665 A Systematic Review of Breast Site Associated Complications Following Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction

Aim

Breast reconstruction with autologous tissue provides durable reconstruction with native tissue. However, perioperative complications impact negatively on patient perception of success and increase the psychological trauma of mastectomy. The Deep Inferior Epigastric Perforator (DIEP) flap has a recognised low rate of donor site complications. This paper provides the first systematic review focussing on breast site associated complications.

Method

PRISMA guidelines informed a systematic search of Medline, Embase and Web of Science. Studies were screened against set inclusion and exclusion criteria; data was collated regarding demographics, flap characteristics and flap complications.

Results

Twenty-nine studies representing 21,680 flaps were included with the rate of major breast-associated complications ranging between 0 and 55.1% of flaps and 0 to 10.3% of patients; the rate of minor complications ranged between 0 and 48.2% of flaps and 0 to 16.3% of patients. All papers reported major complications including total flap loss (1–17.2% flaps, 0–7.4% patients), partial flap loss (0–44.8% flaps, 0–5% patients) and venous congestion or arterial compromise (1.5–55.1% flaps, 4.3–10.3% patients). Twenty-eight papers reported minor complications and included fat necrosis (1.8–48.2% flaps, 3–16.3% patients); wound problems (1–15.6% flaps, 3.7% patients); skin necrosis (9.2–17.8% flaps, 0.3–7.4% patients; seroma (0–4.9% flaps, 0–5.1% patients); haematoma (0.36–9.3% flaps, 0–8.4% patients) and infection (0.2–20% flaps, 0–6.3% patients).

Conclusions

This systematic review concludes that the DIEP flap has an acceptable level of breast site associated complications and should continue to be considered as gold standard in breast reconstruction. This review can be used in preoperative counselling and to inform consent.

483 Complete Sciatic Nerve Transection from A Closed Femoral Fracture: A Case Report

Introduction

Complete transection of the sciatic nerve following a closed femoral fracture is exceedingly uncommon. Delayed diagnosis may result due to this unrecognised injury pattern.

Case Description:

An 18-year-old male motorcyclist was referred following a significantly displaced closed, femoral fracture. The patient was sedated at the scene and transferred to theatre for definitive fixation, where an open reduction was performed via an anterior approach. Symptoms of paresthesia and weakness were reported immediately postoperatively, and formal neurological examination prompted an emergency MRI. On this basis, the patient was transferred to plastics and underwent surgical exploration, where complete transection of the sciatic nerve was identified just proximal to the bifurcation into the common peroneal and tibial nerve. A nerve gap of five centimetres was identified requiring reconstruction with grouped fascicular sural nerve grafts.

Discussion:

Complete transection of the sciatic nerve is a devastating injury that compromises the function of the posterior compartment of the thigh and all motor function below the knee. To our knowledge, reports of complete sciatic nerve transection secondary to a closed fracture of the femoral shaft are extremely rare in the pertinent literature, with only two other cases reported to date.

610 Virtual Burns Care in The Era Of COVID-19: A Regional Burns Unit’s Experience

Introduction

In response to the COVID-19 pandemic a virtual burns service was established in Northern Ireland to reduce face-to-face consultations to only complex burns or those necessitating hospital admission to the regional unit.

Method

A combination of telephone calls, emails, photography, and Microsoft Teams software was utilised to facilitate a virtual review service. Our initial adoption of the system was audited during April and May 2020. Through Plan-Do-Study-Act (PDSA) methodology an electronic tertiary-referral proforma was established prior to closure of the audit cycle in July 2020.

Results

From the start of lockdown a significant reduction in face-to-face consultations was observed. Given the increasing use of virtual telephone consultation only 19.5% of the unit's total referrals (April, May, and July) were either reviewed face-to-face in dressing clinic or admitted. A target of 100% data point entry (including demographic, clinical, and initial management) for patients entering the virtual service was set. Following implementation of the e-Referral pathway an improvement in both the detail and completeness (95%) of patient referral information was achieved.

Conclusions

Our experience demonstrates that virtual burns care can be safely and rapidly adapted in response to evolving need. The potential role of virtual care post-COVID, in selected patients, is an exciting one.

