Journal of the Royal Society of Medicine Volume 84 November 1991
Falls in the elderly In his stimulating editorial Dr Waterston (April 1991 JRSM, p 189) notes that many epidemiological studies have been carried out on populations of elderly fallers, but those which he cites do not do justice to the literature. He refers to a study of postural sway with age that was not population-based', and to a case series in which the falls ascertained were only a 20th of those occurring in the target population2. The latter study has been criticized for being biased heavily in favour of a selectively frail and ill sample, in whom the risk factors for falling and the associated prognosis are different from the majority of elderly fallers3. The relevant literature contains both retrospective4-6 and prospective7-9 studies of falling by elderly people at home in geographically-defined populations. Falling is common, and the causes are complex. Progress in treatment and prevention will depend on carefully designed research which can clearly be related to the available epidemiological evidence. S WINNER
University Division of Geriatric Medicine, The Radcliffe Infirmary, Oxford OX2 6HE
References 1 Overstall PW, Exton-Smith AN, Imms FJ, Johnson AL. Falls in the elderly related to postural imbalance. BMJ 1977;i:261-4 2 Wild D, Nayak USL, Isaacs B. How dangerous are falls in old people at home? BMJ 1981;282:266-8 3 Evans JG. Commentary: Falls and fractures. Age Ageing 1988;17:361-3 4 Prudham D, Grimley Evans J. Factors associated with falls in the elderly: a community study. Age Ageing 1981:10:141-6 5 Campbell AJ, Reinken J, Allan BC, Martinez GS. Falls in old age: a study of frequency and related clinical factors. Age Ageing 1981;10:264-70 6 Blake AJ, Morgan K, Bendall MJ et al. Falls by elderly people at home: prevalence and associated factors. Age Ageing 1988;17:365-72 7 Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-7 8 Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989;44:M112-17 9 Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990; 19:136-41
Waiting list initiatives I read the article 'Waiting list initiatives: crisis management of targeting of resources?' by Mills and Heaton with interest (July 1991 JRSM, p 405). Waiting lists exist for a number of reasons as explained in the article. While consultants may organize an initiative, ENT registrars almost always undertake it as was the case here. Juniors have very little say in these ventures and it is usually their study leave or their half day that is forfeited often with no recompense either in time or money. Little can be said for the surgical experience gained for lists are usually unsupervised. Since there are so few research posts in our specialty such an erosion into time set aside for research is less than praiseworthy. These points were clearly illustrated by the waiting list initiatives undertaken in Birmingham both at
Selly Oak Hospital and at the Queen Elizabeth Hospital: the same registrar on rotation had to undertake both initiatives, one post was derived from waiting list monies and one was undertaken during time set aside for research. In addition no costing of surgical time was built into the bid at the Queen Elizabeth. In the past, one was left with the feeling that these initiatives were political exercises undertaken in collusion between consultants and management to paper over the inadequacies of the system without addressing the real reasons for waiting lists. Once the lists are culled, then theoretically, the surgeons may work more efficiently. Now there is no money for waiting list initiatives: the problem hastobe sorted out within the sessions available. Shorter lists should have more cases on them. Efficiency as envisaged by the production line mentality of the new health service management. Unless a consultant has no waiting list, there is a catch. Long waiting lists result in default and so the theatre lists are shorter! Unfortunately our new district management has put a block on replacing retiring consultants. Our new integrated (but split on two sites) department previously had an initiative in each hospital and now has a retirement. Yes, you have guessed it, he has the longest waiting list. A DRAKE-LEE
Consultant ENT Surgeon, 20 Vernon Road, Edgbaston, Birmingham B16 9SH
