Impact of MidMed, a general practitioner-led modified comprehensive geriatric assessment for patients with frailty.

INTRODUCTION: the identification and management of frailty occurs mostly in primary care. Several different models of care exist. This study aimed to assess the impact of a new General Practitioner (GP)-led modified Comprehensive Geriatric Assessment (CGA) on service delivery, healthcare utilisation and patient outcomes. METHOD: patients with moderate-severe frailty (electronic Frailty Index score > 0.24) in Newbattle Medical Practice, Scotland, were eligible for a novel intervention (MidMed) in which an additional GP performed a modified CGA and was directly accessible for appointments. The recruits to the intervention (MidMed) group were compared with those waiting to be enrolled (non-MidMed). Outcomes included unscheduled hospital admissions, primary care consultations, continuity of care (Usual Provider of Care (UPC) index), outpatient attendances and mortality. Adjusted rate ratios (aRR), for MidMed compared to non-MidMed, were estimated using regression models adjusting for demographics and healthcare utilisation histories. RESULTS: 510 patients were included: 290 MidMed (mean(SD) age 80.1(7.6)years; 59.6% female) and 220 non-MidMed (75.4(8.6)years; 57.7% female). Median follow-up was 396 days. aRR(95%CI) was 0.46(0.30-0.71) for >1 admission, 0.62(0.41-0.95) >1 Emergency Department (ED) attendance and 1.52(1.30-1.75) for use of primary care, with no difference in outpatient appointments or mortality. Continuity of care was better for the MidMed group (MidMed UPC 0.77(SD 0.19), non-MidMed 0.41(0.18), P < 0.001). CONCLUSION: this GP-led service for frail patients was associated with lower risk of hospital readmission/ED reattendance, greater use of primary care and improved continuity of care. More detailed evaluation of novel primary care frailty services, over longer time-periods, including robust randomised controlled trials, are needed.

Benign tumours of the bronchopulmonary system.

The vast majority of tumours arising in the bronchopulmonary system are malignant in nature. Benign tumours of the lung are relatively rare and are often incidental findings during clinical investigations for unrelated conditions. These lesions can arise in the bronchial tree or the pulmonary parenchyma and may be of epithelial, mesenchymal, salivary gland-type or unknown differentiation. Although the spectrum of these lesions is wide, the clinical, pathological and immunohistochemical characteristics of the most relevant will be the subject of this review. In addition, the most important features allowing differentiation from malignant pulmonary neoplasms will be discussed.

The "Is mpMRI Enough" or IMRIE Study: A Multicentre Evaluation of Prebiopsy Multiparametric Magnetic Resonance Imaging Compared with Biopsy.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) is now recommended prebiopsy in numerous healthcare regions based on the findings of high-quality studies from expert centres. Concern remains about reproducibility of mpMRI to rule out clinically significant prostate cancer (csPCa) in real-world settings. OBJECTIVE: To assess the diagnostic performance of mpMRI for csPCa in a real-world setting. DESIGN, SETTING, AND PARTICIPANTS: A multicentre, retrospective cohort study, including men referred with raised prostate-specific antigen (PSA) or an abnormal digital rectal examination who had undergone mpMRI followed by transrectal or transperineal biopsy, was conducted. Patients could be biopsy naïve or have had previous negative biopsies. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary definition for csPCa was International Society of Urological Pathology (ISUP) grade group (GG) ≥2 (any Gleason ≥7); the accuracy for other definitions was also evaluated. RESULTS AND LIMITATIONS: Across ten sites, 2642 men were included (January 2011-November 2018). Mean age and PSA were 65.3yr (standard deviation [SD] 7.8yr) and 7.5ng/ml (SD 3.3ng/ml), respectively. Of the patients, 35.9% had "negative MRI" (scores 1-2); 51.9% underwent transrectal biopsy and 48.1% had transperineal biopsy, with 43.4% diagnosed with csPCa overall. The sensitivity and negative predictive value (NPV) for ISUP GG≥2 were 87.3% and 87.5%, respectively. The NPVs were 87.4% and 88.1% for men undergoing transrectal and transperineal biopsy, respectively. Specificity and positive predictive value of MRI were 49.8% and 49.2%, respectively. The sensitivity and NPV increased to 96.6% and 90.6%, respectively, when a PSA density threshold of 0.15ng/ml/ml was used in MRI scores 1-2; these metrics increased to 97.5% and 91.2%, respectively, for PSA density 0.12ng/ml/ml. ISUP GG≥3 (Gleason ≥4+3) was found in 2.4% (15/617) of men with MRI scores 1-2. They key limitations of this study are the heterogeneity and retrospective nature of the data. CONCLUSIONS: Multiparametric MRI when used in real-world settings is able to rule out csPCa accurately, suggesting that about one-third of men might avoid an immediate biopsy. Men should be counselled about the risk of missing some significant cancers. PATIENT SUMMARY: Multiparametric magnetic resonance imaging (MRI) is a useful tool for ruling out prostate cancer, especially when combined with prostate-specific antigen density (PSAD). Previous results published from specialist centres can be reproduced at smaller institutions. However, patients and their clinicians must be aware that an early diagnosis of clinically significant prostate cancer could be missed in nearly 10% of patients by relying on MRI and PSAD alone.

