Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

An updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018

Introduction

The most common cancers in the UK are keratinocyte cancers (KCs): the combined term for basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCCs). Registration of KC is challenging due to high numbers and multiplicity of tumours per person.

Methods

We provide an updated report on the descriptive epidemiology of trends in KC incidence for the resident populations of UK countries (England, Northern Ireland, Scotland and Wales) using population-based cancer registry and pathology report data, 2013-18.

Results

Substantial increases in cSCC incidence in England, Scotland and Northern Ireland can be detected for the period of 2013-18, and the incidence of cSCC also increased in Wales from 2016 to 2018. In contrast, however, the pattern of annual change in the incidence of BCC across the nations differs. In England, the incidence of BCC declined slightly from 2016 to 2018, however, the overall trend across 2013-18 is not statistically significant. In Scotland, the incidence of BCC shows some variability, declining in 2017 before increasing in 2018, and the overall trend across 2013-18 was also not statistically significant. In Northern Ireland, the incidence of BCC increased significantly over the study period, and in Wales, the incidence of BCC increased from 2016 to 2018. One in five people will develop non-melanoma skin cancers (NMSC) in their lifetime in England. This estimate is much higher than the lifetime risk of melanoma (1 in 36 males and 1 in 47 females born after 1960 in the UK), which further highlights the burden of the disease and importance of early prevention strategies.

Conclusions

We highlight how common these tumours are by publishing the first ever lifetime incidence of NMSC. Additionally, the first time reporting of the age standardised incidence of KC in Wales further confirms the scale of the disease burden posed by these cancers in the UK. With approximately one in five people developing NMSC in their lifetime, optimisation of skin cancer prevention, management and research are essential.

A summary of the updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018

Skin cancer is the commonest cancer in the UK. Skin cancer referrals via the two-week wait (urgent suspected cancer) pathway outnumber any other suspected malignancy.^{1, 2} The commonest skin cancers are keratinocyte cancers (KCs) which represents Basal Cell Carcinomas (BCC) and Cutaneous Squamous Cell Carcinomas (cSCC). Accurate KC incidence reporting is crucial for healthcare planning.

Metabolites downstream of predicted loss-of-function variants inform relationship to disease

A small minority (< 3%) of protein-coding genetic variants are predicted to lead to loss of protein function. However, these predicted loss-of-function (pLOF) variants can provide insight into mode of transcriptional effect. To examine how these changes are propagated to phenotype, we determined associations with downstream metabolites. We performed association analyses of 37 pLOF variants - previously reported to be significantly associated with disease in >400,000 subjects in UK Biobank - with metabolites. We conducted these analyses in three community-based cohorts: the Framingham Heart Study (FHS) Offspring Cohort, FHS Generation 3, and the KORA F4 cohort. We identified 19 new low-frequency or rare (minor allele frequency (MAF) <5%) pLOF variant-metabolite associations, and 12 new common (MAF > 5%) pLOF variant-metabolite associations. Rare pLOF variants in the genes BTN3A2, ENPEP, and GEM that have been associated with blood pressure in UK Biobank, were associated with vasoactive metabolites indoxyl sulfate, asymmetric dimethylarginine (ADMA), and with niacinamide, respectively. A common pLOF variant in gene CCHCR1, associated with asthma in UK Biobank, was associated with histamine and niacinamide in FHS Generation 3, both reported to play a role in this disease. Common variants in olfactory receptor gene OX4C11 that associated with blood pressure in UK Biobank were associated with the nicotine metabolite cotinine, suggesting an interaction between altered olfaction, smoking behaviour, and blood pressure. These findings provide biological validity for pLOF variant-disease associations, and point to the effector roles of common metabolites. Such an approach may provide novel disease markers and therapeutic targets.

Trends in incidence of thick, thin and in situ melanoma in Europe

BACKGROUND

We analysed trends in incidence for in situ and invasive melanoma in some European countries during the period 1995-2012, stratifying for lesion thickness.

MATERIAL AND METHODS

Individual anonymised data from population-based European cancer registries (CRs) were collected and combined in a common database, including information on age, sex, year of diagnosis, histological type, tumour location, behaviour (invasive, in situ) and lesion thickness. Mortality data were retrieved from the publicly available World Health Organization database.

