Sendaway capillary NT-proBNP in pulmonary hypertension.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a biomarker of cardiac ventricular wall stress that is incorporated into pulmonary hypertension (PH) risk stratification models. Sendaway sampling may enable patients to perform NT-proBNP tests remotely. This UK-wide study aimed to assess the agreement of sendaway NT-proBNP with standard venous NT-proBNP and to assess the effect of delayed processing. METHODS: Reference venous NT-proBNP was collected from PH patients. Samples for capillary and venous sendaway tests were collected contemporaneously, mailed to a reference laboratory and processed at 3 and 7 days using a Roche Cobas e411 device. Differences in paired measurements were analysed with Passing-Bablok regression, percentage difference plots and the % difference in risk strata. RESULTS: 113 patients were included in the study. 13% of day 3 capillary samples were insufficient. Day 3 capillary samples were not equivalent to reference samples (Passing Bablok analysis slope of 0.91 (95% CI 0.88 to 0.93) and intercept of 6.0 (95% CI 0.2 to 15.9)). The relative median difference was -7% and there were acceptable limits of agreement. Day 3 capillary NT-proBNP accurately risk stratified patients in 93.5% of cases. By comparison, day 3 venous results accurately risk stratified patients in 90.1% of cases and were equivalent by Passing-Bablok regression. Delayed sampling of sendaway tests led to an unacceptable level of agreement and systematically underestimated NT-proBNP. CONCLUSIONS: Sendaway NT-proBNP sampling may provide an objective measure of right ventricular strain for virtual PH clinics. Results must be interpreted with caution in cases of delayed sampling.

Evaluating the Use of PROMs in Paediatric Orthopaedic Registries.

Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.

Physical performance of children with longitudinal fibular deficiency (fibular hemimelia).

PURPOSE: Longitudinal fibular deficiency (LFD) is the most common congenital long bone deficiency. This study aimed to objectively assess the physical performance of children and adolescents with LFD compared with unaffected peers, and to examine trends over age for subgroups of the LFD population. METHODS: Differences between children with LFD and unaffected peers were examined with hand-held dynamometry for lower-limb muscle strength, Six-Minute Walk Test, Timed up and down stairs test, Star Excursion Balance Test, and Standing long jump. RESULTS: Thirty-nine children with LFD and 284 unaffected peers participated. Children with LFD performed at a lower level than their unaffected peers, on all measures of physical performance (mean 2.1 z-scores lower, all p < 0.01), except in long jump (p = 0.27). When comparing the performance of children with LFD to their unaffected peers across four age groups, there was a significant between-groups difference on all strength measures, and on the Six-Minute Walk distance, between children with and without LFD. These differences were smallest in young children (3-6 years) and largest in the older children (15-18 years) (all p < 0.01). Children with no lengthening surgery performed better on the Six-Minute Walk Test, covering a greater distance during the test, than those who had surgery (mean difference 83 metres, p < 0.01). There were no significant differences between children who had or had not undergone an amputation. CONCLUSIONS: Children with LFD performed at a significantly lower level than unaffected peers on all measures of physical performance other than jumping. The largest differences were in older children. This paper provides baseline functional data for future interventions in LFD. LEVEL OF EVIDENCE: Cross-sectional study.Implications for RehabilitationThis paper provides the first baseline functional data using validated objective measures on a consecutive cohort of children and adolescents with longitudinal fibular deficiency.Children with LFD performed significantly worse than their unaffected peers on all measures of physical performance other than jumping, with children falling further behind their peers as they age.Children who undergo an amputation typically have the most severe anatomical presentation and yet perform at an equivalent functional level.This paper identifies multiple modifiable impairments that represent potential opportunities for rehabilitation professionals to target with conservative treatment options to improve functional performance.

Longitudinal Fibular Deficiency: A Cross-Sectional Study Comparing Lower Limb Function of Children and Young People with That of Unaffected Peers.

Longitudinal fibular deficiency (LFD), or fibular hemimelia, is congenital partial or complete absence of the fibula. We aimed to compare the lower limb function of children and young people with LFD to that of unaffected peers. A cross-sectional study of Australian children and young people with LFD, and of unaffected peers, was undertaken. Twenty-three (12 males) children and young people with LFD (74% of those eligible) and 213 unaffected peers, all aged 7⁻21 years were subject to the Knee Osteoarthritis Outcome Score (KOOS/KOOS-Child) and the Cumberland Ankle Instability Tool (CAIT/CAIT-Youth). Linear regression models compared affected children and young people to unaffected peers. Participants with LFD scored lower in both outcomes (adjusted p < 0.05). The difference between participants with LFD and unaffected peers was significantly greater among younger participants than older participants for KOOS activities and sports domain scores (adjusted p ≤ 0.01). Differences in the other KOOS domains (pain/symptoms/quality of life) and ankle function (CAIT scores) were not affected by age (adjusted p ≥ 0.08). Children and young people with LFD on average report reduced lower limb function compared to unaffected peers. Knee-related activities and sports domains appear to be worse in younger children with LFD, and scores in these domains become closer to those of unaffected peers as they become older.

