A 12-year follow-up study of all-cause and cardiovascular mortality among 10,532 people newly diagnosed with Type 2 diabetes in Tayside, Scotland.

AIMS: To determine absolute and relative risks of all-cause and cardiovascular mortality among patients newly diagnosed with Type 2 diabetes. METHODS: In an observational cohort study using record-linkage databases, based in Tayside, Scotland, UK, we identified newly diagnosed patients with Type 2 diabetes in 1993-2004. We also identified a set of non-diabetic comparators from lists of patients registered with a general practice, individually matched to the diabetic patients by sex, age and deprivation. We followed up patients for mortality and cardiovascular mortality over a 12-year period and calculated hazard ratios using Cox regression. RESULTS: There were 10,532 patients with Type 2 diabetes and 21,056 non-diabetic comparators. Diabetic patients in every age/sex group had higher absolute mortality rates. Even taking deprivation into account, the hazard ratio for mortality was 1.32 (95% CI 1.25-1.40), decreasing to 1.15 (1.09-1.22) after adjusting for pre-existing cardiovascular disease. The hazard ratios for cardiovascular mortality were higher, decreasing from 1.51 (1.37-1.67) to 1.23 (1.11-1.36) after adjusting for pre-existing cardiovascular disease. The hazard ratios decreased with increasing age at diagnosis, although the difference in absolute rate of mortality increased slightly with age. Increased mortality risks were only evident 2 years after diagnosis and increased thereafter. CONCLUSIONS: Patients with Type 2 diabetes have an increased risk of all-cause and cardiovascular mortality compared with non-diabetic comparators, although this is not observable immediately after diagnosis. Age at diagnosis and duration of the disease independently affect absolute and relative mortality risk.

Quantitative data analysis of perceived barriers and motivators to physical activity in stroke survivors.

BACKGROUND: Levels of physical activity after stroke are low, despite multiple health benefits. We explored stroke survivors' perceived barriers, motivators, self-efficacy and intention to physical activity. METHODS: Fifty independently mobile stroke survivors were recruited prior to hospital discharge. Participants rated nine possible motivators and four possible barriers based on the Mutrie Scale, as having 'no influence', 'some influence' or 'a major influence' on physical activity. Participants also rated their self-efficacy and intention to increasing walking. RESULTS: The most common motivator was 'physical activity is good for health' [34 (68%)]. The most common barrier was 'feeling too tired' [24 (48%)]. Intention and self-efficacy were high. Self-efficacy was graded as either 4 or 5 (highly confident) on a five-point scale by [34 (68%)] participants, while 42 (84%) 'strongly agreed' or 'agreed' that they intended to increase their walking. CONCLUSION: Participants felt capable of increasing physical activity but fatigue was often perceived as a barrier to physical activity. This needs to be considered when encouraging stroke survivors to be more active.

Effect of Vitamin K on Vascular Health and Physical Function in Older People with Vascular Disease--A Randomised Controlled Trial.

