Volume 141, No. 0708

Alain Kaelin-Lang, Markus Gnädinger, Hans-Ulrich Mellinghoff (Author)

Parkinson’s disease and the bones

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PRINCIPLES: Bone and joint problems in Parkinson’s disease (PD) are manifold: decreased mobility, abnormal posture, as well as the risk of falling may cause both acute and chronic damage to the musculoskeletal system. In patients with Parkinson’s disease, postural instability and falls are frequently observed. The aim of the study was to review the literature with respect to the bone health and risk of fractures in these patients.

METHODS: We conducted a review on bone health in patients with Parkinson’s disease.

RESULTS: There is evidence that patients with PD have an increased risk of fractures, especially of the hip, due to the elevated risk of falling. While rigidity, bradykinesia and postural instability (but not tremor) predict falls, fractures also correlate with bone mineral density, which is generally lowered in this group of patients as compared to age- and sex-matched controls. Typically PD patients have “high turnover osteoporosis” due to several causes.

CONCLUSIONS: Any newly diagnosed patient with PD should be evaluated for the risk of falling and osteoporosis and routinely be supplemented with vitamin D. In the case of osteoporosis, blood samples for detecting underlying and treatable conditions should be taken and bisphosphonates administered to the patient.

It is unclear whether drugs typically used for PD provoke or worsen osteoporosis. Nevertheless, every long-term medication should undergo safety studies to demonstrate lack of negative interference with bone metabolism. Drug admission authorities should demand these data when registering new substances or when renewing old admissions.

K Paul, D Candinas, VM Banz, Moya de (Author)

Ignoring non-specific abdominal pain in emergency department patients may be related to decreased quality of life

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QUESTIONS UNDER STUDY: Patients suffering from chronic pain have a high prevalence of depression, resulting in a significant impact on overall quality of life. Our aim was to investigate how long term acute non-specific abdominal pain (NSAP) affected overall physical and mental well-being in patients admitted to our emergency department (ED).

METHODS: All patients discharged from the ED with NSAP between 06/2007 and 06/2008 were included for follow up. Current health and well-being was evaluated using the SF-36^® health questionnaire. Ordinal linear regression models were chosen to separately assess variables influencing SF-36^® outcome, with adjustment for age and gender. Results were expressed as differences of means with corresponding 95% confidence intervals and p-values.

RESULTS: Of the 200 patients included (57% female, mean age 33 years), 53 (26.5%) still suffered from NSAP after a 12.5-month mean follow up. Patients with persistent NSAP suffered more from chronic pain (26.4%) or known psychiatric illnesses (15.1%) than unaffected patients (p <0.001 and p = 0.028). Mental (MCS) and physical component scores (PCS) were significantly worse in patients suffering from persistent NSAP, even when adjusted for confounding factors including chronic pain syndromes, pre-existing psychiatric illnesses, other concomitant comorbidities and previous abdominal surgery (p <0.001 for both scores). Other risk factors included chronic pain syndromes, pre-existing psychiatric illnesses, other concomitant comorbidities and previous abdominal surgery.

CONCLUSIONS: NSAP persistence may be associated with a decreased quality of life. Emphasis should be put on providing early counselling and support, with the aim of minimising the long term detrimental side effects of NSAP.

HK Keo, M Umer, T Willenberg, SB Gretener (Author)

Long-term clinical outcomes in patients diagnosed with severe digital ischemia

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QUESTION UNDER STUDY: To investigate the aetiology and long-term clinical outcomes of patients diagnosed with digital ischemia.

METHOD: Data of 36 consecutive patients presenting with digital ischemia were collected in July 2000 to June 2001 from a vascular referral centre. Demographic data, aetiology, medication and treatment were abstracted from the medical records. Clinical outcomes were assessed at 5 year follow-up including ulcer healing, digital amputation and mortality.

RESULTS: Of the 36 patients, 69.4% were male and the mean age was 55 ± 14 years. In 15 patients (41.7%) a systemic disease was present and of those 53.3% was due to connective tissue disease. Twelve patients (33.3%) had hypothenar hammer syndrome and in 8 patients (22.2%) no apparent cause was found. Whereas 13 patients (36.1%) presented with rest pain or trophic lesions at baseline, no patients presented with these symptoms at follow-up. At follow-up, 18 (62.1%) patients had symptoms on provocation and 5 patients (4 patients with systemic disease and 1 with no apparent cause) had died. Digital amputation was performed in one patient at initial presentation and no digital amputation was performed at follow-up. No ulcer reoccurred and no workers’ insurance compensation was applied. Of those with hypothenar hammer syndrome, 80.0% had symptoms on provocation at follow-up.

