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Valve endocarditis is associated with high morbidity and mortality and requires a thorough evaluation including early surgical consultation to identify patients who may benefit from surgery. We review 5 recent articles that highlight the current debates related to best treatment strategies for valve endocarditis. Recent publications have focused on neurologic risk assessment, timing of surgery, and prognostic factors associated with native and prosthetic valve endocarditis. The initial patient assessment and management is best performed by a multidisciplinary team. Future investigations should focus on identifying surgical candidates early and the outcomes affected by replacement valve choice in both native and prosthetic valve endocarditis.

Body shape is predicted to differ among species for functional reasons and in relation to environmental niche and phylogenetic history. We quantified morphological differences in shape and size among 98.5% of the 129 species and all 21 genera of the Australo-Papuan endemic myobatrachid frogs to test the hypothesis that habitat type predicts body shape in this radiation. We tested this hypothesis in a phylogenetic context at two taxonomic levels: across the entire radiation and within the four largest genera. Thirty-four external measurements were taken on 623 museum specimens representing 127 species. Data for seven key environmental variables relevant to anurans were assembled for all Australian-distributed species based on species' distributions and 131,306 locality records. The Australo-Papuan myobatrachid radiation showed high diversity in adult body size, ranging from minute (15 mm snout-vent length) to very large species (92 mm), and shape, particularly sin relative limb length. Five main morphological and environmental summary variables displayed strong phylogenetic signal. There was no clear relationship between body size and environmental niche, and this result persisted following phylogenetic correction. For most species, there was a better match between environment/habitat and body shape, but this relationship did not persist following phylogenetic correction. At a broad level, species fell into three broad groups based on environmental niche and body shape: 1) species in wet habitats with relatively long limbs, 2) species in arid environments with relatively short limbs (many of which are forward or backward burrowers) and 3) habitat generalist species with a conservative body shape. However, these patterns were not repeated within the four largest genera - Crinia, Limnodynastes, Pseudophryne and Uperoleia. Each of these genera displayed a highly conservative anuran body shape, yet individual species were distributed across the full spectrum of Australian environments. Our results suggest that phylogenetic legacy is important in the evolution of body size and shape in Australian anurans, but also that the conservative body plan of many frogs works well in a wide variety of habitats.

Granting clinical staff privileges to physicians is the primary mechanism institutions use to uphold quality care. The Joint Commission requires that medical staff privileges be based on professional criteria specified in medical staff bylaws. Physicians themselves are charged with defining the

Tricuspid regurgitation (TR) is a complex and insidious valvular pathology that represents a complex decision and management algorithm for patients. TR is present in a significant proportion of the population and is especially prevalent in patients with advanced heart failure. Patients with TR have been demonstrated to have a decreased survival even with normal left heart function. TR can be a result of pathology that directly affects the valvular structure (i.e., Ebstein anomaly) or as a result of increased forward pressures (ie, pulmonary hypertension, left heart failure). Conservative management of patients with TR is primarily symptomatic relief. Definitive therapy involves surgical repair of the tricuspid valve. Furthermore, as more patients develop advanced heart failure, the management of TR in patients with left ventricular assist devices has become necessary because of the evidence of increased in-hospital morbidity and a trend toward decreased survival.

Many animals must choose a nest site in order to reproduce. However, it is unclear how nest-site selection strategies vary across different mating systems. We must therefore explore nest-site selection strategies in a range of mating systems, including the interaction between resource-defence polygyny and polyandry (i.e. polygynandry). In this study, we imposed a re-settlement event in the terrestrial toadlet Pseudophryne bibronii and measured the influence of the spatial position of each male’s nest site with respect to rival males on the likelihood that it would be abandoned or receive eggs. We captured every calling male in a population, measured their breeding success and released them back into the breeding area. We then recorded the establishment and abandonment of nest sites by males over 26 consecutive nights. Spatial positioning did not have any significant effects on male-breeding success, supporting claims that females show less discrimination between nest sites when they are polyandrous and spread their eggs amongst multiple male nests. However, we found that males consistently selected nest sites according to a site’s spatial position, which suggests that fitness benefits unrelated to male breeding success (e.g. reduced mortality risk) might influence male nesting decisions. Overall, our study provides new evidence that the mating system adopted by a population can influence the cues that individuals respond to when selecting nest sites.

Emerging pathogens can drive evolutionary shifts in host life-history traits, yet this process remains poorly documented in vertebrate hosts. Amphibian chytridiomycosis, caused by infection with the fungal pathogen Batrachochytrium dendrobatidis (Bd), is the worst recorded wildlife disease and has caused the extinction of over 100 species across multiple continents. A similar number of additional species have experienced mass declines and Bd remains a major source of mortality in many populations of declined species now persisting with the pathogen. Life-history theory predicts that increased extrinsic mortality in Bd-infected populations may alter amphibian life-history traits, but this has not been examined. Here, we investigate whether population Bd status is associated with age and size at maturity by comparing long-exposed Bd-infected populations, Bd-free populations, and museum specimens collected prior to Bd emergence for the endangered Australian frog Litoria verreauxii alpina. We show that Bd-infected populations have a higher proportion of males that mature at 1 year of age, and females that mature at 2 years of age, compared to Bd-free populations. Earlier maturation was associated with reduced size at maturity in males. Consistent with life-history theory, our findings may represent an adaptive evolutionary shift towards earlier maturation in response to high Bd-induced mortality. To our knowledge, this study provides the first evidence for a post-metamorphic Bd-associated shift in an amphibian life-history trait. Given high mortality in other Bd-challenged species, we suggest that chytridiomycosis may be a substantial new selection pressure shaping life-history traits in impacted amphibian species across multiple continents.

