Vitamin D insufficiency and cognitive impairment in Asians: a multi-ethnic population-based study and meta-analysis.

BACKGROUND: The relationship between vitamin D insufficiency and cognitive impairment remains equivocal in Asians. We examined the association between circulating 25-hydroxyvitamin D (25OHD) concentration and cognitive performance in a large multi-ethnic Singaporean population-based study. We also conducted a meta-analysis of 25OHD concentrations amongst cognitively impaired older adults in Asia. METHODS: Our population-based cross-sectional study included 2273 persons ≥60 years of age from the Singapore Epidemiology of Eye Diseases (SEED) study (mean ± SD age 70.4 ± 6.2 years; 44.7% female), who were categorized according to 25OHD concentration (i.e. ≤10, 10.1-20 and >20 ng mL(-1) ). The 25OHD concentration was measured and adjusted to reflect a deseasonalized value. Cognition was assessed using the total and domain scores of the Abbreviated Mental Test (AMT). Global cognitive impairment was defined as AMT score of ≤6 if 0-6 years of education and AMT score of ≤8 if >7 years of education. Fully adjusted multivariate models were used. We included seven studies in a meta-analysis of 25OHD and cognition in Asia (6068 participants; 1179 cognitively impaired cases). RESULTS: Participants with 25OHD levels >20 ng mL(-1) (n = 1302) had higher AMT total scores (mean ± SD 8.5 ± 1.9) and were less likely to have cognitive impairment (14.1%) than participants with lower 25OHD levels (overall P < 0.001, P-trend < 0.001). Deseasonalized 25OHD concentration was associated with AMT score (ß = 0.10 per 10 ng mL(-1) , P = 0.035). Vitamin D insufficiency (25OHD ≤20 ng mL(-1) ) was associated with global cognitive impairment (OR 1.56, P = 0.028). Specifically, 25OHD concentration correlated with semantic memory (r = 0.08, P = 0.009) and orientation in time (r = 0.09, P = 0.003). In the meta-analysis, the pooled mean 25OHD difference was -6.83 ng mL(-1) (95% confidence interval -11.36; -2.30), indicating lower 25OHD concentrations amongst cognitively impaired compared to cognitively healthy participants in Asia. CONCLUSION: Vitamin D insufficiency is associated with a greater likelihood of and more severe cognitive impairment in Asian populations.

Feedback of personal retinal images appears to have a motivational impact in people with non-proliferative diabetic retinopathy and suboptimal HbA1c: findings of a pilot study.

AIM: To conduct a pilot study to explore the potential impact of visual feedback of personal retinal images on diabetes outcomes. METHODS: Twenty-five participants with non-proliferative diabetic retinopathy and suboptimal HbA(1c) (> 53 mmol/mol; > 7%) were randomized to receive visual feedback of their own retinal images or to a control group. At baseline and 3-month follow-up, HbA(1c), standard measures of beliefs, diabetes-related distress and self-care activities were assessed. RESULTS: In unadjusted models, relative to controls, the intervention group showed significantly greater improvement in HbA(1c) at 3-month follow-up (-0.6% vs. +0.3%, P < 0.01), as well as enhanced motivation to improve blood glucose management (P < 0.05). CONCLUSIONS: This small pilot study provides preliminary evidence that visual feedback of personal retinal images may offer a practical educational strategy for clinicians in eye care services to improve diabetes outcomes in non-target compliant patients. A fully powered randomized controlled trial is required to confirm these findings and determine the optimal use of feedback to produce sustained effects.

Frequency and risk factors of non-retinopathy ocular conditions in people with diabetes: the Singapore Malay Eye Study.

