General gastroenterologists supported by paediatricians can provide endoscopic services for children safely and promptly in their local hospital. This is appropriate for the management of common gastrointestinal problems affecting children.

The reduction in patients presenting with ST-elevation myocardial infarction (STEMI) during the COVID19 crisis could have resulted from fears about developing COVID-19 infection in hospital. Patients who delay presenting with STEMI are more likely to develop mechanical complications, including acute ischemic mitral regurgitation (MR). We present a 69-year-old women with an inferior STEMI and cardiogenic shock due to acute ischemic MR who delayed presenting to hospital due to the fear of COVID-19. Early identification of this mechanical complication using transthoracic echocardiography in the Emergency Department enabled the team to target her optimisation. Ultimately these patients require urgent surgery to repair the mitral valve and revascularize the myocardium but they are often too unwell to undergo surgery and even when it is feasible the outcomes are poor.

No abstract

IntroductionCardiac troponin (cTn) concentrations above the manufacturer recommended upper limit of normal (ULN) are frequently seen in hospital patients without a clinical presentation consistent with type 1 myocardial infarction, and the significance of this is uncertain. The aim of this study was to assess the relationship between medium-term mortality and cTn concentration in a large consecutive hospital population, regardless of whether there was a clinical indication for performing the test.MethodThis prospective observational study included 20 000 consecutive in-hospital and outpatient patients who had a blood test for any reason at a large teaching hospital, and in whom a hs-cTnI assay was measured, regardless of the original clinical indication. Mortality was obtained via NHS Digital.ResultsA total of 20 000 patients were included in the analysis and 18 282 of these (91.4%) did not have a clinical indication for cardiac troponin I (cTnI) testing. Overall, 2825 (14.1%) patients died at a median of 809 days. The mortality was significantly higher if the cTnI concentration was above the ULN (45.3% vs 12.3% p<0.001 log rank). Multivariable Cox analysis demonstrated that the log10cTnI concentration was independently associated with mortality (HR 1.76 (95% CI 1.65 to 1.88)). Landmark analysis, excluding deaths within 30 days, showed the relationship between cTnI concentration and mortality persisted.ConclusionIn a large, unselected hospital population, in 91.4% of whom there was no clinical indication for testing, cTnI concentration was independently associated with medium-term cardiovascular and non-cardiovascular mortality in the statistical model tested.

No abstract

Conclusions Hypertension is prevalent, under diagnosed, and contributes to the development of potentially unstable coronary artery disease in healthy male endurance athletes. Recommendations for cardiovascular evaluation of master athletes should consider a low threshold for non-invasive exercise testing and ambulatory BP monitoring for for athletes with hypertension and even high-normal BP. Table 1. ESC definitions of hypertension. Table 2. Prevalence of hypertension according to ESC guideline classifications. Table 3. Logistic regression P values, odds ratios and confidence intervals for a 5mmHg increase in BP parameters.

coronary artery diameter was measured by quantitative angiography. An incremental pacing protocol that raised heart rate to a maximum of 150 bpm was undertaken in all patients via a temporary right atrial pacing wire. Pacing was performed in the presence of saline vehicle and then either L-NMMA or SMTC (one inhibitor per patient; n¼9 each group).Results SMTC (0.625 mmol/min) and L-NMMA (25 mmol/min) both reduced basal CBF to a similar extent (À22.8%61.24% vs À26.8%62.16%; n¼9 each; p¼NS). During saline infusion, CBF increased with atrial pacing from 58.769.90 to 87.4617.3 ml/min (n¼9, p<0.05). During L-NMMA, the increase in CBF was significantly blunted compared to that during saline (DCBF 17.764.54 ml/ min vs 28.768.08 ml/min during saline; n¼9, p<0.05 by 2-way ANOVA). In patients receiving SMTC, however, the increase in CBF with pacing was similar to that during saline (DCBF 36.566.05 ml/ min vs 25.266.65 ml/min during saline; n¼9, p¼NS by 2-way ANOVA). SMTC and L-NMMA both reduced basal coronary artery diameter to a similar extent (n¼9). L-NMMA blunted the pacinginduced increase in coronary artery diameter (n¼9, p<0.05 vs saline vehicle) whereas SMTC had no effect (n¼9, p¼NS). Conclusion These results suggest that increases in human coronary blood flow in response to incremental atrial pacing are mediated by eNOS-derived NO rather than nNOS-derived NO.