Inflation of 430-parsec bipolar radio bubbles in the Galactic Centre by an energetic event.

The Galactic Centre contains a supermassive black hole with a mass of four million Suns1 within an environment that differs markedly from that of the Galactic disk. Although the black hole is essentially quiescent in the broader context of active galactic nuclei, X-ray observations have provided evidence for energetic outbursts from its surroundings2. Also, although the levels of star formation in the Galactic Centre have been approximately constant over the past few hundred million years, there is evidence of increased short-duration bursts3, strongly influenced by the interaction of the black hole with the enhanced gas density present within the ring-like central molecular zone4 at Galactic longitude |l| < 0.7 degrees and latitude |b| < 0.2 degrees. The inner 200-parsec region is characterized by large amounts of warm molecular gas5, a high cosmic-ray ionization rate6, unusual gas chemistry, enhanced synchrotron emission7,8, and a multitude of radio-emitting magnetized filaments9, the origin of which has not been established. Here we report radio imaging that reveals a bipolar bubble structure, with an overall span of 1 degree by 3 degrees (140 parsecs × 430 parsecs), extending above and below the Galactic plane and apparently associated with the Galactic Centre. The structure is edge-brightened and bounded, with symmetry implying creation by an energetic event in the Galactic Centre. We estimate the age of the bubbles to be a few million years, with a total energy of 7 × 1052 ergs. We postulate that the progenitor event was a major contributor to the increased cosmic-ray density in the Galactic Centre, and is in turn the principal source of the relativistic particles required to power the synchrotron emission of the radio filaments within and in the vicinity of the bubble cavities.

Rail or roll: a new, convenient and safe way to position self-gripping meshes in open inguinal hernia repair.

PURPOSE: In open inguinal hernia repair self-gripping meshes are currently commonly employed. Assumed benefits are saving of time, ease of handling and omission of fixation. Self-gripping meshes are, however, not as easy to handle and position as commonly stated. We describe a newly developed way of intra-operative mesh preparation and implantation and compare it to the conventional technique of insertion of self-gripping meshes. METHODS: A two-armed, randomized trial with 64 patients was performed. For implantation of the self-gripping, light weight and partially absorbable mesh we used either a newly described rolling technique (group 1: n = 32) or the conventional way of insertion (group 2: n = 32). Primary endpoints of the study were feasibility with regard to actual implantation time and surgeons' satisfaction with the methods. Secondary endpoints were total operating time, length of hospital stay, postoperative pain, duration of pain medication intake and postoperative morbidity. In addition all patients were prospectively followed up according to the Hernia Med® registry's standards. RESULTS: Implantation time (seconds) 140 ± 74 vs. 187 ± 84, p = 0.008, duration of pain medication intake (days) 3.6 ± 2.8 vs. 4.8 ± 2.6; p = 0.046 and postoperative morbidity 2 (6%) vs. 8 (25%) was significantly beneficial in group 1 (rolling technique) compared to group 2 (conventional method). Blinded questionnaire revealed that rolling the mesh is generally easier with less repositioning maneuvers than conventional placement. Neither overall procedure time, length of stay nor postoperative pain scores differed significantly between groups. CONCLUSION: The newly introduced rolling technique for the actual placement of self-gripping meshes in open inguinal hernia repair is technically less demanding and therefore significantly faster when compared to the conventional way of insertion of the same product. In addition the rolling technique has shown to be safe for the patients and to also provide higher surgeons' satisfaction.

Delayed onset of graft-versus-host disease in immunodeficent human leucocyte antigen-DQ8 transgenic, murine major histocompatibility complex class II-deficient mice repopulated by human peripheral blood mononuclear cells.

Haematopoietic humanization of mice is used frequently to study the human immune system and its reaction upon experimental intervention. Immunocompromised non-obese diabetic (NOD)-Rag1(-/-) mice, additionally deficient for the common gamma chain of cytokine receptors (γc) (NOD-Rag1(-/-) γc(-/-) mice), lack B, T and natural killer (NK) cells and allow for efficient human peripheral mononuclear cell (PBMC) engraftment. However, a major experimental drawback for studies using these mice is the rapid onset of graft-versus-host disease (GVHD). In order to elucidate the contribution of the xenogenic murine major histocompatibility complex (MHC) class II in this context, we generated immunodeficient mice expressing human MHC class II [human leucocyte antigen (HLA)-DQ8] on a mouse class II-deficient background (Aß(-/-) ). We studied repopulation and onset of GVHD in these mouse strains following transplantation of DQ8 haplotype-matched human PBMCs. The presence of HLA class II promoted the repopulation rates significantly in these mice. Virtually all the engrafted cells were CD3(+) T cells. The presence of HLA class II did not advance B cell engraftment, such that humoral immune responses were undetectable. However, the overall survival of DQ8-expressing mice was prolonged significantly compared to mice expressing mouse MHC class II molecules, and correlated with an increased time span until onset of GVHD. Our data thus demonstrate that this new mouse strain is useful to study GVHD, and the prolonged animal survival and engraftment rates make it superior for experimental intervention following PBMC engraftment.

