Evaluation of the risk factors of asymptomatic vertebral fractures in postmenopausal women with osteopenia at the femoral neck.

OBJECTIVES: To identify risk factors of asymptomatic vertebral fracture (aVF) in postmenopausal women with osteopenia at the femoral neck and to evaluate the association between the number of aVFs and the risk of major and hip osteoporotic fracture calculated with the FRAX(®) algorithm. STUDY DESIGN: Epidemiological case-series study with data collected transversally. RESULTS: 728 postmenopausal women with osteopenia were included: 284 (39.0%) had aVF, of whom 200 (70.4%) had prior fragility fractures (FF). The likelihood of having an osteoporotic fracture in the next 10 years increased significantly with the number of aVF. The percentage of women with height loss, which was assessed as the difference between the greatest height reported by participants and that measured at inclusion, was higher in women with an aVF (OR 3.77, 95% CI 2.75-5.16, p<0.05). Multivariate analysis showed that prior FF, height loss and race were factors associated with the presence of aVF. CONCLUSIONS: In this group of postmenopausal women with osteopenia at the femoral neck, the presence of an aVF correlated with a higher risk of estimated major osteoporotic and hip fractures as calculated using the FRAX(®) algorithm. Height loss and prior FF were associated with the presence of aVF.

Recomendaciones sobre ranelato de estroncio en el tratamiento de la osteoporosis / Recommendations on strontium ranelate in the treatment of osteoporosis

Actualmente disponemos de diversas intervenciones que pueden reducir la incidencia de fracturas osteoporóticas, como son medidas higiénico-dietéticas, reducir el riesgo de caídas y tratamientos farmacológicos específicos. El ranelato de estroncio es el único fármaco antiosteoporótico con un mecanismo de acción dual, ya que inhibe la resorción a la vez que estimula la formación ósea. Los estudios realizados demuestran su capacidad para mejorar los parámetros de calidad ósea (microarquitectura), aumentar la densidad mineral ósea y reducir el riesgo de fracturas vertebrales y no vertebrales. Ha demostrado eficacia en mujeres osteopénicas y osteoporóticas, tanto con fracturas como sin ellas, y tanto en los primeros años después de la menopausia como en las mujeres mayores. Existen datos de seguridad a 10 años en condiciones reales de administración, demostrando tener un adecuado perfil de seguridad y tolerancia. El ranelato de estroncio, debido a su eficacia, seguridad y años de experiencia, es un tratamiento de primera elección para las mujeres con osteoporosis posmenopáusica y riesgo de fractura (AU)

At present, several interventions are available to reduce the incidence of osteoporotic fractures, such as lifestyle modifications, reducing the risk of falls and specific pharmacological treatments. Strontium ranelate is the only anti-osteoporotic drug with a dual mechanism of action, since it inhibits bone resorption while stimulating bone formation. The studies performed to date have shown the ability of this drug to improve bone quality parameters (microarchitecture), increase bone mineral density and reduce the risk of vertebral and nonvertebral fractures. Strontium ranelate has demonstrated efficacy in osteopenic and osteoporotic women, with or without fractures, in the first few years after menopause and in older women. Safety data are available for 10 years and under real conditions of administration, and demonstrate an adequate safety profile and tolerance. Due to its efficacy, safety and years of use, strontium ranelate is a first choice treatment for women with postmenopausal osteoporosis and fracture risk (AU)

[Darier and Ferrand dermatofibrosarcoma. About 7 cases at the Ouagadougou teaching hospital, Burkina Faso]. / Le dermatofibrosarcome de Darier et Ferrand (DFDF): A propos de 7 cas au CHU de Ouagadougou, Burkina Faso.

The authors report 7 cases of dermatofibrosarcoma of Darier and Ferrand over a 7 year- period at the Yalgado-Ouédraogo teaching hospital, that is to say an average of 1 case per year. A male predominance was noted (4 males and 3 females), average age: 48; 5 recurrences out of 7, with an average delay of 3 years for recurrence, preferentially localised on the trunk (5 cases) and thigh (2 cases). They emphasize the importance of wide surgical exeresis and histopathology essential to confirm the diagnosis. Finally they point out the importance of clinical surveillance because of frequent recurrences.

