Androgenic status and sexual function in males with rheumatoid arthritis and ankylosing spondylitis

The pituitary-testicular axis was investigated in 31 males with rheumatoid arthritis (age range 19-60 years, median 55 years) and 33 males with ankylosing spondylitis (age range 22-55 years, median 37 years) and compared with a control group of 95 normal male volunteers. Using analysis of covariance, patients with rheumatoid arthritis showed significantly lower serum testosterone (p less than 0.05) and derived free testosterone (p less than 0.01) concentrations and significantly higher serum LH and FSH concentrations (p less than 0.05) compared with controls. All patients had normal serum prolactin and cortisol concentrations. Serum testosterone correlated with ESR, haemoglobin concentrations and rheumatoid factor titres (r = -0.448, p less than 0.02; r = 0.440, p less than 0.02; r = -0.360, p less than 0.05 respectively) in the rheumatoid patients. Although there was a significant negative correlation between ESR and haemoglobin concentrations (p less than 0.005) in the patients with ankylosing spondylitis, neither variable correlated with serum testosterone concentrations. There was no association between testicular dysfunction and the presence of extra-articular features of rheumatoid arthritis. Ten patients (33 per cent) with rheumatoid arthritis and four (13 per cent) with ankylosing spondylitis admitted to periods of impotence while 15 (50 per cent) of the former and 12 (39 per cent) of the latter had periods of decreased libido. There was no evidence for increased rates of infertility in either group.     

Age and Other Determinants of Survival After In-hospital Cardiopulmonary Resuscitation

A retrospective review of 274 patients who received in-hospitalcardiopulmonary resuscitation was performed to determine whetherage is independently associated with survival to discharge.Eighty-two (29.9 per cent) of the 274 patients were resuscitatedinitially, but only 25 (9.1 per cent) were discharged alive.Survival to discharge was significantly poorer in patients aged70 years (6/175; 3.4 per cent) than in patients <70 yearsold (19/99; 19.2 per cent) (p<0.001). Severity of illness,assessed by the number of diagnoses and a multifactorial morbidityindex, did not differ between the two age groups. The best resultswere obtained with witnessed arrests, ventricular arrythmiasand resuscitation lasting less than 5 minutes; however, elderlypatients were less likely to be resuscitated in all circumstances.Age (r=–0.31, p<0.001) and the morbidity index r=–0.18,p<0.05) were independently associated with survival by multivariateanalysis. These results indicate that advanced age is an important independentdeterminant of survival after resuscitation. This should betaken into consideration when making in-hospital resuscitationdecisions.     

Clinico-pathological Correlations and Long-term Follow-up of 253 United Kingdom Patients with IgA Nephropathy. A report from the MRC Glomerulonephritis Registry

The Medical Research Council's Glomerulonephritis Registry wasused to study clinicopathological correlations and renal survivalin patients with IgA nephropathy reported between 1978 and 1985.IgA nephropathy was the histological diagnosis in 9.3 per centof all renal biopsies reported to the registry during this period,and in 18.1 per cent of those with a primary glomerulonephritis.The 10-year cumulative renal survival rate accounting for censoreddata (Kaplan-Meier) was 83.3 per cent. Univariate analysis ofsurvival curves (log-rank test) found the following parametersto be significantly correlated with poor renal survival: serumcreatinine >120 µmol/l (p<0.001), hypertension(p<0.001), serum albumin <40 g/l (p<0.005), proteinuria>1 g (p<0.025), age >30 years (p<0.025), and focalmesangial proliferation (p<0.05). There was no significantdifference in renal survival between males and females. Multivariateanalysis (Cox's proportional hazards model) revealed that onlya serum creatinine of > 120 µmol/l and a serum albuminof <40 g/l were independently predictive of outcome. These findings indicate marked similarities between the UK experienceof IgA nephropathy and the published European experience. IgAnephropathy is not a benign condition in the UK and patientswith impaired renal function and/or those with a reduced serumalbumin are significiantly more likely to progress to end-stagerenal failure within 10 years.     

