Big ‘G’ and Little ‘g’ Geriatrics Education for Physicians

In the July 2016 issue of this journal, Dr. Mary Tinetti proposed that geriatric medicine abandon attempts to increase the numbers of board‐certified geriatricians and change focus to the development of a “small elite workforce.” What would be gained and what sacrificed by accepting this challenge? We agree that the best clinical use of a scarce resource, specialty trained geriatricians, is to care for frail, complex, severely ill elderly adults and to help design and study novel interventions in research, education, and care models to improve the care of all older adults, but for this to happen, all other providers must attain specific competency in the care of older adults. This article responds and discusses alternative pathways for teaching geriatrics care, training specialists, and geriatrics fellows.     

‘μ’ Heavy Chain Type ‘Non-Excretory’ Myeloma

An unusual case of ‘non-excretory’ myeloma is described in which, using immunofluorescen-ce, only ‘\i’ heavy chains were detected in almost all bone marrow plasma-cell cytoplasm. Cytoplasmic light chains were completely lacking, and neither monoclonal whole immuno-globulin (Ig) nor free heavy nor light chains were detected in serum and urine, although the clinical and morphological features showed the classical pattern of myeloma. The possible mechanism which could play a role in the disturbance of the Ig-chain secretion observed in this case is discussed.     

Screening for ‘window‐period’ acute HIV infection among pregnant women in rural South Africa

Objectives

The aim of this study was to evaluate the HIV‐1 RNA pooled nucleic acid amplification testing (NAAT) strategy to screen pregnant women in the ‘window period’ of acute HIV infection (AHI) in rural South Africa.

Methods

In 2007 and 2008, 750 consecutive pregnant women on their first antenatal care visit to a primary health care clinic were tested anonymously for HIV infection. HIV‐1 RNA pooled NAAT was performed on HIV antibody‐negative samples. All positive pools were tested individually and positive samples were classified as incident cases to calculate HIV incidence.

Results

The overall HIV prevalence was 37.3% [95% confidence interval (CI) 34.3–41.3]. Of the 467 HIV antibody‐negative samples, four (0.9%) were HIV‐1 RNA‐positive. The mean viral load in the four samples was 386 260 HIV‐1 RNA copies/mL (range 64 200–1 228 130). The HIV incidence was 11.2% per year (95% CI 0.3–22.1) and all women with AHI were ≤21 years of age.

Conclusions

Identifying AHI in pregnancy is important for health interventions to reduce perinatal and heterosexual transmission of HIV, and to estimate HIV incidence for epidemiological surveillance.     

Von Willebrand disease – the ‘Dos’ and ‘Don'ts’ in surgery

Von Willebrand disease (VWD) is the most common genetic bleeding disorder. VWD is caused by a deficiency or dysfunction of von Willebrand factor (VWF), a plasma protein that mediates the initial adhesion of platelets at sites of vascular injury and binds and stabilises coagulation factor VIII (FVIII) in the blood. Prophylaxis of surgical bleeding in patients with VWD requires consideration of the individual situation, including the type of procedure and the bleeding rate, before decisions about treatment type, dose, duration and adjunctive therapy with antifibrinolytics or antithrombotic prophylaxis can be made. Although desmopressin (DDAVP)‐stimulated release of endogenous VWD is an effective treatment strategy in many patients, plasma concentrates containing VWF are the preferred option for most patients undergoing surgical procedures. Recommendations for the management of surgery in patients with VWD are summarised, including the severity of VWD and the type of the surgical procedure.     

‘AT RISK’ COMMITTEE

The mid to late 80's has witnessed the expanding array of community based services for the aged and the disabled. The emergence of the HACC scheme has played a major role in putting services into communities, to help keep their frail aged and disabled out of institutional care. The frail aged and disabled are often consumers of multiple services, which are provided by autonomously run organisations. For the consumer of services to gain their potential from each service agency, there need to be a high degree of co-operation and co-ordination between organisations.     

Quantitation of D Sites on Selected ‘Weak D’ and ‘Partial D’ Red Cells

Measurements have been made of the number of available sites on 10 examples of red cells in which the only abnormality appeared to be a quantitative reduction in the expression of D (weak D cells); these estimates were carried out using three monoclonal anti-D antibodies, Fog-1, Brad-3 and Los-2. The values varied with the monoclonal antibody that was used and fell within the range of 170–1,870 sites/cell. A further 3 examples of weak D cells which had brought about immunisation following transfusion were found to have between 390 and 1,470 sites per red cell. The implications of the D site density on the immunogenicity of weak D cells are discussed. The number of sites on red cells with structurally abnormal D (partial D cells) were also estimated, using the antibody Fog-1. Four of the 5 examples of cells of category IVa (probable phenotype R₀r) were found to have a high expression of D (range 29,300–41,300), but the available D sites of categories D^Va, D^VIa, and D^VII were considerably reduced (<500, <500 and 2,400–7,500 sites/cell, respectively). As a working hypothesis, it is suggested that there are two types of genetic abnormality leading to an abnormal expression of D. First, a defect in genomic DNA leading only to a quantitative reduction in the number of available D sites; this genomic lesion should be termed ‘weak D’. Secondly, genomic defects leading to amino acid sequence abnormalities and structural change in the D polypeptide; these lesions should be collectively known as ‘partial D’.     

NIV in amyotrophic lateral sclerosis: The ‘when’ and ‘how’ of the matter

Non‐invasive ventilation (NIV) has become an essential part of the treatment of amyotrophic lateral sclerosis (ALS) since 2006. NIV very significantly improves survival, quality of life and cognitive performances. The initial NIV settings are simple, but progression of the disease, ventilator dependence and upper airway involvement sometimes make long‐term adjustment of NIV more difficult, with a major impact on survival. Unique data concerning the long‐term adjustment of NIV in ALS show that correction of leaks, management of obstructive apnoea and adaptation to the patient's degree of ventilator dependence improve the prognosis. Non‐ventilatory factors also impact the efficacy of NIV and various solutions have been described and must be applied, including cough assist techniques, control of excess salivation and renutrition. NIV in ALS has been considerably improved as a result of application of all of these measures, avoiding the need for tracheostomy in the very great majority of cases. More advanced use of NIV also requires pulmonologists to master the associated end‐of‐life palliative care, as well as the modalities of discontinuing ventilation when it becomes unreasonable.     

Processing of five types of ‘threat’ information in anorexic and bulimic women

This study investigated further the ‘escape’ hypothesis of bulimia and compared the processing of ‘threat’ information in control, anorexic and bulimic women. Using a novel information‐processing task, five types of non‐eating ‘threat’ (autonomy, sociotropy, discomfort anxiety, ego threat from others and ego threat from self) were addressed. The women did not differ in response time taken to identify ‘threat’ information, although there was support for the ‘escape’ hypothesis of bulimia. Specific non‐eating ‘threat’ information appeared relevant to both anorexia and bulimia nervosa, suggesting the potential value of addressing general threat schemata in clinical practice. Copyright © 2004 John Wiley & Sons, Ltd and Eating Disorders Association.