Phylogenetics of mud snakes (Squamata: Serpentes: Homalopsidae): A paradox of both undescribed diversity and taxonomic inflation.

Mud snakes (Serpentes: Homalopsidae) are a family of 55 described, mainly aquatic, species primarily distributed throughout mainland Southeast Asia and the Indo-Australian Archipelago. Although they have been the focus of prior research, the basic relationships amongst genera and species remain poorly known. We used a combined mitochondrial and nuclear gene dataset to infer their phylogenetic relationships, using the highest levels of taxon and geographic sampling for any homalopsid phylogeny to date (62% generic and 62% species coverage; 140 individuals). Our results recover two reciprocally monophyletic groups: the fangless Brachyorrhos and its sister clade comprised of all rear-fanged homalopsids. Most genera and interspecific relationships were monophyletic and strongly supported, but intergeneric relationships and intraspecific population structure lack support. We find evidence of both undescribed diversity as well as cases of taxonomic inflation within several species. Tree-based species delimitation approaches (mPTP) support potential new candidate species as distinct from their conspecifics and also suggest that many named taxa may not be distinct species. Divergence date estimation and lineage-through-time analyses indicate lower levels of speciation in the Eocene, with a subsequent burst in diversification in the Miocene. Homalopsids may have diversified most rapidly during the Pliocene and Pleistocene, possibly in relation to tectonic shifts and sea-level fluctuations that took place in Sundaland and the Sahul Shelf. Our analyses provide new insights on homalopsid taxonomy, a baseline phylogeny for the family, and further biogeographic implications demonstrating how dynamic tectonics and Quaternary sea level changes may have shaped a widespread, diverse family of snakes.

Hiding in the lianas of the tree of life: Molecular phylogenetics and species delimitation reveal considerable cryptic diversity of New World Vine Snakes.

The Brown Vine Snake, Oxybelis aeneus, is considered a single species despite the fact its distribution covers an estimated 10% of the Earth's land surface, inhabiting a variety of ecosystems throughout North, Central, and South America and is distributed across numerous biogeographic barriers. Here we assemble a multilocus molecular dataset (i.e. cyt b, ND4, cmos, PRLR) derived from Middle American populations to examine for the first time the evolutionary history of Oxybelis and test for evidence of cryptic lineages using Bayesian and maximum likelihood criteria. Our divergence time estimates suggest that Oxybelis diverged from its sister genus, Leptophis, approximately 20.5 million years ago (Ma) during the lower-Miocene. Additionally, our phylogenetic and species delimitation results suggest O. aeneus is likely a complex of species showing relatively deep species-level divergences initiated during the Pliocene. Finally, ancestral area reconstructions suggest a Central American origin and subsequent expansion into North and South America.

Fat free mass is positively associated with hunger and energy intake at extremes of obesity.

Fat mass (FM) has been shown to be negatively associated with energy intake (EI) in lean individuals but in overweight and Class I obese individuals this relationship is poorly understood. Fat free mass (FFM) is positively associated with EI in lean, overweight and Class I obese individuals. To date, the relationships between FFM, FM, hunger and EI have not been investigated in patients with a body mass index (BMI) > 35 kg/m2. The aim of the present study was to examine the associations between FFM, FM, BMI, hunger and EI in individuals with severe (BMI > 35 kg/m2) obesity. In total, 43 subjects (52% male) with a mean (±standard deviation) BMI of 44.5 ±â€¯6.2 kg/m2 were recruited for this cross-sectional analysis. Dual energy x-ray absorptiometry and an ad libitum food buffet were used to measure body composition and EI respectively, and hunger was measured using a visual analogue scale (0-100 mm). BMI (p = 0.02; p < 0.01) and FFM (p < 0.01; p = 0.02), but not FM (p = 0.18; p = 0.71), were positively associated with both EI and pre-buffet hunger, respectively, on multivariable regression using the general linear model. These findings suggest that in extremes of obesity FFM continues to promote hunger and EI, but the inhibitory effect of FM on EI that has been observed in lean populations was not present in this cohort suffering from severe obesity.

Comparison of time-matched aerobic, resistance, or concurrent exercise training in older adults.

