Is Infrainguinal Bypass Grafting Successful Following Failed Angioplasty?

ObjectivesAngioplasty is often used in the management of lower limb ischaemia and can reduce the need for infrainguinal bypass in some patients. There is an associated failure rate with this technique and bypass surgery is often used in this situation as a secondary limb salvage procedure. We aimed to evaluate the outcome of infrainguinal bypass grafting following failed attempt at angioplasty.MethodsAll cases of infrainguinal bypass at a single centre over a seven year period were identified and notes reviewed. Cases were divided into four groups according to their indication for surgery; acute ischaemia, chronic critical ischaemia, failed angioplasty and an ‘other’ group including aneurysmal disease and claudicants. The failed angioplasty group was compared with the other three groups. Survival analysis was performed using Kaplan Meier curves and groups compared in terms of long term patency and survival.ResultsPrimary patency was 61.2% in the failed angioplasty group at 12 months compared with 60.6% in the other groups (P=1.11). There was also no significant difference in primary patency at 60 months (50% vs 40.6%, P=0.26). Survival at 12 months was also comparable between the groups (failed angioplasty group 74.2% compared with 77.3% in the other groups, P=0.662) as was 60 months survival (33.3% and 35.4% respectively, P=0.166).DiscussionIn this study, outcome of infrainguinal bypass following failed angioplasty was comparable to outcome of surgery performed for another indication. This paper supports the use of distal bypass surgery for limb salvage in cases where minimal access techniques have failed

At what peak velocity ratio value should duplex-detected infrainguinal vein graft stenoses be revised?

Objectives:To determine the peak velocity ratio (PVR) threshold at which to intervene and correct duplex detected vein graft stenoses.Design:Prospective study.Materials:Infrainguinal vein grafts in patients attending the vascular studies for routine postoperative surveillance.Methods:Colour duplex detected stenotic vein graft lesions with a peak velocity ratio (PVR) between 2.0 and 2.9 were identified and monitored by serial duplex scans performed monthly for 3 months and then at 3-monthly intervals thereafter. At the end of the study period, the outcome of these lesions were analysed.Results:Thirty-eight lesions were identified from 32 grafts. Of these lesions, sixteen (42%) resolved, 11 (29%) remained stable and 11 (29%) progressed to a PVR of ≥3.0 and underwent angioplasty. There were no occlusions in any of the grafts during the period of study.Conclusion:Colour duplex detected vein graft stenoses with a PVR of less than 3.0 can be treated expectantly if grafts with stenoses with a PVR 2.0–2.9 are scanned every month for at least 3 months after detection

Bilateral infrainguinal vein grafts and the incidence of vein graft stenosis

Objectives:To elucidate the incidence of significant vein graft stenosis in patients who have undergone bilateral infrainguinal vein grafts.Materials:Between 1987 and 1996, 22 patients were identified from our vascular studies database as having undergone bilateral infrainguinal vein bypass grafting.Methods:Data was obtained from the vascular studies database and by case note review. All patients had been part of a vein graft surveillance programme.Results:Of the 22 patients with bilateral vein grafts, eight were excluded from further analysis because one or more of their grafts failed within 30 postoperative days. In the remaining 14 patients (28 vein grafts) there were 15 primary vein graft stenoses. Six patients (43%) had bilateral vein graft stenoses, which is significantly higher (p = 0.0008) than the predicted value of 9%, for developing bilateral vein graft stenoses. For those patients who developed a vein graft stenosis in their first grafted limb (9/14), 67% (6/14) subsequently developed a vein graft stenosis in their second grafted limb.Conclusion:Patients who develop vein graft stenosis in one limb are at a greater risk of developing a contralateral vein graft stenosis if that limb is grafted. This may well be due to individual vein morphology or unidentified systemic factors that play a role in the aetiology of vein graft stenosis

Extreme events and predictability of catastrophic failure in composite materials and in the Earth

Despite all attempts to isolate and predict extreme earthquakes, these nearly always occur without obvious warning in real time: fully deterministic earthquake prediction is very much a ‘black swan’. On the other hand engineering-scale samples of rocks and other composite materials often show clear precursors to dynamic failure under controlled conditions in the laboratory, and successful evacuations have occurred before several volcanic eruptions. This may be because extreme earthquakes are not statistically special, being an emergent property of the process of dynamic rupture. Nevertheless, probabilistic forecasting of event rate above a given size, based on the tendency of earthquakes to cluster in space and time, can have significant skill compared to say random failure, even in real-time mode. We address several questions in this debate, using examples from the Earth (earthquakes, volcanoes) and the laboratory, including the following. How can we identify ‘characteristic’ events, i.e. beyond the power law, in model selection (do dragon-kings exist)? How do we discriminate quantitatively between stationary and non-stationary hazard models (is a dragon likely to come soon)? Does the system size (the size of the dragon’s domain) matter? Are there localising signals of imminent catastrophic failure we may not be able to access (is the dragon effectively invisible on approach)? We focus on the effect of sampling effects and statistical uncertainty in the identification of extreme events and their predictability, and highlight the strong influence of scaling in space and time as an outstanding issue to be addressed by quantitative studies, experimentation and models

