The variability of Phytophthora infestans isolates collected from Estonian islands in the Baltic Sea

Knowledge of a pathogen's genetic variability and population structure is of benefit to effective disease management. In this study, 193 isolates of Phytophthora infestans collected from three Estonian islands, were characterized over three years using SSRs marker data complemented by information on their mating type and resistance to metalaxyl. In combination with SSR marker data from samples in the neighbouring Pskov region of north west Russia, the impact of regional and landscape structure on the level of genetic exchange was also examined. Among the Estonian islands 111 P. infestans isolates, forty-nine alleles were detected among twelve SSR loci, and 59 SSR multilocus genotypes (MLGs) were found, of which 64% were unique. The genetic variation was higher among years than that among islands, as revealed by AMOVA. The frequency of metalaxyl-resistant isolates increased from 9% in 2012 to 30% in 2014, and metalaxyl resistant was most frequent among A1 isolates. The test for isolation by distance among the studied regions was not significant, and coupled with the absence of genetic differentiation revealed gene flow, and the absence of local adaptation. The data are consistent with a sexual population in which diversity is driven by an annual germination of soil-borne oospores. The absence of shared genotypes over the years has important implications when it comes to the management of disease. Such population diversity can make it difficult to predict the nature of the outbreak in the coming year as the genetic makeup are different for each year.

High Temporal Variability in Late Blight Pathogen Diversity, Virulence, and Fungicide Resistance in Potato Breeding Fields: Results from a Long-Term Monitoring Study

Long-term site-specific studies describing changes in the phenotypic variability of Phytophthora infestans populations allow quantitative predictions of pathogen spread and possible outbreaks of epidemics, and provide key input for regional resistance breeding programs. Late blight samples were collected from potato (Solanum tuberosum) breeding fields in Estonia during a twelve-year study period between 2001 and 2014. In total, 207 isolates were assessed for mating type and 235 isolates for metalaxyl resistance and 251 isolates for virulence factors. The frequency of mating types strongly fluctuated across the years, whereas the later period of 2010–2014 was dominated by the A2 mating. Despite fluctuations, both mating types were recorded in the same fields in most years, indicating sustained sexual reproduction of P. infestans with oospore production. Metalaxyl-resistant and intermediately resistant strains dominated in the first years of study, but with the progression of the study, metalaxyl-sensitive isolates became dominant, reaching up to 88%. Racial diversity, characterized by normalized Shannon diversity index decreased in time, varying from 1.00 in 2003 to 0.43 in 2013. The frequency of several virulence factors changed in a time-dependent manner, with R2 increasing and R6, R8, and R9 decreasing in time. Potato cultivar resistance background did not influence the frequency of P. infestans mating type, response to metalaxyl, and racial diversity. However, the diversity index decreased in time among isolates collected from resistant and susceptible cultivars, and remained at a high level in moderately resistant cultivars. These data demonstrate major time-dependent changes in racial diversity, fungicide resistance, and virulence factors in P. infestans, consistent with alterations in the control strategies and popularity of potato cultivars with different resistance.

Polar Metamaterials: A New Outlook on Resonance for Cloaking Applications

Rotationally resonant metamaterials are leveraged to answer a longstanding question regarding the existence of transformation-invariant elastic materials and the ad hoc possibility of transformation-based passive cloaking in full plane elastodynamics. Combined with tailored lattice geometries, rotational resonance is found to induce a polar and chiral behavior, that is, a behavior lacking stress and mirror symmetries, respectively. The central, and simple, idea is that a population of rotating resonators can exert a density of body torques strong enough to modify the balance of angular momentum on which hang these symmetries. The obtained polar metamaterials are used as building blocks of a cloaking device. Numerical tests show satisfactory cloaking performance under pressure and shear probing waves, further coupled through a free boundary. The work sheds new light on the phenomenon of resonance in metamaterials and should help put transformation elastodynamics on equal footing with transformation acoustics and optics.

A degenerate polar lattice for cloaking in full two-dimensional elastodynamics and statics

A lattice design of a cloak for full two-dimensional elasticity is suggested when the background continuum is isotropic with Lamé parameters (λ,  μ ) satisfying μ  ≤ λ. The lattice is polar in the sense that it elastically resists rotations; and is degenerate meaning it admits a stressless collapse mechanism. These characteristics are attained through the use of appropriately distributed restoring torques in conjunction with hinge-like spring-mass contacts. Thus, the lattice is proven to exhibit a rank-3 elasticity tensor lacking the minor symmetries. Accordingly, it rigorously adheres to the form-invariance requirements of the transformation method under the Brun–Guenneau–Movchan gauge. The cloak is numerically tested in statics and in dynamics under pressure and shear incident waves and shows satisfactory performance. Finally, a theoretical generalization extends the design to three dimensions and to arbitrarily anisotropic backgrounds so as to enable cloaking as well as other transformation-based static and dynamic field manipulation techniques in these cases.

