Williams Bt

Coronary artery ectasia--a variant of occlusive coronary arteriosclerosis.

In a study of 1000 consecutive coronary arteriograms, 12 patients (all men) had coronary artery ectasia. Ectasia was found most frequently in the circumflex or right coronary artery. Only 1 patient had ectasia in the left anterior descending coronary artery. In 11 patients, ectasia of one artery was associated with severe stenosis or occlusion of other vessels, typical of arteriosclerosis. Histology from an ectatic segment in one of this group showed changes of severe arteriosclerosis with extensive intimal fibrosis and destruction of the media. One patient had a mixed collagen vascular disease. Measurement of coronary sinus flow in 2 patients with coronary artery ectasia showed flows in the range of patients with non-ectatic coronary artery disease. At cardiac surgery flows down the graft to ectatic arteries were in the same range as in grafts to non-ectatic vessels. Patients with coronary artery ectasia should be anticoagulated.

An updated review of the clinical development of coumarin (1,2-benzopyrone) and 7-hydroxycoumarin

Several authors have demonstrated that coumarin (1,2-benzopyrone) in combination with cimetidine can produce objective antitumor responses in some patients with advanced renal cell carcinoma. The purpose of this report is to review the clinical development of coumarin, with or without cimetidine, with special reference to renal cell carcinoma (RCC). Previously unpublished data concerning the survival of a population of patients with RCC, who were treated on a phase I trial of coumarin and cimetidine, are presented. The rationale and study design of an active randomized, double-blinded, placebo-controlled trial of coumarin for RCC are discussed. A progress report is given for an ongoing phase I trial of oral 7-hydroxycoumarin, the major human metabolite of coumarin.

Risk factors for development of sexually abusive behaviour in sexually victimised adolescent boys: cross sectional study

Abstract Objective: To identify factors that may increase the risk of a sexually victimised adolescent boy developing sexually abusive behaviour. Design: Sexually victimised boys who had sexually abused other children were compared with sexually victimised boys who had not done so. Setting: Social services departments in south east England were invited to refer sexually abused and sexually abusing boys to a London postgraduate teaching hospital. Subjects: 25 adolescent boys aged between 11 years and 15 years and 11 months. Main outcome measures: Adjusted odds ratios estimated from unconditional logistic regression. Results: Unadjusted odds rations for witnessing (8.1) as well as experiencing (18.0) intrafamilial violence and discontinuity of care (7.2) discriminated boys who had sexually abused from others who were solely victims of sexual abuse. Only the adjusted odds ratios for witnessing intrafamilial violence (39.7)discriminated the two groups. Conclusions: The risk of adolescent boys who have been victims of sexual abuse engaging in sexually abusive behaviour towards other children is increased by life circumstances which may be unrelated directly to the original abusive experience, in particular exposure to a climate of intrafamilial violence. Our findings have implications for the management of boys found to have been sexually abused and raise important questions about the possibility of secondary prevention of subsequent abusive behaviour in those at greatest risk.

The Alcohol Problems Questionnaire: reliability and validity

The Alcohol Problems Questionnaire (APQ) was designed as a clinical instrument for measuring alcohol-related problems. It has been used to study the relationship between alcohol-related problems and dependence within the bi-axial model. The reliability of the APQ was, however, unknown. In the present study 101 subjects participated in a test-retest reliability study. Dependence and consumption scores were obtained along with socio-demographic information in order to study the construct validity of the APQ. The APQ was found to be highly reliable and the previous finding that dependence is a mediating factor in the relationship between consumption and problems was replicated. These findings add further weight to the view that alcohol-related problems represent a phenomenon which is conceptually, as well as statistically, distinct from dependence. Further, the APQ is reliable, simple to administer and is likely to be useful in the assessment and study of problem drinkers in the clinical and research settings.

Randomised controlled trial of cost-effectiveness of lithotripsy and open cholecystectomy as treatments for gallbladder stones

Inpatient extracorporeal shockwave lithotripsy for treatment of gallbladder stones has not previously been compared with open cholecystectomy in terms of cost-effectiveness. In a randomised controlled trial, 163 patients, stratified by gallstone bulk (over 4 cm3 or not), were randomised to lithotripsy or cholecystectomy (38 large-bulk and 27 small-bulk cholecystectomy; 37 large-bulk and 61 small-bulk lithotripsy) and followed up for 1 year. Both treatments gave significant health gains in terms of a reduction in episodes of biliary pain, improved perceived health status, and symptom relief, but few differences between treatments were found. There was some evidence that biliary-pain episodes were less severe after cholecystectomy. Cholecystectomy patients also had greater improvements in mean health gain for three related symptoms: vomiting, feeling sick, and fatty-food upset. However, there were no differences between groups in perceived health status. Among lithotripsy patients, health gain was not related to stone clearance. Lithotripsy was more expensive than cholecystectomy, principally because of the costs of the inpatient stay and adjuvant bile-salt therapy. Conventional lithotripsy appears at least as cost-effective as cholecystectomy for patients with small-bulk stones but less cost-effective for those with large-bulk stones. To some extent treatment choice can be guided by patient preference.

