Effect of additional water supply during grain filling on protein composition and epitope characteristics of winter oats.

Pure oats in gluten-free diets (GFD) represent important nutritional benefits for people suffering from celiac disease (CD). However, oat cultivars do not contain the typical CD-related wheat gliadin analog polypeptides. Emerging evidence suggests that oat cultivars containing gluten-like epitopes in avenin sequences may pose potential health risks for celiac patients in rare cases, depending on the individual's susceptibility. Consequently, it is necessary to screen oats in terms of protein and epitope composition, to be able to select safe varieties for gluten-free applications. The overall aim of our study is to investigate the variation of oat protein composition directly related to health-related and techno-functional properties and to examine how the protein compositional parameters change due to irrigation during the grain-filling period as compared to the natural rain-fed grown, in a large winter oat population of different geographic origin. Elements of an oat sample population representing 164 winter oat varieties from 8 countries and the protein composition of resulting samples have been characterized. Size distribution of the total protein extracts has been analyzed by SE-HPLC, while the 70% ethanol extracted proteins were analyzed by RP-HPLC. Protein extracts are separated into 3 main groups of fractions on the SE-HPLC column; polymeric, avenin, and non-avenin monomeric protein groups, representing 59.17-80.87%, 12.89-31.03%, and 3.40-9.41% of total protein content, respectively. The ratio of polymeric to monomeric proteins varied between 1.71 and 6.07. 91 RP-HPLC-separated peaks have been differentiated from the ethanol extractable proteins of the entire population. The various parameters identified a lot of variation, confirming the significance of genotypic variation. In addition, it was also established that the additional water supply during grain filling significantly affected the various quantitative parameters of protein content, but not its qualitative structure. This environmental effect, however, was strongly genotype-dependent. Winter oat genotypes with low levels of epitope content were identified and it was proven that these characteristics were independent of the environmental factor of water availability. These genotypes are appropriate for initiating a specific breeding program to yield oat cultivars suitable for CD patients.

Surgical Repair of Atrial-Esophageal Fistula Following Catheter Ablation.

Left atrial-esophageal fistula after radiofrequency ablation for atrial fibrillation is a rare and potentially lethal complication. Although surgical management is associated with improved outcomes, the optimal approach remains to be elucidated. We describe a case of atrial-esophageal fistula treated with a simultaneous repair of the atrium and esophagus via a right thoracotomy with an extrapericardial off-pump approach.

Immunoanalytic investigation of grain proteins antigenic for celiac disease patients in an einkorn collection.

Our study focuses on the complex characterization of a wild and cultivated einkorn collection of the Cereal Gene Bank of Agriculture Research Institute in Hungary, using proteomics, immune analytics and bioinformatics analyses. In a serological ELISA pre-screen of 208 different Triticum monococcum L. ssp. monococcum and Triticum monococcum L. ssp. aegilopoides genotypes with celiac disease samples high diversity was observed in the immune response. Based on the immune analytic results, four genotypes with significantly reduced immune reactivity were selected for detailed proteomics characterization. Our results confirm the benefits of high-throughput/large-scale pre-screening and the use of a complex examination platform to get relevant information about the genetic diversity of celiac disease-relevant proteins in the analyzed einkorn genotypes. These genotypes cannot be incorporated into the daily diet of celiac patients; however, they may represent candidates - especially in combination with enzymatic treatments - to improve the lifestyle of individuals suffering from other clinical conditions like non-celiac wheat sensitivity.

Investigation of Protein and Epitope Characteristics of Oats and Its Implications for Celiac Disease.

