A more appropriate cardiac troponin T level that can predict outcomes in end-stage renal disease patients with acute coronary syndrome

Purpose

Cardiac troponin T (cTnT), a useful marker for diagnosing acute myocardial infarction (AMI) in the general population, is significantly higher than the usual cut-off value in many end-stage renal disease (ESRD) patients without clinically apparent evidence of AMI. The aim of this study was to evaluate the clinical usefulness of cTnT in ESRD patients with acute coronary syndrome (ACS).

Materials and Methods

Two hundred eighty-four ESRD patients with ACS were enrolled between March 2002 and February 2008. These patients were followed until death or June 2009. Medical records were reviewed retrospectively. The cut-off value of cTnT for AMI was evaluated using a receiver operating characteristic (ROC) curve. We calculated Kaplan-Meier survival curves, and potential outcome predictors were determined by Cox proportional hazard analysis.

Results

AMIs were diagnosed in 40 patients (14.1%). The area under the curve was 0.98 in the ROC curve (p<0.001; 95% CI, 0.95-1.00). The summation of sensitivity and specificity was highest at the initial cTnT value of 0.35 ng/mL (sensitivity, 0.95; specificity, 0.97). Survival analysis showed a statistically significant difference in all-cause and cardiovascular mortalities for the group with an initial cTnT ≥0.35 ng/mL compared to the other groups. Initial serum cTnT concentration was an independent predictor for mortality.

Conclusion

Because ESRD patients with an initial cTnT concentration ≥0.35 ng/mL have a poor prognosis, it is suggested that urgent diagnosis and treatment be indicated in dialysis patients with ACS when the initial cTnT levels are ≥0.35 ng/mL.     

Basal Metabolic Rate in Narcoleptic Patients

Study Objectives:

We investigated basal metabolic rate (BMR) and energy expenditure (EE) in narcoleptic patients and in BMI- and age-matched controls in order to explore the hypothesis that a reduced BMR or EE plays a role in narcolepsy-associated obesity.

Design:

Control group design with comparison of EE and BMR. EE was determined by indirect calorimetry using the Deltatrac Metabolic Monitor system. BMR was calculated from the oxygen consumption (VO₂) and the carbon dioxide consumption (VCO₂) measurements after 12 hours of fasting in the morning.

Participants:

13 narcoleptic patients and 30 controls.

Results:

BMR and EE were not significantly reduced when all subjects were included into the analysis. Subgroup analysis revealed that only non-obese narcoleptics, but not obese narcoleptics had reduced BMRs in comparison to the BMI matched controls.

Conclusion:

Our study suggests that EE plays a role in narcolepsy associated obesity. We propose that narcolepsy may lead to a shift of individual BMI set points.

Citation:

Dahmen N; Tonn P; Messroghli L; Ghezel-Ahmadi D; Engel A. Basal metabolic rate in narcoleptic patients. SLEEP 2009;32(7):962-964.     

Outcomes of Hemodialysis in Children: A 35-Year Experience at Severance Hospital

Purpose

The aim of this study was to analyze the results of children treated with hemodialysis (HD) at Severance Hospital over 35 years in terms of incidence, etiologies, characteristics, complications, and clinical outcomes.

Materials and Methods

We analyzed 46 children admitted to Severance Hospital who had undergone HD between January 1979 and December 2013.

Results

The main etiologies of the 23 end-stage renal disease (ESRD) patients who had received HD were chronic glomerulonephritis (7 patients, 30.4%) and congenital anomalies of the kidney and urinary tract (7 patients, 30.4%), whereas the etiology of the 23 acute kidney injury (AKI) patients was hemolytic uremic syndrome (6 patients, 26.1%). Compared with ESRD patients, hemocatheter placement in the femoral vein was preferred over the subclavian or internal jugular vein in the AKI patients (p=0.012). The most common complication was catheter related complication (10 patients, 21.7%). The site of hemocatheter insertion was not related to the frequency of oozing. Placing the hemocatheter in the femoral vein resulted in significantly more events of catheter obstruction than insertion in the internal jugular vein or the subclavian vein (p=0.001). Disequilibrium syndrome occurred more frequently in older patients (p=0.004), as well as patients with a greater body weight (p=0.008) and a higher systolic and diastolic blood pressure before HD (systolic: p=0.021; diastolic: p=0.040).

