The multifaceted spectrum of liver cirrhosis in older hospitalised patients: Analysis of the REPOSI registry

Background: Knowledge on the main clinical and prognostic characteristics of older multimorbid subjects with liver cirrhosis (LC) admitted to acute medical wards is scarce. Objectives: To estimate the prevalence of LC among older patients admitted to acute medical wards and to assess the main clinical characteristics of LC along with its association with major clinical outcomes and to explore the possibility that well-distinguished phenotypic profiles of LC have classificatory and prognostic properties. Methods: A cohort of 6,193 older subjects hospitalised between 2010 and 2018 and included in the REPOSI registry was analysed. Results: LC was diagnosed in 315 patients (5%). LC was associated with rehospitalisation (age-sex adjusted hazard ratio, [aHR] 1.44; 95% CI, 1.10-1.88) and with mortality after discharge, independently of all confounders (multiple aHR, 2.1; 95% CI, 1.37-3.22), but not with in-hospital mortality and incident disability. Three main clinical phenotypes of LC patients were recognised: relatively fit subjects (FIT, N = 150), subjects characterised by poor social support (PSS, N = 89) and, finally, subjects with disability and multimorbidity (D&M, N = 76). PSS subjects had an increased incident disability (35% vs 13%, P < 0.05) compared to FIT. D&M patients had a higher mortality (in-hospital: 12% vs 3%/1%, P < 0.01; post-discharge: 41% vs 12%/15%, P < 0.01) and less rehospitalisation (10% vs 32%/34%, P < 0.01) compared to PSS and FIT. Conclusions: LC has a relatively low prevalence in older hospitalised subjects but, when present, accounts for worse post-discharge outcomes. Phenotypic analysis unravelled the heterogeneity of LC older population and the association of selected phenotypes with different clinical and prognostic features

Consumer-led screening for atrial fibrillation using consumer-facing wearables, devices and apps: A survey of health care professionals by AF-SCREEN international collaboration.

AIM: A variety of consumer-facing wearables, devices and apps are marketed directly to consumers to detect atrial fibrillation (AF). However, their management is not defined. Our aim was to explore their role for AF screening via a survey. METHODS AND RESULTS: An anonymous web-based survey was undertaken by 588 health care professionals (HCPs) (response rate 23.7%). Overall, 57% HCPs currently advise wearables/apps for AF detection in their patients: this was much higher for electrophysiologists and nurses/allied health professionals (74-75%) than cardiologists (57%) or other physicians (34-38%). Approximately 46% recommended handheld (portable) single-lead dedicated ECG devices, or, less frequently, wristband ECG monitors with similar differentials between HCPs . Only 10-15% HCPs advised photoplethysmographic wristband monitors or smartphone apps. In over half of the HCP consultations for AF detected by wearables/apps, the decision to screen was entirely the patient's. About 45% of HCPs perceive a potential role for AF screening in people aged >65 years or in those with risk factors. Almost 70% of HCPs believed we are not yet ready for mass consumer-initiated screening for AF using wearable devices/apps, with patient anxiety, risk of false positives and negatives, and risk of anticoagulant-related bleeding perceived as potential disadvantages, and perceived need for appropriate management pathways. CONCLUSIONS: There is a great potential for appropriate use of consumer-facing wearables/apps for AF screening. However, it appears that there is a need to better define suitable individuals for screening and an appropriate mechanism for managing positive results before they can be recommended by HCPs

Epidemiological, chronobiological, and gender-oriented aspects of medical diseases