Prophylactic approach for asymptomatic post-menopausal women: osteoporosis.

To consider what a correct preventive approach for osteoporosis should be in the management of the asymptomatic post-menopausal woman. Literature review and opinions on this issue shared by a group of professionals with wide clinical experience in health care for peri- and post-menopausal women. There is agreement that osteoporosis combines most of the ideal requirements for the application of a preventive strategy. The natural evolution of this pathology leads to serious events, fractures, but it provides various opportunities for prevention. Osteoporosis can be avoided and in particular, fractures due to bone fragility and their consequences should be avoided. Nowadays, there are different courses of action (pharmacological or otherwise) with proven effectiveness for the prevention osteoporosis and osteoporotic fractures. However, long-term action is required for a broad segment of the population, so a certain strategy is necessary to guide clinical decisions for different profiles of women. There is little data in the literature to justify a different preventive approach, depending on the presence or absence of vasomotor symptoms, but clinical experience shows that their absence is not associated with a lower osteoporosis risk. Different strategies have been tried for the prevention of osteoporosis and its complications and some of them might be effective, but there is no analysis with conclusive results. A preventive strategy for osteoporosis should be included in the management of asymptomatic post-menopausal women, because this is an avoidable pathology and the absence of vasomotor symptoms does not reduce the risk of its development. Nevertheless, a well-designed cost-benefit analysis is needed to justify the implementation of any strategy at a community level, because adverse effects and economic cost could exceed the benefits obtained in low fracture risk populations.

A combination of tests for the diagnosis of dementia had a significant diagnostic value.

OBJECTIVE: To study the diagnostic parameters of a number of instruments for a diagnosis of dementia in general practice and the added diagnostic value of these tests. STUDY DESIGN AND SETTING: Cross-sectional diagnostic research in general practice. PARTICIPANTS: 152 persons aged 65 plus. The Mini-Mental State Examination (MMSE), the Clock Drawing Test, the ADMP scale, the Timed Up and Go Test, the Extrapyramidal Sign Scale, the Behavior Observation Scale, the Poon-Baro-Wens computer battery, and the Cognitive Drug Research Computerized Assessment System were evaluated against the Dutch version of the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX-N). Diagnostic characteristics were calculated with their 95% CI. Using forward stepwise logistic regression analysis, a model was built with CAMDEX-N as the dependent variable and the tests under study as independent variables. Area under the curve was the main parameter for the comparisons. RESULTS: The main diagnostic gain results from age and ADMP, followed by the Clock Drawing Test. Subsequent addition of the MMSE and computer tests results in modest additional gain only. The final model including five tests has an area under the curve of 0.95. CONCLUSION: Sophisticated neuropsychological computerized tests have little added value in the diagnostic work-up of dementia in general practice. Basic clinical tests used in an appropriate sequence can be very valuable in establishing the diagnosis of dementia.

Efficacy and safety of a phytoestrogen preparation derived from Glycine max (L.) Merr in climacteric symptomatology: a multicentric, open, prospective and non-randomized trial.

A multicentric, open, prospective, observational and no-randomized clinical trial was carried out in Spain with 190 postmenopausal women receiving a soy preparation rich in isoflavones (PHYTO SOYA, capsules containing 17.5 mg isoflavones). The main object of the present study was to investigate its efficacy in alleviating the symptomatology derived from the lack of estrogen, mainly hot flushes, but also other symptoms such as sleep disorder, anxiety, depression, vaginal dryness, loss of libido and bone pain. Each patient received 35 mg isoflavones per day in two doses. During the four months' treatment, a statistically significant decrease in the number of hot flushes with PHYTO SOYA was experienced by 80.82% women; only 5,48% patients did not improve with the treatment. The average reduction was 47.8%, which is equivalent to 4 hot flushes. All the other studied parameters also showed a statistically significant decrease. No severe side-effects were reported and tolerance was excellent. Treatment with PHYTO SOYA resulted in a significant improvement of the symptomatology that accompanies the lack of estrogen during menopause.

