13
LETTERS TO THE EDITOR Repetitive pneumonia and wheezing in an elderly patient after radiation therapyDear Editor, The pathogenesis of pneumonia in older people is associated with various background conditions and diseases, different from those in younger people. 1 Jensen et al. reported that 9% of deaths in patients who receive chemoradiotherapy for head and neck cancers were associated with aspiration pneumonia. 2 Caudell et al. also reported an 18% incidence of aspiration in patients who received radiation therapy for pharyngeal cancer. 3 On the other hand, tracheal stenosis is an important problem in patients after radiation therapy for head and neck, esoph- ageal, and laryngeal cancer. 4 However, the frequency of esoph- ageal stenosis after radiation therapy alone is low. 2 Here, we describe an elderly patient with repetitive pneumonia with both esophageal and tracheal stenosis after radiation therapy for esophageal and laryngeal cancer. The patient consented to our report. A 74-year-old woman visited our hospital for repetitive and persistent wheezing. She had received radiation therapy for esophageal and laryngeal cancer 6 years previously. Because of esophageal stenosis due to scar formation at the irradiated site, she had received tube feeding through percutaneous endo- scopic gastrostomy (PEG) after undergoing radiation therapy. Respiratory symptoms, such as cough and wheezing, were not observed during tube feeding through PEG. However, the tube feeding was stopped because the condition of the PEG appa- ratus deteriorated. After the tube was removed, she received frequent intravenous transfusion including glucose, electro- lytes and vitamins. She had been treated for pneumonia 6 months before visiting our hospital. When she visited our hospital, her chief complaint was refractory and persistent wheezing. She also felt difficulty in food passage in her neck and back and complained of dysph- agia. Eating was a problem because of frequent coughing. Physical examination revealed a wheeze in the upper airways, including the larynx and trachea. Body temperature was 37.1°C, and blood pressure was 132/83 mmHg. Pulse rate was 77 beats/ min, and oxygen saturation was 96% while breathing room air. Peripheral blood and serum showed inflammation with a white blood leukocyte count of 8300 cells/mL and C-reactive protein (CRP) of 5.1 mg/dL. Chest radiographs showed infiltrative shadows in the right middle part and left lower part of the lung. A computed tomography (CT) scan of her chest showed dense consolidations in the right middle part and left lower part of the lung with an air bronchogram (Fig. 1). These findings indicated the presence of bronchopneumonia. Furthermore, a 3-D image reconstructed from the chest CT scan showed tracheal stenosis in the center (Fig. 2a). A bronchoscopic examination showed fixed dilatation of the left side of the vocal cord and poor mobility of the right side of the vocal cord, which showed recurrent nerve paralysis. The bronchoscopic examination also showed tracheal stenosis in the center portion, but no recur- rence of laryngeal cancer was detected. A flow-volume curve showed obstructive impairment in the upper airway with a trapezoidal appearance, and forced expiratory volume in 1 s in spirometry was mildly reduced (72%). An esophagogastro- scopic examination showed a pinhole shaped opening of the esophagus caused by scar formation and inflammation conse- quent to the radiation therapy for pharyngeal cancer, but no recurrence of esophageal cancer was detected. A barium esophagogram also showed severe esophageal stenosis at the junction with the pharynx (Fig. 2b). Figure 1 A chest computed tomography scan shows dense consolidations in the right middle part and left lower part of the lung with air bronchogram. Figure 2 A 3-D image reconstructed from chest computed tomography scan (a) and a barium esophagogram (b) show tracheal and esophageal stenosis, respectively (arrows). Geriatr Gerontol Int 2012; 12: 352–364 352 © 2012 Japan Geriatrics Society doi: 10.1111/j.1447-0594.2011.00751.x

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LETTERS TO THE EDITOR

Repetitive pneumonia and wheezing in an elderly patient afterradiation therapyggi_751 352..364

Dear Editor,

The pathogenesis of pneumonia in older people is associatedwith various background conditions and diseases, differentfrom those in younger people.1 Jensen et al. reported that 9%of deaths in patients who receive chemoradiotherapy for headand neck cancers were associated with aspiration pneumonia.2

Caudell et al. also reported an 18% incidence of aspiration inpatients who received radiation therapy for pharyngeal cancer.3

On the other hand, tracheal stenosis is an important problemin patients after radiation therapy for head and neck, esoph-ageal, and laryngeal cancer.4 However, the frequency of esoph-ageal stenosis after radiation therapy alone is low.2 Here, wedescribe an elderly patient with repetitive pneumonia withboth esophageal and tracheal stenosis after radiation therapyfor esophageal and laryngeal cancer. The patient consented toour report.

A 74-year-old woman visited our hospital for repetitive andpersistent wheezing. She had received radiation therapy foresophageal and laryngeal cancer 6 years previously. Because ofesophageal stenosis due to scar formation at the irradiated site,she had received tube feeding through percutaneous endo-scopic gastrostomy (PEG) after undergoing radiation therapy.Respiratory symptoms, such as cough and wheezing, were notobserved during tube feeding through PEG. However, the tubefeeding was stopped because the condition of the PEG appa-ratus deteriorated. After the tube was removed, she receivedfrequent intravenous transfusion including glucose, electro-lytes and vitamins. She had been treated for pneumonia6 months before visiting our hospital.

When she visited our hospital, her chief complaint wasrefractory and persistent wheezing. She also felt difficulty infood passage in her neck and back and complained of dysph-agia. Eating was a problem because of frequent coughing.Physical examination revealed a wheeze in the upper airways,including the larynx and trachea. Body temperature was 37.1°C,and blood pressure was 132/83 mmHg. Pulse rate was 77 beats/min, and oxygen saturation was 96% while breathing room air.Peripheral blood and serum showed inflammation with a whiteblood leukocyte count of 8300 cells/mL and C-reactive protein(CRP) of 5.1 mg/dL. Chest radiographs showed infiltrativeshadows in the right middle part and left lower part of the lung.A computed tomography (CT) scan of her chest showed denseconsolidations in the right middle part and left lower part of thelung with an air bronchogram (Fig. 1). These findings indicatedthe presence of bronchopneumonia. Furthermore, a 3-D imagereconstructed from the chest CT scan showed tracheal stenosisin the center (Fig. 2a). A bronchoscopic examination showedfixed dilatation of the left side of the vocal cord and poormobility of the right side of the vocal cord, which showedrecurrent nerve paralysis. The bronchoscopic examination alsoshowed tracheal stenosis in the center portion, but no recur-

rence of laryngeal cancer was detected. A flow-volume curveshowed obstructive impairment in the upper airway with atrapezoidal appearance, and forced expiratory volume in 1 s inspirometry was mildly reduced (72%). An esophagogastro-scopic examination showed a pinhole shaped opening of theesophagus caused by scar formation and inflammation conse-quent to the radiation therapy for pharyngeal cancer, but norecurrence of esophageal cancer was detected. A bariumesophagogram also showed severe esophageal stenosis at thejunction with the pharynx (Fig. 2b).

Figure 1 A chest computed tomography scan shows denseconsolidations in the right middle part and left lower part of the lungwith air bronchogram.

Figure 2 A 3-D image reconstructed from chest computedtomography scan (a) and a barium esophagogram (b) show trachealand esophageal stenosis, respectively (arrows).

