The impact of a complex school nutrition intervention on double burden of malnutrition among Thai primary school children: a 2-year quasi-experiment.

OBJECTIVE: This study assessed the impacts of the Dekthai Kamsai programme on overweight/obesity, underweight and stunting among male and female primary school students. STUDY DESIGN: A quasi-experiment was conducted in 16 intervention and 19 control schools across Thailand in 2018 and 2019. In total, 896 treated and 1779 control students from grades 1 to 3 were recruited. In intervention schools, a set of multifaceted intervention components were added into school routine practices. Anthropometric outcomes were measured at baseline and at the beginning and end of every school term. METHODS: Propensity score matching with linear and Poisson difference-in-difference analyses were used to adjust for the non-randomisation and to analyse the intervention's effects over time. RESULTS: Compared with controls, the increases in mean BMI-for-age Z-score (BAZ) and the incidence rate of overweight/obesity were lower in the intervention schools at the 3rd, 4th and 8th measurements and the 3rd measurement, respectively. The decrease in mean height-for-age Z-score (HAZ) was lower at the 4th measurement. The decrease in the incidence rate of wasting was lower at the 5th, 7th and 8th measurements. The favourable impacts on BAZ and HAZ were found in both sexes, while the favourable impact on overweight/obesity and unfavourable impact on wasting were found in girls. CONCLUSIONS: This intervention might be effective in reducing BAZ, overweight/obesity, poor height gain, but not wasting. These findings highlight the benefits of a multifaceted school nutrition intervention and a need to incorporate tailor-made interventions for wasting to comprehensively address the double burden of malnutrition.

Temporal patterns in the soundscape of a Norwegian gateway to the Arctic.

As an Arctic gateway, the Norwegian Sea sustains a rich diversity of seasonal and resident species of soniferous animals, vulnerable to the effects of climate change and anthropogenic activities. We show the occurrence of seasonal patterns of acoustic signals in a small canyon off Northern Norway, and investigate cetacean vocal behavior, human-made noise, and climatic contributions to underwater sound between January and May 2018. Mostly median sound levels ranged between 68.3 and 96.31 dB re 1 µPa2 across 1/3 octave bands (13 Hz-16 kHz), with peaks in February and March. Frequencies under 2 kHz were dominated by sounds from baleen whales with highest rates of occurrence during winter and early spring. During late-spring non-biological sounds were predominant at higher frequencies that were linked mainly to ship traffic. Seismic pulses were also recorded during spring. We observed a significant effect of wind speed and ship sailing time on received sound levels across multiple distance ranges. Our results provide a new assessment of high-latitude continental soundscapes in the East Atlantic Ocean, useful for management strategies in areas where anthropogenic pressure is increasing. Based on the current status of the local soundscape, we propose considerations for acoustic monitoring to be included in future management plans.

Cattle farmer psychosocial profiles and their association with control strategies for bovine viral diarrhea.

