Environmental risk factors in siblings with Parkinson's disease.

To investigate possible risk factors in Parkinson's disease, we conducted a case-controlled study of 19 families having two or more siblings with Parkinson's disease. Demographic data were collected, including lifetime histories of places of residence; sources of drinking water; occupations, such as farming; and exposure to herbicides and pesticides. Rural living and drinking well water, but not farming and herbicide exposure, were significantly increased in 38 parkinsonians compared with 38 normal control subjects. A comparison of parkinsonian siblings with siblings with essential tremor revealed no differences in any risk factors for the years of shared environment. These data suggest that living in a rural environment and drinking well water are risk factors for Parkinson's disease and that the total life exposure to an environmental toxin may be more important than exposure in early life.

Essential tremor and dystonia.

We reviewed the database of the Dystonia Clinic at the University of Kansas Medical Center for patients with dystonia and tremor. Of 296 patients with idiopathic dystonia, 24 had dystonic tremor, 20 with cervical dystonia had an isolated head-nodding tremor, two patients with writer's cramp had ipsilateral hand tremor, and two patients with generalized dystonia had arm tremor. Eight patients, all with cervical dystonia, had essential tremor that preceded the onset of their dystonia.

Perindopril for elderly people with chronic heart failure: the PEP-CHF study. The PEP investigators.

BACKGROUND: The prevalence of chronic heart failure (CHF) rises with increasing age, from < 1% in those below 65 years of age to > 5% in those over 65 years of age and is a major cause of morbidity and mortality in older people. Recent European guidelines point to a major deficiency in our knowledge of how to treat diastolic chronic heart failure, and a lack of information on treatment for heart failure in the elderly in general. AIMS: The aims of this trial are to assess the potential benefits of the ACE inhibitor perindopril to treat chronic heart failure in elderly people, in the absence of any major left ventricular systolic dysfunction. SUBJECTS: One thousand people over the age of 70 years will be recruited into this study. Evidence of chronic heart failure will be confirmed by clinical criteria and echocardiography. METHODS: Once a diagnosis of chronic heart failure has been confirmed, the patient will receive either perindopril or placebo in addition to their usual treatment. Death, and unplanned heart failure related hospitalisations, are the primary outcomes. Quality of life, as measured by the Guyatt questionnaire will be assessed at the beginning of the study and at 1 year. Sub-studies of this trial include a 6-min walking test and more detailed evaluation of ventricular function (as assessed by echocardiography). Both parameters will be measured at 8 weeks and 1 year, and analysed against baseline data. Cognitive function in this group of patients will also be evaluated at baseline and 1 year. This trial is due to report in the year 2001.

Driving in Alzheimer's disease.

OBJECTIVE: To determine if the impaired mental skills in Alzheimer's Disease (AD) may adversely affect driving ability. DESIGN: Retrospective survey. SETTING: The Alzheimer's Clinic of the University of Kansas Medical Center. PATIENTS: We interviewed 67 AD patients and their families and compared them with 100 elderly, non-spousal controls. MEASURES: The questionnaire was designed to obtain information on their driving habits, with emphasis placed on whether they were still driving, and the number of accidents per year for the past 10 years. RESULTS: Forty-six of the AD subjects had stopped driving because of safety concerns expressed by the subjects, their families, or health care providers, and two had stopped for other reasons. Only two of the normal controls had stopped driving (P < 0.0001, Chi-square test). Over the past 3 years, the 19 AD subjects who were still driving had 263.2 motor vehicle accidents per million vehicle miles of travel compared with 14.3 for the controls (P < 0.002, Mann-Whitney U test) and 5.7 for the general driving population age > or = 55 years (P < 0.05, Students one group, two-tailed t test). CONCLUSION: This study suggests that a significant traffic safety problem exists in subjects with AD who continue to drive. Efforts should be directed to detect patients with AD whose driving presents a traffic safety problem.

The Comorbidity Symptom Scale: a combined disease inventory and assessment of symptom severity.

OBJECTIVES: To develop and evaluate a scale to quantify the presence and severity of symptoms arising from comorbid diseases in older people. DESIGN: A validation cohort study of hospital inpatients and outpatients aged 65 years and older. SETTING: A Hospital and community in Northeast England. PARTICIPANTS: Development of the Comorbidity Symptom Scale-Convenience sample of 50 hospital inpatients and outpatients aged 65 years and older. Evaluation of the Comorbidity Symptom Scale- Convenience sample of 183 patients aged 65 years and older either awaiting cataract surgery or attending a geriatric day hospital. MEASUREMENTS: For development of the Comorbidity Symptom Scale, 22 comorbid conditions were identified and incorporated into a questionnaire (the CmSS). Evaluation of the Comorbidity Symptom Scale-Assessments included the CmSS, activities of daily living, perceived health status, and anxiety and depression. RESULTS: A 23-item scale was developed. Reliability of the CmSS was demonstrated by a test-retest correlation coefficient for the total instrument score of r = 0. 87 (P < .001). The CmSS scores correlated with assessments of activities of daily living, perceived health status, and anxiety and depression. CONCLUSIONS: The CmSS is a simple interviewer-administered tool for use in older people and provides an objective measure of the presence of comorbid disease and the patient's perception of severity of associated symptoms.

