Enhancing organizational health literacy in a rural Missouri clinic: a qualitative case study

PURPOSE

The purpose of this paper is to evaluate a collaborative effort between a health care organization and academic institution to strengthen organizational health literacy.

DESIGN/METHODOLOGY/APPROACH

The intervention took place at a rural, federally qualified health clinic in Missouri between May 2009 and April 2011. Qualitative interviews of key informants were conducted before (n=35) and after (n=23) the intervention to examine program implementation and success in effecting organizational change.

FINDINGS

Intervention activities helped establish a comprehensive understanding of health literacy. The project achieved moderate, fundamental and sustainable organizational change. The program successfully integrated health literacy practices into clinic systems and garnered leadership and organizational commitment, helped the workforce improve interpersonal communication and embedded practices making health education materials more accessible.

ORIGINALITY/VALUE

The study points to programmatic, conceptual and methodological challenges that must be addressed for organizations to improve health literacy practices, and suggests change management strategies to advance organizational health literacy.

Exploring Early Adopter Baby Boomers' Approach to Managing Their Health and Healthcare

The Patient 3.0 Profile is used to explore to the patient engagement strategies of early adopter baby boomers' in three domains: 1) patient relationships, 2) health information use and 3) consumer health technology (CHT) use. Findings from six focus groups with early adopter boomers challenge prior notions about older adults' passive approach to patient engagement. Baby boomers want to make final healthcare decisions with input from providers. While adept at finding and critically assessing online health information for self-education and self-management, boomers want providers to curate relevant and trustworthy information. Boomers embrace CHTs offered through providers (i.e., patient portals, email and text messaging) and sponsored by wellness programs (i.e., diet and activity devices and apps). However, there is no indication they add information to their online medical records or use CHT for diagnosis, treatment or disease management. Additional resources are needed to encourage widespread adoption, support patient effectiveness, and confirm cost-benefit.

Perceptions of Urologists About the Conversational Elements Leading to Treatment Decision-Making Among Newly Diagnosed Prostate Cancer Patients

Widespread adoption and use of the practice of shared decision-making among health-care providers, especially urologists, has been limited. This study explores urologists' perceptions about their conversational practices leading to decision-making by newly diagnosed prostate cancer patients facing treatment. Semi-structured, in-depth interviews were conducted with 12 community and academic urologists practicing in the St. Louis, MO, region. Data were analyzed using a consensus coding approach. Urologists reported spending 30-60 min with newly diagnosed prostate cancer patients when discussing treatment options. They frequently encouraged family members' involvement in discussions about treatment, especially patients' spouses and children. Participants perceived these conversations to be difficult given the emotional burden associated with a cancer diagnosis, and encouraged patients to postpone their decisions or to get a second opinion before finalizing their treatment of choice. Initial discussions included a presentation of treatment options relevant to the patient's condition, side effects, outcome probabilities, and next steps. Urologists seldom used statistics while talking about treatment outcome probabilities and preferred to explain outcomes in terms of the patient's practical, emotional, and social experiences. Their styles to elicit the patient's preferences ranged from explicitly asking questions to making assumptions based on clinical experience and subtle patient cues. In conclusion, urologists' routine conversations included most elements of shared decision-making. However, shared decision-making required urologists to have nuanced discussions and be skilled in elicitation methods and risk discussions which requires further training. Further research is required to explore roles of family and clinical staff as participants in this process.

Becoming a health literate organization: Formative research results from healthcare organizations providing care for undeserved communities

