Trends in the smoking habits of young adults with diabetes

OBJECTIVES—To examine changes in the prevalence of smoking in young adult diabetic patients between 1990 and 1999.
SETTING—Walton Diabetes Centre, University Hospital Aintree, Liverpool, UK.
DESIGN—Direct questioning as well as the urinary cotinine:creatinine ratio were used to assess the smoking habits of 99 young type 1 diabetic patients in 1991 (mean age 21.5 years, duration of diabetes 7.3 years), and in 112 similar patients in 1999 (mean age 23.4 years, duration of diabetes 9.6 years).
RESULTS—The admitted smoking rate was 31/99 (31%) in 1990 compared with 31/112 (28%) in 1999 (not significant). However, in 1990 there were an additional 17 "covert" smokers (patients who denied smoking, but had an unequivocally raised urinary cotinine:creatinine ratio), but only three in 1999 (p<0.05). This gave a corrected validated smoking rate of 48/99 (48%) in 1990 and 34/112 (30%) in 1999, representing a significant fall (p<0.02).
CONCLUSION—Smoking rates in young type 1 diabetic patients appear to have fallen during the last decade, and reporting of smoking behaviour is now more honest.


     

Parents' Perception and their Decision on their Children's Vaccination Against Seasonal Influenza in Guangzhou

Background:Seasonal influenza epidemic occurs every year in Guangzhou,which can affect all age groups.Young children are the most susceptible targets.Parents can decide whether to vaccinate their child...     

Prediction equations for spirometric parameters in Mexican adult population

BACKGROUND: Our objective was to develop prediction equations for spirometric parameters that included the following: forced vital capacity (FVC); 1st-sec forced expiratory volume (FEV1); FEV1/FVC ratio; peak expiratory flow (PEF); maximal expiratory flow 50% FVC (VF50) and maximal expiratory flow 75% FVC (VF75); maximal mid-expiratory flow (FEF25-75), and forced late expiratory flow rate (FEF75-85) in a sample of adult Mexican population of both sexes. Age and height variables were utilized. METHODS: Spirometric studies were carried out, observing the international recommendations and norms in force and effected under basal conditions and post-bronchodilator. Linear regression equations were generated based on gender, age, and height. For each spirometric parameter, we selected a linear model. Studies were carried out with spirometry that was in agreement with quality criteria recommended by the American Thoracic Society (ATS). Bronchodilatator administration allowed for elimination of subjects with subclinical bronchial hyperreactivity RESULTS: We studied 436 patients with normal clinical radiographic and pulmonary function, with negative smoking and age range between 17 and 63 years; 206 were females and 230, males. Linear regression equations obtained had direct linear correlation with height and inverse linear correlation with age; in addition, equations had a determination coefficient equal to or less than those reported by authors recommended by the ATS. CONCLUSIONS: Equations obtained in this study possessed the quality required for application in adult Mexican population exposed or not to occupational and environmental contaminants.     

Delivery of surgical care in a district general hospital without high dependency unit facilities

BACKGROUND—Many hospitals lack the facilities for high dependency care, and patients requiring this level of care are nursed on the surgical ward. The aim of this study was to assess the extent of this problem in a district general hospital, looking at the impact of providing high dependency unit (HDU) care at ward level.
METHODS—A 28 bed surgical ward was studied for 39 consecutive days. Patients were assessed as being either appropriately placed (routine) or inappropriately placed (HDU). Nursing interventions and observations over each 24 hour period were recorded for the most dependent patient in each group.
RESULTS—Data were collected for a total of 1092 bed days. Median bed occupancy was 22 patients/day (78%). Inappropriately placed HDU patients accounted for 55 bed days (5%, mean 1.4 patients/day). These patients required more nursing intervention than routine patients.
HDU patients received more observations during a 24 hour period than routine patients (mean 11.3 and 4.2 respectively, p<0.005). The number of observations recorded for a routine patient in a 24 hour period fell when a HDU patient was nursed concurrently on the ward (mean 5.1/24 hours, falling to 3.8 /24 hours in the presence of an HDU patient, p<0.02 ).
CONCLUSIONS—HDU patients require more intensive nursing care than routine surgical patients, and the nursing of HDU patients on the ward adversely affects the quantity of care available for less dependent patients. High dependency care should therefore be provided in dedicated units.
HDU is an essential facility for all surgical patients, including those who require intensive nursing, and the routine surgical patient whose nursing is compromised by the failure to provide comprehensive postoperative care.


