Characteristics and Outcomes of Patients With Severe Aortic Stenosis Discussed by the Multidisciplinary "Heart Team" According to Treatment Allocation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an alternative and effective contemporary intervention to surgical aortic valve replacement (SAVR) for patients with severe aortic valve disease at increased surgical risk. Guidelines recommend a multidisciplinary "Heart Team" (MHT) review of patients considered for a TAVI procedure, but this has been little studied. We reviewed the characteristics, treatments and outcomes of such patients reviewed by the MHT at our centre. METHODS: Data on consecutive patients with severe aortic valve stenosis discussed by the Auckland City Hospital MHT from June 2011 to August 2016 were obtained from clinical records. Patient characteristics, treatment and outcomes were analysed using standard statistical methods. RESULTS: Over the 5-year period 243 patients (mean age 80.2 ± 8.0 years, 60% male) were presented at the MHT meeting. TAVI was recommended for 200, SAVR for 26 and medical therapy for 17 patients, with no significant difference in mean age (80.2 ± 8.3, 80.4 ± 6.1, 80.4 ± 7.3 years, respectively) or EuroSCORE II (6.5 ± 4.7%, 5.3 ± 3.6%, 6.7 ± 4.3%, respectively). Over time, there was an increase in the number of patients discussed and treated, with no change in their mean age, but the mean EuroSCORE II significantly decreased (TAVI p = 0.026, SAVR p = 0.004). Survival after TAVI and SAVR was similar to that of the age-matched general population, but superior to medical therapy p = 0.002 (93% (n = 162), 84% (n = 21) and 73% (n = 18) at one year and 85% (n = 149), 84% (n = 21) and 54% (n = 13) at 2 years, respectively). CONCLUSIONS: An increasing number of patients were discussed at the MHT meeting with the majority undergoing TAVI, with a similar age and EuroSCORE II to those allocated SAVR or medical therapy. Survival following TAVI and SAVR was superior to medical therapy and similar to the age-matched general population. These findings suggest that the MHT process is robust, consistent and appropriately allocating a limited treatment resource.

Communicating projected survival with treatments for chronic kidney disease: patient comprehension and perspectives on visual aids.

BACKGROUND: Mortality in end stage renal disease (ESRD) is higher than many malignancies. There is no data about the optimal way to present information about projected survival to patients with ESRD. In other areas, graphs have been shown to be more easily understood than narrative. We examined patient comprehension and perspectives on graphs in communicating projected survival in chronic kidney disease (CKD). METHODS: One hundred seventy-seven patients with CKD were shown 4 different graphs presenting post transplantation survival data. Patients were asked to interpret a Kaplan Meier curve, pie chart, histogram and pictograph and answer a multi-choice question to determine understanding. RESULTS: We measured interpretation, usefulness and preference for the graphs. Most patients correctly interpreted the graphs. There was asignificant difference in the percentage of correct answers when comparing different graph types (p = 0.0439). The pictograph was correctly interpreted by 81% of participants, the histogram by 79%, pie chart by 77% and Kaplan Meier by 69%. Correct interpretation of the histogram was associated with educational level (p = 0.008) and inversely associated with age > 65 (p = 0.008). Of those who interpreted all four graphs correctly, there was an association with employment (p = 0.001) and New Zealand European ethnicity (p = 0.002). 87% of patients found the graphs useful. The pie chart was the most preferred graph (p 0.002). The readability of the graphs may have been improved with an alternative colour choice, especially in the setting of visual impairment. CONCLUSION: Visual aids, can be beneficial adjuncts to discussing survival in CKD.

Clinical evaluation of emboli removal by integrated versus non-integrated arterial filters in new generation oxygenators.

