cFFR as an alternative to FFR: please do not contrast simplicity!

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The effects of remote ischaemic preconditioning on coronary artery function in patients with stable coronary artery disease

Background: Remote ischaemic preconditioning (RIPC) is a cardioprotective intervention invoking intermittent periods of ischaemia in a tissue or organ remote from the heart. The mechanisms of this effect are incompletely understood. We hypothesised that RIPC might enhance coronary vasodilatation by an endothelium-dependent mechanism. Methods: We performed a prospective, randomised, sham-controlled, blinded clinical trial. Patients with stable coronary artery disease (CAD) undergoing elective invasive management were prospectively enrolled, and randomised to RIPC or sham (1:1) prior to angiography. Endothelial-dependent vasodilator function was assessed in a non-target coronary artery with intracoronary infusion of incremental acetylcholine doses (10−6 , 10−5 , 10−4 mol/l). Venous blood was sampled pre- and post-RIPC or sham, and analysed for circulating markers of endothelial function. Coronary luminal diameter was assessed by quantitative coronary angiography. The primary outcome was the between-group difference in the mean percentage change in coronary luminal diameter following the maximal acetylcholine dose (Clinicaltrials.gov identifier: NCT02666235). Results: 75 patients were enrolled. Following angiography, 60 patients (mean ± SD age 57.5 ± 8.5 years; 80% male) were eligible and completed the protocol (n = 30 RIPC, n = 30 sham). The mean percentage change in coronary luminal diameter was −13.3 ± 22.3% and −2.0 ± 17.2% in the sham and RIPC groups respectively (difference 11.32%, 95%CI: 1.2– 21.4, p = 0.032). This remained significant when age and sex were included as covariates (difference 11.01%, 95%CI: 1.01– 21.0, p = 0.035). There were no between-group differences in endothelial-independent vasodilation, ECG parameters or circulating markers of endothelial function. Conclusions: RIPC attenuates the extent of vasoconstriction induced by intracoronary acetylcholine infusion. This endothelium-dependent mechanism may contribute to the cardioprotective effects of RIP

Invasive versus medical management in patients with prior coronary artery bypass surgery with a non-ST segment elevation acute coronary syndrome: a pilot randomized controlled trial

Background: The benefits of routine invasive management in patients with prior coronary artery bypass grafts presenting with non-ST elevation acute coronary syndromes are uncertain because these patients were excluded from pivotal trials. Methods: In a multicenter trial, non-ST elevation acute coronary syndromes patients with prior coronary artery bypass graft were prospectively screened in 4 acute hospitals. Medically stabilized patients were randomized to invasive management (invasive group) or noninvasive management (medical group). The primary outcome was adherence with the randomized strategy by 30 days. A blinded, independent Clinical Event Committee adjudicated predefined composite outcomes for efficacy (all-cause mortality, rehospitalization for refractory ischemia/angina, myocardial infarction, hospitalization because of heart failure) and safety (major bleeding, stroke, procedure-related myocardial infarction, and worsening renal function). Results: Two hundred seventeen patients were screened and 60 (mean±SD age, 71±9 years, 72% male) were randomized (invasive group, n=31; medical group, n=29). One-third (n=10) of the participants in the invasive group initially received percutaneous coronary intervention. In the medical group, 1 participant crossed over to invasive management on day 30 but percutaneous coronary intervention was not performed. During 2-years’ follow-up (median [interquartile range], 744 [570–853] days), the composite outcome for efficacy occurred in 13 (42%) subjects in the invasive group and 13 (45%) subjects in the medical group. The composite safety outcome occurred in 8 (26%) subjects in the invasive group and 9 (31%) subjects in the medical group. An efficacy or safety outcome occurred in 17 (55%) subjects in the invasive group and 16 (55%) subjects in the medical group. Health status (EuroQol 5 Dimensions) and angina class in each group were similar at 12 months. Conclusions: More than half of the population experienced a serious adverse event. An initial noninvasive management strategy is feasible. A substantive health outcomes trial of invasive versus noninvasive management in non-ST elevation acute coronary syndromes patients with prior coronary artery bypass grafts appears warranted. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01895751

Socioeconomic Inequality in the Prevalence of Autism Spectrum Disorder: Evidence from a U.S. Cross-Sectional Study

