The complementarity of green supply chain management practices and the impact on environmental performance.

Although the importance of integrating different Green Supply Chain Management (GSCM) activities has been highlighted in the literature, the potential interdependencies between these practices and their performance impacts have not been investigated. The purpose of this study is to examine the collective impact of internal and external GSCM practices on two aspects of environmental performance: environmental impact and environmental cost savings. GSCM is proposed as a collective competency, combining four distinct, but interrelated, sets of practices: environmental management systems, eco design, source reduction and external environmental practices. Using survey data from 138 Omani manufacturing firms and Structural Equation Modelling, we find strong empirical support for the complementarity of GSCM practices. We find a strong positive relationship between the level of collective GSCM competency and the environmental impact achieved. Our findings support the belief that complementarities between GSCM practices lead to better performance. Managers should therefore focus on implementing bundles of GSCM practices rather than searching for individual best practices. We find an indirect, mediated influence on environmental cost savings, which is consistent with previous results in other emerging market contexts.

Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy: a two-year, two-center experience.

BACKGROUND: Some patients with Takotsubo cardiomyopathy (TTC) develop cardiogenic shock due to left ventricular outflow tract (LVOT) obstruction - there is, however, a paucity of data regarding this condition. METHODS: Prevalence, associated factors and management implications of LVOT obstruction in TTC was explored, based on two-year data from two Belgian heart centres. RESULTS: A total of 32 patients with TTC were identified out of 3,272 patients presenting with troponin-positive acute coronary syndrome. In six patients diagnosed with TTC (19%), a significant LVOT obstruction was detected by transthoracic echocardiography. Patients with LVOT obstruction were older and had more often septal bulging, and presented more frequently in cardiogenic shock as compared to those without LVOT obstruction (P < 0.05). Moreover, all patients with LVOT obstruction showed systolic anterior motion (SAM) of the anterior mitral valve leaflet, which was associated with a higher grade of mitral regurgitation (2.2±0.7 vs. 1.0±0.6, P<0.001). Adequate therapeutic management including fluid resuscitation, cessation of inotropic therapy, intravenous ß-blocker, and the use of intra-aortic balloon pump resulted in non-inferior survival in TTC patients with LVOT obstruction as compared to those without LVOT obstruction. CONCLUSIONS: TTC is complicated by LVOT obstruction in approximately 20% of cases. Older age, septal bulging, SAM-induced mitral regurgitation and hemodynamic instability are associated with this condition. Timely and accurate diagnosis of LVOT obstruction by echocardiography is key to successful management of these TTC patients with LVOT obstruction and results in a non-inferior outcome as compared to those patients without LVOT obstruction.

An acute posterior myocardial infarction complicated with late pseudoaneurysm of the posterior wall.

Diagnostic image: An 80-year-old man is referred because of an acute posterior infarction. Because of persisting pain and apparition of a new murmur, an echocardiography is performed showing inferoposterolateral akinesis complicated by ventricular wall pseudoaneurysm. After discussing with patient and family, conservative therapy was continued. A clue for diagnosis of pseudoaneurysm is the presence of a systolic murmur.

Dedicated Bifurcation Stent for the Treatment of Bifurcation Lesions Involving Large Side Branches: Outcomes From the Tryton Confirmatory Study.

OBJECTIVES: The aim of this study was to prospectively study and confirm the safety and efficacy of the Tryton Side Branch Stent in the treatment of coronary artery bifurcations involving large side branches (SBs). BACKGROUND: The TRYTON Pivotal randomized controlled trial (RCT) was designed to compare the Tryton stent with standard provisional SB stenting in large vessels. The trial inadvertently enrolled patients with too small SBs (<2.25 mm). The overall trial did not meet its primary endpoint, because of an increased rate of periprocedural myocardial infarction in the Tryton stent arm. A post hoc analysis restricted to the intended population showed that the trial would have met its endpoint if only patients with SBs ≥2.25 mm in diameter (by core laboratory quantitative coronary angiography) had been enrolled. METHODS: The Tryton Confirmatory Study was a prospective, single-arm extension of the TRYTON Pivotal RCT that enrolled an additional 133 patients treated with the Tryton Side Branch Stent. It was designed to confirm the results of the post hoc analysis and emphasized the inclusion of appropriately sized SBs. The primary endpoint was noninferiority with regard to periprocedural myocardial infarction (creatine kinase myocardial band 3 times the upper limit of normal) compared with a performance goal based on the TRYTON Pivotal RCT. RESULTS: Among the 133 enrolled patients, 132 (99.2%) had SBs ≥2.25 mm. Baseline clinical and angiographic parameters were similar in this study and the RCT. Periprocedural myocardial infarction occurred in 10.5% of patients, which was numerically lower than the provisional group in the TRYTON Pivotal RCT (11.9%). The 95% confidence bounds did not extend beyond the pre-defined performance goal of 17.9%, meeting the noninferiority primary endpoint. CONCLUSIONS: The Tryton Confirmatory Study, in conjunction with the post hoc analysis of the intended population in the TRYTON Pivotal RCT, supports the safety and efficacy of the Tryton Side Branch Stent for treatment of bifurcation lesions involving large SBs.

Treatment of Parkinson's disease with pergolide and relation to restrictive valvular heart disease.

