82-rubidium positron emission tomography determined myocardial flow reserve and outcomes following cardiac revascularisation - A multicentre registry study.

BACKGROUND: Finding patients with chronic coronary syndromes (CCS) whom revascularization could benefit, is complicated. Myocardial flow reserve (MFR), a measurement of myocardial perfusion, has proven prognostic value on survival and risk of major adverse cardiac events (MACE). We investigated if MFR identifies who may benefit from revascularization. METHODS: Among 7462 patients from Danish hospitals examined with 82Rb PET between January 2018 and August 2020, patients with ≥5% reversible perfusion defects were followed for MACE and all-cause mortality. Associations between revascularisation (within 90 days) and outcomes according to MFR (< and ≥ 2) was assessed by Cox regression adjusted by inverse probability weighting for demographics, cardiovascular risk factors, comorbidities, and 82Rb PET variables. RESULTS: Of 1806 patients with ≥5% reversible perfusion defect, 893 (49%) had MFR < 2 and 491 underwent revascularisation (36.6% in MFR < 2 versus 17.9% MFR ≥ 2, p < 0.001). During a median follow-up of 37.0 [31.0-45.8 IQR] months, 251 experienced a MACE and 173 died. Revascularisation was associated with lower adjusted risk of all-cause mortality (hazard ratio [HR], 0.51 [95% CI, 0.30-0.88], p = 0.015) and MACE (HR, 0.54 [0.33-0.87], p = 0.012) in patients with MFR < 2 but not MFR ≥ 2 for all-cause mortality (HR 1.33 [0.52-3.40], p = 0.542) and MACE (HR 1.50 [0.79-2.84], p = 0.211). MFR significantly modified the association between revascularisation and MACE, but not all-cause mortality (interaction p-value 0.021 and 0.094, respectively). CONCLUSIONS: Revascularization was associated with improved prognosis among patients with impaired MFR. No association was seen in patients with normal MFR. In patients with regional ischemia, MFR may identify patients with a prognostic benefit from revascularization.

Multislice image simulations of sheared needle-like precipitates in an Al-Mg-Si alloy.

The image contrast of sheared needle-like ß ' ' precipitates in the Al-Mg-Si alloy system is investigated with respect to shear-plane positions, the number of shear-planes, and the active matrix slip systems through multislice transmission electron microscopy image simulations and the frozen phonon approximation. It is found that annular dark field scanning transmission electron microscopy (ADF STEM) images are mostly affected by shear-planes within a distance ∼6-18 unit cells from the specimen surface, whereas about 5-10 equidistant shear-planes are required to produce clear differences in HRTEM images. The contrast of the images is affected by the Burgers vector of the slip, but not the slip plane. The simulation results are discussed and compared to experimental data. LAY DESCRIPTION: Pure aluminium is too soft to be viable in most structural applications, but this may be remedied by alloying the metal with various elements. Adding small amounts of silicon and magnesium to pure aluminium allows small particles to precipitate during heat treatment. These precipitates resist plastic deformation and can increase the strength of the alloy and make it viable for a range of industrial applications, such as automotive door panels and load-bearing profiles. However, if subjected to large loads, the precipitates are sheared and the strength of the alloy changes dynamically. Designing safe products such as cars or buildings require physically based predictions on this dynamical change. Developing models that can provide such predictions depend in turn on experimental observations of the shearing process. Because the precipitates are nm long, experimental observations must be done by transmission electron microscopy. However, understanding these results sometimes require computer simulations of atomic models. In this work, we have performed image simulations of various models of sheared precipitates and compared the results with earlier experiments. The simulations indicate that certain conditions must be met for the sheared precipitates to appear different from unsheared precipitates. These conditions are most likely to be met if precipitates are sheared several times in a relatively homogeneous manner. This is important for two reasons. First, a localized shearing process would lead to large dynamical changes in precipitate strength during deformation, and in turn drastically reduce the work hardening of the alloy. Secondly, a localized shearing process would have promoted earlier fracture and failure of the alloy during deformation. Finally, our results also show how different slip directions influences the images of precipitates. In the future, these influences can be used to further understand the shearing process of these precipitates. Hence, our results can be used to improve model predictions of strength, work hardening, and fracture. In turn, this may improve alloy design and reduce the use of prototype testing in, e.g. the automotive industry.