BACKGROUND AND AIMS: Vitamin K insufficiency is common and linked to an increased risk of cardiovascular disease and osteoporotic fractures. The aim of this study was to examine whether daily supplementation with oral vitamin K could improve vascular health and physical function in older people with established vascular disease. METHODS AND RESULTS: A double blind, randomised, placebo-controlled trial. Participants aged ≤ 70 years with a history of vascular disease were randomised to receive 6 months of daily oral 100mcg vitamin K2 (MK7 subtype) or matching placebo with outcomes measured at 0, 3 and 6 months. The primary outcome was between-group difference in endothelial function assessed using flow-mediated dilatation of the brachial artery at 6 months. Secondary outcomes included carotid-radial pulse wave velocity, augmentation index, blood pressure, carotid intima-media thickness, C-reactive protein, B-type natriuretic peptide, cholesterol and desphospho-uncarboxylated matrix Gla protein levels. Handgrip strength and the Short Physical Performance Battery assessed physical function, while postural sway was measured using a 3-dimensional force platform. RESULTS: 80 participants were randomised, mean age 77 (SD 5) years; 44/80 were male. Vitamin K levels rose in the intervention arm compared to placebo (+48 pg/ml vs -6 pg/ml, p=0.03) at 6 months. Desphospho-uncarboxylated Matrix Gla protein levels fell in the intervention group compared to placebo at 6 months (-130 [SD 117] pmol/L vs +13 [SD 180] pmol/L, p<0.001). No change was seen in endothelial function (between group difference -0.3% [95%CI -1.3 to 0.8], p=0.62). A modest, non-significant improvement in pulse wave velocity was seen in the vitamin K group (-0.8m/s [95%CI -1.8 to 0.3], p=0.15) while all other vascular and physical function outcomes unchanged. CONCLUSIONS: Six months of vitamin K2 supplementation did not improve markers of vascular health or physical function in older patients with vascular disease.

A cost-effectiveness study of the management of intractable urinary incontinence by urinary catheterisation or incontinence pads.

STUDY OBJECTIVE: The aim was to compare the costs and effects of management of intractable urinary incontinence by urinary catheterisation or incontinence pads. DESIGN: This was a prospective, randomised study comparing catheterisation with pads, supplemented by additional data collected from patients with chronic indwelling catheters. Main outcome measures were costs of equipment, nursing time, patient preference, nursing preference, and clinical and bacteriological assessment of urinary infection. SUBJECTS: 78 intractably incontinent elderly female patients were randomly allocated to management by urinary catheter or pads and toileting. Supplementary data on equipment costs and nursing time were collected from 27 patients, of whom 22 were already catheterised at the time of the randomisation and five were catheterised by the nursing staff after the last date for entry into the randomisation. MAIN RESULTS: Of the 38 patients randomised to catheterisation, 14 refused consent so only 24 were catheterised on day 1 of the study. There was a rapid removal of catheters, especially in the first six weeks of the study and only four of the randomised catheter patients completed the full 26 weeks of the study. However, eight of the pads patients were catheterised between the 7th and 22nd week because of deteriorating general condition and all retained their catheters for the remainder of the study period. Of 35 patients who had experienced catheters and pads, 12 expressed a clear preference for catheters, 12 for pads, and 11 were undecided. Nurses were in favour of the use of pads, mainly because of concerns about urinary infection with catheters. Comparing costs for patients managed with catheters (532 patient weeks) or pads (903 patient weeks), catheter patients required less nursing time (15.4 v 29.0 h per patient per week) but equipment costs were higher (19.20-24.65 pounds v 8.79-11.35 pounds per patient per week), mainly because of the cost of catheter care (12.75 pounds per patient per week). Asymptomatic bacteriuria was prevalent in both groups but 73% of catheterised patients received treatment for clinical signs of infection compared with 40% of pads patients. Only 30% of patients who were treated had any generalised symptoms of infection. CONCLUSIONS: Use of catheters reduces nursing time but may increase weekly equipment costs depending on the cost of laundry. Despite the high dropout rate among patients randomised to catheters a minority of patients (12/35) expressed a clear preference for catheters and we believe that more patients with intractable incontinence should be given a trial of catheterisation to assess acceptability. Bacteriuria was prevalent in pads or catheter patients but no major episodes of invasive infection were noted in either group.

Evaluation of peripheral dual energy X-ray absorptiometry: comparison with single photon absorptiometry of the forearm and dual energy X-ray absorptiometry of the spine or femur.

