Taking care of inpatients with fragility hip fractures: the hip-padua osteosarcopenia (Hip-POS) fracture liaison service model.

PURPOSE: Osteoporotic fragility fractures (FF), particularly those affecting the hip, represent a major clinical and socio-economic concern. These fractures can lead to various adverse outcomes, which may be exacerbated by the presence of sarcopenia, especially among older and frail patients. Early identification of patients with FF is crucial for implementing effective diagnostic and therapeutic strategies to prevent subsequent fractures and their associated consequences. METHODS: The Hip-POS program, implemented at Azienda Ospedale-Università Padova, is a Fracture Liaison Service (FLS) program to evaluate patients aged > 50 years old admitted with fragility hip fractures, involving an interdisciplinary team. After the identification of patients with hip fractures in the Emergency Department, a comprehensive evaluation is conducted to identify risk factors for further fractures, and to assess the main domains of multidimensional geriatric assessment, including muscle status. Patients are then prescribed with anti-fracture therapy, finally undergoing periodic follow-up visits. RESULTS: During the first five months, a total of 250 patients were evaluated (70.4% women, median age 85 years). Following assessment by the Hip-POS team, compared to pre-hospitalization, the proportion of patients not receiving antifracture therapy decreased significantly from 60 to 21%. The prescription rates of vitamin D and calcium increased markedly from 29.6% to 81%. CONCLUSIONS: We introduced the Hip-POS program for the care of older adults with hip fractures. We aspire that our model will represent a promising approach to enhancing post-fracture care by addressing the multifactorial nature of osteoporosis and its consequences, bridging the gap in secondary fracture prevention, and improving patient outcomes.

Spasmodic dysphonia. Emotional status and botulinum toxin treatment.

The objectives of this study were to determine the effects of botulinum toxin injection on measures of depression, anxiety, and somatic complaints in patients diagnosed as having spasmodic dysphonia. Patients were asked to complete preinjection questionnaires with self-ratings of depression, state and trait anxiety, and somatic complaints. Approximately 1 week and 2 months following injection, patients were again asked to complete the questionnaires. The spasmodic dysphonic subjects exhibited significantly elevated mean levels of depression and anxiety. These levels were significantly reduced approximately 1 week after injection. Two months later, depression and anxiety measures did not change significantly from their 1-week postinjection values. The results suggest that patients with spasmodic dysphonia who demonstrate significantly elevated measures of depression and anxiety show a reduction in those measures following treatment with botulinum toxin.

Spasmodic dysphonia subsequent to head trauma.

Spasmodic dysphonia (SD) is a low-incidence voice disorder of unknown origin. A subgroup of seven patients with SD from our larger pool of 70 report vocal symptoms subsequent to head injury. This article is a case report of the neurodiagnostic findings, including computed tomography, magnetic resonance imaging, auditory brain-stem response, brain electrical activity mapping, and single photon emission computed tomography for three such patients. For each patient, two or more tests revealed positive neurologic findings. Each test, except computed tomography, demonstrated abnormalities in one or more patients. Two principles of clinical management are derived: (1) information regarding head trauma sustained before SD symptom onset is significant; (2) the absence of neuropathology on a single measure of central nervous system function should not be considered conclusive evidence that no neurologic lesions exist.

Contextual influences in aphasia: effects of predictive versus nonpredictive narratives.

The influence of prior linguistic predictive and nonpredictive context on the comprehension of reversible passive sentences was investigated in 16 adults with aphasia. Eight subjects were classified as fluent and 8 as nonfluent. Subjects were presented with the sentences in isolation and preceded by nonpredictive and predictive contextual paragraphs. The overall results indicated that the subjects benefited significantly from the prior contextual narratives regardless of whether the paragraphs were predictive or nonpredictive. There were no significant differences between the two subject groups. The significant facilitation generated by the nonpredictive context suggests that redundancy of information may play a role in comprehension.

Effects of thematic structure on syntactic comprehension in aphasia.

This study assessed aphasic subjects' sensitivity to the given-new structure within simple paragraphs and the extent to which narrative discourse is facilitative of syntactic processing in the absence of semantic constraints. Subjects were divided into four groups along the dimensions of comprehension level and fluency. Stimulus items consisted of reversible active and passive sentences that were presented in the following three conditions: isolation, at the end of paragraphs such that the given-new structure was respected, and at the end of paragraphs such that the given-new structure was violated. Fluency did not significantly influence performance but comprehension level did. The high-comprehension group presented no significant differences between contextual conditions. The low-comprehension group, however, favored both paragraph contexts over isolation with no difference occurring between contextual conditions. These results suggest that lower level aphasic subjects are able to utilize thematic, antecedent verbal information for comprehending sentences in connected discourse even when the discourse is not semantically predictive of the underlying meaning of these sentences. Whether the narrative respects or violates the given-new relationship may not be an important factor. The reasons for these findings are explored.

