Gastroenterology: the first 40 years

Functional gastroenterological disorders were diagnosed in over 50 per cent of patients aged 40 years and under, referred to a district general hospital combined gastroenterology clinic. Peptic ulceration, gastro-oesophageal reflux, biliary tract disease and inflammatory bowel disease accounted for almost 70 per cent of the organic disorders encountered. Malignant disease was rare. The implications for diagnostic investigation in this age group are discussed.     

Ambulatory electrocardiography in the elderly: an audit

In a retrospective analysis of 264 episodes of ambulatory electrocardiography (AECG) in 252 elderly out-patients the overall diagnostic yield was only 12 per cent. However, AECG was found to be of significant value in detecting symptomatic tachyarrhythmias, and in confirming the diagnosis of the 'sick sinus syndrome'. The AECG results influenced the management plan in at least 16 per cent, and changes in drug treatment in 10 per cent. When interpreted critically, AECG is useful tool in the investigation of elderly patients with symptoms such as syncope, faintness, dizziness and unexplained falls.     

Out-of-hospital ventricular fibrillation in patients under the age of 40 years and the long-term prognosis.

Among patients with ventricular fibrillation outside hospital seen by our mobile coronary care unit between 1967 and 1988, 28 were aged less than 40 years (range 12-39, mean 28). Coronary artery disease was present in 11 (39 per cent) and was the most common single cause, although none of these patients was aged less than 28 years. Of 15 patients with cardiac disease, only four (27 per cent) had previously sought medical advice. Nineteen patients (68 per cent) collapsed without preceding symptoms. Survival to reach hospital was significantly associated with bystander cardiopulmonary resuscitation and early defibrillation. Eleven patients (39 per cent) survived to hospital discharge, of whom seven remain alive after 2 1/2 to 21 1/2 years, five without symptoms. Thus, as demonstrated for older patients, coronary artery disease is an important cause of sudden death in this age group, and bystander cardiopulmonary resuscitation and early defibrillation are important for survival. Most of these patients collapse without warning and are not already known to have cardiac disease.     

Autosomal dominant polycystic kidney disease: symptoms and clinical findings

In 259 subjects at risk to have inherited autosomal dominant polycystic kidney disease (PKD), the frequency of symptoms consistent with urinary tract infection, haematuria, back and abdominal pain, hypertension, renal stones, and end-stage renal failure was evaluated. The diagnosis of PKD was made in 140 of these subjects (54 per cent). At the time of the study, 36 per cent of males and 7 per cent of females with PKD were asymptomatic, normotensive, and denied any previous problems. In patients younger than 30 years, 66 per cent of males but only 11 per cent of females were asymptomatic. In female patients, urinary tract infection (69 per cent) and hypertension (61 per cent) were the most frequent clinical manifestations. In contrast, in males with PKD, these problems were present in only 19 per cent and 42 per cent, respectively. Frequency of other clinical manifestations was similar in women and men with PKD. End-stage renal failure was present in 5 per cent of the 81 patients younger than age of 40, in 33 per cent of the 27 patients 40-49 years old, and in 47 per cent of the 32 patients aged 50 years or more. Physical examination was unreliable in estimating kidney size in most patients, particularly in early stages of the disease. Hypertension and symptoms such as haematuria and back pain, but not urinary tract infections, correlated well with renal size measured by radiograms.     

Continuous ambulatory peritoneal dialysis and haemodialysis in the elderly

The clinical course and outcome of 58 patients receiving haemodialysis or continuous ambulatory peritoneal dialysis aged 65 years and above at the start of dialysis treatment was examined over a six-year period. Method of presentation and mode of treatment did not affect survival, but the presence of ischaemic heart disease or congestive cardiac failure was significantly associated with increased mortality. The actuarial two-year patient survival was 54 per cent. Survival on continuous ambulatory peritoneal dialysis was 75 per cent, and the incidence of peritonitis was one episode per 7.36 patient-treatment months. The mean duration of hospital admission was 57.2 days per patient year for continuous ambulatory peritoneal dialysis, and 19.9 days per patient year for haemodialysis patients.     

