Dissociating Fibroepithelioma of Pinkus From Internal Malignancy: A Single-Center Retrospective Study.

Fibroepithelioma of Pinkus (FeP) is a rare skin tumor with a clinical presentation similar to benign neoplasms such as acrochordons and seborrheic keratoses. Our study analyzed if there is an association between FeP and internal tumors, specifically gastrointestinal tract tumors. We retrospectively reviewed the medical records of patients with FeP for other tumors throughout their lives until 2020. Although the quality of documentation for each patient may have differed, this study suggests that the presence of FeP does not indicate the presence of gastrointestinal tract tumors, and there is no need for altered cancer screening recommendations for those with FeP.

Treatment Challenges When Stopping Denosumab.

Introduction Denosumab is commonly used to treat osteoporosis. However, discontinuation results in rebound bone loss and increased vertebral fracture risk. We report a clinical case series, illustrating the dilemma in deciding the best treatment should denosumab be stopped. Cases In eight patients aged 56-89 years, zolendronic acid after stopping denosumab resulted in BTM rises and BMD decline.  In a 68-year-old, two years of oral bisphosphonate after three years of denosumab resulted in elevated bone turnover markers (BTM) and decline in bone mineral density (BMD), necessitating a switch to zoledronic acid.  In a 79-year-old, two annual doses of zolendronic acid after three years of denosumab failed to suppress high BTM, with BMD dropping and denosumab being restarted.  In a 60-year-old, on stopping denosumab after 10 years of oral bisphosphonate, BMD remained stable despite no further therapy. Conclusion Drug holidays are not an option with denosumab, with a risk of bone loss even on transitioning to bisphosphonates. Risk is greater with longer duration of treatment6 and may be mitigated by prior bisphosphonate use. Standard dose zoledronic acid does not prevent bone loss in a significant proportion of patients. BTM may help in monitoring treatment and need for further bisphosphonates.

Statistical analysis of fat and muscle mass in osteoporosis in elderly population using total body DXA scans.

BACKGROUND: The magnitude of effects of lean mass and fat mass on bone health is controversial, and this study is a contribution to understand its effects on skeletal composition. AIM: We explored the relationship of body fat and muscle parameters with bone mineral density (BMD) and age and observed if it changed when matched with body mass index (BMI) of the same study subjects. METHODS: One-hundred sixty-four community dwelling, ambulatory elderly attending the osteoporosis services of a Dublin hospital was recruited. Out of these, 158 female patients had a total body DXA scan, and their body composition outcomes were included in this analysis. The relationship between body fat and muscle composition and BMD at all sites was determined and also matched by BMI. RESULTS: Total-Body BMD had a strong positive correlation with lean mass(r = 0.492, p 0.00) and fat mass(r = 0.414, p 0.00), though lean mass remained the strongest predictor of BMD at all sites. Increasing BMI categorically had a positive effect on both lean mass and fat mass. Increasing age was significantly associated with an increase in fat mass(r = 2.40, p 0.00) and a decrease in muscle mass(r = 0.478, p 0.01). CONCLUSION: Both lean mass and fat mass are significant predictors of BMD. To preserve BMD maintenance or increase of lean mass is more effective than fat mass. BMI correlates well with body composition; however, we recommend the use of direct measures of body fat and muscle to make this relation more interpretable. Total Body DXA is a readily available diagnostic tool which provides high-valued information about body composition.

Malnutrition in the elderly and its effects on bone health - A review.

This article aims to provide an overview of the prevalence, causes and risk factors associated with malnutrition in the elderly. It includes the clinical consequences and economic impact of malnutrition in the elderly and in particular the osteoporotic population. It encompasses the significance of dietary protein and its effects on bone health.

An exploration of the bone health of older adults with an intellectual disability in Ireland.

