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1.  Secondary prevention of coronary heart disease in the elderly 
Heart  2005;91(3):396-400.
doi:10.1136/hrt.2004.045054
PMCID: PMC1768768  PMID: 15710740
coronary heart disease; elderly
2.  CKD and Hospitalization in the Elderly: A Community-Based Cohort Study in the United Kingdom 
Background
We previously have shown that chronic kidney disease (CKD) is associated with cardiovascular and all-cause mortality in community-dwelling people 75 years and older. The present study addresses the hypothesis that CKD is associated with a higher rate of hospital admission at an older age.
Study Design
Cohort study.
Setting & Participants
15,336 participants from 53 UK general practices underwent comprehensive health assessment between 1994 and 1999.
Predictor
Data for estimated glomerular filtration rate (eGFR, derived from creatinine levels using the CKD Epidemiology Collaboration [CKD-EPI] study equation) and dipstick proteinuria were available for 12,371 participants.
Outcomes
Hospital admissions collected from hospital discharge letters for 2 years after assessment.
Measurements
Age, sex, cardiovascular risk factors, possible biochemical and health consequences of kidney disease (hemoglobin, phosphate, and albumin levels; physical and mental health problems).
Results
2,310 (17%) participants had 1 hospital admission, and 981 (7%) had 2 or more. After adjusting for age, sex, and cardiovascular risk factors, HRs were 1.66 (95% CI, 1.21-2.27), 1.17 (95% CI, 0.95-1.43), 1.08 (95% CI, 0.90-1.30), and 1.11 (95% CI, 0.91-1.35) for eGFRs <30, 30-44, 45-59, and ≥75 mL/min/1.73 m2, respectively, compared with eGFRs of 60-74 mL/min/1.73 m2 for hospitalizations during <6 months of follow-up. HRs were weaker for follow-up of 6-18 months. Dipstick-positive proteinuria was associated with an increased HR throughout follow-up (HR, 1.29 [95% CI, 1.11-1.49], adjusting for cardiovascular risk factors). Dipstick-positive proteinuria and eGFR <30 mL/min/1.73 m2 were independently associated with 2 or more hospital admissions during the 2-year follow-up. Adjustment for other health factors and laboratory measurements attenuated the effect of eGFR, but not the effect of proteinuria.
Limitations
Follow-up limited to 2 years, selection bias due to nonparticipation in study, missing data for potential covariates, and single noncalibrated measurements from multiple laboratories.
Conclusions
The study indicates that community-dwelling older people who have dipstick-positive proteinuria and/or eGFR <30 mL/min/1.73 m2 are at increased risk of hospitalization.
doi:10.1053/j.ajkd.2010.09.026
PMCID: PMC3392651  PMID: 21146270
Chronic kidney disease; cohort study; dipstick proteinuria testing; general population; hospitalization; older people
3.  The use of orchids in Chinese medicine 
In this article, the therapeutic uses of five Chinese medicines that contain orchids are discussed, together with a brief report of some of the animal experimentation undertaken. The impression that these preparations have no therapeutic use may be incorrect. However, herbal preparations have not usually been subject to the rigorous characterization and standardization necessary for clinical study, and persuading practitioners that substances in use for many centuries still need to be tested in randomized controlled clinical trials is proving a significant challenge.
PMCID: PMC2121637  PMID: 18065708
4.  Irbesartan improves arterial compliance more than lisinopril 
Background
Antihypertensive agents can reduce arterial stiffness. We hypothesized that an angiotensin receptor blocker (ARB) irbesartan and an angiotensin converting enzyme inhibitor (ACEI) lisinopril improved arterial compliance.
Methods
A randomized, double-blind, double-dummy, controlled crossover trial. Fifteen hypertensive patients, mean age 65.5 ± 8.9 years (mean ± SD) were given irbesartan (150 to 300 mg/day) or lisinopril (10 to 20 mg/day) for 12 weeks and then crossed over for 12 weeks. Pulse wave velocity (PWV) in the carotid-femoral (CF), carotid-radial (CR), and femoral dorsalis-pedis (FD) were measured using a Complior® PWV system.
Results
After 12 weeks, systolic blood pressure (SBP) decreased from 162.4 ± 12.9 to 134.5 ± 14.8 with irbesartan and to 145.2 ± 25 mmHg with lisinopril. Irbesartan and lisinopril reduced PWV (CF) in the elastic arterial system from 15.1 ± 5 to 13.3 ± 2.6 (p < 0.005) and to 14 ± 4.7 (p < 0.05) m/s respectively (p = 0.345). Irbesartan reduced PWV (CR) and PWV (FD), whereas lisinopril did not. The difference between treatments was significant after SBP adjustment (p = 0.037 for PWV (CR) and p < 0.001 for PWV (FD)).
Conclusions
Irbesartan improved arterial compliance in elastic and muscular arteries, whereas lisinopril improved it only in elastic arteries.
