The effect of the Cox-maze procedure for atrial fibrillation concomitant to mitral and tricuspid valve surgery

ObjectivesAtrial fibrillation (AF) is associated with less favorable outcomes in patients undergoing mitral valve and tricuspid valve surgery. Despite growing evidence on the potential benefits of surgical ablation for AF there is significant variability among surgeons in treatment of AF. The purpose of our study was to assess the effect of the Cox-maze procedure on operative and follow-up outcomes.MethodsIn our prospective study, patients who underwent isolated mitral valve or mitral valve+tricuspid valve surgery without history of AF (n = 506), with untreated AF (n = 75), or with Cox-maze procedure (n = 236) were included (N = 817). Sinus rhythm was captured according to Heart Rhythm Society guidelines. Patients who underwent the Cox-maze procedure were propensity score matched to patients without history of AF resulting in 208 pairs of patients.ResultsOperative outcomes were comparable after propensity score matching (Cox-maze procedure vs no AF) stroke/transient ischemic attack (0.5% vs 0.5%; P = 1.00), renal failure (2.9% vs 1.4%; P = .34), and operative mortality (1.4% vs 1.4%; P = 1.00). High return to sinus rhythm was documented at 6, 12, and 24 months (92%, 91%, and 86%, respectively) as well as sinus rhythm off antiarrhythmic drugs (79%, 84%, and 82%, respectively). Incidence of embolic stroke in patients who underwent Cox-maze procedure was 1.7% (4 out of 232 patients) and 5.1 cases per 1000 person-years. No difference in 4-year cumulative survival between propensity score-matched groups (91.9% vs 86.9%; log rank, 1.67; P = .20), but higher for patients who underwent Cox-maze procedure versus patients with untreated AF (hazard ratio, 2.47; P = .048). Higher additive European System for Cardiac Operative Risk Evaluation (odds ratio, 1.40; P < .001) and limited surgeon experience with Cox-maze procedure (odds ratio, 3.60; P < .001) were significant predictors for failure to perform Cox-maze procedure.ConclusionsIn our center, 76% of patients undergoing mitral valve or mitral valve+tricuspid valve surgery experiencing AF underwent concomitant Cox-maze procedure, which is considerably higher than the national average. No increased morbidity was associated with the Cox-maze procedure with the benefit of very low thromboembolic rate. These results suggest the need for performance-based education for AF surgical ablation to achieve optimal outcomes

Operational research in Malawi: making a difference with cotrimoxazole preventive therapy in patients with tuberculosis and HIV.

BACKGROUND: In Malawi, high case fatality rates in patients with tuberculosis, who were also co-infected with HIV, and high early death rates in people living with HIV during the initiation of antiretroviral treatment (ART) adversely impacted on treatment outcomes for the national tuberculosis and ART programmes respectively. This article i) discusses the operational research that was conducted in the country on cotrimoxazole preventive therapy, ii) outlines the steps that were taken to translate these findings into national policy and practice, iii) shows how the implementation of cotrimoxazole preventive therapy for both TB patients and HIV-infected patients starting ART was associated with reduced death rates, and iv) highlights lessons that can be learnt for other settings and interventions. DISCUSSION: District and facility-based operational research was undertaken between 1999 and 2005 to assess the effectiveness of cotrimoxazole preventive therapy in reducing death rates in TB patients and subsequently in patients starting ART under routine programme conditions. Studies demonstrated significant reductions in case fatality in HIV-infected TB patients receiving cotrimoxazole and in HIV-infected patients about to start ART. Following the completion of research, the findings were rapidly disseminated nationally at stakeholder meetings convened by the Ministry of Health and internationally through conferences and peer-reviewed scientific publications. The Ministry of Health made policy changes based on the available evidence, following which there was countrywide distribution of the updated policy and guidelines. Policy was rapidly moved to practice with the development of monitoring tools, drug procurement and training packages. National programme performance improved which showed a significant decrease in case fatality rates in TB patients as well as a reduction in early death in people with HIV starting ART. SUMMARY: Key lessons for moving this research endeavour through to policy and practice were the importance of placing operational research within the programme, defining relevant questions, obtaining "buy-in" from national programme staff at the beginning of projects and having key actors or "policy entrepreneurs" to push forward the policy-making process. Ultimately, any change in policy and practice has to benefit patients, and the ultimate judge of success is whether treatment outcomes improve or not

The Kinematic Algebra From the Self-Dual Sector

We identify a diffeomorphism Lie algebra in the self-dual sector of Yang-Mills theory, and show that it determines the kinematic numerators of tree-level MHV amplitudes in the full theory. These amplitudes can be computed off-shell from Feynman diagrams with only cubic vertices, which are dressed with the structure constants of both the Yang-Mills colour algebra and the diffeomorphism algebra. Therefore, the latter algebra is the dual of the colour algebra, in the sense suggested by the work of Bern, Carrasco and Johansson. We further study perturbative gravity, both in the self-dual and in the MHV sectors, finding that the kinematic numerators of the theory are the BCJ squares of the Yang-Mills numerators.Comment: 29 pages, 5 figures. v2: references added, published versio

Gravity waves and the LHC: Towards high-scale inflation with low-energy SUSY

It has been argued that rather generic features of string-inspired inflationary theories with low-energy supersymmetry (SUSY) make it difficult to achieve inflation with a Hubble scale H > m_{3/2}, where m_{3/2} is the gravitino mass in the SUSY-breaking vacuum state. We present a class of string-inspired supergravity realizations of chaotic inflation where a simple, dynamical mechanism yields hierarchically small scales of post-inflationary supersymmetry breaking. Within these toy models we can easily achieve small ratios between m_{3/2} and the Hubble scale of inflation. This is possible because the expectation value of the superpotential relaxes from large to small values during the course of inflation. However, our toy models do not provide a reasonable fit to cosmological data if one sets the SUSY-breaking scale to m_{3/2} < TeV. Our work is a small step towards relieving the apparent tension between high-scale inflation and low-scale supersymmetry breaking in string compactifications.Comment: 21+1 pages, 5 figures, LaTeX, v2: added references, v3: very minor changes, version to appear in JHE