INTRODUCCIÓN: Las mujeres y los hombres son biológicamente diferentes a nivel de células, órganos y organismos, y, por lo tanto, en el sistema cardiovascular (CV); diferencias que pueden generar variaciones en la prevalencia, la presentación e incluso los resultados de las afecciones cardiovasculares. En la enfermedad arterial periférica (EAP), hay una amplia serie de diferencias sexuales, que incluyen la epidemiología y el perfil de riesgo, la presentación clínica y el manejo de la misma. A pesar de que la EAP es la tercera manifestación más común de la enfermedad cardiovascular, después de la enfermedad coronaria y el accidente cerebrovascular, sigue siendo poco diagnosticada y poco tratada en las mujeres. Esto también se debe a que las mujeres tienen tasas más altas de enfermedad asintomática / subclínica y la mayoría tiene síntomas atípicos. La claudicación intermitente restringe la actividad y la movilidad afectando considerablemente la calidad de vida relacionada con la salud, por lo tanto, el objetivo principal del tratamiento en estos pacientes es mejorar su función de deambulación y calidad de vida. Aunque la importancia de la rehabilitación cardiovascular está bien establecida, está infrautilizada en todo el mundo, especialmente entre las mujeres. La tesis está compuesta por dos partes. Por un lado, en base a la experiencia científica específica de mi grupo de investigación, decidí revisar los aspectos epidemiológicos y cronobiológicos de las enfermedades médicas, en particular con referencia a las enfermedades cardiovasculares, bajo una perspectiva de género. Se inició una búsqueda general en la base de datos PubMed con los términos “Género” y “Cardiovascular” (búsqueda cerrada el 1 de agosto de 2018). Se abordaron nuevas adquisiciones y datos, incluso resumiendo en una serie de Tablas los resultados más recientes de estudios que tratan las diferencias de género en términos de terapia, procedimientos de intervención y resultados clínicos. La segunda parte se centra en el tema seleccionado de EAP, una vez más con una perspectiva definida por género. En particular, se discute la relevancia e importancia de la rehabilitación vascular, y se diseñó un estudio ad hoc para evaluar las diferencias relacionadas con el género en un nuevo programa de rehabilitación realizado por nuestro grupo de investigación. OBJETIVOS: General: Describir los aspectos epidemiológicos, cronobiológicos y orientados por género de las enfermedades médicas. Específicos: Determinar diferencias cronobiológicas y por género en las enfermedades cardiovasculares, considerando tratamiento, intervenciones y resultados clínicos. Evaluar diferencias por género en la apliación de un programa de rehabilitación en pacientes con EAP. SUJETOS Y MÉTODOS: Se estudiaron los pacientes con EAP y claudicación inscritos en un programa domiciliario estructurado de 2003 a 2016. El programa se prescribió en el hospital y se basó en dos sesiones diarias de caminata sin dolor de 10 minutos a una velocidad cada vez mayor. Las medidas de resultado, que se evaluaron al inicio y al momento del alta, fueron la velocidad al caminar cuando existen síntomas (PTS) y la máxima (Smax) durante una prueba de esfuerzo y la distancia a pie sin dolor (PFWD) y la distancia total caminada en seis minutos (6MWD). Se determinó el índice tobillo-brazo (IAB), la duración del programa y la adherencia del paciente. RESULTADOS: Se incluyeron 1007 pacientes (mujeres, N = 264; 26%). Al inicio del estudio, en comparación con los hombres, las mujeres mostraron valores IAB similares, pero valores más bajos de PTS y PFWD (p <0,001). En el momento del alta, con una adherencia similar (puntuación de ¾ ± 1 cada uno) en ambos grupos, se observaron importantes mejoras para PTS (0,8 ± 0,8 kmh-1 cada uno), Smax (0,4 ± 0,5 kmh-1 cada uno), PFWD (mujeres: 95 ± 100; hombres 86 ± 104), 6MWD (mujeres: 32 ± 65; hombres: 35 ± 58) y ABI (mujeres: 0.07 ± 0.12; hombres: 0.06 ± 0.11) sin diferencias entre grupos (confirmado después del análisis de propensión). CONCLUSIONES: En comparación con los hombres, las mujeres con EAP y claudicación después de un programa personalizado estructurado de baja intensidad, realizado en el hogar durante unos minutos al día, obtuvieron el mismo beneficio en términos de reducción de la discapacidad para caminar y un grado de adherencia similar. Esta observación también se confirmó después del análisis de propensión, que equilibró a los dos grupos en las características iniciales y demostró que no existen diferencias en los resultados de rehabilitación entre los sexos. Según nuestro conocimiento, la