The Use of Risk Scores for Thromboprophylaxis in Medically Ill Patients-Rationale and Design of the RICO trial

Background  Venous thromboembolism (VTE) in hospitalized medically ill patients is a significant cause of morbidity and mortality. Guidelines suggest that VTE and bleeding risk assessment models (RAMs) should be integrated into the clinical decision-making process on thromboprophylaxis. However, poor evidence is available comparing the use of a RAM versus clinical judgement in evaluating VTE and bleeding occurrence. Methods  Reducing Important Clinical Outcomes in hospitalized medical ill patients (RICO) is a multicenter, cluster-randomized, controlled clinical trial (ClinicalTrials.gov Identifier: NCT04267718). Acutely ill patients hospitalized in Internal Medicine wards are randomized to the use of RAMs-namely the Padua Prediction Score and the International Medical Prevention Registry on Venous Thromboembolism Bleeding Score-or to clinical judgement. The primary study outcome is a composite of symptomatic objectively confirmed VTE and major bleeding at 90-day follow-up. Secondary endpoints include the evaluation of clinical outcomes at hospital discharge and the assessment of VTE prophylaxis prescription during the study period. In order to demonstrate a 50% reduction in the primary outcome in the experimental group and assuming an incidence of the primary outcome of 3.5% in the control group at 90-day; 2,844 patients across 32 centers will be included in the study. Discussion  The RICO trial is a randomized study of clinical management assessing the role of RAMs in hospitalized medical ill patients with the aim of reducing VTE and bleeding occurrence. The study has the potential to improve clinical practice since VTE still represents an important cause of morbidity and mortality in this setting.

Real-world use of remdesivir for the treatment of patients admitted to Italian hospitals with COVID-19: the nationwide retrospective FADOI-RECOVER study

BACKGROUND

Remdesivir is widely used for treatment of SARS-CoV-2 pneumonia. The aim of this study was to evaluate the characteristics of patients with moderate-to-severe COVID-19 treated with remdesivir, and their outcomes during hospitalization.

METHODS

This retrospective observational multicenter study included consecutive patients, hospitalized for moderate-to-severe COVID-19 (September 2020-September 2021), who were treated with remdesivir.

RESULTS

One thousand four patients were enrolled, all with onset of symptoms occurring less than 10 days before starting remdesivir; 17% of patients had 4 or more concomitant diseases. Remdesivir was well tolerated, adverse drug reactions (ADRs) being reported in 2.3% of patients. In-hospital death occurred in 80 patients (8.0%). The median timing of the first remdesivir dose was 5 days after symptom onset. The following endpoints did not differ according to the time span from the onset of symptoms to the first dose: length of hospitalization, in-hospital death, composite outcome (in-hospital death and/or endotracheal intubation). Advanced age, number of comorbidities ≥ 4, and severity of respiratory failure at admission were associated with poor in-hospital outcomes.

CONCLUSION

In a real-world setting, remdesivir proved to be a safe and well-tolerated treatment for moderate-to-severe COVID-19. In patients receiving remdesivir less than 3 or 5 days from the onset of SARS-CoV-2 symptoms, mortality and the need for mechanical ventilation did not differ from the rest of the sample.

Analysis of the characteristics of patients admitted to Internal Medicine wards for exacerbation of chronic obstructive pulmonary disease, and discharge phase optimization. The SDO-ARCA Project of the Scientific Society FADOI

The purpose of this study was to have a nationwide snapshot of the characteristics of patients hospitalized in Internal Medicine Units (IMUs) for exacerbation of chronic obstructive pulmonary disease (COPD), and to assess applicability and contents of a specific Hospital Discharge Form for the patient with exacerbation of COPD discharged from IMUs. This was a prospective study in 44 IMUs in Italy, enrolling patients hospitalized with a diagnosis of COPD exacerbation. Information concerning clinical characteristics of patients, and treatment for COPD at discharge was collected. Specific documents for monitoring of clinical conditions and adherence to therapies as well as a form including individual indications for clinical controls, instrumental tests, etc. were provided upon discharge. Four hundred and seventy-two patients were enrolled (68% male). According to GOLD classification 2015, patients with classes A to D were 12%, 27%, 31%, and 30%, respectively. Triple therapy was prescribed in 14% of GOLD A and 51% of GOLD D patients. Around 10% of patients for each GOLD class received no specific therapy. The vast majority of patients (85%) received instructions on the correct use of inhalers, and in most cases (85%), the quality of counseling was considered optimal/adequate. Indication for performing chest X-ray, spirometry, or blood gas analysis following discharge was addressed to 29%, 59% and 52.1% of patients, respectively. The follow-up sheet for COPD used in our study was shown as applicable. This highlighted the need for greater awareness and more standardized procedures within IMUs in the post-discharge phase.

Prophylaxis of Venous Thromboembolism after Hospital Discharge in Internal Medicine: Findings from the Observational FADOI-NoTEVole Study

BACKGROUND AND AIM

 Post-discharge prophylaxis for venous thromboembolism (VTE) is a challenging issue in patients hospitalised in Internal Medicine Units (IMUs). The aim of this study was to evaluate the frequency and the factors associated with post-discharge prophylaxis for VTE in IMUs.

METHODS

 Multi-centre, retrospective study including consecutive patients who were admitted for any cause and discharged from an IMU.

