The orthogeriatric comanagement improves clinical outcomes of hip fracture in older adults.

Treatment of older adults with hip fracture is a healthcare challenge. Orthogeriatric comanagement that is an integrated model of care with shared responsibility improves time to surgery and reduces the length of hospital stay and mortality compared with orthopedic care with geriatric consultation service and usual orthopedic care, respectively. INTRODUCTION: Treatment of fractures in older adults is a clinical challenge due partly to the presence of comorbidity and polypharmacy. The goal of orthogeriatric models of care is to improve clinical outcomes among older people with hip fractures. We compare clinical outcomes of persons with hip fracture cared according to orthogeriatric comanagement (OGC), orthopedic team with the support of a geriatric consultant service (GCS), and usual orthopedic care (UOC). METHODS: This is a single-center, pre-post intervention observational study with two parallel arms, OGC and GCS, and a retrospective control arm. Hip fracture patients admitted to the trauma ward were assigned by the orthopedic surgeon to the OGC (n = 112) or GCS (n = 108) group. The intervention groups were compared each with others and both with the retrospective control group (n = 210) of older adults with hip fracture. Several clinical indicators are considered, including time to surgery, length of stay, in-hospital, and 1-year mortality. RESULTS: Patients in the OGC (OR 2.62; CI 95% 1.40-4.91) but not those in the GCS (OR 0.74; CI 95% 0.38-1.47) showed a higher probability of undergoing surgery within 48 h compared with those in the UOC. Moreover, the OGC (ß, - 1.08; SE, 0.54, p = 0.045) but not the GCS (ß, - 0.79; SE, 0.53, p = 0.148) was inversely associated with LOS. Ultimately, patients in the OGC (OR 0.31; CI 95 % 0.10-0.96) but not those in the GCS (OR 0.37; CI 95% 0.10-1.38) experienced a significantly lower 1-year mortality rate compared with those in the UOC. All analyses were independent of several confounders. CONCLUSIONS: Older adults with hip fracture taken in care by the OGC showed better clinical indicators, including time to surgery, length of stay and mortality, than those managed by geriatric consultant service or usual orthopedic care.

Association of increased carotid intima-media thickness and lower plasma levels of vitamin C and vitamin E in old age subjects: implications for Alzheimer's disease.

In light of the recent advances regarding the role of vascularity in Alzheimer's disease (AD) pathophysiology, the relationship between plasma levels and activities of the major antioxidant molecules and the carotid intima-media thickness (C-IMT) of older persons with no or very mild cognitive impairment was evaluated. The underlying hypothesis is that the IMT may be an indirect index of vascular damage in persons with low levels of plasma antioxidants. Plasma levels of vitamins A, C, E, of uric acid as well as activities of the plasma antioxidant enzymes superoxide dismutase (SOD) and glutathione peroxidase (GPx) were measured. Plasma levels of vitamins C and E significantly decreased among participants from the first to the fourth IMT quartile, with a linear slope only for vitamin C. Compared to participants in the lowest vitamin C quartile, the probability to have IMT >1.2 mm significantly decreased among persons from the second to the fourth quartile independent of confounders. In conclusion, only vitamin C plasma levels appear to be selectively associated with the risk of increasing C-IMT. An adequate vitamin C status might be particularly important for protection against AD and other clinical manifestations of vascular and cognitive ageing.

Fetal variant of circle of the Willis and bilateral symmetrical parietal stroke.

We described a rare case in which a congenital abnormal vascular structure associated with mild hyperhomocysteinemia could have caused an ischemic stroke, with an unusual localization in the border-zone of MCA and PCA. We think that the lack of compensatory flow distribution from the right vertebral artery and the right posterior communicating artery probably determined the bilateral ischemic lesions in a patient, who possibly had hypotensive crisis.

Validation study of the Italian Addenbrooke's Cognitive Examination Revised in a young-old and old-old population.

