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OBJECTIVE: To determine the prevalence of comorbidities, patterns of healthcare utilisation and primary care recording of clinical indicators in patients with congenital heart disease. PATIENTS AND METHODS: A population-based case-control study using data from general practices across the UK contributing data to the QRESEARCH primary care database. The subjects comprised 9952 patients with congenital heart disease and 29,837 matched controls. Outcome measures were prevalence of selected comorbidities; adjusted odds ratios for risk of comorbidities, healthcare utilisation and clinical indicator recording. RESULTS: The overall crude prevalence of congenital heart disease was 3.05 per 1000 patients (95% CI 2.99 to 3.11). Prevalence of key comorbidities in patients with congenital heart disease ranged from 2.4% (95% CI 2.1% to 2.7%) for epilepsy to 9.3% (95% CI 8.8% to 9.9%) for hypertension. After adjusting for smoking and deprivation, cases were significantly more likely than controls to have each of the cardiovascular comorbidities and an increased risk of diabetes, epilepsy and renal disease. Patients with congenital heart disease were more frequent users of primary care than controls. Patients with congenital heart disease were also more likely than controls to have lifestyle and risk factor measurements recorded in primary care, although overall levels of recording were low. CONCLUSIONS: There is a significant burden of comorbidity associated with congenital heart disease, and levels of primary care utilisation and referral to secondary care are high in this patient group. The predicted future expansion in the numbers of adults with congenital heart disease owing to improvements in survival will have implications for primary and secondary care, and not just tertiary centres offering specialist care.

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OBJECTIVE: To ascertain time trends in rates of hospital admission, operations, in-hospital case fatality and general mortality for congenital heart disease (CHD) in England and Wales. DESIGN: Retrospective analysis of Hospital Episodes Statistics for England (April 1995 to March 2004) and mortality statistics for England and Wales (1994-2003). POPULATION: All NHS patients admitted with a primary diagnosis of CHD to hospitals in England, and all deaths in England and Wales with an underlying cause of CHD. MAIN OUTCOME MEASURES: Age-standardised hospital admission rates, case fatality rates and death rates from congenital heart disease. RESULTS: Between 1995/1996 and 2003/2004 the age-standardised hospital admission rate for CHD increased from 30.7 per 100,000 (95% CI 29.9 to 31.4) to 35.5 per 100,000 (95% CI 34.7 to 36.4) in men and boys and from 28.2 per 100,000 (95% CI 27.4 to 28.9) to 32.8 per 100,000 (95% CI 32.0 to 33.6) in women and girls. Between 1997/1998 and 2003/2004 in-hospital case fatality rates fell from 2.10% (95% CI 1.97 to 2.22) to 0.83% (95% CI 0.74 to 0.92). Population mortality fell steadily over the decade from 1994 to 2003 in men and women, with the largest proportionate decrease in the 1-4-year age group. CONCLUSION: Admission rates for CHD have increased over the past decade, particularly amongst patients in older age groups. There has also been a significant decrease in both in-hospital case fatality rates and in general population mortality rates. These trends are consistent with improvements in the quality of care for these patients, improvements in survival and the predicted expansion in the number of adults living with CHD.

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Education about breast feeding is important, as is correct positioning and practical support from midwife, health visitor or counsellor. A number of products can be purchased from pharmacies and other outlets which claim to help breast feeding in various ways. These include nipple creams and sprays, breast pads, nipple shields and shells, pumps, and equipment to store expressed breast milk. Mothers seem to find many of these helpful, often to overcome difficulties at a particular stage of breast feeding. Certain breast creams are currently prescribable on the NHS. A glass or polycarbonate receiver with PVC bulb can also be prescribed on form FP10.

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BACKGROUND: Allograft vasculopathy after heart transplantation is thought to represent a response to endothelial injury in the graft vessels. To assess endothelial function before the onset of anatomic disease, coronary vasomotor responses to adenosine, acetylcholine, and nitroglycerin were evaluated in transplant recipients by intravascular ultrasound imaging and Doppler flow studies. METHODS AND RESULTS: Nine patients were studied 1 year after heart transplantation. Acetylcholine provoked significant vasoconstriction to 82% of maximal coronary diameter but was associated with an increase in mean coronary blood flow from 63.1 to 204 ml/min. Coronary blood flow increased fivefold in response to adenosine, a normal response. CONCLUSIONS: The vasomotor response to acetylcholine at 1 year after heart transplantation is consistent with endothelial dysfunction in the epicardial conduit vessels. Microvascular function as judged by coronary flow reserve appears to be normal.