Prevalence of Persistent Cough During Long-term Enalapril Treatment: Controlled Study Versus Nifedipine

The prevalence and severity of cough during long-term enalapriltreatment were examined by comparing a cohort of 136 hypertensivepatients who started treatment with enalapril with consecutiveage and sex-matched patients who commenced nifedipine therapyduring the same period. Cough and other symptoms were assessedby a questionnaire designed to avoid bias towards reportingcough. After a mean of 27 months' treatment patients on enalaprilhad an excess of persistent cough (16 per cent, 95 per centCI 7–25, p < 0.01), voice change (14 per cent, 95 percent CI 2–27, p < 0.05) and sore throat (10 per cent,95 per cent CI –0.1 to 20.3 per cent, p < 0.01) whencompared to nifedipine-treated patients. The cough was usuallydry, moderate or severe, paroxysmal, and troublesome at night.Cough tended to be more common in women (23 per cent vs. 7.2per cent), non-smokers, and at higher doses of enalapril, butwas not related to age, duration of treatment, or chronic respiratorydisease. Dry cough commonly persists as a troublesome side-effectduring long-term enalapril treatment, and is often associatedwith voice change and sore throat.     

Patterns of Insulin Dependence in an African Diabetic Clinic

SUMMARY Analysis of the age of onset of diabetes amongst insulin-treatedpatients in a large African diabetic clinic revealed a bimodaltype of distribution, 23 per cent having an age of onset before30 years and 77 per cent with onset at 30 years of age. All66 of the young insulin-treated group (21.7±4.8 years(mean±1 SD)), and a random selection of 50 older insulin-treatedpatients (49.7±10 years), were studied. The older groupwere better controlled (HbA₁ 8.4±1.7 per cent vs. 10.8±2.6per cent, p<0.001), on lower doses of insulin (49±23vs. 71±23 u/day, p<0.001) and had higher body massindex (26.0±5.6 vs. 21.8±3.5, p<0.001). SerumC-peptide (0.24±0.15 vs. 0.07±0.10 nmol/l, p<0.0001),and C-peptide/glucose ratio (2.57±2.65 vs. 0.56+0.98nmol/mmolx 10², p<0.001) were very significantly higher inolder patients. Patients with later onset disease thus had betterpreservation of pancreatic function, higher body mass indexand better glycaemic control on lower doses of insulin. Thesefeatures suggest that older insulin-treated patients could infact be ‘Type 2’ or non-insulin dependent patients,and the condition may be controllable with diet and/or oralhypoglycaemic agents, at least in some.     

Haemostatic Changes in the Loin Pain and Haematuria Syndrome: Secondary to Renal Vasospasm?

Twenty-five patients (seven male, 18 female) were diagnosedas having the loin pain and haematuria syndrome. Presentingsymptoms were either loin pain alone or pain associated withmacroscopic or microscopic haematuria, and were longstanding,having been present for mean of 9.3 years in males, and 10 yearsin females. Ten patients described symptoms of passing gravelor renal stones but these were only demonstrated radiologicallyin two patients. Investigation of all patients showed anatomicallynormal renal tracts, normal renal function, and no significantproteinuria. Phase-contrast microscopy during episodes of haematuriarevealed dysmorphic red cells in all 10 patients studied. Renalbiopsies were performed in 20 patients and showed no glomerularpathology, but arteriolar and arterial hyalinosis was seen in13 of 20 (65 per cent), fibro-elastosis in larger vessels ineight of 20 (40 per cent) and red blood cells in tubules in13 of 20 (65 per cent) patients. The histological appearancein vessels was similar to that seen in cyclosporin A nephrotoxicityand would be consistent with the hypothesis that regional vasospasmoccurs in the cortical circulation. Haematological studies in22 patients, when compared with age and sex matched controls,showed the presence of circulating platelet aggregates, elevationof plasma ß-thromboglobulin (p < 0.001), and increasedplatelet aggregation in response to serotonin and ADP (p <0.05 and p < 0.03, respectively). Plasma concentrations ofD dimer (p < 0.02) and C-reactive protein (p < 0.03) werealso significantly elevated in the patient group. There wasno deterioration of renal function during a mean observationperiod of 3.7 years and no patients developed proteinuria. Treatmentwas largely supportive; seven patients with intractable loinpain underwent surgical denervation with the relief of painin four.     

