Bisphosphonate-induced osteonecrosis of the ear canal: our experience and a review of the literature.

BACKGROUND: Oesophageal disorders and osteonecrosis of the jaw are recognised complications of the commonly prescribed medication bisphosphonate. Despite these diagnoses being seen comparatively frequently within the ENT clinic, osteonecrosis of the external ear is a less well reported complication. METHODS: The current literature is reviewed and our experience with six cases of bisphosphonate-related ear canal osteonecrosis is presented. RESULTS: Six cases were identified as suffering from ear canal osteonecrosis as a result of bisphosphonate treatment. One of our cases suffered bilateral ear canal osteonecrosis after only 20 months of oral alendronic acid treatment. Management ranged from bisphosphonate cessation and topical treatment, to surgical debridement in the operating theatre. CONCLUSION: Bisphosphonate-related ear canal osteonecrosis is undoubtedly under-diagnosed. For such a commonly prescribed medication, the risks and side effects of bisphosphonate should be better known and long-term treatment should be avoided if possible.

Hormonal responses to a single session of wholebody vibration exercise in older individuals.

OBJECTIVE: Whole-body vibration (WBV) has been recently suggested as an alternative form of exercise. In this study, the acute effects of a single session of WBV exercise on anabolic hormones in aged individuals were analysed. DESIGN: A randomised cross-over trial design was used. SETTINGS: Geriatrics Department, Woodend Hospital. PARTICIPANTS: 20 individuals (9 men and 11 women; median age 70 years (range 66 to 85 years) volunteered in the experiment. Interventions Isometric squat on a platform with vibration or no vibration (control) conditions. MAIN OUTCOME MEASUREMENTS: Plasma cortisol, testosterone, growth hormone (GH) and insulin-like growth factor 1 (IGF-1) were measured before, immediately after, and 1 and 2 h after the interventions. REPORTS: A significant difference between treatments (p<0.001) and a time x treatment interaction (p<0.05) was found in IGF-1 levels. Cortisol levels were shown not to be significantly different between treatments (p = 0.43), but a difference over time (p<0.001) and a time6 treatment interaction (p<0.05) were identified. No significant differences were identified in GH and testosterone levels. CONCLUSIONS: As shown by the results of the study, 5 min of WBV exercise characterised by static squat with a frequency of 30 Hz can be performed by older individuals without apparent signs of stress and/or fatigue. Furthermore, WBV produced an acute increase in the circulating levels IGF-1 and cortisol greater than that observed following the same exercise protocol conducted without vibration.

Measuring case-mix and outcome for older people in acute hospital care across Europe: the development and potential of the ACMEplus instrument.

AIM: To identify case-mix variables measured shortly after admission to be included in a patient classification system (ACMEplus) that best explains hospital outcome for older people in different health care systems. DESIGN: Observational prospective cohort study collecting patient factors (sociodemographics, functional, mental, clinical, administrative and perceived health) at different time assessments. METHODS: Multicentre study involving eight hospitals in six European countries (United Kingdom, Spain, Italy, Finland, Greece and Poland). It included consecutive patients aged 65 years or older admitted to hospital for acute medical problems. MAIN OUTCOME MEASURES: discharge status, hospital readmission, mortality and length of stay. RESULTS: Of the 1667 included patients (mean age = 78.1 years; male gender = 43.5%) two-third had at least one 'Geriatric Giant' (immobility, confusion, incontinence or falls) on admission or shortly after. The most frequently affected system was cardiovascular (29.2%) and 31% of patients declared poor or very poor health. Mean length of stay was 17.9 days, 79% of patients were discharged to their usual residence; in-hospital and 1-month follow up mortality were 7.4% and 11.6%, respectively. Physical function explained the highest variation (between 8% and 21%), followed by cognitive status and number of Geriatric Giants, for almost all outcomes except readmission. CONCLUSION: Factors other than diagnosis (physical function, cognition and presenting problems) are important in predicting key outcomes of acute hospital care for older people and are consistent across countries. Their inclusion in a standardized system of measurement may be a way of improving quality and equity of medical care in older people.

Descending necrotising mediastinitis: a safe treatment algorithm.

