Physicians perceived usefulness of high-cost diagnostic imaging studies: results of a referral study in a German medical quality network

BACKGROUND: Medical and technological progress has led to increased numbers of diagnostic tests, some of them inducing high financial costs. In Germany, high-cost diagnostic imaging is performed by a medical specialist after referral by a general practitioner (GP) or specialist in primary care. The aim of this study was to evaluate the physicians' perceived usefulness of high-cost diagnostic imaging in patients with different clinical conditions. METHODS: Thirty-four GPs, one neurologist and one orthopaedic specialist in ambulatory care from a Medical Quality Network documented 234 referrals concerning 97 MRIs, 96 CTs-scan and 41 intracardiac catheters in a three month period. After having received the test results, they indicated if these were useful for diagnosis and treatment of the patient. RESULTS: The physicians' perceived usefulness of tests was lowest in suspected cerebral disease (40% of test results were seen as useful), cervical spine problems (64%) and unexplained abdominal complaints (67%). The perceived usefulness was highest in musculoskeletal symptoms (94%) and second best in cardiological diseases (82%). CONCLUSION: The perceived usefulness of high-cost diagnostic imaging was lower in unexplained complaints than in specific diseases. Interventions to improve the effectiveness and efficiency of test ordering should focus on clinical decision making in conditions where GPs perceived low usefulness

Modifying effect of dual antiplatelet therapy on incidence of stent thrombosis according to implanted drug-eluting stent type

Aim To investigate the putative modifying effect of dual antiplatelet therapy (DAPT) use on the incidence of stent thrombosis at 3 years in patients randomized to Endeavor zotarolimus-eluting stent (E-ZES) or Cypher sirolimus-eluting stent (C-SES). Methods and results Of 8709 patients in PROTECT, 4357 were randomized to E-ZES and 4352 to C-SES. Aspirin was to be given indefinitely, and clopidogrel/ticlopidine for ≥3 months or up to 12 months after implantation. Main outcome measures were definite or probable stent thrombosis at 3 years. Multivariable Cox regression analysis was applied, with stent type, DAPT, and their interaction as the main outcome determinants. Dual antiplatelet therapy adherence remained the same in the E-ZES and C-SES groups (79.6% at 1 year, 32.8% at 2 years, and 21.6% at 3 years). We observed a statistically significant (P = 0.0052) heterogeneity in treatment effect of stent type in relation to DAPT. In the absence of DAPT, stent thrombosis was lower with E-ZES vs. C-SES (adjusted hazard ratio 0.38, 95% confidence interval 0.19, 0.75; P = 0.0056). In the presence of DAPT, no difference was found (1.18; 0.79, 1.77; P = 0.43). Conclusion A strong interaction was observed between drug-eluting stent type and DAPT use, most likely prompted by the vascular healing response induced by the implanted DES system. These results suggest that the incidence of stent thrombosis in DES trials should not be evaluated independently of DAPT use, and the optimal duration of DAPT will likely depend upon stent type (Clinicaltrials.gov number NCT00476957

Robust estimation of bacterial cell count from optical density

Optical density (OD) is widely used to estimate the density of cells in liquid culture, but cannot be compared between instruments without a standardized calibration protocol and is challenging to relate to actual cell count. We address this with an interlaboratory study comparing three simple, low-cost, and highly accessible OD calibration protocols across 244 laboratories, applied to eight strains of constitutive GFP-expressing E. coli. Based on our results, we recommend calibrating OD to estimated cell count using serial dilution of silica microspheres, which produces highly precise calibration (95.5% of residuals <1.2-fold), is easily assessed for quality control, also assesses instrument effective linear range, and can be combined with fluorescence calibration to obtain units of Molecules of Equivalent Fluorescein (MEFL) per cell, allowing direct comparison and data fusion with flow cytometry measurements: in our study, fluorescence per cell measurements showed only a 1.07-fold mean difference between plate reader and flow cytometry data

Low-dose methoxyflurane analgesia in adolescent patients with moderate-to-severe trauma pain: a subgroup analysis of the STOP! study

