Background— The relationship between obstructive sleep apnea (OSA) and cardiovascular events remains unclear. We conducted a systematic review to determine the incident risk of cardiovascular events among patients with OSA. Methods and Results— We searched MEDLINE and EMBASE in January 2011 for prospective studies that followed up patients with OSA for incident ischemic heart disease, stroke, and cardiovascular mortality. Outcomes data were pooled using random effects meta-analysis and heterogeneity assessed with the I 2 statistic. Regression analysis was performed to evaluate the effects of different gradations of OSA severity based on apnea-hypopnea index. We identified 9 relevant studies from 1731 citations. OSA was associated with incident stroke in a meta-analysis of 5 studies (8435 participants), odds ratio (OR) 2.24; 95% confidence interval (CI), 1.57–3.19; I 2 =7%. A significant association was seen in studies that were predominantly on men; OR, 2.87; 95% CI, 1.91–4.31, whereas data on women were sparse. In the overall analysis of 6 studies (8785 participants), OSA was nonsignificantly associated with ischemic heart disease (OR, 1.56; 95% CI, 0.83–2.91), with significant findings in the 5 studies that recruited mainly men (OR, 1.92; 95% CI, 1.06–3.48). Substantial heterogeneity was noted (I 2 =74%). OSA was linked to cardiovascular death in 2 studies involving 2446 participants (OR, 2.09; 95% CI, 1.20–3.65, I 2 =0%). Regression analysis showed greater likelihood of stroke or cardiovascular events with increasing apnea-hypopnea index values. Conclusions— OSA appears to be associated with stroke, but the relationship with ischemic heart disease and cardiovascular mortality needs further research.
Background Several scoring systems have been used to predict mortality in patients with community-acquired pneumonia. The properties of commonly used risk stratification scales were systematically reviewed. Methods MEDLINE and EMBASE (January 1999eOctober 2009) were searched for prospective studies that reported mortality at 4e8 weeks in patients with radiographically-confirmed community-acquired pneumonia. The search focused on the Pneumonia Severity Index (PSI) and the three main iterations of the CURB (confusion, urea nitrogen, respiratory rate, blood pressure) scale (CURB-65, CURB, CRB-65), and test performance was evaluated based on 'higher risk' categories as follows: PSI class IV/V, CURB-65 (score $3), CURB (score $2) and CRB-65 (score $2). Random effects meta-analysis was used to generate summary statistics of test performance and receiver operating characteristic curves were used for predicting mortality. Results 402 articles were screened and 23 studies involving 22 753 participants (average mortality 7.4%) were retrieved. The respective diagnostic odds ratios for mortality were 10.77 (PSI), 6.40 (CURB-65), 5.97 (CRB-65) and 5.75 (CURB). Overall, PSI had the highest sensitivity and lowest specificity for mortality, CRB-65 was the most specific (but least sensitive) test and CURB-65/ CURB were between the two. Negative predictive values for mortality were similar among the tests, ranging from 0.94 (CRB-65) to 0.98 (PSI), whereas positive predictive values ranged from 0.14 (PSI) to 0.28 (CRB-65). Conclusions The current risk stratification scales (PSI, CURB-65, CRB-65 and CURB) have different strengths and weaknesses. All four scales had good negative predictive values for mortality in populations with a low prevalence of death but were less useful with regard to positive predictive values. BACKGROUND
PRACTICEFor the full versions of these articles see bmj.com published a report on the experiences of 866 deaf people across the UK and their views of using various health services. 16 In its survey it found that 42% of respondents who had visited hospital had found communication with NHS staff difficult; this figure increased to 66% for people who used British sign language (BSL). Most worrying was that a third PRACTICE POINTERIn the United Kingdom one in seven of the population (more than six million people aged over 60 and two and a half million aged 60 and under) have a hearing loss. 1 Hospital services are used more by older people, 2 so many of the patients seen by health professionals have a hearing loss. Staff often do not appropriately adapt the way they communicate with this group. [3][4][5] Most people with a hearing loss have either developed the problem in later life (the vast majority) or acquired a loss through, for example, infection or trauma. Nearly all these people communicate with spoken language and may also use hearing aids. A small proportion of people with a hearing loss are congenitally severely or profoundly deaf and are more likely to use sign language. For clarity of terminology, throughout this article we use the term deafness and deaf people to refer in general to hearing loss of all types and degrees and to those who are affected.Deafness can affect a person's ability to communicate properly. It alters their interactions with others and may contribute to depression, anxiety, loneliness, and social withdrawal. 6-11 Deaf people complain that medical professionals frequently lack understanding and empathy. 12 Often they feel that health professionals do not appreciate just how stressful it is to engage in a healthcare setting; this problem primarily results from inadvertent barriers that prevent effective communication. Health professionals could benefit from special training in how best to deal with the communication difficulties of deaf patients. 5 Indeed the Department of Health in England recommends that all frontline National Health Service (NHS) staff should have "deaf awareness" training. 13 In this article we highlight how people's deafness affects them in healthcare settings. We also provide advice and resources on how to meet the communication needs of deaf patients. Box 1 outlines the terminology usually used by people to describe their deafness.