Background Integrating health literacy into primary care institutional policy and practice is critical to effective, patient centered health care. While attributes of health literate organizations have been proposed, approaches for strengthening them in healthcare systems with limited resources have not been fully detailed. Methods We conducted key informant interviews with individuals from 11 low resourced health care organizations serving uninsured, underinsured, and government-insured patients across Missouri. The qualitative inquiry explored concepts of impetus to transform, leadership commitment, engaging staff, alignment to organization wide goals, and integration of health literacy with current practices. Findings Several health care organizations reported carrying out health literacy related activities including implementing patient portals, selecting easy to read patient materials, offering community education and outreach programs, and improving discharge and medication distribution processes. The need for change presented itself through data or anecdotal staff experience. For any change to be undertaken, administrators and medical directors had to be supportive; most often a champion facilitated these changes in the organization. Staff and providers were often resistant to change and worried they would be saddled with additional work. Lack of time and funding were the most common barriers reported for integration and sustainability. To overcome these barriers, managers supported changes by working one on one with staff, seeking external funding, utilizing existing resources, planning for stepwise implementation, including members from all staff levels and clear communication. Conclusion Even though barriers exist, resource scarce clinical settings can successfully plan, implement, and sustain organizational changes to support health literacy.

Systematic Review of Decision Aids for Newly Diagnosed Patients with Prostate Cancer Making Treatment Decisions

PURPOSE

Despite established evidence for using patient decision aids, use with newly diagnosed patients with prostate cancer remains limited partly due to variability in aid characteristics. We systematically reviewed decision aids for newly diagnosed patients with prostate cancer.

MATERIALS AND METHODS

Published peer reviewed journal articles, unpublished literature on the Internet and the Ottawa decision aids web repository were searched to identify decision aids designed for patients with prostate cancer facing treatment decisions. A total of 14 aids were included in study. Supplementary materials on aid development and published studies evaluating the aids were also included. We studied aids designed to help patients make specific choices among options and outcomes relevant to health status that were specific to prostate cancer treatment and in English only. Aids were reviewed for IPDAS (International Patient Decision Aid Standards) and additional standards deemed relevant to prostate cancer treatment decisions. They were also reviewed for novel criteria on the potential for implementation. Acceptable interrater reliability was achieved at Krippendorff α = 0.82.

RESULTS

Eight of the 14 decision aids (57.1%) were developed in the United States, 6 (42.8%) were print based, 5 (35.7%) were web or print based and only 4 (28.5%) had been updated since 2013. Ten aids (71.4%) were targeted to prostate cancer stage. All discussed radiation and surgery, 10 (71.4%) discussed active surveillance and/or watchful waiting and 8 (57.1%) discussed hormonal therapy. Of the aids 64.2% presented balanced perspectives on treatment benefits and risks, and/or outcome probabilities associated with each option. Ten aids (71.4%) presented value clarification prompts for patients and steps to make treatment decisions. No aid was tested with physicians and only 4 (28.6%) were tested with patients. Nine aids (64.2%) provided details on data appraisal and 4 (28.6%) commented on the quality of evidence used. Seven of the 8 web or computer based aids (87.5%) provided patients with the opportunity to interact with the aid. All except 1 aid scored above the 9th grade reading level. No evidence on aid implementation in routine practice was available.

CONCLUSIONS

As physicians look to adopt decision aids in practice, they may base the choice of aid on characteristics that correlate with patient socioeconomic and educational status, personal practice style and practice setting.

Perceptions of Adolescents with Overweight and Obesity for the Development of User-Centered Design Self-Management Tools within the Context of the Chronic Care Model: A Qualitative Study

BACKGROUND

The Chronic Care Model (CCM) is helpful to illustrate multiple levels of influence in the management of chronic disease, such as overweight and obesity in adolescents. Unfortunately, various constraints create gaps in the management process activities performed within the CCM. Consumer health technologies (CHT) may serve as a linkage between adolescents with overweight or obesity, their parents, and their pediatricians.

OBJECTIVE

To conduct formative research to qualitatively identify views of adolescents with overweight and obesity on use of consumer health technologies to manage weight loss across chronic care management settings.

DESIGN

As part of a multi-perspective qualitative study, 10 focus groups were conducted with adolescents with overweight and obesity.

PARTICIPANTS/SETTING

Forty-eight adolescents (15 male, 33 female) aged 12 to 17 years who were current participants of an intensive lifestyle change camp in the summer of 2012 participated in focus groups. All adolescents were classified as overweight (21%) or obese (79%) according to body mass index (BMI) for age charts published by the Centers for Disease Control and Prevention.

