Search

Introduction: Advance care planning (ACP) is a key component of high-quality end-of-life care but is underused. Interventions based on models of behaviour change may fill an important gap in available programmes to increase ACP engagement. Such interventions are designed for broad outreach and flexibility in delivery. The purpose of the Sharing and Talking about My Preferences study is to examine the efficacy of three behaviour change approaches to increasing ACP engagement through two related randomised controlled trials being conducted in different settings (Veterans Affairs (VA) medical centre and community)., Methods and Analysis: Eligible participants are 55 years or older. Participants in the community are being recruited in person in primary care and specialty outpatient practices and senior living sites, and participants in the VA are recruited by telephone. In the community, randomisation is at the level of the practice or site, with all persons at a given practice/site receiving either computer-tailored feedback with a behaviour stage-matched brochure (computer-tailored intervention (CTI)) or usual care. At the VA, randomisation is at the level of the participant and is stratified by the number of ACP behaviours completed at baseline. Participants are randomised to one of four groups: CTI, motivational interviewing, motivational enhancement therapy or usual care. The primary outcome is completion of four key ACP behaviours: identification of a surrogate decision maker, communication about goals, completing advance directives and ensuring documents are in the medical record. Analysis will be conducted using mixed effects models, taking into account the clustered randomisation for the community study., Ethics and Randomisation: The studies have been approved by the appropriate Institutional Review Boards and are being overseen by a Safety Monitoring Committee. The results of these studies will be disseminated to academic audiences and leadership in in the community and VA sites., Trial Registration Numbers: NCT03137459 and NCT03103828., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Spirometric Z-scores from the Global Lung Initiative (GLI) rigorously account for age-related changes in lung function and are thus age-appropriate when establishing spirometric impairments, including a restrictive pattern and air-flow obstruction. However, GLI-defined spirometric impairments have not yet been evaluated regarding associations with static lung volumes (total lung capacity [TLC], functional residual capacity [FRC], and residual volume [RV]) and gas exchange (diffusing capacity)., Methods: We performed a retrospective review of pulmonary function tests in subjects ≥40 y old (mean age 64.6 y), including pre-bronchodilator measures for: spirometry ( n = 2,586), static lung volumes by helium dilution with inspiratory capacity maneuver ( n = 2,586), and hemoglobin-adjusted single-breath diffusing capacity ( n = 2,508). Using multivariable linear regression, adjusted least-squares means (adj LS Means) were calculated for TLC, FRC, RV, and hemoglobin-adjusted single-breath diffusing capacity. The adj LS Means were expressed with and without height-cubed standardization and stratified by GLI-defined spirometry, including normal ( n = 1,251), restrictive pattern ( n = 663), and air-flow obstruction (mild, [ n = 128]; moderate, [ n = 150]; and severe, [ n = 394])., Results: Relative to normal spirometry, restrictive-pattern had lower adj LS Means for TLC, FRC, RV, and hemoglobin-adjusted single-breath diffusing capacity ( P ≤ .001). Conversely, relative to normal spirometry, mild, moderate, and severe air-flow obstruction had higher adj LS Means for FRC and RV ( P < .001). However, only mild and moderate air-flow obstruction had higher adj LS Means for TLC ( P < .001), while only moderate and severe air-flow obstruction had higher adj LS Means for RV/TLC ( P < .001) and lower adj LS Means for hemoglobin-adjusted single-breath diffusing capacity ( P < .001). Notably, TLC (calculated as FRC + inspiratory capacity) was not increased in severe air-flow obstruction ( P ≥ .11) because inspiratory capacity decreased with increasing air-flow obstruction ( P < .001), thus opposing the increased FRC ( P < .001). Finally, P values were similar whether adj LS Means were height-cubed standardized., Conclusions: A GLI-defined spirometric restrictive pattern is strongly associated with a restrictive ventilatory defect (decreased TLC, FRC, and RV), while GLI-defined spirometric air-flow obstruction is strongly associated with hyperinflation (increased FRC) and air trapping (increased RV and RV/TLC). Both spirometric impairments were strongly associated with impaired gas exchange (decreased hemoglobin-adjusted single-breath diffusing capacity)., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2017 by Daedalus Enterprises.)

Objectives: A key objective of advance care planning (ACP) is improving surrogates' knowledge of patients' treatment goals. Little is known about whether ACP outside of a trial accomplishes this. The objective was to examine patient and surrogate reports of ACP engagement and associations with surrogate knowledge of goals., Design: Cohort study SETTING: Primary care in a Veterans Affairs Medical Center., Participants: 350 community-dwelling veterans age ≥55 years and the individual they would choose to make medical decisions on their behalf, interviewed separately., Measurements: Treatment goals were assessed by veterans' ratings of 3 health states: severe physical disability, cognitive disability, and pain, as an acceptable or unacceptable result of treatment for severe illness. Surrogates had knowledge if they correctly predicted all 3 responses. Veterans and surrogates were asked about living will and health care proxy completion and communication about life-sustaining treatment and quality versus quantity of life (QOL)., Results: Over 40% of dyads agreed that the veteran had not completed a living will or health care proxy and that there was no QOL communication. For each activity, sizeable proportions (18-34%) disagreed about participation. In dyads who agreed QOL communication had occurred, 30% of surrogates had knowledge, compared to 21% in dyads who agreed communication had not occurred and 15% in dyads who disagreed (P = .01). This relationship persisted in multivariable analysis. Agreement about other ACP activities was not associated with knowledge., Conclusion: Disagreement about ACP participation was common. Agreement about communication regarding QOL was modestly associated with surrogate knowledge of treatment goals. Eliciting surrogates' perspectives is critical to ACP. Even dyads who agree about participation may need additional support for successful engagement., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Aims: RhoB plays a key role in the pathogenesis of hypoxia-induced pulmonary hypertension. Farnesylated RhoB promotes growth responses in cancer cells and we investigated whether inhibition of protein farnesylation will have a protective effect., Methods and Results: The analysis of lung tissues from rodent models and pulmonary hypertensive patients showed increased levels of protein farnesylation. Oral farnesyltransferase inhibitor tipifarnib prevented development of hypoxia-induced pulmonary hypertension in mice. Tipifarnib reduced hypoxia-induced vascular cell proliferation, increased endothelium-dependent vasodilatation and reduced vasoconstriction of intrapulmonary arteries without affecting cell viability. Protective effects of tipifarnib were associated with inhibition of Ras and RhoB, actin depolymerization and increased eNOS expression in vitro and in vivo. Farnesylated-only RhoB (F-RhoB) increased proliferative responses in cultured pulmonary vascular cells, mimicking the effects of hypoxia, while both geranylgeranylated-only RhoB (GG-RhoB), and tipifarnib had an inhibitory effect. Label-free proteomics linked F-RhoB with cell survival, activation of cell cycle and mitochondrial biogenesis. Hypoxia increased and tipifarnib reduced the levels of F-RhoB-regulated proteins in the lung, reinforcing the importance of RhoB as a signalling mediator. Unlike simvastatin, tipifarnib did not increase the expression levels of Rho proteins., Conclusions: Our study demonstrates the importance of protein farnesylation in pulmonary vascular remodelling and provides a rationale for selective targeting of this pathway in pulmonary hypertension., (© The Author 2017. Published by Oxford University Press on behalf of the European Society of Cardiology)

