Magnesium sulphate in the treatment of acute asthma: evaluation of current practice in adult emergency departments

Background: A recent meta-analysis showed that intravenous and nebulised magnesium sulphate have similar levels of evidence to support their use in the treatment of acute asthma in adults. This consisted of weak evidence of effect on respiratory function and hospital admissions, with wide confidence intervals ranging from no effect to significant positive effects. Current BTS/SIGN guidelines suggest an equivocal role for intravenous magnesium sulphate and no role for nebulised magnesium sulphate. A study was performed to assess what emergency physicians currently do in their management of acute asthma. Method: A postal survey was undertaken of all adult emergency departments within the UK. A structured question naire was sent to all clinical leads in emergency medicine about their current usage of both intravenous and nebulised magnesium sulphate in the treatment of acute asthma. Results: 180 of the 251 emergency departments in the UK responded (72%). Magnesium sulphate was used in 93%, mostly because it was expected to relieve breathlessness (70%) or reduce HDU/ITU admissions (51%). It was predominantly given to those patients with acute severe asthma (84%) and life-threatening exacerbations (87%), with most stating they would give the drug if there was no response to repeated nebulisers (68%). In comparison, nebulised magnesium sulphate was only used in two emergency departments (1%). The main reason for not administering the drug via a nebuliser was insufficient evidence (51%). Conclusions: Intravenous magnesium sulphate is widely used for acute asthma, usually for patients with severe or life-threatening asthma who have not responded to initial treatment. Nebulised magnesium sulphate, by contrast, is hardly used at all. The use of intravenous magnesium sulphate is more extensive than current guidelines or available evidence would appear to support

A randomised controlled trial to measure the effect of chest pain unit care upon anxiety, depression, and health-related quality of life [ISRCTN85078221]

Background The chest pain unit (CPU) has been developed to provide a rapid and accurate diagnostic assessment for patients attending hospital with acute, undifferentiated chest pain. We aimed to measure the effect of CPU assessment upon psychological symptoms and health-related quality of life. Methods We undertook a single-centre, cluster-randomised controlled trial. Days (N = 442) were randomised in equal numbers to CPU or routine care. Patients with acute chest pain, undiagnosed by clinical assessment, ECG and chest radiograph, were recruited and followed up with self-completed questionnaires (SF-36 and HADS) at two days and one month after hospital attendance. Results Patients receiving CPU assessment had significantly higher scores on the physical functioning (difference 5.1 points; 95% CI 1.1 to 9.0), vitality (4.6; 1.3 to 8.0), and general health (5.7; 2.3 to 9.2) dimensions of the SF-36 at two days, and significantly higher scores on all except the emotional role dimension at one month. They also had significantly lower depression scores on the HADS depression scale at two days (0.93; 0.34 to 1.51) and one month (1.0; 0.36 to 1.66). However, initially lower anxiety scores at two days (0.89; 0.21 to 1.56) were not maintained at one month (0.48; -0.26 to 1.23). CPU assessment was associated with reduced prevalence (OR 0.71; 95% CI 0.52 to 0.97) and severity (6.5 mm on 100 m visual analogue scale; 95% CI 2.2 to 10.8) of chest pain at one month, but no significant difference in the proportion of patients taking time off work (OR 0.82; 95% CI 0.54 to 1.04). Conclusion CPU assessment is associated with improvements in nearly all dimensions of quality of life and with reduced symptoms of depression

Disease and psychological status in ankylosing spondylitis.

Objectives. Psychological factors may be important in the assessment and management of ankylosing spondylitis (AS). Our primary objective was to describe associations between disease and psychological status in AS, using AS-specific assessment tools and questionnaires. Our secondary objectives were to identify patient subgroups based on such associations and to determine the stability of the measures over time. Methods. A total of 110 patients were assessed at 6-monthly intervals up to four times using tools to measure disease [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and the Bath Ankylosing Spondylitis Metrology Index (BASMI)], psychological [Hospital Anxiety and Depression Questionnaire (HADS), Health Locus of Control—Form C Questionnaire (HLC-C)] and generic health [Short form (SF)-36] status. Results. Eighty-nine participants completed all four assessments. Throughout the study, BASDAI, BASFI and BASMI scores correlated significantly with anxiety, depression, internality and health status, but not with levels of belief in chance or powerful others. Clinically anxious or depressed subgroups had significantly worse BASDAI and BASFI, but not BASMI, scores. BASMI scores were the least closely linked to psychological status. Mean scores for disease, psychological and health status were clinically stable over the 18 months period. Conclusions. Disease status scores in AS correlated significantly with anxiety, depression, internality and health status. Interpretation of AS disease scores should take an account of psychological status and the choice of measures used. These findings have important potential applications in AS management and monitoring, including the identification of patients for biological therapies

