Prescribing for older people

Approach must be co-ordinated Prescribing by nurses rose by 50 per cent in 2007 ( Information Centre 2008 ). In the UK, those aged over 60 receive 60 per cent of dispensed prescriptions and account for more than half of NHS drug costs ( Information Centre 2008, Milton et al 2008 ). Polypharmacy is common in older people with almost one fifth of those over 70 taking five or more drugs ( Milton et al 2008 ) and care home residents taking an average of eight medications ( Bowker et al 2006 ). Polypharmacy increases the risk of adverse drug reactions, interactions, falls, hospital admissions and readmissions ( Campbell et al 2004, Milton et al 2008 ). This increases the financial burden on the NHS. Inappropriate prescribing in the older population is a major public health issue.

Spectrum of Haemoglobinopathies in a Tertiary Care Hospital of Armed Forces

BACKGROUND

Thalassaemia and other structural haemoglobinopathies are the major genetic disorders prevalent in certain parts of the world including India. This study presents the pattern of haemoglobinopathies amongst the referred patients of anaemia in a two-year period.

METHODS

A total of 1032 patients were studied during a two-year period for anaemia investigation. Haematological indices, sickling test and haemoglobin electrophoresis with quantification of the bands was done in all cases.

RESULT

Out of 1032 cases, 774 (75%) were normal and 258 (25%) cases had abnormal haemoglobin pattern. Of the 258 abnormal cases, 136 (53%) were males and 122 (47%) were females. Of all cases of anaemia 370 (36%) were microcytic hypochromic, 237 (23%) macrocytic, 151 (15%) were dimorphic and the rest (26%) had normocytic normochromic picture. 82% of microcytic hypochromic anaemias had reduced serum iron and elevated total iron binding capacity (TIBC), whereas 85% had decreased serum ferritin levels. Spectrum of haemoglobinopathies prevalent were β-Thalassemia trait (17%), followed by sickle cell trait (2.3%). Other haemoglobinopathies in descending order of frequency were sickle cell disease (1.7%), Hb D trait (1%), Hb E trait (0.8%), sickle cell - β thalassemia, Hb E disease, E - β thalassemia (0.6% each) and thalassemia major (0.4%).

CONCLUSION

This study provides a comprehensive database on the spectrum of haemoglobinopathies in the Armed Forces. It is suggested that detection of HbA2 should be carried out in all the high-risk groups with anaemia.

Glycaemic status and prevalence of comorbid conditions among people with diabetes in Kerala

BACKGROUND

We aimed to assess the glycaemic status and prevalence of comorbid conditions such as obesity, hypertension and dyslipidaemia in people with diabetes in a southern Indian community.

METHODS

A cross-sectional community survey of adults > 18 years of age was done in central Kerala. Among the 3069 subjects surveyed, 276 were known to have diabetes. Of these, 169 who had type 2 diabetes underwent a detailed physical examination and anthropometric measurements, and determination of levels of fasting blood glucose, glycosylated haemoglobin, fasting lipid, serum creatinine and urine protein. Data of 164 subjects who had glycosylated haemoglobin levels were included for final analysis.

RESULTS

The mean (SD) duration of diabetes was 5.5 (5.04) years and the mean age was 56.9 (11.4) years. Among the patients, 28 (17.2%) were receiving no treatment for diabetes, 24 (14.7%) were on diet control and 111 (68%) on pharmacotherapy. Only 6 patients were on insulin. The mean fasting blood glucose was 153 (63) mg/dl and the mean glycosylated haemoglobin level was 8.1 (2.34)%. In 60% of patients, the glycosylated haemoglobin level was above the recommended target of 7%. Obesity (31%), hypertension (51%), low-density lipoprotein cholesterol > 100 mg/dl (90%) and serum triglyceride levels > 150 mg/ dl (38%) were present in the study population. Only 29% of patients were on antihypertensive treatment and 5% on lipid-lowering agents.

