Combined uncertainty estimation for the determination of the dissolved iron amount content in seawater using flow injection with chemiluminescence detection.

This work assesses the components contributing to the combined uncertainty budget associated with the measurement of the Fe amount content by flow injection chemiluminescence (FI-CL) in <0.2 µm filtered and acidified seawater samples. Amounts of loaded standard solutions and samples were determined gravimetrically by differential weighing. Up to 5% variations in the loaded masses were observed during measurements, in contradiction to the usual assumptions made when operating under constant loading time conditions. Hence signal intensities (V) were normalised to the loaded mass and plots of average normalised intensities (in V kg-1) vs. values of the Fe amount content (in nmol kg-1) added to a "low level" iron seawater matrix were used to produce the calibration graphs. The measurement procedure implemented and the uncertainty estimation process developed were validated from the agreement obtained with consensus values for three SAFe and GEOTRACES reference materials (D2, GS, and GD). Relative expanded uncertainties for peak height and peak area based results were estimated to be around 12% and 10% (coverage factor k = 2), respectively. The most important contributory factors were the uncertainty on the sensitivity coefficient (i.e., calibration slope) and the within-sequence-stability (i.e., the signal stability over several hours of operation; here 32 h). For GD, using peak height measurements, these factors contributed respectively 69.7% and 21.6% while the short-term repeatability accounted for only 7.9%. Therefore, an uncertainty estimation based on the intensity repeatability alone, as is often done in FI-CL studies, is not a realistic estimation of the overall uncertainty of the procedure.

Chemical analysis of flotsam ambergris.

The natural product ambergris is only found rarely on beaches, as jetsam. Even more scarce, or even absent, are accounts of flotsam ambergris. Here, we report the chemical analysis of a rare, large piece (>100kg) of flotsam found in the Atlantic in 2019. About 95% of subsamples from the outside of the coprolith was soluble in dichloromethane. Of this, FTIR spectroscopy, APCI-MS and GC-MS indicated the presence of ambrein. Radiocarbon dating indicated that the sample was post 1950s in age. The 13C/12C isotope ratio (-22.5 ‰) was typical of those reported to date for whale 'body' ambergris. Metals of ambergris have hardly been reported previously. The distribution found here for the flotsam, was dominated by copper and zinc, which is similar to that of several squid species. This is also consistent with the presence of squid beaks in the coprolith. Squid are a major prey species of sperm whales.

Direct detection of electron backscatter diffraction patterns.

We report the first use of direct detection for recording electron backscatter diffraction patterns. We demonstrate the following advantages of direct detection: the resolution in the patterns is such that higher order features are visible; patterns can be recorded at beam energies below those at which conventional detectors usefully operate; high precision in cross-correlation based pattern shift measurements needed for high resolution electron backscatter diffraction strain mapping can be obtained. We also show that the physics underlying direct detection is sufficiently well understood at low primary electron energies such that simulated patterns can be generated to verify our experimental data.

Toward Understanding the Environmental Risks of Combined Microplastics/Nanomaterials Exposures: Unveiling ZnO Transformations after Adsorption onto Polystyrene Microplastics in Environmental Solutions.

Over recent decades, there has been a dramatic increase in the manufacture of engineered nanomaterials, which has inevitably led to their environmental release. Zinc oxide (ZnO) is among the more abundant nanomaterial manufactured due to its advantageous properties, used for piezoelectric, semiconducting, and antibacterial purposes. Plastic waste is ubiquitous and may break down or delaminate into smaller microplastics, leaving open the question of whether these small polymers may alter the fate of ZnO through adsorption within aquatic media (tap-water and seawater). Here, scanning electron microscopy analysis confirms the effective Zn nano/microstructures adsorption onto polystyrene surfaces after only 24-h incubation in the aquatic media. After pre-aging the nanomaterials for 7-days in different environmental media, nanoprobe X-ray absorption near-edge spectroscopy analysis reveals significant ZnO transformation toward Zn-sulfide and Zn-phosphate. The interaction between a commercial ZnO-based sunscreen with polystyrene and a cleanser consumer containing microbeads with ZnO nanomaterials is also studied, revealing the adsorption of transformed Zn-species in the microplastics surfaces, highlighting the environmental relevancy of this work. Understanding the structural and functional impacts of the microplastics/ZnO complexes, and how they evolve, will provide insights into their chemical nature, stability, transformations, and fate, which is key to predicting their bioreactivity in the environment.

