[Drug compliance in the elderly: determinants and support]. / L'adhésion thérapeutique du patient âgé ambutatoire: quels déterminants et quet soutien?

Drug adherence needs to be promoted in elderly patients taking multiple medications. Barriers to adherence are numerous and each barrier needs to be addressed specifically. Patients should be included in the therapeutic decision making process. Patient's life expectations and disease/treatment beliefs should be addressed. Healthcare practitioners should discuss the course of treatment with the patient proactively before any problem arises by using open-ended and informative questions. Functional and organizational barriers to adherence should be assessed throughout the treatment. A multidisciplinary approach to promote adherence is crucial and allows healthcare practitioners to combine specific skills (physician, pharmacist, nurse, etc.).

Is fall prevention by vitamin D mediated by a change in postural or dynamic balance?

INTRODUCTION: The objectives were:(1) to validate a quantitative balance assessment method for fall risk prediction; (2) to investigate whether the effect of vitamin D and calcium on the risk of falling is mediated through postural or dynamic balance, as assessed by this method. MATERIALS AND METHODS: A secondary analysis of a double blind randomized controlled trial was employed, which included 64 institutionalized elderly women with complete balance assessment (age range: 65-97; mean 25-hydroxyvitamin D levels: 16.4 ng/ml (SD +/-9.9). Participants received 1,200 mg calcium plus 800 IU cholecalciferol (n=33) or 1,200 mg calcium (n=31) per day over a 3-month treatment period. Using an electronic device attached to the lower back of the participant, balance was assessed as the degree of trunk angular displacement and angular velocity during a postural task (standing on two legs, eyes open, for 20 s) and a dynamic task (get up from a standard height chair with arm rests, sit down and then stand up again and remain standing). RESULTS: It was found that both postural and dynamic balance independently and significantly predicted the rate of falling within the 3-month follow-up. Vitamin D plus calcium reduced the rate of falls by 60% [relative risk (RR)=0.40; 95% CI: 0.17, 0.94] if compared with calcium alone. Once postural and dynamic balance were added to the regression analysis, they both attenuated the effect of vitamin D plus calcium on the rate of falls. For postural balance, the RR changed by 22% from 0.40 to 0.62 if angular displacement was added to the model, and by 9% from 0.40 to 0.49 if angular velocity was added. For dynamic balance, it changed by 1% from 0.40 to 0.41 if angular displacement was added, and by 14% from 0.40 to 0.54 if angular velocity was added. DISCUSSION: Thus, balance assessment using trunk angular displacement is a valid method for the prediction of falls in older women. Of the observed 60% reduction in the rate of falls by vitamin D plus calcium supplementation compared with calcium alone, up to 22% of the treatment effect was explained by a change in postural balance and up to 14% by dynamic balance.

Detection of disseminated tumour cells in the liver of cancer patients.

AIMS: The liver is a common site of metastasis from a variety of solid malignancies. This is due to disseminated tumour cells (DTC) that have spread prior to or during surgery from the primary carcinoma. This article gives a short overview of the data published on the detection of DTC in the liver and describes the commonly used detection methods and respective markers. METHODS: A literature survey was performed in public medical databases comprising the last 15 years with focus on DTC detection in liver tissue of cancer patients. KEY FINDINGS: Although the liver is a preferred site of metastasis, only a few studies have analysed the DTC incidence in inconspicuous liver tissue. The available reports include only patients with pancreatic and colorectal carcinomas. In patients with pancreatic cancer the DTC incidence varied from 5 to 76%. No follow-up data has been reported so far. In patients with colorectal carcinoma hepatic DTC were found in 5-69% of cases. A negative prognostic influence of hepatic DTC was reported in all but one studies with follow-up information. CONCLUSIONS: The detection of DTC in the liver can contribute to identify patients with increased risk who could benefit from an intensified follow-up or new treatment strategies.

Detection of disseminated tumour cells in the liver of colorectal cancer patients.

