Fracture liaison service model: project design and accreditation

Frailty fractures place a significant socioeconomic burden on the health care system. The Italian Society of Orthopaedics and Traumatology (SIOT) is proceeding to fracture liaison service (FLS) model accreditation in several Italian Fracture Units (FUs), which provides a multidisciplinary approach for the management of the fragility fracture patient.

INTRODUCTION

Osteoporosis and the resulting fragility fractures, particularly femoral fractures, place significant socioeconomic burdens on the health care system globally. In addition, there is a general lack of awareness of osteoporosis, resulting in underestimation of the associated risks and suboptimal treatment of the disease. The fracture liaison service (FLS) represents an exemplary model of post-fracture care that involves a multidisciplinary approach to the frail patient through the collaboration of multiple specialists. The purpose of this article is to highlight the path undertaken by the Italian Society of Orthopaedics and Traumatology (SIOT) for the purpose of certification of numerous FLS centers throughout Italy.

METHODS

SIOT is proceeding with international FLS accreditation in several Italian Fracture Units (FUs), following the creation of a model that provides specific operational and procedural steps for the management of fragility fractures throughout the country. FUs that decide to join the project and implement this model within their facility are then audited by an ACCREDIA-accredited medical certification body.

RESULTS

The drafted FLS model, thanks to the active involvement of a panel of experts appointed by SIOT, outlines a reference operational model that describes a fluid and articulated process that identifies the procedure of identification, description of diagnostic framing, and subsequent initiation of appropriate secondary prevention programs for fractures of individuals who have presented with a recent fragility fracture of the femur.

CONCLUSION

Accreditation of this prevention model will enable many facilities to take advantage of this dedicated diagnostic-therapeutic pathway for the purpose of fracture prevention and reduction of associated health and social costs.

Italian validation of Arizona Sexual Experience (ASEX) on patients suffering from psychotic spectrum disorders

Introduction

Many forms of mental disorders, especially psychotic disorders are characterized also by a worsening of sexual functioning. Sexual dysfunction has been shown to significantly correlate with a longer duration of untreated psychosis and with heavier psychotic symptomatology.

Objectives

The aim of this study is to validate the Italian version of the Arizona Sexual Experience (ASEX), a very handy and reliable tool to assess sexual dysfunction, in a population of people suffering from psychotic spectrum disorders.

Methods

Seventy-three psychiatric patients were recruited and assessed for mental illness and sexual functioning. We administered the Italian version of ASEX, adequately translated by two expert bilinguals. After 15 days we administered once again the test for test-retest reliability.

Results

Validation of ASEX revealed Cronbach’s coefficients >0.70 in both single items as in the total score. In addition, the test-retest reliability revealed Pearson’s coefficients >0.50 in the various domains. Confirmatory factor analysis revealed good fit indexes for the two factors model of ASEX (SRMR=0.54; CFI=0.974; RMSEA=0.135).

Conclusions

This study represents the first validation in the Italian psychiatric context of a very useful specific tool for the sexual assessment in people suffering from mental illness. Our analysis revealed good psychometric characteristics in terms of confirmatory factor analysis, internal consistency, and test-retest reliability.

Disclosure

No significant relationships.

Behavioural and physiological indicators of shelter dogs' welfare: reflections on the no-kill policy on free-ranging dogs in Italy revisited on the basis of 15 years of implementation

The Italian National Law 281 of 1991 forbids the euthanatization of free-ranging dogs, unless they have an incurable illness or are proved to be dangerous. Without neglecting the undeniable benefits of the "no-kill" policy, nevertheless it has brought about a chronic overpopulation in shelters and, as a result, higher costs of management and welfare problems since some dogs remain in the shelter for life. In 2004-2008, the Istituto Zooprofilattico Sperimentale of the Lazio and Tuscany regions carried out a survey in the Lazio Region to verify the effects of the Italian National Law 281/91 on free-ranging dog management following 15 years from its implementation. One of the aims of the study was an assessment of the welfare of dogs in a shelter sample (8 shelters out of 47 censused in the Lazio Region). 97 mixed-breed dogs were selected, their behaviour was studied and a blood sample was taken for each dog in order to determine the individual blood concentration of cortisol and the amount of oxidative damage (level of dRoms), as well as the amount of antioxidants to cope with it. Moreover, the total leukocyte count (leukogram) was accomplished. We ran general backward stepwise regression models using "level of antioxidant", "level of dRoms" and "level of serum cortisol" as dependent variables respectively. The results showed that the most important variable that improved the level of welfare of dogs consisted in having the opportunity to regularly go out of the cage for a walk, whereas other variables like gender, size of the cage (small, medium, large), being alone in the cage, and being neutered/entire, had no significant effect on the physiological indicators of welfare. Dogs that enjoyed the regular walk had a higher total antioxidant capacity, and performed a lower frequency of displacing activities and stereotyped behaviour. Moreover, oxidative stress parameters seem to be indicators well matched with behavioural indicators of stress. Thus, for the first time, markers of oxidative status are utilised for the welfare evaluation in the domestic dog. Furthermore, the results of this paper give some suggestion about how small steps can help to improve shelters and, furthermore, this paper intends to solicit the debate on the no-kill policy.

