From intensive care to rehabilitation: survey on the satisfaction with care received during prolonged hospitalization for COVID-19 at a northern Italian university hospital

OBJECTIVE

Investigating the experiences perceived by COVID-19 inpatients is a fundamental research area that is starting to be explored. For this reason, our objective was to provide the first Italian survey on COVID-19 inpatients' satisfaction, obtained through a self-completed questionnaire previously used in a reference study in a UK cohort of COVID-19 patients.

SUBJECTS AND METHODS

Hospitalized COVID-19 patients (>20 days) admitted to Ferrara University Hospital who underwent rehabilitation during their hospital stay were invited to complete an anonymous questionnaire. The survey's questions explored the patients' satisfaction with the health services received, and their completion took place approximately one year after hospitalization. Information on sex, number of wards, ICU stays, and hospital discharge dates was collected.

RESULTS

Sixty-two completed questionnaires were analyzed. The average overall satisfaction score obtained from the answers indicated by the participants in the tenth question was 4.7 out of 5.0. Very positive responses were observed for information about discharge plans, privacy, management of pain, sleep quality, and feeling of safety. The possibility of being consulted about medications and side effects received a very low satisfaction score. Considering overall satisfaction, no significant differences were noted for sex or ICU stay. The obtained results were almost superimposable to those reported in the cohort of COVID-19 patients of the reference study.

CONCLUSIONS

This survey suggested that COVID-19 patients' healthcare satisfaction was high. Nevertheless, some areas must be improved, such as the communication and involvement of the patients in the decision-making of care and the discussion about medications or possible side effects.

Dementia and Related Comorbidity: Analysis of 2 Years of Admissions to Italian Hospitals

BACKGROUND

The aim of the present study was to examine the prevalence of dementia, related comorbidities, and mortality rates in hospitalized elderly patients in Italy.

METHODS

Data were obtained from the Italian Ministry of Health and included all discharge records from Italian hospitals concerning subjects aged 65 years or above admitted to acute Internal Medicine during 2 years (n=3,695,278 admissions). Discharge diagnoses were re-classified into 24 clusters, each including homogeneous diseases by the ICD-9-CM code classification. Dementia was identified by the presence of ICD-9-CM codes 290, 294, or 331 series.

RESULTS

Patients with dementia represented 7.5% of the sample; compared with those without dementia, they were older and more often female, had a greater length of hospital stay and higher mortality rate. Besides delirium [odds ratio (OR): 54.20], enthesopaties (OR: 2.19), diseases of fluids and electrolytes (OR:1.96), diseases of arteries (OR: 1.69), skin diseases (OR: 1.64), and pneumonia and pleurisy (OR: 1.53) were the diseases more strongly associated with the diagnosis of dementia, independent of other clusters, age, sex, and length of stay.

CONCLUSIONS

Some comorbidities are specifically associated with the diagnosis of dementia among hospitalized elderly patients. Overall, these comorbidities describe the typical clinical profile of the patient with advanced dementia and could be treated in the context of the primary care, since they do not require specific skills belonging to hospital settings.

Acute cholestasis as uncommon onset of Kawasaki disease: a case report

BACKGROUND

Kawasaki disease (KD) or mucocutaneous lymph node syndrome is a vasculitis that mostly occurs in young children. Adult-onset KD (AKD) is rare and often misdiagnosed. Here we report a rare case of KD with cholestasis as principal symptom.

CASE PRESENTATION

A 43-year-old caucasian man was admitted to our hospital for high fever, lack of appetite related to nausea and vomiting, headache and significant malaise. Physical examination highlighted fever, increasing jaundice, bilateral laterocervical lymph nodes, erythema of the palms, and strikingly red lips and conjunctiva. The clinical course was complicated by arterial hypotension, tachycardia, decreasing haemoglobin, increasing acute phase reactants tests, and multiorgan failure. Due to cardiovascular instability the patient was admitted to the local Intensive Care Unit. Chest X-ray, abdominal ultrasound, chest and abdominal CT and Colangio Magnetic Resonance were normal. Jaundice was investigated and infections, autoimmune diseases or drugs adverse reactions, were excluded. Also coronary artery computed tomography was carried out excluding coronary artery aneurysms. Broad-spectrum antibiotics were not effective. After exclusion other possible conditions, diagnosis of KD was set. He was treated with high doses of corticosteroids and acetylsalicylic acid and clinical conditions as well as laboratory exams improved.