Objectives: To understand the perspectives of both patients and the person who would make medical decisions for them if they were unable (surrogates) on their participation in advance care planning (ACP)., Design: Qualitative cross-sectional study., Setting: Community., Participants: Thirty-one veterans age 55 years and older and their surrogates., Measurements: In interviews conducted with both the veteran and surrogate, they were asked to discuss their participation in four ACP activities: communication about life-sustaining treatment, communication about views on quality of life, completion of a living will, and appointment of a healthcare proxy. They were asked about barriers to and facilitators of ACP engagement. When they did not agree about engagement, they each provided their perspective on what they believed had or had not occurred., Results: Many of the same barriers to and facilitators of engagement were discussed by both patients and surrogates. These included difficulty thinking about dying, differences in values, and experiences with others that demonstrated the ability of ACP to decrease burden or avoid conflict. Reasons for disagreements in perceptions about whether communication had occurred included surrogates' need for more detailed information, surrogates' lack of readiness to hear what the patient was saying, and surrogates' reliance on what they know about the patient. For some dyads, participation in the study prompted additional communication, resulting in a better shared understanding of ACP engagement., Conclusion: Surrogates can both impede and facilitate engagement in ACP, and they can hold different perceptions from patients regarding this engagement. Efforts to promote ACP may be most successful if they assess and address both patients' and surrogates' attitudes and help to facilitate clear communication between them., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Background: Breast cancer is the most common cancer in women worldwide, and is a leading cause of cancer death among women. Prophylactic or curative mastectomy is often followed by breast reconstruction for which there are several surgical approaches that use breast implants with which surgeons can restore the natural feel, size and shape of the breast., Objectives: To assess the effects of different types of breast implants on capsular contracture, surgical short- and long-term complications, postoperative satisfaction level and quality of life in women who have undergone reconstructive breast surgery after mastectomy., Search Methods: We searched the Cochrane Breast Cancer Group's Specialised Register on 20 July 2015, MEDLINE (1985 to 20 July 2015), EMBASE (1985 to 20 July 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2015). We also searched the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 16 July 2015., Selection Criteria: We included randomised controlled trials (RCTs) and quasi-RCTs that compared different types of breast implants for reconstructive surgery. We considered the following types of intervention: implant envelope surfaces - texturised versus smooth; implant filler material - silicone versus saline, PVP-Hydrogel versus saline; implant shape - anatomical versus round; implant volume - variable versus fixed; brands - different implant manufacturing companies and implant generation (fifth versus previous generations)., Data Collection and Analysis: Two review authors independently assessed methodological quality and extracted data. We used standard Cochrane methodological procedures. The quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system., Main Results: Five RCTs with 202 participants met the inclusion criteria. The women participants were typically in their 50s, and the majority of them (about 82%) received reconstructive surgery following breast cancer, while the others had reconstructive surgery after prophylactic mastectomy. The studies were heterogenous in terms of implant comparisons, which prevented us from pooling the data.The studies were judged as being at an unclear risk of bias for most risk of bias items owing to poor quality of reporting in the trial publications. Three of the five RCTs were judged to be at high risk of attrition bias, and one at high risk of detection bias.Textured silicone versus smooth silicone implants: textured implants were associated with worse outcomes when compared to smooth implants (capsular contracture: risk ratio (RR) 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence; reintervention: RR 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence). No results in this comparison were statistically significant.Silicone versus saline implants: saline-filled implants performed better than silicone-filled implants for some outcomes; specifically, they produced less severe capsular contracture (RR 3.25, 95% CI 1.24 to 8.51; 1 study, 60 participants; very low quality evidence) and increased patient satisfaction (RR 0.60, 95% CI 0.41 to 0.88; 1 study, 58 participants; very low quality evidence). However reintervention was significantly more frequent in the saline-filled implant group than in the silicone-filled group (OR 0.08, 95% CI 0.01 to 0.43; 1 study, 60 participants; very low quality evidence).Poly(N-vinyl-2-pyrrolidone) hydrogel-filled (PVP-hydrogel) versus saline-filled implants: PVP-hydrogel-filled implants were associated with worse outcomes when compared to saline-filled implants (capsular contracture: RR 3.50, 95% CI 0.83 to 14.83; 1 study, 40 participants; very low quality evidence; short-term complications: RR 2.10, 95% CI 0.21 to 21.39; 1 study, 41 participants; very low quality evidence).Anatomical versus round implants: anatomical implants were associated with worse outcomes than round implants (capsular contracture: RR 2.00, 95% CI 0.20 to 20.15; 1 study, 36 participants; very low quality evidence; short-term complications: RR 2.00, 95% CI 0.42 to 9.58; 1 study, 36 participants; very low quality evidence; reintervention: RR 1.50, 95% CI 0.51 to 4.43; 1 study, 36 participants; very low quality evidence). No results in this comparison were statistically significant.Variable-volume versus fixed-volume implants: data about one-stage reconstruction using variable-volume implants were compared with data about fixed-volume implants positioned during the second surgical procedure of two-stage reconstructions. Fixed-volume implant reconstructions were possibly associated with a greater number of women reporting that their reconstruction corresponded with expected results (RR 0.25, 95% CI 0.10 to 0.62; 1 study, 40 participants; very low quality evidence) and fewer reinterventions (RR 7.00, 95% CI 1.82 to 26.89; 1 study, 40 participants; very low quality evidence) when compared to variable-volume implants. A higher patient satisfaction level (rated from 1 to 6, with 1 being very bad and 6 being very good) was found with the fixed-volume implants for overall aesthetic result (mean difference (MD) -1.10, 95% CI -1.59 to -0.61; 1 study, 40 participants; very low quality evidence).There were no studies that examined the effects of recent (fifth) generation silicone implants versus previous generations or different implant manufacturing companies., Authors' Conclusions: Despite the central role of breast reconstruction in women with breast cancer, the best implants to use in reconstructive surgery have been studied rarely in the context of RCTs. Furthermore the quality of these studies and the overall evidence they provide is largely unsatisfactory. Some of our results can be interpreted as early evidence of potentially large differences between different surgical approaches, which should be confirmed in new high-quality RCTs that include a larger number of women. These days - even after a few million women have had breasts reconstructed - surgeons cannot inform women about the risks and complications of different implant-based breast reconstructive options on the basis of results derived from RCTs.

