Improving outpatient services: the Southampton IBD virtual clinic.

The follow-up of inflammatory bowel disease (IBD) patients is challenging due to the relapsing remitting nature of the diseases, the wide spectrum of severity and complexity as well as the need for monitoring of long-term complications and drug treatments. Conventional outpatient follow-up lacks flexibility for patients and there are competing pressures for clinic time. Alternative follow-up pathways include telephone clinics, self-management programmes or discharging patients. The IBD virtual clinic (VC) is a further option. Patients with an established diagnosis for >2 years, who have been stable for >1 year, do not have primary sclerosing cholangitis and who give their consent, are entered into the VC system. Two months before their annual follow-up is due patients are sent blood test forms and a simple questionnaire with an information sheet. If they meet any of the criteria on the questionnaire, they are asked to contact the IBD specialist nursing team to discuss their situation. The blood test results and the patient’s database entry are reviewed to ensure that they are not due surveillance investigations. The patients and their GPs then receive a letter informing them of their management plan. We currently follow-up 20% of the Southampton IBD cohort using the VC. The VC system is an innovative, efficient and patient-responsive method for following up mild to moderate IBD. It is well liked by patients but is dependent on a well-maintained database with good integration of IT systems and requires both clerical and IBD nurse specialist support.
















Care of the patient with an autism spectrum disorder by the general physician.

Autism spectrum disorders (ASD), comprising classic autism, Asperger syndrome, Rett syndrome, childhood disintegrative disorder and pervasive development disorder-not otherwise specified, represent complex neurodevelopmental conditions characterised by impaired social interactions, difficulties with communication and repetitive, stereotyped behaviours. It is estimated that up to 1% of the general population may be affected by an ASD. Whether due to improved diagnostic techniques or a true rise in incidence, the prevalence of patients with ASD is rising, and these individuals are increasingly encountered in a variety of healthcare settings. Care givers of patients with an ASD report frequently that lack of awareness of the complications of these disorders and the method of appropriately assessing these individuals impair the effective delivery of healthcare to this patient population. It is now clear that patients with an ASD, in addition to the defining characteristics of these disorders, can present to the outpatient, emergency department and inpatient settings with a variety of psychiatric, neurological, gastrointestinal, nutritional/metabolic, dental, ophthalmological, cardiovascular, gynaecological, traumatic and musculoskeletal conditions that can require acute intervention. In addition, the common treatments given to patients with an ASD may result in side effects and complications that may require acute intervention. For physicians who encounter patients with an ASD, the combination of impaired social interactions, difficulties with communication and stereotyped behaviours creates an additional barrier to diagnosis and treatment of these individuals. Careful preparation of the examination environment, direct engagement of care givers and the patient and the use of communication techniques and pharmacological adjuncts can aid physicians in treating the patient with an ASD in the outpatient, emergency department and inpatient settings.



Anaphylaxis: current state of knowledge for the modern physician.

Anaphylaxis is a severe, potentially fatal, hypersensitivity reaction of rapid onset. It may trigger life-threatening cardiopulmonary compromise, often with skin and mucosal changes such as urticaria and angioedema. The prevalence of anaphylaxis is increasing and the number of cases of fatal anaphylaxis appears to be rising. Food, insect stings, and drugs are the most common triggers. Novel triggers are increasingly seen and include delayed anaphylaxis to red meat, food-dependent exercise-induced reactions and anaphylaxis to monoclonal antibodies. Anaphylaxis is usually IgE mediated, but other mechanisms also play a role for example direct mast cells activation. Differential diagnosis is discussed including asthma, syncope and shock; excessive endogenous histamine, food related syndromes, and some rare diagnoses. Intramuscular epinephrine is first line treatment. The role of other drugs is reviewed. Timed and serial serum tryptase measurements help to confirm the diagnosis. Long-term management is necessary to minimise the risk of recurrence and includes identification of the trigger(s), management of risk factors, education on avoidance and a formalised treatment plan with an epinephrine auto-injector if appropriate. Every patient who has experienced anaphylaxis should be referred to an allergy clinic for appropriate management. This is endorsed by many national guidelines (eg, UK NICE). Anaphylaxis is often misdiagnosed or miscoded as, for example, asthma or food allergy. Most doctors will encounter a patient with anaphylaxis in their career and should to be familiar with the clinical features, management and mechanisms of this potentially fatal condition.