Study on COgnition and Prognosis in the Elderly (SCOPE): baseline characteristics.

The Study on COgnition and Prognosis in the Elderly (SCOPE) is a multi-centre, prospective, randomized, double-blind, parallel-group study. The primary objective of SCOPE is to assess the effect of the angiotensin II type 1 (AT1) receptor blocker, candesartan cilexetil 8-16 mg once daily, on major cardiovascular events in elderly patients (70-89 years of age) with mild hypertension (DBP 90-99 and/or SBP 160-179 mmHg). The secondary objectives of the study are to test the hypothesis that antihypertensive therapy can prevent cognitive decline (as measured by the Mini Mental State Examination, MMSE) and dementia, and to assess the effect of therapy on total mortality, myocardial infarction (MI), stroke, renal function, and hospitalization. A total of 4964 patients from 15 participating countries were recruited during the randomization phase of SCOPE, exceeding the target population of 4000. The mean age of the patients at enrolment was 76 years, the ratio of male to female patients was approximately 1:2, and 52% of patients were already being treated with an antihypertensive agent at enrolment. The majority of patients (88%) were educated to at least primary school level. At randomization, mean sitting blood pressure values were SBP 166 mmHg and DBP 90 mmHg, and the mean MMSE score was 28. Previous cardiovascular disease in the study population included myocardial infarction (4%), stroke (4%) and atrial fibrillation (4%). Men, more often than women, had a history of previous MI, stroke and atrial fibrillation. A greater percentage of men were smokers (13% vs 6% in women) and had attended university (11% vs 3% of women). Of the randomized patients, 21% were 80 years of age. In this age group smoking was less common (4% vs 10% for 70-79-year-olds) and fewer had attended university (4% vs 7% for 70-79-year-olds). The incidence of MI was similar in both age groups. However, stroke and atrial fibrillation had occurred approximately twice as frequently in the older patients. The patients' mean age at baseline was similar in the participating countries, and most countries showed the approximate 1:2 ratio for male to female patients. There was also little inter-country variation in terms of mean SBP, DBP or MMSE score. However, there was considerable regional variation in the percentage of patients on therapy prior to enrolment.

Study on COgnition and Prognosis in the Elderly (SCOPE).

The Study on COgnition and Prognosis in the Elderly (SCOPE) is a multicentre, prospective, randomized, double-blind, parallel-group study designed to compare the effects of candesartan cilexetil and placebo in elderly patients with mild hypertension. The primary objective of the study is to assess the effect of candesartan cilexetil on major cardiovascular events. The secondary objectives of the study are to assess the effect of candesartan cilexetil on cognitive function and on total mortality, cardiovascular mortality, myocardial infarction, stroke, renal function, hospitalization, quality of life and health economics. Male and female patients aged between 70 and 89 years, with a sitting systolic blood pressure (SBP) of 160-179 mmHg and/or diastolic blood pressure (DBP) of 90-99 mmHg, and a Mini-Mental State Examination (MMSE) score of 24 or above, are eligible for the study. The overall target study population is 4000 patients, at least 1000 of whom are also to be assessed for quality of life and health economics data. After an open run-in period lasting 1-3 months, during which patients are assessed for eligibility and those who are already on antihypertensive therapy at enrolment are switched to hydrochlorothiazide 12.5 mg o.d., patients are randomized to receive either candesartan cilexetil 8 mg once daily (o.d.) or matching placebo o.d. At subsequent study visits, if SBP remains >160 mmHg, or has decreased by <10 mmHg since the randomization visit, or DBP is >85 mmHg, study treatment is doubled to candesartan cilexetil 16 mg o.d. or two placebo tablets o.d. Recruitment was completed in January 1999. At that time 4964 patients had been randomized. All randomized patients will be followed for an additional 2 years. If the event rate is lower than anticipated, the follow-up will be prolonged.

From neuronal and vascular impairment to dementia.

