The “Diabetes Comorbidome”: A Different Way for Health Professionals to Approach the Comorbidity Burden of Diabetes

(1) Background: The disease burden related to diabetes is increasing greatly, particularly in older subjects. A more comprehensive approach towards the assessment and management of diabetes’ comorbidities is necessary. The aim of this study was to implement our previous data identifying and representing the prevalence of the comorbidities, their association with mortality, and the strength of their relationship in hospitalized elderly patients with diabetes, developing, at the same time, a new graphic representation model of the comorbidome called “Diabetes Comorbidome”. (2) Methods: Data were collected from the RePoSi register. Comorbidities, socio-demographic data, severity and comorbidity indexes (Cumulative Illness rating Scale CIRS-SI and CIRS-CI), and functional status (Barthel Index), were recorded. Mortality rates were assessed in hospital and 3 and 12 months after discharge. (3) Results: Of the 4714 hospitalized elderly patients, 1378 had diabetes. The comorbidities distribution showed that arterial hypertension (57.1%), ischemic heart disease (31.4%), chronic renal failure (28.8%), atrial fibrillation (25.6%), and COPD (22.7%), were the more frequent in subjects with diabetes. The graphic comorbidome showed that the strongest predictors of death at in hospital and at the 3-month follow-up were dementia and cancer. At the 1-year follow-up, cancer was the first comorbidity independently associated with mortality. (4) Conclusions: The “Diabetes Comorbidome” represents the perfect instrument for determining the prevalence of comorbidities and the strength of their relationship with risk of death, as well as the need for an effective treatment for improving clinical outcomes

Antidiabetic Drug Prescription Pattern in Hospitalized Older Patients with Diabetes

Objective: To describe the prescription pattern of antidiabetic and cardiovascular drugs in a cohort of hospitalized older patients with diabetes. Methods: Patients with diabetes aged 65 years or older hospitalized in internal medicine and/or geriatric wards throughout Italy and enrolled in the REPOSI (REgistro POliterapuie SIMI—Società Italiana di Medicina Interna) registry from 2010 to 2019 and discharged alive were included. Results: Among 1703 patients with diabetes, 1433 (84.2%) were on treatment with at least one antidiabetic drug at hospital admission, mainly prescribed as monotherapy with insulin (28.3%) or metformin (19.2%). The proportion of treated patients decreased at discharge (N = 1309, 76.9%), with a significant reduction over time. Among those prescribed, the proportion of those with insulin alone increased over time (p = 0.0066), while the proportion of those prescribed sulfonylureas decreased (p < 0.0001). Among patients receiving antidiabetic therapy at discharge, 1063 (81.2%) were also prescribed cardiovascular drugs, mainly with an antihypertensive drug alone or in combination (N = 777, 73.1%). Conclusion: The management of older patients with diabetes in a hospital setting is often sub-optimal, as shown by the increasing trend in insulin at discharge, even if an overall improvement has been highlighted by the prevalent decrease in sulfonylureas prescription

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

HLA-DQB1*0305 and −DQB1*0304 alleles among Sardinians: evolutionary and practical implications for oligotyping

This study, performed in individuals of Sardiaian descent, reports an epidemiologic and molecular analysis of the recently identified DQB1*0304 and DQB1*0305 alleles*. These two alleles having a gene frequency of 0.017 and 0.005, respectively, are not uncommon in Sardinia and are distributed fairly uniformly on the island. The analysis of DQB1 second and third exons of the two alleles revealed that although they have always been found included within the same DRB1*0403-DQA1*03 haplotype, they had a different origin. The sequence pattern of DQB1*0305 confirmed that it originated from the DQB1*0302 “recipient” gene by the insertion of a DQB1*0402 nucleotide stretch, within its β-sheet region, while that of DQB1*0304 suggested that it originated from the DQB1*0301 gene, either by a single point mutation at codon 57 (GCC instead of GAC) or, alternatively, by a segmental transfer of a DQB1*0302 motif, including codon 57, within its α-helic region. Independently from the mechanism of generation, the fact that DQB1*0304 originated from DQB1*0301 allele was intriguing considering that, in over 1500 HLA class II Sardinian haplotypes examined, neither the putative parental DRB1*0403-DQA1*03-DQB1*0301 nor any DRB1*04-DQA1*03-DQB1*0301 haplotypes were found. Finally, since the assignment of DQB1*0305 may be inaccurate with the traditional panel of probes commonly used for DQB1 oligotyping, the use of an additional oligonucleotide probe is recommended

Combinations of specific DRB1, DQA1, DQB1 haplotypes are associated with insulin-dependent diabetes mellitus in Sardinia

