[Epidemiology in support of intervention priorities: the case of diabetes in Turin (Piedmont Region, Northern Italy)]

OBJECTIVES

to describe the epidemiology of diabetes within the city of Turin (Piedmont Region, Northern Italy) and to present the process initiated by the city network of diabetes care for the improvement of prevention and treatment of the disease.

DESIGN

ecological study based on administrative database.

SETTING AND PARTICIPANTS

residents in Turin from 2016 to 2018.

MAIN OUTCOME MEASURES

incidence and prevalence of diabetes, percentage of glycosylated haemoglobin testing, and case-fatality.

RESULTS

in the considered three-year period (2016-2018), the cumulative incidence of diabetes was 11.5 x1,000; as of 31.12.2018 the prevalence was 5.9%. 77% had performed at least one measurement of glycated haemoglobin during the previous year, and the case-fatality was 12.6% in the three-year period. The standardized prevalence per statistical zone varied from a minimum of 2% (95%CI 1.2-3.3) to a maximum of 10.2% (95%CI 9.1-11.4). The highest values were recorded in the most deprived city areas. The geographical distribution of incidence, varying between 5.1 x1,000 (95%CI 2.7-10.0) e 19.4 x1,000 (95%CI 15.8-24.0), reproduces the geography of prevalence, as well as the percentage of measurement of glycated haemoglobin, while the variability of the fatality rate is more modest without an obvious geographic pattern.

CONCLUSIONS

diabetes occurs most frequently in the most deprived areas of the city, but the response of the health care system is adequate and equitable. Sharing of these results with the city health authorities and the diabetologists has led to identify as a priority interventions for the reduction of unhealthy behaviours, and for the improvements of patient care pathway, starting form the most disadvantaged areas of the city. A process of listening and involvement of all actors potentially interested in the prevention and treatment of diabetes has been started.

Promoting health equity through social capital in deprived communities: a natural policy experiment in Trieste, Italy

The Trieste Habitat Micro-area Programme (HMP), an innovative social-health service policy, has offered a natural experiment to empirically evaluate the social mechanisms through which social capital may have an impact on health inequalities. To date, literature clarifying this causal chain is scanty. This empirical study tested the following hypotheses: H1) innovative social-health practices can activate social mechanisms intentionally and systematically so as to generate social capital; H2) such social mechanisms increase specific properties of social capital, in particular those influencing more vulnerable individuals' relationships; H3) investing in these properties can enhance capabilities and, consequently, control over the health of more vulnerable individuals. The study was carried out during 2016-2018 and used both qualitative and quantitative methods. The qualitative part investigated the field experience of the HMP through interviews, focus groups and workshops with HMP professionals. The quantitative part assessed the effect HMP might have on these properties and the capacity to face health risks of more vulnerable individuals. Three samples, each of 200 individuals, residing in the target and in control areas were interviewed using a semi-structured questionnaire. One control sample was matched to the 200 treated subjects using a Propensity Score Matching. The results of the study suggest that the HMP intervention stimulated the development of empowerment, collaboration and interdependence among vulnerable people. This produced an increase in their social capital under several aspects, including enhanced trust, network extension and participation, cooperation and reciprocal help with neighbours, as well as improving their judgement on quality, timing and efficacy of the help received from institutions, relatives or friends. These findings show that socially shared relationships can create innovative local models of a universalistic generative welfare system, which would be both inclusive and able to enhance individual capabilities. These models could be disseminated and carried over to other contexts.

Parathyroid-hormone variance is only marginally explained by a panel of determinants: a cross-sectional study of 909 hip-fracture patients

