News and Reviews
Can stress cause dementia?If the brain was a simple machine, it might be reasonable to suggest that overuse induced by stress could cause dementia. This simplistic hypothesis was tested in a group of twins initially assessed in 1967 (Alzheimer's Disease 2007; 3: 205–9). When they were reviewed 30 years later it was found that there was no relationship between measures of occupational stress and dementia. Much more relevant was that dementia was more common in those who initially showed an adverse response to stress. It would appear that there is a common predisposition to a poor tolerance of stress and an increased risk of dementia.
Do calcium supplements prevent fractures?
Since bone rarefaction is associated with fractures and calcium is a major constituent of bone, can calcium supplements reduce the risk of fractures? Meta-analysis of seven trials of calcium supplements in a total of 170,991 women and 1,074 men established that they were of no benefit (Am J Clin Nutr 2007; 86: 1788–9). It may be, of course, that they could be of greater use when administered with other agents.
Deaths in nursing homes referred to coroners
In the USA, less than 1% of deaths are referred to a coroner (Am J Forensic Med Pathology 2007; 28: 292–8). A review of 208 referrals to a US coroner indicated that 58% of cases were accidental, 38.5% were natural, two were murders, two were suicides and three were undetermined. It is clear that the selection of the cases was biased so that it would be all too easy to misinterpret the results. Nonetheless, it seems clear that much more should be done to reduce the risk of accidents. The prevalence of murder seems low, but if this was interpolated to all deaths in nursing homes there would appear to be enough of them to keep Miss Marple in business for many years. ‘Angels of Death’ make the headlines but it often takes a long time for them to be found out.
Hysterectomy and heart disease
The most unexpected factors can be associated with ischaemic heart disease. A review in Finland on women aged 30–99 years evaluated the relationship between previous hysterectomy and ischaemic heart disease (Obs Gyn Scand 2007; 120: 1476–83). Thirty per cent of subjects over 50 years of age had had a hysterectomy, and this was associated with an increased prevalence of hypertension, angina and stroke. Once an adjustment was made for cardiovascular risk factors, any association between hysterectomy and heart disease was lost. It would appear that patients referred for hysterectomy are more likely to have heart disease, but that a common unknown factor is associated with each.
Monitoring skin temperature in diabetic foot ulcers
One of the most serious complications of late-onset diabetes is foot ulceration. There was the suggestion that monitoring and controlling skin temperature could be of benefit in this situation (Am J Med 2007; 120: 1042–6). This was evaluated in 225 patients divided into treatment and control groups. In the former, the skin of the foot was monitored by dermal thermography. A difference between the temperatures of the two feet was more likely to be associated with impending ulcer, and such patients were given more intensive treatment. The efficacy of monitoring was established when it was observed that ulceration occurred in only 4.7% of patients treated in this way compared with 12.2% in controls.
Age-related macular degeneration treated with ranibizumab
The search is on for a drug to arrest vascularisation in senile macular degeneration. One such drug investigated was ranibizumab, an agent blocking retinal vascular endothelial growth (Am J Opthalm 2007; 144: 850–7). It was compared with photodynamic therapy in 423 patients with the condition. Over a period of 1 year, ranibizumab was found to be more effective. It will be interesting to see whether an even longer period of follow up will show a sustained improvement.
Most of us have seen dogs taking older men and women for walks around our streets. The dogs come in all shapes and sizes. There are fat spoiled dogs that have eaten far too many biscuits; ones growing old gracefully like their human companions; and those dragging their companion around on a route march (Am J Pub Health 2008; 98: 66–67). It would appear then, that dogs are of physical as well as psychological benefit to older people. A cross-sectional study of 1,813 humans established that 77% of those with dogs performed adequate physical activity each day, whereas only 57% without dogs achieved this.
A painful knee and bone attrition
Magnetic resonance imaging (MRI) has recently shown that a painful knee is often associated with a flattened or depressed subchondral bone (Am Rheum Dis 2008; 67: 43–7). Around 25% of patients with knee pain had MRI changes compared with 10% without this pain. In patients with osteoarthritis, 74% of those with MRI changes had knee pain compared with 58% without symptoms. Around 39% of patients with knee pain but without arthritis had MRI changes compared with 27% of those without pain. It would appear that there is a tenuous link between MRI changes in the subchondral bone, but I am not sure what this means. It may be that it should be put in Michael Caine's category of ‘Not many people know that’.
Monitoring leg ulcers with digital photography
Reviewing patients with leg ulcers at an outpatient clinic is inconvenient for them and is expensive in terms of transport and accommodation. A recent initiative was for a community nurse to take a digital photograph of the ulcer at the patient's home and have a consultant review this at a convenient time. (Arch Derm 2007; 143: 1511). In a report on the procedure, it emerged that 89% of photographs were of adequate quality for diagnosis and review. Nurses treating the ulcers, and advised by the consultant, achieved reduction in the size of the ulcer in 71% of cases, and of these, there was complete healing of 31%. In another 22%, there was no change in the size of the ulcer. Most nurses expressed satisfaction at the convenience and efficacy of the approach, and it resulted in a 46% reduction in transport costs.
Hyaluronic acid or hylam in osteoarthritis
The only medication regularly used in osteoarthritis is a simple analgesic. Recently, various agents with a possible effect on joint biochemistry have been tried. Two of these have been hyaluronic acid and hylam. Evidence on their efficacy was provided by a blind, multicentre, randomised trial of anti-articular hyaluronic acid, hylam and no treatment in osteoarthritis of the knee (Arth Rheum 2007; 56: 3670–9). The three groups achieved similar levels of pain relief. It would appear then, that hyaluronic acid and hylam are of no value in the treatment of osteoarthritis.
Improvement in the diagnosis and review of prostate cancer
There has recently been an improvement in the laboratory diagnosis and grading of prostatic cancer, but it remains unclear whether this has been of any practical value. An approach to this was to compare the initial histological results on biopsies between 1991 and 1996, and those obtained by a laboratory review of these (BJU 2007; 100: 1240–4). Later review established that 7% of the cases initially diagnosed as carcinoma were non-malignant, and that the recent review provided a much wider range of malignancy scores. These should provide a more accurate diagnosis of malignancy. Its effect on treatment and long-term outcome has still to be established.
Since geriatricians are often expected to be miracle workers it was interesting to see a paper on real medical workers, namely saints accredited by the Church of Rome (Bull Hist Med 2007; 81: 679–729). The reason why a miracle is so important in the career of a potential saint is that one miracle after death is essential to canonisation. About 95% of miracles relate to healing. These should be categorised as being beyond the bounds of nature, should result in a rapid and complete cure, and be clearly demonstrable to witnesses.
Consideration of an individual for sainthood involves the preparation of a case by contacting as many witnesses as appropriate and reviewing all documentation. A doctor is invariably involved in a healing miracle, and if he is sceptical the case is usually closed.
After all this has been done, the Church does not confer sainthood on the candidate. It merely confirms that God has already done so. Supplication to a saint does not always confer protection. A colleague set off on a pilgrimage with a group of children and had to come back early when most of them got chicken pox.
Notes
Contributions to this column should be sent to Bill MacLennan, 21 Crawford Road Burnside, Glassow G73 4DL, UK
Email: profmaclennan{at}sky.com
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