Diagnostic performance of S100B as a rule-out test for intracranial pathology in head-injured patients presenting to the emergency department who meet NICE Head Injury Guideline criteria for CT-head scan.

BACKGROUND: Traumatic brain injury is a common ED presentation. CT-head utilisation is escalating, exacerbating resource pressure in the ED. The biomarker S100B could assist clinicians with CT-head decisions by excluding intracranial pathology. Diagnostic performance of S100B was assessed in patients meeting National Institute of Health and Clinical Excellence Head Injury Guideline (NICE HIG) criteria for CT-head within 6 and 24 hours of injury. METHODS: This multicentre prospective observational study included adult patients presenting to the ED with head injuries between May 2020 and June 2021. Informed consent was obtained from patients meeting NICE HIG CT-head criteria. A venous blood sample was collected and serum was tested for S100B using a Cobas Elecsys-S100 module; >0.1 µg/mL was the threshold used to indicate a positive test. Intracranial pathology reported on CT-head scan by the duty radiologist was used as the reference standard to review diagnostic performance. RESULTS: This study included 265 patients of whom 35 (13.2%) had positive CT-head findings. Within 6 hours of injury, sensitivity of S100B was 93.8% (95% CI 69.8% to 99.8%) and specificity was 30.8% (22.6% to 40.0%). Negative predictive value (NPV) was 97.3% (95% CI 84.2% to 99.6%) and area under the curve (AUC) was 0.73 (95% CI 0.61 to 0.85; p=0.003). Within 24 hours of injury, sensitivity was 82.9% (95% CI 66.4% to 93.44%) and specificity was 43.0% (95% CI 36.6% to 49.7%). NPV was 94.29% (95% CI 88.7% to 97.2%) and AUC was 0.65 (95% CI 0.56 to 0.74; p=0.046). Theoretically, use of S100B as a rule-out test would have reduced CT-head scans by 27.1% (95% CI 18.9% to 36.8%) within 6 hours and 37.4% (95% CI 32.0% to 47.2%) within 24 hours. The risk of missing a significant injury with this approach would have been 0.75% (95% CI 0.0% to 2.2%) within 6 hours and 2.3% (95% CI 0.5% to 4.1%) within 24 hours. CONCLUSION: Within 6 hours of injury, S100B performed well as a diagnostic test to exclude significant intracranial pathology in low-risk patients presenting with head injury. In theory, if used in addition to NICE HIGs, CT-head rates could reduce by one-quarter with a potential miss rate of <1%.

Cluster analysis of extracellular matrix biomarkers predicts the development of impaired systolic function within 1 year of acute myocardial infarction.

The clinical utility of combining extracellular matrix (ECM) biomarkers to predict the development of impaired systolic function following acute myocardial infarction (AMI) remains largely undetermined. A combination of ELISA and multiplexing assays were performed to measure matrix metalloproteinase (MMP)-2, MMP-3, MMP-8, MMP-9, periostin, N-terminal type I procollagen (PINP) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) in plasma samples from 120 AMI patients. All patients had an echocardiogram within 1 year of AMI, and were divided into impaired (n = 37, LVEF < 50%) and preserved (n = 83, LVEF ≥ 50%) systolic function groups. Exploratory factor analysis was performed on log-transformed biomarkers using principle axis analysis with Oblimin rotation. Cluster analysis was performed on log-transformed and normalised biomarkers using Ward's method of minimum variance and the squared Euclidean distance metric. Upon univariate analysis, current smoking, prescription of ACE inhibitors at discharge, peak hsTnT > 610 ng/L (median), MMP-8 levels, Factor 1 scores and Cluster One assignment were predictive of impaired systolic function. Upon multivariate analysis, Cluster One assignment (odds ratio [95% CI], 2.74 [1.04-7.23], p = 0.04) remained an independent predictor of systolic dysfunction in combination with clinical variables. These observations support the usefulness of combining ECM biomarkers using cluster analysis for predicting the development of impaired systolic function in AMI patients.

Cardiovascular Risk Factor Modification in Asymptomatic Adults and Implications for Pilots.

