Seasonal variation in the incidence of delirium among the patients of a geriatric hospital

Delirium syndrome is common in the hospitalized elderly population. However, data on its numerous etiological factors are scarce. Clinical observations suggest that delirium incidence could be related to seasonality. In order to evaluate the seasonal influence on the incidence of delirium syndrome among the patients of a geriatric hospital, we performed a retrospective study reviewing the medical records of 5218 patients aged 65 years and older, who were hospitalized in three medical wards between the years 1991 and 1997. The diagnoses of delirium were made according to ICD-9-CM. Of the 4929 subjects enrolled, 3548 (72%) were referred for assessment to the psychiatric or neurologic specialist, because of acute changes in their mental or behavioral status. Of those patients, 312 (6.3%) were diagnosed with delirium at admission, and 234 (4.7%) developed delirium during their hospitalization. Statistical analysis of incidence revealed a seasonal variation, with higher rates in the winter than in the summer months (P<0.001). This study suggests a seasonal influence on delirium syndrome incidence and a possible etiological relation with seasonal factors like the light -dark cycle.

Accuracy of recall memory in elderly patients in response to telephone support calls

During the Gulf War, 93 elderly patients (mean age 74 years) received telephone-based support calls from a hospital-based home care facility. Accuracy of memory recall of these telephone support calls was assessed 6 weeks after the termination of the war by means of a postal questionnaire. The relative accuracy of the recall memory of these patients or their caregivers to the telephone calls received exhibited a sensitivity of 75%, a specificity of 78%, a positive predictive value of 60% and a negative predictive value of 88%. Patients who had received four calls demonstrated better memory recall than those receiving less than four. Thus, relying upon patient's memory alone may be insufficient for evaluating survey data in the elderly. In addition, we found that only patients who correctly remembered receiving four individual telephone support calls tended to exhibit a decrease in the anxiety level. This study emphasizes the importance of repeated interventional telephone calls as a method of increasing recall accuracy and decreasing anxiety in aged patients.

CD4 Lymphocyte Count and CD4/CD8 Ratio in Elderly Long-Term Care Patients with Oropharyngeal Dysphagia: Comparison Between Oral and Tube Enteral Feeding

Many institutionalized elderly patients are at risk of undernutrition as a result of oropharyngeal dysphagia (OD) that possibly affects their immunological status. Tube enteral fed (TEF) patients on controlled intake of nutrients enables us to evaluate the effect of inadequate nutrition on the immune system in the orally fed elderly with OD. The aim of our study was to compare CD4 lymphocyte count and CD4/CD8 ratio between these two differently fed groups. Twenty-eight orally fed patients with OD in the Functional Outcome Swallowing Scale (FOSS) stage 2 (group A) and 17 TEF subjects (group B) were studied. CD4 and CD8 counts were determined by flow cytometry. Nutritional markers (albumin, hemoglobin, and basal metabolic index) were recorded for each group. The Charlson index was used for comparison of comorbidity between the two patient groups. The average count of CD4 lymphocytes was significantly lower in group A than in group B (754 +/- 365 vs. 1032 +/- 404 cells/ml, p < 0.01). Six patients in group A (21%) had a CD4 count of less than 400 cells/ml (lower threshold) while all the patients in group B had a CD4 count of over 500 cells/ml (p < 0.001). The CD4/CD8 average ratio was also significantly lower in group A (p < 0.008). Nutritional markers were within normal limits with no difference between the groups. These results confirm our presumption that a low CD4 lymphocyte count and a low CD4/CD8 ratio could prevail among elderly frail patients with dysphagia. This supports the view that under an apparently satisfactory nutritional profile these patients may be in a state of undernutrition that negatively influences their immunodefense.

Rhinoscleroma in an octogenarian woman

Rhinoscleroma, a granulomatous infection caused by Klebsiella rhinoscleromatis and usually afflicting young adults, was diagnosed in an 81-year-old woman. Treatment was started with orally administered antibiotics but was soon halted because of side effects. She was treated instead by local spread of a 3% rifampin ointment. After 6 weeks, the lesion cleared up and she improved remarkably. There was no recurrence during 18 months of follow-up. The current report is the second published case of rhinoscleroma in an elderly person and the first report on its cure by local treatment with a 3% rifampin ointment. This favorable experience contributes to the limited knowledge on rhinoscleroma in the elderly.