Crohn's disease of the vulva We read with interest the case report by Kingsland and Alderman (April 1991 JRSM, p 236). Crohn's disease of the vulva is rare as in one review it was noted that out of 431 cases of Crohn's disease in the female patients, eight women had intractable vulval vaginitis'. So far as we are aware only 16 cases of Crohn's disease ofthe vulva has been reported including the authors' case. Though the authors claim that their patient is unusual to have developed the vulval lesion within 20 years of the onset of the disease, we note that 10 patients with Crohn's disease of the gastrointestinal tract appeared to have developed the vulval lesions within 20 years. Ten women had vulval disease when they were not on any medication2. There is no consensus about therapy of this condition but it is generally agreed that if medical therapy fails, surgical therapy such as vulvectomy or debridement therapy may be required2. J HOSSAIN Departments of Medicine and Surgery King Khalid Hospital, M L BAzAZ Jeddah, Saudi Arabia
References 1 Davidson LB. Crohn's disease. Its gynaecological aspect. Am J Obstet Gynecol 1978;131:196-202 2 Burke T. A 34 year old woman with a history of Crohn's disease with recent vulvular cellulitis. N Engl J Med 1989;320:1741-7
Honey and healing of leg ulcers Dr Frank Tovey (July 1991 JRSM, p 447) advocates a sugar paste to be.applied to chronic leg ulcers, as a means of separating moist slough and promoting the healing of granulating wounds, especially in diabetic patients. For many centuries doctors have applied a wide variety of ointments and lotions to ulcers associated with oedema of the leg or foot.
693
694
Journal of the Royal Society of Medicine Volume 84 November 1991
Oedema is rapidly dispersed by elevating the affected limb for 2 or 3 days1 2. Exudation stops when the leg is 'dried out', and application of a non-stretch bandage boot prevents recurrence of the oedema. If a square of dry gauze is applied to the ulcer a dry scab will form in its meshes, which will separate from the skin when the ulcer is healed3. Two patients with diabetic foot ulcers were cured at home by high elevation of the affected leg until sequestra were extruded and the ulcers healed4. I H J BOURNE
Richmond, Thorndon Approach, Herongate, Brentwood CM13 3PA
References 1 Bourne IHJ. An investigation into the function of apparently flat and empty superficial veins observed in the leg of a patient undergoing treatment by high leg elevation. In: Negus D, Jantet G, eds. Phlebology 85. 1985:282-4 2 Bourne IHJ. Verification of a hypothesis concerning the path along which oedema fluid drains away from an elevated swollen leg with the patient supine. In: Negus D, Jantet G, eds. Phlebology 85. 1985:278-81 3 Bourne IHJ. Drainage of oedema in treatment of leg ulcers. BMJ 1972;581-3 4 Bourne IHJ. Treatment of gravitational ulcers and oedema of the lower limb by postural drainage and inelastic compression bandages. MD Thesis, London University, 1972:236,250,252
Lipids in non-insulin dependent diabetes: a case for treatment? Elkeles recently proposed' that there is a need for long-term studies in non-insulin dependent diabetics (NIDDM) to ascertain whether correcting lipid abnormalities results in beneficial effects in terms of cardiovascular disease (July 1991 JRSM, p 393). Elkeles also suggests that fibrate drugs seem ideally suited to correcting lipid abnormalities in NIDDM because they reduce triglycerides, increase HDL and modestly reduce cholesterol. We offer recent evidence in support of these statements. Plasma fibrinogen concentration is elevated in NIDDM and is an independent predictor of ischaemic heart disease (IHD)1-4. It is therefore important to consider that bezafibrate significantly lowers plasma fibrinogen concentration in NIDDM3 and insulin dependent DM2. However, it is important to consider that all fibrates may not have the same fibrinogenlowering potency2'5. Bezafibrate also normalizes some aspects of nonesterified fatty acid metabolism3'6 and significantly reduces blood glucose and glycated haemoglobin levels in NIDDM3. These are desirable effects, but their significance in terms of the pathogenesis of cardiovascular complications in NIDDM remains to be clarified. Fibrates, and other lipid-lowering drugs, exert beneficial actions on platelets7. This effect is of interest since abnormal platelet function has been documented in diabetics8. Antiplatelet action should also be considered in the light of recent evidence which indicates that platelet hyperactivity predicts the incidence of IHD9. In view of the evidence previously reviewed' and the above observations, we wholeheartedly agree with Dr Elkeles' suggestions. D P MIKHAILIDIS M A BARRADAS
Department of Chemical Pathology & Human Metabolism,
Royal Free Hospital & School of Medicine, Pond Street, London NW3 2QG