This study aims to examine the available evidence that supports a more aggressive approach to managing asymptomatic people with low to intermediate cardiovascular risks; to evaluate the appropriate threshold for initiating pharmacologic interventions to treat hyperglycaemia, hyperlipidaemia, and hypertension; and to describe the implications for airline pilots. A systematic search was performed employing an OvidSP interface, including all EBM Reviews, EMBASE, and Ovid MEDLINE databases. Data, including sixteen randomised controlled trials, on the appropriate threshold for initiating pharmacologic interventions were extracted. Studies on the treatment of hyperlipidaemia indicated that the threshold for initiation of intervention in intermediate-risk people is a LDL-C level of 3.36 mmol/l (130 mg/dl). There was no lower limit or optimal LDL-C level below which further reduction was no longer beneficial. Studies on the treatment of hyperglycaemia suggested that a threshold of fasting plasma glucose of ≥5.3 mmol/l (95 mg/dl) and 2-hour postprandial glucose level of 7.8 mmol/l (140 mg/dl) is reasonable for initiating pharmacologic intervention. Initiating treatment to people with a blood pressure of ≥130/≤89 mmHg or ≤139/≥85 mmHg significantly reduced the risk of developing stage 1 hypertension. Multifactorial intervention studies showed that, in hypertensive patients (BP ≥160/≥100 mmHg), initiating treatment to those with a total cholesterol of 6.5 mmol/l (251.35 mg/dl) or higher resulted in a significant reduction in the risk of developing fatal and non-fatal cardiovascular events. The available evidence from large quality trials supports a more aggressive approach to managing hyperglycaemia, hyperlipidaemia, and hypertension in asymptomatic pilots with a 5-year CVD risk of 5-10% and 10-15%.

The effects of aspirin and ticagrelor on Toll-like receptor (TLR)-mediated platelet activation: results of a randomized, cross-over trial.

Platelet activation underlies the pathology of an acute myocardial infarction (AMI), and dual antiplatelet therapy (DAPT) is administered post-AMI to limit this activation. Platelets express Toll-like receptors (TLRs) 1, 2, and 4 and become potently activated in response to TLR2/1 and TLR4 stimulation. However, it is unknown whether antiplatelet agents can protect against platelet activation via these TLR pathways. This study aimed to determine the extent to which TLR-mediated platelet activation can be inhibited by currently used antiplatelet agents. Ten healthy subjects were enrolled into a single-blinded randomized cross-over trial. Subjects received either aspirin monotherapy or DAPT (aspirin in combination with ticagrelor) for 1 week, were washed out, and crossed over to the other drug regimen. Platelet activation was assessed in response to Pam3CSK4 (a TLR2/1 agonist) and lipopolysaccharide (LPS; a TLR4 agonist) at baseline and after each antiplatelet drug regimen. Platelet-surface expression of CD62p and PAC1 by flow cytometry was measured as markers of platelet activation. At baseline, expression of CD62p and PAC1 increased significantly in response to high-dose LPS and in a dose-dependent manner in response to Pam3CSK4. Aspirin monotherapy did not inhibit platelet activation in response to any TLR agonist tested. DAPT with aspirin and ticagrelor only modestly inhibited expression of both activation markers in response to high doses of Pam3CSK4 and LPS. However, incubation with these TLR agonists led to substantial platelet activation despite treatment with these anti-platelet agents. Platelet-TLR2/1 and platelet-TLR4 represent intact on-treatment platelet activation pathways, which may contribute to on-going platelet activation post-AMI.

Can Surgical Registrars Accurately Identify the Urgent from the Non-Urgent Patient Presenting with Acute Abdominal Pain?

BACKGROUND: Acute abdominal pain is a common surgical presentation with a wide range of causes. Differentiating urgent patients from non-urgent patients is important to optimise patient outcomes and the use of hospital resources. The aim of this study was to determine how accurately urgent and non-urgent patients presenting with abdominal pain can be identified. METHODS: A prospective study of consecutive patients admitted with abdominal pain was undertaken. Urgent patients were classified as requiring treatment (theatre, intensive care unit, endoscopy, or radiologic drainage) within 24 h. Differentiation between urgent and non-urgent was made on the basis of the initial assessment prior to the use of advanced imaging. Outcomes were compared to a final classification based on final diagnosis as adjudicated by an expert panel. RESULTS: Of the 301 patients included, 93 (30.9%) were deemed urgent based on initial assessment, compared to 83 (27.6%) on final diagnosis. Overall sensitivity for recognising urgent patients was 74.7% and specificity 89.9%, and overall accuracy was higher for senior registrars compared to junior registrars (p = 0.015). Urgent patients more often looked unwell or had peritonism on examination (39.8 vs. 17.4% and 56.6 vs. 14.7%, respectively, p < 0.001 for both). CONCLUSIONS: Registrars can accurately differentiate urgent from non-urgent patients with acute abdominal pain in the majority of cases. Accuracy was higher amongst senior registrars. The "end-of-the-bed-o-gram" and clinical examination are the most important features used for making this differentiation. This demonstrates that there is no substitute for exposure to acute presentations to improve a trainee's diagnostic skill.