Study of Lupus Nephritis in Males

Clinical and pathological findings were studied in 23 male patientswith lupus nephritis who were followed up for a period of 41±36months after renal biopsy. Age at renal biopsy was 31±14years and 19 patients (83 per cent) were between 15 and 50 yearsold. C3 and C4 levels were below normal in 23 (100 per cent)and 16 (70 per cent) respectively, CH₅₀ was <25 u/ml in 67per cent, and antinuclear and anti-DNA antibodies were foundin 87 per cent and 82 per cent respectively. Serum albumin levelincreased from 2.9±0.8 g/dl to 3.7±0.8 g/dl duringthe follow up period (p<0.01), while urinary protein decreasedfrom 2.0±2.3 g/day to 1.4±2.5 g/day. There wasa significant improvement in the degree of haematurai (p <0.01),but serum creatinine levels showed no change (mean 1.5 mg/ml).Active proliferative lupus nephritis of, moderate or severedegree was observed in 65 per cent of patients at the initialbiospsy. A trend to regression in this activity was seen inmost serial biopsies, but the chronicity index showed a slightincrease. These data demonstrate that systemic lupus erythematosusin males, in comparison to our previous report of the diseasein female patients, is accompanied by more active nephritis,but that is follows a benign course with therapy.     

A Comparative Study of the Relative Effects of Anticonvulsant Drugs and Dietary Folate on the Red Cell Folate Status of Patients with Epilepsy

In a survey of the red cell folate status of 200 patients withepilepsy, compared to 72 controls, we found that median redcell folate levels were reduced significantly in patients treatedwith phenytoin (p<0.01) or carbamazepine (p<0.001) alone.Patients taking more than one drug had reduced levels also (p<0.001),but in patients treated with sodium valproate alone there wasno significant decrease in red cell folate levels compared tocontrols. Twenty-two per cent of patients in the group takingmore than one drug had reduced levels of red cell folate comparedwith 17 per cent of those taking carbamazepine alone, 13 percent of those taking phenytoin only, and 9 per cent of thosetaking sodium valproate only. Dietary folate intake was significantlyreduced in all the patient groups compared with controls (p<0.001for the carbamazepine and phenytoin groups, p<0.01 for thepolypharmacy and sodium valproate groups); a significant correlation,between red cell folate levels and dietary folate was not established. Significant negative relationships were established betweencarbamazepine dose (r=0.35, p<0.01) or serum level (r=-0.27,p<0.05) and red cell folate level in patients on one drugonly. The correlation between dose or serum level-of phenytoinand red cell folate level was also negative but did not reachsignificance. Our findings show that all anticonvulsant drugs interfere withfolate metabolism. While the effect is greatest with drugs whichinduce microsomal liver enzymes, low levels of folate also occurredin patients taking the non-enzyme inducer sodium valproate.Although a significant relationship between diet and red cellfolate was not established, dietary folate could be a furthercontributory factor.     

Safety and efficacy of increasing wintertime vitamin D and calcium intake by milk fortification

We studied the safety and efficacy of milk fortified with vitaminD₃ and calcium. Over the winter, we conducted a double-blind,placebo-controlled trial of fortified milk (12µg vitaminD₃ and 1525 mg calcium per litre) compared to unfortified milk(0.3µg vitamin D₃ and 1270 mg calcium per litre) in 102adults (aged 17–54 years). Serum 25-hydroxyvitamin D [25(OH)D],ionized calcium, and creatinine were measured at baseline andafter intervention. Fortification reduced the seasonal declinein serum 25(OH)D concentrations by >50%. In the fortifiedgroup, serum 25(OH)D decreased by 15nmol/l from 77±35nmol/l to 62±26 nmol/l (p<0.001). In the control group,serum 25(OH)D fell by 31 nmol/l from 85±39 nmol/l to54±25 nmol/l (p<0.001). We suggest that milk enrichedwith vitamin D be provided in high-latitude European countriesto diminish the wintertime fall in serum 25(OH)D.     

