Atrial fibrillation in acute coronary syndrome: patient characteristics and appropriate utilisation of anti-thrombotic therapy in New Zealand (ANZACS-QI 39).

BACKGROUND: Concomitant atrial fibrillation (AF) and acute coronary syndrome (ACS) present the difficult therapeutic dilemma of balancing bleeding, cardio-embolic and coronary thrombotic risks with appropriate combinations of antithrombotic medications. We aim to evaluate current New Zealand practice by identifying the incidence of AF in ACS; describe the population characteristics; and assess our antithrombotic management. METHODS: Consecutive patients ≥18y presenting with ACS who had coronary angiography (2017-2018) were identified from the All New Zealand ACS Quality Improvement (ANZACS-QI) registry. The cohort was divided into three groups: 1) patients with pre-existing AF; 2) new-onset AF; and 3) no AF. Antithrombotic regimens included dual antiplatelet therapy (DAPT), dual antithrombotic therapy (DAT-single antiplatelet plus an oral anticoagulant (OAC)) and triple antithrombotic therapy (TAT). RESULTS: There were 9,489 patients, 9.6% with pre-existing AF, 4.4% new AF and 86% without AF. Both AF groups were older (median 74 vs 71 vs 65y, p=0.001), had poorer renal function, were more likely to present with heart failure (16% vs 19% vs 8%, p=0.001) and have left ventricular ejection fraction <40% (22% vs 28% vs 13%, p<0.001). They received less percutaneous coronary intervention (PCI) (53% vs 59% vs 70%, p=0.001). In the cohort, 25 different combinations of antithrombotic agents were utilised. Ninety-six percent of patients with any AF had a CHA2DS2VASC stroke risk score of ≥2, of whom 48% did not receive OAC. Twenty-four percent received TAT and 19% DAT. OAC use increased slightly with increasing stroke risk but were independent of CRUSADE bleeding risk. Of patients with AF treated with PCI, 53% received DAPT, 11% DAT and 35% TAT. 51% of those at high stroke risk were discharged on DAPT only. In contrast, 19% at low stroke risk received TAT. CONCLUSION: In New Zealand, one in seven patients presenting with ACS have AF, a third being new-onset AF. Antithrombotic management is inconsistent, with underutilisation of anticoagulants, particularly the DAT regimen, and is inadequately informed by stroke and bleeding risk scores.

Diagnostic coronary angiography and percutaneous coronary intervention practices in New Zealand: The All New Zealand Acute Coronary Syndrome-Quality Improvement CathPCI registry 3-year study (ANZACS-QI 37).

BACKGROUND: Coronary heart disease remains one of the leading causes of mortality and morbidity in New Zealand (NZ) and globally. The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) programme includes the CathPCI registry which records all those referred for diagnostic coronary angiography (DCA) and percutaneous coronary intervention (PCI) in NZ. We present the methods and three-years of data from the ANZACS-QI CathPCI registry. METHODS: The data was extracted from the ANZACS QI CathPCI registry from 01/09/2014 to 24/09/2017. The ANZACS-QI data dictionary defines all the clinical, procedural and outcomes variables collected, and standard statistical analyses were applied. RESULTS: 40,870 patients underwent cardiac catheterisation, with a mean age of 65 years, and males making up 67% of the cohort. Indications included acute coronary syndrome 55%, angina with suspected stable coronary disease 28%, valve surgery workup 8%, planned PCI 3%, heart failure/cardiomyopathy 3%, arrhythmia 1% and other 2%. For those undergoing DCA alone, radial access was used in 85% and two-thirds had at least one major artery with >50% stenosis. PCI was performed in 39% of patients. Drug-eluting stents were used in 97%. CONCLUSION: The CathPCI registry records the characteristics and outcomes of all patients undergoing DCA and PCI in NZ hospitals. As part of the ANZACS-QI programme the registry provides an important platform for quality improvement, research and to inform clinical practice.

Acute reperfusion for ST-elevation myocardial infarction in New Zealand (2015-2017): patient and system delay (ANZACS-QI 29).