Bovine viral diarrhea (BVD) is endemic in the United Kingdom and causes major economic losses. Control is largely voluntary for individual farmers and is likely to be influenced by psychosocial factors, such as altruism, trust, and psychological proximity (feeling close) to relevant "others," such as farmers, veterinarians, the government, and their cows. These psychosocial factors (factors with both psychological and social aspects) are important determinants of how people make decisions related to their own health, many of which have not been studied in the context of infectious disease control by farmers. Farmer psychosocial profiles were investigated using multiple validated measures in an observational survey of 475 UK cattle farmers using the capability, opportunity, motivation-behavior (COM-B) framework. Farmers were clustered by their BVD control practices using latent class analysis. Farmers were split into 5 BVD control behavior classes, which were tested for associations with the psychosocial and COM-B factors using multinomial logistic regression, with doing nothing as the baseline class. Farmers who were controlling disease both for themselves and others were more likely to do something to control BVD (e.g., test, vaccinate). Farmers who did not trust other farmers, had high psychological capability (knowledge and understanding of how to control disease), and had high physical opportunity (time and money to control disease) were more likely to have a closed, separate herd and test. Farmers who did not trust other farmers were also more likely to undertake many prevention strategies with an open herd. Farmers with high automatic motivation (habits and emotions) and reflective motivation (decisions and goals) were more likely to vaccinate and test, alone or in combination with other controls. Farmers with high psychological proximity (feeling of closeness) to their veterinarian were more likely to undertake many prevention strategies in an open herd. Farmers with high psychological proximity to dairy farmers and low psychological proximity to beef farmers were more likely to keep their herd closed and separate and test or vaccinate and test. Farmers who had a lot of trust in other farmers and invested in them, rather than keeping everything for themselves, were more likely to be careful introducing new stock and test. In conclusion, farmer psychosocial factors were associated with strategies for BVD control in UK cattle farmers. Psychological proximity to veterinarians was a novel factor associated with proactive BVD control and was more important than the more extensively investigated trust. These findings highlight the importance of a close veterinarian-farmer relationship and are important for promoting effective BVD control by farmers, which has implications for successful nationwide BVD control and eradication schemes.

The Central Aspects of Pain in the Knee (CAP-Knee) questionnaire; a mixed-methods study of a self-report instrument for assessing central mechanisms in people with knee pain.

OBJECTIVES: Pain is the prevailing symptom of knee osteoarthritis. Central sensitisation creates discordance between pain and joint pathology. We previously reported a Central Pain Mechanisms trait derived from eight discrete characteristics: Neuropathic-like pain, Fatigue, Cognitive-impact, Catastrophising, Anxiety, Sleep disturbance, Depression, and Pain distribution. We here validate and show that an 8-item questionnaire, Central Aspects of Pain in the Knee (CAP-Knee) is associated both with sensory- and affective- components of knee pain severity. METHODS: Participants with knee pain were recruited from the Investigating Musculoskeletal Health and Wellbeing study in the East Midlands, UK. CAP-Knee items were refined following cognitive interviews. Psychometric properties were assessed in 250 participants using Rasch-, and factor-analysis, and Cronbach's alpha. Intra-class correlation coefficients tested repeatability. Associations between CAP-Knee and McGill Pain questionnaire pain severity scores were assessed using linear regression. RESULTS: CAP-Knee targeted the knee pain sample well. Cognitive interviews indicated that participants interpreted CAP-Knee items in diverse ways, which aligned to their intended meanings. Fit to the Rasch model was optimised by rescoring each item, producing a summated score from 0 to 16. Internal consistency was acceptable (Cronbach's alpha = 0.74) and test-retest reliability was excellent (ICC2,1 = 0.91). Each CAP-Knee item contributed uniquely to one discrete 'Central Mechanisms trait' factor. High CAP-Knee scores associated with worse overall knee pain intensity, and with each of sensory- and affective- McGill Pain Questionnaire scores. CONCLUSION: CAP-Knee is a simple and valid self-report questionnaire, which measures a single 'Central Mechanisms' trait, and may help identify and target centrally-acting treatments aiming to reduce the burden of knee pain.

How does the beach ecosystem change without tourists during COVID-19 lockdown?

Urban tourist beach ecosystems provide the essential service of recreation. These ecosystems also support critical ecological functions where biodiversity conservation is not usually a priority. The sudden lockdown due to the COVID-19 pandemic created a unique opportunity to evaluate the effects of human absence in these urban-coastal ecosystems. This study examined bioindicators from 29 urban tourist beaches in seven Latin-American countries and assesses their response to lockdown about some relevant anthropogenic stressors such as pollution, noise, human activities, and user density. The presence of animals and plants, as well as the intensity of stressors, were assessed through a standardized protocol during lockdown conditions. Additionally, the environmental conditions of the beaches before and during lockdown were qualitatively compared using multivariate non-parametric statistics. We found notable positive changes in biological components and a clear decrease in human stressors on almost all the beaches. Dune vegetation increased on most sites. Similarly, high burrow densities of ghost crabs were observed on beaches, except those where cleaning activity persisted. Because of the lockdown, there was an exceptionally low frequency of beach users, which in turn reduced litter, noise and unnatural odors. The observed patterns suggest that tourist beaches can be restored to natural settings relatively quickly. We propose several indicators to measure changes in beaches once lockdown is relaxed. Adequate conservation strategies will render the recreational service of tourist beaches more environmental-friendly.

