An osteoporotic fracture mimicking cervical dystonia in idiopathic Parkinson's disease.

We report on a case of a 65-year-old (CD) woman who sustained an atraumatic neck fracture. A combination of Parkinson's disease with motor fluctuations, chronic cervical dystonia and osteoporosis provided the basis for this interesting diagnosis. Mrs CD had progressed to complex phase idiopathic Parkinson's disease within 13 years of diagnosis. During this time she remained independent, only using a wheelchair when her motor fluctuations were bad. In 2011, she developed a sudden onset of neck spasm and occipital neuralgia, initially attributed to severe spasmodic cervical dystonia. Despite a titration regime of analgesics and weaning off of her Parkinson's disease medications, the pain persisted. An X-ray of her cervical spine showed degenerative discopathies from C4 to C7. Mrs CD underwent a trial of Botox injections to no avail and she was admitted acutely under the spinal team after an MRI of her spine showed abnormal oedema of the odontoid peg. Subsequent CT diagnosed a type II fracture of the odontoid peg on the background of severe osteoporotic bone (spinal T score -3.4 on subsequent DEXA scan) and she underwent a successful occipital cervical fusion of C1-C6. What makes this case interesting is the fact that this lady's profound powerful neck movements on a background of osteoporosis led to fracture of her neck. Post-operatively, she admitted to non-adherence to her bisphosphonates, prioritising levodopa in the morning with food rather than taking her alendronate on an empty stomach. She is now pain free and receives annual zolendronate infusions.

Six month outcomes after emergency admission of elderly patients to a community or a district general hospital.

BACKGROUND: Emergency admissions account for 40% of National Health Service bed usage. Recent policy is to increase the role of intermediate care, which includes the use of community hospitals (CHs). However, the proposed expansion presumes that CH care is as effective as acute hospital care. No direct comparison of outcomes between CHs and district general hospitals (DGHs) has been undertaken. OBJECTIVES: The aim of this study was to compare patient-based outcomes at 6 months following emergency admission to a DGH or CH. METHODS: We designed a prospective cohort study, with strict eligibility criteria. The study was set in one DGH and five CHs in Devon, UK. Study participants were people aged >70 years with an acute illness requiring hospital admission, but whose condition could have been treated in either hospital setting. A cohort of people admitted to each setting was identified and followed-up for 6 months. The primary outcome measure was change in quality of life 6 months after admission, as measured by SF-36 and EuroQol. Secondary outcome measures were death, readmission and place of residence at 6 months. The use of drugs and investigations during the hospital stay were also measured. RESULTS: A total of 376 patients were recruited and completed baseline measures, 254 of whom were followed-up at the 6-month stage (136 CH, 118 DGH). There were no differences in outcome between settings, with a small increase in quality of life scores at 6 months in both cohorts: the mean change in EuroQol 5D in CH was 6.6 points (95% confidence interval, 2.8-10.4) and in DGH was 6.5 (2.4-10.7); P = 0.97. Mortality and place of residence at 6 months were similar in the two groups. The numbers of investigations (median CH four investigations, DGH 22; P < 0.001) and of prescribed medications during the hospital stay (median CH eight drugs, DGH 11; P < 0.001) were significantly higher in the DGH. CONCLUSIONS: The quality of life and mortality in the CH cohort was similar to those in the DGH cohort. CH care can be used as an alternative to DGH care for a wide range of conditions requiring emergency admission.