Gadolinium deposition in the paediatric brain: T1-weighted hyperintensity within the dentate nucleus following repeated gadolinium-based contrast agent administration.

AIM: To determine whether repeated gadolinium-based contrast agent administration (GBCA) in children is associated with the development of increased T1-weighted signal intensity within the cerebellar dentate nucleus. MATERIALS AND METHODS: With institutional review board approval for this The Health Insurance Portability and Accountability Act-compliant retrospective study, a cohort of 41 patients under the age of 18 years who underwent at least four contrast-enhanced magnetic resonance imaging (MR) examinations of the brain from 2005 to 2015 were identified. For each examination, both dentate nuclei were manually contoured, and the mean dentate nucleus-to-pons signal intensity (DN-P SI) ratio was calculated. The DN-P SI ratios from the last to first MRI examination were compared, and the correlation between DN-P SI ratio and cumulative gadolinium dose was calculated using a linear mixed effect model to control for potentially confounding variables. RESULTS: For the 41 patients in the cohort, there was a significant increase in the mean DN-P SI ratio from the first MRI to the last MRI examination (1.05 versus 1.11, p=0.004). After controlling for patient diagnosis, history of chemotherapy or radiation, sex, and age, there was a significant positive association between DN-P SI ratio and cumulative gadolinium dose (coefficient=0.401, p=0.032). CONCLUSION: Repeated GBCA administration in children is associated with increased T1-weighted signal intensity within the dentate nucleus.

Drivers, challenges and opportunities of forage technology adoption by smallholder cattle households in Cambodia.

Forage technology has been successfully introduced into smallholder cattle systems in Cambodia as an alternative feed source to the traditional rice straw and native pastures, improving animal nutrition and reducing labour requirements of feeding cattle. Previous research has highlighted the positive impacts of forage technology including improved growth rates of cattle and household time savings. However, further research is required to understand the drivers, challenges and opportunities of forage technology for smallholder cattle households in Cambodia to facilitate widespread adoption and identify areas for further improvement. A survey of forage-growing households (n = 40) in July-September 2016 examined forage technology adoption experiences, including reasons for forage establishment, use of inputs and labour requirements of forage plot maintenance and use of forages (feeding, fattening, sale of grass or seedlings and silage). Time savings was reported as the main driver of forage adoption with household members spending approximately 1 h per day maintaining forages and feeding it to cattle. Water availability was reported as the main challenge to this activity. A small number of households also reported lack of labour, lack of fencing, competition from natural grasses, cost of irrigation and lack of experience as challenges to forage growing. Cattle fattening and sale of cut forage grass and seedlings was not found to be a widespread activity by interviewed households, with 25 and 10% of households reporting use of forages for these activities, respectively. Currently, opportunities exist for these households to better utilise forages through expansion of forage plots and cattle activities, although assistance is required to support these households in addressing current constraints, particularly availability of water, if the sustainability of this feed technology for smallholder cattle household is to be established in Cambodia.

Challenges for beef production in smallholder communities with low reproductive management skills: a case study from Northern Lao PDR.

Improved large ruminant productivity is increasingly acknowledged as a pathway for the alleviation of rural poverty and food insecurity in smallholder communities in Southeast Asia; yet, in much of Laos, bovine reproductive management is practically absent. Large ruminant reproduction skills were studied, using face-to-face surveys (n=60) of the knowledge, attitudes, and practices (KAP) of farmers, plus an extension of an examination of parameters of reproductive efficiency (n = 1786 cattle and 434 buffalo) in the northern provinces of Luang Prabang and Xieng Khouang. The surveys particularly involved female farmers to provide gender-disaggregated data, with females making up 38.3 % of participants. Results confirmed that KAPs of smallholder farmers on bovine reproductive management were low (34-46 %) with trends toward higher KAP scores in male survey respondents. Poor reproductive parameters were identified in both provinces, with low calving percentages of 54-75 and 45-54 % in cattle and buffalo groups, respectively, and prolonged inter-calving intervals of 14.1-19.8 and 26.0 months for the cattle and buffalo groups, respectively. Improving the reproductive efficiency of large ruminants in the northern upland regions would enable smallholder farmers to be more effectively engaged in the dramatic economic growth of the Southeast Asia region, although these findings indicate that intensive training and supportive interventions are required to improve large ruminant reproductive outcomes in communities that have low-level large ruminant husbandry skills.

