Acute hyperglycaemia affects anorectal motor and sensory function in normal subjects

Background—The pathogenesis of anorectaldysfunction, which occurs frequently in patients with diabetesmellitus, is poorly defined. Recent studies indicate that changes inthe blood glucose concentration have a major reversible effect ongastrointestinal motor function.
Aims—To determine the effects of physiologicalchanges in blood glucose and hyperglycaemia on anorectal motor andsensory function in normal subjects.
Subjects—In eight normal subjects measurements ofanorectal motility and sensation were performed on separate days whileblood glucose concentrations were stabilised at 4, 8, and 12 mmol/l.
Methods—Anorectal motor and sensoryfunction was measured using a sleeve/sidehole catheter incorporating aballoon, and electromyography.
Results—The number of spontaneous anal relaxationswas greater at 12 mmol/l than at 8 and 4 mmol/l glucose (p<0.05 forboth). Anal squeeze pressures were less at a blood glucose of12 mmol/l when compared with 8 and 4 mmol/l (p<0.05 for both).During rectal distension, residual anal pressures were notsignificantly different between the three blood glucose concentrations.Rectal compliance was greater (p<0.05) at a blood glucose of12 mmol/l when compared with 4 mmol/l. The threshold volume forinitial perception of rectal distension was less at 12 mmol/l whencompared with 4 mmol/l (40 (20-100) ml versus 10 (10-150) ml,p<0.05).
Conclusions—An acute elevation of bloodglucose to 12 mmol/l inhibits internal and external anal sphincterfunction and increases rectal sensitivity in normal subjects. Incontrast, physiological changes in blood glucose do not have asignificant effect on anorectal motor and sensory function.

Keywords:hyperglycaemia; anorectum; motility; sensation; diabetes mellitus

     

Mechanical properties of the common carotid artery in Williams syndrome

OBJECTIVE—To determine whether arterial wall hypertrophy in elastic arteries was associated with alteration in their mechanical properties in young patients with Williams syndrome.
METHODS—Arterial pressure and intima-media thickness, cross sectional compliance, distensibility, circumferential wall stress, and incremental elastic modulus of the common carotid artery were measured non-invasively in 21 Williams patients (mean (SD) age 8.5 (4) years) and 21 children of similar age.
RESULTS—Systolic and diastolic blood pressures were higher in Williams patients (125/66 v 113/60 mm Hg, p < 0.05). The mean (SD) intima-media thickness was increased in Williams patients, at 0.6 (0.07) v 0.5 (0.03) mm (p < 0.001). Normotensive Williams patients had a lower circumferential wall stress (2.1 (0.5) v 3.0 (0.7) mm Hg, p < 0.01), a higher distensibility (1.1 (0.3) v 0.8 (0.3) mm Hg⁻¹.10⁻², p < 0.01), similar cross sectional compliance (0.14 (0.04) v 0.15 (0.05) mm².mm Hg⁻¹, p > 0.05), and lower incremental elastic modulus (7.4 (2.0) v 14.0 (5.0) mm Hg.10²; p < 0.001).
CONCLUSIONS—The compliance of the large elastic arteries is not modified in Williams syndrome, even though increased intima-media thickness and lower arterial stiffness are consistent features. Therefore systemic hypertension cannot be attributed to impaired compliance of the arterial tree in this condition.


Keywords: elastin; Williams syndrome; hypertension; compliance     

Prospective comparison of faecal incontinence grading systems

Background—Existing scales forassessing faecal incontinence have not been validated against clinicalassessment, or with regard to reproducibility. They also fail to takeinto account faecal urgency, and the use of antidiarrhoeal medications.
Aims—To establish the validity, andsensitivity to change, of existing scales and a newly designedincontinence scale.
Methods—(1) Twenty three patients(21 females, median age 57 years) were prospectively evaluated by twoindependent clinical observers, using three established scales(Pescatori, Wexner, American Medical Systems), a newly devised scalewhich also includes details about urgency and antidiarrhoeal drugs, andby a 28 day diary. (2) A further 10 female patients were assessed bythe same scales before and after surgery for faecal incontinence.
Results—(1) Assessments by twoindependent clinicians correlated well. All four scales and a diarycard correlated highly and significantly with the clinical impression,with the new scale reaching the highest correlation(r=0.79, p<0.001). (2) All except one scorechanged significantly in response to surgical treatment; the new scaleshowed the greatest change, at the highest level of significance(p=0.004), and correlated best with the clinicians' assessment ofchange (r=0.94, p<0.001).
Conclusions—Existing scalesfor the assessment of faecal incontinence correlate well with carefulclinical impression of severity, and serve as useful and reproduciblemeasures for comparison of patients and treatments. A newly devisedscale has shown high clinical validity and utility.