The use of pure oats (oats cultivated with special care to avoid gluten contamination from wheat, rye, and barley) in the gluten-free diet (GFD) represents important nutritional benefits for the celiac consumer. However, emerging evidence suggests that some oat cultivars may contain wheat gliadin analog polypeptides. Consequently, it is necessary to screen oats in terms of protein and epitope composition to be able to select safe varieties for gluten-free applications. The overall aim of our study is to investigate the variability of oat protein composition directly related to health-related and techno-functional properties. Elements of an oat sample population representing 162 cultivated varieties from 20 countries and the protein composition of resulting samples have been characterized. Size distribution of the total protein extracts has been analyzed by size exclusion-high performance liquid chromatography (SE-HPLC) while the 70% ethanol-extracted proteins were analyzed by RP-HPLC. Protein extracts separated into three main groups of fractions on the SE-HPLC column: polymeric proteins, avenins (both containing three subgroups based on their size), and soluble proteins, representing respectively 68.79-86.60, 8.86-27.72, and 2.89-11.85% of the total protein content. The ratio of polymeric to monomeric proteins varied between 1.37 and 3.73. Seventy-six reversed phase-HPLC-separated peaks have been differentiated from the ethanol extractable proteins of the entire population. Their distribution among the cultivars varied significantly, 6-23 peaks per cultivar. The number of appearances of peaks also showed large variation: one peak has been found in 107 samples, while 15 peaks have been identified, which appeared in less than five cultivars. An estimation method for ranking the avenin-epitope content of the samples has been developed by using MS spectrometric data of collected RP-HPLC peaks and bioinformatics methods. Using ELISA methodology with the R5 antibody, a high number of the investigated samples were found to be contaminated with wheat, barley, or rye.

Radical nephrectomy with resection of vena cava thrombus using extracorporeal circulation and deep hypothermic circulatory arrest.

INTRODUCTION: Patients with renal cell carcinoma (RCC) with level 3 or 4 caval thrombus have a poor prognosis, with reported five-year survival rates of 30-40%. The aim of this study was to assess the perioperative morbidity and long-term oncological outcomes for radical nephrectomy with resection of vena cava thrombus using a combined surgical approach, including extracorporeal circulation and deep hypothermic circulatory arrest. METHODS: A retrospective review was performed of the institutional case log to identify all radical nephrectomies with caval thrombus performed from January 2006 to May 2020. RESULTS: Twenty-five patients were identified with level 2 thrombus in one (4%), level 3 thrombus in eight (32%), and level 4 in 16 (64%). The median followup was 20.6 months (range 0.2-133.3). The median age at surgery was 68.4 years (range 44.2-85.5). Twenty-one (84%) patients were symptomatic at presentation. Six (24%) patients had distant metastases at diagnosis. The median circulatory arrest time was 15 minutes (range 6-35). The 30-day grade ≥3 complication rate was 8%. The 30-day mortality rate was 8%. The one-year, two-year, three-year, and five-year recurrence-free survival (RFS) rates were 53%, 18%, 10%, and 10%, respectively. The median time to systemic treatment was 7.7 months (range 1.2-25.7). The one-year, two-year, three-year, and five-year overall survival (OS) rates were 70%, 43%, 36%, and 31%, respectively. CONCLUSIONS: Radical nephrectomy with resection of vena cava thrombus using extracorporeal circulation and deep hypothermic circulatory arrest is associated with some morbidity and mortality but remains a safe and effective strategy for advanced RCC patients who would otherwise be managed palliatively.

Preparation and Characterization of Avenin-Enriched Oat Protein by Chill Precipitation for Feeding Trials in Celiac Disease.

