Viability and Outcomes With Revascularization or Medical Therapy in Ischemic Ventricular Dysfunction: A Prespecified Secondary Analysis of the REVIVED-BCIS2 Trial

Importance

In the Revascularization for Ischemic Ventricular Dysfunction (REVIVED-BCIS2) trial, percutaneous coronary intervention (PCI) did not improve outcomes for patients with ischemic left ventricular dysfunction. Whether myocardial viability testing had prognostic utility for these patients or identified a subpopulation who may benefit from PCI remained unclear.

Objective

To determine the effect of the extent of viable and nonviable myocardium on the effectiveness of PCI, prognosis, and improvement in left ventricular function.

Design, Setting, and Participants

Prospective open-label randomized clinical trial recruiting between August 28, 2013, and March 19, 2020, with a median follow-up of 3.4 years (IQR, 2.3-5.0 years). A total of 40 secondary and tertiary care centers in the United Kingdom were included. Of 700 randomly assigned patients, 610 with left ventricular ejection fraction less than or equal to 35%, extensive coronary artery disease, and evidence of viability in at least 4 myocardial segments that were dysfunctional at rest and who underwent blinded core laboratory viability characterization were included. Data analysis was conducted from March 31, 2022, to May 1, 2023.

Intervention

Percutaneous coronary intervention in addition to optimal medical therapy.

Main Outcomes and Measures

Blinded core laboratory analysis was performed of cardiac magnetic resonance imaging scans and dobutamine stress echocardiograms to quantify the extent of viable and nonviable myocardium, expressed as an absolute percentage of left ventricular mass. The primary outcome of this subgroup analysis was the composite of all-cause death or hospitalization for heart failure. Secondary outcomes were all-cause death, cardiovascular death, hospitalization for heart failure, and improved left ventricular function at 6 months.

Results

The mean (SD) age of the participants was 69.3 (9.0) years. In the PCI group, 258 (87%) were male, and in the optimal medical therapy group, 277 (88%) were male. The primary outcome occurred in 107 of 295 participants assigned to PCI and 114 of 315 participants assigned to optimal medical therapy alone. There was no interaction between the extent of viable or nonviable myocardium and the effect of PCI on the primary or any secondary outcome. Across the study population, the extent of viable myocardium was not associated with the primary outcome (hazard ratio per 10% increase, 0.98; 95% CI, 0.93-1.04) or any secondary outcome. The extent of nonviable myocardium was associated with the primary outcome (hazard ratio, 1.07; 95% CI, 1.00-1.15), all-cause death, cardiovascular death, and improvement in left ventricular function.

Conclusions and Relevance

This study found that viability testing does not identify patients with ischemic cardiomyopathy who benefit from PCI. The extent of nonviable myocardium, but not the extent of viable myocardium, is associated with event-free survival and likelihood of improvement of left ventricular function.

Trial Registration

ClinicalTrials.gov Identifier: NCT01920048.

Challenges in heart failure care in four European countries: a comparative study

BACKGROUND

In Europe, more than 15 million people live with heart failure (HF). It imposes an enormous social, organizational and economic burden. As a reaction to impending impact on healthcare provision, different country-specific structures for HF-care have been established. The aim of this report is to provide an overview and compare the HF-care approaches of Germany, Ireland, the Netherlands and the UK, and to open the possibility of learning from each other's experience.

METHODS

A mixed methods approach was implemented that included a literature analysis, interviews and questionnaires with HF-patients and caregivers, and expert interviews with representatives from healthcare, health service research and medical informatics.

RESULTS

The models of HF-care in all countries analyzed are based on the European Society of Cardiology guidelines for diagnosis and treatment of HF. Even though the HF-models differed in design and implementation in practice, key challenges were similar: (i) unequal distribution of care between urban and rural areas, (ii) long waiting times, (iii) unequal access to and provision of healthcare services, (iv) information and communication gaps and (v) inadequate implementation and financing of digital applications.

CONCLUSION

Although promising approaches exist to structure and improve HF-care, across the four countries, implementation was reluctant to embrace novel methods. A lack of financial resources and insufficient digitalization making it difficult to adopt new concepts. Integration of HF-nurses seems to be an effective way of improving current models of HF-care. Digital solutions offer further opportunities to overcome communication and coordination gaps and to strengthen self-management skills.

Percutaneous Revascularization for Ischemic Left Ventricular Dysfunction

BACKGROUND

Whether revascularization by percutaneous coronary intervention (PCI) can improve event-free survival and left ventricular function in patients with severe ischemic left ventricular systolic dysfunction, as compared with optimal medical therapy (i.e., individually adjusted pharmacologic and device therapy for heart failure) alone, is unknown.

METHODS

We randomly assigned patients with a left ventricular ejection fraction of 35% or less, extensive coronary artery disease amenable to PCI, and demonstrable myocardial viability to a strategy of either PCI plus optimal medical therapy (PCI group) or optimal medical therapy alone (optimal-medical-therapy group). The primary composite outcome was death from any cause or hospitalization for heart failure. Major secondary outcomes were left ventricular ejection fraction at 6 and 12 months and quality-of-life scores.

RESULTS

A total of 700 patients underwent randomization - 347 were assigned to the PCI group and 353 to the optimal-medical-therapy group. Over a median of 41 months, a primary-outcome event occurred in 129 patients (37.2%) in the PCI group and in 134 patients (38.0%) in the optimal-medical-therapy group (hazard ratio, 0.99; 95% confidence interval [CI], 0.78 to 1.27; P = 0.96). The left ventricular ejection fraction was similar in the two groups at 6 months (mean difference, -1.6 percentage points; 95% CI, -3.7 to 0.5) and at 12 months (mean difference, 0.9 percentage points; 95% CI, -1.7 to 3.4). Quality-of-life scores at 6 and 12 months appeared to favor the PCI group, but the difference had diminished at 24 months.

CONCLUSIONS

Among patients with severe ischemic left ventricular systolic dysfunction who received optimal medical therapy, revascularization by PCI did not result in a lower incidence of death from any cause or hospitalization for heart failure. (Funded by the National Institute for Health and Care Research Health Technology Assessment Program; REVIVED-BCIS2 ClinicalTrials.gov number, NCT01920048.).

