- Email: [email protected]
Effects of posture on sympathetic nervous modulation in patients with chronic heart failure
RESEARCH LETTERS
(5 mg/kg intravenously). All patients met the inclusion criteria for this programme, had treatment-resistant active Crohn’s disease with or without fistulas, and gave written informed consent. The disease duration of the articular symptoms in these patients ranged from 2 months to 25 years. The treatment was well tolerated in all patients; no side-effects were recorded. After treatment, all four patients were in gastrointestinal remission. The first patient was a 51-year-old woman with active synovitis of both knees, right wrist, metacarpophalangeal (MCP) joints one to three of both hands, and proximal interphalangeal (PIP) joints two to four of the right hand. Inflammatory variables were normal. After one dose of infliximab, the swollen joint count dropped from twelve to six; there was clinical remission after a second dose at week 2, which was sustained for up to 6 months. The second patient was a 38-year-old HLA B27-positive man with ankylosing spondylitis with peripheral arthritis of MCP joints one to three of both hands and PIP joints two and three of the right hand. He had a C-reactive protein concentration of 0·022 g/L. 2 weeks after treatment, synovitis had disappeared, and C-reactive protein had returned to normal at 0·006 g/L. However, synovitis recurred after 3 months in the right elbow and right knee. There was a new articular remission after retreatment with infliximab. The third patient was a 31-year-old man with active peripheral arthritis of the right knee, the left ankle, and metatarsophalangeal joints two to four of the left foot. He had a C-reactive protein concentration of 0·1126 g/L. 10 days after treatment, all articular symptoms had disappeared; no synovitis was detectable. C-reactive protein concentration had normalised to 0·004 g/L. Synovitis recurred 3 months after treatment. A repeated dose of infliximab was again successful. The evolution of C-reactive protein and active joints, in correlation to the use of infliximab, is shown in the figure. The fourth patient was a 54-year-old man with HLA-B27positive ankylosing spondylitis who presented with severe inflammatory cervical pain and generalised “bamboo” spine; C-reactive protein was 0·0932 g/L. Axial night pain disappeared after treatment and C-reactive protein concentration returned to normal at 0·0032 g/L. The patient remained in remission during follow-up, which is now 8 weeks. To our knowledge, the studies on anti-TNF-␣ monoclonal antibody treatment in inflammatory bowel disease have not assessed the effect on associated rheumatological manifestations such as spondylitis, synovitis, or enthesopathy. Moreover, the effect of the compound has not been tested in other types of SpA. However, since SpA and gut inflammation are intimately associated in some cases, an effect of infliximab on associated articular disease seems likely. We have shown that TNF-␣ blockade is followed by a fast and substantial improvement of articular as well as axial manifestations of Crohn’s disease. The findings in these four patients suggest that refractory joint manifestations in Crohn’s disease could be a potential indication for infliximab treatment, and warrant further investigation of the treatment potential of TNF-␣ blockade in SpA. 1
2
3
4
Knight DM, Trinh H, Le J, et al. Construction and initial characterization of a mouse-human chimeric anti-TNF antibody. Mol Immunol 1993; 30: 1443–53. Targan SR, Hanauer SB, Van Deventer SJ, et al. A short-term study of chimeric monoclonal antibody cA2 to tumor necrosis factor alpha for Crohn’s disease. Crohn’s Disease cA2 Study Group. N Engl J Med 1997; 337: 1029–35. Present DH, Rutgeerts P, Targan S, et al. Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 1999; 340: 1398–405. Mielants H, Veys EM, Cuvelier C, et al. The evolution of spondyloarthropathies in relation to gut histology III: relation between gut and joint. J Rheumatol 1995; 22: 2273–78.
1822
5
Dougados M, van der Linden S, Juhlin R, et al. The European spondylarthropathy Study Group. The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum 1991; 34: 1218–27.
Departments of Rheumatology (F Van den Bosch MD, E Kruithof MD, F De Keyser MD, H Mielants MD), and Gastroenterology (M De Vos MD PhD), University Hospital, 9000 Gent, Belgium Correspondence to : Dr Filip Van den Bosch
Effects of posture on sympathetic nervous modulation in patients with chronic heart failure Masatoshi Fujita, Shoichi Miyamoto, Hiroyuki Sekiguchi, Shigeru Eiho, Shigetake Sasayama We investigated which recumbent position is preferred by patients with chronic heart failure (CHF) and whether sympathetic nervous modulation differs in three recumbent positions. We assessed 12 patients with CHF by spectral analysis of heart-rate variability and measurement of plasma norepinephrine concentrations. The right lateral decubitus position was preferred for significantly longer periods than the left lateral decubitus and supine positions. Sympathetic nervous modulation was most attenuated in the right lateral decubitus position. The right lateral decubitus position preferred by patients with CHF may be a self-protective mechanism to control increased sympathetic nervous modulation.
