Adult life experiences and health in early old age in Great Britain

In Britain and other developed countries older people comprise a large majority of all those reporting long term illness or disability. However, most studies of socio-demographic variations in health have focussed on those in younger age groups. Moreover approaches to the study of health variations are often fragmented. In this study we have adopted a life course approach to analyse differentials in health in early old age. The data comes from the Retirement and Retirement Plans Survey and follow-up, a two-wave study of persons aged 55-69 in 1988/9. As well as information on current circumstances, the data set includes occupational, marital, and fertility history information. At baseline a nationally representative sample of the population of Great Britain were interviewed at home by trained interviewers (n = 3543). The sample was followed up and in 1994, 2247 survivors were re-interviewed, a response rate of 70% (of survivors). The data were weighted to adjust for non-response bias. Two outcome measures were used: self rated health and presence or absence of disability assessed from a scale derived from detailed questions on thirteen domains of disability. The severity score used was that developed for the 1985/6 ONS Surveys of Disability. The findings indicate that health and disability status at baseline and at follow up were associated with socioeconomic and geographic variables, such as proportion of adult life spent unemployed and residence outside the Southeast of England; demographic factors, such as early age at marriage and high parity; and experience of adverse events, such as the death of a child and being dismissed from work. The results show that socio-economic, demographic, and geographical and life events' factors are all associated with health status in early old age and that integrated, rather than bifurcated, approaches to the study of health differentials are needed.

Delayed proximal repair and distal realignment after patellar dislocation

Twenty athletes with distal malalignment who sustained unilateral traumatic patellar dislocation remained impaired by chronic instability. Surgery was performed at a mean age of 18 years. Posttraumatic attenuation of the medial patellofemoral ligament was repaired near the margin of the patella in 10 knees and avulsion or attenuation posterior to the vastus medialis obliquus in 10 knees. Advancement of the medial patellomeniscal ligament at the margin of the patella and normalization of the Q angle to 10 degrees by tibial tubercle osteotomy were performed in each knee. Distal lateral retinacular release without release of the normal vastus lateralis tendon was performed. Results were judged according to Turba et al, and activity levels were evaluated per guidelines of the International Knee Documentation Committee. Eighteen (90%) patients achieved good or excellent results and were unimpaired at a minimum of 24 months. Two patients achieved fair subjective results with some impairment in vigorous activity. There was no recurrent instability. Radiographically, the mean preoperative patellofemoral congruence angle improved from 20 degrees to 0 degree. Athletes who sustain an initial traumatic patellar dislocation after physeal closure and in whom conservative management fails can be treated successfully by repair of the medial patellofemoral ligament at the site of disruption and advancement of the medial patellomeniscal ligament combined with correction of an elevated Q angle.

Hip geometry, bone mineral distribution, and bone strength in European men and women: the EPOS study

Hip geometry and bone mineral density (BMD) have been shown previously to relate, independently of each other, to risk of hip fracture. We used Lunar DPX "beta" versions of hip strength analysis (HSA) and hip axis length (HAL) software to analyze scans from ten representative age-stratified population samples in the European Prospective Osteoporosis Study (EPOS). All 1617 subjects were >50 years of age, and 1033 were women. The data were modeled with gender and center as categorical variables. The bone mineral density of the upper half of the femoral neck declined at a faster rate with age than that in the lower half. Femoral neck cross-sectional moment of inertia (CSMI), a measure of resistance to bending, showed no significant age reduction in either gender. However, height and weight effects on CSMI were significantly more beneficial in men than in women (0.002 < p < 0.012) and the weight effect appeared to be mediated by bone mineral content (BMC). Compressive stress (Cstress), defined as the stress in the femoral neck at its weakest cross section arising from a standardized fall, was higher in women. Although Cstress increased with body weight when BMC was held constant, in practice it fell through the association and statistical interaction of rising body weight with rising BMC. HAL, as expected, was strongly positively associated with male gender and also height (p < 0.0001). Hip strength-related indices were markedly center-dependent. Significant differences (p < 0.0001) were noted between the centers for all the variables investigated that related to hip geometry. Adjustment for femoral neck bone mineral content (totBMC) showed these center differences to account for >50% of center variation in hip strength, which remained highly significant (p < 0.0001). We conclude that there are substantial geographical differences in femoral neck geometry as well as in BMD. These geometric variations may contribute to the large variations in hip fracture risk across Europe. The effects of aging on hip strength need to be explored in longitudinal studies.