Geriatr Gerontol Int 2012; 12: 352–364

352 � © 2012 Japan Geriatrics Societydoi: 10.1111/j.1447-0594.2011.00751.x

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Serum levels of squamous cell carcinoma antigen (0.8 ng/mL) and carcinoembryonic antigen (3.0 ng/mL) were normal,but serum levels of total protein (6.4 g/dL) and albumin (2.8 g/dL) were low. Klebsiella pneumoniae was detected in the patient’ssputum, while fungi, Mycobacterium tuberculosis, and Mycobacte-rium avium in sputum culture were negative. Antigens ofLegionella pneumophila and Streptococcus pneumoniae in urinespecimens were also negative.

After receiving esophageal dilation, the patient could eatsmall pieces of solid food and liquids, and the frequency andintensity of cough while eating decreased. She was treated withan antibiotic, sulbactam sodium ampicillin sodium (3 g/day),and a transdermally applied long-acting b2 agonist, tulobuterolhydrochloride (2 mg/day), and the shadows in the lung dimin-ished on chest CT and chest radiographs. Body temperature,number of peripheral blood leukocytes, and serum levelsof CRP returned to normal ranges. The severe wheezingimproved, but mild to moderate wheezing continued.

In this case, a chest CT scan and a bronchoscopic exami-nation showed tracheal stenosis in the center portion. A flow-volume curve also showed obstructive impairment in theupper airway. Because chest radiographs and a chest CT scanshowed bronchopneumonia, and the forced expiratory volumein 1 s in spirometry was slightly reduced (72%), the patient wastreated with antibiotics and a long-acting b2 agonist. Afterreceiving these treatments, the severe wheezing and coughimproved, but mild to moderate wheezing continued. Kosh-kareva et al. reported that patients irradiated for carcinomas ofthe oropharynx and larynx are more likely to develop laryn-gotracheal stenosis.5 Therefore, radiation therapy for esoph-ageal and laryngeal cancers might have been the cause oftracheal stenosis in this case, resulting in repetitive and per-sistent wheezing. The complication of bronchial asthma andbronchial inflammation caused by bronchopneumonia mightalso be associated with the severe wheezing that was observedin this patient when she visited the hospital.

Furthermore, in this case, endoscopic examination and abarium esophagogram showed severe esophageal stenosis atthe junction with the pharynx with a pinhole shaped openingof the esophagus. Although the frequency of esophagealstenosis after radiation therapy alone is low,2 our patient hadreceived radiation therapy for both laryngeal and esophageal

cancer. The radiation therapy for laryngeal cancer might haveenhanced inflammation in the esophagus, causing severeesophageal stenosis in this case. The patient complained ofcoughing at meals and dysphagia with a feeling of difficult foodpassage in her neck and back. Jensen et al. reported that 9% ofdeaths in patients who receive chemoradiotherapy for headand neck cancers were associated with aspiration pneumonia.2

Caudell et al. also reported an 18% incidence of aspiration inpatients who receive radiation therapy for pharyngeal cancer.3

As demonstrated in these previous reports, severe esophagealstenosis after radiation therapy for esophageal and laryngealcancer might have induced aspiration and pneumonia in thiscase. The recurrent nerve paralysis in our patient might alsohave been related to aspiration pneumonia, which we havepreviously reported in patients with pneumonia complicatedby aortic aneurysm.6

Motoki Yoshida,1 Mutsuo Yamaya,2 Masanori Asada,1

Hiroshi Kubo2 and Hiroyuki Arai1

1Department of Geriatric Medicine, Tohoku University Hospital,and 2Department of Advanced Preventive Medicine for Infectious

Disease, Tohoku University Graduate School of Medicine,Sendai, Japan

References

1 Sasaki H. Single pathogenesis of geriatric syndrome. Geriatr GerontolInt 2008; 8: 1–4.

2 Jensen K, Lambertsen K, Grau C. Late swallowing dysfunction anddysphagia after radiotherapy for pharynx cancer: frequency, intensityand correlation with dose and volume parameters. Radiother Oncol2007; 85: 74–82.

3 Caudell JJ, Sawrie SM, Spencer SA et al. Locoregionally advancedhead and neck cancer treated with primary radiotherapy: a compari-son of the addition of cetuximab or chemotherapy and the impactof protocol treatment. Int J Radiat Oncol Biol Phys 2008; 71: 676–681.

4 Laurell G, Kraepelien T, Mavroidis P et al. Stricture of the proximalesophagus in head and neck carcinoma patients after radiotherapy.Cancer 2003; 97: 1693–1700.

5 Koshkareva Y, Gaughan JP, Soliman AM. Risk factors for adultlaryngotracheal stenosis: a review of 74 cases. Ann Otol Rhinol Laryn-gol 2007; 116: 206–210.

6 Ebihara T, Yamasaki M, Kubo H, Yamaya M. Dysphagia in patientswith rapidly enlarged thoracic aortic aneurysm. J Am Geriatr Soc 2006;54: 1294–1301.

Necrotizing fasciitis following intra-articular steroid injection:Case report and review of the literatureggi_752 353..365

Dear Editor,

An 85-year-old woman suffering from non-insulin-dependentdiabetes mellitus and hypertension presented to ouremergency department with intense left shoulder pain dueto severe osteoarthritis. In the previous days, she had been

treated with NSAID without improvement and the daybefore she came to our hospital she had received an intra-articular steroid injection. On admission the patient appea-red confused and her temperature was 37°C, heart rate 70b.p.m. and blood pressure 100/60 mmHg. Laboratory datashowed increased levels of glycaemia (245 mg/dL), creatinine

Letters to the Editor

© 2012 Japan Geriatrics Society � 353doi: 10.1111/j.1447-0594.2011.00752.x

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(3.1 mg/dL), myoglobin (610 U/L; normal values 0–60 U/L),creatine phosphokinase (128 U/L; normal values 0–70 U/L),aspartate aminotransferase and alanine aminotransferase(79 U/L and 39 U/L, respectively; normal values 0–30 U/L).Her erytrocyte sedimentation rate was 69 mm/h. Her creati-nine level had been normal a month earlier. Reduction onmoving the left armpit was noted initially on admission, butin the next hours progressive edema of the arm developedrapidly with the overlying skin turning purple in color andserohematic bullae appearing. Fluids, specifically ampicillin/sulbactam and metronidazole were administered imme-diately and surgical debridement was performed. Histologyconfirmed the diagnosis of necrotizing fasciitis (NF) andshowed widespread necrosis of subcutaneous fat and deepfascial layer. The underlying muscle was spared. Gram stainingwas not performed and blood, bullae fluid and tissue samplesdid not show evidence of the condition spreading. While thepatient was admitted, changing her surgical dressing dailyallowed the wounds to slowly granulate, her creatininereturned to normal values and three doses of insulin dailyrestored controlled blood glucose levels. Physical therapywas necessary for a long time to improve the left arm range ofmotion.

