Risk and Protective Factors of Self-harm and Suicidality in Adolescents: An Umbrella Review with Meta-Analysis.

Suicide remains the second most common cause of death in young people aged 10-24 years and is a growing concern globally. The literature reports a vast number of factors that can predispose an adolescent to suicidality at an individual, relational, community, or societal level. There is limited high-level research identifying and understanding these risk and protective factors of adolescent suicidality. The present study used an umbrella review and meta-analysis to synthesize evidence from the review literature in the past 20 years on risk and protective factors of self-harm and suicidality (behavior and ideation) in adolescents. The umbrella review included 33 quantitative reviews with 1149 individual studies on suicidality and self-harm. Based on the data synthesis, it compared the public health impact of exposure on the population of the identified exposure. Bullying victimization was the most attributed environmental exposure for suicidality. The other identified significant school and individual factors were sleeping disturbance, school absenteeism, and exposure to antidepressants. Several significant vulnerable young populations were identified with significantly higher prevalence of suicidality, including lesbian, gay, bisexual, transgender, queer (or questioning) youth and those with mental health disorders, problem behaviors, previous suicidality, self-harm, and gender (female). A person-centered approach emphasizing connectedness and bully-free school environments should be a priority focus for schools, health professionals, and public health policymakers.

Tracking the 3-year trajectory of referrals to an early psychosis intervention service.

AIM: To review the baseline and clinical characteristics of patients referred to a New Zealand Early Psychosis Intervention (EPI) service across a 4-year timeframe. METHOD: We compared two cohorts, and identified variables associated with being accepted or declined, and reasons for decline, by an EPI service between 2013 and 2017. RESULTS: There were 576 people with suspected psychosis referred to the EPI service for assessment: 300 (52%) were accepted, 221 (38%) declined and 55 (10%) were not processed. Reasons for being declined by EPI services were a long duration of psychosis (DUP, 48%) and no evidence of psychosis (47%). There were no significant differences between the accepted and declined group in Emergency Department presentations for self-harm or suicide attempts and acute admissions to a psychiatric inpatient unit over the 3-year follow-up period. CONCLUSION: To optimise the identification of true positive cases, EPI services require clear entry criteria. Replicating this study in other EPI services with different entry criteria may provide evidence to develop a more uniform screening process. Improved outcomes may be enhanced by measuring effectiveness and liaising with other EPI services.

The reliability of the Epworth Sleepiness Score in a sleep clinic population.

Despite the Epworth Sleepiness Score being widely used, there are limited studies of its reliability in clinical practice. The aim of this study was to assess the reliability of the Epworth Sleepiness Score in a clinical population. The study included patients referred to Middlemore Hospital sleep service between October and November 2014, aged over 17 years, with at least two Epworth Sleepiness Score measurements at up to three different points on the diagnostic pathway: on General Practitioner referral (GP Epworth Sleepiness Score); at overnight oximetry assessment (Oximetry Epworth Sleepiness Score); and at a specialist clinic (Specialist Epworth Sleepiness Score). No treatment was administered between scores. One-hundred and thirty-three patients were included in the study. There was a median of 91 days from GP Epworth Sleepiness Score to Oximetry Epworth Sleepiness Score, and 11 days from Oximetry Epworth Sleepiness Score to Specialist Epworth Sleepiness Score. There was poor test-retest reliability between GP Epworth Sleepiness Score and Specialist Epworth Sleepiness Score; 72.4% and 17.8% of patients had an absolute difference of more than 2 and 8 Epworth Sleepiness Score points, respectively. A Bland-Altman plot of mean Epworth Sleepiness Score versus the difference between GP Epworth Sleepiness Score and Specialist Epworth Sleepiness Score demonstrated a wide scatter of data and 95% confidence interval for the difference in Epworth Sleepiness Score for an individual patient of -14 to +10. There was similar variability between GP Epworth Sleepiness Score and Oximetry Epworth Sleepiness Score. The reliability of the Epworth Sleepiness Score is unproven in clinical settings. This study shows poor test-retest reliability of Epworth Sleepiness Score, particularly between primary and secondary care, arguing against the use of Epworth Sleepiness Score for clinical decision-making or prioritisation of services without first assessing the reliability of the Epworth Sleepiness Score in the relevant clinical population.