     

Out-of-hours work in cardiothoracic surgery: implications of the New Deal and Calman for training

With the introduction of the New Deal and the Calman Report, the duration of higher specialist training will be halved. We have examined the effect of reduced on-call rotas on exposure to relatively uncommon out-of-hours emergencies in cardiothoracic surgery. Operations for post-infarction ventricular septal defect, aortic dissection or transection, oesophageal perforation and pulmonary embolus performed out-of-hours between 1990 and 1995 were identified from hospital records. Over 6 years, the period of higher specialist training in cardiothoracic surgery, a trainee would see seven aortic emergencies on a 1:2 rota, four on a 1:4 rota and two on a 1:6 rota. These figures provide a powerful argument in support of the English Clause which allows trainees to be available for 83 hours a week, equivalent to a 1:4 rota, rather than 56 hours a week, equivalent to a 1:6 rota under the New Deal. This may need supplementation by a mechanism whereby trainees are `on call for training''.


     

Drug related medical emergencies in the elderly: role of adverse drug reactions and non-compliance

BACKGROUND—Adverse drug reactions and non-compliance are important causes of admissions in the elderly to medical clinics. The contribution of adverse drug reactions and non-compliance to admission by the medical emergency department was analysed.
METHODS—A total of 578 consecutive elderly patients admitted to the medical emergency department were interviewed to determine the percentage of admissions due to adverse drug reactions or non-compliance with medication regimens, their causes, consequences, and predictors.
RESULTS—Eighty three (14.4%) of the 578 admissions were drug related: 39 (6.7%) caused by adverse drug reactions and 44 (7.6%) caused by non-compliance with medication. One hundred ninety two (33.2%) patients had a history of non-compliance. Factors associated with an increased risk of admission because of an adverse drug reaction were patients with diabetes or neoplasms, and patients using numerous different medications. Factors associated with a higher risk of hospitalisation because of non-compliance were poor recall of the medication regimen, seeing numerous physicians, female sex, polypharmacy, drug costs, and switching over to non-conventional forms of treatment.
CONCLUSION—Many elderly admissions are drug related, with non-compliance accounting for a substantial fraction of these. Elderly people at high risk of suffering a drug related medical emergency are identified and suitable interventions may be planned by the healthcare policymakers to target them.


     

Reduced pulmonary function in wind instrument players

BACKGROUND: Wind instrument playing requires a strenuous respiratory activity. Previous studies investigating effect of wind instrument playing on pulmonary function are equivocal. METHODS: In the present study, 34 male, non-smoker wind players in a military band were compared with 44 healthy non-smoker males by pulmonary function testing. RESULTS: All spirometric values including forced expiratory volume in 1 sec (FEV1), forced vital capacity (FVC), FEV1/FVC, peak expiratory flow rate, forced expiratory flow in 25, 50, 75% of FVC, and during the middle half of the FVC were found significantly diminished in wind players. The class of wind instrument, brass or wood, showed no significant differences. FVC was significantly and negatively correlated with duration of practice. CONCLUSIONS: It was concluded that pulmonary function in wind players might be diminished probably due to development of asthma or constant barotrauma during their playing. This fact should be considered in clinical evaluation of wind instrument players.     

Good prognosis in thyroid cancer found incidentally at surgery for thyrotoxicosis

An analysis of the outcome of thyroid carcinoma incidentally discovered in patients undergoing surgery for hyperthyroidism is presented. Among 986 patients with differentiated thyroid cancer, 23 had presented with symptoms and signs of hyperthyroidism. Graves'' disease was diagnosed in 11, multinodular goitre in eight and toxic adenoma in four. Following thyroidectomy, histology revealed papillary (18), follicular (four) and Hurthle cell (one) carcinoma. Tumour size ranged from 4 mm to 5.5 cm, multifocality was detected in three patients, and lymph node involvement in one. Two patients (one with associated Graves'' disease, one with multinodular goitre) relapsed locally and required further surgery; one developed distant metastases and died 7 years after initial presentation. Two patients died of unrelated causes; the remaining 20 patients are alive and well with a median follow-up of 16 (1-34) years. Differentiated thyroid cancer found incidentally at surgery for hyperthyroidism has a good prognosis.


