Biomarkers of cell damage, neutrophil and macrophage activation associated with in-hospital mortality in geriatric COVID-19 patients

BACKGROUND

The risk for symptomatic COVID-19 requiring hospitalization is higher in the older population. The course of the disease in hospitalised older patients may show significant variation, from mild to severe illness, ultimately leading to death in the most critical cases. The analysis of circulating biomolecules involved in mechanisms of inflammation, cell damage and innate immunity could lead to identify new biomarkers of COVID-19 severity, aimed to improve the clinical management of subjects at higher risk of severe outcomes. In a cohort of COVID-19 geriatric patients (n= 156) who required hospitalization we analysed, on-admission, a series of circulating biomarkers related to neutrophil activation (neutrophil elastase, LL-37), macrophage activation (sCD163) and cell damage (nuclear cfDNA, mithocondrial cfDNA and nuclear cfDNA integrity). The above reported biomarkers were tested for their association with in-hospital mortality and with clinical, inflammatory and routine hematological parameters. Aim of the study was to unravel prognostic parameters for risk stratification of COVID-19 patients.

RESULTS

Lower n-cfDNA integrity, higher neutrophil elastase and higher sCD163 levels were significantly associated with an increased risk of in-hospital decease. Median (IQR) values observed in discharged vs. deceased patients were: 0.50 (0.30-0.72) vs. 0.33 (0.22-0.62) for n-cfDNA integrity; 94.0 (47.7-154.0) ng/ml vs. 115.7 (84.2-212.7) ng/ml for neutrophil elastase; 614.0 (370.0-821.0) ng/ml vs. 787.0 (560.0-1304.0) ng/ml for sCD163. The analysis of survival curves in patients stratified for tertiles of each biomarker showed that patients with n-cfDNA integrity < 0.32 or sCD163 in the range 492-811 ng/ml had higher risk of in-hospital decease than, respectively, patients with higher n-cfDNA integrity or lower sCD163. These associations were further confirmed in multivariate models adjusted for age, sex and outcome-related clinical variables. In these models also high levels of neutrophil elastase (>150 ng/ml) appeared to be independent predictor of in-hospital death. An additional analysis of neutrophil elastase in patients stratified for n-cfDNA integrity levels was conducted to better describe the association of the studied parameters with the outcome.

CONCLUSIONS

On the whole, biomarkers of cell-free DNA integrity, neutrophil and macrophage activation might provide a valuable contribution to identify geriatric patients with high risk of COVID-19 in-hospital mortality.

P-230 Senescence in mammalian embryos as a novel assay for quality control in the IVF laboratory

Study question

Can senescence biomarkers be used as a more sensitive assay for IVF laboratory quality control than a conventional mouse embryo assay (MEA)?

Summary answer

Senescence biomarkers are more sensitive than a MEA and should be considered as a novel quality control assay in assessing overall IVF laboratory environment.

What is known already

An MEA is a bioassay that is utilized to detect toxicity and suboptimal conditions, but only assesses the ability of the embryos to develop to the blastocyst stage. The majority of human embryos created during IVF do not result in a live birth, most either arrest or degenerate. Suboptimal culture conditions and accompanying environmental stressors may be responsible or some of this lack of embryo development. Senescence or developmental arrest, like apoptosis, is a defensive mechanism that halts further development of stress, poor quality or abnormal embryos. Senescence should be considered a possible reason for a high embryos loss rate.

Study design, size, duration

Murine zygotes from the strain B6C3F1 x B6D2F1 (N = 263) were exposed to 12.5nM Doxorubicin (DOX), a known inducer of senescence as a positive control, either 250nM or 500nM H2O2 or atmospheric oxygen conditions (20%) to mimic oxidative stress. These treatment groups were compared to embryos cultured without H2O2 in a low oxygen (5% 02) environment. The zygotes were cultured for 72 hours, and biomarkers of senescence were assessed.

Participants/materials, setting, methods

Embryos were assessed at 72 hours with a confocal microscope (Zeiss) and blastocyst conversion rate and number of cells/blastocyst was calculated. The following senescence markers were examined, SAβ-gal (SPiDER-β-Gal), IL-6 mRNA (RT-qPCR) and CellRox Deep Red, a fluorogenic reactive oxygen species (ROS) indicator was also evaluated. Fiji Image J software was used to calculate Corrected Total Cell Fluorescence (CTCF) as a percentage of the low oxygen group and GraphPad Prism was used for data analysis.

Main results and the role of chance

When comparing the blastocyst conversion rate, all treatment groups showed a blastocyst conversion rate of &gt; 80% after 72 hours of exposure, indicating that all would have “passed” assessment with a conventional MEA (p &gt; 0.05). However, when the average number of cells per blastocyst was compared to the low oxygen group, all groups had a significantly lower average number of cells per blastocyst (112±26.65 for low oxygen, 74±7.95 for high oxygen, 82± 24.54 for 500 nM H2O2, 89 ± 34 for 250 nM H2O2 and 63± 20.01 for 12.5 nM DOX, p &lt; 0.05). All of the treatment groups had a significant increase in the relative fold change of IL-6 mRNA compared to the low oxygen environment (2.2 for the high oxygen, 2.5 for 500 nM H2O2, 2.9 for 250 nM H2O2, and 7.4 for 12.5 nM DOX, p &lt; 0.05). The CTCF for SAβ-Gal using the SPIDER-β- Gal assay was significantly elevated in all treatment groups (145% for high oxygen, 162% for H2O2250 nM, 193% for 12.5 nM DOX and 196% for 500 nM H2O2, p &lt; 0.05). A significant increase in the CTCF for CellRox Deep Red was also observed (289% for 12.5 nM DOX, 492% for 250 nM H2O2, 763% for 500 nM H2O2, and 925% for high oxygen, p &lt; 0.05).

