Exploring hepatitis C virus testing and treatment engagement over time in Melbourne, Australia: a study protocol for a longitudinal cohort study (EC-Experience Cohort study).

INTRODUCTION: The advent of direct acting antiviral therapy for hepatitis C virus (HCV) means the elimination of HCV is possible but requires sustained effort to achieve. Between 2016 and 2019, 44% of those living with HCV were treated in Australia. However, treatment uptake has declined significantly. In Australia, people who inject drugs (PWID) are the population most at risk of HCV acquisition. Eliminating HCV in Australia will require nuanced understanding of the barriers to HCV treatment experienced by PWID and tailored interventions to address these barriers. The EC-Experience Cohort study aims to explore the barriers and enablers reported by PWID to engagement in HCV care. METHODS AND ANALYSIS: The EC-Experience Cohort study is a prospective cohort of PWID, established in Melbourne, Australia in 2018. Participants are assigned into three study groups: (1) those not currently engaged in HCV testing; (2) those diagnosed with HCV but not currently engaged in treatment and (3) those completed treatment. Participants complete a total of four interviews every 6 months across an 18-month study period. Predictors of experience of key outcome events along the HCV care cascade will be explored over time. ETHICS AND DISSEMINATION: Ethical approval for the EC-Experience Cohort study was obtained by the Alfred Hospital Ethics Committee in Melbourne, Australia (Project Number: HREC/16/Alfred/164). All eligible participants are assessed for capacity to consent and partake in a thorough informed consent process. Results from the EC-Experience Cohort study will be disseminated via national and international scientific and public health conferences and peer-reviewed journal publications. Data from the EC-Experience Cohort study will improve the current understanding of the barriers to HCV care for PWID and guide the tailoring of service provision for specific subgroups. Understanding the barriers and how to increase engagement in care of PWID is critical to achieve HCV elimination goals.

Complications related to tube thoracostomy in Southwest Finland hospital district between 2004 and 2014.

BACKGROUND AND AIMS: The purpose of this study was to describe the frequency and types of complications after tube thoracostomy among all patients treated with tube thoracostomy for both traumatic and non-traumatic indications. MATERIAL AND METHODS: Retrospective register-based study of patients treated with tube thoracostomy between the years 2004 and 2014 in a university hospital. RESULTS: In total, 1808 patients who had undergone tube thoracostomy were identified, complete data on tube thoracostomy treatment was available for 1169 patients. A total of 233 (19.9%) patients had 289 complications, 284 (98.3%) were positional resulting in tube malfunction. In 84 (7.2%) patients, malposition of the tube resulted in need for non-urgent operative treatment. There were 103 in-hospital deaths, but none due to tube thoracostomy complications. Empyema as a treatment indication was more frequent in patients with complications (15.9% vs 6.8%, p < 0.001) as was diabetes (21.9% vs 13.2%, p = 0.001). The likelihood of complications was lower with CH16 tubes (odds ratio 0.22, p < 0.001) and higher in diabetics (odds ratio 1.86, p = 0.001). CONCLUSION: Tube thoracostomy is a common procedure and complications occur in 19.9% of patients. Serious complications caused by the chest tube placement, however, are extremely rare. Complications were most common in patients treated for empyema and diabetics. Small CH16 tubes were associated with a lower incidence of complications.

Population-based study of anastomotic stricture rates after minimally invasive and open oesophagectomy for cancer.

