Abstract: In 2000, Alzheimer's disease (AD) and other dementias were the third most expensive health conditions in the USA and in 2005 their annual costs amounted to more than $148 billion. An observational, non-randomized study aimed to evaluate direct costs of demented patients in their homes. Two hundred thirty-six informal caregivers have been enrolled. A financial support, represented by a disability living allowance (15.3%) or attendance allowance (3.4%), was presented in just 19.7% of the cases. Patients receiving assistance from an employed carer were 39% with a mean cost of 800 Euro/month. Receiving assistance from an employed carer is not correlated with cognitive and functional impairment, with the age of the caregiver and with the duration of the disease (t=1.03; t=-0.86; t=1.41; t=-0.16, respectively). The informal caregivers declared that they thoughts about the possibility of institutionalize the patient were 20.9%. The present study underlines the discrepancy between subjects having assistance from an employed caregiver and subjects receiving financial supports. It often happens that patients not reaching the minimum requisites for social assistant or financial support, need at least a supervision.
Abstract: Abstract Delirium usually occurs during hospitalisation. The aims of this study were to evaluate the incidence of delirium in “hospital-at-home” compared to a traditional hospital ward and to assess mortality, hospital readmissions and institutionalisation rates at 6-month follow-up in elderly patients with intermediate/high risk for delirium at baseline according to the criteria of Inouye. We performed a prospective, non-randomised, observational study with 6-month follow-up on 144 subjects aged 75 years and older consecutively admitted to the hospital for an acute illness and followed in a geriatric hospital ward (GHW) or in a geriatric home hospitalisation service (GHHS). Baseline socio-demographic information, clinical data, functional, cognitive, nutritional status, mood, quality of life, and caregiver’s stress scores were collected. Of the 144 participants, 14 (9.7%) had delirium during their initial hospitalisation: 4 were treated by GHHS and 10 in a GHW. The incidence of delirium was 16.6% in GHW and 4.7% in GHHS. All delirious patients were very old, with a high risk for delirium at baseline of 60%, according to the criteria of Inouye. In GHW, the onset of delirium occurred significantly earlier and the mean duration of the episode was significantly longer. The severity of delirium tended to be higher in GHW compared to GHHS. At 6-month follow-up, mortality was significantly higher among patients who suffered from an episode of delirium. Moreover, they showed a trend towards a greater institutionalisation rate. GHHS may represent a protective environment for delirium onset in acutely ill elderly patients.
Abstract: Osteoporosis and atherosclerosis are degenerative disorders of old age that often present together, but recently it has been suggested that the association between osteoporosis and cardio-vascular diseases is not just due to the aging process. The osteoprotegerin (OPG)/receptor activator of nuclear factor-kB (RANK)/RANK ligand (RANKL) system has been identified as a possible mediator of arterial calcification suggesting common links between osteoporosis and vascular diseases. Since the discovery of the OPG/RANK/RANKL system, much has been learned about its role in controlling skeletal biology; however, its role in the context of vascular biology is only beginning to be explored. It has been suggested that OPG might act as an autocrine/paracrine regulator of vascular calcification and might be useful as a serum marker of vascular disease. However, the exact role of OPG (or RANKL/RANK) in vascular calcification is still not completely understood. This review aims to report the recent findings on the relationship between osteoporosis and OPG/RANK/RANKL-mediated vascular disease.
Abstract: Background Although the hospital is the standard venue for short-term medical care, it may be hazardous for older persons. This study was performed to evaluate the feasibility and effectiveness of a physician-led hospital-at-home service for selected elderly patients with acute decompensation of chronic heart failure (CHF).
Methods Prospective, single-blind, randomized controlled trial with 6-month follow-up for patients 75 years or older admitted to the hospital from April 1, 2004, through April 31, 2005, for acute decompensation of CHF. Patients were randomly assigned to the general medical ward (n = 53) or to the Geriatric Home Hospitalization Service (GHHS; n = 48). The GHHS provides diagnostic and therapeutic treatments by hospital health care professionals in the home of the patient.
Results Patient mortality at 6 months was 15% in the total sample, without significant differences between the 2 settings of care. The number of subsequent hospital admissions was not statistically different in the 2 groups, but the mean (SD) time to first additional admission was longer for the GHHS patients (84.3 [22.2] days vs 69.8 [36.2] days, P = .02). Only the GHHS patients experienced improvements in depression, nutritional status, and quality-of-life scores.
Conclusions Substitutive hospital-at-home care is a viable alternative to traditional hospital inpatient care for elderly patients with acutely decompensated CHF. This type of care demonstrated clinical feasibility and efficacy in comparison with its alternative.