CONCLUSIONS

This report dealing with an adult onset of atypical KD may be of benefit to physicians of various specialties, including primary care doctors, hospital internists, intensivists and gastroenterologists due to its peculiarities. It demonstrates that a case of prolonged fever unresponsive to antibiotics and related to cholestatic jaundice, oedema or erythema of the extremity associated with desquamation of feet and hands, and red eyes, may suggest atypical form of KD.

Sex and acute oesophageal variceal bleeding-related in-hospital mortality: a 15-year retrospective study

OBJECTIVE

The relationship between in-hospital mortality (IHM) and acute oesophageal variceal bleeding (AOEVB) has not been fully assessed. The aim of this study was to establish the association between sex and mortality for patients hospitalized with AOEVB.

PATIENTS AND METHODS

We analyzed hospitalizations from the Italian Health Ministry database by identifying all patients discharged with AOEVB from January 2001 to December 2015. A total of 144,943 hospitalizations were for oesophageal varices, but only 24,570 emergency admissions with AOEVB coded as the primary or secondary diagnosis were included for analysis. Factors independently associated with IHM were evaluated by multilevel logistic regression.

RESULTS

Approximately half of the population was aged ≥ 65 years, and nearly 10% was diagnosed with hepatocellular carcinoma. Overall, the IHM was 11.8%, with 12.1% in males and 11.3% in females, increasing from 9.2% among subjects aged < 55 years to 18.9% among those aged ≥ 85 years. The crude risk of death was slightly higher among females; however, when age and clinical presentation were considered, female sex was associated with reduced mortality. For liver disease, the risk of death in women was lower only in those with non-alcoholic liver disease (odds ratio= 0.77, 0.66-0.89), but it was similar to that in men for unspecified, cancer and alcoholic liver disease. The risk declined over time and was increased in patients with multiple comorbidities.

CONCLUSIONS

AOEVB-related IHM decreased from 2001-2005 to 2011-2015. Factors affecting mortality included liver disease, age, sex, development of hepatocellular carcinoma and comorbidities.

Validation and Comparison of a Modified Elixhauser Index for Predicting In-Hospital Mortality in Italian Internal Medicine Wards

Purpose

Burden of comorbidities appears to be related to clinical outcomes in hospitalized patients. Clinical stratification of admitted patients could be obtained calculating a comorbidity score, which represents the simplest way to identify the severity of patients' clinical conditions and a practical approach to assess prevalent comorbidities. Our aim was to validate a modified Elixhauser score for predicting in-hospital mortality (IHM) in internal medicine admissions and to compare it with a different one derived from clinical data previously used in a similar setting, having a good prognostic accuracy.

Patients and Methods

A single-center retrospective study enrolled all patients admitted to internal medicine department between January and June 2016. A modified Elixhauser score was calculated from chart review and administrative data; moreover, a second prognostic index was calculated from chart review only. Comorbidity scores were compared using c-statistic.

Results

We analyzed 1614 individuals without selecting the reason for admission, 224 (13.9%) died during hospital stay. Deceased subjects were older (83.3±9.1 vs 78.4±13.5 years; p<0.001) and had higher burden of comorbidities. The modified Elixhauser score calculated by administrative data and by chart review and the comparator one was 18.13±9.36 vs 24.43±11.27 vs 7.63±3.3, respectively, and the c-statistic was 0.758 (95% CI 0.727-0.790), 0.811 (95% CI 0.782-0.840) and 0.740 (95% CI 0.709-0.771), respectively.

