Ischaemic mitral regurgitation: pathophysiology, outcomes and the conundrum of treatment.

peer reviewedIschaemic mitral regurgitation is a frequent complication of left ventricular global or regional pathological remodelling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces (papillary muscles displacement leading to a more apical position of the leaflets and their coaptation point) and reduced closing forces (reduced contractility, dyssynchrony of the papillary muscles, intra-left ventricular dyssynchrony). Although mitral regurgitation has an unloading effect and reduces impedance, the volume overload begets further left ventricular dilatation, increases ventricular wall stress leading to worsened performance. Ischaemic mitral regurgitation is characteristically dynamic: its severity may vary with haemodynamic conditions. Both the severity of ischaemic mitral regurgitation and its dynamic component worsen prognosis. There are numerous possible treatment modalities, but the management of the individual patient remains difficult. Medical therapy is mandatory; revascularization procedures are frequently not sufficient to reduce mitral regurgitation; the role of combined surgical therapy by mitral valve repair is not yet defined in the absence of large randomized trial. Some patients are good candidates for cardiac resynchronization therapy that may reduce the amount of regurgitation. New therapeutic targets are under investigation

The Greatest Problem with Which the Library is Confronted: A Survey of Academic Library Outreach to the Freshman Course

The Freshman Year Experience movement has created an excellent opportunity for academic library outreach. Its values, which include collaboration among various campus units charged with supporting student success and a focus on student mastery of key academic skills, correspond well with the objective of many college and university libraries: to become a more central part of the institution\u27s educational mission. This chapter provides a discussion of academic library outreach to one of the movement\u27s most significant components, the freshman course. The aim is to provide an overview of historic and contemporary trends in postsecondary freshman programming and corresponding library outreach efforts. A final section explores research findings related to student outcomes

Skin manifestations of Bartonella infections.

peer reviewe

Mutant and chimeric recobinant plasminogen activatorsproduction in eukaryotic cellsand preliminary characterization

Mutant urokinase-type plasminogen activator (u-PA) genes and hybrid genes between tissue-type plasminogen activator (t-PA) and u-PA have been designed to direct the synthesis of new plasminogen activators and to investigate the structure-function relationship in these molecules. The following classes of constructs were made starting from cDNA encoding human t-PA or u-PA: 1) u-PA mutants in which the Arg156 and Lys158 were substituted with threonine, thus preventing cleavage by thrombin and plasmin; 2) hybrid molecules in which the NH2-terminal regions of t-PA (amino acid residues 1-67, 1-262, or 1-313) were fused with the COOH-terminal region of u-PA (amino acids 136-411, 139-411, or 195-411, respectively); and 3) a hybrid molecule in which the second kringle of t-PA (amino acids 173-262) was inserted between amino acids 130 and 139 of u-PA. In all cases but one, the recombinant proteins, produced by transfected eukaryotic cells, were efficiently secreted in the culture medium. The translation products have been tested for their ability to activate plasminogen after in situ binding to an insolubilized monoclonal antibody directed against urokinase. All recombinant enzymes were shown to be active, except those in which Lys158 of u-PA was substituted with threonine. Recombination of structural regions derived from t-PA, such as the finger, the kringle 2, or most of the A-chain sequences, with the protease part or the complete u-PA molecule did not impair the catalytic activity of the hybrid polypeptides. This observation supports the hypothesis that structural domains in t-PA and u-PA fold independently from one to another

Management of a pregnant woman with fibromuscular dysplasia

No abstract available

Stratification of single-vessel coronary stenosis by ischemic threshold at the onset of wall motion abnormality during continuous monitoring of left ventricular function by semisupine exercise echocardiography.

peer reviewedWe studied the relation between the ischemic threshold at the onset of wall motion abnormality on exercise echocardiography (EE) and the severity of coronary stenosis in patients with 1-vessel coronary artery disease (CAD). We screened 216 consecutive patients who underwent coronary angiography and EE for suspected CAD. Ninety-five (74 men; age, 56 +/- 12 years) satisfied the study criteria, that is, the presence of 1-vessel disease or no evidence of CAD on angiography and a normal baseline echocardiogram. Eighty-seven patients had 1-vessel CAD on angiography, and exercise-induced wall motion abnormality occurred in 73 (77%). Optimal cutoff values of percent diameter stenosis and minimal lumen diameter for predicting a positive EE were 61% (sensitivity and specificity of 76%) and 1.12 mm (sensitivity and specificity of 74%). Among patients with positive EE, heart rate-blood pressure product at ischemic threshold was correlated with quantitative coronary stenosis (r = -0.72, P <.001). The ischemic threshold from continuous monitoring of left ventricular function during semisupine EE is correlated with the severity of coronary stenosis among patients with 1-vessel disease and a normal resting echocardiogram

