The appropriateness of use of coronary angiography in Lebanon: implications for health policy

BACKGROUND: Lebanon, characterized by a free-market health care system, has one of the highest reported per capita rates of cardiac catheterization facilities and coronary angiographies in the world. The aim of this study is to evaluate the appropriateness of performance of coronary angiography procedures in Lebanon. METHODS: Data derived from the 2004 Lebanese Interventional Coronary Registry (LICOR) included 5418 patients aged 30 years and older who had not undergone prior percutaneous coronary intervention or coronary artery bypass grafting. Appropriateness was evaluated based on the Class I indications of the ACC/AHA guidelines for coronary angiography. FINDINGS: The overall rate of appropriate procedures was 54.7% (95% CI 53.3-56.0%). Appropriateness varied significantly by gender and across administrative regions. Compared with females, males were more likely to be referred appropriately for coronary angiography (OR = 1.28, 95% CI = 1.15-1.44). Appropriateness was lowest (OR = 0.89, 95% CI = 0.71-1.12) in the region where the per capita density of cardiac catheterization labs increased by six-fold in the latter 2 years. The majority of the patients (84.3%) were not evaluated by any of the non-invasive tests prior to angiography, with only 10.8%, 4% and 1.5% of the patients referred for an exercise stress test, stress echocardiography and thallium stress tests, respectively. DISCUSSION: Findings indicate a high rate of procedures conducted without appropriate indications and a low utilization rate of pre-interventional non-invasive testing. This may be attributed to three factors: a surplus of catheterization facilities in certain regions, the insignificant cost gradient between non-invasive testing and coronary angiography, and the wide case-based reimbursement of coronary angiography, unlike non-invasive testing, by public insurance schemes.     

Congenital anomalies of lumbosacral spine: A pictorial review

Congenital malformations of the lumbosacral spine include spinal dysraphism and caudal anomalies. Most often, these malformations are discovered prenatally or in early infancy, but some are not diagnosed until late childhood or adulthood. The purpose of this pictorial review is to illustrate the multi‐modality imaging characteristics in these complex anomalies and to provide a systematic radiological approach aiming at improving diagnostic accuracy.     

Use of computed tomography in the setting of a tiered trauma team activation system in Australia

This study aims to describe the patterns in the use of computed tomography (CT) imaging in the setting of a two-tiered trauma team activation system without a mandatory whole-body (“panscan”) trauma CT protocol. A prospective study was conducted at a single inner city major trauma centre in Sydney, Australia. Adult patients presenting to the emergency department requiring a trauma team activation were studied over 1 year. Patients in the trauma consult group met predetermined criteria for mechanism of injury without vital sign abnormalities or clinical evidence of major injury. Full trauma team response patients were those who had abnormal predetermined vital signs or evidence of major injury on initial assessment. The outcomes measured were severe injury, multiregion injury and positive CT scans. Of the patients, 1,058 were studied of whom 63 % had at least one CT scan performed. The most common CT studies were CT brain in combination with cervical spines (23 %) and isolated abdominal CT scans (17 %). The full trauma response group was associated with significantly higher rates of severe injury (34 versus 8 %, p?<?0.001), multiregion injury (13 versus 3 %, p?<?0.001), need for operative intervention (37 versus 15 %, p?<?0.001) and in-hospital mortality (4 versus 0.7 %, p?<?0.001). This group was also associated with significantly higher odds of whole-body CT use [odds ratio (OR) 5.6, 95 % confidence interval (CI) 3.6–8.8, p?<?0.001] and higher odds of positive CT brain studies compared to the trauma consult group (OR 2.6, 95 % CI 1.7–4.1, p?<?0.001). A tiered trauma team activation criteria in combination with trauma team assessment may be used to triage patients requiring CT without the need for mandatory CT protocols based on mechanism alone.     

An optimised patient-specific approach to administration of contrast agent for CT pulmonary angiography

Objectives

To investigate pulmonary vasculature opacification during CTPA using an optimised patient-specific protocol for administering contrast agent.

Methods

CTPA was performed on 200 patients with suspected PE. Patients were assigned to two protocol groups: protocol A, fixed 80 ml contrast agent; protocol B used a patient-specific approach. The mean cross-sectional opacification profile of 8 central and 11 peripheral pulmonary arteries and veins was measured and the arteriovenous contrast ratio (AVCR) calculated. Protocols were compared using Mann–Whitney U non-parametric statistics. Jack-knife alternative free-response receiver-operating characteristic (JAFROC) analyses assessed diagnostic efficacy. Interobserver variations were investigated using kappa methods.

Results

A number of pulmonary arteries demonstrated increases in opacification (P?<?0.03) for protocol B compared to A, whilst opacification in the heart and veins was reduced in protocol B (P?=?0.05). Increased AVCR in protocol B compared with A was observed at all anatomic locations (P?<?0.0002). Increased JAFROC (P?<?0.0002) and kappa variation were observed with protocol B (κ?=?0.78) compared to A (κ?=?0.25). Mean contrast volume was reduced in protocol B (33?±?9 ml) compared to A (80?±?1 ml).

Conclusions

Significant improvements in visualisation of the pulmonary vasculature can be achieved with a low volume of contrast agent using injection timing based on a patient-specific contrast formula.

Key points

? Optimal opacification of the pulmonary arteries is essential for CT pulmonary angiography. ? Matching timing with vessel dynamics significantly improves vessel opacification. ? This leads to increased arterial opacification and reduced venous opacification. ? This can also lead to a reduced volume of contrast agent.     

The frequency of prior antenatal corticosteroid therapy in late preterm birth pregnancies

We sought to quantify how often women with late preterm birth (LPTB) receive antenatal corticosteroid (ACS) therapy prior to 34 weeks and to determine its effects on neonatal respiratory morbidity. LPTBs (34 (0)/ (7) to 36 (6)/ (7) weeks) over a 1-year period at a single tertiary care hospital were studied. A composite neonatal respiratory outcome was defined as mechanical ventilation, continuous positive airway pressure with fraction of inspired oxygen (F IO(2)) >40% for >2 hours or F IO(2) >40% for >4 hours within the first 72 hours of life. Multivariate logistic regression analysis was used to evaluate the association between ACS therapy and neonatal respiratory morbidity. Over the study period, 503 LPTBs met the study criteria and 6.8% ( N?=?34) had ACS therapy <34 weeks. Most had exposure >7 days prior to delivery (64.7%). Almost one-half of those receiving prior ACS therapy delivered between 34 and 35 weeks. There was no difference in the rate of prior ACS therapy based on LPTB indication for delivery. After adjusting for confounding factors, prior ACS therapy was not associated with lower respiratory morbidity (odds ratio [OR] 2.0, 95% confidence interval [CI] 0.2 to 16.3, P?=?0.53). Advancing gestational age was the only variable associated with respiratory morbidity (OR 0.50, 95% CI 0.26 to .94, P?=?0.03). In our population, prior ACS therapy was infrequent and was not associated with improvements in neonatal respiratory morbidity following LPTB.