Increased state of activation of CD4 positive T cells and elevated interferon γ production in pouchitis

Background—Immunoregulatory abnormalities of Tcells might be of importance in the pathogenesis of pouchitis afterileoanal pouch anastomosis (IAP).
Aims—To characterise T cell subsets, their stateof activation, and production of cytokines in inflamed and non-inflamedpouches in patients with ulcerative colitis (UC) and familialadenomatous polyposis (FAP). The influence of T cell activation onmucosal transformation was also studied.
Patients—Mucosal biopsy specimens were taken from42 patients with IAP (33 with UC and nine with FAP).
Methods—Mononuclear cells were isolated bystandard techniques and characterised by three colour flow cytometry.Interferon γ (IFN-γ) production was studied using the ELISPOT technique.
Results—In patients with UC with pouchitis therewas a significant increase in the CD4:CD8 ratio, expression ofactivation markers on CD3+ cells, and number of IFNγ producingmononuclear cells compared with patients with UC without pouchitis(CD4:CD8 ratio 1.3 (range 0.7-2.7) versus 0.6 (0.1-1.0), p=0.012). Inaddition, a positive correlation between increased crypt depth and thenumber of CD4+ cells (r=0.57) was shown.
Conclusion—The observed increase in activatedmucosal CD4+ T cells and IFN-γ production might lead to mucosaldestruction and crypt hyperplasia as seen in pouchitis.

Keywords:pouchitis; T cell activation; mucosaltransformation

     

A UK training programme for nurse practitioner flexible sigmoidoscopy and a prospective evaluation of the practice of the first UK trained nurse flexible sigmoidoscopist

Background—Colonoscopic surveillance is astandard procedure in many patients with long standing, extensiveulcerative colitis (UC), in order to avoid death from colorectalcancer. No conclusive proof of its benefits has been presented however.
Aims—To evaluate the association betweencolonoscopic surveillance and colorectal cancer mortality in patientswith UC.
Patients—A population based, nested case controlstudy comprising 142 patients with a definite UC diagnosis, derivedfrom a study population of 4664 patients with UC, was conducted.
Methods—Colonoscopic surveillance in all patientswith UC who had died from colorectal cancer after 1975 was comparedwith that in controls matched for age, sex, extent, and duration of thedisease. Information on colonoscopic surveillance was obtained from themedical records.
Results—Two of 40 patients with UC and 18 of 102 controls had undergone at least one surveillance colonoscopy (relativerisk (RR) 0.29, 95% confidence interval 0.06 to 1.31). Twelve controls but only one patient with UC had undergone two or more surveillance colonoscopies (RR 0.22, 95% confidence interval 0.03 to 1.74), indicating a protective dose response relation.
Conclusion—Colonoscopic surveillance may beassociated with a decreased risk of death from colorectal cancer inpatients with long standing UC.

Keywords:colonoscopic surveillance; colorectal cancer; ulcerative colitis; epidemiology

     

Peripheral arthropathies in inflammatory bowel disease: their articular distribution and natural history

Background—Peripheral arthropathy is a well-recognised complication of inflammatory bowel disease (IBD). Little is known of its natural history, but a variety of joint involvement has been described, from large joint pauciarticular arthropathy to a rheumatoid pattern polyarthropathy.
Aims—To classify the peripheral arthropathies according to pattern of articular involvement, and study their natural history and clinical associations.
Methods—The case notes of all patients attending the Oxford IBD clinic were reviewed, and information on general disease characteristics, extraintestinal features, and arthropathy extracted. This was confirmed by direct patient interview using questionnaires at routine follow up. Patients with recorded joint swelling or effusion were classified as type 1 (pauciarticular) if less than five joints were involved and type 2 (polyarticular) if five or more were involved. Patients without evidence of swelling were classified as arthralgia.
Results—In total, 976 patients with ulcerative colitis (UC) and 483 with Crohn''s disease (CD) were reviewed. Type 1 occurred in 3.6% of patients with UC (83% acute and self-limiting) and in 6.0% of those with CD (79% self-limiting); 83% and 76%, respectively, were associated with relapsing IBD. Type 2 occurred in 2.5% of patients with UC and 4.0% of those with CD; 87% and 89%, respectively, caused persistent symptoms whereas only 29% and 42%, respectively, were associated with relapsing IBD.
Conclusion—Enteropathic peripheral arthropathy without axial involvement can be subdivided into a pauciarticular, large joint arthropathy, and a bilateral symmetrical polyarthropathy, each being distinguished by its articular distribution and natural history.