RESULTS

Our database covered a population of over 117 million inhabitants and included about 415,000 skin lesions, recorded by 18 European CRs (7 of them with national coverage). During the 1995-2012 period, we observed a statistically significant increase in incidence for both invasive (average annual percent change (AAPC) 4.0% men; 3.0% women) and in situ (AAPC 7.7% men; 6.2% women) cases.

DISCUSSION

The increase in invasive lesions seemed mainly driven by thin melanomas (AAPC 10% men; 8.3% women). The incidence of thick melanomas also increased, although more slowly in recent years. Correction for lesions of unknown thickness enhanced the differences between thin and thick cases and flattened the trends. Incidence trends varied considerably across registries, but only Netherlands presented a marked increase above the boundaries of a funnel plot that weighted estimates by their precision. Mortality from invasive melanoma has continued to increase in Norway, Iceland (but only for elder people), the Netherlands and Slovenia.

Comparison of packing material in an animal model of middle ear trauma

PURPOSE

To compare the performance of absorbable gelatin sponge (AGS) with polyurethane foam (PUF) as middle ear packing material after mucosal trauma.

MATERIALS AND METHODS

Using a randomized, controlled and blinded study design fifteen guinea pigs underwent middle ear surgery with mucosal trauma performed on both ears. One ear was packed with either PUF or AGS while the contralateral ear remained untreated and used as non-packed paired controls. Auditory brainstem response (ABR) thresholds were measured pre-operatively and repeated at 1, 2, and 6weeks postoperatively. Histological analysis of middle ear mucosa was done in each group to evaluate the inflammatory reaction and wound healing. Another eighteen animals underwent middle ear wounding and packing in one ear while the contralateral ear was left undisturbed as control. Twelve guinea pigs were euthanized at 2weeks postoperatively, and six were euthanized at 3days post-operatively. Mucosal samples were collected for analysis of TGF-β1 levels by enzyme-linked immunosorbent assay.

RESULTS

ABR recordings demonstrate that threshold level changes from baseline were minor in PUF packed and control ears. Threshold levels were higher in the AGS packed ears compared with both control and PUF packed ears for low frequency stimuli. Histological analysis showed persistence of packing material at 6weeks postoperatively, inflammation, granulation tissue formation, foreign body reaction and neo-osteogenesis in both AGS and PUF groups. TGF-β1 protein levels did not differ between groups.

CONCLUSION

PUF and AGS packing cause inflammation and neo-osteogenesis in the middle ear following wounding of the mucosa and packing.

On the utility of coupling polarised light microscopy to a solubility assay in drug discovery

Knowledge of the physical form at the end of the assay allows the solubility results to be put into context.

Peptide presentation by different HLA-Class I molecules during viral infection (APP2P.106)

Class I Human Leukocyte Antigens reveal intracellular viruses to the immune system by presenting viral epitopes at the cell surface. In this study we hypothesized that during infection particular HLA class I alleles consistently present more virus-derived peptide ligands to virus-specific CD8+ T cells than do other HLA class I. To test this hypothesis, we infected cells with West Nile virus (WNV) and directly identified and enumerated the virus specific peptides presented by various HLA class I molecules. Cells expressing a number of different HLA-A and HLA-B class I were cultured in bioreactors and infected with WNV. HLA/peptide complexes were harvested from infected and uninfected cells, peptides were eluted from affinity-purified HLA, comparatively mapped by mass spectroscopy, and sequenced. Twenty-four peptides, 20 eluted from HLA-A complexes (HLA-A*02:01, A*01:01, A*11:01 and A*24:02) and 4 from HLA-B complexes (HLA-B*27:05, B*07:02 and B*35:01), were identified as unique to infected cells. Ligands represented different parts of the viral polyprotein demonstrating that peptides sampled by class I HLA are distributed widely throughout the WNV proteome. These data indicate that, in WNV-infected cells, HLA-A present more virus-specific peptides than do HLA-B suggesting a potentially different role for HLA class I loci in developing immune responses that control WNV infection whereby HLA-A is responsible for diverse reactivity and HLA-B leads to more focused immunity.

Surveillance for ocular hypertension: an evidence synthesis and economic evaluation

OBJECTIVES

To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways.

DESIGN

A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model.

SETTING

Primary and secondary care.

PARTICIPANTS

Adults with ocular hypertension (IOP > 21 mmHg) and the public (surveillance preferences).

