Annie Britton

The Positive Relationship between Alcohol and Heart Disease in Eastern Europe: Potential Physiological Mechanisms

Research into the effect of alcohol on cardiovascular disease has indicated protective effects from moderate consumption. These observations, made in industrialized countries, have influenced policies on alcohol in countries where the situation may be quite different—specifically, where consumption is substantially higher or patterns of drinking are different. In central and eastern Europe and the former Soviet Union, a growing body of epidemiological research indicates a positive rather than negative association between alcohol consumption and cardiovascular deaths, especially sudden cardiac deaths. By means of a systematic review of published work, we examine whether there is a physiological basis for the observed association between alcohol and heart disease seen in eastern Europe, focusing on the effects of high levels of consumption and of irregular or binge drinking. In binge drinkers, cardioprotective changes in high-density lipoproteins are not seen, and adverse changes in low-density lipoproteins are acquired. Irregular drinking is associated with an increased risk of thrombosis, occurring after cessation of drinking. It predisposes both to histological changes in the myocardium and conducting system and to a reduction in the threshold for ventricular fibrillation. Measures of frequency as well as quantity of consumption should be included in epidemiological studies. Taken with the epidemiological evidence emerging from eastern Europe, these observations have important implications for estimates of the burden of disease attributable to alcohol.

Loss To Follow-up Matters

Survival analysis of joint replacement relies on the assumption that surgical procedures in patients lost to follow-up have the same chance of failing as those in patients who continue to be assessed. Our study questions that assumption. During the 16-year follow-up of 2268 patients who had received total hip replacements 142 (6%) were lost to follow-up. The cumulative loss at 15 years was 20%. At their last assessment, patients who subsequently failed to attend for follow-up had significantly worse pain, range of movement and opinion of their progress (p < 0.001) and significantly worse radiological features than a matched control group (p < 0.01). Patients lost to follow-up have a worse outcome than those who continue to be assessed. Consequently, a survival analysis that does not take into account such patients is likely to give falsely optimistic results. It is therefore essential that vigorous attempts are made to minimise loss to follow-up, and that the rate of such loss is quoted. The overall loss to follow-up disguises the magnitude of the problem, which is best quantified by a cumulative rate of follow-up. The reliability of a study can be assessed by a loss-to-follow-up quotient, calculated by the number of failures: the lower the quotient the more reliable the data. Ideally, the quotient should be less than 1.

Thromboprophylaxis and death after total hip replacement.

The recommendation that patients having a total hip replacement should receive pharmacological thromboprophylaxis is based on the belief that fatal pulmonary embolism is common, and that prophylaxis will decrease the death rate. To investigate these assumptions we performed a meta-analysis of all studies on hip replacement which included information about death or fatal pulmonary embolism. A total of 130 000 patients was included. The studies were so varied in content and quality that the results of our analysis must be interpreted with some caution. The fatal pulmonary embolism rate was 0.1% to 0.2% even in patients who received no prophylaxis. This is an order of magnitude lower than that which is generally quoted, and therefore the potential benefit of prophylaxis is small and may not justify the risks. To balance the risks and benefits we must consider the overall death rate. This was 0.3% to 0.4%, and neither heparin nor any other prophylactic agent caused a significant decrease. Our study demonstrates that there is not enough evidence in the literature to conclude that any form of pharmacological thromboprophylaxis decreases the death rate after total hip replacement. For this reason guidelines which recommend their routine use to prevent death after hip replacement are not justified.

Thromboprophylaxis and death after total hip replacement

The recommendation that patients having a total hip replacement should receive pharmacological thromboprophylaxis is based on the belief that fatal pulmonary embolism is common, and that prophylaxis will decrease the death rate. To investigate these assumptions we performed a meta-analysis of all studies on hip replacement which included information about death or fatal pulmonary embolism. A total of 130 000 patients was included. The studies were so varied in content and quality that the results of our analysis must be interpreted with some caution. The fatal pulmonary embolism rate was 0.1% to 0.2% even in patients who received no prophylaxis. This is an order of magnitude lower than that which is generally quoted, and therefore the potential benefit of prophylaxis is small and may not justify the risks. To balance the risks and benefits we must consider the overall death rate. This was 0.3% to 0.4%, and neither heparin nor any other prophylactic agent caused a significant decrease. Our study demonstrates that there is not enough evidence in the literature to conclude that any form of pharmacological thromboprophylaxis decreases the death rate after total hip replacement. For this reason guidelines which recommend their routine use to prevent death after hip replacement are not justified.

