Patient-controlled epidural fentanyl following spinal fentanyl at Caesarean section.

Spinal fentanyl can improve analgesia during Caesarean section. However, there is evidence that, following its relatively short-lived analgesic effect, there is a more prolonged spinal opioid tolerance effect. The effectiveness of postoperative epidural fentanyl analgesia may therefore be reduced following the use of spinal fentanyl at operation. This randomised, double-blind study was designed to assess whether patient-controlled epidural fentanyl could produce effective analgesia following 25 microg of spinal fentanyl at operation. Patients undergoing elective Caesarean section received spinal bupivacaine combined with either fentanyl 25 microg (fentanyl group; n = 18) or normal saline (saline group; n = 18). Patient-controlled epidural fentanyl was used for postoperative analgesia. The fentanyl group used a mean of 23.4 (SD 14.5) microg x h(-1) of fentanyl, compared with 27.0 (10.8) microg x h(-1) for the saline group (p =0.41). Using a 0-100 mm visual analogue score for pain, the maximum pain score recorded at rest for the fentanyl group was median 24 [IQR 15-35] mm, compared with 15 [13-45] mm for the saline group (p = 0.41). The maximum pain score recorded on coughing for the fentanyl group was 29 [24-46] mm, compared with 27 [19-47] mm for the saline group (p = 0.44). Nine of the fentanyl group rated postoperative analgesia as excellent and nine as good, compared with 10 of the saline group who rated it as excellent and eight as good (p = 0.74). Epidural fentanyl can produce effective analgesia following the use of 25 microg spinal fentanyl at Caesarean section.

Relationship between smoking and cardiovascular risk factors in the development of peripheral arterial disease and coronary artery disease: Edinburgh Artery Study.

AIMS: The aim was to determine whether the effect of smoking on the development of peripheral or coronary artery disease might be mediated by other cardiovascular risk factors, including dietary antioxidant vitamin intake, serum low and high density lipoproteins, blood pressure, plasma fibrinogen, blood viscosity and markers of endothelial disturbance and fibrin turnover. METHODS AND RESULTS: 1592 men and women aged 55-74 years were selected at random from 11 general practices in Edinburgh, Scotland and followed-up for 5 years. The incidences of peripheral arterial disease and coronary artery disease were 5.1% and 11.1%, respectively. Both conditions were more common in moderate and heavy smokers than in never smokers: cigarette smoking was a stronger risk factor for peripheral arterial disease than for coronary artery disease. Smoking was associated with reduced dietary antioxidant vitamin intake, serum high density lipoprotein cholesterol and diastolic blood pressure and with increased alcohol intake, serum triglycerides, blood viscosity, plasma fibrinogen, and markers of endothelial disturbance (tissue plasminogen activator and von Willebrand factor antigens). Simultaneous adjustment for these risk factors reduced the relative risk of peripheral arterial disease only slightly, from 3.94 (95% CI 2.04, 7.62) to 2.72 (95% CI 1.13, 6.53) in heavy smokers and from 1.87 (95% CI 0.91, 3.85) to 1.70 (95% CI 0.72, 3.99) in moderate smokers. Similar adjustment also had little effect on the risk of coronary artery disease associated with smoking. CONCLUSION: The combined effect of smoking on the cardiovascular risk factors studied may explain part of its influence on peripheral and coronary arterial disease, but the majority of the effect appears to be due to other mechanisms.

Blood viscosity and elevated carotid intima-media thickness in men and women: the Edinburgh Artery Study.

BACKGROUND: Several hemostatic and rheological factors have been associated with incident cardiovascular events. However, there have been no reports on the relationship of rheological factors with early atherosclerosis and very few on hemostatic factors. We therefore studied the relationship between these factors and carotid intima-media thickness (IMT). METHODS AND RESULTS: The Edinburgh Artery Study measured fibrinogen, tissue plasminogen activator (tPA), fibrin D-dimer, von Willebrand factor (vWF), blood and plasma viscosities, and hematocrit as part of its baseline examination during 1988-1989. At the 5-year follow-up, valid measurements of IMT had been recorded in 1106 men and women 60 to 80 years old. In men, blood viscosity (P< or =.001) and its major determinants, plasma viscosity, fibrinogen (both P< or =.01), and hematocrit (P< or =.05), were all linearly related to IMT. Furthermore, blood viscosity, fibrinogen (both P< or =.01), and plasma viscosity (P< or =.05) remained significantly associated on multivariate analysis. Correcting blood viscosity to a standard hematocrit of 45% had little effect on its association. In men, there was a significantly increased risk of having an IMT above versus below the upper quartile of its distribution (1.05 mm) for SD increases in blood viscosity (P< or =.01), fibrinogen, corrected blood viscosity, and plasma viscosity (all P< or =.05). With the exception of plasma viscosity, these risks were unaffected by adjustment for other common cardiovascular risk factors. No significant associations were found between any of the hemorheological factors and IMT in women or for tPA, fibrin D-dimer, or vWF in either sex. CONCLUSIONS: These findings suggest that in men, blood viscosity and its major determinants are associated not only with incident cardiovascular events but also with the early stages of atherosclerosis. This may be one explanation for the link between rheological factors and events.