Many neurohumoral changes occur as a consequence of the haemodynamic alterations in chronic heart failure (CHF), of which increased sympathetic nervous modulation is likely to be detrimental to patients with CHF. In such patients, circulating norepinephrine concentration, an index of this modulation, is generally two to three times higher, at rest, than in healthy people.1 Parasympathetic restraint on sinoatrial node automaticity is also substantially reduced in patients with CHF.2 Because many patients with CHF have orthopnoea, they prefer to sleep in a lateral decubitus position. However, it is unclear whether patients with CHF prefer to sleep in either the right or left lateral decubitus position, and how sleep posture affects autonomic nervous activity. We developed a Holter electrocardiographic (ECG) monitoring system, which enabled simultaneous recordings of ECG and the patient’s sleep posture. We studied 12 men (mean age 66 years [SD 12]) with CHF due to coronary-artery disease with a mean left-ventricular ejection fraction of 28 (12)%. Eight patients had New York Heart Association functional class II, and four had class III. Two-channel Holter recorders (Fukuda Densi Co, Tokyo, Japan) were used, one channel for recording the CM5 lead, and the other for recording the patient’s posture with a sensor unit (32 mm diameter and 9 mm thick), attached to the centre of his anterior chest wall. The device provided pulse waves of 0·5, 1·0, and 2·0 Hz corresponding to the left lateral decubitus, supine, and right lateral decubitus positions. Holter recordings were continued for at least 18 h while patients were in bed. The ECG recordings were analysed with a Holter Scanner Medilog OPTIMA EC 2200 (Oxford Co, London, UK), and an R-R interval data file was produced for each recording. Frequency-domain indexes were computed with a fast-Fourier transformation on each 5-min segment of the recording in the three recumbent positions between 0300 h and 0600 h. Total power (TP) spectrum (0·04 to 0·40 Hz), high-frequency (HF) power (0·15 to 0·40 Hz), low-frequency (LF) power (0·04 to 0·15 Hz), and LF/HF ratio3 were recorded. Blood samples were drawn from a peripheral vein through an indwelling catheter in the three different positions at the end of every h in the early morning, and plasma norepinephrine levels were
THE LANCET • Vol 356 • November 25, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
RESEARCH LETTERS
min 150
B
A
(pg/mL) 1000
10
C
* * Norepinephrine
100
50
LF/HF
*
5
*
0
0 L
S
R
*
Correspondence to: Prof Masatoshi Fujita, College of Medical Technology, Kyoto University, 53 Kawaharacho, Shogoin Sakyo-ku, Kyoto 606-8507, Japan (e-mail: [email protected])
* 500
0 L
S R
L
S R
Time in preferred position (A), LF/HF (B), and plasma norepinephrine concentrations (C) among three different positions LF=low-frequency power, HF=high-frequency power, L=left lateral decubitus position, S=supine position, R = right lateral decubitus position, *=p<0.05 versus R by ANOVA.
