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.

Blood pressure and metabolic profile after surgical menopause: comparison with fertile and naturally-menopausal women.

In 1978 a random sample (367 men and 568 women aged 18-65 years) taken from the general population of a north-eastern Italian town was screened for cardiovascular risk; 16 years later, the women were invited to a second screening. Three groups were identified at the initial screening (fertile, naturally menopausal and surgically menopausal) and four in the longitudinal study (137 remained fertile during the whole study, 205 became naturally menopausal, 56 were ovariectomised and 127 were already going through the menopause). The protocol included a questionnaire, blood pressure (BP) measurement, and blood exams. Continuous variables were adjusted for confounders. Systolic BP, prevalence of hypertension, cholesterol, glycaemia and uricaemia were similar, whereas diastolic and triglycerides (TG) were lower in surgically-menopausal than in fertile women (P < 0.001). No significant difference in 16 years' variation from baseline was observed between the four groups, although women who remained fertile showed the smallest increases. In particular, neither systolic or diastolic BP increases differed between the women who were oophorectimised and those who remained fertile. 'Fertile status' was rejected from the logistic equation of incidence of hypertension, and 'age of menopause' was also rejected when this analysis was repeated in ovariectomised women. New coronary artery disease (angina pectoris or myocardial infarction) was observed in one ovariectomised woman, in three naturally menopausal, and in 13 already menopausal women which seemed to reflect the age trend. No new cases were observed in women who remained fertile. In conclusion, in Italian women surgical menopause, similarly to natural menopause, is devoid of any negative prognostic effect. Journal of Human Hypertension (2000) 14, 799-805

The 24-hour rhythm of blood pressure differs from that of leg hemodynamics in orthotopic heart transplant recipients.

BACKGROUND: This study was aimed at investigating whether a circadian rhythm of peripheral resistance exists in patients with orthotopic cardiac transplantation (OCT) and whether it parallels that of blood pressure (BP). METHODS: BP and leg flow and resistance (plethysmography) were monitored for 24 hours in 13 denervated OCT recipients and 13 control patients with native heart, matched for casual blood pressure. RESULTS: On the basis of BP trend, control patients showed a BP reduction during sleep, whereas OCT recipients did not. Leg resistance was significantly lower and leg flow significantly higher during sleep than during waking in all patients, and the extent of the nocturnal decrease was similar in the two categories. CONCLUSIONS: The decrease in leg resistance in patients confined to bed for 24 hours is caused by peripheral mechanisms and does not depend on the autonomic control of the heart. The nocturnal decline in BP depends, on the contrary, on cardiac control and is lost in patients with denervated heart.

Cardiovascular mortality in non-insulin-dependent diabetes mellitus. A controlled study among 683 diabetics and 683 age- and sex-matched normal subjects.

Although non-insulin-dependent diabetes mellitus (NIDDM) is considered a major cause of death, the role of some independent risk factors in diabetic patients is under debate. In fact the prognosis of NIDDM diabetes varies considerably in relation to the individual risk pattern, and the different studies are not directly comparable because of differences in size, age and geography of the samples, and type of statistical analysis. The aim of the study is to identify the independent predictors of mortality in a cohort of subjects with NIDDM, and to verify whether the relative risk (RR) of cardiovascular mortality is different in comparison to that of coeval non-diabetic subjects from a general population. The study includes 683 patients with NIDDM from the Northern Italian town of Pordenone, followed up for 6 years and age- and sex-matched to 683 non-diabetic subjects from a Northern Italian general population. When the two cohorts were compared, NIDDM turned out to be a strong risk factor for cardiovascular mortality (RR: 2.67). Age, coronary artery disease (RR: 1.78), arterial hypertension (RR: 1.39), macro- (RR: 2.97) and microalbuminuria (RR: 2.01) were independent predictors of cardiovascular mortality in the diabetics. In conclusion, survival of diabetic patients is worse than that of non-diabetic coeval subjects. Only few items are able to predict cardiovascular mortality in the diabetics, namely age, hypertension, CAD, macro- and microalbuminuria.

Predictors of cancer mortality in elderly subjects.

