The proximity between styloid process and internal carotid artery as a possible risk factor for dissection: a case-control study.

PURPOSE: The anatomical proximity of the styloid process (SP) to the ipsilateral internal carotid artery (ICA) has been recently recognized as a possible risk factor for carotid artery dissection (CAD). We aimed to verify this hypothesis by comparing the minimum distance between SP and ICA in young adult patients (< 55 years) with and without CAD. METHODS: Thirty-one CAD patients (cases) were compared with 41 sex-matched patients without dissection, group one of control (G1), and with 16 sex-matched patients with vertebral artery dissection (VAD), group two of control (G2). Two independent observers measured, on CT angiography images, the minimum distance on the axial plane between the SP and ICA in cases and controls. They evaluated both the intercentric and the marginal distance. Differences between groups were estimated by Student t-test. RESULTS: SP-ICA intercentric distance ipsilateral to dissection was significantly shorter compared to that of the contralateral side of cases (p < 0.001), to those of left and right side of G1 patients (p < 0.001 for both), and to those of left and right side of G2 patients (p < 0.001 for both). SP-ICA marginal distance of cases was significantly shorter compared to those of left and right side of G1 patients (p < 0.001 for both) and to those of left and right side of G2 patients (p < 0.001 for both). CONCLUSION: A short SP-ICA distance appears to be a risk factor for CAD as it likely induces a continuous microtraumatism of the vessel wall during normal head and neck movements.

Evaluation of laser fluorescence in monitoring non-cavitated caries lesion progression on smooth surfaces in vitro.

The aim of this study was to evaluate the performance of a pen-type laser fluorescence (LF) device (LFpen: DIAGNOdent pen) to detect and monitor the progression of caries-like lesions on smooth surfaces. Fifty-two bovine enamel blocks were submitted to three different demineralisation cycles for caries-like lesion induction using Streptococcus mutans, Lactobacillus casei and Actinomyces naeslundii. At baseline and after each cycle, the enamel blocks were analysed under Knoop surface micro-hardness (SMH) and an LFpen. One enamel block after each cycle was randomly chosen for Raman spectroscopy analysis. Cross-sectional micro-hardness (CSMH) was performed at different depths (20, 40, 60, 80 and 100 µm) in 26 enamel blocks after the second cycle and 26 enamel blocks after the third cycle. Average values of SMH (± standard deviation (SD)) were 319.3 (± 21.5), 80.5 (± 31.9), 39.8 (± 12.7), and 29.77 (± 10.34) at baseline and after the first, second and third cycles, respectively. Statistical significant difference was found among all periods (p < 0.01). The LFpen values were 4.3 (± 1.5), 7.5 (± 9.4), 7.1 (± 7.1) and 5.10 (± 3.58) at baseline and after the first, second, and third cycles, respectively, among all periods (p < 0.05). The CSMH values after the second and third cycles at 20, 40, 60, 80 and 100 µm were 182.8 (± 69.8), 226.1 (± 79.6), 247.20 (± 69.36), 262.35 (± 66.36) and 268.45 (± 65.49), and for the third cycle were 193.7 (± 73.4), 239.5 (± 81.5), 262.64 (± 82.46), 287.10 (± 78.44) and 284.79 (± 72.63) (n = 24 and 23), respectively. No correlation was observed between the LFpen and SMH values (p > 0.05). One sample of each cycle was characterised through Raman spectroscopy analysis. It can be concluded that LF was effective in detecting the first demineralisation on enamel; however, the method did not show any effect in monitoring lesion progression after three cycles of in vitro demineralisation.

Functional neurological disorder mimicking stroke: A case report.

Even in the era of technology-guided medicine, the clinician must integrate into his daily practice a careful anamnesis and physical examination to be conducted within a close doctor-patient relationship. All these elements, together with tools such as teleconsultation and digitalized medical records, are able to significantly increase the effectiveness of health care action.

Correlates of sexual functioning in Italian menopausal women.

