The Frail'BESTest. An Adaptation of the "Balance Evaluation System Test" for Frail Older Adults. Description, Internal Consistency and Inter-Rater Reliability

Introduction

The Balance Evaluation System Test (BESTest) and the Mini-BESTest were developed to assess the complementary systems that contribute to balance function. These tests include functional tasks involving several high-level exercises to assess the balance function, which may be even more difficult in case of frailty. The Frail'BESTest has been developed to make it possible to include frail older adults in systemic assessment. In this first paper, the objective is to present the Frail'BESTest and to describe the usefulness and complementarity of each system and to test the inter-rater reliability of the score measurements in two health centers.

Methods

In the first center, 192 frail and non-frail older patients were enrolled to test I) the contribution of each system, II) internal consistency, and III) the threshold and ceiling effects. The scores of 32 patients from center 1 and 32 patients recruited in another center (center 2) were used to measure the inter-rater reliability of the measurements by means of Kendall's tau coefficients.

Results

The internal consistency was moderate to good for five systems and limited for "biomechanical constraints". The distribution of the Frail'BESTest was more centered than that of the Tinetti and Mini-Motor tests. The Kendall's tau showed strong concordance in center 1 for all systems and only for 4 on 6 systems in center 2.

Discussion

Completing a systemic evaluation, the therapist may prioritize the patient's needs identifying the most challenging systems. This paper presents the Frail'BESTest and confirms the psychometric properties at a first step level.

P4431Cardiopulmonary exerscise stress tests vs standard exercise stress tests in the rational prescription of physical activity in men

Background

The standard exercise stress test (ET) provides direct measurement of the load tolerated by the subject, but the cardiopulmonary exercise stress test (CPET) in addition to the measurement of the work load also provides direct measurement of the corresponding oxygen consumption.

Objective

The aim of the present study was to estimate the differences between the estimated oxygen consumption based on the load (ET) and the one directly measured with the CPET, and to highlight and quantify the inaccuracies of the indirect estimate of oxygen consumption and its consequences on the rational prescription of physical activity.

Material and method

The tests performed on 7544 males from January 2007 to October 2018 were analyzed. For each test the sustained load, the consumption of direct oxygen, and the estimated oxygen consumption based on the load sustained with the use of a formula provided by the American College of Sports Medicine and reported below:

VO2max (ml/kg/min) = (10.51 x Watt) + (6.35 x weight in kg) − (10.49 x Età) + 519.3.

The total population of the subjects examined was divided into two groups: Group A: 1358 subjects without signs of heart disease, and Group B: 6186 subjects with heart disease.

Results

In the total population the oxygen consumption (VO2) estimated on the basis of the load was overestimated in 22% of subjects, underestimated in 55% of subjects and overlapping in 23% of subjects. In Group B the calculated VO2 was overestimated in 38%, underestimated in 54% and overlapping in 8% of the subjects. In group A the calculated VO2 was overestimated in 33%, underestimated in 54% and overlapping in 9% of subjects.

Conclusions

In subjects with heart disease the VO2 calculated on the basis of the sustained load is overestimated or underestimated in 92% of subjects. The CPET through direct measurement of oxygen consumption provides a precise estimate of functional capacity, an essential prerequisite for a correct rational prescription of physical activity. Because of this peculiarity, the CPET is absolutely irreplaceable in cardiac patients in which a correct rational prescription of physical activity is crucial.

Quantitative ultrasound and DXA measurements in aromatase inhibitor-treated breast cancer women receiving denosumab

PURPOSE

Denosumab has been proven to reduce fracture risk in breast cancer (BC) women under aromatase inhibitors (AIs). Quantitative ultrasound (QUS) provides information on the structure and elastic properties of bone. Our aim was to assess bone health by phalangeal QUS and by dual-energy X-ray absorptiometry (DXA), and to evaluate bone turnover in AIs-treated BC women receiving denosumab.

METHODS

35 Postmenopausal BC women on AIs were recruited (mean age 61.2 ± 4.5 years) and treated with denosumab 60 mg administered subcutaneously every 6 months. Phalangeal QUS parameters [Amplitude Dependent Speed of Sound (AD-SoS), Ultrasound Bone Profile Index (UBPI), Bone Transmission Time (BTT)] and DXA at lumbar spine and femoral neck were performed. Serum C-telopeptide of type 1 collagen (CTX) and bone-specific alkaline phosphatase (BSAP) were also measured. The main outcomes were compared with a control group not receiving denosumab (n = 39).

