Radiology: Imaging Trauma Patients in a Deployed Setting.

Medical imaging plays a critical role in the rapid diagnosis, effective triage, and management of complex poly-trauma patients. High-quality medical imaging can be accomplished successfully in a deployed or wartime setting. Due to advances in aggressive resuscitation techniques and the speed of the latest generation computed tomography scanners (64-detector and beyond), rapid trauma scans utilizing computed tomography and ultrasound imaging can routinely be performed prior to taking the patient to the operating room potentially providing the trauma team with lifesaving information. This clinical practice guideline provides an overview of the imaging modalities available in austere settings, the equipment required, and the role that each plays in triaging and diagnosis of the acutely injured poly-trauma patients.

A cluster randomised trial of educational messages to improve the primary care of diabetes.

BACKGROUND: Regular laboratory test monitoring of patient parameters offers a route for improving the quality of chronic disease care. We evaluated the effects of brief educational messages attached to laboratory test reports on diabetes care. METHODS: A programme of cluster randomised controlled trials was set in primary care practices in one primary care trust in England. Participants were the primary care practices' constituent healthcare professionals and patients with diabetes. Interventions comprised brief educational messages added to paper and electronic primary care practice laboratory test reports and introduced over two phases. Phase one messages, attached to Haemoglobin A1c (HbA1c) reports, targeted glycaemic and cholesterol control. Phase two messages, attached to albumin:creatinine ratio (ACR) reports, targeted blood pressure (BP) control, and foot inspection. Main outcome measures comprised practice mean HbA1c and cholesterol levels, diastolic and systolic BP, and proportions of patients having undergone foot inspections. RESULTS: Initially, 35 out of 37 eligible practices participated. Outcome data were available for a total of 8,690 patients with diabetes from 32 practices. The BP message produced a statistically significant reduction in diastolic BP (-0.62 mmHg; 95% confidence interval -0.82 to -0.42 mmHg) but not systolic BP (-0.06 mmHg, -0.42 to 0.30 mmHg) and increased the odds of achieving target BP control (odds ratio 1.05; 1.00, 1.10). The foot inspection message increased the likelihood of a recorded foot inspection (incidence rate ratio 1.26; 1.18 to 1.36). The glycaemic control message had no effect on mean HbA1c (increase 0.01%; -0.03 to 0.04) despite increasing the odds of a change in likelihood of HbA1c tests being ordered (OR 1.06; 1.01, 1.11). The cholesterol message had no effect (decrease 0.01 mmol/l, -0.04 to 0.05). CONCLUSIONS: Three out of four interventions improved intermediate outcomes or process of diabetes care. The diastolic BP reduction approximates to relative reductions in mortality of 3% to 5% in stroke and 3% to 4% in ischaemic heart disease over 10 years. The lack of effect for other outcomes may, in part, be explained by difficulties in bringing about further improvements beyond certain thresholds of clinical performance. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN2186314.

Hematological effects of valproate in psychiatric patients: what are the risk factors?

BACKGROUND: Sodium valproate is an anticonvulsant that is also one of the common treatments used for bipolar disorder. The present study was conducted in psychiatric patients with the aim of examining the effects of valproate on hematological parameters and to explore any association with sex and age. METHODS: A list of all psychiatric patients who underwent valproate level estimation in the years 2004-2008 in Newcastle upon Tyne was drawn from the biochemistry database of the local hospital. The names and date of births of these patients were used to draw corresponding hematological data, including hemoglobin, white blood cell count, mean corpuscular volume (MCV), and platelet count, conducted on the same day or within a week of the valproate level measurement. RESULTS: : The data from 126 patients were analyzed. The prevalence of thrombocytopenia (platelet count, <150,000/microL) was found to be approximately 5%. In female subjects, a significant negative correlation was found between serum valproate level and platelet count; also, a positive correlation between valproate level and MCV was found. Neither correlation was found in male subjects. The risk of a low platelet count was found to be significantly increased at serum valproate level above 80 microg/mL in female subjects. The regression analysis in female patients showed a trend toward fall in platelet count and an increase in MCV with increasing age. CONCLUSIONS: In psychiatric patients on valproate therapy, close monitoring of full blood count is required in women particularly at valproate serum level above 80 microg/mL. This may be particularly important in older patients.

Early emergence of ethnic differences in type 2 diabetes precursors in the UK: the Child Heart and Health Study in England (CHASE Study).

