After a break of 17 years we’re back in Birmingham for the Spring BGS meeting, organised again by Alistair Ritch - same organiser, but what a different city!

One is struck by the transformation wrought by structures of steel and shining glass. The International Convention Centre is a wonderfully spacious building with a space-age feel – just like entering the Matrix. There was agreement throughout the conference that this was probably the best building we had ever been in for a Spring Meeting.

The first keynote event was the Sheldon Lecture given by Prof Shah Ebrahim in honour of Joseph Sheldon, a local pioneer of geriatric medicine. Prof Ebrahim praised Sheldon’s seminal text, “The Social Medicine of Old Age”, for its clarity and forward thinking. Prof Ebrahim’s outline of the use of Mendelian randomisation and “life course” epidemiology was a splendid and stimulating start to the conference.

Clinical updates followed and the organisers had cleverly inserted Shakespearean quotations in the programme prior to each session, to get us into a literary mind. In the lecture on Oral Malignancy we were reminded that 85% of cases of oral squamous carcinoma are in the over 50’s and that tobacco, as in other conditions, is the major risk factor. An important paper from the Winchester Falls Project showed that medication review, as part of secondary care assessment, is the main determinant in subsequent falls reduction.

The neurorehabilitation session opened with Dr Martin Turner delivering a detailed review of the epidemiology, clinical features and management of Motor Neurone Disease. He emphasised the necessity of a multi-disciplinary approach and also touched on ethical issues such as ventilation and assisted suicide. We were then introduced by Melanie Brown to the principles of Conductive Education for adults with chronic conditions such as stroke illness, MS and Parkinson’s disease. We also learnt about a very different NICE (the National Institute for Conductive Education). The session finished with Prof Ann Ashburn sharing the increasing evidence for rehabilitation in Parkinson ’s disease - areas that appear very promising for targeting rehabilitation include gait – stride length, turning and visual cueing.

After a number of references to cueing and queuing during the morning, it was good to be greeted at coffee by a catering service which was highly efficient throughout the conference. The main exhibition hall was exceptionally spacious leaving ample room for poster viewing, the pharmaceutical stands, or just sitting around for a long overdue chat.

A small but enthusiastic audience conducted a lunchtime debate on clinical nursing and the care of older people in acute hospitals. Issues such as training, career structure and the need for support from medical colleagues were highlighted.

Amputations
Parallel sessions on the dysvascular limb and Assessment of older people followed. A wide range of ischaemic conditions from claudication to the black heel was covered. Emphasis was placed on the need for full assessment, especially in chronic peripheral ischaemia where loss of a limb may presage loss of mobility for ever. Jed Rowe gave a highly entertaining account of the trials and satisfactions of setting up an amputation rehabilitation service. How many of us look after the growing number of young men requiring amputation caused by alcohol and self neglect?

Chris Bulpitt provided us with early results from the MRC trial of assessment and management of older people. The trial included 43,000 patients comparing universal versus targeted assessment. The trial had been described by some as “the biggest threat to geriatric medicine for years”. Results proved very unthreatening. There was no great difference between the assessment groups.

Artificial Feeding
In the mid afternoon the ethical issues around artificial feeding were clearly set out by Martin Vernon. The Human Rights Act is having an increasing bearing on the legal aspects. Decisions about the artificial provision of food and water can no longer simply be treated as therapeutic choices. Unfortunately there was no time left for a follow-on discussion but delegates had a chance during the Medical Ethics SIG meeting on Friday to air their views during an excellent session.

Some gleanings from recent trials followed. The Mavis Trial showed that vitamin supplementation had no significant effect on morbidity from subsequent infections. The findings of the Record Trial did not support the use of calcium and/or vitamin D supplementation for the prevention of further fractures in older people with a low-trauma fracture.

Intermediate Care
In the Intermediate Care (IC) session, three quite different research papers were presented. Key themes to emerge included the lack of a precise definition of IC with variation found across sites and within sites. IC does however, appear to have developed as a system defined, in some instances, in terms of purpose, function and structure but with rather “fuzzy” boundaries. Intermediate care, whatever its definition, has become a necessary and integral part of the continuum of care for older people. John Young presented the PATCH study which showed that community hospital based rapid step-down care was not inferior to gold standard DGH care, but that the cost may be as much as £1,000 per patient higher over the six months studied. The debate on Intermediate Care rages on.