Objectives: To develop and test the acceptability of personalized intervention materials to promote advance care planning (ACP) based on the Transtheoretical Model (TTM), in which readiness to change is a critical organizing construct., Design: Development study creating an expert system delivering TTM-personalized feedback reports and stage-matched brochures with more-general information on ACP and modifications based on participant reviews., Setting: Senior centers., Participants: Community-living persons aged 65 and older (N = 77)., Measurements: Participant ratings of length, attractiveness, and trustworthiness of and reactions to reports and brochures., Results: The expert system assessed participants' readiness to engage in each of four ACP behaviors: completion of a living will, naming a health care proxy, communication with loved ones about quality vs quantity of life, and communication with clinicians about quality vs quantity of life. The system also assessed pros and cons of engagement and values and beliefs that influence engagement. The system provided individualized feedback based on the assessment, with brochures providing additional general information. Initial participant review indicating unacceptable length led to revision of feedback reports from full-sentence paragraph format to bulleted format. After review, the majority of participants rated the materials as easy to read, trustworthy, providing new information, making them more comfortable reading about ACP, and increasing interest in participating in ACP., Conclusion: Older adults found an expert system individualized feedback report and accompanying brochure to promote ACP engagement to highly acceptable and engaging. Additional research is necessary to examine the effects of these materials on behavior change., (Published 2016. This article is a U.S. Government work and is in the public domain in the USA.)

The NOS (nitric oxide synthase) inhibitor ADMA (asymmetric dimethylarginine) contributes to the pathogenesis of pulmonary hypertension. Reduced levels of the enzymes metabolizing ADMA, dimethylarginine dimethylaminohydrolases (DDAH1 and DDAH2) and increased levels of miR-21 are linked to disease pathology, but the mechanisms are not understood. In the present study we assessed the potential role of miR-21 in the regulation of hypoxia-induced changes in ADMA metabolism in vitro and in vivo. Hypoxia inhibited DDAH1 and DDAH2 expression and increased ADMA levels in cultured human pulmonary endothelial cells. In contrast, in human pulmonary smooth muscle cells, only DDAH2 was reduced whereas ADMA levels remained unchanged. Endothelium-specific down-regulation of DDAH1 by miR-21 in hypoxia induced endothelial dysfunction and was prevented by overexpression of DDAH1 and miR-21 blockade. DDAH1, but not DDAH2, mRNA levels were reduced, whereas miR-21 levels were elevated in lung tissues from patients with pulmonary arterial hypertension and mice with pulmonary hypertension exposed to 2 weeks of hypoxia. Hypoxic mice treated with miR-21 inhibitors and DDAH1 transgenic mice showed elevated lung DDAH1, increased cGMP levels and attenuated pulmonary hypertension. Regulation of DDAH1 by miR-21 plays a role in the development of hypoxia-induced pulmonary hypertension and may be of broader significance in pulmonary hypertension.

The transfer of melanin from melanocytes to keratinocytes is a crucial process underlying maintenance of skin pigmentation and photoprotection against UV damage. Here, we present evidence supporting coupled exocytosis of the melanin core, or melanocore, by melanocytes and subsequent endocytosis by keratinocytes as a predominant mechanism of melanin transfer. Electron microscopy analysis of human skin samples revealed three lines of evidence supporting this: (1) the presence of melanocores in the extracellular space; (2) within keratinocytes, melanin was surrounded by a single membrane; and (3) this membrane lacked the melanosomal membrane protein tyrosinase-related protein 1 (TYRP1). Moreover, co-culture of melanocytes and keratinocytes suggests that melanin exocytosis is specifically induced by keratinocytes. Furthermore, depletion of Rab11b, but not Rab27a, caused a marked decrease in both keratinocyte-stimulated melanin exocytosis and transfer to keratinocytes. Thus, we propose that the predominant mechanism of melanin transfer is keratinocyte-induced exocytosis, mediated by Rab11b through remodeling of the melanosome membrane, followed by subsequent endocytosis by keratinocytes.

Radiotherapy plays a central role in the local control of breast cancer following conservative surgery, representing the standard treatment for patients undergoing quadrantectomy or lumpectomy and consisting in 5 or 6 weeks of treatment with a total dose of 45-50 Gy. In the last ten years new trends in radiation therapy have been developing with a new planning of duration and extension of breast tissue to irradiate. Moreover some authors presented the idea of combining the use of intraoperatory radiotherapy with the partial breast irradiation, with the aim of irradiate the breast in a single session during breast conserving surgery. From September 2009 to July 2010 we prospectively enrolled 13 patients to undergo electron beam intraoperative radiotherapy after breast conservative treatment for early breast cancer. At a mean follow-up of 46 months no local recurrences have been described and no patients presented distant metastasis or died for any cause. 6 patients (46.2%) presented complications, as fibrosis and liponecrosis. Our results suggest that electron beam intraoperative radiotherapy in the conservative treatment of breast cancer could be considered a suitable option for low risk patients, even if our sample is very small and we need longer follow-up to draw conclusive results., (Copyright © 2014. Published by Elsevier Ltd.)

