Effectiveness of a primary care based multifactorial intervention to improve frailty parameters in the elderly: a randomised clinical trial: rationale and study design

Background

Frailty is a highly prevalent condition in old age leading to vulnerability and greater risk of adverse health outcomes and disability. Detecting and tackling frailty at an early stage can prevent disability. The purpose of this study is to evaluate the effectiveness of a multifactorial intervention program to modify frailty parameters, muscle strength, and physical and cognitive performance in people aged 65 years or more. It also assesses changes from baseline in falls, hospitalizations, nutritional risk, disability, institutionalization, and home-care.

Methods/design

The current study is a randomised single-blind, parallel-group clinical trial, with a one and a half year follow-up, conducted in eight Primary Health Care Centres located in the city of Barcelona. Inclusion criteria are to be aged 65 years or older with positive frailty screening, timed get-up-and-go test between 10 to 30 seconds, and Cognition Mini-Exam (MEC-35) of Lobo greater than or equal to 18. A total of 352 patients have been equally divided into two groups: intervention and control. Sample size calculated to detect a 0.5 unit difference in the Short Physical Performance Battery (Common SD: 1.42, 20% lost to follow-up). In the intervention group three different actions on frailty dimensions: rehabilitative therapy plus intake of hyperproteic nutritional shakes, memory workshop, and medication review are applied to sets of 16 patients. Participants in both intervention and control groups receive recommendations on nutrition, healthy lifestyles, and home risks.

Evaluations are blinded and conducted at 0, 3, and 18 months. Intention to treat analyses will be performed. Multivariate analysis will be carried out to assess time changes of dependent variables.

Discussion

It is expected that this study will provide evidence of the effectiveness of a multidisciplinary intervention on delaying the progression from frailty to disability in the elderly. It will help improve the individual’s quality of life and also reduce the rates of falls, hospital admissions, and institutionalizations, thus making the health care system more efficient. This preventive intervention can be adapted to diverse settings and be routinely included in Primary Care Centres as a Preventive Health Programme.

Trial registration

ClinicalTrials.gov PRS:NCT01969526. Date of registration: 10/21/2013.

Reasons for participating in the Valencian Community Colorectal Cancer Screening Programme by gender, age, and social class

OBJECTIVE

To know the reasons to participate or not in a colorectal cancer (CCR) screening programme and to analyze the differences by sex, age and social class.

METHODS

Cross-sectional study by a telephone survey directed to a sample of men and women aged between 50-74 year old,participants (n = 383) and non participants (n = 383) in the CCR screening programme of Valencian Community. Descriptive analysis and logistic regression models estimating the Odds Ratio (p < 0.05).

RESULTS

The main reasons to participate are "it is important for health" (97.9 %) and "the test is easy" (97.6 %); and to nonparticipate are "no CCR symptoms" (49.7 %) and "didn't receive invitation letter" (48.3 %). Women are more likely not to participate if the reason was to consider the "test unpleasant" (OR: 1.82; IC: 1.00-3.28), and men if the reason was "lack of time" (OR 0.51;IC: 0.27-0.97); persons 60 or more years old if the reason was "diagnostic fear" (OR: 2.31; IC: 1.11-4.80), and persons 50-59 years old if was "lack of time" (OR 0.44; IC: 0.23-0.85); non manual social class persons if the reason was "lack of time" (OR: 2.66; IC: 1.40-5.10); manual women if the reason was "embarrassment to perform the test" (OR: 0.37; IC: 0.14-0.97); and non manual men if was "lack of time" (OR: 4.78; IC: 1.96-11.66).

CONCLUSIONS

There are inequalities in the reasons for not participating in CCR screening programmes by sex, age and social class. It would be advisable to design actions that incorporate specific social group needs in order to reduce inequalities in participation.

