Stratified medicine using invasive coronary function testing in angina: A cost-effectiveness analysis of the British Heart Foundation CorMicA trial.

AIM: Coronary angiography is indicated in many patients with known or suspected angina for the investigation of coronary artery disease (CAD). However, up to half of patients with symptoms of ischaemia have no obstructive coronary arteries (INOCA). This large subgroup includes patients with suspected microvascular angina (MVA) and/or vasospastic angina (VSA). Clinical guidelines relating to the management of patients with INOCA are limited. Uncertainty regarding the diagnosis of patients with INOCA presents a health economic challenge, both in terms of healthcare resource utilisation and of quality-of-life impact on patients. METHODS: A cost-effectiveness analysis of the introduction of stratified medicine into the invasive management of INOCA, based on clinical and resource-use data obtained in the CorMicA trial, from a UK NHS perspective. The intervention included an invasive diagnostic procedure (IDP) of coronary vascular function during coronary angiography to define clinical endotypes to target with linked medical therapy. Outcomes of interest were mean total cost and QALY gain between treatment groups, and the incremental cost-effectiveness ratio. We undertook probabilistic sensitivity and scenario analyses. RESULTS: The incremental cost per QALY gained at 12 months was £4500 (£2937, £33264). Compared with a willingness-to-pay (WTP) threshold of £20,000 per QALY, the use of the IDP test is cost-effective. At this WTP threshold there is a 96% probability of the IDP being cost-effective, based on the uncertainty described by bootstrap analysis. CONCLUSIONS: The burden of INOCA, particularly in women, is known to be significant. These findings provided new evidence to inform this unmet clinical need.

The value of non-invasive computed tomography coronary angiography in imaging patients with coronary artery bypass grafts.

INTRODUCTION: Invasive coronary angiography (ICA) is associated with higher complication rates in patients following coronary artery bypass surgery (CABG). CT coronary angiography (CTCA) has emerged as an attractive alternative. We assessed the impact of CTCA on subsequent ICA. METHODS: We identified 213 CABG patients undergoing CTCA between 2015 and 2018. In 151 the indication was suspected recurrence of angina. We then identified patients undergoing ICA within 1 year of CTCA. RESULTS: CTCA obviated the need for ICA in 115 cases (76%). CTCA was better at identifying targets for percutaneous coronary intervention (PCI) to saphenous vein grafts (SVG's) than to native vessels (89% vs 47%). 7 out of 10 lesions of "probable" significance by CTCA proved flow-limiting, and 4 out of 13 "indeterminate" lesions. CTCA concordance was 97% for left internal mammary (LIMA) grafts. CONCLUSION: CTCA directed management in a majority of patients without ICA. It identified a cohort of patients likely to be candidates for SVG PCI, but was less effective in identifying PCI targets in the native vessels. CTCA renders invasive LIMA cannulation redundant unless a target lesion is suspected.

Population differentiation between Australian and Chinese Helicoverpa armigera occurs in distinct blocks on the Z-chromosome.

Over the last 40 years, many types of population genetic markers have been used to assess the population structure of the pest moth species Helicoverpa armigera. While this species is highly vagile, there is evidence of inter-continental population structure. Here, we examine Z-chromosome molecular markers within and between Chinese and Australian populations. Using 1352 polymorphic sites from 40 Z-linked loci, we compared two Chinese populations of moths separated by 700 km and found virtually no population structure (n = 41 and n = 54, with <1% of variation discriminating between populations). The levels of nucleotide diversity within these populations were consistent with previous estimates from introns in Z-linked genes of Australian samples (π = 0.028 vs. 0.03). Furthermore, all loci surveyed in these Chinese populations showed a skew toward rare variants, with ten loci having a significant Tajima's D statistic, suggesting that this species could have undergone a population expansion. Eight of the 40 loci had been examined in a previous study of Australian moths, of which six revealed very little inter-continental population structure. However, the two markers associated with the Cyp303a1 locus that has previously been proposed to be a target of a selective sweep, exhibited allele structuring between countries. Using a separate dataset of 19 Australian and four Chinese moths, we scanned the molecular variation distributed across the entire Z-chromosome and found distinct blocks of differentiation that include the region containing Cyp303a1. We recommend some of these loci join those associated with insecticide resistance to form a set of genes best suited to analyzing population structure in this global pest.

The effects of remote ischaemic preconditioning on coronary artery function in patients with stable coronary artery disease.

