We assessed the management and outcomes of non-ST segment elevation myocardial infarction (NSTEMI) patients randomly assigned to fractional flow reserve (FFR)-guided management or angiography-guided ...standard care.
We conducted a prospective, multicentre, parallel group, 1 : 1 randomized, controlled trial in 350 NSTEMI patients with ≥1 coronary stenosis ≥30% of the lumen diameter assessed visually (threshold for FFR measurement) (NCT01764334). Enrolment took place in six UK hospitals from October 2011 to May 2013. Fractional flow reserve was disclosed to the operator in the FFR-guided group (n = 176). Fractional flow reserve was measured but not disclosed in the angiography-guided group (n = 174). Fractional flow reserve ≤0.80 was an indication for revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). The median (IQR) time from the index episode of myocardial ischaemia to angiography was 3 (2, 5) days. For the primary outcome, the proportion of patients treated initially by medical therapy was higher in the FFR-guided group than in the angiography-guided group 40 (22.7%) vs. 23 (13.2%), difference 95% (95% CI: 1.4%, 17.7%), P = 0.022. Fractional flow reserve disclosure resulted in a change in treatment between medical therapy, PCI or CABG in 38 (21.6%) patients. At 12 months, revascularization remained lower in the FFR-guided group 79.0 vs. 86.8%, difference 7.8% (-0.2%, 15.8%), P = 0.054. There were no statistically significant differences in health outcomes and quality of life between the groups.
In NSTEMI patients, angiography-guided management was associated with higher rates of coronary revascularization compared with FFR-guided management. A larger trial is necessary to assess health outcomes and cost-effectiveness.
The pathophysiology of aortic stenosis shares many similarities with atherosclerosis and skeletal bone formation. Using non-invasive imaging, we compared aortic valve calcification and inflammation ...activity with that measured in atherosclerosis and bone.
Positron emission and computed tomography was performed using 18F-sodium fluoride (18F-NaF, calcification) and 18F-fluorodeoxyglucose (18F-FDG, inflammation) in 101 patients with calcific aortic valve disease (81 aortic stenosis and 20 aortic sclerosis). Calcium scores and positron emission tomography tracer activity (tissue-to-background ratio; TBR) were measured in the aortic valve, coronary arteries, thoracic aorta, and bone. Over 90% of the cohort had coexistent calcific atheroma, yet correlations between calcium scores were weak or absent (valve vs. aorta r(2) = 0.015, P = 0.222; valve vs. coronaries r(2) = 0.039, P = 0.049) as were associations between calcium scores and bone mineral density (BMD vs. valve r(2) = 0.000, P = 0.766; vs. aorta r(2) = 0.052, P = 0.025; vs. coronaries r(2) = 0.016, P = 0.210). 18F-NaF activity in the valve was 28% higher than in the aorta (TBR: 2.66 ± 0.84 vs. 2.11 ± 0.31, respectively, P < 0.001) and correlated more strongly with the severity of aortic stenosis (r(2) = 0.419, P < 0.001) than 18F-NaF activity outwith the valve (valve vs. aorta r(2) = 0.167, P < 0.001; valve vs. coronary arteries r(2) = 0.174, P < 0.001; valve vs. bone r(2) = 0.001, P = 0.806). In contrast, 18F-FDG activity was lower in the aortic valve than the aortic atheroma (TBR: 1.56 ± 0.21 vs. 1.81 ± 0.24, respectively, P < 0.001) and more closely associated with uptake outwith the valve (valve vs. aorta r(2) = 0.327, P < 0.001).
In patients with aortic stenosis, disease activity appears to be determined by local calcific processes within the valve that are distinct from atherosclerosis and skeletal bone metabolism.
Abstract
All children have a basic right to health care. When a child’s health care needs are not met, for any reason, health care providers (HCPs) must consider the barriers involved and the ...processes required to resolve the situation. Social, economic, or other barriers can prevent parents from accessing care for their child. Sometimes differing opinions, priorities, or values, between a child’s HCPs and parents come to impede the child receiving needed medical care. In some cases, caregiver failure to ensure needed care may be considered medical neglect. Specific skills and knowledge can help HCPs to prevent such situations from arising, and to work effectively with the family if they do. This statement offers an approach that HCPs can use to promote the best interests, well-being, and safety of children or youth at risk for medical neglect.
Résumé
Les soins de santé sont un droit fondamental pour tous les enfants. Lorsque les besoins de santé de l’enfant ne sont pas respectés, quelle qu’en soit la raison, les professionnels de la santé ...doivent réfléchir aux obstacles en cause et aux processus nécessaires pour trouver des solutions. Des obstacles sociaux, économiques ou autres peuvent empêcher les parents d’accéder aux soins pour leur enfant. Il arrive que les avis, les priorités ou les valeurs des professionnels de la santé de l’enfant divergent de ceux des parents, ce qui compromet les soins à l’enfant. Dans certains cas, l’abstention des personnes qui s’occupent de l’enfant à assurer les soins nécessaires peut être considérée comme de la négligence en matière de soins médicaux. Des habiletés et des connaissances particulières peuvent aider les professionnels de la santé à éviter de telles situations et à collaborer avec efficacité avec la famille lorsque ces situations se produisent. Le présent document de principes offre une approche que peuvent utiliser les professionnels de la santé pour promouvoir l’intérêt supérieur, le bien-être et la sécurité des enfants ou des adolescents vulnérables à la négligence en matière de soins médicaux.
