CT coronary angiography in low- to intermediate-risk patients: less radiation, less invasive angiography, and less revascularisation.

OBJECTIVES: We investigated whether any change in the use of invasive coronary angiography and coronary revascularisation after CT coronary angiography in patients with a low to intermediate pre-test probability of coronary artery disease could be explained from alterations in patient characteristics. DESIGN: A cohort study based on data samples from the Western Denmark Heart Registry. Follow-up ended on 11 March 2014. RESULTS: A total of 3541 persons were examined during the period of January 2010-December 2013. The median radiation dose was reduced from 4.2 to 2.2 mSv (p < 0.001) due to improved technology. The immediate referral rate for subsequent myocardial perfusion scans was increased from 2.8% to 10.0% (p < 0.001), while the immediate referral rate for invasive coronary angiography decreased from 25.3% to 10.8% (p < 0.001). The revascularisation rate diminished from 10.4% to 6.3%. The multivariable adjusted hazard ratio (95% confidence interval) for invasive coronary angiography during follow-up after CT coronary angiography was 0.59 (0.47-0.74) and that for coronary revascularisation was 0.66 (0.45-0.97) in 2013 compared to that in 2010. CONCLUSIONS: The radiation dose diminished considerably. The reductions in the use of invasive coronary angiography and coronary revascularisation could not be explained by changes in patient characteristics but are driven by an increased use of perfusion scans in combination with increasing use of measurement of functional coronary flow reserve.

Earlier diagnosis of lung cancer.

The purpose of this article is to review options for more rapid diagnosis of lung cancer at an earlier stage, thereby improving survival. These options include screening, allowing general practitioners to refer patients directly to low-dose computed tomography scan instead of a chest X-ray and the abolition of the "visitation filter", i.e. hospital doctors' ability to reject referrals from general practitioners without prior discussion with the referring doctor.

Magnetic Resonance Enterography and Histology in Patients With Fibrostenotic Crohn's Disease: A Multicenter Study.

INTRODUCTION: Magnetic resonance enterography (MRE) is useful for detecting bowel strictures, whereas a number of imaging biomarkers may reflect severity of fibrosis burden in Crohn's disease (CD). This study aimed to verify the association of MRE metrics with histologic fibrosis independent of inflammation. METHODS: This prospective European multicenter study performed MRE imaging on 60 patients with CD with bowel strictures before surgical resection. Locations of 61 histological samples were annotated on MRE examinations, followed by central readings using the Chiorean score and measurement of delayed gain of enhancement (DGE), magnetization transfer ratio, T2-weighted MRI sequences (T2R), apparent diffusion coefficient (ADC), and the magnetic resonance index of activity (MaRIA). Correlations of histology and MRE metrics were assessed. Least Absolute Shrinkage and Selection Operator and receiver operator characteristic (ROC) curve analyses were used to select composite MRE scores predictive of histology and to estimate their predictive value. RESULTS: ADC and MaRIA correlated with fibrosis (R = -0.71, P < 0.0001, and 0.59, P < 0.001) and more moderately with inflammation (R = -0.35, P < 0.01, and R = 0.53, P < 0.001). Lower or no correlations of fibrosis or inflammation were found with DGE, magnetization transfer ratio, or T2R. Least Absolute Shrinkage and Selection Operator and ROC identified a composite score of MaRIA, ADC, and DGE as a very good predictor of histologic fibrosis (ROC area under the curve = 0.910). MaRIA alone was the best predictor of histologic inflammation with excellent performance in identifying active histologic inflammation (ROC area under the curve = 0.966). DISCUSSION: MRE-based scores for histologic fibrosis and inflammation may assist in the characterization of CD stenosis and enable development of fibrosis-targeted therapies and clinical treatment of stenotic patients.

Danish patients are positive towards fees for non-attendance in public hospitals. A qualitative study.