Several factors affect the levels of parathyroid hormone (PTH) in hip-fracture patients. We hypothesized that a panel of easily assessable determinants could account for both a substantial proportion of PTH variance and the occurrence of secondary hyperparathyroidism. We evaluated 909 of 981 hip-fracture inpatients admitted consecutively to our Rehabilitation division. In each patient we assessed PTH, 25-hydroxyvitamin D, albumin-adjusted total calcium, phosphate, magnesium, and creatinine on a fasting blood sample 21.3 ± 6.1 (mean ± SD) days after fracture occurrence. Glomerular filtration rate (GFR) was estimated by the 4-variable Modification of Diet in Renal Disease Study equation. Functional level was assessed using the Barthel index. On multivariate analysis, six factors (phosphate, albumin-adjusted total calcium, estimated GFR (eGFR), 25-hydroxyvitamin D, age, and magnesium) were significantly associated with PTH levels. Overall, the panel of variables accounted for 23.7 % of PTH variance. Among the 909 patients, 304 (33.4 %) had PTH levels exceeding the normal range. Six factors (phosphate, albumin-adjusted total calcium, eGFR, 25-hydroxyvitamin D, age, and Barthel index scores) were significantly associated with the category of PTH level (either normal or elevated). The model correctly classified 70.4 % of cases. For the optimal cut-off point, sensitivity was 80 % and specificity was 61 %. Data shows that six factors were significantly associated with PTH levels in hip-fracture inpatients. However, the six factors accounted for only 23.7 % of PTH variance and the presence or absence of secondary hyperparathyroidism was correctly categorized in a modest proportion of cases. We conclude that more knowledge is needed on the factors affecting PTH levels after hip fracture.

Parathyroid hormone is significantly associated with body fat compartment in men but not in women following a hip fracture

BACKGROUND AND AIMS

Parathyroid hormone (PTH) exerts several actions beyond mineral metabolism and may affect body composition. The aim of our study was to assess the association between serum PTH and body fat compartment in hip fracture patients.

METHODS

We studied 575 of 630 inpatients with hip fracture consecutively admitted to our Rehabilitation ward. Dual-energy X-ray absorptiometry (DXA) was used to measure body composition. DXA scan was performed 18.5 ± 8.6 (mean ± SD) days after hip fracture occurrence. A blood sample was collected within 4 days after DXA scan. In each subject, we evaluated PTH, 25-hydroxyvitamin D, calcium, phosphate, albumin, magnesium, and creatinine. Glomerular filtration rate was estimated by a conventional formula.

RESULTS

In the 57 men, we found a significant correlation between PTH and both body mass index (BMI) (ρ = 0.37; p = 0.020) and trunk fat percentage (ρ = 0.62; p < 0.001). After multiple adjustments, we confirmed a significant association between PTH and BMI (r = 0.38; p = 0.004) or trunk fat percentage (r = 0.51; p < 0.001). In the 518 women, we found a slightly significant correlation between PTH and BMI (ρ = 0.09; p = 0.047), but after adjustments the correlation coefficient dropped to 0.02 (p = 0.69). We found no significant relationships between PTH and trunk fat percentage at bivariate correlation (ρ = 0.04; p = 0.35) or after adjustments (r = 0.04; p = 0.38).

CONCLUSIONS

PTH serum levels were robustly associated with body fat compartment in men, but not in women following a fracture of the hip. A role of PTH in affecting body composition in hip fracture men is suggested. Its potential role in male prognostic disadvantage needs further investigation.

Low levels of 25-hydroxyvitamin D are associated with the occurrence of concomitant upper limb fractures in older women who sustain a fall-related fracture of the hip

OBJECTIVE

To investigate the association between serum levels of 25-hydroxyvitamin D and the occurrence of simultaneous fractures of the upper limb in older women who sustain a fall-related fracture of the hip.

STUDY DESIGN

Cross-sectional study.

MAIN OUTCOME MEASURES

We investigated 472 of 480 white women consecutively admitted to a rehabilitation hospital because of a fall-related hip fracture. Twenty-seven (5.7%) of the 472 women sustained a concomitant upper-limb fracture of either distal radius (20 women) or proximal humerus (seven women). We assessed serum levels of 25-hydroxyvitamin D 14.2 ± 4.1 (mean ± SD) days after surgical repair of the hip fracture in the 472 women by an immunoenzymatic assay.

RESULTS

Twenty-five-hydroxyvitamin D levels were significantly lower in the 27 women with concomitant fractures of both hip and upper limb than in the remaining 445 hip-fracture women: mean ± SD values were 6.5 ± 5.0 ng/ml and 11.7 ± 10.4 ng/ml respectively in the two groups (mean difference between groups 5.2 ng/ml: 95% CI 1.2-9.2; p=0.011). Low levels of 25-hydroxyvitamin D were significantly associated with concomitant fractures of the upper limb (p=0.017), after adjustment for eight potential confounders including age, height, weight, hip-fracture type, cognitive impairment, neurologic impairment, previous hip fracture, and previous upper-limb fracture.

