Quantitative assessment of the relationship between body mass index and risk of pulmonary embolism: a retrospective case-control study.

In the context of a significant increase in obesity rates, quantifying the relationship between body mass index (BMI) and risk of pulmonary embolism (PE) is an essential component of accurate clinical risk assessment. This observational study is the first to explore this association by clinician-defined cause of the PE. We demonstrate that the association between BMI and PE is driven by patients with otherwise 'unprovoked' PE where there is a strong positive correlation with odds ratios equivalent to well-recognised major risk factors such as cancer, pregnancy and surgery. We make a case for the inclusion of BMI in risk-prediction tools.

Quantitative assessment of the relative effects of patient and pulmonary embolism-related factors on longer-term mortality after pulmonary embolism.

This observational study used a large audit dataset to examine the relative effects of patient-related factors and those related to the pulmonary embolism (PE) on longer-term mortality after PE. We identified that longer-term mortality is higher in provoked compared to unprovoked PE and that, in this group, obesity is relatively protective. Simplified PE severity index (sPESI), known to link to short term mortality, remains predictive in the longer-term and there is no relationship of mortality to right heart strain or extent of clot. Interestingly mortality is higher in those with negative CTPA scans than those with PE. These clinically important results should encourage careful, holistic clinical assessment of patients in these groups prior to discharge to look for treatable comorbidities.

Can we improve patients' physical activity levels after discharge by interventions on the Acute Medical Unit? The 'teachable moment'.

INTRODUCTION: >30% of the population does less physical activity (PA) than recommended and few patients receive PA advice during a hospital admission (2,5). This study aimed to assess the feasibility of recruiting acute medical unit (AMU) in-patients and to examine the effect of delivering PA interventions to them. METHODS: In-patients who were inactive (<150mins/wk) were randomised to either a motivational interview (Long Interview, LI) or brief advice (Short Interview, SI). Participants' physical activity levels were assessed at baseline and at two follow-up consultations. RESULTS: 77 participants were recruited. At 12 weeks 22/39(56.4%) participants were physically active following the LI and 15/38(39.5%) following the SI. DISCUSSION: Recruitment and retention of patients on the AMU was straightforward. PA advice helped a high proportion of participants become physically active.

"State of the Nation"--the Society for Acute Medicine's Benchmarking Audit 2013 (SAMBA '13).

BACKGROUND: Benchmarking is important to improve quality of care. AIM: To audit the performance of Acute Medical Units (AMUs) against the clinical quality indicators published by the Society for Acute Medicine (SAM). METHODS: 24-hour data collection on the 20th of June 2013 with follow-up data at 72 hours. RESULTS: 43 units submitted data on 1425 patients. 76% of patients had early warning scores recorded within 30 minutes of admission, 95% of patients had been seen by a competent decision maker within four hours. 79% of patients were seen by a consultant physicians within the appropriate period of time. CONCLUSION: The difference in compliance with quality standards between UK units opens opportunities for learning. The reasons why some units perform better than others require further investigation.

A day in the life of the AMU--the Society for Acute Medicine's benchmarking audit 2012 (SAMBA '12).

BACKGROUND: The absence of published data for benchmarking serves as a disincentive for Acute Medical Units to improve care. AIM: To test feasibility of a national audit in Acute Medicine for compliance with common standards. METHODS: On line questionnaire with summary data for patients admitted to participating Acute Medicine Units over a 24-hour-period. RESULTS: 30 units submitted summary data. The mean number of admission was 36 (SD 14). Compliance with standards around timing of junior and senior review was highly variable. In almost all other standards only a small number of units achieved high reliability with compliance of more than 90%. CONCLUSION: SAMBA provides a data set that can be used for local and national benchmarking and quality improvement work. Annual audit might be beneficial to track improvements.

Patient need at the heart of workforce planning: the use of supply and demand analysis in a large teaching hospital's acute medical unit.

Timely medical assessment is integral to the safety and quality of healthcare delivery in acute medicine. Medical staff are an expensive resource. This study aimed to develop a modelling system that facilitated efficient workforce planning according to patient need on the acute medical unit. A realistic 24-hour 'supply' of junior doctors was calculated by adjusting the theoretical numbers on the rota for leave allowances, natural breaks and other ward duties by a combination of direct observation of working practice and junior doctor interviews. 'Demand' was analysed using detailed admission data. Supply and demand were then integrated with data from a survey of the time spent on the process of clerking and assessment of medical admissions. A robust modelling system that predicted the number of unclerked patients was developed. The utility of the model was assessed by demonstrating the impact of a regulation-compliant redesign of the rota using existing staff and by predicting the most efficient use of an additional shift. This simple modelling system has the potential to enhance quality of care and efficiency by linking workforce planning to patient need.