RESULTS

 Overall, 3,740 patients (mean age 74.1 ± 15.7 years) were included in the study at 38 IMUs in Italy. At discharge, the percentage of patients receiving pharmacological thromboprophylaxis was 16.0% (20.1% after excluding patients treated with anticoagulants for indications other than VTE prophylaxis). At multivariable analysis, history of ischaemic stroke, hypomobility ≥ 7 days, central venous catheter, ≥ 10 versus ≤ 5 days of hospital stay, use of corticosteroids, cancer, history of falls, availability of a caregiver, infections and age were significantly associated with thromboprophylaxis, while an inverse correlation was observed with concomitant anti-platelet drugs and platelet count < 70,000/mm³. Patients with a Padua Prediction Score ≥ 4 versus < 4 and with an IMPROVE bleeding score ≥ 7 versus < 7 more frequently received prophylaxis at discharge (31.2% vs. 10.6%, p < 0.0001, and 25.7% vs. 19.6%, p = 0.028, respectively).

CONCLUSION

 In this study, one in five patients discharged from an Italian IMU received prophylaxis for VTE. The perceived thrombotic risk is significantly related to the use of prophylaxis.

Gender differences in pain prevalence, characteristics, assessment and treatment in internal medicine patients: a post-hoc analysis of the FADOI-DOMINO study

Conflicting results come from epidemiological studies on the correlations between gender and pain in hospitalized patients. No specific data are reported in patients admitted to Internal Medicine Units (IMUs). Post-hoc analysis of the FADOI-DOMINO study, performed in 26 IMUs in Italy, with two cross-sectional surveys interspersed with an educational program. The 5200 medical charts of the FADOI-DOMINO study were re-analyzed. The following sex differences were highlighted: i) a greater pain prevalence was evidenced in women in the Pre-phase; ii) among patients with chronic pain, anxiety and depression were significantly more present in women compared with men; iii) oncologic pain was more prevalent in men; in a specular way, nononcologic pain showed a greater prevalence in women in both phases; iv) strong opioids therapy was higher for men. Some sex differences in pain seem to exist in IMUs, although less evident if compared with those previously reported in other settings. A more careful assessment of coexisting conditions such as anxiety, depression or cognitive impairment can result in a better management of these problems.

In-hospital symptomatic venous thromboembolism and antithrombotic prophylaxis in Internal Medicine

Hospitalised medical patients are at increased risk of venous thromboembolism (VTE), but the incidence of hospitalisation-related VTE in unselected medical inpatients has not been extensively studied, and uncertainties remain about the optimal use of thromboprophylaxis in this setting. Aims of our prospective, observational study were to assess the prevalence of VTE and the incidence of symptomatic, hospitalisation-related events in a cohort of consecutive patients admitted to 27 Internal Medicine Departments, and to evaluate clinical factors associated with the use of thromboprophylaxis. Between March and September 2006, a total of 4,846 patients were included in the study. Symptomatic VTE with onset of symptoms later than 48 hours after admission (”hospital-acquired” events, primary study end-point) occurred in 26 patients (0.55٪), while the overall prevalence of VTE (including diagnosis prior to or at admission) was 3.65٪. During hospital stay antithrombotic prophylaxis was administered in 41.6٪ of patients, and in 58.7% of those for whom prophylaxis was recommended according to the 2004 Guidelines of the American College of Chest Physicians. The choice of administering thromboprophylaxis or not appeared qualitatively adherent to indications from randomised clinical trials and international guidelines, and bed rest was the strongest determinant of the use of prophylaxis. Data from our real-world study confirm that VTE is a relevant complication in patients admitted to Internal Medicine Departments, and recommended tromboprophylaxis is still under-used, in particular in some patients groups. Further efforts are needed to better define risk profile and to optimise prophylaxis in the heterogeneous setting of medical inpatients.

Misdiagnosis of vertebral fractures on local radiographic readings of the multicentre POINT (Prevalence of Osteoporosis in INTernal medicine) study

BACKGROUND

Osteoporotic vertebral fractures (VFs) are often misdiagnosed because asymptomatic and occurring in the absence of specific trauma. Further, diagnostic assessment of VFs may be suboptimal.

AIM OF THE STUDY

To assess the misdiagnosis of vertebral fractures on local radiographic readings in the cohort of patients enrolled in the POINT study.

METHODS

We enrolled hospitalised patients, admitted for any cause to the Internal Medicine Units of 37 hospitals participating to the cross-sectional previously published POINT study. The assessment of VFs was performed both by local radiologists and by two expert skeletal radiologists, by using semiquantitative method (SQ). To better evaluate mild vertebral deformities, the two central radiologists also used the algorithm-based qualitative assessment (ABQ).

RESULTS

The radiographs of 661 patients (401 females; mean age 75.8±8.0) were evaluated. The inter-reader percent agreement between two central expert radiologists per-vertebra assessment was excellent (99.78%; k=0.984; 95% CI, 0.977-0.991). Central reading identified 318/661 (48.1%) patients with at least one VF. Local and central readings agreed in 502/661 (75.9%) patients, resulting in a fair reproducibility (k=0.52; 95% confidence interval 0.44-0.59). Diagnostic performance parameters of local readings were: sensitivity 76.1%; specificity 75.8%; PPV 74.46%; NPV 77.38%). By examining 9254 vertebrae, central and local readers diagnosed 665 (7.2%) and 562 (6.1%) VFs respectively. Misdiagnosis (102 false positives and 205 false negatives) mainly occurred for mild VFs. Local readings identified correctly 460 out 665 VFs diagnosed by central readings, resulting in sensitivity of 69.2% and PPV of 81.8%.