The Operative Incidence of Syndactyly in Northern Ireland. A 10-Year Review

BACKGROUND

Syndactyly is a common congenital condition that can present sporadically or in relation to an underlying genetic condition. Little contemporary published data exists detailing specific rates of presentation and surgical intervention, especially in Western European population. This is the first published review of operative intervention rates for the condition over time in Northern Ireland.

METHODS

A ten-year retrospective review of electronic operative records from January 2007 - October 2017 was carried out within Northern Ireland's regional tertiary centre Royal Belfast Hospital for Sick Children (RBHSC). All congenital hand surgery in the country was performed here during the period reviewed, by a single surgeon. Patient age at surgical intervention, their sex, digits involved and clinical grade of syndactyly was recorded.

RESULTS

One hundred and twenty four cases were returned following the review. On individual analysis 22 cases were excluded as they were not primary congenital syndactyly. The remaining 102 cases were all Caucasian. Six cases were toe syndactyly while 96 cases involved the upper limb digits. The group consisted of 70 males and 32 female infants. Age range at time of surgical intervention was 8 months to 14 years with a median age of 26 months. For clinical grade of upper limb syndactyly; 35 cases in the data set were classed as simple incomplete, 34 cases as simple complete, 17 as complex and 5 cases as complicated syndactyly. The remaining 5 cases lacked clear documentation. The most common site of syndactyly was between the ring and middle finger (40/102). Annual frequency of operative intervention has trended upwards in the period studied.

CONCLUSION

This case review adds epidemiological data on the operative incidence of syndactyly cases in Northern Ireland - a relatively isolated genetic population. Overall rates of incidence have increased over the past 10 years. It remains unclear if this is due to new environmental influences on the developing population or increased referral for surgical intervention over time.Levels of evidence - IV (Case Series).

Doctors' perceptions, expectations and experience regarding the role of pharmacist in hospital settings of Pakistan

Background The inclusion of pharmacist in health care system is essential to ensure optimal patient care. However, with the passage of time, pharmacist's role has transcended from dispensing, compounding and counting of pills, to more sophisticated clinical duties. Objective To evaluate doctors' experience, perceptions and expectations regarding pharmacists' role in Pakistani healthcare settings. Setting All tertiary care hospitals across 26 cities of Pakistan. Method A cross-sectional study using a self-administered questionnaire was carried out targeting doctors practising in Pakistan. The survey was conducted from January to April 2018. Chi square (χ²) test was used to analyse responses of doctors regarding pharmacist's role in the healthcare system of Pakistan. The associations were considered significant at p value less than 0.05. The study was approved by concerned ethical committee. Main outcome measure Doctors' experience, perceptions and expectations regarding pharmacists' role. Results A total of 483 questionnaires were received and analysed (response rate; 87.9%). Most participants (67.5%) reported interaction with pharmacists at least once daily, and that was mostly related to drug availability inquiry (73.7%). 86.7% of doctors expected pharmacists to ensure safe and appropriate use of medicines to patients. 87.6% of doctors expected pharmacists to monitor patient's response to drug therapy (p < 0.05) and 66.5% expected pharmacists to review patient's medicines as well as discuss possible amendments to therapy (p < 0.05). Besides, most doctors (84.9%) disagreed with the notion of pharmacists prescribing medicine for patients (p < 0.05). Most participants (81.6%) did not want pharmacists to prescribe independently. Conclusion The study highlights that doctors considered pharmacists as drug information specialists, dispensers, educators and counsellors; however, their expectation of pharmacists performing the clinical role and being involved in direct patient care was limited. They negated the idea of prescription intervention and direct involvement of pharmacists in pharmacotherapy plan for patients. It is imparative  to increase doctors' awareness regarding the role pharmacists could play in Pakistan's healthcare system. Currently, the clinical role of pharmacists in Pakistan's healthcare system seems minimal and is seen with scepticism within the community of doctors.