An evaluation of the Osteoscan peripheral dual energy X-ray absorptiometer (pDXA) was carried out to compare its performance with those of a single photon absorptiometer (SPA) (Molsgaard Medical ND1100A) and a dual energy X-ray absorptiometer (DXA) (Lunar DPX alpha) of the spine or femur. In 57 patients, correlation between bone mineral content (BMC) of the forearm at the ultradistal (UD) site by pDXA and by SPA was high (r = 0.94). Comparisons were also made with spine and femur bone mineral density (BMD) DXA measurements. The correlation of z-scores of UD BMD with z-scores for lumbar spine L2-L4 was r = 0.63 (n = 73 patients); and with z-scores for neck of femur was r = 0.72 (n = 33). With the Osteoscan the measurement error coefficient of variation in vivo was 2.6% for BMC, 1.8% for BMD at the ultradistal site; 2.1% for BMC and 1.9% for BMD at the mid-distal site. Repeat measurements were made of the European forearm phantom; precision for SPA was slightly better than either pDXA or Lunar DXA. The Osteoscan has the potential for a rapid throughput of patients and is not affected by calcification and degenerative changes that can corrupt DXA measurements on the anteroposterior spine in older women.

The value of HMPAO SPECT scanning in the diagnosis of early Alzheimer's disease in patients attending a memory clinic.

The value of hexamethylpropyleneamine oxime (HMPAO) single photon emission computed tomography (SPECT) as a diagnostic test for Alzheimer's disease (AD) was assessed in 44 patients attending a Memory Clinic. A comprehensive physical and psychiatric examination and detailed neuropsychological tests were used to arrive at a clinical diagnosis, in accordance with NINCDS-ADRDA criteria. The mean patient age was 69 (range 59-84) years, and the mean score on the Mini-Mental State Examination (MMSE) was 24 (range 7-30). Of 26 patients with a clinical diagnosis of AD, only 15 demonstrated a scan pattern strongly suggestive of AD. Four scans were normal, four showed evidence of ischaemic change and three were in the category 'other', one of which showed bilateral frontal hypoperfusion, but normal temporoparietal flow. Of the eight patients considered by clinical criteria to be non-demented, no scan showed an AD pattern, but three showed an ischaemic pattern. Both of the patients diagnosed clinically as suffering from multi-infarct dementia showed SPECT scan evidence of ischaemic change. Of the remaining eight patients with other clinical diagnoses only one scan suggested AD. We conclude that the HMPAO SPECT scan appearances which arise from AD in the early stages of the disease do not on their own allow the disease to be accurately diagnosed, but they may be useful if interpreted in conjunction with other imaging techniques.

Nutritional supplementation in older adults: pleasantness, preference and selection of sip-feeds.

OBJECTIVES: Malnourishment is common in older adults, and nutritional supplementation is used to improve body weight and well-being. Clinical reports suggest, however, that patients routinely reject sip-feeds. The present study examined the following questions: whether sip-feeds are less preferred and less likely to be selected than other energy-dense foods in healthy elders; and whether eating alone further reduces intake relative to eating in a social setting. METHODS: Twenty-one healthy older adults (aged 60-79 years) attended the laboratory on three occasions. Subjects rated six different flavours of sip-feed and then rated the pleasantness of the taste of the favoured flavour against five other energy-dense familiar foods/drinks. Intake of these foods was measured when subjects ate alone or in a group of familiar others. RESULTS: Favourite flavour of sip-feed compared well with other more familiar foods and was selected as part of a snack. Snack intake increased by 60% when consumed in a group setting compared with eating alone. CONCLUSIONS: The study suggests that sip-feeds are rated as pleasant and selected by free-living elders. Rejection of sip-feeds in hospitalized elders may relate more to loss of appetite than to the taste preference for sip-feeds, and that eating alone rather than in groups of familiar others is likely to compound eating problems.

The effects of once-daily dosing with ranitidine and cimetidine on theophylline pharmacokinetics.