Endocrine Function, Psychiatric and Clinical Consequences in Patients With Macroprolactinomas After Long-term Treatment With the New Non-ergot Dopamine Agonist CV205-502

Although bromocriptine is the mainstay of treatment of macroprolactinomas,its therapeutic usefulness may be limited by poor tolerance,lack of consistent reduction in serum prolactin levels and tumoursize, and the necessity for multiple dosing. Consequently newdopamine agonists have been developed, including the long actingnon-ergot agonist CV205–502 which has been shown to dateto be consistently effective in reducing serum PRL levels andcausing tumour shrinkage. Twelve patients were treated for periods of up to 24 monthswith CV205–502 in doses ranging from 0.075 mg to 1.65mg once daily. Clinical and psychiatric assessments, biochemicalparameters, tumour size determination, and anterior pituitaryfunction tests were performed regularly. Tumour shrinkage wasnoted in all patients, and varied from 11 per cent reductionto complete disappearance of tumour. Prolactin levels becamenormal in seven patients and were reduced by more than 90 percent in the remaining five. Normal menstruation resumed in sixof the eight women, one of whom conceived after one year oftherapy; libido returned in all patients. Psychiatric complicationsoccurred in three patients necessitating withdrawal of therapyin one. Significant weight loss was noted in 11 of 12 patients. Triglyceride concentrations fell from 1.5±0.1 to 1.0±0.1mmol/l at 12 months (p=0.006), and cholesterol fell from 6.3±0.4to 5.3±0.3 mmol/l (p=0.04). The mean TSH response 20min following TRH injection fell from 14.3±2.9 to 8.7±1.3mU/l at 2 months (p=0.027). There was a significant increasein the peak growth hormone response to the insulin stress testfrom basal median (25th–75th centiles) values of 15 (4.4–25.5)mU/l to 24.5 (9–37) mU/l at 2 months (p<0.01) and 31(19.3–63.5) at 12 months (p<0.005). CV205–502 is highly effective in the medical managementof patients with macroprolactinomas, reducing prolactin levelsand tumour size and restoring normal anterior pituitary function.It is, however, associated with the important side effects ofweight loss and pychiatric complications which should be drawnto the attention of clinicians.     

Hyperthyroidism in the Land of Graves: Results of Treatment by Surgery, Radio-iodine and Carbimazole in 837 Cases

A review of the outcome of treatment by subtotal thyroidectomy,radio-iodine and carbimazole of 837 patients with hyperthyroidismseen consecutively over the period 1954–78 inclusive ispresented. The age and sex distribution, the male to femaleratio, the ABO blood group distribution and the prevalence ofpernicious anaemia and diabetes mellitus in these patients wasalso analysed. Life-table data showed that the five-year andten-year cumulative relapse rates following a two-year courseof carbimazole (n = 162) were 56 per cent and 62 per cent; followingsurgery (n = 266), 6 per cent and 10 per cent and followingradio-iodine (n = 43), 3 per cent and 14 per cent. Five-yearand ten-year cumulative hypothyroid rates after surgery were10 per cent and 18 per cent, and after radio-iodine 10 per centand 30 per cent. Hypothyroidism did not occur after carbimazoletherapy. Of 31 patients who took carbimazole for less than twoyears (mean 11 months, range 6–19 months), 91 per centhad relapsed at five years. Of 79 patients treated for longerthan two years (mean 3.8 years, range 2–14 years), relapserates at five and eight years were 49 per cent and 62 per cent.Nine patients (3.4 per cent) suffered permanent vocal cord paralysisand five (1.9 per cent) had permanent hypocalcaemia. The male/female ratio was 9.9 to 1, with a peak female prevalencebetween 25 and 30 years and a peak male prevalence between 40and 45 years. The ABO blood group distribution among patients did not differsignificantly from the distniution in the general population(x² = 13.4, p = 0.2). Forty-seven patients (5.6 per cent) had diabetes mellitus andthyrotoxicosis whilst two patients (0.23 per cent) had diabetes,thyrotoxicosis and pernicious anaemia.     

