Interdependence of social-ecological-technological systems in Phoenix, Arizona: consequences of an extreme precipitation event

Complex adaptive systems - such as critical infrastructures (CI) - are defined by their vast, multi-level interactions and emergent behaviors, but this elaborate web of interactions often conceals relationships. For instance, CI is often reduced to technological components, ignoring that social and ecological components are also embedded, leading to unintentional consequences from disturbance events. Analysis of CI as social-ecological-technological systems (SETS) can support integrated decision-making and increase infrastructure's capacity for resilience to climate change. We assess the impacts of an extreme precipitation event in Phoenix, AZ to identify pathways of disruption and feedback loops across SETS as presented in an illustrative causal loop diagram, developed through semi-structured interviews with researchers and practitioners and cross-validated with a literature review. The causal loop diagram consists of 19 components resulting in hundreds of feedback loops and cascading failures, with surface runoff, infiltration, and water bodies as well as power, water, and transportation infrastructures appearing to have critical roles in maintaining system services. We found that pathways of disruptions highlight potential weak spots within the system that could benefit from climate adaptation, and feedback loops may serve as potential tools to divert failure at the root cause. This method of convergence research shows potential as a useful tool to illustrate a broader perspective of urban systems and address the increasing complexity and uncertainty of the Anthropocene.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43065-023-00085-6.

Development and operation of the defence COVID-19 lab as a SARS-CoV-2 diagnostic screening capability for UK military personnel

BACKGROUND

In the face of the COVID-19 pandemic, the Defence Science and Technology Laboratory (Dstl) and Defence Pathology combined to form the Defence Clinical Lab (DCL), an accredited (ISO/IEC 17025:2017) high-throughput SARS-CoV-2 PCR screening capability for military personnel.

LABORATORY STRUCTURE AND RESOURCE

The DCL was modular in organisation, with laboratory modules and supporting functions combining to provide the accredited SARS-CoV-2 (envelope (E)-gene) PCR assay. The DCL was resourced by Dstl scientists and military clinicians and biomedical scientists.

LABORATORY RESULTS

Over 12 months of operation, the DCL was open on 289 days and tested over 72 000 samples. Six hundred military SARS-CoV-2-positive results were reported with a median E-gene quantitation cycle (Cq) value of 30.44. The lowest Cq value for a positive result observed was 11.20. Only 64 samples (0.09%) were voided due to assay inhibition after processing started.

CONCLUSIONS

Through a sustained effort and despite various operational issues, the collaboration between Dstl scientific expertise and Defence Pathology clinical expertise provided the UK military with an accredited high-throughput SARS-CoV-2 PCR test capability at the height of the COVID-19 pandemic. The DCL helped facilitate military training and operational deployments contributing to the maintenance of UK military capability. In offering a bespoke capability, including features such as testing samples in unit batches and oversight by military consultant microbiologists, the DCL provided additional benefits to the UK Ministry of Defence that were potentially not available from other SARS-CoV-2 PCR laboratories. The links between Dstl and Defence Pathology have also been strengthened, benefitting future research activities and operational responses.

Human health tradeoffs in wellhead drinking water treatment: Comparing exposure reduction to embedded life cycle risks

Treatment of drinking water decreases human health risks by reducing pollutants, but the required materials, chemicals, and energy emit pollutants and increase health risks. We explored human carcinogenic and non-carcinogenic disease tradeoffs of water treatment by comparing pollutant dose-response curves against life cycle burden using USEtox methodology. An illustrative wellhead sorbent groundwater treatment system removing hexavalent chromium or pentavalent arsenic serving 3200 people was studied. Reducing pollutant concentrations in drinking water from 20 μg L^-1 to 10 μg L^-1 avoided 37 potential cancer cases and 64 potential non-cancer disease cases. Human carcinogenicity embedded in treatment was 0.2-5.3 cases, and non-carcinogenic toxicity was 0.2-14.3 cases, depending on technology and degree of treatment. Embedded toxicity impacts from treating Cr(VI) using strong-base anion exchange were <10% of those from using weak base anion exchange. Acidification and neutralization contributed >90% of the toxicity impacts for treatment options requiring pH control. In scenarios where benefits exceeded burdens, tradeoffs still existed. Benefits are experienced by a local population but burdens are born externally where the materials and energy are produced, thus exporting the health risks. Even when burdens clearly exceeded benefits, cost considerations may still drive selecting a detrimental treatment level or technology.