Conclusion

The new modified Elixhauser score showed a similar performance to a previous clinical prognostic index when it was calculated using administrative data; however, its performance improved if calculation was based on chart review.

Impact of hospital admissions subsequent to renal transplantation on Italian regional resources: a retrospective study in the Italian region of Emilia-Romagna

BACKGROUND

Aim of this retrospective study was to investigate costs and resource consuming, expressed by diagnosis related groups (DRG), related only to hospitalizations of renal transplant recipients (RTRs) for all causes in the Region Emilia Romagna (RER) in Italy.

METHODS

We included all hospital admissions of RTRs (International Classification of Diseases 9th Revision, Clinical Modification [ICD-9-CM] code V420) between 2001 and 2015. We calculated number of admissions, RTRs and inhabitants of RER for each year, mean age, length of stay (LOS) in the hospital as total number of days, mean and median days, mean value of DRG and costs of admissions during the 15-year period of the study.

RESULTS

RTRs admitted in the 15 years study period were 9,197 and mean age 56.6±1.6 years. Admissions were 14,558, and mean rate of admitted RTRs (*100,000) was 14.21. Total, mean and median LOS were 122,966, 8.7 and 6 days, respectively. Total costs of admissions during the study period were €72,717,232 with mean DRG values of €3,409. Number of admissions and total number of days required for RTRs as well as mean age of admitted patients increased from 2001 to 2015, however mean and median LOS remained stable.

CONCLUSIONS

Costs due to admissions of RTRs appeared to gradually increase in the long term probably due to the increasing number of admissions and increasing mean age of admitted RTRs.

Infections and internal medicine patients: Could a comorbidity score predict in-hospital mortality?

Infectious diseases (ID) are frequently cause of internal medicine wards (IMW) admission. We aimed to evaluate risk factors for in-hospital mortality (IHM) in IMW patients with ID, and to test the usefulness of a comorbidity score (CS).This study included ID hospital admissions between January 2013, and December 2016, recorded in the database of the local hospital. ICD-9-CM codes were selected to identify infections, development of sepsis, and to calculate a CS.We analyzed 12,173 records, (age 64.8 ± 25.1 years, females 66.2%, sepsis 9.3%). Deceased subjects (1545, 12.7%) were older, had higher percentage of sepsis, pulmonary infections, and endocarditis. Mean value of CS was also significantly higher. At multivariate analysis, the odds ratio (OR) for sepsis (OR 5.961), endocarditis (OR 4.247), pulmonary infections (OR 1.905), other sites of infection (OR 1.671), and urinary tracts infections (OR 0.548), were independently associated with IHM. The CS (OR 1.070 per unit of increasing score), was independently associated with IHM as well. The calculated weighted risk, obtained by multiplying 1.070 for the mean score value in deceased patients, was 19.367. Receiver operating characteristic (ROC) analysis showed that CS and development of sepsis were significant predictors for IHM (area under the curve, AUC: 0.724 and 0.670, respectively).Careful evaluation of comorbidity in internal medicine patients is nowadays matter of extreme importance in IMW patients hospitalized for ID, being IHM related to severity of disease, type and site of infection, and also to concomitant comorbidities. In these patients, a careful evaluation of CS should represent a fundamental step in the disease management.

Higher mortality rate in patients hospitalised for acute pulmonary embolism during weekends