NF is characterized by the rapid, widespread necrosis ofsubcutaneous fat and deep fascial layers. It has a high mortalityrate (30%) and occurs more frequently in the elderly and inpatients with an impaired immune system1. Fournier’s gan-grene is a subset of NF localized to the perineum2. Initialclinical signs of NF are intense pain and soft tissue edema;blisters, subcutaneous crackling, skin discoloration andsloughing, with or without signs of systemic toxicity, appear inthe next 12–24 hour. The gold standard for diagnosis issurgery. Therapy involves supportive care, broad spectrumantibiotics and extensive surgical debridement.2 The frontdoor for infection may be skin lesions or abdominal, genitouri-nary or musculoskeletal infections, though in up to 15% ofcases there is no evidence of any source of infection.3 Intra-articular steroid injections are very rarely reported in the lit-erature as a cause of NF (Table 1).4–7 The puncture itself andthe possible interference of steroids with leucocyte functioncan cause soft tissue infection. It is well known that steroidsinhibit monocyte chemotaxis, reduce phagocytosis anddecrease the production of cytokine.4 Diabetes mellitus hasbeen recognized as a predisposing condition for NF for severalreasons: “sugar-coated” capillaries limit the blood supply tosuperficial and deep structures, causing the rapid progressionof infection;8 peripheral sensory neuropathy increases sus-ceptibility to trauma and delays presentation of patients tomedical examination;9 the immune system response of diabeticpatients is compromised because of the impaired bacterialactivity of granulocytes.10

Intra-articular steroid injections are extensively used inelderly patients suffering from osteoarthritis. Extremely rarethe injection may be followed by NF, even if the puncture isadministered using a strict aseptic technique. The develop-ment of erythema and intensive pain at the injection site dis-proportionate to the physical findings should alert clinicians tothis life-threatening complication. Just an aggressive approachwith supportive care, broad spectrum antibiotics and extensivesurgical debridement can afford patients the best chance ofsurvival. T

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354 � © 2012 Japan Geriatrics Society

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Acknowledgements

The authors would like to express their gratitude to theradiologists and orthopedists who participated in the man-agement of this case. None of the authors has a conflictof interest to disclose in relation to the preparation of thismanuscript.

Francesca Fanfarillo,1 Federica Pace,2 Rosa Maida,1

Daniele Pignata1 and Giannantonio Cerqua1

1Department of Emergency Medicine, San Giovanni AddolorataHospital, and 2Department of Emergency Medicine, San Camillo

Forlanini Hospital, Rome, Italy

References

1 Cainzos M, Gonzalez-Rodriguez FJ. Necrotizing soft tissue infec-tions. Curr Opin Crit Care 2007; 13: 433–439.

2 Young MH, Aronoff DM, Engleberg NC. Necrotizing fasciitis:pathogenesis and treatment. Expert Rev Anti Infect Ther 2005; 3:279–294.

3 Gonzalez MH. Necrotizing fasciitis and gangrene of the upperextremities. Hand Clin 1998; 14: 635–645.

4 Birkinshaw R, O’ Donnel J, Sammy I. Necrotizing fasciitis as acomplication of steroid injection. J Accid Emerg Med 1997; 14: 52–54.

5 Regev A, Weinberger M, Fishman M, Samra Z, Pitlik SD. Necro-tizing fasciitis caused by Staphilococcus Aureus. Eur J Clin MicrobiolInfect Dis 1998; 17: 101–103.

6 Hofmeister E, Engelhardt S. Necrotizing fasciitis as a complicationof injection into grater trochanteric bursa. Am J Orthop 2001; 30:426–427.

7 Unglaub F, Guehring T, Fuchs PC, Perez-Bouza A, Groger A,Pallua N. Necrotizing fasciitis following therapeutic injection in ashoulder pain. Orthopade 2005; 34: 250–252.

8 Gürlek A, Firat C, Oztürk AE, Alaybeyoglu N, Fariz A, Aslan S.Management of necrotizing fasciitis in diabetic patients. J DiabetesComplications 2007; 21: 265–262.

9 McArdle P, Gallen I. Necrotising fasciitis in diabetics. Lancet 1996;348: 552.

10 Kreitzer T, Hrko M. Necrotizing fasciitis in a female diabeticpatient: a case report. W V Med J 2006; 102: 18–19.

Unilateral iliopsoas hematoma in elderly patients with suddenback pain and severe anemia: Report of two casesggi_753 355..367

Dear Editor,

Iliopsoas hematoma is rare and its diagnosis is difficult espe-cially in elderly patients, as many of them have back or legpain normally. We report two cases of unilateral iliopsoashematoma in elderly patients with anemia who complained ofback pain and progression.

Case 1

A 79-year-old man was admitted to our hospital for rehabili-tation after coronary bypass surgery. He was already taking40-mg isosorbide dinitrate, 100-mg aspirin, 80-mg valsartan,2.5-mg carvedilol, 20-mg furosemide, and 25-mg spirono-lactone, and we prescribed 1-mg warfarin/day to preventthrombus in the left ventricular aneurysm. His prothrombintime-international normalized ratio was 1.20. One week afterbeginning to stand again, the patient complained of backpain, and his hemoglobin level fell from 9.0 g/dL to 5.3 g/dL.Emergent computed tomography (CT) showed hematoma inthe left iliopsoas muscle (Fig. 1a). After the patient’s bloodpressure fell to 80/40 mmHg, dopamine infusion was com-menced, followed by blood transfusion. We ceased aspirinand warfarin, administered 10 mg menatetrenone intrave-nously, and started a continuous infusion of 100-mg carba-zochrome per day. After treatment, the patient’s conditiongradually improved.

Case 2

An 82-year-old woman was admitted to our hospital for thetreatment of congestive heart failure with tachycardic atrial

fibrillation. She was taking 2.5-mg warfarin /day for atrialfibrillation, and her prothrombin time-international normal-ized ratio was 2.11. Heart failure improved after the treat-ment with angiotensin receptor blocker, beta-blocker, anddiuretics. Immediately after moving to and sitting in a por-table toilet by herself, she developed sudden-onset rightthigh pain and a high fever of 38°C. Blood tests showed awhite blood cell count of 11 290/mm3 and C-reactive proteinof 15.35 mg/dL; her hemoglobin level fell from 8.6 g/dL to5.4 g/dL. Emergent CT demonstrated bilateral a iliopsoasabscess and left iliopsoas hematoma (Fig. 1b). We ceasedwarfarin, started blood transfusion, and administered 10-mgmenatetrenone intravenously, 100-mg carbazochrome/day asa continuous infusion, and 0.5-g meropenem trihydrate (anantibiotic) b.i.d. MRI clarified that L3 and L4 spondylitis anddiscitis were the cause of the iliopsoas abscess, and surgicaldrainage was performed. We did not detect a pathologic bac-terium. The patient’s condition gradually improved followingthese treatments.

We diagnosed these severe cases of iliopsoas hematoma earlywith emergent CT and then successfully treated them. CT isrecommended for patients with back pain and severe anemiabecause iliopsoas hematoma can be fatal if hypovolemic shockdevelops.1,2 Spontaneous iliopsoas hematoma has beenreported mainly as a complication of heparin therapy,3 and a fewcases have been associated with antiplatelet therapy or war-farin.4,5 However, previous reports have demonstrated thatAPTT and/or prothrombin time-international normalized ratioare within the therapeutic range in the majority of cases ofiliopsoas hematoma.3,5 Based on their experience, Sasson et al.reported that elderly women in particular are at greater risk ofdeveloping this condition.3 When elderly patients present withsudden back pain and severe anemia, we should consider

Letters to the Editor

© 2012 Japan Geriatrics Society � 355doi: 10.1111/j.1447-0594.2011.00753.x

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iliopsoas hematoma, especially if the patient is receiving anti-coagulant and antiplatelet therapy or if the patient has aninfected organ near the iliopsoas muscle – even if the coagula-tion parameters are within the therapeutic range or below.

Hiroaki Kawano,1 Tooru Ikeda,2 Yasuhiro Kawahara3

and Hiroyuki Fujisawa3

1Department of Cardiovascular Medicine, Nagasaki University,Nagasaki, Department of 2Internal Medicine and

3Radiology, Nagasaki Rosai Hospital, Sasebo, Japan

References

1 Lenchiki L, Dovgan DJ, Kier R. CT of the iliopsoas compartment:value in differentiating tumor, abscess and hematoma. Am J Roent-genol 1994; 162: 83–86.

