Home-based versus centre-based cardiac rehabilitation: abridged Cochrane systematic review and meta-analysis.

OBJECTIVE: To update the Cochrane review comparing the effects of home-based and supervised centre-based cardiac rehabilitation (CR) on mortality and morbidity, quality of life, and modifiable cardiac risk factors in patients with heart disease. METHODS: Systematic review and meta-analysis. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and CINAHL were searched up to October 2014, without language restriction. Randomised trials comparing home-based and centre-based CR programmes in adults with myocardial infarction, angina, heart failure or who had undergone coronary revascularisation were included. RESULTS: 17 studies with 2172 patients were included. No difference was seen between home-based and centre-based CR in terms of: mortality (relative risk (RR) 0.79, 95% CI 0.43 to 1.47); cardiac events; exercise capacity (mean difference (MD) -0.10, -0.29 to 0.08); total cholesterol (MD 0.07 mmol/L, -0.24 to 0.11); low-density lipoprotein cholesterol (MD -0.06 mmol/L, -0.27 to 0.15); triglycerides (MD -0.16 mmol/L, -0.38 to 0.07); systolic blood pressure (MD 0.2 mm Hg, -3.4 to 3.8); smoking (RR 0.98, 0.79 to 1.21); health-related quality of life and healthcare costs. Lower high-density lipoprotein cholesterol (MD -0.07 mmol/L, -0.11 to -0.03, p=0.001) and lower diastolic blood pressure (MD -1.9 mm Hg, -0.8 to -3.0, p=0.009) were observed in centre-based participants. Home-based CR was associated with slightly higher adherence (RR 1.04, 95% CI 1.01 to 1.07). CONCLUSIONS: Home-based and centre-based CR provide similar benefits in terms of clinical and health-related quality of life outcomes at equivalent cost for those with heart failure and following myocardial infarction and revascularisation.

Wear study of Total Ankle Replacement explants by microstructural analysis.

The implantation of Total Ankle Replacement (TAR) prostheses generally gives satisfactory results. However, a high revision rate is associated with the Ankle Evolutive System (AES) implant, due to periprosthetic osteolysis that generates significant cortical lesions and bone cysts in the periprosthetic region. Radioclinical and histological analyses of peri-implant tissues show the presence of numerous foreign particles that may come from the implant. It is known that a precocious wear of materials may lead to an important rate of foreign body in tissues and may generate osteolysis lesions and inflammatory reactions. Thus the objectives of this retrospective study of 10 AES TAR implants (recovered after revision surgeries) are to understand how the prostheses wear out, which part is the most stressed and to determine the nature and size of foreign body particles. A better understanding of friction mechanisms between the three parts of the implant and of the nature and morphology of foreign particles generated was needed to explain the in vivo behavior of the implant. This was achieved using microstuctural and tomographic analysis of both implants parts and periprosthetic tissues.

Lowering N2O emissions from soils using eucalypt biochar: the importance of redox reactions.

Agricultural soils are the primary anthropogenic source of atmospheric nitrous oxide (N2O), contributing to global warming and depletion of stratospheric ozone. Biochar addition has shown potential to lower soil N2O emission, with the mechanisms remaining unclear. We incubated eucalypt biochar (550 °C)--0, 1 and 5% (w/w) in Ferralsol at 3 water regimes (12, 39 and 54% WFPS)--in a soil column, following gamma irradiation. After N2O was injected at the base of the soil column, in the 0% biochar control 100% of expected injected N2O was released into headspace, declining to 67% in the 5% amendment. In a 100% biochar column at 6% WFPS, only 16% of the expected N2O was observed. X-ray photoelectron spectroscopy identified changes in surface functional groups suggesting interactions between N2O and the biochar surfaces. We have shown increases in -O-C = N /pyridine pyrrole/NH3, suggesting reactions between N2O and the carbon (C) matrix upon exposure to N2O. With increasing rates of biochar application, higher pH adjusted redox potentials were observed at the lower water contents. Evidence suggests that biochar has taken part in redox reactions reducing N2O to dinitrogen (N2), in addition to adsorption of N2O.