Safe discharge of patients with low-risk upper gastrointestinal bleeding (UGIB): can the use of Glasgow-Blatchford Bleeding Score be extended?

INTRODUCTION: Risk stratification of patients with suspected upper gastrointestinal bleeding (UGIB) using either Glasgow-Blatchford Bleeding Score (GBS) or preendoscopy Rockall score to facilitate early safe discharge (GBS=0, pre-Rockall=0) has been reported. This observational study compared score utility and considered the impact of extending the range of GBS or pre-Rockall scores permitting safe discharge. METHODS: Consecutive adult patients presenting to acute medical admissions or the emergency department from September 2008-March 2009 with suspected UGIB had clinical history, vital signs, laboratory and endoscopy results prospectively recorded using electronic databases. GBS, pre-Rockall scores and a composite endpoint (blood transfusion, endoscopic therapy, interventional radiology, surgery or 30-day mortality) were calculated. RESULTS: 388 patients with suspected UGIB were identified of which 92.3% were admitted (median (range) GBS=5 (0-19) and pre-Rockall=2 (0-11)) and 7.7% discharged (GBS=0 (0-4) and pre-Rockall=0 (0-4)). 186 (47.9%) underwent in-patient endoscopy. 151 (38.9%) were found to have the composite endpoint with 77.5% having transfusion, 45.7% endoscopic treatment and an 8.0% mortality within 30 days. AUROC (95% CI) for 30-day composite endpoint was 0.92 (0.89-0.94) using GBS and 0.75 (0.70-0.80) using pre-Rockall scores. Analysis using different GBS thresholds demonstrated that GBS=0, GBS ≤1 and GBS≤2 had superior utility in identifying freedom from an adverse clinical outcome at 30-days than pre-Rockall score 0. CONCLUSIONS: GBS is superior to pre-Rockall score in identifying patients with suspected UGIB who have a low likelihood of an adverse clinical outcome and can be considered for early discharge. Diagnostic performance at different thresholds suggests that patients with GBS≤2 could be considered for early discharge, doubling the number of eligible patients (15.2 to 32.5%). This has important patient safety and resource implications.

Serial lung function tests in primary immune deficiency.

Pulmonary complications are common in patients with primary immune deficiency (PID). The aim of this study was to assess the usefulness of lung function tests (LFTs) in the management of these patients, and in particular to see if carbon monoxide transfer factor (TLCO) is needed in addition to spirometry. We studied 20 patients (11 female) with PID in a tertiary referral clinic, with a mean age of 47.6 years. Serial LFTs, spanning a mean of 101 months, were correlated with immunoglobulin levels and antibiotic usage. Seven patients showed a decline in forced expiratory volume in 1 second over the period of the study. An additional five patients showed a decline in TLCO. Of these 12 patients, two had no radiographic evidence of lung disease. Higher levels of immunoglobulin were associated with slower decline in LFTs (P < 0.05). The analysis of antibiotic usage and LFTs failed to show a statistically significant effect, although there was a trend towards a slower rate of decline with greater use of antibiotics. LFTs decline slowly in patients with PID. Annual testing (both spirometry and transfer factor) is useful in the assessment of these patients, and should not be confined to those with radiological evidence of lung disease.

Severe hyponatraemia in medical in-patients: aetiology, assessment and outcome.

BACKGROUND: Hyponatraemia is the most commonly identified electrolyte abnormality. Published data on severe hyponatraemia in general medical in-patients is lacking. AIM: To determine the aetiology, adequacy of assessment, and outcome of severe hyponatraemia in general medical in-patients. DESIGN: Retrospective case-note review. METHODS: All general medical in-patients (n = 108) with serum sodium < or =125 mmol/l were identified from the clinical chemistry database, over a six-month period. A full review of notes and computer records was undertaken at the index date and a pre-determined follow-up date. RESULTS: Follow-up data were available in 105 patients. There was a wide range of aetiologies: diuretic therapy (loop and thiazide), congestive cardiac failure and liver disease were the most common, and 75.3% of patients had multiple causes. None of the 48% of patients whose history suggested a possible diagnosis of the syndrome of inappropriate anti-diuretic hormone (SIADH) met the generally accepted diagnostic criteria. Overall mortality was 20% during the index admission and 44.6% at follow-up, vs. 7.1% and 22%, respectively, for other patients admitted to the same directorate over the same time period (p < 0.001). Mortality was linked to aetiology, but not to reduced absolute serum sodium concentration at admission. DISCUSSION: Severe hyponatraemia in general medical patients is associated with a complex, multifactoral aetiology and a very poor prognosis. Outlook is governed principally by aetiology, and not by serum sodium level. Assessment of patients with hyponatraemia requires a practical clinical algorithm for diagnosing SIADH.

