The methane cycle in ferruginous Lake Matano

In Lake Matano, Indonesia, the world's largest known ferruginous basin, more than 50% of authigenic organic matter is degraded through methanogenesis, despite high abundances of Fe (hydr)oxides in the lake sediments. Biogenic CH₄ accumulates to high concentrations (up to 1.4 mmol L⁻¹) in the anoxic bottom waters, which contain a total of 7.4 × 10⁵ tons of CH₄. Profiles of dissolved inorganic carbon (ΣCO₂) and carbon isotopes (δ¹³C) show that CH₄ is oxidized in the vicinity of the persistent pycnocline and that some of this CH₄ is likely oxidized anaerobically. The dearth of NO₃⁻ and SO₄²⁻ in Lake Matano waters suggests that anaerobic methane oxidation may be coupled to the reduction of Fe (and/or Mn) (hydr)oxides. Thermodynamic considerations reveal that CH₄ oxidation coupled to Fe(III) or Mn(III/IV) reduction would yield sufficient free energy to support microbial growth at the substrate levels present in Lake Matano. Flux calculations imply that Fe and Mn must be recycled several times directly within the water column to balance the upward flux of CH₄. 16S gene cloning identified methanogens in the anoxic water column, and these methanogens belong to groups capable of both acetoclastic and hydrogenotrophic methanogenesis. We find that methane is important in C cycling, even in this very Fe-rich environment. Such Fe-rich environments are rare on Earth today, but they are analogous to conditions in the ferruginous oceans thought to prevail during much of the Archean Eon. By analogy, methanogens and methanotrophs could have formed an important part of the Archean Ocean ecosystem.

Precipitation of low-temperature dolomite from an anaerobic microbial consortium: the role of methanogenic Archaea

Here we report precipitation of dolomite at low temperature (30 degrees C) mediated by a mixed anaerobic microbial consortium composed of dissimilatory iron-reducing bacteria (DIRB), fermenters, and methanogens. Initial solution geochemistry is controlled by DIRB, but after 90 days shifts to a system dominated by methanogens. In live experiments conditions are initially saturated with respect to dolomite (Omega(dol) = 19.40) and increase by two orders of magnitude (Omega(dol) = 2 330.77) only after the onset of methanogenesis, as judged by the increasing [CH(4)] and the detection of methanogenic micro-organisms. We identify ordered dolomite in live microcosms after 90 days via powder X-ray diffraction, while sterile controls precipitate only calcite. Scanning electron microscopy and transmitted electron microscopy demonstrate that the precipitated dolomite is closely associated with cell walls and putative extra-cellular polysaccharides. Headspace gas measurements and denaturing gradient gel electrophoresis confirm the presence of both autotrophic and acetoclastic methanogens and exclude the presence of DIRB and sulfate-reducing bacteria after dolomite begins forming. Furthermore, the absence of dolomite in the controls and prior to methanogenesis confirm that methanogenic Archaea are necessary for the low-temperature precipitation of dolomite under the experimental conditions tested.

Modeling distributed axonal delays in mean-field brain dynamics

The range of conduction delays between connected neuronal populations is often modeled as a single discrete delay, assumed to be an effective value averaging over all fiber velocities. This paper shows the effects of distributed delays on signal propagation. A distribution acts as a linear filter, imposing an upper frequency cutoff that is inversely proportional to the delay width. Distributed thalamocortical and corticothalamic delays are incorporated into a physiologically based mean-field model of the cortex and thalamus to illustrate their effects on the electroencephalogram (EEG). The power spectrum is acutely sensitive to the width of the thalamocortical delay distribution, and more so than the corticothalamic distribution, because all input signals must travel along the thalamocortical pathway. This imposes a cutoff frequency above which the spectrum is overly damped. The positions of spectral peaks in the resting EEG depend primarily on the distribution mean, with only weak dependences on distribution width. Increasing distribution width increases the stability of fixed point solutions. A single discrete delay successfully approximates a distribution for frequencies below a cutoff that is inversely proportional to the delay width, provided that other model parameters are moderately adjusted. A pair of discrete delays together having the same mean, variance, and skewness as the distribution approximates the distribution over the same frequency range without needing parameter adjustment. Delay distributions with large fractional widths are well approximated by low-order differential equations.