Report: Interactions and conflicts of interests between prescribers and medical sales representatives (MSRs) regarding prescribing and drug promotion practices in Karachi, Pakistan

Pharmaceutical drug promotion practices are found to have potentially controversial ethical standards. They may compromise on patient's wellbeing especially when it inordinately affects the clinical care and patient's interests by influencing the prescribing behavior of physicians. There is no proper system to keep a watch on the drug marketing and promotion strategies by the pharmaceuticals in Pakistan. A cross sectional study using a specially designed questionnaire and convenience sampling was conducted in Karachi for 6 months targeting prescribers and medical sales representative (MSRs). A total of 600 MSRs and prescribers consented to participate. 66% of MSRs highlighted that prescribers follow ethical prescribing but only (58%) seek evidence base behind promoted drug. This was contradictory to prescribers' response to same, which was 87%. Only (10%) of prescribers acknowledged demanding expensive gifts such as laptops, ACs, furniture and renovation of the clinic which was about 40% according to MSRs. This study offered intricate insights into the MSR and physicians interactions. It highlighted various aspects of these relationships from both MSRs' and prescribers' point of view. Although majority of the physicians negated the notion of expecting expensive favors from the sales representatives, responses by MSRs suggest that anticipation of gifts and incentives exists on part of the physicians. This has the potential to indulge in unethical promotion and irrational prescribing on part of MSRs and prescribers respectively that may further contribute to untoward patient outcomes such as increased treatment costs and adverse drug reactions.

All-Cause Mortality Amongst Patients Undergoing Above and Below Knee Amputation in a Regional Vascular Centre within 2014-2015

BACKGROUND

Major lower limb amputation remains a common treatment for patients with peripheral vascular disease (PVD) in whom other measures have failed. It has been associated with high morbidity and mortality, including risks from venous thromboembolism (VTE).

METHODS

A two-year retrospective cohort study was conducted involving 79 patients who underwent major lower limb amputation (below- or above-knee amputation) between January 2014 and December 2015 in a single tertiary referral centre. Amputation procedures were performed for reasons relating to complications of PVD and/or diabetes mellitus. Patients were followed-up to investigate all-cause mortality rates and VTE events using the Northern Ireland Electronic Care Record database (mean follow-up time 17 months).

RESULTS

Of the 79 patients, there were 52 male and 27 female. Mean age at time of surgery was 72 years (range 34-99 years). Forty-six patients (58%) suffered from diabetes mellitus, 29 (35%) heart failure, 31 (39%) chronic kidney disease (CKD) and 10 (13%) chronic obstructive pulmonary disease (COPD). Twenty patients (25%) were on anticoagulant therapy, and 53 (67%) were on antiplatelet therapy.Thirty-five patients (44%) died during follow-up; mean age at death was 74 years. No statistically significant association was found between mortality rate and the level of amputation (p=0.3702), gender (p=0.3507), or comorbid diabetic mellitus (p=0.1127), heart failure (p=0.1028), CKD (p=0.0643) or COPD (p=0.4987).Two patients experienced radiologically-confirmed non-fatal pulmonary emboli and two patients developed radiologically-confirmed deep vein thrombosis.

CONCLUSIONS

The results are in agreement with current literature that amputation is associated with significant mortality, with almost half of the study population dying during follow-up. Further work should explore measures by which mortality rates may be reduced.

Ultrasound monitoring during first-cycle treatment with clomifene citrate: a national survey of compliance with NICE

The National Institute for Health and Care Excellence Clinical Guideline 156 advises that transvaginal ultrasonography (TVUS) should be used in the first cycle of treatment with clomifene citrate, to assess for multifollicular development and hence the risk of multiple pregnancy. This guidance is based on expert opinion rather than research evidence. We conducted a cross-sectional online and postal survey among UK-based consultant gynaecologists and fertility specialists, to explore compliance with this guideline. A total of 110 responses met the inclusion criteria. During first-cycle treatment with clomifene, 50.9% of respondents were not always using TVUS, and 21.8% never were. Clinicians who did not have immediate access to TVUS were significantly less likely to scan (p < 0.01). Other key factors influencing practice were, personal experience of the clinician, lack of an evidence base to support the guideline and a willingness to accept the risk of multiple pregnancy. Several respondents questioned the value of scanning the first cycle only and highlighted that over-response may be seen in subsequent cycles. This study confirms that there is variation in adherence to the guideline and uncertainty about the clinical need for scan monitoring. Further evidence to support or refute the guideline is required.

