Blood ammonia levels in liver cirrhosis: a clue for the presence of portosystemic collateral veins

<p>Abstract</p> <p>Background</p> <p>Portal hypertension leads to the formation of portosystemic collateral veins in liver cirrhosis. The resulting shunting is responsible for the development of portosystemic encephalopathy. Although ammonia plays a certain role in determining portosystemic encephalopathy, the venous ammonia level has not been found to correlate with the presence or severity of this entity. So, it has become partially obsolete. Realizing the need for non-invasive markers mirroring the presence of esophageal varices in order to reduce the number of endoscopy screening, we came back to determine whether there was a correlation between blood ammonia concentrations and the detection of portosystemic collateral veins, also evaluating splenomegaly, hypersplenism (thrombocytopenia) and the severity of liver cirrhosis.</p> <p>Methods</p> <p>One hundred and fifty three consecutive patients with hepatic cirrhosis of various etiologies were recruited to participate in endoscopic and ultrasonography screening for the presence of portosystemic collaterals mostly esophageal varices, but also portal hypertensive gastropathy and large spontaneous shunts.</p> <p>Results</p> <p>Based on Child-Pugh classification, the median level of blood ammonia was 45 mcM/L in 64 patients belonging to class A, 66 mcM/L in 66 patients of class B and 108 mcM/L in 23 patients of class C respectively (p < 0.001).</p> <p>The grade of esophageal varices was concordant with venous ammonia levels (rho 0.43, p < 0.001). The best area under the curve was given by ammonia concentrations, i, e., 0.78, when comparing areas of ammonia levels, platelet count and spleen longitudinal diameter at ultrasonography. Ammonia levels predicted hepatic decompensation and ascites presence (Odds Ratio 1.018, p < 0.001).</p> <p>Conclusion</p> <p>Identifying cirrhotic patients with high blood ammonia concentrations could be clinically useful, as high levels would lead to suspicion of being in presence of collaterals, in clinical practice of esophageal varices, and pinpoint those patients requiring closer follow-up and endoscopic screening.</p

Hearts and Minds: Mental Health Support for schools

Hearts and Minds is a collection of generic mental health case studies written by students at the University of Southern Queensland. The mental health concerns focus on those typically experienced within schools and include Anxiety, Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder, Depression, Post-Traumatic Stress Disorder and Suicidal Ideation

Untargeted and Targeted Metabolomic Profiling of Preterm Newborns with EarlyOnset Sepsis: A Case-Control Study

Sepsis is a major concern in neonatology, but there are no reliable biomarkers for its early diagnosis. The aim of the study was to compare the metabolic profiles of plasma and urine samples collected at birth from preterm neonates with and without earlyonset sepsis (EOS) to identify metabolic perturbations that might orient the search for new early biomarkers. All preterm newborns admitted to the neonatal intensive care unit were eligible for this proof-of-concept, prospective case-control study. Infants were enrolled as “cases” if they developed EOS, and as “controls”if they did not. Plasma samples collected at birth and urine samples collected within 24 h of birth underwent untargeted and targeted metabolomic analysis using mass spectrometry coupled with ultra-performance liquid chromatography. Univariate and multivariate statistical analyses were applied. Of 123 eligible newborns, 15 developed EOS. These 15 newborns matched controls for gestational age and weight. Metabolomic analysis revealed evident clustering of the cases versus controls, with the glutathione and tryptophan metabolic pathways markedly disrupted in the former. In conclusion, neonates with EOS had a metabolic profile at birth that clearly distinguished them from those without sepsis, and metabolites of glutathione and tryptophan pathways are promising as new biomarkers of neonatal sepsis

Early Treatments of Fragile Children with COVID-19—Results of CLEVER (Children COVID Early Treatment), a Retrospective, Observational Study

