Long term clinical outcome and bleeding complications among hospital survivors with acute coronary syndromes

Objective

To examine the 21 month clinical outcome and bleeding complications in hospital survivors with non‐ST segment elevation acute coronary syndromes (NSTEACS) who were discharged with combined clopidogrel and aspirin anti‐thrombotic therapy, and compare with those having ST segment elevation myocardial infarction (STEMI) who were discharged with aspirin alone.

Design

Observational study.

Setting

A large university hospital.

Patients

224 patients were admitted to hospital with either NSTEACS or STEMI, and survived to discharge between 1 October 2001 and 31 December 2002.

Main outcome measures

Cardiovascular death, total death, new myocardial infarction, unstable angina requiring hospitalisation, stroke or transient ischaemic attack, coronary revascularisation; and fatal, life threatening, major and minor bleeding over 21 months after discharge.

Results

Despite having no or small infarct (median maximum creatine kinase 155 v 1295 u/l; p<0.001) and taking more antianginal drugs, patients with NSTEACS had similar rates of cardiovascular death (9.5% v 8.3%; p = NS), new myocardial infarction (9.5% v 6.5%; p = NS) or unstable angina requiring hospitalisation (15.5% v 10.2%; p = NS) when compared with STEMI. Fatal, life threatening or major bleeding were <1% in both groups (p = NS); and minor bleeding occurred in 4.3% NSTEACS and 2.8% STEMI patients respectively (p = NS).

Conclusions

Patients with NSTEACS had a similar and unfavourable long term outcome when compared with STEMI. There was no difference in serious bleeding complications between both groups.     

Long term prognosis of heart failure after acute coronary syndromes without ST elevation

Background

Information about long term outcomes of patients with acute coronary syndromes (ACS) who have clinically diagnosed heart failure is scarce.

Methods

In a UK registry, this study evaluated patients with non‐ST elevation ACS, recording treatment, and clinical outcomes for six months. In a subgroup, a four year mortality follow up was performed to estimate the impact of the clinical diagnosis of heart failure on survival.

Results

Of 1046 patients, 139 (13%) had a history of clinically diagnosed heart failure. At discharge, ACE inhibitors were prescribed for 58% and 28%, of those with and without a history of heart failure respectively (p<0.001). Rates of angiography, percutaneous intervention, and coronary artery bypass graft were 17.3% and 29.2% (p = 0.003), 5.0% and 8.4% (p = 0.17), and 5.0% and 7.5% (p = 0.3) for these groups respectively. Death or new myocardial infarction at six months occurred in 22% and 10% (p<0.001) and at four years death occurred in 60% and 20% of these groups respectively (p<0.001). In a multivariate analysis prior heart failure carried an odds ratio of 2.0 (p = 0.001) for death or myocardial infarction at six months and 2.4 (p<0.001) for death over four years. New heart failure was associated with an increased risk of death at six months (20% compared with 5%, p<0.001).

Conclusion

A clinical history of heart failure carries a substantial risk of death in patients admitted with ACS without ST elevation. Nearly 60% of those with prior heart failure are dead after four years. After adjustment for confounding factors, prior heart failure more than doubles the risk compared with those with no history.     

Raised cardiac troponin T levels in patients without acute coronary syndrome

Objective

To investigate the frequency, diagnosis and outcome of patients admitted to hospital with acute coronary syndrome (ACS) or other conditions associated with raised levels of cardiac troponin T.

Design

Observational study.

Setting

A large university hospital.

Patients

Consecutive patients admitted over an 8‐week period who had a serum troponin T test as part of their clinical assessment were included. Patients were separated into those with raised (⩾0.01 μg/l) or normal (<0.01 μg/l) troponin T levels, and further categorised into those with or without a diagnosis of ACS.

Main outcome measures

In‐hospital mortality in all patients; and 6‐month hospital re‐admissions and all‐cause mortality in patients without or with ACS and raised levels of troponin T.