Lessons learnt in the pharmacokinetic analysis of the effect of haemoperfusion for acute overdose with sustained-release diltiazem

The effect of charcoal haemoperfusion on the pharmacokinetics of diltiazem is described in a patient with severe clinical toxicity following acute overdose. The patient presented within 3 h following acute ingestion of multiple medications including sustained-release diltiazem. Routine resuscitation and supportive care were administered, but hypotension did not resolve despite intravenous fluids and infusions of calcium, adrenaline, noradrenaline and vasopressin. Multiple-doses of activated charcoal, haemodialysis and charcoal haemoperfusion were prescribed to expedite the elimination of diltiazem. The maximum diltiazem concentration (577 microg.l(-1)) was recorded 7 h post ingestion which was followed by an erratic and prolonged elimination phase. The maximum clearance of diltiazem due to haemoperfusion was calculated to be 19.4 and 15.1 ml.min(-1) at different times, equating to removal of approximately 1.5 mg diltiazem during 4 h of haemoperfusion. Haemoperfusion did not appear to remove sufficient diltiazem to recommend its routine use in the treatment of patients with acute diltiazem overdose.

Association of intra-operative metaphyseal fractures with prosthesis size during hemiarthroplasty of the hip

PURPOSE

To study the possible causes of intra-operative metaphyseal fractures in elderly patients undergoing hemiarthroplasty for displaced intracapsular femoral neck fracture.

METHODS

36 men and 228 women aged 61 to 89 years with 273 displaced femoral neck fractures underwent hemiarthroplasty using a hydroxyapatite ceramic-coated Furlong bipolar prosthesis. Anteroposterior and lateral radiographs were taken immediately after surgery to evaluate the presence and type of any intra-operative fractures (classified according to the Vancouver system) and their effect on stem stability or osseointegration. Pain and clinical outcomes were evaluated using a visual analogue scale and the Harris Hip Score.

RESULTS

Regarding the 273 surgeries for displaced femoral neck fracture, 28 (10%) were associated with intra-operative metaphyseal fracture (21 Vancouver type AL and 7 type AG). There was a correlation between intra-operative metaphyseal fractures and stem size. A size-9 stem was used in 64 surgeries without any fracture. A size-10 stem was used in 129 surgeries in which 11 (9%) sustained fractures, and a size-12 stem was used in 80 surgeries in which 17 (21%) sustained fractures. Postoperatively, 25 cases developed hip-related problems (thigh pain=14 and periprosthetic fractures=8) after 3 to 18 months. No patient whose metaphyseal fracture was fixed had hip problems.

CONCLUSION

In elderly women with compromised bone quality, extra care is needed to achieve better fitting so as to avoid iatrogenic metaphyseal fractures. Under-sizing or cementing of the prosthesis is recommended when encountering difficulties.

First Report of Curvularia Blight of Zoysiagrass Caused by Curvularia lunata in the United States