Summary Background: Pain management is fundamental to good clinical care. All patients who are admitted into hospital with any acute condition should be assessed about the presence or absence of pain and managed appropriately at the time of admission. As the prevalence of pain is high in older people, we examined how well it is assessed and managed in the older people in a typical medical emergency setting in the UK. Methods: We performed a retrospective audit in a district general hospital with catchment population of 250,000 in West Norfolk, UK. We included all patients admitted to care of the elderly wards during October–November 2007. We evaluated management of pain within the first 24 h of acute hospital admission. Results: Of the 140 patients admitted, 74 (53%) were male and their median age was 84 years (range = 56–99; =< 70, n = 8). Only 93 (66%) were asked about the presence or absence of pain on admission. Of those who complained of pain (n = 45), severity of pain was documented in 5 (11%) and the management was documented in 17 (38%). Of 17 with documented pain management, only 4 (23%) had further assessment of effectiveness of pain management. Only 70 (50%) of the patients had their mental state assessed by the abbreviated mental test score (AMTS). Among those who complained of pain and AMTS ≤ 8 (n = 51), only 4 (8%) had objective documentation. Conclusions: Our findings suggest that pain management may be sub‐optimal in older people in the acute medical settings. Regular monitoring and education may have potential to improve assessment and management of pain in these vulnerable older adults.
A 62-year-old female life-long nonsmoker was referred to our department for investigation of persistent cough, weight loss, mild anaemia and gross finger clubbing. Her chest radiograph was essentially normal, computed tomographic imaging showed no significant abnormality and no endobronchial lesion was demonstrated during bronchoscopy.Her case notes became available only following her admission and it was discovered that finger clubbing had been documented 20 years earlier. She had a long history of abdominal pain and intermittent diarrhoea and had undergone numerous gastrointestinal investigations. Sigmoidoscopy 27 years earlier had demonstrated biopsy-proven melanosis coli and, combined with the finding of low potassium, suggested purgative abuse as a cause of her intestinal symptoms. During other admissions spanning several decades, her potassium was intermittently found to be low and urine had proven positive for anthraquinones. Her husband had confirmed an unusually large intake of laxatives by his wife, although this had been denied by the patient herself. During her admission for respiratory investigations, she was using laxatives (lactulose and senna) on a daily basis and despite mild chronic renal failure, her serum potassium was only 2.8 mmol l − 1 . Finger clubbing is associated with a wide range of pulmonary and nonpulmonary conditions and frequently raises the possibility of a serious underlying disorder. The mechanism behind its development remains uncertain, although it can disappear after successful treatment of a given disorder. We feel that congenital finger clubbing was unlikely in this patient, as its presence was noted repeatedly in the notes 20 years prior to her current admission, but not so in many entries before this.In conclusion, our case complements the paucity of literature describing chronic laxative abuse as being a cause of finger clubbing [1][2][3][4] and illustrates that this knowledge may in turn avoid unnecessary investigations. Moreover, in patients where no cause of finger clubbing has been identified, clinical features suggesting laxative abuse should be actively sought.
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