Preliminary evaluation of a convalescence cardiac unit for older patients as a model of "transitional facility" from hospital to home

OBJECTIVES

The increasing number of older cardiac patients combined with the tendency to reduce hospital stays created the need for a Convalescence Cardiac Unit (Con.CU). It functions as a transitional facility for elderly patients discharged from hospitals after cardiac events, and was established within a geriatric medical center using existing infrastructure and staff.

METHODS

Patients from 5 neighboring general hospitals (including 23 internal medicine wards and 3 departments of cardiac surgery) were offered the option of one week stay in the Con.CU after discharge. During the stay in the unit they received medical supervision as well as counsel on matters of nutrition and physical activity.

RESULTS

78 patients were admitted during the first 14 months. Forty patients were after coronary artery bypass grafts (CABG) (51%)30 after acute myocardial infarction (MI) (38%). The average age was 75 +/- 2.5 (SD). Medical complications developed in 57%. Most of these patients were treated by the local staff. Five cases had to be readmitted to the hospital they came from. Elderly cardiac patients that chose the option of Con.CU and their families expressed high appreciation regarding this experience and its contribution in facilitating return home.

CONCLUSION

This innovative model is aimed to improve continuity of care for elderly cardiac patients and provide them with a new service in this era of "early discharge" from hospitalization. Geriatric settings striving to diversify their services, and medical directors required to contribute to policy development may learn from this experience.

Age-associated neovasculopathy with recurrent bleeding

We hypothesize the existence of an age-associated neovasculopathy with recurrent bleeding. It could be the result of age-related defects in the regulation of the angiogenetic process creating pathologic small vessels with a bleeding tendency. Conditions like subdural hematoma, ocular angiopathies, intestinal angiodysplasia, coronary atherosclerotic plaques and others, may be the clinical expression of such a neovasculopathy.

Postmortem examinations in patients of a geriatric hospital

The rate of postmortem examinations (PME) especially in elderly patients is continuously declining, mostly due to the low interest of the medical staff and the reluctance of relatives. We surveyed PME performed over a 20-year period in patients of a geriatric hospital in Israel. The 93 autopsies represent a rate of 2.8% in the first five years which went down to 0.25% in the later years. In 58% of the cases, clinical cause of death was confirmed by the PME. Pulmonary embolism had the lowest confirmation rate, and was more frequently found in females (28%) than in males (10%) (p<0.03). Undiagnosed conditions in the elderly present a clinical challenge that increases with the patient's age. However, despite progress in diagnostic technology, confirmation rates of death causes have not changed much. Therefore, as the age of death rises, it is important to preserve and foster PMEs, the most reliable source of medical evidence.

Clinical, radiologic, demographic, and occupational aspects of hand osteoarthritis in the elderly

OBJECTIVE

Osteoarthritis (OA) of the hand is common in elderly patients. The aim of this study was to characterize OA frequency, severity, and distribution and to trace interrelationships between these findings and the demographic, occupational, and medical data from elderly Jewish nonrheumatologic patients.

METHODS

Study participants were 253 consecutive patients admitted to a geriatric center for a variety of nonrheumatic medical conditions. Excluded patients were those with rheumatoid arthritis; neurologic, orthopedic, or other conditions that would interfere with symmetric hand function; and mental or medical states that would interfere with history taking and radiographic studies. Patient occupations were graded as workload degree (on a scale of 1 to 3) and as the total occupational score (workload degree multiplied by the duration of each job). Clinical findings of Heberden nodes, Bouchard nodes, and malignment, graded on a scale of 0 to 3, were summed as the clinical OA score. Hand radiographs were independently read (modified Altman method), grading 5 parameters in each joint on a scale of 0 to 3, summed as a radiologic OA score. Statistical analyses included the Student t test, chi(2) test, ANOVA, Pearson correlation, and partial correlation coefficients.