Use of Social Media in Breast Cancer Awareness: GCC Countries’ Experience

Background: Breast cancer is the highest incident cancer among women in the world today as well as in the Gulf Cooperation Council (GCC) countries. Improving the public awareness is significant in decreasing the overall morbidity and mortality of breast cancer. Social media brings a new dimension to healthcare as it offers a medium to communicate to be used by the public, patients, and health professionals to communicate health-related issues with the possibility of potentially improving health outcomes. According the Arab Social Media Report 2017 , the GCC countries largely dominate the top five spots in terms of penetration rates of key social media platforms among their populations, including Facebook, Twitter, LinkedIn, and Instagram. Social media platforms are now frequently used on a large adoption rate by the public to address health-related issues especially in GCC countries. Compared with the rest of the Arab region, the Gulf countries largely have more balanced age breakdowns of young users who are under 30 and those who are over 30 years old, indicating the maturity of usage across age groups in society. Aim: This paper aims to provide an overview of the available evidence concerning the use of social media platforms in breast cancer awareness campaigns in GCC. Methods: A literature search was conducted using PubMed and Google Scholar databases for articles published between 2010 and March 2018. Several keywords have been used. Search was limited to articles in English and Arabic describing the use of social media platforms in breast cancer awareness campaigns in any of the GCC countries. Results: More than 500 studies have been identified in the initial search. Fifteen articles have been deemed eligible. The majority are discussing the importance of using media (mass and social) as the main source of breast cancer information, however, a multilevel intervention should be considered as many interventions should be used to create culturally appropriate breast cancer awareness campaigns in the GCC countries. Conclusion: Apparently, media have been used to raise breast cancer awareness to promote breast cancer screening programs including self-exam and mammogram, benefits of early detection, and modifiable risk factors. However, social media should not be viewed as a solution to the complexities of behavior change and improved health outcomes; instead, use of social media in health promotion should be valued for its potential to engage with audiences for enhanced communication and improved capacity to promote programs, products, and services. The use of various social media platforms is variable across age, educational, and socioeconomic groups; therefore, breast cancer awareness campaigns utilizing social media should be tailored according to the target group, however public communication in the GCC still considered as a significant challenge due to the cultural diversity and language barriers.

Non-reciprocal wave propagation in modulated elastic metamaterials

Time-reversal symmetry for elastic wave propagation breaks down in a resonant mass-in-mass lattice whose inner-stiffness is weakly modulated in space and in time in a wave-like fashion. Specifically, one-way wave transmission, conversion and amplification as well as unidirectional wave blocking are demonstrated analytically through an asymptotic analysis based on coupled mode theory and numerically thanks to a series of simulations in harmonic and transient regimes. High-amplitude modulations are then explored in the homogenization limit where a non-standard effective mass operator is recovered and shown to take negative values over unusually large frequency bands. These modulated metamaterials, which exhibit either non-reciprocal behaviours or non-standard effective mass operators, offer promise for applications in the field of elastic wave control in general and in one-way conversion/amplification in particular.

Curvature, metric and parametrization of origami tessellations: theory and application to the eggbox pattern

Origami tessellations are particular textured morphing shell structures. Their unique folding and unfolding mechanisms on a local scale aggregate and bring on large changes in shape, curvature and elongation on a global scale. The existence of these global deformation modes allows for origami tessellations to fit non-trivial surfaces thus inspiring applications across a wide range of domains including structural engineering, architectural design and aerospace engineering. The present paper suggests a homogenization-type two-scale asymptotic method which, combined with standard tools from differential geometry of surfaces, yields a macroscopic continuous characterization of the global deformation modes of origami tessellations and other similar periodic pin-jointed trusses. The outcome of the method is a set of nonlinear differential equations governing the parametrization, metric and curvature of surfaces that the initially discrete structure can fit. The theory is presented through a case study of a fairly generic example: the eggbox pattern. The proposed continuous model predicts correctly the existence of various fittings that are subsequently constructed and illustrated.

Low protective PON1 lactonase activity in an Arab population with high rates of coronary heart disease and diabetes

BACKGROUND

Recent studies showing that high density lipoproteins (HDL) can effect plaque regression indicate that recent trial failures do not exclude an atheroprotective role of HDL. Instead, they highlight differences between HDL function and measured HDL-cholesterol (HDL-C). PON1 is one key functional activity of HDL. Urban Palestinians have lower HDL-C and a higher incidence and mortality of coronary heart disease than those of Israelis. We hypothesized that the cardioprotective PON1 lactonase and arylesterase activities and PON1 functional genotype may differ between Palestinians and Israelis.

METHODS

We measured PON1 activities in a cross-sectional population-based study of Palestinian (n=960) and Israeli (n=694) residents in Jerusalem, 1654 participants in all.

