Prevalence of persistent cough during long-term enalapril treatment: controlled study versus nifedipine.

The prevalence and severity of cough during long-term enalapril treatment were examined by comparing a cohort of 136 hypertensive patients who started treatment with enalapril with consecutive age and sex-matched patients who commenced nifedipine therapy during the same period. Cough and other symptoms were assessed by a questionnaire designed to avoid bias towards reporting cough. After a mean of 27 months' treatment patients on enalapril had an excess of persistent cough (16 per cent, 95 per cent CI 7-25, p less than 0.01), voice change (14 per cent, 95 per cent CI 2-27, p less than 0.05) and sore throat (10 per cent, 95 per cent CI -0.1 to 20.3 per cent, p less than 0.01) when compared to nifedipine-treated patients. The cough was usually dry, moderate or severe, paroxysmal, and troublesome at night. Cough tended to be more common in women (23 per cent vs. 7.2 per cent), non-smokers, and at higher doses of enalapril, but was not related to age, duration of treatment, or chronic respiratory disease. Dry cough commonly persists as a troublesome side-effect during long-term enalapril treatment, and is often associated with voice change and sore throat.     

Androgenic Status and Sexual Function in Males with Rheumatoid Arthritis and Ankylosing Spondylitis

The pituitary-testicular axis was investigated in 31 males withrheumatoid arthritis (age range 19–60 years, median 55years) and 33 males with ankylosing spondylitis (age range 22–55years, median 37 years) and compared with a control group of95 normal male volunteers. Using analysis of covariance, patientswith rheumatoid arthritis showed significantly lower serum testosterone(p<0.05) and derived free testosterone (p<0.01) concentrationsand significantly higher serum LH and FSH concentrations (p<0.05)compared with controls. All patients had normal serum prolactinand cortisol concentrations. Serum testosterone correlated withESR, haemoglobln concentrations and rheumatoid factor titres(r<–0.448, p<0.02; r=0.440, p<0.02; r<–0.360,p<0.05 respectively) in the rheumatoid patients. Althoughthere was a significant negative correlation between ESR andhaemoglobin concentrations (p<0.005) in the patients withankylosing spondylitis, neither variable correlated with serumtestosterone concentrations. There was no association betweentesticular dysfunction and the presence of extraarticular featuresof rheumatoid arthritis. Ten patients (33 per cent) with rheumatoidarthritis and four (13 per cent) with ankylosing spondylitisadmitted to periods of impotence while 15 (50 per cent) of theformer and 12 (39 per cent) of the latter had periods of decreasedlibido. There was no evidence for increased rates of infertilityin either group.     

Clinical Features, Complications and Mortality in Type 1 (Insulin-Dependent) Diabetic Patients in Addis Ababa, Ethiopia, 1976-1990

Clinical features, complications and prognosis of 431 consecutivelyregistered Ethiopian Type 1 (insulin-dependent) diabetic patientsseen in the Diabetic Clinic in Yekatit 12 Hospital in AddisAbaba, Ethiopia, from 1976–1990 are reported. Male:femaleratio was 1.4:1; mean age at diagnosis was 18.1 years (confidenceinterval (CI) 1.6) in women and 21.4 (CI 1.2) in men. A historyof ketoacidosis at some time was present in 38 per cent, in11 per cent at diagnosis of diabetes. Tuberculosis was the mostcommon complicating illness, occurring at some time in 16.5per cent of patients. In addition, 9.5 per cent (CI 4 per cent)were known to have diabetic retinopathy, 6.0 per cent (CI 2per cent) nephropathy and 7.9 per cent (CI 2 per cent) neuropathyat their last clinic visit. During the 15 years of the study,9.7 per cent of the patients have died, with a mean durationof diabetes at death of 9.2 years (CI 1.8), and an overall mortalityrate of 15.5/1000 person-years of diabetes. Five-year survivalwas 96 per cent (CI 3 per cent), 15-year survival 82 per cent(CI 9 per cent), and 20-year survival 63 per cent (CI 17 percent), calculated using the Cox proportional hazards model;prognosis was better in those diagnosed at a younger age (p=0.029)and in those with a body mass index of > 19 kg/m² on treatment(p=0.096).     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Haematological changes and infectious complications in anorexia nervosa: a case-control study

