Reducing no-show visits and disparities in access: The impact of telemedicine.

BACKGROUND: No-show visits have serious consequences for patients, providers, and healthcare systems as they lead to delays in care, increased costs, and reduced access to services. Telemedicine has emerged as a promising alternative to in-person visits by reducing travel barriers, but risks exacerbating the digital divide. The aim of this study was to assess the impact of telemedicine (video and phone) at a tertiary care academic center on no-show visits compared to in-person visits. METHODS: A retrospective cohort analysis of all weekday clinic visits among in-state adult patients at a single tertiary care center in the southeast from January 2020 to April 2023 was performed. Rates of no-show visits for patients who were seen via phone and video were compared with those who were seen in-person. Demographic and clinical characteristics of these groups were also compared, including age, sex, race/ethnicity, socioeconomic status, and visit type. The primary outcome was the rate of no-show visits for each visit type. RESULTS: Our analysis included 3,105,382 scheduled appointments, of which 81.2% were in-person, 13.4% via video, and 5.4% via phone calls. Compared to in-person visits, phone calls and video visits reduced the odds of no-show visits by 50% (aOR 0.5, CI 0.49-0.51) and 15% (aOR 0.85, CI 0.84-0.86), respectively. Older patients, Black patients, patients furthest from clinic, and patients from counties with the greatest degree of vulnerability and disparities in digital access were more likely to use phone visits. No-shows were more common among non-white, male, and younger patients from counties with lower socioeconomic status. CONCLUSION: Telemedicine effectively reduced no-show visits. However, limiting telemedicine to video-based visits only exacerbated disparities in access. Phone calls allow historically underserved patients from lower socioeconomic backgrounds to access healthcare and should be included within the definition of telemedicine.

Society for Surgery of the Alimentary Tract State-of-the-Art Session 2022: Frailty in Surgery.

Given the exponentially aging population and rising life expectancy in the United States, surgeons are facing a challenging frail population who may require surgery but may not qualify based on their general fitness. There is an urgent need for greater awareness of the importance of frailty measurement and the implementation of universal assessment of frail patients into clinical practice. Pairing risk stratification with stringent protocols for prehabilitation and minimally invasive surgery and appropriate enhanced recovery protocols could optimize and condition frail patients before, during, and immediately after surgery to mitigate postoperative complications and consequences on patient function and quality of life. In this paper, highlights from the 2022 Society for Surgery of the Alimentary Tract State-of-the-Art Session on frailty in surgery are presented. This work aims to improve the understanding of the impact of frailty on patients and the methods used to augment the outcomes for frail patients during their surgical experience.

Prescreened Whole O Blood Group Walking Blood Bank Capabilities for Nontraditional Maritime Medical Receiving Platforms: A Case Series.

BACKGROUND: Tactical Combat Casualty Care (TCCC) guidelines recognize low-titer group O whole blood (LTOWB) as the resuscitative fluid of choice for combat wounded. Utilization of prescreened LTOWB in a walking blood bank (WBB) format has been well described by the Ranger O low-titer blood (ROLO) and the United States Marine Corps Valkyrie programs, but it has not been applied to the maritime setting. METHODS: We describe three WBB experiences of an expeditionary resuscitative surgical system (ERSS) team, attached to three nontraditional maritime medical receiving platforms, over 6 months. RESULTS: Significant variations were identified in the number of screened eligible donors, the number of LTOWB donors, and the timely arrival at WBB activation sites between the platforms. Overall, 95% and 84% of the screened eligible group O blood donors on the Arleigh Burke Class Destroyer (DDG) and Nimitz Class Aircraft Carrier (CVN), respectively, were determined to be LTOWB. However, only 37% of the eligible screened group O blood donors aboard the Harper's Ferry Class Dock Landing Ship (LSD) were found to be LTOWB. Of the eligible donors, 66% did not complete screening, with 52% citing a correctable reason for nonparticipation. CONCLUSION: LTOWB attained through WBBs may be the only practical resuscitative fluid on maritime platforms without inherent blood product storage capabilities to perform remote damage control resuscitation. Future efforts should focus on optimizing WBBs through capability development, education, and training efforts.

Healthcare Workers Beliefs about COVID-19; a Longitudinal, Mixed Methods Analysis.