Symptoms of an unknown foliar blight have been observed in zoysiagrass (Zoysia matrella, Z. japonica, and hybrids) landscapes in North Carolina since 2002. Disease activity is most common during spring and summer when temperatures are between 21 and 30°C. Affected leaves initially exhibit small, chocolate brown spots, followed by dieback of leaves from the tips, and eventually blighting of entire tillers. Symptoms appear in small, irregular patches as much as 15 cm in diameter, but numerous patches may coalesce to impact large sections of turf. Infected turf appears tan or brown from a distance, but often turns black during periods of wet or humid weather. Microscopic analysis revealed profuse sporulation of Curvularia spp. on the surface of symptomatic leaves. Leaf sections were surface disinfested in 10% Clorox for 1 to 2 min, blotted dry, then plated on potato dextrose agar (PDA) containing 50 mg/l of tetracycline, streptomycin, and chloramphenicol. Twenty-eight fungal isolates were obtained from six locations. Examination of conidia produced in culture revealed 21 isolates of Curvularia, two isolates of Drechslera, one isolate of Nigrospora, and four unidentified sterile fungi. Curvularia isolates were identified to species on the basis of morphological characteristics (1) and ITS-rDNA sequences. Known isolates of C. eragrostidis, C. geniculata, C. inequalis, C. lunata, C. pallescens, and C. trifolii were obtained from the American Type Culture Collection for comparison. All unknown isolates produced conidia that were characteristic of C. lunata (lacking a protuberant hilum, smooth walled, tri-septate, predominantly curved, and mid- or dark brown, average dimensions 17 to 25 × 8 to 12 μm). Colonies on PDA lacked stroma or the zonate appearance indicative of C. lunata var. aeria. The pathogenicity of C. lunata isolates was tested on zoysiagrass cvs. El Toro (Z. japonica) and Emerald (Z. japonica × matrella). Cores (11.4 cm in diameter) of established zoysiagrass were potted in calcined clay (Turface Allsport; Profile Products LLC, Buffalo Grove, IL), and transferred to a greenhouse where the average temperature was 26°C. Five isolates were selected to represent the geographic range of Curvularia blight in North Carolina, and conidia were produced on PDA under continuous fluorescent illumination. Each isolate was inoculated to one pot of each zoysiagrass variety by spraying with 25 ml of a suspension containing 2 × 10⁵ conidia/ml with an airbrush. Inoculated pots were placed in a sealed, nontransparent plastic container for 48 h at 28°C to encourage infection and then transferred back to the greenhouse bench. Pathogenicity tests were repeated four times over time. Isolates ZFB3 and ZFB28 were most virulent with initial symptoms of foliar dieback appearing within 1 week after inoculation. Continued disease progress resulted in necrosis of the entire plant. Other isolates induced symptoms within 2 to 3 weeks after inoculation; however, disease severity was lower as compared with ZFB3 and ZFB28 throughout each experiment. Cvs. Emerald and El Toro were equally susceptible to infection by C. lunata. To our knowledge, this is the first report of Curvularia blight of zoysiagrass in the United States. This disease was previously described in Japan where it is commonly referred to as 'dog footprint' (3) and Brazil (2). References: (1) M. B. Ellis. Dematiaceous Hyphomycetes. CMI, Kew, Surrey, UK, 1971. (2) F. B. Rocha et al. Australas. Plant Pathol. 33:601, 2004. (3) T. Tani and J. B. Beard. Color Atlas of Turfgrass Diseases. Ann Arbor Press, Chelsea, MI, 1997.

The ORION statement: guidelines for transparent reporting of Outbreak Reports and Intervention studies Of Nosocomial infection

The quality of research in hospital epidemiology (infection control) must be improved to be robust enough to influence policy and practice. In order to raise the standards of research and publication, a CONSORT equivalent for these largely quasi-experimental studies has been prepared by the authors of two relevant systematic reviews, following consultation with learned societies, editors of journals and researchers. It consists of a 22 item checklist, and a summary table. The emphasis is on transparency to improve the quality of reporting and on the use of appropriate statistical techniques. The statement has been endorsed by a number of professional special interest groups and societies. Like CONSORT, ORION should be considered a 'work in progress', which requires ongoing dialogue for successful promotion and dissemination. The statement is therefore offered for further public discussion. Journals and research councils are strongly recommended to incorporate it into their submission and reviewing processes. Feedback to the authors is encouraged and the statement will be revised in 2 years.

Alteration of iron-rich lacustrine sediments by dissimilatory iron-reducing bacteria

The reduction of Fe during bacterial anaerobic respiration in sediments and soils not only causes the degradation of organic matter but also results in changes in mineralogy and the redistribution of many nutrients and trace metals. Understanding trace metal patterns in sedimentary rocks and predicting the fate of contaminants in the environment requires a detailed understanding of the mechanisms through which they are redistributed during Fe reduction. In this work, lacustrine sediments from Lake Matano in Indonesia were incubated in a minimal media with the dissimilatory iron reducing (DIR) bacterium Shewanella putrefaciens 200R. These sediments were reductively dissolved at rates slower than pure synthetic goethite despite the presence of an 'easily reducible' component, as defined by selective extractions. DIR of the lacustrine sediments resulted in the substrate-dependent production of abundant quantities of extracellular polymeric substances. Trace elements, including Ni, Co, P, Si, and As, were released from the sediments with progressive Fe reduction while Cr was sequestered. Much of the initial trace metal mobility can be attributed to the rapid reduction of a Mn-rich oxyhydroxide phase. The production of organo-Fe(III) reveals that DIR bacteria can generate significant metal complexation capacity. This work demonstrates that DIR induces the release of many elements associated with Fe-Mn oxyhydroxides, despite secondary mineralization.

