Long term follow up of severely ill patients who underwent urgent cardiac transplantation.

OBJECTIVE--To assess long term survival (> 5 years) and quality of life in severely ill patients referred for urgent cardiac transplantation. SETTING--Tertiary referral centres: before transplantation at the National Heart Hospital (late 1984 to end 1986); after transplantation at Harefield Hospital. SUBJECTS--Eighteen patients (15 men; three women) who had required intensive support in hospital before cardiac transplantation and were alive at short term follow up. INTERVENTIONS--Intravenous infusions of cardiac drugs (mean 2.2 infusions), intravenous diuretics (17 patients), and many other drugs before transplantation. Intra-aortic balloon counterpulsation (four patients), temporary pacing (two), and resuscitation from cardiac arrest (three). Patients had specialised nursing care on a medical intensive care unit in almost every case. MAIN OUTCOME MEASURES--Long term survival in patients after urgent cardiac transplantation and perceived quality of life. RESULTS--Of 18 patients who were alive at short term follow up (mean (range) 19.4 (10-33) months), 14 were still alive in 1992 (69 (61-83) months). Ten still worked full time, and 11 reported no restrictions in their daily activities. Three of four patients who died in the intervening period survived > 5 years after transplantation. Overall, 17 of 18 patients survived at least 5 years. CONCLUSIONS--In severely ill patients who undergo urgent cardiac transplantation and survive in the short term, long term (5-7 year) survival and quality of life seem good.     

Balloon dilatation of the aortic valve for inoperable aortic stenosis.

The place of balloon dilatation of the aortic valve in the treatment of calcific aortic stenosis is controversial. Thirty two patients (mean age 76) in whom valve replacement was contraindicated were followed up for three to 24 months (mean 8); 25 were in functional class III or IV according to the New York Heart Association''s classification. Major complications of the procedure occurred in four patients. Echocardiography and Doppler studies were performed before operation and before discharge in 28 patients, and the area of the valve was measured again six to 50 (mean 23) weeks after operation in 11 patients. The peak to peak aortic pressure gradient fell from a mean of 65 (SD 24) to 46 (20) mm Hg, but the area of the aortic valve, measured by Doppler echocardiography, in 18 patients showed a modest but significant increase, from 0.61 (0.16) to 0.74 (0.23) cm2. One month after dilatation, 29 patients were alive, of whom 17 had improved symptoms. Only two had lasting clinical benefit. Sixteen patients died, 12 of a cardiac cause. The estimated one year survival rate was 49%. Six patients underwent or required valve replacement because of persisting symptoms. In view of its limited long term efficacy balloon dilatation of the aortic valve should be used only for patients with severe symptoms whose life expectancy is limited by other disease or who are considered to be unsuitable for valve replacement. It may have a role in improving the condition of patients who present with cardiogenic shock or pulmonary oedema before valve replacement is undertaken.     

Utilization of dental health services by community-dwelling older adults in Japan who attended a weekly educational programme

Objectives: The purpose of this study was to describe dental health services utilization and identify factors which influenced a group of independently living elderly persons in an urban area of Japan. Subjects: The study sample consisted of 2,990 participants, 83% of the total sample of the Senior Citizen's College, who were 60 years and over. Measurements: Their dental utilization and satisfaction with dental treatment were measured by a questionnaire from 1993 to 1998 Results: The mean age of the subjects was 66.5 years and 52% were male. Sixty percent of the subjects had visited a dentist within the previous year, and 33% of them had received a regular oral health check‐up. The majority of the subjects (63%) were satisfied with their dental treatment. A multiple stepwise logistic regression analysis showed that dental services utilization had a significant positive association with presence of teeth (p<0.001), being male (p<0.01) and satisfaction with financial status (p<0.05). A regular oral health check‐ups had a significant association with presence of teeth (p<0.001), satisfaction with financial status (p<0.05) and aging (p=0.001). Conclusions: Dental health services utilization was related to the presence of teeth and financial status, rather than age or medical conditions, among independently living elderly persons in an urban area of Japan.     

Management of uraemic pericarditis.

