Aim: To establish the prevalence of bone protective therapy use in postmenopausal women with a history of low trauma fracture

Design and Methods: Clinical audit of 1641 postmenopausal women presenting with a low trauma fracture to the Fracture Liaison Service at Addenbrooke's Hospital, Cambridge between January 2006 and December 2007.

Results: A total of 526 (31%) women presenting with a fracture had a past history of fracture, defined as a low trauma fracture after the age of 45 years. The wrist was the most common site of previous fracture, followed by hip, hand or foot, lower leg and humerus. Of these women, only 27.6% were receiving bone protective therapy with a bisphosphonate (89%) or other medication. Calcium and vitamin D supplements were received by 35.6%. The highest rates of treatment were seen for spine and hip fracture (61.9 and 49.3%, respectively). Only 45.1% of women aged 75 years and over with a previous history of fracture were receiving bone protective therapy.

Conclusions: The results of our audit demonstrate low rates of treatment in postmenopausal women with a history of low trauma fracture. Better education of healthcare professionals, more consistent recording of fractures in primary care and the use of clearly defined care pathways that involve patients and their carers provide rational approaches to reducing this care gap.

Design: Analysis of all emergency medical patients admitted to St James's Hospital (SJH), Dublin, between 1 January 2002 and 31 December 2007. Validation using a dataset of acute medical admissions from Nenagh Hospital 2000–04.

Methods: Using routinely collected vital signs and laboratory findings, a composite 5-day in-hospital mortality risk score, designated medical admissions risk system (MARS), was developed using an iterative approach involving logistic regression and multivariable fractional polynomials. Results are presented as area under receiver operating characteristics curves (AUROC) as well as Hosmer and Lemeshow goodness-of-fit statistics.

Results: A total of 10 712 and 3597 unique patients were admitted to SJH and Nenagh Hospital, respectively. The final score included nine variables [age, heart rate, mean arterial pressure, respiratory rate, temperature, urea, potassium (K), haematocrit and white cell count]. The AUROC for 5-day in-hospital mortality was 0.93 [95% confidence interval (CI) 0.92–0.94] for the SJH cohort (Hosmer and Lemeshow test, P = 0.32) and 0.92 (95% CI 0.90–0.94) for the external Nenagh hospital validation cohort (Hosmer and Lemeshow test, P = 0.28).

Conclusions: In-hospital mortality estimation using only routinely collected emergency department admission data is possible in unselected acute medical patients using the MARS system. Such a score applied to acute medical patients at the time of admission, could assist senior clinical decision makers in promptly and accurately focusing limited clinical resources. Further studies validating the impact of this model on clinical outcomes are warranted.

Aim: The aim of this study was to analyse differences in stroke subtype and risk factor profile between South Asian and White stroke patients admitted to a central London teaching hospital.

Design: Prospective database of all admissions to the St Mary's Hospital stroke unit.

Methods: We examined ethnicity, stroke subtype and risk factor profile of consecutive patients admitted to the stroke unit between 8 October 2003 and 14 February 2007.

Results: A total of 811 patients were identified of whom 736 had strokes. Four hundred and ninety-six (67%) occurred in the White subgroup, and 72 (10%) in the Asian subgroup. The South Asian subgroup was significantly younger (65 vs. 73 years in the White subgroup; P < 0.001). They had higher rates of hypertension (age adjusted frequency 87% vs. 64%; P < 0.0001), diabetes (54% vs. 15%; P < 0.0001), and hyperlipidaemia (70% vs. 45%; P = 0.001). There were lower rates of smoking (15% vs. 33%; P < 0.0001).There was a trend towards more lacunar infarcts and less total anterior circulation infarcts in South Asians, although after age adjustment this was not significant at the 5% level.

Conclusions: The South Asian subgroup has shown important differences in risk factor profile compared with the White population. The higher frequency of hypertension, diabetes and hyperlipidaemia seen in this subgroup are an important consideration in designing secondary prevention programmes tailored specifically to this community.