literatura disponible sobre la respuesta de las mujeres a la rehabilitación en PAD es deficiente, y los resultados actuales representan un informe novedoso. Los programas que favorecen la adherencia y los resultados funcionales en mujeres deben probarse en estudios prospectivos.INTRODUCTION: Women and men are biologically different at the level of cells, organs and organism, and sex differences exist also in the cardiovascular (CV) system, so that they can result in variations in prevalence, presentation, and even outcomes of CV conditions. Also per peripheral arterial disease (PAD), there are a wide series of sex differences, including epidemiology and risk profile, clinical presentation, management. Despite PAD is the third most common manifestation of CV disease, following coronary artery disease and stroke, it remains underdiagnosed and under-treated in women. This also because women have higher rates of asymptomatic/subclinical disease and the majority have atypical symptoms. Intermittent claudication restricts activity and mobility considerably affecting the health-related quality of life, therefore the primary treatment goal in these patients is to improve their deambulatory function and quality of life. Although the importance of CV rehabilitation is well established, it is underutilized worldwide, especially among women. This thesis is composed by two parts. On one hand, based on the specific scientific expertise of my group, I decided to review the epidemiological and chronobiological aspects of medical diseases, in particular with reference to CV diseases, under a gender-oriented perspective. A general search was launched on PubMed database with the terms ‘Gender’ and ‘Cardiovascular’ (search closed August 1, 2018). Novel acquisitions and data are recorded, even by gathering into a series of Tables the most recent results from studies dealing with sex-differences in terns of therapy, intervention procedures, and clinical outcomes. The second part is focused on the selected topic of PAD, once again with a defined perspective by gender. In particular, the relevance and importance of vascular rehabilitation is discussed, and a ad-hoc study has been designed to evaluate the possible difference of sex-related differences in a novel rehabilitation program performed by our research group. OBJECTIVES: General: To describe epidemiological, chronobiological and gender-oriented aspect of medical disease Specific: To determine chronobiological and gender differences in cardiovascular disease, considering therapy, intervention procedures and clinical outcomes. To evaluate gender-related differences in a novel rehabilitation program performed by peripheral arterial disease patients. SUBJECTS AND METHODS: Patients with PAD and claudication enrolled in a structured home-based program from 2003 to 2016 were studied. The program was prescribed at the hospital and based on two daily 10-minute pain-free walking sessions at progressively increasing speed. Outcome measures, which were assessed at baseline and discharge, were the walking speed at symptoms (PTS) and maximal (Smax) during a treadmill test and the pain-free walking distance (PFWD) and total distance walked in six minutes (6MWD). The ankle-brachial index (ABI), program duration and patient adherence were determined. RESULTS: A total of 1007 patients (women, n = 264; 26%) were enrolled. At baseline, compared to men, women exhibited similar ABI values but lower PTS and PFWD values (p<0.001). At discharge, with similar adherence (score ¾±1 each) in both groups, superimposable improvements were observed for PTS (0.8±0.8 kmh-1 each), Smax (0.4±0.5 kmh-1 each), PFWD (women: 95±100; men 86±104), 6MWD (women: 32±65; men: 35±58), and ABI (women: 0.07±0.12; men: 0.06±0.11) without between-group differences (confirmed after propensity analysis). CONCLUSIONS: Compared to men, women with PAD and claudication following a structured low-intensity personalized program, performed inside the home for a few minutes a day, obtained the same benefit in terms of reduction of walking disability as well as a similar degree of adherence. This observation was also confirmed after propensity analysis, which balanced the two groups in baseline characteristics and proved that no differences in rehabilitation outcomes exist between sexes. To the best of our knowledge, the available literature on the response of women to rehabilitation in PAD is poor, and the present results represents a novel report. Programs favoring adherence and functional outcomes in women should be tested in prospective studies

