BMJ  2006;332:38 (7 January), doi:10.1136/bmj.332.7532.38

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Erectile dysfunction could signal cardiovascular disease

Healthy older men who develop erectile dysfunction could be harbouring occult cardiovascular disease, according to a recent study. In a cohort of 8063 US men aged 55 or over with no cardiovascular disease, 4247 had normal erectile function at study entry. Of these, the 2420 (57%) who developed new erection problems during five years of follow-up were 25% more likely to have a later cardiovascular event than the men who did not (hazard ratio 1.25, 95% CI 1.02 to 1.53). An analysis that included the 3816 men with erection problems at study entry found an even stronger association between erectile dysfunction and cardiovascular disease (1.45, 1.25 to 1.69). The authors estimate that erectile dysfunction is an independent risk factor for cardiovascular disease of about the same magnitude as family history or smoking.

This is not the first study to find a link between erection problems and cardiovascular events such as heart attack, angina, or stroke. But the authors say they are the first to use prospective data to show that healthy men who develop these problems are at increased risk afterwards. The men in this study were in the placebo arm of a randomised trial that was testing finasteride as a prophylactic against prostate cancer. They were asked regularly about their sex life, and were followed up carefully for up to seven years.

JAMA 2005;294: 2996-3002[Abstract/Full Text]

Clostridium difficile is now a serious community acquired infection

The incidence of Clostridium difficile infection seems to be rising steadily among general practice patients in the United Kingdom, despite a fall in antibiotic prescribing. Drugs that suppress the secretion of gastric acid could be partly to blame, write researchers, whose case-control study of community acquired infections found a clear and independent association between diarrhoeal disease caused by Clostridium and a recent prescription for one of these agents. Proton pump inhibitors and H₂ receptor antagonists were both implicated (rate ratio 2.9 (95% CI 2.4 to 3.4) for proton pump inhibitors and 2.0 (1.6 to 2.7) for H₂ receptor antagonists).

The researchers studied 1233 cases of community acquired Clostridium infection and 12 330 matched controls, all from an established research database covering 400 UK general practices. The study confirmed the link with antibiotics (rate ratio 3.1, 2.7 to 3.6), but also showed that you don't have to take antibiotics to get an infection—nearly two thirds of the cases in this study had not had antibiotics for at least 90 days before their illness.

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The researchers warn that diarrhoeal disease caused by Clostridium is now a serious public health concern that is no longer confined to hospitals and institutions. Older people are particularly vulnerable—three quarters of affected patients in this study were over 65 years old.

JAMA 2005;294: 2989-95[Abstract/Full Text]

Dementia is a global problem, and it can only get worse

Alzheimer's disease will be 100 years old in September 2006. To mark the centenary of the first ever case (a 51 year old woman called Auguste), 12 experts—armed with a systematic review of epidemiological surveys and a technique called Delphi consensus—tried to find out exactly how many people have dementia worldwide and to determine the expected prevalence and incidence over the next few decades. The final consensus was that 24.3 million people have dementia today, a number that will double every 20 years or so, reaching 81 million by 2040.

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The overall picture is bleak, but it is even bleaker for developing countries. Although numbers are set to double in Western Europe and triple in China, health services in north Africa and the Middle East will have to cope with nearly four times as many people with dementia by 2040. Developing countries already bear 60% of the global burden of this disease. That proportion will increase to 71% by 2040.

The evidence underpinning the figures is patchy, and in some regions non-existent, but the authors say their estimates are good enough for now, and governments should not wait for anything better before taking action.

Lancet 2005;366: 2112-7

Sudden infant death is linked to complications in other pregnancies

Sudden infant death syndrome is rare and usually an isolated event. Even so, subsequent siblings are about five times more likely than other infants to die the same way. This could be because predisposing factors for sudden infant death, including preterm birth and intrauterine growth retardation, continue to operate in later pregnancies.

One recent study supports this theory. Women from Scotland who had had one sudden infant death were more likely than other women to have intrauterine growth retardation or a preterm delivery in the next pregnancy (odds ratio 2.27 (95% CI 1.54 to 3.34), P < 0.0001 and 2.53 (1.82 to 3.53), P < 0.0001, respectively). Similarly, women who had had a preterm delivery or intrauterine growth retardation in one pregnancy were more likely to have a sudden infant death after the next one (1.93 (1.24 to 3.00) and 1.87 (1.19 to 2.94), respectively). Ongoing maternal factors such as smoking partly explained the association; the rest was accounted for by the tendency for risky pregnancy complications to recur.

The study linked three national databases to derive a cohort of 258 096 women who had had two consecutive singleton births in Scotland between 1985 and 2001. The 535 sudden infant deaths included one pair of siblings.

Lancet 2005;366: 2107-111[CrossRef][Medline]

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