The safety of oats for people with celiac disease remains unresolved. While oats have attractive nutritional properties that can improve the quality and palatability of the restrictive, low fiber gluten-free diet, rigorous feeding studies to address their safety in celiac disease are needed. Assessing the oat prolamin proteins (avenins) in isolation and controlling for gluten contamination and other oat components such as fiber that can cause non-specific effects and symptoms is crucial. Further, the avenin should contain all reported immunogenic T cell epitopes, and be deliverable at a dose that enables biological responses to be correlated with clinical effects. To date, isolation of a purified food-grade avenin in sufficient quantities for feeding studies has not been feasible. Here, we report a new gluten isolation technique that enabled 2 kg of avenin to be extracted from 400 kg of wheat-free oats under rigorous gluten-free and food grade conditions. The extract consisted of 85% protein of which 96% of the protein was avenin. The concentration of starch (1.8% dry weight), ß-glucan (0.2% dry weight), and free sugars (1.8% dry weight) were all low in the final avenin preparation. Other sugars including oligosaccharides, small fructans, and other complex sugars were also low at 2.8% dry weight. Liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis of the proteins in these preparations showed they consisted only of oat proteins and were uncontaminated by gluten containing cereals including wheat, barley or rye. Proteomic analysis of the avenin enriched samples detected more avenin subtypes and fewer other proteins compared to samples obtained using other extraction procedures. The identified proteins represented five main groups, four containing known immune-stimulatory avenin peptides. All five groups were identified in the 50% (v/v) ethanol extract however the group harboring the epitope DQ2.5-ave-1b was less represented. The avenin-enriched protein fractions were quantitatively collected by reversed phase HPLC and analyzed by MALDI-TOF mass spectrometry. Three reverse phase HPLC peaks, representing ~40% of the protein content, were enriched in proteins containing DQ2.5-ave-1a epitope. The resultant high quality avenin will facilitate controlled and definitive feeding studies to establish the safety of oat consumption by people with celiac disease.

Development of a cumulative teaching score for tracking surgeon performance in undergraduate medical education

Background: Surgeon educators are important in undergraduate medical education (UME). However, teaching activities are undervalued and under-recognized compared with research, resulting in poorer quantity and quality of surgeon teaching. The purpose of this study was to investigate teaching roles available to surgeons and the amount of effort involved. Methods: A comprehensive review of all possible roles surgeons may take in UME at our institution was assembled. Delphi committee members were asked to evaluate each teaching role on the amount of effort needed per hour. Results were analyzed using descriptive statistics, and a Cronbach α of 0.60 or higher was the threshold to declare consensus. Results: Twenty-five participants, including physicians, residents and medical students, completed the study. Consensus was reached on the amount of effort needed for each teaching role. These values were used to prototype a cumulative teaching score that can be used to qualitatively quantify surgeon teaching. Conclusion: Surgeon teaching is important in UME, but not tracked and thus not valued. To improve the quantity and quality of surgeon teaching in UME, we need to track, reward and recognize surgeon teaching activities. The "effort score" we developed to objectively and transparently qualify teaching was able to determine the relative effort needed for each teaching activity in UME at the University of Toronto. Combining the effort score and time committed to each teaching activity will produce a cumulative teaching score for each instructor.

Contexte: Les chirurgiens formateurs jouent un rôle important pendant les études de premier cycle en médecine. Toutefois, les tâches d'enseignement sont sousévaluées et elles ne sont pas suffisamment reconnues comparativement aux activités de recherche, et cela nuit quantitativement et qualitativement à l'enseignement en chirurgie. Cette étude avait pour but d'analyser les divers rôles assumés par les chirurgiens formateurs et l'effort requis. Méthodes: Nous avons procédé à une revue complète de tous les rôles possibles assumés par les chirurgiens durant les études de premier cycle en médecine dans notre établissement. Les membres d'un comité Delphi ont été invités à évaluer chaque rôle de formateur au plan de l'effort requis par heure. Les résultats ont été analysés à l'aide de statistiques descriptives; et un coefficient α de Cronbach de 0,60 ou plus a servi de seuil consensuel. Résultats: Vingt-cinq participants, dont des médecins, des résidents et des étudiants en médecine, ont participé à l'étude. Un consensus a été atteint pour ce qui est de l'effort requis pour chaque rôle de formateur. Ces valeurs ont servi à élaborer le prototype d'un score cumulatif propre à l'enseignement qui peut être utilisé pour quantifier qualitativement l'enseignement par les chirurgiens. Conclusion: L'enseignement par les chirurgiens est important au premier cycle de la formation en médecine, mais ne fait l'objet ni d'un suivi ni d'une évaluation. Pour améliorer quantitativement et qualitativement l'enseignement en chirurgie au premier cycle, nous devons suivre, récompenser et reconnaître les diverses activités d'enseignement dans cette spécialité. L'« indice d'effort ¼ que nous avons élaboré pour qualifier de manière objective et transparente l'enseignement a permis de déterminer l'effort relatif requis pour chaque activité d'enseignement au premier cycle à l'Université de Toronto. En combinant l'indice d'effort et le temps consacré à chaque activité d'enseignement, on obtient un score cumulatif d'enseignement pour chaque instructeur.