(1) Background: SARS-CoV-2 infection is notably mild in children, though comorbidities may increase the risk of hospitalization and may represent a risk for increased disease severity. There is an urgent need for targeted therapies with an acceptable efficacy and safety profile. To date, most of the medicines for COVID-19-specific treatment are prescribed off-label for children due to a lack of clinical trials and consequent evidence in this population. (2) Methods: This was a retrospective, observational study investigating the safety of treatments for the prevention of severe COVID-19 in fragile pediatric patients who received monoclonal antibodies and antivirals for mild-to-moderate symptoms between December 2021 and July 2022. (3) Results: Thirty-two patients were included. Monoclonal antibodies were prescribed to 62%, intravenous antivirals to 22%, and oral antivirals to 16% of children. Sotrovimab was the most frequently prescribed drug among monoclonal antibodies and overall (59%). The second most prescribed drug was remdesivir (22%). No severe adverse drug reaction was reported. There was no progression to severe disease and no death cases due to COVID-19 or drug administration. At drug-type stratification, resolution of symptoms and swab positivity time showed no difference between the two groups at 7 and 28 days. Off-label prescriptions were 84% overall, and in similar proportions between the two groups. (4) Conclusions: in this small sample, antivirals seemed safe and showed no differences in efficacy as compared to MAbs for the early treatment of COVID-19 in fragile children, thus representing a valuable choice, even when administered off-label

Appropriateness of antiplatelet therapy for primary and secondary cardio- and cerebrovascular prevention in acutely hospitalized older people

Aims: Antiplatelet therapy is recommended for the secondary prevention of cardio- and cerebrovascular disease, but for primary prevention it is advised only in patients at very high risk. With this background, this study aims to assess the appropriateness of antiplatelet therapy in acutely hospitalized older people according to their risk profile. Methods: Data were obtained from the REPOSI register held in Italian and Spanish internal medicine and geriatric wards in 2012 and 2014. Hospitalized patients aged ≥65 assessable at discharge were selected. Appropriateness of the antiplatelet therapy was evaluated according to their primary or secondary cardiovascular prevention profiles. Results: Of 2535 enrolled patients, 2199 were assessable at discharge. Overall 959 (43.6%, 95% CI 41.5–45.7) were prescribed an antiplatelet drug, aspirin being the most frequently chosen. Among patients prescribed for primary prevention, just over half were inappropriately prescribed (52.1%), being mainly overprescribed (155/209 patients, 74.2%). On the other hand, there was also a high rate of inappropriate underprescription in the context of secondary prevention (222/726 patients, 30.6%, 95% CI 27.3–34.0%). Conclusions: This study carried out in acutely hospitalized older people shows a high degree of inappropriate prescription among patients prescribed with antiplatelets for primary prevention, mainly due to overprescription. Further, a large proportion of patients who had had overt cardio- or cerebrovascular disease were underprescribed, in spite of the established benefits of antiplatelet drugs in the context of secondary prevention

Hospital Care of Older Patients With COPD: Adherence to International Guidelines for Use of Inhaled Bronchodilators and Corticosteroids

