Factors affecting adherence to guidelines for antithrombotic therapy in elderly patients with atrial fibrillation admitted to internal medicine wards

Current guidelines for ischemic stroke prevention in atrial fibrillation or flutter (AFF) recommend Vitamin K antagonists (VKAs) for patients at high-intermediate risk and aspirin for those at intermediate-low risk. The cost-effectiveness of these treatments was demonstrated also in elderly patients. However, there are several reports that emphasize the underuse of pharmacological prophylaxis of cardio-embolism in patients with AFF in different health care settings. AIMS: To evaluate the adherence to current guidelines on cardio-embolic prophylaxis in elderly (> 65 years old) patients admitted with an established diagnosis of AFF to the Italian internal medicine wards participating in REPOSI registry, a project on polypathologies/polytherapies stemming from the collaboration between the Italian Society of Internal Medicine and the Mario Negri Institute of Pharmacological Research; to investigate whether or not hospitalization had an impact on guidelines adherence; to test the role of possible modifiers of VKAs prescription. METHODS: We retrospectively analyzed registry data collected from January to December 2008 and assessed the prevalence of patients with AFF at admission and the prevalence of risk factors for cardio-embolism. After stratifying the patients according to their CHADS(2) score the percentage of appropriateness of antithrombotic therapy prescription was evaluated both at admission and at discharge. Univariable and multivariable logistic regression models were employed to verify whether or not socio-demographic (age >80years, living alone) and clinical features (previous or recent bleeding, cranio-facial trauma, cancer, dementia) modified the frequency and modalities of antithrombotic drugs prescription at admission and discharge. RESULTS: Among the 1332 REPOSI patients, 247 were admitted with AFF. At admission, CHADS(2) score was ≥ 2 in 68.4% of patients, at discharge in 75.9%. Among patients with AFF 26.5% at admission and 32.8% at discharge were not on any antithrombotic therapy, and 43.7% at admission and 40.9% at discharge were not taking an appropriate therapy according to the CHADS(2) score. The higher the level of cardio-embolic risk the higher was the percentage of antiplatelet- but not of VKAs-treated patients. At admission or at discharge, both at univariable and at multivariable logistic regression, only an age >80 years and a diagnosis of cancer, previous or active, had a statistically significant negative effect on VKAs prescription. Moreover, only a positive history of bleeding events (past or present) was independently associated to no VKA prescription at discharge in patients who were on VKA therapy at admission. If heparin was considered as an appropriate therapy for patients with indication for VKAs, the percentage of patients admitted or discharged on appropriate therapy became respectively 43.7% and 53.4%. CONCLUSION: Among elderly patients admitted with a diagnosis of AFF to internal medicine wards, an appropriate antithrombotic prophylaxis was taken by less than 50%, with an underuse of VKAs prescription independently of the level of cardio-embolic risk. Hospitalization did not improve the adherence to guideline

Progettazione e Confronto di Barche a Vela Mediante Analisi CFD

Le simulazioni fluidodinamiche computazionali (CFD) forniscono uno strumento particolarmente utile alla valutazione delle caratteristiche di barche a vela. La possibilità di studiare differenti carene e piani velici, ha permesso di mettere a punto geometrie che senza l’ausilio di queste tecniche innovative sarebbero apparse difficilmente raggiungibili. Nel presente lavoro sono state messe a confronto due barche a vela progettate e costruite per partecipare alle regate di Mille e una Vela per l’Università – manifestazione didattico/sportiva organizzata dall’Università Roma Tre

EXPRESSION OF CLASS-I AND CLASS-II MAJOR HISTOCOMPATIBILITY COMPLEX ANTIGENS ON HUMAN HEPATOCYTES

We analyzed whether normal human hepatocytes, which normally do not display Class II major histocompatibility complex antigens, can be induced to express them in vitro, and whether this induction has an in vivo counterpart in chronic liver diseases. While both α- and γ-interferon induced expression of Class I antigens, only γ-interferon induced expression of Class II antigens on hepatocytes in vitro. Recombinant interleukin 2 had no effect on major histocompatibility complex antigen expression. Both Class I and Class II antigens could be detected by indirect immunofluorescence on hepatocytes from patients with various forms of chronic liver disease, regardless of etiology. These findings suggest that γ-interferon produced by T lymphocytes that infiltrate the liver during the course of chronic hepatitis induces Class II major histocompatibility complex antigen expression and may endow the hepatocytes with the capacity to perform accessory (antigen-presenting) cell functions