The management of acute pulmonary embolism (PE) is often challenging and requires specific medical expertise, diagnostic techniques and therapeutic options that may not be available in all hospitals throughout the entire week. The aim of our study was to evaluate whether or not an association exists between weekday or weekend admission and mortality for patients hospitalised with acute PE. Using routinely collected hospital administrative data, we examined patients discharged with a diagnosis of PE from the hospitals of the Emilia- Romagna Region in Italy (January 1999-December 2009). The risk of inhospital death was calculated for admissions at the weekend and compared to weekday admissions. Of a total of 26,560 PEs, 6,788 (25.6%) had been admitted during weekends. PE admissions were most frequent on Mondays (15.8%) and less frequent on Saturdays and Sun- days/holidays (12.8%) (p<0.001). Weekend admissions were associated with significantly higher rates of in-hospital mortality than weekday admissions (28% vs. 24.8%) (p<0.001). The risk of weekend admission and in-hospital mortality was higher after adjusting for sender, hospital characteristics, and the Charlson co-morbidity index. In conclusion, hospitalisation for PE on weekends seems to be associated with a significantly higher mortality rate than on weekdays. Further research is needed to investigate the reasons for this observed difference in mortality in order to try and implement future strategies that ensure an adequate level of care throughout the entire week.

Weekend Versus Weekday Admission and In-Hospital Mortality for Pulmonary Embolism: A 14-Year Retrospective Study on the National Hospital Database of Italy

We assessed the association between weekday (WD) or weekend (WE) admission and mortality for patients hospitalized with acute pulmonary embolism (PE). Weekend included holidays. We analyzed hospital administrative data of all patients discharged with a diagnosis of PE extracted from the Italian Health Ministry database (January 2001 to December 2014). A total of 265 035 hospitalizations with a diagnosis of PE were retrieved, in which PE was the primary diagnosis in 198 565 (74.9%); 200 166 (75.5%) patients were admitted on WD and 64 869 (24.5%) on WE. Admissions for PE were more frequent on Mondays (41 917 admissions, 15.8% of all events) and less frequent on Saturdays (32 295 admissions, 12.2%) and Sundays (32 574 admissions, 12.3%). Patients admitted on WE were on average 1 year older, presented more frequently with respiratory failure, and had more common comorbidities. After adjustment for age, gender, comorbidities, and presence of respiratory failure, in-hospital mortality for patients admitted on WE was greater (odds ratio: 1.15, 95% confidence interval: 1.13-1.18; P < .001). This study supports that, in Italy, hospitalization for PE on WE is associated with a significantly higher mortality rate than on WD.

A modified Elixhauser score for predicting in-hospital mortality in internal medicine admissions

BACKGROUND

In-hospital mortality (IHM) is an indicator of the quality of care provided. The two most widely used scores for predicting IHM by International Classification of Diseases (ICD) codes are the Elixhauser (EI) and the Charlson Comorbidity indexes. Our aim was to obtain new measures based on internal medicine ICD codes for the original EI, to detect risk for IHM.

MATERIAL AND METHODS

This single-center retrospective study included hospital admissions for any cause in the department of internal medicine between January 1, 2000, and December 31, 2013, recorded in the hospital database. The EI was calculated for evaluation of comorbidity, then we added age, gender and diagnosis of ischemic heart disease. IHM was our outcome. Only predictors positively associated with IHM were taken into consideration and the Sullivan's method was applied in order to modify the parameter estimates of the regression model into an index.

RESULTS

We analyzed 75,586 admissions (53.4% females) and mean age was 72.7±16.3years. IHM was 7.9% and mean score was 12.1±7.6. The points assigned to each condition ranged from 0 to 16, and the possible range of the score varied between 0 and 89. In our population the score ranged from 0 to 54, and it was higher in the deceased group. Receiver operating characteristic curve of the new score was 0.721 (95% CI 0.714-0.727, p<0.001).

CONCLUSIONS

In order to make prognostic assessment, the use of a score could be of help in targeting interventions in older adults, identifying subjects at high risk for IHM.

Chronobiology of Takotsubo Syndrome and Myocardial Infarction: Analogies and Differences

Several pathophysiologic factors, not harmful if taken alone, are capable of triggering unfavorable events when presenting together within the same temporal window (chronorisk), and the occurrence of many cardiovascular events is not evenly distributed in time. Both acute myocardial infarction and takotsubo syndrome seem to exhibit a temporal preference in their onset, characterized by variations according to time of day, day of the week, and month of the year, although with both analogies and differences.

