Are women discriminated against for lipid lowering therapy? Results from a prospective cohort of women with coronary artery disease

The objective of the study was to compare the lipid management of men and women with documented coronary artery disease in 587 patients (433 men and 154 women) undergoing coronary angiography between 1991 and 1995. A fasting total cholesterol (TC) was measured in all patients on the morning of angiography. A postal/telephone follow-up was carried out one year after angiography in a subpopulation of 278 patients (194 men and 84 women) who were not taking lipid-lowering therapy (LLT) or whose TC was > 5.2 mmol/l at the time of angiography. At baseline, mean TC was 5.89 mmol/l (SE 0.06) in the men and 6.47 mmol/l (SE 0.09) in the women (p = < 0.0001). Action or recommendation to institute LLT was taken in 141 (32.7%) men and 62 (40.3%) women (p = 0.09). In the follow-up population, comparing men with women, 74 (38.3%) vs 39 (46.4%) were taking LLT (p = 0.21); 56 (28.9%) vs 26 (31.0%) had not undergone repeat TC testing (p = 0.73); when performed, repeat TC was 5.75 (0.09) mmol/l vs 5.64 (0.16) mmol/l (p = 0.53); mean decrease in TC between baseline and follow-up was 0.86 (0.10) mmol/l vs 1.01 (0.21) mmol/l (p = 0.51). There was no significant gender difference in lipid management either at the time of coronary angiography or subsequent follow-up, although the level of lipid-lowering drug use remained inadequate in both sexes.

Optimum imaging for mucoceles

A mucocele is an epithelial lined mucus-containing sac completely filling a paranasal sinus and capable of expansion. They are relatively unusual, occurring most frequently in the fronto-ethmoidal region. The imaging features on plain X-ray, computerized tomography and magnetic resonance imaging are relatively characteristic allowing distinction of the lesion from other pathologies in this area although the mucoceles may occur in association with other pathologies such as nasal polyposis and neoplasia.

A randomised placebo controlled trial of the effects of tibolone on blood pressure and lipids in hypertensive women

The effects of hormone replacement therapy in hypertensive women are controversial. This randomised placebo controlled trial assessed the effect of tibolone 2.5 mg on blood pressure and fasting plasma lipids in 29 hypertensive postmenopausal women over 6 months using a 2:1 randomisation to tibolone. The primary clinical end-point was mean office blood pressure. At 6 months systolic blood pressure declined by 5.30 +/- 2.87% vs 4.94 +/- 3.37% whilst diastolic blood pressure declined 5.38 +/- 2.65% vs 0.85 +/- 3.69% on tibolone and placebo respectively. These differences were not statistically significant. Triglycerides decreased by 33.3 +/- 6.1% vs 7.6 +/- 7.9% (P < 0.01) and high-density lipoprotein (HDL)-cholesterol by 21.7 +/- 3.8% vs 2.4 +/- 2.6% (P < 0.01) with tibolone as opposed to placebo. No significant differences were observed in total cholesterol, low-density lipoprotein (LDL)-cholesterol and lipoprotein (a). Fibrinogen levels were reduced by 13.6 +/- 6.8% on tibolone compared to a 19.3 +/- 15.4% rise (P < 0.05) on placebo. This study suggests that tibolone has no deleterious effect on blood pressure in women with hypertension but has contrasting effects on biochemical risk factors. Large-scale studies are required to determine the overall effect of tibolone on cardiovascular morbidity and mortality.

Fungal rhinosinusitis

Fungal infections in both their invasive and non-invasive forms can prove difficult to diagnose. The often characteristic appearances on imaging are of great assistance. CT is the primary imaging modality and is probably more accurate than MRI in diagnostic specificity and determining the extent of bone erosion. However this may require a modified scanning technique to adequately demonstrate the typical soft tissue density variations of fungi. MRI should be used to supplement CT when intra-cranial or intra-orbital extension is suspected.

Why patients do not attend cardiac rehabilitation: role of intentions and illness beliefs

OBJECTIVE

Many patients fail to attend cardiac rehabilitation. Attempts to identify sociodemographic or clinical predictors of non-attendance have not been very successful; therfore, this study aimed to determine whether the illness beliefs held during hospitalisation by patients who had suffered acute myocardial infarction or who had undergone coronary artery bypass graft surgery could predict cardiac rehabilitation attendance.

SUBJECTS AND METHODS

152 patients were prospectively studied of whom 41% had attended cardiac rehabilitation at six months.

RESULTS

In addition to being older, less aware of their cholesterol values, and less likely to be employed, non-attenders were less likely to believe their condition was controllable and that their lifestyle may have contributed to their illness.

CONCLUSION

It should now be determined whether interventions aimed at optimising certain perceptions could promote cardiac rehabilitation uptake among those patients who could benefit the most.

Alterations in atrial electrophysiology associated with chronic atrial fibrillation in man

BACKGROUND

The purpose of this study was to determine the changes in atrial electrophysiology associated with chronic persistent atrial fibrillation in man.

