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The IRMM-1027 Large-sized dried (LSD) spikes are certified reference materials applied to measure the uranium and plutonium content of dissolved fuel solutions using isotope dilution mass spectrometry. High quality starting metals of uranium and plutonium are dissolved to produce a stock solution, which is dispensed into individual vials and dried down. The present spikes are mixtures of typically 50 mg 20% enriched U and 2 mg enriched 239Pu as dried nitrates, conditioned in an organic substance for stability. Each vial of an IRMM-1027 LSD spike comes with certified masses of uranium (235U and 238U) and 239Pu and isotopic composition with associated uncertainty. This article will discuss major developments since the production of the first batch of LSD spikes and will reflect on the current preparation and certification approaches.

Research Findings: This study used data from a large-scale kindergarten entry assessment (KEA) to understand how well two state screening measures, administered at school entry, predicted the first...

Background Catheter ablations have been traditionally performed with the use of fluoroscopic guidance, which exposes the patient and staff to the inherent risks of radiation. We have developed techniques to eliminate the use of fluoroscopy during cardiac ablations and have been performing completely fluoroless catheter ablations on our patients for over 5 years. Methods We present a retrospective analysis of the safety, efficacy, and feasibility data from 500 consecutive patients who underwent nonfluoroscopic catheter ablation, targeting a total of 639 arrhythmias, including atrioventricular reciprocating tachycardia (AVRT), atrioventricular nodal reentrant tachycardia (AVNRT), atrial tachycardia (AT), atrial fibrillation (AF), premature ventricular contractions (PVCs), and ventricular tachycardia (VT). We perform fluoroless ablations using intracardiac electrograms, electroanatomic mapping, and for most cases intracardiac echocardiography. Our experience includes exclusively endocardial cardiac ablations. Results The mean follow-up was 20.5 months. Recurrence rate for AVRT was 6.5%, for AVNRT 2.5%, for macro-reentrant AT 6.4%, for focal AT 5.4%, for AF 22.6%, for PVC 6.7%, and for VT 21.4%. Major complications occurred in five patients (1.0%); minor complications occurred in three patients (0.6%). No deaths occurred. Fluoroscopy was used in one instance, for 0.3 minutes, to confirm venous access. Conclusions Completely fluoroless catheter ablations may be routinely performed for all endocardial ablations without compromising safety, efficacy, or procedural duration.

In patients with nonvalvular atrial fibrillation (NVAF), the impact of left ventricular diastolic function on the risk for left atrial appendage (LAA) thrombus has not been prospectively studied.At two academic medical centers, patients with NVAF were prospectively enrolled to undergo investigational transthoracic echocardiography immediately before clinically indicated transesophageal echocardiography. Mitral inflow E velocity and tissue Doppler septal and lateral mitral annulus velocities (e') were measured, and E/e' ratios were calculated.Among 266 subjects (mean age, 65 years; 32% women), 17 (6.4%) had LAA thrombus. Patients with LAA thrombus had a higher mean CHA2DS2-VASc score (4.6 ± 1.7 vs 3.0 ± 1.8, P .001), a higher mean lateral E/e' ratio (19.4 ± 10.1 vs 10.2 ± 5.6, P .001), and a lower mean lateral e' velocity (7.0 ± 3.2 vs 10.4 ± 3.7 cm/sec, P = .001). There was a good discriminative capacity for E/e' (area under the curve, 0.83; P .001) and e' velocity (area under the curve, 0.76; P = .001). None of the patients with normal E/e' ratios or normal e' velocities had LAA thrombus. Both E/e' (odds ratio, 1.13 per point; 95% CI, 1.06-1.20; P .001) and e' velocity (odds ratio, 0.76 per 1 cm/sec; 95% CI, 0.63-0.92; P = .005) provided independent and incremental predictive value beyond the CHA2DS2-VASc score; however, E/e' provided greater incremental value than e' velocity (P = .036). Analyses using septal and averaged E/e' and septal e' velocity yielded similar results. Diastolic function parameters were also associated with the presence and intensity of left atrial spontaneous echo contrast, a precursor of LAA thrombus.This prospective and concomitant evaluation of diastolic function and LAA thrombus in patients with NVAF demonstrates that E/e' ratio and e' velocity are associated with LAA thrombus, independent of CHA2DS2-VASc score, and may play a role in identifying patients at low risk for LAA thrombus. These data suggest that diastolic function assessment may improve stroke prediction in patients with NVAF.