Conclusion

Based on the 35 years of experience in our center, HD can be sufficiently and safely carried out even in children without significant complications.     

Body Composition Alterations,Energy Expenditure and Fat Oxidation in Elderly Males Suffering from Prostate Cancer,Pre and Post Orchiectomy

INTRODUCTION

Testosterone is needed for normal male development, muscle strength, bone mineralization, hematopoietic function, and sexual and reproductive functions. The main purpose of androgen deprivation therapy in prostate cancer is to reduce tumor progression, but therapy is often accompanied by significant adverse effects.

OBJECTIVE

This study aimed to determine the effects of androgen deprivation therapy on body composition and resting metabolic rate in patients with prostate cancer.

PATIENTS AND METHODS

A prospective study was performed to evaluate the body composition of 16 elderly males (aged 63–96; median age 71) with prostate cancer scheduled for orchiectomy, one year before and after surgery. Body composition was measured by DEXA, and energy expenditure, fat and carbohydrate oxidation were measured by indirect calorimetry.

RESULTS

Body weight (p=0.01), lean mass (p=0.004), and lipid oxidation (p=0.001) decreased significantly. Carbohydrate oxidation (p=0.02), FSH (p=0.0001) and LH (p=0.0001) levels increased significantly. Changes in fat mass (p=0.06) and bone mineral density (p=0.48) were not significant.

CONCLUSIONS

After 12 months of androgen deprivation therapy, elderly men with metastatic prostate cancer exhibit a decline in lean body mass and lipid oxidation, together with increased carbohydrate oxidation.     

Estimating average glucose levels from glycated albumin in patients with end-stage renal disease

Purpose

In patients with diabetic end stage renal disease (ESRD), glycated albumin (GA) reflects recent glycemic control more accurately than glycated hemoglobin (HbA_1c). We evaluated the relationship between GA and average blood glucose (AG) level and developed an estimating equation for translating GA values into easier-to-understand AG levels.

Materials and Methods

A total of 185 ESRD patients, including 154 diabetic and 31 non-diabetic participants, were enrolled (108 hemodialysis, 77 peritoneal dialysis). Patients were asked to perform four-point daily self-monitoring of capillary blood glucose (SMBG) at least three consecutive days each week for four weeks. Serum levels of GA, HbA_1c and other biochemical parameters were checked at baseline, as well as at 4 and 8 weeks.

Results

Approximately 74.3±7.0 SMBG readings were obtained from each participant and mean AG was 169.1±48.2 mg/dL. The correlation coefficient between serum GA and AG levels (r=0.70, p<0.001) was higher than that of HbA_1c and AG (r=0.54, p<0.001). Linear regression analysis yielded the following equation: estimated AG (eAG) (mg/dL)=4.71×GA%+73.35, and with this formula, serum GA levels could be easily translated to eAG levels. Multivariate analysis revealed significant contributions of postprandial hyperglycemia (β=0.25, p=0.03) and serum albumin (β=0.17, p=0.04) in determining serum GA level, independent to other clinical parameters.

Conclusion

Compared to HbA_1c, serum GA levels were better correlated with AG levels. Using the estimating equation, an average blood glucose level of 155-160 mg/dL could be matched to a GA value of 18-19% in patients with ESRD.     

No Evidence of an Association between A218C Polymorphism of the Tryptophan Hydroxylase 1 Gene and Aggression in Schizophrenia in a Korean Population

Purpose

We investigated the association between the tryptohan hydroxylase 1 (TPH1) gene and aggression in schizophrenia in a Korean population.

Materials and Methods

The sample included 61 aggressive patients as well as 104 non-aggressive patients from psychiatric hospitals and 335 healthy volunteers in Korea. Blood samples were collected from all participants for TPH1 A218C genotyping. The patients were administered standard psychiatric interviews as well as a self-report questionnaire for anger-related traits.

