Factores predictivos del riesgo de fractura de cadera osteoporótica en octogenarios / Predictive factors of osteoporotic hip fracture in octogenarians

Objetivo Este estudio tiene como objetivo identificar los factores de riesgo asociados con las fracturas de cadera osteoporóticas en octogenarios y busca perfeccionar las estrategias de prevención primaria para estas fracturas. Material y métodos Realizamos un estudio de casos y controles en el que participaron personas de 79 años o más con fracturas de cadera, comparándolas con controles de la misma edad y sexo sin antecedentes de fracturas de cadera. Se recogieron factores epidemiológicos, clínicos, antropométricos y analíticos. Se evaluó la presencia de osteoporosis mediante densitometría ósea. Definimos la sarcopenia según los criterios del Grupo de Trabajo Europeo sobre Sarcopenia en Personas Mayores (EWGSOP2). Resultados Se analizaron 95 pacientes por grupo, con una edad media de 82 años, de los cuales 74% eran mujeres. El análisis multivariado incluyó factores estadísticamente significativos encontrados en el análisis univariado (p<0,05). Estos factores incluyeron el índice de Barthel, la evaluación nutricional mediante la herramienta CONUT, el ácido fólico, la deficiencia de vitamina D, la presencia de fracturas previas, la pérdida de agudeza visual, la circunferencia bicipital, la sarcopenia y la osteoporosis (densitometría en el cuello del fémur). El estado nutricional (OR: 0,08 [0,01-0,61]), los niveles de ácido fólico (OR 0,32 [0,1-1]) y la pérdida de agudeza visual (OR 33,16 [2,91-377,87]) fueron los factores de riesgo independientes asociados con fractura de cadera. Conclusiones La evaluación del estado nutricional en pacientes de edad avanzada, junto con una evaluación geriátrica integral, representan herramientas fácilmente reproducibles y rentables. Estas herramientas pueden ayudar eficazmente a identificar a las personas con riesgo de sufrir fracturas de cadera, contribuyendo así a medidas preventivas más específicas y eficientes. (AU)

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<.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. (AU)

Factores predictivos del riesgo de fractura de cadera osteoporótica en octogenarios / Predictive factors of osteoporotic hip fracture in octogenarians

Objetivo Este estudio tiene como objetivo identificar los factores de riesgo asociados con las fracturas de cadera osteoporóticas en octogenarios y busca perfeccionar las estrategias de prevención primaria para estas fracturas. Material y métodos Realizamos un estudio de casos y controles en el que participaron personas de 79 años o más con fracturas de cadera, comparándolas con controles de la misma edad y sexo sin antecedentes de fracturas de cadera. Se recogieron factores epidemiológicos, clínicos, antropométricos y analíticos. Se evaluó la presencia de osteoporosis mediante densitometría ósea. Definimos la sarcopenia según los criterios del Grupo de Trabajo Europeo sobre Sarcopenia en Personas Mayores (EWGSOP2). Resultados Se analizaron 95 pacientes por grupo, con una edad media de 82 años, de los cuales 74% eran mujeres. El análisis multivariado incluyó factores estadísticamente significativos encontrados en el análisis univariado (p<0,05). Estos factores incluyeron el índice de Barthel, la evaluación nutricional mediante la herramienta CONUT, el ácido fólico, la deficiencia de vitamina D, la presencia de fracturas previas, la pérdida de agudeza visual, la circunferencia bicipital, la sarcopenia y la osteoporosis (densitometría en el cuello del fémur). El estado nutricional (OR: 0,08 [0,01-0,61]), los niveles de ácido fólico (OR 0,32 [0,1-1]) y la pérdida de agudeza visual (OR 33,16 [2,91-377,87]) fueron los factores de riesgo independientes asociados con fractura de cadera. Conclusiones La evaluación del estado nutricional en pacientes de edad avanzada, junto con una evaluación geriátrica integral, representan herramientas fácilmente reproducibles y rentables. Estas herramientas pueden ayudar eficazmente a identificar a las personas con riesgo de sufrir fracturas de cadera, contribuyendo así a medidas preventivas más específicas y eficientes. (AU)

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<.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. (AU)

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.