Heat Death Associations with the built environment, social vulnerability and their interactions with rising temperature

In an extreme heat event, people can go to air-conditioned public facilities if residential air-conditioning is not available. Residences that heat slowly may also mitigate health effects, particularly in neighborhoods with social vulnerability. We explored the contributions of social vulnerability and these infrastructures to heat mortality in Maricopa County and whether these relationships are sensitive to temperature. Using Poisson regression modeling with heat-related mortality as the outcome, we assessed the interaction of increasing temperature with social vulnerability, access to publicly available air conditioned space, home air conditioning and the thermal properties of residences. As temperatures increase, mortality from heat-related illness increases less in census tracts with more publicly accessible cooled spaces. Mortality from all internal causes of death did not have this association. Building thermal protection was not associated with mortality. Social vulnerability was still associated with mortality after adjusting for the infrastructure variables. To reduce heat-related mortality, the use of public cooled spaces might be expanded to target the most vulnerable.

Patterns of chromosomal variation in natural populations of the neoallotetraploid Tragopogon mirus (Asteraceae)

Cytological studies have shown many newly formed allopolyploids (neoallopolyploids) exhibit chromosomal variation as a result of meiotic irregularities, but few naturally occurring neoallopolyploids have been examined. Little is known about how long chromosomal variation may persist and how it might influence the establishment and evolution of allopolyploids in nature. In this study we assess chromosomal composition in a natural neoallotetraploid, Tragopogon mirus, and compare it with T. miscellus, which is an allotetraploid of similar age (~40 generations old). We also assess whether parental gene losses in T. mirus correlate with entire or partial chromosome losses. Of 37 T. mirus individuals that were karyotyped, 23 (62%) were chromosomally additive of the parents, whereas the remaining 14 individuals (38%) had aneuploid compositions. The proportion of additive versus aneuploid individuals differed from that found previously in T. miscellus, in which aneuploidy was more common (69%; Fisher's exact test, P=0.0033). Deviations from parental chromosome additivity within T. mirus individuals also did not reach the levels observed in T. miscellus, but similar compensated changes were observed. The loss of T. dubius-derived genes in two T. mirus individuals did not correlate with any chromosomal changes, indicating a role for smaller-scale genetic alterations. Overall, these data for T. mirus provide a second example of prolonged chromosomal instability in natural neoallopolyploid populations.

Siting is a constraint to realize environmental benefits from carbon capture and storage

Carbon capture and storage (CCS) for coal power plants reduces onsite carbon dioxide emissions, but affects other air emissions on and offsite. This research assesses the net societal benefits and costs of Monoethanolamine (MEA) CCS, valuing changes in emissions of CO2, SO2, NOX, NH3 and particulate matter (PM), including those in the supply chain. Geographical variability and stochastic uncertainty for 407 coal power plant locations in the U.S. are analyzed. The results show that the net environmental benefits and costs of MEA CCS depend critically on location. For a few favorable sites of both power plant and upstream processes, CCS realizes a net benefit (benefit-cost ratio >1) if the social cost of carbon exceeds $51/ton. For much of the U.S. however, the social cost of carbon must be much higher to realize net benefits from CCS, up to a maximum of $910/ton. While the social costs of carbon are uncertain, typical estimates are in the range of $32-220 per ton, much lower than the breakeven value for many potential CCS locations. Increased impacts upstream from the power plant can dramatically change the social acceptability of CCS and needs further consideration and analysis.

Single integration and spread of a Copia-like sequence nested in rDNA intergenic spacers of Allium cernuum (Alliaceae)

The 35S ribosomal DNA (rDNA) intergenic spacer (IGS) of Allium cernuum is examined. Initial sequencing of IGS clones revealed that some rDNA units contain a truncated retrotransposon sequence most similar to members of the Copia superfamily. Fluorescence in situ hybridisation (FISH) to metaphase chromosomes indicates that this element is dispersed along both pairs of major rDNA arrays. Southern hybridisation confirmed the presence of this 'relic' Copia-like element in more than 10% of 35S rDNA units, in the same position within the IGS. To measure the intragenomic divergence of the relic retroelement and its flanking sequences amongst different rDNA units, a 1.1-kb region was amplified and cloned. These data collectively point to a single origin for units containing the putative retrotransposon fragment. It is likely that units containing the putative retroelement increased in copy number and dispersed via rDNA homogenisation mechanisms, rather than by multiple retrotransposition events.

Enhanced external counterpulsation for the treatment of stable angina and heart failure: a systematic review and economic analysis

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of enhanced external counterpulsation (EECP) compared with usual care and placebo for refractory stable angina and heart failure, and to undertake analyses of the expected value of information to assess the potential value of future research on EECP.

DATA SOURCES

Major electronic databases were searched between November 2007 and March 2008.

REVIEW METHODS

A systematic review of the literature was undertaken and a decision model developed to compare EECP treatment with no treatment in adults with chronic stable angina.