Improving smallholder cattle reproductive efficiency in Cambodia to address expanding regional beef demand.

This study aimed to identify factors associated with cattle reproductive output in rural smallholder farms in Cambodia in order to determine the main causes of reproductive failure and design efficient interventions for improvement. The majority of the nation's beef is produced on smallholder farms where productivity is constrained by poor animal reproductivity reflected in the recent livestock population decline of approximately 13 % from 2009 to 2013. Farmers (n = 240) from 16 villages from five provinces were surveyed in mid-2015 to determine their baseline knowledge, attitude and practices (KAP) associated with cattle reproduction. In addition, 16 case studies from three of these provinces were conducted to provide a more detailed assessment of current cattle reproductive husbandry practices. In order to assess the reproductive impact of previously implemented interventions, an endpoint KAP survey and longitudinal health and husbandry study from three Cambodian provinces conducted between 2008 and 2013 were also analysed. Three multivariable prediction models (two KAP and one longitudinal) identified the following significant factors associated with the reproductive outcomes 'number of calves born' or probability that cows 'gave birth': target feeding (P = 0.074), growing vegetables (P = 0.005), attitudes towards cattle vaccination (P = 0.010), improving bull selection (P = 0.032), local breed use (P = 0.005), number of joining attempts (P < 0.001), discontinuation of animal draught practices (P = 0.003) and retention of breeding animals (P < 0.001). The identification of significant factors and interventions in this study has led to intervention recommendations that can potentially improve reproductive efficiency, combat the declining cattle population and improve smallholder capacity to supply to expanding regional meat demand in South-East Asia and China.

Investigating the financial impact of porcine reproductive and respiratory syndrome on smallholder pig farmers in Cambodia.

Porcine reproductive and respiratory syndrome (PRRS) was first identified in Cambodia in 2010, causing serious problems on affected farms, although the costs of the disease have not been well defined. The household financial impact of a PRRS outbreak in Cambodia was investigated using partial budget analysis, examining the economic benefit of three proposed interventions: (i) quarterly PRRS vaccine use, (ii) biosecurity implementation, and (iii) implementation of vaccination and biosecurity. The analyses were applied to three farm models: (i) a two-sow breeder; (ii) a five-pig fattener; and (iii) a single-sow, three-pig farrow-to-finish/breeder. Data was derived from a knowledge, attitude, and practice survey of 240 smallholder farmers (61 with pigs) from 16 villages across 5 provinces, plus case studies of 12 farmers selected for more detailed financial analysis. The study indicated that financial losses associated with PRRS were severe, with a 25% mean loss to the annual household income of 61 interviewed farmers. Partial budget analysis identified a strongly positive incentive for vaccination and biosecurity to be implemented in combination, with the highest annual net benefit of USD 357.10 realised by the breeder system. However, due to current scarcity of the PRRS vaccine and its high cost to smallholders, biosecurity interventions may be more cost-effective, especially for low PRRS incidence regions. It was concluded that PRRS critically constrains the profitability of smallholder pig farms and that these findings will assist development of village-level livestock disease risk management programmes that encourage adoption of vaccination and biosecurity practices to enhance farmer livelihoods in Cambodia.

Politzer's test - but which one? A plea for standardisation of terms in otology.

BACKGROUND: Politzer's tuning fork test is a little-known special examination with a chequered history. OBJECTIVE: This paper gives Politzer's original description, and explains how he intended it to be used. METHODS: The historiographical research in this study is based on primary references. Secondary documentation is only cited when it is necessary to substantiate any historical argument. RESULTS AND CONCLUSION: After the apparent disappearance of Politzer's tuning fork test from the otological scene in the 1950s, its consequent resurrection was not what it seemed. This story underlines the need for a standardisation of otological nomenclature, particularly when eponyms are used.

A universal driver of macroevolutionary change in the size of marine phytoplankton over the Cenozoic.

