Serum levels of insulin-like growth factor I in 152 patients with growth hormone deficiency, aged 19-82 years, in relation to those in healthy subjects.

Serum insulin-like growth factor I (IGF-I) levels within normal range for age have been reported to be common in adults with GH deficiency (GHD). Therefore, serum IGF-I levels were determined in 152 consecutive patients (71 women and 81 men) with evidence of hypothalamic-pituitary disorders or previous cranial radiation, who fulfilled the presently used criteria for GHD i.e. peak GH response below 3 microg/L at stimulation test. Patients treated for acromegaly were excluded. Forty-three patients, aged 19-63 yr, had childhood onset GHD, and 109, aged 23-82 yr, had adult-onset GHD. Their IGF-I levels were expressed in SD scores in relation to normal reference values based on 448 healthy subjects, aged 20-96 yr (247 women and 201 men). In healthy subjects a linear inverse correlation, without gender difference, was found between logarithmic transformed IGF-I levels and age (r = -0.774; P < 0.001). In contrast, no age dependency was found in GHD patients. All patients with childhood-onset GHD had IGF-I values below -2 SD, significantly lower than those in adult-onset GHD patients (-6.2 +/- 0.3 vs. -3.2 +/- 0.2 SD score; P < 0.001). In patients with adult-onset GHD, 34% of the IGF-I levels were within normal range, increasing to 40% in the subgroup above 60 yr of age, in whom 86% were diagnosed with hypothalamic-pituitary tumors. Normal IGF-I was more common in men than in women, but no difference was observed between patients with panhypopituitarism and those with partial pituitary insufficiency. High frequencies of IGF-I levels within the normal range were found in GHD patients with pituitary tumors (20 of 57 nonsecreting pituitary adenomas, 5 of 15 prolactinomas, 6 of 12 Cushing's disease, and 4 of 25 craniopharyngiomas), but in only 2 of 43 patients with GHD due to other causes. In conclusion, an IGF-I level below -2 SD seems to be of diagnostic value in GHD with onset in childhood or early adulthood, whereas values within normal range are common in patients over 60 yr of age, especially those with pituitary tumors. The outcome of GH replacement therapy may reveal whether the addition of IGF-I as a diagnostic criterion is of predictive value in older patients.

Health outcomes of post-hospital in-home team care: secondary analysis of a Swedish trial.

OBJECTIVE: To determine patient and treatment-related factors predictive of health outcomes. DESIGN: Secondary analysis of a randomized trial with 6-month follow-up. After using bivariate and three-way analysis in the total sample to screen outcome predictors and interactions among baseline variables, multivariate logistic regression was used to model outcomes. SETTING: A county general hospital in central Stockholm, and patients' homes nearby. PATIENTS: Hospital inpatients stable for discharge from acute care, having at least one chronic condition, and dependent in 1 to 5 Katz activities of daily life (ADLs) were included. Subjects (mean age = 81.1 years) were randomized to "team" (n = 150) or "usual care" (n = 99). INTERVENTIONS: Team patients were eligible for in-home primary care by an interdisciplinary team that included a physician, physical therapist, and 24-hour nursing services and geriatric consultation where necessary. "Usual-care" patients received standard district nurse-administered services at home upon hospital discharge. MEASUREMENTS: Demographic, functional status, and medical characteristics were measured at randomization. Outcomes included survival and higher ADL, instrumental ADL (IADL), and outdoor ambulation scores. MAIN RESULTS: Multiple medical, social, behavioral, and functional factors were associated with outcomes. Primary cardiac disease, number of prescription drugs, alcohol abstinence, and baseline mental status all impacted 6-month survival. Controlling for other factors, team care improved the likelihood of ambulation independent of personal assistance at follow-up (P = .027), treating an estimated 10 patients per 1 benefiting. Further, rehabilitative in-home team care neutralized mortality and functional risk factors (low number of baseline contacts and coresidence) apparent in usual care. CONCLUSIONS: Heterogeneous clinical populations of older patients contain many prevalent characteristics important to outcomes. Secondary analysis of trials including interactions identifies treatable and untreatable risks, what program components may be effective, and who benefits.

Perceived functional health of frail elderly in a primary home care programme and correlation of self-perception with objective measurements.

This study examined the effects of a primary home care intervention programme on self-assessed functional health, and the correlation of self-perception with objective measures in frail elderly subjects. Elderly patients about to be discharged from an acute hospital, at risk for institutionalization, were randomly assigned to physician-led primary home care or to standard care. After early post-hospital in-home intervention and assessment, ongoing medical care and treatment were monitored by a multidisciplinary team. Functional data were collected at baseline and after six months. Self-rated and objectively rated functional variables included medical factors, personal and instrumental activities of daily living, ambulation, and social activities and contacts. From study entry to follow-up, the scores for personal activities of daily living were significantly increased in team and control subjects as were social contacts in the team subjects (P = 0.03). No differences between team and control groups were found for self-rated functions from study entry to follow-up, except for a tentatively statistical significance in self-rated physical health in favour of the team subjects. Positive correlations were recorded between all self-rated and objectively rated functions, but they were stronger at follow-up. Physical health and social contacts were overrated, whereas indoor ambulation and social activities were underrated compared to objective measures at follow-up. Personal activities of daily living, were overrated at study entry, but showed substantial agreement at follow-up (0.62). Within demographic subgroups patients over 80 showed a stronger correlation between self-rated and objectively measured social functions after six months than younger patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of the rehabilitation of elderly primary health care patients after short-stay hospital treatment.

