Avascular necrosis of femoral heads post-adrenal surgery for Cushing's syndrome: a rare presentation.

Avascular necrosis (AVN) is a well-recognized complication of patients on high-dose steroids for a long time. Exogenous hypercortisolism is a well known cause of AVN and a number of cases have been reported. Cushing's syndrome describes hypercortisolism of any cause endogenous or exogenous. A variety of traumatic and non-traumatic factors contribute to the aetiology of AVN although exogenous glucocorticoids administration and alcoholism are among the most common non-traumatic causes. AVN secondary to endogenous hypercortisolism is rare and very few case reports are available describing this complication. No literature is available on AVN presenting post-adrenal surgery. Here we present a young woman who presented with avascular necrosis of both hips 1 year after adrenalectomy for Cushing's syndrome.

Cardiac rehabilitation in the Northwest.

AIM: To audit the cardiac rehabilitation (CR) service in the Northwest. METHODS: Patients were identified on the CR Information System. Indications, rate of uptake, demographics and complications were all recorded. Cardiovascular risk factors and exercise capacity before and after CR were compared. Systems for referral and phases I-IV were analysed. RESULTS: Three hundred ninety-two patients were offered CR in 2006. 151 patients completed phase III. One-fifth attended outreach centres. Mean age was 62.9. 22% were female. No serious adverse events occurred during exercise training. A smoking quit rate of 26% was achieved. Mean blood pressures pre and post CR were 141/76 and 131/73 mmHg, respectively. The mean increase in exercise capacity was 2.85 mets. CONCLUSIONS: CR in the Northwest provides a modern evolving programme. Enhanced referral rate, reduction in the duration of phase II, increased participation by women and improved accessibility will consolidate its contribution to cardiovascular disease management in this region.

Latitudinal variation in the prevalence of multiple sclerosis in Ireland, an effect of genetic diversity.

BACKGROUND: Northern Ireland has a high and rising prevalence rate of multiple sclerosis (MS). The most recent survey in 1996 found a rate of 168.7/100 000. Recorded prevalence rates for the south of Ireland, including County Wexford, have been markedly lower and seemed to suggest the existence of a prevalence gradient within the island. OBJECTIVES: To compare the prevalence of multiple sclerosis in Co. Wexford in the south east of Ireland and Co. Donegal in the north west, and to establish whether a variation in prevalence of MS exists within Ireland. METHODS: Patients were referred from multiple sources. Review of clinical case records and/or patient examination confirmed the diagnosis. RESULTS: In Co. Wexford, 126 patients were found to have clinically definite or probable multiple sclerosis with a prevalence rate of 120.7/100 000 (95% confidence intervals (CI) 100.6 to 143.8), which is similar to other areas of similar latitude within the British Isles. In Co. Donegal, 240 people had clinically definite or probable MS with a prevalence rate of 184.6/100 000 (95% CI 162.0 to 209.5). The difference in prevalence rates is statistically significant (Z = 3.94, p = <0.001). CONCLUSION: There is a latitudinal variation in the prevalence rate of MS between the north and the south of Ireland. The increased prevalence of MS seen in Co. Wexford is likely to represent better case ascertainment and improved diagnostic accuracy rather than an actual increase in prevalence. The north/south variation in prevalence may represent a variation in the genetic predisposition to MS between the background populations of the two counties.

Patients presenting with acute myocardial infarction to a district general hospital: baseline results and effect of audit.