Measuring visual symptoms in British cataract patients: the cataract symptom scale.

AIMS: To develop and validate a scale for the measurement of visual symptoms and functional disability due to cataract in older UK residents. METHODS: In depth semistructured interviews were undertaken with 44 consecutive patients awaiting cataract surgery. Patients were asked to describe visual symptoms and problems with social functioning which were then incorporated into a questionnaire, the cataract symptom scale (CSS). The CSS was further examined in a cohort of 118 consecutive cataract patients awaiting surgery. Further assessments in these patients included visual acuity, visual function using an existing scale (the VF-14), activities of daily living, perceived health status, anxiety and depression, and a global assessment of how much patients felt their visual symptoms affected their daily life. RESULTS: A 15 item scale was derived which was simple to administer to older patients and had a high internal consistency. The test-retest correlation coefficient for the total instrument score was r = 0.91 (p<0.0001). The CSS correlated well with the VF-14 and to a lesser extent with visual acuity in the better eye, activities of daily living, perceived health status, anxiety and depression, and the patients' global assessment of visual symptoms. CONCLUSION: The CSS provides information regarding the symptomatic and functional status of older cataract patients resident in the UK which cannot be obtained by measurement of visual acuity alone.

Treatment of post-stroke hypertension. A practical guide.

Cerebrovascular disease is a common cause of morbidity and mortality, especially in the elderly. Treatment of hypertension is effective in the primary prevention of stroke. Hypertension is seen in 80% of acute stroke patients but, by the tenth day after admission to hospital, only one-third are still hypertensive. The clinical significance of post-stroke hypertension is uncertain and its management is a contentious issue. In this article we review current evidence regarding the risks and benefits of the treatment of post-stroke hypertension. The pathophysiology of post-stroke hypertension is described in relation to autoregulation of cerebral blood flow after cerebral infarction or haemorrhage. In the absence of clinical trial data, recommendations for early treatment of post-stroke hypertension are based on a review of expert opinion that immediate, controlled lowering of blood pressure after acute stroke is required only in defined situations such as hypertensive encephalopathy or aortic dissection. There are no reliable data regarding the comparative effects of different hypotensive agents after acute stroke; short-acting vasodilator drugs are recommended if treatment is essential. The benefits of hypotensive therapy in secondary prevention of recurrent stroke are uncertain but the results of large clinical trials in progress should provide helpful guidelines for clinical practice.

Electromyographic guidance of botulinum toxin treatment in cervical dystonia.

We report the results of electromyographic (EMG) guidance in the treatment of cervical dystonia with botulinum toxin. Eight-four patients received a total of 225 injection sessions. Overall there was moderate objective improvement in 78.7%. The mean dose of toxin was 269 +/- 39 mouse lethal units and the mean duration of maximum effect was 107 +/- 49 days. Complications included excessive neck weakness in 16.0% and dysphagia in 11.1% of the injection sessions. We conclude that EMG guidance is a safe and effective method of administering botulinum toxin in the treatment of cervical dystonia.

State-sponsored primary health care in Africa: the recurrent cost of performing miracles.

In this paper the author suggests that the design and execution of ongoing and future primary health care (PHC) interventions in Africa could be improved by more comprehensive and realistic assessments of the recurrent costs of alternative approaches to providing given levels of health care benefits. He develops the distinction between development and recurrent cost elements; distinguishes between marginal and average costs of interventions; identifies elements of social opportunity cost that are frequently overlooked in assessing project costs and shows how their inclusion magnifies the aggregate social cost of interventions featuring recurrent involvement of state agents; suggests that the perception of benefits conveyed by state-sponsored PHC programs to rural populations is limited, especially in relation to the true social costs; and discusses the implications of the above analysis for future PHC strategy.

Diastolic heart failure in older people--myth or lost tribe?

