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Over the last years, the development of offshore renewable energy installations such as offshore wind farms led to an increasing number of man-made structures in marine environments. Since 2009, benthic impact monitoring programs were carried out in wind farms installed in the southern North Sea. We collated and analyzed data sets from three major monitoring programs. Our analysis considered a total of 2849 sampling points converted to a set of biodiversity response metrics. We analyzed biodiversity changes related to the implementation of offshore wind farms and generalized the correlation of these changes with spatial and temporal patterns. Our results demonstrate that depth, season and distance to structure (soft-bottom community) consistently determined diversity indicators and abundance parameters, whereas the age and the country affiliation were significantly related to some but not all indices. The water depth was the most important structuring factor for fouling communities while seasonal effects were driving most of the observed changes in soft-sediment communities. We demonstrate that a meta-analysis can provide an improved level of understanding of ecological patterns on large-scale effects of anthropogenic structures on marine biodiversity, which were not visible in single monitoring studies. We believe that meta-analyses should become an indispensable tool for management of offshore wind farm effects in the future, particularly in the view of the foreseen development of offshore renewable energies. This might lead to a better picture and more comprehensive view on potential alterations. However, this requires a modern open-source data policy and data management, across institutions and across national borders., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Sphingosine-1-phosphate lyase (SGPL1) insufficiency syndrome (SPLIS) is an autosomal recessive multi-system disorder, which mainly incorporates steroid-resistant nephrotic syndrome and primary adrenal insufficiency. Other variable endocrine manifestations are described. In this study, we aimed to comprehensively annotate the endocrinopathies associated with pathogenic SGPL1 variants and assess for genotype-phenotype correlations by retrospectively reviewing the reports of endocrine disease within our patient cohort and all published cases in the wider literature up to February 2022. Glucocorticoid insufficiency in early childhood is the most common endocrine manifestation affecting 64% of the 50 patients reported with SPLIS, and a third of these individuals have additional mineralocorticoid deficiency. While most individuals also have nephrotic syndrome, SGPL1 variants also account for isolated adrenal insufficiency at presentation. Primary gonadal insufficiency, manifesting with microphallus and cryptorchidism, is reported in less than one-third of affected boys, all with concomitant adrenal disease. Mild primary hypothyroidism affects approximately a third of patients. There is paucity of data on the impact of SGPL1 deficiency on growth, and pubertal development, limited by the early and high mortality rate (approximately 50%). There is no clear genotype-phenotype correlation overall in the syndrome, with variable disease penetrance within individual kindreds. However, with regards to endocrine phenotype, the most prevalent disease variant p.R222Q (affecting 22%) is most consistently associated with isolated glucocorticoid deficiency. To conclude, SPLIS is associated with significant multiple endocrine disorders. While endocrinopathy in the syndrome generally presents in infancy, late-onset disease also occurs. Screening for these is therefore warranted both at diagnosis and through follow-up.

Climate change combined with anthropogenic stressors (e.g. overfishing, habitat destruction) may have particularly strong effects on threatened populations of coastal invertebrates. The collapse of the population of European lobster ( Homarus gammarus ) around Helgoland constitutes a good example and prompted a large-scale restocking program. The question arises if recruitment of remaining natural individuals and program-released specimens could be stunted by ongoing climate change. We examined the joint effect of ocean warming and acidification on survival, development, morphology, energy metabolism and enzymatic antioxidant activity of the larval stages of the European lobster. Larvae from four independent hatches were reared from stage I to III under a gradient of 10 seawater temperatures (13-24°C) combined with moderate (∼470 µatm) and elevated (∼1160 µatm) seawater p CO 2 treatments. Those treatments correspond to the shared socio-economic pathways (SSP), SSP1-2.6 and SSP5-8.5 (i.e. the low and the very high greenhouse gas emissions respectively) projected for 2100 by the Intergovernmental Panel on Climate Change. Larvae under the elevated p CO 2 treatment had not only lower survival rates, but also significantly smaller rostrum length. However, temperature was the main driver of energy demands with increased oxygen consumption rates and elemental C:N ratio towards warmer temperatures, with a reducing effect on development time. Using this large temperature gradient, we provide a more precise insight on the aerobic thermal window trade-offs of lobster larvae and whether exposure to the worst hypercapnia scenario may narrow it. This may have repercussions on the recruitment of the remaining natural and program-released specimens and thus, in the enhancement success of future lobster stocks., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Leiva, Tremblay, Torres, Boersma, Krone and Giménez.)

Offshore human activities lead to increasing amounts of underwater noise in coastal and shelf environments, which may affect commercially-important benthic invertebrate groups like the re-stocked Helgoland European lobster (Homarus gammarus) in the German Bight (North Sea). It is crucial to understand the impact tonal low-frequency noises, like maritime transport and offshore energy operations, may have on substrate choice and lobsters' behavior to assess potential benefits or bottlenecks of new hard-substrate artificial offshore environments that become available. In this study, we investigated the full factorial effect of a tonal low-frequency noise and predator presence on young-of-year (YOY) European lobsters' in a diurnal and nocturnal experiment. Rocks and European oyster shells (Ostrea edulis) were offered as substrate to YOY lobsters for 3 h. Video recordings (n = 134) allowed the identification of lobsters' initial substrate choice, diel activity and key behaviors (peeking, shelter construction, exploration and hiding). To ensure independence, YOY lobsters in the intermolt stage were randomly selected and assigned to the experimental tanks and used only once. We provide the first evidence that stressors alone, and in combination, constrain YOY lobsters' initial substrate choice towards rocks. During nighttime, the joint effect of exposure to a constant low-frequency noise and predator presence decreased antipredator behavior (i.e., hiding) and increased exploration behavior. Noise may thus interfere with YOY lobsters' attention and decision-making processes. This outcome pinpoints that added tonal low-frequency noise in the environment have the potential to influence the behavior of early-life stages of European lobsters under predator pressure and highlights the importance of including key benthic invertebrates' community relationships in anthropogenic noise risk assessments. Among others, effects of noise must be taken into consideration in plans involving the multi-use of any offshore area for decapods' stock enhancement, aquaculture, and temporary no-take zones., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: To determine trends in clinical practice for individuals with DSD requiring gonadectomy., Design: Retrospective cohort study., Methods: Information regarding age at gonadectomy according to diagnosis; reported sex; time of presentation to specialist centre; and location of centre from cases reported to the International DSD Registry and who were over 16 years old in January 2019., Results: Data regarding gonadectomy were available in 668 (88%) individuals from 44 centres. Of these, 248 (37%) (median age (range) 24 (17, 75) years) were male and 420 (63%) (median age (range) 26 (16, 86) years) were female. Gonadectomy was reported from 36 centres in 351/668 cases (53%). Females were more likely to undergo gonadectomy (n = 311, P < 0.0001). The indication for gonadectomy was reported in 268 (76%). The most common indication was mitigation of tumour risk in 172 (64%). Variations in the practice of gonadectomy were observed; of the 351 cases from 36 centres, 17 (5%) at 9 centres had undergone gonadectomy before their first presentation to the specialist centre. Median age at gonadectomy of cases from high-income countries and low-/middle-income countries (LMIC) was 13.0 years (0.1, 68) years and 16.5 years (1, 28), respectively (P < 0.0001) with the likelihood of long-term retention of gonads being higher in LMIC countries., Conclusions: The likelihood of gonadectomy depends on the underlying diagnosis, sex of rearing and the geographical setting. Clinical benchmarks, which can be studied across all forms of DSD will allow a better understanding of the variation in the practice of gonadectomy.