This study was designed to evaluate the hypothesis that the prevalence of autism spectrum disorder (ASD) among children in the United States is positively associated with socioeconomic status (SES).A cross-sectional study was implemented with data from the Autism and Developmental Disabilities Monitoring Network, a multiple source surveillance system that incorporates data from educational and health care sources to determine the number of 8-year-old children with ASD among defined populations. For the years 2002 and 2004, there were 3,680 children with ASD among a population of 557,689 8-year-old children. Area-level census SES indicators were used to compute ASD prevalence by SES tertiles of the population.Prevalence increased with increasing SES in a dose-response manner, with prevalence ratios relative to medium SES of 0.70 (95% confidence interval [CI] 0.64, 0.76) for low SES, and of 1.25 (95% CI 1.16, 1.35) for high SES, (P<0.001). Significant SES gradients were observed for children with and without a pre-existing ASD diagnosis, and in analyses stratified by gender, race/ethnicity, and surveillance data source. The SES gradient was significantly stronger in children with a pre-existing diagnosis than in those meeting criteria for ASD but with no previous record of an ASD diagnosis (p<0.001), and was not present in children with co-occurring ASD and intellectual disability.The stronger SES gradient in ASD prevalence in children with versus without a pre-existing ASD diagnosis points to potential ascertainment or diagnostic bias and to the possibility of SES disparity in access to services for children with autism. Further research is needed to confirm and understand the sources of this disparity so that policy implications can be drawn. Consideration should also be given to the possibility that there may be causal mechanisms or confounding factors associated with both high SES and vulnerability to ASD

Invasive versus medically managed acute coronary syndromes with prior bypass (CABG-ACS): insights into the registry versus randomised trial populations

Background: Coronary artery bypass graft (CABG) patients are under-represented in acute coronary syndrome (ACS) trials. We compared characteristics and outcomes for patients who did and did not participate in a randomised trial of invasive versus non-invasive management (CABG-ACS). Methods: ACS patients with prior CABG in four hospitals were randomised to invasive or non-invasive management. Non-randomised patients entered a registry. Primary efficacy (composite of all-cause mortality, rehospitalisation for refractory ischaemia/angina, myocardial infarction (MI), heart failure) and safety outcomes (composite of bleeding, stroke, procedure-related MI, worsening renal function) were independently adjudicated. Results: Of 217 patients screened, 84 (39%) screenfailed, of whom 24 (29%) did not consent and 60 (71%) were ineligible. Of 133 (61%) eligible, 60 (mean±SD age, 71±9 years, 72% male) entered the trial and 73 (age, 72±10 years, 73% male) entered a registry (preferences: physician (79%), patient (38%), both (21%)). Compared with trial participants, registry patients had more valve disease, lower haemoglobin, worse New York Heart Association class and higher frailty. At baseline, invasive management was performed in 52% and 49% trial and registry patients, respectively, of whom 32% and 36% had percutaneous coronary intervention at baseline, respectively (p=0.800). After 2 years follow-up (694 (median, IQR 558–841) days), primary efficacy (43% trial vs 49% registry (HR 1.14, 95% CI 0.69 to 1.89)) and safety outcomes (28% trial vs 22% registry (HR 0.74, 95% CI 0.37 to 1.46)) were similar. EuroQol was lower in registry patients at 1 year. Conclusions: Compared with trial participants, registry participants had excess morbidity, but longer-term outcomes were similar. Trial registration number: NCT01895751

Des systèmes d'élevage dans une montagne urbanisée : différents itinéraires pour rester en activité

International audienceThe issue is to identify driving forces and favourable factors that ensure persistence of mountain livestock farms over time. The paths and the processes of change are studied in a sample of fourteen livestock farms that still remain near Chambéry (Savoie), thanks to a retrospective approach reaching back to the 1950's. A focus is made on some main factors: workload, restructuring of dairies, off-farm job opportunities. The results show that, in this area, livestock farms achieved persistence thanks to the integration of other farming or off-farm activities in the farm-family system, during at least one phase of their path.L'objectif est d'identifier les moteurs de changement et les facteurs explicatifs qui permettent le maintien d'une activité d'élevage en montagne. Les itinéraires suivis et les processus de changement sont étudiés sur un échantillon de 14 exploitations situées près de Chambéry (massif des Bauges), grâce à une approche rétrospective remontant jusqu'aux années 1950. Les résultats montrent que, dans cette zone d'étude, les exploitations d'élevage se sont maintenues grâce à l'intégration d'autres activités (agricoles ou non) dans le système famille-exploitation, durant au moins une phase de leur itnéraire

Quels liens entre élevages et écosystèmes naturels ?. Lecture croisée en milieu aride et tropical