RESULTS

Palestinians had high prevalences of obesity and diabetes and low mean concentrations of HDL-cholesterol (0.97 mmol/l in men and 1.19 mmol/l in women). Lactonase and arylesterase activities were lower by 10.8% (p=1.2∗10(-14)) and 2.7% (p<0.0005), respectively, in Palestinians as compared to Israelis. The functional genotype distribution, demonstrated by plotting paraoxonase vs lactonase activities, showed a modest between-group difference (p=0.024), with 12.1% RR in Palestinian Arabs vs 8.4% in Israeli Jews, but no overall difference in allele frequencies. Lactonase correlated inversely with age (Spearman's rho=-.156), weakly with BMI (-.059), positively with HDL-C (.173) and non-HDL-C (.103), but was not associated with triglycerides or fasting glucose. Palestinians showed consistently lower lactonase activity in logistic regression models adjusted for multiple covariates and for functional genotype (odds ratios of 1.81 and 1.98, respectively, for the lower fifth vs the upper 4 fifths of lactonase activity p<0.0001).

CONCLUSION

We showed a lower physiologically-significant lactonase PON1 activity in an Arab population, a finding consistent with the high cardiovascular and diabetes risk of Palestinians.

Measurement of radon diffusion length in thin membranes

Building regulations in Israel require the insulating of buildings against radon (222)Rn penetration from soil. In radon-prone areas membranes stretched between the soil and the building foundation are used, together with sealing other possible penetration routes. Designing the radon mitigation procedure requires checking that all sealing materials are practically, radon tight, having a thickness of at least three times the radon diffusion length. In this work, a very simple technique to evaluate the radon diffusion length in thin membranes, using a radon source of known activity and an activated charcoal canister as radon detector is presented. The theoretical formalism and measurement results for polyethylene membranes of different densities obtained in a recent comparison exercise are presented.

Expert panel consensus recommendations for the pharmacological treatment of acute pain in the Middle East region

The findings of an expert panel convened to review critically how best to apply evidence-based guidelines for the treatment of acute pain in the Middle East region are presented. The panel recommended a three-step treatment protocol. Patients with mild-to-moderate levels of acute pain should be treated with paracetamol (step 1). If analgesia is insufficient after 1-2 days, a selective cyclo-oxygenase-2 inhibitor or, if gastrointestinal safety and bleeding risk are not an issue, a non-specific nonsteroidal anti-inflammatory drug, should be used (step 2). If analgesia remains inadequate, treatment with tramadol, or paracetamol plus codeine/tramadol is recommended (step 3). Patients reporting severe pain should be referred to a pain clinic or specialist for opioid analgesic treatment. Measures of pain and functioning that have been validated in Arabic, with culturally appropriate and easy to understand descriptors, should be used. Early and aggressive acute pain management is important to reduce the risk of pain becoming chronic, especially in the presence of neuropathic features.

Benefit-incidence analysis of government spending on Ministry of Health outpatient services in Jordan

A benefit-incidence analysis was conducted for the year 2000 using various data sources including the Jordan healthcare utilization and expenditure survey 2000. The results illustrate that the poorest segment of the Jordanian population were the most likely to report sickness and seek treatment and were the main users of the Ministry of Health outpatient services. The poorest uninsured individuals were the main source of revenues generated through user fees. The targeting efficiency (i.e. total percentage of benefits received) for the poorest quintile was 33.8% compared with 4.0% in the richest quintile. The analysis demonstrates that the Jordanian government in-kind subsidy is reaching the poor.

Maspin expression and localization impact on angiogenesis and prognosis in ovarian cancer

INTRODUCTION

The goal of this study is to evaluate the relation of maspin expression and its cellular localization to markers of angiogenesis in epithelial ovarian serous carcinoma (OSC).

MATERIALS AND METHODS

We identified 118 patients with high-grade advanced stage OSC who were treated at our institution. Clinical data were collected, and immunohistochemistry (IHC) with antibodies to VEGF, CD34, COX-2, and maspin was performed on paraffin-embedded tumor blocks. CD34 immunostaining was used to determine microvessel density. The correlation between the various molecular markers was assessed using the Chi-square test. Survival analysis was computed using the Kaplan-Meier model, and various prognostic variables were compared using Cox regression analysis.

RESULTS

Maspin expression was noted in 81.4% (96/118) of tumors. Expression was localized to the nuclear compartment in 21.2% of cases, whereas 60.2% of cases showed evidence of cytoplasmic +/- nuclear expression. Tumors that exhibited nuclear maspin expression had lower VEGF and COX-2 expression than tumors with negative or cytoplasmic expression. Tumors with high nuclear maspin expression had lower mean MVD than those with low or negative expression. The median survival based on localization of maspin was 1146 days for those with negative tumors, 1803 days for those with nuclear maspin, and 637 days for those with cytoplasmic maspin (P < 0.001). In a Cox regression analysis, maspin localization was an independent prognostic factor.