Results

In the case-control phenotypic comparisons, there was no significant association between the aggressive patients and the TPH1 A218C polymorphism. There was no significant effect of the TPH1 genotype on the anger-related traits, or no significant interaction between the genotype and group (aggressive and non-aggressive patients).

Conclusion

These findings suggest that TPH1 does not play a major role in aggressive behavior via anger in schizophrenic patients.     

The pattern,clinical characteristics and outcome of ESRD in Ile-Ife,Nigeria: Is there a change in trend?

Background

The prevalence of chronic renal failure and End Stage Renal Disease (ESRD) has remained high worldwide and the epidemiology has changed significantly in the last decade in industrialised countries. While there have been significant improvements in these patient''s outcomes in developed countries, their state and survival is still appalling in developing countries.

Objective

To determine the clinical pattern, presentation and management outcomes in our ESRD population over a 19-year period (1989–2007).

Methods

Seven hundred and sixty patients'' records were reviewed. Data on major causes, clinical presentation, management and survival were retrieved and collated. Data was analysed using SPSS package version 16.

Results

Their ages ranged between 15–90 years (mean ± SD; 39.9±1.67years) with male preponderance (70.3%). Major presenting complaints were body swelling and uraemic symptoms in most studied patients. The predisposing conditions included chronic glomerulonephritis, hypertension, obstructive uropathy and diabetes mellitus. Renal replacement therapy offered included HD in 556(73.2%), Continous Ambulatory Peritoneal Dialysis (CAPD) in only 9(1.2%) patients and renal transplantation in only 7(0.9%). Only 38(6.8%) survived on HD for longer than three months while 7(77.8%) CAPD patients and all transplanted patients survived for between six months and four years (p<0.00001). Median duration of survival after diagnosis for all the patients was 2 weeks (range 0–50 months).

Conclusion

End stage renal disease is still prevalent with chronic glomerulonephritis and hypertension being the common causes. Prognosis is still grave hence subsidized renal replacement therapy and preventive nephrology should be targeted in such underserved populations.     

Detection of heart disease by open access echocardiography: a retrospective analysis of general practice referrals

Background

Heart disease is difficult to detect clinically and it has been suggested that echocardiography should be available to all patients with possible cardiac symptoms or signs.

Aim

To analyse the results of 2 years of open access echocardiography for the frequency of structural heart disease according to request.

Design and setting

Retrospective database analysis in a teaching hospital open access echocardiography service.

Method

Reports of all open access transthoracic echocardiograms between January 2011 and December 2012 were categorised as normal, having minor abnormalities, or significant abnormalities according to the indication.

Results

There were 2343 open access echocardiograms performed and there were significant abnormalities in 29%, predominantly valve disease (n = 304, 13%), LV systolic dysfunction (n = 179, 8%), aortic dilatation (n = 80, 3%), or pulmonary hypertension (n = 91, 4%). If echocardiography had been targeted at a high-risk group, 267 with valve disease would have been detected (compared to 127 with murmur alone) and 139 with LV systolic dysfunction (compared to 91 with suspected heart failure alone). Most GP practices requested fewer than 10 studies, but 6 practices requested over 70 studies.

Conclusion

Open access echocardiograms are often abnormal but structural disease may not be suspected from the clinical request. Uptake by individual practices is patchy. A targeted expansion of echocardiography in patients with a high likelihood of disease is therefore likely to increase the detection of clinically important pathology.     

Cardiovascular events in patients with obesity: an observational study

Background

Overweight and obesity are positively correlated with increased risk of morbidity and mortality.

Aim

To evaluate whether obesity may be considered an independent cardiovascular risk factor in patients of ages from 35 to 74 years followed-up for 10 years.

Design of study

Observational, longitudinal retrospective study.

Setting

Primary care practices in Badajoz (Spain).

Method

A cohort of 899 patients (mean 55.7 years; 58.2% female) without evidence of cardiovascular disease was studied.

