Pressure ulcers--prophylaxis and treatment.

BACKGROUND: Pressure sores are common and affect 10-20% of all institutionalized patients. Health personnel should have sufficient knowledge of prevention, evaluation and treatment. MATERIAL AND METHODS: This article is based on a non-systematic search in Medline and EMBASE, and the authors' own clinical experience. RESULTS: The causes of pressure sores are mechanical pressure, shear and frictional forces on the skin and underlying tissue. Neuropathy, nutrition deficiency, moist skin, and infection are risk factors for development and persistence of the wound. Preventive measures and treatment must to be directed towards both causes and risk factors. Pressure sores are graded on a scale from 0 to 4, based on depth of wound penetration into underlying tissue. Superficial wounds are treated conservatively while deeper pressure sores, which affect muscle and bone, must be evaluated for surgical treatment. INTERPRETATION: Alleviation of pressure and reduction of risk factors are important for prevention and treatment of pressure sores. Depending on the depth of wound penetration into underlying tissue, additional treatment may be conservative wound treatment or surgery.

[Hidradenitis suppurativa]. / Hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa is a chronic inflammatory skin disease characterized by recurrent tender nodules and boils, usually in the armpits and groins. Draining fistulas and hypertrophic scarring are hallmarks of more severe disease. The objective of this article is to review the clinical presentation, diagnostic considerations and treatment of the disease. MATERIAL AND METHODS: The article is based on a non-systematic literature search in PubMed, review of dermatology textbooks and the author's personal clinical experience. RESULTS: Hidradenitis suppurativa, also known as acne inversa, is a follicular occlusion disease that can severely reduce quality of life. Staphylococci and other pathogenic bacteria frequently colonize the lesions, but the disease is not primarily a bacterial infection. Smoking and obesity can worsen disease activity. Moderate and severe disease is usually treated with excisional surgery. Antibiotics, often tetracyclines, are indicated for mild disease and as an adjunct to surgery in more severe disease. Antibiotics, however, are not curative. New treatment options, such as TNF-alpha inhibitors and zinc gluconate should still be considered experimental. INTERPRETATION: Hidradenitis suppurativa is probably underdiagnosed. The disease is often recalcitrant to treatment. The effect of medical treatment is not supported by high quality evidence.

Alterations in circulating activin A, GDF-15, TGF-beta3 and MMP-2, -3, and -9 during one year of left ventricular reverse remodelling in patients operated for severe aortic stenosis.

BACKGROUND: Patients with aortic stenosis (AS) develop left ventricular remodelling with cardiomyocyte hypertrophy and increased fibrosis. Following aortic valve replacement (AVR) reverse remodelling usually takes place. AIMS: To examine circulating levels of members of the transforming growth factor (TGF) beta superfamily and matrix metalloproteinases (MMP), known to have important effects on hypertrophy and extracellular matrix, in patients operated for AS. METHODS: Circulating levels of activin A, GDF-15, TGF-beta3, MMP-2, -3, and -9 were measured in twenty-two patients undergoing AVR preoperatively, and 2 days, six months and 12 months postoperatively. Echocardiography and a six minute walking test evaluated reverse remodelling and physical performance. RESULTS: Activin A increased at six (1081.00+/-98.05 pg/ml, p<0.05) and twelve months (1263.09+/-141.43 pg/ml, p<0.05) compared to the preoperative value (855.00+/-76.30 pg/ml) and correlated negatively to physical performance. The preoperative value was also increased compared to controls (639.54+/-63.05 pg/ml, p<0.05). GDF-15, MMP-3 and -9 were all increased at two days postoperatively (p<0.05). MMP-3 correlated with left ventricular end diastolic dimension (p<0.05). MMP-2 did not change during the study period. TGF-beta3 was only slightly reduced at six months postoperatively. CONCLUSION: The observed alteration in circulating levels of members of the TGF-beta superfamily and MMPs might play a role in the reverse remodelling process following AVR for AS.

