Thermoplastic Toughening of a Semiaromatic Polyamide with an Amino-telechelic Polyethylene.

Semiaromatic polyamides are used for metal replacement in advanced engineering applications to reduce weight and improve efficiency, but their range of application is limited by their inherent lack of ductility and toughness. Here, we combined semiaromatic polyamide poly(hexamethylene terephthalamide-co-isophthalamide) (PA6TI) with up to 30 wt % amine-terminated polyethylene (PE(NH2)2) by high-temperature melt compounding, which was suggested to lead to the formation of PA-PE block copolymers at the interface between the PE(NH2)2 and the PA6TI. This resulted in PA6TI/PE(NH2)2 blends with smaller, more uniform particle sizes than in PA6TI blended with nonfunctional PE or the commercial impact modifier, maleic anhydride-functionalized styrene-ethylene-butylene-styrene (SEBS) under the same conditions. The PA6TI/PE(NH2)2 blends and the corresponding glass fiber-reinforced composites consequently showed significantly greater increases in room-temperature tensile ductility and fracture energy with respect to unmodified PA6TI, as well as maintained mechanical stability at high temperatures, and only modest decreases in stiffness and strength, even at high PE(NH2)2 contents. These improvements were attributed to the crystallinity of the PE(NH2)2 particles and to improved morphological stabilization and matrix-particle adhesion, consistent with the presence of PA-PE block copolymer at the matrix-particle interfaces.

Biodegradable polylactide/hydroxyapatite nanocomposite foam scaffolds for bone tissue engineering applications.

Supercritical carbon dioxide processing of poly-L-lactide (PLLA)/hydroxyapatite (nHA) nanocomposites was investigated as a means to prepare foams suitable as scaffolds in bone tissue engineering applications. For given foaming parameters, addition of nHA to the PLLA gave reduced cell sizes and improved homogeneity in the size distribution, but did not significantly affect the degree of crystallinity, which remained of the order of 50 wt% in all the foams. The compressive modulus and strength were primarily influenced by the porosity and there was no significant reinforcement of the matrix by the nHA. The mechanical properties of the foams were nevertheless comparable with those of trabecular bone, and by adjusting the saturation pressure and depressurization rate it was possible to generate porosities of about 85 %, an interconnected morphology and cell diameters in the range 200-400 µm from PLLA containing 4.17 vol% nHA, satisfying established geometrical requirements for bone replacement scaffolds.

Cardiotoxicity of anthracycline agents for the treatment of cancer: systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: We conducted a systematic review and meta-analysis to clarify the risk of early and late cardiotoxicity of anthracycline agents in patients treated for breast or ovarian cancer, lymphoma, myeloma or sarcoma. METHODS: Randomized controlled trials were sought using comprehensive searches of electronic databases in June 2008. Reference lists of retrieved articles were also scanned for additional articles. Outcomes investigated were early or late clinical and sub-clinical cardiotoxicity. Trial quality was assessed, and data were pooled through meta-analysis where appropriate. RESULTS: Fifty-five published RCTs were included; the majority were on women with advanced breast cancer. A significantly greater risk of clinical cardiotoxicity was found with anthracycline compared with non-anthracycline regimens (OR 5.43 95% confidence interval: 2.34, 12.62), anthracycline versus mitoxantrone (OR 2.88 95% confidence interval: 1.29, 6.44), and bolus versus continuous anthracycline infusions (OR 4.13 95% confidence interval: 1.75, 9.72). Risk of clinical cardiotoxicity was significantly lower with epirubicin versus doxorubicin (OR 0.39 95% confidence interval: 0.20, 0.78), liposomal versus non-liposomal doxorubicin (OR 0.18 95% confidence interval: 0.08, 0.38) and with a concomitant cardioprotective agent (OR 0.21 95% confidence interval: 0.13, 0.33). No statistical heterogeneity was found for these pooled analyses. A similar pattern of results were found for subclinical cardiotoxicity; with risk significantly greater with anthracycline containing regimens and bolus administration; and significantly lower risk with epirubicin, liposomal doxorubicin versus doxorubicin but not epirubicin, and with concomitant use of a cardioprotective agent. Low to moderate statistical heterogeneity was found for two of the five pooled analyses, perhaps due to the different criteria used for reduction in Left Ventricular Ejection Fraction. Meta-analyses of any cardiotoxicity (clinical and subclinical) showed moderate to high statistical heterogeneity for four of five pooled analyses; criteria for any cardiotoxic event differed between studies. Nonetheless the pattern of results was similar to those for clinical or subclinical cardiotoxicity described above. CONCLUSIONS: Evidence is not sufficiently robust to support clear evidence-based recommendations on different anthracycline treatment regimens, or for routine use of cardiac protective agents or liposomal formulations. There is a need to improve cardiac monitoring in oncology trials.

