An evaluation of composite indicators of hospital acute myocardial infarction care: a study of 136,392 patients from the Myocardial Ischaemia National Audit Project.

BACKGROUND: Hospital acute myocardial infarction (AMI) care is increasingly evaluated using composite quality scores. We investigated the influence of three aggregation methods for an AMI indicator on mortality and hospital rank. METHODS AND RESULTS: We studied 136,392 patients discharged alive from 199 hospitals with AMI recorded in the Myocardial Ischaemia National Audit Project, between 01/01/2008 and 31/12/2009. A composite of prescription of aspirin, thienopyridine inhibitor, ß-blocker, angiotensin converting enzyme inhibitor, HMG CoA reductase enzyme inhibitor and enrolment in cardiac rehabilitation at discharge was aggregated as opportunity based (OBCS), weighted opportunity-based (WOBCS) and all-or-nothing (ANCS) scores. We quantified adjusted 30-day, 6-month and 1-year mortality rates and hospital performance rank. Median (IQR) scores were OBCS: 95.0% (3.5), WOBCS: 94.7% (0.8) and ANCS: 80.9% (11.8). The three methods affected the proportion of hospitals outside 99.8% credible limits of the national median (OBCS: 52.2%, WOBCS: 64.3% and ANCS: 37.7%) and hospital rank. Each 1% increase in composite score was significantly associated with a 1 to 3% and a 4% reduction in 6-month and 1-year mortality, respectively. However, the ANCS had fewer cases and no significant association with 30-day mortality. CONCLUSIONS: A hospital composite score, incorporating 6 aspects of AMI care, was significantly inversely associated with mortality. However, composite aggregation method influenced hospital rank, number of cases available for analysis and size of the association with all-cause mortality, with the ANCS performing least well. The use and choice of composite scores in hospital AMI quality improvement requires careful evaluation.

Arch-length asymmetry related to an odontoma in a three-year-old.

Odontomas are often discovered after they affect the eruption and position of the permanent teeth. This case report pointed out that as early as thirty months the primary dentition can be altered.

Evaluation of the budget method for screening food additive intakes.

The Budget Method, originally developed for determining food additive use limits, has been proposed as a tool for screening food additive intakes to establish monitoring priorities. Theoretical Maximum Daily Intake (TMDI) estimates derived using the Budget Method rely on assumptions regarding physiological requirements for energy and liquid and on the energy density of food rather than on food consumption survey data. This report summarizes work performed to determine the validity of Budget Method assumptions and to assess the potential for error in assigning monitoring priority based on Budget Method results. Budget Method assumptions regarding energy and liquid intake were compared with data from UK, German and US nationwide food consumption surveys. It was found that the Budget Method assumptions of energy intake and liquid intake are higher than mean intakes reported in surveys. The Budget Method assumption regarding energy density of foods also was found to be a slight overestimate. Budget Method TMDIs for case study additives were in each case larger than survey-based 95th percentile per capita additive intake estimates. Based on these results, the Budget Method appears to be a suitably conservative screen for establishing additive monitoring priorities based on potential lifetime average intakes.

Successful management of an acquired gastric outlet obstruction with endoscopy guided balloon dilatation.

Antral-pyloric strictures and gastric outlet obstruction are known complications of caustic ingestions. These lesions can develop even in the absence of overt signs of potentially serious upper gastrointestinal tract pathology such as oropharyngeal burns, dysphagia, vomiting, or abdominal pain at the time of ingestion. The development of radial balloon catheters, which can be endoscopically guided into narrow strictures and inflated, offers an alternative therapy to surgical resection of obstructing lesions. We report the successful management of a pyloric stricture secondary to a caustic ingestion by sequential endoscopically guided balloon dilatations and offer guidelines for the use of this procedure.

Epicranial arachnoid cyst.

We have reported a case of epicranial arachnoid cyst, a developmental abnormality that occurs at the obelion, and have reviewed characteristic clinical and radiologic features that facilitate diagnosis.

Dose-response relation of diazoxide in children with hypertension.

Diazoxide was administered to sixteen pediatric patients (ages 10 months to 13 years) with secondary forms of hypertension. Admission BP was 178+/-8/130+/-5 mm Hg (mean +/- SEM). Diazoxide was administered rapidly intravenously in doses ranging from 2 to 7.5 mg/kg. A significant (P less than 0.001), linear log dose-response relation was obtained which showed that a 3 mg/kg dose of diazoxide lowered diastolic BP by an average of 30 mm Hg. In five patients reduction of idastolic BP by a single injection of diazoxide was no different than when the same total dose was given as two or three small injections repeated at fifteen to twenty minute intervals. It is concluded that 1) many hypertensive children respons significantly to doses of diazoxide smaller than the usually recommended 5 mg/kg; 2) diazoxide has a significant dose-response relation in hypertensive pediatric patients; and 3) the desired blood pressure response in hypertensive children can be titrated using repeated small injections of diazoxide.