Determinants of acceptance of patients with heart failure and their informal caregivers regarding an interactive decision-making system: a qualitative study

OBJECTIVE

Heart failure is a growing challenge to healthcare systems worldwide. Technological solutions have the potential to improve the health of patients and help to reduce costs. Acceptability is a prerequisite for the use and a successful implementation of new disruptive technologies. This qualitative study aimed to explore determinants that influence the acceptance of patients and their informal caregivers regarding a patient-oriented digital decision-making solution-a doctor-at-home system.

DESIGN

We applied a semistructured design using an interview guide that was based on a theoretical framework influenced by established acceptance theories. The interviews were analysed using a content analysis.

SETTING

A multicentred study in four European countries.

PARTICIPANTS

We interviewed 49 patients and 33 of their informal caregivers. Most of the patients were male (76%) and aged between 60 and 69 years (43%). Informal caregivers were mostly female (85%). The majority of patients (55%) suffered from heart failure with mild symptoms.

RESULTS

Four main categories emerged from the data: needs and expectations, preferences regarding the care process, perceived risk and trust. Participants expressed clear wishes and expectations regarding a doctor-at-home, especially the need for reassurance and support in the management of heart failure. They were receptive to changes to the current healthcare processes. However, trust was identified as an important basis for acceptance and use. Finally, perceived risk for decision-making errors is a crucial topic in need of attention.

CONCLUSION

Patients and informal caregivers see clear benefits of digitalisation in healthcare. They perceive that an interactive decision-making system for patients could empower and enable effective self-care. Our results provide important insights for development processes of patient-centred decision-making systems by identifying facilitators and barriers for acceptance. Further research is needed, especially regarding the influence and mitigation of patients and informal caregivers' perceived risks.

Stress and skin disease quality of life: the moderating role of anxiety sensitivity social concerns

BACKGROUND

Stress is an important factor in the onset, exacerbation and reoccurrence of many skin diseases. Little is known about psychological risk factors that affect the association between stress and dermatological conditions. One relevant factor that may modulate this link is anxiety sensitivity (AS) social concerns - the propensity to respond fearfully to anxiety-related sensations (e.g. sweating, flushing) owing to perceived social consequences (e.g. rejection or humiliation).

OBJECTIVES

To gain insight into psychological factors affecting skin disease, we examined the moderating role of AS social concerns in the relationship between stress and skin disease quality of life (QoL).

METHODS

Participants [n = 237 (161 female), mean ± SD age 34·18 ± 9·57 years] with active skin disease symptoms were recruited online and completed questionnaires assessing stress, AS social concerns, skin disease QoL and global skin disease symptom severity.

RESULTS

AS social concerns moderated the association between stress and skin-related emotional and social functioning in adults with skin disease. Stress was a significant predictor of the impairment associated with skin disease.

CONCLUSIONS

Stress was linked to skin disease-related emotional and functional impairment associated with skin disease among individuals with high AS social concerns. These results highlight the potential for AS reduction interventions to break the vicious cycle of stress and skin disease symptoms and to improve psychosocial well-being in dermatology patients.

Late gadolinium enhancement is common in patients with hypertrophic cardiomyopathy and no clinical risk factors for sudden cardiac death: A single center experience

BACKGROUND

Cardiac magnetic resonance (CMR) is used in the diagnosis and risk stratification of hypertrophic cardiomyopathy (HCM) and can detect myocardial replacement fibrosis (anindependent predictor of adverse cardiac outcomes) using late gadolinium enhancement (LGE).

METHODS

We retrospectively analysed CMR studies carried out over a 2 year period identifying those which were diagnostic of HCM. 117 cases were analysed. Mean age of subjects was 53 years and 78 (67%) were male. Mean ejection fraction (EF) was 68.3% with a mean left ventricular (LV) mass index of 89.4 g/m². Hypertrophy was predominantly asymmetric in 94 (80%).

RESULTS

All subjects received gadolinium and 80 (68%) had evidence of LGE. LVEF was lower (67 vs. 71%; p = 0.015) and LV mass index higher (94 vs. 81 g/m²; p = 0.007) in the LGE group. The proportion of patients with at least 1 clinical risk factor for sudden cardiac death (SCD) was similar in groups with and without LGE (48% vs. 32%; p = 0.160). In this study, a significant proportion (62%) of patients without clinical risk factors for SCD were found to have LGE on CMR. These patients would not currently be considered for therapy with an implantable cardiac defibrillator.

CONCLUSIONS

1. Patients with HCM are at increased risk of SCD, but identifying patients who may benefit from implantable defibrillators is difficult. 2. LGE is associated with adverse cardiovascular outcomes in HCM, but is present in a large proportion of patients. 3. Many patients without clinical risk factors for SCD have LGE and would not currently be considered for an implantable cardiac device.

Four-jet production at the Large Hadron Collider at next-to-leading order in QCD

We present the cross sections for production of up to four jets at the Large Hadron Collider, at next-to-leading order in the QCD coupling. We use the BLACKHAT library in conjunction with SHERPA and a recently developed algorithm for assembling primitive amplitudes into color-dressed amplitudes. We adopt the cuts used by ATLAS in their study of multijet events in pp collisions at √s=7 TeV. We include estimates of nonperturbative corrections and compare to ATLAS data. We store intermediate results in a framework that allows the inexpensive computation of additional results for different choices of scale or parton distributions.

A class-wide phylogenetic assessment of Dothideomycetes

We present a comprehensive phylogeny derived from 5 genes, nucSSU, nucLSU rDNA, TEF1, RPB1 and RPB2, for 356 isolates and 41 families (six newly described in this volume) in Dothideomycetes. All currently accepted orders in the class are represented for the first time in addition to numerous previously unplaced lineages. Subclass Pleosporomycetidae is expanded to include the aquatic order Jahnulales. An ancestral reconstruction of basic nutritional modes supports numerous transitions from saprobic life histories to plant associated and lichenised modes and a transition from terrestrial to aquatic habitats are confirmed. Finally, a genomic comparison of 6 dothideomycete genomes with other fungi finds a high level of unique protein associated with the class, supporting its delineation as a separate taxon.