Systematic review of diagnostic pathways for patients presenting with acute abdominal pain.

PURPOSE: Abdominal pain is the most common reason for surgical referral. Imaging, aids early diagnosis and treatment. However unnecessary requests are associated with increased costs, radiation exposure and increased length of stay. Pathways can improve the quality of the diagnostic process. The aim of this systematic review was to identify the current evidence for diagnostic pathways and their use of imaging and effect on final outcomes. DATA SOURCES: A systematic search of Embase, Medline and Cochrane databases was performed using keywords and MeSH terms for abdominal pain. STUDY SELECTION: All papers describing a pathway and published between January 2000 and January 2017 were included. DATA EXTRACTION: Data was obtained about the use of imaging, complications and length of stay. Quality assessment was performed using MINORS and Level of Evidence. RESULTS: Ten articles were included, each describing a different pathway. Five studies based the pathway on literature reviews alone and five studies on the results of their prospective study. Of the latter five studies, four showed that routine imaging increased diagnostic accuracy, but without showing a reduction in length of stay, complication rate or mortality. None of the studies included evaluated use of hospital resources or costs. CONCLUSION: Pathways incorporating routine imaging will improve early diagnosis, but has not been proven to reduce complication rates or hospital length of stay. On the basis of this systematic review conclusions can therefore not be drawn about the pathways described and their benefit to the diagnostic process for patients presenting with abdominal pain.

Contemporary antiplatelet therapy in acute coronary syndromes: are there differences in outcomes and discontinuation between clopidogrel and ticagrelor?

BACKGROUND/AIM: We studied clinical outcomes and discontinuation rates in a 'real-world' population presenting with myocardial infarction treated with ticagrelor or clopidogrel. METHODS: Between January 2012 and May 2015, 992 patients with acute myocardial infarction undergoing invasive management and adequately pre-treated with dual antiplatelet therapy were prospectively enrolled. Platelet aggregation was measured using the Multiplate analyser. Baseline characteristics, in-hospital outcomes and 1-year outcomes were collected. RESULTS: Patients treated with ticagrelor were younger and less likely to be diabetic, have a previous myocardial infarction or present with a ST-elevation myocardial infarction (all P < 0.05). Those treated with ticagrelor also had lower CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines; 20 ± 9.4 vs 23 ± 10.1, P < 0.0001) and GRACE (119 ± 28 vs 126 ± 32, P = 0.002) scores. High platelet reactivity was greatly reduced with ticagrelor compared to clopidogrel (16.1% vs 37.0%, respectively; P < 0.0001). Non-coronary artery bypass grafting-related thrombolysis in myocardial infarction major and minor bleeding occurred at similar rates in those treated with ticagrelor and clopidogrel. Rates of drug discontinuation in those treated with ticagrelor and clopidogrel were similar in hospital (20.2% vs 16.2%, P = 0.18) and between discharge and 1 year (29.9% vs 27.9%, P = 0.63). However, discontinuation due to dyspnoea, (3.3% vs 0%, P < 0.0001) and discontinuation due to any possible drug-related adverse event (9.3% vs 2.2%, P = 0.0001) was more common in those treated with ticagrelor compared to clopidogrel CONCLUSION: Ticagrelor is paradoxically being used in lower-risk patients rather than those most likely to benefit. Ticagrelor was associated with similar rates of bleeding but higher discontinuation rates due to adverse effects compared to clopidogrel.

Differing Clinical Characteristics Between Young and Older Patients Presenting with Myocardial Infarction.