BACKGROUND: Remote ischaemic preconditioning (RIPC) is a cardioprotective intervention invoking intermittent periods of ischaemia in a tissue or organ remote from the heart. The mechanisms of this effect are incompletely understood. We hypothesised that RIPC might enhance coronary vasodilatation by an endothelium-dependent mechanism. METHODS: We performed a prospective, randomised, sham-controlled, blinded clinical trial. Patients with stable coronary artery disease (CAD) undergoing elective invasive management were prospectively enrolled, and randomised to RIPC or sham (1:1) prior to angiography. Endothelial-dependent vasodilator function was assessed in a non-target coronary artery with intracoronary infusion of incremental acetylcholine doses (10-6, 10-5, 10-4mol/l). Venous blood was sampled pre- and post-RIPC or sham, and analysed for circulating markers of endothelial function. Coronary luminal diameter was assessed by quantitative coronary angiography. The primary outcome was the between-group difference in the mean percentage change in coronary luminal diameter following the maximal acetylcholine dose (Clinicaltrials.gov identifier: NCT02666235). RESULTS: 75 patients were enrolled. Following angiography, 60 patients (mean±SD age 57.5±8.5years; 80% male) were eligible and completed the protocol (n=30 RIPC, n=30 sham). The mean percentage change in coronary luminal diameter was -13.3±22.3% and -2.0±17.2% in the sham and RIPC groups respectively (difference 11.32%, 95%CI: 1.2- 21.4, p=0.032). This remained significant when age and sex were included as covariates (difference 11.01%, 95%CI: 1.01- 21.0, p=0.035). There were no between-group differences in endothelial-independent vasodilation, ECG parameters or circulating markers of endothelial function. CONCLUSIONS: RIPC attenuates the extent of vasoconstriction induced by intracoronary acetylcholine infusion. This endothelium-dependent mechanism may contribute to the cardioprotective effects of RIPC.

Genomic innovations, transcriptional plasticity and gene loss underlying the evolution and divergence of two highly polyphagous and invasive Helicoverpa pest species.

BACKGROUND: Helicoverpa armigera and Helicoverpa zea are major caterpillar pests of Old and New World agriculture, respectively. Both, particularly H. armigera, are extremely polyphagous, and H. armigera has developed resistance to many insecticides. Here we use comparative genomics, transcriptomics and resequencing to elucidate the genetic basis for their properties as pests. RESULTS: We find that, prior to their divergence about 1.5 Mya, the H. armigera/H. zea lineage had accumulated up to more than 100 more members of specific detoxification and digestion gene families and more than 100 extra gustatory receptor genes, compared to other lepidopterans with narrower host ranges. The two genomes remain very similar in gene content and order, but H. armigera is more polymorphic overall, and H. zea has lost several detoxification genes, as well as about 50 gustatory receptor genes. It also lacks certain genes and alleles conferring insecticide resistance found in H. armigera. Non-synonymous sites in the expanded gene families above are rapidly diverging, both between paralogues and between orthologues in the two species. Whole genome transcriptomic analyses of H. armigera larvae show widely divergent responses to different host plants, including responses among many of the duplicated detoxification and digestion genes. CONCLUSIONS: The extreme polyphagy of the two heliothines is associated with extensive amplification and neofunctionalisation of genes involved in host finding and use, coupled with versatile transcriptional responses on different hosts. H. armigera's invasion of the Americas in recent years means that hybridisation could generate populations that are both locally adapted and insecticide resistant.

Behavioural response to combined insecticide and temperature stress in natural populations of Drosophila melanogaster.

Insecticide resistance evolves extremely rapidly, providing an illuminating model for the study of adaptation. With climate change reshaping species distribution, pest and disease vector control needs rethinking to include the effects of environmental variation and insect stress physiology. Here, we assessed how both long-term adaptation of populations to temperature and immediate temperature variation affect the genetic architecture of DDT insecticide response in Drosophila melanogaster. Mortality assays and behavioural assays based on continuous activity monitoring were used to assess the interaction between DDT and temperature on three field-derived populations from climate extremes (Raleigh for warm temperate, Tasmania for cold oceanic and Queensland for hot tropical). The Raleigh population showed the highest mortality to DDT, whereas the Queensland population, epicentre for derived alleles of the resistance gene Cyp6g1, showed the lowest. Interaction between insecticide and temperature strongly affected mortality, particularly for the Tasmanian population. Activity profiles analysed using self-organizing maps show that the insecticide promoted an early response, whereas elevated temperature promoted a later response. These distinctive early or later activity phases revealed similar responses to temperature and DDT dose alone but with more or less genetic variance depending on the population. This change in genetic variance among populations suggests that selection particularly depleted genetic variance for DDT response in the Queensland population. Finally, despite similar (co)variation between traits in benign conditions, the genetic responses across population differed under stressful conditions. This showed how stress-responsive genetic variation only reveals itself in specific conditions and thereby escapes potential trade-offs in benign environments.

OfftargetFinder: a web tool for species-specific RNAi design.

