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Acute kidney injury (AKI) is common after cardiac surgery. We quantified the mortality and costs of varying degrees of AKI using a population-based cohort in Alberta, Canada.A cohort of patients undergoing cardiac surgery from 2004 to 2009 was assembled from linked Alberta administrative databases. AKI was classified by Kidney Disease Improving Global Outcomes stages of severity. Our outcomes were in-hospital mortality, length of stay, and costs; among survivors, we also examined mortality and costs at 365 days. Estimates were adjusted for demographic characteristics, comorbidities, and other covariates.Ten thousand one hundred seventy participants were included, of whom 9771 patients were discharged to community. Overall in-hospital mortality, costs, and length of stay were 4%, 7 days, and Can $34,000, respectively. Postcardiac surgery, AKI occurred in 25%. Compared with those without AKI, AKI was independently associated with increased in-hospital mortality across severity categories, with the highest risk (adjusted odds ratio, 37.1; 95% confidence interval, 26.3-52.1; P .001) in patients who required acute dialysis. AKI severity was associated with increased hospital days and costs, with costs ranging from 1.21 for stage 1 AKI (95% confidence interval, 1.17-1.23) to 2.74 for acute dialysis (95% confidence interval, 2.49-3.00) (P .001) times higher than in patients without AKI, after covariate adjustment. Postdischarge to 365 days, patients with AKI continued to experience increased costs up to 1.35-fold, and patients who required dialysis acutely continued to experience a 2.86-fold increased mortality.AKI remains an important indicator of mortality and health care costs postcardiac surgery.

Coronary artery disease is the leading cause of morbidity and mortality even in the elderly population. Treatment opportunities in the elderly population are often underappreciated. Revascularization procedures (coronary artery bypass graft surgery and percutaneous coronary intervention) can be associated with important benefits in symptom control, quality of life, and long-term mortality, at an upfront cost of an increased risk of in-hospital mortality and morbidity. Risk models to assess periprocedural risk are useful. The best models would balance unique aspects of risk with the very real potential benefit of revascularization. Current models fall short in this regard. Frailty, a clinical syndrome of vulnerability, is present in 25%-50% of cardiac patients, and is associated with increased morbidity and mortality. The addition of frailty can improve the discrimination of risk models. Elderly patients commonly consider quality of life to have greater importance than mortality outcomes. Furthermore, hospital admission is associated with a reduction in mobilization, loss of muscle strength, and worsening frailty, and interferes with a fundamental value in the elderly: the maintenance of independence. Therefore, an understanding of frailty, quality of life, and other unique aspects of risk, as well as individual patient goals, can assist in further defining prognosis and refine decision-making in this important and vulnerable population.

Background Endothelial dysfunction is an early pathogenic event in the progression of cardiovascular disease in patients with Type 2 Diabetes (T2D). Endothelial KCa2.3 and KCa3.1 K+ channels are important regulators of arterial diameter, and we thus hypothesized that SKA-31, a small molecule activator of KCa2.3 and KCa3.1, would positively influence agonist-evoked dilation in myogenically active resistance arteries in T2D. Methodology Arterial pressure myography was utilized to investigate endothelium-dependent vasodilation in isolated cremaster skeletal muscle resistance arteries from 22 to 24 week old T2D Goto-Kakizaki rats, age-matched Wistar controls, and small human intra-thoracic resistance arteries from T2D subjects. Agonist stimulated changes in cytosolic free Ca2+ in acutely isolated, single endothelial cells from Wistar and T2D Goto-Kakizaki cremaster and cerebral arteries were examined using Fura-2 fluorescence imaging. Main findings Endothelium-dependent vasodilation in response to acetylcholine (ACh) or bradykinin (BK) was significantly impaired in isolated cremaster arteries from T2D Goto-Kakizaki rats compared with Wistar controls, and similar results were observed in human intra-thoracic arteries. In contrast, inhibition of myogenic tone by sodium nitroprusside, a direct smooth muscle relaxant, was unaltered in both rat and human T2D arteries. Treatment with a threshold concentration of SKA-31 (0.3 μM) significantly enhanced vasodilatory responses to ACh and BK in arteries from T2D Goto-Kakizaki rats and human subjects, whereas only modest effects were observed in non-diabetic arteries of both species. Mechanistically, SKA-31 enhancement of evoked dilation was independent of vascular NO synthase and COX activities. Remarkably, SKA-31 treatment improved agonist-stimulated Ca2+ elevation in acutely isolated endothelial cells from T2D Goto-Kakizaki cremaster and cerebral arteries, but not from Wistar control vessels. In contrast, SKA-31 treatment did not affect intracellular Ca2+ release by the sarco/endoplasmic reticulum Ca2+-ATPase (SERCA) inhibitor cyclopiazonic acid. Conclusions Collectively, our data demonstrate that KCa channel modulation can acutely restore endothelium-dependent vasodilatory responses in T2D resistance arteries from rats and humans, which appears to involve improved endothelial Ca2+ mobilization.

