Epidemiology of falls among the elderly community dwellers in Singapore

AIM: Falling is a serious medical problem for elderly persons. This study was done to look at prevalence and risk factors for falls in community dwelling elderly in Singapore. METHOD: A random sample of 3,000 persons aged 60 years and above was chosen from a database based on the 1990 population census. Letters were sent out to 2,582 subjects who had local and complete addresses. In the letter, they were informed about the purpose of the survey, and invited to participate in a questionnaire and clinical health screening at an appointed date at a polyclinic. Participants were reminded the day before their appointment by telephone, and a new appointment could be given at the subject's convenience. RESULTS: We found a prevalence rate of falls of 17.2%. Two-thirds of these had single falls, while one-third had recurrent falls, defined as having more than one fall within the previous one year. The following factors were found to be significantly associated with increase falling in the elderly: age > or = 75 years (O.R. = 1.82, 95% C.I. 0.95-3.50), female sex (O.R. = 2.5, 95% C.I. 1.40-4.48), Malay race (O.R. = 2.66, 95% C.I. 1.21-5.86), poor vision (O.R. = 1.7, 95% C.I. 0.99-2.90), Barthel's score of less than 20 (O.R. = 1.76, 95% C.I. 0.94-3.28), those taking 2 or more drugs daily (O.R. = 2.1, 95% C.I. 1.22-3.72) and the presence of hypertension (O.R. = 1.78, 95% C.I. 1.06-3.01). Fall rate is also twice as high in women as in men. At the same time, we found that women in the group we studied also tend to exercise less than the men. Fallers also had significantly more mobility and activities of daily living (ADL) disabilities (reflected by a lower Barthel's score) and this is consistent with other results. The only factor that reduced the risk of falling was regular exercise (O.R. = 1.64, 95% C.I. 0.93-2.93). CONCLUSION: In our study, we found differences between the group with single and recurrent falls. In the group with single falls, the fall tend to occur outdoors (O.R. = 2.97, 95% C.I. 1.03-8.60) and during the day (O.R. = 3.47, 95% C.I. 1.20-10.0), tend to be accidental (O.R. = 3.16, 95% C.I. 1.05-9.50) and tend to seek medical attention (O.R. = 3.68, 95% C.I. 1.23-11.0). Overall, 32 persons (46.4%) seek medical treatment after their falls, and of these, 65.6% were women. Risk factors for falls should be screened for all elderly.     

Evaluation of humoral immune responses in cattle grazing endophyte-infected or endophyte-free fescue

Anecdotal reports suggest cattle with fescue toxicosis may not respond to vaccination and thus, experience increased incidence of Bovine Respiratory Disease Complex (BRDC) when shipped to feedlots. Fescue toxicosis causes hypoprolactemia in cattle. Hypoprolactemia decreases humoral immune responses in mice. Therefore, a study was conducted to compare the magnitude of primary and secondary humoral immune responses against specific antigens in cattle grazing endophyte-infected or endophyte-free fescue. Angus steers were blocked by weight and allocated into four groups. Two groups grazed endophyte-infected (EI) fescue and the other two groups grazed endophyte-free (EF) fescue. All steers were injected IM on d 0 and 21 with lysozyme without adjuvant and concanavalin. A (Con A) with sheep red blood cells (SRBC) in incomplete adjuvant of Freund. Steers were bled on days 0, 21 and 35 post-vaccination. Average daily gains (ADG), alkaline phosphatase (ALP) activity, cholesterol concentrations, rectal temperatures, and serum prolactin concentrations were measured to confirm fescue toxicosis in steers grazing EI fescue. Antibodies to Con A and SRBC were determined by ELISA and hemagglutination assay, respectively. The ADG were decreased for the EI group during the first month. Rectal temperature were elevated and serum prolactin concentrations were decreased in the EI group. Cholesterol and ALP concentrations also were decreased in the EI group. Primary and secondary immune responses against Con A tended to be increased and were increased against SRBC in the EI group. Antibodies against lysozyme were not induced in either group. In conclusion, cattle grazing EI fescue mounted similar humoral immune responses to vaccination, despite hypoprolactemia, as cattle grazing EF fescue. Increases in bovine respiratory disease in cattle maintained on EI fescue probably is not associated with lack of humoral immune response to vaccination protocols as a result of fescue toxicosis.     

