Aims: Access site choice for cases requiring rotational atherectomy (PCI-ROTA) is poorly defined. Using the BritishCardiovascularInterventionSociety PCI database, temporal changes and contemporary associates/outcomes of access site choice for PCI-ROTA were studied. Methods and Results: Data were analysed from 11,444 PCI-ROTA procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes. Results: For PCI-ROTA, radial access increased from 19.6% in 2007 to 58.6% in 2014. Adoption of radial access was slower in females, those with prior CABG, and in patients with chronic occlusive (CTO) or left main disease. In 2013/14, the strongest predictors of femoral artery use were age (OR 1.02, [1.005-1.036], p=0.008), CTO intervention (OR 1.95, [1.209-3.314], p=0.006), and history of previous CABG (OR 1.68, [1.124-2.515], p=0.010). Radial access was associated with reductions in overall length of stay, and increased rates of same-day discharge. Procedural success rates were similar although femoral access use was associated with increased access site complications (2.4 vs. 0.1%, p<0.001). After adjustment for baseline differences, arterial complications (OR 15.6, p<0.001), transfusion (OR 12.5, p=0.023) and major bleeding OR 6.0, p<0.001) remained more common with FA use. Adjusted mortality and MACE rates were similar in both groups. Conclusions: In contemporary practice, radial access for PCI-ROTA results in similar procedural success when compared to femoral access but is associated with shorter length of stay, and lower rates of vascular complication, major bleeding and transfusion.
January 2007 to December 2014 in the BritishCardiovascularInterventionSociety (BCIS) database. BCIS records information on PCI practices in the United Kingdom with data collection managed by the National Institute of Cardiovascular Outcomes Research (NICOR) (23-26) The BCIS database is one of the largest nationally collected datasets containing 113 clinical, procedural and outcome variables with ≈80 000 new records added each year. Using the patient’s unique National Health Service number, mortality is tracked for all patients using data from the Office of National Statistics (ONS) in England and Wales. Patients from Scotland and Northern Ireland were excluded from the mortality outcome analysis because of the absence of the ONS–linked mortality data. All the data were collected as part of a national audit and were anonymised; therefore, institutional review board approval was not required for this study.
Background: Data on arterial access site for left main stem percutaneous intervention (LMS- PCI) are poorly defined. Objectives: Using the BritishCardiovascularInterventionSociety PCI database, temporal trends, predictors and outcomes of radial (RA) vs. femoral access (FA) for unprotected LMS-PCI were studied. Methods: Data were analysed from 19,482 LMS-PCI procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes. Results: The frequency of FA use fell from 77.7% in 2007 to 31.7% in 2014 (p<0.001 for trend). In the most contemporary study years (2012-14), the strongest associates of FA use for unprotected LMS-PCI were renal disease, PCI for restenosis, chronic total occlusion intervention and female sex. Use of intravascular imaging and chronic anticoagulation were associated with a higher likelihood of the RA use. Complexity of the PCI procedure in the RA cohort increased significantly during the study period. Length of stay was shorter (2.6±9.2 vs. 3.6±9.0, p<0.001) and same day discharge greater (43.0% vs. 26.6%, p<0.001) with RA use. After propensity matching, RA use was associated with significant reductions in in-hospital events including access site arterial complications, major bleeding, and major adverse cardiovascular events. Conversion to RA for LMS-PCI was associated with similar reductions in the whole patient cohort. RA use was not associated with lower 12-month mortality. Conclusions: In contemporary practice, the radial artery is the predominant access site for unprotected LMS-PCI, and its use is associated with shorter length of stay, less vascular complications, and less major bleeding than femoral access.
We used data from the BritishCardiovascularInterventionSociety (BCIS) registry to define the patient cohort and study variables. The BCIS registry is a national registry that prospectively collects data around the clinical, procedural and outcome of almost all PCI undertaken in the United Kingdom and is managed by the National Institute of Cardiovascular Research Outcome (NICOR)(22-24). Mortality outcomes are robustly tracked via a linkage to the Office of National Statistics (ONS) using the unique national health system (NHS) number of all patients in England and Wales only. All data collected in the BCIS registry are a part of a national audit initiative by NICOR and were anonymised; therefore, ethical approval was not required for this study. The initial cohort selection was made by including all patients undergoing at least one PCI via either RRA or LRA in the United Kingdom however, as the out of hospital mortality data is not available for patients in Scotland, therefore they were excluded from the outcome analyses. Patients with femoral, brachial, multiple, unknown or missing access site information were excluded.