Limitations, reasons for caution

This analysis is currently limited by the lack of a specific senescence marker. This approach is also invasive, destroying the embryo, not lending itself to clinical human embryo selection. Although the mouse model has advantages, translating these results into human embryos is a limitation of this study.

Wider implications of the findings

This optimized novel assay can be used to provide great insight about the subtle laboratory culture/environmental conditions in the IVF laboratory. The results support the hypothesis that environmental stressors can induce senescence biomarkers and implicate their participation in the degeneration of previously viable embryos.

Trial registration number

not applicable

The FOODia-Net Protocol

The increasing of chronic diseases represents a worldwide issue and conceiving effective operating models of preventive care looks mandatory to satisfy new health and social needs. It is known from Evidence-Based Medicine that to combine a multidisciplinary/multiprofessional care approach with the promotion of patients’ health literacy and correct lifestyle can improve chronic diseases management at global level.

Five Italian Regions are currently collaborating in the framework of the National Centre for Diseases Prevention and Control Research Call funded by the Italian Ministry of Health. The Project ultimate goal is the implementation of an innovative skill-mix-change operating Protocol aimed to promote patient engagement and food literacy about diabetes and its complications. To pursuit this objective and to conduct the Project dissemination activities, the creation of a dedicated web-based platform is scheduled. The assessment of the effectiveness and sustainability of the whole Project is foreseen.

A non-systematic review of available publications about existing skill-mix-change approaches designed to promote food literacy and patient engagement has been performed and a cross-sectional study to investigate food literacy of diabetic patients has been drawn up. It was approved by Local Review Board in February 2020. Meanwhile a requirements audit among Partners has been carried out to outline the ICT framework for commissioning the creation of the web-based platform to support dissemination activities.

The Project is ongoing. With the aim to preliminary map existing educational initiatives on diabetes an initial scenario analysis shows that: counselling initiatives are performed in 89% of GPs groups; patient engagement initiatives in 52% and training initiatives in 58%. Training initiatives for professionals take place in 27% of clinics; at least 1 initiative, on diabetes prevention or food literacy promotion, is carried out in each of the 9 Associations registered.

Selenium Concentrations and Mortality among Community-Dwelling Older Adults: Results from IlSIRENTE Study

BACKGROUND

Selenium has a wide range of pleiotropic effects, influencing redox homeostasis, thyroid hormone metabolism, and protecting from oxidative stress and inflammation. Serum selenium levels are reduced in the older population.

OBJECTIVES

to investigate the association of serum selenium levels with all-cause mortality in a sample of community-dwelling older adults.

DESIGN AND SETTING

Data are from the 'Invecchiamento e Longevità nel Sirente' (Aging and Longevity in the Sirente geographic area, ilSIRENTE) study, a prospective cohort study that collected information on individuals aged 80 years and older living in an Italian mountain community (n=347). The main outcome was risk of death after ten years of follow-up.

PARTICIPANTS AND MEASUREMENTS

Participants were classified according to the median value of selenium (105.3 μg/L) in two groups: high selenium and low selenium.

RESULTS

A total of 248 deaths occurred during a 10-year follow-up. In the unadjusted model, low levels of selenium was associated with increased mortality (HR, 0.66; 95% CI 0.51-0.85). After adjusting for potential confounders the relationship remained significant (HR, 0.71; 95% CI 0.54-0.92).

CONCLUSIONS

Low serum levels of selenium are associated with reduced survival in elderly, independently of age and other clinical and functional variables.

Key Messages for a Frailty Prevention and Management Policy in Europe from the ADVANTAGE JOINT ACTION Consortium

In the 2015 Ageing Report, the European Commission (EC) and the Economic Policy Committee stated that coping with the challenge posed by an ageing population will require determined policy action in Europe, particularly in reforming pension, health care and long-term care systems. The concern for this situation motivated the EC, the Parliament and many of the Member States (MS) to co-fund, in the 2015 call of the Third European Health Programme of the European Union 2014-2020, the first Joint Action (JA) on the prevention of frailty. ADVANTAGE JA brings together 33 partners from 22 MSs for 3 years. It aims to build a common understanding on frailty to be used in the MSs by policy makers and other stakeholders involved in the management, both at individual and population level, of older people who are frail or at risk for developing frailty throughout the European Union (EU). It is a formidable challenge but also a great opportunity for concerted action resulting in fostering effective and successful policies in frailty prevention and management in the participating MS. The Consortium has 2 years of hard work ahead to contribute to the needed change for frailty related disability free Europe. The first practical step towards this aim was the preparation of a document: the State of the Art on Frailty Report to support an overview of evidence of what works and what does not work on frailty prevention and management. Subsequently, this will be reflected in the advice that the JA will give to policy makers at MS level. Overall, these messages intend to be an instrument of added value to advocate for policy driven decisions on frailty prevention and management in the JA participating MSs and subsequently towards a frailty related disability free older population in Europe. The aim of this paper is to describe ADVANTAGE JA general structure, approach and recommendations towards a European health and social policy which will support frailty prevention in the participating MS.

Inappropriate Use of Proton Pump Inhibitors in Elderly Patients Discharged from Acute Care Hospitals

BACKGROUND

Proton-pump inhibitors (PPI) are extensively prescribed in older patients. However, little information is available on factors associated to PPI prescribing patterns among older patients discharged from hospital.

OBJECTIVE

To evaluate the appropriateness and clinical correlates of PPI prescription at discharge in a population of 1081 older patients discharged from acute care Italian hospitals.

DESIGN

We used data from the CRiteria to Assess Appropriate Medication Use among Elderly Complex Patients (CRIME) study, a multicenter observational study. The appropriateness of PPI prescriptions was defined according to the Italian Medicines Agency (AIFA) rules. Correlates of overprescribing (i.e prescribing without recognized AIFA indications) and underprescribing (i.e. not prescribing despite the presence of recognized AIFA indications) were investigated by logistic regression analysis.

