Screening of frailty in elderly patients with disability by the means of Marigliano-Cacciafesta polypathology scale (MCPS) and Canadian Study of Health and Aging (CSHA) scales.

Frailty is an age-related condition, characterized by a decreased homeostatic reserve and increased vulnerability to stressful events, with high risk of adverse outcomes. The aim of this study was to compare the evaluation of the frailty by the means of the MCPS and the Rockwood criteria. We enrolled 98 patients (mean age ± standard deviation, m ± SD, 80.7 ± 7.0 years) and 20 controls (82.7 ± 3.4 ys), who attended our outpatient clinic for the evaluation of disability and the renewal of driving license, respectively. The multidisciplinary geriatric assessment (MGA) was performed including the administration of the following scales for frailty: MCPS scale (range 0-245), CSHA-Rules-Based Definition of Frailty (CSHA-RBDF) (range 0-3) and CSHA-Clinical Frailty Scale (CSHA-CFS) (range 0-7). The patients and controls showed MCPS=52.39 ± 11.36 and 4.6 ± 3.28, CSHA-RBDF=2.27 ± 0.62 and 0.10 ± 0.44, CSHA-CFS=6.22 ± 0.75 and 2.95 ± 0.51, respectively (p<0.000001). Frailty scores were higher in female than in male (p=0.065 for CSHA-RDBF and p<0.05 for CSHA-CFS). The MCPS scores were significantly related to both CSHA-RDBF (r=0.753, p<0.001) and CSHA-CFS scores (r=0.793, p<0.001). The frailty scales were significantly related to disability, cognitive impairment and polypathology. In conclusion, the frail patient may be a carrier of multiple chronic pathologies and/or of physical/cognitive decline. The frail patient has to be considered the elective geriatric patient, characterized by a continuous multidimensional care requirement. MCPS is an useful tool for the frailty screening and to set up a tailored program of geriatric rehabilitation, in order to prevent or reduce the development of frailty-related complications.

Use of multiple providers for regular care and women's receipt of hormone replacement therapy counseling.

BACKGROUND: Prior research has explored women's lifetime receipt of HRT counseling and correlates of counseling, but has not explored receipt of counseling by current health care provider(s). The number and type(s) of provider(s) that women see for their regular care may be an important enabling factor in women's receipt of HRT counseling. OBJECTIVES: Whether there is an association between the number and specialties of physicians that women use for regular care and their receipt of HRT counseling by a current regular physician is explored. RESEARCH DESIGN: A self-administered mail survey was sent to 1,500 female members (ages 40-69) of a Connecticut IPA-model health plan. RESULTS: One thousand seven completed questionnaires were received (response rate = 69%). Twenty-eight percent of women reported seeing only a family practitioner or internist (no OB/GYN) for their regular care; 11% saw an OB/GYN only; and 59% saw both a family practitioner/internist and an OB/GYN. After adjustment for women's other predisposing and enabling characteristics, women who used both a family practitioner/internist and an OB/GYN were 3.1 times as likely (95% CI, 2.02, 4.66) as those seeing only a family practitioner/internist to have been counseled about HRT by a current provider, and those using only an OB/GYN were 2.5 times as likely (95% CI, 1.34, 4.61). CONCLUSIONS: The number and specialty of physician(s) that women use for their regular care is an important enabling factor in women's receipt of HRT counseling. Changes in the organization and delivery of women's primary care may help increase the receipt of female-specific clinical preventive services, particularly among women less likely to use an OB/GYN for regular care, such as low-income and older women.

Are women being counseled about estrogen replacement therapy?