Our study findings are consistent with results from threetwo recent systematic reviews and meta-analyses of the published literature for outcomes based on BMI after coronary revascularisation (22,23). Those studies involved 91,582 patients (in whom detailed medication use data were available) and 242,377 patients respectively, and hence each was significantly smaller than our cohort, in whom 30 day post-PCI mortality data were available in over 350,000 patients. The findings also are consistent with those of a recent meta-analysis of over 1.3 million patients that re-examined the link between mortality and BMI in coronary artery disease patients (not restricted solely to a PCI or revascularisation setting) (24). This too found short and long term mortality advantages for overweight or obese groups compared to normal BMI patients. Sharma et al conducted a systematic review and meta-analysis of the relationship between BMI and mortality, cardiovascular mortality and myocardial infarction after revascularization.[Sharma et al] There review of 36 coronary artery bypass graft and PCI studies found that patients of low BMI had the highest risk of adverse events while those with high BMI had the fewest events. Our current study provides further evidence that supports their findings.
Data on participants' demographics (age, sex, body mass index and smoking status) and comorbidities (diabetes, hypertension, hypercholesterolemia, previous myocardial infarction, previous stroke, peripheral vascular disease, renal disease, valvular heart disease) were collected. Additional information was collected on previous CABG, previous PCI, radial access, cardiogenic shock, circulatory support, receipt of ventilation, diagnosis, glycoprotein IIb/IIIa inhibitor use, warfarin, thrombolysis, embolic protection device, PCI to non-vein graft vessel, use of drug eluting stent and year of PCI procedure. The primary exposure variable was Clopidogrel, Prasugrel and Ticagrelor and the outcome variables were 30-day and 1 year mortality, and in-hospital major adverse cardiovascular events (defined by in-hospital death, in-hospital Non-Q wave and Q wave myocardial infarction, re-infarction, emergency CABG and re-intervention PCI).
Patients were excluded if LV function or diabetic status was unknown. Data collected included age, sex, left ventricular ejection fraction, New York Heart Association (NYHA) class, smoking status, hypertension, hypercholesterolaemia, family history of coronary heart disease, previous myocardial infarction (MI), renal disease, previous PCI, previous coronary artery bypass graft (CABG), intra-aortic balloon pump use, receipt of ventilation, cardiogenic shock, thrombolysis use, radial access, diagnosis (unstable angina, Non-ST elevation MI (NSTEMI) and ST elevation MI), vessel attempted (left main, left anterior descending (LAD), circumflex, right coronary artery, graft), three vessel disease, multivessel disease, type of stent used (bare-metal stent (BMS), drug-eluting stent (DES)), number of stents and the outcomes death at 30 days, in-hospital MACE and in-hospital bleeding. MACE was defined by the composite of re-infarction, repeat PCI and death in-hospital. In-hospital bleeding was defined by a composite of gastrointestinal bleeding, cerebrovascular bleeding, receipt of blood or platelet transfusion, retroperitoneal bleed or bleeding requiring surgical intervention.
intervention for chronic occlusive disease (CTO-PCI) enhancing procedural success. Using the BritishCardiovascularSociety dataset, we examined changes in the use of ES and procedural/clinical outcomes for CTO-PCI. Methods and Results: ES were defined as IVUS, rotational/laser atherectomy, dual arterial access, use of micro-catheters, penetration catheters or CrossBoss, and procedures categorised by number of ESs used. Data were analysed on all elective CTO-PCI procedures performed in England and Wales between 2006 and 2014. Multivariable logistic regression was used to identify predictors of procedural success. During 28,050 CTO-PCIs there were significant temporal increases in ES use. There was a stepwise increase in CTO success with increased ES use with 83.8% of cases successful where ≥3 ES were used. Overall CTO-PCI success rate for the whole cohort increased from 55.4% in 2006 to 66.9% in 2014 (p<0.001) but the greatest increase in procedural success was associated with ≥3 ES use. In multivariable analysis, any ES use and the number of ES used were predictive of procedural success. Coronary perforation increased from 1.2% with zero ES use to 4.0% with three or more (p<0.001). After adjustment, although an arterial complication, in-hospital bleeding, in-hospital mortality and MACCE remained more likely with ES use, 30-day mortality was not significantly different between groups. Conclusions: ES use during CTO-PCI was associated with significant improvements in CTO-PCI success. ES use was associated with increased procedural complications and in-hospital MACE, but not with 30-day mortality.
All variables except blood transfusion, outcomes and variables which caused failure of convergence of models were included in this model. Ticlopidine was not included in this model because very few patients received this treatment and no hemorrhage events occurred in this small group. Next, univariable and multivariable logistic regressions were used to quantify the association of in-hospital retroperitoneal hemorrhage with 30-day mortality and in-hospital MACE. All variables were included in the multivariable models except for variables which caused the models not to converge. Further subgroup analyses were performed to evaluate patients who received any transfusion (blood transfusion or platelet transfusion) and no transfusion and those who had surgical intervention and those without surgical intervention, amongst cases with retroperitoneal hemorrhage.