313noObjectives: We aimed to analyze the prevalence and impact of COPD in older patients hospitalized in internal medicine or geriatric wards, and to investigate adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, associated clinical factors, and outcomes. Design: Data were obtained from REgistro POliterapie SIMI (REPOSI), a prospective multicenter observational registry that enrolls inpatients aged 65 years. Setting and Participants: Older hospitalized patients enrolled from 2008 to 2016 with a diagnosis of COPD. Measures: We evaluated adherence to the 2018 GOLD guidelines at admission and discharge, by examining the prescription of inhaled bronchodilators and corticosteroids in COPD patients. We also evaluated the occurrence of outcomes and its association with COPD and guideline adherence. Results: At hospital admission, COPD was diagnosed in 1302 (21.5%) of 6046 registered patients. COPD patients were older, with more impaired clinical and functional status and multiple comorbidities. Overall, 34.3% of COPD patients at admission and 35.6% at discharge were adherent to the GOLD guidelines. Polypharmacy (5 drugs) at admission [odds ratio (OR): 3.28, 95% confidence interval (CI): 2.24-4.81], a history of acute COPD exacerbation (OR: 2.65, 95% CI: 1.44-4.88) at admission, smoking habit (OR: 1.45, 95% CI: 1.08-1.94), and polypharmacy at discharge (OR: 6.76, 95% CI: 4.15-11.0) were associated with adherence to guidelines. COPD was independently associated with the risk of cardiovascular and respiratory death and rehospitalization occurrence compared to patients without COPD during follow-up. Adherence to guidelines was inversely associated with the occurrence of death from all causes (OR: 0.12, 95% CI: 0.02-0.90). Conclusions/Implications: COPD was common in older patients acutely hospitalized, showing an impaired functional and clinical status. Prescriptions for older COPD patients were often not adherent to GOLD guidelines. Poor adherence to guidelines was associated with a worse clinical status. There is a need to improve adherence to guidelines in treating COPD patients, with the ultimate goal of reducing clinical events.reservedmixedProietti, Marco; Agosti, Pasquale; Lonati, Chiara; Corrao, Salvatore; Perticone, Francesco; Mannucci, Pier Mannuccio; Nobili, Alessandro; Harari, Sergio; Tettamanti, Mauro; Pasina, Luca; Franchi, Carlotta; Marengoni, Alessandra; Salerno, Francesco; Cesari, Matteo; Licata, Giuseppe; Violi, Francesco; Corazza, Gino Roberto; Cortesi, Laura; Ardoino, Ilaria; Prisco, Domenico; Silvestri, Elena; Cenci, Caterina; Emmi, Giacomo; Biolo, Gianni; Zanetti, Michela; Guadagni, Martina; Zaccari, Michele; Vanoli, Massimo; Grignani, Giulia; Pulixi, Edoardo Alessandro; Bernardi, Mauro; Bassi, Silvia Li; Santi, Luca; Zaccherini, Giacomo; Mannarino, Elmo; Lupattelli, Graziana; Bianconi, Vanessa; Paciullo, Francesco; Nuti, Ranuccio; Valenti, Roberto; Ruvio, Martina; Cappelli, Silvia; Palazzuoli, Alberto; Olivieri, Oliviero; Girelli, Domenico; Matteazzi, Thomas; Barbagallo, Mario; Dominguez, Ligia; Cocita, Floriana; Beneduce, Vincenza; Plances, Lidia; Zoli, Marco; Lazzari, Ilaria; Brunori, Mattia; Pasini, Franco Laghi; Capecchi, Pier Leopoldo; Palasciano, Giuseppe; Modeo, Maria Ester; Di Gennaro, Carla; Cappellini, Maria Domenica; Maira, Diletta; Di Stefano, Valeria; Fabio, Giovanna; Seghezzi, Sonia; Mancarella, Marta; Rossi, Paolo Dionigi; Damanti, Sarah; Clerici, Marta; Conti, Federica; Miceli, Emanuela; Lenti, Marco