Surgical management of ventricular tachycardia

BACKGROUND: Ventricular tachyarrhythmias are the leading cause of death from coronary artery disease. A small percentage of these arrhythmias originate in chronically ischemic myocardium, rather than acutely ischemic myocardium, and can be refractory to medical management. Epicardial mapping and focal cryoablation of foci demonstrating early activation may provide definitive therapy when pharmacologic management fails. We report a series of 42 consecutive patients with refractory ventricular tachycardia (VT) who were treated with open epicardial mapping and focal cryoablation after pharmacologic management failed. METHODS: We retrospectively reviewed the records of patients who underwent surgical treatment of malignant VT. For patients not recently seen in the clinic, we conducted telephone interviews. At the time of operation, epicardial mapping was performed to locate foci of early electrical activation. These foci were then cryoablated, using 2-minute applications of liquid nitrogen-cooled probes. All patients underwent postoperative electrophysiologic studies to test for inducible VT. RESULTS: Of these 42 patients, 34 (81%) were male, 8 (19%) female. Average age was 62.9 +/- 10.6 years; ejection fraction, 0.20 (range, 0.04 to 0.50); and number of foci ablated, 2.1 +/- 1.1 (range, 1 to 6). At the time of cryoablation, all patients underwent additional procedures, including aneurysmectomy, coronary artery bypass, or valve replacement. The 30-day operative mortality was 9.5% (4 of 42). Of the 38 survivors, 36 (94.7%) were clinically free of VT; the remaining 2 had spontaneous or inducible VT. CONCLUSIONS: Open cryoablation of foci propagating VT appears to be safe and effective. It may be the most definitive treatment for malignant VT.     

Post-traumatic stress disorder and functioning and quality of life outcomes in female Vietnam veterans

OBJECTIVE: This investigation assessed whether current post-traumatic stress disorder (PTSD) was associated with impaired functioning in a nationally representative sample of female Vietnam veterans. METHODS: Logistic models were used to determine the association between PTSD and outcome while adjusting for demographic characteristics and medical and psychiatric co-morbidities. RESULTS: PTSD was associated with significantly elevated odds of poorer functioning in five of the six outcome domains; only the association between perpetration of violence in the past year and PTSD did not achieve statistical significance. After adjusting for demographics and medical and psychiatric co-morbidities, PTSD remained associated with significantly elevated odds of bed days, poorer physical health, and currently not working. CONCLUSIONS: Among female Vietnam veterans PTSD is associated with a broad profile of functional impairment. The significantly increased odds of impaired functioning and diminished quality of life suggest that PTSD may be the core problem of the set of problems afflicting female Vietnam veterans.     

Association between plasma homocysteine and extracranial carotid arterial disease in older persons

The data demonstrate that high plasma homocysteine levels and low plasma folate and vitamin B12 levels are associated with a higher prevalence of 40% to 100% extracranial carotid arterial disease (ECAD) in older men and women. Elevated plasma homocysteine levels were observed in 45% of the older men with 40% to 100% ECAD versus 20% of the older men with 0% to 39% ECAD, and in 40% of the older women with 40% to 100% ECAD versus 18% of the older women with 0% to 39% ECAD.     

The current status of somatostatin receptors in malignant melanoma

On the basis that melanomas are of neural crest origin and might contain somatostatin receptors, the authors utilized 111In Pentetreotide (OctreoScan) to image 16 melanoma patients with known sites of disease. Twelve of 16 patients were positive with 38 percent imaging all sites. No lesion less than 1.5 cm imaged nor did one ocular and one amelanotic melanoma. Of the five described somatostatin receptors, OctreoScan binds only 2 and 5 suggesting that not all melanomas contain those receptors. It is concluded that melanomas contain somatostatin receptors and that this property might be used for imaging, tumor suppression with Octreotide, and/or as a target for Octreotide labelled with therapeutic agents such as immune complexes, chemotherapeutic agents or high energy radioisotopes.     