Descending necrotising mediastinitis can complicate oropharyngeal infection and has a high associated mortality. We present three cases treated in our department and propose a treatment algorithm based on our experience and literature review. The primary oropharyngeal infection was peritonsillar abscess in two cases and odontogenic abscess in one. Two patients underwent cervicotomy and later thoracotomy. The third underwent cervicotomy with transcervical mediastinal drainage and later required pericardial drainage via a subxiphoid incision. All recovered fully and were discharged within 6 weeks. To enable successful treatment, diagnosis needs to be prompt and surgical drainage adequate. Thoracic management of the chest is essential.

Mediastinitis: a life-threatening complication of acute tonsillitis.

Acute tonsillitis is a common condition and usually runs a benign course. However life-threatening complications do still occur, even in this postantibiotic era. Infection can spread downwards into the mediastinum through the anatomic cervical spaces, causing widespread cellulitis, necrosis, abscess formation and sepsis. We present a case of descending mediastinitis in an 18-year-old woman, arising from her first episode of tonsillitis and treated successfully by surgical drainage. We believe that an awareness of this complication, early diagnosis using computed tomography scanning, and prompt, adequate surgical drainage will reduce morbidity and mortality.

A comparison of water turnover in older people in community and institutional settings.

BACKGROUND: Maintaining water balance is essential for health, but environmental factors, pathology and the ageing process can adversely affect water homeostasis. OBJECTIVE: This study examined the relationship between physical dependency and daily water turnover rate in an older population. DESIGN: Daily water turnover (DWT) was estimated, using deuterium oxide ((2)H(2)O) as a tracer for water, over two separate 7-day periods in summer and winter in two older populations. The independent group (N = 22) lived in their own homes and were self-caring. The dependent group (N = 15) lived in institutional care, and were more physically dependent. None of the subjects had significant mental impairment. Total body water (TBW) and DWT were estimated from the equilibration concentration of ingested (2)H(2)O and its subsequent elimination rate. RESULTS: The independent group had a median (range) age of 75(69-88) y, a mean Barthel Index (BI) of 19.8, and a mean Abbreviated Mental Test (AMT) score of 9.8. The dependent group were older (83(72-93) y), with a mean BI of 13 and a mean AMT of 9.3. Average median (range) DWT in the independent group was similar in summer (2.2(1.3-3.6) l.d(-1)) and winter (2.1(1.4-3.6) l.d(-1)), but faster than in the dependent group (1.5(0.9-2.9) and 1.6(1.0-2.8) l.d(-1), respectively) during the same two periods. Median urine output in the independent group was similar in summer (1.7(0.8-3.3) l.d(-1)) and winter (1.7(0.9-3.2) l.d(-1)), but greater than in the dependent group (1.1(0.6-2.7) and 0.9(0.5-1.6) l.d(-1), respectively). CONCLUSION: These results show that the water turnover rate of many older people is low, and that intake may be affected especially in those with physical disability.

Assessment of individual quality of life using the SEIQoL-DW in older medical patients.

BACKGROUND: Many hospital admissions aim to optimize quality of life (QoL). However, the standard medical clerking does not systematically record QoL items. AIM: To examine whether the current disease-based clerking could be supplemented in older people with QoL information. DESIGN: Survey of non-elective admissions aged > or = 65 years. METHODS: Participants (n = 60) were interviewed on day 3-5 of their admission. QoL was measured using the SEIQoL-DW and the SF36 (version 2). Cognitive and physical function were also assessed. Aspects of feasibility and acceptability were explored, and the potential clinical benefits of the information investigated. RESULTS: Mean patient age was 81 years; 36 (60%) were female. Forty-five completed the SEIQoL-DW, (mean time 37.7 min), of whom 17 experienced practical difficulties drawing the cue levels, and 25 had difficulty manipulating the direct weighting device of the SEIQoL-DW. However, the assessment process was judged as acceptable, and elicited more subjective information than was recorded in medical and nursing notes. Doctors considered the individual QoL information potentially useful for planning discharge and follow-up. DISCUSSION: The SEIQoL-DW is probably too time-consuming for standard medical clerking. However, as it was judged acceptable by patients, and according to medical staff, gives potentially valuable information, there may be circumstances in which its use is worthwhile.