Impact of atrial fibrillation on the diagnostic performance of B-type natriuretic peptide concentration in dyspneic patients: an analysis from the breathing not properly multinational study.

OBJECTIVES: This study was designed to assess the diagnostic performance of B-type natriuretic peptide (BNP) in the diagnosis of acute congestive heart failure (CHF) in patients with permanent/paroxysmal atrial fibrillation (AF) presenting with acute dyspnea. BACKGROUND: It is unknown to what extent AF affects the diagnostic performance of BNP in patients presenting with acute dyspnea. METHODS: We studied 1,431 patients drawn from a cohort of patients (n = 1,586) with acute dyspnea who had BNP levels measured on arrival. Patients were prospectively classified according to the presence or absence of permanent/paroxysmal AF. RESULTS: In total, 292 patients had permanent/paroxysmal AF. In patients without HF, permanent/paroxysmal AF was associated with significantly higher BNP levels (p = 0.001). Conversely, in patients with HF, BNP levels did not differ significantly between patients with and without AF (p = 0.533). A BNP cutoff value of 100 pg/ml had a specificity of 40% and 79% for the diagnosis of acute HF in patients with and without AF, respectively. The areas under the receiver-operating characteristic curves were 0.84 (95% confidence interval 0.78 to 0.89) and 0.91 (95% confidence interval 0.89 to 0.93) for patients with and without AF, respectively. CONCLUSIONS: In patients without, but not in those with HF, the presence of AF is associated with higher circulating BNP levels, suggesting that a higher diagnostic threshold should be used in patients with AF.

How obesity affects the cut-points for B-type natriuretic peptide in the diagnosis of acute heart failure. Results from the Breathing Not Properly Multinational Study.

BACKGROUND: B-type natriuretic peptide (BNP) is valuable in diagnosing heart failure (HF), but its utility in obese patients is unknown. Studies have suggested a cut-point of BNP > or = 100 pg/mL for the diagnosis of HF; however, there is an inverse relation between BNP levels and body mass index. We evaluated differential cut-points for BNP in diagnosing acute HF across body mass index levels to determine whether alternative cut-points can improve diagnosis. METHODS: The Breathing Not Properly Multinational Study was a 7-center, prospective study of 1586 patients who presented to the Emergency Department with acute dyspnea. B-type natriuretic peptide was measured on arrival. Height and weight data were available for 1368 participants. The clinical diagnosis of HF was adjudicated by 2 independent cardiologists who were blinded to BNP results. RESULTS: Heart failure was the final diagnosis in 46.1%. Mean BNP levels (pg/mL) in lean, overweight/obese, and severely/morbidly obese patients were 643, 462, and 247 for patients with acute HF, and 52, 35, and 25 in those without HF, respectively (P < .05 for all comparisons except 35 vs 25). B-type natriuretic peptide cut-points to maintain 90% sensitivity for a HF diagnosis were 170 pg/mL for lean subjects, 110 pg/mL for overweight/obese subjects, and 54 pg/mL in severely/morbidly obese patients. CONCLUSIONS: Body mass index influences the selection of cut-points for BNP in diagnosing acute HF. A lower cut-point (BNP > or = 54 pg/mL) should be used in severely obese patients to preserve sensitivity. A higher cut-point in lean patients (BNP > or = 170 pg/mL) could be used to increase specificity.

The effect of aortic valve replacement on plasma B-type natriuretic peptide in patients with severe aortic stenosis--one year follow-up.