First Report of Juneberry Rust Caused by Gymnosporangium nelsonii on Juneberry in Michigan

Amelanchier alnifolia (Nutt.) Nutt. ex M. Roem., commonly known as juneberry or Saskatoon serviceberry, was historically a widely used prairie fruit that is native to the Northern Great Plains, southern Yukon and Northwest Territories (4). While juneberry is an important fruit crop in the prairie provinces of Canada, small commercial plantings also occur throughout the northern United States (2), including Michigan. On July 18, 2009, severe rust symptoms were observed on plants in a 2-year-old field of A. alnifolia 'Northline' in Northport, MI. The plants had been sourced as seedlings from a nursery in Alberta, Canada in 2007. Signs and symptoms were present on fruits and leaves on virtually all of the plants. Symptomatic fruit were still immature, and on average, more than 70% of the fruit surface was covered with tubular, whitish aecia with conspicuous orange aeciospores. Portions of twigs also showed fusiform swellings (1 to 3 cm long) covered with aecia. Aecia were hypophyllous, fructicolous and caulicolous, roestelioid, and 2 to 4 mm high. The peridium was cylindric and tapering toward the apex, dehiscent at the apex, retaining a tubular shape for a long time and at times becoming lacerated on the sides with age. Peridial cells were linear rhomboidal, 50 to 105 μm long, hyaline to brownish, outer walls smooth, inner walls with small papillae, and side walls delicately verrucose-rugose with elongate papillae having variable lengths. Aeciospores were globoid, 20 to 35 × 25 to 38 μm (average 30.7 × 32.5 μm), orange to cinnamon brown, and densely verrucose with walls 2.5 to 3.5 μm thick. On the basis of these morphological characters, the host, and comparison with a reference specimen (BPI 122010), the pathogen was identified as Gymnosporangium nelsonii Arthur (1,3). The 5' region of the 28S rDNA was sequenced (GenBank Accession No. HM591299.1), confirming the identification as a species of Gymnosporangium, one distinct from previously sequenced specimens available in GenBank. The specimen has been deposited at the U.S. National Fungus Collections (BPI 880671 and 880709). Four other species found previously on Amelanchier spp. in the Midwest differ as follows: G. clavipes and G. clavariiforme have verrucose peridial cells and different 28S rDNA sequences; G. nidus-avis has rugose peridial cells; and G. corniculans has cornute peridia that dehisce from lateral slits while apices remain intact and verrucose peridial walls with verrucae on the side walls (1). The infection was likely caused by basidiospores originating from telia on Juniperus spp. in the area surrounding the field. However, no telia of G. nelsonii were found on junipers in the immediate vicinity. To our knowledge, this is the first report of G. nelsonii on juneberry in Michigan and the Midwest. Because of the devastating impact of this disease on fruit quality, fungicide programs have been devised for disease control and were effective in 2010. Juneberry growers in the Midwest need to be aware of this disease and monitor their crop carefully for symptoms and signs. References: (1) F. D. Kern. A Revised Taxonomic Account of Gymnosporangium. Pennsylvania State University Press, University Park, 1973. (2) K. Laughlin et al. Juneberry for Commercial and Home Use on the Northern Great Plains. North Dakota State University, Fargo 1996. (3) S. K. Lee and M. Kakishima. Mycoscience 40:121, 1999. (4) G. Mazza and C. G. Davidson. Page 516 in: New Crops. Wiley, New York, 1993.

First Report of Leaf Rust of Blueberry Caused by Thekopsora minima in Mexico

Blueberry (Vaccinium corymbosum L.) is becoming an important crop in the states of Jalisco and Michoacan in Mexico. Leaf rust, a disease causing extensive defoliation on plants with severe infections, was observed in the autumn of 2007 and it has become one of the most significant diseases of blueberry in these states. Symptoms on the upper surfaces of leaves appear as small, yellow spots that later turn necrotic as they enlarge and coalesce and eventually cover large areas of individual leaves. On the undersides of leaves, small flecks surrounded by small water-soaked halos appear, turn yellow, and produce powdery sori that are uredinia with urediniospores. Uredinia were hypophyllous, scattered to gregarious and at times superficially appearing confluent, up to about 300 μm in diameter, dome shaped and peridium hemispherical in cross section, orangish, becoming pulverulent, lacking obviously enlarged, well-differentiated ostiolar cells. Urediniospores were subglobose, obovate, oblong or ellipsoid, 17.6 to 27.2 × 12.8 to 17.6 μm, with hyaline, echinulate walls that are 1.2 to 1.8 μm thick, and with yellow-to-hyaline contents. Telia were not observed. On the basis of uredinial morphology (3,4), the rust was identified as Thekopsora minima P. Syd. & Syd. To distinguish this rust from other rust species causing disease on Vaccinium (2,3), a 1,414-bp region consisting of ITS2 and the 5' end of the 28S was amplified with primers Rust2inv/LR6 from uredinial lesions on infected leaves of V. corymbosum 'Biloxi' and sequenced (BPI 880580; GenBank Accession No. HM439777) (1). Results of a BLAST search of GenBank found 100% (1,414 of 1,414) identity to T. minima (GenBank Accession No. GU355675) from South Africa (3). Pathogenicity tests were completed as follows: (i) during the autumn of 2009, rusted leaves of cvs. Biloxi and Sharpblue were collected from the field; (ii) mature leaves from healthy plants of both blueberry cultivars were surface disinfested with 1% sodium hypochlorite for 2 min and rinsed with sterile distilled water; (iii) fresh urediniospores from rusted leaves were brushed directly onto the undersides of disinfested detached leaves; (iv) to avoid drying, wet cotton balls were placed on the petioles of inoculated leaves that were subsequently placed in resealable plastic bags; and (v) leaves were then incubated in a growth chamber at 22°C with a 12-h photoperiod. For each cultivar, 20 leaves were inoculated and five uninoculated leaves were included as controls and the test was repeated once. Yellow uredinia were observed 13 and 10 days after inoculation in cvs. Biloxi and Sharpblue, respectively. Leaf symptoms and uredinial characters were the same as observed previously in the field. To our knowledge, this is the first report of T. minima in Mexico. This report is significant for growers who need a diagnosis to control the disease and for breeders and plant pathologists who should consider developing more resistant cultivars. References: (1) M. C. Aime. Mycoscience 47:112, 2006. (2) F. L. Caruso and D. C. Ramsdell, eds. Compendium of Blueberry and Cranberry Diseases. The American Phytopathological Society, St. Paul, MN, 1995. (3) L. Mostert et al. Plant Dis. 94:478, 2010. (4) P. Sydow and H. Sydow. Monographia Uredinearum. Vol. III. Fratres Borntraeger, Leipzig, Germany, 1915.