Reconcile livestock farming development with management of ecosystems recognized as Common goods are at stake in many countries. But the actual way in which farmers use ecosystems and its vegetation to feed their herds remain under investigated. Qualifying the diversity of links between livestock farming and natural ecosystems is the objective of this article, by crossing two situations of familial livestock farming greatly contrasting each other regarding their ecological as well as socioeconomic conditions: small ruminant farming in southern Tunisia and dairy farming in Brazilian Amazonia. In both countries, herd feeding practices based on pasture are blamed for causing desertification and deforestation. We implemented a comprehensive and formalized approach, combining monitoring of livestock farming practices and an iterative categorisation. We identified different links between livestock strategies and ecosystems according to the function of natural resources in feeding the herds and the role of the livestock in the farms. Describing and explaining this diversity allowed us to deconstruct the reductive image of livestock farming devastating the ecosystems. Our results are discussed and allow us to propose research paths to reconcile livestock farming development with sustainable management of ecosystems and to question the nature of what is called “resources” for the farmers.Concilier développement de l’élevage et gestion d’écosystèmes reconnus comme biens communs est un enjeu pour de nombreux pays. Mais la manière dont les éleveurs utilisent réellement les écosystèmes, en particulier pour alimenter leurs troupeaux, reste peu explorée. Notre objectif est de qualifier la diversité des liens existant entre élevages et écosystèmes naturels en croisant deux situations d’élevage familial contrastées au niveau écologique et socioéconomique : petits ruminants en Tunisie, bovins laitiers au Brésil. En formalisant des types de pratiques et stratégies d’élevage, nous montrons que les écosystèmes locaux ne constituent pas toujours des ressources de même nature pour les éleveurs. Ces résultats nuancent leur responsabilité vis-à-vis de la dégradation des ressources dites naturelles et ouvrent de nouvelles questions de recherche pour concilier développement de l’élevage et gestion durable des ressources

Comunidades tradicionais tecendo o desenvolvimento territorial: três experiências de interações entre sociobiodiversidade, mercados, políticas públicas e ação coletiva.

Desde os anos 1990 o estado do Amapá apostou num desenvolvimento territorial sustentável a partir da valorização econômica dos produtos da sociobiodiversidade e do reconhecimento dos saberes associados a estes recursos e detidos pelos povos e comunidades tradicionais (PCT). Este modelo de desenvolvimento endógeno se deu em sinergia com as dinâmicas globais na política federal brasileira, assim como dos mercados globais. O artigo questiona o papel de diversos fatores, a começar pelo papel das populações tradicionais, no sucesso do mercado do açaí, que hoje é reconhecido como um catalisador de desenvolvimento territorial sustentável. A partir de uma análise reflexiva de três experiências em diferentes localidades do Estado (Mazagão, Bailique, Oiapoque), as autoras mostram distintas estratégias relacionando populações tradicionais com o mercado, em função de proximidades (geográficas e sociais) e grau de organização coletiva. Estratégias nas quais os instrumentos de fomento públicos ou privados são necessários e mobilizados de forma diferenciada (PGPM-Bio nas comunidades ribeirinhas na proximidade da Capital, PNGATI nas Terras Indígenas, Fundos privados nas comunidades ribeirinhas do Bailique), apenas para reforçar dinâmicas sociais internas. A informalidade fragiliza ainda fortemente a posição dos povos e comunidades tradicionais em todos os elos da cadeia, porém, abre espaços para consolidação dos mercados locais e (assim) para a soberania alimentar

Good stability and mid-term subjective outcomes after repeated anterior cruciate ligament (ACL) revision surgery using allografts

Purpose: To evaluate the mid-term clinical outcomes of a cohort of patients who underwent multiple ACL revision reconstructions. The hypothesis was that patients with pre-existing meniscal deficiency conditions, malalignment and cartilage degeneration would have obtained lower results. Methods: All cases of multiple ACL revisions performed with allograft tissue at one single sport-medicine institution were extracted and patients with a minimum 2&nbsp;years of follow-up were included. WOMAC, Lhysolm, IKDC, and Tegner activity level before the injury and at last follow-up was collected and laxity evaluated with KT-1000 arthrometer and KiRA triaxial accelerometer. Results: From a cohort of 241 ACL revisions, 28 patients (12%) with Repeated ACL Revision reconstructions were included. Fourteen cases (50%) were considered “Complex” due to the addition of meniscal allograft transplantation (8) or meniscal scaffold (3) or high tibial osteotomy (3). The remaining 14 cases (50%) were considered as “Isolate”. The mean WOMAC score was 84.6 ± 11.4, Lysholm 81.7 ± 12.3, subjective IKDC 77.2 ± 12.1, and median Tegner score 6 (IQR 5–6) at pre-injury and at final follow-up. Statistically significant inferior values of WOMAC (p = 0.008), Lysholm (p = 0.02) and Subjective IKDC (p = 0.0193) were detected between “Complex” and “Isolate” revision groups. Higher average values of anterior translation at KT-1000 at both 125 N (p = 0.03) and manual maximum displacement test (p = 0.03) were reported in “Complex” with respect to “Isolate” revisions. Four patients were considered as failures and occurred in patients with “Complex” revisions, none occurred in the “Isolate” (30% vs 0%; p = 0.04). Conclusion: Good mid-term clinical results can be obtained after repeated ACL revision with allograft in patients who experienced multiple failures; however, those who need additional procedure due to malalignment or post-meniscectomy syndrome reported lower objective and subjective results. Level of evidence: III