Development and validation of a fall risk Questionnaire in Greek community-dwelling individuals over 60 years old.

Objectives: The purpose of this study was to develop a questionnaire that can reliably recognize Greek individuals over the age of 60 with increased risk of falls. Methods: An 11-item self-reported Questionnaire (LRMS) was developed and delivered to 200 individuals. Collected data were compared to Timed Up and Go (TUG), Falls Efficacy Scale-International (FES-I), Tinetti Assessment Tool, Geriatric Depression Scale-15 (GDS-15) and Morse fall scale. The results were statistically analyzed. Results: Correlation between LRMS and the examined tools was high TUG (r=0.831), FES-I (r=-0.820), Tinetti balance (r=-0.812), Tinetti gait (r=-0.789), GDS-15 (r=-0.562), and Morse fall scale (r=0.795). Cronbach's alpha for LRMS total score was 0.807. ICC of the LRMS total score was 0.991. The area under the curve of LRMS was 0.930 (cut-off point 10.5, 95% C.I. 0.88 - 0.98, p<0.001, sensitivity=86%, specificity=98%) with TUG as gold standard, 0.919 (cut-off point 11.5, 95% C.I. 0.88 - 0.96, p<0.001, sensitivity=85%, specificity=89%) with FES-I and 0.947 (cut-off point 10.5, 95% C.I. 0.91 - 0.98, p<0.001, sensitivity=93%, specificity=91%) with Tinetti. Conclusions: The LRMS Questionnaire showed sufficient internal consistency, excellent test-retest reliability and high correlation with the already established tools for fall risk assessment. It is short and easy to use without assistance from specially trained personnel.

Change in kyphosis does not affect the risk of falling in postmenopausal osteopenic and osteoporotic women.

OBJECTIVES: To examine the influence of the annual change in kyphosis on the risk of falling in postmenopausal osteopenic and osteoporotic women. METHODS: This prospective observational study included 498 postmenopausal Greek women over the age of 50, suffering from either osteoporosis or osteopenia. Data on age, height, weight, and self-reported falls were collected. Additionally, we evaluated the degree of the kyphosis angle, the balance, the mobility, the functionality and the handgrip strength on both hands of each subject using the Debrunner kyphometer, the Berg Balance Scale, the Timed-Up-and-Go test, the 30 Seconds Sit-to-Stand test and the Jamar Hydraulic Hand Dynamometer, respectively. All the above data were recorded at the baseline visit and the 12-month follow-up visit for each participant. RESULTS: All examined variables presented a statistically significant change at the 12-month follow-up visit. Nevertheless, the annual change in kyphosis did not show any association with the risk of falling. CONCLUSION: No association was shown between the annual change in kyphosis and the risk of falling in postmenopausal osteopenic and osteoporotic women, nor bears any substantial prognostic value for future falls.

Bone metabolism subgroups identified as hip fracture patients via clustering.

PURPOSE: The aim of the study was to describe the bone metabolism status that underlies a hip fracture. METHODS: Estimated glomerular filtration rate (e-GFR), calcium (Ca), phosphorus (P), total (ALP) and bone specific alkaline phosphatase (b-ALP), intact parathyroid hormone (i-PTH), 25-hydroxy-vitamin D (25OHD), total procollagen type I amino-terminal propeptide (PINP), and N-terminal peptide of collagen I (NTx), measured at admission in 272 hip fracture patients, were ex post analyzed by K-means clustering and principal component analysis and were evaluated by a clinician. RESULTS: Four components, mainly consisting of b-ALP, PINP, ALP, and NTx; e-GFR and P; i-PTH and 25OHD; and Ca explained about 70% of the variability. A total of 184 patients clustered around a centroid (A) with low 25OHD (13.2 ng/ml), well-preserved kidney function (e-GFR=67.19 ml/min/1.73m2), normal Ca, P, i-PTH and bone markers, with the exception of slightly increased NTx (24.82nMBCE). Cluster B (n=70) had increased i-PTH (93.38 pg/ml), moderately decreased e-GFR, very low 25OHD (8.68 ng/dl), and high bone turnover (b-ALP 28.46 U/L, PINP 69.87 ng/ml, NTx 31.3nMBCE). Cluster C (n=17) also had hyperparathyroidism (80.35 pg/ml) and hypovitaminosis D (9.15 ng/ml), low e-GFR(48.89 ml/min/1.73m2), and notably high ALP (173 U/L) and bone markers (b-ALP 44.64 U/L, PINP 186.98 ng/ml, NTx 38.28nMBCE). According to the clinician, 62 cases clearly had secondary hyperparathyroidism. CONCLUSIONS: Based on serum measurements, the dominant patterns of bone metabolism were normal bone turnover with high normal NTx, and secondary hyperparathyroidism related to chronic kidney disease and hypovitaminosis D. The bone formation markers, e-GFR, NTx, and P composed the most important factors.

Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition.

Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fractureamong people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, andsubcutaneous pharmacotherapies are efficaciousandcanreduce risk of future fracture.Patientsneededucation,however, about thebenefitsandrisks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive butmay be beneficial for selected patients at high risk.Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the earlypost-fractureperiod,prompt treatment is recommended.Adequate dietary or supplemental vitaminDand calciumintake shouldbe assured. Individuals beingtreatedfor osteoporosis shouldbe reevaluated for fracture risk routinely, includingvia patienteducationabout osteoporosisandfracturesandmonitoringfor adverse treatment effects.Patients shouldbestronglyencouraged to avoid tobacco, consume alcohol inmoderation atmost, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease).

Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition.

Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, and subcutaneous pharmacotherapies are efficacious and can reduce risk of future fracture. Patients need education, however, about the benefits and risks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive but may be beneficial for selected patients at high risk. Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the early post-fracture period, prompt treatment is recommended. Adequate dietary or supplemental vitamin D and calcium intake should be assured. Individuals being treated for osteoporosis should be reevaluated for fracture risk routinely, including via patient education about osteoporosis and fractures and monitoring for adverse treatment effects. Patients should be strongly encouraged to avoid tobacco, consume alcohol in moderation at most, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease). © 2019 American Society for Bone and Mineral Research.

Application of current sarcopenia definitions in spinal cord injury.

OBJECTIVE: Little is known about how appropriate the working definitions of sarcopenia are in subjects with spinal cord injury (SCI). This study aimed to evaluate the application of current sarcopenia definitions in SCI. METHODS: We compared 31 complete SCI men with 33 able-bodied age matched subjects. All were examined by whole body DXA (Norland XR 36, USA) regarding muscle and fat mass and by peripheral quantitative computed tomography (pQCT XCT-3000, Germany) in 66% of tibia's length (muscle cross sectional area, (CSA) in mm2). Low muscle mass was defined by skeletal muscle index, (SMI= appendicular lean mass (aLM)/height2 in Kg/m2) and by the residual method: relative aLM, 20th percentile of the distribution of residuals as the cutoff point, (RASM), respectively. CSA is a surrogate for force. RESULTS: We found lower values on RASM (p<0.001), and SMI (p<0.001) compared to controls in SCI and difference in the rate of sarcopenia according to sarcopenia definitions. CSA was significantly decreased in SCI (p<0.001) and correlation with duration of paralysis was weak. CONCLUSION: Current functional definitions of sarcopenia classify different individuals as sarcopenic. Sarcopenia was more prevalent in SCI. The sensitivity and specificity of using these measurements in SCI remain unclear.

Evaluation of physical performance in musculoskeletal and rheumatic diseases with jumping mechanography.

OBJECTIVE: Low muscle function is a component of sarcopenia. Rheumatic and musculoskeletal diseases are related to increased muscle loss and decreased muscle performance. Our purpose was to study muscle function among pre and postmenopausal women and women with rheumatic diseases. METHODS: Two hundred fifty seven women were included in the study: Group POST OST included 61 osteoporotic postmenopausal women under treatment with osteoporotic drugs and calcium/vitamin D supplements (mean age 65±9.6 years), group POST HEALTH consisted of 117 healthy postmenopausal women (mean age 62.9±9.8 yrs), Group RHEUM included 20 women with rheumatic diseases (mean age 58.85±13yrs), and group PRE included 59 healthy premenopausal women (mean age 35±7.6 yrs). For the measurement of objective parameters of movement (Force, velocity, Power), we used the mechanography system in Leonardo platform (Novotec, Germany). Personal Power (Power/Weight) was also calculated. RESULTS: Height was decreased with age, while body mass index (BMI) and weight were significantly increased. In groups POST OST, POST HEALTH, RHEUM, all measured parameters were statistically decreased in comparison with group PRE. No statistical significance was found among POST HEALTH and POST OST women. CONCLUSIONS: Jumping mechanography can be proposed as a novel tool to assess physical performance in musculoskeletal and rheumatic diseases. It offers to the clinician additional information, while quantitatively assesses muscle function, for assessing sarcopenia.

Clinical manifestations of osteoarthritis in osteoporotic and osteopenic postmenopausal women.