A phase I trial using patupilone (epothilone B) and concurrent radiotherapy for CNS malignancies

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Background: Based on pre-clinical data indicating the radiosensitizing potential of Epothilone B, this study was designed to evaluate the toxicity and response rate of patupilone (EPO906), an anti-microtubule stabilizing agent, with concurrent radiotherapy in the treatment of patients with CNS malignancies. Methods: This phase I study evaluated the toxicities associated with patupilone in combination with radiotherapy for the treatment of CNS malignancies in order to establish maximum tolerated dose (MTD). Eligible patients had recurrent gliomas (10), primary (5), or metastatic (17) brain tumors. Dose escalation occurred if no dose limiting toxicities (DLT) defined as any Grade 4–5 toxicity or Grade 3 toxicity requiring hospitalization or interruption of radiation therapy. Results: A total of 32 patients were enrolled. Five patients were treated with weekly patupilone at 1.5 mg/m2, 4 patients at 2.0 mg/m2, 4 patients at 2.5 mg/m2 and one patient at 4mg/m2. Based on sponsor recommendations, the protocol was changed to a q-3 week dosing schedule with a starting dose of 6 mg/m2. Seven patients were treated in the 6 mg/m2 group, 6 patients in the 8 mg/m2 cohort and 5 patients in the 10 mg/m2 group. Radiation treatment was determined by the patient's diagnosis. Primary CNS malignancies received a median dose of 60 Gy in 1.8–2.0 Gy fractions. CNS metastases received whole brain radiation with a median dose of 37.4 Gy in 1.8–2.5 Gy fractions and patients with recurrent gliomas received stereotactic radiotherapy with a median dose of 37.5 Gy in 2.0–3.5 Gy fractions. No DLTs were observed in patients who received weekly patupilone or in the 6 mg/m2 q3wk cohort. One DLT (pneumonia/infection without neutropenia) was observed at the 8 mg/m2 q3wk group. In the subsequent dose level (10 mg/m2), two grade 4 DLTs occurred (renal failure and pulmonary hemorrhage) making 8 mg/m2 q3wk the MTD and recommended phase II dose. Median overall survival was 12 months for recurrent gliomas, 15 months for primary brain tumors and 4 months for CNS metastasis. Conclusions: Combined with a variety of radiation doses and fractionation schedules, concurrent patupilone is well tolerated and safe with a MTD of 8 mg/m2 q3wk. A phase II study to characterize efficacy should be considered.

No significant financial relationships to disclose.

Verbal short-term memory in individuals with congenital articulatory disorders: new empirical data and review of the literature

BACKGROUND

To investigate the nature of the articulatory rehearsal mechanism of the Articulatory Loop in Baddeley's Working Memory model, it seems particularly important to study individuals who developed a deficit (dysarthria) or total abolition (anarthria) of the ability to articulate language following a cerebral lesion.

METHOD

In this study, a forced-choice recognition procedure for word sequences of increasing length was used to evaluate verbal short-term memory in nine individuals with severe congenital motor and verbal disabilities (seven anarthric and two severely dysarthric) and associated intellectual disability (ID) and 30 normal children of comparable mental age.

RESULTS

The normal children exhibited classical phonological similarity effects (better performance on acoustically dissimilar than on similar word lists), word length (greater accuracy on two-syllable than on four-syllable word lists) and frequency of occurrence (an advantage of high-frequency over low-frequency words). Instead, all of these effects were lacking in the experimental group.

CONCLUSIONS

These data suggest that persons with congenital anarthria/dysarthria and ID present defective maturation at many levels of the Articulatory Loop and reduced contribution of semantic-lexical processing in the temporary retention of phonological sequences. It is likely that in these individuals both communicative deficits and ID play a role in the impaired development of verbal short-term memory abilities.

Gross morphology and morphometric sequelae in the hippocampus, fornix, and corpus callosum of patients with severe non-missile traumatic brain injury without macroscopically detectable lesions: a T1 weighted MRI study

OBJECTIVE

The gross morphology and morphometry of the hippocampus, fornix, and corpus callosum in patients with severe non-missile traumatic brain injury (nmTBI) without obvious neuroradiological lesions was examined and the volumes of these structures were correlated with performance on memory tests. In addition, the predictability of the length of coma from the selected anatomical volumes was examined.