References 1 Rosove MH, Frank HJL, Harwig SSL. Plasma betathromboglobulin, platelet factor 4, fibrinopeptide A, and other haemostatic functions during improved short-term glycemic control in diabetes mellitus. Diabetes Care 1984;7:174-9 2 Winocour PH, Durrington PN, Bhatnagar, et al. Doubleblind placebo-controlled study of the effects of bezafibrate on blood lipids, lipoproteins, and fibrinogen in hyperlipidaemic type 1 diabetes mellitus. Diabetic Med 1990; 7:736-43 3 Mathur S, Barradas MA, Mikhailidis DP, Dandona P. The effect of a slow release formulation of bezafibrate on lipids, glucose homeostasis, platelets and fibrinogen in type II diabetics: a pilot study. Diabetes Res 1990;14:133-8 4 Meade TW, Mellows S, Brozovic M, et al. Haemostatic function and ischaemic heart disease: principal results of the Northwick Park Heart Study. Lancet 1986;ii:533-7 5 Stringer MD, Steadman CA, Kakkar VV. Gemfibrozil in hyperlipidaemic patients with peripheral arterial disease: some undiscovered actions. Curr Med Res Opin 1990; 12:207-14 6 Alberti KGMM, Jones IR, Laker MF, Swai ABM, Taylor R. Effect of bezafibrate on metabolic profiles in non-insulin-dependent diabetes mellitus. J Cardiovasc Pharmacol 1990;16(suppl. 9):S21-S25 7 Mikhailidis DP, Barradas MA. Haemostatic effects of lipid-lowering drugs. J Drug Develop 1989;2:69-71 8 Hendra T, Betteridge DJ. Platelet function, platelet prostanoids and vascular prostacyclin in diabetes mellitus. Prostaglandins Leukot Essntl Fatty Acids (Reviews) 1989;35:197-212 9 Mikhailidis DP, Barradas MA, Jeremy JY. Platelet Hyperactivity: a predictor of cardiac events and death from myocardial infarction. Platelets 1990;1:217-18
Value of emergency cardiac enzymes I fear that underdiagnosis of myocardial infarction will inevitably occur if we rigidly adhere to the enzyme cut off levels (ie, 2xupper limit of normal) recommended by Lewis et al. (July 1991 JRSM, p 398), since 'some patients show clear evidence of a characteristic rise and fall entirely within the normal range". Much more specific is the presence of the isoenzyme MBCPK which can be diagnostic not only in its pattern of release but also in the absolute levels attained even in patients with normal or borderline total CPK'-3. Finally, unless blood samples are taken 4 hourly for 48 h and 6 hourly for the next 24 h, total CPK levels which attain the diagnostic levels prescribed by Lewis et al. could be missed altogether'. Dufour et al. recommended 8 hourly blood tests for 24 h, but the optimum sampling frequency is not known. O M P JOLOBE
Department of Medicine for the Elderly Tameside General Hospital, Ashton-Under-Lyne OL6 9RW
References 1 Yusef S, et aL Significance of elevated MB isoenzyme with normal creatine kinase in myocardial infarct. Am J Cardiol 1987:59:245-50 2 Dillin MC et al. Diagnostic problem in acute myocardial infarction CK-MB in the absence of abnormally elevated total creatine kinase activity. Arch Inter Med 1982:142:33-38 3 Heller GV, Blaustein AS, Wei JY. Implications of increased myocardial isoenzyme level in the presence of normal serum creatine kinase activity. Am J Cardiol 1983;51:24-8 4 Dufour DR, LaGrenade A, Guena J. Rapid serial enzyme measurements in evaluation of patients with suspected myocardial infarction. Am J Cardiol 1989;63:652-5
Falls in the elderly In his stimulating editorial Dr Waterston (April 1991 JRSM, p 189) notes that many epidemiological studies have been carried out on populations of elderly fallers, but those which he cites do not do justice to the literature. He refers to a study of postural sway with age that was not population-based', and to a case series in which the falls ascertained were only a 20th of those occurring in the target population2. The latter study has been criticized for being biased heavily in favour of a selectively frail and ill sample, in whom the risk factors for falling and the associated prognosis are different from the majority of elderly fallers3. The relevant literature contains both retrospective4-6 and prospective7-9 studies of falling by elderly people at home in geographically-defined populations. Falling is common, and the causes are complex. Progress in treatment and prevention will depend on carefully designed research which can clearly be related to the available epidemiological evidence. S WINNER
University Division of Geriatric Medicine, The Radcliffe Infirmary, Oxford OX2 6HE