CONCLUSIONS

Low levels of 25-hydroxyvitamin D were significantly associated with concomitant upper-limb fractures in our sample of older women with a fall-related fracture of the hip. Preventing vitamin D deficiency may lower the incidence of simultaneous fractures due to a singe fall in elderly women.

The relationship between initial trunk control or postural balance and inpatient rehabilitation outcome after stroke: a prospective comparative study

Objective: To compare the predictive validity of trunk control in sitting position assessed by Trunk Impairment Scale and balance in lying, sitting and standing posture assessed by Postural Assessment Scale for Stroke patients on functional outcome in stroke survivors.

Design: Prospective observational study.

Setting: A single rehabilitation hospital in Italy.

Subjects: Sixty of 68 consecutive subjects admitted to a rehabilitation hospital after stroke.

Main measures: We performed Trunk Impairment Scale and Postural Assessment Scale for Stroke patients at admission to inpatient rehabilitation. Outcome measures at discharge were Functional Independence Measure score and destination (classified as either home or institution).

Results: After adjustment for 14 potential confounders, including Functional Independence Measure score at admission to rehabilitation, both Trunk Impairment Scale and Postural Assessment Scale for Stroke patients scores were significantly associated with the Functional Independence Measure score at discharge (P = 0.010 and P =0.04, respectively), change in the Functional Independence Measure score during rehabilitation (P = 0.003 and P<0.001, respectively), Functional Independence Measure effectiveness (P = 0.024 and P =0.017, respectively) and destination at discharge (P = 0.040 and P =0.032, respectively). The panel of prognostic variables predicted 64—65% of the variance in the final Functional Independence Measure score, 30—35% of the variance in the change of the Functional Independence Measure score during rehabilitation, and 45—46% of the variance in the Functional Independence Measure effectiveness depending on the inclusion of either Trunk Impairment Scale or Postural Assessment Scale for Stroke patients score among the predictors.

Muscle Mass and Functional Recovery in Men with Hip Fracture

OBJECTIVE

To investigate the association between muscle mass and functional recovery in men after hip fracture.

DESIGN

We investigated 27 of 33 men admitted consecutively to a rehabilitation hospital after hip fracture. For each patient, we also studied two control women, matched for age and fracture type. Lean mass (LM) was assessed by dual-energy x-ray absorptiometry (DXA) 21.9 +/- 7.5 (mean +/- SD) days after fracture occurrence in the 27 men (22.8 +/- 7.2 days in the 54 control women). Appendicular LM (aLM) was calculated as the sum of LM in arms and legs. Functional recovery was assessed using Barthel index scores. Barthel index efficiency was calculated as the change in the Barthel index score after rehabilitation divided by the length of stay in hospital.

RESULTS

After adjustment for age, height, fat mass, Barthel index scores at admission, and time between fracture occurrence and DXA assessment, aLM was significantly associated with Barthel index scores after rehabilitation (r = 0.480; P = 0.013) and Barthel index efficiency (r = 0.633; P = 0.001) in the 27 men. Conversely, in the 54 control women, no significant associations were found between aLM and the functional scores.

CONCLUSIONS

LM assessed after hip fracture is significantly associated with the functional outcome in men.

Skeletal muscle mass, fat mass, and hip bone mineral density in elderly women with hip fracture

Soft tissue body composition strongly affects bone health. Our aim was to investigate the relationship between both skeletal muscle mass (SMM) and fat mass (FM) and femoral bone mineral density (BMD) in a sample of elderly women with hip fracture. We assessed 293 of 325 hip fracture women admitted consecutively to a rehabilitation hospital. Soft tissue body composition and BMD were assessed by dual-energy X-ray absorptiometry (DXA), 23.2 +/- 7.7 (mean +/- SD) days after fracture occurrence. BMD was measured at four sites (neck, total femur, trochanter, intertrochanteric area) in the unfractured femur. Appendicular lean mass (aLM) was calculated as the sum of LM in arms and legs. We used two approaches to adjust aLM for body size: aLM divided by height squared (aLM/ht(2)), and aLM adjusted for height and FM (residuals). Both FM and aLM were significantly correlated with femoral BMD. However, the correlation coefficients for aLM were lower than for FM; they further decreased after adjustment for height squared, and were no longer significant after correction for both height and FM (residuals). When FM, aLM/ht(2), age, and time spent between fracture occurrence and DXA assessment were included together as the independent variables in a regression model, FM was the only independent variable significantly associated with BMD. The coefficients of partial correlation ranged from 0.414 to 0.647 depending on the femoral region of BMD assessment (P < 0.001). FM, but not SMM emerged as a pivotal determinant of BMD in our sample of hip fracture women.