Table 2a reports patient and procedural factors overall and by volume, stratified by quartiles: Q1 0-128; Q2 129-178; Q3 179-239; Q4 240-714. The 30-day mortality rate was 2.6% though this differed significantly by volume, with mortality decreasing as volume increased, from 2.9% in the lowest volume stratum to 2.5% in the highest. Some factors relating to cardiovascular risk were typically more common when operator volume was higher, for instance previous MI (24.2% lowest volume to 29.6% highest volume), previous CABG (8.9% to 10.0%), previous stroke (3.8% to 4.7%), hypertension (52.3% to 59.1%), and PVD (3.9% to 5.8%). However, shock and ventilation were proportionally lower when volume was higher. Radial access was more common in high volume operators (57.2% to 71.8%), as was left main stem intervention (3.6% to 7.2%) and multi-vessel PCI (10.4% to 17.8%). Tables 2b and 2c reports these factors in elective–only and ACS-only cohorts respectively.
Major bleeding is a common complication following percutaneous coronary intervention (PCI), although little is known about how bleeding rates have changed over time and what has driven this. We analyzed all patients undergoing PCI in England and Wales from 2006 to 2013. Multivariate analyses using logistic regression models were performed to identify predictors of bleeding in order to identify potential factors influencing bleeding trends over time. 545,604 participants who had PCI in England and Wales between 2006 and 2013 were included in the analyses. Overall bleeding rates declined from 7.0 (CI:6.2–7.8) per 1000 procedures in 2006 to 5.5 (CI:4.7–6.2) per 1000 in 2013. Increasing age, female sex, GPIIb/IIIa inhibitor use and circulatory support was independently associated with increased risk of bleeding complications whilst radial access and vascular closure device use were independently associated with decreases in risk. Decreases in bleeding rates over time were associated with radial access site, and changes in pharmacology, but this was offset by greater proportion of ACS cases and more the adverse patient clinical demographics. In conclusion, Major bleeding complications after PCI has declined due to changes in access site practice and decreased usage of GPIIb/IIIa inhibitors, but this is offset by the increase of patients with higher propensity to bleed. Changes in access site practice nationally have the potential to significantly reduce major bleeding following PCI.
Very quickly every section of society was involved in voluntary action none more so than schoolchildren. Boys at Harrow school made munitions, schools linked with local hospitals to provide supplies, older girls from London volunteered their time to work processing Belgian refugees whilst others translated newspapers for French-speaking refugees. Later on the Girls’ Patriotic Union, mainly comprising young ladies from the public schools, supplied four recreation huts for France (one each for the army, navy, airmen and the women’s army corps). They also became involved in the founding of ‘Star and Garter’ Home for which they raised the considerable sum of £5,500 (equivalent to £275,000 today), which endowed fourteen rooms at the new establishment in Richmond. 9
AAOS: American Society of Orthopaedic Surgeons; BCTQ: Boston Carpal Tunnel Questionnaire; BNF: British National Formulary; BSSH: BritishSociety of Surgery for the Hand; CTS: Carpal tunnel syndrome; CTU: Clinical trials unit; EQ5d-5L: EuroQol Health related quality of life questionnaire; FSS: Functional symptoms subscale; GCP: Good clinical practice; GP: General practitioner; IMP: Investigational medicinal product; ITT: Intention to treat; MDC: Minimum data collection; MHRA: Medicines and Healthcare Products Regulatory Agency; NHS: National Health Service (UK); NICE: National institute for health and clinical excellence; NRS: Numerical rating scale; NSAIDs: Non-steroidal anti-inflammatory drugs; PCRS: Primary Care Rheumatology Society; PPI: Patient and Public Involvement; QoL: Quality of life; QUALY: Quality- adjusted life-year; RCT: Randomised clinical trial; RN: Research nurse; SAE: Serious adverse event; SAR: Serious adverse reaction; SD: Standard deviation; SPC: Summary of product characteristics; SSS: Pain severity symptom subscale; SUSAR: Suspected unexpected serious adverse reaction; TSC: Trial Steering Committee; WHO: World Health Organization
This guideline is based on the best avail- able evidence. The methodology used to write the guideline adheres strictly to the criteria as set by the Appraisal of Guide- lines, Research and Evaluation collabora- tion, which is available online ( www. agreet- rust. org/ resource- centre/ agree- ii/). The British Thoracic Society Standards of Care Committee guideline production manual is also available online (http://www. brit- thoracic. org. uk/ guidelines- and- quality- standards/).