We sought to determine and prospectively validate, with concomitantly performed transthoracic (TTE) and transesophageal echocardiograms (TEE), a TTE-assessed E/e′ threshold that can be useful in predicting left atrial appendage (LAA) thrombus in patients with nonvalvular atrial fibrillation (NVAF). The retrospective derivation cohort was comprised of 297 patients with NVAF with TTE performed within 1 year of TEE. The validation cohort was comprised of 266 prospectively enrolled patients with TTE performed immediately prior to TEE. LAA thrombus was detected by TEE in 6.4 % of patients in both cohorts. Receiver operating characteristic (ROC) analyses demonstrated a good discriminatory capacity of lateral E/e′ in predicting LAA thrombus in the derivation cohort (AUC 0.72; CI 0.63–0.82; P = 0.001) which was confirmed in the validation cohort (AUC 0.83; CI 0.75–0.91; P < 0.001). In the derivation cohort, ROC curve point-coordinates identified E/e′ thresholds of both 9.0 and 8.0 to be associated with 100 % sensitivity, with specificities of 36 and 30 %, respectively. An E/e′ threshold of ≥8 was selected a priori for prospective validation, and was associated with 100 % sensitivity and 41 % specificity for LAA thrombus, with positive and negative predictive values of 10 and 100 %, respectively, and positive and negative likelihood ratios of 1.69 and 0, respectively. We determined and validated an E/e′ threshold of 8 as a highly sensitive and useful parameter that can aid in identifying patients at very low risk for LAA thrombus and potentially obviate the need for a TEE prior to electrophysiology procedures and restoration of sinus rhythm.

240Pu and 242Pu targets were prepared by the so-called “molecular plating” on an Al backing for cross-section measurements. The total activity of the actinide layer was determined by low-geometry alpha-particle counting. The atomic abundances of the two Pu materials were determined via thermal ionization mass spectrometry. A radiochemical separation was performed by anion exchange prior to the preparation of the layers to prevent interferences with the ingrown daughter nuclide during the characterization and cross-section measurements. The targets were prepared to be used in the project “Metrology for New Generation Nuclear Power Plants” (MetroFission), within the frame of the European Metrology Research Programme, directed to improve the knowledge on neutron cross sections through metrological approaches. For measurements of the 240Pu(n,f) and 242Pu(n,f) cross sections 240Pu and 242Pu targets were produced and mounted in fission chambers. In parallel, 240Pu and 242Pu targets were prepared for the ANDES project (Accurate Nuclear Data for Nuclear Energy Sustainability) for cross-section measurements at the CERN neutron time-of-flight facility n_TOF, and the Van de Graaff laboratories of IRMM and CNRS/CENBG.

Catheter ablations have been traditionally performed with the use of fluoroscopic guidance, which exposes the patient and staff to the inherent risks of radiation. We have developed techniques to eliminate the use of fluoroscopy during cardiac ablations and have been performing completely fluoroless catheter ablations on our patients for over 5 years.We present a retrospective analysis of the safety, efficacy, and feasibility data from 500 consecutive patients who underwent nonfluoroscopic catheter ablation, targeting a total of 639 arrhythmias, including atrioventricular reciprocating tachycardia (AVRT), atrioventricular nodal reentrant tachycardia (AVNRT), atrial tachycardia (AT), atrial fibrillation (AF), premature ventricular contractions (PVCs), and ventricular tachycardia (VT). We perform fluoroless ablations using intracardiac electrograms, electroanatomic mapping, and for most cases intracardiac echocardiography. Our experience includes exclusively endocardial cardiac ablations.The mean follow-up was 20.5 months. Recurrence rate for AVRT was 6.5%, for AVNRT 2.5%, for macro-reentrant AT 6.4%, for focal AT 5.4%, for AF 22.6%, for PVC 6.7%, and for VT 21.4%. Major complications occurred in five patients (1.0%); minor complications occurred in three patients (0.6%). No deaths occurred. Fluoroscopy was used in one instance, for 0.3 minutes, to confirm venous access.Completely fluoroless catheter ablations may be routinely performed for all endocardial ablations without compromising safety, efficacy, or procedural duration.

Purpose Cryothermal ablation (CTA) for atrioventricular nodal reentrant tachycardia (AVNRT) is considered safer than radiofrequency ablation (RFA) since it eliminates the risk of inadvertent AV block. However, it has not been widely adopted due to high late recurrence rate (LRR). In an effort to improve LRR, we evaluated a new approach to cryothermal mapping (CTM): “time to tachycardia termination” (TTT). Methods This single-center study had 88 consecutive patients who underwent CTA using TTT for AVNRT. The CTA catheter was positioned in sinus rhythm at the posteroseptal tricuspid annulus, and then AVNRT was induced. The CTA target site was identified by prompt tachycardia termination in ≤20 s during CTM. Procedural success was defined as no inducible AVNRT and ≤1 single AV nodal echoes. Results Acute procedural success was achieved in 87 of 88 patients (98.9 %) and was similar to prior studies for both CTA and RFA. No permanent AV block was observed. LRR was 3.7 % at a mean follow-up of 19.7 months. LRR was equivalent to that commonly reported for RFA and improved when compared to conventional CTA. Conclusion TTT for CTA of AVNRT provides enhanced safety and similar long-term efficacy when compared to RFA. Based upon this experience, TTT provides an enhancement to conventional CTA that appears to result in improved long-term outcomes. In light of these findings, it seems reasonable to undertake additional randomized trials to determine whether RFA or CTA using TTT is the optimal approach for the catheter ablation of AVNRT.

