Beta-Blocker Use in Older Hospitalized Patients Affected by Heart Failure and Chronic Obstructive Pulmonary Disease: An Italian Survey From the REPOSI Register

Beta (β)-blockers (BB) are useful in reducing morbidity and mortality in patients with heart failure (HF) and concomitant chronic obstructive pulmonary disease (COPD). Nevertheless, the use of BBs could induce bronchoconstriction due to β2-blockade. For this reason, both the ESC and GOLD guidelines strongly suggest the use of selective β1-BB in patients with HF and COPD. However, low adherence to guidelines was observed in multiple clinical settings. The aim of the study was to investigate the BBs use in older patients affected by HF and COPD, recorded in the REPOSI register. Of 942 patients affected by HF, 47.1% were treated with BBs. The use of BBs was significantly lower in patients with HF and COPD than in patients affected by HF alone, both at admission and at discharge (admission, 36.9% vs. 51.3%; discharge, 38.0% vs. 51.7%). In addition, no further BB users were found at discharge. The probability to being treated with a BB was significantly lower in patients with HF also affected by COPD (adj. OR, 95% CI: 0.50, 0.37-0.67), while the diagnosis of COPD was not associated with the choice of selective β1-BB (adj. OR, 95% CI: 1.33, 0.76-2.34). Despite clear recommendations by clinical guidelines, a significant underuse of BBs was also observed after hospital discharge. In COPD affected patients, physicians unreasonably reject BBs use, rather than choosing a β1-BB. The expected improvement of the BB prescriptions after hospitalization was not observed. A multidisciplinary approach among hospital physicians, general practitioners, and pharmacologists should be carried out for better drug management and adherence to guideline recommendations

Antidiabetic Drug Prescription Pattern in Hospitalized Older Patients with Diabetes

Objective: To describe the prescription pattern of antidiabetic and cardiovascular drugs in a cohort of hospitalized older patients with diabetes. Methods: Patients with diabetes aged 65 years or older hospitalized in internal medicine and/or geriatric wards throughout Italy and enrolled in the REPOSI (REgistro POliterapuie SIMI—Società Italiana di Medicina Interna) registry from 2010 to 2019 and discharged alive were included. Results: Among 1703 patients with diabetes, 1433 (84.2%) were on treatment with at least one antidiabetic drug at hospital admission, mainly prescribed as monotherapy with insulin (28.3%) or metformin (19.2%). The proportion of treated patients decreased at discharge (N = 1309, 76.9%), with a significant reduction over time. Among those prescribed, the proportion of those with insulin alone increased over time (p = 0.0066), while the proportion of those prescribed sulfonylureas decreased (p < 0.0001). Among patients receiving antidiabetic therapy at discharge, 1063 (81.2%) were also prescribed cardiovascular drugs, mainly with an antihypertensive drug alone or in combination (N = 777, 73.1%). Conclusion: The management of older patients with diabetes in a hospital setting is often sub-optimal, as shown by the increasing trend in insulin at discharge, even if an overall improvement has been highlighted by the prevalent decrease in sulfonylureas prescription

The “Diabetes Comorbidome”: A Different Way for Health Professionals to Approach the Comorbidity Burden of Diabetes

(1) Background: The disease burden related to diabetes is increasing greatly, particularly in older subjects. A more comprehensive approach towards the assessment and management of diabetes’ comorbidities is necessary. The aim of this study was to implement our previous data identifying and representing the prevalence of the comorbidities, their association with mortality, and the strength of their relationship in hospitalized elderly patients with diabetes, developing, at the same time, a new graphic representation model of the comorbidome called “Diabetes Comorbidome”. (2) Methods: Data were collected from the RePoSi register. Comorbidities, socio-demographic data, severity and comorbidity indexes (Cumulative Illness rating Scale CIRS-SI and CIRS-CI), and functional status (Barthel Index), were recorded. Mortality rates were assessed in hospital and 3 and 12 months after discharge. (3) Results: Of the 4714 hospitalized elderly patients, 1378 had diabetes. The comorbidities distribution showed that arterial hypertension (57.1%), ischemic heart disease (31.4%), chronic renal failure (28.8%), atrial fibrillation (25.6%), and COPD (22.7%), were the more frequent in subjects with diabetes. The graphic comorbidome showed that the strongest predictors of death at in hospital and at the 3-month follow-up were dementia and cancer. At the 1-year follow-up, cancer was the first comorbidity independently associated with mortality. (4) Conclusions: The “Diabetes Comorbidome” represents the perfect instrument for determining the prevalence of comorbidities and the strength of their relationship with risk of death, as well as the need for an effective treatment for improving clinical outcomes