The size structure of phytoplankton assemblages strongly influences energy transfer through the food web and carbon cycling in the ocean. We determined the macroevolutionary trajectory in the median size of dinoflagellate cysts to compare with the macroevolutionary size change in other plankton groups. We found the median size of the dinoflagellate cysts generally decreases through the Cenozoic. Diatoms exhibit an extremely similar pattern in their median size over time, even though species diversity of the two groups has opposing trends, indicating that the macroevolutionary size change is an active response to selection pressure rather than a passive response to changes in diversity. The changes in the median size of dinoflagellate cysts are highly correlated with both deep ocean temperatures and the thermal gradient between the surface and deep waters, indicating the magnitude and frequency of nutrient availability may have acted as a selective factor in the macroevolution of cell size in the plankton. Our results suggest that climate, because it affects stratification in the ocean, is a universal abiotic driver that has been responsible for macroevolutionary changes in the size structure of marine planktonic communities over the past 65 million years of Earth's history.

First Report of Colletotrichum cereale Causing Anthracnose Foliar Blight of Creeping Bentgrass in Mississippi and Alabama.

Colletotrichum cereale Manns, formerly C. graminicola (Ces.) G.W. Wils., is the causal agent of anthracnose foliar blight (AFB) of creeping bentgrass (Agrostis stolonifera L.) and other grass species (1). AFB is most prevalent on creeping bentgrass during summer heat stress (2). Symptoms of AFB progress from older to younger leaves with leaf tips becoming chlorotic and eventually developing complete leaf necrosis. Symptoms in turf stands appear as yellow-to-bronze, irregularly shaped patches often associated with a loss of turf density (2). When C. cereale is actively infecting the foliar tissue, appressoria can be observed microscopically in the leaf sheaths of creeping bentgrass. C. cereale colonizes the foliar tissue, producing abundant acervuli, where conidia and setae develop. Creeping bentgrass samples exhibiting symptoms of AFB were collected from West Point, MS and Birmingham, AL in July 2006. Symptomatic plants with signs of C. cereale were surface disinfested and plated onto one-quarter-strength potato dextrose agar (PDA). Monoconidial C. cereale isolates were grown on full-strength PDA for 21 days at 25°C under fluorescent lights. Single-celled conidia were mostly falcate, ranged from 13.1 to 25.6 µm long × 3.6 to 6.3 µm wide, and averaged 22.2 × 4.7 µm. Hyphal appressoria were irregularly shaped and heavily lobed, ranging from 5.6 to 16.1 µm long × 4 to 10.6 µm wide, and averaged 12.1 × 7.9 µm. In culture, setae were acicular, five to seven septate, thick walled, ranged from 74 to 213.5 µm long, and averaged 151.3 µm. The morphological characteristics of 44 AFB isolates were similar to those of C. cereale reported by Crouch et al. (1). Nucleotide sequences were generated for the internal transcribed spacer rDNA for isolates OO7-T42, OW15-H32, and 04-111 (GenBank Accession Nos. EU859957, EU859958, and EU859959). Maximum likelihood-based phylogenetic analyses of these sequences with authentic isolates of Colletotrichum species from grass hosts (2) indicated that all three isolates were C. cereale. 'Penn A-1' creeping bentgrass seedlings (10.16-cm pots) were inoculated with the C. cereale isolates OO7-T42, OW15-H32, or 04-111 by spraying a conidial suspension (1.5 × 105 conidia/ml) on plants until water droplets were evident within the canopy. An uninoculated control sprayed with distilled water only was used for comparison. Three replicates per C. cereale isolate were included simultaneously when performing Koch's postulates. The inoculated creeping bentgrass seedlings were placed in covered plastic boxes to maintain humidity and incubated under 12 h of fluorescent light with day/night temperatures at 35/28°C. After 4 days, the covers were removed and creeping bentgrass was maintained an additional 14 days until symptoms and signs were observed on the foliage. C. cereale was reisolated from inoculated creeping bentgrass exhibiting symptoms of AFB for all three isolates used. No acervuli, setae, or conidial masses were observed on uninoculated control plants. To our knowledge, this is the first report of C. cereale causing AFB on creeping bentgrass in Mississippi and Alabama. References: (1) J. A. Crouch et al. Phytopathology 96:46, 2006. (2) R. W. Smiley et al. Compendium of Turfgrass Diseases. The American Phytopathological Society, St. Paul, MN, 2005.

Gadolinium Deposition within the Pediatric Brain: No Increased Intrinsic T1-Weighted Signal Intensity within the Dentate Nucleus following the Administration of a Minimum of 4 Doses of the Macrocyclic Agent Gadoteridol.