Effective activation of sperm motility is fundamental to successful artificial fertilisation; however, studies investigating optimal procedures in amphibians are lacking. This study found the optimal osmolality of activation media for sperm motility activation and evaluated the effect of phosphodiesterase (PDE) inhibitors on sperm activation and longevity in the critically endangered booroolong frog, Litoria booroolongensis. To assess the effect of medium osmolality (10, 25, 50, 75, 100 and 200 mOsmol kg−1) and PDE inhibitors (control, 2.5 mM caffeine, 5 mM caffeine, 2.5 mM pentoxifylline, 5 mM pentoxifylline, 2.5 mM theophylline and 5 mM theophylline) on initial activation, percentage sperm motility and sperm velocity were quantified using computer-assisted sperm analysis. To assess the effect of PDE inhibitors (control, 2.5 mM caffeine and 2.5 mM theophylline) on sperm longevity, percentage motility and velocity were assessed hourly until 10 h after activation. High (>60%) percentage motility was achieved in a broad range of activation-medium osmolalities (10–75 mOsmol kg−1). PDE inhibitors did not have an effect on initial sperm motility or velocity, but caffeine and theophylline improved sperm longevity, significantly increasing motility and velocity at 8, 9 and 10 h after activation. Data also show that sperm longevity in L. booroolongensis is extreme, with spermatozoa remaining motile more than twice as long as those of any other anuran amphibian.

Antibiotics can inhibit bacterial contamination and extend sperm longevity during storage; a primary goal of captive facilities conducting biobanking and artificial fertilisation (AF). This study evaluated the effects of gentamicin on the short-term storage of Booroolong frog sperm. Sperm suspensions were obtained via either testis maceration, or as spermic urine, following hormonal induction of sperm-release. The effect of 0, 1, 2, 3 or 4mgmL-1 gentamicin on bacterial abundance (CFUmL-1) was determined and sperm motility assessed. In both testis macerate samples and spermic urine samples, gentamicin administered at intermediate-to-high doses (2, 3 & 4mgmL-1) eliminated, or significantly reduced, bacterial abundance. Sperm samples obtained via testis maceration exhibited significantly lower sperm motility at the highest doses (3 & 4mgmL-1). All remaining treatments (0, 1 & 2mgmL-1) were statistically similar and maintained sperm motility >55%. Sperm samples obtained as spermic urine exhibited no difference in sperm motility or velocity when treated with gentamicin at any dose. While antibiotic treatment did not improve sperm longevity as predicted, this is the first study to demonstrate that antibiotic treatment can reduce bacterial abundance without compromising sperm motility in an anuran amphibian. Antibiotic supplementation may be an important tool for reducing pathogen transmission where sperm samples are transferred between captive institutions for biobanking and AF.

The success of captive breeding programs (CBPs) for threatened species is often limited due to a lack of knowledge of the nutritional conditions required for optimal growth and survival. Carotenoids are powerful antioxidants known to accelerate vertebrate growth and reduce mortality. However, the effect of carotenoids on amphibian life-history traits remains poorly understood. The aim of our study was to use a manipulative laboratory experiment to test the effect of dietary-carotenoid supplementation during the larval life stage on the survival, growth and development of the critically endangered southern corroboree frog (Pseudophryne corroboree). Larvae were fed either a carotenoid supplemented diet or an unsupplemented diet and the survival, growth and development of individuals was monitored and compared. There was no significant effect of dietary treatment on larval survival, growth rate, time taken to reach metamorphosis, or body size at metamorphosis. Our findings provide no evidence that carotenoid supplementation during the larval life stage improves the growth and development of southern corroboree frogs. However, because the carotenoid dose used in our study did not have any detrimental effects on P. corroboree larvae, but has previously been shown to improve adult coloration, immunity, and exercise performance, carotenoid supplementation should be considered when evaluating the nutritional requirements of P. corroboree in captivity. Carotenoid supplementation studies are now required for a diversity of anuran species to determine the effects of carotenoids on amphibian survival, growth and development. Understanding the effects of dietary carotenoids on different life-history traits may assist with amphibian captive breeding and conservation.

The rapid spread of infectious disease has resulted in the decline of animal populations globally. Amphibians support a diversity of microbial symbionts on their skin surface that help to inhibit pathogen colonisation and reduce disease susceptibility and virulence. These cutaneous microbial communities represent an important component of amphibian immune defence, however, very little is known about the environmental factors that influence the cutaneous microbiome. Here, we characterise the cutaneous bacterial communities of a captive colony of the critically endangered Australian southern corroboree frog, Pseudophyrne corroboree, and examine the effect of dietary carotenoid supplementation on bacterial abundance, species richness and community composition. Individuals receiving a carotenoid-supplemented diet exhibited significantly higher bacterial abundance and species richness as well as an altered bacterial community composition compared to individuals that did not receive dietary carotenoids. Our findings suggest that dietary carotenoid supplementation enhances the cutaneous bacteria community of the southern corroboree frog and regulates the presence of bacteria species within the cutaneous microbiome. Our study is the second to demonstrate that carotenoid supplementation can improve amphibian cutaneous bacterial community dynamics, drawing attention to the possibility that dietary manipulation may assist with the ex situ management of endangered species and improve resilience to lethal pathogens such as Batrachochytrium dendrobatidis (Bd).