Results

Of 1021 patients, 118 patients had no ACS but raised troponin T levels, 195 had ACS with raised troponin T, 80 had ACS with normal troponin T and 628 had no ACS with normal troponin T. Their in‐hospital all‐cause mortalities were 36%, 18%, 0% and 3%, respectively (p<0.001, highest mortality v other groups). 6‐month all‐cause mortality remained higher in patients without ACS and with raised levels of troponin T than in those with ACS and raised troponin T (42% v 29%; p = 0.020).

Conclusions

Patients without ACS but with raised levels of troponin T comprised 38% of all hospitalised patients found to have raised troponin T. These patients had worse in‐hospital and 6‐month outcome than those having ACS with raised levels of troponin T.     

Investigation and management of severe hyponatraemia in a hospital setting

Aims

To evaluate the assessment and management of severe hyponatraemia in a large teaching hospital.

Methods

Inpatients with serum sodium <125 mmol/l were identified prospectively from a laboratory database over a six month period. Notes were examined and data extracted. Case notes were carefully reviewed retrospectively by a consultant endocrinologist with regard to accuracy of the diagnosis and the appropriateness of investigations and management.

Results

104 patients with a serum sodium <125 mmol/l were identified. Mean (SD) age was 69 (14), 52% were female, mean hospital stay was 16 (12) days, and overall mortality 27%. Adequate investigations were rarely performed. Only 28 (26%) had plasma osmolality measured, 29 (27%) urine osmolality, 11 (10%) urinary sodium, 8 (8%) plasma cortisol, and 2 (2%) a short Synacthen test. Comparing the “ward” and “specialist review” diagnoses, there were significant discrepancies for “no cause found” (49% v 27%, p<0.001), alcohol (6% v 11% p<0.01), and syndrome of inappropriate antidiuresis (20% v 32%, p = 0.001). Treatment was often illogical with significant management errors in 33%. These included fluid restriction and intravenous saline given together (4%) and fluid restriction in diuretic induced hyponatraemia (6%). Mortality was higher in the group with management errors (41% v 20% p = 0.002).

Conclusion

Severe hyponatraemia is a serious condition, but its investigation and evaluation is often inadequate. Some treatment patterns seem to be arbitrary and illogical, and are associated with higher mortality.     

Effects of comorbidity and hospital care on 6-month mortality in patients with elevated cardiac troponin T

Objective

To examine the effects of comorbidity and hospital care on mortality in patients with elevated cardiac troponin T.

Design

Observational study.

Setting

A large university hospital with on‐site diagnostic cardiac catheter laboratory.

Patients

All hospitalised patients with elevated cardiac troponin T level (⩾0.01 μg/l) over an 8‐week period.

Main outcome measures

6‐month all‐cause mortality.

Results

Among 313 patients with elevated cardiac troponin T, 195 had acute coronary syndrome and 118 had other conditions. Multivariate analysis showed that among patients with acute coronary syndrome, increasing comorbidity score (odds ratio (OR) 1.23 per point increase, 95% confidence interval (CI) 1.00 to 1.51; p = 0.048), age (OR 1.08 per year, 95% CI 1.04 to 1.13; p<0.001), raised troponin T level (OR 2.22 per 10‐fold increase, 95% CI 1.27 to 3.89; p = 0.005), and ST depression (OR 3.12, 95% CI 1.38 to 7.03; p = 0.006) were independent adverse predictors, while cardiologist care (OR 0.22, 95% CI 0.09 to 0.51; p<0.001) was associated with a better survival. Increasing troponin T level (OR 3.33 per 10‐fold increase, 95% CI 1.24 to 8.91; p = 0.017) was found to predict a worse prognosis among patients without acute coronary syndrome, and cardiologist care did not affect outcome in this group. Among hospital survivors with acute coronary syndrome, increasing comorbidity score, age and a lack of cardiologist care were independently associated with lesser use of effective medications.

