41 research outputs found
A cascade of complications in a hospitalized frail older patient: is a better management possible?
Methods. Describing the complications that an older patient under- went during his hospital stay.Results. An 87-year-old man was admitted to the San Raffaele Hos- pital for a transient loss of consciousness (LOC). He was hospitalized for assessing the causes of the LOC. The LOC lasted 2 minutes, was associated with bilateral upper limb clonus and subsequent confu- sion. The patient was severely comorbid: he suffered from metabolic syndrome, chronic kidney failure, hemodynamically significant carotid atheromasia, anemia, and he had a dubious history of epilepsy. More- over, the patient was cognitively impaired and many episodes of LOC were reported in his medical history. During the hospital stay the patient developed many complications: a fall, nosocomial pneumonia, urinary retention and deconditioning.Conclusions. Global aging poses several challenges to society and public health systems. The traditional models of care are not suitable to face the complex needs of frail older people for whom standard deci- sional algorithms are seldom applicable. The context of hospitalization, though necessary, may be hazardous risky for the health of older peo- ple, especially the frailer ones
Dyspnea as a symptom of progressive chronic myeloproliferative disease: a rare case of hemorrhagic alveolitis and pulmonary fibrosis, due to extramedullary erythropoiesis
n/
Maintenance sunitinib or observation in metastatic pancreatic adenocarcinoma: a phase II randomised trial
Background: New strategies to prolong disease control warrant investigation in patients with metastatic pancreatic adenocarcinoma. This open-label, randomised, multi-centre phase II trial explored the role of maintenance sunitinib after first-line chemotherapy in this setting. Methods: Patients with pathologic diagnosis of metastatic pancreatic adenocarcinoma, performance status >50%, no progression after 6 months of chemotherapy were centrally randomised by an independent contract research organisation, which was also responsible for data collection and monitoring, to observation (arm A) or sunitinib at 37.5mg daily until progression or a maximum of 6 months (arm B). The primary outcome measure was the probability of being progression-free at 6 months (PFS-6) from randomisation. Assuming P0 = 10%; P1 = 30%, α .10; ÎČ .10, the target accrual was 26 patients per arm. Results: 28 per arm were randomised. One arm B patient had kidney cancer and was excluded. Sunitinib was given for a median of 91 days (7-186). Main grade 3-4 toxicity was thrombocytopenia, neutropenia and hand-foot syndrome (12%), diarrhoea 8%. In arm A versus B, PFS-6 was 3.6% (95% confidence interval (CI): 0-10.6%) and 22.2% (95% CI: 6.2-38.2%; P<0.01); 2 y overall survival was 7.1% (95% CI: 0-16.8%) and 22.9% (95% CI: 5.8-40.0%; P = 0.11), stable disease 21.4% and 51.9% (P = 0.02). Conclusion: This is the first randomised trial on maintenance therapy in metastatic pancreatic adenocarcinoma. The primary end-point was fulfilled and 2 y overall survival was remarkably high, suggesting that maintenance sunitinib is promising and should be further explored in this patient population
Low inâhospital mortality rate in patients with COVIDâ19 receiving thromboprophylaxis: data from the multicentre observational STARTâCOVID Register
Abstract
COVID-19 infection causes respiratory pathology with severe interstitial pneumonia and extra-pulmonary complications; in particular, it may predispose to thromboembolic disease. The current guidelines recommend the use of thromboprophylaxis in patients with COVID-19, however, the optimal heparin dosage treatment is not well-established. We conducted a multicentre,
Italian, retrospective, observational study on COVID-19 patients admitted to ordinary wards, to describe clinical characteristic of patients at admission, bleeding and thrombotic events occurring during hospital stay. The strategies used for thromboprophylaxis and its role on patient outcome were, also, described. 1091 patients hospitalized were included in
the START-COVID-19 Register. During hospital stay, 769 (70.7%) patients were treated with antithrombotic drugs: low molecular weight heparin (the great majority enoxaparin), fondaparinux, or unfractioned heparin. These patients were more frequently affected by comorbidities, such as hypertension, atrial fibrillation, previous thromboembolism, neurological disease,and cancer with respect to patients who did not receive thromboprophylaxis. During hospital stay, 1.2% patients had a major bleeding event. All patients were treated with antithrombotic drugs; 5.4%, had venous thromboembolism [30.5% deep vein thrombosis (DVT), 66.1% pulmonary embolism (PE), and 3.4% patients had DVT + PE]. In our cohort the mortality rate
was 18.3%. Heparin use was independently associated with survival in patients aged â„ 59 years at multivariable analysis. We confirmed the high mortality rate of COVID-19 in hospitalized patients in ordinary wards. Treatment with antithrombotic drugs is significantly associated with a reduction of mortality rates especially in patients older than 59 years