     

Subtypes of constipation predominant irritable bowel syndrome based on rectal perception

Background—Patients whocomplain of constipation can be divided into those who have lost thenatural call to stool, but develop abdominal discomfort after severaldays without a bowel movement (no urge); and those who experience aconstant sensation of incomplete evacuation (urge).
Aims—To determine whether the twogroups differ in symptoms, colonic transit, and perceptual responses tocontrolled rectal distension.
Methods—Forty four patients withconstipation were evaluated with a bowel symptom questionnaire, colonictransit (radiopaque markers), and rectal balloon distension. Stool (S)and discomfort (D) thresholds to slow ramp (40 ml/min) and rapid phasicdistension (870 ml/min) were determined with an electronic distensiondevice. Fifteen healthy controls were also studied.
Results—All patients had Romepositive irritable bowel syndrome (IBS); 17 were no urge and 27 urge.Mean D threshold to phasic rectal distensions was 28 (3) mm Hg in nourge, 27 (3) mm Hg in urge (NS), but higher in the control group (46 (2) mm Hg; p<0.01). Sixty seven per cent of no urge and 69% of urgewere hypersensitive for D. Slow ramp distension thresholds were higherin no urge (S: 26 (3); D: 45 (4) mm Hg) compared with urge (S: 16 (2);D: 31 (3) mm Hg; p<0.01), or with controls (S: 15 (1); D: 30 (3); p<0.01).
Conclusions—Hyposensitivity to slowrectal distension is found in patients with IBS who complain ofconstipation and have lost the call to stool even though theirsensitivity to phasic distension is increased.

Keywords:visceral sensation; colonic transit

     

Natural history and surgical outcomes for isolated discrete subaortic stenosis in children

OBJECTIVE—To document the natural history and surgical outcomes for discrete subaortic stenosis in children.
DESIGN—Retrospective review.
SETTING—Tertiary care paediatric cardiology centres.
PATIENTS—92 children diagnosed between 1985 and 1998.
MAIN OUTCOME MEASURES—Echocardiographic left ventricular outflow gradient (echograd), and aortic insufficiency (AI).
RESULTS—The mean (SEM) age at diagnosis was 5.3 (0.4) years; the mean echograd was 30 (2) mm Hg, with AI in 22% (19/87) of patients. The echograd and incidence of AI increased to 35 (3) mm Hg and 53% (36/68) (p < 0.05) 3.6 (0.3) years later. The echograd at diagnosis predicted echograd progression and appearance of AI. 42 patients underwent surgery 2.2 (0.4) years after diagnosis. Preoperatively echograd and AI incidence increased to 58 (6) mm Hg and 76% (19/25) (p < 0.05). The echograd was 26 (4) mm Hg 3.7 (0.4) years postoperatively, with AI in 82% (31/38) of patients. Surgical morbidities included complete heart block, need for prosthetic valves, and iatrogenic ventricular septal defects. Eight patients underwent reoperation for recurrent subaortic stenosis. The age at diagnosis of 44 patients followed medically and 42 patients operated on did not differ (5.5 (0.6) v 5.0 (0.6) years, p < 0.05). However, the echograd at diagnosis in the former was less (21 (2) v 40 (5) mm Hg, p < 0.05) and did not increase (23 (2) mm Hg) despite longer follow up (4.1 (0.4) v 2.2 (0.4) years, p < 0.05). The incidence of AI at diagnosis and at last medical follow up was also less (14% (6/44) v 34% (13/38); 40% (17/43) v 76% (19/25), p < 0.05).
CONCLUSIONS—Many children with mild subaortic stenosis exhibit little progression of obstruction or AI and need not undergo immediate surgery. Others with more severe subaortic stenosis may progress precipitously and will benefit from early resection despite risks of surgical morbidity and recurrence.


