Osteoporosis in pulmonary clinic patients: does point-of-care screening predict central dual-energy X-ray absorptiometry?

STUDY OBJECTIVES: Patients in a pulmonary clinic have disorders that predispose them to osteoporosis and may use glucocorticoid therapy, which has been associated with low bone mineral density (BMD) and increased fracture risk. Ideally, all patients at risk for osteoporosis would be screened using the best test available, which is central BMD by dual-energy x-ray absorptiometry (DXA). We proposed to stratify the risk for osteoporosis by the use of a simple questionnaire and point-of-care heel ultrasound BMD measurements. DESIGN: Cross-sectional screening study. SETTING: Pulmonary clinic in a single Veterans Affairs Medical Center. PATIENTS: Approximately 200 male and female patients who had not had previous BMD testing were eligible for the study, and 107 gave consent. INTERVENTIONS: One hundred seven men (white, 71 men; black, 35 men; and Asian, 1 man) underwent heel BMD testing and filled out a questionnaire. Ninety-eight men underwent a central DXA. RESULTS: Of 98 subjects, 24.5% had a spine, total hip, or femoral neck (FN) T-score of or= 7 days, and race, which accounted for 52 to 57% of the variance. When a heel ultrasound T-score of -1.0 was tested to predict a central DXA T-score of -2.0, the sensitivity was 61% and the specificity 64%. Adding the questionnaire score and body mass index (BMI) to the heel T-score improved sensitivity but not specificity. Moreover, BMI and age predicted central BMD with similar sensitivity and specificity. Importantly, of 24 patients with a central DXA T-score of 相似文献   

Implementing remote triage in large health systems: A qualitative evidence synthesis

Remote triage (RT) allows interprofessional teams (e.g., nurses and physicians) to assess patients and make clinical decisions remotely. RT use has developed widespread interest due to the COVID‐19 pandemic, and has future potential to address the needs of a rapidly aging population, improve access to care, facilitate interprofessional team care, and ensure appropriate use of resources. However, despite rapid and increasing interest in implementation of RT, there is little research concerning practices for successful implementation. We conducted a systematic review and qualitative evidence synthesis of practices that impact the implementation of RT for adults seeking clinical care advice. We searched MEDLINE®, EMBASE, and CINAHL from inception through July 2018. We included 32 studies in this review. Our review identified four themes impacting the implementation of RT: characteristics of staff who use RT, influence of RT on staff, considerations in selecting RT tools, and environmental and contextual factors impacting RT. The findings of our systemic review underscore the need for a careful consideration of (a) organizational and stakeholder buy‐in before launch, (b) physical and psychological workplace environment, (c) staff training and ongoing support, and (d) optimal metrics to assess the effectiveness and efficiency of implementation. Our findings indicate that preimplementation planning, as well as evaluating RT by collecting data during and after implementation, is essential to ensuring successful implementation and continued adoption of RT in a health care system.     

Meta-analytic evidence for neuroimaging models of depression: State or trait?

Background

Major Depressive Disorder (MDD) is a leading cause of disease burden worldwide. With the rapid growth of neuroimaging research on relatively small samples, meta-analytic techniques are becoming increasingly important. Here, we aim to clarify the support in fMRI literature for three leading neurobiological models of MDD: limbic–cortical, cortico–striatal and the default mode network.

Methods

Searches of PubMed and Web of Knowledge, and manual searches, were undertaken in early 2011. Data from 34 case-control comparisons (n=1165) and 6 treatment studies (n=105) were analysed separately with two meta-analytic methods for imaging data: Activation Likelihood Estimation and Gaussian-Process Regression.

Results

There was broad support for limbic–cortical and cortico–striatal models in the case-control data. Evidence for the role of the default mode network was weaker. Treatment-sensitive regions were primarily in lateral frontal areas.

Limitations

In any meta-analysis, the increase in the statistical power of the inference comes with the risk of aggregating heterogeneous study pools. While we believe that this wide range of paradigms allows identification of key regions of dysfunction in MDD (regardless of task), we attempted to minimise such risks by employing GPR, which models such heterogeneity.

Conclusions

The focus of treatment effects in frontal areas indicates that dysregulation here may represent a biomarker of treatment response. Since the dysregulation in many subcortical regions in the case-control comparisons appeared insensitive to treatment, we propose that these act as trait vulnerability markers, or perhaps treatment insensitivity. Our findings allow these models of MDD to be applied to fMRI literature with some confidence.     

