Second-hand smoke levels in UK pubs and bars: do the English Public Health White Paper proposals go far enough?

BACKGROUND

The English Public Health White Paper proposes introducing smoke-free workplaces except in pubs and bars that do not prepare and serve food. The bar area will be non-smoking in exempted pubs.

OBJECTIVE

To explore the likely impact of these proposals in UK pubs and bars.

METHODS

A total of 59 pubs and bars within Greater Manchester in 2001 were chosen. Thirteen were mechanically ventilated, 12 were naturally ventilated and 34 had extractor fans; 23 provided non-smoking areas. We measured time-weighted average concentrations of respirable suspended particles (RSP), solanesol tobacco-specific particles and vapour-phase nicotine (VPN) over a 4-h sampling period on a Tuesday or Saturday night.

RESULTS

Second-hand smoke (SHS) levels in smoking areas were high (mean RSP 114.5 microg/m3, VPN 88.2 microg/m3, solanesol 101.7 microg/m3). There were only small (5-13 per cent) reductions in bar areas. Mean levels were lower in non-smoking areas: by 33 per cent for RSPs, 52 per cent for solanesol particles and 69 per cent for VPN. Compared with other settings (homes and other workplaces) with unrestricted smoking, mean SHS levels were high throughout all areas of the pubs regardless of ventilation strategy.

CONCLUSION

Partial measures, like those in the English Public Health White Paper, will leave bar staff in exempted pubs unprotected from the occupational hazard of SHS.

Cross-sectional survey of beta-blockers use in primary and secondary care for patients with arterial disease

Beta-blockers reduce mortality in ischaemic heart disease and, when given perioperatively, in vascular surgery. We investigated the use of and attitudes towards beta-blockers by British vascular surgeons and primary care physicians (GPs). We performed a cross-sectional postal survey by questionnaire sent to 367 GPs and 397 members of the Vascular Surgical Society. Specific questions related to beta-blockers use and indications. Two hundred and thirty-four GPs, 95 full-time vascular surgeons (VS) and 137 general surgeons (GS) with a vascular interest responded. Thirty-eight percent of VS and 16% of GS often or always used perioperative beta-blockade (p<0.001). Common indications were ischaemic heart disease (39.2%), hypertension (30.6%), arrhythmia (16.3%) and myocardial protection (6.9%). Sixty-eight percent of VS and 42% of GS would prescribe beta-blockers to patients with occlusive arterial disease (p < 0.001). Common indications were ischaemic heart disease (39.6%), hypertension (29.2%) and arrhythmia (13.3%). Of those who would not prescribe beta-blockers in occlusive arterial disease, 65% felt that beta-blockers were contraindicated in this condition. GPs widely regarded occlusive arterial disease as a contraindication to beta-blockade. Beta-blockers are underused by GPs and GS especially, perhaps because of a perceived risk of side effects in patients with occlusive arterial disease. Further evidence is needed on the effect of beta-blockade on quality of life of patients with arterial disease.

Emergency repair of groin herniae: outcome and implications for elective surgery waiting times

Patients with groin herniae do not always seek medical advice and, when listed for surgery, often wait many months for elective repair. We audited our emergency admissions for complicated groin herniae to establish whether a change in policy for elective surgery could lower their incidence. We performed a retrospective review of all admissions for complicated groin herniae from 1 January 2000 to 31 December 2001. Besides outcome, we recorded patients' awareness of their diagnosis before admission and whether they had been listed for elective surgery. We identified 19 patients (16 men and three women) with an inguinal and 19 (four men and 15 women) with a femoral hernia. Sixteen (42%) knew of their hernia before admission (11 inguinal and five femoral), but only three had been awaiting surgical repair for 1, 7 and 26 weeks, respectively. The median (interquartile range) age was 70 (54-84) years in inguinal and 79 (64-88) years in femoral herniae. Surgery was performed in all but an 84-year-old man who died pre-operatively. Two patients with inguinal and 11 with femoral herniae required a laparotomy (p = 0.006). Bowel resection was necessary in one patient with an inguinal and 12 with femoral herniae (p = 0.001). Complications occurred in 12 cases (31%). Four patients, all with femoral herniae, died post-operatively, for an overall mortality of 13% (5/38). Morbidity and mortality for complicated groin hernia, particularly femoral, remain high. As most patients were elderly and unaware of their diagnosis, reducing waiting times for elective repair is unlikely to influence the incidence of complicated herniae.

