cardiac rehabilitation; coronary heart disease; National Service Framework
In South Wales cancer registration is done principally by means of the Hospital Activity Analysis. Altogether 1460 hospital records of cancer patients (19% of the 1972 registrations received by May 1973) were studied and the principal items of information required for cancer registrations by the Office of Population Censuses and Surveys were copied and subsequently compared with the corresponding registrations at the Welsh Hospital Board's cancer bureau. Differences between these 're-registrations' and the original registrations were analysed item by item. There were 234 registrations with errors in the diagnostic summary (although 110 of these would cause misclassification only under the fourth digit of the ICD code), 164 with errors in date of birth (36 of which would cause classification in the wrong WHO age group) and 198 with errors in the date of registration (112 of which were wrongly ascribed to the year 1972). Error and omission rates were particularly high for NHS number, occupation, place of birth, and histology.
OBJECTIVE: To evaluate rehabilitation after myocardial infarction. DESIGN: Randomised controlled trial of rehabilitation in unselected myocardial infarction patients in six centres, baseline data being collected on admission and by structured interview (of patients and spouses) shortly after discharge and outcome being assessed by structured interview at six months and clinical examination at 12 months. SETTING: Six district general hospitals. SUBJECTS: All 2328 eligible patients admitted over two years with confirmed myocardial infarction and discharged home within 28 days. INTERVENTIONS: Rehabilitation programmes comprising psychological therapy, counselling, relaxation training, and stress management training over seven weekly group outpatient sessions for patients and spouses. MAIN OUTCOME MEASURES: Anxiety, depression, quality of life, morbidity, use of medication, and mortality. RESULTS: At six months there were no significant differences between rehabilitation patients and controls in reported anxiety (prevalence 33%) or depression (19%). Rehabilitation patients reported a lower frequency of angina (median three versus four episodes a week), medication, and physical activity. At 12 months there were no differences in clinical complications, clinical sequelae, or mortality. CONCLUSIONS: Rehabilitation programmes based on psychological therapy, counselling, relaxation training, and stress management seem to offer little objective benefit to patients who have experienced myocardial infarction compared with previous reports of smaller trials.
OBJECTIVE--To assess current clinical practice in coronary artery bypass surgery and compare it with a previous survey conducted five years ago. SETTING--United Kingdom. DESIGN--Postal questionnaires were sent in March 1993 to 120 consultant cardiac surgeons currently performing coronary artery bypass surgery. 104 (87%) were returned by May 1993. RESULTS--The 104 surgeons who returned the questionnaire performed an estimated total of 25,234 coronary artery bypass operations in 1992 with an average case load per surgeon similar to that in 1987 (243 v 214, NS). The internal mammary artery was regarded as the conduit of choice by 101 surgeons (97%) and was used in 93% of bypass grafts to the left anterior descending coronary artery compared with 73% in 1987 (p < 0.001) but only in 7% of grafts to the circumflex and right coronary systems. There was also a significant increase in the number of surgeons using both internal mammary arteries (88% v 59%, p < 0.01) but only a small increase in those using the internal mammary artery as a sequential graft (55% v 44%, NS). The age of the patient remains one of the main contraindications to the use of the internal mammary artery (40%), together with insufficient mammary flow (42%), endarterectomy (22%), and unstable angina (17%). The right gastroepiploic and inferior epigastric arteries were used only occasionally (3%) when the internal mammary artery or the saphenous vein were not available. Most surgeons (96%) still advocate the use of aspirin to enhance graft patency, with 87% of surgeons continuing treatment indefinitely, compared with 50% in the previous survey (p < 0.001). As for methods of myocardial protection, 72% of surgeons used cardioplegic arrest whereas 28% preferred intermittent aortic cross clamping and fibrillation. CONCLUSIONS--It is the consensus among British cardiac surgeons that the internal mammary artery is the graft conduit of choice. Its use has been significantly extended over the past five years (1987 to 1992) suggesting a quick response to advancing scientific knowledge. The use of alternative arterial conduits is still limited, perhaps as a reflection of the relative lack of information on their long-term performance. The recently advocated technique of retrograde cardioplegia and continuous warm cardioplegia is not yet popular.
Resistance to cytotoxic agents may be encountered during the treatment of acute myeloblastic leukaemia (AML). P-glycoprotein encoded by the MDR-1 gene has been implicated as a potential drug resistance mechanism in leukaemic cells. In recent years, many data have been accrued concerning the expression of P-glycoprotein in leukaemia, and several studies have been published which have related MDR status to outcome in AML. Conclusions as to the effect of P-glycoprotein expression on prognosis in AML have varied widely. The studies are not immediately comparable, since they differ in methodology, treatment regimens, demographic profile and, perhaps most importantly, criteria for positivity of MDR status. The technique of statistical overview (meta-analysis) can be used to pool observational studies. Application of this statistical method to existing studies suggests an estimated relative risk of 0.68 for P-glycoprotein expression with respect to complete remission in AML. Further large studies are required to determine fully the role of P-glycoprotein in AML.
