The implications of a growing evidence base for drug use in elderly patients. Part 4. Vitamin D and bisphosphonates for fractures and osteoporosis.

Fractures are common in elderly subjects, disabling and occasionally fatal. Their incidence increases exponentially with age, with the commonest affected sites being the wrist, vertebrae, hip and humerus. Of these, hip fractures are the most relevant in terms of morbidity and financial cost.

Exercising in the cold inhibits growth hormone secretion by reducing the rise in core body temperature.

Objective: Ambient temperature alters exercise induced GH secretion. It is unknown whether temperature affects GH secretion at exercise intensities above the anaerobic threshold when other factors may override the relationship seen at lower intensities.

Design: Cross-over study of ambient temperature on exercise induced GH in swimmers and rowers.

Relationships between long-term stroke disability, handicap and health-related quality of life.

Objectives: To estimate levels of disability, handicap and health-related quality of life (HRQOL) up to 3 years after stroke and examine the relationships between these domains.

Design: A longitudinal, observational study

Setting: Population-based register of first-ever strokes

Methods: Subjects, registered between 1 January 1995 and 31 December 1997, were assessed at 1 year (n = 490) and 3 years (n = 342) post-stroke for disability [Barthel index (BI)], handicap [Frenchay activity index (FAI)] and HRQOL (SF-36). BI was categorised as severe, moderate, mild and independent (0-9, 10-14, 15-19 and 20); FAI was categorised as inactive, moderately active and very active (0-15, 16-30 and 31-45).

Sleep-related problems of Parkinson's disease.

Objective: To define the epidemiology, characteristics and aetiology of nocturnal symptoms and sleep disorders in patients with Parkinson's disease (PD) and evaluate the available methods for their diagnosis and management.

Methods: A review of the English-language literature pertaining to sleep disturbances associated with PD, using the Medline database and bibliographies in relevant articles.

Results: Sleep-related problems specific to PD may occur early and even predate the diagnosis of the disease but are generally more frequent and more severe in patients with advanced PD.

The effect of noninvasive ventilation on ALS patients and their caregivers.

Background: Noninvasive ventilation (NIV) reduces mortality and improves some aspects of quality of life (QoL) in ALS. However, concerns remain that progressive disability may negate these benefits and unnecessarily burden caregivers.

Methods: Thirty-nine patients requiring NIV were offered treatment.

Cancer and laterality: a study of the five major paired organs (UK).

Objective: The human body displays marked asymmetry: paired organs differ bilaterally exerting effects upon cancer incidence and progression. However the factors involved remain contentious. In this large study involving over a quarter of a million cancer patients, we examine the epidemiological correlates of cancer laterality including incidence, stage at diagnosis and survival in the five major paired organs: the breasts, lungs, kidneys, testes and ovaries.

Thromboprophylaxis in major abdominal surgery for cancer.

Aims: To review the epidemiology and pathogenesis of venous thromboembolism (VTE) in surgical cancer patients, in addition to the use of thromboprophylaxis in major abdominal surgery, such as low-molecular-weight heparin (LMWH) and fondaparinux.

Methods: Systematic review of the literature, focussing on risk factors for VTE, parenteral methods of thromboprophylaxis, approaches to prolonged prophylaxis, and effects on patient survival.

Findings: Patients with cancer undergoing abdominal surgery are at substantially higher risk for VTE than patients without cancer.

In vivo suppression of major histocompatibility complex class II expression on porcine vascular endothelial cells by an HMG-CoA reductase inhibitor.

Background: Vascular endothelial cells of man and pig, but not rodents, strongly express major histocompatibility complex (MHC) class II antigens in vivo, probably via the inducible promoter IV of the class II transactivator. There is abundant in vitro evidence that MHC class II positive vascular endothelial cells can activate T cells. Peripheral antigen presentation by endothelial cells is potentially important for organ-specific immunity, for allograft rejection, and possibly for immune responsiveness in general.