Aim: To test the relative performance of a computerized name recognition algorithm (SANGRA) in identifying South Asian names using the UKRR database.

Design: Cross-sectional study of patients (n = 27 832) starting RRT in 50 renal centres in England and Wales from 1997 to 2005.

Methods: Kappa statistics were used to assess the degree of agreement of SANGRA coding with existing ethnicity information in UKRR centres.

Results: In 12 centres outside London (number of patients = 7555) with 11% (n = 747) self-ascribed South Asian ethnicity, the level of agreement between SANGRA and self-ascribed ethnicity was high (=0.91, 95% CI 0.90–0.93). In two London centres (n = 779) with 21% (n = 165) self-ascribed South Asian ethnicity, SANGRA's agreement with self-ascribed ethnicity was lower (=0.60, 95% CI 0.54–0.67), primarily due to difficulties in distinguishing between South Asian ethnicity and other non-White ethnic minorities. Use of SANGRA increased numbers defined as South Asian from 1650 to 2076 with no overall change in percentage of South Asians. Kappa values showed no obvious association with degree of missing data returns to the UKRR.

Conclusion: SANGRA's use, taking into account its lower validity in London, allows increased power and generalizability for both ethnic specific analyses and for analyses where adjustment for ethnic origin is important.

Aims: (i) To assess the extent to which preventive medical drugs are prescribed in patients with CHD and to examine the reasons for drug omissions and (ii) to assess the relative use of branded and generic drugs and the reasons for drug selection.

Methods: The medication charts and hospital notes of consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) at a large cardiothoracic centre were reviewed over a 3-month period. Interviews with patients, attending cardiologists and general practitioners were undertaken to establish why drugs were and were not prescribed.

Results: Among 1008 patients (755 who had PCI and 253 who had CABG) the use of aspirin, statins, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), beta blockers and calcium channel blockers were, respectively, 97, 98, 81, 76 and 18%. The combination of any 4 classes of drug were used in 65% of patients. Almost all patients who did not receive aspirin or a statin had clinical contraindications and were on alternative drugs. In about 12% of patients without an ACE inhibitor (or ARB) and 7% of patients without a beta blocker, no reason to withhold such treatment was identified. Branded drugs were used in 52% of patients; the most commonly prescribed being atorvastatin in 33%. Clinical reasons for using branded rather than generic drugs were identified in 13% of cases.

Conclusion: Our results show a high rate of use of secondary preventive cardiac medications in patients undergoing coronary revascularization procedures, but the use of ACE inhibitors or beta blockers is still overlooked in about 1 in 10 patients. Branded drugs are prescribed in about half of all patients undergoing PCI and CABG, but in almost 90% of cases, a generic equivalent could have been used to achieve similar risk reduction. If our results reflect wider practice, an estimated £11 million a year would be saved by the National Health Service by switching to generic alternative drugs.

Aim and design: We performed a retrospective observational study to examine this and the predictive value of RIFLE stage on patient outcome in this setting.

Methods: We included all patients who were treated with gentamicin at our centre over a 1-month period. Data on 228 patients across all specialities were collected by manual searching of hospital notes and electronic pathology reporting systems. Information collected included baseline and peak serum creatinine results, gentamicin dose and serum levels, the presence of additional renal insults and the Stoke co-morbidity index.

Results: AKI occurred in 51 (24.4%) patients; 37 (17.7%) ‘Risk’, 9 (4.3%) ‘Injury’, 5 (2.4%) ‘Failure’. Independent predictors of gentamicin associated AKI were number of gentamicin levels >2 mg/l (OR 1.845, 95% CI 1.22 to 2.79) and higher baseline serum creatinine (OR 1.014, 95% CI 1.001–1.028). There was a greatly increased risk of in-hospital mortality in the AKI group as compared to those without AKI (45.1% vs. 19.1%, OR 3.48, 95% CI 1.8–6.9, P = 0.0004). Risk of in hospital mortality increased with each RIFLE stage (P < 0.0001).