BACKGROUND: Many risk factors have been confirmed for poor bone health among the general population including age, gender and corticosteroid use. There is a paucity of investigation among people with intellectual disability; however, research points to differing risks namely anti-epileptic medication use, Down syndrome and poor behaviour lifestyle. METHODS: Data was extracted from the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing in Ireland. In total, 753 participants took part, and data was gathered on participants' health status, behavioural health, health screenings and activities of daily living. The prevalence of osteoporosis and related risk factors were specifically examined. RESULTS: Overall, 8.1% reported a doctor's diagnosis of osteoporosis with over 20% reporting history of fracture. Risk identified included older age (P < 0.0001), female gender (P < 0.0001), difficulty walking (P < 0.0001) with older age and being female the stronger predictors for osteoporosis, odds ratio = 6.53; 95% confidence interval 2.82-15.11 and odds ratio = 4.58; 95% confidence interval 2.29-9.17, respectively. There was no gender difference regarding the level of fractures; however, epilepsy and anti-epileptic medication were strong predictors. Overall, 11.1% attended for bone screening diagnostics. CONCLUSION: Despite low levels of reported doctor's diagnosis of osteoporosis risk factor prevalence was high. Considering the insidious nature of osteoporosis and the low levels of diagnostic screening, prevalence could be possibly higher.

Assessment of hospital inpatient discharge summaries, written for general practitioners, from a department of medicine for the elderly service in a large teaching hospital.

BACKGROUND: The discharge document summarising an acute inpatient stay in hospital is often the only means of communication between secondary and primary care. This is especially important in the elderly population who have multiple morbidities and are often on many medications. AIMS: This study aimed to assess if information important to general practitioners is being included in inpatient hospital discharge summaries for patients of the medicine for the elderly service in a large teaching hospital. METHODS: After a thorough literature review, a "gold standard" letter was defined as having included a discharge diagnosis, medications on discharge and follow-up plans. Forty computerised discharge summaries were retrospectively assessed for inclusion of these parameters. The study group consisted of the first eight sequentially discharged patients under the care of each of the five consultants during a 1-month period (1 September 2011-30 September 2011). RESULTS: A discharge diagnosis was included in 37 of the 40 summaries (92.5 %), medications on discharge were included in 39 summaries (97.5 %) and follow-up was recorded in 35 summaries (87.5 %). CONCLUSIONS: This study showed that the information assessed was available in the vast majority of discharge summaries for patients admitted acutely under the care of this medicine for the elderly service. Improvements can be made, including documentation of follow-up plans.

An Association between MicroRNA-21 Expression and Vitamin D Deficiency in Coronary Artery Disease.

BACKGROUND: Atherosclerosis-related cardiovascular disease and osteoporosis (OP) occur concurrently and may share a common pathogenesis. Aberrant expression of miR-21 and vitamin D deficiency have been independently linked to the pathogenesis of atherosclerosis and OP. OBJECTIVES: To examine the relationship between miR-21 expression and vitamin D in aorta and bone in atherosclerotic disease. METHODS: Aorta, internal mammary artery (IMA) and sternal bone samples were collected from patients undergoing coronary artery bypass graft (CABG) surgery. Bone density was measured by dual x-ray absorbtiometry (DXA). MiR-21 was quantified using a two-step reverse transcription-polymerase chain reaction. RESULTS: Ten patients were included for analysis; 5 were vitamin D deficient (<25nmol/L). MiR-21 was expressed at a greater level in aorta compared with the IMA (p = 0.003), and sternal bone (p = 0.002). Expression of miR-21 between the IMA and bone was similar (p = 0.7). A positive correlation between the magnitude of difference (fold-difference) of miR-21 expression between aorta and IMA and CRP (correlation coefficient 0.9, p = 0.009) was found. Vitamin D deficient patients had greater expression of miR-21 in aorta compared with non-deficient patients (p = 0.03). Increasing CRP and vitamin D deficiency were independent predictors of miR-21 expression in aorta. The lower the difference in miR-21 expression between aorta and bone, the lower the bone density. CONCLUSION: In atherosclerosis, miR-21 is increased in the aorta and associated with vitamin D deficiency. Vitamin D deficiency may influence aberrant miR-21 expression in vasculature and bone contributing to the concurrent development of atherosclerosis and osteoporosis.

Discharge of patients to long-term care from a large acute hospital over a 12-year period.