This commentary describes practical implications of Schmidt's (International Journal of Selection and Assessment, 20, 1–13 (2012)) rationale supporting content validity evidence for cognitive tests. These implications include descriptions of the meaning of six key inferences about local, specific cognitive tests, four of which are supported by the traditional methods of content evidence, and two of which are not. These help clarify the important incremental inference from Schmidt's proposed methodology that cognitive tests supported by content evidence will also be predictive of job performance in the local setting. A caution is raised that content evidence does not support a general inference that local, specific cognitive tests will take on all empirical properties of general cognitive measures. An additional job analysis step is recommended to strengthen the linkage between the specific cognitive job skills/behaviors and the more general theory of general cognitive ability.

In nuclear safeguards, precise and accurate isotopic analyses are needed for two major elements from the nuclear fuel cycle: uranium and plutonium. This can be achieved by Isotope Dilution Mass Spectrometry (IDMS), which is one of the most reliable analytical techniques for the determination of plutonium amount content to a high level of accuracy. In order to achieve reliable isotope measurements isotopic reference materials with certified amount of plutonium and isotopic composition are required. At the Institute for Reference Materials and Measurements (IRMM) various plutonium spike reference materials for isotopes 239Pu, 240Pu, 242Pu and 244Pu are available. This enabled the setup of an inter-calibration campaign inter-linking selected plutonium spikes on a metrological basis applying state-of-the-art measurement procedures. The aim of this campaign is threefold: firstly to perform measurements on selected plutonium spike isotopic reference materials for quality control purposes, secondly to verify the amount content and the isotopic composition of the recently produced IRMM-1027m large sized dried (LSD) spikes and thirdly to demonstrate IRMM’s measurement capabilities for plutonium analysis via external quality tools. The obtained results using various spike isotopic reference materials will be presented and discussed in this paper. The measurement uncertainties of the IDMS results were calculated according to the guide to the expression of uncertainty in measurement (GUM).

A new series of gravimetrically prepared synthetic isotope reference materials, the so-called IRMM-075 series, with n(236U)/n(238U) isotope ratios varying from 10−4 to 10−9 has been prepared and certified. This series is suited for calibration of n(236U)/n(238U) measurements made by various mass spectrometric techniques such as TIMS (Thermal Ionization Mass Spectrometry), ICPMS (Inductively Coupled Plasma Mass Spectrometry), AMS (Accelerator Mass Spectrometry) and RIMS (Resonance Ionization Mass Spectrometry). Natural uranium with low 236U isotope abundance and highly enriched 236U were both purified using well proven chemical methodology. The oxides were calcined into U3O8 in an oven installed in a glove-box with controlled humidity. Primary solutions of the same concentration were prepared by dissolving the oxides of 236U and natural U. From the 236U solution a series of four dilutions was made by weighing. Weighed amounts of the dilutions of 236U and weighed amounts of natural U were mixed to form a set of n(236U)/n(238U) mixtures at a concentration of 1 mg U g−1. Verification of the mixtures IRMM-075/1–6 was performed by TIMS measurements using Faraday collectors and a secondary electron multiplier in combination with an energy filter for improved abundance sensitivity. The results agreed well with the certified values obtained from the gravimetrical mixing calculations. The uncertainties of the calculated isotopic ratios are significantly lower compared to typical uncertainties from mass spectrometric techniques such as TIMS and ICPMS and in particular to AMS and RIMS. The methods for the preparation and mixing of the IRMM-075/1–6 series are described and the certification and verification procedures are reported.

