La ventilazione non invasiva in Medicina Interna

Legenda delle più comuni abbreviazioni e acronimi Prefazione P. Navalesi Presentazione M. Campanini La NIV in Medicina Interna F. Lari Il ventilatore e i suoi componenti F. Lari Maschere ed interfacce F. Lari Sistemi CPAP (pressione positiva continua applicata alle vie aeree) F. Lari Principi e tecniche di ventilazione meccanica F. Giostra, E. Di Flaviano Insufficienza respiratoria acuta cardiogena - ruolo della ventilazione non invasiva F. Ventrella Riacutizzazione di broncopneumopatia cronica ostruttiva M. La Regina, F. Orlandini Altre indicazioni alla ventilazione meccanica non invasiva F. Pieralli, O. Para, C. Nozzoli Le apnee del sonno: competenza multidisciplinare e ruolo dell’internista F. Lari La ventilazione meccanica non invasiva nella palliazione del paziente oncologico terminale S. Orlando, M. Giorgi-Pierfranceschi La NIV nel paziente con insufficienza respiratoria cronica, la gestione domiciliare - Competenza specialistica nelle patologie pneumologiche pure A. Marchioni, E.M. Clini, B. Beghé Approccio al paziente internistico, candidato alla ventilazione meccanica non invasiva: key messages M. Giorgi Pierfranceschi La ventilazione meccanica non invasiva: conclusioni M. Errico, A. Greco NIV in Medicina Interna: sono necessari sistemi di monitoraggio emodinamico? N. Di Battista, F. Savell

Clinical outcomes during anticoagulant therapy in fragile patients with venous thromboembolism.

Subgroup analyses from randomized trials suggested favorable results for the direct oral anticoagulants in fragile patients with venous thromboembolism (VTE). The frequency and natural history of fragile patients with VTE have not been studied yet. To compare the clinical characteristics, treatment and outcomes during the first 3 months of anticoagulation in fragile vs non-fragile patients with VTE. Retrospective study using consecutive patients enrolled in the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry. Fragile patients were defined as those having age ≥75 years, creatinine clearance (CrCl) levels ≤50 mL/min, and/or body weight ≤50 kg. From January 2013 to October 2016, 15 079 patients were recruited. Of these, 6260 (42%) were fragile: 37% were aged ≥75 years, 20% had CrCl levels ≤50 mL/min, and 3.6% weighed ≤50 kg. During the first 3 months of anticoagulant therapy, fragile patients had a lower risk of VTE recurrences (0.78% vs 1.4%; adjusted odds ratio [OR]: 0.52; 95% confidence intervals [CI]: 0.37-0.74) and a higher risk of major bleeding (2.6% vs 1.4%; adjusted OR: 1.41; 95% CI: 1.10-1.80), gastrointestinal bleeding (0.86% vs 0.35%; adjusted OR: 1.84; 95% CI: 1.16-2.92), haematoma (0.51% vs 0.07%; adjusted OR: 5.05; 95% CI: 2.05-12.4), all-cause death (9.2% vs 3.5%; adjusted OR: 2.02; 95% CI: 1.75-2.33), or fatal PE (0.85% vs 0.35%; adjusted OR: 1.77; 95% CI: 1.10-2.85) than the non-fragile. In real life, 42% of VTE patients were fragile. During anticoagulation, they had fewer VTE recurrences and more major bleeding events than the non-fragile

Rate and duration of hospitalisation for acute pulmonary embolism in the real-world clinical practice of different countries : Analysis from the RIETE registry

publishersversionPeer reviewe

Factors associated with survival in older patients affected by COVID-19: A retrospective cohort study