The psychological impact of COVID-19 on Health Care Workers (HCWs) has been widely reported. Few studies have sought to examine HCWs personal models of COVID-19 utilising an established theoretical framework. We undertook a mixed methods study of beliefs about COVID-19 held by HCWs in the Mid-West and South of Ireland during the first and third waves of COVID-19. Template analysis was undertaken on the free text responses of 408 HCWs about their perceptions of the Cause of COVID-19 as assessed by the Brief Illness Perception Questionnaire (B-IPQ). Responses were re-examined in the same cohort for stability at 3 months follow-up (n = 100). This analytic template was subsequently examined in a new cohort (n = 253) of HCWs in the third wave. Female HCWs perceived greater emotional impact of COVID-19 than men (t = -4.31, df405, p < 0.01). Differences between occupational groups were evident in relation to Timeline (F4,401 = 3.47, p < 0.01), Treatment Control (F4,401 = 5.64, p < 0.001) and Concerns about COVID-19 (F4,401 = 3.68, p < 0.01). Administration staff believed that treatment would be significantly more helpful and that COVID-19 would last a shorter amount of time than medical/nursing staff and HSCP. However, administration staff were significantly more concerned than HSCP about COVID-19. Template analysis on 1059 responses to the Cause items of the B-IPQ identified ten higher order categories of perceived Cause of COVID-19. The top two Causes identified at both Waves were 'individual behavioural factors' and 'overseas travel'. This study has progressed our understanding of the models HCWs hold about COVID-19 over time, and has highlighted the utility of the template analysis approach in analysing free-text questionnaire data. We suggest that group and individual occupational identities of HCWs may be of importance in shaping HCWs responses to working through COVID-19.

Nocturnal swallowing augments arousal intensity and arousal tachycardia.

Cortical arousal from sleep is associated with autonomic activation and acute increases in heart rate. Arousals vary considerably in their frequency, intensity/duration, and physiological effects. Sleep and arousability impact health acutely (daytime cognitive function) and long-term (cardiovascular outcomes). Yet factors that modify the arousal intensity and autonomic activity remain enigmatic. In this study of healthy human adults, we examined whether reflex airway defense mechanisms, specifically swallowing or glottic adduction, influenced cardiac autonomic activity and cortical arousal from sleep. We found, in all subjects, that swallows trigger rapid, robust, and patterned tachycardia conserved across wake, sleep, and arousal states. Tachycardia onset was temporally matched to glottic adduction-the first phase of swallow motor program. Multiple swallows increase the magnitude of tachycardia via temporal summation, and blood pressure increases as a function of the degree of tachycardia. During sleep, swallows were overwhelmingly associated with arousal. Critically, swallows were causally linked to the intense, prolonged cortical arousals and marked tachycardia. Arousal duration and tachycardia increased in parallel as a function of swallow incidence. Our findings suggest that cortical feedback and tachycardia are integrated responses of the swallow motor program. Our work highlights the functional influence of episodic, involuntary airway defense reflexes on sleep and vigilance and cardiovascular function in healthy individuals.

Emotional outcomes in clinically isolated syndrome and early phase multiple sclerosis: a systematic review and meta-analysis.

OBJECTIVE: To study depression, anxiety, suicide risk, and emotional health-related quality of life (HRQoL) in people with clinically isolated syndrome (CIS) and in early phase multiple sclerosis (MS). METHODS: A systematic literature review was conducted with inclusion criteria of observational studies on outcomes of depression, anxiety, suicide risk, and emotional HRQoL in CIS and within five years since diagnosis of MS. Studies were screened using the Preferred Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, and study quality was determined for included studies. Meta-analysis and meta-regression were performed if applicable. RESULTS: Fifty-one studies were included in the systematic review. In early phase MS, meta-analyses of the Hospital Anxiety Depression Scale (HADS) indicated prevalence levels of 17% (95% confidence interval (CI): 9 to 25%; p < .001) for depressive and 35% (95% CI: 28 to 41%; p < .001) for anxiety symptoms. Meta-regression analyses revealed an increase in mean HADS-D and HADS-A associated with larger sample size, and higher HADS-D mean with increased study quality. Similar depressive and anxiety symptoms were observed in CIS, and increased suicide risk and low emotional HRQoL was associated with depressive symptoms in early phase MS. The methodological quality of the studies was considered fair. CONCLUSIONS: Findings suggest that mild-to-moderate symptoms of depression and anxiety might be prevalent in CIS and in early phase MS. Future research on both clinical populations are needed, especially longitudinal monitoring of emotional outcomes.

