriuretic peptide to rule out heart failure was 280 pg/mL. N-terminal pro-B-type natriuretic peptide measurement improve work-out diagnoses and could be cost-effectiveness.
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Affiliation(s)
- José M Verdú
- Equip d'Atenció Primària, Sant Martí de Provençals, Institut Català de la Salut, Barcelona, Spain.
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Sabatasso S, Vaucher P, Augsburger M, Donzé N, Mangin P, Michaud K. Sensitivity and specificity of NT-proBNP to detect heart failure at post mortem examination. Int J Legal Med 2011; 125:849-56. [PMID: 21597901 PMCID: PMC3192281 DOI: 10.1007/s00414-011-0581-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Accepted: 05/02/2011] [Indexed: 11/03/2022]
Abstract
NT-proBNP, a marker of cardiac failure, has been shown to be stable in post mortem samples. The aim of this study was to assess the accuracy of NT-proBNP to detect heart failure in the forensic setting. One hundred sixty-eight consecutive autopsies were included in the study. NT-proBNP blood concentrations were measured using a chemiluminescent immunoassay kit. Cardiac failure was assessed by three independent forensic experts using macro- and microscopic findings complemented by information about the circumstances of body discovery and the known medical story. Area under the receiving operator curve was of 65.4% (CI 95%, from 57.1 to 73.7). Using a standard cut-off value of >220 pg/mL for NT-proBNP blood concentration, heart failure was detected with a sensitivity of 50.7% and a specificity of 72.6%. NT-proBNP vitreous humor values were well correlated to the ones measured in blood (r (2) = 0.658). Our results showed that NT-proBNP can corroborate the pathological findings in cases of natural death related to heart failure, thus, keeping its diagnostic properties passing from the ante mortem to the post mortem setting. Therefore, biologically inactive polypeptides like NT-proBNP seem to be stable enough to be used in forensic medicine as markers of cardiac failure, taking into account the sensitivity and specificity of the test.
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Affiliation(s)
- Sara Sabatasso
- University Centre of Legal Medicine, Lausanne-Geneva, University of Lausanne, Rue du Bugnon 21, Lausanne, Switzerland.
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Abstract
Telomeres carry out conserved and possibly ancient functions in meiosis. During the specialized prophase of meiosis I, meiotic prophase, telomeres cluster on the nuclear envelope and move the diploid genetic material around within the nucleus so that homologous chromosomes can align two by two and efficiently recombine with precision. This recombination is in turn required for proper segregation of the homologs into viable haploid daughter cells. The meiosis-specific telomere clustering on the nuclear envelope defines the bouquet stage, so named for its resemblance to the stems from a bouquet of cut flowers. Here, a comparative analysis of the literature on meiotic telomeres from a variety of different species illustrates that the bouquet is nearly universal among life cycles with sexual reproduction. The bouquet has been well documented for over 100 years, but our understanding of how it forms and how it functions has only recently begun to increase. Early and recent observations document the timing and provide clues about the functional significance of these striking telomere movements.
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Affiliation(s)
- H W Bass
- Department of Biological Science, Florida State University, Tallahassee, Florida 32306-4370, USA.
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