Bacterial evolution is accelerated by mobile genetic elements. To spread horizontally and to benefit the recipient bacteria, genes encoded on these elements must be properly regulated. Among the legionellae are multiple integrative conjugative elements (ICEs) that each encode a paralog of the broadly conserved regulator csrA . Using bioinformatic analyses, we deduced that specific csrA paralogs are coinherited with particular lineages of the type IV secretion system that mediates horizontal spread of its ICE, suggesting a conserved regulatory interaction. As a first step to investigate the contribution of csrA regulators to this class of mobile genetic elements, we analyzed here the activity of the csrA paralog encoded on Legionella pneumophila ICE-βox. Deletion of this gene, which we name csrT , had no observed effect under laboratory conditions. However, ectopic expression of csrT abrogated the protection to hydrogen peroxide and macrophage degradation that ICE-βox confers to L. pneumophila . When ectopically expressed, csrT also repressed L. pneumophila flagellin production and motility, a function similar to the core genome's canonical csrA . Moreover, csrT restored the repression of motility to csrA mutants of Bacillus subtilis , a finding consistent with the predicted function of CsrT as an mRNA binding protein. Since all known ICEs of legionellae encode coinherited csrA -type IV secretion system pairs, we postulate that CsrA superfamily proteins regulate ICE activity to increase their horizontal spread, thereby expanding L. pneumophila versatility. IMPORTANCE ICEs are mobile DNA elements whose type IV secretion machineries mediate spread among bacterial populations. All surveyed ICEs within the Legionella genus also carry paralogs of the essential life cycle regulator csrA . It is striking that the csrA loci could be classified into distinct families based on either their sequence or the subtype of the adjacent type IV secretion system locus. To investigate whether ICE-encoded csrA paralogs are bona fide regulators, we analyzed ICE-βox as a model system. When expressed ectopically, its csrA paralog inhibited multiple ICE-βox phenotypes, as well as the motility of not only Legionella but also Bacillus subtilis . Accordingly, we predict that CsrA regulators equip legionellae ICEs to promote their spread via dedicated type IV secretion systems.

A complete cytotoxic profile of exposure to silver (AgNP) nanoparticles investigating their biological effects on the innate immune response of circulating white blood cells is required to form a complete understanding of the risk posed. This was explored by measuring AgNP-stimulated gene expression of the pro-inflammatory cytokines interleukin-1 (IL-1), interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-α) in THP-1 monocytes. A further study, on human monocytes extracted from a cohort of blood samples, was carried out to compare with the AgNP immune response in THP-1 cells along with the detection of pro-IL-1β which is a key mediator of the inflammasome complex. The aims of the study were to clearly demonstrate that AgNP can significantly up-regulate pro-inflammatory cytokine gene expression of IL-1, IL-6 and TNF-α in both THP-1 cells and primary blood monocytes thus indicating a rapid response to AgNP in circulation. Furthermore, a role for the inflammasome in AgNP response was indicated by pro-IL-1β cleavage and release. These results highlight the potential inflammatory effects of AgNP exposure and the responses evoked should be considered with respect to the potential harm that exposure may cause. Copyright © 2016 John WileySons, Ltd.

Transporters are integral membrane proteins with central roles in the efficient movement of molecules across biological membranes. Many transporters exist as oligomers in the membrane. Depending on the individual transport protein, oligomerization can have roles in membrane trafficking, function, regulation and turnover. For example, our recent studies on UapA, a nucleobase ascorbate transporter, from Aspergillus nidulans, have revealed both that dimerization of this protein is essential for correct trafficking to the membrane and the structural basis of how one UapA protomer can affect the function of the closely associated adjacent protomer. Here, we review the roles of oligomerization in many particularly well-studied transporters and transporter families. © 2016 The Author(s).

Secondary salinization has been identified as a major stressor to amphibians. Exposure to elevated salinity necessitates physiological adjustments and biochemical changes that may be energetically demanding. As such, exposure to non-lethal levels of salinity during development could potentially alter anuran metabolic rates and individual performance in both pre- and post-metamorphic life stages. We investigated the effects of non-lethal levels of salinity on metamorphic traits (time to reach metamorphosis and metamorphic mass), tadpole oxygen consumption, escape response behaviour (pre- and post-metamorphosis) and foraging ability post-metamorphosis in two native Australian frog species, the southern brown tree frog ( Litoria ewingii ) and the striped marsh frog ( Limnodynastes peronii ). We found that both Lit. ewingii and Lim. peronii exhibited differences in metamorphic traits in response to elevated salinity. Neither species showed significant change in oxygen consumption during development in response to salinity, relative to freshwater controls. Both species displayed impaired escape response behaviours in response to salinity during larval development, but flow-on effects to adult escape response behaviours and foraging performance were species-specific. Our results show that the influence of stressors during development can have consequences for anuran physiology and behaviour at multiple life stages, and emphasize the need for studies that examine the energetics of anuran responses in order to better understand the responses of biota to stressful environments.

Heavy metal pollution has likely played an important role in global biodiversity decline, but there remains a paucity of information concerning the effects of metals on amphibian diversity. This study assessed anuran species richness and distribution in relation to sediment metal content and water chemistry in wetlands located along the Merri Creek corridor in Victoria, south-eastern Australia. Anurans were present in 60% (21/35) of study sites, with a total of six species detected: the eastern common froglet (Crinia signifera), the eastern sign-bearing froglet (Crinia parinsignifera), the southern brown tree frog (Litoria ewingii), the growling grass frog (Litoria raniformis), the eastern banjo frog (Limnodynastes dumerilii) and the spotted marsh frog (Limnodynastes tasmaniensis). Mean species richness was 1.77 ± 0.32 per site, and species richness ranged from zero to six species per site. Across sites, species richness correlated negatively with sediment concentrations of six heavy metals: copper, nickel, lead, zinc, cadmium and mercury. Species richness also correlated negatively with wetland water electrical conductivity (a proxy for salinity) and concentrations of orthophosphate. Distributions of the three most commonly observed frog species (C. signifera, L. tasmaniensis and L. ewingii) were significantly negatively associated with the total level of metal contamination at individual sites. The study is the first to provide evidence for an association between metal contamination and anuran species richness and distribution in the southern hemisphere, adding to a small but growing body of evidence that heavy metal pollution has contributed to global amphibian decline.