Abstract: It has been suggested that iron-deficient rats have lower bone mass than iron-replete animals, but a clear association between bone and iron repletion has not been demonstrated in humans. A growing body of evidences also suggests a relation between lipid oxidation and bone metabolism and between iron metabolism and LDL oxidation. Iron availability to cells also depends on haptoglobin (Hp) phenotypes. Hp has also important antioxidant properties according to its phenotype, hence we evaluate whether Hp phenotype could influence bone density, iron metabolism and lipid oxidation. This cross-sectional study enrolled 455 postmenopausal women affected by osteoporosis (260) or not (195). Bone mineral density, markers of bone and iron metabolism, levels of oxidized LDL (oxLDL) and Hp phenotype were measured in all the subjects. Hp 1.1 and 2.2 frequency was higher and Hp 2.1 was lower in the patients with fragility fractures (80) compared with the controls. We therefore evaluate different Hp phenotypes as risk or protective factors against fragility fracture: Hp 2.1 is a protective factor against fracture while 1.1 is an important and 2.2 a moderate risk factor for fragility fractures. Lower serum iron was associated with elevated transferrin in patients with Hp 1.1; moreover patients had relative iron deficiency compared with the controls and fractured patients had higher level of oxLDL. We found that both iron metabolism and oxLDL varies according to Hp phenotypes and are predictive of bone density. Our data indicate that Hp 2.1 is a protective factor for fragility fractures, depending on its role on iron metabolism and its antioxidant properties.
Abstract: Background. Most chronic myelogenous leukemia (CML) patients (pts) restore non-neoplastic hematopoiesis following treatment with tyrosine kinase (TK) inhibitors. However little is presently known on the functional and genetic integrity of Ph-negative hematopoietic cells (HC) repopulating the bone marrow after successful treatment. Indeed, the frequent detection of cytogenetic abnormalities (CA) reminiscent of those seen in myelodysplastic syndromes suggests the potential presence of functional and genetic defects. These issues have been addressed using short and long term HC cultures and telomere restriction fragment length (TRF-L) analysis, which is considered a reliable marker of proliferative and oxidative damage. Aims and methods. We investigated 77 CML pts in stable complete cytogenetic remission (CR) (CR had to be documented at least one year before the analysis). 67 pts were treated with Imatinib and 10 with α-interferon associated or not to ara-C. Median age was 64 (23-88), M/F ratio was 1.5, median time from diagnosis and from complete CR were 53 (7-915), and 39 months (12-150). 33 pts had low Sokal score, 24 intermediate, and 13 high. For 7 patients it has been impossible to evaluate Sokal score. Complete and partial molecular responders were 35 and 24, respectively. 11 pts showed evidence of acquired CA in Ph-negative HC. TRF-L analysis was performed by Southern Blotting as previously described (Ladetto M et Al, Blood 2004), both on polymorphonucleates (PMN) and on monocyte-depleted PBMC (MD-PBMC) (as described by Rocci et al Exp Hematol 2007) to monitor both the myeloid and lymphoid compartment. Colony-forming unit granulocyte-macrophage (CFU-GM), burst-forming unit erythroid (BFU-E) and colony forming unit-mix (CFU-Mix) along with long-term culture-initiating cells (LTC-ICs) have been so far performed on 30 patients, using bone marrow mononuclear cells as previously described (Sutherland HJ et al Blood 1994). For both TRF-L and cell culture studies a control database of 86 healthy subjects has been used for comparison. Results. PMN from CML patients showed a striking erosion of their telomeric DNA (figure 1A). Also MD-PBMC showed a degree of telomere shortening although the finding was much less pronounced and not statistically significant (mean telomeric loss in PMN 1767 pb p<0.001; in MD-PBMC: 584 pb, p=0.1) We found no correlation between TRF-L and previously mentioned clinical parameters. Telomeric erosion is more severe in younger CML pts, resulting in loss of the association between TRF-L and age, typically seen in healthy subjects (figure 1B) Telomere shortening was observed regardless of the use of TK inhibitors. When a multivariate analysis on pts and healthy controls was performed, the presence of CML resulted a stronger predictor of telomeric damage compared to age. We found no correlation between TRF-L and previously mentioned clinical and demographic parameters. Telomeric erosion show no evidence of recovery on 46 follow-up samples taken after a median time of 10 months (range 6-15). Moreover, Ph-negative HC of CML pts were functionally impaired compared to controls with reduced numbers of CFU-Mix (median 2,62 vs 4, p=0,01), CFU-GM (median 99,5 vs 181, p<0,0001) and particularly of LTC-IC (median 88 vs 198, p<0,0001) (figure 1C). Conclusion. Ph-negative HC repopulating the bone marrow after successful CML treatment display severe telomeric DNA erosion, roughly comparable to 35 years of physiological aging. Moreover they display major defects in their functional performances. These findings underline the need of additional investigations and careful clinical monitoring of the Ph-negative haemopoietic compartment in these subjects.