RESULTS

Among 253 elderly patients (171 women, 82 men; mean age, 79 years) OA was frequent (occurring in about 80% of patients), involving most severely the second and third distal interphalangeal, right first interphalangeal, and both first carpometacarpal joints. The prevalence of OA was similar in women and men, with higher scores in women, and reached significance only in the distal interphalangeal joints. Metacarpophalangeal joints were more involved in men. Age had a clear influence on OA scores. Ethnicity affected OA severity, with Ashkenazi Jews having significantly higher scores than Sepharadi Jews. Dominant hands had significantly higher global OA scores as well as isolated joint scores (except for the first carpometacarpal joint). Occupational load, housekeeping tasks, and the number of children did not influence the total or specific joint OA scores. Associated conditions such as obesity, diabetes, hypothyroidism, and chondro calcinosis were not associated with more pronounced OA.

CONCLUSIONS

Hand OA was prevalent in our elderly cohort, and its severity was influenced by inherent traits such as age, female gender, ethnicity, and handedness. In contrast, acquired factors such as workload, number of children, and associated diseases did not appear to influence OA expression.

A 10-year perspective on the patients referred to a geriatric rehabilitation complex: the influence of managed care

OBJECTIVE

In the past 10 years, HMOs have used managed care to reduce patients referrals for rehabilitation in our Geriatric Rehabilitation Complex (GRC).

DESIGN

This study compares data regarding patients referred for rehabilitation for 4 months in 1998 with data from a similar study we performed in 1989.

SETTING

The GRC, which is part of a 396-bed geriatric hospital, includes a 36-bed ward complemented by departments of physical and occupational therapy, a speech therapy unit, and a rehabilitation psychologist. It is supported by modern rehabilitation equipment and facilities and is staffed by experienced, highly qualified academic personnel.

RESULTS

The overall number of patients referred for rehabilitation decreased by 36% during this period. However, the average age of patients is higher, the number of patients with Recc. Stroke dominates, and length of stay was reduced by 20%.

CONCLUSION

Although the rehabilitation needs of older people are increasing, fewer patients are referred to our GRC. Those who are referred are older, and their condition is more complicated; nevertheless, their length of stay has also been reduced. These are the results of HMO policies to refer older patients to new "rehabilitation settings" that charge lower prices while offering services of still unproved quality. As geriatricians, it is our duty to prevent cost considerations from overtaking the need to maximizing functional recovery.

Skilled nursing facilities as a setting for comprehensive care of older people with advanced cancer: a model of care in the post oncologic stage

METHODS

We surveyed the elderly cancer patients admitted to the Skilled Nursing Wards of Shmuel Harofe Hospital, Geriatric Medical Center, during a 5-year period.

RESULTS

The 304 elderly patients admitted with advanced cancer represented 16% of the skilled nursing patients admitted during this period. Their average time of survival was 4.2 months, ranging from 9.1 for breast cancer to 1.8 months for gastric cancer. Ninety-five percent were severely dysfunctional, and all had a high rate of medical complications.

CONCLUSIONS

Our study reveals the benefits of a skilled nursing system that provides comprehensive care, flexibility, and continuity of care at a difficult and demanding stage of this illness. This model functions at reasonable cost, and we recommend it for the care of elderly patients with advanced cancer in the post oncologic stage.

Barium enema in frail elderly patients

BACKGROUND

Barium enema (BE) examinations for the investigation of suspected colonic disease are often unsuccessful in elderly patients.

OBJECTIVE

The purpose of this study was to evaluate the success rate of BE in hospitalized frail elderly patients.

METHODS

Four hundred and seventy-two elderly patients hospitalized for different reasons underwent BE examinations. The medical charts and radiological reports were retrospectively reviewed.

