Guideline-based survey of outpatient COPD management by pulmonary specialists in Germany

Background

Little is known about the role of guidelines for the practical management of chronic obstructive pulmonary disease (COPD) by office-based pulmonary specialists. The aim of this study was to assess their outpatient management in relation to current guideline recommendations for COPD.

Methods

A nationwide prospective cross-sectional COPD questionnaire survey in the form of a multiple-choice questionnaire was sent to 1000 office-based respiratory specialists in Germany. The product-neutral questions focused on routine COPD management and were based on current national and international COPD guideline recommendations being consistent in severity classification and treatment recommendations.

Results

A total of 590 pulmonary specialists (59%) participated in the survey. Body plethysmography was considered the standard for diagnosis (65.9%), followed by spirometry (32%). Most respondents were able to cite the correct spirometric criteria for classifying moderate (87%) to very severe COPD (77%). A quarter of the respondents equated the World Health Organization (WHO) definition of chronic bronchitis with COPD. Notably, most participants preferred the updated national COPD guidelines (51.4%) to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines (40.2%). Improvement of functional exercise capacity and quality of life were considered the two most relevant treatment goals; whereas impact on mortality was secondary. Treatment of COPD largely complied with the guidelines. However, a significant percentage of the pulmonary specialists differed in their assessment of the benefits of various therapeutic measures from evidence-based results. Referral for pulmonary rehabilitation was uncommon, regardless of the severity of COPD.

Conclusion

The findings of this large national survey suggest that most pulmonary specialists adhere to the current COPD guideline recommendations in daily practice. However, physicians’ knowledge of guidelines is not sufficient as the sole benchmark when assessing their implementation in day-to-day practice. Necessary changes in the health care system must include more effective ways to transfer knowledge to clinical practice and to give access to interventions of proven clinical benefit.

The clinical significance of drug craving

Although drug craving has received considerable research attention over the past several decades, to date there has been no systematic review of the general clinical significance of craving. This paper presents an overview of measurement issues of particular relevance to a consideration of use of craving in clinical settings. The paper then considers the relevance of craving across a broad array of clinical domains, including diagnosis, prognostic utility, craving as an outcome measure, and the potential value of craving as a direct target of intervention. The paper is both descriptive and prescriptive, informed by the current state of the science on craving with recommendations for the definition of craving, assessment practices, future research, and clinical applications. We conclude that craving has considerable utility for diagnosis and as a clinical outcome, and that findings from future research will likely expand the clinical potential of the craving construct in the domains of prognosis and craving as a treatment target.

Breast cancer risk assessment in 64,659 women at a single high-volume mammography clinic

RATIONALE AND OBJECTIVES

In 2007, the American Cancer Society (ACS) recommended that women at elevated risk of breast cancer be screened with breast magnetic resonance imaging (MRI) as an adjunct to mammography. This study estimates the proportion of women presenting for screening mammography who are at elevated lifetime risk of breast cancer as determined by the Gail model. This study provides preliminary information for a proposed follow-up study, including the proportion of women who completed the recommended MRI at the same clinic that had conducted the risk assessment.

MATERIALS AND METHODS

This study is an observational prospective cohort of 64,659 women presenting for mammographic screening at a single high-volume clinic. If a woman reported a first-degree maternal relative with breast cancer and had at least 20% lifetime risk on the Gail model, the radiologist's report included a recommendation that the primary care physician refer the woman for breast MRI screening. Records were examined to determine if women completed the recommended MRI at the clinic within one year of the initial risk assessment.

RESULTS

Of 64,659 women, 1,246 (1.9%) had a lifetime risk of breast cancer of 20% or greater, and 436 (0.7 %) had a lifetime risk of breast cancer 25% or greater. Of the women at elevated risk, 173 (13.9%) completed the recommended breast MRI screening at the clinic within a year.

CONCLUSION

The effectiveness of matching screening intensity to risk on cancer detection, biopsy rate, and cost should be evaluated by studying multiple clinics and multiple risk assessment tools.

Chronic pancreatitis

The abstract is available at the Clinical pancreatic disorder I: Acute pancreatitis. North Am J Med Sci 2011; 3: 316-319. doi: 10.4297/najms.2011.3316

Poor clinical outcomes among pneumonia patients with schizophrenia

Despite the recent attention to patient safety and quality of care, no prior studies have addressed outcomes of hospitalization for pneumonia among patients with schizophrenia. This study investigated the extent to which clinical outcomes of pneumonia were different among patients with schizophrenia. This study used data from the Taiwan National Health Insurance Research Database. Of the total of 81,599 patients admitted with a principal diagnosis of pneumonia from 2002 to 2004, 949 had previously been admitted with a principal or secondary diagnosis of schizophrenia within the 2 years of their index pneumonia admission. We randomly selected 2847 pneumonia patients matched with the study group in terms of gender, age, year of admission, length of stay, and Charlson Comorbidity Index score as the comparison cohort. Conditional logistic regression models were used for analysis. Findings indicated a higher prevalence of adverse outcomes among patients with schizophrenia. Patients with schizophrenia were independently associated with a 1.81 times greater risk of intensive care unit admission (95% confidence interval [CI] = 1.37-2.40), a 1.37 times greater risk of acute respiratory failure (95% CI = 1.08-1.88), and a 1.34-fold greater risk of mechanical ventilation (95% CI = 1.04-1.92) after adjusting for characteristics of patients, physicians, hospitals, and potential clustering effects. Adjusted odds ratios were further evident among those treated in private hospitals and in regional/district hospitals. Significant barriers to prompt and appropriate medical care for pneumonia persist for patients with schizophrenia. Careful monitoring of physical health and proper integration between psychiatrists and physicians should be stressed to reduce poor clinical outcomes in this vulnerable population.