Influence of Cardiac CT based disease severity and clinical symptoms on the diagnostic performance of myocardial perfusion.

We aimed to identify factors influencing the sensitivity of perfusion imaging after an initial positive coronary computed tomography angiography (CCTA) using invasive coronary angiography (ICA) with conditional fractional flow reserve (FFR) as reference. Secondly we aimed to identify factors associated with revascularisation and to evaluate treatment outcome after ICA. We analysed 292 consecutive patients with suspected significant coronary artery disease (CAD) at CCTA, who underwent perfusion imaging with either cardiac magnetic resonance (CMR) or myocardial perfusion scintigraphy (MPS) followed by ICA with conditional FFR. Stratified analysis and uni- and multiple logistic regression analyses were performed to identify predictors of diagnostic agreement between perfusion scans and ICA and predictors of revascularisation. Myocardial ischemia evaluated with perfusion scans was present in 65/292 (22%) while 117/292 (40%) had obstructive CAD evaluated by ICA. Revascularisation rate was 90/292 (31%). The overall sensitivity for perfusion scans was 39% (30-48), specificity 89% (83-93), PPV 69% (57-80) and NPV 68% (62-74). Stratified analysis showed higher sensitivities in patients with multi-vessel disease at CCTA 49% (37-60) and typical chest pain 50% (37-60). Predictors of revascularisation were multi-vessel disease by CCTA (OR 3.51 [1.91-6.48]) and a positive perfusion scan (OR 4.69 [2.49-8.83]). The sensitivity for perfusion scans after CCTA was highest in patients with typical angina and multiple lesions at CCTA and predicted diagnostic agreement between perfusion scans and ICA. Abnormal perfusion and multi vessel disease at CCTA predicted revascularisation.

Diagnosing coronary artery disease after a positive coronary computed tomography angiography: the Dan-NICAD open label, parallel, head to head, randomized controlled diagnostic accuracy trial of cardiovascular magnetic resonance and myocardial perfusion scintigraphy.

Aims: Perfusion scans after coronary computed tomography angiography (CCTA) in patients with suspected coronary artery disease (CAD) may reduce unnecessary invasive coronary angiographies (ICAs). However, the diagnostic accuracy of perfusion scans after primary CCTA is unknown. The aim of this study was to determine the diagnostic accuracy of cardiac magnetic resonance (CMR) and myocardial perfusion scintigraphy (MPS) against ICA with fractional flow reserve (FFR) in patients suspected of CAD by CCTA. Methods and results: Included were consecutive patients (1675) referred to CCTA with symptoms of CAD and low/intermediate risk profile. Patients with suspected CAD based on CCTA were randomized 1:1 to CMR or MPS followed by ICA with FFR. Obstructive CAD was defined as FFR ≤ 0.80 or > 90% diameter stenosis by visual assessment. After initial CCTA, 392 patients (23%) were randomized; 197 to CMR and 195 to MPS. Perfusion scans and ICA were completed in 292 patients (CMR 148, MPS 144). Based on the ICA, 117/292 (40%) patients were classified with CAD. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for CMR were 41%, 95% CI [28-54], 84% [75-91], 62% [45-78], and 68% [58-76], respectively. For the MPS group 36% [24-50], 94% [87-98], 81% [61-93], and 68% [59-76], respectively. Conclusion: Patients with low/intermediate CAD risk and a positive CCTA scan represent a challenge to perfusion techniques indicated by the low sensitivity of both CMR and MPS with FFR as a reference. The mechanisms underlying this discrepancy need further investigation.

Ketoprofen pharmacokinetics of R- and S-isomers in juvenile loggerhead sea turtles (Caretta caretta) after single intravenous and single- and multidose intramuscular administration.