Pyrolysing poultry litter reduces N2O and CO2 fluxes.

Application of poultry litter (PL) to soil can lead to substantial nitrous oxide (N2O) emissions due to the co-application of labile carbon (C) and nitrogen (N). Slow pyrolysis of PL to produce biochar may mitigate N2O emissions from this source, whilst still providing agronomic benefits. In a corn crop on ferrosol with similarly matched available N inputs of ca. 116 kg N/ha, PL-biochar plus urea emitted significantly less N2O (1.5 kg N2O-N/ha) compared to raw PL at 4.9 kg N2O-N/ha. Urea amendment without the PL-biochar emitted 1.2 kg N2O-N/ha, and the PL-biochar alone emitted only 0.35 kg N2O-N/ha. Both PL and PL-biochar resulted in similar corn yields and total N uptake which was significantly greater than for urea alone. Using stable isotope methodology, the majority (~80%) of N2O emissions were shown to be from non-urea sources. Amendment with raw PL significantly increased C mineralisation and the quantity of permanganate oxidisable organic C. The low molar H/C (0.49) and O/C (0.16) ratios of the PL-biochar suggest its higher stability in soil than raw PL. The PL-biochar also had higher P and K fertiliser value than raw PL. This study suggests that PL-biochar is a valuable soil amendment with the potential to significantly reduce emissions of soil greenhouse gases compared to the raw product. Contrary to other studies, PL-biochar incorporated to 100mm did not reduce N2O emissions from surface applied urea, which suggests that further field evaluation of biochar impacts, and methods of application of both biochar and fertiliser, are needed.

Identification and treatment of anaemia in patients awaiting hip replacement.

INTRODUCTION: The correction of anaemia prior to total hip arthroplasty reduces surgical risk, hospital stay and cost. This study considers the benefits of implementing a protocol of identifying and treating pre-operative anaemia whilst the patient is on the waiting list for surgery. PATIENTS AND METHODS: From a prospective series of 322 patients undergoing elective total hip arthroplasty (THA), patients identified as anaemic (haemoglobin (Hb) < 12 g/dl) when initially placed upon the waiting list were appropriately investigated and treated. Pre- and postoperative Hb levels, need for transfusion, and length of hospital stay were collated for the entire patient cohort. RESULTS: Of the cohort, 8.8% of patients were anaemic when initially placed upon the waiting list for THA and had a higher transfusion rate (23% versus 3%; P < 0.05) and longer hospital stay (7.5 days versus 6.6 days; P < 0.05). Over 40% of these patients responded to investigation and treatment whilst on the waiting list, showing a significant improvement in Hb level (10.1 g/dl to 12.7 g/dl) and improved transfusion rate. CONCLUSIONS: Quantifying the haemoglobin level of patients when initially placed on the waiting list helps highlight those at risk of requiring a postoperative blood transfusion. Further, the early identification of anaemia allows for the utilisation of the waiting-list time to investigate and treat these patients. For patients who respond to treatment, there is a significant reduction in the need for blood transfusion with its inherent hazards.

Systematic Review of Quality of Life following Laparoscopic and open colorectal surgery.

OBJECTIVE: To compare the health-related quality of life (HRQoL) of patients following laparoscopic and open colorectal surgery. METHODS: A systematic review was performed according to Quorum guidelines. Prospective studies comparing the HRQoL of patients after laparoscopic and open colorectal surgery were identified. The primary outcome measure was postoperative quality of life; performance status and cosmesis were secondary outcome measures. RESULTS: 23 studies were identified that satisfied the inclusion criteria; 18 assessed HRQoL, 4 performance status, and 3 cosmesis. It was not possible to perform a meta-analysis due to study heterogeneity. The studies reported outcomes for 2946 patients. The most frequent HRQoL instruments employed were SF-36, EORTC, and GIQLI. 6 studies, using a total of 12 separate measures, evaluated QoL during the first 3 post-operative months: 10 of these measures showed no significant difference, and 2 showed an improved HRQoL with laparoscopy. Twelve further studies evaluated HRQoL up to 5 years post-operatively: 9 showed no difference between the 2 groups, and 3 demonstrated a benefit for laparoscopy. Three of 4 studies assessing performance status on discharge, and all 3 studies assessing cosmesis, reported benefits with the laparoscopic approach. CONCLUSIONS: The current evidence suggests there is no significant difference in HRQoL following laparoscopic and open colorectal surgery, although there is a lack of good quality data. There is a trend towards improved quality of life outcomes and performance status with laparoscopy in the early post-operative period. There is a need for further research, particularly assessing quality of life in the early post-operative period.

