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There has been an increasing demand for rapid access clinic appointments in the Paediatric department in Northampton General Hospital over the past 2 years, which has led to an increase in wait time for an appointment. (21 patients per month on average in 2015 and 34 per month in 2016). This rapid access clinic is led by a consultant, and runs up to two times per day. A large proportion of the patients seen in this clinic have prolonged jaundice, and can be managed by a junior doctor. Therefore, our proposal is to introduce a junior doctor led clinic to see patients with prolonged jaundice, to free up more space in the consultant-led rapid access clinic. The overall aim of the project was to reduce the average wait time for the paediatric hot-clinic to below 2 days by December 2017. Training on running the clinic, using a new proforma, was delivered to support the junior doctors with the new clinic. A process was established to ensure all investigations undertaken after the appointment were discussed with the Consultant of the Week. A patient information document was produced for prolonged jaundice as no current one existed. Furthermore, parent experience was recorded during the introduction of the clinics to ensure they remained satisfied with the service delivered. The new junior doctor-led clinics started in June 2017. Preliminary data has shown the wait time for the paediatric rapid access clinic has already reduced to below 2 days on average for June – August 2017. This compares to 3.5 days on average for the same period in 2016. The introduction of this new junior doctor-led clinic for prolonged jaundice babies continues to provide a high-level service for patients and their parents, whilst reducing the wait time for the consultant-led rapid access clinic to the internal standard of less than 2 days on average.

Therapeutic thrombolysis is an immense opportunity in acute stroke care. For the first time, there is a treatment that has a high probability of being effective if given early enough to patients with acute ischemic stroke. However, the risks of intracranial hemorrhage are substantial and as yet the exact indications and contraindications have not been worked out. And indeed how to deliver this treatment in routine clinical practice. As stroke units proliferate and become more organized, and physicians become more specialized in stroke care, it will become easier both to further assess in randomized trials and to deliver thrombolysis, certainly intravenously and maybe in some centers intra-arterially in suitable cases.

Patients with "migraine aura without headache" can be separated from those with transient ischaemic attacks (TIA) on the basis of the onset of symptoms, which is generally gradual and which spread or intensify over minutes or hours, and from the typical migrainous nature of their visual symptoms. Fifty cases were prospectively identified and these were compared with 50 age matched patients with a TIA. Surprisingly, there were no significant differences in the prevalence of vascular risk factors and diseases in the two groups although those with TIAs tended to have more. Only one patient with "migraine aura without headache" suffered a subsequent vascular event (a myocardial infarction). Three patients with TIAs had strokes and two others died from vascular disease. Although the results are not conclusive, they do suggest that patients with the clinical characteristics of "migraine aura without headache" have a low risk of subsequent vascular events, lower than those with TIAs, despite perhaps having similar prevalence of vascular risk factors. Although their risk factors should be treated, patients with "migraine aura without headache" should be reassured and not subjected to inappropriate and potentially hazardous investigations and treatment.

From 1979-85, 2435 patients with a transient ischaemic attack or minor ischaemic stroke were randomly allocated to receive long term "blind" treatment with aspirin 600 mg twice daily (n = 815), aspirin 300 mg once daily (n = 806) or placebo (n = 814). No patient was lost to follow up. The "intention to treat" comparison included all the serious vascular events and deaths which occurred before the end of the follow up period on 30 September 1986. There was no difference in efficacy between the 300 mg and 1200 mg daily doses of aspirin, but the lower dose was undoubtedly less gastrotoxic. Also, there was no definite difference in the response of males and females to aspirin. The odds of suffering a major stroke, myocardial infarction or vascular death were 15% less in the combined aspirin groups compared with the placebo group (95% confidence interval 29% reduction to 3% increase in odds) which is compatible with the continuing overview of all the similar trials of antiplatelet drugs where the relative reduction in odds was 25%. There was no statistically significant reduction in the likelihood of either disabling major stroke and vascular death or vascular death occurring.

