Who will care for our elderly people?

A conference on the topic 'Who will care for our elderly people?' was held at the Royal College of Physicians on 16 March 1992. It began with a consideration of the challenge in terms of numbers and problems.

Shear bond strengths of resin adhesive cements to dentin and Ni-Cr-Be alloy

Two adhesives, Super Bond and Panavia, were evaluated for shear bond strength to dentin. Twenty human teeth were used for each adhesive. Bonding sites were prepared in dentin (600 grit) and the adhesives applied according to the manufacturers' instructions. Bond strengths were determined with an Instron testing machine at 24 hours. Super Bond developed the strongest bond of 21.59 +/- 3.91 MPa. Panavia produced a lower bond strength of 2.68 +/- 1.45 MPa. Statistically, Super Bond was found to have a stronger bond than Panavia. The same two adhesives were applied to Ni-Cr-Be specimens and compared to Comspan. Twenty Rexillium III specimens were used for each adhesive at 24 hours and 20 for thermocycling. The metal specimens were ground flat (600 grit) and then air abraded with 50-micron aluminous oxide. The adhesives were applied to the metal surface in accordance with the manufacturers' instructions. One group was tested at 24 hours while the second group was tested after thermocycling (2,500 cycles at 6 degrees C to 60 degrees C). At 24 hours, Super Bond had a significantly stronger bond than the other materials. Comparison of the 24-hour to thermocycled bond strengths found Comspan had a significant increase in bond strength, Panavia had no significant change and Super Bond had a significant decrease in bond strength. After 2,500 thermocycles, Comspan, Panavia, and Super Bond were not significantly different in bond strength.

Porcelain to dentin bond strength with a dentin adhesive

Adhesion of porcelain to dentin may be important in those cases with little remaining enamel. The purpose of this study was to determine the bond strength of porcelain to dentin using a dentin adhesive (All-Bond) and compare it to the enamel bond strength. Sixty human molar teeth had either a dentin or enamel bonding site prepared by flat grinding to a 600 grit. The teeth were divided into three groups of 20 each. Sixty porcelain cylinders were prepared, hydrofluoric acid etched on one end and silane treated. Twenty of the cylinders were bonded to enamel, 20 bonded to dentin with a dentin adhesive to be tested at 48 hours, and 20 bonded to dentin with a dentin adhesive to be tested after 24 hours of thermocycling (800 cycles at 6 degrees C to 60 degrees C). The specimens were tested in an Instron at a crosshead speed of 0.5 mm/minute. The following bond strengths were found: enamel (19.0 +/- 2.9 MPa), dentin at 48 hours (14.4 +/- 5.4 MPa), and dentin after thermocycling (10.1 +/- 3.8 MPa). When this data was subjected to statistical analysis (ANOVA), there was a significant difference between the groups. A Scheffe's test found that the dentin-porcelain bond at 48 hours was stronger than the thermocycled group, and that the enamel bond was significantly stronger than the two dentin bonds.

Time spent in hospital by the elderly in the final year of life as a health care indicator: inter-district comparisons

We have studied the amount of time spent in hospital by elderly people in their final year of life in 1976, 1981 and 1986 in six districts covered by the Oxford record linkage study to determine the extent of differences between districts. There was consistent but insubstantial variation between the districts. Variation declined over time, suggesting that the use of hospital care for the elderly may, in this respect, be nearing consensus. We conclude that the measure of total time spent in hospital by the elderly in their last year of life was not a powerful discriminator between districts in this region. When record linkage is implemented elsewhere in England, it will be possible to make wider geographical comparisons to determine whether important variations exist elsewhere.

Geriatric primary care: a European perspective, Part II

Europe is considered the parent of geriatric medicine, which was first recognized as a specialty in the United Kingdom. For the benefit of U.S. primary care physicians, GERIATRICS Editor-in-Chief Robert N. Butler, MD, convened a panel of leading European geriatricians in Lausanne, Switzerland, for a discussion of the successes and problems they are encountering in providing medical care to the aging world population. In Part I (Geriatrics 1992; 47 [Jan]:31-41) panelists described the healthcare services available to the elderly. In Part II, they discuss treatment and evaluation of dementia, use of hypnotics, rehabilitation approaches, and dietary and exercise recommendations for the elderly.