BACKGROUND: Several factors may be important in determining the discharge of patients to long-term care from the acute hospital. AIMS: We aimed to look at factors associated with discharge to long-term care from St. James's Hospital, Dublin between 1997 and 2008. METHODS: Data obtained from a long-term care database within the geriatric service were analysed. This service is responsible for assessing and listing all patients for long-term care within the hospital. RESULTS: 3,107 patients were listed and 2,520 discharged to long-term care during the period. Mean age was 81.7±7.3 years and 64.1% were female. The number listed increased since 1997, but there was no change in age or gender. Median time to discharge was 52 days, but varied by year and was longer for public versus private facilities (mean difference=18 days, P=0.006). Mortality of those awaiting long-term care was 17.0%, but varied significantly by year and ranged form 9.3-29.0%. Mortality was higher in males, in those of older age and during the winter months. CONCLUSIONS: Variation in the time to discharge appears to be associated with changes in the provision of publicly funded private nursing home beds.

Patient profile in a bone health and osteoporosis prevention service in Ireland.

OBJECTIVES: To (1) characterise a cohort of patients attending a major osteoporosis clinic in Ireland and (2) examine the prescribing of preventative therapies amongst these patients. METHODS: Data were taken from 2006-2007 on patients attending the Osteoporosis Clinic at St. James's Hospital, Dublin. Information gathered included age, gender, fracture history, past medical and surgical history, co-morbidities, the results of the first DXA scans, anti-resorptive therapies along with other medications prescribed. RESULTS: Of all patients 87.6% were female and the mean age was 68 years (SD = 14.31). In total 166 (74%) patients had osteoporosis, 40 (17.8%) had osteopenia and 18 patients (8%) had normal T-score values, 163 (72.7%) had a history of a fracture. Only 13.7% of the patients did not have a documented history of other co-morbidities. CONCLUSION: Comprehensive services such as the Osteoporosis Clinic at St. James's Hospital can provide the necessary screening, monitoring and prescribing of appropriate osteoporosis medications with additional follow-up if required to this at risk group reducing the unnecessarily traumatic effects of the disease on patients.

Loneliness and vascular biomarkers: the Dublin Healthy Ageing Study.

BACKGROUND: Loneliness has been associated with poor physical health and a link has been suggested between the presence of loneliness, cardiovascular health and inflammatory markers. OBJECTIVE: To investigate the association between vascular disease biomarkers and loneliness in a community-dwelling non-demented elderly population. DESIGN: cross-sectional community based assessment. PARTICIPANTS: 466 subjects with mean age 75.45 (SD, 6.06) years. 208 (44.6%) were male. RESULTS: Higher levels of HbA1c, but not other vascular biomarkers were independently associated with being lonely. CONCLUSION: Loneliness was associated with raised levels of HbA1c in a community dwelling elderly population. The mechanism for this association has yet to be elucidated but may reflect an abnormal stress response in people who are lonely.

Subjective well-being amongst community-dwelling elders: what determines satisfaction with life? Findings from the Dublin Healthy Aging Study.

BACKGROUND: Life satisfaction is a subjective expression of well-being and successful aging. Subjective well-being is a major determinant of health outcomes in older people. The aim of this study was to determine which factors predicted well-being in older people living in the community as measured by their satisfaction with life. METHODS: The relationship between life satisfaction, as measured by the Life Satisfaction Index (LSI-A) and physical, cognitive and demographic variables was examined in 466 older people living in the community using a stepwise regression model. RESULTS: Depression, loneliness, neuroticism, extraversion, recent participation in physical activity, age and self-reported exhaustion, were the independent predictors of life satisfaction in our elderly cohort. CONCLUSION: Subjective well-being, as measured by the Life Satisfaction Scale, is predicted by depression, loneliness, personality traits, recent participation in physical activity and self-reported exhaustion. The mental and emotional status of older individuals, as well as their engagement in physical activity, are as important as physical functionality when it comes to life satisfaction as a measure of well-being and successful aging. These areas represent key targets for intervention.

Loneliness and cognition in older people: the Dublin Healthy Ageing study.

INTRODUCTION: While several studies have found a link between impaired cognition and social isolation, few have examined the relationship between cognition and loneliness. Loneliness has been thought to increase the risk of development of Alzheimer's dementia. AIM: The aims of this study were to explore the relationship between loneliness and cognition and to determine whether specific cognitive domains are associated with loneliness. DESIGN: Cross-sectional community-based study. PARTICIPANTS: This study included 466 community-dwelling subjects with mean age 75.45 (SD 6.06) years, of which 208(44%) were males. RESULTS: Loneliness was significantly associated with impaired global cognition independent of social networks and depression. The domains of psychomotor processing speed and delayed visual memory were specifically associated with self-reported loneliness. CONCLUSION: This cross-sectional study demonstrated an association between loneliness and specific aspects of cognition independent of depression, social networks and other demographics. The mechanism for this association is unclear and warrants further investigation.