CONCLUSIONS

Following a standardized protocol of acquisition techniques and of interpretation criteria, an excellent agreement between local and central readings for moderate and severe vertebral fractures resulted. However a significant amount of mild vertebral fractures, that are the most of VFs, were misdiagnosed by local radiologists. In order to improve VFs assessment, the radiologists should be trained and sensitized in relation to the relevant clinical significance of osteoporotic VFs identification.

Evaluation of safety at work in a psychiatric setting: the "Workplace Safety Assessment"

OBJECTIVES

Workplace violence is a common risk for mental health professionals, and psychiatrists often encounter it in a variety of settings. The aim of this study was to estimate the prevalence and features of violent episodes toward psychiatrists in various mental healthcare system settings.

METHODS

All psychiatrists from the Region of Puglia (Apulia) were contacted (N=285) via email and were administered an on-line standardized questionnaire.

RESULTS

The response rate by psychiatrists was 57%. The main types of violence revealed were "threats" and "verbal aggression" and, of particular importance, "stalking". Female psychiatrists seemed to be at a higher risk of becoming victims of workplace violence, especially as regards verbal abuse (OR: 2.7, 95% CI: 1.2-6.5, c2 6.7, p=0.0095) and reported more serious psychological consequences with need for rest after the episode of aggression.

CONCLUSIONS

Our data confirm that mental health workers, particularly psychiatrists, are healthcare professionals at high risk for workplace violence. Future implementation of preventive strategies with the aim of reducing aggressive episodes towards psychiatrists should be a high priority for managers and policy-makers operating in the Italian healthcare sector.

Prulifloxacin vs Levofloxacin for Exacerbation of COPD after Failure of Other Antibiotics

The chronic course and evolution of chronic obstructive pulmonary disease (COPD) is often characterized by periods of exacerbation of symptoms, which have a negative impact on the quality of life of patients, as well as on the evolution of COPD, and represent a significant cause of medical intervention and hospitalization. Very few data are available on the efficacy of rescue antibiotics in patients with acute exacerbation of COPD (AECOPD) unresponsive to previous treatment. The aim of this study was to evaluate the efficacy of two fluoroquinolones in AECOPD previously treated without success. The FADOI-FLOR study is a randomized, single-blind, non-inferiority comparison between levofloxacin and prulifloxacin. Primary end-point was "therapeutic success" at Day 10 of treatment, defined as disappearance of signs/symptoms or decrease of at least three points of a global score of symptomatology (maximum score = 15). 258 patients were enrolled (128 levofloxacin and 130 prulifloxacin), in 25 centers. A very high proportion of patients in the two groups had therapeutic success at Day-10 (levofloxacin 93.0% vs prulifloxacin 96.7%, population intention-to-treat; 94.6% vs 99.1%, population per-protocol). Earlier therapeutic success (within 7 days) was achieved in 32.0% and 36.2% of patients receiving levofloxacin or prulifloxacin, respectively. At 3-month follow-up, re-exacerbations occurred in 17.8% of patients treated with levofloxacin and 14.2% of those receiving prulifloxacin (p = 0.44). In conclusion, fluoroquinolones are very effective in the treatment of AECOPD resistant to other antibiotics.

Complexity of patients with chronic obstructive pulmonary disease hospitalized in internal medicine: a survey by FADOI

Chronic obstructive pulmonary disease (COPD) is one of the most frequent pathologies among patients hospitalized in Internal Medicine (IM) Departments. COPD is frequently associated with concomitant diseases, which represent major causes of death, and affect disease management. Objectives of our study are to assess the prevalence of COPD patients in IM, to evaluate their comorbidity status, and to describe their complexity, by means of the validated multidimensional prognostic index (MPI) score. COMPLEXICO is an observational, prospective, multicenter study, enrolling consecutive patients hospitalized for any cause in IM, with diagnosis of COPD documented by spirometry. A total of 1002 patients in 43 IM Units in Italy were enrolled. The prevalence of COPD in IM was found to be 18.1%, and 72.8% of patients had at least three chronic diseases other than COPD. The mean MPI was 0.43±0.15, and according to a stratification algorithm 31.8% of patients were classified as having low-risk, 58.9% moderate-risk and 9.3% severe-risk of adverse outcome. More than two-thirds of COPD patients in our study present moderate to severe risk of poor outcome according to the MPI stratification.

High prevalence of fragility vertebral fractures in patients hospitalised in Internal Medicine Units. Results of the POINT (Prevalence of Osteoporosis in INTernal medicine) study

BACKGROUND

Osteoporotic vertebral fractures (VFs) often go unrecognised in both healthy individuals and in pathological conditions. Few data exist on VFs in patients hospitalised in Internal Medicine Units (IMUs), who often suffer from multiple concomitant chronic disorders.

AIM OF THE STUDY

This multicentre cross-sectional study was aimed at assessing the prevalence of VFs in an unselected population of patients referring to IMUs. Correlations between VFs and the main coexisting diseases were also investigated.

METHODS

Information on demographic, clinical and laboratory findings, and on the presence of known risk factors for osteoporosis was recorded. The Genant's semi-quantitative method was used to evaluate, in a central reading centre, the presence and severity of VFs in the thoracic and lumbar spine.