Use of the atypical antipsychotics Olanzapine and Risperidone in adults with intellectual disability

The present study was designed to monitor the use of atypical antipsychotics in adults with intellectual disability and to evaluate the clinical effectiveness of these drugs. Twenty-one patients were commenced on an atypical antipsychotic: 12 on Olanzapine and nine on Risperidone. The ICD-10 diagnoses of the subjects were mild (13 cases) or moderate (8 cases) mental retardation, and psychiatric disorders (17 cases) with significant impairment of behaviour in 10 cases. Tolerability was good for 15 patients experiencing minimum or no side-effects, and medication was only stopped as a result of side-effects in one case. Clinical global outcome was rated as minimally improved or better for 16 cases. The present findings suggest that the atypical antipsychotics Olanzapine and Risperidone are well tolerated by patients with intellectual disability and psychiatric disorders, and are broadly effective against target symptoms.

Mental health services for people with intellectual disability: a conceptual framework

The present paper discusses the application of the 'matrix model' to mental health services for people with intellectual disability. There is great variability between the service models in this area, which makes comparisons and conclusions difficult. The present model facilitates the breaking down of these complexities into understandable parts so that future directions for research, service planning and delivery can be logical, coherent and evidence-based.

An analysis of concordance among hospital databases and physician records

BACKGROUND

Hospital databases contain vital demographic patient information, which is increasingly being used as a basis to dictate care. It is hypothesized that the validity of data administratively generated from such sources is suboptimal, especially for rare subspecialties. The authors examined three databases to determine their concordance in an academic orthopaedic oncology subspecialty practice.

METHODS

A 2-year retrospective review was performed on three databases searching for seven fundamental variables: additions/deletions; identification number; birthdate; procedure date; admit/discharge date; procedure code; and diagnostic code. Two university-maintained hospital databases (medical records and physician billing) were compared to the surgeon's personal handwritten daily log, which served as the "gold standard."

RESULTS

All seven variables were in agreement with the physician's log in only 60% of the medical records and 61% of the physician billing patient entries (n = 564). On more detailed statistical analysis using chi(2), cross tabulations, and the K statistic for interobserver agreement, it was determined that poor concordance exists among the databases.

CONCLUSION

Surgeons delivering quartenary care should maintain his or her own database because the hospital's information often differs on one or more important variables. Further investigation into the accuracy of hospital databases regarding commonly practiced medical disciplines appears warranted.

Diogenes' syndrome in patients with intellectual disability: 'a rose by any other name'?

Diogenes' syndrome is characterized by marked self-neglect, domestic squalor, social withdrawal and hoarding of rubbish (syllogomania). The syndrome has been reported to occur in association with a wide variety of conditions, but the present authors were unable to find any previous reports of Diogenes' syndrome in patients with intellectual disability.

Cellular immunity and immunotherapy against deoxyribonucleic acid virus-induced tumors

An important role in the immune defense against deoxyribonucleic acid virus induced tumors is mediated by T-cells, as is evident from aetiological, animal model, and clinical data. In this review the most recent observations in this field are described for three prominent members of this family of viruses, namely human papillomavirus associated with human cervical cancer, human adenovirus associated with lung infections in humans and tumors in rodents, and simian virus 40 associated with rodent tumors and human mesothelioma, osteosarcoma and ependymoma.