Management of gallstone disease in the elderly

AIM

To determine the outcome of management of symptomatic gallstone disease (GSD) in patients aged 80 years or more.

PATIENTS AND METHODS

A retrospective review of the outcome of 79 patients admitted to 2 district general hospitals with symptomatic GSD over a 1-year period was undertaken. Patients were grouped according to method of management: non-operative, ERCP, and cholecystectomy. POSSUM scores for the ERCP and cholecystectomy groups were calculated and observed, and predicted outcome compared.

RESULTS

Obstructive jaundice and biliary colic were the most common presenting symptoms. Each patient had been admitted at least once before the study period (median, 2; range, 1-3). Outcomes are detailed in Table 1. Non-operative management failed in 18 of 23 patients, with 17.4% mortality. ERCP was successful in 40 of 47 patients with 3 complications (0.24 of predicted) and no mortality. In all, 11 laparoscopic and 12 open cholecystectomies were performed with 6 complications and 1 mortality (0.95 and 0.83 of predicted, respectively): 4 complications and the only death occurring after emergency cholecystectomy. Table 1 Outcomes Management Number Mortality Morbidity Outcome Non-operative 23 4 9 5 OK, 13 re-admitted, 4 still symptomatic ERCP 47 0 3 1 PTC, 6 operated Operative 23 1 6 CONCLUSIONS: This study suggests that recurrent GSD in elderly patients managed non-operatively may have fatal outcome. Elective cholecystectomy has acceptable morbidity and mortality in this age group and there is often ample opportunity to avoid emergency surgery, but a prospective randomised study is required to improve clinical algorithms.

Maternal hypothyroidism in the rat influences placental and liver glycogen stores: fetal growth retardation near term is unrelated to maternal and placental glucose metabolic compromise

Maternal hypothyroidism impairs fetal growth in the rat, but the mechanisms by which this occurs are unknown. Since the fetus derives its glucose supply from the mother, and maternal thyroidectomy may disturb maternal and placental glucose metabolism, we postulated that maternal and/or placental glucose metabolic compromise may contribute to fetal growth retardation in hypothyroid dams. Feto-placental growth, tissue glycogen stores and glucose levels in sera and amniotic fluid were determined in rat dams partially thyroidectomized (TX) before pregnancy and in euthyroid controls. Fetal body weight at 16, 19 and 21 days gestation (d.g.) was related to pre-mating maternal serum total thyroxine (TT(4)) levels; permanent fetal growth retardation occurred in severely (TX(s); pre-mating maternal serum TT(4)<or=16.19 nM) - but not in moderately (TX(m)) - hypothyroid dams. In TX(s) dams, glycogen concentration was elevated in maternal liver and in the fetal side of the placenta at 16 and 19 d.g., and in the maternal side of the placenta at 19 and 21 d.g., despite maternal euglycemia. In contrast, fetal liver glycogen concentration was deficient in TX(m) dams at 19 d.g. and in TX(s) dams at 19 and 21 d.g., and fetal hypoglycemia occurred in TX(s) dams at 21 d.g. Multiple regression analyses indicate that these fetal deficits are strongly associated with the retardation in fetal growth, while the elevated maternal liver and placental glycogen concentrations have no impact on fetal growth near term. The mechanisms by which severe maternal hypothyroidism permanently retards rat fetal growth remain to be determined.

