Elevated lipoprotein (a) and apolipoprotein B to AI ratio in South Asian patients with ischaemic stroke.

BACKGROUND: Stroke is a continuing cause of excess cardiovascular disease (CVD) mortality amongst migrants from the Indian subcontinent (South Asians) living in Britain. However, little is known about the dyslipidaemia associated with stroke in South Asians. In particular, the highly atherogenic lipoprotein (a) [Lp(a)] and high apolipoprotein (Apo) B to AI ratio are emerging risk factors for CVD. METHODS: Using a case-control study, we investigated features of the dyslipidaemia in South Asian patients with stroke compared with South Asian subjects with no history of clinically detectable stroke. We studied 55 consecutive South Asian patients with ischaemic stroke (confirmed on computerised scan of the brain) and 85 controls. RESULTS: The stroke patients were significantly older than controls (65.2 vs. 59.8 years, p = 0.001), but were similarly matched for male gender (63.6 vs. 61.2%), smoking habit (20.7 vs. 18.1%) and presence of type 2 diabetes (25.5 vs. 19.3%). There were no differences between serum total cholesterol (p = 0.07) and high-density lipoprotein cholesterol (p = 0.08) between the groups, but stroke patients had higher serum triglycerides (p = 0.005). Mean [95% confidence interval (CI)] Apo B to AI ratio was higher amongst stroke patients [1.0 (0.9-1.0) vs. 0.7 (0.7-0.75), p < 0.001]. Similarly, geometric mean serum Lp(a) was significantly higher (p = 0.037) in stroke patients [19.9 mg/dl (14.0-28.5)] vs. controls [15.1 mg/dl (11.4-20.1)]. On logistic regression, stroke was independently associated with age and Apo B to AI ratio (p < 0.01). CONCLUSION: The present study suggests that Lp(a) and the Apo B to AI ratio are associated with ischaemic stroke in South Asians. A prospective analysis is needed to elucidate the role of Lp(a), Apo B and AI as risk factors for ischaemic stroke in this population, as well as the effects of intervention.

Management of urinary incontinence.

Urinary incontinence is one of the most embarrassing disabilities in the elderly people. It may be defined as an involuntary loss of urine in a quantity or frequency sufficient to cause a social or hygienic problem. Its magnitude is both overlooked and underestimated by the medical community. Unfortunately, urinary incontinence lacks the glamour of other 'high tech' medical problems.

Ethnic influence on health and dependency of elderly inner city residents.

The objectives of the study were to assess and compare the social characteristics, prevalence of disease, health needs, dependency and use of health services by elderly people in the different ethnic groups living in an inner city. A prevalence study was conducted using a questionnaire administered to people aged 65 years and over living at home, selected from the registers of inner city general practices in West Birmingham. Contact was made with 736 individuals from the original sample of 1,450 names, and completed questionnaires were obtained from 669 individuals (297 men, 372 women). Respondents were divided by place of birth into four groups: UK, Asia, West Indies, and 'Other'. Outcome measures were demographic data, language, household composition, prevalence of disease and health problems, help with activities of daily living, and contact with and knowledge of community health services. We found that those born in the UK were likely to be older, female, unmarried and living alone. In the Asian group, only 15% spoke English and 59% lived in a household with more than three other people compared with 4% in both the UK and West Indian groups. Hypertension was more common in West Indians, arthritis in Asians and diabetes mellitus more common in both groups than in the UK group. Asians were more likely to complain of poor vision. The level of dependency was similar in all groups despite age differences. Contact with community health services was low among Asians who also had a low awareness of the availability of these services. The conclusions from the study were that the average age of elderly individuals in ethnic minority groups is less than that of the indigenous population, making direct comparison difficult. Nevertheless, they have a higher prevalence of age-related disease and a similar level of dependency. They are less well served by, and have little knowledge of the existence of, community health services. For older Asians, difficulty in communicating with English-speaking health personnel is a major barrier to effective health care. Access to health care by older people from ethnic minorities needs to be improved, and services developed in a more culturally sensitive manner.

Senior registrar training in geriatric medicine 1977-1990.

Higher medical training in geriatric medicine was assessed in 1977, 1983 and 1990 by a questionnaire distributed to members of the British Geriatrics Society Senior Registrar Group. Comparisons over this 14 year span show consistent concern about training programmes, particularly in relation to research, health service management and psychiatry of the elderly.

Sick sinus syndrome aggravated by carbamazepine therapy for epilepsy.

A case of sick sinus syndrome aggravated by carbamazepine prescribed for epilepsy is described. A 70 year old woman with previously stable psychomotor epilepsy experienced syncope of increased frequency after her anticonvulsant was changed to carbamazepine. ECG monitoring confirmed a severe sick sinus syndrome which improved on carbamazepine withdrawal. Failure to distinguish carbamazepine-induced cardiac syncope from epileptic attacks may lead to an increase in dosage and aggravation of syncope.

Neurofibrosarcoma in Von Recklinghausen's disease presenting with hypochromic anaemia.

A patient with Von Recklinghausen's disease who developed a retroperitoneal neurofibrosarcoma is described. The presenting clinical picture was one of hypochromic anaemia with a large mass palpable in the left hypochondrium. At operation the tumour was found to be invading the small intestine with resultant blood loss. The patient had presented 21 years before with unexplained severe iron deficiency anaemia.

Pharmacokinetics of azapropazone in the elderly.

