Plasma Hepatocyte Growth Factor for Diagnosis and Prognosis in Light Chain and Transthyretin Cardiac Amyloidosis.

BACKGROUND: Delays in diagnosis of cardiac amyloidosis are common, usually resulting from nonspecific findings on clinical examination and testing. A discriminatory plasma biomarker could result in earlier diagnosis and improve prognosis assessment. OBJECTIVES: To determine the diagnostic and prognostic utility of hepatocyte growth factor (HGF) in light chain and transthyretin cardiac amyloidosis. METHODS: 188 patients with cardiac amyloidosis, amyloidosis without cardiac involvement, or symptomatic heart failure with left ventricular hypertrophy (LVH) or reduced ejection fraction (HFrEF) were enrolled prospectively. Serum biomarkers were measured at study enrollment, and all patients with amyloidosis were followed for all-cause mortality, cardiac transplant, or left ventricular assist device implant. Multinomial logistic regression and Kaplan-Meier survival estimates tested the association of biomarker levels with cardiac amyloidosis and clinical outcomes, respectively. Harrell's C-statistic and the likelihood ratio test compared the prognostic accuracy of plasma biomarkers. RESULTS: HGF was significantly higher in patients with cardiac amyloidosis (p<0.001). An HGF level of 205 pg/mL discriminated cardiac amyloidosis from LVH and HFrEF with 86% sensitivity, 84% specificity, and an area under the curve of 0.88 (95% CI 0.83-0.94). In patients with amyloidosis, elevated HGF levels were associated with worse event-free survival over a median follow-up period of 2.6 years (p<0.001) with incremental prognostic accuracy over NT-proBNP and troponin-T (p<0.001). CONCLUSIONS: HGF discriminates light chain and transthyretin cardiac amyloidosis from patients with symptomatic HF with LVH or HFrEF, and is associated with worse cardiac outcomes. Confirmation of these findings in a larger, multi-center study enrolling confirmed and suspected cases of cardiac amyloidosis is underway.

Bedside Usability Surveys: Adding Authentic User Detail to the Assessment.

Errors in healthcare are a leading cause of death in the United States. Equipment usability and user interfaces remain an area not fully elucidated. Infusion pumps play a vital role in care delivery, often essential for critical therapies. While pump function is comparatively simple, their programming, configuration, and form provide opportunity for error. Our purpose was to assess qualities nurses identified as important to pump operation by electronic survey. A self-developed usability survey was distributed to a random sample of 500 nurses, stratified by unit type and employed at the large academic quaternary care hospital. The overall response rate was 48% (n = 240). Descriptive and inferential statistics describe the responses and represent more than 5500 weekly infusions. Nurses described confident use of the system with some differences by unit type. Ninety percent of respondents indicated they have omitted use of the dose error reduction system, which should raise safety concerns. Users reported issues with the user interface and error prevention systems. Qualitative items elicited suggestions for improving aspects of the pump. Employing a usability survey in a clinical area proved to be a simple, inexpensive way to gather more information on the use and potential improvements of infusion pumps.

Longitudinal Assessment of Vascular Function With Sunitinib in Patients With Metastatic Renal Cell Carcinoma.