A Survey of Bariatric Surgical and Reproductive Health Professionals' Knowledge and Provision of Contraception to Reproductive-Aged Bariatric Surgical Patients

BACKGROUND

Over 80 % of bariatric surgical patients are women with obesity in their reproductive years. Obesity adversely affects fertility; the rapid weight loss following bariatric surgery can increase fecundity. Current guidelines recommend avoiding pregnancy for up to 24 months following surgery, but little is known about current contraceptive care of women who undergo bariatric surgery. Two surveys were undertaken with bariatric surgical and contraceptive practitioners in England to establish current contraceptive practices in both groups.

METHODS

Two anonymous on-line surveys were sent to all 382 members of the British Obesity and Metabolic Surgery Society (BOMSS) and an estimated 300 contraceptive practitioners in the North East of England.

RESULTS

The BOMSS survey elicited a response rate of 17 % (n = 65), mainly from bariatric surgeons (n = 24 (36 %)). Most respondents (97 %) acknowledged the need to educate patients, but contraceptive information was only provided by 7 % (n = 4) of respondents in bariatric surgical clinics. Less than half of respondents were confident discussing contraception, and the majority requested further training, guidance and communication with contraceptive practitioners. The majority of respondents to the contraceptive practitioner survey were general practitioners (28 %, n = 20). Three quarters of respondents reported little knowledge of bariatric surgery, and many reported not seeing women with obesity requiring contraception before (66 %, n = 45) or after surgery (71 %, n = 49).

CONCLUSIONS

There is a need to increase knowledge levels of contraception within bariatric surgical teams and to understand why, despite increasing levels of bariatric surgery, women do not seem to be appearing for advice in contraceptive settings.

Is screening for urine infection in well infants with prolonged jaundice required? Local review and meta-analysis of existing data

BACKGROUND

The National Institute for Health and Care Excellence (NICE) neonatal jaundice guidance recommends a urine culture for investigation of babies with prolonged jaundice. However, the evidence cited for this guidance is limited. We aimed to review local data and the existing literature to identify evidence to either support or refute this guidance.

METHOD

We retrospectively reviewed 3 years of urine cultures from our outpatient prolonged jaundice clinic. We then conducted literature review with meta-analysis of studies presenting original data on urine tract infection (UTI) rates in jaundiced and prolonged jaundiced babies.

RESULTS

From our local data, none of the 279 patients met our unit clinical criteria for UTI. Literature review revealed considerable differences worldwide in UTI rates in both jaundiced and prolonged jaundiced cases. Using pooled data from our literature review and our local population, the incidence of UTI in prolonged jaundiced babies is 0.21% (95% CI 0.0% to 0.73%) in the UK. This is significantly lower than the figure indicated from the data from elsewhere in the world, 8.21% (95% CI 4.36% to 13.0%).

CONCLUSIONS

The findings both from our local data and the current literature do not support the practice of routine screening for urine infection in well babies with prolonged jaundice. In view of the above, we no longer include urine culture in screening of well infants with prolonged jaundice. We hope that NICE will re-examine the evidence and recommend changes to their guidance on the role of routine screening for urine infection in babies with prolonged jaundice.

Knowledge exchange systems for youth health and chronic disease prevention: a tri-provincial case study

INTRODUCTION

The research teams undertook a case study design using a common analytical framework to investigate three provincial (Prince Edward Island, New Brunswick and Manitoba) knowledge exchange systems. These three knowledge exchange systems seek to generate and enhance the use of evidence in policy development, program planning and evaluation to improve youth health and chronic disease prevention.

METHODS

We applied a case study design to explore the lessons learned, that is, key conditions or processes contributing to the development of knowledge exchange capacity, using a multi-data collection method to gain an in-depth understanding. Data management, synthesis and analysis activities were concurrent, iterative and ongoing. The lessons learned were organized into seven "clusters."

RESULTS

Key findings demonstrated that knowledge exchange is a complex process requiring champions, collaborative partnerships, regional readiness and the adaptation of knowledge exchange to diverse stakeholders.

DISCUSSION

Overall, knowledge exchange systems can increase the capacity to exchange and use evidence by moving beyond collecting and reporting data. Areas of influence included development of new partnerships, expanded knowledge-sharing activities, and refinement of policy and practice approaches related to youth health and chronic disease prevention.

