tecnología

Single BMD Scan Predicts Future Fracture Risk in Older Women

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Pam Harrison

A single measurement of bone mineral density (BMD) at the femoral neck in women 67 years of age and older predicts a woman’s risk of having either a nonvertebral or hip fracture over the next 20 to 25 years, respectively, a new analysis of the Study of Osteoporotic Fractures (SOF) indicates.

Also strongly predictive of a woman’s risk of fracture over the long term is a history of any nonvertebral fracture, say Dennis Black, PhD, University of California, San Francisco, and colleagues in their study published online July 18, 2017 in the Journal of Bone and Mineral Research. 

The ability of BMD and other risk factors to predict fracture risk is well-established for 5 to 10 years, but their value in predicting longer-term risk had not previously been studied, they explain.

“We conclude that a single BMD and fracture history assessment [in a woman aged 65 years and older] can predict fracture risk over 20 to 25 years,” they state.

They also discovered that remaining lifetime fracture probability seems to be higher than previously indicated, approximately twice as high, among women over aged 65 years ― who had a 25-year risk of hip fracture of almost 18%.

And in those aged over 80, they found a 25-year risk for hip fracture of 23%, which is at least as high as seen in similar studies.

Dr Black told Medscape Medical News that some healthcare professionals believe that “the 10-year risk of hip fracture goes down as people get older because of competing mortality risks.”

“But this study really dispels this thinking. So one of the important messages from this paper is that physicians should be paying attention to the oldest women, as their risk of hip fracture is very high, and they should be screened [for risk factors] and potentially treated [for osteoporosis] if they meet guideline criteria.”

“Treatment — which has been shown to be safe and effective in the oldest of the old — can prevent the devastating consequence of fracture,” he added.

History of Any Fracture An Important Predictor

Dr Black and colleagues used data from the SOF cohort of 7959 primarily Caucasian women, mean age 73.4 years, among whom BMD was first measured by dual-energy X-ray absorptiometry (DXA) between 1988 to 1990.

Overall, 38.4% of women reported a history of at least one nonvertebral fracture, while 2.3% of the cohort reported a history of experiencing a hip fracture from age 50 years onwards.

Over the next 20 years of follow-up, 43.7% of women had one or more nonvertebral fractures, while 15.9% of the cohort sustained one or more hip fractures over the next 25 years.

There has been some controversy about whether the history of hip fracture is superior to that of nonvertebral fractures in predicting risk of future hip fracture, the authors say.

“Our results showed no important advantage to history of hip fracture compared with history of any nonvertebral fracture for predicting subsequent fracture,” they note.

“Moreover, a history of any fracture is much more common than a history of hip fracture, and therefore will be more useful on a population level as a predictor.”

BMD at Femoral Neck Is Strongly Predictive

BMD at the femoral neck was “strongly predictive” of the long-term risk of both hip and nonvertebral fractures — even after accounting for competing mortality risks.

The long-term risk of having a hip fracture was almost five-fold higher over the next 25 years for women in the lowest BMD quartile (29.6%) compared with those in the highest BMD quartile (7.6%).

Corresponding rates for nonvertebral fracture were almost twice as high among women in the lowest BMD quartile (59.7%) vs the highest BMD quartile (32.9%).

And, “BMD remained very strongly predictive within each age group,” the investigators observe.

For example, in women over age 75 years at baseline, the risk of sustaining a hip fracture over the next 25 years went from a low of 7.1% for women with a femoral neck T-score in excess of –1.0 to a high of 31.5% for women with a T-score below –2.5 at baseline.

Still, “as expected, the cumulative incidence of both hip and nonvertebral fractures was related to age,” the researchers note.

For women over age 80 years at baseline, the risk of sustaining a hip fracture over 25 years was 22.6%, compared with only 13.9% for women under age 70 years at baseline.

For nonvertebral fracture, women over age 80 years at baseline had a 50% risk over the next 20 years, compared with 42.6% of women under age 70 years at baseline.

Only One BMD Measurement Needed

Explaining that their results show just a single BMD measurement is sufficient to predict fracture risk, Dr Black told Medscape Medical News: “Some have suggested that BMD measurements should be done very frequently, such as every year or every 2 years, in older women.”