RESULTS

A cohort of 995 patients was evaluated. At least one VF of any grade was found in 47.5% of patients, with similar prevalence between females (48.1%) and males (46.7%). Older age, chronic obstructive pulmonary disease, and previous diagnosis of osteoporosis showed a significant association with VFs in multivariable analysis. However, 79.7% of the VFs were observed in patients without previous diagnosis of osteoporosis. Moreover, a VF of grade 2 or greater was found in 20.8% of patients.

CONCLUSIONS

Fragility VFs is a very frequent finding in patients hospitalised in IMUs. Consequently, more attention should be devoted in this clinical setting to this comorbidity, which is known to be an additional factor for mortality and, when localised in the thoracic part of the spine, may negatively influence a concomitant respiratory insufficiency.

Pain management in internal medicine and effects of a standardised educational intervention: the FADOI-DOMINO study

PURPOSE

Few real-world data are available on the frequency and management of pain in Internal Medicine (IM). Aims of our study were to assess the prevalence of pain in IM, and to evaluate the effects on pain management of a standardised educational programme.

MATERIALS AND METHODS

The study was performed in 26 IM Units in Italy, with two cross-sectional surveys (PRE phase and POST phase) interspersed with an educational programme. In PRE phase each Centre reviewed the hospital charts of the last 100 consecutive patients hospitalised for any cause. An educational programme was conducted in each Centre by means of the 'outreach visit', a face-to-face meeting between health personnel and a trained external expert. Six months after, each Centre repeated the data collection (POST phase), specular to the PRE.

RESULTS

A total of 5200 medical charts were analysed. Pain was documented in 37.5% of the patients. After the educational intervention, the intensity of pain was appropriately assessed in a higher percentage of patients (77.4% vs. 47.8%, p = 0.0001), and it was more frequently monitored during hospitalisation. Qualitative definition of pain (pathogenesis, duration, etc.) increased in POST phase (75.4% vs. 62.7%, p = 0.0001). A 73.3% increase in the use of strong opioids was detected following educational programme.

CONCLUSIONS

Pain affects 4 out of 10 patients hospitalised in IM. According to our large real-world study, to implement a standardised one-shot educational programme may persistently improve the attitude of health personnel towards the characterisation and management of pain.

Effects of iloprost on pain-free walking distance and clinical outcome in patients with severe stage IIb peripheral arterial disease: the FADOI 2bPILOT Study

BACKGROUND

Patients with peripheral arterial disease (PAD) at stage IIb, pain-free walking distance (PFWD) less than 100 m and unsuitable for revascularization have both impaired quality of life and severe clinical outcome. Aim of the study was to evaluate the efficacy of the prostacyclin analogue iloprost, added to standard therapy, in these patients.

MATERIAL AND METHODS

Patients were randomized to receive standard medical therapy (Group A) or standard therapy plus iloprost (Group B), for 1 year. Iloprost was administered for 10 days every 3 months. Treadmill test was performed every 3 months, in Group B before starting the 10-day iloprost cycle.

RESULTS

Fifty patients in Group A and 51 in Group B were enrolled. Mean baseline and 12-month PFWD values were 75.4 ± 21.3 and 128.9 ± 62.9 for iloprost group and 70.3 ± 21.6 and 99.6 ± 62.6 m for controls. Patients treated with iloprost had significantly higher PFWD at 9 and 12 months. This finding was confirmed after carrying forward the last valid observation (124.7 ± 63.4 vs. 88.4 ± 63.1 m, P < 0.01). Major cardiovascular events occurred in 32.0% and 3.9% of patients in Group A and Group B, respectively (P < 0.001). Five patients in Group A died vs. none in Group B (P = 0.02). No serious unexpected adverse reactions occurred in patients receiving iloprost.

CONCLUSIONS

Iloprost, added to standard therapy, significantly increases exercise capacity in patients with PAD at severe stage IIb. The percentage of patients who died or experienced major cardiovascular events was significantly lower in patients receiving iloprost. Future studies should focus on the effects of this therapy on clinical outcome.

Abstract book of the XVIII Congresso Nazionale della Società Scientifica FADOI, Giardini Naxos, 11-14 maggio 2013

Abstract book of the XVIII Congresso Nazionale della Società Scientifica FADOI, Giardini Naxos, 11-14 maggio 2013

Risk factors for venous thromboembolism and prophylaxis in medical inpatients: data from the FADOI ‘‘GEMINI’’ study

Background: Though venous thromboembolism (VTE) frequently occurs in non-surgical setting, epidemiology and risk factors for VTE in unselected medical inpatients have not been extensively studied, and uncertainties remain about the prophylactic strategy in these patients. Materials and methods: In a prospective, observational, multicenter study we aimed to contemporarily assess the epidemiology of symptomatic VTE in consecutive patients hospitalized in Internal Medicine, to evaluate the impact of potential risk factors, and the attitude of internists towards thromboprophylaxis. A total of 4,846 patients were included, during the period March-September 2006. Results: Symptomatic VTE was registered in 177 (3.65%) patients; of these, 26 cases (0.55%) occurred with onset of symptoms > 48 hours after admission (‘‘hospital-acquired’’ events, primary study end-point). Previous VTE and bed resting were significantly associated with venous thromboembolism, while a trend for increased risk was documented in cancer patients. During hospital stay antithrombotic prophylaxis was globally administered in 41.6% of patients, and in 58.4% of those for which prophylaxis was recommended according to 2004 guidelines by the American College of Chest Physicians. The choice of administering tromboprophylaxis appeared qualitatively adherent to indications from randomized trials and international guidelines, and bed rest was the strongest determinant of the use of prophylaxis. Conclusions: Data from our real-world study confirm that VTE is a quite common finding in patients admitted to Internal Medicine departments, and recommended tromboprophylaxis is still underused, in particular in some patients groups. Further efforts are needed to better define the risk profile and to optimize prophylaxis in the heterogeneous setting of medical patients.