Fat mass and skeletal muscle mass in hip-fracture women: a cross-sectional study

OBJECTIVES

To investigate the association between appendicular lean mass (aLM) and age, fat mass (FM), serum levels of Vitamin D, parathyroid hormone, three parameters of the protein nutritional status (total lymphocyte count, serum albumin, and insulin-like growth factor I), levels of independence in activities of daily living (assessed by using Barthel index scores), type both of hip fracture and surgical operation, number of medications in use, and number of concomitant diseases in hip-fracture women.

METHODS

We investigated 299 of 327 hip-fracture women admitted consecutively to a rehabilitation hospital. Soft tissue body composition was assessed by dual-energy X-ray absorptiometry, 22.1+/-7.5 (mean+/-S.D.) days after fracture occurrence. Appendicular LM was calculated as the sum of LM in arms and legs. Because metal implants (prostheses and nails) affect the regional assessment of body composition, aLM was corrected by substituting LM in unfractured leg for LM in fractured leg: corrected aLM=(LM in unfractured leg x 2)+LM in arms. We divided corrected aLM by height squared (aLM/ht(2)), to adjust it for body size.

RESULTS

Four variables were significantly correlated with corrected aLM: age, height, FM, and Barthel index score. FM was the only variable significantly correlated with aLM/ht(2) (r=0.492; p<0.001). This significant correlation was not affected after adjustment for age and Barthel index score.

CONCLUSIONS

FM measured after hip fracture was significantly associated with aLM/ht(2) in women.

Bone Mineral Density in Hip-Fracture Patients With Parkinson’s Disease: A Case-Control Study

OBJECTIVE

To investigate bone mineral density (BMD) levels in patients with Parkinson's disease (PD) who sustained a hip fracture.

DESIGN

Case-control study.

SETTING

Rehabilitation hospital in Italy.

PARTICIPANTS

We investigated 831 out of 887 white patients consecutively admitted to a rehabilitation hospital because of an original hip fracture resulting from a fall. Twenty-eight (3.37%) of the 831 patients were affected by PD. Twenty-eight controls matched for sex, age, and hip-fracture type (cervical or trochanteric) were found among the 803 non-PD patients.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

BMD was assessed by dual-energy x-ray absorptiometry (DXA) at the unfractured femur. Five sites were investigated in each subject: total proximal femur, femoral neck, trochanter, intertrochanteric area, and Ward's triangle. DXA scan was performed a mean +/- standard deviation of 22.2 +/- 7.8 days after fracture occurrence in the 28 patients and 22.0 +/- 5.3 days after fracture occurrence in the 28 controls.

RESULTS

BMD expressed as a T score did not differ significantly between the 28 PD patients and the 28 controls, whereas z score in the PD patients was significantly lower than 0 +/- 1 in the age- and sex-matched general population at 4 of the 5 sites of BMD assessment.

CONCLUSIONS

A sample of PD fallers who sustained a hip fracture had femoral BMD levels similar to those found in matched hip-fracture fallers who did not suffer from PD and significantly lower than those found in the matched reference population.

Muscle mass and functional recovery in women with hip fracture

OBJECTIVE

To investigate the association between muscle mass and functional recovery in women with hip fracture.

DESIGN

A total of 200 of 230 women with hip fracture admitted consecutively to a rehabilitation hospital were investigated in this survey study. Lean mass (LM) was assessed by dual-energy x-ray absorptiometry, 23.1 +/- 7.9 (mean +/- SD) days after fracture occurrence. Appendicular LM (aLM) was calculated as the sum of LM in arms and legs. Because metal implants (prostheses and nails) affect the regional assessment of body composition, aLM was corrected by substituting LM in the unfractured leg for LM in the fractured leg: corrected aLM = (LM in unfractured leg x 2) + LM in arms. We used two approaches to adjust corrected aLM for body size: corrected aLM divided by height squared (aLM/ht), and corrected aLM adjusted for height and fat mass (residuals). Functional recovery was assessed by using Barthel index scores.