Valvular heart disease imposes varying degrees of stress on the myocardium, which, untreated, leads to eventual ventricular dysfunction. The pathophysiologic mechanisms by which these lesions act depend not only on the affected valve, but also the degree to which they causes stenosis, regurgitation, or both. The goal of patient treatment is to identify and correct the defect before irreversible ventricular changes have occurred. Historically, the conventional surgical approach for valvular disease was via median sternotomy. Minimally invasive valve surgery (MIVS) refers to alternative surgical techniques, which avoid the trans-sternal approach. The objective is to (1) minimize surgical trauma, (2) reduce blood utilization, and (3) hasten postoperative convalesce. These goals are accomplished through the use of partial sternal, para-sternal, or thoracotomy incisions and can be adapted to robotic technologies. As with all evolving surgical techniques, the therapeutic aim of valve repair or replacement must be performed at or above the same standard of conventional surgery. Outcomes must not be sacrificed for the sake of better cosmesis. In addition, percutaneous catheter-based valvular interventions have seen rapid advances. These emerging technologies have dramatically broadened the therapeutic options, especially for an ever-increasing group of high-risk patients. As expected with all minimally invasive techniques, the major differences in the hard outcomes of mortality and major morbidity are seen in these highest risk groups. However, intermediate and low risk patients receive a tremendous benefit with regard to shortened hospital stay and quicker functional recovery. With the myriad of interventional options now available, the clinical challenge now is how best to individualize the treatment approach to a given patient providing the most durable result in order to alleviate symptoms and preserve myocardial function.

This study tested the hypothesis that interruption of the renin-angiotensin system with either an angiotensin-converting enzyme inhibitor or a mineralocorticoid receptor antagonist will decrease the prevalence of atrial fibrillation after cardiac surgery.Randomized double-blind placebo-controlled study.University-affiliated hospitals.Four hundred forty-five adult patients in normal sinus rhythm undergoing elective cardiac surgery.One week to 4 days prior to surgery, patients were randomized to treatment with placebo, ramipril (2.5 mg the first 3 days followed by 5 mg/day, with the dose reduced to 2.5 mg/day on the first postoperative day only), or spironolactone (25 mg/day).The primary endpoint was the occurrence of electrocardiographically confirmed postoperative atrial fibrillation. Secondary endpoints included acute renal failure, hyperkalemia, the prevalence of hypotension, length of hospital stay, stroke, and death.The prevalence of atrial fibrillation was 27.2% in the placebo group, 27.8% in the ramipril group, and 25.9% in the spironolactone group (p=.95). Patients in the ramipril (0.7%) or spironolactone (0.7%) group were less likely to develop acute renal failure than those randomized to placebo (5.4%, p=.006). Patients in the placebo group tended to be hospitalized longer than those in the ramipril or spironolactone group (6.8±8.2 days vs. 5.7±3.2 days and 5.8±3.4 days, respectively, p=.08 for the comparison of placebo vs. the active treatment groups using log-rank test). Compared with patients in the placebo group, patients in the spironolactone group were extubated sooner after surgery (576.4±761.5 mins vs. 1091.3±3067.3 mins, p=.04).Neither angiotensin-converting enzyme inhibition nor mineralocorticoid receptor blockade decreased the primary outcome of postoperative atrial fibrillation. Treatment with an angiotensin-converting enzyme inhibitor or mineralocorticoid receptor antagonist was associated with decreased acute renal failure. Spironolactone use was also associated with a shorter duration of mechanical ventilation after surgery.

Obesity increases oxidative stress, endothelial dysfunction, and inflammation, but the effect of obesity on postoperative AKI is not known. We examined the relationship between body mass index (BMI) and AKI in 445 patients undergoing cardiac surgery and whether oxidative stress (F(2)-isoprostanes), inflammation (IL-6), or antifibrinolysis (plasminogen activator inhibitor-1 [PAI-1]) contribute to any identified relationship. Overall, 112 (25%) of the 445 patients developed AKI. Higher BMI was independently associated with increased odds of AKI (26.5% increase per 5 kg/m(2) [95% confidence interval, 4.3%-53.4%]; P=0.02). Baseline F(2)-isoprostane (P=0.04), intraoperative F(2)-isoprostane (P=0.003), and intraoperative PAI-1 (P=0.04) concentrations also independently predicted AKI. BMI no longer predicted AKI after adjustment for the effect of F(2)-isoprostanes, suggesting that obesity may affect AKI via effects on oxidative stress. In contrast, adjustment for IL-6 or PAI-1 did not substantially alter the association between BMI and AKI. Further, deconstruction of the obesity-AKI relationship into direct (i.e., independent of candidate pathways) and indirect (i.e., effect of BMI on AKI via each candidate pathway) effects indicated that F(2)-isoprostanes, but not IL-6 or PAI-1, partially mediate the relationship between obesity and AKI (P=0.001). In conclusion, obesity independently predicts AKI after cardiac surgery, and oxidative stress may partially mediate this association.

Robert A. Harrington, MD, FACC, Chair Eric R. Bates, MD, FACC[¶][1] Deepak L. Bhatt, MD, MPH, FACC Charles R. Bridges, MD, MPH, FACC[¶][1] Mark J. Eisenberg, MD, MPH, FACC[¶][1] Victor A. Ferrari, MD, FACC John D. Fisher, MD, FACC Timothy Gardner, MD, FACC Federico Gentile, MD, FACC