     

Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients

OBJECTIVE—To determine the effect of adjunctive prednisolone on morbidity, pericardial fluid resolution, and mortality in HIV seropositive patients with effusive tuberculous pericarditis.
DESIGN—Double blind randomised placebo controlled trial.
SETTING—Two medical school affiliated referral hospitals in Harare, Zimbabwe.
PATIENTS—58 HIV seropositive patients aged 18-55 years with tuberculous pericarditis.
INTERVENTIONS—All patients received standard short course antituberculous chemotherapy and were randomly assigned to receive prednisolone or placebo for six weeks.
MAIN OUTCOME MEASURES—Clinical improvement, echocardiographic and radiologic pericardial fluid resolution, and death.
RESULTS—29 patients were assigned to prednisolone and 29 to placebo. After 18 months of follow up there were five deaths in the prednisolone treated group and 10 deaths in the placebo group. Mortality was significantly lower in the prednisolone group (log rank χ² = 8.19, df = 1, p = 0.004). Resolution of raised jugular venous pressure (p = 0.017), hepatomegaly (p = 0.007), and ascites (p = 0.015), and improvement in physical activity (p = 0.02), were significantly more rapid in the prednisolone treated patients. However, there was no difference in the rate of radiologic and echocardiographic resolution of pericardial effusion.
CONCLUSIONS—Adjunctive prednisolone for effusive tuberculous pericarditis produced a pronounced reduction in mortality. It is suggested prednisolone should be added to standard short course chemotherapy to treat HIV related effusive tuberculous pericarditis.


Keywords: tuberculous pericarditis; HIV infection; echocardiography; prednisolone     

Five genetic markers in the interleukin 1 family in relation to inflammatory bowel disease

Background—An imbalance between theproinflammatory cytokine interleukin 1β (IL-1β) and theanti-inflammatory cytokine IL-1 receptor antagonist (IL-1ra) has beenpostulated as a pathogenic factor in inflammatory bowel disease (IBD).
Aims—To study allelic frequenciesof novel polymorphisms in the genes for IL-1β and IL-1ra in patientswith IBD and to assess the relation between ex vivo cytokine productionand allelic variants of the IL-1β and IL-1ra genes.
Subjects—Two hundred and seventyhealthy controls, 74 patients with ulcerative colitis (UC), 72 withCrohn's disease (CD), 40 with primary sclerosing cholangitis for theallelic frequencies, and 60 healthy individuals for the ex vivostimulation test.
Methods—Genotyping was performed bypolymerase chain reaction and subsequent cleavage with specificendonucleases (Mwo1, MspAI1, Alu1, Taq1, BsoF1) for five novelrestriction fragment length polymorphisms (RFLPs) in the genes forIL-1ra and IL-1β.
Results—No significant differences were found inthe allelic frequencies or allele carriage rates of the markers in theIL-1β and IL-1ra genes between CD, UC, and healthy controls. Noassociation between the genetic markers and cytokine production levelswas observed. Patients with UC carried the combination of both the infrequent allele of the Taq1 RFLP and the Mwo1 RFLP significantly morefrequently (35.2% in UC versus 71.1% in controls).
Conclusions—UC is associatedwith carriage of both infrequent alleles of the Taq1 and Mwo1 RFLPs.However, it could not be confirmed whether the association reflects apathogenic mechanism underlying UC.