RESULTS

After adjustment for body size, corrected aLM was neither significantly correlated with Barthel index scores nor with the change in Barthel index scores after rehabilitation. Also, after stratification for quintiles of aLM/ht and residuals, no significant differences in functional recovery were found among the five groups.

CONCLUSIONS

LM assessed after hip fracture is not associated with functional outcome in women.

Body mass index and functional recovery after hip fracture: a survey study of 510 women

BACKGROUND AND AIMS

Low body mass index (BMI) is associated with high risk of osteoporosis and fractures, but its impact on functional recovery after fractures is unknown. Our aim was to investigate the association between BMI and both functional recovery and period of rehabilitation in hip-fractured women.

METHODS

510 out of 580 Caucasian women with hip fracture, admitted consecutively to a rehabilitation hospital, were investigated in this retrospective study. Functional recovery was assessed using the Barthel index score.

RESULTS

In the 510 women, BMI was 22.8 +/- 4.1 kg/m2 (mean +/- SD). After adjustment for age, femur bone mineral density, and the Barthel index assessed on admission to rehabilitation, a significant negative association was found between BMI and both the Barthel index score after rehabilitation and changes in it resulting from rehabilitation (p < 0.001). After adjustment for age and the Barthel index assessed on admission to rehabilitation, a significant positive association was found between BMI and period of rehabilitation (p < 0.001). The results were similar when BMI was evaluated either as individual values or after categorization according to World Health Organization criteria.

CONCLUSIONS

In a sample of hip-fractured women, BMI was negatively associated with Barthel index scores and positively associated with period of rehabilitation. BMI may affect function after hip fracture, apart from hip fracture risk: subjects with higher BMI and low hip fracture risk may have poorer functional recovery in case of hip fracture, despite prolonged rehabilitation. Conversely, subjects with lower BMI and high hip fracture risk may have better functional recovery in case of hip fracture.

25-hydroxyvitamin D, parathyroid hormone, and functional recovery after hip fracture in elderly patients

There is increasing interest in the effects of vitamin D and parathyroid hormone (PTH) on extraskeletal tissues, including the muscle. These effects may explain impairment in functional ability found in vitamin D-deficient subjects. Our aim was to investigate the roles of vitamin D and PTH in affecting the ability to perform activities of daily living after hip fracture. We studied 456 of 521 hip-fracture patients admitted consecutively to a rehabilitation hospital. Functional outcome was assessed after acute inpatient rehabilitation by using the Barthel index score. The functional scores were significantly correlated with serum levels of 25-hydroxyvitamin D (rho = 0.190; P < 0.001) and PTH (rho = -0.164; P < 0.001) and the 25-hydroxyvitamin D/PTH ratio (rho = 0.261; P < 0.001). At multiple regression, 25-hydroxyvitamin D and PTH levels were independently associated with Barthel index scores. The correlation between the 25-hydroxyvitamin D/PTH ratio and Barthel index scores was significantly stronger than the one between 25-hydroxyvitamin D and Barthel index scores (difference between the two correlation coefficients = 0.071; 95% CI = 0.009-0.133; P = 0.011). The significant association between the 25-hydroxyvitamin D/PTH ratio and the Barthel index scores persisted after adjustment for 12 prognostic factors (P = 0.012). On the whole, the panel of prognostic factors we studied predicted 50.1% of the variance of the functional score. Data shows that PTH and 25-hydroxyvitamin D were significantly associated with the ability to function after hip fracture and suggest that the two hormones act through independent mechanisms. The 25-hydroxyvitamin D/PTH ratio significantly contributed to a predictive model of functional outcome.

Serum levels of 25-Hydroxyvitamin D and functional recovery after hip fracture

OBJECTIVE

To evaluate the association between serum levels of 25-hydroxyvitamin D (25[OH]D(3)) and functional recovery after hip fracture.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation hospital in Italy.

PARTICIPANTS

A total of 350 white hip-fracture patients consecutively admitted to a rehabilitation hospital. Thirty-five patients were excluded because their hip fracture was caused by major trauma or cancer affecting the bone or they could not complete rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients underwent 25(OH)D(3) assessment at a mean +/- standard deviation of 21.3+/-8.1 days after the hip fracture. Functional recovery was evaluated by using Barthel Index scores.