Cancer mortality was analysed in 3282 elderly subjects aged > or =65 years from 2 cohorts of general population having different life-style patterns. They took part in the CASTEL (CArdiovascular STudy in the ELderly), a 12-year lasting prospective Italian study. The aim of the present analysis was to identify the items able to influence cancer mortality. A biochemical profile and a questionnaire on lifestyle were collected. Continuous items were averaged and compared with analysis of variance, frequencies with the Pearson's chi2 test. Mortality was recorded yearly for 12 years from the Registrar's Office and causes of death double-checked by consulting medical case sheets and family doctors' files. The influence of items on mortality was evaluated with the Cox multivariate analysis. Relative risk (RR) of each item was adjusted for confounders. Age, gender, tobacco smoking, the presence of respiratory symptoms, low body mass index in males, serum alanine transaminase (ALT) and alkaline phosphatase (ALP), as well as the town of residence, were powerful predictors of cancer mortality. In the entire population, 12-year overall mortality was 49.4%, cardiovascular 22.8%, and neoplastic 11%; the latter was higher in males than in females (15.7% vs. 7.9%, p < 0.00001). In subjects with respiratory symptoms neoplastic mortality was 11.6% (RR: 1.47) vs. 9.7% in those without symptoms (p < 0.01). Subjects with very low cholesterol (< or = 178 mg/dl), those with high uric acid (> or =8.7 mg/ dl) and males with low body mass index (< or =22.7 kg/ m2) has an increased risk of cancer mortality. RR of cancer mortality increased with increasing ALT or ALP. It was approximately 1 in those having ALT and ALP between 9 and 41.2 U/I, 1.41 in those exceeding this latter level and < 1 in those below 9 U/I. RR of ALP had a similar trend, the best protective cut-off value being < 106 and the worst one > 177 U/I. When both serum enzymes were simultaneously raised, RR of cancer mortality increased to 2.84.

Cancer mortality trends in two cohorts of elderly people having different life-styles.

We analyzed cancer mortality trends in 3282 elderly subjects from two general Italian populations with different life-style patterns taking part in the Cardiovascular Study in the Elderly (CASTEL). The aim of the study was to evaluate which predictors were able to influence cancer mortality. Age, gender, tobacco smoking, the presence of respiratory symptoms, increased serum levels of ALT and ALP, and the town of residence were powerful predictors. Subjects living in Chioggia (low income, rural) had significantly greater lung and liver cancer mortality, compared with those living in Castelfranco (industrial). The findings suggest that an incongruous life-style (smoking, alcohol consumption, poor hygienic conditions) may increase cancer mortality despite the favorable environmental conditions typical of rural Mediterranean areas.

24-hour leg and forearm haemodynamics in transected spinal cord subjects.

OBJECTIVE: A circadian rhythm of blood pressure has been demonstrated both in subjects who are physically active during the day and in those confined to bed. The study of the circadian rhythm of arterial flow and peripheral resistance, on the other hand, is limited to pioneer experiments. This paper is aimed at demonstrating that leg peripheral resistance has circadian fluctuations which are modulated by spinal neural traffic. METHODS: Eleven normal (able-bodied) human subjects and 11 patients with spinal transection due to spinal cord injury (SCI) were studied. They were confined to bed for 24 h. Blood pressure and heart rate were monitored every 15 min with an automatic device and leg flow with an automatic strain-gauge plethysmograph synchronised to the pressurometer. Peripheral resistance was calculated at the same intervals. RESULTS: In able-bodied subjects leg resistance was significantly higher during waking hours (when the sympathetic system is more activated) than during sleep, while in subjects with spinal cord injury no difference was detected between day-time and night-time. CONCLUSIONS: The circadian rhythm is controlled by adrenergic fibres transmitted via the spinal cord.

Effects of caffeine on glucose tolerance: a placebo-controlled study.

OBJECTIVE: The investigation was performed to study the effects of 200 mg oral caffeine on glucose tolerance. DESIGN: Single-blind Latin square with active treatment (caffeine) and placebo. SETTING: The University of Padova, Department of Internal Medicine. SUBJECTS: 30 nonsmoking healthy subjects aged 26-32 years who abstained not only from coffee but also from tea, chocolate and cola for 4 weeks and who had given their informed consent. INTERVENTIONS: A 75 g oral glucose tolerance test (OGTT) was performed after giving caffeine or placebo (highly decaffeinated coffee). RESULTS: The glycaemic curve was normal in all subjects and was similar in the two groups until the second hour; in subjects taking caffeine a shift towards the right was detected at the 2nd, 3rd and 4th hours in comparison to those taking the placebo. Blood insulin levels were comparable after caffeine and after placebo along the entire OGTT. CONCLUSIONS: The data suggest that caffeine intake induces a rise in blood glucose levels that is insulin independent.

