[Severe pneumonia and delirium in a 90-year-old male patient with postdeglutition regurgitation]. / Schwere Pneumonie und Delir bei einem 90-jährigen Patienten mit postdeglutitivem Aufstoßen.

Pneumonia and in particular aspiration pneumonia, is a common disease in geriatrics. These aspirations are often due to dysphagia, which is frequently first noticed in the context of a geriatric assessment. The reasons for dysphagia are manifold. In this geriatric department several patients have been detected in recent months in whom a Zenker diverticulum was the cause of recurrent aspiration pneumonia. The swallowing disorder was already apparent during the logopedic examination on admission to hospital. A supplementary fiber optic endoscopic evaluation of swallowing (FEES) revealed a postswallow hypopharyngeal reflux (PSHR), which is typical for a Zenker diverticulum. A supplementary contrast esophagography confirmed the findings. In the present case the treatment of choice was a myotomy with a flexible endoscope performed by gastroenterologists. After successful treatment, swallowing was again possible with no indications of penetration or aspiration in the FEES control. The case highlights the importance of logopedic diagnostics and treatment in geriatric patients with recurrent pneumonia. With the aid of early diagnostics it was possible to quickly recognize the finding of a PSHR that is typical for a Zenker diverticulum. The findings in this case could be clearly demonstrated based on the images of the FEES and contrast esophagography.

Bone density in an immigrant population from Southeast Asia.

The epidemiology of bone loss in populations of Asian heritage is still poorly known. This study compared the skeletal status of a convenience sample of 396 Southeast Asian immigrants (172 Vietnamese, 171 Cambodians and 53 Laotians) residing in Rochester, Minnesota in 1997 with 684 white subjects previously recruited from an age-stratified random sample of community residents. Areal bone mineral density (BMD, g/cm2) and volumetric bone mineral apparent density (BMAD, g/cm3) were determined for lumbar spine and proximal femur using the Hologic QDR 2000 instrument for the white population and the QDR 4500 for Southeast Asian subjects; the machines were cross-calibrated from data on 20 volunteers. Lumbar spine BMD was 7% higher in white than Southeast Asian women (p < 0.001), and similar results were observed for the femoral neck; lumbar spine BMD was 12% higher in white than nonwhite men (p < 0.001). Race-specific discrepancies were reduced by calculating BMAD: for premenopausal women, lumbar spine and femoral neck differences between whites and Southeast Asians were eliminated; for postmenopausal women the lumbar spine differences persisted (p < 0.0001), while femoral neck BMAD was actually higher for Southeast Asians. There were no race-specific differences in femoral neck BMAD among men of any age (p = 0.312), but lumbar spine BMAD was less for younger (p = 0.042) but not older (p = 0.693) Southeast Asian men. There were differences among the Southeast Asian subgroups, but no clear pattern emerged. Predictors of lumbar spine BMAD in Southeast Asian women were age (p < 0.001), weight (p = 0.015) and gravidity (p = 0.037). Even after adjusting for bone size using BMAD, 32% and 9% of Southeast Asian women and men, respectively, would be considered to have osteoporosis at the femoral neck and 25% and 4%, respectively, at the lumbar spine. These findings indicate a need for culturally sensitive educational interventions for Southeast Asians and for physicians to pursue diagnosis and treatment to prevent osteoporosis-related disabilities in this population.

Bone mass and muscle strength in female college athletes (runners and swimmers).

OBJECTIVE: To determine whether female college athletes had increased muscle strength and bone mass in comparison with age-matched nonathletic female subjects and, if so, whether participation in weight-bearing versus non-weight-bearing exercise made a difference. MATERIAL AND METHODS: We performed a comparative statistical analysis of the bone mineral density (BMD) of the total body, lumbar spine, and femoral neck, maximal oxygen uptake (VO2max), muscle strength, and level of physical activity in 21 runners, 22 swimmers, and 20 control subjects. The study participants were female college students, 18 to 24 years old, who had had more than 8 normal menstrual cycles during the past year. RESULTS: Statistical analyses showed significantly higher VO2max in the two athletic study groups than in the control subjects (P < 0.0001). No significant difference in BMD was noted among the three groups. Total body BMD (r = 0.30; P = 0.02) and femoral neck BMD (r = 0.39; P = 0.002) were positively correlated with weight-bearing activity but not with non-weight-bearing activity. VO2Max (an index of physical fitness) was positively correlated with femoral neck BMD (r = 0.33; P = 0.009) and trochanteric BMD (r = 0.29; P = 0.021). Shoulder muscle strength (determined by isokinetic dynamometry) was positively correlated with total body BMD (r = 0.34; P = 0.007) and lumbar spine BMD (r = 0.28; P = 0.028). Swimmers had higher muscle strength in the back and upper extremities than did runners and control subjects. Hip girdle muscle strength was not significantly different among the three groups. Total body BMD had a positive correlation with percentage of body fat and height. Lumbar spine BMD was higher in subjects who had previously used oral contraceptives. The athletes had a lower percentage of body fat, were less likely to have used oral contraceptives, and had fewer years of normal menses than did the control subjects. CONCLUSION: Our study shows that (1) total body BMD and femoral neck BMD were significantly higher in the study group that performed weight-bearing exercises than in control subjects, (2) swimming exercise had no effect on BMD, and (3) although swimming is not a bone-building exercise, it can significantly improve shoulder, back, and grip muscle strength.