When arteriovenous malformations (AVMs) of the brain were first described in the middle of the 19th century, deciding on treatment was easy, because there was none. Since the first reports of the neurosurgical exposure of brain AVMs at the end of that century,1,2 their management has been dogged by controversy. In 1928, Cushing and Bailey wrote, “…to extirpate one of these aneurysmal angiomas in its active state would be unthinkable…”,3 but, while their book was in press, Walter Dandy published a case series of people whose brain AVMs had been surgically resected (with variable success).4 Later developments in catheter angiography, bipolar coagulation, the operating microscope, and stereotactic surgery have all encouraged surgical intervention and no doubt improved the completeness and safety of resection.5,6 However, clinicians still struggle with the original dilemma of whether some brain AVMs should be treated at all. Interventions for brain AVMs diversified during the latter half of the 20th century, giving clinicians a further dilemma about which intervention to use should treatment be appropriate. Endovascular embolisation, by injecting artificial agents in the afferent feeding vessels of brain AVMs, was first reported in 1960.7 The technique has been refined ever since, initially as an adjunct to neurosurgical excision,8 but more recently, with the development of microcatheters and liquid polymer glues, as a potentially curative procedure.9 Unfractionated stereotactic radiotherapy, confusingly referred to as "radiosurgery" by some, was first used to treat brain AVMs a decade after the first report of endovascular embolisation.10 Stereotactic radiotherapy, using gamma knife, linear accelerator, and charged particle (proton beam) techniques, can provoke vascular obliteration of compact brain AVMs ⩽3 cm in diameter and of larger AVMs that have been reduced to this size with embolisation. Despite the chronology of the development of these …

We describe a group of 14 patients aged 8-38 years at presentation who had one or more sudden transient attacks of bilateral blindness. Eight patients described bilateral blindness as their only symptom whereas six others experienced some mild associated symptoms. Visual loss always developed within seconds and attacks were often precipitated by exercise, stress, or postural change. Of 13 patients available for review, none suffered a major vascular event during a mean follow up of 10 years. When adolescents and young adults present with transient bilateral blindness, investigations are unlikely to reveal a cause and the long-term prognosis appears benign.

Background Blood pressure is a determinant of the risk of stroke among both hypertensive and non-hypertensive individuals with cerebrovascular disease. However, there is uncertainty about the efficacy and safety of blood-pressure-lowering treatments for many such patients. The perindopril protection against recurrent stroke study (PROGRESS) was designed to determine the effects of a blood-pressure-lowering regimen in hypertensive and non-hypertensive patients with a history of stroke or transient ischaemic attack. Methods 6105 individuals from 172 centres in Asia, Australasia, and Europe were randomly assigned active treatment (n=3051) or placebo (n=3054). Active treatment comprised a flexible regimen based on the angiotensin-converting-enzyme inhibitor perindopril (4 mg daily), with the addition of the diuretic indapamide at the discretion of treating physicians. The primary outcome was total stroke (fatal or non-fatal). Analysis was by intention to treat. Findings Over 4 years of follow up, active treatment reduced blood pressure by 9/4 mm Hg. 307 (10%) individuals assigned active treatment suffered a stroke, compared with 420 (14%) assigned placebo (relative risk reduction 28% [95% Cl 17-38], p