measured by radioimmunoassay. All patients gave written informed consent to the protocol, which was approved by the ethics committee of Takeda Hospital. Between 0300 h and 0600 h, patients with CHF preferred the right lateral decubitus position (figure, A). The ratio of LF/HF, indicating the balance of sympathetic to parasympathetic nervous modulation was lowest in the right lateral decubitus position (figure, B). Plasma norepinephrine concentrations were lower in the right lateral decubitus position than those in the left lateral decubitus and supine positions (figure, C). In healthy individuals matched for age and sex, there were no significant differences in these indexes among the three recumbent positions. When measuring heart-rate variability (HRV) with Holter recordings in patients with CHF, the patient’s posture must be taken into account or cardiac autonomic nervous function may be misjudged. An over-dependence of measurements of HRV on patient’s posture may hinder the assessment of circadian variation of cardiac autonomic function in patients with CHF.4 In many clinical studies, the effects of pharmacological or other treatments on autonomic nervous function in CHF is assessed with indexes of HRV. Because abnormal HRV is related to risk of subsequent death in patients with CHF,5 it is important to assess HRV in the same posture before and after interventions. This study was supported by a grant-in-aid for Scientific Research ([b] 10557067) from the Ministry of Education, Science, and Culture, Tokyo, Japan, and the “Research for the Future” Program (JSPS-RFTF 99 I 00201) from the Japan Society for the Promotion of Science. 1
2
3
4
5
Hasking GJ, Esler MD, Jennings GL, Burton D, Johns JA, Korner PI. Norepinephrine spillover to plasma in patients with congestive heart failure: evidence of increased overall and cardiorenal sympathetic nervous activity. Circulation 1986; 73: 615–21. Eckberg DL, Drabinsky M, Braunwald E. Defective cardiac parasympathetic control in patients with heart disease. N Engl J Med 1971; 285: 877–83. Pagani M, Lombardi F, Guzzetti S et al. Power spectral analysis of heart rate and arterial pressure variabilities as a marker of sympathovagal interaction in man and conscious dog. Circ Res 1986; 59: 178–93. Huikuri HV, Niemelä MJ, Ojala S, Rantala A, Ikäheimo MJ, Airaksinen KEJ. Circadian rhythms of frequency domain measures of heart rate variability in healthy subjects and patients with coronary artery disease. Circulation 1994; 90: 121–26. Fauchier L, Babuty D, Cosnay P, Fauchier JP. Prognostic value of heart rate variability for sudden death and major arrhythmic events in patients with idiopathic dilated cardiomyopathy. J Am Coll Cardiol 1999; 33: 1203–07.
THE LANCET • Vol 356 • November 25, 2000
College of Medical Technology, Kyoto University, Kyoto, Japan (Prof M Fujita MD); Cardiology Division, Takeda Hospital (S Miyamoto MD); Department of Systems Science, Graduate School of Informatics, Kyoto University (H Sekiguchi PhD, Prof S Eiho PhD); and Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan (Prof S Sasayama MD)
Health-seeking behaviour of individuals with a cough of more than 3 weeks A Thorson, N P Hoa, N H Long Sex inequalities can lead to poorer access to health care and delays to diagnosis of tuberculosis in women. In a populationbased survey we assessed health-seeking behaviour in adults with long-term cough. The prevalence of cough was 1% (213) and 2% (279) in men and women, respectively. Women took more health-care actions than men, but chose less qualified providers and reported lower health expenditure per visit. Delay before seeking hospital treatment was longer for women (41 days) than men (19 days; p=0·04), and more men (27; 36%) than women (14; 14%; p=0.0006) reported giving a sputum sample at hospital. Sex-sensitive strategies for tuberculosis control are needed and should take into account sex differences in health-care seeking behaviour as well as a possible sex bias among health-care providers.
Worldwide, about two-thirds of all known people with tuberculosis are men.1 Whether this proportion indicates a true difference in frequency between the sexes or an undernotification of female cases is subject to speculation.2 Long’s findings3 indicate that sex inequalities lead to poorer access to health care and delays in diagnosis and treatment of tuberculosis in women. We undertook a population-based survey in Ha Tay province, Vietnam, within the setting of an epidemiological field laboratory. The study group consisted of 34 127 people aged 15 and over (table 1). Household interviews, with a structured questionnaire, identified 492 (1%) individuals, including 213 men and 279 women, as having had a cough for more than 3 weeks anytime during the 3 months before the study (table 1). Among these, 92 (43%) men and 18 (7%) women were smokers. 253 (91%) women and 188 (88%; p=0·05) men reported having taken a health-care action. Additionally, 44 (16%) and 18 (8%; p=0·02) women and men, respectively, reported three or more health-care actions (table 2). Regression analysis, with age, sex, education, and income as independent variables, indicated that being a woman was the only variable associated with an increase in the number of health-care actions taken. About 10% (51) of both men and women with long-term cough did not seek health care at all, indicating a failure of the national health programme to reach parts of the population. Of the types of actions reported by the study group, women used more self-medication than did men, and more often visited private practitioners. More women than men chose less-qualified providers (self-medication, pharmacist, or private practitioner) as the first health-care action (table 2). Convenience and close proximity to home were more commonly reported by women than men as reasons for choosing their particular first action. More men than women visited a hospital, and mean delay
1823
For personal use only. Not to be reproduced without permission of The Lancet.