Long-term effects of calcium supplementation on serum parathyroid hormone level, bone turnover, and bone loss in elderly women.

We report a 4-year randomized, double-blind, placebo-controlled clinical trial in 236 normal postmenopausal women (mean age +/- SE, 66.3+/-0.2 years) who were randomized to a calcium (1600 mg/day as the citrate) or placebo group. The women were seen every 6 months; 177 completed the trial. Net percentage changes in each group are given relative to baseline. The differences in net percentage changes (calcium group minus placebo group) in medians were: for lumbar spine bone density, 2.0% (p < 0.001) at year 1 and 0.3% (not significant) at year 4; for proximal femur bone density, 1.3% (p = 0.003) at year 1 and 1.3% (p = 0.015) at year 4; and for total body bone mineral, 0.4% (p = 0.002) at year 1 and 0.9% (p = 0.017) at year 4. Similar differences at year 4 were: -18.9% (p = 0.002) for parathyroid hormone (PTH), -11.9% (p = 0.026) for serum osteocalcin, and -32.2% (p = 0.003) for urine free pyridinoline. We conclude that long-term administration of calcium supplements to elderly women partially reverses age-related increases in serum PTH level and bone resorption and decreases bone loss. However, the effects on bone loss were weaker than those reported for estrogen, bisphosphonates, or calcitonin therapy, indicating that calcium supplements alone cannot substitute for these in treating established osteoporosis. Nonetheless, because of their safety, high tolerance, and low expense, calcium supplements may be a useful preventive measure for elderly postmenopausal women whose bone mineral density values are normal for their age.

Role of estrogen deficiency in pathogenesis of secondary hyperparathyroidism and increased bone resorption in elderly women.

Whether the increased bone resorption and secondary hyperparathyroidism in elderly women is due to aging or to estrogen deficiency is unclear. To address this issue, we measured serum intact parathyroid hormone (PTH) and biochemical markers in serum and urine samples from 30 premenopausal women (32 +/- 0.5 years, mean age +/- SE), 30 estrogen-deficient postmenopausal women (74.2 +/- 0.6 years), and 30 elderly women (73.8 +/- 0.6 years) receiving long-term estrogen treatment. Because of the first and third groups were comparable in estrogen status but not in age, whereas the second and third groups were comparable in age but not in estrogen status, the independent effects of age and estrogen deficiency could be assessed quantitatively. Mean values were higher in the estrogen-deficient postmenopausal women than in the premenopausal women for serum PTH (by 33%, p < .01) and for bone resorption markers [by 50% p < .001) for urine cross-linked N-teleopeptide of type I collagen (NTx); 34% (p < .001) for urine pyridinoline (Pyd); and 36% (p < .001) for urine deoxypyridinoline (Dpd)]. However, mean values for serum PTH in the postmenopausal women receiving estrogen treatment did not differ from those in the premenopausal women, and mean values for bone resorption markers were not different (urine NTx and Pyd) or were lower [urine Dpd, by -12%, (p < .005)]. These findings suggest that late consequences of estrogen deficiency rather than age-related processes per se are the principal causes of the secondary hyperparathyroidism and increased bone resorption in elderly women.

The contribution of vitamin D receptor gene alleles to the determination of bone mineral density in normal and osteoporotic women.