Medical downgrading, self-perception of health, and psychological symptoms in the British Armed Forces.

Objective: To investigate the contribution of psychological symptoms to limited employability for medical reasons in the British Armed Forces.

Methods: A sample of 4500 military personnel was randomly selected to receive either a full or an abridged questionnaire. The questionnaires asked whether the participant was medically downgraded and if yes, the reason for it.

The history of robotics in urology.

Despite being an ancient surgical specialty, modern urology is technology driven and has been quick to take up new minimally invasive surgical challenges. It is therefore no surprise that much of the early work in the development of surgical robotics was pioneered by urologists. We look at the relatively short history of robotic urology, from the origins of robotics and robotic surgery itself to the rapidly expanding experience with the master-slave devices.

International multicenter pilot study of the first comprehensive self-completed nonmotor symptoms questionnaire for Parkinson's disease: the NMSQuest study.

Nonmotor symptoms (NMS) of Parkinson's disease (PD) are not well recognized in clinical practice, either in primary or in secondary care, and are frequently missed during routine consultations. There is no single instrument (questionnaire or scale) that enables a comprehensive assessment of the range of NMS in PD both for the identification of problems and for the measurement of outcome. Against this background, a multidisciplinary group of experts, including patient group representatives, has developed an NMS screening questionnaire comprising 30 items.

Single cell PCR amplification of microsatellites flanking the COL7A1 gene and suitability for preimplantation genetic diagnosis of Hallopeau-Siemens recessive dystrophic epidermolysis bullosa.

Background: Hallopeau-Siemens recessive dystrophic epidermolysis bullosa (HS-RDEB) is a severe inherited blistering skin disorder caused by mutations in the anchoring fibril type VII collagen gene, COL7A1. There is currently no effective treatment but DNA-based prenatal testing in families at risk of recurrence is possible, mostly involving chorionic villus sampling at 10-11 weeks' gestation.

Objectives: An alternative method, for avoiding recurrence of HS-RDEB, is preimplantation genetic diagnosis (PGD).

End-of-life care: lessons from other nations.

Palliative care and hospice services have evolved across the globe in different contexts and in different ways, although many of the challenges faced are similar. Comparison between countries helps to identify the best solutions for individual patients and their families, who have complex needs and problems. This paper describes the globally shared challenges and beginnings in hospice and palliative care.

Non-motor symptoms of Parkinson's disease: diagnosis and management.

The clinical diagnosis of Parkinson's disease rests on the identification of the characteristics related to dopamine deficiency that are a consequence of degeneration of the substantia nigra pars compacta. However, non-dopaminergic and non-motor symptoms are sometimes present before diagnosis and almost inevitably emerge with disease progression. Indeed, non-motor symptoms dominate the clinical picture of advanced Parkinson's disease and contribute to severe disability, impaired quality of life, and shortened life expectancy.

Involvement of the nicotinamide adenosine dinucleotide phosphate oxidase isoform Nox2 in cardiac contractile dysfunction occurring in response to pressure overload.

Objectives: This study sought to examine the role of Nox2 in the contractile dysfunction associated with pressure-overload left ventricular hypertrophy (LVH).

Background: Reactive oxygen species (ROS) production is implicated in the pathophysiology of LVH. The nicotinamide adenosine dinucleotide phosphate oxidase isoform, Nox2, is pivotally involved in angiotensin II-induced hypertrophy but is not essential for development of pressure-overload LVH.

Clinical notes for informal carers in palliative care: recommendations from a random patient file audit.

Although palliative care aims to support family members and informal carers, current evidence suggests that high levels of unmet need persist, and that this population is challenging to work with. This study aimed to 1) measure the proportion of patients that have an informal carer, 2) describe the clinical notes data on existing needs and coping, 3) measure the completeness of assessment data recording, 4) appraise the utility of existing informal carers' sections in the patient files, and 5) make recommendations for improvement. An audit was conducted reviewing 145 closed patient files.