The Sardinian population has an extremely high incidence of IDDM (30.2 of 100.000 in the age group of 0–14 years). This study reports the molecular characterization of HLA class II genes in 120 IDDM sporadic patients and 89 healthy subjects of Sardinian origin. Compared with other Caucasians, both Sardinian patients and controls had an unusual distribution of haplotypes and genotypes. In particular, there was a high gene frequency of the DRB1*0301, DQA1*0501, DQB1*0201 susceptibility haplotype both in patients (0.58) and controls (0.23) while a reduction of the BRB1*1501, DQA1*0102, DQB1*0602 protective haplotype (0.03) was observed in the healthy population. This distribution may partially explain the high incidence of IDDM reported in Sardinia. The analysis of the DQβ57 and DQα52 residues showed that the absence of Asp 57 and the presence of Arg 52 were associated with IDDM in a dose-response manner. On the other hand, we found that (a) a very similar distribution of these residues was found when comparing Sardinians with another healthy Caucasian population from the same latitude but with a lower rate of IDDM incidence; (b) several genotypes encoding the identical DQα52/DQβ57 phenotype carried very differnt relative risks; and (c) the DRB1*0403, DQA1*0301, DQB1*0304 haplotype (DQβ57 Asp-neg and DQα52 Argpos) was found in 40% of the DR4-positive controls but not in patients (p = 0.00034), while the DRB1*0405, DQA1*0301, and DQB1*0302 haplotype carrying the same residues at the same positions was found in 70% of the DR4-positive patients and in only one control (p = 0.00003). These findings suggest that S0IDDM susceptibility cannot be completely explained by the model in which only DQα52 and DQβ57 residues are taken into account

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

Knowledge on the main clinical and prognostic characteristics of older multimorbid subjects with liver cirrhosis (LC) admitted to acute medical wards is scarce

Prescription appropriateness of anticoagulant drugs for prophylaxis of venous thromboembolism in hospitalized multimorbid older patients

The aims were to assess: the prescription prevalence of anticoagulant drugs for thromboprophylaxis (TP) in hospitalized older patients; the appropriateness of their prescription or non-prescription; the in-hospital mortality in appropriately versus non-appropriately prescribed or not prescribed patients. 4836 patients aged 65 or older, admitted to the Italian internal medicine and geriatric wards participating to the REPOSI register from 2012 to 2019 were assessed for prescription of anticoagulant drugs for TP at admission and/or during hospital stay. The Padua Prediction Score (PPS) and the IMPROVE score were used to assess the thrombotic and bleeding risk. Patients were considered to be appropriately prescribed when had PPS ≥ 4 and IMPROVE < 7, and appropriately not prescribed when PPS < 4. Logistic regression model was used to assess whether appropriateness was associated with in-hospital mortality. Among 4836 patients included, anticoagulants were prescribed for TP in 1233 (25.5%). In all, 4461 patients were assessable for appropriateness: 3136 (70.3%) were appropriately prescribed or non-prescribed according to their thrombotic and bleeding risk. Among 1138 patients receiving prophylaxis, only 360 (31.7%) were appropriately prescribed, while among 3323 non-prescribed patients, 2776 (83.5%) were appropriately non-prescribed. The in-hospital mortality rate was lower in patients appropriately prescribed or non-prescribed than in those inappropriately prescribed or non-prescribed (OR: 0.63; 95% CI: 0.46-0.83). In conclusion, a high prevalence of multimorbid hospitalized patients were appropriately prescribed or non-prescribed for TP with anticoagulants, appropriate non-prescription being mainly driven by a high bleeding risk. The appropriateness of prescription or non-prescription was associated with lower in-hospital mortality

Low serum albumin is associated with mortality and arterial and venous ischemic events in acutely ill medical patients. Results of a retrospective observational study

Background: In general population hypoalbuminemia is associated with poor survival. Aim of this study was to assess the impact of hypoalbuminemia on mortality and venous and arterial ischemic events in hospitalized acutely ill medical patients. Patients and methods: Retrospective observational analysis from the "REgistro POliterapie SIMI" (REPOSI). Patients were followed up to 12 months. Serum albumin was obtained in each patient. Mortality and ischemic events were registered throughout the follow-up period. Results: In the entire population including 4152 patients, median levels of serum albumin were 3.4 g/dL and 2193 patients (52.8 %) had levels ≤3.4 g/dL. Cases with albumin ≤3.4 g/dL were older, frailer, had more comorbidities and were most frequently underweight than those with serum albumin >3.4 g/dL. During the 12-month follow-up, all-cause mortality was 14.8 % (613 patients), with a higher rate in cases with serum albumin ≤3.4 g/dL (459, 20.9 % vs 154, 7.9 % in those with serum albumin >3.4 g/dL; p < 0.0001). During follow-up 121 ischemic events (2.9 %) were registered, 86 (71.1) arterial and 35 (28.9 %) venous. Proportional hazard analysis showed that patients with albumin ≤3.4 g/dL had a higher chance of dying. Furthermore, patients with albumin ≤3.4 g/dL had a higher likelihood of experiencing ischemic events. Conclusions: Acutely ill hospitalized medical patients with serum levels ≤3.4 g/dL are at higher risk of all-cause mortality and ischemic events, measurement of albumin may help to identify hospitalized patients with a poorer prognosis