RESULTS

In patients treated with denosumab, differently from controls, QUS and DXA measurements improved after 24 months, and a reduction of CTX and BSAP was detected at 12 and 24 months in comparison to baseline (P < 0.05). The percent changes (Δ) of QUS measurements were significantly associated with ΔBMD at femoral neck, and ΔCTX and ΔBSAP were associated with ΔBMD at lumbar spine (r = -0.39, P = 0.02; r = -0.49, P = 0.01, respectively).

CONCLUSIONS

Denosumab preserves bone health as assessed by phalangeal QUS and DXA. Since inexpensive and radiation-free, phalangeal QUS may be considered in the follow-up of AIs-treated BC women receiving denosumab.

Alexithymia in Kidney Transplantation Patients

Alexithymia is a marked difficulty in recognizing, exploring, and expressing inner feelings. Studies have proven the presence of a significant proportion of patients with alexithymia in samples from the transplantation population. This study aims to analyze the presence of alexithymia in a sample of 32 kidney transplantation patients from a deceased donor and to compare this construct with the presence of psychological symptoms and the physical and mental state of health perceived by the patients. Alexithymia assessment was analyzed using the Toronto Alexithymia Scale. The psychological symptoms were studied through the Symptom Checklist-90-R. The quality of life was studied through The Complete Form Health Survey. The study showed a high percentage of the presence of alexithymia in the examined transplant recipients. The construct is more present where the perception of their quality of life is low and where there is a greater presence of psychosomatic symptoms.

Aortic surgery and laparoscopy: still a future in the endovascular surgery era?

Laparoscopic surgery (LS) is the minimally invasive alternative to open surgery and endovascular approach for treating major aortic diseases. Only few reports in the literature describe the long-term outcomes of the laparoscopic approach for major vascular diseases. Furthermore, the widespread use of endovascular techniques has limited the use of LS to wellselected patients. This review evaluated the results of LS for aortic disease and compared the clinical outcomes of laparoscopic technique with those of open and endovascular surgery. A systematic review was performed by using the MEDLINE database, along with a meta-analysis of the reported studies on the treatment of abdominal aortic aneurysm (AAA) and/or aorto-iliac occlusive disease (AIOD). Forty-three studies were analyzed (17 for AAA and 26 for AIOD), with a total of 1197 patients with AAA and 1307 patients with AIOD. Laparoscopic surgery, when performed in experienced centers, is a feasible and safe technique for the treatment of AAA and AIOD in patients unfit for open and endovascular repair. Assisted laparoscopic approach has shown better outcomes than totally laparoscopic repair, with a lower rate of mortality and morbidity. Endovascular repair, however, remains the gold standard in the treatment of AAA.

KEY WORDS

Abdominal aortic aneurysm, Aorta, Aneurysm, Aorto-iliac occlusive disease, Endovascular aneurysm repair, EVAR, Laparoscopy, Endovascular, Repair, Laparoscopic Assisted, Laparoscopy Vascular, Laparoscopic surgery, Totally.

Psychological perspective of medication adherence in transplantation

AIM

To identify the risk factors and the post-transplant psychological symptoms that affect adherence to therapy in a population of kidney transplant recipients.

METHODS

The study examined the psychological variables likely responsible for the non-adherent behavior using a psychological-psychiatric assessment, evaluation of the perception of patients’ health status, and an interview regarding the anti-rejection drug therapy assumption. The study included 74 kidney transplant recipients.

RESULTS

Individuals with a higher level of education and more years since transplantation showed better mental balance. Regarding gender, women appeared to be less adherent to therapy. Further, the years since transplantation adversely affected the proper pharmacological assumption. Adherence to therapy did not significantly change with the mental health index.

CONCLUSION

The biopsychosocial illness model provides a conceptual frame of reference in which biological, psychological, and social aspects take on the same importance in the adherence to treatment protocols. For effective management, it is necessary to understand the patients’ personal experiences, their assumptions about the disease, health status perception, and mood, and to identify any “barriers” that could cause them to become noncompliant.

Aortic surgery and laparoscopy: still a future in the endovascular surgery era?