CONCLUSION

In this population, only 40% of people with diabetes had adequate glycaemic control. The use of insulin was infrequent. Comorbid conditions were common and inadequately treated. This indicates a lack of proper diabetic care in this community, which could lead to an increase in the burden of cardiovascular disease in the future.

Protein-c deficiency presenting with subacute intestinal obstruction due to mesenteric vein thrombosis

We describe a patient with protein C deficiency who presented with subacute intestinal obstruction due to ischaemic small bowel stricture. The patient also had left sided ileofemoral thrombosis. Venous thrombosis at unusual sites especially if associated with deep vein thrombosis of lower limb warrants a thorough screen for underlying thrombophilia. This, however, is a rare cause for ischaemic small bowel stricture.

The Role of Pannus in the Longevity of an Ionescu-Shiley Pericardial Bioprosthesis

As the population ages, bioprosthetic heart valves are increasingly being used to replace diseased native valves. Bioprosthetic valve durability depends on patient age and other factors, but rarely exceeds 15 years. Explanted bioprosthetic valves commonly show tissue degeneration, tears, and calcification. Host tissue overgrowth (pannus), to the extent of interfering with their function, is another finding in bioprostheses that have been in place for long periods. We present a case in which a bovine pericardial valve was explanted after more than 20 years of implantation. The longevity of this pericardial valve may have been related to excessive pannus growth, which most likely protected the valve from earlier failure.

Ochronosis and aortic valve stenosis

Valvular heart disease has numerous etiologies. These range from congenital malformations to infectious and degenerative diseases. Clinically, these result in significant problems, the management of which can necessitate valve replacement with prosthetic heart valves. A rare cause is the deposition of foreign material in the valvular tissues, and these include inborn errors of metabolism of the essential amino acids. Alkaptonuria, an autosomal recessive trait, can result in the accumulation of excess homogentisic acid. This can manifest as pigmentation in the skin and other tissues, including heart valves. Accumulation of this pigment can lead to an inflammatory reaction and to progressive valve dysfunction.

Audit of care of patients with congenital adrenal hyperplasia due to 21-Hydroxylase deficiency in a referral hospital in South India

We carried out an audit of management of patients with 21-Hydroxylase deficiency CAH who presented to the Department of Endocrinology OPD from 1999 till 2004 and had a minimum follow up of 6 months. Of the 30 patients analysed 24 were girls and 6 were boys. The majority belonged to the Christian community. One third had a history of consanguinity or family history of similar illness. Sex assignment was appropriate in most. Karyotyping was done in half. Half the patients had adequate follow up and 17 OHP measurements. Only 7 out of 30 children had normal height for age. Bone age was done in 16 patients only. Most were on hydrocortisone. The average age of genital surgery was 31 months.

Leiomyosarcoma of the inferior vena cava

Leiomyosarcoma of the inferior vena cava is a rare neoplasm; however, it is the most frequent tumor of vascular origin. It is classified according to site of origin that reflects its clinical presentation and prognosis. They are generally recognized to be of smooth muscle cell origin. Surgical resection is the treatment of choice. The role of adjuvant therapy for leiomyosarcoma is not established.

A bicuspid pulmonary valve associated with tetralogy of fallot

Congenitally bicuspid pulmonary valves are uncommon. When they occur, it is usually in association with other congenital cardiac lesions, most often a tetralogy of Fallot. We present a rare case of a patient with a congenitally bicuspid pulmonary valve who had pulmonary valve and RVOT reconstruction. The patient did well for 17 years, but needed further reconstruction when the pulmonary valve started getting stenosed and RV pressures went up significantly. The pulmonary valve showed fibroses, thickening, and focal calcification.

Morphological findings in explanted Toronto stentless porcine valves

BACKGROUND

Stentless porcine valves have many documented advantages over stented valves. Since its introduction in 1991, the Toronto stentless porcine valve (T-SPV) has shown excellent hemodynamic performance.