Results

A total of 33.5% of the population were obese (body mass index ≥30 kg/m2). Patients meeting the obesity criteria were more commonly female (36.6%) and were older, had higher mean values of blood pressure and triglycerides, higher percentages of diabetes, and higher coronary risk using either the original Framingham or the Framingham function calibrated for the Spanish population (Framingham-REGICOR). During the follow-up period, the rates of cardiovascular events and death in patients with obesity tended to be higher: 16.3% versus 11.7%, P = 0.056 and 4.7% versus 2.2%, P<0.05, respectively. In the final model of the logistic regression multivariate analysis, the significant predictors of cardiovascular events in patients with obesity were age, sex (male), diastolic blood pressure, diabetes, and smoking. The highest odds ratio corresponded to smoking (odds ratio 2.03; 95% confidence interval = 1.22 to 3.38).

Conclusion

Obesity may not be considered an independent cardiovascular risk factor in patients aged from 35 to 74 years followed-up for 10 years.     

Incidence of appropriate cardioverter-defibrillator shocks and mortality in patients with implantable cardioverter-defibrillators with ischemic cardiomyopathy versus nonischemic cardiomyopathy at 33-month follow-up

Introduction

The aim of the study was to investigate at long-term follow-up the incidence of appropriate implantable cardioverter-defibrillator (ICD) shocks and of all-cause mortality in patients with ICDs with ischemic cardiomyopathy versus nonischemic cardiomyopathy.

Material and methods

ICDs were implanted in 485 patients with ischemic cardiomyopathy and in 299 patients with nonischemic cardiomyopathy, all of whom had coronary angiography. Baseline characteristics were not significantly different between the 2 groups. Follow-up was 965 days in patients with ischemic cardiomyopathy versus 1039 days in patients with nonischemic cardiomyopathy (p not significant). The ICDs were interrogated every 3 months to see if shocks occurred.

Results

Appropriate ICD shocks occurred in 179 of 485 patients (37%) with ischemic cardiomyopathy and in 93 of 299 patients (31%) with nonischemic cardiomyopathy (p not significant). All-cause mortality occurred in 162 of 485 patients (33%) with ischemic cardiomyopathy and in 70 of 299 patients (23%) with nonischemic cardiomyopathy (p = 0.002).

Conclusions

The incidence of appropriate ICD shocks was not significantly different at 33-month follow-up in patients with ischemic cardiomyopathy versus nonischemic cardiomyopathy. However, patients with ischemic cardiomyopathy had a significantly higher incidence of all-cause mortality than patients with nonischemic cardiomyopathy (p = 0.002).     

HBsAg level and clinical course in patients with chronic hepatitis B treated with nucleoside analogue: five years of follow-up data

Background/Aims

Quantification of the hepatitis B surface antigen (HBsAg) is increasingly used to determine the treatment response in patients with chronic hepatitis B (CHB). However, there are limited data about the clinical implications of Quantification of HBsAg long-term nucleoside analogue treatment for CHB. We investigated the clinical correlation between HBsAg level and clinical course in patients with CHB who are treated long-term with nucleoside analogues.

Methods

Patients with CHB who started lamivudine or entecavir monotherapy before June 2007 were enrolled. HBsAg was quantified at baseline, at 6 months, and at 1, 2, 3, 4, and 5 years of treatment. We compared data between the groups according to the presence or absence of a virological response (VR) and resistance.

Results

Forty-eight patients were analyzed. There was no definite reduction in HBsAg level during the early period of treatment; differences in HBsAg levels between baseline and each time point were significant only at 5 years (P=0.028). In a subgroup analysis, this difference was significant only in non-resistant patients at 5 years (P=0.041).

Conclusions

There was no definite decrease in the HBsAg level during the early period of nucleoside analogue treatment, with long-term treatment being required to observe a significant reduction.     

Serum adenosine deaminase,catalase and carbonic anhydrase activities in patients with bladder cancer

OBJECTIVES:

The relationship between adenosine deaminase and various cancers has been investigated in several studies. However, serum adenosine deaminase activity and carbonic anhydrase and catalase activities in patients with bladder cancer have not previously been reported. Therefore, the aim of this study was to measure serum adenosine deaminase, carbonic anhydrase and catalase activities in patients with bladder cancer.