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

Las fracturas vertebrales son las fracturas osteoporóticas más prevalentes y paradójicamente siguen siendo también las más infradiagnosticadas. Solo un tercio de los pacientes presentan dolor agudo, pero también pueden presentar otras complicaciones crónicas asociadas. Las fracturas vertebrales se asocian a la aparición de nuevas fracturas tanto vertebrales como no vertebrales. La radiografía de columna dorso-lumbar es una buena herramienta para su detección, pero es una técnica que depende de la interpretación subjetiva del médico que la valora. Recientemente nuevas técnicas, como la morfometría vertebral, que se realiza de forma concomitante a la densitometría ósea, han demostrado una mayor eficacia en la detección de fracturas vertebrales. Identificar las fracturas vertebrales es primordial para la prevención secundaria de nuevas fracturas y para mejorar la calidad de vida de nuestros pacientes (AU)

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 (AU)

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.

Investigación en sarcopenia: importancia de la metodología / Sarcopenia research: relevance of methodology

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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.

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

Objetivo. Describir los pacientes diagnosticados de hematoma del recto anterior del abdomen (HRAA). Material y métodos. Análisis retrospectivo de pacientes diagnosticados de HRAA durante los últimos 8 años en nuestro centro. Resultados. Se incluyen 17 pacientes (9 mujeres) con edad media de 73 años. En el 52% de los casos el HRAA fue la causa del ingreso. El tratamiento anticoagulante se documentó en el 70%. Más de la mitad de pacientes tratados con heparinas de bajo peso molecular tenían insuficiencia renal. En el grupo de los que recibían AO, un 86% tenía un INR superior a 4. La tos paroxística aparecía en 13. La presentación más habitual fue dolor abdominal y masa palpable. La sensibilidad de la TAC fue superior a la ecografía. La localización más frecuente fue la inferior derecha. El tratamiento fue conservador en todos, excepto uno. Dos pacientes fallecieron. El descenso medio de la hemoglobina fue 4,7g/dl. La estancia media fue de 19 días. Conclusiones. En nuestro centro el HRAA afecta casi por igual a ambos sexos y aparece en personas de edad avanzada con exceso de tratamiento anticoagulante y tos. La presentación clínica, mayor sensibilidad diagnóstica de la TAC y predominancia en la afectación derecha del abdomen, es similar a otras series. La mortalidad y la estancia hospitalaria son superiores a lo descrito(AU)

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 4.7g/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(AU)

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

Este documento presenta la primera experiencia de la Sociedad Española de Medicina Interna en el desarrollo de un programa de formación médica continuada basado en Internet para los miembros de la sociedad, acreditado por el Ministerio de Sanidad y la Universidad Autónoma de Barcelona, y financiado por el Grupo Menarini SA. Los resultados académicos y el grado de satisfacción de los participantes en este curso han sido muy elevados, tanto por lo que respecta a los contenidos científicos como al entorno virtual de aprendizaje. Esta experiencia demuestra que la formación médica continuada basada en Internet es un campo de gran futuro y con una buena aceptación por parte de los médicos participantes, y que las sociedades científicas, con la colaboración de otras instituciones y empresas, pueden liderar programas de formación médica continuada no presencial especialmente dirigidos y adaptados a sus afiliados(AU)

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(AU)

[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.

Valoración del paciente frágil en urgencias / Assessing frail patients in the emergency department

Los pacientes ancianos frágiles utilizan cada vez más y de forma adecuada los servicios de urgencias hospitalarios (SUH). No existen evidencias que demuestren la efectividad de un modelo concreto de valoración geriátrica aplicado en los servicios de urgencias. Sin embargo, la valoración del paciente frágil en los SUH se debería utilizar adecuándola al entorno y con unos objetivos claros que permitieran realizar un diagnóstico multidimensional y establecer prioridades terapéuticas. La valoración del estado funcional aporta beneficios en la continuidad de cuidados por parte de la atención primaria, cuando los pacientes son dados de alta del SUH (AU)

Frail, elderly patients appropriately use hospital emergency services with increasing frequency. An effective evidence based model for evaluating such patients in the emergency department has not been developed. Nonetheless, when assessing the frail elderly we are advised to establish clear objectives appropriate to their overall situation so that a multidimensional diagnosis can be made and treatment priorities set. An evaluation of functional status is useful for planning continuity of care to be provided by the primary care team after these patients are discharged (AU)

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.