(5 mg/kg intravenously). All patients met the inclusion criteria for this programme, had treatment-resistant active Crohn’s disease with or without fistulas, and gave written informed consent. The disease duration of the articular symptoms in these patients ranged from 2 months to 25 years. The treatment was well tolerated in all patients; no side-effects were recorded. After treatment, all four patients were in gastrointestinal remission. The first patient was a 51-year-old woman with active synovitis of both knees, right wrist, metacarpophalangeal (MCP) joints one to three of both hands, and proximal interphalangeal (PIP) joints two to four of the right hand. Inflammatory variables were normal. After one dose of infliximab, the swollen joint count dropped from twelve to six; there was clinical remission after a second dose at week 2, which was sustained for up to 6 months. The second patient was a 38-year-old HLA B27-positive man with ankylosing spondylitis with peripheral arthritis of MCP joints one to three of both hands and PIP joints two and three of the right hand. He had a C-reactive protein concentration of 0·022 g/L. 2 weeks after treatment, synovitis had disappeared, and C-reactive protein had returned to normal at 0·006 g/L. However, synovitis recurred after 3 months in the right elbow and right knee. There was a new articular remission after retreatment with infliximab. The third patient was a 31-year-old man with active peripheral arthritis of the right knee, the left ankle, and metatarsophalangeal joints two to four of the left foot. He had a C-reactive protein concentration of 0·1126 g/L. 10 days after treatment, all articular symptoms had disappeared; no synovitis was detectable. C-reactive protein concentration had normalised to 0·004 g/L. Synovitis recurred 3 months after treatment. A repeated dose of infliximab was again successful. The evolution of C-reactive protein and active joints, in correlation to the use of infliximab, is shown in the figure. The fourth patient was a 54-year-old man with HLA-B27positive ankylosing spondylitis who presented with severe inflammatory cervical pain and generalised “bamboo” spine; C-reactive protein was 0·0932 g/L. Axial night pain disappeared after treatment and C-reactive protein concentration returned to normal at 0·0032 g/L. The patient remained in remission during follow-up, which is now 8 weeks. To our knowledge, the studies on anti-TNF-␣ monoclonal antibody treatment in inflammatory bowel disease have not assessed the effect on associated rheumatological manifestations such as spondylitis, synovitis, or enthesopathy. Moreover, the effect of the compound has not been tested in other types of SpA. However, since SpA and gut inflammation are intimately associated in some cases, an effect of infliximab on associated articular disease seems likely. We have shown that TNF-␣ blockade is followed by a fast and substantial improvement of articular as well as axial manifestations of Crohn’s disease. The findings in these four patients suggest that refractory joint manifestations in Crohn’s disease could be a potential indication for infliximab treatment, and warrant further investigation of the treatment potential of TNF-␣ blockade in SpA. 1
2
3
4
Knight DM, Trinh H, Le J, et al. Construction and initial characterization of a mouse-human chimeric anti-TNF antibody. Mol Immunol 1993; 30: 1443–53. Targan SR, Hanauer SB, Van Deventer SJ, et al. A short-term study of chimeric monoclonal antibody cA2 to tumor necrosis factor alpha for Crohn’s disease. Crohn’s Disease cA2 Study Group. N Engl J Med 1997; 337: 1029–35. Present DH, Rutgeerts P, Targan S, et al. Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 1999; 340: 1398–405. Mielants H, Veys EM, Cuvelier C, et al. The evolution of spondyloarthropathies in relation to gut histology III: relation between gut and joint. J Rheumatol 1995; 22: 2273–78.
1822
5
Dougados M, van der Linden S, Juhlin R, et al. The European spondylarthropathy Study Group. The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum 1991; 34: 1218–27.
Departments of Rheumatology (F Van den Bosch MD, E Kruithof MD, F De Keyser MD, H Mielants MD), and Gastroenterology (M De Vos MD PhD), University Hospital, 9000 Gent, Belgium Correspondence to : Dr Filip Van den Bosch
Effects of posture on sympathetic nervous modulation in patients with chronic heart failure Masatoshi Fujita, Shoichi Miyamoto, Hiroyuki Sekiguchi, Shigeru Eiho, Shigetake Sasayama We investigated which recumbent position is preferred by patients with chronic heart failure (CHF) and whether sympathetic nervous modulation differs in three recumbent positions. We assessed 12 patients with CHF by spectral analysis of heart-rate variability and measurement of plasma norepinephrine concentrations. The right lateral decubitus position was preferred for significantly longer periods than the left lateral decubitus and supine positions. Sympathetic nervous modulation was most attenuated in the right lateral decubitus position. The right lateral decubitus position preferred by patients with CHF may be a self-protective mechanism to control increased sympathetic nervous modulation.
