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Routine chest radiographs in admissions to coronary care
several days might be needed for maximum steady-state concentrations of blood nicotine to be reached.2 Experiments are needed to elucidate the mechanism of myasthenia gravis worsening caused by wearing a nicotine patch in myasthenic patients. *Thibault Moreau, Stephane Vandenabeele, Patricia Depierre, Christian Confavreux Service de
1 2
3
Neurologie, Hôpital
de l’Antiquaille, 69005
Lyon, France
Benowitz NL, Jacob PIII. Daily intake of nicotine during cigarette smoking. Clin Pharmacol Ther 1984; 35: 499-504. Kochak GM, Sun JX, Choi RI, et al. Pharmacokinetic disposition of multiple-dose transdermal nicotine in healthy adult smokers. Pharm Res 1992; 9: 1451-55. Russel MAH. Nicotine replacement: the role of blood nicotine levels, their rate of change, and nicotine tolerance. In: Pomerleau OF, Pomerleau CS, eds. Nicotine replacement: a critical evaluation. New York: Alan R Liss, 1988: 63-94.
Routine chest coronary care
radiographs in admissions to
clinical practice, chest radiographs are a investigation for all patients admitted to many coronary care units (CCU).’,2 We assessed the role of routine chest radiographs in the clinical management of 229 consecutive patients admitted to CCU in the hospital. Patients’ age, diagnosis, chest auscultatory findings, duration of stay in CCU, and complications were recorded. If a chest radiograph was done, we noted whether it was commented upon, had any unexpected findings, helped or changed the management plan, and if a further film was done. In acute myocardial infarction (MI), we noted the site, use of thrombolysis and peak creatine kinase. These factors could have influenced the decision to do a chest radiograph. The average age was 61 years (range 17-90), 137 were male. The mean duration of stay was 2-78 days (range 1-9); 44-7% had MI, 13-1% had unstable angina, 14-2% had arrhythmia, 5-3% had pulmonary oedema, 3-1% were postcardiopulmonary arrest, and 1-3% had problems with permanent pacemakers. The rest were admitted to CCU for diverse reasons, the commonest being "chest pain to exclude myocardial ischaemia". There were abnormal chest auscultatory findings in 38%, most had basal crepitations. A chest radiograph was done in 149 patients (65-1%) on admission. Each patient was more likely than not to have a chest radiograph done, regardless of the possible diagnosis (p=0003). There were comments in the case notes on 94 of the 149 films (63-1%). The radiograph helped in the management of only 9 patients; it prompted further investigation, drainage of pleural effusions, and antibiotic therapy. It changed the planned action in 3 patients. It prompted fluoroscopic screening of a prosthetic mitral valve in a patient with ventricular fibrillation whose chest film showed severe pulmonary oedema. There were basal effusions in 2 patients which had not been noted on clinical examination. 10 patients had further chest radiographs done as follow-up, or to check the position of central venous lines. There were no complications in 69-5% of the patients. The remainder required other interventions such as central venous catheterisation or temporary pacemakers (20-2%), had arrhythmia or pericarditis (5-4%), or died (4-9%). The outcome was not influenced by the performance of a chest
SiR-In routine
current
radiograph (p=0-17). In a prospective study3 in 284 paediatric patients, the routine chest radiograph led to a change in policy in 7-7% and was helpful in establishing the diagnosis in only 3-8%. 62