Conclusions: This study shows that gentamicin-associated AKI remains a common and potentially serious clinical problem. There is a strong correlation between RIFLE class and in-hospital mortality.

Design and Methods: Fifteen electronic databases were searched. People who were research-active in the field were contacted and asked about further published or unpublished work. All studies identified as relevant to the purpose of the review were assessed. Searches were not restricted by publication type or date.

Results: Of 1288 unique references identified, 11 met the eligibility criteria. Studies were excluded where research had been conducted outside the UK; where information on herbal medicine use was not differentiated from that relating to complementary and alternative therapies more broadly, and where neither prevalence of use nor information on user characteristics was included. Prevalence estimates ranged from 3.1 to 24.9%. Most studies did not obtain information specifically on herbal medicines and only one examined the characteristics and motivations of users of herbal medicines as distinct from complementary and alternative therapies in general.

Conclusions: The high degree of heterogeneity of methodology, sample selection and characteristics, and research design resulted in a wide range of estimates of prevalence. Well-designed research is needed to define the evidence base about the herbal medicines taken by people with cancer in the UK, the reasons for use, knowledge about possible effects and potential risks, and where people seek information.

Aim: We report the performance and cost analysis of a newly established EBUS service in a prospective real world cohort of patients to assess the impact of Payment by Results (PbR).

Design: Prospective cohort study.

Methods: Fifty-four patients between June 2008 and April 2009 underwent EBUS for evaluation of unexplained mediastinal lymphadenopathy on CT. Cost analysis was performed from local Trust financial data and 2008–09 tariffs.

Results: EBUS had an 89% sensitivity, 75% negative predictive value and 92% accuracy for malignancy. EBUS coding was inaccurate in 15.6% of cases. The actual cost of an EBUS is £1252–1433 but is coded as a standard bronchoscopy (£561). EBUS reduces health community costs by £107824/year, as a result of a Primary Care Trust cost saving of £113968/year and a Trust cost deficit of £6144/year. Coding inaccuracies further alter the Primary Care Trust costs.

Conclusions: Medical innovation is fundamental to improved patient care. EBUS can potentially reduce morbidity for lung cancer patients and save health community costs. However, with PbR the service provider delivers this at a loss as the tariffs do not reflect innovation and because of coding inaccuracies. We suggest tariffs for innovative procedures need to reflect the true cost.

Aim: To explore the effects of envenoming by Old World tarantulas.

Design and Methods: Clinical studies and review of conventional literature and hobbyist web sites.

Results: Two men bitten on their index fingers by pet Old World tarantula spiders, Lampropelma nigerrimum (Ornithoctoninae) and Pterinochilus murinus (Harpactirinae) in England, developed intense local pain, swelling and episodic, agonising, generalised muscle cramps. In one of them, cramps persisted for 7 days and serum creatine kinase concentration was mildly elevated. A third man bitten on a finger by Poecilotheria regalis (Poecilotheriinae), suffered persistent local cramps in the affected hand. Reports since 1803, including recent ones on hobbyist web-sites, have been largely overlooked. They mentioned muscle spasms after bites by these and other genera of Old World tarantulas, including Eumenophorus, Selenocosmia and Stromatopelma. The severe muscle spasms seen in two of our patients were a challenge to medical treatment and might, under some circumstances, have been life threatening. They demand a toxinological explanation.

Conclusions: Bites by several genera of African, Asian and Australasian tarantulas can cause systemic neurotoxic envenoming. In the absence of available antivenom, severe persistent muscle spasms, reminiscent of latrodectism, pose a serious therapeutic challenge. Discovery of the toxin responsible would be of scientific and potential clinical benefit. Tarantula keepers should be warned of the danger of handling these animals incautiously.