Familial hypercholesterolaemia is one of the most common dominantly inherited disorders to be identified in primary care, leading to raised serum cholesterol evident from the first year of life. Around 1 in 500 people are affected by this condition, but less than 15% of these are currently attending lipid clinics, suggesting that the vast majority are unrecognised in general practice. The recently released National Institute for Health and Clinical Excellence evidencebased guideline on the identification and management of familial hypercholesterolaemia provides an opportunity to bridge this gap. Primary care has a role in systematic and opportunistic case finding, such as recognising the relevance of a family history of premature coronary heart disease and/or grossly elevated cholesterol. Although affected individuals need specialist care, GPs can reinforce the information provided by specialists and support cascade screening to other affected members of the extended family.

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BackgroundIn vitro fertilization (IVF) patients receive various adjuvant therapies to enhance success rates, but the true benefit is actively debated. Growth hormone (GH) and dehydroepiandrosterone (DHEA) supplementation were assessed in women undergoing fresh IVF transfer cycles and categorized as poor prognosis from five criteria.MethodsData were retrospectively analyzed from 626 women undergoing 626 IVF cycles, where they received no adjuvant, GH alone, or GH–DHEA in combination. A small group received DHEA alone. The utilization of adjuvants was decided between the attending clinician and the patient depending on various factors including cost.ResultsDespite patients being significantly older with lower ovarian reserve, live birth rates were significantly greater with GH alone (18.6%) and with GH-DHEA (13.0%) in comparison to those with no adjuvant (p < 0.003). No significant difference was observed between the GH groups (p = 0.181). Overall, patient age, quality of the transferred embryo, and GH treatment were the only significant independent predictors of live birth chance. Following adjustment for patient age, antral follicle count, and quality of transferred embryo, GH alone and GH–DHEA led to a 7.1-fold and 5.6-fold increase in live birth chance, respectively (p < 0.000).ConclusionThese data indicated that GH adjuvant may support more live births, particularly in younger women, and importantly, the positive effects of GH treatment were still observed even if DHEA was also used in combination. However, supplementation with DHEA did not indicate any potentiating benefit or modify the effects of GH treatment. Due to the retrospective design, and the risk of a selection bias, caution is advised in the interpretation of the data.

IntroductionThe development of the concept and practice of business process re-engineering from the "Management in the 1990s" research programme at MIT[1], Hammer's well-known initial article on re-engineering in Harvard Business Review [2] and Davenport's book on process innovation[3], was at first sight highly biased towards the exploitation of IT. However, it was clear that many of the examples given of BPR had a very strong operations management and services management content. Some authors on BPR do, of course, already acknowledge antecedents in manufacturing, logistics and supply chain concepts [4]. The purpose of this article is not to claim BPR as an operations management approach but to examine the concepts and techniques of the field which might have application for BPR. Hence the learning which has been gained from other improvement philosophies may be valuably transferred to BPR programmes.Our starting point for this examination is the following description of BPR:An organisation may be considered as a collection of processes characterised as strategic, operational and enabling. BPR is an approach to achieving radical improvements in performance by using resources in ways which maximise value added activities and minimise activities which only add cost -either at the level of the individual process or at the level of the whole organisation.Implicit in this definition of BPR is the consideration of organizational structure. If an organization is viewed as a collection of processes how do the processes impact on a functional view of the organization? The debate about the relative importance of processes over functions where processes cross traditional functional boundaries is likely to be a feature of implementation of BPR [5]. The rules of BPRAs a prescription or framework for how to undertake BPR we have combined the principles of re-engineering proposed by Hammer[2] and the characteristics

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