Ozone affects gas exchange, growth and reproductive development in Brassica campestris (Wisconsin fast plants)

Exposure to ozone (O(3)) may affect vegetative and reproductive development, although the consequences for yield depend on the effectiveness of the compensatory processes induced. This study examined the impact on reproductive development of exposing Brassica campestris (Wisconsin Fast Plants) to ozone during vegetative growth. Plants were exposed to 70 ppb ozone for 2 d during late vegetative growth or 10 d spanning most of the vegetative phase. Effects on gas exchange, vegetative growth, reproductive development and seed yield were determined. Impacts on gas exchange and foliar injury were related to pre-exposure stomatal conductance. Exposure for 2 d had no effect on growth or reproductive characteristics, whereas 10-d exposure reduced vegetative growth and reproductive site number on the terminal raceme. Mature seed number and weight per pod and per plant were unaffected because seed abortion was reduced. The observation that mature seed yield per plant was unaffected by exposure during the vegetative phase, despite adverse effects on physiological, vegetative and reproductive processes, shows that indeterminate species such as B. campestris possess sufficient compensatory flexibility to avoid reductions in seed production.

Optimisation of imaging technique used in direct digital radiography

The purpose of the study was to optimise the technique employed for AP shoulder and lateral cervical spine examinations following an investigation into image quality, based on clinical assessment, and effective dose, calculated from patient entrance surface dose measurements. A study was therefore conducted in an attempt to determine whether the increased radiation dose to the patient following the introduction of an anti-scatter grid was justified by the level of improvement in image quality. The study, involving 100 patients, was able to demonstrate that the increase in radiation dose to the patient when using an anti-scatter grid for AP shoulder examinations is not justified by the improved image quality. A poor level of inter-rater reliability between the consultants scoring the lateral cervical spine images prevented a firm conclusion from being reached. The fact that all images were of diagnostic quality, however, suggested that the use of the anti-scatter grid was unnecessary. Following completion of the project the hospital involved was informed of all findings.

Biological control of Fasciola gigantica with Echinostoma revolutum

A field trial was carried out in West Java to investigate the potential for control of fasciolosis of antagonism between larvae of Fasciola gigantica and Echinostoma revolutum in Lymnaea rubiginosa. The trial was undertaken in 26 farmers' irrigated rice fields, each chosen because it was adjacent to a cattle pen the effluent from which flowed into or was used as fertiliser in the rice field. Fourteen of the fields chosen at random were retained as controls and received no treatment while in 12, faeces from 5 to 15 ducks containing eggs of E. revolutum were introduced to the rice from a duck pen located over the effluent drain from the cattle pen before it emptied into the adjacent rice field, or at the site bovine faeces was added to the field as fertiliser. After harvest significantly fewer L. rubiginosa were found infected with F. gigantica in fields where duck and cattle dung entered the field together than in control fields, supporting a conclusion that this method of biological control would reduce the infectivity of rice fields fertilised with bovine dung (which are those with the highest potential for being a source of infection with F. gigantica). Positive features of using dung from ducks infected with E. revolutum to control F. gigantica are the minimum additional work and disruption to existing farming practices required to implement the scheme, the common natural infection with E. revolutum in village ducks, and effectiveness of dung from 5 to 15 ducks, a number commonly kept by farmers.

The effect of temperature and humidity on longevity of metacercariae of Fasciola gigantica

Studies were undertaken on the viability of the metacercariae of Fasciola gigantica when stored in water at 13 degrees C for periods up to 23 weeks, exposed to the sunlight for up to 8 h or stored at a range of temperatures and humidities for up to 10 weeks. Excysted metacercariae were catergorized microscopically as viable (motile and undamaged), dubious (not motile and undamaged) or dead (visible necrosis). The infectivity of viable and dubious metacercariae and unselected reference metacercariae held in water at 7 degrees C for 20 days or longer was assessed by comparing numbers of flukes recovered from infected Merino sheep. Mean recovery rates were 54.6%, 7.2% and 37.2%, respectively, for viable, dubious and unselected metacercariae. Metacercariae immersed in water remained viable longer than those allowed to desiccate. Viability was promoted by decreasing temperature and increasing humidity. Exposure to direct sunlight killed metacercariae within 8 h. Results indicated that in lowland Indonesian irrigated rice paddies, metacercariae immersed in water are likely to survive for less than 5 weeks while those that become desiccated will survive less than 2 weeks. This information, together with the option of exposing fresh rice stalks to direct sunlight before feeding them to livestock, can assist farmers in reducing infection with F gigantica.