Facial eczema (FE) is a hepato‐mycotoxicosis found mainly in New Zealand sheep and cattle. When genetics was found to be a factor in FE susceptibility, resistant and susceptible selection lines of ...Romney sheep were established to enable further investigations of this disease trait. Using the Illumina OvineSNP50 BeadChip, we conducted a selection‐sweep experiment on these FE genetic lines. Two analytical methods were used to detect selection signals, namely the Peddrift test (Dodds & McEwan, 1997) and fixation index FST (Weir & Hill, 2002). Of 50 975 single nucleotide polymorphism (SNP) markers tested, there were three that showed highly significant allele frequency differences between the resistant and susceptible animals (Peddrift nominal P < 0.000001). These SNP loci are located on chromosomes OAR1, OAR11 and OAR12 that coincide precisely with the three highest genomic FST peaks. In addition, there are nine less significant Peddrift SNPs (nominal P ≤ 0.000009) on OAR6 (n = 2), OAR9 (n = 2), OAR12, OAR19 (n = 2), OAR24 and OAR26. In smoothed FST (five‐SNP moving average) plots, the five most prominent peaks are on OAR1, OAR6, OAR7, OAR13 and OAR19. Although these smoothed FST peaks do not coincide with the three most significant Peddrift SNP loci, two (on OAR6 and OAR19) overlap with the set of less significant Peddrift SNPs above. Of these 12 Peddrift SNPs and five smoothed FST regions, none is close to the FE candidate genes catalase and ABCG2; however, two on OAR1 and one on OAR13 fall within suggestive quantitative trait locus regions identified in a previous genome screen experiment. The present studies indicated that there are at least eight genomic regions that underwent a selection sweep in the FE lines.
Pithomycotoxicosis, more commonly known as facial eczema (FE), is a liver disease that occurs predominantly in New Zealand because of its toxigenic Pithomyces chartarum strains. The first reported ...case was in sheep in 1887. Since the 1930s, a number of studies have been conducted in an attempt to mitigate the problems FE has on the sheep and dairy industries. The research in these studies included work on fungicide and biological control of the saprophytic fungus, use of different pasture plants to inhibit fungal growth, stock management with respect to pasture fungal spore counts and the use of zinc prophylaxis on animals. The finding that there was a genetic basis in FE sensitivity in sheep prompted research for a genetic approach to mitigation in the form of a diagnostic DNA test for susceptibility to the disease. Recently, we have used the Illumina OvineSNP50 BeadChip to develop a genome‐enabled prediction approach to screen for FE‐tolerant sheep. Our current best genomic prediction for FE is for the Romney breed and has an accuracy of 0.38. This prediction accuracy is not as high as the individual accuracy gained by an artificial challenge test (0.64). However, it has the advantage of being a non‐invasive test and can be provided as part of genomic testing for other traits at minimal cost.
Contraception is one of the keystones of reproductive health. The availability of effective contraception has helped to change dramatically the structure of the world’s population during the last 50 ...years, through a demographic transition involving lower fertility rates and longer survival. As the transition evolves more slowly in developing countries, different effects on population structures contribute to civil strains. Oral contraception (OC) is an extremely effective method of contraception that also confers health benefits beyond pregnancy prevention. Notable effects on the reproductive system include relief from troublesome symptoms associated with menstruation such as heavy periods, painful periods and irregular bleeding. Many women also have improvement in acne and hirsutism. Moreover, OCs may be used to treat menorrhagia or symptomatic endometriosis. Use of OCs is associated with a long lasting reduction in the risk of developing cancer of the ovary and the endometrium. The effects on benign breast disease (BBD), bone health and colon cancer are less clear and merit further investigation.
Hazard analysis critical control points (HACCP) is a quality assurance system widely used in the food industry to ensure safety. We adopted the HACCP approach when conventional infection control ...measures had failed to solve an ongoing problem with an increased incidence of postoperative endophthalmitis, and our ophthalmology unit was threatened with permanent cessation of intraocular surgery. Although time-consuming, the result was an entirely new set of protocols for the care of patients undergoing intraocular surgery, the development of an integrated care pathway, and a comprehensive and robust audit programme, which enabled intraocular surgery to continue in a new spirit of confidence. HACCP methodology has so far been little used in healthcare, but it might be usefully applied to a variety of apparently intractable infection control problems.
A synthetic sex pheromone trapping survey of the leaf skeletonizer Uraba lugens Walker (Lepidoptera: Nolidae) demonstrated the unexpectedly widespread distribution of the insect across >40,000 ha of ...urban Auckland, New Zealand. A survey of eucalyptus trees planted in parks and other public areas showed a significant spatial correlation between trap catch and breeding populations, validating the trap survey results. Traps in trees showing damage had four-fold higher catches than traps placed in undamaged or nonhost trees, and <1% of damaged trees with traps failed to catch adult moths. Damage by larval feeding was correlated with male trap catch in the previous generation, offering good prospects for a pest management decision support system, provided that an economic threshold is developed. Catches increased by 3.4-fold in the same georeferenced trapping grid between November and December 2003 and between March and April 2004 across two generations, over the summer. A vertical transect showed that catches increased with height up to the top trap at 13 m (60% of mean tree height). Options for managing the insect will need to overcome the high rate of increase, the rate of spread, and the vertical distribution of the insect on tall eucalyptus trees.
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