Reduced peripheral activity leading to hepato-preferential action of basal insulin peglispro compared with insulin glargine in patients with type 1 diabetes.

AIMS: Basal insulin peglispro (BIL), a novel PEGylated basal insulin with a large hydrodynamic size, has a delayed absorption and reduced clearance that prolongs the duration of action. The current study compared the effects of BIL and insulin glargine (GL) on endogenous glucose production (EGP), glucose disposal rate (GDR) and lipolysis in patients with type 1 diabetes. MATERIALS AND METHODS: This was a randomized, open-label, four-period, crossover study. Patients received intravenous infusions of BIL and GL, each at two dose levels selected for partial and maximal suppression of EGP, during an 8 to 10 h euglycemic clamp procedure with d-[3-3 H] glucose. RESULTS: Following correction for equivalent human insulin concentrations (EHIC), low-dose GL infusion resulted in similar EGP at the end of the clamp compared to low-dose BIL infusion (GL/BIL ratio of 1.03) but a higher GDR (GL/BIL ratio of 2.42), indicating similar hepatic activity but attenuated peripheral activity of BIL. Consistent with this, the EHIC-corrected GDR/EGP at the end of the clamp was 1.72-fold greater for GL than BIL following low-dose administration. At the lower dose of BIL and GL (concentrations in the therapeutic range), BIL produced less suppression of lipolysis compared with GL as indicated by free fatty acid and glycerol levels at the end of the clamp. CONCLUSIONS: Compared with GL, BIL restored the hepato-peripheral insulin action gradient seen in normal physiology via its peripherally restricted action on target tissues related to carbohydrate and lipid metabolism.

Coronary angiography and failure to rescue after postoperative myocardial infarction in patients with coronary stents undergoing noncardiac surgery.

BACKGROUND: We evaluated coronary angiography use among patients with coronary stents suffering postoperative myocardial infarction (MI) and the association with mortality. METHODS: Patients with prior coronary stenting who underwent inpatient noncardiac surgery in Veterans Affairs hospitals between 2000 and 2012 and experienced postoperative MI were identified. Predictors of 30-day post-MI mortality were evaluated. RESULTS: Following 12,096 operations, 353 (2.9%) patients had postoperative MI and 58 (16.4%) died. Post-MI coronary angiography was performed in 103 (29.2%) patients. Coronary angiography was not associated with 30-day mortality (odds ratio [OR]: .70, 95% CI: .35-1.42). Instead, 30-day mortality was predicted by revised cardiac risk index ≥3 (OR 1.91, 95% CI: 1.04-3.50) and prior bare metal stent (OR 2.12, 95% CI: 1.04-4.33). CONCLUSIONS: Less than one-third of patients with coronary stents suffering postoperative MI underwent coronary angiography. Significant predictors of mortality were higher revised cardiac risk index and prior bare metal stent. These findings highlight the importance of comorbidities in predicting mortality following postoperative MI.

A MultiCenter Pilot Randomized Controlled Trial of Remote Ischemic Preconditioning in Major Vascular Surgery.

A pilot randomized controlled trial that evaluated the effect of remote ischemic preconditioning (RIPC) on clinical outcomes following major vascular surgery was performed. Eligible patients were those scheduled to undergo open abdominal aortic aneurysm repair, endovascular aortic aneurysm repair, carotid endarterectomy, and lower limb revascularization procedures. Patients were randomized to RIPC or to control groups. The primary outcome was a composite clinical end point comprising any of cardiovascular death, myocardial infarction, new-onset arrhythmia, cardiac arrest, congestive cardiac failure, cerebrovascular accident, renal failure requiring renal replacement therapy, mesenteric ischemia, and urgent cardiac revascularization. Secondary outcomes were components of the primary outcome and myocardial injury as assessed by serum troponin values. The primary outcome occurred in 19 (19.2%) of 99 controls and 14 (14.1%) of 99 RIPC group patients (P = .446). There were no significant differences in secondary outcomes. Our trial generated data that will guide future trials. Further trials are urgently needed.

Comparison of noradrenaline, dopamine and serotonin in mediating the tachycardic and thermogenic effects of methamphetamine in the ventral medial prefrontal cortex.

