Timing of intervention in high-risk non-ST-elevation acute coronary syndromes in PCI versus non-PCI centres : Sub-group analysis of the ELISA-3 trial

AIMS

To compare the effect of timing of intervention in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) in percutaneous coronary intervention (PCI) versus non-PCI centres.

METHODS AND RESULTS

A post-hoc sub-analysis was performed of the ELISA III trial, a randomised multicentre trial investigating outcome of early (< 12 h) versus late (> 48 h) angiography and revascularisation in 542 patients with high-risk NSTE-ACS. 90 patients were randomised in non-PCI centres and tended to benefit more from an early invasive strategy than patients included in the PCI centre (relative risk 0.23 vs. 0.85 [p for interaction = 0.089] for incidence of the combined primary endpoint of death, reinfarction and recurrent ischaemia after 30 days of follow-up). This was largely driven by reduction in recurrent ischaemia. In non-PCI centres, patients randomised to the late group had a 4 and 7 day longer period until PCI or coronary artery bypass grafting, respectively. This difference was less pronounced in the PCI centre.

CONCLUSIONS

This post-hoc analysis from the ELISA-3 trial suggests that NSTE-ACS patients initially hospitalised in non-PCI centres show the largest benefit from early angiography and revascularisation, associated with a shorter waiting time to revascularisation. Improved patient logistics and transfer between non-PCI and PCI centres might therefore result in better clinical outcome.

An argument-based approach to the validation of UHTRUST: can we measure how recent graduates can be trusted with unfamiliar tasks?

There is a need for valid methods to assess the readiness for clinical practice of medical graduates. This study evaluates the validity of Utrecht Hamburg Trainee Responsibility for Unfamiliar Situations Test (UHTRUST), an authentic simulation procedure to assess whether medical trainees are ready to be entrusted with unfamiliar clinical tasks near the highest level of Miller's pyramid. This assessment, in which candidates were judged by clinicians, nurses and standardized patients, addresses the question: can this trainee be trusted with unfamiliar clinical tasks? The aim of this paper is to provide a validity argument for this assessment procedure. We collected data from various sources during preparation and administration of a UHTRUST-assessment. In total, 60 candidates (30 from the Netherlands and 30 from Germany) participated. To provide a validity argument for the UHTRUST-assessment, we followed Kane's argument-based approach for validation. All available data were used to design a coherent and plausible argument. Considerable data was collected during the development of the assessment procedure. In addition, a generalizability study was conducted to evaluate the reliability of the scores given by assessors and to determine the proportion of variance accounted by candidates and assessors. It was found that most of Kane's validity assumptions were defendable with accurate and often parallel lines of backing. UHTRUST can be used to compare the readiness for clinical practice of medical graduates. Further exploration of the procedures for entrustment decisions is recommended.

A computer program to assist in the choice of restriction endonucleases for use in DNA analyses

Type II restriction endonucleases cleave double stranded DNA molecules at sites characterized by one or more sets of nucleotide pairs sequences. These digestions are essential in such procedures as DNA cloning, DNA sequencing and restriction fragment length polymorphism (RFLP) analyses. A large number of enzymes with different sequence specificities are available. To date, most choices of restriction endonucleases have been made by trial and error. A computer program, REDI, has been developed that predicts the ability of a particular restriction enzyme to detect mutations. Characteristics of both the restriction endonuclease used and the DNA being cut are incorporated as variables in the program. The program was tested using mouse mitochondrial DNA (mtDNA) and bacteriophage lambda DNA because these have been sequenced and are well characterized. REDI was strongly correlated (rs = +0.862, n = 11, P less than 0.001) with mouse mtDNA RFLP detected by Ferris et al. [1] (Genetics, 105 (1983) 681-721). Even though predictions may be altered by a non-random association of nucleotides, which varies among DNA molecules, the predictions increase the probability of selecting the most efficient enzymes for use in the analysis of a particular DNA molecule.