METHODS AND RESULTS

Atrial monophasic action potential duration at 90% repolarization and the effective refractory period were measured in 13 patients with chronic persistent atrial fibrillation after low-energy endocardial cardioversion, and compared to eight controls without a history of atrial fibrillation. Measurements were made at the right atrial appendage and midlateral right atrial wall at basic, 600 ms and 400 ms drive cycle lengths. In control patients, the effective refractory periods were significantly longer at the atrial appendage than the lateral wall at 600 ms (right atrial appendage 265 ms, midlateral right atrial wall 228 ms, P<0.05), and 400 ms cycle lengths (right atrial appendage 270 ms, midlateral right atrial wall 218 ms, P<0.05), but this was not evident in patients with atrial fibrillation. The monophasic action potentials and effective refractory periods at both atrial sites were shorter in the atrial fibrillation patients compared to controls; however, only the effective refractory periods at atrial appendage at 600 ms (atrial fibrillation 210 ms, controls 265 ms, P<0.001), and 400 ms cycle lengths (atrial fibrillation 200 ms, controls 270 ms, P>0.001) reached statistical significance. Effective refractory period dispersion was significantly greater in controls than in patients with atrial fibrillation (cycle length 600 ms: controls 36, atrial fibrillation 13, P=0.01; cycle length 400 ms: controls 54, atrial fibrillation 18, P<0.01).

CONCLUSIONS

In patients without a history of atrial fibrillation, the refractory period at the right atrial appendage is significantly longer than at the midlateral right atrial wall. This 'normal' pattern of atrial refractory dispersion is lost in patients with chronic persistent atrial fibrillation, with marked shortening of the effective refractory period at the right atrial appendage. This may explain the high risk of recurrence of atrial fibrillation following successful electrical cardioversion.

Prevalence of antibodies to Coxiella burnetii (Q fever) in bulk tank milk in England and Wales

In the United Kingdom, the infection of people with Coxiella burnetii, the causative agent of Q fever, is of significant public health importance and is associated with contact with dairy cattle. An ELISA was developed for the detection of IgG antibodies against C burnetii in bulk tank milk, and in a survey of randomly selected samples from dairy herds in England and Wales, 21 per cent showed serological evidence of C burnetii infection.

Psychiatric and social outcome following liver transplantation for alcoholic liver disease: a controlled study

Psychiatric outcome, quality of life, and alcohol consumption were compared between patients transplanted for alcoholic liver disease and those transplanted for other chronic liver diseases. Instruments used included the Clinical Interview Schedule, the 28-item General Health Questionnaire, the Hospital Anxiety and Depression Scale, and the Nottingham Health Profile. There was no difference between the two groups with regard to median scores or "caseness" on these instruments, except for physical mobility on the Nottingham Health Profile, where the alcoholic group was more likely to experience difficulties (p = 0.03). The majority of those transplanted for alcoholic liver disease remained abstinent, although 7 of the 31 in the alcoholic group (23%) were drinking above recommended safe limits. Psychosocial outcome is similar for individuals transplanted for alcoholic liver disease and those transplanted for other chronic liver diseases. Patients should not be excluded from transplantation on grounds of their drinking history.

Juvenile angiofibroma: the lessons of 20 years of modern imaging

Seventy-two patients with juvenile angiofibroma have been investigated by computerized tomography (CT) and/or magnetic resonance imaging (MRI) over a period of 20 years. The evidence from these studies indicates that angiofibroma takes origin in the pterygo-palatine fossa at the aperture of the pterygoid (vidian) canal. An important extension of the tumour is posteriorly along the pterygoid canal with invasion of the cancellous bone of the pterygoid base, and greater wing of the sphenoid (60 per cent of patients). Distinctive features of angiofibroma are the high recurrence rate, and the rapidity with which many tumours recur. It is postulated that the principal determinant of recurrence is a high tumour growth rate at the time of surgery coupled with incomplete surgical excision. The inability to remove the tumour in toto is principally due to deep invasion of the sphenoid, as described above. In this series 93 per cent of recurrences occurred with this type of tumour extension. A contributory cause in these patients is the use of pre-operative embolization. The treatment implications of these findings are examined.

Protection against herpes B virus infection in rabbits with a recombinant vaccinia virus expressing glycoprotein D

Herpes B virus infects naturally monkeys of the macaque genus in whom it can cause recurrent oral and genital lesions. However, when the virus infects humans it causes a neurological illness with a high case fatality rate. Successful treatment is possible but this depends on diagnosis prior to the onset of respiratory arrest, and fatalities over the last 10 years have been the result of late or no diagnostic data on which to base anti-viral intervention. An effective vaccine would be an ideal way to combat the risk of herpes B virus disease in humans working with potentially infected monkeys or their tissues. A recombinant vaccinia virus expressing herpes B virus glycoprotein D (gD) was constructed and rabbits inoculated with the chimeric virus were tested for immunoglobulin responses to herpes B virus by virus neutralisation, ELISA and Western blot analyses. Anti-gD humoral responses were detected in all vaccinated animals by ELISA and Western blot but neutralising antibody was not detected prior to challenge with herpes B virus. Non-vaccinated rabbits died within 8 days of challenge while 10/11 vaccinated animals were protected against herpes B virus disease. No antibodies to herpes B virus proteins other than gD were detectable in surviving animals, suggesting minimal herpes B virus replication post challenge. Autopsies were carried out on 4/10 rabbits which had remained healthy at 31 days post challenge and the dorsal root ganglia adjacent to the inoculation site were removed. Attempts to detect herpes B virus DNA by PCR followed by hybridisation proved negative suggesting protection against latent herpes B virus infection.