Many neurohumoral changes occur as a consequence of the haemodynamic alterations in chronic heart failure (CHF), of which increased sympathetic nervous modulation is likely to be detrimental to patients with CHF. In such patients, circulating norepinephrine concentration, an index of this modulation, is generally two to three times higher, at rest, than in healthy people.1 Parasympathetic restraint on sinoatrial node automaticity is also substantially reduced in patients with CHF.2 Because many patients with CHF have orthopnoea, they prefer to sleep in a lateral decubitus position. However, it is unclear whether patients with CHF prefer to sleep in either the right or left lateral decubitus position, and how sleep posture affects autonomic nervous activity. We developed a Holter electrocardiographic (ECG) monitoring system, which enabled simultaneous recordings of ECG and the patient’s sleep posture. We studied 12 men (mean age 66 years [SD 12]) with CHF due to coronary-artery disease with a mean left-ventricular ejection fraction of 28 (12)%. Eight patients had New York Heart Association functional class II, and four had class III. Two-channel Holter recorders (Fukuda Densi Co, Tokyo, Japan) were used, one channel for recording the CM5 lead, and the other for recording the patient’s posture with a sensor unit (32 mm diameter and 9 mm thick), attached to the centre of his anterior chest wall. The device provided pulse waves of 0·5, 1·0, and 2·0 Hz corresponding to the left lateral decubitus, supine, and right lateral decubitus positions. Holter recordings were continued for at least 18 h while patients were in bed. The ECG recordings were analysed with a Holter Scanner Medilog OPTIMA EC 2200 (Oxford Co, London, UK), and an R-R interval data file was produced for each recording. Frequency-domain indexes were computed with a fast-Fourier transformation on each 5-min segment of the recording in the three recumbent positions between 0300 h and 0600 h. Total power (TP) spectrum (0·04 to 0·40 Hz), high-frequency (HF) power (0·15 to 0·40 Hz), low-frequency (LF) power (0·04 to 0·15 Hz), and LF/HF ratio3 were recorded. Blood samples were drawn from a peripheral vein through an indwelling catheter in the three different positions at the end of every h in the early morning, and plasma norepinephrine levels were
THE LANCET • Vol 356 • November 25, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
RESEARCH LETTERS
min 150
B
A
(pg/mL) 1000
10
C
* * Norepinephrine
100
50
LF/HF
*
5
*
0
0 L
S
R
*
Correspondence to: Prof Masatoshi Fujita, College of Medical Technology, Kyoto University, 53 Kawaharacho, Shogoin Sakyo-ku, Kyoto 606-8507, Japan (e-mail: [email protected])
* 500
0 L
S R
L
S R
Time in preferred position (A), LF/HF (B), and plasma norepinephrine concentrations (C) among three different positions LF=low-frequency power, HF=high-frequency power, L=left lateral decubitus position, S=supine position, R = right lateral decubitus position, *=p<0.05 versus R by ANOVA.