Pharmacological versus microvascular decompression approaches for the treatment of trigeminal neuralgia: clinical outcomes and direct costs

In idiopathic trigeminal neuralgia (TN) the neuroimaging evaluation is usually normal, but in some cases a vascular compression of trigeminal nerve root is present. Although the latter condition may be referred to surgery, drug therapy is usually the first approach to control pain. This study compared the clinical outcome and direct costs of (1) a traditional treatment (carbamazepine [CBZ] in monotherapy [CBZ protocol]), (2) the association of gabapentin (GBP) and analgesic block of trigger-points with ropivacaine (ROP) (GBP+ROP protocol), and (3) a common TN surgery, microvascular decompression of the trigeminal nerve (MVD protocol). Sixty-two TN patients were randomly treated during 4 weeks (CBZ [n = 23] and GBP+ROP [n = 17] protocols) from cases of idiopathic TN, or selected for MVD surgery (n = 22) due to intractable pain. Direct medical cost estimates were determined by the price of drugs in 2008 and the hospital costs. Pain was evaluated using the Numerical Rating Scale (NRS) and number of pain crises; the Hospital Anxiety and Depression Scale, Sickness Impact Profile, and satisfaction with treatment and hospital team were evaluated. Assessments were performed at day 0 and 6 months after the beginning of treatment. All protocols showed a clinical improvement of pain control at month 6. The GBP+ROP protocol was the least expensive treatment, whereas surgery was the most expensive. With time, however, GBP+ROP tended to be the most and MVD the least expensive. No sequelae resulted in any patient after drug therapies, while after MDV surgery several patients showed important side effects. Data reinforce that, (1) TN patients should be carefully evaluated before choosing therapy for pain control, (2) different pharmacological approaches are available to initiate pain control at low costs, and (3) criteria for surgical interventions should be clearly defined due to important side effects, with the initial higher costs being strongly reduced with time.

Long-term daclizumab therapy in relapsing-remitting multiple sclerosis

We performed a retrospective review of side effects and clinical outcomes in relapsing-remitting (RR) multiple sclerosis (MS) patients receiving long-term treatment with daclizumab. Twelve patients with RR MS were initially treated with daclizumab at 1 mg/kg IV, again 14 days later and then monthly treatments (average duration 42.1 months). Daclizumab dose (0.85 mg/kg to 1.5 mg/kg) was adjusted based on clinical response. Daclizumab was generally well tolerated. There was a significant reduction in relapse rate and improvement in Expanded Disability Status Scores (EDSSs) (p < 0.0001). Long-term treatment with daclizumab in RR MS patients has apparent benefit that will require formal confirmation.

Changes in plasma fibronectin isoform levels predict distinct clinical outcomes in critically ill patients

INTRODUCTION

Concentrations of the total pool of fibronectin in plasma (TFN), and the subset of this pool that contains the alternatively spliced EDA segment (A(+)FN), are both affected by disease processes, and the latter pool has gained a reputation as a biomarker for vascular injury. We therefore wished to determine if changes in either FN pool correlate with clinical outcomes in critically ill individuals.

METHODS

We analyzed a database for 57 patients with major trauma (n = 33) or sepsis syndrome (n = 24) in which plasma levels of TFN and A(+)FN had been measured at intervals, along with clinical parameters. Logistic regression analysis was performed to detect associations between predictive variables and three clinical outcomes: 1) the acute respiratory distress syndrome (ARDS), 2) milder acute lung injury designated acute hypoxemic respiratory failure (AHRF), and 3) survival to hospital discharge.

RESULTS

An increase in plasma TFN during the first 24 hours of intensive care unit (ICU) observation was negatively associated with progression to ARDS (odds ratio 0.98 per 1 microgram (μg)/ml increase, 95% CI (0.97, 1.00)) and AHRF (OR 0.97 per 1 μg/ml increase, (0.95, 0.99)), whereas an increase in A(+)FN over the first 24 hours was positively associated with progression to AHRF (OR 1.65 per 1 μg/ml increase, (1.04, 2.62)). Additionally, the ratio of the partial pressure of oxygen in arterial blood (PaO(2)) to the percentage of oxygen in inspired air (FIO(2)) after 24 hours was positively associated with survival (OR 1.01 per 1 unit increase in ratio, (1.00, 1.03)), along with change in A(+)FN (OR 1.30 per 1 μg/ml increase, (0.90, 1.88)).

CONCLUSIONS

Different FN isoforms may constitute predictive covariate markers for distinct clinical outcomes in critically ill patients. The data also suggest that early TFN accumulation in the circulation may confer a clinical benefit to patients at risk for acute lung injury.

Changing needs of community-acquired pneumonia

Community-acquired pneumonia (CAP) is a serious condition associated with significant morbidity and potential long-term mortality. Although the majority of patients with CAP are treated as outpatients, the greatest proportion of pneumonia-related mortality and healthcare expenditure occurs among the patients who are hospitalized. There has been considerable interest in determining risk factors and severity criteria assessments to assist with site-of-care decisions. For both inpatients and outpatients, the most common pathogens associated with CAP include Streptococcus pneumoniae, Haemophilus influenzae, group A streptococci and Moraxella catarrhalis. Atypical pathogens, Gram-negative bacilli, methicillin-resistant Staphylococcus aureus (MRSA) and viruses are also recognized aetiological agents of CAP. Despite the availability of antimicrobial therapies, the recent emergence of drug-resistant pneumococcal and staphylococcal isolates has limited the effectiveness of currently available agents. Because early and rapid initiation of empirical antimicrobial treatment is critical for achieving a favourable outcome in CAP, newer agents with activity against drug-resistant strains of S. pneumoniae and MRSA are needed for the management of patients with CAP.

