Excess of mortality in patients with chest pain peaks in the first 3 days period after the incident and normalizes after 1 month.

BACKGROUND: patients presenting with chest pain have a 5% chance of experiencing a coronary event. These patients are at risk of mortality and should be recognized and referred to secondary care. Aim. To determine the relationship between referral type and mortality in patients with chest pain. METHODS: the design of the study is an observational study. The setting of the study is a sentinel network of general practices in Belgium, covering 1.6% of the total population. The subjects are 1558 consecutive patients consulting with chest pain in 2003. Descriptive analyses report the standardized mortality ratios. We used the Belgian population of 1999 as the reference population and as the standard population. RESULTS: the standardized mortality ratios of 3 days were 151.0 [95% confidence interval (CI): 82.3-250.3] for the urgent referred group, 45.5 (95% CI: 12.4-116.0) for non-urgent and 13.6 (95% CI: 1.7-49.4) for the non-referred group. The standardized ratios of 1 month were, respectively, 27.6 (95% CI: 18.0-40.4), 6.7 (95% CI: 2.5-14.6) and 4.7 (95% CI: 1.9-9.7). The standardized ratios of 2-12 months were normal for the urgent referral group (1.3; 95% CI: 0.7-2.2) and for the non-urgent referral group (1.0; 95% CI: 0.5-1.9) and even less in the non-referred group (0.4; 95% CI: 0.2-0.9). CONCLUSIONS: mortality in the first 3 days and first month after consulting for chest pain is very high. There is a marked trend in mortality according to the referral type-urgently referred, non-urgently referred and not referred-suggesting risk stratification by the GP. After 1 month, mortality normalizes for all groups, suggesting that the surviving patients are well treated and the condition causing the chest pain no longer influences survival compared to the general population.

GPs' reasons for referral of patients with chest pain: a qualitative study.

BACKGROUND: Prompt diagnosis of an acute coronary syndrome is very important and urgent referral to a hospital is imperative because fast treatment can be life-saving and increase the patient's life expectancy and quality of life. The aim of our study was to identify GPs' reasons for referring or not referring patients presenting with chest pain. METHODS: In a semi-structured interview, 21 GPs were asked to describe why they do or do not refer a patient presenting with chest pain. Interviews were taped, transcribed and qualitatively analysed. RESULTS: Histories of 21 patients were studied. Six were not referred, seven were referred to a cardiologist and eight to the emergency department. GPs' reasons for referral were background knowledge about the patient, patient's age and cost-benefit estimation, the perception of a negative attitude from the medical rescue team, recent patient contact with a cardiologist without detection of a coronary disease and the actual presentation of signs and symptoms, gut feeling, clinical examination and ECG results. CONCLUSION: This study suggests that GPs believe they do not exclusively use the 'classical' signs and symptoms in their decision-making process for patients presenting with chest pain. Background knowledge about the patient, GPs' personal ideas and gut feeling are also important.

Why does the general practitioner refer patients with chest pain not-urgently to the specialist or urgently to the emergency department? Influence of the certainty of the initial diagnosis.

BACKGROUND: Chest pain is an initial symptom for several minor diseases but acute myocardial infarction (AMI) should not be missed. AIM: To assess the influence of initial diagnosis and degree of certainty of this initial diagnosis on the referral decision and the referral method (urgent-non-urgent) in patients contacting their GP with chest pain. STUDY DESIGN: Observational study. SETTING: The study was performed in a sentinel network of general practices in Belgium, covering almost 1.6% of the population. SUBJECTS: All patients attending their GP and complaining of chest pain during 2003. METHOD: The relationships were reported as proportions and in odds ratios (OR) with their 95% confidence intervals. RESULTS: 1996 patients were included (men 52%). Men were referred more often (OR = 1.44; 95% CI: 1.13-1.82). Age shows no relation to referral (OR = 1.06; 95% CI: 0.83-1.35) but predicts urgent referral (OR = 1.46; 95% CI: 1.02-2.08). Odds ratios in case of serious heart disease were high with 11.58 (95% CI: 5.72-23.44) when the GP was certain of his diagnosis and 2.96 (95% CI: 1.59-5.51) if not. If the GP was uncertain, in all disease categories 54% (95% CI: 48-59) of the patients were referred non-urgently. CONCLUSION: Referral rates for patients with chest pain were influenced by the initial diagnosis and the degree of certainty of this initial diagnosis.

Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis.