How I treat ... the athlete's foot and its non-mycotic cutaneous pathology

peer reviewedSkin and nails of the foot of sport practitioners of various disciplines are subjected to the effects of benign but invalidating pathologies. Microtraumatisms are frequently involved. Beside dermatomycoses and onychomycoses, a dozen of typical disorders are identified

MRSA clonal complex 22 strains harboring toxic shock syndrome toxin (TSST-1) are endemic in the primary hospital in Gaza, Palestine

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen in both community and healthcare-related settings worldwide. Current knowledge regarding the epidemiology of S. aureus and MRSA in Gaza is based on a single community-based carriage study. Here we describe a cross-sectional analysis of 215 clinical isolates collected from Al-Shifa Hospital in Gaza during 2008 and 2012. METHODS: All isolates were characterized by spa typing, SCCmec typing, and detection of genes encoding Panton-Valentine leukocidin (PVL) and toxic shock syndrome toxin (TSST-1). Representative genotypes were also subjected to multilocus sequence typing (MLST). Antibiotic susceptibility testing was performed using VITEK2 and MicroScan. RESULTS: MRSA represented 56.3% of all S. aureus strains, and increased in frequency from 2008 (54.8%) to 2012 (58.4%). Aside from beta-lactams, resistance was observed to tetracycline, erythromycin, clindamycin, gentamicin, and fluoroquinolones. Molecular typing identified 35 spa types representing 17 MLST clonal complexes (CC), with spa 998 (Ridom t223, CC22) and spa 70 (Ridom t044, CC80) being the most prevalent. SCCmec types I, III, IV, V and VI were identified among MRSA isolates, while type II was not detected. PVL genes (lukF/S-PV) were detected in 40.0% of all isolates, while the TSST-1 gene (tst) was detected in 27.4% of all isolates, with surprisingly high frequency within CC22 (70.4%). Both PVL and TSST-1 genes were found in several isolates from 2012. CONCLUSIONS: Molecular typing of clinical isolates from Gaza hospitals revealed unusually high prevalence of TSST-1 genes among CC22 MRSA, which is noteworthy given a recent community study describing widespread carriage of a CC22 MRSA clone known as the \u27Gaza strain\u27. While the latter did not address TSST-1, tst-positive spa 998 (Ridom t223) has been detected in several neighboring countries, and described as endemic in an Italian NICU, suggesting international spread of a \u27Middle Eastern variant\u27 of pandemic CC22 strain EMRSA-15

How can emerging economies meet development and climate goals in the transport-energy system? Modelling co-developed scenarios in Kenya using a socio-technical approach

Transport-energy transitions pose complex challenges that have been extensively studied in high-income countries in response to national mandates for climate action. Low- and middle-income countries, however, have low but rapidly growing motorisation rates and face very different challenges in adopting new technologies to foster economic development and ensure equitable access to clean transportation. Here, we present a set of narrative scenarios for the future of the Kenyan transport-energy system co-developed through engagement with 41 local experts and decision-makers. Through the co-development of a Kenyan transport-energy system model, we present a decision-support tool, populated with those scenarios, to assist policymakers at regional, national and international levels in building policy and investment pipelines to support low-carbon economic growth. We find that Kenya’s transport-energy system can meet both development and climate goals, but this demands strong policy support for efficient public transport and targeted support for road vehicle electrification. Increased support for non-motorised transport is essential to provide equitable access to services and economic opportunities. Favourable pathways result in significant e-mobility uptake, which is anticipated to increase electricity demand by 5%–56% from 2023 to 2040, relative to the IEA Kenya Energy Outlook’s Stated Policies scenario, representing a 2.7–3.9x increase in Kenya’s total electricity demand over the same period. From a macro-fiscal perspective, results show that e-mobility has two important consequences for Kenya. Firstly, under high e-mobility scenarios, there is a negative fiscal impact that taxation revenues from the sale of transport fuels reduce by up to 41% relative to the low e-mobility scenario (though, notably, they still increase marginally from the 2023 level because of increasing transport demand). Secondly, high e-mobility scenarios have a positive impact on balance of payments by reducing the fuel import bill by up to 69% relative to the low e-mobility baseline. This corresponds to a reduction in foreign exchange requirement of up to $4.2bn annually by 205

Extensive propagation of a pancreatic pseudocyst along the lower limb through the sciatic foramen.

The extremely rare extensive propagation of a giant retroperitoneal pancreatic pseudocyst into the posterior compartment of the lower limb as far as the knee is reported. The extension was found producing through the sciatic foramen and the full diagnosis was made by MDCT. A complete healing was progressively obtained in the 78-year old female after a six months period of sequential multidisciplinary therapeutic approach comprising combined medical and surgical intra-abdominal and external drainage