BACKGROUND: To date, there has been no detailed study of the risk factors and clinical characteristics of patients presenting with myocardial infarction (MI) at a young age in our region. The purpose of this study was to assess the rate and clinical profile of those presenting with young MI in New Zealand. METHODS: We identified a cohort of 1199 patients presenting with acute MI between January 2012 and November 2015 from the Wellington Acute Coronary Syndrome Registry. We compared those presenting with young MI, defined as presentation with MI aged 50 years or younger, to those aged over 50 years. RESULTS: Myocardial infarction at a young age occurred in 154 (12.8%) patients. Compared to those in the older MI group, the young MI group were more likely to be male (80% vs. 71%, p=0.026), of Maori or Pacific Island ethnicity (21% vs. 10%, p<0.0001), have a higher BMI (31kg/m2 vs. 29kg/m2, p<0.0001), have a family history of premature coronary artery disease (49% vs. 34%, p<0.0001) and to be current smokers (47% vs. 20%, p<0.001). Young MI patients were less likely to have hypertension, dyslipidaemia and diabetes than the older MI patient population. Within the young MI group 36% had none or only one traditional risk factor for MI, and would have been classified as low risk prior to their index event. CONCLUSION: Those with young MI accounted for 12.8% of our cohort and had a different risk factor profile to the older MI group with smoking and obesity being particularly prevalent.

Out-of-hospital Cardiac Arrest Patient Characteristics: Comparing ventricular arrhythmia and Pulseless Electrical Activity.

BACKGROUND: The proportion of patients suffering out-of-hospital cardiac arrest presenting with ventricular arrhythmias/ventricular fibrillation (VT/VF) is decreasing, while the proportion presenting with pulseless electrical activity (PEA) is increasing. Cardiac arrest interventions target VT/VF and survival rates from PEA are much lower. The aim of this study was to compare clinical characteristics of those suffering PEA and VT/VF. METHODS: We examined the past medical history of all patients suffering cardiac arrest in the Wellington region between 2008-2012 and compared clinical features of those with PEA to VT/VF. RESULTS: We identified 749 cardiac arrests in the study period, and were able to obtain detailed medical histories in 735 (98%) cases. The presenting rhythm was VF/VT in 337 (46%) cases, PEA in 127 (17%), and asystole in 271 (37%). Patients with PEA were older (68±14 versus 63±15 years, p=0.003), a higher proportion were female (35% versus 22%, p=0.002) and were less likely to have prior cardiovascular disease than those with VT/VF (48% versus 59%, p=0.03). Respiratory disease was more common in those with PEA (35% versus 23%, p=0.008). CONCLUSION: The population suffering PEA differs from the VT/VF cohort in a number of ways, and PEA is associated with significantly worse outcomes.

Cardiac troponin levels following implantable cardioverter defibrillation implantation and testing.

AIMS: Previous studies have reported the defibrillation testing during implantable cardioverter defibrillator (ICD) implantation is associated with elevated cardiac biomarkers and ST-segment electrocardiogram (ECG) changes suggesting that shocks during testing may cause harm. However, the effects of testing have not been isolated from the implant procedure itself, where lead deployment may cause myocardial damage. This prospective study examined high sensitivity troponin T (hs-TnT) levels and ECG changes during ICD implanting alone, ICD implantation with testing and device testing as a stand-alone procedure. METHODS AND RESULTS: We examined hs-TnT at baseline, and 6-8 h post procedure and 12 lead ECG at baseline, and 30 s, 5 min, and 10 min post right ventricle lead deployment and post defibrillation. There was no significant change in hs-TnT levels in a group of patients (n = 11) undergoing defibrillation testing alone, while hs-TnT was significantly elevated in patients undergoing implantation alone (n = 13, median increase 96%, P = 0.005) and in patients undergoing implantation and testing (n = 13, median increase 161%, P = 0.005). There was a significant correlation between the number of lead deployments and the percentage change in hs-TnT (r = -0.51, P = 0.01), but no correlation between either the number of shocks (r = 0.26, P = 0.25) or the total delivered energy (r = 0.24, P = 0.30) and percentage change in hs-TnT. CONCLUSION: Implantation of ICD leads was associated with release of troponin, but we did not observe any evidence that ICD shocks alone cause myocardial injury.

Elevated baseline cardiac troponin levels in the elderly - another variable to consider?