Keywords: subaortic stenosis; congenital heart disease; cardiac surgery     

Effect of endoscopic sphincterotomy on gall bladder bile lithogenicity and motility

Background—Endoscopic sphincterotomyhas been shown to inhibit stone formation in the gall bladder ofexperimental animals.
Aims—To investigate the alterations in bilecomposition and gall bladder motility after endoscopic sphincterotomy.
Patients—A study was performed of gall bladderbile composition and gall bladder motility in patients with gallstonedisease ((n = 20; age 40-60 years, median age 55 years: seven men),with gall bladder calculi (n = 12) and with diseased gall bladder(chronic inflammation) without gall bladder calculi (n = 8)), who hadreceived endoscopic sphincterotomy for common bile duct stones. Age and sex matched disease controls comprised 20 patients with gallstone disease but without stones and an intact sphincter of Oddi (with gallbladder calculi (n = 10) and diseased gall bladder without gall bladdercalculi (n =10)).
Methods—Gall bladder motility was assessed byultrasound. Duodenal bile collected by nasoduodenal tube afterstimulation of gall bladder by intravenous ceruletid infusion wasanalysed for cholesterol, phospholipid, and bile acidconcentrations, cholesterol saturation index, and nucleation time.
Results—There was a significant reduction in mean(SEM) fasting volume (12.5 (1.7) ml v 26.4 (2.5) ml;p<0.001) and mean (SEM) residual volume (4.34 (0.9) ml v14.7 (0.98) ml; p<0.001), and increase in mean (SEM) ejection fraction(65.7 (4.2)% v 43.6 (5.52)%; p<0.001) and mean (SEM)rate constant of gall bladder emptying (−0.031/min v−0.020/min; p<0.01) in patients who had been subjected to endoscopicsphincterotomy. Median nucleation time was significantly longer (17 days v 6 days; p<0.006) in treated patients. There was areduction in total mean (SEM) lipid concentrations (6.73(0.32) g/dlv 7.72 (0.84) g/dl; p<0.05), cholesterol (5.6 (1.5) mmol/l v 10.3 (2.23) mmol/l; p<0.001) and CSI (0.72 (0.15) v 1.32(0.31); p<0.001). There was no significantchange in mean (SEM) phospholipid (25.6 (3.5) mmol/l v23.4 (6.28) mmol/l) and bile acid (93.7 (7.31) mmol/l v105.07 (16.6) mmol/l) concentrations.
Conclusions—After endoscopic sphincterotomy therewas enhanced contractility of the gall bladder, accompanied by aprolongation of nucleation time and reduction in cholesterol saturation index.

Keywords:gall bladder emptying; gall bladder contractility; nucleation time; cholesterol saturation index; gallstones; endoscopicpapillotomy

     

Symptomatic improvement after radiofrequency catheter ablation for typical atrial flutter

OBJECTIVE—To assess the changes in quality of life, arrhythmia symptoms, and hospital resource utilisation following catheter ablation of typical atrial flutter.
DESIGN—Patient questionnaire to compare the time interval following ablation with a similar time interval before ablation.
SETTING—Tertiary referral centre.
PATIENTS—63 consecutive patients were studied. Four patients subsequently underwent an ablate and pace procedure, two died of co-morbid illnesses, and two were lost to follow up. The remaining 55 patients form the basis of the report.
RESULTS—Patients were followed for a mean (SD) of 12 (9.5) months. Atrial flutter ablation resulted in an improvement in quality of life (3.8 v 2.5, p < 0.001) and reductions in symptom frequency score (2.0 v 3.5, p < 0.001) and symptom severity score (2.0 v 3.8, p < 0.001) compared with preablation values. There was a reduction in the number of patients visiting accident and emergency departments (11% v 53%, p < 0.001), requiring cardioversion (7% v 51%, p < 0.001), or being admitted to hospital for a rhythm problem (11% v 56%, p < 0.001). Subgroup analysis confirmed that patients with atrial flutter and concomitant atrial fibrillation before ablation and those with atrial flutter alone both derived significant benefit from atrial flutter ablation. Patients with concomitant atrial fibrillation had an improvement in quality of life (3.5 v 2.5, p < 0.001) and reductions in symptom frequency score (2.3 v 3.5, p < 0.001) and symptom severity score (2.2 v 3.7, p < 0.001) compared with preablation values.
CONCLUSIONS—Ablation of atrial flutter is recommended both in patients with atrial flutter alone and in those with concomitant atrial fibrillation.


Keywords: atrial flutter; radiofrequency ablation; quality of life     

Altered vagal and intestinal mechanosensory function in chronic unexplained dyspepsia

