Anaesthetic choice in the colposcopy clinic: a retrospective analysis of routinely collected data.

OBJECTIVES: Current guidelines recommend that less than 20% of treatments in colposcopy clinics should be under general anaesthetic. The objective of this study was to increase the evidence base for guidelines by establishing the proportion of women receiving general anaesthesia for treatment, determining the predictors of and reasons recorded for general anaesthetic use. DESIGN: Retrospective analysis of routinely collected data. SETTING: NHS Trust in the West Midlands. PARTICIPANTS: Colposcopy patients; January 2003 to March 2005. METHODS: Logistic regression of factors associated with general anaesthetic choice. MAIN OUTCOME MEASURES: Proportion of women treated under general anaesthesia, factors associated with anaesthetic choice and reasons recorded for general anaesthetic use. RESULTS: About 5.4% (204/3777) of new appointments for colposcopy received treatment under general anaesthetic. Of women requiring treatment, 20% (204/1003) received general anaesthetic. General anaesthetic was more likely to be used when the woman required loop excision (OR = 3.63, 95% CI 2.11-6.24) and less likely when directed biopsy was performed (OR = 0.11, 95% CI 0.01-0.80), when the patient appointment date was after introduction of new guidelines (OR = 0.37, 95% CI 0.24-0.56) or when the assessment visit was with a nonconsultant status doctor rather than nurse or consultant (OR = 0.70, 95% CI 0.50-0.97). General anaesthetic use varied between colposcopists ranging from 0 to 16.5% of new patients seen. Woman's choice was the most commonly specified reason for the use of general anaesthetic. CONCLUSIONS: The proportion of colposcopy patients treated under general anaesthetic is 20%, within guideline limits. Substantial variation in general anaesthetic rates between colposcopists was observed, and further investigation is required to discover the reason for this.

The heart failure revascularisation trial (HEART): rationale, design and methodology.

BACKGROUND: Most patients with heart failure due to left ventricular systolic dysfunction (LVSD) secondary to coronary artery disease (CAD) have evidence of myocardium in jeopardy (reversible ischaemia and/or stunning hibernation). It is not known whether revascularisation in such cases is safe or beneficial. AIMS: To determine whether revascularisation will improve the survival of patients with LVSD and heart failure secondary to CAD and myocardium in jeopardy. METHODS: This is a randomised controlled trial comparing revascularisation or not, in addition to optimal medical therapy with ACE inhibitors, beta-blockers, aldosterone antagonists and an anti-thrombotic agent. Patients must have heart failure requiring treatment with diuretics, a left ventricular ejection fraction <35% and evidence of coronary disease. Myocardial viability and ischaemia are assessed by a broad range of techniques including stress echocardiography and nuclear imaging. All imaging tests are reviewed in core laboratories to ensure uniform reporting. Any conventional revascularisation technique is permitted. The primary outcome measure is all cause mortality. Symptoms, quality of life and health economic issues will also be explored. Assuming an annual mortality of 10% in the control group and allowing for substantial cross-over rates, a study of 800 patients followed for 5 years has 80% power with an alpha of 0.05 (two-sided) to show a 25% reduction in mortality with revascularisation. RESULTS: At the time of writing 180 patients have been screened for inclusion, 111 have consented to participate and 70 have been randomised. The results of viability testing are awaited in 22 patients. Twenty-six patients had been investigated for myocardial viability and/or by angiography prior to consent, as part of the routine practice in that cardiology department. Of 68 patients who have completed assessment only after consent, 47 (69%) were included. The principal reason for drop-out between consent and randomisation was lack of evidence of myocardial ischaemia or hibernation. CONCLUSION: The HEART trial will help to determine whether investigation of myocardial ischaemia and/or viability with a view to revascularisation should become part of the routine care of patients with heart failure due to LVSD and CAD.

The EuroHeart Failure Survey programme--a survey on the quality of care among patients with heart failure in Europe. Part 2: treatment.