BACKGROUND AND PURPOSE: Our aim was to evaluate whether serial administration of the macrocyclic gadolinium-based contrast agent gadoteridol in children is associated with T1-weighted hyperintensity within the dentate nucleus, an imaging surrogate for gadolinium deposition. MATERIALS AND METHODS: We identified a retrospective cohort of 10 patients younger than 18 years of age who underwent between 4 and 8 gadoteridol-enhanced MR imaging examinations of the brain from 2016 to 2017. For comparison, we identified a retrospective cohort of 9 pediatric patients who each underwent 6 gadodiamide-enhanced MR imaging examinations. For each examination, both dentate nuclei were contoured on unenhanced images and the mean dentate-to-pons signal intensity ratio was calculated. Dentate-to-pons signal intensity ratios from the first and last scans were compared using paired t tests. RESULTS: In the gadoteridol group, there was no significant change in the mean dentate-to-pons signal intensity ratio from the first to the last scan (0.99 versus 0.99, P = .59). In the gadodiamide group, there was a significant increase in the mean dentate-to-pons signal intensity ratio from the first to the last scan (0.99 versus 1.10, P = .001). CONCLUSIONS: Repeat administration of the macrocyclic gadolinium-based contrast agent gadoteridol in children was not associated with T1-weighted dentate hyperintensity, while the repeat administration of the linear gadolinium-based contrast agent gadodiamide was associated with T1-weighted dentate hyperintensity, presumably due to gadolinium deposition.

Investigation of infectious reproductive pathogens of large ruminants: Are neosporosis, brucellosis, leptospirosis and BVDV of relevance in Lao PDR?

N. caninum, bovine viral diarrhoea virus, Brucella abortus and Leptospira interrogans serovar Hardjo are globally significant reproductive pathogens that cause abortion and reproductive loss in large ruminants. Prevalence information is lacking in Lao People's Democratic Republic (Laos) despite the poor reproductive performance of cattle and buffalo. Serological examination of frozen cattle (n=90) and buffalo (n=61) sera by commercially available enzyme-linked immunosorbent assays provided the first reported screening of some of these pathogens in Laos. Seroprevalence differed amongst these large ruminant species, with N. caninum, BVDV and L. interrogans serovar Hardjo antibodies found in 68.9% (95% CI±11.6), 4.9% (95% CI±5.4) and 3.3% (95% CI±4.5) of buffalo sera, respectively, and in 7.8% (95% CI±5.5), 10.0% (95% CI±6.2) and 22.2% (95% CI±8.6) of cattle sera, respectively. Buffalo sera had a significantly higher seroprevalence of N. caninum compared to cattle (p<0.001) and cattle sera had a significantly higher seroprevalence of L. interrogans serovar Hardjo compared to buffalo (p=0.003). Variability was also observed across provinces for N. caninum in buffalo (p=0.007) and for L. interrogans serovar Hardjo in cattle (p=0.071), suggesting provincial risk factors conducive to pathogen transmission. BVDV and N. caninum seropositivity were negatively associated in buffalo (p=0.018) and cattle (p=0.003). In buffalo, L. interrogans serovar Hardjo and BVDV seropositivity were associated (p=0.035, p=0.039). The identification of antibodies against three major abortifacient pathogens in Laos prompts further research to determine if infection is associated with low reproductive efficiency and the risk factors for infection. This is needed for the development of evidence based prevention strategies for improved large ruminant reproductive management among smallholders in Laos.

Ingi, a 5.2-kb dispersed sequence element from Trypanosoma brucei that carries half of a smaller mobile element at either end and has homology with mammalian LINEs.

A dispersed repetitive element named ingi, which is present in the genome of the protozoan parasite Trypanosoma brucei, is described. One complete 5.2-kilobase element and the ends of two others were sequenced. There were no direct or inverted terminal repeats. Rather, the ends consisted of two halves of a previously described 512-base-pair transposable element (G. Hasan, M.J. Turner, and J.S. Cordingley, Cell 37:333-341, 1984). Oligo(dA) tails and possible insertion site duplications suggested that ingi is a retroposon. The sequenced element appears to be a pseudogene copy of an original retroposon with one or more open reading frames occupying most of its length. Significant homologies of the encoded amino acid sequences with reverse transcriptases and mammalian long interpersed nuclear element sequences suggest a remote evolutionary origin for this kind of retroposon.