Background: The population-based incidence of anastomotic stricture after minimally invasive oesophagectomy (MIO) and open oesophagectomy (OO) is not known. The aim of this study was to compare rates of anastomotic stricture requiring dilatation after the two approaches in an unselected cohort using nationwide data from Finland and Sweden. Methods: All patients who had MIO or OO for oesophageal cancer between 2007 and 2014 were identified from nationwide registries in Finland and Sweden. Outcomes were the overall rate of anastomotic stricture and need for single or repeated (3 or more) dilatations for stricture within the first year after surgery. Multivariable Cox regression provided hazard ratios (HRs) with 95 per cent confidence intervals, adjusted for age, sex, co-morbidity, histology, stage, year, country, hospital volume, length of hospital stay and readmissions. Results: Some 239 patients underwent MIO and 1430 had an open procedure. The incidence of strictures requiring one dilatation was 16·7 per cent, and that for strictures requiring three or more dilatations was 6·6 per cent. The HR for strictures requiring one dilatation was not increased after MIO compared with that after OO (HR 1·19, 95 per cent c.i. 0·66 to 2·12), but was threefold higher for repeated dilatations (HR 3·25, 1·43 to 7·36). Of 18 strictures following MIO, 14 (78 per cent) occurred during the first 2 years after initiating this approach. Conclusion: The need for endoscopic anastomotic dilatation after oesophagectomy was common, and the need for repeated dilatation was higher after MIO than following OO. The increased risk after MIO may reflect a learning curve.

Antecedentes: Se desconoce la incidencia poblacional de estenosis anastomóticas tras esofaguectomía mínimamente invasiva (minimally invasive oesophagectomy, MIO) y esofaguectomía abierta (open oesophagectomy, OO). El objetivo de este estudio fue comparar las tasas de estenosis anastomótica que precisan dilataciones después de los dos abordajes de esofaguectomía en una cohorte no seleccionada utilizando los datos poblacionales de Finlandia y Suecia. Métodos: Todos los pacientes sometidos a MIO (n = 239) o OO (n = 1430) por cáncer de esófago entre 2007 y 2014 fueron identificados a partir de los registros nacionales en Finlandia y Suecia. Las variables de resultados fueron la incidencia global de estenosis anastomótica y la necesidad de una sola dilatación o dilataciones repetidas (≥ 3) para la estenosis durante el primer año de la cirugía. La regresión multivariable de Cox proporcionó los cocientes de riesgos instantáneos (hazard ratios, HRs) con los i.c. del 95% ajustados por edad, sexo, comorbilidad, histología, estadio, año, país, volumen del hospital, duración de la estancia hospitalaria y reingresos. Resultados: La incidencia de estenosis que precisaron una dilatación fue del 16,7%, y del 6,6% para estenosis que precisaron ≥ 3 dilataciones. El HR de estenosis que requirieron una dilatación no se incrementó tras MIO en comparación con OO (HR 1,19, i.c. del 95% 0,66­2,12), pero fue 3 veces más para dilataciones repetidas (≥ 3) (HR 3,25, i.c. del 95% 1,43­7,36). De las 18 estenosis tras MIO, 14 (78%) ocurrieron durante los primeros dos años en los que se inició este abordaje. Conclusión: La necesidad de dilatación endoscópica de la anastomosis tras esofaguectomía fue frecuente y la necesidad de dilataciones repetidas fue más alta tras MIO en comparación con OO. El riesgo aumentado tras MIO puede deberse a la curva de aprendizaje.

Location-Specific Comparison Between a 3D In-Stent Restenosis Model and Micro-CT and Histology Data from Porcine In Vivo Experiments.

BACKGROUND: Coronary artery restenosis is an important side effect of percutaneous coronary intervention. Computational models can be used to better understand this process. We report on an approach for validation of an in silico 3D model of in-stent restenosis in porcine coronary arteries and illustrate this approach by comparing the modelling results to in vivo data for 14 and 28 days post-stenting. METHODS: This multiscale model includes single-scale models for stent deployment, blood flow and tissue growth in the stented vessel, including smooth muscle cell (SMC) proliferation and extracellular matrix (ECM) production. The validation procedure uses data from porcine in vivo experiments, by simulating stent deployment using stent geometry obtained from micro computed tomography (micro-CT) of the stented vessel and directly comparing the simulation results of neointimal growth to histological sections taken at the same locations. RESULTS: Metrics for comparison are per-strut neointimal thickness and per-section neointimal area. The neointimal area predicted by the model demonstrates a good agreement with the detailed experimental data. For 14 days post-stenting the relative neointimal area, averaged over all vessel sections considered, was 20 ± 3% in vivo and 22 ± 4% in silico. For 28 days, the area was 42 ± 3% in vivo and 41 ± 3% in silico. CONCLUSIONS: The approach presented here provides a very detailed, location-specific, validation methodology for in silico restenosis models. The model was able to closely match both histology datasets with a single set of parameters. Good agreement was obtained for both the overall amount of neointima produced and the local distribution. It should be noted that including vessel curvature and ECM production in the model was paramount to obtain a good agreement with the experimental data.