Stereotactic body radiotherapy for prostate cancer: treatment approaches and clinical outcomes

Extreme hypofractionation may be a radiobiologically sound strategy against prostate cancer cells with presumed low radiosensitivity (α) and high repair capacity (β) to small treatment fractions. In this case, large doses per fraction may be more effective in the tumor cell killing. Hence, the fractionation sensitivity differential (tumor/normal tissue) favors the use of hypofractionated radiotherapy (RT) as tumor α/β values are lower than the values considered for late normal-tissue morbidity. High-dose rate brachytherapy (HDR-BT) and stereotactic body RT (SBRT) are competing extreme hypofractionated treatment methods aiming to efficiently escalate the dose against prostate cancer. Focal treatment strategies to the dominant and non-dominant tumor nodules inside the prostate have been considered with both treatment approaches.The present status of SBRT for prostate cancer is presented as well as a comparative summary of the existing studies on partial prostate boost irradiation either with HDR-BT or SBRT. Extreme hypofractionation (i.e., >6 Gy/fraction) still deserves investigation in prospective trials provided that the precaution is taken to assure an homogeneous tumor dose distribution, a short overall treament time (<5 weeks), and an optimally short fraction duration.

PI3K/PTEN/AKT/mTOR pathway genetic variation predicts toxicity and distant progression in lung cancer patients receiving platinum-based chemotherapy

Non-small cell lung cancer (NSCLC) is still the leading cause of cancer-related deaths. The effect of the PI3K/PTEN/AKT/mTOR signaling pathway on cancer treatment, including NSCLC, has been well documented. In this study, we analyzed associations between genetic variations within this pathway and clinical outcomes following platinum-based chemotherapy in 168 patients with stage IIIB (wet) or stage IV NSCLC. Sixteen tagging SNPs in five core genes (PIK3CA, PTEN, AKT1, AKT2, and FRAP1) of this pathway and identified SNPs associated with development of toxicity and disease progression. We observed significantly increased toxicity for patients with PIK3CA:rs2699887 (OR: 3.86, 95% CI: 1.08-13.82). In contrast, a SNP in PTEN was associated with significantly reduced risk for chemotherapeutic toxicity (OR: 0.44, 95% CI: 0.20-0.95). We identified three SNPs in AKT1 resulting in significantly decreased risks of distant progression in patients carrying at least one variant allele with HRs of 0.66 (95% CI: 0.45-0.97), 0.52 (95% CI: 0.35-0.77), and 0.62 (95% CI: 0.42-0.91) for rs3803304, rs2498804, and rs1130214, respectively. Furthermore, these same variants conferred nearly 2-fold increased progression-free survival times. The current study provides evidence that genetic variations within the PI3K/PTEN/AKT/mTOR signaling pathway are associated with variation in clinical outcomes of NSCLC patients. With further validation, our findings may provide additional biomarkers for customized treatment of platinum-based chemotherapy for NSCLC.

Geriatric hip fracture clinical pathway: the Hong Kong experience

Geriatric hip fracture is one of the commonest fractures in orthopaedic trauma. There is a trend of further increase in its incidence in the coming decades. Besides the development of techniques and implants to overcome the difficulties in fixation of osteoporosis bone, the general management of the hip fracture is also very challenging in terms of the preparation of the generally poorer pre-morbid state and complicate social problems associated with this group of patients. In order to cope with the increasing demand, our hospital started a geriatric hip fracture clinical pathway in 2007. The aim of this pathway is to provide better care for this group of patients through multidisciplinary approach. From year 2007 to 2009, we had managed 964 hip fracture patients. After the implementation of the pathway, the pre-operative and the total length of stay in acute hospital were shortened by over 5 days. Other clinical outcomes including surgical site infection, 30 days mortality and also incidence of pressure sore improved when compared to the data before the pathway. The rate of surgical site infection was 0.98%, and the 30 days mortality was 1.67% in 2009. The active participation of physiotherapists, occupational therapists as well as medical social workers also helped to formulate the discharge plan as early as the patient is admitted. In conclusion, a well-planned and executed clinical pathway for hip fracture can improve the clinical outcomes of the geriatric hip fractures.

Diffusion imaging in multiple sclerosis: research and clinical implications

Multiple sclerosis (MS) is an inflammatory-demyelinating and neurodegenerative disease of the central nervous system (CNS) and the most frequent cause of non-traumatic disability in young and middle-age adults. Although conventional MRI (including T2-weighted, pre- and post-contrast T1-weighted scans) has had a huge impact on MS by enabling an earlier diagnosis, and by providing surrogate markers for monitoring treatment response, it is limited by the low pathological specificity and the low sensitivity to diffuse damage in normal-appearing white matter and gray matter. Diffusion weighted MRI is a quantitative technique able to overcome these limitations by providing markers more specific to the underlying pathologic substrates and more sensitive to the full extent of 'occult' brain tissue damage. This review describes diffusion studies in MS, discusses their pathophysiological implications and emphasizes their clinical relevance.

Recent injury and health-related quality of life in adolescent athletes

CONTEXT

Health-related quality of life (HRQOL) is a global concept that takes into account the physical, psychological, and social domains of health. Determining the extent to which injury affects HRQOL is an important aspect of rehabilitation practice, enabling comparisons of clinical outcomes across different conditions in diverse patient groups.

OBJECTIVE

To examine the extent to which a self-reported recent injury affected HRQOL in adolescent athletes using 2 generic patient self-report scales.

DESIGN

Cross-sectional study.

SETTING

High school classrooms and athletic training facilities.