ANALYSIS

All focus groups were recorded, transcribed verbatim, and checked for accuracy. Predefined and open coding were used to analyze transcripts for emerging themes.

RESULTS

Adolescents perceive CHT, with its functional requirements of assistance with restaurant food selection, teaching cooking skills, and providing encouragement and motivation, to be helpful with overweight and obesity self-management. Desired features to carry out these functional requirements included avatars, self-monitoring capabilities, social networking, and rewards.

CONCLUSION

Our findings largely agree with previously reported parental perceptions of the benefit of CHT for adolescent overweight and obesity self-management and strengthen support for the design and implementation of CHT within the CCM.

Challenges and Opportunities with Empowering Baby Boomers for Personal Health Information Management Using Consumer Health Information Technologies: an Ecological Perspective

"Baby Boomers" (adults born between the years of 1946 and 1964) make up the largest segment of the population in many countries, including the United States (about 78 million Americans) [1]. As Baby Boomers reach retirement age and beyond, many will have increasing medical needs and thus demand more health care resources that will challenge the healthcare system. Baby Boomers will likely accelerate the movement toward patient self-management and prevention efforts. Consumer Health Information Technologies (CHIT) hold promise for empowering health consumers to take an active role in health maintenance and disease management, and thus, have the potential to address Baby Boomers' health needs. Such innovations require changes in health care practice and processes that take into account Baby Boomers' personal health needs, preferences, health culture, and abilities to use these technologies. Without foundational knowledge of barriers and opportunities, Baby Boomers may not realize the potential of these innovations for improving self-management of health and health outcomes. However, research to date has not adequately explored the degree to which Baby Boomers are ready to embrace consumer health information technology and how their unique subcultures affect adoption and diffusion. This position paper describes an ecological conceptual framework for understanding and studying CHIT aimed at satisfying the personal health needs of Baby Boomers. We explore existing literature to provide a detailed depiction of our proposed conceptual framework, which focuses characteristics influencing Baby Boomers and their Personal Health Information Management (PHIM) and potential information problems. Using our ecological framework as a backdrop, we provide insight and implications for future research based on literature and underlying theories represented in our model.

How Do African American Men Rate Their Health Care? An Analysis of the Consumer Assessment of Health Plans 2003-2006

African American (AA) men remain one of the most disconnected groups from health care. This study examines the association between AA men’s rating of health care and rating of their personal physician. The sample included 12,074 AA men aged 18 years or older from the 2003 to 2006 waves of the Consumer Assessment of Healthcare Providers and Systems Adult Commercial Health Plan Survey. Multilevel models were used to obtain adjusted means rating of health care systems and personal physician, and the relationship of ratings with the rating of personal physician. The adjusted means were 80 (on a 100-point scale) for most health ratings and composite health care scores: personal physician (83.9), specialist (83.66), health care (82.34), getting needed care (89.57), physician communication (83.17), medical staff courtesy (86.58), and customer service helpfulness (88.37). Physician communication was the strongest predictor for physician rating. AA men’s health is understudied, and additional research is warranted to improve how they interface with the health care system.

The Minimization of Public Health Risks in Newspapers after Hurricane Katrina

During natural disasters, mass media facilitate the timely provision of accurate information about health risks to the public. This study informs our understanding of such public health discourse utilizing content-analysis of 235 newspaper articles in four major metropolitan newspapers published in the five weeks after Hurricane Katrina hit the Gulf coast in August 2005. These data reveal a small and diminishing number of articles included public health information over time, detailed the hurricane impact on affected communities, and used reliable health sources. The implications for future research from a public health and media relations perspective are discussed.

The use of multi-media messaging in the referral of musculoskeletal limb injuries to a tertiary trauma unit using: a 1-month evaluation

OBJECTIVES

New developments in telecommunications will have a profound effect on the delivery of medical care throughout the world. In Northern Ireland three trauma centres provide fracture care for their own and surrounding Emergency Departments. All trauma referrals are currently taken by telephone. It is our experience that the verbal description of the radiographs of a musculoskeletal limb injury can be inaccurate, necessitating us to view the plain films of the patient. By utilising a recent advance in telecommunications technology, the launch of mobile handsets with multi-media messaging (MMS) service capability, it is now possible to digitally capture and instantly send an image of a plain film.