Objectives: Create and evaluate the effectiveness of a structured education program in children and young people (CYP) with type 1 diabetes using continuous glucose monitoring (CGM)., Design and Methods: Step 1: CGM devices were evaluated for predetermined criteria using a composite score. Step 2: The education program was developed following review of international structured education guidance, dynamic glucose management (DynamicGM) literature, award-winning diabetes educators' websites, and CGM user feedback. Step 3: Program effectiveness was assessed at six months by change in time below range (TBR) (<3.9mmol/L), time in range (TIR) (3.9-10.0mmol/L), time above range level 2 (TAR2) (>13.9mmol/L), severe hypoglycemia and HbA1c using a paired T-test. A DynamicGM score was developed to assess proactive glucose management. Factors predicting TBR and TIR were assessed using regression analysis., Results: Dexcom G6 was chosen for integrated CGM (iCGM) status and highest composite score (29/30). Progressive DynamicGM strategies were taught through five sessions delivered over two months. Fifty CYP (23 male) with a mean (±SD) age and diabetes duration of 10.2 (±4.8) and 5.2 (±3.7) years respectively, who completed the education program were prospectively evaluated. Evaluation at six months showed a significant reduction in TBR (10.4% to 2.1%, p<.001), TAR2 (14.1% to 7.3%, p<.001), HbA1c [7.4 to 7.1% (57.7 to 53.8 mmol/mol), p<.001] and severe hypoglycemic episodes (10 to 1, p<.05); TIR increased (47.4% to 57.0%, p<.001). Number of Dexcom followers (p<.05) predicted reduction in TBR and DynamicGM score (p<.001) predicted increased TIR., Conclusion: Teaching DynamicGM strategies successfully improves TIR and reduces hypoglycemia., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Although congenital adrenal hyperplasia (CAH) is known to be associated with adrenal crises (AC), its association with patient- or clinician-reported sick day episodes (SDE) is less clear., Methods: Data on children with classic 21-hydroxylase deficiency CAH from 34 centers in 18 countries, of which 7 were Low or Middle Income Countries (LMIC) and 11 were High Income (HIC), were collected from the International CAH Registry and analyzed to examine the clinical factors associated with SDE and AC., Results: A total of 518 children-with a median of 11 children (range 1, 53) per center-had 5388 visits evaluated over a total of 2300 patient-years. The median number of AC and SDE per patient-year per center was 0 (0, 3) and 0.4 (0.0, 13.3), respectively. Of the 1544 SDE, an AC was reported in 62 (4%), with no fatalities. Infectious illness was the most frequent precipitating event, reported in 1105 (72%) and 29 (47%) of SDE and AC, respectively. On comparing cases from LMIC and HIC, the median SDE per patient-year was 0.75 (0, 13.3) vs 0.11 (0, 12.0) (P < 0.001), respectively, and the median AC per patient-year was 0 (0, 2.2) vs 0 (0, 3.0) (P = 0.43), respectively., Conclusions: The real-world data that are collected within the I-CAH Registry show wide variability in the reported occurrence of adrenal insufficiency-related adverse events. As these data become increasingly used as a clinical benchmark in CAH care, there is a need for further research to improve and standardize the definition of SDE., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In this article international trends in surgical practice in girls with congenital adrenal hyperplasia (CAH) are evaluated. All cases that had been classified in the I-CAH/I-DSD registry as 46,XX CAH and who were born prior to 2017 were identified. Centers were approached to obtain information on surgical decision making. Of the 330 included participants, 208 (63.0%) presented within the first month of life, and 326 (98.8%) cases were assigned female. Genital surgery had been performed in 250 (75.8%). A total of 64.3, 89.2, and 96.8% of cases residing in Europe, South America and Asia, respectively, had at least one surgery. In a logistic regression model for the probability of surgery before the second birthday (early surgery) over time an increase of probability for early vaginal surgery could be identified, but not for clitoral surgery or both surgeries combined. Genitoplasty in girls with CAH remains controversial. This large international study provides a snapshot of current practice and reveals geographical and temporal differences. Fewer surgeries were reported for Europe, and there seems to be a significant trend towards aiming for vaginal surgery within the first 2 years of life., (© 2021 The Author(s). Published by S. Karger AG, Basel.)

Context: No consensus exists for optimization of mineralocorticoid therapy in patients with primary adrenal insufficiency., Objective: To explore the relationship between mineralocorticoid (MC) replacement dose, plasma renin concentration (PRC), and clinically important variables to determine which are most helpful in guiding MC dose titration in primary adrenal insufficiency., Design: Observational, retrospective, longitudinal analysis., Patients: A total of 280 patients (with 984 clinical visits and plasma renin measurements) with primary adrenal insufficiency were recruited from local databases and the international congenital adrenal hyperplasia (CAH) registry (www.i-cah.org). Thirty-seven patients were excluded from the final analysis due to incomplete assessment. Data from 204 patients with salt-wasting CAH (149 adults and 55 children) and 39 adult patients with Addison disease (AD) were analysed., Main Outcome Measures: PRC, electrolytes, blood pressure (BP), and anthropometric parameters were used to predict their utility in optimizing MC replacement dose., Results: PRC was low, normal, or high in 19%, 36%, and 44% of patients, respectively, with wide variability in MC dose and PRC. Univariate analysis demonstrated a direct positive relationship between MC dose and PRC in adults and children. There was no relationship between MC dose and BP in adults, while BP increased with increasing MC dose in children. Using multiple regression modeling, sodium was the only measurement that predicted PRC in adults. Longitudinally, the change in MC dose was able to predict potassium, but not BP or PRC., Conclusions: The relationship between MC dose and PRC is complex and this may reflect variability in sampling with respect to posture, timing of last MC dose, adherence, and concomitant medications. Our data suggest that MC titration should not primarily be based only on PRC normalization, but also on clinical parameters such as BP and electrolyte concentration., (© Endocrine Society 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Monitoring of hormonal control represents a key part of the management of congenital adrenal hyperplasia (CAH). Monitoring strategies remain suboptimal because they rely on frequent blood tests and are not specific for adrenal-derived hormones. Recent evidence suggests the crucial role of adrenal-specific 11-oxygenated-C19 androgens in the pathogenesis of CAH., Objective: To establish a correlation between plasma and salivary adrenal-specific androgens in CAH as a noninvasive monitoring strategy., Design: This prospective cross-sectional study recruited patients between 2015 and 2018., Setting: Multicenter study including 13 tertiary centers in the United Kingdom., Participants: Seventy-eight children with CAH and 62 matched healthy controls., Methods: Using liquid chromatography-tandem mass spectrometry, plasma and salivary concentrations of five steroids were measured: 17-hydroxyprogesterone (17OHP), androstenedione (A4), testosterone (T), 11-hydroxyandrostenedione (11OHA4), and 11-ketotestosterone (11KT). The correlation between plasma and salivary steroids was analyzed to assess their use in clinical practice., Results: Strong correlations between plasma and salivary steroid concentrations in patients with CAH were detected: 17OHP (rs = 0.871; P < 0.001), A4 (rs = 0.931; P < 0.001), T (rs = 0.867; P < 0.001), 11OH4A (rs = 0.876; P < 0.001), and 11KT (rs = 0.944; P < 0.001). These results were consistent for patient subgroups based on sex and age. Analysis of patient subgroups based on 17OHP concentrations established clear correlations between plasma and salivary concentrations of the adrenal-specific androgen 11KT., Conclusions: The current study identified tight correlations between plasma and saliva for the adrenal-derived 11-oxygenated C19 androgen 11KT, as well as 17OHP and A4, which are widely used for monitoring treatment in CAH. This combination of steroid hormones will serve as an improved noninvasive salivary test for disease monitoring in patients with CAH., (Copyright © 2019 Endocrine Society.)

Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines provide a class I recommendation for patients with type 2 diabetes mellitus and multivessel coronary artery disease (CAD) to be treated with coronary artery bypass graft surgery (CABG). However, these patients are heterogeneous in terms of the risks and benefits associated with CABG. We sought to develop a risk score to identify low-risk patients with diabetes and multivessel CAD in whom CABG can be safely deferred., Methods: Patients in the CABG strata randomized to intensive medical therapy (IMT) in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial who experienced death, myocardial infarction (MI), or stroke were compared with those who did not. We developed a risk score for death, MI, or stroke using a Cox proportional hazards model that included the following variables: age, history of heart failure, history of hypercholesterolemia, history of stroke, transient ischemic attack, serum creatinine, insulin use, myocardial jeopardy index, and HbA1c., Results: Among patients with a risk score less than the median, those randomized to IMT or prompt CABG experienced similar rates of event-free survival at 5 years (77.8% vs. 83.2%, logrank P  = 0.24). Among patients with a risk score greater than the median, those randomized to IMT experienced worse rates of event-free survival at 5 years than those randomized to prompt CABG (60.3% vs 73.2%, logrank P  = 0.01)., Conclusions: A novel risk score identifies low-risk patients with diabetes and stable, symptomatic multivessel CAD in whom CABG can be safely deferred., Competing Interests: The Human Research Protection Office at Washington University granted this study exemption from Institutional Review Board oversight. Patients enrolled in the original BARI 2D trial provided informed consent and the study received ethics approval at each of the enrolling sites.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Mixtures of group-based Markov models of evolution correspond to joins of toric varieties. In this paper, we establish a large number of cases for which these phylogenetic join varieties realize their expected dimension, meaning that they are nondefective. Nondefectiveness is not only interesting from a geometric point-of-view, but has been used to establish combinatorial identifiability for several classes of phylogenetic mixture models. Our focus is on group-based models where the equivalence classes of identified parameters are orbits of a subgroup of the automorphism group of the abelian group defining the model. In particular, we show that for these group-based models, the variety corresponding to the mixture of r trees with n leaves is nondefective when [Formula: see text]. We also give improved bounds for claw trees and give computational evidence that 2-tree and 3-tree mixtures are nondefective for small n.

Environmental exposure to organic endocrine disrupting chemicals, including dioxins, dibenzofurans, bisphenol A (BPA), and phthalates has been associated with neurodevelopmental disorders, including autism spectrum disorder (ASD). We conducted a pilot monitoring study of 30 ASD cases and 10 typically developing (TD) controls ages 2-8 years from communities along the Gulf of Mexico near Alabama, which houses 14 Superfund sites, to assess the concentrations of dioxins and dibenzofurans in serum, and BPA and phthalate ester metabolites in urine. Based on General Linear Models, the lipid- or creatinine-adjusted geometric mean concentrations of the aforementioned chemicals did not differ between the ASD case and TD control groups (all p ≥ 0.27). We compared our findings to the adjusted means as reported by the National Health and Nutrition Examination Survey, survey years 2011-2012, and found that TD controls in our study had lower BPA (59%) and MEHHP (26%) concentrations, higher MBP (50%) concentration, and comparable (<20% difference) MEP, MBZP, MEOHP, and MCPP concentrations. We also conducted a preliminary investigation of dietary exposures and found that the consumption of certain types of fish may be associated with higher OCDD concentrations, and the consumption of soft drinks and juices may be associated with lower BPA and MEOHP concentrations, respectively., Competing Interests: The authors declare no conflict of interest.

Much has been written about brainstorming and prototyping in medical devices. These 2 topics are the crucial ingredients to innovation; which, if well seeded by organized and structured forays into each, will net much higher quality and more valuable results. Structure and process, although slightly counterintuitive as applied to brainstorming and prototyping, can greatly improve the value proposition of the innovation itself., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Poor growth and delayed puberty in children with cerebral palsy is frequently felt to be related to malnutrition. Although growth hormone deficiency is commonly described in these children, multiple pituitary hormone deficiency (MPHD) has not been previously reported. We present a series of four children with cerebral palsy who were born before 29 weeks gestation who were referred to the regional endocrinology service, three for delayed puberty and one for short stature, in whom investigations identified MPHD. All patients had a height well below -2 standard deviation score (2nd centile) at presentation and three who had MRI scans had an ectopic posterior pituitary gland. We therefore recommend that the possibility of MPHD should be considered in all children with cerebral palsy and poor growth or delayed puberty. Early diagnosis and treatment is essential to maximise growth and prevent associated morbidity and mortality., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Primary adrenal insufficiency is life threatening and can present alone or in combination with other comorbidities. Here, we have described a primary adrenal insufficiency syndrome and steroid-resistant nephrotic syndrome caused by loss-of-function mutations in sphingosine-1-phosphate lyase (SGPL1). SGPL1 executes the final decisive step of the sphingolipid breakdown pathway, mediating the irreversible cleavage of the lipid-signaling molecule sphingosine-1-phosphate (S1P). Mutations in other upstream components of the pathway lead to harmful accumulation of lysosomal sphingolipid species, which are associated with a series of conditions known as the sphingolipidoses. In this work, we have identified 4 different homozygous mutations, c.665G>A (p.R222Q), c.1633&#95;1635delTTC (p.F545del), c.261+1G>A (p.S65Rfs*6), and c.7dupA (p.S3Kfs*11), in 5 families with the condition. In total, 8 patients were investigated, some of whom also manifested other features, including ichthyosis, primary hypothyroidism, neurological symptoms, and cryptorchidism. Sgpl1-/- mice recapitulated the main characteristics of the human disease with abnormal adrenal and renal morphology. Sgpl1-/- mice displayed disrupted adrenocortical zonation and defective expression of steroidogenic enzymes as well as renal histology in keeping with a glomerular phenotype. In summary, we have identified SGPL1 mutations in humans that perhaps represent a distinct multisystemic disorder of sphingolipid metabolism.