Conclusions

Comorbidity was associated with a higher 6‐month mortality in patients having acute coronary syndrome, and lesser use of effective medicines among hospital survivors. Cardiologist care was associated with better 6‐month survival in patients with acute coronary syndrome, but not in those without acute coronary syndrome.Prognostic indices including the original Charlson''s comorbidity index¹ have shown that comorbidity was important in determining the short and long term outcome in patients with various medical conditions, including those with acute myocardial infarction.^2,3,4,5 Among patients admitted to hospital with suspected acute coronary syndrome, an abnormally raised cardiac troponin level can be found in patients with, and also without, acute coronary syndrome.^6,7 An increasing cardiac troponin level was associated with increasing mortality in patients with acute coronary syndrome,⁸ and also those without acute coronary syndrome.⁹ Despite the availability of international management guidelines, care provided for patients with acute coronary syndrome varied in hospitals with or without interventional facilities, and was affected by whether patients received cardiologist care.¹⁰ We examine the effects of comorbid diseases, including a validated comorbidity index,¹¹ and hospital care on the 6‐month outcome among patients with elevated cardiac troponin T, caused by acute coronary syndrome and other conditions.     

Cardiovascular complications of severe acute respiratory syndrome

Background and Aims

Severe acute respiratory syndrome (SARS) is a virulent viral infection that affects a number of organs and systems. This study examined if SARS may result in cardiovascular complications.

Methods and Results

121 patients (37.5 (SD13.2) years, 36% male) diagnosed to have SARS were assessed continuously for blood pressure, pulse, and temperature during their stay in hopsital. Hypotension occurred in 61 (50.4%) patients in hospital, and was found in 28.1%, 21.5%, and 14.8% of patients during the first, second, and third week, respectively. Only one patient who had transient echocardiographic evidence of impaired left ventricular systolic function required temporary inotropic support. Tachycardia was present in 87 (71.9%) patients, and was found in 62.8%, 45.4%, and 35.5% of patients from the first to third week. It occurred independent of hypotension, and could not be explained by the presence of fever. Tachycardia was also present in 38.8% of patients at follow up. Bradycardia only occurred in 18 (14.9%) patients as a transient event. Reversible cardiomegaly was reported in 13 (10.7%) patients, but without clinical evidence of heart failure. Transient atrial fibrillation was present in one patient. Corticosteroid therapy was weakly associated with tachycardia during the second (χ² = 3.99, p = 0.046) and third week (χ² = 6.53, p = 0.01), although it could not explain tachycardia during follow up.

Conclusions

In patients with SARS, cardiovascular complications including hypotension and tachycardia were common but usually self limiting. Bradycardia and cardiomegaly were less common, while cardiac arrhythmia was rare. However, only tachycardia persisted even when corticosteroid therapy was withdrawn.     

Ethnic differences in control of cardiovascular risk factors in patients with type 2 diabetes attending an Inner London diabetes clinic

Background

South Asians have higher risk of diabetic complications compared with white Europeans. The aim of this study was to compare management of cardiovascular risk factors between Bangladeshis and white Europeans.

Methods

A retrospective survey of all diabetic patients attending an Inner London hospital diabetic clinic over one year was undertaken. Data were obtained from the hospital diabetes database: presence of macrovascular (myocardial infarction, angina, stroke, transient ischaemic attack, cardiac intervention) and microvascular disease (neuropathy, retinopathy, and nephropathy), glycated haemoglobin, blood pressure, lipids, smoking, and body mass index (BMI) were all determined.

Results

A total of 1162 white European and 912 Bangladeshi patients with full data available were included in the analyses. The groups were equivalent in age, sex, duration of diabetes. Compared with white Europeans, Bangladeshis had more macrovascular disease (19.5% v 11.9% p<0.01), sight threatening retinopathy (7.2% v 3.8%, p<0.01), and nephropathy (15.3% v 9.1%, p<0.01). In addition, Bangladeshis had significantly more male smokers (28.1% v 22.1%, p<0.01), poorer glycaemic control (mean HbA1c 8.6% v 8.1%, p = 0.039), greater proportion with uncontrolled hypercholesterolaemia (total cholesterol >5.0 mmol/l, 31.6% v 26% p = 0.05), and poorer control of blood pressure (proportion with BP >140/80 mm Hg, 43.2% v 32.1%, p<0.01).

Conclusions

South Asians with type 2 diabetes have poorer glycaemic, blood pressure, and lipid control than white Europeans. The reasons for this are probably multifactorial.     