OBJECTIVES: To analyze the sexuality of Italian menopausal women. DESIGN: Cross-sectional study. POPULATION: Menopausal women consecutively observed during the study period in menopause clinics. METHODS: Women were interviewed about their current and premenopausal sexual activity: sexual intercourse frequency and self-rated sexual desire, capacity for orgasm and sexual satisfaction were recorded. Women were defined as having poor sexual functioning if they had one or less sexual intercourses per week or answered 'absent/poor' to the questions about the sexual domains. RESULTS: Oral hormone therapy (HT) use (odds ratio (OR) 0.43 for desire, 0.54 for orgasm and 0.56 for overall sexual satisfaction, all p < 0.001) and transdermal HT (OR 0.38, 0.53 and 0.53, respectively, all p < 0.001) were significantly associated with lower risk of poor sexual functioning. Higher physical and mental component scores (PCS and MCS, range 0-100) of the Short Form-12 are inversely related to poor sexual functioning (OR by point 0.96, 0.95, 0.95 for PCS and 0.96, 0.96 and 0.95, for MCS, respectively, all p < 0.001). Pain during and symptoms after sexual intercourse were significantly related to desire (OR 1.96 and 1.78, respectively), orgasm (OR 2.22 and 2.06, respectively) and sexual satisfaction (OR 2.02 and 1.79, respectively). The partner's health problems were associated with low sexual intercourse frequency (OR 4.18, p < 0.001) and absent/poor overall satisfaction (OR 2.61, p < 0.001). CONCLUSIONS: This study shows that, in menopausal Italian women attending menopause clinics, sexual function is associated with the quality of sexual life in reproductive age, partner's health status, current quality of life, HT and occurrence of pain during and symptoms after sexual intercourse.

[Vaginal intraepithelial neoplasia and human papillomavirus infection: a report of 75 cases]. / La neoplasia intraepiteliale vaginale e l'infezione da virus del papilloma umano. Un resoconto di 75 casi.

AIM: Vaginal intraepithelial neoplasia (VaIN) is an uncommon and poorly understood disease. Risk factors other than human papillomavirus (HPV) infection could be linked to the onset and evolution of some VaIN. METHODS: In this paper, the results achieved from the analysis of 75 patients with VaIN are reported. From these cases, women with HIV, previous hysterectomy, autoimmune diseases and radio- and chemotherapy have been excluded. Thus, most of these selected cases should be linked to the HPV infection. They have been examined after a distinction between grade and association with coilocytosis. VaIN preferential localization, mean age of patients and manifestation pattern after vaginal colposcopy have then been examined. RESULTS: Although the population size cannot allow evidences, it seems that VaIN with coilocytosis and VaIN I without coilocytosis have preferential localization in the upper third of the vagina. It does not appear that mean age of patients for each grade of VaIN differs significativly, both associated and not associated with coilocytosis. Finally, after vaginal colposcopy, the pattern of VaIN for each grade is absolutely not typical, and it seems that white thin epithelium or negative Lugol area are usually the manifestation of high grades of VaIN too. CONCLUSIONS: These results, if confirmed, could mean that VaIN due to HPV may have a different natural history relating to the site of localization in the vagina and, moreover, that also VaIN of high grade could appear with an innocent vaginal pattern.

The unchanging incidence of hospitalization for diabetic nephropathy in a population-based cohort of IDDM patients in Finland.

OBJECTIVE: Finland has the highest documented incidence of childhood IDDM in the world, but the incidence of diabetic nephropathy in Finland is unknown. The aim of the present study was to determine the incidence of hospitalization for diabetic nephropathy in a population-based cohort of Finnish IDDM patients and to analyze the prognostic effect of sex, age at diagnosis, and calendar year of diagnosis of IDDM. RESEARCH DESIGN AND METHODS: We included all Finnish patients who had onset of IDDM before age 18 years, were diagnosed between January 1965 and December 1979 (n = 5,149), and were traced for hospitalizations between January 1970 and the end of December 1989 in the Hospital Discharge Register, using the unique personal identification code given to all Finnish citizens. The development of diabetic nephropathy was defined as the first hospitalization with a diagnosis of nephropathy (International Classification of Diseases-8th Revision [ICD-8] 250.04, or 9th Revision [ICD-9] 2503B/2503X). RESULTS: Among the 5,149 patients included, we identified 446 cases of diabetic nephropathy. The incidence of hospitalization for diabetic nephropathy was very low during the first 8 years of diabetes duration, and after that increased to a maximum of 1.6-2.0% per year. Female subjects developed nephropathy slightly earlier than male subjects, but the cumulative risk was independent of sex. Patients diagnosed at ages 5-14 years had the highest risk of hospitalization for diabetic nephropathy. We observed no effect of calendar year of diagnosis. CONCLUSIONS: We found a 20% cumulative incidence of hospitalization for diabetic nephropathy during a total 24 years of IDDM duration. This finding is compatible with the cumulative incidence of hospitalization for diabetic nephropathy found in other European populations. The incidence of hospitalization for diabetic nephropathy did not decrease during the 20-year observation period.

