The consequences of applying NICE chest pain guidelines to an acute medical population: a role for cardiac computed tomography

BACKGROUND

Cardiac computed tomography (CCT) is a well-validated investigation for the non-invasive assessment of coronary artery disease (CAD). The National Institute for Clinical Excellence (NICE) have recently released guidelines incorporating CCT into the diagnostic algorithm for chest pain of recent onset.

AIM

To assess the frequency of eligibility for CCT in medical admissions with suspected cardiac chest pain using criteria defined by NICE.

DESIGN

A retrospective, observational study, set in a teaching hospital acute medical unit.

METHODS

A total of 198 consecutive patients admitted over a 4-month period with suspected cardiac chest pain (57% male; mean age 63.5 years) were assessed for eligibility for CCT based on NICE guideline criteria.

RESULTS

Of the 198 patients admitted, 65 (33%) patients were excluded by a raised troponin I or ischaemic ECG changes; 100 (51%) patients were excluded by pain categorized as non-anginal and 171 (86%) patients were excluded by a modified Diamond Forrester score outside the range 10-29%. Applying NICE criteria to this population ultimately resulted in 2 (1%) patients recommended for CCT, 12 (6%) for functional cardiac testing and 17 (9%) for invasive angiography.

CONCLUSION

Applying current NICE guidelines for chest pain of recent onset to medical admissions results in a lesser uptake of CCT than functional testing and invasive angiography. If the NICE guidelines are revised to include patients with an intermediate pre-test probability of CAD, CCT may have a greater role.

An isometric hand tester: quantifying motor function in the hand

The aim of this study was to develop and assess an isometric hand tester to measure multiple strength parameters of the muscles of the hand. Nineteen men and 22 women took part in a first study and 17 men were tested in a second one. Five different tests were developed: wrist flexion, wrist extension, metacarpophalangeal joint flexion, thumb adduction and proximal and distal interphalangeal joint flexion. Reliability was tested with an intraclass correlation coefficient for single measures. When the results from men and women were analysed separately, all tests except metacarpophalangeal joint flexion and thumb adduction produced intraclass correlation coefficients greater than 0.7. Combining the genders gave intraclass correlation coefficients greater than 0.9 except for metacarpophalangeal joint flexion and thumb adduction. After adjustments, intraclass correlation coefficients for metacarpophalangeal joint flexion and thumb adduction were between 0.70 and 0.83 in the second study. The new isometric hand tests improve the measurement of intrinsic and extrinsic hand muscle strength.

Interactions between endothelial cells and electrospun methacrylic terpolymer fibers for engineered vascular replacements

A compliant terpolymer made of hexylmethacrylate (HMA), methylmethacrylate (MMA), and methacrylic acid (MAA) intended for use in small diameter vascular graft applications has been developed. The mechanical properties and in vitro biostability of this terpolymer have been previously characterized. The goal of this investigation was to examine the interactions between endothelial cells and the new terpolymer and to evaluate endothelial cell function. Electrospinning was used to produce both oriented and random terpolymer fiber scaffolds. Smooth solution cast films and tissue culture polystyrene were used as negative and positive controls, respectively. Human blood outgrowth endothelial cells and human umbilical vein endothelial cells were incubated with the test and control samples and characterized with respect to initial cell attachment, proliferation, viability, and maintenance of the endothelial cell phenotype. It was found that the terpolymer is cytocompatible allowing endothelial cell growth, with random fibers being more effective in promoting enhanced cellular activities than oriented fibers. In addition, endothelial cells cultured on these substrates appeared to maintain their phenotype. The results from this study demonstrate that electrospun HMA:MMA:MAA terpolymer has the potential to be used successfully in fabricating small diameter blood vessel replacements.

Assessment of aspirin resistance varies on a temporal basis in patients with ischaemic heart disease

Objective:

Laboratory tests including optical platelet aggregometry (OPA), platelet function analyser (PFA-100), and thromboxane B₂ (TXB₂) metabolite levels have been used to define aspirin resistance. This study characterised the prevalence of aspirin resistance in patients with ischaemic heart disease (IHD) and investigated the concordance and repeatability of these tests.

Design, setting and patients:

Consecutive outpatients with stable IHD were enrolled. They were commenced on 150 mg aspirin daily (day 0) and had platelet function assessment (OPA and PFA-100) and quantitative analysis of serum/urine TXB₂ at day ⩾7 and then at a second visit approximately 2 weeks later.

Main outcome measures:

We assessed the prevalence of aspirin resistance by each method, concordance between methods of measuring response to aspirin and association between time points to assess the predictability of response over time.

Results:

172 patients (62.7 (SD 8.7) years, 83.1% male) were recruited. At visits 1 and 2, respectively, 1.7% and 4.7% were aspirin resistant by OPA, whereas 22.1% and 20.3% were aspirin resistant by PFA-100. There were poor associations between PFA-100 and OPA, and between TXB₂ metabolites and platelet function tests. OPA and PFA-100 results were poorly associated between visits (κ = 0.16 and κ = 0.42, respectively) as were TXB₂ metabolites, suggesting that aspirin resistance is not predictable over time.

