The Spanish version of the SF-36 and its recently developed versions is a suitable instrument for use in medical research, as well as in clinical practice.

Objectives: To describe the characteristics, treatment, and outcomes of active infective endocarditis (IE) in Europe. Design: Prospective survey of medical practices in Europe. Setting: 92 centres from 25 countries. Patients: The EHS (Euro heart survey) on valvar heart disease (VHD) enrolled 5001 adult patients between April and July 2001. Of those, 159 had active IE. Results: 118 patients (74%) had native IE and 41 (26%) had prosthetic IE. Mean (SD) age was 57 (16) years. Blood cultures were obtained for 113 patients (71%) before antibiotic treatment was started. Surgery was performed in 52% of patients. Reasons for surgery were heart failure in 60%, persistent sepsis in 40%, vegetation size in 48%, or embolism in 18%. Surgery was for implantation of mechanical prosthesis in 63%, bioprosthesis in 21%, aortic homograft in 5%, and valve repair in 11%. In-hospital mortality was 12.6%, being 10.4% in the medical group and 15.6% in the surgical group. Among the total population of 5001 patients, only 50% of those with native VHD had been educated on endocarditis prophylaxis and only 33% regularly attended dental follow up. Of patients with IE who had had a procedure at risk during the preceding year only 50% had received adequate prophylaxis. Conclusions: The EHS on VHD shows that patients with active IE have a high risk profile and often undergo surgery. However, there are deficiencies in obtaining blood cultures and applying prophylaxis. Mortality remains high, which is a justification for the improvement of patient management through education and the implementation of guidelines.

Use of composite end points as the main outcome in randomised trials can hide wide differences in the individual measures. How should you apply the results to clinical practice? Improvements in medical care over the past two decades have decreased the frequency with which patients with common conditions such as myocardial infarction develop subsequent adverse events. Although welcome for patients, low event rates provide challenges for clinical investigators, who consequently require large sample sizes and long follow up to test the incremental benefits of new treatments. Clinical trialists have responded to these challenges by relying increasingly on composite end points, which capture the number of patients experiencing any one of several adverse events-for example, death, myocardial infarction, or hospital admission. 1 Use of composite end points is usually justified by the assumption that the effect on each of the components will be similar and that patients will attach similar importance to each component. 1 But this is not always the case. In this article we provide a strategy to interpret the results of clinical trials when investigators measure the effect of treatment on an aggregate of end points of varying importance. Example caseConsider a 76 year old man who has disabling angina despite taking blockers, nitrates, aspirin, an angiotensin converting enzyme inhibitor, and a statin. His doctor suggests cardiac catheterisation and possible revascularisation. The patient is reluctant to have invasive management, and wonders how much benefit he might expect from surgery.The trial of invasive versus medical therapy in elderly patients (TIME) is relevant. 2 The study randomised 301 patients aged 75 years or older with resistant angina to optimised drug treatment or cardiac catheterisation and possible revascularisation. Although the groups showed no difference in quality of life at 12 months, the frequency of a composite end point (death, non-fatal myocardial infarction, and hospital admission for acute coronary syndrome) was much lower in the revascularisation group (25.5%) than in the medical management arm (64.2%; hazard ratio 0.31, 95% confidence interval 0.21 to 0.45).Although the overall result suggests invasive treatment would be beneficial, marked differences existed in the absolute reduction in risk across components (table 1). In the invasive group, five more patients died but there were six fewer myocardial infarctions and 78 fewer hospital admissions. How should you interpret these results and inform the patient? Evaluating composite end pointsClinicians can use three questions to help decide whether to base a clinical decision on the effect of treatment on a composite end point or on the component end points (box). We will not expand on statistical issues here, but box A on bmj.com gives a brief outline. Importance of individual components to patientsWhen all components of a composite end point are of equal importance to the patient, it will not be misleading to assume that the effect of the int...

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In our experience, the spectrum of purulent pericarditis has not changed in recent years. Many patients do not have the classical findings of pericarditis, and diagnosis is made only at autopsy or after tamponade has developed. Empyema remains a common predisposing condition. Purulent pericarditis is still a severe disease, but its prognosis is excellent in patients who can be discharged from the hospital.

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Effusive-constrictive pericarditis is an uncommon pericardial syndrome that may be missed in some patients who present with tamponade. Although evolution to persistent constriction is frequent, idiopathic cases may resolve spontaneously. In our opinion, extensive epicardiectomy is the procedure of choice in patients requiring surgery.

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