We hypothesized that PET myocardial perfusion imaging with 82 Rb (PET MPI), would reduce downstream utilization of diagnostic arteriography, compared with SPECT, in patients matched for pretest likelihood of coronary disease (pCAD). PET MPI is more accurate for assessment of impaired coronary flow reserve compared with SPECT MPI, potentially reducing the demand for subsequent arteriography, percutaneous transcoronary intervention, and coronary artery bypass grafting (CABG), with attendant cost savings, while avoiding a negative impact on coronary events. Methods: The frequency of diagnostic arteriography, revascularization, costs, and 1-y clinical outcomes in 2,159 patients studied with PET MPI was compared with 2 control groups studied with SPECT MPI matched to the PET group by pCAD: an internal control group of 102 patients and an external SPECT control group of 5,826 patients. CAD management costs were approximated with realistic global fee estimates. Results: Arteriography rates were 0.34 and 0.31 for the external and internal control SPECT groups and 0.13 for the patients studied with PET (P , 0.0001). pCAD averaged 0.39 in patients studied with PET MPI, and in the external SPECT control group, and 0.37 in the internal SPECT controls. Revascularization rates were 0.13 and 0.11 for external and internal SPECT patients and 0.06 for the PET group (P , 0.0001; P , 0.01), with a cost savings of 30% noted for PET patients, with no significant difference in cardiac death or myocardial infaction at 1-y follow-up. Conclusion: PET MPI in patients with intermediate pCAD results in a .50% reduction in invasive coronary arteriography and CABG, a 30% cost savings, and excellent clinical outcomes at 1 y compared with SPECT.

Background. The value of transesophageal echocardiography in the assessment of patients with aortic dissection was studied.Methods and Results. Group 1 (34 patients) represented all patients studied at our institution with this technique in whom aortic dissection was proven by aortography, surgery, or autopsy. Group 2 (27 patients) represented all patients studied with this technique at our institution in whom aortic dissection was excluded by aortography. Transesophageal echocardiography made a correct diagnosis of aortic dissection in 33 of 34 patients (sensitivity, 97%; specificity, 100%). It also correctly demonstrated the type of dissection in all 29 patients with aortographic or surgical proof. On the other hand, computed tomography scanning, performed in 24 of 34 patients in group 1, made a correct diagnosis in only 67% of patients and misclassified the type of dissection in 33%. Transesophageal echocardiography correctly identified involvement of the coronary arteries by aortic dissection in six of seven patients as well as absence of both left and right coronary artery involvement in 10 patients with aortic dissection. This technique was also useful in detecting communications between the true and false lumens, presence of thrombi in the false lumen, and, in two patients, localized dissection rupture with formation of a false aneurysm. In both groups 1 and 2, transesophageal echocardiography correctly identified patients with moderate to severe aortic regurgitation.Conclusions. Transesophageal echocardiography is very useful in the assessment of aortic dissection. (Circulation 1991;84:1903-1914

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Urban drainage has developed from an engineering discipline concerned principally with public health and safety outcomes, into a multi-faceted vision linking drainage with environmental and wider social and economic imperatives to deliver multi-functional outcomes. UK attention is too often focused on surface water as a problem despite international progress and initiatives showing that an opportunity-centred approach needs to be taken. Sustainable Drainage Systems (SuDS/SUDS) as part of an integrated approach to water management, cost-effectively provide many benefits beyond management of water quality and quantity. New tools are available that can provide the means to design SuDS for maximum value to society and this requires greater collaboration across disciplines to seize all of the opportunities available. Tools and a roadmap for this are introduced, including guidance, design objectives and criteria for maximising benefits. These new supporting tools and guidance can help provide the business case for using SuDS.