Documenting psychiatric risk: more than ticking boxes.

OBJECTIVE: The purpose of this study was to audit the completion of risk assessment documentation by staff working within an acute adult mental health setting. METHOD: Fifty risk assessment forms in a district health board's acute adult mental health service were audited for completion. Clinicians provided verbal feedback on the audit results. RESULTS: Risk assessment forms were completed in 58.3% of cases. A risk formulation statement was completed in 43.8% of cases. Rates of completion varied between senior medical officers, registrars and nurses. CONCLUSION: Accurate risk formulation and safety planning are more important than ensuring all boxes are ticked on a form. Optimising the design of electronic forms may enhance access to information about historical risk.

Do community-dwelling Maori and Pacific peoples present with dementia at a younger age and at a later stage compared with NZ Europeans?

OBJECTIVE: Ethnicity may affect presentation to clinical services in people with dementia; however, no studies have examined this in Maori or Pacific peoples in New Zealand (NZ). Our objective was to examine the routinely collected clinical data from a memory assessment service in South Auckland to examine the presentation of dementia in the major NZ ethnic groups. METHODS: A total of 360 patients presenting to a memory service with a new diagnosis of dementia were included in this study. Demographic data (age, sex, and ethnicity) and dementia sub-type and severity were analyzed. RESULTS: There were 142 NZ European (mean age: 79.2, SD 7.4), 43 Maori (mean age: 70.2, SD 7.6), 126 Pacific (mean age: 74.3, SD 7.6), and 49 other ethnicities (mean age: 78.0, SD 8.5) presenting with a new diagnosis of dementia. After adjustment for gender and dementia subtype, Maori and Pacific patients were 8.5 and 5.3 years younger than NZ European patients (P < 0.0001). Pacific peoples tended to present with more advanced dementia (OR = 1.63, 95% CI: 0.98-2.70, P = 0.06) after adjustment for age and gender. There was little difference in the subtypes of dementia between ethnic groups. CONCLUSIONS: Maori and Pacific peoples with dementia presented to an NZ memory service at a younger age than NZ Europeans, and Pacific peoples presented with more advanced dementia. A population-based epidemiological study is critical to determine whether Maori and Pacific peoples have indeed a higher risk of developing dementia at a younger age.

Periprosthetic Joint Infection Is the Main Cause of Failure for Modern Knee Arthroplasty: An Analysis of 11,134 Knees.

BACKGROUND: Although large series from national joint registries may accurately reflect indications for revision TKAs, they may lack the granularity to detect the true incidence and relative importance of such indications, especially periprosthetic joint infections (PJI). QUESTIONS/PURPOSES: Using a combination of individual chart review supplemented with New Zealand Joint Registry data, we asked: (1) What is the cumulative incidence of revision TKA? (2) What are the common indications for revising a contemporary primary TKA? (3) Do revision TKA indications differ at various followup times after primary TKA? METHODS: We identified 11,134 primary TKAs performed between 2000 and 2015 in three tertiary referral hospitals. The New Zealand Joint Registry and individual patient chart review were used to identify 357 patients undergoing subsequent revision surgery or any reoperation for PJI. All clinical records, radiographs, and laboratory results were reviewed to identify the primary revision reason. The cumulative incidence of each revision reason was calculated using a competing risk estimator. RESULTS: The cumulative incidence for revision TKA at 15 years followup was 6.1% (95% CI, 5.1%-7.1%). The two most-common revision reasons at 15 years followup were PJI followed by aseptic loosening. The risk of revision or reoperation for PJI was 2.0% (95% CI, 1.7%-2.3%) and aseptic loosening was 1.2% (95% CI, 0.7%-1.6%). Approximately half of the revision TKAs secondary to PJI occurred within 2 years of the index TKA (95% CI, 0.8%-1.2%), whereas half of the revision TKAs secondary to aseptic loosening occurred 8 years after the index TKA (95% CI, 0.4%-0.7%). CONCLUSIONS: In this large cohort of patients with comprehensive followup of revision procedures, PJI was the dominant reason for failure during the first 15 years after primary TKA. Aseptic loosening became more important with longer followup. Efforts to improve outcome after primary TKA should focus on these areas, particularly prevention of PJI. LEVEL OF EVIDENCE: Level III, therapeutic study.

