Israel Gil

Improvement of Pain and Disability in Elderly Patients with Degenerative Osteoarthritis of the Knee Treated with Narrow-Band Light Therapy

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

The impact of hemiparalysis on the expression of osteoarthritis

OBJECTIVE Primary generalized osteoarthritis (OA), the most prevalent joint disease, is usually symmetric. Sporadic case reports mention decreased OA manifestations in limbs in which there are neurologic deficits, but no systematic research has been published. The aim of the present study was to examine these observations in a planned and controlled survey in a group of patients with OA. METHODS Seventy-five geriatric patients with a history of stroke and hemiparalysis were studied clinically and radiographically (hand radiographs; graded according to a modified Altman method) for the presence and the degree of OA in the hands. Detailed clinical and radiologic scores were calculated for each hand. Demographic, occupational, and neurologic data were collected. Patients with other joint or neurologic conditions were excluded. A group of 55 elderly patients without stroke were similarly studied (controls). Scores in the paralyzed hand were compared with those in the nonparalyzed hand in the stroke patients and subgroups (by Students paired t-test and Wilcoxon test). Scores in the dominant hands were compared with those in the nondominant hands in stroke patients and control subjects (by Students paired t-test and Mann-Whitney test). Correlation between the degree of neurologic damage and OA asymmetry (Pearsons correlation coefficient) was also sought. RESULTS Paralyzed hands showed significantly fewer OA changes than nonparalyzed hands, both clinically and radiologically. This trend, accentuated in patients with more severe paralysis, disappeared in those with mild residual paresis. Asymmetry of OA was more pronounced in patients with flaccid, compared with spastic, paralysis. The degree of paralysis and loss of muscle strength correlated with the degree of OA asymmetry. Women had significantly higher OA scores than men. In the control group, dominant hands had higher OA scores, but this finding was concealed among hemiparalyzed patients. Lifetime gross occupational load and present grip strength did not correlate with the degree of OA. CONCLUSION In elderly patients, hemiparalysis reduces ipsilateral hand expression of OA, while OA is accentuated (or increased) in the dominant hand of patients without paralysis. This first systematic study confirms the findings of previous case reports and lends support to the role of biomechanical factors in the development of OA.

Management of adverse clinical events by duty physicians in a nursing home

Background and aims: The nature of adverse clinical events (ACE) during duty hours (16:00-08:00 and holidays), as well as the way they are addressed by duty physicians (DP) in a nursing home (NH) are the subject of this study. Methods: Data, including medical details concerning ACEs and the resultant referrals to hospital, were collected prospectively during 183 consecutive days in a 90-bed NH. Results: Ninety-six residents experienced 370 ACEs, representing an average of one for every 44.5 patient days. The highest rate of events was during evening hours (18:00–21:00). The most prevalent ACE was fever (32%). Most cases (53%) were treated by the DPs on site. No intervention was needed in 19% of cases, whereas 28% of ACEs (104 cases) were referred to the Emergency Room (ER) of a general hospital. Sixty-six percent of these were actually admitted. The rate of ER referral of residents was one for every 158 patient days. About 40% of the referred patients had been discharged from hospital the previous week. High fever was the commonest cause for referral: 47%. During the working hours of the study period, the rate of referral by the staff physician was only 1 for every 915 patient days. Only 17% of these had high fever. Conclusions: Evening rounds by staff physicians, strengthening of working relations with hospital physicians, as well as fostering intravenous treatment in NHs, are suggested as means for reducing hospital transfers. A standardized method for the reporting of ACEs and referrals to hospitals should be adopted in order to facilitate comparisons between NHs and to evaluate its use as a quality indicator.

Radionuclide cystography: the significance of retention time of the refluxed radioisotope

We studied 36 patients with vesicoureteral reflux into 45 renal units by means of isotope cystography and a dynamic renal function scan performed 24 to 48 hours after the cystography. Functional impairment was found in 21 renal units. To evaluate the significance of the time between voiding and complete disappearance of the radioisotope that refluxed from the kidney (retention time) the presence of the labeled particles in the kidney was followed continuously and intermittently during a prolonged interval. There was a significant difference between the retention time found in the impaired kidneys and that in the normally functioning kidneys. In 91.7 per cent of the normally functioning kidneys retention time was less than 5 minutes, whereas in 86 per cent of the impaired kidneys it was more than 10 minutes and in 56 per cent it was more than 20 minutes. No significant correlation was found between the retention time and intrarenal reflux or dilatation of the collecting system (patients classified as having radiological grades III and IV reflux were not included in this study). A retention time greater than 10 minutes may be correlated with decreased renal function. The retention of technetium sulfur colloid particles may be analogous to the retention of similar size bacteria and suggests a possible pathophysiologic explanation for the development of renal dysfunction owing to the prolonged presence of bacteria in the kidney after reflux.

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.

Malignant testicular tumors in identical twins

Two cases of testicular malignancy in a pair of identical twins are reported. The literature is also reviewed. The tumors appeared within 7 years of each other. The histology was different in both cases.

Sarcoid nephrocalcinotic renal failure reversed by sodium cellulose phosphate.

A case of renal failure due to sarcoidosis with hypercalciuria and nephrocalcinosis is described. Prolonged treatment with inorganic absorbable phosphate significantly deteriorated the patients renal function. After a sodium cellulose phosphate treatment, renal failure was completely reversed. We suggest that sodium cellulose phosphate is the treatment of choice in sarcoidotic renal failure induced by nephrocalcinosis.

Electrocardiographic monitoring during digital rectal examination in demented long-term care patients

Digital rectal examination (DRE) is frequently performed in nursing home patients and may be associated with pain, discomfort and electrocardiographic disturbances. In view of the high number of demented residents in long-term care, and the communication difficulties due to their condition, we performed ECG monitoring during rectal examination in order to detect any changes. In the great majority (85%) of the 28 patients in the study no ECG changes were recorded. Four patients had tachycardia not directly related to the rectal examination and two female patients had bradycardia with no hemodynamic consequences. Our study suggests that DRE in demented patients is not associated with significant ECG disturbances.