Abstract: BACKGROUND Lo SC (SC) è una patologia ad elevata prevalenza, in aumento nella popolazione anziana dei Paesi Occidentali, che può richiedere cure ad elevata complessità . Molti studi hanno dimostrato come l’Ospedalizzazione a Domicilio (OAD) possa garantire le cure adeguate a pazienti con elevata complessità clinica, migliorarne la qualità di vita, ridurre i tassi di reingresso in ospedale e ottimizzare i costi sanitari. Tale approccio tuttavia non è stato indagato in modo sistematico a beneficio dei pazienti con SC avanzato e/o refrattario.
SCOPO Valutare se un trattamento multidisciplinare nell’ambito dell’OAD comporti differenze significative della riospedalizzazione per SC e di mortalità rispetto al modello di ricovero ospedaliero tradizionale. Obiettivi secondari sono: durata della degenza nei due setting (OAD-REPARTO), causa, durata e numero cumulativo di riospedalizzazioni, valutazione delle complicanze, analisi della qualità di vita, della percezione del proprio stato di salute, tono dell’umore, qualità di vita e grado di stress del caregiver, valutazione dei costi.
METODI Studio clinico randomizzato controllato, monocentrico in singolo cieco condotto su pazienti in classe NYHA III-IV, con disfunzione cardiaca ed almeno un ricovero per SC negli ultimi 12 mesi, residenti nell'area geografica dell'OAD e con assistenza continuativa da parte di un caregiver. Entro 24 ore dall’ingresso in PS e previa accettazione del consenso informato, il paziente viene assegnato in modo randomizzato al braccio di intervento (OAD) o al braccio di controllo (REPARTO) e trasferito nei reparti ospedalieri; entro 120 ore viene avviato verso uno dei setting di cura. I pazienti assegnati al gruppo dell’OAD sono affidati a un'equipe multidisciplinare costituita dal team di OAD, un cardiologo, uno psicologo/psichiatra, un fisioterapista e un dietista. Oltre alle visite domiciliari quotidiane, viene garantita la possibilità di intervenire alle chiamate di emergenza e di effettuare accertamenti diagnostici specialistici. Tutti i pazienti vengono sottoposti ad accertamenti quali: valutazione ecocardiografica, della qualità di vita (SF-36/Minnesota Questionnaire), del proprio stato di salute (European Heart Failure Self-Care Behaviour Scale), identificazione di disturbi depressivi secondo il DSM-IV, valutazione del tono dell’umore (scala di Hamilton), stima delle comorbilità (indice di Charlson), valutazione dello stato funzionale (Activities of Daily Living e Instrumental Activities of Daily Living) e dello stato nutrizionale (Mini Nutritional Assessment). La stessa valutazione viene ripetuta alla dimissione ed al follow-up a 3, 6 e 12 mesi.
RISULTATI I risultati preliminari riguardano 17 pazienti (8 ricoverati in OAD e 9 in reparto) di età media di 75 anni: 7 in classe NYHA III e 10 in NYHA IV. Gli anni di malattia sono stati in media 4.83 e la FE media di 41.84%. Tutti i pazienti sono risultati funzionalmente compromessi all’ingresso (Reparto: ADL 2,85; IADL 5,14. OAD: ADL 2,66; IADL 5,83). La mortalità alla dimissione è stata del 17% dell’intero campione senza differenze tra i due gruppi. Alla dimissione abbiamo rilevato un miglioramento del tono dell’umore solo nei pazienti seguiti in OAD.
CONCLUSIONI I dati preliminari consentono al momento di trarre solo delle indicazioni in merito alla fattibilità di gestire al domicilio tali pazienti. Il progetto ha l'obiettivo di proporre un'alternativa al trattamento ospedaliero tradizionale per i pazienti affetti da SC avanzato, dimostrandone la fattibilità e le ricadute sul tono dell’umore e sulla qualità della vita dei pazienti trattati a casa.
Abstract: This project is aimed at evaluating the use of a telemonitoring platform in the real life context of the
Geriatric Hospital at Home Service (GHHS) managed by the Molinette Hospital team. It is a
multidisciplinary team consisting of 3 geriatricians, 13 nurses, 2 physiotherapists, one social worker
and one counsellor. The team operates 7 days a week and looks after 25 patients a day and an
average of 450 patients per year. GHHS can be activated by a direct request from the Emergency
Department’s physicians.
The main goal of this study is to evaluate how telemedicine could be helpful in the home treatment
of acute decompensated chronic heart failure patients, contributing to improve the quality of life
and reduce the stress of patients and their caregivers. The secondary goal of the study is to
demonstrate a reduction in the number of visits made by GHHS physicians or/and nurses to each
patient and, consequently, a reduction in the cost of care.