Long-term outcomes of endoscopic vein harvesting after coronary artery bypass grafting.

BACKGROUND: Use of endoscopic saphenous vein harvesting has developed into a routine surgical approach at many cardiothoracic surgical centers. The association between this technique and long-term morbidity and mortality has recently been called into question. The present report describes the use of open versus endoscopic vein harvesting and risk of mortality and repeat revascularization in northern New England during a time period (2001 to 2004) in which both techniques were being performed. METHODS AND RESULTS: From 2001 to 2004, 8542 patients underwent isolated coronary artery bypass grafting procedures, 52.5% with endoscopic vein harvesting. Surgical discretion dictated the vein harvest approach. The main outcomes were death and repeat revascularization (percutaneous coronary intervention or coronary artery bypass grafting) within 4 years of the index admission. The use of endoscopic vein harvesting increased from 34% in 2001 to 75% in 2004. In general, patients undergoing endoscopic vein harvesting had greater disease burden. Endoscopic vein harvesting was associated with an increased adjusted risk of bleeding requiring a return to the operating room (2.4 versus 1.7; P=0.03) but a decreased risk of leg wound infections (0.2 versus 1.1; P<0.001). Use of endoscopic vein harvesting was associated with a significant reduction in long-term mortality (adjusted hazard ratio, 0.74; 95% confidence interval, 0.60 to 0.92) but a nonsignificant increased risk of repeat revascularization (adjusted hazard ratio, 1.29; 95% confidence interval, 0.96 to 1.74). Similar results were obtained in propensity-stratified analysis. CONCLUSIONS: During 2001 to 2004 in northern New England, the use of endoscopic vein harvesting was not associated with harm. There was a nonsignificant increase in repeat revascularization, and survival was not decreased.

Determination of metallic nanoparticles in biological samples by single particle ICP-MS: a systematic review from sample collection to analysis.

A systematic review of the use of single particle ICP-MS to analyse engineered nanomaterials (ENMs) in biological samples (plants, animals, body fluids) has highlighted that efforts have focused on a select few types of ENMs (e.g., Ag and TiO2) and there is a lack of information for some important tissues (e.g., reproductive organs, skin and fatty endocrine organs). The importance of sample storage is often overlooked but plays a critical role. Careful consideration of the ENM and matrix composition is required to select an appropriate protocol to liberate ENMs from a tissue whilst not promoting the transformation of them, or genesis of new particulates. A 'one size fits all' protocol, applicable to all possible types of ENM and biological matrices, does not seem practical. However, alkaline-based extractions would appear to show greater promise for wide applicability to animal tissues, although enzymatic approaches have a role, especially for plant tissues. There is a lack of consistency in metrics reported and how they are determined (e.g. size limit of detection, and proportions of recovery), making comparison between some studies more difficult. In order to establish standardised protocols for regulatory use, effort is needed to: develop certified reference materials, achieve international agree on nomenclature and the use of control samples, and to create a decision tree to help select the best sample preparation for the type of tissue matrix.

Alkylnaphthalenes: priority pollutants or minor contributors to the poor health of marine mussels?

Alkylnaphthalenes (AN) are relatively water-soluble hydrocarbons which, following spillages of crude oils, have been widely reported in contaminated marine organisms such as mussels. In the present report we show, by tandem-gas chromatography-time-of-flight-mass spectrometry (GC × GC-ToF-MS), that the range of AN in contaminated wild mussels from the UK extends beyond the previously GC resolved isomers to those with at least seven substituent carbon atoms. Since surprisingly little information on AN toxicity to such marine organisms has been reported we synthesized two C(8) AN and measured the toxicity of C(2-8) AN to mussels (clearance rate assay). C(2-3) AN were appreciably toxic (concentration for 50% clearance rate inhibition, 48 h IC(50) 1.4-2.6 µmol g(-1) dry weight tissue), but several C(4), (6) and C(8) AN, including branched isomers expected to be resistant to biodegradation and more accumulative, were relatively nontoxic (48 h IC(50) > 10 µmol g(-1)) and longer term exposure (8d) failed to elicit a greater toxic response. The accumulation profiles of AN in laboratory mussels exposed to oil were similar to those of the wild mussels. Moreover, laboratory oil-exposed mussels depurated toxic C(2-3) AN within 5 days in clean water and clearance rates recovered. The latter might imply that, in contrast with branched alkyl benzenes tested previously, AN are of less toxic concern, but such a straightforward conclusion cannot necessarily be drawn; a synthetic branched C(8) AN persisted following depuration and was as toxic to mussels as a C(3) AN (IC(50) 1.3 µmol g(-1)). This indicates that the structures of AN are also important.

