Unexplained swelling symptoms in women (idiopathic oedema) comprise one component of a common polysymptomatic syndrome.

BACKGROUND: Non-menstrually-related swelling symptoms (idiopathic oedema) are common in women. The community prevalence of such symptoms, their association with other symptoms, and their underlying aetiology, are uncertain. AIM: To determine the community prevalence of swelling symptoms and the independent contributions of major risk factors. DESIGN: Comparison of major risk factors in women with and without swelling symptoms. METHODS: We assessed 196 women attending a menopause clinic, 201 women attending a fracture clinic and 201 women attending their general practitioner. Each documented family histories of swelling symptoms and diabetes mellitus, age, height and current weight. Women attending the menopause and fracture clinics also completed Visual Analogue Symptom (VAS) scales documenting the perceived severity of swelling symptoms, and of 20 affective, somatic and functional autonomic symptoms. The independent contributions of risk factors to swelling symptom risk were estimated by logistic regression analysis. RESULTS: Of those attending a fracture clinic or their general practitioner, 28% and 33%, respectively, experienced non-menstrually-related swelling symptoms in the month before interview. Severe (RR 43, 95%CI 16-112, p < 0.001) and moderate (RR 7.8, 95%CI 4-15, p < 0.001) affective symptoms, a family history of swelling symptoms (RR 4.5, 95%CI 2.3-8.8, p < 0.001) and a body mass index (BMI) >or=25 kg/m(2) (RR 4.8, 95%CI 2.5-8.9, p < 0.001) were significantly associated with the presence of mild to severe swelling symptoms (VAS 1-9). The prevalence of swelling symptoms increased from 8% in women with no risk factors to 100% in women with three risk factors, which included severe affective symptoms. DISCUSSION: Affective symptom severity provides the principal independent contribution to swelling symptom risk. BMI >or=25 and a family history of swelling symptoms provide smaller independent contributions. The nature of the mechanisms underlying these associations remains uncertain.

Nutritional support for patients with intellectual disability and nutrition/dysphagia disorders in community care.

Patients with intellectual disability and neurological handicaps associated with swallowing difficulties are vulnerable to dehydration and undernutrition. Some patients are severely undernourished, a condition which is usually associated with recurrent food aspiration and respiratory infections. Underweight patients are usually provided with adequate dietary protein by carers: their low energy intakes reflect inadequate intakes of fat and carbohydrate. Many patients gain weight following the provision of easily assimilated energy-dense fat- and sugar-containing foods. Where these measures fail, the provision of a percutaneous endoscopic gastrostomy (PEG) tube may be life-saving. Optimal supervision of patients with severe nutrition/dysphagia problems requires a support network linking carers at home or in community care facilities with the primary health care team and the local district general hospital.

Thyroid function in idiopathic oedema.

BACKGROUND: The role of abnormal thyroid function in the aetiology of idiopathic oedema is unclear. Previous studies of small samples of patients have suggested a high prevalence of latent hypothyroidism and a possible deiodination defect in the conversion of T4 to T3 in this condition. There is a need to clarify the possible significance of abnormal thyroid function in a larger sample of idiopathic oedema patients. OBJECTIVE: The study was undertaken to compare basal thyroid function in idiopathic oedema patients and in an age and sex-matched control group. PATIENTS AND DESIGN: After excluding one idiopathic oedema patient and three control subjects with abnormal thyroid function, basal thyroid function was compared in 44 idiopathic oedema patients and in 44 age and sex-matched controls. MEASUREMENTS: Basal thyroid function was assessed in patient and control groups by measuring serum T4, fT4, T3, fT3 and TSH by standard methods. RESULTS: There were no significant differences in basal thyroid function between patient and control groups except for an elevated mean fT4 concentration in the idiopathic oedema group (P = 0.03). Exclusion of patients and controls taking oestrogen abolished this difference. T4:T3 ratios were similar in patient and control groups. CONCLUSION: Abnormalities of basal thyroid function are uncommon in patients with idiopathic oedema and appear unrelated to the pathogenesis of this disorder. Similar T4:T3 ratios between patient and control groups exclude a deiodination defect in idiopathic oedema.

Seasonal variation in coronary heart disease in Scotland.