Pneumonia in nursing home patients: is it time for a specific therapeutic strategy?

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). Results: The study examined 1,219 patients coming from private residence, and 179 with NHAP. Failures of therapy were significantly more frequent in patients with NHAP (35.8% vs 24.9%; Odds Ratio 1.48; 95% confidence interval 1.05-2.09). Mortality was higher in patients coming from nursing home (24.0% vs 9.8%; OR 2.59; 95% CI 1.72-3.90). Antibiotic treatment was more frequently performed as monotherapy in case of NHAP. Conclusions: At the time of FASTCAP, NHAP was included in the category of CAP, and coherently, treatment of NHAP was not more aggressive if compared to community-acquired infections. However, our results confirm that NHAP is at increased risk for worst outcome, and probably worth considering for specific therapeutic strategies. Future studies are needed to better assess the microbiology of NHAP, and to evaluate if specific treatments, as those recommended by recent guidelines, may improve the outcome for these high-risk patients.

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

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.

Use of glucocorticoids in pregnancy

For many years glucocorticoids have been used world-wide in pregnant women for treatment of a variety of medical disorders, from bronchial asthma to systemic lupus erythematosous, to renal transplant. More recently their administration has been successfully addressed to the prevention of congenital fetal diseases. In some of these, such as for instance the 21-hydroxylase deficiency leading to congenital adrenal hyperplasia, the pathogenic mechanism is well known, while in others, such as the cystic adenomatoid malformation of the lung, it is not yet understood. Besides these types of diseases, there are acquired inflammatory conditions impairing the physiologic evolution of pregnancy that benefit from glucocorticoid administration. This is the case in recurrent miscarriage due to increased concentration of decidual Natural Killer cells, as well as in the Romero's syndrome, leading to premature parturition and related life threatening fetal complications. However, in spite of its prominent efficacy, the therapy is generally viewed with some suspicion because of possible fetal and maternal adverse effects. With the aim to contribute to a better knowledge of the basic mechanisms of glucocorticoid protection, we reviewed the regulation of their trans-placental passage, their biological effects on gestational environment, their possible 'programming' and teratogenic action, and their accepted use for prevention and cure of pregnancy complications. We believe that a more qualified and liberal use of these compounds will lead in many cases to a significant improvement of fetal and maternal prognosis.

Incidence and predictors of venous thromboembolism in post-acute care patients. A prospective cohort study

Few studies have addressed the topic of venous thromboembolism (VTE) in patients hospitalised in rehabilitation facilities. This patient population is rapidly growing, and data aimed to better define VTE risk in this setting are needed. Primary aim of this prospective observational study was to evaluate the frequency of symptomatic, objectively confirmed VTE in a cohort of unselected consecutive patients admitted to rehabilitation facilities, after medical diseases or surgery. Further objectives were to assess overall mortality, to identify risk factors for VTE and mortality, and to assess the attitude of physicians towards thromboprophylaxis. A total of 3,039 patients were included in the study, and the median duration of hospitalisation was 26 days. Seventy-two patients (2.4%) had symptomatic VTE. The median time to VTE from admission to the long-term care unit was 13 days. According to multivariable analysis, previous VTE (hazard ratio 5.67, 95% confidence interval 3.30-9.77) and cancer (hazard ratio 2.26, 95% confidence interval 1.36-3.75) were significantly associated to the occurrence of VTE. Overall in-hospital mortality was 15.1%. Age over 75 years, male gender, disability, cancer, and the absence of thromboprophylaxis were significantly associated to an increased risk of death (multivariable analysis). In-hospital antithrombotic prophylaxis was administered to 75.1% of patients, and low-molecular-weight heparin was the most widely used agent. According to our study, patients admitted to rehabilitation facilities remain at substantially increased risk for VTE. Because this applies to the majority of these patients, there is a great need for clinical trials assessing optimal prophylactic strategies.

In-hospital symptomatic venous thromboembolism and antithrombotic prophylaxis in Internal Medicine. Findings from a multicenter, prospective study

Hospitalised medical patients are at increased risk of venous thromboembolism (VTE), but the incidence of hospitalisation-related VTE in unselected medical inpatients has not been extensively studied, and uncertainties remain about the optimal use of thromboprophylaxis in this setting. Aims of our prospective, observational study were to assess the prevalence of VTE and the incidence of symptomatic, hospitalisation-related events in a cohort of consecutive patients admitted to 27 Internal Medicine Departments, and to evaluate clinical factors associated with the use of thromboprophylaxis. Between March and September 2006, a total of 4,846 patients were included in the study. Symptomatic VTE with onset of symptoms later than 48 hours after admission ("hospital-acquired" events, primary study end-point) occurred in 26 patients (0.55%), while the overall prevalence of VTE (including diagnosis prior to or at admission) was 3.65%. During hospital stay antithrombotic prophylaxis was administered in 41.6% of patients, and in 58.7% of those for whom prophylaxis was recommended according to the 2004 Guidelines of the American College of Chest Physicians. The choice of administering thromboprophylaxis or not appeared qualitatively adherent to indications from randomised clinical trials and international guidelines, and bed rest was the strongest determinant of the use of prophylaxis. Data from our real-world study confirm that VTE is a relevant complication in patients admitted to Internal Medicine Departments, and recommended tromboprophylaxis is still under-used, in particular in some patients groups. Further efforts are needed to better define risk profile and to optimise prophylaxis in the heterogeneous setting of medical inpatients.