Variations in the survival of Fasciola gigantica eggs in bovine dung stored in the sun as opposed to the shade

Eggs of F. gigantica were placed in dung heaps that were located in the shade or exposed to sun light, and examined at intervals for up to 14 weeks. The rate and extent of decline in viability of eggs was greater in dung exposed to sun light than in shaded dung. This difference was attributed the higher temperature in dung in sun light, owing to the effect of direct sunlight and to a higher rate of fermentation in exposed than in shaded dung. It was concluded that strategies for storing dung that would reduce the risk it poses for infecting L. rubiginosa with F. gigantica when used as fertilizer in rice fields include storing dung in sun light rather than in the shade, preferably in a thin layer to allow sunlight to heat and desiccate it, and mixing a carbohydrate with the stored dung to increase heat through fermentation.

Optimization of the procedure for counting the eggs of Fasciola gigantica in bovine faeces

This paper describes a method for counting eggs of F. gigantica in bovine faeces that optimizes the proportion of eggs recovered and the repeatability of estimates. The method uses 3 g of faeces suspended in 0.05% Tween 20. The suspension is passed through three 6 cm diameter sieves in tandem to remove fibrous debris, with respective apertures of 1 mm, 450 microm, and either 266 or 200 microm. The filtrate is allowed to sediment for 3 min in a conical flask; the sediment is recovered, then resuspended in 200 ml of 0.05% Tween 20 and allowed to sediment. After 3 min the sediment is washed in a sieve with an aperture of 53 microm, which retains the eggs. Eggs suspended in 15 ml of 1% methylene blue are counted using a dissecting microscope. Use of Tween 20 instead of water as the suspending agent for faeces gave a significant threefold increased the proportion of eggs recovered and reduced variability between repeated counts. This method is able to detect about one-third of the eggs present. It was concluded that the high proportion of F. gigantica eggs lost may be due to the presence of hydrophobic and covalent bonds on the eggs that bind them to debris, with which they are discarded.

Validation of influenza and pneumococcal vaccine status in adults based on self-report

Self-report of polysaccharide pneumococcal vaccination is not thought reliable because of the increased risk of adverse events from inadvertent re-vaccination in elderly people. Some studies suggest a high sensitivity of self-report and hence a low risk of adverse events if vaccination is administered when medical records are unavailable. Self-report of pneumococcal and influenza vaccination in a sample of >64-year-olds in the United Kingdom was compared with information in their medical records. Self-report of pneumococcal vaccination, in contrast to some of the other studies had a low sensitivity. The findings here support the need for accurate knowledge of prior vaccine status before offering the polysaccharide pneumococcal vaccine. The study also confirms that self-report of influenza vaccination could be relied upon if rapid knowledge of uptake is required.

Development of multiplex PCRs for detection of common viral pathogens and agents of congenital infections

Potential causes of congenital infection include Toxoplasma gondii and viruses such as cytomegalovirus (CMV), enterovirus, hepatitis C virus, herpes simplex virus types 1 and 2 (HSV-1 and -2), human herpesvirus types 6, 7, and 8, lymphocytic choriomeningitis virus, parvovirus, rubella virus, and varicella-zoster virus. Testing for each of these agents using nucleic acid tests is time consuming and the availability of clinical samples such as amniotic fluid or neonatal blood is often limited. The aim of this study was to develop multiplex PCRs (mPCRs) for detection of DNA and RNA agents in the investigation of congenital infection and an mPCR for the viruses most commonly requested in a diagnostic virology laboratory (CMV, Epstein-Barr virus, enterovirus, HSV-1, HSV-2, and varicella-zoster virus). The assays were assessed using known pathogen-positive tissues (cultures, placentae, plasma, and amniotic fluid) and limits of detection were determined for all the agents studied using serial dilutions of plasmid targets. Nested PCR was performed as the most sensitive assay currently available, and detection of the amplicons using hybridization to labeled probes and enzyme-linked immunosorbent assay detection was incorporated into three of the four assays. This allowed detection of 10 to 10(2) copies of each agent in the samples processed. In several patients, an unexpected infection was diagnosed, including a case of encephalitis where HSV was the initial clinical suspicion but CMV was detected. In the majority of these cases the alternative agent could be confirmed using reference culture, serology, or fluorescence methods and was of relevance to clinical care of the patient. The methods described here provide useful techniques for diagnosing congenital infections and a paradigm for assessment of new multiplex PCRs for use in the diagnostic laboratory.