Abstract Circulating levels of asymmetric dimethylarginine (ADMA), a nitric oxide synthase inhibitor, are increased in patients with idiopathic pulmonary hypertension (IPAH). We hypothesized that ADMA abrogates gap junctional communication, required for the coordinated regulation of endothelial barrier function and angiogenesis, and so contributes to pulmonary endothelial dysfunction. The effects of ADMA on expression and function of gap junctional proteins were studied in human pulmonary artery endothelial cells; pulmonary endothelial microvascular cells from mice deficient in an enzyme metabolizing ADMA, dimethylarginine dimethylaminohydrolase I (DDAHI); and blood-derived endothelial-like cells from patients with IPAH. Exogenous and endogenous ADMA inhibited protein expression and membrane localization of connexin 43 (Cx43) in a nitric oxide/soluble guanosine monophosphate/c-jun-dependent manner in pulmonary endothelial cells, resulting in the inhibition of gap junctional communication, increased permeability, and decreased angiogenesis. The effects of ADMA were prevented by overexpression of DDAHI or Cx43 and by treatment with rotigaptide. Blood-derived endothelial-like cells from IPAH patients displayed a distinct disease-related phenotype compared to cells from healthy controls, characterized by reduced DDAHI expression, increased ADMA production, and abnormal angiogenesis. In summary, we show that ADMA induces pulmonary endothelial dysfunction via changes in expression and activity of Cx43. Cells from IPAH patients exhibit abnormal DDAHI/Cx43 signaling as well as differences in gap junctional communication, barrier function, and angiogenesis. Strategies that promote DDAHI/Cx43 signaling may have an endothelium-protective effect and be beneficial in pulmonary vascular disease.

Background: Soil is among the most diverse and complex environments in the world. Soil microorganisms play an essential role in biogeochemical cycles and affect plant growth and crop production. However, our knowledge of the relationship between species-assemblies and soil ecosystem processes is still very limited. The aim of this study was to generate a comprehensive metagenomic survey to evaluate the effect of high-input agricultural practices on soil microbial communities., Results: We collected soil samples from three different areas in the Argentinean Pampean region under three different types of land uses and two soil sources (bulk and rhizospheric). We extracted total DNA from all samples and also synthetized cDNA from rhizospheric samples. Using 454-FLX technology, we generated 112 16S ribosomal DNA and 14 16S ribosomal RNA amplicon libraries totaling 1.3 M reads and 36 shotgun metagenome libraries totaling 17.8 million reads (7.7 GB). Our preliminary results suggested that water availability could be the primary driver that defined microbial assemblages over land use and soil source. However, when water was not a limiting resource (annual precipitation >800 mm) land use was a primary driver., Conclusion: This was the first metagenomic study of soil conducted in Argentina and our datasets are among the few large soil datasets publicly available. The detailed analysis of these data will provide a step forward in our understanding of how soil microbiomes respond to high-input agricultural systems, and they will serve as a useful comparison with other soil metagenomic studies worldwide.

In Facultad de Ciencias Exactas y Naturales,Universidad de Buenos Aires there is a service called Servicio de Identificación de Hongos Tóxicos, directed by researchers of the Program of Medicinal Plants and Fungi Involved in Biological Degradation (PROPLAME-PRHIDEB, CONICET) that assist hospitals and other health establishments, identifying the different samples of fungi and providing information about their toxicity, so that patients can receive the correct treatment. The objective of the present study was to analyze all the cases received from 1985 to 2012. This analysis permitted the confection of a table identifying the most common toxic species. The information gathered revealed that 47% of the patients were under 18 years of age and had eaten basidiomes; the remaining 53% were adults who insisted that they were able to distinguish edible from toxic mushrooms. Chlorophyllum molybdites turned out to be the main cause of fungal intoxication in Buenos Aires, which is commonly confused with Macrolepiota procera, an edible mushroom. In the second place Amanita phalloides was registered, an agaric known to cause severe symptoms after a long period of latency (6-10 hours), and which can lead to hepatic failure even requiring a transplant to prevent severe internal injuries or even death, is not early and correctly treated.

Motivation: In this paper we demonstrate the usage of RIO; a framework for detecting syntactic regularities using cluster analysis of the entities in the signature of an ontology. Quality assurance in ontologies is vital for their use in real applications, as well as a complex and difficult task. It is also important to have such methods and tools when the ontology lacks documentation and the user cannot consult the ontology developers to understand its construction. One aspect of quality assurance is checking how well an ontology complies with established 'coding standards'; is the ontology regular in how descriptions of different types of entities are axiomatised? Is there a similar way to describe them and are there any corner cases that are not covered by a pattern? Detection of regularities and irregularities in axiom patterns should provide ontology authors and quality inspectors with a level of abstraction such that compliance to coding standards can be automated. However, there is a lack of such reverse ontology engineering methods and tools., Results: RIO framework allows regularities to be detected in an OWL ontology, i.e. repetitive structures in the axioms of an ontology. We describe the use of standard machine learning approaches to make clusters of similar entities and generalise over their axioms to find regularities. This abstraction allows matches to, and deviations from, an ontology's patterns to be shown. We demonstrate its usage with the inspection of three modules from SNOMED-CT, a large medical terminology, that cover "Present" and "Absent" findings, as well as "Chronic" and "Acute" findings. The module sizes are 5 065, 20 688 and 19 812 asserted axioms. They are analysed in terms of their types and number of regularities and irregularities in the asserted axioms of the ontology. The analysis showed that some modules of the terminology, which were expected to instantiate a pattern described in the SNOMED-CT technical guide, were found to have a high number of regularity deviations. A subset of these were categorised as "design defects" by verifying them with past work on the quality assurance of SNOMED-CT. These were mainly incomplete descriptions. In the worst case, the expected patterns described in the technical guide were followed by only 5% of the axioms in the module., Conclusion: It is possible to automatically detect regularities and then inspect irregularities in an ontology. We argue that RIO is a tool to find and report such matches and mismatches, for evaluations by the domain experts. We have demonstrated that standard clustering techniques from machine learning can offer a tool in the drive for quality assurance in ontologies., Availability: http://riotool.sourceforge.net/, Contact: http://eleni.mikroyannidi@manchester.ac.uk, http://robert.stevens@manchehster.ac.uk.

Breast cancer is the most common form of cancer and second main cause of death in women in western countries. Breast-conserving therapy, consisting of lumpectomy and radiation therapy, has become the standard local treatment for T1-T2 breast tumors. There is general agreement that successful breast conservation requires complete tumor excision with a "tumor-free" or "negative" margin of resection, but the definition of a negative margin is controversial. A commonly accepted definition of adequate margins requires a 2-mm distance between ink and tumor but opinions range from the original National Surgical Adjuvant Breast and Bowel Project definition of "no ink on tumor", to a recommended width of 10 mm or more. The ability to perform real-time molecular imaging analysis of margins during surgery would clearly be a significant advance; several groups have engaged in this effort, with encouraging reports of preliminary data. Further development of such techniques promises to lead to a point at which accurate intraoperative margin evaluation may be possible and may even be combined with therapeutic interventions, using techniques such as photodynamic therapy.