Lipoprotein(a) and cognitive performances in an elderly white population: Cross-sectional and follow-up data.

BACKGROUND AND PURPOSE: Elevated lipoprotein(a) [Lp(a)] serum levels have been associated with an increased risk of vascular diseases, and preliminary observations suggest that they are a risk factor for vascular dementia. The relationship between Lp(a) levels and cognitive performances in the general population has never been investigated. Our aim was to evaluate the effect of elevated Lp(a) levels on cognitive functions in the elderly. METHODS: Cognitive performances were assessed by means of the Mini-Mental State Examination (MMSE), the Babcock Short Story, and the Matrix Test in a population sample of 435 white subjects aged 65 to 84 years who were evaluated at baseline and after 3 years. Lp(a) levels were determined by ELISA. RESULTS: No statistically significant difference was found in neuropsychological test scores between subjects with and without elevated Lp(a) levels, although subjects with elevated Lp(a) levels had slightly better cognitive performances. This difference reached a statistical significance level only in a subscore of the Matrix Test (number of correct responses) when adjusted for age, sex, education, smoking, and history of stroke. At follow-up, no statistically significant difference was found in cognitive performances between subjects with and without elevated Lp(a) serum levels in either univariate or multivariate analyses. Subjects with and without elevated Lp(a) showed a similar decline rate during follow-up. CONCLUSIONS: In this sample of elderly white subjects, elevated Lp(a) levels were not associated with poorer cognitive performances or with an increased rate of cognitive decline. Elevated Lp(a) levels do not appear to be a major determinant of cognitive impairment in the elderly.

Socioeconomic status and ischemic stroke: The FINMONICA Stroke Register.

BACKGROUND AND PURPOSE: It has been shown that low socioeconomic status is associated with death from stroke. More-detailed data have, however, remained scanty. The purpose of the present study was to examine the association of socioeconomic status with ischemic stroke. Besides mortality, we analyzed the incidence, case-fatality ratio, and prognosis of ischemic stroke events. METHODS: Our population-based study included 6903 first stroke events registered by the FINMONICA Stroke Register in 3 areas of Finland during 1983 to 1992. Indicators of socioeconomic status, such as taxable income and education, were obtained by record linkage of the stroke register data with files of Statistics Finland. RESULTS: Incidence, case-fatality ratio, and mortality rates for ischemic stroke were all inversely related to income. Furthermore, 28 days after the onset of symptoms, a greater proportion of patients with low income than of those with high income was still in institutionalized care and/or in need of help for their activities of daily living. Population-attributable risk of the incidence of first ischemic stroke due to low socioeconomic status was 36% for both sexes. For the death from first ischemic stroke, it was 56% for both sexes. CONCLUSIONS: Persons with low socioeconomic status have considerable excess rates of morbidity and mortality from ischemic stroke in Finland. A reduction in this excess could markedly decrease the burden of ischemic stroke to the society and thus constitute an important public health improvement.

A comparison of the costs and survival of hospital-admitted stroke patients across Europe.

