WELL DONE! BBC

Recently there have been several programmes on the TV and radio which were of interest to THROB members. In spite of comments about the dumbing down of the BBC, there are still many occasions when good information is provided.

In a TV series on problems within the NHS, one programme was devoted to problems associated with bypass surgery. They concentrated on several patients who had problems after bypass surgery due to minor brain damage. This was caused by very small pieces of plaque from arteries being dislodged by the clamping procedure and which were then carried to the brain where they lodged, causing 'hits' which could cause post-operative problems. It was suggested that up to 1000 hits could be registered during an operation, but that, with best practice, this should be significantly reduced by the use of a filter in the blood stream and selecting for clamping a part of the artery with only a small deposit of plaque.

Shortly after this, there was a radio programme on rehabilitation generally, but which included a section on cardiac rehabilitation. For those of us who have been involved, this did not offer any new information, but it was very interesting to hear what strides are being made in rehabilitation of other conditions, particularly strokes, where it is sometimes possible to regenerate physical and mental activity through repetitive action, so that new pathways are produced in the brain to take over from those that have been destroyed.

And then there was the TV programme on the Brontes, which recorded that Patrick Bronte had had a cataract operation, from which he had recovered enough sight to continue as an active clergyman. It is amazing that cataract operations were being performed in 1846 and even more that it was carried out without anaesthetic and was successful.

Are we not glad that we live in 2003!

SIXTH ANNUAL THROB LECTURE

This year's lecture was given by Mr. Peter Wright whose official title was "Secretary of the Maunday".

Peter traced the history of the Maunday from it's origin when Christ washed the feet of his Disciples on the day before He was crucified. In this country the ceremony could be traced back to the time of King John (1199-1216) who washed the feet of some of his subjects on the day before Good Friday. Not all monarchs went in for foot washing apparently: Elizabeth I initially gave away gowns to poor and needy women but eventually changed this to a gift of money. Charles II washed feet and also his sucessor James II who reigned from 1685. He apparently washed as many pairs of feet as his age (52 at the start) which seemed to be the first connection between the number of people benefitting from the Maunday and the age of the Monarch. The foot washing ceremony was eventually delegated to other dignatories on behalf of the Crown and died out in 1734.

The Maundy ceremony was dormant until revived by George V in 1932 but was not carried out every year. George VI had a few Maundy ceremonies during his reign but it was our present Queen who really reinstated it as an annual event. She has presented Maunday Money every year of her reign save four when she was either out of the country or busy having children! She presents the Maunday Money to as many people as her age and these are selected by Peter in the area where the ceremony is held. The present Queen instigated the practice of moving the ceremony around the country so that more people could witness the event.

Peter showed the audience the Maunday Money struck each year by the Mint, consisting of 1p, 2p, 3p and 4p silver pieces enclosed in a small kid leather purse. In the actual ceremony Peter introduces each recipient, the purse is passed to the Queen by the Lord High Almoner for presentation. Recipients are people aged over 65, of good character and have served both the Church and the Community in which they live. So are you in with a chance? This was a fascinating and informative lecture and it is a pity it was not enjoyed by a larger audience.

DIARY OF A GUINEA-PIG

I had a quadruple by-pass operation in 1997 and, like others who have been along the same route, I received a lot of t-l-c, both at the Brompton and St. Marks, Maidenhead, at given periods during the following two years. In January 1999, I was asked if I would volunteer to take part in a new drug trial - along with 10,000+ other volunteers from 24 countries in the European zone - the trial to be known under the acronym EUROPA (EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease). The EUROPA trial is the largest morbidity-mortality trial ever conducted with an ACE-inhibitor specifically in patients with cornary artery disease using so many patients in this large number of countries. I thought that this was something I could take part in, as a small 'payback' into the system, following all the kind and professional treatment I had had - tests, consultations, angiogram and finally, the by-pass, after my heart attack in July 1995. I only had to take the tablets regularly as instructed and to attend the periodic consultations. The drug in question - perindopril - is an ACE (angio converting enzyme) inhibitor and, at the time of the commencement of the trial, we were told that it had already been in use for the treatment of high blood pressure and heart failure, with good results. Clinical trials had shown that with some myocardial infarction patients, long-term use of ACE inhibitors decreases cardiac complications and improves survivial chances. However, the purpose of this trial has been to determine whether there was any application for patients with Coronary Artery Disease.