Background Dural puncture is a common procedure, but leakage of CSF from the resulting dural defect may cause postural headache after the procedure, and this can be disabling. Injecting an epidural blood patch around the site of the defect may stop this leakage, and so may have a role in preventing or treating post dural puncture headache. Objectives To assess the possible benefits and harms of epidural blood patching in both the prevention and the treatment of post-dural puncture headache. Search strategy We searched the Cochrane Controlled Trials Register (Cochrane Library, Issue 4, 2000), MEDLINE (January 1994 to December 1998), and EMBASE (January 1980 to December 1998). We also searched the reference lists of relevant articles identified electronically, and asked both the authors of all included trials and colleagues with an interest in this area to let us know of any other potentially relevant studies not already identified. Date of last search: December 2000. Selection criteria We sought all properly randomised, unconfounded trials that compared epidural blood patch versus no epidural blood patch in the prevention or treatment of post-dural puncture headache among all types of patients undergoing dural puncture for any reason. The primary outcome of effectiveness was postural headache. Data collection and analysis One reviewer extracted details of trial methodology and outcome data from the reports of all trials considered eligible for inclusion. We invited the authors of all such trials both to check the information extracted and to provide any details that were unavailable in the published reports. Intention-to-treat analyses were performed using the Peto O-E method. Information about adverse effects (post-dural puncture backache, epidural infection and lower limb paraesthesia) was also extracted. Main results Three trials (77 patients) were eligible for inclusion. Methodological details were generally incomplete. Although the results of our analyses suggested that both prophylactic and therapeutic epidural blood patching may be of benefit, the very small numbers of patients and outcome events, as well as uncertainties about trial methodology, precluded reliable assessments of the potential benefits and harms of this intervention. Reviewer's conclusions Further, adequately powered, randomised trials (including at least a few hundred patients) are required before reliable conclusions can be drawn about the role of epidural blood patching in the prevention and treatment of post-dural puncture headache.

Long-term daily aspirin is of benefit in the years after ischemic stroke, and 2 large randomized trials (the Chinese Acute Stroke Trial [CAST] and the International Stroke Trial [IST]), with 20 000 patients in each, have shown that starting daily aspirin promptly in patients with suspected acute ischemic stroke also reduces the immediate risk of further stroke or death in hospital and the overall risk of death or dependency. However, some uncertainty remains about the effects of early aspirin in particular categories of patient with acute stroke.To assess the balance of benefits and risks of aspirin in particular categories of patient with acute stroke (eg, the elderly, those without a CT scan, or those with atrial fibrillation), a prospectively planned meta-analysis is presented of the data from 40 000 individual patients from both trials on events that occurred in the hospital during the scheduled treatment period (4 weeks in CAST, 2 weeks in IST), with 10 characteristics used to define 28 subgroups. This represents 99% of the worldwide evidence from randomized trials.There was a highly significant reduction of 7 per 1000 (SD 1) in recurrent ischemic stroke (320 [1.6%] aspirin versus 457 [2. 3%] control, 2P0.000001) and a less clearly significant reduction of 4 (SD 2) per 1000 in death without further stroke (5.0% versus 5. 4%, 2P=0.05). Against these benefits, there was an increase of 2 (SD 1) per 1000 in hemorrhagic stroke or hemorrhagic transformation of the original infarct (1.0% versus 0.8%, 2P=0.07) and no apparent effect on further stroke of unknown cause (0.9% versus 0.9%). In total, therefore, there was a net decrease of 9 (SD 3) per 1000 in the overall risk of further stroke or death in hospital (8.2% versus 9.1%, 2P=0.001). For the reduction of one third in recurrent ischemic stroke, subgroup-specific analyses found no significant heterogeneity of the proportional benefit of aspirin (chi(2)(18)=20. 9, NS), even though the overall treatment effect (chi(2)(1)=24.8, 2P0.000001) was sufficiently large for such subgroup analyses to be statistically informative. The absolute risk among control patients was similar in all 28 subgroups, so the absolute reduction of approximately 7 per 1000 in recurrent ischemic stroke does not differ substantially with respect to age, sex, level of consciousness, atrial fibrillation, CT findings, blood pressure, stroke subtype, or concomitant heparin use. There was no good evidence that the apparent decrease of approximately 4 per 1000 in death without further stroke was reversed in any subgroup or that in any subgroup the increase in hemorrhagic stroke was much larger than the overall average of approximately 2 per 1000. Finally, there was no significant heterogeneity between the reductions in the composite outcome of any further stroke or death (chi(2)(18)=16.5, NS). Among the 9000 patients (22%) randomized without a prior CT scan, aspirin appeared to be of net benefit with no unusual excess of hemorrhagic stroke; moreover, even among the 800 (2%) who had inadvertently been randomized after a hemorrhagic stroke, there was no evidence of net hazard (further stroke or death, 63 aspirin versus 67 control).Early aspirin is of benefit for a wide range of patients, and its prompt use should be routinely considered for all patients with suspected acute ischemic stroke, mainly to reduce the risk of early recurrence.

Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic.The objective of this review was to assess the effect of endarterectomy under local compared with general anaesthetic.We searched the Cochrane Stroke Group trials register, Medline (1966 to 1995), Embase (1980 to 1995), and Index to Scientific and Technical Proceedings (1980 to 1994). We handsearched Annals of Surgery (1981 to 1995), British Journal of Surgery (1985 to 1995), European Journal of Vascular Surgery (1988 to 1995) and World Journal of Surgery (1978 to 1995). Reference lists of articles were searched.Randomised trials and non-randomised studies comparing carotid endarterectomy under local versus general anaesthetic.One reviewer selected studies for inclusion and another independently checked the decisions. Two reviewers assessed trial quality and independently extracted the data.Three randomised trials involving 143 patients, and 17 non-randomised studies involving about 5970 patients were included. The methodological quality of the randomised trials was questionable. Two of the non-randomised studies were prospective and 12 reported on a consecutive series of patients. In nine non-randomised studies the number of patients, as opposed to the number of arteries, was unclear. There were insufficient data to enable conclusions to be drawn from the randomised trials. In 15 non-randomised studies, no significant difference was shown between local and general anaesthetic in deaths within 30 days of operation (odds ratio 0.61, 95% confidence interval 0.32 to 1.16). Non-randomised studies showed that local anaesthetic was associated with a significant reduction in the odds of stroke (15 studies), stroke or death (14 studies), myocardial infarction (12 studies), and pulmonary complications (five studies), within 30 days of the operation. Patient and surgeon satisfaction were not reported in any study.There is not enough evidence from randomised trials comparing carotid endarterectomy performed under local as opposed to general anaesthetic. Non-randomised studies suggest potential benefits with local anaesthetic. However these studies are likely to be significantly biased.

Carotid patch angioplasty (with either a venous or a synthetic patch) may reduce the risk of carotid artery restenosis and subsequent ischaemic stroke.The objective of this review was to assess the effect of routine or selective carotid patch angioplasty compared to carotid endarterectomy with primary closure.We searched the Cochrane Stroke Group trials register, Medline (1966 to 1995), Embase (1980 to 1995) and Index to Scientific and Technical Proceedings (1980 to 1994). We handsearched Annals of Surgery (1981 to 1995), British Journal of Surgery (1985 to 1995), European Journal of Vascular and Endovascular Surgery (1987 to 1995) and World Journal of Surgery (1978 to 1995).Randomised trials comparing carotid patch angioplasty with primary closure in any patients undergoing carotid endarterectomy.Two reviewers independently assessed eligibility, trial quality and extracted the data.Six trials involving 794 patients and 882 operations were included. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Carotid patch angioplasty showed a reduction in the risk of stroke of any type, ipsilateral stroke, and stroke or death, during the perioperative period and longterm follow-up. However, data were not available from all trials, the number of events was small and there was significant loss to follow-up. Patching appeared to reduce the risk of perioperative arterial occlusion (six trials, odds ratio 0.17, 95% confidence interval 0.06 to 0.46). Patching was also associated with decreased restenosis during longterm follow-up in five trials, (odds ratio 0.32, 95% confidence interval 0.19 to 0.53). However, these results are uncertain because of loss to follow-up and the small number of events. Very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation were recorded with either patch or primary closure.Limited evidence suggests that carotid patch angioplasty may lower the risk of perioperative arterial occlusion and restenosis. It is unclear whether this reduces the risk of death or stroke.