A supervised 12-week intervention of time-matched aerobic vs resistance versus concurrent exercise training was employed to investigate mode- and time course-specific effects of exercise training in older adults. Community-dwelling men and women (n = 84; M/F, 45/39; 69.3 ± 3.5 years; 26.4 ± 3.8 kg m-2 ) were randomly assigned (n = 21 each) to either non-exercise control (CON), aerobic exercise only (AER), resistance exercise only (RES), or concurrent aerobic and resistance exercise (CEX). Training groups trained three times per week, each performing 72 minutes of active exercise time per week. Body composition, physical and cognitive function, and markers of metabolic health were assessed before (PRE), and after 6 (MID) and 12 (POST) weeks of exercise training. Hand-grip strength, 1RM chest press, and arm LBM were improved by both RES and CEX, but not AER. Aerobic fitness increased in AER and RES, but not CEX. Cognitive function improved in all groups, but occurred earlier (ie, at MID) in AER. CEX improved gait speed and lower limb strength and reduced trunk fat compared to either AER or RES. Leg LBM was unchanged in any group. Temporal patterns were observed as early as 6 weeks of training (gait speed, upper and lower limb strength, aerobic fitness), whereas others were unchanged until 12 weeks (hand-grip strength, timed up-and-go, sit-to-stand). Compared to either aerobic or resistance exercise training alone, concurrent exercise training is as efficacious for improving a range of health-related parameters and is more efficacious for increasing gait speed and lower limb strength, and decreasing trunk fat in older adults.

Hamstring injuries in elite Gaelic football: an 8-year investigation to identify injury rates, time-loss patterns and players at increased risk.

BACKGROUND: Hamstring injuries occur frequently in field sports, yet longitudinal information to guide prevention programmes is missing. AIM: Investigate longitudinal hamstring injury rates and associated time loss in elite Gaelic football, while identifying subgroups of players at increased risk. METHODS: 38 data sets from 15 elite male Gaelic football teams were received by the National Gaelic Athletic Association (GAA) Injury Surveillance Database between 2008 and 2015. Injury and exposure data were provided by the team's medical staff via an online platform. RESULTS: 391 hamstring injuries were sustained accounting for 21% (95% CI 20.0% to 21.7%) of all injuries. Prevalence was 21% (95% CI 19.2% to 23.4%). Incidences were 2.2 (95% CI 1.9 to 2.4) per 1000 exposure hours, and 7.0 (95% CI 6.5 to 7.1) times greater in match play than in training. Typically each team sustained 9.0 (95% CI 7.0 to 11.0) hamstring injuries per season affecting the: bicep femoris belly (44%; 95% CI 39.4% to 48.7%); proximal musculotendinous junction (13%; 95% CI 9.8% to 16.3%); distal musculotendinous junction (12%; 95% CI 8.6% to 14.9%) and semimembranosis/semitendinosis belly (9%; 95% CI 6.3% to 11.7%). ∼36% (95% CI 31.5% to 41.0%) were recurrent injuries. Mean time loss was 26.0 (95% CI 21.1 to 33.0) days, which varied with age, injury type and seasonal cycle. Hamstring injuries accounted for 31% (95% CI 25.8% to 38.2%) of injury-related time loss. Previously injured players (rate ratio (RR)=3.3), players aged 18-20 years (IRR=2.3) or >30 years (RR=2.3), as well as defensive (IRR=2.0) and midfield players (RR=1.5), were most at risk of sustaining a hamstring injury. Comparisons of 2008-2011 with 2012-2015 seasons revealed a 2-fold increase in hamstring injury incidences. Between 2008 and 2015 training incidence increased 2.3-fold and match-play incidences increased 1.3-fold. CONCLUSIONS: Hamstring injuries are the most frequent injury in elite Gaelic football, with incidences increasing from 2008-2011 to 2012-2015. Tailoring risk management strategies to injury history, age and playing position may reduce the burden of hamstring injuries.

The Effects of the Gaelic Athletic Association 15 Training Program on Neuromuscular Outcomes in Gaelic Football and Hurling Players: A Randomized Cluster Trial.