Left ventricular diastolic dysfunction occurs due to a variable combination of abnormal myocardial relaxation and reduced ventricular compliance. The diagnosis of diastolic congestive heart failure is controversial. Some studies suggest that up to one-third of older people with symptomatic congestive heart failure (CHF) have echocardiograph evidence of diastolic dysfunction. Other authors have suggested the comorbid diseases often found in persons with suspected diastolic CHF explain the patient's symptoms and hence diastolic CHF is a misdiagnosis in many cases. Many of the characteristic echo features of diastolic dysfunction occur in normal ageing hearts. Unlike in systolic CHF, evidence for disease modifying treatment is lacking. Clinical trials currently in progress to determine the effectiveness of ACE inhibitors and angiotensin II receptor antagonists in the management of diastolic CHF may clarify the prognosis and management of this condition.

Visual field loss after stroke: confrontation and perimetry in the assessment of recovery.

The purpose of this study was to examine the recovery of visual field deficits after first-ever stroke and to determine the accuracy of standard clinical assessment using oculokinetic perimetry. Of 148 patients with a hemisphere stroke and a normal conscious level, 75 (50.6%) were found to have a visual field deficit by clinical examination. Only 19 (11 women) stroke patients with visual field deficits were able to complete a perimetric examination within 1 week of their stroke. They were followed-up for a period of 12 weeks with serial clinical and perimetric examinations every 4 weeks. Clinical assessment of the patient failed to note further recovery after 4 weeks. By using oculokinetic perimetry, 8 (42.1%) patients recovered central vision but had a persistent peripheral field loss; maximal recovery of central vision was noted in the first 4 weeks. By using oculokinetic perimetry as the gold standard, the sensitivity of clinical assessment of visual field deficits was 94.4% on admission. The sensitivity fell to 55.5% during follow-up because of the clinicians' inability to detect central recovery by confrontation. The small numbers recruited show the difficult in recruiting acute stroke patients in measurements of recovery.

Computerised tomography and stroke.

To evaluate the utilisation of CT diagnostic imaging in patients admitted to hospital with a clinical diagnosis of stroke, and to identify factors which influence the use of CT imaging in stroke. Two hundred and fifty consecutive (155 females) stroke patients were assessed median age 76 years (range 39-95 y). Ninety-seven patients underwent CT scanning; median time to scan from admission was two days (range 0-43). The time to CT scanning was significantly shorter in patients aged < 65 years (p < 0.001), and in patients with a non-disabling stroke (p < 0.05). The factors (odds ratios and 95% confidence limits) significantly associated with CT scanning were male sex (2.21:1.31-3.74); normal Glasgow coma score (2.48:1.59-3.85); Rankin score 1-3 (6.40:1.74-23.56); age < 65 years (10.23:4.49-23.32) and no previous cerebrovascular event (1.97:1.10-3.51). In this study, those patients who would benefit most from medical intervention with antiplatelet agents to reduce the risk of recurrence were more likely to receive CT diagnostic imaging.

Home assessments in geriatrics revisited: an audit of a routine home visiting service.

Routine home visiting is a luxury not afforded to other medical specialties. The practice of routine home assessment visiting in geriatric medicine was evaluated in a prospective study of 110 consecutive referrals to determine whether; the response to general practitioners referrals could be predicted from the information given at the time of referral and; to identify where home visiting identified additional information of value in directing services more appropriately. Requests for admission were accurately predicted in 86-96% of cases by the visiting and a control doctor respectively. Additional information of value in directing services and patient management was gained from the home visit in 30% of admissions, 58% of day hospital cases and 80% of outpatients. It is possible to predict the outcome of home visits although implementation of such predictions without direct communication with general practitioners would result in a small number of unnecessary admissions and referrals to day hospital services.

Systematic review: Helicobacter pylori and the risk of upper gastrointestinal bleeding risk in patients taking aspirin.

BACKGROUND: Aspirin is widely used to modify the risk of recurrent vascular events. It is, however, associated with increased upper gastrointestinal bleeding risk. The influence of Helicobacter pylori on this risk is uncertain. AIM: To determine the influence of H. pylori on upper gastrointestinal bleeding risk in patients taking aspirin. METHODS: MEDLINE and EMBASE databases were searched. All studies providing data regarding H. pylori infection in adults taking aspirin and presenting with upper gastrointestinal bleeding were included. RESULTS: A total of 13 studies that included 1 case-control, 10 cohort studies and 2 randomized-controlled trials (RCTs) were analysed. The case-control study (n = 245) determined H. pylori to be a significant independent risk factor for upper gastrointestinal bleeding. The cohort studies were heterogeneous, varying in inclusion criteria, doses and duration of aspirin used, mode of H. pylori testing and causative GI pathology considered. Comprising 5465 patients, H. pylori infection was tested for in 163 (0.03%) aspirin users with upper gastrointestinal bleeding. The RCTs yielded no significant results. CONCLUSIONS: The current data are not sufficient to allow meta-analyses. The widely held belief that H. pylori is a risk factor for upper gastrointestinal bleeding in regular aspirin users is not supported by the very limited evidence available.