Vincenzo; Pisati, Martina; Dominioni, Costanza Caccia; Murialdo, Giovanni; Marra, Alessio; Cattaneo, Federico; Pontremoli, Roberto; Secchi, Maria Beatrice; Ghelfi, Davide; Anastasio, Luigi; Sofia, Lucia; Carbone, Maria; Cipollone, Francesco; Guagnano, Maria Teresa; Angelucci, Ermanno; Valeriani, Emanuele; Mancuso, Gerardo; Calipari, Daniela; Bartone, Mosè; Delitala, Giuseppe; Berria, Maria; Muscaritoli, Maurizio; Molfino, Alessio; Petrillo, Enrico; Zuccalà, Giuseppe; D'Aurizio, Gabriella; Romanelli, Giuseppe; Zucchelli, Alberto; Picardi, Antonio; Gentilucci, Umberto Vespasiani; Gallo, Paolo; Dell'Unto, Chiara; Annoni, Giorgio; Corsi, Maurizio; Bellelli, Giuseppe; Zazzetta, Sara; Mazzola, Paolo; Szabo, Hajnalka; Bonfanti, Alessandra; Arturi, Franco; Succurro, Elena; Rubino, Mariangela; Serra, Maria Grazia; Bleve, Maria Antonietta; Gasbarrone, Laura; Sajeva, Maria Rosaria; Brucato, Antonio; Ghidoni, Silvia; Fabris, Fabrizio; Bertozzi, Irene; Bogoni, Giulia; Rabuini, Maria Victoria; Cosi, Elisabetta; Manfredini, Roberto; Fabbian, Fabio; Boari, Benedetta; De Giorgi, Alfredo; Tiseo, Ruana; Paolisso, Giuseppe; Rizzo, Maria Rosaria; Borghi, Claudio; Strocchi, Enrico; De Sando, Valeria; Pareo, Ilenia; Sabbà, Carlo; Vella, Francesco Saverio; Suppressa, Patrizia; Schilardi, Andrea; Loparco, Francesca; Fenoglio, Luigi; Bracco, Christian; Giraudo, Alessia Valentina; Fargion, Silvia; Periti, Giulia; Porzio, Marianna; Tiraboschi, Slivia; Peyvandi, Flora; Rossio, Raffaella; Ferrari, Barbara; Colombo, Giulia; Monzani, Valter; Savojardo, Valeria; Folli, Christian; Ceriani, Giuliana; Pallini, Giada; Dallegri, Franco; Ottonello, Luciano; Liberale, Luca; Caserza, Lara; Salam, Kassem; Liberato, Nicola Lucio; Tognin, Tiziana; Bianchi, Giovanni Battista; Giaquinto, Sabrina; Purrello, Francesco; Di Pino, Antonino; Piro, Salvatore; Rozzini, Renzo; Falanga, Lina; Spazzini, Elena; Ferrandina, Camillo; Montrucchio, Giuseppe; Petitti, Paolo; Salmi, Raffaella; Gaudenzi, Piergiorgio; Perri, Ludovica; Landolfi, Raffaele; Montalto, Massimo; Mirijello, Antonio; Guasti, Luigina; Castiglioni, Luana; Maresca, Andrea; Squizzato, Alessandro; Molaro, Marta; Grossi, Alessandra; Bertolotti, Marco; Mussi, Chiara; Libbra, Maria Vittoria; Dondi, Giulia; Pellegrini, Elisa; Carulli, Lucia; Colangelo, Lidia; Falbo, Tania; Stanghellini, Vincenzo; De Giorgio, Roberto; Ruggeri, Eugenio; Vecchio, Sara del; Salvi, Andrea; Leonardi, Roberto; Damiani, Giampaolo; Gabrielli, Armando; Capeci, William; Mattioli, Massimo; Martino, Giuseppe Pio; Biondi, Lorenzo; Pettinari, Pietro; Ghio, Riccardo; Col, Anna Dal; Minisola, Salvatore; Colangelo, Luciano; Afeltra, Antonella; Marigliano, Benedetta; Pipita, Maria Elena; Castellino, Pietro; Blanco, Julien; Zanoli, Luca; Pignataro, Samuele; Saracco, Valter; Fogliati, Marisa; Bussolino, Carlo; Mete, Francesca; Gino, Miriam; Cittadini, Antonio; Vigorito, Carlo; Arcopinto, Michele; Salzano, Andrea; Bobbio, Emanuele; Marra, Alberto Maria; Sirico, Domenico; Moreo, Guido; Gasparini, Francesca; Prolo, Silvia; Pina, Gloria; Ballestrero, Alberto; Ferrando, Fabio; Berra, Sergio; Dassi, Simonetta; Nava, Maria Cristina; Graziella, Bruno; Baldassarre, Stefano; Fragapani, Salvatore; Gruden, Gabriella; Galanti, Giorgio; Mascherini, Gabriele; Petri, Cristian; Stefani, Laura; Girino, Margherita; Piccinelli, Valeria; Nasso, Francesco; Gioffrè, Vincenza; Pasquale, Maria; Scattolin, Giuseppe; Martinelli, Sergio; Turrin, Mauro; Sechi, Leonardo; Catena, Cristina; Colussi, Gianluca; Passariello, Nicola; Rinaldi, Luca; Berti, Franco; Famularo, Giuseppe; Patrizia, Tarsitani; Castello, Roberto; Pasino, Michela; Ceda, Gian