Diagnostic accuracy of cardiothoracic ratio on admission chest radiography to detect left or right ventricular systolic dysfunction: a retrospective study.

OBJECTIVES: To determine the diagnostic accuracy of the cardiothoracic ratio on postero-anterior or antero-posterior chest radiographs in predicting left ventricular or right ventricular dysfunction on echocardiography in an inpatient population. DESIGN: Retrospective study. SETTING: Two secondary care hospitals in the United Kingdom. PARTICIPANTS: Four hundred consecutive inpatient echocardiograms were screened for inclusion along with chest radiographs (both postero-anterior and antero-posterior). The cardiothoracic ratio was calculated from chest radiographs along with quantitative and qualitative measures of left ventricular or right ventricular dysfunction on echocardiography. MAIN OUTCOME MEASURES: Sensitivity and specificity of cardiothoracic ratio across a range of values to detect moderate/severe left ventricular and/or right ventricular dysfunction on echocardiography. RESULTS: Overall, 272 records met inclusion criteria. The prevalence of left ventricular/right ventricular dysfunction on echocardiography was 26% in an inpatient population with high clinical suspicion of cardiac disease referred for echocardiography. Over a range of cardiothoracic ratio values on postero-anterior films, a value of >0.55 yielded the best sensitivity (62.5%) and specificity (76.5%) for diagnosing left ventricular/right ventricular impairment (positive likelihood ratio 2.56), with a positive predictive value of 29.5%. Cardiothoracic ratio on antero-posterior film was not predictive of left ventricular/right ventricular impairment on echocardiography. CONCLUSIONS: In conclusion, in the context of an acute admission, cardiothoracic ratio measured on postero-anterior or antero-posterior films has limited value in detecting moderate left ventricular and/or right ventricular systolic dysfunction. Previously established absolute values may be unreliable by modern standards.

Warfarin-induced purple toe syndrome successfully treated with apixaban.

Purple toe syndrome is a recognised adverse effect of warfarin therapy. The literature has described resolution of the ischaemic symptoms on withdrawal of the warfarin and switching to a low molecular weight heparin alternative. We present a case of an 82-year-old man with bilateral blanching vivacious toes and a livedo-reticularis type rash developing 2 weeks after being loaded with warfarin for first detected atrial fibrillation. Vascular surgical review and haematology thrombotic screen did not yield any other pathology and a diagnosis of purple toe syndrome due to warfarin was carried out. The warfarin was stopped and oral anticoagulation started with an oral factor Xa inhibitor, apixaban with resolution of his symptoms. This is the first case report of one of the novel oral anticoagulants being used to treat purple toe syndrome.

The survival time of chocolates on hospital wards: covert observational study.

OBJECTIVE: To quantify the consumption of chocolates in a hospital ward environment. DESIGN: Multicentre, prospective, covert observational study. SETTING: Four wards at three hospitals (where the authors worked) within the United Kingdom. PARTICIPANTS: Boxes of Quality Street (Nestlé) and Roses (Cadbury) on the ward and anyone eating these chocolates. INTERVENTION: Observers covertly placed two 350 g boxes of Quality Street and Roses chocolates on each ward (eight boxes were used in the study containing a total of 258 individual chocolates). These boxes were kept under continuous covert surveillance, with the time recorded when each chocolate was eaten. MAIN OUTCOME MEASURE: Median survival time of a chocolate. RESULTS: 191 out of 258 (74%) chocolates were observed being eaten. The mean total observation period was 254 minutes (95% confidence interval 179 to 329). The median survival time of a chocolate was 51 minutes (39 to 63). The model of chocolate consumption was non-linear, with an initial rapid rate of consumption that slowed with time. An exponential decay model best fitted these findings (model R(2)=0.844, P<0.001), with a survival half life (time taken for 50% of the chocolates to be eaten) of 99 minutes. The mean time taken to open a box of chocolates from first appearance on the ward was 12 minutes (95% confidence interval 0 to 24). Quality Street chocolates survived longer than Roses chocolates (hazard ratio for survival of Roses v Quality Street 0.70, 95% confidence interval 0.53 to 0.93, P=0.014). The highest percentages of chocolates were consumed by healthcare assistants (28%) and nurses (28%), followed by doctors (15%). CONCLUSIONS: From our observational study, chocolate survival in a hospital ward was relatively short, and was modelled well by an exponential decay model. Roses chocolates were preferentially consumed to Quality Street chocolates in a ward setting. Chocolates were consumed primarily by healthcare assistants and nurses, followed by doctors. Further practical studies are needed.