BACKGROUND: National surveys suggest that treatment of heart failure in daily practice differs from guidelines and is characterized by underuse of recommended medications. Accordingly, the Euro Heart Failure Survey was conducted to ascertain how patients hospitalized for heart failure are managed in Europe and if national variations occur in the treatment of this condition. METHODS: The survey screened discharge summaries of 11304 patients over a 6-week period in 115 hospitals from 24 countries belonging to the ESC to study their medical treatment. RESULTS: Diuretics (mainly loop diuretics) were prescribed in 86.9% followed by ACE inhibitors (61.8%), beta-blockers (36.9%), cardiac glycosides (35.7%), nitrates (32.1%), calcium channel blockers (21.2%) and spironolactone (20.5%). 44.6% of the population used four or more different drugs. Only 17.2% were under the combination of diuretic, ACE inhibitors and beta-blockers. Important local variations were found in the rate of prescription of ACE inhibitors and particularly beta-blockers. Daily dosage of ACE inhibitors and particularly of beta-blockers was on average below the recommended target dose. Modelling-analysis of the prescription of treatments indicated that the aetiology of heart failure, age, co-morbid factors and type of hospital ward influenced the rate of prescription. Age <70 years, male gender and ischaemic aetiology were associated with an increased odds ratio for receiving an ACE inhibitor. Prescription of ACE inhibitors was also greater in diabetic patients and in patients with low ejection fraction (<40%) and lower in patients with renal dysfunction. The odds ratio for receiving a beta-blocker was reduced in patients >70 years, in patients with respiratory disease and increased in cardiology wards, in ischaemic heart failure and in male subjects. Prescription of cardiac glycosides was significantly increased in patients with supraventricular tachycardia/atrial fibrillation. Finally, the rate of prescription of antithrombotic agents was increased in the presence of supraventricular arrhythmia, ischaemic heart disease, male subjects but was decreased in patients over 70. CONCLUSION: Our results suggest that the prescription of recommended medications including ACE inhibitors and beta-blockers remains limited and that the daily dosage remains low, particularly for beta-blockers. The survey also identifies several important factors including age, gender, type of hospital ward, co morbid factors which influence the prescription of heart failure medication at discharge.

Using effectiveness studies for prescribing research, part 2.

Trials that consider the effects of interventions on prescribing behaviour amongst clinicians often have complex design implications resulting in data that has inherent hierarchical structure. It follows that both experimental design and analysis plans must account for this structure and thus results should be considered in terms of clinician behaviour rather than individual patient response. We describe this change in perspective and the necessity for using statistical techniques that allow incorporation of potential confounding effects. We also discuss the appropriateness of some specific outcomes in relation to these trials.

Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey.

BACKGROUND: Heart failure is a prevalent condition that is generally treated in primary care. The aim of this study was to assess how primary-care physicians think that heart failure should be managed, how they implement their knowledge, and whether differences exist in practice between countries. METHODS: The survey was undertaken in 15 countries that had membership of the European Society of Cardiology (ESC) between Sept 1, 1999, and May 31, 2000. Primary-care physicians' knowledge and perceptions about the management of heart failure were assessed with a perception survey and how a representative sample of patients was managed with an actual practice survey. FINDINGS: 1363 physicians provided data for 11062 patients, of whom 54% were older than 70 years and 45% were women. 82% of patients had had an echocardiogram but only 51% of these showed left ventricular systolic dysfunction. Ischaemic heart disease, hypertension, diabetes mellitus, atrial fibrillation, and major valve disease were all common. Physicians gave roughly equal priority to improvement of symptoms and prognosis. Most were aware of the benefits of ACE inhibitors and beta blockers. 60% of patients were prescribed ACE inhibitors, 34% beta blockers but only 20% received these drugs in combination. Doses given were about 50% of targets suggested in the ESC guidelines. If systolic dysfunction was documented, ACE inhibitors were more likely and beta blockers less likely to be prescribed than when there was no evidence of systolic dysfunction. INTERPRETATION: Results from this survey suggest that most patients with heart failure are appropriately investigated, although this finding might be as a result of high rates of hospital admissions. However, treatment seems to be less than optimum, and there are substantial variations in practice between countries. The inconsistencies between physicians' knowledge and the treatment that they deliver suggests that improved organisation of care for heart failure is required.

Using effectiveness studies for prescribing research, part 1.

The process of evaluating pharmaceuticals has become highly conceptualized in contrast to the lack of formal rules for assessing effects of interventions on practice. We argue that clinical audit is a key factor prior to instigating an intervention and that randomized controlled evaluations are preferable. We discuss the need for small-scale experiments prior to full trials to validate the underlying concept of an intervention with the recognition that different approaches may be necessary. This includes open rather than blind assessments and greater emphasis on qualitative issues during development of interventions followed by quantitative appraisal of their impact.

The Euro Heart Failure Survey of the EUROHEART survey programme. A survey on the quality of care among patients with heart failure in Europe. The Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. The Medicines Evaluation Group Centre for Health Economics University of York.

BACKGROUND: The EUROHEART programme is a rolling programme of cardiovascular surveys among the member nations of the European Society of Cardiology (ESC). These surveys will provide information on the nature of cardiovascular disease and its management. This manuscript describes a survey into the nature and management of heart failure. AIMS: The EuroHeart Failure survey aims to describe the quality of hospital care, diagnostic and therapeutic, for patients with suspected or confirmed heart failure in ESC member countries. Patients will be interviewed subsequent to hospital discharge to assess their understanding of their condition, side effects from and their compliance with therapy and their satisfaction with the management for heart failure. The quality of management will be judged against the recommendations contained in the ESC guidelines on diagnosis and treatment of heart failure. Outcome will be further assessed by repeat interviews in 6-12 months time. A further survey of heart failure in 2001/2002 is also planned. METHODS: A prospective survey of all deaths and discharges from medical (cardiology, internal medicine and geriatric medicine) and cardiac surgical wards to identify patients with heart failure, suspected or confirmed. Approximately 70 hospital clusters, comprising two to six hospitals in each cluster, in 24 member countries of the ESC are conducting the study. At the time of writing, approximately 30000 deaths and discharges have been screened and approximately 4000 patients have been enrolled. CONCLUSIONS: The EuroHeart Survey will allow actual practice to be compared to ESC guidelines on the diagnosis and treatment of heart failure. The surveys and guidelines should prove mutually informative. The main EuroHeart Failure project will be completed by late 2000. However, new centres volunteering to participate in the study (contact corresponding author) may be accepted providing they have the necessary research personnel and provided funding can be agreed for statistical support and administration.