RESULTS

One hundred and ninety-two (41%) BE examinations were considered inadequate; mostly (32%) because of inappropriate preparation. Sixty-seven patients (14%) were not cooperative and could not retain the contrast material, and in 25 patients (5%), the examination failed due to both these reasons. The characteristics associated with unsuccessful BE examination were the mean number of medical problems (p < 0.001), the mean number of scheduled medications (p < 0.05) and in particular the long-term use of laxatives (p < 0.01) or antiparkinsonian drugs (p < 0.01). Of great significance in predicting an inadequate BE were the patient's functional status (p < 0.001) and the presence of dementia (p < 0.001).

CONCLUSIONS

The high percentage of unsuccessful BEs in the frail elderly suggests that clinicians should carefully consider the need for that examination in these patients. We suggest that only in patients where there is a clear suspicion of a bleeding or obstructing tumor should a BE examination be performed, and even in these cases, colonoscopy or CT may be preferable as the initial examination in the frail elderly.

["Medicine on the Intenet"-- model course for physicians in the use of the Internet]

The Internet is efficient in coping with the ever-increasing volume of medical knowledge. This and other functions have lead to its integration into daily medical practice. It is therefore imperative to disseminate its use among physicians, as some, unfamiliar with the personal computer (PC), may be reluctant to learn to use it. We therefore developed a course for training physicians in the basics of Internet use, consisting of 6 sessions of 2 hours each. It includes training in PC operation as well as in the main Internet functions. The topics are medicine-oriented, including Medline search, general info search, exploring medical sites and reading medical journals on-line. 41 physicians (8 groups of 4-6 each) with various specialties attended, of whom 38 completed a feedback questionnaire 4 weeks later. 79% reported using the Internet either at home or at their working place. The function used mostly was Medline Search (68%). Although 83% had not been familiar with the PC before, 96% stated that the course was clear and understandable and 99% expressed satisfaction with the quality of the teaching. Based on these results we recommend this course as a model for teaching physicians the use of the Internet.

The effect of mini-dose aspirin on renal function and uric acid handling in elderly patients

OBJECTIVE

Aspirin is known to have a bimodal effect on the renal handling of uric acid (UA). High dosages (>3 gm/day) are uricosuric, while low dosages (1-2 gm/day) cause UA retention. Although very-low-dose (mini-dose) aspirin is used increasingly as a platelet aggregation inhibitor, no studies have been published on whether aspirin's renal effects occur at dosages of <0.5 gm/day. The aim of the present study was to evaluate the effects of commonly used mini-dosages of aspirin on renal function and UA handling in elderly patients.

METHODS

The study included 49 elderly inpatients (age 61-94). Patients were excluded if they had renal failure, hyperuricemia, gout, or a history of bleeding, or if they were receiving anticoagulants, aspirin, or nonsteroidal antiinflammatory drugs. Previous medications and diet were kept unchanged. Aspirin was administered as follows: 75 mg/day (week 1), 150 mg/day (week 2), 325 mg/day (week 3), and 0 mg/day (week 4). Baseline and weekly samples of blood and urine were evaluated for UA, creatinine, blood urea nitrogen, creatinine clearance, UA excretion, UA clearance, and plasma levels of aspirin.

RESULTS

At the lowest dosage, aspirin caused a 15% decrease in the rate of UA excretion (P = 0.045 by t-test), which was associated with a slight but significant increase in serum levels of UA (P = 0.009). These effects on UA levels were gradually reduced with increasing dosages of aspirin (multivariate analysis of variance with repeated measures showed no statistically significant difference in the rate of UA excretion between weeks 1-3 and week 0 [baseline], but the difference in serum UA levels for the same comparison was statistically significant [P = 0.038]). Generally, creatinine and UA clearance rates paralleled each other during aspirin treatment. However, 1 week after aspirin was discontinued, creatinine clearance remained decreased while UA clearance returned to baseline. Plasma aspirin concentrations were low and variable. However, patients with above-median aspirin levels had significantly greater changes in serum creatinine levels, urinary UA excretion rates, and UA clearance rates following the first week of aspirin treatment. Hypoalbuminemia and concomitant treatment with diuretics enhanced the effects of aspirin on renal function and UA retention.