Recently, the Australian Cardiovascular Health and Rehabilitation Association published a guidance document highlighting the core components of sec- ondary prevention and CR which should be con- tained within effective services. 10 One of the core components is that structured exercise training should be provided to all patients unless contraindi- cated. However, beyond the recommendations to measure baseline functional capacity, increase phys- ical activity levels to meet guidelines, 18 and refer to exercise specialists, there is no clear guidance about the exercise prescription in Australian clinical prac- tice. An earlier national framework document 19 also suggested that the exercise prescription could be varied according to the available resources and patient needs. Consequently, it is possible that the nature of exercise intervention provided in Australian CR programmes may vary considerably.
The third meeting, on the 28th October 1948, was at University College and played host to a Dr. P.D. Nieuwkoop. He came from the Hubrecht Laboratory in Holland, a private foundation for descriptive, comparative and experimental embryology. The Laboratory was associated with the Institute Internationale d’Embryologie (founded in 1911) and through that body with UNESCO. He said that his Laboratory was interested in all problems relating to embryology including pathology, but that the main aim was the furtherance of embryology proper. The boundary of the science would alter with its development, and genetics was now an important subsidiary sci- ence. It was generally agreed that contact and cooperation between the Embryologists' Club and the Hubrecht Laboratory would be mutually beneficial. In April 1949, a committee member, Alan Fisk, attended a meeting of UNESCO in Brussels on behalf of the Embryologists’ Club. Due to an administrative mix up, he was obliged to sign the statues of the Conceil Permanent on behalf of the Institute Internationale d’Embryologie (now the International Society of De- velopmental Biologists) with which body he had no contact whatso- ever. He was obviously quaking with fear at the possible conse- quences of this signature and wrote a lengthy memorandum to the committee on his return explaining how it had happened.
The purpose of this study was to use a large, contem- porary, multi-centre series of mGFRs from healthy indi- viduals to determine age- and gender-specific reference ranges. We also examined whether age and gender are de- terminants of GFR in a subgroup of individuals selected on the basis of having no evidence of kidney pathology. Further, we describe how our GFR reference ranges can be used to inform minimum thresholds of GFR considered safe for prospective living kidney donors to proceed to nephrectomy. This work formed the basis of new recom- mendations for the assessment of kidney function in the updated British Transplantation Society (BTS) guidelines on living donor kidney transplantation .
stereotypes and particularly the preponderance of ideas that racial intermixing could jeopardise white British racial stock. Turning to consider post-war Commonwealth immigration Schaffer shows that the parameters of the debate in which legislation was framed had hardly shifted in half a century save for an understanding that certain things were best left unsaid if one was to avoid controversy. Indeed the premises of the 1962 Commonwealth Immigration Act owed more to eugenic thinking than it did to the now prevalent social science though its framers would have been loath to admit it.
talents refuse easy classification. Matthews situates Self’s sprawling oeuvre against broader contemporary cultural trends to assess running concerns in this “Magus of the Quotidian” (119). The monograph focuses on Self’s texts, bypassing lurid excursions into biography to track the development of a singular satiric voice and a fiction providing not only a satire of “Britishsociety but a comment on the function of satire, which not only defamiliarizes the world but in the process suggests that the everyday appears normal and therefore lies unquestioned” (23). Matthews’s readings precisely chart these surrealistic defamiliarizations in Self’s fiction.
The implications of this persistent logic are worrying, both at home — concerning issues of democracy and bipartisanship — and abroad — in terms of the nature of international intervention. Our concerns here centre on the impact of strategic rhetorical balancing on: (i) the possibility, nature, effectiveness and ethicality of intervention, if it is shaped by the demands of domestic coercion; and (ii) the health of the marketplace of ideas, if the suffocation of alternative policies is a central component of achieving policy dominance in a democracy. While our argument and use of the phrase ‘ balance of rhetoric ’ makes no attempt to map onto theories pertaining to a ‘ balance of power ’ , it is certainly true that power is crucial here. Rhetorical coercion, at its most effective, can lead to an imbalance of power within the domestic politics of an interventionist state. This imbalance can lead to hegemony in the production of interventionist discourses, suffocating potentially less violent alternatives. We fear that pursuing a war of position through coercive tactics of justification helps to drown out (useful and often more effective or principled) policy alternatives. We therefore offer a threefold strategy of resistance. A rebalancing of rhetoric might usefully be informed by: considerations of the longue durée (beyond political short-termism); expansion of the fractures in divergent coalition framings; and/or the immanent critique of justifications wherein policy fails to deliver on promise. These strategies of resistance should follow further research on rhetorical coercion generally and strategic rhetorical balancing specifically.