OBJECTIVE: We investigated the frequency of clinical manifestations of osteoarthritis in women with low BMD. METHODS: This prospective epidemiological study investigated the degree of osteoarthritic pain and functional disability in symptomatic joints of a randomly selected population of postmenopausal Greek women aged >45 years with osteoporosis or osteopenia. Degree of osteoarthritic impairment (none, mild, moderate or severe) was classified at the knee, hip, neck or hand using a site-specific internationally validated osteoarthritis questionnaire. RESULTS: 3000 women were included with mean age of 66.7 years. Osteoporosis was more common than osteopenia. Mild osteoarthritic impairment was most prevalent. An inverse relationship between severity of osteoarthritic impairment and mean femoral neck T-score was observed, regardless of site. There was a significant difference in mean femoral neck T-score between patients with severe osteoarthritic impairment and those with no, mild, or moderate impairment. This was also observed when lumbar spine BMD results were pooled. CONCLUSIONS: Most postmenopausal women with low BMD suffer from osteoarthritic impairment, with an inverse association between severity of osteoarthritic impairment and mean femoral neck T-score. Mean lumbar spine or femoral neck T-scores of patients with severe osteoarthritic impairment were significantly lower than those of patients with less impairment.

Assessment of the antiosteoporotic treatment initiation: A retrospective observational study in Greece.

OBJECTIVE: A study to retrospectively assess the decision to implement treatment for osteoporosis based on Greek version of FRAX tool. METHODS: The study population was 1000 postmenopausal women aged 45 or above, excluding those with medical conditions demanding specific osteoporosis management. Data were collected regarding their medical history and additionally, risk factors incorporated in FRAX questionnaire. FRAX score was estimated at the time of the anti-osteoporotic treatment initiation. RESULTS: The mean age of the study sample was 58.5±8.79 years. 46.8% of the participating osteopenic women had initiated treatment for osteoporosis at their first consultation while the 80.6% met the current national intervention threshold of FRAX tool. CONCLUSION: Stemming from our results there is an indication that women who are borderline eligible for treatment and seek consultation for osteoporosis are likely to be given treatment regardless of the potential benefit. One cannot ignore the fact that a clinician's good clinical judgment is of the utmost importance and under no circumstances can be replaced by any prognostic assessment tool.

Evaluation of commonly used nutritional assessment methods in hip fracture patients.

OBJECTIVE: Malnutrition is a common problem in hip fracture patients. The prevalence of malnutrition and available nutritional markers for use for nutritional assessment in this population group was investigated. METHODS: This is a case control study including 214 patients with a hip fracture from "KAT" Hospital in Athens, Greece, and 108 controls from three Elderly Open Protection Centers. Main outcome measures were anthropometric [Body Mass Index (BMI), triceps skinfold thickness (TST) and mid-arm muscle circumference (MAMC)] and biochemical parameters (serum albumin and serum cholesterol). Mini Nutritional Assessment (MNA) was used for malnutrition assessment. RESULTS: Based on MNA score only, we found 19.5 % vs. 0.9% malnourished, 54.6% vs. 32.4% at risk and 25.9% vs. 66.7% well-nourished, in hip fracture group and controls, respectively. All anthropometric parameters of malnutrition were significantly lower in the hip fracture patients compared to controls (p value<0.05). Serum albumin and serum-cholesterol levels correlated negatively significantly with s-CRP levels (R2=0.247, p<0.001 and R2=0.06, p<0.001, respectively) in the hip fracture group. CONCLUSIONS: Hip fracture patients are often malnourished. MNA application may be helpful in identifying malnourished hip fracture patients. Moreover, serum cholesterol may be a useful marker of malnutrition in hip fracture patients.

Evaluation of the first fracture liaison service in the Greek healthcare setting.

We evaluated the first implementation of FLS in the Greek healthcare setting, at the 251 Hellenic Air Force and VA General Hospital of Athens. Participation rate was moderate (54.5%) and needs improvement; osteoporosis medication was either suggested or reviewed in 74 out of the 116 patients recruited. PURPOSE: The purpose of this study was to evaluate the first implementation of a fracture liaison service (FLS) in Greece, at the 251 Hellenic Air Force and VA General Hospital, Athens. METHODS: Single-center, prospective study from May 1, 2013 to April 30, 2015 (first year-second year follow-up) was conducted. Patients of both genders aged 40-90 years old, with a history of a low trauma fracture and willing to participate, were included after identification by an FLS nurse. Following recruitment, osteoporosis risk factors were assessed, FRAX score was calculated for treatment-naïve patients, bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (DXA), and osteoporosis treatment was suggested where applicable. The rate of participation, the indication of osteoporosis treatment, and the difficulties met were evaluated. RESULTS: Of the eligible 213 patients, 97 (45.5%) were reluctant to participate for personal reasons. From the 116 initially recruited patients (mean age 74.8 ± 12 years), 77 (66.4%) discontinued their participation at some point for various reasons and 39 patients concluded the study. All 116 patients were assessed for osteoporosis risk factors and given a tailor-made exercise and education program, while FRAX score was assessed in all treatment-naïve patients (74 patients, 63.8%). Osteoporosis medication was suggested or reviewed in 74 patients; however, an adherence rate of 100% is only available for the 24 who concluded the study. CONCLUSIONS: We report the first implementation of FLS in the Greek healthcare setting. The participation rate is moderate and definitely needs improvement.