measured by radioimmunoassay. All patients gave written informed consent to the protocol, which was approved by the ethics committee of Takeda Hospital. Between 0300 h and 0600 h, patients with CHF preferred the right lateral decubitus position (figure, A). The ratio of LF/HF, indicating the balance of sympathetic to parasympathetic nervous modulation was lowest in the right lateral decubitus position (figure, B). Plasma norepinephrine concentrations were lower in the right lateral decubitus position than those in the left lateral decubitus and supine positions (figure, C). In healthy individuals matched for age and sex, there were no significant differences in these indexes among the three recumbent positions. When measuring heart-rate variability (HRV) with Holter recordings in patients with CHF, the patient’s posture must be taken into account or cardiac autonomic nervous function may be misjudged. An over-dependence of measurements of HRV on patient’s posture may hinder the assessment of circadian variation of cardiac autonomic function in patients with CHF.4 In many clinical studies, the effects of pharmacological or other treatments on autonomic nervous function in CHF is assessed with indexes of HRV. Because abnormal HRV is related to risk of subsequent death in patients with CHF,5 it is important to assess HRV in the same posture before and after interventions. This study was supported by a grant-in-aid for Scientific Research ([b] 10557067) from the Ministry of Education, Science, and Culture, Tokyo, Japan, and the “Research for the Future” Program (JSPS-RFTF 99 I 00201) from the Japan Society for the Promotion of Science. 1
2
3
4
5
Hasking GJ, Esler MD, Jennings GL, Burton D, Johns JA, Korner PI. Norepinephrine spillover to plasma in patients with congestive heart failure: evidence of increased overall and cardiorenal sympathetic nervous activity. Circulation 1986; 73: 615–21. Eckberg DL, Drabinsky M, Braunwald E. Defective cardiac parasympathetic control in patients with heart disease. N Engl J Med 1971; 285: 877–83. Pagani M, Lombardi F, Guzzetti S et al. Power spectral analysis of heart rate and arterial pressure variabilities as a marker of sympathovagal interaction in man and conscious dog. Circ Res 1986; 59: 178–93. Huikuri HV, Niemelä MJ, Ojala S, Rantala A, Ikäheimo MJ, Airaksinen KEJ. Circadian rhythms of frequency domain measures of heart rate variability in healthy subjects and patients with coronary artery disease. Circulation 1994; 90: 121–26. Fauchier L, Babuty D, Cosnay P, Fauchier JP. Prognostic value of heart rate variability for sudden death and major arrhythmic events in patients with idiopathic dilated cardiomyopathy. J Am Coll Cardiol 1999; 33: 1203–07.
THE LANCET • Vol 356 • November 25, 2000
College of Medical Technology, Kyoto University, Kyoto, Japan (Prof M Fujita MD); Cardiology Division, Takeda Hospital (S Miyamoto MD); Department of Systems Science, Graduate School of Informatics, Kyoto University (H Sekiguchi PhD, Prof S Eiho PhD); and Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan (Prof S Sasayama MD)
Health-seeking behaviour of individuals with a cough of more than 3 weeks A Thorson, N P Hoa, N H Long Sex inequalities can lead to poorer access to health care and delays to diagnosis of tuberculosis in women. In a populationbased survey we assessed health-seeking behaviour in adults with long-term cough. The prevalence of cough was 1% (213) and 2% (279) in men and women, respectively. Women took more health-care actions than men, but chose less qualified providers and reported lower health expenditure per visit. Delay before seeking hospital treatment was longer for women (41 days) than men (19 days; p=0·04), and more men (27; 36%) than women (14; 14%; p=0.0006) reported giving a sputum sample at hospital. Sex-sensitive strategies for tuberculosis control are needed and should take into account sex differences in health-care seeking behaviour as well as a possible sex bias among health-care providers.
Worldwide, about two-thirds of all known people with tuberculosis are men.1 Whether this proportion indicates a true difference in frequency between the sexes or an undernotification of female cases is subject to speculation.2 Long’s findings3 indicate that sex inequalities lead to poorer access to health care and delays in diagnosis and treatment of tuberculosis in women. We undertook a population-based survey in Ha Tay province, Vietnam, within the setting of an epidemiological field laboratory. The study group consisted of 34 127 people aged 15 and over (table 1). Household interviews, with a structured questionnaire, identified 492 (1%) individuals, including 213 men and 279 women, as having had a cough for more than 3 weeks anytime during the 3 months before the study (table 1). Among these, 92 (43%) men and 18 (7%) women were smokers. 253 (91%) women and 188 (88%; p=0·05) men reported having taken a health-care action. Additionally, 44 (16%) and 18 (8%; p=0·02) women and men, respectively, reported three or more health-care actions (table 2). Regression analysis, with age, sex, education, and income as independent variables, indicated that being a woman was the only variable associated with an increase in the number of health-care actions taken. About 10% (51) of both men and women with long-term cough did not seek health care at all, indicating a failure of the national health programme to reach parts of the population. Of the types of actions reported by the study group, women used more self-medication than did men, and more often visited private practitioners. More women than men chose less-qualified providers (self-medication, pharmacist, or private practitioner) as the first health-care action (table 2). Convenience and close proximity to home were more commonly reported by women than men as reasons for choosing their particular first action. More men than women visited a hospital, and mean delay
1823
For personal use only. Not to be reproduced without permission of The Lancet.