A new method for the assessment of suturing ability

A new method for the formal assessment of surgical ability in simple wound closure is presented. Suture tension and accuracy of placement are measured indirectly in a standardized rig using Lyofoam as a skin substitute. This method has been used to assess a group of seven junior hospital doctors before and after instruction in a workshop setting. Formal instruction reduced suture tension by an average of 30.3% for the group as a whole (P < 0.01). Standard deviation in inter-suture distance was reduced by an average of 39.4% (P < 0.05), suggesting increased accuracy of suture placement following teaching. On the basis of this study, it appears that those involved in suturing wounds would benefit from postgraduate instruction in workshop setting early in their career.

Directional coronary atherectomy for lesions of the proximal left anterior descending artery: initial clinical results, complications and histopathological findings

BACKGROUND

Directional coronary atherectomy is a percutaneous technique which extends the role of balloon angioplasty to bulky eccentric coronary lesions.

AIMS

To report the early experience, clinical results, complications and histopathological findings of directional coronary atherectomy (DCA) in proximal left anterior descending artery (LAD) stenosis.

METHODS

Study of 25 lesions in 24 patients on whom directional atherectomy was performed on the proximal LAD artery with the Simpson coronary atherectomy device.

RESULTS

Twenty-five procedures were performed on 24 patients with stenosis in the proximal LAD artery. There were 21 males and three females with a mean age of 56.5 years. Sixteen patients presented with stable angina and eight with unstable angina. Eight patients had previous myocardial infarction (MI). Angiographic success was obtained in 24 of 25 lesions (96%). The mean lesion length was 13.1 +/- 3.7 mm and the mean LAD artery diameter was 3.6 +/- 0.5 mm. Minimal luminal diameter improved from 0.9 +/- 0.4 mm to 3.0 +/- 0.5 mm and the percentage diameter stenosis reduced from 75 +/- 12% to 16 +/- 9%. Complications included acute occlusion in one patient, non-Q MI in three patients, local vascular complications in one patient and side-branch loss in one patient. Histology demonstrated fibrous cap of atherosclerotic plaque in 100%, media and internal elastic lamina in 28% and intimal hyperplasia in 100% of restenotic lesions and 27% of native lesions. Restenosis rates in angiographically restudied patients was 27%. The mean minimal luminal diameter at follow-up was 2.3 +/- 0.9 mm and the mean percentage diameter stenosis was 35 +/- 21%.

CONCLUSION

From this initial study, we conclude that DCA is an effective and safe procedure for the treatment of large proximal LAD lesions. DCA provides a large luminal diameter and "smoother' angiographic appearance compared to coronary angioplasty. Acute complication rates are low and restenosis rates were comparable with percutaneous transluminal coronary balloon angioplasty.

Care of the elderly patient following surgery for a fracture of the proximal femur

A short postal questionnaire was sent to all practising orthopaedic surgeons in the United Kingdom, to determine the current pattern of post-operative care for patients with a fracture of the proximal femur, and to determine the current contribution to care being undertaken by geriatricians. This paper presents the responses of 616 orthopaedic surgeons who are actively involved in the care of patients with a fracture of the proximal femur. For the patient who had been partially dependent on family and social services before injury, and thus had most to benefit from an effective rehabilitation, there was a diversity of care on offer. Sixty-three per cent of surgeons stated that this category of patient was routinely cared for on an acute orthopaedic ward; 36% regularly transferred such patients to rehabilitation units, which were geriatric units in 18% of cases, 'second line' orthopaedic beds in 9% of cases and orthogeriatric units in a further 9% of cases. Surgeons who regularly transferred patients to designated rehabilitation units were more satisfied than those whose patient care took place in the environment of the acute orthopaedic ward. Eighty per cent of surgeons were satisfied with orthogeriatric units, and 62% were satisfied with transfer of patients to units supervised by geriatricians. By contrast, only 17% of surgeons were satisfied with a system of care in which geriatricians were available for consultation by written request only. The specialties of orthopaedic surgery and geriatric medicine have a vital role to play in the post-operative care of patients, and a combined effort to address this issue should be made.