AIMS: The aim of this study was to assess the incidence and lobar distribution of three surrogate tumour cell markers in biopsies from both liver lobes. PATIENTS AND METHODS: This study comprised 189 patients for whom DNA and/or RNA was available from both liver lobes and who showed at least one positive marker in one liver lobe. Detection of cytokeratin 20 (CK20) and guanylylcyclase C (GCC) was performed by nested reverse transcription-PCR. For detection of K-ras mutations in codons 12 and 13, a PCR-restriction-fragment-length-polymorphism assay was used. RESULTS: The incidence of all markers and their combinations was higher in the smaller left lobe than in the larger right lobe (CK20: 62 vs 38%; GCC: 52 vs 48%; K-ras: 61 vs 39%; CK20+GCC: 61 vs 39%; CK20+GCC and/or K-ras: 61 vs 39%). The marker incidence in the two liver lobes was independent from the location of the respective primary colorectal carcinoma. CONCLUSIONS: The markers CK20, GCC, and K-ras indicating cells shed from the primary CRC were detected more often individually and in combination in biopsies from the smaller left lobe than from the larger right lobe. The site of the primary tumour did not influence the marker incidence in both liver lobes.

[Effect of vitamin D on muscle strength and relevance in regard to osteoporosis prevention]. / Wirkung von Vitamin D auf die Muskulatur im Rahmen der Osteoporose.

A successful prevention strategy for fractures in the elderly should not be limited to an improvement in bone mineral density. Equally important is the prevention of falls. Thus, 90% of fractures in the elderly are associated with a fall and 30% of all ambulatory, and 50% of institutionalized elderly age 65 years and older fall at least once a year. Fall incidence increases 10% per decade thereafter. According to recent studies, vitamin D and calcium supplementation may be a promising treatment strategy targeting both bone mineral density, as well as muscle strength and the risk of falling. The protective effect of vitamin D on fractures has been attributed to the established moderate benefit of vitamin D on bone mineral density. However, an alternative explanation might be that vitamin D affects factors directly related to muscle strength, thus, reducing fracture risk through improved function and fall prevention, in addition to its benefits on calcium homeostasis.

[Hip protectors in prevention of proximal femoral fracture]. / Hüftprotektoren bei der Prävention der proximalen Femurfraktur.

Hip fractures are a major cause of impairment, disability and death in elderly people. The incidence of hip fractures is increasing. Most attempts to prevent hip fractures have focused on reducing underlying medical disorders and risk. In 1993 Lauritzen et al. reported the results of a clinical trial which showed a significant (53%) reduction for hip fractures in the protector wearing group. These results were reproduced many times. Hip protectors offer a powerful new method for reducing the risk of hip fractures. Their use should be encouraged for people with advanced osteoporosis or high fall risk and for those living in nursing homes.

Self-reported exercise before age 40: influence on quantitative skeletal ultrasound and fall risk in the elderly.

OBJECTIVES: To compare musculoskeletal factors with bone structure, as measured by quantitative ultrasound (QUS) at the calcaneus, and their potential to predict fall risk in geriatric inpatients. DESIGN: Longitudinal. SETTING: Two geriatric hospitals in Switzerland. PARTICIPANTS: A total of 134 of 207 long-stay geriatric patients (96 women, 38 men) who were able to perform the timed up and go (TUG) test. INTERVENTIONS: Five musculoskeletal tests: 2 functional tests (TUG, for mobility; functional reach test, for balance), and 3 muscle strength tests (knee flexor, knee extensor, grip). Falls were monitored prospectively in a subgroup of 94 mobile subjects of 1 geriatric hospital throughout each individual length of stay (median, 31.4wk: interquartile range, 16-56.4wk). MAIN OUTCOME MEASUREMENTS: Functional and strength tests, mobility status, and self-reported exercise before age 40 were musculoskeletal factors to be compared with QUS. RESULTS: QUS was higher in mobile subjects without walking aid (p < .0001) and correlated significantly with muscle strength (knee flexor: r = .36; knee extensor: r = .30) and functional tests (TUG: r = -.25; functional reach: r = .16). Women who reported regular exercise before age 40 had higher QUS (p = .01) and fewer falls (p = .01). Falls were less frequent in subjects with walking aid (p = .03). No single musculoskeletal test, but rather a combination of demographic variables, musculoskeletal factors, and QUS could predict 76% of total variation of fall risk. CONCLUSION: This study showed the important impact of current mobility and muscle strength status on bone structure, as measured by QUS at the calcaneus. In addition, a beneficial effect of former exercise on QUS and fall risk at advanced age could be documented in women. Both findings support life-long engagement in exercise, which might be particularly meaningful for women.

