Positive predictive value of CT coronary angiography vs. CT fractional flow reserve in a real-world population

Background

Computerised tomography coronary angiography and fractional flow reserve (CTCA and CT-FFR) are non-invasive diagnostic tools for the detection of flow limiting coronary artery stenoses. Although their negative predictive values are well established, there is a concern that the high sensitivity of these tests may lead to overestimation of coronary artery disease (CAD) and unnecessary invasive coronary angiography (ICA). We compared the positive predictive value (PPV) of CT-FFR with computerised tomography coronary angiography (CTCA) against the gold standard of ICA in different real-world patient groups.

Methods

We conducted a retrospective study of 477 patients referred for CTCA or CT-FFR for investigation of possible coronary ischaemia. Patients were excluded if the image quality was poor or inconclusive. Patient-based PPV was calculated to detect or rule out significant CAD, defined as more than 70% stenosis on ICA. A sub-analysis of PPV by indication for scan was also performed. Patients that underwent invasive non-hyperaemic pressure wire measurements had their iFR or RFR compared with their CT-FFR values.

Results

In a patient-based analysis, the overall PPV was 59.3% for CTCA and 76.2% for CT-FFR. This increased to 81.0% and 86.7% respectively for patients with stable angina symptoms. In patients with atypical angina symptoms, CT-FFR considerably outperformed CTCA with a PPV of 61.3% vs. 37.5%. There was not a linear relationship between invasive pressure wire measurement and CT-FFR value (r=0.23, p=0.265).

Conclusion

The PPV of CTCA and CT-FFR is lower in the real-world than in previously published trials, partly due to the heterogeneity of indication for the scan. However, in patients with typical angina symptoms, both are reliable diagnostic tools to determine the presence of clinically significant coronary stenoses. CT-FFR significantly outperforms CTCA in patients with more atypical symptoms and the targeted use of CT-FFR in this group may help to avoid unnecessary invasive procedures.

Funding Acknowledgement

Type of funding sources: None.

Predicting Outcome in Patients with Acute Coronary Syndrome: Evaluation of B-Type Natriuretic Peptide and the Global Registry of Acute Coronary Events (GRACE) Risk Score

Background

Accurate risk stratification soon after admission for patients with acute coronary syndromes (ACS) is vital in guiding management. Clinical risk scores and B-type natriuretic peptide (BNP) can predict mortality and re-infarction in ACS, but it is unknown whether BNP provides prognostic information over and above that of the clinical risk scores.

Methods

142 unselected patients with ACS were prospectively studied. BNP was measured and patients were stratified according to BNP and Global Registry of Acute Coronary Events (GRACE) score. In-hospital and 30-day events were characterised.

Results

20.4% of ACS subjects had ST-elevation myocardial infarction (MI), 14.1%, non-ST elevation MI and 65.5% unstable angina. Elevated BNP predicted inhospital and 30-day heart failure (p<0.01), and the risk of in-hospital recurrent ACS (p<0.05). Increasing GRACE score predicted in-hospital recurrent ACS (p<0.05), heart failure (p<0.001), arrhythmias (p<0.05) and angioplasty (p<0.05). GRACE score also predicted 30-day heart failure (p<0.05). In contrast, the predictive accuracy of troponin elevation was less robust.

Conclusion

BNP and the GRACE score predict complementary outcomes from ACS, but both predicted heart failure. BNP is a powerful indicator of heart failure in patients with ACS and provides prognostic information above and beyond conventional biomarkers and risk scores.

HIV infection among heroin users and area of residence

The aim of this study was to develop a hypothesis to explain the link between HIV prevalence and area of residence. The study was conducted in two parts using two existing data sources. In Part 1, the bloodborne viral test status and test results of a sample of clients attending treatment in December 2001 in two areas of Dublin, an inner city area (Dublin 8) and a suburban area (Dublin 24), were extracted from the Bloodborne Viral Status Dataset created by Grogan. In Part 2 the characteristics of heroin users seeking treatment for the first time at treatment services in their respective areas of residence, Dublin 8 or Dublin 24, between 1997 and 2000 were examined, using data from the National Drug Treatment Reporting System. A higher proportion of heroin users in Dublin 8 had HIV and hepatitis C than did their counterparts in Dublin 24. The analysis suggests that heroin users in Dublin 8 were more likely both to have ever used cocaine and to have used heroin daily, than were those who lived in Dublin 24. Also, a higher proportion of injectors living in Dublin 8 used heroin and cocaine concurrently than did their counterparts in Dublin 24. In both samples, heroin users who lived in Dublin 8 were older than those who lived in Dublin 24. The findings led to a hypothesis:'The risk of acquiring HIV is associated with area of residence and may be linked to cocaine use.