Outcomes of patients undergoing concomitant aortic and mitral valve surgery in northern new England.

BACKGROUND: Concomitant aortic (AV) and mitral (MV) valve surgery accounts for 4% of all valve procedures in northern New England. We examined in-hospital and long-term mortality. METHODS AND RESULTS: This is a report of a prospective study of 1057 patients undergoing concomitant AV and MV surgery from 1989 to 2007. The Social Security Administration Death Master File was used to assess long-term survival. Kaplan-Meier and log-rank tests were performed. In-hospital mortality was 15.5% (11.0% for patients <70 years, 18.0% for 70- to 79-year-olds, and 24% for those > or =80 years). Overall median survival was 7.3 years. Median survival without coronary artery bypass grafting was 9.5 years and with coronary artery bypass grafting was 5.7 years (P<0.001). Survival in women was worse than in men (7.3 versus 9.3, years, P=0.033). Median survival by age was 11.0 years for patients <70 years, 5.4 years for 70- to 79-year-olds, and 4.8 years for those > or =80 years. Median survival was not significantly different for patients > or =80 years compared with those who were 70 to 79 years old (P=0.245). CONCLUSIONS: Double-valve surgery has a high in-hospital mortality rate and a median survival of 7.3 years. After patients have survived surgery, long-term survival is similar between men and women, smaller and larger patients, and those receiving MV repair or replacement. Survival continues to decline after surviving surgery for patients > or =70 years old and those who undergo concomitant coronary artery bypass grafting. In patients <70 years, either mechanical valves in both positions or a tissue AV and mitral repair have the lowest in-hospital mortality and the best long-term survival. In patients > or =70 years, tissue valves in both positions have the best in-hospital and long-term survival.

Long-term survival of the very elderly undergoing aortic valve surgery.

BACKGROUND: Increasing numbers of the very elderly are undergoing aortic valve procedures. We describe the short- and long-term survivorship for this cohort. METHODS AND RESULTS: We conducted a cohort study of 7584 consecutive patients undergoing open aortic valve surgery without (51.1%; AVR) or with (48.9%; AVR + CABG) concomitant coronary artery bypass graft surgery between November 10, 1987 through June 30, 2006. Patient records were linked to the Social Security Administration's Death Master File. Survivorship was stratified by age and concomitant CABG surgery. During 39 835 person-years of follow-up, there were 2877 deaths. Among AVR, there were 3304 patients <80 years of age, 419 patients 80 to 84 years, and 156 patients > or =85 years (24 patients >90 years). Among AVR+CABG patients, there were 2890 patients <80 years of age, 577 patients 80 to 84 years, and 238 patients > or =85 years (22 patients >90 years). Median survivorship for patients undergoing isolated AVR was 11.5 years (<80 years), 6.8 years (80 to 84 years), 6.2 years (> or =85 years); for patients undergoing AVR+CABG, median survivorship was 9.4 years (<80 years), 6.8 years (80 to 84 years), and 7.1 years (> or =85 years). Among both procedures, adjusted survivorship was significantly different across strata of age (P<0.001). These findings are similar to life expectancy of the general population from actuarial tables: 80 to 84 years (7 years) and > or =85 years (5 years). CONCLUSIONS: Survivorship among octogenarians is favorable, with more than half the patients surviving more than 6 years after their surgery. Concomitant CABG surgery does not diminish median survivorship among patients >80 years of age.

Stability of Arsenic Species During Bioaccessibility Assessment Using the In Vitro UBM and HPLC-ICP-MS Detection.

The stability of four major arsenic (As) species during application of the BARGE (Bioaccessibility Research Group of Europe) unified bioaccessibility method (UBM) has been assessed. The concentrations of As species in the UBM gastric and gastro-intestinal (gastric + intestinal) phases were determined using HPLC-ICP-MS whilst the total As content in the samples was determined using ICP-MS alone. The arsenic species studied were arsenite As(III), arsenate As(V), dimethylarsinic acid (DMA) and monomethylarsonic acid (MMA). These species were separated in 10 min using an anion exchange column (Hamilton PRP-X100) with a mobile phase containing 20 mmol L-1 NH4H2PO4/1% methanol (pH 6.0). The recoveries of arsenic species spiked into the gastric and gastro-intestinal fluids were in the range 90-108%. No interconversion between As species was observed as a result of applying the BARGE UBM, which is a particularly important finding for the reliability of As(III) measurements. The accuracy of the BARGE UBM for in vitro extractable As(V) was verified using British Geological Survey (BGS) guidance material 102 (an ironstone soil). For a commercial rice sample, the bioaccessibility sequence of As was DMA > As(III) > As(V) for the gastric phase and As(III) > DMA > As(V) for the gastro-intestinal phase.