Of 250 patients undergoing haemodialysis from 1967 to 1974 17 presented with uraemic pericarditis. Seven of these patients who had been transferred early enough to peritoneal dialysis treatment were cured without pericardiectomy (mean survival 18 months (range 6-36); no deaths). Only one patient was cured from his pericarditis by "aggressive haemodialysis." In seven out of 10 patients treated with haemodialysis, pericardiectomy finally had to be performed because of pericardial tamponade (postoperative survival 20 months (range 8-36); one death). Two patients died from pericardial tamponade before surgery. In patients with evidence of uraemic pericarditis frequent peritoneal dialysis with high fluid withdrawal is the treatment of choice, but in cardiac tamponade pericardiectomy should follow a preoperative pericardiocentesis with limited fluid aspiration. Of possible significance in the aetiology of pericarditis were the findings that 10 of the 17 patients had hypertension with cardiac enlargement and that 14 presented with evidence of underdialysis, possibly due to the reuse of dialysis components.     

Effects of ACTH on plasma levels of adrenal steroids in essential hypertension.

Plasma concentrations of progesterone (P), deoxycorticosterone (DOC), 17-hydroxyprogesterone (17-OH P), corticosterone (B), deoxycortisol (S), cortisol (F) and aldosterone (A) in 8 control subjects (mean age: 40.5 years) and 10 patients with essential hypertension (EH) (mean age: 48.5 years) were determined before, 4 and 8 hours after an infusion of ACTH at a rate of 25 units per 8 hours. Secretion rates (SR) of 18-hydroxy-11-deoxycorticosterone (18-OH DOC) were measured 24 hours before and again on the day of ACTH infusion. All subjects were studied on the fourth day of a diet containing 135 mEq of sodium and 90 mEq of potassium. There was no statistically significant difference between 8 control subjects and 10 patients with EH in the 7 plasma steroid levels and the SR of 18-OH DOC before ACTH infusion. The mean plasma P response to ACTH was slightly lower in controls than in patients with EH, while that of 17-OH P (in male subjects) was slightly higher. The mean plasma B response was significantly lower after 4 hours of ACTH infusion (p less than 0.01), while that of DOC was significantly higher after 8 hours of ACTH infusion (p less than 0.05) in patients with EH. The mean plasma S rose significantly more in patients with EH (p less than 0.025) at 4 and 8 hours after ACTH infusion. The mean plasma F response to ACTH infusion was slightly lower in patients with EH than in controls. The mean response of 18-OH DOC SR to ACTH infusion was slightly higher in patients with EH than in controls. The mean plasma A response was significantly higher in patients with EH than in controls 4 (p less than 0.05) and 8 hour (p less than 0.001) after an ACTH infusion. These results could be explained in part by abnormalities in the 17- and 11-hydroxylase systems, and that the abnormality in 11-hydroxylation was more pronounced than that in the 17-position. Furthermore, we suspect that the sensitivity of adrenal aldosterone to ACTH might be increased or another accelerated pathway to aldosterone biosynthesis might exist in patients with EH.     

Course of angina pectoris after an acute coronary event.

The course of postcoronary angina pectoris was examined in 555 men who had survived a first attack of myocardial infarction or unstable angina. Patients were aged less than 60 and were followed up yearly for up to 17 years. Only 25 (4.5%) had coronary artery bypass surgery. Most patients with angina were treated by nitrates alone. One year after infarction 24.1% of survivors (124/515) reported the presence of angina pectoris, and the proportions at five, 10, and 15 years were 29.9%, 30.4%, and 43.5% respectively. Seventeen years after the initial event 35.3% of the survivors had never reported postcoronary anginal symptoms. The patients who experienced anginal symptoms in the year after their coronary attack had a poorer long term survival than the group who were symptom free over the first year. These patients also had longer subsequent periods with angina, though in 41.7% angina resolved before death after a median of 2.9 years. Throughout follow up mortality during periods in which patients experienced angina was higher than in the symptom free periods. This long term follow up study of patients after a coronary event confirms that the presence or absence of angina may vary considerably over time in patients treated medically and that the presence of angina is associated with a poorer prognosis. These findings have important implications when assessing the effects of various treatment modalities on postcoronary angina, including coronary artery bypass surgery.     

Tooth loss, the wearing of dentures and associated factors in Sri Lankan older individuals

Objective: To determine tooth loss, wearing of dentures and associated factors in older individuals from Sri Lanka. Design: A cross‐sectional survey where the data were collected by means of an oral examination and an interviewer administered questionnaire. Setting: Negambo within the Gampaha district of Sri Lanka. Subjects: A total of 630 subjects who were aged 60 years and above. Results: Only 11 subjects had all 32 teeth and 17% were edentulous. Age, gender and level of income were significantly associated with the number of missing teeth. Of those with missing teeth, 22% wore dentures. Only 16% of the non‐denture wearers perceived a need for dentures. Among the non‐denture wearers who perceived a need for dentures, a majority had cited ‘cost’ as the main barrier for obtaining dentures. Logistic regression analysis revealed that age, gender, levels of income and education and missing teeth were significant predictors of wearing of dentures. Conclusions: Knowledge of factors that influence tooth loss and wearing of dentures may have implications for oral health care planners in the provision and delivery of oral health services to the older individuals.     