Inequity of access to implantable cardioverter defibrillator therapy in England: possible causes of geographical variation in implantation rates.

AIMS: There is marked geographical variation in implantable cardioverter defibrillator (ICD) implantation rates in England. This study examined factors which might explain this variation. METHODS AND RESULTS: Detailed data relating to 1510 patients who received an implanted defibrillator and who were reported to a national pacemaker and implantable defibrillator registry in 2002 were examined and correlated with factors which have been suggested as affecting ICD implantation. None of the factors examined, which included factors related both to the need for ICD implantation and service provision, in addition to socio-economic deprivation, was found to correlate with regional ICD implantation rates. CONCLUSION: There appears to have been no systematic planning of ICD services. Whether this has led to the marked regional variation and in inequity of service provision is not clear.

A novel algorithm increases the delivery of effective cardiac resynchronization therapy during atrial fibrillation: The CRTee randomized crossover trial.

BACKGROUND: Cardiac resynchronization therapy (CRT) requires a high percentage of ventricular pacing (%Vp) to maximize its clinical benefits. Atrial fibrillation (AF) has been shown to reduce %Vp in CRT due to competition with irregular intrinsic atrioventricular (AV) conduction. We report the results of a prospective randomized crossover trial evaluating the amount of effective CRT delivered during AF with a novel algorithm (eCRTAF). OBJECTIVE: The purpose of this study was to determine whether eCRTAF increases the amount of effective CRT delivered during AF compared to a currently available rate regularization algorithm. METHODS: Patients previously implanted with a cardiac resynchronization therapy-defibrillator and with a history of AF and intact AV conduction received up to 4 weeks of control (Conducted AF Response) and up to 4 weeks of eCRTAF in a randomized sequence. The percent effective CRT (%eCRT) pacing, which excludes beats without left ventricular capture, %Vp, and mean heart rate (HR) were recorded during AF and sinus rhythm. RESULTS: The eCRTAF algorithm resulted in a significantly higher %eCRT during AF than control (87.8% ± 7.8% vs 80.8% ± 14.3%; P <.001) and %Vp during AF than control (90.0% ± 5.9% vs 83.2% ± 11.9%; P <.001), with a small but statistically significant increase in mean HR of 2.5 bpm (79.5 ± 9.7 bpm vs 77.0 ± 9.9 bpm; P <.001). CONCLUSION: In a cohort of CRT patients with a history of AF, eCRTAF significantly increased %eCRT pacing and %Vp during AF with a small increase in mean HR. This algorithm may represent a novel noninvasive method of significantly increasing effective CRT delivery during AF, potentially improving CRT response.

The morphology of submicronsized core-shell latex particles: an electron microscopy study.

The core-shell structure of a range of acrylic-acrylic latexes has been investigated by combining different specimen preparation methods with transmission electron microscopy (TEM), dark-field scanning transmission electron microscopy (DSTEM) and low-voltage scanning electron microscopy (LV-SEM), including the first reported use of LV-SEM to observe composite latex particles at ambient and subambient temperatures. Spin-coating of liquid latex dispersions directly onto TEM grids or SEM stubs is shown to be a relatively straightforward mean of avoiding film formation during specimen preparation. In conjunction with double staining techniques, it has been found to be particularly convenient for characterizing the fine structure of particles with diameters down to below 100 nm.