Precise predictions for W+4-jet production at the large hadron collider

We present the next-to-leading order (NLO) QCD results for W+4-jet production at hadron colliders. This is the first hadron-collider process with five final-state objects to be computed at NLO. It represents an important background to many searches for new physics at the energy frontier. Total cross sections, as well as distributions in the jet transverse momenta, are provided for the initial LHC energy of √s = 7  TeV. We use a leading-color approximation, known to be accurate to 3% for W production with fewer jets. The calculation uses the BLACKHAT library along with the SHERPA package.

First Report of the Telial Stage of Japanese Apple Rust on Juniperus chinensis in North America and the Aecial Stage on Malus domestica

Following a report in April 2009 of the presence of Gymnosporangium yamadae Miyabae ex G. Yamada on crabapple (Malus toringo Siebold) in Wilmington, DE (2), University of Delaware, State of Delaware, and USDA/APHIS PPQ personnel collaborated to confirm and document the pathogen. G. yamadae is the causal agent of Japanese apple rust. The fungus is known from Asia with an aecial state on economically important Malus species and telial state on Juniperus chinensis. During the April 2009 site visit, ornamental J. chinensis were observed near the original crabapples. On May 7, 2009, telial galls were collected from the ornamental J. chinensis at the Wilmington site. The telia were confirmed to be G. yamadae by morphometric analysis and molecular data. The rDNA large subunit (LSU) sequence derived from the collected telial galls (GenBank Accession No. GU058012) was identical to the eight G. yamadae LSU sequences (GenBank Accession Nos. FJ848760-FJ848765, FJ559373, and FJ559375) reported from Korea by Yun et al. (3). Teliospores were 45 to 54 μm long with pedicels that were wide (7.0 to 8.4 μm) along the full length. The G. yamadae telial gall collected from Wilmington, DE was deposited into the U.S. National Fungus Collection (BPI 879273). Leaves of M. domestica on the University of Delaware farm in Newark were confirmed to have Japanese apple rust on Aug 4, 2009. Identification was made on the morphological presence of unique roestelioid aecia with long cornulated peridia that lacerate along the sides. The aecia differ from those of G. juniperi-virginianae, the causal agent of cedar apple rust, which has aecial peridia that fimbriate to the base and are strongly recurved (1). Following release of a USDA Pest Alert, subsequent samples submitted to USDA/APHIS PPQ indicated widespread incidence of the G. yamadae aecial state in the northeast, including Maryland, Maine, New Hampshire, New Jersey, New York, Pennsylvania, and Rhode Island. Japanese apple rust likely went undetected for several years because of similar symptomatology to cedar apple rust. To our knowledge, this is the first report of the telial stage of G. yamadae in North America and the first report of this pathogen on Malus domestica in the United States. Knowledge of the geographic distribution of G. yamadae is of significance because of the actionable regulatory status of the pathogen and its potential impact on ornamental and fruit growers of Malus spp. in the United States. References: (1) F. D. Kern. A Revised Taxonomic Account of Gymnosporangium. Pennsylvania State University Press, University Park, PA, 1973. (2) H. Y. Yun et al. Plant Dis. 93:430, 2009. (3) H. Y. Yun et al. Mycologia 101:790, 2009.

Uromyces ciceris-arietini, the Cause of Chickpea Rust: New Hosts in the Trifolieae, Fabaceae

Uromyces ciceris-arietini has been reported on Cicer arietinum (chickpea) and Medicago polyceratia. Plants of Medicago polymorpha in Riverside and San Diego, CA were collected with severe rust caused by U. ciceris-arietini. To confirm the identification and potential new host range, a monouredinial isolate of U. ciceris-arietini from M. polymorpha was inoculated on eight accessions each of C. arietinum and M. polyceratia. All plants showed symptoms of the disease. Consequently, a range of fabaceous hosts were evaluated for their reaction to U. ciceris-arietini. New hosts for U. ciceris-arietini included 29 species of Medicago, specifically M. arabica, M. blancheana, M. ciliaris, M. constricta, M. coronata, M. doliata, M. granadensis, M. intertexta, M. italica, M. laciniata, M. lanigera, M. lesinsii, M. lupulina, M. minima, M. murex, M. muricoleptis, M. orbicularis, M. praecox, M. radiata, M. rigidula, M. rotata, M. rugosa, M. sativa, M. sauvagei, M. scutellata, M. soleirolii, M. tenoreana, M. truncatula, and M. varia, and three species of Melilotus, specifically M. italicus, M. speciosus, and M. spicatus. This isolate of U. ciceris-arietini produced no symptoms on plants in the 33 accessions tested in the genera Anthyllis, Astragalus, Lotus, and Lupinus. DNA sequences are provided to aid in the identification of this pathogen.

First Report of Uromyces acuminatus on Honckenya peploides, the Endangered Seabeach Sandwort