Development and validation of an osteoporosis treatment questionnaire (OSTREQ) evaluating physicians' criteria in the choice of treatment.

OBJECTIVE: This article describes the development and validation of the osteoporosis treatment questionnaire (OSTREQ), which is a physician-reported outcome tool aiming to evaluate physicians' criteria in the choice of osteoporosis treatment. DESIGN: The questionnaire -named OSTREQ- consisting of 17 questions that were divided into eight sections "Health Care System", "Patients' Preference in administration routes", "Usage, Cost", "Severity of Disease", "Treatment Efficacy", "Safety Profile", "Pharmaceutical Industry", affecting the decision and overall execution of a therapeutic approach, was developed by an expert panel and was later officially translated into English. In the second phase, orthopedic surgeons were asked to complete OSTREQ. Six indirect methods to evaluate validity were adopted: exploratory factor analysis, confirmatory factor analysis, subscale validity, known group validity, floor or ceiling effects, interpretability. To assess the reliability of the questionnaire, internal consistency validity as well as test-retest and parallel forms were calculated. RESULTS: One hundred seventy-two orthopedic surgeons were interviewed with an average period of experience in clinical practice of 10.5 years (SD ±8.9 years). The factors "Severity of Disease" and "Treatment Efficacy" were the most important in the choice of osteoporosis treatment, while the factor "Pharmaceutical Industry" had the least impact. The methodology of validation proved that the questionnaire possesses construct validity, discriminate ability, reliability, and sensitivity to change. CONCLUSIONS: OSTREQ represents a comprehensive and focused tool that, for the first time, assesses physicians' criteria in the choice of osteoporosis treatment. This tool could assist health care systems and pharmaceutical companies to be aware which parameters drive physicians' preferences regarding osteoporosis treatment.

Bone disease in anorexia nervosa.

Anorexia nervosa is a serious psychiatric disorder accompanied by high morbidity and mortality. It is characterized by emaciation due to self-starvation and displays a unique hormonal profile. Alterations in gonadal axis, growth hormone resistance with low insulin-like growth factor I levels, hypercortisolemia and low triiodothyronine levels are almost universally present and constitute an adaptive response to malnutrition. Bone metabolism is likewise affected resulting in low bone mineral density, reduced bone accrual and increased fracture risk. Skeletal deficits often persist even after recovery from the disease with serious implications for future skeletal health. The pathogenetic mechanisms underlying bone disease are quite complicated and treatment is a particularly challenging task.

Effect of parathyroidectomy versus risedronate on volumetric bone mineral density and bone geometry at the tibia in postmenopausal women with primary hyperparathyroidism.

The objective of the study was to evaluate the effect of parathyroidectomy (PTX) versus 35 mg once-weekly (ow) risedronate administration on volumetric bone mineral density (vBMD) and bone geometry at the tibia in postmenopausal women with primary hyperparathyroidism (PHPT). Our open-label prospective observational study included 32 postmenopausal women with PHPT as the study group: 16 underwent PTX and 16 were treated with 35 mg ow risedronate for 2 years. We assessed areal BMD (aBMD) by DXA, and vBMD and bone mineral content (BMC) (cortical and trabecular area) by peripheral quantitative computed tomography (pQCT) at the tibia at baseline and at 2 years. Risedronate did not result in any significant change on vBMD and structural pQCT indices. PTX resulted in significant increase in trabecular (trab) BMC (6.44 %) and vBMD (4.64 %), with percent increase being significantly higher than risedronate (p < 0.05). At cortical sites, there was no significant change following PTX. However, the percent change in cortical (cort) vBMD was higher following PTX versus risedronate (0.39 % vs. -0.26 %, p < 0.05). In conclusion, in postmenopausal women with PHPT, PTX is superior to ow risedronate, in terms of improvement of trabecular mineralization and vBMD at the tibia, whereas the effect at cortical sites is less pronounced.