The project will use the Telecom Italia telemonitoring platform, called “MyDoctor@Home”. This
platform allows patients at home to measure their physiological parameters (e.g. blood pressure,
oximetry, blood glucose, spirometry, weight, ECG) using medical devices equipped with Bluetooth
communication capabilities to transfer the measurements via a mobile phone gateway to the
centralized platform. Through web access to the platform, the physicians can monitor in real time
the patients and may be alerted if measurements exceed predefined thresholds. Patients, according
to the settings of the system, may also receive messages reminding them to take measurements
and/or to follow their medication schedule.
The project is implemented as a field trial and presents three phases. 1) A training course for GHHS
physicians and nurses. 2) A preliminary and brief (2 months) pilot study (involving 5 patients)
aimed at evaluating technical problems. The pilot study is currently in progress, focused on service
model consolidation as well as the evaluation of system usability. Following a User Centric
Approach, the evaluation involves physicians, caregivers and patients. 3) A randomized, controlled
trial evaluating two groups of 40 patients affected by reacutization of chronic heart failure. The first
group, the control group, will be treated in GHHS in the customary way while the second group, the
study group, will be furnished with telemonitoring devices.
Patients admitted to GHHS from the Emergency Department with a pre-existing diagnosis of
chronic heart failure (HF) and a persistent functional impairment indicative of New York Heart
Association (NYHA) class III or IV status will be enrolled in the study and randomly assigned to
one of the two groups. Patients enrolled will follow a common protocol in order to analyse their
characteristics. At baseline and on discharge, functional, nutritional and cognitive status,
depression, quality of life, co morbidity and caregiver’s stress will be evaluated with specific
questionnaires.
Abstract: In the Western World, health care systems are facing the challenge of providing high quality services in a cost effective fashion (Madgwick KV and Yardumian A 1999, Szterling LN 2005). At the same time, the number of old and frail patients is increasing. For these reasons, medical home services have been recently developed that can guarantee hospital-like assistance, with lower costs (Cartoni C et al 2007) and greater respect of patients’frailty. Despite the increasing number of haematological home services world-wide, the volume of out-of-hospital transfusions, in the United States, is estimated to be <1% of the total blood transfusions (Benson K 2006). Here, we present our Hospital at Home Service (HHS), together with a one-year serie (January 2007 to December 2007) of patients admitted for an acute illness and with a main or secondary diagnosis of haematological illness or requiring emocomponent transfusion. HHS is a service of the University Hospital of Torino, aiming to provide selected, acutely ill patients with a hospital-like assistance at their home. In this alternative setting of care, physicians and nurses work as a real mobile team, while the care-givers are educated to actively take part in the nursing of the patients. Blood tests, instrumental investigations (EKG, pulse oximetry, spirometry, abdominal, vascular and cardiac ultrasonography, radiograms), intravenous therapies, emocomponent transfusions, oxygen therapy and surgical treatment of pressure ulcers are performed at the patients’ home. As to transfusion of emocomponents at home, pre-transfusion blood samples are collected by a nurse the day before and the entire process is started by a physician and then monitored by a specialist nurse. Randomized controlled trials of patients affected by minor stroke, exacerbated heart failure and exacerbated COPD have been conducted (Aimonino Ricauda N et al 2004 and 2008), showing the non-inferiority and the higher cost-effectiveness of HHS as compared to admission to traditional hospital wards. In the present retrospective study general data, functional status (Activities of Daily Living – ADL, Instrumental Activities of Daily Living – IADL, Karnofsky performance status), comorbidity level (Cumulative Illness Rating Scale – CIRS) and severity of diseases (Acute Physiology and Chronic Health Evaluation – APACHE II) at admission, blood parameters and length of stay were collected. Over a total of 481 patients treated in 2007, 54 (11.2%) patients were enrolled on the basis of their diagnosis code at discharge: 4 (7.4%) with lymphatic cell neoplasia, 42 (77.7%) with anemia and 8 (14.8%) with anemia and lymphatic cell neoplasia. Mean age was 80.9 ± 9.6 years. Patients showed severe functional impairment and comorbidity. Mean length of stay was 26.04 ± 21.26 days. Thirty-five patients 41 (76%) were discharged at home, 3 (5.5%) were transferred to another hospital unit and 10 (18.5%) died. Thirty one (64.8%) needed an emocomponent transfusion, for a total of 112 blood units and 49 platelet pools. No adverse reactions were observed. The data presented show that a consistent proportion of the patients admitted to the HHS have a haematological illness. Even though we have no comparative data, our experience shows the feasibility of the treatment of selected haematological patients in a hospital-at-home setting of care.