A new series of gravimetrically prepared uranium isotope reference materials, the so-called IRMM-074 series, with the n((235)U)/n((238)U) isotope ratio held constant at unity and the n((233)U)/n((238)U) isotope ratios varying from 1.0 to 10(-6) has been prepared and certified. This series is suited for calibration or secondary electron multipliers used widely in isotope mass spectrometry, in particular for techniques such as thermal ionization mass spectrometry (TIMS), inductively coupled plasma mass spectrometry (ICPMS), accelerator mass spectrometry (AMS) and resonance ionization mass spectrometry (RIMS). The new IRMM-074 was prepared as a replacement for the already exhausted IRMM-072 predecessor series. Uranium materials with high isotopic enrichments of (233)U, (235)U and (211)U were purified using identical methods involving separation on anion and cation column followed by a precipitation as peroxide. The oxides were calcined to convert them to U(3)O(8) simultaneously, in an oven installed in a glove-box that provided a controlled low-humidity environment. The oxides of (235)U and (238)U were weighed and mixed with a mole ratio n((235)U)/n((211)U)=1.0 and then dissolved. The (233)U oxide was dissolved to form a separate solution with the same concentration and from this primary solution three dilutions were made by weighing. A weighed amount of the n((235)U)/n((238)U) solution and weighed amounts of the (233)U solutions were mixed in various proportions in order to achieve n((233)U)/n((238)U) isotope ratios varying from 1.0 to 10(-6). The methods for the preparation, the mixing and the mixing calculations are described. The expanded uncertainties (coverage factor k-2) of the certified isotope ratios for the IRMM-074 series are 0.015% for the n((235)U)/n((231)U) ratio and 0.025% for the n((233)U)/n((238)U) ratios, which constitutes an improvement compared to those of the predecessor IRMM-072 series. In addition, recent observations regarding the linearity response of secondary electron multipliers (SEMs) and suitable reference materials for investigating detector linearity are reviewed. Two measurement procedures for applying the IRMM-072 and IRMM-073 (diluted from the remaining fraction of IRMM-072) series as well as the new IRMM-074 series for assessing SEM linearity are suggested. The procedures are tailor-made for the specific instrumental characteristics of thermal ionization mass spectrometers (TIMS) and multiple-collector inductively coupled plasma mass spectrometers (MC-ICPMS) but can be adapted also for further types of isotope ratio mass spectrometers. (C) 2009 Elsevier B.V. All rights reserved.

This paper offers an organizational perspective about the Pareto-optimality of trade-offs between selection quality and adverse impact reduction described by De Corte, Lievens and Sackett. Based on considerations of culture and human resource strategy, the need to understand the impact of any trade-off, and a desire to compare this approach to alternatives, it is concluded that organizations may be strategically disinclined to implement such trade-offs and, if interested, organizations would desire more information than is available from the accumulated research in this domain. In particular, validity differences between Pareto-optimal composites are not likely to be good indicators of selection quality differences and the comparative effectiveness of alternative approaches is not clear.

Over the past decade an extraordinary increase has been experienced in the practice of B2B online trading. Portals, hubs, brokerages, and in particular electronic marketplaces (e-marketplaces) have emerged as everyday channels for business trading. The decision process behind joining such an e-marketplace, and evaluating which particular ones offer the best mix of services for a particular business's requirements, is not a straightforward undertaking. There are a host of variants on offer, numerous different membership schemes, service ranges, functionality types, product ranges, and technology platforms in existence, so it can prove to be a very confusing process for any prospective company contemplating joining. In earlier work (Hopkins and Kehoe 2006) an interrelationship matrix-based method was developed for evaluating, and rating, the appropriateness of a range of services offered by e-marketplaces in comparison with specific customer requirements. The system was designed to be used not only for evaluating existing e-marketplaces, but also in assisting with the design of new ones, and was intended be of equal value to both buyers and sellers. This paper now describes how the developed system has been tested, in two case study environments, in order to gauge its suitability for e-marketplace evaluation at both component level and sector level.

The process of joining an electronic marketplace (e‐marketplace), and the evaluation of which particular ones offer the most suitable mix of services for a particular business, is not a straightforward undertaking. With a myriad of variants on offer, and with the numerous membership models, features, services, functionality, product types, and technology platforms in existence, it can prove to be a very confusing process for any prospective company looking to join. For that reason this paper take steps toward developing an effective, intuitive, and user friendly mechanism for assisting in e‐marketplace selection, to be employed by practitioners looking to either subscribe to existing e‐marketplaces or examining the prospect of developing a bespoke e‐marketplace of their own. The investigation describes two case studies, one depicting the development of an e‐marketplace, by an SME in the UK, and the other describing a set of three new classification models derived after analysis of the wider global e‐marke...

Prolonged QRS duration (>120 ms), as a marker of ventricular dyssynchrony, is an independent predictor of mortality in systolic heart failure (HF). Little information exists about the characteristics of patients with preserved ejection fractions (EFs) and prolonged QRS (intraventricular conduction defects [IVCDs]). The electronic records of 334 consecutive patients hospitalized with acutely decompensated HF were reviewed. A significant number of patients hospitalized with decompensated HF had preserved EFs with IVCD. They had similar readmission and mortality rates compared with their systolic HF counterparts and higher rates compared with those with preserved EFs without IVCD. These findings and the resulting possible therapeutic interventions (resynchronization) need further analysis in a larger prospective cohort.