A randomized trial on subject tolerance and the adverse effects associated with higher- versus lower-flow oxygen through a standard nasal cannula.

STUDY OBJECTIVE: Experts advocate the use of a standard nasal cannula to provide oxygen at flow rates of up to 15 L/minute during emergency intubation. However, because of concerns about potential patient discomfort, some providers avoid providing nasal cannula oxygen at flow rates greater than 6 L/minute. This trial is designed to determine the participants' ability to tolerate 10 minutes of nasal cannula oxygen at higher flow rates. METHODS: This was a prospective, randomized, crossover trial of healthy volunteers at an emergency department in New Zealand. Participants were randomized to first receive either higher-flow (15 L/minute) or lower-flow (6 L/minute) nasal cannula oxygen for 10 minutes. After a 1-hour washout period, they received the alternate flow rate for 10 minutes. The primary outcome was the ability to tolerate 10 minutes of the nasal cannula oxygen at each flow rate. The secondary outcome was the difference in discomfort between the flow rates as measured on a 100-mm visual analog scale. RESULTS: All 77 of the participants (100%) were able to tolerate 10 minutes at both flow rates. Participants rated the higher-flow nasal cannula oxygen as a mean of 25 mm (SD 20 mm) more uncomfortable than the lower-flow nasal cannula oxygen. One minute after the oxygen was discontinued, the mean difference in discomfort between the flow rates was a clinically insignificant 9.8 mm (SD 17 mm) more uncomfortable. There were no adverse events. CONCLUSION: Participants were able to tolerate higher-flow nasal cannula oxygen for 10 minutes without difficulty. Higher-flow nasal cannula oxygen at 15 L/minute was associated with some discomfort, but the discomfort quickly dissipated and caused no adverse events.

Two optimization strategies of multi-stage design in clinical proteomic studies.

We evaluated statistical approaches to facilitate and improve multi-stage designs for clinical proteomic studies which plan to transit from laboratory discovery to clinical utility. To find the design with the greatest expected number of true discoveries under constraints on cost and false discovery, the operating characteristics of the multi-stage study were optimized as a function of sample sizes and nominal type-I error rates at each stage. A nested simulated annealing algorithm was used to find the best solution in the bounded spaces constructed by multiple design parameters. This approach is demonstrated to be feasible and lead to efficient designs. The use of biological grouping information in the study design was also investigated using synthetic datasets based on a cardiac proteomic study, and an actual dataset from a clinical immunology proteomic study. When different protein patterns presented, performance improved when the grouping was informative, with little loss in performance when the grouping was uninformative.

Primary prophylaxis with granulocyte colony-stimulating factor (GCSF) reduces the incidence of febrile neutropenia in patients with non-Hodgkin lymphoma (NHL) receiving CHOP chemotherapy treatment without adversely affecting their quality of life: cost-benefit and quality of life analysis.

