Achieving better in-hospital and after-hospital care of patients with acute cardiac disease

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after hospital care, patient self-care, and hospital-community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital-community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before-after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and beta-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF. Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, beta-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P=0.06) and from 13.4% to 10.1% (P= 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P= 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

Acute appendagitis: emergency presentation and computed tomographic appearances

Acute epiploic appendagitis is an uncommon cause of abdominal pain. It is caused by torsion of an epiploic appendage or spontaneous venous thrombosis of a draining appendageal vein.1 The diagnosis of this condition primarily relies on cross-sectional imaging and is made most often after computed tomography (CT). Clinically, it is most often mistaken for acute diverticulitis. Approximately 7.1% of patients investigated to exclude sigmoid diverticulitis have imaging findings of primary epiploic appendagitis.

Combined arteriovenous fistula and venous aneurysm following knee arthrodesis

We study a case of a 65-year-old woman who developed popliteal arteriovenous fistula (AVF) and venous aneurysm following left knee arthrodesis. Presenting features included left popliteal and calf pain, a tender pulsatile mass posterior to her left knee, popliteal bruit and a thrill at the popliteal fossa and ankle. Left femoral angiography showed an AVF arising from the right tibioperoneal trunk and an aneurysm at the level of the AVF. Findings at open investigation included AVF between the tibioperoneal trunk and the popliteal vein, and a venous aneurysm arising from the popliteal vein opposite the neck of the arteriovenous communication. The aneurysm and fistula were repaired using prolene suture.

Translation and validation of the Chinese version of the Charing Cross Venous Ulcer Questionnaire

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