Hospital management and complications in comorbid patients

INTRODUCCIÓN. La carga de comorbilidades parece estar relacionada con los resultados clínicos en pacientes hospitalizados y la estratificación clínica de los pacientes ingresados podría derivarse utilizando bases de datos administrativas. El objetivo principal de los datos administrativos es obtener retorno de información, no están planificados para la investigación clínica, por lo tanto, cuando se utilizan con fines clínicos, deben evaluarse cuidadosamente porque los temas de interés no pueden definirse con precisión. Por otro lado, las bases de datos administrativas tienen varias ventajas, como la cobertura de la población, el tamaño de muestra muy grande, la heterogeneidad de la población cubierta (perspectiva del "mundo real"), largos períodos de observación, información actualizada, sin costos adicionales para recopilar datos, posibilidad de vincular varias fuentes de información (por ejemplo, hospitalizaciones, atención ambulatoria, recetas de medicamentos, estado vital). Durante la última década, el grupo de investigación de la Unidad Clinica Médica del University Hospital Santa Anna (Ferrara, Italy) ha publicado varios artículos que relacionan bases de datos administrativas con condiciones clínicas. OBJETIVOS General Evaluar la importancia de las comorbilidades recodificadas durante la hospitalización en bases de datos administrativas para comprender el manejo y los factores de riesgo de mortalidad hospitalaria. en la Región Emilia-Romaña de Italia. Específicos - Conocer la relación entre comorbilidad e infecciones en pacientes de Medicina Interna. - Evaluar los factores de riesgo de mortalidad hospitalaria. - Conocer la utilidad de un índice de comorbilidad derivado de una modificación del índice de Elixhauser. - Evaluar el impacto de los ingresos hospitalarios posteriores al trasplante renal en los servicios regionales italianos. - Conocer los costes y el consumo de recursos, expresados por grupos de diagnósticos relacionados (GRD). Diagnósticos relacionados solo con hospitalizaciones de receptores de trasplante renal por todas las causas en la Región Emilia Romagna en Italia. MATERIAL Y MÉTODOS. Estudio retrospectivo en la base de datos administrativa regional de la Región Emilia-Romaña de Italia. La investigación sobre enfermedades infecciosas incluyó ingresos hospitalarios entre enero de 2013 y diciembre de 2016, registrados en la base de datos del hospital local. Se seleccionaron códigos administrativos para identificar infecciones, desarrollo de sepsis y calcular un puntaje de comorbilidad. La segunda parte del trabajo evaluó todos los ingresos hospitalarios de receptores de trasplante renal entre 2001 y 2015. Calculamos el número de ingresos, la edad media, la duración de la estancia en el hospital, el valor medio de GRD y los costos de los ingresos durante el período de los 15 años estudiados. RESULTADOS En la primera parte del presente trabajo evaluamos más de 12.000 registros. Los sujetos fallecidos (n = 1545, 12,7%) eran mayores, tenían un mayor porcentaje de sepsis, infecciones pulmonares y endocarditis. El valor medio de la puntuación de comorbilidad también fue significativamente mayor. La sepsis, la endocarditis, las infecciones pulmonares y las infecciones del tracto urinario se asociaron independientemente con la mortalidad hospitalaria. Del mismo modo, el puntaje de comorbilidad (Odd Ratio – OR 1,070 por unidad de puntaje creciente), también se asoció independientemente con mortalidad intrahopitalaria (MIH). El riesgo ponderado calculado, obtenido al multiplicar 1.070 por el valor de puntaje promedio en pacientes fallecidos, fue de 19,367. Las áreas bajo la curva derivadas del análisis de las características operativas del receptor (ROC) relacionadas con la comorbilidad y el desarrollo de sepsis como predictores de mortalidad hospitalaria fueron 0,724 y 0,670, respectivamente. En la segunda parte del trabajo analizamos 9.197 receptores de trasplante renal ingresados en 15 años. La edad fue de 56,6 ± 1,6 años. Los ingresos fueron de 14,558, y la tasa media de receptores renales