AIM: To investigate the frequency and risk factors of non-retinopathy ocular conditions in persons with diabetes. METHODS: A population-based cross-sectional study of 3176 Malay persons aged between 40 and 79 years in Singapore was conducted. Cataract, glaucoma, refractive errors, age-related macular degeneration, dry eye, epiretinal membrane, ocular hypertension and retinal conditions were assessed based on standardized interviews, clinical examinations and laboratory investigations. RESULTS: A total of 768 participants (24.2%) had diabetes. People with diabetes were more likely to have cortical cataract (52.1 vs. 37.3%, P < 0.001), ocular hypertension (10.9 vs. 7.4%, P = 0.002) and epiretinal membrane (17.2 vs. 10.1%, P < 0.001) compared with those without diabetes. The odds of having cortical cataract (odds ratio 1.63, 95% CI 1.20-2.20) and epiretinal membrane (among those with previous cataract surgery: odds ratio 1.63, 95% CI 1.20-2.20) were significantly higher in people with diabetes compared with those without. The population attributable risks for cortical cataract and epiretinal membrane because of diabetes were 8.7 and 9.0%, respectively. In persons with diabetes, hypertension and high cholesterol were the major risk factors associated with non-retinopathy eye complications such as ocular hypertension (odds ratio 1.18, 95% CI 1.04-1.33) and retinal emboli (odds ratio 1.99, 95% CI 1.05-3.80). CONCLUSION: Our results allow clinicians to better inform patients with diabetes that they are more likely to have cortical cataract and epiretinal membranes (those with previous cataract surgery) in addition to diabetic retinopathy. Two modifiable risk factors-blood pressure and cholesterol associated with ocular hypertension and retinal emboli, respectively-are also risk factors for non-retinopathy ocular conditions in persons with diabetes.

Republished article: The impact of diabetic retinopathy: understanding the patient's perspective.

Understanding the impact of a condition from the patient's perspective is important, and different types of patient-reported outcomes or instruments are available to help with this. This review article summarises the current evidence on the impact of diabetic retinopathy (DR) and its associated vision impairment on patient-reported outcomes. We have included research that has used a range of outcome measures to assess the impact of DR on generic health-related quality of life, utility, vision-functioning and vision-specific quality of life. This review also offers clarification on frequently misused psychometric terminologies to help clinicians and researchers better understand the literature associated with patient-reported outcome research. Overall, the evidence suggests that DR, particularly in its vision-threatening stages, has a substantial, negative impact on the patient. However, our understanding of the impact of DR is currently restricted due to limitations inherent in currently available patient-reported outcome measures. We conclude by discussing potential directions for future research in this area, such as item banking and computer adaptive testing.

Blood pressure control and awareness among patients with diabetes and hypertension attending a tertiary ophthalmic clinic.

AIMS: To assess the proportion of patients who had diabetes and hypertension with optimal blood pressure (BP) control and to describe patients' awareness of the importance of BP control. METHODS: A cross-sectional survey of out-patients with diabetes who attended the Royal Victorian Eye and Ear Hospital (Melbourne, Australia) was conducted between October 2006 and February 2007. Of 245 patients invited, 220 (90%) participated. Optimal BP control was defined as BP < 130/80 mmHg recorded at the latest visit; proportions of patients with awareness of BP control were defined non-exclusively by: (i) ability to recall a previous BP record and rate the appropriateness of that BP level; (ii) ability to recall the recommended optimal BP control level by current diabetes management guidelines; (iii) knowledge that optimal BP control is important to diabetes management; and (iv) knowledge that optimal BP control is important to eye health. RESULTS: Of the 220 patients, 176 had both diabetes and hypertension. Of these, 49 of 176 (28%) had BP controlled optimally, and 30 of 176 (17%) recalled and rated a previous recorded BP level appropriately. Fewer than one in four (22%) acknowledged the recommended optimum BP level of < 130/80 mmHg, fewer than one in two (48%) rated BP as important to diabetes management, and one in three (35%) rated BP control as important to eye health. CONCLUSIONS: In this sample of patients with diabetes and hypertension, fewer than one-third achieved the BP level recommended by clinical guidelines, and fewer than half were aware of the importance of BP control.

Occult dysplasia in a localized giant pseudopolyp in Crohn's colitis: a case report.

Localized giant pseudopolyposis of the colon (pseudopolyp larger than 1.5 cm in size) is a rare complication of inflammatory bowel disease. There is one report of an occult carcinoma within such a lesion, and no reports of sole dysplasia. A case of a 42-year-old man with longstanding Crohn's colitis who underwent a colonoscopy revealing a large, multilobulated mass at the splenic flexure that was not amenable to endoscopic removal, is described. Multiple biopsies showed no dysplasia and histology was consistent with an inflammatory pseudopolyp. Computed tomographic colonography demonstrated a mass resembling a large villous tumour. A decision for surgery was made. The surgical specimen was a complex anastomosing inflammatory pseudopolyp 5 cm x 4 cm x 3 cm in size, with a focus of low-grade dysplasia in an area free of inflammation. The present case is the first reported occult dysplasia in a giant pseudopolyp. Occult dysplasia without superficial dysplasia may exist in these lesions and further studies are needed to examine risk factors that make a giant pseudopolyp more likely to harbour dysplasia and/or carcinoma.

