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The urea nitrogen salvaging process (UNS) supports the symbiotic relationship between ruminants and their gastrointestinal microbiome by both supplying nitrogen and buffering bacterially-derived short chain fatty acids (SCFAs). Studying such physiological processes via investigation of rumen papillae morphology and functioning, as well as western blotting to detect rumen urea transporters, allows researchers to test hypotheses linking physiology and ecology. The goal of this innovative approach is to indicate the way forward for future research. Our previous studies have shown the importance of the UT-B2 urea transporters in the rumen of wild fallow deer living in Phoenix Park, Dublin. In this current pilot study, we investigated the effects on these transporters of seasonal changes – linked to changes in feeding intake during and after the mating season - and acceptance of artificial food from park visitors in adult male bucks. Investigation of the rumen papillae revealed that animals culled in January had significantly longer papillae than those culled just after the rutting season in November, when bucks interrupted feeding from a few days to weeks. In contrast, western blotting analysis showed that there was no significant difference in the abundance of UT-B2 transporters between these two groups. Adult males that had displayed consistent begging behaviour to obtain food from human visitors to the park had a higher papillae density. Furthermore, these animals had a significantly higher abundance of UT-B2 transporters, which was shown by immunolocalization studies to be predominantly in the stratum basale layer of the rumen papillae. Our research suggests that human-wildlife feeding interactions can have subtle effects on the physiology of individual animals involved. The findings of this novel study therefore improve our understanding of basic rumen physiological processes, but also add insight into the unseen effects that humans feeding wildlife may have.

AimsTo assess processes of care and clinical outcomes in cancer patients with ST elevation myocardial infarction (STEMI) according to cancer type.Methods and resultsThis is a national population-based study of patients admitted with STEMI in the UK between January 2005 and March 2019. Data were obtained from the National Heart Attack Myocardial Infarction National Audit Project (MINAP) registry and the Hospital Episode Statistics registry. We identified 353 448 STEMI-indexed admissions between 2005 and 2019. Of those, 8581 (2.4%) had active cancer. Prostate cancer (29% of STEMI patients with cancer) was the most common cancer followed by haematologic malignancies (14%) and lung cancer (13%). Cancer patients were less likely to receive invasive coronary revascularization (60.0% vs. 71.6%, P ConclusionSTEMI patients with cancer have a higher risk of short- and long-term mortality, particularly lung cancer. Colon cancer is the main cancer associated with major bleeding. Cardiovascular disease was the main cause of death in the first month, whereas cancer was the main cause of death within 1 year.

In their own terms, the intellectual and political spheres of the American 1980s spoke on conversations on gender through human bodies. Feminist theorist Sandy Stone wrote the foundational text for transgender studies in 1987 at the height of the Reagan Administration, which was defined by its own masculine politics. Between Jimmy Carter and Ronald Reagan, their White House Office of Communications staffers were tasked with upholding this image of masculinity, specifically upholding the physical bodies of men, going against 1980s feminist theorists that upheld binary views on gender. Horror filmmakers in Hollywood, however, more closely aligned with feminist thought regarding the flexibility of gender, and like the White House Office of Communications, used the bodies of characters onscreen to convey their ideas. This thesis is a comparative history of Washington and Hollywood in the 1980s, using the psychoanalytic framework of Julia Kristeva’s abject as a means to look beyond the gendered boundaries set by Washington and seeing how those same boundaries were manipulated by Hollywood.

Aims The importance of standard modifiable cardiovascular risk factors (SMuRFs) in preventing non-ST-segment elevation myocardial infarction (NSTEMI) is established. However, NSTEMI may present in the absence of SMuRFs, and little is known about their outcomes. Methods and results We analysed 176 083 adult (≥18 years) hospitalizations with NSTEMI using data from the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP). Clinical characteristics and all-cause in-hospital mortality were analysed according to SMuRF status, with 135 223 patients presenting with at least one of diabetes, hypertension, hypercholesterolaemia, or current smoking status and 40 860 patients without any SMuRFs. Those with a history of coronary artery disease were excluded. Patients without SMuRFs were more frequently older (median age 72 year vs. 71 years, P Conclusion More than one in five patients presenting with NSTEMI had no SMuRFs, who were less frequently received guideline-recommended management and had lower in-hospital (all-cause and cardiac) mortality and MACE than patients with SMuRFs.

In North America, alternative energy policies have been mostly focused on first-generation biofuels. There is continued development of second-generation biofuels (SGB), crops founded upon low-value...