[Results of neurorehabilitation. An outcome study 20 months after stroke]. / Ergebnisse der Neurorehabilitation. Eine Outcomestudie 20 Monate nach Schlaganfall.

65 stroke survivors who were discharged home after completing an in-patient rehabilitation program were evaluated at home 20 months post-stroke by physiotherapists. 59 patients (91%) still lived in the community. Functional abilities remained stable with only 11% deteriorating and 25% improving in basal activities of daily living (BADL). 58% of patients needed assistance for at least one BADL and 46% showed signs of impaired cognition. Falls occurred in more than half of patients. Rehospitalisation was common (31%). Aside from living partners, care was provided by relatives in 58% and by home services in 46%. 25% of patients attended day care. Nearly half of patients still received rehabilitative therapy, especially if marked initial deficit was present. In conclusion, 20 months post stroke the majority of survivors who have completed rehabilitation successfully experience persistent limitations but remain in a stable functional status. This seems to be true for more severely disabled patients, too, if rehabilitative therapies, home services and day care are consequently provided.

Influence of physical mobility and season on 25-hydroxyvitamin D-parathyroid hormone interaction and bone remodelling in the elderly.

OBJECTIVE: To investigate influences of physical mobility and season on 25-hydroxyvitamin D-intact parathyroid hormone (iPTH) interaction in the elderly. DESIGN: We examined 188 frail institutionalized elderly at the expected nadir of their serum vitamin D concentrations (winter). This group was compared with 309 healthy ambulatory elderly at the expected time of maximum vitamin D repletion (summer), to accentuate the influences of season and physical activity. METHODS: Serum concentrations of 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, iPTH and urinary deoxypyridinoline (DPD) were measured. RESULTS: Vitamin D metabolites were significantly lower in the institutionalized elderly (P<0.0001), with an 82.5% prevalence of vitamin D deficiency (25-hydroxyvitamin D <12ng/ml) in institutionalized elderly in wintertime and 15.5% in ambulatory elderly in summertime. Overall, median iPTH did not differ between groups. However, median iPTH secretion in the presence of low vitamin D serum concentrations (5-30ng/ml) was greater in ambulatory elderly. This could be explained by lower mobility status being correlated with greater serum calcium concentrations (r=0.24, P=0.02 in women; r=0.35, P=0. 001 in men) and greater urinary excretion of DPD (r=0.41, P=0.0001 in women; r=0.42, P=0.0002 in men), independent of 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D and iPTH. CONCLUSIONS: These data support the hypothesis that immobility, even in the presence of vitamin D deficiency, acts as an overriding influence on bone metabolism by promoting bone resorption (measured as urinary DPD) and increasing serum calcium independent of iPTH. Therefore mobility status may substantially affect 25-hydroxyvitamin D threshold values and the degree to which patients benefit from vitamin supplementation.

No influence of osteoarthritis of the hand on phalangeal osteography in elderly women.

We investigate the influence of hand osteoarthritis on skeletal quantitative ultrasound (QUS) measurement through the proximal phalanges in female geriatric inpatients. In a cross-sectional study, bone status was assessed with QUS at the distal metaphysis of the first phalanges of fingers II-V. Thirty-three of 101 female geriatric inpatients met the clinical criteria of the American College of Rheumatology for osteoarthritis of the hands (median age: 85 years) and were compared to 68 female inpatients without swellings of the small finger joints (median age: 88 years). Amplitude-dependent speed of sound at the distal metaphysis, the electronic signal of the ultrasonic wave after crossing the phalanx (graphic trace), and the thickness of the each phalanx were measured and compared between the two groups by a phalangeal QUS device (DBM-Sonic 1200). There were no significant differences between the phalangeal QUS readings of both groups. The only statistically significant difference was observed in the comparison of the small finger thickness with a lower value in the osteoarthritis group (p = 0.02). These findings suggest that at the metaphyseal level of phalanges, the degenerative process of osteoarthritis doesn't influence the QUS assessment. This could be explained by the finger thickness at metaphyseal level, which was not increased in patients with osteoarthritis compared with control subjects, at least as detected by the applied finger ultrasound method.

[A patient with cryoglobulinemia and hepatitis C]. / Eine Patientin mit Kryoglobulinämie und Hepatitis-C.