The U.S. Preventive Services Task Force and several medical professional associations have published guidelines recommending that all women be counseled around the time of menopause about the benefits and risks of estrogen replacement therapy (ERT) so that they may make an informed decision about its use. Despite the proliferation of ERT counseling guidelines, little is known about whether these guidelines are being followed. There were 1,500 female members (aged 40 to 69) of a Northeastern U.S. Independent Practice Association--model Health Maintenance Organization who were surveyed, and 51 percent reported that a health care provider had talked with them about the benefits and risks of ERT. In multivariate analyses, a woman's demographic characteristics (age, race, income), stage of menopause, severity of menopausal symptoms, and body weight were the major correlates of receipt of ERT counseling. Women at greater risk for osteoporosis or heart disease were no more likely to be counseled, although those with diagnosed osteoporosis were. What appear to be selective ERT counseling practices will need to be modified if the goal of providing universal ERT counseling to midlife women is to be attained.

A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care.

STUDY DESIGN: Randomized, controlled trial. OBJECTIVE: To evaluate a four-session self-management group intervention for patients with pain in primary care, led by trained lay persons with back pain. The intervention was designed to reduce patient worries, encourage self-care, and reduce activity limitations. BACKGROUND DATA: Randomized trials of educational interventions suggest that activating interventions may improve back pain outcomes. Expert opinion increasingly regards effective self-management of back pain as important in achieving good outcomes. In this study, an educational intervention designed to activate patients and support effective self-management was evaluated. METHODS: Six to 8 weeks after a primary care visit for back pain, patients were invited to participate in an educational program to improve back pain self-management. Those showing interest by returning a brief questionnaire became eligible for the study. Participants (n = 255) randomly were assigned to either a self-management group intervention or to a usual care control group. The effect of the intervention, relative to usual care, was assessed 3, 6, and 12 months after randomization, controlling for baseline values. The intervention consisted of a four-session group applying problem-solving techniques to back pain self-management, supplemented by educational materials (book and videos) supporting active management of back pain. The groups were led by lay persons trained to implement a fully structured group protocol. The control group received usual care, supplemented by a book on back pain care. RESULTS: Participants randomly assigned to the self-management groups reported significantly less worry about back pain and expressed more confidence in self-care. Roland Disability Questionnaire Scores were significantly lower among participants in the self-management groups relative to the usual care controls at 6 months (P = 0.007), and this difference was sustained at 12 months at borderline significance levels (P = 0.09). Among self-management group participants, 48% showed a 50% or greater reduction in Roland Disability Questionnaire Score at 6 months, compared with 33% among the usual care controls. CONCLUSIONS: Self-management groups led by trained lay persons following a structured protocol were more effective than usual care in reducing worries, producing positive attitudes toward self-care, and reducing activity limitations among patients with back pain in primary care.

Patient education as medical intervention: a pilot study.

OBJECTIVE: To describe and assess the perceived impact of an innovative patient health informatics tool among members of a managed care organization. SETTING: Mixed-model HMO in Connecticut. DESIGN: Intervention group only, post-test only (telephone interview using structured protocol). PARTICIPANTS: Members of a Connecticut HMO who responded to a free video offer and met study eligibility requirements. INTERVENTION: Patient education videos from the entire Time Life Medical At Time of Diagnosis series. MAIN OUTCOME MEASURES: Knowledge of condition and treatment options, attitude and outlook towards condition, patient-provider communication, behavior change, physician contacts for condition. RESULTS: Study participants reported that the video improved their understanding and knowledge of treatment options for their condition. They also reported a positive impact of the videos on a range of attitudes and behaviors pertinent to their condition. Participants endorsed the involvement of their HMO in distributing the videos, and few adverse effects from use of the videos were observed. CONCLUSIONS: This study provides preliminary evidence for a positive impact of health informatics tools on patient attitudes, including expectancies for care, quality of patient-physician communication, and satisfaction with health plan. The fact that most persons responding to the video offer had their condition for several years suggests that distribution of health informatics tools should not be limited to the newly-diagnosed.

Extrapelvic endometriosis.

