ABSTRACT
BACKGROUND: To increase recognition of airflow obstruction in primary care, we compared two models of spirometry delivery in a target group at risk of chronic obstructive pulmonary disease (COPD). METHODS: A 6 month qualitative/quantitative cluster randomised study in eight practices compared opportunistic spirometry by "visiting trained nurses" (TN) with optimised "usual care" (UC) from general practitioners (GPs) for smokers and ex-smokers, aged over 35 years. Outcomes were: spirometry uptake and quality, new diagnoses of COPD and GPs' experiences of spirometry. RESULTS: In the eligible target population, 531/904 (59%) patients underwent spirometry in the TN model and 87/1130 (8%) patients in the UC model (p < 0.0001). ATS spirometry standards for acceptability and reproducibility were met by 76% and 44% of tests in the TN and UC models, respectively (p < 0.0001). 125 (24%) patients tested with the TN model and 38 (44%) with the UC model reported a pre-existing respiratory diagnosis (p < 0.0001). Three months after spirometry, when the ratio of forced expiratory volume in 1 s/forced vital capacity (FEV(1)/FVC) was < 0.7 and no prior COPD diagnosis was reported, nine (8%) participants had a new doctor recorded COPD diagnosis in practices with the TN model and two (8%) participants in practices with the UC model. Mislabelling of participants with a diagnosis of COPD when FEV(1)/FVC was > or = 0.7 was present in both models prior to and after spirometry. GPs valued high quality spirometry and increased testing of patients at risk of COPD in the TN model. They identified limitations, including the need for better systematic follow-up of abnormal spirometry and support with interpretation, which may explain persisting underdiagnosis of COPD in practice records. CONCLUSIONS: Although opportunistic testing by visiting trained nurses substantially increased and improved spirometry performance compared with usual care, translating increased detection of airflow obstruction into diagnosis of COPD requires further development of the model. TRIAL REGISTRATION NUMBER: Australian Clinical Trials Registry: registration No 12605000019606.
Subject(s)
Pulmonary Disease, Chronic Obstructive/diagnosis , Spirometry/methods , Adult , Aged , Family Practice , Female , Forced Expiratory Volume/physiology , Humans , Male , Middle Aged , Patient Acceptance of Health Care/statistics & numerical data , Pulmonary Disease, Chronic Obstructive/nursing , Quality Assurance, Health Care , Risk Factors , Rural Health , Smoking/physiopathology , Spirometry/nursing , Spirometry/standards , Tasmania , Urban Health , Vital Capacity/physiologyABSTRACT
Myasthenia gravis is characterised by muscle weakness and fatigability, particularly of the facial and extremity muscles, deteriorating during the day. During pregnancy, myasthenia gravis is rare and the course of illness is unpredictable. The present case illustrates that first diagnosed during pregnancy, recurrent exacerbations can appear and lead to life-threatening situations.
Subject(s)
Myasthenia Gravis/diagnosis , Pregnancy Complications , Adult , Cesarean Section , Cholinesterase Inhibitors/therapeutic use , Female , Gestational Age , Humans , Myasthenia Gravis/therapy , Plasmapheresis , Prednisone/therapeutic use , Pregnancy , Pregnancy Outcome , Pyridostigmine Bromide/therapeutic useABSTRACT
The authors describe a new angiographic catheter, which delivers equal flow rates through the side holes and reduced flow through the end hole compared with conventional catheters. Computer analysis of catheter-flow models revealed that placement of larger side holes proximally and smaller side holes distally produces more uniform flow rates out of the holes. This decreases the risk of potentially hazardous delivery of high-pressure jets of contrast material from the end hole. The flow pattern is so uniform that it resembles a cloud of contrast material on injection. This catheter design is particularly applicable for 3-5-F catheters, which require high-pressure injections. Clinical testing in 50 cases revealed no extravasations or unintentional selective injections with use of this catheter.