Factors influencing uptake of influenza vaccination among hospital-based health care workers.

BACKGROUND: Vaccination of health care workers against influenza has been shown to lower mortality among elderly patients, but uptake of voluntary vaccination among health care workers remains low. AIMS: Factors influencing uptake of vaccination were examined among a cross-section of health care workers based in an NHS Trust. METHODS: A structured, self-administered questionnaire was mailed to a random sample of health care workers based in the acute services sector of a UK National Health Service Trust, 6 months following a voluntary immunization programme implemented as part of the Scottish Executive Health Department winter planning arrangements for 2000-2001. The programme was promoted using posters in clinical areas and a single leaflet given to all staff through a paycheck advice note. RESULTS: Five hundred and fifty-one health care workers (53%) responded to the questionnaire and influenza vaccination was accepted by 150 (28%). The occupational health poster strongly influenced the decision to accept vaccination [odds ratio (OR) = 11.01; 95% confidence interval (CI) = 2.13-56.80; P < 0.0001]. Other significant influences included female sex (OR = 9.11; 95% CI = 1.26-65.72) and perceived risk of contracting flu without the vaccine (OR = 7.70; 95% CI = 1.44-41.05). Misconceptions regarding the purpose of the vaccination campaign were common and concern regarding possible side-effects was a deterring factor for vaccination uptake. CONCLUSION: Our study showed that visual material displayed throughout the workplace strongly influenced the acceptance of influenza vaccination. Future campaigns should also emphasize the positive benefits to patients of health care worker immunization, with readily accessible information regarding side-effects available from all sources.

Aggressive treatment of metastasis to the parotid.

OBJECTIVES: Assess the value of aggressively treating metastatic lesions in the parotid, taking into account the histology of the disease. STUDY DESIGN: Retrospective analysis of 13 patients diagnosed with metastasis to the parotid treated by one surgeon in a tertiary referral head and neck unit in the United Kingdom. METHODS: The following variables were reviewed and tabulated: age, sex, histology, latent period to secondary tumour, treatment instituted, postoperative facial nerve outcome, follow-up and survival. RESULTS: Twelve patients were treated aggressively with at least total parotidectomy and adjunctive therapy, whilst one patient required only a superficial parotidectomy. Ten patients had metastatic cutaneous tumours, and three had metastatic adenocarcinoma. Seven of these 13 patients (53.8 %) are alive and well (six had metastatic cutaneous tumours, one had metastatic adenocarcinoma). Four patients succumbed to tumour (two had metastatic cutaneous tumours and two had metastatic adenocarcinoma), and two patients succumbed from unrelated medical causes (both had metastatic cutaneous tumours). The mean follow-up for those alive is 65.9 months and mean follow-up for those deceased is 15.3 months. CONCLUSIONS: In the absence of systemic spread, parotid metastases from primary cutaneous squamous cell carcinoma should be treated aggressively, while metastases from non-cutaneous primary tumours should be approached with caution.

Pharyngo-laryngo-oesophagectomy and gastric pull-up for post-cricoid and cervical oesophageal squamous cell carcinoma.

Pharyngo-laryngo-oesophagectomy and gastric pull-up (PLOGP) is a complex and relatively uncommon procedure. The aim of this study is to analyse the results of PLOGP in patients with post-cricoid and cervical oesophageal squamous cell carcinomas. This study was a retrospective review of 26 patients (11 males + 15 females, mean age 63.5 years) who underwent PLOGP from 1988 to 1997. Eighteen (69 per cent) patients were staged as T(3) and eight (31 per cent) T(4). Eighteen (69 per cent) patients had N(0), seven (27 per cent) N(1) and one (four per cent) N(2) disease. Multiple primary tumours were recorded in three (11.5 per cent) patients. Four (15 per cent) patients had pre-operative radiotherapy with poor response and two (eight per cent) required emergency tracheotomy prior to surgery. Feeding jejunostomy was performed on 19 (73 per cent) and neck lymph node dissection in eight (31 per cent) patients. The mean duration of surgery was five hours (range 3.5 to 7.5) with a mean blood loss of 840 ml (range 160 to 1800), a mean stay in ICU of 4.2 days and hospital stay ranged from nine to 84 days (mean 34). Three (11.5 per cent) patients died (pneumonia - one, congestive heart failure - one, pulmonary embolus - one) in the early post-operative period. Eight (31 per cent) patients remain alive from 30 to 136 months (mean 58 months). Two (eight per cent) patients died with no evidence of disease. Thirteen (50 per cent) patients died of their disease between two to 51 months (mean 17.3 months) post-operatively. Kaplan-Meier survival estimates for one year was 65 per cent, for three years 35 per cent and for five years 26 per cent (see Figure 1). Median survival in the whole series was 18 months. Post-operative speech was with an electrolarynx in 16 (62 per cent). One patient (four per cent) used gastric speech and one patient (four per cent) used a Blom-Singer valve effectively. Five (19 per cent) patients had no speech post-operatively. All patients maintained oral feeding. Gastric transposition constitutes a safe and reliable method of restoring the continuity of the upper digestive tract following pharyngo-laryngo-oesophagectomy.