admitidos fue de 14.21 (* 100.000). La duración media y mediana de la estancia fue de 8,7 y 6 días, respectivamente. Los costos totales de las admisiones durante el período de estudio fueron de 72.717.232 € con valores medios de DRG de 3.409 €. El número de ingresos y el número total de días necesarios para los receptores de trasplante renal, así como la edad media de los pacientes ingresados, aumentaron de 2001 a 2015, sin embargo, la duración media y mediana de la estancia se mantuvo estable. CONCLUSIONES. La evaluación cuidadosa de la comorbilidad es importante en los pacientes hospitalizados en las Unidades de Medicina Interna por enfermedades infecciosas, ya que la mortalidad hospitalaria está relacionada con la gravedad de la enfermedad y con la multimorbilidad. En estos pacientes, una evaluación cuidadosa de la comorbilidad debe representar un paso fundamental en el manejo de la enfermedad. La base de datos administrativa regional mostró que los costos relacionados con los ingresos de una población específica, como los receptores de trasplante renal, aumentaron gradualmente, probablemente debido al aumento del número de ingresos y al aumento de la edad. Mediante el uso de estas grandes bases de datos es posible evaluar un gran número de pacientes y diferentes entornos hospitalarios. Las bases de datos administrativas contienen información sobre demografía, tipo de hospital donde se realiza la atención, diagnóstico, procedimientos, duración de la estancia y estado al alta. Los investigadores podrían seleccionar condiciones y procedimientos específicos conociendo resultados complejos como la mortalidad. Aunque las bases de datos administrativas subestiman algunas enfermedades, se ha demostrado que son confiables con respecto a la comorbilidad. Es necesario tener en cuenta la comorbilidad para reducir la posible confusión en la investigación epidemiológica y las bases de datos administrativas permiten el desarrollo de nuevos índices de comorbilidad. En la primera parte del trabajo, se informó que la comorbilidad era un factor de riesgo de mortalidad hospitalaria en sujetos ingresados con enfermedades infecciosas. Indirectamente, también probamos un nuevo puntaje de comorbilidad. Finalmente, utilizamos la base de datos administrativa regional para probar una función peculiar de estos archivos. Evaluamos los costos de las hospitalizaciones por trasplante renal. Llegamos a la conclusión de que las bases de datos administrativas podrían utilizarse para la investigación de gestión clínica con diferentes objetivos.INTRODUCTION. Burden of comorbidities appears to be related to clinical outcomes in hospitalized patients and clinical stratification of admitted patients could be derived using administrative databases. The main aim of administrative data is obtained reimbursement, they are not planned for clinical research, therefore when they are used for clinical purposes, they should be carefully evaluated because subjects of interest could not be accurately defined. On the other hand administrative databases have several advantages such as population coverage, very large sample size, heterogeneity of covered population (“real-world” perspective), long observation periods, up to date information, no additional costs for gathering data, possibility to link several sources of information (e.g. hospitalizations, outpatient care, drug prescriptions, vital status). During the last decade, the research group from the Clinica Medina Unit (University Hospital Santa Anna, Ferrara) published several papers relating administrative databases to clinical conditions OBJECTIVES General To evaluate the importance of comorbidities recoded during hospitalization in administrative databases in order to understand management and risk factors for in-hospital mortality in the Region Emilia-Romagna of Italy. Specifics - To know the relationship between comorbidity and infections in internal medicine patients. - To evaluate risk factors for in-hospital mortality - To test the usefulness of a comorbidity score derived from a modification of Elixhauser’s index. - To evaluate impact of hospital