O'Malley, E, Murphy, JC, McCarthy Persson, U, Gissane, C, and Blake, C. The effects of the Gaelic Athletic Association 15 training program on neuromuscular outcomes in Gaelic football and hurling players: A randomized cluster trial. J Strength Cond Res 31(8): 2119-2130, 2017-Team-based neuromuscular training programs for injury prevention have been tested primarily in female and adolescent athletes in soccer, handball, and basketball with limited research in adult male field sports. This study explored whether the GAA 15, a multifaceted 8-week neuromuscular training program developed by the Gaelic Athletic Association (GAA), could improve risk factors for lower limb injury in male Gaelic footballers and hurlers. Four Gaelic sports collegiate teams were randomized into intervention or control groups. Two teams (n = 41), one football and one hurling, were allocated to the intervention, undertaking a 15 minutes program of neuromuscular training exercises at the start of team training sessions, twice weekly for 8 weeks. Two matched teams (n = 37) acted as controls, participating in usual team training. Lower extremity stability (Y-Balance test [YBT]) and jump-landing technique using the Landing Error Scoring System (LESS) were assessed preintervention and postintervention. There were moderate effect sizes in favor of the intervention for right (d = 0.59) and left (d = 0.69) composite YBT scores, with adjusted mean differences between intervention and control of 3.85 ± 0.91% and 4.34 ± 0.92% for right and left legs, respectively (p < 0.001). There was a greater reduction in the mean LESS score in favor of the intervention group after exercise training (Cohen's d = 0.72, adjusted mean difference 2.49 ± 0.54, p < 0.001). Clinically and statistically significant improvements in dynamic balance and jump-landing technique occurred in collegiate level Gaelic football and hurling players who adopted the GAA 15, when compared with usual training. These findings support application and evaluation of the GAA 15 in other player groups within the Gaelic games playing population.

A molecular and morphological characterization of Oliver's parrot snake, Leptophis coeruleodorsus (Squamata: Serpentes: Colubridae) with the description of a new species from Tobago.

Currently, two snake species of the genus Leptophis occur in Trinidad and Tobago. One, L. stimsoni, is endemic to Trinidad's Northern Range and known from relatively few specimens. The second is the diurnal, arboreal, brightly colored parrot snake Leptophis coeruleodorsus Oliver. It was originally described based on 23 specimens from Trinidad, Tobago, and four locations in northern Venezuela but remains poorly known. It was later assigned as a subspecies of Leptophis ahaetulla; a widespread, polytypic species. Here we compare 11 specimens of the L. ahaetulla Group using DNA sequences from two mitochondrial genes (cytochrome b and 16S, 1,383 bp total) from island and mainland populations, report on the variation in the morphology of 54 museum specimens of Leptophis a. coeruleodorsus; describe the previously undescribed holotype of L. coeruleodorsus Oliver, and restrict its type locality. Additionally, we describe a new species of Leptophis from the island of Tobago that can be distinguished from L. coeruleodorsus on the basis of snout shape, upper labial architecture, elongated prefrontal scales, and ventral scale counts. The new Leptophis raises the number of endemic Tobago amphibians and reptiles to 11 taxa.

Unveiling underestimated species diversity within the Central American Coralsnake, a medically important complex of venomous taxa.

Coralsnakes of the genus Micrurus are a diverse group of venomous snakes ranging from the southern United States to southern South America. Much uncertainty remains over the genus diversity, and understanding Micrurus systematics is of medical importance. In particular, the widespread Micrurus nigrocinctus spans from Mexico throughout Central America and into Colombia, with a number of described subspecies. This study provides new insights into the phylogenetic relationships within M. nigrocinctus by examining sequence data from a broad sampling of specimens from Mexico, Guatemala, Honduras, Nicaragua, Costa Rica, and Panama. The recovered phylogenetic relationships suggest that M. nigrocinctus is a species complex originating in the Pliocene and composed of at least three distinct species-level lineages. In addition, recovery of highly divergent clades supports the elevation of some currently recognized subspecies to the full species rank while others may require synonymization.

Injury in elite county-level hurling: a prospective study.