Are Randomized Controlled Trials Controlled? Patient Preferences and Unblind Trials

ABDOMINAL PAIN: and psychosis, 414(C) of psychotic origin, 221 wheelchairs as a sign, 59(C) ACCIDENT AND EMERGENCY: Scottish, assault patients attending, 322 ACROMEGALY: and cutis verticis gyrata, 79 ACUTE ABDOMEN: thyrotoxic crisis presenting as, 681 ADOLESCENTS: deliberate self-harm, brief family intervention, 484 ADVANCE DIRECTIVES: from the perspective of the patient and physician (correction), 120 ADVERTISING: are images mirages?, 62(E) which doctor? The patients view, 302(E) AFRICA: coronary heart disease, 235(C), 413(C) coronary heart disease outlook, 23 gastroenterology research, 578 AGEING: personality and health, 27(M;S32) AGUE: cure for, the contribution of Robert Talbor (1642-81), 285 cure for, 471(C), 589(C) of Essex, 415(C) AIR DISASTERS: of airships, space shuttles and biological products, 163 ALCOHOL: is it really good for you?, 651(E) problems in the older person, 16(M;S32) ALTERNATIVE MEDICINE: ancient and its modern survival, 60(C) ALTRUISM: gift relationships, 529(E) AMUNDSEN, ROALD: Lind, Scott and scurvy, 299(C) AMYLOIDOSIS: primary, multiple myeloma with, 502 ANDROCONICUS III PALAEOLOGUS: (13281341 AD), the fatal disease of the Byzantine Emperor, 106 ANEURYSM, FALSE: innominate artery due to air rifle injury, 685 ANGIOGENESIS: and the heart, therapeutic implications, 307 ANGIOGRAPHY: cholesterol emboli syndrome, 543 ANIMAL TESTING, 710(C) ANNE, QUEEN: and diabetes, 415(C) and smallpox, 60(C) ANOMIE: and suicide, 86 ANORECTAL EVERSION: effect on long-term clinical outcome of restorative proctocolectomy, 375 ANTIBIOTIC THERAPY: home intravenous, practical aspects in children, 26(M;S3 1), 34(M;S31) ANTICOAGULANTS: oral control in general practice, validation of current practice and a near patient testing method, 657 ARNICA: C30 double-blind, placebo-controlled, randomized clinical trial for pain and infection after total abdominal hysterectomy, 73 homeopathic, randomized trial, 239(C) ASCITES: with a raised CA 125, 448 ASSAULT: patients attending a Scottish accident and emergency department, 322 ASTHMA: mortality, the worldwide response, 265 ATOPIC DERMATITIS: dietary regimes in childhood, 9(M;S30) pathogenesis and food sensitivity, 2(M;S30) ATOPIC DISEASE: and food allergy, prevention, 21 (M;S30) intestinal involvement, I 5(M;S30) ATTENTION DEFICIT HYPERACTIVITY DISORDER: and encephalitis virus, 709(C) ATTORNEY-AT-THE-GATE: in the year 2005, 293

Long-term comparison of Charnley and Stanmore design total hip replacements.

We reviewed the records of the long-term outcome of 208 Charnley and 982 Stanmore total hip replacements (THR) performed by or under the supervision of one surgeon from 1973 to 1987. The Stanmore implant had a better survival rate before revision at 14 years (86% to 79%, p = 0.004), but the difference only became apparent at ten years. The later Stanmore implants did better than the early ones (97% to 92% at ten years, p = 0.005), the improvement coinciding with the introduction of a new cementing technique using a gun. Most of the Charnley implants were done before most of the Stanmore implants so that the difference between the results may in part be explained by improved methods, but this is not the complete explanation since a difference persisted for implants carried out during the same period of time. We conclude that improved techniques have reduced failure rates substantially. This improvement was much greater than that observed between these two designs of implant. Proof of the difference would require a very large randomised controlled trial over a ten-year period.

Why do women doctors in the UK take hormone replacement therapy

STUDY OBJECTIVES: To ascertain the determinants and experiences of hormone replacement therapy (HRT) use by menopausal women doctors. DESIGN: Postal questionnaire. SETTING: UK. PATIENTS: A randomized stratified sample of women doctors who obtained full registration between 1952 and 1976, taken from the current Principal List of the UK Medical Register. MAIN OUTCOME MEASURES: Current and previous use of HRT; reasons for and against HRT use; menopausal status; hormonal contraceptive use; lifestyle patterns; family and personal history of disease. MAIN RESULTS: While 73.2% of 471 users had started HRT for symptom relief, 60.9% cited prevention of osteoporosis and 32.7 prevention of cardiovascular disease. Altogether 18.7% had started for preventive purposes alone. Significant predisposing factors to starting HRT were the presence and severity of menopausal symptoms, surgical menopause, past use of hormonal contraception, and a family history of osteoporosis. HRT users were also more likely to use skimmed rather than full fat milk, to try to increase their intake of fruit, vegetables, and fibre, and to undertake vigorous physical activity at least once a week. They were less likely to have had breast cancer. Long duration users were more likely than short duration users to be past users of hormonal contraception and to be using HRT for prevention of osteoporosis as well as symptom relief; they were less likely to have experienced side effects. CONCLUSIONS: The high usage of HRT by women doctors reflects the fact that many started HRT on their own initiative and with long term prevention in mind. The results may become generalisable to the wider population as information on the potential benefits of HRT is disseminated and understood. However, HRT users may differ slightly from non-users in health-related behaviour and a substantial minority may never take up HRT, at least until the benefit-risk ratio is more clearly established.

The costs and benefits of primary total hip replacement. How likely are new prostheses to be cost-effective?

Many new hip prostheses are now available for use in total hip replacement. The majority remain untested relative to standard prostheses; however, many new prostheses are substantially more costly. We examine how much more effective new prostheses must be, in terms of reducing the need for revision operations, in order to justify this increased cost.