Research productivity of the medical faculty at the American University of Beirut

Objective

To analyse the quality and quantity of scientific publications of the medical faculty at the American University of Beirut (AUB) during a six year period (1996–2001)

Methods

The study included all faculty members in the medical school of AUB in the year 2001. A Medline search inclusive of the years 1996–2001 was done for each faculty member and a total number of 881 publications was obtained.

Results

The faculty consisted of 203 members. Their average productivity rate (mean (SD)) was 1.24 (1.38) publications/faculty member/year (PFY), with a mean impact factor of 2.69 (4.63). Eighteen per cent of the faculty did not have any publication in the six year study period, and only 20% had two or more publications per year. There was a significantly higher publication rate among newly recruited faculty members (0.93 (1.40) PFY for those appointed before 1990, 1.45 (1.24) PFY for those appointed during 1990–1995, and 1.67 (1.43) for those appointed after 1995, p = 0.007), and among those who are younger in age (p<0.01). Collaboration with international investigators resulted in more original publications than work done only at AUB (65% v 35%, p<0.001), and a higher journal impact factor for the publications (3.20 (3.85) v 1.71 (2.36), p<0.05).

Conclusions

This is one of the first studies that analyse the research productivity of the medical faculty in a university setting in a developing country. It shows a wide variation in the research productivity of the faculty members that seems to be related to individual as well as institutional characteristics. Further analysis is needed to define and characterise these factors.     

Is rheumatoid arthritis a disease that starts in the intestine? A pilot study comparing an elemental diet with oral prednisolone

Objectives

This pilot study aimed to determine if an elemental diet could be used to treat patients with active rheumatoid arthritis and to compare its effect to that of oral prednisolone.

Methods

Thirty patients with active rheumatoid arthritis were randomly allocated to 2 weeks of treatment with an elemental diet (n = 21) or oral prednisolone 15 mg/day (n = 9). Assessments of duration of early morning stiffness (EMS), pain on a 10 cm visual analog scale (VAS), the Ritchie articular index (RAI), swollen joint score, the Stanford Health Assessment Questionnaire, global patient and physician assessment, body weight, erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP) and haemoglobin, were made at 0, 2, 4 and 6 weeks.

Results

All clinical parameters improved in both groups (p<0.05) except the swollen joint score in the elemental diet group. An improvement of greater than 20% in EMS, VAS and RAI occurred in 72% of the elemental diet group and 78% of the prednisolone group. ESR, CRP and haemoglobin improved in the steroid group only (p<0.05).

Conclusions

An elemental diet for 2 weeks resulted in a clinical improvement in patients with active rheumatoid arthritis, and was as effective as a course of oral prednisolone 15 mg daily in improving subjective clinical parameters. This study supports the concept that rheumatoid arthritis may be a reaction to a food antigen(s) and that the disease process starts within the intestine.     

Pulmonary leptospirosis: an excellent response to bolus methylprednisolone

Background

This case series analyses the beneficial effect of methylprednisolone in pulmonary leptospirosis, which usually has an aggressive course and grave outcome.

Methods

30 patients of pulmonary leptospirosis were evaluated. The initial 13 patients did not receive corticosteroids while the remaining 17 all received bolus methylprednisolone one gram intravenously for three days followed by oral prednisolone 1 mg/kg for seven days, on the basis of occasional case reports of benefit in pulmonary leptospirosis. APACHE III and lung injury scores of similar severity were considered while comparing outcomes in those who received methylprednisolone with those who did not.

Results

Dyspnoea and haemoptysis were the commonest symptoms in those with pulmonary manifestations. Overall mortality was 18% (3 of 17) in patients who received methylprednisolone, as compared with 62% (8 of 13 patients) in those who did not (p<0.02). In patients with established acute lung injury (ALI score >2.5), five of eight patients survived in the subgroup with corticosteroids (37% mortality) while only one of nine patients survived in the group that did not receive corticosteroids (89% mortality). Corticosteroids affected outcome only if given within the first 12 hours after the onset of pulmonary manifestations. Mortality seemed to correlate with the APACHE scores, and number of quadrants affected on chest radiographs, more than with blood gas pressures.

Conclusions

Corticosteroids reduce mortality and change outcome significantly when used early in the management of pulmonary leptospirosis.     