AIMS: This study aimed to determine the frequency of baseline high-sensitivity troponin T (hs-TnT) elevation in different age groups presenting to the Emergency Department without acute coronary syndromes (ACS) or other acute illnesses known to cause to troponin elevation. We additionally sought to determine whether the relationship between age and hs-TnT was independent of co-morbidities. METHODS: We retrospectively analysed data on all patients presenting to the Emergency Department (ED) between November 2010 and June 2011 in whom hs-TnT was measured. Patients presenting with acute coronary syndromes (ACS) or other acute illness known to elevate hs-TnT levels were excluded. Demographics, clinical characteristics and diagnosis were recorded, together with hs-TnT assay results. RESULTS: Of 3219 patients with hs-TnT testing in the ED during the study period, 526 with proven/suspected ACS and 1376 with other acute medical conditions known to elevate troponin concentrations were excluded. The percentage of patients with hs-TnT concentrations elevated above the upper reference limit (>14ng/L) increased with age: <50 years (1.8%), 50-69 years (7.3%), ≥70 years (41.5%), p=0.001. Multivariate analysis identified age over 70 years (p<0.001) as the strongest independent predictor of elevated hs-TnT. Other independent predictors included atrial fibrillation (p<0.001), age 50-69 years (p<0.001) male gender (p<0.001), previous heart failure (p<0.007) and previous ischaemic heart disease (p<0.04). CONCLUSIONS: Hs-TnT elevations (>14ng/L) are common in elderly patients presenting to the ED without ACS or other acute illnesses known to cause to troponin elevation. This finding appears to be independent of the higher burden of co-morbidities in this age group.

Correlation between vectorcardiographic measures and cardiac magnetic resonance imaging of the left ventricle in an implantable cardioverter defibrillator population.

BACKGROUND: Measures of vectorcardiographic changes and LV remodelling have been associated with arrhythmic risk. However the correlation between the two modalities is not well characterised. METHODS: We correlated spatial QRS-T angle and ventricular gradient with cardiac MRI derived LV global measures and scar pattern in 66 ICD recipients. RESULTS: Spatial QRS-T angle was significantly larger in patients with ischaemic scar than those without scar (150°±22° vs. 119°±46°, p=0.01). Larger spatial QRS-T angle was also correlated with more depressed LV function, more dilated LV and larger LV mass. Ventricular gradient azimuth was significantly different between patients with no scar, non-ischaemic scar and ischaemic scar (20°±49° vs. 38°±62° vs. 65°±48°, p=0.009), but independent of spatial QRS-T angle and LV structure. CONCLUSIONS: Spatial QRS-T angle and ventricular gradient are partially related to LV structural properties. Further investigation is warranted to examine their comparative and combined prognostic value in risk stratification of ventricular arrhythmias.

Calcium scores in the risk assessment of an asymptomatic population: implications for airline pilots.

BACKGROUND: This study evaluated whether coronary artery calcium score (CACS) improved cardiovascular disease risk prediction when compared to the New Zealand Cardiovascular Risk Charts (NZ-CRC), and describes the potential utilization of CACS in cardiovascular disease (CVD) risk assessment of pilots. METHODS: A cross-sectional study was performed among asymptomatic patients who underwent coronary computed tomography angiography at Pacific Radiology Wellington, New Zealand, between August 2007 and July 2012 and had their CACS and CVD risk score calculated. Receiver-operating characteristics (ROC) analyses were used to measure the accuracy of the NZ-CRC and CACS. Reclassification analyses were performed to examine the net reclassification improvement (NRI) of CACS when compared to NZ-CRC. RESULTS: Over a 5-yr study period, 237 male asymptomatic patients with ages ranging from 30 to 69 yr with a mean (SD) of 53.24 (8.18) yr, were included. The area under the ROC curves (AUC) (95% CI) for CACS and NZ-CRC were 0.88 (0.83-0.93) and 0.66 (0.59-0.73), respectively. The NRI (95% CI) of the calcium scores was 0.39 (0.17-0.62). CACS should be assessed in pilots with 5-yr CVD risk scores of 5-10% and 10-15%. CONCLUSION: CACS has a better accuracy than the NZ-CRC and reclassified a considerable proportion of asymptomatic patients into correct cardiovascular risk categories. An approach on how the CACS should be employed in the cardiovascular risk assessment of airline pilots is noted in this paper.

Standard 12-lead electrocardiography measures predictive of increased appropriate therapy in implantable cardioverter defibrillator recipients.