OBJECTIVE: To compare the emboli filtration efficiency of five integrated or non-integrated oxygenator-filter combinations in cardiopulmonary bypass circuits. METHODS: Fifty-one adult patients underwent surgery using a circuit with an integrated filtration oxygenator or non-integrated oxygenator with a separate 20 µm arterial line filter (Sorin Dideco Avant D903 + Pall AL20 (n=12), Sorin Inspire 6 M + Pall AL20 (n=10), Sorin Inspire 6M F (n=9), Terumo FX25 (n=10), Medtronic Fusion (n=10)). The Emboli Detection and Classification quantifier was used to count emboli upstream and downstream of the primary filter throughout cardiopulmonary bypass. The primary outcome measure was to compare the devices in respect of the median proportion of emboli removed. RESULTS: One device (Sorin Inspire 6 M + Pall AL20) exhibited a significantly greater median percentage reduction (96.77%, IQR=95.48 - 98.45) in total emboli counts compared to all other devices tested (p=0.0062 - 0.0002). In comparisons between the other units, they all removed a greater percentage of emboli than one device (Medtronic Fusion), but there were no other significant differences. CONCLUSION: The new generation Sorin Inspire 6 M, with a stand-alone 20 µm arterial filter, appeared most efficient at removing incoming emboli from the circuit. No firm conclusions can be drawn about the relative efficacy of emboli removal by units categorised by class (integrated vs non-integrated); however, the stand-alone 20 µm arterial filter presently sets a contemporary standard against which other configurations of equipment can be judged.

Outcome following heart transplantation in New Zealand Maori.

BACKGROUND: Disparities in health care access and outcomes between Maori (M) and Non-Maori (NM) New Zealanders have been reported but little is known about access to and outcomes following heart transplantation (HT). METHODS: A retrospective analysis was performed of M and NM who underwent HT in New Zealand. Demographic, clinical and outcome data were collected. RESULTS: Of 253 patients transplanted, 176 were European, 47 M (19%) and 30 of other ethnicities. M and NM groups were compared. Median age (both 46 years), gender (17% vs 21% female), waiting time (90 vs 76 days) and diagnosis (dilated cardiomyopathy - 62% vs 58%) were similar for both groups. M were heavier (81 vs 71 kg, p<0.0001) and more were blood group A (58% vs 39%). Five year survival was similar (79% vs 78%) but 10 year survival was significantly reduced in M (54% vs 67% p=0.02). CONCLUSION: The proportion of Maori who have undergone heart transplantation in New Zealand compares favourably with their proportion in the New Zealand population. The reasons for the adverse diverging outcomes after five years require further investigation.

The World Heart Federation criteria raise the threshold of diagnosis for mild rheumatic heart disease: Three reviewers are better than one.

BACKGROUND: The World Heart Federation (WHF) criteria, published in 2012, provided an evidence-based guideline for the minimal diagnosis of echocardiographically-detected RHD. Primary aim of the study was to determine whether use of the WHF criteria altered the threshold for the diagnosis of echocardiographically-detected RHD compared with the previous WHO/NIH criteria. A secondary aim was to explore the utility of a three reviewer reporting system compared to a single or two reviewer reporting structure. METHODS: 144 de-identified echocardiograms (RHD, congenital valvar abnormality, physiological valvar regurgitation) were independently reported using the WHF criteria by two reviewers blinded to the previous WHO/NIH diagnosis. If there was discordance between the two reviewers, a third cardiologist independently performed a tie-breaker review. RESULTS: There was a 21% reduction of cases classified as RHD using the WHF criteria compared to the modified WHO/NIH criteria (68 cases compared to 86, p = 0.04). There was a 60% consensus across the different diagnostic categories with 2 reviewers, 89% majority agreement with 3 reviewers. 11% required an open label discussion. There was moderate agreement between 2 reviewers for any RHD, kappa 0.57 (CI 0.44-0.70), with no significant difference in agreement between the different categories. CONCLUSION: The WHF criteria have raised the threshold for the diagnosis of RHD compared to the WHO/NIH criteria. However, inter-reporter variability of the WHF criteria is high. A three reviewer system is likely more accurate than a single or two reporter system for the diagnosis of mild RHD. This has resource implications for echocardiographic screening programmes.

Utilization of cardiac resynchronization therapy in patients with heart failure in the Northern Region of New Zealand.

