All-cause mortality in elderly adults diagnosed with cardiorenal syndrome after an internal medicine unit admission.

Background: Impaired kidney function is associated with all-cause and cardiovascular mortality even in oldest patients. The cardio-renal syndrome (CRS) is a heart and kidneys disorder in which the acute or chronic dysfunction of one can induce an acute or chronic dysfunction of the other, and is divided into 5 types. We aimed to evaluate the prognosis of a cohort of previously studied patients with different types of CRS after adequate follow-up. Subjects and methods: Population consisted of 438 Caucasians, selected among 2998 subjects consecutively discharged from our ward (June 2007-December 2009), and diagnosed with type 1 to 5 CRS according to Acute Dialysis Quality Initiative criteria. All-cause mortality was the final end-point, and mean follow-up was 2.4 ± 1.4 years. Results: Data for survival analysis were obtained in 374 patients (51.9% males). Mean age was 79.5±7.8 years, mean serum creatinine was 2.0±1.1 mg/dl, and eGFR was 31±12 ml/min/1.73 m2. One hundred forty-four deaths (38.7%) were recorded. Regression analysis showed that all-cause mortality was independently associated with age (HR=1.049, 95% CI 1.023-1.075, p<0.001), and eGFR (HR=0.972, 95% CI 0.957-0.988, p<0.001). Conclusions: In older persons, renal function cannot appropriately be measured by serum creatinine, and estimated GFR is strongly suggested. Studies on long-term mortality in older persons with CRS are limited. Even if different types of CRS appear to exhibit different survival curves, at least in our groups of elderly patients suffering from both heart and renal dysfunction, the main risk factors for all-cause mortality remain age and severity of renal failure

Circadian rhythms and medical diseases: Does it matter when drugs are taken?

BACKGROUND: Chronobiology is devoted to the study of biological rhythms. It is possible that a given medication may be therapeutic and safe when administered at some time, but subtherapeutic or poorly tolerated at another. METHODS: We focused on some classes of drugs, widely used by the internists, performing a PubMed search with the single drugs associated with the MeSH terms "Chronotherapy", "Circadian rhythm", and "Chronobiology, phenomena". Among the studies found, we considered only those provided with discrete numerosity or clearly stated methodological characteristics. RESULTS: The results of available studies were given, along with a series of short take-home messages at the end of each mini-chapter devoted to: antihypertensives, statins, anticoagulants, analgesics, drugs for acid-related disorders, and anti-asthmatic drugs. In particular, evidence of morning vs. evening administration, when applicable, was given for each medication. CONCLUSIONS: Adequate evidence seems to support that at least ACE-inhibitors or angiotensin receptor blockers, simvastatin, corticosteroids (slow-release formulation) for arthritic patients, and ranitidine should preferably be administered in the evening. Morning dosing could be better for proton pump inhibitors, whereas time of administration is not crucial for asthma inhalation drugs. Studies are available for other drugs, but not so strong enough to draw definite conclusions. For now, we need prospective intervention trials specifically designed to investigate the long-term effects of a temporal approach to medical therapy. However, since switching to morning-evening administration or vice versa is simple and inexpensive, in some cases it could be considered, remembering that, in any case, adherence remains the crucial point

Cadute e funzione renale: un'associazione pericolosa.

Le cadute rappresentano un serio problema di salute pubblica, e il decadimento della funzione renale è spesso presente nella popolazione anziana. L'articolo ripercorre i fattori di rischio principali, l'identificazione e la gestione del rischio cadute, e tratta l'argomento delle cadute nei pazienti con disfunzione renale e/o in dialisi

Pain prevalence and management in an internal medicine setting in Italy.