The Cardiovascular Health Strategy recommended that patients presenting with acute myocardial infarction receive thrombolysis within ninety minutes of alerting medical or ambulance services. The aim of this prospective study was to describe the management of patients with acute myocardial infarction (AMI) presenting to a district general hospital in Donegal. All patients with a confirmed diagnosis of acute myocardial infarction, excluding those from the Donegal Area Rapid Treatment Study (DARTS) practices, admitted to Letterkenny General Hospital (LGH) from 31.08.99 to 31.08.01 were included in the study. 349 patients were included in the study; average age of 68 ranging from 30 to 96 years and 69% were male. Of the 349 patients, 101 (29%) were located more than 30 miles from LGH at the time of onset of symptoms. The median time taken from the onset of symptoms to calling for help was 119 minutes. The median time from hospital arrival to patients being admitted to CCU was 90 minutes. Thrombolytic therapy was administered in 31% of patients; for these patients the median call to needle time was 200 minutes. Call to needle times differed significantly between rural (median 227.5 minutes n = 64) and urban patients (median 175 minutes n = 37, p < 0.05, Mann-Whitney). Hospital delay times decreased throughout the study period (p > 0.05, Mann-Whitney). The study extends the findings from previous research by investigating the individual time delay components from onset of symptoms to treatment in AMI patients. Delay times exceed the recommended call to needle and door to needle times suggesting the need for interventions to reduce these times.

The clinical relevance of alcohol in the Blood Pressure Clinic.

There is a limited number of studies conducted in hypertensive patients which support the hypothesis that high alcohol intake is an important reversible cause of raised blood pressure. The validity and effectiveness of alcohol restriction as a treatment of hypertension is difficult to study as there is no suitable placebo substance that can be employed on a clinical trial basis. However, such clinical data that there are, taken with the confirmatory epidemiological work, strongly suggest that hypertensive patients should be questioned and investigated for evidence of high alcohol intake and advised accordingly.

Similarity of blood pressure in blacks, whites and Asians in England: the Birmingham Factory Study.

Factory workers aged 16-64 years were screened for ethnic differences in blood pressure. The 78% response rate was evenly spread between whites (439 men; 164 women), black West Indians (173 men; 101 women) and Asians (172 men). Mean systolic and diastolic pressures by age decade in men were similar in all three groups, but there was a modest excess of both higher and lower blood pressures in blacks and Asians. Older black women had higher blood pressures than whites, but body mass indices were 2-5 kg/m2 greater. Multiple regression analysis revealed no significant effect of ethnic group on either systolic or diastolic blood pressure variance and that the higher pressures in black women were accounted for by differences in age and body mass index. The influence of body mass index was more marked on diastolic than systolic pressure. In men, alcohol intake and a family history of hypertension had small independent positive effects on systolic pressure. The lack of black/white difference in blood pressure differs from the United States results and may be due to the similarity in social class of participants. This should be confirmed in further population samples with larger numbers of black (and Asian) subjects.

Effect of alcohol withdrawal on blood pressure, plasma renin activity, aldosterone, cortisol and dopamine beta-hydroxylase.

Sixty-five alcoholic patients admitted for detoxification had blood pressure, withdrawal symptoms, plasma cortisol (PC) and plasma aldosterone (PA) levels, plasma renin activity (PRA), and serum dopamine beta-hydroxylase (DBH) levels measured on the first and fourth days after admission. On the morning after admission blood pressure was elevated (greater than 140/90) in 32 patients (49%) and was 160/95 mmHg or more in 21 (32%). PRA was initially elevated in 41 patients, PA levels in 14, and 13 patients had raised PC levels. By the fourth day, blood pressure and biochemical measures had fallen significantly while urine volume and sodium output, low on admission, had increased significantly. On admission urinary metanephrine levels were raised in four out of the 31 patients who had them measured. The height of both the systolic and diastolic blood pressures was significantly related to the severity of the alcohol withdrawal symptoms. Of the biochemical parameters measured, PC level correlated with systolic but not diastolic pressure, and urinary volume was inversely correlated with the height of the diastolic pressure. No relationship was found between blood pressure and PRA or PA level. The pressor effect of alcohol withdrawal could be due to sympathetic nervous system overactivity, or possibly to hypercortisolaemia . The first hypothesis seems more likely.

The effect of a non-selective lipophilic beta-blocker on the blood pressure and noradrenaline, vasopressin, cortisol and renin release during alcohol withdrawal.