Trends in alcohol consumption in undergraduate third level students: 1992-1999

BACKGROUND

Alcohol consumption has increased in the Irish population in recent years. It is not known to what extent the student population has been affected by this increase.

AIM

To determine levels of alcohol consumption among undergraduates in one Irish university and identify changes in drinking patterns in the years 1992-1999.

METHODS

Information on alcohol use was obtained by anonymous self-completed questionnaire in a stratified random cross-faculty sample of undergraduates in 1992 and 1999. The CAGE questionnaire to determine problem drinking was included in both surveys.

RESULTS

A statistically significant (p=0.01) drop in weekly alcohol consumption by males was found, although the proportion of male problem drinkers increased. Consumption for females remained the same.

CONCLUSIONS

Findings are contrary to recent figures for drinking patterns in young Irish people in general. The fall in alcohol consumption in male students may be linked to improved male insight into the negative effects of alcohol or to the substitution of cheaper available substances.

The changing status of 'filler syllables' on the way to grammatical morphemes

The appearance of 'filler syllables' (called here PAEs, for Prefixed Additional Elements) in the late single-word period is analysed in relation to the emergence of grammatical morphemes, by confronting data from the longitudinal study of one child acquiring French, video-recorded between 1;3.2 and 2;2.6, with four hypotheses making different claims about the kind of language knowledge underlying their production: the devices to lengthen single-word utterances, the syntactic slots, the selectivity of occurrence, and the organization of surface regularities hypotheses. The pattern of results concerning the first two to three months' production of PAEs points to the existence of a premorphological period in which PAEs result from the organization of phonoprosodic regularities of the language rather than being constrained by structural rules relative to syntactic slots or to the class of the word they precede. This premorphological period is followed by a protomorphological one in which incipient properties of grammatical morphemes and of word classes start to appear at the same time.

Stress and morale in general practice: a comparison of two health care systems

BACKGROUND

Poor morale and high levels of stress among general practitioners (GPs) are causing concern. Little research has previously been carried out to study possible differences in morale and stress between GPs working in two different but geographically similar health care systems.

AIM

To compare perceived levels of stress and morale between GPs working in two different health care systems--one having a state monopoly (Northern Ireland) and the other having mixed private and state funding (Republic of Ireland)--and to look for factors that might help explain any differences in stress levels and morale between the two systems.

METHOD

Anonymous and confidential questionnaires were sent to all 986 National Health Service (NHS) GPs in Northern Ireland (NI) and a random sample of 900 GPs in the Republic of Ireland (ROI). A common set of core questions on demographic details, partners and work patterns, perceived levels of stress and morale, safety, violence, and complaints were asked.

RESULTS

Response rates were high in both areas: 91% in NI and 78% in the ROI. GPs in NI had significantly higher stress levels and significantly lower levels of morale than GPs in the ROI. The NI sample expect matters to get worse over the following year. Doctors in the ROI were more likely to be single handed and to work from two sites. Also, more GPs in ROI had fears for their safety and had been the subject of physical violence, but fewer had received complaints and medico-legal actions than in NI.

CONCLUSIONS

A significant proportion of both groups of doctors report feeling highly stressed but GPs in NI appear more unhappy and have a poorer outlook for the future. It is suggested that the structure, management, and expectations of the NHS have taken a severe toll on its GPs, whereas a system in which doctors have less practice support but more control is good for morale.

Agalactosyl IgG [Gal(o)]--an analysis of its clinical utility in the long-term follow-up of patients with rheumatoid arthritis

This long-term prospective study of patients with newly diagnosed RA assesses the relative value of certain clinical and laboratory measures at first consultation in order to determine factors that help to discriminate between patients likely to go into early remission and those with relapsing/remitting or persistent disease. Validation was sought in a similar group from a separate but comparable prospective study. Measures of clinical activity such as joint score, early morning stiffness (EMS) and acute phase (ESR) improved over 4 yr in both groups, whereas agalactosyl IgG [Gal(o)] levels increased. Using discriminant functional analysis in the first cohort to identify features at entry which would predict outcome at 4 yr, a combination of Gal(o), grip strength, age at onset and gender predicted the course of RA correctly in 95% of the patients. This combination was confirmed in the second cohort, although with reduced power (78% correct). Thus, we show that Gal(o) does not reflect activity of the disease like the ESR, but has greater potential as a prognostic index early in the course of disease.

