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This volume examines the theoretical and empirical landscape of social entrepreneurship in both non-profit and profit sectors. It extends the traditional view of social entrepreneurship to include the environmental and institutional factors that affect the emergence of social entrepreneurship activities, such as formal laws, regulations, procedures and informal institutions. The editors aim to provide evidence and increased understanding of this growing phenomenon. Social Entrepreneurship is gaining recognition as a key element of economic and social development. It embraces a wide set of situations with a broad scope of activities in for-profit and non-profit organizations interested in social performance and/or in economically profitable performance, with an emphasis on achieving social aim. In the strict sense, social entrepreneurship corresponds to entrepreneurs whose main concern is to achieve social objectives rather than to obtain personal financial profits. However, there is still much to be learned about the dynamics and processes of social entrepreneurship. The current literature in the field has tended to focus on psychological experiences and personal characteristics, or on organizational perspectives such as resources, capabilities and leadership. This book intends to provide theoretical frameworks and empirical studies to this very new and broad field. Specifically, this book provides a collection of contemporary research in the following topics: How to create opportunity through social innovation How to detect entrepreneurial opportunity to meet social needs How to develop social entrepreneurship, while still seeking profits How to discover opportunities for different forms of social entrepreneurship Featuring contributions from around the world, this book is a valuable source for students, academics, researchers, policy makers, and professionals in the area of social entrepreneurship.

Background/Objectives: The prevalence of malnutrition in hospitals is high. No nutritional screening tool is considered the gold standard for identifying nutritional risk. The aims of this study were to evaluate nutritional risk in hospitalized patients using four nutritional screening tools. Subjects/Methods: Four nutritional screening tools were evaluated: nutritional risk screening (NRS-2002), the malnutrition universal screening tool (MUST), the subjective global assessment (SGA) and the mini nutritional assessment (MNA). Patients were assessed within the first 36 h after hospital admission. Date of admission, diagnosis, complications and date of discharge were collected. To compare the tools, the results were reorganized into: patients at risk and patients with a good nutritional status. The statistical analysis included the χ2-test to assess differences between the tests and the κ statistic to assess agreement between the tests. Results: The study sample comprised 400 patients (159 women, 241 men), mean age 67.3 (16.1) years. The prevalence of patients at nutritional risk with the NRS-2002, MUST, SGA and MNA was 34.5, 31.5, 35.3 and 58.5%, respectively. Statistically significant differences were observed between the four nutritional screening tools (P<0.001). The agreement between the tools was quite good except for the MNA (MNA–SGA κ=0.491, NRS-2002–SGA κ=0.620 and MUST–SGA κ=0.635). Patients at nutritional risk developed more complications during admission and had an increased length of stay. Conclusions: The prevalence of nutritional risk in hospitalized patients was high with all the tools used. The best agreement between the tools was for NRS-2002 with SGA and MUST with SGA. At admission, NRS-2002 and MUST should be used to screen for nutritional status.

Second-generation antipsychotics (SGA) are associated with weight gain and metabolic alterations including hyperglycemia, dyslipidemia, hypertension and metabolic syndrome. These metabolic side effects increase cardiovascular risk and are related to medication non-compliance. Patients without previous exposure to these or other antipsychotic drugs (naive patients) seem to be more prone to develop these metabolic abnormalities. The mechanisms behind weight gain can be an increase in food intake and/or a decrease in energy expenditure. This review comprehensively examines the current knowledge on the impact of these drugs on food intake and energy expenditure. The influence of these drugs on appetite and food intake (total caloric intake and food sources) is reviewed as well as the evidence of abnormal eating behaviors. The studies evaluating the effect on resting energy expenditure are critically examined, taking into account the influence of body composition and previous exposure to antipsychotics (naive vs non-naive patients). Finally, the influence of these drugs on physical activity is also discussed. The knowledge of the mechanisms of weight gain in patients starting these drugs may be useful to further prompt research in this field and ameliorate the metabolic side effects associated with these treatments.

The evaluation and treatment of osteoporosis differ depending on several conditions such as the associated risk factors for the development of osteoporosis and fragility fractures, gender, age and menopausal status of the individual, and the presence of other secondary associated processes, among others. In addition, some types of secondary osteoporosis, such as glucocorticoid induced osteoporosis, present fractures with relatively higher bone mineral density values, whereas other metabolic bone diseases, such as osteomalacia, can easly be misdiagnosed with this condition. All these data should be taken into account when evaluating the diagnosis and treatment of these patients. Besides general measures, the pharmacological management of osteoporosis, including the type of antiosteoporotic drug, administration route, optimal treatment duration and monitoring, depend on the characteristics of the patient, the fracture risk and the type of treatment. Thus, whereas bisphosphonates are commonly used in postmenopausal osteoporotic women and men, they should be used with caution in premenopausal women. Moreover, additional non-pharmacologic therapies, such as the use of percutaneous vertebroplasty for the treatment of painful vertebral fractures need appropriate patient selection. In summary, the therapeutic approach of osteoporosis managment involves several aspects that include the identification of individuals at risk of fracture, the correction of modifiable risk factors and, when indicated, the selection of the most appropriate drug therapy. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6220