BACKGROUND: Prompt diagnosis of acute myocardial infarction or acute coronary syndrome is very important. AIM: A systematic review was conducted to determine the accuracy of 10 important signs and symptoms in selected and non-selected patients. DESIGN OF STUDY: Diagnostic meta-analysis. METHOD: Using MEDLINE, CINAHL, EMBASE, tracing references, and by contacting experts, studies were sought out that described one of the 10 signs and symptoms on one or both conditions. Studies were excluded if they were not based on original data. Validity was assessed using QUADAS and all data were pooled using a random effects model. RESULTS: Sixteen of the 28 included studies were about patients who were non-selected. In this group, absence of chest-wall tenderness on palpation had a pooled sensitivity of 92% (95% confidence interval [CI] = 86 to 96) for acute myocardial infarction and 94% (95% CI = 91 to 96) for acute coronary syndrome. Oppressive pain followed with a pooled sensitivity of 60% (95% CI = 55 to 66) for acute myocardial infarction. Sweating had the highest pooled positive likelihood ratio (LR+), namely 2.92 (95% CI = 1.97 to 4.23) for acute myocardial infarction. The other pooled LR+ fluctuated between 1.05 and 1.49. Negative LRs (LR-) varied between 0.98 and 0.23. Absence of chest-wall tenderness on palpation had a LR- of 0.23 (95% CI = 0.18 to 0.29). CONCLUSIONS: Based on this meta-analysis it was not possible to define an important role for signs and symptoms in the diagnosis of acute myocardial infarction or acute coronary syndrome. Only chest-wall tenderness on palpation largely ruled out acute myocardial infarction or acute coronary syndrome in low-prevalence settings.

Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care.

BACKGROUND: Serious infections in children (sepsis, meningitis, pneumonia, pyelonephritis, osteomyelitis, and cellulitis) are associated with considerable mortality and morbidity. In children with an acute illness, the primary care physician uses signs and symptoms to assess the probability of a serious infection and decide on further management. AIM: To analyse the diagnostic accuracy of signs and symptoms, and to create a multivariable triage instrument. DESIGN OF STUDY: A prospective diagnostic accuracy study. SETTING: Primary care in Belgium. METHOD: Children aged 0-16 years with an acute illness for a maximum of 5 days were included consecutively. Signs and symptoms were recorded and compared to the final outcome of these children (a serious infection for which hospitalisation was necessary). Accuracy was analysed bivariably. Multivariable triage instruments were constructed using classification and regression tree (CART) analysis. RESULTS: A total of 3981 children were included in the study, of which 31 were admitted to hospital with a serious infection (0.78%). Accuracy of signs and symptoms was fairly low. Classical textbook signs (meningeal irritation impaired peripheral circulation) had high specificity. The primary classification tree consisted of five knots and had sensitivity of 96.8% (95% confidence interval [CI] = 83.3 to 99.9), specificity 88.5% (95% CI = 87.5 to 89.5), positive predictive value 6.2% (95% CI = 4.2 to 8.7), and negative predictive value 100.0% (95% CI = 99.8 to 100.0), by which a serious infection can be excluded in children testing negative on the tree. The sign paramount in all trees was the physician's statement 'something is wrong'. CONCLUSION: Some individual signs have high specificity. A serious infection can be excluded based on a limited number of signs and symptoms.

Signs and symptoms in children with a serious infection: a qualitative study.

BACKGROUND: Early diagnosis of serious infections in children is difficult in general practice, as incidence is low, patients present themselves at an early stage of the disease and diagnostic tools are limited to signs and symptoms from observation, clinical history and physical examination. Little is known which signs and symptoms are important in general practice. With this qualitative study, we aimed to identify possible new important diagnostic variables. METHODS: Semi-structured interviews with parents and physicians of children with a serious infection. We investigated all signs and symptoms that were related to or preceded the diagnosis. The analysis was done according to the grounded theory approach. Participants were recruited in general practice and at the hospital. RESULTS: 18 children who were hospitalised because of a serious infection were included. On average, parents and paediatricians were interviewed 3 days after admittance of the child to hospital, general practitioners between 5 and 8 days after the initial contact. The most prominent diagnostic signs in seriously ill children were changed behaviour, crying characteristics and the parents' opinion. Children either behaved drowsy or irritable and cried differently, either moaning or an inconsolable, loud crying. The parents found this illness different from previous illnesses, because of the seriousness or duration of the symptoms, or the occurrence of a critical incident. Classical signs, like high fever, petechiae or abnormalities at auscultation were helpful for the diagnosis when they were present, but not helpful when they were absent. CONCLUSION: behavioural signs and symptoms were very prominent in children with a serious infection. They will be further assessed for diagnostic accuracy in a subsequent, quantitative diagnostic study.

The diagnostic value of macroscopic haematuria for the diagnosis of urological cancer in general practice.