Background: In-hospital cardiopulmonary resuscitation (CPR) has seen a steady increase in the application of technology and techniques since the introduction of closed cardiac massage in 1960. Despite this progress, there has not been a demonstrated improvement in survival rates after in-hospital cardiac arrest over the last 40 years. Identification of prognostic factors associated with survival after a resuscitation attempt can help physician decisions and patients' end-of-life choices in a pre-arrest situation. Methods: Using an Utstein-based template we analyzed 219 consecutive adult attempted resuscitations in a large urban teaching hospital over a 3-year period. The main outcome measures were survival to discharge, 1 and 3 months. Backwards stepwise logistic regression was used to select baseline variables that predict survival at discharge, 1 and 3 months. Results: Survival rates at discharge, 1 and 3 months were 15.1, 13.3, and 11.5%. Meaningful neurological status (cerebral performance score of 1) at discharge was achieved in 61% of survivors. Independent predictors of survival were: higher body-mass index (BMI), presence of chronic renal insufficiency (CRI), respiratory arrest, ventricular tachycardia/fibrillation (VT/VF) as initial rhythm and arrest early during the hospital stay. A risk model based on these variables demonstrated a significant fit between predicted and observed survival at discharge with goodness of fit test P -value of 0.87. Conclusions: Survival after in-hospital cardiopulmonary arrest is poor and can be estimated by using clinical variables. If validated in a large prospective trial, this score could help physicians in attempting resuscitation, patients and families in making end-of-life decisions and hospitals in resource allocation.

A particular form of test score banding, in which bands are based on the reliability of the test and in which selection within bands takes into account criteria that are likely to enhance workforce diversity, has been proposed as an alternative to the traditional top-down (rank-order) hiring systems, but it has been hotly debated among both scientists and practitioners. In a question-and-answer format, this article presents three different viewpoints (proponents, critics, and neutral observers) on the scientific, legal, and practical issues. The article also attempts to seek some consensus among experts on this controversial procedure.

Sotalol is the prototype class III agent that combines beta-blocking properties with the propensity to prolong the effective refractory period by lengthening the action potential duration. Its precise effect on the prevention of ventricular tachycardia-ventricular fibrillation (VTVF) compared to class I agents has not been evaluated in a blinded study. In a double-blind parallel-design multicenter study, the electrophysiologic and antiarrhythmic effects of intravenous and oral sotalol (n = 55) and procainamide (n = 55) were therefore compared in patients with VTVF inducible by programmed electric stimulation. Sotalol produced a greater effect on lengthening the ventricular effective refractory period (VERP). It prevented the inducibility of VTVF in 30% versus 20% for procainamide, but this was not significantly different. In an alternate therapy group (n = 41) of similar patients previously refractory to or intolerant of procainamide, intravenous sotalol prevented inducibility in 32%. The pooled overall sotalol efficacy rate was 31%. There was a significant relation between the increase in the VERP and the prevention of inducibility of VTVF (n = 56; p or = 300 msec was critical for the prevention of VTVF inducibility. Thirteen sotalol and 6 procainamide responders from the randomized group and 30 from the nonrandomized groups completed 1 year of oral sotalol therapy follow-up. Life-table analysis of these patient in each group showed a trend in favor of sotalol; however, statistical analysis was not possible because of the small numbers of patients. Both sotalol and procainamide were well tolerated. In the randomized group there was one case of sudden death during treatment with sotalol and two cases of nonfatal torsades de pointes in the procainamide group and two in the sotalol group; in the nonrandomized alternate therapy group, there were 6 cases of nonfatal torsades de pointes. The data support the emerging role of sotalol in the control of symptomatic ventricular tachycardia and fibrillation.

Nonfluoroscopic Catheter Ablation of Cardiac Arrhythmias in Adults Background: Catheter ablations are traditionally performed using fluoroscopic guidance, exposing both patients and medical staff to the risks of radiation. Nonfluoroscopic catheter ablation has been used successfully to treat limited types of arrhythmias in children, but whether this approach has broad application in adults is uncertain. The purpose of this study was to evaluate the feasibility, safety, and efficacy of fluoroless catheter ablation in adults being treated for a range of arrhythmias. Methods and Results: Retrospective analysis was performed in 2 patient groups (both n = 60): (1) the nonfluoroscopy (NF) group consisting of consecutive adult patients, in which catheter positioning was accomplished exclusively with intracardiac electrograms (IE), electroanatomic mapping (EAM), and intracardiac echocardiography (ICE); and (2) the fluoroscopy (F) group, in which catheter positioning was additionally guided by fluoroscopy. The patients in the F group were selected to match the types of arrhythmias in the NF group. All ablation procedures were performed by one operator. The total procedure time did not differ between groups for any specific type of arrhythmia ablated. Acute procedural success was similar in both groups (NF, 59/60 [98%] and F, 60/60 [100%]). The complications were limited to a groin pseudoaneurysm in the NF group, and pericardial effusion and groin hematoma in the F group. Conclusion: Catheter ablations were efficiently and effectively performed in adults with a variety of arrhythmias using only IE, EAM, and ICE for catheter guidance. This nonfluoroscopic technique was feasible, posed no additional safety concerns, and should be readily implementable in most electrophysiology laboratories. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1078-1086, October 2012)