Intravenous glomus tumour of the upper arm.

Glomus tumours are rare, benign tumours of the glomus body, most frequently located in the subungual region of digits, palms and soles, but they have been reported throughout the body. Our patient is a 65-year-old man who presented with a 3-year history of a very painful area on his left upper arm. The overlying skin was normal and there was no lesion to palpate, but the symptoms were very striking, warranting further investigation. An exploratory operation identified a prominent vein with a noticeable bulge in the vessel wall. The vein was ligated and excised. On dissection of the vein, a tumour was present within its lumen. Histological examination and immune profile of the tumour confirmed an intravascular glomus tumour. Following surgical excision, symptoms resolved.

Recurrent pyogenic granuloma with satellitosis.

A 26-year-old woman was treated by curettage and cautery for a pyogenic granuloma on her left shoulder. This recurred 3 months later and was excised. After a further 5 months, she developed three vascular papules and one lobulated vascular lesion at the site. These ranged in size from 1-4 mm and the largest of these bled easily on minimal trauma. The authors treated the four vascular lesions with curettage and cautery and took a punch biopsy from an erythematous area in the scar. Histology was identical to the original lesion, confirming a diagnosis of recurrent pyogenic granuloma with satellitosis. One year later she had no evidence of recurrence of the lesions.

Evaluation of the electrocardiographic criteria for left ventricular hypertrophy.

OBJECTIVE: Left ventricular hypertrophy (LVH) is an independent predictor of cardiovascular (CV) mortality. This study compared different criteria including Sokolow-Lyon and Cornell, in terms of voltage and voltage-QRS-duration products, as well as point-scoring systems such as the Romhilt-Estes, Perugia and Glasgow-Royal-Infirmary modified Romhilt-Estes score. METHODS: Patients undergoing echocardiography were recruited from the cardiology department in Glasgow Royal Infirmary. Echocardiographically derived left ventricular mass was indexed to body surface area and using sex dependent thresholds, LVH was determined. Electrocardiograms (ECG) were processed using The University of Glasgow Analysis Program, permitting different LVH criteria to be calculated and evaluated. Inclusion criteria for this study were that the patients had a technically adequate echocardiogram and ECG. RESULTS: The main analysis used 51 male and 76 female patients. At published thresholds, the Lewis index gave the greatest sensitivity of the voltage criteria (12%). However, adjusted to 95% specificity, the Cornell index produced the greatest sensitivity at 19%. The best voltage-duration product was the Cornell product that gave 15% sensitivity and 19% when adjusted to 95% specificity. The point scoring systems proved to be the most accurate with the Perugia score being 22% sensitive and the Glasgow Royal Infirmary modified Romhilt-Estes score 24 % sensitive, both at 95% specificity. CONCLUSION: This study finds that ECG criteria for LVH that use only voltage are relatively poor predictors of LVH. This study also finds that the best criteria for assessing LVH are the point scoring criteria, in particular the Glasgow Royal Infirmary Modified Romhilt-Estes score.

Clinical, information and business process modeling to promote development of safe and flexible software.

Using a factorial vignette survey and modeling methodology, we developed clinical and information models - incorporating evidence base, key concepts, relevant terms, decision-making and workflow needed to practice safely and effectively - to guide the development of an integrated rule-based knowledge module to support prescribing decisions in asthma. We identified workflows, decision-making factors, factor use, and clinician information requirements. The Unified Modeling Language (UML) and public domain software and knowledge engineering tools (e.g. Protégé) were used, with the Australian GP Data Model as the starting point for expressing information needs. A Web Services service-oriented architecture approach was adopted within which to express functional needs, and clinical processes and workflows were expressed in the Business Process Execution Language (BPEL). This formal analysis and modeling methodology to define and capture the process and logic of prescribing best practice in a reference implementation is fundamental to tackling deficiencies in prescribing decision support software.