AIM: Prompt access to cardiac defibrillation and reperfusion therapy improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The study aim was to describe the 'patient' and 'system' delay in patients who receive acute reperfusion therapy for ST-elevation myocardial infarction (STEMI) in New Zealand. METHODS: In 2015-17, 3,857 patients who received acute reperfusion therapy were captured in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. 'Patient delay' is the time from symptom onset to first medical contact (FMC), and 'system delay' the time from FMC until reperfusion therapy (primary percutaneous coronary intervention (PCI) or fibrinolysis). RESULTS: Seventy percent of patients received primary PCI and 30% fibrinolysis. Of those receiving fibrinolysis, 122 (10.5%) received pre-hospital fibrinolysis. Seventy-seven percent were transported to hospital by ambulance. After adjustment, people who were older, male and presented to a hospital without a routine primary PCI service were less likely to travel by ambulance. Patient delay: The median delay was 45 minutes for ambulance-transported patients and 97 minutes for those self-transported to hospital, with a quarter delayed by >2 hours and >3 hours, respectively. Delay >1 hour was more common in older patients, Maori and Indian patients and those self-transported to hospital. System delay: For ambulance-transported patients who received primary PCI, the median time was 119 minutes. For ambulance-transported patients who received fibrinolysis, the median system delay was 86 minutes, with Maori patients more often delayed than European/Other patients. For patients who received pre-hospital fibrinolysis the median delay was 46 minutes shorter. For the quarter of patients treated with rescue PCI after fibrinolysis, the median needle-to-rescue time was prolonged-four hours. CONCLUSIONS: Nationwide implementation of the NZ STEMI pathway is needed to reduce system delays in delivery of primary PCI, fibrinolysis and rescue PCI. Ongoing initiatives are required to reduce barriers to calling the ambulance early after symptom onset.

Economic and Environmental Assessment of Seed and Rhizome Propagated Miscanthus in the UK.

Growth in planted areas of Miscanthus for biomass in Europe has stagnated since 2010 due to technical challenges, economic barriers and environmental concerns. These limitations need to be overcome before biomass production from Miscanthus can expand to several million hectares. In this paper, we consider the economic and environmental effects of introducing seed based hybrids as an alternative to clonal M. x giganteus (Mxg). The impact of seed based propagation and novel agronomy was compared with current Mxg cultivation and used in 10 commercially relevant, field scale experiments planted between 2012 and 2014 in the United Kingdom, Germany, and Ukraine. Economic and greenhouse gas (GHG) emissions costs were quantified for the following production chain: propagation, establishment, harvest, transportation, storage, and fuel preparation (excluding soil carbon changes). The production and utilization efficiency of seed and rhizome propagation were compared. Results show that new hybrid seed propagation significantly reduces establishment cost to below £900 ha-1. Calculated GHG emission costs for the seeds established via plugs, though relatively small, was higher than rhizomes because fossil fuels were assumed to heat glasshouses for raising seedling plugs (5.3 and 1.5 kg CO2 eq. C Mg [dry matter (DM)]-1), respectively. Plastic mulch film reduced establishment time, improving crop economics. The breakeven yield was calculated to be 6 Mg DM ha-1 y-1, which is about half average United Kingdom yield for Mxg; with newer seeded hybrids reaching 16 Mg DM ha-1 in second year United Kingdom trials. These combined improvements will significantly increase crop profitability. The trade-offs between costs of production for the preparation of different feedstock formats show that bales are the best option for direct firing with the lowest transport costs (£0.04 Mg-1 km-1) and easy on-farm storage. However, if pelleted fuel is required then chip harvesting is more economic. We show how current seed based propagation methods can increase the rate at which Miscanthus can be scaled up; ∼×100 those of current rhizome propagation. These rapid ramp rates for biomass production are required to deliver a scalable and economic Miscanthus biomass fuel whose GHG emissions are ∼1/20th those of natural gas per unit of heat.

30-day mortality after percutaneous coronary intervention in New Zealand public hospitals (ANZACS-QI 18).

