12 research outputs found
Acute coronary events in general practice: the Imminent Myocardial Infarction Rotterdam Study
With the advent of coronary care units in the early sixties, the
first concentrated effort was made to reduce mortality from myocardial
infarction. Subsequent experience has demonstrated that in-hospital
deaths, particularly those from arrhythmias, have decreased
from some thirty-five per cent to below ten per cent. However, several
studies had indicated that up to 60% of the total mortality from acu¡
te coronary events, i.e. sudden cardiac death and acute myocardial
infarction, took place in pre-hospital phase 1-6 and as early as the
late sixties, both clinicians and epidemiologists began to realize
that the greatest further gains had to be achieved by decreasing mortality
in that particular phase. In 1969, Bondurant7 stated: "the
pre-hospital mortality due to ischaemic heart disease is greater
than the total mortality due to any other single cause of death" and
also: "the pre-hospital phase of acute myocardial infarction poses
the greatest single medical problem of our nation in terms of loss
of potential salvageable life". This seems to apply to the U.S.A. as
well to the entire western world of today. Fulton et al. from Edinburgh,
Scotland, concluded also in 1969: "The majority of deaths occur
before patients with acute myocardial infarction reach hospital.
Most of these are sudden and unattended medically. In many, symptoms
of ischaemic heart disease have been present, but often they have passed
unnoticed or at least undeclared. It is difficult to conceive of
any system which would allow effective treatment of these patients.
Therefore, reliable identification of those prone to sudden death and
the development of prophylactlcmeasures would do as much or more to
combat the problem of acute coronary attacks as any other approach.
Thus, the emphasis began to swing away from further intra-hospital
efforts at reducing death from coronary atherosclerotic heart disease
(C.A.H.D.) to the out-of-hospital pre-coronary phase. For instance,
Lown and Wolf stated in 1971: "Coronary care units, while effective
in lowering hospital mortality, can not significantly reduce sudden
cardiac death, which occurs primarily out-of-hospital and accounts
for the majority of deaths from coronary heart disease
The occurrence and inter-rater reliability of myofascial trigger points in the quadratus lumborum and gluteus medius: A prospective study in non-specific low back pain patients and controls in general practice
The presence of a trigger point is essential to the myofascial pain syndrome. This study centres on identifying clearer criteria for the presence of trigger points in the quadratus lumborum and gluteus medius muscle by investigating the occurrence and inter-rater reliability of trigger point symptoms. Using the symptoms and signs as described by Simons' 1990 definition and two other former sets of criteria, 61 non-specific low back pain patients and 63 controls were examined in general practice by 5 observers, working in pairs. From the two major criteria of Simons' 1990 definition only âlocalized tendernessâ has good discriminative ability and inter-rater reliability (kappa > 0.5). This study does not find proof for the clinical usefulness of âreferred painâ, which has neither of these two abilities. The criteria âjump signâ and ârecognitionâ, on the condition that localized tenderness is present, also have good discriminative ability and inter-rater reliability. Trigger points defined by the criteria found eligible in this study allow significant distinction between non-specific low back pain patients and controls. This is not the case with trigger points defined by Simons' 1990 criteria. Concerning reliability there is also a significant difference between the two different criteria sets. This study suggests that the clinical usefulness of trigger points is increased when localized tenderness and the presence of either jump sign or patient's recognition of his pain complaint are used as criteria for the presence of trigger points in the M. quadratus lumborum and the M. gluteus medius
Higher prevalence of depressive symptoms in middle-aged men with low serum cholesterol levels
OBJECTIVE: Investigators from several studies have reported a positive
relationship between low cholesterol levels and death due to violent
causes (eg, suicide and accidents), possibly mediated by depressive
symptoms, aggression or hostility, or impulsivity. We set out to establish
whether middle-aged men with chronically low cholesterol levels (< or =4.5
mmol/liter) have a higher risk of having depressive symptoms, according to
scores on the Beck Depression Inventory, compared with a reference group
of men with cholesterol levels between 6 and 7 mmol/liter. A similar
comparison was also made for measures of anger, hostility, and
impulsivity. METHODS: Cholesterol measurements were obtained as part of a
population-based cholesterol screening study in 1990-1991. These levels
were remeasured in 1993-1994. Only those whose cholesterol level remained
in the same range were included in the study. Depressive symptoms were
assessed by using the Beck Depression Inventory; anger, by questionnaires
based on the Spielberger Anger Expression Scale and State-Trait Anger
Scale; hostility, by the Buss-Durkee Hostility Inventory; and impulsivity,
by the Eysenck and Eysenck Impulsivity Questionnaire. RESULTS: Men with
chronically low cholesterol levels showed a consistently higher risk of
having depressive symptoms (Beck Depression Inventory score > or =15 or >
or =17) than the reference group, even after adjusting for age, energy
intake, alcohol use, and presence of chronic diseases. No differences in
anger, hostility, and impulsivity were observed between the two groups.