Transluminal balloon angioplasty, stents, and atherectomy

Arterial bypass grafting for occlusive disease is still considered the gold standard in the treatment of arterial occlusive disease. However, less invasive methods are available for select patients. Percutaneous balloon angioplasty has been shown to be effective in focal iliac artery stenosis, with patency rates of 50% to 90% at 5 years. Patency rates for femoropopliteal lesions are generally less than 50% at 2 years. Complications seen with balloon angioplasty often can be treated with arterial stents. Stents can be categorized into balloon-expandable, which provide a rigid scaffold to support the artery, self-expanding, which exert radial force to resist external compression, and thermal expanding stents, which allow for the use of a smaller introducer sheath. Another treatment option is atherectomy, in which the offending lesion is removed instead of fracturing and dilating the lumen. Although overall initial results of atherectomy have not been favorable, short lesions with eccentric atheroma or intimal hyperplasia, such as those seen in dialysis access fistulas or vein graft stenoses, may respond well.     

Impaired bone marrow microenvironment and immune function in T cell protein tyrosine phosphatase-deficient mice

The T cell protein tyrosine phosphatase (TC-PTP) is one of the most abundant mammalian tyrosine phosphatases in hematopoietic cells; however, its role in hematopoietic cell function remains unknown. In this report, we investigated the physiological function(s) of TC-PTP by generating TC-PTP-deficient mutant mice. The three genotypes (+/+, +/-, -/-) showed mendelian segregation at birth (1:2:1) demonstrating that the absence of TC-PTP was not lethal in utero, but all homozygous mutant mice died by 3-5 wk of age, displaying runting, splenomegaly, and lymphadenopathy. Homozygous mice exhibited specific defects in bone marrow (BM), B cell lymphopoiesis, and erythropoiesis, as well as impaired T and B cell functions. However, myeloid and macrophage development in the BM and T cell development in the thymus were not significantly affected. BM transplantation experiments showed that hematopoietic failure in TC-PTP -/- animals was not due to a stem cell defect, but rather to a stromal cell deficiency. This study demonstrates that TC-PTP plays a significant role in both hematopoiesis and immune function.     

Effect of evaluator and resident gender on the American Board of Internal Medicine evaluation scores

OBJECTIVE: To examine the effects of resident and attending physician gender on the evaluation of residents in an internal medicine training program. DESIGN: Cross-sectional study. SETTING: Large urban academic internal medicine residency program. PARTICIPANTS: During their first 2 years of training, 132 residents (85 men, 47 women) received a total of 974 evaluations from 255 attending physicians (203 men, 52 women) from 1989 to 1995. MEASUREMENTS: The primary measurements were the numerical portions of the American Board of Internal Medicine evaluation form. Separate analyses were performed for each of the nine evaluation dimensions graded on a scale of 1 to 9. The primary outcome was the difference in the average scores received by each resident from male versus female attending physicians. RESULTS: Compared with female trainees, male residents received significantly higher scores from male attending physicians than from female attending physicians in six of the nine dimensions: clinical judgment, history, procedures, relationships, medical care, and overall. Similar trends, not reaching conventional levels of statistical significance, were observed in the other three categories: medical knowledge, physical exam, and attitude. These differences ranged from 0.24 to 0.60 points, and were primarily due to higher grading of male residents by male attending physicians than by female attending physicians. CONCLUSIONS: In one academic training program, we found a significant interaction in the grading process between the gender of internal medicine residents and the gender of their attending evaluators. This study raises the possibility that subtle aspects of gender bias may exist in medical training programs.     

Risk factors for new coronary events in older African-American men and women

Independent risk factors for new coronary events in older African-American men were (1) age (risk ratio = 1.037), (2) cigarette smoking (risk ratio = 2.231), (3) hypertension (risk ratio = 2.531), (4) serum total cholesterol (risk ratio = 1.012), (5) serum high-density lipoprotein (HDL) cholesterol (inverse association) (risk ratio = 0.948), and (6) prior coronary artery disease (CAD) (risk ratio = 2.288). Independent risk factors for new coronary events in older African-American women were (1) cigarette smoking (risk ratio = 2.202), (2) hypertension (risk ratio = 2.344), (3) diabetes mellitus (risk ratio = 1.632), (4) serum total cholesterol (risk ratio = 1.008), (5) serum HDL cholesterol (inverse association) (risk ratio = 0.936), (6) age (risk ratio = 1.026), and (7) prior CAD (risk ratio = 2.368).