CONCLUSION

Mini-dose aspirin, even at a dosage of 75 mg/day, caused significant changes in renal function and UA handling within 1 week in a group of elderly inpatients, mainly in those with preexisting hypoalbuminemia. Given the widespread (and often unmonitored) use of mini-dose aspirin, especially among the elderly, these findings call for clinician alertness as well as for further studies to clarify the mechanisms underlying these phenomena.

Morbidity, comorbidity, and their association with disability among community-dwelling oldest-old in Israel

BACKGROUND

The impact of chronic conditions on the development of disability has not yet been comprehensively studied among the elderly population living in Israel. This study evaluates the prevalence of disability and morbidity among the community-dwelling oldest-old population and examines the association between medical conditions, comorbidity, and disability in basic and instrumental activities of daily living (ADLs, IADLs).

METHOD

The data are based on a national random stratified sample of 1,820 Israeli Jewish individuals 75-94 years old, of whom 1,487 lived in the community.

RESULTS

Nineteen percent of the population was disabled in ADLs and 36% in IADLs. Disability rose with age and was higher for women and among individuals of Middle Eastern and North African origin. Stepwise logistic regression indicates that the variables associated with disability in ADLs and IADLs were older age, Middle Eastern or North African origin, living with others, and the following conditions: stroke, hip fracture, diabetes, osteoporosis, anemia, and heart attack. In addition, lower education and suffering from urinary or kidney diseases, respiratory disease, and/or Parkinson's disease were related to disability in ADLs; being a woman and suffering from heart diseases other than heart attack were related to disability in IADLs. Comorbidity was related to increased disability only for individuals with three or more conditions.

CONCLUSIONS

The identification of medical conditions and sociodemographic variables related to limitations in functioning may serve as a basis for health promotion and disease prevention in elders by attempting to reduce the incidence and disabling consequences of known disabling conditions.

Elevated serum digoxin level associated with coadministered fluoxetine

After her daughter died, depression developed in a 93-year-old woman with congestive heart failure receiving digoxin therapy. After treatment with fluoxetine hydrochloride she became anorexic and her serum digoxin level increased. A possible interaction, which has not been reported in the literature, may have occurred between fluoxetine and digoxin.

Psychiatric and polysomnographic evaluation of sleep disturbances

BACKGROUND

We evaluated psychiatrically 100 subjects, who were referred to a sleep laboratory in a general hospital because of sleep complaints.

METHODS

All subjects were interviewed using a Structured Clinical Interview for DSM-III-R and underwent one night of standard polysomnography (PSG) examination.

RESULTS

Forty three percent of the population had at least one Axis I DSM-III-R disorder. High rate of depressive mood disorder (24%) was observed in our sample, in contrast to low prevalence of alcohol and drug abuse (4%). Our results of a Israeli population are different from the United States studies in respect to alcohol and drug abuse. Furthermore, 11% of patients with PSG diagnosis exhibited comorbid psychiatric disorder.

CONCLUSION

it appears that individuals with sleep complaints have high rate of psychiatric morbidity, especially mood disorders.

LIMITATION

The rapid eye movement (REM) latency, a biological marker for depression, was not investigated.

CLINICAL RELEVANCE

it seems that both PSG and psychiatric evaluation of sleep disturbance are of importance for appropriate therapeutic strategy for individuals with sleep complaints, especially in those with features of suspected depressive mood disorders.

[Prevalence rate, place of hospitalization and source of referral of complex nursing care patients in geriatric hospitalization]

For the past several years, the hospitalization and care of complex nursing care patients (CNCP) has caused concern among organizers, funders and care-givers of the geriatric hospitalization system (GHS). To assist in improving efficiency of the GHS and to address the lack of comprehensive, empirical and up-to-date information on these patients, we conducted a survey to characterize CNCP, to assess their medical problems and to determine their prevalence among the patients in GHS. The survey was conducted in 1994 using a day census. Data were collected on the 2,319 patients in geriatric beds in all the general hospitals and geriatric hospitals in Israel on the day of the survey. 28% of the patients in the GHS were CNCP and a quarter of them (7% of all patients) suffered from more than 1 medical condition. Tube feeding was the most prevalent condition (13% of all patients), followed by terminal illness (9%), deep pressure sores (7%) and intravenous transfusion for more than 3 days (6%). The 80% of the CNCP were hospitalized in geriatric hospitals, primarily in geriatric rehabilitation wards. Their average length of stay was over a year. Internal medicine wards of general hospitals were the most frequent source of patient referral. The survey's findings raise issues related to the organization of care of CNCP. They may serve as a basis for the reorganization of the geriatric hospitalization system in order to improve efficiency and quality of care for the benefit of patients, their families and services providers.