Trace element deficiency is highly prevalent and associated with infection and mortality in patients with alcoholic hepatitis.

BACKGROUND: Malnutrition is common in patients with alcohol-related liver disease and is associated with outcome in patients with alcoholic hepatitis. Trace elements (cobalt, copper, iron, selenium and zinc) are micronutrients essential for many cellular processes including antioxidant pathways. The prevalence and relevance of trace element deficiency is unknown in alcoholic hepatitis. AIM: To determine the prevalence of trace element deficiency and its association with clinical outcomes in patients with alcoholic hepatitis. METHODS: Serum was obtained from patients with alcoholic hepatitis, alcohol-related cirrhosis and healthy volunteers as part of clinical trials, cohort studies and a biobank. Trace element concentration was measured by inductively coupled plasma mass spectrometry. Association of trace element levels with development of infection within 90 days and mortality within 28 and 90 days was evaluated by multivariate logistic regression. RESULTS: Sera from 302 patients with alcoholic hepatitis, 46 with alcohol-related cirrhosis and 15 healthy controls were analysed for trace element concentration. The prevalence of zinc deficiency (85%) and selenium deficiency (67%) in alcoholic hepatitis was higher than in alcohol-related cirrhosis (72% [p=0.04] and 37% [p<0.001], respectively). Zinc, selenium, copper and chromium were significantly different between groups. Iron deficiency was a predictor of development of infection within 90 days. Zinc deficiency was a predictor of mortality within 28 and 90 days. CONCLUSION: Trace element deficiency in patients with alcoholic hepatitis is highly prevalent and associated with infection and mortality. Supplementation with selected trace elements may improve clinical outcomes in this patient group but further insight is required of their biological and clinical effects.

The association of perioperative red blood cell transfusions and decreased long-term survival after cardiac surgery.

BACKGROUND: Exposure to red blood cell (RBC) transfusions has been associated with increased mortality after cardiac surgery. We examined long-term survival for cardiac surgical patients who received one or two RBC units during index hospitalization. METHODS: Nine thousand seventy-nine consecutive patients undergoing coronary artery bypass graft, valve, or coronary artery bypass graft/valve surgery at eight centers in northern New England during 2001-2004 were examined after exclusions. A probabilistic match between the regional registry and the Social Security Administration's Death Master File determined mortality through June 30, 2006. Cox Proportional Hazard and propensity methods were used to calculate adjusted hazard ratios. RESULTS: Thirty-six percent of patients (n = 3254) were exposed to one or two RBC units. Forty-three percent of RBCs were given intraoperatively, 56% in the postoperative period and 1% were preoperative. Patients transfused were more likely to be anemic, older, smaller, female and with more comorbid illness. Survival was significantly decreased for all patients exposed to 1 or 2 U of RBCs during hospitalization for cardiac surgery compared with those who received none (P < 0.001). After adjustment for patient and disease characteristics, patients exposed to 1 or 2 U of RBCs had a 16% higher long-term mortality risk (adjusted hazard ratios = 1.16, 95% CI: 1.01-1.34, P = 0.035). CONCLUSIONS: Exposure to 1 or 2 U of RBCs was associated with a 16% increased hazard of decreased survival after cardiac surgery.

The isotopic record of atmospheric lead fall-out on an Icelandic salt marsh since AD 50.

