The assessment of body sway and the choice of the stability parameter(s).

This methodological study aims at comparison of the practical usefulness of several parameters of body sway derived from recordings of the center of pressure (CoP) with the aid of a static force platform as proposed in the literature. These included: mean displacement velocity, maximal range of movement along x- and y-co-ordinates, movement area, planar deviation, phase plane parameter of Riley and the parameters of the diffusion stabilogram according to Collins. They were compared in over 850 experiments in a group of young healthy subjects (n = 10, age 21-45 years), a group of elderly healthy (n = 38, age 61-78 years) and two groups of elderly subjects (n = 10 and n = 21, age 65-89 years) with stability problems under different conditions known to interfere with stability as compared to standing with open eyes fixing a visual anchoring point: closing the eyes, standing on plastic foam in stead of a firm surface and performing a cognitive task: the modified stroop test. A force platform (Kistler) was used and co-ordinates of the body's center of pressure were recorded during 60 s of quiet barefoot standing with a sampling frequency of 10 Hz. In general, the results show important overlapping among groups and test conditions. Mean displacement velocity shows the most consistent differences between test situations, health conditions and age ranges, but is not affected by an extra cognitive task in healthy old people. Mean maximal sideways sway range is different among groups and test conditions except for the cognitive task in young and elderly subjects. Standardised displacement parameters such as standard deviations of displacements and planar deviation discriminate less well than the actual range of motion or the velocity. The critical time interval derived from the diffusion stabilogram according to Collins et al. seems to add a specific type of information since it shows significant influence from addition of a cognitive task in old subjects standing on a firm surface but not when standing on plastic foam. The critical time interval shows no consistent relation to any other parameter. The influence of cognitive activity on balance merits further exploration. A new parameter, sum of maximal deviation time (SDT) was proposed showing complete discrimination between frail elderly and other old subjects when obtained while visual input was suppressed. It was concluded that mean displacement velocity seems to be the most informative parameter in most situations.

[Cognitive deterioration in elderly due to primary hyperparathyroidism--resolved by parathyroidectomy]. / Cognitief verval bij ouderen door primaire hyperparathyreoïdie--opgelost door parathyreoïdectomie.

Three patients, two women aged 79 and 80 and a man aged 84, showed symptoms of cognitive impairment caused by primary hyperparathyroidism. Parathyroidectomy lead to a marked improvement in the symptoms. The incidence of primary hyperparathyroidism increases with age. Most patients only show slight symptoms. In addition, clinical symptoms in elderly patients differ from those in younger patients with mental changes, general tiredness and reduced muscular strength being prevalent. In accordance with the literature, which shows high cure rates with low morbidity and mortality, we recommend that parathyroid surgery be considered in elderly patients who exhibit only slight or mental symptoms of primary hyperparathyroidism.

Fluoride therapy for cochlear otosclerosis? an audiometric and computerized tomography evaluation.

The progress of sensorineural hearing loss (SNHL) in patients with cochlear otosclerosis was compared for 19 patients treated with fluoride for 1-5 years and 22 untreated controls. CT scans of eight patients before and after fluoride treatment were evaluated visually. Fluoride therapy arrested the progression of SNHL in the low (250, 500 and 1,000 Hz) (p < 0.001) and high (2 and 4 kHz) (p = 0.008) frequencies. It seemed to be more effective for the higher frequencies in cases with an initial SNHL of < 50 dB. Fluoride administration for 4 years did not seem to be superior to a shorter treatment period (1-2 years). For six patients followed up after discontinuing fluoride therapy there was minimal deterioration in SNHL. There was no clear relationship between the size and site of otospongiotic lesions on CT and the severity of SNHL. Follow-up with CT evaluation did not provide reliable information as to the efficacy of fluoride therapy.

[Fluoride treatment: a good choice in osteoporosis]. / Fluoride: een goede keus bij osteoporose.

