J. S. Chandan

Validity and interpretation of spirometric recordings to diagnose COPD in UK primary care

Background The diagnosis of COPD is dependent upon clinical judgment and confirmation of the presence of airflow obstruction using spirometry. Spirometry is now routinely available; however, spirometry incorrectly performed or interpreted can lead to misdiagnosis. We aimed to determine whether spirometry undertaken in primary care for patients suspected to have COPD was of sufficient quality and whether their spirometry was correctly interpreted. Methods Two chest physicians re-read all spirometric readings for both quality of the procedure and interpretation, received as a part of COPD validation studies using data from the Clinical Practice Research Datalink (CPRD). We then used logistic regression to investigate predictors of correct interpretation. Results Spirometry traces were obtained for 306 patients, of which 221 (72.2%) were conducted in primary care. Of those conducted in primary care, 98.6% (n=218) of spirometry traces were of adequate quality. Of those traces that were of adequate quality and conducted in primary care, and in whom a general practitioner (GP) diagnosis of COPD had been made, 72.5% (n=218) were consistent with obstruction. Historical records for asthma diagnosis significantly decreased odds of correct interpretation. Conclusion The quality of the spirometry procedure undertaken in primary care is high. However, this was not reflected in the quality of interpretation, suggesting an unmet training in primary care. The quality of the spirometry procedure as demonstrated by spirometric tracings provides a re-assurance for the use of spirometric values available in the electronic health care record databases for research purposes.

Recording of hospitalizations for acute exacerbations of COPD in UK electronic health care records.

Background Accurate identification of hospitalizations for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) within electronic health care records is important for research, public health, and to inform health care utilization and service provision. We aimed to develop a strategy to identify hospitalizations for AECOPD in secondary care data and to investigate the validity of strategies to identify hospitalizations for AECOPD in primary care data. Methods We identified patients with chronic obstructive pulmonary disease (COPD) in the Clinical Practice Research Datalink (CPRD) with linked Hospital Episodes Statistics (HES) data. We used discharge summaries for recent hospitalizations for AECOPD to develop a strategy to identify the recording of hospitalizations for AECOPD in HES. We then used the HES strategy as a reference standard to investigate the positive predictive value (PPV) and sensitivity of strategies for identifying AECOPD using general practice CPRD data. We tested two strategies: 1) codes for hospitalization for AECOPD and 2) a code for AECOPD other than hospitalization on the same day as a code for hospitalization due to unspecified reason. Results In total, 27,182 patients with COPD were included. Our strategy to identify hospitalizations for AECOPD in HES had a sensitivity of 87.5%. When compared with HES, using a code suggesting hospitalization for AECOPD in CPRD resulted in a PPV of 50.2% (95% confidence interval [CI] 48.5%–51.8%) and a sensitivity of 4.1% (95% CI 3.9%–4.3%). Using a code for AECOPD and a code for hospitalization due to unspecified reason resulted in a PPV of 43.3% (95% CI 42.3%–44.2%) and a sensitivity of 5.4% (95% CI 5.1%–5.7%). Conclusion Hospitalization for AECOPD can be identified with high sensitivity in the HES database. The PPV and sensitivity of strategies to identify hospitalizations for AECOPD in primary care data alone are very poor. Primary care data alone should not be used to identify hospitalizations for AECOPD. Instead, researchers should use data that are linked to data from secondary care.

P223 Validity and interpretation of spirometry for patients in primary care

Background Previous studies have questioned the validity and interpretation of spirometry undertaken in primary care. Knowing that data are accurate is important as many respiratory diseases are diagnosed and managed in primary care. Additionally researchers use data entered into electronic health records both as single measurements and to track changes in lung function over time. We aimed to determine whether spirometry undertaken in primary care for patients suspected to have COPD was of sufficient quality, and was correctly interpreted. Methods As part of previous studies to validate the recording of COPD diagnosis and exacerbations of COPD in the clinical practice research datalink (CPRD) we obtained additional information from GPs which included spirometry traces. In this subset, a respiratory physician assessed spirometry traces for: 1) quality and 2) diagnostic interpretation. We used logistic regression to assess predictors of GPs interpretation of spirometric traces with the outcome of COPD diagnosis confirmed by respiratory physician adjudication of spirometry traces as correct and age, sex and previous record for asthma as covariates. Results We obtained spirometry traces for 306 patients, of which 221 (72.2%) were conducted in primary care. 96.5% of traces were of adequate quality such that a valid interpretation could be made. Of those traces which were of adequate quality and conducted in primary care, and in whom a GP diagnosis of COPD had been made (N = 218), 73.4% showed obstruction, suggestive of COPD (Table 1). There was some evidence that correct interpretation of spirometry (either as obstructive, restrictive or normal) was influenced by a previous asthma diagnosis (OR 0.49, 95% CI 0.26–0.93). There was no evidence that correct interpretation was modified by age (OR 0.98, 0.96–1.01) or sex (OR 1.28, 0.69–2.38).Abstract P223 Table 1 Interpretation of spirometry for patients diagnosed with COPD in primary care (N = 218) Conclusions Spirometry is performed in primary care to a high standard. Interpretation in patients with suspected COPD in primary care is moderate. Efforts should be made to improve spirometry interpretation for high quality patient care, and for research. As quality of spirometry measurements were high, researchers could use actual recorded values of FEV1 and FVC, however should exercise caution with using interpretation of spirometry values documented in primary care records.