On the polymerization of hexavalent uranium. An electrospray mass spectrometry study.

Polymerization in hexavalent uranium solutions was measured by electrospray ionization time-of-flight mass spectrometry in three different acidic media at pH values from 3 to 5.3 in order to detect all hydrolysis species present in solution. The aqueous solutions were directly measured without further dilution in organic solvents. At high uranyl concentrations ([U(VI)] = 10(- 3) M) artifacts were observed due to the presence of more than one solution species per formed microdroplet. Those artifacts were composed of ions and neutral species being present in the same droplet. However, by analyzing the detected species carefully, the origin of the artifacts could be traced back to the physically meaningful species. Still, only general trends of the hydrolysis behavior can be deduced from the measurements at [U(VI)] = 1 ⋅ 10(- 3) M. The solutions at [U(VI)] = 5 ⋅ 10(- 5) M did not show any comparable artifact formation. The detected species distributions resemble the expected trends calculated from the equilibrium constants published in the Nuclear Energy Agency Thermodynamic Database (NEA-TDB). The neutral (UO(2))(CO(3))(0) species present in solution causes, if located in the same microdroplet as a charged species, the apparent formation of dimeric and trimeric ternary hydroxo carbonate complexes at pH 5.3. As the uncharged species is not repelled from the ionic species, it might remain in the same droplet during the droplet fission process. By dividing those detected species into the uncharged (UO(2))(CO(3))(0) and a second ionic species, the relative abundances of the solution species can be corrected, leading to a good agreement with the predictions of the published equilibrium constants. In addition to the well-known trimer, we report the direct mass spectrometric detection of the dimeric (UO(2))(2)(OH)(2)(2+) species.

[Differential diagnosis of CRPS from a dermatologist's viewpoint]. / Differenzialdiagnose des CRPS aus dermatologischer Sicht.

Because of clinical similarities many dermatological diseases must be differentiated from both the acute and chronic phases of the complex regional pain syndrome (CRPS). The differential diagnosis of CRPS in the acute phase includes erythema migrans, early inflammatory lesions of acrodermatitis chronica atrophicans, hypodermitis in chronic venous insufficiency, eosinophilic fasciitis, erythromelalgia and an acute contact dermatitis. The chronic phase of CRPS with trophic disturbances of the skin, joints, and bones needs to be distinguished from the atrophic stage of acrodermatitis chronica atrophicans, dermatoliposclerosis and scleroderma.

[The light-adjustable lens. Principles and clinical application]. / Die lichtadjustierbare Linse. Grundlagen und klinische Anwendung.

Despite improvements in preoperative lens power calculations many patients are in need of spectacle correction to achieve emmetropia and/or optimal distance vision after cataract surgery. A method to adjust residual spherical and astigmatic errors postoperatively in a predictable and non-invasive way is the implantation of the light-adjustable lens (LAL). Selective irradiation of the LAL with UV light (365 nm) using a digital light delivery device enables a customized light pattern for each patient which produces modifications in the lens curvature and lens power by polymerization of silicon monomers in the lens matrix. In Europe this therapeutic option is currently only available in Spain and Germany, therefore, the number of patients treated is limited. In the future this technique will be available for correction of higher order aberrations and to design individual multifocality.

Quantification of left-to-right shunting in adult congenital heart disease: phase-contrast cine MRI compared with invasive oximetry.