There is an increasing awareness and clinical interest in cardiac safety during cancer therapy as well as in optimally addressing cardiac issues in cancer survivors. Although there is an emerging expertise in this area, known as cardio-oncology, there is a lack of organization in the essential components of contemporary training. This proposal, an international consensus statement organized by the International Cardioncology Society and the Canadian Cardiac Oncology Network, attempts to marshal the important ongoing efforts for training the next generation of cardio-oncologists. The necessary elements are outlined, including the expectations for exposure necessary to develop adequate training. There should also be a commitment to local, regional, and international education and research in cardio-oncology as a requirement for advancement in the field., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The comparative analysis of marine litter in different marine compartments has rarely been attempted. In this study, long-term time series of marine litter abundance on the seafloor and on the coast, both from the southeastern North Sea, were analyzed for temporal trends and correlations. On four beach sections of 100 m length, mean abundances of total beach litter collected four times a year from 2002 to 2008 varied between 105 and 435 items. Mean densities of total inorganic litter on the seafloor amounted to 10.6 ± 9.7 kg km(-2) in the offshore region (2001-2010) and 13.7 ± 12.6 kg km(-2) in the Wadden Sea (1998-2007), respectively. In the offshore region, there was no significant long-term trend, while in the Wadden Sea, densities of marine litter declined significantly. Correlations between time series were weak, indicating different sources and transport processes responsible for compositions of beach litter and litter on the seafloor. Decreases in inputs from fisheries and substantial export due to resuspension are discussed as reasons for the decrease in litter on the seafloor in the Wadden Sea., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Aims: Hospitalization for worsening heart failure (HF) is known to increase mortality and morbidity risk and has been frequently used as an endpoint in randomized clinical trials. Whether outpatient management of HF exacerbation carries similar prognostic and therapeutic information is less well known, but could be important for the design of trials that use HF hospitalization as an endpoint., Methods and Results: MADIT-CRT randomized patients with mild HF symptoms to resynchronization therapy vs. control with an average follow-up of 3.3 years and a total of 191 deaths. HF events were centrally adjudicated for receiving i.v. decongestive therapy in an outpatient setting, or an augmented HF regimen during a hospital stay. Patients were compared according to whether their first HF was an out- or inpatient event. The first primary event was non-fatal outpatient HF, non-fatal inpatient HF, and death in 52, 331, and 78 patients, respectively. Patients with inpatient HF tended to be older and more likely to have HF of ischaemic aetiology than subjects who developed outpatient HF events. The risk of death following either type of non-fatal HF events was extremely high [hazard ratio (HR) 12.4, 95% confidence interval (CI) 9.1-16.9 for inpatient HF; HR 10.7, 95% CI 6.1-18.7 for outpatient HF] compared with subjects without non-fatal HF events. Allocation to CRT-D was associated with significant reduction in both types of HF., Conclusion: Outpatient management of worsening HF portends a high risk of death, similar to inpatient HF events, and may be equally sensitive to the effects of therapy. These findings suggest that outpatient HF events should be considered in publicly reported outcomes measures and future HF clinical trials., Trial Registration: NCT01294449., (© 2014 The Authors. European Journal of Heart Failure © 2014 European Society of Cardiology.)

We present a method of characterizing the nonlinear stress-strain behavior of thin films of extremely soft, water-based polymer gels using uniaxial tension testing of bilayer laminates, in conjunction with methods of membrane nonlinear elasticity. A custom tensile testing apparatus is used to conduct quasi-static, uniaxial extension tests of narrow strips of thin, laminated sheets of bonded hydrogel and silicone rubber, submerged in a saline bath. The tensile load is measured via sensitive load cell and the position of material markers, at a central test-section of the sample, is optically tracked via digital image tracking methods. Stress-strain relationships are calculated for the hydrogel component of the bilayer, considered hyperelastic, homogeneous, isotropic, and incompressible, using membrane theories of finite hyperelasticity. We present the stress response for strains up to about 35% for poly(ethylene glycol) (PEG)-based hydrogels (>90% water) with polymer concentrations by weight of 5% to 10%. Polynomial functions are fit to the data for each formulation, whereby the one-dimensional strain-energy function for each formulation is determined by taking the indefinite integral., (© 2013 Elsevier Ltd. All rights reserved.)

Coronary steal could develop in patients with chronic coronary artery disease (CAD) with collateral circulation, and adversely affect ventricular function and long-term clinical outcome. Poorly developed collaterals are more prone than well-developed collaterals to withdrawing their blood support to the collateralized myocardium due to higher collateral pathway resistance and lower vasodilatory reserve of the collateral bed. Even with well-developed coronary collaterals, coronary steal could still occur when perfusion pressure in the donor artery becomes low, or the recipient microvasculature is maximally dilated with exhaustion of vasodilatory reserve. The evaluation of distinctive coronary collateral function with or without steal provides important therapeutic and prognostic information in patients with chronic CAD. However, due to lack of reliable assessment methods, the detection and quantitative measurement of coronary steal remains a challenge. In this article, we present typical clinical scenarios to illustrate the major mechanisms underlying coronary steal in patients with chronic CAD and coronary collateral circulation, and review invasive and noninvasive methods currently available to assess coronary steal in myocardium supplied by coronary collaterals. We specifically focus on recent advances in the resting and stress echocardiography with speckle tracking techniques., (© 2013, Wiley Periodicals, Inc.)

Introduction: The increase in detected vitamin D deficiency appears to be multifactorial: an increasingly multicultural society, reduced exposure to sunlight due to concern about skin cancer and a more sedentary lifestyle and dietary changes within the population., Methods: This was a retrospective survey of children found to be vitamin D deficient after attending the emergency department from March 2009 until March 2010. These data were then subdivided according to their age, ethnic origin, presenting complaint and biochemical associated features., Results: We identified 89 patients with a low vitamin D level (total vitamin D levels less than 50 nmol/l), with 83% of those having very low vitamin D levels (less than 25 nmol/l). The most common presenting features were abdominal pain (19%), a seizure (17%) and limb pain (15%). The most common ethnic origins in our series were Pakistani (37%) followed by black African (11.2%)., Conclusions: Vitamin D deficiency should be considered in children with pigmented skin presenting with a range of symptoms. The detected vitamin D deficiency probably represents only a very small proportion of the vitamin D deficiency in children in Birmingham.