To determine the prevalence of haematological abnormalitiesin patients with anorexia nervosa (AN), and assess the relationshipsbetween these changes, the severity of AN and the propensityto infections, we retrospectively studied 67 patients who metthe DSM-III-R diagnostic criteria for AN. We recorded physicalfindings and routine haematological data on admission, and infectiousevents during hospitalization. The patients were compared with67 normal controls matched for age and sex. Mean haemoglobin(Hb) was normal but lower in AN patients than in controls (131± 1 9 vs. 137 + 11 g/l, p=0.03) and the prevalence ofanaemia (Hb<120 g/l) was higher in the AN group (27% vs.1.5%, p<0.0001). Patients had a lower leucocyte count (4.94+ 1.9 vs. 6.78 + 2.4 x10⁹/ l , p< 0.0001), and increasedprevalence of leucopenia ( < 4 x 10 ⁹ cells/l)(36% vs. 1.5%,p<0.0001), neutropenia (<1500x10⁶ cells/l)(17% vs. 0%,p=0.0015)and thrombocytopenia (<150x109 / l ) (10% vs. 0%, p = 0.03).Only 2 patients (3%) had pancytopenia, but 9/17 patients withanaemia (53%) also had leucopenia. There was a slight but significantcorrelation between body-mass index (BMI) and total leucocyte,neutrophil and red blood cell counts. Severe infectious complicationsoccurred in 9% of AN patients vs. 0% in controls (p = 0.01);they were more frequent with neutropenia (relative risk, 15.1:95% Cl, 10–20.2) or low (<12) BMI (relative risk, 11.6:95% Cl, 6.6–16.6) on admission. Compared with controls,AN patients thus had an increased prevalence of anaemia, leucopeniaand thrombocytopenia. The severity of AN, as assessed by BMI,correlated with leucocyte, neutrophil and red blood cell countsbut not with platelet count The risk for subsequently developingsevere infections was significantly increased when low BMI orneutropenia was found on admission.     

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.     

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.     

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.     

Outcome of Pregnancy in an Oxford-Cardiff Cohort of Women with Previous Bacteriuria

To investigate the influence of asymptomatic bacteriuria inchildhood on subsequent pregnancy, we reviewed the outcome of139 pregnancies in 88 women who were first identified duringa programme of screening schoolgirls for asymptomatic bacteriuriacarried out between 1970–1972 [1]. Data were analysedfor the following groups: 50 pregnancies in 28 women with knownrenal scars (group 1); 16 pregnancies in 14 women with normalkidneys and reflux (group 2); 73 pregnancies in 46 women withnormal urinary tracts (group 3); 139 healthy controls. Women in group 1 had a 3.3-fold increased relative risk of hypertension(p < 0.01) and a 7.6-fold increased risk of pre-eclampsia(p< 0.05) compared to controls, and a higher rate of obstetricinterventions, including emergency caesarean section. Womenin groups 2 and 3 appeared to carry a slightly increased riskof hypertension during the last trimester (RR = 1.8) but therewere no significant differences in this or the incidence ofpre-eclampsia or mode of delivery. Bacteriuria was more prevalentin all index groups compared to controls (37 per cent vs. 8per cent, p < 0.01) and included four cases of acute pyelonephritisin the study group. Fetal outcome was satisfactory in all cases.These results suggest that women with renal scars are at riskof hypertension and pre-eclampsia during pregnancy but thatmodern obstetric care minimizes these risks.     

The association between glycemic, lipids and blood pressure control among Israeli diabetic patients

Background: It is recommended that in diabetes mellitus patientsall risk factors for cardiovascular disease should be controlled. Aim: To evaluate the rate of reaching all glycemic, lipids andblood pressure target levels among diabetic patients in Israeland to analyze demographic and clinical parameters associatedwith it. Design: A cross-sectional study. Methods: The study was conducted in Maccabi Healthcare Services,Israel's second largest health maintenance organization. Allpatients (n = 41 936), older than 20 years, who were listedon Maccabi Healthcare Service's diabetes mellitus computerizeddatabase and had all three study parameters (HbA1c, LDL-C andblood pressure levels during 2005) were eligible for the study.The rate of reaching HbA1c <7.0%, LDL-C <100 mg/dl andblood pressure <130/85 mmHg, as well as its association withvarious demographic and clinical parameters were analyzed. Results: Only 13% of all study patients achieved all three targetlevels. The parameters which were significantly associated withgoal achievement were compliance to medical treatment for allthree parameters (OR 1.56, 95% CI 1.44–1.69, P = 0.0001),male gender (OR 1.42, 95% CI 1.31–1.54, P = 0.0001), comorbiditywith ischemic heart disease (OR 1.23, 95% CI 1.13–1.34,P = 0.0001), and >12 visits per year to family physician(OR 1.10, 95% CI 1.02–1.19, P = 0.012). Conclusion: Non-compliance with treatment and sub-optimal follow-upby family physicians are associated with increased risk of failureto control major risk factor among diabetic patients.     