Atrial septum defects (ASDs), ventricular septum defects (VSDs) and patent ductus arteriosus (PDA) are the most common adult congenital heart defects. The degree of left-to-right shunting as assessed by the ratio of flow in the pulmonary (Qp) and systemic circulation (Qs) is crucial in the management of these conditions. This study compared phase-contrast cine magnetic resonance imaging (PC-MRI), a non-invasive imaging technique, with invasive oximetry for the measurement of shunt volumes during cardiac catheterisation in adults with left-to-right shunting. Both invasive oximetry and shunt quantification by PC-MRI (1.5 T scanner; Sonata, Siemens Medical Solutions) were performed on 21 patients with left-to-right shunting (14 ASD, 5 VSD, 2 PDA) and data on Qp/Qs ratios and left-to-right shunt fraction compared. Mean Qp/Qs ratios assessed by PC-MRI and oximetry were 2.10+/-0.76 and 1.96+/-0.77, respectively (p = 0.37). Mean shunt fraction was 46.3+/-19.6% when calculated by PC-MRI and 42.3+/-20.1% when obtained by oximetry (p = 0.12). There was a strong correlation of Qp/Qs ratios and shunt fraction between both methods (r = 0.61, p < 0.01 and r = 0.84, p < 0.0001, respectively). The two methods had a good agreement according to Bland and Altman plots with a small but non-significant overestimation of Qp/Qs-ratios and shunt fraction by PC-MRI. On receiver operating characteristic analysis, the sensitivity and specificity of PC-MRI to detect an oximetry-derived Qp/Qs ratio of > or =1.5:1 were 93% and 100% at a PC-MRI threshold of a Qp/Qs ratio > or =1.75:1 (area under curve (AUC) = 0.99). Quantification of left-to-right shunting can be performed reliably and accurately by PC-MRI and the data obtained by this method correlate closely to those from invasive oximetry.

Unicuspid aortic valve disease: a magnetic resonance imaging study.

PURPOSE: Congenitally malformed aortic valves are a common finding in adults with aortic valve disease. Most of these patients have bicuspid aortic valve disease. Unicuspid aortic valve disease (UAV) is rare. The aim of our study was to describe valve morphology and the dimensions of the proximal aorta in a cohort of 12 patients with UAV in comparison to tricuspid aortic valve disease (TAV) using magnetic resonance imaging (MRI). MATERIALS AND METHODS/RESULTS: MRI studies were performed on a 1.5 T scanner in a total of 288 consecutive patients with aortic valve disease. 12 aortic valves were retrospectively classified as UAV. Annulus areas and dimensions of the thoracic aorta were retrospectively compared to a cohort of 103 patients with TAV. In UAV, valve morphology was unicuspid unicommissural with a posterior commissure in all patients. Mean annulus areas and mean diameters of the ascending aorta were significantly greater in UAV compared to TAV (12.6 +/- 4.7 cm (2) vs. 8.7 +/- 2.3 cm (2), p < 0.01 and 4.6 +/- 0.7 cm vs. 3.6 +/- 0.5 cm, p < 0.0001, respectively), while no differences were observed in the mean diameters of the aortic arch (2.3 +/- 0.6 cm vs. 2.3 +/- 0.4 cm, p = 0.69). The diameters of the descending aorta were slightly smaller in UAV compared to TAV (2.2 +/- 0.5 cm vs. 2.6 +/- 0.3 cm, p < 0.05). CONCLUSION: In UAV, visualization of valve morphology by MRI is possible with good image quality. Valve morphology was classified as unicuspid unicommissural in all UAV patients. Dilatation of the proximal aorta > 4.5 cm is a frequent finding in UAV. Additional assessment of aortic dimensions is therefore recommended in patients with UAV.

Size dispersion and colloid mediated radionuclide transport in a synthetic porous media.

Size dispersion effects during the migration of natural submicron bentonite colloids (<200 nm) through a ceramic column are observed for the first time by laser-induced breakdown detection (LIBD) at ppm (parts per million) mass concentration. Larger size fractions ( approximately 200 nm) arrive prior to smaller size fractions (<100 nm) at the column outlet in agreement with model predictions and earlier findings with carboxylated polystyrene spheres. By addition of trace amounts of americium(III) and plutonium(IV), colloid mediated transport of these radionuclides is studied. The peak arrival times of Pu-244 and Am-241, as measured by ICP-MS, match the bentonite colloid breakthrough and occur significantly prior to the conservative tracer (HTO) indicating the colloid-borne migration of tri- and tetravalent radionuclides.

Assessment of the anatomic regurgitant orifice in aortic regurgitation: a clinical magnetic resonance imaging study.

