Predictive factors of osteoporotic hip fracture in octogenarians.

OBJECTIVE: This study aims to identify the risk factors associated with osteoporotic hip fractures in octogenarians and seeks to refine primary prevention strategies for these fractures. MATERIAL AND METHODS: We conducted a case-control study involving individuals aged 79 years and older with hip fractures, comparing them to age- and sex-matched controls without a history of hip fractures. We collected epidemiological, clinical, anthropometric, and analytical factors. We evaluated the presence of osteoporosis using bone densitometry. We defined sarcopenia according the European Working Group on Sarcopenia in Older People criteria (EWGSOP2). RESULTS: Ninety-five patients per group were analyzed, with a mean age of 82 years, of which 74% were women. The multivariate analysis included statistically significant factors found in the univariate analysis (p < 0.05). These factors included the Barthel Index, nutritional assessment using the CONUT tool, folic acid, vitamin D deficiency, presence of previous fractures, loss of visual acuity, bicipital circumference, sarcopenia, and osteoporosis (densitometry in the neck of the femur). The Nutritional state (OR: 0.08 [0.01-0.61]), the folic acid levels (OR 0.32 [0.1-1]), and a loss of visual acuity (OR 33.16 [2.91-377.87]) were the independent risk factors associated with hip fracture. CONCLUSIONS: The assessment of nutritional status in elderly patients, coupled with a comprehensive geriatric assessment, represents easily reproducible and cost-effective tools. These tools can effectively aid in identifying individuals at risk of hip fractures, thereby contributing to more targeted and efficient preventive measures.

Osteoporotic vertebral fractures: A diagnostic challenge in the 21st century.

Vertebral fractures are the most prevalent osteoporotic fractures and are paradoxically the most underdiagnosed. While only one-third of patients have acute pain, they can present other associated chronic complications. Vertrebal fractures are associated with the onset of new fractures, both vertebral and nonvertebral. Radiography of the dorsal-lumbar spine is a useful tool for detecting them but depends on the subjective interpretation of the physician conducting the assessment. New techniques, such as vertebral morphometry, have recently demonstrated greater efficacy in detecting v vertebral fractures and are performed concomitantly with bone densitometry. Knowing how to identify vertebral fractures is essential for the secondary prevention of new fractures and improving our patients' quality of life.

Osteoporotic vertebral fractures: A diagnostic challenge in the 21ST century. / Fracturas vertebrales osteoporóticas: un reto diagnóstico en el siglo XXI.

Vertebral fractures are the most prevalent osteoporotic fractures and are paradoxically the most underdiagnosed. While only one-third of patients have acute pain, they can present other associated chronic complications. Vertrebal fractures are associated with the onset of new fractures, both vertebral and nonvertebral. Radiography of the dorsal-lumbar spine is a useful tool for detecting them but depends on the subjective interpretation of the physician conducting the assessment. New techniques, such as vertebral morphometry, have recently demonstrated greater efficacy in detecting v vertebral fractures and are performed concomitantly with bone densitometry. Knowing how to identify vertebral fractures is essential for the secondary prevention of new fractures and improving our patients' quality of life.

Cut-off Points for Muscle Mass - Not Grip Strength or Gait Speed - Determine Variations in Sarcopenia Prevalence.

OBJECTIVES: The European Working Group on Sarcopenia in Older People (EWGSOP) has proposed different methods and cut-off points for the three parameters that define sarcopenia: muscle mass, muscle strength and physical performance. Although this facilitates clinical practice, it limits comparability between studies and leads to wide differences in published prevalence rates. The aim of this study was to assess how changes in cut-off points for muscle mass, gait speed and grip strength affected sarcopenia prevalence according to EWGSOP criteria. METHODS: Cross-sectional analysis of elderly individuals recruited from outpatient clinics (n=298) and nursing homes (n=276). We measured muscle mass, grip strength and gait speed and assessed how changes in cut-off points changed sarcopenia prevalence in both populations. RESULTS: An increase from 5.45 kg/m2 to 6.68 kg/m2 in the muscle mass index for female outpatients and nursing-home residents increased sarcopenia prevalence from 4% to 23% and from 9% to 47%, respectively; for men, for an increase from 7.25 kg/m2 to 8.87 kg/m2, the corresponding increases were from 1% to 22% and from 6% to 41%, respectively. Changes in gait speed and grip strength had a limited impact on sarcopenia prevalence. CONCLUSION: The cut-off points used for muscle mass affect the reported prevalence rates for sarcopenia and, in turn, affect comparability between studies. The main factors influencing the magnitude of the change are muscle mass index distribution in the population and the absolute value of the cut-off points: the same difference between two references (e.g., 7.5 kg/m2 to 7.75 kg/m2 or 7.75 kg/m2 to 8 kg/m2) may produce different changes in prevalence. Changes in cut-off points for gait speed and grip strength had a limited impact on sarcopenia prevalence and on study comparability.