RESULTS

Overprescribing was observed in 30% of patients receiving PPIs at discharge. Underprescribing was observed in 11% of patients not receiving PPIs at discharge. Overprescribing of PPIs at discharge was negatively associated with age (OR=0.88, 95%CI=0.85-0.91), depression (OR=0.58, 95%CI=0.35-0.96), use of aspirin (OR=0.03, 95%CI=0.02-0.06) and systemic corticosteroids (OR=0.02, 95%CI=0.01-0.04). The negative association with number of medications (OR=0.95, 95%CI=0.88-1.03) and overall comorbidities (OR=0.92, 95%CI=0.83-1.02) was nearly significant. Conversely, older age (OR=1.09, 95%CI=1.04-1.14), use of aspirin (OR=24.0, 95%CI=11.5-49.8) and systemic corticosteroids (OR=19.3, 95%CI=11.5-49.8) and overall comorbidities (OR=1.22, 95%CI=1.04-1.42) were independent correlates of underprescribing.

CONCLUSION

Overprescribing of PPIs is more frequent in younger patients with lower burden of depression, whilst underprescribing is characterized by older age and greater burden of comorbidity and polypharmacy. Hospitalization should be considered as a clue to identify inappropriate use of PPIs and improve appropriateness of prescribing.

Diagnosing and treating depression in older and oldest old

Depression is very common in older people and it is associated with negative consequences such as functional decline, increased morbidity and mortality and higher healthcare costs. Despite this, it is still underdiagnosed and undertreated and the issue is particularly relevant for people older than 80 years. The main reasons for underdiagnosis are: atypical presentation, concomitant cognitive decline, inadequate diagnostic tools, and prejudice that depression is a normal part of ageing. On the other hand, the main reasons for undertreatment are: multimorbidity, concerns about adverse events and drug interactions, lack of confidence in the efficacy and safety of pharmacological and non-pharmacological treatments in the oldest old depressed patients, who are underrepresented in clinical studies. The new antidepressants are the drugs most frequently used, due to their perceived more favorable safety profile than older antidepressants. Psychotherapy is equally effective but less frequently used and should request some adaptive strategies for the peculiarities of octogenarians. Electroconvulsive therapy is limited to severe psychotic late-life depression resistant to other treatments. In light of the heterogeneity of people aged 80 years and over, with multiple and different medical, functional, socioeconomic problems, a multidimensional approach is probably the most suitable both for diagnosis and treatment, in order to develop an individualized care plan. These considerations should guide the formulation of future research studies, specifically tailored for the oldest depressed patients.

Diabetes-related quality of life is enhanced by glycaemic improvement in older people

AIMS

To investigate the validity and reliability of the Audit of Diabetes-Dependent Quality of Life instrument in older Italians with diabetes and to test the association of diabetes-related quality of life with glycaemic control over time.

METHODS

A total of 558 outpatients with Type 2 diabetes from the Diabetic Unit of the Italian National Research Centre on Aging Hospital in Ancona were enrolled to complete questionnaires (Audit of Diabetes-Dependent Quality of Life-19 and the Short-Form-12), and to undergo clinical and biochemical testing at baseline and at 12 months of follow-up. The overall impact of diabetes using the average weighted impact score from the Audit of Diabetes-Dependent Quality of Life questionnaire was calculated. Participants were categorized according to this score as having either less or more negative diabetes-related quality of life.

RESULTS

Participants had a mean ± SD age of 67.7 ± 9.2 years and 51.8% were male. Factor analysis and Cronbach's coefficient of internal consistency (Cronbach's α = 0.931) confirmed that the 19 domain-specific Audit of Diabetes-Dependent Quality of Life items could be combined into a single scale in this Italian population. The impact score correlated with the physical (r = 0.275; P < 0.001) and mental components (r = 0.291; P < 0.001) of the Short-Form-12 questionnaire. Significant differences were found according to diabetic complications in specific Audit of Diabetes-Dependent Quality of Life items and impact scores. Insulin use had a greater association with a more negative quality of life compared with other antidiabetic agents. A multivariate linear regression model with restricted linear spline application showed that the relationship between HbA1c and impact score was not linear and that the change in the impact score was associated with improved glycaemic control in those with a less negative diabetes-related quality of life at 12 months.

CONCLUSIONS

The Audit of Diabetes-Dependent Quality of Life-19 is a valid tool for measuring the impact of diabetes on quality of life in older Italians. Perception of diabetes-related quality of life is associated with glycaemic control over time.

The impact of drug interactions and polypharmacy on antimicrobial therapy in the elderly

Infectious diseases are more prevalent in older people than in younger adults, and represent a major healthcare issue in older populations. Indeed, infections in the elderly are often associated with higher morbidity and mortality, and may present atypically. Additionally, older patients are generally treated with polypharmacy regimens, which increase the likelihood of drug-drug interactions when the prescription of an antimicrobial agent is needed. A progressive impairment in the functional reserve of multiple organs may affect either pharmacokinetics or pharmacodynamics during aging. Changes in body composition occurring with advancing age, reduced liver mass and perfusion, and reduced renal excretion may affect either pharmacokinetics or pharmacodynamics. These issues need to be taken into account when prescribing antimicrobial agents to older complex patients taking multiple drugs. Interventions aimed at improving the appropriateness and safety of antimicrobial prescriptions have been proposed. Educational interventions targeting physicians may improve antimicrobial prescriptions. Antimicrobial stewardship programmes have been found to reduce the length of hospital stay and improve safety in hospitalized patients, and their use in long-term care facilities is worth testing. Computerized prescription and decision support systems, as well as interventions aimed at improving antimicrobial agents dosage in relation to kidney function, may also help to reduce the burden of interactions and inherent costs.

Relationship between use of proton pump inhibitors and IGF system in older subjects

OBJECTIVES

to investigate the effects of proton pump inhibitors (PPIs) on the insulin-like-growth factor 1(IGF-1) system in the elderly.

