Elements: In this month's issue
I wish to draw your attention to the review articles in this month's issue of QJM. The first of these by Bennett and colleagues from Birmingham explores an important topic that has, until recently, relatively little attention: the relationship between ethnicity and the development of peripheral artery disease (PAD). The health burden resulting from PAD is considerable with a prevalence that may be as high as 18% in patients aged 55 years and more. However, the majority of studies on PAD to date have focussed on mainly White populations. We are reminded that at least 8% of the UK population is either Asian or Black and there is some evidence that the predisposing factors, presentation and complication rates for PAD may vary for different ethnic groups. The review focuses on the pathophysiological differences with respect to PAD between three ethnic groupings: White, South Asians and Afro-Caribbeans. The discussion reveals that this subject area is far from being straightforward. The authors helpfully summarise what is known in this subject area; however, the overall picture is one of significant complexity and relevant questions for further research are raised.The second review paper explores a commonly encountered clinical disorder, especially in the elderly, i.e. cobalamin or vitamin B12 deficiency. Dali-Youcef and Emmanuel Andrès provide a useful comprehensive review that should also serve as a topic update. While the clinical presentation and subsequent diagnosis of cobalamin deficiency may be relatively easy, in many cases the symptoms may be subtle or even absent requiring a high index of suspicion on the part of the clinician. It should be noted that B12 deficiency may be associated with a variety of neurological and psychiatric syndromes but the precise relationship is at present unclear. The association between cobalamin deficiency and pernicious anaemia has been long recognised. However, it is now thought that food-cobalamin malabsorption (FCM) may be much more common than previously thought. FCM refers to a situation where B12 is not released from food. It is a multifactorial entity that is linked with Helicobacter pylori infection, long-term ingestion of antacids and the use of metformin. The inference is that physicians need to be aware of the possibility of FCM in older patients who possess one or more of these risk factors. Management of cobalamin deficiency is usually undertaken by means of B12 injection; however novels methods of cobalamin administration by oral and nasal routes are in the process of current evaluation. These latter methods may prove to be especially appropriate for FCM.
The management of type 1 diabetes mellitus (T1DM) has been the subject of significant change over the past two decades. There are now in place recognised targets for the lowering of HbA1C, blood pressure and cholesterol. The methods by which these outcomes should be achieved are also agreed. The study by Saunders et al reviews outcomes for a cohort of T1DM patients over a five year period. Encouragingly, improvements in outcome were found but there was evidence of significant increase in weight and body mass index in the patients studied. The authors conclude although fewer patients with diabetes achieve the tighter targets that have been set more recently, the proportion achieving the preceding goals has increased significantly.
Patients who have psychiatric disorders are more likely to be prescribed anti-epileptic drugs (AEDs). Epilepsy may co-exist with a variety of psychiatric illness and, in addition, some AEDs may be of use in the management of certain bipolar disorders. The net result is that AEDs are prescribed to a group of patients who overall are at increased risk of self harm by means of excessive ingestion of prescribed medication. A retrospective observational study examined patterns of antiepileptic drug overdose in patients admitted to the Edinburgh Poisons Unit over a seven year period. It was found that 3.4% of patients admitted to the Unit had ingested at least one AED. Interestingly, there was a definite gender bias with respect to the drug ingested: women were more likely to ingest lamotrigine than men. Furthermore, patients who ingested AEDs required more intensive medical and psychiatric intervention compared to those patients who had ingested other agents. The findings are of relevance to the general physician as prescribing practices can have unintended consequences.
Finally, how confident are we in making a secure diagnosis of transient ishcaemic attack (TIA)? Current guidance is that patients with established or suspected TIA should be rapidly referred for further assessment because of the significant risk of developing a full blown stroke. Dawson and colleagues from Glasgow point out that while scoring systems to assist rapid identification of acute stroke are in place, there is no such tool to assist the clinician with the more challenging diagnosis of TIA. Accordingly, using logistic regression analysis, they have developed a recognition tool for the indentification of TIA. Admittedly, the model does look somewhat complicated but the authors claim that 97% of TIA and 22% of non-TIA patients were accurately identified by means of using the tool. The benefits would seem self-evident but obviously further refinement of the scoring system and validation is needed.
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