Effects of teriparatide in postmenopausal women with osteoporosis pre-treated with bisphosphonates: 36-month results from the European Forsteo Observational Study.

OBJECTIVES: To describe fracture rates, back pain, and health-related quality of life (HRQoL) in postmenopausal women with osteoporosis and prior bisphosphonate therapy, treated with teriparatide for up to 18 months and followed up for a further 18 months. DESIGN: Prospective, multinational, and observational study. METHODS: Data on prior bisphosphonate use, clinical fractures, back pain visual analog scale (VAS), and HRQoL (EQ-5D) were collected over 36 months. Fracture data were summarized in 6-month intervals and analyzed using logistic regression with repeated measures. Changes from baseline in back pain VAS and EQ-VAS were analyzed using a repeated measures model. RESULTS: Of the 1581 enrolled patients with follow-up data, 1161 (73.4%) had a history of prior bisphosphonate use (median duration: 36 months). Of them, 169 (14.6%) sustained ≥1 fracture during 36-month follow-up. Adjusted odds of fracture were significantly decreased at each 6-month interval compared with the first 6 months of teriparatide treatment: 37% decrease in the 12 to <18 months period during teriparatide treatment (P=0.03) and a 76% decrease in the 12- to 18-month period after teriparatide was discontinued (P<0.001). Significant reductions in back pain and improvement in HRQoL were observed. CONCLUSIONS: Postmenopausal women with severe osteoporosis previously treated with bisphosphonates had a significant reduction in the incidence of fractures compared with the first 6 months of therapy, a reduction in back pain and an improvement in HRQoL during up to 18 months of teriparatide treatment. These outcomes were still evident for at least 18 months after teriparatide was discontinued. The results should be interpreted in the context of an uncontrolled, observational study in a routine clinical setting.

Fracture rate and back pain during and after discontinuation of teriparatide: 36-month data from the European Forsteo Observational Study (EFOS).

UNLABELLED: In this observational study in postmenopausal women with severe osteoporosis, the incidence of fractures was decreased during 18 months of teriparatide treatment with no evidence of further change in the subsequent 18-month post-teriparatide period when most patients took other osteoporosis medications. Fracture reduction was accompanied by reductions in back pain. INTRODUCTION: To describe fracture outcomes and back pain in postmenopausal women with severe osteoporosis during 18 months of teriparatide treatment and 18 months post-teriparatide in normal clinical practice. METHODS: The European Forsteo Observational Study (EFOS) was a prospective, multinational, observational study. Data on incident clinical fractures and back pain (100 mm Visual Analogue Scale [VAS] and questionnaire) were collected. Fracture data were summarised in 6-month intervals and analysed using logistic regression with repeated measures. Changes from baseline in back pain VAS were analysed using a repeated measures model. RESULTS: A total of 208 (13.2%) of 1,576 patients sustained 258 fractures during 36 months of follow-up: 34% were clinical vertebral fractures and 66% non-vertebral fractures. The adjusted odds of fracture were reduced during teriparatide treatment and there was no evidence of further change in the 18-month post-teriparatide period, during which 63.3% patients took bisphosphonates. A 74% decrease in the adjusted odds of fracture in the 30- to <36-month period compared with the first 6-month period was observed (p < 0.001). Back pain decreased during teriparatide treatment and this decrease was sustained after teriparatide discontinuation. Adjusted mean back pain VAS decreased by 26.3 mm after 36 months (p < 0.001) from baseline mean of 57.8 mm. CONCLUSIONS: In a real-life clinical setting, the risk of fracture decreased during teriparatide treatment, with no evidence of further change after teriparatide was discontinued. The changes in back pain seen during treatment were maintained for at least 18 months after teriparatide discontinuation. These results should be interpreted in the context of the design of an observational study.

Primary-care prescribing of anti-osteoporotic-type medications following hospitalisation for fractures.