Laparoscopic surgery (LS) is the minimally invasive alternative to open surgery and endovascular approach for treating major aortic diseases. Only few reports in the literature describe the long-term outcomes of the laparoscopic approach for major vascular diseases. Furthermore, the widespread use of endovascular techniques has limited the use of LS to wellselected patients. This review evaluated the results of LS for aortic disease and compared the clinical outcomes of laparoscopic technique with those of open and endovascular surgery. A systematic review was performed by using the MEDLINE database, along with a meta-analysis of the reported studies on the treatment of abdominal aortic aneurysm (AAA) and/or aorto-iliac occlusive disease (AIOD). Forty-three studies were analyzed (17 for AAA and 26 for AIOD), with a total of 1197 patients with AAA and 1307 patients with AIOD. Laparoscopic surgery, when performed in experienced centers, is a feasible and safe technique for the treatment of AAA and AIOD in patients unfit for open and endovascular repair. Assisted laparoscopic approach has shown better outcomes than totally laparoscopic repair, with a lower rate of mortality and morbidity. Endovascular repair, however, remains the gold standard in the treatment of AAA.

KEY WORDS

Abdominal aortic aneurysm, Aorta, Aneurysm, Aorto-iliac occlusive disease, Endovascular aneurysm repair, EVAR, Laparoscopy, Endovascular, Repair, Laparoscopic Assisted, Laparoscopy Vascular, Laparoscopic surgery, Totally.

Vitamin D and bone mineral density changes in postmenopausal women treated with strontium ranelate

OBJECTIVE

Vitamin D deficiency is widespread and often reported in subjects treated for osteoporosis. Optimal vitamin D repletion was previously shown to maximize the efficacy of anti-resorptive agents. To date, no information exists about the role of vitamin D in the response to strontium ranelate (SrR) treatment. The aim of our study was to investigate the BMD response to SrR in accordance with change of vitamin D status.

METHODS

A retrospective analysis of 108 women receiving SrR for postmenopausal osteoporosis was carried out. Women were treated with SrR (2 g/day), with cholecalciferol (25,000 IU biweekly) and calcium carbonate as appropriate. Lumbar spine and femoral neck BMD, bone formation markers (BGP, ALP), resorption marker (OH-PRO) and serum 25(OH)D were measured at baseline after 18-months. All participants were divided into two groups according to the median variation of 25(OH)D over the observation period.

RESULTS

SrR was associated with improvement of BMD at lumbar spine (p < 0.0001) and to a non significant variation at femoral neck (p = 0.2). Only subjects with Δ25(OH)D > 6.14 %, reported a significant BMD gain at femoral neck (p = 0.03). Change of BMD at femoral neck was positively associated with modification of ALP (r = 0.28, p = 0.01). This association was not maintained when considering only women with Δ25(OH)D < 6.14 % (r = 0.28, p = 0.09). At a multiple regression analysis, ALP change was the only predictor of femoral neck BMD modification (β 0.13; SE 0.05; p = 0.01).

CONCLUSION

Improvement of vitamin D status was associated with enhancement of BMD response to SrR in women with postmenopausal osteoporosis, in particular, at femoral neck.

Subclinical hypercortisol-assessment of bone fragility: experience of single osteoporosis center in Sicily

AIM

Hypercortisolism is known to cause osteoporosis. Some evidence suggests that osteoporotic fractures may be the presenting manifestations of otherwise-asymptomatic hypercortisolism. The aim of our research was to investigate the prevalence of subclinical hypercortisolism (SH) in postmenopausal women evaluated for bone fragility.

PATIENTS AND METHODS

One hundred consecutive postmenopausal women attending the Osteoporosis Centre in the Department of Internal Medicine of the University of Messina (Messina, Italy), for the first time, were screened and a total of 50 patients (age 58±5 years) were studied. Hypercortisolism was diagnosed by unsuppressed serum cortisol levels after 2 day low dose dexamethasone suppression test.

RESULTS

Among the 50 postmenopausal women studied, 3 had SH. This prevalence was 6%. The three patients with SH had a normal bone mineral density (BMD) at lumbar spine and were osteopenic at femoral neck, and presented one or more vertebral fractures at spinal radiography.

CONCLUSIONS

Physicians should always consider SH among the causes of bone fragility, especially in individuals with vertebral fractures and the presence of an only slightly reduced BMD.