PATIENTS OR OTHER PARTICIPANTS

A convenience sample of uninjured (n = 160) and injured (n = 45) adolescent athletes.

INTERVENTION(S)

THE INDEPENDENT VARIABLE WAS INJURY STATUS: uninjured versus injured. All participants completed a self-administered brief health status questionnaire and the Short Form-36 Health Survey Questionnaire (SF-36) and Pediatric Outcomes Data Collection Instrument (PODCI) in a counterbalanced manner.

MAIN OUTCOME MEASURE(S)

Dependent variables included 8 subscale and 2 composite scores of the SF-36 and 5 subscale scores and 1 global score of the PODCI. Group differences were assessed with the Mann-Whitney U test (P < or = .05) and reported as median and interquartile range.

RESULTS

On the SF-36, the injured group demonstrated lower scores (P < .008) for physical functioning, limitations due to physical health problems, bodily pain, social functioning, and the physical composite. On the PODCI, the injured group reported lower scores (P < .01) on the pain and comfort subscale and the global score.

CONCLUSIONS

Adolescent athletes with self-reported injuries demonstrated lower HRQOL than their uninjured peers. As expected, recent injury affected physical functioning and pain. Social functioning (on the SF-36) and global HRQOL (on the PODCI) also decreased, suggesting that injuries affected areas beyond the expected physical component of health. Clinicians need to recognize the full spectrum of negative influences that injuries may have on HRQOL in adolescent athletes.

The value of various assessment techniques in detecting the effects of concussion on cognition, symptoms, and postural control

Reference/Citation:

Broglio SP, Puetz TW. The effect of sport concussion on neurocognitive function, self-report symptoms, and postural control: a meta-analysis. Sports Med. 2008;38(1):53–67.

Clinical Question:

How effective are various concussion assessment techniques in detecting the effects of concussion on cognition, balance, and symptoms in athletes?

Data Sources:

Studies published between January 1970 and June 2006 were identified from the PubMed and PsycINFO databases. Search terms included concussion, mild traumatic brain injury, sport, athlete, football, soccer, hockey, boxing, cognition, cognitive impairment, symptoms, balance, and postural control. The authors also handsearched the reference list of retrieved articles and sought the opinions of experts in the field for additional studies.

Study Selection:

Studies were included if they were published in English; described a sample of athletes concussed during athletic participation; reported outcome measures of neurocognitive function, postural stability, or self-report symptoms; compared the postconcussion assessments with preseason (healthy) baseline scores or a control group; completed at least 1 postinjury assessment within the first 14 days after the concussion (to reflect neurometabolic recovery); and provided enough information for the authors to calculate effect sizes (means and SDs at baseline and postinjury time points). Selected studies were grouped according to their outcome measure (neurocognitive function, symptoms, or postural control) at initial and follow-up (if applicable) time points. Excluded articles included review articles, abstracts, case studies, editorials, articles without baseline data, and articles with data extending beyond the 14-day postinjury time frame.

Data Extraction:

From each study, the following information was extracted by one author and checked by the second author: participant demographics (sport, injury severity, incidence of loss of consciousness, and postconcussion assessment times), sample sizes, and baseline and postconcussion means and SDs for all groups. All effect sizes (the Hedge g) were computed so that decreases in neurocognitive function and postural control or increases in symptom reports resulted in negative effect sizes, demonstrating deficits in these domains after concussion. The authors also extracted the following moderators: study design (with or without control group), type of neurocognitive technique (Standardized Assessment of Concussion, computerized test, or pencil-and-paper test), postconcussion assessment time, and number of postconcussion assessments.

Main Results:

The search identified 3364 possible abstracts, which were then screened by the authors, with 89 articles being further reviewed for relevancy. Fifty articles were excluded because of insufficient data to calculate effect sizes, lack of a baseline assessment or control group, or because the data had been published in more than one study. The remaining 39 studies met all of the inclusion criteria and were used in the meta-analysis; 34 reported neurocognitive outcome measures, 14 provided self-report symptom outcomes, and 6 presented postural control as the dependent variable. The analyzed studies included 4145 total participants (concussed and control) with a mean age of 19.0 ± 0.4 years. The quality of each included study was also evaluated by each of the 2 authors independently using a previously published 15-item scale; the results demonstrated excellent agreement between the raters (intraclass correlation coefficient  =  0.91, 95% confidence interval [CI]  =  0.83, 0.95). The quality appraisal addressed randomization, sample selection, outcome measures, and statistical analysis, among other methodologic considerations. Quality scores of the included studies ranged from 5.25 to 9.00 (scored from 0–15).

The initial assessment demonstrated a deficit in neurocognitive function (Z  =  7.73, P &lt; .001, g  =  −0.81 [95% CI  =  −1.01, −0.60]), increase in self-report symptoms (Z  =  2.13, P  =  .03, g  =  −3.31 [95% CI  =  −6.35, −0.27]), and a nonsignificant decrease in postural control (Z  =  1.29, P  =  .19, g  =  −2.56 [95% CI  =  −6.44, 1.32]).

For the follow-up assessment analyses, a decrease in cognitive function (Z  =  2.59, P  =  .001, g  =  −26 [95% CI  =  −0.46, −0.06]), an increase in self-report symptoms (Z  =  2.17, P  =  .03, g  =  −1.09 [95% CI  =  −2.07, −0.11]), and a nonsignificant decrease in postural control (Z  =  1.59, P  =  0.11, g  =  −1.16 [95% CI  =  −2.59, 0.27]) were found.

Neurocognitive and symptom outcomes variables were reported in 10 studies, and the authors were able to compare changes from baseline in these measures during the initial assessment time point. A difference in effect sizes was noted (QB(1)  =  5.28, P  =  .02), with the increases in self-report symptoms being greater than the associated deficits in neurocognitive function.