Background Health-related quality of life (HRQoL) of patients with X-linked hypophosphatemia (XLH) is lower than that of both the general population and the patients with other chronic diseases, mainly due to diagnostic delay, treatment difficulties, poor psychosocial support, and problems with social integration. Early diagnosis and optimal treatment are paramount to control the disease in patients with XLH, avoid complications, and maintain or improve their HRQoL. We, therefore, analyzed the HRQoL of pediatric and adult patients with XLH treated with conventional therapy in Spain. Results We used several versions of the EuroQol-5 dimensions (EQ-5D) instrument according to the age of patients with XLH. Then we compared the HRQoL of patients to that of the general Spanish population. Children with XLH (n = 21) had moderate problems in walking about (61.9%), washing or dressing themselves (9.52%), and performing their usual activities (33.33%). They also felt moderate pain or discomfort (61.9%) and were moderately anxious or depressed (23.81%). Adults with XLH (n = 29) had lower HRQoL, with problems in walking (93%, with 3.45% unable to walk independently), some level of pain (86%, with 3.45% experiencing extreme pain), problems with their usual activities (80%) and self-care (> 50%), and reported symptoms of anxiety and/or depression (65%). There were important differences with the general Spanish population. Conclusions XLH impacts negatively on physical functioning and HRQoL of patients. In Spanish patients with XLH, the HRQoL was reduced despite conventional treatment, clearly indicating the need to improve the therapeutic approach to this disorder. Plain English summary X-linked hypophosphatemia (XLH) is a severe inherited disease. It is caused by loss of phosphorus by kidneys. As a result, blood level of phosphorus is low, affectingX-linked hypophosphatemia (XLH) is a severe inherited disease. It is caused by loss of phosphorus by kidneys. As a result, blood level of phosphorus is low, affecting bones and muscles. Patients can have growth retardation, short stature, rickets, limb deformities, pain and other health problems despite traditional treatment. Consequently, their quality of life can be very bad. However, a recently available new treatment (burosumab) can improve this quality of life. We studied the quality of life of children and adults with XLH treated with traditional treatment in Spain. Results showed that children had moderate problems, but adults reported moderate-to-severe problems in walking and performing their usual activities and self-care. Pain and anxiety and/or depression were very frequent. There were important differences with the general Spanish population. Moreover, we also found that XLH is associated to high healthcare cost and even higher socioeconomic cost. Our results highlight the need of improving the treatment of XLH.bones and muscles. Patients can have growth retardation, short stature, rickets, limb deformities, pain and other health problems despite traditional treatment. Consequently, their quality of life can be very bad. However, a recently available new treatment (burosumab) can improve this quality of life. We studied the quality of life of children and adults with XLH treated with traditional treatment in Spain. Results showed that children had moderate problems, but adults reported moderate-to-severe problems in walking and performing their usual activities and self-care. Pain and anxiety and/or depression were very frequent. There were important differences with the general Spanish population. Moreover, we also found that XLH is associated to high healthcare cost and even higher socioeconomic cost. Our results highlight the need of improving the treatment of XLH.

Background/Objectives: The pathogenesis of enteritis after abdominal radiotherapy (RT) is unknown, although changes in fecal microbiota may be involved. Prebiotics stimulate the proliferation of Lactobacillus spp and Bifidobacterium spp, and this may have positive effects on the intestinal mucosa during abdominal RT. Subjects/Methods: We performed a randomized, double-blind, placebo-controlled trial involving patients with gynecological cancer who received abdominal RT after surgery. Patients were randomized to receive prebiotics or placebo. The prebiotic group received a mixture of fiber (50 inulin and 50% fructo-oligosaccharide), and the placebo group received 6 g of maltodextrin twice daily from 1 week before to 3 weeks after RT. The number of bowel movements and stool consistency was recorded daily. Diarrhea was evaluated according to the Common Toxicity Criteria of the National Cancer Institute. Stool consistency was assessed using the 7-point Bristol scale. Patients’ quality-of-life was evaluated at baseline and at completion of RT using the EORTC-QLQ-C30 (European Organization for Research and Treatment of Cancer quality-of-life Questionnaire C30) test. Results: Thirty-eight women with a mean age of 60.3±11.8 years participated in the study. Both groups (prebiotic ( n =20) and placebo (n =18)) were comparable in their baseline characteristics. The number of bowel movements per month increased in both groups during RT. The number of bowel movements per day increased in both groups. The number of days with watery stool (Bristol score 7) was lower in the prebiotic group (3.3±4.4 to 2.2±1.6) than in the placebo group ( P =0.08). With respect to quality-of-life, the symptoms with the highest score in the placebo group were insomnia at baseline and diarrhea toward the end of the treatment. In the prebiotic group, insomnia was the symptom with the highest score at both assessments, although the differences were not statistically significant. Conclusions: Prebiotics can improve the consistency of stools in gynecologic cancer patients on RT. This finding could have important implications in the quality-of-life of these patients during treatment.

