News and Reviews
Diagnosis and management of transient ischaemic attacks (TIAs)A useful review on the diagnosis and treatment of TIAs has recently been published (Cerebrovasc Dis 2005; 20: 220). All its recommendations are based on a critical review of the recent literature followed by a discussion of issues by a multidefinition of a TIA, the diagnosis of the condition and treatment strategies. Of value to clinicians in general, the paper would also be of value to specialists dealing with this extremely perplexing condition.
MR imaging of the cervical spine (CS) in rheumatoid arthritis (RA)
A worrying effect of RA is that it can cause changes to the CS and, in particular, the atlantoaxial joint. There has been a recent study of the problem by applying MR imaging to this site (Clin Exp Rheumatol 2005; 23: 666–70). The technique was applied to 51 patients with RA but no history of a previous neck injury or infection. It defined a high prevalence of general CS involvement, but damage to the atlantoaxial joint or the odontoid process or brain stem compression was rare. Though MR proved a useful tool in investigating the CS, it should probably be reserved for diagnoses that are particularly problematic.
Paediatric pneumococcal serotypes in old age
Given that a pneumococcal infection causes serious problems in children, it was disturbing to note that the organisms may also be found in old people. A team from Atlanta, GA, investigated the records of 2,987 subjects for evidence of infection by ‘paediatric’ serotypes 6B, 9V, 14, 19F or 23F (Clin Infect Dis 2005; 481–7). These were present in 32.5% of those aged between 35 and 49 years and in 51.2% of those aged 85 years or over. For individuals aged 65–74 years, the relative risk of a ‘paediatric’ infection compared with those aged between 35 and 49 was 1.68, while in the group over 85 years, the risk had risen to 2.29.
Infection by the ‘paediatric’ types may relate to immunosuppression in old age. Another suggestion was that many old people had increased contact with children. There is also the more worrying suggestion that antibiotics used in old people have selected out more resistant organisms such as those also affecting children.
Predicting the outcome of patients discharged from a stroke unit
A more accurate means of assessing the outcome of patients discharged from a stroke unit would be of value to patients, relatives and carers in the community. In a recent study, 26 factors that might have affected outcome were evaluated in 338 patients discharged from a stroke unit (Clin Rehabil 2005; 19: 370–5). Those predicting a low outcome included a low Barthel index (BI), poor sitting balance, cognitive impairment and an older age. Willingness of the family to provide support only emerged after multivariant analysis. It remains to be seen how such data can be used to enhance methods already used in making decisions about discharge.
Functional capacity and oral hygiene
A group in Spain has investigated the relationship between functional capacity and oral hygiene amongst people in a residential home for the elderly (Community Dent Oral Epidemiol 2005; 4: 363–9). The scores used were the Barthel Index and activities of daily oral hygiene. There was a strong correlation between the two scores, indicating that patients with severe incapacity were in need of increased oral care.
Vitamin D deficiency and non-traumatic non-vertebral fractures
A paper has returned to the theme of whether vitamin D deficiency is an important cause of fractures of the long bones of elderly patients (Curr Med Res Opin 2005; 21: 1355–61). The study involved a retrospective review of patients aged 50 years or over admitted to hospital with a hip fracture and a prospective review of 50 patients aged 50 years or over with non-traumatic non-vertebral fractures.
Five hundred and forty-eight patients in the retrospective group were aged over 60 years and were not receiving vitamin D supplements. Of these, 92% had 25-hydroxy-vitamin D (25-OHD) levels under 50 nml/l. Many fewer of those in the prospective group had low levels especially those with non-hip fractures.
Concerns about hip fractures in old people and vitamin D deficiency must have first been raised about 50 years ago, and it is disappointing that we seem little further forward in deciding whether or not the risk of the condition could be substantially reduced with vitamin supplements.
Homocysteine levels and Alzheimer’s disease
Several studies have linked high plasma homocysteine levels with mental impairment. The hypothesis is that there is a deficiency of the vitamin cobalmin, a co-enzyme essential for the conversion of homocysteine into methionine. Since the latter is important in brain metabolism, deficiency results in cognitive impairment. The homocysteine not converted into methionine remains in the circulation resulting in increased plasma levels.
