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

Prescription appropriateness of anti-diabetes drugs in elderly patients hospitalized in a clinical setting: evidence from the REPOSI Register

Diabetes is an increasing global health burden with the highest prevalence (24.0%) observed in elderly people. Older diabetic adults have a greater risk of hospitalization and several geriatric syndromes than older nondiabetic adults. For these conditions, special care is required in prescribing therapies including anti- diabetes drugs. Aim of this study was to evaluate the appropriateness and the adherence to safety recommendations in the prescriptions of glucose-lowering drugs in hospitalized elderly patients with diabetes. Data for this cross-sectional study were obtained from the REgistro POliterapie-Società Italiana Medicina Interna (REPOSI) that collected clinical information on patients aged ≥ 65 years acutely admitted to Italian internal medicine and geriatric non-intensive care units (ICU) from 2010 up to 2019. Prescription appropriateness was assessed according to the 2019 AGS Beers Criteria and anti-diabetes drug data sheets.Among 5349 patients, 1624 (30.3%) had diagnosis of type 2 diabetes. At admission, 37.7% of diabetic patients received treatment with metformin, 37.3% insulin therapy, 16.4% sulfonylureas, and 11.4% glinides. Surprisingly, only 3.1% of diabetic patients were treated with new classes of anti- diabetes drugs. According to prescription criteria, at admission 15.4% of patients treated with metformin and 2.6% with sulfonylureas received inappropriately these treatments. At discharge, the inappropriateness of metformin therapy decreased (10.2%, P < 0.0001). According to Beers criteria, the inappropriate prescriptions of sulfonylureas raised to 29% both at admission and at discharge. This study shows a poor adherence to current guidelines on diabetes management in hospitalized elderly people with a high prevalence of inappropriate use of sulfonylureas according to the Beers criteria