BACKGROUND: B-type natriuretic peptide (BNP) is synthesized in cardiac tissue in response to increased wall stress and myocardial hypertrophy. AIMS: In patients with severe aortic stenosis (AS) we examined the effect of aortic valve replacement (AVR) on plasma BNP and association between BNP and left ventricular mass index (LVMI) preoperatively and in the reverse-remodeling phase twelve months postoperatively. We also examined the correlation between BNP and NYHA-class and between BNP and age. METHODS AND RESULTS: Plasma BNP analyses and echocardiographic measurements were performed preoperatively, before discharge after AVR, and at twelve months in twenty-two patients. BNP was additionally measured at six months. Preoperatively, BNP was 283+/-45 pg/ml (mean+/-SEM). Following an immediate postoperative increase (441+/-38 pg/ml), BNP values decreased towards normal values at six and twelve months (139+/-25 and 130+/-18 pg/ml, respectively). LVMI was 206.5+/-15.8 g/m(2) preoperatively and decreased to 119.7+/-7.2 g/m(2) at twelve months with a correlation between LVMI and BNP preoperatively only (r=0.45, p<0.05). There was no correlation between BNP and NYHA-class, whereas BNP correlated to age both pre- and post-operatively. CONCLUSION: We report an increase in plasma BNP in patients with AS. Following a further transient increase postoperatively, BNP levels decreased at six and twelve months after AVR. BNP correlated with LVMI preoperatively, and with age both preoperatively and at twelve months.

B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational Study.

BACKGROUND: We sought to determine the degree to which B-type natriuretic peptide (BNP) adds to clinical judgment in the diagnosis of congestive heart failure (CHF). METHODS AND RESULTS: The Breathing Not Properly Multinational Study was a prospective diagnostic test evaluation study conducted in 7 centers. Of 1586 participants who presented with acute dyspnea, 1538 (97%) had clinical certainty of CHF determined by the attending physician in the emergency department. Participants underwent routine care and had BNP measured in a blinded fashion. The reference standard for CHF was adjudicated by 2 independent cardiologists, also blinded to BNP results. The final diagnosis was CHF in 722 (47%) participants. At an 80% cutoff level of certainty of CHF, clinical judgment had a sensitivity of 49% and specificity of 96%. At 100 pg/mL, BNP had a sensitivity of 90% and specificity of 73%. In determining the correct diagnosis (CHF versus no CHF), adding BNP to clinical judgment would have enhanced diagnostic accuracy from 74% to 81%. In those participants with an intermediate (21% to 79%) probability of CHF, BNP at a cutoff of 100 pg/mL correctly classified 74% of the cases. The areas under the receiver operating characteristic curve were 0.86 (95% CI 0.84 to 0.88), 0.90 (95% CI 0.88 to 0.91), and 0.93 (95% CI 0.92 to 0.94) for clinical judgment, for BNP at a cutoff of 100 pg/mL, and for the 2 in combination, respectively (P<0.0001 for all pairwise comparisons). CONCLUSIONS: The evaluation of acute dyspnea would be improved with the addition of BNP testing to clinical judgment in the emergency department.

Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study.

OBJECTIVES: This study examines B-type natriuretic peptide (BNP) levels in patients with systolic versus non-systolic dysfunction presenting with shortness of breath. BACKGROUND: Preserved systolic function is increasingly common in patients presenting with symptoms of congestive heart failure (CHF) but is still difficult to diagnose. METHODS: The Breathing Not Properly Multinational Study was a seven-center, prospective study of 1,586 patients who presented with acute dyspnea and had BNP measured upon arrival. A subset of 452 patients with a final adjudicated diagnosis of CHF who underwent echocardiography within 30 days of their visit to the emergency department (ED) were evaluated. An ejection fraction of greater than 45% was defined as non-systolic CHF. RESULTS: Of the 452 patients with a final diagnosis of CHF, 165 (36.5%) had preserved left ventricular function on echocardiography, whereas 287 (63.5%) had systolic dysfunction. Patients with non-systolic heart failure (NS-CHF) had significantly lower BNP levels than those with systolic heart failure (S-CHF) (413 pg/ml vs. 821 pg/ml, p < 0.001). As the severity of heart failure worsened by New York Heart Association class, the percentage of S-CHF increased, whereas the percentage of NS-CHF decreased. When patients with NS-CHF were compared with patients without CHF (n = 770), a BNP value of 100 pg/ml had a sensitivity of 86%, a negative predictive value of 96%, and an accuracy of 75% for detecting abnormal diastolic dysfunction. Using Logistic regression to differentiate S-CHF from NS-CHF, BNP entered first as the strongest predictor followed by oxygen saturation, history of myocardial infarction, and heart rate. CONCLUSIONS: We conclude that NS-CHF is common in the setting of the ED and that differentiating NS-CHF from S-CHF is difficult in this setting using traditional parameters. Whereas BNP add modest discriminatory value in differentiating NS-CHF from S-CHF, its major role is still the separation of patients with CHF from those without CHF.

