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Sir- Shah and colleagues report (1) about the prevalence of
psychiatric disorders affecting elderly people institutionalised in a
rehabilitation unit, concludes about depression that it is common among
older adults, it is a treatable condition and that in cases which there
are cognitive impairments associated to concomitant depression, the
cognitive impairments are worsened by the depressive disease. Although the
relev...
Sir- Shah and colleagues report (1) about the prevalence of
psychiatric disorders affecting elderly people institutionalised in a
rehabilitation unit, concludes about depression that it is common among
older adults, it is a treatable condition and that in cases which there
are cognitive impairments associated to concomitant depression, the
cognitive impairments are worsened by the depressive disease. Although the
relevance about the high prevalence of cognitive impairments and
depression in these patients is important and it is necessary to call
attention on it, I believe that from the psychiatric perspective, the
problem has been oversimplified. Therefore, we cannot accept the Shah et
al elementary proposition about a drug trial with the selective serotonin
reuptake inhibitors (SSRI’s) to elucidate the correct diagnosis when
diagnostic doubts remain.
Depressive states in older patient groups have a tremendous clinical
heterogeneity. Besides the depressive elderly patient without complicated
somatic pathology or psychiatric co-morbidity, which will respond usually
to antidepressant drugs, a significant proportion of other symptomatic
depressed patients (whose cases are precisely studied by Shah and
colleagues in this article) should be considered into the following
distribution : A first subgroup of elderly depressed patients, may show
greater cognitive deficits as compared to age-similar normal subjects (2)
. These patients also present (subcortical) dysfunction of learning and
memory, comprising the so-called "depressive pseudodementia", and may show
reversible cognitive deficits after successful somatic treatment of
depression. A second patients subgroup, display cognitive deficits
characterised by severe prefrontal dysfunction, with perseveration,
psychomotor retardation and long P300 latency (3) . A third subgroup,
presents features of depression that are related to underlying vascular
disease and neurological lesions, corresponding to the hypothesised
"vascular depression" (4). In the fourth place, many patients with late-
life onset of cognitive deficits, psychomotor retardation and limited
depressive ideation, correspond to the "apathy syndrome (5) " that
frequently follows brain damage in caudate, putamen and thalamus, usually
secondary to cerebrovascular heterogeneous diseases.
While SSRI’s may be useful for the first subgroup, they are useless
in the second and third one, while in the fourth, the dopamine agonists
like bromocriptine are required. Hence, it is erroneous to overgeneralise
that "depressed elderly respond well to SSRI’s" like Shah et al suggest.
And what about the caution needed in the SSRI’s prescription (where Shah
and colleagues state that these drugs are safe in the elderly, in spite of
their habitually need of multiple medications) because of its significant
drug interactions resulting from interference with components of the
hepatic "P-450 enzyme system" (6)?.
Moreover, Shah and colleagues also state that patients with dementia
may become depressed, particularly if they have insight into their
condition. Evidence based medicine shows that the frequent depressive
symptoms founded in these patients, are indeed early manifestations of
Alzheimer disease (7), in which case, cholinesterase inhibitor drugs
instead antidepressants is indicated.
Incidentally, Shah and colleagues state that there are no biological
diagnostic tests for depression. Besides the dexametasone-cortisol test,
the high prevalence of brain dysfunction in the geriatric depressed and
cognitive impaired patient suggests that the computer analysed,
quantitative electroencephalographic record (QEEG) may help not only in
the brain damage differential diagnosis but also in signalling depressive
disease by showing the characteristic increased anterior alpha power and
decreased generalised coherence (8).
Drug treatments for every elderly disturbance, like for any other
human complaint, must to be always a carefully skilled decision.
1.- Shah DC, Evans M, King D. Prevalence of mental illness in a
rehabilitation unit for older adults. Postgrad Med 2000 ; 76 : 153 - 156
2.- Kramer-Ginsberg E, Greenwald BS, Krishnan RR, Christiansen B, Hu
J, Ashtari M et al. Neuropsychological Functioning and MRI Signal
Hyperintensities in Geriatric Depression. Am J Psychiatry 1999 ; 156 :
438 - 444
3.- Kalayam B, Alexopoulos GS. Prefrontal Dysfunction and Treatment
Response in Geriatric Depression. Arch Gen Psychiatry 1999 ; 56 : 713 -
718
4.- Alexopoulos GS, Meyers BS, Young RC, Campbell S, Silbersweig D,
Charlson M. Vascular Depression Hypothesis. Arch Gen Psychiatry 1997 ; 54
: 915 - 922
6.- The P-450 System : Definition and Relevance to the Use of
Antidepressants in Medical Practice. Arch Fam Med 1996 ; 5 : 406 - 412
7.- Chen P, Ganguli M, Mulsant BH, DeKosky ST. The Temporal
Relationship Between Depressive Symptoms and Dementia. Arch Gen
Psychiatry 1999 ; 56 : 261 - 266
8.- Hughes JR, John R. Conventional and Quantitative
Electroencephalography in Psychiatry. J Neuropsychiatry Clin Neurosci
1999 ; 11 : 190 - 208
Dear Sirs:
A good friend of mine in Europe, Dr. Gonzalo Herranz MD/Phd emailed me
your article, which I found exceedingly well researched as well as well
written.