BACKGROUND AND PURPOSE: Policy makers require evidence on the costs and outcomes of different ways of organizing stroke care. This study compared the costs and survival of different ways of providing stroke care. METHODS: Hospitalized stroke patients from 13 European centers were included, with demographic, case-mix, and resource use variables measured for each patient. Unit costs were collected and converted into US dollars using the purchasing power parity (PPP) index. Cox and linear regression analyses were used to compare survival and costs between the centers adjusting for case mix. RESULTS: A total of 1847 patients were included in the study. After case-mix adjustment, the mean predicted costs ranged from $466 [95% CI 181 to 751] in Riga (Latvia) to $8512 [7696 to 9328] in Copenhagen (Denmark), which reflected differences in unit costs, and resource use. The mean length of hospitalization ranged from 8.3 days in Menorca (Spain) to 36.8 days in Turku B (Finland). In the 3 Finnish centers at least 80% of patients were admitted to wards providing organized stroke care, which was not provided at the centers in Almada (Portugal), Menorca, or Riga. Patients in Turku A and Turku B were less likely to die than those in Riga, Warsaw (Poland), or Menorca. The adjusted hazard ratios were 0.18 [0.10 to 0.32] for Turku A, 0.18 [0.10 to 0.32] for Turku B, 0.68 [0.48 to 0.96] for Warsaw, and 0.56 [0.33 to 0.96] for Menorca, all compared with Riga. CONCLUSIONS: The cost of stroke care varies across Europe because of differences in unit costs, and resource use. Further research is needed to assess which ways of organizing stroke care are the most cost-effective.

Associations of orthostatic blood pressure fall in older patients with isolated systolic hypertension. Syst-Eur Investigators.

OBJECTIVES: To investigate the associations of the orthostatic blood pressure changes in older patients with isolated systolic hypertension. METHODS: A total of 2716 patients, 917 men and 1799 women, aged > or = 60 years, were examined at three separate outpatient visits whilst receiving placebo during the single-blind run-in phase of the Syst-Eur trial. The orthostatic blood pressure changes were calculated by subtracting the average of two blood pressure readings with the patient in the supine position from the mean of two readings obtained after the patient had stood for 2 min. An orthostatic blood pressure drop by at least 20 mmHg systolic or 10 mmHg diastolic was considered exaggerated. RESULTS: For the three run-in visits combined, the supine blood pressure was 175 +/- 13 mmHg systolic and 86 +/- 6 mmHg diastolic (means +/- SD). With the patients standing the systolic blood pressure was 5 +/- 12 mmHg lower, whereas the diastolic blood pressure was 2 +/- 7 mmHg higher. An exaggerated fall in systolic blood pressure was observed on at least 1 visit in 21.0% of the patients and on all three visits in 2.5%. The corresponding values for diastolic blood pressure were 9.7 and 0.4%. The orthostatic fall in systolic blood pressure increased with previous antihypertensive treatment, age and smoking, but decreased with a higher sitting pulse rate and usual alcohol consumption versus none. The rise in diastolic blood pressure upon standing was higher in women than in men, was curvilinearly associated with age and increased with the sitting diastolic blood pressure. By multiple logistic regression analysis, the odds of having a persistent or occasional exaggerated orthostatic fall in systolic blood pressure were 22% higher in women than in men. The odds increased with previous antihypertensive treatment (by 42%), age (by 1.4%/year), electrocardiographic left ventricular mass (by 15%/mV) and sitting systolic blood pressure (by 0.9%/mmHg), but decreased with sitting pulse rate (by 1.9%/beat per min). An exaggerated orthostatic fall in diastolic blood pressure was 30% more likely in men; the likelihood increased with age (by 6.4%/year) and decreased with sitting diastolic blood pressure (by 6.6%/mmHg). CONCLUSION: An exaggerated orthostatic blood pressure fall in older patients with isolated systolic hypertension is associated mainly with gender, age and blood pressure level. Previous antihypertensive treatment, a lower pulse rate and a lower electrocardiographic left ventricular mass were also associated with an exaggerated orthostatic fall in systolic blood pressure.

Trends in stroke mortality and incidence in Finland in the 1970s and 1980s.