Outcome for children born after in utero laser ablation therapy for severe twin-to-twin transfusion syndrome

OBJECTIVE

To examine the postnatal development of a group of children born after in utero laser ablation therapy for severe twin-to-twin transfusion syndrome.

DESIGN

Retrospective cohort outcome study involving assessment of neurodevelopment and physical well being.

SETTING

Harris Birthright Centre, King's College Hospital, London.

PARTICIPANTS

Twins and singleton survivors treated via laser ablation therapy for twin-to-twin transfusion syndrome over a four-year period.

METHODS

Of 54 families contacted to participate in the study, who had been treated for twin-to-twin transfusion syndrome during a four-year period, 24 families attended for paediatric assessment; 12 pairs of twins and 12 singleton survivors were assessed for perinatal, neurological and neurodevelopmental outcome using the Griffiths scales of mental development. A further 20 families were assessed via a proforma after contact with their general practitioner. A comparison of these groups showed no significant differences in sociodemographic factors or severity of disease between responders (44 families, 81.5%) and non-responders (10 families).

RESULTS

The group of children assessed by a paediatrician had low birthweight (1619g donor, 1814g recipient, 1877g singleton) and had been born preterm (33 weeks twins, 31.2 weeks singleton) with attendant increased resuscitation, neonatal unit admission (mean 40 days) and instrumental delivery. Mean Griffiths scores were within the normal range of ability (91.2 donor vs 97.7 recipient and 101.6 singletons) with the only significant difference being in the locomotor subscale where donor (82.6) and recipient (85.3) were less than singletons: -99.1 (P < 0.05). There was no cerebral palsy in the singleton survivors, but there were five cases in the twin group. All except one affected child (with quadriplegia) had mean Griffiths scores in the normal range. In the GP proforma group there was one case, in a twin, of cerebral palsy.

CONCLUSION

The overall cerebral palsy rate was 9%: 0% in the singleton survivors group and 13.3% in the twin survivors group. This pilot data highlights the need for careful long term follow up of children affected by twin-to-twin transfusion syndrome.

Prospective randomized double-blind placebo-controlled trial of glyceryl trinitrate in endoscopic retrograde cholangiopancreatography-induced pancreatitis

BACKGROUND

One possible aetiology of pancreatitis following endoscopic retrograde cholangio pancreatography (ERCP) is cannulation-induced spasm of the sphincter of Oddi and consequent pancreatic duct obstruction. Sublingual glyceryl trinitrate (GTN) has been shown to produce periampullary sphincter relaxation. The aim of this study was to determine whether prophylactic long-acting GTN could reduce the incidence of ERCP-induced pancreatitis.

METHODS

In a randomized double-blind study, prophylactic treatment with GTN (2 mg given sublingually 5 min before endoscopy) was compared with placebo in 186 patients who presented for elective ERCP. The primary endpoint was the occurrence of pancreatitis within 24 h, defined as a serum amylase concentration greater than 1000 units/ml in association with a visual analogue pain score of more than 5.

RESULTS

The incidence of pancreatitis was lower in the GTN group compared with placebo (seven of 90 versus 17 of 96; P < 0.05). Mean serum amylase values were similar in the two groups. The protective effect of GTN appears to be highest in the diagnostic ERCP group (one of 54 versus ten of 66; P = 0.012) and in the group in which cholangiography alone was performed (one of 54 versus eight of 57; P = 0.032).

CONCLUSION

Prophylactic treatment with GTN reduces the incidence of pancreatitis following ERCP but does not seem to reduce the extent of hyperamylasaemia or the severity of pancreatitis.

Prospective randomized double-blind placebo-controlled trial of glyceryl trinitrate in endoscopic retrograde cholangiopancreatography-induced pancreatitis

BACKGROUND

One possible aetiology of pancreatitis following endoscopic retrograde cholangio pancreatography (ERCP) is cannulation-induced spasm of the sphincter of Oddi and consequent pancreatic duct obstruction. Sublingual glyceryl trinitrate (GTN) has been shown to produce periampullary sphincter relaxation. The aim of this study was to determine whether prophylactic long-acting GTN could reduce the incidence of ERCP-induced pancreatitis.

