Postgraduate Medical Journal current issue

Improving care for patients after transient ischaemic attack (TIA)

Rudd, A. G. — 2012-05-14T15:40:28-07:00

There is no doubt that progress has been made in the care of patients with transient ischaemic attack (TIA) over recent years. Virtually all hospitals now offer rapid access neurovascular clinics or admission for high risk patients with many units running clinics 7 days a week. Availability of brain and carotid imaging has improved1 and the UK Carotid Interventions Audit has shown dramatic improvements in the symptom to surgery times coming down from a median of 28 days in 2008 to 21 days in 2010 and 14 days in 2012.2 However, in this edition of the journal Lager et al report the results of a study examining how effectively risk factors are managed in primary care in the UK after a diagnosis of TIA has been made in a specialist clinic.3 The key message is that substantial improvements are needed if we are to minimise the risk...

Quality of secondary prevention measures in TIA patients: a retrospective cohort study

Lager, K. E., Wilson, A., Khunti, K., Mistri, A. K. — 2012-05-14T15:40:28-07:00

Objective

Pharmacological and lifestyle interventions are recommended for the reduction of stroke risk in people who have had a transient ischaemic attack (TIA). This study aimed to investigate the quality of secondary stroke prevention in primary care following diagnosis of TIA in a specialist clinic.

Methods

Quality standards were identified from the Royal College of Physicians (RCP) national clinical guideline for stroke and the general practice Quality and Outcomes Framework (QOF) indicators. Patients who were diagnosed with TIA between February and October 2009 were identified from a TIA clinic database. Achievement of quality standards was assessed 12–24 months following clinic attendance.

Results

General practices were sent structured data collection forms for 233 patients, and the response rate was 80% (n=186). Complete data were available for 163 eligible patients (70%). Overall, 94% were prescribed antithrombotic medication. QOF standards were achieved by 82% for blood pressure (≤150/90 mm Hg) and 61% for total cholesterol (≤5.0 mmol/l). RCP standards were achieved by 35% for blood pressure (≤130/80 mm Hg) and 28% for total cholesterol (<4.0 mmol/l). RCP standards for the provision of dietary and exercise advice were achieved by 29% and 34% of patients, respectively.

Conclusion

Only a minority of TIA patients achieved RCP standards whereas QOF standards were generally well achieved. Substantial benefits in terms of stroke prevention stand to be gained if risk factors are managed in line with more stringent RCP standards.

Republished: Simulation training improves ability to manage medical emergencies

Ruesseler, M., Weinlich, M., Muller, M. P., Byhahn, C., Marzi, I., Walcher, F. — 2012-05-14T15:40:28-07:00

Objective

In the case of an emergency, fast and structured patient management is crucial for a patient's outcome. Every physician and graduate medical student should possess basic knowledge of emergency care and the skills to manage common emergencies. This study determines the effect of a simulation-based curriculum in emergency medicine on students' abilities to manage emergency situations.

Methods

A controlled, blinded educational trial of 44 final-year medical students was carried out at Frankfurt Medical School; 22 students completed the former curriculum as the control group and 22 the new curriculum as the intervention group. The intervention consists of simulation-based training with theoretical and simulation-based training sessions in realistic encounters based on the Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and adapted Advanced Trauma Life Support (ATLS) training. Further common emergencies were integrated corresponding to the course objectives. All students faced a performance-based assessment in a 10 station Objective Structured Clinical Examination (OSCE) using checklist rating within a maximum of 4 months after completion of the intervention.

Results

The intervention group performed significantly better at all of the 10 OSCE stations in the checklist rating (p<0.0001 to p=0.016).

Conclusions

The simulation-based intervention offers a positively evaluated possibility to enhance students' skills in recognising and handling emergencies. Additional studies are required to measure the long-term retention of the acquired skills, as well as the effect of training in healthcare professionals.