Serum leptin levels are higher in females affected by frontotemporal lobar degeneration than Alzheimer's disease

Frontotemporal lobar degeneration (FTLD) includes different heterogeneous conditions, mainly characterised by personality changes, along with cognitive deficits in language and executive functions. Movement disorders are variably represented. Behavioural disturbances constitute the core feature of FTLD, and eating disorders represent one of the most distinguishing symptoms between FTLD and Alzheimer's disease (AD). The biochemical correlates of such dysfunctions remain to be defined. The adipocyte derived hormone leptin is known to play a foundamental role in food intake and energy balance. To understand whether leptin could be involved in FTLD eating abnormalities, we measured serum leptin levels in 59 patients with FTLD compared with 25 with AD. Serum leptin levels in patients with FTLD were comparable with those in patients with AD. Nevertheless, females with FTLD showed significantly higher leptin levels compared with females with AD. No difference was found between FTDL and AD males or within the spectrum of patients with FTLD. Hyperphagic FTLD females showed higher circulating leptin levels in comparison with those without eating abnormalities; no differences were found between males with FTLD with respect to serum leptin and food intake disturbances. The present study showed a selective gender difference in leptin levels between females with FTLD and AD, which may suggest specific cognitive and behavioural networks need to be investigated.

Targeting IKK2 by pharmacological inhibitor AS602868 prevents excitotoxic injury to neurons and oligodendrocytes

Among the diverse mechanisms involved in the pathophysiology of post-ischemic and post-traumatic injuries, excitotoxicity and nuclear factor-kappaB (NF-kappaB) activation through induction of IkappaB kinase (IKK) complex have a primary role. We investigated the effects of the selective inhibitor of the IKK2 subunit, the anilinopyrimidine derivative AS602868, on excitotoxic injury produced in rat organotypic hippocampal slices and cerebellar primary neurons. Brief exposure to N-methyl-D-aspartate (NMDA) induces astrocyte reactivity, neuron cell death and oligodendrocyte degeneration in hippocampal slices. Application of AS602868 elicited a long-lasting protection of both neurons and oligodendrocytes. Maximal effect was observed with prolonged application of the compound after NMDA exposure. Neuroprotection was also evident in primary cultures of cerebellar granule cells starting from 20 nM concentration. AS602868-elicited neuroprotection correlated with inhibition of NF-kappaB activity. Our results suggest that AS602868 may prove to be a valuable approach in treating neurodegeneration and demyelination associated with cerebral trauma and ischemia.

Genotyping of Pneumocystis jiroveci pneumonia in Italian AIDS patients. Clinical outcome is influenced by dihydropteroate synthase and not by internal transcribed spacer genotype

BACKGROUND

Two Pneumocystis jiroveci independent genomic regions, internal transcribed spacer (ITS) 1 and ITS2, and dihydropteroate synthase (DHPS) gene have been used for typing a cohort of HIV-infected Italian patients with P jiroveci pneumonia (PcP).

METHODS

Bronchoalveolar lavage samples isolated from 207 HIV-infected adults were ITS and DHPS genotyped by DNA sequencing and by restriction fragment length polymorphism analysis, respectively. Mutant DHPS samples were cloned and ITS typed. Data on severity, treatment, and outcome of PcP were obtained by chart review.

RESULTS

High diversity with 46 different ITS genotypes was observed. At the DHPS locus, 9.1% of samples analyzed were found to be mutated. A correlation was observed between DHPS mutants and greater severity of PcP, as defined by higher lactate dehydrogenase (P = 0.015) and need for intubation (P = 0.002), and worse outcomes, as defined by failure of sulfa treatment (P = 0.04), death, and/or relapse of PcP (P = 0.008). There was a significant difference in ITS genotype patterns between DHPS wild-type and mutants (P = 0.028).

CONCLUSIONS

The present data suggest the absence of a correlation between P jiroveci ITS types and specific clinical characteristics. DHPS mutations correlate with possible failure of anti-P jiroveci sulfa therapy, and a trend of association is shown between DHPS mutations and some clinical PcP features.

Comparison of sequential combined spinal-epidural anesthesia and spinal anesthesia for cesarean section

AIM

The aim of our study was to prove that by using sequential combined spinal-epidural (CSE) anesthesia it is possible to overcome the limits connected to the use of spinal anesthesia (SA) alone for elective cesarean section.