Baseline self-report 'central mechanisms' trait predicts persistent knee pain in the Knee Pain in the Community (KPIC) cohort.

OBJECTIVES: We investigated whether baseline scores for a self-report trait linked to central mechanisms predict 1 year pain outcomes in the Knee Pain in the Community cohort. METHOD: 1471 participants reported knee pain at baseline and responded to a 1-year follow-up questionnaire, of whom 204 underwent pressure pain detection thresholds (PPTs) and radiographic assessment at baseline. Logistic and linear regression models estimated the relative risks (RRs) and associations (ß) between self-report traits, PPTs and pain outcomes. Discriminative performance for each predictor was compared using receiver-operator characteristics (ROC) curves. RESULTS: Baseline Central Mechanisms trait scores predicted pain persistence (Relative Risk, RR = 2.10, P = 0.001) and persistent pain severity (ß = 0.47, P < 0.001), even after adjustment for age, sex, BMI, radiographic scores and symptom duration. Baseline joint-line PPTs also associated with pain persistence (RR range = 0.65 to 0.68, P < 0.02), but only in univariate models. Lower baseline medial joint-line PPT was associated with persistent pain severity (ß = -0.29, P = 0.013) in a fully adjusted model. The Central Mechanisms trait model showed good discrimination of pain persistence cases from resolved pain cases (Area Under the Curve, AUC = 0.70). The discrimination power of other predictors (PPTs (AUC range = 0.51 to 0.59), radiographic OA (AUC = 0.62), age, sex and BMI (AUC range = 0.51 to 0.64), improved significantly (P < 0.05) when the central mechanisms trait was included in each logistic regression model (AUC range = 0.69 to 0.74). CONCLUSION: A simple summary self-report Central Mechanisms trait score may indicate a contribution of central mechanisms to poor knee pain prognosis.

Exploring the psychology of suicidal ideation: A theory driven network analysis.

Two leading theories within the field of suicide prevention are the interpersonal psychological theory of suicidal behaviour (IPT) and the integrated motivational-volitional (IMV) model. The IPT posits that suicidal thoughts emerge from high levels of perceived burdensomeness and thwarted belongingness. The IMV model is a multivariate framework that conceptualizes defeat and entrapment as key drivers of suicide ideation. We applied network analysis to cross-sectional data collected as part of the Scottish Wellbeing Study, in which a nationally representative sample of 3508 young adults (18-34 years) completed a battery of psychological measures. Network analysis can help us to understand how the different theoretical components interact and how they relate to suicide ideation. Within a network that included only the core factors from both models, internal entrapment and perceived burdensomeness were most strongly related to suicide ideation. The core constructs defeat, external entrapment and thwarted belonginess were mainly related to other factors than suicide ideation. Within the network of all available psychological factors, 12 of the 20 factors were uniquely related to suicide ideation, with perceived burdensomeness, internal entrapment, depressive symptoms and history of suicide ideation explaining the most variance. None of the factors was isolated, and we identified four larger clusters: mental wellbeing, interpersonal needs, personality, and suicide-related factors. Overall, the results suggest that relationships between suicide ideation and psychological risk factors are complex, with some factors contributing direct risk, and others having indirect impact.

Behavioral and epigenetic consequences of oxytocin treatment at birth.