[Laparoscopic treatment of abdominal wall hernias: prosthesis material comparison]

Hernia is due to abdominal wall weakening. This allows the contents of the abdomen to protrude from normal boundaries. Hernias are repaired by implanting a sterile surgical mesh to strengthen the weakened abdominal wall. Aim of this study is to compare the results obtained by bard Composix® L/P mesh or Dualmesh Plus Gore® implanting. The mesh has various beneficial characteristics. It is a reinforcing material for the abdominal wall, even when in the direct contact with the intestinal tract does not cause adhsion problems. The use of biocompatible materials is necessary in laparoscopic hernia repair. e-PTFE prosthesis and Dual Mesh® were the first to be used for laparoscopic treatment of the abdominal wall defects. These prosthesis are the result of many improvements, actually they are 1-mm thick and the two surfaces have different characteristics. Compound meshes are composed by e-PTFE and polypropylene with different percentage of the two materials and methods of interactions. The incidence of early complications were poor in relation to both types of implants, only seroma cases e-PTFE treated showed a prevalence of complication, in agreement with literature. About relapses in our experience we found that e-PTFE cases were predominantly. Dual Mesh® has better adaptability than Bard Composix®, which allows easier placement of the prosthesis as well as a better adaptation to the wall surface. The Bard Composix®, thanks to rigidity due to the polypropylene component has better handling than the Dual Mesh®, as it promotes a rapid and easy deployment of the prosthesis inside the abdominal cavity, favoring its positioning. The use of both prosthesis depends also on the experience specific to each operator, moreover, a rigorous surgical technique remains fundamental for the application of the mesh used.

Adrenal effects of teriparatide in the treatment of severe postmenopausal osteoporosis

The aim of our study was to investigate the effects of teriparatide on the hypophysis-adrenal axis in postmenopausal women. Treatment with teriparatide increased plasmatic and urinary levels of cortisol after 6 and 12 months. Our paper demonstrates a possible direct secretagogue effect of teriparatide on adrenals in osteoporotic postmenopausal women.

INTRODUCTION

Teriparatide, recombinant human parathyroid hormone (1-34) (rhPTH [1-34]), is approved for the treatment of osteoporosis in men and postmenopausal women at high risk for fracture. In literature, data regarding the secretagogue effect of PTH on adrenocortical cells are present on in vitro, but not on in vivo, studies. The aim of our study was to investigate the effects of teriparatide on the hypophysis-adrenal axis in postmenopausal women.

METHODS

Twenty postmenopausal women with severe osteoporosis were treated with teriparatide in a regimen of 20 μg daily, self-administered injections at bedtime for 12 months and a calcium and vitamin D supplementation. At the same time, 20 osteopenic women matched for age and body mass index with the patients were enrolled and treated only with calcium and vitamin D. In all subjects, calcium, adrenocorticotropic hormone (ACTH), and plasmatic and urinary cortisol were evaluated at baseline and after 6 and 12 months.

RESULTS

Treatment with teriparatide increased plasmatic and urinary levels of cortisol after 6 and 12 months, reaching statistical significance only after 1 year. Plasmatic levels of ACTH did not change significantly.

CONCLUSIONS

Our paper, for the first time, demonstrates a possible direct secretagogue effect of teriparatide on adrenals in osteoporotic postmenopausal women.

Is interleukin-22 a possible indicator of chronic heart failure's progression?

Chronic heart failure (CHF) is a complex and heterogeneous clinical syndrome and because of its rising incidence and prevalence, it can be considered a global epidemic. Interleukin (IL)-22 is a pro-inflammatory cytokine, belonging to the IL-10 family. Forty-seven consecutive older patients, hospitalized with an admitting diagnosis of CHF at the Geriatric Medicine Unit (University of Messina, Italy), from 01/01/06 to 30/06/06, were enrolled in the study. Serum concentrations of IL-22 were measured by a quantitative enzyme immunoassay technique. IL-22 levels in all CHF patients were significantly higher than those in controls, in particular, only the II and III NYHA class had IL-22 values significantly higher than the controls, whereas there was no difference between the IL-22 levels of NYHA class IV and the controls. The reason may be the declining immune function in CHF older patients, in fact we can hypothesize that the fall in IL-22 levels, with the progression of NYHA class, is due to the reduced ability in CHF patients to respond to infections, as IL-22 has anti-microbial properties. We detected different outcomes correlated to different IL-22 levels, and the Kaplan-Meier curves suggest a trend.