Poor professionalism identified through investigation of unsolicited healthcare complaints.

Aim To determine whether analysis of unsolicited healthcare complaints specifically focusing on unprofessional behaviour can provide additional information from the patients’ perspective.

Methods A qualitative study with content analysis of healthcare complaints and associated judgements using complaints filed from 2004 to 2009 at the complaints committee of a tertiary-referral centre. Subsequent comparison of the resulting categories of poor professionalism to categories perceived relevant by physicians in a previous study was performed.

Results 137 complaints (98%) yielded 46 different unprofessional behaviours grouped into 18 categories. The element ‘perceived medical complications and error’ occurred most commonly (n=77), followed by ‘having to wait for care’ and ‘insufficient or unclear clarification’ (n=52, n=48, respectively). The combined non-cognitive elements of professionalism (especially aspects of communication) were far more prominently discussed than cognitive issues (knowledge/skills) related to medical error. Most categories of professionalism elements were considered important by physicians but, nevertheless, were identified in patient complaints analysis. Some issues (eg, ‘altruism’, ‘appearance’, ‘keeping distance/respecting boundaries with patients’) were not perceived as problematic by patients and/or relatives, while mentioned by physicians. Conversely, eight categories of poor professionalism revealed from complaint analysis (eg, ‘having to wait for care’, ‘lack of continuity of care’ and ‘lack of shared decision making’) were not considered essential by physicians.

Conclusions The vast majority of unprofessional behaviour identified related to non-cognitive, professionalism aspects of care. Complaints pertaining to unsatisfactory communication were especially noticeable. Incongruence is noted between the physicians’ and the patients’ perception of actual care.




Early and late mortality in hospitalised patients with raised cardiac troponin T.

Cardiac troponins are measured in acute coronary syndrome (ACS) and other conditions. The authors investigate the prognostic significance of cardiac troponin T (TnT) test and comorbid medical conditions.

Methods Consecutive patients admitted to the Aintree University Hospital, Liverpool, between 2 January 2004 and 29 February 2004 who had TnT measurement were included. Patients were separated into normal (<0.01 μg/l) or raised TnT levels (≥0.01 μg/l), and further categorised into: (1) normal TnT with unstable angina; (2) normal TnT with non-ACS; (3) raised TnT with ACS; and (4) raised TnT with non-ACS. Cox regression was used to identify prognostic variables, and logrank test to compare 7-year survival.

Results Of 1021 patients, 313 had raised TnT (195 ACS, 118 non-ACS) and 708 normal TnT (80 ACS, 628 non-ACS). Age (HR 1.06; 95% CI 1.05 to 1.07), congestive cardiac failure (HR 1.37; 95% CI 1.11 to 1.69), cerebrovascular disease (HR 1.37; 95% CI 1.10 to 1.71), chronic obstructive airway disease (HR 1.44; 95% CI 1.19 to 1.75), liver disease (HR 4.16; 95% CI 2.37 to 7.31), renal disease (HR 1.83; 95% CI 1.27 to 2.64), tumour (HR 1.39; 95% CI 1.07 to 1.79), lymphoma (HR 4.81; 95% CI 2.07 to 11.16), metastatic cancer (HR 3.55; 95% CI 2.32 to 5.45) and a higher Charlson’s comorbidity score (HR 1.20, 95% CI 1.13 to 1.26) were adverse predictors. Both raised TnT with ACS (HR 1.92, 95% CI 1.54 to 2.39) and raised TnT with non-ACS (HR 2.37, 95% CI 1.87 to 3.00) were associated with worse survival. Raised TnT with non-ACS had a worse survival than raised TnT with ACS (p=0.001).