RESULTS

Low levels of 25(OH)D(3) were found (median, 6.9 ng/mL). By using the Spearman rank correlation test, a significant positive correlation was observed between serum 25(OH)D(3) and Barthel Index score assessed on admission (rho=.218, P <.001) and discharge (rho=.198, P <.001), but not with the change in Barthel Index score attributable to rehabilitation. Linear multiple regression showed that the association between 25(OH)D(3) and Barthel Index score was independent of 11 confounding variables: age, sex, hip-fracture type, pressure ulcers, cognitive impairment, neurologic impairment, infections, time between fracture occurrence and 25(OH)D(3) evaluation, comorbidity, surgical procedure type, and previous hip fractures.

CONCLUSIONS

In the study population, serum 25(OH)D(3) was an independent predictor of functional recovery assessed by Barthel Index score after hip fracture but not of the change in the functional score resulting from rehabilitation.

Functional recovery and length of stay after hip fracture in patients taking corticosteroids

OBJECTIVE

To evaluate the functional recovery and the length of stay after hip fracture in patients receiving corticosteroids.

DESIGN

A total of 796 inpatients with hip fracture consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 36 of 796 were currently treated with either oral (n = 23) or inhaled (n = 13) corticosteroids.

RESULTS

No significant differences were shown between corticosteroid users and controls for Barthel index score at admission or discharge, change in Barthel index score resulting from rehabilitation, and length of stay. Multiple regression, including 11 confounding variables, showed that several factors, but not the treatment with corticosteroids, were significantly associated with the Barthel index score or the length of stay. The results were similar when the two subgroups of patients receiving corticosteroids were evaluated separately. In the subgroup of the patients receiving oral corticosteroids, no meaningful correlations were observed between the daily dose (milligrams of prednisone equivalent) and the Barthel index score, the change in the Barthel index score attributable to rehabilitation, or the length of stay.

CONCLUSIONS

After hip fracture, neither the functional recovery nor the length of stay were significantly affected by the current treatment with corticosteroids.

Total lymphocyte count and femoral bone mineral density in postmenopausal women

In vitro studies showed that several cytokines produced by the immune system can play a relevant role in modulating bone turnover, thus affecting the health of bone tissue. Our aim was to evaluate the association between total lymphocyte count (TLC) and femoral bone mineral density (BMD) in a sample of postmenopausal women. We studied 114 out of 124 consecutive, caucasian, home-dwelling, apparently healthy postmenopausal women referred for osteodensitometry by general practitioners. Femoral BMD was measured by dual-energy X-ray absorptiometry at five sites. A significant positive correlation (p < 0.001) was observed between TLC and BMD (T score) measured the five sites: total proximal femur ( r = 0.45), trochanter (r = 0.43), intertrochanteric region (r = 0.38), femoral neck (r = 0.49), and Ward's triangle (r = 0.42). With a linear multiple regression model, TLC adjusted for age, weight, height, body mass index, and erythrocyte sedimentation rate showed a significant association with femoral BMD assessed at each of the five sites. The R(2) values ranged from 0.33 with BMD measured at Ward's triangle to 0.51 with BMD measured at the trochanter. The significance of the association between TLC and BMD ranged from P < 0.001 with BMD measured at the femoral neck to P < 0.05 with BMD measured at the intertrochanteric area. The results were similar when BMD was expressed as either a Z score (in the 110 of the 114 women aged 84 years or younger) or as absolute values. Our data show a positive association between TLC and femoral BMD in a sample of apparently healthy, postmenopausal women, supporting the view of a close connection between the immune system and bone tissue.

Primary hyperparathyroidism in elderly patients with hip fracture

Primary hyperparathyroidism (PHPT) is associated with low bone mineral density (BMD), but its association with fractures is controversial. Our aim was to evaluate the prevalence of PHPT in hip fracture patients. We studied 444 of 450 consecutive elderly patients (404 women and 40 men) admitted to a rehabilitation hospital after hip fracture. All the fractures were either spontaneous or sustained as a result of minimal trauma. The diagnosis of PHPT was established when both serum calcium adjusted for serum albumin exceeded the normal range and PTH was either elevated or high normal. Also, 444 sex-matched subjects, aged 65 years and older, who were referred for their first osteodensitometry, were studied as controls. Among the hip fracture patients, 21/444 (i.e., 4.7%) fulfilled the diagnostic criteria of PHPT. Logistic multiple regression showed no meaningful associations between PHPT and sex, age, weight, height, fracture type (cervical or trochanteric), and femoral BMD in the hip fracture patients. Among the 444 controls, 5 patients (i.e., 1.13%) fulfilled the diagnostic criteria of PHPT. When evaluated by Pearson's chi-square, the difference in PHPT prevalence between the hip fracture patients and the controls was significant ( P < 0.01). Data show that the prevalence of PHPT in a sample of elderly patients after hip fracture was increased when compared to that found in a sample of control subjects, suggesting that PHPT enhances hip fracture risk.