DESIGN

cross-sectional.

SETTING

InCHIANTI study.

PARTICIPANTS

938 older subjects (536 women, 402 men, mean age 75.7±7.4 years).

MEASUREMENTS

complete data on age, sex, BMI, liver function, medications, dietary intake, IGF-1, IGF-binding protein-1 and -3 (IGFBP-1, IGFBP-3).

RESULTS

Participants were categorized by PPI use, identifying 903 PPI non users and 35 users. After adjusting for age, male PPI users (107.0 ± 69.6 vs. 127.1 ± 55.8, p<0.001) and female PPI users (87.6 ± 29.1 vs. 107.6 ± 52.3, p=0.03) had lower IGF-1 levels than non-users. IGFBP-1 levels were similar in the two groups in both sexes. In whole population, after adjustment for age and sex, PPI users had lower IGF-1 levels 81.9 [61.1-113.8] than non-users 110 [77.8-148.6], p=0.02. After further adjustment for BMI, albumin, liver function, C-reactive protein, Interleukin-6, number of medications, ACE-inhibitors use, caloric intake, protein intake, physical activity, glycemia, and IGFBP-1, the use of PPIs remained significantly and negatively associated with IGF-1 levels (β±SE = -19.60±9.83, p=0.045).

CONCLUSION

Use of PPIs was independently and negatively associated with IGF-1 levels.

Physical performance measures and polypharmacy among hospitalized older adults: results from the CRIME study

OBJECTIVE

To investigate the association of polypharmacy and physical performance measures in a sample of elderly patients aged ≥65 years admitted to acute care hospitals.

DESIGN, SETTING AND PARTICIPANTS

Prospective study conducted among 1123 hospitalized older adults participating to the CRiteria to Assess Appropriate Medication Use among Elderly Complex Patients (CRIME) project.

MEASUREMENTS

Physical performance was measured at hospital admission by the 4-meter walking speed (WS) and the grip strength (GS). Polypharmacy was defined as the use of ≥10 drugs during hospital stay.

RESULTS

Mean age of 1123 participants was 81.5±7.4 years and 576 (51.3%) were on polypharmacy. Prevalence of polypharmacy was higher in patients with low WS and GS. After adjusting for potential confounders, participants in the highest tertile of WS were less likely to be on polypharmacy as compared with those in the lowest tertile (OR 0.58; 95% CI 0.35 - 0.96). Similarly, participants in the highest tertile of GS had a significantly lower likelihood of polypharmacy as compared with those in the lowest tertile (OR 0.55; 95% CI 0.36 - 0.84). When examined as continuous variables, WS and GS were inversely associated with polypharmacy (WS: OR 0.77 per 1 SD increment; 95% CI 0.60 - 0.98; GS: OR 0.71 per 1 SD increment; 95% CI 0.56 - 0.90).

CONCLUSION

Among hospitalized older adults WS and GS are inversely related to polypharmacy. These measures should be incorporated in standard assessment of in-hospital patients.

Screening for frailty in elderly emergency department patients by using the Identification of Seniors At Risk (ISAR)

OBJECTIVES

Frail older adults are at an increased risk for adverse outcomes after an Emergency Department (ED) visit. Comprehensive geriatric assessment (CGA) has been proposed to screen for frailty in the ED, but it is difficult to carry out. We tested whether a CGA-based approach using the Identification of Seniors At Risk (ISAR) screening tool was associated with the brief deficit accumulation index (DAI) of frailty.

DESIGN

Prospective observational study.

SETTING

Two urban EDs in Italy.

PARTICIPANTS

A cohort of 200 elderly (≥65 years) ED patients.

MEASUREMENTS

Identifiers, triage, clinical and social data along with the administration of ISAR. CGA was performed using: Charlson Index, Short Portable Mental Status Questionnaire and Katz's ADL. Follow-up data at 30 and 180 days included: mortality, ED revisit, hospital admission, and functional decline. Frailty was defined according to a brief DAI. Logistic regression evaluated the consistency of the frailty definition; ROC curves evaluated ISAR ability in identifying frailty.

RESULTS

Frailty was present in 117 (58.5%) subjects and predicted ED revisit and frequent ED return, hospitalization and 6-month mortality. ISAR had an AUC of 0.92 (95%CI 0.88-0.96, p<0.0001) in identifying frail elders in the ED and using a cut-off of 2 showed 94% sensitivity and 63% specificity.

CONCLUSION

ISAR is a useful screening tool for frailty and identifies elderly patients at risk of adverse outcomes after an ED visit. ISAR can also be used to select high-risk patients more likely to benefit from a geriatric approach or intervention, independently of admission or discharge.

Effects of anorexia on mortality among older adults receiving home care: an observation study

PURPOSE

We describe the prevalence of secondary anorexia in a population of older people living in community and receiving home care. In addition, we examined the relationship between secondary anorexia and mortality.

METHODS

We analyzed data from a large collaborative observational study group, the Italian Silver Network Home Care project, that collected data on patients admitted to home care programs. A total of twelve Home Health Agencies participated in such project evaluating the implementation of the Minimum Data Set for Home Care (MDS-HC) instrument. A total of 2757 patients were enrolled in the present study. The main outcome measures were the prevalence of anorexia, weight loss and survival.

RESULTS

More than 25% (744 subjects) of the study sample suffered from anorexia. During a mean follow-up of 10 months from initial MDS-HC assessment, 468 patients (17%) died. There was uneven distribution of the risk. After adjusting for age, gender and for all other possible risk factors for death (living alone, physical and cognitive disability, behavior problems, urinary incontinence, pressure ulcer, hearing impairment, congestive heart failure, hypertension, depression, diabetes, renal failure, cancer), subjects with anorexia were more likely to die relative to patients without anorexia (RR, 1.83; 95% CI 1.45-2.31). Even though the risk of mortality was higher among subjects suffering from anorexia and weight loss, the anorexia per se was associated with higher risk compared with subjects without anorexia (RR, 1.45; 95% CI 1.01-2.19).