This article presents trends in stroke mortality and incidence in Finland among people aged 25 to 74 years. Between 1971 and 1980, stroke mortality declined steeply: 4.1% per year among men and 5.5% per year among women. Between 1981 and 1991 the decline was smaller; about 2.2% per year in men and 2.8% per year in women. The North Karelia stroke register showed that stroke mortality declined in men from 155 per 100,000 per year in 1972 to 1973, to 87 per 100,000 per year in 1982 to 1983, and in women from 114 to 44 per 100,000 per year. A slight decline in mortality was observed during the 1980s in men, but not in women. The incidence of stroke also declined in North Karelia during the 1970s, from 328 to 248 per 100,000 per year in men, and from 230 to 141 per 100,000 in women. In the FINMONICA stroke register, the average rate of decline in incidence of stroke between 1983 and 1989 was 1.7% per year in men and 1.8% per year in women. Declines in incidence and mortality from subarachnoid hemorrhage were observed in both men and women; nevertheless it was the decline in cerebral infarction that accounted for most of the changes since about 80% of all strokes are cerebral infarctions. In conclusion, despite steep falls in stroke mortality and incidence in the 1970s, stroke mortality is still high in Finland compared with other nations. During the 1980s, the decline in stroke mortality was less and incidence leveled off until it resumed from 1987 to 1989.(ABSTRACT TRUNCATED AT 250 WORDS)

Declining trends in incidence, case-fatality and mortality of stroke in three geographic areas of Finland during 1983-1989. Results from the FINMONICA stroke register.

Stroke mortality has decreased during the last decade in many industrialized countries, but there has been no clear evidence for a decline in the incidence of stroke. The present study analyzes the trends in the incidence, mortality and case-fatality of stroke in Finland from 1983 to 1989. We used data from the FINMONICA stroke register, a community based register collecting information on all suspected stroke cases aged 25-74 in three geographical areas of Finland. Annual attack rate, incidence, mortality and case-fatality rates were calculated for all strokes and for different subcategories of stroke. A linear regression model was applied to calculate the yearly trends of these rates. In men, the attack rate of stroke was 336/100,000 in 1983 and 310/100,000 in 1989 (-8% during the observation period); incidence declined from 269/100,000 in 1983 to 236/100,000 in 1989 (-12%); mortality declined from 82/100,000 to 64/100,000 (-22%), and case-fatality declined from 25% to 21% (-18%). Also among women similar declining trends were observed (-11%, -13%, -16%, and -10% respectively), but they were not statistically significant. In both incidence and mortality of stroke, the decline was seen in all age groups. Incidence and mortality of cerebral infarction declined similarly to all strokes. A large fall in the incidence (-24% in both men and women) and mortality (-38% in men and -27% in women) of subarachnoid haemorrhage was also observed. An increasing trend, although not significant, was instead observed for cerebral haemorrhage. First stroke and especially first cerebral infarction contributed most to the decline in case-fatality. The availability of computerized brain tomography improved from 18% in 1983 to 60% in 1989. We observed a fall in the incidence, mortality, and case-fatality of stroke during 1983-1989. Among the subtypes of stroke, cerebral infarction contributed most to the decline, but the data suggested also a declining trend in the incidence and mortality of subarachnoid haemorrhage, observed now for the first time in Finland since the 1960s. The fall in the incidence of stroke was not as steep during the 1980s as it was during the 1970s; Finland is anyhow the only European country which has reported a decreasing trend in stroke incidence during the 1980s. We need now to investigate how much the decline in the classical risk factors for stroke observed in Finland during the last two decades predicts the observed trends.

Profile of Female Sexual Function: a patient-based, international, psychometric instrument for the assessment of hypoactive sexual desire in oophorectomized women.

OBJECTIVE: The purpose of this study was to develop a self-administered, patient-based questionnaire to assess loss of sexual desire and associated symptoms in postmenopausal women with hypoactive sexual desire disorder (HSDD) experiencing distress. DESIGN: Preliminary items and domains of sexual function were identified through individual and focus group interviews with postmenopausal women in the United States and Europe. A subset of items was selected for translation and further analysis. Cognitive interviews were conducted with women with HSDD and non-HSDD women in eight countries to ensure items would have the same meaning in seven languages. The resulting instrument was tested in 325 oophorectomized women with HSDD and 255 age-matched nonoophorectomized control women in the United States, Canada, Europe, and Australia. RESULTS: Psychometric item reduction analyses resulted in 37 items organized into seven domains characterizing female sexual function in postmenopausal women with HSDD. Excellent reliability and validity of the domains of the Profile of Female Sexual Function (PFSF) were observed in all geographic areas tested. Statistically significant differences between oophorectomized women with low libido and control women were found for all domains and all geographic areas. CONCLUSIONS: The PFSF is a new instrument specifically designed for measurement of sexual desire in oophorectomized women with low libido. Robust psychometric properties have been established in a large number of geographic regions and languages, making it useful for assessing therapeutic change in multinational clinical trials.