Climate-driven shifts in sediment chemistry enhance methane production in northern lakes.

Freshwater ecosystems are a major source of methane (CH4), contributing 0.65 Pg (in CO2 equivalents) yr-1 towards global carbon emissions and offsetting ~25% of the terrestrial carbon sink. Most freshwater CH4 emissions come from littoral sediments, where large quantities of plant material are decomposed. Climate change is predicted to shift plant community composition, and thus change the quality of inputs into detrital food webs, with the potential to affect CH4 production. Here we find that variation in phenol availability from decomposing organic matter underlies large differences in CH4 production in lake sediments. Production is at least 400-times higher from sediments composed of macrophyte litter compared to terrestrial sources because of inhibition of methanogenesis by phenol leachates. Our results now suggest that earth system models and carbon budgets should consider the effects of plant communities on sediment chemistry and ultimately CH4 emissions at a global scale.

The Danger Zone in the Anterior Neck: Anatomical Landmarks to Avoid Injury to Anterior Jugular Vein During Face-Lift and Neck-Lift.

Background: An estimated 125,711 face-lifts and 54,281 neck-lifts were performed in 2015. Regardless of the technique employed, facial and neck flap elevation carries with it anatomical risk of which any surgeon performing these procedures should be aware of. Statistics related to anterior jugular vein injury during these procedures have not been published. Objective: To define a "danger zone" that will contain both of the anterior jugular veins on the basis of anatomical landmarks to aid surgeons with planning their surgical approach during rhytidectomy in the anterior neck region. Methods: Ten fresh tissue heminecks were dissected. All specimens were dissected under loupe magnification in a 45° (face-lift) position in which a midline incision was used for exposure. Measurements from the anterior jugular vein to the hyoid, thyroid cartilage, and cricoid cartilage bilaterally were taken. The transverse distance between the anterior jugular veins at the level of the hyoid, thyroid cartilage, and cricoid cartilage was also measured. Results: The anterior jugular veins remain in an anatomical danger zone while they travel in the anterior neck. Regardless of anatomical variation of the vessels between bodies, they generally reside in this danger zone from their inferior emergence behind the sternocleidomastoid muscle until they branch in the suprahyoid region. Conclusions: Knowledge of the anatomy, course, and location of the anterior jugular veins through the anterior neck based on anatomical landmarks and distance ratios can facilitate a safer dissection during rhytidectomy procedures.

Comprehensive Review and Case Study on the Management of Buried Penis Syndrome and Related Panniculectomy.

Objective: This paper discusses the various surgical techniques and outcomes associated with management of buried penis syndrome. Methods: Presented is the case of a 49-year-old man with morbid obesity, leading to massive panniculus and buried penis. We review our technique for reconstruction of the buried penis and treatment of the overlying large panniculus. Literature search was conducted to review current techniques in correcting buried penis syndrome. Results: The patient underwent a successful panniculectomy with removal of all excess skin and tissue. Thoughtful planning and coordination between plastic surgery and urology were paramount to externalize the penis for an excellent functional and cosmetic result. Conclusions: Management of a buried, hidden penis is complex and difficult. Patients are often obese and have poor hygiene due to the inability to cleanse areas that are entrapped by excessive fat. Following removal of the overhanging panniculus, satisfactory reconstruction of a hidden penis is possible when proper care is taken to adhere the base of the penis to the pubis. Split-thickness skin grafts are often necessary but depend on the viability of the penile skin and whether it is restricting penile length. Complications with wound dehiscence and infection are not uncommon; however, patients generally recover well, are satisfied with results, and are reported to have fully regained urinary and sexual functions following surgical correction of the buried penis.

