Utility of biomarkers in the differential diagnosis of heart failure in older people: findings from the heart failure in care homes (HFinCH) diagnostic accuracy study.

BACKGROUND: The performance of biomarkers for heart failure (HF) in older residents in long-term care is poorly understood and has not differentiated between left ventricular systolic dysfunction (LVSD) and HF with preserved ejection fraction (HFpEF). METHODS: This is the first diagnostic accuracy study in this population to assess the differential diagnostic performance and acceptability of a range of biomarkers against a clinical diagnosis using portable echocardiography. A total of 405 residents, aged 65-100 years (mean 84.2), in 33 UK long-term care facilities were enrolled between April 2009 and June 2010. RESULTS: For undifferentiated HF, BNP or NT-proBNP were adequate rule-out tests but would miss one in three cases (BNP: sensitivity 67%, NPV 86%, cut-off 115 pg/ml; NT-proBNP: sensitivity 62%, NPV 87%, cut-off 760 pg/ml). Using higher test cut-offs, both biomarkers were more adequate tests of LVSD, but would still miss one in four cases (BNP: sensitivity 76%, NPV 97%, cut-off 145 pg/ml; NT-proBNP: sensitivity 73%, NPV 97%, cut-off 1000 pg/ml). At these thresholds one third of subjects would test positive and require an echocardiogram. Applying a stricter 'rule out' threshold (sensitivity 90%), only one in 10 cases would be missed, but two thirds of subjects would require further investigation. Biomarkers were less useful for HFpEF (BNP: sensitivity 63%, specificity 61%, cut-off 110 pg/ml; NT-proBNP: sensitivity 68%, specificity 56%, cut-off 477 pg/ml). Novel biomarkers (Copeptin, MR-proADM, and MR-proANP) and common signs and symptoms had little diagnostic utility. CONCLUSIONS: No test, individually or in combination, adequately balanced case finding and rule-out for heart failure in this population; currently, in-situ echocardiography provides the only adequate diagnostic assessment. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN19781227.

Heroin users' experiences of depression: a qualitative study.

BACKGROUND: Heroin users represent a challenging group of patients for GPs, with a high morbidity including a high prevalence of depression. Compared to other groups, management of 'depression' in heroin users is likely to require different approaches. Aim. To examine heroin users' beliefs about connections between depressive symptoms and drug taking. DESIGN: Qualitative. SETTING: Primary care. METHODS: A total of 17 semi-structured interviews were conducted with patients receiving opioid substitution therapy and antidepressants. One focus group of service users was also interviewed. RESULTS: A wide range of thoughts and emotions were described as 'depression'. Adverse childhood events were viewed as both the cause of depression and as simultaneously placing the individual in social circles where drug use was common. Drug taking was thought to lead to depression through resultant adverse social consequences, though illicit drug use was also regarded as an understandable way to cope with depression. Examples of stigma from taking drugs were commonly described and thought a cause of depression; in contrast, stigmatizing effects of depression were not apparent. The participants often felt isolated. Beliefs about how antidepressants worked incorporated ideas about blocking out thoughts, stopping thoughts racing and keeping emotions level. Self-management techniques for treating depression were rarely described. CONCLUSIONS: Heroin users' experiences of depression-including ideas about causation, how symptoms are felt and experienced and treatment strategies-are overwhelmingly framed by the context of drug taking.

The impact of nutritional status on the outcome of Indian patients undergoing neurosurgical shunt surgery.

Undernutrition is common in surgical patients, is frequently unrecognised and is strongly associated with adverse outcomes such as high rates of complications and mortality, worsening functional status and prolonged hospitalisation. Owing to the associated infection and symptoms such as repeated vomiting, a high prevalence of undernutrition is expected in hydrocephalus patients, which may contribute to their poor surgical outcomes. The aim of this study was to evaluate the influence of preoperative nutritional status on the outcome of Indian patients with hydrocephalus undergoing neurosurgical shunt surgery. One hundred and twenty-four consecutive patients undergoing scheduled hydrocephalus shunt surgery were studied prospectively. All patients underwent nutritional screening according to different parameters prior to surgery. The patients were classified into normally nourished and undernourished groups. The undernourished group was further subdivided into moderately and severely undernourished. The surgical outcome was compared between these groups. A high prevalence (53%) of undernutrition was observed in these patients. Postoperative complications such as shunt infection (P = 0.0023), shunt revision (P = 0.0074) and mortality (P = 0.0003) were significantly more common in undernourished patients compared with normally nourished patients. Serum albumin emerged as the most significant independent predictor of postoperative mortality. The present study demonstrated a high prevalence of undernutrition in hydrocephalus patients in India and its adverse influence on the outcome of shunt surgery. Early preoperative nutritional status screening and its optimisation may decrease the morbidity and mortality of shunt surgery for hydrocephalus.

Coxiella burnetii infection of an aortic graft with multiple vertebral body erosion.

Q fever is caused by Coxiella burnetii and often has an insidious clinical presentation. We describe a rare case of Q fever infection of an aortic graft presenting with pyrexia and constant severe midlumbar pain due to erosion of multiple vertebral bodies. After successful treatment with graft resection and extra-anatomic vascular reconstruction, the patient continues on lifelong antibiotic therapy. We also present regional Q fever epidemiologic data together with a review of all previously documented cases of Q fever infections of vascular prostheses.