Strategies for Multivessel Revascularization in Patients with Diabetes

BACKGROUND In some randomized trials comparing revascularization strategies for patients with diabetes, coronary-artery bypass grafting (CABG) has had a better outcome than percutaneous coronary intervention (PCI). We sought to discover whether aggressive medical therapy and the use of drug-eluting stents could alter the revascularization approach for patients with diabetes and multivessel coronary artery disease. METHODS In this randomized trial, we assigned patients with diabetes and multivessel coronary artery disease to undergo either PCI with drug-eluting stents or CABG. The patients were followed for a minimum of 2 years (median among survivors, 3.8 years). All patients were prescribed currently recommended medical therapies for the control of low-density lipoprotein cholesterol, systolic blood pressure, and glycated hemoglobin. The primary outcome measure was a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke. RESULTS From 2005 through 2010, we enrolled 1900 patients at 140 international centers. The patients' mean age was 63.1 +/- 9.1 years, 29% were women, and 83% had three-vessel disease. The primary outcome occurred more frequently in the PCI group (P=0.005), with 5-year rates of 26.6% in the PCI group and 18.7% in the CABG group. The benefit of CABG was driven by differences in rates of both myocardial infarction (P<0.001) and death from any cause (P=0.049). Stroke was more frequent in the CABG group, with 5-year rates of 2.4% in the PCI group and 5.2% in the CABG group (P=0.03). CONCLUSIONS For patients with diabetes and advanced coronary artery disease, CABG was superior to PCI in that it significantly reduced rates of death and myocardial infarction, with a higher rate of stroke. (Funded by the National Heart, Lung, and Blood Institute and others; FREEDOM ClinicalTrials.gov number, NCT00086450.)

Clinical relevance of coronary angiography at the time of percutaneous closure of a patent foramen ovale

BACKGROUND: The value of incidental coronary angiography during percutaneous shunt closure to screen for asymptomatic coronary artery disease (CAD) is unknown. METHODS: On the occasion of percutaneous closure of patent foramen ovale (PFO), incidental coronary angiography routinely offered to men >40 and women >50 years, or younger patients with particular risk patterns, was performed in 575 patients (64% men, mean age 55 +/- 10 years, mean 1.5 +/- 1.1 cardiovascular risk factors) without overt history, signs, or symptoms of CAD. RESULTS: CAD was found in 164 patients (29%); 53 (9%) had >or=50% diameter stenoses. Thirty patients (5%) had one-vessel, 13 (2%) two-vessel, and 10 (2%) three-vessel disease. Patients with CAD (n = 164) were older (60 +/- 9 vs. 53 +/- 10 years; P < 0.0001), more frequently male (76% vs. 59%; P = 0.0002), and had a higher body mass index (26.5 +/- 4.0 vs. 25.4 +/- 4.6; P = 0.006) and more cardiovascular risk factors (2.0 +/- 1.1 vs. 1.2 +/- 1.0; P < 0.0001). There were six procedural complications (1%). Two were unequivocally related to coronary angiography: one minor stroke (diplopia), and one iatrogenic dissection of the right coronary ostium requiring stenting. Furthermore, four arteriovenous fistulae at the puncture site requiring elective surgical closure were possibly related to coronary angiography. Forty-five patients (8% of total) underwent percutaneous (n = 43) or surgical (n = 2) revascularization. CONCLUSIONS: In selected asymptomatic patients referred for percutaneous PFO closure, incidental coronary angiography discloses a rather high prevalence of clinically unsuspected CAD. These findings are relevant not only for timely revascularization but also for maintenance of long-term antiplatelet therapy beyond the few months recommended after PFO closure.