PURPOSE

To evaluate the use of multi-media messaging as a supplement to the telephone referral of musculoskeletal limb injures.

METHOD

: Following a referral using, the emergency physician and the trauma surgeon evaluated the multi-media consult through a survey questionnaire.

RESULTS

Between the 1st December 2003 and the 1st January 2004, 46 multi-media consultations were performed. Picture quality was acceptable in all but one of the referrals. In 35 of the 46 referrals the multi-media image of the plain films was felt to improve the management of the patient. In 8 of the 46 referrals the multi-media image of the plain films was felt to change the management of the patient.

CONCLUSION

A multi-media messaging store- and forward telemedicine system has potential to facilitate the rapid, cost-effective management of musculoskeletal limb injuries thereby enhancing clinical care.

Hypertriglyceridaemia and malignancy

Severe hypertriglyceridaemia is a rare presentation usually associated with acute pancreatitis. We present two case reports of severe hypertriglyceridaemia occurring in patients with previous autoimmune disease and haematological and solid malignancies but no evidence of prior or concurrent pancreatitis or hyperlipidaemia. These case reports illustrate that haematological and solid organ malignancies and autoimmunity may be relevant as exacerbating factors in the presentation of severe type IV or V hypertriglyceridaemia.

What does the public want to know in the event of a terrorist attack using plague?

We used formative research to assess the information needs and information-seeking strategies with general public audience segments in response to a hypothetical attack using plague, and we pretested informational materials about plague. Twelve focus groups were conducted across the country, with 129 individuals being purposively sampled by ethnicity and place of residence. Across groups, participants wanted to understand: the nature of the threat of plague, how to protect themselves from transmission, how to detect exposure and symptoms, how to treat infection, and progress in apprehending perpetrators. Participants reported that they would seek information from both the news media and local authorities. Based on the findings and the challenges posed by a terrorist attack using plague, the authors recommend that message materials answer key questions, provide clear action steps, be clear and easily understood, include sources for credibility, and reflect full government disclosure. A dissemination plan is required to ensure that critical information will be available when people need it and where they look.

Drug treatment of combined hyperlipidemia

Combined hyperlipidemia is increasing in frequency and is the most common lipid disorder associated with obesity, insulin resistance and diabetes mellitus. It is associated with other features of the metabolic syndrome including hypertension, hyperuricemia, hyperinsulinemia and highly atherogenic subfractions of lipoprotein remnant particles including small dense low density lipoprotein-cholesterol. This review examines the mechanisms by which combined hyperlipidemia arises and the various drugs including fibric acid derivatives, hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, and nicotinic acid which can be used either as monotherapy or in combination to manage it and to improve prognosis from atherosclerotic disease in diabetes mellitus, insulin resistant states and primary combined hyperlipidemia. The therapeutic approach to combined hyperlipidemia involves determination of whether the cause is hepatocyte damage or metabolic derangements. Combined hyperlipidemia due to hepatocyte damage should be treated by attention to the primary cause. In the case of metabolic dysfunction because of imbalance in glucose and fat metabolism, therapy of diabetes mellitus and obesity should be optimised prior to commencement of lipid lowering drugs. Both fibric acid derivatives and HMG-CoA reductase inhibitors can be used in the treatment of combined hyperlipidemia with fibric acid derivatives having greater effects on triglycerides and HMG-CoA reductase inhibitors on LDL-C though both have effects on the other cardiovascular risk factors. There is some evidence of benefit with both interventions in mild combined hyperlipidemias and large scale trials are underway. Fibric acid derivatives and HMG-CoA reductase inhibitor therapy can be combined with care, provided that gemfibrozil is avoided, fibric acid derivatives are given in the mornings and shorter half -life HMG-CoA reductase inhibitors are used at night. Combined hyperlipidemia emergencies occur with predominant hypertriglyceridemia in pregnancy or as a cause of pancreatitis. Therapy in the former should aim to reduce chylomicron production by a low fat diet and intervention to suppress VLDL-C secretion using omega-3 fatty acids. In the latter case, fluid therapy alone and medium chain plasma triglyceride infusions usually reduce levels satisfactorily though apheresis may be required. Blood glucose levels also need aggressive management in these conditions. Combined hyperlipidemia is likely to become an increasing problem with the increase in the prevalence of obesity and diabetes mellitus and needs aggressive management to reduce cardiovascular risk.