References 1 Overstall PW, Exton-Smith AN, Imms FJ, Johnson AL. Falls in the elderly related to postural imbalance. BMJ 1977;i:261-4 2 Wild D, Nayak USL, Isaacs B. How dangerous are falls in old people at home? BMJ 1981;282:266-8 3 Evans JG. Commentary: Falls and fractures. Age Ageing 1988;17:361-3 4 Prudham D, Grimley Evans J. Factors associated with falls in the elderly: a community study. Age Ageing 1981:10:141-6 5 Campbell AJ, Reinken J, Allan BC, Martinez GS. Falls in old age: a study of frequency and related clinical factors. Age Ageing 1981;10:264-70 6 Blake AJ, Morgan K, Bendall MJ et al. Falls by elderly people at home: prevalence and associated factors. Age Ageing 1988;17:365-72 7 Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-7 8 Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989;44:M112-17 9 Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990; 19:136-41
Waiting list initiatives I read the article 'Waiting list initiatives: crisis management of targeting of resources?' by Mills and Heaton with interest (July 1991 JRSM, p 405). Waiting lists exist for a number of reasons as explained in the article. While consultants may organize an initiative, ENT registrars almost always undertake it as was the case here. Juniors have very little say in these ventures and it is usually their study leave or their half day that is forfeited often with no recompense either in time or money. Little can be said for the surgical experience gained for lists are usually unsupervised. Since there are so few research posts in our specialty such an erosion into time set aside for research is less than praiseworthy. These points were clearly illustrated by the waiting list initiatives undertaken in Birmingham both at
Selly Oak Hospital and at the Queen Elizabeth Hospital: the same registrar on rotation had to undertake both initiatives, one post was derived from waiting list monies and one was undertaken during time set aside for research. In addition no costing of surgical time was built into the bid at the Queen Elizabeth. In the past, one was left with the feeling that these initiatives were political exercises undertaken in collusion between consultants and management to paper over the inadequacies of the system without addressing the real reasons for waiting lists. Once the lists are culled, then theoretically, the surgeons may work more efficiently. Now there is no money for waiting list initiatives: the problem hastobe sorted out within the sessions available. Shorter lists should have more cases on them. Efficiency as envisaged by the production line mentality of the new health service management. Unless a consultant has no waiting list, there is a catch. Long waiting lists result in default and so the theatre lists are shorter! Unfortunately our new district management has put a block on replacing retiring consultants. Our new integrated (but split on two sites) department previously had an initiative in each hospital and now has a retirement. Yes, you have guessed it, he has the longest waiting list. A DRAKE-LEE
Consultant ENT Surgeon, 20 Vernon Road, Edgbaston, Birmingham B16 9SH
Crohn's disease of the vulva We read with interest the case report by Kingsland and Alderman (April 1991 JRSM, p 236). Crohn's disease of the vulva is rare as in one review it was noted that out of 431 cases of Crohn's disease in the female patients, eight women had intractable vulval vaginitis'. So far as we are aware only 16 cases of Crohn's disease ofthe vulva has been reported including the authors' case. Though the authors claim that their patient is unusual to have developed the vulval lesion within 20 years of the onset of the disease, we note that 10 patients with Crohn's disease of the gastrointestinal tract appeared to have developed the vulval lesions within 20 years. Ten women had vulval disease when they were not on any medication2. There is no consensus about therapy of this condition but it is generally agreed that if medical therapy fails, surgical therapy such as vulvectomy or debridement therapy may be required2. J HOSSAIN Departments of Medicine and Surgery King Khalid Hospital, M L BAzAZ Jeddah, Saudi Arabia
References 1 Davidson LB. Crohn's disease. Its gynaecological aspect. Am J Obstet Gynecol 1978;131:196-202 2 Burke T. A 34 year old woman with a history of Crohn's disease with recent vulvular cellulitis. N Engl J Med 1989;320:1741-7
Honey and healing of leg ulcers Dr Frank Tovey (July 1991 JRSM, p 447) advocates a sugar paste to be.applied to chronic leg ulcers, as a means of separating moist slough and promoting the healing of granulating wounds, especially in diabetic patients. For many centuries doctors have applied a wide variety of ointments and lotions to ulcers associated with oedema of the leg or foot.