Haemoglobin responses to transfusion in severe iron deficiency anaemia: potential impact of gastrointestinal disorders.

BACKGROUND AND OBJECTIVES: Red blood cell (RBC) transfusion may be justified in iron deficiency anaemia (IDA) when an increase in oxygen delivery is needed, as sometimes occurs in subjects with haemoglobin <8·0 mg/dL, serious comorbidities or at risk of cardiovascular instability. Earlier investigations showed that some patients with severe IDA requiring transfusion had lower than expected post-transfusion haemoglobin levels with poorer clinical outcomes than other patients. After hypothesizing that haemoglobin responses to transfusion were different and that the underlying gastrointestinal (GI) disorders causing IDA could be a confounder explaining this association, these responses were analysed in a prospective cohort of IDA adults referred for outpatient GI investigation. MATERIALS AND METHODS: Transfused patients with proven IDA, baseline haemoglobin at referral <9·0 g/dL and no extraintestinal bleeding were eligible. To assess a homogeneous population, only GI disorders known to cause occult bleeding were considered. Haemoglobin increments per 100 mL of RBCs were investigated. RESULTS: In total, 2818 patients were enrolled over 10·5 years. On multivariable regression, diffuse angiodysplasias and GI cancer independently predicted for reduced increments in post-transfusion haemoglobin [adjusted regression coefficients: -0·082 (95% confidence interval, -0·093 to -0·072) and -0·073 (95% confidence interval, -0·081 to -0·066), respectively, P < 0·001 in both]. Haemoglobin responses in the remaining bleeding disorders were adequate and agreed with the principle that one RBC unit increases the haemoglobin an average of 1 g/dL. CONCLUSION: The potential differential impact of GI disorders on changes in haemoglobin levels after RBC transfusion could be useful for transfusing physicians, especially for diagnostic purposes.

Inappropriate prescribing in elderly people with diabetes admitted to hospital.

AIMS: To assess inappropriate prescribing in older people with diabetes mellitus during the month prior to a hospitalization, using tools on potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs) and comparing inappropriate prescribing in patients with without diabetes. METHODS: In an observational, prospective multicentric study, we assessed inappropriate prescribing in 672 patients aged 75 years and older during hospital admission. The Beers, Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) criteria and Assessing Care of Vulnerable Elders (ACOVE-3) medicine quality indicators were used. We analysed demographic and clinical factors associated with inappropriate prescribing. RESULTS: Of 672 patients, 249 (mean age 82.4 years, 62.9% female) had a diagnosis of diabetes mellitus. The mean number of prescribing drugs per patient with diabetes was 12.6 (4.5) vs. 9.4 (4.3) in patients without diabetes (P < 0.001). Of those patients with diabetes, 74.2% used 10 or more medications; 54.5% of patients with diabetes had at least one Beers-listed PIM, 68.1% had at least one STOPP-listed PIM, 64.6% had at least one START-listed PPO and 62.8% had at least one ACOVE-3-listed PPO. Except for the Beers criteria, these prevalences were significantly higher in patients with diabetes than in those without. After excluding diabetes-related items from these tools, only STOPP-listed PIMs remained significantly higher among patients with diabetes (P = 0.04). CONCLUSIONS: Polypharmacy is common among older patients with diabetes mellitus. Inappropriate prescribing is higher in older patients with diabetes, even when diabetes-related treatment is excluded from the inappropriate prescribing evaluation.