Molecular dynamics simulations of the intrinsically disordered protein amelogenin.

Amelogenin refers to a class of intrinsically disordered proteins that are the major constituents of enamel matrix derivative (EMD), an extract of porcine fetal teeth used in regenerative periodontal therapy. Modifications in molecular conformation induced by external stresses, such as changes in temperature or pH, are known to reduce the effectiveness of EMD. However, detailed descriptions of the conformational behavior of native amelogenin are lacking in the open literature. In the present work, a molecular model for the secondary and tertiary structure of the full-length major porcine amelogenin P173 was constructed from its primary sequence by replica exchange molecular dynamics (REMD) simulations. The REMD results for isolated amelogenin molecules at different temperatures were shown to be consistent with the available spectroscopic data. They therefore represent an important first step toward the simulation of the intra- and intermolecular interactions that mediate self-organization in amelogenin and its behavior in the presence of other EMD components under conditions representative of its therapeutic application.

Scaffold requirements for periodontal regeneration with enamel matrix derivative proteins.

Periodontitis affects the attachment of natural teeth, and infection or inflammation associated with periodontitis may affect peri-implant tissues. Enamel matrix derivative (EMD) proteins provide stimulation for self-regeneration of the damaged tissue when applied to wide intrabony defects as part of a mixture with bone graft material. As a first step of the process enhancing cell proliferation and ligament formation, we demonstrated that EMD protein precipitation depends strongly on the physical and chemical characteristics of the bone grafts used in the mixture. To guarantee optimum protein-stimulated self-regulation, the pH of the initial EMD formulation must therefore be adjusted between 3.9 and 4.2 in order to compensate the change in pH induced by the bone graft. Moreover, the interaction between the two components resulted in precipitates of different shape and size differently covering the grafts. This outcome might potentially have clinical implications on cell attachment and periodontal ligament extension, which deserve further in vitro and in vivo tests.

Cost-effectiveness of implantable cardiac devices in patients with systolic heart failure.

OBJECTIVE: To evaluate the cost-effectiveness of implantable cardioverter defibrillators (ICDs), cardiac resynchronisation therapy pacemakers (CRT-Ps) and combination therapy (CRT-D) in patients with heart failure with reduced ejection fraction based on a range of clinical characteristics. METHODS: Individual patient data from 13 randomised trials were used to inform a decision analytical model. A series of regression equations were used to predict baseline all-cause mortality, hospitalisation rates and health-related quality of life and device-related treatment effects. Clinical variables used in these equations were age, QRS duration, New York Heart Association (NYHA) class, ischaemic aetiology and left bundle branch block (LBBB). A UK National Health Service perspective and a lifetime time horizon were used. Benefits were expressed as quality-adjusted life-years (QALYs). Results were reported for 24 subgroups based on LBBB status, QRS duration and NYHA class. RESULTS: At a threshold of £30 000 per QALY gained, CRT-D was cost-effective in 10 of the 24 subgroups including all LBBB morphology patients with NYHA I/II/III. ICD is cost-effective for all non-NYHA IV patients with QRS duration <120 ms and for NYHA I/II non-LBBB morphology patients with QRS duration between 120 ms and 149 ms. CRT-P was also cost-effective in all NYHA III/IV patients with QRS duration >120 ms. Device therapy is cost-effective in most patient groups with LBBB at a threshold of £20 000 per QALY gained. Results were robust to altering key model parameters. CONCLUSIONS: At a threshold of £30 000 per QALY gained, CRT-D is cost-effective in a far wider group than previously recommended in the UK. In some subgroups ICD and CRT-P remain the cost-effective choice.

Safe use of MRI in people with cardiac implantable electronic devices.