RESULTS

Five studies were included in the review. In the Multicenter Study of Enhanced External Counterpulsation (MUST-EECP), time to greater than or equal to 1-mm ST segment depression (exercise-induced ischaemia) was statistically significantly improved in the EECP group compared with the control group (sham EECP), mean difference (MD) 41 seconds [95% confidence interval (CI) 9.10-73.90]. However, there was no statistically significant difference between the EECP and control groups in the change in exercise duration from baseline to end of treatment, self-reported angina episodes or daily nitroglycerin use, and the clinical significance of the limited benefits was unclear. There was also a lack of data on long-term outcomes. There were more withdrawals due to adverse events in the EECP group than in the control group, as well as a greater proportion of patients with adverse events [relative risk (RR) 2.13, 95% CI 1.35-3.38]. The three non-randomised studies compared EECP with elective percutaneous coronary intervention (PCI) and usual care. There was a high risk of selection bias in all three studies and the results should be treated with considerable caution. The study comparing an EECP registry with a PCI registry reported similar 1-year all-cause mortality in both groups. In the Prospective Evaluation of EECP in Congestive Heart Failure (PEECH) trial, patients with heart failure were randomised to EECP or to usual care (pharmacotherapy only). At 6 months post treatment, the proportion of patients achieving at least a 60-second increase in exercise duration was higher in the EECP group (RR 1.39, 95% CI 0.89-2.16), but the proportion with an improvement in peak VO2 was similar in both groups. The clinical significance of this is unclear. The proportion of patients in the EECP group with an improvement in New York Heart Association classification was higher (RR 2.25, 95% CI 1.25-4.06) at 6 months, as was mean exercise duration, MD 34.6 (95% CI -4.86 to 74.06). There were more withdrawals in the EECP group than in the control group as a result of adverse events (RR 1.05, 95% CI 0.67-1.66). There were limitations in the generalisability of results of the trial and, again, a lack of data on long-term outcomes. The review of cost-effectiveness evidence found only one unpublished study but demonstrated that the long-term maintenance of quality of life benefits of EECP is central to the estimate of its cost-effectiveness. The incremental cost-effectiveness ratio of EECP was 18,643 pounds for each additional quality-adjusted life-year (QALY), with a probability of being cost-effective of 0.44 and 0.70 at cost-effectiveness thresholds of 20,000 pounds and 30,000 pounds per QALY gained respectively. Results were sensitive to the duration of health-related quality of life (HRQoL) benefits from treatment.

CONCLUSIONS

The results from a single randomised controlled trial (MUST-EECP) do not provide firm evidence of the clinical effectiveness of EECP in refractory stable angina or in heart failure. High-quality studies are required to investigate the benefits of EECP, whether these outweigh the common adverse effects and its long-term cost-effectiveness in terms of quality of life benefits.

Cellulosic ethanol from municipal solid waste: a case study of the economic, energy, and greenhouse gas impacts in California

As cellulosic ethanol technologies advance, states could use the organic content of municipal solid waste as a transportation fuel feedstock and simultaneously reduce externalities associated with waste disposal. We examine the major processes required to support a lignocellulosic (employing enzymatic hydrolysis) municipal solid waste-to-ethanol infrastructure computing cost, energy, and greenhouse gas effects for California. The infrastructure is compared against the Business As Usual case where the state continues to import most of its ethanol needs from the Midwest. Assuming between 60% and 90% practical yields for ethanol production, California could produce between 1.0 and 1.5 billion gallons per year of ethanol from 55% of the 40 million metric tonnes of waste currently sent to landfills annually. The classification of organic wastes and ethanol plant operation represent almost the entire system cost (between $3.5 and $4.5 billion annually) while distribution has negligible cost effects and savings from avoided landfilling is small. Fossil energy consumption from Business As Usual decreases between 82 and 130 PJ largely due to foregone gasoline consumption. The net greenhouse gas impacts are ultimately dependent on how well landfills control their emissions of decomposing organics. Based on the current landfill mix in the state, the cellulosic infrastructure would experience a slight gain in greenhouse gas emissions. However, net emissions can rise if organics diversion releases carbon that would otherwise be flared and sequestered. Emissions would be avoided if landfills are not capable of effectively controlling emissions during periods of active waste decay. There is currently considerable uncertainty surrounding the recovery efficiency of landfill emissions controls. In either case, burying lignin appears to be better than burning lignin because of its decay properties, energy and carbon content We estimate the breakeven price for lignocellulosic ethanol between $2.90 and $3.47/gal (mu = $3.13/gal).