Convergence of marine megafauna movement patterns in coastal and open oceans.

The extent of increasing anthropogenic impacts on large marine vertebrates partly depends on the animals' movement patterns. Effective conservation requires identification of the key drivers of movement including intrinsic properties and extrinsic constraints associated with the dynamic nature of the environments the animals inhabit. However, the relative importance of intrinsic versus extrinsic factors remains elusive. We analyze a global dataset of ∼2.8 million locations from >2,600 tracked individuals across 50 marine vertebrates evolutionarily separated by millions of years and using different locomotion modes (fly, swim, walk/paddle). Strikingly, movement patterns show a remarkable convergence, being strongly conserved across species and independent of body length and mass, despite these traits ranging over 10 orders of magnitude among the species studied. This represents a fundamental difference between marine and terrestrial vertebrates not previously identified, likely linked to the reduced costs of locomotion in water. Movement patterns were primarily explained by the interaction between species-specific traits and the habitat(s) they move through, resulting in complex movement patterns when moving close to coasts compared with more predictable patterns when moving in open oceans. This distinct difference may be associated with greater complexity within coastal microhabitats, highlighting a critical role of preferred habitat in shaping marine vertebrate global movements. Efforts to develop understanding of the characteristics of vertebrate movement should consider the habitat(s) through which they move to identify how movement patterns will alter with forecasted severe ocean changes, such as reduced Arctic sea ice cover, sea level rise, and declining oxygen content.

Safe Plastic Surgery of the Breast II: Saving Nipple Sensation.

Background: Since its inception, reduction mammoplasty has matured considerably. Primary evolution in clinical research and practice initially focused on developing techniques to preserve tissue viability; breast parenchyma, skin, and nipple tissue that has expanded to include sensation and erectile function play a large role in the physical intimacy of women. Studies regarding primary innervation to the nipple are few and often contradictory. Our past anatomical study demonstrated that primary innervation to the nipple to come from the lateral branch of the fourth intercostal nerve. We propose an unsafe zone in which dissection during reduction mammoplasty ought to be avoided to preserve nipple sensation. Objective: To identify the trajectory of innervation to the nipple and translate these findings to the clinical setting so as to preserve nipple sensation. Methods: Eighty-six patients underwent reduction mammoplasty using the Wise pattern inferior pedicle (n = 72), vertical Hall-Findlay superomedial pedicle (n = 11), and Drape pattern inferior pedicle (n = 3). Aggressive dissection in the most superficial and deep tissue in the inferolateral quadrant of the breast was avoided. Results: All 86 patients reported having the same normal sensation to the breast at postoperative evaluation. Conclusions: The fourth intercostal nerve provides the major innervation to the nipple-areola complex. Avoiding dissection in inferolateral quadrant "unsafe zone" of the breast during reduction mammoplasty can reliably spare nipple sensation and maximize patient outcomes.

Preservation of the Sterile Matrix, Hyponychium, and Fingertip Pad in Fingertip Reconstruction With Composite Fingertip and Nail Bed Graft and Volar V-Y Advancement Flap.

Background: The goals of fingertip reconstruction are to achieve adequate soft-tissue coverage and a functional nail plate and to maintain sensation, proprioception, and cosmesis. Objective: We present a composite tissue graft and volar V-Y advancement flap for reconstruction of a traumatic amputation of a fingertip, which provided optimal preservation of the hyponychium and the volar pad for prevention of a hook nail. Historically, composite fingertip grafts have not been recommended for adults with large defects. Methods: The amputated nail bed, hyponychium, and a 10 × 20-mm segment of the fingertip were utilized as a composite graft for reconstruction of the nail bed in an adult. The addition of a volar V-Y advancement flap to reconstruct the fingertip was necessary for complete soft-tissue reconstruction. Results: The reconstruction resulted in nail plate adhesion without significant nail deformity and a functional and sensate fingertip. Conclusion: Components of amputated fingertips including the sterile matrix, hyponychium, and part of the fingertip can be utilized in a composite graft to yield satisfactory functional and cosmetic results in adults.