Paolo; Maggio, Marcello Giuseppe; Morganti, Simonetta; Artoni, Andrea; Del Giacco, Stefano; Firinu, Davide; Losa, Francesca; Paoletti, Giovanni; Montalto, Giuseppe; Licata, Anna; Malerba, Valentina; Antonino, Lasco; Basile, Giorgio; Antonino, Catalano; Malatino, Lorenzo; Stancanelli, Benedetta; Terranova, Valentina; Di Marca, Salvatore; Mecocci, Patrizia; Ruggiero, Carmelinda; Boccardi, Virginia; Meschi, Tiziana; Lauretani, Fulvio; Ticinesi, Andrea; Minuz, Pietro; Fondrieschi, Luigi; Pirisi, Mario; Fra, Gian Paolo; Sola, Daniele; Porta, Massimo; Riva, Piero; Quadri, Roberto; Scanzi, Giorgio; Mengoli, Caterina; Provini, Stella; Ricevuti, Laura; Simeone, Emilio; Scurti, Rosa; Tolloso, Fabio; Tarquini, Roberto; Valoriani, Alice; Dolenti, Silvia; Vannini, Giulia; Tedeschi, Alberto; Trotta, Lucia; Volpi, Riccardo; Bocchi, Pietro; Vignali, Alessandro; Cattaneo, MaraProietti, Marco; Agosti, Pasquale; Lonati, Chiara; Corrao, Salvatore; Perticone, Francesco; Mannucci, Pier Mannuccio; Nobili, Alessandro; Harari, Sergio; Tettamanti, Mauro; Pasina, Luca; Franchi, Carlotta; Marengoni, Alessandra; Salerno, Francesco; Cesari, Matteo; Licata, Giuseppe; Violi, Francesco; Corazza, Gino Roberto; Cortesi, Laura; Ardoino, Ilaria; Prisco, Domenico; Silvestri, Elena; Cenci, Caterina; Emmi, Giacomo; Biolo, Gianni; Zanetti, Michela; Guadagni, Martina; Zaccari, Michele; Vanoli, Massimo; Grignani, Giulia; Pulixi, Edoardo Alessandro; Bernardi, Mauro; Bassi, Silvia Li; Santi, Luca; Zaccherini, Giacomo; Mannarino, Elmo; Lupattelli, Graziana; Bianconi, Vanessa; Paciullo, Francesco; Nuti, Ranuccio; Valenti, Roberto; Ruvio, Martina; Cappelli, Silvia; Palazzuoli, Alberto; Olivieri, Oliviero; Girelli, Domenico; Matteazzi, Thomas; Barbagallo, Mario; Dominguez, Ligia; Cocita, Floriana; Beneduce, Vincenza; Plances, Lidia; Zoli, Marco; Lazzari, Ilaria; Brunori, Mattia; Pasini, Franco Laghi; Capecchi, Pier Leopoldo; Palasciano, Giuseppe; Modeo, Maria Ester; Di Gennaro, Carla; Cappellini, Maria Domenica; Maira, Diletta; Di Stefano, Valeria; Fabio, Giovanna; Seghezzi, Sonia; Mancarella, Marta; Rossi, Paolo Dionigi; Damanti, Sarah; Clerici, Marta; Conti, Federica; Miceli, Emanuela; Lenti, Marco Vincenzo; Pisati, Martina; Dominioni, Costanza Caccia; Murialdo, Giovanni; Marra, Alessio; Cattaneo, Federico; Pontremoli, Roberto; Secchi, Maria Beatrice; Ghelfi, Davide; Anastasio, Luigi; Sofia, Lucia; Carbone, Maria; Cipollone, Francesco; Guagnano, Maria Teresa; Angelucci, Ermanno; Valeriani, Emanuele; Mancuso, Gerardo; Calipari, Daniela; Bartone, Mosè; Delitala, Giuseppe; Berria, Maria; Muscaritoli, Maurizio; Molfino, Alessio; Petrillo, Enrico; Zuccalà, Giuseppe; D'Aurizio, Gabriella; Romanelli, Giuseppe; Zucchelli, Alberto; Picardi, Antonio; Gentilucci, Umberto Vespasiani; Gallo, Paolo; Dell'Unto, Chiara; Annoni, Giorgio; Corsi, Maurizio; Bellelli, Giuseppe; Zazzetta, Sara; Mazzola, Paolo; Szabo, Hajnalka; Bonfanti, Alessandra; Arturi, Franco; Succurro, Elena; Rubino, Mariangela; Serra, Maria Grazia; Bleve, Maria Antonietta; Gasbarrone, Laura; Sajeva, Maria Rosaria; Brucato, Antonio; Ghidoni, Silvia; Fabris, Fabrizio; Bertozzi, Irene; Bogoni, Giulia; Rabuini, Maria Victoria; Cosi, Elisabetta; Manfredini, Roberto; Fabbian, Fabio; Boari, Benedetta; De