PURPOSE: Treatment of non-Hodgkin lymphoma (NHL) with cyclophosphamide, vincristine, doxorubicin and prednisone (CHOP) is known to be associated with a significant risk of febrile neutropenia (FN) of up to 50% [Osby et al. 2003 Blood 101(10): 3840-3848; Lyman and Delgado 2003 Cancer 98(11): 2402-2409]. This study sought to examine the impact of primary granulocyte colony-stimulating factor (GCSF) prophylaxis on the incidence of FN, quality of life and overall cost. METHODS: In this retrospective cohort study, a group of 65 consecutive patients who received CHOP chemotherapy for NHL between December 2006 and October 2009 was studied. Patients either received filgrastim (300 mcg, average of seven doses), pegylated filgrastim (6 mg, single dose), or no GCSF prophylaxis. In addition, 19 patients were asked to complete Functional Assessment of Cancer Therapy: General quality-of-life questionnaires. RESULTS: Overall, patients who received primary GCSF prophylaxis had significantly fewer FN compared to those who did not (5 vs. 60%, p < 0.0001; numbers needed to treat of 1.8; 95% confidence interval, 1.6-2.9). Cost-benefit analysis showed that the GCSF prophylaxis was associated with only a small increase in direct financial cost ($238 NZD [US$189] more to give primary GCSF prophylaxis per patient vs. no prophylaxis). The quality of life assessment showed that the patients' quality of life scores were similar to the published data from the validation study population (466 patients with mixed cancers) for Functional Assessment of Cancer Therapy. CONCLUSIONS: Our study shows that primary GCSF prophylaxis is effective in preventing FN in patients receiving CHOP chemotherapy for NHL without adversely affecting their quality of life, and is cost effective.

Clinical trial participation improves outcome: a matched historical cohort study.

BACKGROUND: Well-conducted, investigator-led randomized controlled trials (RCTs) are the gold standard for evaluating the efficacy of new treatments and are a key component of evidence-based medicine. It is unclear whether participating in an RCT is beneficial to the individual before the results of RCTs are known. PURPOSE: In a matched historical cohort study, we examined whether participation in RCTs was associated with improved health outcomes. METHODS: Participants in the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE), Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET), or Telmisartan Randomized Assessment Study in ACE-intolerant Subjects with Cardiovascular Disease (TRANSCEND) studies and non-participant controls were selected from patients attending outpatient clinics at Middlemore Hospital between 2001 and 2003. RESULTS: A total of 251 RCT participants and 502 randomly selected patients not enrolled in a trial but who met study entry criteria were matched for age, gender, and ethnicity. There was a significant difference in all-cause mortality for trial participants versus non-participants over the study period (unadjusted relative risk reduction (RRR) = 63%; 95% confidence interval (CI) = 28%-81%) and a significant reduction in cardiovascular mortality (unadjusted RRR = 81%; 95% CI = 17%-95%) favouring RCT participants. Allowing for co-morbidity, the adjusted RRR of all-cause mortality associated with trial participation was 55% (95% CI = 10%-77%). Active treatment in an RCT was found to be less explanatory than trial participation. The adjusted RRR for cardiovascular mortality associated with active treatment in a trial was 86% (95% CI = -2% to 98%), with trial participation found to be less explanatory than active treatment. LIMITATIONS: The main limitations of this trial relate to its design as a retrospective study with a historical cohort comparison group. Limitations include lack of complete data for some patients, bias in selection of the comparison group, and the effects of confounding variables. However, the study design and analysis were planned so as to minimize these as much as possible. CONCLUSION: This study revealed significantly lower all-cause mortality among participants in industry-sponsored RCTs compared with non-participants who received routine hospital outpatient care. This effect was independent of study drug.

Combined therapy with tiotropium and formoterol in chronic obstructive pulmonary disease: effect on the 6-minute walk test.

Combined therapy with tiotropium and long-acting beta 2 agonists confers additional improvement in symptoms, lung function and aspects of health-related quality of life (QOL) compared with each drug alone in patients with COPD. However, the efficacy of combined therapy on walking distance, a surrogate measure of daily functional activity and morbidity remains unclear. The aim was, therefore, to quantify the benefit of this therapy on the six minute walk test. Secondary outcomes included change in lung function, symptoms, the BODE index and QOL. In a double-blind, crossover study, 38 participants with moderate to severe COPD on tiotropium were randomised to receive either formoterol or placebo for 6 weeks. Following a 2-week washout period, participants crossed over to the alternate arm of therapy for a further 6 weeks. Thirty-six participants, with an average age of 64.3 years and FEV1 predicted of 53%, completed the study. Combined therapy improved walking distance by a mean of 36 metres [95% CI: 2.4, 70.1; p = 0.04] compared with tiotropium. FEV1 increased in both groups (160 mL combination therapy versus 30 mL tiotropium) with a mean difference of 110 mL (95% CI: -100, 320; p = 0.07) between groups, These findings further support the emerging advantages of combined therapy in COPD. Australian New Zealand Clinical Trials.