BACKGROUND: The aim of our study was to determine whether planimetry of the anatomic regurgitant orifice (ARO) in patients with aortic regurgitation (AR) by magnetic resonance imaging (MRI) is feasible and whether ARO by MRI correlates with the severity of AR. METHODS AND RESULTS: Planimetry of ARO by MRI was performed on a clinical magnetic resonance system (1.5 T Sonata, Siemens Medical Solutions) in 45 patients and correlated with the regurgitant fraction (RgF) and regurgitant volume (RgV) determined by MRI phase velocity mapping (PVM; MRI-RgF, MRI-RgV, n = 45) and with invasively quantified AR by supravalvular aortography (n = 32) and RgF upon cardiac catheterisation (CATH-RgF, n = 15). Determination of ARO was possible in 98% (44/45) of the patients with adequate image quality. MRI-RgF and CATH-RgF were modestly correlated (n = 15, r = 0.71, p<0.01). ARO was closely correlated with MRI-RgF (n = 44, r = 0.88, p<0.001) and was modestly correlated with CATH-RgF (n = 14, r = 0.66, p = 0.01). Sensitivity and specificity of ARO to detect moderately severe and severe aortic regurgitation (defined as MRI-RgF > or =40%) were 96% and 95% at a threshold of 0.28 cm2 (AUC = 0.99). Of note, sensitivity and specificity of ARO to detect moderately severe and severe AR at catheterisation (defined as CATH-RgF > or =40% or supravalvular aortography > or =3+) were 90% and 91% at a similar threshold of 0.28 cm2 (AUC = 0.95). Lastly, sensitivity and specificity of ARO to detect severe aortic regurgitation (defined as MRI-RgF > or =50% and/or regurgitant volume > or =60 ml) were 83% and 97% at a threshold of 0.48 cm2 (AUC = 0.97). CONCLUSIONS: Visualisation and planimetry of the ARO in patients with AR are feasible by MRI. There is a strong correlation of ARO with RgV and RgF assessed by PVM and with invasively graded AR at catheterisation. Therefore, determination of ARO by MRI is a new non-invasive measure for assessing the severity of AR.

[Toric phakic intraocular lenses]. / Torische phake Intraokularlinsen.

After more than 3 years of follow-up, the satisfactory results achieved with the toric iris-fixated phakic intraocular lens (IOL) mean we can regard implantation of this lens as a procedure with the potential to provide safe, predictable, effective and stable correction of astigmatic errors, providing patients are carefully selected and receive adequate preparation for surgery. The iris-fixated toric phakic IOL (Verisyse, Advanced Medical Optics; Artisan, Ophtec) is a PMMA lens with a total diameter of 8.5 mm and an optic diameter of 5 mm. It has a spherical anterior and a toric posterior surface. Its refractive power ranges from -2 dpt to -21 dpt for myopia and from +2 dpt to +12.5 dpt for the correction of hyperopia. Cylindrical correction is available from 2 dpt to 7.5 dpt. The Visian toric implantable Collamer lens (Staar) differs in that it is foldable and can be inserted through a very small incision of about 2.8 mm. It is placed in front of the natural lens in the ciliary sulcus. The aim of implanting these phakic IOLs is to correct the entire refractive error, meaning both the spherical and the astigmatic error, in a single step. Different lens models are available, and the selection depends on the direction of the cylinder axis and the anatomical situation, among other things.

[Schnitzler's syndrome with urticaria vasculitis]. / Schnitzler-Syndrom mit Urtikaria-Vaskulitis.

Schnitzler's syndrome is a rare disease characterized by the association of chronic urticaria, intermittent fever, bone pain, arthritis, and monoclonal IgM gammopathy. It was first described by the French dermatologist Liliane Schnitzler in 1974. Because of the variety of clinical signs, the syndrome is of concern to doctors of different specialties and is of special interest to internists, rheumatologists, hematologists and dermatologists. Up to now, treatment was often difficult and disappointing. Interleukin-1 receptor antagonists offer a new therapeutic option.

[MR imaging and MR spectroscopy for characterization of cardiomyopathies in adolescents - preliminary results]. / MR-Bildgebung und MR-Spektroskopie zur Charakterisierung von Kardiomyopathien bei Jugendlichen - erste Ergebnisse.