ObjectiveCoronary artery bypass graft (CABG) surgery with arterial conduits is considered optimal. A deterrent to bilateral internal thoracic artery (BITA) grafting is the risk of deep sternal wound infection (DSWI). We introduced infection prevention measures sequentially, attempting to reduce DSWIs. The aim was to determine (1) if the absence of DSWIs in the last 469 of 1001 consecutive operations was significant; (2) which measures explained the change; and (3) the impact of diabetes.MethodsThe measures included internal thoracic artery (ITA) skeletonization, no bone wax, wound irrigation, 1 observer per case, harmonic scalpel harvest of ITAs, vancomycin paste on sternal marrow, iodine-impregnated skin drapes, chlorhexidine-alcohol skin preparation, no BITA grafts in obese, diabetic women, more off-pump procedures, aseptic wound care, and marrow irrigation before sternal approximation.ResultsMean age was 65 ± 10.4 years, 78% were male, 34% had diabetes, and 34% were obese. The first 532 patients had 16 DSWIs (3%) and the subsequent 469 had none (P

Background The efficacy of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with coronary artery disease has been well defined by randomized controlled trials. However, patients with severe left ventricular dysfunction (ejection fraction Methods The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH), a clinical data collection and outcome monitoring initiative for the province of Alberta, Canada, was used to identify 2925 patients with coronary artery disease and left ventricular dysfunction undergoing CABG (n = 1,326) or PCI (n = 1,599) between 1995 and 2008. Patients were propensity matched to obtain comparable subgroups among left ventricular dysfunction patients. Results Cox proportional hazard analysis of the propensity-matched subgroups identified that CABG was significantly associated with lower rates of repeat revascularization and better survival compared with PCI at 1, 5, 10, and 15 years. Other significant independent predictors of poor long-term survival included age, renal failure, heart failure, diabetes mellitus, peripheral vascular disease, prior myocardial infarction, left main coronary artery disease, and prior CABG. Conclusions For patients with coronary artery disease and left ventricular dysfunction, CABG was associated with lower rates of repeat revascularization and improved survival over PCI, after adjustment for baseline risk profile differences. Further research exploring the factors leading to use of a particular revascularization modality in this patient population is required.

In future lead cooled nuclear power systems the heavy liquid-metal pump will be placed in the hot temperature region of the reactor. This combines corrosion problematic at elevated temperatures with erosion at the impeller of the pump. Several steels designed for conventional mechanical high loaded pumps and the SiSiC have been tested in oxygen containing stagnant lead (10 −6 and 10 −8 wt%) at 550 and 600 °C for 2000 and 4000 h in the COSTA-facilities. Only SiSiC shows no influence by the liquid metal. No dissolution attack occurs at cast iron steels but inner oxidation takes place. NORILOY shows no dissolution attack. All other steels are attacked by liquid lead at one of the conditions. To evaluate the erosion–corrosion attack a new test facility allowing velocities of the lead of up to 20 m/s was designed and constructed. With a CFD-code the behaviour and flow velocity of the lead are simulated.

