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Young patients presenting with cryptogenic stroke should be investigated for cardiac and extra-cardiac sources of emboli. We present a patient who was investigated for a cardiac source of emboli, following multiple ischaemic strokes and migraine with aura over a period of 17 years. The events were initially thought to be related to a patent foramen ovale (PFO) on bubble contrast echocardiography, however, due to an unusual flow pattern to the left heart, she underwent a CT angiogram to exclude intrapulmonary shunting. This confirmed the presence of a moderate sized congenital pulmonary arteriovenous fistula in the left lung. Transcatheter occlusion of the vascular malformation has resolution of her symptoms. Bubble contrast echocardiography is routinely used to diagnose a PFO in these cases, but extreme caution is required during the procedure to differentiate the pattern of flow seen in patients with a pulmonary arteriovenous malformation. [ABSTRACT FROM AUTHOR]

Introduction Hip and knee arthroplasties have revolutionised the management of degenerative joint diseases and, due to an ageing population, are becoming increasingly common. Follow-up of joint prostheses is to identify problems in symptomatic or asymptomatic patients due to infection, osteolysis, bone loss or potential periprosthetic fracture, enabling timely intervention to prevent catastrophic failure at a later date. Early revision is usually more straight-forward surgically and less traumatic for the patient. However, routine long-term follow-up is costly and requires considerable clinical time. Therefore, some centres in the UK have curtailed this aspect of primary hip and knee arthroplasty services, doing so without an evidence base that such disinvestment is clinically or cost-effective. Methods Given the timeline from joint replacement to revision, conducting a randomised controlled trial (RCT) to determine potential consequences of disinvestment in hip and knee arthroplasty follow-up is not feasible. Furthermore, the low revision rates of modern prostheses, less than 10% at 10 years, would necessitate thousands of patients to adequately power such a study. The huge variation in follow-up practice across the UK also limits the generalisability of an RCT. This study will therefore use a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence-based and consensus-based recommendations as to how, when and on whom follow-up should be conducted. Four interconnected work packages will be completed: (1) a systematic literature review; (2a) analysis of routinely collected National Health Service data from five national data sets to understand when and which patients present for revision surgery; (2b) prospective data regarding how patients currently present for revision surgery; (3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models and (4) a Delphi-consensus process, involving all stakeholders, to develop a policy document which includes a stratification algorithm to determine appropriate follow-up care for an individual patient. Ethics and Dissemination Favourable ethical opinion has been obtained for WP2a (RO-HES) (220520) and WP2B (220316) from the National Research Ethics Committee. Following advice from the Confidentiality Advisory Group (17/CAG/0122), data controllers for the data sets used in WP2a (RO-HES) - NHS Digital and The Phoenix Partnership - confirmed that Section 251 support was not required as no identifiable data was flowing into or out of these parties. Application for approval of WP2a (RO-HES) from the Independent Group Advising on the Release of Data (IGARD) at NHS Digital is in progress (DARS-NIC-147997). Section 251 support (17/CAG/0030) and NHS Digital approval (DARS-NIC-172121-G0Z1H-v0.11) have been obtained for WP2a (NJR-HES-PROMS). ISAC (11_050MnA2R2) approval has been obtained for WP2a (CPRD-HES). [ABSTRACT FROM AUTHOR]