Oxytocin is used in approximately half of all births in the United States during labor induction and/or augmentation. However, the effects of maternal oxytocin administration on offspring development have not been fully characterized. Here, we used the socially monogamous prairie vole to examine the hypothesis that oxytocin exposure at birth can have long-term developmental consequences. Maternally administered oxytocin increased methylation of the oxytocin receptor (Oxtr) in the fetal brain. As adults, oxytocin-exposed voles were more gregarious, with increased alloparental caregiving toward pups and increased close social contact with other adults. Cross-fostering indicated that these effects were the result of direct action on the offspring, rather than indirect effects via postnatal changes in maternal behavior. Male oxytocin-exposed offspring had increased oxytocin receptor density and expression in the brain as adults. These results show that long-term effects of perinatal oxytocin may be mediated by an epigenetic mechanism.

Transitioning young adults with neurogenic bladder-Are providers asking too much?

INTRODUCTION: Significant numbers of young adults with chronic health conditions fail to transition. OBJECTIVE: The aim of the study was to evaluate how ready transitioned urologic patients were for that process. Owing to the cognitive impairments frequently seen with spina bifida (SB), it is hypothesized that these individuals will be less prepared to transition their medical care to adult providers compared with their healthy counterparts. METHODS: Participants included consecutive patients in the transitional SB clinic at the study institution and controls (college students without obvious physical disability or interest in healthcare-related fields aged 18-25 years). Both groups were administered the Transition Readiness Assessment Questionnaire (TRAQ) over a nine-month period. Five TRAQ domains assess 20 skills necessary to transition. Likert scale responses range from 1 "no, I do not know how" to 5 "yes, I always do this when I need to" (which the authors considered appropriate for transitioned patients). Demographics and the number of daily medications taken were collected. Patients and healthy controls were compared using (1) total and domain TRAQ scores, (2) the proportion of non-transitioned skills ("1"), and (3) fully transitioned skills ("5"). Non-parametric statistics were used. RESULTS: Forty-three unique SB patients (30.8% shunted, 46.5% female) and 100 controls were enrolled. Patients with SB were older than controls (21 vs 20 years, p < 0.001). There was no gender difference between groups (p = 0.33). Transitioned patients and college students were fully transitioned only in the "Talking with Providers" domain (Figure). College students performed significantly better than patients in the domains of "Appointment Keeping" (p = 0.04) and "Tracking Health Issues" (p = 0.02). Transitioned patients were less likely to be interested in learning how to perform skills in the domains of "Appointment Keeping" and "Tracking Health Issues" (p < 0.001 for both domains). DISCUSSION: The transition readiness of young adults with SB compared to healthy controls and other youths with chronic health conditions is described. The limitations include the small sample size, potentially limiting generalizability, and cross-sectional nature. CONCLUSION: "Transitioned" patients with SB had lower TRAQ scores in some domains compared to healthy college students, who themselves had scores indicating that they were not fully ready for transition. Increased attention to transition readiness in people with SB is necessary, as even healthy young adults struggle with these tasks and are poorly prepared for transition.

The colorectal surgeon's personality may influence the rectal anastomotic decision.

AIM: Colorectal surgeons regularly make the decision to anastomose, defunction or form an end colostomy when performing rectal surgery. This study aimed to define personality traits of colorectal surgeons and explore any influence of such traits on the decision to perform a rectal anastomosis. METHOD: Fifty attendees of The Association of Coloproctology of Great Britain and Ireland 2016 Conference participated. After written consent, all underwent personality testing: alexithymia (inability to understand emotions), type of thinking process (intuitive versus rational) and personality traits (extraversion, agreeableness, openness, emotional stability, conscientiousness). Questions were answered regarding anastomotic decisions in various clinical scenarios and results analysed to reveal any influence of the surgeon's personality on anastomotic decision. RESULTS: Participants were: male (86%), consultants (84%) and based in England (68%). Alexithymia was low (4%) with 81% displaying intuitive thinking (reflex, fast). Participants scored higher in emotional stability (ability to remain calm) and conscientiousness (organized, methodical) compared with population norms. Personality traits influenced the next anastomotic decision if: surgeons had recently received criticism at a departmental audit meeting; were operating with an anaesthetist that was not their regular one; or there had been no anastomotic leaks in their patients for over 1 year. CONCLUSION: Colorectal surgeons have speciality relevant personalities that potentially influence the important decision to anastomose and could explain the variation in surgical practice across the UK. Future work should explore these findings in other countries and any link of personality traits to patient-related outcomes.