The association between idiopathic thrombocytopenic purpura and cardiovascular disease : a retrospective cohort study

Essentials We estimated the cardiovascular risk of patients with idiopathic thrombocytopenic purpura (ITP). The risk of cardiovascular disease was 38% higher in ITP patients compared with controls. Among the ITP patients, splenectomy was associated with higher cardiovascular disease. Clinicians should consider cardiovascular risk when managing ITP patients.

Regular and frequent feedback of specific clinical criteria delivers a sustained improvement in the management of diabetic ketoacidosis

ABSTRACT Efficient management of diabetic ketoacidosis (DKA) improves outcomes and reduces length of stay. While clinical audit improves the management of DKA, significant and sustained improvement is often difficult to achieve. We aimed to improve the management of DKA in our trust through the implementation of quality improvement methodology. Five specific targets (primary drivers: fluid prescription, fixed rate intravenous insulin infusion, glucose measurement, ketone measurement and specialist referral) were selected following a baseline audit. Interventions (secondary drivers) were developed to improve these targets and included monthly feedback to departments of emergency medicine, acute medicine, and diabetes. Following our intervention, the mean average duration of DKA reduced from 22.0 hours to 10.2 hours. We demonstrate that regular audit cycles with interventions introduced through the plan-do-study-act model is an effective way to improve the management of DKA.

Are they high on steroids? Tailored interventions help improve screening for steroid-induced hyperglycaemia in hospitalised patients

Steroid-induced hyperglycaemia (SIH) is a common adverse effect in patients both with and without diabetes. This project aimed to improve the screening and diagnosis of SIH by improving the knowledge of healthcare professionals who contribute to the management of SIH in hospitalised patients. Monitoring and diagnosis of SIH were measured in areas of high steroid use in our hospital from May 2016 to January 2017. Several interventions were implemented to improve knowledge and screening for SIH including a staff education programme for nurses, healthcare assistants and doctors. The Trust guidelines for SIH management were updated based on feedback from staff. The changes to the guideline included shortening the document from 14 to 4 pages, incorporating a flowchart summarising the management of SIH and publishing the guideline on the Trust intranet. A questionnaire based on the recommendations of the Joint British Diabetes Societies for SIH was used to assess the change in knowledge pre-intervention and post-intervention. Results showed an increase in junior doctors’ knowledge of this topic. Although there was an initial improvement in screening for SIH, this returned to near baseline by the end of the study. This study highlights that screening for SIH can be improved by increasing the knowledge of healthcare staff. However, there is a need for ongoing interventions to sustain this change.

Anticoagulants: Updates on idarucizumab

Sir, fifty million cartridges of local anaesthetic are delivered annually by dentists and surgeons in the UK.1 Fortunately, needle breakage is uncommon and is typically a complication of inferior alveolar nerve blocks.2-4 Only one needle breakage during an infiltration has been found in the literature.5 We wish to share a rare encounter during an infiltration using a single use system (Fig. 1). When a 27-gauge needle was used under general anaesthetic, the plastic hub failed to retain the metal needle. Upon withdrawal, the needle separated from the plastic hub and remained in the patient’s tissue. Due to careful observation by the surgeon this was spotted immediately and recovered uneventfully with a fine mosquito clip. Within one month, two further identical needle breakages occurred, experienced by a total of three different clinicians. All three needles were retrieved without complication. We theorised that the disposable plastic syringe used was not compatible with the needle tip as both of these parts are manufactured by different companies. Screwing this particular needle into that particular syringe may have led to over-working of the threads within the plastic hub of the needle resulting in a loosened grip between plastic and metal. Given this rare and potentially dangerous occurrence repeating itself within a short space of time where the correct anaesthetic technique had been employed and where patient movement could not be attributed to the breakage, we flagged our concern to the manufacturer. Interestingly, this type of mechanical failure of the needle had never before been reported to the manufacturer. When an investigation was launched, it became apparent that all the broken needles belonged to the same batch, highlighting the importance of recording batch number. The retained broken needle and a total of 206 unused needles belonging to that batch were retrieved from outpatients, A&E, operating theatres and equipment stores and returned to the manufacturer as per their request. Each was visually inspected and underwent rigorous testing of the glue point. The broken needle and one other unused needle showed a low quantity of glue between the plastic hub and the metal needle. All the tested needles passed a resistance test (dynamometer test) to observe the behaviour of the cannula on the hub. The formal analysis report concluded that the repeated needle breakage was due to an insufficient quantity of glue secondary to deficiencies during glue distribution. The manufacturer’s actions included replenishing all the collected needles, re-briefing their staff on the importance of visual controls and implementing a new production process to commence in 2017. A major learning point from this is for clinicians to always diligently watch the needle during administration as well as on withdrawal until it is safely out of the patient’s mouth. Needle fractures in tissues can be devastating and stressful for both clinician and patient therefore to prevent the risk posed to patient safety by faulty equipment we highly recommend liaising with the manufacturer if problems arise. We also advise not discarding any faulty equipment but retaining it for testing. M. Makwana, S. Walsh, Western Sussex Hospitals NHS Foundation Trust

