Age and sex differences in the management of ischaemic heart disease

Objective

To investigate age and sex differences in the utilisation of hospital services for ischaemic heart disease.

Design

Analysis of routine mortality data and hospital activity data.

Setting

South West Thames Regional Health Authority.

Subjects

Residents of the South West Thames Regional Health Authority who in 1991 either died from ischaemic heart disease or were admitted to an NHS hospital in England and Wales with a main diagnosis of ischaemic heart disease.

Main outcome measures

Ratio of consultant episodes to deaths from ischaemic heart disease (as a proxymeasure of the utilisation of hospital care), and the percentages of consultant episodes in which further investigation (angiography or catheterisation) or revascularisation treatment (coronary artery bypass grafting or angioplasty) were carried out.

Results

The ratio of episodes to deaths was similar in men and women (odds ratio for men vs. women 0.96, 95% confidence intervals 0.90 to 1.03). The percentage of episodes in which further investigation was carried out was higher in men than women (odds ratio for men vs. women 1.46, 95% confidence intervals 1.25 to 1.70) as was the percentage of episodes in which revascularisation treatment was carried out (odds ratio for men vs. women 1.46, 95% confidence intervals 1.20 to 1.77). The ratio of episodes to deaths, the percentage of episodes in which further investigation was carried out, and the percentage of episodes in which revascularisation treatment was carried out all declined with age (all p values <0.001).

Conclusions

Women with ischaemic heart disease are as likely as men to be admitted to hospital, but afteradmission are less likely to undergo further investigation and revascularisation treatment. Elderly patients with ischaemic heart disease are less likely than younger patients to be admitted to hospital; after admission, they are also less likely to undergo further investigation and revascularisation treatment. Further research is needed to determine whether these age and sex differences in the use of hospital services are clinically justified.     

Congenital pulmonary atresia with ventricular septal defect: angiographic and surgical correlates

Of 181 patients with severe congenital pulmonary atresia and ventricular septal defect or "type IV truncus" (an obsolete term), all but 11% had true central pulmonary arteries. These arteries were demonstrable by large serial biplane angiograms using multiple selective injections into collateral vessels, frequent photographic subtraction, and occasional pulmonary vein-wedge angiograms. These techniques are extremely important for accurate diagnosis and in planning corrective or palliative surgery, which was done in 77% of patients with pulmonary arteries.     

Klatskin tumors of the bile ducts: sonographic appearance

The authors present 3 cases of surgically proved Klatskin tumor diagnosed by ultrasound alone. Sonographic features of these tumors include (a) dilatation of the intrahepatic biliary ducts but not the extrahepatic duct, (b) non-union of the right and left hepatic ducts, and (c) small, solid masses at the hepatic hilus. Local spread to the liver may also be seen. If the pancreas appears normal and no primary tumor can be found, Klatskin tumor can be diagnosed with a high degree of accuracy.     

Twenty consecutive cases of endograft repair of traumatic aortic disruption: lessons learned

OBJECTIVES: Endograft repair holds considerable promise in the treatment of traumatic disruption of the thoracic aorta because patients often have multiple coexisting injuries further complicating traditional open repair. In addition, patients are often young, with an aortic anatomy dissimilar to those with atherosclerotic aneurysms. As a result, techniques for endograft repair have to be refined accordingly. METHODS: The records of 20 consecutive cases of traumatic aortic disruption treated by endograft repair at a single institution were reviewed. RESULTS: Mean patient age was 40 years (range, 17 to 88 years), and 17 (85%) of 20 patients were men. All cases were completed. There were no procedure related deaths, but four (20%) patients died of their co-injuries. Only two (10%) of 20 required a graft >28 mm in diameter, and nine (45%) aortas were small enough to require use of 23-mm abdominal cuffs. Six (30%) of 20 cases required complete or partial coverage of the left subclavian artery. Placement of a proximal extension was required in one patient for a type I endoleak. A graft collapse occurred in one patient that required surgical removal and aortic repair. CONCLUSIONS: Endovascular repair of traumatic aortic disruption can be accomplished in most cases. Compared with atherosclerotic aneurysms, the proximal thoracic aorta tends to be smaller and the arch angle tighter in an aorta 19mm in diameter. This frequently necessitates the use of smaller devices and less stiff wires. Surgeons should be prepared to cover the left subclavian artery if needed, have a wide range of device sizes in stock to avoid over-sizing, and show restraint if the anatomy appears unsuitable.     

The relationship of human platelet density to platelet age: platelet population labeling by monoamine oxidase inhibition

The relationship between platelet density and platelet age appears to vary between species with relatively few labeling studies in humans reported. In this study, irreversible monoamine oxidase (MAO) inhibitors were used to biochemically label the circulating platelet population in 15 humans. Platelet samples were then isolated during the 15 days after drug ingestion. The platelets were separated by density on continuous linear Percoll gradients and the density distributions were divided into five fractions containing approximately equal numbers of platelets. Baseline MAO activity was strongly correlated with platelet density. Twenty-four hours after a single dose of tranylcypromine, platelet MAO activities in the density subpopulations were reduced to 14% to 17% of the baseline values. During the first five days after inhibition, the rates of recovery of MAO activity (percentage per day) were inversely proportional to platelet density. The recovery rates in the two most dense fractions were initially slow but increased after five days. Percentage recovery of MAO activity in the least dense fraction was significantly greater than the percentage recovery in the most dense fraction on days 2, 3, 5, and 8 (P less than .01, sign test). These results support the hypothesis that normal human platelets show a small increase in density with age, but they do not exclude the additional possibility that human platelet lifespan is positively correlated with platelet density.