“But we found that [a single measure of] bone density is a very strong predictor of a very important disease, which is fracture ― particularly hip fracture ― over the long term,” he added.

“And while bone density can suddenly change if, for example, women start using glucocorticoids or there is marked weight loss,” knowing a woman’s single BMD measurement “can help you stratify patients in terms of how worried you are about their fracture risk. And if a woman has a BMD of –1 at the age of 65, you certainly don’t have to worry about her for another 5 years,” he added.

SOF is supported by the National Institutes of Health. Dr Black reports receiving grant support from Alexion and consulting fees from Amgen, Merck, Asahi-Kasei, and Radius.

J Bone Miner Res. Published online July 18, 2017. Abstract

 

New app predicts cardiovascular events in liver transplant patients

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Scientists have created the first liver transplant-specific score to predict cardiac risk in liver transplant patients.

Scientists have developed the first app and score to determine one-year risk of a liver transplant patient dying or being hospitalised for myocardial infarction or other cardiovascular (CV) complication.

Approximately one-third of liver transplant recipients will have a CV complication in the first year after a liver transplant. Until now however, doctors have depended on risk tools developed in non-liver transplant populations to estimate the risk for CV events after orthotopic liver transplantation (OLT).

The new Cardiovascular Risk in Orthotopic Liver Transplantation (CAR-OLT) score was developed using data from a cohort of 1,024 patients, aged 18-75 years, who underwent first OLT in a tertiary care teaching hospital over a 10-year period. Among the cohort, major cardiovascular disease (CVD) complications occurred in 32.1 per cent. The CAR-OLT point-based score was found to be superior to other published risk models for postoperative CVD morbidity and mortality.

Writing in Hepatology , the authors said further external validation of the findings in a larger multicenter clinical trial is needed to assess whether use of the CAR-OLT score for risk stratification and the decision to proceed with more intensive cardiovascular testing or targeted risk factor reduction would be helpful to improve CVD outcomes after OLT.

Más del 70% de los españoles padece # síndrome visual informático por el uso diario de dispositivos electrónicos

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Los usuarios de videojuegos, los más afectados.

Los usuarios de videojuegos, los más afectados.

Más del 70% de la población española sufre síndrome visual informático por el uso diario de dispositivos electrónicos, el cual se caracteriza por dolor de cabeza, fatiga visual, sequedad ocular, picor, enrojecimiento de los ojos y visión borrosa.

Y es que, tal y como ha comentado la óptico-optometrista y doctora en Ciencias de la Visión, del Hospital Universitario Miguel Servet de Zaragoza, Irene Altemiry, cuando se mira un teléfono móvil o una pantalla de ordenador, el ojo enfoca gracias al llamado sistema acomodativo, si bien en estas situaciones debe hacer un trabajo extra, provocando así la aparición del síndrome visual informático.

Además, la elevada concentración a la que exponen las tareas frente a pantallas digitales hace que disminuya el número de veces que se parpadea por minuto. Un importante problema si se tiene en cuenta que el parpadeo sirve, entre otras cosas, para mantener el ojo hidratado y, por ende, tener una visión nítida.

Ahora bien, las personas más afectadas por este síndrome son los jugadores de videojuegos, que se cree que en España ya rondan los 15 millones y que suelen jugar una media de 6,5 horas semanales. En estas personas, el número de parpadeos por minuto se suele reducir a la mitad e, incluso, hasta tres veces menos cuando son videojuegos de acción.

“Este menor número de parpadeos provocará una mayor sensación de sequedad en los ojos, de picor o de irritación. Los jugadores de videojuegos debido a la gran cantidad de horas que pasan delante de monitores tienen más posibilidades de sufrir síntomas. Por eso es importante concienciarles de la importancia de hacer un buen uso”, ha confirmado Altemiry.

Asimismo, la experta ha aconsejado revisar la visión regularmente para ajustar la graduación, ya que se ha demostrado que la miopía o pequeños grados de astigmatismo son un desencadenante de los síntomas del síndrome visual informático cuando se realizan tareas con pantallas digitales.