693
694
Journal of the Royal Society of Medicine Volume 84 November 1991
Oedema is rapidly dispersed by elevating the affected limb for 2 or 3 days1 2. Exudation stops when the leg is 'dried out', and application of a non-stretch bandage boot prevents recurrence of the oedema. If a square of dry gauze is applied to the ulcer a dry scab will form in its meshes, which will separate from the skin when the ulcer is healed3. Two patients with diabetic foot ulcers were cured at home by high elevation of the affected leg until sequestra were extruded and the ulcers healed4. I H J BOURNE
Richmond, Thorndon Approach, Herongate, Brentwood CM13 3PA
References 1 Bourne IHJ. An investigation into the function of apparently flat and empty superficial veins observed in the leg of a patient undergoing treatment by high leg elevation. In: Negus D, Jantet G, eds. Phlebology 85. 1985:282-4 2 Bourne IHJ. Verification of a hypothesis concerning the path along which oedema fluid drains away from an elevated swollen leg with the patient supine. In: Negus D, Jantet G, eds. Phlebology 85. 1985:278-81 3 Bourne IHJ. Drainage of oedema in treatment of leg ulcers. BMJ 1972;581-3 4 Bourne IHJ. Treatment of gravitational ulcers and oedema of the lower limb by postural drainage and inelastic compression bandages. MD Thesis, London University, 1972:236,250,252
Lipids in non-insulin dependent diabetes: a case for treatment? Elkeles recently proposed' that there is a need for long-term studies in non-insulin dependent diabetics (NIDDM) to ascertain whether correcting lipid abnormalities results in beneficial effects in terms of cardiovascular disease (July 1991 JRSM, p 393). Elkeles also suggests that fibrate drugs seem ideally suited to correcting lipid abnormalities in NIDDM because they reduce triglycerides, increase HDL and modestly reduce cholesterol. We offer recent evidence in support of these statements. Plasma fibrinogen concentration is elevated in NIDDM and is an independent predictor of ischaemic heart disease (IHD)1-4. It is therefore important to consider that bezafibrate significantly lowers plasma fibrinogen concentration in NIDDM3 and insulin dependent DM2. However, it is important to consider that all fibrates may not have the same fibrinogenlowering potency2'5. Bezafibrate also normalizes some aspects of nonesterified fatty acid metabolism3'6 and significantly reduces blood glucose and glycated haemoglobin levels in NIDDM3. These are desirable effects, but their significance in terms of the pathogenesis of cardiovascular complications in NIDDM remains to be clarified. Fibrates, and other lipid-lowering drugs, exert beneficial actions on platelets7. This effect is of interest since abnormal platelet function has been documented in diabetics8. Antiplatelet action should also be considered in the light of recent evidence which indicates that platelet hyperactivity predicts the incidence of IHD9. In view of the evidence previously reviewed' and the above observations, we wholeheartedly agree with Dr Elkeles' suggestions. D P MIKHAILIDIS M A BARRADAS
Department of Chemical Pathology & Human Metabolism,
Royal Free Hospital & School of Medicine, Pond Street, London NW3 2QG