Ketoprofen is a nonsteroidal anti-inflammatory and analgesic agent that nonselectively inhibits cyclooxygenase, with both COX-1 and COX-2 inhibition. Recent studies on COX receptor expression in reptiles suggest that nonselective COX inhibitors may be more appropriate than more selective inhibitors in some reptiles, but few pharmacokinetic studies are available. The goal of this study was to determine single- and multidose (three consecutive days) pharmacokinetics of racemic ketoprofen administered intravenously and intramuscularly at 2 mg/kg in healthy juvenile loggerhead turtles (Caretta caretta). The S-isomer is the predominant isomer in loggerhead sea turtles, similar to most mammals, despite administration of a 50:50 racemic mixture. Multidose ketoprofen administration demonstrated no bioaccumulation; therefore, once-daily dosing will not require dose adjustment over time. S-isomer pharmacokinetic parameters determined in this study were Cmax of 10.1 µg/ml by IM injection, C0 of 13.4 µg/ml by IV injection, AUC of 44.7 or 69.4 µg*hr/ml by IM or IV injection, respectively, and T½ of 2.8 or 3.6 hr by IM or IV injection, respectively. Total ketoprofen plasma concentrations were maintained for at least 12 hr above concentrations determined to be effective for rats and humans. A dose of 2 mg/kg either IM or IV every 24 hr is likely appropriate for loggerhead turtles.

The sex-shift in single disease and multimorbid asthma and rhinitis during puberty - a study by MeDALL.

BACKGROUND: Cross-sectional studies suggested that allergy prevalence in childhood is higher in boys compared to girls, but it remains unclear whether this inequality changes after puberty. We examined the sex-specific prevalence of asthma and rhinitis as single and as multimorbid diseases before and after puberty onset in longitudinal cohort data. METHODS: In six European population-based birth cohorts of MeDALL, we assessed the outcomes: current rhinitis, current asthma, current allergic multimorbidity (ie, concurrent asthma and rhinitis), puberty status and allergic sensitization by specific serum antibodies (immunoglobulin E) against aero-allergens. With generalized estimating equations, we analysed the effects of sex, age, puberty (yes/no) and possible confounders on the prevalence of asthma and rhinitis, and allergic multimorbidity in each cohort separately and performed individual participant data meta-analysis. FINDINGS: We included data from 19 013 participants from birth to age 14-20 years. Current rhinitis only affected girls less often than boys before and after puberty onset: adjusted odds ratio for females vs males 0.79 (95%-confidence interval 0.73-0.86) and 0.86 (0.79-0.94), respectively (sex-puberty interaction P = .089). Similarly, for current asthma only, females were less often affected than boys both before and after puberty onset: 0.71, 0.63-0.81 and 0.81, 0.64-1.02, respectively (sex-puberty interaction P = .327). The prevalence of allergic multimorbidity showed the strongest sex effect before puberty onset (female-male-OR 0.55, 0.46-0.64) and a considerable shift towards a sex-balanced prevalence after puberty onset (0.89, 0.74-1.04); sex-puberty interaction: P < .001. INTERPRETATION: The male predominance in prevalence before puberty and the "sex-shift" towards females after puberty onset were strongest in multimorbid patients who had asthma and rhinitis concurrently.

Small composite field correction factors for the CyberKnife radiosurgery system: clinical and PCSR plans.

A formalism has been proposed for small and non-standard photon fields in which [Formula: see text] correction factors are used to correct dosimeter response in small fields (indiviual or composite) relative to that in a larger machine-specific reference (MSR) field. For clinical plans consisting of several fields, a plan-class specific reference (PCSR) plan can also be defined, serving as an intermediate calibration field between the MSR and clinical plans within a certain plan-class. In this work, the formalism was applied in the calculation of [Formula: see text] for 21 clinical plans delivered by the [Formula: see text] radiosurgery system, each plan employing one or two of the smallest diameter collimators: 5 mm, 7.5 mm, and 10 mm. Three detectors were considered: the Exradin A16 and A26 micro chambers, and the W1 plastic scintillator. The clinical plans were grouped into 7 plan-classes according to commonly shared characteristics. The suitability of using a PCSR plan to represent the detector response of each plan within the plan-class was investigated. Total and intermediate correction factors were calculated using the [Formula: see text] Monte Carlo user code. The corrections for the micro chambers were large, primarily due to the presence of the low-density air cavity and the volume averaging effect. The correction for the scintillator was found to be close to unity for most plans, indicating that this detector may be used to measure small clinical plan correction factors in any plan except for those using the 5 mm collimator. The PCSR plan was shown to be applicable to plan-classes comprising isocentric plans only, with plan-classes divided according to collimator size. For non-isocentric plans, the variation of [Formula: see text] as a function of the point of measurement within a single plan, as well as the high inter-plan-class variability of the correction factor, precludes the use of a PCSR plan.

Exuberant granulation tissue response associated with Neobenedenia sp. (Monogenea: Capsalidae) infestation in two cobia, Rachycentron canadum (Linnaeus).

