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Objective: To assess the cost effectiveness of drug eluting stents (DES) compared with conventional stents for treatment of symptomatic coronary artery disease in the UK. Design: Cost-utility analysis of audit based patient subgroups by means of a simple economic model. Setting: Tertiary care. Participants: 12 month audit data for 2884 patients receiving percutaneous coronary intervention with stenting at the Cardiothoracic Centre Liverpool between January 2000 and December 2002. Main outcome measures: Risk of repeat revascularisation within 12 months of index procedure and reduction in risk from use of DES. Economic modelling was used to estimate the cost-utility ratio and threshold price premium. Results: Four factors were identified for patients undergoing elective surgery (n = 1951) and two for non- elective surgery (n = 933) to predict risk of repeat revascularisation within 12 months. Most patients fell within the subgroup with lowest risk (57% of the elective surgery group with 5.6% risk and 91% of the non-elective surgery group with 9.9% risk). Modelled cost-utility ratios were acceptable for only one group of high risk patients undergoing non-elective surgery (only one patient in audit data). Restricting the number of DES for each patient improved results marginally: 4% of stents could then be drug eluting on economic grounds. The threshold price premium justifying 90% substitution of conventional stents was estimated to be £112 (US$212, &3x20AC;162) (sirolimus stents) or £89 (US$167, &3x20AC;130) (paclitaxel stents). Conclusions: At current UK prices, DES are not cost effective compared with conventional stents except for a small minority of patients. Although the technology is clearly effective, general substitution is not justified unless the price premium falls substantially. [ABSTRACT FROM AUTHOR]

Community-based healthcare organisations manage competing, and often conflicting, priorities. These conflicts can arise from the multiple roles these organisations take up, and from the diverse range of stakeholders to whom they must be responsive. Often such conflicts may be titled conflicts of interest; however, what precisely constitutes such conflicts and what should be done about them is not always clear. Clarity about the duties owed by organisations and the roles they assume can help identify and manage some of these conflicts. Taking divisions of general practice in Australia as an example, this paper sets out to distinguish two main types of conflicts of interest, so that they may be more clearly identified and more effectively managed. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article about segmental coronary endothelial dysfunction in patients having minimal atherosclerosis.

Introduction Narrow band imaging (NBI) has been investigated as a technique to improve adenoma detection; however most randomised studies have shown no differences from white light examination (WLE). We recently reported no significant difference in adenoma detection rate for our trial of NBI for detection in high risk patients (n=214; 73% NBI vs 66% WLE, p=0.26); however patients were not evenly matched by gender in NBI and WLE groups. We therefore undertook a multivariate analysis to account for this and investigate other subgroups Methods The primary outcome measure, patients with at least one adenoma detected, was reanalysed after adjustment for demographic and clinical variables including all of: age, gender, indication (3+ adenomas, cancer follow up, +ve FOBT), family history of colorectal cancer, bowel preparation (good or adequate), endoscopist (three operators), and withdrawal time, using logistic regression. Count outcomes (polyp numbers by type) were analysed by Poisson regression. An interaction was noted with both endoscopist and bowel preparation, which were analysed as subgroups Results Following multivariate analysis there was no significant difference for the primary outcome measure between WLE and NBI arms, p=0.30, OR (adjusted) 1.46 (95% CI 0.72 to 2.96). No difference was seen for total number of adenomas, total polyps, advanced adenomas or non-adenomatous polyps; however the mean (SD) number of flat adenomas was higher in NBI arm 0.4 (0.9) versus 0.2 (0.4), adjusted comparison ratio 2.58 (1.42–4.68), p=0.002. One of three endoscopists performed significantly better with NBI (). In patients with good bowel prep NBI significantly outperformed WLE for numbers of adenomas detected, but there was no difference with adequate bowel prep (). OC-091 Comparison ratios for numbers of adenomas detected by WLE or NBI Conclusion Overall, after adjustment, NBI did not improve adenoma detection; however detection of flat adenomas appears improved. One of three endoscopists performed better with NBI than white light, and NBI was more effective in patients with good bowel preparation. Under optimal conditions, NBI may assist some endoscopists to optimise detection particularly of flat adenomas. Aggregated results of randomised controlled trials may obscure situations where advanced imaging techniques could provide benefit. ClinicalTrials.gov identifier NCT00279357. [ABSTRACT FROM PUBLISHER]