Percutaneous Transluminal Angioplasty for Atheromatous Renal Artery Stenosis - Blood Pressure Response and Discriminant Analysis of Outcome Predictors

Percutaneous transluminal angioplasty was performed in 39 consectivepatients with atheromatous renal artery stenosis associatedwith hypertension. The mean blood pressure before angioplastywas 191/107 mm Hg and this had dropped to a mean of 167/90 mmHG at the patient's most recent visit, representing a significantfall in both systolic (p<0.01) and diastolic pressures (p<0.001).The mean serum creatinine was 166.7 µmol/l before percutaneoustransluminal angioplasty and 155.3 µmol/1 at the mostrecent visit (not statistically significant. The mean numberof anti-hypertensive drugs fell from 2.4 to1.9 after percutaneoustransluminal angioplasty (p<0.05). Three patients (eightper cent) were ‘cured’ (diastolic blood pressure<90 mm Hg without medication), 25 (64 per cent) had ‘improved’(diastolic blood pressure <109 mmHg, with a fall of morethan 15 per cent) and 11 (28 per cent) had not improved. Logisticdiscriminant analysis showed that pre-percutaneous transluminalangioplasty diastolic blood pressure, age, serum creatinineand smoking habit together correctly predicted the outcome ofpercutaneous transluminal angioplasty in 90 per cent of patients,with four ‘false positives’ and no ‘falsenegatives’. Ten patients suffered, a total of 12 seriouscomplications related to the procedure: one death in acute renalfailure, one myocardial infarction, one severe hypotension,just after the procedure, one deep vein thrombosis, one episodeof transient ischaemia of the toes and seven groin haematomas.Thus percutaneous transluminal angioplasty for atheromatousrenal artery stenosis rarely ‘cures’ hypertension,but improved blood pressure control is often achieved, albeitat the expense of troublesome complications. A prospective,randomized trial is needed to establish whether or not the improvementis due directly to percutaneous transluminal angioplasty.     

Lipoprotein(a) as a determinant of the severity of angiographically defined carotid atherosclerosis

We measured fasting serum lipids, lipoproteins, apolipoproteinsand lipoprotein(a) [Lp(a)] in 49 Caucasian patients with transientischaemic attacks undergoing carotid angiography. The severityof extracranial cerebrovascular disease was assessed visuallyby a highly reproducible grading system that focused on theinternal carotid artery and carotid bifurcation. Compared witha healthy reference group, patients had significantly higherserum concentrations of: total cholesterol (mean ± SD),6.2 ± 1.6 vs. 5.6 + 1.0 mmol/l, p = 0.02; apolipoproteinB, 1.4 ±0.5 vs. 1.2±0.3g/l, p = 0.03; triglyceride[geometric mean(95% Cl)], 2.02(1.75–2.32) vs. 1.66(0.67–4.06)mmol/l, p = 0.03; and Lp(a), 0.33(0.26–0.42) vs. 0.17(0.40–0.76)g/l, p <0.001. Regression analysis showed that of the lipoprotein-relatedvariables, only Lp(a) was significantly related to the severityof carotid artery disease (p = 0.04) in the patients; this associationremained significant after adjusting for age, sex, blood pressure,and a history of stroke. Serum Lp(a) concentration was significantlyhigher in patients with carotid artery disease severity scoreabove the median value of the sample population compared withthose below the median: 0.45 vs. 0.24 g/l (95% Cl for difference0.35–0.88), p = 0.01. Elevated serum Lp(a) is a significantdeterminant of the extent of carotid atherosclerosis and maybe useful in identifying patients most at risk of stroke.     

Epidemiological Survey of Coeliac Disease and Inflammatory Bowel Disease in First-Degree Relatives of Coeliac Patients

One hundred and sixty-two of 182 patients with coeliac diseaseprovided satisfactory details of family size and the prevalenceof coeliac disease and inflammatory bowel disease among theirfirst-degree relatives. Patients ranged in age from 11 monthsto 79 years with a mean age of 41 (± 23) years. Twentypatients had at least one first-degree relative with coeliacdisease: a total of 25 of 861 relatives were affected (prevalence=2904/100,000)compared with an expected 0.9 cases (prevalence=100/100,000;p <0.001). Six relatives had inflammatory bowel disease (prevalence=697/100,000)compared with an expected 1.3 cases (prevalence=150/100,000;p <0.001). Five of these had ulcerative colitis, and onehad Crohn's disease. The relative risk of ulcerative colitisis, therefore, five times greater for first-degree relativesof people with coeliac disease than for the general population(95 per cent confidence interval, 4.7–7.2). There is clearassociation between coeliac disease and ulcerative colitis,which may point to factors involved in the aetiology of colitis.     