Analysis of predictors of success in the MRCP (UK) PACES examination in candidates attending a revision course

Objective

To determine factors that predict success of candidates taking a revision course in preparation for the MRCP (UK) PACES (practical assessment of clinical examination skills) examination.

Design

A questionnaire survey of candidates attending a PACES revision course. Results were correlated with subsequent pass lists published by the Colleges of Physicians

Setting and subjects

Candidates attending courses in June and October 2002. In total, 523 candidates completed questionnaires, evenly balanced between UK and overseas graduates.

Results

Of 483 candidates who took the examination immediately after the course, 219 (45.3%) passed. UK graduates were more likely to pass (67.0%) than overseas graduates (26.2%) (p = 0.003, odds ratio 5.72). For UK graduates, pass rates were higher for white candidates (73%) than for ethnic minorities (56%) (p = 0.012, OR 2.15) and for those who passed at the first attempt in the MRCP (UK) part 2 written paper (p = 0.003, OR 2.90). For overseas graduates, those who had been qualified for less than eight years were more likely to pass (p = 0.001, OR 2.78). More overseas (45.7%) than UK (30.8%) graduates were confident that they would pass, but confidence did not predict success.

Conclusion

Among candidates taking a revision course, UK graduates are more likely to pass the PACES examination than non‐UK graduates. Ethnic minority UK graduates seem to have a significantly poorer success rate, although this requires confirmation in an independent sample. If confirmed, these differences merit further investigation to assess whether they reflect genuine differences in ability.     

Effect of methionine loading on pulse wave analysis in elderly volunteers

Objective

To test the hypothesis that an acute increase in plasma homocysteine produced by methionine is associated with an acute increase in pulse wave velocity.

Design

A double blind, cross over, placebo controlled design was used and pulse wave velocity, plasma homocysteine, total cholesterol: high density lipoprotein ratio, plasma triglyceride, oxidised low density lipoprotein cholesterol concentrations, apolipoproteins A1 and B, and C reactive protein were measured between 12.5 and 20 hours after methionine loading or placebo.

Results

Between 12.5 and 20 hours after exposure to a methionine loading test, arterial pulse wave velocity showed no significant difference compared with placebo. At 12 hours after exposure to the methionine loading test, in the presence of a controlled diet, triglyceride concentration significantly increased by 32.6% (p<0.02), cholesterol: high density lipoprotein ratio increased significantly by 22.5% (p<0.05) compared with placebo. Simultaneously, systolic blood pressure increased significantly by 4.9% (p<0.02).

Conclusion

In elderly volunteers, acute hyperhomocysteinaemia induced by methionine loading resulted in no overall significant delayed reduction in peripheral arterial distensibility. A significant deterioration in the lipid profile and increased blood pressure was seen during acute hyperhomocysteinaemia.     

Evaluation of the need for endoscopy to identify low-risk patients presenting with an acute upper gastrointestinal bleed suitable for early discharge

Aims

To audit the safety of differing protocol‐driven early‐discharge policies, from two sites, for low‐risk acute upper gastrointestinal (GI) bleeding and determine if default early (<24 h) in‐patient endoscopy is necessary.

Methods

All patients with low‐risk acute upper GI bleeding presenting to two separate hospital sites in Leeds from August 2002 to March 2005 were identified. Both hospitals operate nurse‐led process‐driven protocols for discharge within 24 h, but only one includes default endoscopy. Relevant information was obtained from patients'' notes, patient administration systems, discharge letters and endoscopy records.

Results

120 patients were admitted to site A and 74 to site B. Median length of stay on the clinical decisions unit was 12.6 h at site A and 9.4 h at site B (p = 0.045). Oesophagogastroduodenoscopy was performed on 89/120 (74%) patients at site A compared with only 7/74 (9%) at site B (p<0.001). Six of 120 (5%) patients from site A were admitted to hospital for further observation compared with 6/74 (8%) from site B (p = 0.38). Of the remaining patients, all were discharged within 24 h, and 8/114 (7%) at site A vs 17/68 (25%) at site B were given hospital clinic follow‐up (p<0.001). None of the 194 patients had further bleeding or complications within 30 days.