Ginkgo biloba special extract EGb 761, an anti-dementia drug, enhances cognitive functioning and stabilizes mood in cognitively impaired elderly subjects. Moreover, EGb 761 had been found to alleviate symptoms of anxiety in people with mental decline, therefore it was now tested for clinical efficacy in younger patients suffering from anxiety. One hundred and seven patients with generalized anxiety disorder (GAD, n=82) or adjustment disorder with anxious mood (ADWAM, n=25) according to the diagnostic and statistical manual of mental disorders, third edition - revised (DSM-III-R) were randomized to daily doses of 480 mg EGb 761, 240 mg EGb 761 or placebo for 4 weeks. Intention-to-treat (ITT) analyses were performed on the primary outcome measure, the Hamilton rating scale for anxiety (HAMA), and the secondary variables, the clinical global impression of change (CGI-C), the Erlangen anxiety tension and aggression scale (EAAS), the list of complaints (B-L'), and the patient's global rating of change. The HAMA total scores decreased by -14.3 (+/-8.1), -12.1 (+/-9.0) and -7.8 (+/-9.2) in the high-dose EGb 761, the low-dose EGb 761 and the placebo group, respectively. Changes were significantly different from placebo for both treatment groups with p=0.0003 (high-dose group) and p=0.01 (low-dose). Regression analyses revealed a dose-response trend (p=0.003). EGb 761 was significantly superior to placebo on all secondary outcome measures. It was safe and well tolerated and may thus be of particular value in elderly patients with anxiety related to cognitive decline.

In Nollan v. California Coastal Commission, 483 U.S. 825 (1987), and Dolan v. City of Tigard, 512 U.S. 374 (1994), the Supreme Court held that an agency could not, consistent with the Takings Clause, condition a permit on a land exaction unless the exaction bears an “essential nexus” and “rough proportionality” to the harms the government seeks to mitigate. Then, in Koontz v. St. Johns Water Management District, 133 S. Ct. 2586 (2013), the Court extended Nollan and Dolan to exactions that were never completed because the property owner refused to acquiesce to the demand. Nevertheless, the Court held that such property owners suffer a “constitutionally cognizable injury” under the unconstitutional conditions doctrine because the government has significantly burdened their right not to have property taken without just compensation. Because the case arose under a Florida statute, the Court did not decide what the proper federal remedy would be in these “failed exaction” cases.This Article argues that failed exaction plaintiffs should be entitled to actual damages under the federal civil rights statute, 42 U.S.C. § 1983. Because failed exactions do not involve a completed taking, the Just Compensation Clause is not the proper remedy. But a recognized constitutional injury cannot go uncompensated. Limiting the remedy to invalidation of the offending condition suffers from two faults. First, it fails to provide property owners with adequate compensation. Second, it does not serve as a deterrent to agencies. An invalidation remedy standing alone gives permitting agencies a “do-over” and encourages them to use to permitting process to prevent development through the use of unconstitutional conditions. On the contrary, a damages remedy is supported by Section 1983 and serves the twin aims of deterrence and compensation. Courts should hold that property owners bringing a failed exaction claim under Koontz are entitled to their actual economic damages.Along with that federal damages remedy, the Article argues that these plaintiffs should be able to bring their claims directly in federal court. Because failed exaction plaintiffs have not suffered a taking, they cannot seek Just Compensation. Therefore, the ripeness rule for federal takings claims established in Williamson County Regional Planning Commission v. Hamilton Bank, 473 U.S. 185 (1985), which generally requires property owners to seek just compensation in state court to “ripen” a takings claim, does not apply to failed exactions. Property owners suing under a Koontz theory should be able to assert their federal constitutional rights directly in federal court.

In a randomized, double-blind, placebo-controlled, multicenter study, the clinical efficacy and safety of two different extracts of St. John's wort were investigated in 147 male and female out-patients suffering from mild or moderate depression according to DSM-IV criteria. Fifty-six (38.1%) of them had an initial total score ≥ 22 points on the Hamilton Rating Scale for Depression (HAMD, 17-item version). Following a placebo run-in period of three to seven days, the patients were randomized to one of three treatment groups: During the 42-day treatment period, they received 3×1 tablet of either placebo, Hypericum extract WS 5573 (300mg, with a content of 0.5% hyperforin), or Hypericum extract WS 5572 (300 mg, with a content of 5% hyperforin). The manufacturing process for both Hypericum preparations was identical, they only differed with regard to their content of hyperforin. Efficacy regarding depressive symptoms was assessed on days 0, 7,14,28, and 42. The last observation of patients withdrawn from the trial prematurely was carried forward. At the end of the treatment period (day 42), the patients receiving WS 5572 (5% hyperforin) exhibited the largest HAMD reduction versus day 0 (10.3 ± 4.6 points; mean ± SD), followed by the WS 5573 group (0.5% hyperforin; HAMD reduction 8.5 ± 6.1 points) and the placebo group (7.9 ± 5.2 points). The monotonie trend was significant (Jonckheere-Terpstra test; p = 0.017). In patients with an initial HAMD total score ≥ 22, the HAMD reduction was even by 16.5% larger than in the total study group receiving WS 5572. More severely depressed patients treated with WS 5573, however, showed a 22.4% lower reduction of the HAMD total score than the entire WS 5573 treatment group. In patients with HAMD ≥ 22, WS 5572 showed a 53.8% larger HAMD reduction than placebo, whereas WS 5573 was not relevantly different from the placebo level. The mean HAMD reductions, treatment end versus baseline, for the more severely depressed patients were 12.0 (3.7) points, 6.6 (7.7) points and 7.8 (5.4) points [mean (SD)] for WS 5S72, WS 5573 and placebo, respectively. The results of a responder analysis support these findings. The data point to a dose-response relationship between the antidepressant efficacy of Hypericum extract and its hyperforin content. The extract with a higher content of hyperforin was particularly effective in patients who were more severely depressed.