METHODS

We examined 100 women submitted to cesarean section; SA was administered to 50 patients and sequential CSE technique to the other 50. In every woman before execution of the anesthesia we infused 500 mL of a plasma expander and a previous administration of 5 mg of ephedrine. The CSE was executed at the L1-L2 intervertebral space, administering in spinal anesthesia 5 mg of levobupivacaine with 5 _g of sufentanil, and in peridural anesthesia 10-12 mL of levobupivacaine 0.25% according to the patient's height. The peridural catheter for postoperative analgesia was then positioned. In the group of women submitted only to SA, 7.5-8 mg of levobupivacaine was injected, according to the patient's height, in the L1-L2 intervertebral space, with 5 _g of sufentanil. We considered the following adverse effects: hypotension; bradycardia; vomiting; intraoperative discomfort and motor block.

RESULTS

The results obtained showed that, with a P < or = 0.05, the incidence of motor block (P < 0.001), discomfort (P < 0.001) and hypotension (P = 0.021) in the SA group is greater than in the CSE group. The difference in the incidence of vomiting (P = 0.147) and bradycardia (P = 0.067) between the 2 groups is not statistically significant.

CONCLUSIONS

In our opinion sequential CSE can be considered an important step forward in the regional anesthesia used for elective cesarean section.

Altered glucose metabolism and proteolysis in pancreatic cancer cell conditioned myoblasts: searching for a gene expression pattern with a microarray analysis of 5000 skeletal muscle genes

BACKGROUND AND AIMS

We verified whether conditioned media (CM) from pancreatic cancer cell lines (MIAPaCa2, CAPAN-1, PANC-1, BxPC3) alter glucose metabolism and gene expression profiles (microarray experiment with a platform of 5000 skeletal muscle cDNA) in mice myoblasts.

METHODS

Myoblasts were incubated with control or pancreatic cancer CM for 24 and 48 hours.

RESULTS

Lactate significantly increased in CM compared with non-conditioned myoblasts. No variations in expression levels of the main genes involved in glycolysis were found in CM myoblasts. Propionyl coenzyme A carboxylase and isocitrate dehydrogenase 3 beta genes, which encode enzymes of the tricarboxylic acid cycle, were overexpressed, while IGFIIR and VAMP5 genes were underexpressed in CM myoblasts. PAFAH1B1 and BCL-2 genes (intracellular signal transduction) and the serine protease cathepsin G (proteolysis), were overexpressed in CM myoblasts. Tyrosine accumulation in CM myoblasts suggested that proteolysis overcomes protein synthesis. Sorcin, actin alpha, troponin T1, and filamin A were underexpressed in CM myoblasts.

CONCLUSIONS

Our findings demonstrate that pancreatic cancer cell conditioned media enhanced lactate production and induced proteolysis, possibly by altering expression levels of a large number of genes, not only those involved in protein biosynthesis and degradation or glucose metabolism, but also those involved in the tricarboxylic acid cycle and in vesicle traffic.

Assessment of immune reconstitution to Pneumocystis carinii in HIV-1 patients under different highly active antiretroviral therapy regimens

The introduction of protease inhibitors (PIs) gave a dramatic drop in AIDS-related opportunistic events, mainly due to induced immune reconstitution. Discontinuation of prophylaxis against Pneumocystis carinii is considered safe when CD4 > 200 cells/mm(3). Ideally, we should have specific functional tests for HIV-1-related decisions. We examined viro-immunological profiles, clinical outcome and lymphocyte proliferation (LP) to P. carinii and other antigens in 108 subjects: 28 AIDS presenters with P. carinii pneumonia (PCP) (CD4 < 200 cells/mm(3)), 22 untreated asymptomatic HIV-1-infected patients (CD4 > 200 cells/mm(3)), 44 HIV-1-infected patients immune-reconstituted on antiretroviral regimens and 14 HIV-1-uninfected healthy controls. As regards viral load, there was no significant difference in therapy duration, nadir, or actual CD4, CD8, natural killer or B cell counts in immune-reconstituted patients receiving protease inhibitor (PI)-based versus those receiving PI-sparing antiretroviral regimens. Among subjects showing abnormally low P. carinii-specific LP, three patients receiving a non-nucleoside reverse transcriptase inhibitor (nNRTI) developed PCP despite having CD4 > 250 cells/mm(3). P. carinii-specific LP could be considered for doubtful situations, i.e. for a safer clinical decision of discontinuing or restarting prophylaxis in patients with a low CD4 nadir or experiencing a sudden CD4 decrease under highly active antiretroviral therapy (HAART). HIV-1 PIs, having in vitro aspecific effects against Pneumocystis, could play a clinically significant anti-opportunistic role, thus offering a further benefit in heavily immunosuppressed patients during early stages of antiretroviral therapy.

Mutations in the dihydropteroate synthase gene of human-derived Pneumocystis carinii isolates from Italy are infrequent but correlate with prior sulfa prophylaxis

Mutations in the human-derived Pneumocystis carinii dihydropteroate synthase (DHPS) gene have been reported with increasing frequency and have been linked to prior sulfa prophylaxis and possible emergence of sulfa resistance. This study was done to examine the prevalence and clinical significance of P. carinii DHPS mutations in Italian patients. A previously described single-strand conformation polymorphism technique was used to identify P. carinii DHPS mutations in 107 patients with acquired immunodeficiency syndrome. Overall prevalence (8%) was low compared with that in other reports. Mutations were observed in 19% (6/31) of patients exposed to sulfa prophylaxis, compared with 4% (3/76) of patients not exposed to sulfa prophylaxis (P=.017). No significant association was observed between the presence of DHPS mutations and mortality, CD4 cell count, or demographic factors. The study confirms the association between DHPS mutations and prior sulfa prophylaxis and shows that the prevalence of DHPS mutations in an Italian patient population is lower than that in other populations.