Statin-fibrate combination: therapy for hyperlipidemia: a review

Statins and fibrates are well-established treatments for hyperlipidaemias and the prevention of vascular events. However, fibrate + statin therapy has been restricted following early reports of rhabdomyolysis that mainly involved gemfibrozil, originally with bovastatin, and recently, with cerivastatin. Despite this limitation, several reports describing combination therapy have been published. This review considers these studies and the relevant indications and contraindications. Statin + fibrate therapy should be considered if monotherapy or adding other drugs (e.g. cholesterol absorption inhibitors, omega-3 fatty acids ornicotinic acid) did not achieve lipid targets or is impractical. Combination therapy should be hospital-based and reserved for high-risk patients with a mixed hyperlipidaemia characterised by low density lipoprotein cholesterol (LDL) >2.6 mmol/l(100 mg/dl, high density lipoprotein cholesterol (HDL) <1.0 mmol/l (40 mg/dl) and/or triglycerides> 5.6 mmol/l (500 mg/dl. These three 'goals' are individually mentioned in guidelines. Patients should have normal renal, liver and thyroid function tests and should not be receiving therapy with cyclosporine, protease inhibitors or drugs metabolised through cytochrome P450 (especially 3A4). Combination therapy is probably best conducted using drugs with short plasma half-lives; fibrates should be prescribed in the morning and statins at night to minimise peak dose interactions. Both drug classes should be progressively titated from low doses. Regular (3-monthly) monitoring of liver function and creatine kinase is required. In conclusion, fibrate + statin therapy remains an option in high-risk patents. However, long-term studies involving safety monitoring and vascular endpoints are required to demonstrate the efficacy of this regimen.

Very low-density lipoprotein apolipoprotein B-100 turnover in glycogen storage disease type Ia (von Gierke disease)

Mixed hyperlipidaemia is a common finding in glycogen storage disease type Ia (GSD Ia). Although cross-sectional studies have demonstrated increases in intermediate-density lipoproteins (IDLs) and reductions in lipoprotein lipase activity, no studies have investigated the dynamics of apolipoprotein B-100 (apo B) metabolism in GSD Ia. This study investigated apoB turnover in GSD Ia using an exogenous labelling method in one sib from a kinship with established GSD Ia. The study demonstrated normal hepatic secretion of very low-density lipoprotein (VLDL), but hypocatabolism of VLDL, probably due to lack of lipoprotein lipase activity. The production rate of IDL was slightly increased, but the turnover rate of low-density lipoprotein was normal. The findings suggest that, as well as a corn starch diet and dietary fat restriction, treatment of severe mixed hyperlipidaemia in GSD Ia and its attendant risk of pancreatitis should possibly involve fibrates that activate lipoprotein lipase and may enhance the clearance of IDL, rather than omega-3 fatty acids, which principally suppress hepatic secretion of VLDL.

A paradoxical severe decrease in serum HDL-cholesterol after treatment with a fibrate

There have been a handful of reports in the literature of a paradoxical decrease in serum high density lipoprotein (HDL)-cholesterol in patients on fibrate drugs. The reason for this decline in cardioprotective HDL-cholesterol is not known and may have potential deleterious effects on the patient. This report describes a decrease in serum HDL-cholesterol in a patient on both simvastatin and bezafibrate. This patient also developed abnormal renal function, probably interstitial nephritis. In addition, the literature of fibrate induced serum HDL-cholesterol decline is reviewed and possible mechanisms for this phenomenon discussed.