BackgroundThe development of osteoporosis and fractures is a well-documented complication of bariatric surgery (BS), especially with procedures associated with malabsorption. Due to the gradual increase of BS performed worldwide, several national and international societies have developed clinical guidelines for managing these patients, with special attention to osteoporosis prevention and treatment. Nevertheless, these subjects can also develop osteomalacia, which can easily be misdiagnosed as osteoporosis. It is crucial to differentiate osteoporosis and osteomalacia in BS patients since different therapeutic approaches are necessary.ObjectivesTo analyse the prevalence of osteomalacia and the main clinical characteristics of subjects with previous BS referred to the Rheumatology Department for osteoporosis treatment.MethodsThis was a retrospective study of a cohort of 46 subjects (aged 42-77 years) referred to the Metabolic Bone Diseases Unit of the Rheumatology Department for evaluating osteoporosis treatment. Clinical data were obtained from an in-depth review of medical records, including the type of BS (restrictive: gastric banding, and sleeve gastrectomy, or malabsorptive surgery: Roux-en-Y gastric bypass [RYGB], biliopancreatic diversion with duodenal switch), time since surgery, previous treatment with calcium and/or vitamin D, anthropometric data, clinical, laboratory, radiologic and densitometric findings. Osteomalacia was diagnosed by compatible bone biopsy and/or by Bingham and Fitzpatrick criteria[1] (two of the following: low calcium, low phosphate, elevated total alkaline phosphatase [TAP] or suggestive radiology).ResultsFive of the 46 patients (10.8%) presented criteria compatible with osteomalacia, two being confirmed by bone biopsy. All subjects with osteomalacia were Caucasian and most were women (4/5) treated with malabsorptive surgery (mainly RYGB) from 4 to 23 years prior to the visit. All presented increased serum TAP values (some presenting a progressive increase 1-3 years prior to the visit). Most subjects showed low serum calcium (4/5) and vitamin D serum levels; the latter were markedly decreased in 4 individuals (with only one presenting values >20 ng/ml). Parathyroid hormone (PTH) levels were increased in all subjects. Bone scan showed a pattern compatible with osteomalacia in all evaluated subjects (4/4) and bone densitometry showed values compatible with densitometric osteoporosis in most (4/5), with four individuals developing fractures/pseudofractures after BS. Three of these subjects were poorly adherent to calcium and vitamin D supplements and in 2 cases higher doses of calcium (3 g/day) and/or parenteral vitamin D administration were necessary to achieve serum vitamin D levels >30 ng/ml and decrease serum PTH levels in the posterior follow-up. Of note, no subject was referred to the Rheumatology Department with clinical suspicion of osteomalacia. Among the remaining 41 subjects, 28 (68%) presented densitometric osteoporosis and 18 (45%) developed fractures (mainly vertebral) after BS; one subject developed primary hyperparathyroidism (treated with surgery). Again, malabsorptive surgery was the most frequent surgical procedure in these subjects.ConclusionNearly 10% of subjects with previous BS referred for osteoporosis treatment may have osteomalacia. Increased serum TAP values should alert clinicians to this diagnosis since it requires a differential treatment approach with some of these patients needing high doses of calcium or even parenteral vitamin D supplementation.Reference[1]Bingham CT, Fitzpatrick LA. Non-invasive testing in the diagnosis of osteomalacia. Am J Med 1993; 95(5):519-23.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

SummaryThe incidence of vertebral fractures (VF) by vertebral fracture assessment (VFA) was 6.6% in postmenopausal women (FRODOS cohort) after 4 years of follow-up, increasing with prevalent VF and minor vertebral deformities, age, lower bone mass, glucocorticoid use, and rheumatoid arthritis. This study supports the usefulness of VFA to identify VF.PurposeVertebral fracture assessment (VFA) is increasingly used to identify spine fractures, but few cohort studies have used this method in prevalence and incidence assessment. We previously reported the prevalence of vertebral fractures (VF) and minor vertebral deformities (MVD) by morphometric VFA in a population-based cohort of postmenopausal women (FRODOS study). Therefore, the aim of this study was to analyze the incidence of VF, the associated risk factors, and particularly the role of MVD in this cohort of subjects.MethodsWe performed a longitudinal analysis of 2510 women aged 59–70 years participating in the FRODOS prevalence study (2006–2009) with evaluable VFA 4 years later. VFA at baseline and in the present study was assessed by quantitative vertebral morphometry and by visual semiquantitative measurement. The multivariate Poisson regression model was performed, and relative risks with confidence interval of 95% were calculated for the incidence of VF. Bone mineral density (BMD) and an osteoporosis questionnaire were collected.ResultsOverall, the incidence of VF was 6.6%, increasing with prevalent VF (24.5%) and in women with prevalent MVD (17.7%). Age and low BMD were also associated risk factors as were the presence of rheumatoid arthritis and exposure to glucocorticoids and bisphosphonates.ConclusionsThe presence of prevalent VF assessed by VFA is associated with further incident spinal fractures in postmenopausal women. In addition, having MVD confers an increased risk of new VF.