A clinical trial is a research study designed to investigate new therapies, new ways of using existing treatments, as well as better ways to prevent, diagnose or treat diseases. It is also used to investigate the usefulness, safety and reliability and cost-effectiveness of a treatment, as well as identifying the correct dosage for treatments. As has been mentioned, in this case the EUROPA trial was specifically to research the potential of the perindopril drug to Coronary Artery Disease. This trial was known as a 'blind' or 'masked' trial, wherein the treatment group receives the study drug and the control group receives the placebo. Participants are not aware which group they are in. Neither do the participants' physicians know the treatment their particular patient is receiving. This is referred to as a 'double-blind trial' and is designed to prevent patient and physician from anticipating the results.The volunteers were first put through a series of tests to establish if they would be suitable to take part in the trial - blood tests were done at 1, 14 and 28 days after the first tablet was taken and also a test to detect the possible presence of a gene (ACE gene) which could affect the response to prindopril. If all was in order, the volunteer would then be included in the main trial. Diabetics would receive special treatment in accordance with their condition and, if any change were found, then the volunteer's own G.P. would be advised. Once the volunteers were considered as suitable for inclusion, they were asked to take two tablets of perindopril/placebo half an hour before breakfast, each day without fail, as well as their other heart medication. After three months we had to attend for a complete check-up and every six months thereafter and an ECG and blood tests were done annually. This was a nice little bonus for us 'hearties'. At each assessment consultation we had to hand back the remainder of the trial tablets we still had, together with the boxes which they had been supplied in. We were then handed a fresh supply for the next six months in order to continue on with our place in the trial.

The original trial was set to last three years and I must say, that after a year or so had passed, I was quite looking forward to the end of that time. However, at the end of the third year, volunteers were asked to continue ofr a further year, because the trial organisers, who were bceoming increasingly impressed with the results coming through to them, wanted to coninue for a further period of time to reassure themselves that the trial was becoming very worthwhile. The only difficulty as far as I had been concerned, was that my lifestyle is such that I am away for quite long periods of time during the year and sometimes it was a problem to ensure that I presented myself at the Wexham Cardiac Clinic for the bi-annual assessment. I also recall one time when I reealise I was goung to run out of the test tablets and I telephoned the Brompton for advice. "No problems, we can post them to you in Ibiza" and, despite the unreliability of the Spanish postal system, they arrived in the nick of time and I was able to continue to take my place in the trial programme. However, apart from one other blip when I had my "wrist slapped", I did manage to keep to the system. The main point was that the 'medication' had to be taken regularly and the volunteers had to attend at the appointed time for further assessment. The trial, as far as the volunteers are concerned, is now at an end - I have been put on to perindopril permanently (one tablet daily, half an hour before breakfast), along with any other medication I might be taking and have been told that the results of the trial will be published this autumn. In fact the report, which was extremely favourable, was published at the Europena Society of Cartiology in Vienna on 31st August 2003. So all of us 'hearties' may now be in for a slight alteration to our medication. And for me, personally, all will be revealed when I attend Prof. Fox's clinic in November.

Pauline Hulett

CARDIAC REHAB "Down Under"

(The author is a retired airline captain aged 61. He had a double heart bypass in Jan 2001 after months of angina pain, but luckily has not had a heart attack - touch wood!)