Computerised biofeedback games: a new method for teaching stress management and its use in irritable bowel syndrome

OBJECTIVES

To develop and test a computer biofeedback game designed to teach deep relaxation to patients with a stress related disorder and to assess whether relaxation can improve symptomatic episodes.

STUDY DESIGN AND SETTING

An open, prospective, single centre study. Department of Gastroenterology, Royal Free Hospital, London.

SUBJECTS

Forty patients with irritable bowel syndrome refractory to conventional medical treatment.

MAIN OUTCOME MEASURES

Development of a computer aided biofeedback apparatus directed at the gut for teaching relaxation to patients with irritable bowel syndrome. The patients' ability to complete a computer game involving biofeedback modulated by a physiological loop that related changes in stress (monitored by electrodermal activity) to animated computer graphics. The degree to which deep relaxation was achieved was measured numerically by a progressive reduction in the sensitivity level of the biofeedback loop. The success of relaxation in ameliorating physical symptoms of irritable bowel syndrome was assessed by daily diaries in which global and weighted bowel symptom scores were entered.

RESULTS

A computer biofeedback game based on animated gut imagery was successfully developed. Most patients learned to achieve progressively deeper levels of relaxation after four 30 minute biofeedback sessions (mean difference in sensitivity level 2.0 (95% confidence interval 0.96 to 2.93), p < 0.001). Use of 'dosed' relaxation when bowel symptoms were troublesome was helpful in 50% of patients. It reduced the global symptom score (mean difference 0.5 (0.02 to 0.32), p < 0.04) and the bowel symptom score (mean difference 0.8 (0.04 to 1.58), p < 0.04). At long term follow up, 64% of patients who had been helped by dosed relaxation continued to use the technique, although they had had no further contact with the hospital.

CONCLUSIONS

This computer biofeedback game taught deep relaxation rapidly and effectively. Half the patients with refractory irritable bowel syndrome found the technique helpful on most occasions on which it was used. Computer biofeedback games may offer a simple, inexpensive strategy for managing other stress related medical disorders.

Establishing a European network for the diagnosis of &quot;imported&quot; viral diseases (ENIVD)

The epidemics in recent years of Ebola haemorrhagic fever in Zaire and Gabon acted as a reminder that dangerous infections can be imported very quickly into Europe. Meetings on emerging and re-emerging pathogens organised by the World Health Organization.

Establishing a European network for the diagnosis of

The epidemics in recent years of Ebola haemorrhagic fever in Zaire and Gabon acted as a reminder that dangerous infections can be imported very quickly into Europe. Meetings on emerging and re-emerging pathogens organised by the World Health Organization

Information delivery: the provision of written information for patients following coronary angiography and post-discharge management

To improve management of risk factors in patients diagnosed with significant coronary artery disease after day case angiography, we gave patients a discharge information sheet emphasising the importance of prognostic therapy, risk factors and follow-up. The sheet was evaluated in 40 patients. A nurse talked through the information sheet with the patients after their angiogram and helped to complete relevant sections. One group of patients was given a copy of the sheet to take home, while the second group remained a 'verbal information only' group. Providing written information resulted in improvements in follow-up regarding blood pressure and drug therapy checks, but there was no significant difference between the groups in the follow-up management of cholesterol or in patient awareness of their cholesterol level. Patients were not likely to remember the sheet, even though a nurse had talked them through it, unless it was backed up with a written copy which could be taken away. It became apparent that the vast majority of patients remembered a pictorial representation of the extent of their disease (routinely provided) in contrast to the relatively disappointing numbers (43%) who remembered the information sheet. To evaluate further the importance of content and style in effective information delivery, we are evaluating the combination of written information with a visual representation of the heart.

Retrospective review of 100 cases of endoluminal aortic stent-graft surgery from an anaesthetic perspective

One hundred cases of endoluminal aortic stent surgery were retrospectively reviewed and analysed with respect to outcome. The overall mortality rate was consistent with standard rates for open surgical repair. One hundred per cent of patients who developed multiorgan failure died (7), as did 78% of those who developed acute renal failure (9), and 55% of those who had a serum creatinine rise greater than 100 mumol/l (9). Patients given mannitol had an increased incidence of a serum creatinine rise of greater than 100 mumol/l, at 16% versus 4% for those not given mannitol. Patients with documented intra- or postoperative anaemia (Hb < or = 80 g/l) had a mortality rate of 22% compared to 5% for non-anaemic patients. The mortality rate increased from 3% to 15% if the procedure took more than four hours. The anaesthetic requirements for this new type of surgery are outlined and discussed with respect to these results. The surgical technique is summarized.