Effect of rheumatoid arthritis on volumetric bone mineral density and bone geometry, assessed by peripheral quantitative computed tomography in postmenopausal women treated with bisphosphonates.

OBJECTIVE: To investigate the effect of rheumatoid arthritis (RA) on volumetric bone mineral density (vBMD) and bone geometry in postmenopausal women treated with bisphosphonates. METHODS: Fifty-three postmenopausal women with RA and 87 control subjects, comparable in terms of age, body mass index, and years since menopause, underwent peripheral quantitative computed tomography (pQCT) of the nondominant tibia. RESULTS: At 4% (trabecular site), trabecular bone mineral content (BMC) and vBMD (p < 0.001) were lower in the RA group, while trabecular area was comparable. At 38% (cortical site), cortical BMC (p < 0.01), area (p < 0.05), and thickness (p < 0.001) were lower in the RA group, whereas vBMD was comparable. Endosteal circumference was higher (p < 0.05), whereas periosteal circumference was comparable, indicating cancellization of cortical bone. In the RA group, muscle area was lower (p < 0.001), while at 14% polar stress strength index was significantly lower (p < 0.01) in patients with RA, indicating impairment of bone mechanical properties. CONCLUSION: RA is associated with negative effects on both cortical and cancellous bone in postmenopausal women treated with bisphosphonates. Cortical geometric properties are also adversely affected mainly by increased endosteal circumference, whereas trabecular geometric properties are generally preserved.

Hypovitaminosis D as a risk factor of subsequent vertebral fractures after kyphoplasty.

BACKGROUND CONTEXT: Over the past 20 years, methods of minimally invasive surgery have been developed for the treatment of vertebral compression fractures. Balloon kyphoplasty and vertebroplasty are associated with a recurrent fracture risk in the adjacent levels after the surgical procedure. In certain patient categories with impaired bone metabolism, the risk of subsequent fractures after kyphoplasty is increased. PURPOSE: To determine the incidence of recurrent fractures after kyphoplasty and explore whether the status of bone metabolism and 25-hydroxyvitamin D (25(OH)D) levels affect the occurrence of these fractures. STUDY DESIGN: Prospective longitudinal clinical study. PATIENT SAMPLE: Forty female postmenopausal women with primary osteoporosis and acute symptomatic vertebral compression fractures. OUTCOME MEASURES: Identification of new vertebral fractures and documentation of indicators of bone metabolism. METHODS: A total of ninety-eight kyphoplasties were performed in 40 female patients. Balloon kyphoplasty was performed on all symptomatic acute vertebral compression fractures. Age, body mass index, history of tobacco use, number of initial vertebral fractures, intradiscal cement leakage, history of nonspinal fractures, use of antiosteoporotic medications, bone mineral density, bone turnover markers, and 25(OH)D levels were assessed. All participants were evaluated clinically and/or radiographically. Follow-up period was 18 months. RESULTS: The mean population age was 70.6 years (range, 40-83 years). After initial kyphoplasty procedure, nine patients (11 levels) (22.5% of patients; 11.2% of levels) developed a postkyphoplasty vertebral compression fracture. Cement leakage was identified in seven patients (17.5%). The patients without recurrent fractures after kyphoplasty demonstrated higher levels of 25(OH)D (22.6±5.51 vs. 14.39±7.47; p=.001) and lower N-terminal cross-linked telopeptide values (17.11±10.20 vs. 12.90±4.05; p=.067) compared with the patients with recurrent fractures. CONCLUSIONS: Bone metabolism and 25(OH)D levels seem to play a role in the occurrence of postkyphoplasty recurrent vertebral compression fractures.

Postural profile and falls of osteoporotic women.

OBJECTIVES: 1. To compare postural alignment in erect standing between osteoporotic fallers, osteoporotic non-fallers and healthy women. 2. To compare BMI, number of fractures and intensity of pain between osteoporotic fallers and non-fallers. METHODS: Thirty-six osteoporotic women with vertebral fractures and 40 healthy women participated in the study. Spinal curvatures were assessed with a digital inclinometer. Photographic measurements of knee, hip, shoulder and head were carried out in sagittal plane. RESULTS: Significant differences were found between osteoporotic fallers and healthy women in the head (p=0.040), and thoracic angles (p=0.001). Significant differences were found between fallers and non-fallers in BMI (p=0.000), number of fractures (p=0.033) and pain (p=0.005), with fallers being heavier, with less fractures and pain than non-fallers. CONCLUSIONS: Osteoporotic fallers probably differ from osteoporotic non-fallers and healthy women. Researchers and clinicians may consider, in the future, the above differences when planning research and clinical intervention in this field. Replication studies are necessary to confirm the present findings.