Attaining a correct diagnosis of COPD in general practice

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is common. Diagnosis should include objective evidence of airways obstruction and spirometry is recommended in guidelines and the general medical services contract in the UK. We assessed the impact of spirometry in general practice. METHOD: We determined by questionnaire the availability, staff training, use and the interpretation results of spirometry in 72% of general practices in Wales. We reviewed the diagnosis of COPD previously made in two general practices without spirometry. RESULTS: Most practices had a spirometer (82.4%) and used it (85.6%). Confidence in use and interpretation of results varied widely: 58.1% were confident in use and 33.8% confident in interpretation. Spirometry was performed more often if confident in use and interpretation (both P<0.001) and was related to greater training periods (P<0.001). Spirometric confirmation of COPD varied widely (0-100%, median 37%). Of the 125 patients previously diagnosed with COPD 61 had spirometric confirmation, while 25 had reversible obstruction (range 210-800 mls), 34 had normal and 5 had restrictive spirometry. CONCLUSION: Despite incentives to perform spirometry in general practice, lack of adequate training in use and interpretation suggests use is confounded and the diagnosis of COPD is likely to be made on imprecise clinical grounds.     

Salivary heterotopia of the parathyroid gland: a report of two cases and review of the literature

Two cases of periparathyroid salivary gland heterotopia are described. A review of the records of the Department of Pathology, Long Island Jewish Medical Center, over a 4-year period, identified 759 surgical specimens containing parathyroid gland tissue. Of these, 2 (0.26%) contained foci of ectopic salivary gland tissue. Both cases were associated with cyst formation. To date, 9 additional cases of heterotopic salivary gland tissue associated with the parathyroid gland have been described in the literature.     

High gamma activity in response to deviant auditory stimuli recorded directly from human cortex

We recorded electrophysiological responses from the left frontal and temporal cortex of awake neurosurgical patients to both repetitive background and rare deviant auditory stimuli. Prominent sensory event-related potentials (ERPs) were recorded from auditory association cortex of the temporal lobe and adjacent regions surrounding the posterior Sylvian fissure. Deviant stimuli generated an additional longer latency mismatch response, maximal at more anterior temporal lobe sites. We found low gamma (30-60 Hz) in auditory association cortex, and we also show the existence of high-frequency oscillations above the traditional gamma range (high gamma, 60-250 Hz). Sensory and mismatch potentials were not reliably observed at frontal recording sites. We suggest that the high gamma oscillations are sensory-induced neocortical ripples, similar in physiological origin to the well-studied ripples of the hippocampus.     

Evaluating best practice guidelines

Clinical practice guidelines are developed with the purpose of improving patient care. The Registered Nurses Association of Ontario (RNAO) Nursing Best Practice Guidelines (BPG) Project was implemented in 1999. It has resulted in the development, implementation and evaluation of 17 BPGs with agencies in different healthcare sectors. This article describes the process, challenges and lessons learned by the team responsible for evaluating the BPGs.     

Post-acute intermediate care in nursing-led units: a systematic review of effectiveness

OBJECTIVE: In order to determine whether post-acute intermediate care in nursing-led inpatient units (NLUs) is effective in preparing patients for discharge from hospital we conducted a systematic review of the evidence. REVIEW METHODS: The Cochrane Library, Effective Practice and Organisation of Care specialist register, Medline, Cinahl, Embase, British Nursing Index and the HMIC databases were searched for all available dates up to mid-2003. The science and social science citation indices were searched for papers that cited key works. Authors of papers were asked to identify additional research. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time-series designs that compared the NLU to usual post-acute inpatient care for adults were included in the review. Studies were assessed for quality. Statistical meta-analysis on the results of controlled trials was performed. Sensitivity analyses were conducted to determine the impact of methodological quality on conclusions. OUTCOMES: Outcomes considered were mortality, institutionalisation after discharge, functional status early readmission, length of inpatient stay and cost. RESULTS: Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Quality was variable. The mean age of patients in all studies was over 70 years. There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care (OR 1.10, 95% CI 0.56-2.16). The NLU was associated with reduced odds of discharge to institutional care (OR 0.44 95% CI 0.22-0.89), better functional status at discharge (SMD 0.37, 95% CI 0.20-0.54) and reduced odds of early readmission (OR 0.52 95% CI 0.34-0.80). Length of stay until discharge home was increased by 5.13 days (WMD) (95% CI-0.5-10.76 days). At longest follow up (3-6 months) there was no statistically significant difference in the proportion of patients in institutional care (OR 0.97, 95% CI 0.60-1.58). The results were not generally sensitive to study quality. CONCLUSIONS: The NLU successfully functions as a form of intermediate care, so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term.