Monogenean parasite infestations are common in captive marine teleosts, and are generally found on the skin and gills. This report describes an unusual pathological presentation of exuberant granulation tissue of the gills, suspected to be related to Neobenedenia infestation in two cobia housed together at a North Carolina aquarium.

Counter-regulatory hormone responses to hypoglycaemia in people with type 1 diabetes after 4 weeks of treatment with liraglutide adjunct to insulin: a randomized, placebo-controlled, double-blind, crossover trial.

AIMS: To investigate the effect of glucagon-like peptide 1 receptor agonist liraglutide on the counter-regulatory hormone response to hypoglycaemia in type 1 diabetes. METHODS: We conducted a randomized, double-blind, placebo-controlled, single-centre trial, in which a total of 45 adults with type 1 diabetes [mean ± standard deviation age 34.5 ± 11.2 years, BMI 23.9 ± 2.4 kg/m(2) , glycated haemoglobin (HbA1c) 7.6 ± 0.8%, diabetes duration 16.6 ± 9.4 years] underwent a hypoglycaemic clamp after 4 weeks' crossover treatment with once-daily liraglutide/placebo added to insulin in one of three liraglutide dose groups: 0.6 mg (n = 15); 1.2 mg (n = 14); and 1.8 mg (n = 16). The main outcome measure was glucagon concentration at nadir plasma glucose (2.5 mmol/l). Clinical outcomes were also evaluated. Five participants were withdrawn from the trial; three because of adverse events. All participants were included in the analysis. RESULTS: Glucagon concentration at nadir plasma glucose was modest, trending towards lower concentrations at increasing liraglutide dose versus placebo: 34.7 versus 38.1 pg/ml, p = 0.555 (0.6 mg); 28.8 versus 37.2 pg/ml, p = 0.126 (1.2 mg); and 28.4 versus 37.5 pg/ml, p = 0.092 (1.8 mg). There was no difference, however, between liraglutide and placebo in incremental change in glucagon during hypoglycaemia. Other counter-regulatory hormone levels increased during hypoglycaemia with no systematic differences between groups. Glucose infusion rates were significantly lower with liraglutide versus placebo during the clamp. After 4 weeks' treatment, HbA1c remained unchanged in the liraglutide and placebo groups. Greater reductions in insulin dose and body weight were seen with liraglutide versus placebo. CONCLUSIONS: Liraglutide did not compromise hypoglycaemic responses in type 1 diabetes after 4 weeks' treatment.

Solitary Large Intestinal Diverticulitis in Leatherback Turtles (Dermochelys coriacea).

Leatherback sea turtles are globally distributed and endangered throughout their range. There are limited data available on disease in this species. Initial observations of solitary large intestinal diverticulitis in multiple leatherbacks led to a multi-institutional review of cases. Of 31 subadult and adult turtles for which complete records were available, all had a single exudate-filled diverticulum, as large as 9.0 cm in diameter, arising from the large intestine immediately distal to the ileocecal junction. All lesions were chronic and characterized by ongoing inflammation, numerous intralesional bacteria, marked attenuation of the muscularis, ulceration, and secondary mucosal changes. In three cases, Morganella morganii was isolated from lesions. Diverticulitis was unrelated to the cause of death in all cases, although risk of perforation and other complications are possible.

Preoperative blood glucose concentrations and postoperative outcomes after elective non-cardiac surgery: an observational study.

BACKGROUND: The association between preoperative blood glucose (BG) concentration and outcomes after non-cardiac surgery and the impact of the diabetes diagnosis status remain unclear. We tested two hypotheses: that preoperative BG is related to surgical outcomes; and that this relationship depends on the diabetes diagnosis status of the patient. METHODS: We retrospectively analysed data on 61 536 consecutive elective non-cardiac surgery patients treated at our tertiary care facility. Logistic regression models were used to test the hypotheses before and after adjustment for baseline patient characteristics. Our primary outcome was a composite of in-hospital serious complications and mortality. A second primary outcome was 1 yr mortality. RESULTS: The crude incidence of the composite in-hospital outcome was significantly related to preoperative BG (P<0.001), but not after covariable adjustment (P=0.40). This relationship did not significantly differ between patients with and without diagnosed diabetes (P=0.09). One year mortality was significantly related to preoperative BG, both univariably (P<0.001) and after covariable-adjustment (P<0.001). Patients with diagnosed diabetes and preoperative euglycaemia generally had worse 1 yr mortality than those without diabetes at the same BG {e.g. odds ratio (OR) [95% confidence interval (CI)] of 1.27 (1.06, 1.53) at 6 mmol litre(-1) (108 mg dl(-1)), P=0.003}. Conversely, hyperglycaemic patients with diagnosed diabetes displayed a significantly lower 1 yr mortality than hyperglycaemic patients without diabetes [OR (95% CI) of 0.58 (0.44, 0.77) at 12 mmol litre(-1) (216 mg dl(-1)), P<0.001]. CONCLUSIONS: For elective non-cardiac surgery, preoperative hyperglycaemia should be given greater consideration in patients without diabetes than in those with diagnosed diabetes.