Objectives: To design a tool for nonvalvular atrial fibrillation (NVAF) to inform individuals of their individual stroke and bleeding risks, assist in clarifying priorities, and promote communication., Design: Clustered randomized controlled trial., Setting: Primary care clinics., Participants: Individuals with NVAF (N = 135)., Intervention: Completion of tool before regularly scheduled visit., Measurements: Primary outcomes included the 100-point informed and values clarity subscales of the decisional conflict scale (lower scores indicate individual is more informed and has greater clarity). Secondary outcomes included knowledge, patient-clinician communication, and change in treatment., Results: Sixty-nine individuals were enrolled in the intervention group and 66 in the control group. After their visit, intervention participants had lower scores on the informed (mean difference = -11.9, 95% confidence interval (CI) = -21.1 to -2.7) and values clarity subscales (mean difference = -14.6, 95% CI = -22.6 to -6.6). Greater proportions of intervention participants knew medications for reducing stroke risk (61% vs 31%, P < .001) and side effects (49% vs 37%, P = .07). Stroke (71% vs 12%) and bleeding risk (69% vs 20%) were discussed more frequently in the intervention than control group (P < .001). Five intervention participants expressed a preference for medication that was not concordant with their current treatment plan. There was no change in treatment plan in either group., Conclusion: The tool was effective in improving perceived and actual knowledge and values clarity and in increasing physician-patient communication but did not change treatment., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

This pilot study examined the feasibility and potential efficacy of a self-management program for seniors with chronic back pain and assessed for possible race/ethnicity differences in program impact. Sixty-nine seniors (24 African Americans, 25 Hispanics, and 20 non-Hispanic Whites) enrolled in the 8-wk community-based program. Efficacy outcomes included pain-related disability as measured by the Roland Morris Disability Questionnaire (RMDQ), pain intensity, pain self-efficacy, depressive symptoms, social activity, and functional status. Eighty percent of enrollees completed the program. Clinically important decreases in RMDQ scores were found for non-Hispanic White (adjusted change score = -3.53), African American (-3.89), and Hispanic (-8.45) participants. Improvements in all other outcomes were observed, but only for Hispanic participants. Results confirm that implementation of the protocol in urban senior centers is feasible, and the program shows potential efficacy. The race/ethnicity differences observed in the current study merit further investigation.

A study of the use of common qualifiers in SNOMED CT definitions and the resulting classification was undertaken using combined lexical and semantic techniques. The accuracy of SNOMED authors in formulating definitions for pre-coordinated concepts was taken as a proxy for the expected accuracy of users formulating post-coordinated expressions. The study focused on "acute" and "chronic" as used within a module based on the UMLS CORE Problem List and using the pattern of SNOMED CT's definition Acute disease and Chronic disease. Scripts were used to identify potential candidate concepts whose names suggested that they should be classified as acute or chronic findings. The potential candidates were filtered by local clinical experts to eliminate spurious lexical matches. Scripts were then use to determine which of the filtered candidates were not classified under acute or chronic findings as expected. The results were that 28% and 20% of candidate chronic and acute concepts, respectively, were not so classified. Of these candidate misclassifications, the large majority occurred because "acute" and "chronic" are sometimes specified by qualifiers for clinical course and sometimes for morphology, a fact mentioned but not fully detailed in the User Guide distributed with the SNOMED releases. This heterogeneous representation reflects a potential conflict between common usage in patient care and SNOMED's origins in pathology. Other incidental findings included questions about the qualifier hierarchies themselves and issues with the underlying model for anatomy. The effort required for the study was kept modest by using module extraction and scripts, showing that such quality assurance of SNOMED is practical. The results of a preliminary study using proxy measures must be taken with caution. However, the high rate of misclassification indicates that, until the specifications for qualifiers are better documented and/or brought more in line with common clinical usage, anyone attempting to use post-coordination in SNOMED CT must be aware that there are significant pitfalls., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Ontologies are being developed for the life sciences to standardise the way we describe and interpret the wealth of data currently being generated. As more ontology based applications begin to emerge, tools are required that enable domain experts to contribute their knowledge to the growing pool of ontologies. There are many barriers that prevent domain experts engaging in the ontology development process and novel tools are needed to break down these barriers to engage a wider community of scientists., Results: We present Populous, a tool for gathering content with which to construct an ontology. Domain experts need to add content, that is often repetitive in its form, but without having to tackle the underlying ontological representation. Populous presents users with a table based form in which columns are constrained to take values from particular ontologies. Populated tables are mapped to patterns that can then be used to automatically generate the ontology's content. These forms can be exported as spreadsheets, providing an interface that is much more familiar to many biologists., Conclusions: Populous's contribution is in the knowledge gathering stage of ontology development; it separates knowledge gathering from the conceptualisation and axiomatisation, as well as separating the user from the standard ontology authoring environments. Populous is by no means a replacement for standard ontology editing tools, but instead provides a useful platform for engaging a wider community of scientists in the mass production of ontology content.

Objective: To develop measures representing key constructs of the Transtheoretical Model (TTM) of behavior change as applied to advance care planning (ACP) and to examine whether associations between these measures replicate the relationships posited by the TTM., Methods: Sequential scale development techniques were used to develop measures for Decisional Balance (Pros and Cons of behavior change), ACP Values/Beliefs (religious beliefs and medical misconceptions serving as barriers to participation), Processes of Change (behavioral and cognitive processes used to foster participation) based on responses of 304 persons age≥65 years., Results: Items for each scale/subscale demonstrated high factor loading (>.5) and good to excellent internal consistency (Cronbach α .76-.93). Results of MANOVA examining scores on the Pros, Cons, ACP Values/Beliefs, and POC subscales by stage of change for each of the six behaviors were significant, Wilks'λ=.555-.809, η(2)=.068-.178, p≤.001 for all models., Conclusion: Core constructs of the TTM as applied to ACP can be measured with high reliability and validity., Practice Implications: Cross-sectional relationships between these constructs and stage of behavior change support the use of TTM-tailored interventions to change perceptions of the Pros and Cons of participation in ACP and promote the use of certain Processes of Change in order to promote older persons' engagement in ACP., (Published by Elsevier Ireland Ltd.)

