Joseph Grinblat

Different C-Reactive Protein Kinetics in Post-Operative Hip-Fractured Geriatric Patients with and without Complications

Background: Hip fracture is a frequent injury in the elderly, and is associated with a high incidence of functional impairment, complications and mortality. Objective: To determine kinetics of C-reactive protein (CRP), fibrinogen and erythrocyte sedimentation rate (ESR) in hip-fractured patients over a 1-month post-operative period; to examine the relationship of these parameters to cognition, operation type, post-operational complications, functional level 1 month post-operatively and 6-month mortality. Methods and Subjects: 32 aged patients operated on for hip fracture were prospectively followed-up for 6 months. Fracture, type of operation and anesthetic risk were recorded. Cognition was evaluated by the Mini-Mental State Examination and pre-fracture functional level evaluated by the Katz Index of ADL. Follow-up included complications, mortality and functional outcome. CRP, fibrinogen and ESR were assessed during the first 10 h post-fracture; 48–60 h, and 7 and 30 days post-operatively, respectively. Results: Only CRP kinetics were found to differ in patients with complications vs. those without, as a group (p = 0.006), and in patients suffering infections, delirium and cardiovascular complication vs. patients with no complications (p = 0.06, 0.03, 0.02, respectively). Mean (±SEM) CRP 48–60 h post-operatively was 20.9 ± 2.1 and 13.1 ± 1.6 mg/dl in complicated and uncomplicated patients, respectively (p = 0.002). The mean CRP 48–60 h post-operatively was highly correlated with the CRP area under the curve, R = 0.88 (p < 0.001). A cut-off level of 15 mg/dl for CRP, 48– 60 h post-operatively, was calculated for patients with complications (sensitivity 93%, specificity 65%, p = 0.003). CRP, fibrinogen and ESR were not related to fracture or type of operation, cognition, anesthetic risk, 1-month post-operative functioning and 6-month mortality. Conclusions: CRP measurement in elderly patients operated for hip fracture may be valuable in assessing and monitoring complications.

Dementia does not significantly affect complications and functional gain in elderly patients operated on for intracapsular hip fracture.

Abstract Fifty-three elderly patients with intracapsular hip fracture were hospitalized in the Department of Orthopaedics. Forty-two underwent operations: 38 hemiarthroplasty; 2 total hip replacements and 2 closed reduction interior fixation. They were followed up and assessed prospectively five times for 6 months post-fracture. Cognition was evaluated by the Mini-Mental State Examination. Pre-fracture functioning was determined by the Functional Independence Measure (FIM) and the Katz index of activities of daily living (ADL). The functional outcome was assessed by the FIM gain defined as the difference between FIM scores at 6 months and just prior to discharge. FIM gain, length of stay, complications and mortality rates were not significantly different between three cognitive groups: normal, moderately and severely demented patients. The majority of patients were independent and partially dependent in their ADL. We conclude that dementia does not significantly affect complications and functional gain in elderly patients operated on for intracapsular hip fracture if they were mobile before the fracture.

Influence of orthostatic hypotension on mortality among patients discharged from an acute geriatric ward

BACKGROUND: Orthostatic hypotension (OH) is a common finding among older patients. The impact of OH on mortality is unknown.OBJECTIVE: To study the long-term effect of OH on total and cardiovascular mortality.PATIENTS AND METHODS: A total of 471 inpatients (227 males and 244 females), with a mean age of 81.5 years who were hospitalized in an acute geriatric ward between the years 1999 and 2000 were included in the study. Orthostatic tests were performed 3 times during the day on all patients near the time of discharge. Orthostatic hypotension was defined as a fall of at least 20 mmHg in systolic blood pressure (BP) and/or 10mmHg in diastolic BP upon assuming an upright posture at least twice during the day. Patients were followed until August 31, 2004. Mortality data were taken from death certificates.RESULTS: One hundred and sixty-one patients (34.2%) experienced OH at least twice. Orthostatic hypotension had no effect on all cause and cause specific mortality. Over a follow-up of 3.47±1.87 years 249 patients (52.8%) had died 83 of whom (33.3%) had OH. Age-adjusted mortality rates in those with and without OH were 13.4 and 15.7 per 100 person-years, respectively. Cox proportional hazards model analysis demonstrated that male gender, age, diabetes mellitus, and congestive heart failure increased and high body mass index decreased total mortality.CONCLUSIONS: Orthostatic hypotension is relatively common in elderly patients discharged from acute geriatric wards, but has no impact on vascular and nonvascular mortality.