Diagnostic value of longterm ambulatory ECG in patients with syncope,dizziness or palpitations

Summary. The diagnostic value of longterm ambulatory ECG recording (LTER) was determined in 63 patients referred for investigation of syncope, in 32 with dizziness and in 89 with palpitations. Among patients referred for syncope, dizziness or palpitations 8, 13 and 54%, respectively, had typical symptoms during the recording with concomitant arrhythmia explaining the symptom, and 6, 50 and 11% had a typical symptom without concomitant arrhythmia. In 12 and 3% of the patients referred for syncope or dizziness, respectively, arrhythmia was observed and probably explained their previous complaint, but no symptoms occurred during LTER. LTER was found to be of diagnostic value in 24% of the patients with syncope, in 66% of those with dizziness and in 65% of those with palpitations. In the latter two groups the presence of symptoms the week before the start of these recordings predicted the occurrence of symptoms during LTER. Only occasionally was there a higher yield of typical symptoms beyond 48 h of recording.     

Continuous Ambulatory Peritoneal Dialysis and Haemodialysis in the Elderly

The clinical course and outcome of 58 patients receiving haemodialysisor continuous ambulatory peritoneal dialysis aged 65 years andabove at the start of dialysis treatment was examined over asix-year period. Method of presentation and mode of treatmentdid not affect survival, but the presence of ischaemic heartdisease or congestive cardiac failure was significantly associatedwith increased mortality. The actuarial two-year patient survivalwas 54 per cent. Survival on continuous ambulatory peritonealdialysis was 75 per cent, and the incidence of peritonitis wasone episode per 7.36 patient-treatment months. The mean durationof hospital admission was 57.2 days per patient year for continuousambulatory peritoneal dialysis, and 19.9 days per patient yearfor heamodialysis patients.     

Mitral Valve Prolapse: An Assessment of Clinical Features, Associated Conditions and Prognosis

One hundred and eighty-two patients (100 females, 82 males)with mitral valve prolapse (MVP) confirmed by echocardiographyare described. Their ages range from 12 to 87 years (mean 48years). The symptoms of breathlessness, pain in the chest andpalpitations were analysed. They were associated with left ventricularfailure, co-existing ischaemic heart disease and arrhythmiasin some, but in a proportion the symptoms were thought to bedue to psychoneurosis. Seventy-two patients (40 per cent) werereferred because of complications of MVP. In 67 patients (37per cent) the condition was discovered by chance and in 43 patients(24 per cent) neurotic symptoms had led to referral to hospital.A systolic click was heard in 117 patients (54 per cent); 41patients (23 per cent) had a late systolic murmur and 30 patients(16 per cent) had a pansystolic murmur. The incidence of murmursrose with increasing age, and pansystolic murmurs were morefrequent in males. Thirty-two patients (18 per cent) had neithera click nor a murmur. Twenty-four patients (13 per cent) hadassociated supraventricular tachycardia and 22 (12 per cent)atrial fibrillation. Twelve patients (7 per cent) had severemitral incompetence and eight (4 per cent) developed bacterialendocarditis. Only three patients had symptoms suggesting cerebralischaemia. Twelve patients (7 per cent) had associated aorticincompetence. Twenty-two patients had had an inguinal hernia,the incidence in males over 50 being 26 per cent. Twenty-sixpatients (14 per cent) had non-specific T wave changes in theelectrocardiogram. Echocardiography showed that 112 patients(62 per cent) had mid-systolic buckling of the posterior leafletand 70 patients (38 per cent) had holosystolic prolapse. Inview of the high incidence of complications it is felt thatthe long-term prognosis not as good as has been generally believed.     

Duplex ultrasound screening for carotid arteriosclerotic disease in asymptomatic patients.

Duplex carotid sonography was performed on 254 asymptomatic patients over the age of 55, yielding 500 adequate vessel examinations. Overall, 19.8 per cent of vessels were normal, 27 per cent had mild disease (less than 30 per cent diameter stenosis), 23 per cent had 30-49 per cent stenosis, 18.8 per cent had 50-69 per cent stenosis, 8.6 per cent had severe stenosis of 70-99 per cent, and 2.8 per cent of vessels were occluded. Many of the patients eventually underwent major surgical procedures and there were no cases of operative or perioperative morbidity or mortality. Only one of 254 patients has had a stroke in the two-year study period. Arteriosclerotic disease is common in patients over 55 years of age, but, in this series, does not seem to be of clinical significance. This supports the view that invasive tests and carotid endarterectomy should be reserved for symptomatic patients. Duplex sonography is an excellent noninvasive method of evaluation and follow-up of asymptomatic patients, and long-term studies with this modality should help to determine the natural history and clinical significance of extracranial carotid arteriosclerotic disease.     