Methods of adjusting group differences in assessment and test scores are described, classified, and evaluated. The adjustments are classified on the basis of (a) the type of adjusted difference, (b) the method of adjustment, and (c) the purpose of the adjustment. Adjustments used to improve the social fairness of outcomes either could not be fully evaluated or were inconsistent with the underlying fairness model. Adjustments designed to reduce score bias, in the technical sense, could be meaningful and internally consistent only if the observed group difference could be related to constructs targeted by the assessment procedure

Creatinine clearance was estimated using a formulaic method from serum creatinine, age and sex in 740 unselected lithium-treated patients in southeastern Scotland. Psychiatric history and details of prescribing and monitoring of lithium treatment were obtained from existing case registers. Lithium treatment duration and glomerular filtration, controlling for the effects of age, were weakly related, but only in males. Cases who had been exposed to higher serum lithium concentrations had lower creatinine clearance than those maintained within therapeutic range. Of cases within the lowest quartile of renal function, proportionally more were supervised in general practice rather than at hospital clinics. Suggestions are made for the clinical practice of monitoring serum lithium concentrations and serum creatinine.

The safety and efficacy of oral sotatol were evaluated in 481 patients with drug-refractory sustained ventricular tachyarrhythmias (VT) In an open-label multicenter study. After drug-free baseline evaluations, therapy was initiated at 80 mg every 12 hours, with upward dose titrations of 160 mg/day being allowed at intervals of 72 hours to a maximum dose of 480 mg every 12 hours. Efficacy determinations were made by either programmed electrical stimulation (PES) or Holter monitoring responses. Of the 481 patients enrolled, 473 underwent acute-phase titration. Of the 269 patients assessable by PES, 94 (34.9%) exhibited complete response (suppression of inducible VT), with an additional 67 patients (24.9%) exhibiting partial response. Of the 109 patients assessable by Holter monitoring, 43 (39.4%) exhibited a complete response. There were no significant differences between responders and nonresponders with regard to left ventricular ejection fraction. Although response rates tended to improve as the sotatol dose was increased to 640 mg/day, efficacy was most commonly achieved at a sotalol dose of 320 mg/day. Sotalol was discontinued because of adverse effects in 42 (8.9%) of the acute-phase patients. The most common adverse effect was proarrhythmia, which was observed in 23 patients (4.9%). Proarrhythmia took the form of torsades de pointes in 12 patients and an increase in VT episodes in 11. In 3 acute-phase patients (0.6%), sotalol was discontinued because of the emergence of congestive heart failure. A total of 286 patients entered the long-term phase. Life-table estimates of the proportion of patients who remained free of recurrence of arrhythmia at 12, 18, and 27 months were 0.76,0.72, and 0.66, respectively. There were no significant differences in time to recurrence of arrhythmia as related to PES response, Hotter monitor response, baseline left ventricular ejection fraction, or history of congestive heart failure. Among the 70 patients (24.5%) in whom there was recurrence of arrhythmia, sudden death occurred in 17 and sustained VT in 41. Sotalol was discontinued owing to presumed adverse effects in 21 (7.3%) of the long-term patients, including 8 with proarrhythmia; proarrhythmia consisted of torsades de pointes in 3 patients and increased episodes of VT in 5. These findings suggest that sotalol is an effective drug for the long-term treatment of patients with drug-refractory sustained VT. Proarrhythmia was observed in only 6.4% of the study population and tended to occur during the acute titration phase. The need to discontinue therapy because of congestive heart failure was uncommon. The risk of recurrence of arrhythmia appeared to be unrelated to response to PES or ambulatory monitoring, type of heart disease, or extent of toft ventricular dysfunction.

Structured systems analysis and design methods have been widely used in recent years in the specification of requirements for information systems. The development of techniques such as data flow diagramming and entity modelling and the supporting Computed Aided Software Engineering (CASE) tools have been applied since the 1970s in data processing environments. More recently, such methodologies have been applied to manufacturing systems through programmes such as IDEF. A research project is detailed which has identified the development needs for the application of structured methods to flexible manufacturing. A structured methodology for tool management information systems is outlined, together with the role of supporting CASE tools. The methodology models the current information systems associated with tool management, and guides the user in the generation of a requirements specification. The main stages in the implementation of the methodology are described, together with examples of an industrial application within a collaborating advanced manufacturing company.