Conclusions:

The prevalence of aspirin resistance is dependent on the method of testing. Response varies on a temporal basis, indicating that testing on a single occasion is inadequate to diagnose resistance or guide therapy in a clinical setting.

Improving the management and referral of patients with transient ischaemic attacks: a change strategy for a health community

PROBLEM

Rapid referral and management of patients with transient ischaemic attacks is a key component in the national strategy for stroke prevention. However, patients with transient ischaemic attacks are poorly identified and undertreated.

DESIGN AND SETTING

Before and after evaluation of quality improvement programme with controlled comparison in three primary care trusts reflecting diverse populations and organisational structures in an urban district in the North of England.

KEY MEASURES FOR IMPROVEMENT

The proportion of patients receiving antiplatelet drugs and safe driving advice on referral to a specialty clinic, and the numbers of referrals, adjusted for age, to the specialist clinic before and after the improvement programme.

STRATEGIES FOR CHANGE

Interviews with patient and professionals to identify gaps and barriers to good practice; development of evidence based guidelines for the management of patients with transient ischaemic attacks; interactive multidisciplinary workshops for each primary care trust with feedback of individual audit results of referral practice; outreach visits to teams who were unable to attend the workshops; referral templates and desktop summaries to provide reminders of the guidelines to clinicians; incorporation of standards into professional contracts.

EFFECTS OF CHANGE

A significant improvement occurred in identification and referral of patients with transient ischaemic attacks to specialist clinics, with a 41% increase in referrals from trained practices compared with control practices. There were also significant improvements in the early treatment and safety advice provided to patients before referral.

LESSONS LEARNT

A strategic approach to effective quality improvement across a diverse health community is feasible and achievable. Careful planning with patient and professional involvement to develop a tailored and multifaceted quality improvement programme to implement evidence based practice can work in very different primary care settings. Key components of the effectiveness of the model include contextual analysis, strong professional support, clear recommendations based on robust evidence, simplicity of adoption, good communication, and use of established networks and opinion leaders.

Application of laser spectroscopy for measurement of exhaled ethane in patients with lung cancer

There is increasing interest in ethane (C(2)H(6)) in exhaled breath as a non-invasive marker of oxidative stress (OS) and thereby a potential indicator of disease. However, the lack of real-time measurement techniques has limited progress in the field. Here we report on a novel Tunable Diode Laser Spectrometer (TDLS) applied to the analysis of exhaled ethane in patients with lung cancer. The patient group (n=52) comprised randomly selected patients presenting at a respiratory clinic. Of these, a sub-group (n=12) was subsequently diagnosed with lung cancer. An age-matched group (n=12) corresponding to the lung cancer group was taken from a larger control group of healthy adults (n=58). The concentration of ethane in a single exhaled breath sample collected from all subjects was later measured using the TDLS. This technique is capable of real-time analysis of samples with accuracy 0.1 parts per billion (ppb), over 10 times less than typical ambient levels in the northern hemisphere. After correcting for ambient background, ethane in the control group (26% smokers) ranged from 0 to 10.54 ppb (median of 1.9 ppb) while ethane in the lung cancer patients (42% smokers) ranged from 0 to 7.6 ppb (median of 0.7 ppb). Ethane among the non-lung cancer patients presenting for investigation of respiratory disease ranged from 0 to 25 ppb (median 1.45 ppb). We conclude that, while the TDLS proved effective for accurate and rapid sample analysis, there was no significant difference in exhaled ethane among any of the subject groups. Comments are made on the suitability of the technique for monitoring applications.

Association study of detoxification genes in age related macular degeneration

BACKGROUND/AIMS

Age related macular degeneration (AMD) is a complex disorder leading to loss of central vision, and identification of risk factors associated with susceptibility to AMD has been a key objective for ophthalmic genetics research for almost a decade. This association study has examined genetic polymorphisms in 12 candidate genes as possible risk factors for predisposition to the development of the exudative variant of AMD in a Northern Irish population. The choice of genes was based on their function in the breakdown of industrial pollutants, cigarette smoke, defence against oxidative stress, or involvement in the general ageing process.

METHODS

Up to five single nucleotide polymorphisms (SNPs) were typed for CYP1A1, CYP1A2, CYP2E1, CYP2D6, EPHX1, MnSOD, AhR, NAT2, CAT, GPX1, PON1, and ADPRT1 by multiplex snapshot single base primer extension method. Genes showing high linkage disequilibrium (LD) between SNPs were analysed by haplotype analysis. Genes showing low LD were assessed using individual SNPs based on genotypes.

RESULTS

After correction for number of genes/SNPs tested, no significant association with AMD was found although several genes merit further investigation. This study suggests that a coding SNP in EPHX1 (Y113H) may be important in AMD and supports a previous observation of an association with exudative AMD. In addition, haplotype analysis highlighted ADPRT1, CYP2D6, and AhR as worthy of further study.