Some surgeons who use carotid patching favour using the saphenous vein, whilst others favour synthetic materials.The objective of this review was to assess the effect of different materials for carotid patch angioplasty.We searched the Cochrane Stroke Group trials register, Medline (1966 to 1995), Embase (1980 to 1995) and Index to scientific and technical proceedings (1980 to 1994). We handsearched Annals of Surgery (1981 to 1995), British Journal of Surgery (1985 to 1995), European Journal of Vascular and Endovascular Surgery (1987 to 1995) and World Journal of Surgery (1978 to 1995).Randomised trials comparing one type of carotid patch with another for carotid endarterectomy.One reviewer applied the inclusion criteria and extracted the data. Trial quality was assessed.Three trials involving 326 operations were included. The trials compared saphenous vein patches with synthetic polytetrafluroethylene patches. Allocation was not adequately concealed in two trials, and only one followed-up patients until hospital discharge. Intention-to-treat analysis was only possible for the latter trial. In all trials a patient could be randomised twice and have each carotid artery randomised to different treatment groups. One trial was excluded from the analyses of death and any stroke because it was not possible to clarify how many patients, rather than arteries, were allocated to each treatment. There were too few events to determine whether there was any difference between the patch materials for perioperative stroke, death and arterial complications. During longterm follow-up for more than one year, no difference was shown between the two types of patch for the risk of stroke, death, or arterial restenosis. However, the number of events was small. Based on 236 patients in two trials, there were significantly fewer pseudoaneurysms associated with synthetic patches (odds ratio 0.15, 95% confidence interval 0.05 to 0.44).There is not enough evidence to differentiate between venous and synthetic patches in carotid endarterectomy.

Carotid endarterectomy may well be the most studied operation ever. Unlike many if not most surgical interventions, there are several randomised trials, and now meta-analyses, to inform clinical practice. On balance, accepting the small but definite risk of stroke as a result, surgery-is a reasonable option for many patients with severe and recently symptomatic carotid stenosis who have such a high risk of stroke without surgery. Although operating on asymptomatic stenosis is safer, the unoperated risk of stroke is--on average--so low that surgery is generally not worthwhile. The challenge now is to make surgery even safer, and perhaps angioplasty will be safer still and as durable although so far there is no good randomised evidence. At the same time we must identify, if we can, those few patients with severe symptomatic stenosis who will have a stroke and focus surgery just on them, and not offer it to all the patients with severe symptomatic stenosis who might have a stroke. This will require the development and validation of mathematical models of risk. But, however well focused surgery becomes and so however small we can make "the numbers-needed-to-treat", it will have a negligible impact on stroke incidence because so few strokes are preceded by transient ischaemic attacks in patients with severe carotid stenosis.

A prospective multicentre randomised study of continued antiepileptic treatment vs slow withdrawal was conducted in 1013 patients who had been free of seizures for at least 2 years. Comparison of randomised and eligible, but non-randomised, patients suggests the results should be applicable to a wider patient population. By 2 years after randomisation, 78% of patients in whom treatment was continued and 59% of those in whom it was withdrawn remained seizure free, but thereafter the differences between the two groups diminished. Non-compliance with continued treatment accounted for only a small proportion of the risk to the group continuing with treatment. The most important factors determining outcome were longer seizure-free periods (reducing the risk) and more than one antiepileptic drug and a history of tonic-clonic seizures (increasing the risk). Other factors (eg, history of neonatal seizures, specific electroencephalographic features) seemed to have smaller effects, but even in such a large study the confidence intervals for these observations were wide.

In a community-based study of stroke survivors, we identified 73 consecutive patients with a stroke, the first ever in a lifetime, who had a CT scan which showed a neurologically appropriate single stroke lesion, and who did not have a psychiatric disorder in the year preceding the stroke. A detailed follow-up study of these patients using standardized psychiatric assessments failed to confirm a number of recent claims about poststroke depressive disorders. We found no evidence that left-sided lesions were associated with more severe or persistent depressive symptoms, or that right-sided lesions were associated with hypomania. The DSM III syndrome of major depression was much less common than has previously been reported, and was not specifically associated with lesions placed anteriorly in the left hemisphere. There was a weak correlation between mood symptom scores and the proximity of the stroke lesion to the frontal pole of the hemisphere, but no evidence of a difference between right and left hemisphere strokes in the nature of the relationship between lesion distribution and mood symptoms. We suggest that previous studies have different findings because of differences in the conventions applied to the definition and measurement of psychiatric disorders after stroke, and because other studies have concentrated on selected inpatient populations.