Functional recovery after concomitant fractures of both hip and upper limb in elderly people

OBJECTIVE

To investigate functional recovery after concomitant fractures of both hip and upper limb in elderly people.

DESIGN

Survey study.

SETTING

Rehabilitation hospital in Italy.

PARTICIPANTS

586 consecutive in-patients with hip fracture.

MAIN OUTCOME MEASURES

Functional recovery was evaluated by using Barthel index score.

RESULTS

4.1% of patients (i.e. 24/586) suffered from a concomitant fracture of an upper limb, involving proximal humerus (n = 8) or distal radius (n = 16). After adjustment for 9 prognostic factors, a significant reduction in the Barthel index score on admission but not on discharge was found in the patients with an upper limb fracture. The length of stay was not significantly associated with the presence of the concomitant upper limb fracture.

CONCLUSIONS

In a sample of hip-fractured patients, neither the functional recovery at the end of a course of rehabilitation nor the length of stay were influenced by the presence of a concomitant fracture involving an upper limb.

Functional recovery and length of stay after hip fracture in patients with neurologic impairment

OBJECTIVE

To evaluate the functional recovery and the length of stay after hip fracture in patients with neurologic impairment.

DESIGN

A total of 577 inpatients with hip fracture consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 71 of 577 were affected by neurologic impairment caused by stroke with hemiplegia (n = 37), Parkinson's disease (n = 25), or other diseases (n = 9).

RESULTS

Mean Barthel index was significantly lower in the patients with neurologic impairment than in the controls: 10.8 (95% confidence interval, 5.9-15.6; P < 0.001) at admission and 13.1 (95% confidence interval, 5.55-20.65; P < 0.001) at discharge. Multiple regression including eight confounding variables showed that neurologic impairment was negatively associated with the Barthel index. However, the mean increase in Barthel index through the course of rehabilitation was not affected by neurologic impairment. The length of stay was significantly higher in the patients with neurologic impairment, 3.84 days (95% confidence interval, 0.51-7.17; P < 0.05), and multiple regression showed that neurologic impairment was positively associated with the length of stay.

CONCLUSIONS

After hip fracture, the presence of neurologic impairment was associated with lower Barthel index and longer length of stay, but it did not affect the increase in Barthel index due to a course of rehabilitation.

Biochemical markers of nutrition and bone mineral density in the elderly

BACKGROUND

Protein depletion is detrimental in bone health, but the association between bone mineral density (BMD) and serum albumin is controversial. We recently showed a positive association between femur BMD and total lymphocyte count (TLC), a validated marker of protein nutrition status, in hip-fractured women.

OBJECTIVE

To investigate the association between femur BMD and both serum albumin and TLC in hip-fractured men and women.

METHODS

286 of 315 hip-fractured patients (243 women and 43 men) consecutively admitted to a rehabilitation hospital were studied. BMD was measured by DXA in the unfractured femur. The correlation between BMD and both TLC and serum albumin was studied by Pearson's coefficient and Bonferroni adjustment.

RESULTS

In women a positive correlation was observed between, TLC but not albumin, and BMD measured in the total femur (r = 0.26; p < 0.01), femur neck (r = 0.21, p < 0.01), trochanter (r = 0.22, p < 0.01), intertrochanteric area (r = 0.25, p < 0.01) and Ward's triangle (r = 0.17, p < 0.05). Conversely in men a positive correlation was found between albumin, but not TLC, and BMD measured in the total femur (r = 0.50, p < 0.01), femur neck (r = 0.52, p < 0.01), intertrochanteric area (r = 0.52, p < 0.01) and Ward's triangle (r = 0.49, p < 0.01). Linear multiple regression showed that the associations were independent of age, weight, height, body mass index, erythrocyte sedimentation rate, time between surgery and blood sample collection and type of hip fracture.