BACKGROUND: Sunitinib, used widely in metastatic renal cell carcinoma, can result in hypertension, left ventricular dysfunction, and heart failure. However, the relationships between vascular function and cardiac dysfunction with sunitinib are poorly understood. METHODS AND RESULTS: In a multicenter prospective study of 84 metastatic renal cell carcinoma patients, echocardiography, arterial tonometry, and BNP (B-type natriuretic peptide) measures were performed at baseline and at 3.5, 15, and 33 weeks after sunitinib initiation, correlating with sunitinib cycles 1, 3, and 6. Mean change in vascular function parameters and 95% confidence intervals were calculated. Linear regression models were used to estimate associations between vascular function and left ventricular ejection fraction, longitudinal strain, diastolic function (E/e'), and BNP. After 3.5 weeks of sunitinib, mean systolic blood pressure increased by 9.5 mm Hg (95% confidence interval, 2.0-17.1; P=0.02) and diastolic blood pressure by 7.2 mm Hg (95% confidence interval, 4.3-10.0; P<0.001) across all participants. Sunitinib resulted in increases in large artery stiffness (carotid-femoral pulse wave velocity) and resistive load (total peripheral resistance and arterial elastance; all P<0.05) and changes in pulsatile load (total arterial compliance and wave reflection). There were no statistically significant associations between vascular function and systolic dysfunction (left ventricular ejection fraction and longitudinal strain). However, baseline total peripheral resistance, arterial elastance, and aortic impedance were associated with worsening diastolic function and filling pressures over time. CONCLUSIONS: In patients with metastatic renal cell carcinoma, sunitinib resulted in early, significant increases in blood pressure, arterial stiffness, and resistive and pulsatile load within 3.5 weeks of treatment. Baseline vascular function parameters were associated with worsening diastolic but not systolic function.

A Cost and Quality Analysis of Utilizing a Rectal Catheter for Medication Administration in End-of-Life Symptom Management.

Technology that can improve the ability to provide quick symptom control while decreasing the cost and burden of care could help hospice agencies deal with current hospice industry challenges. This paper describes how the use of a new rectal medication delivery technology at a large hospice in western New York has improved patient care and nursing efficiency while at the same time decreasing the cost of care.

Canadian Physical Activity Guidelines for the Early Years (aged 0-4 years).

The Canadian Society for Exercise Physiology (CSEP), with assistance from multiple partners, stakeholders, and researchers, developed the first Canadian Physical Activity Guidelines for the Early Years (aged 0-4 years). These national guidelines were created in response to an urgent call from public health, health care, child care, and fitness practitioners for healthy active living guidance for the early years. The guideline development process was informed by the Appraisal of Guidelines for Research Evaluation (AGREE) II instrument and the evidence assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The recommendations are informed by evidence from a systematic review that examined the relationships between physical activity and health indicators (healthy body weight, bone and skeletal health, motor skill development, psychosocial health, cognitive development, and cardio-metabolic disease risk factors) for three age groups (infants aged <1 year; toddlers aged 1-2 years; preschoolers aged 3-4 years). The new guidelines include a preamble to provide context, followed by the specific recommendations. The final guidelines benefitted from an extensive on-line consultation process with input from over 900 domestic and international stakeholders, end-users, and key informants. The final guideline recommendations state that for healthy growth and development, infants (aged <1 year) should be physically active several times daily - particularly through interactive floor-based play. Toddlers (aged 1-2 years) and preschoolers (aged 3-4 years) should accumulate at least 180 min of physical activity at any intensity spread throughout the day, including a variety of activities in different environments, activities that develop movement skills, and progression toward at least 60 min of energetic play by 5 years of age. More daily physical activity provides greater benefits.

Pediatric nurses' knowledge and attitudes survey regarding pain: a competency tool modification.

Nurses' knowledge and attitudes about pain affect their ability to manage patients' pain. A mechanism was sought to evaluate nursing competency in pain management at eight pediatric hospitals. Several pain survey tools were reviewed, considering the patient population around which they were designed, the basis for survey content, and format. A survey with established validity and reliability, the Pediatric Nurses' Knowledge and Attitude Survey Regarding Pain (PNKAS) (Manworren 1999) was chosen as the most appropriate for this group. The tool was modified for applicability to the nurses caring for pediatric populations that do not include oncology. Revisions were made with the concurrence of Manworren to assure that neither the content being tested, nor the integrity of the tool, was affected. Stability of the modified tool (PNKAS-Shriners Version 2002) was verified by retesting 6-8 weeks after initial survey.

Exercise-induced alterations in plasma concentrations of ghrelin, adiponectin, leptin, glucose, insulin, and cortisol in horses.