Assessing the Grid Impact of Renewable Energy Communities in a Small Island

The paper presents a study carried out on the island of Pantelleria aimed at assessing the impact of the rise of renewable energy communities (RECs) on the distribution grid parameters. A comparison of various scenarios is done considering different operational strategies of BESSes and electric storage water heaters and different penetration of photovoltaic systems, whose maximum power is defined according to the Italian requirements for small islands (Decree “Isole minori”). The analysis of the impact on the grid is a key element for the evolution and development of RECs in small islands. The study highlight the beneficial impacts of RECs on the distribution grid if associated with suitable Demand Response strategies

T-CELL SUBSETS IN THE HYPORESPONSIVENESS TO HEPATITIS-B SURFACE-ANTIGEN (HBSAG) AND ANTIGEN-SPECIFIC SUPPRESSOR LYMPHOCYTES IN CHRONIC HEPATITIS-B VIRUS (HBV) INFECTION

In contrast to convalescent hepatitis B patients, who exhibit the ability to elicit a specific immune response to HBsAg, patients with chronic hepatitis B virus (HBV) infection are markedly hyporesponsive to HBsAg and show a decrease in the nomal ratio of OKT4-positive (helper/inducer) to OKT8-positive (suppressor/cytotoxic) lymphocytes. In this study the role of OKT4-positive and OKT8-positive cells on cellular immune response to HBsAg was evaluated in patients with chronic HBV infection and the ability of such patients to develop antigen-specific suppressor lymphocytes after in vitro sensitization of HBsAg. Elimination of OKT8-positive cells markedly improved the in vitro lymphocyte proliferative response to HBsAg without altering the reactivity of cells from the same donor to PPD or Candida. In contrast, the degree of responsiveness to HBsAg was not affected by the depletion of OKT4-positive cells. In vitro coculture experiments, performed in the seven chronically HBV-infected patients who showed a proliferative response when their PBM were cultured with purified HBsAg or PPD, have demonstrated that lymphocytes from chronic HBV carriers, stimulated with HBsAg, inhibit the response of autologous PBM to HBsAg but not to the unrelated antigen PPD. © 1985

Persistent hepatitis G virus (HGV) infection in chronic hemodialysis patients and non-B, non-C chronic hepatitis

Abstract Three groups of patients have been studied longitudinally for 24 months to analyze the role of hepatitis G virus (HGV) in hepatic disease. Group 1 consisted of 50 patients with non-B, non-C chronic hepatitis, group 2 consisted of 44 hemodialyzed patients, and group 3 consisted of 50 healthy blood donors. The presence of HGV RNA was detected by both reverse transcription-polymerase chain reaction (RT-PCR) and capillary zone electrophoresis (CZE). At the baseline visit the HGV RNA was detected in seven out of 50 patients with non-B, non-C chronic hepatitis, in two out of 44 hemodialyzed patients, and in three out of 50 healthy blood donors. HGV-infected hemodialyzed patients and HGV viremic blood donors had serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels within normal limits. During the follow-up period the two HGV-positive hemodialyzed patients and the three infected healthy blood donors did not show any sign of hepatic disease. There were no significant differences between HGV-positive patients in the three groups at the beginning and at the end of the follow-up. No considerable deterioration of general health conditions was observed on the basis of clinical and laboratory data in HGV-positive chronic hepatitis patients. Finally, HGV does not seem to be responsible for hepatic disease

Evaluation of myocardial involvement in systemic lupus erythematosus by signal-averaged electrocardiography and echocardiography

Abstract OBJECTIVE: The myocardial involvement in systemic lupus erythematosus (SLE) patients, frequently found at autopsy or at endomyocardial biopsy, is less easily detected clinically. The myocardial lesions are characterized by an increase in interstitial connective tissue and myocardial scarring. Signal-averaged electrocardiography (ECG-SA) is currently used for recording ventricular late potentials which are the expression of slowed and disorganized conduction through zones of myocardial scarring. M-mode, two-dimensional and Doppler echocardiography (ECHO) represent relatively simple methods for evaluating the left ventricular function. This study was aimed to evaluate by ECG-SA and ECHO the myocardial involvement of SLE patients without clinical and electrocardiographic evidence of cardiac disease. METHODS AND RESULTS: Twenty outpatients with SLE were studied and compared with 18 normal controls. Late potentials were recorded in 20% of SLE patients and in 5.5% of controls. A significant increase of abnormal left ventricular diastolic filling was found in the SLE patients, characterized by reduced E/A (p = 0.018), a lower deceleration rate of early diastolic flow velocity (p = 0.048) and a prolonged isovolumic relaxation time (p = 0.001). SLE patients had diastolic dysfunction of various degrees although the depolarization abnormalities detected by ECG-SA were found only in a few subjects. CONCLUSIONS: The depolarization abnormalities, revealed by ECG-SA, probably reflect a longer extent of myocardial fibrosis in SLE patients with ECHO evidence of abnormal left ventricular filling. The simultaneous occurrence of ECHO and ECG-SA alterations could be a marker of subclinical myocardial involvement