CONCLUSION

Maspin expression and localization seem to play a role in ovarian cancer angiogenesis and progression. High nuclear expression was associated with reduced markers of angiogenesis and prolonged survival.

40Ca(alpha, gamma)44Ti reaction in the energy regime of supernova nucleosynthesis

The 44Ti(t1/2=59 yr) nuclide, an important signature of supernova nucleosynthesis, has recently been observed as live radioactivity by gamma-ray astronomy from the Cas A remnant. We investigate in the laboratory the major 44Ti production reaction 40Ca(alpha, gamma)44Ti (Ec.m. approximately 0.6-1.2 MeV/u by direct off-line counting of 44Ti nuclei. The yield, significantly higher than inferred from previous experiments, is analyzed in terms of a statistical model using microscopic nuclear inputs. The associated stellar rate has important astrophysical consequences, increasing the calculated supernova 44Ti yield by a factor approximately 2 over previous estimates and bringing it closer to Cas A observations.

Stellar (n,gamma) cross section of 62Ni

The 62Ni(n,gamma)63Ni(t(1/2)=100+/-2 yr) reaction plays an important role in the control of the flow path of the slow neutron-capture (s) nucleosynthesis process. We have measured for the first time the total cross section of this reaction for a quasi-Maxwellian (kT=25 keV) neutron flux. The measurement was performed by fast-neutron activation, combined with accelerator mass spectrometry to detect directly the 63Ni product nuclei. The experimental value of 28.4+/-2.8 mb, fairly consistent with a recent calculation, affects the calculated net yield of 62Ni itself and the whole distribution of nuclei with 62<A<90 produced by the weak s process in massive stars.

The Cutting Balloon--a new technology?

The Cutting Balloon consists of a standard balloon dilatation catheter with four microtome-sharp blades that incise the plaque and minimize arterial wall trauma. It was used in 31 patients; nine had calcified arteries, ten had non-compliant lesions, three had in-stent restenosis and nine had aorto-ostial lesions. Seventeen lesions were predilated, 28 were post-dilated and 18 required stent implantation. The procedure was very effective in aorto-ostial lesions, non-compliant lesions that were not responsive to high-pressure balloon dilatation, and was partially successful in calcified arteries. It has a very specific niche in selected lesions.

Use of ThinPrep monolayer technique and cytospin preparation in urine cytology: a comparative analysis

We compared the ThinPrep (TP) technique to the cytospin (CS) preparation in the cytological diagnosis of urine by processing 79 specimens by these two techniques. Ten cases were positive for malignancy (six high grade (HG)/carcinoma in situ; four low grade (LG) transitional cell carcinomas (TCC)). Forty-eight cases were within normal limits (59%) and 21 cases had atypical cytological features (19%). The TP technique was better in terms of a cleaner background with fewer obscuring inflammatory cells and blood and with a more even distribution of cells. In general, the cytomorphology was comparable in both techniques. However, in cases with malignancy, CS was relatively superior in the cytomorphologic details; in TP, the diagnostic cells were mostly dispersed as single cells with loss of architectural features and were difficult to find. Artifactual empty spaces and air-drying were more frequently present in TP. In cases contaminated with squamous cells, the urothelial cells were difficult to find in TP. Screening time was comparable for both techniques. In conclusion, to avoid false-negative diagnosis, CS would be complementary to the TP technique in malignant cases and, in particular, those with low cellularity.

Clinicopathologic analysis of invasive micropapillary differentiation in breast carcinoma

Invasive micropapillary carcinoma (IMPCa) of breast is histologically characterized by growth of cohesive tumor cell clusters within prominent clear spaces resembling dilated angiolymphatic vessels. In this study, eighty three breast carcinomas with IMPCa differentiation were identified by review of the invasive carcinoma cases in our institution and correlated retrospectively with standard clinicopathologic parameters and survival status relative to a control series of cases (mean follow up 7 years). IMPCa growth pattern was present in 6% of all breast carcinomas; it was generally a focal component in otherwise typical invasive ductal carcinoma. It comprised more than 80% of the total neoplasm in only 10 cases (12%), 50-80% of the neoplasm in 7 cases (8%), 20-50% of the neoplasm in 22 cases (26%) and less than 20% in 44 cases (53%). The mean tumor size was 4 cm, 22% invaded skin, and 58% were poorly differentiated, but 71% were ER positive. Axillary node metastases were present in 77% of cases, were typically multiple (51% had three or more positive), and usually contained an IMPCa component (81% of the cases). There was no significant difference in node status, ER status, size, tumor grade, or peritumoral angiolymphatic invasion between tumors with predominant (more than 50%) v/s focal IMPCa components. In both groups 46% of the patients died from their disease (mean interval to death = 36m). Skin involvement and nodal status were the only parameters which predicted poor survival (P =.01). The outcome of patients with IMPCa did not differ significantly from infiltrating ductal carcinomas of similar node status. In conclusion, our results suggest that IMPCa growth pattern may be a manifestation of aggressive behavior, as shown by frequent skin invasion and extensive nodal involvement. However, clinicopathologic features and outcome of IMPCa are not strongly dependent on the relative amount of micropapillary component.

Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage

In our attempts to salvage massive lower-extremity injuries, even in the presence of severe peripheral vascular pathology, adequate soft-tissue coverage is no longer a limiting factor due to recent advances in microvascular composite tissue transfer. Restoration of tibial continuity without shortening has emerged as the last obstacle in the formidable task of salvaging lower extremities with grade III B and III C defects. Proposed solutions to this problem include conventional free cancellous bone-grafting applicable to small defects only, vascularized bone grafts, or shortening of the leg with subsequent elongation using the Ilizarov technique. We present our experience with 3 consecutive cases of lower-limb salvage, utilizing a new approach in which microsurgical soft-tissue reconstruction has been combined with bony reconstruction by distraction osteosynthesis. Bone transport by distraction osteosynthesis under a free flap performed while preserving the initial limb length throughout the treatment period proved to be superior to other methods in selected cases and is presented as a new technique for the management of problematic lower-limb injuries.

Long-term outcome of patients with very long stents for treatment of diffuse coronary disease

OBJECTIVES

The study sought to determine the 6-month clinical outcome of patients who underwent implantation of very long coronary stents to treat diffuse disease and/or long dissections and to compare the findings with those reported in the literature for patients who underwent implantation of multiple short coronary stents.

BACKGROUND

New designs of flexible stents enable the implantation of long stents rather than multiple short, older design stents. The initial experience is very promising but the long-term outcome has not been described yet.

METHODS

Fifty-seven consecutive patients in whom 67 long stents (>/=30 mm) were successfully deployed were included in this study. Six-month clinical and angiographic follow-up was prospectively collected. Patients with recurrent angina underwent coronary angiography without further testing. Patients who remained asymptomatic at the 6-month follow-up visit underwent positron emission tomographic imaging, and those with results suggestive of ischemia underwent coronary angiography. A combined study end point was defined as death, myocardial infarction, and the need for target vessel revascularization.

RESULTS

Only 1 patient (2%) reached a study end point at hospital discharge. An additional 20 patients (total 21 patients [37%]) reached an end point by 6 months. The outcome was not influenced by the clinical presentation (stable or unstable angina) or by the indication for stenting (elective or emergency). Predictors for adverse outcome were multiple stents per narrowing (63% vs 29%, P <. 04), and stents smaller than 3.5 mm (49% vs 22%). Narrowing and stent length were not predictive of a study end point in narrowings that were successfully treated by a single long stent.

CONCLUSIONS

Elective stenting provides an effective solution for patients with diffuse coronary disease provided that a single long stent (usually <40 mm) can cover the full length of the narrowing. The results are better when vessels larger than 3 mm are treated. Compared with multiple short stents, implantation of a single long stent is probably at least as effective, and the procedure is quicker and cheaper and thus should be the preferred approach.

Effects of the superoxide dismutase-mimic compound TEMPOL on oxidant stress-mediated endothelial dysfunction

The aim of this study was to investigate the effects of oxidant stress on endothelium-dependent and endothelium-independent arterial relaxation. For this, oxidant stress was generated by preincubation of rat aortic rings (RARs) in either 25 mM glucose (mimicking hyperglycemic stress) or 0.5 mM pyrogallol (a superoxide generator) and the effects of the superoxide dismutase (SOD)-mimetic compound 4-hydroxy-2,2,6,6-tetramethylpiperidinyloxy free radical (TEMPOL) on the vasorelaxant and cGMP-producing effects of acetylcholine (ACh) and glyceryl trinitrate (GTN) in control RARs and RARs exposed to oxidant stress were examined. Pyrogallol, and to a lesser extent high glucose concentration, enhanced the contractile response of RARs to phenylephrine and markedly inhibited the vasorelaxant response to ACh. Although they existed, the inhibitory effects of high glucose and pyrogallol on the vasorelaxant response to GTN were less profound, especially with pyrogallol. Moreover, both pyrogallol and high glucose concentration inhibited the basal and the ACh-induced vascular cyclic guanosine monophosphate (cGMP) production. Treatment with TEMPOL (1-5 mM) slightly increased the ACh and GTN-induced cGMP levels in control RARs but had a significant effect in high glucose and pyrogallol-pretreated RARs. Additionally, concomitant treatment of RARs with TEMPOL (5 mM) abolished the difference in the relaxation response between control RARs and RARs exposed to either pyrogallol or high glucose concentration. These results further support the theory that reactive oxygen species (ROS), especially superoxide, play a key role in mediation of endothelial dysfunction accompanying diabetes, probably through their effects on the ability of the endothelium to synthesize, release or respond to endogenous nitric oxide (NO) or NO donated by nitrovasodilators.