Prolactin Dynamics and Tumour Size in the Prediction of Surgical Outcome for Prolactinoma

Each of 62 females were studied for a period of between twoand 72 months ( mean 36 months) following the removal of a prolactinomaby transsphenoidal pituitary surgery. Our aims were to definethe relationships between pre- and post-operative features,the operative findings and the functional outcome. Pre-operativeserum prolactin (PRL) concentrations correlated with tumourdiameter (r = 0.55, p < 0.001). Following surgery two groupsof patients were identified: Group 1, 46 spontaneously and regularlymenstruating patients and Group 2, 16 patients with persistentamenorrhoea. The patients in Group 1 had significantly lowerpre-operative and postoperative serum (PRL) concentrations (p< 0.02 and p < 0.001 respectively) and significantly greaterPRL responses to thyrotrophin releasing hormone (TRH) and metoclopramidestimulation after surgery (p < 0.001). There was not a significantdifference in tumour size between the groups. Forty-four (96per cent) of the patients in Group 1 had normal post-operativeserum PRL concentrations within one week of surgery. By comparison(p < 0.001) only 42 and 20 per cent respectively of Group1 patients who were tested had normal TRH and metoclopramideevoked PRL secretion following surgery. Return of regular menstruationwas associated with cessation of galactorrhoea in 44 patients(96 per cent) and ovulation occurred in 37 of 38 menstruatingpatients for whom data are available. All patients with normalTRH and metoclopramide stimulation tests menstruated spontaneously.Nevertheless most patients who menstruated did so in spite ofretaining suppressed PRL responses. Of 46 patients followedto date whose serum PRL was normal one week after surgery, sevenlater were found to have an elevation of serum PRL outside thenormal range but in only two has this been persistent. We suggestthat a single measurement of serum PRL one week following transsphenoidalpituitary surgery for prolactinoma provides a good basis fordeciding about the future management of patients who desiremenstruation and pregnancy.     

The Relationship Between Long-term Glycaemic Control and Diabetic Nephropathy

Urine albumin excretion was studied by two widely accepted methodsin 210 patients with insulin-dependent diabetes mellitus andrelated to the mean of serial glycosylated haemoglobin (HbA₁)measurements made every 3 months during the previous 6 years.Microalbuminuria (albumin excretion rate > 20 µg/min)was present in 9.5 per cent of patients when defined by a 24-hourcollection and 8.1 per cent of patients when defined by a timedovernight urine sample. Those with microalbuminuria, as estimatedfrom a timed overnight urine sample, had a longer duration ofdiabetes but otherwise did not differ in age, duration of diabetesor arterial blood pressure from patients whose albumin excretionrate was 20 µg/min or less irrespective of the methodof urine collection. The mean and the most recent HbA₁ levelsdiffered significantly between the normal and the microalbuminuriagroups when defined by the 24-hour albumin excretion rate (p<0.001,p<0.01), but no significant difference between these groupswas found when albumin excretion rates were calculated fromthe timed overnight urine sample. Albumin excretion rate, examinedin relation to mean HbA₁, increased significantly with worseningglycaemic control whether measured over 24 hours or overnight(p<0.05, p< 0.01). These findings support an associationbetween glycaemic control and microalbuminuria, but the correlationis weak, dependent on the method of urine collection and isjust as good for a relatively short-term as for a long-termmeasure of average blood glucose.     

Progression of Diabetic Autonomic Neuropathy over a Decade in Insulin-Dependent Diabetics