Plasma levels of mannan-binding lectin (MBL)-associated serine proteases (MASPs) and MBL-associated protein in cardio- and cerebrovascular diseases

Growing evidence suggests a prominent role of the complement system in the pathogenesis of cardio- and cerebrovascular diseases (CVD). Mannan-binding lectin-associated serine proteases (MASPs) MASP-1 and MASP-2 of the complement lectin pathway contribute to clot formation and may represent an important link between inflammation and thrombosis. MBL-associated protein MAp44 has shown cardioprotective effects in murine models. However, MAp44 has never been measured in patients with CVD and data on MASP levels in CVD are scarce. Our aim was to investigate for the first time plasma levels of MAp44 and MASP-1, -2, -3 concomitantly in patients with CVD. We performed a pilot study in 50 healthy volunteers, in stable coronary artery disease (CAD) patients with one-vessel (n = 51) or three-vessel disease (n = 53) and age-matched controls with normal coronary arteries (n = 53), 49 patients after myocardial infarction (MI) and 66 patients with acute ischaemic stroke. We measured MAp44 and MASP-1 levels by in-house time-resolved immunofluorometric assays. MASP-2 and MASP-3 levels were measured using commercial enzyme-linked immunosorbent assay kits. MASP-1 levels were highest in subacute MI patients and lowest in acute stroke patients. MASP-2 levels were lower in MI and stroke patients compared with controls and CAD patients. MASP-3 and MAp44 levels did not differ between groups. MASP or MAp44 levels were not associated with severity of disease. MASP and MAp44 levels were associated with cardiovascular risk factors including dyslipidaemia, obesity and hypertension. Our results suggest that MASP levels may be altered in vascular diseases. Larger studies are needed to confirm our results and elucidate the underlying mechanisms.

The International Surface Pressure Databank version 2

The International Surface Pressure Databank (ISPD) is the world's largest collection of global surface and sea-level pressure observations. It was developed by extracting observations from established international archives, through international cooperation with data recovery facilitated by the Atmospheric Circulation Reconstructions over the Earth (ACRE) initiative, and directly by contributing universities, organizations, and countries. The dataset period is currently 1768–2012 and consists of three data components: observations from land stations, marine observing systems, and tropical cyclone best track pressure reports. Version 2 of the ISPD (ISPDv2) was created to be observational input for the Twentieth Century Reanalysis Project (20CR) and contains the quality control and assimilation feedback metadata from the 20CR. Since then, it has been used for various general climate and weather studies, and an updated version 3 (ISPDv3) has been used in the ERA-20C reanalysis in connection with the European Reanalysis of Global Climate Observations project (ERA-CLIM). The focus of this paper is on the ISPDv2 and the inclusion of the 20CR feedback metadata. The Research Data Archive at the National Center for Atmospheric Research provides data collection and access for the ISPDv2, and will provide access to future versions.

An analysis of IN.PACT DEEP randomized trial on the limitations of the societal guidelines-recommended hemodynamic parameters to diagnose critical limb ischemia.

OBJECTIVE Recent small single-center data indicate that the current hemodynamic parameters used to diagnose critical limb ischemia are insensitive. We investigated the validity of the societal guidelines-recommended hemodynamic parameters against core laboratory-adjudicated angiographic data from the multicenter IN.PACT DEEP (RandomIzed AmPhirion DEEP DEB vs StAndard PTA for the treatment of below the knee Critical limb ischemia) Trial. METHODS Of the 358 patients in the IN.PACT DEEP Trial to assess drug-eluting balloon vs standard balloon angioplasty for infrapopliteal disease, 237 had isolated infrapopliteal disease with an available ankle-brachial index (ABI), and only 40 of the latter had available toe pressure measurements. The associations between ABI, ankle pressure, and toe pressure with tibial runoff, Rutherford category, and plantar arch were examined according to the cutoff points recommended by the societal guidelines. Abnormal tibial runoff was defined as severely stenotic (≥70%) or occluded and scored as one-, two-, or three-vessel disease. A stenotic or occluded plantar arch was considered abnormal. RESULTS Only 14 of 237 patients (6%) had an ABI <0.4. Abnormal ankle pressure, defined as <50 mm Hg if Rutherford category 4 and <70 mm Hg if Rutherford category 5 or 6, was found only in 37 patients (16%). Abnormal toe pressure, defined as <30 mm Hg if Rutherford category 4 and <50 mm Hg if Rutherford category 5 or 6, was found in 24 of 40 patients (60%) with available measurements. Importantly, 29% of these 24 patients had an ABI within normal reference ranges. A univariate multinomial logistic regression found no association between the above hemodynamic parameters and the number of diseased infrapopliteal vessels. However, there was a significant paradoxic association where patients with Rutherford category 6 had higher ABI and ankle pressure than those with Rutherford category 5. Similarly, there was no association between ABI and pedal arch patency. CONCLUSIONS The current recommended hemodynamic parameters fail to identify a significant portion of patients with lower extremity ulcers and angiographically proven severe disease. Toe pressure has better sensitivity and should be considered in all patients with critical limb ischemia.