Ventricular late potentials in systemic sclerosis: Relationship with skin involvement

Objective. To detect the myocardial involvement in patients with systemic sclerosis (SSc) by signal averaged electrocardiography method (SA-ECG) in relationship to the skin changes. Methods. We selected 24 SSc outpatients according to American Rheumatism Association criteria, without clinical and instrumental evidence of cardiac disease, and compared them with 24 control subjects. All patients and controls underwent SA-ECG to detect ventricular late potentials (LP). The extent and severity of skin involvement in SSc patients was detected by modified Rodnan (m-Rodnan) skin score. Results. SSc patients had higher prevalence of LP compared to controls (46 versus 8%, p < 0.003). Median skin score value in the overall SSc population was 7 [mean, SD (range): 7.8, 3.2, (4-18)]. Patients with LP had a higher median skin score value compared to SSc patients without LP [median (range): 10 (6-18) versus 6 (4-9); Mann-Whitney U test 22.5, p < 0.0051. A subset analysis was also performed to verify the correlation of antibodies positivity (anti-centromere and Scl 70) pattern and the presence of LP. Our findings showed that higher values of skin score correlated with the presence of LP independent of antibody subsets. Conclusions. Our data suggest that diffuse abnormalities of the cardiac tissue detected by SA-ECG may be present, even in patients without cardiac symptoms. The relationship between LP and skin involvement in patients without clinical evidence of cardiac involvement may help detect of a subset of patients who may develop scleroderma heart disease

Prevalence and clinical features of skin diseases in chronic HCV infection - A prospective study in 96 patients

Background. Between extra-hepatic manifestations of hepatitis C virus (HCV) infection particular interest is focused on some dermatological diseases such as: leukocytoclastic vasculitis, oral lichen planus, pruritus-urticaria, psoriasis, etc. The aim of this study was to determine the prevalence of some dermatoses in our population of patients with HCV infection and describe the more characteristics clinical pictures. Methods. Ninety-six patients (36 men and 60 women) aged from 35 to 74 years with HCV documented by 3(rd) generation ELISA and RIBA tests were prospectively examined for 3 years to determine the prevalence of some skin disorders, reported as associated with HCV infection. All patients were also studied for presence and quantification of HCV-RNA by polymerase chain reaction and genotyping when possible. Eighty-one underwent a liver biopsy. Routine laboratory tests and some immunological investigations (ANA, AMA, SMA, LKM, ANCA, ICC, crioglobulins) were performed using standard procedures and indirect immunofluorescence, nephelometric, RIA methods. Results. Twelve of 96 patients (12.5%) presented skin disorders in progress of chronic virus C hepatitis: 5 cases of leukocytoclastic vasculitis (LCV) by mixed cryoglobulinemia, 1 case of pruritus, 2 cases of oral lichen planus (OLP), 2 cases of alopecia areata, 1 case of urticaria, 1 case of psoriasis. Conclusions. Our findings show a calculated prevalence of clinical dermatoses in HCV-infected patients around 12.5%. These findings confirm however the importance of liver examination in presence of skin diseases not related to other pathogenetic mechanisms

Effects of mud-pack treatment on plasma cytokine and soluble adhesion molecule levels in healthy volunteers

The suggested hypothesis of a direct anti-inflammatory property of mud-pack treatment has led us to speculate that its action on the cytokine network might counteract the heat-stress-related effects on platelet and endothelial cell function often reported following hot-spring baths. Therefore, the present study was designed to investigate the effects of a cycle of 12 daily mud-pack treatments on bio-humoral markers of inflammation, as well as on markers of in vivo platelet and/or endothelial cell activation, in plasma samples obtained from healthy volunteers. METHODS: Blood samples were obtained before (T(0)), at the end of the first treatment (T(1)) and after a cycle of 12 daily mud-pack treatments (T(2)). Plasma cytokines (TNF-alpha IL-1beta, and IL-6) and adhesion molecules (sP-selectin, sE-selectin and sVCAM) levels, as well as hematocrit and complete and differential blood cell counts were determined at every time point. RESULTS: Plasma sP-selectin levels were not modified during treatment, as were not sE-selectin or sVCAM. Similarly, IL-1beta and TNF-alpha levels were unchanged through a 12 daily mud-pack treatment. Conversely, plasma IL-6 levels were significantly lowered at the end of a 20-min 47 degrees C mud-pack treatment (p<0.01). CONCLUSIONS: The lack of effects on in vivo platelet and/or endothelial cell activation suggests that hot mud-pack treatment might be used as a relatively safe procedure in patients with atherothrombotic disorders