Our daughter Julia lives with her husband in the suburbs of Sydney Australia. Last winter my wife and I excitedly prepared for an extended visit as Julia was to give birth to our first grandchild. This happy event occurred in November 2002 and after returning to UK for Christmas we again visited Australia in the January 2003. Our planned stay over the two visits was five months. Well you can do these things when you are retired.

However I realised how much I would miss my cardiac rehab sessions. I do two a week with Leslie at Carnation Hall. So I duly contacted the cardiac department at the nearest hospital to my daughters house (Royal North Shore on the Pacific Highway in St Leonard's for anyone who may know Sydney) To my delight I discovered that they have a very active cardiac rehab programme. Yes they would be delighted to have me puff along with the rest. They sent me a complimentary ticket and on the due day, armed with a doctor's letter, bottle of water and towel, I duly pitched up.

First thing to realise is that Cardiac Rehab in Australia is done at the hospitals, in the physiotherapy gymnasium in the case of the Royal North Shore. The second difference is that there is a Cardiac Nurse and an Aerobics Teacher in attendance and thirdly, classes, which are on five nights a week, are much larger. There was on average 30 –40 people at each session.

Sessions begin with brisk walking around the hall with faster walkers encouraged to overtake slower walkers. As the group files past the aerobics/exercise teacher different parts of the upper anatomy are stretched. The music is very rhythmic, fast beat and increasing in speed and one is urged almost to a jog by the end of the 10-15 minute session.

Then the whole group then takes part in a quite intensive aerobic exercise session. It starts, obviously, with quite gentle movements but builds up over 15 minutes or so to a full blown aerobic workout and everyone is expected to be puffing gently and "glowing" a little. The old hands do this session with weights.

The participants then split into four sets. One set on bikes, another on steps, another with the aerobic teacher with weights and the fourth doing resistance exercises with bunjees. Approximately ten minutes on each station but you are strictly watched and exhorted to greater efforts. The bikes are especially demanding with our teacher demanding three ten second sprints one after another.

Then after a cool-down walk with stretching, some floor stretching which is quite prolonged and again well supervised and encouraged. Some stomach exercises are also thrown in at that time. No pretty music or a few minutes relaxation I'm afraid.

So at the end of it you have found that you have done more or less the same stretches and exercises as UK but slacking is discouraged. Consequently nearly every one has a sweaty shirt at the end of it. Whilst there is some social aspect to it, not as much as here. No tea at the end, or even an Aussie beer, but you do feel good.

Paul Moore

(Sounds a bit gruelling! I don't want any of our exercise class instructors getting any ideas but it would be most interesting to get their views on the subject. Comments on a postcard please, Instructors - or email would do - dtread84@hotmail.com Ed.)

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RECTUS ABDOMINIS (Stomach muscles)

Where are my Rectus Abdominis muscles?

The Rectus Abdominis muscle is divided into two (left and right side); they are joined along their length exactly mid line of the body. They are joined by a band called the linea alba (Latin for white line). The Rectus Abdominis originates from the pubic crest (towards the bottom of the pelvis) and inserts into the bottom of the breastbone and the ribs 5, 6 and 7.

What is the action of the Rectus Abdominis muscles?

The Rectus Abdominis muscle flexes the trunk (curling the trunk forward). This muscle also plays an important role in stabilizing the spinal column.

How can I strengthen my Rectus Abdominis muscles?

A safe exercise to work these muscles is called mad cat-mellow cat. When performing this exercise you'll see how the exercise got its name.

Start on your hands and knee's with a straight back, draw your belly button towards the spine and arch the upper back upwards. Lower the head between the arms, whilst tilting the pelvis forward. Relax and return to the starting position. Repeat 10-15 times

How can I stretch my Rectus Abdominis muscles?

Lie flat on your front and support the weight of the upper body on your elbows, gradually raise the upper body keeping your hips in contact with the floor. You should feel the stretch. Hold for 15-30 seconds.