AIMS: The main aims of the study were the translation and the subsequent validation in Italian of the Addenbrooke's Cognitive Examination Revised (ACE-R), and the evaluation of its usefulness in discriminating cognitively normal subjects from patients with mild dementia in an elderly population. METHODS: The ACE-R was translated and adapted into Italian. The Italian ACE-R was administered to a group of 179 elderly subjects (72 cognitively healthy and 107 subjects with mild dementia, mean age 75.4±6.4 years). The group was stratified into two subsamples according to age, i.e. a young-old (<75 years) and an old-old (≥75 years) group, in order to evaluate the sensitivity and specificity of the test in detecting dementia in different age strata of elderly subjects. RESULTS: The reliability of the Italian ACE-R was extremely good (α-coefficient=0.85). Two different cutoffs were identified for young-old (cutoff 79; sensitivity 90% and specificity 80%) and old-old subjects (cutoff 60; sensitivity 82% and specificity 100%). CONCLUSIONS: The Italian ACE-R is a valid screening tool to detect dementia, especially in the old-old population, which represents not only the fastest growing age group but also the group at the highest risk of dementia in Western countries.

Cognitive performance in elderly patients undergoing carotid endarterectomy or carotid artery stenting: a twelve-month follow-up study.

BACKGROUND: It is still a matter of debate if and to what extent carotid endarterectomy (CEA) and carotid artery stenting (CAS) impair cognitive functioning in the elderly. METHODS: We conducted a nonrandomized clinical trial on subjects with asymptomatic carotid artery stenosis comparing CEA (n = 28; 24 males and 4 females; 72.6 +/- 5.8 years old) with CAS (n = 29; 17 males and 12 females; 75.1 +/- 5.7 years old). Cognition, mood and functional status were evaluated by a broad spectrum of tests performed on the day prior to carotid reopening as well as 3 and 12 months after. RESULTS: No significant differences in scores on cognitive tests including the Babcock story recall test and Rey's auditory verbal learning test (memory), category naming test (verbal fluency), trail-making test parts A and B (attention and executive function) and controlled oral word association test (executive functioning) were observed 3 and 12 months after carotid reopening independent of the technique used. Only scores on the copy drawing test (visuospatial and constructional abilities) slightly but significantly (p < 0.05) worsened in the CAS group 12 months after the intervention. No significant differences between the CEA and CAS groups were detected regarding mood and functional status after 3 and 12 months. CONCLUSIONS: CEA and CAS seem to be safe procedures in elderly patients in terms of cognitive, mood and functional status in the short and long term. CAS might be preferred for the shorter hospital stay, but further studies with a larger number of old and oldest old subjects with a longer follow-up are needed to better understand the cost-effectiveness of both treatments.

Vascular risk factors in mild cognitive impairment subtypes. Findings from the ReGAl project.

BACKGROUND AND AIM: To investigate the role of vascular risk factors in different subtypes of mild cognitive impairment (MCI) in a multicentric, clinic-based, cross-sectional study. METHODS: Two-hundred and seven subjects with MCI were included in the study: 33 with single non-memory MCI (snmMCI), 42 with multiple-domain amnestic MCI (mdMCI-a) and 132 with amnestic MCI (aMCI). Several clinical vascular risk factors and magnetic resonance imaging (MRI) brain lesions were evaluated. RESULTS: snmMCI showed a higher frequency of ischaemic heart disease and of transient ischaemic attack (TIA)/stroke, a higher Hachinski ischaemic score and a higher frequency of white-matter lesions on MRI compared to aMCI. Subjects with mdMCI-a showed clinical characteristics similar to aMCI, except for a higher frequency of a history of TIA/stroke. CONCLUSION: Our findings suggest that snmMCI may be considered a vascular cognitive disorder.

Anticholinergic Burden and Functional Status in Older People with Cognitive Impairment: Results from the Regal Project.