Honckenya peploides (L.) Ehrh. (Caryophyllaceae), commonly known as seabeach sandwort, is a species of special concern in Connecticut (4). Nearly an entire population of H. peploides in New London County, CT was found to be severely infected by the aecial stage of a rust fungus in June of 2008. Representative plants in the population were infected with aecia on more than 50% of the leaves. Aecia were amphigenous, gregarious, cupulate, pulverulent, yellowish, and erumpent with a hyaline to whitish peridium having a lacerate, somewhat recurved margin. Peridial cells were rhomboidal, 26 to 31 × 25 to 29 μm, smooth to finely verrucose. Aeciospores were globose to ellipsoid, 23.5 to 29 × 20.5 to 22 μm, hyaline to pale yellowish with a verrucose surface and hyaline walls 1.5 to 2 μm thick. Morphological characters corresponded to a reference specimen (BPI 000105) of the aecial stage of Uromyces acuminatus Arthur from Nova Scotia, as well as published descriptions (1,2). Subsequently, telia of U. acuminatus were discovered on Spartina patens (Aiton) Muhl. (Poaceae) in May of 2009 in New London County, CT. Telia were adaxial, intercostal, scattered to gregarious, linear and at times elongate, dark brown to black, pulverulent, and erumpent. Teliospores were obovate to ellipsoid with rounded to acuminate apices rarely having two points, 30 to 41 × 19 to 24 μm, with a smooth surface and brownish-yellow to brown walls 9 to 14 μm thick at apex, which is sometimes paler, and 1 to 3 μm thick laterally, pedicels with a portion persisting on the teliospore that is up to 82 μm long and brownish-yellow. The ITS2 and 5' region of the 28S rDNA (998 bp) from the rust on H. peploides (GenBank Accession No. GU109282, BPI 879300) and the rust on S. patens (GenBank Accession No. GU058008, BPI 879285B) were sequenced to confirm the identification of U. acuminatus on H. peploides with the resulting sequences identical. U. acuminatus is widespread in the eastern United States and Canada (1-3). The telial stage is found on Spartina spp., while the aecial stage is found on numerous taxa including members of the Asparagaceae (formerly Ruscaceae, Liliaceae), Caryophyllaceae, Polemoniaceae, and Primulaceae (1-3). Puccinia arenariae (Schumach.) G. Winter, previously reported from H. peploides (4), is microcyclic and stages 0, I, and II are unknown. To our knowledge, this is the first report of U. acuminatus on the genus Honckenya. This report has significance to natural resource conservation managers and scientists working in endangered plant habitats because H. peploides and H. peploides subsp. robusta are listed as plants of special concern or endangered/extirpated in Connecticut, Maryland, New Hampshire, and Rhode Island (4). References: (1) J. C. Arthur. Order Uredinales. N. Am. Flora 7(3):161, 1912. (2) G. B. Cummins. The Rust Fungi of Cereals, Grasses and Bamboos. Springer-Verlag, New York, 1971. (3) D. F. Farr and A. Y. Rossman. Fungal Databases. Systematic Mycology and Microbiology Laboratory. Online publication. ARS, USDA, 2009. (4) USDA, NRCS. The PLANTS Database. Online publication. National Plant Data Center, Baton Rouge, LA, 2009.

First Report of Orange Rust of Sugarcane Caused by Puccinia kuehnii in Mexico, El Salvador, and Panama

Symptoms of sugarcane orange rust were observed on July 17, 2008 on sugarcane cvs. Mex 57-1285, Mex 61-230, and Co 301 (a clone received in Mexico in 1953) at the Centro de Investigación y Desarrollo de la Caña de Azúcar en Tuxtla Chico, Chiapas, Mexico. In El Salvador, from August 2008 through January 2009, rust symptoms were observed on cv. CP 72-2086 (previously resistant to brown rust caused by Puccinia melanocephala Syd. & P. Syd.) in 117 dispersed sugarcane-production fields in various localities of El Salvador. Likewise, rust symptoms were first observed on sugarcane cv. SP 74-8355 (more than 25% severity and considered resistant to brown rust) at Natá, Coclé Province in Panama from January to February 2008. Dried herbarium leaf samples of sugarcane rust-infected leaves collected in El Salvador and Mexico were sent to the ARS, USDA Systematic Mycology and Microbiology Laboratory in Beltsville MD for identification. Panamanian samples were collected similarly and analyzed at the CALESA Biotechnology Laboratory. Morphological features of uredinial lesions and urediniospores were distinct from those of P. melanocephala and consistent with P. kuehnii E. J. Butler observed previously on specimens from Florida, Guatemala, Costa Rica, and Nicaragua (1-3). Analysis of the ITS1, 5.8S, and ITS2 and 28S large subunit rDNA sequences of the rust on infected cvs. Mex 57-1285, Mex 61-230, and Co 301 (BPI 878930, 879139, and 879140; GenBank Accession Nos. GO283006, GO283004, and GO283005, respectively) from Mexico and cv. CP 72-2086 from three locations in El Salvador (BPI 879135, 879136, and 879137; GenBank Accession Nos. GO283009, GO283007, and GO283008, respectively) all confirmed the identification of P. kuehnii. Similar analysis of the ITS1, 5.8S, and ITS2 rDNA sequence for the rust infecting cv. SP 74-8355 (GenBank Accession No. GO281584) confirmed the identification of P. kuehnii in Panama. To our knowledge, this is the first report of P. kuehnii causing orange rust disease of sugarcane in El Salvador, Mexico, and Panama. These findings also confirm the wider distribution of orange rust in the Western Hemisphere. References: (1) E. Chavarria et al. Plant Dis. 93:425, 2009. (2) J. C. Comstock et al. Plant Dis. 92:175, 2008. (3) W. Ovalle et al. Plant Dis. 92:973, 2008.

A case of ST-elevation and nystagmus--when coronary thrombosis is not to blame

We present the case of a post-menopausal female who, following a prolonged period of vomiting and diarrhoea, presented acutely with Wernicke's; encephalopathy, chest pain, ST-segment elevation and congestive cardiac failure associated with hypotension. Coronary angiography demonstrated no abnormality. Haemodynamics improved significantly in the short-term following intravenous thiamine replacement, with complete resolution of all ST-segment abnormalities and normalization of left ventricular function at six-week follow-up. Shoshin beriberi in the context of metabolic alkalosis, secondary to severe electrolyte depletion, is exceptional and is a differential diagnosis to be considered in all malnourished patients presenting with symptoms and signs suggestive of an acute coronary syndrome, especially those with a history of alcohol-dependence.

Host specialization and phylogenetic diversity of Corynespora cassiicola

The fungus Corynespora cassiicola is primarily found in the tropics and subtropics, and is widely diverse in substrate utilization and host association. Isolate characterization within C. cassiicola was undertaken to investigate how genetic diversity correlates with host specificity, growth rate, and geographic distribution. C. cassiicola isolates were collected from 68 different plant species in American Samoa, Brazil, Malaysia, and Micronesia, and Florida, Mississippi, and Tennessee within the United States. Phylogenetic analyses using four loci were performed with 143 Corynespora spp. isolates, including outgroup taxa obtained from culture collections: C. citricola, C. melongenae, C. olivacea, C. proliferata, C. sesamum, and C. smithii. Phylogenetic trees were congruent from the ribosomal DNA internal transcribed spacer region, two random hypervariable loci (caa5 and ga4), and the actin-encoding locus act1, indicating a lack of recombination within the species and asexual propagation. Fifty isolates were tested for pathogenicity on eight known C. cassiicola crop hosts: basil, bean, cowpea, cucumber, papaya, soybean, sweet potato, and tomato. Pathogenicity profiles ranged from one to four hosts, with cucumber appearing in 14 of the 16 profiles. Bootstrap analyses and Bayesian posterior probability values identified six statistically significant phylogenetic lineages. The six phylogenetic lineages correlated with host of origin, pathogenicity, and growth rate but not with geographic location. Common fungal genotypes were widely distributed geographically, indicating long-distance and global dispersal of clonal lineages. This research reveals an abundance of previously unrecognized genetic diversity within the species and provides evidence for host specialization on papaya.