The decomposition of wood products in landfills in Sydney, Australia.

Three landfill sites that had been closed for 19, 29 and 46 years and had been operated under different management systems were excavated in Sydney. The mean moisture content of the wood samples ranged from 41.6% to 66.8%. The wood products recovered were identified to species, and their carbon, cellulose, hemicellulose and lignin concentration were determined and compared to those of matched samples of the same species. No significant loss of dry mass was measured in wood products buried for 19 and 29 years, but where refuse had been buried for 46 years, the measured loss of carbon (as a percentage of dry biomass) was 8.7% for hardwoods and 9.1% for softwoods, equating to 18% and 17% of their original carbon content, respectively. The results indicate that published decomposition factors based on laboratory research significantly overestimate the decomposition of wood products in landfill.

A novel approach in the management of a recurrent adenomatoid tumor of the uterus utilizing a Strassman technique.

Adenomatoid tumors of the uterus are uncommon benign lesions derived from mesothelium, with a prevalence of 1.2% in one study of 1 000 unselected hysterectomy specimens. They are usually small and near the serosal surface; however, they may be large and diffuse (giant adenomatoid tumors). They coexist with leiomyomas in 60% of cases. A 33-year-old nulliparous woman was referred for severe menorrhagia and dysmenorrhea, thought to be due to a submucosal fibroid on ultrasound. This transpired to be an adenomatoid tumor, and she underwent three transcervical resections of the tumor (TCRT) over a period of 12 months for tumor recurrence and failure of symptom resolution. The last TCRT was performed with ultrasound guidance and laparoscopic visualization of the uterus to the resection point of blanching of the serosal surface. She failed to respond to a GnRH analogue throughout. A specialist opinion on the suitability of vascular embolization of the tumor judged that it would be ineffective for this lesion. She then underwent a Strassman procedure and removal of the adenomatoid tumor. This involved dissection of ureters and pelvic vasculature, selective temporary ligation of uterine arteries, hemisection of the uterus, and excision of the tumor with frozen sections to ensure clear tumor margins and resuturing of the uterine halves. Temporary vascular occlusion of the uterine arteries and ovarian vessels allowed a Strassman procedure, which resulted in successful resection of a recurrent giant adenomatoid tumor of the uterus, with fertility preservation in a young nulliparous woman. Two and a half years on there is no evidence of tumor recurrence.

Trimethoprim versus gentamicin for the prevention of bacteriuria following transrectal biopsy of the prostate--do patients need additional anaerobic cover?