BACKGROUND: The diagnostic value and the impact of some signs and symptoms in most diseases in primary care have only been studied incompletely. AIM: To assess the diagnostic value of macroscopic haematuria for the idagnosis of urological cancer (bladder, kidney) in a general practice setting, as well the influence of age, sex, and some additional signs and symptoms. DESIGN OF STUDY: Diagnostic study. SETTING: The study was performed in a sentinel station network of general practices in Belgium, covering almost 1% of the population. SUBJECTS: All patients attending their general practitioner and complaining of haematuria during 1993 and 1994 were included for the prospective part of the study. Every patient diagnosed with a urological cancer in this period was registered for the retrospective part. METHOD: Mean outcome measures of sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio were used to assess diagnostic value. RESULTS: Within the registration year 1993-1994, patient-doctor encounters, related to 83,890 patient-years, were registered. The positive predictive value (PPV) for urological cancer was 10.3% (95% CI = 7.6% to 13.7%). Sensitivity was 59.5% (95% CI = 50.4% to 60.1%). The PPV of patients aged over 60 years was 22.1% (95% CI = 15.8% to 30.1%) for men and 8.3% (95% CI = 3.4% to 17.9%) for women. In the age group 40 to 59 years, the PPV was 3.6% (95% CI = 0.6% to 13.4%) for men and 6.4% (95% CI = 1.7% to 18.6%) for women. In the prospective part of the study, no urological cancer was found in the age group under 40 years. CONCLUSION: Men older than 60 years of age with macroscopic haematuria have a high positive predictive value for urological cancer. In these patients, a thorough investigation is indicated. In patients over 40 years of age of either sex, referral or watchful waiting can be justified.

Studies on the use of BD Vacutainer® SST II™ and RST™ in general practice: investigation of artefactual hyperkalaemia.

BACKGROUND: Current sampling and transport conditions of samples in general practice can result in pseudohyperkalaemia. This study was undertaken to determine, in a general practice setting, whether there is any difference in haemolysis obtained when using BD Vacutainer® Rapid Serum Tubes (BD RST) compared with using BD Vacutainer® SST™ II Advance Blood Collection Tubes (BD SSTII). METHODS: Blood was collected from 353 patients requiring blood sampling who were attending 31 general practitioner practices in Belgium. For each patient, two BD SSTII tubes and two BD RST tubes were drawn in a randomized order. One of each pair of tubes was inverted five times, the other was not. Serum potassium concentration, serum LDH activity and haemolysis index were measured in each sample. RESULTS: There was no significant difference in measured potassium concentration according to tube type (P = 0.16). Measured LDH activities were 1.7% higher in serum collected into BD SSTII tubes compared to BD RST tubes (P = 0.02). When comparing serum from unmixed BD RST with BD SSTII tubes, there was a slight reduction in the haemolysis index but no significant difference in measured potassium concentration or LDH activity. Risk of hyperkalaemia was 4.8 times higher in serum from tubes that were incompletely filled compared to those that were filled with the correct amount of blood. CONCLUSION: Both types of blood tubes are suitable for the measurement of serum potassium and LDH in patients from general practice. Tube inversion does not improve the accuracy of either serum potassium or LDH measurement. Blood tubes should be filled to the level recommended by the manufacturer to avoid artefactual increases in measured serum potassium concentration and LDH activity.

Half of the patients with chest pain that are urgently referred are transported in unsafe conditions.

BACKGROUND: Patients with an acute coronary syndrome should be referred to hospital urgently to start reperfusion therapy as soon as possible. Owing to the risks of ventricular fibrillation and pulseless ventricular tachycardia, urgent transport should be organized under safe conditions, that is, with a defibrillator at hand. AIM: To evaluate the type of transport of patients with chest pain referred by their general practitioner (GP). DESIGN OF STUDY: Observational study. SETTING: A sentinel network of general practices in Belgium, covering almost 1.6% of the total population. PATIENTS: One thousand nine hundred and ninety-six patients with chest pain attending their GP in 2003. METHOD: Descriptive analyses reporting proportions along with their 95% confidence interval (CI). RESULTS: Male patients were referred to hospital more often than female patients: 44.9% (95% CI: 41.6-47.8) versus 36.5% (95% CI: 33.4-39.6). For patients who were referred routinely, 92.7% (95% CI: 89.1-95.2) were transported by family and neighbours, 4.8% (95% CI: 2.8-7.9) by ambulance and 2.5% (95% CI: 1.2-5.1) by GPs. For patients who were referred urgently, ambulances transported 56.9% (95% CI: 51.1-62.7), family and neighbours 36.9% (95% CI: 31.4-42.7) and the GP 6.1% (95% CI: 3.7-9.5). CONCLUSION: Almost half of the patients with chest pain who require urgent referral are transported in unsafe conditions.