Conclusion Hospitalised patients with raised TnT levels from any cause predicted a higher mortality than normal TnT, with worst survival in those without an obvious ACS.


Outcome and relapse risks of thrombotic thrombocytopaenic purpura: an Egyptian experience.

Thrombotic thrombocytopaenic purpura (TTP) is a rare life-threatening disease. Plasma exchange has significantly decreased the mortality from this disease, which still tends to recur in a substantial proportion of patients. This study describes the clinical spectrum and response to treatment and explores the risks of relapse in a cohort of patients.

Methods Patients treated for TTP at the Clinical Haematology Unit, Cairo University, Egypt, between 2000 and 2008 were identified. Complete demographic, clinical history and full clinical examination, laboratory, treatment modalities and duration, and outcome data were collected and analysed. The follow-up duration was 24 months.

Results 30 patients; 13 men (43%) and 17 women (57%) with a median age of 42 years were treated for 46 episodes of TTP. The median duration of disease onset to diagnosis for the first episode was 7 days. Twenty-three patients (76.66%) were diagnosed as idiopathic primary and seven patients (23.33%) were secondary TTP. Four patients died during the first 24 h. Of the 26 patients, 22 (85.6%) achieved remission with an average of 7.55 plasma exchange sessions, Another nine patients had 25 relapses (mean 2.7). Splenectomy was performed in three patients (11.5%). The 24-month overall survival was 80%. The initial low platelet count and high LDH were the only two statistically significant relapse predictors.

Conclusions The current results conform to the reported literature on the outcome of TTP. The very early mortality due to late referral highlights the need of education about the disease among primary healthcare providers.




Gout and Diuretics in Hypertensive Patients.

Diuretic use raised risk for gout by several percentage points.

Observational data have suggested that gout is associated independently with both hypertension and diuretic use. In a prospective study, researchers determined incidence of diuretic-associated gout in nearly 6000 hypertensive patients with no histories of gout at baseline.

During 9 years of follow-up, 37% of patients received diuretics. Incidence of gout was 5.5% among diuretic users (5.0% among thiazide users and 7.0% among loop-diuretic users) and 2.9% among patients who did not use diuretics. After adjustment for potentially confounding variables (except serum uric acid), use of thiazides and loop diuretics were both significantly associated with incident gout (hazard ratios, 1.4 and 2.3, respectively). Compared with serum uric acid levels in nonusers of diuretics, levels rose by a mean of 0.65 mg/dL among those who began taking thiazides and 0.96 mg/dL among those who began taking loop diuretics. The association between diuretics and gout was no longer significant after additional adjustment for serum uric acid; this finding is consistent with the assumption that diuretic-induced increases in serum uric acid mediate the association between diuretic use and gout.

Comment: According to these results, diuretic use raises risk for gout by several percentage points in hypertensive patients. Increased risk for gout is among the potential adverse effects of thiazides that clinicians should consider when choosing first-line antihypertensive drugs.

Source: Journal Watch General Medicine

Vitamin D and Calcium Supplementation in Older Adults.

A randomized trial found no effect on cancer or vascular mortality.

Intense interest surrounds the idea that vitamin D supplementation can prevent just about any disease under the sun (no pun intended). To address this issue, U.K. researchers present new findings from a previously published trial of vitamin D and calcium supplementation. Nearly 5300 patients (age, 70) with previous fractures were randomized to receive vitamin D3 (800 IU daily), calcium (1000 mg daily), both, or placebo. During 2 to 5 years of treatment, neither vitamin D nor calcium lowered rates of new fractures (JW Gen Med Jun 10 2005).

Now, these researchers have examined nonfracture outcomes that occurred during the trial plus 3 more years of follow-up; the additional follow-up was added because clinically evident effects on cancer and cardiovascular disease might be delayed. During a median follow-up of 6 years, neither vitamin D nor calcium was associated with significantly higher or lower overall mortality, cancer mortality, cancer incidence, or vascular mortality (compared with placebo).