Conclusions:

Sport-related concussion had a large negative effect on cognitive function during the initial assessment and a small negative effect during the first 14 days postinjury. The largest neurocognitive effects were found with the Standardized Assessment of Concussion during the immediate assessment and with pencil-and-paper neurocognitive tests at the follow-up assessment. Large negative effects were noted at both assessment points for postural control measures. Self-report symptoms demonstrated the greatest changes of all outcomes variables, with large negative effects noted both immediately after concussion and during the follow-up assessment. These findings reiterate the recommendations made to include neurocognitive measures, postural control tests, and symptom reports into a multifaceted concussion battery to best assess these injuries.

Prospective comparative study of anterior cruciate ligament reconstruction using the double-bundle and single-bundle techniques

BACKGROUND

The intent of double-bundle anterior cruciate ligament reconstruction is to reproduce the normal anterior cruciate ligament anatomy and improve knee joint rotational stability. However, no consensus has been reached on the advantages of this technique over the single-bundle technique.

HYPOTHESIS

We hypothesized that double-bundle anterior cruciate ligament reconstruction could provide better intraoperative stability and clinical outcome than single-bundle reconstruction.

TYPE OF STUDY

Cohort study; Level of evidence, 2.

METHODS

Forty patients with anterior cruciate ligament injury in one knee were recruited; 20 were allocated to a double-bundle anterior cruciate ligament reconstruction group and 20 to a single-bundle anterior cruciate ligament reconstruction group. Intraoperative stabilities at 30 degrees of knee flexion were compared between the 2 groups using a navigation system. Clinical outcomes including Lysholm knee scores, Tegner activity scores, Lachman and pivot-shift test results, and radiographic stabilities were also compared between the 2 groups after a minimum of 2 years of follow-up.

RESULTS

Intraoperative anterior and rotational stabilities after anterior cruciate ligament reconstruction in the double-bundle group were significantly better than those in single-bundle group (P = .020 and P < .001, respectively). Nineteen patients (95%) in each group were available at a minimum 2-year follow-up. Clinical outcomes including Lysholm knee and Tegner activity scores were similar in the 2 groups at 2-year follow-up (P > .05). Furthermore, stability results of the Lachman and pivot-shift tests, and radiologic findings at 2-year follow-up failed to reveal any significant intergroup differences (P > .05).

CONCLUSION

Although double-bundle anterior cruciate ligament reconstruction produces better intraoperative stabilities than single-bundle anterior cruciate ligament reconstruction, the 2 modalities were found to be similar in terms of clinical outcomes and postoperative stabilities after a minimum of 2 years of follow-up.

Functional state following the Fontan procedure

BACKGROUND

Despite improvements in outcomes after completion of the Fontan circulation, long-term functional state varies. We sought to identify pre- and postoperative characteristics associated with overall function.

METHODS AND RESULTS

We analyzed data from 476 survivors with the Fontan circulation enrolled in the Pediatric Heart Network Fontan Cross-sectional Study. Mean age at creation of the Fontan circulation was 3.4 plus or minus 2.1 years, with a range from 0.7 to 17.5 years, and time since completion was 8.7 plus or minus 3.4 years, the range being from 1.1 to 17.3 years. We calculated a functional score for the survivors by averaging the percentile ranks of ventricular ejection fraction, maximal consumption of oxygen, the physical summary score for the Child Health Questionnaire, and a function of brain natriuretic peptide. The mean calculated score was 49.5 plus or minus 17.3, with a range from 3 to 87. After adjustment for time since completion of the circulation, we found that a lower score, and hence worse functional state, was associated with: right ventricular morphology (p less than 0.001), higher ventricular end-diastolic pressure (p equals 0.003) and lower saturations of oxygen (p equals 0.047) prior to completion of the Fontan circulation, lower income for the caregiver (p equals 0.003), and, in subjects without a prior superior cavopulmonary anastomosis, arrhythmias after completion of the circulation (p equals 0.003). The model explained almost one-fifth (18%) of the variation in the calculated scores. The score was not associated with surgical centre, sex, age, weight, fenestration, or the period of stay in hospital after completion of the Fontan circuit. A validation model, using 71 subjects randomly excluded from initial analysis, weakly correlated (R equals 0.17, p equals 0.16) with the score calculated from the dataset.

CONCLUSIONS

Right ventricular morphology, higher ventricular end-diastolic pressure and lower saturations of oxygen prior to completion of the Fontan circuit, lower income for the provider of care, and arrhythmias after creation of the circuit, are all associated with a worse functional state. Unmeasured factors also influence outcomes.

Does higher diastolic augmentation predict clinical benefit from enhanced external counterpulsation?: Data from the International EECP Patient Registry (IEPR)

BACKGROUND

Enhanced external counterpulsation (EECP) has been demonstrated to be an effective treatment for stable angina in patients with coronary disease. The hemodynamic effects of EECP are maximized when the ratio of diastolic to systolic pressure area is in the range of 1.5 to 2.0.

HYPOTHESIS

It is hypothesized that patients undergoing EECP who are able to achieve higher diastolic augmentation (DA) ratios may derive greater clinical benefit. This study examines the relationship between the DA ratio and clinical outcomes in patients undergoing EECP.

METHODS

We analyzed demographic, noninvasive hemodynamic, and clinical outcome data on 1,004 patients enrolled in the International EECP Patient Registry (IEPR) for treatment of chronic angina between January 1998 and August 1999. Blood pressure waveforms were recorded from finger plethysmography. Six-month clinical outcomes were obtained by telephone interview.