OBJECTIVES: To study the incidence of aerobic and anaerobic bacteriuria in patients undergoing transrectal ultrasound-guided biopsies of the prostate. A comparative assessment of efficacy of trimethoprim with gentamicin for the prevention of bacteriuria following the transrectal biopsy of the prostate. To assess the need for additional prophylaxis against anaerobes for patients undergoing transrectal biopsies of the prostate gland. PATIENTS AND METHODS: In a pilot study during 1995-1997, all the patients undergoing transrectal ultrasound-guided biopsy of the prostate were randomised to receive either trimethoprim or gentamicin prophylaxis prior to the procedure. Midstream urine (MSU) samples were taken just prior to biopsy and 72 h later. A patient questionnaire to determine the symptoms of urinary tract infection (UTI) accompanied the 72-hour MSU request form. Urine samples were cultured aerobically, using a semiquantitative technique if dipstick analysis revealed the presence of blood, pus cell or nitrite. In addition to the routine aerobic culture, post-biopsy samples were also cultured for anaerobes by direct and enrichment methods. Bacteriuria was defined as a pure or mixed growth of 10(5) colony-forming units/ml. Fisher's test of exact probability was used for statistical analysis. RESULTS: 115 patients were available for final analysis. 53 had received gentamicin and 62 trimethoprim. Four patients had pre-existing bacteriuria (3.5%), 3 in the trimethoprim group and 1 in the gentamicin group. Post-operative bacteriuria developed in 5 patients given gentamicin (9.4%) and 1 given trimethoprim (1.6%). This difference was not statistically significant (p = 0.085). Post-procedure bacteriuria was asymptomatic in all but 1 case. Anaerobes were detected in only 5 MSUs (4.3%) post-biopsy. CONCLUSION: Though there was no statistical significant difference in the rates of bacteriuria following administration of trimethoprim and gentamicin, data appear to favour trimethoprim prophylaxis. Further studies are warranted. Transrectal biopsy of the prostate is associated with a low incidence of anaerobic UTI. In view of the very low incidence of anaerobic bacteriuria, routine antibacterial prophylaxis against anaerobes does not appear to be justified.

A combined medical and surgical approach to hydatid disease: 12 years' experience at the Hospital for Tropical Diseases, London.

BACKGROUND: There is no consensus as to the most appropriate treatment for the varied and often complicated presentations of hydatid disease in Britain. We looked at our own results over a 12-year period to see if a consistent and logical plan had emerged. PATIENTS AND METHODS: 70 patients presenting between 1986 and 1998 were analysed retrospectively, with regard to their presentation, diagnosis, treatment and outcome, with particular reference to the use of chemotherapy, and to the difficulties of post-treatment assessment by serology and imaging. RESULTS: 37 patients had been treated previously. 35 had hepatic cysts and 26 multiple cysts. 4 patients were treated by surgery alone, 44 by chemotherapy and surgery, and 14 by chemotherapy alone. The combined use of albendazole and praziquantel pre-operatively reduced significantly the number of cysts that contained viable protoscolices: 1/25 versus 5/8 that received albendazole alone (P = 0.00013). During the 12-year period, it became our policy to aim for 3 months drug treatment (albendazole throughout with praziquantel for 2 weeks), re-assess and proceed either to surgery or to continue with chemotherapy. CONCLUSIONS: It is possible to construct an algorithm for the management of patients with hydatid disease by chemotherapy and surgery, but the assessment of results by indirect techniques remains difficult.

The complete sequence of the 1,683-kb pSymB megaplasmid from the N2-fixing endosymbiont Sinorhizobium meliloti.

Analysis of the 1,683,333-nt sequence of the pSymB megaplasmid from the symbiotic N(2)-fixing bacterium Sinorhizobium meliloti revealed that the replicon has a high gene density with a total of 1,570 protein-coding regions, with few insertion elements and regions duplicated elsewhere in the genome. The only copies of an essential arg-tRNA gene and the minCDE genes are located on pSymB. Almost 20% of the pSymB sequence carries genes encoding solute uptake systems, most of which were of the ATP-binding cassette family. Many previously unsuspected genes involved in polysaccharide biosynthesis were identified and these, together with the two known distinct exopolysaccharide synthesis gene clusters, show that 14% of the pSymB sequence is dedicated to polysaccharide synthesis. Other recognizable gene clusters include many involved in catabolic activities such as protocatechuate utilization and phosphonate degradation. The functions of these genes are consistent with the notion that pSymB plays a major role in the saprophytic competence of the bacteria in the soil environment.

The composite genome of the legume symbiont Sinorhizobium meliloti.