Anaesthetic management and postoperative care of cardiac surgical patients in a general recovery ward

The postoperative care of 143 cardiac surgical patients has been successfully conducted in a general surgical recovery ward. Admission was limited to overnight stay only and all but two patients were returned to the general ward the following day. There were no deaths. The intra‐operative anaesthetic management was considered to have played an important part in the success of this technique.

Postoperative cardiac surgical care: an alternative approach

Combined appropriate anaesthetic and surgical techniques have allowed increasing numbers of patients to be successfully managed in a general surgical recovery ward after cardiac surgery rather than in an intensive care unit. From 1983 to 1989, 933 of 1542 patients undergoing open heart surgery were transferred to the general surgical recovery ward in the immediate postoperative period. Of these, 718 (77%) had undergone coronary artery bypass grafts, sometimes combined with other procedures and 168 (18%) had had cardiac valve replacements with or without other procedures. The remaining 47 (5%) had had miscellaneous cardiac operations. Significant cardiac complications occurred in 29 (3%) patients. The 24 hour chest radiograph was reported as abnormal (mainly atelectasis and effusion) in 63% of patients. Most resolved spontaneously or with physiotherapy. Twenty nine (3%) patients were re-explored to achieve haemostasis. There were no deaths in the general surgical recovery ward. Thirty seven (4%) patients had to be transferred to the intensive care unit for various reasons. The remaining 896 patients were transferred to the general ward after one night (871 patients) or two nights (25 patients) in the general surgical recovery ward. The average duration of stay in hospital for these patients was 9·3 days. Because of the overall success of such management and the low rate of complications over 80% of patients are now managed in the general surgical recovery ward after open heart surgery. The resulting savings in capital expenditure of equipment, medical, nursing, and technical personnel are substantial, and there are major implications for the planning of new cardiothoracic units.

Role of the private sector in elective surgery in England and Wales, 1986.

From a sample of 19,000 treatment episodes at 183 of the 193 independent hospitals with operating facilities in England and Wales that were open in 1986 it is estimated that 287,000 residents of England and Wales had elective surgery as inpatients in 1986 (an increase of 77% since 1981) and 72,000 as day cases. From 1985 Hospital In-Patient Enquiry data it was estimated that a further 36,000 similar elective inpatient treatments were undertaken in NHS pay beds (a decrease of 38%) and 21,000 as day cases. Overall, an estimated 16.7% of all residents of England and Wales who had non-abortion elective surgery as inpatients were treated in the private sector, as were 10.5% of all day cases. An estimated 28% of all total hip joint replacements were done privately, and in both the North West and South West Thames regions the proportion of inpatients treated privately for elective surgery was 31%. It is concluded that mainly for reasons of available manpower private sector activity may not be able to grow much more without arresting or reversing the growth of the NHS, in which case some method of calculating NHS resource allocation which takes account of the local strength of the private sector will be needed.

Microalbuminuria associated with diabetic neuropathy.

Objective To test the hypothesis that microalbuminuria may show an independent statistical association with diabetic neuropathy. Research Design and Methods An observational study of a prospectively identified cohort was conducted at the University Medical Center. The cohort consisted of 78 consecutive diabetic patients who fulfilled the criteria of having diabetes for >10 yr, a normal serum creatinine, urine negative for macroalbuminuria by a commonly used dipstick method, a blood glucose <13.8 mM (<250 mg/dl), and an HbA1 <11% (normal range 5.5–8.5%). Medical record review established the presence of chronic complications of diabetes. Urine albumin level was measured by radioimmunoassay. Albumin concn ≥15 mg/L was used as a cutoff value for microalbuminuria. RESULTS Twenty-five of 78 patients (32%) showed microalbuminuria. Of these, 51% had neuropathy, 39% had retinopathy, 35% arterial hypertension, 17% peripheral vascular disease, and 15% ischemic heart disease. After adjusting for age, sex, and type and duration of diabetes, diabetic neuropathy and hypertension showed a significant association with microalbuminuria. After adjusting for other diabetic complications, diabetic neuropathy showed a significant association with microalbuminuria. Conclusions Microalbuminuria is independently associated with diabetic neuropathy. This association lends support to the theory of a vascular etiology for diabetic distal symmetrical neuropathy.

Prevalence of hypoxaemic chronic obstructive lung disease with reference to long-term oxygen therapy

Of the Sheffield population aged 45 years or more, an estimated 0.3% (confidence interval 0.06%-0.5%) had intra-arterial oxygen pressures less than or equal to 7.3 kPa and forced expiratory volumes less than 50% of predicted values (ie, had hypoxaemic chronic obstructive lung disease). According to both the USA Medicare criteria for reimbursement and the UK Department of Health and Social Security draft guidelines for prescribing long-term oxygen, 603 (confidence interval 134-1072) subjects in Sheffield would be eligible to have oxygen supplied by concentrator, and 60 000 (confidence interval 13 000-107 000) in England and Wales. This is considerably higher than the number now prescribed long-term oxygen by general practitioners. In less than a quarter of the cases was there hypercapnia (PaCO2 greater than or equal to 6.1 kPa). The majority of those most severely affected were current smokers, and one-quarter were receiving no medication. General practitioners are unlikely to be able to assess accurately a patients need for long-term oxygen treatment without specialised advice and measurement.