A unifying explanation of primary generalized seizures through nonlinear brain modeling and bifurcation analysis

The aim of this paper is to explain critical features of the human primary generalized epilepsies by investigating the dynamical bifurcations of a nonlinear model of the brain's mean field dynamics. The model treats the cortex as a medium for the propagation of waves of electrical activity, incorporating key physiological processes such as propagation delays, membrane physiology, and corticothalamic feedback. Previous analyses have demonstrated its descriptive validity in a wide range of healthy states and yielded specific predictions with regards to seizure phenomena. We show that mapping the structure of the nonlinear bifurcation set predicts a number of crucial dynamic processes, including the onset of periodic and chaotic dynamics as well as multistability. Quantitative study of electrophysiological data supports the validity of these predictions. Hence, we argue that the core electrophysiological and cognitive differences between tonic-clonic and absence seizures are predicted and interrelated by the global bifurcation diagram of the model's dynamics. The present study is the first to present a unifying explanation of these generalized seizures using the bifurcation analysis of a dynamical model of the brain.

Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): systematic review of the literature

OBJECTIVE

To evaluate the evidence for the effectiveness of isolation measures in reducing the incidence of methicillin resistant Staphylococcus aureus (MRSA) colonisation and infection in hospital inpatients.

DESIGN

Systematic review of published articles.

DATA SOURCES

Medline, Embase, CINAHL, Cochrane Library, System for Information on Grey Literature in Europe (SIGLE), and citation lists (1966-2000).

REVIEW METHODS

Articles reporting MRSA related outcomes and describing an isolation policy were selected. No quality restrictions were imposed on studies using isolation wards or nurse cohorting. Other studies were included if they were prospective or employed planned comparisons of retrospective data.

RESULTS

46 studies were accepted; 18 used isolation wards, nine used nurse cohorting, and 19 used other isolation policies. Most were interrupted time series, with few planned formal prospective studies. All but one reported multiple interventions. Consideration of potential confounders, measures to prevent bias, and appropriate statistical analysis were mostly lacking. No conclusions could be drawn in a third of studies. Most others provided evidence consistent with a reduction of MRSA acquisition. Six long interrupted time series provided the strongest evidence. Four of these provided evidence that intensive control measures including patient isolation were effective in controlling MRSA. In two others, isolation wards failed to prevent endemic MRSA.

CONCLUSION

Major methodological weaknesses and inadequate reporting in published research mean that many plausible alternative explanations for reductions in MRSA acquisition associated with interventions cannot be excluded. No well designed studies exist that allow the role of isolation measures alone to be assessed. None the less, there is evidence that concerted efforts that include isolation can reduce MRSA even in endemic settings. Current isolation measures recommended in national guidelines should continue to be applied until further research establishes otherwise.

Methicillin-resistant Staphylococcus aureus in hospitals and the community: stealth dynamics and control catastrophes

Methicillin-resistant Staphylococcus aureus (MRSA) represents a serious threat to the health of hospitalized patients. Attempts to reduce the spread of MRSA have largely depended on hospital hygiene and patient isolation. These measures have met with mixed success: although some countries have almost eliminated MRSA or remained largely free of the organism, others have seen substantial increases despite rigorous control policies. We use a mathematical model to show how these increases can be explained by considering both hospital and community reservoirs of MRSA colonization. We show how the timing of the intervention, the level of resource provision, and chance combine to determine whether control measures succeed or fail. We find that even control measures able to repeatedly prevent sustained outbreaks in the short-term can result in long-term control failure resulting from gradual increases in the community reservoir. If resources do not scale with MRSA prevalence, isolation policies can fail "catastrophically."

A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery

OBJECTIVES

To compare the clinical- and cost-effectiveness of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous transluminal coronary angioplasty (PTCA) with or without stenting in patients with single-vessel disease of the left anterior descending coronary artery (LAD).

DESIGN

Multi-centre randomised trial without blinding. The computer-generated sequence of randomised assignments was stratified by centre, allocated participants in blocks and was concealed using a centralised telephone facility.