Problems in using health survey questionnaires in older patients with physical disabilities. The reliability and validity of the SF-36 and the effect of cognitive impairment.

Reliability and validity of the SF-36 Health Survey Questionnaire was assessed in older rehabilitation patients, comparing cognitively impaired with cognitively normal subjects. The SF-36 was administered by face-to-face interview to 314 patients (58-93 years) in the day hospital and rehabilitation wards of a department of medicine for the elderly. Reliability was measured using Cronbach's alpha (for internal consistency) on the main sample and intraclass correlation coefficients on a test-retest sample; correlations with functional independence measure (FIM) were examined to assess validity. In 203 cognitively normal patients (Mini-Mental State Examination > or =24), Cronbach's alpha scores on the eight dimensions of the SF-36 ranged from 0.545 (social function) to 0.933 (bodily pain). The range for the 111 cognitively impaired patients was 0.413-0.861. Cronbach's alpha values were significantly higher (i.e. reliability was better) in the cognitively normal group for bodily pain (P = 0.003), mental health (P = 0.03) and role emotional (P = 0.04). In test-retest studies on a further 67 patients, an intraclass correlation coefficient of 0.7 was attained for five out of eight dimensions in cognitively normal patients, and four out of eight dimensions in the cognitively impaired. Only the physical function dimension in the cognitively normal group attained the criterion level (r > 0.4) for construct validity when correlated with the FIM. In this group of older physically disabled patients, levels of reliability and validity previously reported for the SF-36 in younger subjects were not attained, even on face-to-face testing. Patients with coexistent cognitive impairment performed worse than those who were cognitively normal.

Problems in using health survey questionnaires in older patients with physical disabilities. Can proxies be used to complete the SF-36?

BACKGROUND: The SF-36 Health Survey questionnaire has been proposed as a generic measure of health outcome. However, poor rates of return and high levels of missing data have been found in elderly subjects and, even with face-to-face interview, reliability and validity may still be disappointing, particularly in cognitively impaired patients. These patients may be the very patients whose quality of life is most affected by their illness and their exclusion will lead to biased evaluation of health status. A possible alternative to total exclusion is the use of a proxy to answer on the patient's behalf, but few studies of older people have systematically studied patient-proxy agreement. OBJECTIVE: To compare the agreement between patients, lay and professional proxies when assessing the health status of patients with the SF-36. METHODS: The SF-36 was administered by interview to 164 cognitively normal, elderly patients (Mini-mental State Examination 24 or more) referred for physical rehabilitation. The SF-36 was also completed by a patient-designated lay proxy (by post) and a professional proxy. Agreement between proxies and patients was measured by intraclass correlation coefficients (ICCs), and a bias index. RESULTS: Professional proxies were better able to predict the patients' responses than were the lay proxies. Criterion levels of agreement (ICC 0.4 or over) were attained for four of the eight dimensions of the SF-36 by professional proxies, but for only one dimension by lay proxies. In professional proxies, the magnitude of the bias was absent or slight (<0.2) for six of the eight dimensions of the SF-36 with a small (0.2-0.49) negative bias for the other two. Lay proxies showed a negative bias (i.e. they reported poorer function than did the patients themselves) for seven of the eight dimensions of the SF-36 (small in two and moderate (0.5-0.79) in five). CONCLUSIONS: For group comparisons using the SF-36, professional proxies might be considered when patients cannot answer reliably for themselves. However, in the present study, lay proxy performance on a postal questionnaire showed a strong tendency to negative bias. Further research is required to define the limitations and potentials of proxy completion of health status questionnaires.