Perceval Sutureless Valve - are Sutureless Valves Here?

With the advent of transcatheter aortic valve implantation (TAVI) techniques, a renewed interest has developed in sutureless aortic valve concepts in the last decade. The main feature of sutureless aortic valve implantation is the speed of insertion, thus making implantation easier for the surgeon. As a result, cross clamp times and myocardial ischemia may be reduced. The combined procedures (CABG with AVR in particular) can be done with a short cross clamp time. Perceval valve also provides an increased effective orifice area as compared with a stented bioprosthesis. Sutureless implantation of the Perceval valve is not only associated with shorter cross-clamp and cardiopulmonary bypass times but improved clinical outcomes too. This review covers the sutureless aortic valves and their evolution, with elaborate details on Perceval S valve in particular (which is the most widely used sutureless valve around the globe).

Planting the 'SEAD': early comprehensive exposure to surgery for medical students.

INTRODUCTION: The popularity of surgical specialties is declining amongst Canadian medical students. Limited early exposure of students to surgery and minor involvement of surgeons in preclerkship education are barriers to creating interest in the field. Although many informal observerships and interest groups exist, there are no structured programs in Canada that offer preclerkship medical students a comprehensive exposure to surgery. METHODS: Twenty first-year medical students participated in the Surgical Exploration and Discovery (SEAD) Program. SEAD is a pilot project at the University of Toronto providing a unique combination of (1) observerships, (2) informal discussions on surgical careers, and (3) hands-on simulation workshops across all 7 direct-entry specialties within the Department of Surgery. All participants underwent pretraining and posttraining evaluation of learning through a paper-based knowledge test and all completed a structured survey on the benefit of the course. RESULTS: Comparison of test scores revealed an overall significant improvement in learning (p<0.0001). The improvement in test scores was seen in the knowledge of all 3 components of the course (p<0.0001). Qualitative evaluation revealed a positive student experience, with 100% of students indicating that SEAD helped them identify new interests in surgical subspecialties. Finally, 100% of students stated that they would recommend the program to incoming medical students. CONCLUSION: The SEAD Program successfully improves preclerkship students' knowledge of surgical principles, understanding of a career in surgery, and basic surgical skills. Participation in the program also positively influenced their interest in pursuing a career in surgery. Programs such as SEAD may be offered to preclerkship medical students to improve their exposure to surgery at this level of training and to enhance perspectives toward surgical careers.

Cut-off values for transit time flowmetry: are the revision criteria appropriate?

BACKGROUND: Graft Imaging to Improve Patency (GRIIP), a single-center, randomized blinded clinical trial, reported that intraoperative graft assessment with graft revision according to a priori criteria of transit time flowmetry (TTF) and intraoperative fluorescent angiography did not improve graft patency at one year after coronary artery bypass grafting (CABG) when compared with standard intraoperative management. The objective of this study is to investigate whether other TTF values are more predictive of the saphenous vein graft (SVG) failure and/or clinical outcomes. METHODS: This is a case control retrospective study of 65 SVGs from 44 patients from GRIIP. Study outcomes were graft patency at 12 months and major adverse cardiac events (MACE; death, myocardial infarction, repeat revascularization). RESULTS: Twenty-two SVGs were occluded. In receiver operating characteristic curve analysis, TTF mean flow was significantly predictive of one-year SVG failure (area under the curve = 0.698, p < 0.01), and 31 mL/min was the best cut-off value (p = 0.017, sensitivity 63.6%, specificity 67.4%). The risk of graft occlusion was 14/28, 50% for grafts with mean flow <31 mL/min and 8/37, 21.6% for grafts with mean flow ≥ 31 mL/min. In logistic regression models, mean flow was a significant predictor of early SVG failure (Odds Ratio 0.95 [0.91-0.99] per mL/min, p = 0.014) whereas other TTF values, patient comorbidities, and/or medication at discharge were not. However, TTF values were not predictive of MACE. CONCLUSIONS: TTF can identify non-functional grafts during CABG, but is of questionable value to improve one-year graft patency.