Marital Status, Cardiovascular Diseases, and Cardiovascular Risk Factors: A Review of the Evidence

BACKGROUND

There is evidence showing that marital status (MS) and marital disruption (i.e., separation, divorce, and being widowed) are associated with poor physical health outcomes, including for all-cause mortality. We checked for the available evidence on the association between MS and cardiovascular (CV) diseases, outcomes, and CV risk factors.

METHODS

A search across the PubMed database of all articles, including the term "marital status" in their title, was performed. All articles were then manually checked for the presence of the following terms or topic: CV diseases, acute myocardial infarction, acute coronary syndrome, coronary artery disease, cardiac arrest, heart failure, heart diseases, and CV mortality. Moreover, other search terms were: CV risk factors, hypertension, cholesterol, obesity, smoking, alcohol, fitness and/or physical activity, and health. Systematic reviews, meta-analyses, controlled trials, cohort studies, and case-control studies were potentially considered pertinent for inclusion. Case reports, comments, discussion letters, abstracts of scientific conferences, articles in other than English language, and conference abstracts or proceedings were excluded.

RESULTS

In total, 817 references containing the title words "marital status" were found. After elimination of articles dealing with other topics, 70 records were considered pertinent. Twenty-two were eliminated for several reasons, such as old articles, no abstract, full text unavailable, other than English language, comments, and letters. Out of the remaining 48 articles, 13 were suitable for the discussion, and 35 (accounting for 1,245,967 subjects) were included in this study.

CONCLUSIONS

Most studies showed better outcomes for married persons, and men who were single generally had the poorest results. Moreover, being married was associated with lower risk factors and better health status, even in the presence of many confounding effects.

Lung and kidney: a dangerous liaison? A population-based cohort study in COPD patients in Italy

Background

COPD is among the major causes of death, and it is associated with several comorbid conditions. Chronic kidney disease (CKD) is frequently diagnosed in older people living in Western societies and could impact COPD patients’ mortality. We evaluated the relationship between burden of comorbidities, CKD, and mortality in a population-based cohort of patients discharged with a diagnosis of COPD.

Methods

A longitudinal cohort study was conducted evaluating 27,272 COPD patients. Recruitment of COPD subjects and identification of CKD and other comorbidities summarized by the Charlson comorbidity index (CCI) were based on claims data coded according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Severity of COPD was classified by hospital diagnosis or exemption from medical charges due to respiratory failure or previous hospitalizations for COPD. The impact of comorbidities on survival was assessed by Cox regression.

Results

Less than 40% of patients were still alive at the end of a median follow-up of 37 months (17 months for patients who died and 56 months for those alive at the end of follow-up). After adjustment for age, gender, and severity score of COPD, CKD (hazard ratio =1.36, 95% confidence interval 1.30–1.42) independently from comorbidities summarized by the CCI was a significant risk factor for mortality.

Conclusion

In spite of limitations due to the use of claims data, long-term survival of COPD patients was heavily affected by the presence of CKD and other comorbidities.

Renal Transplantation and Outcome

Emergency surgery represents an independent risk factor for death and postoperative complications. The aim of this study was to investigate the literature data regarding outcome of daytime or nighttime renal transplantation surgery. Relevant papers, focused on renal transplantation surgery, time of the day, and complications, were searched across the PubMed database. We used the following search terms: “renal”, “transplantation”, “surgery”, “daytime”, “nighttime”, and “outcome”. A total of five papers, including 6,991 adult patients were evaluated. All patients received renal transplantation from deceased donor. Daytime or nighttime surgery do not seem to negatively impact on graft survival in renal transplantation. However, two out five studies reported higher odds of complications after nighttime operation. Since it is not possible to predict the availability of a deceased donor, nighttime surgery remains a valid option when necessary, maybe deserving a higher level of caution to reduce or avoid complications.