This article reviews extrapelvic endometriosis, emphasizing classic papers as well as recent research. Because of the nature of the existing literature, specifically case reports and retrospective analyses, this article is primarily descriptive in nature. Extrapelvic endometriosis is discussed based on some main areas of occurrence, including gastrointestinal, urinary, and thoracic; other areas are also reviewed. What is known about the epidemiology, pathogenesis, diagnosis, and treatment of extrapelvic endometriosis is highlighted. Areas for future direction of research in the field are also identified.

24,25 Dihydroxyvitamin D supplementation corrects hyperparathyroidism and improves skeletal abnormalities in X-linked hypophosphatemic rickets--a clinical research center study.

Therapy for X-linked hypophosphatemia (XLH) only partially corrects skeletal lesions and is often complicated by hyperparathyroidism. 24,25(OH)2 D3 improves skeletal lesions in a murine model of XLH and suppresses PTH secretion in animals. Therefore, we undertook a placebo-controlled trial of 24,25(OH)2 D3 supplementation to standard treatment in patients with XLH to improve bone disease and reduce hyperparathyroid complications. Fifteen subjects with XLH receiving standard treatment [1,25(OH)2 D3 or dihydrotachysterol plus phosphate] were evaluated, supplemented with placebo, and reevaluated one yr later. 24,25(OH)2 D3 supplementation was then begun and studies repeated after another year. Each patient underwent a detailed evaluation of calcium homeostasis over a 24-h period. Rachitic abnormalities were assessed radiographically in children. Adults underwent bone biopsies. 24,25(OH)2 D3 normalized PTH values in nine subjects (peak PTH was 46.5 +/- 6.6 pmol/L at entry, 42.3 +/- 5.9 pmol/L after placebo, and 23.3 +/- 5.4 pmol/L after 24,25(OH)2 D3). Nephrogenous cAMP decreased at night, coincident with the decrease in PTH, and serum phosphorus was slightly greater with 24,25(OH)2 D3. Radiographic features of rickets improved during 24,25(OH)2 D3 supplementation in children, and osteoid surface decreased in adults. 24,25(OH)2 D3 is a useful adjunct to standard therapy in XLH by effecting correction of hyperparathyroidism and improvement of rickets and osteomalacia.

Duplicate cervix and vagina associated with infertility, endometriosis, and chronic pelvic pain.

BACKGROUND: Müllerian anomalies are associated with several gynecologic complications including endometriosis, infertility, and pelvic pain. CASE: A woman with duplicate cervix and a non-communicating longitudinal vaginal septum, but no other uterine anomalies, presented with pelvic pain, secondary infertility, and a long history of endometriosis. She was treated with operative laparoscopy and excision of the vaginal septum. CONCLUSION: A thorough evaluation, including history, physical examination, and appropriate imaging techniques (hysterosalpingography and magnetic resonance imaging) facilitates accurate diagnosis of anatomical defects and any associated disease in cases of unusual müllerian anomalies. An accurate preoperative diagnosis allows a planned, efficient surgical approach.

Female pelvis: impact of MR imaging on treatment decisions and net cost analysis.

PURPOSE: To determine the impact of gynecologic magnetic resonance (MR) imaging on treatment decisions and net cost. MATERIALS AND METHODS: Sixty-nine consecutive women were referred for 70 pelvic MR imaging examinations. Diagnosis and treatment plans were obtained from referring physicians before and immediately after they were given verbal reports of MR imaging results. Outcome regarding treatment and symptoms was obtained at a mean follow-up of 10.9 months. RESULTS: Of 49 (71%) patients originally recommended for surgery, 36 (73%) either did not undergo surgery or less invasive surgery was performed. In 58 (84%) patients, the treatment performed was that recommended after performance of MR imaging. Symptoms resolved in 57 (83%) patients. Use of MR imaging resulted in an overall savings of $63 per patient ($1,736 per patient originally recommended for surgery). CONCLUSION: Use of pelvic MR imaging in diagnosis of some gynecologic diseases may alter treatment, decrease the number of invasive surgical procedures performed, and reduce total health care expenditures.