Prevalence of sarcopenia in healthy community-dwelling elderly in an urban area of Barcelona (Spain).

INTRODUCTION: The purpose of this study was to evaluate the prevalence of sarcopenia in a cohort of healthy community-dwelling elderly in an urban area in Barcelona (Spain) for native benchmarks and compare them with those published in other geographical areas. MATERIAL AND METHODS: We prospectively evaluated a series of 200 healthy elderly in the community with preserved functional capacity and absence of cognitive impairment. We performed a comprehensive geriatric assessment and determined anthropometric data, muscle mass (MM) and the muscle mass index (MMI). Assessment of muscle mass was performed by bioelectrical impedance analysis (BIA). The cut-off point for defining sarcopenia MMI was established as less than 2 SD of the mean of a reference group comprising 220 healthy volunteers (20-42 years) in the same area. Results were compared with studies undertaken in the USA, France and Taiwan. RESULTS: The cut-off points obtained were 8.31 Kg/m(2) for men and 6.68 Kg/m2 for women, being similar to those observed in France and Taiwan but different from the USA. The prevalence of sarcopenia observed was 33% for elderly women and 10% for males. On comparison of the prevalence of sarcopenia in the four populations, we observed some differences, particularly in males. CONCLUSIONS: We have defined reference values for sarcopenia, determined by BIA, in our setting. We also observed a remarkable prevalence of sarcopenia in the healthy elderly community, especially in females, showing some differences from those in other geographical regions.

[Hematoma of the rectus abdominis. experience of a primary care hospital]. / Hematoma del recto anterior del abdomen: experiencia en un hospital comarcal.

OBJECTIVE: To describe patients diagnosed with hematoma of the rectus abdominis (HRA) muscle. MATERIAL AND METHODS: A retrospective analysis of patients diagnosed with HRA over the past 8 years in our center. RESULTS: A total of 17 patients (9 women) with mean age of 73 years were included in the study. In 52% of the cases the HRA was the cause of hospitalization. Anticoagulant therapy was documented in 70%. More than half of patients treated with low molecular weight heparin had renal insufficiency. In the group receiving oral anticoagulants (OA), 86% had INR greater than 4. Paroxysmal cough appeared in 13. The most common presentation was abdominal pain and palpable mass. CT scan sensitivity was superior to that of the ultrasound. The most common location was the lower right. Treatment was conservative in all but one. Two patients died. Mean decrease in hemoglobin was 4.7 g/dl. Average stay was 19 days. CONCLUSIONS: In our center, HRA almost equally affects both genders and appears in older people with excessive anticoagulation and cough. The clinical presentation, increased diagnostic sensitivity of CT scan and predominance in the right abdominal involvement are similar to other series. Mortality and hospital stay are higher than described.

[Internet-based Continuing Medical Education. Presentation of the first experience of the Spanish Society of Internal Medicine]. / Formación médica continuada basada en Internet. Presentación de la primera experiencia de la Sociedad Española de Medicina Interna.

This paper presents the first experience of the Spanish Society of Internal Medicine in the development of an Internet-based Continuing Medical Education program for Society members, accredited by the Health Ministry and the Autonomous University of Barcelona, and funded by the Menarini Group SA. Academic performance and satisfaction of participants in this course have been very satisfactory, both with respect to scientific content and the virtual learning environment. This experience shows that Internet-based continuing medical education is a field with a great future that is well accepted by participating physicians, and that the scientific societies, with the collaboration of other institutions and companies, can lead Internet-based Continuing Medical Education programs especially designed and tailored to their members.

HDAC3 represses the expression of NKG2D ligands ULBPs in epithelial tumour cells: potential implications for the immunosurveillance of cancer.

