BackgroundThe National Institute for Health and Care Excellence (NICE) 2016 guidelines (CG95) recommend patients with new stable chest pain be investigated with computed tomography coronary angiography (CTCA). An updated guideline (MTG32) recommended using CT fractional flow reserve (CTFFR) as a gatekeeper to invasive coronary angiography (ICA) for patients with coronary stenosis on CTCA. Subsequently, NHS England negotiated a UK-wide contract with HeartFlow, the provider of CTFFR. We describe our experience with CTFFR and consider the impact of the recent ISCHEMIA trial on these guidelines. MethodsWe prospectively collected ICA and revascularisation data on all patients undergoing CTFFR from January 2019 to March 2020. ResultsOne-hundred and twenty-five of 140 patients completed CTFFR analysis. Eighty-one patients had CTCA stenosis >50%. Thirty-six had positive CTFFR; 29 underwent ICA with 22 (75.9%) revascularised. Forty-five had negative CTFFR; 14 underwent ICA and four (28.6%) were revascularised. The average cost of investigation per patient (PP) was £971.95. Had these patients undergone ICA directly with no functional test after CTCA, the average cost would be £932.51 PP. ConclusionOur revascularisation rates suggest that CTFFR can potentially be a gatekeeper to ICA but does not necessarily yield cost savings.

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not time spent per COI (OR 0.89, 95% [0.68 to 1.16], p=0.38, n=11). An ordinal regression model did not show an association between presenter's H-index and total quality score (OR 0.94, 95% CI [0.87 to 1.01], p=0.11, n=11) Conclusion A large minority of presenters did not display a COI statement. Those COI statements that were present were of variable quality. Many were displayed for insufficient time, lacked any verbal explanation or used a small font. These factors may limit the ability of audience members to understand the potential conflicts. Seniority of presenter correlated with number of conflicts but not quality of the COI statement. Strategies should be implemented to ensure all presenters outline whether they have any potential COI in a standardised manner.

Jini networking technology represents an exciting paradigm in distributed systems. Its elegant approach in computer networking possesses immense advantages, but also generates security problems. Extensive research has been undertaken and existing security methodologies have been applied to provide a safe execution environment. However the unique nature of Jini has made it hard for traditional security mechanisms to be applied effectively. Part of the problem lies within the downloaded code and in the lack of centralised control. Current solutions are based on assumptions; therefore they are inadequate for enforcing the security requirements of the system. The goal of our research is to increase the security of the Jini model without altering its initial characteristics. We present our preliminary research efforts in providing an alternative, fault tolerant security architecture that uses a trusted local verifier in order to evaluate and certify the correctness of remote calls.

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