Case study of the effects of prolonged and severe anorexia nervosa on bone mineral density.

Among the most severe sequelae of anorexia nervosa (AN) are its skeletal complications. Young women who have AN during adolescence may not attain their expected peak skeletal mass, and may enter adulthood with reduced bone mineral density (BMD) and an increased risk of fracture. This case history describes a young woman with severe AN that included prolonged exposure to both low body weight and amenorrhea. BMD measurement during the acute stage of her illness revealed severe osteopenia. Six years after recovery from AN, follow-up studies demonstrated only modest gains in BMD, with measurements for the hip and lumbar spine that are greater than 2 SDs below the age-matched mean.

Treatment of leiomyomata uteri with leuprolide acetate depot: a double-blind, placebo-controlled, multicenter study. The Leuprolide Study Group.

The purpose of this study was to evaluate efficacy and safety parameters in women with leiomyomata uteri treated with the GnRH agonist leuprolide acetate depot, 3.75 mg intramuscularly every 4 weeks for 24 weeks. One hundred twenty-eight patients were enrolled in a randomized, double-blind, placebo-controlled multicenter study involving 13 investigative centers. Mean uterine volume decreased by 36% at 12 weeks and 45% at 24 weeks of leuprolide therapy. Patients treated with placebo had increased in mean uterine volume of 16% at 12 weeks and 5% at 24 weeks. Seventy-seven percent of leuprolide-treated patients had a more than 25% reduction in uterine volume, compared with 9% of placebo-treated controls. Mean uterine volume returned to pre-treatment size 24 weeks after cessation of leuprolide treatment. The majority of patients had resolution or improvement of their fibroid-related symptoms after 24 weeks of leuprolide treatment. Of 38 leuprolide-treated patients presenting with menorrhagia, 37 (97%) had resolution of this symptom at the time of the final visit. Although 95% of women treated with leuprolide acetate experienced some side effects related to hypoestrogenism, only five patients (8%) terminated treatment prematurely. We conclude that leuprolide acetate depot treatment of leiomyomata uteri is safe and causes significant but temporary reductions in uterine size and fibroid-related symptoms.

Monitoring therapy with a gonadotropin-releasing hormone analog: utility of MR imaging.

The utility of magnetic resonance (MR) imaging in assessing response to therapy with a gonadotropin-releasing hormone (GnRH) analog was assessed in 19 women with uterine leiomyomas and 19 women with endometriosis. There was a significant reduction in individual fibroid volumes at 3 months (P less than .05) and at 6 months (P less than .005) in the drug group, whereas there was no significant change in the placebo group. Vessel conspicuity significantly decreased at 3 months (P less than .02) and at 6 months (P less than .01) in the drug group but not in the placebo group. In the patients with endometriosis, there was a significant decrease (P less than .0006) in the number of endometriomas visualized. Significant changes were also noted in the pelvis in women who were receiving the GnRH analog. After 6 months of therapy, the identifiability of the ovaries was significantly poorer (P less than .05). The authors conclude that the utility of conservative therapy with a GnRH analog can be quantitatively assessed with MR imaging.

High-field MRI and US evaluation of the pelvis in women with leiomyomas.

Magnetic resonance imaging (MRI) and real-time transabdominal ultrasonography (US) were performed on 23 women with uterine leiomyomas. The uterus, ovaries, and cul de sac were evaluated. Accurate determination of uterine volume was possible in all cases by MRI, but was limited on US in uteri larger than 140 cc. Marked enlargement also prevented visualization of contour abnormalities in eight patients on US, but none on MRI. The endometrial stripe and junctional zone could not be adequately visualized in 21/23 US examinations, whereas they were identified in all 23 MRI (8 normal and 15 distorted). Individual leiomyomas were clearly depicted on 4 US and 19 MR scans, the smallest being 1.1 cm and 0.8 cm, respectively. Of the 31 fibroids present on MRI: 13 were intramural, 4 subserosal, and 14 submucosal. MRI successfully identified 44/46 ovaries as compared to 21/46 on US. Cul de sac fluid was noted in seven women by MRI alone. This data suggests that MRI is superior to US in examination of the entire pelvis in women with leiomyomas.