Spatiotemporal scales of larval dispersal and connectivity among oil and gas structures in the North Sea

The ecological role of offshore man-made infrastructure is of growing international interest. By 2030, globally more than 7500 oil and gas platforms could be removed, many of which now host mature hard substrate ecosystems formed by sessile benthic species including sponges, corals and mussels. We investigated the spatiotemporal scales of generalised species dispersal and connectivity among oil and gas structures in the North Sea using strategically designed 3D advective passive particle tracking experiments forced by high resolution (1.8 km, hourly) velocity fields including tide-, density- and wind-driven currents. Trajectories from 2 seasonal releases during mixed winter (February) and stratified summer (July) conditions of 2010 were analysed for a variety of pelagic larval durations (PLDs) spanning 2 to 28 d. Particles dispersed on average 32 km away from their origins after just 5 d, 67 km after 15 d, and 109 km after 28 d, with considerable spatial variability and limited seasonal variations. Short (2 d) PLDs generated highly connected networks over smaller spatial scales, while longer PLDs (28 d) generated less fragmented networks covering a much larger area but with fewer connections. Tidally driven dispersal was isolated using a new method based on the harmonic analysis of the velocity fields: the resulting maximum linear dispersal distances varied from ~4 km in the northern North Sea to ~8 km in the southern North Sea. The present study provides baseline spatiotemporal scales of dispersal and connectivity patterns and optimized relocatable methods to assess connectivity in tidally active shelf seas

Inflation on the Brane with Vanishing Gravity

Many existing models of brane inflation suffer from a steep irreducible gravitational potential between the branes that causes inflation to end too early. Inspired by the fact that point masses in 2+1 D exert no gravitational force, we propose a novel unwarped and non-supersymmetric setup for inflation, consisting of 3-branes in two extra dimensions compactified on a sphere. The size of the sphere is stabilized by a combination of a bulk cosmological constant and a magnetic flux. Computing the 4D effective potential between probe branes in this background, we find a non-zero contribution only from exchange of level-1 KK modes of the graviton and radion. Identifying antipodal points on the 2-sphere projects out these modes, eliminating entirely the troublesome gravitational contribution to the inflationary potential.Comment: 19 pages, 11 figures, JHEP forma

Thinking differently about sustainability: experiences from the UK Open University

Systems thinking is often invoked as a panacea for dealing with issues of sustainable development. Imperatives towards being more holistic - getting the bigger picture – are often coupled with a need for greater interdisciplinarity - joined-up-thinking – particularly amongst triple bottom line disciplines of economics, social studies and natural sciences. So why are systems thinking courses not more prevalent? And how might the teaching of systems thinking enhance the value of thinking differently about sustainable development? The Open University, UK, is a recognised international leader in the provision of Systems education for over 40 years. More recent experiences with the launch of a postgraduate Systems Thinking in Practice suite of qualifications at Certificate, Diploma, and Masters level, suggest an appetite for systems thinking amongst mature-age part-time students from a variety of professional backgrounds with an interest in learning for sustainability. This paper outlines three key features of the two core modules of the programme - epistemic understanding, active pedagogy, and design praxis. Significantly, these attributes have helped to complement rather than replace existing skill-sets amongst professionals from different sectors working in the field of sustainable development

Memory for medication side effects in younger and older adults: the role of subjective and objective importance

Older adults often experience memory impairments, but can sometimes use selective processing and schematic support to remember important information. The current experiments investigate to what degree younger and healthy older adults remember medication side effects that were subjectively or objectively important to remember. Participants studied a list of common side effects, and rated how negative these effects were if they were to experience them, and were then given a free recall test. In Experiment 1, the severity of the side effects ranged from mild (e.g., itching) to severe (e.g., stroke), and in Experiment 2, certain side effects were indicated as critical to remember (i.e., “contact your doctor if you experience this”). There were no age differences in terms of free recall of the side effects, and older adults remembered more severe side effects relative to mild effects. However, older adults were less likely to recognize critical side effects on a later recognition test, relative to younger adults. The findings suggest that older adults can selectively remember medication side effects, but have difficulty identifying familiar but potentially critical side effects, and this has implications for monitoring medication use in older age

Transiting extrasolar planetary candidates in the Galactic bulge

More than 200 extrasolar planets have been discovered around relatively nearby stars, primarily through the Doppler line shifts owing to the reflex motions of their host stars, and more recently through transits of some planets across the face of the host stars. The detection of planets with the shortest known periods, 1.2 to 2.5 days, has mainly resulted from transit surveys which have generally targeted stars more massive than 0.75 M_sun. Here we report the results from a planetary transit search performed in a rich stellar field towards the Galactic bulge. We discovered 16 candidates with orbital periods between 0.4 and 4.2 days, five of which orbit stars of 0.44 to 0.75 M_sun. In two cases, radial-velocity measurements support the planetary nature of the companions. Five candidates have orbital periods below 1.0 day, constituting a new class of ultra-short-period planets (USPPs), which occur only around stars of less than 0.88 M_sun. This indicates that those orbiting very close to more luminous stars might be evaporatively destroyed, or that jovian planets around lower-mass stars might migrate to smaller radii.Comment: To appear in October 5, 2006 issue of Natur