CONCLUSION

This study has identified a number of genes requiring further investigation including EPHX1, ADPRT1, CYP2D6, and AhR.

Keratoconus: an analysis of corneal asymmetry

BACKGROUND

Keratoconus, a non-inflammatory corneal ectasia, is reported to have bilateral involvement in over 90% of patients. The purpose of this study was to quantify the extent of asymmetry of disease at presentation to a regional corneal clinic.

METHODS

Eighty three patients diagnosed at presentation, using a combination of videokeratography, slit lamp examination, and refractive findings were retrospectively selected. On this basis, 73 patients were designated as having evidence of keratoconus in both eyes. In order to quantify the degree of asymmetry between fellow eyes in these bilateral patients, intraclass correlation was calculated for best spectacle corrected visual acuity (BSCVA) and for 13 different topographical indices generated using videokeratography. In order to examine the link between each index and visual function, the intrapatient differences in each index were compared to the intrapatient differences in BSCVA using Pearson's correlation.

RESULTS

BSCVA showed a high degree of asymmetry between fellow eyes with a correlation coefficient of r = 0.006. With the exception of area analysed, all of the topographical indices also showed disparity between paired eyes (r = 0.01 to r = 0.25). Pearson's analysis found that the intrapatient differences in the standard deviation of the power (SDP), average corneal power (ACP), central corneal power (K), as well as the composite keratoconus prediction index (KPI) inversely correlated with the intrapatient differences in best spectacle corrected acuity (r = -0.76,-0.75,-0.69, and -0.73 respectively).

CONCLUSIONS

This study demonstrates, quantitatively, the asymmetry of disease found in patients at the point of initial diagnosis of keratoconus. It also suggests that increases in indices which reflect various aspects of corneal power as well as the composite index KPI correlate with a decrease in BSCVA.

A multilevel analysis of socioeconomic (small area) differences in household food purchasing behaviour

STUDY OBJECTIVE

To examine the association between area and individual level socioeconomic status (SES) and food purchasing behaviour.

DESIGN

The sample comprised 1000 households and 50 small areas. Data were collected by face to face interview (66.4% response rate). SES was measured using a composite area index of disadvantage (mean 1026.8, SD = 95.2) and household income. Purchasing behaviour was scored as continuous indices ranging from 0 to 100 for three food types: fruits (mean 50.5, SD = 17.8), vegetables (61.8, 15.2), and grocery items (51.4, 17.6), with higher scores indicating purchasing patterns more consistent with dietary guideline recommendations.

SETTING

Brisbane, Australia, 2000.

PARTICIPANTS

Persons responsible for their household's food purchasing.

MAIN RESULTS

Controlling for age, gender, and household income, a two standard deviation increase on the area SES measure was associated with a 2.01 unit increase on the fruit purchasing index (95% CI -0.49 to 4.50). The corresponding associations for vegetables and grocery foods were 0.60 (-1.36 to 2.56) and 0.94 (-1.35 to 3.23). Before controlling for household income, significant area level differences were found for each food, suggesting that clustering of household income within areas (a composition effect) accounted for the purchasing variability between them.

CONCLUSIONS

Living in a socioeconomically advantaged area was associated with a tendency to purchase healthier food, however, the association was small in magnitude and the 95% CI for area SES included the null. Although urban areas in Brisbane are differentiated on the basis of their socioeconomic characteristics, it seems unlikely that where you live shapes your procurement of food over and above your personal characteristics.

Clinical experience of galantamine in dementia: a series of case reports

OBJECTIVE

To use case studies to add the benefit of personal experience with galantamine to published literature and to demonstrate the type of patients that may benefit from this treatment.

METHODS

We describe eleven patients, aged 57-90 years, fulfilling the consensus diagnostic criteria for probable Alzheimer's disease, mixed dementia, vascular dementia, Lewy body dementia or Parkinson's dementia. All patients were treated with galantamine that may enhance cholinergic function in the brain by inhibiting acetylcholinesterase and potentiating the effects of acetylcholine at nicotinic acetylcholine receptors. Clinical features were rated according to eight assessment scales in old age psychiatry and additional information was obtained from family and other carers. In some cases caregiver distress was measured.

RESULTS

All patients described showed a general improvement in cognition and neuropsychiatric symptoms, although observed improvements and effects were not always reflected by the results of formal assessments. Several patients became more independent, particularly in their activities of daily living, and treatment was felt to have helped maintain independence in their home environment, either alone or with their family or carers. One man continued in employment. Adverse events included nausea and vomiting.

CONCLUSIONS

Outcomes in this case series indicate that galantamine is well tolerated and highlight aspects of the different side-effect profiles of the anticholinesterase inhibitors. Subjective benefits were not always apparent from objective measures. These case studies demonstrate the type of patients that may benefit from galantamine.