Hospital readmissions to internal medicine departments: a higher risk for females?

OBJECTIVE

Readmissions to hospital after discharge are considered adverse, serious and costly outcomes. In the last years, two new scores have been proposed to identify patients at high risk of hospital readmission, the HOSPITAL and the Elders Risk Assessment (ERA) indexes. The aim of this study was to evaluate these two scores and the risk of death among internal medicine readmitted patients.

PATIENTS AND METHODS

During a 30-month period, we identified 613 readmitted patients out of 13,237 admissions. Age, sex, length-of-hospital stay (LOS), and deaths were retrospectively analyzed. Readmissions with diagnosis coincident with the index hospitalization were classified as avoidable, whilst those with a different diagnosis were defined as non-avoidable. HOSPITAL score for 30-day potentially avoidable readmission and ERA indexes were calculated.

RESULTS

Readmitted patients (56.6% women), were aged 79±10.4 years. The incidence of 30-day readmission was 20.4 patients/month. Re-hospitalization could be classified as avoidable in 286 cases (46.7%), and death at the end of follow-up was recorded in 366 (59.7%). HOSPITAL score ≥ 7 and ERA score ≥ 16, both able to identify high risk patients for readmission, were present in 108 (17.6%) and 385 (64.4%) of cases, respectively. Patients with non-avoidable readmissions were older, more frequently female, diabetic, and had higher ERA score than subjects with avoidable readmission. Multivariate logistic regression analysis showed that non-avoidable readmissions were independently associated with female gender (OR 1.410 [95% CI 1.012-1.964], p=0.042), and age (OR 1.025 [95% CI 1.006-1.043], p=0.01), while only age (OR 1.034 [95% CI 1.015-1.054], p<0.001) and ERA score (OR 1.047 [95% CI 1.001-1.095], p=0.047) were independently associated with death at the end of follow-up.

CONCLUSIONS

Although re-hospitalization represents frequent phenomenon related to age, non-avoidable readmissions mainly involve female patients. ERA score appears to be an useful practical tool, able to identify high risk patients.

Impact of comorbidity on outcome in kidney transplant recipients: a retrospective study in Italy

The aim of this study was to relate in-hospital mortality (IHM), cardiovascular events (CVEs) and non-immunologic comorbidity evaluated on the basis of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codification, in Italian kidney transplant recipients (KTRs). We evaluated IHM and admissions due to CVEs between 2000 and 2013 recorded in the database of the region Emilia Romagna. The Elixhauser score was calculated for evaluation of non-immunologic comorbidity. Three main outcomes (i.e. IHM, admission due to major CVEs and combined outcome) were the dependent variables of the multivariate models, while age, gender and Elixhauser score were the independent ones. During the examined period, a total of 9063 admissions in 3648 KTRs were recorded; 1945 patients were males (53.3 %) and 1703 females (46.7 %) and the mean age was 52.9 ± 13.1 years. The non-immunological impaired status of the KTRs, examined by the Elixhauser score, was 3.88 ± 4.29. During the 14-year follow-up period, IHM for any cause was 3.2 % (n = 117), and admissions due to CVEs were 527 (5.8 %). Age and comorbidity were independently associated with CVEs, IHM and the combined outcome. Male gender was independently associated with IHM and combined outcome, but not with CVEs. Evaluation of non-immunological comorbidity is important in KTRs and identification of high-risk patients for major clinical events could improve outcome. Moreover, comorbidity could be even more important in chronic kidney disease patients who are waiting for a kidney transplant.