MR scanning in patients with cardiac implantable electronic devices (CIEDs) was formerly felt to be contraindicated, but an increasing number of patients have an implanted MR conditional device, allowing them to safely undergo MR scanning, provided the manufacturer's guidance is adhered to. In addition, some patients with non-MR conditional devices may undergo MR scanning if no other imaging modality is deemed suitable and there is a clear clinical indication for scanning which outweighs the potential risk. The following guidance has been formulated by the British Heart Rhythm Society and endorsed by the British Cardiovascular Society and others. It describes protocols that should be followed for patients with CIEDs undergoing MR scanning. The recommendations, principles and conclusions are supported by the Royal College of Radiologists.

The Influence of Arginine on the Response of Enamel Matrix Derivative (EMD) Proteins to Thermal Stress: Towards Improving the Stability of EMD-Based Products.

In a current procedure for periodontal tissue regeneration, enamel matrix derivative (EMD), which is the active component, is mixed with a propylene glycol alginate (PGA) gel carrier and applied directly to the periodontal defect. Exposure of EMD to physiological conditions then causes it to precipitate. However, environmental changes during manufacture and storage may result in modifications to the conformation of the EMD proteins, and eventually premature phase separation of the gel and a loss in therapeutic effectiveness. The present work relates to efforts to improve the stability of EMD-based formulations such as Emdogain™ through the incorporation of arginine, a well-known protein stabilizer, but one that to our knowledge has not so far been considered for this purpose. Representative EMD-buffer solutions with and without arginine were analyzed by 3D-dynamic light scattering, UV-Vis spectroscopy, transmission electron microscopy and Fourier transform infrared spectroscopy at different acidic pH and temperatures, T, in order to simulate the effect of pH variations and thermal stress during manufacture and storage. The results provided evidence that arginine may indeed stabilize EMD against irreversible aggregation with respect to variations in pH and T under these conditions. Moreover, stopped-flow transmittance measurements indicated arginine addition not to suppress precipitation of EMD from either the buffers or the PGA gel carrier when the pH was raised to 7, a fundamental requirement for dental applications.

Practical method for high-resolution imaging of polymers by low-voltage scanning electron microscopy.

Morphologic characterization of polymers by scanning electron microscopy (SEM) is often made difficult by their sensitivity to electron beam damage. We describe here a specimen preparation method for the imaging of polymer blends by low-voltage SEM (LV-SEM) that improves their stability in the electron beam and hence facilitates focusing and recording of high magnification images. Its application to nanosized core-shell latexes embedded in a polymethylmethacrylate matrix and semi-crystalline polypropylene/ethylene-propylene rubber blends is discussed.

Comparison of Sprint Fidelis and Riata defibrillator lead failure rates.

BACKGROUND/OBJECTIVES: Sprint Fidelis and Riata defibrillator leads are prone to early failure. Few data exist on the comparative failure rates and mortality related to lead failure. The aims of this study were to determine the failure rate of Sprint Fidelis and Riata leads, and to compare failure rates and mortality rates in both groups. METHODS: Patients implanted with Sprint Fidelis leads and Riata leads at a single centre were identified and in July 2012, records were reviewed to ascertain lead failures, deaths, and relationship to device/lead problems. RESULTS: 113 patients had Sprint Fidelis leads implanted between June 2005 and September 2007; Riata leads were implanted in 106 patients between January 2003 and February 2008. During 53.0 ± 22.3 months of follow-up there were 13 Sprint Fidelis lead failures (11.5%, 2.60% per year) and 25 deaths. Mean time to failure was 45.1 ± 15.5 months. In the Riata lead cohort there were 32 deaths, and 13 lead failures (11.3%, 2.71% per year) over 54.8 ± 26.3 months follow-up with a mean time to failure of 53.5 ± 24.5 months. There were no significant differences in the lead failure-free Kaplan-Meier survival curve (p=0.77), deaths overall (p=0.17), or deaths categorised as sudden/cause unknown (p=0.54). CONCLUSIONS: Sprint Fidelis and Riata leads have a significant but comparable failure rate at 2.60% per year and 2.71% per year of follow-up respectively. The number of deaths in both groups is similar and no deaths have been identified as being related to lead failure in either cohort.