The expression of the NKG2D ligands on cancer cells leads to their recognition and elimination by host immune responses mediated by natural killer and T cells. UL16-binding proteins (ULBPs) are NKG2D ligands, which are scarcely expressed in epithelial tumours, favouring their evasion from the immune system. Herein, we investigated the epigenetic mechanisms underlying the repression of ULBPs in epithelial cancer cells. We show that ULBP1-3 expression is increased in tumour cells after exposure to the inhibitor of histone deacetylases (HDACs) trichostatin A (TSA), which enhances the natural killer cell-mediated cytotoxicity of HeLa cells. Our experiments showed that the transcription factor Sp3 is crucial in the activation of the ULBP1 promoter by TSA. Furthermore, by small interfering RNA-mediated knockdown and overexpression of HDAC1-3, we showed that HDAC3 is a repressor of ULBPs expression in epithelial cancer cells. Remarkably, TSA treatment caused the complete release of HDAC3 from the ULBP1-3 promoters. HDAC3 is recruited to the ULBP1 promoter through its interaction with Sp3 and TSA treatment interfered with this association. Together, we describe a new mechanism by which cancer cells may evade the immune response through the epigenetic modulation of the ULBPs expression and provide a model in which HDAC inhibitors may favour the elimination of transformed cells by increasing the immunogenicity of epithelial tumours.

Characteristics of falls producing hip fractures in nonagenarians.

OBJECTIVES: To evaluate the characteristics associated with falls causing hip fracture in patients 90 years of age or older (nonagenarians). A second objective was to compare these characteristics with those present in younger patients (65-79 year-olds). DESIGN: Prospective, observational study. SETTING: Six hospitals in Barcelona (Spain) and its surrounding area. PARTICIPANTS: 105 nonagenarians diagnosed with hip fracture after a fall. Most patients were women (78; 74%), with a mean age of 92.2+/-2 years. All of them were living in the community, except for eight institutionalized patients. 221 patients aged 65 to 79 composed the younger patient's comparison group. MEASUREMENTS: Characteristics of falls causing hip fracture were analyzed: location, time and the risk factor for the fall, classified as intrinsic, extrinsic or combined. RESULTS: The mean number of falls in the previous year was 1.5 - 22% of the patients reported having fallen two or more times. Falls usually happened while at home (70%) and during the day (64%). An intrinsic risk factor was considered the most likely cause in 37% of the cases, an extrinsic risk factor in 35%, and a combination in 28%. Multiple stepwise logistic regression analysis showed that nonagenarians were characterized by lower BI scores, more falls happening during night time, a higher use of, benzodiazepines and diuretics, and a lower use of non-benzodiazepinic hypnotics. CONCLUSIONS: Most falls causing hip fracture in nonagenarians happen during the day and at home. Falls in nonagenarians happening more frequently during nighttime, and these oldest subjects had lower BI scores, and a higher use of benzodiazepines and diuretics and less use of non-benzodiazepines hypnotics compared with the younger patients.

[Circumstances associated to falls resulting in hip fracture in community-dwelling subjects older than 94 years old]. / Circunstancias asociadas a las caídas responsables de fractura de fémur en pacientes mayores de 94 años no institucionalizados.

OBJECTIVE: To evaluate the circumstances associated with falls resulting in hip fracture in the 95 years of age or older community-dwelling patients. MATERIAL AND METHODS: A prospective, observational study, was conducted in 6 hospitals in the Barcelona area on the characteristics associated with falls resulting in hip fracture in 30 patients aged > 94 years old. Location, time and the risk factor for the fall (classified as intrinsic, extrinsic or combined) were evaluated. RESULTS: Mean number of falls in the previous year was 1.6, 5 (16.7%) of the patients reporting having fallen two or more times. Falls usually occurred while at home, a high percentage (46.7%) of which occurred during the night. When the differences were evaluated by sex, there was a high percentage of uncorrected auditory loss in men and high number of chronic drugs and psychotropic drugs in women. CONCLUSIONS: Most falls causing hip fracture in community-dwelling very elderly subjects occur at home. Nearly half of the falls occur during the night.

MHC class I chain-related gene B (MICB) is associated with rheumatoid arthritis susceptibility.