There is no doubt that Western Civilization is in a culture war, a
war "within", a "spreading spiritual malaise" in the words of Irving
Kristol. Writing in 1840, Tocqueville imagined a society consumed with
such a malaise, in which government, com...
Dear Sirs:
A good friend of mine in Europe, Dr. Gonzalo Herranz MD/Phd emailed me
your article, which I found exceedingly well researched as well as well
written.
There is no doubt that Western Civilization is in a culture war, a
war "within", a "spreading spiritual malaise" in the words of Irving
Kristol. Writing in 1840, Tocqueville imagined a society consumed with
such a malaise, in which government, compassionate toward its subjects,"
provides for their security, foresees and supplies their necessities,
facilitates their pleasures, manages their principal concerns, directs
their industry, makes rules for their testaments, and divides their
inheritances....It does not break men's will, but softens, bends, and
guides it; it seldom enjoins, but often inhibits action; it does not
destroy anything, but prevents much being born...."
Leaders in the Western world need to take a stand on what is right,
what is moral and to lift up the youth not tear them down with false
alchemies. There is something deep in the human spirit that wants to
know, love and live the truth. Young people need to know the truth about
human sexuality, about true love, the need to be challenged to live an
ideal, not to be given to animal instincts. The greatest evil legacy that
President Clinton will leave the youth of America is his scandalous
behaviour in the White House with an intern. Young people deserve better
leaders. In a few years the Dow Jones will not provide a false sense of
security to those who have put their treasure in something that by nature
is ephemeral.
Youth will respond to a challenge from leadrs to overcome themselves,
just as they respond to a challenge to sacrifice themselves for a team.
There is no conflict between faith and reason. The best science and
medical facts support the teachings of all the historical religions that
life is precious and must be protected and nurtured at all stages. This is
the mission of our foundation and can be found in the ever evolving web
site http.//www.culture-of-life.org. Your work is very well done and we
shall with your permission, post it on our web site.
Thanks for confirming that "life is beautiful."
Sincerely,
Robert A. Best
President Culture of Life Foundation and it's Research &
Communications Institute
A recent review article in your journal gives the impression that the
case for heparinisation of patients with cerebral venous thrombosis (CVT)
is proven [1]. The largest and most robust study did not come to this
conclusion and its results did not achieve statistical significance [2].
Given that CVT has a spectrum of presentations from headache to coma, a
blanket approach to treatment in the absence of good evidence and...
A recent review article in your journal gives the impression that the
case for heparinisation of patients with cerebral venous thrombosis (CVT)
is proven [1]. The largest and most robust study did not come to this
conclusion and its results did not achieve statistical significance [2].
Given that CVT has a spectrum of presentations from headache to coma, a
blanket approach to treatment in the absence of good evidence and
continued debate [3] does not seem sensible.
2. de Bruijn SF, Stam J, for the CVST Study Group. Randomised,
placebo-controlled trial of anticoagulant treatment with low-molecular-
weight heparin for cerebral sinus thrombosis. Stroke 1999;30:484-488.
3. Lewis MB. Cerebral venous thrombosis: nothing, heparin, or local
thrombolysis? Stroke 1999;30:1729.
Whilst Huang and Dutta correctly state that re-sheathing of
needles is almost universally condemned, one must also remember
that needle-stick injuries can also occur as a result of needles
not being re-sheathed. This happened to me as a young house-
officer, when a nurse dropped an unsheathed needle from a tray,
and it promptly embedded itself int...
Whilst Huang and Dutta correctly state that re-sheathing of
needles is almost universally condemned, one must also remember
that needle-stick injuries can also occur as a result of needles
not being re-sheathed. This happened to me as a young house-
officer, when a nurse dropped an unsheathed needle from a tray,
and it promptly embedded itself into my thigh!
This case is extremely useful as an illustration of the varying
presentations of phaeochromocytomas. The inclusion of the CT and the
details of the differential effects given depending upon the catecholamine
released were helpful.