A Psychoneuroendocrino-immune approach in the nursing treatment of anorexia and bulimia nervosa

Recent clinical reports have shown an increasing number of patients afflicted by eating disorders in the western world. There are numerous causes and mechanisms leading to eating disorders that affect the psychoneuroendocrinoimmune system. In this study, we define a novel psychoneuroendocrinoimmune nursing approach for anorexic and bulimic patients’ treatment. According to the specific diagnostic items deriving from the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, and clinical guidelines in eating disorders formulated by the National Institute for Clinical Excellence, we carried out a qualitative study on the nursing treatment chosen by 210 international centers considered as a sample. This study was based on a no structured interview via e-mail to better understand the nursing approach in anorexia and bulimia nervosa. Thanks to the selected centers’ answers, four different levels of nursing care were identified, that include:

1. the nursing role analyzing the spectrum of patients’ problems;

2. the nursing intervention in inpatient care;

3. the nursing intervention in outpatient care;

4. the day hospital treatment.

All four prove to be especially useful in the nursing practice.     

Structural and Functional Support in the Prediction of Smoking Cessation in Caregivers of Children with Asthma

Caregivers of children with asthma smoke at rates similar to the general population. Research on the relative importance of structural or functional social support in smoking cessation has been mixed. Participants were smokers (N = 154) who were caregivers of children with asthma. Both functional (Interpersonal Support Evaluation List) and structural social support (living with another smoker, partner status, and the proportion of smoking friends) were measured at baseline. Participants received an asthma-education and smoking cessation intervention based on Motivational Interviewing. Biochemically-verified abstinence was assessed at six months post treatment. Results indicated that functional support predicted smoking abstinence even when controlling for relevant covariates and structural support (OR = .896, p = .025). Exploratory analyses revealed that this effect was driven primarily by the self-esteem ISEL subscale. Smoking cessation that focuses on building general functional support, particularly self-esteem support, may be beneficial for smoking cessation in caregivers of children with asthma.     

A Randomized Controlled Trial of High-Intensity Exercise and Executive Functioning in Cognitively Normal Older Adults

BackgroundThere is a paucity of interventional research that systematically assesses the role of exercise intensity and cardiorespiratory fitness, and their relationship with executive function in older adults. To address this limitation, we have examined the effect of a systematically manipulated exercise intervention on executive function.MethodsNinety-nine cognitively normal participants (age = 69.10 ± 5.2 years; n = 54 female) were randomized into either a high-intensity cycle-based exercise, moderate-intensity cycle-based exercise, or no-intervention control group. All participants underwent neuropsychological testing and fitness assessment at baseline (preintervention), 6-month follow-up (postintervention), and 12-month postintervention. Executive function was measured comprehensively, including measures of each subdomain: Shifting, Updating/ Working Memory, Inhibition, Verbal Generativity, and Nonverbal Reasoning. Cardiorespiratory fitness was measured by analysis of peak aerobic capacity; VO₂peak.ResultsFirst, the exercise intervention was found to increase cardiorespiratory fitness (VO₂peak) in the intervention groups, in comparison to the control group (F =10.40, p≤0.01). However, the authors failed to find mean differences in executive function scores between the high-intensity, moderate intensity, or inactive control group. On the basis of change scores, cardiorespiratory fitness was found to associate positively with the executive function (EF) subdomains of Updating/Working Memory (β = 0.37, p = 0.01, r = 0.34) and Verbal Generativity (β = 0.30, p = 0.03, r = 0.28) for intervention, but not control participants.ConclusionAt the aggregate level, the authors failed to find evidence that 6-months of high-intensity aerobic exercise improves EF in older adults. However, it remains possible that individual differences in experimentally induced changes in cardiorespiratory fitness may be associated with changes in Updating/ Working Memory and Verbal Generativity.     

Ketogenic diets cause opposing changes in synaptic morphology in CA1 hippocampus and dentate gyrus of late-adult rats

Ketogenic diets (KDs) have beneficial effects on several diseases, such as epilepsy, mitochondriopathies, cancer, and neurodegeneration. However, little is known about their effects on aging individuals. In the present study, late-adult (19-month-old) rats were fed for 8 weeks with two medium chain triglycerides (MCT)-KDs, and the following morphologic parameters reflecting synaptic plasticity were evaluated in stratum moleculare of hippocampal CA1 region (SM CA1) and outer molecular layer of hippocampal dentate gyrus (OML DG): average area (S), numeric density (Nv(s)), and surface density (Sv) of synapses, and average volume (V), numeric density (Nv(m)), and volume density (Vv) of synaptic mitochondria. In SM CA1, MCT-KDs induced the early appearance of the morphologic patterns typical of old animals (higher S and V, and lower Nv(s) and Nv(m)). On the contrary, in OML DG, Sv and Vv of MCT-KDs-fed rats were higher (as a result of higher Nv(s) and Nv(m)) versus controls; these modifications are known to improve synaptic function and metabolic supply. The opposite effects of MCT-KDs might reflect the different susceptibility to aging processes: OML DG is less vulnerable than SM CA1, and the reactivation of ketone bodies uptake and catabolism might occur more efficiently in this region, allowing the exploitation of their peculiar metabolic properties. Present findings provide the first evidence that MCT-KDs may cause opposite morphologic modifications, being potentially harmful for SM CA1 and potentially advantageous for OML DG. This implies risks but also promising potentialities for their therapeutic use during aging.     