Fluoride changes the composition of the hydroxyapatite crystal, reducing the solubility of the bone crystals. Fluoride also stimulates the production of DNA and new osteoblasts, which results in formation of new bone. The therapeutical range of fluoride is narrow. With monofluorophosphate in a dose of 76 mg twice daily positive effect on bone mass is obtained and measurement of serum fluoride concentration is unnecessary. For the treatment of osteoporosis the best result could be obtained with a combined treatment with monofluorophosphate, stimulating osteoblasts and production of new bone, and a bisphosphonate, which simultaneously inhibits osteoclasts and bone resorption. Using this combined treatment only few side effects and no lower extremity pain syndrome were observed. Patients > 65 years of age and younger patients showed similar positive effects on bone mass.

Surveillance of nosocomial infections in geriatric patients.

Prospective surveillance of hospital-acquired infections was undertaken in the geriatric ward of the University Hospital, Utrecht, the Netherlands. The medical records of 300 patients were studied for the presence of nosocomial infections using the criteria defined by the Centers for Disease Control (CDC), Atlanta, Georgia, USA. Data were collected from patients with and without infection, which allowed for the analysis of risk factors for nosocomial infection. In 100 out of 300 patients (33.3%), a total of 126 infections was diagnosed. The incidence of nosocomial infections was 16.9 per 1000 days of stay in the hospital. The mean length of stay of patients with infection was 39 days, while that of patients without infection was 17.8 days. Infections developed after an average stay of 13.3 days in the hospital. Patients with infections were 2.6 years older than patients without infections (P = 0.005). Dehydration was shown to be a major risk factor for infection (RR = 2.1, 95% CI: 1.4-3.2). Of the infections, 58.7% were urinary tract infections (UTIs, asymptomatic and symptomatic). The most important risk factor for an asymptomatic UTI was an indwelling urinary catheter (RR = 7.3, 95% CI: 3.1-17.1). The duration of use of the indwelling urinary catheter was of significant influence in the development of a UTI. Seventy percent of the patients with an asymptomatic UTI were treated with antibiotics. Infections of the gastrointestinal tract accounted for 19.8% of all nosocomial infections. The majority of these infections were due to an outbreak of Clostridium difficile. In conclusion, the length of stay may be prolonged by a nosocomial infection. In this study, the main risk factors for developing a nosocomial infection were age, dehydration and the presence of an urinary catheter. Our observations showed that age is a predisposing factor for nosocomial infection and that the risk increases with each year, even for geriatric patients.

[Hot spots: metastases or osteoporosis?]. / 'Hot spots': metastasen of osteoporose?

Radionuclide bone scintigraphy is a sensitive but not a specific technique for the diagnosis of bone metastases. Three patients, a man of 67 on steroid therapy because of chronic obstructive pulmonary disease and prostate cancer, a woman of 76 on steroid therapy because of temporal arteritis and a 50-year-old man with pain in the back, had bone scintigrams showing abnormal uptake (hot spots). There were delays of months before the diagnosis of osteoporosis instead of bone metastases was made. Abnormal uptake on a bone scintigram is often non-specific and requires further evaluation using supplementary diagnostic techniques.

Methods to score vertebral deformities in patients with rheumatoid arthritis.

The objective was to compare four different scoring methods for vertebral deformities: the semiquantitative Kleerekoper score and three quantitative scores (according to Minne, Melton and Raymakers) in patients with rheumatoid arthritis (RA). Lateral radiographs of the thoracic and lumbar vertebral column were scored in 52 RA patients treated with corticosteroids (Cs) and 52 RA patients not Cs treated (matched for age and gender). Clinically manifest vertebral fractures were defined as a vertebral deformity leading to the prescription of therapy: bedrest and/or analgesies. The number of Cs-treated RA patients with vertebral deformities was only increased according to the Kleerekoper score (relative risk 2.31; 95% confidence interval 1.36-3.90). The total number of vertebral deformities was increased in Cs-treated RA patients according to the method of Kleerekoper. Minne and Raymakers, but not according to Melton. The Spinal Deformity Index was increased in the Cs-treated RA patients according to Minne (P < 0.05), but not according to Raymakers. In both patient groups, the number of patients with clinically manifest vertebral fractures was much lower than that of vertebral deformities, e.g. in the Cs-treated patients 13% vs 35.79% (depending on the scoring method used). All eight patients with clinically manifest vertebral fractures had severe height loss (25% or more) in at least one vertebra. Vertebral deformities seem to occur more often in Cs-treated patients than in those not Cs-treated. However, differences exist in the number of patients with vertebral deformities and in the total number of vertebral deformities between different scoring methods. This emphasizes the need for a gold standard or consensus for defining vertebral deformities, in which, in our opinion, a Spinal Deformity Index has to be included. Clinically manifest vertebral fractures are predominantly characterized by severe vertebral deformities on X-rays.