admissions subsequent to renal transplantation on Italian regional resources. - To know costs and resource consuming, expressed by diagnosis related groups (DRG) related only to hospitalizations of renal transplant recipients for all causes in the Region Emilia Romagna in Italy. MATERIAL AND METHODS. Retrospective study in the regional administrative database of the Region Emilia-Romagna of Italy. The investigation regarding infectious diseases included hospital admissions between January 2013, and December 2016, recorded in the database of the local hospital. Administrative codes were selected to identify infections, development of sepsis, and to calculate a comorbidity score. The second part of the work evaluated all hospital admissions of renal transplant recipients between 2001 and 2015. We calculated number of admissions, mean age, length of stay in the hospital, mean value of DRG and costs of admissions during the 15 year period of the study. RESULTS In the first half of this work we evaluated more than 12,000 records. Deceased subjects (n=1545, 12.7%) were older, had higher percentage of sepsis, pulmonary infections, and endocarditis. Mean value of comorbidity score was also significantly higher. Sepsis, endocarditis, pulmonary infections, and urinary tracts infections were independently associated with in-hospital mortality. In the same way, comorbidity score (OR 1.070 per unit of increasing score), was independently associated with IHM as well. The calculated weighted risk, obtained by multiplying 1.070 for the mean score value in deceased patients, was 19.367. The areas under the curve derived from receiver operating characteristic (ROC) analysis related to comorbidity and development of sepsis as predictors for in-hospital mortality were 0.724 and 0.670, respectively. In the second part of the work we analysed 9,197 renal transplant recipients admitted in 15 years. Age was 56.6±1.6 years. Admissions were 14,558, and mean rate of admitted renal recipients was 14.21(*100,000). Mean and median length of stay were 8.7 and 6 days, respectively. Total costs of admissions during the study period were € 72,717,232 with mean DRG values of € 3,409. Number of admissions and total number of days required for renal transplant recipients as well as mean age of admitted patients increased from 2001 to 2015, however mean and median length of stay remained stable. CONCLUSIONS. Careful evaluation of comorbidity is important in internal medicine ward patients hospitalized for infectious disease, being in-hospital mortality related to severity of disease, and to multimorbidity. In these patients, a careful evaluation of comorbidity should represent a fundamental step in the disease management. Regional administrative database showed that costs related to admissions of a specific population such as renal transplant recipients gradually increased probably due to the increasing number of admissions and increasing age. By the use of these large databases it is possible to evaluate large number of patients and different hospital settings. Administrative databases contain information on demographic, type of hospital where care take place, diagnosis, procedures, length of stay and discharge status. Researchers could select specific conditions and procedures knowing hard outcomes such as mortality. Although administrative databases underestimate some diseases, it has been shown that they are reliable regarding comorbidity. Comorbidity needs to be taken into account in order to reduce potential confounding in epidemiological research and administrative databases allow the development of new comorbidity indexes. Then in the first part of the work it was reported that comorbidity was a risk factor for inhospital mortality in subjects admitted with infectious diseases. Indirectly, we also tested a new comorbidity score. Finally we used the regional administrative database for testing a function peculiar for these files. We evaluated costs of renal transplant hospitalizations. We conclude that administrative databases could be used for clinical management research aiming at different targets