Efficiency of a solid-phase chemiluminescence immunoassay for detection of antinuclear and cytoplasmic autoantibodies compared with gold standard immunoprecipitation

Purpose

The aim of this study was to compare the degree of agreement of a novel Zenit RA chemiluminescent immunoassay (CLIA) from A. Menarini Diagnostics (Florence, Italy) and the gold standard immunoprecipitation assay to screen for the presence of specific anti-U1snRNP, anti-Sm, anti-Ro/SS-A, anti-La/SS-B, anti-Jo-1(^histRNA-Synthetase) and anti-Scl-70(Topo I) antibodies.

Materials and methods

We studied 114 sera, 98 from patients with well-defined autoimmune connective tissue diseases and 16 from blood donor volunteers. All samples were fully characterized using the new chemiluminescent immunoassay and immunoprecipitation. In addition, all the samples were analyzed by indirect immunofluorescence (IIF) and anti-Scl-70(Topo I) antibodies were analyzed by immunoblot (IB) assay. Discrepant samples were analyzed using a commercial dot blot technique (Recomline from Mikrogen). The simple Kappa coefficient was used to measure the level of agreement between the results of Zenit RA CLIA and the gold standard.

Results

The Kappa agreement between Zenit RA CLIA and gold standard immunoprecipitation, as well as IB and IIFassays for the presence of anti-Scl-70(Topo I)(0.948) was excellent. The concordance between Zenit RA CLIA and gold standard immunoprecipitation for the presence of anti-U1snRNP (0.883), anti-Ro/SS-A (0.878), anti-Jo-1(^histRNA-Synthetase) (0.791) and anti-Sm (0.786) was good, and excellent when the cut-off was raised to 14 U/ml (arbitrary units/ml). Between Zenit RA CLIA and gold standard immunoprecipitation for the presence of anti-La/SS-B, the Kappa agreement had a value of 0.689, but this improved to 0.775 when the cut-off was raised to14 U/ml. Precision was good based on the evaluation of replicate samples. Inter-assay coefficient variation was lower than 3.4 % (CV in %) in all the kits and <1.2 % (CV in  %) for intra-assay measurements.

Conclusion

Our findings show that Zenit RA CLIA was specific and sensitive to detect anti-U1snRNP, anti-Sm, anti-Ro/SS-A, anti-La/SS-B, anti-Jo-1(^histRNA-Synthetase) and anti-Scl70(Topo I) autoantibodies. This simple, fast and precise method can be a suitable option to analyze these autoantibody specificities.

Bioresponsive nanohydrogels based on HEAA and NIPA for poorly soluble drugs delivery

Environmentally sensitive hydrogels have gained considerable attention in recent years as one of the most promising drug delivery systems. In the present study, two new formulations of pH and temperature stimuli-responsive nanogels (NGs) based on poly-N-isopropylacrylamide (NIPA), N-hydroxyethyl acrylamide (HEAA) and tert-butyl 2-acrylamidoethyl carbamate (2AAECM) were synthesized and evaluated for passive targeting of paclitaxel (PTX). Nanogels were prepared by microemulsion polymerization method using N-methylenebis(acrylamide) (NMBA) as crosslinking agent. TEM images and DLS results showed nanosized spherical hydrogels. FTIR spectra confirmed the synthesis of nanogels by radical polymerization among vinyl groups of monomers. The PTX loading capacity, encapsulation efficiency and in vitro release were analyzed by HPLC. The cumulative release profile of the PTX-loaded nanohydrogels within 144h showed a faster drug release at acid pH (pH 5), similar to those observed at lysosome compartment, whereas a fewer PTX amount was released from NGs at pH similar to plasma levels. Cellular uptake assays revealed rapid penetration and intracellular accumulation of those nanogels in MCF7, HeLa and T47D cells after 48h incubation. MTT assays showed cell viability dependence on concentration and time incubation. Finally, the PTX effect on cell viability showed a G2/M cell arrest after using PTX-loaded NGs and pure PTX.