Primary hyperparathyroidism: neuropsychiatric manifestations and case report

We describe an elderly patient with primary hyperparathyroidism and dementia who was admitted to a psychogeriatric department because of delusions of new onset. While hospitalized he had three episodes of delusions that coincided with mild hypercalcemia. Treatment for the hypercalcemia resulted in rapid remission of the delusional state, but did not induce any change in his cognitive abilities or in the severity of dementia. We review the relevant literature and offer recommendations for treatment and follow-up of elderly patients with hyperparathyroidism associated with a delusional state.

[Geriatric consultations in a general hospital]

The increasing numbers of the elderly admitted to general hospitals, and the complexity of their problems, has increased the need for geriatric consultations. We evaluated geriatric consultations given at the Wolfson Medical Center by the geriatricians of Shmuel Harofeh Hospital. Data on 6-months of consultations in medical, surgical, urologic, neurologic, orthopedic and intensive care departments were evaluated. 7,910 elderly (65 years and over) were admitted during this period, representing 58% of all admissions; 742 (9.4%) were targeted for geriatric consultation. The largest number of consultations (525) were in the medical wards, but the highest rate of consultations was in the orthopedic ward for rehabilitation after operations for hip fractures. The selection of patients for geriatric consultation at Wolfson Hospital was done by the staff of each ward. This method differs from that in most general hospitals abroad, where selection is by geriatric teams. Despite this difference, our data show that the rates of consultations were similar. Also, the multidisciplinary teams consisted of members of the staff of each ward and the geriatric consultant. The method of geriatric consultations presented is easy to set up, simple to operate, efficient and appreciated by the medical staff of the departments.

[Elderly cancer patients requiring skilled nursing care]

Cancer is an age-associated disease, and 55% of newly diagnosed cases and 67% of cancer deaths are in those above 65 years. There has recently been increasing interest in geriatric oncology, and more of the elderly are being screened for early cancer detection. Elderly cancer patients present problems not only because of their primary disease, but also because of comorbidity, reduced functional reserve, and diminished social support. Because of this combination of factors many of them need the specially skilled nursing care available in special units. 304 elderly cancer patients were admitted to our "skilled nursing division" of 156 beds during the 6 years 1987-1992. They represented 16% of all admissions and their average age was 78 +/- 0.4 (SD). Mean survival after admission was 4.1 +/- 0.4 months. In the 143 men it was 3.1 +/- 0.4 months and in the 161 women, significantly longer, 4.9 +/- 0.5. The most common location in men was colorectal (22.6%), followed by prostate (16%), while in women it was breast (25.4%), followed by colorectal (16.0%). The longest survival was for women with breast cancer (9.1 +/- 1.3 months) and the shortest for women with gastric cancer (1.9 +/- 0.6). On admission 81% had more than 1 comorbid condition: 91% had restricted mobility, 215 urinary incontinence and 12% various kinds of stomas. Serious conditions were urinary tract infections in 40%, sepsis 20%, pneumonia 12%, gastrointestinal bleeding 10% and bedsores in 7%. 77% needed intravenous fluids and/or drugs for infections, 50% narcotics for analgesia, 27% nasogastric tubes, 20% blood transfusions, 6% debridement, and 5% paracentesis. The elderly with cancer are the most difficult long term patients to treat, since their conditions are dynamic, continuously deteriorating, and they require intensive medical, nursing and psychological care.