Small vessel disease and intracoronary plaque composition: a single centre cross-sectional observational study.

Cardiac events are commonly triggered by rupture of intracoronary plaque. Many studies have suggested that retinal small vessel abnormalities predict cardiac events. The present study examined retinal microvascular abnormalities associated with intracoronary plaque. This was a single centre cross-sectional observational study of consecutive subjects who underwent coronary angiography and intracoronary optical coherence tomography (OCT) of occlusive coronary artery disease. Subjects' retinal images were deidentified and graded for microvascular retinopathy (Wong and Mitchell classification), and vessel calibre using a semiautomated method based on Knudtson's modification of the Parr Hubbard formula. Control subjects had no significant plaque on angiography. Analysis used the Fisher's exact test or student t-test. Thirty-two subjects with intracoronary plaque including 22 males (79%) had a mean age of 62.6 ± 9.4 years. Twenty-four (86%) had hypertension, 10 (36%) had diabetes, and 21 (75%) were current or former smokers. Their average mean arterial pressure was 90.5 ± 5.8 mm Hg, and mean eGFR was 74 ± 15/min/1.73 m2. On angiography, 23 (82%) had a left anterior descending artery (LAD) stenosis, their mean diseased vessel score was 1.86 ± 1.21, and mean total stent number was 1.04 ± 1.00. Plaque type was mainly (>50%) fibrous (n = 7), lipid (n = 7), calcific (n = 10), or mixed (n = 4). Control subjects had a lower mean diastolic BP (p = 0.01), were less likely to have an LAD stenosis (p < 0.001), a lower mean diseased vessel score (p < 0.001) and fewer stents (p = 0.02). Subjects with plaque were more likely to have a moderate microvascular retinopathy than those with none (p = 0.004). Moderate retinopathy was more common with lipid (p = 0.05) or calcific (p = 0.003) plaque. Individuals with calcific plaque had a larger arteriole calibre (158.4 ± 15.2 µm) than those with no plaque (143.8 ± 10.6 µm, p = 0.02), but calibre was not related to diabetes or smoking. Calibre did not correlate with plaque length, thickness or arc angle. Thus, subjects with intracoronary artery plaque are more likely to have a moderate microvascular retinopathy. Those with calcific plaque have larger retinal arterioles which is consistent with our previous finding of larger vessel calibre in triple coronary artery disease. Retinal microvascular imaging warrants further evaluation in identifying severe coronary artery disease.

Self-management programs for adults with low vision: needs and challenges.

OBJECTIVE: To explore the needs of individuals with low vision in order to inform the contents of a low vision self-management (SM) program and determine potential barriers to participation. METHODS: Semi-structured interviews were conducted with 48 participants with low vision resulting different from eye conditions. Qualitative analysis was conducted in order to identify major themes. RESULTS: All participants described a range of consequences as a result of vision loss including difficulties with functional activities, social interaction and emotional distress. Less than half were interested in attending a SM program. Barriers included practical reasons as well as a perceived lack of need and unclear or negative perceptions of such a program. CONCLUSION: SM programs for low vision are a promising way to help address the range of difficulties experienced by this population if barriers to participation can be overcome. PRACTICE IMPLICATIONS: SM programs should include vision-specific strategies, training in generic problem-solving and goal setting skills and how to cope with emotional reactions to vision impairment. Programs should be delivered and promoted in such a way to enhance access and encourage uptake by those with a range of vision loss in the community.

Impact of age related macular degeneration on quality of life.