Subjects with obstructive pulmonary disease tend to be chronically vasodilated.

1. In 12 unselected outpatients with chronic obstructive pulmonary disease and six controls, arterial pH, PaO2, PaCO2 and oxygen saturation (SaO2), forced expiratory volume in 1.0 s (FEV1.0) and vital capacity were measured. Subjects were grouped into those with or without obstruction based on the Tiffenau index. The Baseline Dyspnoea Index was employed to objectify the severity of dyspnoea and the Borg index to evaluate the subjective sensation. Blood pressure was measured with a sphygmomanometer; calf arterial flow both at rest and during reactive hyperaemia with a plethysmograph. Basal and minimal resistance were calculated.2.FEV1.0 was 26% lower in patients with obstruction than in controls, and was also lower in patients with moderate-to-severe obstruction compared with those with mild or no obstruction. Arterial flow (75% greater in the patients with obstruction) progressively increased with increasing severity of obstruction, being 54% higher in those with mild obstruction than in those with no obstruction (P<0.001), and 28% higher in moderate-severe than in mild obstruction (P<0.005). In multiple regressions, F correlated inversely with FEV1.0, PaO2 and SaO2, and directly with PaCO2. Basal resistance correlated positively with FEV1.0, SaO2 and the Tiffenau index, and inversely with PaCO2 (r=-0.52, P=0.02). Minimal resistance was significantly lower in obstructed than in non-obstructed subjects. Both basal and minimal resistance progressively decreased, although insignificantly, with worsening bronchial obstruction. PaCO2 did not correlate with any haemodynamic parameter. Borg index correlated indirectly with FEV1.0 and basal resistance directly with arterial flow.3. Patients with chronic obstructive pulmonary disease therefore tend to show chronic vasodilatation depending on hypoxia rather than PaCO2. Other mechanisms could be involved in this phenomenon. The Borg index is a good indicator of oxygen desaturation and vasodilatation.

Characterisation of hypertensive patients according to 24 H peripheral resistance.

To clarify whether a circadian rhythm of peripheral resistance exists in humans and whether hypertensive patients represent a homogeneous category in this respect, 15 normotensives aged 31 +/- 4 years and 30 hypertensives aged 41 +/- 13 years were confined to bed for 22 h and forearm flow recorded automatically. Night-time BP values were higher in hypertensive patients (Group B) whose night/day ratios of mean BP were below the 95% C.I. of the normal regression of the normotensives, than in those falling within the 95% C.I. (Group A). Forearm resistance was lower during sleep than during waking in Group A and in the normotensive controls, paralleling the nocturnal blood pressure fall. On the contrary, in the Group B hypertensives, despite a comparable night-time BP decrease, forearm resistance was higher during sleep than during waking.

Should digoxin be proscribed in elderly subjects in sinus rhythm free from heart failure? A population-based study.

Increased mortality in digoxin-treated subjects has been demonstrated in patients with recent myocardial infarction. Those with congestive heart failure (CHF) due to causes other than myocardial infarction seem to be free from this effect. No information is currently available concerning mortality in elderly people who are frequently prescribed digitalis even in the absence of CHF. The aim of this study was to investigate whether subjects improperly receiving digoxin were worse off than those not receiving this drug. This analysis is a part of CASTEL, a population-based prospective study that has enrolled a cohort of 2,254 subjects aged > or = 65 years. CHF was diagnosed in 187 subjects and atrial fibrillation (AF) in 90. The remaining 1,977 were free from CHF and in sinus rhythm, but 447 were treated with digitalis. Cumulative mortality and morbid events by digitalis treatment were calculated in all these categories. Among subjects free from CHF and AF (improper use), all-cause and cardiovascular mortality was significantly higher among those taking digitalis than in those who did not. Non-fatal events including CHF were also more apparent in the former than in the latter. Cox analysis confirmed digitalis as a predictor of mortality in these subjects. No effect of digitalis on survival was found in patients with CHF or AF (proper use). In elderly subjects without atrial fibrillation or CHF, the use of digitalis worsens morbidity and mortality.