Changes in heart rate and heart rate variability over time in middle-aged men and women in the general population (from the Whitehall II Cohort Study)

Previous cross-sectional studies have shown that heart rate (HR) and HR variability (HRV) are influenced by several behavioral, biologic, and psychosocial factors. There are very few longitudinal studies that enable analyses of changes in HRV over time at an individual level. This study aimed to describe changes in HR and HRV in a general population setting and to determine predictors of HR and HRV at follow-up. From 1997 to 2004, 1,999 participants (29% women) in the United Kingdom Whitehall II Cohort Study had 2 measurements of cardiac autonomic function (mean time between measurements 5.47 years, range 4.07 to 6.93). The mean +/- SD age at the first measurement was 55.6 +/- 6.0 years. At baseline, men showed higher low-frequency power than women, suggesting that they may have higher sympathetic activity. Conversely, women had higher high-frequency power, indicating higher parasympathetic tone. Over the 5-year follow-up period, men and women had decreases in HR. Men had reductions in HRV in time and frequency dimensions, whereas women showed increases in HRV. In conclusion, the probability of being in the adverse quartile of HRV function and HR at follow-up was related to baseline exercise, body mass index, cholesterol, and blood pressure.     

The impact of arm position on the measurement of orthostatic blood pressure

Blood pressure is a standard vital sign in patients evaluated in an Emergency Department. The American Heart Association has recommended a preferred position of the arm and cuff when measuring blood pressure. There is no formal recommendation for arm position when measuring orthostatic blood pressure. The objective of this study was to assess the impact of different arm positions on the measurement of postural changes in blood pressure. This was a prospective, unblinded, convenience study involving Emergency Department patients with complaints unrelated to cardiovascular instability. Repeated blood pressure measurements were obtained using an automatic non-invasive device with each subject in a supine and standing position and with the arm parallel and perpendicular to the torso. Orthostatic hypotension was defined as a difference of ≥ 20 mm Hg systolic or ≥ 10 mm Hg diastolic when subtracting standing from supine measurements. There were four comparisons made: group W, arm perpendicular supine and standing; group X, arm parallel supine and standing; group Y, arm parallel supine and perpendicular standing; and group Z, arm perpendicular supine and parallel standing. There were 100 patients enrolled, 55 men, mean age 44 years. Four blood pressure measurements were obtained on each patient. The percentage of patients meeting orthostatic hypotension criteria in each group was: W systolic 6% (95% CI 1%, 11%), diastolic 4% (95% CI 0%, 8%), X systolic 8% (95% CI 3%, 13%), diastolic 9% (95% CI 3%, 13%), Y systolic 19% (95% CI 11%, 27%), diastolic 30% (95% CI 21%, 39%), Z systolic 2% (95% CI 0%, 5%), diastolic 2% (95% CI 0%, 5%). Comparison of Group Y vs. X, Z, and W was statistically significant (p < 0.0001). Arm position has a significant impact on determination of postural changes in blood pressure. The combination of the arm parallel when supine and perpendicular when standing may significantly overestimate the orthostatic change. Arm position should be held constant in supine and standing positions when assessing for orthostatic change in blood pressure.     

Streptococcus milleri and complex groin abscesses in intravenous drug abusers.

Intravenous drug abuse is an increasing problem. Septic complications occur frequently at the injection site, especially in the groin where large abscesses around the femoral vessels can threaten life or limb. We report four patients with extensive or complex groin abscesses following attempted self-injection into the femoral vein. Streptococcus milleri was cultured from all of these abscesses and prompted a review of the isolation of this organism in this hospital.     

Marketing and public relations in the emergency department

This article outlines the elements of successful ED marketing, as well as providing definitions for terms used within the marketing process. In today's competition and rapidly changing environment, marketing and public relations are tools that every ED Medical Director may want to consider. Because the marketing process requires a great deal of time and effort, as well as a high degree of intellectual honesty, it should never be entered into without a strong commitment. However, marketing the ED can be among the most productive, stimulating, and gratifying experiences for the ED Medical Director, the emergency department physicians, and all ED service personnel.     

Serum concentrations of soluble adhesion molecules in patients with colorectal cancer.

The concentrations of the soluble adhesion molecules E-cadherin, E-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) were investigated in 48 patients with colorectal cancer before treatment, and their relation to clinical, histological and routine laboratory parameters was examined. Data were collected on tumour stage at presentation, presence and sites of metastatic disease, tumour pathology and results of routine laboratory tests. Serum concentrations of ICAM-1 and VCAM-1 were significantly elevated in the patients with colorectal cancer in comparison with a group of healthy subjects (P < 0.00001). Levels of circulating ICAM-1 and VCAM-1 were increased both in patients with local and those with metastatic disease. Although elevated in some patients soluble E-cadherin and E-selectin concentrations were not significantly elevated compared with the control group (P = 0.71 and P = 0.052 respectively). The levels of circulating ICAM-1 were significantly correlated with those of VCAM-1 and E-selectin. A correlation was also found between the serum concentrations of E-selectin and ICAM-1 and alkaline phosphatase, total white cell count and platelet count. VCAM-1 was positively correlated with age and negatively with degree of tumour differentiation and haemoglobin concentration. The biological implications and possible clinical relevance of these findings are discussed.     

Outcome of stable angina in a working population: the burden of sickness absence.

