R. Teoh

Hypertension, lipoprotein(a), and apolipoprotein A-I as risk factors for stroke in the Chinese.

We analyzed the serum concentrations of lipids and lipoproteins and the prevalence of other risk factors in a case-control study of 304 consecutive Chinese patients with acute stroke (classified as cerebral infarction, lacunar infarction, or intracerebral hemorrhage) and 304 age- and sex-matched controls. For all strokes we identified the following risk factors: a history of ischemic heart disease, diabetes mellitus, or hypertension; the presence of atrial fibrillation or left ventricular hypertrophy; a glycosylated hemoglobin A1 concentration of greater than 9.1%; a fasting plasma glucose concentration 3 months after stroke of greater than 6.0 mmol/l; a serum triglyceride concentration 3 months after stroke of greater than 2.1 mmol/l; and a serum lipoprotein(a) concentration of greater than 29.2 mg/dl. We found the following protective factors: a serum high density lipoprotein-cholesterol concentration of greater than 1.59 mmol/l and a serum apolipoprotein A-I concentration of greater than or equal to 106 mg/dl. The patterns of risk factors differed among the three stroke subtypes. When significant risk factors were entered into a multiple logistic regression model, we found a history of hypertension, a high serum lipoprotein(a) concentration, and a low apolipoprotein A-I concentration to be independent risk factors for all strokes. The attributable risk for hypertension was estimated to be 24% in patients aged greater than or equal to 60 years. In this population, in which cerebrovascular diseases are the third commonest cause of mortality, identification of risk factors will allow further studies in risk factor modification for the prevention of stroke.

Stroke subtypes among Chinese living in Hong Kong The Shatin Stroke Registry

The Shatin Stroke Registry is a prospective study of all patients admitted with acute stroke to a generd hospital in Hong Kong where thc population is predominantly Chinese. Each patient was examined by a neurologist and 95.5% of the patients had a brain CT. Of 777 patients included in the study, 44.0% had a cortical/subcortical infarct, 18.5% a supratentorial lacunar infarct, 24.2% a supratentorial intracerebral hemorrhage, 5.8% brainstem/cerebellar infarct, 2.9% a brainstem/cerebellar hemorrhage, and 4.5% an uncertain diagnosis. The overall 30-day case fatality rate was 25.4% Comparison with five stroke registries from the West suggests that intracerebral hemorrhage occurs between two and three times more frequently in the Chinese than in Westerners. Whether there is any difference in the relative frequencies for lacunar infarction remains unclear.

Acute and long-term changes in serum lipids after acute stroke.

We studied serum lipid profiles in 171 patients less than or equal to 48 hours after the onset of acute stroke and 3 months later. The 83 patients suffering cerebral infarction had significantly higher serum concentrations of total cholesterol, low density lipoprotein-cholesterol, and apolipoprotein B and significantly lower serum concentrations of triglycerides and lipoprotein (a) less than or equal to 48 hours after ictus than 3 months later. The lipid profiles of the 53 patients suffering lacunar infarction were similar on both occasions, the only significant differences being higher total cholesterol and low density lipoprotein-cholesterol concentrations less than or equal to 48 hours after ictus. No significant changes were observed among the 35 patients suffering cerebral hemorrhage apart from a significantly higher concentration of high density lipoprotein3-cholesterol less than or equal to 48 hours after ictus. Our study, with many patients classified according to stroke subtype, gives results different from those of previous studies with much fewer patients. We conclude that in studies of serum lipid and lipoprotein concentrations as risk factors for cerebral infarction, comparing values obtained less than or equal to 48 hours after admission with control values may incorrectly identify certain lipid fractions as risk factors.

Neuroleptic malignant syndrome successfully treated with amantidine.