Por ello, y con el objetivo de minimizar los riesgos de padecer molestias relacionadas con el uso de pantallas digitales, la compañía Bausch + Lomb, en colaboración con profesionales de la visión y la Liga de Videojuegos Profesional, ha desarrollado la primera guía de salud visual para ‘gamers’.

“Para Bausch + Lomb es clave ofrecer productos que ayuden a los usuarios de dispositivos como lágrimas artificiales, toallitas para la higiene de los párpados o tratamientos para terapia con frío y calor. Además, con la elaboración de esta Guía queríamos ir más allá en el cuidado total de la visión, ofreciendo consejos para ayudar y concienciar a la población de la importancia de cuidar la visión y así evitar las molestias relacionadas con el uso de dispositivos digitales”, ha zanjado el responsable de Relaciones Profesionales de Bausch + Lomb, Diego Ramos.

#Brain Training: No Effect on Cognitive Performance

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Pauline Anderson

Using commercial brain training programs is no better than playing video games for improving cognitive performance, influencing decision making, or altering brain activity, new research shows.

Any changes in these domains is likely due to a practice effect, the study suggests.

“The findings raise a great deal of skepticism about the claims being made about the benefits of cognitive exercise training,” author Caryn Lerman, PhD, from the University of Pennsylvania, Philadelphia, told Medscape Medical News.

“Commercial adaptive cognitive training in young adults appears to have no effects beyond those of standard video games on neural activity, choice behavior, or cognition.”

The study was published online July 10 in the Journal of Neuroscience.

Previous research by Dr Lerman’s group and others has shown that individuals with increased activity in the brain’s executive control network, including the prefrontal cortex, have better self-control. Other research suggests that practicing certain cognitive exercises may activate these brain areas.

“Based on those two lines of research, we hypothesized that computer training games would increase activity in the executive control network that would enhance self-control processes, and that would influence decision making and lead people to make less risky choices in these decision-making paradigms,” said Dr Lerman.

The new analysis included 128 participants (mean age, 25 years; 44% female) with no history of neurologic, psychiatric, or addictive disorders (excluding nicotine) who completed a 1-week “run-up” period to screen for nonadherence.

They were randomly assigned to a cognitive training group or to an active control group.

The cognitive training condition used Lumosity (Lumos Labs), a commercially available platform that consists of Internet-based games targeting multiple cognitive domains involved in executive function.

All participants in this group were assigned identical games in a standardized order that rotated between the following five cognitive domains:

  • Working memory;
  • Attention;
  • Flexibility;
  • Problem solving; and
  • Short-term memory.

Individual games were about 2 to 3 minutes long, so a 30-minute training session included 10 to 15 games.

A core aspect of cognitive training is that it is adaptive, meaning that difficulty increases progressively across sessions as performance improves, the authors note.

Participants in the “active intervention” control group played video games. They were not prompted to complete particular games within each session and could spend as much time on each game as they wanted, as long as they played for 30 minutes total.

The authors note that these video games were not specifically designed to tax executive function. The control condition, they add, had a similar level of engagement, expectancy, novelty, motivation, and interpersonal interaction as the cognitive training condition.

All participants were instructed to complete the assigned Web-based training from home five times a week for 30 minutes per session, for a total of 50 sessions over 10 weeks. They were monitored for adherence and given small monetary incentives.

Participants in both groups were given the same information on the study purpose: to investigate the effects of certain types of computer games on brain activity and decision-making behavior.

To control for motivation and contact, participants in both groups received the same completion incentives and the same weekly phone calls to review study adherence and were blinded to their specific training condition.

“Both groups were blinded to the hypothesis that one form of training would be more effective than the other,” said Dr Lerman. “We wanted to have equal expectations.”

Participants underwent functional MRI (fMRI) at baseline and after the 10-week training period. While in the MRI scanner, participants completed the delay discounting test, in which they chose between receiving a smaller amount of money immediately or a larger amount of money later.

“That’s like immediate gratification vs being able to exert some control and wait for gratification later,” said Dr Lerman.