BACKGROUND: Cardiac resynchronization therapy (CRT) has been shown to improve morbidity and mortality for heart failure (HF) patients. Little is known about the trends in CRT use and outcomes of these patients in New Zealand. METHOD: Mortality, hospitalization events and complications in HF patients in the Northern Region of New Zealand implanted with CRT devices from Jan-2007 to June-2015 were reviewed. RESULTS: Two-hundred patients underwent CRT implantation during the study period. There was a gradual increase in CRT-D implantation (n = 157) but the number remained static for CRT-P (n = 43). Patients who received CRT-P were older (mean age 65.9 ± 14.0 years vs 61.5 ± 10.2 years, P < 0.0007) but had a higher left ventricular ejection fraction (LVEF) (33.7 ± 10.5% vs 24.7 ± 6.1%, P < 0.0001) than those undergoing CRT-D implant procedures. During a median follow-up of 4 (2.8) years, 29 (14.5%) patients (14.7% in CRT-D vs 13.9% in CRT-P, P = 0.91) had died. HF was the cause of death in 73.9% of the patients. There was no difference in all-cause mortality between patients with CRT-D and CRT-P. CONCLUSIONS: Despite the proven benefits of CRT in selected HF patients, there continued to be under-utilization of these devices in HF patients in the Northern Region. Reasons for under-utilization of these devices need further exploration. These data should be useful for benchmarking individual patient management and national practice against wider experience in the country.

Inter-rater and intra-rater reliability and agreement of echocardiographic diagnosis of rheumatic heart disease using the World Heart Federation evidence-based criteria.

OBJECTIVE: Different definitions have been used for screening for rheumatic heart disease (RHD). This led to the development of the 2012 evidence-based World Heart Federation (WHF) echocardiographic criteria. The objective of this study is to determine the intra-rater and inter-rater reliability and agreement in differentiating no RHD from mild RHD using the WHF echocardiographic criteria. METHODS: A standard set of 200 echocardiograms was collated from prior population-based surveys and uploaded for blinded web-based reporting. Fifteen international cardiologists reported on and categorised each echocardiogram as no RHD, borderline or definite RHD. Intra-rater and inter-rater reliability was calculated using Cohen's and Fleiss' free-marginal multirater kappa (κ) statistics, respectively. Agreement assessment was expressed as percentages. Subanalyses assessed reproducibility and agreement parameters in detecting individual components of WHF criteria. RESULTS: Sample size from a statistical standpoint was 3000, based on repeated reporting of the 200 studies. The inter-rater and intra-rater reliability of diagnosing definite RHD was substantial with a kappa of 0.65 and 0.69, respectively. The diagnosis of pathological mitral and aortic regurgitation was reliable and almost perfect, kappa of 0.79 and 0.86, respectively. Agreement for morphological changes of RHD was variable ranging from 0.54 to 0.93 κ. CONCLUSIONS: The WHF echocardiographic criteria enable reproducible categorisation of echocardiograms as definite RHD versus no or borderline RHD and hence it would be a suitable tool for screening and monitoring disease progression. The study highlights the strengths and limitations of the WHF echo criteria and provides a platform for future revisions.

Gender differences in the use of primary prevention ICDs in New Zealand patients with heart failure.

OBJECTIVE: Women have been under-represented in randomised clinical trials for primary prevention implantable cardioverter defibrillators (ICDs), and there are concerns about the efficacy of devices between genders. Our study aimed to investigate gender differences in the use of primary prevention ICD in patients with heart failure from the northern region of New Zealand. METHODS: Patients with heart failure with systolic dysfunction who received primary prevention ICD/cardiac resynchronisation therapy-defibrillator (CRT-D) in the northern region of New Zealand from 1 January 2007 to 1 June 2015 were included. Complications, mortality and hospitalisation events were reviewed. RESULTS: Of the 385 patients with heart failure implanted with ICD/CRT-D, women comprised 15.1% (n=58), and no change in utilisation of these devices was observed over the study period among women. Women were more likely to have non-ischaemic cardiomyopathy and have higher perioperative complications (8.6% vs 2.5%, P=0.02), with non-significant higher trend towards increased lead displacement (5.2% vs 1.8%, P=0.12). Women appeared to have lower all-cause (10.3% vs 18.7%, P=0.12), cardiovascular (5.2% vs 11.9%, P=0.13) and heart failure (3.5% vs 7.9%, P=0.22) mortalities but was not statistically significant. There were no gender differences in all-cause (70.7% vs 67%, P=0.58) or heart failure (19% vs 25%, P=0.32) readmissions. CONCLUSION: Perioperative complications were significantly more common in women referred for ICD/CRT-D. Although there has been a significant increase in ICD implantation rates, gender differences in the use of these devices still exist in New Zealand, in keeping with the demographics of ischaemic heart disease and systolic dysfunction between genders.

Long-term outcomes of heart failure patients who received primary prevention implantable cardioverter-defibrillator: An observational study.

