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Illustrations and rhyming text present animals in silly situations, such as a pig in a wig and a moose drinking juice, along with a reminder not to tease.

We use the 3‐D Whole Atmospheric Community Climate Model to investigate stratospheric ozone depletion due to the launch of small satellites (e.g., CubeSats) with an iodine propulsion system. The model considers the injection of iodine from the satellites into the Earth's thermosphere and suggests a 4‐yr timescale for transport of the emissions down to the troposphere. The base case scenario is 40,000 small satellite launches per year into low orbit (100–600 km), which would inject 8 tons I yr−1 above 120 km as I+ ions and increase stratospheric inorganic iodine by ∼0.1 part per trillion (pptv). The model shows that this scenario produces a negligible impact on global stratospheric ozone (∼0.05 DU column depletion). In contrast, a 100‐fold increase in the launch rate, and therefore thermospheric iodine injection, is predicted to result in modeled ozone depletion of up to 14 DU (approximately 2%–7%) over the polar regions. Plain Language Summary Iodine has the potential to cause stratospheric ozone depletion. Small satellites (<10 kg) in low Earth orbit require electric propulsion to prolong their time in orbit, and there is strong interest in replacing the rare gas propellant (Xe or Kr) with I2. Here we estimate the potential impact of thermosphere iodine injection from such satellites on stratospheric ozone. Since the demand for small satellites could increase greatly in the future, it is important to understand the potential risks to ozone depletion if iodine propulsion systems are used. Assuming a scenario in which 40,000 small satellites are launched each year into relatively low orbits and each satellite is assumed to contain 200 g I2, this could inject 8 tons/year of iodine ions into the upper atmosphere (above 120 km). Using a 3‐D atmospheric chemistry‐climate model, we show that the perturbation to the total column ozone is very small, decreasing by 0.05 DU (<0.02%) globally and 0.2 DU (<0.1%) for September/October in the Antarctic polar region. However, a 100‐fold increase in the number of launches and therefore mass of iodine emitted into near‐Earth orbit is predicted to cause significant ozone depletion up to 14 DU (5.6%) in the Antarctic spring. Key Points The effect of injecting iodine into the atmosphere from I2‐propelled satellites has been modeled using an atmosphere chemistry‐climate model Injection of 8 tons I yr−1, based on the expected launch rate, is predicted to cause negligible O3 depletion (0.05 DU) globally O3 depletion increases near‐linearly with iodine mass injected, reaching up to 14 DU in the polar regions for 800 tons I yr−1

Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are alternative treatments for multivessel coronary disease. Although the procedures have been compared in several randomised trials, their long-term effects on mortality in key clinical subgroups are uncertain. We undertook a collaborative analysis of data from randomised trials to assess whether the effects of the procedures on mortality are modified by patient characteristics. We pooled individual patient data from ten randomised trials to compare the effectiveness of CABG with PCI according to patients' baseline clinical characteristics. We used stratified, random effects Cox proportional hazards models to test the effect on all-cause mortality of randomised treatment assignment and its interaction with clinical characteristics. All analyses were by intention to treat. Ten participating trials provided data on 7812 patients. PCI was done with balloon angioplasty in six trials and with bare-metal stents in four trials. Over a median follow-up of 5·9 years (IQR 5·0–10·0), 575 (15%) of 3889 patients assigned to CABG died compared with 628 (16%) of 3923 patients assigned to PCI (hazard ratio [HR] 0·91, 95% CI 0·82–1·02; p=0·12). In patients with diabetes (CABG, n=615; PCI, n=618), mortality was substantially lower in the CABG group than in the PCI group (HR 0·70, 0·56–0·87); however, mortality was similar between groups in patients without diabetes (HR 0·98, 0·86–1·12; p=0·014 for interaction). Patient age modified the effect of treatment on mortality, with hazard ratios of 1·25 (0·94–1·66) in patients younger than 55 years, 0·90 (0·75–1·09) in patients aged 55–64 years, and 0·82 (0·70–0·97) in patients 65 years and older (p=0·002 for interaction). Treatment effect was not modified by the number of diseased vessels or other baseline characteristics. Long-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes. CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups. Agency for Healthcare Research and Quality.