Incidence and mortality of idiopathic pulmonary fibrosis and sarcoidosis in the UK.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) and sarcoidosis are common diagnoses in patients attending chest clinics, but little is known about the epidemiology of these diseases. We used data from a general practice database to provide information on the current incidence of IPF and sarcoidosis in the UK. METHODS: Data were extracted for all patients with a diagnosis of IPF or sarcoidosis between 1991 and 2003. The whole population of the database was used to calculate disease incidence stratified by age, sex, region, and time period. Poisson regression was used to compare the incidence between populations and Cox regression was used to compare survival between populations. RESULTS: 920 cases of IPF (mean age 71 years, 62% male) and 1019 cases of sarcoidosis (mean age 47 years, 47% male) were identified. The overall incidence rate per 100 000 person-years was 4.6 for IPF and 5.0 for sarcoidosis. The incidence of IPF increased progressively between 1991 and 2003 (p<0.00001), and was highest in Northern England and Scotland (p<0.0001). The survival of patients with IPF was stable over time. In contrast, the incidence of sarcoidosis was highest in London, West Midlands and Northern Ireland and remained stable over time. CONCLUSIONS: The incidence of IPF has more than doubled between 1990 and 2003; this is not due to the ageing of the UK population or an increased ascertainment of milder cases. The incidence of sarcoidosis has not changed during this time period. Our findings suggest that more than 4000 new cases of IPF and 3000 new cases of sarcoidosis are currently diagnosed each year in the UK.

Under utilisation of the 2-week wait initiative for lung cancer by primary care and its effect on the urgent referral pathway.

The '2-week wait' scheme for referral of patients with cancer to secondary care coincided with the introduction of Department of Health (DoH) Guidelines on referral of patients with suspected lung cancer. The aim of this study was to examine the impact of this process on the urgent referral pathway for lung cancer. Medical records of all patients referred with suspected lung cancer were reviewed for the year prior to introduction of the 2-week wait and DoH guidelines and for the subsequent 24 months. A total of 1044 patients were referred, of which 650 (62%) were found to have malignancy. In the first and second years of the 2-week wait scheme, only 57 and 58% were referred via the scheme. Department of Health guidelines were followed in all but a small number. Median wait time increased from 7 to 9 days. The proportion of all urgent referrals seen within 2 weeks fell from 84 to 71%. The proportion of non-2-week wait urgent referrals being seen within 2 weeks was only 75.5% in the first year of the scheme and fell further to 60.9% in the second year. The absolute number of referrals rose and the proportion having cancer fell from 78% before the scheme to 46% in the second year. During this time, there was no change in stage at presentation. Symptoms were not helpful in discriminating benign from malignant disease and haemoptysis was actually more common in the benign group. However, over 50% of patients in the benign group were appropriate to be seen in secondary care. The 2-week wait scheme has so far failed to reduced waiting times for lung cancer. The findings of this study suggest that this is partly due to continued usage of urgent referral routes outside the 2-week wait scheme and secondly due to a large increase in referrals, probably generated by the introduction of the DoH guidelines. Some adjustment to the guidelines may be appropriate to reflect more emphasis on the early performance of a chest X-ray and the use of direct access to other imaging modalities such as CT. Patients referred outside the 2-week wait are disadvantaged and thus practitioners would be wise to refer all their patients through the 2-week wait system.

Beta2 adrenoceptor promoter polymorphisms: extended haplotypes and functional effects in peripheral blood mononuclear cells.

BACKGROUND: The beta2 adrenoceptor and its 5' untranslated region contain a number of genetic variants. The aim of this study was to investigate the potential for genetic variation at this locus to influence the expression of beta2 adrenoceptors on circulating peripheral blood mononuclear cells (PBMCs). METHODS: Genotype was determined in 96 individuals with asthma for four polymorphisms at the beta2 adrenoceptor locus. Beta2 adrenoceptor binding and cyclic AMP responses to isoprenaline in PBMCs were determined and the relationship between genotype/haplotype and beta2 adrenoceptor expression and response to isoprenaline examined. RESULTS: Beta2 adrenoceptor promoter polymorphisms were found to be common in white subjects. Strong linkage disequilibrium exists across this locus, resulting in the occurrence of several common haplotypes. No single polymorphism or haplotype was correlated with the level of beta2 adrenoceptor expression or cyclic AMP responses to isoprenaline in vitro. CONCLUSION: Beta2 adrenoceptor polymorphisms, when considered in isolation or by extended haplotypes, do not determine the basal level of expression or coupling of beta2 adrenoceptors in PBMCs from asthmatic subjects.