Impact of the SIGN head injury guidelines and NHS 4-hour emergency target on hospital admissions for head injury in Scotland: an interrupted times series.

OBJECTIVES: Head injury is a common reason for emergency department (ED) attendance. Around 1% of patients have life-threatening injuries, while 80% of patients are discharged. National guidelines (Scottish Intercollegiate Guidelines Network (SIGN)) were introduced in Scotland with the aim of achieving early identification of those with acute intracranial lesions yet safely reducing hospital admissions.This study aims to assess the impact of these guidelines and any effect the national 4-hour ED performance target had on hospital admissions for head injury. SETTING: All Scottish hospitals between April 1998 and March 2016. PARTICIPANTS: Patients admitted to hospital for head injury or traumatic brain injury (TBI) diagnosed by CT imaging identified using administrative Scottish Information Services Division data. There are 275 hospitals in Scotland. In 2015/2016, there were 571 221 emergency hospital admissions in Scotland. INTERVENTIONS: The SIGN head injury guidelines introduced in 2000 and 2009. The 4-hour ED target introduced in 2004. OUTCOMES: The monthly rate of hospital admissions for head injury and traumatic brain injury. STUDY DESIGN: An interrupted time series analysis. RESULTS: The first guideline was associated with a reduction in monthly admissions of 0.14 (95% CI 0.09 to 4.83) per 100 000 population. The 4-hour target was associated with a monthly increase in admissions of 0.13 (95% CI 0.06 to 0.20) per 100 000 population. The second guideline reduced monthly admissions by 0.09 (95% CI-0.13 to -0.05) per 100 000 population. These effects varied between age groups.The guidelines were associated with increased admissions for patients with injuries identified by CT imaging-guideline 1: 0.06 (95% CI 0.004 to 0.12); guideline 2: 0.05 (95% CI 0.04 to 0.06) per 100 000 population. CONCLUSION: Increased CT imaging of head injured patients recommended by SIGN guidelines reduced hospital admissions. The 4-hour ED target and the increased identification of TBI by CT imaging acted to undermine this effect.

Acupuncture in Osgood-Schlatter disease.

This article describes the use of acupuncture in the management of knee pain in Osgood-Schlatter disease. Manual and electroacupuncture were used. The patient responded well to acupuncture and found it effective in relieving his knee pain. Acupuncture should be considered in Osgood-Schlatter disease, both to manage the pain and to limit the need to take oral analgaesics for a prolonged period.

Mitral valve enlargement in chronic aortic regurgitation as a compensatory mechanism to prevent functional mitral regurgitation in the dilated left ventricle.

OBJECTIVES: The aim of this study was to test the hypothesis that mitral valve (MV) enlargement occurring in chronic aortic regurgitation (AR) prevents functional mitral regurgitation (FMR). BACKGROUND: Chronic AR causes left ventricular (LV) dilation, creating the potential for FMR. However, FMR is typically absent during compensated AR despite substantial LV enlargement. Increased mitral leaflet area has been identified in AR, but it is unknown whether increased MV size can represent a compensatory mechanism capable of preventing FMR. METHODS: Database review of 816 patients with at least moderate AR evaluated the prevalence of FMR. A total of 90 patients were enrolled prospectively for 3-dimensional echocardiography (30 AR, 30 FMR, and 30 controls) to assess MV geometry including total leaflet area. RESULTS: FMR was present in 5.6% of AR patients by database review. Prospectively, only 1 AR patient had more than mild FMR despite increased LV end-diastolic volume (82 ± 22, 86 ± 23, and 51 ± 12 cm(3)/m(2), respectively, for AR, FMR vs. control patients; p < 0.01) and similar sphericity index, annular area, and tethering distances compared with FMR. Total MV area was largest in AR (31.3% greater than normal), increasing significantly more than in FMR. The ratio of valve size to closure area was maintained in AR, whereas decreases in this ratio and LV ejection fraction independently predicted FMR. CONCLUSIONS: FMR prevalence is low in chronic AR. MV leaflet area is significantly increased compared with control and FMR patients, preserving a normal relationship to the area needed for closure in the dilated LV. Understanding the mechanisms underlying this adaptation could lead to new therapeutic interventions to prevent FMR.

Diagnostic value of vena contracta area in the quantification of mitral regurgitation severity by color Doppler 3D echocardiography.