'Outfoxed' - out of season

A 65 year old woman presented to the Emergency Department of our district general hospital three hours following ingestion of a blended mixture of apples and foxglove leaves, mistaking them for spinach leaves. She complained of nausea, vomiting, abdominal cramps, dizziness and blurred vision.

Residential proximity to large airports and potential health impacts in New York State

OBJECTIVE

This study assessed whether residents living near commercial airports have increased rates of hospital admissions due to respiratory diseases compared to those living farther away from these airports.

METHODS

This cross-sectional study included all residents living within 12 miles from the center of each three airports (Rochester in Rochester, LaGuardia in New York City and MacArthur in Long Island). We obtained hospital admission data collected by the NYS Department of Health for all eligible residents who were admitted for asthma, chronic bronchitis, emphysema, chronic obstructive pulmonary disease and, for children aged 0-4 years, bronchitis and bronchiolitis during 1995-2000. Exposure indicators were distance from the airport (< or =5 miles versus >5 miles) and dominant wind-flow patterns from the airport (>75th percentile versus < or =75th percentile), as well as their combinations.

RESULTS

Increased relative risks of hospital admissions for respiratory conditions were found for residents living within 5 miles from the airports (1.47; 95% CI 1.41, 1.52 for Rochester and 1.38; 95% CI 1.37, 1.39 for LaGuardia) compared to those living >5 miles. We did not find positive associations between wind-flow patterns and respiratory hospital admissions among the residents in any airport vicinity. No differences were observed for MacArthur airport using either exposure measure.

CONCLUSION

There is the suggestion that residential proximity to some airports may increase hospital admissions for respiratory disorders. However, there are many factors that could influence this association that may differ by airport, which should be measured and studied further.

A multi-layered approach to protein data integration for diabetes research

OBJECTIVE

Recent advances in high-throughput experimental techniques have enabled many protein-protein interactions to be identified and stored in large databases. Understanding protein interactions is fundamental to the advancement of science and medical knowledge, unfortunately the scale of the requires an automated approach to analysis. We describe our graph-mining techniques to identify important structures within protein-protein interaction networks to aid in human comprehension and computerised analysis.

METHODS AND MATERIALS

We describe our techniques for characterizing graph type and associated properties which is constructed from data collated from the Human Protein Reference Database. Using random graph rewiring comparative techniques and cross-validation with other identification methods a further analysis of the identified essential proteins is presented to illustrate the accuracy of these measures. We argue for using techniques based upon graph structure for separating and encapsulating proteins based upon functionality.

RESULTS

We demonstrate how rational Erdos numbers may be used as a method to identify collaborating proteins based solely upon network structure. Further, by using dynamic cut-off limit it demonstrates how collaboration subgraphs can be generated for each protein within the network, and how graph containment can be used as a means of identifying which of many possible graphs are likely to be actual protein complexes. The demonstration protein interaction network built for diabetes is found to be a scale-free, small-world graph with a power-law degree distribution of interactions on nodes. These findings are consistent with many other protein interaction networks.

CLAIRE

Many users of image retrieval systems would prefer to express initial queries using keywords. However, manual keyword indexing is very time-consuming. Therefore, a content-based image retrieval system which can automatically assign keywords to images would be very attractive. Unfortunately, it has proved very challenging to build such systems, except where either the image domain is restricted or the keywords relate only to low-level concepts such as color. This article presents a novel image indexing and classification system, called CLAIRE (CLAssifying Images for REtrieval), composed of one image processing module and three modules of support vector machines for color, texture, and high-level concept classification for keyword assignment. The experimental prototype system described here assigns up to five keywords selected from a controlled vocabulary of 60 terms to each image. The system is trained offline by 1639 examples from the Corel stock photo library. For evaluation, five judges reviewed a sample of 800 unknown images to identify which automatically assigned keywords were actually relevant to the image. The system proved to have an 80% probability to assign at least one relevant keyword to an image.