Background: Measurement of fractional flow reserve (FFR) has an established role in guiding percutaneous coronary intervention. We tested the hypothesis that, at the stage of diagnostic invasive coronary angiography, systematic FFR-guided assessment of coronary artery disease would be superior, in terms of resource use and quality of life, to assessment by angiography alone. Methods: We performed an open-label, randomized, controlled trial in 17 UK centers, recruiting 1100 patients undergoing invasive coronary angiography for the investigation of stable angina or non–ST-segment–elevation myocardial infarction. Patients were randomized to either angiography alone (angiography) or angiography with systematic pressure wire assessment of all epicardial vessels >2.25 mm in diameter (angiography+FFR). The coprimary outcomes assessed at 1 year were National Health Service hospital costs and quality of life. Prespecified secondary outcomes included clinical events. Results: In the angiography+FFR arm, the median number of vessels examined was 4 (interquartile range, 3–5). The median hospital costs were similar: angiography, £4136 (interquartile range, £2613–£7015); and angiography+FFR, £4510 (£2721–£7415; P =0.137). There was no difference in median quality of life using the visual analog scale of the EuroQol EQ-5D-5L: angiography, 75 (interquartile range, 60–87); and angiography+FFR, 75 (interquartile range, 60–90; P =0.88). The number of clinical events was as follows: deaths, 5 versus 8; strokes, 3 versus 4; myocardial infarctions, 23 versus 22; and unplanned revascularizations, 26 versus 33, with a composite hierarchical event rate of 8.7% (48 of 552) for angiography versus 9.5% (52 of 548) for angiography+FFR ( P =0.64). Conclusions: A strategy of systematic FFR assessment compared with angiography alone did not result in a significant reduction in cost or improvement in quality of life. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01070771.

This paper reports how high failure rates in the first quantitative course that college business majors take were significantly reduced by implementing course-embedded remediation. More specifically, this paper details our process for identifying students at risk, placing them in special sections of the first quantitative course, and adding an additional hour of application of course concepts which resulted in a statistically significant increase in pass rates. The study focused on the learning environment, the attitude of the student, the utility of the material and the role of the professor for this special course. We feel this research is timely, as many colleges in the United States consider removing entrance exams as a means of evaluation into higher education.

Aims: :To evaluate safety and efficacy of distal right radial access (DRRA) compared to right radial access (RRA), for coronary procedures, in patients with smaller diameter radial arteries (SDRA) (radial artery diameter (RAD)

Odontogenic keratocysts (OKCs) are aggressive lesions that have been variously classified as neoplasms or cysts according to the World Health Organisation (WHO). They can be challenging to surgically remove and the cysts can exhibit locally aggressive behaviour if incompletely excised. We describe a case of recurrent OKC invading the orbit requiring multidisciplinary approach for extended surgical excision, and review the current literature regarding this condition.

Monoclonal gammopathy of renal significance is defined as any B cell or plasma cell clonal lymphoproliferation which neither causes tumor complications nor meets any current hematological criteria for specific therapy, with one or more kidney lesions related to the produced monoclonal immunoglobulin, such as amyloidosis. A 50-year-old male presented with heavy proteinuria and blood tests showing IgA and Lambda paraproteinemia. Light microscopy showed mesangial eosinophilic ground substance extending into the capillary loops, and positive staining within the glomeruli and vessel walls for amyloid P immunohistochemistry was also noted. Immunofluorescence showed positive staining for IgA and Lambda in the mesangia and capillary loops. Electron microscopy exhibited organized fibrils measuring 4–5 nm in diameter in the mesangia, glomerular basement membranes and vessel walls. We interpreted the overall findings as atypical renal amyloidosis with IgA and Lambda deposition on immunofluorescence. Further amyloid typing using laser microdissection-liquid chromatography and mass spectrometry will be useful.

Introduction Biclonal lymphoid disorders, when two distinct lymphoproliferative disorders (LPD) co-exist, are rare (incidence of 1.4%) and associated with a poor prognosis. NOTCH1 mutations occur in 10% of CLL at diagnosis, associated with a short disease-free interval and increased risk of Richter's transformation. We hypothesised that the incidence of NOTCH1 mutations in CLL with a second LPD may be increased, because the mutation occurs early in leukaemogenesis, permitting clonal divergence. Methods We identified 19 patients with biclonal LPD at diagnosis: 11 with CLL and a second LPD (group A) and 8 with a second distinct CLL (group B). NOTCH1 mutation analysis was performed and clinical outcome investigated. Results Ten of 19 (52%) were NOTCH1 mutated: 5 in group A (45%) and 5 in group B (62.5%) with a favourable clinical outcome observed among this cohort with 28.7 (range 1-99) months of follow-up. Conclusion In conclusion, we identified a significant (52%) incidence of NOTCH1 mutations in CLL in the context of biclonal LPD, associated with an indolent clinical course.