BACKGROUND: Accurate quantification of mitral regurgitation (MR) is important for patient treatment and prognosis. Three-dimensional echocardiography allows for the direct measure of the regurgitant orifice area (ROA) by 3D-guided planimetry of the vena contracta area (VCA). We aimed to (1) establish 3D VCA ranges and cutoff values for MR grading, using the American Society of Echocardiography-recommended 2D integrative method as a reference, and (2) compare 2D and 3D methods of ROA to establish a common calibration for MR grading. METHODS AND RESULTS: Eighty-three patients with at least mild MR underwent 2D and 3D echocardiography. Direct planimetry of VCA was performed by 3D echocardiography. Two-dimensional quantification of MR included 2D ROA by proximal isovelocity surface area (PISA) method, vena contracta width, and ratio of jet area to left atrial area. There were significant differences in 3D VCA among patients with different MR grades. As assessed by receiver operating characteristic analysis, 3D VCA at a best cutoff value of 0.41 cm(2) yielded 97% of sensitivity and 82% of specificity to differentiate moderate from severe MR. There was significant difference between 2D ROA and 3D VCA in patients with functional MR, resulting in an underestimation of ROA by 2D PISA method by 27% as compared with 3D VCA. Multivariable regression analysis showed functional MR as etiology was the only predictor of underestimation of ROA by the 2D PISA method. CONCLUSIONS: Three-dimensional VCA provides a single, directly visualized, and reliable measurement of ROA, which classifies MR severity comparable to current clinical practice using the American Society of Echocardiography-recommended 2D integrative method. The 3D VCA method improves accuracy of MR grading compared with the 2D PISA method by eliminating geometric and flow assumptions, allowing for uniform clinical grading cutoffs and ranges that apply regardless of etiology and orifice shape.

Assessing mitral valve area and orifice geometry in calcific mitral stenosis: a new solution by real-time three-dimensional echocardiography.

BACKGROUND: Planimetry of mitral valve area (MVA) is difficult in calcific mitral stenosis (CaMS) in which limiting orifice is near the annulus, and unlike rheumatic mitral stenosis (RhMS), does not present an area for planimetry at the leaflet tips. Moreover, pressure half time (PHT)-derived MVA (MVA(PHT)) has limitations in patients with CaMS in whom there are coexisting conditions that affect LV chamber compliance. We tested the hypothesis that real-time 3-dimensional echocardiography (RT3D) can guide measurement at the narrowest orifice in CaMS. METHODS: In 34 patients with CaMS, MVA by RT3D (MVA(RT3D)) was obtained using a color-defined planimetry technique performed "en face" at the smallest annular orifice cross-section (diastolic maximum). MVA(RT3D) and MVA(PHT) were compared with an independent standard: MVA by continuity equation (MVA(CEQ)). In a subgroup of 10 patients with CaMS or RhMS, the 3-dimensional shape of the stenotic mitral valve was examined, guided by color flow mapping. RESULTS: MVA(PHT) overestimated the mitral orifice area compared with MVA(CEQ) (2.01 +/- 0.52 cm(2) vs 1.75 +/- 0.46 cm(2); P = .037), whereas there was no significant difference in MVA(RT3D) and MVA(CEQ) (1.83 +/- 0.52 cm(2) vs 1.75 +/- 0.46 cm(2), respectively, P = .61). MVA(RT3D) had a greater correlation with MVA (CEQ) than MVA(PHT) (R = 0.86 vs 0.59 MVA(RT3D) vs MVA(PHT), respectively). There was better agreement between MVA by RT3D and MVA by continuity equation than MVA by PHT and MVA by continuity equation (difference in MVA: 0.23 +/- 0.15 cm(2) vs 0.43 +/- 0.29 cm(2); P < .0001, MVA(RT3D) - MVA(CEQ) vs MVA(PHT) - MVA(CEQ,) respectively). In CaMS, there was a tubular geometry to the valve shape. In contrast, RhMS had a doming funnel-shaped geometry. CONCLUSION: RT3D provides an accurate measurement of MVA in CaMS. In contrast with the doming valve shape present in RhMS, the limiting anatomic orifice area occurs at the annulus in CaMS as measured by RT3D and reflects the effective orifice area as present in a tubular valve geometry.

Childhood abuse and later medical disorders in women. An epidemiological study.

BACKGROUND: There have been many studies documenting adverse psychiatric consequences for people who have experienced childhood and adult sexual and physical abuse. These include posttraumatic stress disorder, anxiety, depression, substance abuse, eating disorders and probably some personality disorders or trait abnormalities. Much less is known about the links between abuse and physical/psychosomatic conditions in adult life. Hints of causal links are evident in the literature discussing headache, lower back pain, pelvic pain and irritable bowel syndrome. These studies are not definitive as they use clinic-based samples. METHODS: This study used interview data with a random community sample of New Zealand women, half of whom reported childhood sexual abuse and half who did not. Details about childhood physical abuse and adult abuse were also collected in a two-phase study. RESULTS: Complex relationships were found, as abuses tended to co-occur. Seven of 18 potentially relevant medical conditions emerged as significantly increased in women with one or more types of abuse. These were chronic fatigue, bladder problems, headache including migraine, asthma, diabetes and heart problems. Several of these associations with abuse are previously unreported. CONCLUSIONS: In this random community sample, a number of chronic physical conditions were found more often in women who reported different types of sexual and physical abuse, both in childhood and in adult life. The causal relationships cannot be studied in a cross-sectional retrospective design, but immature coping strategies and increased rates of dissociation appeared important only in chronic fatigue and headache, suggesting that these are not part of the causal pathway between abuse experiences and the other later physical health problems. This finding and the low co-occurrence of the identified physical conditions suggest relative specificity rather than a general vulnerability to psychosomatic conditions in women who have suffered abuses. Each condition may require separate further study.