High Risk of Secondary Infections Following Thrombotic Complications in Patients With COVID-19
Background. This studyâs primary aim was to evaluate the impact of thrombotic complications on the development of secondary infections. The secondary aim was to compare the etiology of secondary infections in patients with and without thrombotic complications. Methods. This was a cohort study (NCT04318366) of coronavirus disease 2019 (COVID-19) patients hospitalized at IRCCS San Raffaele Hospital between February 25 and June 30, 2020. Incidence rates (IRs) were calculated by univariable Poisson regression as the number of cases per 1000 person-days of follow-up (PDFU) with 95% confidence intervals. The cumulative incidence functions of secondary infections according to thrombotic complications were compared with Grayâs method accounting for competing risk of death. A multivariable Fine-Gray model was applied to assess factors associated with risk of secondary infections. Results. Overall, 109/904 patients had 176 secondary infections (IR, 10.0; 95% CI, 8.8â11.5; per 1000-PDFU). The IRs of secondary infections among patients with or without thrombotic complications were 15.0 (95% CI, 10.7â21.0) and 9.3 (95% CI, 7.9â11.0) per 1000-PDFU, respectively (P = .017). At multivariable analysis, thrombotic complications were associated with the development of secondary infections (subdistribution hazard ratio, 1.788; 95% CI, 1.018â3.140; P = .043). The etiology of secondary infections was similar in patients with and without thrombotic complications. Conclusions. In patients with COVID-19, thrombotic complications were associated with a high risk of secondary infections
Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19
IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19.
Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19.
DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 nonâcritically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022).
INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (nâ=â257), ARB (nâ=â248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; nâ=â10), or no RAS inhibitor (control; nâ=â264) for up to 10 days.
MAIN OUTCOMES AND MEASURES The primary outcome was organ supportâfree days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes.
RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ supportâfree days among critically ill patients was 10 (â1 to 16) in the ACE inhibitor group (nâ=â231), 8 (â1 to 17) in the ARB group (nâ=â217), and 12 (0 to 17) in the control group (nâ=â231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ supportâfree days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively).
CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes.
TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570
Integrating static and dynamic analysis to improve the comprehension of existing web applications
Web Applications are today becoming more and more interactive and dynamic: the pages rendered in a browser on the client side can be dynamically built by server pages according to the user inputs or requests. Moreover, even pieces of code (e.g., client-side scripts) can be dynamically generated. The comprehension of such applications, needed to effectively perform maintenance or testing, may be very hard. Indeed, for highly dynamic Web Applications, static analysis is likely to give only an imprecise and approximate picture, thus, also dynamic analysis is required to gain a proper understanding of complex and dynamic application behavior. This paper presents the integration and the enhancement of two existing Web Application reverse engineering tools: one, WARE, performing static analysis, the other, WANDA, dynamic analysis. In particular, the paper shows how the integrated toolkit can be used to identify equivalence classes from groups of dynamically built client pages, with the aim of improving comprehension. To validate the proposed approach, results from a case study are presented and discussed
Testing Web-based applications: The state of the art and future trends
Software testing is a difficult task and testing Web-based applications may be even more difficult, due to the peculiarities of such applications. In the last years, several problems in the field of Web-based applications testing have been addressed by research work, and several methods and techniques have been defined and used to test Web-based applications effectively. This paper will present the main differences between Web-based applications and traditional ones, how these differences impact the testing of the former ones, and some relevant contributions in the field of Web application testing developed in recent years. The focus is mainly on testing the functionality of a Web-based application, even if some discussion about the testing of non-functional requirements is provided too. Some indications about future trends in Web application testing are also outlined in the paper