PURPOSE: We examined the prescribing of antiosteoporotic medications pre- and post hospital admission in patients with fragility fractures as well as factors associated with prescribing of these treatments following admission. METHODS: We identified all patients aged ≥ 55 years at a large teaching hospital between 2005 and 2008 with a fracture using the Hospital In-Patient Enquiry (HIPE) system. These data were linked to prescribing data from the Health Service Executive Primary Care Reimbursement Services (HSE-PCRS) scheme before and after discharge (821 patients). Logistic regression analysis was used to examine the likelihood of prescription of antiosteoporotic medication pre- and post discharge in relation to year of discharge, age, gender, and type of fracture. RESULTS: Prescribing of antiosteoporotic treatment before fracture increased from 2.6% [95% confidence interval (CI) 2.23-2.93%] in 2005 to 10.6% (95% CI 9.32-11.86) by 2008, whereas post fracture prescribing increased from 11% (95% CI 9.64-12.36) to 47% (95% CI 43.6-50.3). In patients discharged from hospital in 2007, postfracture prescribing was 31.8% (95% CI 28.66-35.02) at 12 months, increasing to 50.3% (95% CI 46.6-53.9) at 24 months. The highest rate of prescribing was in the 65- to 69-year age group [odds ratio (OR) 8.51, 95% CI 1.75-41.35]. Patients discharged in 2008 were eight times more likely to be treated than patients discharged in 2005 (OR 8.01, 95% CI 4.55-14.09). CONCLUSION: The percentage of patients on antiosteoporotic treatment post fracture increased significantly from 2005 to 2008. This may be largely due to the introduction of the Osteoporosis Clinic to the hospital in 2005.

Detecting prodromal Alzheimer's disease in mild cognitive impairment: utility of the CAMCOG and other neuropsychological predictors.

BACKGROUND: The Cambridge cognitive examination (CAMCOG) is a mini neuropsychological battery which is well established and widely used. The utility of the CAMCOG in detecting prodromal Alzheimer's disease (AD) in patients with mild cognitive impairment (MCI) has not been determined. The objectives of this study are: to establish which subtests of cognitive domains contained within the CAMCOG are predictive of conversion to AD, to compare these with an extended version of the delayed word recall (DWR) test and to establish optimal cut points for all measures used. METHODS: 182 patients with MCI were identified from consecutive referrals to a memory clinic. Logistic regression, cox regression and receiver operating characteristic curve (ROC) analyses were conducted. RESULTS: The DWR displayed the best sensitivity (77%) and specificity (76%). The composite memory score contained within the CAMCOG achieved similar sensitivity (78%) and specificity (74%). The recognition component of the extended DWR demonstrated good specificity (85%) but poor sensitivity (57%). The optimal predictive model combined category fluency with the DWR and achieved predictive accuracy of 83%. CONCLUSION: The DWR, which is a test specifically designed to have high predictive accuracy for AD, performed best. The composite measure of memory contained within the CAMCOG performed similarly well. The DWR has the advantage of being brief, easy to administer and suitable for use in non-specialist settings. The CAMCOG takes longer to administer but provides information regarding additional cognitive domains and is sensitive to change over time. Category fluency may be usefully combined with the DWR to improve predictive accuracy.

Survival of patients discharged to long term care.

Data on the life expectancy of elderly people in long term care facilities will be important for effective service planning and monitoring quality of care. To date there are no such data from an Irish perspective. A random sample of patients discharged to long term care between Jan 1st 1997 and December 31st 2003 from a single Dublin hospital was studied. Death by January 1st 2005 was ascertained through the register of births deaths and marriage. Median survival was calculated and factors associated with mortality were determined in a logistic regression. Mean (sd) age was 82 (11) years and 61 (29%) were female. Median survival was 30.3 (95%CI 22.4-45.0) months (mean Irish life expectancy at this age is about 78 months). Three factors were independently associated with death by 2 years: age (Odds ratio 1.11 [95%CI 1.05-1.17, F ratio 15.1, p=0.0001] per year), male gender (Odds ratio 1.52 [95%CI 1.05-3.68, F ratio 5.2, p=0.024]) and discharge to continuing care (Odds ratio 1.96 [1.05-3.68, F ratio 4.4, p=0.037]). These results (which are the first such Irish data) show that patients discharged to long term care are a frail group with a reduced life expectancy. Encouragingly survival for this cohort (25% at 1 year) was similar to that seen in other countries. Data on nursing home survival will allow more accurate planning of long term residential services and help monitor quality of care.