Endoscopic retrograde cholangiopancreatography in octogenarians

Thirty patients > or = 80 years of age (mean 86) underwent diagnostic and/or therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The low mortality (6.6%) and complication (6.6%) rates lead us to believe that ERCP in octogenarians provides an acceptable route for diagnosis and treatment of biliary and pancreatic disorders.

Effects of anesthesia in elective surgery on the memory of the elderly

The effects of anesthesia in elective operations on the cognitive functioning of the elderly, was examined in 88 patients aged 60-90 years. These patients were assessed pre-operatively and at a week and three months post-operatively. Forty patients (44.5%) received general anesthesia and 48 (54.5%) received regional anesthesia. The results show no significant difference between the two anesthetic methods. Differences were noted in remote memory index between the three examination time periods. (In contrast to a later work, it was found that patients whose cognitive state had been low deteriorated more than others). The only differences found between younger and older patients were in remote, recent and immediate memory. One of the major conclusions was that the effects of the methods of anesthesia, general and regional, are no different in young and elderly patients.

[Nasogastric tubes in geriatric patients]

The nasogastric tube (NGT) not only provides nutritional support, but is also an effective diagnostic and therapeutic aid. We present the profile of the geriatric patient who needs the NGT, the reasons for its use, and mortality in these patients. 25 women (aged 83.9 +/- 5.5) and 25 men (aged 79 +/- 7.7) required the NGT, 15 of them only temporarily (TNGT) and 35 permanently (PNGT). The percentage of those with chronic neurologic disorders and/or incontinence (fecal or urinary), was highest in the PNGT group, as was the number of drugs used per patient (4.2 +/- 1.8 vs. 2.9 +/- 1.4). Laboratory studies showed no differences between the groups. PNGT was used in those whose conditions were chronic and progressive (inability to swallow or not sufficiently alert for oral nutrition). TNGT was used commonly as a diagnostic or therapeutic aid. During the study 20 patients died (40%), all in the PNGT group. Pneumonia was the main cause of death (18%), followed by decubitus ulcer (14%) and urinary tract infections (8%).

Patent ductus arteriosus involving three generations--a case history

The authors present a family with patent ductus arteriosus (PDA) involving three generations, in the absence of consanguinity.

Isolated tuberculous pericarditis still exists: a case history

A fifty-four-year-old woman from a high socioeconomic class developed acute isolated tuberculous pericarditis, three years after her sister had recovered from such disease. She was treated successfully by a triple drug regimen including isoniazid, rifampin, and ethambutol.

Bleeding angiodysplasia of stomach associated with severe ischemic congestive cardiomyopathy--a case history

The authors present a case of gastric angiodysplasia with upper gastrointestinal bleeding, associated with severe ischemic congestive cardiomyopathy.

[A severe skin reaction following mexiletene]

A 70-year-old man was treated with oral mexiletene because of ventricular premature beats due to ischemic heart disease. He developed a severe maculopapular rash which did not respond to antiallergic treatment, but disappeared after discontinuation of the drug. Adverse effects on the central nervous, cardiovascular and gastrointestinal systems have been described. A rash is rare, and in our case was of unusual severity.

Holt-Oram syndrome in an elderly patient--a case history

The authors present a typical case of Holt-Oram syndrome in an eighty-year-old woman. The patient had atrial-septal defect and phocomelia but was independent in the activities of daily living.

Hypernatremic dehydration complicated by peripheral gangrene in elderly--case reports

The authors describe the association of hypernatremic dehydration and peripheral gangrene in elderly patients. This association is known in infancy but hitherto has not been described in the elderly.

Profuse diaphoresis as the presenting symptom of myocardial ischemia with normal appearance of coronary arteriogram--a case report

The authors present a case of a patient suffering from profuse diaphoresis as the sole manifestation of myocardial ischemia (syndrome x or coronary vasospasm). The diagnosis was established by positive exercise thallium 201 imaging and normal-appearing coronary arteriogram.

Cessation of recurrent bleeding from gastrointestinal angiodysplasia, after beta blocker treatment in a patient with hypertrophic subaortic stenosis--a case history

The authors present the case of an elderly patient suffering from obstructive cardiomyopathy and bleeding colonic angiodysplasia. After treatment with propranolol, the bleeding stopped without recurrence.