Alcoholics during detoxification have elevated blood pressures which are related to the severity of their withdrawal symptoms. We studied the effect of a non-selective beta-blocker, timolol on symptoms, blood pressure and plasma levels of cortisol (PC), noradrenaline (NA), vasopressin (AVP) and renin activity (PRA) during alcohol withdrawal. Eighteen alcoholics, admitted for detoxification, were randomly allocated to timolol or placebo in a double blind trial. Alcohol withdrawal symptoms did not differ either before or after timolol or placebo but patients receiving timolol required less sedation with chlormethiazole. Systolic blood pressures (SBP) and pulse both fell significantly during detoxification in both groups, the change being greater with timolol. Plasma levels of cortisol, NA, AVP and PRA fell significantly, though only NA and PC correlated with initial SBP. Timolol had no effect on any of the biochemical parameters observed. The pressor response to alcohol withdrawal is reduced by beta-blockade and the height of the blood pressure is related to plasma NA and PC levels. Alcohol withdrawal hypertension is probably due to increased sympathetic activity.

Blood pressure and pressor mechanisms during alcohol withdrawal.

Blood pressure, alcohol withdrawal symptoms and plasma levels of cortisol, aldosterone and renin activity and serum dopamine beta-hydroxylase concentrations were measured in 65 alcoholics on the first and fourth days after admission for detoxification. On the day after admission blood pressure was elevated (greater than 140/90 mmHg) in 32 patients (49%) and was 160/95 mmHg or more in 21 (32%). Plasma renin activity was elevated in 41 patients and plasma aldosterone concentration in 14, but neither correlated with blood pressure. Plasma cortisol levels were elevated in 13 patients and were positively correlated with systolic blood pressure. Blood pressure and all biochemical measures fell significantly by the fourth day while urine volume and sodium output, low on admission, increased significantly. Urinary metanephrine levels were elevated in four of 31 patients in whom they were measured on admission. Alcohol withdrawal was accompanied by raised blood pressure and high plasma concentrations of cortisol, renin and aldosterone but only plasma cortisol concentrations and withdrawal symptoms were significantly related to blood pressure.

Blood pressure in black, white and Asian factory workers in Birmingham.

A screening survey was conducted among factory workers, aged 15-64 years, in Birmingham, England to investigate ethnic differences in blood pressure. One-thousand and forty-nine subjects (784 men, 265 women) were screened, representing 79% of the eligible population. Mean systolic and diastolic blood pressures generally did not differ between men of black West Indian (n = 173), local white (n = 439) or Asian (n = 172) origin, when matched by 10-year age groups. Analysis of covariance using age as the covariate revealed that, overall, Asian men had significantly lower systolic but higher diastolic pressures than the other ethnic groups. The proportion of men arbitrarily defined as hypertensive (greater than or equal to 160 mmHg systolic or greater than or equal to 95 diastolic or blood pressures below this figure whilst receiving antihypertensive therapy) was 26% of West Indians, 22% of whites and 17% of Asians, but these were not significantly different when age was accounted for. Black West Indian women (n = 101) did have higher diastolic pressure than white women (n = 164), but this difference was dependent on body mass index. Overall, systolic pressures in women were not significantly different. These findings differ from those consistently reported from the United States.

The Birmingham blood pressure school study.

Four-hundred and twenty-eight school leavers of 3 ethnic groups (white, black and Asian) were screened for blood pressure, resting pulse rate and general anthropometric characteristics. Asian pupils were both shorter and lighter than the other two groups whilst black males were heavier and taller. There was no significant difference in the mean systolic or diastolic blood pressure between the 3 groups, although the black pupils had a stronger family history of hypertension, particularly on the mother's side. These observations differ in some respects from other ethnic blood pressure studies and establish values for the local population.

Ethnic differences in peak expiratory flow rate in Birmingham factory workers.

Among 698 Birmingham factory workers, Asian men (n = 75) tended to have lower peak expiratory flow rates (PEFR) than black (n = 156) or white (n = 138) men when age, height and smoking habits were accounted for. This trend reached statistical significance in Asian females (n = 20), despite a small sample size. There were no significant differences in PEFR between blacks and whites of either sex.