Prevalence of asthma and atopy in sarcoidosis.

BACKGROUND AND OBJECTIVE: We hypothesized that the prevalence of allergic disorders, characterized by the release of type 2 cytokines (IL-4, IL-5, IL-10), would be lower in sarcoidosis in which there is a dominant type 1 immune response (IL-2, interferon-gamma). The objective was to measure the prevalence of atopy and self-reported asthma in patients with sarcoidosis. METHODS: Sarcoidosis patients (n = 136, 72 M, age range 22-75), recruited in the outpatient setting, completed a modified European Community Respiratory Health Survey. 123 of these patients provided blood for allergy testing. RESULTS: For the cohort as a whole the self-reported prevalence of asthma ever (21.5%) and asthma attack in the last 12 months (7.5%), was high as was wheezing (42.1%), breathlessness with wheeze (22.3%) and use of an asthma medication (13.1%). The prevalence of atopy was 34%. These data are not different from the previously reported prevalence of asthma and atopy in New Zealand. CONCLUSIONS: The same prevalence of asthma symptoms and atopy as in the normal population suggests that the immune system is not skewed away from mounting T helper type 2 immune responses in sarcoidosis.

The prevalence and predictors of airway hyperresponsiveness in sarcoidosis.

BACKGROUND AND OBJECTIVE: Obstructive airflow limitation is the most common physiological impairment in sarcoidosis. This study determined the prevalence of airway hyperresponsiveness (AHR) in sarcoidosis, the correlation between responses to direct (using histamine) and indirect (using hypertonic saline) bronchial challenge, and the clinical, physiological and radiological predictors of AHR. METHODS: Subjects with sarcoidosis and a baseline forced expiratory volume in 1 s (FEV(1)) >35% predicted underwent hypertonic and histamine challenge, lung function testing and high resolution computed tomography (HRCT) of the chest. AHR was defined as a 15% fall in FEV(1) to hypertonic saline and a 20% fall in FEV(1) to histamine. RESULTS: The 52 subjects had well-preserved lung function (FEV(1) = 2.8 ± 0.7 L, 87% predicted). AHR was detected in 5/47 (11%) to hypertonic saline and 19/43 (44%) to histamine challenge. On univariate analysis, response to histamine challenge was predicted by conglomerate fibrosis (P = 0.02) and reticular pattern (P = 0.03) on HRCT. The baseline % predicted forced expiratory volume in 1 s was significantly inversely associated with AHR on univariate (P = 0.004) and multivariate analysis (P = 0.01) when adjusted by HRCT patterns. CONCLUSIONS: The higher prevalence of AHR using histamine challenge than hypertonic saline challenge and the association with baseline % predicted FEV(1) suggest that the AHR in sarcoidosis may reflect the consequences of airway remodelling following inflammation.

A Secondary-Primary Mental Health Integrated Care Model for Communities with Diverse Population and Complex Health Needs - a Case Study with Health Care Utilization Evaluation.