2 Türk EE, Verhoff MA, Tsokos M. Anticoagulant-related iliopsoasmuscle bleeding leading to fatal exsanguination: report of twoautopsy cases. Am J Forensic Med Pathol 2002; 23: 342–344.

3 Sasson Z, Mangat I, Peckham KA. Spontaneous iliopsoas hematomain patients with unstable coronary syndromes receiving intravenousheparin in therapeutic doses. Can J Cardiol 1996; 12: 490–494.

4 Nakao N, Sakagami K, Mitsuoka S, Uda M, Tanaka N. Retroperito-neal hematoma associated with femoral neuropathy: a complicationunder antiplatelet therapy. Acta Med Okayama 2001; 55: 363–366.

5 Wada Y, Yanagihara C, Nishimura Y. Bilateral Iliopsoas hematomascomplicating anticoagulant therapy. Intern Med 2005; 44: 641–643.

Stroke and an unexplained dyspnea in an elderly patient:Platypnea-orthodeoxia syndromeggi_758 356..368

Dear Editor,

We describe an uncommon association that resulted inplatypnea-orthodeoxia syndrome. A 75-year-old woman wasadmitted to our hospital (University Hospital UCL of Mont-Godinne) for persistent arterial oxygen desaturation after sheexperienced a pulmonary embolism and a sepsis caused by rightpneumonia associated with a cerebellum ischemic stroke. Inher medical history, we noted no risk factors for stroke, but shehad had a cryptogenic transient ischemic accident 2 yearsbefore. Blood pressure, full blood examination and coagulationtests, spirogram, venous Doppler ultrasonagraphy of her legs,

and extracranial Doppler ultrasonography were normal. Whilebreathing without assistance, the patient’s arterial oxygen satu-ration decreased from 96% when recumbent to 80% whenupright, with dyspnea and cyanosis. Electrocardiogram wasnormal. Chest X-ray showed marked aortic elongation andmild enlargement without cardiomegaly, signs of pulmonaryhypertension, or pulmonary disease. Transthoracic echocar-diography revealed normal left ventricular contraction, nosignificant valvular disease, cardiac chamber dilatation, or pul-monary hypertension, and ascendant aortic dilatation of 43 mm(Fig. 1a). Contrast transesophageal echocardiography showeda mild left-to-right shunt through the patent foramen oval

Figure 1 (a) In case 1, computed tomography (CT) scan showed an enlarged left iliopsoas muscle and areas of low attenuation (arrows) mixedwith some material of high attenuation (arrow head) consistent with hematoma. (b) In case 2, CT scan showed air-filled loculi (arrow heads) in thebilateral iliopsoas muscles, an enlarged left iliopsoas muscle with a fluid-fluid interface area of low attenuation mixed with some material of highattenuation (arrows). These findings indicate an abscess in the right iliopsoas muscle and hematoma with abscess in the left iliopsoas muscle.

M Floria et al.

356 � © 2012 Japan Geriatrics Societydoi: 10.1111/j.1447-0594.2011.00758.x

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while the patient was supine, but when she became upright, asevere right-to-left shunt was observed and her arterial oxygensaturation decreased from 96% to 80%, with dyspnea. Transe-sophageal echocardiography showed a patent foramen ovalwith an atrial septal aneurysm, and slight left-to-right shuntingto the defect was visible (Fig. 1b). Eustachian valve was notobserved. The patient’s transient ischemic attack recurredduring hospitalization (in the cerebellum area). Cardiac cath-eterization revealed normal arterial pulmonary pressure,cardiac output, and coronary artery. Chest CT excluded pul-monary embolism, abnormal pulmonary veins return, andintrapulmonary shunting or lung diseases. Because thepatient’s dyspnea and hypoxemia occurred only while she wasupright, we repeated the contrast transthoracic echocardiogramin both the supine and upright positions (Fig. 1c). Based on theechocardiogram, we diagnosed her as having platypnea–orthodeoxia syndrome. Because percutaneous closure of patentforamen oval failed because of increased atrial septum mobility,

a surgical treatment using the left mini-thoracotomy approachwas proposed and then performed successfully

“Platypnea” refers to dyspnea induced by upright posturethat is relieved by recumbency. “Orthodeoxia” is hypoxemiainduced by orthostatic conditions. The syndrome can becaused by right-to-left cardiac or pulmonary shunting,though in each case the mechanism differs.1–3 In intracardiacshunting through a patent foramen oval, postural hypoxemiaappears to be a consequence of redirecting flow in the infe-rior vena cava towards the interatrial septum; the redirectedflow distorts the anatomical relations such as that betweenas the aortic root and the ascending aortic dilatation or thelong Eustachian valve).4 Two factors must coexist to causeplatypnea–orthodeoxia syndrome related to intracardiacright-to-left shunting: an anatomical factor, represented inour patient by patient foramen oval associated with interatrialseptum aneurysm, and a functional factor that worsens right-to-left shunting in orthostatism.5 Aging increases functional

ca

b

Ao

LA

LA

RA

Figure 1 (a) Ascending aortic dilation (Ao) may have reduced the distance between the aorta and the atrial posterior wall, probably reducinginteratrial septum tautness. Combined with atrial septal aneurysm, this may have allowed the flap valve of the fossa ovalis to move more freely,keeping the foramen oval wide open. (b) Transesophageal echocardiography showed a patent foramen oval (arrow) with an atrial septal aneurysmand slight left-to-right shunting (in color Doppler) through to the defect. (c) Contrast transthoracic echocardiogram showing micro-bubblesflowing from the right atrium through the foramen; this is more evident in the sitting position than in the decubitus position. LA, left atrium;RA, right atrium.

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© 2012 Japan Geriatrics Society � 357

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factors promoting orthostatic right-to-left shunting and para-doxical embolism. Diagnosis of patent foramen oval withplatypnea–orthodeoxia syndrome should be done using thetilt test, arterial saturation measurements in different posi-tions such as clino and orthostatism, and contrast echo-cardiography. Platypnea–orthodeoxia syndrome should beconsidered as a possible diagnosis in older patients withstroke complaining of unexplained dyspnea and hypoxemia.

Disclosure statement

The authors did not receive any financial support and have norelationships that may pose a conflict of interest.

Mariana Floria,1,2 Laurence Gabriel,1 Erwin Schroeder,1

Patrick Chenu,1 Valentin Ambarus2 andBaudouin Marchandise1

1Cardiology Unit, University Hospital UCL of Mont-Godinne,Catholic University of Louvain, Yvoir, Belgium, and

2II Medical Clinic, Sf. Spiridon University Hospital, University ofMedicine and Pharmacy Gr. T. Popa, Iasi, Romania

References

1 Burchell HB, Helmolz HF Jr, Wood EH. Reflex orthostatic dyspneaassociated with pulmonary hypotension. Am J Physiol 1949; 159:563–564.

2 Angelini M, Lambru G, Montepietra S et al. Unexplained dyspnea inan old patient with recurrent stroke: platypnea-orthodeoxia syn-drome and evidence of patent foramen ovale. Neurol Sci 2010; 31:93–94.

3 Cheng TO. Transcatheter closure of patent foramen ovale: a defini-tive treatment for platypnea-orthodeoxia. Catheter Cardiovasc Interv2000; 51: 120.

4 Bertaux G, Eicher J-C, Petit A, Dobsa’k P, Wolf J-E. Anatomicinteraction between the aortic root and the atrial septum: a pro-spective echocardiographic study. J Am Soc Echocardiogr 2007; 20:409–414.

