Application of NHG guidelines in patients referred for stable chest pain syndromes

Purpose. Guidelines of the Dutch Association of General Practitioners (NHG) dictate the evaluation, treatment, and referral process of patients with stable chest pain syndromes (CPS). Adherence to this guideline was assessed in a consecutive group of patients referred to our hospital. Methods. We retrospectively studied the records of 296 subjects referred to our outpatient department in 2007 for evaluation of stable CPS. Referral letters were checked for completeness (past and present history, mentioning of risk factors for cardiovascular disease, physical examination, listing of medication) and used to judge adherence to the guideline. In a subset of patients, additional information regarding the referral process was gathered by telephone interview. Results. The referral letter was complete in only 67 patients (23%); items most often not reported were physical examination (63%) and cardiovascular risk factors (62%). Judging from the referral letter, 23 patients (8%) were evaluated in accordance with the NHG guideline prior to their referral. In patients in whom the final diagnosis of angina pectoris was made by the cardiologist, this was 20%. Seventy-nine patients were contacted by telephone after their work-up by the cardiologist; 36 of them (44%) reported being referred at their first visit to their primary physician, while 14 (18%) were referred at their own request. Conclusion: Prior to referral, only a minority of patients with stable CPS were evaluated and treated in accordance with NHG guidelines. Furthermore, their referral letter was often incomplete. (Neth Heart J 2010;18:178-82.)     

Association between cardiovascular disease and a history of cancer in patients with chest pain on the fast track outpatient clinic

Background

The purpose of this study is to investigate the prevalence of a history of malignancy in patients with chest pain who were referred for computed tomography angiography as well as the long-term survival and cardiovascular outcomes, including coronary artery disease (CAD) and coronary artery calcium (CAC) percentiles of cancer survivors. These data are relevant since it is unknown how cancer survivors, who underwent cardio-toxic therapies, should be monitored.

Methods

We analysed all patients with chest pain, who came to the outpatient clinic and underwent computed tomography angiography. The primary study endpoint was long-term survival. The secondary endpoints included CAD on computed tomography angiogram (CTA), CAC percentiles, suspected and confirmed malignancy on CTA, and other accidental findings on CTA.

Results

Of all 1,892 patients included in the analyses, 133 (7%) had a history of malignancy and 1,759 (93%) did not. Mortality rates were higher for the cancer survivors (6.5% vs 20.9% after ten years, p < 0.001). The multivariable Cox regression model also showed higher mortality for cancer survivors after ten years (adjusted hazard ratio 2.48 [95% confidence interval: 1.58–3.90]). CAD did not differ between both groups. CAC percentiles were higher in cancer survivors (p = 0.037). Cancer survivors had more suspected malignancies (3.8% vs 0.5%; p = 0.001) and also more confirmed malignancies on CTA (3.0% vs 0.1%; p < 0.001).

Conclusions

Cancer survivors have higher mortality rates, no difference in CAD on CTA, higher CAC percentiles and more often malignancy on CTA compared with patients without a cancer history.

     

Attitudes to the psychiatric outpatient clinic.

Fifty patients were interviewed before their first ever appointment at a psychiatric outpatient clinic about their attitude to the forthcoming visit. Many did not know that it was a psychiatrist they were to see at the hospital. Widespread misconceptions about the nature of a psychiatric consultation were uncovered. Many felt the referral carried an implicit threat of social stigma. Patient''s misconceptions were relieved, and only 13% subsequently failed to attend the clinic compared with 30% of a control group.     

Consumption of diagnostic procedures and other cardiology care in chest pain patients after presentation at the emergency department

Objective

The HEART score serves risk stratification of chest pain patients at the emergency department (ED). Quicker and more solid decisions may be taken in these patients with application of this score. An analysis of medical consumption of 122 acute chest pain patients admitted before the introduction of this score may be indicative of possible savings.

Methods

Numbers of cardiology investigations and clinical admission days were counted. Charged cost of medicine was divided into three categories: ED, in-hospital, and outpatient clinic.

Results

The total cost of care was € 469,631, with an average of € 3849 per patient. Seventy-five percent of this cost was due to hospitalisation under the initial working diagnosis of acute coronary syndrome (ACS). This diagnosis was confirmed in only 29/122 (24 %) of the patients. The low-risk group (41 patients with HEART scores 0–3) included one patient with a previously scheduled CABG. In the remaining 40 patients, hospitalisation occurred in 12/40 (30 %) patients and 30/40 (75 %) patients visited the outpatient clinic. The total cost of medical care after presentation of these 40 patients was € 37,641; there were no cases where a new diagnosis of coronary artery disease was made. When medical care in this subgroup is declared redundant, major savings on national medical care budgets could be made.