Lipoprotein(a) serum levels and vascular diseases in an older Caucasian population cohort. Italian Longitudinal Study on Aging (ILSA).

OBJECTIVE: To investigate elevated lipoprotein(a) [Lp(a)] levels as a risk factor for stroke, myocardial infarction, angina, intermittent claudication, and combination of the above in a cohort of unselected older individuals. DESIGN: Population cohort from one of the eight centers participating in the Italian Longitudinal Study on Aging (ILSA). SETTING: General community. PARTICIPANTS: A subsample of 446 subjects (M/F: 231/ 215, mean age: 74.5 +/- 5.7 years) of the original, randomly selected, population cohort of 704 individuals, 65 to 84 years of age, free-living or institutionalized in the Impruneta Municipality, area of Florence, Italy. MEASUREMENTS: Conventional vascular risk factors and vascular diseases defined following a two-step procedure (screening phase and confirmation on positives) using standard and validated criteria. Lp(a) levels determined by an ELISA method. RESULTS: No association was observed between elevated Lp(a) levels alone and any of the examined vascular diseases (stroke, myocardial infarction, angina, and intermittent claudication). In contrast, examining the interactions between elevated Lp(a) and conventional vascular risk factors, when elevated Lp(a) was combined with a history of smoking, a marked increase in the risk of vascular diseases combined (odds ratio [OR]: 4.12; 95% confidence interval [CI]: 1.27-13.40) was observed, much higher than that expected based on the additive effect of smoking and elevated Lp(a) alone. CONCLUSIONS: With the cautions due to the cross-sectional design of the study and the limited statistical power, these results suggest a possible synergistic effect between elevated Lp(a) levels and other pro-atherogenic factors such as smoking on the risk of vascular diseases in older individuals.

Atrial fibrillation in older stroke patients: association with recurrence and mortality after first ischemic stroke.

OBJECTIVES: The objective of this study was to determine the association of atrial fibrillation (AF) with stroke recurrence and mortality and with the causes of death in ischemic stroke patients aged 75 years and older. DESIGN: A population-based study. SETTING: The cities of Turku and Kuopio in Finland. PARTICIPANTS: The study cohort consisted of 2635 consecutive patients aged 75 years and older, with a first ischemic stroke, registered in the FINMONICA Stroke Register. MEASUREMENTS: 28-day and 1-year stroke mortality, causes of death, and recurrence of stroke. RESULTS: There were 767 stroke patients with AF (mean age 82.2) and 1868 patients without AF (mean age 81.4). Mortality was higher in the AF group both 28 days (33.9% vs 28.1%, P = .003) and 1 year after the attack (52.7% vs 43.0%, P < .001). The age- and sex-adjusted relative risk of death at 28 days was 1.25 in the AF group (95% confidence interval (CI) 1.04-1.50, P = .018), and at 1 year it was 1.41 (95% CI 1.18-1.67, P < .001). In a Cox proportional hazards model, 1-year mortality risk comparing the AF-group with non-AF group was 1.24 (95% CI 1.10-1.39, P < .001). The strongest risk factor predicting 1-year mortality was recent myocardial infarction (MI) (RR 1.90, 95% CI 1.49-2.42). Myocardial infarction was more often the underlying cause of death in the AF group during the period of 28 days, but not from 28 days up to 1 year. The 1-year recurrence rate among those alive at day 28 was 11.5% in the AF group and 9.4% in the non-AF group (P = .240). CONCLUSION: Recent MI and AF are independent negative prognostic factors in older patients with stroke. Although the relative risk estimates attributable to AF are of the same magnitude in older as in middle-aged stroke patients, the much higher prevalence of AF in the older patients emphasizes its absolute impact on the mortality and recurrence after the first ischemic stroke in the age group 75 years and older. The treatment of coexisting cardiac disease also has the potential to prevent deaths and recurrent stroke events in older persons.