     

Survival of patients with a new diagnosis of heart failure: a population based study

OBJECTIVE—To describe the survival of a population based cohort of patients with incident (new) heart failure and the clinical features associated with mortality.
DESIGN—A population based observational study.
SETTING—Population of 151 000 served by 82 general practitioners in west London.
PATIENTS—New cases of heart failure were identified by daily surveillance of acute hospital admissions to the local district general hospital, and by general practitioner referral of all suspected new cases of heart failure to a rapid access clinic.
INTERVENTIONS—All patients with suspected heart failure underwent clinical assessment, and chest radiography, ECG, and echocardiogram were performed. A panel of three cardiologists reviewed all the data and determined whether the definition of heart failure had been met. Patients were subsequently managed by the general practitioner in consultation with the local cardiologist or admitting physician.
MAIN OUTCOME MEASURES—Death, overall and from cardiovascular causes.
RESULTS—There were 90 deaths (83 cardiovascular deaths) in the cohort of 220 patients with incident heart failure over a median follow up of 16 months. Survival was 81% at one month, 75% at three months, 70% at six months, 62% at 12 months, and 57% at 18 months. Lower systolic blood pressure, higher serum creatinine concentration, and greater extent of crackles on auscultation of the lungs were independently predictive of cardiovascular mortality (all p < 0.001).
CONCLUSIONS—In patients with new heart failure, mortality is high in the first few weeks after diagnosis. Simple clinical features can identify a group of patients at especially high risk of death.


Keywords: heart failure; prognosis; survival; epidemiology     

Aortic balloon dilatation for congenital aortic stenosis: report of 90 cases (1986-98)

OBJECTIVE—To review 12 years of experience of balloon aortic valvoplasty in childhood.
DESIGN—Early and mid-term clinical and instrumental evaluation of 104 consecutive balloon aortic valvoplasties performed from 1986 to 1998.
SETTING—A tertiary referral centre for congenital heart disease.
PATIENTS—90 patients with congenital aortic stenosis: 20 neonates (group 1), 16 infants (group 2), and 54 children (group 3).
INTERVENTIONS—Balloon aortic valvotomy.
MAIN OUTCOME MEASURES—Doppler and peak to peak aortic gradient before and after valvoplasty, degree of aortic regurgitation before and after valvoplasty, early and late mortality, need for repeat intervention or surgery.
RESULTS—Balloon aortic valvoplasty produced a gradient reduction of > 50% in 59 patients, 12 having a residual peak to peak gradient of > 50 mm Hg. Early mortality included three procedure related and six procedure unrelated deaths. There were no intraprocedural deaths. Grade III aortic regurgitation occurred in 20 patients. Five non-lethal complications occurred. At a mean follow up of 5.1 (group 1), 5.7 (group 2), and 7.6 years (group 3), survival was 75%, 88%, and 96%, respectively. Redilatation was performed in three patients in group 1, one in group 2, and 10 in group 3. Surgery was necessary for six in group 1, one in group 2, and eight in group 3. Freedom from events at last follow up was 50%, 75%, and 64%, respectively. There was a residual maximum Doppler gradient of < 30 mm Hg in 22 patients and > 60 mm Hg in 23; 50 patients have mild to moderate aortic regurgitation.
CONCLUSIONS—Balloon aortic valvoplasty is effective and repeatable and offers good palliation for congenital aortic stenosis in childhood.


Keywords: aortic valve disease; paediatric cardiology; percutaneous valvotomy; interventional catheterisation     

Effects of smoking on the urine excretion of oral 51Cr EDTA in ulcerative colitis

Background—Smokers have a reduced risk andex-smokers an increased risk of ulcerative colitis (UC). Stoppingsmoking often precedes onset and relapses. Smoking reduces the 24 hoururine excretion of oral chromium-51 labelled EDTA in healthy individuals.
Aims—To estimate the effects of smoking on theurine excretion of oral ⁵¹Cr EDTA in well characterisedpatients with UC.
Subjects—Sixteen smoking and 16 non-smokingpatients with UC in remission were studied. The non-smokers had neversmoked. Most were taking 5-aminosalicylic acid. No patient tooksteroids or immunosuppressants. The control group comprised 25 smoking healthy volunteers and 25 who had never smoked. The median cigarette consumption was equal in the patients and volunteers.
Methods—The 24 hour urine excretion of oral⁵¹Cr EDTA was measured and the results were correlated withsmoking habits, number of cigarettes, and disease extent.
Results—Patients with UC had significantly higher24 hour urine recoveries than healthy controls (p=0.04). Thisdifference was more pronounced when patients who smoked were comparedwith healthy smokers (p=0.005) No significant differences were found when comparing non-smoking patients with non-smoking controls or whencomparing smoking and non-smoking patients. Urine recoveries did notcorrelate with number of cigarettes or disease extent. Smoking was moreprevalent in patients with a more limited disease extent (p=0.033).
Conclusions—Effects of smoking on the urineexcretion of ⁵¹Cr EDTA in health were abolished by thepresence of UC. The protective effects of smoking in established UC arenot due to a moderating effect of smoking on intestinal permeability.

