WEMJ Volume 110 No. 1 - January 2011
West of England Medical Journal (online) ISSN 2050-8530
Welcome to the first edition of the e-journal of the Bristol Medico-Chirurgical Society. Although new as an e-journal the West of England Medical Journal is long-established as a journal. It was first published as the Bristol Medico-Chirurgical Journal in 1883 and continued, with various name changes, until 1994 when it went into temporary abeyance.
?As a general medical journal it has covered all clinical specialties and all medical conditions. It is the intention of the editorial board that it should continue to do so.
This first issue addresses the problem of respiratory disease in the elderly. The articles have been edited by Dr. Nabil Jarad and they provide an interesting and challenging introduction to the subject.
In future issues we will cover such diverse subjects as AIDS, Breast reconstruction after treatment for carcinoma, advances in radiology, chaos mathematics and its role in medicine and a large variety of other subjects. There will be a section called "science watch" looking at published research at the forefront of medical science.
We will also peer back through the archives of over one hundred years of the journal and re-publish some of the more interesting, ground-breaking or prophetic subjects.This will hopefully give us a glimpse or taster of medicine and surgery over a period that saw such rapid change.
We all hope that you will enjoy the journal.
Prof. Paul Goddard Editor-in-chief
1. Respiratory Medicine and Old Age - The Size of the problem by Nabil Jarad
West of England Medical Journal (Volume 110, Number 1, Article 1, January 2011)
The increase in world population over the past century is unparalleled in human history. By 2020, over 4 million persons in the UK, 18 million in the US and 50 million in China will be over 80 years of age. The impact of an increase in the number of aging population is a major health and economical issue. Age and aging is now regarded as a priority for health, social and economical reasons and is regarded as a UK governmental priority . In parallel, research in age and aging is now considered to be one of the main priorities in the UK and other western countries.
2. The reality of COPD in old age by Nabil Jarad
West of England Medical Journal (Volume 110, Number 1, Article 2 January 2011)
Chronic obstructive pulmonary disease (COPD) is a progressive disease characterised by a combination of airflow obstruction and pulmonary and systemic inflammation which is manifested by respiratory and systemic manifestations that lead to premature death . COPD is caused in the majority of patients by cigarette smoking that leads to lung damage due to oxidative stress, impaired apopotosis and impairment of the balance between trypsin and anti-trypsin.
COPD is currently a major health concern worldwide and, unlike most chronic diseases where future prevalence is expected to decline, the prevalence of COPD will increase and in 2020, COPD will be the 3rd cause of death worldwide.
3. The Interaction of Ageing and Lung Disease by Christopher Dyer (Royal United Hospital Bath, BA1 3NG)
West of England Medical Journal Volume 110, Number 1, Article 3, January 2011
Respiratory disease is the second commonest cause of severe disability in older adults, second only to musculoskeletal disorders (and four times more common than stroke). Atypical presentations are more common in old age, and older patients may report less breathlessness  than younger adults despite similar physician assessed severity .
There is still compelling evidence that older people are not treated purely on the basis of their physiological condition and their wishes, but on age per se. The medical profession is unduly pessimistic about the outcomes for older people. It is never more true that patients in this age group are either over treated when palliative care would have been preferable to the patient, or under-treated because of the physician’s expectation of a poor outcome.
There is very good evidence regarding the futility of basing treatment decisions on the ground of age alone. In the 2007 CAOS study of prognosis for patients with COPD in intensive care units, age was only a small independent factor . In this study, there was a marked deviation between physician-predicted survival and actual survival. In fact, the tenth of patients with the poorest clinician prognosis had a predicted 180 day survival of around 3% and an actual survival of around 36%. Eleven characteristics were found to have a significant independent association with increased hospital mortality in addition to age, such as the presence of severe respiratory disease, low pH, low serum albumin and multi-organ failure.
Pre-morbid physical and cognitive function should also be added to that list, something that is not well assessed and probably a better surrogate than age itself. The only thing that does increase with age is variability of physical activities– from the marathon runner to the bedbound!
Homeostatic instability is a hallmark of ageing – there is no homogeneous biomass called “the elderly”. And so we have to distinguish between the fit and the frail...and a large number of people somewhere in between.
4. Acute pulmonary embolic disease in the elderly Dr. Jay Suntharalingam (Royal United Hospital Bath, BA1 3NG)
West of England Medical Journal Volume 110, Number 1, Article 4 January 2011
Acute pulmonary embolic disease is a common condition that, whilst potentially treatable, often confers considerable morbidity and mortality. This review considers the impact of the disease in the elderly, focussing particularly on the diagnostic and management challenges faced in this particular patient group.
Pulmonary embolic disease is often under-recognised in the elderly, with one study suggesting that up to 40% of all fatal PE’s in this population group go undiagnosed prior to death.
Whilst there is still a role for PTP scoring and D-Dimer assessment in the elderly, a higher proportion will need to go on to second line investigations to more definitively exclude a diagnosis of PE
This may include leg ultrasonography, ventilation-perfusion studies (in those with normal chest Xray) and CT pulmonary angiography (CTPA).
CTPA is now the recommended imaging modality for diagnosing pulmonary embolism
5. From the Archives of 1883: A reproduction of a short piece in the journal from July 1887 detailing a device to be swallowed which would purportedly catch the head of a tapeworm.
6. Book Review: ENJOY EATING LESS – Letters to a Grandchild by Alick Dowling
ISBN 978-1-4457-3192-6 Price £ 6.00 from Lulu.com
Although Pugwash is still fighting the message on the cover by remaining true to his original size the reissue of this excellent short book is aptly in a slimmed down A5 format from its original 2006 size. The layout is easier to read as the text is not split into two columns and each of the 24 letters starts at the top of the left hand page. The author has a very straightforward writing style and is a natural com municator. He launches into his simple theme that the only effective way to lose weight is to eat less in the introduction and constantly reiterates the message in each of the letters. His down to earth approach to the dreaded obesity problem for affluent societies with superfluities of food is most welcome. He backs up his thesis in each letter by weighing up the pros and cons of various dietary and food fads and discussing them with the help of hard facts gleaned from up to date research data. Half the population of any society will suffer from obesity due to their genetic programming to store fat rather than burn it up and this book is an aide to them all in changing their eating habits to eat less. The message is so sim ple that by the end of the book the read er’s resolve is firmly made up and their approach to the food they will consume is tempered to consuming smaller portions. It certainly works and I have lost a stone and find the Body Mass Index (BMI) table in Letter 2 invaluable in reminding myself that I still have a way to go to reach my “normal” weight.
Not content with only directing the reader to eat less, he has put his money where his mouth is and lost 3 stone 2lb and kept it off by guess what – eating less! This is an invaluable book that should not be restricted to any health care worker to recommend to an overweight patient but be available for sale by the till of any food or pharmacy emporium! It is as good to “dip into” as to read from cover to cover. To obtain a copy go to LULU.com and type in the title and make your order. Copies arrive in 3-5 working days.
Lois M Tutton MSc, BDS
18th August 2010