Prevalence of Mental Illness among Homeless People in Hong Kong

MetholodogyThis study examined the prevalence and correlates of mental illness in homeless people in Hong Kong and explored the barriers preventing their access to health care. Ninety-seven Cantonese-speaking Chinese who were homeless during the study period were selected at random from the records of the three organisations serving the homeless population. The response rate was 69%. Seventeen subjects could not give valid consent due to their poor mental state, so their responses were excluded from the data analysis. A psychiatrist administered the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I) and the Mini -Mental State Examination. Consensus diagnoses for subjects who could not complete the SCID-I were established by three independent psychiatrists.FindingsThe point prevalence of mental illness was 56%. Seventy-one percent of the subjects had a lifetime history of mental illness, 30% had a mood disorder, 25% had an alcohol use disorder, 25% had a substance use disorder, 10% had a psychotic disorder, 10% had an anxiety disorder and 6% had dementia. Forty-one percent of the subjects with mental illness had undergone a previous psychiatric assessment. Only 13% of the subjects with mental illness were receiving psychiatric care at the time of interview. The prevalence of psychotic disorders, dementia and the rate of under treatment are hugely underestimated, as a significant proportion (18%) of the subjects initially selected were too ill to give consent to join the study.ConclusionThe low treatment rate and the presence of this severely ill and unreached group of homeless people reflect the fact that the current mode of service delivery is failing to support the most severely ill homeless individuals.     

Productivity of estrogens by human placental organ culture at different stages of gestation

The productivity of estrogens from 6 to 39 weeks of pregnancy was assessed by using human placental organ culture. It was revealed that the placenta gains the capacity to generate a significant amount of estrogens at around 8 weeks of pregnancy. Therefore, it was suggested that the luteoplacental shift takes place between 6 and 8 weeks of gestation (or 4 to 6 weeks after fertilization). The productivity of estrogens showed a distinct difference before and after 10 weeks of pregnancy when the placental localization is established. The amount of estrone formed by the placenta before 10 weeks of pregnancy was 0.043 +/- 0.005 nanomoles/mg protein/hour (mean +/- s.e, n = 6), while it was 0.034 +/- 0.002 nanomoles/mg protein/hour from 10 weeks to term (mean +/- s.e, n = 18 ; not significantly different) during which no marked change was observed, however that of 17 beta-estradiol was 0.099 +/- 0.002 nanomoles/mg protein/hour (mean +/- s.e, n = 6) before 10 weeks of pregnancy and 0.072 +/- 0.002 nanomoles/mg protein/hour (mean +/- s.e, n = 18) from 10 weeks to term (significant difference with p less than 0.005). The 17 beta-estradiol/estrone ratio remained almost constant throughout pregnancy, which ranged from 2.00 to 3.00.     

Elevated frequencies of 6-thioguanine-resistant lymphocytes in multiple sclerosis patients treated with cyclophosphamide: a prospective study

An autoradiographic assay for 6-thioguanine-resistant (TGr) lymphocytes was used to determine the frequency of in vivo derived variant T lymphocytes in peripheral blood from multiple sclerosis (MS) patients treated with monthly intravenous infusions of 750 mg/m2 of cyclophosphamide (CP). To analyze the time-course of response to CP, the MS patients were studied prospectively. Samples were obtained from the patients before the beginning of CP therapy, 4-5 times during the course of treatment, and, finally, 2 or 3 months after the completion of therapy. 2 weeks after the first CP infusion, the variant frequencies (Vfs) of the MS patients were significantly increased (p less than 0.05) above their pre-treatment values, but by 4 weeks following the first CP infusion the Vfs had fallen to normal or near-normal levels. After subsequent treatments, the frequencies of variant TGr cells were again higher than pre-treatment Vfs. However, within 7-13 weeks after the cessation of CP therapy, the Vfs of all subjects had returned to normal levels. The transient nature of the response indicates rapid in vivo selection against CP-induced TGr mutant cells. The mean pre-treatment Vf of the 4 MS patients who were cigarette smokers was 6.56 X 10(-6) which was significantly greater (p less than 0.05) than the mean Vf (1.52 X 10(-6) of the 4 MS patients who were non-smokers. The mean Vf from 8 assays of healthy non-smokers was 1.92 X 10(-6).     