pH and glutathion-responsive hydrogel for localized delivery of paclitaxel

pH and glutathion (GSH)- responsive nanogels (NGs) based on poly-N-isopropylacrilamide (NIPA), N-hydroxyethyl acrylamide (HEAA) and tert-butyl 2-acrylamidoethyl carbamate (2AAECM) were synthesized by a microemulsion polymerization method using N, N'-cystaminebisacrylamide (CBA) as a crosslinking agent and evaluated for passive targeting of paclitaxel (PTX). Physicochemical characterizations of unloaded and PTX-loaded NGs, such as particle size, morphology, encapsulation efficiency and in vitro PTX release were also assessed. Electron microscopy techniques (SEM and TEM) as well as dynamic light scattering (DLS) analysis showed nanosized spherical hydrogels. FTIR spectra confirmed the synthesis of nanogels by free radical polymerization among vinyl groups of monomers. In vitro release was analyzed by high-performance liquid chromatography (HPLC) and differences between two NG formulations were obtained. Nanogels released almost 64% of PTX after 50h at GSH concentrations equivalent to that in the cellular cytosol, whereas less PTX was released from NGs at pH and GSH levels similar to plasma. Cellular uptake and cytotoxicity were also demonstrated by using coumarin-6 and MTT assays, respectively, for three tumor cell lines (MCF7, HeLa and T47D). Cellular uptake assays revealed rapid uptake within 2h and intracellular accumulation of coumarin-6-loaded nanogels after 48 h incubation. MTT assays showed changes in cell viability at different concentrations of PTX formulations, as well as pure PTX (10 μM, 20 μM and 30 μM). To investigate PTX effect on cell viability, changes in cell cycle were examined by flow cytometry and a G2/M cell arrest was demonstrated. Overall, synthesized nanogels may be used as potential carriers for hydrophobic anticancer drugs.

Cytocompatibility of a matrix of methylated cassava starch and chitosan

Starches can be used to form edible or biodegradable films, and recently modified starches have been used to form self-supporting films by casting from aqueous solution. In this work, we aimed to propose a novel starch-based composite biomaterial matrix for use in biomedical applications, especially tissue engineering. The goal of the study was to evaluate the cytocompatibility of composite hydrogels of methylated starch and chitosan, using glutaraldehyde as the cross-linker. Commercial cassava starch with high purity (96.69%) was methylated with dimethyl sulfate in order to obtain a rigid material that could possibly render stronger mechanical properties to chitosan hydrogels. Therefore, methylated starch was mixed with a solution of chitosan and the cross-linking was induced by the addition of glutaraldehyde, allowing the formation of hydrogel films which were visualized under scanning electron microscopy. The method of fabrication was optimized based on the capacity of the cells to attach to the material and proliferate. After thorough washes with ethanol and saline solution, human fibroblasts were seeded on top of the gels and allowed to grow for 3 to 5 days. Cell viability was measured using an (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) MMT assay, and cell morphology was visualized by light microscopy. It was found that cells were viable at every time point, with their metabolic activity comparable to the controls (tissue culture plastic and chitosan alone), as well as clear cell–matrix interactions. Moreover, an increase in the metabolic activity over time indicated the capacity of the material to support cell proliferation. The proposed methylated starch–chitosan system is an excellent matrix that allows cell adhesion and could thereby be further assessed as a scaffold for tissue engineering.

[Health personnel assessment about medical order entry systems of pharmacologic treatments in hospitalized patients]

OBJECTIVE

to evaluate health personnel perceptions about medical order entry systems concerning the effect on workflow, medication errors risk and assessment of its potential advantages.

MATERIAL AND METHODS

A cross-section opinion interview was conducted in a tertiary care hospital. Questionnaire consisted of three sections: perception of its effect on workflow, influence on medication error risk and assessment of potential advantages. We also asked them to assess drawbacks and provide suggestions about this prescription system.