Functional changes in early child language: the appearance of references to the past and of explanations

Spontaneous speech samples from children during the period of transition from one word to multi-word utterances in interaction with their French-speaking mothers were explored in order to study the appearance and development of functional changes in their use of language. Two types of such change were noted in the longitudinal records of four children when they were still essentially one-word speakers: the beginnings of references to the past, and the appearance of explanations and justifications, especially in communicative situations of request and refusal. The co-appearance of these behaviours is discussed in relation to two more general developmental changes: a detachment from the immediately perceptible situation linked to a further elaboration of the signifier-signified relation, and a socio-cognitive development leading to a view of the interlocutor as an alter ego, as a person whose psychological states may be different from the child's own.

Two cases of Wegener's granulomatosis involving the pituitary

We describe two patients with Wegener's granulomatosis involving the pituitary. The diagnosis of Wegener's granulomatosis was inferred from the histological appearance of biopsy tissue and the presence of anti-neutrophil cytoplasmic antibodies with cytoplasmic distribution in the first case, in which disease remained confined to the pituitary, causing anterior and posterior pituitary dysfunction. In the second case the diagnosis was made by the progressive involvement of other organ systems, compatible histology and the presence of anti-neutrophil cytoplasmic antibodies with cytoplasmic distribution. In neither patient did posterior pituitary dysfunction respond to immunosuppressive therapy, despite remission of other features of systemic vasculitis. Panhypopituitarism in association with isolated pituitary Wegener's granulomatosis has not previously been described.

Secular trends in mortality from asthma in children and young adults: Republic of Ireland, 1970-91

Trends in mortality attributed to asthma in children (0-14 years) and young adults (15-44 years) and the age group 5-34 years were examined for the Republic of Ireland over the period 1970-91. Childhood mortality rates were low with no clear trend. A recent rise in asthma mortality was observed in the 5-34 year olds but not in the 15-44 year age group. More detailed examination of these rates revealed that the rise in mortality in the 5-34 year olds derived from the age band 25-34 years. This increase is masked in the 15-44 year age group by wide fluctuations in mortality in the age band 35-44 years. A similar discrepancy in asthma mortality trends for the 15-44 and 5-34 year age groups has been reported in Britain. Possible reasons for the recent rise in asthma mortality in the 25-34 year age group are discussed.

Pharmacology of high-threshold calcium currents in GH4C1 pituitary cells and their regulation by activation of human D2 and D4 dopamine receptors

1. The objective of this study was to characterize the pharmacology of calcium currents in GH4C1 pituitary cells and determine whether activation of heterologously expressed human dopamine receptors can regulate their function. Human D2(short), D3 and D4.2 receptor cDNA's were separately transfected into GH4C1 cells and whole cell calcium currents were recorded by use of nystatin-perforated patch clamp techniques. 2. High-threshold calcium currents were antagonized in a biphasic manner by the dihydropyridine, nisoldipine. The half-maximally effective concentration for each site was 0.2 nM (pIC50 = 9.78 +/- 0.21, n = 4) and 339 nM (pIC50 = 6.47 +/- 0.12, n = 4). The component of current inhibited by 10 nM nisoldipine was also blocked by omega-conotoxin GVIA (30 +/- 9% at 30 nM, n = 6) or by omega-agatoxin IVA (34 +/- 7% at 100 nM, n = 4). 3. Activation of either D2 or D4 receptors by dopamine (10 microM) or quinpirole (0.1 to 10 microM) reduced the peak calcium current by ca. 20% in the majority of cells studied. No inhibition was observed in control or D3 transfected GH4C1 cell lines. 4. The mobilisation of intracellular calcium by thyrotropin releasing hormone in hD4-GH4C1 cells was also studied using Fura-2 AM microspectrofluorimetry. Thyrotropin releasing hormone caused a concentration-dependent increase in calcium mobilisation with an EC50 of 7 nM. D4 receptor activation had no effect upon either basal or hormone-induced [Ca2+]i transients. 5. These results demonstrate that GH4C1 pituitary cells have at least two types of dihydropyridine sensitive high-threshold calcium currents and that like D2 receptors, human D4 receptors can also regulate calcium channel function.