Energy, greenhouse gas, and cost reductions for municipal recycling systems

Curbside recycling programs can be more cost-effective than landfilling and lead to environmental benefits from the recovery of materials. Significant reductions in energy and emissions are derived from the decrease of energy-intensive production with virgin materials. In many cities, competing priorities can lead to limited consideration given to system optimal collection and processing strategies that can drive down costs and increase revenue while simultaneously reducing system energy consumption and greenhouse gas (GHG) emissions. We evaluate three alterations to a hypothetical California city's recycling network to discern the conditions under which the changes.constitute system improvements to cost, energy, and emissions. The system initially operates with a collection zoning scheme that does not mitigate the impact of seasonal variations in consumer tonnage. In addition, two collection organizations operate redundantly, collecting recyclables from different customer types on the same street network. Finally, the system is dual stream, meaning recyclables are separated at the curbside. In some scenarios, this practice can limit the consumer participation rate leading to lower collection quantities. First, we evaluate a "business as usual" (BAU) scenario and find that the system operates at a $1.7 M/yr loss but still avoids a net 18.7 GJ and 1700 kg of greenhouse gas equivalent (GGE) per ton of material recycled. Second, we apply an alternative zoning scheme for collection that creates a uniform daily pickup demand throughout the year reducing costs by $0.2 M/yr, energy by 30 MJ/ton, and GHG emissions by 2 kg GGE/ton. Next, the two collection organizations are consolidated into a single entity further reducing vehicle fleet size and weekly vehicle miles traveled resulting in savings from BAU of $0.3 M/yr, 100 MJ/ton, and 8 kg GGE/ton. Lastly, we evaluate a switch to a single-stream system (where recyclables are commingled). We showthat single-stream recycling can increase the total amount of material collected to a degree that lowers overall net cost ($0.2 M/yr) and leads to further reductions in energy use (210 MJ/ton) and emissions(16 kg GGEton). However,there can be circumstances in which maintaining a consolidated dual stream system is preferred over single stream. A sensitivity analysis is also performed and a discussion is presented addressing the applicability of this city network to others.

A preliminary study of genetic variation in populations of Monstera adansonii var. klotzschiana (Araceae) from North-East Brazil, estimated with AFLP molecular markers

BACKGROUND AND AIMS

This study sought genetic evidence of long-term isolation in populations of Monstera adansonii var. klotzschiana (Araceae), a herbaceous, probably outbreeding, humid forest hemi-epiphyte, in the brejo forests of Ceará (north-east Brazil), and clarification of their relationships with populations in Amazonia and the Atlantic forest of Brazil.

METHODS

Within-population genetic diversity and between-population dissimilarity were estimated using AFLP molecular markers in 75 individuals from eight populations located in Ceará, the Brazilian Atlantic Forest and Amazonia.

KEY RESULTS

The populations showed a clinal pattern of weak genetic differentiation over a large geographical region (F(ST) = 0.1896). A strong correlation between genetic and geographical distance (Mantel test: r = 0.6903, P = 0.002) suggests a historical pattern of isolation by distance. Genetic structure analysis revealed at least two distinct gene pools in the data. The two isolated Ceará populations are significantly different from each other (pairwise Phi(PT) = 0.137, P = 0.003) and as diverse (Nei's gene diversity, average H(e) = 0.1832, 0.1706) as those in the Atlantic and Amazon forest regions. The population in southern Brazil is less diverse (Nei's gene diversity, average H(e) = 0.127) than the rest. The Ceará populations are related to those of the Atlantic forest rather than those from Amazonia (AMOVA, among-groups variation = 11.95 %, P = 0.037).

CONCLUSIONS

The gene pools detected within an overall pattern of clinal variation suggest distinct episodes of gene flow, possibly correlated with past humid forest expansions. The Ceará populations show no evidence of erosion of genetic diversity, although this was expected because of their isolation. Their genetic differentiation and relatively high diversity reinforce the importance of conserving the endangered brejo forests.

A giant γ-ray flare from the magnetar SGR 1806–20

Two classes of rotating neutron stars-soft gamma-ray repeaters (SGRs) and anomalous X-ray pulsars-are magnetars, whose X-ray emission is powered by a very strong magnetic field (B approximately 10(15) G). SGRs occasionally become 'active', producing many short X-ray bursts. Extremely rarely, an SGR emits a giant flare with a total energy about a thousand times higher than in a typical burst. Here we report that SGR 1806-20 emitted a giant flare on 27 December 2004. The total (isotropic) flare energy is 2 x 10(46) erg, which is about a hundred times higher than the other two previously observed giant flares. The energy release probably occurred during a catastrophic reconfiguration of the neutron star's magnetic field. If the event had occurred at a larger distance, but within 40 megaparsecs, it would have resembled a short, hard gamma-ray burst, suggesting that flares from extragalactic SGRs may form a subclass of such bursts.