Surgical management of complicated and medically refractory inflammatory bowel disease during pregnancy.

AIM: The medical management of inflammatory bowel disease (IBD) in pregnancy and the puerperium is well defined. Data on surgical management of complicated IBD in this setting are lacking. This study aimed to determine the optimal surgical strategy for medically refractory IBD during pregnancy and the puerperium. METHOD: Three databases were systematically reviewed to identify all published series or case reports of women undergoing surgery for Crohn's disease (CD) or ulcerative colitis (UC) while pregnant or during the puerperium. RESULTS: Thirty-two papers were identified, including 86 patients. Nearly one-fifth (18%) of cases were de novo presentations and intervention was required at all stages of pregnancy. UC refractory to medical treatment and perforated small bowel CD were the commonest indications for surgery. Operations used included colectomy, colectomy with mucous fistula and Turnbull-blowhole colostomy for complicated UC and open or laparoscopic small bowel resection with stoma formation for CD. Surgical intervention during the third trimester universally resulted in the onset of labour. Endoscopic and radiological interventions were rarely employed. In studies after 1980 there was no maternal or foetal mortality but there was an almost 50% preterm delivery rate. CONCLUSION: Surgical management of complicated IBD during pregnancy and the puerperium needs to be tailored to disease severity, the type of complications and foetal status. It should involve gastroenterologists, colorectal surgeons, obstetricians and neonatal specialists in a multidisciplinary manner within a single unit.

A fast feedback controlled magnetic drive for the ASDEX Upgrade fast-ion loss detectors.

A magnetically driven fast-ion loss detector system for the ASDEX Upgrade tokamak has been designed and will be presented here. The device is feedback controlled to adapt the detector head position to the heat load and physics requirements. Dynamic simulations have been performed taking into account effects such as friction, coil self-induction, and eddy currents. A real time positioning control algorithm to maximize the detector operational window has been developed. This algorithm considers dynamical behavior and mechanical resistance as well as measured and predicted thermal loads. The mechanical design and real time predictive algorithm presented here may be used for other reciprocating systems.

Conceptual design of the ITER fast-ion loss detector.

A conceptual design of a reciprocating fast-ion loss detector for ITER has been developed and is presented here. Fast-ion orbit simulations in a 3D magnetic equilibrium and up-to-date first wall have been carried out to revise the measurement requirements for the lost alpha monitor in ITER. In agreement with recent observations, the simulations presented here suggest that a pitch-angle resolution of ∼5° might be necessary to identify the loss mechanisms. Synthetic measurements including realistic lost alpha-particle as well as neutron and gamma fluxes predict scintillator signal-to-noise levels measurable with standard light acquisition systems with the detector aperture at ∼11 cm outside of the diagnostic first wall. At measurement position, heat load on detector head is comparable to that in present devices.

Prenatal exposure to cannabis and maternal and child health outcomes: a systematic review and meta-analysis.