Plasma concentrations of azapropazone have been measured in young and elderly subjects after a single dose of 600 mg azapropazone. Maximum concentrations were higher in the elderly. Renal function was impaired in the older subjects. Mean azapropazone clearance was significantly reduced (P less than 0.001) in the old, compared to the young. Elimination half-life was prolonged but the difference did not reach statistical significance due to the wide variation of the values in the elderly. The volume of distribution of azapropazone and degree of adipose tissue did not differ between the two groups. Azapropazone clearance correlated well with creatinine clearance (P less than 0.001) when all the subjects were included and for the younger subjects only but not for the elderly patients alone. The addition of fat mass into the regression equation improved the relationship in all groups but in the older group levels of statistical significance were not achieved. Reasons for the difference between young and old are discussed. The effects of age on the pharmacokinetics of azapropazone suggest that therapeutic plasma levels may be achieved with a dose of 600 mg daily.

The lack of effect of intramuscular emepronium bromide for urinary incontinence.

Six elderly volunteers (4 men and 2 women), suffering from urinary incontinence due to small capacity, hyper-reflexic bladders, were assessed cystometrically 1/2 h, 1 h and 4 h after an intramuscular injection of emepronium bromide (Cetiprin). The dose given was sufficient to raise serum levels of emepronium to approximately 10 times those that could be reached with an oral dose. Analysis of the results showed that there was no significant difference in the state of the bladder at any time. The study confirms that emepronium bromide is ineffective in increasing bladder capacity in subjects with small, hyper-reflexic bladders. It has no value, therefore, in the management of urinary incontinence in elderly patients with this condition.

Are potassium supplements for the elderly necessary?

Plasma and total-body potassium (TBK) were measured in 19 elderly patients receiving diuretics and potassium supplements for cardiac failure and in 13 elderly controls. The mean value for the ratio of TBK to fat-free mass (TBK:FFM) was significantly reduced in the patient group. TBK:FFM showed a negative correlation with age but no correlation with plasma potassium or dose of supplements. When controls and patients were matched for sex and age decade, the mean TBK:FFM was decreased significantly in the diuretic group, giving a mean potassium deficit of 13.3%. These results suggest that ageing influences potassium status, and that diuretics and cardiac failure have a greater effect on TBK in old age than in youth or middle age.

Long-term anabolic therapy in the elderly.

The anabolic agent stanozolol has been used to increase weight and activity in the elderly, but its long-term effect are largely unknown. A double-blind trial of stanozolol against placebo was continued for 12 months. Measuremtnes of weight, fat, fat-free mass, behaviour and activity were made at regular intervals, plus detailed biochemical and haematological profiles. There were no differences between the two groups in respect of weight, fat, fat-free mass and activity levels. There were significant increases in haemoglobin at six and 12 months and packed cell volume at 12 months in the active group. No androgenic side-effect were encountered.

A second look at emepronium bromide in urinary incontinence.

Response to oral and intramuscular emepronium bromide was assessed cystometrically in nine patients with urinary incontinence caused by an uninhibited bladder. Oral therapy had no effect, whereas intramuscular administration increased bladder capacity and significantly delayed the onset of bladder spasm and the desire to void. Plasma-propranolol response was delayed and concentrations were reduced after an oral 40 mg dose of propranolol in 3 patients who had received oral emepronium bromide. These results indicate that although oral emepronium bromide had some anticholinergic effect--i.e., in reducing gastrointestinal motility--absorption of an oral dose was not sufficient for the bladder to be affected.

A double-blind trial of an anabolic steroid (stanozolol) in the disabled elderly.

Anabolic steroids have been widely recommended in the management of debility in association with the diseases of old age. Their action in promoting weight gain and in speeding rehabilitation is said to depend on nitrogen retention leading to increased muscle bulk reflected by increased fat-free mass (lean-body mass). In elderly patients undergoing rehabilitation a double-blind trial over 4 months of stanozolol, an orally active anabolic agent, is reported in which measurements of total body weight, body fat and fat-free mass were recorded. Physical activity and performance levels were also measured. Total body weight was found to have increased in both groups of patients, mainly due to increased body fat. There was no evidence of fluid retention due to the drug. Despite the absence of an anabolic effect, the group taking stanozolol increased their levels of physical activity significantly.

The significance of carotid sinus hypersensitivity in the elderly.

The carotid sinus stimulation test was performed under electrocardiographic control in 100 consecutive patients admitted to a psychogeriatric assessment unit. An abnormal cardioinhibitory response was obtained in two patients, and a borderline response in 13 patients. The incidence of carotid sinus hypersensitivity was no higher in those with dementia, coronary artery disease, and arteriosclerosis, nor in the very elderly. The increased frequency in males was significant. It is suggested that age alone is not a predisposing factor. Further studies are needed to determine the importance of a hypersensitive reflex as a clinical entity in the elderly.

Routine screening for venous thrombosis by ultrasound in the elderly.

One hundred admissions to a geriatric assessment unit were screened over a three-week period with a Sonicaid Ultrasound apparatus for the development of venous thrombosis in the legs, as denoted by an abnormal ultrasound scan. Any patients with suggestive physical signs were also noted and all such patients, together with those with abnormal ultrasound findings, were investigated at the same time by the 125I-fibrinogen test. Eight patients developed an abnormal ultrasound scan confirmed with the fibrinogen method, and of these three developed abnormalities bilaterally, giving an incidence of thrombosis expressed in terms of legs of 5.5 per cent. Technical difficulties were encountered with this group of elderly patients, these being that in some there was difficulty in positioning the ultrasound probe and in others of producing an adequate flow noise to monitor changes effectively.