In 2008 I completed a PhD which looked at the experiences of aged care nurses who cared for residents with dementia that displayed aggression. One of the themes I identified was nurses who cared for aggressive residents tended to be as quick as possible in delivering care for fear of being injured.

Prasugrel is more effective than clopidogrel in reducing platelet aggregation in acute coronary syndromes. Data available on prasugrel reloading in clopidogrel treated patients with high residual platelet reactivity (HRPR) i.e. poor responders, is limited. To determine the effects of prasugrel loading on platelet function in patients on clopidogrel and high platelet reactivity undergoing percutaneous coronary intervention for acute coronary syndrome (ACS). Patients with ACS on clopidogrel who were scheduled for PCI found to have a platelet reactivity ≥40 AUC with the Multiplate Analyzer, i.e. \"poor responders\" were randomised to prasugrel (60 mg loading and 10 mg maintenance dose) or clopidogrel (600 mg reloading and 150 mg maintenance dose). The primary outcome measure was proportion of patients with platelet reactivity <40 AUC 4 hours after loading with study medication, and also at one hour (secondary outcome). 44 patients were enrolled and the study was terminated early as clopidogrel use decreased sharply due to introduction of newer P2Y12 inhibitors. At 4 hours after study medication 100% of patients treated with prasugrel compared to 91% of those treated with clopidogrel had platelet reactivity <40 AUC (p = 0.49), while at 1 hour the proportions were 95% and 64% respectively (p = 0.02). Mean platelet reactivity at 4 and 1 hours after study medication in prasugrel and clopidogrel groups respectively were 12 versus 22 (p = 0.005) and 19 versus 34 (p = 0.01) respectively. Routine platelet function testing identifies patients with high residual platelet reactivity (\"poor responders\") on clopidogrel. A strategy of prasugrel rather than clopidogrel reloading results in earlier and more sustained suppression of platelet reactivity. Future trials need to identify if this translates into clinical benefit. ClinicalTrials.gov NCT01339026.

Several observational studies have suggested that mortality and major complications after high-risk percutaneous coronary intervention (PCI) can be reduced by elective insertion of an intra-aortic balloon pump (IABP). However, to date, this assertion has never been tested in a randomized trial, and as such, international guidelines do not provide formal recommendations for IABP use in this setting. The BCIS-1 is a randomized trial that addresses the hypothesis that elective IABP insertion before high-risk PCI will reduce major adverse cardiac and cerebrovascular events (MACCEs) at hospital discharge or 28 days after index PCI, whichever occurs sooner. High risk is defined by the presence of severe left ventricular dysfunction as well as a large amount of myocardium at risk. Patients who are in cardiogenic shock, have a class I indication for IABP use, or have an absolute contraindication to IABP use will be excluded. Three hundred eligible patients will be randomized to receive elective IABP insertion or no planned IABP insertion. The findings of BCIS-1 are expected to define the role of balloon counterpulsation in high-risk PCI. Confirmation of the efficacy of elective IABP use may prompt review of the international guidelines, which are currently very restricted. In contrast, a neutral or adverse outcome with elective counterpulsation in these high-risk patients will allow evidence-based rationalization of the current disparity between guidelines and the frequent real-world use of elective IABP support.

Registries have shown that quality of care for acute coronary syndromes (ACS) often falls below the standards recommended in professional guidelines. Quality improvement (QI) is a strategy to improve standards of clinical care for patients, but the efficacy of QI for ACS has not been tested in randomized trials. We undertook a prospective, cluster-randomized, multicenter, multinational study to evaluate the efficacy of a QI program for ACS. Participating centers collected data on consecutive admissions for non–ST-elevation ACS for 4 months before the QI intervention and 3 months after. Thirty-eight hospitals in France, Italy, Poland, Spain, and the United Kingdom were randomized to receive the QI program or not, 19 in each group. We measured 8 in-hospital quality indicators (risk stratification, coronary angiography, anticoagulation, β-blockers, statins, angiotensin-converting enzyme inhibitors, and clopidogrel loading and maintenance) before and after the intervention and compared composite changes between the QI and non-QI groups. A total of 2604 patients were enrolled. The absolute overall change in use of quality indicators in the QI group was 8.5% compared with 0.8% in the non-QI group (odds ratio for achieving a quality indicator in QI versus non-QI 1.66, 95% CI 1.43-1.94; P < .001). The main changes were observed in the use of risk stratification and clopidogrel loading dose. The QI strategy resulted in a significant improvement in the quality indicators measured. This type of QI intervention can lead to useful changes in health care practice for ACS in a wide range of settings.