OBJECTIVE: To assess the effects of use of cannabis during pregnancy on maternal and fetal outcomes. DATA SOURCES: 7 electronic databases were searched from inception to 1 April 2014. Studies that investigated the effects of use of cannabis during pregnancy on maternal and fetal outcomes were included. STUDY SELECTION: Case-control studies, cross-sectional and cohort studies were included. DATA EXTRACTION AND SYNTHESIS: Data synthesis was undertaken via systematic review and meta-analysis of available evidence. All review stages were conducted independently by 2 reviewers. MAIN OUTCOMES AND MEASURES: Maternal, fetal and neonatal outcomes up to 6 weeks postpartum after exposure to cannabis. Meta-analyses were conducted on variables that had 3 or more studies that measured an outcome in a consistent manner. Outcomes for which meta-analyses were conducted included: anaemia, birth weight, low birth weight, neonatal length, placement in the neonatal intensive care unit, gestational age, head circumference and preterm birth. RESULTS: 24 studies were included in the review. Results of the meta-analysis demonstrated that women who used cannabis during pregnancy had an increase in the odds of anaemia (pooled OR (pOR)=1.36: 95% CI 1.10 to 1.69) compared with women who did not use cannabis during pregnancy. Infants exposed to cannabis in utero had a decrease in birth weight (low birth weight pOR=1.77: 95% CI 1.04 to 3.01; pooled mean difference (pMD) for birth weight=109.42 g: 38.72 to 180.12) compared with infants whose mothers did not use cannabis during pregnancy. Infants exposed to cannabis in utero were also more likely to need placement in the neonatal intensive care unit compared with infants whose mothers did not use cannabis during pregnancy (pOR=2.02: 1.27 to 3.21). CONCLUSIONS AND RELEVANCE: Use of cannabis during pregnancy may increase adverse outcomes for women and their neonates. As use of cannabis gains social acceptance, pregnant women and their medical providers could benefit from health education on potential adverse effects of use of cannabis during pregnancy.

Penetrating trauma; experience from Southwest Finland between 1997 and 2011, a retrospective descriptive study.

BACKGROUND: (1) There is lack of epidemiological data on penetrating trauma in European countries. (2) In Finland most acts of violence are performed under the influence of alcohol. The aim of this study was to determine the incidence and types of injury, treatment and survival of patients with penetrating injuries to the thorax and abdomen. METHODS: This study includes two trauma centers with combined catchment area of approximately 720,000 patients. Patients were identified from patient records using ICD-10 codes. RESULTS: Patients were predominantly young males and they were stab victims. The average yearly incidence for penetrating trauma was 0.9/100,000 inhabitants. Thirteen percent of patients admitted gave a negative toxicology screen or breathalyzer test for alcohol. Twenty two percent of wounds were self-inflicted. Fifty five percent of patients received a chest tube and 30 patients (23%) underwent emergent thoracotomy after sustaining critical injury to the thorax. A considerable proportion (12%) of the study group also later died due to alcohol and/or violence, highlighting the psychosocial co-morbidity among penetrating trauma victims. DISCUSSION: Chest tube insertion is a skill to be mastered by any on-call physician. This simple procedure can be potentially life-saving. There is also a call for assessment of psychosocial well-being among penetrating trauma victims.

Wetlands as long-term sources of metals to receiving waters in mining-impacted landscapes.

Wetlands are prevalent in the Sudbury, Ontario region and often operate at the interface between terrestrial and aquatic ecosystems, modifying water chemistry and potentially affecting the recovery of impacted lakes. The deposition of metals and sulphur in Sudbury in 2010-2012 was far below that reported in the 1970's, but still higher than background values. Wetlands in the area have accumulated large quantities of metals, and high concentrations of these metals in streams occurred primarily in response to SO4-related acidification events or associated with high dissolved organic carbon production in early summer. Concentrations of most metals in streams exceeded provincial guidelines and fluxes of some metals from catchments exceeded deposition inputs to lakes by as much as 12 times. The release of metals long after emissions reductions have been achieved must be considered in ecosystem recovery studies, particularly as dry conditions may become more prevalent in boreal regions affected by mining.

Impact of anti-centromere antibodies on pulmonary function test results in patients with systemic sclerosis without established or suspected pulmonary disease.