INTERVENTIONS

We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, 'NICE intensive' (4-monthly to annual monitoring) and 'NICE conservative' (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a 'treat all' pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community.

MAIN OUTCOME MEASURES

Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs).

RESULTS

The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. 'Treat all' was the least costly and 'NICE intensive' the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a 'treat all' pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The 'NICE intensive' pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence.

LIMITATIONS

Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates.

CONCLUSIONS

For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment.

FUNDING

The National Institute for Health Research Health Technology Assessment Programme.

Middle ear packing: comparison of materials in an animal model of mucosal trauma

OBJECTIVE

To compare absorbable gelatin sponge (AGS) with an injectable esterified hyaluronic acid (EHA) as middle ear packing material after mucosal trauma.

STUDY DESIGN

Randomized, blinded, and controlled study.

SETTING

Tertiary university-based hospital.

SUBJECTS AND METHODS

Twenty-three guinea pigs underwent middle ear surgery with mucosal trauma performed on both ears and one ear packed with either EHA or AGS. Contralateral ears were used as nonpacked paired controls. Auditory brainstem response (ABR) thresholds were measured preoperatively and repeated at 1, 2, and 6 weeks postoperatively. Macroscopic and microscopic analysis measured inflammatory reaction in each group.

RESULTS

ABR threshold changes from baseline in the EHA and both control groups were minor. Threshold levels were higher in the AGS group compared with the AGS control group. This trend was seen in each frequency tested at each time interval. Macroscopic analysis showed tympanic membrane perforation was rare, effusions were common in the AGS group, mucosal edema was most frequent in the AGS group, and unabsorbed packing was usually detected in the AGS group with little EHA detectable at 6 weeks. Microscopic analysis showed normal mucosal healing in all groups. Two AGS ears demonstrated excessive middle ear packing with exuberant osteoneogenesis.

CONCLUSIONS

Middle ear function and mucosal healing after surgery occurred similarly between the EHA control group and the EHA group. In contrast, the AGS group demonstrated worse hearing and a greater level of osteoneogenesis compared with the AGS control group. These results support EHA as an alternative middle ear packing material in otologic surgery.

Backscatter measurements for NIF ignition targets (invited)

Backscattered light via laser-plasma instabilities has been measured in early NIF hohlraum experiments on two beam quads using a suite of detectors. A full aperture backscatter system and near backscatter imager (NBI) instrument separately measure the stimulated Brillouin and stimulated Raman scattered light. Both instruments work in conjunction to determine the total backscattered power to an accuracy of ∼15%. In order to achieve the power accuracy we have added time-resolution to the NBI for the first time. This capability provides a temporally resolved spatial image of the backscatter which can be viewed as a movie.

The first measurements of soft x-ray flux from ignition scale Hohlraums at the National Ignition Facility using DANTE (invited)

The first 96 and 192 beam vacuum Hohlraum target experiments have been fielded at the National Ignition Facility demonstrating radiation temperatures up to 340 eV and fluxes of 20 TW/sr as viewed by DANTE representing an ∼20 times flux increase over NOVA/Omega scale Hohlraums. The vacuum Hohlraums were irradiated with 2 ns square laser pulses with energies between 150 and 635 kJ. They produced nearly Planckian spectra with about 30±10% more flux than predicted by the preshot radiation hydrodynamic simulations. To validate these results, careful verification of all component calibrations, cable deconvolution, and software analysis routines has been conducted. In addition, a half Hohlraum experiment was conducted using a single 2 ns long axial quad with an irradiance of ∼2×10(15) W/cm(2) for comparison with NIF Early Light experiments completed in 2004. We have also completed a conversion efficiency test using a 128-beam nearly uniformly illuminated gold sphere with intensities kept low (at 1×10(14) W/cm(2) over 5 ns) to avoid sensitivity to modeling uncertainties for nonlocal heat conduction and nonlinear absorption mechanisms, to compare with similar intensity, 3 ns OMEGA sphere results. The 2004 and 2009 NIF half-Hohlraums agreed to 10% in flux, but more importantly, the 2006 OMEGA Au Sphere, the 2009 NIF Au sphere, and the calculated Au conversion efficiency agree to ±5% in flux, which is estimated to be the absolute calibration accuracy of the DANTEs. Hence we conclude that the 30±10% higher than expected radiation fluxes from the 96 and 192 beam vacuum Hohlraums are attributable to differences in physics of the larger Hohlraums.