We report a record of atmospheric Pb deposition at a coastal site in western Iceland that spans the last two millennia. The elemental concentrations of Pb, Al, Li and Ti are determined using ICP-MS from a sediment monolith collected from a salt marsh. Multicollector (MC) ICP-MS analysis is used to obtain isotopic ratios of stable Pb. The Pb/Ti and Pb/Li ratios are used to separate natural Pb background concentrations from Pb derived from remote anthropogenic sources. The pollution record in western Iceland is subdued in comparison with Pb records from the European mainland, but the isotopic character, profile and timing of Pb deposition show good agreement with the atmospheric Pb fall-out reported from sites in Scandinavia and northwestern Europe. At the bottom of the sequence we isolate a low-level (0.1-0.4 mg kg(-1)) Pb enrichment signal dated to AD 50-150. The isotopic signature and timing of this signal suggest Roman metal working industries as the source. In the subsequent millennium there was no significant or very low (i.e. elemental concentrations<0.01 mg kg(-1)) anthropogenic Pb deposition at the site up to, and including, the early Medieval period. Above a pumice layer, dated to AD 1226-1227, a small increase in Pb deposition is found. This trend is maintained until a more substantive and progressive increase is signalled during the late 1700s and early 1800s. This is followed by a substantial enrichment signal in the sediments (>3.0 mg kg(-1)) that is interpreted as derived from industrial coal burning and metal working during the 19th and 20th centuries in northern Europe. During the late 20th century, significant fall-out from European fuel additives reached Iceland.

Uncertainty associated with the leaching of aerosol filters for the determination of metals in aerosol particulate matter using collision/reaction cell ICP-MS detection.

High quality observational data with a firm uncertainty assessment are essential for the proper validation of biogeochemical models for trace metals such as iron. Typically, concentrations of these metals are very low in oceanic waters (nM and sub nM) and ICP-MS is therefore a favoured technique for quantitative analysis. Uncertainties in the measurement step are generally well constrained, even at sub-nM concentrations. However, the measurement step is only part of the overall procedure. For the determination of trace metal solubilities from aerosols in the surface ocean, aerosol collection on a filter paper followed by a leaching procedure is likely to make a significant contribution to the overall uncertainty. This paper quantifies the uncertainties for key trace metals (cobalt, iron, lead and vanadium), together with aluminium as a reference element, for a controlled, flow through laboratory leaching procedure using filters collected from three different sampling sites (Tudor Hill (Bermuda), Heraklion (Crete) and Tel-Shikmona (Israel)) and water, glucuronic acid and desferrioxamine B as leachants. Relative expanded uncertainties were in the range of 12-29% for cobalt, 12-62% for iron, 13-45% for lead and 5-11% for vanadium. Fractional solubilities for iron ranged from 0.2 ±â€¯0.1% to 16.9 ±â€¯3.5%.

Tissue versus mechanical aortic valve replacement in younger patients: A multicenter analysis.

OBJECTIVE: The goal of this study was to examine the long-term survival of patients between the ages of 50 and 65 years who underwent tissue versus mechanical aortic valve replacement (AVR) in a multicenter cohort. METHODS: A multicenter, retrospective analysis of all AVR patients (n = 9388) from 1991 to 2015 among 7 medical centers reporting to a prospectively maintained clinical registry was conducted. Inclusion criteria were: patients aged 50 to 65 years who underwent isolated AVR. Baseline comorbidities were balanced using inverse probability weighting for a study cohort of 1449 AVRs: 840 tissue and 609 mechanical. The primary end point of the analysis was all-cause mortality. Secondary end points included in-hospital morbidity, 30-day mortality, length of stay, and risk of reoperation. RESULTS: During the study period, there was a significant shift from mechanical to tissue valves (P < .001). There was no significant difference in major in-hospital morbidity, mortality, or length of hospitalization. Also, there was no significant difference in adjusted 15-year survival between mechanical versus tissue valves (hazard ratio, 0.87; 95% confidence interval [CI], 0.67-1.13; P = .29), although tissue valves were associated with a higher risk of reoperation with a cumulative incidence of 19.1% (95% CI, 14.4%-24.3%) versus 3.0% (95% CI, 1.7%-4.9%) for mechanical valves. The reoperative 30-day mortality rate was 2.4% (n = 2) for the series. CONCLUSIONS: Among patients 50 to 65 years old who underwent AVR, there was no difference in adjusted long-term survival according to prosthesis type, but tissue valves were associated with a higher risk of reoperation.

Intensity of Glycemic Control Affects Long-Term Survival After Coronary Artery Bypass Graft Surgery.