Background—Abnormal visceral mechanosensory andvagal function may play a role in the development of functionalgastrointestinal disorders.
Aims—To assess whether vagal efferent andafferent function is linked with small intestinal mechanosensory function.
Methods—In seven patients with functionaldyspepsia, six patients with a history of Billroth I gastrectomy and/orvagotomy, and seven healthy controls, intestinal perception thresholdswere tested by a randomised ramp distension procedure performed with abarostat device. On a separate day, an insulin hypoglycaemia test wasperformed to assess the plasma levels of pancreatic polypeptide (PP) in response to hypoglycaemia, as a test of efferent vagal function.
Results—First perception of intestinal balloondistension occurred at significantly lower pressures in patients withfunctional dyspepsia (median 19.3, range 14.7-25.3 mm Hg) comparedwith healthy controls (median 26.0, range 21.7-43.7 mm Hg, p<0.01).Sensory thresholds were significantly lower in patients aftergastrectomy (median 12.2, range 8.0-14.7 mm Hg, p<0.05 versus allothers). In healthy controls and patients with functional dyspepsia,insulin hypoglycaemia significantly (p<0.001) increased plasma PPlevels. However, only two out of seven patients with functionaldyspepsia had a more than twofold increase in PP values whereas allhealthy controls had a more than twofold increase in PP levels afterinsulin hypoglycaemia (p<0.05). In contrast, there was no significant PP response in the gastrectomised patients (median 2%, range −10 to+23%). PP responses and visceral sensory thresholds were significantly correlated (r=0.65, p<0.002).
Conclusions—The diminished PP response afterinsulin hypoglycaemia indicates disturbed efferent vagal function in asubgroup of patients with functional dyspepsia. The data also suggestthat the intact vagal nerve may exert an antinociceptive visceral effect.

     

Ventricular mass and diastolic function in patients infected by the human immunodeficiency virus

OBJECTIVE—Echocardiographic and Doppler analysis of myocardial mass and diastolic function in patients infected with HIV.
DESIGN—Case-control study.
SETTING—Tertiary referral centre, Huelva, Spain.
PATIENTS—61 asymptomatic patients with HIV infection and 32 healthy controls.
MAIN OUTCOME MEASURES—Time motion, cross sectional, and Doppler echocardiographic studies were performed, and left ventricular mass and diastolic function variables determined (peak velocity of early and late mitral outflow and isovolumic relaxation time).
RESULTS—Left ventricular mass index (LVMI) was decreased in patients compared with healthy controls (mean (SD): 76.7 (23.6) v 118.8 (23.5) g/m², p < 0.001). Linear regression analysis showed a correlation between LVMI and brachial fat and muscle areas. The ratio of peak velocities of early and late mitral outflow was decreased in HIV infected patients compared with controls (1.19 (0.44) v 1.58 (0.38), p < 0.001). This ratio was exclusively related to haemodynamic variables (heart rate, systolic and diastolic blood pressures). HIV infected patients had a prolonged isovolumic relaxation time (103.0 (10.5) v 72.9 (12.9) ms, p < 0.001). Isovolumic relaxation time was correlated only with brachial muscle area on multivariate analysis.
CONCLUSIONS—HIV infected patients had a reduced left ventricular mass index and diastolic functional abnormalities. These cardiac abnormalities are predominantly related to nutritional status.


Keywords: HIV infection; cardiac function; nutrition     

Paradoxical sphincter contraction is rarely indicative of anismus

Background—Anismus is thought to be a cause ofchronic constipation by producing outlet obstruction. The underlyingmechanism is paradoxical contraction of the anal sphincter orpuborectalis muscle. However, paradoxical sphincter contraction (PSC)also occurs in healthy controls, so anismus may be diagnosed too often because it may be based on a non-specific finding related to untoward conditions during the anorectal examination.
Aims—To investigate the pathophysiologicalimportance of PSC found at anorectal manometry in constipated patientsand in patients with stool incontinence.
Methods—Digital rectal examination and anorectalmanometry were performed in 102 chronically constipated patients, 102 patients with stool incontinence, and in 18 controls without anorectal disease. In 120 of the 222 subjects defaecography was also performed. Paradoxical sphincter contraction was defined as a sustained increase in sphincter pressure during straining. Anismus was assumed when PSCwas present on anorectal manometry and digital rectal examination andthe anorectal angle did not widen on defaecography.
Results—Manometric PSC occurred about twice asoften in constipated patients as in incontinent patients (41.2% versus25.5%, p<0.017) and its prevalence was similar in incontinentpatients and controls (25.5% versus 22.2%). Oroanal or rectosigmoidtransit times in constipated patients with and without PSC did notdiffer significantly (total 64.6 (8.9) hours versus 54.2 (8.1) hours; rectosigmoid 14.9 (2.4) hours versus 13.8 (2.5) hours).
Conclusions—Paradoxical sphincter contraction is acommon finding in healthy controls as well as in patients with chronic constipation and stool incontinence. Hence, PSC is primarily a laboratory artefact and true anismus is rare.