Both coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI) have been shown to provide symptomatic relief and to increase long-term survival in patients with coronary artery disease.1–3 Hybrid coronary revascularization (HCR) seeks to combine the respective strengths of CABG and PCI in an attempt to offer a technique that is less invasive than conventional surgery without diminishing the efficaciousness of therapy offered. Response by Shannon et al on p 2510 The major therapeutic benefits of CABG arise from the graft from the left internal mammary artery (LIMA) to the left anterior descending artery (LAD). This can be attributed to the fact that the LIMA-to-LAD graft has excellent long-term patency, reaching as high as 95% to 98% at 10 years,1–3 as opposed to saphenous vein grafts (SVGs), which have high early failure rates, ranging from 6.2% to 30%, averaging ≈20% throughout the literature.4–6 The LIMA-to-LAD graft is also superior to PCI in terms of long-term patency, event-free survival, and relief of angina. The major benefits of multivessel PCI with drug-eluting stents (DES) to treat multivessel coronary artery disease are that it is less invasive, has shorter recovery times, and has lower stroke rates compared with CABG.2,7 It also has lower stent failure rates than SVG (defined as stent restenosis and thrombosis compared with SVG occlusion).2,7 Tables 1 and 2 present existing data on current outcomes with DES and SVGs in non-LAD territories.4,5,8–18 View this table: Table 1. Data From Randomized Trials on Drug-Eluting Stent Restenosis Rate and Stent Thrombosis for Non–Left Anterior Descending Artery Revascularization (n=3631) View this table: Table 2. Data From Studies of 12-Month Postoperative Saphenous Vein Graft Patency With Coronary Angiography for Non–Left Anterior Descending Artery Revascularization (n=7919) Hence, the logic underlying the …

The effects of angiotensin-converting enzyme (ACE) inhibition and angiotensin II type 1 receptor blockade (ARB) on fibrinolysis and inflammation after cardiopulmonary bypass (CPB) are uncertain. This study tested the hypothesis that ACE inhibition enhances fibrinolysis and inflammation to a greater extent than ARB in patients undergoing CPB. One week to 5 days before surgery, patients were randomized to ramipril 5 mg/day, candesartan 16 mg/day, or placebo. ACE inhibition increased intraoperative bradykinin and tissue-type plasminogen activator (t-PA ) concentrations as compared to AR B. Both ACE inhibition and AR B decreased the need for plasma transfusion relative to placebo, but only ACE inhibition decreased the duration of hospital stay. Neither ACE inhibition nor AR B significantly affected concentrations of plasminogen activator inhibitor-1 (PAI -1), interleukin (IL )-6, IL -8, or IL -10. ACE inhibition enhanced intraoperative fibrinolysis without increasing the likelihood of red-cell transfusion. By contrast, neither ACE inhibition nor ARB affected the inflammatory response. ACE inhibitors and ARBs may be safely continued until the day of surgery.

Although behaviours associated with territory maintenance are extensively studied, little is known about the establishment of territorial boundaries, a key process influencing individual fitness and population demography. In this regard, conspicuous features of the landscape and constructions such as scent marks (landmarks) can have an effect on whether and where boundaries are established. Landmarked boundaries have also been associated with altered social interactions, particularly contests that take place on boundaries. Some of these landmarks physically constrain a resident’s perception or movement and may thus make the use of space beyond the landmark too costly. Other landmarks are purely conspicuous and appear to have no constraining effect, yet still have strong influences on boundary location by affecting social interactions. Factors that may influence whether a landmark is adopted for a boundary include the properties of the resident, properties of the landmark and the rate of encounter between neighbours. The purpose of this review is to consolidate and explicitly describe hypotheses relating to landmarked boundaries and highlight areas most in need of research. Ultimately, understanding the decision to adopt landmarked boundaries and the implications of these decisions for territorial populations is critical for understanding the link between landscapes, individual decisions and population ecology.

2011;58;2584-2614; originally published online Nov 7, 2011; J. Am. Coll. Cardiol. Winniford Joseph F. Sabik, Ola Selnes, David M. Shahian, Jeffrey C. Trost, and Michael D. A. Lange, Martin J. London, Michael J. Mack, Manesh R. Patel, John D. Puskas, Adolph M. Hutter, Jr, Michael E. Jessen, Ellen C. Keeley, Stephen J. Lahey, Richard Bridges, John G. Byrne, Joaquin E. Cigarroa, Verdi J. DiSesa, Loren F. Hiratzka, L. David Hillis, Peter K. Smith, Jeffrey L. Anderson, John A. Bittl, Charles R. Surgeons Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Developed in Collaboration With the American Association for Thoracic Foundation/American Heart Association Task Force on Practice Guidelines Executive Summary: A Report of the American College of Cardiology 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: This information is current as of January 22, 2012 http://content.onlinejacc.org/cgi/content/full/58/24/2584 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Adler), who responds to the information, sharing his reasoning with the reader (regular type). A discussion by the authors follows. Patient presentation: Mr H is a 61-year-old man with a medical history significant for hypertension, hyperlipidemia, and benign prostatic hyperplasia who was admitted to the medical service with a chief complaint of fevers. Eleven years before presentation, the patient underwent a prostate biopsy for a rapidly rising prostate-specific antigen, and there was no evidence for malignancy. The biopsy was complicated by septicemia, which was treated with antibiotics. Four months before admission, the patient presented to the urology clinic with worsening urinary retention, and the decision was made to proceed to transurethral resection of the prostate. A preoperative workup was significant only for a urine culture growing 1000 colonies of enterococcus, and no antimicrobial treatment was given. He underwent a technically successful transurethral resection of the prostate and was discharged home the next day after passing a voiding trial. Two days after being discharged, the patient had fevers to 102°F and was readmitted to the hospital. He was found to have an Enterococcus faecalis urinary tract infection and was treated with 1 day of intravenous cefepime before being discharged the next day on a 7-day course of amoxicillin–clavulanic acid. On the day after discharge, blood cultures that were drawn on admission grew E faecalis with the same susceptibility pattern cultured from the urine, but there was no alteration in the treatment plan. The patient’s fevers resolved. One month before admission, the patient presented to an outside emergency department with decreased exercise capacity, pleuritic back pain, and malaise. Computed tomography of the chest with contrast identified a right …