A survey of current clinical practice was carried out among the 84 consultant cardiac surgeons currently performing coronary artery bypass surgery in the United Kingdom. The 80 surgeons who returned the questionnaire performed an estimated total of 17,100 coronary artery bypass graft operations in 1987, a mean case load of 214 operations each. Sixty two of the 80 surgeons regarded the internal mammary artery as the graft conduit of choice, and seven preferred the saphenous vein. The internal mammary artery was used in 73% of bypass grafts to the left anterior descending coronary artery but in only 4% of grafts to the circumflex and right coronary systems. Contraindications to the use of the internal mammary artery included advanced age of the patient (51 surgeons), insufficient flow through the internal mammary artery (49), and endarterectomy (35). Seventy four of the 80 surgeons considered intraoperative damage to the saphenous vein to be a possible cause of vein graft failure, but there was no agreement about how it should be reduced. All surgeons advocated pharmacological measures to enhance graft patency. Dipyridamole and aspirin constituted the most popular regimen (58 surgeons), though only 28 started dipyridamole preoperatively. Warfarin was prescribed postoperatively on occasion by 22 surgeons, but 14 of these used it only after endarterectomy.
A consecutive series of 644 women who presented with breast nodularity between 1976 and 1982 have been followed up to determine their rate of subsequent breast cancer. Fifteen women have developed breast cancer, 14 of these were among 352 women with an aspirated cyst (relative risk 4.4). Women with multiple cysts had the highest risk and women with breast nodularity had no excess risk. Review of histology specimens from those women who had undergone biopsy showed an excess of florid epithelial hyperplasia in women who subsequently developed breast cancer and women with multiple aspirated cysts were more likely to have florid epithelial hyperplasia. Multiple cysts are clinical markers of histological breast proliferation and women who have had multiple breast cysts aspirated have an increased risk of breast cancer and should be advised to practice regular self examination.
A total of 219 families of patients with cystic fibrosis living in Wales were studied for the occurrence of other diseases and for cause of death, and the findings in relation to leukaemia are reported. There were eight deaths due to leukaemia, five of the myeloid type, in first and second degree relatives; this is significantly more than the expected on the basis of national age specific mortality rates. In comparison, mortality among siblings, parents, aunts and uncles, and grandparents from all causes was within the expected. Screening the five patients with myeloid leukaemia for the delta F508 mutation showed that four were carriers of this mutation. It is concluded that carriers of the delta F508 mutation may have an increased risk of developing acute myeloid leukaemia. This could happen through the direct effect of the cystic fibrosis gene itself, or through its influence on another gene, such as the met oncogene, or gene(s) involved in granulocyte function on the long arm of chromosome 7.
To assess the prevalence of Gardnerella vaginalis in the community 300 women aged 16-59 were randomly selected from a general practice's age-sex register and invited to attend for a health check. Out of 282 women who were eligible to attend, 192 did so. They were asked whether they had any vaginal symptoms, and swabs were taken from 182 women for culture for G vaginalis. Sixty women were positive for G vaginalis, of whom 26 had symptoms.
Infections with G vaginalis may be present in women who have no symptoms. By careful questioning, examination, and side room testing general practitioners may be able to diagnose these infections in such women consulting them for other reasons.
In a study of 162 women with vaginal symptoms the clinical features of increased discharge, yellow discharge, 'high cheese' odour and pH greater than 5 were statistically strongly associated with the presence of Gardnerella vaginalis, confirmed by microbiological culture. The sensitivities and specificities of these clinical tests, although not as high as those of previously described sideroom tests using the amine test and microscopy for 'clue cells' nevertheless allow the clinician to predict G. vaginalis reliably and initiate treatment at first consultation.
In a study of 154 adult women who presented to their general practitioner with vaginal symptoms 30 (20%) had Gardnerella vaginalis on its own and 51 (33%) had G vaginalis in combination with anaerobes or known pathogens. Thirty one (20%) patients were culture negative. Those who were culture negative had fewer symptoms and signs of vaginitis than those with G vaginalis alone or G vaginalis plus anaerobes. Those with known pathogens had more symptoms and signs than those with G vaginalis alone or G vaginalis plus anaerobes. Those with known pathogens plus G vaginalis had the most severe signs and symptoms of vaginitis. It is concluded that G vaginalis can cause vaginitis on its own, and it makes vaginitis worse when present with other organisms. G vaginalis was also found in 30 (21%) of the 138 control patients who, although they presented "asymptomatically," had worse signs than control patients without G vaginalis. It seems that G vaginalis can occur in a spectrum ranging from the uncomplaining patient to those with severe vaginitis.