AIMS: Identification of patients most likely to benefit from implantable cardioverter defibrillator (ICD) implant remains a complex challenge. This study aimed to investigate the utility of measures derived from standard 10 s 12-lead electrocardiogrphy (ECG) without complex signal processing in predicting appropriate therapy in an ICD population. METHODS AND RESULTS: We examined 108 ICD patients for primary (n = 32) and secondary prevention (n = 76). Baseline clinical data and characteristics of QRS complex, T-wave, and heart rate from standard 12-lead ECG were examined and related to the occurrence of subsequent appropriate therapy. Over a mean follow-up of 29 ± 11 months, 44% of patients received appropriate therapy. Patients with depressed heart rate variability (HRV) (≤6.5%) were 2.68 [95% confidence interval (CI) 1.21-5.90, P = 0.015] times more likely to receive appropriate therapy than patients with HRV >6.5%. In patients with bundle branch block (BBB), large QRS dispersion of >39 ms was associated with 2.88 times risk (95% CI 1.24-6.71, P = 0.014) of experiencing appropriate therapy than those with QRS dispersion <39 ms. In patients without BBB, reduced maximum T-wave amplitude (<0.4 mV) were 3.82 times (95% CI 1.63-8.93, P = 0.002) more likely to receive appropriate therapy compared with those with maximum T-wave amplitude >0.4 mV. History of atrial arrhythmia [hazard ratio (HR) = 2.30, 95% CI 1.29-4.12, P = 0.005] and secondary prevention (HR = 2.55, 95% CI 1.14-5.71, P = 0.022) were also predictive of device therapy. CONCLUSION: Measurements from standard 12-lead ECG were predictive of appropriate therapy in a heterogeneous ICD population. Incorporation of 12-lead ECG parameters such as these into risk stratification models may improve our ability to select patients for ICD implantation.

Methodological considerations for the assessment of ADP induced platelet aggregation using the Multiplate® analyser.

Factors affecting the Multiplate® assay's analytical precision have not been well defined. We investigated the effect of methodological factors on the measurement of ADP-induced platelet aggregation using the Multiplate® assay. ADP-induced platelet aggregation was analysed in whole blood using the Multiplate® assay. We tested the reproducibility of measurement, the effect of different anticoagulants (hirudin, citrate and heparin) and the effect of time delay (15, 30, 45, 60, 120 and 180 minutes) between sampling and analysis in patients. The use of a manual calibrated pipette with the Multiplate® analyser was also tested. The mean coefficient of variation (CV) using the manufacturers recommended methods was 10.8 ± 8.7% (n = 30). When compared to hirudin (359.5 ± 309 AU*min) the use of heparin (521.0 ± 316 AU*min, p = 0.0015) increased platelet aggregation, while the use of sodium citrate (245.0 ± 209 AU*min, p = 0.003) decreased the platelet aggregation (n = 20). The addition of CaCl2 to the citrate-anticoagulated blood resulted in platelet aggregation levels similar to hirudin. Platelet aggregation varied with time delay (n = 20). When compared to platelet aggregation at 30 minutes (391.1 ± 283 AU*min), platelet aggregation was reduced at 60 minutes (335.2 ± 251.6 AU*min, p < 0.05), 120 minutes (198.8 ± 122.9 AU*min, p < 0.001) and 180 minutes (160.7 ± 92 AU*min, p < 0.001). The use of a manual calibrated pipette did not significantly reduce the mean CV in the assay (n = 20). Methodological factors such as the anticoagulant used and the time delay should be standardised where possible to reduce variability, and allow thresholds derived from one study to be comparable across multiple studies.

Complex transradial percutaneous coronary intervention using a sheathless guide catheter.

BACKGROUND: Radial access for percutaneous coronary intervention (PCI) has been shown to reduce access site complications, improve patient comfort and reduce mortality. Use of a sheathless guiding catheter for transradial PCI has the potential reduce trauma to the radial artery and to further expand the type of cases where this approach can be utilised. We report our initial experience with the recently developed Sheathless Eaucath. METHODS: We retrospectively evaluated outcomes in consecutive patients who underwent PCI using the Sheathless Eaucath at our institution between February 2009 and November 2011. All procedures were performed via radial access. There were no exclusion criteria. RESULTS: The study included 120 patients. Of these 87 (72.5%) presented with acute coronary syndromes. Primary PCI was performed in nine and rescue PCI in seven patients. Interventions were performed on a total of 147 lesions. The majority of lesions were complex (68% classified as type B2 or C). Bifurcation lesions were treated in 42.5% and chronic total occlusions in 5% of patients. Adjunctive devices including rotablation, IVUS and 6 or 7 Fr thrombus aspiration catheters were used in 30% of patients. Angiographic success was achieved in 97.5%. Five patients suffered peri-procedural non-ST-elevation myocardial infarctions. There was no in-hospital target vessel revascularisation or death. Peri-procedural radial artery occlusion was infrequent (2.3%). Haematomas larger than 5cm occurred in two patients. No other vascular complications occurred. CONCLUSION: Use of the Sheathless Eaucath is safe and allows complex interventions to be undertaken transradially with a high success rate.