Pain and Frailty in Hospitalized Older Adults

Introduction: Pain and frailty are prevalent conditions in the older population. Many chronic diseases are likely involved in their origin, and both have a negative impact on quality of life. However, few studies have analysed their association. Methods: In light of this knowledge gap, 3577 acutely hospitalized patients 65&nbsp;years or older enrolled in the REPOSI register, an Italian network of internal medicine and geriatric hospital wards, were assessed to calculate the frailty index (FI). The impact of pain and some of its characteristics on the degree of frailty was evaluated using an ordinal logistic regression model after adjusting for age and gender. Results: The prevalence of pain was 24.7%, and among patients with pain, 42.9% was regarded as chronic pain. Chronic pain was associated with severe frailty (OR = 1.69, 95% CI 1.38–2.07). Somatic pain (OR = 1.59, 95% CI 1.23–2.07) and widespread pain (OR = 1.60, 95% CI 0.93–2.78) were associated with frailty. Osteoarthritis was the most common cause of chronic pain, diagnosed in 157 patients (33.5%). Polymyalgia, rheumatoid arthritis and other musculoskeletal diseases causing chronic pain were associated with a lower degree of frailty than osteoarthritis (OR = 0.49, 95%CI 0.28–0.85). Conclusions: Chronic and somatic pain negatively affect the degree of frailty. The duration and type of pain, as well as the underlying diseases associated with chronic pain, should be evaluated to improve the hospital management of frail older people

Cross-Cultural Adaptation and Validation of the Italian Version of the Observational Scale of Level of Arousal

none11noObjectives: Along with deficit of attention, level of arousal is a primary criterion for the diagnosis of delirium. The Observational Scale of Level of Arousal (OSLA) is a quick, simple, and observational instrument used to evaluate the variation of arousal for rapid screening of delirium in clinical practice. The current study aims to perform a cross-cultural adaption of and to validate the Italian version of the OSLA scale to detect delirium in older aged, hospitalized patients. Design: Longitudinal study. Setting and Participants: In hospital and transitional care setting. Old age patients. Methods: A cross-cultural adaptation of the OSLA from English into Italian was conducted, including back-translation. The validation of the OSLA was assessed in 116 older patients (age &gt;65 years) admitted to geriatric, internal medicine, and transitional care wards. The 4 “A”s Test serves as the gold standard for the measurement of delirium. Results: Incident delirium was assessed longitudinally at different time points during hospitalization. The Italian version of OSLA demonstrated adequate internal consistency, specificity, sensitivity, agreement, test-retest reliability, and sensitivity to change, indicating adequate its clinometric properties in the detection of delirium in a real world hospitalized cohort of older adults. Conclusions and Implications: The current study is among the few studies to assess arousal as a core feature of delirium by virtue of a longitudinal assessment of delirium, moving a step forward in the implementation of a brief and easy to use delirium-screening tool for the measurement of important clinical outcomes in a frail, old aged hospitalized population.noneMartella L.A.; Carmisciano L.; Giannotti C.; Signori A.; Pontremoli R.; Giusti M.; Gualco E.; Beccati V.; Marengoni A.; Nencioni A.; Monacelli F.Martella, L. A.; Carmisciano, L.; Giannotti, C.; Signori, A.; Pontremoli, R.; Giusti, M.; Gualco, E.; Beccati, V.; Marengoni, A.; Nencioni, A.; Monacelli, F

Appropriateness of prescription of oral anticoagulant therapy in acutely hospitalized older people with atrial fibrillation. Secondary analysis of the SIM-AF cluster randomized clinical trial.

AIMS: To assess the appropriateness of oral anticoagulant (OAC) prescription and its associated factors in acutely hospitalized elderly patients. METHODS: Data were obtained from the prospective phase of SIM-AF (SIMulation-based technologies to improve the appropriate use of oral anticoagulants in hospitalized elderly patients with Atrial Fibrillation) randomized controlled trial, aimed to test whether an educational intervention improved OAC prescription, compared to current clinical practice, in internal medicine wards. In this secondary analysis, appropriateness of OAC prescription was assessed at hospital admission and discharge. RESULTS: For 246 patients, no significant differences were found between arms (odds ratio 1.38, 95% confidence interval [CI] 0.84-2.28) in terms of appropriateness of OAC prescription. Globally, 92 patients (37.4%, 95% CI = 31.6-43.6%) were inappropriately prescribed or not prescribed at hospital discharge. Among 51 patients inappropriately prescribed, 82% showed errors on dosage, being mainly under-dosed (n = 29, 56.9%), and among 41 inappropriately not prescribed, 98% were taking an antiplatelet drug. Factors independently associated with a lower probability of appropriateness at discharge were those related to a higher risk of bleeding (older age, higher levels of aspartate aminotransferase, history of falls, alcohol consumption) and antiplatelet prescription at admission. The prescription of OACs at admission was the strongest predictor of appropriateness at discharge (odds ratio = 7.43, 95% CI = 4.04-13.73). CONCLUSIONS: A high proportion of hospitalized older patients with AF remains inappropriately prescribed or nonprescribed with OACs. The management of these patients at hospital admission is the strongest predictor of prescription appropriateness at discharge