RESULTS

At the end of EECP treatment, 370 (37%) patients had a higher DA ratio (defined as > or = 1.5) and 634 (63%) had a lower DA ratio (defined as < 1.5). Factors associated with a lower DA ratio included age > or =65 years (p <0.001), female gender (p < 0.001), left ventricular ejection fraction < 35% (p < 0.05), hypertension (p < 0.01), prior coronary bypass surgery (p < 0.01), noncardiac vascular disease (p < 0.001), multivessel disease (p < 0.01), congestive heart failure (p < 0.01), current smoking (p < 0.01), unsuitability for further revascularization (p < 0.001), and higher baseline angina class (p < 0.001). There were no significant differences regarding diabetes mellitus, prior coronary angioplasty, prior myocardial infarction, or antianginal medication use between patients with higher or lower DA ratios. Based on a multiple logistic regression model, independent predictors of a DA ratio < 1.5 at the end of EECP included current smoking (odds ratio 3.3; 95% confidence intervals 2.0-5.4); multivessel disease (1.7; 1.3-2.3); female gender (2.2; 1.7-3.0); no prior EECP (1.9; 1.1-3.3); noncardiac vascular disease (2.3; 1.7-2.9); age > or = 65 years (1.7; 1.4-2.2), and patients not suitable for revascularization (1.6; 1.2-2.0). By the end of therapy, there were no significant differences in myocardial infarction, revascularization rates, or nitroglycerin use with respect to higher DA ratios. At 6-month follow-up, patients with higher DA had a trend toward a greater reduction in angina class compared with those with lower DA (p = 0.069). There was a significantly higher rate of unstable angina and congestive heart failure in the group not achieving higher augmentation (p < 0.05).

CONCLUSIONS

Patients who are younger, male, nonsmoking, and without multivessel coronary or noncardiac vascular disease are most likely to have higher DA with EECP. Patients with higher DA tended to have a greater reduction in angina class at 6-month follow-up compared with those with lower DA ratios. There is evidence that higher DA ratios are associated with improved short- or long-term clinical outcomes, suggesting that clinical benefit from EECP is associated with the magnitude of DA.

Effect of statins on a wide range of health outcomes: a cohort study validated by comparison with randomized trials

AIMS

To assess the effect of statins on a range of health outcomes.

METHODS

We undertook a population-based cohort study to assess the effect of statins on a range of health outcomes using a propensity score-based method to control for differences between people prescribed and not prescribed statins. We validated our design by comparing our results for vascular outcomes with the effects established in large randomized trials. The study was based on the United Kingdom Health Improvement Network database that includes the computerized medical records of over four and a half million patients.

RESULTS

People who initiated treatment with a statin (n = 129,288) were compared with a matched sample of 600,241 people who did not initiate treatment, with a median follow-up period of 4.4 years. Statin use was not associated with an effect on a wide range of outcomes, including infections, fractures, venous thromboembolism, gastrointestinal haemorrhage, or on specific eye, neurological or autoimmune diseases. A protective effect against dementia was observed (hazard ratio 0.80, 99% confidence interval 0.68, 0.95). There was no effect on the risk of cancer even after > or =8 years of follow-up. The effect sizes for statins on vascular end-points and mortality were comparable to those observed in large randomized trials, suggesting bias and confounding had been well controlled for.

CONCLUSIONS

We found little evidence to support wide-ranging effects of statins on health outcomes beyond their established beneficial effect on vascular disease.

Resting heart rate: a modifiable prognostic indicator of cardiovascular risk and outcomes?

A growing body of evidence from clinical trials and epidemiological studies has identified elevated resting heart rate as a predictor of clinical events. Proof of direct cause and effect is limited, because current drugs that lower heart rate (eg, beta-blockers) have multiple mechanisms of action. A new class of drug, selective I(f) inhibitors, is under investigation as a 'pure' heart rate-reducing medication and will help confirm if there is a causal link between elevated heart rate and cardiovascular outcomes. The present paper reviews the evidence for elevated heart rate as a cardiovascular risk factor and some of the current clinical trials testing this hypothesis.

Artificial Neural Networks for Early Prediction of Mortality in Patients with Non Variceal Upper GI Bleeding (UGIB)

BACKGROUND

Mortality for non variceal upper gastrointestinal bleeding (UGIB) is clinically relevant in the first 12-24 hours of the onset of haemorrhage and therefore identification of clinical factors predictive of the risk of death before endoscopic examination may allow for early corrective therapeutic intervention.

AIM

1) Identify simple and early clinical variables predictive of the risk of death in patients with non variceal UGIB; 2) assess previsional gain of a predictive model developed with conventional statistics vs. that developed with artificial neural networks (ANNs).

METHODS AND RESULTS

Analysis was performed on 807 patients with nonvariceal UGIB (527 males, 280 females), as a part of a multicentre Italian study. The mortality was considered "bleeding-related" if occurred within 30 days from the index bleeding episode. A total of 50 independent variables were analysed, 49 of which clinico-anamnestic, all collected prior to endoscopic examination plus the haemoglobin value measured on admission in the emergency department. Death occurred in 42 (5.2%). Conventional statistical techniques (linear discriminant analysis) were compared with ANNs (Twist® system-Semeion) adopting the same result validation protocol with random allocation of the sample in training and testing subsets and subsequent cross-over. ANNs resulted to be significantly more accurate than LDA with an overall accuracy rate near to 90%.

CONCLUSION

Artificial neural networks technology is highly promising in the development of accurate diagnostic tools designed to recognize patients at high risk of death for UGIB.