Integrated care is expected to improve patient experience, patient outcomes and assist with the increasing demand on health services from those with long term conditions including mental disorder. Few studies have evaluated health care utilization as a consequence of increased integration of mental health care. This study considers the factors known to influence secondary health service utilization and investigated the impact of a locality based mental health integrated model of care (ILoC) providing specialist consultation and liaison advice to primary care, to support early diagnosis and treatment. Using existing hospital databases, the study-cohort was identified (service users supported by ILoC, and then referred within 6 months to specialist mental health services (MHS) care between 2017- 2018) and compared on health services utilization with a matched-cohort (without ILoC support before referral to specialist services). The length-of-care in the non-acute MHS was 71% shorter for the ILoC study-cohort, and differences increased in the subgroup taking antidepressants. The ILoC study-cohort was less likely to be admitted to acute MHS on first referral post ILoC intervention and had a 25% lower relative risk of acute MHS admissions at any time in follow-up. There was no difference in the average MHS inpatient length-of-stay. The risk of general hospital acute inpatient admission was marginally higher in the ILoC study-cohort. Conclusions: ILoC appears to shorten non-acute length-of-specialist-care and reduce acute mental health admission. The study provides a first step in understanding the clinical characteristics and specialist services health-care utilization of patients supported by an integrated mental care approach.

Environmental Influences on the Behavioural and Emotional Outcomes of Children: A Network Analysis.

BACKGROUND: Intellectual developmental disorders are a serious source of health morbidity with negative consequences for adults as well as children. However, there is limited evidence on the environmental, trace element, behavioural, and emotional outcomes in children. Here, we investigated whether there is any association between child behaviour and emotional outcomes and micronutrients using network analysis. METHODS: A cross-sectional study was conducted in 9-year-old children within a Pacific Island Families study birth cohort. Elemental concentration was determined in children's toenails after acid digestion and analysed using inductively coupled plasma mass spectrometry. We used network analysis to identify closely associated trace elements and tested the directions and strength of these trace elements. MANCOVA were used to identify the significant associations between individual elements and the behavioural/emotional function of the children using the children behaviour checklist (CBCL). At the final step, quantile regression analysis was used to assess and quantify the identified associations between CBCL function scores and manganese, adjusted by sex, ethnicity, and standardized BMI. RESULTS: Three major nutrient networks were identified. In the Mn network, Mn was strongly positively associated with Al (0.63) and Fe (r = 0.65) and moderately associated with Pb (r = 0.45) and Sb (r = 0.42). Al was also strongly associated with Fe (r = 0.9). Children in the second or third clinical group, with an elevated externalized CBCL score, had a much higher mean and median level of Mn as compared to the normal range group. The aggression score was significantly associated with Mn concentration and sex. Higher Mn concentrations were associated with a higher aggression score. A 1 ug/g unit increase in Mn was associated with a 2.44-fold increase (95% confidence interval: 1.55-4.21) in aggression score, and boys had higher median aggression score than girls (difference: 1.7, 95% CI: 0.9-2.8). Attention and rule breaking scores were both significantly associated with Mn concentration. Higher Mn concentrations were associated with higher attention behaviour problem and rule breaking scores. A 1 ug/g unit increase in Mn was found to be associated with a 1.80-fold increase (95% confidence interval: 1.37-2.82) in attention score, and a 1.46-fold increase (95% confidence interval: 1.01-1.74) in the rule breaking score. Thought score was not significantly associated with Mn concentration (p = 0.13) but was significantly lower in boys (p = 0.004). CONCLUSIONS: Exceeding Mn levels is potentially toxic and has been identified to be associated with worse externalized children's behavioural health and emotional well-being. Future studies are necessary to find the exposure paths so that advice shall be provided to family and care providers in public health and environmental protection.

Trans-fatty acids in New Zealand patients with coronary artery disease.