Introduction Incomplete colonoscopy is one explanation for missed cancers in the right colon. Patients with incomplete colonoscopy are more likely to be older, female and have a history of abdominal or pelvic surgery. Most difficulties during colonoscopy arise from often unpredictable and recurrent looping of the colonoscope within floppy and elastic bowel. Magnetic endoscope imaging (ScopeGuide; Olympus) allows accurate visualisation of loops. The aim of this study was to assess the effect of ScopeGuide in a group of patients likely to have technically difficult colonoscopy. Methods Consecutive patients over 60, attending St Mark's hospital for a screening colonoscopy between September 2009 and July 2010 were identified and those scoring ≥2 on the predicted difficulty score were included (table 1). This was a randomised parallel trial in which patients were randomised in 1:1 ratio to a colonoscopy with ScopeGuide view available or not. All colonoscopies were performed by consultant endoscopists. The primary outcome measure was caecal intubation time in the study and control groups. Secondary outcome measures included: caecal intubation rates within 20 min (intention to treat analysis), patient pain scores and numbers of polyps detected. Results 44 patients (22 in each arm) completed the study protocol. Colonoscopy was complete to caecum in all 44 cases. Intubation to caecum was achieved within 20 min in 21 of 22 (95%) patients when the ScopeGuide view was available. When the ScopeGuide view was not available, in 18 of 22 (82%) patients caecal intubation was achieved within 20 min, p=0.35. In 3 cases, the endoscopist elected to view the ScopeGuide in order to complete the procedure – these were analysed as failed caecal intubations. Median time taken to complete intubation to caecum in the ScopeGuide arm was 6.6 min (IQR 4.3–11.1) compared to 9.1 min (7.4–13.5) (p=0.07) in the no ScopeGuide arm. There was a trend towards shorter duration of looping when ScopeGuide was available compared to when it was not, but this did not reach statistical significance (2.2 vs 4.3 min, p=0.07). Median patient pain score in the group when ScopeGuide view was available was 4 (IQR 0–22) compared to 15 (10–25) when ScopeGuide view was not available (p=0.03). PTH-003 Conclusion ScopeGuide does not improve caecal intubation rates and times, but does improve comfort levels in patients with technically difficult colonoscopies performed by very experienced colonoscopists. The effect of ScopeGuide on caecal intubation rates and times in technically difficult colonoscopies in the hands of less experienced colonoscopists should be studied. [ABSTRACT FROM PUBLISHER]

Introduction Chromoendoscopy at colonoscopy for surveillance in colitis, improves detection of dysplastic lesions by 3–4 fold, but has not gained widespread acceptance due to perceived increase in time for the procedure. Narrow band imaging (NBI) has been described as ‘electronic chromoendoscopy’. The aim of this trial was to assess the effect of NBI on dysplasia detection in colitis. Methods 112 patients with long-standing UC were randomised in a 1:1 ratio to intervention group of examination with high definition NBI (n = 56) or to a control group of high definition WLE (n = 56) for colonoscopic extubation (Lucera; Olympus, Tokyo) in a parallel group design at 2 tertiary endoscopy units in the UK (6 endoscopists). Targeted biopsies of suspicious areas and quadrantic random biopsies every 10 cm were taken in both groups. The primary outcome measure was the proportion of patients with at least one area of dyplasia detected, which was analysed on an intention-to-treat basis. Outcome data were compared between the groups, both unadjusted and adjusted for withdrawal time, family history of colorectal cancer and previous history of dysplasia. Results There was no difference in the primary outcome between the two groups, with five patients having at least one dysplastic lesion in each group (OR 1.00, 95% CI 0.27 to 3.67, p = 1.00), nor when adjusted for other variables (OR 0.69, 95% CI 0.16 to 2.96, p = 0.62). Overall dysplasia detection was 9% in each arm. During NBI colonoscopy, 17 endoscopically suspicious lesions were detected in 13 patients. Histopathology confirmed five dysplastic lesions in five patients (all five low-grade dysplasia).In the WLE arm, 11 suspicious lesions were detected in 8 patients and 7 lesions (in 5 patients) were neoplastic (low-grade dysplasia, n = 5 and high-grade dysplasia n = 2). Although there was a trend that NBI detected more false positive lesions, this was not statistically significant (p = 0.06). Yield of dysplasia from random non-targeted biopsies was 1/2707 (0.04%). Conclusion Overall in this multi-centre parallel group trial, even after adjustment, there was no difference in dysplasia detection when using NBI compared to high definition WLE colonoscopy. This confirms previous single centre tandem data, which suggests no improvement with NBI for colitis surveillance. Random background biopsies were ineffective in picking up dysplasia and we would therefore support the use of chromoendoscopy and targeted biopsies as the current endoscopic surveillance strategy of choice as suggested in the 2010 BSG guidelines. [ABSTRACT FROM PUBLISHER]

The article presents a case study of an old woman with right coronary artery lesion. Results of intravascular ultrasound and virtual histology showed that the complaint is associated to an ulcerated lesion and distal lesion haziness. The clinical investigation also consider the possible association between the lesion and her history of a thrombolyzed inferior ST elevation myocardial infarction.

The article presents the case of a 72 year old man with medical history of exertional angina of the left coronary system. Hypertension and hyperlipidaemia are two common risk factors of the coronary system abnormalities. Computed tomography scanning confirms that the left side of the main stem of the coronary system is growing adjacent to the right coronary ostium in an anterior position. The study reveals that only 1 percent of the coronary artery abnormalities affect the population.

This article focuses on a study related to operator specific outcome in percutaneous coronary intervention (PCI) and impact of risk adjustment on apparent mace rate. Publication of operator specific outcomes in PCI is likely to replace centre specific major adverse cardiac event data currently audited by BCIS. Researchers examined the use of risk adjustment techniques in the comparison of outcomes between operators. Crude outcome data can suggest significant differences in operator outcome that appears to be related to differences in case mix.

A 59-year-old man underwent quadruple coronary artery bypass grafting in 1989. Ten years later he was admitted to hospital as an emergency with a two week history of increased abdominal swelling, breathlessness and ankle swelling. Examination revealed a sinus tachycardia, raised jugular venous pressure and piting oedema of the ankles. Transthoracic echocardiography revealed moderate left ventricular systolic impairment and localised right ventricular tamponade. Computed tomography confirmed significant compression of the right ventricle by a pericardial mass which contained some central calcification. At surgery the mass was excised. Histological analysis revealed an organized, partly calcified hematoma.