Comment: This study population was limited to elders with previous fractures, duration of treatment was only a few years, baseline serum 25-hydroxyvitamin D levels were low (about 15 ng/mL), and the 800-IU supplement increased serum levels by only about 10 ng/mL. However, vitamin D and calcium trials have been performed in various other populations; the authors review that literature and conclude that no decisive evidence yet exists to support a beneficial effect of vitamin D or calcium supplementation on vascular or cancer risk.

Source: Journal Watch General Medicin


Adding Newer Cardiac Risk Markers to the Framingham Risk Score.

Only 2 of 12 new markers significantly improve risk prediction when added to the FRS.

Which, if any, additional cardiac risk markers improve prediction of coronary heart disease (CHD) risk when added to the Framingham Risk Score (FRS)? To answer this question, researchers used data that were collected prospectively from the Rotterdam Study of almost 6000 asymptomatic community-dwelling participants (mean age, 69) without known CHD. At baseline, participants underwent assessment of risk factors to calculate FRS. They also were evaluated for levels of prohormone brain-type natriuretic peptide (NT-proBNP), von Willebrand factor antigen, fibrinogen, C-reactive protein (CRP), homocysteine, and uric acid and for glomerular filtration rate, leukocyte count, coronary artery calcium score (CAC), carotid intima–media thickness, presence of peripheral artery disease, and pulse wave velocity. Only half of the participants were evaluated for CAC and CRP.

After controlling for FRS, the only markers with hazard ratios greater than 2 for 10-year incident CHD were NT-proBNP (HR, 2.5) and CAC (HR, 6.2). When each marker was added to the FRS, the net reclassification index (NRI) — the proportion of people whose risk class changed across standard low-, intermediate-, and high-risk categories — was highest for CAC score (NRI, 19%) and NT-proBNP (NRI, 8%). The remaining markers all had NRI scores of <3%. Among patients at intermediate Framingham risk, the NRI for CAC was 39% and for NT-proBNP was 33%.

Comment: In this study of an older white European population, the most clinically meaningful improvement in risk prediction came with obtaining CAC scores. But, as noted by an editorialist, improving risk prediction alone is insufficient; researchers must determine whether adverse outcomes can be prevented.

Source: Journal Watch General Medicine

The Risks and Benefits of Aspirin in Primary Prevention of CVD.

Risk for nontrivial bleeding roughly equals benefit in preventing nonfatal myocardial infarction.

Aspirin’s benefits in preventing cardiovascular (CV) events in patients with cardiovascular disease (CVD) are clear. The benefit in patients not known to have CVD is more modest and has not been weighed fully against the risk for bleeding. In this meta-analysis, researchers analyzed data from nine randomized, controlled trials of aspirin use in primary prevention; most of the 102,000 participants (mean age, 57; 47% men) were at elevated risk for CVD.

During mean follow-up of 6 years, nearly 2200 CV events were identified, including 1540 nonfatal myocardial infarctions (MIs) and 592 fatal events. More than 10,000 nontrivial bleeding events (defined in various studies as gastrointestinal bleeding, hemorrhagic stroke, nasal bleeding, and hematuria) were also identified. Aspirin treatment lowered risk for nonfatal CV events by about 20% (number needed to treat, 162), did not lower risk for fatal CV events, and raised risk for nontrivial bleeding events by 31% (number needed to harm, 73).

Comment: Based on these findings, the authors urge reappraisal of current guidelines, which recommend widespread use of aspirin for primary prevention in people at increased CVD risk. In contrast, an editorialist cautiously supports guidelines that endorse aspirin for patients who are at elevated risk for CV events (>1% incidence yearly) but at low risk for bleeding. Lastly, recent evidence that long-term daily aspirin use reduces the incidence of certain cancers may tip the balance toward aspirin for certain patients (JW Gen Med Jan 13 2011).

Source: Journal Watch General Medicine