CONCLUSION

Our results support the role of protein nutrition in bone health, at least in elderly frail patients. TLC and serum albumin were suitable markers, however sex-related differences in their usefulness were observed.

Femur bone mineral density is independently associated with functional recovery after hip fracture in elderly women

OBJECTIVE

To evaluate the association between femur bone mineral density (BMD) and functional recovery after hip fracture.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation hospital in Italy.

PARTICIPANTS

A total of 233 of 263 white women with hip fracture consecutively admitted to a rehabilitation hospital.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients underwent BMD assessment by dual-energy x-ray absorptiometry (DXA) at the proximal femur (5 sites) on admission. Functional recovery was evaluated by using Barthel Index scores.

RESULTS

A positive correlation was found between BMD and Barthel Index scores assessed on both admission and discharge (r range,.16-.24, depending on the site of BMD measurement). Linear multiple regression showed that the association between BMD and Barthel Index score was independent of 10 confounding variables: age, body mass index, fracture type, pressure ulcers, cognitive impairment, neurologic diseases, total lymphocyte count as a nutritional index, time between fracture occurrence and DXA assessment, comorbidity, and surgical procedure. Conversely, no significant associations were found between BMD and the change in Barthel Index score attributable to rehabilitation.

CONCLUSIONS

In the study population, femur BMD was an independent predictor of the functional recovery assessed by Barthel Index score after hip fracture, but not of the change in the functional score resulting from rehabilitation.

Positive association between total lymphocyte count and femur bone mineral density in hip-fractured women

BACKGROUND

Protein depletion appears to play a detrimental role in the causes of hip fracture and low bone mineral density has been observed in protein-depleted subjects.

OBJECTIVE

To investigate the association between femur bone mineral density and total lymphocyte count, a marker of the protein nutrition status, in elderly hip-fractured women.

METHODS

210 white women affected by their first hip fracture either spontaneous or due to minimal trauma consecutively admitted to a rehabilitation hospital were studied. 34 women were ruled out because of confounding factors altering their lymphocyte count. Both total lymphocyte count and bone mineral density at the unfractured femur were evaluated. The correlation between these two variables was studied by Pearson's coefficient. Bonferroni adjustment was used for multiple comparisons. Bone density was measured by DXA (Hologic QDR 4500W).

RESULTS

A positive correlation was observed between lymphocyte count and bone mineral density measured at both total proximal femur (r = 0.21; p < 0.05) and intertrochanteric area (r = 0.21; p < 0.05). Stepwise linear multiple regression analysis showed that the association with total lymphocyte count was independent of age, weight, height, body mass index, time between surgery and blood sample collection for lymphocyte count and type of hip fracture (cervical or trochanteric) when bone mineral density was evaluated both at total proximal femur (p < 0.05) and intertrochanteric area (p < 0.05).

CONCLUSION

Our results support the role exerted by protein nutrition in bone health, at least in elderly frail women. From this point of view, a total lymphocyte count is a suitable, inexpensive marker.

Functional recovery and length of stay after recurrent hip fracture

OBJECTIVE

To evaluate the functional recovery and the rehabilitation length of stay after the sequential fracture of both hips in elderly patients.

DESIGN

A total of 372 in-patients with hip fractures consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 333 out of 372 were admitted for rehabilitation of their first hip fracture, and the other 39 patients had a second contralateral fracture. The functional recovery was evaluated by the Barthel index. The comparison between the two groups was performed by unpaired t test. Stepwise linear multiple regression analysis was performed, including nine prognostic factors together with the number of hip fractures (first or recurrent) as independent variables and the Barthel index score on discharge as the dependent variable. The statistical analysis was repeated, substituting hospital length of stay for Barthel index.

RESULTS

Both the functional recovery and the length of stay of the patients affected by recurrent fracture were similar to the ones of the patients suffering from a single fracture. Regression analysis showed that the previous hip fracture was associated neither with the Barthel index nor with the length of stay.

CONCLUSIONS

Our data suggest that the functional recovery in elderly patients with hip fractures is not significantly influenced by a previous fracture of the contralateral hip and that no significant prolonged rehabilitation length of stay is needed after the recurrent fracture.