Pictorial outcome measures for the hospital care of older patients--a suggested toolkit.

OBJECTIVE: to propose three pictorial methods of presenting hospital outcome data, suitable for use in older patients entering medical specialties (including rehabilitation). PATIENTS: 224 patients (mean age 80.6 years, 56% female, 75% emergencies) admitted to a department of medicine for the elderly. PRESENTATIONAL TECHNIQUES: the methods we propose for the presentation of outcome data are (i) place of discharge, using a two-dimensional diagram; (ii) 'survival' analyses, but using discharge from hospital rather than death as the endpoint; and (iii) 'phase diagrams', a novel method of charting the progress of a cohort of patients. To illustrate these methods, the relationship between admission case-mix (with patients put into tertiles on the basis of their Barthel index score) and outcome is shown graphically. RESULT: each of the three techniques has different relative strengths, but their pictorial nature allows for rapid interpretation of data, showing, for example, the marked influence of case-mix. Separate analyses of subgroups of patients (such as those who die in hospital and those who survive) are also readily attainable by the three methods. CONCLUSIONS: the three methods of presenting outcome should be of benefit in comparing the performance of different units, particularly when case-mix is taken into account. The pictorial methods are complementary both to more conventional patient-based methods (mean duration of stay, median duration of stay, percentile duration of stay, regression analyses etc) and to modelling techniques using 'census' data from large numbers of patients.

Oesophageal ulceration caused by doxycycline: an unusual complication.

Oesophageal ulceration is an unusual complication of doxycycline treatment (Vibramycin) presenting to an Otorhinolaryngology department. A case report is presented with discussion of investigations and management of the patient.

Equilibrium and kinetic studies of substrate binding to 6-hydroxymethyl-7,8-dihydropterin pyrophosphokinase from Escherichia coli.

6-Hydroxymethyl-7,8-dihydropterin pyrophosphokinase (HPPK) catalyzes the pyrophosphorylation of 6-hydroxymethyl-7,8-dihydropterin (HMDP) by ATP to form 6-hydroxymethyl-7,8-dihydropterin pyrophosphate, an intermediate in the pathway for folic acid biosynthesis. The enzyme has been identified as a potential target for antimicrobial drugs. Equilibrium binding studies showed that Escherichia coli HPPK-bound ATP or the nonhydrolyzable ATP analogue alpha, beta-methyleneadenosine triphosphate (AMPCPP) with high affinity. The fluorescent ATP analogue 2'(3')-O-(N-methylanthraniloyl) adenosine 5'-triphosphate (MANT-ATP) exhibited a substantial fluorescence enhancement upon binding to HPPK, with an equilibrium dissociation constant comparable with that for ATP (10.4 and 4.5 micrometer, respectively). The apoenzyme did not bind the second substrate HMDP, however, unless AMPCPP was present, suggesting that the enzyme binds ATP first, followed by HMDP. Equilibrium titration of HPPK into HMDP and AMPCPP showed an enhancement of fluorescence from the pterin ring of the substrate, and a dissociation constant of 36 nm was deduced for HMDP binding to the HPPK.AMPCPP binary complex. Stopped flow fluorimetry measurements showed that the rate constants for the binding of MANT-ATP and AMPCPP to HPPK were relatively slow (3.9 x 10(5) and 1.05 x 10(5) m(-1) s(-1), respectively) compared with the on rate for binding of HMDP to the HPPK.AMPCPP binary complex. The significance of these results with respect to the crystal structures of HPPK is discussed.

Influenza and pneumococcal vaccination: patient perceptions.