PURPOSE: Cardiomyopathy is a rare but life-threatening disease in children and adolescents. Recent studies reported morphological, functional or metabolic alterations of the heart. We discuss a combined MR imaging and (31)P MR spectroscopy (MRS) protocol allowing the analysis of interdependencies between these parameters. Since normal values of cardiac MR parameters in this age group are not available, we included studies of age-matched healthy adolescents. MATERIALS AND METHODS: 2D-CINE was used to assess left ventricular (LV) parameters. Additional 3D-Chemical Shift Imaging (3D-CSI) and Spectral Localization with Optimal Pointspread Function (SLOOP) reconstruction allowed quantification of the cardiac energy metabolism. Patients (n = 4; all male; age 16.8 +/- 2.9 years) were included on the basis of an echocardiographic diagnosis of possible cardiomyopathy. The same protocol was applied to healthy young volunteers (n = 4; 1 female, 3 male; age 15.5 +/- 0.6 years). RESULTS: The patients had a significantly higher LV mass index compared to the control group (147 +/- 41 g/m (2) versus 97 +/- 16 g/m2; p = 0.04). The other LV parameters (including LV EF with 59 +/- 22 % versus 67 +/- 10 %) showed no significant differences. The phosphocreatine to adenosine triphosphate ratio (PCr/ATP-ratio) of the patients was reduced to 1.71 +/- 0.40 versus 2.44 +/- 0.30 (p = 0.01), combined with a tendency towards decreased PCr concentrations of 9.1 +/- 2.5 versus 7.9 +/- 1.0 mmol/kg. CONCLUSION: The combination of (31)P MR spectroscopy and MR imaging allows quantitative determination of morphologic, functional and metabolic alterations in adolescents with suspected cardiomyopathy in one examination procedure. The reduction of energy metabolism combined with unaltered global function may indicate a primary role of metabolism in the pathogenesis of cardiomyopathies in adolescents.

Swiss recommendations for the management of varicella zoster virus infections.

Infections with varicella zoster virus (VZV) are common viral infections associated with significant morbidity. Diagnosis and management are complex, particularly in immunocompromised patients and during pregnancy. The present recommendations have been established by a multidisciplinary panel of specialists and endorsed by numerous Swiss medical societies involved in the medical care of such patients (Appendix). The aim was to improve the care of affected patients and to reduce complications.

MR Imaging in Anderson-Fabry Disease: What Are We Expected to Find?

Anderson-Fabry disease (FD) is a genetic disorder of glycosphingolipid metabolism that can involve CNS and is easily detectable with MRI. We reviewed 32 MRI performed in ten patients to detect an eventual specific pattern of the disease suggesting that finding vascular lesions in young adults must be addressed to diagnose different pathologies including FD.

MRI planimetry for diagnosis and follow-up of valve area in mitral stenosis treated with valvuloplasty.

PURPOSE: We sought to determine whether noninvasive planimetry by magnetic resonance imaging (MRI) is suitably sensitive and reliable for visualizing the mitral valve area (MVA) and for detecting increases in the MVA after percutaneous balloon mitral valvuloplasty (PBMV). MATERIALS AND METHODS: In 8 patients with mitral valve stenosis, planimetry of the MVA was performed before and after PBMV with a 1.5 T MR scanner using a breath-hold balanced gradient echo sequence (True FISP). The data was compared to the echocardiographically determined MVA (ECHO-MVA) as well as to the invasively calculated MVA by the Gorlin formula at catheterization (CATH-MVA). RESULTS: PBMV was associated with an increase of 0.79 +/- 0.30 cm (2) in the MVA (Delta MRI-MVA). The correlation between Delta MRI-MVA and Delta CATH-MVA was 0.92 (p < 0.03) and that between Delta MRI-MVA and Delta ECHO-MVA was 0.90 (p < 0.04). The overall correlation between MRI-MVA and CATH-MVA was 0.95 (p < 0.0001) and that between MRI-MVA and ECHO-MVA was 0.98 (p < 0.0001). MRI-MVA slightly overestimated CATH-MVA by 8.0 % (1.64 +/- 0.45 vs. 1.51 +/- 0.49 cm (2), p < 0.01) and ECHO-MVA by 1.8 % (1.64 +/- 0.45 vs. 1.61 +/- 0.43 cm (2), n. s.). CONCLUSION: Magnetic resonance planimetry of the mitral valve orifice is a sensitive and reliable method for the noninvasive quantification of mitral stenosis and visualization of small relative changes in the MVA. This new method is therefore capable of diagnosing as well as following the course of mitral stenosis. It must be taken into consideration that planimetry by MRI slightly overestimates the MVA as compared to cardiac catheterization.

Delayed hyperenhancement in magnetic resonance imaging of left ventricular hypertrophy caused by aortic stenosis and hypertrophic cardiomyopathy: visualisation of focal fibrosis.