[Percutaneous revascularization of the left main coronary artery as coronary artery bypass in high surgical risks]

Coronary artery bypass grafting is the treatment of choice for obstructive disease of the left main coronary artery. Its proximal location and easy accessibility make the left main artery an inviting target for percutaneous intervention, an approach contraindicated by the high associated risk. We describe 2 patients at high operative risk in whom the obstructed main coronary artery was successfully revascularized percutaneously. Coronary stenting and rotational ablation of calcified arteries are essential for successful outcome and minimize complications.

Long-term angiographic follow-up of coronary balloon angioplasty in patients with diabetes mellitus: a clue to the explanation of the results of the BARI study. Balloon Angioplasty Revascularization Investigation

OBJECTIVES

We sought to compare the angiographic outcome of diabetic patients (treated with insulin or oral hypoglycemic agents) after successful coronary angioplasty with that in nondiabetic patients. The analysis included the outcome of the dilated (restenosis) and nondilated narrowings (disease progression).

BACKGROUND

Recent data have confirmed that diabetes mellitus is an important risk factor for long-term adverse events. These adverse events are more common after balloon angioplasty than after bypass surgery (Bypass Angioplasty Revascularization Investigation [BARI]).

METHODS

We examined retrospectively 353 coronary angiograms of 248 patients (55 diabetic, 193 nondiabetic) who were referred for diagnostic angiography >1 month after successful angioplasty (1.4 +/- 0.6 [mean +/- SD] repeat angiograms/patient). Restenosis and disease progression/regression were compared between groups by means of quantitative angiography.

RESULTS

Baseline clinical and angiographic characteristics were similar in both groups. There was a nonsignificant trend for a higher restenosis rate of dilated narrowings in diabetic patients. There were no significant changes between diabetic and nondiabetic patients in the rates of progression and regression of narrowings that were not dilated during the initial angioplasty. The main difference was in the rate of appearance of new narrowings: There was a 22% increase in the number of narrowings on the follow-up angiogram in diabetic patients (38 new, 174 preexisting narrowings) compared with 12% (86 new, 734 preexisting narrowings) in nondiabetic patients (p < 0.004). Diabetes mellitus and the performance of angioplasty in the artery had an additive risk for development of new narrowings, which were identified in 15 (16.9%) of 89 arteries with and 16 (13.2%) of 121 without angioplasty in diabetic patients and in 42 (12.7%) of 331 arteries with and 38 (7.3%) of 518 without angioplasty in nondiabetic patients (p = 0.009).

CONCLUSIONS

The combination of diabetes mellitus and an artery that was instrumented during balloon angioplasty is additive and increases the risk of formation of new narrowing in that artery. This finding may explain the high adverse event rates observed in diabetic patients in the angioplasty arm of the BARI study, most of whom had angioplasty performed in at least two arteries.

Atherosclerosis studies by intracoronary ultrasound

Intravascular ultrasound (IVUS) is a new technique of tomographic visualization of the coronary arteries: its lumen, wall and pathology. Three dimensional (3D) reconstruction shows the tubular structure of the arterial wall and its pathology. IVUS has many advantages over coronary angiography: it has better resolution and shows many hidden lesions. IVUS has helped uncover the underlying mechanisms of percutaneous transluminal coronary angioplasty (PTCA), restenosis, the use and value of other interventional techniques such as directional coronary atherectomy (DCA), rotational atherectomy and stent implantation, and has great value in planning complex interventional procedures. The new American Heart Association (AHA) classification of coronary atherosclerosis pathology can be demonstrated by IVUS. IVUS is sensitive for studies of atheroma regression and progression and shows the coronary artery lesions after cardiac transplantation.

Initial experience with long coronary stents: the changing practice of coronary angioplasty

The initial experience with the use of long coronary stents (> 30 mm in length) was analyzed retrospectively. Sixty-seven stents were deployed in 58 narrowings in 57 patients (34 AVE Microstents, 16 Nir stents, four Gianturco-Roubin II stents, and 13 Wallstents). Stents were implanted in 22 patients with unstable angina, 34 patients with stable angina, and one patient during direct angioplasty for acute myocardial infarction. Eighteen additional short stents were implanted to cover the entire length of the lesions so that an average of one and a half stents were deployed per patient. The length of the narrowings before stenting was 40 +/- 20 mm and the length of the stented segments was 45 +/- 20 mm. Stents were deployed for "bailout" in 23 narrowings, to improve suboptimal results of balloon angioplasty in 18 narrowings, and electively in 17 narrowings. Twenty of the 67 long stents were deployed in saphenous vein grafts. The success rate of stent implantation was 100%. One patient had a rupture of a saphenous vein graft after deployment of two long stents, with tamponade treated by emergency surgery. One patient had chest pain 18 hours after stent deployment; by the time he arrived at the catheterization laboratory the pain had subsided and the angiogram revealed a patent artery with normal flow. There were no other major complications during the hospital course and 1-month follow-up. We conclude that long coronary stents can be deployed successfully in native coronary arteries and vein grafts. They are useful for elective implantation and extremely helpful in bailout situations. The immediate results are excellent, but long-term outcome is awaited.