INTRODUCTION: Patients' non-attendance is a significant problem in modern healthcare. Non-attendance delays treatment, reduces efficiency and increases healthcare costs. For several years, the introduction of financial incentives such as a non-attendance fee has been discussed in Denmark. Set in the context of a tax-financed, free-for-all healthcare system, the political hesitance to introduce fees relates to concerns that additional fees may be badly received by tax-paying citizens and may undermine the political priority of patient equity. The aim of this qualitative sub-study was to investigate patients' attitudes towards a fee for non-attendance. METHODS: Six semi-structured focus group interviews were conducted with a total of 44 patients who had been informed about being charged a fee for non-attendance. Data were transcribed verbatim and analysed using a qualitative content analysis. RESULTS: Overall, patients' attitudes towards the non-attendance fee were positive. Non-attendance was viewed as evidence of disregard for the common free-for-all healthcare, and a fee was expected to motivate non-attendees to show up. However, most patients argued that certain groups (e.g. the mentally disabled) should be exempted from the fee. Furthermore, an implementation of fees should be easy to manage administratively and should not increase bureaucracy. CONCLUSION: In general, patients' attitudes towards implementing non-attendance fees are positive. FUNDING: Danish Regions, Ministry of Health and Central Denmark Region. TRIAL REGISTRATION: not relevant.

Coronary computed tomography angiography and calcium scoring in routine clinical practice for identification of patients who require revascularization.

BACKGROUND: The predictive value of CCTA to predict coronary artery disease is high in particular in the absence of coronary calcification. However, the consideration of both CCTA and the calcium score, in addition to the risk factors to determine the indication for coronary revascularization, has not been yet studied. MATERIALS AND METHODS: This study included 2302 patients (mean age: 60±9.8 years, 46% men), without known coronary artery disease (CAD), who underwent 320-row CCTA. Logistic regression, c-statistic and net reclassification improvement (NRI) were used to assess the role of coronary artery calcium score (CACS) in predicting revascularization after CCTA. RESULTS: The revascularization rates were 0.75% in patients with a CACS of 0, and there were no adverse events during the follow-up period. The revascularization rates were 3.3% in patients with a CACS of 1-99, 15.4% in patients with a CACS of 100-399, 25.6% in patients with a CACS of 400-999, and 42.4% in patients with a CACS≥1000. The crude and adjusted odds ratios (95% confidence interval) for revascularization per CACS group category were 2.89 (2.53-2.3) and 2.71 (2.33-3.15), respectively; the area under the ROC curve (AUC) was 0.85 (0.83-0.88). The addition of CACS to conventional risk factors improved the accuracy of risk prediction model for revascularization (AUC 0.74 vs 0.63, P=0.001), but it did not reclassify a substantial proportion of patients with positive CACS to risk categories (NRI=-0.023, P=0.66). CONCLUSIONS: The 320-row CCTA might rule out CAD in low- to intermediate-risk patients. However, its accuracy in identifying patients who require revascularization is limited. The CACS added to the conventional risk factors did not improve the identification of patients who require revascularization.

Single-centre cohort study of gender influence in coronary CT angiography in patients with a low to intermediate pretest probability of coronary heart disease.

BACKGROUND: In 'real-world' patient populations undergoing coronary CT angiography (CCTA), it is unclear whether a correlation exists between gender, coronary artery calcium (CAC) score and subsequent referral for invasive coronary angiography and coronary revascularisation. We therefore investigated the relationship between gender, CAC and use of subsequent invasive coronary angiography and coronary revascularisation in a cohort of patients with chest discomfort and low to intermediate pretest probability of coronary artery disease who underwent a CCTA at our diagnostic centre. METHODS: This is a cohort study that included patients examined between 2010 and 2013. Data were obtained from the Western Denmark Heart Registry. The follow-up ended 11 March 2014. RESULTS: A total of 3541 people (1621 men and 1920 women) were examined by CCTA. The rate of invasive coronary angiography during follow-up was 28.5% in men versus 18.3% in women (p<0.001). The rate of coronary revascularisation during follow-up was 11.4% in men versus 5.1% in women (p<0.001). The CAC-adjusted HR in women versus men was 0.98 (95% CI 0.85 to 1.13) for invasive coronary angiography and 0.73 (95% CI 0.57 to 0.93) for coronary revascularisation. Further adjustment for age and other risk factors did not change these estimates. CONCLUSIONS: Women had a lower CAC score than men and a corresponding lower rate of invasive coronary angiography. The risk of coronary revascularisation was modestly reduced in women, irrespective of CAC. This may reflect a gender-specific difference in coping with chest discomfort, gender-specific referral bias for CCTA, and/or a gender-specific difference in the balance between coronary calcification and obstructive coronary heart disease.