OBJECTIVES: Several recent studies have shown that the MHC class III region, located telomeric to HLA-DRB1, contains an additional genetic factor that predisposes to rheumatoid arthritis (RA). In this study, we investigate whether inhibitor of kappaB-like (IkappaBL), MICB or MICA located in the MHC class III region are the second susceptibility gene associated with RA. METHODS: A total of 154 healthy controls and 140 RA patients were genotyped for HLA-DRB1, MICA, MICB and the polymorphism -62 of the IkappaBL gene. RESULTS: A significant increase of HLA-DRB1 shared epitope (SE) alleles was detected in RA patients (61.4 vs 43.5%, P(c) = 0.01, OR = 2.1, 95% CI = 1.3-3.3). Among SE alleles, the HLA-DRB1*0401 (13.5 vs 5.1%, P(c) = 0.04, OR = 3.2, 95% CI = 1.3-8.1) and HLA-DRB1*0404 (6.4 vs 1.2%, P = 0.02, P(c) = NS) showed the most significantly association with RA. No increase of risk was associated with HLA-DRB1*01. Remarkably, the allele MICB*004 was also significantly associated with RA susceptibility (40.7 vs 23.3%, P(c) = 0.01, OR = 2.2, 95% CI = 1.3-3.7). MICB*004 was in linkage disequilibrium with HLA-DRB1*0404 (lambda(s) = 0.33) and HLA-DRB1*0405 (lambda(s) = 0.34). However, MICB*004 was also increased in HLA-DRB1 SE negative patients (37 vs 21.5%, P = 0.04). No significant association between IkappaBL and MICA with RA was found. CONCLUSIONS: MICB*004 allele was associated with RA susceptibility. This allele was in linkage disequilibrium with HLA-DRB1*0404 and DRB1*0405. The association of MICB with RA susceptibility and the functional role of MIC genes in the pathogenesis of RA converts MICB into a candidate to be an additional MHC gene associated with RA susceptibility.

[Characteristics of falls producing hip fracture in an elderly population. Differences according to age and gender]. / Circunstancias asociadas a las caídas responsables de fractura de fémur en pacientes ancianos. Diferencias por grupo de edad y género.

BACKGROUND: The majority of hip fractures are produced because of a fall. We examined the characteristics associated with falls causing hip fracture in elderly patients. MATERIAL AND METHODS: Characteristics of falls owing to hip fracture were analyzed in 410 consecutive patients admitted in 6 hospitals during the 2004. We evaluated the location, time and the possible cause of fall: intrinsic risk factor, extrinsic or combined. RESULTS: We evaluated 316 women (77%) and 94 men, mean age 81.9 years. Previous to the hip fracture, the mean BI was 77.5. The mean value of falls during the last year was 1.9. Previously to the fall that caused hip fracture, we found that 24% of the patients had fallen repeatedly (more than two falls). Usually falls were at home (68%) and during daytime (80%). In 45% of patients an intrinsic risk factor was considered the most likely cause, in 33% an extrinsic risk factor and in 22% a combination. CONCLUSIONS: The majority of falls owing to hip fracture in elderly people happen in daytime, at home and due to intrinsic risk factors. Efforts to identify elderly people at risk of fall should be stressed in order to establish preventive measures.

[Study of hypertensive very elderly population admitted to a regional hospital]. / Estudio de la población hipertensa muy anciana ingresada en un hospital comarcal.

OBJECTIVES: To analyse the characteristics of the hospitalized very elderly people (age equal or superior to 80 years) with hypertension (HT). PATIENTS AND METHODS: Prospective study including the patients with HT who need hospitalization in our medical institution. Data collected were: demographic, clinical parameters, factors of vascular risk, hygienic-dietetic strategies, pharmacological treatment, cause of hospitalization, and biochemical determinations. RESULTS: There were included 92 very elderly patients (71 women); they represent 14 % of total hospitalized people. Two third parts had not realized academic studies, being 60 % of rural origin. Almost the half (41 %) was diabetic, and 27 % had dyslipidemia. Overall 62 % had 4 or more factors of cardiovascular risk. The hospitalization was related to the HT in the half of the cases, and 61 % had already previously some cardiovascular event. The lifestyle modifications more frequent were: not to smoke (95 %), no alcohol (81 %), and diet without salt (75 %). Diuretics were the most frequent anti-hypertensive agent used. The global mortality was two times superior to the hypertensive population < 80 years in the same period. CONCLUSIONS: The very elderly hypertensive patients of our study are fundamentally women, of rural origin and without academic studies. The above mentioned hospitalization is attributable directly to the HT in the half of the cases. They are a population of high cardiovascular risk, with previous events cardiac and cerebral-vascular. They confess to realize frequently the hygienic-dietetic strategies recommended. The diuretics are the anti-hypertensive agents most used for the HT. Since it was of waiting for the mortality in this group it is high.