Methamphetamine (METH) is a psychostimulant that disrupts monoaminergic neurotransmission to evoke profound behavioral and physiological effects. Rapidly distributing to forebrain regions to increase synaptic concentrations of three monoamines (dopamine (DA), serotonin (5-HT) and noradrenaline (NA)), the medial prefrontal cortex (mPFC) is important in METH-altered behavioral and psychological profiles. Activation of the ventral mPFC can modify physiological variables, however, METH-evoked autonomic changes from this region are unknown. Therefore, the aim of this study was to characterize the respiratory, metabolic and cardiovascular effects of microinjection of METH, DA, 5-HT and NA into the ventral mPFC in urethane-anesthetized Sprague-Dawley rats. METH and NA microinjection evoked dose-related increases in heart rate, interscapular brown adipose tissue temperature and expired CO2, a pattern of response characteristic of non-shivering thermogenesis. NA and 5-HT microinjection elicited pressor and depressor responses, respectively, with matching baroreflex adjustments in sympathetic nerve activity while METH and DA evoked no change in vasomotor outflow. Low doses of METH and DA may evoke respiratory depression. These data suggest that METH's actions in the ventral mPFC, likely via adrenergic receptors, evoke non-shivering thermogenesis which may contribute to the increased body temperature and tachycardia seen in those that abuse METH.

The role of venous diameter in predicting arteriovenous fistula maturation: when not to expect an AVF to mature according to pre-operative vein diameter measurements? A best evidence topic.

This best evidence topic was investigated according to a described protocol. We asked the question: what is the minimal vein diameter that can successfully predict maturation of an arteriovenous fistula (AVF) in patients undergoing dialysis. Using the reported search 804 papers were found, of which five represented the best evidence to answer the clinical question. All studies assessed the association between successful AVF maturation and the size of vein used. The strongest evidence came from a nonrandomised controlled follow-up study in which 76% of fistulas created using >2 mm cephalic vein successfully matured compared to 16% when the vein measured ≤2 mm. Another prospective, multicentre study showed 65% successful maturation using veins >4 mm compared to 45% with veins <3 mm. Vein diameter was found to be an independent predictor of maturation in multivariate regression analysis in two retrospective observational studies. Another retrospective observational study found that using venous measurements of ≥2.5 mm following tourniquet application resulted in more fistulas been created that would have otherwise been denied based on venous ultrasound mapping. A large multicentre randomised clinical trial assessing the use of different vein sizes both with and without tourniquet application using proper statistical tools - such as receiver operating characteristic - is required to make a final recommendation. Until then, a vein diameter of <2.5 mm should be considered inadequate for formation of an AVF, particularly if those measurements remain unchanged following the use of tourniquet.

Diagnostic accuracy of non-radiologist performed ultrasound for abdominal aortic aneurysm: systematic review and meta-analysis.

BACKGROUND: Ultrasonography is increasingly used by clinicians to identify abdominal aortic aneurysms (AAA). We performed a systematic review and meta-analysis comparing the accuracy of non-radiologist performed ultrasound (NRPUS) for AAA disease to the 'gold standard' of radiologist performed aortic imaging (RPI), intra-operative findings or postmortem findings. METHODS: Cochrane Library, MEDLINE, EMBASE, SCOPUS-V.4, trial registries, conference proceedings, and article reference lists were searched to identify studies comparing NRPUS with RPI as the reference standard. Data abstracted from eligible studies was used to generate 2 × 2 contingency tables allowing calculation of pooled sensitivity and specificity values. RESULTS: 11 studies (944 patients) evaluated NRPUS for AAA detection. NRPUS had a pooled sensitivity of 0.975 [95% confidence interval (CI), 0.942-0.992] for AAA detection and a pooled specificity of 0.989 (95% CI, 0.979-0.995). CONCLUSIONS: Non-radiologist performed ultrasound achieves acceptable sensitivity and specificity for both detection and measurement of AAA. There was no evidence of significant heterogeneity with respect to pooled sensitivity or specificity.

Assessing the quality of online information for patients with carotid disease.