Ultraviolet behavior of N = 8 supergravity at four loops

We describe the construction of the complete four-loop four-particle amplitude of N=8 supergravity. The amplitude is ultraviolet finite, not only in four dimensions, but in five dimensions as well. The observed extra cancellations provide additional nontrivial evidence that N=8 supergravity in four dimensions may be ultraviolet finite to all orders of perturbation theory.

Takotsubo cardiomyopathy in two preoperative patients with pain

Reversible stress-induced cardiomyopathy, i.e., Takotsubo cardiomyopathy, rarely presents in preoperative patients. We provide the case reports of two patients who presented with Takotsubo cardiomyopathy, which we surmise was due to excess endogenous catecholamine production in response to acute pain. Electrocardiogram revealed T-wave inversion, with peak Troponin-T elevation in each case, i.e., 0.66 microg/L and 0.14 microg/L (normal range <0.03 microg/L). Despite these findings consistent with acute myocardial infarction, neither patient had obstructive coronary disease at angiography. Left ventriculography showed apical ballooning, a typical feature of the Takotsubo syndrome. Ventricular dysfunction had resolved completely at repeat echocardiography 2 wk later, after adequate analgesia and surgery.

Precise predictions for w+3 jet production at hadron colliders

We report on the first next-to-leading order QCD computation of W+3-jet production in hadronic collisions including all partonic subprocesses. We compare the results with data from the Tevatron and find excellent agreement. The required one-loop matrix elements are computed using on-shell methods, implemented in a numerical program, BlackHat. We use the SHERPA package to generate the real-emission contributions and to integrate the various contributions over phase space. We use a leading-color (large-N_{c}) approximation for the virtual part, which we confirm in W+1, 2-jet production to be valid to within three percent.

Cancellations beyond finiteness in N=8 supergravity at three loops

We construct the three-loop four-point amplitude of N=8 supergravity using the unitarity method. The amplitude is ultraviolet finite in four dimensions. Novel cancellations, not predicted by traditional superspace power-counting arguments, render its degree of divergence in D dimensions no worse than that of N=4 super-Yang-Mills theory--a finite theory in four dimensions. Similar cancellations can be identified at all loop orders in certain unitarity cuts, suggesting that N=8 supergravity may be a perturbatively finite theory of quantum gravity.

Impaired endothelium-dependent and -independent vasodilation in elderly patients with chronic heart failure

BACKGROUND

Impaired endothelium-dependent and independent vasodilator responses in chronic heart failure (CHF) have been well described. Previous studies involved younger patients and omitted medications prior to study.

AIMS

We explored if new therapeutic interventions would restore vasodilator responses in typical patients with chronic heart failure.

METHODS AND RESULTS

24 patients and 15 controls were recruited, patients were maintained on their usual medications. Forearm blood flow responses were measured by venous occlusion plethysmography in response to incremental doses of sodium nitroprusside (SNP) (6, 9 and 12 nmol/min), acetylcholine (ACH) (120, 180 and 240 nmol/min), angiotensin II (AII) (1, 10 and 100 nmol/min) and N(g)-Nitro-L-arginine methyl ester (L-NAME) (1, 2 and 4 nmol/min) infused into the non-dominant brachial artery. FBF responses to SNP were impaired in patients compared with controls (13.7(9.9,17.4) vs. 24.8(18.6,30.9)) arbitrary units, P<0.001). Similarly FBF responses to ACH were reduced in patients compared with controls (7.5(4.2,10.9) vs. 24.8(16.4,33.2)) arbitrary units, P<0.001. Decreased FBF was noted in response to AII and L-NAME but was significant only for AII and did not differ between groups.

CONCLUSIONS

In elderly patients with CHF, endothelium-dependent and independent vasodilator responses were blunted compared with controls. Defects in nitric oxide bioavailability and smooth muscle responsiveness are not reversed by modern medical management of the heart failure syndrome.

Effects of dietary omega-3 fatty acid supplementation on endothelium-dependent vasodilation in patients with chronic heart failure

We investigated the effects of omega-3 fatty acids administration on endothelium-dependent vasodilation in patients > or =65 years old who received treatment for chronic heart failure (CHF). Twenty patients (mean age 73 years; 15 men) with grade II and III CHF who were on maximal medical management were recruited. Patients were randomized in a double-blind, crossover fashion to 6 weeks of omega-3 fatty acid (1.8 g ecosapentaenoic acid and 1.2 g docosahexaenoic acid) or olive oil. Forearm blood flow (FBF) responses to incremental doses of intra-arterial sodium nitroprusside, acetycholine (ACH), angiotensin-II, and N(g)-nitro-L-arginine methyl ester were assessed by venous occlusion strain gauge plethysmography. The endothelium-dependent increase in FBF was greater in response in ACH infusion after omega-3 fatty acid administration (7.9, 95% confidence interval [CI] 4.81 to 11.08 to 11.3, 95% CI 7.31 to 15.23 arbitrary units (p <0.05) compared with baseline (7.95, 95% CI 4.8 to 11.08 arbitrary units) and olive oil administration (7.27, 95% CI 4.66 to 9.88 arbitrary units) (p = NS for both). Neither omega-3 fatty acid nor olive oil altered endothelium-independent vasodilation in response to infusion of sodium nitroprusside, nor did they influence vasoconstrictor responses to angiotensin-II or N(g)-nitro-L-arginine methyl ester. Dietary omega-3 fatty acid supplementation was accompanied by an increase in FBF response to ACH, which represents enhanced endothelium-dependent vasodilation in CHF. Further studies are warranted to assess the mechanism responsible for the beneficial actions of omega-3 fatty acids in CHF.

