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Distinguishing patients with post-stroke dementia
SCIENCE AND MEDICINE
Good and bad news for diabetic heart disease
T
he bad news, as cardiologists know, is that diabetic patients with multivessel coronary disease do not do as well with angioplasty as they do with bypass surgery. “The good news is that doctors are doing a pretty good job in medical decision making”, says William Weintraub (Emory University School of Medicine, Atlanta, GA, USA). “The sicker patients are going to surgery and the less sick ones are going to angioplasty.” Weintraub and a US team compared the outcomes of 2639 diabetic patients with multivessel coronary disease who underwent either cardiac bypass surgery or balloon angioplasty (J Am Coll Cardiol 1998; 31: 10–19). On the initial, unadjusted analysis there were no
substantial differences in long-term outcomes between the two groups. However, after adjustment for baseline differences between the groups, angioplasty did indeed seem to worsen the prognosis of these patients. The corrected 5 and 10 year survival rates were 68% and 36% in the angioplasty group and 75% and 47% in the surgery group. In an editorial, William O’Neill (William Beaumont Hospital, Royal Oak, MI, USA) calls for further research to explore whether strict glycaemic control, aggressive adjunctive pharmacological therapy, or stents can help improve the outcome of percutaneous interventions in these patients . Larry Husten
Gene predisposes carriers to mental illness eople who have a single mutation in the Wolfram-syndrome gene have an increased risk of developing a psychiatric illness. Carriers of the mutation have an estimated 26-fold increased risk of hospitalisation for psychiatric treatment when compared with non-carriers (Mol Psychiatry 1998; 3: 86–89). People homozygous for the mutant gene develop the rare neurodegenerative Wolfram syndrome, characterised by diabetes mellitus and optic nerve atrophy. Previous work had shown a high number of psychiatric hospitalisations and suicide attempts among blood relatives of people with Wolfram syndrome. In the new study, US researchers looked for heterozygous carriers of the mutant gene among the relatives
P
that had been hospitalised for psychiatric treatment. 10 out of 11 relatives were heterozygotes—only 3·1 heterozygotes were expected. About 1% of the population and 25% of patients hospitalised for similar problems could be carriers, note the authors. In psychiatric genetics, the use of hospitalisation as the marker for psychiatric illness, rather than individual clinical diagnoses, is controversial. But author Michael Swift (New York Medical College, NY, USA) says that hospitalisation is more objective because diagnoses can change over time. The next step, he explains, is to clone the gene and find out what it does.
News in brief 21st century vaccination Up to 12 million lives could be saved by new global vaccination efforts, according to the Children’s Vaccine Initiative Strategic Plan, released Jan 9. The report notes that existing vaccines are underused and many deaths could be prevented by vaccines in development. Cost-effectiveness is a key principle, which means, says Richard Feachem of the World Bank, that “there are few ways to spend your money better than vaccinating children”. CMV suspicions A study of cytomegalovirus (CMV) in AIDS has found that plasma CMV DNA predicts CMV disease and death. A log10 increase in baseline CMV DNA load was associated with a 3·1-fold increase in CMV disease and a 2·2-fold increase in mortality (J Clin Invest 1998; 101: 497–502). Detecting pregnancy problems Abnormal circadian blood-pressure (BP) variability in any trimester can predict 96% of women who will develop gestational hypertension and pre-eclampsia, say Ramón Hermida et al in this month’s Hypertension. Their test involves 48hour ambulatory BP monitoring, which “could be cost-effective in evaluating high risk women”. Seasonal knees? The human circadian clock is thought to adapt to the seasons via light entering the eye. Now, light has also been shown to adjust circadian rhythms when it falls on the back of the knees alone (Science 1998; 279: 384–87).
Hannah Wunsch
Distinguishing patients with post-stroke dementia ore than 30% of stroke survivors have dementia. This figure, which is higher than previous estimates, comes from a Finnish study planned to identify clinical features that distinguish stroke survivors with dementia from those without. In the study by researchers from the Memory Research Unit at the University of Helsinki, 486 consecutive patients aged 55–85 years were evaluated 3 months after having an ischaemic stroke. 337 patients completed all tests, including neuropsychological testing for dementia and brain magnetic resonance imaging.
