Role of a multidisciplinary program in improving outcomes in cognitively impaired heart failure older patients.

Background: Cognitive impairment (CI) frequently complicates Heart failure (HF) and is associated with increased mortality and morbidity. Previous studies reported that nurse-lead home-based multidisciplinary program (MP) may not improve the prognosis of this high-risk group. In the present study, we analysed the relative effectiveness of an integrated hospital-based MP in patients with cognitive impairment. Methods: Consecutive (n=173) community-living outpatients aged >70 years (mean 77+6, 48% women) randomized to a MP (n=86) or usual care (UC) (n=87) were enrolled in stable clinical conditions. Cognitive status was assessed by means of Folstein Mini Mental State Examination (MMSE). Results: CI (MMSE<24) was present in 41.6% (42,5% UC vs 40.7% MP p=ns). The variables independently associated to CI were: older age, education level <5 years, anemia and severe renal dysfunction. During a 2-year follow-up, 59 patients died (31.4%) with no significant difference between intervention group. At multivariate analysis, in the entire cohort, CI was independently associated to death (HR 2,077[95%CI 1,097- 3,931]), HF admissions (2,133[1,346-3,381]), death/HF admissions (1,784[1,132-2,811]) and all-cause admissions (1,473[1,008-2,153]. When considered according to intervention groups, CI was independently associated to all-cause death (3,603 [1,553-8,358], death/HF admissions (2,029[1,200-3,432]) and HF admissions (2,474[1,406-4,353]) but not to all-cause admissions. The assignment of patients with CI to MP was associated to a significant reduction in HF admissions vs UC (0,503[0,253-0,999] (all interaction tests p=ns). Conclusions: This study suggests that CI is very common and associated to worse prognosis in heart failure and that hospital-based MP seems to improve outcomes in these patients through reduction of heart failure hospital admission

Clinical and hormonal findings in patients presenting with high IGF-1 and growth hormone suppression after oral glucose load: a retrospective cohort study

High insulin-like growth factor 1 (IGF-1) and unsuppressed growth hormone (GH) levels after glucose load confirm the diagnosis of acromegaly. Management of patients with conflicting results could be challenging. Our aim was to evaluate the clinical and hormonal evolution over a long follow-up in patients with high IGF-1 but normal GH nadir (GHn < 0.4 μg/L according to the latest guidelines)

Reasons why patients suffering from chronic heart failure at very high risk for death survive

Background: An accurate prognostic stratification is essential for optimizing the clinical management and treatment decision-making of patients with chronic heart failure (HF). Among the best available models, we used the Cardiac and Comorbid Conditions HF (3C-HF) Score, to predict all-cause mortality in patients with CHF. Methods: we selected and characterized the subgroup of patients at very high risk with the worst mid-term prognosis belonging to the highest decile of 3C-HF score with the aim to assess predictors of survival in subjects with an expected probability of 1-year mortality near to 45%. Methods and results: We recruited 1777 consecutive chronic HF patients at 3 Italian Cardiology Units. Median age was 76\ub110 years, 43% were female, and 32% had preserved ejection fraction. Subjects belonging to the highest decile of 3C-HF score were 246 (13.8% of total population). During a median follow-up of 21 [12\u201340] months, 110 of these patients (45%) survived and 136 (55%) died. The variables that contributed to survival prediction emerged by Cox regression multivariate analysis were the lower degree of renal dysfunction and higher body mass index. Conclusions: The prognostic stratification of chronic HF patients allows in daily practice to select patients at different risk for death and identify prognosticators of survival in outliers at very high risk of death. The reasons why these patients outlive the matching part of subjects who expectedly die are related to the maintenance of a satisfactory renal function and body mass index

Adrenal insufficiency at the time of COVID-19: a retrospective study in patients referring to a tertiary centre

Context COVID-19 represents a global health emergency and infected patients with chronic diseases often present with a severe impairment. Adrenal insufficiency (AI) is supposed to be associated with an increased infection risk which could trigger an adrenal crisis. Objective Our primary aim was to evaluate the incidence of COVID-19 symptoms and complications in AI patients. Design and setting We conducted a retrospective case-control study. All patients were on active follow-up and lived in Lombardy, one of the most affected areas. Patients We enrolled 279 patients with primary and secondary AI and 112 controls (patients with benign pituitary lesions without hormonal alterations). All AI patients had been previously trained to modify their replacement therapy on stress doses. Intervention By administering a standardized questionnaire by phone, we collected data on COVID-19 suggestive symptoms and consequences. Results In February-April 2020, the prevalence of symptomatic patients (complaining at least one symptom of viral infection) was similar between the two groups (24% in AI and 22.3% in controls, p 0.79). Highly suggestive COVID-19 symptoms (at least two including fever and/or cough) also occurred equally in AI and controls (12.5% in both groups). No patient required hospitalization and no adrenal crisis was reported. Few nasopharyngeal swabs were performed (n=12) as indicated by sanitary regulations, limiting conclusions on the exact infection rate (two positive results in AI and none in controls, p 0.52). Conclusions AI patients who are adequately treated and trained, seem to display the same incidence of COVID-19 suggestive symptoms and disease severity as controls