Reduced bone mass in reproductive-aged women with endometriosis.

Cortical and trabecular bone masses were measured by quantitative computed tomography of the distal radius in 41 women (30 +/- 1 yr) with endometriosis documented by laparoscopy and compared to those in 35 normal women (32 +/- 1 yr). Hormonal status was assessed, and a subset of 10 women with endometriosis underwent evaluation of calcium absorption and excretion. Menstrual cycles were regular in all women, and hormonal medication had not been administered during the 3 months before evaluation. Estradiol and progesterone varied as expected with the day of the cycle. Fasting calcium excretion was normal. Mean cortical and trabecular bone mass values in women with endometriosis were compared to those in the normal women. Women with endometriosis had significantly decreased cortical and trabecular bone mass. Cortical bone mass in normal subjects was 1263 +/- 11 Hounsfield units (HU), whereas in endometriosis, cortical bone mass measured 1133 +/- 16 HU (P less than 0.0001). Normal trabecular bone mass was 226 +/- 10 HU compared to a mean trabecular bone mass of 173 +/- 9 HU (P less than 0.0001) in endometriosis. Despite the decrease in bone mass documented by quantitative computed tomography, hormonal and calcium dynamics were normal and, therefore, did not appear to be significant etiological factors in regard to the bone loss. Since immunological abnormalities have been reported in association with endometriosis, immune factors may play a role in the development of bone loss in endometriosis and might be of pathogenic significance in this reproductive disorder.

Endometriosis: appearance and detection at MR imaging.

Thirty-nine magnetic resonance (MR) studies were performed on 31 women with surgically proved endometriosis. A total of 88 endometriotic lesions ranging in size from 0.2 to 7.5 cm were detected on 24 of 30 MR images of women. The signal intensities ranged from hyperintense on all pulse sequences (41 of 88) to hypointense on all sequences (24 of 88); the remainder demonstrated signal intensities corresponding to the appearances of acute, subacute, and chronic hematomas. Hypointense or signal-void rims on both T1- and T2-weighted images were detected in 35 lesions. Identification of the disease with MR imaging versus concurrent surgery was compared for 76 sites in 19 patients. Findings were true-positive in 24 cases, false-negative in ten, true-negative in 32, and false-positive in seven, resulting in an MR sensitivity of 71% and specificity of 82%. Adhesions obscured the disease at laparoscopy in three patients. MR imaging cannot be used as a substitute for laparoscopy in the definitive diagnosis or staging of endometriosis. However, it can be used to monitor treatment response in place of laparoscopy once a diagnosis is firmly established.

Blood pressure and body size in precocious puberty.

Blood pressure increases with age in normal children. This increase appears to be related to body size. To assess the role of body size as a determinant of blood pressure in precocious puberty, we compared the blood pressure of 81 children with precocious puberty with the blood pressure standards for normal children from the NHLBI Task Force on Blood Pressure Control in Children. Children with precocious puberty had significantly increased blood pressure for chronologic age (p less than 0.05) but generally appropriate blood pressure for height age or weight age. These data are consistent with the hypothesis that increased body size causes the increased blood pressure for chronologic age in children with precocious puberty. Physicians who evaluate such children should assess whether blood pressure is appropriate for height age rather than chronologic age.

Bipolar mood disorder and endometriosis: preliminary findings.

A consecutive sample of 16 women with laparoscopy-diagnosed endometriosis were evaluated for mood disorders. Twelve women met DSM-III criteria for a mood disorder: seven for bipolar disorder, mixed, three for bipolar disorder, manic, and two for major depression. Two women had equivocal diagnoses and two showed no evidence of mood disorder. Nine subjects had first-degree relatives with histories of severe mood disorders.