MATERIALS AND METHODS:

Forty patients with bladder cancer and 30 healthy controls were enrolled in the study. Serum adenosine deaminase, carbonic anhydrase and catalase activities were measured spectrophotometrically.

RESULTS:

Serum adenosine deaminase, carbonic anhydrase and catalase activities were significantly higher in patients with bladder cancer than controls (all significant, p<0.001).

CONCLUSIONS:

These markers might be a potentially important finding as an additional diagnostic biochemical tool for bladder cancer.     

Analysis of the reactivity of indirect immunofluorescence in patients with pemphigus foliaceus and pemphigus vulgaris using rat bladder epithelium as a substrate

OBJECTIVES:

To evaluate the reactivity of indirect immunofluorescence using rat bladder epithelium as a substrate in patients with pemphigus foliaceus and pemphigus vulgaris from the Department of Dermatology, University of São Paulo Medical School, Brazil.

METHODS:

Thirty-two patients (8 male and 24 female) from the Department of Dermatology, University of São Paulo Medical School, were selected. Three had mucosal pemphigus vulgaris, 20 had mucocutaneous pemphigus vulgaris, and 9 had pemphigus foliaceus. Patients'' sera were tested by indirect immunofluorescence performed on human foreskin and rat bladder epithelium and by ELISA assays utilizing baculovirus-expressed recombinant desmoglein 3 and desmoglein 1.

RESULTS:

No patients with mucosal pemphigus vulgaris, 5 of 20 patients with mucocutaneous pemphigus vulgaris (25%) and 4 of 9 patients with pemphigus foliaceus (44%) had positive indirect immunofluorescence using rat bladder epithelium as a substrate.

CONCLUSION:

Indirect immunofluorescence using rat bladder epithelium as a substrate is recommended whenever a diagnosis of paraneoplastic pemphigus is considered. The identification of a subset of pemphigus foliaceus and pemphigus vulgaris patients that recognizes desmoplakins by this laboratory tool is critical to avoid the misdiagnosis of paraneoplastic pemphigus.     

Understanding and Predicting Social Media Use Among Community Health Center Patients: A Cross-Sectional Survey

Background

The use of social media by health care organizations is growing and provides Web-based tools to connect patients, caregivers, and providers.

Objective

The aim was to determine the use and factors predicting the use of social media for health care–related purposes among medically underserved primary care patients.

Methods

A cross-sectional survey was administered to 444 patients of a federally qualified community health center.

Results

Community health center patients preferred that their providers use email, cell phones for texting, and Facebook and cell phone apps for sharing health information. Significantly more Hispanic than white patients believed their providers should use Facebook (P=.001), YouTube (P=.01), and Twitter (P=.04) for sharing health information. Use and intentions to use social media for health-related purposes were significantly higher for those patients with higher subjective norm scores.

Conclusions

Understanding use and factors predicting use can increase adoption and utilization of social media for health care–related purposes among underserved patients in community health centers.     

Anticipatory care planning and integration: a primary care pilot study aimed at reducing unplanned hospitalisation

Background

Anticipatory care for older patients who are frail involves both case identification and proactive intervention to reduce hospitalisation.

Aim

To identify a population who were at risk of admission to hospital and to provide an anticipatory care plan (ACP) for them and to ascertain whether using primary and secondary care data to identify this population and then applying an ACP can help to reduce hospital admission rates.

Design and setting

Cohort study of a service intervention in a general practice and a primary care team in Scotland.

Method

The ACP sets out patients’ wishes in the event of a sudden deterioration in health. If admitted, a proactive approach was taken to transfer and discharge patients into the community. Cohorts were selected using the Nairn Case Finder, which matched patients in two practices for age, sex, multiple morbidity indexes, and secondary care outpatient and inpatient activity; 96 patients in each practice were studied for admission rate, occupied bed days and survival.

Results

Survivors from the ACP cohort (n = 80) had 510 fewer days in hospital than in the 12 months pre-intervention: a significant reduction of 52.0% (P = 0.020). There were 37 fewer admissions of the survivors from that cohort post-intervention than in the preceding 12 months, with a significant reduction of 42.5% (P = 0.002). Mortality rates in the two cohorts were similar, but the number of patients who died in hospital and the hospital bed days used in the last 3 months of life were significantly lower for the decedents with an ACP than for the controls who had died (P = 0.007 and P = 0.045 respectively).