OBJECTIVE: To determine the incidence, prevalence and nature of sports injuries in elite male hurling players. DESIGN: Prospective study of county-grade hurling teams. Incidence, prevalence and descriptions of injuries were collated. SETTING: Four county teams during the 2007 season; January to September inclusive. PARTICIPANTS: A total of 127 male players were followed over 34 weeks. Data were collected on a median (IQR) of 31 (30-32) players per team per week. The mean age was 23.3±2.5 years. RESULTS: There were 204 injuries to 104 players (82%, 95% CI (74 to 88)). Injury incidence rate during match-play (102.5 (84.4 to 123.2)) was 19 times higher than for training (5.3 (4.2 to 6.5)) (RR=19.5 (14.8 to 25.6)). The mean weekly prevalence of injury was 13.9% (12.5 to 14.8). Most injuries were new (n=170, 83.3%, (77.6 to 87.8)) and acute (n=165, 80.9% (74.9 to 85.7)). Muscle strain (n=86) accounted for 42.2% (35.6 to 49) of the total. 71% of injuries were to the lower limb (n=143, (63.5 to 76.0)) with hamstring strain (n=33, 16.5% (11.8 to 21.8)) predominating. Fractures constituted 7.4% injuries (n=15, 95% CI (4.5 to 11.8)), 12 of which were to the upper limb. There were three (1.5% (0.5 to 4.2)) eye injuries and one concussion injury (0.5% (0.1 to 2.7)). CONCLUSIONS: These results provide data on hurling injuries using definitions that reflect international consensus statements. Injury incidence from match-play in particular is high compared with other sports. These findings have relevance for clinicians and coaches.

The epidemiology of back injuries in elite Gaelic football athletes: An 8-year prospective study.

OBJECTIVES: To describe the epidemiology of back injury in elite male Gaelic football athletes between 2008 and 2016. DESIGN: Prospective cohort study. SETTING: Injury data from the National GAA Injury Surveillance Database. PARTICIPANTS: Elite male Gaelic football athletes. MAIN OUTCOME MEASURES: Incidence of injury as a rate per 1000 h of exposure. RESULTS: 38 datasets were analysed. Out of a total of 1606 time-loss injuries, 76 were back injuries (4.73%, 95% CI 3.80%-5.88%). The incidence of back injuries in match play was 1.72 (CI 95% 1.21 to 2.45) and in training was 0.2 (CI 95% 0.14 to 0.28) injuries per 1000 h of exposure. The majority of back injuries (63.16%, CI 95% 51.93-73.12) were new, as opposed to recurrent (35.53% CI 95% 25.7-46.74). Most back injuries were acute (51.32%, CI 95% 40.29-62.22), compared to chronic (31.58%, CI 95% 22.23-42.7) or overuse (11.84%, CI 95% 6.36-21.00). The majority of back injuries occurred during non-contact player activities (n = 60, 78.94% CI 95% 68.50-86.60). CONCLUSIONS: Back injury rates in Gaelic football are similar to soccer and Australian football but less than rugby union. Further research is needed to understand the factors leading to the onset and recurrence of back injury in Gaelic football athletes.

The Terrific Skink bite force suggests insularity as a likely driver to exceptional resource use.

Natural history museum collections hold extremely rare, extinct species often described from a single known specimen. On occasions, rediscoveries open new opportunities to understand selective forces acting on phenotypic traits. Recent rediscovery of few individuals of Bocourt´s Terrific Skink Phoboscincus bocourti, from a small and remote islet in New Caledonia allowed to genetically identify a species of land crab in its diet. To explore this further, we CT- and MRI-scanned the head of the holotype, the only preserved specimen dated to about 1870, segmented the adductor muscles of the jaw and bones, and estimated bite force through biomechanical models. These data were compared with those gathered for 332 specimens belonging to 44 other skink species. Thereafter we recorded the maximum force needed to generate mechanical failure of the exoskeleton of a crab specimen. The bite force is greater than the prey hardness, suggesting that predation on hard-shelled crabs may be an important driver of performance. The high bite force seems crucial to overcome low or seasonal variations in resource availability in these extreme insular environments. Phoboscincus bocourti appears to be an apex predator in a remote and harsh environment and the only skink known to predate on hard-shelled land crabs.

First molecular evidence for the phylogenetic placement of the enigmatic snake genus Brachyorrhos (Serpentes: Caenophidia).

BrachyorrhosSchlegel, 1826a is a terrestrial-fossorial snake genus endemic to eastern Indonesia that has been assigned to six different families and subfamilies within Colubroidea (advanced snakes) over the past ~200 years. Here we report the first molecular sequences for Brachyorrhos and use them to test the position of the genus within snake phylogeny. Our Bayesian and Maximum Likelihood analyses of three mitochondrial and one nuclear gene strongly resolve Brachyorrhos within the rear-fanged semiaquatic Homalopsidae (Colubroidea), as the sister taxon to all other genera and sampled species.