Background. Since data on pain evaluation and management in patients admitted to internal medicine wards (IMWs) are limited, we aimed to evaluate these aspects in a cohort of internistic patients. Methods. We considered all patients consecutively admitted from June to December 2011 to our unit. Age, gender, and length-of-hospital-stay (LOS) were recorded. Comorbidities were arbitrarily defined, and pain severity was evaluated by Numeric Rating Scale (NRS) on admission and discharge. Results. The final sample consisted of 526 patients (mean age 74 ± 14 years; 308 women). Significant pain (NRS ≥ 3) was detected in 63% of cases, and severe (NRS ≥ 7) in 7.6%. Pain was successfully treated, and NRS decreased from 4.65 ± 2.05 to 0.89 ± 1.3 (P < 0.001). Compared with subjects with NRS < 3, those with significant pain were older (75.5 ± 13.9 versus 72.9 ± 14.5 years, P = 0.038), and had a higher LOS (7.9 ± 6.1 versus 7.3 ± 6.8, P = 0.048). Significant pain was independently associated with age (OR 0.984, P = 0.018), cancer (OR 3.347, P < 0.001), musculoskeletal disease (OR 3.054, P < 0.0001), biliary disease (OR 3.100, P < 0.01), and bowel disease (OR 3.100, P < 0.003). Conclusion. In an internal medicine setting, multiple diseases represent significant cause of pain. Prompt pain evaluation and management should be performed as soon as possible, in order to avoid patients' suffering and reduce the need of hospital stay

Renal dysfunction and all-cause mortality in cardio-renal syndrome: calculation of glomerular filtration rate is crucial, independent of the equation.

Background: Impaired renal function has negative impact on cardiovascular outcome, and cardiorenal syndrome (CRS), with its five classes, encompasses the complex heart-kidney relationship. Although glomerular filtration rate (GFR) is considered the best overall index of kidney function, the topic is debated, since different formulae may provide different values in different groups of patients. Methods: We retrospectively investigated 438 adult Caucasian subjects admitted to an internal medicine unit. Mean age was 80±8 years, 50.6% males. CRS type 1 to 5 was diagnosed in 48.2%, 21.9%, 20.1%, 6.6%, and 3.2% of cases, respectively. Kidney function was evaluated by estimated GFR (eGFR) using the following equations: (a) Modification of Diet in Renal Disease MDRD186 (GFRMDRD186); (b) MDRD175 (GFRMDRD175); (c) Mayo Clinic Quadratic (GFRMAYO); (d) Chronic Kidney Disease Epidemiology Collaboration (GFR CDK-EPI); (e) Cockcroft-Gault (GFRC-G); and (f) Schaeffner’s equation (GFRBIS1) [3-4]. Duration of follow-up was 2.4±1.4 years, and the primary endpoint was all-cause mortality. Results: As for estimation of renal function in the different age subgroups, significant differences were given only by GFRC-G and GFRBIS1 formulae, with lower values in subjects aged >80 years and higher in those aged 60 years. Out of the 438 considered subjects, 144 deaths (38.7%) were recorded after a follow-up of 2.4±1.4 years. Deceased patients had a higher mean age compared with survivors (82±8 vs. 78±9, p<0.001), and showed lower GFR values as well (GFRMDRD186 30.7±12.3 vs. 36.4±12.7 ml/min/1.73 m2; GFRMDRD175 28.8±11.6 vs. 34.2±12; GFRMAYO 31.7±15.3 vs. 39±16.5; GFRCDK-EPI 27.4±11.4 vs. 33.2±12.3; GFRC-G 26.8±11.8 vs. 35±15.2; GFRBIS1 28.7±9.4 vs. 34.4±10.9, respectively, p<0.001 for all). ROC analysis showed that the area under the curve was similar using the different equations. Age (HR 1.047 [1.022-1.072]) and GFR were predictors of all-cause mortality, but for GFR the HR values calculated by the different equations were quite similar: GFRMDRD1860.973 [0.960-0.986]; GFRMDRD1750.971 [0.957-0.986]; GFRMAYO0.970 [0.956-0.985]; GFRCDK-EPI 0.971 [0.957-0.985]; GFRC-G0.979 [0.968-0.990]; GFRBIS1 0.963 [0.946-0.981] (p<0.001 for all). Conclusions: GFR calculation (with any equation) should always be performed in subjects admitted to internal medicine wards, since its close relationship with mortality

Invasive procedure for intractable epistaxis in an old comorbid woman: a case report.