AIM: The aim of this report is to provide hospitals in New Zealand with data about their own outcomes for percutaneous coronary intervention (PCI) procedures and allow comparisons with other New Zealand units and with international data. METHODS: All PCI procedures (n=5,033) were identified in nine public hospital catheterisation laboratories between 1 October 2014 and 30 September 2015. Risk-adjusted mortality rates were derived for each hospital and compared with the national rate. RESULTS: The overall 30-day mortality rate after PCI was 1.23%. The national 30-day mortality rates were 3.28% for the subgroup of patients treated for a ST segment elevation myocardial infarct and 0.66% for those treated for other acute coronary syndrome (ACS) or non-ACS indications. There were no statistically significant differences in outcomes between the different New Zealand public hospital catheterisation laboratories, either overall or for each patient subgroup. CONCLUSIONS: Mortality rates in the first 30 days after PCI are low and comparable across New Zealand public hospitals. The outcomes are comparable with international experience.

Progress on Optimizing Miscanthus Biomass Production for the European Bioeconomy: Results of the EU FP7 Project OPTIMISC.

This paper describes the complete findings of the EU-funded research project OPTIMISC, which investigated methods to optimize the production and use of miscanthus biomass. Miscanthus bioenergy and bioproduct chains were investigated by trialing 15 diverse germplasm types in a range of climatic and soil environments across central Europe, Ukraine, Russia, and China. The abiotic stress tolerances of a wider panel of 100 germplasm types to drought, salinity, and low temperatures were measured in the laboratory and a field trial in Belgium. A small selection of germplasm types was evaluated for performance in grasslands on marginal sites in Germany and the UK. The growth traits underlying biomass yield and quality were measured to improve regional estimates of feedstock availability. Several potential high-value bioproducts were identified. The combined results provide recommendations to policymakers, growers and industry. The major technical advances in miscanthus production achieved by OPTIMISC include: (1) demonstration that novel hybrids can out-yield the standard commercially grown genotype Miscanthus x giganteus; (2) characterization of the interactions of physiological growth responses with environmental variation within and between sites; (3) quantification of biomass-quality-relevant traits; (4) abiotic stress tolerances of miscanthus genotypes; (5) selections suitable for production on marginal land; (6) field establishment methods for seeds using plugs; (7) evaluation of harvesting methods; and (8) quantification of energy used in densification (pellet) technologies with a range of hybrids with differences in stem wall properties. End-user needs were addressed by demonstrating the potential of optimizing miscanthus biomass composition for the production of ethanol and biogas as well as for combustion. The costs and life-cycle assessment of seven miscanthus-based value chains, including small- and large-scale heat and power, ethanol, biogas, and insulation material production, revealed GHG-emission- and fossil-energy-saving potentials of up to 30.6 t CO2eq C ha-1y-1 and 429 GJ ha-1y-1, respectively. Transport distance was identified as an important cost factor. Negative carbon mitigation costs of -78€ t-1 CO2eq C were recorded for local biomass use. The OPTIMISC results demonstrate the potential of miscanthus as a crop for marginal sites and provide information and technologies for the commercial implementation of miscanthus-based value chains.

The All New Zealand Acute Coronary Syndrome Quality Improvement Programme: Implementation, Methodology and Cohorts (ANZACS-QI 9).

The All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) uses a web-based system to create a clinical registry of patients with acute coronary syndrome (ACS) and other cardiac problems admitted to hospitals across New Zealand. This detailed clinical registry is complemented by parallel analyses of, and individual linkage to, New Zealand's multiple routine health information datasets. The programme is primarily designed to support secondary care clinicians to implement evidence based guidelines and to meet national performance targets for New Zealand cardiac patients. ANZACS-QI simultaneously generates a large-scale research database and provides an electronic data infrastructure for clinical registry studies. ANZACS-QI has been successfully implemented in all the 41 public hospitals across New Zealand where acute cardiac patients are admitted. By June 2015 25,273 patients with suspected ACS and 30,696 referred for coronary angiography were registered in ANZACS-QI. In this report we describe the development and national implementation of ANZACS-QI, its governance, the data collection processes and the current ANZACS-QI cohorts and available outputs.

National variation in coronary angiography rates and timing after an acute coronary syndrome in New Zealand (ANZACS-QI 6).