Acute coronary syndromes, including myocardial infarction and unstable angina, are important causes of premature mortality, morbidity and hospital admissions. Acute coronary syndromes consume large amounts of health care resources, and have a major negative economic and social impact through days lost at work, support for disability, and coping with the psychological consequences of illness. Several registries have shown that evidence based treatments are under-utilised in this patient population, particularly in high-risk patients. There is evidence that systematic educational programmes can lead to improvement in the management of these patients. Since application of the results of important clinical trials and expert clinical guidelines into clinical practice leads to improved patient care and outcomes, we propose to test a quality improvement programme in a general group of hospitals in Europe. This will be a multi-centre cluster-randomised study in 5 European countries: France, Spain, Poland, Italy and the UK. Thirty eight hospitals will be randomised to receive a quality improvement programme or no quality improvement programme. Centres will enter data for all eligible non-ST segment elevation acute coronary syndrome patients admitted to their hospital for a period of approximately 10 months onto the study database and the sample size is estimated at 2,000-4,000 patients. The primary outcome is a composite of eight measures to assess aggregate potential for improvement in the management and treatment of this patient population (risk stratification, early coronary angiography, anticoagulation, beta-blockers, statins, ACE-inhibitors, clopidogrel as a loading dose and at discharge). After the quality improvement programme, each of the eight measures will be compared between the two groups, correcting for cluster effect. If we can demonstrate important improvements in the quality of patient care as a result of a quality improvement programme, this could lead to a greater acceptance that such programmes should be incorporated into routine health training for health professionals and hospital managers. Clinicaltrials.gov NCT00716430.

Results of trials, comparing percutaneous transluminal coronary angioplasty (PICA) with coronary artery bypass grafting (CABG), indicate that rates of death or myocardial infarction are similar with either treatment strategy. Management with PICA is, however, associated with an increased requirement for subsequent, additional revascularisation. Coronary stents, used as an adjunct to PICA, reduce restenosis and the need for repeat revascularisation. The aim of the Stent or Surgery (SoS) trial was to assess the effect of stent-assisted percutaneous coronary intervention (PCI) versus CABG in the management of patients with multivessel disease. In 53 centres in Europe and Canada, symptomatic patients with multivessel coronary artery disease were randomised to CABG (n=500) or stent-assisted PCI (n=488). The primary outcome measure was a comparison of the rates of repeat revascularisation. Secondary outcomes included death or Q-wave myocardial infarction and all-cause mortality. Analysis was by intention to treat. All patients were followed-up for a minimum of 1 year and the results are expressed for the median follow-up of 2 years. 21% (n=101) of patients in the PCI group required additional revascularisation procedures compared with 6% (n=30) in the CABG group (hazard ratio 3·85, 95% Cl 2·56–5·79, p<0·0001). The incidence of death or Q-wave myocardial infarction was similar in both groups (PCI 9% [n=46], CABG 10% [n=49]; hazard ratio 0·95, 95% Cl 0·63–1·42, p=0·80). There were fewer deaths in the CABG group than in the PCI group (PCI 5% [n=22], CABG 2% [n=8]; hazard ratio 2·91, 95% Cl 1·29–6·53, p=0·01). The use of coronary stents has reduced the need for repeat revascularisation when compared with previous studies that used balloon angioplasty, though the rate remains significantly higher than in patients managed with CABG. The apparent reduction in mortality with CABG requires further investigation.

In 2008 I completed a PhD which looked at the experiences of aged care nurses who cared for residents with dementia that displayed aggression.