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

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

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

Distortion and faults detection in shipboard AC/DC power distribution system

Nowadays electric propulsion has become a valid alternative to mechanical propulsion for large ships that require high speed. The electric propulsion advantages are well known and widely documented in the literature: higher dynamic performance of the electric propulsion motors; internal combustion engines separation from shafts; increased flexibility in space/zones subdivision; increased efficiency through the modulation of number of running generators; noise and vibration reduction; increasing in automation, with a consequent crew reduction. The use of electric propulsion along with the progressive increase, in number and power, in electrical loads used for ship services, led to the development of the All Electric Ship (AES) concept. Over the last years, the All Electric Ships (AESs) concept has begun to be adopted by the most important Navies, principally by the U.S. Navy, giving a boost to the technological research. An AES is a ship where all onboard electrical loads (including propulsion) are powered by a single electrical system, called Integrated Electrical System (IPS). The IPS requires careful design and management in order to ensure both high Power Quality standard and the continuity of the service. With the technological progress, the shipboard electrical systems have changed considerably, rising from few MW of installed power to values of the order of hundred MW, both in cruises and military ships. Especially in military vessels, considering the number of special devices that are present on board (weapon systems, communication equipment, radar, sonar, and missile guidance systems), a performing and reliable electrical systems is required. Moreover, it is necessary to notice that some of the new electrical pulsed loads specific to military applications (e.g. radar, electromagnetic launchers, etc.) together with electric drives for propulsion engines can cause strong disturbances to the system, thus causing the malfunction of other electric utilities that may endanger the continuity of the service. The penetration of power electronics converters is the main issue for the contribution of harmonic distortion in AC grids, which must be limited not to increase system power losses, and to allow the correct operation of system and user devices. Standards dictate the maximum admissible values of the total voltage harmonic distortion and of the individual harmonics amplitudes, as a function of the rated system voltage. The relatively limited short-circuit power available on board also exposes the IPS to significant voltage sags and flickers caused by switching and/or intermittent loads. In this scenario, DC electrical distribution systems can be very attractive, thanks to their intrinsic immunity to harmonic problems. If DC micro-grids are interfaced to AC networks by means of Front End Converters (FECs), both AC/DC grid decoupling and considerable AC-side harmonic distortion reduction can be achieved. In addition, they simplify the power supply of converter-fed loads and the interfacing of storage systems. The latter can perform several tasks, including ensuring power supply in case of AC grid loss, peak-shaving and levelling pulsating loads further improving both the quality and the continuity of supply to DC islands loads. In the light of the above, it is evident that the electric power system is of primary importance for a modern ship. Moreover, if high-performance is required, careful analysis of the disturbances in the power system is mandatory. In fact, in order to achieve a reliable and performing power system, together with a high-Power Quality, it is necessary to assess this situation and propose guidelines to be observed for the solution of various problems. The definition and evaluation of possible IPS architectures should take into account AC/DC protection devices in order to carry out an integrated analysis of the system. Different MVAC/MVDC electrical distribution layouts coupling with all-electric or hybrid propulsion (electric/diesel/gas turbine) needs to be accurately investigated to show its advantages in terms of reliability, safety and quality of power. The thesis focusses on the Naval Smart Grid (NaSG) research project completed in partnership with the University of Trieste and the Polytechnic University of Milan. The aim of the research is to produce useful results for the design of a new ship, equipped with the following innovative features: modular power system; subsystem flexible integration; efficiency improvement; security improvement; new weapon systems; survivability improvement and high Power Quality standard. The main focus was the study of methodologies/solutions able to improve and define the onboard Power Quality (PQ). The research project reports Power Quality analysis about aspects of continuity of service, harmonic disturbances, pulsed power loads impact on the system, electromechanical transient evaluation and use of power and energy storage systems. An exhaustive investigation was carried out on system architectures in frequency domain to identify resonances and non-linear loads to detect disturbance frequencies. Moreover, the guidelines for the correct coordination of all the elements of the power system design affecting system performance (protections, converters, control systems, energy storage systems, etc.) are reported. A brief abstract for each Chapter is reported. Chapter 1 and 2 - Overview of Electrical Naval Systems and Integrated Power System in Military Ships The chapter reports the complete state of the art on naval electrical system and a brief description of naval classification, showing technological improvements and historical evolution. Details about electric propulsion, electrical generation on board, energy distribution and network layout are carried out. A complete description of the main IPS military ships with their own architecture and features is reported. Chapter 3 - Methodologies for Harmonic Disturbances Analysis and Power Quality (Service Continuity) In the field of Power quality (harmonic content, asymmetries, voltage sags, power factor), methodologies applied for the analysis/detection of harmonic disturbances are reported with an overview of electrical systems dependability in order to evaluate the service continuity of the system. Harmonic distortion could affect equipment on shipboard causing its outages, consequently, in an island system, power distribution network should ensure high re-configurability after faults, damage or untimely switch off. However, the increased interest in system’s safety and resilience generates, in turn, an increase in design burden necessary to analyze the consequences of faults and demonstrate the system’s compliance with the relevant regulations. The chapter presents the models and calculation code used for simulation activities. A Simulink model for time domain analysis and for time varying non-linear load, as well as a Fortran model for harmonic domain are described. Chapter 4 and 5 - Characterization of a military aircraft carrier and Aircraft Cavour – Measurement campaign A measurement campaign onboard the ship Cavour was carried out with the aim to characterize the relevant electric loads on board military vessel and to validate the models of the system’s components to be used. The analysis of data collected, allows to model the behavior of loads in terms of time and frequency domains, thus permitting their use for the required studies. Some specific electrical loads, such as new electrically pulsed loads specific for military applications (e.g. radar, electromagnetic launchers, etc.) with high distorted current absorption were identified. Their characterization was carried out in order to define their contribution to harmonic disturbances and their impact on the network. A model validation based on a measurement campaign is carried out. Chapter 6 - A New layout for an Integrated Power System Naval Unit-All Electric/Hybrid Different IPS architectures are defined: a full MVAC (Medium Voltage Alternate Current) power system, a hybrid MVAC plus MVDC/LVDC islands (Medium/Low Voltage Direct Current) and a MVAC 50-60 Hz, with a hybrid (electric/diesel/gas turbine) propulsion. In the architecture of the latter, the power of the installed engines is much lower than the first two cases. Chapter 7 - Network Equivalents in Harmonic Domain The needs to easily represent a complex network with high accuracy, lead to the development of a methodology based on aggregation of loads, creating a simplified network to carry out harmonic analysis. Different equivalent network models have been proposed that show their accuracy, through network impedances, and compare them with the overall representation of the network. The influence of cables was also studied. The best radial equivalent network was identified. Chapter 8 - Harmonic Analysis In order to propose appropriate solutions designed to improve power quality, the study of system impedance and power systems in frequency domain were studied. This analysis, carried out on the basis of the schematics and data load obtained in cooperation with the IT Navy, revealed some criticalities in the frequency range for both the systems architectures. As to full MVAC (Medium Voltage Alternate Current) power system and hybrid MVAC plus MVDC/LVDC islands, the aim was to evaluate whether or not the inclusion of capacitors (on shore, for power factor correction in shore connections) or filters (onboard, to reduce harmonic disturbances produced by propulsion systems) cause special issues, because of the high power of installed propulsion engines. Moreover, the advantages of DC island on electrical distribution in order to ensure high reliability and quality of service, in addition to the need to increase the efficiency of the ships’ power systems are highlighted. For the MVAC 50-60 Hz layout, the goal is to show how the use of hybrid (electric/diesel/gas turbine) propulsion where the power of engines is significantly reduced as compared to previous cases could solve some issues relating to power quality aspects. Chapter 9 - Reliability Analysis Preliminary studies about dependability, re-configurability and some top-events relevant for the vessel, were evaluated for all electric MVAC/MVAC "hybrid" models. The analysis of electrical disconnection of load areas due to a fault or an untimely tripping of the switches caused by harmonic disturbances was carried out. Chapter 10 - Three-Phase Short Circuit Analysis For MVAC 50-60 Hz Layout Preliminary evaluations were performed by analyzing the system within the perspective of given faults to perform system analysis in both permanent and short-circuit conditions. To highlight possible protection issues, the steady state condition and the three-phase short-circuit faults were studied and simulated under different load conditions for the MVAC architecture plus rotary converters, with hybrid (electric/diesel/gas turbine) propulsion