Biliary tract infection and bacteraemia: presentation, structural abnormalities, causative organisms and clinical outcomes

BACKGROUND

Biliary tract infection is a common cause of bacteraemia and is associated with high morbidity and mortality. Few papers describe blood culture isolates, underlying structural abnormalities and clinical outcomes in patients with bacteraemia.

AIMS

To determine the proportion of bacteraemias caused by biliary tract infection and to describe patient demographics, underlying structural abnormalities and clinical outcomes in patients with bacteraemia.

DESIGN

Prospective cohort study.

METHODS

Biliary tract infection that caused bacteraemia was defined as a compatible clinical syndrome and a blood culture isolate consistent with ascending cholangitis. Patients aged 16 years and over were included in the study. From June 2003 to May 2005, demographic and clinical data were collected prospectively on all adult patients with bacteraemia. Radiological and endoscopic retrograde cholangiopancreatography findings were collected retrospectively.

RESULTS

In 49 patients, the biliary tract was the site of infection for 39/592 (6.6%) community-acquired and 19/466 (4.1%) hospital-acquired episodes of bacteraemia. Three patients had mixed bacteraemias, and four had recurrent bacteraemia. The proportion of patients presenting with a structural abnormality was 34/49 (69%), and, of these structural abnormalities, 18/34 (53%) were pre-existing or newly diagnosed malignancies. Gram-negative organisms caused 55/58 (95%) episodes of bacteraemia. The most common Gram-negative organisms were Escherichia coli (34/55; 62%) and Klebsiella pneumoniae (14/55; 26%). Of the E coli isolates, 6/34 (18%) were extended spectrum beta-lactamase producers or multiply drug resistant. Thirty-day mortality was 7/49 (14%). There was no difference in time taken to administer an effective antibiotic to survivors and non-survivors (0.86 vs 1.05 days, respectively, p = 0.92). Of the seven who died, four died from septic shock within 48 h of admission caused by "susceptible" Gram-negative organisms. Two others died from disseminated malignancy.

CONCLUSIONS

The proportion of bacteraemias caused by biliary tract infection was 5.5%. The most common infecting organisms were E coli and K pneumoniae. There was a strong association with choledocholithiasis and malignancies, both pre-existing and newly diagnosed. Death was uncommon but when it occurred was often caused by septic shock within 48 h of presentation.

Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients

OBJECTIVES

To investigate patients' experience with coordination of their postsurgical care across multiple settings and the effects on key outcomes.

DATA SOURCES

Primary data collected over 18 months from 222 unilateral knee-replacement patients at Brigham and Women's Hospital in Boston, MA.

STUDY DESIGN

Patients were surveyed about the coordination of their postdischarge care during the 6-week period postdischarge when they received care from rehabilitation facilities and/or home care agencies and follow-up care from the surgeon.

DATA COLLECTION

Patients were surveyed before surgery and at 6 and 12 weeks postsurgery.

PRINCIPAL FINDINGS

Patient reports highlight problems with coordination across settings and between providers and themselves. These problems, measured at 6 weeks, were associated with greater joint pain, lower functioning, and lower patient satisfaction at 6 weeks after surgery. At 12 weeks after surgery, coordination problems were associated with greater joint pain, but were not associated with functional status.

CONCLUSION

Coordination across settings affects patients' clinical outcomes and satisfaction with their care. Although accountable for transfer to the next care setting, providers are neither accountable for nor supported to coordinate across the continuum. Addressing this system problem requires both introducing coordinating mechanisms and also supporting their use through changes in providers' incentives, resources, and time.

Meta-analysis: anticholinergics, but not beta-agonists, reduce severe exacerbations and respiratory mortality in COPD

BACKGROUND

Anticholinergics and beta2-agonists have generally been considered equivalent choices for bronchodilation in chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To assess the safety and efficacy of anticholinergics and beta2-agonists in COPD.

DESIGN

We comprehensively searched electronic databases from 1966 to December 2005, clinical trial websites, and references from selected reviews. We included randomized controlled trials of at least 3 months duration that evaluated anticholinergic or beta2-agonist use compared with placebo or each other in patients with COPD.

MEASUREMENTS

We evaluated the relative risk (RR) of exacerbations requiring withdrawal from the trial, severe exacerbations requiring hospitalization, and deaths attributed to a lower respiratory event.

RESULTS

Pooled results from 22 trials with 15,276 participants found that anticholinergic use significantly reduced severe exacerbations (RR 0.67, confidence interval [CI] 0.53 to 0.86) and respiratory deaths (RR 0.27, CI 0.09 to 0.81) compared with placebo. Beta2-agonist use did not affect severe exacerbations (RR 1.08, CI 0.61 to 1.95) but resulted in a significantly increased rate of respiratory deaths (RR 2.47, CI 1.12 to 5.45) compared with placebo. There was a 2-fold increased risk for severe exacerbations associated with beta2-agonists compared with anticholinergics (RR 1.95, CI 1.39 to 2.93). The addition of beta2-agonist to anticholinergic use did not improve any clinical outcomes.

CONCLUSION

Inhaled anticholinergics significantly reduced severe exacerbations and respiratory deaths in patients with COPD, while beta2-agonists were associated with an increased risk for respiratory deaths. This suggests that anticholinergics should be the bronchodilator of choice in patients with COPD, and beta2-agonists may be associated with worsening of disease control.

