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Objective: To assess whether a novel 'direct access pathway' (DAP) for the management of high-risk non-ST-elevation acute coronary syndromes (NSTEACS) is safe, results in 'shorter time to intervention and shorter admission times'. This pathway was developed locally to enable London Ambulance Service to rapidly transfer suspected high-risk NSTEACS from the community to our regional heart attack centre for consideration of early angiography. Methods: This is a retrospective case-control analysis of 289 patients comparing patients with high-risk NSTEACS admitted via DAP with age-matched controls from the standard pan-London high-risk ACS pathway (PLP) and the conventional pathway (CP). The primary end point of the study was time from admission to coronary angiography/intervention. Secondary end point was total length of hospital stay. Results: Over a period of 43 months, 101 patients were admitted by DAP, 109 matched patients by PLP and 79 matched patients through CP. Median times from admission to coronary angiography for DAP, PLP and CP were 2.8 (1.5-9), 16.6 (6-50) and 60 (33-116) hours, respectively (p<0.001). Median length of hospital stay for DAP and PLP was similar at 3.0 (2.0-5.0) days in comparison to 5 (3-7) days for CP (p<0.001). Conclusions: DAP resulted in a significant reduction in time to angiography for patients with high-risk NSTEACS when compared to existing pathways. [ABSTRACT FROM AUTHOR]

Objective: To assess the safety and effectiveness of nurse led elective cardioversion of atrial fibrillation under sedation. Design: Prospective, longitudinal study. Setting: Cardiac catheterisation laboratory and recovery area of a district general hospital. Patients: 300 patients referred for elective cardioversion of persistent atrial fibrillation. Interventions: Pre-procedure evaluations (history, physical examination, blood tests), consent, sedation administration, cardioversions, and post-procedure monitoring until discharge by advanced life support certified coronary care unit nurses trained in the techniques. A doctor was immediately available if required but not present. Main outcome measures: Success rates at discharge and at six weeks, energy delivered, number of shocks, dose of sedation, immediate, 24, and 48 hour patient perceptions, complications, waiting times, and cost effectiveness. Results: Cardioversion success rate was 87% at discharge and 48% at six weeks. Mean (SD) cumulative energy was 497 (282) J and number of shocks 1.6 (0.8). Mean (SD) dose of sedation was 23 (9) mg intravenous diazepam. No patient required reversal of sedation, airway support, or medical intervention. Ninety eight per cent of patients had no pain or recall of the procedure. Four patients who were adequately anticoagulated experienced embolic phenomena. Ninety eight per cent of patients would repeat the procedure if necessary. Without requirement for a physician or anaesthetist, waiting times for elective cardioversion fell from three months to under four weeks. There was a significant reduction in the estimated cost of the procedure from £337 with general anaesthesia to £130 with nurse led sedation and cardioversion (p < 0.001). Conclusion: With appropriate training, a nurse led cardioversion service with sedation is safe, effective, well tolerated, and cost efficient. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate optical coherence tomographic elastography as a method for assessing the elastic properties of atherosclerotic plaque and the parameters that influence interpretation.Methods: Phantoms and aorta were examined in vitro to quantify speckle modulation and measure the displacement and strain maps. A correlation method was used as a speckle tracking technique for measuring axial and lateral displacement vectors and calculation of strain maps. The influence of correlation kernel size on accuracy of the method was evaluated.Results: In terms of a percentage error between calculated and measured displacements, the best results for phantoms were obtained with a 41 x 41 kernel (1.88% error). For both phantom and aorta images, it was found that, with the increasing size of cross correlation kernel, the axial and lateral displacement maps are less noisy and the displacement vectors are more clearly defined. However, the large kernels tend to average out the differences in displacements of small particles in phantoms and decrease the ability of speckle tracking to make microstructural assessments. Therefore, it is important to select kernel size carefully, based on the image features.Conclusions: Optical tomographic elastography can be used to assess the microstructural properties of atherosclerotic tissue at micrometre scale resolution, but preselected analysis criteria must be understood in a critical interpretation of the results. [ABSTRACT FROM AUTHOR]

Van Buchem disease is an autosomal recessive skeletal dysplasia characterised by generalised bone overgrowth, predominantly in the skull and mandible. Clinical complications including facial nerve palsy, optic atrophy, and impaired hearing occur in most patients. These features are very similar to those of sclerosteosis and the two conditions are only differentiated by the hand malformations and the tall stature appearing in sclerosteosis. Using an extended Dutch inbred van Buchem family and two inbred sclerosteosis families, we mapped both disease genes to the same region on chromosome 17q12-q21, supporting the hypothesis that van Buchem disease and sclerosteosis are caused by mutations in the same gene. In a previous study, we positionally cloned a novel gene, called SOST, from the linkage interval and identified three different, homozygous mutations in the SOST gene in sclerosteosis patients leading to loss of function of the underlying protein. The present study focuses on the identification of a 52 kb deletion in all patients from the van Buchem family. The deletion, which results from a homologous recombination between A/u sequences, starts approximately 35 kb downstream of the SOST gene. Since no evidence was found for the presence of a gene within the deleted region, we hypothesise that the presence of the deletion leads to a down regulation of the transcription of the SOST gene by a cis regulatory action or a position effect. [ABSTRACT FROM AUTHOR]