Conclusions

Patients admitted with a low‐risk acute upper GI bleeding can be managed safely by a nurse‐led process‐driven protocol, based on readily available clinical and laboratory variables, with early discharge <24 h. Avoiding in‐patient endoscopy appears to be safe but at the price of greater clinic follow‐up.     

Distal adenomatous polyps are rare in patients with inflammatory bowel disease

Objective

There is an increased risk of colorectal cancer in patients with inflammatory bowel disease (IBD). The aim of this study was to compare the prevalence of left sided adenomas in patients with IBD aged 55–64 years with a local age matched control population.

Method

A review of clinical notes. The prevalence of adenomas in patients with IBD attending for either sigmoidoscopy or colonoscopy was compared with local age matched controls that participated in the national screening trial for colorectal cancer with flexible sigmoidoscopy.

Results

Of 106 patients (61 male, 45 female, mean age of 59 years), 80 suffered from ulcerative colitis, 20 from Crohn''s disease, and six from indeterminate colitis. All patients had undergone at least one flexible sigmoidoscopy and 75 had a colonoscopy. Distal adenomas were found in three patients with ulcerative colitis compared with 67 of 749 controls (2.8% v 8.9%, χ² = 4.6, p = 0.03).

Conclusions

The results suggest that distal adenomatous polyps are rare in patients aged 55–64 years with IBD compared with a control population. This supports the hypothesis that lesions other than polyps are important for the development of colorectal cancer in patients with IBD.     

Effect of an acute medical admission unit on key quality indicators assessed by funnel plots

Objective

To determine the effect of the introduction of an acute medical admissions unit (AMAU) on key quality efficiency and outcome indicator comparisons between medical teams as assessed by funnel plots.

Methods

A retrospective analysis was performed of data relating to emergency medical patients admitted to St James'' Hospital, Dublin between 1 January 2002 and 31 December 2004, using data on discharges from hospital recorded in the hospital in‐patient enquiry system. The base year was 2002 during which patients were admitted to a variety of wards under the care of a named consultant physician. In 2003, two centrally located wards were reconfigured to function as an AMAU, and all emergency patients were admitted directly to this unit. The quality indicators examined between teams were length of stay (LOS) <30 days, LOS >30 days, and readmission rates.

Results

The impact of the AMAU reduced overall hospital LOS from 7 days in 2002 to 5 days in 2003/04 (p<0.0001). There was no change in readmission rates between teams over the 3 year period, with all teams displaying expected variability within control (95%) limits. Overall, the performance in LOS, both short term and long term, was significantly improved (p<0.0001), and was less varied between medical teams between 2002 and 2003/04.

Conclusions

Introduction of the AMAU improved performance among medical teams in LOS, both short term and long term, with no change in readmissions. Funnel plots are a powerful graphical technique for presenting quality performance indicator variation between teams over time.     

A 30 year perspective of the quality of evidence published in 25 clinical journals: Signs of change?

Methods

The quality of clinical studies published in five different specialties, over three decades was evaluated. Computerised search of the Medline database was undertaken to evaluate the articles published in 25 clinical journals in 1983, 1993, and 2003 from five different specialties (medicine, surgery, paediatrics, anaesthesia, and psychiatry). The number of randomised controlled trials (RCTs), meta‐analyses, and other clinical trials (non‐RCT) were noted.

Results

From the 27 030 articles evaluated, there were 2283 (8.4%) RCTs, 166 (0.6%) meta‐analyses, and 4153 (15.4%) other clinical trials. For the proportion of RCTs, the rank order of the specialties was; anaesthesia (503; 18%), psychiatry (294; 9.6%), medicine (899; 8.1%), paediatrics (326; 6.4%), and surgery (261; 5.3%) (p<0.001). For the proportion of meta‐analysis, the rank order of the specialties was; psychiatry (36; 1.2%), medicine (105; 0.9%), paediatrics (15; 0.3%), anaesthesia (6; 0.2%), and surgery (4; 0.1%) (p<0.001). Overall, from 1983 to 2003, there were increases in the proportion of RCTs (449, 5.9% to 1027, 9.6%), meta‐analysis (0, 0% to 127, 1.2%), and other clinical trials (897, 12% to 1983, 19%) (p<0.001). This trend was apparent in each clinical specialty (p<0.001).