Background A simplified minimally invasive mitral valve surgery (MIMVS) approach avoiding cross-clamping and cardioplegic myocardial arrest using a small (5 cm) right antero-lateral incision was developed. We hypothesized that, in high-risk patients and in patients with prior sternotomy, this approach would yield superior results compared to those predicted by the Society of Thoracic Surgeons (STS) algorithm for standard median sternotomy mitral valve surgery. Methods Five hundred and four consecutive patients (249 males/255 females), median age 65 years (range 20-92 years) underwent MIMVS between 1/06 and 8/09. Median preoperative New York Heart Association function class was 3 (range 1-4). Eighty-two (16%) patients had an ejection fraction ≤35%. Forty-seven (9%) had a STS predicted mortality ≥10%. Under cold fibrillatory arrest (median temperature 28°C) without aortic cross-clamp, mitral valve repair (224/504, 44%) or replacement (280/504, 56%) was performed. Results Thirty-day mortality for the entire cohort was 2.2% (11/504). In patients with a STS predicted mortality ≥ 10% (range 10%-67%), the observed 30-day mortality was 4% (2/47), lower than the mean STS predicted mortality of 20%. Morbidity in this high-risk group was equally low: 1 of 47 (2%) patients underwent reexploration for bleeding, 1 of 47 (2%) patients suffered a permanent neurologic deficit, none had wound infection. The median length of stay was 8 days (range 1-68 days). Conclusions This study demonstrates that MIMVS without aortic cross-clamp is reproducible with low mortality and morbidity rates. This approach expands the surgical options for high-risk patients and yields to superior results than the conventional median sternotomy approach.

In externally fertilizing animals in which females mate with multiple males at the same time (simultaneous polyandry), the possibility that females accrue genetic benefits that improve offspring viability remains largely unexamined. Here, we investigate whether simultaneous polyandry influences offspring fitness in a wild population of the Grey Foam Nest Treefrog Chiromantis xerampelina. Simultaneous polyandry in this frog is the most extreme reported for any vertebrate, with more than 90% of females mating with 10 or more males during the deposition of a single clutch. We compared growth (using age and size at metamorphosis as proxies) and survival of offspring produced by females that naturally mated with either 1 male (monandrous females) or 10‐12 males (polyandrous females). Polyandry did not influence size or age at metamorphosis, but we found that offspring from polyandrous matings had both significantly higher mean survival and reduced variance in offspring survival. These findings implicate a genetic mechanism, but targeted cross-classified breeding experiments that control for both maternal and material effects will be required to conclusively determine whether elevated offspring viability is linked to enhanced genetic diversity, intrinsic sire effects, or genetic compatibility. Irrespective of the causation, the findings provide the first evidence that naturally formed polyandrous matings have increased offspring viability in an anuran amphibian. Key words: anuran amphibian, genetic benefits, offspring viability, polyandry, sexual selection. [Behav Ecol]

Surgical therapy for cardiovascular disease carries excellent long-term outcomes but it is relatively invasive. With the development of new devices and techniques, modern cardiovascular surgery is trending toward less invasive approaches, especially for patients at high risk for traditional open heart surgery. A hybrid strategy combines traditional surgical treatments performed in the operating room with treatments traditionally available only in the catheterization laboratory with the goal of offering patients the best available therapy for any set of cardiovascular diseases. Examples of hybrid procedures include hybrid coronary artery bypass grafting, hybrid valve surgery and percutaneous coronary intervention, hybrid endocardial and epicardial atrial fibrillation procedures, and hybrid coronary artery bypass grafting/carotid artery stenting. This multi-disciplinary approach requires strong collaboration between cardiac surgeons, vascular surgeons, and interventional cardiologists to obtain optimal patient outcomes.

A hybrid strategy is a combination of catheter-based therapy and traditional surgical intervention. This concept of combining the tools available only in the catheterization laboratory with the tools available only to the surgeon in order to minimize surgical morbidity has evolved since its implementation in the 1990s.1 Over the past decade, with advancement in stent technology and refinement of minimally invasive surgical approaches, a hybrid strategy has become an attractive alternative to standard surgical or catheter-based techniques. The indications, patient selection, and standardization of these procedures are still under way. Currently, there are no randomized clinical trials on hybrid procedures, and the clinical practice is based on single institutional experiences. The National Heart, Lung, and Blood Institute has just launched the first observational trial on hybrid coronary intervention to define the population eligible for hybrid coronary revascularization (HCR). Until more data become available, the hybrid strategy depends on close collaboration between the surgeon and the cardiologist at single institutions and should be tailored to individual patient needs. Both coronary artery bypass graft (CABG) surgery and conventional percutaneous coronary intervention (PCI) offer certain advantages in the treatment of patients with multivessel coronary artery disease (CAD).2,3 Although CABG provides superior clinical outcomes compared to PCI in certain high-risk patients, including most with diabetes, the majority of patients with left main CAD, and many patients with reduced cardiac function,4,5 it is likely that the major aspect of CABG that confers these benefits is the left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD). The LIMA-to-LAD graft has excellent patency at 10- to 20-year angiographic follow-up,6 setting the gold standard with which other revascularization strategies should be compared. It is important to emphasize that although all patients with significant multivessel coronary disease …

Captive breeding programmes are increasingly relied upon for threatened species management. Changes in morphology can occur in captivity, often with unknown consequences for reintroductions. Few studies have examined the morphological changes that occur in captive animals compared with wild animals. Further, the effect of multiple generations being maintained in captivity, and the potential effects of captivity on sexual dimorphism remain poorly understood. We compared external and internal morphology of captive and wild animals using house mouse (Mus musculus) as a model species. In addition, we looked at morphology across two captive generations, and compared morphology between sexes. We found no statistically significant differences in external morphology, but after one generation in captivity there was evidence for a shift in the internal morphology of captive-reared mice; captive-reared mice (two generations bred) had lighter combined kidney and spleen masses compared with wild-caught mice. Sexual dimorphism was maintained in captivity. Our findings demonstrate that captive breeding can alter internal morphology. Given that these morphological changes may impact organismal functioning and viability following release, further investigation is warranted. If the morphological change is shown to be maladaptive, these changes would have significant implications for captive-source populations that are used for reintroduction, including reduced survivorship.