Keywords:anismus; paradoxical sphincter contraction; constipation; stool incontinence; anorectal manometry

     

Asian Indians,coronary artery disease,and physical exercise

Objective—To evaluate the relation of physical activity to different clinical and biochemical risk factors for coronary artery disease among people from different ethnic groups with angiographically proven coronary artery disease.
Subjects—British Asians, Indian Asians, and white people suffering from coronary artery disease, and their respective controls.
Interventions—History, physical examination, coronary angiography (at baseline), laboratory investigations.
Main outcome measures—Relation of physical activity level to serum insulin, glucose, cholesterol, triglycerides, and high density lipoproteins, systolic and diastolic blood pressures, and body mass index in patients and controls.
Results—391 male patients were studied, of whom 260 (66.5%) were classified as sedentary. Mean serum insulin at 0, 1, and 2 hours after 75 g oral glucose was higher among the sedentary population (17.1 v 11.6, 88.2 v 62.1, and 57.9 v 36.2 µU/ml, respectively (all p < 0.0001). Mean body mass index was also higher among the sedentary population (25.53 v 23.95, p < 0.0001), as were mean serum triglycerides (1.85 v 1.60 mmol/l, p < 0.01) and systolic and diastolic blood pressures (133.9 v 129.4, p < 0.05, and 81.1 v 79.0, p < 0.01). There was no difference in the mean serum cholesterol and high density lipoprotein between the two groups. British Asians were the most sedentary and Indian Asians the most physically active.
Conclusions—There are marked differences in the level of physical activity among the various ethnic groups in the United Kingdom. In each ethnic group, physical activity reduced mean serum insulin, body mass index, and serum triglycerides and had a favourable effect on systolic and diastolic blood pressures. Promotion of physical activity could be of value for the Asian community in the United Kingdom.

     

Patients with acute coronary syndromes express enhanced CD40 ligand/CD154 on platelets

OBJECTIVE—To investigate whether CD40L/CD154 on platelets and soluble CD40L/CD154 may play a role in the inflammatory process of acute coronary syndromes.
DESIGN AND SETTING—Observational study in a university hospital.
PATIENTS—15 patients with acute myocardial infarction, 25 patients with unstable angina, 15 patients with stable angina, and 12 controls.
MAIN OUTCOME MEASURES—CD40L/CD154 on platelets, P-selectin/CD62P on platelets, soluble CD40L/CD154 serum concentrations.
RESULTS—Mean (SD) CD40L/CD154 expression on platelets was 6.2 (2.8) MFI (mean fluorescence intensity) in the infarct group, 11 (3.3) MFI in the unstable angina group (p < 0.001 v infarction), 3.6 (0.9) MFI in the stable angina group (p < 0.01 v infarction; p < 0.001 v unstable angina), and 3.2 (1.0) MFI in the controls (p < 0.01 v infarction; p < 0.001 v unstable angina; NS v stable angina). Soluble CD40L/CD154 concentration was 5.2 (1.1) ng/ml in the infarct group, 4.2 (0.7) ng/ml in the unstable angina group (p < 0.001 v infarction), 2.9 (1.0) ng/ml in stable angina group (p < 0.001 v infarction and unstable angina), and 3.0 (0.5) ng/ml in the controls (p < 0.001 v infarction and unstable angina; NS v stable angina). At a six months follow up, there was lower expression of CD40L/CD154 on platelets in patients with unstable angina (12.3 (3.6) v 3.8 (1.2) MFI, p < 0.0001) and acute myocardial infarction (6.2 (2.8) v 3.5 (0.8) MFI, p < 0.01) compared with their admission values six months earlier. Patients with unstable angina who needed redo coronary angioplasty (PTCA) or who had recurrence of angina were characterised by increased CD40L/CD154 expression on platelets compared with the remainder of the study group (recurrence of angina: 12.7 (3.2) v 9.7 (1.6) MFI, p < 0.05; re-do PTCA: 14.3 (4.2) v 10.3 (2.1) MFI, p < 0.05).
CONCLUSIONS—Both CD40L/CD154 on platelets and soluble CD40L/CD154 are raised in patients with unstable angina and myocardial infarction. These findings suggest that CD40-CD40L/CD154 interactions may play a pathogenic role in triggering and propagation of acute coronary syndromes.