Choroideremia (CHM), an X-linked degeneration of the retinal pigmented epithelium (RPE), photoreceptors, and choroid, ultimately leads to blindness. It is caused by loss-of-function of the CHM gene product, the Rab escort protein 1 (REP1) that is involved, together with its homologue REP2, in prenylation of Rab GTPases, key regulators of intracellular vesicular traffic. Here, we report the molecular characterization of 20 unrelated Italian families affected by CHM. We identified 19 different mutations, nine of which are new. In most cases, we analyzed the effect of the mutations at the mRNA level. Furthermore, we demonstrated, by in vitro trancription/translation assays, that the mutated mRNAs produced truncated proteins in all cases but one. In fact, we also identified a novel REP1 missense variant (c.1520A>G; p.H507R) associated to CHM. Thus far, only two other CHM-associated missense mutations have been identified, one of which was a splicing alteration. We investigated the impact of the p.H507R amino acid change on REP1 structure and function, thus providing the first experimental demonstration that correlates a missense mutation in CHM with a functional impairment of REP1. Overall, our results indicate that the REP1-Rab geranyl-geranyl transferase interaction and consequently REP1-mediated Rab prenylation is essential for RPE and photoreceptor function., (© 2011 Wiley Periodicals, Inc.)

Objectives: To examine agreement between older persons and their surrogates regarding participation in advance care planning (ACP)., Design: Observational cohort study., Setting: Community., Participants: Persons aged 65 and older and the individual they identified as most likely to make treatment decisions on their behalf., Measurements: Older persons were asked about participation in four activities: completion of living will, completion of healthcare proxy, communication regarding views about life-sustaining treatment, and communication regarding views about quality versus quantity of life. Surrogates were asked whether they believed the older person had completed these activities., Results: Of 216 pairs, 81% agreed about whether a living will had been completed (κ=0.61, 95% confidence interval (CI) 0.51-0.72). Only 68% of pairs agreed about whether a healthcare proxy had been completed (κ=0.39, 95% CI 0.29-0.50), 64% agreed about whether they had communicated regarding life-sustaining treatment (κ=0.22, 95% CI 0.09-0.35), and 62% agreed about whether they had communicated regarding quality versus quantity of life (κ=0.23, 95% CI 0.11-0.35)., Conclusion: Although agreement between older persons and their surrogates regarding living will completion was good, agreement about participation in other aspects of ACP was fair to poor. Additional study is necessary to determine who is providing the most accurate report of objective ACP components and whether agreement regarding participation in ACP is associated with greater shared understanding of patient preferences., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Background: Quality-assurance initiatives encourage adherence to evidenced-based guidelines based on a consideration of treatment benefit. We examined older persons' willingness to take medication for primary cardiovascular disease prevention according to benefits and harms., Methods: In-person interviews were performed with 356 community-living older persons. Participants were asked about their willingness to take medication for primary prevention of myocardial infarction (MI) with varying benefits in terms of absolute 5-year risk reduction and varying harms in terms of type and severity of adverse effects., Results: Most (88%) would take medication, providing an absolute benefit of 6 fewer persons with MI out of 100, approximating the average risk reduction of currently available medications. Of participants who would not take it, 17% changed their preference if the absolute benefit was increased to 10 fewer persons with MI, and, of participants who would take it, 82% remained willing if the absolute benefit was decreased to 3 fewer persons with MI. In contrast, large proportions (48%-69%) were unwilling or uncertain about taking medication with average benefit causing mild fatigue, nausea, or fuzzy thinking, and only 3% would take medication with adverse effects severe enough to affect functioning., Conclusions: Older persons' willingness to take medication for primary cardiovascular disease prevention is relatively insensitive to its benefit but highly sensitive to its adverse effects. These results suggest that clinical guidelines and decisions about prescribing these medications to older persons need to place emphasis on both benefits and harms.

Objective: To develop and test a simple tool to elicit the preferences of older persons based on prioritization of universal health outcomes., Methods: Persons age ≥ 65 participating in a larger study were asked to rank 4 outcomes on a visual analogue scale: (1) maintaining independence, (2) staying alive, (3) reducing/eliminating pain, (4) reducing/eliminating other symptoms., Results: Interviewers rated 73% of the 81 participants as having good to excellent understanding, and cognitive interviews demonstrated the tool captured how participants thought about trade-offs. Test-retest reliability was fair to poor for ranking most of the outcomes as either most or least important (kappa .28-1.0). Patient characteristics associated with ranking "keeping you alive" as most important have been shown to be associated with a preference for life-sustaining treatment, a related construct. There was substantial variability in the outcome ranked as most important., Conclusions: The task of ranking 4 universal health outcomes was well understood, captured what was important when considering trade-offs, and demonstrated content validity. However, test-retest reliability was fair to poor., (Published by Elsevier Ireland Ltd.)

Objectives: To develop stages-of-change measures for advance care planning (ACP), conceptualized as a group of interrelated but separate behaviors, and to use these measures to characterize older persons' engagement in and factors associated with readiness to participate in ACP., Design: Observational cohort study., Setting: Community., Participants: Persons aged 65 and older recruited from physician offices and a senior center., Measurements: Stages of change for six ACP behaviors: completion of a living will and healthcare proxy, communication with loved ones regarding use of life-sustaining treatments and quantity versus quality of life, and communication with physicians about these same issues., Results: Readiness to participate in ACP varied widely across behaviors. Whereas between approximately 50% and 60% of participants were in the action or maintenance stage for communicating with loved ones about life-sustaining treatment and completing a living will, 40% were in the precontemplation stage for communicating with loved ones about quantity versus quality of life, and 70% and 75% were in the precontemplation stage for communicating with physicians. Participants were frequently in different stages for different behaviors. Few sociodemographic, health, or psychosocial factors were associated with stages of change for completing a living will, but a broader range of factors was associated with stages of change for communication with loved ones about quantity versus quality of life., Conclusion: Older persons show a range of readiness to engage in different aspects of ACP. Individualized assessment and interventions targeted to stage of behavior change for each component of ACP may be an effective strategy to increase participation in ACP., (© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.)

p27(BBP)/eIF6 (beta4-binding protein/eukaryotic initiation factor 6) regulates the joining of 40S and 60S ribosomal subunits, on receptor for activated C kinase 1 binding and protein kinase C phosphorylation in serine 235. In Xenopus, p27(BBP)/eIF6 is abundantly expressed in the majority of the embryonic anlagen. Although p27(BBP)/eIF6 abundance may be required for a general regulation of protein synthesis, our data suggest that p27(BBP)/eIF6 may target the translation of specific mRNAs. We injected Xp27(BBP)/eIF6 mRNA in one blastomere of two-cell-stage embryos and obtained a bent phenotype, the curvature being lateral with respect to the embryo antero-posterior axis. The injected side had fewer apoptotic cells than the uninjected side, whereas cell proliferation appeared unaffected. Accordingly, in Xp27(BBP)/eIF6 morphants, endogenous apoptosis increased. Injection of Xp27(BBP)/eIF6 point mutants indicated that the anti-apoptotic action of Xp27(BBP)/eIF6 requires the conserved S235. The bent phenotype was also obtained with B-cell lymphoma gene-2 (Bcl-2) overexpression and was rescued by Bcl-2-associated X protein (Bax)/Xp27(BBP)/eIF6 co-injection. In addition, embryos overexpressing Xp27(BBP)/eIF6 had a higher amount of Bcl-2 and an unchanged amount of Bax with respect to controls. In Xp27(BBP)/eIF6 morphants, Bcl-2 levels were unaffected and Bax levels were higher than in the controls. Thus, we propose that Xp27(BBP)/eIF6 is part of a mechanism acting on the specific translation of messengers regulating cell survival. In particular, we suggest that Xp27(BBP)/eIF6 may regulate the translation of factors upstream of Bcl-2/Bax.