BACKGROUND: Adults of South Asian origin living in the United Kingdom have high risks of type 2 diabetes and central obesity; raised circulating insulin, triglyceride, and C-reactive protein concentrations; and low HDL-cholesterol when compared with white Europeans. Adults of African-Caribbean origin living in the UK have smaller increases in type 2 diabetes risk, raised circulating insulin and HDL-cholesterol, and low triglyceride and C-reactive protein concentrations. We examined whether corresponding ethnic differences were apparent in childhood. METHODS AND FINDINGS: We performed a cross-sectional survey of 4,796 children aged 9-10 y in three UK cities who had anthropometric measurements (68% response) and provided blood samples (58% response); ethnicity was based on parental definition. In age-adjusted comparisons with white Europeans (n = 1,153), South Asian children (n = 1,306) had higher glycated haemoglobin (HbA1c) (% difference: 2.1, 95% CI 1.6 to 2.7), fasting insulin (% difference 30.0, 95% CI 23.4 to 36.9), triglyceride (% difference 12.9, 95% CI 9.4 to 16.5), and C-reactive protein (% difference 43.3, 95% CI 28.6 to 59.7), and lower HDL-cholesterol (% difference -2.9, 95% CI -4.5 to -1.3). Higher adiposity levels among South Asians (based on skinfolds and bioimpedance) did not account for these patterns. Black African-Caribbean children (n = 1,215) had higher levels of HbA1c, insulin, and C-reactive protein than white Europeans, though the ethnic differences were not as marked as in South Asians. Black African-Caribbean children had higher HDL-cholesterol and lower triglyceride levels than white Europeans; adiposity markers were not increased. CONCLUSIONS: Ethnic differences in type 2 diabetes precursors, mostly following adult patterns, are apparent in UK children in the first decade. Some key determinants operate before adult life and may provide scope for early prevention.

Repeatability of the low-dose ACTH test in asthmatic children on inhaled corticosteroids.

AIM: To assess the repeatability of low-dose Synacthen test (LDST) in asthmatic children receiving high-dose fluticasone propionate (FP). METHODS: Low-dose Synacthen test was performed on 18 children with stable chronic asthma treated with FP at a constant daily dose of > or =500 microg and repeated 1 month later. Repeatability was assessed using the Kappa statistic for categorical variables. RESULTS: Fifteen patients had consistent results (either two normal or two abnormal responses) and three patients had inconsistent results (one normal and one abnormal response). The Kappa statistic was 0.56 indicating fair to good agreement between the tests. CONCLUSION: The results of adrenal function testing in patients on inhaled steroids can have major implications for patient management, making it important to use a test with excellent repeatability. The LDST conducted using our protocol does not fulfil this criterion.

Serum 25-hydroxyvitamin D measurement in a large population survey with statistical harmonization of assay variation to an international standard.

CONTEXT: An automated application of Immunodiagnostic Systems Limited (IDS) OCTEIA 25-hydroxyvitamin D [25(OH)D] enzyme immunoassay was developed for analyses of 25(OH)D in more than 7000 participants of the 1958 cohort. Variation between 25(OH)D assays hampers between-study comparisons and the definition of relevant cutoffs for hypovitaminosis D. OBJECTIVE: The objective of the study was to evaluate the importance of assay variation on the estimated prevalence of hypovitaminosis D and assess the use of statistical harmonization to overcome the observed differences. DESIGN: Agreement analyses were performed between two commercial 25(OH)D assays (IDS enzyme immunoassay and Diasorin RIA), with validation using performance data from Vitamin D External Quality Assessment Scheme (DEQAS). SETTING: The study was conducted in England, Scotland, and Wales. PARTICIPANTS: Members of the 1958 British birth cohort participated in the study. MAIN OUTCOME MEASURES: 25(OH)D was measured both by IDS and Diasorin RIA in 781 samples. Additional quality control data were obtained through participation in DEQAS (five distributions throughout the survey). RESULTS: Average 25(OH)D concentrations by IDS were -15.7 and -13.7 nmol/liter lower, compared with Diasorin or DEQAS mean, respectively (both P < 0.0001). Graphical examination demonstrated a dose-related bias between IDS with Diasorin and DEQAS mean, but log transformation removed the bias. After using the log difference between the measurements as an adjustment factor, there were no differences in average 25(OH)D concentrations (P >or= 0.21 for comparison of IDS with Diasorin or DEQAS) and estimates for hypovitaminosis D obtained by IDS were similar to Diasorin. CONCLUSIONS: Differences between assays have implications for public health messages about hypovitaminosis D. Harmonization of results with DEQAS enabled the use of previously determined cutoffs for hypovitaminosis D.