OBJECTIVE: The use of drugs with intrinsic anticholinergic properties is widespread among old age persons. A growing body of evidences suggest that a high anticholinergic burden is associated with physical and cognitive impairment. However, the association between anticholinergic drug use and functional status is still poorly investigated, particularly among subjects with initial cognitive impairment. DESIGN: Cross-sectional study examining the association between drug-related anticholinergic burden and functional status in cognitively healthy (CH) (n=691), mild cognitive impairment (MCI) (n=541) or mild Alzheimer's diseases (AD) (n=1127) subjects. SETTING: Data were gathered from the ReGAl project (Rete Geriatrica Alzheimer-Geriatric Network on Alzheimer's disease), a large longitudinal Italian multicentric clinical-based study, promoted by the Italian Society of Gerontology and Geriatrics (SIGG). PARTICIPANTS: 2359 outpatients, older than 65 years, admitted to memory clinics. The total sample size, estimated according to a global effect size of 25% with type I error of 0.05 and a power of 95% is 2010 subjects. MEASUREMENT: Functional status was evaluated by the Katz Index of Independence in Activities of Daily Living (ADL) and the Lawton-Brody Instrumental Activities of Daily Living (IADL) scales. The drug-related anticholinergic burden was estimated by the Anticholinergic Risk Scale (ARS). RESULTS: The 15.9 % (n=375) of total population used at least one drug with anticholinergic properties. Such a drug use was associated with partially dependence in ADL (OR:1.42, CI95%: 1.10-1.83; p=0.006), independently of gender, number of drugs, comorbidity index, presence of clinically relevant neuropsychiatric symptoms and adjusted MMSE. Anticholinergic drug use was associated with un-ability at each IADL task only in male MCI subjects, with significant impairment in shopping (p=0.011), and drug management (p=0.05). CONCLUSIONS: The use of medications with anticholinergic properties is common among older persons cognitively health as well as with cognitive impairment. Our results suggest that the use of anticholinergic drugs is associated with functional impairment, especially in old age subjects with initial cognitive impairment. Minimizing anticholinergic burden should result in maintaining daily functioning, especially in a vulnerable population, such as MCI and mild AD.

[Quality control of spirometric tests used in health surveillance for occupational exposure risk, in the province of Viterbo]. / Controllo di qualità delle prove spirometriche eseguite nell'ambito della sorveglianza sanitaria per esposizione a rischio lavorativo, in provincia di Viterbo.

A quality control survey on spirometry assessments carried out in a number of factories in the province of Viterbo (Lazio Region) was made by the Local Health Unit in Viterbo, as required by law 626/94 on the promotion of workers health. The survey concerned 734 measurements concerning the same number of employees from 29 different factories. Each spirometry assessment was repeated in this study according to the quality standards defined in the literature and our own results were compared with the values which had been obtained over one year during the health surveillance program (ASP). A few main functional parameters were considered according to the following criteria: percentage of agreement (tolerance +/- 5%) between the two FVC, FEV1 and FEF25-75 measures or degree of discrepancy; for FEV1/FVC ratio, the occurrence of < 70 (suggestive of an obstructive lesion) and > 90 values (reflecting poor reliability in the measurement of the lung volumes) in the two sets of data. Further criteria concerned the comparison of the height of the individuals (tolerance range +/- 1 cm), and the comparison of the overall spirometry rating expressed as the number of tests rated normal or abnormal (during the first assessment as compared to the second). The results show poor agreement (11.4%) for FVC with as many as 85.8% underestimated values; 30.1% agreement and 64.2% underestimate for FEV1; 17% agreement and 53.5% overestimate for FEF25-75. There were 6.5% fewer < 70 FEV1/FVC ratios, and 18.3% more > 90 ratios in the tests carried out in the factories as compared to our own. There was 32.9% agreement on the height, with overestimation in 63.7% of the cases. There were 12.3% "false abnormal" and 2.6% "false normal" results in the overall rating of the spirometry (as carried out by the factories compared to our own). In conclusion, the survey revealed a trend in the measurements carried out by the factories to underestimate the volumes, overestimate the flows, improperly select the theoretical reference values because of a mistake in measuring the height, to overestimate restrictive abnormalities, and underestimate the obstructive ones.

Influence of comorbidity and cognitive status on instrumental activities of daily living in amnestic mild cognitive impairment: results from the ReGAl project.