5 Cheng TO. Mechanisms of platypnea-orthodeoxia: what causeswater to flow uphill? Circulation 2009; 105: 47.

Pink urine in an elderly womanggi_760 358..370

Dear Editor,

Urine color may change for many reasons, and some urinediscolorations have clinical significance. For example, purpleurine may be related to intestinal intussusception or a urinarytract infection.1 A green color can occur when a patient hastaken methylene blue, amitriptyline, indomethacin, or doxo-rubicin.2 Pink urine has been reported in morbidly obesepatients following gastric bypass procedures or during propo-fol anesthesia, though this has rarely occurred.3–5 Here, wereport the first case of uric acid crystalluria-associated pinkurine in a non-obese patient.

A 67-year-old woman was admitted to the intensive careunit for the management of spontaneous peritoneal peritoni-tis, upper gastrointestinal tract bleeding, and hepatic encepha-lopathy. Her BMI was 27, which might indicate mild obesity inthe case of an East Asian individual. The patient had a medicalhistory of liver cirrhosis and diabetes mellitus but no goutor urolithiasis. Her medications included pantoprazole,tazobactam/piperacillin, furosemide, insulin, and hydrocorti-sone. Two days after admission, pink urine was noted stainingthe patient’s draining tube and collecting bag (Fig. 1a). Labo-ratory examinations revealed hemoglobin 10.1 g/dL, white cellcount 14 700/mm3, blood urea nitrogen 41 mg/dL, creatinine1.2 mg/dL, phosphorus 2.2 mg/dL, sodium 150.8 mmol/dL,potassium of 3.27 mmol/dL, and uric acid of 3.6 mg/dL. Pinksediment was seen when the urine was kept in a clear tube andstood for 2 hours (Fig. 1b). Urinalysis showed a pH value of5.5, but no protein, occult blood, bilirubin, urobilinogen,pyuria or hematuria were noted. Amorphous uric acid crystalswere seen under microscopic examination.

Changes in urine color may have the clinical significance.Pink or red urine is an unusual occurrence that can be causedby hematuria, hemoglobinuria, propofol,1 certain laxatives,antipsychotics such as chlorpromazine and thioridazine,chronic lead or mercury poisoning, phenolphthalein, bee-turia,6 or alkaptonuria.7 In addition, pink urine related to uricacid crystal related has rarely been reported in morbidly obesepatients following gastric bypass procedures.4,5 A thoroughreview of the patient’s medical history, medications, and urineanalysis is helpful for physicians in making a differential diag-nosis. A positive dipstick for blood suggests the presence of redcells, free hemoglobin (from broken down red blood cells), ormyoglobin (from broken down muscle cells).

Pure uric acid dihydrate crystals are colorless but canbecome pink when they absorb urinary pigments. Pink urinehas been reported to be associated with increased urine osmo-larity and decreased urine pH.4 The mechanism of pink urineremains unclear. It has been postulated that stress-relatedsecretions of antidiuretics hormones increase the renal clear-ance of uric acid and cause uric acid crystalluria, which turnsurine pink.5 Although pink urine is rare in elderly patients andthe etiologies are protean, our case reminds us that uric acidcan cause pink urine and a simple urinalysis is helpful for thediagnosis.

Disclosure statement

No authors report any conflict of interest.

Che-Kim Tan1 and Chih-Cheng Lai2

1Department of Intensive Care Medicine, Chi Mei Medical Center,Yong Kang and 2Department of Intensive Care Medicine, Chi Mei

Medical Center, Liouying, Tainan, TaiwanAuthorship: Both author had access the data and a role in

writing the manuscript.

C-K Tan and C-C Lai

358 � © 2012 Japan Geriatrics Societydoi: 10.1111/j.1447-0594.2011.00760.x

Page 8: Pink urine in an elderly woman

References

1 Tan CK, Wu YP, Wu HY, Lai CC. Purple urine bag syndrome.CMAJ 2008; 179: 491.

2 Tan CK, Lai CC, Cheng KC. Propofol-related green urine. Kidney Int2008; 74: 97.

3 Masuda A, Hirota K, Satone T, Ito Y. Pink urine during propofolanesthesia. Anesth Analg 1996; 83: 666–667.

4 Deitel M, Thompson DA, Saldanha CF, Ramshaw PJ, Patterson MC,Pritzker KP. “Pink urine” in morbidly obese patients followinggastric partitioning. Can Med Assoc J 1984; 130: 1007–1011.

5 Saran R, Abdullah S, Goel S, Nolph KD, Terry BE. An unusualcause of pink urine. Nephrol Dial Transplant 1998; 13: 1579–1580.

6 Watts AR, Lennard MS, Mason SL, Tucker GT, Woods HF. Bee-turia and the biological fate of beetroot pigments. Pharmacogenetics1993; 3: 302–311.

7 Sutherland DA, Nicol AD, Williams AJ. Pink napkins–presentingfeature in a case of alkaptonuria. J Inherit Metab Dis 1984; 7: 56.

Dysphagia in older adults at high risk of requiring careggi_762 359..371

Dear Editor,

The risk for disordered oropharyngeal swallowing (dysphagia)increases with age. Loss of swallowing function not onlydeprives older adults of the joy of eating, but it can havedevastating health implications, including pneumonia by aspi-ration, which can reduce quality of life. Age-related changes,including sensory changes, new medications and sarcopenia,increase risk for dysphagia.1

A repetitive saliva swallowing test (RSST) was developed asa safe evaluation method for swallowing function, within anestablished normal range.2,3

In Japan, the public long-term care insurance system pro-vides services to older adults who have been certified as requir-ing support (levels 1–2) or care (levels 1–5). Uncertified butnot quite healthy older adults who are considered at highrisk for needing support/care (termed as “specified elderly”) areprovided with preventive care services by the municipalitiesin which they reside. The specified elderly is community-dwelling and has neither basic activities of daily living impair-ments nor dementia.4 Local governments provide an annualhealth check for the uncertified elderly in which all examinedsubjects complete a basic yes-no questionnaire consisting ofsimple assessments of instrumental activities of daily living(seven items), memory problems (three items), walking status(five items), dysphagia (three items), nutritional status (twoitems) and depressive mood (five items). In the current report,we compared the questionnaire answers of the group with

normal swallowing function and the one with declined swal-lowing function, as defined by RSST, in order to characterizedysphagia among the specified elderly for a possible interven-tional approach to the symptom. Data for 1163 men and 2651women considered specified elderly were obtained frommunicipality-sponsored annual health checks in central Japanduring October and November 2009. Subjects with completedata, including RSST results, were included in the analysis.Continuous variables were compared using Student’s t-testand others by c2 analysis.

As shown in Table 1, declined swallowing function byRSST was observed in 10.9% of the subjects. These subjectswere older, less active, cognitively more impaired and moredepressed. A multiple logistic analysis using statistically sig-nificant factors from the univariate analysis was performed(Table 2). Because of strong co-linearities with depressivemood, three items were thrown into the statistical modelseparately, only to find no difference in results regardless ofthe model.

Itoh et al. reported that 22% of dependent elderly alreadyreceiving care at nursing homes had dysphagia assessed byRSST.5 The subjects in the current survey were those at risk ofrequiring care but not yet receiving it, which may explain theprevalence rate from the previous report. The causal relation-ship between dysphagia and depressive mood can be bidirec-tional. Declined swallowing function can spoil quality of life.6

However, emotional factors are believed to cause disturbancesin eating behavior.7 Also cerebrovascular lesions may underlie

Figure 1 (a) Pink urine was noted stainingthe draining tube and collecting bag.(b) Pink sediment following centrifugation.