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

METABOLIC FACTORS IN THE PATHOGENESIS OF CHRONIC HEPATITIS C, WITH PARTICULAR REFERENCE TO HEPCIDIN

L'epatite cronica da virus C \ue8 una delle maggiori cause di patologia epatica; la sua storia naturale comporta la progressione della fibrosi epatica fino alla cirrosi e l'eventuale sviluppo di epatocarcinoma. In questa tesi abbiamo voluto analizzare l'influenza di alcuni aspetti metabolici che associati all'epatite cronica da virus possono accelerare la progressione del danno epatico e ridurre la risposta alla terapia antivirale: la resistenza insulinica (IR) e il sovraccarico marziale. In relazione al primo aspetto vi sono evidenze in letteratura di una maggior prevalenza di diabete tipo 2 nei pazienti affetti da HCV, inoltre HCV pu\uf2 favorire lo sviluppo di IR, bench\ue8 il meccanismo non sia chiaro completamente. La presenza di IR riduce la probabilit\ue0 di risposta alla terapia antivirale. Abbiamo valutato la presenza di IR misurata mediante HOMA-IR in una coorte di 412 pazienti affetti da epatite cronica HCV correlata trattati con peginterferone e ribavirina. IR \ue8 risultata essere un predittore indipendente di risposta virologica rapida; quest'ultima a sua volta \ue8 il pi\uf9 importante predittore di risposta virologica sostenuta. Pazienti affetti da epatite cronica HCV correlata presentano frequentemente un certo grado di sovraccarico marziale, la cui presenza pu\uf2 accelerare la progressione della fibrosi in cirrosi e ridurre la probabilit\ue0 di risposta al trattamento antivirale. Recentemente l'ormone epatico epcidina \ue8 stato individuato come un elemento chiave nella regolazione dell'omeostasi marziale. La riduzione dei livelli ematici di epcidina porebbe rivestire un ruolo importante nel determinare il sovraccarico marziale nei pazienti affetti da epatite da HCV. Nel nostro studio \ue8 stata valutata una coorte di 81 pazienti affetti da epatite HCV, mai precedentemente trattati con terapia antivirale, e di 57 controlli sani. L'epcidina sierica \ue8 stata misurata con metodica ELISA validata. I risultati hanno dimostrato una significativa riduzione dei livelli di epcidina sierica nei pazienti rispetto ai controlli. L'epcidina correlava con i livelli di ferrtitina e con il total iron score istologico. Dopo stratificazione dei pazienti in quartili di ferritinemia si osservava come i livelli di epcidina fossero significativamente inferiori nei pazienti rispetto ai controlli per ogni quartile corrispondente. Tali risultati mostrano come bench\ue8 la regolazione dell'epcidina da parte dei depositi di ferro sia mantenuta nei pazienti con epatite C, l'effetto soppressivo di HCV gioca probabilmente un ruolo importante nel determinare il sovraccarico marziale in questa condizione.Chronic Hepatitis C is a major cause of liver disease worldwide; this condition may progress to severe liver disease with the developement of cirrhosis and eventually of hepatocellular carcinoma. The aim of this thesis was to evaluate some metabolic factors that may influence the progression of disease as well as the responsiveness to treatment: insulin resistance and iron overload. Epidemiological data have documented an increased prevalence of type 2 diabetes in patints with chronic HCV infection, and there are evidences that HCV may promote insulin resistance with a mechanism that is still unclear. Basal IR is also associated with a reduced responsiveness to antiviral treatment. In our study we evaluated a cohort of 412 CHC patients treated with peginterferon and ribavirin; IR was determined by HOMA-IR. The results showed that Insulin resitance is a major independent predictor of rapid virologic response (RVR). RVR is the best predictor of sustained virologic response. Patients with chronic hepatitis C (CHC) often have increased liver iron, condition associated with reduced responsiveness to antiviral therapy and more rapid progression to cirrhosis. The epatic hormone hepcidin is the major regulator of iron metabolism. Decreased levels of this hormone are a possible pathophysiological mechanism of iron overload in CHC but studies in humans have been hampered by the the lack of reliable quantitative assay. We measured with a recently validated immunoassay serum hepcidin levels in a population of 81 CHC patients and 57 controls with rigorous definition of normal iron status. S-hepcidin was significantly lower in CHC patients then in controls (p<0.001); in CHC patients hepcidin correlated with ferritin and hostological total iron score but not with IL-6. After stratification for ferritin quartiles hepcidin increased significantly across quartiles in both patients and controls, however in patients s-hepcidin levels were significantly lower then controls for each corresponding quartile.These results indicate that though hepcidin regulation by iron stores is mantained in CHC patients, the suppression of this hormone by HCV is likely an important factor in liver iron accumilation in this condition