The purpose of this study was to evaluate the impact of a primary home care intervention program on patient outcomes after selected patients were discharged from a short-stay hospital. Random assignment of 249 frail, elderly patients was made to a group provided with physician-led primary home care, and home assistance service on a 24-hour basis, or to a control group given standard care. At randomization, patients were considerably disabled, had a mean age of 80.5 years, and had a high likelihood of long-stay hospital care. Medical and functional data were essentially the same at baseline for both groups. At 6-months follow-up, significant improvement in instrumental activities of daily living (P = 0.04) and outdoor walking (P = 0.03), and medical condition was found in the primary care intervention group compared with the controls and less utilization of long-stay hospital facilities was displayed in the team patients (P < 0.001) than in the controls. A selection of elderly, dependent patients can be cared for in their homes after short-stay hospital discharge and benefit from this primary home care intervention program in terms of improved medical and functional outcomes and less long-stay hospitalization.

The cost-effectiveness of rehabilitation in the home: a study of Swedish elderly.

OBJECTIVES: To investigate whether care of elderly and disabled patients could be more cost-effective after a short-term hospital stay, we examined the impact of a primary home care intervention program on functional status, use and costs of care after 6 months. METHODS: When clinically ready for discharge from the hospital, chronically ill patients with dependence in one to five functions in personal activities of daily living were randomized to physician-led primary home care with a 24-hour service, and the controls were offered ordinary care. Physical, cognitive, social, and medical functions were assessed in 110 team subjects and 73 controls. Data regarding inpatient days and outpatient visits were collected and converted to costs. RESULTS: Team patients demonstrated better instrumental activities of daily living and outdoor walking and significantly fewer diagnoses and drugs at 6 months. They used less inpatient and more outpatient care compared with the control patients. Significant cost reductions were found in the team group. CONCLUSIONS: This primary home care intervention program is cost-effective, at least for a selection of patients at risk for long-term hospital care.

Vitamin D status, parathyroid function and femoral bone density in an elderly Swedish population living at home.

The aim of this study was to determine vitamin D status and bone mineral density (BMD) in elderly, independent Scandinavians. A cross-sectional examination was conducted in a sample of 104 subjects (mean age 84.5 years), for possible correlations among anthropometric data, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, intact parathyroid hormone (PTH) and femoral neck BMD. Daily dietary calcium and vitamin D intakes were below the recommended levels. Five percent of the subjects were taking calcium, and 30% vitamin D supplements. Previous fragility fracture was reported in 30% of the men, and 55% of the women. Higher mean values of serum 25-hydroxyvitamin D (p = 0.03) and femoral neck BMD (p = 0.03) were recorded in subjects spending > or = 3 hours outdoors weekly. Independently of time spent outdoors, subjects taking daily supplements of vitamin D (on average 5 micrograms) had higher 25-hydroxyvitamin D (p < 0.001) levels, without significant changes in femoral neck BMD values. Serum levels of intact PTH (reference range 8-51 ng/L) were elevated in 41%, of which 5% had mild primary hyperparathyroidism. Serum levels of 25-hydroxyvitamin D (reference range 10-65 ng/mL) and 1,25-dihydroxyvitamin D (reference range 15-55 pg/mL) were below the reference ranges in 4% and 5% of the subjects, respectively. When serum levels of 25-hydroxyvitamin D were lower than approximately 30 ng/mL, the serum intact PTH values began to increase from a level of 43 pg/mL. This threshold most probably reflected a more relevant value of vitamin D insufficiency, indicating that 45% of our subjects rather than 4% actually had hypovitaminosis. Multiple regression analysis demonstrated femoral neck BMD to be significantly and positively associated with higher body mass index, male gender, no history of fragility fracture and 25-hydroxyvitamin D (R2 = 0.39). It is concluded that in this sample of healthy elderly people who regularly spend time outdoors, vitamin D levels leading to secondary hyperparathyroidism seem to be a major cause of osteoporosis. Correcting chronic dietary calcium deficiency is likely to eliminate another factor contributing to poor bone health.

Effect of nifedipine on exercise tolerance in patients with angina pectoris.

To test if nifedipine, 10 mg sublingually, could increase exercise tolerance, ten patients with angina pectoris each performed two types of bicycle exercise test, one with a stepwise increase in load and the other with a continuously increasing load. The drug was given in a double-blind cross-over trial. Nifedipine raised the heart rate and diminished the systemic blood pressure at rest, on standing and during exercise at comparable loads. Work time was prolonged and higher work loads were achieved. The total work performed rose by 50 per cent in one of the tests and by 23 per cent in the other, about 50 minutes after taking the drug. The mechanism of the greater work capacity in angina pectoris after nifedipine was assumed to be diminished heart work due to a fall in systemic vascular resistance.