Early follow-up for a hybrid total hip arthroplasty using a metal-backed acetabular component designed to reduce "backside" polyethylene wear

Modular acetabular systems have several advantages; however, increased polyethylene wear has been recognized as a disadvantage. In our study, an acetabular shell design with a highly polished inner surface, a locking mechanism that minimizes micromotion, and a high polyethylene liner to shell conformity was evaluated. A prospective cohort of 50 consecutive hips was followed up for a mean of 3.6 years (range, 2-7 years). One patient required an early revision for recurrent instability. Mean linear head penetration rates were 0.242 mm/year (range, 0.048-0.655 mm/year). The true linear wear rate was calculated after subtracting the linear wear in the first follow-up year from the total wear at the end of the follow-up. The true linear wear rate was 0.173 mm/year (range, 0.03-0.423 mm/year). A positive correlation was found between wear rate and male gender. The low head penetration rates suggest that a polished liner with an improved locking mechanism and increased liner conformity can reduce polyethylene wear.

Managing high-risk patients with acute coronary syndromes: the Prospective Registry of Acute Ischaemic Syndromes in the UK (PRAIS-UK)

A study was carried out to find out whether more intense treatment (both medical and revascularisation) is targeted towards higher-risk patients with acute coronary syndromes. A prospective UK registry of patients admitted with non-ST elevation acute coronary syndromes was established to examine practice patterns and clinical outcomes with respect to the risk profile of the patients. Clinically important high-risk subgroups included the elderly, diabetics, those with heart failure and those with ST depression or bundle branch block on the presenting ECG. Elderly patients were less likely to receive evidence-based treatments, including beta blockers, statins and revascularisation. Diabetics received more revascularisation procedures but the overall revascularisation rate was low. Heart failure patients received less evidence-based treatment, with the exception of angiotensin-converting enzyme (ACE) inhibitors. Heparin was used less frequently in those with a normal ECG, although rates of revascularisation were not different when compared with those with ECG abnormalities. The conclusions of the study were that groups of patients with particularly high event rates are readily identified by their clinical characteristics, but use of evidence-based treatments and invasive investigations do not appear to be targeted towards those at greatest risk. Risk stratification and the appropriate application of treatments for patients with acute coronary syndromes need to be reviewed in the clinical setting.

The Auckland cataract study: co-morbidity, surgical techniques, and clinical outcomes in a public hospital service

AIM

To prospectively assess cataract surgery in a major New Zealand public hospital by defining presenting clinical parameters and surgical and clinical outcomes in a cohort of subjects just below threshold for treatment, based upon a points based prioritisation system.

METHODS

The prospective observational study comprised 488 eyes of 480 subjects undergoing consecutive cataract operations at Auckland Hospital. All subjects underwent extensive ophthalmic examination before and after surgery. Details of the surgical procedure, including any intraoperative difficulties or complications, were documented. Postoperative review was performed at 1 day and 4 weeks after surgery. Demographic data, clinical outcomes, and adverse events were correlated by an independent assessor.

RESULTS

The mean age at surgery was 74.9 (SD 9.6) years with a female predominance (62%). Significant systemic disease affected 80% of subjects, with 20% of the overall cohort exhibiting diabetes mellitus. 26% of eyes exhibited coexisting ocular disease and in 7.6% this affected best spectacle corrected visual acuity (BSCVA). A mean spherical equivalent of -0.49 (1.03) D and mean BSCVA of 0.9 (0.6) log MAR units (Snellen equivalent approximately 6/48) was noted preoperatively. Local anaesthesia was employed in 99.8% of subjects (94.9% sub-Tenon's). The majority of procedures (97.3%) were small incision phacoemulsification with foldable lens implant. Complications included: 4.9% posterior capsule tears, 3.8% cystoid macular oedema, and one case (0.2%) of endophthalmitis. Mean BSCVA after surgery was 0.1 (0.2) log MAR units (6/7.5 Snellen equivalent), with a mean spherical equivalent of -0.46 (0.89) D, and was 6/12 or better in 88% of all eyes. A drop in BSCVA, thought to be directly attributable to the surgical intervention, was recorded in a small percentage of eyes (1.5%) after surgery.

CONCLUSION

This study provides a representative assessment of the management of cataract in the New Zealand public hospital system. A predominantly elderly, female population, frequently exhibiting significant systemic illness and coexisting ocular disease, relatively advanced cataracts, and poor BSCVA, presented for cataract surgery. The majority of subjects underwent small incision, phacoemulsification, day case surgery. While almost 90% achieved at least 6/12 BSCVA post-surgery, approximately 5% sustained an adverse intraoperative event and 1.5% of eyes exhibited a reduction in BSCVA postoperatively.

Respiratory illness caused by picornavirus infection: a review of clinical outcomes

BACKGROUND

Respiratory infections result from invasion of the respiratory tract, mainly by viruses, and are the leading cause of acute morbidity in individuals of all ages worldwide. During peak season, picornaviruses cause 82% of all episodes of acute nasopharyngitis (the common cold), the most frequent manifestation of acute respiratory infection, and produce more restriction of activity and physician consultations annually than any other viral or bacterial source of respiratory illness.

OBJECTIVE

This article reviews the clinical impact and outcomes of picornavirus-induced respiratory infections in specific populations at risk for complications. It also discusses the potential economic impact of the morbidity associated with picornavirus-induced respiratory infection.

METHODS

Relevant literature was identified through searches of MEDLINE, OVID, International Pharmaceutical Abstracts, and Lexis-Nexis. The search terms used were picornavirus, rhinovirus, enterovirus, viral respiratory infection, upper respiratory infection, disease burden, economic, cost, complications, asthma, COPD, immunocompromised, elderly otitis media, and sinusitis. Additional publications were identified from the reference lists of the retrieved articles.

CONCLUSIONS

Based on the clinical literature, picornavirus infections are associated with severe morbidity as well as considerable economic and societal costs. Future research should focus on identifying patterns of illness and the costs associated with management of these infections. New treatments should be assessed not only in terms of their ability to produce the desired clinical outcome, but also in terms of their ability to reduce the burden of disease, decrease health care costs, and improve productivity.