RESULTS

76 health professionals were interviewed (58 physicians, 9 pharmacists and 9 nurses). They were satisfied mainly due to decrease the workload (85.5%; IC 95%: 75.58-92.55). They thought that the main characteristics that contribute to reduce medication errors are clinical decision supports related to predefined aspects which the program provided by default. Among potential benefits of medical order entry systems, legibility and warnings triggered by the program (98.7%; IC 95%: 92.90-99.97 and 97,4%; IC 95%: 90.81-99.68 respectively) were the most valuable. High technology dependence, IT failures and lack of infrastructure and medication therapy discontinuities at times of transition between different hospitals' units were the main drawbacks considered. The most repeated suggestion was related to the improvement of links between other health informatics applications used in the hospital.

CONCLUSION

health personnel were highly satisfied with the CPOE system, which is considered to be effective and safe. Technology dependence and IT failures were the main disadvantages reported. According to them, a greater coordination and unification of all software applications available in the hospital would be desirable.

[Measuring patient satisfaction and identifying opportunities for improvement in the preparation of bariatric surgery patients]

OBJECTIVE

To evaluate the satisfaction of patients candidates for bariatric surgery with the performance of a group training program prior to surgery, identifying opportunities for improvement in the program and evaluating participants satisfaction following their implementation.

METHOD

An "ad hoc" designed survey was used, addressed to assess opinions on different aspects of the program, overall satisfaction and identification of areas for improvement. The survey was administered to two groups of patients: the first after one year of implementation of the program to identify suggestions for improvement, and the second after one year of the implementation of the improvement. A total of 112 patients were assessed, 66 in the first pass of the questionnaire and 46 in the second. Both groups were homogeneous in demographic variables

RESULTS

The main improvement detected was expert patients in the preparation of the program. After implantation, slight changes in the ratings of the questions were produced, that were not significant. Overall satisfaction rose from 9.5 to 9.74 out of 10. The other proposals for improvement were to improve audiovisuals and to fit the room furniture to the characteristics of the patients.

CONCLUSIONS

The very high satisfaction levels obtained are usual in studies on hospital satisfaction, our results still being above the studies consulted, as well as in levels of excellence. This prevents statistically significant differences being found. There were no significant differences in the results before and after implementation of improvement. Continuous assessment allows new possibilities for improvement.

Relationship between bacterial load, morbidity and cagA gene in patients infected by Helicobacter pylori

One hundred and seventy-six biopsies of the gastric corpus and antrum from 97 patients were processed using classical and molecular methods in order to study the relationship between the factor cagA of Helicobacter pylori, bacterial load and morbidity. Bacterial load in patients with cagA was greater than in patients without it, both in the antrum and corpus (p<0.01). There was a statistically significant association between cagA and consumption of proton pump inhibitors (adjusted odds ratio 3.11). Haemorrhage of the upper digestive tract was more associated with bacterial load than with the cagA gene (adjusted odds ratio 2.34 and 1.12, respectively), but none of these associations yielded statistical significance.

Early estimates of the effectiveness of the 2011/12 influenza vaccine in the population targeted for vaccination in Spain, 25 December 2011 to 19 February 2012

We present early estimates of influenza vaccine effectiveness (VE) in the population targeted for vaccination, during 25 December 2011 to 19 February 2012. The adjusted VE was 55% (95% CI: 3 to 79) against any type of influenza virus and 54% (95% CI: 1 to 79) against influenza A(H3N2) virus. This suggests a moderate protective effect of the vaccine in the targeted population in a late influenza epidemic with limited match between vaccine and circulating strains.

Chemical composition and cooking properties of beef forequarter muscles of Mexican cattle from different genotypes

Beef forequarter muscles biceps brachii (BRB), brachialis (BRA), complexus (COM), splenius (SPL), infraspinatus (INF), teres major (TER), rhomboideus (RHO), subscapularis (SUB), supraspinatus (SUP), triceps brachii long-head (TRB) and triceps brachii lateral-head (TRI) were obtained from Mexican beef carcasses originated from Bos indicus (Bi, n=10) or Bos taurus (Bt, n=10) young bulls. Muscles were analyzed for WBSF, cooking loss, and moisture and fat contents. INF had the lowest WBSF (37.23N) and cooking loss (31.78%) of all. RHO exhibited the lowest moisture (72.62%) and highest fat content (5.23%) of all. Bi genotype exhibited higher WBSF (53.78, 48.69N), higher cook loss (36.27, 34.32%), higher fat content (2.93, 2.35%), and lower moisture content (73.70, 75.07%) than Bt. Further research is needed to estimate the actual consumer acceptance of beef forequarter muscles and their marketing potential as individual cuts in the Mexican market.