Folate and Vitamin B12Levels in an Urban Elderly Population With Chronic Diseases

Folate levels of serum and red blood cells (RBC) and vitamin B12 serum levels were investigated in 326 urban chronically ill elderly ambulatory patients and 41 healthy young control subjects. Two laboratory methods were used for investigating the folate levels, the microbiologic assay (MBA) with Lactobacillus casei and radioassay (RA). Serum and RBC samples of 326 patients were tested by the folate MBA and 270 of the same samples by the RIA methods. In the MBA 6.8% of the patients and 12.2% of controls had low levels of folate RBC (less than 200 nglmL) and 1.8% of patients and 4.8% of controls had low serum folate levels (less than 5 ng/mL). All of the patients with the low folate levels had normal hematologic findings and no clinical symptoms of folate deficiency. In the RIA method, all of the patients and almost all of the control subjects (except one) had normal folate levels. Ten of the patients (3%) had low levels of serum vitamin (less than 200 pg/mL). They were hematologically normal. They had normal Schilling tests and normal vitamin B12 dietary intake. Their RBC folate levels were normal and even somewhat higher. Forty percent of these patients had macular degeneration of the eyes. The data indicate the superiority of the RA method over the MBA and bring into question the accuracy of previous studies. The data furnish further evidence that a low vitamin B12 level in the elderly is not necessarily a true vitamin B12deficiency and raise the possibility of an association between low B12 serum levels and macular degeneration of the eyes.

Rupture of the pectoralis major muscle in nursing home residents

Pectoralis major rupture is relatively rare; only about 150 cases have been reported (1,2). The injury can occur in men from infancy to old age, but is most frequent between the ages of 20 and 40 years (1,3). It usually occurs during sports activity (e.g., weight lifting, wrestling, football, and rugby), or at work (2), after extreme muscle tension or direct trauma (2,4,5), although spontaneous rupture has been reported (6). We report a series of cases involving nursing home residents who had rupture of the pectoralis major muscle.

Pectoralis major rupture in the elderly:Clinical and sonographic findings

We describe clinical and sonographic features of pectoralis major rupture in the elderly, which is relatively rare and unknown. Patients presented with a large pectoral ecchymosis extending to the axilla, chest wall, breast and arm. The pectoral area was sensitive, sometimes with a visible and palpable defect in the axilla. Ultrasound examination showed a large hypoechoic, well-circumscribed structure representing a hematoma within the pectoralis major muscle, partially replacing the normal echo muscle pattern. Ultrasonography is a useful, low cost diagnostic tool, and is recommended in the investigation of pectoralis major rupture in the elderly.

Uncontrolled crying: characteristics and differences from normative crying.

Background: Uncontrolled crying (UC) is a prevalent poststroke phenomenon of elderly patients, socially disabling and interfering with rehabilitation. There are many differences in opinions and nonclarity in the literature relating to UC. Objective: To examine two basic questions regarding UC that have as yet not been experimentally studied: typical situations where UC occurs and how UC differs from normative crying (NC). Methods: Crying episodes of elderly patients suffering from poststroke UC were documented. From 235 crying documented episodes, instructions for further follow-up documentation were received. According to these instructions, 1,098 crying episodes were documented. Using the ‘truncated pyramid’ model developed during this study, 47 crying situations typical of poststroke UC processed into seven categories were identified. Based on these findings, we compared UC and NC. Results: UC and NC were found to differ in all tested variables: crying situations, content areas of crying situations, crying frequency, crying frequency of men as compared with that of women, and crying frequency when alone as compared with the crying frequency in the presence of others. Conclusions: UC should be approached as an entity totally different from NC within a wide range of variables. The study’s findings assist in understanding UC, the reasons for its disabling effect, and the need for exploring ways to aid elderly patients suffering from poststroke UC. The situations typical of UC and their categories found in this study may serve as additional clinical and research means for these purposes.

Giant incidental cardiac mass compatible with myxoma in a 92-year-old woman

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The prehospitalization functional and cognitive status and the course of acute infectious disease in the elderly

A total of 105 elderly patients hospitalized for acute infectious disease were classified into prehospital demented and non demented groups and into dependent and independent groups. Demographic data, clinical and biological parameters and previous health problems were recorded. There was a significant difference between the two cognitive and functional groups in complications, length of stay, dehydration, confusion, albumin and hemoglobin. A logistic regression analysis taking into account the epidemiologic parameters, functional and cognitive status and the medical health problems has shown that only age, dementia and previous neurologic disease (mainly stroke) are independent risk factors for confusion and complications. Thus, the prehospitalization function, cognitive status and previous neurologic disease in elderly patients with acute infections may have a predictive and prognostic value.