Neural networks in the diagnosis of malignant ovarian tumours.

OBJECTIVE: To assess the role of neural networks in predicting the likelihood of malignancy in women presenting with ovarian tumours. DESIGN: Retrospective case study. SETTING: University Department of Obstetrics and Gynaecology, St James's Hospital, Leeds. METHODS: Information from 217 cases with histologically proven benign, borderline or malignant tumours was extracted for study. Four variables (age, ultrasound findings with and without colour Doppler imaging and CA125) were entered in the neural network classifier. The neural network results were compared with logistic regression analysis. RESULTS: When used in the neural network the variables of age, CA125 and ultrasound score produced the best result with a sensitivity of 95% and a corresponding specificity of 78% in predicting malignancy. Logistic regression gave a sensitivity or 82% for a specificity of 51%. CONCLUSION: The neural network is a good method of combining diagnostic variables and may be a useful predictor of malignancy in women presenting with ovarian tumours. A comparison of the performance of the neural network with conventional diagnostic methods would be warranted prior to use in clinical practice.

The application of neural networks in predicting the outcome of in-vitro fertilization.

Infertility affects one in six couples at some time in their lives, with 48% of these couples requiring assisted conception techniques in order to achieve a pregnancy. Whilst the overall clinical pregnancy rate per embryo transfer is 23%, this varies widely between clinics. The Human Fertilisation and Embryology Authority has attempted to analyse the results of all units, with weighting of different factors affecting assisted conception, and the published data have invariably led to comparisons between units. However, statistical models need to be developed to eliminate bias for valid comparisons. Neural networks offer a novel approach to pattern recognition. In some instances neural networks can identify a wider range of associations than other statistical techniques due in part to their ability to recognize highly non-linear associations. It was hoped that a neural network approach may be able to predict success for individual couples about to undergo in-vitro fertilization (IVF) treatment. A neural network was constructed using the variables of age, number of eggs recovered, number of embryos transferred and whether there was embryo freezing. Overall the network managed to achieve an accuracy of 59%.

Putting the squeeze on emergency medicine. The many pressures on today's ED.

Whether it's indigent care, cost containment, transfer laws, financially wary HMOs, overcrowding, reimbursement, or emergency-department inefficiency, the factors "putting the squeeze" on emergency medicine seem to multiply with each new survey. These pressures, the authors feel, are not only weakening the provision of emergency care but also strengthening the argument for a national health plan.

Infectious and toxic syndromes from fish and shellfish consumption. A review.

Primary care physicians care for large numbers of patients presenting with "food poisoning" or gastroenteritis. When a patient who presents with acute gastrointestinal illness, especially in conjunction with neurologic or cutaneous symptoms, is evaluated, the history should focus on past seafood consumption (particularly raw or undercooked seafood). The infectious syndromes are generally self-limited and respond to supportive care; exceptions are those caused by Vibrio cholerae and Vibrio vulnificus, which may be fatal in severe cases. The toxic syndromes are uncommon and fall into two categories: the histaminelike syndrome of scombroid poisoning and the neurotoxic syndromes, including ciguatera, paralytic shellfish poisoning, and puffer fish poisoning. Recognition of these clinical entities may lead to more appropriate management and preventive measures.

The early repolarization syndrome.

The syndrome of the early repolarization variant is described. This benign ECG phenomenon is noted in 1% to 2% of the adult population and generally occurs in the absence of myocardial disease. The ECG manifestations may mimic acute myocardial injury or pericarditis. Exercise and isoproterenol tend to normalize the RST segment elevation. The presence of "early repolarization" does not preclude diagnosis of exercise-induced myocardial ischemia by treadmill testing, and coronary vaso-occlusive lesions may be demonstrated in some patients with the early repolarization pattern on ECG. The presence of S-T elevation in a patient with chest pain of possible cardiac origin mandates hospitalization and cardiac monitoring even if the ECG may confirm to a classic pattern of early repolarization; in this context, the diagnosis of benign early repolarization is one of exclusion. Recognition of this clinical entity and the use of previous ECGs for comparison would in most cases forestall the administration of thrombolytic agents to patients with S-T segment elevation due to benign early repolarization.

Prospective payment systems: steps to enhance quality, efficiency, and regionalization.

The prospective payment system has many benefits and risks for the hospital industry. A quality-enhancing bidding process can be used to redistribute any unfair windfall profits, and foster quality care, effectiveness, efficiency, and productivity.