PMCID: PMC2710973  PMID: 19649309
arterial compliance; angiotensin receptor blockers; ACE inhibitors; hypertension
5.  Use of probiotic Lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial 
BMJ : British Medical Journal  2007;335(7610):80.
Objective To determine the efficacy of a probiotic drink containing Lactobacillus for the prevention of any diarrhoea associated with antibiotic use and that caused by Clostridium difficile.
Design Randomised double blind placebo controlled study.
Participants 135 hospital patients (mean age 74) taking antibiotics. Exclusions included diarrhoea on admission, bowel pathology that could result in diarrhoea, antibiotic use in the previous four weeks, severe illness, immunosuppression, bowel surgery, artificial heart valves, and history of rheumatic heart disease or infective endocarditis.
Intervention Consumption of a 100 g (97 ml) drink containing Lactobacillus casei, L bulgaricus, and Streptococcus thermophilus twice a day during a course of antibiotics and for one week after the course finished. The placebo group received a longlife sterile milkshake.
Main outcome measures Primary outcome: occurrence of antibiotic associated diarrhoea. Secondary outcome: presence of C difficile toxin and diarrhoea.
Results 7/57 (12%) of the probiotic group developed diarrhoea associated with antibiotic use compared with 19/56 (34%) in the placebo group (P=0.007). Logistic regression to control for other factors gave an odds ratio 0.25 (95% confidence interval 0.07 to 0.85) for use of the probiotic, with low albumin and sodium also increasing the risk of diarrhoea. The absolute risk reduction was 21.6% (6.6% to 36.6%), and the number needed to treat was 5 (3 to 15). No one in the probiotic group and 9/53 (17%) in the placebo group had diarrhoea caused by C difficile (P=0.001). The absolute risk reduction was 17% (7% to 27%), and the number needed to treat was 6 (4 to 14).
Conclusion Consumption of a probiotic drink containing L casei, L bulgaricus, and S thermophilus can reduce the incidence of antibiotic associated diarrhoea and C difficile associated diarrhoea. This has the potential to decrease morbidity, healthcare costs, and mortality if used routinely in patients aged over 50.
Trial registration National Research Register N0016106821.
doi:10.1136/bmj.39231.599815.55
PMCID: PMC1914504  PMID: 17604300
6.  Fracture risk and the use of a diuretic (indapamide sr) ± perindopril: a substudy of the Hypertension in the Very Elderly Trial (HYVET) 
Trials  2006;7:33.
Background
The Hypertension in the Very Elderly Trial (HYVET) is a placebo controlled double blind trial of treating hypertension with indapamide Slow Release (SR) ± perindopril in subjects over the age of 80 years. The primary endpoints are stroke (fatal and non fatal). In view of the fact that thiazide diuretics and indapamide reduce urinary calcium and may increase bone mineral density, a fracture sub study was designed to investigate whether or not the trial anti-hypertensive treatment will reduce the fracture rate in very elderly hypertensive subjects.
Methods
In the trial considerable care is taken to ascertain any fractures and to identify risk factors for fracture, such as falls, co-morbidity, drug treatment, smoking and drinking habits, levels of activity, biochemical abnormalities, cardiac irregularities, impaired cognitive function and symptoms of orthostatic hypotension.
Potential results
The trial is expected to provide 10,500 patient years of follow-up. Given a fracture rate of 40/1000 patient years and a 20% difference in fracture rate, the power of the sub study is 58% to detect this difference at the 5% level of significance. The corresponding power for a reduction of 25% is 78%.
Conclusion
The trial is well under way, expected to complete in 2009, and on target to detect, if present, the above differences in fracture rate.
doi:10.1186/1745-6215-7-33
PMCID: PMC1769508  PMID: 17177983
7.  Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis 
BMJ : British Medical Journal  2002;324(7350):1361.
Objective
To evaluate efficacy of probiotics in prevention and treatment of diarrhoea associated with the use of antibiotics.
Design
Meta-analysis; outcome data (proportion of patients not getting diarrhoea) were analysed, pooled, and compared to determine odds ratios in treated and control groups.
Identification
Studies identified by searching Medline between 1966 and 2000 and the Cochrane Library.
Studies reviewed Nine randomised, double blind, placebo controlled trials of probiotics.
Results
Two of the nine studies investigated the effects of probiotics in children. Four trials used a yeast (Saccharomyces boulardii), four used lactobacilli, and one used a strain of enterococcus that produced lactic acid. Three trials used a combination of probiotic strains of bacteria. In all nine trials, the probiotics were given in combination with antibiotics and the control groups received placebo and antibiotics. The odds ratio in favour of active treatment over placebo in preventing diarrhoea associated with antibiotics was 0.39 (95% confidence interval 0.25 to 0.62; P<0.001) for the yeast and 0.34 (0.19 to 0.61; P<0.01 for lactobacilli. The combined odds ratio was 0.37 (0.26 to 0.53; P<0.001) in favour of active treatment over placebo.