A retrospective questionnaire and interview study of 10 year survivors of uncomplicated myocardial infarction examined smoking, diet, exercise, weight, medication, and treatment since discharge from hospital in 1973-4 and made comparisons with controls (using the same questionnaire) and with normal populations (as reported by others). Long term survivors of myocardial infarction previously smoked more than controls; made more dietary changes than controls; and presently eat less butter, sugar, cake, and biscuits and drink less milk than controls; previously weighed more than controls; exercised less than controls both previously and presently; use more 'non-cardiac' as well as 'cardiac' drugs than controls; and are more depressed and more anxious than controls.
In a randomised controlled trial a lactation nurse assisted mothers during the early weeks after parturition both in hospital and at home. All mothers who started breast feeding were entered into the trial. The lactation nurse significantly extended duration in the study group compared with controls, particularly during the first four weeks and among women of lower social class.
A Welsh multicentre trial of early (fifth day) compared with late (tenth day) mobilisation in 742 patients after uncomplicated myocardial infarction, reported previously, found that there were no significant differences in survival during the first year, but a partial follow up beyond the first year survival showed a significantly reduced survival during the second and third years among patients mobilised early. A full 10 year follow up of all patients admitted to the trial was therefore carried out. A small difference in survival was confirmed, which reached about 5% at four years; but the difference was not statistically significant. Further analysis suggested the possibility of real differences in survival in certain subgroups, but the present evidence was not sufficient to provide contraindication to mobilisation five days after uncomplicated myocardial infarction.
Thirty nine adult women who were not pregnant and had the urethral syndrome in a general practice underwent detailed microbiological investigations. Patients monitored their own symptoms, and those with persisting symptoms were entered into a randomised controlled trial of treatment with doxycycline and placebo. Chlamydia trachomatis and Neisseria gonorrhoeae were not isolated and fastidious organisms were not causally associated with the urethral syndrome. Treatment with doxycycline showed no benefit; each episode of the urethral syndrome was short and self limiting and there were no recurrences in a median observation period of 12 months.
In a study of 40 women with the urethral syndrome and 46 women with conventional urinary tract infection, none of whom was pregnant, general practitioners predicted the diagnosis correctly before the report on the midstream urine specimen was received, as evidenced by their management. They seemed to do this by balancing the symptom of dysuria with the psychological make up of the patient: patients with the urethral syndrome suffered appreciably less dysuria than patients with urinary tract infection; patients with the urethral syndrome suffered appreciably more psychological illness. This ability to distinguish between the two disorders has important clinical and economic implications.
There is a long waiting list for orthopaedic outpatient appointments in South Glamorgan Area Health Authority as elsewhere. A detailed study of that waiting list was undertaken to identify factors that might lead to its better management and reduction. One-third of patients on the list failed to attend when appointments were offered. A postal-questionnaire to all those listed as waiting confirmed that many no longer sought specialist orthopaedic consultation. Another third of the patients reported that they had been treated previously for the same orthopaedic problem. It is concluded that improved management of long outpatient waiting lists could be achieved by correspondence with referring general practitioners to weed out those patients who no longer wish to attend, to reduce the burden of reviews and re-referrals of patients with "chronic" conditions, and to request priorities fairly so that earlier appointments may be offered to truly "new" patients with treatable or with potentially serious conditions.
A cohort of 342 infants in a group practice population were studied during the first year of life to assess whether hot-air central heating was associated with more severe respiratory infections than radiator central heating.
Infants born into council house families with ducted hot-air central heating were at no greater risk of contracting severe respiratory infections than those with radiator central heating. The risk of a respiratory infection was positively correlated with size of sibship and maternal smoking habits.
In a study designed to investigate the variations in rates of admission to hospital for appendicitis in Wales Hospital Activity Analysis listings were analysed according to the sex and age of the patients and the month and day of the week of admission. The incidence of hospitalisation was greatest among boys aged 10-14 and girls aged 15-19. The number of admissions was higher on weekdays than at weekends, but there were no seasonal variations. Durations of stay differed between the 17 health districts. We conclude that admission rates vary mainly because of differing hospital admission policies. Admission is not wholly governed by the sudden onset of abdominal pain; other factors include the threshold of consultation of each patient, the referral habits of general practitioners, the availability of hospital beds, and the degree to which doctors and patients expect admission.
Analysis ofthe proportional mortality attributed to ischaemic heart disease, adjusted for age, reminds us that many of the well known geographical, environmental, social, and economic variations within England and Wales are not disease specific.