Keywords:ulcerative colitis; smoking; intestinalpermeability; ⁵¹Cr EDTA

     

Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings,mortality, and revascularisation rate? The ACRE study

OBJECTIVE—To determine whether ratings of coronary angiography appropriateness derived by an expert panel on hypothetical patients are associated with actual angiographic findings, mortality, and subsequent revascularisation in the ACRE (appropriateness of coronary revascularisation) study.
DESIGN—Population based, prospective study. The ACRE expert panel rated hypothetical clinical indications as inappropriate, uncertain, or appropriate before recruitment of a cohort of real patients.
SETTING—Royal Hospitals Trust, London, UK.
PARTICIPANTS—3631 consecutive patients undergoing coronary angiography (no exclusion criteria).
MAIN OUTCOME MEASURES—Angiographic findings, mortality (n = 226 deaths), and revascularisation (n = 1556 procedures) over 2.5 years of follow up.
RESULTS—The indications for coronary angiography were rated appropriate in 2253 (62%) patients. 166 (5%) coronary angiograms were performed for indications rated inappropriate, largely for asymptomatic or atypical chest pain presentations. The remaining 1212 (33%) angiograms were rated uncertain, of which 47% were in patients with mild angina and no exercise ECG or in patients with unstable angina controlled by inpatient management. Three vessel disease was more likely among appropriate cases and normal coronaries were more likely among inappropriate cases (p < 0.001). Mortality and revascularisation rates were highest among patients with an appropriate indication, intermediate in those with an uncertain indication, and lowest in the inappropriate group (log rank p = 0.018 and p < 0.0001, respectively).
CONCLUSION—The ACRE ratings of appropriateness for angiography predicted angiographic findings, mortality, and revascularisation rates. These findings support the clinical usefulness of expert panel methods in defining criteria for performing coronary angiography.


Keywords: coronary artery disease; coronary angiography; coronary artery bypass graft; appropriateness of coronary revascularisation     

Imbalance of the interleukin 1 system in colonic mucosa—association with intestinal inflammation and interleukin 1 receptor agonist genotype 2

Background—Interleukin 1 (IL-1) α and β arepotent cytokines which play key roles in inflammation. They arecontrolled by IL-1 receptor antagonist (IL-1ra).
Aims—To investigate the influence of mucosalinflammation and IL-1ra genotype on the IL-1ra:IL-1 balance.
Patients and methods—IL-1α, IL-1β, and IL-1rawere measured by enzyme linked immunosorbent assay (ELISA) in biopsyspecimens taken from inflamed and non-inflamed colon of 60 patientswith Crohn's disease (CD), 34 with ulcerative colitis (UC), 15 inflammatory controls, and 103 non-inflamed controls. IL-1ra genotypewas determined by polymerase chain reaction and gel electrophoresis.
Results—IL-1α and IL-1β were significantlyincreased in inflamed mucosa in inflammatory bowel disease (IBD) (CD:53.5 (22.4) and 409.9 (118.7) pg/mg protein, respectively; UC: 18.9 (6.8) and 214.5 (78.2) pg/mg, respectively) and non-IBD patients (19.2(7.4) and 281.4 (121.0) pg/mg, respectively; p<0.0001) compared withnormal controls (2.8 (0.6) and 30.6 (5.6) pg/mg, respectively). In CDIL-1α and β were also significantly increased in non-inflamed mucosa (6.1 (1.3) pg/mg and 88.7 (17.4) pg/mg, respectively;p<0.0012). IL-1ra:(IL-1α+β) ratios were significantly decreased ininflamed mucosa of patients with CD (182 (45); p<0.0001), UC (425 (136); p=0.0018) and without IBD (221 (76); p<0.0001), and innon-inflamed mucosa in CD (369 (149); p<0.0001) compared with normalcontrols (1307 (245); p<0.0001). Patients with IL-1ra genotype 2 hadslightly but significantly reduced mucosal IL-1ra concentrations(p=0.003). The greatest difference was seen in colonic biopsy specimensfrom patients with inflamed Crohn's disease.
Conclusion—Mucosal inflammation can modulate thebalance of the IL-1:IL-1ra system in colonic mucosa.