Seismic velocities and elastic properties of gabbroic rocks from ODP Hole 118-735B

The nearly continuous recovery of 0.5 km of generally fresh, layer 3 gabbroic rocks at Hole 735B, especially near the bottom of the section, presents scientists an unusual opportunity to study the detailed elastic properties of the lower oceanic crust. Extending compressional-wave and density shipboard measurements at room pressure, Vp and Vs were measured at pressures from 20 to 200 MPa using the pulse transmission method. All of the rocks exhibit significant increases in velocity with increasing pressure up to about 150 MPa, a feature attributed to the closing of microcrack porosity. Measured velocities reflect the mineralogical makeup and microstructures acquired during the tectonic history of Hole 735B. Most of the undeformed and unaltered gabbros are approximately 65:35 plagioclase/clinopyroxene rocks plus olivine or oxide minerals, and the observed densities and velocities are fully consistent with the Voigt-Reuss-Hill (VRH) averages of the component minerals and their proportions. Depending on their olivine content, the predominant olivine gabbros at 200 MPa have average Vp = 7.1 ± 0.2 km/s, Vs = 3.9 ± 0.1 km/s, and grain densities of 2.95 ± 0.5 g/cm3. The less abundant iron-titanium (Fe-Ti) oxide gabbros average Vp = 6.75 ± 0.15 km/s, Vs = 3.70 ± 0.1 km/s, and grain densities of 3.22 ± 0.05 g/cm3, reflecting the higher densities and lower velocities of oxide minerals compared to olivine. About 30% of the core is plastically deformed, and the densities and directionally averaged velocities of these shear-zone tectonites are generally consistent with those of the gabbros, their protoliths. Three sets of observations indicate that the shear-zone metagabbros are elastically anisotropic: (1) directional variations in Vp, both vertical and horizontal and with respect to foliation and lineation; (2) discrepancies among Vp values for the horizontal cores and the VRH averages of the component minerals and their mineral proportions, suggesting preferred crystallographic orientations of anisotropic minerals; and (3) variations of Vs of up to 7%, with polarization directions parallel and perpendicular to foliation. Optical inspection of thin sections of the same samples indicates that plagioclase feldspar, clinopyroxene, and amphibole typically display crystallographic-preferred orientations, and this, plus the elastic anisotropy of these minerals, suggests that preferred orientations are responsible for much of the observed anisotropy, particularly at high pressure. Alteration tends to be localized to brittle faults and brecciated zones, and typical alteration minerals are amphibole and secondary plagioclase, which do not significantly change the velocity-density relationships.

Physical oceanography, current meter data, and microstructure measurements 180 km downstream of Denmark Strait sill during Maria S. Merian cruise MSM21/1b

The main objectives of the cruise MSM21/1b were to characterize the spatio-temporal variability of the Denmark Strait overflow and to identify processes responsible for the exchange of the overflow plume with ambient water downstream of Denmark Strait. A multi-platform approach was taken to achieve the goals, based on moorings, an autonomous underwater vehicle (AUV), as well as lowered and vessel-mounted observations. From these platforms, measurements of temperature, salinity, dissolved oxygen, current velocity, dissipation of turbulent kinetic energy, and bottom pressure were obtained.

