An audit of the UK national cancer referral guidelines for suspected oral mucosal malignancy

BACKGROUND AND OBJECTIVE: This study aimed to assess the effectiveness of the UK National Guidelines for identifying patients with potentially malignant oral disease which were introduced in 2000. DESIGN: Retrospective audit. SETTING: The oral medicine unit in a university teaching hospital in London. METHODS: All new referrals over a one year period were retrospectively reviewed in a departmental audit to evaluate guideline effectiveness. Reasons for referral and final diagnosis were compared in a randomly selected sub-population. RESULTS: Four hundred and eighty-seven of 901 new patients referred were classified as having potentially malignant disease from the referral letter. In a randomly selected subgroup of 241 patients, 18 actually had malignant (8) or dysplastic lesions (10). Of 75 patients referred with a persistent oral ulcer, only nine were actually malignant or dysplastic. Eight of 116 patients referred with a white patch and none with red patches were found to have dysplastic or malignant lesions. The criteria failed to identify three carcinomas and two severely dysplastic lesions (15% of the malignant or dysplastic lesions). All of the latter had been referred by primary care physicians with orofacial pain of unknown cause. CONCLUSIONS: UK National Guidelines discriminate poorly between potentially malignant and other oral mucosal disease.     

Right atrial ‘thrombus in transit’ and atrial septal defect in a 70-year-old man: cardioembolic source of pulmonary and paradoxical cerebral embolization

A 70-year-old man was admitted with sudden onset of dyspnea, near syncope and left hemiparesis. Clinical examination, blood gas analysis, ECG and the chest X-ray were consistent with pulmonary embolism. Transthoracic echocardiography (TTE) revealed right atrial free-floating thrombus, large atrial septal defect (ASD), right heart enlargement and pulmonary artery hypertension. Anticoagulation therapy was initiated immediately, soon after thrombolytic therapy was started but the patient died due to possible pulmonary or cerebral embolization. We underscore rapid diagnosis by TTE that revealed right heart thrombus in transit and large ASD.     

Acute rest perfusion imaging in high risk unstable angina: association with troponin T and clinical endpoints

BACKGROUND: Troponin T (TnT) and rest perfusion imaging (RPI) have been reported to be important diagnostic tools for risk stratification in patients with chest pain. METHODS: We investigated the association between two methods in 60 patients presenting with typical chest pain at rest within the last 6 h before admission. All patients underwent Tc-99m gated SPECT imaging and serial TnT measurements and were followed for occurrence of adverse cardiac events up to 30 days. RESULTS: Perfusion defect was detected in 42 patients and elevated TnT was observed in 23 patients. All of the patients with an elevated TnT have also perfusion defect in RPI. Half of the patients with normal TnT level (51%) presented a perfusion defect detected by RPI (p = NS). The patients with elevated TnT levels had more perfusion defect numbers than those with normal TnT levels (8.2 +/- 2.9 vs. 5.3 +/- 2.2; p = 0.0007). Cardiac events occurred in 38 patients (14 MI, 24 revascularisation). In predicting cardiac events, RPI and TnT had sensitivities (97 vs. 58%; p < 0.001), specificities (77 vs. 95%, p = NS), positive predictive values (PPV) (88 vs. 96%; p = NS) and negative predictive values (NPV) (94% vs. 57%; p = NS), respectively. In predicting MI, the two tests had sensitivities (93 vs. 93%; p = NS), specificities (37 vs. 78%; p < 0.001), PPVs (31 vs. 57%; p = NS) and NPVs (94 vs. 97%; p = NS), respectively. CONCLUSIONS: These results suggest that in patients with rest angina (1) TnT elevation is associated with the extent of myocardial perfusion defect; (2) both tests are valuable, while positive RPI is more sensitive in predicting all cardiac events irrespective of TnT; both positive TnT and positive RPI predict a high probability to have MI; (3) both negative test results predict a very low probability to have cardiac event, including MI.     

Effect of mechanical dyssynchrony and cardiac resynchronization therapy on left ventricular rotational mechanics

Alterations in rotational mechanics can bring new aspects to the understanding of left ventricular (LV) dyssynchrony. The aims of this study were to investigate LV rotational mechanics in candidates for cardiac resynchronization therapy (CRT) and to assess the effect of CRT by speckle-tracking echocardiography. Fifty-four patients with heart failure and 33 healthy controls were studied. Thirty-three underwent CRT. Speckle tracking was applied to short- and long-axis views. Radial and longitudinal dyssynchrony were assessed as previously defined. Apical and basal rotations were measured as the average angular displacement about the LV central axis. LV twist and torsion were then calculated. Peak apical and basal rotation, peak LV twist and torsion, apical and basal rotation at aortic valve closure (AVC), and LV twist and torsion at AVC were significantly lower in patients than controls. Apical-basal rotation delay and AVC-to-peak LV twist interval were longer in patients and associated with decreased peak LV twist and LV twist at AVC, respectively. In patients, rotational indexes, particularly LV twist and torsion, were correlated strongly with radial dyssynchrony. LV torsion (cutoff 0.1 degrees /cm) and twist (cutoff 1 degrees ) at AVC had the highest sensitivity (90%) and specificity (77%) to predict CRT responders among all other parameters, including radial and longitudinal dyssynchrony. In conclusion, LV dyssynchrony is associated with discoordinate rotation of the apical and basal regions, which in turn significantly decreases peak LV twist and torsion and LV twist and torsion at AVC. CRT significantly restored the altered rotational mechanics in responders. These parameters have potential for predicting responders to CRT.