BACKGROUND: Implantable cardioverter-defibrillator (ICD) therapy is indicated for selected heart failure patients for the primary prevention of sudden cardiac death. Little is known about the outcomes in patients selected for primary prevention device therapy in the northern region of New Zealand. METHOD: Heart failure patients with systolic dysfunction who underwent primary prevention ICD/cardiac resynchronization therapy-defibrillator (CRT-D) implantation between January 1, 2007, and June 1, 2015, were included. Complications, mortality, and hospitalization events were reviewed. RESULTS: Three hundred and eighty-five primary prevention devices were implanted (269 ICD, 116 CRT-D). Mean age at implant was 59.1 ± 11.4 years. Mean duration of follow-up was 3.64 ± 2.17 years. The commonest cause of death was heart failure (41.8%). Only 2 patients died from sudden arrhythmic death. The 5-year heart failure mortality rate was 6%, whereas the 5-year sudden arrhythmic death rate was 0.3%. Heart failure hospitalizations were commoner in those who received ICD than CRT-D (67.7% vs 25.8%, P < .001). Maori patients have low implant rates (14%) with relatively high rates of admissions with heart failure and ventricular arrhythmia admissions. CONCLUSIONS: Even in appropriately selected heart failure patients who received primary prevention devices, only a small percentage died as a result of sudden arrhythmic death. CRT-D should be the device of choice where appropriate in heart failure patients. Significant challenges remain to improve access to device therapy and maximize benefit to those who do get implanted.

Management of coronary artery disease in patients on dialysis.

AIMS: Coronary artery disease is common in patients with end-stage renal failure (ESRF). However, there is little evidence that revascularisation improves outcomes, compared with medical management. This study assessed survival and cardiovascular outcomes in patients with ESRF undergoing coronary angiography and then having coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI) or medical management. METHODS: Survival and major adverse cardiac events (MACE) were examined in all patients with ESRF who underwent coronary angiography at Auckland City Hospital between 2003 and 2012. Outcomes of patients who underwent revascularisation (CABG or PCI) were compared with those managed medically. RESULTS: Two hundred and eighty-eight patients with ESRF had a total of 382 diagnostic coronary angiograms. Ninety-one (32%) patients underwent revascularisation (61 PCI, 30 CABG), with the other 197 (68%) treated medically or requiring no specific cardiac treatment. The median survival was 3.3 (IQR 2.1-5.3) years in patients undergoing CABG, 2.9 (IQR 1.5-5.4) years in patients treated with PCI and 2.9 (IQR 1.3-5.5) years in patients managed medically. There was no significant difference in survival between treatment modalities in the entire cohort, nor in the 108 patients with triple vessel disease. Similarly, there was no difference in the incidence of major adverse cardiac events, comparing medical management with revascularisation. CONCLUSION: There was no apparent survival advantage with revascularisation by either CABG or PCI, compared with medical management, in patients with ESRF undergoing coronary angiography. This study confirms the poor prognosis of patients with ESRF and coronary disease. Observational studies cannot control for all potential confounders; randomised trial data are needed to guide optimal management of this high-risk patient cohort.

Normal echocardiographic mitral and aortic valve thickness in children.

OBJECTIVE: We aimed to define the normal range of aortic and mitral valve thickness in healthy schoolchildren from a high prevalence rheumatic heart disease (RHD) region, using a standardised protocol for imaging and measurement. METHODS: Measurements were performed in 288 children without RHD. Anterior mitral valve leaflet (AMVL) thickness measurements were performed at the midpoint and tip of the leaflet in the parasternal long axis (PSLA) in diastole, when the AMVL was approximately parallel to the ventricular septum. Thickness of the aortic valve was measured from PSLA imaging in systole when the leaflets were at maximum excursion. The right coronary and non-coronary closure lines of the aortic valve were measured in diastole in parasternal short axis (PSSA) imaging. Results were compared with 51 children with RHD classified by World Heart Federation diagnostic criteria. RESULTS: In normal children, median AMVL tip thickness was 2.0 mm (IQR 1.7-2.4) and median AMVL midpoint thickness 2.0 mm (IQR 1.7-2.4). The median aortic valve thickness was 1.5 mm (IQR 1.3-1.6) in the PSLA view and 1.4 mm (IQR 1.2-1.6) in the PSSA view. The interclass correlation coefficient for the AMVL tip was 0.85 (0.71 to 0.92) and for the AMVL midpoint was 0.77 (0.54 to 0.87). CONCLUSIONS: We have described a standardised method for mitral and aortic valve measurement in children which is objective and reproducible. Normal ranges of left heart valve thickness in a high prevalence RHD population are established. These results provide a reference range for school-age children in high prevalence RHD regions undergoing echocardiographic screening.