Validation of the exercise addiction inventory in a Danish sport context.

Exercise addiction is characterized by excessive exercise behavior with potential negative consequences. The symptoms consist of salience, mood modification, tolerance, withdrawal symptoms, conflicts, and relapse. The purpose of this study was to test the psychometric properties of the exercise addiction inventory (EAI) and to estimate the prevalence of exercise addiction in a Danish normal weight sport population. A sample of 780 habitual fitness and football exercisers were contacted and 590 completed the EAI and an in-house questionnaire containing questions about variables related to exercise addiction: (a) exercise frequency; (b) continuance despite injuries; and (c) personal perception of addiction. The results demonstrated an overall prevalence of exercise addiction of 5.8%. There was no significant difference between fitness and football prevalences. The internal reliability of EAI was acceptable with a Cronbach's α of 0.66. The criterion validity was tested toward the three variables related to exercise addiction. The dependent group had significantly higher scores on the three variables than the non-dependent group. Exercise addiction seems to exist in both fitness and football. The EAI is a useful screening tool and might be applicable in future screening and prevention of exercise addiction. However, further investigation about the population is needed to understand the phenomenon and to identify the risk group.

In vitro and mouse in vivo characterization of the potent free fatty acid 1 receptor agonist TUG-469.

Activation of the G protein-coupled free fatty acid receptor 1 (FFA1; formerly known as GPR40) leads to an enhancement of glucose-stimulated insulin secretion from pancreatic ß-cells. TUG-469 has previously been reported as a potent FFA1 agonist. This study was performed to confirm the higher in vitro potency of TUG-469 compared to the reference FFA1 agonist GW9508 and to prove in vivo activity in a pre-diabetic mouse model. The in vitro pharmacology of TUG-469 was studied using Ca(2+)-, cAMP-, and impedance-based assays at recombinant FFA1 and free fatty acid receptor 4, formerly known as GPR120 (FFA4) expressing 1321N1 cells and the rat insulinoma cell line INS-1. Furthermore, we investigated the systemic effect of TUG-469 on glucose tolerance in pre-diabetic New Zealand obese (NZO) mice performing a glucose tolerance test after intraperitoneal administration of 5 mg/kg TUG-469. In comparison to GW9508, TUG-469 showed a 1.7- to 3.0-times higher potency in vitro at 1321N1 cells recombinantly expressing FFA1. Both compounds increased insulin secretion from rat insulinoma INS-1 cells. TUG-469 is > 200-fold selective for FFA1 over FFA4. Finally, a single dose of 5 mg/kg TUG-469 significantly improved glucose tolerance in pre-diabetic NZO mice. TUG-469 turned out as a promising candidate for further drug development of FFA1 agonists for treatment of type 2 diabetes mellitus.

Risk for attempted suicide in children and youths after contact with somatic hospitals: a Danish register based nested case-control study.