It is only fair: blood donors are more sensitive to violations of fairness norms than nondonors - converging psychometric and ultimatum game evidence.

BACKGROUND AND OBJECTIVES: The design of effective donor recruitment campaigns requires an accurate understanding of donor motivations. This requires cross-validation of theoretically derived, psychometrically assessed motivations with behavioural preferences. Theoretical models suggest that blood donors should be more sensitive than nondonors to violations of fairness norms. Specifically, active blood donors, compared to nondonors, should endorse beliefs of reciprocal fairness, norms of both positive and negative reciprocity and reject more unfair offers in a behavioural economic game (the ultimatum game). This study is the first to test this hypothesis. MATERIALS AND METHODS: Two studies are reported. One experimental psychometric study (N = 400) and one behavioural economic game using the ultimatum game (N = 60). RESULTS: Consistent with the predictions, active and lapsed donors, compared to nondonors, were more likely to endorse beliefs of reciprocal fairness and active donors to endorse norms of both positive and negative reciprocity and reject more unfair offers in the ultimatum game. This pattern of motivations was unique to blood donors and not observed for other health (i.e. being on the organ donor register) and nonhealth (e.g. volunteering) prosociality. CONCLUSION: Blood donors have a heightened sensitivity to unfairness violations. This indicates a very clear and specific line for the development of interventions that align fairness, self-interest and reciprocity, for example voluntary reciprocal altruism (VRA). We also highlight the importance of establishing intervention development within a clinical trials model and emphasize why experimental work of this type is vital.

Safety culture: the Nottingham Veterinary Safety Culture Survey (NVSCS).

Safety culture is a vital concept in human healthcare because of its influence on staff behaviours in relation to patient safety. Understanding safety culture is essential to ensure the acceptance and sustainability of changes, such as the introduction of safe surgery checklists. While widely studied and assessed in human medicine, there is no tool for its assessment in veterinary medicine. This paper therefore presents initial data on such an assessment: the Nottingham Veterinary Safety Culture Survey (NVSCS). 350 pilot surveys were distributed to practising vets and nurses. The survey was also available online. 229 surveys were returned (65 per cent response rate) and 183 completed online, resulting in 412 surveys for analysis. Four domains were identified: (1) organisational safety systems and behaviours, (2) staff perceptions of management, (3) risk perceptions and (4) teamwork and communication. Initial indications of the reliability and the validity of the final survey are presented. Although early in development, the resulting 29-item NVSCS is presented as a tool for measuring safety culture in veterinary practices with implications for benchmarking, safety culture assessment and teamwork training.

Adult height of preterm infants: a longitudinal cohort study.

BACKGROUND: Many infants born prematurely experience growth failure following delivery, with subsequent catch-up growth. Traditionally catch-up was thought to be complete in the first few years of life. Most studies have focused on groups of infants defined by birth weight, for example <1500 g, resulting in disproportionate numbers of small for gestational age infants. This study aimed to determine whether appropriate weight for gestation (AGA) preterm born children reach their expected adult height when compared with term controls. METHODOLOGY: This UK based prospective longitudinal cohort study recruited 204 preterm children born at a tertiary neonatal unit during 1994 and 50 matched controls. Growth parameters have been assessed annually until the completion of growth. RESULTS: There was no significant difference in the final height SD score (SDS) of children born at term (n=30) and those born prematurely and AGA (n=70) (0.45 term vs 0.22 preterm). Catch-up growth however, continued throughout the whole of childhood. When the difference between final height SDS and mid-parental height SDS were compared, there were again no significant differences (0.13 term vs 0.03 preterm). CONCLUSIONS: Those born prematurely with an AGA achieve a comparable adult height to children born at term, however, catch-up growth continues for much longer than traditionally thought.