A first British case of fish-eye disease presenting at age 75 years: a double heterozygote for defined and new mutations affecting LCAT structure and expression

Fish-eye disease is a familial syndrome with corneal opacification, major high density lipoprotein (HDL) deficiency in plasma, significant cholesterol esterification in plasma on non-HDL lipoproteins, generally without premature coronary disease. This first British male case from unrelated British parents had infarcts when aged 49 and 73 years but was asymptomatic at age 81 years, with plasma cholesterol 4.3-7.1 mmol/litre, triglycerides 1.8-2.2 mmol/litre, HDL cholesterol < 0.1 mmol/litre, apolipoprotein A-I < 0.16 g/litre, lipoprotein(a) 0.61 g/litre. Cholesterol esterification was impaired using HDL-3 and A-I proteoliposomes but not using VLDL/IDL/LDL. The findings are those of LCAT deficiency with the classic fish-eye disease defect. Most of the 22 reported cases were homozygous or heterozygous for a Thr-Ile mutation at codon 123 of the lecithin:cholesterol acyltransferase (LCAT) gene. This patient was a double heterozygote for this mutation and a second new incompletely defined mutation affecting LCAT expression as defined by reduced mass and activity in plasma.

Community health collaboration models for the 21st century

The development of partnerships with physicians and other health professionals is a key strategy to improving the community's health. This article reviews the role of nurse leaders as advocates for health care improvement and leading community improvement efforts.

Nosocomial acquisition of pertussis diagnosed by polymerase chain reaction

Awareness is growing of the role of pertussis infection among adolescents and adults, and of the possibility of nosocomial transmission. However, pertussis remains difficult to diagnose. We report a case of nosocomially acquired pertussis in a healthcare worker, diagnosed by polymerase chain reaction. The high sensitivity and rapid turnaround time for this test is useful to confirm the diagnosis when advising a healthcare worker to refrain from working.

On the causes of collapse and sudden death by Avicenna

Avicenna's views on the causes of collapse and sudden death are presented from a literal translation of the mediaeval Arabic text. Medical knowledge based on observation mixed with pure abstract reasoning forms the essence of Avicenna's medical writings.

Screening for hyperlipidaemia in childhood. Recommendations of the British Hyperlipidaemia Association

Children with familial hypercholesterolaemia are at high risk of developing coronary artery disease in early adulthood. The diagnosis should therefore be made in childhood. Population screening identifies a small number of children with major genetically determined disorders of lipid metabolism and a large number with polygenic hypercholesterolaemia of uncertain prognostic significance. Selective screening based on a family history of familial hypercholesterolaemia or premature coronary artery disease is an appropriate strategy for identifying most children with familial hypercholesterolaemia. A non-fasting total cholesterol measurement is a suitable screening test: if the concentration exceeds 5.5 mmol/l, a fasting measurement of total cholesterol, high-density lipoprotein cholesterol and triglyceride is required. The diagnosis in a child under 16 years should be based on finding a total cholesterol concentration greater than 6.7 mmol/l and a low-density lipoprotein cholesterol concentration above 4.0 mmol/l on at least two measurements taken more than one month apart. Children should not usually be screened before the age of two years, but the aim should be to diagnose heterozygous familial hypercholesterolaemia before the age of 10 years. Affected children should be referred for specialist care.

Long-term safety of statin-fibrate combination treatment in the management of hypercholesterolaemia in patients with coronary artery disease

OBJECTIVE

To evaluate the long-term safety profile of treatment with a statin-fibrate combination in a cohort of patients with documented coronary artery disease.

DESIGN

Retrospective cohort analytical study.

SETTING

District general hospital.

PATIENTS

102 (81 male and 21 female) hypercholesterolaemic (total cholesterol concentration > 6.5 mmol/l) patients with documented coronary artery disease and who had been treated with a statin-fibrate combination for over 1 year. Coronary artery disease was confirmed by angiography in 93 patients and by a positive (Bruce protocol) exercise test in the remainder. Fifty eight patients had a history of previous coronary bypass graft surgery.