A Three-Year Survey of Viral Hepatitis in West London

During a total population survey of viral hepatitis in the LondonBoroughs of Hounslow, Richmond and Ealing, 784 patients wereseen in three years from 1 March 1972 to 28 February 1975. Adiagnosis of viral hepatitis was accepted in 489. The annualincidence was 24 per 100 000. 455 of the patients were testedfor the hepatitis B surface antigen (HBsAg) by a radioimmunoassaytechnique and 93 (20 per cent) of these were positive. The majorityof the patients with typc B hepatitis were in their third orfourth decades. None was under the age of 16. The male to femaleratio among patients with hepatitis B was 2 to 1 in those underthe age of 30 and 5 to 1 in those aged 30 and over. The seasonal distribution of viral hepatitis showed a peak inthe spring, solely from an increased incidence of non-B hepatitis,and a second, smaller peak in the autumn. There was no appreciableclustering of patients except for one local outbreak in a housingestate during the first year affecting mainly children goingto the same primary school, and their parents. Patients with hepatitis B had a longer pre-icteric illness (p< 0·05), greater duration of jaundice (p < 0·001)and higher peak levels of serum bilirubin (p < 0·0005)and sernum alanine amino transferase (A1 T) (p < 0·03)than patients with non-B hepatitis. The finding of the surfaceantigen was also associated with a higher frequency of skinrash (p < 0·0005) and a greater duration of arthralgia(p < 0·03). Among the HBsAg negative patients theincidence of arthralgia increased with age (p < 0·0005).Abdominal pain (p < 0·005) and vomiting (p < 0·005)were more common in the young. The injection experience of patients with hepatitis B showeda high proportion of ‘nontherapeutic’' exposuresuch as drug addiction. Significantly more HBsAg positive menwere single than in the local community (p < 0·0001)or among the HBsAg negative men (p < 0·01). Therewas no significant difference between the proportions of singlewomen among the antigen positive and negative patients. Manyof the HBsAg positive single men were either known to be orstrongly suspected of being homosexual. The ad subtype of the HBsAg was found more often in males (p< 0·01), particularly over the age of 30. All eightdrug addicts tested for subtype were ay, as were two non-addictedfemale consorts. The association between addiction and ay subtypewas highly significant in the males (p < 0·001). Tbcad subtype was found in an 11 of the admitted homosexual HBsAgpositive men and in all but one of the 17 strongly suspectedof being homosexual.     

Long-term Survival After Resuscitation From Ventricular Fibrillation Occurring Before Hospital Admission

Factors related to long-term (post-discharge) outcome followingsuccessful resuscitation from pre-hospital ventricular fibrillationby a physician-manned mobile coronary care unit were studied.Between 1 January 1966 and 31 December 1987, 190 patients wereresuscitated from pre-hospital ventricular fibrillation (158male; mean age 56 years). The aetiology of ventricular fibrillationwas acute myocardial infarction in 131 patients (69 per cent),ischaemic heart disease without infarction in 48 (25 per cent)and other or unknown in 11 (6 per cent). Predicted actuarialsurvival rates at 1, 2, 5, 10 and 20 years were 76 per cent,66 per cent, 41 per cent, 27 per cent and 12 per cent respectively.Of 128 recorded deaths over 20 years, 85 per cent were cardiacand 48 per cent were defined as sudden death outside hospital.Factors significantly associated with increased long-term mortality(p<0.05), based on analysis of 10 year actuarial life tablesusing the Lee–Desu statistic were ventricular fibrillationdue to ischaemic heart disease without infarction rather thanacute myocardial infarction, a history of previous myocardialinfarction, a history of hypertension, digoxin and diuretictherapy before ventricular fibrillation and digoxin as dischargemedication, and failure to stop smoking after discharge fromhospital by patients who had been smoking prior to ventricularfibrillation. In addition, Cox's regression analysis showedthat patient age     

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.