The simultaneous use of a biventricular implantable cardioverter defibrillator (ICD) and transcutaneous electrical nerve stimulation (TENS) unit: implications for device interaction

Undesirable sensing of external sources of electromagnetic interference by ICDs is well known. A transcutaneous electrical nerve stimulation (TENS) device has been reported to interfere with an ICD resulting in an inappropriate shock and patients with implanted defibrillators or pacemakers have been cautioned about the use of such units to treat chronic pain. We describe a patient regularly using TENS therapy for pain who subsequently received a biventricular ICD for malignant ventricular arrhythmias and medically refractory cardiac failure. He underwent testing for device interaction immediately post-implant. This did not show inappropriate sensing by either ICD or pacemaker component of his heart failure device. However, six months later, the patient complained of dizziness and bradycardia with application of TENS. Further testing did reveal interference with pacemaker function. Thus, even if initial testing is negative and reassuring, patients with a biventricular ICD still require careful follow-up for potential interaction and should be cautioned against the use of TENS, especially if they are pacemaker-dependent.

Neuromodulation for chronic refractory angina

Neuromodulation is the use of therapies which alter the relationship between the heart, its autonomic innervation and the central nervous system with the objective of reducing the ischaemic burden and diminishing the perception of angina.

'Cold hand, ischemic heart': treatment by stenting of the left subclavian artery

A 59-year-old man presented with worsening angina and a cold, painful left hand, eight years after coronary artery bypass surgery. Coronary angiography showed extensive coronary atherosclerosis with blocked vein grafts to his left circumflex and right coronary arteries. There was a severe narrowing in the left subclavian artery before the origin of the left internal mammary artery (LIMA) which appeared patent. PTCA and stent implantation to the left subclavian artery stenosis restored normal flow to the left hand and the LIMA with abolition of his ischemic hand symptoms and marked improvement of his angina.

Blood hemostasis in exercise and training

Formation of the blood clot is a slow but normal physiological process occurring as a result of the activation of blood coagulation pathways. Nature's guard against unwanted blood clots is the fibrinolytic enzyme system. In healthy people, there is a delicate dynamic balance between blood clot formation and blood clot dissolution. Available evidence suggests that exercise and physical training evoke multiple effects on blood hemostasis in normal healthy subjects and in patients. A single bout of exercise is usually associated with a transient increase in blood coagulation as evidenced by a shortening of activated partial thromboplastin time (APTT) and increased Factor VIII (FVIII). The rise in FVIII is intensity dependent and continues into recovery. The effects of acute exercise on plasma fibrinogen have yielded conflicting results. Thus, the issue of whether exercise-induced blood hypercoagulability in vitro mirrors an in vivo thrombin generation and fibrin formation remains disputable. Exercise-induced enhancement of fibrinolysis has been repeatedly demonstrated using a wide range of exercise protocols incorporating various exercise intensities and durations. Moderate exercise appears to enhance blood fibrinolytic activity without a concomitant activation of blood coagulation mechanisms, whereas, very heavy exercise induces simultaneous activation of blood fibrinolysis and coagulation. The increase in fibrinolysis is due to a rise in tissue-type plasminogen activator (tPA) and decrease in plasminogen activator inhibitor (PAI). The mechanism of exercise-induced hyperfibrinolysis is poorly understood, and the physiological utility of such activation remains unresolved. Strenuous exercise elicits a transient increase in platelet count, but there are conflicting results concerning the effect of exercise on platelet aggregation and activation. Few comprehensive studies exist concerning the influence of exercise training on blood hemostasis, making future investigation necessary to identify whether there are favorable effects of exercise training on blood coagulation, fibrinolysis, and platelet functions.

Variant complex translocations involving chromosomes 1, 9, 9, 15 and 17 in acute promyelocytic leukemia without RAR alpha/PML gene fusion rearrangement