Conclusion

This approach produced statistically significant reductions in unplanned hospitalisation for a cohort of patients with multiple morbidities. It demonstrates the potential for providing better care for patients as well as better value for health and social care services. It is of particular benefit in managing end-of-life care.     

Association between a Serotonin Transporter Length Polymorphism and Primary Insomnia

Study Objective:

To test the hypothesis that a 44-base-pair insertion/deletion polymorphism in the 5'' regulatory region of the serotonin transporter gene (5-HTTLPR) is associated with primary insomnia.

Design:

Association study.

Setting:

Sleep laboratory at the Central Institute of Mental Health, Mannheim, Germany.

Patients:

157 patients with primary insomnia and 827 healthy controls.

Interventions:

N/A.

Measurement and Results:

We found the short (s-) allele of the 5-HTTLPR to be significantly more frequent in patients suffering from insomnia than in control individuals (47.1% vs. 39.9%: OR = 1.34).

Conclusions:

This finding contributes to the understanding of the pathophysiology of primary insomnia and suggests a biological basis between the prevalent comorbidity of primary insomnia and other psychiatric disorders.

Citation:

Deuschle M; Schredl M; Schilling C; Wöust S; Frank J; Witt SH; Rietschel M; Buckert M; Meyer-Lindenberg A; Schulze TG. Association between a serotonin transporter length polymorphism and primary insomnia. SLEEP 2010;33(3):343-347.     

Measures of Physical Activity Using Cell Phones: Validation Using Criterion Methods

Background

Physical activity is associated with reduced risks of many chronic diseases. Data collected on physical activity in large epidemiological studies is often based on paper questionnaires. The validity of these questionnaires is debated, and more effective methods are needed.

Objective

This study evaluates repeated measures of physical activity level (PAL) and the feasibility of using a Java-based questionnaire downloaded onto cell phones for collection of such data. The data obtained were compared with reference estimates based on the doubly labeled water method and indirect calorimetry (PAL_ref).

Method

Using a Java-based cell phone application, 22 women reported their physical activity based on two short questions answered daily over a 14-day period (PAL_cell). Results were compared with reference data obtained from the doubly labeled water method and indirect calorimetry (PAL_ref). Results were also compared against physical activity levels assessed by two regular paper questionnaires completed by women at the end of the 14-day period (PAL_quest1 and PAL_quest2). PAL_cell, PAL_quest1, and PAL_quest2 were compared with PAL_ref using the Bland and Altman procedure.

Results

The mean difference between PAL_cell and PAL_ref was small (0.014) with narrow limits of agreement (2SD = 0.30). Compared with PAL_ref, the mean difference was also small for PAL_quest1 and PAL_quest2 (0.004 and 0.07, respectively); however, the limits of agreement were wider (PAL_quest1, 2SD = 0.50 and PAL_quest2, 2SD = 0.90). The test for trend was statistically significant for PAL_quest1 (slope of regression line = 0.79, P = .04) as well as for PAL_quest2 (slope of regression line = 1.58, P < .001) when compared with PAL_ref.

Conclusion

A Java-based physical activity questionnaire administered daily using cell phones produced PAL estimates that agreed well with PAL reference values. Furthermore, the limits of agreement between PAL obtained using cell phones, and reference values were narrower than for corresponding estimates obtained using paper questionnaires. Java-based questionnaires downloaded onto cell phones may be a feasible and cost-effective method of data collection for large-scale prospective studies of physical activity.     

Calcium,inorganic phosphates,alkaline and acid phosphatase activities in breast cancer patients in Calabar,Nigeria

Background

Breast cancer is the commonest malignancy of women in Nigeria. Change in serum levels of some biochemical parameters could assist diagnosis and follow-up of breast cancer.

Objective

To determine serum levels of calcium, inorganic phosphates, alkaline phosphatase (ALP) and acid phosphatase (ACP) activities in patients with breast cancer, and change in the serum levels over time.