Keywords: acute coronary syndromes; unstable angina; CD40L/CD154; platelets     

Long term outcome and cost-effectiveness of stenting versus balloon angioplasty for acute myocardial infarction

OBJECTIVE—To investigate the long term clinical outcome and cost-effectiveness of stenting compared with balloon angioplasty in patients with acute myocardial infarction.
METHODS—Patients with acute myocardial infarction were randomly allocated to primary stenting (112) or balloon angioplasty (115). The primary end point was the cumulative first event rate of death, non-fatal reinfarction, or target vessel revascularisation. Secondary end points were restenosis at six months and the cost-effectiveness at follow up.
RESULTS—After 24 months, the combined clinical end point of death/reinfarction was 4% after stenting and 11% after balloon angioplasty (p = 0.04). Subsequent target vessel revascularisation was necessary in 15 patients (13%) after stenting and in 39 (34%) after balloon angioplasty (p < 0.001). The cumulative cardiac event-free survival rate was also higher after stenting (84% v 62%, p < 0.001). The angiographic restenosis rate after stenting was less than after balloon angioplasty (12% v 34%, p < 0.001). Despite the higher initial costs of stenting (Dfl 21 484 v Dfl 18 625, p < 0.001), the cumulative costs at 24 months were comparable with those of balloon angioplasty (Dfl 31 423 v Dfl 32 933, p = 0.83).
CONCLUSIONS—Compared with balloon angioplasty, primary stenting for acute myocardial infarction results in a better long term clinical outcome without increased cost.


Keywords: stenting; angioplasty; myocardial infarction; cost-benefit analysis     

Combination treatment with trimetazidine and diltiazem in stable angina pectoris

Objective—To assess antianginal efficacy and possible adverse haemodynamic effects of combination treatment with trimetazidine and diltiazem in patients with stable angina.
Design—Double blind, randomised, placebo controlled trial of four weeks duration.
Setting—Outpatient department of two Indian hospitals.
Subjects—64 male patients with stable angina, uncontrolled on diltiazem alone.
Interventions—Diltiazem 180 mg and trimetazidine 60 mg, or diltiazem 180 mg and placebo daily.
Main outcome measure—Change in exercise time to 1 mm ST segment depression.
Results—33 patients (55%) had no exercise induced angina at 3 mm ST segment depression at inclusion in the study (silent ischaemia). Intention to treat analysis showed that of 32 patients in each treatment group, the number (%) of patients responding to trimetazidine compared to placebo was: for anginal attacks, 28 (87.5) v 15 (46.9), p < 0.001; for exercise time to 1 mm ST segment depression, 21 (65.6) v 9 (28.1), p < 0.003; for exercise time to angina, 12 (37.5) v 5 (15.6), p < 0.05; and for maximum work at peak exercise, 17 (53.1) v 8 (25), p < 0.02. Compared to placebo, there was net improvement with trimetazidine in mean anginal attacks of 4.8/week (95% confidence interval (CI) 7.5 to 2.1; p < 0.002); in mean exercise times at 1 mm ST segment depression of 94.2 seconds (95% CI 182.8 to 5.6; p < 0.05), and at onset of angina of 113.1 seconds (95% CI 181.6 to 44.6; p < 0.02); and in mean maximum work at peak exercise of 1.4 metabolic equivalents (95% CI 2.4 to 0.3; p < 0.05).
Conclusions—Patients with stable angina uncontrolled with diltiazem had a clinically important improvement after combination treatment with trimetazidine, without adverse haemodynamic events or increased side effects.

Keywords: trimetazidine;  diltiazem;  blood pressure;  stable angina;  treatment     

Left ventricular function in adults with mild pulmonary insufficiency late after Fallot repair

OBJECTIVE—To assess left ventricular function in adult Fallot patients with residual pulmonary regurgitation.
SETTING—The radiology department of a tertiary referral centre.
PATIENTS—14 patients with chronic pulmonary regurgitation and right ventricular volume overload after repair of tetralogy of Fallot and 10 healthy subjects were studied using magnetic resonance imaging.
MAIN OUTCOME MEASURES—Biventricular volumes, global biventricular function, and regional left ventricular function were assessed in all subjects.
RESULTS—The amount of pulmonary regurgitation in patients (mean (SD)) was 25 (18)% of forward flow and correlated significantly with right ventricular enlargement (p < 0.05). Left ventricular end diastolic volume was decreased in patients (78 (11) v 88 (10) ml/m²; p < 0.05), ejection fraction was not significantly altered (59 (5)% v 55 (7)%; NS). No significant correlation was found between pulmonary regurgitation and left ventricular function. Overall left ventricular end diastolic wall thickness was significantly lower in patients (5.06 (0.72) v 6.06 (1.06) mm; p < 0.05), predominantly in the free wall. At the apical level, left ventricular systolic wall thickening was 20% higher in Fallot patients (p < 0.05). Left ventricular shape was normal.
CONCLUSIONS—Adult Fallot patients with mild chronic pulmonary regurgitation and subsequent right ventricular enlargement showed a normal left ventricular shape and global function. Although the left ventricular free wall had reduced wall thickness, compensatory hypercontractility of the apex may contribute to preserved global function.