Conclusion

If the HEART score were to be routinely applied, diagnostic pathways could be shortened and costs reduced, in particular in low-risk patients.     

Prevalence of accessory deep peroneal nerve in referred patients to an electrodiagnostic medicine clinic

Background

Variations in the branching of posterior cord are important during surgical approaches to the axilla and upper arm, administration of anesthetic blocks, interpreting effects of nervous compressions and in repair of plexus injuries. The patterns of branching show population differences. Data from the African population is scarce.

Objective

To describe the branching pattern of the posterior cord in a Kenyan population.

Materials and methods

Seventy-five brachial plexuses from 68 formalin fixed cadavers were explored by gross dissection. Origin and order of branching of the posterior cord was recorded. Representative photographs were then taken using a digital camera (Sony Cybershot ^R, W200, 7.2 Megapixels).

Results

Only 8 out of 75 (10.7%) posterior cords showed the classical branching pattern. Forty three (57.3%) lower subscapular, 8(10.3%) thoracodorsal and 8(10.3%) upper subscapular nerves came from the axillary nerve instead of directly from posterior cord. A new finding was that in 4(5.3%) and in 3(4%) the medial cutaneous nerves of the arm and forearm respectively originated from the posterior cord in contrast to their usual origin from the medial cord.

Conclusions

Majority of posterior cords in studied population display a wide range of variations. Anesthesiologists administering local anesthetic blocks, clinicians interpreting effects of nerve injuries of the upper limb and surgeons operating in the axilla should be aware of these patterns to avoid inadvertent injury. A wider study of the branching pattern of infraclavicular brachial plexus is recommended.     

Characteristics of children presenting with chest pain to a pediatric emergency department.

Chest pain among children is a common complaint in primary care practice. However, the demographic features and treatment of such patients are controversial. We distributed a questionnaire to 336 consecutive patients with a complaint of chest pain seen during 1 year at an urban pediatric emergency department. Such visits represented 0.6% of all emergency encounters; the male:female ratio was 1.0. Physical examination was done in 325 patients. Chest-wall pain was the most common diagnosis (in 28% of cases). Other causes included pulmonary (in 19%), minor traumatic (in 15%), idiopathic (in 12%) and psychogenic (in 5%); miscellaneous causes (in 21%) most often indicated pain referred from the upper respiratory tract and the abdomen. The most common physical finding was chest tenderness (in 41% of cases). Investigations included chest radiography (in 50% of cases), electrocardiography (in 18%) and determination of the hemoglobin concentration and of the leukocyte count (in 13%); the results were rarely positive. Only eight patients (2%) required admission to hospital, and there were no cases of myocardial ischemia. The findings suggest that health care costs may be reduced by more judicious use of investigations. We conclude that chest pain is an uncommon and usually benign complaint in the pediatric emergency department. Most causes are evident on careful physical examination.     

Depression comorbidity among patients with tuberculosis in a university teaching hospital outpatient clinic in Nigeria

Background Tuberculosis (TB) remains a leading infectious cause of morbidity and mortality throughout the world. Medication non-compliance has been recognised as one of the drawbacks in the successful management of this disease. Hence, different approaches for ensuring medication compliance have been adopted; these include the Directly Observed Therapy Short course (DOTS). TB is associated with psychiatric morbidity, particularly depressive disorder, and this has been recognised as a cause of poor compliance and a cause of increased morbidity and mortality from the disease. Despite this recognition, little attention is paid to the identification of depression among TB patients, particularly in the DOTS clinics that most of these patients attend. This study was designed to determine the prevalence of depression in patients with TB attending the DOTS outpatient clinic in a university teaching hospital in Nigeria, and to find out the factors that may be associated with this.Method All consenting TB patients attending the clinic completed a socio-demographic questionnaire and nine-item Patient Health Questionnaire (PHQ-9) designed to screen for depression, especially in outpatient and primary care settings.Results Sixty-five patients participated in the study of whom 41 (63.1%) were males. The mean age of the respondents was 35.1 ± 14.4 (range 15-70 years). Eighteen (27.7%) of the patients had depression, comprising 14 (21.5%) with mild depression and four (6.2%) with moderate depression. Socio-demographic factors (age groups, P=0.024; and financial status, P=0.02) and a clinical factor (persistent cough, P=0.04) were significantly associated with depression.Conclusion Measures to reduce depression among patients with TB should include effective symptom control, particularly of coughing, and measures to improve the financial status of this group of patients. Financial empowerment of patients may reduce depression in them, improve the compliance rate to anti-TB medication, and could furthermore bring an improvement to their quality of life.     