Polymorphisms in Toll-like receptors-2 and -4 are not associated with disease manifestations in acute Q fever

Coxiella burnetii is a macrophage-tropic, Gram-negative organism, which causes acute Q fever infection in humans. This zoonotic infection causes illness ranging from asymptomatic seroconversion to severe and protracted disease featuring hepatitis and pneumonia. Interactions between C. burnetii lipopolysaccharide (LPS) and host Toll-like receptors (TLR)-2 and -4 have been implicated in pathogen recognition, phagocytosis and signaling responses. Nonconservative single nucleotide polymorphisms in the coding regions of TLR-2 (Arg677Trp and Arg753Gln) and TLR-4 (Asp299Gly) have been found to correlate with mycobacterial infections and Gram-negative sepsis respectively. Associations between the TLR-2 and -4 polymorphisms, illness characteristics and immune response parameters were examined in subjects with acute Q fever (n=85) and comparison subjects with viral infections (n=162). No correlation was demonstrated between these polymorphisms and susceptibility to Q fever, illness severity or illness course.

Advantage of EUS Trucut biopsy combined with fine-needle aspiration without immediate on-site cytopathologic examination

BACKGROUND

Endoscopic ultrasonographically guided fine-needle aspiration (EUS-FNA) is a safe and accurate method for obtaining diagnostic material from lesions within and immediately adjacent to the upper GI tract.

OBJECTIVE

To determine whether EUS Trucut biopsy (EUS-TCB) (Quickcore, Wilson-Cook, Winstom Salem, NC) can increase the accuracy of EUS-guided tissue sampling when combined with FNA when no cytopathologist is present.

DESIGN

Retrospective case review.

SETTING

University-based referral practice.

PATIENTS

All patients who had lesions that were accessible through the esophagus or stomach and that were greater than 20 mm and amenable to Trucut biopsy were included.

INTERVENTIONS

A total of 41 patients underwent both EUS-FNA and TCB with a separate pathologist evaluating each specimen.

MAIN OUTCOME MEASUREMENTS

The diagnostic performance of FNA, TCB, and its combination were compared.

RESULTS

The overall accuracy in our series was as follows: FNA, 76%; TCB, 76% (P not significant); and combination of FNA and TCB, 95% (P = .007). In the 26 patients with malignant diagnoses, the accuracy of combination was 100% versus 77% for FNA (P = .03). The median number of passes with the FNA and TCB was 4.4 (range 2-8) and 2.8 (range 2-5), respectively. One patient in the series had fever and chest pain after EUS biopsy.

LIMITATIONS

Retrospective study.

CONCLUSION

In our series EUS-TCB accuracy was equal to FNA when no on-site cytopathologist is present. TCB was helpful in the diagnosis of pancreatic masses, gastric submucosal lesions, lymphoma, and necrotic tumors. A 100% accuracy of FNA + TCB was seen in patients with malignant diseases and in patients who had failed or been refused biopsy by other modalities in the past. More data are needed before the exact role of TCB in the absence of on-site cytopathology can be accurately defined.

Improving the accuracy of intraocular pressure readings

AIM

To discover whether a protocol for calibration can improve the accuracy of intraocular pressure measuerements.

METHOD

A protocol for checking the calibration of equipment was implemented in an ophthalmic outpatient department. After seven months, calibration checks were compared with those done on equipment in other ophthalmic areas that were not following a protocol.

RESULTS

There was a statistically significant association between errors and areas not following the protocol (p = 0.02). In comparing errors found in the area using the protocol with all other areas, a significant difference was evident at the test point of 20 mmHg (p = 0.003).

CONCLUSION

Using a protocol significantly reduces calibration errors.

Resting pulse rates in a glaucoma clinic: the effect of topical and systemic beta-blocker usage

INTRODUCTION

Beta-blockers have, for 25 years, been a commonly used agent in the treatment of raised intraocular pressure (IOP). Beta-blockers can also reduce the pulse rate. With no available literature examining a cohort of patients, this study aims to investigate the resting pulse rates in patients attending a specialist glaucoma clinic in order to identify if routine review of ophthalmic medication use is indicated.