CONCLUSIONS

Anorexia is associated with a significant higher risk of all-cause mortality. The present findings support the possibility that anorexia has an independent effect on survival even among old people receiving home care.

Discovering pathways of sarcopenia in older adults: a role for insulin resistance on mitochondria dysfunction

The precise cause of sarcopenia, skeletal muscle loss and strength, in older persons is unknown. However, there is a strong evidence for muscle loss due to insulin resistance as well as mitochondrial dysfunction over aging. Considering that epidemiological studies have underlined that insulin resistance may have a specific role on skeletal muscle fibre atrophy and mitochondrial dysfunction has also been extensively shown to have a pivotal role on muscle loss in older persons, a combined pathway may not be ruled out. Considering that there is growing evidence for an insulin-related pathway on mitochondrial signaling, we hypothesize that a high degree of insulin resistance will be associated with the development of sarcopenia through specific alterations on mitochondrial functioning. This paper will highlight recent reviews regarding the link between skeletal muscle mitochondrial dysfunction and insulin resistance. We will specifically emphasize possible steps involved in sarcopenia over aging, including potential biomolecular mechanisms of insulin resistance on mitochondrial functioning.

Persistent ex vivo low number and functional in vitro recovery of circulating gammadelta T cells after removal of a cutaneous primary melanoma

We recently described gammadelta T cells alterations in patients with a cutaneous primary melanoma. To evaluate whether gammadelta T cells alterations persisted after melanoma removal, we performed a follow-up study comparing the number and function of gammadelta T lymphocytes from 19 subjects, 4 years after the removal of a cutaneous primary melanoma, with the data obtained in the same subjects before the surgical intervention and with control donors. The number of circulating gammadelta(+) T cells after melanoma removal was not recovered to the levels found in controls. gammadelta(+) T cells producing TNF-alpha or IFN-gamma were increased after melanoma removal in comparison with the same subjects before surgical intervention or with control donors. After in vitro culture, both the percentage and the expansion of gammadelta T cells were recovered to the values found in controls. In conclusion, the functional capacity of gammadelta T cells was in vitro recovered after melanoma removal, whereas their ex vivo number remained at lower levels than control donors.

Decreased numeric density of succinic dehydrogenase-positive mitochondria in CA1 pyramidal neurons of 3xTg-AD mice

Alzheimer disease (AD) is associated with mitochondrial dysfunction. In this study, we investigated succinic dehydrogenase (SDH) activity in mitochondria of hippocampal CA1 pyramidal neurons obtained from 10-month-old 3xTg-AD mice, an animal model of AD, as well as from age-matched control mice PS1-KI. In SDH-positive mitochondria, we measured numeric density (Nv, number of mitochondria/microm(3) of cytoplasm), average organelle volume (V), volume density (Vv, volume fraction of mitochondria/microm(3) of cytoplasm), average length (Fmax), and the ratio (R) between the total area of the cytochemical precipitate due to SDH activity and the total mitochondrial area. Our results indicate that 3xTg-AD mitochondria show a significant decrease of Nv, increase in V and Fmax, as well as a trend toward a reduction of R, whereas Vv is unchanged. Our findings further support the idea that mitochondrial dysfunction is involved in AD and are in line with studies indicating that both amyloid precursor protein (APP) and amyloid-beta (Abeta) localize to mitochondria.

Frailty and muscle metabolism dysregulation in the elderly

The frailty syndrome is increasingly recognized by geriatricians to identify elders at an extreme risk of adverse health outcomes. The physiological changes that result in frailty are complex and up to now have been extremely difficult to characterize due to the frequent coexistence of acute and chronic illness. Frailty is characterized by an decline in the functional reserve with several alterations in diverse physiological systems, including lower energy metabolism, decreased skeletal muscle mass and quality, altered hormonal and inflammatory functions. This altered network leads to an extreme vulnerability for disease, functional dependency, hospitalization and death. One of the most important core components of the frailty syndrome is a decreased reserve in skeletal muscle functioning which is clinically characterized by a loss in muscle mass and strength (sarcopenia), in walking performance and in endurance associated with a perception of exhaustion and fatigue. There are a number of physiological changes that occur in senescent muscle tissues that have a critical effect on body metabolism. The causes of sarcopenia are multi-factorial and can include disuse, changing hormonal function, chronic diseases, inflammation, insulin resistance, and nutritional deficiencies. In this review, we will explore the dysregulation of some biological mechanisms that may contribute to the pathophysiology of the frailty syndrome through age-related changes in skeletal muscle mass and function.

Omega-3 polyunsaturated fatty acids and immune-mediated diseases: inflammatory bowel disease and rheumatoid arthritis

Inflammation is part of the normal host response to infection and injury. However, inappropriate inflammation contributes to several diseases, including inflammatory bowel disease (IBD) and rheumatoid arthritis (RA). Both conditions are characterized by the excessive production of inflammatory cytokines, arachidonic acid (AA)-derived eicosanoids, and other inflammatory agents (e.g., reactive oxygen species, adhesion molecules). By virtue of their anti-inflammatory action, omega-3 polyunsaturated fatty acids (PUFA) may be beneficial in inflammatory diseases. A large body of evidence supports a protective effect of omega-3 PUFA in experimental animal and ex-vivo models of Crohn's disease (CD), Ulcerative colitis (UC) and Rheumatoid arthritis (RA). Although fish oil supplementation in patients with IBD results in omega-3 PUFA incorporation into gut mucosal tissue and modification of inflammatory mediator profiles, the evidence of clinical benefits of omega-3 PUFA is weak. On the other hand, more convincing data support the efficacy of omega-3 PUFA in reducing pain, number of tender joints, duration of morning stiffness, use of non-steroidal anti-inflammatory drugs and improving physical performance in RA patients. In both IBD and RA further clinical trials with large sample size are needed to clarify the efficacy of omega-3 PUFA as a treatment.