Autosomal Dominant Polycystic Kidney Disease: Symptoms and Clinical Findings

In 259 subjects at risk to have inherited autosomal dominantpolycystic kidney disease (PKD), the frequency of symptoms consistentwith urinary tract infection, haematuria, back and abdominalpain, hypertension, renal stones, and end-stage renal failurewas evaluated. The diagnosis of PKD was made in 140 of thesesubjects (54 per cent). At the time of the study, 36 per centof males and 7 per cent of females with PKD were asymptomatic,normotensive, and denied any previous problems. In patientsyounger than 30 years, 66 per cent of males but only 11 percent of females were asymptomatic. In female patients, urinarytract infection (69 per cent) and hypertension (61 per cent)were the most frequent clinical manifestations. In contrast,in males with PKD, these problems were present in only 19 percent and 42 per cent, respectively. Frequency of other clinicalmanifestations was similar in women and men with PKD. End-stagerenal failure was present in S per cent of the 81 patients youngerthan age of 40, in 33 per cent of the 27 patients 40–49years old, and in 47 per cent of the 32 patients aged 50 yearsor more. Physical examination was unreliable in estimating kidneysize in most patients, particularly in early stages of the disease.Hypertension and symptoms such as haematuria and hack pain,but not urinary tract infections, correlated well with renalsize measured by radiograms.     

Age and other determinants of survival after in-hospital cardiopulmonary resuscitation.

A retrospective review of 274 patients who received in-hospital cardiopulmonary resuscitation was performed to determine whether age is independently associated with survival to discharge. Eighty-two (29.9 per cent) of the 274 patients were resuscitated initially, but only 25 (9.1 per cent) were discharged alive. Survival to discharge was significantly poorer in patients aged greater than or equal to 70 years (6/175; 3.4 per cent) than in patients less than 70 years old (19/99; 19.2 per cent) (p less than 0.001). Severity of illness, assessed by the number of diagnoses and a multifactorial morbidity index, did not differ between the two age groups. The best results were obtained with witnessed arrests, ventricular arrhythmias and resuscitation lasting less than 5 minutes; however, elderly patients were less likely to be resuscitated in all circumstances. Age (r = -0.31, p less than 0.001) and the morbidity index (r = -0.18, p less than 0.05) were independently associated with survival by multivariate analysis. These results indicate that advanced age is an important independent determinant of survival after resuscitation. This should be taken into consideration when making in-hospital resuscitation decisions.     

Referral of elderly patients with end-stage renal failure for renal replacement therapy

An increasing number of patients with end-stage renal failure is being treated in the United Kingdom and in 1987 approximately 50 new patients per million started renal replacement therapy. Nevertheless comparatively fewer patients are treated in this country than in some other European countries and in North America. During the 3 years 1985 to 1988, 95 patients from West Glamorgan started chronic renal replacement therapy (87 patients/million population/year). Of these, 16 were aged 75 years or over on starting treatment. In addition two others attained the age of 75 years during the study period. The proportion of elderly new patients is increasing and in the year 1987 to 1988, 59 per cent were older than 65 years and 32 per cent were older than 75 years. Throughout the United Kingdom many elderly patients are being denied treatment, due partly to under-referral.     

Evaluation of the effect of tobacco on trandolapril tolerance

The objective of this study was to evaluate the impact of smoking habits on safety of trandolapril assessed by interrogation and by visual analogue scales (VAS). A total of 3402 hypertensive smokers (> or = 1 cigarette/d for at least 6 months) and non-smokers (no smoking or ceased at least 6 months previously) received trandolapril 2 mg/d for 4 weeks. The safety profile of trandolapril was assessed by both interrogation and by VAS. The VAS completed by the patients at D0 and D28 explored the following symptoms: asthenia, nausea, cough, headaches and dizziness. A significant change in cough VAS was previously defined by an at least 19 mm change. VAS analysis was performed on 2840 patients (1296 smokers and 1544 non-smokers), mean age 59 +/- 12 years. Smokers and non-smokers were significantly different for age 56 +/- 12 years vs. 62 +/- 12 years, sex ratio 74 per cent males vs. 45 per cent, history of hypertension 4.5 +/- 6.1 years vs. 5.3 +/- 6.5 years and cough VAS score at D0 35 +/- 26 mm vs. 20 +/- 21 mm. In the total population, 214 adverse events were reported by 177 patients (5.2 per cent). The most frequent adverse events were a cough (2.1 per cent), bronchitis (0.6 per cent), headaches (0.5 per cent), rhinitis (0.4 per cent), nausea (0.4 per cent) and asthenia (0.3 per cent). Cough was reported by 23 smokers (1.5 per cent) and by 49 (2.6 per cent) non-smokers (p = 0.02). In the VAS population, 151 adverse events were reported by 130 patients, 47 smokers (3.6 per cent) and 83 non-smokers (5.4 per cent, p = 0.03). The difference between the two groups was mainly due to a cough: 15 smokers (1.2 per cent) reported a cough vs. 38 non-smokers (2.5 per cent, p = 0.01) and 77 smokers (5.9 per cent) presented a significant change of cough VAS score vs. 124 non-smokers (8.0 per cent, p = 0.03). In this large scale study, 1.9 per cent of patients treated with trandolapril exhibited a cough. Smokers were less likely to present a cough. Use of VAS confirmed this trend.     