Experience with the Gianturco-Roubin stent for abrupt vessel closure complicating percutaneous transluminal coronary angioplasty

BACKGROUND

Emergency coronary artery bypass grafting (CABG) has previously been the only option in the treatment of refractory abrupt vessel closure complicating percutaneous transluminal coronary angioplasty (PTCA), and has been associated with high rates of morbidity and mortality. Intracoronary stenting now provides an alternative to emergency CABG.

AIM

To assess our initial experience with emergency coronary artery stenting as a new technique.

METHODS

Retrospective case study review with clinical and angiographic follow-up.

RESULTS

The Gianturco-Roubin (GR) stent was deployed in 13 patients in whom PTCA was complicated by abrupt vessel closure refractory to standard balloon techniques. Indications for PTCA were unstable angina (six), stable angina (six) and acute myocardial infarction (MI) (one). The arteries stented included left anterior descending (LAD) artery lesions (eight) and right coronary artery lesions (five). Two patients required urgent CABG, one due to failed stent deployment and one for inadequate control of vessel dissection. In seven of the stented patients the creatine kinase rose to greater than twice the upper limit or normal. Three patients had subacute thrombotic occlusion at seven to 19 days post stent deployment, managed with intravenous thrombolysis or repeat PTCA. At seven months follow-up, 11 patients were free of angina, two patients had Canadian Heart Association class II angina and there were no deaths. Eleven patients had repeat angiography at mean six months post stent. Five patients had evidence of restenosis managed with repeat PTCA in four and CABG in one.

CONCLUSIONS

The GR stent is an effective alternative to urgent CABG in the treatment of refractory abrupt vessel closure complicating PTCA.

Percutaneous transluminal coronary angioplasty: clinical and quality of life outcomes one year later

BACKGROUND

The quality of life status of patients prior to and following percutaneous transluminal coronary angioplasty (PTCA) has not been comprehensively investigated.

AIM

This study was carried out to determine the effect that PTCA has on patients' quality of life.

METHODS

Data on 209 patients were collected one day pre-PTCA and at a mean of two and 11 months post-PTCA. Data on symptomatic status, functional capacity, life satisfaction and psychological well-being were analysed quantitatively. Clinical outcomes, patient perception of PTCA and employment status wee analysed by descriptive statistics.

RESULTS

Highly significant improvement in all quality of life measures was found at the early follow-up (p < .001). This improvement was sustained at the late follow-up. At the late follow-up, 58% of patients felt that PTCA had been very beneficial to their health and well-being, and 79% of workers had returned to work. PTCA was primarily successful in 91% of vessels dilated. There were no procedural-related deaths, 12 patients (6%) developed acute occlusion and three patients (1.5%) experienced myocardial infarction (MI). A symptomatic restenosis rate of 16% was found, including 19 patients (9%) requiring repeat PTCA and 14 (7%) undergoing coronary artery bypass grafting (CABG).

CONCLUSION

These findings suggest that, after PTCA, the majority of patients experienced improved quality of life which was sustained one year later.

The prevalence of Trichinella sp. in Arctic foxes (Alopex lagopus) in Svalbard

The prevalence of Trichinella sp. in arctic foxes (Alopex lagopus) from Svalbard was studied from 1983 to 1989. Diaphragms of 697 foxes were examined for larvae; 59 foxes (8.5%) were infected. The prevalence of Trichinella sp. increased from 4% in juveniles to 36% in foxes aged more than 6 years of age. There were no significant correlations when condition and body weight each were correlated to the occurrence and number of larvae of Trichinella sp. More foxes were infected in the northern than in the central part of Svalbard. There were only minor differences in prevalence among years.

Clinical results and quality of life after percutaneous transluminal coronary angioplasty: a preliminary report

To evaluate the effect of percutaneous transluminal coronary angioplasty (PTCA) on quality of life, data on symptomatic status, functional capacity, life satisfaction, and psychological wellness were collected on 102 patients at 1 day pre-PTCA and 2 months post-PTCA, and on the first 50 of these patients at 10 months post-PTCA. There were highly significant changes (p < 0.001) in all quality of life measures between pre-PTCA and the 1st follow-up measurements. No further significant changes occurred in these measures between the 1st and 2nd follow-up measurements, indicating that the initial improvement in quality of life was sustained over this period. Data on primary success rate, complications, and pre- and post-PTCA risk factor scores are also reported.