Changes in high sensitivity troponin T in incident haemodialysis patients.

AIM: To characterise the changes in high sensitivity troponin T (hsTnT) in incident haemodialysis patients. BACKGROUND: Previous studies had shown that stable chronic haemodialysis patients have elevated cardiac troponin compared to the general population. Cardiac troponin on incident haemodialysis patients had not been characterised. METHODS: This prospective descriptive study included all patients who started haemodialysis in Auckland City Hospital over 18 months. A troponin level was measured prior to the commencement of their first haemodialysis session and regular pre-dialysis troponin levels are measured every two to four months. Each patient has two to four troponin measurements during the study with a minimum follow-up of six months. RESULTS: A total of 91 patients started on haemodialysis during this period. Fifty-five patients had two troponin measurements and 40 of these patients had four troponin measurements. The baseline median troponin level prior to commencement of dialysis was 91ng/L (54-191ng/L) and declined with subsequent measurements. There was a significant decrease in the 3rd and 4th troponin measurements compared to baseline troponin. The baseline troponin levels were not independently associated with mortality. The decrease in troponin levels did not correlate with a decline in weight. CONCLUSIONS: This is the first study to describe and show a decline in cardiac troponin post-initiation of haemodialysis. The baseline troponin measurements were not predictive of mortality.

Isolated tricuspid valve surgery at a single centre: the 47-year Auckland experience, 1965-2011.

OBJECTIVES: Isolated tricuspid valve surgery is not commonly performed with few studies and limited numbers published. We reviewed the characteristics and outcomes, including survival, reoperation rates and their predictors of different types of isolated tricuspid surgery. METHODS: Patients coded for isolated tricuspid valve surgery were identified from the Green Lane Hospital database. Relevant clinical characteristics were collected from both clinical and written clinical records. Mortality was checked against the national 'Births, Deaths and Marriages' database from the Ministry of Health. RESULTS: Seventy-two consecutive patients (48 ± 16 years; 71% women, body mass index 25 ± 6) underwent isolated tricuspid valve surgery from 1965 to 2011. Valve repair was performed in 53 and 47% had a valve replacement. The majority of these operations were performed in the last two decades. Early mortality within 30 days of operation was 7.9% for repair and 17.6% for replacement (P = 0.29). The 1-, 5-, 10- and 25-year survival rates were 83.8, 74.5, 63.6 and 32.8% for tricuspid repair and 81.8, 68.2, 61.4 and 15.2% for tricuspid replacement, respectively. Preoperative loop diuretic dose (P = 0.0120) and preoperative haemoglobin level (P = 0.0377) were independent predictors of survival for all isolated tricuspid surgery, while preoperative creatinine level (P = 0.04) independently predicted reoperation during the follow-up. CONCLUSIONS: Both isolated tricuspid replacement and repair were associated with significant but acceptable early and late mortality with no statistically significant difference in cumulative survival. Preoperative loop diuretic dose, haemoglobin and creatinine are individually associated with survival and/or reoperation after isolated tricuspid valve surgery.

Prognostic value and long-term variation of high sensitivity troponin T in clinically stable haemodialysis patients.

AIM: To provide data on the long-term prognostic relevance and variation of high sensitivity troponin T (hsTnT) in haemodialysis patients. METHODS: In 238 stable, asymptomatic haemodialysis patients from a single-centre hsTnT was measured at baseline, 18 and 22 months and outcomes assessed for 24 months. RESULTS: Baseline hsTnT was a significant predictor of all cause (+10 ng/l, HR 1.017, 95%CI 1.011-1.023, p<0.0001) and cardiovascular death (HR 1.02, 95%CI 1.013-1.0026, p<0.0001). HsTnT>140 ng/L was a strong predictor of cardiovascular mortality (HR 8.51, 95%CI 1.907-38.032; p<0.0001). HsTnT increased by >50% in less than one-third of patients, and doubled in only 10% of patients, during 18 and 22 months follow up. CONCLUSION: In clinically stable hemodialysis patients, higher hsTnT was associated with both total and CV mortality. In most patients variation in levels of hsTnT between 18 and 22 months was <50%, and on average the increase in hsTnT was small.