AIM: The New Zealand Cardiac Clinical Network and the Ministry of Health recommend a "3-day door-to-catheter target" for acute coronary syndromes (ACS) admissions, requiring that at least 70% of ACS patients referred for invasive coronary angiography (ICA) undergo this within 3 days of hospital admission. We assessed the variability in use of ICA, timing of ICA, and duration of hospital admission across New Zealand District Health Boards (DHBs). METHODS: All patients admitted to all New Zealand public hospitals with suspected ACS undergoing ICA over 1 year ending November 2014 had demographic, risk factor, and diagnostic data collected prospectively using the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. Complete datasets were available in 7,988 (98.4%) patients. DHBs were categorised as those able to perform percutaneous coronary intervention on-site (intervention-capable) or not. RESULTS: There was a near two-fold variation between DHBs in the age standardised rate (ASR) of ICA ranging from 16.8 per 10,000 to 34.1 per 10,000 population (New Zealand rate; 27.9 per 10,000). Patients in intervention-capable DHBs had a 30% higher ASR of ICA. The proportion of ACS patients meeting the 3-day target ranged from 56.7% to 92.9% (New Zealand; 76.4%). Those in intervention-capable DHBs were more likely to meet the target (78.7% vs 68.0%, p<0.0001) and spent 0.84 days (p<.0001) less in hospital. CONCLUSIONS: There is a considerable variation in the rate and timing of ICA in New Zealand. Patients with ACS admitted to DHBs without interventional-capability are disadvantaged. New initiatives to correct this discrepancy are needed.

Recurrent ventricular tachycardia managed with balloon aortic valvuloplasty: an unusual presentation of severe aortic stenosis.

A 68-year-old woman was transferred from a regional hospital with recurrent polymorphic ventricular tachycardia associated with haemodynamic instability. A diagnosis of severe aortic stenosis (AS) with normal left ventricular systolic function had recently been established on echocardiography. Correction of hypokalaemia and intravenous amiodarone infusion were ineffective. On transfer, ongoing ventricular arrhythmias requiring repeat defibrillation occurred. Urgent coronary angiography was unremarkable. Following consultation with the cardiosurgical team, emergency bridging balloon aortic valvuloplasty (BAV) was performed. Two weeks later the patient proceeded to an uneventful inpatient surgical aortic valve replacement (AVR). This case highlights an unusual presentation of severe AS, and describes the use of emergency BAV to correct arrhythmia-induced haemodynamic instability prior to surgical AVR.

A new oxidant for hair coloring.

Coloring hair using a level 3 permanent colorant involves two processes, lightening the underlying melanin and information of the colored chromophores inside the hair. In a typical in-market products the oxidant used to achieve these changes is hydrogen peroxide buffered at pH 10 with an alkalizer such as ammonium hydroxide. A new oxidant has been developed based on the combination of ammonium carbonate, hydrogen peroxide and glycine at pH 9 that can match the lightening and color performance of the current oxidant. It has the advantage that both the carbonate and hydrogen peroxide concentrations can be changed to alter the lightening performance making it a more flexible oxidant. This allows the capability to lighten the hair in a shorter time, or with lower hydrogen peroxide levels. This paper discusses the key oxidizing species that are present in both systems and the mechanisms of melanin lightening. In addition, the lightening performance will be assessed as a function of time, pH, hydrogen peroxide concentration and carbonate concentration. The importance of glycine to the oxidant is also described along with a proposal for its mechanism of action. It has been demonstrated that the addition of glycine can control the undesired formation of carbonate radicals that can be generated from the oxidant. The control of these radicals enables the oxidant to deliver excellent lightening with no negatives in fiber damage bs. conventional oxidants.

Bilateral tension pneumothoraces following jet ventilation via an airway exchange catheter.

We report a case involving a 55-year-old man who had a recent resection of tracheal carcinoma and tracheal reanastomosis. He subsequently developed tracheomalacia and anastomotic dehiscence requiring airway stenting via an armored endotracheal tube (ETT). Placement of the armored ETT was technically difficult. It required insertion of an airway exchange catheter through the tracheal stoma to oxygenate, ventilate, and serve as a guide for ETT placement through the tracheotomy and across the dehiscence. During transtracheal jet ventilation our patient developed bilateral tension pneumothoraces requiring cardiopulmonary resuscitation and chest tube placement. The patient was quickly recovered, stabilized, and later discharged after a prolonged intensive care unit (ICU) course. We review the recommendations for jet ventilation via airway exchange catheters, common problems during this technique, and potential methods for avoiding these problems. The risk of barotrauma and pneumothoraces during jet ventilation via an airway exchange catheter should be kept in mind.