BACKGROUND: Dietary surveys indicate that New Zealanders have a low intake of trans-fatty acids (TFA) with little derived from industrial sources. This observational cross-sectional study in New Zealand patients with surgical coronary artery disease assesses the plasma levels of TFA and the association of TFA levels with clinical markers of vascular disease. METHODS: 390 patients with severe coronary artery had fasting blood tests taken. Plasma levels of four TFA derived from hydrogenated vegetable oils and ruminant animal products were measured by gas chromatography. Relations between plasma TFA levels and the recent occurrence of myocardial infarction, the presence of polyvascular disease, and serum levels of C-reactive protein (CRP) were assessed. RESULTS: The median TFA level was 0.85% by weight of total fatty acids (IQR 0.59-1.79%), with skewed distribution to the right. For the lowest (<0.74%), middle (0.74-1.07%), and highest (>1.07%) thirds of total TFA, respectively, the proportion of patients with polyvascular disease was 10%, 16%, and 27% (p = 0.0004). Plasma CRP also increased by tertile of TFA (median 2.0, 2.9, 3.2 mg/l, p = 0.007). The association with polyvascular diseases and CRP remained significant after adjustment for risk factors. Significant associations were present between plasma TFA from both ruminant and hydrogenated vegetable oil sources and these markers of cardiovascular risk. CONCLUSIONS: There is an association between relatively low plasma levels of total TFA, mostly derived from ruminant sources, and an increased risk of polyvascular disease and increased CRP in patients with severe coronary artery disease. These high-risk patients may benefit from a targeted approach to minimize all sources of TFA in the diet.

Left ventricular systolic and diastolic function assessed by tissue Doppler imaging and outcome in asymptomatic aortic stenosis.

AIMS: Left ventricular (LV) hypertrophy and abnormal non-invasive measures of LV diastolic function are common in patients with severe aortic stenosis (AS) but their prognostic importance is uncertain. This study aimed to determine whether tissue Doppler measures of LV systolic and/or diastolic function or echocardiographic LV hypertrophy are useful for risk stratifying asymptomatic patients with severe calcific AS. METHODS AND RESULTS: One hundred and eighty-three initially asymptomatic patients with moderate or severe AS (valve area mean 0.96 ± SD 0.3 cm(2)) and a normal LV ejection fraction were followed for median 31 (IQR 14-40) months. Peak systolic (S') and diastolic (E') mitral annular velocities and LV mass were measured by echocardiography at baseline and during follow-up. During follow-up 106 (58%) patients suffered symptomatic deterioration, including three sudden deaths and one resuscitated cardiac arrest. Peak aortic velocity (for 0.5 m/s increase HR = 1.43, 95% CI 1.25, 1.64, P < 0.0001) and aortic valve area (-0.1 cm(2)/m(2) HR = 1.23, 95% CI 1.12, 1.35, P = 0.004) at baseline were most strongly associated with symptomatic deterioration. After peak aortic velocity adjustment neither LV mass index nor any measure of LV systolic or diastolic function was associated with symptomatic deterioration (P > 0.2 for all). CONCLUSION: In patients with calcific AS who have a normal LV ejection fraction the severity of stenosis is the most important correlate of symptomatic deterioration. Tissue Doppler measures of LV systolic and diastolic function and LV mass provide limited predictive information after accounting for the severity of stenosis.

Optimising echocardiographic screening for rheumatic heart disease in New Zealand: not all valve disease is rheumatic.

AIMS: Echocardiography detects a greater prevalence of rheumatic heart disease than heart auscultation. Echocardiographic screening for rheumatic heart disease combined with secondary prophylaxis may potentially prevent severe rheumatic heart disease in high-risk populations. We aimed to determine the prevalence of rheumatic heart disease in children from an urban New Zealand population at high risk for acute rheumatic fever. METHODS AND RESULTS: To optimise accurate diagnosis of rheumatic heart disease, we utilised a two-step model. Portable echocardiography was conducted on 1142 predominantly Maori and Pacific children aged 10-13 years. Children with an abnormal screening echocardiogram underwent clinical assessment by a paediatric cardiologist together with hospital-based echocardiography. Rheumatic heart disease was then classified as definite, probable, or possible. Portable echocardiography identified changes suggestive of rheumatic heart disease in 95 (8.3%) of 1142 children, which reduced to 59 (5.2%) after cardiology assessment. The prevalence of definite and probable rheumatic heart disease was 26.0 of 1000, with 95% confidence intervals ranging from 12.6 to 39.4. Portable echocardiography overdiagnosed rheumatic heart disease with physiological valve regurgitation diagnosed in 28 children. A total of 30 children (2.6%) had non-rheumatic cardiac abnormalities, 11 of whom had minor congenital mitral valve anomalies. CONCLUSIONS: We found high rates of undetected rheumatic heart disease in this high-risk population. Rheumatic heart disease screening has resource implications with cardiology evaluation required for accurate diagnosis. Echocardiographic screening for rheumatic heart disease may overdiagnose rheumatic heart disease unless congenital mitral valve anomalies and physiological regurgitation are excluded.