A B

Letters to the Editor

© 2012 Japan Geriatrics Society � 359doi: 10.1111/j.1447-0594.2011.00762.x

Page 9: Pink urine in an elderly woman

Table 1 Subjects with normal swallowing function and declined function

Normalswallowingfunction

Declinedswallowingfunction

P-value

Number 3436 378Age, (years) 74.9 1 6.1 77.1 1 6.4 <0.01Gender (men/women) 1053/2383 110/268 0.56Systolic blood pressure (mmHg) 134.0 1 17.8 134.7 1 18.2 0.45Dyastolic blood pressure (mmHg) 74.4 1 10.9 73.7 1 11.1 0.22Hemoglobin (g/dL) 12.8 1 1.4 12.7 1 13.8 0.06Albumin (g/dL) 4.3 1 2.9 4.2 1 2.5 0.28Do you go out alone using transportation? (% yes) 85.4 82.0 <0.08Do you shop for daily necessities by yourself? (% yes) 89.6 84.7 <0.01Do you manage your bank account on your own? (% yes) 84.9 83.5 0.12Do you visit your friends alone? (% yes) 84.7 81.5 0.12Are you consulted by your family or friends? (% yes) 81.4 78.5 0.02Do you climb the stairs without holding on to handrails or walls? (% yes) 39.0 35.7 0.22Do you stand up without assistance? (% yes) 62.0 52.9 0.01Can you walk for more than 15 minutes without rest? (% yes) 79.0 74.6 0.06Have you fallen within the past year? 38.4 38.1 0.96Are you anxious about falls? (% yes) 67.0 68.3 0.65Have you lost more than 2–3 kg in weight in the past 6 months? (% yes) 28.2 25.9 0.37BMI <18.5 kg/m2 (% yes) 15.2 15.9 0.76Do you have difficulty in eating hard food? (% yes) 54.3 56.1 0.51Do you choke when you swallow liquid? (% yes) 43.7 49.7 0.03Do you have problems with dry mouth? (% yes) 59.0 63.2 0.12Do you go out more than once a week? (% yes) 89.3 88.4 0.60Do you go out less frequently than last year? (% yes) 40.7 50.8 <0.01Are you told that you repeatedly ask the same questions? (% yes) 30.0 34.1 0.10Do you look up telephone numbers, dial and make phone calls without help? (% yes) 87.7 89.2 0.46Do you sometimes forget the date? (% yes) 32.6 37.8 0.04Have you felt unfulfilled with daily life (in the last two weeks)? (% yes) 21.5 27.0 0.02I have not enjoyed my life as much as I used to (in the last 2 weeks). (% yes) 42.1 49.2 <0.01I feel more bothered doing everyday things than I did before (in the last 2 weeks).

(% yes)38.8 49.1 <0.01

I have not felt that I am useful (in the last 2 weeks). (% yes) 27.3 28.3 0.72I have felt tired for no reason (in the last 2 weeks). (recent 2 weeks) (% yes) 56.1 51.6 0.10

Per RSST, subjects who can swallow saliva more than three times within 30 seconds were considered to have normal swallowing function.

Table 2 Results of multiple logistic analysis

B P-value Odds ratio 95%CI

Sex 0.051 0.680 1.052 0.827–1.339Age** 0.047 0.000 1.048 1.029–1.066Shop for daily necessities 0.181 0.279 1.198 0.864–1.663Consulted by your family or friends -0.034 0.810 0.967 0.734–1.273Climb the stairs without holding* 0.236 0.042 1.266 1.008–1.590Choke on liquid* 0.294 0.009 1.342 1.078–1.672Go out less frequently* 0.245 0.037 1.278 1.014–1.611Forget the date 0.080 0.500 1.084 0.858–1.368Unfulfilled with daily life -0.109 0.404 0.897 0.694–1.158

**P < 0.01; *P < 0.05

H Umegaki et al.

360 � © 2012 Japan Geriatrics Society

Page 10: Pink urine in an elderly woman

the observed association between depressive mood and dyspa-gia,8 although past histories, including ischemic stroke, werenot taken, which limits the interpretation of the findings.

Acknowledgement

This work was supported by Research Fundingfor Longevity Science (21A-10) from the Center for Geriatricsand Gerontology (NCGG), Obu, Aichi, Japan.

Disclosure statement

We have no conflicts of interest to declare.

Hiroyuki Umegaki,1 Yusuke Suzuki,1 Madoka Yanagawa,1

Zen Nonogaki,1 Hirotaka Nakashima1 and Hidetoshi Endo2

1Department of Community Healthcare and Geriatrics, NagoyaUniversity Graduate School of Medicine, Nagoya and 2Departmentof Comprehensive Geriatric Medicine, National Center for Geriatrics

and Gerontology, Obu, Aichi, Japan

References

1 Ney DM, Weiss JM, Kind AJ, Robbins J. Senescent swallowing:impact, strategies, and interventions. Nutr Clin Pract 2009; 24: 395–413.

2 Tamura F, Mizukami M, Ayano R, Mukai Y. Analysis of feedingfunction and jaw stability in bedridden elderly. Dysphagia 2002; 17:235–241.

3 Oguchi K, Saitoh E, Mizuno M, Baba M, Okui M, Suzuki M. Therepetitive saliva swallowing test of functional dysphagia (1) normalvalue of RSST. Jpn J Rehabil Med 2000; 37: 375–382.

4 Tsutsui T, Muramatsu N. Japan’s universal long-term care systemreform of 2005: costs and realizing a vision. J Am Geriatr Soc 2007; 55:1458–1463.

5 Itoh H, Kikutani T, Tamura F, Hamura A. The occlusal condition,feeding and nutritional status of the dependent elderly at home. JpnJ Gerodontology 2008; 23: 21–30.

6 Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Socialand psychological burden of dysphagia: its impact on diagnosis andtreatment. Dysphagia 2002; 17: 139–146.

7 Folks DG, Kinney FC. The role of psychological factors in gas-trointestinal conditions. A review pertinent to DSM-IV. Psychosomat-ics 1992; 33: 257–270.

8 Santos M, Kövari E, Hof PR, Gold G, Bouras C, Giannakopoulos P.The impact of vascular burden on late-life depression. Brain Res Rev2009; 62: 19–32.

Toe clearance rehabilitative slipper for fall risk ininstitutionalized older peopleggi_773 361..373

Dear Editor,

Prevention of falls is one of the important targets for care ofself-care dependent older people. The UK government isfacing up to the challenge through increased investment inresearch into factors associated with maintaining muscle massand strength, the two main modulators of physical indepen-dence in healthy older age. Ribeiro et al.1 proposed that low-cost strength training of dorsi- and plantar flexors improvedstrength, balance and functional mobility in institutionalizedolder people. Chiba et al.2 suggested that among gait patterns,abnormally low toe clearance is one of the factors that con-tributes to tripping on small obstacles or surface roughness ofthe floor or ground. Mechanically, a shorter toe clearance canresult from functional disturbance of the anterior tibial muscleduring dorsiflexion.

Sato et al.3 developed a new rehabilitative training slipper,which has a space on the top of the slipper to insert a weightmade of lead beads (400 g). The slipper has a back strap toprevent it coming off during walking. The mechanism bywhich the slipper is simulative of the anterior tibials muscleis simple; adding a weight on the top of the foot induces atorque secondary to gravity and the distance of the weight’scenter of mass to the ankle joint. Proprioceptive control ofthe foot dorsiflexion during the swing phase of normal gaitthus required increased anterior tibial tone, being an isotonicexercise load on the muscle during that phase. Sato et al.3

observed an improved Timed Up & Go test after 3 months ofexercise in the intervention group using the rehabilitation

slipper. They suggested that the rehabilitation slipper mightbe a useful tool for older patients with gait disorders. In thepresent study using the rehabilitation slipper, risk of fall wasstudied during a 1-year prospective intervention.

