BackgroundEvaluating geriatric patients with fever is time-consuming and challenging. We investigated independent mortality predictors of geriatric patients with fever and developed a prediction rule for emergency care, critical care, and geriatric care physicians to classify patients into mortality risk and disposition groups.Materials and MethodsConsecutive geriatric patients (≥65 years old) visiting the emergency department (ED) of a university-affiliated medical center between June 1 and July 21, 2010, were enrolled when they met the criteria of fever: a tympanic temperature ≥37.2°C or a baseline temperature elevated ≥1.3°C. Thirty-day mortality was the primary endpoint. Internal validation with bootstrap re-sampling was done.ResultsThree hundred thirty geriatric patients were enrolled. We found three independent mortality predictors: Leukocytosis (WBC >12,000 cells/mm3), Severe coma (GCS ≤ 8), and Thrombocytopenia (platelets <150 103/mm3) (LST). After assigning weights to each predictor, we developed a Geriatric Fever Score that stratifies patients into two mortality-risk and disposition groups: low (4.0%) (95% CI: 2.3–6.9%): a general ward or treatment in the ED then discharge and high (30.3%) (95% CI: 17.4–47.3%): consider the intensive care unit. The area under the curve for the rule was 0.73.ConclusionsWe found that the Geriatric Fever Score is a simple and rapid rule for predicting 30-day mortality and classifying mortality risk and disposition in geriatric patients with fever, although external validation should be performed to confirm its usefulness in other clinical settings. It might help preserve medical resources for patients in greater need.

The 30-day mortality increased with the number of independent mortality predictors. With at least four predictors, 100% of the patients died within 30 days. With none of the predictors, just 1.8% died. These findings might help physicians make decisions about geriatric patients with fever.

From 1986 to 1992 there was a significant change in the definition of hypoglycaemia both among paediatricians and in neonatal textbooks compared with the definition in use during 1965-88. The findings suggest that neonatal paediatricians do change in their practice. The changes in the definition of hypoglycaemia may be due to the data available and discussion on hypoglycaemia since 1988. Neonatal paediatricians still attach significance to clinical signs associated with hypoglycaemia.

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To the Editor:Osteoporosis is associated with fragility fractures. An increased homocysteine level has been found to be, not only a strong and independent risk factor for osteoporotic fractures, but also a player in bone metabolism. 1-3 Moreover, it has been demonstrated that a Hcy-lowering therapy reduces the hip fracture rate. 4 Osteoporosis and osteopenia are common findings in patients with primary biliary cirrhosis (PBC) and recent reports have evidenced high levels of homocysteinemia associated to low levels of folate in such population. 5 We examined the association between plasma homocysteine levels and bone mineral density in 20 postmenopausal women with osteoporosis or osteopenia affected by PBC.Data were collected retrospectively from a database of 91 patients affected by PBC who referred to our Gastroenterology Unit. Only 20 patients had all the parameters needed for the analysis. Bone mineral density, measured by dual-energy x-ray absorptiometry, at the lumbar spine and neck of femur were examined. Subjects were classified as osteopenic if t-score at hip or lumbar spine was between À 1 and À 2 and osteoporotic if it was lower than À 2. Fasting and after methionine loading plasma homocysteine levels, plasma folate and vitamin B 12 were also recorded.Mean age and body mass index of patients were respectively 64 years (range: 50 to 75) and 24.7 Kg/m 2 (range: 18.5 to 30.4). Our PBC population was composed by: 7 patients in stage I, 5 in stage II, 6 in stage III, and 2 in stage IV. Fifty percent of patients resulted osteoporotic whereas the others were osteopenic. Mean homocysteine (fasting and after methionine oral load), folate and vitamin B 12 plasma levels were 11.4 and 30.6 mg/L, 5.9 ng/mL and 435 pg/mL, respectively. Fasting and after methionine loading plasma homocysteine levels were significantly and negatively associated with bone mineral densities at neck of femur (r = 0.61, P = 0.01) (r = 0.56, P = 0.034). This relationship was found also considering bone mineral densities of lumbar spine, but statistical significance was present for fasting plasma homocysteine levels (r = 0.50, P = 0.036) but not for plasma homocysteine levels after methionine loading (r = 0.46, P = 0.078). No significant correlation was found between folate and vitamin B 12 and bone mineral densities at both neck of femur and lumbar spine.Results from this study suggest hyperhomocysteinemia is associated with low bone mineral density and may represent a risk factor for osteoporosis also in patients with PBC. Further studies are needed to confirm these findings and to clarify if a correction of homocysteine levels may decrease the progression of bone loss.