BACKGROUND: A patient's hemoglobin (Hb) A1c level, regardless of diabetic status, is a measure of glycemic control. Studies have found it is an independent predictor of short-term death in patients undergoing coronary artery bypass grafting (CABG). In this study, we used preoperative HbA1c to assess whether levels are associated with short-term and long-term survival after CABG. METHODS: From a regional registry of consecutive cases, we identified 6,415 patients undergoing on-pump isolated CABG from 2008 to 2015 with documented preoperative HbA1c level. We defined four HbA1c groups: less than 5.7% (n = 1,713), 5.7% to 6.4% (n = 2,505), 6.5% to 8.0% (n = 1,377), and more than 8% (n = 820). Relationship to in-hospital outcomes and long-term survival was assessed. Outcome rates and hazard ratios were adjusted for patient and disease risk factors using multivariable logistic regression and Cox models. RESULTS: The study included 3,740 patients (58%) not diagnosed as having diabetes and 2,674 with diabetes. Prediabetes (HbA1c 5.7% to 6.4%) was documented in 52% (n = 1,933) of nondiabetic patients. Higher HbA1c values were associated with younger age, female sex, greater body mass index, more comorbid diseases, lower ejection fraction, more 3-vessel coronary disease, and recent myocardial infarction (p < 0.05 trend for all). After adjustment for patient risk, greater HbA1c values were not associated with higher rates of in-hospital death or morbidity. Long-term survival was significantly worse as HbA1c increased. Risk of death increased by 13% for every unit increase in HbA1c (adjusted hazard ratio, 1.13; 95% confidence interval, 1.07 to 1.19; p < 0.001). CONCLUSIONS: Preadmission glycemic control, as assessed by HbA1c, is predictive of long-term survival, with higher levels associated with poorer prognosis. Whether this risk can be modified by better glycemic control postoperatively remains to be determined.

Equivalent uniform dose, D(90), and V(100) correlation with biochemical control after low-dose-rate prostate brachytherapy for clinically low-risk prostate cancer.

PURPOSE: To assess the correlation of postimplant dosimetric quantifiers with biochemical control of prostate cancer after low-dose-rate brachytherapy. MATERIALS AND METHODS: Generalized equivalent uniform dose (EUD), dose in Gy to 90% of the prostate gland (D(90)), and percentage of the prostate receiving 100% of the prescribed dose (V(100)) were calculated from the postimplant dose-volume histogram (DVH) for 140 patients undergoing low-dose-rate prostate brachytherapy (LDRPB) monotherapy from 1997 to 2003 at Duke University and the Durham VA Medical Center. Biochemical recurrence was defined according to the American Society for Therapeutic Radiology and Oncology consensus definition. RESULTS: Median followup after LDRPB was 50 months. There was a 7% biochemical recurrence rate (10/140) at last clinical followup. The median EUD was 167 Gy (range, 41-245). The median D(90) was 139 Gy (range, 45-203). The median V(100) was 88% (range, 44-100). The overall 5-year biochemical recurrence-free survival (bRFS) was 94.2%. The 5-year bRFS was 100% for EUD> or =167 Gy and 89.4% for EUD <167 Gy (p=0.008); 100% for D(90) > or =140 Gy and 90.4% for D(90) <140 Gy (p=0.020); 100% for V(100) > or =88%; and 90.3% for V(100) <88% (p=0.017). There was no statistically significant correlation between any of these factors and overall survival. CONCLUSIONS: In our series of 140 patients with low-risk prostate cancer treated with LDRPB alone, we observed a statistically significant correlation between EUD, D(90), and V(100) and bRFS. The generalized EUD, a calculated value that incorporates the entire prostate DVH, appears to be at least as well correlated with bRFS as D(90) or V(100), and may more completely represent the totality of the dose distribution.

Long-term survival and cardiac troponin T elevation in on- and off-pump coronary artery bypass surgery.