Polyarteritis and the kidney

We report data on 43 patients with polyarteritis affecting the kidneys. The majority (41 patients) had renal histological evidence of microscopic polyarteritis. Although most patients (30 of 43) had significant renal impairment at the time of diagnosis (serum creatinine greater than 250 mumol/l) only five had a symptom, macroscopic haematuria, that directed attention to the kidneys. In the majority of patients in whom data was available there was rapid deterioration in renal function between presentation and diagnosis. Renal function at diagnosis was worse in patients aged over 50 of whom 20 out of 29 had a serum creatinine greater than 500 mumol/l compared with only four of 14 patients aged less than 50. The prognosis was worse in patients over 50 (41 per cent died), in patients with a serum creatinine higher than 500 mumol/l (54 per cent died) and in patients treated with intravenous methylprednisolone, (four also had intravenous cyclophosphamide) (38 per cent died). The major cause of death was sepsis and the actuarial one-year survival was 62 per cent. These results suggest that our approach to treatment should be modified towards lessening immunosuppression in older patients and in patients with renal failure at diagnosis.     

Continuous ambulatory peritoneal dialysis: three years' experience

We review the experience of the Renal Unit at Newcastle upon Tyne over the three years 1979-1981, during which 122 patients with chronic renal failure were treated by continuous ambulatory peritoneal dialysis (CAPD). Advantages of the technique included wide acceptability to a cross-section of patients reaching the renal unit, including the elderly and diabetics. Patients who experienced both techniques preferred CAPD to haemodialysis because of the greater freedom and sense of well-being. Patient survival was 94 per cent at two years and rehabilitation was as good as could be expected for the age and primary medical complications of the patients. Control of plasma potassium and phosphate was easier than with haemodialysis. Renal osteodystrophy responded well to a combination of CAPD and alfacalcidol therapy over the two year period for which we have performed serial bone biopsies. Serum aluminium was slightly raised as a result of consumption of phosphate binders and presumed uptake from dialysis fluid but no aluminium related disease has yet been encountered. Anaemia was partly corrected by CAPD with haemoglobin rising to about 10 g/dl on average. CAPD was less costly than home haemodialysis over the first three years and has been adopted as our standard treatment for patients who can expect an early transplant. Disadvantages were persisting problems with peritonitis which still occurred at an incidence of one attack per 39 patient weeks over the last two years, and an actuarial success rate for the technique of only 63 per cent at two years. Twenty patients developed hernias. Weight gain was common and occasionally gross. There was a significant rise in serum cholesterol. The arrival of CAPD has allowed us to increase the intake to our renal failure programme by 50 per cent. However, continued expansion of the technique demands advances in prevention of peritonitis, adequate facilities for admission and particularly an expanding hospital haemodialysis programme to accept the less successful patients from CAPD.     

Survival in elderly patients presenting with uraemia

A retrospective study was made of 93 patients aged 60 years or greater presenting with renal failure between 1976 and 1981 to assess survival and analyse the factors influencing it. Two-year survival of 28 patients with acute renal failure was 50 per cent and of 65 patients with chronic renal failure it was 40 per cent. Higher initial plasma urea and creatinine values and increasing age had a significantly adverse effect on survival. Patients requiring dialysis likewise fared less well although only one patient succumbed as a direct result of the dialysis procedure. The study reveals a worthwhile survival in both acute and chronic renal failure even though during the period under consideration long-term dialysis of patients in this age group with terminal chronic renal failure was rarely undertaken.     

Chronic renal failure and transplantation

Chronic renal failure may be treated by haemodialysis, continuous ambulatory peritoneal dialysis, or renal transplantation. The advent of CAPD has allowed many more patients to be treated, especially the elderly and very young children. Transplantation is being offered increasingly over a wider age range and patients may now expect to have a 75 per cent chance of keeping a kidney for one year and a 60 per cent chance of keeping it for five years.     