Factors associated with pain level in non-cardiac chest pain patients with comorbid panic disorder

Background

Panic disorder (PD) is highly prevalent in patients with non-cardiac chest pain (NCCP). This study aims to explore the role of psychological factors (PD intensity, anxiety sensitivity, heart-related fear, attention and avoidance) common to NCCP and PD in predicting chest pain levels in patients with both conditions.

Methods

This association was investigated in emergency department patients with NCCP and PD receiving either evidence-based treatment of PD or treatment as usual. Patients were assessed at baseline and 14 weeks later for post-treatment.

Results

Only heart-focused fear and attention for cardiac sensations independently explained a significant portion of the variance in baseline pain (n?=?66). At 3 months follow-up (n?=?53), changes in heart-related fear was the only factor independently associated with changes in chest pain intensity. Even in patients with PD, fear specific to cardiac sensations seems to play a central role in determining NCCP intensity.

Conclusion

These results suggest that the efficacy of intervention for patients with PD and comorbid NCCP could be improved by targeting heart-related fear and attention.

Trial registration

NCT00736346

     

Skin disease in a geriatric patients group in outpatient dermatologic clinic Karlovac, Croatia

To determine the characteristic pattern and frequency of dermatoses in dermatologic patients over 65 years we used electronic data base of General hospital Karlovac and conducted a retrospective cross sectional study evaluating age, sex and proportion of dermatoses. Total number of patients was 3200. There were 822 (25.69%) patients older than 65 years, and 2378 (74.31%) patients aged from 18-64 years. Ratio male/female in population over 65 years in our study was 0.76:1. Males had higher frequncy of verrucae vulgares 26 (7.3%) and dermatitis nummularis 47 (13.2%) then female and that difference was statistically significant. Female had higher frequency of keratosis acitinca 124 (26.61%) and fibroma 23 (4.94%), and that difference was statistically significant. The ten most common diagnosis in population over 65 years old were: keratosis actinica in 184 patients (22.38%) verrucae seborrhoicae in 156 (18.98%), dermatitits nummularis in 77 patients (9.37%), dermatitis allergica e contactu in 60 (7.30%) patients, mycosis in 56 (6.81%) patients, psoriasis in 51 (6.20%), verrucae vulgares in 39 (4.74%), fibromas in 27 (3.28%), naevi in 9 (1.09%) and acne in 1 (0.12%) patient. The number of patients with diagnosis of keratosis actinica, verrucae seborrhoicae and mycoses in population over 65 years old are greater then in younger subpopulation and that difference was statistically significant. There are specific pattern of frequency of dermatoses in elderly. Verrucae seborrhoica, keratosis actinica and mycoses are more common then in general population. In elderly risk for development of skin cancer is increased. Early detection of skin cancers and treatment of precanceroses is of utmost interest of health providers.     

Acute chest pain in a patient treated with capecitabine

A 61-year-old male with a history of metastatic colorectal cancer was referred to our hospital for primary coronary intervention because of acute ST-elevation myocardial infarction. Coronary angiography, however, revealed no significant stenoses. When asked, the patient revealed that capecitabine (Xeloda®) was started by his oncologist one day before admission. It is known that this oral 5-FU analogue drug, used in metastatic colorectal cancer, can cause coronary artery spasms. The main treatment of capecitabine-induced vasospasm is discontinuation of the drug. Indeed, after cessation of the drug the patient remained free of symptoms and the ECG abnormalities normalised. (Neth Heart J 2009;17:288–91.)     

GOLDmineR: improving models for classifying patients with chest pain

The laboratory is dealing with reporting tests as information needed to make clinical decisions. The traditional statistical quality control measures which assigns reference ranges based on 95 percent confidence intervals is insufficient for diagnostic tests that assign risk. We construct a basis for risk assignment by a method that builds on the 2 x 2 contingency table used to calculate the C2 goodness-of-fit and Bayesian estimates. The widely used logistic regression is a subset of the regression method, as it only considers dichotomous outcome choices. We use examples of multivalued predictor(s) and a multivalued as well as dichotomous outcome. Outcomes analyses are quite easy using the ordinal logit regression model.     

Results of a heart failure outpatient clinic in a non-university hospital with a two-year follow-up

The growing number of heart failure patients has stimulated the development of intensified guidance and follow-up of these patients using specific outpatient clinics and specialised nurses. This is also the case in the Netherlands, where the first positive results of this system have been obtained in academic settings. In this article we present data from an intensified programme for CHF patients as obtained at a non-university cardiology department. It demonstrates that also in this setting the use of a cardiologist, a heart failure outpatient clinic and a specialised nurse dedicated to these patients results in a significant decrease in readmission rate. Furthermore patient characteristics are described. Finally the important role of the nurse is stressed by indicating the number and content of telephone calls he is receiving, resulting in medication changes in 58% of calls.