     

Permanent pacemaker insertion in a district general hospital: indications, patient characteristics, and complications

This report reviews the experience of permanent pacemaker insertion in a district general hospital (catchment population of 350 000) and makes a comparison with the national database and other hospitals in the UK.
METHODS—The records of all patients receiving a permanent pacemaker in the inclusive period January 1996 to December 1998 were reviewed. Data collected included number of patients paced each year, age, sex, indications, and complications.
RESULTS—In the three years reviewed 200 patients received new permanent pacemakers, a rate of 190 per million population per year, which is similar to the national implantation rate of permanent pacemakers but lower than that of most European countries (see discussion). The majority of patients paced were elderly (75% were above the age of 70 years).
Atrioventricular block (including complete heart block, 45%, and Mobitz type 2 block, 12.5%) was the commonest indication for permanent pacemaker insertion, followed by sick sinus syndrome (25%) and these findings are comparable to those reported previously. However, carotid sinus syndrome was responsible for 16% of the patients paced and this was higher than that reported in the national database (6.5%). Only 1% of the pacemaker modes used was inappropriate and the complication rate was low at 3%.
CONCLUSIONS—This report confirms that permanent pacemaker insertion can be effectively and safely provided locally for the increasingly ageing population. The implantation rate both locally and nationally is still much lower than that of some countries in Europe.


     

Evolution of an inguinal hernia surgery practice

BACKGROUND—Inguinal hernia surgery has undergone numerous advances in the last few years. This study analysed the changes in the practice of one surgeon in a district general hospital over a seven year interval. The effect of changing from Bassini to Lichtenstein repair in 1994 was evaluated.
METHODS—The study involved two parts: first a search of a computerised database of inguinal hernia procedures, and second, postal audits of men who had an inguinal hernia repair in 1993 and 1994 with outpatient follow up for those with a possible recurrence.
RESULTS—A total of 1037 hernias were repaired over the seven years. There was an increase in the proportion of day cases from 18% to 70% and the number of operations performed under local anaesthetic rose from 1% to 45%. The postal audits had response rates of 79% (1993) and 66% (1994). Some 5/98 (5%) recurrent hernias were identified from the 1993 (Bassini) patients compared with 1/67 (1.5%) from the 1994 (Lichtenstein) cohort.
CONCLUSION—Lichtenstein hernia repair can be performed safely as a day case using local anaesthetic in the majority of patients and appears to have a lower recurrence rate than Bassini repair.


     

Evolution of insulin resistance in coronary artery disease patients on four different pharmacological therapies

The objective of the study was to examine the evolution of insulin sensitivity in a group of patients with stable coronary artery disease receiving one of four different pharmacological therapies. Insulin sensitivity was evaluated using an insulin suppression test in 40 newly diagnosed patients with coronary artery disease and no previous history of metabolic disorders, who were not taking any medication which might affect insulin sensitivity. The insulin suppression test consisted of a constant infusion of glucose, insulin and somatostatin for 150 min; insulin resistance was estimated by determining the steady-state plasma glucose concentrations during the last 60 minutes of the test. The insulin sensitivity index was calculated by the formula: insulin sensitivity index = (glucose infusion rate/steady state plasma glucose concentrations) × 10³. A second insulin suppression test was performed after 6 months'' therapy with either isosorbide mononitrate, atenolol, diltiazem or captopril in 30 of the 40 patients.
  There were no differences between any of the groups before therapy was initiated. After 6 months, patients treated with captopril and, to a lesser extent, those treated with diltiazem showed statistically significantly decreased steady state plasma glucose concentrations and increased insulin sensitivity index compared to basal values. No statistically significant differences were found in the other two groups. We conclude that captopril and, to a lesser extent, diltiazem improve insulin sensitivity in patients with stable coronary artery disease.


     

Evaluation of renal function in elderly heart failure patients on ACE inhibitors

A total of 187 heart failure patients aged 65-92 years, with pretreatment serum creatinine levels below 200 µmol/l, were monitored for more than 12 months on angiotensin-converting enzyme (ACE) inhibitor therapy. Optimal ACE inhibitor dosage was found in 27% of patients, while a significant deterioration in renal function, characterised by >20% increase in serum creatinine to >200 µmol/l, occurred in 25 patients. This was most closely attributable to ACE inhibitor treatment per se (implying co-existence of bilateral renal artery stenosis) in only four cases, including one in whom renal deterioration was reproducible on inadvertent rechallenge. In the other 21, renal deterioration was attributable to diuretic-related blood volume depletion (two cases), nonsteroidal anti-inflammatory drugs (two cases), obstructive uropathy (two cases), preterminal renal shutdown (two cases), and the interaction between diuretic and ACE inhibitor dosage (including long-acting vs short-acting drugs) (13 cases). This study could serve as the basis for future comparisons of ACE-inhibitor-related renal deterioration when the entry requirement is optimal ACE inhibitor dosage.