Imaging in pulmonary hypertension, part 2: large vessel diseases

McCann, C., Gopalan, D., Sheares, K., Screaton, N. — 2012-05-14T15:40:28-07:00

Pulmonary hypertension is defined by physiological parameters but there are numerous causes that differ in their pathogenesis, management and prognosis. Causes include chronic cardiac or pulmonary diseases and diffuse small vessel disease but also a range of large vessel obstructive diseases. The physiological manifestation of all these diseases is increased pulmonary vascular resistance and pulmonary arterial hypertension, and while clinical features may provide a clue to diagnosis, imaging plays a fundamental role in establishing a precise diagnosis and therefore guiding therapy. Chronic thromboembolic pulmonary hypertension (CTEPH) is the most common large vessel cause of pulmonary hypertension. It is increasingly recognised as a major cause of morbidity and mortality which is underdiagnosed and often diagnosed late. The importance of CTEPH is that for patients in whom the distribution of disease lies predominantly in the proximal vasculature there is potential for symptomatic and physiological cure by surgical pulmonary endarterectomy. More distal disease may be suitable for medical management. Increased awareness on behalf of both clinicians and imagers is therefore paramount. However, there are other rare causes or large vessel obstruction/stenosis such as large vessel vasculitis, pulmonary artery tumour, fibrosing mediastinitis, congenital stenosis or extrinsic compression of the pulmonary arteries/veins. Atypical imaging appearance such as unilateral central pulmonary artery obstruction should lead to consideration of a diagnosis other than CTEPH.

Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes: an important cause of stroke in young people

2012-05-14T15:40:28-07:00

Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes is a progressive, multisystem mitochondrial disease affecting children and young adults. Patients acquire disability through stroke-like episodes and have an increased mortality. Eighty per cent of cases have the mitochondrial mutation m.3243A>G which is linked to respiratory transport chain dysfunction and oxidative stress in energy demanding organs, particularly muscle and brain. It typically presents with seizures, headaches and acute neurological deficits mimicking stroke. It is an important differential in patients presenting with stroke, seizures, or suspected central nervous system infection or vasculitis. Investigations should exclude other aetiologies and include neuroimaging and cerebrospinal fluid analysis. Mutation analysis can be performed on urine samples. There is no high quality evidence to support the use of any of the agents reported in small studies. This article summarises the core clinical, biochemical, radiological and genetic features and discusses the evidence for a number of potential therapies.

Lobar collapse demystified: the chest radiograph with CT correlation

Mullett, R., Jain, A., Kotugodella, S., Curtis, J. — 2012-05-14T15:40:28-07:00

Collapse of a lobe of a lung is an important indicator of a range of conditions, including malignancy. Clinical symptoms and signs may suggest a diagnosis of lobar collapse; however, it is often diagnosed, and always needs to be confirmed, with radiological examination. The radiological signs may be subtle, difficult to interpret and sometimes confusing to both clinicians and radiologists. Although multidetector CT (MDCT) is now widely in use for confirming and diagnosing lobar collapse, the plain chest radiograph is usually the first imaging modality performed and so recognition on the plain film remains of vital importance. The basics of chest radiograph interpretation are reviewed, concentrating on the concepts of radiographic density and the silhouette sign. MDCT images are used to demonstrate the general radiological signs of collapse, and the signs of collapse that are specific to the different lobes of the lung are reviewed.

Republished: Sensitive troponin assays

Collinson, P. O. — 2012-05-14T15:40:28-07:00

Sensitive troponin assays have been developed to meet the diagnostic goals set by the universal definition of myocardial infarction (MI). The analytical advantages of sensitive troponin assays include improved analytical imprecision at concentrations below the 99th percentile and the ability to define a reference distribution fully. Clinically, the improved sensitivity translates into the ability to diagnosis MI earlier, possibly within 3 h from admission and the ability to use the rate of change of troponin ( troponin) for diagnosis. Very sensitive assays may, in appropriately selected populations (perhaps with the addition of troponin), allow diagnosis on hospital admission or within 1–2 h of admission. An elevated troponin level occurring in patients without suspected acute coronary syndromes has, in all studies to date in which outcome has been examined, been shown to indicate an adverse prognosis whatever the underlying clinical diagnosis. Failure of elevation means a good prognosis allowing early, safe hospital discharge, whereas a raised value requires investigation and should help prevent clinically significant pathology being overlooked. Sensitive troponins do present a challenge to the laboratory and the clinician. For the laboratory, the diagnosis of MI requires a change in troponin value. For the clinician, the challenge is to shift from a simplistic yes/no diagnosis of MI based on a single troponin value to a diagnosis that utilises early troponin changes as part of the clinical picture, and to relate the new class of detectable troponin elevation in patients with ischaemic myocardial disease to existing clinical guidelines and trial evidence.