This paper reviews aspects of existing knowledge and recent concepts related to the development of vascular dementia which, after Alzheimer's disease, is the most frequent type of dementia. The disorder may result from cerebrovascular disorders, including multi-infarct dementia due to thromboembolic disease, other less common vasculopathies and ischemic brain damage secondary to systemic hypotension. Characteristic clinical features are stepwise cognitive deterioration resulting from repeated strokes and the presence of focal signs and symptoms. The clinical distinction between Alzheimer's disease and vascular dementia may be difficult and strict criteria (NINDS/ AIREN) have recently been adopted as standard guidelines for research studies. Vascular dementia and Alzheimer's disease can co-exist, so-called "mixed dementia", and the presence of cerebrovascular disease may worsen Alzheimer dementia. Indeed, there is often a vascular component in the pathogenesis of dementia. The pathogenesis of vascular dementia is complex. Post-stroke patients are at increased risk; some predisposing or risk factors are the volume, number and site (whether strategic or not) of cerebral injuries, distal field vascular injury with reduced cerebral blood flow, white matter ischemia due to small vessel disease, the co-existence of vascular disease and Alzheimer's dementia, and the presence of cognitive decline prior to stroke. There is increasing evidence of a complex relationship between vascular dementia and Alzheimer's disease. When post-stroke dementia is progressive this may reflect associated Alzheimer's disease either unrecognized or asymptomatic prior to the stroke. The apolipoprotein E4 genotype is a risk factor for ischemic stroke, vascular dementia and Alzheimer dementia. Although dementia is usually irreversible, it is now accepted that cognitive impairment may be delayed, stabilized or sometimes reversed. The treatment of vascular dementia consists of two approaches: preventive measures, including attempts to control risk factors for stroke and the use of antiplatelet agents and/or surgery, and the treatment of cognitive symptoms. Nootropic and vasodilator agents have been reported to improve cognitive impairment from various causes. Ongoing research is attempting to show their specific benefit in vascular dementia.

Correlations between triplet repeat expansion and clinical features in Huntington's disease.

OBJECTIVE: To investigate possible correlations between the length of the (CAG)n trinucleotide repeat in Hungtington's disease gene IT15 and clinical features (age at onset, symptoms at onset, and mode of progression) in Huntington's disease. DESIGN: In 59 patients with Huntington's disease, the expansion of the (CAG)n trinucleotide repeat was determined and clinical data were obtained retrospectively. SETTING: The Center for Human Genetics, affiliated with a university hospital. PATIENTS: All patients belonged to an initial group of 248 individuals tested in an indirect predictive testing procedure. RESULTS: A good correlation was found between the expansion of the (CAG)n trinucleotide repeat and the age at onset (r = -.71). No correlation was found between the repeat length of the normal allele and the age at onset. No correlations were found between repeat expansion and other clinical features, such as the nature of the symptoms at onset (neurologic, psychiatric/cognitive, or both) and the mode of progression. CONCLUSION: Factors that determine the nature of symptoms at onset and the mode of progression of Huntington's disease seem to be operating independently of the (CAG)n trinucleotide repeat in gene IT15.

Sense of coherence, coping and caregiver role overload.

The focus of the present study is to examine the relationship between Antonovsky's Sense of Coherence (SOC), the nature of patient pathology, situational coping responses, and role overload in Belgian primary caregivers to dementing and nondementing chronically ill family members (n = 126). The hypotheses that caregivers with a strong SOC are likely to cope in situationally-appropriate ways were confirmed. Sense of Coherence appears to have a protective effect, in the sense of being related to management of the meaning of the situation, the selection of realistic coping strategies, and the avoidance of potentially maladaptive or unhealthy behaviors. Multi-variate analyses revealed that SOC alone predicted 29% of the variance in role overload for caregivers to dementing patients, while strategies to manage the situation and symptoms of distress were the only significant, yet maladaptive, coping responses for caregivers to nondementing patients. It is arguable that these findings indicate a threshold effect of the nature of patient disability on the protective effects of the sense of coherence. The multi-dimensional impact of caring for a patient with a dementing disorder exerts a unique and particular strain, one that requires caregivers to be able to cope by redefining the meaning of their relationship with their dependent. The theoretical rationale for the hypothesized threshold effect is explored.

How do general practitioners diagnose dementia?