Behavioural disturbance triggers recognition of dementia by family informants.

OBJECTIVE: To determine the frequency of unrecognised dementia in a group of community dwelling elderly, and to identify factors associated with dementia recognition by informants. SAMPLE SELECTION: People over 65 years with an AGECAT case or subcase organic diagnosis or an MMSE < or = 23 were identified from a database of community dwelling elderly. A psychiatrist to confirm the diagnosis of dementia according to ICD-10 criteria interviewed these individuals. STUDY PARTICIPANTS: Sixty-two community dwelling elderly meeting ICD-10 criteria for dementia whom had reliable informants. METHODS: Prior to the start of the interview the informant was questioned about whether they felt the patient had memory difficulties and if so whether they had a medical evaluation for their memory problems. A psychiatrist then interviewed the patient and informant to establish whether that patient met ICD-10 criteria for dementia. Basic sociodemographic details were collected and the following assessments were carried out: the Blessed Dementia Rating Scale, the Clinical Dementia Rating Scale, the Behave-AD and the Baumgarten Behavioural Disturbance Scale. ANALYSIS: Univariate and step-wise forward logistic regression analysis were used to examine the factors associated with recognition of memory difficulties. RESULTS: Twenty-nine percent of family informants of people with dementia failed to recognise a problem with their relatives'memory. Where memory difficulties were recognised only 39% of this group received a medical evaluation. Using univariate analysis recognition of memory difficulties by family informants was associated higher levels of behaviour disturbance ( p = or < 0.0011), greater functional impairment ( p = 0.0039), with increasing cognitive impairment ( p = 0.013). Using a logistic regression model, to test the independence of these variables, increasing behavioural disturbance (p = 0.0001) was associated with recognition of dementia by family informants. CONCLUSIONS: Recognition of memory problems by family members is associated with increasing behavioural disturbance. Even with recognition of dementia, families often fail to seek medical attention. Education of the lay public on the early signs and symptoms of dementia must be a key first step in improving recognition of dementia in the community dwelling elderly.

Co-morbid and socio-demographic factors associated with cognitive performance in an elderly community dwelling Irish population.

BACKGROUND: Epidemiological studies suggest an association between health factors and dementia. The impact of these factors on the cognitive performance of the elderly population is unclear. Possible correlates of poor cognitive performance in a community dwelling elderly Irish population were examined. METHODS: Subjects were from a sample of individuals over 65 years agreeable to interview using the Geriatric Mental State (GMS)-Automated Geriatric Examination for Computed Assisted Taxonomy (AGECAT) package conducted at the subject's home. Associations between patient profiles and Mini Mental State Examination (MMSE) score were investigated in a multivariate model. RESULTS: There were 793 subjects, 528 (66.6%) female with mean (s.d.) age 74.8 (6.7) yrs. Mean MMSE score was 26.5 (3.3). 169 (21.3%) were current smokers, 198 (25%) ex-smokers. Two hundred and twenty-four (28.3%) had a history of hypertension, 85 (10.7%) case level anxiety or depression, 51 (6.4%) stroke, ten0 (1.3%) epilepsy, nine (1.1%) Parkinson's disease and 29 (3.7%) dementia. Two hundred and fifty-five (32.2%) subjects were on psychotropic medications. Factors associated with MMSE score included age (p < or = 0.0001), diagnosis of dementia (p < or = 0.0001), socioeconomic group (p < or = 0.0001), education (p < or = 0.0001), previous stroke (p = 0.0013) and use of psychotropic medication (p = 0.03). Case level anxiety or depression (p = 0.99), Parkinson's disease (p = 0.52), epilepsy (p = 0.26), smoking status (p = 0.99) and hypertension (p = 0.34) were not found to be associated with cognitive performance. CONCLUSION: Factors associated with cognitive performance included age, socioeconomic group, education, previous stroke and use of psychotropic medication. These factors should be adjusted for in studies assessing cognition in this population. Stroke prevention strategies and avoidance of psychotropic medication may benefit cognitive performance.