Mortality rates from motor neuron disease in England and Wales for the years 1959-1979 were studied through death certification data supplied by the Office of Population Censuses and Surveys. The age- and sex-adjusted mortality rate increased over the period from 1.2 per 100 000 per year in 1959-61 to 1.6 in 1977-79, the increase being most apparent in women over age 45 years and men over 60 years. The ratio of the sex-specific mortality rates remained fairly constant at 1.6:1 (male to female). The distribution of motor neuron disease deaths within England and Wales showed more variation between counties and between Hospital Regions than expected, and areas of high motor neuron disease mortality along the south coast and low mortality in the Midlands could be identified. The variation was most marked in those aged over 65 years at death. Examination of occupation, as listed on the death certificates, showed an excess of motor neuron disease deaths in leather workers in all three periods for which data were available (1959-63, 1970-72 and 1975). A small study of the certified cause of death of 56 motor neuron disease patients showed that a high percentage (88%) had motor neuron disease given as the cause of death.

91 consecutive patients with transient ischaemic attacks (TIAs) were examined for potential source of emboli using echo cardiographyand ambulatory ECG monitoring in addition to clinical examination and angiography. Patients were divided into those with amaurosis fugax and/or carotid TIAs (45), “hemiphenomena” TIAs “Structural” cardiac defects (of which mitral valve prolapse accounted for just under half) occurred in 34% of patients, significantly more than in age-matched controls. 40% of patients with amaurosis fugax and/or carotid TIAs had carotid artery lesions, as did 30% of those with “hemiphenomena” attacks.6 patients had both cardiac and carotid lesions. Arrhythmias were detected in 15% of patients and a similar proportion of controls. Hypertension and ischaemic heart disease were more common in the patients.Structural cardiac abnormalities, which may not be haemodynamically significant, might account for cerebral and retinal emboli in about a third of patients presenting with TIAs. The natural history and the most effective therapy of this subgroup require evaluation independently of patients with predominantly carotid atheromatous lesions.

In 1977 and 1978 Cook and his associates demonstrated a positive association between ownership of small dogs and both familial and sporadic cases of multiple sclerosis in New Jersey. Because of the far reaching implications of this work, a similar study was carried out and 72 patients with clinically definite multiple sclerosis (MS) who were resident in the area covered by the Oxford Regional Health Authority, were interviewed to ascertain their past exposure to housepets and other animals. Two hospital controls were chosen for each patient matched for age and sex and area of residence, and these were interviewed in the same manner as the MS cases by the same interviewer, usually in the patients' homes. Similar proportions of cases and controls had resided in a household with a dog at some time prior to the onset of their disease and there was no evidence that cases had lived with more dogs or had lived with them for longer periods than had controls. There was no indication that cases had greater exposure than controls to dogs or any other housepet in the early years of their life or in the period immediately prior to disease onset. Our data suggest that exposure to housepets and other domestic animals is unlikely to be an aetiological factor in MS.

This book discusses coal-bearing rocks of the Frontier Formation which record the earliest peat accumulations in swamps overlying linear shoreline and delta lobe sand bodies formed during marine regressive cycles. Similarly, Mesaverde Formation coals formed above sandstones related to distributary channels, barrier bars, and prograding delta systems. In contrast, thick coal in the Meeteetse Formation formed in a subsiding intermontane basin. Tonsteins in these Upper Cretaceous coals and in tuff beds of the lower Eocene Indian Meadows Formation record repeated volcanism during the Late Cretaceous and early Tertiary.