Which diagnostic tests are most useful in a chest pain unit protocol?

Background The chest pain unit (CPU) provides rapid diagnostic assessment for patients with acute, undifferentiated chest pain, using a combination of electrocardiographic (ECG) recording, biochemical markers and provocative cardiac testing. We aimed to identify which elements of a CPU protocol were most diagnostically and prognostically useful. Methods The Northern General Hospital CPU uses 2–6 hours of serial ECG / ST segment monitoring, CK-MB(mass) on arrival and at least two hours later, troponin T at least six hours after worst pain and exercise treadmill testing. Data were prospectively collected over an eighteen-month period from patients managed on the CPU. Patients discharged after CPU assessment were invited to attend a follow-up appointment 72 hours later for ECG and troponin T measurement. Hospital records of all patients were reviewed to identify adverse cardiac events over the subsequent six months. Diagnostic accuracy of each test was estimated by calculating sensitivity and specificity for: 1) acute coronary syndrome (ACS) with clinical myocardial infarction and 2) ACS with myocyte necrosis. Prognostic value was estimated by calculating the relative risk of an adverse cardiac event following a positive result. Results Of the 706 patients, 30 (4.2%) were diagnosed as ACS with myocardial infarction, 30 (4.2%) as ACS with myocyte necrosis, and 32 (4.5%) suffered an adverse cardiac event. Sensitivities for ACS with myocardial infarction and myocyte necrosis respectively were: serial ECG / ST segment monitoring 33% and 23%; CK-MB(mass) 96% and 63%; troponin T (using 0.03 ng/ml threshold) 96% and 90%. The only test that added useful prognostic information was exercise treadmill testing (relative risk 6 for cardiac death, non-fatal myocardial infarction or arrhythmia over six months). Conclusion Serial ECG / ST monitoring, as used in our protocol, adds little diagnostic or prognostic value in patients with a normal or non-diagnostic initial ECG. CK-MB(mass) can rule out ACS with clinical myocardial infarction but not myocyte necrosis(defined as a troponin elevation without myocardial infarction). Using a low threshold for positivity for troponin T improves sensitivity of this test for myocardial infarction and myocardial necrosis. Exercise treadmill testing predicts subsequent adverse cardiac events

EDITORIAL Water, water, every where, but rarely any drop to drink

I would like to give all readers a very warm welcome to 2014 and the first issue of the tenth volume of Metabolomics. As you may be able to work out: the front cover is a celebration of this achievement, and I thank my colleague Dr Steve O’Hagan for his artistry. I am delighted that the journal is in such good shape and this is due to the excellent papers that are submitted and published, and of course the very valuable reviewing that many of you do. Metabolomics has an excellent Editorial board and I am also very grateful to them for their valuable support. You may be pondering over the title, so let me explain. Whilst I have somewhat moderated the quote from ‘‘The Rime of the Ancient Mariner’ ’ by Samuel Taylor Coleridge written in 1797–1798, the water does not refer to any liquid substance per se, nor does the drinking to the ‘dryathlon 1 ’ that I did early last year and will be doing so again to combat any Christmas excesses. Rather the water is an analogy to data—both metabolomics and metadata. Water here is a very apt comparison, as it seems rather ironic that a typical metabolomics experiments generates so much data that it is often referred to in terms of natural disasters—like data floods, data torrents or even data tsunamis. Yet even more ironic that very rarely do we make publicly available the metabolomics data (raw or processed) and the associated metadata with our publications. These metadata are as important as the metabolite data as these refer to the data about the data. We mainly think of these in terms of the important traits or features that we may want to predict, but these also refer to our experimental protocols that ar