Histopathological subgroups in knee osteoarthritis.

OBJECTIVE: Osteoarthritis (OA) is a heterogeneous, multi-tissue disease. We hypothesised that different histopathological features characterise different stages during knee OA progression, and that discrete subgroups can be defined based on validated measures of OA histopathological features. DESIGN: Medial tibial plateaux and synovium were from 343 post-mortem (PM) and 143 OA arthroplasty donations. A 'chondropathy/osteophyte' group (n = 217) was classified as PM cases with osteophytes or macroscopic medial tibiofemoral chondropathy lesions ≥grade 3 to represent pre-surgical (early) OA. 'Non-arthritic' controls (n = 48) were identified from the remaining PM cases. Mankin histopathological scores were subjected to Rasch analysis and supplemented with histopathological scores for subchondral bone marrow replacement and synovitis. Item weightings were derived by principle components analysis (PCA). Histopathological subgroups were sought using latent class analysis (LCA). RESULTS: Chondropathy, synovitis and osteochondral pathology were each associated with OA at arthroplasty, but each was also identified in some 'non-arthritic' controls. Tidemark breaching in the chondropathy/osteophyte group was greater than in non-arthritic controls. Three histopathological subgroups were identified, characterised as 'mild OA', or 'severe OA' with mild or moderate/severe synovitis. CONCLUSIONS: Presence and severity of synovitis helps define distinct histopathological OA subgroups. The absence of a discrete 'normal' subgroup indicates a pathological continuum between normality and OA status. Identifying specific pathological processes and their clinical correlates in OA subgroups has potential to accelerate the development of more effective therapies.

Obstetric and gynecologic problems associated with eating disorders.

OBJECTIVE: This article summarizes the literature on obstetric and gynecologic complications associated with eating disorders. METHOD: We performed a comprehensive search of the current literature on obstetric and gynecologic complications associated with eating disorders using PubMed. More recent randomized-controlled trials and larger data sets received priority. We also chose those that we felt would be the most relevant to providers. RESULTS: Common obstetric and gynecologic complications for women with eating disorders include infertility, unplanned pregnancy, miscarriage, poor nutrition during pregnancy, having a baby with small head circumference, postpartum depression and anxiety, sexual dysfunction and complications in the treatment for gynecologic cancers. There are also unique associations by eating disorder diagnosis, such as earlier cessation of breastfeeding in anorexia nervosa; increased polycystic ovarian syndrome in bulimia nervosa; and complications of obesity as a result of binge eating disorder. DISCUSSION: We focus on possible biological and psychosocial factors underpinning risk for poor obstetric and gynecological outcomes in eating disorders. Understanding these factors may improve both our understanding of the reproductive needs of women with eating disorders and their medical outcomes. We also highlight the importance of building multidisciplinary teams to provide comprehensive care to women with eating disorders during the reproductive years.

We need to talk about error: causes and types of error in veterinary practice.

Patient safety research in human medicine has identified the causes and common types of medical error and subsequently informed the development of interventions which mitigate harm, such as the WHO's safe surgery checklist. There is no such evidence available to the veterinary profession. This study therefore aims to identify the causes and types of errors in veterinary practice, and presents an evidence based system for their classification. Causes of error were identified from retrospective record review of 678 claims to the profession's leading indemnity insurer and nine focus groups (average N per group=8) with vets, nurses and support staff were performed using critical incident technique. Reason's (2000) Swiss cheese model of error was used to inform the interpretation of the data. Types of error were extracted from 2978 claims records reported between the years 2009 and 2013. The major classes of error causation were identified with mistakes involving surgery the most common type of error. The results were triangulated with findings from the medical literature and highlight the importance of cognitive limitations, deficiencies in non-technical skills and a systems approach to veterinary error.