METHOD

High spatial resolution T1 weighted MRI scans of the brain (1 mm3) and neuropsychological evaluations with standardised tests were performed at least 3 months after trauma in 19 patients.

RESULTS

In comparison with control subjects matched in terms of gender and age, volume reduction in the hippocampus, fornix, and corpus callosum of the nmTBI patients was quantitatively significant. The length of coma correlated with the volume reduction in the corpus callosum. Immediate free recall of word lists correlated with the volume of the fornix and the corpus callosum. Delayed recall of word lists and immediate recall of the Rey figure both correlated with the volume of the fornix. Delayed recall of the Rey figure correlated with the volume of the fornix and the right hippocampus.

CONCLUSION

These findings demonstrate that in severe nmTBI without obvious neuroradiological lesions there is a clear hippocampal, fornix, and callosal volume reduction. The length of coma predicts the callosal volume reduction, which could be considered a marker of the severity of axonal loss. A few memory test scores correlated with the volumes of the selected anatomical structures. This relationship with memory performance may reflect the diffuse nature of the damage, leading to the disruption of neural circuits at multiple levels and the progressive neural degeneration occurring in TBI.

Neuropsychological assessment of patients with severe neuromotor and verbal disabilities

In people with cerebral palsy, severe neuromotor disability and communication problems make standard neuropsychological tests impossible. Therefore, alternative methods and specific aids must be developed to allow patients to autonomously respond to the examiner's questions. In the present individuals and study, a neuropsychological evaluation was made of a group of eight individuals with cerebral palsy, and severe neuromotor and verbal disabilities, and a group of 19 normal subjects matched for mental age. The tests were administered using an autonomous selection method in which the patient selects the various responses through specific aids without the examiner's interference. Patients' group performances in visuo-spatial and memory tests were on average lower than the mean of the control group. In the verbal domain, patients' scores were comparable to those of normal children in all tests but one assessing the comprehension of syntactically complex sentences. An analysis of the patients' individual performances also revealed heterogeneous cognitive profiles: some patients presented a homogeneously distributed cognitive impairment and others a more selective one. This finding is particularly important for planning differentiated learning programmes, and identifying suitable communicative instruments in rehabilitative and educational settings.

Poor agreement of occupational data between a hospital-based cancer registry and interview

With occupation recognized as a risk factor for various cancers, collecting occupation and industry data by a number of vital registries, including cancer registries, has developed. Registries may be data sources for cancer etiology research and occupational disease surveillance, despite concerns that their data are fragmentary and may lack validity. To improve completeness and validity of occupational information in a hospital-based cancer registry, this study compared information obtained through abstracting medical records for the registry with information obtained through lung-cancer patient interviews. Employing the kappa statistic, agreement was generally poor, largely due to data missing in the medical record. Data quality of hospital-based cancer registries can be improved by employing trained cancer registrars to elicit occupational histories from patients.

Patterns of axillary nodal involvement in breast cancer. Predictability of level one dissection

Two hundred consecutive mastectomies with total axillary dissection were analyzed for patterns of involvement at levels one, two and three. The purpose was to determine the accuracy of level one axillary dissection in predicting the status of the entire lymph node chain in carcinoma of the breast. Level one was defined as latissimus dorsi to lateral pectoralis minor; level two behind the pectoralis minor and level three medial pectoralis minor to thoracic inlet. The average number of nodes analyzed per patient was 22. The average number of nodes recovered per level was 14 at level one, 11.5 at level two and eight at level three. One hundred twenty patients (60%) had no nodal involvement, while 80 patients had metastases to axillary lymph nodes. There were seven patients (3.5% of the entire 200) who had positive nodes at levels two and/or three without metastasis to level one. This represents the incidence of "skip" metastases. The group exhibiting "skip" metastases comprise 5.5% of patients (seven of 127) with negative axillary nodes at level one and 8.7% of patients (seven of 80) with axillary metastases secondary to carcinoma of the breast. In the authors' experience, level one lymph node dissection is an accurate predictor of the status of the entire lymph node chain. Negative nodes at level one would indicate lack of involvement at levels two and three with nearly 95% accuracy.

Reconstruction of the orbit with antibiotic acrylic in cases of severe bone loss

The advantages of using antibiotic acrylic resin in the reconstruction of the orbit following injury or tumor removal are described. Four cases are presented whose long-term results confirm the value of the new method.