METHODS

A total of 332 T-SPVs have been implanted at our institution up to December 2003, 25 of which have been explanted at surgery. Herein, we report a study of 30 explanted T-SPVs seen at our institution over a 5-year period.

RESULTS

The mean patient age at explant was 61.2+/-11.8 years with a mean implant duration of 100.7+/-27.8 months (after excluding one valve removed early postoperatively for infective endocarditis). Twenty-seven of 30 valves (90%) showed structural deterioration characterized by tissue degeneration, cusp tears, calcification, and lipid insudation. Eight valves (26.7%) showed evidence of calcification on gross inspection and a total of 23 valves (76.7%) showed at least one microscopic focus of calcification, located primarily in the basal and commissural regions of the cusp. Twenty valves (66.6%) showed cusp tears. Pannus was visible grossly on the surface of 27 of 30 valves (90%), while histologically, at least some degree of pannus was observed on both the inflow and outflow surfaces of all but two valves. Twelve T-SPV (40.0%) showed calcification in the porcine aortic tissue, four of which involved calcification of the porcine muscle shelf in the right coronary cusp. Two T-SPV showed no significant structural deterioration. Their clinical reason for explantation was incompetence or infective endocarditis.

CONCLUSION

With a freedom from reoperation of about 87.0% at up to 10 years, the T-SPV shows excellent durability. The majority of explanted valves show structural valve deterioration similar to that seen in other porcine heart valves.

Real-time quantitative PCR for Marek's disease vaccine virus in feather samples: applications and opportunities

Marek's disease, an economically-important lymphoid neoplasm of chickens, is controlled by vaccination with CVI988 strain of Marek's disease herpesvirus. Sub-optimal vaccinal protection can have multiple causes. Accurate quantification of CVI988 in vaccinated chickens will assist in understanding the causes of these vaccine breaks. We developed, optimised and validated a real-time PCR assay for quantification of CVI988 vaccine virus (in terms of CVI988 genomes per 10,000 cells) in the feather tips, a rich source of viral DNA which can easily be sampled in a non-invasive manner. CVI988 load in feathers was predictive of CVI988 load in spleen, so is anticipated to be a good predictor of protection. The optimal age of chicks for feather collection is between two to five weeks, and feathers are preferentially taken from the axillary tract. This PCR test is now used to monitor vaccine virus levels in commercial chicks. For each flock under test, fifty birds are feather sampled for q-PCR. We describe how the feather CVI988 genome profile can show the flock's response to vaccination, and the likelihood of vaccine breaks. Furthermore, the q-PCR test can be applied to researching optimal timing and vaccine delivery routes, and optimal vaccination regimes for different breeds of chick.

Extensive chronic graft-versus-host disease of skin successfully treated with thalidomide

Thirty years female underwent allogenic peripheral blood stem cell transplantation for chronic myeloid leukaemia--chronic phase. She developed grade II acute skin graft-versus-host disease (GVHD) which was treated with cyclosporine and a short course of steroids. She developed extensive chronic GVHD of the skin and liver three hundred days post-transplant. She was managed with the standard immunosuppressants with partial response of liver dysfunction but no response of skin lesions. She showed a good response to therapy with resolution of skin lesions after treatment with thalidomide.

Infective Endocarditis in a Hancock Bioprosthetic Heart Valve

Contemporary prosthetic heart valves (PHV) are a good mode of treatment of valvular heart disease. They last for an average of 5 to 10 years and bioprostheses fail due to the tissue degeneration. Infective endocarditis of the prosthetic valve is a relatively rare complication occurring in 0.5% to 1% of cases per year, and its late occurrence is even less common. Patients with PHV who undergo interventional or surgical procedures under adequate antibiotic coverage, infective endocarditis should not occur. We present a case of a 54-year-old woman who developed infective endocarditis on a porcine bioprosthesis, implanted 15 years earlier. The microorganism was Streptococcus viridans and the vegetations were surprisingly large and led to prosthesis obstruction.