Health care for older people in Italy: The U.L.I.S.S.E. Project (Un link informatico sui servizi sanitari esistenti per l'anziano - a computerized network on health care services for older people)

OBJECTIVES

The U.L.I.S.S.E. study is aimed at describing older patients who are cared for in hospitals, home care or nursing homes in Italy.

DESIGN

The U.L.I.S.S.E. study is an observational multicenter prospective 1-year study.

SETTING

Overall, 23 acute geriatric or internal medicine hospital units, 11 home care services and 31 nursing homes participated in the study.

MEASUREMENTS

The patient's evaluation was performed using comprehensive geriatric assessment instruments, i.e. the interRAI Minimum Data Set, while data on service characteristics were recorded using ad-hoc designed questionnaires.

RESULTS

The older subjects who are in need of acute and long term care in Italy have similar characteristics: their mean age is higher than 80 years, they have a high level of disability in ADL, an important multimorbidity, and are treated with several drugs. The prevalence of cognitive impairment is particularly high in nursing homes, where almost 70% of residents suffer from it and 40% have severe cognitive impairment. On the other hand, there is a shortage of health care services, which are heterogeneous and fragmented.

CONCLUSIONS

Health care services for older people in Italy are currently inadequate to manage the complexity of the older patients. An important effort should be undertaken to create a more integrated health care system.

Relationship between socio-economic features and health status in elderly hospitalized patients

We aimed at investigating the relationship between socioeconomic (SES) and health status in the context of an observational multicenter study of elderly hospitalized patients. Our series consisted of 473 patients aged 70 years or more. K-means cluster analysis was used to generate 3 clusters on the basis of age, gender, education, perception of personal economic situation, difficulty to reach health services, need for formal or informal support, family arrangement, and population density of residence municipality. Logistic regression analysis was used to identify correlates of "negative" SES. Correlates of "negative" SES cluster were older age (odds ratio=OR=5.19, 95% Cl=2.28-11.8), cognitive impairment (OR=6.36, 95%CI=3.11-13.0), emergency hospital admission (OR=3.11; 95%CI=1.52-6.35), and dependency in at least 1 BADL (OR=4.36, 95%CI=1.53-12.4). In conclusion, "negative" SES is associated with age and selected indices of frailty in elderly hospitalized patients. The evaluation of socio-economic problems should be routinely addressed in elderly hospitalized patients in order to tailor appropriately post-discharge use of health care resources.

Heart failure and adverse drug reactions among hospitalized older adults

The aim of this study was to assess whether heart failure (HF) could be a risk factor for adverse drug reactions (ADRs) among hospitalized older adults. This study included 19,496 patients admitted to community- and university-based hospitals in Italy (mean age 70 +/- 14 years; 49.7% female). ADRs were identified in 207 of the 2,413 (8.6%) patients with HF and in 855 (5.0%) of the 17,083 patients without HF (P < 0.001). After adjusting for potential confounders, HF was shown to be associated with an increased likelihood of experiencing an ADR (odds ratio (OR) 1.29; 95% confidence interval (CI) 1.06-1.56). After stratifying the sample by gender, the association continued to be seen in the women (OR 1.58; 95% CI 1.22-2.05) but not in the men (OR 0.99; 95% CI 0.74-1.34). In conclusion, HF appears to be associated with a higher rate of ADRs among hospitalized patients. Gender may influence the effect of HF on the risk of ADRs.

Antithrombotic drugs in secondary stroke prevention among a community dwelling older population

BACKGROUND

Patients who suffer a cerebrovascular event are at high risk of a recurrence. Secondary prevention is crucial in reducing the burden of cerebrovascular disease.

OBJECTIVE

To estimate the percentage of stroke survivors receiving antiplatelet or anticoagulant drugs and to identify factors associated with such treatment.

DESIGN

Cross sectional retrospective cohort study.

METHODS

Data were analysed from a large collaborative observational study, the Italian "silver network" home care project, which collected data (from 1997 to 2001) on patients admitted to home care programmes (n = 5372). Twenty two home health agencies participated in evaluating the implementation of the minimum dataset for home care (MDS-HC) instrument. For the present study, 648 individuals with a diagnosis of stroke were selected and the initial MDS-HC assessment reported.

RESULTS

70% of stroke survivors did not receive any antiplatelet or anticoagulant drugs (95% confidence interval (CI), 66.5 to 73.5). Among all age categories, aspirin and ticlopidine were the two most commonly prescribed drugs. Living alone (odds ratio (OR), 0.49 (95% CI, 0.24 to 0.89)), dependency in activities of daily living (0.66 (0.40 to 0.99)), cognitive impairment (0.58 (0.38 to 0.86)), and low educational level (0.58 (0.34 to 0.98)) were associated with a reduced likelihood of receiving secondary stroke prevention treatment. Cardiac arrhythmias, coronary artery disease, heart failure, and peripheral vascular disease were associated with the use of antiplatelet or anticoagulant treatment.

CONCLUSIONS

Negative attitudes among physicians with respect to secondary stroke prevention are prevalent and reinforce the need for increased awareness of existing data on the risks and benefits for elderly individuals. Social problems and functional impairment may be issues concerning physicians when deciding whether or not the risks of treatment exceed the benefit.

Pain management in frail, community-living elderly patients

BACKGROUND

Pain is a common problem among older people living in different community settings. As indicated by the World Health Organization (WHO), pain can be relieved using pharmacologic agents. However, pain continues to be addressed inadequately.

OBJECTIVES

To describe the prevalence of pain in frail elderly people living in the community and to evaluate the adequacy of pain management.