Are Village Animal Health Workers Able to Assist in Strengthening Transboundary Animal Disease Control in Cambodia?

A cross-sectional survey of 445 Village Animal Health Workers (VAHWs) from 19 provinces in Cambodia was undertaken. The aim was to establish their levels of training, farm visit frequency, reasons for visits and disease reporting practices, enabling the strengths and weaknesses of the VAHW system in Cambodia to be determined, in providing both a fee-based smallholder livestock clinical service and a government partnership in transboundary animal disease (TAD) surveillance and control. The study used 'guided group interviews' and identified that VAHWs had good contact with farmers with 61.5% making more than one farm visit daily. However, incomes from services remained low, with 45% VAHWs obtaining between 20 and 40% of their household income from VAHW activities. VAHWs recorded relatively high rates of disease reporting, with 72% claiming they report diseases immediately and 74% undertaking monthly reporting to veterinary authorities. Logistic regression analysis revealed VAHW contact frequency with district and/or provincial officers was associated with more VAHW farm visits, and frequency of VAHW visits to smallholder farms was positively associated with average monthly expenditure on animal medication and equipment. This suggests that increased veterinary extension to VAHWs and access to veterinary equipment, vaccines and drugs may further increase VAHW-farmer engagement. VAHWs provide an accessible, market-based, animal health 'treatment and reporting' service linked to livestock smallholders across Cambodia. However, for improved TAD prevention and more efficient control of outbreaks, research that assesses provision of an animal health 'preventive-based' business model is urgently needed to reduce both the costs to farmers and the risks to the economy due to foot-and-mouth disease and other TADs in Cambodia.

Investigation of smallholder farmer biosecurity and implications for sustainable foot-and-mouth disease control in Cambodia.

In Cambodia, the majority of the population is rural and reliant on subsistence agriculture, with cattle raised by smallholder farmers using traditional practices, resulting in low productivity and vulnerability to foot-and-mouth disease (FMD). As FMD causes deleterious impacts on rural livelihoods, known FMD risk factors were reviewed, using knowledge, attitudes and practice (KAP) surveys of smallholders (n = 240) from four regions. The study aimed to understand current biosecurity threats to smallholder livelihoods and investigate the hypothesis that smallholder farmers practising FMD risk management should be associated with higher incomes from cattle. Descriptive data were examined to demonstrate trends in KAP and a multivariable linear regression model developed to identify cattle income predictors. Results showed that baseline mean knowledge scores were low at 28.4% across all regions and basic biosecurity practices, including quarantine of new cattle, isolation of sick cattle and FMD vaccination, were lacking. As farmers purchase and sell cattle from and to various administration levels (including export), there is high risk of FMD transmission into and from smallholder communities. The final multivariable linear regression model identified significant explanatory parameters for annual cattle income, including region, number of calves born, forage plot size (ha), vaccination of cattle and the number of cattle purchased (F pr. < 0.001, R2  = 29.9). Individual biosecurity practices including FMD vaccination were not significant predictors of income. With the current focus of farmers on treatment of FMD with inappropriate antibiotics leading to potential anti-microbial residue issues, yet receptivity to payment for vaccine in most regions, there is an urgent need for a coordinated national biosecurity and FMD management public awareness campaign. Further, to enhance the association between improved cattle health and rural livelihoods, it is recommended that livestock development programmes implement a systems approach to enhance farmer KAP in biosecurity, nutrition, reproduction and marketing of cattle.

Benefit-Cost Analysis of Foot and Mouth Disease Control in Large Ruminants in Cambodia.

