Editorial articles

The donor crisis in heart transplantation John Pepper n the area of heart failure, public debate and research funding have been focused on new trends such as xenotransplantation and tissue engineering. Neither approach is expected to have an important role during this decade. We should not neglect organ transplantation, though it is dependent on a scarce resource. Legislation can be effective in the long term, but improving rates of organ donation has more to do with changing attitudes and behaviour.

With the publication recently of the results of learned deliberations of two working parties of the Royal College of Physicians (RCP),1,2 attention continues to focus on the organisational and training aspects of the care of the seriously ill. These documents are the latest in a series of publications that have made proposals for improvement. The intensive care medicine (ICM) community has for many years been drawing attention to the plight of the critically ill, with frustratingly little response from the UK Department of Health. The Audit Commission report Critical to Success3 provided independent evidence that variation in facilities and patterns of operation had important impacts on patient care and cost-effectiveness. Published subsequently were a report of the National Expert Group Comprehensive Critical Care4 and an operational document from the Department of Health.

The first public report on how the NHS manages acute myocardial infarction (MI) in English hospitals was published on 19th November 2002. The report, based on almost 40,000 records collected by the Myocardial Infarction National Audit Project (MINAP) team based at the Royal College of Physicians (RCP), gave rise to much media commentary, the BBC news leading with the headline Heart units too slow with vital drugs.

The concept of chronic disease self-management programmes together with the emerging expert patient has not been widely studied in the context of heart disease. But many of our patients with chronic heart disease are already experts. The knowledge and experience held by the patient has been untapped as a healthcare resource. Research from Stanford1 has shown that lay people with chronic conditions – when given a detailed leader’s manual – can be as effective as professionals in managing their disease and its impact on their daily life. It has also been acknowledged in the report ‘The expert patient: a new approach to chronic disease management for the 21st Century’,2 which recommends action over a six-year period to introduce lay led self-management training programmes for patients with chronic diseases within the NHS in England. A pilot phase between 2001 and 2004 will evaluate local programmes; between 2004 and 2007, programmes will be mainstreamed within all NHS areas.

A commentary on the sign guideline on cardiac rehabilitation, and links between the
British Association for Cardiac Rehabilitation and the British Journal of Cardiology

German bears, Greek philosophers and Mediterranean diets – this year’s PCCS Annual Scientific Meeting goes European PCCS This year’s Primary Care Cardiovascular Society annual meeting was the occasion for a number of firsts. Not only was it the first Annual Scientific Meeting to be held outside England, it was also the first time members had the opportunity to take part in a Socratic Dialogue. The Greek philosopher’s technique did stimulate lively interaction and subsequent proceedings proved to be highly participative. With the highest attendance so far recorded, Chairman, Professor Richard Hobbs, felt that the 2002 meeting easily qualified as the best to date. Ola Soyinka reports from Cardiff.

So the Human Genome Project is complete. To some, perhaps the most extraordinary finding is that of just how few genes each of us possesses – no more, it seems, than 35–40,000. Of course, every single one of us has the same basic set of genes: it is this common genetic inheritance that makes us human rather than any other species. And yet, apart from our shared human characteristics, we are all remarkably different. Why is this?

Heart attack and stroke are major causes of mortality and morbidity in developed countries but in the last two decades lifestyle, clinical and pharmaceutical endeavour have reduced age-adjusted cardiovascular disease rates. As longevity increases, however, macrovascular disease risk also increases. Unfortunately, two lifestyle changes – lack of exercise and increasing obesity – are in the wrong direction, aggravating hyperlipidaemia, hypertension, diabetes mellitus and insulin resistance. Thus, major challenges are still present, highlighted in the National Service Frameworks (NSFs) for coronary heart disease and diabetes. To maximise their contributions to these problems, the British Hyperlipidaemia Association (BHA) and Family Heart Association (FHA) have merged to form the Hyperlipidaemia Education And Research Trust – HEART UK. Both associations have been concerned with scientific, medical and social issues of cholesterol and lipids in the UK. HEART UK marks a substantial move forward for scientific lipid study, for recognition of the high-risk individual, and for patient treatment.

The first reported combined heart and kidney transplant occurred in 1978.1 The patient died of gram negative sepsis 15 days after transplantation. It was not until 1986 that a case was reported with long-term (> 18-month) survival.2 Since that time, there have been more than 40 publications examining the pros and cons of simultaneous heart and kidney transplantation. Initial reports consisted mainly of small case series demonstrating proof of concept and adequate 1–3 year survival, mostly in line with that of heart transplantation alone.3-5 Later it was noted that simultaneous transplantation seemed to protect against rejection of the heart transplant (although different immunosuppressive protocols were frequently employed) and that rejection of one organ often occurred independently of immunological damage to the other.

Biotechnology and cardiovascular medicine – a hazy past and bright future? Melinda Swann, Adam Raman, Michael KirchengastFrom such successful beginnings, the biotechnology sector has since gone on to have a rather hazy past, for which there are many plausible explanations. In March 2000, the sector was grossly overvalued and, since then, investors’ aversion to the area has flourished due to the perceived risk they felt they were taking. This has led to the growth of many biotechnology companies being stunted since access to capital has become more difficult – studies, especially long-term survival trials in cardiovascular medicine.