Natural history of chronic HBV infection: special emphasis on the prognostic implications of the inactive carrier state versus chronic hepatitis

The evaluation of the natural history of chronic hepatitis B virus (HBV) infection requires the precise definition of the various clinical conditions that can be encountered (i.e. inactive carrier state or subject with liver disease activity). This can be achieved by repeat monitoring of ALT, serum HBV-DNA levels (over a period of at least 1 year, according to international guidelines) and/or evaluation of HBsAg titre. Liver biopsy may offer additional information although it is not mandatory. Overall, the natural history of the true inactive carrier is benign: reactivation of hepatitis, especially in Western countries, is rare and is usually due to co-factors (like alcohol or drugs); spontaneous HBsAg loss is frequent (around 1% per year) and HCC development rare. On the other hand, in patients with chronic hepatitis B or cirrhosis, the risk of reactivation, of HCC development and of liver-related mortality is much higher, especially in Eastern countries, and should therefore lead to antiviral therapy

Long-term outcome of chronic hepatitis B in caucasian patients: mortality after 25 years

OBJECTIVE: To assess risk factors for liver-related death, we re-evaluated, after a median follow-up of 25 years, a cohort of 70 Caucasian patients with hepatitis B e antigen (HBeAg) positive chronic hepatitis (CH) at presentation. METHODS: Follow-up studies included clinical and ultrasound examinations, biochemical and virological tests, and cause of death. RESULTS: Sixty-one (87%) patients underwent spontaneous HBeAg seroconversion. During a median period of 22.8 years after HBeAg seroclearance, 40 (66%) patients became inactive carriers, whereas the remaining 21 (34%) showed alanine aminotransferase elevation: one (1%) had HBeAg reversion, nine (15%) detectable serum HBV DNA but were negative for HBeAg, eight (13%) concurrent virus(es) infection and three (5%) concurrent non-alcoholic fatty liver disease. Liver-related death occurred in 11 (15.7%) patients, caused by hepatocellular carcinoma in five and liver failure in six. The 25-year survival probability was 40% in patients persistently HBeAg positive, 50% in patients with HBeAg negative CH or HBeAg reversion and 95% in inactive carriers. Older age, male sex, cirrhosis at entry and absence of sustained remission predicted liver-related death inhttps://www.univr.u-gov.it/univr/#dependently. The adjusted hazard ratios (95% CI) for liver related death were 33 (3.01-363) for persistently HBeAg positive patients and 38.73 (4.65-322) for those with HBeAg negative CH or HBeAg reversion relative to inactive carriers. CONCLUSION: Most patients with HBeAg seroconversion became inactive carriers with very good prognosis. The risk of liver-related mortality in Caucasian adults with CH is strongly related with sustained disease activity and ongoing high level of HBV replication independently of HBeAg status