NAD(P)H-dependent superoxide production in platelets: The role of angiotensin II and protein kinase C

OBJECTIVES

Vascular NAD(P)H oxidase represents a major source for excessive superoxide production in hypertension. Angiotensin II (AngII) can activate NAD(P)H oxidase via the angiotensin II type 1 (AT1) receptor and protein kinase C (PKC). Platelets possess AT1 receptors and all the components of the NAD(P)H oxidase system. We employed this tissue model to explore mechanisms involved in AngII-mediated superoxide production.

DESIGN AND METHODS

Platelet suspensions from hypertensive patients' blood were activated with AngII or phorbol 12-myristate 13-acetate (PMA). Inhibitors of NAD(P)H oxidase, PKC, and the AT1 receptor were employed to study their effects on superoxide production.

RESULTS

Superoxide production was stimulated by AngII and PMA and attenuated by AT1 receptor antagonists (mean percentage reduction 80.2%, P<0.01) and inhibitors of PKC (mean reduction 94.8%, P<0.001) and NAD(P)H oxidase (mean reduction 100%, P< 0.001).

CONCLUSIONS

AngII stimulates platelet superoxide production through activation of vascular NAD(P)H oxidase via the AT1 receptor and PKC.

Increased superoxide production in hypertensive patients with diabetes mellitus: role of nitric oxide synthase

BACKGROUND

Hypertension and diabetes are important independent risk factors for increased oxidative stress and increased cardiovascular risk. The combination of hypertension and diabetes results in a dramatic increase in cardiovascular risk. Enhanced oxidative stress in hypertension and diabetes is linked to decreased nitric oxide (NO) bioavailability because of its interaction with vascular superoxide (O(2)(*-)), derived predominantly from NAD(P)H-dependent oxidases. When uncoupled from essential cofactors, NO synthase III (NOS III) can also produce O(2)(*-). We studied platelet superoxide production in patients with hypertension alone and in patients with coexistent diabetes mellitus, investigating the contribution of NOS III uncoupling to platelet superoxide production.

METHODS AND RESULTS

Gel-filtered platelets were obtained and were stimulated with Phorbol 12-myristate 13-acetate, and O(2)(*-) production was detected using lucigenin-enhanced chemiluminescence. Superoxide production was significantly higher in patients with diabetes and hypertension (6.4 +/- 1.6 pmol/min/10(8) platelets) than in patients with hypertension (1.6 +/- 0.6 pmol/min/10(8) platelets) (P < .04). After incorporation of N(omega)-nitro-l-arginine methyl ester (L-NAME, 1 mmol/L), O(2)(*-) detection increased in 40% of patients with diabetes and hypertension and in 87% of patients with hypertension. This expected response results from L-NAME inhibition of NO production preventing NO scavenging of O(2)(*-). A reduction in O(2)(*-) production in response to L-NAME occurred in the remaining patients and indicates O(2)(*-) production by the uncoupled NOS III enzyme.

CONCLUSIONS

This study provides first published evidence that NOS III can reside in the uncoupled state in patients with hypertension and, to a greater extent, in patients with coexisting hypertension and diabetes, and that it contributes significantly to increased superoxide production in these disease states.

Reduction in hospitalization rates following cardiac resynchronisation therapy in cardiac failure: experience from a single centre

AIMS

Frequent, lengthy hospital admissions for congestive cardiac failure (CCF) result in excessive health care costs. Cardiac resynchronisation therapy (CRT) is a novel treatment option for patients with CCF and associated cardiac conduction defects. We investigated whether CRT resulted in significant improvements in New York Heart Association (NYHA) symptom class, exercise tolerance, and hospitalization rates in such patients.

METHODS

Twenty-seven patients who underwent CRT in a single centre were studied, with NYHA symptom class, exercise tolerance and hospitalization rates noted in the 12 months prior to and following CRT.

RESULTS

Following 12 months of CRT, NYHA symptom class improved from 3.3 +/- 0.5 to 2.1 +/- 0.4 (P < 0.05). Exercise tolerance, assessed by 6 min hall walk test increased by 64% from 195 +/- 114 m to 320 +/- 85 m (P = 0.007). Days in hospital for stabilisation of cardiac failure decreased by 98% from 472 to 9 days (P < 0.001). Significant hospitalization cost savings of 201,684 euros were calculated, with an overall saving of 12,420 euros.

CONCLUSIONS

These data demonstrate that CRT results in significant improvement in clinical parameters, and considerable reductions in hospital admissions, and costs in patients with CCF.

Central and peripheral haemodynamic effects of L-NAME infusion in healthy volunteers

AIMS

To evaluate the effects of the intravenous administration of the nitric oxide synthesis inhibitor N(g)nitro-L-arginine methyl ester (L-NAME) in healthy volunteers.

METHODS

L-NAME (0.25, 0.5 and 0.75 mg/kg over 8 min) was infused in 13 healthy male volunteers. Finally, subjects were infused with either L- or D-arginine.

RESULTS

L-NAME resulted in dose-dependent falls in heart rate 60 bpm (55-64 bpm) to 49 bpm (46-52 bpm) (P<0.01) and increased mean arterial pressure 77.0 mmHg (73.2-80.8 mmHg) to 90.0 mmHg (87.1-92.8 mmHg) (P<0.01). The cardiac output was significantly reduced after each L-NAME infusion, and systemic vascular resistance increased linearly over the dosage range. Cardiac stroke volume was significantly reduced only following 0.75 mg/kg/min L-NAME: from 100 ml (91.3-108.7 ml) to 83 ml (74.7-91.4 ml); P<0.01. Forearm blood flow was unchanged at any dosage. L-arginine but not D-arginine infusion reversed the haemodynamic effects of L-NAME.

CONCLUSIONS

Contrasting with the profound dose-dependent effects of L-NAME had significant effects on central haemodynamics but no discernible effects on peripheral blood flow.