We describe a 73-year-old woman who presented with purpura, recurrent ulcerations of both lower limbs as well as worsening of her condition. Laboratory tests revealed a mixed cryoglobulinemia (type-II). Two years after diagnosis, an amputation of the right femur had been performed due to extensive necrotizing ulcerations. Further complications such as membranoproliferative glomerulonephritis, cirrhosis of the liver with portal hypertension and ultimately, hepatocellular carcinoma developed. A chronic hepatitis C infection was diagnosed rather late, mainly because of the false negative results of the first generation EIA. This case report illustrates the various complications-hepatic and extrahepatic-of chronic hepatitis C infection. The pathogenesis of mixed cryoglobulinemia remains unclear. However, a current literature review suggests a strong association with chronic hepatitic C. Diagnosis, clinical features and course of hepatitis C infection are discussed.

[Unusual intestinal manifestations of tuberculosis]. / Ungewöhnliche intestinale Manifestation einer Tuberkulose.

In an 87-year-old Swiss female referred with complaints of bloody diarrhea and weight loss, colonoscopy revealed three ulcers in the rectum and colon. Cultures from the colonic ulcers were positive for Mycobacterium tuberculosis. There was no evidence of pulmonary infection. One week after adequate therapy was begun, a perforation occurred at the rectosigmoid junction. The sigmoid was resected and left-sided colostomy was performed. Seven days after surgery the patient died. Clinical features, diagnosis and morphological changes of intestinal tuberculosis are discussed.

Quality of emergency room triage of medical inpatients to an acute care clinic or chronic health care facilities.

OBJECTIVE: To evaluate the accuracy of emergency room triage by general internists assigning medical patients to four different health care settings. DESIGN: Prospective trial. SETTING: Medical emergency room of a university hospital providing primary and referral care. PATIENTS: 974 consecutive patients admitted for acute medical care, excluding patients admitted to intensive care units. INTERVENTION AND MEASUREMENTS: After primary evaluation patients were assigned to one of four groups: A) acutely ill requiring acute care in a general medical ward (n = 598); B) acutely ill requiring acute care limited to two to three days (n = 201); C) chronically ill with realistic chances for rehabilitation (n = 77); and D) chronically ill requiring definite referral to skilled nursing home care (n = 98). Nine months later, outcome and placement after index hospitalization were evaluated in surviving patients. MAIN RESULTS: 159 (16%) patients died; three (1%) were lost to follow-up. Evolution confirmed the appropriateness of the initial triage of 90% of the remaining 812 patients (83%). Allocations were correct in 96%, 95%, and 91% of cases in groups A, B, and C, respectively. In group D, only 44% were definitely transferred to nursing homes; 56% were rehabilitated and returned to their previous social settings or entered homes for the aged. CONCLUSIONS: Clinical judgment of general internists in an emergency room adequately identifies patients requiring acute care of regular or short duration and chronically ill patients with realistic prospects for rehabilitation. But the need for nursing home placement is overestimated. To avoid patient misplacement the authors propose direct access to a specialized geriatric assessment facility.

[Phase contrast microscopy demonstration of glomerular erythrocytes in urine: practicable in ambulatory practice?]. / Der Nachweis glomerulärer Erythrozyten im Urin mit Phasenkontrastmikroskopie: praktikabel in der ambulanten Praxis?

The use of phase-contrast microscopy in microhematuria, as proposed in 1979 by Birch and Fairley, renders morphological changes in red cells easily detectable and makes it possible to distinguish glomerular from non-glomerular bleeding. The aim of this study was to evaluate the practicability of this method as a routine laboratory test in ambulatory care. 60 patients with asymptomatic microhematuria (greater than or equal to 2 erythrocytes per high power field) were followed up over a one-year period. All patients were investigated by intravenous pyelography, ultrasound of urinary tract and three cytological examinations of the urine. The description of urine samples was done with phase-contrast microscopy by a first investigator at the beginning of the study and by a second after 12.8 months, blinded to clinical results and previous examinations. In 21 patients a definitive diagnosis was possible. In 18 patients the morphologic descriptions of the two investigators correlated with the clinical results. Only in two patients with established diagnosis there were differences between the urine description of the two investigators, and in one patient the interpretations of both investigators were wrong. These incorrect descriptions concerned patients with low-grade microhematuria. Thus, phase-contrast microscopy is a practicable method for the practitioner's use as a routine laboratory investigation. In low-grade microhematuria the method seems to be of minor value.