The role of menopausal hormone therapy in preventing osteoporotic fractures: a critical review of the clinical evidence

Osteoporosis is a common disease resulting in millions of potentially preventable fractures each year. Women are disproportionately affected by osteoporosis compared to men, with loss of gonadal functioning and aging being the 2 most important contributing factors to osteoporosis. For many decades, menopausal hormone therapy (HT) has been the mainstay for the prevention and treatment of osteoporosis among menopausal women. While recent randomized trial data have confirmed findings from observational studies concerning HT's protective effect on osteoporosis, they showed that HT increases the risks of breast cancer, venous thromboses, stroke, and coronary heart disease. With a strong body of evidence showing the benefit of HT in preventing osteoporotic fractures, the challenge facing clinicians is not whether HT helps to prevent osteoporotic fractures, but whether HT's fracture-prevention benefits outweigh its risks. With several medications now available having efficacy comparable to HT in preventing fractures, decisions about therapy for osteoporosis or osteopenia should take into consideration bone mineral density, other risk factors for osteoporotic fracture, and a careful examination of the benefits and risks of each treatment option. After a brief discussion of the epidemiology and pathophysiology of osteoporosis, we review the evidence from observational studies and randomized studies examining the impact of menopausal hormone therapy on osteoporosis. We focus on whether there are specific subgroups of women that accrue greater or smaller benefit from HT in terms of osteoporotic fracture reduction. We then expand our perspective to include clinical endpoints other than osteoporosis, presenting a framework for factoring in the many risks and benefits of HT. We conclude that all women should be informed of all alternative treatment options and allowed to make an informed treatment decision according to their personal risks, preferences, values, and willingness to tolerate the risks of treatment.

The management of acute myocardial infarction--practical problems in implementing the evidence

Cardiovascular disease is the leading cause of death in Europe. Acute myocardial infarction (AMI) is among the most common of its manifestations. Women and older patients are under-represented in most trials of treatment for AMI, as are those with significant co-morbidities. These patients also have a worse long term outcome after AMI. We sought to evaluate the management of AMI in a small non-academic general hospital. A review was performed of cases of AMI during 2000. Ninety-two cases were analysed, 69% were male. The mean age was 70 years. In-hospital mortality was 12%; 30-day mortality was 14%. There was no gender or age difference in mortality. Of thirty eligible patients, twenty-eight were thrombolysed (93%). Aspirin (81%) and beta-blocker (41%) prescription on discharge were below published European and American rates. Females were significantly less likely to receive aspirin or beta-blockers on discharge. Those aged 70 years or more were less likely to receive beta-blockers, statins or ACE inhibitors on discharge. Those with co-morbidities were less likely to receive beta-blockers or statins on discharge. This study highlights the difficulty in realising evidence based guidelines optimal management of AMI in clinical practice. While the outcome with regard to mortality is similar to national figures, there is a need to enhance care, with particular emphasis on secondary pharmacological measures prescribed on discharge.

Deliberate self-poisoning in an Irish county hospital

BACKGROUND

In 1997, 433 people committed suicide in Ireland, one-quarter of whom were less than 24 years of age.

AIM

To determine demographics, agent choice and source, suicidality and follow-up care of deliberate self-poisoning patients.

METHOD

Details of 111 patients admitted to one hospital in 1997 following drug overdose were studied retrospectively. Eleven had been accidental ingestions, the remaining 100 were deliberate self-poisoning.

RESULTS

Men accounted for 38% of the presentations and were more likely to have suicidal intent than women. An average of 2.3 different agents were used. Paracetamol was taken by 37%, hypnotics/anxiolytics by 33% and nonsteroidal anti-inflammatories by 17%. Alcohol was consumed synchronously by 51% and 17% fulfilled criteria for alcohol dependency. One-third of patients were clinically depressed. All six patients requiring ventilation had consumed a combination of tricyclic antidepressants and alcohol. There were no deaths.

CONCLUSION

Deliberate self-poisoning remains a significant problem. Paracetamol and alcohol use are particularly marked in this population. The combination of tricyclic antidepressant drugs and alcohol were the most dangerous.

Social security, economic growth, and the rise in elderly widows' independence in the twentieth century

The percentage of elderly widows living alone rose from 18% in 1940 to 62% in 1990, while the percentage living with adult children declined from 59% to 20%. This study finds that income growth, particularly increased Social Security benefits, was the single most important determinant of living arrangements, accounting for nearly one-half of the increase in independent living. Unlike researchers in earlier studies, we find no evidence that the effect of income become stronger over the period. Changes in age, race, immigrant status, schooling, and completed fertility explain a relatively small share of the changes in living arrangements.