The Vega debris disc: A view from Herschel

We present five band imaging of the Vega debris disc obtained using the Herschel Space Observatory. These data span a wavelength range of 70-500 mu m with full-width half-maximum angular resolutions of 5.6-36.9 ''. The disc is well resolved in all bands, with the ring structure visible at 70 and 160 mu m. Radial profiles of the disc surface brightness are produced, and a disc radius of 11 '' (similar to 85AU) is determined. The disc is seen to have a smooth structure thoughout the entire wavelength range, suggesting that the disc is in a steady state, rather than being an ephemeral structure caused by the recent collision of two large planetesimals

ELF5 suppresses estrogen sensitivity and underpins the acquisition of antiestrogen resistance in luminal breast cancer

We have previously shown that during pregnancy the E-twenty-six (ETS) transcription factor ELF5 directs the differentiation of mammary progenitor cells toward the estrogen receptor (ER)-negative and milk producing cell lineage, raising the possibility that ELF5 may suppress the estrogen sensitivity of breast cancers. To test this we constructed inducible models of ELF5 expression in ER positive luminal breast cancer cells and interrogated them using transcript profiling and chromatin immunoprecipitation of DNA followed by DNA sequencing (ChIP-Seq). ELF5 suppressed ER and FOXA1 expression and broadly suppressed ER-driven patterns of gene expression including sets of genes distinguishing the luminal molecular subtype. Direct transcriptional targets of ELF5, which included FOXA1, EGFR, and MYC, accurately classified a large cohort of breast cancers into their intrinsic molecular subtypes, predicted ER status with high precision, and defined groups with differential prognosis. Knockdown of ELF5 in basal breast cancer cell lines suppressed basal patterns of gene expression and produced a shift in molecular subtype toward the claudin-low and normal-like groups. Luminal breast cancer cells that acquired resistance to the antiestrogen Tamoxifen showed greatly elevated levels of ELF5 and its transcriptional signature, and became dependent on ELF5 for proliferation, compared to the parental cells. Thus ELF5 provides a key transcriptional determinant of breast cancer molecular subtype by suppression of estrogen sensitivity in luminal breast cancer cells and promotion of basal characteristics in basal breast cancer cells, an action that may be utilised to acquire antiestrogen resistance

Developing manufacturing control software: A survey and critique

The complexity and diversity of manufacturing software and the need to adapt this software to the frequent changes in the production requirements necessitate the use of a systematic approach to developing this software. The software life-cycle model (Royce, 1970) that consists of specifying the requirements of a software system, designing, implementing, testing, and evolving this software can be followed when developing large portions of manufacturing software. However, the presence of hardware devices in these systems and the high costs of acquiring and operating hardware devices further complicate the manufacturing software development process and require that the functionality of this software be extended to incorporate simulation and prototyping.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/45542/1/10696_2005_Article_BF01328739.pd

High-dimensional maximum marginal likelihood item factor analysis by adaptive quadrature

Although the Bock–Aitkin likelihood-based estimation method for factor analysis of dichotomous item response data has important advantages over classical analysis of item tetrachoric correlations, a serious limitation of the method is its reliance on fixed-point Gauss-Hermite (G-H) quadrature in the solution of the likelihood equations and likelihood-ratio tests. When the number of latent dimensions is large, computational considerations require that the number of quadrature points per dimension be few. But with large numbers of items, the dispersion of the likelihood, given the response pattern, becomes so small that the likelihood cannot be accurately evaluated with the sparse fixed points in the latent space. In this paper, we demonstrate that substantial improvement in accuracy can be obtained by adapting the quadrature points to the location and dispersion of the likelihood surfaces corresponding to each distinct pattern in the data. In particular, we show that adaptive G-H quadrature, combined with mean and covariance adjustments at each iteration of an EM algorithm, produces an accurate fast-converging solution with as few as two points per dimension. Evaluations of this method with simulated data are shown to yield accurate recovery of the generating factor loadings for models of upto eight dimensions. Unlike an earlier application of adaptive Gibbs sampling to this problem by Meng and Schilling, the simulations also confirm the validity of the present method in calculating likelihood-ratio chi-square statistics for determining the number of factors required in the model. Finally, we apply the method to a sample of real data from a test of teacher qualifications.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/43596/1/11336_2003_Article_1141.pd