METHODS

In a randomized double-blind study, prophylactic treatment with GTN (2 mg given sublingually 5 min before endoscopy) was compared with placebo in 186 patients who presented for elective ERCP. The primary endpoint was the occurrence of pancreatitis within 24 h, defined as a serum amylase concentration greater than 1000 units/ml in association with a visual analogue pain score of more than 5.

RESULTS

The incidence of pancreatitis was lower in the GTN group compared with placebo (seven of 90 versus 17 of 96; P < 0.05). Mean serum amylase values were similar in the two groups. The protective effect of GTN appears to be highest in the diagnostic ERCP group (one of 54 versus ten of 66; P = 0.012) and in the group in which cholangiography alone was performed (one of 54 versus eight of 57; P = 0.032).

CONCLUSION

Prophylactic treatment with GTN reduces the incidence of pancreatitis following ERCP but does not seem to reduce the extent of hyperamylasaemia or the severity of pancreatitis.

Exercise training for claudicants: changes in blood flow, cardiorespiratory status, metabolic functions, blood rheology and lipid profile

OBJECTIVE

Exercise training improves the walking distance of claudicants. The aim of this study was to investigate factors associated with the improvement in the maximum walking distance (MWD) in respect to cardiovascular, respiratory and metabolic adaptations.

METHODS

Forty claudicants were studied. Common femoral artery blood flow (BF), heart rate (HR), oxygen consumption (VO(2)), respiratory exchange ratio (RER), lactate levels, blood rheology and lipid profiles were measured. Tests were repeated after 3 months of exercise training.

RESULTS

Fifteen patients did not complete the exercise program. For patients who did complete the program, MWD improved by 82%. A significant reduction in HR and VO(2)during exercise was demonstrated. No significant changes occurred in BF or RER. Although MWD increased significantly, there was no increase in recovery VO(2)(oxygen debt). A significant reduction in post-exercise lactate levels occurred. Blood rheology was unchanged, but an improvement in HDL levels was noted.

CONCLUSIONS

Many claudicants could not complete an exercise program, mainly due to osteoarthritis. Exercise training improved exercise tolerance significantly without any increase in BF. The HR and oxygen cost of similar exercise was reduced. An improved MWD did not correlate with a higher oxygen debt or lactate load. Favourable changes in lipid profiles occurred.

New approaches for the analysis of molecular recognition using the IAsys evanescent wave biosensor

Trends in the analysis of molecular recognition using the IAsys evanescent wave biosensor are outlined. Diversification of sensor surface chemistry, an open cuvette format and the advent of robotics controlled by intelligent software are widening the range and throughput of applications. Analyses of binding and dissociation are now carried out across a wide spectrum of biomolecules, including protein, nucleic acid, carbohydrate and lipid. Determinations are obtained from a range of experimental formats. These include qualitative 'yes/no' screening assays, through semi quantitative ranking of kinetic association, dissociation and equilibrium constants for a family of binding partners, to deriving constants comparable with those which would be obtained in free solution. A dependence of the initial rate of biomolecular association on concentration allows analyte concentration to be measured--an increasingly common application class. This is often employed in situations where a rapid determination is required The ability to recover bound analyte from the sensor surface in sufficient amounts for subsequent characterization is opening up new routes to the parallel analysis of structure and function.

Exercise training and peripheral vascular disease

BACKGROUND

Conservative management is advocated as a treatment of choice for patients with intermittent claudication. This is a review of the mechanisms behind the improvement following an exercise rehabilitation programme.

METHODS

All Medline articles from the National Library of Medicine, USA containing the text words 'claudication' or 'peripheral vascular disease' and 'exercise' were reviewed. Cross-referencing from relevant articles was carried out.