Six Standardbred (STB) mares (11+/-2 years, 521+/-77 kg; means+/-SD) performed an exercise trial (EX) where they underwent an incremental exercise test (GXT) as well as a parallel control trial (CON) to test the hypothesis that short-term, high intensity exercise would alter plasma concentrations of glucose, leptin, adiponectin, ghrelin, insulin and cortisol. Plasma samples were taken before (0 min), during (last 10s at 6, 8m/s, and the velocity eliciting VO(2max)), and after exercise (2, 10, 30, 60 min; 12 and 24h post-GXT). A second set of blood samples was collected before and after an afternoon meal given at 1515 h (at 1500, 1514, 1530, and 1545 h). Data were analyzed using ANOVA for repeated measures and Tukey's test. During the GXT, there were no changes (P>0.05) in the plasma concentrations of glucose, leptin, adiponectin or ghrelin. However, there was a 29% increase (P<0.05) in mean plasma cortisol concentration and a 35% decrease (P<0.05) in mean plasma insulin concentration. Substantial increases (P<0.05) in the mean plasma concentrations of glucose and cortisol of 36% and 102%, respectively, were seen in the EX trial during the first 60 min post-GXT. Plasma leptin concentration, measured at the 24h post-GXT time point, was 20% lower (P<0.05) during the EX trial compared with the parallel time point in the standing control (CON) trial. Plasma ghrelin concentration was 37% lower (P<0.05) in the EX trial compared with CON before and after the afternoon meal, but was 43% higher (P<0.05) 12h post-GXT. There were no differences between EX and CON for plasma concentrations of insulin or adiponectin during recovery. It was concluded that short-term high intensity exercise alters plasma leptin and ghrelin concentrations in STB mares post-exercise, which may signal the exercised animals to alter energy intake.

Plasma leptin, ghrelin and adiponectin concentrations in young fit racehorses versus mature unfit standardbreds.

Concentrations of hormones related to energy homeostasis may differ between populations with varied body compositions, acting as signals to increase or decrease energy intake and/or expenditure. How these parameters correlate with body composition in horses and how they vary in fit (F) versus unfit (UF) Standardbred racehorses is unclear. The purpose of this study was to test the hypothesis that plasma concentrations of glucose (GLU), insulin (INS), cortisol (CORT), ghrelin (GHRL), adiponectin (ADIP) and leptin (LEP) would be correlated with body composition and differ in fit (F) versus unfit (UF) horses. Fasting plasma samples were taken from 12 unfit (11 +/- 2 years, 521 +/- 77 kg; mean +/- SD) and 34 fit (4 +/- 2 years, 475 +/- 83 kg) Standardbred horses. GHRL, LEP, ADIP, INS and CORT concentrations were measured using radioimmunoassay. GLU concentration was measured using colorometric kits. Body composition data included body weight, body condition score (BCS), and percent fat (%fat) calculated using rump fat thickness measured ultrasonically and the Westervelt equation. Data were analyzed using Pearson Product moment and Student's t tests. There were no differences (P>0.05) between F and UF horses for the plasma concentrations of CORT (69 +/- 14 versus 76 +/- 23 microg/dL), INS (7.2 +/- 3.5 versus 7.1 +/- 1.8 microIU/mL) or GLU (90 +/- 6 versus 86 +/- 7 mg/dL). Plasma GHRL and ADIP concentrations were greater (P<0.05) in F versus UF horses (54 +/- 27 versus 33 +/- 17 pg/mL and 1820 +/- 276 versus 1333 +/- 249 ng/mL, respectively), while plasma LEP was lower in F versus UF (1.0 +/- 0.6 versus 4.4 +/- 2.4 ng/mL, P<0.001). BCS and %fat were lower in F versus UF horses (4.8 +/- 0.3 versus 6.7 +/- 0.5 and 11.9 +/- 1.6 versus 15.4 +/- 2.5%, respectively), with no correlation between %fat and GHRL (-0.12, P>0.05), although there was a positive correlation between %fat and LEP (+0.72, P<0.05), and a negative correlation between %fat and ADIP (-0.40, P<0.05). The data show that in comparing fit and unfit horses, there are variations in body composition as well as concurrent and substantial differences in the concentrations of hormones, cytokines, and other parameters related to the control of appetite and feed intake.