Effects of high and low fat dairy food on cardio-metabolic risk factors: a meta-analysis of randomized studies.

IMPORTANCE: Clear guidelines on the health effects of dairy food are important given the high prevalence of obesity, cardiovascular disease and diabetes, and increasing global consumption of dairy food. OBJECTIVE: To evaluate the effects of increased dairy food on cardio metabolic risk factors. DATA SOURCES: Searches were performed until April 2013 using MEDLINE, Science Direct, Google,Embase, the Cochrane Central Register of Controlled Trials, reference lists of articles, and proceedings of major meetings. STUDY SELECTION: Randomized controlled studies with healthy adults randomized to increased dairy food for more than one month without additional interventions. DATA EXTRACTION AND SYNTHESIS: A standard list was used to extract descriptive, methodological and key variables from all eligible studies. If data was not included in the published report corresponding authors were contacted. RESULTS: 20 studies with 1677 participants with a median duration of dietary change of 26 (IQR 10-39) weeks and mean increase in dairy food intake of 3.6 (SD 0.92) serves/day were included. Increased dairy food intake was associated with a modest weight gain (+0.59, 95% confidence interval 0.34 to 0.84kg, p<0.0001) but no significant change in waist circumference (0.35 , -0.75 to 1.45 cm); insulin resistance (HOMA ­IR -0.94 , -1.93 to 0.05 units); fasting glucose (0.87, -0.27 to 2.01 mg/dl); LDL-cholesterol (1.36 ,-2.38 to 5.09 mg/dl); HDL-cholesterol (0.45, -2.13 to 3.04 mg/dl); systolic (-0.13, -1.73 to 1.98 mmHg) and diastolic blood pressure (0.13, -1.73 to 1.98 mmHg) or C-reactive protein (-0.08, -0.63 to 0.48 mg/L). Results were similar for studies with low-fat and whole-fat dairy interventions. LIMITATIONS: Most clinical trials were small and of modest quality. . CONCLUSION: Increasing whole fat and low fat dairy food consumption increases weight but has minor effects on other cardio-metabolic risk factors. TRIAL REGISTRATION ACTRN: Australian New Zealand Clinical Trials Registry ACTRN12613000401752, http://www.anzctr.org.au. ETHICS APPROVAL NUMBER: NTX/10/11/115.

Do echocardiographic parameters predict mortality in patients with end-stage renal disease?

BACKGROUND: Left ventricular function predicts cardiovascular mortality both in the general population and those with end-stage renal disease. Echocardiography is commonly undertaken as a screening test before kidney transplantation; however, there are little data on its predictive power. METHODS: This was a retrospective review of patients assessed for renal transplantation from 2000 to 2009. A survival analysis using demographic and echocardiographic variables was undertaken using the Cox proportional hazards regression model. RESULTS: Of 862 patients assessed for transplantation, 739 had an echocardiogram and 217 of 739 (29%) died during a mean follow-up of 4.2 years. In a multivariate survival analysis, increased age (P<0.0001), diabetes (P<0.0001), transplant listing status (P<0.0001), severely impaired left ventricular function (P<0.01), pulmonary hypertension and/or right ventricular dysfunction (P=0.01), and regional wall motion abnormalities (P<0.01) were associated with all-cause mortality. Combined in a score where one point was given for the presence of each of the parameters above, these factors were strongly predictive of increased mortality with a hazard ratio of 3.57, 6.80, and 44.47 for the presence of one, two, or more factors, respectively, compared with the absence of any of these factors. CONCLUSIONS: In patients with end-stage renal disease, multiple easily determined echocardiographic parameters, including regional wall motion abnormalities and pulmonary hypertension and/or right ventricular dysfunction, were independently associated with all-cause and cardiovascular mortality. Combining these factors in a simple score may further assist in risk stratifying patients being considered for renal transplantation.

Evaluation of a novel sphygmomanometer, which estimates central aortic blood pressure from analysis of brachial artery suprasystolic pressure waves.