Geriatric primary care: a European perspective, Part I

Europe is considered the parent of geriatric medicine, which was first recognized as a specialty in the United Kingdom. For the benefit of U.S. primary care physicians, GERIATRICS Editor-in Chief Robert N. Butler, MD, convened a panel of leading European geriatricians in Lausanne, Switzerland, for a discussion of the successes and problems they are encountering in providing medical care to the aging world population. In this first installment, the panelists describe the healthcare services available to the elderly, particularly in the United Kingdom and Switzerland. A physician who is a regional adviser for the World Health Organization adds the perspective of other European nations.

Analysis of the Ha-ras oncogene in C3H/He mouse liver tumours derived spontaneously or induced with diethylnitrosamine or phenobarbitone

In a study of the mechanisms involved in the induction of tumours by chemicals, the Ha-ras oncogene was analysed in liver tumours induced by the genotoxic carcinogen diethylnitrosamine (DEN), or the non-genotoxic agent phenobarbitone (PB) in C3H/He mice. Mutations were detected using the polymerase chain reaction and oligonucleotide hybridization. Codon 61 mutations were detected in 41% of DEN-induced tumours (19/46), either in the first base (CG----AT, 12/19), a transversion, or the second base (AT----GC, 7/19), a transition. Codon 61 mutations were also found in 29% of spontaneous tumours (all CG----AT, 6/21) but none were detected in PB-induced tumours (0/15) or in normal liver tissue of untreated mice (0/30). No mutations were detected at codon 12. Low and variable expression of the Ha-ras gene was detected in all liver tissues with moderately raised levels (175-200%) in spontaneous, DEN and PB-induced tumours as compared to normal liver tissue. The H-ras gene was methylated to some extent in all liver tissues, with no discernible difference between the treatments. The frequency of the Ha-ras mutation at codon 61 in DEN-induced tumours is greater than in spontaneously arising tumours. This increase is not accompanied by any specific alteration in the expression or methylation of the gene. Since PB-induced tumours do not possess mutations in the Ha-ras gene at codons 12 or 61, the data suggest that the non-genotoxic agent PB induces tumours in the C3H/He mouse liver with a mechanism distinct from that of spontaneous tumours or those that result from treatment with a potent genotoxic carcinogen such as DEN.

An ultrastructural study of spontaneous and phenobarbitone-induced nodules in the mouse liver

Male C3H/He mice were given 0 (control) or 85 mg/kg/day phenobarbitone (PB) in the diet. At 40, 60 and 93 weeks, groups of mice were killed and the ultrastructure of spontaneous and PB-induced liver nodules was examined. Treated mice showed typical centrilobular hypertrophy and eosinophilic nodules which may be considered as an end stage lesion. The nodule cells were similar in appearance to those in areas of centrilobular hypertrophy except for the presence of convoluted membranes which are considered to be indicative of proliferation. The incidence of carcinoma was not increased by PB treatment. The carcinomas from control and treated animals differed in their ultrastructure in that increased levels of smooth endoplasmic reticulum (SER) were seen in the carcinomas of the PB animals. The presence of SER proliferation in the carcinomas of PB animals suggests that carcinoma may respond to the enzyme-inducing effects of PB.

Fractures of the hip and distal forearm in West Africa and the United Kingdom

Comparison of age- and sex-specific incidence rates of fractures of the proximal femur and the distal forearm showed significantly lower rates in Ibadan than in two urban centres in England, with risk ratio of up to 20. In the Ibadan data no evidence of higher rates in women or of a prominent age-associated increase in rates was observed.

