A controversy: linking atypical femoral fractures to bisphosphonate therapy.

Several cases have been reported of unusual spontaneous fractures with minimal trauma in the subtrochanteric and diaphyseal areas of the femur linked to long-term bisphosphonate use. After encountering three such patients, we conducted a review of published cases. The average age of these individuals were 68 years and approximately 25% had received concomitant glucocorticoids. Histomorphometric bone biopsy studies performed in some individuals have suggested that severe suppression of bone turnover may be the underlying cause; however, cause and effect has not been firmly established. Moreover, population studies have found this type of fracture rare and not increased in patients who have received bisphosphonate treatment. Physicians should continue to use bisphosphonate agents as a primary treatment for osteoporosis.

Causes of death in elderly nursing home residents.

OBJECTIVES: According to previous studies, 20% to 24% of deaths in the United States occur in nursing homes. This number is increasing. Overall vital statistics document that the leading causes of death in the United States remain cardiovascular/cerebrovascular and cancer, with Alzheimer's disease seventh as of 2004. However there are few statistics on causes of death specifically in the nursing home population. The objective of this study was to determine the most common causes of death in one nursing home in our practice, and specifically to see how common it was to die of dementia in the nursing home. DESIGN, SETTING, AND PARTICIPANTS: To improve on these inadequate data, we conducted a retrospective chart review study of all patients who died in a Philadelphia nursing home during a 6-month period from May to October 2006. The 2 authors manually extracted select data from individual charts including site, date and cause of death, patient age and comorbidities, and whether the patient was on hospice or had an advance directive. There was no intervention related to the study. MEASUREMENTS/RESULTS: Thirty-nine patients expired in the nursing facility during the 6-month study time period. The primary cause of death was determined to be Alzheimer's/dementia in 14 cases (36%), cardiac/cerebrovascular (30%), 9 pulmonary (23%), 3 hematologic and other malignancies (7%), and 1 ESRD. There were 66% patients on hospice and 89% had advance directives usually including a DNR/DNH order. None received resuscitation in the nursing home, and none had autopsies. CONCLUSION: The single most common cause of death occurring within the nursing home was Alzheimer's, with most dying appropriately on hospice care. This is markedly different from the general population, where the most common causes of death are cardiac, pulmonary, renal, malignancies, infections, and accidents. However the true cause of death in the nursing home resident is often difficult to specify when patients often have little workup before they die and seldom have autopsies.

Methimazole-induced cholestatic jaundice in an elderly hyperthyroid patient.

BACKGROUND: Hyperthyroidism is a common disease in the elderly. Antithyroid medications such as methimazole are one of the few treatment options. CASE SUMMARY: A 76-year-old white woman presented to the clinic with a 1-week history of fatigue, sleepiness, 7-pound weight loss, and tachycardia. Her blood work showed low levels of thyroid-stimulating hormone and high levels of free thyroxine. Due to persistence of her symptoms, she was hospitalized and started on methimazole 10 mg TID. Six weeks after receiving methimazole for the treatment of hyperthyroidism, she had severe jaundice and itching. Results of her liver function tests showed elevation of her alkaline phosphatase and liver transaminase levels, as well as hyperbilirubinemia, formed mainly of the conjugated fraction. Methimazole-induced cholestatic jaundice was diagnosed. Her symptoms gradually improved after discontinuation of the medication, and plasma bilirubin levels were near normal after 8 weeks without methimazole. CONCLUSIONS: We report here a probable association between methimazole use and severe cholestatic jaundice in an elderly hyperthyroid patient. The patient's jaundice was reversed after drug discontinuation.