Disruption of reference in aging.

A homogeneous sample of normal adults living in a religious order in a study of age effects on reference as a cohesive device in discourse production and comprehension. Narrative and procedural discourse were examined across various levels of complexity and stimulus/response requirements. Results indicate that significant ambiguity of reference emerges in the younger elderly group (age 64-76) in comparison to the middle-aged group (age 27 to 55), and increases markedly in the older elderly group (age 77-92). Related impairments of comprehension and cognition were also observed. These findings are interpreted to be general features of linguistic variation with advancing age. Communicative consequences of ambiguous reference are discussed.

The self-lined superiorly based pull-through velopharyngoplasty: plastic surgery-speech pathology interaction in the management of velopharyngeal insufficiency.

We present a rationale and step-by-step description of a previously unpublished innovative surgical technique designed to overcome velopharyngeal insufficiency. This procedure maintains the anatomic integrity and physiologic function of the velopharynx by limiting interpalatal dissection and incorporates a method for flap attachment through the velum that is accessible, predictable, and versatile. The efficacy of this procedure in eliminating velopharyngeal insufficiency was evaluated by using rigorously controlled quantitative psychophysical scaling procedures of presurgical and postsurgical perceptual ratings of resonance, nasal emission, and intelligibility and instrumental acoustic analyses. The results indicated significantly better postsurgical speech outcomes by individuals treated with the pull-through velopharyngoplasty than did patients treated with other procedures designed for the secondary management of velopharyngeal insufficiency. Based on our experience with more than 150 patients, we believe that the self-lined superiorly based pull-through velopharyngoplasty represents an advancement in the surgical treatment of velopharyngeal insufficiency.

Magnetic resonance imaging findings and correlations in spasmodic dysphonia patients.

A sample of 19 spasmodic dysphonia (SD) patients was selected from a larger population of such patients to undergo magnetic resonance imaging (MRI), auditory brain stem response (ABR) testing, speech analysis, and extensive physical examination. Six patients had abnormal spin-echo MRI findings, ranging from infarcts within the basal ganglia to demyelinating lesions within the supralateral angles of the lateral ventricles. A weakly positive correlation was noted between the abnormal MRI findings and an abnormal ABR. The lack of a significant correlation between the MRI findings and other predictors of brain stem and midbrain disease, and the current spatial resolution limitations of MRI, suggest that we are visualizing the associated lesions rather than the actual foci of SD. The range of MRI findings is consistent with the concept that SD is a voice disorder in a heterogeneous patient population.

Disfluency in spasmodic dysphonia: a multivariate analysis.

This study examined visual analog scaling (VAS) judgments of disfluency by normal listeners in response to oral reading by speakers with spasmodic dysphonia (SD) and by nondysphonic controls, as well as the variables of frequency of occurrence of disfluencies, speaking rate, number of reading errors, and temporal acoustic measures of interword interval duration and articulation time. MANOVA yielded statistically significant differences between SD and control speakers for all variables except reading errors. Although no significant fluency-related differences were observed in terms of type of vocal spasm or voice tremor, significant differences in disfluency measures were obtained for clinical ratings of severity of dysphonia. Greater dysphonia severity ratings were associated with decreased fluency, but milder ratings were not necessarily associated with disfluency. Stepwise multiple regression analysis demonstrated that frequency of disfluency occurrence, speaking rate, and reading errors accounted for more than three fourths of the variability in VAS judgments of disfluency. Findings suggest that although disfluency is not a defining feature of SD, it does contribute significantly to the overall clinical impression of severity of the disorder.

Emotional considerations in spasmodic dysphonia: psychometric quantification.

Whereas recent research has focused upon neuromotor aspects of spasmodic dysphonia, the disorder has historically been regarded as having a psychogenic basis. Relatively little empirical evidence, however, has been offered either to support or refute that claim. The present study examines emotional characteristics of 18 female spasmodic dysphonic subjects in comparison to matched normal controls across psychometric measures of depression, anxiety, and somatic complaints. Statistically significant differences were noted between groups for all measures and over half of the dysphonic subjects exhibited clinically significant levels of depression and anxiety relative to published test norms. Correlational analysis revealed the presence of an "affective factor" among the dysphonics that was not evident among the controls. These findings raise serious concerns for neuromotor interpretations given in various areas of recent spasmodic dysphonia research. Theoretical, clinical and methodological implications are discussed.