Mitroflow pericardial bioprosthesis: structured failure at 4.5 years.

BACKGROUND: Prosthetic heart valves are commonly used in the management of significant valvular disease. Although bioprostheses are increasingly popular, structural deterioration with cusp tears and calcification persists. METHODS: We present a case of a Mitroflow pericardial bioprosthesis (Sorin Group Inc., Mitroflow Division, Vancouver, Canada) explanted after 4.5 years from a 78-year-old woman for bioprosthesis stenosis. RESULTS: The morphological reasons for bioprosthesis failure include structural tissue deterioration with thickening of the pericardial cusps, cusp calcification, and parastent post tears resulting in significant valvular dysfunction. CONCLUSION: To the best of our knowledge, this is the first detailed morphological description of the failure modes of a surgically explanted Mitroflow (A12) pericardial bioprosthesis.

Technique of harvesting an internal thoracic artery densely adherent to the periosteum.

The internal thoracic artery (ITA) has been universally accepted as a superior conduit for patients undergoing coronary artery bypass operations. The harvesting of the ITA is a routine procedure. Rarely, one encounters an ITA densely adherent to the overlying periosteum. We describe a technique of safely harvesting such an ITA using an orthopedic chisel. It is harvested along with a thin bone-flap and periosteum, giving a patent and uninjured ITA.

Are stentless valves hemodynamically superior to stented valves? Long-term follow-up of a randomized trial comparing Carpentier-Edwards pericardial valve with the Toronto Stentless Porcine Valve.

OBJECTIVE: The benefit of stentless valves remains in question. In 1999, a randomized trial comparing stentless and stented valves was unable to demonstrate any hemodynamic or clinical benefits at 1 year after implantation. This study reviews long-term outcomes of patients randomized in the aforementioned trial. METHODS: Between 1996 and 1999, 99 patients undergoing aortic valve replacement were randomized to receive either a stented Carpentier-Edwards pericardial valve (CE) (Edwards Lifesciences, Irvine, Calif) or a Toronto Stentless Porcine Valve (SPV) (St Jude Medical, Minneapolis, Minn). Among these, 38 patients were available for late echocardiographic follow-up (CE, n = 17; SPV, n = 21). Echocardiographic analysis was undertaken both at rest and with dobutamine stress, and functional status (Duke Activity Status Index) was compared at a mean of 9.3 years postoperatively (range, 7.5-11.1 years). Clinical follow-up was 82% complete at a mean of 10.3 years postoperatively (range, 7.5-12.2 years). RESULTS: Preoperative characteristics were similar between groups. Effective orifice areas increased in both groups over time. Although there were no differences in effective orifice areas at 1 year, at 9 years, effective orifice areas were significantly greater in the SPV group (CE, 1.49 +/- 0.59 cm(2); SPV, 2.00 +/- 0.53 cm(2); P = .011). Similarly, mean and peak gradients decreased in both groups over time; however, at 9 years, gradients were lower in the SPV group (mean: CE, 10.8 +/- 3.8 mm Hg; SPV, 7.8 +/- 4.8 mm Hg; P = .011; peak: CE, 20.4 +/- 6.5 mm Hg; SPV, 14.6 +/- 7.1 mm Hg; P = .022). Such differences were magnified with dobutamine stress (mean: CE, 22.7 +/- 6.1 mm Hg; SPV, 15.3 +/- 8.4 mm Hg; P = .008; peak: CE, 48.1 +/- 11.8 mm Hg; SPV, 30.8 +/- 17.7 mm Hg; P = .001). Ventricular mass regression occurred in both groups; however, no differences were demonstrated between groups either on echocardiographic, magnetic resonance imaging, or biochemical (plasma B-type [brain] natriuretic peptide) assessment (P = .74). Similarly, Duke Activity Status Index scores of functional status improved in both groups over time; however, no differences were noted between groups (CE, 27.5 +/- 19.1; SPV, 19.9 +/- 12.0; P = .69). Freedom from reoperation at 12 years was 92% +/- 5% in patients with CEs and 75% +/- 5% in patients with SPVs (P = .65). Freedom from valve-related morbidity at 12 years was 82% +/- 7% in patients with CEs and 55% +/- 7% in patients with SPVs (P = .05). Finally, 12-year actuarial survival was 35% +/- 7% in patients with CEs and 52% +/- 7% in patients with SPVs (P = .37). CONCLUSION: Although offering improved hemodynamic outcomes, the SPV did not afford superior mass regression or improved clinical outcomes up to 12 years after implantation.