Keywords:interleukin 1; interleukin 1 receptor antagonist; inflammatory bowel disease; Crohn's disease; mucosal inflammation; genotype

     

Early and intermediate term clinical outcome after multiple coronary stenting

Objective—To examine the immediate and intermediate term clinical outcome of multiple coronary stenting.
Design—Consecutive patients were prospectively entered on a dedicated database. Follow up information was obtained from outpatient and telephone interviews with patients and family physicians.
Setting—A tertiary referral centre.
Patients—140 consecutive patients underwent multiple coronary stenting between April 1994 and November 1996. Most patients had unstable coronary syndromes.
Main outcome measures—Death, cerebrovascular accidents, myocardial infarction (MI), coronary artery bypass surgery (CABG), and repeat angioplasty (PTCA).
Results—The angiographic success rate was 100% and the clinical procedural success rate 93%. The mean (SD) follow up was 11.9 (7.2) months (range 2-32). The mean (SD) number of stents per patient was 2.4 (0.7). The mean (SD) number of lesions treated per patient was 1.4 (0.6). There were four in-hospital deaths (2.9%) and five patients (3.6%) had an MI before hospital discharge. All in-hospital deaths occurred in patients presenting with an acute MI and cardiogenic shock. Three patients (2.2%) had a late MI. One patient with stent thrombosis underwent emergency CABG. Three patients (2.2%) underwent late CABG. Eight patients (5.7%) had a repeat PTCA. Eighty three patients (61.5%) were asymptomatic at follow up and 121 (86.4%) were free from major clinical events.
Conclusion—In an era of increased operator experience, high pressure stent deployment, and reduced anticoagulation with antiplatelet treatment alone, multiple coronary stenting may be performed with a high procedural success rate and good intermediate term outcome.

Keywords: angioplasty;  stents;  clinical outcome;  interventional cardiology     

Cost effectiveness of ramipril treatment for cardiovascular risk reduction

OBJECTIVE—To assess the cost effectiveness of ramipril treatment in patients at low, medium, and high risk of cardiovascular death.
DESIGN—Population based cost effectiveness analysis from the perspective of the health care provider in the UK. Effectiveness was modelled using data from the HOPE (heart outcome prevention evaluation) trial. The life table method was used to predict mortality in a medium risk cohort, as in the HOPE trial (2.44% annual mortality), and in low and high risk groups (1% and 4.5% annual mortality, respectively).
SETTING—UK population using 1998 government actuary department data.
MAIN OUTCOME MEASURE—Cost per life year gained at five years and lifetime treatment with ramipril.
RESULTS—Cost effectiveness was £36 600, £13 600, and £4000 per life year gained at five years and £5300, £1900, and £100 per life year gained at 20 years (lifetime treatment) in low, medium, and high risk groups, respectively. Cost effectiveness at 20 years remained well below that of haemodialysis (£25 000 per life year gained) over a range of potential drug costs and savings. Treatment of the HOPE population would cost the UK National Health Service (NHS) an additional £360 million but would prevent 12 000 deaths per annum.
CONCLUSIONS—Ramipril is cost effective treatment for cardiovascular risk reduction in patients at medium, high, and low pretreatment risk, with a cost effectiveness comparable with the use of statins. Implementation of ramipril treatment in a medium risk population would result in a major reduction in cardiovascular deaths but would increase annual NHS spending by £360 million.