CONCLUSIONS: Men with a lower cholesterol level (< or =4.5 mmol/liter)
have a higher prevalence of depressive symptoms than those with a
cholesterol level between 6 and 7 mmol/liter. These data may be important
in the ongoing debate on the putative association between low cholesterol
levels and violent death
Optimal use of coronary care units: A review
Patients at a low probability of acute cardiac pathology constitute a considerable proportion in many coronary care units (CCUs), such that physicians should consider more effective alternatives than CCU admission âto rule out myocardial infarction.â In this article, strategies to increase the efficiency of managing patients with acute chest pain are reviewed. Algorithms aiming to improve the diagnostic accuracy of the general practitioner have been developed but require an electrocardiogram recorded at the home of the patient. Another method of triage encompasses the identification in the emergency room of the hospital of patients at a low probability of acute cardiac pathology by using predictive models that include laboratory assessments. A third strategy includes alternatives to CCUs for patients at a low risk of acute cardiac pathology, such as the creation of a simple observation unit. Finally, some investigators have sought to identify patients with good prognosis for early transfer from the CCU to lower levels of care. It is concluded that a combination of these approaches will be most efficient, and that the most appropriate choice will be determined by local circumstances
Vertraging bij de opname van hartinfarctpatienten
Timely treatment of patients with an evolving myocardial infarction improves the short and long term prognoses. Because of a wrong judgement of the situation by the patient, a significant other or by a general practitioner (GP), treatment may be delayed. To examine this delay 300 patients with myocardial infarction took part in a study between March 1990 and October 1991. After written consent was given, they were interviewed about the pre-hospital period. The significant others received a questionnaire about this period. Medical information was collected from the cardiologists. Fifty percent of all patients called for medical help within 30 minutes. The GP arrived within 11 minutes at the patient's place in 50% of all cases. However, in 50% of all cases the decision making of the GPs before the patient was sent to a hospital required more than 82 minutes. The ambulance arrived within 15 minutes at the patient's place in 90% of all cases. Stabilisa
Selecting subjects for ultrasonographic screening for aneurysms of the abdominal aorta: four different strategies
BACKGROUND: We studied whether the effectiveness of ultrasound screening
for abdominal aortic aneurysms could be increased by preselecting
high-risk subjects, based on the presence of risk indicators for the
disease. METHODS: In a population-based screening programme for abdominal
aortic aneurysms among 5328 subjects living in Rotterdam, The Netherlands,
we studied four different strategies to select subjects for ultrasound
screening of the abdominal aorta, based on risk indicators for abdominal
aortic aneurysm disease. Risk indicators used in each strategy were
entered in a logistic regression model to predict the probability of an
individual having an abdominal aortic aneurysm. Using several cutoff
values for the probability of a subject having an aneurysm for each
strategy, we estimated the proportion of subjects that should be referred
for ultrasound screening and the proportion of aneurysms that would be
diagnosed by each strategy (sensitivity). RESULTS: When a probability of
1.5% of having an aneurysm is chosen as the cutoff point above which
ultrasound screening is indicated, the proportion of subjects that would
be referred for screening ranged from 36% (first strategy) to
approximately 50% (other strategies), while 80% (first strategy) to
approximately 94% (other three strategies) of all aneurysms would be
detected. CONCLUSION: Effectiveness in screening for abdominal aortic
aneurysms can be increased by selecting subjects by means of a short
medical questionnaire, filled out by the screening candidates, including
questions on medical history
Feasibility of AsthmaCritic, a decision-support system for asthma and COPD which generates patient-specific feedback on routinely recorded data in general practice
BACKGROUND: Introducing decision-support systems as a tool to stimulate
the dissemination of clinical guidelines in daily practice has been
disappointing. Researchers have argued that integration of such systems
with clinical practice is a prerequisite for acceptance. The big question
concerns the feasibility of a true integration--if only routinely recorded
data are used for such a system, can patient-specific feedback be
produced? OBJECTIVE: The aim of this study was to assess the feasibility
of generating patient-specific feedback based on routinely recorded data
in general practice by AsthmaCritic, a decision-support system for asthma
and chronic obstructive pulmonary disease (COPD). METHODS: We built the
decision-support system AsthmaCritic and assessed its ability to detect
asthma and COPD patient records and generate patient-specific feedback by
retrospective analysis of routinely recorded data in 103 713 electronic
patient records from primary care practices. We grouped feedback into
categories of comments by age group ( or =12 years). The
main outcome measures were the number and percentage of "triggered"
(selected) asthma and COPD patient records, and the number and percentage
of records on which AsthmaCritic produced at least one feedback comment
during the 1-year study period, by category of comments. RESULTS:
AsthmaCritic detected 8784 (8.5%) asthma and COPD patient records. During
the study period, AsthmaCritic generated 255 664 feedback comments (mean
3.4 per patient visit). The most frequently generated category of comments
in the case of patients aged > or =12 years was "non-compliant
prescription" (23.7%), whereas the most frequent category in the case of
patients <12 years was "non-compliant route" (31.1%). CONCLUSIONS: This
study shows that, using routinely recorded data only, AsthmaCritic is able
to detect asthma and COPD patient records for further analysis and to
produce patient-specific feedback