Primary mesenteric liposarcoma of jejunum: presentation like a cystic mass.

This report describes a rare case of intra-abdominal liposarcoma in a 67-year-old woman. The patient presented at Internal Medicine Unit in May 2004, to study of thyroid pathology. The clinical examination was normal, except for the finding of an asymptomatic mass in the abdomen. The patient knew the existence of tumor since time ago, but she confesses to have only occasional discomfort. In the abdominal ultrasonography a solid mass with large cystic component was detected but relation with other organs was not clear. Computed tomography revealed the presence of a mass with solid and cystic components, in contact with small intestine in the left side of abdomen. A complete resection of tumor arising from mesentery of jejunum was performed successfully with end to end anastomosis. The gross specimen was lobulated and measured 8.5 x 7.5 cm. The histopathology analysis showed proliferating lipoblasts with irregular nuclei on a myxoid background, with plexiform vascular pattern, characteristics belongs to myxoid type liposarcoma. The patient is alive and well one year after removal of tumor. The uncommon site and the exceptional cystic morphology of tumor are discussed, and so it must be included the primary mesenteric liposarcoma in the differential diagnosis of intra-abdominal tumors with cystic large areas.

Abnormalities in liver enzyme levels during Salmonella enteritidis enterocolitis.

OBJECTIVE: To evaluate the prevalence, associated factors, and time-course changes of abnormal liver enzyme serum levels in adult patients with Salmonella enteritidis enterocolitis. METHODS: The clinical records of 104 patients (age range 15-86 years, 46.2% males) admitted to hospital because of S. enteritidis enterocolitis were reviewed. The prevalence of abnormal liver enzyme levels was evaluated, as well as its possible relationship to data of systemic inflammatory response, severe sepsis, and bacteremia. In addition, time-course changes in serum levels of liver enzymes were studied in 16 cases with available follow-up after hospital discharge. RESULTS: In patients without a pre-existing cause for liver enzyme abnormalities (n = 84), the prevalence of serum AST elevation was 23.0% (95% CI 15.4-34.5%), of serum ALT elevation was 17.9% (95% CI 0.6-20.0%), and of GGT elevation was 19.0% (95% CI 11.6-29.3%). The prevalence of abnormality for any of these enzymes (AST, ALT, or GGT) was 35.7% (95% CI 25.7-46.8%). The prevalence of altered serum alkaline phosphatase was lower. Alteration in liver enzyme serum levels was moderate in the majority of cases, and was found in association with the presence of fever. Serum enzyme levels decreased during the convalescence period after hospital discharge. CONCLUSIONS: Abnormalities in liver enzyme levels are frequent during severe enterocolitis due to S. enteritidis in adult patients. These abnormalities are moderate and self-limited.

[Study of the derivations to an external consultation of Internal Medicine: can be managed the waiting list?]. / Estudio de las derivaciones a una consulta externa de Medicina Interna: se puede gestionar la lista de espera?

BACKGROUND: The lack of coordination and organization between primary and specialized attention, generates inefficiency bags in the area of external consultations. MATERIAL AND METHOD: The characteristics of the attention of 120 patients derived consecutively to an external Internal Medicine consultation of a local hospital are analyzed. RESULTS: Of the 120 mentioned patients 19 did not appear (16.23%). 70.3% of the taken care of patients came from primary attention and 29.7% did it of specialized attention. Of the patients derived by primary attention: 63.3% went without data adapted in the derivation leaf, 59.2% did not contribute complementary diagnostic tests and 40.8% were registered in the first consultation. Of the patients derived from specialized attention: 100% contribute clinical information to the consultation, 90% contribute complementary studies and 56.65% are registered in the first consultation. CONCLUSIONS: The discontinuity in the attention between primary and specialized attention generates an inefficient use of the resources, that in the area of external consultations influences in the appearance of waiting lists.