Spastic dysphonia: a continuum disorder.

Recently, two types of spastic dysphonia, adductor and abductor, have been proposed. The literature suggests that patients may be categorized as having one form of the disorder or the other. The present study presents case history and spectrographic data on a patient who evidences vocal characteristics of both disorder types. It is suggested that spastic dysphonia is a disorder involving a harshness-breathiness continuum and is not amenable to strict, binary categorization.

Episodic reactive dysphonia: a case study.

This case study exemplifies successful diagnosis through stroboscopic fiberoptic examination, illustrates the critical importance of a careful case history, and demonstrates potential hazards of supposedly benign environmental substances for hypersensitive individuals.

Inferential abilities of normal and right hemisphere damaged adults.

There were two aims of this study. The first was to compare indirect inferencing abilities by nine right hemisphere brain-damaged (RHD) adults with 18 matched normal controls. The second purpose was to determine the best condition in which to present information to the RHD individuals for the purpose of forming these inferences. Three conditions were evaluated: (1) Auditory-Only, (2) Orthographic-Only, and (3) Combined Auditory/Orthographic. It was hypothesized that right hemisphere damaged persons would perform most successfully when the materials (narrative paragraphs) were presented using the combined condition. Both groups performed significantly better in the combined Auditory/Orthographic condition. There were no significant differences in the performances of the RHD group as compared to the normal controls. This suggested that the RHD group did not exhibit an inference impairment on this type of linguistic task.

Rapid manual abilities in spasmodic dysphonic and normal female subjects.

This study quantitatively examined upper extremity motor performance in 18 spasmodic dysphonic females, in comparison to matched normal controls, across variables of finger lift reaction time, index finger tapping speed, and peg placing (Purdue Pegboard) speed. Significant differences were noted for both upper extremities on the finger tapping and pegboard tasks, with better performance by the controls. A linear combination of these manual variables was able to discriminate the spasmodic dysphonic from matched normal subjects with 78% accuracy. Motor performance was uncorrelated with psychometric measures of anxiety and depression in both groups. The dysphonic subjects exhibited a significant correlation between nondominant finger tapping speed and severity ratings of motor speech impairment. Possible localizing significance of these findings is discussed.

Influence of verbal and nonverbal contexts on the sentence intelligibility of a speaker with dysarthria.

The influence of verbal and nonverbal contextual factors on intelligibility was examined using sentences produced under varying conditions by a speaker with severe flaccid dysarthria. Contextual factors included (a) concurrent production of communication gestures, (b) predictiveness of message content, (c) relatedness of sentences to specific situational contexts, and (d) prior familiarization with the speaker. Sentences produced by the speaker were audio- and video-recorded and presented to 96 listeners/viewers who were assigned to three different methods of presentation of the stimuli: (a) audio+video, (b) audio-only, or (c) video-only conditions. Results indicated that gestures, predictiveness, and context influenced intelligibility; however, complex interactions were observed among these factors and methods of presentation of the stimuli. Results were interpreted in light of Lindblom's "mutuality model," indicating that when signal fidelity is poor, as in the present speaker with dysarthria, differing combinations of signal-independent information may be employed to enhance listener understanding of spoken messages.

Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation.

This study examines the functional and physiologic outcomes of treatment in a group of 10 patients with chronic dysphagia subsequent to a single brainstem injury. All patients participated in a structured swallowing treatment program at a metropolitan teaching hospital. This program differs from more traditional swallowing treatment by the inclusion of surface electromyography biofeedback as a treatment modality and the completion of 10 hr of direct treatment in the first week of intervention. A retrospective analysis of medical records and patient questionnaires was used to gain information regarding medical history, site of lesion, prior interventions, and patient perception of swallowing recovery. Physiologic change in swallowing treatment, as measured by severity ratings of videofluoroscopic swallowing studies, was demonstrated in nine of 10 patients after 1 week or 10 sessions of treatment. Functional change was measured by diet level tolerance after 1 week of treatment, at 6 months, and again at 1 year posttreatment. Eight of the 10 patients were able to return to full oral intake with termination of gastrostomy tube feedings, whereas two demonstrated no long-term change in functional swallowing. Of the eight who returned to full oral intake, the average duration of tube feedings following treatment until discontinuation was 5.3 months, with a range of 1-12 months. Six patients who returned to oral intake maintained gains in swallowing function, and two patients returned to nonoral nutrition as the result of a new unrelated medical condition.