le polmoniti nei pazienti provenienti da residenze sanitarie assistenziali e necessaria una strategia terapeutica dedicata

Summary Background: Nursing home-acquired pneumonia (NHAP) was described in 1978, but only in 2005 it has been proposed as part of a new category (health care-associated pneumonia) distinct from community- or hospital-acquired infections. However, limited clinical data exist to validate this proposal. Aim of the study: To compare characteristics and outcome of patients hospitalised for pneumonia and coming from private residence or nursing home. Methods: Post-hoc analysis of the prospective phase of the FASTCAP study, performed to evaluate the impact of the Recommendations issued by the Italian Federation of Internal Medicine (FADOI) in 2002 on the management of hospitalised community-acquired pneumonia (CAP)

Direct oral anticoagulants for secondary prevention in patients with non-valvular atrial fibrillation

The patients with non-valvular atrial fibrillation (NVAF), both permanent and paroxysmal, and history of previous transient ischemic attack (TIA) or stroke represent a category of patients at high risk of new embolic events, independently of the presence of other risk factors. In these patients, national and international guidelines recommend oral anticoagulants as first choice for antithrombotic prevention. Direct oral anticoagulants (DOACs) have been demonstrated to be not inferior to warfarin for many end points in NVAF patients in terms of efficacy and safety. The post hoc analysis in selected subgroups of patients enrolled in the three mega trials of phase III comparing DOACs (RE-LY, ROCKET-AF and ARISTOTLE) with warfarin help to evaluate whether superiority and non-inferiority persist in these subgroups. Here, patients with NVAF and history of previous TIA/stroke receiving DOACs as secondary prevention are compared with patients with the same characteristics receiving warfarin. An analysis of these patients has been recently published (separately for each of three DOACs). This analysis shows that DOACs maintain their non-inferiority when compared with warfarin in secondary prevention, representing a real alternative in this context of patients at high risk for ischemic and bleeding events

Adherence to treatment and anticoagulation control in vitamin K antagonists-treated patients: an administrative databases analysis in a large Italian population

Oral anticoagulant therapy is essential for the treatment and prevention of many thromboembolic disorders. The aim of the present study is to evaluate the level of anticoagulation intensity in patients treated with vitamin K antagonists (VKAs) in a clinical practice setting and to explore the relationship between anticoagulation intensity and adherence to VKA treatment. We conducted a retrospective cohort study using the administrative databases of three Italian Local Health Units. Patients were enrolled if they had filled at least one prescription for VKAs (ATC code B01AA) between January 1st, 2007 and June 30th, 2008. In the same period all determinations of the international normalised ratio (INR) were collected. The parameters evaluated were anticoagulation control and adherence to VKA treatment.The survey showed that only 47.9% and 56.3% of INR determinations, in VKA naïve and established patients respectively, were into the recommended range (2.0-3.0). Moreover, the percentage of INR determination below the recommended range was higher than the percentage of INR determination above the recommended range for both naïve and established patients. Moreover, adherence to VKA treatment was poor both in naïve and established patients and, consequently, anticoagulation control is poor. Also in patients with the highest adherence to VKA treatment, only about 60% of INR determinations were into the recommended range. Our findings evidence that the anticoagulation control in clinical practice settings is still unsatisfactory and it is necessary to evaluate interventions to increase the amount of time at which patients' INR are within the recommended range

The influence of physical activity performed at 20-40 years of age on cardiovascular outcomes in medical patients aged 65-75