The Graft Imaging to Improve Patency (GRIIP) clinical trial results.

OBJECTIVE: This trial aimed to determine whether intraoperative graft assessment with criteria for graft revision would decrease the proportion of patients with 1 or more graft occlusions or stenoses or major adverse cardiac events 1 year after coronary artery bypass grafting. METHODS: A single-center, randomized, single-blinded, controlled clinical trial was designed. Patients were randomized to either of 2 groups: intraoperative graft patency assessment using indocyanine-green fluorescent angiography and transit-time flowmetry, with graft revision according to a priori criteria (imaging group), or standard intraoperative management (control group). Patients underwent follow-up angiography at 1 year. RESULTS: Between September 2005 and August 2008, 156 patients undergoing isolated coronary bypass grafting were enrolled (imaging, n = 78; control, n = 78). Demographic and angiographic characteristics were similar between groups. Operative, crossclamp, and cardiopulmonary bypass times were all nonsignificantly longer in the imaging arm. The number of grafts per patients was similar (imaging, 3.0 +/- 0.7; control, 3.0 +/- 0.7). The frequency of major adverse cardiac events (death, myocardial infarction, repeat revascularization) was not different between groups at 1 year postoperatively (imaging, 7.7%; control, 7.7%). One-year angiography was performed in 107 patients (imaging, 55 patients/160 grafts; control, 52 patients/152 grafts). The proportion of patients with 1 graft occlusion or more was comparable in the imaging (30.9%) and control (28.9%) groups (relative risk [95% confidence interval], 1.1 [0.6-1.9]; P = .82), as were other graft patency end points. The incidence of saphenous vein graft occlusion was high in both groups. CONCLUSIONS: Routine intraoperative graft assessment is safe but does not lead to a marked reduction in graft occlusion 1-year after bypass grafting. The incidence of saphenous vein graft failure remains high despite contemporary practice and routine intraoperative graft surveillance.

Troponin after cardiac surgery: a predictor or a phenomenon?

