Exercise in a healthy heart program: a cohort study.

OBJECTIVE: To assess the effects of exercise on resting heart rate (RHR), weight, lipid profile, and blood pressure. We hypothesized that the participants who increased their physical activity would show improvement in their cardiovascular risk factors compared to those who did not. DESIGN: Retrospective chart review over the mean duration of 4.9 years of follow-up. SETTING: Healthy Heart Program Prevention Clinic at St. Paul's Hospital, Vancouver, British Columbia, Canada. PARTICIPANTS: We reviewed 300 charts of patients randomly selected from those who attended the Prevention Clinic between 1984 and 2009. 248 (82.7%) patients were referred for primary prevention and 52 (17.3%) for secondary prevention. PRIMARY AND SECONDARY OUTCOME MEASURES: Weight, RHR, lipid profile, and blood pressure were recorded at the initial and last visit. RESULTS: During a mean of 4.9 years of follow-up, 55% of participants improved their exercise. The mean decrease in the RHR for these patients (group 1) was 5.9 beats per minute (bpm) versus the mean increase of 0.3 bpm for the "no change" group (group 2) (P < 0.01). The mean net weight increase in group 1 was 0.06 kg/year versus 0.25 kg/year in group 2. Because of medications, all patients had a significant improvement in their lipid profiles. Furthermore, there was a statistically significant greater reduction in Framingham Risk Score (FRS) in group 1 versus group 2 (11.8% versus 15.1%, P < 0.01). CONCLUSION: Participation in the program significantly reduces modifiable risk factors for cardiovascular disease. Improved exercise regimen results in lower RHR and greater reduction in FRS. However, even in a Prevention Program, despite strong advocacy of the importance of exercise, a significant percentage of participants does not improve their exercise habits.

To ED or not to ED: NHS 24 referrals to the emergency department.

INTRODUCTION: This study aimed to compare the opinions of consultants in emergency medicine and general practitioners (GPs) on the appropriateness of NHS 24 referrals to the emergency department (ED). METHODS: 170 NHS 24 referrals to the ED were reviewed by six GPs and six emergency consultants who were asked their opinion as to which out-of-hours service would be most appropriate for the patient. Modal responses from both groups were calculated for each referral. Consensus within groups and levels of agreement were calculated. RESULTS: Modal responses agreed with an ED disposal in 59.2% of cases in the emergency consultant group with a 90% consensus rate. The GP group agreed with an ED disposal in only 47% of cases with a 75.9% consensus rate. A primary care referral response was the mode in 20.8% of the emergency consultant group compared with 35.7% in the GP group. Consensus was reached in 76.3% of the emergency consultant responses and 81.7% of GP responses. The difference in opinion between the two study groups was statistically significant. CONCLUSIONS: GPs and consultants in emergency medicine both believe a high proportion of NHS 24 referrals to the ED should be handled by primary care services. This would suggest that, compared with previous out-of-hours practice, NHS 24 favours an ED outcome. The results indicate a large proportion of primary care patients are being handled inappropriately and uneconomically in the ED setting. There is a need for ongoing improvement of the telephone triage service provided by NHS 24.

Detection and management of epidural haematomas related to anaesthesia in the UK: a national survey of current practice.

BACKGROUND: Epidural haematoma is a rare, but potentially disastrous complication of epidural analgesia. Favourable neurological outcome depends upon early recognition and surgical decompression; therefore, the management of epidural analgesia should include a systematic approach to recognition of the signs of epidural haematoma. METHODS: We conducted a national postal survey of the policies and protocols used by acute pain services for investigating clinical signs suggestive of epidural haematoma, and the availability of urgent MRI scans. This was a repeat of a survey that was carried out in 2001, but not published. RESULTS: The response rate was 84%. Of the acute pain services that responded, 99% have a written protocol for running epidural infusions, 91% include regular assessment of sensory and motor function, and 55% have a written protocol for the investigation of abnormal motor block. On-site 24 h access to MRI scanning facilities was available to 57%, 33% have arrangements with another hospital, and 10% do not have 24 h access to MRI. Thirty per cent of respondents knew of an epidural haematoma related to epidural analgesia in their hospital, one-third of which were not diagnosed and treated within 24 h. CONCLUSIONS: Improvements in monitoring have occurred over the last 5 yr, but observations of neurological function are not routine in all units, and are not continued after removal of the epidural catheter in the majority. The authors suggest that acute pain services should be responsible for protocols for the investigation and treatment of epidural haematomas.

Hyperventilation and dizziness: case reports and management.

Dizziness is a common symptom in patients presenting to an otorhinolaryngologist. Hyperventilation accounts for up to 5% of cases with dizziness and is a contributory factor in a further 20% of cases. Six cases of dizziness due to hyperventilation are presented to illustrate the author's simple management policy. A high index of suspicion in the absence of an organic cause of dizziness and a simple provocation test will identify these cases. Management is aimed at demonstrating resting hypocapnia, investigations to exclude organic causes of hyperventilation and rehabilitation in collaboration with a clinical psychologist ensures the appropriate treatment for the dizziness and can avoid the development of chronic somatisation behaviours.

Collecting midstream specimens of urine--the research base.

The study reported here, which is based on an undergraduate dissertation, analyses the content of medical and nursing articles published between 1956 and 1989 which consider the collection of mid-stream specimens of urine (MSSUs). Subjective or qualitative and objective or quantitative content analyses were performed. A large disparity was discovered between the results of the two methods of analysis, implying that this research base cannot be translated into recommendations for collecting MSSUs.

The treatment of disseminated non-Hodgkin's lymphoma of unfavourable histology.

Forty-eight consecutive previously untreated adults with advanced non-Hodgkin's lymphoma (NHL) of unfavourable histological type were referred to the Department of medical Oncology at St. Bartholomew's Hospital, london, between 1972 and 1977. They received adriamycin, vincristine, prednisolone and L-asparaginase (OPAL) initially, and those in whom complete remission was achieved proceeded to cranial irradiation and intrathecal methotrexate, followed by continuous oral maintenance chemotherapy comprising weekly methotrexate, cyclophosphamide, and daily 6-mercaptopurine for 3 years. Complete remission was achieved in 24 of the 48 (50%). The median duration of remission was 10 months, none patients continuing without relapse for between 3 and 7 years. The median survival was 9 months, 12 patients being alive and disease-free (three in second remission) after between 3 1/2 and 8 1/2 years. The prognosis was significantly better in patients with nodal stages II and III (disease) than in those with stage IV, for both response (P = less than 0.05) and survival (P = 0.002). Patients in whom complete remission was achieved survived significantly longer than those in whom it was not, regardless of stage. These results confirm our preliminary observations with this treatment programme that a proportion of patients with stage II and II unfavourable histology NHL may be curable although the outlook for stage IV remains poor.