Republished: Improving hand hygiene in a paediatric hospital: a multimodal quality improvement approach

Jamal, A., O'Grady, G., Harnett, E., Dalton, D., Andresen, D. — 2012-05-14T15:40:29-07:00

Background

Effective hand hygiene has long been recognised as an important way to reduce the transmission of bacterial and viral pathogens in healthcare settings. However, many studies have shown that adherence to hand hygiene remains low, and improvement efforts have often not delivered sustainable results. The Children's Hospital at Westmead is the largest tertiary paediatric hospital in Sydney, Australia. The hospital participated in a state-wide ‘Clean hands save lives’ campaign which was initiated in 2006.

Intervention

Strong leadership, good stakeholder engagement, readily accessible alcohol-based hand rub at the point of patient care, a multifaceted education programme, monitoring of staff, adherence to recommended hand hygiene practices and contemporaneous feedback of performance data have significantly improved and maintained compliance with hand hygiene.

Results

Hand hygiene compliance has increased from 23% in 2006 to 87% in 2011 (p<0.001). Sustained improvement in compliance with hand hygiene has been evident in the last 4 years. A decline in a set of hospital-acquired infections (including rotavirus, multiresistant organism transmission, and nosocomial bacteraemia) has also been noted as hand hygiene rates have improved. Monthly usage of alcohol-based hand rub has increased from 16 litres/1000 bed days to 51 litres/1000 bed days during this same period.

Conclusion

This project has delivered sustained improvement in hand hygiene compliance by establishing a framework of multimodal evidence-based strategies.

Left ventricular outflow tract obstruction in Tako-Tsubo cardiomyopathy

Showkathali, R., Jagathesan, R. — 2012-05-14T15:40:29-07:00

A 77-year-old lady was brought to our primary percutaneous coronary intervention service with chest pain and ST elevation in anterior chest leads. She had an emotional stress the day prior to her presentation. She was haemodynamically stable with a blood pressure of 110/64 mm Hg and had grade 5 ejection systolic murmur. Her coronary angiogram showed unobstructed coronary arteries. Her left ventriculogram showed akinetic apical and mid-segment with hyperkinetic basal segment, typical of Tako-Tsubo cardiomyopathy (figure 1, figure 2 and supplement file-S1). Transthoracic echocardiography on the same day showed normal aortic valve structure and function (supplement file-S2) with a left ventricular outflow tract (LVOT) gradient of 45 mm Hg (figure 3). Her Troponin T was slightly elevated at 0.8 (normal <0.04). She was treated with aspirin, β-blocker and ACE-I. A repeat echocardiogram in 7 days showed her left ventricular (LV) function slightly improved with disappearance of LVOT gradient...

Waiting rooms and the unconscious

Launer, J. — 2012-05-14T15:40:29-07:00

If you ask patients what they dislike about seeing doctors, there is a fair chance they will mention having to sit in waiting rooms for ages. Doctors tend to get defensive when they hear this and are likely to offer reasons why it happens. These usually include the following. ‘There are never enough doctors, so we are always working against the clock.’ ‘Consultations are unpredictable and may go on longer than anyone expected, delaying others.’ ‘Doctors may be called away from a clinic or surgery to deal with emergencies, leaving remaining colleagues to fit in other patients’. ‘Some patients will always fail to turn up for their appointments, and it is better to have others ready than to have doctors twiddling their thumbs.’ And so on and so forth.

These explanations are not very convincing, and it is easy to find counter-arguments. Consultation lengths and emergencies do vary, but...

Retraction

2012-05-14T15:40:29-07:00

Lloyd-Williams M, Dogra N. Attitudes of preclinical medical students towards caring for chronically ill and dying patients: does palliative care teaching make a difference? Postgrad Med J 2004;80:31–4. This article has been withdrawn.