A cluster randomised controlled trial of educational prompts in diabetes care: study protocol.

BACKGROUND: Laboratory services have a central role in supporting screening, diagnosis, and management of patients. The increase in chronic disease management in primary care for conditions such as diabetes mellitus requires regular monitoring of patients' biochemical parameters. This process offers a route for improving the quality of care that patients receive by using test results as a vehicle for delivering educational messages as well as the test result itself. AIM: To develop and evaluate the effectiveness of a quality improvement initiative to improve the care of patients with diabetes using test report reminders. DESIGN: A programme of four cluster randomised controlled trials within one population of general practices. PARTICIPANTS: General practices in Newcastle-upon-Tyne, UK. INTERVENTION: Brief educational messages added to paper and electronic general practice laboratory test reports introduced over two phases. Phase One messages, attached to Haemoglobin A1c (HbA1c) reports, targeted glycaemic and cholesterol control. Phase Two messages, attached to albumin:creatinine ratio (ACR) reports, targeted blood pressure (BP) control and foot inspection. OUTCOMES: General practice mean levels of HbA1c and cholesterol (Phase One) and diastolic and systolic BP and proportions of patients having undergone foot inspections (Phase Two); number of tests requested.

Life-course influences on health in British adults: effects of socio-economic position in childhood and adulthood.

BACKGROUND: Little evidence exists on the role of socio-economic position (SEP) in early life on adult disease other than for cardiovascular mortality; data is often retrospective. We assess whether childhood SEP influences disease risk in mid-life, separately from the effect of adult position, and establish how associations vary across multiple measures of disease risk. METHODS: Prospective follow-up to adulthood of all born in England, Scotland and Wales during 1 week in 1958, and with medical data at age 45 years (n = 9377). Outcomes include: blood pressure, body mass index (BMI), glycosylated haemoglobin (HbA1c), total and high density lipoprotein (HDL) cholesterol, triglycerides, fibrinogen, total immunoglobulin E (IgE), one-second forced expiratory volume (FEV1), hearing threshold (4 kHz), visual impairment, symptoms of depression and anxiety, chronic widespread pain. RESULTS: Social class in childhood was associated with blood pressure, BMI, HbA1c, HDL cholesterol, triglycerides, fibrinogen, FEV1, hearing threshold, depressive symptoms and chronic widespread pain, with a general trend of deteriorating health from class I to V. Adult social class was also associated with these measures. Mutually adjusted analyses of child and adult social class suggest that both contribute to disease risk in mid-life: in general, associations for childhood class were as strong as for adult class. Individuals with a manual class at both time-points tended to have the greatest health deficits in adulthood. CONCLUSIONS: Adverse SEP in childhood is associated with a poorer health profile in mid-adulthood, independently of adult social position, and across diverse measures of disease risk and physical and mental functioning.

Lifecourse influences on health among British adults: effects of region of residence in childhood and adulthood.

BACKGROUND: It has been suggested that early life exposures are important determinants of geographical variations in adult diseases. We examined inter-regional migrants in Britain to evaluate the relative importance of early and recent exposures for adult cardiorespiratory risk factors, mental ill-health and sensory function. METHODS: A total of 9023 persons born throughout England, Scotland and Wales during 1 week in 1958 were followed periodically through childhood into adulthood. At 44-45 years, height, body mass index (BMI), blood pressure (BP), glycosylated haemoglobin, total and high-density lipoprotein (HDL) cholesterol, triglycerides, fibrinogen, total immunoglobulin E (IgE), one-second forced expiratory volume (FEV1), hearing threshold at 4 kHz, visual impairment, symptoms of depression and anxiety, and chronic widespread pain were measured. Analysis of migration between 12 regions included 3125 cohort members who were examined in a region different to their birthplace. RESULTS: Height, BMI, diastolic BP (DBP), FEV1, log-transformed IgE and hearing threshold varied by region among non-migrants (each P < 0.05). Among inter-regional migrants, the spatial associations with current region, independent of birthplace, followed closely the geographical pattern shown among non-migrants for BMI, DBP and FEV1 (each P < 0.001). In contrast, of the 15 outcomes, only adult height was related to region of birth, after adjustment for region of examination (P = 0.002) CONCLUSIONS: Although individual disease risk is predicted by early life factors, early exposures do not explain regional variations in cardiovascular and respiratory risk factors among middle-aged adults in Britain. Geographical inequalities in cardiorespiratory health are more strongly related to factors associated with region of examination that influence obesity, BP and ventilatory function.