Sir, I recently had occasion to review the literature on the association between sarcoidosis and lymphoma. This has been a topic for discussion in your journal in the recent past (Brennan et al., 1983). Due to the paucity of cases with both conditions, it is difficult to substantiate the theory that sarcoidosis predisposes to lymphoma (Romer, 1980, 1982). It has been proposed that it is the steroid treatment, rather than sarcoidosis itself, which is responsible for precipitating steroid sensitive lymphomas. This would not account for the predominance of Hodgkins disease, as opposed to other lymphomas, in reported cases. It would support the average latent period of 2 years between discovery of the sarcoidosis and the lymphoma, but is less credible in those cases exhibiting a more prolonged interval. Up to 17 years has been previously recorded (Brincker, 1972). My interest was aroused by recently encountering a patient who developed a B cell lymphoma of the caecum 33 years after treatment for pulmonary sarcoidosis. This further strengthened my view that any such association between the two conditions is purely coincidental. P.D. McInerney Department of Surgery, Clatterbridge Hospital, Bebington, Wirral, Merseyside L63 4JY, UK.

Pyrazinamide and Rifampicin Regimens for Patients on Maintenance Dialysis

We measured pyrazinamide and rifampicin plasma concentrations in five patients with pulmonary tuberculosis and end stage renal failure treated by haemodialysis or continuous ambulatory peritoneal dialysis. Using conventional daily doses of oral pyrazinamide and rifampicin, we found that the drugs were removed efficiently by both dialysis methods, so that plasma levels were sub-optimal for maximal bactericidal action. These findings suggest that in patients with tuberculosis on maintenance dialysis, treatment should be either with higher doses of these two drugs, or with additional replacement doses given after each dialysis. Further detailed pharmacokinetic studies on larger numbers of patients are indicated.

Serum vitamin E concentrations in adult-onset spinocerebellar degeneration.

improvement in both hand and leg tremor, but the beneficial effect was only sustained for about 3 months. Clonazepam was started at a dose of 2 mg/day and increased to 4 mg/ day over a 2-month period. Amplitude and frequency of hand and leg tremor was measured objectively (see ref 8 for method) throughout incremental dosing and again 6 months after reaching the optimal dose. Leg tremor showed a marked dose-related decrease in amplitude on clonazepam by objective measures (fig) and by the patients own reports. Hand tremor was unchanged, objectively and subjectively, by clonazepam. Involvement of the legs is not uncommon in essential tremor. In a survey of 185 consecutive essential tremor patients we found leg tremor to be present in 29 (15-7%) although isolated leg tremor (that is, in the absence ofhand tremor) was found in only 4 (2-2%) (unpublished data). Essential tremor of the legs is generally present during any voluntary muscle activity but is often exacerbated on standing. In a single case study, Thompson et al2 noted that 16 Hz orthostatic tremor of the legs was not present during all types of voluntary muscle activity thus tremor occurred when standing or pressing the feet against the floor as if preparing to stand, but was absent when the patient was seated and extending the leg horizontally against gravity. The authors concluded that orthostatic tremor arose from an abnormality in the organisation of the motor program for standing. Deuschl et al,3 however, described a patient with a similar, 16 Hz leg tremor which was present during all kinds ofmuscle activation in sitting, lying or standing positions. The pathophysiology of essential tremor and orthostatic tremor is not known. Interpatient variability in the clinical appearance of essential tremor and in its responsiveness

Health status of elderly in Hong Kong sheltered housing.

AMULTIDIMENSIONAL assessment including socioeconomic, functional, physical, mental, and dietary status of the elderly living in shel tered housing was undertaken, in order to formulate a policy to provide adequate primary health care aimed at improving the quality of life. Method of assessment consisted of questionnaires, physical examination, urine testing, anthropometric measurements, respirat ory function and blood tests. Four hundred and twenty- eight (96%) of the residents, all aged 60 and above, were interviewed. Improvement in the following areas were considered desirable: (1) Although sheltered housing with adequate health care support is a good arrangement for elderly with low income without relatives, adequate living space is necessary to avoid conflict among tenants; (2) Low cost or free health care services should be made more available to the elderly. The health visitor has an important role to play in ensuring that chronic diseases continued to be treated and in supervising such treatment; (3) Regular supervision of those with impaired mental function, and visits at intervals for those who are depressed should be arranged; (4) Dietary advice on increasing the consumption of calcium — containing foods and vitamin B com plex supplementation should be considered.