Electric transportation

The discussion reports the main features of common public mass transportation systems, highlighting the vehicles and infrastructure peculiarities. The systems described are referred exclusively to the most common land vehicles, as trolleybus, tram, light rail, metro, monorail and driverless systems. They are differentiated according to the type of driving: autonomous (on the road) or constrained to an infrastructure (tracks or electric transmission lines); a short description of different charging mode for the first one is given

Energy storage systems for voltage regulation: Analysis for the railway junction of Rome

The paper reports a preliminary evaluation concerning the design of a stationary storage system for voltage regulation in the railway junction of Rome. In particular the case study concerns the 3 kV dc 'Trastevere-Cesano' railway line. The constant increase in railway traffic, together with the improvement of comfort, has led to an increase of the energy required in the railway sector, causing larger voltage drops along the line. The growth of the railway traffic needs solutions to manage and analyze the capability of the railway junction. Power systems simulations of a railway junction requires high computational effort and the present work reports a methodology to simulate a railway line belonging to a complex railway junction, taking into account network equivalents

Eco-friendly urban transport systems. Comparison between energy demands of the trolleybus and tram systems

A computational code implementing experimentally tested mathematical models was used to conduct a study on an urban center of southern Italy comprising the cities of Cosenza and Rende that, seat of the University of Calabria, has recorded a systematic and significant expansion in recent years in terms of both urban and demographic development. In Italy the first electric tramway was built in Florence in 1890 and it linked Florence to Fiesole. In 1920 major tramway development was reached. In Europe, North America, South America and Australia, almost all medium and large size cities had urban and intercity networks. In the late 20s, North America first and then Europe reduced the tramway systems replacing them with trolleybuses and buses. The traction electric motor used in most new vehicles is the four-pole three-phase asynchronous motor, that with its control systems, has introduced a number of advantages compared to the DC motor in terms of reliability, less maintenance, high efficiency and control

An environmental sustainable transport system: A trolley-buses Line for Cosenza city

In the present paper, a comparison among different types of urban mass transport systems, which can be implemented for medium-sized cities, is reported. For each mobility system, advantages and disadvantages, in terms of transport capacity and environmental impact, are highlighted. Then the focus is pointed on the trolley-bus solution. A real case study of deployment of this type of mobility system, for a medium size Italian city, is analyzed. The results of traffic and electrical simulations of the proposed trolley-buses system are exposed, including energy performance and economic evaluations. © 2012 IEEE