Objectives: The purpose of this study was to compare in-hospital outcomes of percutaneous coronary intervention (PCI) in extreme obesity (EO) (body mass index [BMI] ≥ 40 kg/m²) with those of normal-weight (NW) patients and to examine the influence of access site on outcomes., Background: Little is known about the outcomes of PCI in EO patients., Methods: We analyzed CathPCI Registry data from patients who underwent radial or femoral PCI and were discharged between July 2009 and June 2011 and compared in-hospital outcomes of EO (N = 83,861) with those of NW patients (BMI 20 to 25 kg/m²; N = 217,616). Outcomes included in-hospital mortality and procedural and bleeding complications. Multivariable logistic regression models were used to assess the independent association of EO with outcomes, using previously validated risk models derived from the CathPCI Registry. The role of access site was specifically examined., Results: Compared with NW patients, EO patients were younger (median age 60 vs. 69 years), more likely female (47% vs. 37%), and more likely African American (12% vs. 7%). EO patients had lower unadjusted mortality (1.2% vs. 2.0%); however, after multivariable adjustment, EO was independently associated with increased risk of in-hospital mortality (odds ratio: 1.22; 95% CI: 1.08 to 1.39) in those presenting with ST-segment elevation myocardial infarction (STEMI). Access site had no effect on bleeding or outcome., Conclusions: EO patients who underwent PCI were younger and had less bleeding compared with NW patients. After multivariable adjustment for risk, EO was independently associated with higher in-hospital mortality overall and particularly in the patients undergoing STEMI., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

An increasing number of academic senior physicians are approaching their potential retirement in good health with accumulated clinical and research experience that can be a valuable asset to an academic institution. Considering the need to let the next generation ascend to leadership roles, when and how should a medical career be brought to a close? We explore the roles for academic medical faculty as they move into their senior years and approach various retirement options. The individual and institutional considerations require a frank dialogue among the interested parties to optimize the benefits while minimizing the risks for both. In the United States there is no fixed age for retirement as there is in Europe, but European physicians are initiating changes. What is certain is that careful planning, innovative thinking, and the incorporation of new patterns of medical practice are all part of this complex transition and timing of senior academic physicians into retirement., (Copyright © 2013 Elsevier Inc. All rights reserved.)

In the light of the introduction of thousands of large offshore wind power foundations into the North Sea within the next decades, this manuscript focuses on the biofouling processes and likely reef effects. The study explores the macrozoobenthos (biofouling) colonization at an offshore platform which is comparable to offshore wind turbine foundations. A total of 183 single samples were taken and the parameters water depth and time were considered comparing biofouling masses and communities. The blue mussel Mytilus edulis, Anthozoa and the Amphipoda Jassa spp. were the dominant species. The community from the 1 m zone and those from the 5 and 20-28 m zones can clearly be differentiated. The 10 m zone community represents the transition between the M. edulis dominated 1 m and 5 m zones and the Anthozoa dominated 20-28 m zone. In the future offshore wind farms, thousands of wind turbine foundations will provide habitat for a hard bottom fauna which is otherwise restricted to the sparse rocky habitats scattered within extensive sedimentary soft bottoms of the German Bight. However, offshore wind power foundations cannot be considered natural rock equivalents as they selectively increase certain natural hard bottom species. The surface of the construction (1280 m²) was covered by an average of 4300 kg biomass. This foundation concentrates on its footprint area (1024 m²) 35 times more macrozoobenthos biomass than the same area of soft bottom in the German exclusive economic zone (0.12 kg m(-2)), functioning as a biomass hotspot. Concerning the temporal biomass variation, we assume that at least 2700 kg biomass was exported on a yearly basis. 345 × 10(4) single mussel shells of different sizes were produced during the study period. It is anticipated that the M. edulis abundance will increase in the North Sea due to the expansion of the offshore wind farm development. This will result in the enhanced production of secondary hard substrate (mussel shells) and its associated fauna and will intensify filtration rates of the seawater. This predicted ecological system change is coined the 'Mytilusation' of the German Bight., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to evaluate the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for exercise testing (EXT) after successful coronary revascularization (CR) using the Bypass Angioplasty Revascularization Investigation experience., Background: The ACC/AHA guidelines state that EXT within three years of successful CR is not useful., Methods: The 1,678 patients randomized to CR by either angioplasty or bypass surgery were required to take symptom-limited treadmill tests one, three and five years after revascularization., Results: Patients who took the test at each specified time had a much lower subsequent two-year mortality than those who did not (1.9% vs. 9.4%, 3.5% vs. 12.6% and 3.3% vs. 11.0% at one, three and five years, respectively, after CR [p < 0.0001 for each]). Exercise parameters at the one- and three-year test did not improve a multivariable model of survival after including clinical parameters. Exercising to Bruce stage 3 or generating a Duke score >-6 were independently predictive of two-year survival after the five-year test. ST depression on the one-year test was associated with more revascularizations (relative risk = 1.6; p < 0.001)., Conclusions: Patients with stable multivessel coronary disease who took a protocol-mandated exercise test at one, three and five years after revascularization were at low risk for mortality in the two years subsequent to each test. Exercise parameters did not improve prediction of mortality in the two years after the one- and three-year tests. The ACC/AHA guidelines on exercise testing after CR (no value for routine testing in stable patients for three years after revascularization) are supported by these results.

Objectives: This study was designed to determine the effect of coronary stents on in-hospital mortality., Background: Despite extensive use of stents for percutaneous coronary interventions (PCIs), their effect on serious in-hospital events, especially mortality, is not well defined., Methods: A cohort study was performed using 16,811 consecutive native-vessel PCI procedures performed on patients in the Society for Cardiac Angiography & Interventions Registry from July 1, 1996, through December 31, 1998. Patients undergoing balloon-only angioplasty were compared with those receiving a planned or unplanned stent. Procedures with other devices were excluded. Multivariable analyses adjusted for detailed clinical characteristics and for individual laboratory., Results: Stents were associated with a significant reduction in in-hospital mortality (0.3%) compared with balloon procedures (0.6%; multivariable odds ratio [OR] 0.55; 95% confidence interval [CI] 0.34, 0.89; p = 0.014). The risk of emergency coronary bypass also was reduced by stenting (0.3% vs. 0.7%; multivariable OR 0.47; 95% CI: 0.29, 0.76; p = 0.002). Adjustment for the use of glycoprotein IIb/IIIa inhibitors did not change the results, and the effects of stenting relative to balloon procedures were similar in those procedures with and without glycoprotein IIb/IIIa blockade (p = 0.94)., Conclusions: This study suggests that coronary stenting, compared with balloon procedures, reduces in-hospital mortality, independent of the clinical setting.

This report of the Registry for the Society for Cardiac Angiography and Interventions provides data on the trends in coronary interventional procedures from the time period June 1966 through December 1998. A total of 19,510 consecutive coronary interventional procedures were recorded. Over this time period, significant trends in coronary stent implantation were recorded along with a decreasing reliance on balloon angioplasty as sole therapy. Patients with acute myocardial infarction comprised an increased fraction of all procedures. Almost half of all interventions were performed in patients with multivessel disease. Finally, decreasing rates of in-hospital death and emergent bypass surgery compared to prior reports from the registry characterize the current practice of interventional cardiology. Cathet. Cardiovasc. Intervent. 49:19-22, 2000., (Copyright 2000 Wiley-Liss, Inc.)