Bone mass and its mineral content are under genetic control. The vitamin D receptor (VDR) gene has been shown to be a major locus for genetic effects on bone mineral density (BMD), and polymorphisms in this gene accounted for a large proportion of genetic variance in BMD in an Australian population. In this study, we investigated whether similar associations are present in a North American population. We studied 139 normal healthy women (age 53.2 +/- 14.5, mean +/- SD) and 43 severely osteoporotic postmenopausal women (age 65.8 +/- 5.9). In the 127 of them with complete genetic studies, the distribution of genotypes, determined by polymerase chain reaction on leukocyte DNA samples, agreed closely with that in the Australian population. BMD was strongly related to age and weight, and, thus was adjusted for these parameters prior to genetic analysis. We found that age modulated the effect of VDR genotypes on femoral neck BMD (FN-BMD) (TaqI, p = 0.036; BsmI, p = 0.118; ApaI, p = 0.041) such that the effect of genotype was greatest among younger (premenopausal) women and declined with age so that there was no discernible difference by age 70. Among the younger women, a high FN-BMD was associated with the TT (or aa or bb) genotype while low FN-BMD was associated with the tt (or AA or BB) genotype.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical trial of fluoride therapy in postmenopausal osteoporotic women: extended observations and additional analysis.

In a 4 year clinical trial in 202 postmenopausal osteoporotic women receiving NaF at 75 mg/day or placebo (both groups received supplementary calcium at 1500 mg/day), we found (N Engl J Med 322:801, 1990) that NaF increased bone mineral density in the lumbar spine (LS-BMD) substantially but did not decrease vertebral fracture rate (VFR), and it increased the nonvertebral fracture rate. Additional analyses and extended observations are now available on 50 women from the NaF group followed for up to 6 years of treatment. In these women, LS-BMD increased linearly over the 6 years (median rate, 8.7%/year or 0.063 g/cm2/year). Because during the 4 year trial the NaF dosage was decreased (because of side effects) in 54 of the 101 women randomized to NaF, dose-response relationships could be evaluated. For the entire study population, serum F level correlated directly with increase in LS-BMD (r = 0.61, P < 0.001). When individual person-years of observation were grouped by deciles of LS-BMD, VFR (per 100 person-years) decreased to a nadir of 24 as mean LS-BMD for the group increased from 0.6 to 1.2 g/cm2 and then doubled to 52 in the group with mean LS-BMD of 1.6 g/cm2. Multivariate analyses and inspection of three-dimensional plots revealed a complex pattern in which VFR was influenced by interaction of several variables. When the effects of LS-BMD, changes in LS-BMD, and serum F were assessed simultaneously, VFR was seen to decrease with increasing LS-BMD except when the higher LS-BMD was associated with rapid rate of increase in LS-BMD or a large increase from baseline serum F. For some patients (noncompliers or nonresponders), serum F or LS-BMD failed to increase. Thus, it is possible that lower dosages of NaF produce moderate decreases in VFR.

Effect of fluoride treatment on the fracture rate in postmenopausal women with osteoporosis.

Although fluoride increases bone mass, the newly formed bone may have reduced strength. To assess the effect of fluoride treatment on the fracture rate in osteoporosis, we conducted a four-year prospective clinical trial in 202 postmenopausal women with osteoporosis and vertebral fractures who were randomly assigned to receive sodium fluoride (75 mg per day) or placebo. All received a calcium supplement (1500 mg per day). Sixty-six women in the fluoride group and 69 women in the placebo group completed the trial. As compared with the placebo group, the treatment group had increases in median bone mineral density of 35 percent (P less than 0.0001) in the lumbar spine (predominantly cancellous bone), 12 percent (P less than 0.0001) in the femoral neck, and 10 percent (P less than 0.0001) in the femoral trochanter (sites of mixed cortical and cancellous bone), but the bone mineral density decreased by 4 percent (P less than 0.02) in the shaft of the radius (predominantly cortical bone). The number of new vertebral fractures was similar in the treatment and placebo groups (163 and 136, respectively; P not significant), but the number of nonvertebral fractures was higher in the treatment group (72 vs. 24; P less than 0.01). Fifty-four women in the fluoride group and 24 in the placebo group had side effects sufficiently severe to warrant dose reduction; the major side effects were gastrointestinal symptoms and lower-extremity pain. We conclude that fluoride therapy increases cancellous but decreases cortical bone mineral density and increases skeletal fragility. Thus, under the conditions of this study, the fluoride-calcium regimen was not effective treatment for postmenopausal osteoporosis.