Lack of a “Weekend Effect” for Renal Transplant Recipients

The “weekend (WE) effect” defines the association between WE hospital admissions and higher rate of mortality. The aim of this study was to evaluate the relationship between WE effect and renal transplant recipients (RTRs) using the database of the Emilia-Romagna region (ERR), Italy. We included ERR admissions of RTRs ( International Classification of Diseases, Ninth Revision, Clinical Modification [ ICD-9-CM] code V420) between 2000 and 2013. In-hospital mortality, admissions due to cardiovascular events (CVEs), and the Elixhauser score were evaluated on the basis of ICD-9-CM codification. Out of 9063 hospital admissions related to 3648 RTRs (mean age 53 ± 13 years, 62.9% male), 1491 (16.5%) were recorded during the WE. During the follow-up period, 1581 (17.4%) patients deceased and 366 (4%) had CVEs. Length of hospital stay (LOS) was 9.7 ± 12.1 days. Logistic regression analysis showed that only LOS was independently associated with WE admissions (odds ratio: 1594, confidence interval: 1.385-1.833; P < .001). Renal transplant recipients are not exposed to higher risk of adverse outcome during WE admissions. However, WE admissions were characterized by an increased duration of hospitalization.

Seasonal Variation in Onset of Pulmonary Embolism is Independent of Patients' Underlying Risk Comorbid Conditions

As for many cardiovascular events, pulmonary embolism (PE) is not randomly distributed over time, but shows rhythmic patterns. The purpose of this study was to investigate whether such temporal pattern of occurrence varied in subgroups of patients according to different risk comorbid conditions. All cases of PE observed at the Hospital of Ferrara, Italy, from 1998 to 2001, were considered. After determination of the day of onset, the population was grouped by gender and the most common underlying risk comorbid conditions, e.g., deep vein thrombosis (DVT), neoplasms, cardiomyopathies, traumas/surgical operations, diabetes mellitus, pulmonary diseases, hypertension, cerebrovascular diseases, heart failure, hematologic diseases. For statistical analysis, chi-square test for goodness of fit and partial Fourier series were used. A total of 784 cases (mean age 71 ± 14 years) were included. Frequency of onset was higher in winter for total population (p=0.002), men (p=0.004), DVT (p=0.001), pulmonary disease (p=0.008), cardiomyopathies (p=0.011), and major traumas/surgical operations (p=0.049). Chronobiologic analysis identified a winter peak for total population (p=0.008), men (p<O.OOl), DVT (p=0.006), pulmonary diseases (p=0.017), and hypertension (p=0.026). This study confirms the winter peak of PE and provides evidence that it is not influenced by the underlying clinical conditions, but probably by endogenous variations.

"Timing" of arrival and in-hospital mortality in a cohort of patients under anticoagulant therapy presenting to the emergency departments with cerebral hemorrhage: A multicenter chronobiological study in Italy

Therapy with oral anticoagulants (OACs) is a risk factor for cerebral hemorrhage (CH). Although different studies have been undertaken to investigate the timing of the onset of major cardiovascular events, no data exist on temporal patterns of the onset of CH in subjects treated with OACs. The aim of this study is to evaluate the timing of CH in patients treated with OACs. All patients who developed CH under OACs therapy and admitted to 28 Italian Emergency Departments (EDs) between September 2011 and July 2013 were enrolled. Age, sex, time and location of the hemorrhagic lesion, type of the bleeding events (idiopathic or post-traumatic), anticoagulant therapy (warfarin or new oral anticoagulants - NOAs) and time of ED admission (i.e., hour, day, month and season) were recorded. Five hundred and seventeen patients (63.2% male aged 80 ± 7.9 yrs) with CH were involved. Warfarin was taken by 494 patients (95.6%), and NOAs by 23 (4.4%). In-hospital mortality (IHM) was recorded in 208 cases (40.2%). Cosinor analysis showed a peak of CH arrival between 12:00 and 14:00 h both in the whole population (PR 73.9%, p = 0.002) and the male subgroup (PR 65.2%, p = 0.009), whereas females showed an anticipated morning peak between 08:00 and 10:00 h (PR 65.7%, p = 0.008). A further analysis between idiopathic and post-traumatic CH confirmed the presence of a 24 h pattern with a peak between 12:00 and 14:00 h (PR 58.5%, p = 0.019) and between 08:00 and 10:00 h (PR80.1%, p < 0.001) for idiopathic events and post-traumatic hemorrhages, respectively. Moreover, a seasonal winter peak was identified for idiopathic forms (PR 74%, p = 0.035), and a summer peak for post-traumatic forms (PR 77%, p = 0.025). The present study suggests the presence of a temporal pattern of ED arrivals in CH patients treated with OACs.

