The attitudes of patients to integrated medical care.

AIM: To establish the attitude of inpatients to integrated medical care. SETTING: A district general hospital which had recently adopted the model of integrated medical care. METHODS: 205 patients of all ages were interviewed and asked about their general views and their personal experience of integrated medical care and their preference had they been given a choice. Those patients who had previously been admitted before integration were asked if they felt the quality of care had changed. RESULTS: Integrated medical wards were preferred by most patients and this preference was greater in older patients. However, 30% identified patients on their wards who they felt should be segregated on account of confusion, frailty or youthfulness. Of the 69 who had been admitted before integration, 88% commented that the quality of care was either the same or better. CONCLUSION: Integrated medical care was the preferred model of care, especially by elderly patients. The special needs of some patients were, however, recognized. Perhaps the ideal model is a needs-related policy within a fully integrated system.

Rectus sheath haematoma in elderly patients: a diagnostic challenge.

CASE REPORTS: We report three cases of rectus sheath haematoma in elderly women. This condition is commonly misdiagnosed at any age but is an even more elusive diagnosis in elderly patients. CONCLUSION: It is important to consider rectus sheath haematoma in older patients with an abdominal or pelvic mass or spontaneous abdominal ecchymoses.

Can the elderly tolerate endoscopy without sedation?

The cardiopulmonary complications associated with gastroscopy could be reduced by giving little or no prior sedation. The ability to tolerate the procedure with and without sedation was compared in 62 elderly patients by recording responses to a questionnaire designed to evaluate the patient's own assessment of the examination. A similar percentage of sedated and unsedated patients described the procedure as mildly unpleasant (63% vs 57%; chi 2 = 0.500; p > 0.10). The majority (73%) of unsedated patients did not want to be sedated for future examinations because of the inconvenience of the recovery period. Elderly patients should therefore be given the choice of undergoing the procedure without sedation. Full counselling and explanation of the procedure are however even more important to allay anxiety and apprehension if the procedure is undertaken without sedation.

Attitudes of relatives to autopsies of elderly patients.

The attitudes of 233 relatives to autopsy of elderly medical patients (mean age 82 years) who died in a district general hospital were examined prospectively. Forty-three (18%) relatives were asked permission for autopsy, 24 (56%) agreed and 19 (44%) refused. Of 190 (82%) relatives whose permission was not sought, 109 (57%) would have agreed and 81 (43%) would have refused permission had they been asked. Advancement of medicine and reassurance about the correct diagnosis were the main reasons for consent, while dislike of autopsy, family distress at disfigurement of the body and the patient 'having suffered enough' were the main reasons for refusal. Living near rather than with the deceased (64% vs 45%; chi 2 = 6.985, p = 0.01) and being a male rather than female relative (63% vs 49%; chi 2 = 3.879, p = 0.05) were predictive of a positive response to autopsy. Of the 39 autopsies performed, 24 (9.6%) followed relatives' permission and 15 (6%) were at the request of the coroner. The overall autopsy rate of 16% was lower than the rate recommended for medical audit (35%). Although there is a need for educating relatives about the benefits of autopsy, a more urgent study is required to find reasons for the low request by medical staff.

Oxygen desaturation during endoscopy in the elderly.

Arterial oxygen desaturation during oesophago-gastro duodenoscopy (OGD) is well recognised. It has been suggested that severe desaturation (greater than 7%) may predispose patients with cardiopulmonary disease and the elderly to cardiac arrhythmias. During OGD, of 106 elderly patients 26 developed ventricular and/or supraventricular ectopics, but these were not related to the degree of oxygen desaturation induced in this study. Apart from one episode of vasovagal syncope, which responded to intravenous atropine, no serious arrhythmias were recorded. Arterial oxygen desaturation during OGD was easily preventable with oxygen administration via nasal cannulae and was not associated with any adverse haemodynamic effects. Continuous cardiac and oxygen saturation monitoring should be routine practice in order to identify such problems.

beta blockade and intermittent claudication: placebo controlled trial of atenolol and nifedipine and their combination.

OBJECTIVE: To determine the effects of the beta 1 selective adrenoceptor blocker atenolol, the dihydropyridine calcium antagonist nifedipine, and the combination of atenolol plus nifedipine on objective and subjective measures of walking performance and foot temperature in patients with intermittent claudication. DESIGN: Randomised controlled double blind four way crossover trial. SETTING: Royal Hallamshire Hospital, Sheffield. SUBJECTS: 49 patients (40 men) aged 39-70 with chronic stable intermittent claudication. INTERVENTIONS: Atenolol 50 mg twice daily; slow release nifedipine 20 mg twice daily; atenolol 50 mg plus slow release nifedipine 20 mg twice daily; placebo. Each treatment was given for four weeks with no washout interval between treatments. MAIN OUTCOME MEASURES: Claudication and walking distances on treadmill; skin temperature of feet as measured by thermistor and probe; blood pressure before and after exercise; subjective assessments of walking difficulty and foot coldness with visual analogue scales. RESULTS: Atenolol did not significantly alter claudication distance (mean change -6%; 95% confidence interval 1% to -13%), walking distance (-2%; 4% to -8%), or foot temperature. Nifedipine did not alter claudication distance (-4%; 3% to -11%), walking distance (-4%; 3% to -10%), or foot temperature. Atenolol plus nifedipine did not alter claudication distance but significantly reduced walking distance (-9%; -3% to -15% (p less than 0.003)) and skin temperature of the more affected foot (-1.1 degrees C; 0 to -2.2 degrees C (p = 0.05)). These effects on walking distance and foot temperature seemed unrelated to blood pressure changes. CONCLUSIONS: There was no evidence of adverse or beneficial effects of atenolol or nifedipine, when given singly, on peripheral vascular disease. The combined treatment, however, affected walking ability and foot temperature adversely. This may have been due to beta blockade plus reduced vascular resistance, which might also explain the reported adverse effects of pindolol and labetalol on claudication.

