Sex differences in the clinical presentation and natural history of dilated cardiomyopathy

Background Biological sex has a diverse impact on the cardiovascular system. Its influence on dilated cardiomyopathy (DCM) remains unresolved. Objectives This study aims to investigate sex-specific differences in DCM presentation, natural history, and prognostic factors. Methods We conducted a prospective observational cohort study of DCM patients assessing baseline characteristics, cardiac magnetic resonance imaging, biomarkers, and genotype. The composite outcome was cardiovascular mortality or major heart failure (HF) events. Results Overall, 206 females and 398 males with DCM were followed for a median of 3.9 years. At baseline, female patients had higher left ventricular ejection fraction, smaller left ventricular volumes, less prevalent mid-wall myocardial fibrosis (23% vs 42%), and lower high-sensitivity cardiac troponin I than males (all P < 0.05) with no difference in time from diagnosis, age at enrollment, N-terminal pro-B-type natriuretic peptide levels, pathogenic DCM genetic variants, myocardial fibrosis extent, or medications used for HF. Despite a more favorable profile, the risk of the primary outcome at 2 years was higher in females than males (8.6% vs 4.4%, adjusted HR: 3.14; 95% CI: 1.55-6.35; P = 0.001). Between 2 and 5 years, the effect of sex as a prognostic modifier attenuated. Age, mid-wall myocardial fibrosis, left ventricular ejection fraction, left atrial volume, N-terminal pro-B-type natriuretic peptide, high-sensitivity cardiac troponin I, left bundle branch block, and NYHA functional class were not sex-specific prognostic factors. Conclusions We identify a novel paradox in prognosis for females with DCM. Female DCM patients have a paradoxical early increase in major HF events despite less prevalent myocardial fibrosis and a milder phenotype at presentation. Future studies should interrogate the mechanistic basis for these sex differences

The costs of training a nurse practitioner in primary care: the importance of allowing for the cost of education and training when making decisions about changing the professional

What is already known on this topic • Cost containment through the most effective mix of staff achievable within available resources and organisational priorities is of increasing importance in most health systems. However, there is a dearth of information about the full economic implications of changing skill mix. • In the UK a major shift in the primary care workforce is likely in response to the rapidly developing role of nurse practitioners and policies aimed to encourage GP practices to transfer some of their responsibilities to other, less costly, professionals. • Previous research has developed an approach to incorporating the costs of qualifications, and thus the investment required to develop a skilled workforce, for a variety of health service professionals including GPs. What this study adds • This paper describes a methodology of costing nurse practitioners that incorporates the human capital cost implications of developing a skilled nurse practitioner workforce. With appropriate sources of data the method could be adapted for use internationally. • Including the full cost of qualifications results in nearly a 24 per cent increase in the unit cost of a Nurse Practitioner. • Allowing for all investment costs and adjusting for length of consultation, the cost of a GP consultation was nearly 60 per cent higher than that of a Nurse Practitione

Endonuclease G is a novel determinant of cardiac hypertrophy and mitochondrial function

10.1038/nature10490Nature4787367114-11