SETTING

Four tertiary cardiothoracic surgery centres in England.

PARTICIPANTS

Patients with ischaemic heart disease with at least 50% proximal stenosis of the LAD, suitable for either PTCA or MIDCAB, and with no significant disease in another vessel.

INTERVENTIONS

Patients randomised to PTCA had local anaesthetic and underwent PTCA according to the method preferred by the operator carrying out the procedure. Patients randomised to MIDCAB had general anaesthetic. The chest was opened through an 8-10-cm left anterior thoracotomy. The ribs were retracted and the left internal thoracic artery (LITA) harvested. The pericardium was opened in the line of the LAD to confirm the feasibility of operation. The distal LITA was anastomosed end-to-side to an arteriotomy in the LAD. All operators were experienced in carrying out MIDCAB.

MAIN OUTCOME MEASURES

The primary outcome measure was survival free from cardiac-related events. Relevant events were death, myocardial infarction, repeat coronary revascularisation and recurrence of symptomatic angina or clinical signs of ischaemia during an exercise tolerance test at annual follow-up. Secondary outcome measures were complications, functional outcome, disease-specific and generic quality of life, health and social services resource use and their costs.

RESULTS

A total of 12,828 consecutive patients undergoing an angiogram were logged at participating centres from November 1999 to December 2001. Of the 1091 patients with proximal stenosis of the LAD, 127 were eligible and consented to take part; 100 were randomised and the remaining 27 consented to follow-up. All randomised participants were included in an intention-to-treat analysis of survival free from cardiac-related events, which found a non-significant benefit from MIDCAB. Cumulative hazard rates at 12 months were estimated to be 7.1 and 9.2% for MIDCAB and PTCA, respectively. There were no important differences between MIDCAB and PTCA with respect to angina symptoms or disease-specific or generic quality of life. The total NHS procedure costs were 1648 British pounds and 946 British pounds for MIDCAB and PTCA, respectively. The costs of resources used during 1 year of follow-up were 1033 British pounds and 843 British pounds, respectively.

CONCLUSIONS

The study found no evidence that MIDCAB was more effective than PTCA. The procedure costs of MIDCAB were observed to be considerably higher than those of PTCA. Given these findings, it is unlikely that MIDCAB represents a cost-effective use of resources in the reference population. Recent advances in cardiac surgery mean that surgeons now tend to carry out off-pump bypass grafting via a sternotomy instead of MIDCAB. At the same time, cardiologists are treating more patients with multi-vessel disease by PTCA. Future primary research should focus on this comparison. Other small trials of PTCA versus MIDCAB have now finished and a more conclusive answer to the original objective could be provided by a systematic review.

Contribution of ovarian steroid production to urinary estrone conjugate concentrations in Macaca mulatta

This study was designed to test the hypothesis that basal estrone conjugate (E1C) profiles do not accurately detect ovarian function when ovarian estrogen production is low or absent. We employed surgical removal of active ovaries from laboratory rhesus macaques to simulate an acute decline in ovarian estrogen production. In the first experiment, urine samples collected prior to and following ovariectomy (Ovx) were subjected to high-performance liquid chromatography (HPLC) separation. Eluates were then assayed for E1C immunoreactive components. The results indicated a modest decrease in total immunoreactive polar conjugates following ovariectomy, with no substantial change in the overall retention profile. In the second experiment, estradiol (E2) cypionate injections were used to replace the E2 component of ovarian estrogen production in the treated (Tx) group, while the control group (C) received only vehicle. Urine samples were hydrolyzed and individual estrogens were separated by celite chromatography prior to immuno-assay. Both the Tx and C groups exhibited similar urinary excretion levels of estrone (E1), E2, and E1C prior to Ovx (Pre-Ovx) and after Ovx (Post-Ovx), but there were significant differences between groups after treatment (Post-Tx). Significant differences were observed in the Tx group's excretion of E1, E2, and E1C in the Pre- vs. Post-Ovx samples and in the Post-Ovx and Post-Tx samples. The C group also showed the expected significant differences in the Pre- vs. Post-Ovx samples, as well as in the Pre-Ovx and Post-Tx samples. The results indicate that the use of E1C measurements is clearly a suitable method for monitoring ovarian function in intact, cycling animals, but urinary E2 measurements are required to verify loss of follicular activity.