Stuart Hartshorn,1 Patrick Dissmann,2 Frank Coffey,3 Mark Lomax4 1Emergency Department, Birmingham Children’s Hospital, Birmingham, UK; 2Academic Department of Emergency Medicine, James Cook University Hospital, Middlesbrough, UK; 3DREEAM: Department of Research and Education in Emergency Medicine, Acute Medicine and Major Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK; 4Data Management & Statistics, Mundipharma Research Limited, Cambridge, UK Introduction: The undertreatment of acute pain presents a significant challenge in the Emergency Department. This post hoc subgroup analysis of a previously reported randomized controlled UK study reports the efficacy and safety of low-dose methoxyflurane analgesia in treating adolescent patients with moderate-to-severe trauma pain. Patients and methods: Three hundred patients (96 in the adolescent subgroup) aged ≥12 years requiring analgesia for acute trauma pain (pain score of 4–7 on the Numerical Rating Scale) at triage were randomized 1:1 to methoxyflurane (up to 6 mL) or placebo (normal saline), both administered using a Penthrox® inhaler. The patient could request rescue medication (paracetamol/opioids) at any time. The primary endpoint was the change from baseline in visual analog scale (VAS) pain intensity. Results: Mean VAS pain score for the adolescent subgroup at baseline was ~61 mm. Adjusted mean change in VAS pain intensity from baseline to 5, 10, 15, and 20 minutes was −24.5, –28.1, –31.6, and –31.7 mm for methoxyflurane and −14.6, –18.8, –19.2, and –23.7 mm for placebo, with a statistically significant treatment effect in favor of methoxyflurane overall across all four time points (–9.9 mm; 95% CI: −17.4, –2.4 mm; P=0.0104). Median time to first pain relief was significantly shorter with methoxyflurane (1 minute) than placebo (3 minutes, P<0.0001). Pain relief was reported within 1–10 inhalations in 95.7% of methoxyflurane-treated patients and 64.6% of placebo-treated patients. Rescue medication was requested by two (4.3%) methoxyflurane-treated patients and three (6.3%) placebo-treated patients. Over 95% of patients, physicians, and nurses rated methoxyflurane treatment as “Excellent”, “Very Good” or “Good” compared with between 64% and 68% for placebo. The incidence of adverse events was higher with methoxyflurane (51%) than placebo (42%), mostly comprising mild/transient dizziness and headache. Conclusion: This subgroup analysis shows that low-dose inhaled methoxyflurane is a rapid-acting and effective analgesic in adolescent patients presenting with moderate-to-severe trauma pain. Trial registration: Clinicaltrials.gov identifier: NCT01420159, EudraCT number: 2011-000338-12. Keywords: acute pain, analgesic, emergency department, injury, pediatric, Penthro

Pulmonale Komplikationen beim erworbenen Immundefektsyndrom: Ergebnisse einer prospektiven Untersuchung

Höffken G, Lode H, Dissmann T, et al. Pulmonale Komplikationen beim erworbenen Immundefektsyndrom: Ergebnisse einer prospektiven Untersuchung. Deutsche medizinische Wochenschrift. 1988;113(19):755-762.Zwischen 1983 und 1987 wurde bei 37 von 100 HIV-Antikörper-positiven Patienten mit 40 bronchopulmonalen Infektionen prospektiv ein abgestuftes diagnostisches Programm durchgeführt, das im wesentlichen aus einer flexiblen Bronchoskopie, verbunden mit einer Lavage, transbronchialen Biopsie und (oder) bronchialem Bürstenabstrich, bestand. Unter Berücksichtigung sämtlicher intravitaler und autoptischer Untersuchungsverfahren hatten 25 der 37 Patienten eine Pneumocystis-carinii-Pneumonie (67,5 %), dreizehn Patienten bakterielle Pneumonien, davon sechs mykobakterielle Infektionen (atypische Mykobakterien n = 4), acht Patienten Neoplasien (pulmonales Kaposi-Sarkom n = 5, Plattenepithelkarzinom n = 2, M. Hodgkin n = 1) und vier Patienten eine Cytomegalievirus-Infektion. Die diagnostische Gesamtausbeute der flexiblen Bronchoskopie betrug 78 %, bezogen auf die Pneumocystis-Pneumonie 91 %.Between 1983 and 1987, a stepwise diagnostic programme was undertaken prospectively in 37 of 100 HIV-positive patients with 40 bronchopulmonary infections. It consisted chiefly of flexible bronchoscopy combined with lavage, transbronchial biopsy and/or removal of bronchial brush cells. Taking into account all examinations performed in life and at autopsy, 25 of the 37 patients had Pneumocystis carinii pneumonia (67.5 %), 13 had bacterial pneumonia, six of these were mycobacterial infections (atypical mycobacteria in four), eight had neoplasms (pulmonary Kaposi's sarcoma in five, squamous-cell carcinoma in two, and Hodgkin's disease in one), and four patients had cytomegalovirus infection. Total diagnostic success of bronchoscopy was 78 %; related to Pneumocystis pneumonia it was 91 %