The impact of inflammatory bowel disease on oral health

Inflammatory bowel disease (IBD) mainly comprises of two separate inflammatory conditions: Crohns disease (CD) and ulcerative colitis (UC). The aetiology of these conditions is still being explored with current evidence pointing towards a combination of environmental and genetic components. However, the pathophysiology is understood as a cytokine driven inflammatory response. There is significant association between IBD and dental conditions such as dental caries, other infections and periodontitis. Anti-inflammatory medications such as 5 aminosalicylic acid (5ASA), steroids and biological therapies are the treatment of choice for these chronic conditions, dependent on aetiology. Therefore, this article aims to educate dentists regarding possible implications IBD and its treatment can have for clinical practice and future research.

Oral health: Dental neglect on wards

1. Oxley C J, Dennick R, Batchelor P. The standard of newly qualified dental graduates – foundation trainer perceptions. Br Dent J 2017; 222: 391–395. 2. Farzianpour F, Monzavi A, Yassini E. Evaluating the quality of education at Dentistry School of Tehran University of Medical Sciences. Dent Res J (Isfahan) 2011; 8: 71–79. 3. Garcia R I, Sohn W. the paradigm shift to prevention and its relationship to dental education. J Dent Educ 2012; 76: 36–45. 4. Cabot L B, Radford D R. Are graduates as good as they used to be? Br Dent J 1999; 186: 318–319. DOI: 10.1038/sj.bdj.2017.693

Incidence, morbidity and mortality of patients with achalasia in England: findings from a study of nationwide hospital and primary care data

Background Achalasia is an uncommon condition characterised by failed lower oesophageal sphincter relaxation. Data regarding its incidence, prevalence, disease associations and long-term outcomes are very limited. Methods Hospital Episode Statistics (HES) include demographic and diagnostic data for all English hospital attendances. The Health Improvement Network (THIN) includes the primary care records of 4.5 million UK subjects, representative of national demographics. Both were searched for incident cases between 2006 and 2016 and THIN for prevalent cases. Subjects with achalasia in THIN were compared with age, sex, deprivation tand smoking status matched controls for important comorbidities and mortality. Results There were 10 509 and 711 new achalasia diagnoses identified in HES and THIN, respectively. The mean incidence per 100 000 people in HES was 1.99 (95% CI 1.87 to 2.11) and 1.53 (1.42 to 1.64) per 100 000 person-years in THIN. The prevalence in THIN was 27.1 (25.4 to 28.9) per 100 000 population. Incidence rate ratios (IRRs) were significantly higher in subjects with achalasia (n=2369) compared with controls (n=3865) for: oesophageal cancer (IRR 5.22 (95% CI: 1.88 to 14.45), p<0.001), aspiration pneumonia (13.38 (1.66 to 107.79), p=0.015), lower respiratory tract infection (1.33 (1.05 to 1.70), p=0.02) and mortality (1.33 (1.17 to 1.51), p<0.001). The median time from achalasia diagnosis to oesophageal cancer diagnosis was 15.5 (IQR 20.4) years. Conclusion The incidence of achalasia is 1.99 per 100 000 population in secondary care data and 1.53 per 100 000 person-years in primary care data. Subjects with achalasia have an increased incidence of oesophageal cancer, aspiration pneumonia, lower respiratory tract infections and higher mortality. Clinicians treating patients with achalasia should be made aware of these associated morbidities and its increased mortality.