To determine the extent of intrapartum intervention received by primigravidas. Cross sectional survey of NHS hospitals in the UK. One hundred and one randomly selected hospital maternity units. Forty consecutive primigravid women, judged to be at low risk at the start of labour, in each hospital. Seven groups of interventions or monitoring procedures were identified from the first, second, and third stages of labour: fetal monitoring, vaginal examinations, artificial rupture of membranes, augmentation of labour, pain relief, type of delivery, and episiotomy. Data were collected during 1993. Ninety eight hospitals took part in the study and data were collected on 3160 low risk primigravidas. Seventy four per cent of these women had continuous cardiotocography. The proportion of women having restrictive or invasive fetal monitoring showed appreciable geographical variation for both the first and second stages of labour. Using the criterion of a vaginal examination every four hours and allowing for the length of each woman's labour, 72% had more vaginal examinations than expected; there was a significant geographical variation in the number of women receiving more than five examinations. Fifty three per cent had artificial rupture of membranes; the procedure was performed over a wide range of cervical dilatations (0 cm-10 cm). Thirty eight per cent of labours were augmented, most commonly by intravenous syntocinon; the procedure showed significant geographical variation. Twenty eight per cent had a spinal block or epidural analgesia for the relief of pain; this intervention varied by geographical region only for the second stage of labour. Over one quarter of the women required instrumental delivery. Forty six per cent had an episiotomy; the frequency of this intervention varied substantially by region. There were no infant deaths. Twelve babies were recorded at birth as having a congenital anomaly. The rates of several interventions seem high for this low risk group and there was substantial geographical variation in the use of six interventions. Clinical trials are needed to evaluate the optimum criteria for using these interventions from which guidelines should be drawn up by local groups and the Royal College. [ABSTRACT FROM AUTHOR]

A non-directive programme of prenatal counselling was used during a four year period. Forty-three couples at risk for having a baby with a haemoglobinopathy were identified. Prenatal diagnosis was offered in 19 pregnancies to 14 couples at risk of having a baby with sickle cell anaemia and in two pregnancies in two couples at risk of a baby with beta thalassaemia major, who presented before the 18th week of pregnancy. Six couples at risk for sickle cell anaemia accepted prenatal diagnosis in 10 pregnancies, as did both couples at risk for thalassaemia. Couples who were eligible for prenatal diagnosis but refused it tended not to have been informed about sickle cell disease before counselling, one partner was more frequently absent at the time of the initial counselling session, or they either had no children with sickle cell disease or the children were not severely affected. Other factors influencing their decision included a poor obstetric history and rejection of abortion, mainly on moral grounds. The approximately 50% uptake of prenatal diagnosis in this initial study highlights the complex issues involved. Our experience indicates that with systematic screening and counselling in the antenatal clinic, and with increased awareness of the haemoglobinopathies, couples at risk will be in a better position to make informed decisions. [ABSTRACT FROM PUBLISHER]

This article focuses on a study that compares poorer short term outcome in indo-asians and Caucasians after percutaneous coronary intervention (PCI) for ethnicity as an independent risk factor. Despite the complex nature of this patient group there is a low incidence of tropinin elevation and myocardial necrosis following PCI. Coronary artery disease tends to be more extensive and diffuse in Indo-Asians (IA) as compared with Caucasians. There are, however, few data relating to ethnicity and outcome after revoscularisation. Ethnicity in relation to lAs emerged as an independent risk factor for poor short term outcome following PCI.

Objective This project aims to: (1) describe the frequency of news coverage in mass media related to the National Institute for Health and Clinical Excellence (NICE) draft or final guidance; (2) analyse the types of evidence and sources of information that was quoted in the news; (3) compare whether the patterns of coverage differ between media. Design A survey of news articles related to decisions made by NICE's Health Technology Appraisal committees was conducted. Relevant news articles were retrieved from websites of major UK news media. Inclusion criteria were: (1) news articles related to specific NICE decision(s); (2) articles were written by a reporter/writer/editor of the news media. Articles that mentioned NICE for other reasons, columns and readers' letters were excluded. Setting Major UK news media, including national newspapers and news channels. Samples News articles published during 2007–2008 in 13 different sources of media including tabloids (Daily Express, Daily Mail, News of the World, The Mirror, The Sun), broadsheets (Independent, Guardian, The Telegraph, The Times) and news channels (BBC, ITN, Sky News and Reuters). Main outcome measure The following data were collected by one author and checked by another: nature of guidance (disease area; positive or negative recommendation), use of generic or brand name and source/type of evidence that was quoted. Descriptive statistics were compiled and comparisons between types/sources of news media were made using χ test. Results 329 articles were included. BBC, Daily Mail and The Telegraph published more than 50 articles related to health technology appraisal whereas ITN and News of the World published less than 10 articles during the 2-year period assessed. Two-thirds (220/329) of the articles were related to negative recommendations. There was significant difference in the proportion of articles relating to negative recommendations between individual sources of media (p=0.001) but not between types of media (p=0.286). Cancer (33%), neurology–mainly Alzheimer's disease (22%), ophthalmology (13%) and rheumatology (10%) were most frequently covered areas. 58% (192/329) of the articles quoted only brand names without mentioning generic names of the drugs. Approximately 50% of articles included statements of effectiveness without referring to the source of evidence and another 40% did not describe clinical effectiveness. 24% of articles did not mention drug costs or cost-effectiveness. Conclusion NICE decisions on new drugs, particularly negative recommendations, attracted significant media attention but the coverage and contents varied substantially between individual sources. [ABSTRACT FROM AUTHOR]