MOTIVATION: RNA interference (RNAi) technology is being developed as a weapon for pest insect control. To maximize the specificity that such an approach affords we have developed a bioinformatic web tool that searches the ever-growing arthropod transcriptome databases so that pest-specific RNAi sequences can be identified. This will help technology developers finesse the design of RNAi sequences and suggests which non-target species should be assessed in the risk assessment process. AVAILABILITY AND IMPLEMENTATION: http://rnai.specifly.org CONTACT: crobin@unimelb.edu.au.

Effects of reduced winter duration on seed dormancy and germination in six populations of the alpine herb Aciphyllya glacialis (Apiaceae).

The life stages of seed germination and seedling establishment play a vital role in maintaining plant populations and determining range dynamics of species. Thus, it is not surprising that specific germination requirements and dormancy mechanisms have evolved in all major angiosperm clades. In a rapidly changing climate, we face growing pressure to manage, conserve and restore native plant species and communities. To achieve these aims, we require solid knowledge of whether and how seed germination requirements and dormancy status vary between different populations of a given species and how germination strategies may be affected by warming climatic conditions. We assessed the effect of decreasing durations of cold stratification (i.e. conditions representing a shortened winter as predicted under climate change) on germination and dormancy of the alpine herb Aciphylla glacialis. Our results confirmed previous research showing that A. glacialis seeds possess physiological dormancy that can be alleviated by cold stratification. In addition, the results demonstrated that A. glacialis seeds have underdeveloped embryos at dispersal; these grow to germinable size following 4-9 weeks at both constant 5°C and 10-5°C (day-night) temperatures. We conclude that A. glacialis exhibits morphophysiological dormancy. Furthermore, we found that the final percentage germination and dormancy status varied significantly among natural populations and that this variation did not correlate with elevation at the site of seed origin. Seeds germinated following 6-8 weeks of cold stratification, and seedlings showed no detrimental effects as a result of shorter stratification periods. Together, these results suggest that reduced duration of winter is unlikely to have direct negative impacts on germination or early seedling growth in A. glacialis. The causes and implications of the population variation in germination traits are discussed.

A proline repeat polymorphism of the Frost gene of Drosophila melanogaster showing clinal variation but not associated with cold resistance.

Genetic polymorphisms underlying adaptive shifts in thermal responses are poorly known even though studies are providing a detailed understanding of these responses at the cellular and physiological levels. The Frost gene of Drosophila melanogaster is a prime candidate for thermal adaptation; it is up-regulated under cold stress and knockdown of this gene influences cold resistance. Here we describe an amino-acid INDEL polymorphism in proline repeat number in the structural component of this gene. The two main repeats, accounting for more than 90% of alleles in eastern Australia, show a strong clinal pattern; the 6P allele was at a high frequency in tropical locations, and the 10P allele was common in temperate populations. However, the frequency of these alleles was not associated with three different assays of cold resistance. Adult transcription level of Frost was also unrelated to cold resistance as measured through post chill coma mobility. The functional significance of the proline repeat polymorphism therefore remains unclear despite its clinal pattern. The data also demonstrate the feasibility of using Roche/454 sequencing for establishing clinal patterns.

Universal primers for fluorescent labelling of PCR fragments--an efficient and cost-effective approach to genotyping by fluorescence.

Directly labelling locus-specific primers for microsatellite analysis is expensive and a common limitation to small-budget molecular ecology projects. More cost-effective end-labelling of PCR products can be achieved through a three primer PCR approach, involving a fluorescently labelled universal primer in combination with modified locus-specific primers with 5' universal primer sequence tails. This technique has been widely used but has been limited largely due to a lack of available universal primers suitable for co-amplifying large numbers of size overlapping loci and without requiring locus-specific PCR conditions to be modified. In this study, we report a suite of four high-performance universal primers that can be employed in a three primer PCR approach for efficient and cost-effective fluorescent end-labelling of PCR fragments. Amplification efficiency is maximized owing to high universal primer Tm values (approximately 60+ °C) that enhance primer versatility and enable higher annealing temperatures to be employed compared with commonly used universal primers such as M13. We demonstrate that these universal primers can be combined with multiple fluorophores to co-amplify multiple loci efficiently via multiplex PCR. This method provides a level of multiplexing and PCR efficiency similar to microsatellite fluorescent detection assays using directly labelled primers while dramatically reducing project costs. Primer performance is tested using several alternative PCR strategies that involve both single and multiple fluorophores in single and multiplex PCR across a wide range of taxa.

Update on cardiopulmonary resuscitation.