Subjects were 61 self-care dependent in patients(54 women and 17 men, aged 80.4 1 9 years) selected ran-domly from the patient pool at eight nursing homes. Theethics committee of Akita University of Nursing and Welfareapproved this trial, and all subjects participated after writteninformed consent. Participants were randomly assigned intotwo groups. The intervention group comprised 28 patients.The other 33 patients were assigned to the control group andreceived usual care. Among the 28 patients in the interven-tion group, four patients refused to participate or stoppedsoon after intervention, three patients were discharged fromthe nursing home, and one patient suffered arthritis andstopped intervention. Finally, 20 patients participated in thefull intervention study. Among the 33 control patients, sevenpatients refused to participate in the control group, onepatient suffered lung cancer, one patient suffered pneumoniaand three patients suffered hip fractures after falls. Finally, 21patients completed a 1-year observation examination. Physi-cal characteristics of both groups are shown in Table 1. Carelevel is followed by Care Insurance established by the Japa-nese Ministry of Health and Welfare (from 1 to 5 grade, thehigher points show severer care level). The exercise protocolwas as follows. Two to four days each week for 1 year, sub-jects walked wearing the slippers for 10 min at a self-chosencomfortable walking speed. This was followed by 10 min of

Letters to the editor

© 2012 Japan Geriatrics Society � 361doi: 10.1111/j.1447-0594.2011.00773.x

Page 11: Pink urine in an elderly woman

rest, and a repeated period of walking with the slippers for10 min.

The risk of falls was measured by the Berg Balance Scale4

and Tinetti’s Performance-Oriented Mobility Index (POMAtest)5 before and after the 1-month period, 3-month period,6-month period, 9-month period and 12-month period (eitherintervention or control). Both tests have been reported to showthe risk of falls (Berg Balance Scale is a maximum of 56 points,the higher points show less risk of fall and POMA test is amaximum of 28 points, the higher points show less risk of fall).Both tests were examined by two nurses who were not told ofthe meaning of the study. Serial points of fall risk scores areshown in Table 2. Both the Berg Balance Scale and POMA testin the intervention group using the rehabilitation slipperimproved significantly (Wilcoxon signed rank test). Comparedwith control values, the differences of scores show significantimprovement (Wilcoxon signed rank test). The Barthel Index(used to assess activity of daily living, has a 100-point scale in5-point increments, with 0 representing the worst state) didnot change from baseline in the intervention group and sig-nificantly deceased in the control group (P < 0.05). Mini-Mental State Examination (MMSE) did not change during1 year. During 1 year of study, the control patients sufferedfalls; one patient after a 3-month period, three patients after a9-month period and one patient after a 12-month period.Three control patients suffered hip fracture after a 9-monthperiod. There were no patients who complained of falls in theintervention group. Many patients in the exercise group spon-taneously reported a feeling of lightness in their step andincreased their periods of walking after the exercise. One exer-cise patient complained of arthritis after the 9-month periodand dropped out of the study. A few subjects complained ofmild anterior tibial muscle tightness the day after exercise, butthis quickly disappeared.

The annual rate of falls in older people is reported to be10–30% in Japan. In the present study, we observed five of

the 41 patients falling, approximately 12%. Because falls area pivotal cause of bone fracture, establishing preventive mea-sures against falls is important to decrease the number ofbedridden older people. In the present study, three controlpatients suffered bone fracture and dropped out of the study.Both the Berg Balance Scale and POMA tests have beenreported to be good indicators of falls and could be taken asfall risks.4,5 We observed significant improvement of fall riskusing the rehabilitation slipper.

The mechanisms of improving fall risk are not known.First, improved anterior tibia function might contribute to animproved fall risk,3 thereby keeping toe clearance high andreducing the risk of falls from tripping. Second, the sense ofambulatory well being after exercise can itself be a motivationfor continued exercise and improved ambulation, which inturn can lead to an improvement in overall quality of life.Third, intimate contact of caregivers to persuade exercisemight bring special comfort to the participants. Many inter-vention methods have been reported, but problems aroseregarding patients not continuing to exercise.6–8 In thepresent study caregivers encouraged and persuaded thepatients not to drop out of the study. Fourth, the rehabili-tation slipper is very simple and small, easy to use and cheap.Therefore, both caregivers and participants could easily use itand could continue exercise. Actually, six patients stillwanted to continue exercise using the rehabilitation slipperafter 1 year. The present rehabilitation slipper would benefitolder patients who wanted to exercise without any expensive,large, space-occupying machines.

Atsuko Satoh,1 Hideaki Kudoh,2 Seiko Fujita,3 Sangun Lee,2

Takuma Sotoh,4 Masahiko Fujii5 and Hidetada Sasaki5

1Akita University of Nursing and Welfare, Akita, 2AomoriUniversity of Health and Welfare, Aomori,

3Hirosaki Kensei Hospital, Hirosaki, 4Miyama Hospital, Oshu, and5Sendai Tomizawa Hospital, Sendai, Japan

Table 1 Physical characteristics of patients

Variable Intervention (n = 20) Control (n = 21) PMean 1 SD or n (%) Mean 1 SD or n (%)

SexFemale/male 14/6 14/7

Age 78 1 9 81 1 10 NSHeight 151.3 1 8.1 147.0 1 8.7 NSWeight 49.3 1 9.8 48.2 1 9.5 NSBMI 20.2 1 5.6 22.4 1 2.8 NSCare level 2.9 1 0.9 2.5 1 0.8 NSBarthel Index 76.3 1 19.7 82.8 1 18.0 NSMMSE 18.7 1 10.4 17.8 1 6.9 NSMain diagnosis of patients (overlapped)

Dementia 13 11 NSParkinson’s disease 2 2 NSDiabetes mellitus 5 4 NSBrain stroke 2 2 NSCardiovascular disease 3 2 NS

Fall history (last 1 year) 3 4 NS

BMI, body mass index; MMSE, Mini-Mental State Examination, NS, not significant.

A Satoh et al.

362 � © 2012 Japan Geriatrics Society

Page 12: Pink urine in an elderly woman

References

1 Ribeiro F, Teixeira F, Brochado G, Oliveira J. Impact of low coststrength training of dorsi- and plantar flexors on balance and func-tional mobility in institutionalized elderly people. Geriatr Gerontol Int2009; 9: 75–80.

2 Chiba H, Ebihara S, Tomita N, Sasaki H, Butler JP. Differential gaitkinematics between fallers and non-fallers in community-dwellingelderly people. Geriatr Gerontol Int 2005; 5: 127–134.

3 Sato T, Ebihara S, Kudo H, Fujii M, Sasaki H, Butler JP. Toeclearance rehabilitative slipper for gait disorder in the elderly. GeriatrGerontol Int 2007; 7: 310–311.

4 Berg KO, Sharon L, Wood-Dauphinee SL, William JT, Maki B.Measuring balance in the elderly: validation of an Instrument. Can JPublic Health 1992; 83: S7–S11.

5 Tinetti ME. Performance-oriented assessment of mobility problemin elderly patients. J Am Geriatr Soc 1986; 34: 119–126.

6 Kikuchi R, Kozaki K, Iwata A, Hasegawa H, Toba K. Evaluation ofrisk of falls in patients at a memory impairment outpatient clinic.Geriatr Gerontol Int 2009; 9: 298–303.

7 Nagai K, Inoue T, Yamada Y et al. Effects of toe and ankle trainingin older people: a cross-over study. Geriatr Gerontol Int 2011; 11:246–255.