Mechanism of altruism approach to blood donor recruitment and retention: a review and future directions.

Why do people donate blood? Altruism is the common answer. However, altruism is a complex construct and to answer this question requires a systematic analysis of the insights from the biology, economics and psychology of altruism. I term this the mechanism of altruism (MOA) approach and apply it here for understanding blood donor motivation. The answer also has enormous implications for the type of interventions we choose to adopt as a society. A MOA approach so far shows that blood donors are a mixture of (i) warm-glow givers (donation is emotionally rewarding) and (ii) reluctant altruists (cooperate rather than defect when free-riding is high). Donors also show 'saintly sinning' with the extra 'moral currency' form blood donation allowing them to be less generous in other contexts. The MOA approach suggests why financial incentives, in terms of gifts/lottery tickets, are effective and suggests a number of novel interventions for donor recruitment: 'voluntary reciprocal altruism' and 'charitable incentivisation'. The MOA approach also highlights the need for an intervention developed specifically for recipients to allow them to show their gratitude to donors and for society to celebrate blood donation. It is suggests a 'Monument to Blood Donors' will achieve this. The approach suggests a number of novel research questions into (i) donor self-selection effects, (ii) conditional cooperation and (iii) construct overlap with Theory of Planned Behaviour (e.g. affective attitudes and warm-glow). The MOA offers a powerful way to understand blood donor motivations around altruism and develop theoretically driven interventions.

Optimisation of rheumatology indices: dactylitis and enthesitis in psoriatic arthritis.

Outcome measures are a key part of study design and clinical assessment. Enthesitis and dactylitis are typical features of psoriatic arthritis (PsA) and the spondyloarthritides but traditionally scoring systems for enthesitis have mainly been validated in ankylosing spondylitis (AS). There are many scoring systems which are not validated used for dactylitis although newer validated scores are now available. Recently there have been advances in composite scores that include enthesitis and dactylitis to assess disease activity. These are currently being validated further and have not yet been tested in routine clinical practice.

Does a 'direct' transfer protocol reduce time to coronary angiography for patients with non-ST-elevation acute coronary syndromes? A prospective observational study.

OBJECTIVE: National guidelines recommend 'early' coronary angiography within 96 h of presentation for patients with non-ST elevation acute coronary syndromes (NSTE-ACS). Most patients with NSTE-ACS present to their district general hospital (DGH), and await transfer to the regional cardiac centre for angiography. This care model has inherent time delays, and delivery of timely angiography is problematic. The objective of this study was to assess a novel clinical care pathway for the management of NSTE-ACS, known locally as the Heart Attack Centre-Extension or HAC-X, designed to rapidly identify patients with NSTE-ACS while in DGH emergency departments (ED) and facilitate transfer to the regional interventional centre for 'early' coronary angiography. METHODS: This was an observational study of 702 patients divided into two groups; 391 patients treated before the instigation of the HAC-X pathway (Pre-HAC-X), and 311 patients treated via the novel pathway (Post-HAC-X). Our primary study end point was time from ED admission to coronary angiography. We also assessed the length of hospital stay. RESULTS: Median time from ED admission to coronary angiography was 7.2 (IQR 5.1-10.2) days pre-HAC-X compared to 1.0 (IQR 0.7-2.0) day post-HAC-X (p<0.001). Median length of hospital stay was 3.0 (IQR 2.0-6.0) days post-HAC-X v 9.0 (IQR 6.0-14.0) days pre-HAC-X (p<0.0005). This equates to a reduction of six hospital bed days per NSTE-ACS admission. CONCLUSIONS: The introduction of this novel care pathway was associated with significant reductions in time to angiography and in total hospital bed occupancy for patients with NSTE-ACS.