Elements: In this month's issue
Cardiac troponins are considered to be highly sensitive biochemical markers of myocardial cell injury. As a result, they are useful both in terms of diagnosis and prognosis following myocardial infarction (MI). In addition, it has been known for some time that significant elevation of troponins may be observed following percutaneous coronary intervention (PCI). The meta-analysis by Testa and colleagues in this month's issue of QJM attempts to address two particular questions: what is the significance of elevated troponin levels that are associated with PCI-related MI and what is the long term impact of this association? The authors used the new definition of PCI-related MI which refers to patients who have normal baseline levels of troponin but who demonstrate a post-procedural rise that is three times the 99th percentile of the upper reference limit. They looked at 15 studies which included over 7000 patients. While troponin was raised in just under 30% of PCI patients, the incidence of PCI-related MI was nearly 15%. An increased risk of major adverse cardiac events was associated with raised troponin levels during hospital stay and also at 18 months later. As a result, the authors conclude that the new definition of PCI-MI readily identifies a population of patients who are at high risk of future adverse cardiac events. There are obvious clinical implications of this finding. Risk of adverse events should be discussed in the consent process for PCI and the implications of significant elevation of troponin should be communicated effectively to patients where appropriate.Two papers consider various aspects of the management of chronic renal failure from a primary-secondary care interface perspective. The rate of progression of early chronic kidney disease (CKD) may be slowed if identified and treated early. Previous studies would indicate that CKD was not always identified early enough in primary care. Estimated glomerular filtration rate (eGFR) is considered by some (but not by all) to represent a more sensitive identifier of early CKD than serum creatinine concentration alone. Hence, taking both of these observations into account, it would seem appropriate that some of the responsibility for early identification of CKD should be undertaken by primary care using eGFR as an index. In the UK, a new contract for General Practice, the General Medical Services (GMS) Contract, was introduced some years ago. The contract determines that a significant proportion of practice income is derived from performance against targets in a new Quality and Outcomes Framework (QOF). QOF requires general practitioners (GPs) to maintain a register of patients with CKD with eGFRs below 60 ml/min/1.73 m2 for reporting purposes. The study by Phillips from Wales observed that this standard resulted in a significant increase in referrals by GPs to secondary care renal services; however a high proportion of referrals were found to be either inappropriate or inadequate in detail. In order to address this challenge, a web based renal care pathway resource was developed and implemented in a number of practices. This provided clear guidance for GPs on referral criteria along with minimal clinical data required to prioritise out patient appointments. Furthermore, the pathway provided educational support for GPs with clear guidelines on future monitoring and re-referral criteria. The authors claim encouraging success with this approach with reduction in inappropriate referrals and improvement in discharge of patients into the community in those practices where the resource was implemented. Could this joined-up model of working between primary and secondary care be applied to the management of other chronic diseases?
The second paper on this broad theme (this time from Scotland) raises the question: is it safe for patients with stable early CKD, who were previously followed in nephrology clinics, to be discharged back to primary care? Steevens et al examined the case notes of 160 CKD patients who were treated at a peripheral nephrology clinic and subsequently discharged for monitoring in primary care. The results were reassuring in that the patients studied were, by and large, well monitored in the context of primary care and that the majority of re-referrals to the nephrology clinic were appropriate.
The accompanying commentary by O’Callaghan discusses the subject of CKD from a population perspective and should be read in conjunction with both of the previously mentioned papers. The problems associated with precise quantification of renal function and the interpretations of eGFR are considered.
Community acquired pneumonia (CAP) continues to represent a leading cause of mortality, even in developed countries. Early assessment of CAP severity will help to inform the most appropriate treatment decisions. Unsurprisingly, there are numerous CAP severity assessment aids available to the admitting physician. These include: pneumonia-specific treatment decision support systems, generic sepsis scores and predictive biomarkers. However, there is no uniform agreement about the optimum severity assessment tool (or combination of tools) to use in this clinical context. The review article by Singanayagam and colleagues is a useful critique of the subject. They consider the advantages and limitations of the currently available clinical prediction rules for CAP and discuss the present and future role of biomarkers in its treatment. They conclude that CRB65 is the most useful clinical score currently available because its inherent simplicity enhances its acceptance for general use.
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