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.     

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.     

Paediatric acute peritoneal dialysis in southern Nigeria

Background

Acute peritoneal dialysis (APD) is the preferred treatment for isolated failure of the kidney. The authors reviewed children with acute renal failure (ARF) who had APD in Port Harcourt, Nigeria.

Results

221 patients, 147 boys and 74 girls (M: F, 1.99:1), mean (SD) age 5.4 (4.9) years had ARF. Dialysis was indicated in 112 cases. The main clinical indication being convulsion/uraemia 30 (26.8%) Only 27 patients (21 boys and 6 girls) had APD, giving an access rate of 24.1%. The commonest dialysis related complication was catheter malfunction 12 (44.4%). The mortality rate among the dialysed patients was 22.2%. Lack of dialysis and intractable hypertension significantly increased mortality (χ² = 7.13, p<0.01) and (χ² = 14.9, p<0.001) respectively.

Conclusion

APD is effective in reducing mortality of children with ARF. However, there were low dialysis access rate and few complications.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Clinical presentation and incidence of complications in patients with coeliac disease diagnosed by relative screening

Background

There is an increased prevalence of coeliac disease (CD) among relatives of those with the disease.

Aims

To compare the clinical features in patients with CD detected via family screening with those in patients diagnosed routinely.

Methods

Information on screening was provided to relatives of patients. Those who wished to be screened were tested for endomysial and/or tissue transglutaminase antibodies. Duodenal biopsy was performed in those with positive antibodies. The clinical details of the relative screening group were compared with those of 105 patients diagnosed routinely.

Results

183 relatives underwent screening, of whom 32 had positive serology, 24 had histology diagnostic of CD, six had normal biopsies and two declined duodenal biopsy. Patients in the relative screening group were younger with a median age of 33 years (range 17–72 years) compared to the routine group which had a median age of 54 years (range 25–88 years). In the relative screening group, there was a male preponderance (M:F ratio 16:8), anaemia at presentation was significantly less common (13% v 58%; p<0.001) and osteoporosis was less frequent (9% v 22%; p<0.244) compared with the routine group. 65% of the relative screening group had gastrointestinal symptoms or anaemia at diagnosis.

Conclusions

Patients detected by family screening are younger with a male preponderance, but fewer had anaemia and osteoporosis.     

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.     

Intravenous administration of metoclopramide by 2?min bolus vs 15?min infusion: does it affect the improvement of headache while reducing the side effects?

Objective

To determine the therapeutic effect (alleviation of vascular type headache) and side effects of a slow intravenous metoclopramide infusion over 15 min compared with those effects of a bolus intravenous metoclopramide infusion over 2 min in the treatment of patients with recent onset vascular type headache.

Material and methods

All adults treated with metoclopramide for vascular type headache were eligible for entry into this clinical randomised double blinded trial. This study compared the effects of two different rates of intravenous infusion of metoclopramide over a period of 13 months at a university hospital emergency department. During the trial, side effects and headache scores were recorded at baseline (0 min), and then at 5, 15, 30 and 60 min. Repeated measures analysis of variance was used to compare the medication''s efficacy and side effects.

Results

A total of 120 patients presenting to the emergency department met the inclusion criteria. Of these, 62 patients (51.7%) were given 10 mg metoclopramide as a slow intravenous infusion over 15 min (SIG group) and 58 patients (48.3%) were given 10 mg metoclopramide intravenous bolus infusion over 2 min (BIG group). 17 of the 58 patients in the BIG group (29.3%) and 4 of the 62 patients (6.5%) in the SIG group had akathisia (p = 0.001). There were no significant differences between the BIG and SIG groups in terms of mean headache scores (p = 0.34) and no adverse reactions in the study period. Metoclopramide successfully relieved the headache symptom(s) of patients in both the BIG and SIG groups.

Conclusion

Slowing the infusion rate of metoclopramide is an effective strategy for the improvement of headache and reducing the incidence of akathisia in patients with vascular type headache.     

Polymorbidity in diabetes in older people: consequences for care and vocational training

Objective

To investigate the prevalence of complicating and concurrent morbidities in older diabetic patients and to evaluate to what extent their occurrence affects the burden of disease and use of medical healthcare.

Study design

Cross‐sectional analysis of retrospectively obtained data on comorbidities and use of medical healthcare. Healthcare registration systems were used to retrieve data on 300 patients with diabetes aged ⩾60 years who, according to the severity of their disease and intensity of care required, were treated in a regional general practitioner (GP), diabetes nurse specialist (DNS) or medical specialist (MS) practice.

Results

Complicating and concurrent morbidities were often found irrespective of the type of practice involved. After adjustments for differences in sex, age and glycosylated haemoglobin (HbA1c), the extent of complicating comorbidities showed sequential increases in patients managed by GP, DNS and MS (mean number of 3.6, 4.7 and 6.7, respectively; p_trend<0.001). However, the mean number of concurrent comorbidities was similar across all three settings (2.1, 1.8 and 2.0, respectively). Both complicating and concurrent comorbidities were similarly associated with the extent of drug use (β = 0.49 (95% CI 0.40 to 0.58) and β = 0.57 (95% CI 0.52 to 0.72), respectively) and the number of consultations with specialists other than the main care giver (β = 1.19 (95% CI 1.15 to 1.24) and β = 1.21 (95% CI 1.14 to 1.28), respectively). However, the mean number of different specialists involved in a patient''s care per additional concurrent comorbidity was twice as high as per any additional complicating comorbidity (β = 0.60 (95% CI 0.48 to 0.71) vs β = 0.31 (95% CI 0.24 to 0.39)).

Conclusions

The use of healthcare facilities by older patients with diabetes is substantial, irrespective of the complexity of the disease and the kind of practice involved. The common manifestation of complicating and concurrent comorbidities and their varying complexity in individual patients requires a patient‐oriented rather than a disease‐oriented approach and vocational training programmes for care givers that are tailored to the complexity of multiple chronic diseases.     

Retrospective analysis of the use of inferior vena cava filters in routine hospital practice

Introduction

Characteristics and outcomes of patients undergoing inferior vena cava (IVC) filter insertion are not well reported. Particularly, the role of long term anticoagulation in these patients is unclear.

Aims

(1) To describe in a cohort of patients undergoing IVC filter insertion, underlying diseases, indications for filter insertion, complications, and survival. (2) To determine the effect of long term anticoagulant treatment on thromboembolism and patient survival.

Study design

A retrospective analysis of 109 consecutive patients undergoing IVC filter insertion in two university hospitals.

Results

Average age was 67.4 years. Median duration of follow up was two years. Indications for IVC filter insertion were: contraindication to anticoagulation (n = 61, 56%), prophylactic insertion (n = 29, 27%), thromboembolism while receiving adequate anticoagulation (n = 17, 15%), and non‐compliance with anticoagulation (n = 2, 2%). Insertion related complications were groin haematoma in four patients (3.5%) and localised infection at the puncture site in one patient (0.9%). Fifty six patients (51.4%) died during the study period. Of these, 22 received long term anticoagulants and 34 did not. Overall and thrombosis free survival was greater in the anticoagulant treated group (median survival not reached) than in the untreated group (median survival = 12 months). Patients not receiving long term anticoagulation after IVC filter insertion were nearly 2.5‐fold more likely to die or experience venous thromboembolism.

Conclusion

IVC filter insertion was a safe procedure and was performed for appropriate indications in the patients studied. In patients surviving for longer than 30 days, prolonged administration of oral anticoagulants was associated with improved survival with no significant increase in haemorrhagic complications.