Tamoxifen-loaded nanoparticles based on a novel mixture of biodegradable polyesters: characterization and in vitro evaluation as sustained release systems

Nanoparticles (NP) from mixtures of two poly(D,L-lactide-co-caprolactone) (PLC) copolymers, PLC 40/60 and PLC 86/14, with poly(D,L-lactide) (PDLLA) and PCL were prepared: PLC 40/60-PCL (25:75), PLC 86/14-PCL (75:25) and PLC 86/14-PLA (75:25). Tamoxifen was loaded with encapsulation efficiency between 65% and 75% (29.9-36.3 µg TMX/ mg NP). All selected systems showed spherical shape and nano-scale size. TMX-loaded NPs were in the range of 293-352 nm. TMX release from NP took place with different profiles depending on polymeric composition of the particles. After 60 days, 59.81% and 82.65% of the loaded drug was released. The cytotoxicity of unloaded NP in MCF7 and HeLa cells was very low. Cell uptake of NP took place in both cell types by unspecific internalization in a time dependent process. The administration of 6 and 10 µm TMX by TMX-loaded NP was effective on both cellular types, mainly in MCF7 cells.

[Toxoplasmic retinochoroiditis: relapse vs choroidal neovascular membrane]

CLINICAL CASE

We report four patients with both decreased visual acuity and retinochoroidal lesions compatible with ocular toxoplasmosis in which a diagnosis of active toxoplasmic retinochoroiditis or choroidal neovascular membrane was made based on a specifically designed diagnostic screening.

DISCUSSION

In the context of a compatible clinical picture, with retinochoroidal scars and low grade or absence of inflammation, choroidal neovascular membranes may mimic active toxoplasmic retinochoroiditis and vice-versa. A thorough ophthalmic, serological, and immunological examination (in ocular fluids) may help in the differential diagnosis allowing for proper therapeutic decision-making.

Combined therapy versus usual care for the treatment of depression in oncologic patients: a randomized controlled trial

OBJECTIVE

To compare narrative therapy (NT) plus escitalopram versus escitalopram plus usual care on quality of life and depressive symptomatology of depressed patients with oncologic disease.

METHODS

A total of 72 subjects (mean age 54.6 years), predominantly female with non-metastatic breast, lung and colon cancer and depressive disorder (DSM-IV-TR) were randomized to receive treatment with NT plus escitalopram (n=39) or escitalopram (10-20 mg QD) plus usual care (n=33). Main endpoints were improvement in dimensions of quality of life measured by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C-30 and reduction of depressive symptoms using the Hospital Anxiety and Depression Scale at weeks 12 and 24.

RESULTS

The combined therapy group showed significantly greater improvement in all the functioning dimensions (p<0.01), pain scale (p=0.02), global health (p=0.02), and global quality of life (p=0.007) at weeks 12 and 24. There were no statistically significant differences in depressive symptomatology between the groups. From week 12 to week 24 study retention was higher in the combined treatment group (p=0.01).

CONCLUSIONS

Brief NT in combination with escitalopram was superior to usual care and escitalopram in improving functioning dimensions of quality life.

Milan criteria versus San Francisco criteria in hepatocellular carcinoma: our center's experience

BACKGROUND AND AIM

Liver transplantation (OLT) represents the best treatment for hepatocellular carcinoma (HCC) in advanced cirrhosis showing a 70% 5-year survival rate. Our study sought to compare overall survivals among patients who underwent OLT under Milan Criteria (MC) or San Francisco Criteria (UCSFC).