They also completed the risk sensitivity task, which Dr Lerman described as “like a gambling risk.” For this, participants chose between getting a smaller certain reward immediately or a larger but riskier reward later.

The final analysis of the task fMRI data included 114 of the 128 participants.

Validated Tests

Cognitive testing was performed a week before training, at 5 weeks, and at the end of the 10-week training period.

The 1-hour cognitive battery included assessments of attention, working memory, response inhibition, interference control, and cognitive flexibility. The tests were selected on the basis of evidence that performance in these domains may improve after cognitive training.

“These tests are very well validated in the literature,” said Dr Lerman. “If in fact the brain training was transferring from the games people play to other tests of performance in those same domains, we would see it.”

The investigators found no effects of the training condition on decision making or changes in decision making. There was no main effect of time on delayed discount rates (P = .89) or degree of risk sensitivity (P = .40) and no treatment by time interaction effect on discount rates (P = .74) or degree of risk sensitivity (P = .87).

There were no between-group differences in changes in neural activity during decision making. And both groups showed similar improvement on the cognitive assessments.

The researchers also carried out a follow-up study of 29 young adults not currently using Lumosity’s online training. Those participants completed the cognitive test battery three times, a week apart, with no intervention between.

This was a very important part of the study, said Dr Lerman, because it enabled the research team to test for practice effects, wherein the more individuals take tests, the better they get at them.

This analysis showed that levels of improvement on cognitive tests in this third group, which had no training, were similar to those in the two intervention groups.

“All [groups] improved the same amount, which suggests that it’s a practice effect,” said Dr Lerman.

Cognitive training games “can be fun and engaging,” said Dr Lerman. “This is not to say that people shouldn’t practice them, but they need to maybe manage their expectations about the potential therapeutic benefit or the idea that it will strengthen their cognitive performance.”

She pointed out that the study focused on younger cognitively healthy adults and doesn’t rule out the possibility that older adults with some cognitive impairment might see more improvement.

“The jury is still out on that point, and we hope to see some research in that area,” she said.

The new findings differ from those of a previous study that reported beneficial effects of cognitive training on delay discounting.

The discrepancy could be due to different training and control conditions. The current study was larger (the previous one had 27 participants) and included healthy young adults, whereas the prior study included stimulant addicts undergoing treatment.

Not Surprising

Commenting on the findings for Medscape Medical News, David S. Knopman, MD, professor of neurology, Mayo Clinic, Rochester, Minnesota, said the findings were not unexpected given that studies of elderly persons participating in cognitively stimulating computer activities “does not generalize in daily life.”

“Therefore, that it didn’t work in young healthy people is not at all surprising,” Dr Knopman said.

Young adults are presumably “already tech savvy” and probably employed, unlike elderly retired patents more at risk for dementia, said Dr Knopman.

“So they’re using their brains optimally. It’s hard to believe that doing some additional computer exercises would generalize in any way and would be a substantial dose increase of mental activity compared to what they were already exposed to.”

The findings are also not all that helpful in that fMRI measures “are not validated for making claims about clinically relevant neural activity,” said Dr Knopman.

The study authors and Dr Knopman have disclosed no relevant financial relationships.

J Neurosci. Published July 10, 2017. Abstract

 

Investigan la eficacia de la terapia cognitivo-conductual presencial y ‘on line’ para afrontar el dolor lumbar crónico

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Es una "escuela de espalda" para aprender y modificar comportamientos y pautas mentales de afrontamiento de este dolor crónico.

Es una “escuela de espalda” para aprender y modificar comportamientos y pautas mentales de afrontamiento de este dolor crónico.

Investigadores del CEU-UCH, la Universitat Jaume I de Castellón, la Universitat de València y el Hospital Arnau de Vilanova de València estudian por primera vez en pacientes españoles la eficacia de la terapia cognitivo-conductual presencial y online para afrontar el dolor crónico lumbar.