BACKGROUND: The decline in acute event rates among patients with stable angina emphasizes the need for outcome events that are commonly experienced, externally observed and sensitive to changing functional impairments. In the absence of previous studies, we sought to determine the burden of medically certified spells of sickness absence among individuals with angina and their relation to risk factors and co-morbidity. DESIGN AND METHODS: A prospective study of 33 148 employees and 1 year experience of medically certified sickness absence in 341 physician-diagnosed angina patients (417 absence spells, total absence days 9733). RESULTS: Among individuals with angina, sickness absence occurred at a rate of 125 spells per 100 person-years, with age and sex adjusted hazard ratios (compared with their colleagues with no chronic diseases) of 2.90 (95% confidence interval 2.51-3.36), greater than the effect of prolapsed intervertebral disc. Co-morbid diseases were stronger predictors of absence than behavioural risk factors or cardiovascular diseases, and explained 71% of the excess risk of absence in angina. CONCLUSION: In a working population, angina has a significant impact on sick leave, largely because of co-morbid diseases. Angina intervention studies that include employed patients should measure, and seek to reverse, this prognostic burden.     

The perceptions of nurses towards barriers to the safe administration of medicines in mental health settings

The purpose of this study was to investigate perceptions of barriers to safe administration of medicines in mental health settings. A cross‐sectional survey was used, and 70 mental health nurses and 41 students were recruited from a mental health trust and a university in Yorkshire, UK. Respondents completed a questionnaire comprising closed‐ and open‐response questions. One item, which contained seven sub‐items, addressed barriers to safe administration of medication. Seven themes—five nurse‐ and prescriber‐focused and two service user‐focused—were abstracted from the data, depicting a range of barriers to safe administration of medicines. Nurse‐ and prescriber‐focused themes included environmental distractions, insufficient pharmacological knowledge, poorly written and incomplete medication documentation, inability to calculate medication dosage correctly, and work‐related pressure. Service user‐focused themes comprised poor adherence to medication regimens, and cultural and linguistic communication barriers with service users. Tackling medication administration error is predominantly an organizational rather than individual practitioner responsibility.     

Mental health and learning disability nursing students' perceptions of the usefulness of the objective structured clinical examination to assess their competence in medicine administration

The aim of this study was to evaluate mental health and learning disability nursing students' perceptions of the usefulness of the objective structured clinical examination (OSCE) in assessing their administration of medicine competence. Learning disability (n = 24) and mental health (n = 46) students from a single cohort were invited to evaluate their experience of the OSCE. A 10‐item survey questionnaire was used, comprising open‐ and closed‐response questions. Twelve (50%) learning disability and 32 (69.6%) mental health nursing students participated. The OSCE was rated highly compared to other theoretical assessments; it was also reported as clinically real and as a motivational learning strategy. However, it did not rate as well as clinical practice. Content analysis of written responses identified four themes: (i) benefits of the OSCE; (ii) suggestions to improve the OSCE; (iii) concern about the lack of clinical reality of the OSCE; and (iv) OSCE‐induced stress. The themes, although repeating some of the positive statistical findings, showed that participants were critical of the university setting as a place to conduct clinical assessment, highlighted OSCE‐related stress, and questioned the validity of the OSCE as a real‐world assessment. The OSCE has an important role in the development of student nurses' administration of medicine skills. However, it might hinder their performance as a result of the stress of being assessed in a simulated environment.     

Survival in relation to angina symptoms and diagnosis among men aged 70-90 years: the Whitehall Study.

BACKGROUND: While the excess mortality associated with a diagnosis of angina, myocardial infarction in middle-aged individuals is well established, there is little available evidence on the natural history of angina in population-based studies of older people. DESIGN: We conducted a 5-year follow-up of 6655 older men aged 67-90 years (mean age 77 years) who participated in the Whitehall Study of London Civil Servants. METHODS: Survival was examined in relation to a diagnosis of angina or myocardial infarction and to angina symptoms in a population-based study of older men living in the United Kingdom in the late 1990s. RESULTS: Compared with men without a diagnosis of myocardial ischaemia (n=5219), a diagnosis of angina alone (n=617), myocardial infarction alone (n=421) or both (n=398) were associated with about a threefold, fourfold and sixfold higher risk of death from coronary heart disease, respectively. Median expectation of life at age 70 years was reduced by about 2, 5 and 6 years for those with angina, myocardial infarction, or both, respectively. Current symptoms of angina among those without previously diagnosed angina, was associated with a 2-fold higher risk of coronary heart disease mortality than those without either diagnosis or symptoms. CONCLUSIONS: Both angina symptoms and diagnosis have a significant adverse effect on survival among men aged 70-90 years highlighting the importance of diagnosis and appropriate treatment of angina in old age.     

Effect of dietary fat content on the bioavailability of a sustained release quinidine gluconate tablet

Quinidine gluconate 324 mg sustained release tablets (Quinaglute) was administered as a single dose to 15 healthy male subjects following an overnight fast, immediately following a high fat (HF) breakfast or immediately following a low fat (LF) breakfast. Serum samples were obtained over a 48 h period and analyzed for quinidine content using a high performance liquid chromatographic assay. Under the conditions of the study, both the rate and extent of quinidine bioavailability was significantly affected by food. The extent of bioavailability was statistically significantly greater (p less than 0.05) following both the HF and LF meals as compared to that in the fasted state. Rate of bioavailability was significantly enhanced following the LF meal as compared to that of the other two treatment groups. Although peak concentrations were greater and time to peak concentrations somewhat later following the HF meal versus those under fasting conditions, these differences were not statistically significant. In addition, the characteristics of the serum concentration-time profile (as defined by the number, magnitude, and time of occurrence of the multiple absorption maxima) was unique for each of the three treatment groups. Possible mechanisms underlying these results are explored.