Acute promyelocytic leukemia (APL;M3) is specifically characterized by a predominance of malignant promyelocytes having atypical reciprocal translocation involving chromosome 15 and 17 [t(15;17)(q22;q11)] resulting in the fusion of retinoic acid receptor alpha (RAR alpha) on chromosome 17 and the putative transcription factor gene PML, ie the translocation generates two fusion transcripts, PML/RAR alpha and RAR alpha/PML. We describe a patient with clinical and morphologic characteristics of atypical APL but with a previously undescribed variant translocation. A 35-year-old Hispanic having atypical APL was referred for cytogenetic evaluation. The cytogenetic findings with GTG-banding coupled with FISH analysis revealed the following karyotype: 46,XX,der(9)t(1;9)(q25;q34)der(9)t(9;?)(q34;?), t(15;17)(q22;q11)ish. der(9)t(1;9)(q25;q34)(WCP1+,WCP9+),t(9;17;15)(q34;q11;q22) (WCP9+,WCP15+,PML+;WCP17+,RAR alpha +;WCP15+,WCP17+,PML-)[20]/46,XX[5]. The chromosome 17q was translocated to the chromosome 15q. However, chromosome 15q including the PML gene normally translocating to 17q and creating the RAR alpha/PML fusion gene, translocated to chromosome 9q. Does this patient have another subset of APL? Or is the genetics of APL different in cases with variant translocations as opposed to those with atypical t(15;17) translocation, though in the majority of the cases their clinical presentation remains the same.

[The diagnosis of myocardial damage during coronary angioplasty by the analysis of the isoforms of the enzyme creatine kinase MB]

BACKGROUND

The existence of myocardial damage during percutaneous transluminal coronary angioplasty (PTCA) is controversial. Mild elevations in creatine kinase (CK) activity and its isoenzyme MB (CKMB) in patients who underwent PTCA have been reported. However, other authors failed to confirm these elevations. The low sensitivity of total CK and CKMB activity for the detection of myocardial damage in different settings other than myocardial infarction might account for the controversial findings. Measurement of CKMB isoforms has been shown to have a higher sensitivity than the assessment of CK or CKMB activity for early diagnosis of myocardial infarction. Its sensitivity for the diagnosis of myocardial damage in settings other than infarction is not well described.

OBJECTIVES

The aim of our study was two-fold: 1) to assess the incidence of myocardial damage after PTCA and 2) to compare the sensitivity of total CK and CKMB activity and measurement of CKMB isoforms for the detection of myocardial damage.

METHODS

14 patients (11 men and 3 women) with chronic stable angina underwent PTCA. Two electrocardiographic leads were monitored from the beginning of the procedure until 30 minutes after the PTCA. ST segment shifts of at least 1 mm, lasting for more than 1 minute, were considered indicative of myocardial ischemia. The duration of ischemic episodes was measured from the onset of the ST shift until its return to baseline. Total ischemic time, in minutes, was the sum of the duration of every ischemic episode. Blood samples were drawn before PTCA and serially during the first 24 hours post PTCA. CK (normal < 200 U/l) and CKMB (normal < 14 U/l) activities were measured. The CKMB isoforms were separated by electrophoresis, measured by densitometric scanning and their ratio calculated (CKMB2/CKMB1 normal < 1.5).

RESULTS

Vessels which underwent PTCA were: the left anterior descending artery (LDA) in 5 patients, the circumflex coronary artery (Cx) in 3 patients, right coronary artery (RCA) in 3 patients, LDA and Cx in 1 patient and Cx and RCA in 2 cases. Eleven patients underwent balloon dilatation, 1 underwent atherectomy (Rotablator) and two patients had treatment with both Rotablator and balloon angioplasty. Ischemic ST segment shifts were found in ten patients and the median of total ischemic time was 13.5 minutes (interquartile range: 2-15 minutes). Total CK and CKMB activities were within the normal range in every patient whereas in 7 patients (50%) the peak ratio CKMB2/CKMB1 was above the normal range. There were no differences in age, sex, number of vessels or lesions treated or in the time of balloon inflation between patients with and without abnormal CKMB2/CKMB1 peak. However, the ischemic time was significantly higher in patients with CKMB2/CKMB1 > 1.5 (median 15 vs 0 minutes; p = 0.023).

CONCLUSIONS

Myocardial damage during PTCA is not an uncommon finding. The CKMB isoforms are more sensitive markers of myocardial damage during PTCA than total CK or CKMB activities.

Aggressive pattern of angina after successful coronary angioplasty: the role of clinical and angiographic factors

To assess possible clinical and angiographic factors associated with acute coronary events following PTCA, we performed quantitative angiography in 168 consecutive patients who had undergone successful angioplasty in a native vessel (94 for stable angina, 74 for unstable angina), and who were restudied (24 +/- 15 weeks; range 4 to 52) because of recurrent anginal symptoms. Of the 168 patients, 38 (Group 1) were restudied because the pattern of angina was aggressive (unstable angina in 31, myocardial infarction in 7) and 130 because of effort-related angina (Group 2). the two patient groups were well matched for extent of initial disease but patients in Group 1 were younger (P=0.03). PTCA for unstable angina was originally performed more frequently in Group 1 than in Group 2 (27 of 38 patients (71% vs 47 of 130 patients (36%), P=0.0004). Disease progression in non-dilated segments occurred in 10 patients (26%) in Group 1 compared with eight (6%) in Group 2 (P=0.0004). Disease progression in non-dilated segments occurred in nine patients (24%) in Group 1 and in Group 2 (P=0.0004). Disease progression in non-dilated segments occurred in nine patients (24%) in Group 1 and in 10 (8%) in Group 2 (P=0.0006). Our conclusion is that patients who require re-investigation as a result of angina which has become aggressive following PTCA are usually those who originally underwent PTCA for unstable angina. These patients have a higher incidence of occlusive restenosis or disease progression.