OBJECTIVES: To investigate whether amnestic mild cognitive impairment (aMCI) is characterised by restriction in instrumental activities of daily living (IADL). Further, to examine the role of comorbidity and cognitive performance on IADL changes in aMCI subjects. METHODS: The study included 132 subjects with aMCI and 249 subjects with no cognitive impairment (NCI), consecutively enrolled as outpatients in a multicentric Italian clinical-based study, the ReGAl Project. All subjects underwent a comprehensive evaluation including clinical examination, laboratory screening, neuroimaging and cognitive and behavioral assessments. Functional status was evaluated by the Lawton's Instrumental Activities of Daily Living (IADL) scale. Comorbidity was evaluated by the Cumulative Illness Rating Scale (CIRS). Cognitive evaluation included tests assessing episodic memory, language, attention/executive functioning and praxis, as well as the the Mini-Mental State Examination (MMSE) as a measure of global cognition. RESULTS: Subjects with aMCI had higher IADL changes than NCI. Among IADL items, aMCI subjects showed a significant impairment in shopping, taking drugs, and handling economy; however also NCI had minor IADL changes regarding cooking, washing and cleaning. IADL restriction in aMCI subjects was significantly associated with cognitive performance, mainly related to executive functioning, but not with comorbidity. On the contrary, in NCI sensory impairment accounts for slight IADL changes. CONCLUSION: In aMCI subjects a mild degree of cognitive deterioration has a stronger impact on IADL than somatic comorbidity. Current diagnostic criteria for MCI should include a mild impairment in IADL.

[Mammography and echography in male breast pathology]. / La mammografia e l'ecografia nella patologia mammaria maschile.

From January 1988 through December 1991, 81 men were examined for breast enlargement or mass in our Institute, by means of clinical examination, mammography, and US. The patients' age ranged 15-71 years (mean: 52 years). Of 81 studied patients, 71 had gynecomastia, 8 had adipomastia, 1 had an infiltrating ductal carcinoma, 1 an angiofibrolipoma and 1 a simple cyst. Both the carcinoma and the cyst were associated with gynecomastia. Three mammographic patterns of gynecomastia were observed: a glandular pattern in 42 cases (32 bilateral and 10 monolateral), a dendritic pattern in 12 (8 bilateral and 4 monolateral), and a nodular pattern in 15 (9 bilateral and 6 monolateral). On US, gynecomastia appeared diffuse in 54 patients and focal in 15. The infiltrating ductal carcinoma was clinically evident; no asymptomatic cancers were detected. Surgical biopsy was performed in 40 cases. A good correlation was observed between mammographic and US signs. The combined use of the two modalities can improve diagnostic accuracy. Biopsy must be performed in all questionable cases.

[Aneurysm of the superior mesenteric vein]. / Anévrysme de la veine mésentérique supérieure.

Aneurysms originating in the superior mesenteric vein are extremely rare: 4 cases have been reported in the international literature. The authors describe a case of a female patient admitted to hospital for vague abdominal pain. The CT findings revealed a cyst-like neoformation. By means of angiography it was then identified as a dilatation of the superior mesenteric vein. The causes of such dilatations are not altogether clear. Current interpretations refer to possible congenital and acquired factors, as well as trauma. The accompanying symptoms are abdominal pain, icterus, gastrointestinal haemorrhage or portal hypertension, but occasionally patients may present no symptoms whatsoever.

Bilateral median and ulnar neuropathy at the wrist in a parquet floorer.

Many cases of work related compression neuropathy of the ulnar and median nerves at the wrist have been described. This report presents a case of bilateral distal neuropathy of the median and ulnar nerves in a parquet floorer, who laid wooden block flooring by hand and used the palms and volar surface of both hands to hit the blocks into place. He also used an electric sander and polisher. Bilateral numbness and paraesthesias in all fingers had been present for about one year. Clinical examination was normal; the neurological assessment indicated slight impairment in response to tactile, heat, and pain stimuli in all 10 fingers. Electroneurography showed increased distal motor latencies of median and ulnar nerves at both wrists, although the lower limbs were normal. The results of blood, urine, and instrumental tests excluded systemic disease or local factors that could cause compression neuropathy. After stopping work for three months, the clinical picture and electroneurographic results improved. These data support the hypothesis that the damage to the median and ulnar nerves had been caused by the patient's way of working, which provoked repeated bilateral microtrauma to his wrists. To diagnose work related multiple neuropathy can be difficult and an accurate work history is necessary. Preventive measures and diligent health care are required for this category of worker.