METHODS

We retrospectively analyzed patients who underwent liver transplantation for HCC in our institution from November 2001 to December 2007. We analyzed age, gender, OLT indication, maximal tumor size, histology, and survival. We compared survival among patients who met MC versus UCSFC.

RESULTS

From November 2001 to December 2007, 48/177 (27%) liver transplantations performed in our hospital were indicated due to HCC. The two patients who did not show any tumor in the explanted liver (false-positive ratio 4.2%) were excluded from the analysis. Another two patients were included who showed incidental HCC lesions (false-negative ratio 1.7%), yielding 48 analyzed patients. The mean diameter of the HCC nodules were 3.1 cm before OLT and 3.8 cm in the pathologic examination, a statistically significant difference. Two patients exceeded MC before OLT, and six patients showed this feature in the explanted liver. There was a significant difference in the degree of vascular invasion between the two groups. Overall mortality was 25.9% at 4 years; the MC group show an 11.9% versus UCSFC group, a 66.6% rate.

CONCLUSIONS

HCC is a common indication for OLT. Hepatitis C virus is the most common etiology. Survival among the MC group was significantly better than that of subjects beyond the MC, a difference that supports the use of MC for HCC.

Colloidal stability dependence on polymer adsorption through disjoining pressure isotherms

The disjoining pressure of polymers confined by colloidal walls was computed using dissipative particle dynamics simulations at constant chemical potential, volume, and temperature. The polymers are able to adsorb on the surfaces according to two models. In the so-called surface-modifying polymers, all monomers composing the chains have the same affinity for the substrate, whereas for the end-grafted polymer only the monomer at one of the ends of the polymer molecule adsorbs on the colloidal surface, resembling the behavior of dispersing agents. We find that these adsorption models yield markedly different disjoining pressure isotherms, which in turn predict different stability conditions for the colloidal dispersion. Our results show that for end-grafted polymers, a larger degree of polymerization at the same monomer concentration leads to better stability than for the surface-modifying ones. But also the unbound monomers of the surface-modifying type dominate over both kinds of polymers at large surface distances. The origin of these differences when the chemical nature of monomers is the same, and molecular weight and polymer concentration are used to characterize colloidal stability, is found to be mainly entropic.

IL1 gene cluster polymorphisms and its haplotypes may predict the risk to develop invasive pulmonary aspergillosis and modulate C-reactive protein level

OBJECTIVE

The aim of this study was to determine whether interleukin-1 alpha (IL1alpha), interleukin-1 beta (IL1beta), and IL1 receptor antagonist (IL1Ra) polymorphisms are implicated in invasive pulmonary aspergillosis (IPA) pathogenesis.

MATERIALS AND METHODS

Subjects comprised 110 hematological patients and 148 healthy controls. Genotypic and allelic frequencies were similar between hematological patients and controls. IPA was diagnosed in 59 of the 110 patients according to consensus criteria published by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group (EORTC/IFICG).

RESULTS AND DISCUSSIONS

Individual locus analysis showed that IL1alpha and IL1Ra polymorphisms were not associated with the presence of IPA (p = 0.560 and p = 0.680, respectively). However, a trend towards a higher presence of IL1beta( - ) (511TT) genotype (or IL1beta(-511T) allele) in the IPA group than in the non-IPA patient group (p = 0.092 and p = 0.095, respectively) was found. Haplotype analysis revealed that VNTR2/-889C/-511T haplotype was strongly associated with susceptibility to develop IPA infection (p = 0.020). Haplotype analysis also showed an association between VNTR2/-889C/-511C haplotype and resistance to IPA infection (p = 0.028). Furthermore, patients with IL1Ra VNTR2/2 and IL1beta(-511)T/T genotypes had a higher positive serum galactomannan percentage versus patients with other genotypes. Finally, C-reactive protein (CRP) production was significantly associated with IL1 gene cluster polymorphisms, although CRP values were similar between IPA and non-IPA groups.

CONCLUSION

These findings indicate a critical role of IL1 gene cluster polymorphisms in the susceptibility to IPA infection and CRP production.