The scarcity of usable nitrogen frequently limits plant growth. A tight metabolic association with rhizobial bacteria allows legumes to obtain nitrogen compounds by bacterial reduction of dinitrogen (N2) to ammonium (NH4+). We present here the annotated DNA sequence of the alpha-proteobacterium Sinorhizobium meliloti, the symbiont of alfalfa. The tripartite 6.7-megabase (Mb) genome comprises a 3.65-Mb chromosome, and 1.35-Mb pSymA and 1.68-Mb pSymB megaplasmids. Genome sequence analysis indicates that all three elements contribute, in varying degrees, to symbiosis and reveals how this genome may have emerged during evolution. The genome sequence will be useful in understanding the dynamics of interkingdom associations and of life in soil environments.

The storage defects in grey platelet syndrome and alphadelta-storage pool deficiency affect alpha-granule factor V and multimerin storage without altering their proteolytic processing.

Among proteins stored in alpha-granules, multimerin and factor V share unusual features: they bind to each other, are proteolysed to unique forms and are stored eccentrically in alpha-granules. These unique features of their processing led us to study these proteins in alpha delta storage pool deficiency (alphadelta-SPD) and grey platelet syndrome (GPS, alpha-SPD), two conditions known to impair alpha-granule protein storage. Platelet factor V and multimerin were severely reduced in GPS, whereas they ranged from reduced to normal in alphadelta-SPD. The platelet levels of factor V and multimerin in these disorders indicated multimerin deficiency was not predictive of platelet factor V deficiency, although it reduced the amount of multimerin associated with platelet factor V. In GPS only, the defect in storing proteins was associated with increased multimerin and multimerin-factor V complexes in plasma. Like normal platelets, GPS and alphadelta-SPD platelets contained factor V mainly in granules. Platelet factor V and multimerin were proteolysed to normal platelet forms in GPS and alphadelta-SPD platelets, indicating that these conditions preserve some aspects of normal alpha-granule protein processing. Although we found factor V can be stored in platelets deficient in multimerin, our data indicate that multimerin storage influences the point at which multimerin binds factor V.

Platelets from patients with the Quebec platelet disorder contain and secrete abnormal amounts of urokinase-type plasminogen activator.

The Quebec platelet disorder (QPD) is an autosomal dominant platelet disorder associated with delayed bleeding and alpha-granule protein degradation. The degradation of alpha-granule, but not plasma, fibrinogen in patients with the QPD led to the investigation of their platelets for a protease defect. Unlike normal platelets, QPD platelets contained large amounts of fibrinolytic serine proteases that had properties of plasminogen activators. Western blot analysis, zymography, and immunodepletion experiments indicated this was because QPD platelets contained large amounts of urokinase-type plasminogen activator (u-PA) within a secretory compartment. u-PA antigen was not increased in all QPD plasmas, whereas it was increased more than 100-fold in QPD platelets (P <.00009), which contained increased u-PA messenger RNA. Although QPD platelets contained 2-fold more plasminogen activator inhibitor 1 (PAI-1) (P <.0008) and 100-fold greater u-PA-PAI-1 complexes (P <.0002) than normal platelets, they contained excess u-PA activity, predominantly in the form of two chain (tcu-PA), which required additional PAI-1 for full inhibition. There was associated proteolysis of plasminogen in QPD platelets, to forms that comigrated with plasmin. When similar amounts of tcu-PA were incubated with normal platelet secretory proteins, many alpha-granule proteins were proteolyzed to forms that resembled degraded QPD platelet proteins. These data implicate u-PA in the pathogenesis of alpha-granule protein degradation in the QPD. Although patients with the QPD have normal to increased u-PA levels in their plasma, without evidence of systemic fibrinogenolysis, their increased platelet u-PA could contribute to bleeding by accelerating fibrinolysis within the hemostatic plug. QPD is the only inherited bleeding disorder in humans known to be associated with increased u-PA.

Combining the strength-duration curve of the external anal sphincter with manometry for the assessment of faecal incontinence.

