Biomedical subjects
Publications and source records attributed to J B Walsh.
A clinical picture of Purtscher's retinopathy was observed in three patients with acute pancreatitis. In two patients, fluorescein angiography revealed arteriolar obstruction. Since fat emboli occur in pancreatitis, and since fat emboli may produce the picture of Purtscher's retinopathy, we proposed that fat emboli caused the retinal findings in these patients.
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We describe three cases of disseminated herpes zoster occurring in the elderly, and discuss the investigation and diagnosis of this condition. The presentation may be atypical with excoriated papular lesions. We suggest that disseminated herpes zoster does occur in the non-immunocompromised elderly patient, and is sometimes overlooked.
BACKGROUND: When worn external Hip Protectors (EHP) reduce hip fracture but poor compliance results in reduced efficacy. AIMS: We determined the compliance with EHP therapy among a group of elderly people attending a day hospital. METHODS: Forty-five patients or their care-givers were interviewed a mean (sd) 334 (150) days after they had been given EHP. RESULTS: There were 12 men and 33 women with mean age of 80 (7) years. Only ten (22%) were still wearing EHP properly. Those who were compliant were given their EHP more recently than those who were not (277 (118) days vs 403 (159), p = 0.0062) and were more likely to feel safer when wearing them (p = 00.017, chi2= 5.68). Reasons for non-compliance included exclusive outdoor wear, discomfort and inconvenience. CONCLUSIONS: Hip protector compliance was poor in this small study of elderly individuals attending a day hospital. Better patient education may improve compliance though this needs to be determined.
Although optic disc drusen have been of interest to ophthalmologists for more than 100 years, their etiology and many aspects of their relationship to other clinical conditions remain obscure. They have been clinically observed in 0.3% of the population, although autopsy studies suggest an incidence of 2%. Drusen are seldom accompanied by visual symptoms; however, decreased vision and visual field changes may occur. The historical and epidemiological aspects of drusen are reviewed; clinical and histological features, as well as special diagnostic techniques (ultrasonography and fluorescein angiography) are discussed in detail.
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Each mitochondrion and chloroplast organelle has tens to hundreds of genomes, and there are tens to hundreds of such organelles within each cell. This results in a genetic organization generating a population structure akin to a geographically structured population. Since genomes and organelles replicate and gene conversion can occur between copies, this offers the possibility for directional evolutionary forces acting within the cell. The consequences of genetic exchange within the cell (between genomes within an organelle and between individual organelles) and between individuals (biparental inheritance) when within-cell directional forces are present is examined. The net effect of genetic exchange is to increase the importance of any directional forces present within the cell. The consequences of within-cell forces when the variants they act on also have fitness consequences for individuals are also examined.
A patient who became blind following an episode of alcohol-induced pancreatitis is described. The clinical appearance of this patient's retinal changes corresponds most closely to post-traumatic (Purtscher's) retinopathy. The etiology of the retinopathy is best explained by retinal vascular occlusion due either to fat embolism or thrombosis.
The present study investigated the accuracy of an extended version of the Delayed Word Recall (DWR) test in distinguishing patients with very mild Alzheimer's disease (AD) (Mini Mental State Examination score > or = 23) from community-dwelling depressed/dysthymic patients. The DWR test was administered to 26 non-depressed patients who, at the time of DWR administration or on follow-up, fulfilled NINCDS/ADRDA criteria for probable AD, and to 20 age-matched non-dementing patients with a diagnosis of major depression (n = 12) or dysthymia (n = 8) according to DSM-III-R criteria. Sensitivity and specificity were, respectively, 96 and 100% for DWR free recall, and 92 and 100% for DWR recognition. In this study both DWR free recall and recognition measures were highly sensitive and specific in distinguishing very-mild-AD patients from depressed/dysthymic patients. The investigation of more severely depressed patients is warranted.
This study investigated differential patterns of performance by 40 Alzheimer's disease (AD) patients on standardised letter and category fluency tests. The performance of 24 age and education matched controls was used to classify patients as relatively more letter fluency impaired (L < C, n = 15) or more category fluency impaired (C < L, n = 25), and clinical features distinguishing these patient subgroups were investigated. Category performance was equally impaired in both patient subgroups, whereas the L < C subgroups were particularly impaired on letter fluency. The subgroups differed significantly in duration of illness (24 months for L < C group, 47 months for C < L group; t = 2.69, p = 0.01) but did not differ in global dementia severity, age, education, general language ability, or functional status. Data on annual rate of change (ARC) on the Mini-Mental State Examination were available for 26 patients. While not statistically significant, subgroup ARC differences were suggestive of more rapid decline in the L < C patients, consistent with the finding of shorter duration of illness in this group. Word fluency tests may have potential as early predictors of rate of progression in AD.