BACKGROUND: Restrictive valvular heart disease has been reported in patients with Parkinson's disease treated with pergolide. However, few data are available on frequency, severity, dose dependency, and reversibility of pergolide-induced disease, nor on the pulmonary pressures of these patients. We aimed to clarify these characteristics in a large group of patients. METHODS: 78 patients with Parkinson's disease treated with pergolide and 18 never treated with an ergot-derived dopamine agonist (controls) were evaluated by echocardiography. A valvular scoring system was used, ranging from 1 (proven ergot-like restrictive valvular heart disease) to 4 (no disease). For the mitral valve, tenting areas and tenting distances were measured. Systolic pulmonary artery pressures were derived from the tricuspid regurgitant jet. FINDINGS: Restrictive valvular heart disease of any type was present in 26 (33%) patients in the pergolide group and none in controls (p=0.0025). Important disease (score 1 or 2) was present in 15 (19%) patients in the pergolide group and none in controls (p=0.066). Mean tenting distances and tenting areas of the mitral valve were 1.08 cm (range 0.55-2.66) and 2.39 cm2 (0.88-4.59) in the restrictive mitral valve group versus 0.63 cm (0.22-1.20) and 1.39 cm2 (0.39-3.23) in the non-restrictive group (p=0.003 and p<0.0001, respectively). Significant correlation was noted between cumulative doses of pergolide and tenting areas of the mitral valves (r=0.412, p=0.017). Mean systolic pulmonary artery pressures were 39.3 mm Hg (range 25-71) in the high-dose group versus 38.5 mm Hg (20-65) in the low-dose group (p=0.76) and 31 mm Hg (25-40) in controls (p=0.02 vs all patients given pergolide). In six patients, pergolide treatment was stopped because of restrictive valvular heart disease, in two of whom regression of disease was shown. INTERPRETATION: Restrictive valvular heart disease is not a rare finding in patients treated with pergolide. Clinicians should consider changing to a non-ergot drug if this disease is diagnosed.

Prevalence of mechanical dyssynchrony in patients with heart failure and preserved left ventricular function (a report from the Belgian Multicenter Registry on dyssynchrony).

The present study evaluated the prevalence of mechanical inter- and intraventricular dyssynchrony in patients with heart failure and preserved left ventricular (LV) ejection fraction (LVEF). We studied 138 patients with heart failure (age 67+/-11 years; 76% men); 60 patients had preserved LVEF (>40%). Using conventional Doppler echocardiography, an interventricular mechanical delay>or=40 ms was defined as interventricular dyssynchrony. Using pulse-wave tissue Doppler imaging, the time from the beginning of the QRS complex to onset of systolic motion was measured in 4 basal LV segments. A dispersion of >or=60 ms was defined as intraventricular dyssynchrony. The prevalence of inter- and intraventricular dyssynchrony was lower in patients with preserved LVEF than in those with reduced LVEF (17% vs 41%, p<0.01 for interventricular dyssynchrony, 18% vs 36%, p<0.01 for intraventricular dyssynchrony). However, patients with preserved LVEF and a QRS width>or=120 ms had higher values for the parameters for inter- and intraventricular dyssynchrony than patients with a QRS width<120 ms (interventricular mechanical delay 33+/-20 vs 20+/-16 ms, p<0.05; tissue Doppler imaging dispersion 42+/-26 vs 33+/-22 ms, p<0.05). In patients with a QRS width>or=120 ms, the prevalence of inter- and intraventricular dyssynchrony was comparable for patients with preserved and reduced LVEF (42% vs 55%, p=NS for interventricular dyssynchrony and 45% vs 46%, p=NS for intraventricular dyssynchrony). In conclusion, the prevalence of inter- and intraventricular dyssynchrony was low (17% and 18%, respectively) in patients with heart failure and preserved LVEF. However, in the presence of a QRS width of >or=120 ms, this prevalence increased to almost 50%, comparable to that for patients with heart failure and reduced LVEF and a QRS width of >or=120 ms.

Second harmonic transthoracic echocardiography: the new reference screening method for the detection of patent foramen ovale.

AIM: Transesophageal echocardiography (TEE) is still considered as the reference method for the non-invasive detection of right-to-left shunts. Echocardiographic laboratories are spending most of their time performing TEE studies to exclude a thromboembolic cardiac disease. In a considerable proportion of these patients the question can be simplified to exclude a PFO. Replacing these TEE studies by TTE would result in a considerable gain in time and money. We evaluated the value of transthoracic echocardiography with second harmonic imaging (TTE) (SH) and peripheral intravenous agitated saline solutions in the detection of patent foramen ovale (PFO) in a large cohort of patients. METHODS: In 256 consecutive patients, TEE and TTE (SH) with the consecutive administration of three intravenous contrast injections of agitated saline injections before the release phase of the Valsalva manoeuvre were performed. Semi-quantification and timing of contrast passage were assessed during both imaging modalities. A shunt was present if at least one imaging modality showed microbubbles appearing in the left atrium. PFO was defined when these bubbles appeared early and arteriovenous pulmonary malformations were suspected if bubbles appeared late after the opacification of the right atrium. Shunts were considered important when >20 bubbles were present in one frame in the left atrium or left ventricle. RESULTS: From the 256 patients, 60 presented a passage of contrast from the right to the left atrium in at least one imaging modality. PFO was detected by TEE in 53 patients and by TTE in 55 patients (sensitivity: 90.5% and specificity: 96.5% if TEE is accepted as the golden standard) (p>0.05). Considering only the important shunts TEE detected 39 important shunts and TTE 46 important shunts (sensitivity: 89.7% and specificity: 94.6%) (p>0.05). AV pulmonary malformations were detected by TEE in 7 patients and by TTE in 10 patients (sensitivity: 85.7% and specificity: 98.3%) (p>0.05). CONCLUSIONS: In this large cohort of patients TTE (SH) is as accurate as TEE for the detection of PFO and late right-to-left shunts. If the only purpose of TEE is the detection of PFO such as in young cryptogenic stroke patients and in divers, TEE can be replaced by TTE (SH).