SummaryBone turnover markers are decreased in GC-treated subjects with DM. Decreased OC levels in GC-treated patients were associated with an increased risk of DM. These results suggest the involvement of OC in glucose homeostasis regulation in DM.IntroductionOsteocalcin (OC) is involved in the regulation of glucose homeostasis. Glucocorticoid (GC) treatment is associated with impaired osteoblast function, decreased OC levels, and the development and/or worsening of pre-existing diabetes mellitus (DM). Whether decreased OC levels in GC-treated subjects contribute to DM is not well known. The aim of this study was to analyse whether OC levels in GC-treated patients are associated with the presence of DM.MethodsOne hundred twenty-seven patients (aged 61.5 ± 17.9 years) on GC treatment were included. GC dose, treatment duration, presence of DM and bone formation (OC, bone ALP, PINP) and resorption markers (urinary NTX, serum CTX) were analysed. The cut-offs of each bone turnover marker (BTM) for the presence of DM were evaluated and optimised with the Youden index and included in the logistic regression analysis.ResultsAmong the patients, 17.3% presented DM. No differences were observed in GC dose or duration or the presence of fractures. Diabetics showed lower levels of OC (7.57 ± 1.01 vs. 11.56 ± 1; p < 0.001), PINP (21.48 ± 1.01 vs. 28.39 ± 1; p = 0.0048), NTX (24.91 ± 1.01 vs. 31.7 ± 1; p = 0.036) and CTX (0.2 ± 1.01 vs. 0.3 ± 1; p = 0.0016). The discriminating BTM cut-offs for DM presence were < 9.25 ng/mL for OC, < 24 ng/mL for PINP, < 27.5 nMol/mM for NTX and < 0.25 ng/mL for CTX. In a multivariate logistic regression model adjusted for GC dose, BMI, age and the above four BTMs, only OC remained independently associated with DM presence. Thus, in a model adjusted for GC dose, BMI and age, OC was significantly associated with DM (OR: 6.1; 95%CI 1.87–19.89; p = 0.001).ConclusionDecreased OC levels in GC-treated patients are associated with increased odds of DM, and only OC was independently associated with DM in a model including four BTMs.

Summary Osteoporosis is a frequent complication related to spinal cord injury (SCI), and data on osteoporosis treatment after SCI is scarce. Treatment with denosumab increases lumbar and femoral BMD and decreases bone turnover markers in individuals with recent SCI. This drug may be a promising therapeutic option in SCI-related osteoporosis. Introduction Osteoporosis development is a frequent complication related to SCI, especially at the sublesional level. Nevertheless, data on osteoporosis treatment after SCI is scarce, particularly short term after injury, when the highest bone loss is produced. The aim of this study was to analyze the efficacy of denosumab in the treatment of SCI-related osteoporosis. Methods Fourteen individuals aged 39 ± 15 years with osteoporosis secondary to recent SCI (mean injury duration 15 ± 4 months) were treated with denosumab for 12 months. Bone turnover markers (BTMs) (PINP, bone ALP, sCTx), 25-hydroxyvitamin D (25OHD) levels and bone mineral density (BMD) at the lumbar spine (LS), total hip (TH), and femoral neck (FN) were assessed at baseline and at 12 months. All participants received calcium and vitamin D supplementation. Results At 12 months, SCI denosumab-treated participants showed a significant increase in BMD at TH (+2.4 ± 3.6 %, p  = 0.042), FN (+3 ± 3.6 %, p  = 0.006), and LS (+7.8 ± 3.7 %, p  < 0.001) compared to baseline values. Denosumab treatment was associated with significant decreases in BTMs (bone ALP −42 %, p  < 0.001; PINP −58 %, p  < 0.001, sCTx −57 %, p  = 0.002) at 12 months. BMD evolution was not related to BTM changes or 25OHD serum levels. No skeletal fractures or serious adverse events were observed during follow-up. Conclusions Treatment with denosumab increases lumbar and femoral BMD and decreases bone turnover markers in individuals with recent SCI. This drug may be a promising therapeutic option in SCI-related osteoporosis.