Conclusions
The meta-analysis suggests that probiotics can be used to prevent antibiotic associated diarrhoea and that S boulardii and lactobacilli have the potential to be used in this situation. The efficacy of probiotics in treating antibiotic associated diarrhoea remains to be proved. A further large trial in which probiotics are used as preventive agents should look at the costs of and need for routine use of these agents.
What is already known on this topicProbiotics are well known for their microbiological properties and have been used to treat gastrointestinal and vaginal mucosal infectionsConflicting results have prevented probiotics from being accepted as viable alternatives to conventional treatments for antibiotic associated diarrhoeaThe commercial availability of probiotics is increasingWhat this study addsProbiotics may prevent antibiotic associated diarrhoeaThe potential of specific probiotics to prevent Clostridium difficile infection secondary to the use of antibiotics should be re-examinedA large trial looking at the efficacy of probiotics in preventing antibiotic associated diarrhoea, particularly in elderly patients, with an emphasis on the optimal dose and cost benefits is needed
PMCID: PMC115209  PMID: 12052801
8.  Randomised comparison of three methods of administering a screening questionnaire to elderly people: findings from the MRC trial of the assessment and management of older people in the community 
BMJ : British Medical Journal  2001;323(7326):1403.
Objective
To compare three different methods of administering a brief screening questionnaire to elderly people: post, interview by lay interviewer, and interview by nurse.
Design
Randomised comparison of methods within a cluster randomised trial.
Setting
106 general practices in the United Kingdom.
Participants
32 990 people aged 75 years or over registered with participating practices.
Main outcome measures
Response rates, proportion of missing values, prevalence of self reported morbidity, and sensitivity and specificity of self reported measures by method of administration of questionnaire for four domains.
Results
The response rate was higher for the postal questionnaire than for the two interview methods combined (83.5% v 74.9%; difference 8.5%, 95% confidence interval 4.4% to 12.7%, P<0.001). The proportion of missing or invalid responses was low overall (mean 2.1%) but was greater for the postal method than for the interview methods combined (4.1% v 0.9%; difference 3.2%, 2.7% to 3.6%, P<0.001). With a few exceptions, levels of self reported morbidity were lower in the interview groups, particularly for interviews by nurses. The sensitivity of the self reported measures was lower in the nurse interview group for three out of four domains, but 95% confidence intervals for the estimates overlapped. Specificity of the self reported measures varied little by method of administration.
Conclusions
Postal questionnaires were associated with higher response rates but also higher proportions of missing values than were interview methods. Lower estimates of self reported morbidity were obtained with the nurse interview method and to a lesser extent with the lay interview method than with postal questionnaires.
What is already known on this topicThe optimum method of administering a brief multidimensional screening assessment to elderly people is not knownWhat this study addsPostal questionnaires produce a higher response rate than interviews by nurses or lay interviewers but also higher proportions of missing dataInterview by nurses and to a lesser degree by lay interviewers is associated with lower levels of self reported morbidity than are postal questionnaires
PMCID: PMC60986  PMID: 11744565
9.  How well can blood pressure be controlled? Progress report on the Systolic Hypertension in Europe Follow-Up Study (Syst-Eur 2) 
Background
The randomised, double-blind, placebo-controlled Systolic Hypertension in Europe trial (Syst-Eur 1) proved that blood pressure (BP) lowering therapy starting with nitrendipine reduces the risk of cardiovascular complications in elderly patients with isolated systolic hypertension. In an attempt to confirm the safety of long-term antihypertensive therapy based on a dihydropyridine, the Syst-Eur patients remained in open follow-up after the end of Syst-Eur 1. This paper presents the second progress report of this follow-up study (Syst-Eur 2). It describes BP control and adherence to study medications.
Methods
After the end of Syst-Eur 1 all patients, treated either actively or with placebo, were invited either to continue or to start antihypertensive treatment with the same drugs as previously used in the active treatment arm. In order to reach the target BP (sitting SBP <150 mmHg), the first line agent, nitrendipine, could be associated with enalapril and/or hydrochlorothiazide.
Results
Of the 3787 eligible patients, 3516 (93%) entered Syst-Eur 2. At the last available visit, 72% of the patients were taking nitrendipine. SBP/DBP at entry in Syst-Eur 2 averaged 160/83 mmHg in the former placebo group and 151/80 mmHg in the former active-treatment group. At the last follow-up visit SBP/DBP in the patients previously randomised to placebo or active treatment had decreased by 16/5 mmHg and 7/5 mmHg, respectively. The target BP was reached by 74% of the patients.
Conclusion
Substantial reductions in systolic BP may be achieved in older patients with isolated systolic hypertension with a treatment strategy starting with the dihydropyridine calcium-channel blocker, nitrendipine, with the possible addition of enalapril and/or hydrochlorothiazide.
doi:10.1186/cvm-2-6-298
PMCID: PMC64833  PMID: 11806817
calcium-channel blockers; elderly; isolated systolic hypertension

Results 1-9 (9)