Twelve healthy non-smokers (7M and 5F) completed a balanced three-way crossover investigation designed to characterise the influence of oral cimetidine (800 mg), ranitidine (300 mg) and placebo pretreatment for 7 days on the pharmacokinetics of a 250 mg single oral dose of theophylline. The oral clearance of theophylline after ranitidine pretreatment, 4.55 +/- 1.69 l/h (mean +/- SD) was indistinguishable from that after placebo, 4.78 +/- 1.96 l/h, but cimetidine was associated with a significant 21% reduction in theophylline clearance, 3.58 +/- 1.07 l/h (P = 0.006). There was a correspondingly significant increase in the terminal half-life of theophylline following cimetidine, 6.11 +/- 1.29 h (P = 0.017), compared with 5.05 +/- 1.43 h and 4.88 +/- 1.45 h for placebo and ranitidine, respectively. There was no change in maximum theophylline concentration or time to maximum but following cimetidine the plasma theophylline levels between 4 and 12 hours were 15-50% higher than following placebo (P less than 0.002). These data indicate a significant interaction between 800 mg cimetidine given once daily and theophylline which is likely to be the result of enzyme inhibition. Once-daily dosing with 300 mg ranitidine had no significant effect on theophylline pharmacokinetics.

Physical activity and health in old age.

Regular physical activity is an important component of a healthy life at all ages, and mounting scientific evidence has linked exercise to a wide array of physical and mental health benefits. This article will highlight some recent advances in knowledge. It will explore common myths that discourage the largely sedentary older population of the UK from changing their exercise habits.

Benign monoclonal gammopathy in the elderly--a prevalence study and review.

Monoclonal gammopathy of uncertain significance (MGUS) may present the clinician with diagnostic difficulties. This paper reviews the literature relating to MGUS, presents findings of a local prevalence study, and provides advice on monitoring.

Closing the loop in an audit of urinary incontinence.

Urinary incontinence (UI) fulfils the criteria for an indicator condition of quality of care. A records review audit in 1992 indicated that the minimum standards for history taking, physical examination and investigation of UI were not being met, so this was repeated in 1993 after full discussion with staff. 40% of the 368 patients studied met the definition of UI. In Assessment and Rehabilitation wards 57% met the standard for history (60% in the previous audit), 24% for examination (50% previously), and 86% for investigation (100% previously). As previously results were worse on Continuing Care wards, where minimum standards were being met in only 17% for history, 14% for examination and 47% for investigation. However, management planning had improved with care plans for 71% of incontinent patients in Assessment and Rehabilitation wards and 97% in Continuing Care wards. Our repeat audit has highlighted the difficulties inherent in encouraging health professionals to alter practice to correct apparent deficiencies.

Rediscovering the joy of food: the need for long-term review of swallowing ability in stroke patients.

Stroke is commonly associated with dysphagia, which may necessitate the use of enteral feeding best provided by a percutaneous endoscopic gastrostomy (PEG) tube. Resolution of dysphagia complicating stroke is observed in the days, weeks and months following the event. This may allow the resumption of a normal diet, and cessation of enteral feeding. However at the time dysphagia resolves many patients--with enteral feeding still in place--will have been discharged from facilities where expert speech and language therapy is available to assess recovery of swallow. We report three cases of patients with dysphagia following stroke who benefited from long term review of swallowing ability. We then discuss the benefits of such follow-up, and how it might best be achieved in the community.

Preferences for different high-energy foods in elderly medical in-patients.

Malnourishment is a common finding in hospitalised elderly patients. It is often addressed by the provision of nutritional supplements, in the form of sip-feeds. Patients' intake of these is frequently inadequate. We assessed the palatability of sip-feed nutritional supplements and other high-energy foods to elderly medical in-patients. Using the Lickhert Scale, 49 subjects rated the taste of a previously selected sip-feed supplement and five other high-energy foods, cheese biscuit, plain potato crisps, chocolate, cherry-flavoured cereal bar and stout beer. Subjects rated the taste of sip-feeds as favourably as all other offered foods, with the exception of the lower rated stout beer (p = 0.0001). Taste alone is unlikely to account for the poor intake of sip-feed nutritional supplements by elderly hospital patients.