Foot and mouth disease (FMD) is endemic in Cambodia and throughout the Greater Mekong Subregion and causes significant losses to rural smallholders owning the majority of the national large ruminant population. However, due to underreporting, paucity of knowledge of FMD impacts, limited veterinary capacity and deficits of data available for analysis, the quantifiable benefits of a national FMD control programme are unknown. To address this deficit, existing literature and research data from the 'Best practice health and husbandry of cattle, Cambodia' project conducted between 2007 and 2012, were used to develop a three-phase analysis framework to: assess the impacts of the recent widespread FMD epizootic in Cambodia in 2010, conduct a value chain analysis of the large ruminant market and estimate the costs and benefits for a national large ruminant biannual FMD vaccination programme. A trader survey conducted in 2010-2011 provided cattle and buffalo value chain information and was matched to village herd structure data to calculate a total large ruminant farm-gate value of USD 1.271 billion in 2010. Monte Carlo simulation modelling that implemented a 5-year biannual vaccination programme at a cost of USD 6.3 an animal per year identified a benefit-cost ratio of 1.40 (95% CI 0.96-2.20) when accounting for recent prices of cattle and buffalo in Cambodia and based on an expected annual incidence of 0.2 (assuming one major epizootic in the 5-year vaccination programme). Given that the majority of the large ruminants are owned by rural smallholders, and mostly the poor are involved in agricultural employment, the successful implementation of an FMD control programme in Cambodia would be expected to avoid estimated losses of USD 135 million; equivalent to 10.6% of the 2010 farm-gate value and contributing to important reductions in rural poverty and food insecurity.

Financial Impacts of Foot-and-Mouth Disease at Village and National Levels in Lao PDR.

To assist policies on Foot-and-Mouth Disease (FMD) control in Laos and the Mekong region, the financial impact of recent outbreaks at village and national levels was examined. Village-level impacts were derived from recent research on financial losses due to FMD per smallholder household and number of households with FMD-affected livestock in the village. National-level impacts of FMD were determined from examination of 2011-2013 FMD reported to the Lao Department of Livestock and Fisheries (DLF), with the 2011 epidemic reported separately due to the large number and size of outbreaks of FMD in that year. Estimates of the national financial impact of FMD were based on (i) total FMD financial losses at the village level and (ii) the costs of FMD responses and other related costs at the DLF, provincial and district levels where FMD was reported, but excluding the costs of revenue forgone. A Monte Carlo simulation was utilized to account for likelihood of FMD over- and under-reporting. Foot-and-mouth disease was recorded in four provinces of Phonsaly, Bokeo, Xayyabouli and Champasak in three consecutive years from 2011 to 2013. However, the FMD epidemic in 2011 was more widely distributed and involved 414 villages in 14 provinces, with thousands of cases of morbidity in cattle and buffalo and some mortalities. The estimated financial losses due to FMD in 2011 were USD 30 881(±23 176) at the village level and USD 13 512 291 at the national level based on the number of villages with FMD outbreaks reported. However, when the likelihood of FMD under-reporting was accounted for, the estimated financial losses at the national level could potentially increase to USD 102 094 464 (±52 147 261), being almost 12% of the estimated farm gate value of the national large ruminant herd. These findings confirm that FMD causes substantial financial impacts in villages and to the national economy of Laos, providing justification for sustained investments in FMD control programmes.

Recommendations for training in vascular medicine. American College of Cardiology Peripheral Vascular Disease Committee.

Each trainee in vascular medicine must be eligible for the board certification examination of the American Board of Internal Medicine or its equivalent. Training faculty, preferably at least two members, should meet the qualifications and training requirements described in this report. They must be dedicated, effective teachers and should spend most of their time in research, education and patient care related to peripheral vascular diseases. A curriculum of training should be established. Faculty experts in related specialties and in the related basic sciences should be available for teaching. The institution should have a fully equipped noninvasive vascular laboratory and areas where catheter revascularization techniques and vascular surgery are performed. The period of training should not be less than 1 year, preferably continuous.

Safety of one-stage bilateral hip and knee arthroplasties under regional anaesthesia and routine anaesthetic monitoring.

Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists' physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again.

Coronary angiography in 506 patients with extracranial cerebrovascular disease.

Coronary angiography was performed during the evaluation of a prospective series of 506 patients (mean age, 65 years) presenting with extracranial cerebrovascular disease and previous neurologic symptoms (N = 288) or asymptomatic carotid bruits (N = 218). Severe, surgically correctable coronary artery disease was documented in 37% of patients suspected to have coronary artery disease by conventional clinical criteria, compared with 16% of those who were not. Severe inoperable coronary disease was present in 9.8% and 1.5% of these respective subsets and was especially common (14%) among diabetics. As the result of this investigation, an algorithm for perioperative cardiac screening has been developed in an attempt to reduce the eventual mortality caused by myocardial infarction in patients who require extracranial reconstruction.