The conclusion was the chest film is of little help in the cardiological evaluation of children, and its only justification was for the purposes of documentation. In an audit of preoperative chest radiographs’ it was found that 75% had not been reviewed by clinicians. The subsequent use of strict guidelines led to a fall in the rate of such requests from 24% to 7%. Based on the results of our survey, we suggest that chest radiographs may not be necessary as a routine investigation for patients admitted to CCU. They should be done only to fulfil specific clinical needs. We intend to alter our clinical practice accordingly, and we recommend that others do the same. *Dzifa Wosornu, M Pitt, J M Beattie, R G
Murray
Department of Cardiology, Birmingham Heartlands Hospital NHS Trust, Birmingham B9 5SS, UK
Murray RG, Beattie JM, Lowry PJ, Schofield T. Administrative policy of the coronary care unit, Birmingham Heartlands Hospital NHS Trust, 1994. 2 Rhoden WE. Cardiac care unit guidelines. Wynthenshawe Hospital, Manchester, UK. 3 Temmerman AM, Mooyaart EL, Taverne PP. The value of the routine chest roentgenogram in the cardiological evaluation of infants and children: a prospective study. Eur J Pediatr 1991; 150: 623-26. 4 Walker D, Williams P, Tawn J. Audit of requests for preoperative chest radiography. BMJ 1994; 309: 772-73. 1
Use of thiacetazone SiR-We welcome the contribution made by Okwera and colleagues (Nov 12, p 1323) to the now overwhelming evidence about the dangers of thiacetazone use in areas with high rates of HIV infection in tuberculosis patients. Although thiacetazone is inexpensive, it has hidden costs that should be taken into account when deciding whether it should still be used. Okwera and co-workers speculate that RHZ regimens (isoniazid, rifampicin, and pyrazinamide initially, followed by isoniazid and rifampicin) might be more cost-effective in populations with high HIV seroprevalence. Our findings from a district hospital in Zambia confirm that this is so.’ We have gone on to analyse the costs of a policy of testing for HIV in all patients with tuberculosis before giving treatment, as suggested by Nunn et al .2 We compared the costs of two regimens for initial phasenamely, STH (streptomycin, isoniazid, and thiacetazone, then isoniazid and thiacetazone) and RHZ and examined the costs of implementing a policy of HIV testing. The drug costs of RHZ for all patients would be L890 per 100 patients. If HIV testing were introduced, the costs of testing per 100 patients (with one ELISA test at 1.50) would be L200. This figure includes a nominal CO.50 to cover the costs of pre-test and post-test counselling. In our patient sample, and elsewhere in Zambia, rates of HIV seroprevalence among tuberculosis patients are about 70%, so after testing, 70% of patients would require RHZ and 30% could be given STH. The drug costs would be £ 694 GC71 for STH and L623 for RHZ), and thus the overall costs of carrying out HIV testing and counselling would be 894. We therefore conclude that at HIV seroprevalence rates of about 70% there are no savings to be made by introducing HIV testing of tuberculosis patients. Such a policy would raise other issues-namely its acceptability to patients and the possibility that coercive measures would be needed to force reluctant patients to accept an HIV test; the impact on case detection; the identification and resulting stigmatisation of HIV-positive patients; the availability of counsellors; the additional
1 2
3
Neurologie, Hôpital
de l’Antiquaille, 69005
Lyon, France
Benowitz NL, Jacob PIII. Daily intake of nicotine during cigarette smoking. Clin Pharmacol Ther 1984; 35: 499-504. Kochak GM, Sun JX, Choi RI, et al. Pharmacokinetic disposition of multiple-dose transdermal nicotine in healthy adult smokers. Pharm Res 1992; 9: 1451-55. Russel MAH. Nicotine replacement: the role of blood nicotine levels, their rate of change, and nicotine tolerance. In: Pomerleau OF, Pomerleau CS, eds. Nicotine replacement: a critical evaluation. New York: Alan R Liss, 1988: 63-94.