Optimization of the precordial leads of the 12-lead electrocardiogram may improve detection of ST-segment elevation myocardial infarction.

BACKGROUND: For the assessment of patients with chest pain, the 12-lead electrocardiogram (ECG) is the initial investigation. Major management decisions are based on the ECG findings, both for attempted coronary artery revascularization and risk stratification. The aim of this study was to determine if the current 6 precordial leads (V(1)-V(6)) are optimally located for the detection of ST-segment elevation in ST-segment elevation myocardial infarction (STEMI). METHODS: We analyzed 528 (38% anterior [200], 44% inferior [233], and 18% lateral [95]) patients with STEMI with both a 12-lead ECG and an 80-lead body surface map (BSM) ECG (Prime ECG, Heartscape Technologies, Bangor, Northern Ireland). Body surface map was recorded within 15 minutes of the 12-lead ECG during the acute event and before revascularization. ST-segment elevation of each lead on the BSM was compared with the corresponding 12-lead precordial leads (V(1)-V(6)) for anterior STEMI. In addition, for lateral STEMI, leads I and aVL of the BSM were also compared; and limb leads II, III, aVF of the BSM were compared with inferior unipolar BSM leads for inferior STEMI. Leads with the greatest mean ST-segment elevation were selected, and significance was determined by analysis of variance of the mean ST segment. RESULTS: For anterior STEMI, leads V(1), V(2), 32, 42, 51, and 57 had the greatest mean ST elevation. These leads are located in the same horizontal plane as that of V(1) and V(2). Lead 32 had a significantly greater mean ST elevation than the corresponding precordial lead V(3) (P = .012); and leads 42, 51, and 57 were also significantly greater than corresponding leads V(4), V(5), V(6), respectively (P < .001). Similar findings were also found for lateral STEMI. For inferior STEMI, the limb leads of the BSM (II, III, and aVF) had the greatest mean ST-segment elevation; and lead III was significantly superior to the inferior unipolar leads (7, 17, 27, 37, 47, 55, and 61) of the BSM (P < .001). CONCLUSION: Leads placed on a horizontal strip, in line with leads V(1) and V(2), provided the optimal placement for the diagnosis of anterior and lateral STEMI and appear superior to leads V(3), V(4), V(5), and V(6). This is of significant clinical interest, not only for ease and replication of lead placement but also may lead to increased recruitment of patients eligible for revascularization with none or borderline ST-segment elevation on the initial 12-lead ECG.

Liraglutide Does Not Adversely Impact Fat-Free Mass Loss.

OBJECTIVES: This study aimed to examine fat-free mass (FFM) loss between successful responders to lifestyle intervention alone compared with lifestyle intervention plus liraglutide 3.0 mg. An additional objective was to examine the effects of varying resistance training frequencies (days per week) on FFM retention. METHODS: This prospective study examined patients with BMI ≥ 35 kg/m2 receiving treatment in a tertiary care obesity clinic. Body composition (dual-energy x-ray absorptiometry) was captured at baseline and after 16 weeks of treatment. Exercise-related data (aerobic minutes per week and resistance training frequency) were captured at week 16. A total of 78 individuals were examined in two groups, the first with lifestyle intervention alone (n = 19) and the second with lifestyle intervention plus liraglutide 3.0 mg (n = 59). Linear mixed-effects models were used to examine between-group differences. RESULTS: Compared with lifestyle intervention alone, participants on liraglutide lost more weight (-12.2 kg vs. -9.7 kg, P = 0.048) and FFM (-2.3 kg vs. -1.5 kg, P = 0.06). After controlling for weight loss, there was no difference in FFM loss between groups (0.14 kg/wk vs. -0.09 kg/wk, P = 0.12). Absolute weight loss (kilograms) was associated with FFM loss (kilograms) (ρ = 0.58, P < 0.0001). Exercise did not increase weight loss, and resistance training frequency (days per week) did not attenuate FFM loss. CONCLUSIONS: Liraglutide does not have effects on FFM beyond what can be expected from total weight loss. Resistance training did not attenuate FFM loss in the liraglutide or lifestyle-alone groups. To ameliorate FFM loss after liraglutide, a new strategy may be needed that may combine exercise with specific nutritional interventions.

Initial Experiences of Percutaneous Coronary Intervention Using a New-Generation Everolimus-Eluting Stent Platform.