I might venture a further, perhaps more important, mediator of the
dramatic drop in K+ noted in this patient and other phaeos. There are a
large number of beta ad...
This case is extremely useful as an illustration of the varying
presentations of phaeochromocytomas. The inclusion of the CT and the
details of the differential effects given depending upon the catecholamine
released were helpful.
I might venture a further, perhaps more important, mediator of the
dramatic drop in K+ noted in this patient and other phaeos. There are a
large number of beta adrenoceptors and sympathetic nerves in the renin-
secreting apparatus of the kidney. Stimulation of these should
precipitate, eventually, a raised aldosterone level and thus a drop in K+
(with an increased Na+). Neither Na+ nor any of the components of this
renin-(ACE)-AGII-Aldosterone axis were measured in the article. I wonder
what any relevant tests actually did show? When discussing how beta-
blockers work in hypertension, this is undoubtedly part of the wider
explanation.
Goldhammer et al (1) concluded from their retrospective study of
patients treated with streptokinase that efficacy was higher in the early
evening hours. There are at least two important confounding variables
which may explain these observations. Firstly, it has been previously
found that the time of day has an impact not only on the incidence, but
also on the severity of AMI (2). Hence, the apparent reduction in
effi...
Goldhammer et al (1) concluded from their retrospective study of
patients treated with streptokinase that efficacy was higher in the early
evening hours. There are at least two important confounding variables
which may explain these observations. Firstly, it has been previously
found that the time of day has an impact not only on the incidence, but
also on the severity of AMI (2). Hence, the apparent reduction in
efficacy of streptokinase during early morning hours may be due to a
greater degree of coronary artery obstruction. The authors adjusted for
the location but not the size of the infarct. Secondly, the higher
success rate in the early evenings compared to early mornings may be
confounded by the fact senior clinicians are more likely to be present and
available in the early evenings than in the early morning hours.
Finally, multiple tests were used in determining the statistical
significance of the success rates at different times of the day.
Appropriate adjustments should be made for multiple tests.
Reference
1) Goldhammer E, Kharash L, Abinader EG. Circadian fluctuations in
the efficacy of thrombolysis with streptokinase. Postgrad Med J 1999; 75:
667-671.
2) Hansen O, Johansson BW, Gullberg B. The clinical outcome of acute
myocardial infarction is related to the circadian rhythm of myocardial
infarction onset. Angiology 1993; 44:7, 509-16.
A 39-year diabetic, for six months had primary hypothyroidism three
years ago, normalized with thyroxine. Seventeen months later he was
hyperthyroid, reversed by carbimazole (30 mg/d) and recurred on stopping.
His thyroid microsomal antibody was positive (1:25,600).
Thyroid disorders were present in 6.9% adult diabetics in Edinburgh
(1). Type 2 diabetes was seen in 7.6% patients with Grave’s thyrotoxicosis
in Ja...
A 39-year diabetic, for six months had primary hypothyroidism three
years ago, normalized with thyroxine. Seventeen months later he was
hyperthyroid, reversed by carbimazole (30 mg/d) and recurred on stopping.
His thyroid microsomal antibody was positive (1:25,600).
Thyroid disorders were present in 6.9% adult diabetics in Edinburgh
(1). Type 2 diabetes was seen in 7.6% patients with Grave’s thyrotoxicosis
in Japan (2).
In our database of endocrine diseases, among 8225 diabetics 73 had
thyroid disorders (0.89%): 65 had hypothyroidism (65/73; 89%), and eight
thyrotoxicosis (8/73;11%). Out of 1777 persons with thyroid disorders 31
had diabetes mellitus (1.74%; 16 had hypothyroidism (51.6%), eight
thyrotoxicosis (25.8%) and seven other conditions.)
Consanguinity (2) , increasing age, when thyroid diseases are
common, and some type 2 diabetic patients being slow-onset type 1 diabetic
were implicated (3).
Hypothyroidism going into hyperthyroidism is unusual. It is likely
due to the switch of blocking antibodies replaced by stimulatory
antibodies to TSH and resultant hyperthyroidism (5).