Cardiovascular investigations of airline pilots with excessive cardiovascular risk.

BACKGROUND: This study examined the prevalence of airline pilots who have an excessive cardiovascular disease (CVD) risk score according to the New Zealand Guideline Group (NZGG) Framingham-based Risk Chart and describes their cardiovascular risk assessment and investigations. METHODS: A cross-sectional study was performed among 856 pilots employed in an Oceania based airline. Pilots with elevated CVD risk that had been previously evaluated at various times over the previous 19 yr were reviewed retrospectively from the airline's medical records, and the subsequent cardiovascular investigations were then described. RESULTS: There were 30 (3.5%) pilots who were found to have 5-yr CVD risk score of 10-15% or higher. Of the 29 pilots who had complete cardiac investigations data, 26 pilots underwent exercise electrocardiography (ECG), 2 pilots progressed directly to coronary angiograms and 1 pilot with abnormal echocardiogram was not examined further. Of the 26 pilots, 7 had positive or borderline exercise tests, all of whom subsequently had angiograms. One patient with a negative exercise test also had a coronary angiogram. Of the 9 patients who had coronary angiograms as a consequence of screening, 5 had significant disease that required treatment and 4 had either trivial disease or normal coronary arteries. CONCLUSION: The current approach to investigate excessive cardiovascular risk in pilots relies heavily on exercise electrocardiograms as a diagnostic test, and may not be optimal either to detect disease or to protect pilots from unnecessary invasive procedures. A more comprehensive and accurate cardiac investigation algorithm to assess excessive CVD risk in pilots is required.

A comparison of operative autonomy between men and women in orthopaedic surgical training in Aotearoa New Zealand.

AIM: Recent studies have shown that women training in surgical and procedural specialties achieve less operative autonomy during training than men do. The aim of this study was to discern if there is a disparity in surgical autonomy for orthopaedic trainees by gender. METHODS: This was a retrospective study of operative procedures performed by 53 orthopaedic trainees (43 men, 10 women) in Aotearoa New Zealand over 10 years. The main outcome measure was the amount of surgical autonomy afforded to individual trainees as recorded in the training logbook, categorised as assisting a: primary surgeon with consultant scrubbed or present; or, primary surgeon unsupervised and teaching a colleague the procedure. RESULTS: Data was obtained for 41,622 procedures in total. Eighty point seven percent were performed by men and 19.3% by women. On average men performed 229 cases per year and women performed 251 cases per year. There was an overall significant difference in autonomy between men and women (p <0.001), with men performing more procedures unsupervised than women (45% of all cases versus 39% of all cases). This difference remained significant when trainee year group was accounted for. CONCLUSIONS: We conclude that women orthopaedic trainees in Aotearoa New Zealand perform fewer cases with meaningful autonomy than men. This disparity may have implications for the quality of training received by men versus women.

Neutrophil-Enriched Biomarkers and Long-Term Prognosis in Acute Coronary Syndrome: a Systematic Review and Meta-analysis.

Activated neutrophils release a range of inflammatory products that represent potential biomarkers, and there is interest in the prognostic value of these in acute coronary syndrome (ACS) patients. We conducted a systematic review to examine neutrophil-enriched biomarkers and the occurrence of major adverse cardiovascular events (MACE) in patients with ACS. We identified twenty-seven studies including 17,831 patients with ACS. The most studied biomarkers were neutrophil gelatinase-associated lipocalin (NGAL) and myeloperoxidase (MPO). Meta-analyses showed that elevated NGAL was associated with higher MACE rates (unadjusted risk ratio (RR) 1.52, 95% CI 1.12-2.06, p = 0.006) as were elevated MPO levels (unadjusted RR 1.61, 95% CI 1.22-2.13, p = 0.01). There was limited data suggesting that increased levels of calprotectin, proteinase-3 and double-stranded DNA were also associated with MACE. These results suggest that higher levels of neutrophil-enriched biomarkers may be predictive of MACE in patients with ACS, although higher-quality studies are needed to confirm these observations.