Conclusions

Over the three decades evaluated, clinical trials, notably RCTs and meta‐analysis form only a small proportion of articles published in prominent journals from five clinical specialties. This is notwithstanding the modest increases in the proportions of RCTs and meta‐analysis over the same period.     

Ethnic variations in the management of patients with acute stroke

Background

There is increasing interest in the management of stroke in ethnic minorities but few studies have considered this issue. This study investigated if differences in acute stroke management exist between a white European and Bangladeshi populations living in London, England.

Methods

All stroke surviving patients discharged over a five year period in a major London teaching hospital based in an ethnically diverse area of inner city London were recruited. Cerebrovascular risk factors, their management, and investigation for acute stroke syndromes were recorded and comparison between white and Bangladeshi cohorts was made. Categorical data were analysed using Fisher''s exact test.

Results

Measurement of cholesterol concentrations are undertaken less often in those from a Bangladeshi background (25%) compared with white Europeans (76%) (p<0.0001). Statin therapy tends to be given less often to Bangladeshis. However, neuroimaging (p<0.05) and echocardiography (p<0.0001) is performed more often in Bangladeshis compared with white Europeans.

Conclusion

There are variations in the management of acute stroke because of ethnicity and these variations could have substantial consequences on secondary rates of cerebrovascular and cardiovascular disease. Whether the reasons for this disparity are attributable to inequity or iniquity of care need to be further investigated perhaps along with the development of ethnicity specific protocols. Overall the management of stroke and its risk factors in either racial group remains lamentable.     

Preventing fragility hip fracture in high risk groups: an opportunity missed

Objective

The national guideline recommends selective case finding as the main strategy by identification of high risk people. This study assessed whether high risk patients were identified before their presentation with fragility fracture.

Methods

A prospective study for 3.5 consecutive months on patients with low energy hip fractures to Brighton and Sussex University Hospital NHS Trusts, which serves a population of 460 000. Data were collected by interview using standardised form, medical record review, and communication with family physicians. Definition of high risk: (1) untreated hypogonadism (2) corticosteroid users (3) disorders with increased bone loss (4) previous fragility fractures.

Results

98 patients were admitted with hip fracture. Thirty nine (40%) had at least one high risk factor. High risk patients (7 of 39, 18%) were no more likely to receive prophylaxis compared with patients without high risk factor (5 of 59, 8%) (p = 0.21). Previous fragility fracture (23) was the commonest risk factor followed by disorders with increased bone loss (10), premature menopause (10), and corticosteroid users (5). Fifteen patients (15%) had susceptibility to frequent falls and two had maternal history of osteoporosis. The proportion of treated patients were 20% (2 of 10) in premature menopause, 10% (1 of 10) in diseases with secondary osteoporosis, 13% (3 of 23) in previous fragility fracture, and 80% (4 of 5) in corticosteroid users (p = 0.01)

Conclusion

Prevention of hip fracture is still inadequate in high risk patients. Discrepancy seemed to exist in treatment frequency among different high risk groups suggesting that emphasis on prevention of osteoporosis has not been reinforced in all people at risk.     

Application of Gleason analogous grading system and flow cytometry DNA analysis in a novel knock-in mouse prostate cancer model

Objective

A new knock‐in mouse adenocarcinoma prostate model (KIMAP) was established, which showed a close to human kinetics of tumour development. This study used a new mouse histological grading system similar to the human Gleason grading system and flow cytometry DNA analysis to measure and compare the new KIMAP model with human CaP and transgenic mouse adenocarcinoma prostate (TGMAP) model.

Methods

According to heterogeneity of the clinical standard for prostate cancer diagnosis, a close to human mouse standard for histological grading and scoring system, Gleason analogous grading system, was established in this study. Sixty KIMAP and 48 TGMAP prostate cancer samples were measured and compared with human CaP. Flow cytometry DNA analysis was performed on malignant prostate tissues obtained from both TGMAP and KIMAP models.