BACKGROUND: A range of studies have found an association between some somatic diseases and increased risk of suicide and attempted suicide. These studies are mostly analyses of adult populations and illnesses related to adulthood. OBJECTIVES: To study the risk of attempted suicide in children and youths with a somatic diagnosis, and to assess a possible association from a somatic perspective. METHODS: From a cohort of 403 431 individuals (born 1983-89), 3465 children and youths who had attempted suicide were identified. Each case was matched with 20 population controls. 72 765 children and youths constituted the case-control population. All data were obtained from national population registers and analysed in a nested case-control design. RESULTS: Contact of children and youths with a somatic hospital is correlated with increased risk of attempted suicide; the risk peaks in the time immediately after contact. Risk factors were treatment for injury caused by violence, epilepsy, asthma and malformation for males; and spontaneous and medical abortions, treatment for injury caused by violence, epilepsy, asthma, insulin dependent diabetes mellitus and malformation for females. Not all the mentioned diagnoses were significant in the adjusted model. CONCLUSIONS: Based on the results of the study a strategy to minimise the risk of attempted suicide among children and youths must be implemented. The strategy should mainly focus on children at high risk-that is, children from families with low socioeconomic status, and children with a psychiatric history, a history of previous suicide attempts and with an unstable somatic disease subsequently causing many admissions.

Youth suicide attempts and the dose-response relationship to parental risk factors: a population-based study.

BACKGROUND: There is a lack of specific knowledge about the dose-response effect of multiple parental risk factors for suicide attempts among children and adolescents. The aim of this study was to determine the dose-response effect of multiple parental risk factors on an offspring's risk for suicide attempt. METHOD: We designed a population-based two-generation nested case-control study and used Danish register data. A population of 403 431 individuals born between 1983 and 1989 was sampled. Among these, 3465 (0.8%) were registered as having had a suicide attempt. Twenty controls were matched to each case and a link to the offspring's biological parents was established. RESULTS: There was a dose-response relationship between the number of exposures and the risk of suicide attempts, with the increased risk seeming to be a multiplicative effect. Parental suicide, suicide attempt, psychiatric illness and low level of income were all significant independent risk factors for offspring's suicide attempts. CONCLUSIONS: Knowledge of the effect of multiple risk factors on the likelihood of suicide attempts in children and adolescents is important for risk assessment. Dose-response effects of multiple parental risk factors are multiplicative, but it is rare for children and adolescents to be exposed to multiple parental risk factors simultaneously. Nevertheless, they should be considered along with the offspring's own multiple risk factors in determining the overall risk of a suicide attempt. Further research incorporating both parental and offspring's risk factors is indicated to determine the overall dose-response effect of multiple risk factors.

Three synchronous gastrointestinal tumours.

Mucinous cystadenomas of the appendix are rare, with significant malignant potential [Lo and Sarr in Hepatogastroenterology 50(50):432-437, 2003]. Carcinoid tumours are similarly uncommon, rarely occurring in Meckel's diverticula but are still the commonest tumour of Meckel's diverticulae [Nies et al. in Dis Colon Rectum 35(6):589-596, 1992; Modlin and Lye in Cancer 97(4):934-959, 2003; Sutter et al. in Schweiz Med Wochenschr Suppl 89:20S-24S, 1997; Weber and McFadden DW in J Clin Gastroenterol 11(6):682-686, 1989]. A 77-year-old woman presented to our clinic with a 6-week history of non-specific lower abdominal pain. A pelvic ultrasound showed an 8 × 3 × 2.5 cm mass in the right iliac fossa. Colonoscopy and CT confirmed this mass and also revealed a left colonic tumor. At laparotomy, three tumours were identified; in the appendix, a Meckel's diverticulum, and the descending colon. A subtotal colectomy and diverticulectomy were performed. Histology confirmed a T3N0 Dukes B colonic adenocarcinoma, a carcinoid of Meckel's diverticulum and a mucinous adenoma of the appendix. The patient is tumor free to date, 5 years after presentation. The presence of three synchronous tumours of different histological origin in the gastrointestinal tract has not previously been described in the literature.

Central venous pressure during the post-anhepatic phase is not associated with early postoperative outcomes following orthotopic liver transplantation.

BACKGROUND: Fluid management during orthotopic liver transplantation poses unique challenges for the anesthesiologist. Maintenance of hypovolemia as indicated by low central venous pressure has been associated with reduced blood loss and improved outcomes in some studies, but with higher 30-day mortality and increased incidence of renal dysfunction in others. The primary aim was to evaluate the association of central venous pressure management after liver allograft reperfusion with immediate postoperative patient outcomes. METHODS: This was a retrospective investigation evaluating the intraoperative and postoperative records of 144 consecutive patients who underwent orthotopic liver transplantation at a single institution. RESULTS: We did not find any important association between central venous pressure management after graft reperfusion and postoperative patient outcomes. Specifically, these data do not support the hypothesis that maintenance of lower central venous pressure during the post-anhepatic phase of orthotopic liver transplantation is associated with improved immediate postoperative allograft function (except for a steeper decrease in post operative days 1-3 in 2 of the 3 liver function test: alanine aminotransferase and bilirubin) or overall patient survival, graft survival, composite graft/patient survival, intensive care length of stay, hospital length of stay or the occurrence of infections. CONCLUSION: Maintaining a lower central venous pressure during the post-anhepatic phase during orthotopic liver transplantation is not associated with any benefit in terms of immediate postoperative allograft function, graft survival or patient survival.