METHODS

We analyzed data from a large collaborative observational study group, the Italian Silver Network Home Care project, that collected data on patients admitted to home health care programs. Twelve home health care agencies participated in the project evaluating the implementation of the Minimum Data Set for Home Care instrument. We enrolled 3046 patients, 65 years and older, in the present study. The main outcome measures were the prevalence of daily pain and analgesic treatment.

RESULTS

A total of 1341 individuals (39%, 49%, and 41% of those aged 65-74, 75-84, and > or = 85 years, respectively) reported daily pain. Of patients with daily pain, 25% received a WHO level 1 drug; 6%, a WHO level 2 drug; and 3%, a WHO level 3 drug (eg, morphine sulfate). Patients 85 years or older were less likely to receive analgesics compared with the younger patients (univariate odds ratio, 0.73; 95% confidence interval [CI], 0.60-0.89). Another independent predictor of failing to receive any analgesic was low cognitive performance (adjusted odds ratio, 0.80; 95% CI, 0.69-0.93).

CONCLUSIONS

Daily pain is prevalent among frail elderly patients living in the community and is often untreated, particularly among older and demented patients.

Functional status and clinical correlates in cognitively impaired community-living older people

We describe the prevalence of cognitive impairment in a population of community-living older people, its association with functional decline, and degree of comorbidity. In addition, we examined the relationship between different levels of cognitive impairment and mortality. We conducted an observational study of 1787 patients aged 65 years and above with any degree of cognitive impairment. Patient data were collected with the Minimum Data Set for Home Care. More than 50% of patients had some level of cognitive impairment, which correlates with the degree of physical frailty. On the contrary, patients with cognitive impairment appear to have fewer comorbid conditions and are less likely to receive medications than patients with normal cognitive status. In particular, hypertension, congestive heart failure, chronic obstructive pulmonary disease, cancer, diabetes mellitus, and osteoporosis are found more frequently among patients with normal mental status compared with those showing some level of cognitive defects. Yet, more severe cognitive impairment is associated with a higher mortality rate. Demented patients are characterized by a high prevalence of functional disability and by increased mortality. This increased morbidity and mortality rate is associated with a lower prevalence of comorbid clinical conditions and drug use, relative to patients with normal cognitive performance. The present findings support the possibility that severe cognitive impairment has an independent effect on survival.

Minimum data set for home care: a valid instrument to assess frail older people living in the community

BACKGROUND

Optimal care for frail elderly patients depends on comprehensive assessment. This is especially true in the complex setting of interdisciplinary home care programs. To facilitate comprehensive assessment, as well as to generate a useful, policy-relevant patient database, standardized, multidimensional, and validated instruments are very helpful.

OBJECTIVES

The aim of the present study was to demonstrate that the Minimum Data Set assessment instrument for Home Care (MDS-HC) can be used to detect functional and cognitive impairment as defined by analogous research instruments.

RESEARCH DESIGN

This was a cross-sectional correlation study.

SUBJECTS

We studied 95 patients admitted to home care services of the Health Care Agency of Bergamo (Italy).

MEASURES

The MDS-HC form was completed for all patients by well-trained nurses, independently of and with nurses blinded to the results from the research rating scales. The Barthel Activities of Daily Living (ADL) Index, the Instrumental Activities of Daily Living of Lawton (IADL), and the Mini Mental State Examination (MMSE) were considered the gold standard.

RESULTS

Agreement between the MDS-HC scales and the research rating scales was assessed with Pearson's correlation coefficient. This coefficient was 0.74 for MDS-ADL versus Barthel Index, 0.81 for MDS-IADL versus Lawton Index, and 0.81 for Cognitive Performance Scale versus MMSE, indicating an excellent agreement.

CONCLUSIONS

The MDS-HC scales, when performed by trained nurses using recommended protocols, provide a valid measure of function and cognitive status in frail home care patients. These findings point out the overall validity of the functional and clinical data contained in the MDS-HC assessment. Use of the MDS-HC gives the unique opportunity of setting up a database, a prerequisite for all epidemiological evidence-based medicine studies.

A model for integrated home care of frail older patients: the Silver Network project. SILVERNET-HC Study Group

Home care programs for the treatment of frail elderly have been developed in many countries around the world. In the Silver Network project all services are provided in an integrated fashion by one "single entry" center, differently from the traditional fee-for-service or not integrated systems. The delivery of health and social services for frail elderly individuals are integrated and coordinated by a case manager who uses a "second generation" assessment instrument, the Minimum Data Set for Home Care (MDS-HC). We describe the principal clinical and functional characteristics of nearly 1300 patients admitted between 1997 and 1998 to such an integrated home care program in eleven Italian Health Agencies. The database, derived from the serial MDS-HC assessments of each patient, provides a unique opportunity to delineate the different criteria for eligibility for home care, and compare the selected populations of the participating Health Agencies.

Detection of arrhythmogenic cellular magnesium depletion in hip surgery patients

The use of high-dose magnesium infusions in critically ill and surgical patients is increasing. This practice is associated with considerable risk of toxicity, as no reliable criteria are currently available to detect significant intracellular magnesium depletion. We have evaluated, before and after surgery, 33 elderly patients with hip fracture, by 24-h Holter ECG monitoring, Doppler echocardiography and serum chemistry; lymphocyte magnesium was measured using atomic absorption spectrophotometry. The severity of ventricular arrhythmias increased, and serum and mononuclear magnesium concentrations decreased significantly after surgery. Decreases in either serum magnesium concentrations > 0.125 mmol litre-1 or cellular magnesium > 6 nmol mg-1, but not serum or lymphocyte absolute magnesium concentrations, were associated with postoperative development of repetitive arrhythmias. Variations in serum magnesium concentrations correlated with intracellular decreases, and yielded good accuracy in predicting the postoperative worsening of arrhythmias. Thus perioperative differences in serum magnesium concentrations reflected intracellular variations and allowed us to identify patients with clinically relevant cellular magnesium depletion.