Cervical screening in Perth and Kinross since introduction of the new contract.

OBJECTIVE--To determine changes in the cervical screening service since the introduction of the new general practitioner contract on 1 April 1990. DESIGN--Analysis of computerised records of cervical screening both before and after introduction of the new contract. SETTING--General practices in Perth and Kinross Unit, Tayside. PATIENTS--A total of 30,071 women aged 21-60 on 26 general practitioner partnership lists. MAIN OUTCOME MEASURES--Percentage average of target population for cervical screening in each practice for first three quarters on introduction of the contract. RESULTS--Perth and Kinross Unit completed a computerised cervical screening call programme in July 1989, which produced an increase from 71% to 78% in the mean percentage of women aged 20-60 who had had cervical smear tests within 5.5 years. Six months after the introduction of the new general practitioner contract the mean population coverage was increased to 85% in women aged 21-60 and only four practices had not attained the 80% upper target compared with 10 on 1 April 1990. Detailed examination of randomly selected practices immediately before the new contract was introduced showed an average artificial list inflation of 4.3% in health board records when compared with practice records, a hysterectomy rate of 6.2%, and an additional 3% of women who were considered to be ineligible for smear testing due to putative virginity or illness or infirmity, or both. There was a considerable shift away from use of well woman clinics (2.7% of smears in 1990 compared with 5.6% in 1988) for taking cervical smears, potentially threatening the long term viability of the clinics. CONCLUSION--The introduction of the new contract for general practitioners has brought about a further sustained increase in population coverage for cervical screening in a small Scottish unit with a stable population, well motivated general practitioners, and a fully integrated computerised call and recall system based on the community health index. To optimise the screening service revision of the targets levels is necessary.     

Responses of the autonomic nervous system in altitude adapted and high altitude pulmonary oedema subjects

Studies were carried out to ascertain the role of sympatho-parasympathetic responses in the process of adaptation to altitude. The assessment of status of autonomic balance was carried out in a group of 20 young male subjects by recording their resting heart rate, blood pressure, oral temperature, mean skin temperature, extremity temperatures, pupillary diameter, cold pressor response, oxygen consumption, cardioacceleration during orthostasis and urinary excretion of catecholamines; in a thermoneutral laboratory. The same parameters were repeated on day 3 and at weekly intervals for a period of 3 weeks, after exposing them to 3,500 m; and also after return to sea level. At altitude, similar studies were carried out in a group of 10 acclimatized lowlanders, 10 high altitude natives and 6 patients who had recently recovered from high altitude pulmonary oedema. In another phase, similar studies were done in two groups of subjects, one representing 15 subjects who had stayed at altitude (3,500–4,000 m) without any ill effects and the other comprising of 10 subjects who had either suffered from high altitude pulmonary oedema (HAPO) or acute mountain sickness (AMS). The results revealed sympathetic overactivity on acute induction to altitude which showed gradual recovery on prolonged stay, the high altitude natives had preponderance to parasympathetic system. Sympathetic preponderance may not be an essential etiological factor for the causation of maladaptation syndromes.     

Modifying risk of developing lung cancer by changing habits of cigarette smoking.

Data from a hospital based case-control study of lung cancer in Western Europe were used to examine changes in the risk of developing lung cancer after changes in habits of cigarette smoking. Only data for subjects who had smoked regularly at some time in their lives were included. The large size of the study population (7181 patients and 11 006 controls) permitted precise estimates of the effect of giving up smoking. Risks of developing lung cancer for people who had given up smoking 10 or more years before interview were less than half of those for people who continued to smoke. The reduction in risk was seen in men and women and in former smokers of both filter and non-filter cigarettes but varied by duration of smoking habit before giving up. The protective effect of giving up became progressively greater with shorter duration of smoking habit. The risks after not smoking for 10 years for both men and women who had previously smoked for less than 20 years were roughly the same as those for lifelong non-smokers. Reducing the number of cigarettes smoked a day or switching from non-filter to filter cigarettes also lowered the risk of developing lung cancer but not to the extent associated with giving up smoking.     

