Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

A quality improvement study: Optimizing pneumococcal vaccination rates in children with cochlear implants

Children with cochlear implants are at increased risk of invasive pneumococcal disease, with national and international guidelines recommending additional pneumococcal vaccines for these children. This study aimed to examine the pneumococcal immunization status and rate of invasive pneumococcal disease in children with cochlear implants at a tertiary paediatric hospital over a 12-year period. Additionally, the impacts of vaccination reminders and a dedicated immunization clinic on pneumococcal vaccination rates were assessed. This quality improvement study included 200 children who had received a cochlear implant through the Children's Hearing Implant Program at a tertiary paediatric hospital servicing the state of Western Australia. The majority of children (88%) were not up to date with additionally recommended pneumococcal vaccinations. Over the 12-year study period, 2% of children developed invasive pneumococcal disease associated with cochlear implant infections. Generic and personalized electronic immunization reminders improved pneumococcal vaccine up-take in this paediatric cochlear implant setting from 12% (19/153) at baseline to 49% (75/153, p < 0.0001) post implementation. The value of a nurse-led dedicated immunization clinic was also demonstrated with all children (42/42, 100%) up to date with Prevenar13 and the majority (34/42, 81%) up to date with Pneumovax23 post initiation of this referral pathway. These data support the expansion of this model to other medically-at-risk paediatric groups that have been highlighted consistently to be under-vaccinated.

P2797Clinical outcomes of an ultra-thin strut sirolimus-eluting stent with biodegradable polymer in all-comers patients undergoing coronary intervention

Background

Thin stent struts may be associated with reduced vessel injury and use of biodegradable polymers may further improve long term outcomes. However, data with earlier stents has been inconsistent; thus further studies with newer devices are needed.

Purpose

To evaluate the efficacy and safety of a new ultra-thin (65um) strut cobalt chromium sirolimus-eluting stent with a hybrid design (closed cell at ends and open cells in middle to reduce edge injury and optimise conformability) in all-comers patients undergoing percutaneous coronary intervention (PCI).

Methods

We enrolled 752 patients from 14 sites undergoing PCI into a prospective, non-randomised, multi-centre, open-label, observational registry. Inclusion of patients with complex anatomy (long stent lengths, bifurcations and chronic total occlusions) was encouraged. Clinical follow-up was scheduled at 1, 9, 12 and 24 months. The primary endpoint was incidence of major adverse cardiac events (MACE) - cardiac death, non-fatal myocardial infarction (MI), or target vessel revascularization (TVR) - at 9 months.

Results

Mean patient age was 64.7±12.2 years, 20.7% had diabetes, 58.8% had dyslipidaemia, 40.4% had multi-vessel disease, 22% had previous PCI, 4.7% had previous coronary-artery bypass graft, and 19.6% had a clinical history of previous MI. Mean lesion length was 25.7±17.3 mm. The primary endpoint of cumulative MACE up to 9 months (from 624 patients reaching 9 months follow-up) occurred in 12 patients (1.92%), including 6 (0.96%) cardiac death, 5 (0.80%) MI and 6 (0.96%) clinically indicated TVR. Definite stent thrombosis was reported in 3 patients (0.48%) and probable stent thrombosis in 2 patients (0.32%).

Conclusions

Use of an ultra-thin strut biodegradable polymer sirolimus-eluting stent in all-comers patients undergoing PCI was associated with good clinical efficacy and safety.

Acknowledgement/Funding

Meril Life

Transcranial–facial Approach for Tumours of Superior Paranasal Sinuses and Orbit

A monobloc resection of the fronto-ethmoid sphenoid area may be performed through a combined cranial and facial approach. Osmotic cerebral dehydration increases the exposure of the anterior cranial fossa. The results of treatment in 26 patients (24 with malignant disease of the ethmoid area who had disease recurrence after previous radiotherapy with or without surgery) and the complications encountered are described. The clinical details of 9 of these patients have been included in an earlier report (Clifford 1977).

Nutritional Status and General Immune Competence in Patients with Head and Neck Cancer

Anergy to 2,4-dinitrochlorobenzene (DNCB) has been reported as a highly significant adverse prognostic immunological factor in several studies of patients with squamous cell carcinomas involving the head and neck. Patients with these tumours often present with concurrent nutritional deficiencies. This paper reports the findings of a prospective study into both the nutritional status and general immune competence of 53 such patients.