Epistaxis is a condition mainly self-limiting or easily treated conservatively, although in rare cases it could become life-threatening. We discuss the case of a 73 year comorbid old woman with severe and recurrent epistaxis treated with superselective catheterism and embolization of the internal maxillary artery. The possible underlying causes, including drug related issues, are discussed

The estimation of glomerular filtration rate in type 2 diabetic patients may depend on the equation used,

Background: The aim of this study was to compare the estimation of glomerular filtration rate (GFR) in type 2 diabetes mellitus (DM) outpatients. Methods: The study included 1686 subjects, aged 68±10 years. GFR was evaluated with five different equations: GFRMDRD186, GFRMDRD175, GFRCKD-EPI, GFRMAYO, GFRCG. Results: GFR was lower than 60 ml min-1 kg-1 in 456 patients (27%) by GFRMDRD186, in 531 (31.5%) by GFRMDRD175, in 504 (30%) by GFRCKD-EPI, in 433 (26%) by GFRC-G, and in 255 (15%) by GFRMAYO. The mean differences in measuring GFR with the different formulae ranged from 1.03±6.20 to -14.5±11.9 ml min-1 1.73 m2-1. Conclusions: The evaluation of GFR with different formulae in type 2 DM patients may identify different chronic kidney disease (CKD) stages. Physicians could take advantage by the knowledge of the formula used for evaluation of renal function, for a better interpretation of values and a more appropriate use in the everyday clinical practice

Time of occurrence of in-hospital falls: a systematic minireview

Background: Falls represent growing problem among older people worldwide. According to US emergency department data, the estimated number of fall-related hospitalizations in older adults increased 50%. At today, we do know much on where, how, and why an older hospital inpatient falls. However, when falls occur is not often reported. We aimed to explore the recent literature on in-hospital falls, to evaluate how frequently the epidemiological studies reported time of events. Methods and Results: Relevant papers published from 2009 to 2011 were searched across the PubMed database. The following Medical Subject Heading (MeSH) terms were used: "Aged”, “Aged, 80 and over", and "Accidental Falls". Systematic reviews, meta-analyses, controlled trials, cohort studies, case-control studies and transversal studies were considered for inclusion. Out of 320 references, we considered 15 studies (3314 cases). Settings were included psychiatric or psychogeriatric, rehabilitation, either stroke, orthopaedic, trauma, geriatric, medicine, nephrology and hemodialysis, intensive care unit, long term care, palliative care and hospice. The lowest number of cases per study was 17 and highest 657. Eight studies (53%, 1749 cases) contained report on time of falls, although the method of time reporting was not homogenous. Discussion: Falls are among the most common and severe adverse events for hospitalized older patients, and more often fall events occur during the night. Daytime or nighttime preferred peaks of events may underly different causes. The majority of diurnal/morning falls occur in patients' room and bathroom/toilet, in relation with daily common activities, i.e., moving/transferring and taking shower/toileting. Bathroom, however, represents a risk also during night hours, due to the use of antihypertensive medications (in particular thiazide diuretics) and sedatives. It is possible that different risk windows may be present in a same setting, and prevention strategies need a deep knowledge of all the potential risk factors. Adding precise indication of time of falls to the minimum data set, could provide useful additional information and help prevention efforts

Sudden death in competitive athletes: does a circadian variation in occurrence exist?

Sudden death (SD) is an unexpected death, occurring within one hour from onset of symptoms, in ordinary conditions of life, and in presence of witnesses. The majority of SD are sudden cardiac deaths (SCD), since coronary heart disease is the most frequent cause, but pulmonary embolism, rupture of aortic aneurysms, and stroke are also included. Many studies has shown that the occurrence of acute cardiovascular events, including SCD, is not evenly distributed in time, but respects circadian patterns. In the lack of available data, we aimed to investigate whether a circadian pattern of SD in athletes exists, searching across multiple public, non-specialized web databases, cases of SD occurred in competitive athletes during their competition, from the year 2000. Different databases were independently cross-searched from two authors with specific different competence, a medical doctor and a journalist with sport competence. The collected cases were included in two groups for analysis: (A) cases with precise (30 minutes) time of SD, and (B) cases with probable (within a 6-hour interval: night: 00:00–05:59 AM; morning: 06:00–11:59 AM; afternoon 12:00–05:59 PM; and evening: 06:00–11:59 PM). The group (A) was analyzed applying partial Fourier series, by means of a chronobiologic software that selects the harmonic(s) best explaining the variance of the data. Thirty-seven athletes with SD were included in the group (A), and a total of 63 were included in the group (B) (age 18-37 years, mean 26.64.8). As for group (A), chronobiologic analysis yielded a significant circadian variation, characterized by a bimodal frequency peak. The main circadian peak was registered at 04:58 PM, and a smaller accessory peak was found at 08:29 AM/PM. Overall, the circadian rhythm (peak at 07:00 PM, trough at 2:56 AM) was highly significant (p<0.001). For group (B), chi-square test showed a statistically significant difference (p=0.024), with highest frequency of cases in the evening (n= 25, 39.7%) and lowest during nighttime (n= 7, 11.1%). This preliminary study shows that also in athletes SD exhibits a circadian pattern of onset, characterized by two frequency peaks. Although with the limitations of small size sample and the possible conditioning effect of competition time schedule, it is interesting that the circadian pattern of SD onset in athletes resembles that of common people, with evening and morning peaks. It is possible that, in addition to vigorous exercise during competition, temporally related physiologic changes determining electrical myocardial vulnerability, may also play a triggering role