     

体描仪测定哮喘儿童和成人肺功能的临床意义

目的探讨人体体积描记仪(人体体描仪)测定哮喘儿童和成人肺功能的临床意义.方法采用人体体描仪测定哮喘发作期儿童及成人治疗前后的肺功能,比较第1秒用力呼气容积(FEV1)、用力呼气肺活量(FVC)、第1秒用力呼气容积占用力呼气肺活量比值(FEV1/FVC)、最大呼气流量(PEF)和用力呼气25%、50%肺活量时瞬间流量(FEF25%、FEF50%)等肺功能指标的变化幅度.结果治疗前儿童和成人组PEF异常率分别为92.58%和86.36%,治疗后上述指标均有不同程度提高,差异显著(均为P<0.001);两组间肺功能变化幅度除PEF(P>0.05)外,FVC、FEV1、FEV1/FVC、FEF25%、FEF50%差异均有显著性(均为P<0.01).结论采用人体体描仪进行肺功能测定有利于哮喘诊断和发作期病情评估,更适合于年长儿童肺功能指标的监测.     

结缔组织病的肺功能及血气变化

目的了解结缔组织病(CTD)致肺损害的变化及特征,以便及早发现结缔组织病的肺部病变。方法(1)检测27例CTD患者的肺功能,测定用力肺活量(FVC)、1秒钟用力呼气容积(FEV1)、50%肺活量最大呼气流量(V50)、25%肺活量最大呼气流量(V25)、肺一氧化碳弥散量(DLCO)。选取27例非吸烟健康者作为对照组。(2)检测43例CTD患者动脉血气分析,测定pH值、动脉血氧分压(PaO2)、动脉血二氧化碳分压(PCO2)和肺泡-动脉血氧分压差(PA-aO2)。选取43例无肺部疾患健康者作为对照组。结果CTD组肺功能检测弥散功能明显受损(P<0.01)、肺活量减损。血气分析结果CTD组PO2低于对照组(P<0.01),PA-aO2增高。结论CTD患者肺功能损害主要表现为弥散功能减退、限制性通气功能障碍及动脉血氧降低,及时测定CTD患者肺功能及血气分析对早期肺损害诊断及早期治疗有重要意义。     

Quadruple therapy for symptomatic spontaneous duodenal ulcer disease

AIM—To investigate Helicobacter pylori eradication in duodenal ulcer patients with a new regimen, lansoprazole 30 mg daily for one or four weeks plus twice daily tetracycline 500 mg, clarithromycin 250 mg, and metronidazole 400 mg.
BACKGROUND—Spontaneous duodenal ulcer is regularly associated with H pylori, and permanent cure follows eradication of this bacterium. Numerous treatments have been proposed and none is ideal, possibly because of primary or acquired antibiotic resistance. Quadruple regimens with proton pump inhibitor therapy and three antibiotics offer promise as the most effective therapy.
METHODS—From November 1995 all patients with spontaneous duodenal ulcer were offered quadruple therapy. A month after completion a carbon 14 urea breath test (UBT) was performed. Sensitivity of H pylori to the antibiotics used was tested in 1992-3, 1996, and 1999.
RESULTS—A total of 331 patients were treated; 313 attended for a UBT, of which 299 were negative (95.5%). Of those patients who had an endoscopy with positive urease test immediately before treatment, 95/101 (94.0%) on lansoprazole for one week and 116/121 (95.8%) on lansoprazole for four weeks had a negative UBT. H pylori antibiotic sensitivity did not change.
CONCLUSION—This regimen produced some of the best results yet seen and may be generally recommended as first line therapy.


     

What is the prevalence of rheumatic disorders in general medical inpatients?

It has been suggested that rheumatological disorders are underdiagnosed in patients with medical problems and that this might be rectified by incorporating a standard brief screening examination as part of the routine assessment of all patients admitted to hospital with medical conditions. Therefore the GALS screening examination was used to assess the prevalence of rheumatic disease in 100 patients admitted with acute medical problems and in a further 100 in the rehabilitative phase of their disease. The nature of locomotor dysfunction in all patients with a positive result was defined by an independent review and then sensitivity and specificity of the screening test was calculated for rheumatic disease in both populations.
The median age of the two populations were 63 and 78 years respectively, with more females in the rehabilitation group. The overall prevalence of a positive screening test was 53% in the acute and 94% in the chronic disease groups, although the false positive rate in the rehabilitation patients was 30% due to factors other than rheumatic disorders limiting locomotor function (mainly orthopaedic and neurological conditions). The diagnosis of a rheumatological disorder was made de novo in a significant minority (10%) of patients and was usually amenable to treatment. The commonest rheumatic disorder was osteoarthritis which accounted for 55% of all rheumatic disease, followed by inflammatory joint disease (16%), and osteoporosis (12%). In addition to osteoporosis, Paget''s disease of bone and polymyalgia rheumatica were found more frequently in those patients undergoing rehabilitation than in those admitted with an acute medical problem. A number of clinically important associations between medical and rheumatic disorders were found, such as stroke disease with shoulder capsulitis and heart failure with gout.
The sensitivity of the GALS screening test was extremely high (92% and 100%), while its specificity fell in the rehabilitation group from 83% to 17%. None the less, it is felt that this study indicates that the routine use of this test should be considered as part of the assessment of all hospitalised patients with medical problems, whether acute or chronic.


