Background-Low 25-hydroxyvitamin D levels, commonly found in older patients with heart failure, may contribute to the chronic inflammation and skeletal myopathy that lead to poor exercise tolerance. We tested whether vitamin D supplementation of patients with heart failure and vitamin D insufficiency can improve physical function and quality of life. Methods and Results-In a randomized, parallel group, double-blind, placebo-controlled trial, patients with systolic heart failure aged Ն70 years with 25-hydroxyvitamin D levels Ͻ50 nmol/L (20 ng/mL) received 100 000 U of oral vitamin D2 or placebo at baseline and 10 weeks. Outcomes measured at baseline, 10 weeks, and 20 weeks were 6-minute walk distance, quality of life (Minnesota score), daily activity measured by accelerometry, Functional Limitations Profile, B-type natriuretic peptide, and tumor necrosis factor-␣. Participants in the vitamin D group had an increase in their 25-hydroxyvitamin D levels compared with placebo at 10 weeks (22.9 versus 2.3 nmol/L [9.2 versus 0.9 ng/mL]; PϽ0.001) and maintained this increase at 20 weeks. The 6-minute walk did not improve in the treatment group relative to placebo. No significant benefit was seen on timed up and go testing, subjective measures of function, daily activity, or tumor necrosis factor. Quality of life worsened by a small, but significant amount in the treatment group relative to placebo. B-type natriuretic peptide decreased in the treatment group relative to placebo (Ϫ22 versus ϩ78 pg/mL at 10 weeks; Pϭ0.04). Conclusions-Vitamin D supplementation did not improve functional capacity or quality of life in older patients with heart failure with vitamin D insufficiency.

Ž .Background: Heart failure HF is difficult to diagnose and treat in older patients. Symptoms may be non-specific and the presence of co-morbidities and polypharmacy complicate treatment strategies. There are, however, few data to quantify the Ž . extent of these problems in the very elderly. Methods: A retrospective study of 116 patients median age 86; range 65᎐98 with an established diagnosis of HF during their hospital admission. Main outcome measures: the accuracy of diagnosis of heart Ž . failure according to the European Society of Cardiology ESC definition. The aetiology and frequency of associated co-morbidities and the nature of drug treatment. Results: The specificities of clinical signs, chest X-rays and abnormal ECGs Ž . for heart failure ESC definition were 50%, 20% and 9%, respectively. Only 28% of patients were admitted for worsening symptoms which could be attributed to HF. None of the patients had HF as their only medical problem. Co-morbidities Ž . Ž . Ž . Ž . included chest disease 30% , incontinence 29% , cerebrovascular disease 26% , musculoskeletal problems 41% . Barthel Ž . Ž . activities of daily living score was F 16r20 in 35%. Mental state questionnaire MSQ score was F 7r10 in 38%. Ninety percent were taking four or more different medications. Thirty-nine percent were on psychotropic drugs. On discharge, a total of 88% of patients returned home to live independently and 35% were monitored by regular day hospital attendance. Conclusion: Heart failure in frail elderly patients is often compounded by other major illnesses and polypharmacy which have a profound impact on their functional status. This has implications for the most effective targeting of evidence based treatment. ᮊ

Objectives: To compare the prevalence of use of potentially inappropriate medicines (PIMs) between older patients living in their own homes versus those living in nursing or residential homes, and to test the association between exposure to PIMs and mortality. Design: Cohort study stratified by place of residence. Setting: Tayside, Scotland. Participants: All people aged between 66 and 99 years who were resident or died in Tayside from 2005 to 2006. Main outcome measures: The exposure variable was PIM use as defined by Beers' Criteria. All cause mortality was the main outcome measure. Results: 70 299 people were enrolled in the cohort of whom 96% were exposed to any medicine and 31% received a PIM. Place of residence was not associated with overall risk of receiving PIMs, adjusted OR 0.94, 95% CI 0.87 to 1.01. Exposure to five of the PIMs (including long-acting benzodiazepines) was significantly higher in nursing homes whereas exposure to five other PIMs (including amitriptyline and NSAIDs) was significantly lower. Exposure to PIMs was similar (20e46%) across all 71 general practices in Tayside and was not associated with increased risk of mortality after adjustment for age, gender and polypharmacy (adjusted OR 0.98, 95% CI 0.92 to 1.05). Conclusions: The authors question the validity of the full list of PIMs as an indicator of safety of medicines in older people because one-third of the population is exposed with little practice variation and no significant impact on mortality. Future studies should focus on management of a shorter list of genuinely high-risk medicines.

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Objective-To assess the ability ofa cohort of junior hospital doctors to interpret ECGs which have immediate clinical relevance and influence subsequent management of patients Methods-57 junior hospital doctors were interviewed and asked to complete a standard questionnaire which included eight ECGs for interpretation and a supplementary question relating to the administration of thrombolytic treatment. Each doctor was assessed over a 48 h period while they performed their daily clinical duties. Results-The major abnormality of anterior myocardial infarction was recognised by almost all doctors. There was difficulty in the interpretation of posterior myocardial infarction and second degree heart block. Most myocardial infarctions would have been given satisfactory thrombolysis, but there was a reluctance to use this treatment in patients with posterior myocardial infarction and left bundle brach block. A few patients without myocardial infarction would have received thrombolytic treatment. Conclusions-There is varying ability among junior hospital doctors in the interpretation of the emergency electrocardiogram. The results are of concern as poor interpretation of the ECG can result in inappropriate management. As a result of the findings of this study it is proposed to introduce more formal training in the interpretation of clinically relevant ECG abnormalities for junior hospital doctors.

Objective: To assess correlation between type of breast cyst and risk of breast cancer in women with gross cystic disease of the breast. Design: Cohort study of women with breast cysts aspirated between 1983 and 1993 who were followed up until December 1994 for occurrence of breast cancer. Setting: Major cancer prevention centre. Subjects: 802 women with aspirated breast cysts. Main outcome measures: Type of breast cyst based on cationic content of cyst fluid: type I (potassium:sodium ratio > 1.5), type II (potassium:sodium ratio < 1.5), or mixed (both types). Subsequent occurrence and type of breast cancer. Results: After median follow up of six years (range 2-12 years) 15 cases of invasive breast cancer and two ductal carcinomas in situ were diagnosed in the cohort: 12 invasive cancers (and two carcinomas in situ) among the 417 women with type I cysts, two cancers among the 325 women with type II cysts, and one among the 60 women with mixed cysts. The incidence of breast cancer in women with type I cysts was significantly higher than that in women with type II cysts (relative risk 4.62 (95% confidence interval 1.26 to 29.7)). These results were confirmed after adjustment for several risk factors for breast cancer (relative risk 4.24 (1.12 to 27.5)). Conclusions:The increased risk of breast cancer of women with breast cysts seems to be concentrated among women with type I breast cysts.

B-type natriuretic peptide may be a useful marker for cardiac disease in patients attending Day Hospital. Half of the patients assessed had cardiac disease detected. Both the electrocardiogram and B-type natriuretic peptide were sensitive in the detection of left ventricular systolic dysfunction but lacked specificity. B-type natriuretic peptide was superior to the electrocardiogram in the detection of valvular disease. If used to pre-screen cardiovascular disease in Day Hospital patients, B-type natriuretic peptide and the electrocardiogram could reduce the need for echocardiography in some patients before implementing evidence-based treatments. B-type natriuretic peptide increases progressively as the number of different cardiac abnormalities increases and this may explain why B-type natriuretic peptide is of such prognostic value in older patients.