Clinical and anatomical characteristics are often considered key factors in deciding between percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with complex coronary artery disease (CAD) such as left-main CAD or 3-vessel disease. However, little is known about the interaction between self-reported preprocedural physical/mental health and clinical outcomes after revascularization.This subgroup analysis of the SYNTAXES trial (SYNTAX Extended Survival), which is the extended follow-up of the randomized SYNTAX trial (Synergy Between PCI With Taxus and Cardiac Surgery) comparing PCI with CABG in patients with left-main CAD or 3-vessel disease, stratified patients by terciles of Physical (PCS) or Mental Component Summary (MCS) scores derived from the preprocedural 36-Item Short Form Health Survey, with higher PCS and MCS scores representing better physical and mental health, respectively. The primary end point was all-cause death at 10 years.A total of 1656 patients with preprocedural 36-Item Short Form Health Survey data were included in the present study. Both higher PCS and MCS were independently associated with lower 10-year mortality (10-point increase in PCS adjusted hazard ratio, 0.84 [95% CI, 0.73-0.97]; P=0.021; in MCS adjusted hazard ratio, 0.85 [95% CI, 0.76-0.95]; P=0.005). A significant survival benefit with CABG over PCI was observed in the highest PCS (>45.5) and MCS (>52.3) terciles with significant treatment-by-subgroup interactions (PCS Pinteraction=0.033, MCS Pinteraction=0.015). In patients with both high PCS (>45.5) and MCS (>52.3), 10-year mortality was significantly higher with PCI compared with CABG (30.5% versus 12.2%; hazard ratio, 2.87 [95% CI, 1.55-5.30]; P=0.001), whereas among those with low PCS (≤45.5) or low MCS (≤52.3), there were no significant differences in 10-year mortality between PCI and CABG, resulting in a significant treatment-by-subgroup interaction (Pinteraction=0.002).Among patients with left-main CAD or 3-vessel disease, patient-reported preprocedural physical and mental health status was strongly associated with long-term mortality and modified the relative treatment effects of PCI versus CABG. Patients with the best physical and mental health had better 10-year survival with CABG compared with PCI. Assessment of self-reported physical and mental health is important when selecting the optimal revascularization strategy.URL: https://www.gov; SYNTAXES Unique identifier: NCT03417050. URL: https://www.gov; SYNTAX Unique identifier: NCT00114972.
<p> Under-deck cable-stayed bridges are innovative bridge configurations in which stays are located underneath the deck. This bridge typology can lead to highly efficient and slender decks, resulting in a large reduction of the amount of materials employed. Nevertheless, if very slender decks are designed, vibration problems can arise potentially compromising the comfort of bridge users. The dynamic response of an under-deck cable-stayed bridge with a steel-concrete composite deck under the action of moving loads is studied. After an initial modal analysis, the contribution of each mode is identified. Loads applied eccentrically on the cross-section of the deck are found to increase accelerations substantially. Amplification and cancellation speeds are observed to govern the maximum accelerations registered on the deck. A parametric analysis reveals the maximum slendernesses that can be achieved to satisfy different comfort criteria.</p>
No abstract is provided for this article.
Autonomic nerves influence airway tone by activating specific receptors on the target cells in the airways. The different components of the autonomic nervous system interact with each other, by affecting release of neurotransmitter, at ganglia in the airways, and by interaction at postjunctional receptors. Muscarinic receptors regulate mucus secretion from both submucosal glands and airway epithelial goblet cells. In the cholinergic pathway, acetylcholine released from postganglionic nerve endings stimulates muscarinic cholinergic receptors. Adrenergic mechanisms include sympathetic nerves that release noradrenaline and circulating adrenaline secreted from the adrenal medulla; these catecholamines activate α- and ß-adrenoceptors. Autoradiographic studies have revealed that ß-receptors are localized to many different cell types within the lung, including smooth muscle of all airways from trachea to terminal bronchioles, submucosal glands, airway epithelium and alveolar walls. Evidence has been found for a ß-receptor-mediated inhibition of cholinergic transmission in human and in dog airways. Changes in ß2-receptor function have been reported to occur in lung diseases, such as asthma.