BACKGROUND: Increased cardiac troponin is observed after virtually every cardiac operation, indicating perioperative myocardial injury. The clinical significance of this elevation is controversial. This study aimed to correlate postoperative troponin levels with major adverse cardiac events (MACE). METHODS: The study included 1918 consecutive patients undergoing adult cardiac operations, including 1515 isolated coronary procedures, 229 valvular operations, and 174 combined coronary/valve procedures. Peak troponin T (normal value < 0.1 microg/L) was measured at less than 24 hours postoperatively. Excluded were 506 patients with a recent myocardial infarction (< 30-days of operation). The primary outcome was a composite of death, electrocardiogram-defined infarction, and low output syndrome (MACE). RESULTS: Mortality rates were 1.4%, 6.1%, and 7% in the coronary bypass, valve, and combined groups, respectively (p < 0.001). The rates of MACE were 17%, 35%, and 44% (p < 0.0001), and mean troponin T levels were 0.9 +/- 1.5, 1.2 +/- 2.9, and 1.3 +/- 1.2 microg/L (p < 0.001), in the coronary bypass, valve, and combined groups, respectively. All patients were divided into quintiles based on their peak postoperative troponin level (Q1, 0.0 to 0.39; Q2, 0.4 to 0.59; Q3, 0.6 to 0.79; Q4, 0.8 to 1.29; and Q5, > 1.3 microg/L). Adverse outcomes were similar and stable in the lower quintiles. A stepwise increase in adverse outcomes was observed in the higher quintiles. Receiver operating characteristic curve analysis revealed a troponin cutoff of 0.8 microg/L was the most discriminatory for MACE (area under the curve, 0.7). Multivariable analyses showed a troponin value of more than 0.8 microg/L was independently associated with MACE. CONCLUSIONS: Moderate elevations in troponin are common after cardiac operations; troponin is a well-described predictor of outcomes. Troponin levels exceeding 0.8 microg/L are associated with increased MACE in patients without a history of preoperative myocardial infarction within 30 days of operation.

A randomized comparison of intraoperative indocyanine green angiography and transit-time flow measurement to detect technical errors in coronary bypass grafts.

BACKGROUND: Early coronary bypass graft failures may be preventable if identified intraoperatively. The purpose of this investigation was to compare the diagnostic accuracy of two intraoperative graft assessment techniques, transit-time ultrasound flow measurement and indocyanine green fluorescent-dye graft angiography. METHODS: Patents undergoing isolated coronary artery bypass grafting with no contraindications for postoperative angiography were enrolled in the study. Patients were randomly assigned to be evaluated with either indocyanine green angiography (Novadaq Spy angiography system; Novadaq Technologies Inc, Concord, Ontario, Canada) and then transit-time ultrasonic flow measurement (Medtronic Medi-Stim Butterfly Flowmeter TTF measurement system; Medtronic Inc, Minneapolis, Minn) or transit-time flow then indocyanine green angiography. Patients underwent x-ray angiography on postoperative day 4. The primary end point of the trial was to determine the sensitivity and specificity of the two techniques versus reference standard x-ray angiography to detect graft occlusion or greater than 50% stenosis in the graft or perianastomotic area. RESULTS: Between February 2004 and March 2005, 106 patients were enrolled and x-ray angiography was performed in 46 patients. In total, 139 grafts were reviewed with all three techniques and 12 grafts (8.2%) were demonstrated to have greater than 50% stenosis or occlusion by the reference standard. The sensitivity and specificity of indocyanine green angiography to detect greater than 50% stenosis or occlusion was 83.3% and 100%, respectively. The sensitivity and specificity of transit-time ultrasonic flow measurement to detect greater than 50% stenosis or occlusion was 25% and 98.4%, respectively. The P value for the overall comparison of sensitivity and specificity between indocyanine green angiography and transit-time flow ultrasonography was .011. The difference between sensitivity for indocyanine green angiography and transit-time flow measurement was 58% with a 95% confidence interval of 30% to 86%, P = .023. CONCLUSION: Indocyanine green angiography provides better diagnostic accuracy for detecting clinically significant graft errors than does transit-time ultrasound flow measurement.

Age-dependent changes in body size of Greek boys from 1982 to 2002.