Objectives: To explore whether models of health behavior change can help to inform interventions for advance care planning (ACP)., Design: Qualitative cross-sectional study., Setting: Community., Participants: Sixty-three community-dwelling persons aged 65 and older and 30 caregivers with experience as surrogate decision-makers., Measurements: In focus groups conducted separately with older persons and caregivers, participants were asked to discuss ways they had planned for future declines in health and why they had or had not engaged in such planning. Transcripts were analyzed using grounded theory., Results: Four themes illustrated the potential of applying models of health behavior change to improve ACP. (1) Participants demonstrated variable readiness to engage in ACP and could be in different stages of readiness for different components of ACP, including consideration of treatment goals, completion of advance directives, and communication with families and physicians. (2) Participants identified a wide range of benefits of and barriers to ACP. (3) Participants used a variety of processes of change to progress through stages of readiness, and ACP was only one of a broader set of behaviors that participants engaged in to prepare for declines in their health or for death. (4) Experience with healthcare decision-making for loved ones was a strong influence on perceptions of susceptibility and engagement in ACP., Discussion: The variability in participants' readiness, barriers and benefits, perceptions of susceptibility, and use of processes to increase readiness for participating in each component of ACP suggests the utility of customized, stage-specific interventions based on individualized assessments to improve ACP.

Different natural antimicrobials affected viability of bacterial contaminants isolated at critical steps during a beer production process. In the presence of 1 mg/ml chitosan and 0.3 mg/ml hops, the viability of Escherichia coli in an all malt barley extract wort could be reduced to 0.7 and 0.1% respectively after 2 hour- incubation at 4 degrees C. The addition of 0.0002 mg/ml nisin, 0.1 mg/ml chitosan or 0.3 mg/ml hops, selectively inhibited growth of Pediococcus sp. in more than 10,000 times with respect to brewing yeast in a mixed culture. In the presence of 0.1 mg ml chitosan in beer, no viable cells of the thermoresistant strain Bacillus megaterium were detected. Nisin, chitosan and hops increased microbiological stability during storage of a local commercial beer inoculated with Lactobacillus plantarum or Pediococcus sp. isolated from wort. Pulsed Electric Field (PEF) (8 kV/cm, 3 pulses) application enhanced antibacterial activity of nisin and hops but not that of chitosan. The results herein obtained suggest that the use of these antimicrobial compounds in isolation or in combination with PEF would be effective to control bacterial contamination during beer production and storage.

Aim: To evaluate the clinical and endoscopic patterns in a large series of patients with metastatic tumors in the stomach., Methods: A total of 64 patients with gastric metastases from solid malignant tumors were retrospectively examined between 1990 and 2005. The clinicopathological findings were reviewed along with tumor characteristics such as endoscopic pattern, location, size and origin of the primary sites., Results: Common indications for endoscopy were anemia, bleeding and epigastric pain. Metastases presented as solitary (62.5%) or multiple (37.5%) tumors were mainly located in the middle or upper third of stomach. The main primary metastatic tumors were from breast and lung cancer and malignant melanoma., Conclusion: As the prognosis of cancer patients has been improving gradually, gastrointestinal (GI) metastases will be encountered more often. Endoscopic examinations should be conducted carefully in patients with malignancies, and endoscopic biopsies and information on the patient's clinical history are useful for correct diagnosis of gastric metastases.

Stents were deployed in 83 renal artery lesions of 63 subjects. All were hypertensive and 29 were renal insufficient (RI). Technical success was 99%. Long-term (11.3 +/- 3.8 months) patency was evaluated with ultrasound in 69 lesions (51 ostial). Technical success and long-term patency rates were not significantly different between ostial and non-ostial lesions. Ten lesions restenosed (14%). At most recent follow-up (10.2 +/- 4.5 months) hypertensive subjects were classified as cured (3.7%), improved (35.2%), unchanged (53.7%), or worse (7.4%). Systolic pressure was significantly improved throughout follow-up but diastolic pressure was only significantly lower at discharge. Based on serum creatinine, Rl subjects were classified as improved (36%), unchanged (46%), or worse (18%). Complications included transfusion (10), renal artery perforation (3), and renal failure (8). Eight transfused subjects also had retroperitoneal bleeds. Rl subjects were more likely to develop acute renal failure. Subjects who died (9) were more likely to have Rl at baseline and to suffer renal artery perforation during the procedure. Patient risk factors and procedural technique contributed to complications in this study, but for most patients stenting yielded excellent technical success and long-term patency for ostial and non-ostial lesions. The effect on blood pressure and renal function was favorable.

Purpose: To report the results of the FDA phase II, multicenter trial of the Wallstent in the iliac and femoral arteries., Patients and Methods: Two hundred twenty-five patients entered the trial. Stents were placed in the iliac system in 140 patients and in the femoral system in 90 (five patients required both iliac and femoral stents). Clinical patency was measured over 2 years by means of life-table analysis with use of clinical and hemodynamic data and the Rutherford scale. Angiographic patency was measured at 6 months., Results: In the iliac system the primary clinical patency was 81% at 1 year and was 71% at 2 years. The secondary clinical patency was 91% and 86%, respectively. The 6-month angiographic patency was 93%. In the femoral system the primary clinical patency was 61% at 1 year and 49% at 2 years. The secondary patency was 84% and 72%, respectively. The 6-month angiographic patency was 80%., Conclusions: The results are similar to those with the Palmaz stent in the iliac system and with angioplasty alone in the iliac and femoral systems.