METHOD

The resting pulse rates of patients attending a glaucoma clinic were measured using pulseoximetry, with a medical and drug history established for each patient.

RESULTS

In all, 205 patients were included in the study. A total of 101 (49%) of patients were using beta-blockers in some form. The mean pulse rate for patients not using beta-blockers (104 patients) was 76 beats per minute (bpm), for topical use only (68 patients) it was 70.3 bpm, for oral use (18 patients) it was 64.7 bpm, and 58 bpm for patients using both topical and oral beta-blockers (15 patients). Groups using beta-blockers (oral, topical, oral and topical) were considered in relation to patients not using beta-blockers. All groups using beta-blockers showed a significant association with causing a bradycardia of less than 60 bpm. Patients with a pulse rate of less than 50 bpm were significantly more likely to be using topical and oral beta-blockers than oral beta-blockers alone (P=0.01).

CONCLUSION

Topical beta-blockers should be used with caution, even in the presence of established systemic beta-blocker use. Routine pulse rate monitoring and review of ophthalmic medication are indicated in patients using beta-blocker therapy.

Children's experiences of school toilets present a risk to their physical and psychological health

OBJECTIVE

To ascertain why children and parents frequently describe problems with school toilets.

SETTING

Two contrasting cities in Northern England (Newcastle upon Tyne 394 pupils) and Southern Sweden (Goteborg/Mölndal 157 pupils)

METHODS

Self-administered questionnaires were given to children aged 9-11 years in England and Sweden. Researchers administered questionnaires to Head teachers and recorded their observations of facilities according to predetermined basic standards.

RESULTS

Children from both countries said they found school toilets unpleasant, dirty, smelly, and frightening and that bullying occurred there. Many children avoided using the school toilets (62% of boys and 35% of girls (in the UK site) and 28% boys and girls in Swedish site avoided using the school toilets to defaecate). Results were similar in both centres.

CONCLUSION

European standards are needed for school toilets in order to prevent children developing problems such as constipation, urinary tract infections and incontinence.

Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial. Investigators of the Department of Veterans Affairs Cooperative Study #385, the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME)

BACKGROUND

Percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) are being applied to high-risk populations, but previous randomized trials comparing revascularization methods have excluded a number of important high-risk groups.

OBJECTIVES

This five-year, multicenter, randomized clinical trial was designed to compare long-term survival among patients with medically refractory myocardial ischemia and a high risk of adverse outcomes assigned to either a CABG or a PCI strategy, which could include stents.

METHODS

Patients from 16 Veterans Affairs Medical Centers were screened to identify myocardial ischemia refractory to medical management and the presence of one or more risk factors for adverse outcome with CABG, including prior open-heart surgery, age >70 years, left ventricular ejection fraction <0.35, myocardial infarction within seven days or intraaortic balloon pump required. Clinically eligible patients (n = 2,431) underwent coronary angiography; 781 were angiographically acceptable; 454 (58% of eligible) patients consented to random assignment between CABG and PCI.

RESULTS

A total of 232 patients was randomized to CABG and 222 to PCI. The 30-day survivals for CABG and PCI were 95% and 97%, respectively. Survival rates for CABG and PCI were 90% versus 94% at six months and 79% versus 80% at 36 months (log-rank test, p = 0.46).

CONCLUSIONS

Percutaneous coronary intervention is an alternative to CABG for patients with medically refractory myocardial ischemia and a high risk of adverse outcomes with CABG.

Assessment of older people: politics and practice in primary care

This paper reviews some of the key policy changes in the United Kingdom in relation to older people that have influenced assessment practice across health and social care, and have implications for nursing within emerging primary care groups. The role of assessment in purchasing care packages raises tensions and paradoxes for health and social care professionals that the paper sets out to elucidate with particular reference to district nurses. The issues for nursing have not been well described previously and questions such as key accountability, rationing, multiagency and interprofessional working, and the consumer voice, are discussed.