Functional consequences of endothelial nitric oxide synthase uncoupling in congestive cardiac failure

BACKGROUND

Impaired endothelium-mediated vasodilatation (EMVD) in congestive cardiac failure (CCF) has been linked to decreased nitric oxide (NO) bioavailability because of its interaction with vascular superoxide (O2*-), derived predominantly from NAD(P)H-dependent oxidases. When uncoupled from essential cofactors, endothelial nitric oxide synthase (eNOS) produces O2*-. We studied the functional consequences of eNOS uncoupling in relation to EMVD in patients with CCF.

METHODS AND RESULTS

We employed the platelet as a compartmentalized ex-vivo model to examine O2*- and NO production. When eNOS is functioning normally, incorporation of Nomega-Nitro-L-Arginine methyl ester (L-NAME, 1 mmol/L), results in increased O2*- detection, as inhibition of NO production prevents NO scavenging of O2*-. This was observed in controls and 9 of the CCF patients, in whom O2*- detection increased by 63% and 101%, respectively. In the remaining 9 CCF patients, incorporation of L-NAME reduced O2*- production by 39%, indicating O2*- production by eNOS uncoupling. Detection of platelet-derived NO was significantly greater in eNOS-coupled platelets compared with the uncoupled group (2.8+/-1.4 versus 0.9+/-0.4 pmol/108 platelets, P=0.04). Endothelium-dependent and -independent vasodilator responses to acetylcholine and sodium nitroprusside recorded using venous occlusion plethysmography were significantly impaired in patients exhibiting eNOS uncoupling.

CONCLUSIONS

This study provides first evidence that platelet eNOS can become uncoupled in human CCF. Impaired endothelium-dependent and -independent vasodilator responses and diminished platelet-derived NO production occurred in association with enzyme uncoupling.

Early vascular abnormalities and de novo nitrate tolerance in diabetes mellitus

OBJECTIVE

The haemodynamic consequence of altered mechanical wall properties in diabetes can impair the compliance characteristics or pulsatile function of arteries before changes in calibre or peripheral resistance become evident. We studied the sensitivity of pulsatile and steady-state haemodynamic variables in identifying vascular abnormalities and assessing arterial responsiveness to glyceryl trinitrate (GTN) in patients with diabetes, free from clinical complications of the disease.

METHODS

Radial artery pressure waveforms were recorded in 22 patients with diabetes and 22 age- and sex-matched control subjects, using a calibrated tonometer device. A computer-based assessment of the diastolic pressure decay was used to quantify changes in arterial waveform morphology in terms of pulsatile (arterial compliance) and steady-state (peripheral resistance) haemodynamics. Pressure pulse waveforms were recorded before and 3, 6 and 9 min after the administration of 300 micro g of GTN.

RESULTS

Of the pulsatile and steady-state impedance parameters, only small artery compliance was significantly different in patients, 4.7 ml/mmHg (95% CI 3.8-5.8), compared with control subjects 7.1 ml/mmHg (95% CI 5.4-8.7); (p < 0.05). In response to GTN small artery compliance increased, and systemic vascular resistance decreased significantly in control subjects; (p < 0.05) but remained unchanged in patients with diabetes.

CONCLUSIONS

Arterial waveform analysis proved more sensitive in detecting early vascular abnormalities and tracking the haemodynamic effects of GTN in patients with diabetes than changes in total peripheral resistance. The diminished responsiveness of the arterial vasculature to organic nitrates may have therapeutic implications for the treatment of cardiovascular disease in diabetes mellitus.

Platelet nitric oxide and superoxide release during the development of nitrate tolerance: effect of supplemental ascorbate

BACKGROUND

The therapeutic benefits that accompany the continuous administration of organic nitrates are attenuated by the development of tolerance to the compounds. Altered superoxide production and NO bioavailability have been implicated in contributing to the development of tolerance, an effect that may be ameliorated by the administration of antioxidants.

METHODS AND RESULTS

We studied the effect of 3 days of continuous transdermal administration of nitroglycerin (NTG) (10 mg/24 hours) on platelet free radical (NO and superoxide anion [O2*-] activity) with and without coadministration of supplemental ascorbate (2.4 g/24 hours). NAD(P)H oxidase activity, nitric oxide synthase (NOS) activity, and cyclic guanosine monophosphate (cGMP) content were also assessed. Radial artery pressure pulse waveforms were used to track the hemodynamic actions of NTG. Three days of NTG/placebo was associated with a significant increase in platelet NO and O2*- production from 1.0+/-1.17 to 2.52+/-0.88 pmol/10(8) platelets and 13.2+/-4.8 to 72.5+/-34.4 pmol/10(8) platelets, respectively (P<0.01 for both). These changes were accompanied by increased platelet NADH oxidase activity from 47.9+/-11.0 to 65.3+/-13.6 pmol O2*- min/mg protein and cGMP content from 0.60+/-0.10 to 0.89+/-0.16 pmol/10(9) platelets (P<0.05 for both). Administration of NTG/ascorbate attenuated both NO and O2*- release in platelets.

CONCLUSIONS

Three days of continuous transdermal administration of NTG was accompanied by increased platelet NO and O2*- production and NADH oxidase activity that was suppressed by coadministration of oral ascorbate. Although a significant degree of tolerance would be expected during continuous nitrate administration, a residual hemodynamic action could be identified by arterial pulse contour analysis.

Anomalies of cardiac venous drainage associated with abnormalities of cardiac conduction system

The embryological development of the superior vena cava (SVC) is complex. If the left common cardinal vein fails to occlude it can, along with the left duct of Cuvier form a left SVC, which frequently drains into the coronary sinus. This may result in abnormalities in the anatomy of this structure. A persistent left SVC occurs in 0.5% of the normal population, and 3% to 4.3% of patients with congenital heart anomalies. The pacemaking tissue of the heart is derived from two sites near the progenitors of the superior vena cava. The right-sided site forms the sinoatrial node, the left-sided site is normally carried down to an area near the coronary sinus. Out of 300 patients with cardiac rhythm abnormalities, who have undergone electrophysiological studies (EPS), or permanent pacemaker insertion (PPI), we identified 12 patients with cardiac conduction abnormalities and anomalies of venous drainage. Anomalies of the coronary sinus may be associated with abnormalities of the conduction system of the heart. This may be due to the close proximity of the coronary sinus to the final position of the left-sided primitive pacemaking tissue. In our series of 300 patients, 4% had an associated left SVC, a similar incidence to that found in previous studies of congenital heart disease.