The prognosis for diabetics with autonomic neuropathy is littleknown. We therefore studied the progress of young insulin-dependentdiabetics, first identified as having abnormal autonomic function10–15 years ago. We have shown that the mortality of diabeticswith symptomatic authonomic neuropathy is increased, but isless than previously reported. Mortality in asymptomatic diabeticswith an isolated abnormality in autonomic function tests isnot increased. The heart rate variability declines at 1.02±0.47(SD) per annum in diabetics with an initially normal heart ratevariability. While symptoms of autonomic neuropathy do not usuallyremit even over a decade, they do not commonly progress. Three groups of young insulin-dependent diabetics had heartrate variability tested between 1972 and 1977 and have beenreviewed 10–15 years later. Group A (n=49) had symptomaticautonomic neuropathy and an abnormal heart rate variability(<12), Group B (n=24) were asymptomatic yet had an abnormalheart rate variability and Group C (n=38) were asymptomaticand had a normal heart rate variability (16–26). The 10-yearsurvival in Group A (73.4 per cent) was less (P<0.05) thanin Groups B (91.7 per cent) or C (89.5 per cent) which did notdiffer from each other. The 18 Group A deaths were due predominantlyto renal failure (n=4), myocardial infarction in patients withnephropathy (n=3) and sudden unexpected death (n=3). The chiefsymptoms of autonomic neuropathy-diarrhoea, postural hypotensionand gustatory sweating, were very persistent but did not necessarilydeteriorate or become disabling in the majority of patients.The development of autonomic symptoms in asymptomatic patientswith abnormal heart rate variability was uncommon over a decade.     

Quality of Life and Survival Following Intensive Medical Care

SUMMARY The relation between quality of life before admission and theoutcome of admission to the intensive care unit (ICU) was studiedprospectively among 126 patients in a community hospital witha predominantly geriatric patient population. Fifty-four percent of our patients were older than 65 years and 66 per centsuffered from chronic ill health. Their mean APACHE score was18±8 (mean±SD). Quality of life was assessed bythe Karnofsky index of physical performance; the linear analogueself assessment (LASA) score; sleep index; level of employment;sexual activity; housing status. Thirty-seven per cent of thepatients died in ICU and another 10 per cent in hospital. Theone year survival of the entire group was 37 per cent. Survivalrates were significantly higher in patients with a Karnofskyindex of 6 or more, LASA score of 55 or more, in employment,and with sleep index of 2 or more (p<0. 05). The 12-monthsurvival among patients with four favourable indicators was59 per cent, with two or three favourable indicators 36 percent (p<0. 05), and in patients with no favourable indicatorsof quality of life or only one 17 per cent (p<0. 001). Qualityof life in patients who survived longer than six months afterICU care was high (Karnofsky index 7. 9±2.0; LASA score71±20 (mean±SD) and unimpaired when compared withtheir ratings before admission to the unit. These findings indicatethat quality of life before admission is an important predictorof survival and that a high proportion of critically-ill subjectswhose quality of life was relatively good before the episoderequiring admission will be long-term survivors whose qualityof life is comparable to that preceding critical care.     

Prognosis of Critically-ill Patients with Acute Renal Failure: APACHE II Score and Other Predictive Factors

The survival from acute renal failure requiring renal replacementtherapy was studied in 90 critically-ill patients admitted toan intensive care unit. Mean age (± SD) was 51 ±14.6 (range 17 to 81) years. Mechanical ventilation was requiredin 88 patients and 71 patients received total parenteral nutrition.Thirty-three per cent of patients left the intensive care unitalive and 24 per cent survived to leave hospital. Final survivalwas 20 per cent in medical patients (n= 49), 29 per cent insurgical patients (n= 38) and 100 per cent in obstetric patients(n= 3). Hypotension, requirement for inotropic support, oliguriaand sepsis were all associated with a poorer prognosis. Themode of renal replacement therapy did not affect survival, butadditional haemodialysis was required in 33 of 65 patients treatedby continuous arteriovenous haemofiltration but none of 22 treatedwith continuous arteriovenous haemodialysis (p < 0.001).APACHE II score was calculated for 87 patients. Mean APACHED score was 26.1 ± 6.9 (range 14 to 44). APACHE II scoreon admission predicted the likelihood of survival well. No patientswith a score of more than 40 survived, compared to 40 per centof those with scores of 10 to 19. Pre-existing organ insufficiencyor immunosuppression meriting a CHE score of 5 was associatedwith a very poor survival (1 of 30 patients). APACHE II scoreis a reliable indicator of severity of illness and likelihoodof survival in critically-ill patients with acute renal failure.The widespread adoption of APACHE II scoring for patients withacute renal failure requiring intensive care would facilitatemedical audit and comparison of studies from various centres.