By means of a qualitative study, we set out to generate hypotheses about the way general practitioners (GPs) diagnosed dementia. We looked for triggers for the diagnosis of dementia. Ten GPs were interviewed about four dementia cases taken from their own practices. GPs are more concerned with treatment than with the diagnosis of dementia as such, as diagnosis is performed in relation to treatment. The most important aid was the evolution of the clinical tables based on the information of caregivers. Important triggers were changes of activities of daily life function, behaviour and cognition. Acute illness and loss of the key caregiver were relevatory moments. Recommendations are made for the improvement of the diagnostic abilities of GPs.

The prevalence of dementia in Belgium: a population-based door-to-door survey in a rural community.

The project Epidemiology Research on Dementia in Antwerp (ERDA) estimated the prevalence of dementia in a random, population-based sample, stratified for age and sex. The sample of 1,736 elderly was screened at home with the Mini-Mental State Examination. All elderly under the cutoff of 23-24/30 got a diagnostic examination with the Cambridge Mental Disorders of the Elderly Examination and the DSM-IIIR criteria. The prevalence of dementia in the population above 65 years was estimated at 9%. The following age-specific prevalences of dementia (included mild dementia) were found in the age-groups 65-69, 70-74, 75-79, 80-84, 85+: 0.6, 5.1, 7.6, 16.2 and 33.6%. The prevalence of at least moderate dementia was 0.3, 3.9, 4.0, 11.2 and 25.0%, respectively. The prevalence of dementia, vascular dementia and dementia of the Alzheimer type was markedly higher in women than in men.

Heparan sulfate expression patterns in the amyloid deposits of patients with Alzheimer's and Lewy body type dementia.

Heparan sulfate (HS), along with serum amyloid P component, has been identified in all types of amyloid investigated so far, regardless of the type of amyloid protein deposited. To assess whether unique or specific HS proteoglycans (HSPGs) may be involved in the formation of these lesions, we have investigated the accumulation of several distinct HSPG epitopes in the cerebra of patients with different forms of neurodegenerative disease. A panel composed of several antibodies revealed distinctive patterns of HSPG accumulation. In patients with dementia of the Lewy body type, the burned-out-type plaques and preamyloid-type plaques were strongly stained by both the anti-HS 'chain' and anti-HS 'stub' antibodies, but by none of the available anti-core protein antibodies. In Alzheimer's disease, the preamyloid-type plaques, dense-cored-type plaques, neuritic-type plaques and the neurofibrillary tangles were stained by the anti-'stub' antibody. The anti-'chain' and the anti-core protein antibodies, in contrast, failed to stain the preamyloid-type plaques and burned-out-type plaques, but stained the neuritic-type plaques in these patients. These data suggest differences in the types of HS and HSPG (fragments) that accumulate in amyloid lesions that may hallmark neurodegenerative disorders of different etiologies.

Epidemiology research on dementia in Antwerp, Belgium.

Epidemiological research on dementia in Belgium started in 1990 with a prevalence study. In the first phase of the MMSE was used for screening a random sample, stratified by age, of 1,800 aged people. In the second phase the diagnostic work was done by a psychiatrist using the CAMDEX. An incidence study will start after 2 years. Potential risk factors will be examined in a case-control study.

[Aspects of cognitive functioning in the aged. A transversal study]. / Aspecten van het cognitief functioneren van bejaarden. Een transversaal leeftijdsonderzoek.

In the context of a WHO study on psychosocial needs of the elderly, a sample of 519 subjects from the region of Louvain was psychometrically tested. This sample consisted of men and woman between 55 and 94 years of age, most of them living at home. The test battery was composed of ten verbal and nonverbal tests and tasks currently used in psychogeriatric clinical practice but lacking validation and normative data for those aged populations. This study (psychometric testing took place in 1979-1980) was intended as a first step in a follow up program to gather more definite information about mental deterioration. Up to now it can be considered however as a cross-sectional study, providing normative data for the assessment of cognitive functioning in aged individuals up to 94 years. The decline in performances, found on all these tests, reflect generation as well as aging effects; the increasing proportions of aged subjects failing on the tests however, seem to indicate a high occurrence of partial or global cognitive deficits in elderly people beyond the eighth decade.