B-type natriuretic peptide levels in patients in the emergency department with possible heart failure and previous stable angina pectoris and/or healed myocardial infarction.

We examined the relation between B-type natriuretic peptide (BNP) levels and a history of stable angina pectoris and/or healed myocardial infarction in 1,240 patients who were evaluated in the emergency department for possible heart failure. In patients who had heart failure, there was no relation between BNP levels and previous stable angina pectoris and/or healed myocardial infarction. However, in patients who did not have heart failure, there was a relation between BNP levels and previous stable angina pectoris and/or healed myocardial infarction but no significant independent relation in multiple regression analysis.

Surgical left ventricular remodeling in heart failure.

The high mortality and morbidity of patients in terminal heart failure are a therapeutic challenge to modern medicine. Surgically, cardiac transplantation is an excellent treatment for many patients. However, lack of donors combined with an increasing number of patients has led to the search for other surgical strategies. Patients with symptomatic large left ventricular aneurysms have been treated with resection of the aneurysm and closure of the left ventricle either directly (linear closure, first reported by Cooley) or by implantation of a patch (endoventricular patch plasty or Dor procedure). Akinetic areas of the left ventricle have also been successfully treated by the latter method. According to the law of Laplace, large dilated ventricles have increased wall tension and thus increased oxygen consumption. Based on this fact, Batista and coworkers have reduced the volume of enlarged left ventricles in patients in terminal heart failure by removing a wedge of myocardium from the apex of the heart towards the base of the left ventricular free wall. Although a favorable outcome has been reported in selected patients, this method is currently not recommended for treatment of heart failure because of high surgical failure rates. The present paper reviews some of the relevant literature regarding surgical left ventricular remodeling in heart failure. Two new techniques (Myosplint and CorCap cardiac support device) are also briefly described.

B-type natriuretic peptide and renal function in the diagnosis of heart failure: an analysis from the Breathing Not Properly Multinational Study.

BACKGROUND: Both B-type natriuretic peptide (BNP) and renal function are prognostic indicators of survival in patients with congestive heart failure (CHF). However, relationships between BNP, renal function, and heart failure as an emergency diagnosis are unknown. METHODS: The Breathing Not Properly Multinational Study was a prospectively designed diagnostic test evaluation study conducted in seven centers. Of 1,586 participants who presented with acute dyspnea, 1,452 patients (91.6%) had both BNP level and baseline estimated glomerular filtration rate (eGFR) available. Patients with an eGFR less than 15 mL/min/1.73 m2 and those on dialysis therapy were excluded. The final diagnosis was adjudicated by two independent cardiologists who were blinded to BNP results. RESULTS: The final diagnosis was CHF in 715 patients (49.2%). Raw and log-log transformed correlations between BNP and eGFR values were r = -0.19 and r = -0.17 for those with CHF and r = -0.20 and r = -0.31 for those without CHF (both P < 0.0001 for r not equal 0). Mean BNP levels were 561.6 pg/mL (162.3 fmol/mL), 647.5 pg/mL (187.1 fmol/mL), 745.6 pg/mL (215.5 fmol/mL), and 850.7 pg/mL (245.8 fmol/mL) for those with CHF and 85.4 pg/mL (24.7 fmol/mL), 131.7 pg/mL (38.1 fmol/mL), 297.2 pg/mL (85.9 fmol/mL), and 285.0 pg/mL (82.3 fmol/mL) for those without CHF in eGFR categories of 90 or greater, 89 to 60, 59 to 30, and less than 30 mL/min/1.73 m2, respectively. The area under the receiver operating characteristic curve and optimum cut points for BNP were 0.91 and 70.7 pg/mL (20.4 fmol/mL), 0.90 and 104.3 pg/mL (30.1 fmol/mL), 0.81 and 201.2 pg/mL (58.1 fmol/mL), and 0.86 and 225.0 pg/mL (65.0 fmol/mL) for the eGFR categories of 90 or greater, 89 to 60, 59 to 30, and less than 30 mL/min/1.73 m2, respectively. CONCLUSION: Renal function correlates weakly with BNP and influences the optimal cut point for BNP, particularly in those with an eGFR less than 60 mL/min/1.73 m2.