Background: Thrombosis is a pivotal event in the pathogenesis of coronary disease. We hypothesized that the presence of blood factors that reflect enhanced thrombogenic activity would be associated with an increased risk of recurrent coronary events during long-term follow-up of patients who have recovered from myocardial infarction., Methods and Results: We prospectively enrolled 1045 patients 2 months after an index myocardial infarction. Baseline thrombogenic blood tests included 6 hemostatic variables (D-dimer, fibrinogen, factor VII, factor VIIa, von Willebrand factor, and plasminogen activator inhibitor-1), 7 lipid factors [cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, lipoprotein(a), apolipoprotein (apo)A-I, and apoB], and insulin. Patients were followed up for an average of 26 months, with the primary end point being coronary death or nonfatal myocardial infarction, whichever occurred first. The hemostatic, lipid, and insulin parameters were dichotomized into their top and the lower 3 risk quartiles and evaluated for entry into a Cox survivorship model. High levels of D-dimer (hazard ratio, 2.43; 95% CI, 1.49, 3.97) and apoB (hazard ratio, 1.82; 95% CI, 1.10, 3.00) and low levels of apoA-I (hazard ratio, 1.84; 95% CI, 1.10, 3.08) were independently associated with recurrent coronary events in the Cox model after adjustment for 6 relevant clinical covariates., Conclusions: Our findings indicate that a procoagulant state, as reflected in elevated levels of D-dimer, and disordered lipid transport, as indicated by low apoA-1 and high apoB levels, contribute independently to recurrent coronary events in postinfarction patients.

Background: Patients with treated diabetes in the randomized-trial segment of the Bypass Angioplasty Revascularization Investigation (BARI) who were randomized to initial revascularization with PTCA had significantly worse 5-year survival than patients assigned to CABG. This treatment difference was not seen among diabetic patients eligible for BARI who opted to select their mode of revascularization. We hypothesized that differences in patient characteristics, assessed and unmeasured, together with the treatment selection in the registry, at least partially account for this discrepancy., Methods and Results: Among diabetics taking insulin or oral hypoglycemic drugs at entry, angiographic and clinical presentations were comparable between randomized and registry patients. However, more registry patients were white, and registry diabetics tended to be more educated and more physically active and to report better quality of life. Procedural characteristics and in-hospital complications were comparable. The 5-year all-cause mortality rate was 34.5% in randomized diabetic patients assigned to PTCA versus 19.4% in CABG patients (P=0.0024; relative risk [RR]=1.87); corresponding cardiac mortality rates were 23.4% and 8.2%, respectively (P=0.0002; RR=3.10). The CABG benefit was more apparent among patients requiring insulin. In the registry, all-cause mortality was 14.4% for PTCA versus 14.9% for CABG (P=0.86, RR=1.10), with corresponding cardiac mortality rates of 7.5% and 6. 0%, respectively (P=0.73; RR=1.07). These RRs in the registry increased to 1.29 and 1.41, respectively, after adjustment for all known differences between treatment groups., Conclusions: BARI registry results are not inconsistent with the finding in the randomized trial that initial CABG is associated with better long-term survival than PTCA in treated diabetic patients with multivessel coronary disease suitable for either surgical or catheter-based revascularization.

Patients with coronary disease react differently to ischemia. Some (types I and II) experience no symptoms, while most patients with silent ischemia have both symptomatic and asymptomatic ischemia. The best evidence suggests that prognosis is determined by the amount of ischemia, not its presentation. In addition, in these patients, silent ischemia during daily living is not common. Prospective prognostic studies have not been performed in patients who do not experience angina with ischemia, therefore treatment must be individualized in these patients, considering the lack of a "warning system".

Objectives: Our objectives were to identify and define a minimum set of variables for interventional cardiology that carried the most statistical weight for predicting adverse outcomes. Though "gaming" cannot be completely avoided, variables were to be as objective as possible and reproducible and had to be predictive of outcome in current databases., Background: Outcomes of percutaneous coronary interventions depend on patient risk characteristics and disease severity and acuity. Comparing results of interventions has been difficult because definitions of similar variables differ in databases, and variables are not uniformly tracked. Identifying the best predictor variables and standardizing their definitions are a first step in developing a universal stratification instrument., Methods: A list of empirically derived variables was first tested in eight cardiac databases (158,273 cases). Three end points (in-hospital death, in-hospital coronary artery bypass graft surgery, Q wave myocardial infarction) were chosen for analysis. Univariate and multivariate regression models were used to quantify the predictive value of the variable in each database. The variables were then defined by consensus by a panel of experts., Results: In all databases patient demographics were similar, but disease severity varied greatly. The most powerful predictors of adverse outcome were measures of hemodynamic instability, disease severity, demographics and comorbid conditions in both univariate and multivariate analyses., Conclusions: Our analysis identified 29 variables that have the strongest statistical association with adverse outcomes after coronary interventions. These variables were also objectively defined. Incorporation of these variables into every cardiac dataset will provide uniform standards for data collected. Comparisons of outcomes among physicians, institutions and databases will therefore be more meaningful.

Objectives: This study was designed to determine the risk of performing percutaneous transluminal coronary angioplasty (PTCA) at the time of diagnostic catheterization ("combined procedures")., Background: Health care providers are under increasing pressure to combine diagnostic and interventional coronary procedures to reduce costs. However, the risk associated with combined procedures has not been rigorously assessed., Methods: A multicenter cohort study of 35,700 patients undergoing elective PTCA from 1992 through 1995 was performed to determine the risk of major complications (myocardial infarction, emergency coronary artery bypass graft surgery or death) from combined relative to staged procedures (i.e., performing PTCA at a session subsequent to diagnostic catheterization)., Results: The risks of major complications from combined and staged procedures were 2.0% and 1.6%, respectively (unadjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.05 to 1.57). After adjusting for clinical and angiographic differences and clustering by laboratory, the risk from combined procedures was not significantly elevated (multivariable OR 1.18, 95% CI 0.89 to 1.55). However, several subgroups of patients did have an increased risk from combined procedures: patients with multivessel disease (multivariable OR 1.64, 95% CI 1.13 to 2.39); women (multivariable OR 1.64, 95% CI 1.05 to 2.55); patients > 65 years old (multivariable OR 1.40, 5% CI 1.02 to 1.93); and patients undergoing multilesion PTCA (multivariable OR 1.53, 95% CI 1.06 to 2.21). The risk of combined relative to staged procedures decreased over the 4-year period (multivariable p = 0.029)., Conclusions: Combining PTCA with diagnostic catheterization appears to be safe in many patients. However, several subgroups of patients may be at increased risk. Careful patient selection will most likely remain critical to ensuring the safety of combined procedures.

Objectives: The purpose of this study was to determine predictors of successful coronary angioplasty for acute myocardial infarction (MI) and associated predictors of the major complications of in-hospital mortality and emergency coronary artery bypass graft surgery., Background: Primary angioplasty is being increasingly used to treat acute MI, but factors affecting the success and major complications have not been well studied. Forty laboratories have been contributing clinical and procedural data to the Society of Cardiac Angiography and Interventions (SCA&I) on primary angioplasty for acute MI., Methods: Univariable and stepwise multivariable logistic regression analysis of clinical and procedural variables was used to calculate predictors of success and major complications., Results: There were 4,366 primary angioplasty procedures reported from 1990 through 1994, with an overall success rate of 91.5%, an in-hospital mortality rate of 2.5% and a rate of emergency surgery of 4.3%. Higher laboratory primary angioplasty volume and lower age were predictive of success. An intraaortic balloon pump in place, cardiogenic shock and a moribund condition had negative predictive effects. Unsuccessful angioplasty, cardiogenic shock or a moribund state were predictive of in-hospital death. Unsuccessful angioplasty, the absence of a history of hypertension and the absence of congestive heart failure were predictive of emergency surgery., Conclusions: The rates of success and major complications in the SCA&I Registry are similar to other series. Predictors of success and major complications can be assessed and may be useful for risk stratifying candidates for primary angioplasty in acute MI.