Comorbidity and cancer in the aged: the geriatrician's point of view

Demographic trends in Italy and Western countries show a progressive aging of the population, which concerns the 80+ segment. The aging population is characterized by increased comorbidity and functional decline. The "frail elderly", who has problems in a variety of areas, including the physical, cognitive, psychological, social and economic ones, represents the paradigm of the emerging demographic and epidemiologic reality. In oncology, there is increasing awareness of the impact of comorbidity on cancer management in the elderly (including both screening and treatment). The Comprehensive Geriatric Assessment represents the only answer to such problems, allowing to improve the quality of life, prolong survival and maintain functional status.

Effect of age on left atrial function in patients with coronary artery disease

Both coronary artery disease and aging produce a similar pattern of left ventricular diastolic dysfunction with increased left atrial (LA) activity. We studied the Doppler left ventricular filling pattern in 75 patients (age 40-91 years) with coronary artery disease. A linear correlation with age was found for isovolumic relaxation time, peak atrial flow velocity, and atrial filling fraction; an independent effect of age and LA size on these parameters could be demonstrated. As an overall correlation was found between LA diameter and atrial function indexes, we compared such parameters among four subgroups with increasing LA size; the LA function indexes were increased with minor degrees of LA dilation and decreased with further LA expansion. As LA dilation was found only in older patients, it can be supposed that the combined effects of aging and disease on LA wall stress accounted for LA dilation and dysfunction in these subjects.

Cell surface-binding sites for progesterone mediate calcium uptake in human sperm

Recent studies (e.g. Blackmore, P. F., Beebe, S. J., Danforth, D. R., and Alexander, N.) (1990) J. Biol. Chem. 265, 1376-1380) have shown that in human sperm, progesterone produces a rapid increase in intracellular free calcium ([Ca2+]i) and an induction of the acrosome reaction (e.g. Osman, R. A., Andria, M. L., Jones, A. D., and Meizel, S. (1989) Biochem, Biophys. Res. Commun. 160, 828-833). In this study, the location of progesterone receptors on the cell surface of human sperm was identified using progesterone immobilized on bovine serum albumin (BSA) (progesterone 3-(O-carboxymethyl)oxime:BSA) as well as progesterone and its 3-O-carboxymethyloxime derivative. Using fluorescence microscopy, BSA-fluorescein isothiocyanate was shown to be excluded from intact sperm, thus validating the use of progesterone 3-(O-carboxymethyl)oxime:BSA to identify cell surface-binding sites for progesterone. The immobilized progesterone and the 3-O-carboxymethyloxime derivative rapidly increased [Ca2+]i and were full agonists, although they were approximately 1.5 orders of magnitude less potent than progesterone. They also displayed an identical time course to increase [Ca2+]i as free progesterone, and the entire increase in [Ca2+]i was due to the influx of Ca2+. This progesterone-mediated response displayed different steroid receptor characteristics since the very potent inhibitors of genomic progesterone responses, RU38486 and ZK98.299, were very ineffective at inhibiting the progesterone-mediated increase in [Ca2+]i. Also the synthetic progestins megestrol, medroxyprogesterone acetate, norgestrel, norethynodrel, norethindrone, R5020, and cyproterone acetate did not mimic the effects of progesterone to increase [Ca2+]i. It is proposed that a distinct nongenomic cell surface receptor for progesterone exists in human sperm.

Simultaneous measurement of intracellular pH and Ca2+ using the fluorescence of SNARF-1 and fura-2

Upon cell stimulation with hormones and other mitogens, a variety of biochemical and physiological responses occur within the first few minutes. Changes in both intracellular pH (pHin) and intracellular Ca2+ concentration ([Ca2+]in) are prominent and play a major role in the signal transduction mechanism leading to the physiological response, i.e., secretion, neurotransmission, proliferation, or differentiation. However, it is not clear whether these ions work independently in the activation pathway leading to a particular physiological response. The fluorescence characteristics of most Ca2+ indicators are pH sensitive, and quantitative estimates of [Ca2+]in cannot be made without knowledge of pHin. Thus it is desirable to have a technique to simultaneously monitor these two ions with relatively high time resolution. Here we have developed experimental conditions that allow us to use optimum emission conditions for a pH fluorescent indicator SNARF-1 and optimum excitation conditions for the Ca2+ indicator fura-2. The fluorescence spectra of these compounds are sufficiently different to allow simultaneous measurement of pH and Ca2+ both in vitro and in situ. We have observed simultaneous changes in both pHin and [Ca2+]in in BALB/c 3T3 cells on treatment with the nonfluorescent Ca2+ ionophore 4-bromo-A23187. This temporal relationship between pHin and Ca2+ gives further credence to the interrelationship between these two second messengers in the expression of physiological responses.

5,6-Epoxyeicosatrienoic acid mobilizes Ca2+ in anterior pituitary cells

Luteinizing hormone releasing hormone stimulates the concomitant release of luteinizing hormone and 45Ca2+ from prelabeled anterior pituitary cells. Indomethacin (10 microM) and nordihydroguaiaretic acid (10 microM) had no effect on the luteinizing hormone releasing hormone-stimulated release of either luteinizing hormone or 45Ca2+. Eicosatetraynoic acid (10 microM) blocked both luteinizing hormone releasing hormone-stimulated luteinizing hormone secretion and luteinizing hormone releasing hormone-stimulated 45Ca2+ efflux. 5,6-Epoxyeicosatrienoic acid stimulated both luteinizing hormone secretion and 45Ca2+ efflux from anterior pituitary cells. Additionally, 5,6-epoxyeicosatrienoic acid closely mimics the ability of luteinizing hormone releasing hormone to increase intracellular free calcium. These results are consistent with the hypothesis that 5,6-EET alters calcium homeostasis in a manner similar to that observed during luteinizing hormone releasing hormone stimulation of luteinizing hormone release.