A multicenter, randomized trial of percutaneous coronary intervention versus bypass surgery in high-risk unstable angina patients. The AWESOME (Veterans Affairs Cooperative Study #385, angina with extremely serious operative mortality evaluation) investigators from the Cooperative Studies Program of the Department of Veterans Affairs

This multicenter, prospective randomized trial was designed to test the hypotheses that percutaneous coronary intervention (PCI) is a safe and effective alternative to coronary artery bypass grafting (CABG) for patients with refractory ischemia and high risk of adverse outcomes. As a comparison of revascularization strategies, the trial specifically allows surgeons and interventionists to use new techniques as they become clinically available. After 42 months of this 72-month trial, 17,624 patients have been screened and 2022 met eligibility requirements: 341 have been randomized to either CABG or PCI, and the remaining 1681 are being prospectively followed in a registry. The 3-year overall survival of patients in the registry and randomized trial is comparable. To enhance accrual into the randomized trial, site visits were conducted, a few low-accruing hospitals were put on probation and/or replaced, eligibility criteria were reviewed at annual meetings of investigators, and the accrual period was extended by 1 year. These data demonstrate that a prospective randomized trial and registry of coronary revascularization for medically refractory high-risk patients is feasible.

Transfusion-free surgery is a treatment plan for all patients

Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal.

Myocardial viability in patients with chronic coronary artery disease and previous myocardial infarction: comparison of myocardial contrast echocardiography and myocardial perfusion scintigraphy

The aim of this study was to compare perfusion patterns on myocardial contrast echocardiography with those on myocardial perfusion scintigraphy for the assessment of myocardial viability in patients with previous myocardial infarction. Accordingly, perfusion scores with the two techniques were compared in 91 ventricular regions in 21 patients with previous (>6 weeks old) myocardial infarction. Complete concordance between the two techniques was found in 63 (69%) regions; 25 (27%) regions were discordant by only 1 grade, and complete discordance (2 grades) was found in only 3 (3%) regions. A kappa statistic of 0.65 indicated good concordance between the two techniques. Although the scores on both techniques demonstrated a relation with the wall motion score, the correlation between the myocardial contrast echocardiography and wall motion scores was closer (r = -0.63 vs r = -0.50, p = 0.05). It is concluded that myocardial contrast echocardiography provides similar information regarding myocardial viability as myocardial perfusion scintigraphy in patients with coronary artery disease and previous myocardial infarction.

Are you ready for bloodless surgery?

'Bloodless' medicine and surgery is saving lives of individuals whose religious faith forbids blood transfusions. And the innovations it comprises are introducing new considerations to the nursing care of many patients undergoing complex operations.

How general practitioners manage children with urinary tract infection: an audit in the former Northern Region

BACKGROUND

Urinary tract infections (UTIs) in childhood are common and may be difficult to diagnose because of non-specific symptoms and technical problems with urine collection. Active management is important because UTIs may cause permanent renal scarring in young children.

AIM

To determine how general practitioners (GPs) manage children with suspected UTIs.

METHOD

A postal questionnaire to 494 GPs in the former Northern Region (a random selection of 26.2%) asking how they manage children with suspected UTI and their perception of their training needs.

RESULTS

A total of 333 (67.4%) GPs replied. On weekdays, up to 22.9% of GPs treated children who had symptoms suggestive of UTI without collecting a diagnostic urine sample, and up to 64.8% did so at weekends. Urine collection was satisfactory in 73.2% of boys and girls aged under one year, but in only 50.4% of older boys and 48.0% of older girls, caused in part by the use of unreliably 'cleaned' potties in the older group. On weekdays, up to 87.2% of GPs culture the urine, but up to 4.8% use dipsticks as the sole diagnostic test; at weekends, only up to 58.6% culture urines, and up to 19.1% rely on dipsticks alone. Up to 11.0% of GPs examine urine under a microscope for bacteria to test for UTI on weekdays and at weekends. Up to 23.8% of GPs who collect urines on weekdays wait for a positive culture result before starting antibiotics. At weekends, only 3.9% of GPs build in this delay to treatment, mainly because far fewer take urine samples at all. GPs refer younger children for diagnostic imaging more readily than older ones, and boys more readily than girls at all ages. Although virtually all GPs refer all children under five years, some still do so only after recurrent infections. Over half the GPs wanted more training in managing UTI in children.

CONCLUSION

There is a wide variation in clinical practice by GPs. Some always appropriately collect and test urine samples, treat without delay and refer for imaging after one proven UTI. Some never collect urines, treat blindly and refer only young infants with recurrent UTIs. Many vary their standards of practice from weekdays to weekends. The provision for GPs of clear, local, practical guidelines, drawn up between paediatricians and GPs and backed up with study days, might produce a consistent improvement in standards.