CONCLUSIONS: Among patients with digital ischemia, systemic disease and hypothenar hammer syndrome were the most frequent aetiologies. In patients with hypothenar hammer syndrome the clinical outcome was remarkably benign, although symptoms may persist with provocation, whereas patients with systemic disease have a high mortality rate.

CF Hagmann, B Brotschi, V Bernet, B Latal, TM Berger, NJ Robertson (Author)

Hypothermia for perinatal asphyxial encephalopathy

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BACKGROUND: Perinatal asphyxial encephalopathy occurs in 1– per 1000 live births and is associated with high mortality and morbidity. Therapeutic hypothermia increases intact survival and improves neurodevelopmental outcome in survivors.

AIMS: To evaluate (i) the opinion and practice of therapeutic hypothermia as a therapy for moderate to severe perinatal asphyxial encephalopathy amongst Swiss neonatologists and paediatric intensive care specialists, (ii) the current clinical management of infants with perinatal asphyxial encephalopathy and (iii) the need for a national perinatal asphyxia and therapeutic hypothermia registry.

METHODS: Two web-based questionnaires were sent to 18 senior staff physicians within the Swiss Neonatal Network.

RESULTS: Therapeutic hypothermia was considered effective by all responders, however only 11 of 18 units provided therapeutic hypothermia. Cooling was initiated during transfer and performed passively in 82% of centres with a target rectal temperature of 33–34 °C. Most units ventilated infants with perinatal asphyxial encephalopathy if clinically indicated and 73% of responders gave analgesia routinely to cooled infants. Neuromonitoring included continuous amplitude integrated EEG (aEEG) and EEG. Neuroimaging included cranial ultrasound (cUS), magnetic resonance imaging (MRI) and computed tomography (CT). Sixty-seven percent of units treating infants with perinatal asphyxial encephalopathy performed MRI routinely. All heads of departments questioned indicated that a “Swiss National Asphyxia and Cooling Registry” is needed.

CONCLUSIONS: In Switzerland, access to therapeutic hypothermia is widespread and Swiss neonatologists believe that therapeutic hypothermia for perinatal asphyxia is effective. National cooling protocols are needed for the management of infants with perinatal asphyxial encephalopathy in order to ensure safe cooling, appropriate monitoring, imaging and follow-up assessment. A national registry is needed to collect data on diagnosis, treatment, adverse events and outcome.

I Guessous (Author)

Health care renunciation for economic reasons in Switzerland

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BACKGROUND: Most societies elaborate ways to contain increasing health care expenditures. In Switzerland out of pocket payments and cuts in the catalogue of reimbursed services are used as cost-containment measures. The aims of the study were to estimate the extent of health care renunciation for economic reasons and to identify associated factors.

METHODS:A population-based cross-sectional survey (2008–2009) of a representative sample in the Canton of Geneva, Switzerland. Health care underuse, income level categories (<CHF 3000/month, 3000–4999, 5000–6999, 7000–9499, 9500–13 000, >13 000), education, occupation, insurance status and cardiovascular comorbidities were collected using self-rated questionnaires.

RESULTS:765 men and 814 women aged 35–74 years participated. 14.5% (229/1579) (95%CI 12.7-16.2) renounced health care for economic reasons. Among those who renounced (N = 229), 74% renounced dental care, 37% physician consultation (22% specialist, 15% general practitioner), 26% health devices, 13% medication, and 5% surgery. Income was negatively correlated with renouncement (r = –0.18, p <.0001). Each decrease in income level category provided a 48% increased risk of renouncing health care for economic reasons (OR 1.48, 1.31–1.65). This association remained when dental care was excluded from the definition of health care renunciation.

CONCLUSIONS:In a region of Switzerland with a high cost of living, such as Geneva, socioeconomic status may influence the use of the health care system, and renunciation for economic reasons was not uncommon. More than 30% of the lowest income group renounced health care for economical reasons in the previous year. Health care underuse and renunciation may worsen the health status of a substantial part of society.