OBJECTIVE: To compare the extent and distribution of focal fibrosis by gadolinium contrast-enhanced magnetic resonance imaging (MRI; delayed hyperenhancement) in severe left ventricular (LV) hypertrophy in patients with pressure overload caused by aortic stenosis (AS) and with genetically determined hypertrophic cardiomyopathy (HCM). METHODS: 44 patients with symptomatic valvular AS (n = 22) and HCM (n = 22) were studied. Cine images were acquired with fast imaging with steady-state precession (trueFISP) on a 1.5 T scanner (Sonata, Siemens Medical Solutions). Gadolinium contrast-enhanced MRI was performed with a segmented inversion-recovery sequence. The location, extent and enhancement pattern of hyperenhanced myocardium was analysed in a 12-segment model. RESULTS: Mean LV mass was 238.6 (SD 75.3) g in AS and 205.4 (SD 80.5) g in HCM (p = 0.17). Hyperenhancement was observed in 27% of patients with AS and in 73% of patients with HCM (p < 0.01). In AS, hyperenhancement was observed in 60% of patients with a maximum diastolic wall thickness >or= 18 mm, whereas no patient with a maximum diastolic wall thickness < 18 mm had hyperenhancement (p < 0.05). Patients with hyperenhancement had more severe AS than patients without hyperenhancement (aortic valve area 0.80 (0.09) cm(2)v 0.99 (0.3) cm(2), p < 0.05; maximum gradient 98 (22) mm Hg v 74 (24) mm Hg, p < 0.05). In HCM, hyperenhancement was predominant in the anteroseptal regions and patients with hyperenhancement had higher end diastolic (125.4 (36.9) ml v 98.8 (16.9) ml, p < 0.05) and end systolic volumes (38.9 (18.2) ml v 25.2 (1.7) ml, p < 0.05). The volume of hyperenhancement (percentage of total LV myocardium), where present, was lower in AS than in HCM (4.3 (1.9)% v 8.6 (7.4)%, p< 0.05). Hyperenhancement was observed in 4.5 (3.1) and 4.6 (2.7) segments in AS and HCM, respectively (p = 0.93), and the enhancement pattern was mostly patchy with multiple foci. CONCLUSIONS: Focal scarring can be observed in severe LV hypertrophy caused by AS and HCM, and correlates with the severity of LV remodelling. However, focal scarring is significantly less prevalent in adaptive LV hypertrophy caused by AS than in genetically determined HCM.

NT-ProBNP in outpatients after myocardial infarction: interaction between symptoms and left ventricular function and optimized cut-points.

BACKGROUND: N-terminal pro-brain natriuretic peptide (NT-proBNP) allows us to rule out left ventricular dysfunction (LVD) in the general population at a recommended cut-off concentration of 125 pg/mL. It was our objective to reassess this cut-point in outpatients after myocardial infarction. METHODS AND RESULTS: NT-proBNP was assessed in 418 randomly selected outpatients who had experienced myocardial infarction and 352 siblings who had not experienced myocardial infarction (control). Left ventricular ejection fraction (LVEF) and mass-index (LVMI) were assessed by echocardiography. NT-proBNP was elevated in outpatients after myocardial infarction (mean [+/-SEM], 305 +/- 25 pg/mL vs control, 84 +/- 8 pg/mL; P < .01) and was correlated inversely with LVEF ( P < .001). When patients were stratified according to the presence or absence of heart failure, NT-proBNP was elevated significantly throughout all LVEF strata (each P < .05). On regression analysis, NT-proBNP was correlated independently with LVEF, LVMI, heart failure, and glomerular filtration rate (all P < .01). In patients with heart failure, the optimal cut-point for the detection of an LVEF <35% was 348 pg/mL (sensitivity 80%; specificity 69%) and for the detection of an LVEF <45% was 260 pg/mL (sensitivity 60%; specificity 60%). The relative risk for LVD in the presence of elevated NT-proBNP increased from 2.7 to 7.7 (EF < 35%) and from 1.4 to 2.4 (EF < 45%) when these cut-points were applied instead of the 125 pg/mL cut-point. An LVEF of <35% could be ruled out in symptomatic outpatients after myocardial infarction with a negative predictive value of 97% (cut-point 348 pg/mL) and in asymptomatic outpatients after myocardial infarction with a negative predictive value of 98% (cut-point 157 pg/mL). CONCLUSION: NT-proBNP is higher in outpatients after myocardial infarction than in the general population. In symptomatic patients, a cut-point of 348 pg/mL yields satisfactory sensitivity and specificity for the detection of significant LVD (EF < 35%). Furthermore, significant LVD can be virtually ruled out in symptomatic and asymptomatic outpatients after myocardial infarction at below-threshold concentrations.