Non-enzymatic and enzymatic hydrolysis of alkyl halides: A haloalkane dehalogenation enzyme evolved to stabilize the gas-phase transition state of an SN2 displacement reaction

The semiempirical PM3 method, calibrated against ab initio HF/6–31+G(d) theory, has been used to elucidate the reaction of 1,2-dichloroethane (DCE) with the carboxylate of Asp-124 at the active site of haloalkane dehalogenase of Xanthobacter autothropicus. Asp-124 and 13 other amino acid side chains that make up the active site cavity (Glu-56, Trp-125, Phe-128, Phe-172, Trp-175, Leu-179, Val-219, Phe-222, Pro-223, Val-226, Leu-262, Leu-263, and His-289) were included in the calculations. The three most significant observations of the present study are that: (i) the DCE substrate and Asp-124 carboxylate, in the reactive ES complex, are present as an ion-molecule complex with a structure similar to that seen in the gas-phase reaction of AcO− with DCE; (ii) the structures of the transition states in the gas-phase and enzymatic reaction are much the same where the structure formed at the active site is somewhat exploded; and (iii) the enthalpies in going from ground states to transition states in the enzymatic and gas-phase reactions differ by only a couple kcal/mol. The dehalogenase derives its catalytic power from: (i) bringing the electrophile and nucleophile together in a low-dielectric environment in an orientation that allows the reaction to occur without much structural reorganization; (ii) desolvation; and (iii) stabilizing the leaving chloride anion by Trp-125 and Trp-175 through hydrogen bonding.

Race, Power and Economic Extraction in Benton Harbor, MI

My dissertation investigates twin financial interventions—urban development and emergency management—in a single small town. Once a thriving city drawing blacks as blue-collar workers during the Great Migration, Benton Harbor, Michigan has suffered from waves of out-migration, debt, and alleged poor management. Benton Harbor’s emphasis on high-end economic development to attract white-collar workers and tourism, amidst the poverty, unemployment, and disenfranchisement of black residents, highlights an extreme case of American urban inequality. At the same time, many bystanders and representative observers argue that this urban redevelopment scheme and the city’s takeover by the state represent Benton Harbor residents’ only hope for a better life. I interviewed 44 key players and observers in local politics and development, attended 20 public meetings, conducted three months of observations, and collected extensive archival data. Examining Benton Harbor’s time under emergency management and its luxury golf course development as two exemplars of a larger relationship, I find that the top-down processes allegedly intended to alleviate Benton Harbor’s inequality actually reproduce and deepen the city’s problems. I propose that the beneficiaries of both plans constitute a white urban regime active in Benton Harbor. I show how the white urban regime serves its interests by operating an extraction machine in the city, which serves to reproduce local poverty and wealth by directing resources toward the white urban regime and away from the city.

Specific mass blance of Aletschgletscher and Hintereisferner, Alps

More than 25 years of mass budget measurements of Hintereisferner allow a correlation with simultaneous observations of the climatological station Vent (1900 m a. s. l.). By this means it is possible to estimate the mass budget of earlier periods. Extreme values in the period between 1934/35 and 1951/52 span a range nearly twice as wide as in the pcriod thereafter.