Efficacy of mexiletine in the medium-term treatment of ventricular arrhythmias. A randomized, double-blind, crossover trial against placebo in ambulatory patients

A double-blind, crossover study was designed to compare the safety and efficacy of mexiletine with that of placebo in reducing premature ventricular complexes (PVC) in ambulatory patients and to find out the dose which gives a good therapeutic response with a minimal incidence of side-effects. Twenty-six patients, who had on average 427.9 PVCs/hour, were admitted to the study. The doses given were designed to reduce the frequency of PVCs by 50% or more from the baseline value. Two out of the twenty-six patients stopped treatment because of major side-effects. In the remaining twenty-four patients the 3 weeks of treatment with mexiletine significantly reduced the rate of PVCs by comparison with placebo (-63.8% versus +7.5%). In the nineteen responders (per cent reduction of PVCs over 50%) the dose of mexiletine was 600 mg daily (200 mg every 8 hours). In the non-responders plasma levels of mexiletine proved to be in the therapeutic range, not in any way different from responders. The most frequent side-effects were digestive difficulties (fifteen patients taking mexiletine and six taking placebo). These results show that mexiletine is an effective anti-arrhythmic drug in the management of ventricular arrhythmias occurring in ambulatory patients. In the majority of patients mexiletine was found to be effective even at the lowest dose studied of 600 mg/day.     

Clinical features and natural history of von Hippel-Lindau disease

The clinical features, age at onset and survival of 152 patients with von Hippel-Lindau disease were studied. Mean age at onset was 26.3 years and 97 per cent of patients had presented by aged 60 years. Retinal angioma was the first manifestation in 65 patients (43 per cent), followed by cerebellar haemangioblastoma (n = 60, 39 per cent) and renal cell carcinoma (n = 15, 10 per cent). Overall, 89 patients (59 per cent) developed a cerebellar haemangioblastoma, 89 (59 per cent) a retinal angioma, 43 (28 per cent) renal cell carcinoma, 20 (13 per cent) spinal haemangioblastoma and 11 (7 per cent) a phaeochromocytoma. Renal, pancreatic and epididymal cysts were frequent findings but their exact incidence was not accurately assessed. Mean age at diagnosis of renal cell carcinoma (44.0 +/- 10.9 years) was significantly older than that for cerebellar haemangioblastoma (29.0 +/- 10.0 years) and retinal angioma (25.4 +/- 12.7 years). The probability of a patient with von Hippel-Lindan disease developing a cerebellar haemangioblastoma, retinal angioma or renal cell carcinoma by age 60 years was 0.84, 0.7 and 0.69, respectively. A comprehensive screening protocol for affected patients and at-risk relatives is presented, based on detailed analysis of age at onset data for each of the major complications. Median actuarial survival was 49 years, with renal cell carcinoma the leading cause of death.     

A Prospective Study Utilizing a Transtelephonic Electrocardiographic Transmission Program to Manage Patients in the First Several Months Post-ICD Implant

We prospectively enroled 20 consecutive patients (11 men and 9 women; mean age 63 ± 9.5 years) post-AICD implant in a transtelephonic electrocardiographic transmission (TET) program. The monitor was chosen for its retrograde (30 seconds) and antegrade memory capabilities (45 seconds). The patients were discharged from the hospital after receiving instructions to utilize the system for any cardiac symptoms. The monitor was worn 1–3 months (mean 2.5 ± 0,7 months). During the follow-up period there were 54 TETs received. Nine were for documented AICD discharges, 19 were for symptoms associated with arrhythmias (11 of these 19 reported AICD discharges that were not documented), and 26 for symptoms not associated with arrhythmias. Eight of the 9 AICD discharges documented were appropriate for ventricular tachycardia (mean 185 ± 40 beats/min). The arrhythmias associated with symptoms were: atrial fibrillation (12); nonsustained ventricular tachycardia (3); ventricular couplets (2); ventricular premature beats (10); and atrial premature contractions (2). Several TETs documented multiple arrhythmias. The most common symptoms not associated with arrhythmias were shortness of breath, dizziness, chest pain, and nervousness. Office interrogation of the AICDs revealed 12 of the 20 patients (60%) had received AICD discharges, with 5 of these 12 patients unaware of this occurring. We found the TET monitoring system a useful tool in the management of the AICD patient the first several months postoperatively. We were able to assess device function and avoid unnecessary office visits and/or hospitalizations.