Analysis of the results has demonstrated a statistically highly significant positive correlation between nutritional status and both the delayed hypersensitivity response to DNCB, and the pretreatment total lymphocyte count levels. It is suggested that nutritional deficit may be a primary adverse prognostic factor in this disease group, with immunoincompetence a secondary phenomenon, and supporting evidence is presented. The consequent probable importance of nutritional status with regard to clinical trials, and the necessity for controlled studies to determine the possible beneficial effect of nutritional support on ‘cure’ rates, are discussed.

Point-based polygonal models for random graphs

We define a class of two-dimensional Markov random graphs with I, V, T and Y-shaped nodes (vertices). These are termed polygonal models. The construction extends our earlier work [1]– [5]. Most of the paper is concerned with consistent polygonal models which are both stationary and isotropic and which admit an alternative description in terms of the trajectories in space and time of a one-dimensional particle system with motion, birth, death and branching. Examples of computer simulations based on this description are given.

International mental health outcomes and benchmarking using the FACE (functional analysis of care environments) approach

This article describes and compares the nature and severity of problems encountered by persons receiving mental health services in the United Kingdom and Australia, and the outcome of their treatment. The perspective of service providers and service users in the two countries was strikingly similar. Treatment was effective in alleviating problems with social circumstances, and in increasing adaptive and interpersonal functioning. Treatment was less effective in addressing psychological or physical problems. Service users in the United Kingdom were more involved in developing their treatment care plan than those in Australia. The study demonstrates how data required for benchmarking and outcome evaluation purposes can be generated as part of routine clinical processes.

Comparing patients' experience of mental health services in England: a five-Trust survey

The implementation of the Care Programme Approach (CPA) in English mental health services has been slow to proceed despite general support, both in England and in other countries, of its principles of good practice. This study set out to evaluate the implementation of the CPA directly from patients' experience using the "Your Treatment and Care" assessment tool. The results of a survey of 503 patients across five NHS Trusts in England showed that many patients did not have a copy of their care plan and had not been involved in the care planning procedure. Many reported shortcomings in their experience of their key worker and their psychiatrist. However, there was substantial variation in experience across services. "Your Treatment and Care" showed good internal reliability, was acceptable to users, and appeared to be able to access actual experiences better than a traditional "satisfaction" item. It appears to be very useful as a benchmarking tool and is now being used in services across the UK, the USA and Australia.

Neurodevelopmental consequences associated with the premature neonate

Changes in neonatal care have resulted in an increased survival rate among low birth weight infants. Because their neurologic system is immature, these infants are vulnerable to neurologic injury. Major and minor neurodevelopmental consequences can result. Most preterm infants survive without serious difficulties; however, the lower the birth weight, the higher the likelihood that problems will occur. Numerous factors can increase a preterm infant's risk for disease and impairment, and the neonatal nurse can perform a significant role in minimizing this risk.

Coping with chronic pain: assessing narrative approaches

Individuals suffering from chronic pain are of concern to social workers because such pain disrupts job, family, and overall social functioning and can lead to depression, excessive health concerns, and withdrawal from activities. This article discusses a project developed to gain understanding of the experiences of people suffering from fibromyalgia, a chronic pain condition with no visible symptoms, and to test the use of narrative approaches in group work with this population. The study used a qualitative ethnographic approach as the primary method and also used some quantitative measures to assess the usefulness of the approach. Both qualitative and quantitative findings suggest that narrative approaches helped participants find their own strengths and means of coping and helped them find identities other than as patients.

The results of open reduction and Internal fixation of distal femur fractures using a biologic (indirect) reduction technique

The results of 57 A-O type A or C supracondylar femur fractures treated by open reduction and internal fixation using indirect reduction techniques are reported. No bone grafting or dual plating was used. All patients were placed in a continuous passive motion (CPM) machine postoperatively. Patients were followed at 4-week intervals until fracture healing had occurred. All patients were followed for at least 1 year after injury. All fractures were treated by a single surgeon. The average time for fracture healing was 10.7 weeks (range 8-16). Hardware failure did not occur in this series. Outcomes were assessed using a modified Schatzker scoring method. Using the scale, there were 84% good to excellent results, 11% fair results, and 5% poor outcomes. Fair and poor results tended to occur in more severe fractures and were primarily due to limited knee motion. Complications included two broken screws, one deep infection, and one malunion. No fractures failed to unite. In conclusion, holding the surgical skill factor constant, it appeared that biologic reduction techniques, although they provided excellent bone healing capability, did not guarantee universally satisfactory outcomes.