Challenge of aging

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Evaluation of a 4-META porcelain repair system

A recently introduced porcelain repair system utilizing 4-META (Etch-Free Primer with C & B-Metabond) was evaluated for bond strength to porcelain. This system purportedly eliminates hydrofluoric acid-etching and silane pretreatment. Forty porcelain specimens were prepared and treated with the 4-META repair system. A resin cylinder was bonded to the treated porcelain surface. Twenty of the specimens were tested after 24 hours while the other 20 were tested after thermocycling (800 cycles at 6 degrees C to 60 degrees C). The mean bond strengths were: 24 hours 17.4 MPa (+/- 4.8), thermocycled 19.1 MPa (+/- 7). Cohesive failure of the porcelain occurred in all of the specimens, both the 24 hour and the thermocycled. These bond strengths compare favorably with or exceed those of other porcelain repair systems tested in other studies.

Age-specific incidence of Guillain-Barré syndrome in Oxfordshire

The epidemiology of Guillain-Barré syndrome was examined in a population-based retrospective study using defined diagnostic criteria and linked hospital records. Between 1974 and 1986 there were 72 incident cases, giving a crude annual incidence rate (95 per cent confidence interval) of 1.1 per 100,000 persons per year (0.8-1.4). Age-adjusted incidence rates were insignificantly higher for women, 1.23 (0.8-1.6), than for men, 1.0 (0.6-1.3). After infancy, rates increased with age, and remained high in the over-75 age group. These variations in incidence were not explained by variations in severity. There was evidence of an increase in rates over the period surveyed. Rates tended to be higher in the winter and early spring. The incidence of Guillain-Barré syndrome in the elderly has been underestimated in the past, and this study shows no evidence of a previously reported bimodal distribution of age-specific incidence in adult life.

Ultrastructural features of diethylnitrosamine-induced lesions in the mouse liver

Mice were given a single dose of diethylnitrosamine (DEN). After 12 and 15 months, the ultrastructural features of simple hepatic nodules and defined hepatocellular carcinomas were compared. The main difference between these two lesions is the presence of highly convoluted membranes in the hepatocytes of the carcinomas. A third population of nodules was also found which could not be easily classified at the light microscope level into either simple hepatic nodules or carcinomas. Ultrastructural examination of these lesions showed them to have areas resembling both simple hepatic nodules and carcinomas. Within both these areas hepatocytes with convoluted plasma membranes were observed. Changes in membrane pattern may be indicative of an altered cell growth pattern and the acquisition of invasive or metastatic properties. This provides further evidence suggesting that a sub-population of cells can be identified which has the potential to develop into overt carcinoma.

Diuretics for elderly patients

Diuretics compare well with the large number of other classes of antihypertensive agents now available as first-line treatment in the elderly. Other drugs might be considered for first-line treatment in elderly patients with diabetes, untreated gout, or renal failure, a previous myocardial infarction or multiple ventricular ectopics and for men concerned about potency. A thiazide with a potassium-sparing agent may be preferred in the elderly population. The most telling feature in favor of diuretics is that they comprise the only group of drugs for which a beneficial effect in reducing cardiovascular disease in the elderly has been demonstrated in clinical trials. Although compliance may decline somewhat with age, compliance rates of 80% or more can be expected, even among very elderly patients.

Tumours and malformations in the adult offspring of cyclophosphamide-treated and control male rats--preliminary communication

Adult offspring aged 52-104 weeks, from male Sprague-Dawley rats treated chronically with cyclophosphamide (CP) were examined for tumours and gross abnormalities. Litter size at birth and at weaning was found to be greatly reduced as a result of paternal CP treatment. No unusual abnormalities were found at post-mortem examination but there was an increase in the incidence of hydronephrosis in offspring from CP-treated males compared with offspring from control males. This increase could have been indirectly caused by CP-treatment through reduced litter size. Histological examination of 26 tumours showed a variety of tumour types in the offspring of CP-treated and control males. Two of the four uterine tumours in offspring from CP-treated males were examined histologically; one was a sarcoma and the other an adenocarcinoma. Although no uterine tumours were found in offspring from control males, it is not clear whether this difference in frequency was treatment-related. The most common tumour site in female offspring from both CP-treated and control males was the mammary gland, and all six of these tumours which were examined histologically were adenofibromas. Abnormal karyotypes were observed in 2 out of 21 offspring showing abnormalities from CP-treated males and none out of 2 offspring with abnormalities from control males. These were not associated with tumours. It was concluded from this limited study that there was no clear evidence of increased tumour incidence in the offspring from CP-treated males. There was an indication that abnormal karyotypes may have been caused by the paternal CP treatment and these abnormalities persisted into adulthood.