Giorgi, Alfredo; Tiseo, Ruana; Paolisso, Giuseppe; Rizzo, Maria Rosaria; Borghi, Claudio; Strocchi, Enrico; De Sando, Valeria; Pareo, Ilenia; Sabbà, Carlo; Vella, Francesco Saverio; Suppressa, Patrizia; Schilardi, Andrea; Loparco, Francesca; Fenoglio, Luigi; Bracco, Christian; Giraudo, Alessia Valentina; Fargion, Silvia; Periti, Giulia; Porzio, Marianna; Tiraboschi, Slivia; Peyvandi, Flora; Rossio, Raffaella; Ferrari, Barbara; Colombo, Giulia; Monzani, Valter; Savojardo, Valeria; Folli, Christian; Ceriani, Giuliana; Pallini, Giada; Dallegri, Franco; Ottonello, Luciano; Liberale, Luca; Caserza, Lara; Salam, Kassem; Liberato, Nicola Lucio; Tognin, Tiziana; Bianchi, Giovanni Battista; Giaquinto, Sabrina; Purrello, Francesco; Di Pino, Antonino; Piro, Salvatore; Rozzini, Renzo; Falanga, Lina; Spazzini, Elena; Ferrandina, Camillo; Montrucchio, Giuseppe; Petitti, Paolo; Salmi, Raffaella; Gaudenzi, Piergiorgio; Perri, Ludovica; Landolfi, Raffaele; Montalto, Massimo; Mirijello, Antonio; Guasti, Luigina; Castiglioni, Luana; Maresca, Andrea; Squizzato, Alessandro; Molaro, Marta; Grossi, Alessandra; Bertolotti, Marco; Mussi, Chiara; Libbra, Maria Vittoria; Dondi, Giulia; Pellegrini, Elisa; Carulli, Lucia; Colangelo, Lidia; Falbo, Tania; Stanghellini, Vincenzo; De Giorgio, Roberto; Ruggeri, Eugenio; Vecchio, Sara del; Salvi, Andrea; Leonardi, Roberto; Damiani, Giampaolo; Gabrielli, Armando; Capeci, William; Mattioli, Massimo; Martino, Giuseppe Pio; Biondi, Lorenzo; Pettinari, Pietro; Ghio, Riccardo; Col, Anna Dal; Minisola, Salvatore; Colangelo, Luciano; Afeltra, Antonella; Marigliano, Benedetta; Pipita, Maria Elena; Castellino, Pietro; Blanco, Julien; Zanoli, Luca; Pignataro, Samuele; Saracco, Valter; Fogliati, Marisa; Bussolino, Carlo; Mete, Francesca; Gino, Miriam; Cittadini, Antonio; Vigorito, Carlo; Arcopinto, Michele; Salzano, Andrea; Bobbio, Emanuele; Marra, Alberto Maria; Sirico, Domenico; Moreo, Guido; Gasparini, Francesca; Prolo, Silvia; Pina, Gloria; Ballestrero, Alberto; Ferrando, Fabio; Berra, Sergio; Dassi, Simonetta; Nava, Maria Cristina; Graziella, Bruno; Baldassarre, Stefano; Fragapani, Salvatore; Gruden, Gabriella; Galanti, Giorgio; Mascherini, Gabriele; Petri, Cristian; Stefani, Laura; Girino, Margherita; Piccinelli, Valeria; Nasso, Francesco; Gioffrè, Vincenza; Pasquale, Maria; Scattolin, Giuseppe; Martinelli, Sergio; Turrin, Mauro; Sechi, Leonardo; Catena, Cristina; Colussi, Gianluca; Passariello, Nicola; Rinaldi, Luca; Berti, Franco; Famularo, Giuseppe; Patrizia, Tarsitani; Castello, Roberto; Pasino, Michela; Ceda, Gian Paolo; Maggio, Marcello Giuseppe; Morganti, Simonetta; Artoni, Andrea; Del Giacco, Stefano; Firinu, Davide; Losa, Francesca; Paoletti, Giovanni; Montalto, Giuseppe; Licata, Anna; Malerba, Valentina; Antonino, Lasco; Basile, Giorgio; Antonino, Catalano; Malatino, Lorenzo; Stancanelli, Benedetta; Terranova, Valentina; Di Marca, Salvatore; Mecocci, Patrizia; Ruggiero, Carmelinda; Boccardi, Virginia; Meschi, Tiziana; Lauretani, Fulvio; Ticinesi, Andrea; Minuz, Pietro; Fondrieschi, Luigi; Pirisi, Mario; Fra, Gian Paolo; Sola, Daniele; Porta, Massimo; Riva, Piero; Quadri, Roberto; Scanzi, Giorgio; Mengoli, Caterina; Provini, Stella; Ricevuti, Laura; Simeone, Emilio; Scurti, Rosa; Tolloso, Fabio; Tarquini, Roberto; Valoriani, Alice; Dolenti, Silvia; Vannini, Giulia; Tedeschi, Alberto; Trotta, Lucia; Volpi, Riccardo; Bocchi, Pietro; Vignali, Alessandro; Cattaneo, Mar