Aims and methodTo describe the implementation of a plan to use a validated outcome measure in the care and treatment of people with severe mental illness within a district general hospital psychiatric service. Multiple techniques were necessary to promote actual change of practice.ResultsA survey of practice found 77% of full Care Programme Approach patients to have recorded Health of the Nation Outcome Scales (HoNOS) scores in their care plans one year after the beginning of the implementation plan.Clinical implicationsIt is possible to incorporate the use of HoNOS in to everyday practice but it takes a lot of time, effort and resources. Mental health services may require a clearer indication from the NHS Executive regarding the use of such outcome scales before committing themselves.

The safety and efficacy of oral sotalol, an investigational β-adrenergic blocker with class III antiarrhythmic drug properties, were examined in a multicenter study in 236 patients with sustained ventricular tachyarrhythmias. In 104 patients, the index arrhythmia was a cardiac arrest, and all patients had undergone at least 3 previous unsuccessful antiarrhythmic trials (mean = 5 per patient). In the 106 patients assessed by programmed electrical stimulation, sotalol completely suppressed induction of ventricular tachycardia (VT) in 33 (31%) and rendered VT slower (>100 ms prolongation of cycle length) or more difficult to induce in 29 (27%). Using continuous 24-hour ambulatory monitoring methods, sotalol complete- and partial-response rates were 51 and 12%, respectively. Of the 236 acute-phase patients, 151 were discharged receiving long-term sotalol therapy. The median sotalol dose was 480 mg/day. At a mean follow-up of 346 ± 92 days, 27 patients (18%) had recurrence of sustained arrhythmia; 9, sudden death; 11, sustained VT; 5, automatic defibrillator discharge; and 2, syncope. Adverse effects forced discontinuation of therapy in 10 patients (7%): 6 secondary to symptomatic bradyarrhythmia, 2 due to refractory heart failure, 1 due to torsades de pointes, and 1 from bronchospasm. Life-table analysis of sotalol's overall long-term efficacy at 6, 12 and 18 months were 80, 76 and 72%, respectively. Although mean follow-up was short ( Proarrhythmia was documented in 18 patients (7%), 17 during the acute phase and 1 during long-term follow-up. Proarrhythmia was manifested as torsades de pointes in 11 patients and as an increase in sustained VT episodes in 7. Of the 18 proarrhythmic complications, 14 (78%) occurred within 7 days of therapy. Symptomatic bradycardia occurred in 8 patients (3%) (7 during the acute phase, 1 long-term) and aggravation of heart failure in 7 (3%) (6 acute phase, 1 long-term). Thus, sotalol appears to be an effective agent for suppressing refractory, sustained ventricular tachyarrhythmias and is well tolerated during long-term therapy. Proarrhythmia was observed in 7% of patients and tended to occur during the acute titration phase. Accordingly, it is recommended that patients with sustained ventricular tachyarrhythmias treated with sotalol be observed under continuous electrocardiographic monitoring until acutephase dose titration has been completed.

Dofetilide is currently recommended as second-tier therapy to maintain sinus rhythm in patients with paroxysmal atrial fibrillation (PAF) and normal left ventricular function, yet limited data support this recommendation. We examined the safety and efficacy of dofetilide in this setting through a retrospective chart review. We evaluated patients who had symptomatic PAF, normal left ventricular function, and no significant valvular disease. The end points were complete suppression of symptomatic PAF and subjective symptomatic improvement with dofetilide treatment. Over a 3-year period, 34 patients who had failed previous antiarrhythmic therapy were included. Of these, 3 discontinued dofetilide treatment before discharge. Of the remaining 31 who continued treatment after discharge, it was eventually discontinued in 13. At 12 months, symptomatic improvement was observed in 18 of 31 patients, 6 of whom remained asymptomatic. Treatment with dofetilide in this study was successful in less than 1 in 5 patients. Despite careful precautions, serious proarrhythmias, the major limiting side effect of dofetilide, still occurred during long-term follow-up.

Lay involvement in clinical audit has been advocated but rarely reported. Since early 1994 in the mental health unit at Airedale, Yorkshire, lay representatives have participated in all stages of clinical audit, Including selection of topics and methods, data collection and standard setting. After 8 months of lay involvement, all respondents to a brief questionnaire saw lay involvement as important, although none identified specific benefits that had already occurred. The paper outlines themes in respondents' perceptions of the benefits and problems of lay involvement and in their suggestions for minimising difficulties.

This paper considers the possible relevance to psychiatry trainees of a period of training in public health medicine. The work of public health doctors is to identify ways of Improving the health of populations and to promote relevant change. It is of relevance to psychiatrists, who have to consider needs of whole catchment populations rather than Just of patients who seek help, and who have historically experienced difficulty in competing for resources. We discuss tasks that trainees might undertake during a brief public health attachment, the potential benefits of such an attachment and some of the practical considerations.