Rapid angiographic progression of "target" and "nontarget" stenoses in patients awaiting coronary angioplasty

OBJECTIVES

Our aim was to compare the short-term evolution of "target" versus "nontarget" stenoses in patients awaiting coronary angioplasty.

BACKGROUND

Coronary angioplasty is effective therapy for angina pectoris, but coronary events occur after successful angioplasty that are caused by both restenosis and progression of mild preexisting nontarget stenoses.

METHODS

We prospectively studied 161 consecutive patients with stable angina (124 men and 37 women). After diagnostic angiography, target stenoses for angioplasty and nontarget lesions were identified. Patients were put on a routine waiting list and followed up regularly until repeat coronary arteriography was performed (mean +/- SD 7 +/- 3 months), either immediately before angioplasty (138 patients) or soon after an acute coronary event (23 patients), if one occurred. Stenosis diameter was measured by using computerized arteriography. Progression of disease was defined as > or = 20% lesion diameter reduction, new total occlusion or development of a "new" stenosis > or = 30%.

RESULTS

At study entry, the mean diameter of target (n = 207) and nontarget (n = 184) lesions was 68 +/- 9% and 38 +/- 9%, respectively (p < 0.001). Disease progression occurred in 33 patients (20%). Seven new lesions (one total occlusion) developed. Eighteen target (9%) and 15 nontarget (8%) stenoses progressed. The power of the study to detect a difference of 1% between the risks of progression of target and nontarget stenoses with a 90% probability was < 0.1. Total occlusion developed in 15 (83%) of the 18 target and 6 (40%) of the 15 nontarget stenoses (p = 0.03). During follow-up, a myocardial infarction developed in 3 patients (2%) and unstable angina in 20 (12%). These coronary events were associated with progression of target stenoses in 10 patients and nontarget stenoses in 7 and with the development of new lesions in 1. In five patients coronary events were not associated with stenosis progression.

CONCLUSIONS

Despite differences in baseline severity, a similar proportion of target and nontarget lesions progressed rapidly. However, target stenoses were more likely than nontarget lesions to progress to total occlusion. Progression of nontarget stenoses may contribute to recurrence of angina and new coronary events after successful angioplasty and should be considered when developing strategies aimed at improving outcome after angioplasty.

Clinical factors and angiographic features associated with premature coronary artery disease

BACKGROUND

Clinical, angiographic, and biochemical features may differ in young patients with coronary heart disease compared with older patients.

METHODS

We compared clinical and angiographic characteristics in 100 male patients with clinical onset of disease at age < or = 45 years (group 1) with those of 100 older male patients (clinical onset of disease at > or = 60 years) (group 2). All patients had documented coronary artery disease. The two patient groups were compared in terms of the pattern of angina at disease onset, angiographic features, and coronary risk factors.

RESULTS

Seventy-six patients in group 1 and 49 patients in group 2 presented with acute coronary syndromes (unstable angina or myocardial infarction) at clinical disease onset (p < 0.001). Compared with patients in group 2, younger patients (group 1) showed a preponderance of single-vessel disease (54 vs 36%; p < 0.001) and complex stenosis morphologic features (59 vs 36%; p < 0.01). Family history of coronary artery disease (39 vs 11%; p < 0.001) and smoking (73 vs 46%; p < 0.001) were also more prevalent in younger patients. Mean plasma total cholesterol level was 6.4 +/- 1.3 mmol/L in group 1 and 6.1 +/- 1.2 mmol/L in group 2 (p = NS). Younger patients, however, had lower high-density lipoprotein (HDL) cholesterol (0.9 +/- 0.2 mmol/L and 1.1 +/- 0.4 mmol/L; p < 0.01) and higher plasma triglyceride levels compared with patients of group 2 (2.7 +/- 1.3 mmol/L vs 2.1 +/- 1.1 mmol/L; p < 0.001).

CONCLUSIONS

Patients with premature coronary disease referred to coronary angiography commonly have unheralded acute onset of symptoms, angiographically complex stenosis morphologic features, and less extensive coronary artery disease. In addition to previously identified risk factors such as family history and smoking, we observed that high plasma triglyceride and low HDL cholesterol levels are associated with premature coronary artery disease.