Diurnal excretion of urinary cortisol, cortisone, and cortisol metabolites in chronic fatigue syndrome.

Objective: The aim of this study was to obtain comprehensive information on basal hypothalamic-pituitary-adrenal (HPA) axis activity in chronic fatigue syndrome (CFS) patients who were not affected by medication or comorbid psychiatric disorder likely to influence the HPA axis.

Method: Steroid analysis of urine collections from 0600 to 2100 h at 3-h intervals in CFS patients and in controls.

Results: Urinary free cortisol and cortisone concentrations showed a significant normal diurnal rhythm, but levels were lower across the cycle in CFS.

Intravenous immunoglobulin for Guillain-Barré syndrome.

Background: Guillain-Barré syndrome is an acute, paralysing, inflammatory peripheral nerve disease. Intravenous immunoglobulin is beneficial in other autoimmune diseases.

Objectives: We aimed to determine the efficacy of intravenous immunoglobulin for treating Guillain-Barré syndrome.

Advantages of ProSeal and SLIPA airways over tracheal tubes for gynecological laparoscopies.

Purpose: To compare the efficacy of the ProSeal LMA and SLIPA supralaryngeal airways (SLA) with the standard tracheal tube (TT) in 150 consecutive day-case laparoscopic gynecological surgery procedures requiring general anesthesia.

Methods: One hundred and fifty patients were randomized into three groups. An identical general anesthesia technique was used in all patients apart from the addition of muscle relaxants and reversal drugs in the TT group.

Lessons from developing and running a clinical database for colorectal cancer.

Background: Recent policy developments in the UK require the routine monitoring of the performance of cancer services. Developing and using clinical databases is one approach to meet this objective, but to date their implementation has been challenging.

Objective: To describe the development of the Thames Cancer Registry clinical database for colorectal cancer, and to present the lessons learnt in the first five years since its establishment.

HIV/AIDS mitigation strategies and the State in sub-Saharan Africa--the missing link?

Background: The HIV/AIDS pandemic in sub-Saharan Africa is widely recognised as a development disaster threatening poverty reduction, economic growth and not merely a health issue. Its mitigation includes the societal-wide adoption and implementation of specific health technologies, many of which depend on functional institutions and State.

Discussion: Donor and International Institutions' strategies to mitigate HIV/AIDS in sub-Saharan Africa are premised on a single optimal model of the State, one which focuses on the decentralised delivery of public goods alone (such as healthcare) - the service delivery state.

Bullous pemphigoid antigen II (BP180) and its soluble extracellular domains are major autoantigens in mucous membrane pemphigoid: the pathogenic relevance to HLA class II alleles and disease severity.

Background: Mucous membrane pemphigoid (MMP), a chronic autoimmune subepithelial blistering disease, is associated with circulating IgG and/or IgA autoantibodies against several basement membrane zone antigens. The heterogeneity of clinical presentation and diversity of target autoantigens have contributed to difficulties in characterizing this condition immunologically.

Objectives: To analyse serum autoantibody profile and HLA class II alleles in MMP patients and to correlate this with the clinical presentation of disease.

The long-term effects of tibolone on aortic stiffness and endothelial function.

Objective: To investigate the effect of 10 years of treatment with tibolone on aortic stiffness and endothelial function.

Design: Cross-sectional study of women currently participating in an open-label, non-randomized study of the long-term efficacy of tibolone. A total of 113 recently postmenopausal women were recruited in 1988.

Chronic manifestations of respiratory syncytial virus infection in premature infants.

Background: Respiratory syncytial virus (RSV) infection in healthy infants born at term results in long term sequelae. Infants born prematurely are at increased risk of severe acute RSV infection; thus it would seem likely that such infants would be at increased risk of long term respiratory sequelae.

Methods: Methods of assessing the long term outcome of RSV infection are discussed and the results of retrospective and prospective studies investigating chronic respiratory morbidity after RSV infection in premature infants are reviewed.