Diagnostic value of a rapid test for B-type natriuretic peptide in patients presenting with acute dyspnoe: effect of age and gender.

BACKGROUND: B-type natriuretic peptide (BNP) measurements are useful for diagnosing congestive heart failure (CHF) in patients presenting to the Emergency Department with acute dyspnoe. Whether the diagnostic accuracy of BNP is affected by the age and gender of the patients remains unknown. AIMS: To evaluate the accuracy of BNP testing for diagnosing CHF in an unselected group of patients admitted to the emergency department of a Norwegian teaching hospital with a principal complaint of shortness of breath and to assess whether the diagnostic accuracy of the test differs according to age and gender. METHODS: BNP levels in plasma were determined by a point-of-care device upon arrival in 155 patients presenting with acute dyspnoe. The diagnostic 'gold' standard for CHF was adjudicated by two independent cardiologists who were blinded to the BNP data. RESULTS: By univariate logistic regression analysis, BNP was strongly related to a diagnosis of CHF. In a multivariate model BNP provided additional prognostic information to patient age and gender, radiographic evidence of pulmonary congestion and cardiomegaly, and the presence of pulmonary rales and jugular vein distention by physical examination. There was no significant interaction between age and BNP or between gender and BNP with regard to the accuracy of diagnosing CHF. The area under the receiver-operating characteristics-curve was 0.86 (95% confidence interval 0.78-0.93) in women and 0.90 (0.82-0.97) in men. The area under the curves were 0.82 (0.73-0.92) and 0.88 (0.80-0.97) for patients (both genders) aged > or = 76 and <76 years, respectively. CONCLUSION: Point-of-care BNP measurement in the emergency department discriminates well between patients with dyspnoe of cardiac and non-cardiac origin regardless of age and gender.

Uncovering heart failure in patients with a history of pulmonary disease: rationale for the early use of B-type natriuretic peptide in the emergency department.

UNLABELLED: Plasma B-type natriuretic peptide (BNP) can reliably identify acute congestive heart failure (CHF) in patients presenting to the emergency department (ED) with acute dyspnea. Heart failure, asthma, and chronic obstructive pulmonary disease (COPD) are syndromes where dyspnea and wheezing are overlapping signs, and hence, these syndromes are often difficult to differentiate. OBJECTIVE: To determine whether BNP can distinguish new-onset heart failure in patients with COPD or asthma presenting with dyspnea to the ED. METHODS: The BNP Multinational Study was a seven-center prospective study of 1,586 adult patients presenting to the ED with acute dyspnea who had blinded BNP levels measured on arrival with a rapid, point-of-care device. This study evaluated the 417 patients with no previous history of heart failure and a history of asthma or COPD as a subgroup from the 1,586 adult patients in the BNP Multinational Study. The reference standard for CHF was adjudicated by two independent cardiologists, also blinded to BNP results, who reviewed all clinical data and standardized CHF scores. RESULTS: A total of 417 subjects (mean age 62.2 years, 64.4% male) had a history of asthma or COPD without a history of CHF. Of these, 87/417 (20.9%, 95% CI = 17.1% to 25.1%) were found to have CHF as the final adjudicated diagnosis. The emergency physicians identified a minority, 32/87 (36.8%), of these patients with CHF. The mean BNP values (+/- SD) were 587.0 +/- 426.4 and 108.8 +/- 221.3 pg/mL for those with and without CHF (p < 0.0001). At a cutpoint of 100 pg/mL, BNP had the following decision statistics: sensitivity 93.1%, specificity 77.3%, positive predictive value 51.9%, negative predictive value 97.7%, accuracy 80.6%, positive likelihood ratio 4.10, and negative likelihood ratio 0.09. If BNP would have been added to clinical judgment (high > or = 80% probability of CHF), at a cutpoint of 100 pg/mL, 83/87 (95.4%) of the CHF subjects would have been correctly diagnosed. Multivariate analysis found BNP to be the most important predictor of CHF (OR = 12.1, 95% CI = 5.4 to 27.0, p < 0.0001). In the 87 subjects found to have CHF, 39.0%, 22.2%, and 54.8% were taking angiotensin-converting enzyme inhibitors (ACEIs), beta-blockers (BBs), and diuretics on a chronic basis, respectively. CONCLUSIONS: The yield of adding routine BNP testing in patients with a history of asthma or COPD in picking up newly diagnosed CHF is approximately 20%. This group of patients presents a substantial therapeutic opportunity for the initiation and chronic administration of ACEI and BB therapy, as well as other CHF management strategies.