RESULTS AND CONCLUSION

The poor physical status of a patient with intermittent claudication is not solely due to a reduction in blood flow to the lower limbs; associated factors, such as metabolic inefficiency, poor cardiorespiratory reserve and exercise-induced inflammation contribute. An exercise programme frequently improves both the physical aspect and quality of life, and the success of such exercise is multifactorial. An increase in the blood flow to the lower extremity is uncommon. Other factors, such as a redistribution of blood flow, changes in oxidative capacity of the skeletal muscles and greater utilization of oxygen, occur and the associated metabolic dysfunction of the skeletal muscles is rectified. Following exercise training, blood rheology improves and exercise-induced inflammation is ameliorated; cardiorespiratory status also benefits and the oxygen cost of exercise decreases.

Maternal hypothyroxinemia influences glucose transporter expression in fetal brain and placenta

The influence of maternal hypothyroxinemia on the expression of the glucose transporters, GLUT1 and GLUT3, in rat fetal brain and placenta was investigated. Fetal growth was retarded in hypothyroxinemic pregnancies, but only before the onset of fetal thyroid hormone synthesis. Placental weights were normal, but placental total protein concentration was reduced at 19 days gestation (dg). Immunoblotting revealed a decreased abundance of GLUT1 in placental microsomes at 16 dg, whereas GLUT3 was increased. Fetal serum glucose levels were reduced at 16 dg. In fetal brain, the concentration of microsomal protein was deficient at 16 dg and the abundance of parenchymal forms of GLUT1 was further depressed, whereas GLUT3 was unaffected. Northern hybridization analysis demonstrated normal GLUT1 mRNA levels in placenta and fetal brain. In conclusion, maternal hypothyroxinemia results in fetal growth retardation and impaired brain development before the onset of fetal thyroid function. Glucose uptake in fetal brain parenchyma may be compromised directly, due to deficient GLUT1 expression in this tissue, and indirectly, as a result of reduced placental GLUT1 expression. Though corrected by the onset of fetal thyroid hormone synthesis, these deficits are present during the critical period of neuroblast proliferation and may contribute to long term changes in brain development and function seen in this model and in the progeny of hypothyroxinemic women.

SHORT COMMUNICATION maternal thyroid dysfunction and c- fos and c- jun expression in rat placenta

Maternal thyroid dysfunction is associated with perturbed fetal brain development and neurological deficits in adulthood in rat and human. To investigate whether these effects occur secondary to placental dysfunction, c- fos and c- jun expression in placenta from normal (euthyroid) and moderately hypothyroid rat dams were investigated by Northern hybridization analysis. In normal placenta, c- fos expression increased by 74 per cent between 16 and 21 days of gestation (dg) whereas c- jun expression declined by 46 per cent. Moderate maternal hypothyroidism depressed placental c- fos expression by 32 per cent at 19 dg, but elevated c- fos and c- jun expression by 139 and 86 per cent, respectively, at 21 dg. Maternal hypothyroidism may therefore induce c- fos/c- jun -related placental dysfunction, but only relatively late in gestation when fetal thyroid function is already established.

Analysis of molecular recognition using optical biosensors

Optical biosensors have made the analysis of molecular interactions rapid and convenient. The field is still young, with commercial instrumentation having been available for less than ten years. For this reason instrument development is still an important factor and the past year has seen continuing advances in instrumentation and particularly in novel sensor surfaces.

Maternal hypothyroxinemia disrupts neurotransmitter metabolic enzymes in developing brain