INTERVENTIONS

Twice daily lipid lowering treatment was given, with the fibrate administered in the morning (either bezafibrate 400 mg (n = 101) or fenofibrate 200 mg (n = 1)) and the statin in the evening (either simvastatin 10 mg (n = 23), 20 mg (n = 72), or 40 mg (n = 2) or pravastatin 10 mg (n = 1) or 20 mg (n = 4)). Treatment continued for 1 (n = 9), 2 (n = 58), or 3 (n = 35) years.

MAIN OUTCOME MEASURES

Selected laboratory variables (total cholesterol concentration and liver (aspartate transaminase (AST)) and muscle enzyme (creatine kinase (CK)) activities) and documented symptomatology.

RESULTS

A mean (SD) total cholesterol concentration of 5.2 (0.8) mmol/l was achieved after combined treatment for 1 year which was maintained at annual follow up. Over a maximum 3 year follow up no patient reported myalgic symptoms and none had a measured CK activity > 10 times above nomal. Four men on a simvastatin-bezafibrate combination had a CK activity rise to less than three times normal. Fourteen patients with a negative history of alcohol excess (consumption < 21 units/week) had borderline raised AST values.

CONCLUSIONS

Statin-fibrate combination treatment for up to 3 years in a cohort of patients with coronary artery disease was not associated with serious disturbances in biochemical markers of muscle or liver function.

Combined bezafibrate and simvastatin treatment for mixed hyperlipidaemia

The safety and efficacy of combined bezafibrate-simvastatin therapy was evaluated in 49 patients with diet-resistant mixed hyperlipidaemia (type IIb). After a two-month placebo phase, patients were randomized to receive either Bezafibrate Slow Release (SR) 400 mg mane or simvastatin 20 mg nocte followed by three months combination therapy. Total cholesterol, triglycerides and high-density lipoprotein (HDL) cholesterol were measured at monthly intervals. Apolipoproteins (apo) A1 and B, lipoprotein (a) [Lp(a)] and fibrinogen were measured before and after each treatment. Simvastatin was more effective than Bezafibrate SR in reducing total cholesterol (2.0 vs. 1.1 mmol/l, p = 0.003) and lowering LDL cholesterol (1.7 vs. 0.4 mmol/l, p = 0.0001) whereas Bezafibrate SR was more effective in reducing triglycerides (by 41% vs. 17%, p = 0.001) and fibrinogen (by 23% vs. 3%, p = 0.004). Compared with simvastatin monotherapy, combined drug therapy induced further reductions in triglycerides (by 26%, p = 0.0003) and apoB (by 11 mg/dl, p = 0.03) and an increase in apoA1 (by 21 mg/dl, p = 0.0008). Symptomatic and biochemical adverse events did not occur more frequently on combined drug therapy than on monotherapy. The combination of bezafibrate and simvastatin was more effective in controlling mixed hyperlipidaemia than either drug alone and did not provoke more adverse events.

Rotational ablation of discrete lesions in the coronary arteries is safe. A nonrandomized comparison with percutaneous transluminal coronary angioplasty

Rotational ablation is receiving increasing attention as a new therapeutic intervention for coronary artery disease. In a nonrandomized study, we compared echocardiographic regional wall-motion scores of patients treated with rotational ablation with those of patients treated with percutaneous transluminal coronary angioplasty. We found that rotational ablation achieved angiographic results comparable to those of percutaneous transluminal coronary angioplasty, and was in fact associated with less myocardial ischemia. The reduction in ischemia observed in the ablation group might arise from shorter treatment times in those patients, from the use of nitroglycerin infusion in the ablation group, or from both factors.

The successful surgical repair of a ruptured interventricular septum following a myocardial infarct in an 89 year old man

This case report describes the successful repair of an acquired ventricular septal defect following an anterior full thickness myocardial infarct in an 89 year old man. Four months after the infarct the patient was in severe congestive cardiac failure (NYHA Class IV), despite medical treatment, with signs of a ventricular septal defect. This was confirmed by echodoppler and cardiac catheterization. Surgical repair of the ventricular septal defect was performed. He made an uncomplicated recovery and two and a half years later is well and active. We believe he is the oldest patient who has had this operation successfully.