Osseointegrated total knee replacement connected to a lower limb prosthesis: 4 cases

Background and purpose — Osseointegrated implants are an alternative for prosthetic attachment in individuals with amputation who are unable to wear a socket. However, the load transmitted through the osseointegrated fixation to the residual tibia and knee joint can be unbearable for those with transtibial amputation and knee arthritis. We report on the feasibility of combining total knee replacement (TKR) with an osseointegrated implant for prosthetic attachment.Patients and methods — We retrospectively reviewed all 4 cases (aged 38–77 years) of transtibial amputations managed with osseointegration and TKR in 2012–2014. The below-the-knee prosthesis was connected to the tibial base plate of a TKR, enabling the tibial residuum and knee joint to act as weight-sharing structures. A 2-stage procedure involved connecting a standard hinged TKR to custom-made implants and creation of a skin-implant interface. Clinical outcomes were assessed at baseline and after 1–3 years of follow-up using standard measures of health-related quality of life, ambulation, and activity level including the questionnaire for transfemoral amputees (Q-TFA) and the 6-minute walk test.Results — There were no major complications, and there was 1 case of superficial infection. All patients showed improved clinical outcomes, with a Q-TFA improvement range of 29–52 and a 6-minute walk test improvement range of 37–84 meters.Interpretation — It is possible to combine TKR with osseointegrated implants.Socket-related discomfort leads to a significant reduction in the quality of life of individuals with lower limb amputation (Dillingham et al. 2001, Gholizadeh et al. 2014). Socket-skin interface problems lead to poor fit, diminished proprioception in the amputated limb, lack of rotational control, and reduction of ipsilateral proximal joint movement (Legro et al. 1999, Lyon et al. 2000, Meulenbelt et al. 2006).A direct connection of the prosthetic limb to the bone using osseointegrated implants can address these socket-related problems (Van de Meent et al. 2013, Tsikandylakis et al. 2014). Brånemark introduced this surgical procedure in 1995. He adapted osseointegration principles established in dental surgery to the rehabilitation of individuals with transfemoral amputation using a percutaneous bone anchoring implant screwed into the femur (Brånemark et al. 2001). Hip replacement spongiosa surface coating technology has been used to make a chrome cobalt intramedullary press-fit implant (Endo-Exo Prosthesis) allowing larger surface area for osseointegration and faster rehabilitation (Staubach and Grundei 2001). Al Muderis et al. (2015) adapted highly porous plasma-sprayed titanium implants to provide optimum initial press-fit and solid bone ingrowth.Studies of transfemoral implants have found improved quality of life, prosthetic use, body image, hip range of motion, sitting comfort, and walking ability (Van de Meent et al. 2013, Hagberg et al. 2014). For example, substantial improvements in health-related quality of life using the Global component of the questionnaire for transfemoral amputees (Q-TFA)—of 38 points (Hagberg et al. 2014) and 24 points (Van de Meent et al. 2013)—have been reported in 2 case series of 51 and 22 patients, respectively.Similar benefits could be expected for transtibial amputees using osseointegrated implants, as the knee joint could possibly enhance their gait. A study of 39 cases involving upper and lower limb prostheses (Tillander et al. 2010) found infections in 7 patients at an average follow-up period of 54 (3–132) months, with no infections reported for 1 tibial implant. At our own center, preliminary evidence of the safety and effectiveness of the tibial impants in 22 transtibial amputees with a minimum of 6 months of follow-up gave results consistent with the published results for transfemoral amputations (Khemka et al. 2015).Few authors have reported on the safety of this procedure (Brånemark et al. 2014, Tsikandylakis et al. 2014). One of the largest studies included 51 patients and reported superficial infections in approximately half of these patients at 2-year follow-up. In that study, the implant was removed in 1 patient due to deep infection and in 3 patients due to aseptic loosening (Brånemark et al. 2014).Osseointegrated implants are not currently recommended for transtibial amputees with ultra-short residuum. In addition to the practical technical challenges, biomechanical studies have suggested that small bone-implant contact is more likely to increase the risk of loosening (Lohr et al. 2000, Henriksen et al. 2003, Carvalho et al. 2012). Osseointegration is also not currently recommended for those suffering from ipsilateral knee osteoarthritis because it is hypothesized that an osseointegrated tibial implant will aggravate arthritic symptoms due to mechanical forces (Frossard et al. 2008).We describe the surgical procedure and early results of combining a total knee replacement (TKR) with an osseointegrated implant for prosthetic attachment for the first time.