Genetics of stroke--a review.

Evidence from twin and family shows that genetic factors contribute to the risk of stroke and that their role may be at least as important in stroke as in coronary heart disease. Additional support for the significance of genetic factors comes from other findings such as epidemiological data showing phenotypic heterogeneity of stroke, genetic influence on many of the risk factors for stroke, and racial and geographic differences in morbidity and mortality in stroke victims. Yet, apart from the reported associations of a small number of cases with Mendelian cerebrovascular diseases, only a few studies have directly investigated gene markers or molecular genetics of stroke. This review presents the existing evidence on the genetic background of stroke and discusses results from the genetic studies of stroke published to date.

Prevalence and persistency of orthostatic blood pressure fall in older patients with isolated systolic hypertension. Syst-Eur Investigators.

Postural hypotension in older people has been the subject of many studies, but there remains some doubt as to its true prevalence. This study investigated the prevalence and persistency of an exaggerated orthostatic blood pressure (BP) fall in a large group of older patients with isolated systolic hypertension. A total of 2716 patients, 917 men and 1799 women, whose age ranged from 60-100 years, were examined at three separate outpatient visits on a placebo in the single-blind run-in phase of the Syst-Eur Trial. The supine and standing BPs at each visit were the averages of two readings. An exaggerated BP fall was defined as a drop in systolic pressure by at least 20 mm Hg 2 min after assuming the standing from the supine position, or as a drop in the diastolic pressure by at least 10 mm Hg. The reproducibility of orthostatic BP changes was evaluated by the Bland and Altman technique. With the three run-in visits combined, the sitting pressure averaged ( +/- standard deviation) 174 +/- 11 mm Hg systolic and 86 +/- 6 mm Hg diastolic. Systolic pressure fell on average by 5 +/- 12 mm Hg from the supine to the standing position, whereas diastolic pressure increased by 2 +/- 7 mm Hg. The percentage of patients showing an exaggerated orthostatic BP fall was constant at each of the three run-in visits, ie 11-12% for systolic pressure and 4% for diastolic pressure. An exaggerated BP fall at each of the three run-in visits was only present in 3% of the patients for systolic pressure and in 0.4% for diastolic pressure. An exaggerated BP fall at the run-in visits was not associated with dizziness and syncope, which occurred in only 1% of the patients. The orthostatic fall in systolic, but not diastolic pressure, was greater (0.6 mm Hg; P < 0.05) at the second than at the first visit. The repeatability coefficients tended to be higher (60-65%), signifying lower reproducibility, than those for the BP levels (45-55%). An exaggerated fall in systolic or diastolic pressure may occasionally occur in nearly 10% of older patients with isolated systolic hypertension even without antihypertensive drug therapy, but a persistent orthostatic response in only rarely observed.

Therapy in old patients with isolated systolic hypertension: fourth progress report on the Syst-Eur trial.

The Syst-Eur trial is a multicentre, randomized, double-blind, placebo controlled therapeutical trial in patients at least 60 years old and with isolated systolic hypertension. Its scope is to investigate the effects of modern antihypertensive drug treatment on morbidity and mortality and to assess possible adverse effects of the drugs used. Patients were recruited in 22 countries in western and eastern Europe and Israel. At three run-in visits 1 month apart their sitting systolic blood pressure (SBP) on single-blind placebo treatment averaged 180-219 mm Hg with diastolic blood pressure (DBP) lower than 95 mm Hg. After stratification for sex and the presence of cardiovascular complications, the patients were randomized either to active treatment or placebo. Active treatment consisted of nitrendipine (10-40 mg/day) with the possible addition of enalapril (5-20 mg/day) and/or hydrochlorothiazide (12.5-25 mg/day), titrated or combined to reduce the sitting SBP by at least 20 mm Hg to below 150 mm Hg. Matching placebos were employed similarly. The present progress report is based on the data received at the Coordinating Office before 1 March 1996. At that time 3433 subjects had been randomized. A total of 2015 patients had been followed for at least 1 year on double-blind treatment and 1298 patients for at least 2 years. At baseline BP was similar in both treatment groups and averaged 174/86 mm Hg. According to a per-protocol analysis at 1 year, BP fell (P < 0.001) on average by 22.6 +/- 15.7/6.0 +/- 8.0 mm Hg in the active treatment group and by 12.2 +/- 15.9/1.7 +/- 7.3 mm Hg in the placebo group. At 2 years BP was 10.2/5.7 mm Hg lower (P < 0.001) on active treatment than on placebo. At 1 year the percentage of patients who had reached goal BP was 19.9% in the placebo group and 41.4% in the active treatment group. At 2 years these percentages were 20.9 and 43.2 respectively.