Effect of glucocorticoid replacement therapy on bone mineral density in patients with Addison disease.

OBJECTIVE: To study the influence of glucocorticoid replacement therapy on bone mineral density. DESIGN: Cross-sectional. SETTING: University hospital in the Netherlands. PATIENTS: 91 patients with Addison disease who had been receiving glucocorticoid replacement therapy for a mean of 10.6 years (range, 0.5 to 36.5 years). MEASUREMENTS: Bone mineral density of the lumbar spine and both femoral necks using a dual-energy x-ray absorptiometer and basal serum concentrations of adrenocorticotropin, gonadal hormones, and adrenal androgens. RESULTS: Decreased bone mineral density (less than 2 standard deviations [SD] of the mean value of an age-matched reference population) was found in 10 of 31 men (32%; 95% Cl, 17% to 51%) and in 4 of 60 women (7%; Cl, 2% to 16%). No statistically significant differences were found between men and women with regard to age, duration of glucocorticoid substitution, or glucocorticoid dose, either in absolute quantities or when expressed per kilogram of body weight. However, in men with decreased bone mineral density, the daily hydrocortisone dose per kilogram of body weight (0.43 +/- 0.08 mg/kg; mean +/- SD) was significantly (P = 0.032) higher than in men with normal bone mineral density (0.35 +/- 0.10 mg/kg). After correction for possible confounding variables, a significant linear correlation was found between hydrocortisone dose per kilogram of body weight and bone mineral density of the lumbar spine in the men (regression coefficient, -0.86; Cl, -1.60 to -0.13; P = 0.029) but not in the women. CONCLUSIONS: Long-term treatment with standard replacement doses of glucocorticoids may induce bone loss in men with Addison disease. Adjustment of glucocorticoid therapy to the lowest acceptable dose is mandatory in Addison disease, and regular measurement of bone mineral density may be helpful in identifying men at risk for the development of osteoporosis.

Epidemiology of hip fractures in The Netherlands: women compared with men.

In this retrospective study the epidemiology of hip fractures in The Netherlands was evaluated. The number of hip fractures over the period 1972-1987 was collected from the Dutch Centre for Health Care Information (Stichting Informatiecentrum voor de Gezondheidszorg, SIG). The demographic data were collected from the Dutch Centre for Statistics (Centraal bureau voor de Statistiek, CBS). The age-adjusted incidence of hip fractures for both women and men 50 years of age and over, increased linearly over the period 1972-1987. There was also a linear rise in the age-adjusted incidence of hip fractures in women and men 65 years of age and over, but the rise in incidence was equal in both sexes. After the age of 50 years women and men showed an equal proportional increase in the age-specific incidence of hip fractures by 5-year age groups. This proportional increase was independent of the calendar year studied during the period 1972-1987. The increase over time in the age-adjusted incidence of hip fractures in inhabitants 50 years of age and over is the result of changes that act well before the age of 50 years, because the proportional increase in the age-specific incidence of these fractures after the age of 50 years did not change over the period studied. The cohort analysis showed that the age-specific incidence of hip fractures in more recently born birth cohorts is higher than that in birth cohorts born long ago. This observation agrees with the other observations.(ABSTRACT TRUNCATED AT 250 WORDS)

Is 1 mg of estradiol valerate or 0.625 mg of conjugated estrogens sufficient for all women to prevent menopausal bone loss?