Quality assurance in mental health: the QUARTZ system

This paper is concerned with how quality might be assured in mental health services. It includes an account of why a concern with quality and quality assurance procedures are now high on the agenda of the Health Service. A quality assurance programme requires a decision about what elements of a service to monitor, what information is relevant, how it can be collected, and a system for acting on the results. This paper provides a brief review of the kind of information that has been considered relevant and the methods that have been used to collect it. In addition, the principles underlying good and comprehensive quality assurance programmes will be outlined and the development of a particular system, known as QUARTZ, which has attempted to incorporate these principles, described briefly.

A national audit of new long-stay psychiatric patients. I: Method and description of the cohort

BACKGROUND

This first report of a national audit of new long-stay (NLS) psychiatric patients conducted in 1992 describes the survey method and characteristics of the cohort.

METHOD

Psychiatrists from 59 UK mental health services returned data on 905 patients, aged 18-64 on admission, who had been in hospital for between six months and three years.

RESULTS

Two particular sub-groups were observed. Younger NLS patients (aged 18-34) were predominantly single men with schizophrenia; 43% of these had a history of serious violence, dangerous behaviour or admission to a Special Hospital and over one-third were formally detained. Older NLS patients (aged 55-67) were predominantly married or previously married women, more often with a diagnosis of affective disorder or dementia and with poor personal and social functioning; over half were at moderate or severe risk of non-deliberate self-harm.

CONCLUSIONS

Despite the continued policy of bed closures and focus on care in the community, some patients admitted recently to psychiatric units in the UK still have protracted hospital stays.

Harm reduction: an emerging new paradigm for drug education

Harm reduction is a new paradigm now emerging in the field of drug education. This strategy recognizes that people always have and always will use drugs and, therefore, attempts to minimize the potential hazards associated with drug use rather than the use itself. The rationale for a harm reduction strategy is presented, followed by an example of the kind of needs assessment which may be needed for planning a harm reduction strategy.

A needs survey among patients in Leros asylum

The recent exposure of the plight of inmates living in poor conditions at the state asylum on the Greek island of Leros has caused public and professional outrage. If Greece is to avoid mistakes made by other countries, the plans for rehabilitating the patients and closing the hospital should from the outset include identification of the precise needs of patients for support and care. The survey of the patients' characteristics and needs for care found that most patients had no outside friends or relatives, and most were unable to perform basic daily skills. They shared many basic characteristics, however, with a large sample of the long-stay population in the UK, and 25% were thought to be able to live independently.

Planning for community care: the Community Placement Questionnaire

The article reviews methodological issues relating to planning surveys of long-stay populations and describes the development of an assessment instrument, the Community Placement Questionnaire, designed to aid planning for long-stay patients resident in hospitals scheduled for rundown or closure. Reliability and validity data are presented and the advantages and limitations of the instrument are discussed.

Planning for community care. Long-stay populations of hospitals scheduled for rundown or closure

Using the Community Placement Questionnaire, the long-stay populations of five hospitals were surveyed. The results suggest that there is little need for large hospitals if adequate community provision is made. However, a small number of patients continue to accumulate for whom community placement is hard to envisage. Investigating the characteristics of the 'new long-stay' patients suggests that the usual definition should be extended to include those over 65 years old with no diagnosis of dementia and those in hospital for 1-10 years. About 20% of 'new long-stay' patients have organic diagnoses and the needs of this group require assessment.

The privatization of treatment services for alcohol abusers: effect on the black community

This article discusses the "new wave" of privatization of treatment services for alcohol abusers. Despite the prevalence of alcohol abuse among ethnic minorities, the problem is still only marginally accepted as a focus for public health services. Instead of a consolidated effort or an integrated network, there are territorial fights among providers, a mistargeting of audiences, and a lack of any effort directed toward preventive health care. Recent research indicates that 68.5% of private sector employees are now covered by alcohol abuse treatment benefits as compared with only 36.2% in 1982. The growing number of employee assistance programs also has addressed the financial problems associated with long-term treatment in the work environment. Unfortunately these efforts are only directed at those in the society who are employed. As minority employment is much lower than that of the majority, minorities have not received the benefits of employer-financed treatment. This article assesses the growing privatization of treatment services and the failure of public alcohol prevention and rehabilitation programs to provide needed treatment for American minorities.

Assessing the significance of the correlation between two spatial processes

Modified tests of association based on the correlation coefficient or the covariance between two spatially autocorrelated processes are presented. These tests can be used both for lattice and nonlattice data. They are based on the evaluation of an effective sample size that takes into account the spatial structure. For positively autocorrelated processes, the effective sample size is reduced. A method for evaluating this reduction via an approximation of the variance of the correlation coefficient is developed. The performance of the tests is assessed by Monte Carlo simulations. The method is illustrated by examples from geographical epidemiology.