Objective To investigate early haemodynamic changes after transfemoral transcatheter aortic valve implantation (TAVI) and the relationship with myocardial injury and neurohormonal activation. Design Single-centre prospective observational study. Setting Tertiary cardiac centre. Patients 42 patients undergoing transfemoral TAVI were included in this study. Main outcome measures Haemodynamic measurements and echocardiography-derived indices characterising myocardial function were recorded at baseline, 6 and 24 h postprocedure. Postprocedural myocardial injury was quantified using serum troponin I and CK-MB levels. In addition, biomarkers of myocardial dysfunction/heart failure and neurohormonal activation were measured. Results 6 h Post-TAVI there was a significant deterioration in both systolic and diastolic function as measured by dP/dtmax/EDV, myocardial performance index and mean E/e' index. Recovery of myocardial function was observed at 24 h. These haemodynamic changes were associated with a significant increase in both troponin I (0.0760.01 vs 1.5960.21 mg/l, p<0.005) and CK-MB (1.9960.19 vs 6.8260.7 ng/ml, p<0.005). There was a positive correlation among myocardial injury and NT-BNP (r¼0.34, p<0.0005), aldosterone (r¼0.56, p<0.0001) and ST2 levels (r¼0.21, p<0.05). Conclusions This is the first study to demonstrate that procedurally successful TF-TAVI results in a transient depression of both systolic and diastolic left ventricular function within the first 24 postoperative hours, despite impressive relief of previously severe, chronic pressure overload. The rise in the markers of myocardial damage suggests that this may be due to periprocedural myocardial injury. Complete recovery of contractility is generally observed after 24 h. [ABSTRACT FROM AUTHOR]

The article discusses a retrospective, case control study which determined if exogenous estrogen use, which stabilizes estradiol levels, had any association with the presence of cerebral aneurysms in women. The results showed a significant association between a lower rate of oral contraceptive and hormone replacement therapy use and the presence of a cerebral aneurysm. Data also suggest that exposure to exogenous estrogen agents in women is linked with a lower frequency of cerebral aneurysms.

Discusses the ethical dilemmas confronting general practitioners in Great Britain after changes enacted by the National Health Service (NHS). Rationing of health care; Effects of NHS general practice changes; Fund-holding practices and non-fund-holding practices; Costs of medication.

Reports the contribution of general practitioners on hospital intrapartum care in maternity units in Great Britain. Types of general practitioner unit; Number of transfers and deliveries booked by general practitioners; Participation of general practitioners on the policy and audit of the unit.

Examines the content of hospital obstetric vocational training for general practitioners in Great Britain. Measurement of trainee's competence and beliefs on Likert scale; Confirmation of numbers of procedures witnessed and performed; Consideration of the type of maternity care trainees intended to provide.

Presents several correspondence related to medicine. Decisions for the use of thrombolytic treatment in myocardial infarction; Warning for Islamic patients in stopping from oral and inhaled drug treatment during Ramadan; Debate on the funding policies for HIV infection and AIDS.

Determines the content of practice obstetric vocational training in maternity care. Roles of midwives and general practitioners in maternity care; Occurrence of vocational obstetric training during hospital practice; Belief of trainees on the role of physicians in maternity care.

Inadvertent deformation and displacement of a fully deployed closed-cell intracranial nitinol stent may occur with manipulation of other devices through or beyond them. Such displaced and deformed stents may obstruct the lumen, risking formation of thromboemboli, and/or fail to no function as a scaffold to assist with coil embolization. We review two such cases whereby an Alligator retrieval device (ARD) (ev3, Irvine, California, USA) was used to salvage a deployed misshapen intracranial stent. [ABSTRACT FROM PUBLISHER]

Focuses on the necessary preparations for foreign physicians in Great Britain. Documentation needed; Agreement on a draft protocol of proposed work; Inspection of accommodations for the visiting physician; Knowledge in salary and cost of living. INSET: Suggested documentation for a foreign fellow.

Investigates the role of midwives and general practitioners in hospital intrapartum care in Great Britain. Involvement in the audit of isolated units; Provision of personal care to low risk women; Assistance to labor and delivery.

The article discusses a study which examined the effectiveness of interventions led by nurses in improving control of blood pressure in hypertensive people in Great Britain. Randomised controlled trials that compared any intervention intended to improve blood pressure delivered by nurses were identified by the authors. Based on the results of the systematic review and meta-analysis conducted, the authors supported structured algorithm driven care of hypertension provided by nurses and nurse prescribers.

The article presents a study which examined whether management method for miscarriage during the first trimester affects long term fertility rates. Women who had experienced an early miscarriage were recruited from acute hospitals in the south west region of England. It was found that bleeding after the index miscarriage was higher among those who were randomised to expectant or medical management. Bias, confounding, and other reasons for caution are discussed.

Competing Interests: Competing interests: None declared.