INTRODUCTION: Controversy exists relating to carotid endarterectomy (CEA) versus carotid artery stenting (CAS). We aimed to assess the quality of online patient information relating to both. METHODS: The Google search engine was searched for "carotid endarterectomy" and "carotid stenting". The first 50 webpages returned were assessed. The Gunning Fog Index (GFI) and Flesch Reading Ease Score (FRES) were calculated to assess readability. The LIDA tool (Minervation Ltd., Oxford, U.K.) was used to assess accessibility, usability and reliability. RESULTS: 20% (n = 10) of the webpages returned for CEA were from peer reviewed sources with 34% (n = 17) posted by hospitals or health services. Comparatively, for CAS, 40% (n = 20) were peer reviewed with 16% (n = 8) posted by hospitals or health services. GFI and FRES scores indicated webpages for both CEA and CAS had poor general readability. Webpages for CEA were easier to read than those for CAS (mean FRES difference of 6.7 (95% CI 0.51 to 12.93, p = 0.03). Median LIDA scores demonstrated acceptable reliability, accessibility and usability of information for both CEA and CAS webpages. The more readable webpages were not associated with higher LIDA scores for either CEA or CAS webpages. CONCLUSION: Webpages providing information on carotid disease management must be made more readable. Online information currently available to patients regarding CAS is more difficult to read and comprehend than CEA.

The impact of regional reconfiguration on the management of appendicitis.

BACKGROUND: Reconfiguration of surgical services in the Mid-West in 2009 resulted in a large increase in numbers of patients undergoing emergency surgery for appendicitis in University Hospital Limerick (UHL). AIMS: The aim of this study was to assess the impact of reconfiguration on the management of appendicitis in this area. METHODS: Data on all patients who underwent appendicectomy between January and June 2007 were compared with the corresponding data from January to June 2011. The numbers of operations, types of operations, lengths of stay (LOS), operation start times, rates of negative histology specimens and readmissions within 30 days were compared. One hundred and twenty-five appendicectomies [48 laparoscopic (38.4 %)] were performed in the 2007 group of which 32 specimens (25.6 %) were histologically negative. Three hundred and nineteen appendicectomies [238 laparoscopic (74.6 %)] were performed in the 2011 group of which 62 specimens (19.4 %) were histologically negative. The increase in numbers of laparoscopic procedures was significant (p < 0.001). The reduction in the negative appendicectomy rate was not statistically significant (p = 0.16). There were 10 conversions (20.8 %) to open surgery in the 2007 period and 12 (5 %) in the 2011 period (p = 0.001). Mean LOS for the 2007 and 2011 groups was 4.45 and 3.16 days (p < 0.001). Six (4.8 %) readmissions within 30 days occurred in the 2007 group with 20 (6.3 %) in the 2011 group (p = 0.66). CONCLUSION: Though reconfiguration of surgical services has resulted in a significant increase in workload, LOS has decreased significantly while maintaining acceptably low negative appendicectomy, conversion and readmission rates.

Cleaning, disinfection and sterilization of surface prion contamination.

BACKGROUND: Prion contamination is a risk during device reprocessing, being difficult to remove and inactivate. Little is known of the combined effects of cleaning, disinfection and sterilization during a typical reprocessing cycle in clinical practice. AIM: To investigate the combination of cleaning, disinfection and/or sterilization on reducing the risk of surface prion contamination. METHODS: In vivo test methods were used to study the impact of cleaning alone and cleaning combined with thermal disinfection and high- or low-temperature sterilization processes. A standardized test method, based on contamination of stainless steel wires with high titres of scrapie-infected brain homogenates, was used to determine infectivity reduction. FINDINGS: Traditional chemical methods of surface decontamination against prions were confirmed to be effective, but extended steam sterilization was more variable. Steam sterilization alone reduced the risk of prion contamination under normal or extended exposure conditions, but did show significant variation. Thermal disinfection had no impact in these studies. Cleaning with certain defined formulations in combination with steam sterilization can be an effective prion decontamination process, in particular with alkaline formulations. Low-temperature, gaseous hydrogen peroxide sterilization was also confirmed to reduce infectivity in the presence and absence of cleaning. CONCLUSION: Prion decontamination is affected by the full reprocessing cycle used on contaminated surfaces. The correct use of defined cleaning, disinfection and sterilization methods as tested in this report in the scrapie infectivity assay can provide a standard precaution against prion contamination.

Paget-Schrotter syndrome and complications of management.

An 18-year-old man presented to the emergency department with an acutely swollen right upper limb having spent the previous day canoeing. Venography confirmed right subclavian venous thrombosis at middle one-third of right clavicle with no evidence of cervical rib or other structural abnormalities. Following heparinisation, catheter directed thrombolysis was performed which restored luminal flow. Postprocedure the patient developed spontaneous small-volume haemoperitoneum and acute renal failure. The patient was admitted to the intensive care unit for haemodialysis and supportive management. The patients' renal function improved and he was discharged well following his 28th day of admission. Paget-Schroetter syndrome or effort thrombosis involves subclavian venous thrombosis associated with strenuous activity of upper extremities. In these cases, catheter directed thrombolysis with first rib resection provides greater patency rate than anticoagulation therapy alone. Acute kidney injury following mechanical thrombolysis is rarely reported in the literature.