BACKGROUND: The strength-duration curve of a muscle is thought to be a measure of its innervation. This study was designed to evaluate the ability of the strength-duration curve of the external anal sphincter to discriminate between controls and patients with faecal incontinence. METHODS: Forty-three women with faecal incontinence due to sphincter weakness were studied together with 45 age-matched women with no disorders of defaecation. Strength-duration curves of the external anal sphincter and anorectal manometry were recorded for all subjects with the additional measurement of pudendal nerve terminal motor latency in the incontinent group. RESULTS: Logistic regression was performed using resting and voluntary squeeze pressures and current strengths at 28 different pulse durations to develop a predictive equation for incontinence. Only currents at 1 and 6 ms were significant predictors. When anorectal manometry data were included, only the current required to elicit contraction at 1 ms was necessary. The following regression equation can be applied to predict continence in this population with a sensitivity of 95 per cent and a specificity of 100 per cent: logit(P)=4.1605-(0.0559 x squeeze pressure)-(0.1755 x resting pressure)+0.8622I(1 ms). A negative value indicates continence. CONCLUSION: The strength-duration curve, when used in conjunction with anorectal manometry, may have a role in the investigation of faecal incontinence.

Chimeric structure of the NAD(P)+- and NADP+-dependent malic enzymes of Rhizobium (Sinorhizobium) meliloti.

Malic enzymes catalyze the oxidative decarboxylation of malate to pyruvate in conjunction with the reduction of a nicotinamide cofactor. We determined the DNA sequence and transcriptional start sites of the genes encoding the diphosphopyridine nucleotide-dependent malic enzyme (DME, EC 1.1.1.39) and the triphosphopyridine nucleotide-dependent malic enzyme (TME, EC 1.1.1. 40) of Rhizobium (Sinorhizobium) meliloti. The predicted DME and TME proteins contain 770 and 764 amino acids, respectively, and are approximately 320 amino acids larger than previously characterized prokaryotic malic enzymes. The increased size of DME and TME resides in the C-terminal extensions which are similar in sequence to phosphotransacetylase enzymes (EC 2.3.1.8). Modified DME and TME proteins which lack this C-terminal region retain malic enzyme activity but are unable to oligomerize into the native state. Data base searches have revealed that similar chimeric malic enzymes were uniquely present in Gram-negative bacteria. Thus DME and TME appear to be members of a new class of malic enzyme characterized by the presence of a phosphotransacetylase-like domain at the C terminus of the protein.

Bcl-2 mutants with restricted subcellular location reveal spatially distinct pathways for apoptosis in different cell types.

Human Bcl-2 is located in multiple intracellular membranes when expressed in MDCK and Rat-1/myc cells. We restricted expression to the endoplasmic reticulum or mitochondria by exchanging the Bcl-2 carboxy-terminal insertion sequence for an equivalent sequence from cytochrome b5 or ActA, respectively. MDCK cells are protected from serum deprivation-induced apoptosis by both wild-type Bcl-2 and the mutant targeted to mitochondria but not by the mutant targeted to endoplasmic reticulum. In contrast, when expressed in Rat-1/myc cells, the Bcl-2 mutant located at the endoplasmic reticulum is more effective than that targeted to mitochondria. In MDCK cells both mutants bind Bax as effectively as wild-type, demonstrating that Bax binding is not sufficient to prevent apoptosis.

31P NMR studies of human skin using a modified zig-zag surface coil.

Results are presented from an in vivo study of human skin in which a zig-zag surface coil together with a three-pulse Fourier Series Window (FSW) protocol have been used to obtain minimally contaminated 31P skin spectra of the posterior calf. Phantom experiments indicate that while the fall-off in the B1 field profile of the zig-zag surface coil is superior to conventional surface coil designs, it is still not sufficient on its own to reduce muscle signal contamination to acceptable levels in human studies. The additional spatial localization required is provided by the FSW, which reduces signal contamination to less than 30% of the total signal collected. In a study of 18 normal controls the measured pH was found to be relatively high (7.39 +/- 0.08), while the ratios of skin PCr/ beta-ATP (1.04 +/- 0.35) and PCr/Pi (1.67 +/- 0.4) were found to be low compared with that of skeletal muscle. In addition, substantial signal from phosphomonoesters and phosphodiesters were also observed.