The incidence of implantable cardioverter defibrillator indications in patients admitted to all coronary care units in a single district.

AIMS: Implantable cardioverter defibrillators (ICDs) have been shown to reduce all-cause mortality in groups of patients at high risk of ventricular arrhythmias. The true incidence of ICD indications is unknown but we hypothesize that it far exceeds the number actually implanted. METHODS: In a one month observational audit, we reviewed the clinical records of all 336 patients admitted to coronary care units serving a district with a population of 471,000, to determine the additional screening tests required in myocardial infarction (MI) survivors and the number of additional ICDs which would be implanted for the primary and secondary prevention indications recommended in UK National Institute for Clinical Excellence (NICE) guidance. A further analysis was performed to determine the effect of extending the primary prevention indications to include the selection criteria used in the second multicentre automatic defibrillator trial, MADIT II. RESULTS: Using NICE criteria, we found the incidence of ICD indications to be 98.4/10(6)/year. The addition of patients fulfilling MADIT II selection criteria for primary prevention would have increased this to 453/10(6)/year. CONCLUSION: We conclude that the implementation of national guidance on the use of ICDs for arrhythmias will require the systematic screening of MI survivors, and would identify an incidence of ICD indications at least three times that anticipated by NICE, and eight times as many as were actually implanted in the UK in 2000. If the primary prevention indications were widened to include MADIT II selection criteria, the total would be nearer to 12 times that anticipated, and 47 times the number actually implanted.

Implications of national guidance for implantable cardioverter defibrillation implantation in the United Kingdom.

To determine the number of patients fulfilling recently issued national guidelines on the use of ICDs in patients with arrhythmias, the authors undertook two observational audits of clinical records. The first audit included patients investigated and treated at a tertiary referral cardiothoracic center during a 1-month period, and the second included patients admitted to the three coronary care units serving a circumscribed district population during a second month. Patient records were audited against the recommendations for ICD implantation made by the National Institute for Clinical Excellence to determine if the patient fulfilled the criteria for ICD implantation. The audit was repeated with the same patient records against the MADIT 2 selection criteria. The audit identified underprovision of ICD therapy in the United Kingdom for a variety of reasons. It also demonstrated that the number of patients fulfilling selection criteria defined by the national guidelines for ICD implantation is far in excess of the numbers predicted. The annual incidence of patients fulfilling national criteria is about 150/million, with an additional "prevalence" of at least 41/million. Applying the less restrictive MADIT II criteria to select patients for ICDs as a primary prevention increased the numbers to 504/million ("new incidence") and 311/million ("prevalence") per year, in excess of the predictions by a factor of between 10 and 25.

Designing new materials from wheat protein.

We recently discovered that wheat gluten could be formed into a tough, plasticlike substance when thiol-terminated, star-branched molecules are incorporated directly into the protein structure. This discovery offers the exciting possibility of developing biodegradable high-performance engineering plastics and composites from renewable resources that are competitive with their synthetic counterparts. Wheat gluten powder is available at a cost of less than dollars 0.5/lb, so if processing costs can be controlled, an inexpensive alternative to synthetic polymers may be possible. In the present work, we demonstrate the ability to toughen an otherwise brittle protein-based material by increasing the yield stress and strain-to-failure, without compromising stiffness. Water absorption results suggest that the cross-link density of the polymer is increased by the presence of the thiol-terminated, star-branched additive in the protein. Size-exclusion high performance liquid chromatography data of molded tri-thiol-modified gluten are consistent with that of a polymer that has been further cross-linked when compared directly with unmodified gluten, handled under identical conditions. Remarkably, the mechanical properties of our gluten formulations stored in ambient conditions were found to improve with time.