Aim: Mortality is high in Coronavirus disease 2019 patients with pre-existing comorbidities and advanced age. Associated complications have added to the negative prognosis. Nevertheless, many have fully recovered, even among the most fragile. Factors associated with their survival was investigated. Methods: Retrospective study of patients aged ≥90 years admitted for COVID-19 to the Internal Medicine wards of two hospitals in Lombardy, Italy. Results: Among 34 patients with SARS-CoV-2 pneumonia, 33 (97.1%) had respiratory failure. Eighteen patients (52.9%) survived and 16 (47.1%) died during hospital stay. Survivors compared to deceased had a significantly longer hospitalization (19 vs. 10 days respectively; p = 0.02), a better PaO2:FiO2 ratio (241 vs. 171 respectively; p = 0.003), higher lymphocyte counts (p = 0.01) and lower serum LDH levels (p < 0.001) at admission. At multivariate analysis only higher PaO2:FiO2 was associated with survival (OR 1.06 [95%CI 1.0–1.03]; p = 0.02). Kaplan-Meier analysis showed a significant difference in event-free survival between patients treated or not with LMWH (p < 0.0001) and between those treated or not with beta-blockers (p = 0.008). Cox regression, performed in the subgroup of patients who received LMWH, did not show significant difference for sex (HR 2.7 [95% CI 0.53–14.3], p = 0.23), CCI (HR 0.7 [95% CI 0.37–1.45], p = 0.38), PaO2:FiO2 ratio (HR 0.98 [95% CI 0.97–1.0], p = 0.07), corticosteroid therapy (HR 0.99 [95% CI 0.22–4.5], p = 0.99) and beta-blocker therapy (HR 2.8 [95% CI 0.56–14,7], p = 0.21). Conclusions: Despite higher mortality in elderly, treatment with LMWH and betablockers might be associated with better survival. Dedicated studies are required to confirm our result

Dabigatran in nonvalvular atrial fibrillation: From clinical trials to real-life experience

Atrial fibrillation is the most common arrhythmia in over-midlife patients. In addition to systolic heart failure, cerebral thromboembolism represents the most dramatic complication of this rhythm disorder, contributing to morbidity and mortality. Traditionally, anticoagulation has been considered the main strategy in preventing stroke and systemic embolism in atrial fibrillation patients and vitamin K-dependent antagonists have been widely used in clinical practice. Recently, the development of direct oral anticoagulants has certainly improved the management of this disease, providing, for the first time, the opportunity to go beyond vitamin K-dependent antagonists limits. In the RE-LY trial, dabigatran 150mg twice daily was superior to warfarin in the prevention of stroke or systemic embolism and dabigatran 110mg twice daily was noninferior. Both doses greatly reduced hemorrhagic stroke, and dabigatran 110mg twice daily significantly reduced major bleeding compared with warfarin. Based on these results, dabigatran, a direct thrombin inhibitor, was the first direct oral anticoagulant to receive the regulatory approval for nonvalvular atrial fibrillation patients. To date, a specific reversal agent has just been approved as an antidote for this molecule. This review provides a summary of randomized trials, postmarket registries and specific clinical-settings summary on dabigatran in nonvalvular atrial fibrillation

Platelet Count and Major Bleeding in Patients Receiving Vitamin K Antagonists for Acute Venous Thromboembolism, Findings From Real World Clinical Practice.

The outcome of patients with acute venous thromboembolism (VTE) and abnormal platelet count (PlC) at baseline has not been consistently studied. In real-world clinical practice, a number of patients with abnormal PlC receive vitamin K antagonists (VKAs) to treat acute VTE despite their higher risk of bleeding.We used the Registro Informatizado de Enfermedad TromboEmbólica registry database to compare the rate of major bleeding in patients receiving VKA for long-term therapy of acute VTE according to PlC levels at baseline. Patients were categorized as having very low (&lt;100,000/μL), low (100,000-150,000/μL), normal (150,000-300,000/μL), high (300,000-450,000/μL), or very high (&gt;450,000/μL) PlC at baseline.Of 55,369 patients recruited as of January 2015, 37,000 (67%) received long-term therapy with VKA. Of these, 611 patients (1.6%) had very low PlC, 4006 (10.8%) had low PlC, 25,598 (69%) had normal PlC, 5801 (15.6%) had high PlC, and 984 (2.6%) had very high PlC at baseline. During the course of VKA therapy (mean, 192 days), there were no differences in the duration or intensity (as measured by international normalized ratio levels) of treatment between subgroups. The rate of major bleeding was 3.6%, 2.1%, 1.9%, 2.1%, and 3.7%, respectively, and the rate of fatal bleeding was 0.98%, 0.17%, 0.29%, 0.34%, and 0.50%, respectively. Patients with very low or very high PlC levels were more likely to have severe comorbidities.We found a nonlinear "U-shaped" relationship between PlC at baseline and major bleeding during therapy with VKA for VTE. Consistent alteration of PlC values at baseline suggested a greater frailty