Experience with the AVE Micro stent in native coronary arteries

Experience with implantation of 62 AVE Micro stents is described. Stents were quickly and successfully deployed in 62 of 63 attempts (98.4%), in tortuous coronary vessels, through proximally deployed stents, and under conditions of hemodynamic instability. It is therefore a very attractive choice to treat difficult anatomy during urgent situations.

Surgical therapy for pulmonary hydatidosis

Surgical treatment of pulmonary hydatidosis varies from one country to another. Whereas some reports describe marsupialization of the residual cavity others favor capitonnage (imbrication) to decrease complications and hospital stay. Post operative complications and hospital stay were compared in a retrospective study of 53 patients treated surgically at the American University Hospital over a period of 10 years. Forty eight cysts were treated by evacuation after chemical sterilization. Fifteen were marsupialized and 33 were imbricated. Five were excised with lung parenchyma, 5 were delivered intact and one cyst was treated by lobectomy. There was no postoperative mortality. There was no statistical difference in the hospital stay or the complication rate between the marsupialized and imbricated cases. Both imbrication and marsupialization are equally effective methods of treatment of pulmonary hydatid cysts. Anatomic resection is rarely required.

Acute myocardial infarction--the angiographic picture: new insights into the pathogenesis of myocardial infarction

The angiographic appearance of the coronary arteries were examined in 302 patients with stable angina pectoris and compared to 308 patients with acute myocardial infarction, who received high-dose intravenous thrombolytic therapy, in order to elucidate the underlying angiopathological picture in the two diseases. In each group coronary lesions were present in proximal segments of the arteries and were closely related to bifurcations. Lesions were more extensively distributed in the coronary tree in patients with stable angina and they had an average of 5.4 lesions per patient, compared to the acute myocardial infarction group who had only 2.4 lesions. Also, in the acute myocardial infarction patients, four-fifths of the culprit arteries were patent, 104 (34%) had a ruptured plaque, 22 (7%) had an ulcerated plaque and in 190 (62%) the lesions were eccentric. The study shows that patients with myocardial infarction who are suitable for thrombolysis have a unique coronary angiographic picture and the acute episode is caused by sudden rupture of a localized atheromatous plaque which initiates an obstructive thrombotic cascade.

Transradial approach for coronary angiography and angioplasty

The transradial approach has currently been advocated as an alternative catheterization method for coronary angiography and angioplasty, due to the recent miniaturization of angioplasty equipment. The purpose of this study was to assess the practical clinical applicability of this method. From June to November 1994, 100 patients underwent coronary angiography and angioplasty with the transradial approach. Their mean age was 66.6 +/- 11.2 years, and 79 were men. In 4, radial puncture was not successful, and in 3, femoral access was necessary to complete the procedure. Coronary angioplasty was performed in 63 patients (76 lesions) with angiographic success (per lesion) of 96%. In 5 patients, a stent was successfully implanted. All patients were ambulatory on the day after the angioplasty procedure. In 98% of the patients, the introducer was taken out 1 to 4 hours after the procedure by local compression using a special custom-made device. No patient required blood transfusion. Major complications occurred in 2 patients; both had a cerebrovascular accident (1 probably not procedure-related), and both recovered. A radial pulse was palpated in 91 of the patients before discharge, and in 6 others, adequate flow could be heard with Doppler. In 2 patients, radial flow was restored within several weeks. None of the patients suffered from ischemia of the hand. Two patients had a small pseudoaneurysm successfully treated by local compression. Thus, coronary angioplasty can be performed safely using the transradial approach with relatively few vascular complications and with better patient comfort. However, the procedure is more time-consuming initially compared with the transfemoral approach due to a learning curve regarding equipment selection and catheter manipulation.

Dissecting aortic aneurysm in systemic lupus erythematosus

Many cardiovascular manifestations have been described in systemic lupus erythematosus (SLE). Aortic involvement, however, is very rare. We describe a 30-year-old woman with SLE who presented with extensive aortic dissection, and review the few reported cases. We discuss possible pathogenic mechanisms for aortic involvement in lupus and the appropriate diagnostic work-up.

Creation and healing of severe coronary dissection by the use of oversized balloon for the treatment of restenosis after an initially successful angioplasty

We describe two patients who underwent successful coronary angioplasty with a balloon that matched the normal size of the artery. Both patients returned for a second angioplasty because of restenosis. The morphology of the restenotic lesion was very similar to that of the original lesion. In the second angioplasty a larger balloon was used, and in both cases severe dissection occurred. Repeat angiography 3 months later demonstrated an open artery with clinically insignificant residual stenosis. We believe that in these two cases the initial angioplasty stretched the artery and it recoiled slowly to its original dimensions. A larger balloon size was necessary to crack atherosclerotic plaque and cause a successful long-term outcome.