Bone mineral content was measured by dual photon absorptiometry in 35 women who needed estrogen replacement therapy but did not want the addition of progestogens because they did not want regular bleeding. A total of 23 women were treated with estradiol valerate 1 mg per day over a mean period of 3.7 years; 12 women received conjugated estrogens 0.625 mg per day over a mean period of 5.3 years. The mean values of bone mineral content in both groups did not change. In the women on estradiol valerate, 61% had a decrease, and in those on conjugated estrogens, 67% had a decrease in bone mineral content. However, the calculated decrease per year was within the limits of the intraindividual reproducibility of the measurements. A difference between two measurements with a decrease of > 1.0 g hydroxyapatite/year over a period of > 3 years is larger than the limits of the intraindividual reproducibility. A decrease in bone mineral content > 1.0 g hydroxyapatite/year over a mean period of 3.98 years, SD 0.35, was observed in six of 23 (26%) of the women on estradiol valerate with a mean decrease of 5.28 g hydroxyapatite, SD 0.97. Only one of 12 (8%) of the women on conjugated estrogens had a decrease of 6.1 g hydroxyapatite over a period of 5.2 years. Periodic measurement of bone mineral is recommended in women on estrogen replacement therapy with estradiol valerate 1 mg per day or conjugated estrogens 0.625 mg per day for prevention of postmenopausal bone loss.

Mortality and causes of death after hip fractures in The Netherlands.

The mortality rate and causes of death after a hip fracture were studied in 493 consecutive patients with a hip fracture. All patients were treated in three hospitals in Utrecht, The Netherlands. The mortality rate following hip fractures is high and age dependent. Forty-five patients, 38 women and 7 men, died during the period of hospitalization (9.1%). One year after the date of hip fracture 23.6% of the women had died and 33.0% of the men. Four years after the date of hip fracture the mortality rates in women and men were 44.4% and 55.3%, respectively. Male sex, concomitant illnesses and in-hospital complications are negative determinants of survival. The in-hospital mortality was due to: cerebrovascular accident (n = 7), cardiac decompensation (n = 12), myocardial infarction (n = 4), pulmonary infection (n = 6), intestinal bleeding (n = 1) and sepsis (n = 5). From the registration of death causes we learned that 54 deaths were directly due to the hip fracture, 4 due to bed sores, 34 due to infectious diseases, 62 due to cardiovascular disease, 22 due to cerebrovascular accidents, 14 due to diabetes mellitus, and 33 due to neoplasm. The high mortality rate within the first 8 weeks after the date of hip fracture was mainly attributed to the hip fracture.

The incidence of hip fractures in The Netherlands.

The number of hip fractures in women 65 yr of age and over increased from 3416 in 1972 to 8075 in 1987. In men of the same age group the number of hip fractures increased from 1167 in 1972 to 2285 in 1987. This increase can only in part be explained by the increase in the proportion of aged people in the Dutch population. The age-adjusted incidence of hip fractures in The Netherlands rose linearly from 479/100,000 to 669/100,000 per year in women aged 65 yr and over during the period 1972-1987. In men of the same age group the age-adjusted incidence of hip fractures increased linearly from 198/100,000 to 308/100,000 per year over the period studied. The total number of hip fractures in the year 2010 has been estimated at 22,726. The mean duration of a hospital stay because of a hip fracture was 30 days in 1987. The annual need for hospital beds in 1987 for the treatment of hip fractures was calculated at 851. For the year 2010, the annual need for hospital beds, based on a 30-day hospital stay, has been estimated at 1866. Should the duration of a hospital admission due to a hip fracture be reduced to 20 days, then the annual need for hospital beds in 2010 would be 1244.

Urinary fluoride excretion in responders and nonresponders after fluoride therapy in osteoporosis.