The possible association between aluminium and Alzheimer's disease is still contentious. If aluminium neurotoxicity is implicated in the pathophysiology of Alzheimer's disease, it may result either from excessive aluminium exposure or increased brain aluminium uptake. In a pilot study to test the former hypothesis, trabecular bone aluminium content, which reflects long-term aluminium exposure, was evaluated in 7 patients with a clinical diagnosis of senile dementia of the Alzheimer type (SDAT; mean age 80.8 +/- 3.35 years) and 19 non-demented age-matched controls (mean age 79.6 +/- 6.09 years). Trabecular bone was obtained from post-traumatic femoral neck fracture specimens taken from patients during femoral head prosthesis surgery. Bone aluminium content was expressed quantitatively by atomic absorption spectrometry and qualitatively by the acid solochrome azurine histological staining technique. Quantitative analysis showed a lower aluminium content in the SDAT (11.9 +/- 4.04 micrograms/g dry bone) versus the non-demented group (18.2 +/- 7.37 micrograms/g), which was significant at the 95% but not at the 99% confidence limit. Aluminium deposition from qualitative histological analysis was not detectable in either group. These results do not support a hypothesis of excessive aluminium absorption and tissue accumulation in Alzheimer's disease.
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Hypovitaminosis D is a common finding in the healthy elderly population and has significant sequelae. No clear dietary or sunlight-related risk factors were identified by dietary assessment and modified outdoor score. Fortified liquid milk and vitamin supplements were associated with significantly higher serum 25-hydroxyvitamin D levels. These results emphasise the need for foodstuff fortification and supplement use in the healthy elderly, as well as the 'high-risk' housebound and institutionalised elderly.
The aims and experience of work in a specialist memory clinic' are described with reference to the first 200 patients attending the service. 93.5% of attenders were found to suffer from dementia. 67.9% of these fulfilled criteria for probable/possible Alzheimer's disease or other primary degenerative dementias and 8.6% fulfilled criteria for vascular dementia. In the remaining cases the aetiology of the dementia was considered to be multifactorial. The memory clinic proved to be an important resource for demented patients, their carers, and for research projects.
'Saturday Flit, Short Sit' is a phrase recognised by 58% of our patient population. The superstition implies that leaving hospital on a Saturday is bad luck and will mean early re-admission to hospital. 13.7% of all patients interviewed would refuse to go home on a Saturday and 40% of doctors would allow postponement of discharge because of the patients superstition.
Increasing patient knowledge of drug therapy is said to improve compliance and may reduce adverse drug reactions. We assessed patient knowledge of prescribed drugs in fifty patients attending a hypertension clinic [outpatients] and in elderly patients on admission to (n = 129) and on discharge from (n = 100) an acute geriatric assessment unit. We found that 88% of outpatients, 40% of elderly admissions, and 41% of elderly discharges knew the indications for their therapy; only 40% of outpatients, 8% of elderly admissions and 12% of elderly discharges could name their medications. Patients said that their information came principally from the prescribing doctor. In a further study we assessed doctor, nurse, young and elderly patients' ability to discriminate between commonly prescribed white tablets. Errors were made by the doctors on 25% occasions, nurses on 40% occasions and patients on 61% occasions. Young patients made errors 67% of the time and elderly patients 55% of the time. These studies indicate that both inpatients and outpatients, both young and elderly have poor knowledge of their medications. In addition, many commonly prescribed drugs are not easily distinguishable by patient, prescriber or drug administrator. We conclude that there is a need to improve knowledge both in patients and in prescribers. We suggest that prescribers should consider the colour and shape of medications prescribed concurrently as many "little white tablets" are difficult to tell apart.
Poor vision is considered to be a common unreported illness in the elderly population. To determine its prevalence we carried out an eye screen on 150 randomly selected co-operative elderly subjects attending St James's Hospital. A database [mean age 78.2 years (range 65 to 97)], medical history, mini-mental test score [mean score 9.1 (range 2 to 10)], mobility assessment and history of eye problems was gathered. A visual test of both eyes together (standard N6 and N8), inspection of the eyes, tonometry (Perkin's handheld tonometer) and fundoscopy were performed on each subject and the need and reason for referral to an optician or an ophthalmologist was documented. Results show that 64% of subjects could read N6 or N8. Tonometry revealed no subject with raised intraocular pressure, including 4 subjects who were currently on treatment for glaucoma. Fundoscopy showed that 57.3% of subjects had some evidence of cataracts, 16.6% moderate and 3% severe. The retina appeared normal in 58.6% of subjects, 20.6% of the population had hypertensive changes, 4.6% had diabetic changes, 3% had optic atrophy, 1.3% had macular degeneration and a further 10% could not be clearly visualised due to cataracts. 90% of subjects wore glasses and the average duration since the glasses were last changed was 3.7 years (range 2 weeks to 20 years). No glasses examined were in need of cleaning or repair. 36% of subjects could not read N8 (28 of these had forgotten their glasses and were advised to visit their optician if they could not read newsprint). 7.3% of subjects were referred to an optician for new glasses, 1.3% were referred to an ophthalmologist for newly diagnosed cataracts and 6.6% were regular attenders to an ophthalmologist. We conclude that the rate of new referrals for the occurrence of correctable undetected visual acuity deficit was lower than expected at 8.6% of subjects screened.