BACKGROUND: Outcomes from the new Synergy Megatron drug-eluting stent (DES) platform (Boston Scientific) are not yet reported. This study sought to evaluate periprocedural outcomes in patients undergoing percutaneous coronary intervention (PCI) using this technology. METHODS: This was a retrospective study across two United Kingdom centers of 139 patients undergoing PCI of 146 coronary lesions using the Synergy Megatron DES. The primary endpoint was the rate of cardiovascular death. The secondary endpoint was the rate of a composite of non-fatal myocardial infarction, target-vessel revascularization, in-stent restenosis, and probable/definite stent thrombosis. Available intravascular ultrasound (IVUS) imaging was reviewed post hoc and evaluated according to predefined IVUS optimization criteria. RESULTS: Mean follow-up duration was 137.3 ± 38.3 days. The primary endpoint occurred in 0.7% of patients and the secondary endpoint occurred in 0.0% of patients. There were no cases of longitudinal stent deformation (LSD); in patients undergoing an IVUS-guided procedure, our criteria for successful IVUS optimization was achieved in 74.1% of left main stem (LMS) and 83.3% of right coronary artery (RCA) lesions. Mean minimal stent area (MSA) was 14.5 ± 3.4 mm² in the LMS, 10.0 ± 2.5 mm² in the left anterior descending coronary artery, 9.8 ± 3.0 mm² in the left circumflex, and 12.2 ± 4.0 mm² in the RCA. CONCLUSION: This study demonstrated very low rates of short-term major adverse cardiovascular events with no cases of LSD or acute/subacute stent thrombosis. It highlights the overexpansion capabilities of the Synergy Megatron DES platform. The technology safely and effectively facilitates IVUS-optimized stent parameters for the treatment of large proximal vessels and bifurcations.

Biogeographical patterns of amphibians and reptiles in the northernmost coastal montane complex of South America.

We examine, for the first time, biogeographic patterns in a series of tropical montane coastal systems in northern South America. We use amphibians and reptiles, which constitute the most critical communities based upon the prevalence of endemic taxa, to assess the region's biodiversity. The montane coastal system spans an east-west distance of 925 km. It includes peaks ranging from 549 m to 2765 m above sea level and encompasses the montane complexes of northern Venezuela (including Isla de Margarita), an outlier at Santa Marta (Colombia), and ranges on the islands Trinidad and Tobago. The area supports 14 family level amphibian clades and 23 family level reptile clades. Fieldwork, museum specimen surveys, and a literature review suggest that biodiversity decreases at higher elevations. Here we examine the biogeographic patterns in the region to assess the role of the montane systems as possible refugia. We also look at the possible island and sky island effects using data from altitudes >200 m. At lower elevations, we tabulated 294 species, comprising 112 amphibians and 182 reptiles. About 45% of these taxa are endemic or exclusive to different sub-regions. At mid-elevation montane cloud forests, we find a much-reduced biodiversity with a total of 125 species (66 amphibians and 59 reptiles) exclusive or restricted to the region, and few species shared between systems. We find that biogeographical patterns follow a natural topographic disposition above 200 m in elevations. At the lower elevation cut off, there are 118 species (26 amphibians and 92 reptiles) shared among two or more of the studied mountain systems, suggesting a common origin and dispersal events, despite what seem to be topographic barriers. Biogeographical relationships support a topographic disposition of the region with close associations between the islands of Trinidad and Tobago, the Paria Range and the Turimiquire Massif, and close associations between the Sierra Nevada de Santa Marta and the Sierra de San Luis. Overall, the biogeographic relationships between amphibians and reptiles are similar. Species diversity in the eastern Caribbean region is less rich than in the west. This study includes the first herpetological surveys at the two easternmost mountains (Cerro La Cerbatana and Campeare) belonging to the Paria Range biogeographic unit, and aims to contribute to a better understanding of the rich biodiversity of the region.

Late aortic perforation with an Atriasept device resulting in life-threatening tamponade.

Patients with compelling evidence of cryptogenic stroke due to patent foreamen ovale (PFO) are increasingly likely to be offered percutaneous closure of the defect. With improvements in technique there is now a high procedural success rate with low rates of periprocedural complications. Late complications are also rare, but include late perforation of the aortic root, which is rapidly progressive and potentially fatal. This has lead to the development of lower profile devices, which aim to reduce the risk of both early and late complications. At this stage, it is not clear if lower profile devices have safety profiles which are superior to the more established devices. We report the first case of late perforation of the aortic sinus by the lower profile Atriasept (Cardia) device presenting as life threatening cardiac tamponade in an adult who previously underwent percutaneous PFO closure.