Exploring morally relevant issues facing families in their decisions to monitor the health-related behaviours of loved ones.

Patient self-management of disease is increasingly supported by technologies that can monitor a wide range of behavioural and biomedical parameters. Incorporated into everyday devices such as cell phones and clothes, these technologies become integral to the psychosocial aspects of everyday life. Many technologies are likely to be marketed directly to families with ill members, and families may enlist the support of clinicians in shaping use. Current ethical frameworks are mainly conceptualised from the perspective of caregivers, researchers, developers and regulators in order to ensure the ethics of their own practices. This paper focuses on families as autonomous decision-makers outside the regulated context of healthcare. We discuss some morally relevant issues facing families in their decisions to monitor the health-related behaviours of loved ones. An example - remote parental monitoring of adolescent blood glucose - is presented and discussed through the lens of two contrasting accounts of ethics; one reflecting the predominant focus on health outcomes within the health technology assessment (HTA) framework and the other that attends to the broader sociocultural contexts shaping technologies and their implications. Issues discussed include the focus of assessments, informed consent and child assent, and family co-creation of system characteristics and implications. The parents' decisions to remotely monitor their child has relational implications that are likely to influence conflict levels and thus also health outcomes. Current efforts to better integrate outcome assessments with social and ethical assessments are particularly relevant for informed decision-making about health monitoring technologies in families.

Spontaneous coronary artery dissection: a Western Denmark Heart Registry study.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) that associates with a high acute-phase mortality rate, whereas long-term outcome is less well described. OBJECTIVE: To describe the incidence, predictors, and prognosis of SCAD. DESIGN: Retrospective case-identification study from the Western Denmark Heart Registry and the database of the Forensic Institute at Aarhus University from 1999 through 2007. RESULTS: SCAD was documented in 22 of 32,869 (0.7 per thousand) angiograms in the angiographic registry. The SCAD incidence among cases of ACS was 22 of 11,175 (2.0 per thousand). None was seen in the forensic database. The mean age was 48.7 +/- 8.9 years (range: 37-71 years). Females constituted 17 of 22 (77%) patients and all had undergone one or more pregnancies; two cases occurred in the postpartum period. The left descending artery (LAD) was the predominant site of entry. The age distribution, prevalence of the cardiovascular risk factors, presence of coronary atherosclerosis, and entry of the dissection were comparable among genders. Treatment was percutaneous coronary intervention in 13 of 22 (59%), coronary artery bypass operation in 2 of 22 (9%), and medical treatment in 7 of 22 (32%) patients. The mean follow-up period was 3.6 +/- 2.9 years. One patient suffered from recurrent SCAD; another patient died suddenly. The MACE- (cardiac death, nonfatal myocardial infarction, and new revascularization) free survival was 81% after 24 months. CONCLUSION: SCAD is a rare disease that mainly affects younger women. Compared with earlier reports, the prognosis seems to be improved by early diagnosis and interventional treatment.

Primary PCI as the preferred reperfusion therapy in STEMI: it is a matter of time.

There is a continuing controversy about the acceptable time-window for primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI). Recent American and European guidelines recommend PPCI if the delay in performing PPCI instead of administering fibrinolysis (PCI-related delay) is <60 min and the presentation delay is more than 3 h. Based on a review of the literature, this viewpoint recommends a revision of the guidelines. The evidence supports an acceptable PCI-related delay of 80-120 min and PPCI as the better reperfusion strategy also in the early incomers. Furthermore, the previous assumption that PPCI is less time-dependent than fibrinolysis is questioned. To maximise the number of patients with STEMI eligible for PPCI the optimal logistic may be to establish the diagnosis in the prehospital phase, to bypass local hospitals and re-route patients directly to catheterisation laboratories running 24/7.