Relationship between carotid intima-media thickness and symptomatic and asymptomatic peripheral arterial disease. The Edinburgh Artery Study.

BACKGROUND AND PURPOSE: Ultrasonic evaluation of intimamedia thickness (IMT) is one method of assessing the development of early atherosclerosis. This report describes the distribution of IMT within the general population and is one of the first to investigate its association with noninvasively assessed symptomatic and asymptomatic peripheral arterial disease. METHODS: Ultrasonic evaluation of IMT was included in the 5-year follow-up examination of participants of the Edinburgh Artery Study. Valid readings of IMT were recorded in 1106 subjects aged 60 to 80 years, and the maximum from the right and left sides of the neck was used in the analysis. Existing symptomatic and asymptomatic peripheral arterial disease and coronary heart disease were also assessed at follow-up using previously validated noninvasive techniques. RESULTS: IMT increased continuously with age (P < or = .01), and its distribution was positively skewed in both sexes. The results suggest that levels of atherosclerotic development in the common carotid artery are 5 to 10 years more advanced in men than in women. In this population, the overall prevalence of moderate to severe disease was very low (only 1.2% of study participants had IMT values > 2 mm). The presence of symptomatic (intermittent claudication) or asymptomatic (ankle brachial pressure index < or = 0.9) peripheral arterial disease was significantly associated with increased IMT (P < or = .05). CONCLUSIONS: Although the prevalence of advanced atherosclerosis was very low, small changes in IMT were associated with clinically significant development of atherosclerosis in the peripheral arteries. However, further longitudinal studies are needed that standardize measurement techniques and would allow accurate comparisons across studies.

Cardiovascular risk factors for early carotid atherosclerosis in the general population: the Edinburgh Artery Study.

BACKGROUND: Recent attempts to identify cardiovascular risk factors affecting early-stage carotid atherosclerosis, measured by ultrasonographically assessed intima-media thickness, have been inconclusive. OBJECTIVE: To study the relationship between traditional cardiovascular risk factors and intima-media thickness. METHODS: Ultrasonic evaluation of the intima-media thickness of the common carotid artery was included in the 5-year follow-up examination of participants of the Edinburgh Artery Study. We had valid readings of intima-media thickness for 1106 men and women aged 60-80 years. Information on a range of cardiovascular risk factors had been collected during the baseline examination. RESULTS: For men, in addition to age, lifetime smoking (measured in terms of pack years) was the only cardiovascular risk factor associated with increased intima-media thickness (P< or = 0.01) in the univariate analysis. Both systolic blood pressure (P < or = 0.001) and the high-density lipoprotein (HDL: total cholesterol ratio (P < or = 0.01) were correlated with intima-media thickness for women. When all the variables had been included in a multivariate analysis, pack years of smoking and the HDL:total cholesterol ratio were associated with early atherosclerotic development in men. In an equivalent analysis for women, alcohol consumption, systolic blood pressure and the HDL:total cholesterol ratio were associated with intima-media thickness. CONCLUSION: These data suggest that risk factors affecting intima-media thickness differ for men and women. Further sex-specific analyses of prospective population studies are required in order to clarify the role of 'traditional' cardiovascular risk factors in the early stages of carotid atherosclerosis.

My dear Harry: a life of Henry Bonham-Carter.

Henry Bonham-Carter was both a relative and the 'workhorse' of Florence Nightingale. His administrative skills contributed much to the development of nursing yet he is less well-known than his cousin. This article describes a recent exhibition in London to celebrate his life and involvement in nursing.