OBJECTIVE: The prevalence of childhood obesity has been rising during the past decades in many parts of the world, including Greece. The dispersion of these trends across age, however, is less clear. The aim of this study was to examine the relationship between age and 20-year changes in anthropometric characteristics of Greek boys. RESEARCH METHODS AND PROCEDURES: A total of 204 and 106 boys 9 years old, 163 and 274 boys 12 years old, and 161 and 240 boys 15 years old were randomly recruited in 1982 and 2002, respectively, throughout the county of Iraklio, Crete, Greece. Height, weight, and BMI were measured. RESULTS: Contemporary 9 and 12 year olds were taller than their peers in 1982 (+2.9% and +1.2%, respectively; p < 0.005), but this was not the case for 15 year olds (-0.8%; p = 0.083). Body weight and BMI were higher now than in the 1980s, and this held true for all age groups (p < 0.001). Increases in weight also showed a decline with advancing age (+17.4%, +13.9%, and +4.0% for 9, 12, and 15 year olds, respectively), whereas BMI changes were similar for those 9 and 12 years of age (approximately 10.5%), but were almost 2-fold higher than in 15 year olds (+5.5%). DISCUSSION: Contemporary boys are taller, heavier, and have higher BMI values than their peers in 1982, but the magnitude of these increases gradually declines with advancing age. Rates of increase in BMI, however, seem to have greatly accelerated compared with previous decades.

Changing relationships of obesity and dyslipidemia in Greek children: 1982-2002.

BACKGROUND: The prevalence of childhood overweight and obesity has been increasing rapidly during the past decades in many parts of the world. Less is known with respect to the effects of increasing adiposity on blood lipid profile. The present study was designed to examine the influence of adiposity on secular trends in anthropometric characteristics and plasma lipids of Greek children. METHODS: A total of 419 and 374 boys with normal body weight and 109 and 246 boys with abnormal body weight (overweight and obese) were randomly recruited in 1982 and 2002, respectively (aged 12.1 +/- 0.1 years). Height, weight, body mass index (BMI, kg/m(2)), Rohrer index (kg/m(3)), plasma total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), triglyceride (TG), TC/HDL-C ratio, and LDL-C/HDL-C ratio were determined. RESULTS: Temporal changes in weight (positive), BMI (positive), HDL-C (negative), and cholesterol ratios (positive) were greater among overweight and obese vs. normal-weight boys (P < 0.05), while those for height (positive), LDL-C (positive), TG (positive), and TC (no change) were of similar magnitude. The increase in Rohrer index since 1982 failed to reach significance for children with normal body weight (P = 0.077) but did so for overweight and obese subjects (P = 0.027). CONCLUSIONS: These results indicate that secular increases in measures of fatness and adverse changes in plasma lipids were more pronounced among overweight and obese children than among normal-weight individuals, although qualitatively similar shifts were observed across the entire population.

Improving the quality of coronary bypass surgery with intraoperative angiography: validation of a new technique.

OBJECTIVES: We report a comprehensive assessment and validation of a new intraoperative angiography technique. BACKGROUND: Technical problems at the site of the distal anastomosis compromise an underappreciated proportion of coronary bypass grafts. The absence of a systematic, validated technique to verify graft patency in the operating room represents a significant breach in quality assurance. METHODS: Fluorescent indocyanine green (ICG) dye is excited with dispersed laser light to create an angiographic depiction of the graft, native vessel, and anastomosis. One-hundred twenty patients underwent ICG angiography. Angiograms were reviewed for reliability and validity studies. RESULTS: A total of 348 coronary bypass grafts were studied. Each ICG angiogram took 2.2 +/- 1.1 min to perform. The ICG angiography found 4.2% of patients had significant graft problems requiring major revision. Quality of visualization was rated according to a seven-point Likert scale (1 = worst, 7 = best). Among conduits, saphenous veins were best visualized (mean score +/- standard deviation), 6.4 +/- 1.5 versus 5.5 +/- 1.9 for internal mammary arteries and 4.4 +/- 2.3 for radial arteries (p = 0.02). Location of distal anastomosis did not influence quality of visualization. There was high inter-rater reliability for graft revision (kappa = 1.0) and graft patency (kappa = 0.97) between surgeons. Sensitivity and specificity of the ICG angiograms for graft stenosis >50% was 100% among 22 grafts also studied with X-ray angiography. CONCLUSIONS: Information from ICG angiograms led to graft revisions for technical problems in 4.2% of patients that would have otherwise gone unrecognized. Intraoperative angiography is an emerging tool for improving the quality of coronary bypass surgery.