Según ha informado en un comunicado el CEU-UCH, los investigadores han sido premiados por este ensayo clínico en el 31º Congreso Nacional de la Sociedad Española de Columna Vertebral-GEER 2017. El ensayo clínico de la investigación, dirigida por el profesor de Medicina del CEU-UCH Julio Doménech, jefe del Servicio de Cirugía Ortopédica y Traumatología del Arnau, se ha realizado sobre 200 pacientes y cuenta con financiación del Fondo de Investigaciones Sanitarias (FIS) del Instituto de Salud Carlos III y del Ministerio de Economía y Competitividad.

El 69% de la población española manifiesta sufrir o haber sufrido dolor lumbar crónico por un periodo de más de tres años, lo que convierte a la lumbalgia en la causa más frecuente de baja laboral en España y la primera causa de discapacidad en menores de 45 años. En un 85% de los casos, “no es posible encontrar una causa precisa de este tipo de dolor crónico”, explica la institución.

Diversos estudios realizados en países nórdicos han demostrado la eficacia del tratamiento cognitivo-comportamental (TCC) para combatir la lumbalgia: una “escuela de espalda” para aprender y modificar comportamientos y pautas mentales de afrontamiento de este dolor crónico.

Ahora, estos investigadores españoles han estudiado por primera vez en pacientes del país la eficacia de este tipo de tratamiento. Según destaca el Dr. Julio Doménech, “el objetivo de este ensayo clínico ha sido evaluar la eficacia en el dolor lumbar y la discapacidad de un programa de sesiones presenciales de TCC añadidas a la rehabilitación, a corto y medio plazo, comparándolo con el tratamiento rehabilitador aislado”.

Asimismo, han medido la eficacia del TCC cuando las sesiones presenciales de esta ‘escuela de espalda’ son reforzadas con el seguimiento por parte del paciente a través de Internet y de su móvil, “para promover su adhesión al tratamiento”.

Los pacientes han sido evaluados en varios momentos: antes de aprender estos comportamientos y pautas mentales de afrontamiento del dolor crónico en la ‘escuela de espalda’, justo al finalizar las sesiones y a los 3 y 6 meses de haberlas seguido. En todos ellos se evaluó, mediante cuestionarios validados, el nivel de dolor, el grado de discapacidad, la calidad de vida, las comorbilidades, las creencias y actitudes maladaptativas sobre su dolor, las estrategias de afrontamiento del dolor y la satisfacción con el tratamiento.

Para ello, se dividió a los 200 pacientes participantes en tres grupos: el grupo control, que recibió sesiones individuales presenciales de ‘escuela de espalda’; el grupo TCC, que recibió sesiones de Terapia Cognitivo-Conductual presenciales grupales; y el grupo TCC+TIC, que complementó las sesiones con apoyo de un programa online desarrollado por investigadores de la UV y la UJI. Todos los pacientes recibieron, paralelamente, el mismo tratamiento rehabilitador.

Según destaca el Prof. Doménech, “en los tres grupos se produjo una mejoría significativa y clínicamente relevante en el dolor y la discapacidad como resultado de la participación en la ‘escuela de espalda’, tanto de forma inmediata, como en los controles realizados una vez transcurridos 3 y 6 meses”.

Además, añade el Prof. Doménech, “tanto los pacientes que participaron en las sesiones grupales de la ‘escuela de espalda’, como aquellos que reforzaron el seguimiento a través de Internet y del móvil, mostraron una “significativa reducción del dolor, una mejoría en la calidad de vida y mayor satisfacción con el tratamiento, en comparación con la rehabilitación aislada”.

Aunque, pese a lo esperado, entre estos dos grupos, con y sin sesiones virtuales, las diferencias en el dolor, la discapacidad y en la calidad de vida no fueron clínicamente significativas”.

The digital revolution has largely bypassed the NHS, experts say

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The first report from Google’s Deep Mind Health project says doctors are using Snapchat to send scans.

In the first annual report from Google’s Deep Mind Health  project, a panel of independent authors say, by seeing the benefits technology delivers in their own lives, doctors are keen to bring technology into the workplace and are using social media and lifestyle apps to do so. Snapchat is being used to send scans from one clinician to another, while camera apps are being used to record particular details of patient information in a convenient manner.

The authors say that while it is “difficult to criticise these individuals, given that this makes their job possible”, the practice is not without its downfalls and is “clearly an insecure, risky, and non-auditable way of operating, and cannot continue”.