Postcricoid carcinoma: a retrospective study of 13 patients

Thirteen consecutive patients presenting with squamous cell carcinoma in the postcricoid region (PCC) are studied and details of their age, sex, TNM status, treatment and results are analysed. Follow-up ranges from 33 months to 11 years. Three patients presented with cervical node involvement and 2 of these remain disease free without surgical intervention, at 33 months and 9 years. The principal treatment policy has been the combination of multi-agent chemotherapy with radical radiotherapy, reserving wide excision surgery for patients with residual or recurrent carcinoma. Only 4 patients underwent pharyngolaryngectomy, one radical neck dissection was performed and 7 of the 13 patients have remained free of disease for more than 3 years.

Use of health services by diabetic persons. II. Hospital admissions

Over a 10-mo period, a computerized admission discharge system was scrutinized to identify all persons with diabetes mellitus admitted to a general hospital in Christchurch, North Canterbury (population 342,000), New Zealand. The 274 admissions by 197 diabetic persons (42% were insulin treated, 14% were newly diagnosed, 44% were non-insulin-dependent) contributed to 3.6% of the total hospital admissions, with duration of stay being longer than for nondiabetic persons (13.6 versus 11.3 days, P = 0.05). Patients admitted were aged 11-91 yr (mean 59 yr); those over 50 yr of age were numerically the largest admission group. Although cardiovascular illnesses were the most frequent events precipitating admission (34%), potentially preventable admissions for reasons of infection, poor glycemic control, or hypoglycemia were found in all age groups. Just under half of the 902 registered insulin-treated diabetic patients living in this health region had at some stage participated in diabetes education programs at the time this admission survey was undertaken. Of these, only nine were admitted. The other 70 insulin-treated patients admitted who lived in this region had never had diabetes education. Overall, only 11.7% of patients admitted had received diabetes education. These data show that, for insulin-treated diabetic individuals at least, admission rates were substantially lower among those who were sufficiently motivated to attend diabetes education programs.

Patterns and mechanisms of bone invasion by squamous carcinomas of the head and neck

Patterns and mechanisms of local bone invasion by squamous carcinomas of the head and neck have been investigated. Detailed surgical pathology has shown that these tumors invade contiguous skeletal or metaplastic bone principally through an indirect process; the normal bone resorbing cells of the host (osteoclasts) are activated and erode bone in front of the advancing tumor edge. Tumor cells take over the destructive process when the osteoclast response has waned. These morphologic patterns have been reproduced in an in vitro model where calcium-45-labelled mouse calvaria, cocultured with a tumor for 3 days, are resorbed by osteoclasts. Freshly excised tumors, established tumor cell lines, and tumor xenografts release osteolysins in vitro which act as osteoclastic stimulants. They include both prostaglandins E2 and F2 alpha, and nonprostaglandin factors, and are derived from tumor cells and from the associated host stroma. Virtually all the tumors examined released osteolysins and resorbed bone in vitro independent of their site, size, degree of differentiation, and the presence or absence of clinical bone invasion.

Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway

We examined the incidence of seven common surgical procedures in seven hospital service areas in southern Norway, in 21 districts in the West Midlands of the United Kingdom, and in the 18 most heavily populated hospital service areas in Vermont, Maine, and Rhode Island. Although surgical rates were higher in the New England states than in the United Kingdom or Norway, there was no greater degree of variability in the rates of surgery among the service areas within the three New England states. Hernia repair was more variable in England (P less than 0.05) and hysterectomy in Norway (P less than 0.05) than in the other countries. There was consistency among countries in the rank order of variability for most procedures: tonsillectomy, hemorrhoidectomy, hysterectomy, and prostatectomy varied more from area to area than did appendectomy, hernia repair, or cholecystectomy. The degree of variation generally appeared to be more characteristic of the procedure than of the country in which it was performed. Thus, differences among countries in the methods of organizing and financing care appear to have little relation to the intrinsic variability in the incidence of common surgical procedures among hospital service areas in these countries. Despite the differences in average rates of use, the degrees of controversy and uncertainty concerning the indications for these procedures seem to be similar among clinicians in all three countries.

The diagnosis and surgical management of olfactory neuroblastoma: the role of craniofacial resection

The diagnosis and clinical management of olfactory neuroblastoma are discussed. Computerized tomography is a valuable means of assessing the pre-operative extent of disease and the efficacy of subsequent major surgery. The tissue diagnosis is facilitated by electron microscopy, demonstrating the presence of dense core vesicles and cytoplasmic filaments. Radiotherapy followed by craniofacial resection is the treatment of choice for olfactory neuroblastomas that are locally extensive at presentation.