Currently, transradial access (TRA) is the recommended access for coronary procedures because of increased safety, with radial artery occlusion (RAO) being its most frequent complication, which will increasingly affect patients undergoing multiple procedures during their lifetimes. Recently, distal radial access (DRA) has emerged as a promising alternative access to minimize RAO risk. A large-scale, international, randomized trial comparing RAO with TRA and DRA is lacking.The aim of this study was to assess the superiority of DRA compared with conventional TRA with respect to forearm RAO.DISCO RADIAL (Distal vs Conventional Radial Access) was an international, multicenter, randomized controlled trial in which patients with indications for percutaneous coronary procedure using a 6-F Slender sheath were randomized to DRA or TRA with systematic implementation of best practices to reduce RAO. The primary endpoint was the incidence of forearm RAO assessed by vascular ultrasound at discharge. Secondary endpoints include crossover, hemostasis time, and access site-related complications.Overall, 657 patients underwent TRA, and 650 patients underwent DRA. Forearm RAO did not differ between groups (0.91% vs 0.31%; P = 0.29). Patent hemostasis was achieved in 94.4% of TRA patients. Crossover rates were higher with DRA (3.5% vs 7.4%; P = 0.002), and median hemostasis time was shorter (180 vs 153 minutes; P 0.001). Radial artery spasm occurred more with DRA (2.7% vs 5.4%; P = 0.015). Overall bleeding events and vascular complications did not differ between groups.With the implementation of a rigorous hemostasis protocol, DRA and TRA have equally low RAO rates. DRA is associated with a higher crossover rate but a shorter hemostasis time.

Aims Little is known about the outcomes and processes of care of patients with non-ST-segment myocardial infarction (NSTEMI) who present with ‘polyvascular’ disease. Methods and results We analysed 287 279 NSTEMI patients using the Myocardial Ischaemia National Audit Project registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed—coronary artery disease (CAD), cerebrovascular disease (CeVD), and peripheral vascular disease (PVD)—with comparison to a historically disease-free control group, comprising 167 947 patients (59%). After adjusting for demographics and management, polyvascular disease was associated with increased likelihood of major adverse cardiovascular events (MACEs) [CAD odds ratio (OR): 1.06; 95% confidence interval (CI): 1.01–1.12; P = 0.02] (CeVD OR: 1.19; 95% CI: 1.12–1.27; P Conclusion Polyvascular disease patients had a higher incidence of in-hospital mortality and MACEs. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT.

The 2018 iteration of the ASCO-CAP HER2 testing guidelines proposes significant changes with an emphasis on the integration of concurrent immunohistochemistry (IHC) and in situ hybridization (ISH). We wished to evaluate the impact of these changes on clinical practice. Between Jan 2012 to Feb 2017, 2132 consecutive invasive breast carcinomas were evaluated with IHC and ISH for HER2. The sample tested was the breast primary or axillary nodes in all but 57 (2.7%) distant metastases. For 1824 cases with both dual-probe ISH and IHC results, the ISH subgroup was 1: 299 (16.4%), 2: 19 (1.0%), 1.0%, 3: 6 (0.3%), 4: 48 (2.6%) and 5: 1452 (79.6%). Ultimately 21% of group 2 and 4 cases and 80% of group 4 cases were positive. The change in HER2 status between the 2018 vs 2013 was: amplified in 323 (15.2%) vs 15.5%; not amplified in 1804 (84.6%) vs 82.2%; equivocal in 0 vs 2.3% previously. In 22 of 2127 cases (1.03%) the 2013 and 2018 results were discordant, all in groups 2-4. The discrepant cases included 15 of 331 (4.5%) of 2013 amplified cancers, now negative (all in groups 2 or 3) and 7 of 1796 (0.4%) 2013 nonamplified cases, now positive (all in group 4). Because of routine testing with both IHC and ISH, we found 6 of 1147 (0.52%) IHC negative (0 or 1+) cases were amplified by ISH. Further, 19 of 289 (6.6%) of IHC 3+ cases were nonamplified by ISH, circumstances not covered by these guidelines. In summary at the population level, the 2018 ASCO-CAP guidelines have a 99% agreement with the 2013 results. A major advantage is the abolishment of the clinically problematic equivocal category. Routine performance of both IHC and ISH uncovers a small proportion of cancers whose HER2 status is not addressed by these guidelines.