Cytokine imbalance in pregnancies with fetal chromosomal abnormalities

BACKGROUND

The aim of the present study is to investigate the levels of some of the cytokines which may be involved in the mechanisms leading to the impairment of placental perfusion and to the onset of uterine contractions in pregnancies with fetal genetic abnormalities compared with controls.

METHODS

The amniotic fluid and maternal plasma levels of interleukin-6, interleukin-8 and tumour necrosis factor-beta in patients with fetal chromosomal abnormalities were measured, as well as in euploid pregnancies in the seventh week of gestation.

RESULTS

An increase of interleukin-6 (P = 0.034) and a decrease of interleukin-8 (P < or =0.0001) in amniotic fluid, and a decrease of interleukin-6 in the maternal plasma (P = 0.026) was shown in pregnancies with fetal chromosomal abnormalities. A positive correlation was observed between amniotic interleukin-8 and serum interleukin-6 in the presence of fetal aneuploidy (P < 0.006).

CONCLUSION

Further investigations of cytokine imbalance in pregnancies with poor outcome as a consequence of genetic disorders rather than infection is warranted.

Alternative splicing of mGlu6 gene generates a truncated glutamate receptor in rat retina

A novel splice variant of metabotropic glutamate receptor type 6 (mGlu6 receptor) was identified by reverse transcription-polymerase chain reaction amplification and sequence analysis of rat retina cDNA. The new rat receptor isoform (mGlu6b receptor) is characterized by an additional exon of 88 nucleotides containing an inframe stop codon, thus predicting the expression of a truncated protein of 508 amino acids. In situ hybridization reveals mGlu6b receptor mRNA to be predominantly expressed in the outer part of the inner nuclear layer of rat retina, containing ON-bipolar cells. The mGlu6b protein would comprise the extracellular domain of the receptor containing the ligand-binding site, but would lack the transmembrane and intracellular portions, thus possibly acting as a retinal soluble receptor for glutamate.

Combination of continuous subcutaneous infusion of insulin and octreotide in Type 1 diabetic patients

The effect of 7 day continuous subcutaneous infusion of octreotide (200 microg day(-1)) was evaluated in seven insulin-pump treated Type 1 diabetic patients (age 43+/-1.5 year; BMI 25.1+/-0.7 kg m(-2); HbA(1c) 7.4+/-0.3%). A 24-h metabolic and hormonal profile, and a euglycaemic hyperinsulinaemic clamp (0.25, 0.5, 1.0 mg kg(-1) min(-1)), with [3H]glucose infusion and indirect calorimetry, were performed before and after a 7-day octreotide infusion. Mean 24-h plasma glucose was similar before and after octreotide (9.7+/-0.8 vs. 9.1+/-1.0 mmol l(-1)) but insulin requirement dropped by 45% (49+/-4 vs. 27+/-2 U day(-1); P<0.01). Both 24-h plasma hGH and glucagon were suppressed by octreotide (1.85+/-0.35 vs. 0.52+/-0.04 microg l(-1), and 117+/-23 vs. 102+/-14 ng l(-1), respectively). Glucose utilisation increased after octreotide (insulin 0.5 mU kg(-1) min(-1) clamp 3.09+/-0.23 vs. 4.19+/-0.19 mg kg(-1) min(-1); 1 mU kg(-1) min(-1) clamp 5.64+/-0.61 vs. 7.93+/-0.57 mg kg(-1) min(-1); both P<0.05) and endogenous glucose production was similarly suppressed. Glucose oxidation was not affected by octreotide, while the improvement in glucose storage (insulin 1.0 mU kg(-1) min(-1) clamp 3.89+/-0.60 vs. 5.64+/-0.67 mg kg(-1) min(-1), P<0.05) entirely accounted for the increase in glucose disposal. Endogenous glucose production was more effectively suppressed at the two lower insulin infusion rates (P>0.05). Energy expenditure declined after octreotide. Continuous subcutaneous octreotide infusion suppresses counterregulatory hormones, increases insulin-mediated glucose metabolism by enhancing glucose storage, and reduces energy expenditure. These results support a role for counterregulatory hormones in the genesis of insulin resistance and the catabolic state of Type 1 diabetes.

Identification of novel alternatively-spliced mRNA isoforms of metabotropic glutamate receptor 6 gene in rat and human retina

Novel splice variants of metabotropic glutamate receptor type 6 (mGlu6 receptor) were identified by reverse transcription-polymerase chain reaction (RT-PCR) amplification and sequence analysis of rat and human retina cDNAs. The new rat mGlu6 receptor mRNA isoform is characterized by an additional exon of 88 nucleotides containing an in frame stop codon, thus predicting the expression of a truncated protein of 508 amino acids. The human retina was found to express two different mGlu6 receptor mRNA variants: one lacking 97 nucleotides from exon 6, the other including five nucleotides of intron 5. These mRNAs would encode truncated receptors of 425 and 405 amino acids, respectively. Both in rats and in humans, the truncated mGlu6 receptor proteins would comprise the extracellular domain but lack the transmembrane and intracellular portion of the receptor, thus possibly acting as retinal soluble receptors for glutamate. Though generated by different patterns of alternative splicing, the inter-species conservation of truncated mGlu receptor molecules strongly suggest their relevance in the regulatory network of glutamatergic neurotransmission.