Background This study reviews a single institution experience with the Carpentier-Edwards pericardial aortic valve bioprosthesis, concentrating on late outcomes. Methods From December 1991 to June 2002, 1,000 patients underwent aortic valve replacement with the Carpentier-Edwards pericardial valve (mean follow-up 6.01 ± 3.56 years). The institutional database was reviewed. Follow-up data were acquired through telephone interviews and mail-in questionnaires. Time-to-event analyses were performed by the Kaplan-Meier method. Mean age was 74.1 years; 545 patients (54.5%) were male. Mean preoperative ejection fraction was 52.5%. Isolated aortic valve replacement occurred in 372 cases (37.2%). Combined aortic valve replacement with coronary artery bypass grafting occurred in 443 cases (44.3%). The remaining 185 patients (18.5%) underwent complex procedures with concomitant mitral, tricuspid, or arch repair. One hundred forty patients (14.0%) had prior aortic valve surgery. Follow-up was 99.4% complete. Results Overall operative mortality was 7.2% (72 of 1,000). There were 503 late deaths (50.3%). Age-stratified survival at 15 years was 43.7% for patients less than 65 years of age; 18.2% for patients aged 65 to 75; and 9.4% for patients aged more than 75 years. There were 26 failed bioprostheses (2.6%) requiring reoperation. Structural valve deterioration was the cause in 13 of 26 cases (50%), endocarditis in 11 of 26 (42%), and perivalvular leak in 2 of 26 (7.6%). Age-stratified freedom from reoperation due to structural valve deterioration at 15 years was 34.7% for patients less than 65 years of age; 89.4% for patients aged 65 to 75; and 99.5% for patients aged more than 75 years. Conclusions The Carpentier-Edwards pericardial bioprosthesis shows long-term durability with low rates of structural failure.

Fundamental knowledge of the optimal hormone concentrations required to stimulate amplexus and spawning in breeding pairs of amphibians is currently lacking, hindering our understanding of the proximate mechanisms underpinning mating behaviour. The present study investigated the effects of: (1) the dose of a gonadotropin-releasing hormone analogue (GnRH-a) administered; (2) male–female hormone administration interval; and (3) topical application of GnRH-a, on spawning success in the northern corroboree frog. Administration of GnRH-a at doses of 0.5, 1.0 and 2.0 μg g−1 were highly successful, with a significantly greater proportion of hormone-treated pairs ovipositing (89–100%) compared with the 0 μg g−1 treatment (22%). Of the hormone-treated pairs, those receiving 0.5 μg g−1 GnRH-a exhibited the highest fertilisation success (61%). Administration of GnRH-a to males and females simultaneously (0 h) was more effective than injecting males either 48 or 24 h before the injection of females. Overall, administration of GnRH-a was highly successful at inducing spawning in northern corroboree frogs. For the first time, we also effectively induced spawning following the topical application of GnRH-a to the ventral pelvic region. Topical application of GnRH-a eliminates the need for specialised training in amphibian injection, and will allow assisted reproductive technologies to be adopted by a greater number of captive facilities globally.

Combined coronary artery valvular heart disease is a major cause of morbidity and mortality in the adult patient population. The standard treatment for such disease has been open heart surgery in which coronary artery bypass grafting (CABG) is performed concurrently with valve surgery using a median sternotomy and cardiopulmonary bypass. With the increasing complexity of patients referred to surgery, some patients may prove to be poor surgical candidates for combined valve and CABG surgery. In certain selected patients who fall into this category, valve surgery and percutaneous coronary intervention (PCI) have been considered a feasible alternative. Conventionally, valve surgery is performed in the cardiac surgical operating room, whereas PCI is carried out in the cardiac catheterization laboratory. Separation of these two procedural suites has presented a logistic limitation because it impedes the concomitant performance of both procedures in one setting. Hence, PCI and valve surgery usually have been performed as a "two-stage" procedure in two different operative suites, with the procedures being separated by hours, days, or weeks. Technologic advancements have made possible the construction of a "hybrid" procedural suite that combines the facilities of a cardiac surgical operating room with those of a cardiac catheterization laboratory. This design has enabled the concept of "one-stage" or "one-stop" PCI and valve surgery, allowing both procedures to be performed in a hybrid suite in one setting, separated by minutes. The advantages of such a method could prove to be multifold by enabling a less invasive surgical approach and improving logistics, patient satisfaction, and outcomes in selected patients.

Graft patency strongly influences early and late outcomes after coronary artery bypass grafting (CABG) surgery. The current standard of care in CABG surgery does not require intraoperative imaging. Because coronary angiography is rarely available in the operating room (OR), other techniques have been developed to assess graft integrity intraoperatively. The 2 most commonly used are the transit time flow measurement (TTFM) and the intraoperative fluorescence imaging (IFI). The TTFM is a quantitative volume flow technique, whereas the IFI is based on the fluorescent properties of indocyanine green. TTFM cannot define the degree of graft stenosis nor discriminate between the influence of the graft conduit and the coronary arteriolar bed on the mean graft flow. IFI provides a "semiquantitative" assessment of the graft patency with images that provide some details about the quality of coronary anastomoses. Both methods are valuable in identifying only at the extremes, that is, either patent or occluded grafts, and can confirm very good grafts; however, neither method is sensitive or specific enough in identifying more subtle abnormalities. These abnormal grafts most likely have poor long-term patency and are predestined to fail. The hybrid suite has the capability of serving both as a complete surgical OR and as a catheterization laboratory. It allows for routine completion angiogram following CABG surgery and identifies abnormal grafts, providing the opportunity to revise them with percutaneous coronary intervention or surgery before leaving the OR.