Hospital mortality of acute myocardial infarction in the thrombolytic era

OBJECTIVE

To examine the management and outcome of an unselected consecutive series of patients admitted with acute myocardial infarction to a tertiary referral centre.

DESIGN

A historical cohort study over a three year period (1992-94) of consecutive unselected admissions with acute myocardial infarction identified using the HIPE (hospital inpatient enquiry) database and validated according to MONICA criteria for definite or probable acute myocardial infarction.

SETTING

University teaching hospital and cardiac tertiary referral centre.

RESULTS

1059 patients were included. Mean age was 67 years; 60% were male and 40% female. Rates of coronary care unit (CCU) admission, thrombolysis, and predischarge angiography were 70%, 28%, and 32%, respectively. Overall in-hospital mortality was 18%. Independent predictors of hospital mortality by multivariate analysis were age, left ventricular failure, ventricular arrhythmias, cardiogenic shock, management outside CCU, and reinfarction. Hospital mortality in a small cohort from a non-tertiary referral centre was 14%, a difference largely explained by the lower mean age of these patients (64 years). Five year survival in the cohort was 50%. Only age and left ventricular failure were independent predictors of mortality at follow up.

CONCLUSIONS

In unselected consecutive patients the hospital mortality of acute myocardial infarction remains high (18%). Age and the occurrence of left ventricular failure are major determinants of short and long term mortality after acute myocardial infarction.

Transfer behavior within the family: results from the Asset and Health Dynamics Study

When individuals fall on hard times, can they rely on their family for financial support? In view of proposed reductions in public assistance programs, it is important to understand the mechanisms through which families provide support for their members. In this article we provide evidence that intrafamily transfers are compensatory, directed disproportionately to less well-off members. In a given year, adult children in the lowest income category are 50 percent more likely to receive a financial transfer from their parents, and on average they receive over $300 more than their siblings who are in the highest income category. The dataset used in the new Asset and Health Dynamics (AHEAD) study contains information on all children in the family; therefore, we are able to estimate models that control for unobserved differences across families. Our results are robust to these specifications. In addition, we do not find evidence that parents provide financial assistance to their children in exchange for caregiving.

Medical insurance and the use of health care services by the elderly

The objective of this paper is to find how health insurance influences the use of health care services by the elderly. On the basis of the first wave of the Asset and Health Dynamics Survey, we find that those who are the most heavily insured use the most health care services. Because our data show little relationship between observable health measures and either the propensity to hold or to purchase private insurance, we interpret this as an effect of the incentives embodied in the insurance, rather than as the result of adverse selection in the purchase of insurance.

Familial Hypertrophic cardiomyopathy with Wolff-Parkinson-White syndrome maps to a locus on chromosome 7q3

We have mapped a disease locus for Wolff-Parkinson-White syndrome (WPW) and familial hypertrophic cardiomyopathy (FHC) segregating in a large kindred to chromosome 7 band q3. Although WPW syndrome and FHC have been observed in members of the same family in prior studies, the relationship between these two diseases has remained enigmatic. A large family with 25 surviving individuals who are affected by one or both of these conditions was studied. The disease locus is closely linked to loci D7S688, D7S505, and D7S483 (maximum two point LOD score at D7S505 was 7.80 at theta = 0). While four different FHC loci have been described this is the first locus that can be mutated to cause both WPW and/or FHC.