To determine whether specific psychological characteristics are associated with angina pectoris in clinically stable patients 1 to 6 months after recovery from an acute coronary event, a battery of tests was administered to 92 Japanese and 646 North American participants (22% females) in the Multicenter Study of Myocardial Ischemia. Of these 738 patients, 541 had originally suffered acute myocardial infarction, 188 had unstable angina, and 9 were admitted for other acute ischemic events. At the time of enrollment, an average of 2.7 months after the index event, 205 patients reported having had anginal symptoms during the preceding months. Compared to those who did not report angina, these patients scored higher on a modified Autonomic Perception Questionnaire (p = 0.04) and lower on the Internal Health Locus of Control Scale (p = 0.004). These differences were generalized across the Japanese and North American cohorts. These results indicate that in these patients, angina pectoris was associated with an increased awareness of a wide range of physical symptoms and a decreased sense of personal control over one's own health and prognosis.

The Society for Cardiac Angiography and Interventions has maintained a registry of cardiac catheterizations since 1979 and of percutaneous cardiac interventions since 1990. Data from 392,923 procedures (317,592 diagnostic catheterizations, 74,963 coronary interventions, and 368 valvuloplasties) for the years 1990-1994 inclusive are presented. Over the 5 year period there was a trend toward same day and 23 hr discharges (19% in 1990 to 29% in 1994), and a decrease in combined right and left heart procedures from 38% to 26%. For cardiac catheterizations ionic contrast use declined from 26% of procedures to 13% in 1994. The use of ionic contrast was even lower in interventional procedures, with laboratories reporting use in 21% of procedures in 1990 dropping to 9% in 1994. Balloons were the first choice device in 92.5% of native arteries and 82.7% of grafts in 1994. For the first time in 1994 more mitral than aortic valvuloplasties were reported.

Percutaneous transluminal coronary angioplasty (PTCA) is currently performed in many patients seeking care because of severe manifestations of multivessel coronary artery disease. Previously, the majority of such patients would have undergone coronary artery bypass grafting (CABG). No definitive evidence is available as to which initial revascularization strategy has the best long-term clinical and economic outcomes. The Bypass Angioplasty Revascularization Investigation (BARI) is the largest of several recent clinical trials that were designed to test the hypothesis that an initial strategy of PTCA in selected patients with multivessel coronary artery disease does not compromise long-term clinical outcome compared with an initial strategy of CABG. This report describes how patients were screened, selected, and recruited in BARI and how this process may influence the results and the interpretation of the trial. During the enrollment period, 25,200 patients undergoing diagnostic coronary angiography at the participating institutions or with off-site angiograms referred to BARI investigators were screened for BARI eligibility. Excluded from screening were patients without coronary artery disease, those with single-vessel disease, prior revascularization, primary congenital, valvular, or myocardial disease, and age > 80 years. Slightly more than half of the patients screened (12,670) were not clinically eligible for BARI because of left main disease, insufficient symptoms, emergency revascularization, or other logistic reasons. Thus, 12,530 patients had severe angina and/or ischemia and were clinically eligible for BARI. Nearly 33% of them (4,110) had multivessel disease, which was suitable for both PTCA and CABG.(ABSTRACT TRUNCATED AT 250 WORDS)

Objectives: This study evaluated the value of noninvasive testing to predict cardiac events in patients with stable coronary disease after hospital admission (and risk stratification) for an acute coronary event., Background: Exercise testing with thallium perfusion imaging identifies patients with obstructive coronary artery disease and has been used to stratify patients after myocardial infarction. Its usefulness for predicting cardiac events in patients with stable coronary disease after recovery from an acute coronary event was explored., Methods: Nine hundred thirty-six patients were enrolled 1 to 6 months after hospital admission for a coronary event. Patients underwent exercise treadmill testing with planar thallium-201 scintigraphy and were followed up for an average of 23 months (range 6 to 43). End points were 1) unstable angina requiring hospital admission, nonfatal myocardial infarction or cardiac death; 2) nonfatal infarction or cardiac death; or 3) cardiac death alone., Results: Twelve patients died of cardiac causes (1.2%); 32 had a nonfatal myocardial infarction (3.4%); and 79 patients (8.4%) developed unstable angina in the first year. Exercise testing improved proportional hazards models constructed from clinical variables for all three end points (p < 0.05). The perfusion scan further improved models for the end points (nonfatal infarction or cardiac death and cardiac death alone, p < 0.05). However, the exercise test with or without thallium added little to the overall prediction of primary events (area under the receiver operating curve increased from 0.649 to 0.663), and only 2% to 13% of patients with abnormal results either had a nonfatal infarction or died., Conclusions: Thallium-201 scintigraphy and exercise testing variables identify patients at risk for subsequent cardiac events. However, the poor predictive performance of these tests in this group of patients with stable coronary disease severely limits their usefulness. These results suggest a limited role for exercise and thallium testing in predicting cardiac events in patients with known coronary disease.

Objectives: The purpose of this study was to evaluate the long-term prognostic value of ST segment depression on the electrocardiogram (ECG) in patients with acute myocardial infarction., Background: The prognostic importance of ST segment depression on the ECG has been studied in small groups of patients with infarction, but larger numbers are needed., Methods: Coronary care unit ECGs of 1,234 patients who survived the coronary care unit with acute Q wave (n = 896) or non-Q wave (n = 338) myocardial infarction were analyzed for the presence of ST segment depression. Patients were followed up for up to 4 years., Results: ST segment depression was present in 607 patients. Those with ST segment depression had a 1-year mortality rate of 10.3% compared with a rate of 5.6% for those without ST segment depression (p = 0.002). This effect was seen in both the Q wave and non-Q wave subgroups. Of the 437 patients with anterior ST segment elevation, those with ST segment depression in other regions had a 13.6% 1-year mortality rate compared with a rate of 6.9% for those with no ST segment depression (p = 0.0005). Of the 514 patients with inferior ST segment elevation, those with ST segment depression in other leads had an 11.0% 1-year mortality rate compared with a 1.8% rate for those with no ST segment depression (p = 0.0001). The Cox proportional hazards model showed that ST segment depression was an independent predictor of mortality over the follow-up period., Conclusions: ST segment depression on the admitting ECG in patients with acute myocardial infarction is a predictor of increased mortality in the year after infarction.

This report summarizes the results of the 1991 Registry of the Society for Cardiac Angiography and Interventions in which 72 laboratories reported a total of 92,157 patients, including 17,073 coronary angioplasties, studied between January 1 through December 31, 1991. Complications were similar to previous reports of this Registry.

This report presents the first year's experience of a totally computerized cardiac catheterization laboratory reporting system, including the results and complications of invasive and interventional procedures. Sixty-three laboratories reported a total of 71,916 patients studied between January 1 through December 31, 1990. Two previous registry reports have been published. Compared with data acquired by previous methods, in spite of an older and sicker population, the mortality for diagnostic procedures has remained remarkably constant (0.11%). The computerized format facilitates data collection and analysis, helps resolve new issues as they arise and serves as a method of monitoring quality of laboratories and individuals.