We tested the hypotheses that a dual-chamber pacemaker that paces when intrinsic rate drops abruptly would reduce the number of syncopal spells and improve the quality of life in patients with highly recurrent neurally mediated syncope. Twelve patients with highly frequent neurally mediated syncope and at least 1 syncopal spell after tilt testing received dual-chamber pacemakers with automatic rate-drop sensing. The pacemakers were implanted 17+/-26 months after tilt testing, and the patients then were followed for 12+/-2 months. We compared the time to the first recurrence of syncope, syncope frequency, and quality of life for the 2 periods between tilt testing and pacemaker implantation, and between implantation and last follow-up. Only 6 of 12 patients fainted after pacemaker insertion. The median time to syncope recurrence before and after pacing was 7 days and 5.3 months, respectively. The geometric mean frequency of faints before and after pacing was 5.0 spells/month (95% confidence interval 2.7 to 9.2) and 0.30 spells/month (95% confidence interval 0.2 to 0.4), p0.001. After 6 months the mean perception of health on the 100-point EuroQol scale rose from 55 to 82 (p = 0.003), and the general health perception on the SF-36 scale rose from 51 to 72 (p = 0.005). Permanent dual-chamber pacing with automatic rate-drop sensing in patients with highly frequent syncope is associated with a marked reduction in the likelihood of syncope and a marked improvement in quality of life.

Implantable defibrillators reduce the risk of sudden death in patients with malignant ventricular arrhythmias, but significant restriction in quality of life can occur as a result of frequent device activation. To determine if a device that provides both antitachy-cardia pacing and shock therapy can safely reduce the frequency of shocks after implantation, 46 consecutive patients undergoing initial implantation of a defibrillator were studied. In all patients, the implanted device provided antitachycardia pacing and shock therapy. Detected tachycardia characteristics and the results of therapy were stored in the device's memory.There were 42 men and 4 women, aged 26 to 71 years (mean 58.7 ± 13.5). Left ventricular ejection fraction ranged from 13% to 67% (mean 32.2 ± 13.4%) and 31 patients had experienced one or more episodes of cardiac arrest. Induced arrhythmias included sustained monomorphic ventricular tachycardia in 38 patients, nonsustained polymorphic ventricular tachycardia in 2 and ventricular fibrillation in 4.Over a total follow-up period of 255 patient-months (range 1 to 13, mean 6.1), 25 patients experienced spontaneous arrhythmic events. In 22 patients, 909 episodes of tachycardia were treated by antitachycardia pacing, which was successful on 840 occasions (92.4%). Acceleration of ventricular tachycardia by pacing therapy was estimated to have occurred 39 times. Syncope occurred once during pacing-induced acceleration of ventricular tachycardia. Forty-four episodes of tachycardia in seven patients were treated directly by shocks because of short tachycardia cycle length; 88% of all detected tachycardias were treated without the need for shocks. Four patients died from cardiorespiratory failure and one patient died suddenly without any detected tachyarrhythmia.These initial results demonstrate that a device that provides graded therapy with antitachycardia pacing for ventricular arrhythmias reduces the need for high energy shocks and rarely results in detrimental delays in the treatment of ventricular tachycardia.