Color-coding triage and allergic reactions in an Italian ED.

Emergency Department (ED) crowding is an international public health problem. Moreover, it is associated with prolonged stay and increased risk of adverse drug events (ADEs). Adverse drug reactions (ADRs) account for 3-6% of all hospital admissions, and occur in 10-15% of hospitalized patiens. An ADE should be differentiated from ADR, the latter including harm related to medication errors and drug/food medications. Only few studies have focused prevalence and incidence of drug allergy in hospital-based populations. We were interested to drug allergy, defined as an immunologically-mediated drug hypersensitivity reaction, characterized by either IgE or non-IgE mediated mechanism. In particular, we aimed to focus on drug allergies referring to the ED and requiring hospitalization, to evaluate type and prevalence, and relationships between initial triage assessment and hospital lenght of stay (LOS). This study was conducted, between January and December 2009, at the Emergency Department of St. Anna Hospital of Ferrara, a 863-bed tertiary care teaching hospital, with a yearly patient flow in the ED of approximately 76 000. Allergic reactions were defined as erythema, exanthema, urticaria and angioedema. Age, sex, triage assessment colour code, history, body temperature, drugs involved, LOS, and therapy were evaluated. Descriptive analysis and chi-square test were performed, and triage assessment represented the grouping variable. Multivariate analysis was not performed due to the limited sample size. Out of 75 966 patients arrived to the ED in the year 2009, 2842 (3.7%) were admitted to the ED ward. Of these, 58 (2%) presented a drug-related allergic reaction. Mean age was 58±5 years (range 18-88), 62% were female. Comorbilities included metabolic, heart, bone, infectious, gastric, vascular, neurologic, renal, and bowel diseases; 14% had a history of cancer. Allergic reactions were due to several kind of medications: anti-infective, anti-inflammatory, endocrine, cardiovascular, antineoplastic, and other. Triage assessment showed colour code green in 26% of cases, yellow in 55% and red in 19%. LOS was 6-12 hours in 19% of cases, between 12 hours and 3 days in 41%, and >3 days in 40%. Therapy at first evaluation included antihistaminics, steroids, non-steroidal-anti-inflammatory drugs, plasma expanders, and oxygen. Triage assessment colour code red was associated with history of heart disease, lung disease and vascular disease, whereas only allergic reactions defined as urticaria were related to the green code. The red code was significantly associated with longer LOS >3 days. Allergic reactions are very frequent among ED attenders: national data in the USA estimated incidence of ADRs as 2.4 visits x 1000 population. Of these, 33.5% were drug allergies, and 11.3% required hospitalization. Although triage represents a highly useful tool to prioritize patients’s care in EDs, very limited data relating triage assessment colour code for allergic reactions are available. The importance of a correct triage is important, since it has been shown that ED patients presenting with ADEs incurred great health services utilization and costs of hospital care. To the best of our knowledge, this is the first study evaluating the relationship between triage colour code, clinical features, and LOS in subjects with allergic reactions presenting to the ED. Patients’ age was younger compared with previous reports, and LOS exceeded 3 days in more than 40% of cases, with a good correspondence with the triage colour code assigned upon ED arrival. EDs could represent optimal settings for research, and support important translational knowledge