Improvement of pain and disability in elderly patients with degenerative osteoarthritis of the knee treated with narrow-band light therapy

OBJECTIVE

To evaluate the effects of low-power light therapy on pain and disability in elderly patients with degenerative osteoarthritis of the knee.

DESIGN

Partially double-blinded, fully randomized trial comparing red, infrared, and placebo light emitters.

PATIENTS

Fifty patients with degenerative osteoarthritis of both knees were randomly assigned to three treatment groups: red (15 patients), infrared (18 patients), and placebo (17 patients). Infrared and placebo emitters were double-blinded.

INTERVENTIONS

Self-applied treatment to both sides of the knee for 15 minutes twice a day for 10 days.

MAIN OUTCOME MEASURES

Short-Form McGill Pain Questionnaire, Present Pain Intensity, and Visual Analogue Scale for pain and Disability Index Questionnaire for disability were used. We evaluated pain and disability before and on the tenth day of therapy. The period from the end of the treatment until the patient's request to be retreated was summed up 1 year after the trial.

RESULTS

Pain and disability before treatment did not show statistically significant differences between the three groups. Pain reduction in the red and infrared groups after the treatment was more than 50% in all scoring methods (P less than 0.05). There was no significant pain improvement in the placebo group. We observed significant functional improvement in red- and infrared-treated groups (p less than 0.05), but not in the placebo group. The period from the end of treatment until the patients required treatment was longer for red and infrared groups than for the placebo group (4.2 +/- 3.0, 6.1 +/- 3.2, and 0.53 +/- 0.62 months, for red, infrared, and placebo, respectively).

CONCLUSIONS

Low-power light therapy is effective in relieving pain and disability in degenerative osteoarthritis of the knee.

Vasculitic skin ulcers associated with myelofibrosis--a case report

This is the case report of a seventy-seven-year-old woman with ulcerated skin vasculitis of the lower extremities that preceded the appearance of myelofibrosis. No previous report of this association has been found in a survey of the literature.

Leukocyte alkaline phosphatase score in patients with cerebrovascular disease and in patients with primary and metastatic brain tumors

Leukocyte alkaline phosphatase (LAP) activity in peripheral blood was determined in 54 patients with cerebrovascular disease (CVD), 11 patients with primary brain tumor, and 23 patients with metastatic brain tumor. The LAP score of the primary brain tumor patients (155 +/- 40) was significantly higher (P less than 0.03) than the LAP score for cerebrovascular disease patients (96 +/- 87). The LAP score levels of the metastatic brain tumor patients (251 +/- 55) was significantly higher as compared with both the cerebrovascular disease (P less than 0.001) and primary brain tumor groups (P less than 0.001). The LAP score could serve as an additional, although non-specific, marker to assist in the differentiation between cerebrovascular disease and brain tumors.

[Anaphylactic shock after i.v. verapamil]

A 61-year-old woman who was being treated with verapamil because of atrial fibrillation with rapid ventricular rate, went into anaphylactic shock. Verapamil is safe and effective for treating supraventricular tachyarrhythmias and serious adverse effects are uncommon. However, hypotension, cardiogenic shock, bradycardia and precipitation or aggravation of heart failure have been described. The patient presented was successfully treated with corticosteroids and antihistaminics.

Nutritional status of the institutionalized elderly

The nutritional status of 84 elderly ambulant, self-feeding residents in public institutions was evaluated in terms of their food supply and the biochemical constituents in their blood. Calculations were made of the energy, protein, vitamin and iron composition of the food supply in the institution. The amount of nutrients supplied were adequate when compared with the recommended dietary allowances. Deficiency levels in the blood (expressed as a percentage of the population) were found in the following constituents; riboflavin 46%, hemoglobin 44%, plasma carotene 34%, thiamine 19%, leukocyte ascorbic acid 20%, retinol 5%, and plasma iron 2%. No deficiency was found in pyridoxine. Problems of monitoring the nutritional status of the institutionalized elderly are discussed.