Adult cardiopulmonary resuscitation (CPR) has been shown to improve survival for individuals suffering cardiac arrest. Despite this, the delivery of basic life support to victims outside the clinical environment remains poor, particularly as only a minority receive resuscitation. In addition, research continues to examine the optimal techniques for CPR and guidelines have been modified to reflect the latest developments. These guidelines are a compromise between simplicity and effectiveness. While the core of the guidelines remains unchanged, the latest recommendations focus on minimising any delay in the assessment of the collapsed patient and the initiation of CPR. They also address the recent body of opinion promoting compression-only CPR as an alternative to the combined technique of compression and mouth-to-mouth ventilation. Throughout the guidelines a more pragmatic approach to resuscitation is adopted to try to encourage all individuals, whether trained healthcare professionals or lay people, to initiate resuscitation. An acknowledgement of the reasons why individuals may be reluctant to start resuscitation through fear or anxiety will hopefully help to encourage the instigation of these techniques. This overview will summarise the guidelines and highlight alterations or alternatives where appropriate.

A comparison of match-only algorithms for the analysis of Plasmodium falciparum oligonucleotide arrays.

This study is motivated by two data sets which employ a custom Plasmodium falciparum version of the Affymetrix GeneChip, containing only perfect match (PM) oligonucleotides. A PM-only chip cannot be analysed using the standard Affymetrix-supplied software. We compared the performance of three match-only algorithms on these data: the Match Only Integral Distribution (MOID) algorithm, Robust Multichip Analysis (RMA), and the Model Based Expression Index (MBEI). We validated the differential expression of several genes using quantitative reverse transcriptase-PCR. We also performed a comparison using two publicly available 'benchmarking' data sets: the Latin Square spike-in data set generated by Affymetrix, and the Gene Logic dilution series. Since we know what the true fold changes are in these special data sets, they are helpful for assessment of expression algorithms.

Nonmyeloablative allogeneic bone marrow transplantation for treatment of childhood overlap syndrome and small vessel vasculitis.

A 13-year-old Caucasian female with a systemic connective tissue disease (overlap syndrome with pulmonary vasculitis) underwent nonmyeloablative allogeneic BMT after failure of prolonged combination immunosuppressives to induce remission. The procedure also included cotransplantation of donor bone chips as a source of stromal cells. The unique protocol allowed good engraftment of hematopoietic (>95%) and bone core stromal cells (>60%). The patient was clinically improved, stable, and off all immunosuppressive medications 36 months post-transplant. To our knowledge, this is the first pediatric nonmyeloablative BMT with cotransplantation of stromal cells solely for treatment of an autoimmune disease.

Effects of fludarabine treatment on murine lupus nephritis.

BXSB mice, a murine model of systemic lupus erythematosus (SLE), were treated with two different doses of fludarabine for a four-week period and examined two weeks after the final dose. Control mice were treated with saline or cyclophosphamide. Mice treated with fludarabine had a significant reduction in renal pathology compared to control mice. Fludarabine-treated mice also had an almost 10-fold increase in percentile of CD8+CD25+ T cells in the spleen and a smaller but significant increase in CD4+CD25+ cells. Mice treated with cyclophosphamide had a greater leucopenia compared to the other groups and a significant reduction in percentile of B220+ cells in peripheral blood and spleen. Serum autoantibody levels to dsDNA did not differ significantly among the groups, but were higher in 4/10 mice treated with fludarabine. Although few trials of fludarabine for human SLE have been conducted, additional studies may be warranted.

Descriptive and surveillance studies of suppliers to New York and New Jersey retail live-bird markets.

Low pathogenicity avian influenza virus (AIV) H7N2 has been isolated since 1994 from retail live-bird markets (LBMs) in the northeastern United States. This study examines the suppliers to the LBMs in New York and New Jersey. In 2001, 185 supplier premises in nine states were surveyed for the presence of AIV by virus isolation (VI) in embryonating chicken eggs. No H7 or H5 virus was isolated. In addition, 104 producer premises in two states were serologically negative for H7 and H5 AIV. Information on management practices was obtained via questionnaire for 191 premises in 12 states. The survey results suggest that current biosecurity practices at supplier premises could be improved, especially regarding movement of birds. The study supports the hypothesis that H7N2 AIV is primarily maintained within the LBMs and, if reintroduction from suppliers is occurring, it is likely reintroduced at a very low level or from suppliers not included in this study.

Epidemiologic and surveillance studies on avian influenza in live-bird markets in New York and New Jersey, 2001.

In 2001, all 109 retail live-bird markets (LBMs) in New York and New Jersey were surveyed for the presence of avian influenza virus (AIV) by a real time reverse transcriptase/polymer chain reaction assay (RRT/PCR) and results compared to virus isolation (VI) in embryonating chicken eggs. The RRT/PCR had a 91.9% sensitivity and 97.9% specificity in detecting presence of AIV at the market level. However, the sensitivity at the sample level is 65.87%. The RRT/PCR is a reliable method to identify AIV at the market level. In addition, a cross-sectional epidemiologic study of the LBMs showed that, during the past 12 months, markets that were open 7 days per week and those that also sold rabbits had the highest risk for being positive for AIV. Markets that were closed one or more days per week and those that performed daily cleaning and disinfecting had the lowest risk for being AIV positive.