Maternal thyroid status influences early brain development and, consequently, cognitive and motor function in humans and rats. The biochemical targets of maternal thyroid hormone (TH) action in fetal brain remain poorly defined. A partially thyroidectomized rat dam model was therefore used to investigate the influence of maternal hypothyroxinemia on the specific activities of cholinergic and monoaminergic neurotransmitter metabolic enzymes in the developing brain. Maternal hypothyroxinemia was associated with reduced monoamine oxidase (MAO) activity in fetal whole brain at 16 and 19 days gestation (dg). A similar trend was observed for choline acetyltransferase (ChAT) activity. In contrast, DOPA decarboxylase (DDC) activity was markedly elevated at 21 dg. Further study of these enzymes at 14 dg showed no differences between normal and experimental progeny - suggesting they become TH sensitive after this age. Tyrosine hydroxylase (TyrH) and acetylcholinesterase (AChE) activities were unaffected prenatally. During postnatal development, the activities of TyrH, MAO, DDC and, to a lesser extent, AChE were increased in a brain region- and age-specific manner in experimental progeny. The prenatal disturbances noted in this study may have wide-ranging consequences since they occur when neurotransmitters have putative neurotropic roles in brain development. Furthermore, the chronic disturbances in enzyme activity observed during postnatal life may affect neurotransmission, thereby contributing to the behavioural dysfunction seen in adult progeny of hypothyroxinemic dams.

Hypertension management of medical aid patients attending private practices

OBJECTIVES

The study aimed to describe the treatment status of hypertensive patients and the prescribing patterns of private medical practitioners treating medical aid scheme patients with hypertension.

METHOD

Data on hypertensive patients belonging to medical aid schemes were provided to the drug utilisation review consultancy, Quality Health Services (QHS), by private medical practitioners. The data were computerised and included the age and gender of the patient, the diastolic and systolic blood pressure (BP), the medication prescribed for the condition and the qualifications of the reporting doctor. All the prescribed drugs were categorised into 12 drug classes and combination preparations had each constituent categorised. The level of BP allowed the degree of BP control to be described as controlled (< 140/90 mmHg), borderline (140/90-< 160/95 mmHg) and uncontrolled (> or = 160/95 mmHg).

RESULTS

Included in the study were 11,696 hypertensive patients (46.3% male and 53.7% female) and the 3,503 doctors who cared for them. The systolic BP showed an age-related increase, but the diastolic BP did not. The level of BP control was high, with less than a quarter of patients having uncontrolled hypertension. The most frequently prescribed drug class was angiotensin-converting enzyme (ACE) inhibitors (32.2%). Beta-blockers accounted for 20.8% and calcium antagonists for 14% of all prescriptions. Thiazide and thiazide-like diuretics on their own accounted for only 7.8% of prescriptions. However, a further 13.8% of prescriptions contained this class of diuretics in combination with other drug classes. Diuretics of all classes taken on their own or in combination were used by 33.9% of patients.

CONCLUSIONS

Good levels of hypertension control were reported for hypertensive patients by their private practitioners. Almost half of all prescriptions were for the newer and more costly antihypertensive drugs (ACE inhibitors and calcium antagonists), although their effectiveness in reducing long-term complications of hypertension is still unproven. Furthermore, these prescribing patterns do not conform to those recommended by the Southern African Hypertension Society's hypertension management guidelines.

Second-order kinetic analysis of IAsys biosensor data: its use and applicability

The kinetic analysis of IAsys biosensor association data usually relies upon the assumption of constant ligate concentration. In certain circumstances this assumption may no longer be valid. In a similar vein, the analysis of the dissociation phase assumes the concentration of ligate to be negligible in the liquid phase-an assumption that may not be sustainable for high-affinity interactions. In this paper we derive analytical solutions of the second-order differential kinetic equations for the association and dissociation phases, together with a binding isotherm that also allows for changes in concentration of both the ligand and the ligate. Using these equations it is possible to determine the conditions under which the pseudo-first-order assumption ceases to be valid. It is found that the effect of ligate depletion on the association rate constant becomes significant only when binding low ligate concentrations to ligand on surfaces with high binding capacities or high affinities. Similarly, the rebinding in the dissociation phase is dependent upon the affinity and the ligand capacity together with the starting dissociation response compared to the capacity. Finally, depletion also affects the form of the binding isotherm, particularly in situations involving high matrix capacities for ligate and high-affinity interactions.