Objectives: This study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (...

A hybrid strategy combines the treatments traditionally available only in the catheterization laboratory with those traditionally available only in the operating room to offer patients the best available therapies for any given set of cardiovascular lesions. Examples include hybrid coronary revascularization (coronary artery bypass grafting [CABG]/percutaneous coronary intervention [PCI]) wherein a left internal mammary artery graft is placed on the left anterior descending artery (left anterior descending coronary artery [LAD]) either by minimally invasive or open technique and combined with PCI of non-LAD vessels. Other examples include minimally invasive valve surgery combined with PCI to coronary lesions (valve/PCI), to convert a high-risk valve/CABG into a lower-risk isolated minimally invasive valve procedure. Several questions remain unresolved, such as the order in which surgery and PCI should be performed, the duration of the staging of the 2 procedures, antiplatelet strategies, the costs, and the logistics. Other areas in which hybrid approaches are being developed include hybrid endomyocardial/epicardial atrial fibrillation procedures and hybrid aortic arch debranching combined with endovascular grafting for thoracic aortic procedures. The key requirement in all of these approaches is the need for collaboration between cardiac surgeons, vascular surgeons, and interventional cardiologists to obtain optimal patient outcomes.

Sequential polyandry may evolve as an insurance mechanism to reduce the risk of choosing a mate that is infertile, closely related, genetically inferior or incompatible, but polyandry also might insure against nest failure in unpredictable environments. Most animals are oviparous, and in species where males provide nest sites whose quality varies substantially and unpredictably, polyandrous females might insure offspring success by distributing their eggs across multiple nests. Here, we test this hypothesis in a wild population of an Australian terrestrial toadlet, a polyandrous species, where males construct nests and remain with broods. We found that females partitioned their eggs across the nests of two to eight males and that more polyandrous females gained a significant increase in mean offspring survivorship. Our results provide evidence for the most extreme case of sequential polyandry yet discovered in a vertebrate and also suggest that insurance against nest failure might favour the evolution of polyandry. We propose that insurance against nest failure might be widespread among oviparous taxa and provide an important explanation for the prevalence of sequential polyandry in nature.

An increasing number of patients are being referred for mitral valve repair in the redo cardiac surgery setting. The most common clinical scenarios involve prior coronary bypass surgery or aortic valve replacement, each presenting special challenges in terms of gaining valve exposure to enable repair while limiting dissection as much as possible. A right anterior thoracotomy approach is preferred in most patients, coupled with hypothermic fibrillatory arrest. A repeat sternotomy may be favored in select circumstances such as when there is a need for bypass grafting or moderate aortic insufficiency is present. Special attention to cannulation techniques, perfusion conditions, valve exposure, and de-airing maneuvers are all important to ensure good clinical results. Using a tailored approach we have performed mitral valve repair in 22 patients with a patent left internal mammary artery graft following coronary artery bypass grafting between July 1992 and February 2000 with acceptable morbidity and low mortality.

In animals that display acoustically, males may use the presence of conspecifics to choose optimal times for display, and in doing so minimize costs of advertisement while maximizing the probability of mating success. Among anuran amphibians, it is well known that males can adjust their calling behavior in response to fluctuating social conditions. Within a species, it is not known whether males adjust their calling activity differently in response to females, and the immediate chance of mating, than in response to males, and the risk of competition for mates. In the Australian toadlet Pseudophryne bibronii, males construct terrestrial nests and call to advertise territory occupation and to attract potential mates. In this study, I presented either males or females to nesting males and found that male call type, and aspects of call structure, are influenced by the sex presented. More importantly, I found that males called at a significantly higher rate in response to females than in response to males. These results suggest that nesting male toadlets strategically adjust calling behavior according to contingent chances of male–male competition and mate attraction. These findings are unique because they indicate that males do not advertise maximally until there is an immediate chance of mating success.

Among anuran amphibians evidence for chemical communication is scarce. We carried out three experiments to evaluate whether chemosignals influence the sexual behaviour of an Australian terrestrial toadlet, Pseudophryne bibronii. Substrate choice trials (experiment 1) revealed that females preferred to associate with substrate marked by either sex rather than an unmarked substrate and that males preferred substrate marked by females, but avoided substrate marked by other males. These results suggest that the odour of both sexes functions as a sexual attractant and that male odour may also function to repel potential male competitors. In experiment 2 we assessed whether females use male chemosignals during mate location by making gravid females navigate a two-choice Y-maze to reach calling males. Almost invariably, females followed a path outlined with male gland secretions. This result indicates that male chemosignals combined with acoustic signals improve the ability of females to find nest sites. In experiment 3 we tested whether conspecific odour influences the calling behaviour of nesting males. Female odour stimulated a twofold increase in advertisement calling and male odour stimulated a switch to territorial calling. These findings indicate that nesting males use conspecific odour as a cue for regulating investment in acoustic courtship and territory defence. Our results advance a small body of evidence to suggest that anurans use chemosignals to identify and locate potential mates and provide the first demonstration that odour can influence anuran calling behaviour.

Benign intracranial hypertension (BIH) is reported in three children from Australia and one from New Zealand, who were being treated with recombinant human growth hormone (rhGH). Three males and one female, aged between 10.5 and 14.2 y, developed intracranial hypertension within 2 weeks to 3 months of starting treatment. A national database, OZGROW, has been prospectively collecting data on all 3332 children treated with rhGH in Australia and New Zealand from January 1986 to 1996. The incidence of BIH in children treated with growth hormone (GH) is small, 1.2 per 1000 cases overall, but appears to be greater with biochemical GHD (