The effect of diltiazem on long-term outcome after acute myocardial infarction (AMI) was assessed in 2,377 patients enrolled in the Multicenter Diltiazem Post-Infarction Trial and subsequently followed for 25 +/- 8 months. The study population included 855 patients (36%) with at least 1 prior AMI before the index infarction and 1,522 patients (64%) with a first AMI, of whom 409 (27%) had a first non-Q-wave AMI, 664 (44%) a first inferior Q-wave AMI, and 449 (30%) a first anterior Q-wave AMI. This post hoc analysis revealed that, among patients with first non-Q-wave and first inferior Q-wave AMI, there were fewer cardiac events during follow-up in the diltiazem than in the placebo group, and that the reverse was true for patients with first anterior Q-wave AMI or prior infarction. The diltiazem:placebo Cox hazard ratio (95% confidence limits) for the trial primary end point (cardiac death or nonfatal reinfarction, whichever occurred first) was: first non-Q-wave AMI-0.48 (0.26, 0.89); first inferior Q-wave AMI-0.66 (0.40, 1.09); first anterior Q-wave AMI-0.82 (0.51, 1.31); and prior AMI-1.11 (0.85, 1.44). Use of cardiac death alone as an end point gave an even more sharply focused treatment difference: first non-Q-wave AMI-0.46 (0.18, 1.21); first inferior Q-wave AMI-0.53 (0.27, 1.06); first anterior Q-wave AMI-1.28 (0.68, 2.40); prior infarction-1.26 (0.90, 1.77). Further analysis revealed that these differences in the effect of diltiazem in large part reflected the different status of the 4 electrocardiographically defined subsets in terms of left ventricular function.(ABSTRACT TRUNCATED AT 250 WORDS)

Indications for PTCA continue to grow. In complex multivessel lesions, PTCA now has high primary success and low complication rates. Dilation of chronic total occlusions is less successful than in subtotal occlusions but may relieve angina in some patients. Occluded saphenous vein grafts can be dilated and long-term patency achieved--particularly in grafts implanted for less than 36 months. Restenosis remains a major drawback; antithrombotic therapy (with heparin during PTCA and aspirin thereafter) is recommended. PTCA is a useful adjunct in acute myocardial infarction when thrombolytic therapy fails or is contraindicated, or when significant luminal narrowing remains after thrombolysis. Investigational devices--atherectomy catheters, lasers or laser balloons, and intracoronary stents--may further expand the role of PTCA.

This prospective, randomized, double-blind, crossover study examined the effects of oral iron ingestion on fecal occult blood testing. One hundred healthy and asymptomatic volunteers collected stool samples after 2-wk courses of both oral iron (either ferrous sulfate or ferrous gluconate) and placebo, while following strict medicinal, dietary, and collection instructions. Each sample was tested by both the Hemoccult II and Hemoccult Sensa methods. Of the participants who completed this study (n = 78), there were no positive results for occult blood after iron ingestion when tested by either method. Only one participant displayed a positive result while taking the placebo, with this specimen considered contaminated by unexpected menses. From these findings, it can be concluded that oral iron supplementation does not cause false-positive results when the Hemoccult II or Hemoccult Sensa method is used for fecal occult blood testing.

Cycle length variability (CLV), defined as the standard deviation of normal cycle length intervals, has been found to be a powerful predictor of subsequent mortality in a population of 808 survivors of acute myocardial infarction. Decreased CLV is associated with a significant increase in mortality. CLV remained an independent predictor of outcome even after adjusting for left ventricular ejection fraction, clinical risk factors, heart rate and ventricular arrhythmias. In the same population of survivors of acute myocardial infarction, the results of exercise testing also strongly predicted outcome, with those failing to take the test having the worst survival, and those completing the low-level stress test taken before discharge having the best prognosis. The hypothesis that the status of stress test (completed; did not complete; failed to take) and CLV were measuring the same factor related to mortality was tested. Although the distribution of CLV was shifted to higher CLV in patients who completed the test and to lower CLV in those who failed to take the test, both predictors of mortality remained independent predictors of long-term mortality (average of 31 months of follow-up) after controlling for each other. Moreover, subgroups with an approximate 15-fold difference in mortality were defined using both variables (CLV less than 50 ms, did not take test had a 54% mortality; CLV greater than 100 ms, completed the test had a mortality of 3.5%). CLV is a measure of autonomic tone; it is not strongly related to exercise ability and using the results of both stress testing and CLV results in the identification of subgroups of postinfarction patients with markedly disparate risks of mortality.

Treatment of ventricular arrhythmias at the present time is difficult and requires a strong commitment on the part of the physician and the patient. Adequate documentation of the arrhythmia with continuous ECG recordings (Holter recordings), preferably for 24 hours, should be performed in each case. Exercise testing can be utilized in selected patients, but is generally inferior to the Holter technique. Underlying cardiac pathology should be searched for, utilizing echocardiography in all patients and coronary angiography and left ventriculography in patients with more severe ventricular tachycardias. Estimation of the prognostic significance of the VPBs must be made in the context of the underlying disease, and goals for treatment must be set. Treatment in all cases first requires measures to avoid known precipitating factors. If antiarrhythmic therapy is utilized, a systematic empirical trial of available agents should be undertaken, utilizing repeated Holter monitoring to document effectiveness. Serum levels of the antiarrhythmic medications should be measured in most cases. Combinations of antiarrhythmic agents can be employed if the need is great, but the agents singly are ineffective. If treatment is determined to be ineffective, it should be discontinued. Surgical techniques may be useful in cases of refractory ventricular tachycardia, and they include overdrive pacing, surgical sympathectomy, or ventricular aneurysmectomy with or without coronary bypass. Coronary bypass alone or resection of a hypokinetic but not aneurysmal area of myocardium may be successful in some cases, but the results are less predictable than when a true aneurysm is resected. Electrophysiologic studies, performed as part of the preoperative evaluation and provoking a self-perpetuating ventricular tachycardia, may permit selection of patients suitable for ventriculotomy to interrupt the re-entry pathway. At present, this must be considered experimental and is performed in only a few centers equipped for the required complex epicardial mapping. Surgery has not been shown to affect complex VPBs outside the setting of acute ischemia. Control of ventricular arrhythmias requires a highly individualistic approach with documentation of effectiveness.

Left ventricular (LV) pressure waveforms for 20 beats, originally recorded at 200 scale (200 torr/10 cm) were rescaled by a computer system to represent the identical beats recorded at 40 scale (40 torr/10 cm). Both the original and the rescaled beats were independently evaluated by eight cardiologists who were unaware of the nature of the manipulated data. For each beat the average left ventricular end-diastolic pressure (LVEDP) identified by the eight cardiologists was higher when analyzed on the 200 scale, with an average difference of 2.8 torr (P Less Than 0.001). This scale-dependence of pressure analysis has implications for the development of automated pressure analysis algorithms and for physician review of computer-determined LVEDP data points.