Pulmonary arterial hypertension (PAH) occurs in approximately 15% of patients with systemic sclerosis (SSc). Annual screening with pulmonary function tests (PFT) is recommended to help identify those patients at risk of PAH. We have noted that patients with SSc who carry anti-centromere autoantibodies (ACA) often have PFT abnormalities, in the absence of clinical evidence of PAH. To evaluate this further, we undertook a retrospective case-control study evaluating PFT results in patients with SSc in whom pulmonary complications have neither been diagnosed nor suspected. Patients were divided according to ACA carriage and groups compared for PFT results. The median forced vital capacity (FVC) was higher in ACA-positive patients (106 vs. 93%, p=0.004). The gas transfer factor (TLco) was significantly lower in the ACA group (62.5 vs. 71%, p=0.013). The resulting FVC:TLco was significantly higher for ACA-positive vs. ACA-negative patients with SSc (1.70 vs. 1.29, p<0.001). Our findings suggest patients carrying ACA, without established or suspected pulmonary complications, have PFT abnormalities consistent with indolent increased pulmonary vascular resistance despite the majority of such patients not subsequently developing PAH. The long-term sequelae of PFT abnormalities in those patients with ACA who do not subsequently develop PAH are unknown.

Effects of neuregulin-1 genetic variation and depression symptom severity on longitudinal patterns of psychotic symptoms in primary care attendees.

A better understanding of the factors associated with psychotic symptoms could aid early identification and treatment of psychotic disorders. Previous studies have typically utilized cross-sectional study designs and have focused on individuals with psychotic disorders. Thus, examination of promising correlates of psychotic symptoms using longitudinal designs among more broadly defined populations is warranted. Two such correlates are neuregulin-1 (NRG1) genotypic variation and depression symptom severity. Both NRG1 and depression symptom severity have cross-sectional evidence for an association with psychosis but their affect on longitudinal patterns of psychotic symptoms and their potential interaction effects are less clear. Using repeated measures analysis of variance and covariance we modeled the main and interaction effects of NRG1 genotypic variation and depressive symptom severity on longitudinal psychotic symptom patterns in 301 primary care attendees assessed annually over 4 years. One-fifth (19.9%) of the participants reported one or more psychotic symptoms over the 4-year assessment period. We observed a curvilinear (i.e., cubic) association between depression symptom severity at baseline and longitudinal patterns of psychotic symptoms but did not observe a main effect for NRG1 genotypic variation on psychotic symptom patterns. However, NRG1 rs6994992 genotype moderated the curvilinear association between depression symptom severity and psychotic symptom patterns. Specifically, depression symptom severity had less of an effect on longitudinal psychotic symptoms among carriers of the rs6994992 TT genotype compared to CC and CT carriers. Our findings suggest a curvilinear association between depression symptom severity and longitudinal patterns of psychotic symptoms that is moderated by NRG1 genotype.

The prognostic significance of declining health-related quality of life scores at 6 months after coronary artery bypass surgery.

PURPOSE: Health-related quality of life (HRQoL) measured on the EQ-5D (European quality of life-5 dimensions)-questionnaire has been shown to improve after coronary artery bypass grafting (CABG), this study investigated whether changes in HRQoL predict later morbidity. METHODS: Included were 404 consecutive patients undergoing isolated CABG between 2008 and 2010 who filled the EQ-5D-questionnaire at baseline and 6 months postoperatively. Records were reviewed for later major adverse cardiac and cerebrovascular events (MACCE) after 6 months. Follow-up was 38.6 months (10-58). RESULTS: Patients who suffered later MACCE more often had suffered an in-hospital postoperative stroke, had a longer in-hospital stay, had lower HRQoL scores at 6 months and deteriorated on several EQ-5D-subscales. Logistic regression showed 6 months visual analogue scale scores and declining function scores to be independent predictors of later MACCE. CONCLUSION: Deteriorating function and HRQoL-scores at 6 months as compared to baseline postoperatively predict later adverse cardiovascular events after CABG.

ST elevation in ECG lead aVR signals severe acute left main coronary artery disease.

Patients with suspected acute coronary syndrome are commonly assessed by acute physicians on arrival in hospital. Although most will recognise the typical ECG features of ST elevation myocardial infarction, the significance of ST elevation in lead aVR may not always be appreciated. This case series describes 6 cases in which this ECG abnormality was the predominant feature in patients whose subsequent angiogram revealed severe acute left main coronary artery disease. The importance of early referral of such patients to a centre in which percutaneous coronary intervention can be performed, is discussed.