Transient neurological dysfunction and risk of stroke in an elderly English population: the different significance of vertigo and non-rotatory dizziness

A sample of people aged 65 and over were interviewed at home and asked a series of questions aimed at identifying episodes of possible transient neurological dysfunction. During follow-up of respondents initially free from manifest cerebrovascular disease, no relationship was found between subsequent stroke and reported episodes of diplopia, transient numbness or weakness, non-rotatory dizziness or blackouts. There was an association of stroke with reported blurring or dimming of vision, statistically significant only for the sexes combined (relative incidence ratio 1.5), and a consistently increased risk in men and women reporting rotatory vertigo (relative incidence ratio 2.5). This relationship remained significant when adjusted for the association of rotatory vertigo with ECG evidence of heart disease. Thus rotatory vertigo is a risk factor for stroke but non-rotatory dizziness is not. Conversely a previous study of falling in the same population sample had shown an association with rotatory vertigo but not with non-rotatory dizziness.

Cytokeratin expression in cells of the rodent bile duct developing under normal and pathological conditions

A polyclonal anti-cytokeratin antibody has been used to examine the expression of this intermediate filament both during normal development in the rat and in a variety of pathological states in the rat and mouse. Bile duct proliferation induced by the administration of alpha-naphthylisothiocyanate (ANIT) as well as the oval cell proliferation induced by 3'-methyl-4-dimethylaminoazobenzene (3-MeDAB) have been used to examine the expression of the rodent cytokeratins in the proliferating cells regarded as being of bile duct origin. Examples of cholangiofibrosis and cholangiocarcinomas were also examined for evidence of cytokeratin expression using this antibody, as well as proliferations of a morphological intermediate type between epithelial and mesenchymal. In all cases we have been able to demonstrate continuity of phenotypic expression of the cytokeratins recognized by this antibody in cells which are recognized as bile duct in origin, even where their morphological appearance does not resemble an epithelial cell type. Because this antibody can be used on formalin-fixed, paraffin-processed tissues, after trypsin treatment, it is proposed that it can be used routinely in the toxicological evaluation (even retrospectively) of bile duct related proliferations and tumours.

The lectin binding characteristics of spontaneous and phenobarbitone induced hepatic lesions in C3H/He mice

The surface membrane glycoprotein patterns of spontaneous hepatic nodules, phenobarbitone induced nodules and hepatocellular carcinoma were studied in the C3H mouse using lectin histochemistry. The lectin binding patterns of hepatocellular carcinoma cells were markedly different to those of non-tumour cells and similar to the pattern in chemically induced hepatocellular carcinomas. This supports the hypothesis that changes in surface glycoprotein are a consistent feature associated with malignancy. Similar changes in the distribution of lectin binding sites were also seen in the phenobarbitone induced eosinophilic nodules and in a proportion of spontaneous basophilic nodules. Two populations of early basophilic nodules were identified on the basis of their lectin binding patterns, and this may indicate a link between one nodular type and carcinoma.

Operative or conservative treatment for trochanteric fractures of the femur. A randomised epidemiological trial in elderly patients

All elderly patients with extracapsular hip fractures seen in hospitals in Newcastle upon Tyne over a 12-month period were studied and followed up for six months. At one of the hospitals, patients were randomised to treatment by AO dynamic hip-screw or by traction. Complications specific to the two treatments were low, and general complications, six-month mortality and prevalence of pain, leg swelling and unhealed sores, showed no difference between the two modes of treatment. Operative treatment gave better anatomical results and a shorter hospital stay, but significantly more of the patients treated by traction showed loss of independence six months after injury.