Before engaging on any new exercises please consult with a BACR exercise instructor first

MERCURY

The British Heart Foundation (BHF) have reported that scientists from nine countries, including the UK, have suggested that frequent consumption of tuna and swordfish could be a heart attack risk, since the flesh of these fish have the highest known concentrations of mercury found in any fish. The mercury is absorbed by the fish from seawater and can accumulate to sufficiently toxic levels to be a heart attack risk. These findings differ from another study of a large group of male professionals which found no link between mercury and the risk of coronary heart disease. The BHF has not changed its advice with these new findings. They recommend eating fish twice a week with one portion being oily which should provide the benefits from the Omega-3 oils in the oily fish wilst avoiding any harmful effects from mercury.

CRANBERRY JUICE

Patients taking the anti-clotting drug warfarin should limit or avoid drinking cranberry juice because of the risk of haemorrhage. So maintains the Committee on Safety of Medicines who also said it had received five reports—one fatal— suggesting the juice and warfarin interact, increasing the potency of the drug. "Until this possible interaction between cranberry juice and warfarin has been investigated further, it would be prudent for patients taking warfarin to be advised to limit or avoid drinking it," the committee said.

The fatal haemorrhage case involved a man whose blood clotting levels changed dramatically six weeks after starting to drink cranberry juice, it reported in its newsletter "Current Problems in Pharmacovigilance."

Cranberry juice has boomed in popularity in recent years and is often used by women to prevent cystitis. Warfarin is known to interact with many other drugs, which either increase or reduce its potency. Modern anti-depressants, for example, can enhance the anti-coagulant effect, while the herbal remedy St. John's Wort diminishes it.

Reuters (Sept 2003)

GRAPE FRUIT JUICE

Grapefruit is healthy and has many nutrients such as the antioxidant lycopene, but grapefruit does interact with some medications. Researchers first discovered an interaction between grapefruit juice and the drugs felodipine (Plendil) and nifedipine (Adalat, Procardia), which are used to treat cardiovascular disease. Later studies showed that grapefruit juice alters the blood levels of many other drugs as well.

Grapefruit juice is unique among juices from citrus fruits. Chemicals in grapefruit interfere with certain enzymes that break down certain drugs in your intestinal tract and liver. This can result in higher-than-desired blood levels of the drug and an increased risk of serious side effects. The exact chemical or chemicals in grapefruit juice that cause this interaction aren't known. But these chemicals are present in the pulp and peel of grapefruit as well as in the juice. For this reason, any grapefruit product - including dietary supplements that contain grapefruit bioflavonoids - can interact with these medications. You may also want to avoid tangelos, a hybrid grapefruit. They may have a similar effect.

Drugs that are known to have potentially serious interactions with grapefruit products include:

· Anti-seizure drugs such as carbamazepine (Carbatrol, Tegretol)

· Anti-depressants such as buspirone (BuSpar), clomipramine (Anafranil) and sertraline (Zoloft)

· Benzodiazepines such as diazepam (Valium) and triazolam (Halcion)

· Calcium channel blockers such as felodipine (Plendil), nifedipine (Adalat, Procardia, nimodipine (Nimotop), nisoldipine (Sular) and possibly verapamil (Isoptin, Verelan)

· Human immuno-deficiency virus (HIV) protease inhibitors such as saquinavir (Fortovase, Invirase) and indinavir (Crixivan)

· HMG-CoA reductase inhibitors such as simvastatin (Zocor), lovastatin (Mevacor) and atorvastatin (Lipitor)

· Immuno-suppressant drugs such as cyclosporine (Neoral, Sandimmune), tacrolimus (Prograf) and sirolimus (Rapamune)

· Anti-arrhythmic drugs such as amiodarone (Cordarone)

Even waiting to take these medications up to 24 hours after you drink grapefruit juice doesn't prevent an interaction. The best advice is to avoid grapefruit products if you take any of these drugs, unless your doctor or pharmacist approves.

Lesley Richards