Identification of patients at high risk for adverse coronary events while awaiting routine coronary angioplasty

BACKGROUND

Identification of patients at risk for progression of coronary stenosis and adverse clinical events while awaiting coronary angioplasty is desirable.

OBJECTIVE

To determine the standard clinical or angiographic variables, or both, present at initial angiography associated with the development of adverse coronary events (unstable angina, myocardial infarction, and angiographic total coronary occlusion) in patients awaiting routine percutaneous transluminal coronary angioplasty (PTCA).

PATIENTS AND METHODS

Consecutive male patients on a waiting list for routine PTCA. Routine clinical details were obtained at initial angiography. Stenosis severity was measured using computerised angiography.

OUTCOME MEASURES

Development of one or more of myocardial infarction, unstable angina, or angiographic total coronary occlusion while awaiting PTCA were recorded as an adverse event.

RESULTS

Some 214 of 219 patients underwent a second angiogram. One had a fatal myocardial infarction and four (2%) were lost to follow up. Fifty patients (23%) developed one or more adverse events (myocardial infarction five, unstable angina 35, total coronary occlusion 23) at a median (range) interval of 8 (3-25) months. Twenty (57%) of the 35 patients with unstable angina developed adverse events compared with 30 (17%) of the 180 with stable angina (P = 0.0001). Plasma triglyceride concentration was 2.6 (1.2) mmol/l in patients with adverse coronary events compared with 2.2 (1.1) mmol/l in those without such events (P < 0.05). Patients with adverse events were younger than those without (54 (9) years v 58 (9) years, P < 0.01). The relative risk of an adverse event in patients with unstable angina and increased plasma triglyceride concentrations was 6.9 compared with those presenting with stable angina and a normal triglyceride concentration (P < 0.02).

CONCLUSIONS

The study shows that adverse events are not uncommon in patients awaiting PTCA. Patients at high risk for adverse events may be predicted by the presence of acute coronary syndrome, increased concentration of plasma triglyceride, and younger age at the time of the first angiogram.

Photodynamic killing of human squamous cell carcinoma cells using a monoclonal antibody-photosensitizer conjugate

We have developed procedures in which the photosensitizer benzoporphyrin derivative monoacid ring A (BPD) can be covalently linked to carrier molecules of modified polyvinyl alcohol (PVA) to produce water-soluble PVA-BPD conjugates with a molecular mass in the range of 30 kd. These carriers can subsequently be covalently linked to monoclonal antibodies (MoAbs) using heterobifunctional linking agents. We describe here such a conjugate in which the MoAb (5E8) has specificity for a glycoprotein detected on human squamous cell carcinomas of the lung. We provide evidence that the conjugates produced were covalently linked and retained both their photosensitizing and antigen-binding activities. We show further that the MoAb-PVA-BPD conjugate, in the presence of 10% fetal calf serum, exhibited highly enhanced phototoxic killing of the target cell line (A549) over that exhibited by free BPD or a control MoAb-PVA-BPD conjugate. These results demonstrate, therefore, both the selectivity and specificity of this MoAb conjugate.

Functional and autoradiographic evidence for endothelin 1 receptors on human and rat cardiac myocytes. Comparison with single smooth muscle cells

This study aimed to determine whether receptors for endothelin were present on the cardiac myocyte as well as on vascular smooth muscle cells. Low- and high-resolution autoradiography was performed using 125I-endothelin 1 on intact rat myocardium and samples of human ventricle obtained from explanted hearts at the time of transplant. In addition to specific binding to the smooth muscle of the blood vessel lumen, there was considerable binding associated with cardiac myocytes. To discover whether there was any functional correlate for this binding, muscle cells were isolated enzymatically from human and rat ventricle and from rat femoral artery, and their contractile characteristics were studied. Single cardiac cells were superfused with physiological saline at 32 degrees C, and their length change was displayed continuously on a chart recorder. Endothelin 1 had a pronounced effect on shortening in both rat and human myocytes. The contraction amplitude was approximately doubled in both cases, from 4.1 +/- 0.8% cell length to 8.1 +/- 1.3% for rat (mean +/- SEM, n = 9, p less than 0.001), and from 2.1 +/- 0.5% to 4.0 +/- 0.5% in human (n = 10, p less than 0.001). In rat, the magnitude of the effect was comparable to that of the alpha-adrenoceptor agonist phenylephrine. The maximum contraction amplitude of the human cells, produced by raising extracellular calcium to greater than 10 mM, was 11.4 +/- 1.1% cell length (n = 9), significantly greater than that produced by endothelin (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)