INTRODUCTION: The long-term clinical usefulness of conventional coronary artery bypass graft surgery (CCAB) versus off-pump surgery (OPCAB) remains controversial. Long-term survival and elevation in cardiac troponin T (cTnT) concentration following CCAB and OPCAB have not been assessed. We tested the hypothesis that long-term survival rates for CCAB and OPCAB patients were similar when stratified by cTnT concentration. METHODS AND RESULTS: In this prospective cohort, we followed 1511 nonemergency patients with 2- or 3-vessel disease (778 CCAB and 733 OPCAB cases) from a hospital in northern New England to determine if 6-year survival rates for CCAB and OPCAB patients were similar. The patients underwent surgery between 2000 and 2004 by surgeons who used both procedures. Postoperative cTnT elevation was defined as > or =1 ng/mL, the upper quartile of cTnT values. Data were linked to the Social Security Administration Death Master File. Kaplan-Meier analysis and Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI), with adjustments for baseline patient and disease characteristics. Patients were followed for a median of 4.1 years (mean, 4.0 years). Patients were similar with regard to baseline disease characteristics, comorbidities, cardiac history, function, and anatomy. OPCAB was associated with increased rates of postoperative bleeding and with a worse 6-year survival rate compared with CCAB, regardless of cTnT concentration (cTnT <1 ng/mL, P < .013; cTnT > or =1 ng/mL, P = .017). Compared with CCAB patients, the adjusted HR (95% CI) was 1.59 (1.09-2.32) for OPCAB patients with cTnT concentrations <1 ng/mL and 1.93 (1.12-3.31) for OPCAB patients with cTnT concentrations > or =1 ng/mL. CONCLUSION: Survival is better for CCAB patients than for OPCAB patients, regardless of cTnT concentration. This effect is sustained after multivariable adjustment for baseline mortality risk factors.

The risk of carotid stenosis in head and neck cancer patients after radiation therapy.

OBJECTIVES: Head and neck radiotherapy (RT) is a risk factor for cerebrovascular disease. We performed a retrospective cohort study to evaluate carotid artery stenosis (CAS) incidence in head and neck cancer (HNC) patients undergoing RT, characterizing associated risk factors. MATERIALS AND METHODS: Records were retrospectively reviewed for HNC patients undergoing carotid ultrasound screening after definitive or adjuvant RT between January 2000 and May 2016. CAS was defined as ≥50% stenosis on imaging, stroke, or transient ischemic attack. Actuarial CAS rates were calculated by Kaplan-Meier method. Univariate and multivariate analyses predicted CAS risk based on carotid dosimetric and clinical parameters. RESULTS: 366 patients met inclusion criteria. Median time from RT completion to last follow-up was 4.1 yr. Actuarial risk for CAS was 29% (95% CI 22-36%) at 8 years. Univariate analysis showed that smoking (HR 1.7; 95% CI 1.1-2.7), hyperlipidemia (HR 1.6; 95% CI 1.03-2.6), diabetes (HR 2.8; 95% CI 1.6-4.8), coronary artery disease (HR 2.4; 95% CI 1.4-4.2), and peripheral artery disease (HR 3.6; 95% CI 1.1-11.6) were significantly associated with increased CAS. In multivariate analysis, diabetes was predictive of time to CAS (HR 1.9; 95% CI 1.1-3.4). Carotid dose parameters were not significantly associated with CAS. CONCLUSIONS: CAS incidence is high after head and neck radiotherapy, gradually rising over time. No clear dose-response effect between carotid dose and CAS was identified for HNC patients. Carotid artery screening and preventative strategies should be employed in this high-risk patient population.

Comparative effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention in a real-world Surgical Treatment for Ischemic Heart Failure trial population.

OBJECTIVE: There are no prospective randomized trial data to guide decisions on optimal revascularization strategies for patients with multivessel coronary artery disease and reduced ejection fraction. In this analysis, we describe the comparative effectiveness of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in this patient population. METHODS: A multicenter, retrospective analysis of all CABG (n = 18,292) and PCIs (n = 55,438) performed from 2004 to 2014 among 7 medical centers reporting to the Northern New England Cardiovascular Disease Study Group. After applying inclusion and exclusion criteria from the Surgical Treatment for Ischemic Heart Failure trial, there were 955 CABG and 718 PCI patients with an ejection fraction ≤ 35% and 2- or 3-vessel disease. Inverse probability weighting was used for risk adjustment. The primary end point was all-cause mortality. Secondary end points included rates of 30-day mortality, stroke, acute kidney injury, and incidence of repeat revascularization. RESULTS: The median duration of follow-up was 4.3 years (range, 1.59-6.71 years). CABG was associated with improved long-term survival compared with PCI after risk adjustment (hazard ratio, 0.59; 95% confidence interval, 0.50-0.71; P < .01). Although CABG and PCI had similar 30-day mortality rates (P = .14), CABG was associated with a higher frequency of stroke (P < .001) and acute kidney injury (P < .001), whereas PCI was associated with a higher incidence of repeat revascularization (P < .001). CONCLUSIONS: Among patients with reduced ejection fraction and multivessel disease, CABG was associated with improved long-term survival compared with PCI. CABG should be strongly considered in patients with ischemic cardiomyopathy and multivessel coronary disease.