Effect of nesiritide in patients with acute decompensated heart failure.

BACKGROUND: Nesiritide is approved in the United States for early relief of dyspnea in patients with acute heart failure. Previous meta-analyses have raised questions regarding renal toxicity and the mortality associated with this agent. METHODS: We randomly assigned 7141 patients who were hospitalized with acute heart failure to receive either nesiritide or placebo for 24 to 168 hours in addition to standard care. Coprimary end points were the change in dyspnea at 6 and 24 hours, as measured on a 7-point Likert scale, and the composite end point of rehospitalization for heart failure or death within 30 days. RESULTS: Patients randomly assigned to nesiritide, as compared with those assigned to placebo, more frequently reported markedly or moderately improved dyspnea at 6 hours (44.5% vs. 42.1%, P=0.03) and 24 hours (68.2% vs. 66.1%, P=0.007), but the prespecified level for significance (P≤0.005 for both assessments or P≤0.0025 for either) was not met. The rate of rehospitalization for heart failure or death from any cause within 30 days was 9.4% in the nesiritide group versus 10.1% in the placebo group (absolute difference, -0.7 percentage points; 95% confidence interval [CI], -2.1 to 0.7; P=0.31). There were no significant differences in rates of death from any cause at 30 days (3.6% with nesiritide vs. 4.0% with placebo; absolute difference, -0.4 percentage points; 95% CI, -1.3 to 0.5) or rates of worsening renal function, defined by more than a 25% decrease in the estimated glomerular filtration rate (31.4% vs. 29.5%; odds ratio, 1.09; 95% CI, 0.98 to 1.21; P=0.11). CONCLUSIONS: Nesiritide was not associated with an increase or a decrease in the rate of death and rehospitalization and had a small, nonsignificant effect on dyspnea when used in combination with other therapies. It was not associated with a worsening of renal function, but it was associated with an increase in rates of hypotension. On the basis of these results, nesiritide cannot be recommended for routine use in the broad population of patients with acute heart failure. (Funded by Scios; ClinicalTrials.gov number, NCT00475852.

The Neural Basis of Decision-Making and Reward Processing in Adults with Euthymic Bipolar Disorder or Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) share DSM-IV criteria in adults and cause problems in decision-making. Nevertheless, no previous report has assessed a decision-making task that includes the examination of the neural correlates of reward and gambling in adults with ADHD and those with BD

Immediate changes in feedforward postural adjustments following voluntary motor training

There is limited evidence that preprogrammed feedforward adjustments, which are modified in people with neurological and musculoskeletal conditions, can be trained and whether this depends on the type of training. As previous findings demonstrate consistent delays in feedforward activation of the deep abdominal muscle, transversus abdominis (TrA), in people with recurrent low back pain (LBP), we investigated whether training involving voluntary muscle activation can change feedforward mechanisms, and whether this depends on the manner in which the muscle is trained. Twenty-two volunteers with recurrent LBP were randomly assigned to undertake either training of isolated voluntary activation of TrA or sit-up training to activate TrA in a non-isolated manner to identical amplitude. Subjects performed a trunk perturbation task involving arm movement prior to and after training, and surface and fine-wire electromyography (EMG) recordings were made from trunk and arm muscles. Following a single session of training of isolated voluntary activation of TrA, onset of TrA EMG was earlier during rapid arm flexion and extension, to more closely resemble the responses in pain-free individuals. The magnitude of change in TrA EMG onset was correlated with the quality of isolated training. In contrast, all of the abdominal muscles were recruited earlier during arm flexion after sit-up training, while onset of TrA EMG was further delayed during arm extension. The results provide evidence that training of isolated muscle activation leads to changes in feedforward postural strategies, and the magnitude of the effect is dependent on the type and quality of motor training