Clinical efficacy of xamoterol, a beta 1-adrenoceptor partial agonist, in mild to moderate heart failure. U.K. Xamoterol Study Group

The clinical efficacy of xamoterol, alpha beta 1-adrenoceptor partial agonist, was determined in a multicentre double-blind, randomized, parallel group study of 240 patients with mild to moderate heart failure. At entry, 62% of patients were receiving diuretics (thiazides, or loop diuretics at a dose no greater than the equivalent of 80 mg of frusemide); 32% were taking nitrate formulations and 14% digoxin for control of atrial fibrillation. Assessments were carried out after a 1-week placebo run-in and after 3 months of treatment with either xamoterol or placebo. 198 patients completed the study of whom 186 had valid exercise tests. Mean exercise duration increased by 7% after placebo and by 19% after xamoterol during a progressive treadmill exercise protocol. Xamoterol significantly reduced peak exercise heart rate compared with placebo. Subjectively, there was improvement in breathlessness on the visual analogue scale after treatment with xamoterol compared with placebo, but no change in fatigue. We conclude that xamoterol produces sustained improvement in symptoms and exercise duration in mild to moderate heart failure.

Comparative clinical trial of bemetizide/triamterene and cyclopenthiazide/potassium chloride combinations in patients with mild to moderate hypertension

A double-blind trial was carried out to compare the combination of 25 mg bemetizide plus 50 mg triamterene ('Hypertane') and 0.25 mg cyclopenthiazide plus 600 mg potassium chloride ('Navidrex' K) in the treatment of mild to moderate essential hypertension. Two well matched groups of patients were treated for periods of 6 weeks with one or other of the drugs under test. There were 2-week placebo run-in and run-out periods. Blood pressure and laboratory investigations were performed every 2 weeks during the trial period. Both treatments resulted in similar overall statistically significant reductions in blood pressure during the trial. With bemetizide/triamterene, mean lying blood pressure decreased by 11.1/11.2 mmHg and mean standing blood pressure by 15.9/10.3 mmHg; with cyclopenthiazide/potassium chloride the corresponding reductions were 14.9/12.1 mmHg and 9.1/11.7 mmHg. The fact that some of the observed overall reduction seen with both drugs was due to 'placebo effect' is discussed but the clinical importance of overall changes is stressed. There were no significant differences between changes in blood pressure with the two treatments. Biochemical changes were those expected with thiazide diuretics. However, the decrease in potassium and increases in urea and uric acid levels were less with bemetizide/triamterene than with cyclopenthiazide/potassium chloride. Clinical tolerance of both treatments was good.

Echocardiographic studies in anaemic patients before and after blood transfusions

Echocardiographic studies were undertaken in 15 patients with acute blood loss and 15 patients with chronic anaemia, before and after blood transfusion. Clinically adequate blood transfusions resulted in a 5 mm increase in mean left ventricular internal dimensions at end systole in those with acute blood loss and a 3 mm increase in those with chronic anaemia. None of these patients developed acute pulmonary oedema. This study provides base-line data for changes in ventricular dimension resulting from the standard medical management of patients with acute and chronic blood loss. Functional aortic valvular insufficiency was documented in some cases and pericardial effusion resolving after blood transfusion was common.

Echocardiography in elderly patients with systolic murmurs

Clinical examination, phonocardiography and echocardiography were performed on 49 elderly patients with systolic murmurs. Patients with mitral murmurs had increased left atrial and left ventricular diameters, increased mitral valve closure rate and excursion with a higher frequency of previous congestive cardiac failure. There was no difference in aortic root diameter or aortic valve excursion between the two groups. Patients with mitral murmurs were more likely to have an abnormal echocardiogram and abnormalities of mitral valve leaflet function were most commonly observed.

Complete heart block and systemic lupus erythematosus

An 18-year-old girl with systemic lupus erythematosus developed progressive electrocardiographic abnormalities over a period of 16 years, culminating in complete heart block with Adams-Stokes attacks. A permanent ventricular pacing system was implanted successfully.