Cushing’s disease: a prospective case-control study of health-related quality of life and cognitive status before and after surgery

Some studies have highlighted psychological and neuropsychological difficulties and a potential reduction in health-related quality of life (HRQOL) in patients with pituitary tumors, despite hormone deficits or excess. To the authors' knowledge, this study is the first prospective longitudinal case-control study with the aim of simultaneously testing whether HRQOL and psychiatric and neuropsychological disabilities are related to neural dysfunction due to hypercortisolism per se, or tumor mass and/or surgery in patients with Cushing's disease (CD). The authors evaluated a homogeneous cohort of patients with CD and nonfunctioning pituitary adenomas (NFPAs) before and after neurosurgery and compared these patients with healthy controls

Cushing's disease: a prospective case-control study of health-related quality of life and cognitive status before and after surgery

Some studies have highlighted psychological and neuropsychological difficulties and a potential reduction in health-related quality of life (HRQOL) in patients with pituitary tumors, despite hormone deficits or excess. To the authors' knowledge, this study is the first prospective longitudinal case-control study with the aim of simultaneously testing whether HRQOL and psychiatric and neuropsychological disabilities are related to neural dysfunction due to hypercortisolism per se, or tumor mass and/or surgery in patients with Cushing's disease (CD). The authors evaluated a homogeneous cohort of patients with CD and nonfunctioning pituitary adenomas (NFPAs) before and after neurosurgery and compared these patients with healthy controls

Incremental value of gait speed in predicting prognosis of older adults with heart failure. insights from the IMAGE-HF study

OBJECTIVES The aim of this study was to assess the relationship between gait speed and the risk for death and/or hospital admission in older patients with heart failure (HF). BACKGROUND Gait speed is a reliable single marker of frailty in older people and can predict falls, disability, hospital admissions, and mortality. METHODS In total, 331 community-living patients $70 years of age (mean age 78 6 years, 43$1.0 m/s. RESULTS There was a significant association between gait speed tertiles and 1-year mortality: 38.3%, 21.9%, and 9.1% (p < 0.001), respectively. On multivariate analysis, gait speed was associated with a lower risk for all-cause death (hazard ratio: 0.62; 95% confidence interval: 0.43 to 0.88) independently of age, ejection fraction <20%, systolic blood pressure, anemia, and absence of beta-blocker therapy. Gait speed was also associated with a lower risk for hospital- ization for HF and all-cause hospitalization. When gait speed was added to the multiparametric Cardiac and Comorbid Conditions Heart Failure risk score, it improved the accuracy of risk stratification for all-cause death (net reclassification improvement 0.49; 95% confidence interval: 0.26 to 0.73, p < 0.001) and HF admissions (net reclassification improvement 0.37; 95% confidence interval: 0.15 to 0.58; p < 0.001). CONCLUSIONS Gait speed is independently associated with death, hospitalization for HF, and all-cause hospitalization and improves risk stratification in older patients with HF evaluated using the Cardiac and Comorbid Conditions Heart Failure score. Assessment of frailty using gait speed is simple and should be part of the clinical evaluation process

Treatment of Acromegalic Osteopathy in Real-life Clinical Practice: The BAAC (Bone Active Drugs in Acromegaly) Study.

Background: Vertebral fractures (VFs) are a frequent complication of acromegaly, but no studies have been so far published on effectiveness of anti-osteoporotic drugs in this clinical setting. Objective: To evaluate whether in real-life clinical practice bone-active drugs may reduce the risk of VFs in patients with active or controlled acromegaly. Study design: Retrospective-longitudinal study including 9 tertiary care Endocrine Units. Patients and methods: Two-hundred-forty-eight patients with acromegaly (104 males; mean age 56.0\ub113.6 years) were evaluated for prevalent and incident VFs by quantitative morphometric approach. Bone-active agents were used in 52 patients (20.97%) and the median period of follow-up was 48 months (range 12-132). Results: During the follow-up, 65 patients (26.21%) developed incident VFs in relationship with pre-existing VFs (odds ratio (OR) 3.75; p<0.001), duration of active acromegaly (OR 1.01; p=0.04), active acromegaly at the study entry (OR 2.48; p=0.007) and treated hypoadrenalism (OR 2.50; p=0.005). In the entire population, treatment with bone active drugs did not have a significant effect on incident VFs (p=0.82). However, in a sensitive analysis restricted to patients with active acromegaly at the study entry (111 cases), treatment with bone-active drugs was associated with a lower risk of incident VFs (OR 0.11; p=0.004), independently of prevalent VFs (OR 7.65; p<0.001) and treated hypoadrenalism (OR 3.86; p=0.007). Conclusions: Bone-active drugs may prevent VFs in patients with active acromegaly