Keywords: left ventricular function; pulmonary insufficiency; tetralogy of Fallot; magnetic resonance imaging     

Motor function of the proximal stomach and visceral perception in gastro-oesophageal reflux disease

Background—The abnormally high postprandial rateof transient lower oesophageal sphincter relaxations seen in patientswith reflux disease may be related to altered proximal gastric motor function. Heightened visceral sensitivity may also contribute toreporting of symptoms in these patients.
Aims—To assess motor function of the proximalstomach and visceral perception in reflux disease with a barostat.
Methods—Fasting and postprandial proximal gastricmotility, sensation, and symptoms were measured in nine patients withreflux disease and nine healthy subjects. Gastric emptying of solids and liquids was assessed in six of the patients on a different day (andcompared to historical controls).
Results—Minimal distending pressure and gastriccompliance were similar in the two groups, whereas the patientsexperienced fullness at lower pressures (p<0.05) and discomfort atlower balloon volumes (p<0.005) during isobaric and isovolumetricdistensions respectively. Maximal gastric relaxation induced by themeal was similar in the two groups. Late after the meal, however,proximal gastric tone was lower (p<0.01) and the score for fullnesshigher (p<0.01) in the reflux patients, in whom the retention of both solids and liquids in the proximal stomach was greater (p<0.05).
Conclusions—Reflux disease is associated withdelayed recovery of proximal gastric tone after a meal and increasedvisceral sensitivity. The former may contribute to the increasedprevalence of reflux during transient lower oesophageal sphincterrelaxations and the delay in emptying from the proximal stomach,whereas both may contribute to symptom reporting.

Keywords:barostat; tone; compliance; mechanics

     

Plasma N terminal pro-brain natriuretic peptide and cardiotrophin 1 are raised in unstable angina

OBJECTIVE—To compare circulating concentrations of N terminal pro-brain natriuretic peptide (N-BNP) and cardiotrophin 1 in stable and unstable angina.
DESIGN AND SETTING—Observational study in a teaching hospital.
PATIENTS—15 patients with unstable angina, 10 patients with stable angina, and 15 controls.
MAIN OUTCOME MEASURES—Resting plasma N-BNP and cardiotrophin 1 concentrations.
RESULTS—N-BNP concentration (median (range)) was 714 fmol/ml (177-3217 fmol/ml) in unstable angina, 169.5 fmol/ml (105.7-399.5 fmol/ml) in stable angina (p = 0.005 v unstable angina), and 150.5 fmol/ml (104.7-236.9 fmol/ml) in controls (p < 0.0001 v unstable angina; NS v stable angina). Cardiotrophin 1 concentration was 142.5 fmol/ml (42.2-527.4 fmol/ml) in unstable angina, 73.2 fmol/ml (41.5-102.1 fmol/ml) in stable angina (p < 0.05 v unstable angina), and 27 fmol/ml (6.9-54.1 fmol/ml) in controls (p < 0.0005 v stable angina; p < 0.0001 v unstable angina). Log cardiotrophin 1 correlated with log N-BNP in unstable angina (r = 0.93, p < 0.0001).
CONCLUSIONS—Both circulating N-BNP and cardiotrophin 1 are raised in unstable angina, while cardiotrophin 1 alone is raised in stable angina. The role of cardiotrophin 1 and the relation between cardiotrophin 1 and N-BNP in myocardial ischaemia remain to be defined.


Keywords: cardiotrophin 1; brain natriuretic peptide; angina pectoris     

Stent implantation for aortic coarctation and recoarctation

OBJECTIVE—To determine the early results of balloon expandable stent implantation for aortic coarctation or recoarctation.
DESIGN—Prospective observational study.
SETTING—Two paediatric cardiology tertiary referral centres.
PATIENTS—17 patients, median age 17 years (range 4.4 to 45) and median weight 61 kg (17 to 92). Six had native aortic coarctation and 11 had aortic recoarctation; 14 had upper limb systolic hypertension. Of those with recoarctation, eight had had at least one previous balloon dilatation attempt and two of these patients also had further surgical interventions.
INTERVENTION—Balloon expandable Palmaz iliac stent implantation.
MAIN OUTCOME MEASURES—Systolic pressures gradients, minimum aortic diameter, upper limb blood pressures, and incidence of aneurysm formation.
RESULTS—18 stents were implanted during 18 procedures in the 17 patients. Mean peak systolic pressure gradient fell from 26 mm Hg (95% confidence interval (CI), 21 to 31 mm Hg) before to 5 mm Hg (2 to 8 mm Hg) after stent implantation (p < 0.001), and mean minimum aortic diameter increased from 7 mm (95% CI, 6 to 8 mm) before to 11.3 mm (10 to 12.6 mm) after implantation (p < 0.001). Complications occurred in five patients (bleeding in two, stent migration in two, and aneurysm formation in one). Two patients remained borderline hypertensive and eight were receiving antihypertensive treatment at most recent assessment.
CONCLUSIONS—Stent implantation for aortic recoarctation and native coarctation gives good immediate results. Careful follow up is necessary to evaluate complications and the long term effect on blood pressure.