The relationship between cholesterol and stroke: implications for antihyperlipidaemic therapy in older patients.

Various studies on the relationship between serum cholesterol level and the risk of stroke have been published recently. Subsequent reviews have extrapolated information on stroke from the clinical trials originally aimed at lowering cholesterol for the primary and secondary prevention of myocardial infarction (MI) in middle-aged patients. We have reviewed the epidemiological knowledge on the relationship between serum cholesterol levels and stroke, and also focused on possible reduction of the risk of stroke with hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor treatment. Possible benefits from such therapy are particularly relevant for the elderly population which is at particularly high risk for stroke. The effects of serum cholesterol levels on the risk for haemorrhagic and ischaemic stroke have been evaluated. Indirect epidemiological evidence indicates that serum levels of total cholesterol and its subfractions are determinants of stroke, but their associations are relatively weak. When exploring the possible association of serum cholesterol levels with the increased risk of stroke with aging, we concluded that, as in younger adults, elevated total cholesterol and decreased high density lipoprotein-cholesterol levels predispose to ischaemic stroke in the elderly. The mechanism through which serum cholesterol levels increase stroke risk is based on its actions on the artery walls. Indirect evidence suggests that the reduction in the stroke risk with HMG-CoA reductase inhibitors is larger than would be expected with reduction of elevated serum cholesterol level alone. Therefore, antioxidant and endothelium-stabilising properties of HMG-CoA reductase inhibitors may contribute in reducing the risk of stroke in recipients. Lowering high serum cholesterol with HMG-CoA reductase inhibitors has been beneficial in the primary and secondary prevention of MI. No trials have specifically tested the effect of cholesterol lowering with HMG-CoA reductase inhibitors on stroke occurrence. High serum cholesterol levels are a risk factor for ischaemic stroke, although the risk imparted is lower than that for MI. Although the relative risk of stroke associated with elevated serum cholesterol levels is only moderate, its population attributable risk is high given the increase in the elderly population worldwide. The effect of cholesterol reduction with HMG-CoA reductase inhibitors on prevention of ischaemic stroke should be evaluated in prospective, randomised, placebo-controlled trials in the elderly. The tolerability of lipid-lowering drugs in the elderly and the cost effectiveness of primary prevention of stroke using lipid-lowering drugs also needs to be assessed in the elderly.

Assessment of the QoL in Italian menopausal women: comparison between HRT users and non-users.

OBJECTIVES: The aim of this cross-sectional study was to describe QoL in a large sample of women attending menopause centres and compare untreated postmenopausal women and matched HRT users by employing the Women's Health Questionnaire (WHQ) and two generic instruments, the SF-36 and the EQ-5D. METHODS: Overall, 2906 women were recruited by 64 menopause centres throughout Italy, of whom 2160 filled in the questionnaire (1093 on HRT and 1067 not on HRT; response rate: 74%). RESULTS: HRT users tended to be younger, healthier and with shorter menopause duration as opposed to non users, while no major socio-economic differences were present. At multivariate analysis, the presence of chronic diseases, low socio-economic status and living in Southern Italy represented the most important predictors of poor QoL. Furthermore, HRT users showed a lower probability of reporting problems in usual activities and pain/discomfort (EQ-5D), role limitations due to emotional problems (SF-36) and anxiety/fears (WHQ). HRT users also showed highly significant better outcomes in those areas that are more directly attributable to hormonal changes of mid age, namely vasomotor symptoms and sexual problems. CONCLUSIONS: Although QoL is mainly influenced by socio-economic and cultural factors, HRT has the potential for improving not only symptoms, but also more general aspects of physical and psychological well-being of symptomatic postmenopausal women.