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This case report demonstrates a role for transesophageal echocardiography in defining the course of anomalous coronary arteries. Origin of the right coronary artery (RCA) from the left main (LM) (single coronary artery) is an exceedingly rare congenital anomaly. It is not always benign and may result in myocardial infarction. This may be due to compression between the aorta and the pulmonary artery. Transesophageal echocardiography offers a low-risk, noninvasive means of imaging the proximal coronary arteries. In the majority of patients, the proximal segments of the three major coronaries can be clearly visualized. With the addition of color flow, it is possible to visualize flow in most patients. Proximal obstructive lesions can be seen in some patients although sensitivity thus far seems low.

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Consecutive admissions to a university hospital coronary intensive care unit were prospectively evaluated using a modified version of the Structured Clinical Interview for DSM-III-R by interviewers blind to the patient's cardiac status. Panic disorder was present in almost one-third of the patients. Four (21%) of the 19 patients with panic disorder also had positive cardiac findings, including 2 who had myocardial infarctions. Of the 27 patients with negative cardiac findings, 15 (55.5%) had panic disorder. Whereas panic disorder and coronary heart disease may coexist in patients with acute chest pain, there appears to be a very high prevalence of panic disorder among patients in whom cardiac disease has been excluded.

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To investigate patients' views and expectations when attending outpatient clinics a questionnaire-based study was performed. The questionnaires asked about appointment systems, continuity of care, staff appearance, chaperons and medical students. Patients wanted fixed appointment times, to see the same doctor on successive visits, for the staff to be formally dressed and to have chaperons during examination. The number of medical students should be restricted especially for women patients. Staff should be sensitive to patients' needs.

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A means of estimating the degree of enhancement of structure and suppression of background noise in filtered two-dimensional echocardiographic images is described. The method is termed the peak-to-background ratio. To test the method, two-dimensional short-axis echocardiographic images were enhanced with Laplacian operations of increasing mask size. There was excellent correlation between the calculated peak-to-background ratio and the subjective opinion of trained echocardiographers. Furthermore, radial length measurements made from images that were thought to be optimally enhanced by the peak-to-background ratio calculation showed the lowest interobserver mean differences. We conclude that the peak-to-background ratio does reflect improvement in characteristics of the image that favor more precise measurement (amplification of peaks and suppression of background) and can be used to help guide a dynamic approach to image processing.

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The relationship between retained fluid and survival has previously been reported from our burn unit. Two hundred thirty cc/kg lean body mass accurately delineated survivors from nonsurvivors. Our previous study did not account for fluid lost through the burn wound. This study was undertaken to evaluate fluid retention per square meter of body surface area which has been corrected for fluid loss from the burn wound using a formula suggested by Mason et al. Data collected from 95 adult patients with burns greater than or equal to 20% body surface area burn (mean age, 42.4 years; mean burn size, 37.7%), who were admitted to our burn unit between January 1978 and September 1985, were evaluated. All patients included in the study were adequately resuscitated and survived the initial 48 hours. A calculation of the total fluid retained during the first 48 hours postburn and estimation of fluid loss from the burn wound were made. A comparison was made between lean body retained fluid and surface area retained fluid. A positive correlation (r = 0.921; p less than 0.001) was demonstrated between these two methods of assessing fluid retention. Fluid retention determined by either method resulted in a higher correlation with survival than any single predictor (age, per cent body surface area burned) of burn survival. Surface area fluid is as accurate as lean body fluid in predicting survival. Additionally, we determined that for the first 48 hours postburn, 4,425 cc fluid retained per meter square body surface area accurately differentiated survivors from nonsurvivors.(ABSTRACT TRUNCATED AT 250 WORDS)

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Mice were treated for 7 weeks with doses of methyldopa somewhat exceeding those given to man, and mixed immunotoxic effects were observed. Daily subcutaneous injections of 5 mg (in 0.1 ml) methyldopa or saline (0.1 ml) did not generally alter body weights, except on day 19, when the methyldopa-treated mice weighed significantly less. During treatment, all mice were immunized twice with sheep red blood cells (SRBC) and bled four times. Anti-SRBC titers were not affected by methyldopa treatment, but leukocyte counts were dramatically decreased, and hematocrits to a lesser degree. Although in methyldopa-treated mice spleen and kidneys were increased in size, liver, lung, heart, and thymus size was not affected. These results are discussed in the context of other studies on the mode of action of methyldopa in eliciting an autoimmune anemia in man treated therapeutically with this drug.

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A survey of serum samples from mammals trapped in Central Ontario showed that many contained antibodies to Toxoplasma gondii. The prevalence of infection as reflected by positive reactions in the Sabin-Feldman Dye Test appeared to be related to the type of diet of each species examined, and specifically, to the proportion of rodents in the diet. Of the fox blood samples tested, 84% were positive. The percentage of positive samples diminished through, coyote, mink, bear, fisher skunk, raccoon, marten and rabbit. Blood samples from squirrel, deer, hare and groundhog were negative.

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