Summary Introduction Several studies show that physical activity can reduce the risk of cardiovascular disease, but the vast majority of these focus on the short- to intermediate-term benefits or refer to very specific populations. This observational study was conducted to determine whether physical activity performed during the third or fourth decade of life influences the occurrence of cardiovascular events in patients aged 65-75 years. Materials and methods We studied a cohort of 2191 unselected patients admitted to Internal Medicine Departments. Data were collected on the patients' medical history and their physical activity level when they were 20 to 40 years old. For the latter purpose, we used a specific questionnaire to assess the levels of physical activity related to the patients' job, daily life, leisure time, and sports. Results Almost half (44.2%) of the patients we evaluated reported moderate-intense physical activity when they were 20-40 years old. Around one third (35.8%) of the patients had experienced at least one major cardiovascular event, and there was a slight trend towards fewer cardiovascular events in patients with histories of physical activity (mean risk reduction: 4%, multivariate analysis). More evident benefits were observed in the subgroup of patients with diabetes, where cardiovascular outcomes were much better in patients who had been physically active than in those with sedentary life-styles (mean risk reduction: 24%). Conclusions Given its design, our study may have underestimated the cardiovascular benefits of physical activity. Nonetheless, our results suggest that moderate-intense exercise during young adulthood may have limited beneficial effects on cardiovascular disease in old age, except in specific high-risk populations (diabetic patients). More evident benefits are probably associated with regular physical activity throughout life

Complexity in hospital internal medicine departments: What are we talking about?

Internal medicine (IM) patients are mostly elderly, with multiple complex co-morbidities, usually chronic. The complexity of these patients involves the intricate entanglement of two or more systems (e.g. body and disease, family-socio-economic and environmental status, coordination of care and therapies) and this requires comprehensive, multi-dimensional assessment (MDA). Despite attempts to improve management of chronic conditions, and the availability of several MDA tools, defining the complex patient is still problematic. The complex profile of our patients can only be described through the best assessment tools designed to identify their characteristics. In order to do this, the Federation of Associations of Hospital Doctors on Internal Medicine FADOI has created its own vision of IM. This involves understanding the different needs of the patient, and analyzing diseases clusters and the possible relationships between them. By exploring the real complexity of our patients and selecting their real needs, we can exercise holistic, anthropological and appropriate choices for their treatment and care. A simpler assessment approach must be adopted for our complex patients, and alternative tools should be used to improve clinical evaluation and prognostic stratification in a hierarchical selection of priorities. Further investigation of complex patients admitted to IM wards is needed

efficacia e sicurezza dei nuovi farmaci anticoagulanti orali rispetto al warfarin nella profilassi cardioembolica del paziente con fibrillazione atriale non valvolare piu luci che ombre

Summary Introduction The prophylaxis of thromboembolic events represents a key point in the modern management of patients with non valvular atrial fibrillation (AF), both paroxysmal and persistent/permanent. Up to now, vitamin K antagonist (VKA) drugs are the first choice in thromboembolic prophylaxis. Their treatment limitations have lead to development and clinical experimental use of new molecules aimed to overcome their limits. The new oral anticoagulants, such as dabigatran, a direct inhibitor of thrombin or rivaroxaban and apixaban, direct inhibitors of activated factor X, have been compared to warfarin in randomized clinical phase three trials (RCTs) for thromboembolic prevention in patients with non valvular AF with the aim to demonstrate their non inferiority when compared to warfarin. The results of these trials have been recently published. In this article the authors review the results of efficacy and safety of these three more recently published large RCTs. Conclusions All RCTs, RE-LY for dabigatran, ROCKET-AF for rivaroxaban and ARISTOTLE for apixaban met the study end-points and demonstrated a good safety profile of each new oral anticoagulant, so promising a new era for thromboembolic prevention therapy in AF

Medicina interna, paziente complesso, evidence based medicine e le non evidenze

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Internal Medicine wards overcrowding and clinical risk management: structural or systemic interventions needed?

Not availabl

Hypertriglyceridemia, a common dyslipidemia of complex definition

Background: Hypertriglyceridemia is a common biochemical finding. Depending on the triglyceride levels it can be associated with increased risk of acute pancreatitis and of cardiovascular disease. The most severe forms have a genetic basis. Clinical case: We report a case of a 60-year-old woman with very high triglycerides (800- 3,000 mg/dL) and normal cholesterol levels. The patient is a non smoker, on hypolipemic diet, non alcoholic consumer, and on regular physical exercise. Her blood pressure is normal, BMI is 20, waist circumference is 78 cm. Thyroid, renal and hepatic function are normal. She has never had acute pancreatitis or cardiovascular disease. Discussion: The diagnostic and therapeutic management of this case is discussed. Causes of primary (genetic) and secondary hypertriglyceridemia are also reviewed, together with clinical features and management on every day practice. We focused on severe hypertriglyceridemia