Complementary Medicine
“Complementary medicine in chronic disease management”, was the title of the keynote lecture given by Prof George Lewith. Important messages were that people may actually get better just by being entered into a trial, and that belief (or not) in complementary medicine doesn’t affect outcome. His research had shown that the actual expectation of acupuncture caused endorphin-rich areas in the brain to “light-up” on PET scanning.

By the time of the sponsored evening symposia, some intrepid souls were entering their twelfth hour of education. However, Ray Tallis soon sharpened us up again with the topic of epilepsy in older people. He and Prof Ramsay, from Miami, delivered clear messages on diagnosis and management considering that up to 40% of all new diagnoses of epilepsy are in the over 60’s age group. Seizures should always be considered in recurrent fallers.

The alternative symposium, on Parkinson’s disease dementia, was opened by the President, Jeremy Playfer, providing an overview of the “cholinergic hypothesis” and outlining the potential benefits of cholinesterase inhibitors in the Parkinson’s related dementias. Dr Anthony Beyers presented some of the latest trial evidence supporting the use of these agents identifying a possible subset of patients, “hallucinators”, who might benefit most from treatment. Malcolm Steiger shared his experience of using these agents over recent years and outlined the multidisciplinary and the shared care approach needed. We were left with the thought that despite the recent Yellow Card from NICE for cholinesterase inhibitors, the emerging evidence continues to suggest potential important uses for these agents.

Dinner and Luminaries
The social evening was held in the splendid Victorian surroundings of the Art Gallery and Council House of the City of Birmingham. The Deputy Lord Mayor delighted delegates with the shortest welcome speech in BGS Spring meeting history. After a splendid dinner, Dame Rachel Waterhouse gave a learned account of the 18th century Lunar Men who met monthly in Birmingham, at the full moon, to discuss scientific ideas. They went home by moonlight as there was no lighting in the Birmingham streets.

Hearts and tremors
Refreshed with sleep and rehydration, delegates started Friday with clinical updates on Essential tremor and heart failure. An excellent review of essential tremor (ET) was given by Carl Clarke. In a succinct overview of the condition, he emphasised that ET remained largely a clinical diagnosis with only a small number requiring a DaT scan to help distinguish it from tremor-dominated Parkinson’s disease. We were reminded that the mainstays of treatment remain information, reassurance plus beta-blocker or Primidone. Disappointingly the PowerPoint video clips failed to materialise – one of the few glitches in the audiovisual support to the Spring Meeting conference.

In the session on heart failure one of the key points made was that setting up a CHF service required the establishment of a one-stop diagnostic heart failure clinic run by a cardiologist/ physician and heart failure nurse. Problems commonly encountered included acquiring permanent funding, training and asking patients to undergo polypharmacy. Ann Taylor’s talk on exercise in chronic heart failure included an extensive review of the trial literature with full references. However, she warned that within two months of stopping an exercise programme all the benefits achieved are lost – a lesson for all of us in our armchairs.

Following poster viewing, a caffeine fix and some more social interaction we were treated to a keynote lecture by Prof Robert Howard who asked the challenging question, “Can the brain reorganise itself to cope with Alzheimer’s disease?” His series of carefully controlled functional MRI studies failed to show evidence of plasticity/recruitment of other brain areas. This provoked a very lively debate from the floor. We were left with plenty to ponder over lunch.

In the afternoon the Diabetes SIG session opened with a whizz through the management of DKA + HONK. Important messages were that IV bicarbonate is very rarely needed in DKA and ketone monitoring is an important means of charting recovery. During the rest of the session we were reminded that diet, BP control and exercise remained the strategy to avoid type 2 diabetes, and details on the new European Guidelines for diabetes in the elderly were shared (www.eugms.org) The session closed with a detailed “horizon scanning” on future therapies for diabetes.

In the final session on Asthma and Pulmonary rehabilitation, we were treated to the key aspects of the NICE guidelines for COPD. Key messages were that we should regard COPD as preventable and treatable and that these patients benefit from and need access to pulmonary rehabilitation.

As there was no Saturday morning session, we all set off home on Friday evening in trains, planes and automobiles. It had been a very full, intensive and compact conference in a wonderfully modernised Birmingham. As always, we thank our hosts for a superb event (attendance of 530 being up on the last three Spring Meetings), as well as Hampton Medical Conferences for their excellent organisation. And so...on to Harrogate in October.

J Kelly
E Hodkinson
reporting on behalf of the N Irish Council