Fiber-optic holography employing multiple beam fringe stabilization and object/reference beam intensity variability.

The use of fiber optics in the field of optical holography is discussed with emphasis on the design of systems used to overcome several inherent shortcomings associated with fiber-optic holographic systems. Specifically, random environmentally induced optical phase changes within the fiber are minimized by employing a Michelson interferometer in conjunction with a closed loop feedback system. Furthermore, by using several passive single-mode couplers, complete object illumination via several illumination fibers is observed. Finally, by implementing a Mach-Zehnder interferometric technique, control of the object and reference beam intensity ratios in a fiber-optic holographic system can be accomplished. The resulting schemes are very stable and highly versatile systems suitable for remote holographic interferometric sensing and other applications where conventional holography techniques are impractical. Experimental results on fringe visibility, fringe stability, and the stabilization of object/reference beam intensity ratios are also given along with a composite summary of the overall system constraints associated with fiber-optic holographic systems.

Mechanism of acute lower extremity pain syndrome in fluoride-treated osteoporotic patients.

Acute pain in the lower extremity, which has previously been attributed to synovitis or fasciitis, develops in about 15 percent of osteoporotic patients treated with sodium fluoride. This report describes 11 osteoporotic women in whom this syndrome developed while they were being treated with sodium fluoride (mean dose 78 mg per day; range, 60 to 90). [99mTc]Hydroxymethylene diphosphonate scintiscanning showed an increased number of foci of abnormal uptake in the lower extremities (p less than 0.05), when compared with results of scintiscanning in 12 nonsymptomatic osteoporotic women treated with sodium fluoride and 12 osteoporotic women treated with oral calcium carbonate only. The increased uptake was not restricted to the areas of pain. Roentgenography revealed stress microfractures in five of the 11 symptomatic patients. It is concluded that the acute lower extremity pain syndrome during fluoride therapy usually results from intense regional bone remodeling, which may be complicated by stress microfractures.

The risk of hepatitis B transmission from health care workers to patients in a hospital setting--a prospective study.

A prospective study was designed to determine the risk of hepatitis B transmission from health care deliverers to patients in the hospital setting. Six chronic carriers of hepatitis B were identified: 2 surgeons, 1 dialysis nurse, 1 pediatric ICU nurse, 1 pharmacist and 1 orderly. Three of the six were HBeAg-positive. Two of the HBeAG-positive chronic carriers also had circulating hepatitis B virus DNA and accounted for approximately two-thirds of the total patient contacts. Two hundred thirteen patients were exposed 450 times to these six hepatitis B carrier staff without evidence of hepatitis B acquisition over a 6-month follow up. One-hundred nineteen control patients, exposed 789 times to noncarrier health care deliverers, were also negative. Another 33 patients were exposed to three additional individuals who were in the prodrome of acute hepatitis B: an intensive care nurse, a dental hygienist and a medical student. These patients showed no evidence of hepatitis B during 6 months of follow-up, nor did 25 separate control patients. Thus, 246 patients were exposed a total of 483 times to nine health care personnel who had either acute or chronic hepatitis B. No evidence of hepatitis B transmission was found. One-hundred forty-four controls revealed similar results after 814 exposures. Based on the number of exposures to chronic carriers alone, the risk of hepatitis B transmission is estimated to be less than 1%.(ABSTRACT TRUNCATED AT 250 WORDS)

Outpatient percutaneous biopsy of the iliac crest: methods, morbidity, and patient acceptance.

Bone histology and histomorphometry have become important in the diagnosis and management of metabolic bone disease, but the invasive nature of the biopsy procedure has limited its use. We describe an outpatient technique for obtaining one or more transiliac bone biopsy specimens. Thirty-eight women with osteoporosis, each of whom had sustained one or more spinal compression fractures, underwent two separate bone biopsies during which two 7.5-mm transiliac cores of bone were removed. No morbidity (such as infection or hemorrhage) was encountered. Subjective responses to the level of pain were surveyed by questionnaire. At the time of biopsy, 46% of the study subjects experienced no or only mild discomfort, and 24% judged their pain to be severe. At 16 hours after biopsy, 64% had no or mild pain and 8% experienced severe pain. At 7 days after biopsy, 79% experienced no or mild pain but 9% judged their pain to be severe. In four patients, temporary ambulatory disability occurred but resolved spontaneously in 7 to 10 days. We conclude that the described outpatient bone biopsy procedure is safe, efficient, and generally acceptable to patients.