Necrotizing lesions in the intestine, gizzard, and liver in captive capercaillies (Tetrao urogallus) associated with Clostridium perfringens

During the period from 1982 to 1991, 863 captive and 32 wild capercaillies (Tetrao urogallus) were necropsied. The most common cause of death in captive capercaillies was necrotizing enteritis, diagnosed in 110 (13%) birds. Of these, 31 (28%) birds also had necrotizing lesions in the liver. Necrotizing gastritis occurred in 29 birds, two of which had concurrent necrotizing enteritis. In the capercaillies with necrotizing enteritis, Clostridium perfringens type A was isolated more frequently and in larger numbers than in birds which died from other causes. Thus, Clostridium perfringens type A may be of etiological importance in necrotizing enteritis. Necrotizing enteritis was not diagnosed in wild capercaillies.

Mitotic instability of integrated plasmids in Penicillium chrysogenum transformants

Transformation vectors based on the Streptoalloteichus hindustanus phleomycin-resistance gene placed under the control of either the Penicillium chrysogenum trpC or pcbC promoters were constructed (plasmids pGS1 and pGS7 respectively). Up to 100 transformants per microgram of DNA were obtained with pGS7 in P. chrysogenum strain P2. In order to follow the expression of additional penicillin biosynthetic genes introduced by transformation, a pcbC::lacZ gene fusion was introduced into pGS1, generating pGS6. Southern analysis of three pGS6 transformants indicated that the plasmid was integrated in tandem arrays. Revertants which had lost the exogenous beta-galactosidase activity, were detected for each transformant after several cycles of subculture on non-selective medium. Southern analysis indicated that the different phenotypes obtained resulted from the loss of part or all of the integrated plasmid copies.

Transcript analysis of penicillin genes from Penicillium chrysogenum

The presence of a transcriptional control simultaneously affecting the expression of the three penicillin biosynthetic genes, pcbAB, pcbC, and penDE (pen genes), was demonstrated in Penicillium chrysogenum. Using probes specific to each gene, it was observed that the highest level of expression of the pen genes occurred during exponential growth, in both the original ancestral strain (NRRL1951) and a high-penicillin producing strain P2. Expression also occurred in the presence of high concentrations of glucose, indicating that carbon catabolite repression was not directly involved in the regulation. Transcription of the pen genes appeared to cease as the growth rate decreased. Growth was limited in a fermenter by the rate of oxygen transfer. The phosphoglycerate kinase gene (pgk), used as a control, was strongly induced by the reduced oxygen levels, suggesting a stress-related response. By maintaining optimum growth conditions in fermenters, no induction of the pgk gene was observed whereas expression of the pen genes could be maintained. It was also possible to re-establish expression of the pen genes, after normal cessation, by the addition of cycloheximide to the culture medium.

Cloning and selective overexpression of an alkaline protease-encoding gene from Aspergillus oryzae

The gene alpA encoding Aspergillus oryzae alkaline protease (ALP) was isolated from a genomic library of an industrial strain used in Thailand by using oligodeoxyribonucleotide probes based on the published cDNA sequence [Tatsumi et al., Agric. Biol. Chem. 52 (1988) 1887-1888]. The entire nucleotide sequence of the genomic clone obtained was determined. By comparison with the published cDNA sequence, it was found that ALP is encoded by four exons of 314, 445, 89 and 351 bp. Three introns, which interrupt the coding sequence, are 50, 59 and 56 bp in length. The gene contains a typical TATA box 103 bp upstream from the start codon, and a consensus polyadenylation signal, AATAAA, 189 bp from the stop codon. The alpA gene, introduced into a protease deficient strain (A. oryzae U1638) by cotransformation, directed the secretion of enzymatically active ALP into the culture medium. Cotransformants of the high-level ALP-producing strain U212 containing multiple copies of the alpA gene were able to secrete up to five times more ALP than the parental strain.