Development of a knowledge sharing framework for improving the testing processes in global product development

As identified by Griffin (1997) and Kahn (2012), manufacturing organisations typically improve their market position by accelerating their product development (PD) cycles. One method for achieving this is to reduce the time taken to design, test and validate new products, so that they can reach the end customer before competition. This paper adds to existing research on PD testing procedures by reporting on an exploratory investigation carried out in a UK-based manufacturing plant. We explore the organisational and managerial factors that contribute to the time spent on testing of new products during development. The investigation consisted of three sections, viz. observations and process modelling, utilisation metrics and a questionnaire-based investigation, from which a proposed framework to improve and reduce the PD time cycle is presented. This research focuses specifically on the improvement of the utilisation of product testing facilities and the links to its main internal stakeholders - PD engineers.

Processamento de Dados GNSS em Modo Cinemático

O princípio do posicionamento por GNSS baseia-se, resumidamente, na resolução de um problema matemático que envolve a observação das distâncias do utilizador a um conjunto de satélites com coordenadas conhecidas. A posição resultante pode ser calculada em modo absoluto ou relativo. O posicionamento absoluto necessita apenas de um recetor para a determinação da posição. Por sua vez, o posicionamento relativo implica a utilização de estações de referência e envolve a utilização de mais recetores para além do pertencente ao próprio utilizador. Assim, os métodos mais utilizados na determinação da posição de uma plataforma móvel, com exatidão na ordem dos centímetros, baseiam-se neste último tipo de posicionamento. Contudo, têm a desvantagem de estarem dependentes de estações de referência, com um alcance limitado, e requerem observações simultâneas dos mesmos satélites por parte da estação e do recetor. Neste sentido foi desenvolvida uma nova metodologia de posicionamento GNSS em modo absoluto, através da modelação ou remoção dos erros associados a cada componente das equações de observação, da utilização de efemérides precisas e correções aos relógios dos satélites. Este método de posicionamento tem a designação Precise Point Positioning (PPP) e permite manter uma elevada exatidão, equivalente à dos sistemas de posicionamento relativo. Neste trabalho, após um estudo aprofundado do tema, foi desenvolvida uma aplicação PPP, de índole académica, com recurso à biblioteca de classes C++ do GPS Toolkit, que permite determinar a posição e velocidade do recetor em modo cinemático e em tempo real. Esta aplicação foi ensaiada utilizando dados de observação de uma estação estática (processados em modo cinemático) e de uma estação em movimento instalada no NRP Auriga. Os resultados obtidos permitiram uma exatidão para a posição na ordem decimétrica e para a velocidade na ordem do cm/s.

Preliminary observations in the design and operation of a three panel, double trawl net

Fishing operations were conducted off Kakinada using a 3 panel double trawl net with twin cod-ends to study the utility of the net in catching both bottom and off bottom fishes. The observations indicate that the net is effective in simultaneous catching of bottom as well as off-bottom fishes and separating them while in operation. The design details of the net and the particulars of the fishing operations conducted are presented.

Simultaneous multiwavelength observations of sagittarius A

We observed Sgr A* using the Very Large Array (VLA) and the Giant Metrewave Radio Telescope (GMRT) at multiple centimeter and millimeter wavelengths on 2003 June 17. The measured flux densities of Sgr A*, together with those obtained from the Submillimeter Array (SMA) and the Keck II 10 m telescope on the same date, are used to construct a simultaneous spectrum of Sgr A* from 90 cm to 3.8 mu m. The simultaneous spectrum shows a spectral break at about 3.6 cm, a possible signature of synchrotron self-absorption of the strong radio outburst that occurred near epoch 2003 July 17. At 90 cm, the flux density of Sgr A* is 0.22 +/- 0.06 Jy, suggesting a sharp decrease in flux density at wavelengths longer than 47 cm. The spectrum at long cm wavelengths appears to be consistent with free-free absorption by a screen of ionized gas with a cutoff similar to 100 cm. This cutoff wavelength appears to be three times longer than that of similar to 30 cm suggested by Davies, Walsh, & Booth based on observations in 1974 and 1975. Our analysis suggests that the flux densities of Sgr A* at wavelengths longer than 30 cm could be attenuated and modulated by stellar winds from massive stars close to Sgr A*.