AIMS: To describe the impact of age related macular degeneration (AMD) on quality of life and explore the association with vision, health, and demographic variables. METHODS: Adult participants diagnosed with AMD and with impaired vision (visual acuity <6/12) were assessed with the Impact of Vision Impairment (IVI) questionnaire. Participants rated the extent that vision restricted participation in activities affecting quality of life and completed the Short Form General Health Survey (SF-12) and a sociodemographic questionnaire. RESULTS: The mean age of the 106 participants (66% female) was 83.6 years (range 64-98). One quarter had mild vision impairment, (VA<6/12-6/18) and 75% had moderate or severely impaired vision. Participants reported from at least "a little" concern on 23 of the 32 IVI items including reading, emotional health, mobility, and participation in relevant activities. Those with mild and moderate vision impairment were similarly affected but significantly different from those with severe vision loss (p<0.05). Distance vision was associated with IVI scores but not age, sex, or duration of vision loss. CONCLUSION: AMD affects many quality of life related activities and not just those related to reading. Referral to low vision care services should be considered for people with mild vision loss and worse.

The reliability of data collection periods of personal costs associated with vision impairment.

PURPOSE: To determine the reliability of vision-related personal costs collected over 1, 3 and 6 months (extrapolated to 12 months) compared to one-year data. METHODS: Participants of any age, with a presenting visual acuity of < 20/40 in the better eye and an ability to converse in English, were recruited. Monthly cost diaries, in large print and electronic copies with instructions available in audio and Braille, were used prospectively to collect personal costs. The personal expenses were grouped under four categories, namely: (a) medicines, products and equipment, (b) health and community services, (c) informal care and support and (d) other expenses. Sociodemographic and clinical data were also collected. RESULTS: 104 participants (59 females) with a mean age of 64 years completed the 12-months diaries. Almost 40% of the participants had severe visual impairment (< 20/200) in the better eye and the most common cause of vision loss was AMD (n=40; 38%). The mean total personal costs collected from the 12-months diaries were 3,330+/-2,887 AUS dollars. There were no significant differences between the 12-months data and extrapolated 1, 3 and 6-months diaries (t-tests; p=0.17, 0.89 and 0.73, respectively). However, the 1-month variation was substantially larger (SD+/-5,860) compared to the 3-month and 6-month variances (SD+/-3,037 and 3,030, respectively) for total costs. Also, compared to the 12-months diaries, the 1-month data consistently recorded the weakest correlation coefficients for all cost categories compared to the other time intervals. CONCLUSIONS: Given that diary completion can be particularly challenging for individuals with impaired vision, a minimum 3-months data collection period can provide reliable estimates of annual costs associated with vision impairment.

Metastatic carcinoma resulting in hepar lobatum.

Hepar lobatum is an acquired liver deformity mostly known as the end-stage of tertiary syphilis. The authors report two cases of hepar lobatum resulting from metastatic mammary ductal carcinoma in the liver and reassess the clinicopathologic features of seven previously reported cases (two in the German language). A liver of near-normal weight with an irregularly lobulated contour, capsular indentations/crevices from which intersecting (carcinoma-bearing) fibrous septa extended deep into the parenchyma, a predominant centrifugal distribution of lesional areas, and many septa abutting on the degenerated center of tumor nodules were the salient gross features. No significant tumor/fibrous occlusion of intrahepatic branches of portal or hepatic veins, nor cirrhotic type nodular hepatocellular regeneration was observed. Both of these patients experienced a drastic decrease in CEA serum levels during multiagent palliative chemotherapy. In one patient, abundant macrophages in conjunction with minimal residual tumor were present within intrahepatic septa. The pathogenesis of this condition appears largely related to an active phase of chemo-induced tumor regression with subsequent tissue collapse, followed by an organizing phase of healing and scar contraction.

Differences in the neuromuscular capacity and lean muscle tissue in old and older community-dwelling adults.

BACKGROUND: This study investigated whether there was a worsening of the neuromuscular capacity of older adults after the seventh decade of life. METHODS: Fifteen healthy community-dwelling old (< 70 years of age) and 15 older adults (> or = 70 years of age) were assessed for maximal isometric strength (MVC) and force production characteristics, a one-repetition maximum (1-RM) performance, electromyographic (EMG) activity, and bone-free lean tissue (BFLT) mass of the lower extremity. RESULTS: The isometric MVC, 1-RM, and BFLT mass values in the old group were significantly greater than in the older group. In addition, the individual BFLT mass values correlated significantly with the isometric MVC values (r = .85) and the 1-RM scores of the thigh muscle groups (r = .54-.80). The old group generated significantly greater isometric maximal rate of torque development than the older group and performed significantly better at all intervals of the absolute and relative force-time curves. The voluntary muscle activation of the knee extensors of the old group produced significantly higher integrated EMG (iEMG) activity at each epoch in the early iEMG-time curve compared with the old group. CONCLUSIONS: The results suggest that the age-related deterioration in maximal strength measures and rapid force production characteristics in older adults could be related to a reduction in the mass and neural activation of the thigh muscles. The deterioration of the neuromuscular system of community-dwelling older adults may contribute to an increased difficulty in performing daily activities and may increase their risks of tripping and falling.