STUDY OBJECTIVE: Seasonality of coronary heart disease (CHD) was examined to determine whether fatal and non-fatal disease have the same annual rhythm. DESIGN: Time series analysis was carried out on retrospective data over a 10 year period and analysed by age groups ( < 45 to > 75 years) and gender. SETTING: Data by month were obtained for the years 1962-71. The Registrar General provided information on deaths and the Research and Intelligence Unit of the Scottish Home and Health Department on hospital admissions. SUBJECTS: In Scotland, between 1962 and 1971, 123 000 patients were admitted to hospital for CHD, of whom 29 000 died. There were a further 97 000 CHD deaths outside hospital. These two groups were also examined as one (coronary incidence) - that is, all coronary deaths and coronary admissions discharged alive. STATISTICAL ANALYSIS AND MAIN RESULTS: Where there was a single annual peak, the sine curve was analysed by cosinor analysis. When there were two peaks the analysis was by normal approximation to Poisson distribution. In younger men (under 45 years) admitted to hospital there was a dominant spring peak and an autumn trough. A bimodal pattern of spring and winter peaks was evident for hospital admissions in older male age groups: with increasing age the spring peak diminished and the winter peak increased. In contrast, female hospital admissions showed a dominant winter/summer pattern of seasonal variation. In male and female CHD deaths seasonal variation showed a dominant pattern of winter peaks and summer troughs, with the winter peak spreading into spring in the two youngest male age groups. CHD incidence in women showed a winter/summer rhythm, but in men the spring peak was dominant up to the age of 55. CONCLUSION: The male, age related spring peak in CHD hospital admissions suggests there is an androgenic risk factor for myocardial infarction operating through an unknown effector mechanism. As age advances and reproduction becomes less important, the well defined winter/summer pattern of seasonal variation of CHD is superimposed, and shows a close relationship with the environment, especially temperature, or the autumn and early winter fall in temperature.

The role of diuretics in the aetiology of idiopathic oedema.

The hypothesis that diuretic use and abuse and other purging behaviours cause idiopathic oedema was investigated in 102 patients. Of 91 symptomatic idiopathic oedema patients tested at referral, 16 (17.6%) had diuretic and four (4.4%) laxative in their urine. None had grossly disturbed serum urea and electrolytes. Examination of primary care records from 41 idiopathic oedema patients who denied current diuretic consumption, and denied or were uncertain about past consumption, showed that 20 had not been prescribed diuretics by their general practitioners at any time; a further 18 had not been prescribed diuretics for between seven months and 12 years before referral. The absence of evidence of plasma volume depletion (as judged by similar concentrations of mean serum urea, creatinine, total protein and albumin in patient and age-matched control groups) suggests that neither systematic diuretic and laxative use or abuse, nor episodic overeating and vomiting were responsible for symptoms of idiopathic oedema in our patients. Idiopathic oedema has a strong genetic basis, and correction of major and minor risk factors for this condition leads to substantial amelioration of symptoms in most cases.

Artificial ultraviolet whole-body radiation does not modify serum lipoprotein, plasma fibrinogen, plasminogen or antithrombin III concentrations in post-myocardial infarction patients.

The relationship of ischaemic heart disease (IHD) to seasonal and latitude variation has prompted speculation that exposure to the ultraviolet component of solar radiation may reduce IHD risk. This hypothesis was partially tested by exposing 14 post-myocardial infarction patients to a 6 week course of artificial whole-body ultraviolet radiation (UVR). Serum lipoprotein and plasma coagulation factor concentrations were measured before and after the course of UVR. Results were compared with similar measurements from a placebo-controlled group of 13 post-myocardial patients. Despite a more than two-fold rise in mean serum 25-OHD, serum lipoprotein and plasma fibrinogen, antithrombin III and plasminogen concentrations did not change significantly in the UVR group. Significant but minor change in prothrombin time and thrombin time in the placebo group appear unlikely to be of biological significance. Seasonal and latitude variation in these IHD risk factors appear unrelated to corresponding variation in solar UVR exposure.

Familial idiopathic oedema in prepubertal children: a new syndrome.

Idiopathic oedema has not been previously described in prepubertal children. Between 1977 and 1991, eighteen children (15 girls, three boys) from 13 unrelated kindreds presented with the clinical features of idiopathic oedema commencing between the neonatal period and 12 years. These comprised a triad of swelling, affective disturbance and functional autonomic symptoms. There was a family history of idiopathic oedema in 16 (89%) children, including all 15 girls, and of diabetes mellitus in 12 (67%) children, suggesting a major genetic basis for the syndrome. Laboratory investigations excluded cardiovascular, hypoproteinaemic, allergic and obstructive causes of oedema. Adherence to a restricted carbohydrate diet, the avoidance of refined carbohydrate and the correction of precipitating weight gain controlled symptoms in most children. Relapses followed dietary non-compliance and life-event stress. A neurotransmitter-based autonomic abnormality of vascular and visceral smooth muscle tone modulated by metabolic and neuroendocrine mechanisms provides a partial explanation for this syndrome. Insulin-mediated modulation of capillary permeability to water and electrolytes may also be involved. The pathogenesis, clinical features and management of paediatric idiopathic oedema may provide a model for the adult syndrome.

Asian osteomalacia is determined by dietary factors when exposure to ultraviolet radiation is restricted: a risk factor model.