A placebo-controlled, double-blind study of eicosapentaenoic acid-rich fish oil in patients with stable angina pectoris.

A study was carried out to evaluate the clinical and haematological effects of dietary supplementation with eicosapentaenoic acid (EPA)-rich fish oil (MaxEPA', 2.8 g EPA daily) compared to placebo (olive oil) in 10 patients with stable angina pectoris. After 3 months, there was a significant increase in red cell deformability (p less than 0.001), reduced whole blood viscosity (p less than 0.02), and prolonged skin bleeding time (p less than 0.001) in the fish oil group compared to the placebo group. Haematocrit, plasma viscosity, fibrinogen concentration, platelet count, and in vitro platelet aggregation were unaltered. No significant symptomatic or objective improvement was noted in angina pectoris in either group despite the significant rheological changes produced in the patients receiving fish oil.

The acute effects of cigarette smoking on treadmill exercise distances in patients with stable intermittent claudication.

The hypothesis that smoking has an acute effect on treadmill exercise performance in patients with peripheral vascular disease was investigated in a crossover trial. Twelve patients with stable intermittent claudication who were regular smokers attended on two occasions within one week and treadmill tests were performed after 1/2, 1, 1 1/2, and 2 hours. Immediately before the second exercise test, two standard cigarettes were smoked or an unlit cigarette was "sham-smoked." Because participants could not be blinded, an attempt to control for patient bias was made. Half were told that we expected smoking to make no difference or possibly cause some improvement, and half were told that we expected it to make no difference or possibly cause some deterioration. These explanations and the order of study days were determined by balanced randomization. Suggestion had a significant influence on claudication distance immediately after smoking (p less than 0.01) but no significant effect on walking distance. Combining data from both groups assumes that no overall bias was introduced by the explanations given. Immediately after smoking, small, nonsignificant increases in claudication distance (+10%, 95% CI-7%, +27%) and walking distance (+9%, 95% CI-2%, +19%) were observed. Smoking caused a mean increase in heart rate of 9 beats per minute, which persisted for one hour, but no consistent change in blood pressure. The results show that suggestion may have a significant influence on treadmill exercise distances. Smoking is unlikely to have an important acute effect on exercise performance in claudicants.

Severe disseminated intravascular coagulation associated with massive ventricular mural thrombus following acute myocardial infarction.

We describe three patients who developed severe disseminated intravascular coagulation associated with large ventricular mural thrombi shortly after presenting with acute myocardial infarction. To our knowledge this association has not been reported before.

Comparison of ketanserin and slow-release nifedipine added to the treatment of hypertensive patients uncontrolled by a thiazide diuretic plus beta-adrenoceptor blocker.

1. Ketanserin or slow-release nifedipine were added to the treatment of 24 patients with hypertension uncontrolled by a thiazide diuretic plus beta-adrenoceptor antagonist in an observer-blind, randomised parallel-group study of 6 months duration. 2. At 6 months the mean falls in supine blood pressure were for ketanserin (mean daily dose 77 mg) 7/5 mm Hg and for nifedipine (mean daily dose 62 mg) 27/10 mm Hg. The difference between the treatments was significant for systolic blood pressure (P less than 0.02) and mean arterial pressure (P less than 0.05). Six nifedipine-treated patients reached target blood pressure, compared with one patient with ketanserin (P less than 0.02). 3. One patient taking nifedipine, and none taking ketanserin withdrew because of side-effects. The tolerability of the two drugs was broadly similar. 4. Ketanserin treatment was associated with significant changes in supine pulse rate (-8 beats min-1, P less than 0.05) and corrected QT interval (+27 ms, P less than 0.05). Nifedipine treatment had no effect on these variables. The change in pulse rate was significantly different between the groups. 5. In patients treated with a diuretic and beta-adrenoceptor blocker who required additional treatment ketanserin was significantly inferior to nifedipine.

Tolerability of combined treatment with verapamil and beta-blockers in angina resistant to monotherapy.

We have used a combination of a beta-blocker and verapamil to treat 42 consecutive patients with angina resistant to either agent alone. Patients with heart failure, heart block or uncontrolled hypertension were excluded. The mean duration of follow-up was 6.5 months. Thirty-six patients (81%) reported an improvement and the number of angina attacks was reduced from 17/week to 5/week. Side effects necessitated withdrawal of one or both drugs in 6 patients, 2 of whom developed bradyarrhythmias not solely related to drug treatment. The most common complication was mild left ventricular failure (6) treated by reducing or stopping the beta-blocker. The data suggest that the combination of verapamil and a beta-blocker may be used in a relatively unselected group of patients with difficult angina. However, as dosage adjustment and close observation may be necessary to minimise side effects, the use of this combination should be limited to hospital practice.