8 Katsumata Y, Arai A, Tomimori M, Ishida K, Lee RB, Tamashiro H.Fear of falling and falls self-efficacy and their relationship to higher-level competence among community-dwelling senior men andwomen in Japan. Geriatr Gerontol Int 2011; 11: 282–289.

Tab

le2

Fall

risk

scor

esof

patie

nts

Var

iabl

e1

mon

thbe

fore

the

inte

rven

tion

peri

od(b

ase

line)

3m

onth

saf

ter

the

inte

rven

tion

peri

od

6m

onth

saf

ter

the

inte

rven

tion

peri

od

9m

onth

saf

ter

the

inte

rven

tion

peri

od

12m

onth

saf

ter

the

inte

rven

tion

peri

od

Ber

gB

alan

ceSc

ale

Inte

rven

tion

grou

p(n

=20

)38

.61

14.0

39.71

13.5

40.61

11.8

42.51

11.1

43.81

10.1

**D

iffer

ence

from

base

line

0-0

.11

5.4

0.051

10.3

3.91

9.1

5.21

8.0*

*C

ontr

olgr

oup

(n=

21)

40.11

11.8

39.31

10.8

38.71

12.7

39.91

8.3

§38

.71

11.0

§§

Diff

eren

cefr

omba

selin

e0

-1.21

6.4

-1.01

8.3

-1.21

6.8

-1.61

5.2

POM

Ate

stIn

terv

entio

ngr

oup

(n=

20)

21.91

7.1

23.21

6.9

24.01

5.1*

24.51

5.2*

24.81

5.2*

*D

iffer

ence

from

base

line

00.

81

3.0

1.681

3.2

2.61

4.3*

2.91

3.9*

*C

ontr

olgr

oup

(n=

21)

22.21

5.3

21.81

6.4

22.21

6.8

21.61

5.1

§22

.01

5.7

§

Diff

eren

cefr

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selin

e0

-0.61

4.0

0.31

5.0

-0.81

4.6

-0.41

3.9

Bar

thel

Inde

xIn

terv

entio

ngr

oup

(n=

20)

76.31

19.7

73.71

20.0

73.71

21.5

Con

trol

grou

p(n

=21

)77

.31

18.3

72.91

20.0

72.61

17.5

*M

MSE

Inte

rven

tion

grou

p(n

=20

)18

.71

10.4

15.21

7.1

16.91

7.7

Con

trol

grou

p(n

=21

)18

.71

6.8

17.91

6.1

16.91

6.3

Sign

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ntdi

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scor

esfr

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own

at*P

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cant

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betw

een

scor

esof

the

inte

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pco

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with

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the

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roup

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esar

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own

at§ P

<0.

05an

d§§

P<

0.01

.

Letters to the editor

© 2012 Japan Geriatrics Society � 363

Page 13: Pink urine in an elderly woman

Prevalence of resuscitation orders among residents from agedcare facilities admitted to general medical unitsggi_774 364..376

Dear Editor,

In Australia and New Zealand, older patients occupy 50% ormore of bed days in our hospitals.1 At 30 June 2009, there werenearly 162 300 residents in mainstream residential aged careservices in Australia.2 Over half of all these residents (55%)were aged 85 years or over. Almost 82 000 residents (51%) hada recorded diagnosis of dementia. To provide optimal care forour aging and dementing population, advance care planning isessential including detailed orders regarding resuscitation.

Advance directives can facilitate end-of-life care, record aperson’s wishes in this regard and guide appointment of aproxy to make decisions when the person is unable to decide.However, little is known about the implementation of thisprocess within a residential care facility, nor is there assurancethat this information is communicated effectively when resi-dents are transferred to a hospital for acute care. The presentstudy was a cross-sectional survey to ascertain the prevalenceof early documentation of resuscitation orders in aged carefacility residents admitted to general medical units in fourteaching hospitals across South Australia and New Zealand(Flinders Medical Centre, Royal Adelaide Hospital, LyellMcEwin Hospital in Adelaide and Auckland City Hospital inNew Zealand).

We reviewed the records of 1647 acute general medicaladmissions in 2009. Of these, 255 were either from residentiallow- or high-level aged care facilities. A “not-for-resuscitation”(NFR) order was defined as a written order by a medical prac-titioner specifying that the resident was not to be resuscitated inthe event of cardiopulmonary arrest. A “full resuscitation” orderwas defined as a written order by a medical practitioner speci-fying that every effort be made to resuscitate the resident inthe event of cardiopulmonary arrest. In addition, residentcharacteristics, namely age and the diagnosis of dementia,were evaluated in association with the presence and natureof any resuscitation orders. Data are presented hereafteras means 1 SD, unless otherwise indicated. The study wasapproved by the Research Ethics Committees of the participat-ing hospitals.

The 255 residents included in the present studywere 80.4 1 14.4 years-of-age and 63.5% were female. Within24 h of admission, NFR orders were documented in 115 (45%)of the residents and 40 (16%) were documented for full resus-citation. The remaining 100 (39%) residents did not have aresuscitation order, suggesting that end-of-life care issues hadnot been discussed with the residents or their proxy, or thatsuch discussion had not been communicated to the admittinginpatient medical team. Of these 255 residents, 59% came

from low-level care facilities. A diagnosis of dementia wasrecorded in 114 patients; 39% of patients from low-level carehad dementia and 55% of those from high-level care haddementia. Of those without resuscitation orders, 30% haddementia; 32.5% of those for full resuscitation had dementiaand 61% of those NFR had dementia.

It is encouraging to observe that 61% of residents trans-ferred from an aged care facility to a hospital for medical carehad resuscitation orders documented. One interventionalstudy designed to address the end-of-life needs of nursinghome residents observed improved end-of-life outcomes,including a reduction in terminal hospitalizations, an increasein palliative care referrals and improvement of advance direc-tive completion.3 The increasing complexity of medicine, thefinite financial resources for medical care to maintain life, theapparent interest of the elderly to participate in end-of-life caredecision-making and the high prevalence of cognitive impair-ment among aged care facility residents all argue for moreactive exploration of the process of advanced care planningincluding determining resuscitation status in institutionalcare.

Disclosure statement

The authors declare no conflict of interest.

Jordan YZ Li,1,3 Tuck Y Yong,1,3 Diana McNeill,7

David Spriggs,7 Muhmmad Fazal,4 Paul Hakendorf,2,3

David I Ben-Tovim2,3 and Campbell H Thompson5,6

1Department of General Medicine, 2Clinical Epidemiology Unit,Flinders Medical Centre, 3School of Medicine, Flinders University,

4Division of Medicine, Lyell McEwin Hospital, 5Department ofGeneral Medicine, Royal Adelaide Hospital, and 6Discipline of

Medicine, University of Adelaide, Adelaide, South Australia,Australia, and 7Department of General Medicine, Auckland District

Health Board, Auckland, New Zealand

References

1 Gray LC, Yeo MA, Duckett SJ. Trends in the use of hospital beds byolder people in Australia: 1993–2002. Med J Aust 2004; 181: 478–481.

2 Australian Institute of Health and Welfare (AIHW). Residential AgedCare in Australia 2008–09. Aged care statistics series no. 31. Cat. no.AGE 62. AIHW: Canberra, 2010.

3 Levy C, Morris M, Kramer A. Improving end-of-life outcomes innursing homes by targeting residents at high-risk of mortality forpalliative care: program description and evaluation. J Palliat Med2008; 11: 217–225.

JYZ Li et al.

364 � © 2012 Japan Geriatrics Societydoi: 10.1111/j.1447-0594.2011.00774.x