References:
1. Perros P, McCrimmon RJ, Shaw G, Frier BM. Frequency of thyroid
dysfunction in diabetic patients: value of annual screening. .Diabetic Med
1995;12:622-7
2. Komiya I, Takasu N, Yamada T, Ohara N, Ootsuka H, Ota M, Fukushima
H, Sekikawa A, Tominaga M, Sasaki H. Studies on the association of NIDDM
in Japanese patients with hyperthyroid Grave’s disease. Horm Res
1992;38:264-8
3. Jaworski MA, Slater JD, Severini A, Henning KR, Mansour G, Mehta
JG, Jeske R, Schlaut J, Pak CY, Yoon JW. Unusual clustering of diseases in
a Canadian Old Colony (Chortitza) Mennonite kindred and community. CMAJ
1988;138:1017-25
4. McKenzie JM, Zakarija M. Antibodies in autoimmune thyroid disease.
In Braverman LE, Utiger RD (eds). Werner and
The excellent case report on verrucous carcinoma is not only of value
because of being a "first" on tumours of the female breast (1), but also
of focussing attention on this condition.
A myth was unintentionally started by Perez-Meza in 1966 (2)
when they suggested that there may be a possibility that this tumour could
be aggravated by radiation therapy. This started a misconception which is
still widely believed...
The excellent case report on verrucous carcinoma is not only of value
because of being a "first" on tumours of the female breast (1), but also
of focussing attention on this condition.
A myth was unintentionally started by Perez-Meza in 1966 (2)
when they suggested that there may be a possibility that this tumour could
be aggravated by radiation therapy. This started a misconception which is
still widely believed and propagated in the world literature (2).
Whereas surgery still remains the treatment of choice for small
verrucous carcinoma wherever it may occur, radiotherapy is an acceptable
choice of treatment. However, a dose of 50 Gray in fractions of 2 Gray
treating 5 days a week is not enough to control this disease. Despite
being a low grade malignant lesion which rarely if ever metastasizes the
larger dose of 60 Gray is preferred and is in fact mandatory. The disease
will recur if only 50 Gray is given.
References:
1. Munro RA et.al., PMJ 1999;75:674-675
2. Reinecke L & Thornley A L. Review: Radiotherapy as an effective
treatment for vaginal verrucous carcinoma. Brit J Radiol 1993;66:375-374
Sir- Shah and colleagues report (1) about the prevalence of psychiatric disorders affecting elderly people institutionalised in a rehabilitation unit, concludes about depression that it is common among older adults, it is a treatable condition and that in cases which there are cognitive impairments associated to concomitant depression, the cognitive impairments are worsened by the depressive disease. Although the relev...
Dear Sirs: A good friend of mine in Europe, Dr. Gonzalo Herranz MD/Phd emailed me your article, which I found exceedingly well researched as well as well written.
There is no doubt that Western Civilization is in a culture war, a war "within", a "spreading spiritual malaise" in the words of Irving Kristol. Writing in 1840, Tocqueville imagined a society consumed with such a malaise, in which government, com...
A recent review article in your journal gives the impression that the case for heparinisation of patients with cerebral venous thrombosis (CVT) is proven [1]. The largest and most robust study did not come to this conclusion and its results did not achieve statistical significance [2]. Given that CVT has a spectrum of presentations from headache to coma, a blanket approach to treatment in the absence of good evidence and...
Dear Editor,
Whilst Huang and Dutta correctly state that re-sheathing of needles is almost universally condemned, one must also remember that needle-stick injuries can also occur as a result of needles not being re-sheathed. This happened to me as a young house- officer, when a nurse dropped an unsheathed needle from a tray, and it promptly embedded itself int...
Dear Sir,
This case is extremely useful as an illustration of the varying presentations of phaeochromocytomas. The inclusion of the CT and the details of the differential effects given depending upon the catecholamine released were helpful.
I might venture a further, perhaps more important, mediator of the dramatic drop in K+ noted in this patient and other phaeos. There are a large number of beta ad...
Goldhammer et al (1) concluded from their retrospective study of patients treated with streptokinase that efficacy was higher in the early evening hours. There are at least two important confounding variables which may explain these observations. Firstly, it has been previously found that the time of day has an impact not only on the incidence, but also on the severity of AMI (2). Hence, the apparent reduction in effi...
A 39-year diabetic, for six months had primary hypothyroidism three years ago, normalized with thyroxine. Seventeen months later he was hyperthyroid, reversed by carbimazole (30 mg/d) and recurred on stopping. His thyroid microsomal antibody was positive (1:25,600).
Thyroid disorders were present in 6.9% adult diabetics in Edinburgh (1). Type 2 diabetes was seen in 7.6% patients with Grave’s thyrotoxicosis in Ja...
The excellent case report on verrucous carcinoma is not only of value because of being a "first" on tumours of the female breast (1), but also of focussing attention on this condition.
A myth was unintentionally started by Perez-Meza in 1966 (2) when they suggested that there may be a possibility that this tumour could be aggravated by radiation therapy. This started a misconception which is still widely believed...