BACKGROUND: Central arterial pressure is a better predictor of adverse cardiovascular outcomes than brachial blood pressure, but noninvasive measurement by applanation tonometry is technically demanding. METHOD: Pulsecor R6.5 is a novel device adapted from a standard sphygmomanometer which estimates the central aortic pressure from analysis of low-frequency suprasystolic waveforms at the occluded brachial artery. A physics-based model, which simulates the arterial system using elastic, thin-walled tube elements and Navier-Stokes equations, is used to calculate arterial pressure and flow propagation. To determine the reliability of the device, we compared 94 central systolic pressures estimated by Pulsecor to the simultaneous directly measured central aortic pressures at the time of coronary angiography in 37 individuals. RESULTS: There was good correlation in central SBP between catheter measurements and Pulsecor estimates by either invasive or noninvasive calibration methods (r = 0.99, P < 0.0001 and r = 0.95, P < 0.0001, respectively). The mean difference in central systolic pressure was 2.78 (SD 3.90) mmHg and coefficient of variation was 0.03 when the invasive calibration method was used.When the noninvasive calibration method was used, the mean difference in central systolic pressure was 0.25 (SD 6.31) mmHg and coefficient of variation was 0.05. CONCLUSION: We concluded that Pulsecor R6.5 provides a simple and easy method to noninvasively estimate central SBP, which has highly acceptable accuracy.

Prevalence of airway and parenchymal abnormalities in newly diagnosed rheumatoid arthritis.

BACKGROUND: Pulmonary disease is a well recognised and important extra-articular manifestation of rheumatoid arthritis (RA). The objective of this study was to determine the prevalence of airway and parenchymal abnormalities in newly diagnosed patients with RA and to correlate these with clinical measures of RA severity and laboratory tests. METHODS: 60 patients with a new (symptom duration <12 months) diagnosis of RA (43 females, 42 European, mean age 54, 33 ever smoker, (17 current) underwent lung function testing and high resolution computed tomography (HRCT) scored by two independent radiologists. RESULTS: Eighteen (30%) patients reported respiratory symptoms: dyspnoea (11), cough (11), and wheeze (8). Twelve (20%) patients had physiologic evidence of airflow obstruction and 24 (40%) had reduced gas transfer. The prevalence of HRCT abnormalities (in any lobe) was as follows: decreased attenuation 67%, bronchiectasis 35%, bronchial wall thickening 50%, ground glass opacification 18%, reticular changes 12%. All abnormalities were more common in the lower lobes. With the exception of reduced DLCO, there were no significant differences in the prevalence of HRCT patterns or lung function parameters between smokers and non smokers. Anti-CCP antibodies and rheumatoid factor (RF) correlated strongly with DLCO and variably with other physiologic measures but poorly with radiologic abnormalities. CONCLUSION: Patients with newly diagnosed RA have a moderate prevalence of airway and parenchymal abnormalities on HRCT and lower than predicted lung function parameters which cannot entirely be explained by smoking. These data suggest that pulmonary involvement is present early in the disease course in RA.

The prevalence of depression among Maori patients in Auckland general practice.

INTRODUCTION: There has been concern over high rates of mental illness in Maori. Previous studies in general practice have had small sample sizes. AIM: To determine the prevalence of major depression among Maori patients in Auckland general practice using the CIDI and the PHQ as measurement tools. METHODS: This prevalence study is part of a larger randomised trial. The patients were recruited from 77 general practitioners from around Auckland who could provide a private room for interviewing. The patients were invited to participate in the waiting room and all consecutive patients were approached. For this study all patients received a computerised CIDI examination and one third received a PHQ assessment prior to getting the CIDI. The interviewer was blind to the questionnaire results when the patient did the CIDI. RESULTS: There were 7994 patients approached from whom there were data on 7432. The prevalence of Maori in the study was 9.7%. The overall 12-month prevalence of major depression based on the CIDI was 10.1% 95% CI (8.8 to 11.4). For Maori the prevalence was 11.5% 95% CI (8.8 to 14.2) and for non-Maori 10.1% 95% CI (8.6 to 11.3). For Maori men and Maori women the prevalence was 8.5% and 13.4% and for non-Maori men and non-Maori women it was 8.3% and 11.1%. The prevalence of depression over at least the previous two weeks on the PHQ > or = 9 for all participants was 12.9% 95% CI (11.2 to 14.5). DISCUSSION: The prevalence of depression among Maori is high, but not as high as earlier studies. This may be due to the bigger sample size of this study.