Inhibition of protein kinase A activity depresses phrenic drive and glycinergic signalling, but not rhythmogenesis in anaesthetized rat.

The cAMP-protein kinase A (PKA) pathway plays a critical role in regulating neuronal activity. Yet, how PKA signalling shapes the population activity of neurons that regulate respiratory rhythm and motor patterns in vivo is poorly defined. We determined the respiratory effects of focally inhibiting endogenous PKA activity in defined classes of respiratory neurons in the ventrolateral medulla and spinal cord by microinjection of the membrane-permeable PKA inhibitor Rp-adenosine 3',5'-cyclic monophosphothioate (Rp-cAMPS) in urethane-anaesthetized adult Sprague Dawley rats. Phrenic nerve activity, end-tidal CO2 and arterial pressure were recorded. Rp-cAMPS in the preBötzinger complex (preBötC) caused powerful, dose-dependent depression of phrenic burst amplitude and inspiratory period. Rp-cAMPS powerfully depressed burst amplitude in the phrenic premotor nucleus, but had no effect at the phrenic motor nucleus, suggesting a lack of persistent PKA activity here. Surprisingly, inhibition of PKA activity in the preBötC increased phrenic burst frequency, whereas in the Bötzinger complex phrenic frequency decreased. Pretreating the preBötC with strychnine, but not bicuculline, blocked the Rp-cAMPS-evoked increase in frequency, but not the depression of phrenic burst amplitude. We conclude that endogenous PKA activity in excitatory inspiratory preBötzinger neurons and phrenic premotor neurons, but not motor neurons, regulates network inspiratory drive currents that underpin the intensity of phrenic nerve discharge. We show that inhibition of PKA activity reduces tonic glycinergic transmission that normally restrains the frequency of rhythmic respiratory activity. Finally, we suggest that the maintenance of the respiratory rhythm in vivo is not dependent on endogenous cAMP-PKA signalling.

Patient satisfaction following emergency admission via a surgical assessment unit and an emergency department.

AIM: Acute surgical patients are admitted to our regional hospital through the emergency department (ED) and through a new surgical assessment unit (SAU). The aim of this study was to compare the efficiency of the two units in seeing and assessing acute surgical patients, as well as patients' satisfaction with their experiences in both units. METHODS: A patient satisfaction scoring questionnaire was distributed to 115 consecutive surgical patients attending the SAU and ED over an 8-week period. Patients' impressions of waiting times, pain management and interactions with staff were detailed. The actual times taken for assessment, admission and discharge were recorded and compared with those perceived by the patients. RESULTS: Patients' perceptions of care were very high within both the ED and the SAU, with 95 % of SAU patients reporting their care as excellent or very good compared with 86 % of ED patients (p = 0.014). Patients were assessed considerably faster in the SAU compared with the ED, with an average wait from registration to admission or discharge totalling 5 h in the SAU compared with 12 h in the ED. CONCLUSION: The SAU provides an effective and efficient mode of assessment of acute surgical patients. While patients were discharged faster from the SAU than the ED, patients rated both units highly in terms of satisfaction with the service provided.

Four BSE cases with an L-BSE molecular profile in cattle from Great Britain.

Bovine spongiform encephalopathy (BSE) is a prion disease of cattle which was first observed in Great Britain (GB) in 1986. Throughout the subsequent BSE epidemic, cases identified by passive surveillance have shown consistent histopathological, immunohistochemical, biochemical and biological properties. However, since the start of active surveillance in 2001, across Europe and elsewhere, approximately 67 cases with different biochemical characteristics have been identified by Western blotting (WB). These cases fall into two categories; 'H-type' (H-BSE) or 'L-type' (L-BSE), based on the relatively heavy (H-BSE) or light (L-BSE) mass of the unglycosylated band of the prion protein, as compared with WB against that obtained from classical BSE (C-BSE) cases. Here we report the detection and confirmation of the first four L-BSE cases by active surveillance in GB, two of which were born after the reinforced feed ban of 1996 (BARB cases). These four L-BSE cases were found in relatively old cattle (age range; 11-21 years old) and the carcases did not enter the human food chain or animal feed chains.