[B-type natriuretic peptide and clinical judgement in the diagnosis of heart failure in patients presenting with acute dyspnoea]. / B-type natriuretisk peptid i diagnostisering av hjertesvikt hos pasienter med akutt dyspné.

BACKGROUND: B-type natriuretic peptide (BNP) is increased in left ventricular dysfunction and congestive heart failure e. The aim of the study was to determine the diagnostic accuracy of BNP and the degree to which BNP adds to clinical judgement in the diagnosis of heart failure. MATERIAL AND METHODS: The BNP Multinational Study was a seven-centre prospective study of 1586 patients presenting to emergency departments with acute dyspnoea who had BNP levels measured with a rapid, point-of-care device on arrival. 1538 (97%) had pre-test probability of congestive heart failure determined from 0-100% by the attending physician in the emergency department who was blinded to the BNP levels. The final diagnosis was adjudicated by two independent cardiologists, also blinded to BNP results, who reviewed all clinical data and standardised congestive heart failure scores. RESULTS: The final diagnosis was congestive heart failure in 722 (47%) patients. Pre-test probability of this condition > or = 80% as determined by the attending physician had a sensitivity of 49% and specificity of 96 % for correct diagnosis. BNP > or = 100 pg/ml had a sensitivity of 90% and a specificity of 73% for correct diagnosis. In determining the correct diagnosis (congestive heart failure or not), adding BNP to clinical judgement would have enhanced diagnostic accuracy from 74% to 81%. INTERPRETATION: Measurement of BNP adds to the clinical information in the diagnosis of congestive heart failure in patients presenting with acute dyspnoea.

Impact of systemic hypertension on the diagnostic performance of B-type natriuretic peptide in patients with acute dyspnea.

Hypertension may affect the diagnostic performance of B-type natriuretic peptide (BNP). The objective of the present study was to assess the impact of a history of hypertension or blood pressure elevation on admission on the diagnostic performance of BNP in the diagnosis of heart failure (HF) in patients with acute dyspnea. BNP levels were measured using a rapid point-of-care device in 1,586 patients with acute dyspnea. In patients with HF, BNP levels did not differ between those with and without histories of hypertension. Conversely, in patients without HF, a history of hypertension was associated with higher median BNP levels (38 pg/ml [interquartile range 13 to 119] vs 21 pg/ml [interquartile range 7 to 64], p <0.001). The areas under the receiver-operating characteristic curves were 0.88 and 0.93 for those with and without histories of hypertension, respectively (p <0.001). Blood pressure elevation on admission did not affect the diagnostic accuracy of BNP (areas under the curve 0.90 in the 2 groups). In conclusion, although a history of hypertension is associated with higher BNP levels in patients with acute dyspnea without HF, the impact on the overall diagnostic performance of BNP is modest. Accordingly, BNP performs well as an indicator of HF in patients presenting in emergency departments regardless of a history of hypertension or elevated blood pressure on admission.