We evaluated, retrospectively, the hospital records of 100 consecutive patients with acute myocardial infarction who underwent emergency coronary angiography and percutaneous transluminal coronary angioplasty between January 1984 and August 1990. Intracoronary streptokinase (250,000 to 1 million units) was administered to 46 of these patients. Reperfusion was achieved in 82 patients, 8 of whom died in the hospital within 30 days. Angioplasty failed in 18 patients. Six were managed medically and survived, 7 survived emergency coronary bypass surgery at a nearby facility, and 5 died. The overall mortality rate was 13%. No facilities for open-heart surgery were available at our hospital; however, surgical back-up was available at another hospital, 0.5 miles away. No death was related to the transfer of a patient or to the unavailability of an in-house cardiac surgery facility. The American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures has written guidelines for cardiac surgical back-up for percutaneous transluminal coronary angioplasty. These guidelines strongly recommended that an experienced cardiovascular surgical team be available for emergency surgery in the institution as a back-up for all angioplasty procedures. Our study shows, however, that with careful case selection, emergency angioplasty for acute myocardial infarction can be performed safely with good results in a setting without on-site cardiac surgery facilities.

Sixteen patients (2 women, 14 men) aged 29 to 72 years with continued cardiogenic shock during intraaortic balloon pumping (IABP) had additional treatment with percutaneous cardiopulmonary bypass (PBY). Cause of cardiogenic shock was myocardial infarction in 7 (3 survived), failed percutaneous transluminal coronary angioplasty requiring emergency coronary artery bypass grafting in 5, postoperative aortic valve replacement in 1, postoperative emergency coronary artery bypass grafting in 1, after cardiac transplantation in 1, and bridging to transplantation in 1. Mean blood pressure with PBY and IABP combined was 75 mm Hg versus 60 mm Hg with IABP off. Percutaneous cardiopulmonary bypass flows ranged from 0.8 to 2.1 L/min with a mean flow of 1.3 L/min. Time on IABP ranged from 24 hours to 1 week. Time on IABP to PBY ranged from 1 to 20 hours, and time on PBY ranged from 65 minutes to 20 hours. Ten of 16 (63%) were successfully weaned, and 3 died after weaning. Seven of 16 (44%) survive. Combined IABP with PBY appears to be a better therapy than either one individually. Staging the therapy as the balloon first in and last out appears to be a good methodology.

A technique is described that allows insertion of a standard percutaneous intraaortic balloon without use of the larger 12F sheath. Standard 9.5-cm. Percor balloons were inserted in a series of patients without using the provided sheath. Elimination of the sheath reduced the potential vascular complications related to the extra bulk placed in the femoral artery by the sheath. No serious complications were noted in more than 25 patients.

A 47-year-old woman presented with progressive angina and failed medical therapy. After an unsuccessful attempt at angioplasty of a totally occluded right coronary artery, coronary artery bypass using the right internal mammary artery was performed. She presented 2 years later with stenosis in the mammary graft, right coronary artery, and axillary artery. These lesions were all treated with angioplasty.

Coronary artery spasm is a well-documented phenomenon in patients undergoing medial treatment. We describe coronary artery spasm occurring in the immediate postoperative period following coronary artery bypass operation. The spasm occurred in a vessel that was not operated on and that had no apparent lesion. The diagnosis of spasm was made by coronary angiography immediately after operation. Complications associated with this spasm are discussed. Emphasis is placed on early postoperative angiography for patients whose condition is inexplicably unstable after operation.

A patient with acute right ventricular failure and severe hemodynamic instability following coronary artery revascularization was treated with intra-aortic and intravenous balloon pumping. The intravenous balloon was timed to inflate during diastole and deflate during systole as did the intra-aortic balloon; in fact, the two were connected to the same system through a Y-connector. The intravenous balloon acted as an artificial atrium, which allowed approximately 20% improvement in the cardiac output when this intravenous balloon was functioning. Hemodynamic stability was achieved with this system. Intravenous balloon pumping should be considered for patients with unstable hemodynamics secondary to acute right ventricular failure.

Of 2,859 patients having percutaneous transluminal coronary angioplasty, 201 (7%) underwent emergency coronary artery bypass grafting. Two categories of patients were reviewed. Group 1 consisted of 126 patients of 2,304 who had immediate coronary artery bypass grafting after failed elective percutaneous transluminal coronary angioplasty. Ninety-eight of these patients had angiographic evidence of occlusion of a coronary artery, and 28 had angiographic evidence of coronary artery dissection. Epicardial hemorrhage was observed at operation in 20% (25 patients). Three deaths (2.4%) occurred in group 1, and an average of 3.3 grafts was performed per patient. Group 2 comprised 75 of 555 patients who had unsuccessful attempted percutaneous transluminal coronary angioplasty during an evolving myocardial infarction and required immediate coronary artery bypass grafting. Angiography revealed coronary artery occlusion in 61 patients with dissection in 14. All group 2 patients had evidence of myocardial injury by electrocardiographic and enzymatic (myocardial-specific isoenzyme of creatine kinase) criteria. Three deaths (4%) occurred in this group, and there was an average of 3.4 grafts per patient. Percutaneous transluminal coronary angioplasty is routinely performed without surgical consultation, although an operating room and team are usually available. Supportive techniques include the intraaortic balloon pump and percutaneous cardiopulmonary bypass. In those patients with coronary artery dissection, care must be taken to reestablish the true lumen of the coronary artery. Hemopericardium should be surgically explored and broken guidewires or other foreign bodies or debris removed. From 1979 through 1986, the number of patients requiring emergency coronary artery bypass grafting after percutaneous transluminal coronary angioplasty steadily declined to less than 5%.

One hundred thirty-eight selected patients underwent emergency coronary artery revascularization as the treatment for early evolving myocardial infarction. Low early and late (3.6 and 2.9%) mortality and morbidity up to 54 months, with favorable post surgical hemodynamic improvement demonstrates the operability with beneficial results in selected patients with early evolving myocardial infarction.

A permanent parallel aortic pump (PAP), essentially a permanent intra-aortic balloon pump or modified dynamic aortic patch, has been designed to support failing left ventricles The PAP is a counterpulsation system in which an external energy source delivers a pulsatile wave into the central circulation during cardiac diastole and relaxes during cardiac systole. Clinical improvement occurred in two patients after PAP implantation. The initial regimen of continuous pumping evolved to intermittent left ventricular assistance, and the patients were able to be periodically disconnected from the pump and ambulated. The patients expired 39 and 34 days after implantation due to gastrointestinal bleeding and complications of chronic emphysema and tracheostomy. Autopsy revealed that surgery for both devices had entirely healed.