Antihypertensive and renal haemodynamic effects of atenolol and nadolol in elderly hypertensive patients

As little is known of the antihypertensive efficacy or renal haemodynamic effects of beta-adrenoceptor blocking drugs in the elderly we studied two such drugs, atenolol and nadolol, in elderly hypertensive patients. Ten patients took part in a placebo-controlled double-blind study of atenolol and 10 received nadolol in a single-blind placebo-controlled study. Treatment phases lasted 12 weeks for atenolol or 10 weeks for nadolol. Blood pressure, effective renal blood flow and glomerular filtration rate data obtained at the end of each treatment phase were analysed. Atenolol lowered mean arterial pressure (mean +/- s.e. mean) from 129.9 +/- 1.5 to 108.2 +/- 2.3 mm Hg (P less than 0.01) while it increased mean effective renal blood flow 512.5 +/- 86.6 to 646.0 +/- 116.1 ml min-1 1.73 m-2 (P less than 0.05). Nadolol reduced mean arterial pressure from 133.2 +/- 2.0 to 113.5 +/- 3 mm Hg (P less than 0.001) but reduced mean effective renal blood flow from 558.8 +/- 32.2 to 446.0 +/- 26.9 ml min-1 1.73 m-2 (P less than 0.05). Glomerular filtration did not alter significantly with either drug. We conclude that beta-adrenoceptor blocking drugs are effective antihypertensive agents in the elderly but have disparate effects on effective renal blood flow perhaps because of differences in cardioselectivity. These data suggest that comparative studies with thiazide diuretics and beta-adrenoceptor blocking drugs are warranted in elderly hypertensives.

Baroreflex function in elderly hypertensives

Baroreflex function was assessed in elderly hypertensive patients and compared with that observed in young hypertensives and young normotensives. Mean arterial pressure was reduced by 20% using intravenous nitroprusside infusion in 10 elderly hypertensive patients (older than 65 years and diastolic pressures over 95 mm Hg), in 10 young hypertensives (under 60 years and diastolic pressures over 95 mm Hg), and in seven young normotensive subjects (under 60 years and diastolic pressures under 95 mm Hg). Elderly subjects demonstrated greater sensitivity (p less than 0.005) and greater variability of response (p less than 0.025) to nitroprusside than either young group. There was no significant difference between the slight heart rate increases observed in the supine position in the three groups. However, in the erect position, heart rate increases were significantly less in the elderly hypertensive group than in the young hypertensive group (p less than 0.01) or the young normotensive group (p less than 0.005). Furthermore, the slope of the regression line relating change in blood pressure with change in R-R interval was less for the elderly patients than for the young hypertensives (p less than 0.05) or the young normotensives (p less than 0.025). We conclude that the heart rate component of the baroreflex is impaired in elderly hypertensives, and anticipate that the clinical response to antihypertensive drugs will be altered.

Bioavailability of labetalol increases with age

The antihypertensive drug labetalol was administered orally and intravenously to ten hypertensive patients aged between 28 and 75 years. There was a significant increase with age in both bioavailability and half-life of labetalol. Clearance tended to be lower in the elderly subjects. First pass metabolism results in variable oral bioavailability of labetalol which is greater in the elderly and this should be borne in mind when using the drug in this age group.

Clinical pharmacology of tolmesoxide in refractory heart failure

The haemodynamic effects and pharmacokinetics of single intravenous doses of tolmesoxide, a new vasodilator agent, were studied in 6 patients with severe cardiac failure secondary to ischaemic cardiomyopathy and refractory to conventional therapy. The mean (+ SEM) baseline cardiac index (CI) and pulmonary artery diastolic pressure (PADP) were 1.7 +0.11/min/m2 and 30.5 +4.1 mm Hg respectively. The mean % rise in CI was 78.8 +23.3 and the mean % fall in PADP was 35.2 +5.2. The mean half life of tolmesoxide in these patients was markedly prolonged at 15.6 +6.6h. Side effects were minimal - vomiting was seen in 1 patient. This agent warrants further study in the long term management of refractory cardiac failure.

Management of pregnancy in patients with hypertrophic cardiomyopathy

The outcome of 54 pregnancies in 23 patients with hypertrophic cardiomyopathy was analysed. No mother or infant died in the perinatal period. Six patients developed dyspnoea requiring treatment with diuretics. Beta-adrenergic blocking drugs were given in 18 pregnancies and three of the infants in this were small for dates and in two fetal bradycardia occurred. The results comfirmed that pregnancy is safe in patients with hypertrophic cardiomyopathy. A flexible approach should be adopted towards administering beta-adrenergic blocking drugs to pregnant women with hypertrophic cardiomyopathy. Many such patients do well without these drugs and can thus avoid the potential hazards--namely, small-for-dates babies and fetal bradycardia--that are associated with them.