Keywords: angiotensin converting enzyme inhibitor; cardiovascular risk; cost effectiveness; ramipril     

Long term results of heart transplantation in patients with amyloid heart disease

OBJECTIVE—To determine the outcome of heart transplantation for end stage amyloid heart disease in patients treated at a single centre.
DESIGN—Records of all patients with amyloid heart disease who underwent heart transplantation were examined to determine survival, graft involvement by amyloid, the course of systemic amyloid disease, and the cause of death.
PATIENTS—10 patients, mean (SD) age 54 (8) years, received transplants in the 13 year period 1984 to 1997.
RESULTS—Two patients, both with AL amyloid (primary systemic amyloidosis), died perioperatively. Mean follow up in the remaining eight patients was 49.9 (39.5) months (range 3-116 months). Amyloid deposits in the grafts became evident histologically in five patients with AL amyloid at 5, 11, 12, 28, and 30 months after transplantation, and in one patient with familial amyloid at 60 months. Echocardiography showed no evidence of left ventricular systolic impairment at the time of recurrence. Seven patients died, at 3, 11, 26, 32, 49, 85, and 116 months after transplantation; four of these deaths were related to amyloidosis. Actuarial survival at one and two years was 60% and at five years, 30%.
CONCLUSIONS—Heart transplantation for amyloid heart disease remains controversial because of the scarcity of hearts for transplantation, the systemic nature of amyloidosis, and the potential for amyloid deposition in the graft. Postoperative mortality was high (20%), reflecting extracardiac amyloid. Heart transplantation for end stage cardiac amyloidosis is feasible but, without treatment of the underlying process, it is a palliative procedure.


Keywords: heart transplantation; amyloid heart disease; heart failure     

Failure of thrombolysis: experience with a policy of early angiography and rescue angioplasty for electrocardiographic evidence of failed thrombolysis

OBJECTIVE—To assess the outcome of a policy of emergency coronary angiography with or without rescue angioplasty in patients with acute myocardial infarction and ECG evidence of failed reperfusion after thrombolysis.
DESIGN—A cohort study.
SETTING—Regional cardiothoracic unit.
PATIENTS—197 patients with acute myocardial infarction fulfilling a simple ECG criterion of failed reperfusion.
INTERVENTIONS—Emergency coronary angiography proceeding to rescue angioplasty for inadequate antegrade flow.
MAIN OUTCOME MEASURES—Hospital mortality for all 197 patients; incidence of successful and failed rescue angioplasty; need for additional revascularisation in those receiving rescue angioplasty compared with those not treated in this way.
RESULTS—197 patients had emergency angiography for ECG evidence of failed reperfusion; 156 patients received immediate rescue angioplasty. Overall hospital mortality for those undergoing rescue angioplasty was 11.5%. Rescue angioplasty achieved TIMI 2 (11) or TIMI 3 (124) in 135 patients, who had a hospital mortality of 5.9%. Failure to achieve at least TIMI 2 flow following rescue angioplasty occurred in 21 patients, with a hospital mortality of 48%. In the 41 patients in whom immediate rescue angioplasty was not performed, reinfarction or requirement for revascularisation occurred in 37%. Reinfarction occurred in three patients (1.9%) who had immediate rescue angioplasty. Hospital mortality for the whole cohort was 10.7%.
CONCLUSIONS—A policy of emergency coronary angiography proceeding to rescue angioplasty where appropriate reduces mortality in a high risk group to a level less than expected for patients with acute myocardial infarction and ECG evidence of failed reperfusion. Unsuccessful rescue angioplasty is associated with a high mortality.


Keywords: acute myocardial infarction; rescue angioplasty; failed reperfusion     

The falling mortality from coronary heart disease: a clinicopathological perspective