The efficacy of the influenza vaccine in reducing mortality and hospital admissions is established, particularly in the elderly. However, up to 50% of those at risk do not receive the vaccine. These patients are also at risk from pneumococcal infection and there is considerable overlap between the target group for each vaccine. This study sought to identify at risk individuals from consecutive admissions to an acute geriatric unit and to gain an insight into their perceptions with regard to vaccination. The awareness of each vaccine was recorded, together with the vaccination history. Seventy four per cent of the final cohort had heard of the influenza vaccine, while only 13% had heard of the pneumococcal vaccine. Fifty per cent perceived themselves to be at risk from influenza and its complications and 87% of the cohort believed it to be a serious infection. Influenza vaccine was judged to confer good protection by 72% of the sample and yet up to 50% believed that the vaccine can make the recipient ill. Influenza is perceived as a serious infection by patients and yet many do not believe themselves to be at particular risk. Although influenza vaccination is believed to confer protection, the decision whether, or not, to accept the vaccine is coloured by many factors, including popular myths and anecdotal information from friends and relatives. The uptake of influenza vaccine is suboptimal and the awareness of the pneumococcal vaccine certainly in the elderly is poor. The need for a comprehensive nationwide education campaign promoting both influenza and pneumococcal vaccine is highlighted.

Management of myocardial infarction in the very elderly--impact of clinical effectiveness on practice.

The presentation of myocardial infarction in the elderly is often atypical and there is therefore a broad range of clinical presentations where this diagnosis should be actively considered and the appropriate investigations arranged. The early use of aspirin and thrombolytic therapy has revolutionised management and efforts should be made to employ these interventions wherever possible. We present the results of an audit showing how the introduction of local guidelines improved the early management of myocardial infarction in the elderly. We also found that in this group of patients cardiac enzyme assays were more useful in establishing the diagnosis than the electrocardiogram.

Care management in three practices--scope for improvement?

OBJECTIVE: The process of assessment of older people for residential/nursing home care may take place by hospital based social workers, or by care managers working in the community. We sought to compare the assessment process in each setting. The standards for the audit were that the data collection for both groups was equivalent, that both groups had a multi-disciplinary assessment, and that outcomes in both settings were appropriate. DESIGN: Identification of all older people assessed as requiring residential/nursing home care from 1/7/97-31/12/97, who were registered with the three general practices in Aberdeen participating in this study. Social Work case files and care plans were reviewed. All individuals were visited and dependency scores obtained--Abbreviated Mental Test, Barthel Index, and CAPE (Clifton Assessment Procedures for the elderly--Behaviour Rating Scale component) score. SETTING: Review of hospital social work case files, and community based case files. Interviewing of the older person in their own home, hospital, residential or nursing home to obtain dependency scores. SUBJECTS: Thirty three people were referred-17 from the community, and 16 from hospital. RESULTS: Case files in both groups were well maintained. There were differences in procedures between the assessment processes, but outcomes appeared to be similar. There was no statistical difference in mean dependency scores between each group. However, information on levels of support in the files was limited, particularly for the community group. Dependency scores correlated with residential/nursing home care being appropriate for the 33 individuals, but only 50% of people were identified as wanting such arrangements. Evidence of a recorded medical assessment was absent in 47% of the community referred population. CONCLUSION: Evidence of a multi-disciplinary assessment was not always available, especially for the community referred individuals. A greater emphasis on a multi-disciplinary assessment could highlight a need for rehabilitation, which might allow for the improvement and maintenance of some frail older people in the community, this often being in accordance with their wishes.

Determinants of survival in continuing care settings.

OBJECTIVE: To assess the relationship between the Barthel Index, a widely used assessment measure of physical dependency, and long-term survival in continuing care settings. DESIGN AND SUBJECTS: One hundred and eighty five older people moving into continuing care (hospital or nursing home) were prospectively assessed with regard to physical and mental impairment in 1991/2 and this population was followed up in 1996. RESULTS: In addition to the 185 patients who were assessed, there were 41 patients who died before they could be seen. Out of the total of 226 patients, 177 had died by the time of the census point in 1996. Multivariate (Cox regression) analysis of survival in the 185 patients indicated that only the Barthel Index (BI) and female sex were statistically significantly related to survival rates. Those with a BI of 12-20 had better survival than those with a BI of 7-11 (P = 0.015) or a BI of 0-6 (P = 0.007). CONCLUSIONS: The importance of careful assessment of those moving into continuing care settings is emphasised. Those patients who are physically less dependent are likely to have significantly longer survival periods and related use of continuing care resources.