Multimorbidity and polypharmacy in the elderly: Lessons from REPOSI

The dramatic demographic changes that are occurring in the third millennium are modifying the mission of generalist professionals such as primary care physicians and internists. Multiple chronic diseases and the related prescription of multiple medications are becoming typical problems and present many challenges. Unfortunately, the available evidence regarding the efficacy of medications has been generated by clinical trials involving patients completely different from those currently admitted to internal medicine: much younger, affected by a single disease and managed in a highly controlled research environment. Because only registries can provide information on drug effectiveness in real-life conditions, REPOSI started in 2008 with the goal of acquiring data on elderly people acutely admitted to medical or geriatric hospital wards in Italy. The main goals of the registry were to evaluate drug prescription appropriateness, the relationship between multimorbidity/polypharmacy and such cogent outcomes as hospital mortality and re-hospitalization, and the identification of disease clusters that most often concomitantly occur in the elderly. The findings of 3-yearly REPOSI runs (2008, 2010, 2012) suggest the following pertinent tasks for the internist in order to optimally handle their elderly patients: the management of multiple medications, the need to become acquainted with geriatric multidimensional tools, the promotion and implementation of a multidisciplinary team approach to patient health and care and the corresponding involvement of patients and their relatives and caregivers. There is also a need for more research, tailored to the peculiar features of the multimorbid elderly patient