There is a recent report that 31% of patients with high levels of homocysteine developed Alzheimer’s disease, whereas 50% of individuals with normal levels also developed the condition (Dementia Ger Gog Dis 2005; 20: 209–14). None of the subjects with low levels developed dementia. The conclusion is that high levels of homocysteine are not associated with dementia but that low levels may protect against the condition. The reader may feel as confused as the patients in question. It seems clear that further studies are required.
Ethnic group and diabetic foot ulcers
In a review of 15,592 type 1 and type 2 diabetic patients, it was found that the prevalence of foot ulcers was 5.5% in Europeans, 1.8% in South Asians and 2.7% in African-Caribbeans (Diabetes Care 2005; 28: 1869–75). The low prevalence in South Asians may be due to them having a lower prevalence of peripheral vascular disease, neuropathy, use of insulin and foot deformity. These merely beg the question of why they should have a lower prevalence of these particular features. There is room for much more work in this field. Are the differences ethnic or environmental?
Patterns of heat-related deaths in different places
A rapid change in the ambient temperature is a well-recognised cause of death amongst vulnerable individuals. Review of mortality records from Dehli, Sao Paulo and London produced some interesting variations in the pattern of heat-related mortality (Epidemiology 2005; 16: 613–20).
When the temperature rose above 20 °C, there was a particularly high mortality within the first 24 h. The mortality was much lower in London over this period. Thereafter, the mortality in Bombay remained high for about 3 weeks and then fell to a level less than that prior to the heat wave. In London, the excess mortality only lasted 2 days after which the mortality fell below the level before the heat wave. The pattern for Sao Paulo lay between those for Dehli and London. The hypothesis is that in India, the change in temperature affects individuals already incapacitated by poverty and malnutrition. This being the case, it is children as well as frail elderly people who are affected.
Rate control versus rhythm control in atrial fibrillation
Atrial fibrillation is a particularly common condition in old age. Researchers recently asked the question as to whether it should be treated by reducing the heart rate or changing the rhythm. Review of five studies involving a total of 5,299 patients with atrial fibrillation followed-up for 1 to 3.5 years suggested that rate control was more effective than rhythm control (Eur Heart J 2005; 26: 2000–6). In particular, it achieved a statistically significant greater reduction in stroke (OR 0.84) and greater, though statistically insignificant, reduction in mortality. There was no difference in the risk of bleeding or of systemic embolism between the treatment strategies.
Vitamin D status of teenage girls and elderly women in Northern Europe
Papers such as this one put into perspective our concerns about vitamin D deficiency in elderly women (Eur J Clin Nutr 2005; 59: 533–4). It concerns the vitamin D status of teenage girls and elderly women in Denmark, Finland, Ireland and Poland. The subjects in question were 199 girls with a mean age of 12.6 years and 221 women with a mean age of 71.8 years. Plasma 25-OHD levels were below 50 nmol/l in 92% of the girls and 37% of the women. Why there should be such a difference remains unclear, but the strong message is that it is not only old people who have nutritional problems. Is this another example of ‘teaching grannies to suck eggs’?
Operative mortality for ruptured aortic aneurysm
One of the most critical emergency operations is repairing a ruptured aortic aneurysm. Surgeons in the Netherlands have reviewed their experience in that country over the last 10 years (Euro J Endocard Surg 2005; 30: 357–64). In 5,593 patients, there was a mortality of 41%. The only determinants of an increased mortality were age and the type of hospital. Gender and the year and season of the operation did not appear to be factors. Given the prohibitive mortality of surgery for the condition, the only way forward may be to improve methods for identifying abdominal aneurysms so that the condition can be treated before it ruptures.
DIOGENES
Contributions to this column should be sent to Professor Bill MacLennan, 26 Caiystane Avenue, Edinburgh EH10 6SG, UK Email: profmaclennan{at}aol.com
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