Very early thrombolysis in acute myocardial infarction--a light at the end of the tunnel

Myocardial damage in acute myocardial infarction is a time-dependent process. Thrombolytic therapy effectively opens the coronary artery, restores coronary blood flow and prevents ongoing necrosis. We examined the effect of very early thrombolytic therapy (including prehospital administration) in a consecutive group of 510 patients with myocardial infarction on the following factors: mortality, complications and the preservation of left ventricular function. The treatment was given to 89 at home (time delay to treatment 1.2 +/- 0.6 h) and 421 in hospital (2.0 +/- 1.0 h). Twelve patients died in hospital and major hemorrhage occurred in 10. The arterial patency rate in 416 patients who underwent coronary angiography 6 days later was 82%. Infarct size measured by left ventriculography was determined by the area at risk, the delay time until the initiation of thrombolytic therapy, the total duration of ischemic pain and the degree of restoration of arterial blood flow. We conclude that early thrombolytic therapy, particularly prehospital management, is feasible and safe and reduces infarct size and mortality. A further decrease in the delay to initiation of treatment and more effective thrombolytic therapy will further decrease mortality and myocardial damage.

Autodecremental pacing for the interruption of ventricular tachycardia and atrial flutter

The efficacy and safety of autodecremental pacing (ADP) to interrupt ventricular tachycardia (VT) and atrial flutter was examined. Once tachycardia was recognized, ADP was initiated using a short train of stimuli with gradual shortening (3%) of the interstimulus interval. ADP was applied to 13 consecutive patients during 75 episodes of VT (mostly following induction by ventricular stimulation). Successful interruption of VT occurred in 88% of the episodes. In 6 episodes (8%), ADP resulted in ventricular fibrillation and in 3 episodes VT was unaffected by ADP. The only significant discriminator between the failure or success of ADP was the rate of VT. ADP was also applied to 17 consecutive patients with an atrial flutter that was resistant to conventional antiarrhythmic agents. Successful conversion of atrial flutter to sinus was seen in only 8 patients (47%). A temporary acceleration to atrial fibrillation appeared in 3 patients (18%), and in 6 patients atrial flutter was unaffected by ADP. ADP was successful in 70% (7/10) of patients with type 1 (< 300 beats/min) atrial flutter. The authors conclude that ADP is beneficial in the interruption of VT and atrial flutter in a selected group of patients, especially with a slower rate of tachyarrhythmia (atrial rate during atrial flutter < 300 beats/min and ventricular tachycardia < 180 beats/min).

Angiographic findings in the coronary arteries after thrombolysis in acute myocardial infarction

The angiographic appearance of the coronary arteries was examined in 308 patients with acute myocardial infarction (AMI) who received high-dose intravenous thrombolytic therapy. Coronary angiography was performed on day 7 after admission to the hospital. Patients had an average of 2.4 discrete arterial narrowings or obstructions. The narrowings were proximal and related to bifurcations. Four fifths of the culprit arteries were patient; 104 (34%) had a ruptured plaque, 22 (7%) had an ulcerated plaque, and in 190 (62%) the lesions were eccentric. Patients differed from a comparable, previously studied, control series of 302 patients with chronic stable angina pectoris who had more extensive disease. They had 5.7 narrowings/patient, also located proximally and at bifurcations, but more widely distributed in the coronary tree. Patients with AMI who are suitable for thrombolysis have a unique coronary angiographic picture. The data confirm that AMI is caused by sudden rupture of a localized atheromatous plaque that initiates an obstructive thrombotic cascade.

Recombinant interleukin-2 and interferon alpha immunotherapy following autologous bone marrow transplantation. A case report of cardiovascular toxicity with serial echocardiographic evaluation

The most serious side effects of recombinant interleukin-2 (rIL-2) and recombinant interferon-alpha (rIFN alpha) immunotherapy are cardiovascular disturbances, including systemic hypotension, left-ventricular dysfunction and pulmonary edema. We present a 25-year-old female who developed reversible cardiogenic shock during intermediate dose rIL-2 and low dose rIFN alpha therapy. Rapid clinical improvement occurred after intravenous fluid and dopamine support. A serial echocardiographic evaluation, which has not been described previously in this setting, is reported.

Cardiac tamponade following coronary arterial rupture during coronary angioplasty

We describe a patient in whom percutaneous transluminal coronary angioplasty (PTCA) was complicated by rupture of the left anterior descending coronary artery (LAD) with pericardial tamponade. The outcome was favorable with drastic intervention which included: occlusion of the bleeding vessel with the PTCA balloon, pericardiocentesis, and ligation of the vessel without the need of aortocoronary bypass graft.