     

Prevalence of microalbuminuria in type 2 diabetes mellitus at a diabetes centre in southern India

OBJECTIVE—The aim of this study was to determine the prevalence and risk factors for microalbuminuria among south Indian type 2 diabetic patients attending a diabetes centre.
METHODS—One thousand four hundred and twenty five type 2 diabetic patients attending a diabetes centre in south India were recruited for the study. Urinary albumin concentration was measured by immunoturbodimetric assay. Microalbuminuria was diagnosed if the urinary albumin excretion was >30 mg/g of creatinine.
RESULTS—Overall prevalence of microalbuminuria was 36.3% (95% confidence interval 33.8 to 38.9). The prevalence of microalbuminuria increased with the increase in duration of diabetes. Multivariate regression analysis revealed age, diastolic blood pressure, glycated haemoglobin, fasting plasma glucose, and duration of diabetes to be associated with microalbuminuria.
CONCLUSION—The overall prevalence of microalbuminuria in this south Indian clinic population and its risk factors are similar to that reported in Europeans.


     

Delays by patients in seeking treatment for acute chest pain: implications for achieving earlier thrombolysis

A study was set up to identify why patients delay seeking medical assistance after myocardial infarction. The study was performed in 100 consecutive patients with suspected acute myocardial infarction admitted to either the University Hospital of Wales, Cardiff, UK, or the Royal Jubilee Hospital, Victoria, British Columbia, Canada (50 patients from each centre). The main outcome measure was the delay from the onset of symptoms to admission to hospital. The mean total delay before admission was 385 minutes (SEM 45). The mean delay incurred by the patient in seeking assistance was 172 minutes (SEM 27), representing 45% of the total. Delay was longer in patients with crescendo angina and shorter in those later confirmed to have myocardial infarction. Patients with prior ischaemic heart disease (74% of patients) presented later than those with no such history. No other demographic or clinical factors predicted early or late presentation.
Delays in seeking medical assistance after the onset of severe chest pain contribute significantly to total delays in patients'' hospital admission and thrombolysis. The unexpected observation that patients with known ischaemic heart disease delay longer before seeking help in spite of their frequent contact with doctors, suggests that opportunities for educating patients are being wasted. Major efforts are needed to understand and modify behaviour of patients with chest pain to further reduce delays in treatment.


     

Prognostic value of stress echocardiography in women with high (> or = 80%) probability of coronary artery disease

OBJECTIVE—To assess the prognostic significance of stress echocardiography in women with a high probability of coronary artery disease (CAD).
SETTING—Secondary and tertiary cardiology unit at a university teaching hospital.
PARTICIPANTS—A total of 135 women (mean (SD) age 63 (9) years) with pre-test probability of CAD ⩾80% were selected from a database of patients investigated by treadmill or dobutamine stress echocardiography between 1995 and 1998.
MAIN OUTCOME MEASURES—Patients were followed up for occurrence of subsequent cardiac events (cardiac death, myocardial infarction, admission with unstable angina, and revascularisation) using a structured telephone interview and case note review.
RESULTS—Each patient had between two and seven (mean 3.5) CAD risk factors and pre-test probability of CAD ⩾80%. Ninety three patients (68.9%) had negative stress echocardiography. Mean (SD) follow up was 20.1 (8.5) months. There were six events in the positive stress echocardiography group (two cardiac deaths, one unstable angina, three revascularisations), and one event in the negative stress echocardiography group. Cox regression analysis showed positive stress echocardiography (p=0.02) and age (p=0.03) to be the only univariate predictors and positive stress echocardiography to be the only independent predictor of future cardiac events (relative risk 8.9, confidence interval 1.0 to 76.5, p=0.04). Cumulative event free survival to 38 months was 98% in the negative stress echocardiography and 50.7% in the positive stress echocardiography groups.
CONCLUSION—In women with high pre-test likelihood of CAD: (1) negative stress echocardiography identifies a subgroup with low risk of cardiac events who do not require further invasive investigation and (2) positive stress echocardiography identifies a subgroup with increased risk of subsequent cardiac events.