Heart failure and chronic kidney disease in a registry of internal medicine wards

Background: The aim of the present study was to evaluate the association between heart failure (HF) and chronic kidney disease (CKD) in tertiary care centers using the clinical records of patients enrolled in internal medicine departments.Patients and methods: We used the clinical records of 1380 elderly patients to identify patients with a history of HF and CKD using admission ICD codes and glomerular filtration rate (GFR) formulas. Magnitude and strength of such associations were investigated by univariable and multivariable analysis.Results: Of the 1380 patients enrolled, 27.9% had HF (age 80 \ub1 7, BMI 27 \ub1 6 kg/m2) and 17.4% CKD (age 81 \ub1 7, BMI 26.8 \ub1 6 kg/m2). Both groups were significantly older (P <' 0.0001) with BMI higher than the patients without those diagnosis (P < 0.02). Patients with a history of CKD showed higher non-fasting glycaemia (140 \ub1 86 vs. 125 \ub1 63 mg/dL, P < 0.001). CKD was significantly associated with HF (P < 0.0001). Patients with HF had an estimated GFR lower than patients without HF (P < 0.0001). Comorbidity and severity indices were significantly higher in subjects with HF (P < 0.0001) and CKD (P < 0.0001) than in those without. Multivariable analysis showed a significant association between HF and age (for five years increase OR 1.13, P < 0.009), BMI (for each 3 kg/m2 increase OR 1.15, P < 0.001), GFR (for each decrease of 10 mL/min increase OR 0.92, P < 0.002) and severity index (IS) (for each 0.25 units increase OR 1.43, P < 0.001).Conclusion: HF on admission is strongly associated with CKD, older age, BMI, and SI. These data focus the value of epidemiological studies such REPOSI in identifying and monitoring multimorbidity in elderly

Antipsychotic prescription and mortality in hospitalized older persons

Background: Recent scientific reports have shown that older persons treated with antipsychotics for dementia-related behavioural symptoms have increased mortality. However, the impact of these drugs prescribed during hospitalization has rarely been assessed. We aimed to investigate whether antipsychotics are associated with an increased risk of mortality during hospitalization and at 3-month follow-up in elderly inpatients. Methods: We analyzed data gathered during two waves (2010 and 2012) by the REPOSI (Registro Politerapie Società Italiana Medicina Interna). All new prescriptions of antipsychotic drugs during hospitalization, whether maintained or discontinued at discharge, were collected, and logistic regression models were used to analyze their association with in-hospital and 3-month mortality. Covariates were age, sex, the Short Blessed Test (SBT) score, and the Cumulative Illness Rating Scale. Results: Among 2703 patients included in the study, 135 (5%) received new prescriptions for antipsychotic drugs. The most frequently prescribed antipsychotic during hospitalization and eventually maintained at discharge was haloperidol (38% and 36% of cases, respectively). Patients newly prescribed with antipsychotics were older and had a higher Cumulative Illness Rating Scale comorbidity index both at admission and at discharge compared to those who did not receive a prescription. Of those prescribed antipsychotics, 71% had an SBT score ≥10 (indicative of dementia), 12% had an SBT score of 5–9 (indicative of questionable dementia); and 17% had an SBT score <5 (indicative of normal cognition). In-hospital mortality was slightly higher in patients prescribed antipsychotic drugs (14.3% vs 9.4%; P = 0.109), but in multivariate analysis only male sex, older age, and higher SBT scores were significantly related to mortality during hospitalization. At 3-month follow-up, only male sex, older age, and higher SBT scores were associated with mortality. Conclusion: We found that the prescription of antipsychotic drugs during hospitalization was not associated with in-hospital or follow-up mortality. Short-term antipsychotic prescriptions (for acutely ill patients) may have a different effect than long-term, repeated prescriptions