Keywords: coarctation; aortic recoarctation; stents     

Late onset systemic lupus erythematosus in southern Chinese

OBJECTIVE—Systemic lupus erythematosus (SLE) is a multisystem disorder that predominately affects women of the reproductive age. Onset of the disease beyond the age of 50 years is unusual. This study was undertaken to compare retrospectively the clinical and laboratory features between early and late onset (onset of disease beyond the age of 50 years) SLE patients in a Chinese population.
METHODS—Case records of all SLE patients who attended our rheumatology clinics between 1971 and 1997 were reviewed. Patients with a disease onset beyond the age of 50 years were identified. One hundred consecutive SLE patients who had their disease onset before the age of 50 were recruited as controls. The presenting clinical features, autoantibody profile, number of major organs involved, number of major relapses, and the use of cytotoxic agents in the two groups of patients were obtained and compared.
RESULTS—25 patients with late onset SLE were identified. All the female patients in the late onset group were postmenopausal. The female to male ratio was 3.2 to 1, compared with 13.3 to 1 in the control group (p<0.02). Both groups had a comparable duration of disease. There were no significant differences in the presenting features between the two groups except for a lower prevalence of malar rash (24% v 86%, p<0.0001) and a higher prevalence of rheumatoid factor (32% v 1%, p<0.0001) in the late onset patients. On subsequent visits, the late onset group had a lower prevalence of lupus nephritis (4% v 51%, p<0.001), fewer major organs involved (mean number of major organs involved; 0.3 v 0.9, p<0.02), fewer major relapses (mean number of major relapses/patient; 0.08 v 0.47, p<0.002, number of major relapses/patient year; 0.009 v 0.12, p<0.001), and required fewer cytotoxic agents for disease control (percentage of patients on cytotoxic agents; 32% v 79%, p<0.002).
CONCLUSION—Late onset SLE in Chinese tends to run a more benign course with fewer major organ involvement and fewer major relapses. The significantly higher incidence of male sex in late onset SLE and the milder disease course in the postmenopausal female patients suggest that oestrogen status may influence disease activity.

Keywords: systemic lupus erythematosus; southern Chinese; Asians     

Pathology of idiopathic megarectum and megacolon

Background—The aetiology and pathology of bothidiopathic megarectum and idiopathic megacolon are unknown. Inparticular, it is unknown whether there are abnormalities involvingenteric nerves or smooth muscle.
Methods—Resected tissue was examined from 24 patients who underwent surgery for idiopathic megarectum, from sixpatients who had tissue resected for idiopathic megacolon, and 17 control patients who had surgery for non-obstructing large bowelcancer. Qualitative and quantitative histological examination wasperformed after staining with haematoxylin and eosin, periodic acidSchiff (PAS), Martius scarlet blue (MSB), and phosphotungstic acidhaematoxylin (PTAH). Neural and glial tissue were examined afterimmunostaining with S100 and PGP9.5.
Results—Compared with controls, patients withidiopathic megarectum had significant thickening of their muscularismucosae (median 78 v 33 µm, p<0.005), circular muscle(1000 v 633 µm, p<0.005), and longitudinal muscle (1083 v 303 µm, p<0.005), despite rectal dilatation. Thisthickening was relatively greater in the longitudinal than in thecircular muscle. Fibrosis of the longitudinal muscle was seen, usingMSB staining, in 58%, of circular muscle in 38%, and of muscularismucosae in 29% of patients. The relation between muscle thickening andfibrosis was variable. The density of neural tissue in the longitudinalmuscle seemed to be reduced in patients with idiopathic megarectum.There was no thickening of enteric muscle or alteration in the densityof innervation in patients with idiopathic megacolon.
Conclusion—There is notable thickening of theenteric smooth muscle in patients with idiopathic megarectum, but thearchitecture of the enteric innervation seems to be intact. Functionalabnormalities of the latter remain a possible cause of the smoothmuscle hypertrophy.

Keywords:idiopathic megarectum; idiopathic megacolon