Objective—(1) To compare mortality estimates based on clinicopathological diagnoses of death from acute coronary heart disease with official estimates of coronary heart disease mortality; (2) to compare present day mortality figures with those from earlier reports.
Design—Prospective community study over the two years 1994 and 1995.
Setting—The health districts of Brighton, South Glamorgan, and York.
Subjects—1589 men and women under 75 years of age who, based on our study criteria, died from acute coronary events were compared with certified cases of coronary death in the same age group.
Main outcome measures—(1) Comparison of the underlying cause recorded on death certificates with the diagnosis of acute coronary death defined by our study criteria; (2) comparison of age specific mortality figures of the present with earlier studies.
Results—Up to age 65, age specific mortality for coronary heart disease, using study criteria, was similar to official estimates. However, at ages 65-74 years there was a shortfall in study deaths of about 20% compared with official figures. One reason for this was that many death certificates in elderly people attributed death to coronary disease in the absence of confirmatory evidence. Despite this, deaths in the under 65 age group in the 1990s appear to be occurring in people who are about 10 years older than was the case during the 1970s.
Conclusions—There are differences, most noticeable in elderly subjects, between estimates of coronary mortality made according to strict clinical and pathological definitions and official rates based on death certification. Recognition of these differences will be important for future epidemiological studies.

Keywords: mortality;  coronary heart disease;  clinicopathological diagnosis;  epidemiology     

Coronary artery bypass graft surgery in dialysis patients

Objective—To examine the short term results and long term survival of patients on long term dialysis undergoing coronary artery bypass graft surgery.
Methods—A retrospective analysis of 19 patients on established dialysis who underwent coronary revascularisation between 1983 and 1995; 14 patients (73%) had class IV angina and five (25%) had unstable angina requiring heparin and nitrate infusions before surgery.
Results—The 30 day mortality was 5%. Follow up was completed in the remaining 18 patients. The mean follow up time was 34 months (range eight to 61). During the follow up period four patients died of cardiac causes. The actuarial survival at one, two, and three years was 87%, 78%, and 59%, respectively. The overall functional status was significantly improved compared to preoperative levels, with a mean Karnofsky score of 76% (p < 0.01) at three years.
Conclusions—Coronary artery bypass graft surgery can be performed with increased but acceptable morbidity and mortality in chronic dialysis patients. It results in considerable improvement in symptoms and functional status. However, long term survival is limited and this requires further investigation.

     

Prognostic value of non-sustained ventricular tachycardia and the potential role of amiodarone treatment in hypertrophic cardiomyopathy: assessment in an unselected non-referral based patient population

Background—Amiodarone has been reported to reduce the likelihood of sudden death in patients with hypertrophic cardiomyopathy (HCM). However, data regarding the clinical course in HCM have traditionally come from selected referral populations biased toward assessment of high risk patients.
Aims—To evaluate antiarrhythmic treatment for sudden death in an HCM population not subject to tertiary referral bias, closely resembling the true disease state present in the community.
Methods—Cardiovascular mortality was assessed in relation to the occurrence of non-sustained ventricular tachycardia (NSVT) on 24 or 48 hour ambulatory Holter recording, a finding previously regarded as a marker for sudden death, particularly when the arrhythmia was frequent, repetitive or prolonged. 167 consecutive patients were analysed by multiple Holter ECG recordings (mean (SD) 157 (129) hours) and followed for a mean of 10 (5) years. Only patients with multiple repetitive NSVT were treated with amiodarone, and in relatively low doses (220 (44) mg/day).
Results—Nine HCM related deaths occurred: 8 were the consequence of congestive heart failure, but only 1 was sudden and unexpected. Three groups of patients were segregated based on their NSVT profile: group 1 (n = 39), multiple ( 2 runs) and repetitive bursts (on 2 Holters) of NSVT, or prolonged runs of ventricular tachycardia, included 4 deaths due to heart failure; group 2 (n = 38), isolated infrequent bursts of NSVT, included 1 sudden death; group 3 (n = 90), without NSVT, included 4 heart failure deaths. Kaplan-Meier survival analysis showed no significant differences in survival between the three groups throughout follow up.
Conclusions—In an unselected patient population with HCM, isolated, non-repetitive bursts of NSVT were not associated with adverse prognosis and so this arrhythmia does not appear to justify chronic antiarrhythmic treatment. Amiodarone, administered in relatively low doses, did not carry an independent and additive risk for cardiac mortality. Amiodarone may have contributed to the absence of sudden cardiac death in patients believed to be at higher risk because of multiple repetitive NSVT.