Prevalence of risk factors for cardiovascular disease in Canadians 55 to 74 years of age: results from the Canadian Heart Health Surveys, 1986-1992

BACKGROUND: By 2016, the proportion of Canadians older than 65 years of age will increase to 16%, and there will be an increase in the absolute number of cases of cardiovascular disease in older Canadians. The Canadian Heart Health Surveys database provides information about this population upon which health policy related to cardiovascular disease can be based. This paper presents for the first time population-based data on the risk factors for cardiovascular disease in older Canadians. METHODS: Canadians from all 10 provinces participated in surveys of cardiovascular risk factors; health insurance registries were used as sampling frames. In each province, probability samples of 2200 adults 18 to 74 years old not living in institutions, on reserves or in military camps were asked to participate in interviews and to undergo testing at clinics for major risk factors for cardiovascular disease. RESULTS: A total of 2739 men (response rate 70%) and 2617 women (response rate 66%) aged 55 to 74 years participated in the survey and also provided follow-up clinical measurements at the clinic. Overall, 52% of participants were hypertensive, 26% had isolated systolic hypertension, and 30% had a total blood cholesterol level of 6.2 mmol/L or greater. Rates of current smoking were lower in women than men (17% v. 22%). Overall, 87% of men and 78% of women who were current smokers smoked at least 10 cigarettes per day. Only slightly more than half of participants exercised at least once a week for at least 15 minutes, and almost half had a body mass index of 27 or greater. In only 4% was no major risk factor for cardiovascular disease detected. INTERPRETATION: Significant numbers of older Canadians have one or more major risk factors for cardiovascular disease. Many of these risk factors are amenable to modification.     

Circadian placebo and ACTH effects on urinary cortisol in arthritics

The effect of placebo and ACTH-1-17 (Synchrodyn®, Hoechst) upon urinary free cortisol was examined at 5 different circadian stages on 10 men with Steinbrocker Stage II–III rheumatoid arthritis. A mean cosinor analysis of urinary cortisol data from the subjects prior to treatment with either ACTH or placebo revealed a statistically highly-significant rhythm. A circadian variation in a response of urinary free cortisol to a placebo was also seen. Moreover, the response of the midline-estimating statistic of rhythm (rhythm-adjusted circadian average) of urinary free cortisol to ACTH-1-17 by patients with rheumatoid arthritis is circadian rhythmic. This reactivity rhythm is out of phase with the spontaneous rhythm in urinary cortisol acrophases—in the tests limited thus far to midsummer. The further assessment of the circadian component in the context of broader interactions by rhythms with other frequencies in various conditions in health and disease is warranted by the demonstration of rhythms here presented for men with rheumatoid arthritis.     

Effects of preventive home visits to elderly people.

OBJECTIVES--To assess the effect of preventive home visits by public health nurses on the state of health of and use of services by elderly people living at home. DESIGN--Randomised controlled trial. SETTING--General population of elderly people in one of the southern regions of the Netherlands. SUBJECTS--580 subjects aged between 75 and 84 years randomly allocated to intervention (292) or control (288) group. INTERVENTIONS--Four visits a year over three years in intervention group. Control group received no home visits. MAIN OUTCOME MEASURES--Self rated health, functional state, well being, loneliness, aspects of the mental state (depressive complaints, memory disturbances), and mortality. Use of services and costs. RESULTS--Visits had no effect on the health of the subjects. In the group visited no higher scores were seen on health related measures, fewer died (42 (14%) v 50 (17%)), and community care increased slightly. In the control group more were referred to outpatient clinics (166 (66%) v 132 (55%)), and they had a 40% increased risk of admission (incidence rate ratio 1.4; 90% confidence interval 1.2 to 1.6). No differences were found in long term institutional care, and overall expenditure per person in the intervention group exceeded that in the control group by 4%. Additional analyses showed that visits were effective for subjects who initially rated their health as poor. CONCLUSIONS--Preventive home visits are not beneficial for the general population of elderly people living at home but might be effective when restricted to subjects with poor health.     

Geriatric assessment unit in a teaching hospital.

A geriatric assessment unit has been in operation in a Canadian teaching hospital since October 1979. In the first 15 months of operation there were 203 admissions involving 153 persons aged 65 years or older, many of whom were impaired both physically and mentally.In many cases these patients could be discharged back to the community following assessment and rehabilitation. Only a few had to be placed immediately in extended care facilities. The mean stay in the unit was less than 3 weeks. There was a mortality of 3% among patients in the unit. For older persons who present with complex health problems a geriatric assessment unit provides an environment for comprehensive assessment, treatment and rehabilitation. A thorough assessment at, or preferably before, the point at which their health breaks down enables older people to return to and remain in the community and helps to prevent them from being admitted to an institution while they are still able to function with reasonable independence.