M
190
Writing in Stroke (1998; 29: 75–81), the researchers note that patients with post-stroke dementia were more often older, current smokers, and educated to a lower level than non-demented stroke patients. The strongest risk factors for dementia were dysphasia (odds ratio [OR] 5·6), major dominant stroke syndrome (OR 5·0), and history of previous cerebrovascular disease (OR 2·0). Other features associated with dementia included: walking impairment; urinary incontinence; and lower arterial blood-pressure values. “By defining a stroke–dementia
patient’s profile, we may be better able to tell the difference between stroke dementia and Alzheimer’s disease”, says Timo Erkinjunti, Memory Research Unit chief. “It may turn out that some features, such as dysphasia or gait impairment, are more common in one disorder than the other.” Clinically, such distinctions are important because although there are no proven treatments to reverse memory loss, other problems associated with stroke dementia—eg, depression—can be improved. Janet Fricker
THE LANCET • Vol 351 • January 17, 1998
Good and bad news for diabetic heart disease
T
he bad news, as cardiologists know, is that diabetic patients with multivessel coronary disease do not do as well with angioplasty as they do with bypass surgery. “The good news is that doctors are doing a pretty good job in medical decision making”, says William Weintraub (Emory University School of Medicine, Atlanta, GA, USA). “The sicker patients are going to surgery and the less sick ones are going to angioplasty.” Weintraub and a US team compared the outcomes of 2639 diabetic patients with multivessel coronary disease who underwent either cardiac bypass surgery or balloon angioplasty (J Am Coll Cardiol 1998; 31: 10–19). On the initial, unadjusted analysis there were no
substantial differences in long-term outcomes between the two groups. However, after adjustment for baseline differences between the groups, angioplasty did indeed seem to worsen the prognosis of these patients. The corrected 5 and 10 year survival rates were 68% and 36% in the angioplasty group and 75% and 47% in the surgery group. In an editorial, William O’Neill (William Beaumont Hospital, Royal Oak, MI, USA) calls for further research to explore whether strict glycaemic control, aggressive adjunctive pharmacological therapy, or stents can help improve the outcome of percutaneous interventions in these patients . Larry Husten
Gene predisposes carriers to mental illness eople who have a single mutation in the Wolfram-syndrome gene have an increased risk of developing a psychiatric illness. Carriers of the mutation have an estimated 26-fold increased risk of hospitalisation for psychiatric treatment when compared with non-carriers (Mol Psychiatry 1998; 3: 86–89). People homozygous for the mutant gene develop the rare neurodegenerative Wolfram syndrome, characterised by diabetes mellitus and optic nerve atrophy. Previous work had shown a high number of psychiatric hospitalisations and suicide attempts among blood relatives of people with Wolfram syndrome. In the new study, US researchers looked for heterozygous carriers of the mutant gene among the relatives
P
that had been hospitalised for psychiatric treatment. 10 out of 11 relatives were heterozygotes—only 3·1 heterozygotes were expected. About 1% of the population and 25% of patients hospitalised for similar problems could be carriers, note the authors. In psychiatric genetics, the use of hospitalisation as the marker for psychiatric illness, rather than individual clinical diagnoses, is controversial. But author Michael Swift (New York Medical College, NY, USA) says that hospitalisation is more objective because diagnoses can change over time. The next step, he explains, is to clone the gene and find out what it does.
News in brief 21st century vaccination Up to 12 million lives could be saved by new global vaccination efforts, according to the Children’s Vaccine Initiative Strategic Plan, released Jan 9. The report notes that existing vaccines are underused and many deaths could be prevented by vaccines in development. Cost-effectiveness is a key principle, which means, says Richard Feachem of the World Bank, that “there are few ways to spend your money better than vaccinating children”. CMV suspicions A study of cytomegalovirus (CMV) in AIDS has found that plasma CMV DNA predicts CMV disease and death. A log10 increase in baseline CMV DNA load was associated with a 3·1-fold increase in CMV disease and a 2·2-fold increase in mortality (J Clin Invest 1998; 101: 497–502). Detecting pregnancy problems Abnormal circadian blood-pressure (BP) variability in any trimester can predict 96% of women who will develop gestational hypertension and pre-eclampsia, say Ramón Hermida et al in this month’s Hypertension. Their test involves 48hour ambulatory BP monitoring, which “could be cost-effective in evaluating high risk women”. Seasonal knees? The human circadian clock is thought to adapt to the seasons via light entering the eye. Now, light has also been shown to adjust circadian rhythms when it falls on the back of the knees alone (Science 1998; 279: 384–87).
Hannah Wunsch
Distinguishing patients with post-stroke dementia ore than 30% of stroke survivors have dementia. This figure, which is higher than previous estimates, comes from a Finnish study planned to identify clinical features that distinguish stroke survivors with dementia from those without. In the study by researchers from the Memory Research Unit at the University of Helsinki, 486 consecutive patients aged 55–85 years were evaluated 3 months after having an ischaemic stroke. 337 patients completed all tests, including neuropsychological testing for dementia and brain magnetic resonance imaging.
M
190
Writing in Stroke (1998; 29: 75–81), the researchers note that patients with post-stroke dementia were more often older, current smokers, and educated to a lower level than non-demented stroke patients. The strongest risk factors for dementia were dysphasia (odds ratio [OR] 5·6), major dominant stroke syndrome (OR 5·0), and history of previous cerebrovascular disease (OR 2·0). Other features associated with dementia included: walking impairment; urinary incontinence; and lower arterial blood-pressure values. “By defining a stroke–dementia
patient’s profile, we may be better able to tell the difference between stroke dementia and Alzheimer’s disease”, says Timo Erkinjunti, Memory Research Unit chief. “It may turn out that some features, such as dysphasia or gait impairment, are more common in one disorder than the other.” Clinically, such distinctions are important because although there are no proven treatments to reverse memory loss, other problems associated with stroke dementia—eg, depression—can be improved. Janet Fricker
THE LANCET • Vol 351 • January 17, 1998