Keywords: hypertrophic cardiomyopathy; ventricular tachycardia; amiodarone     

Outcomes of transposition of the great arteries in the era of atrial inflow correction

Objective—To examine long term morbidity and mortality following atrial inflow corrective procedures for transposition of the great arteries (TGA) and to investigate factors that influence morbidity and mortality.
Design—Retrospective cohort study from a single centre.
Setting—Cardiology and cardiothoracic surgical unit in a large tertiary referral centre.
Patients—All 130 patients who had TGA diagnosed between August 1972 and May 1988 and were considered suitable for atrial inflow correction; 109 of these underwent surgery (operative cohort: 84 Mustard operations and 25 Senning operations); 95 survived to hospital discharge (hospital surviving cohort).
Main outcome measures—Death and cardiac events.
Results—There were relatively good long term results from atrial inflow correction for TGA with 5, 10, and 15 year survivals of 77.3%, 75.9%, and 71.3%. However, there was an appreciable incidence of late cardiac death and events, with 5, 10, and 15 year cardiac event-free survivals of 74.5%, 67.1%, and 39.6%. Supraventricular tachycardia was the only significant risk factor for late cardiac death (relative risk 8.72, 95% confidence interval, 2.86 to 26.64). Senning patients had better event-free survival (p = 0.04).
Conclusions—Atrial inflow correction for TGA has a reasonably good 15 year survival (71.3%), but there is an appreciable incidence of late cardiac deaths and events (15 year event-free survival 39.6%). The Senning procedure is preferable to the Mustard procedure for cases unsuitable for arterial switching.

Keywords: transposition of the great arteries; congenital heart disease; Mustard operation; Senning operation     

Effect of social deprivation on disease severity and outcome in patients with rheumatoid arthritis

OBJECTIVE—Social deprivation is now recognised to have an important impact on morbidity and mortality. This study sought to ascertain the effect of deprivation, if any, on disease severity, functional disability, and outcome in rheumatoid patients in Glasgow.
METHODS—814 patients with rheumatoid arthritis (RA) were assessed for clinical, functional, and laboratory indices of disease activity. Deprivation categories for individual patients were determined using the Carstairs index. Five year follow up is available for 440 patients.
RESULTS—The study population of RA patients live largely in the most deprived areas. Patients from deprived areas have significantly poorer function at outset and at five years as defined by the Health Assessment Questionnaire (HAQ) score. This is not attributable to differences in disease duration in patients from the most deprived regions or compliance with treatment. Furthermore, these patients do not achieve over five years the initial functional level of those living in the most advantaged localities.
CONCLUSION—RA patients from deprived areas have poorer function, which is associated with greater need—medical, social, and paramedical. Strategies and resources for healthcare need to be adjusted according to this variation.

     

Mitral valve replacement in children: mortality, morbidity, and haemodynamic status up to medium term follow up

OBJECTIVE—To investigate the outcome of mechanical mitral valve replacement in children after up to 11 years of follow up.
DESIGN—Retrospective analysis of case records. Operative survivors underwent echocardiographic studies to define current haemodynamic status and prosthetic valve function.
SETTING—Tertiary referral centre.
PATIENTS—All 54 children who underwent mitral valve replacement between January 1987 and December 1997.
RESULTS—30 day mortality was 20.3% and was associated with small valve size and supra-annular position. The actuarial freedom from the following events at five years (70% confidence interval (CI)) was: death, including 30 day mortality and transplantation, 68% (70% CI 62% to 75%); bleeding, 89% (70% CI 84% to 94%); non-structural valve dysfunction and reoperation, 92% (70% CI 87% to 97%). The incidence of endocarditis and thromboembolism was low and there was no structural valve failure. Event-free survival was 52% (70% CI 45% to 60%). Low weight, young age, and small valve size increased the chance of death or reoperation. On echocardiography, left ventricular dilatation and wall motion abnormalities were often observed. A high mean gradient over the prosthesis was associated with small valve size but not with length of follow up.
CONCLUSIONS—With the use of mechanical prostheses for mitral valve replacement in children, the problem of structural valve failure is no longer an issue. However, the procedure is still associated with a high complication rate, both at surgery and during follow up, and should therefore be reserved for patients in whom valve repair is not technically feasible.


Keywords: mitral valve replacement; prosthetic mitral valve; child; outcome