Appropriateness of oral anticoagulant therapy prescription and its associated factors in hospitalized older people with atrial fibrillation

AIMS: Although oral anticoagulants (OACs) are effective in preventing stroke in older people with atrial fibrillation (AF), they are often underused in this particularly high-risk population. The aim of the present study was to assess the appropriateness of OAC prescription and its associated factors in hospitalized patients aged 65 years or older. METHODS: Data were obtained from the retrospective phase of Simulation-based Technologies to Improve the Appropriate Use of Oral Anticoagulants in Hospitalized Elderly Patients With Atrial Fibrillation (SIM-AF) study, held in 32 Italian internal medicine and geriatric wards. The appropriateness of OAC prescription was assessed, grouping patients in those who were and were not prescribed OACs at hospital discharge. Multivariable logistic regression was used to establish factors independently associated with the appropriateness of OAC prescription. RESULTS: A total of 328 patients were included in the retrospective phase of the study. Of these, almost 44% (N = 143) were inappropriately prescribed OACs, being mainly underprescribed or prescribed an inappropriate antithrombotic drug (N = 88). Among the patients prescribed OACs (N = 221), errors in the prescribed doses were the most frequent cause of inappropriate use (N = 55). Factors associated with a higher degree of patient frailty were inversely associated with the appropriateness of OAC prescription. CONCLUSIONS: In hospitalized older patients with AF, there is still a high prevalence of inappropriate OAC prescribing. Characteristics usually related to frailty are associated with the inappropriate prescribing. These findings point to the need for targeted interventions designed for internists and geriatricians, aimed at improving the appropriate prescribing of OACs in this complex and high-risk population

Prevalence, characteristics and treatment of chronic pain in elderly patients hospitalized in internal medicine wards.

BACKGROUND: Chronic pain is a frequent characteristic of elderly people and represents an actual and still poorly debated topic. OBJECTIVE: We investigated pain prevalence and intensity, and its pharmacological therapy in elderly patients hospitalized in 101 internal medicine wards. METHODS: Taking advantage of the "REgistro POliterapie Società Italiana Medicina Interna" (REPOSI), we collected 2535 patients of whom almost a quarter was older than 85 years old. Among them, 582 patients were affected by pain (either chronic or acute) and 296 were diagnosed with chronic pain. RESULTS: Patients with pain showed worse cognitive status, higher depression and comorbidities, and a longer duration of hospital stay compared to those without pain (all p < .0366). Patients with chronic pain revealed lower level of independency in their daily life, worse cognitive status and higher level of depression compared to acute pain patients (all p < .0156). Moreover, most of them were not treated for pain at admission (73.4%) and half of them was not treated with any analgesic drug at discharge (50.5%). This difference affected also the reported levels of pain intensity. Patients who received analgesics at both admission and discharge remained stable (p = .172). Conversely, those not treated at admission who received an analgesic treatment during the hospital stay decreased their perceived pain (p < .0001). CONCLUSIONS: Our results show the need to focus more attention on the pharmacological treatment of chronic pain, especially in hospitalized elderly patients, in order to support them and facilitate their daily life after hospital discharge