A survey of new attenders at a paediatric accident and emergency department

A prospective study of one week's new attendances (sampled over three consecutive weeks) at the A&E Department of the National Children's Hospital (NCH) was undertaken. A total of 310 children attended over the composite week. Of these, 307 took part in the study, all but three of which were accompanied by an adult. Almost three-quarters (72%) of the children attended without medical referral. Most children (80%) resided within two miles of the hospital. While 46% of respondents claimed they had used the hospital at least once during the previous twelve months, frequent attendance did not appear to be a problem. The majority of children (83%) were seen by a casualty officer within one hour of arrival. Injuries accounted for over half (53%) of the conditions presented. A fifth (21%) of the attenders were admitted, half (54%) of whom were discharged within 24 hours. The study provides baseline data on paediatric A&E services in Dublin and should assist planning of future services.

Depression of high-threshold calcium currents by activation of human D2 (short) dopamine receptors expressed in differentiated NG108-15 cells

1. This study examined the regulation of calcium currents in differentiated NG108-15 cells that had been stably transfected with cDNA encoding the short isoform of the human D2 dopamine receptor. Whole cell calcium currents were recorded by nystatin-perforated patch clamp recording. 2. Transient low-threshold calcium currents elicited by depolarizations from -100 mV to -20 mV were reversibly depressed by NiCl2 (84 +/- 8% at 30 microM; n = 3) and by omega-agatoxin IVA (15 +/- 5%; 100 nM, n = 7). These currents were unaffected by hD2 receptor activation. 3. High-threshold calcium currents elicited by depolarizations from -80 mV to 0 mV were partly blocked by omega-conotoxin GVIA (67 +/- 6% at 100 nM, n = 4) and by the subsequent addition of the dihydropyridine, nisoldipine (94 +/- 3% at 1 microM). Consistent with the presence of at least two distinct types of high-threshold calcium channels, nisoldipine alone (38 +/- 15% at 1 microM, n = 6) did not preclude the inhibition caused by omega-conotoxin GVIA (69 +/- 13% at 100 nM, n = 4). The residual current was completely blocked by 100 microM CdCl2 (98.8 +/- 0.4%, n = 7). 4. In hD2-transfected cells, but not untransfected cells, high-threshold currents were depressed by quinpirole (30 +/- 4% at 100 nM; n = 15) with a pEC50 of 8.61 +/- 0.22 (n = 5), as well as by (-)-noradrenaline (28 +/- 5% at 1 microM, n = 9). Responses to both agonists were selectively antagonized by S-(-)sulpiride (100 nM) but not by the alpha-adrenoceptor antagonist, phentolamine (1O microM). The depression caused by (-)-noradrenaline was positively correlated with that of quinpirole for each cell(r2 = 0.91, slope = 0.99).5. hD2-receptor-mediated inhibition of high-threshold calcium currents was abolished by pretreatment of cells with omega-conotoxin GVIA (100 nM; n = 4). However, a component of the high-threshold current was reversibly depressed by omega-conotoxin GVIA (67% to 45% depression after 10 min wash). This current was also depressed by hD2 receptor activation (59 +/- 9% depression in 100 nM quinpirole, n = 3),and was completely blocked by nisoldipine (95 +/- 2% at 1 MicroM).6. These data demonstrate that activation of hD2(short) dopamine receptors can regulate both wconotoxinGVIA, and dihydropyridine-sensitive high-threshold calcium currents in neuroblastoma cells.Morever, the ability of human D2 dopamine receptors to regulate more than one type of calcium current supports the notion that these receptors have a diverse functional role in the central nervous system.

Hospital initiated prescribing in the General Medical Services scheme

Twenty-seven general practitioners associated with the Department of Community Health and General Practice, TCD, agreed to record details of the drugs prescribed on 30 consecutive GMS prescriptions. Doctors were asked to indicate whether the items they were prescribing were initiated by themselves or by a hospital doctor and whether they agreed with the latter items in terms of their clinical appropriateness and cost. Information on 1,471 prescribed items was obtained from a total of 754 prescriptions. General practitioners initiated 63% of these items, hospital doctors 35% and in 2% the person responsible was unknown. Hospital initiated items accounted for 44.5% of total ingredient costs compared with 54% in general practice. General practitioners agreed with most of the hospital initiated items in terms of their clinical appropriateness and cost. Given the extent of hospital initiated GMS prescribing in this study there is a clear need to differentiate between those items originating in hospital and those in general practice for accountability purposes.