Results

Mice with CaP from KIMAP (n = 60) and TGMAP (n = 48) models showed a different distribution of histological scores (p = 0.000). KIMAP mice showed higher percentage (53.3%) of compound histological score rate than TGMAP (25%), but closer to the human clinical average (50%), which showed significant correlation with age (p = 0.001), while TGMAP mice showed unbalanced and random score distribution in all age groups. Flow cytometry analyses showed that most tumour tissues in KIMAP were diploid, analogous to the human condition, while all the TGMAP mice showed aneuploid tumours.

Conclusions

Results of this study further show that KIMAP, a new generation of murine prostate cancer model, could be used as a supplementary model in addition to the currently widely used transgenic models.     

Comparison of classical and non-classical cardiovascular risk factors influencing the patency of native arteriovenous fistulas after percutaneous transluminal angioplasty therapy among haemodialysis patients

Objective

To evaluate the classical and non‐classical cardiovascular risk factors that effect patency of native arteriovenous fistulas (AVF) in end stage renal disease (ESRD) patients who are undergoing regular haemodialysis treatment and have a percutaneous transluminal angioplasty (PTA) procedure.

Methods

All PTAs performed between 1 October 2002 and 30 September 2004 were identified from case notes and the computerised database and follow up to 31 March 2005. The definition of patency of AVF after PTA was including primary or secondary patencies. Risks were analysed to assess the influence on survival following PTAs of age, sex, serum cholesterol, serum triglyceride, diabetes, use of aspirin, current smoking and hypertension, serum albumin, serum calcium–phosphate product, intact parathyroid hormone (I‐PTH), and urea reduction ratio (URR).

Results

The patency rate of AVFs of all interventions was 65% at 6 months. Factors with poor patencies of AVFs after PTA procedures were higher serum calcium–phosphate product (p = 0.033), higher URR (p<0.001), lower serum albumin (p<0.001), non‐hypertension (p = 0.010) and “non‐smoker + ex‐smoker group” (p = 0.033). The hypertensive patients and current smokers had lower patency failure after PTAs (p<0.01 and p<0.05, respectively).

Conclusions

Unfavourable cumulative patency rates are observed in haemodialysis patients with higher URR, higher serum calcium–phosphate product and hypoalbuminaemia (lower serum albumin before the PTA procedure). Hypertension and current smoking were associated with better patency rates of AVF after PTA.Construction and maintenance of a well‐functioning vascular access remains one of the most important tasks for haemodialysis patients. Complications related to vascular access are the main cause of hospitalisations, being responsible for up to 25% of hospitalisations among dialysis patients.¹ Thrombosis (occlusion) and atherosclerosis (stenosis) are the leading cause of arteriovenous fistula (AVF) dysfunction among dialysis patients.² Percutaneous transluminal angioplasty (PTA) is an accepted therapeutic procedure for AVF dysfunction management.¹ Generally, the native AVF is considered the best access for chronic haemodialysis. Age, diabetes, increased serum lipoprotein Lp(a), increased serum fibronectin and synthetic grafts (polytetrafluoroethylene (PTFE)) have been associated with vascular access dysfunction and may influence the survival of AVFs in patients on haemodialysis.^3,4A variety of factors are involved in the pathogenesis of vascular diseases associated with chronic renal failure. Classical cardiovascular risk factors such as age, male gender, smoking, hypertension, dyslipidaemia, and diabetes exist in the general population and in patients with chronic renal failure. Additional non‐classical risk factors such as oxidative stress, dysparathyroidism, hyperhomocysteinaemia, dialytic inadequacy, malnutrition and disruption of calcium–phosphate homeostasis play more important roles in cardiovascular disease in chronic renal failure patients.^5,6 In fact, classical cardiovascular risk factors alone have been reported to be inadequate predictors of cardiovascular disease in haemodialysis patients in a recent report.⁵ To our knowledge, the comparison of classical and non‐classical cardiovascular risk factors influencing the patency of native AVF in ESRD patients is rarely investigated. The first aim of our study is to identify possible cardiovascular risk factors influencing patency rate of native AVF after PTAs among haemodialysis patients. The second aim is to determine whether non‐classical cardiovascular risk factors play more important roles in influencing the patency rate of AVF after PTAs.