Routine chest coronary care
radiographs in admissions to
clinical practice, chest radiographs are a investigation for all patients admitted to many coronary care units (CCU).’,2 We assessed the role of routine chest radiographs in the clinical management of 229 consecutive patients admitted to CCU in the hospital. Patients’ age, diagnosis, chest auscultatory findings, duration of stay in CCU, and complications were recorded. If a chest radiograph was done, we noted whether it was commented upon, had any unexpected findings, helped or changed the management plan, and if a further film was done. In acute myocardial infarction (MI), we noted the site, use of thrombolysis and peak creatine kinase. These factors could have influenced the decision to do a chest radiograph. The average age was 61 years (range 17-90), 137 were male. The mean duration of stay was 2-78 days (range 1-9); 44-7% had MI, 13-1% had unstable angina, 14-2% had arrhythmia, 5-3% had pulmonary oedema, 3-1% were postcardiopulmonary arrest, and 1-3% had problems with permanent pacemakers. The rest were admitted to CCU for diverse reasons, the commonest being "chest pain to exclude myocardial ischaemia". There were abnormal chest auscultatory findings in 38%, most had basal crepitations. A chest radiograph was done in 149 patients (65-1%) on admission. Each patient was more likely than not to have a chest radiograph done, regardless of the possible diagnosis (p=0003). There were comments in the case notes on 94 of the 149 films (63-1%). The radiograph helped in the management of only 9 patients; it prompted further investigation, drainage of pleural effusions, and antibiotic therapy. It changed the planned action in 3 patients. It prompted fluoroscopic screening of a prosthetic mitral valve in a patient with ventricular fibrillation whose chest film showed severe pulmonary oedema. There were basal effusions in 2 patients which had not been noted on clinical examination. 10 patients had further chest radiographs done as follow-up, or to check the position of central venous lines. There were no complications in 69-5% of the patients. The remainder required other interventions such as central venous catheterisation or temporary pacemakers (20-2%), had arrhythmia or pericarditis (5-4%), or died (4-9%). The outcome was not influenced by the performance of a chest
SiR-In routine
current
radiograph (p=0-17). In a prospective study3 in 284 paediatric patients, the routine chest radiograph led to a change in policy in 7-7% and was helpful in establishing the diagnosis in only 3-8%. 62
The conclusion was the chest film is of little help in the cardiological evaluation of children, and its only justification was for the purposes of documentation. In an audit of preoperative chest radiographs’ it was found that 75% had not been reviewed by clinicians. The subsequent use of strict guidelines led to a fall in the rate of such requests from 24% to 7%. Based on the results of our survey, we suggest that chest radiographs may not be necessary as a routine investigation for patients admitted to CCU. They should be done only to fulfil specific clinical needs. We intend to alter our clinical practice accordingly, and we recommend that others do the same. *Dzifa Wosornu, M Pitt, J M Beattie, R G
Murray
Department of Cardiology, Birmingham Heartlands Hospital NHS Trust, Birmingham B9 5SS, UK
Murray RG, Beattie JM, Lowry PJ, Schofield T. Administrative policy of the coronary care unit, Birmingham Heartlands Hospital NHS Trust, 1994. 2 Rhoden WE. Cardiac care unit guidelines. Wynthenshawe Hospital, Manchester, UK. 3 Temmerman AM, Mooyaart EL, Taverne PP. The value of the routine chest roentgenogram in the cardiological evaluation of infants and children: a prospective study. Eur J Pediatr 1991; 150: 623-26. 4 Walker D, Williams P, Tawn J. Audit of requests for preoperative chest radiography. BMJ 1994; 309: 772-73. 1
Use of thiacetazone SiR-We welcome the contribution made by Okwera and colleagues (Nov 12, p 1323) to the now overwhelming evidence about the dangers of thiacetazone use in areas with high rates of HIV infection in tuberculosis patients. Although thiacetazone is inexpensive, it has hidden costs that should be taken into account when deciding whether it should still be used. Okwera and co-workers speculate that RHZ regimens (isoniazid, rifampicin, and pyrazinamide initially, followed by isoniazid and rifampicin) might be more cost-effective in populations with high HIV seroprevalence. Our findings from a district hospital in Zambia confirm that this is so.’ We have gone on to analyse the costs of a policy of testing for HIV in all patients with tuberculosis before giving treatment, as suggested by Nunn et al .2 We compared the costs of two regimens for initial phasenamely, STH (streptomycin, isoniazid, and thiacetazone, then isoniazid and thiacetazone) and RHZ and examined the costs of implementing a policy of HIV testing. The drug costs of RHZ for all patients would be L890 per 100 patients. If HIV testing were introduced, the costs of testing per 100 patients (with one ELISA test at 1.50) would be L200. This figure includes a nominal CO.50 to cover the costs of pre-test and post-test counselling. In our patient sample, and elsewhere in Zambia, rates of HIV seroprevalence among tuberculosis patients are about 70%, so after testing, 70% of patients would require RHZ and 30% could be given STH. The drug costs would be £ 694 GC71 for STH and L623 for RHZ), and thus the overall costs of carrying out HIV testing and counselling would be 894. We therefore conclude that at HIV seroprevalence rates of about 70% there are no savings to be made by introducing HIV testing of tuberculosis patients. Such a policy would raise other issues-namely its acceptability to patients and the possibility that coercive measures would be needed to force reluctant patients to accept an HIV test; the impact on case detection; the identification and resulting stigmatisation of HIV-positive patients; the availability of counsellors; the additional