Background Readmissions after PCI are a burden to patients and health services that are not well understood. Methods A systematic review was performed to identify studies of readmission after PCI. Readmission rates and causes of readmission were examined and factors associated with 30-day readmissions were combined using meta-analyses. Results A total of 39 studies evaluated readmissions after PCI (6,569,690 patients, 31 studies). The 30-day readmission rate varied from 3.3%–15.8%. Beyond 30-days, the readmission rate was 6% at 2 months, 31.5% at 6 months, 18.6–50.4% at 12 months and 26.3–71% beyond 48 months. The pooled proportion of patients with cardiac cause for readmissions ranged from 4.6%–75.3%. The range of rates of 30-day readmissions for reinfarction/stent thrombosis, heart failure, chest pain and bleeding were 2.5%–9.5%, 5.9%–12%, 6.7–38.1% and 0.7–7.5%, respectively. Meta-analysis suggests that female gender (RR 1.25(1.20–1.30), I2 = 65.2%), diabetes (RR 1.22(1.20–1.25), I2 = 0%), heart failure (RR 1.43(CI 1.28–1.60), I2 = 92.8%), renal failure (RR 1.50(1.45–1.55), I2 = 0%), chronic lung disease (RR 1.34(1.26–1.44), I2 = 87.5%), peripheral artery disease (RR 1.20(1.15–1.25), I2 = 46.5%) and cancer (RR 1.35(1.15–1.58), I2 = 72.8%) were associated with 30-day readmissions. The average cost of unplanned and all 30-day readmissions has been reported to be $12,636 and $17,576, respectively. Conclusions We estimate that 1 in 7 patients who undergo PCI are readmitted within 30-days and the rate can rise to up to 3 in 4 patients beyond 3 years. Interventions should be considered to reduce readmissions such as discharge checklists, evaluation of medication compliance at follow-up and prompt management when patients re-present to emergency department.

Objectives: This study aimed to examine the cost of coronary syndrome treated with percutaneous coronary intervention (PCI) and 30-day unplanned readmissions.\ud \ud Background: There is limited understanding of the hospital cost of index PCI and 30-day unplanned readmissions.\ud \ud Methods: Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were included. The primary outcome was total cost defined by cost of index PCI and first unplanned readmission within 30-days.\ud \ud Results: This analysis included 2,294,245 patients who underwent PCI, and the mean cost was $23,541±$20,730 (~$10.8 billion/year). There was a modest increase in cost over the study years of 17.5%. Of the 9.4% with an unplanned readmission within 30 days, the mean total cost was $35,333±24,230 versus $22,323±19,941 for those not readmitted. The variables most strongly associated with the highest quartile of cost were heart failure (adjusted odds ratio (aOR) 25.60 [95% CI 21.59-30.35]), need for circulatory support (aOR 11.62 [10.13-13.32]), periprocedural coronary artery bypass graft (CABG, aOR 585.08 [357.85-956.58]), and readmission within 30 days (aOR 24.49 [22.40-26.77]). An acute kidney injury (8.5%), major bleed (0.8%), vascular injury (0.8%), or need for periprodedural CABG (1.4%) had an average increased cost of $21,935, $30,898, $27,875 and $43,005, respectively, compared to PCI without adverse outcome.\ud \ud Conclusions: The annual 30-day hospital cost of PCI is approximately $10.8 billion, and the costs associated with in-hospital adverse events, particularly the need for acute kidney injury and emergency CABG, were significant.

Highlights •RAO remains the most frequent post-procedural complication of transradial access, restricting the use of the same radial artery for future procedures, as a conduit for coronary artery bypass grafting or for arteriovenous fistula creation in patients requiring hemodialysis. •The real-world reported incidence of RAO remains high, with wide variability in the uptake of RAO prevention strategies. •The paper reviews the main recent advances in the field of RAO prevention and provides a series of expert recommendations to prevent RAO. •This consensus document is meant to provide guidance to increase the adoption of simple and effective methods to achieve an institutional rate of RAO