The aim of the study was to investigate the usefulness of urinary fluoride excretion in evaluating fluoride therapy. In a prospective study, 35 patients with osteoporosis were treated for about 44 months with a mean dosage of 31.4 mg fluoride ion per day. Urinary fluoride excretion and serum alkaline phosphatase activity were measured at 3-month intervals. Bone mineral content (BMC) was measured in L2-L4 with dual-photon absorptiometer. The mean number of BMC measurements was 5.7 per patient. The interindividual reproducibility for measurements in 10 patients was 2.1%. For each individual, the regression coefficient of BMC for the period of treatment was calculated. Responders were defined as those who had a positive value and nonresponders had 0 or a negative value. The percentage responders was 83%. Between responders and nonresponders no differences were found for age, fluoride dosage, duration of treatment, or changes in serum alkaline phosphatase activity. Urinary fluoride excretion was higher in responders than in nonresponders (p less than 0.001) and a positive correlation (p less than 0.001) was obtained between the changes in BMC and urinary fluoride excretion. In the responders, 90% had a urinary fluoride excretion greater than 8 mg/24 h. All nonresponders had a urinary fluoride excretion less than 8 mg/24 h. Urinary fluoride excretion is a valuable predictor of BMC response during fluoride therapy for osteoporosis.

[Hypercalcemia in the elderly]. / Hypercalciëmie bij bejaarden.

The symptoms which are caused by hypercalcemia are variable and unspecific. In the elderly the functional capacity of homeostatic mechanisms is less than in young people and at the same time the prevalence of diseases which may cause hypercalcemia is greater. One should be aware of the possibility of hypercalcemia in patients presenting vague gastrointestinal and/or psychiatric complaints or symptoms. The prevalence of hypercalcemia in elderly women may well be 3%. Hypercalcemia leads to renal loss of salt and disturbances of renal function. An increasing inability to excrete the calcium overload is the result. Only in primary hyperparathyroidism renal function remains generally normal and moderately increased calcium levels may exist for years without serious consequences. Important causes of hypercalcemia in the elderly are hyperthyroidism, malignant disease and abrupt immobilization with previously elevated skeletal remodelling activity. Thiazide diuretics may precipitate the hypercalcemic state. Diagnosis is relatively simple and is based on a limited package of laboratory tests. Treatment should always begin with the restoration of the extracellular fluid volume. This is followed by inhibition of bone resorption by means of bisphosphonates or corticosteroids and treatment of the underlying disease.

The value of local 99mTc(Sn)-MDP bone to soft tissue uptake ratio in osteoporosis, before and during fluoride therapy.

The reproducibility and diagnostic value of local bone to soft tissue uptake ratio of 99mTc(Sn)-MDP as a bone tracer was examined in a prospective study in 35 patients who were under investigation and/or treatment for postmenopausal osteoporosis. The ratio of tracer uptake in the second lumbar vertebra (L2) and both femoral shafts was calculated from the number of counts in suitable regions of interest. Results obtained with settings and calculations in the routine practice were compared to the results obtained by revision of all raw data in one run by one person. The results were compared to the serum alkaline phosphatase activity (AP) and to local bone mineral mass as determined by dual photon absorptiometry (DPA). In 15 patients serial measurements during fluoride therapy were also compared to serum osteocalcin values and to bone histomorphometric data. The precision error of the calculation of uptake ratios from raw counts (including selection of region of interest) was 13.9% for the femoral shaft and 14.7% for L2. The mean difference between left and right femoral shaft in individuals was not significant and its variance was small P greater than 0.1). There was a weak but significant linear correlation between local uptake ratio in the spine and AP in the total material (r = 0.328 P less than 0.01). However, changes in local uptake ratio during therapy with fluoride in 15 patients were too small to be of any value and did not correlate with changes in alkaline phosphatase or osteocalcin or trabecular surface covered with osteoblasts.(ABSTRACT TRUNCATED AT 250 WORDS)