Twenty-seven previously osteomalacic and 77 normal Asian women participated in a seven-day survey of dietary intake and daylight outdoor exposure. Individual levels of daylight outdoor exposure discriminated poorly between normal and osteomalacic women. The presence of osteomalacia was strongly related to varying degrees of vegetarianism. Lactovegetarianism (no meat, fish or egg consumption) was associated with significantly greater osteomalacic risk than ovolactovegetarianism (no meat or fish consumption). Unlike Asian rickets, high-extraction wheat cereal as chapatti was not a significant risk factor for osteomalacia in Asian women and dietary fibre was a less important risk factor than absent dietary meat, fish or egg. When exposure to ultraviolet radiation is limited, Asian osteomalacia (and Asian rickets) are determined by dietary factors.

The relationship between 'normal' fluid retention in women and idiopathic oedema.

A sample of women attending a gynaecological outpatient clinic were examined for symptoms and objective signs of fluid retention. Patients completed a questionnaire on symptoms suggesting fluid retention and recorded daily weight and abdominal girth variation. Daily weight variation varied from 0-9 pounds (mode 2 pounds) with no discernable difference between premenstrual and intermenstrual variation. Daily girth variation varied from 0-6 inches (mode 1 inch). Symptoms of breast swelling were more common premenstrually, finger/hand and ankle swelling intermenstrually and abdominal swelling occurred with equal frequency in both periods. No correlation between symptoms and weight variation was seen although abdominal swelling and girth variation were associated (P less than 0.04). The results indicate that symptoms of mild fluid retention and of diurnal weight and abdominal girth variation are part of the everyday experience of our study population. There is no clear-cut separation between 'normal' and 'abnormal' fluid retention (idiopathic oedema, periodic oedema, fluid retention syndrome); the latter may be an exaggeration of normal fluid-retaining mechanisms common to most women or may represent a pathological state. An approach which evaluates individual risk factors and the severity of fluid retention in each patient is recommended.

Hypernatraemic dehydration in patients in a large hospital for the mentally handicapped.

OBJECTIVE: To determine the prevalence of hypernatraemic dehydration and to assess the hydration and nutritional state of patients in a large hospital for the mentally and physically handicapped; also to assess the efficacy of an intervention programme to reduce the prevalence of hypernatraemic dehydration in the hospital. DESIGN: Prospective study of patients admitted with hypernatraemic dehydration from a large hospital for mentally and physically handicapped patients (hospital A) to a district general hospital between 1986 and 1988. In 1986 the hydration and nutritional state of a random sample of patients from hospital A was compared with a random sample of patients from a small hospital for the physically and mentally handicapped (hospital B) and with control groups from the community. The hydration of the patients from hospital A examined in 1986 was reassessed in 1988. PATIENTS: 12 Patients were admitted from hospital A to the district general hospital during 1986-8 (seven women, five men; age range 29-82). In 1986, 72 patients were randomly selected for the assessment of hydration and nutritional state from hospital A, 33 who required help with feeding and 39 who could feed independently. Fifty patients were similarly selected from hospital B, half of them requiring help with feeding. In 1988 the hydration state of 60 of the 72 patients from hospital was reassessed. Control values were taken from two published studies. INTERVENTIONS: In 1987 nursing staff in hospital A were asked to provide between 2.5 and 3.0 litres of fluid daily for all patients. The use of hypertonic enemas was discontinued, and the ratio of staff to patients was increased. MAIN OUTCOME MEASURES: Serum concentrations of urea and electrolytes (hydration) and body mass index (nutritional state). RESULTS: Of the 10 patients admitted with hypernatraemic dehydration from hospital A to the district general hospital in 1986, four died of intercurrent infection. No patients were admitted from hospital B with hypernatraemic dehydration during the same time. In 1986 the hydration and nutritional state of patients in hospital A were inferior to those in patients from hospital B and control subjects from the community (serum urea concentrations were 6.1 (SD 1.8) mmol/l v 5.5 (1.9) and 5.6 (0.4) mmol/l, respectively) 50% (36/72) of patients in hospital A had a body mass index less than or equal to 20 compared with 34% (17/50) of patients from hospital B and 12% (1141/9434) of control subjects). After the initiation of the preventive programme only one patient was admitted with hypernatraemic dehydration in each of the years 1987 and 1988. The mean serum urea concentration of the 60 patients who were reassessed in 1988 fell significantly between 1986 and 1988 from 6.1 (SD 1.8) mmol/l to 5.7 (2.1) mmol/l, the value in a control group matched for age and sex. CONCLUSIONS: Hypernatraemic dehydration, subclinical underhydration, and undernutrition were common in a large hospital for the mentally and physically handicapped. The problem of hypernatraemic dehydration was successfully dealt with by the hospital management team. Similar problems may be encountered in hospitals for patients who are mentally and physically handicapped and mentally ill, including psychogeriatric units.