BACKGROUND: The CORONARY trial (NCT00463294, N1⁄44752 patients randomly assigned to offor on-pump CABG) demonstrated similar results between off-pump CABG compared with on-pump CABG at 1 year. As CABG aims to restore adequate blood supply to the ischemic heart, the success of the operation depends mainly on the patency of the grafts. The long-term patency, especially vein grafts, is limited and graft failure has consequences similar to those of native coronary artery disease: recurrent angina, myocardial infarct (MI), additional revascularization procedures, or death. It is still debated whether off-pump CABG surgery is associated with worse graft patency when performed by skilled surgeons in higher risk patients. The purpose of this study was to determine whether off-pump compared to on-pump is associated with lower CABG patency, and if there is an association between graft failure and clinical outcomes. METHODS: PATENCY-CORONARY (NCT01414049) is a multicenter trial of a consecutive subset of patients from the CORONARY trial undergoing graft patency assessment using non-invasive ECG-gated computed tomography angiography (CTA). All CORONARY patients from 3 high volume offpump CABG Canadian Centers reaching one-year follow-up (window of eligibility 9 months-24 months) were systematically approached to be included in the study. RESULTS: From the 335 patients eligible to participate in PATENCY-CORONARY (no kidney failure, no atrial fibrillation, NYHA

Thermal analyses on samples of the composition (Ba,RE)F2,33 revealed seven new compounds Ba2REF7 (RE  Dy-Lu, Y). They are stable only above about 940 °C but can be quenched after annealing for several days at 950–1000 °C. These phases which are metastable at room temperature were characterized by X-ray powder diffraction. A tetragonal distortion of the fluorite parent structure was detected, analogous to that in the Ln3F7, Ca2REF7 and Sr2REF7 phases. In contrast, however, the superstructure is not fully pronounced and only tripling along the c axis is observed. This indicates that only the cation order and not the reorganization of the highly mobile anion sublattice is fully developed in these layer structures. This behavior is not unexpected for fluorite-related high temperature phases which belong to the class of fast anionic conductors.

Sequential venous coronary bypass grafts have presented problems, mainly because of commonly reported differences between patency of side-to-side and end-to-side vein-coronary anastomoses. Better to define this, we have studied sequential anastomosis grafts done during a 13 year period. We concentrated specifically on 212 "double" grafts with 100% selective angiographic follow-up early, 90% at 1-year, and 44% at 5 years after operation. Four hundred twenty-four control single grafts were studied similarly. We found that patency rates of side-to-side anastomoses were much better than those of end-to-side anastomoses, whether of sequential or control single grafts. Considering specifically diagonal coronary artery-anterior descending coronary artery sequential grafts, the combined patency of all sequential anastomoses theoretically exceeds that of a comparable number of single grafts at all times of study, but the differences are small. Furthermore, there is definite danger of preserving proximal and perhaps limited bypass runoff at the cost of losing distal and perhaps more important myocardial perfusion. On balance, we believe that single vein grafts are to be preferred over sequential grafts unless shortage of conduit material or local aortic wall conditions dictate otherwise.

The compounds Ba 4 Pr 3 F 17 , Ba 4 Nd 3 F 17 , Ba 4 Gd 3 F 17 and Ba 4 Dy 3 F 17 were investigated by single-crystal electron diffraction to clarify discrepancies in the literature. All four phases showed the rhombohedral fluorite-related superstructure rhδ with a s ≈ 0.5√14 a F and c s ≈ 2√3 a F ( Z = 42). These data are in agreement with our earlier X-ray powder diffraction study on Ba 4 RE 3 F 17 with RE  Ce-Nd, Sm-Lu and Y. In contrast, no evidence was found for a superstructure with a s ≈ 3.5√2 a F and c s ≈ 4√3 a F ( Z =588), as reported by Russian researchers on the basis of single-crystal X-ray work.

A 61-year-old World War II fighter pilot sustained a gunshot injury to the right fibula and an arteriovenous fistula subsequently developed. Angiographic examination 44 years later for evaluation of an abdominal aortic aneurysm showed an unusually shaped aneurysm and the right arteriovenous fistula with antegrade dilatation of the ipsilateral arterial system in continuity with the aneurysm. We hypothesize that this arteriovenous fistula, which involved the peroneal and anterior tibial arteries of the right leg of 44 years' duration, was responsible for the development of this man's abdominal aortic aneurysm. (J VASC SURG 1987;5:882-6.)