References 1 Rosove MH, Frank HJL, Harwig SSL. Plasma betathromboglobulin, platelet factor 4, fibrinopeptide A, and other haemostatic functions during improved short-term glycemic control in diabetes mellitus. Diabetes Care 1984;7:174-9 2 Winocour PH, Durrington PN, Bhatnagar, et al. Doubleblind placebo-controlled study of the effects of bezafibrate on blood lipids, lipoproteins, and fibrinogen in hyperlipidaemic type 1 diabetes mellitus. Diabetic Med 1990; 7:736-43 3 Mathur S, Barradas MA, Mikhailidis DP, Dandona P. The effect of a slow release formulation of bezafibrate on lipids, glucose homeostasis, platelets and fibrinogen in type II diabetics: a pilot study. Diabetes Res 1990;14:133-8 4 Meade TW, Mellows S, Brozovic M, et al. Haemostatic function and ischaemic heart disease: principal results of the Northwick Park Heart Study. Lancet 1986;ii:533-7 5 Stringer MD, Steadman CA, Kakkar VV. Gemfibrozil in hyperlipidaemic patients with peripheral arterial disease: some undiscovered actions. Curr Med Res Opin 1990; 12:207-14 6 Alberti KGMM, Jones IR, Laker MF, Swai ABM, Taylor R. Effect of bezafibrate on metabolic profiles in non-insulin-dependent diabetes mellitus. J Cardiovasc Pharmacol 1990;16(suppl. 9):S21-S25 7 Mikhailidis DP, Barradas MA. Haemostatic effects of lipid-lowering drugs. J Drug Develop 1989;2:69-71 8 Hendra T, Betteridge DJ. Platelet function, platelet prostanoids and vascular prostacyclin in diabetes mellitus. Prostaglandins Leukot Essntl Fatty Acids (Reviews) 1989;35:197-212 9 Mikhailidis DP, Barradas MA, Jeremy JY. Platelet Hyperactivity: a predictor of cardiac events and death from myocardial infarction. Platelets 1990;1:217-18
Value of emergency cardiac enzymes I fear that underdiagnosis of myocardial infarction will inevitably occur if we rigidly adhere to the enzyme cut off levels (ie, 2xupper limit of normal) recommended by Lewis et al. (July 1991 JRSM, p 398), since 'some patients show clear evidence of a characteristic rise and fall entirely within the normal range". Much more specific is the presence of the isoenzyme MBCPK which can be diagnostic not only in its pattern of release but also in the absolute levels attained even in patients with normal or borderline total CPK'-3. Finally, unless blood samples are taken 4 hourly for 48 h and 6 hourly for the next 24 h, total CPK levels which attain the diagnostic levels prescribed by Lewis et al. could be missed altogether'. Dufour et al. recommended 8 hourly blood tests for 24 h, but the optimum sampling frequency is not known. O M P JOLOBE
Department of Medicine for the Elderly Tameside General Hospital, Ashton-Under-Lyne OL6 9RW
References 1 Yusef S, et aL Significance of elevated MB isoenzyme with normal creatine kinase in myocardial infarct. Am J Cardiol 1987:59:245-50 2 Dillin MC et al. Diagnostic problem in acute myocardial infarction CK-MB in the absence of abnormally elevated total creatine kinase activity. Arch Inter Med 1982:142:33-38 3 Heller GV, Blaustein AS, Wei JY. Implications of increased myocardial isoenzyme level in the presence of normal serum creatine kinase activity. Am J Cardiol 1983;51:24-8 4 Dufour DR, LaGrenade A, Guena J. Rapid serial enzyme measurements in evaluation of patients with suspected myocardial infarction. Am J Cardiol 1989;63:652-5