Diffuse hepatic intravascular carcinomatous embolization resulting in fatal liver failure: a clinicopathologic study of 4 cases.

The authors report four cases in which patients died of acute or fulminant hepatic failure resulting from massive intravascular metastatic carcinomatous embolization, a rarely reported manifestation of metastatic disease. Neoplasms were high grade carcinomas. Tumor emboli were present within portal branches ranging 0.12-2.9 mm in diameter and were free floating or attached to the vascular wall, with or without varying degrees of superimposed organization. In one case, intravascular tumor necrosis was prominent and appeared as granular casts with superimposed dystrophic calcification and/or entrapped foamy histiocytes. There were associated geographical areas of parenchymal (4 cases) and tumor (1 case) ischemic necrosis with a multifocal and regional topographic distribution. An associated predominant pattern of intrasinusoidal tumor infiltration (with or without fibrosis) was present in 3 cases, whereas the fourth case had underlying micronodular cirrhosis, providing ancillary evidence for preexisting altered intrahepatic microcirculation. The literature on fatal hepatic failure resulting from neoplasia is reviewed with a reassessment of its pathobiological significance.

Cholestasis in Crohn's disease: a diagnostic challenge.

A 24-year-old male with Crohn's disease who developed three independent episodes of cholestatic liver disease over an eight-year period is described. The first episode was related to an idiosyncratic drug reaction while on sulfasalazine. The second episode, at the time of an exacerbation of his colitis, was characterized by moderate portal inflammation on liver biopsy and resolved quickly while he was on corticosteroid therapy. The most recent episode, occurring when the bowel disease was quiescent, was due to granulomatous hepatitis and resolved clinically with no specific therapy. Because numerous potentially serious hepatobiliary complications have been associated with inflammatory bowel disease, prompt and aggressive investigation in these instances is recommended.

Helicobacter heilmannii-like spiral bacteria in gastric mucosal biopsies. Prevalence and clinical significance.

BACKGROUND: Gastric Helicobacter pylori (Hp) is highly associated with histological gastritis and peptic ulcer disease, yet Helicobacter heilmannii (Hh, also known as Gastrospirillum hominis) may be a less frequent gastric pathogen about which less is known. PATIENTS AND METHODS: We evaluated 1223 gastric biopsies from 1042 upper endoscopies with biopsies performed over 1 year. Spiral bacteria were specifically sought in biopsies from 912 endoscopies. Clinical and pathologic data from patients with unusual spiral bacteria were tabulated and sera were evaluated for anti-Hp antibodies. RESULTS: The histologic prevalences of Hp and Hh-like bacteria were 59% and 0.5%, respectively, in 912 endoscopies. All four patients with Hh-like spiral bacteria had gastrointestinal symptoms and histologic gastritis. Two had immigrated from the Philippines and one from Belgium. Endoscopic findings and clinical course varied. One improved spontaneously; one improved following antibiotic therapy. One patient's symptoms and bacteria persisted without therapy. One patient coinfected with Hp was treated with apparent clearance of Hh but persistence of Hp. CONCLUSIONS: Helicobacter heilmannii-like bacteria can be distinguished from Hp with routine histologic stains; both bacteria are irregularly distributed. Helicobacter heilmannii appears to be a significant though uncommon cause of gastric inflammation. Some patients with Hh-like bacteria may benefit from anti-Hp therapy.

Lung scintigraphy in pulmonary capillary hemangiomatosis. A rare disorder causing primary pulmonary hypertension.

The authors report the results of lung scintigraphy in two patients with primary pulmonary hypertension caused by pulmonary capillary hemangiomatosis, a rare disorder resulting from the proliferation of histologically normal capillaries in the lung. Perfusion studies revealed a nonhomogeneous pattern with some focal defects, similar to that seen with some other histologic types of primary pulmonary hypertension. The mechanisms underlying this perfusion pattern are unknown.