Deep Mind Health is currently working with the UK’s National Health Service on a number of projects. The authors say the “digital revolution has largely bypassed the NHS”. Digital solutions “have been laid on top of the hundreds of different ageing IT systems employed, even within a single NHS trust or authority,” they say. According to the report, the average NHS Trust has 160 different computer systems in operation.

Desarrollan nuevos materiales, con vidrio bioactivo y flúor, para evitar la degradación y remineralizar los dientes (J Dent Res)

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Protege el colágeno desmineralizado de la dentina afectada por la caries.

Protege el colágeno desmineralizado de la dentina afectada por la caries.

Un estudio de investigadores de Finlandia, Brasil, Bélgica, Alemania y Reino Unido en el que también ha participado el profesor de Dentistry del CEU-UCH, Salvatore Sauro, ha desarrollado nuevos materiales, con vidrio bioactivo y flúor, para evitar la degradación y remineralizar de los dientes. Esta investigación sobre biomateriales para la regeneración de los tejidos dentales ha sido publicada en “Journal of Dental Research”.

Según el estudio los nuevos composites experimentales con vidrio bioactivo enriquecido con flúor han mostrado su eficacia para proteger y remineralizar el colágeno desmineralizado de la dentina afectada por la caries.

Las bacterias que causan las caries generan ácidos que desmineralizan la dentina, por lo que hallar nuevos biomateriales con propiedades remineralizantes es uno de los principales retos de la odontología restauradora y mínimamente invasiva.

El estudio ha comparado la acción inhibidora de las enzimas proteolíticas de la dentina y la remineralización inducida lograda por dos tipos de resinas experimentales que contienen vidrio bioactivo: una de ellas, con micropartículas de Bioglass 45S5 y la otra, con vidrio bioactivo experimental enriquecido con flúor y fosfatos.

Los efectos de ambos tipos de material experimental se han testado sobre muestras de dentina completamente desmineralizadas, sumergidas en saliva artificial durante un periodo de treinta días. Mediante un proceso inmunohistoquímico, se evaluó la degradación del colágeno dentinal por la acción de las enzimas proteolíticas.

Por otro lado, mediante técnicas de espectroscopia infrarroja y microscopía electrónica de barrido, se ha evaluado la remineralización inducida por ambas resinas bioactivas experimentales, comparando los resultados antes y después del proceso.

Sauro, ha explicado que la resina con vidrio bioactivo que han enriquecido con flúor y fosfatos ha demostrado ser más activa para inhibir las enzimas proteolíticas de la dentina y más bioactiva que la que contenía solo Bioglass. “Según hemos observado en el estudio, esto se debe a los iones fluorados que libera y a la gran cantidad de fosfatos que aceleran la remineralización de la dentina y frenan su degradación”.

Este tipo de material experimental bioactivo y enriquecido sería, por tanto, más adecuado para el desarrollo de nuevos materiales dentales destinados al tratamiento de la caries, que destruye los tejidos del diente como consecuencia de la desmineralización provocada por los ácidos que genera la placa bacteriana.

El Prof. Sauro dedica su labor investigadora al desarrollo de tratamientos odontológicos mínimamente invasivos contra la caries, que permitan eliminar la menor parte posible de tejido de la dentina afectado y que empleen para su restauración composites dentales bioactivos de carácter terapéutico capaces de remineralizar los tejidos dentales, como los testados en este estudio.

Uno de los trabajos más recientes del profesor Sauro se ha centrado en un nano-mineral bioactivo llamado halloysite, sobre el que ha demostrado sus propiedades óptimas para transportar agentes terapéuticos antibacterianos, como el triclosan, para evitar la reaparición de la caries, favoreciendo al mismo tiempo la remineralización del tejido dental dañado.

El profesor del CEU-UCH ha sido premiado por la European Federation of Conservative Dentistry (EFCD), por su estudio sobre la eficacia de la fotopolimerización en atmósfera de argón para aumentar la dureza y las propiedades de pulido de los composites dentales, conservando así por más tiempo su resistencia y aspecto estético.