The effect of intracoronary nifedipine on regional and global left ventricular performance, coronary vasomotility, and myocardial oxygen consumption is reported. Left ventricular pressures and volume indices of contractility and relaxation were simultaneously recorded in five patients without coronary artery disease. In these patients, nifedipine in the left main coronary artery not only delayed (+115 ms) anterior wall contraction but also slowed (3.5 vs 1.9 cm/s) and depressed it (-26%), resulting in a depression of global left ventricular ejection. This asynchrony and depression of regional contraction is considered to be responsible for the slowed isovolumic contraction and relaxation of the whole ventricle. In 10 other patients with coronary artery disease, coronary sinus blood flow and myocardial oxygen consumption were measured before and after intracoronary nifedipine. The observed decrease in myocardial oxygen consumption (-28%) depended primarily on a decrease in contractility and left ventricular performance. In a third study group of 12 patients with coronary artery disease, the effects of intracoronary nifedipine on the coronary vasomotility of 40 coronary segments (normal, prestenotic, stenotic, poststenotic) were quantitatively determined. Left ventricular haemodynamics and coronary sinus saturation were monitored while the cineangiograms were recorded before and after nifedipine. Nifedipine provoked vasodilatation of the normal (+10.3%), prestenotic, stenotic (+4 to 30%), and poststenotic (+16.4%) coronary segments, which persisted after the disappearance of its direct effects on the myocardium. This transient regional "cardioplegic" effect of nifedipine, associated with an increase in coronary blood flow, a reduction in myocardial oxygen consumption, and a vasodilatation of the epicardial vessels is likely to be beneficial during temporary coronary occlusion such as occurs in spasm or transluminal angioplasty.
No abstract is provided for this article.
No currently available treatments reduce the progression of COPD or suppress the inflammation in small airways and lung parenchyma. However, several new treatments that target the inflammatory process are in clinical development. A group of specific therapies are directed against the influx of inflammatory cells into the airways and lung parenchyma that occurs in COPD; these include adhesion molecule and chemokine-directed therapy, as well as therapies to combat tumour necrosis factor-alpha and augment interleukin-10. Broad spectrum anti-inflammatory drugs are now in phase III development for COPD, and include phosphodiesterase-4 inhibitors. Other drugs that inhibit cell signalling include inhibitors of p38 mitogen-activated protein kinase, nuclear factor-kappaB and phosphoinositide-3 kinase-gamma. More specific approaches are to give antioxidants, inhibitors of inducible nitric oxide synthase, and leukotriene B4 receptor antagonists. Epidermal growth factor receptor kinase inhibitors and calcium-activated chloride channel inhibitors have potential to combat mucus overproduction. Therapy to inhibit fibrosis is being developed against transforming growth factor-beta1 and protease activated receptor-2. There is also a search for serine proteinase and matrix metalloproteinase inhibitors to prevent lung destruction and the development of emphysema, as well as drugs such as retinoids that may even reverse this process. Effective delivery of drugs to the sites of disease in the peripheral lung is an important consideration, and there is the need for validated biomarkers and monitoring techniques in early clinical studies with new therapies for COPD.
There is increasing evidence that chronic inflammation in asthma is mediated via a network of cytokines emanating from inflammatory and structural cells in the airways. The prominent eosinophilic inflammation that characterizes asthma appears to be orchestrated by cytokines derived from type 2 T-helper (Th2)-like lymphocytes, suggesting that immunosuppressants might be beneficial in the control of asthma. Indeed, one of the critical modes of action of glucocorticoids in controlling asthma may be the suppression of Th2-lymphocyte-derived cytokines, such as interleukin-5 (IL-5). Cyclosporin-A may have a similar immunomodulatory role, but its potential beneficial effects are outweighed by its toxicity, at least when given parenterally. Future immunomodulators need to be more selective, either by means of delivery (inhalation, liposomes) or by a more specific effect on Th2, as opposed to Th1, lymphocytes or their products. Such approaches may include new immunomodulators, such as mycophenolate mofetil, specific cytokine inhibitors (such as interleukin-5 antibodies), endogenous suppressors of Th2 cells (interferon-gamma or interleukin-12), or type 4 phosphodiesterase inhibitors.