Methods

Total serum calcium and inorganic phosphates, and serum ALP and ACP activities were determined in 25 women with breast cancer and 25 age-matched controls using colorimetric and enzymatic methods, over 6 months with bimonthly analysis.

Results

The serum calcium level, ALP and ACP activities were significantly higher (p<0.05) in the study group than in the control group. No significant difference was seen in the inorganic phosphate levels of both groups. There were significant increases in serum calcium levels, ALP and ACP activities in the study group with time (p<0.05), whereas no significant increase was observed in the control group.

Conclusion

Breast cancer patients have higher calcium levels and higher ALP and ACP activities. The increase in the levelsof these parameters with time shows that they could be of importance in monitoring treatment and disease progress in a resource-poor setting.Key words: Breast cancer, serum calcium, inorganic phosphate, alkaline phosphatase, acid phosphatase, tumor markers     

Efficacy of two interventions on the discontinuation of benzodiazepines in long-term users: 36-month follow-up of a cluster randomised trial in primary care

Background

Primary care interventions that promote cessation of benzodiazepine (BZD) use in long-term users are effective at 1 year, but their efficacy at 3 years is uncertain.

Aim

To assess the 3-year efficacy of two primary care interventions delivered by GPs on cessation of BZD use in long-term users.

Design and setting

Multicentre, three-arm, cluster randomised, controlled trial, with random allocation at the GP level.

Method

Seventy-five GPs and 532 patients were randomly allocated to three groups: usual care (control), structured intervention with stepped-dose reduction and follow-up visits (SIF), or structured intervention with written stepped-dose reduction (SIW). The primary outcome was BZD use at 36 months.

Results

At 36 months, 66/168 patients (39.2%) in the SIW group, 79/191 patients (41.3%) in the SIF group, and 45/173 patients (26.0%) in the control group had discontinued BZD use. The relative risks (RR) adjusted by cluster were 1.51 (95% CI = 1.10 to 2.05; P = 0.009) in the SIW group and 1.59 (95% CI = 1.15 to 2.19; P = 0.005) in the SIF group. A total of 131/188 patients (69.7%) who successfully discontinued BZD use at 12 months remained abstinent at 36 months. The groups showed no significant differences in anxiety, depression, or sleep dissatisfaction at 36 months.

Conclusion

The interventions were effective on cessation of BZD use; most patients who discontinued at 12 months remained abstinent at 3 years. Discontinuation of BZD use did not have a significant effect on anxiety, depression, or sleep quality.     

Effectiveness of GP access to magnetic resonance imaging of the knee: a randomised trial

Background

GPs commonly see patients with knee problems. Magnetic resonance imaging (MRI) of the knee is an accurate diagnostic test for meniscus and ligament injuries of the knee, but there is uncertainty about the appropriate use of MRI and when it should enter the diagnostic pathway for patients with these problems.

Aim

To assess the effectiveness of GP referral to early MRI and a provisional orthopaedic appointment, compared with referral to an orthopaedic specialist without prior MRI for patients with continuing knee problems.

Design of study

Pragmatic multicentre randomised trial with two parallel groups.

Setting

A total of 553 patients consulting their GP about a continuing knee problem were recruited from 163 general practices at 11 sites across the UK.

Method

Patients were randomised to MRI within 12 weeks of GP referral including a provisional orthopaedic appointment, or orthopaedic appointment without prior MRI within a maximum of 9 months from GP referral. The primary outcome measures were the Short Form 36-item (SF-36) physical functioning scale and the Knee Quality of Life 26-item Questionnaire (KQoL-26) at 6, 12, and 24 months.

Results

Patients randomised to MRI improved mean SF-36 physical functioning scores by 2.81 (95% confidence interval [CI] = −0.26 to 5.89) more than those referred to orthopaedics (P = 0.072). Patients randomised to MRI improved mean KQoL-26 physical functioning scores by 3.65 (95% CI = 1.03 to 6.28) more than controls (P = 0.007). There were no other significant differences.

Conclusion

GP access to MRI yielded small, but statistically significant, benefits in patients'' knee-related quality of life but non-significant improvements in physical functioning.