Comparison of atrial and brain natriuretic peptide for the assessment of mitral stenosis.

BACKGROUND: Accurate evaluation of the functional consequences of mitral stenosis (MS) can be difficult. The aim of this study was to evaluate the relationship between both atrial (ANP) and brain natriuretic peptides (BNP) and symptoms, exercise capacity and echocardiographic measures of MS severity. METHODS: Thirty patients with moderate to severe MS and 14 normal controls underwent clinical assessment, exercise stress echocardiography, measurement of ANP and BNP and two years follow up for clinical events. RESULTS: BNP was higher in MS patients than controls (BNP 58 [IQR 34, 93] vs. 16 [14, 25], p < 0.0001). There was considerable overlap in exercise capacity and echocardiographic severity between asymptomatic and symptomatic patients. An increase in BNP was associated with a larger left atrial area index (r = 0.67, p < 0.0001), reduced mitral valve area (r = -0.38, p = 0.05) and higher resting pulmonary artery pressure (r = 0.47, p = 0.008). Increased BNP predicted lower treadmill exercise capacity (AUC = 0.82 [95% confidence interval 0.67, 0.97], p = 0.004), guideline criteria for intervention (AUC = 0.87 [0.74, 0.99], p = 0.006) and adverse events during follow up (AUC = 0.81 [0.64, 0.99], p = 0.03). Associations for ANP in general were similar but slightly weaker, and ANP did not provide additional predictive information to BNP. CONCLUSION: BNP may improve risk stratification of patients with MS, particularly when symptoms are equivocal.

Sputum procalcitonin: a potential biomarker in stable bronchiectasis.

Sputum procalcitonin is elevated in exacerbations of bronchiectasis. The primary aim of this study was to investigate whether sputum procalcitonin levels are higher in patients with stable bronchiectasis than in healthy controls. We also assessed differences in procalcitonin levels in spontaneously expectorated and induced sputum samples and their repeatability 1 week later. Participants included were aged over 18 years and either had radiologically confirmed bronchiectasis or were healthy controls. Patients with bronchiectasis were clinically stable for at least 6 weeks and had spontaneous and induced sputum collected at visit 1 and again 7 days later. Only induced sputum samples were collected from healthy controls during visit 1. Sputum procalcitonin concentrations in sputum were measured. In total, 30 patients with bronchiectasis and 15 healthy controls were enrolled in this observational study. In the pooled data from visit 1 and 2, the geometric mean procalcitonin level in induced sputum was significantly higher in the bronchiectasis group than in the healthy control group (1.5 ng·mL-1, 95% CI 1.0-2.1 ng·mL-1 versus 0.4 ng·mL-1, 95% CI 0.2-0.9 ng·mL-1; mean ratio 3.6, 95% CI 1.5-8.6; p=0.006). Mean procalcitonin level was higher in spontaneous sputum than in induced sputum at visit 1 (1.8 ng·mL-1, 95% CI 1.2-2.7 ng·mL-1 versus 1.1 ng·mL-1, 95% CI 0.7-1.8 ng·mL-1) and visit 2 (1.5 ng·mL-1, 95% CI 1.0-2.5 ng·mL-1 versus 1.2 ng·mL-1, 95% CI 0.8-1.6 ng·mL-1; p=0.001). Repeating spontaneous and induced sputum procalcitonin levels 1 week later produced similar concentrations (p=0.29, intraclass correlation coefficient (ICC)=0.76 and p=0.72, ICC=0.70, respectively). Sputum procalcitonin is increased in patients with stable bronchiectasis and has potential as a biomarker of airway inflammation and infection in bronchiectasis.