To determine the availability of career guidance within psychiatric training, the Collegiate Trainees Committee surveyed 300 trainees who had recently sat the MRCPsych Part II examination and 136 (45%) responded. Most trainees had received little or no career guidance and some had sought career advice without success. One third of trainees felt they had encountered discrimination within their psychiatric training. We urge trainees to be pro-active in seeking career guidance, identify sources of advice and make suggestions for topics to be discussed within consultant supervision sessions. We recommend that local access to career advice should be assessed by visiting College inspection panels.

A patient who presented with a new apparent seizure was found to have abnormal electrocardiographic findings, with classic features of the Brugada syndrome. He had spontaneous episodes of nonsustained ventricular tachycardia, easily inducible ventricular fibrillation at electrophysiological study in the absence of structural heart disease, and a negative neurological evaluation. These findings suggested that sustained ventricular arrhythmias known to be associated with the Brugada syndrome and resultant cerebral hypoperfusion, rather than a primary seizure disorder, were responsible for the event. Patients with the Brugada syndrome often present with sudden death or with syncope resulting from ventricular arrhythmias. In consideration of its variability in presentation sometimes mimicking other disorders, primary care physicians and internists should be aware of its often transient electrocardiographic features.

Objectives: To describe existing Scottish psychiatric emergency services, particularly the staffing levels and supervision of junior staff, to assess the level of recording of the urgency of referrals to such services and to determine the approximate rates of emergency presentations. Method: A postal questionnaire was sent to all 29 Scottish psychiatric hospitals, addressed to the physician superintendent or the consultant in charge of emergency services. Twenty-six were returned and further details on these and the other three services were clarified by telephone contact with medical records and medical staff. Description of services, number of presentations, staffing levels and degree of supervision were recorded. Rates of referral were estimated for Health Board populations. Results: Services varied from hospital based walk-in clinics through to community orientated domicillary assessment services. Emergency presentations are usually seen by junior staff in a psychiatric hospital outpatient department, a psychiatric ward or at an accident and emergency department. Out of hours supervision is typically by telephone advice from a consultant. Rates of emergency presentations based on collected and estimated figures were highest in urban areas. Conclusions: Scottish psychiatric emergency services are disparate in nature but all provide a 24 hour service. There is a lack of reliably collected data on the urgency of referrals but estimates suggest that there is a greater need for emergency psychiatric care in the large urban areas. Working definitions are proposed to assist in the classification of the urgency of referrals.

When planning new service initiatives it is important to review the role and functioning of existing services. As more patients are discharged from long-stay beds, there is increasing concern regarding the quality of community care and the accessibility of urgent psychiatric help. The Department of Health has recently expressed concern over the level of such services provided (DoH, 1989). In Edinburgh, alternative methods of delivering psychiatric emergency care are currently being considered. Community-orientated crisis intervention teams may be useful, but only a small proportion of people presenting to general psychiatric services fit into the stereotyped model of crisis. Centres with short-term admission facilities have been developed in other countries and within the United Kingdom many general hospital casualty departments have a psychiatrist available on call. Walk-in or self-referral psychiatric clinics provide an easily accessible service but few have been systematically reported (Lim, 1983; Haw, 1987). Such clinics have been described as seeing mainly chronic patients of the hospital who are already in current contact and who present with less severe psychiatric disorders than GP-referred cases. In a climate of NHS financial restraint it is pertinent to ask whether such clinics are needed.

BackgroundEarly manic relapse following lithium discontinuation offers an important opportunity to investigate the relationship between symptoms, effects of treatment and regional brain activation in bipolar affective disorder.MethodFourteen stable bipolar patients on lithium were examined with neuropsychological measures, clinical ratings and single photon emission computed tomography (SPECT) before and after acute double-blind withdrawal of lithium. Brain perfusion maps were spatially transformed into standard stereotactic space and compared pixel-by-pixel. A parametric analysis was used to examine the change in brain perfusion on lithium withdrawal, and the relationship between symptom severity and brain perfusion separately both between and within subjects.ResultsLithium withdrawal was associated with an important redistribution of brain perfusion, with increases in inferior posterior regions and decreases in limbic areas, particularly anterior cingulate cortex. Seven of the 14 patients developed manic symptoms during the placebo phase, correlating with relative increases in perfusion of superior anterior cingulate and possibly left orbito-frontal cortex.ConclusionsThe important effect of lithium withdrawal on brain perfusion implies that after withdrawal of lithium, the brain develops an abnormal state of activity in limbic cortex. The structures involved did not co-localise with those apparently modulated by manic symptoms.