The influence of skeletal muscle on appetite regulation.

INTRODUCTION: Fat-free mass, of which skeletal muscle is amajor component, correlates positively with energy intake at energy balance. This is due to the effects of metabolically active tissue on energy expenditure which in itself appears to signal to the brain adrive to eat to ensure cellular energy homeostasis. The mechanisms responsible for this drive to eat are unknown but are likely to be related to energy utilization. Here muscle imparts an indirect influence on hunger. The drive to eat is also enhanced after muscle loss secondary to intentional weight loss. The evidence suggests loss of both fat mass and skeletal muscle mass directly influences the trajectory and magnitude of weight regain highlighting their potential role in long-termappetite control. The mechanisms responsible for the potential direct drive to eat stemming from muscle loss are unknown. AREAS COVERED: The literature pertaining to muscle and appetite at energy balance and after weight loss was examined. Aliterature search was conducted to identify studies related to appetite, muscle, exercise, and weight loss. EXPERT OPINION: Understanding the mechanisms which link energy expenditure and muscle loss to hunger has the potential to positively impact both the prevention and the treatment of obesity.

A new species of Erythrolamprus from the oceanic island of Tobago (Squamata, Dipsadidae).

Tobago is a small island on the southeast edge of the Caribbean Plate with a continental flora and fauna. Using DNA sequences from Genbank, new sequences, and morphological data from the snakes Erythrolamprusepinephalus, E.melanotus, E.reginae, and E.zweifeli, the species status of specimens of a Tobago snake previously considered to be Erythrolamprusreginae was assessed. Erythrolampruszweifeli, long considered a subspecies of E.reginae, was found to be a northern Venezuela-Trinidad endemic and the sister to E.reginae. The trans-Andean species E.epinephalus is shown to be non-monophyletic while the Costa Rican lineage of E.epinephalus is weakly supported as the sister to the Tobago population. The Tobago Erythrolamprus is described as a distinct taxon based upon five specimens from four localities in lower montane rainforest. Much of the new species range includes the Main Ridge Forest Reserve of Tobago, the oldest protected forest in the Western Hemisphere. All known locations fall within a 400-ha area, and its total geographic distribution is likely to be less than 4,566 ha. The restricted distribution of this new snake makes it a likely candidate for threatened status. The new species also becomes another biogeographic link between northern Venezuela and Tobago.

Risk stratification of chest pain patients in the emergency department by a nurse utilizing a point of care protocol.

OBJECTIVE: Risk stratification of patients with ischaemic type chest pain assessed in the emergency department utilizing a point of care (POC) protocol. METHODS: Patient demographics, cardiac biomarkers, management and follow-up at 6 months were reviewed for patients seen over 20 months. RESULTS: Out of 546 patients, 351 (64%) were admitted. The diagnoses after admission were confirmed as acute myocardial infarction in 59 patients and unstable angina, (cTroponin T<0.09 ng/ml) in 92 patients. The c-statistic of the receiver operating curves for myocardial infarction (myocardial infarction, cTroponinT at 12 h >0.09 ng/ml) as determined by the POC assay was cTroponin I=0.884, CK-MB=0.883, myoglobin=0.845 and beta-type natriuretic peptide (BNP)=0.755. The c-statistic for the same sample assessed by the hospital laboratory was cTroponin T=0.893: for CK-MB within 12 h of admission it was 0.918; the 12 h cTroponin T was 0.982 and within 24 h of admission NT pro-BNP was 0.789. POC BNP in patients admitted was 68 ng/l (median) vs. 24 ng/l (median) for those not admitted, (P<0.001). POC BNP for patients admitted with unstable angina (12 h cTroponin T <0.09 ng/ml) was 47 ng/l (median, P<0.001). At 6 months, 14 patients had died; five during admission, two within 30 days and seven up to 6 months. During admission two died from heart failure, two with respiratory tract infection and one from carcinoma. Of those not admitted one had died from asbestosis. CONCLUSION: Risk stratification by a specialist nurse utilizing a POC protocol is an appropriate means of assessing patients with chest pain.