Agalactosyl IgG: an aid to differential diagnosis in early synovitis

Sixty consecutive patients presenting with early-onset synovitis were studied by measuring rheumatoid factor (RF) titers and the percentage of oligosaccharide chains attached to the C gamma 2 domain of IgG that lack galactose (GAL[0]). After 2 years of followup, 39 patients (65%) had developed rheumatoid arthritis (RA), and 21 had developed a variety of other inflammatory joint diseases. A combination of RF positivity and GAL(0) levels above the age-corrected mean gave a positive predictive value for a diagnosis of RA in 94% of these patients. These observations may well have clinical utility.

Local injection treatment of tennis elbow--hydrocortisone, triamcinolone and lignocaine compared

Corticosteroid injections are the mainstay of treating tennis elbow even though their effectiveness has not been well established by controlled studies. A survey of consultant rheumatologists confirmed a widespread preference for this treatment but they varied in their choice of steroid dose and preparation. We examined the value of some practices by comparing local injections of 2 ml 1% lignocaine with either 10 mg triamcinolone or 25 mg hydrocortisone made up to 2 ml with 1% lignocaine (Study 1). The investigation was conducted double blind. Within the first 8 weeks, pain relief was greater for triamcinolone than hydrocortisone although the differences were not statistically significant. The response to both steroid preparations was significantly better than for lignocaine up to this point but at 24 weeks, the degrees of improvement were similar for all three groups and many patients still had pain. Relapse was common. In a separate but similarly designed study, triamcinolone 10 mg was compared with 20 mg of the same agent. Improvements of pain were similar and followed the same time scale. Post-injection worsening of pain occurred in approximately half of all steroid treated patients in both studies and this was sometimes severe and persistent. It was less frequent amongst those given lignocaine alone. Skin atrophy was reported in all groups but was more frequent amongst those given triamcinolone in Study 1. In conclusion, more rapid relief of symptoms was achieved with 10 mg triamcinolone than with 25 mg hydrocortisone or lignocaine alone and there was less needed to repeat injections. Results obtained with 20 mg triamcinolone were similar to those of the smaller dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Estimating the prevalence of chronic respiratory disease

A method is described for estimating the prevalence of chronic respiratory disease in a middle aged and elderly general practice based population, using the prescription of drugs in order to identify the disease. The prevalence estimates ranged from 15 per 1,000 in men aged 45-50 years to 62 per 1,000 in those aged 75-80 years. For women the corresponding values were 11 to 29 per 1,000. The estimates attained displayed the age and sex patterns expected on the basis of other data sources including morbidity surveys in the United Kingdom and the Netherlands. The similarity suggests that this may be a valid method for estimating quickly and cheaply the prevalence of certain diseases in the community.

Early detection of carpal erosions in patients with rheumatoid arthritis: a pilot study of magnetic resonance imaging

A pilot study comparing standard radiography to magnetic resonance imaging (MRI) was performed on the wrists of 10 patients with early (anatomic Stage I or II) rheumatoid arthritis (RA). MRI was found to be superior to standard radiographs in 2 respects: (1) synovial inflammation was impressively demonstrated on T2 weighted images, whereas plain films merely suggested soft tissue swelling; and (2) T1 and T2 weighted images clearly revealed erosions of several carpal bones which were not noted on standard radiographs. Although the expense of MRI currently precludes its routine use in clinical practice, the apparent sensitivity of this diagnostic modality for detecting early changes in RA might make it an invaluable tool for therapeutic decision making or for assessing response in interventional trials.

Nursing careers: findings of a follow-up survey of graduates of the nursing education and administration certificate courses of the Department of Nursing Studies, University of Edinburgh, 1958?1975

The paper discusses the findings of a survey of the career progress of graduates of certificate courses in nursing administration and education, between 1958 and 1975, at the Department of Nursing Studies, University of Edinburgh. Five sections are presented: age, sex, career patterns, educational attainments and scholarly work. Issues arising within these sections are discussed.