Is female gender as harmful as bacteria? analysis of hospital admissions for urinary tract infections in elderly patients

BACKGROUND

Urinary tract infections (UTIs) are common bacterial diseases. We related diagnosis of UTIs based on International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and in-hospital mortality (IHM) in a cohort of hospitalized elderly subjects.

METHODS

All patients admitted between 2000 and 2013 to the general hospital of Ferrara, in northeast Italy, with ICD-9-CM code of UTIs were included. IHM was the main outcome, and age, sex, type of microorganism, sepsis, and Charlson comorbidity index (CCI) based on ICD-9-CM, were also analyzed.

RESULTS

The total sample included 2,266 patients (1,670 women, 73.7%) with UTIs and identification of a cultural organism. Mean age was 81.7±7.5 years (range, 65-103). One hundred and sixteen (5.1%, of whom 34.5% were male and 65.5% were female) cases developed sepsis, and 84 (3.7%, of whom 45.2% were male, 54.8% were female) had a fatal outcome. Nonsurvivors had lower prevalence of IVUs due to Escherichia coli (53.6 vs. 71.7%, p<0.001) and higher prevalence of UTIs due to Pseudomonas aeruginosa (19 vs 7.1%, p<0.001). Moreover, non-survivors developed more frequently sepsis (31% vs. 4.1%, p<0.001), and had higher CCI (2.81±2.43 vs. 2.21±2.04, p=0.011). IHM was independently associated, in decreasing order of odds ratios (ORs), with sepsis (OR 10.3; 95% confidence interval [95% CI] 6.113-17.460, p<0.001), P. aeruginosa infection (OR 2.541; 95% CI 1.422-4.543, p=0.002), female gender (OR 2.324; 95% CI 1.480-3.650, p<0.001), CCI (OR 1.103; 95% CI 1.005-1.210, p=0.038), age (OR 1.034; 95% CI 1.002-1.066, p=0.036), and E. coli infection (OR 0.5; 95% CI 0.320-0.780, p=0.002).

CONCLUSIONS

In a large sample of elderly patients hospitalized for UTIs in a single center in northeastern Italy, apart the development of sepsis, IHM was much more dependent on pathogen and female gender than comorbidity index and age.

The crucial factor of hospital readmissions: a retrospective cohort study of patients evaluated in the emergency department and admitted to the department of medicine of a general hospital in Italy

Background

Early hospital readmissions, defined as rehospitalization within 30 days from a previous discharge, represent an economic and social burden for public health management. As data about early readmission in Italy are scarce, we aimed to relate the phenomenon of 30-day readmission to factors identified at the time of emergency department (ED) visits in subjects admitted to medical wards of a general hospital in Italy.

Methods

We performed a retrospective 30-month observational study, evaluating all patients admitted to the Department of Medicine of the Hospital of Ferrara, Italy. Our study compared early and late readmission: patients were evaluated on the basis of the ED admission diagnosis and classified differently on the basis of a concordant or discordant readmission diagnosis in respect to the diagnosis of a first hospitalization.

Results

Out of 13,237 patients admitted during the study period, 3,631 (27.4%) were readmitted; of those, 656 were 30-day rehospitalizations (5% of total admissions). Early rehospitalization occurred 12 days (median) later than previous discharge. The most frequent causes of rehospitalization were cardiovascular disease (CVD) in 29.3% and pulmonary disease (PD) in 29.7% of cases. Patients admitted with the same diagnosis were younger, had lower length of stay (LOS) and higher prevalence of CVD, PD and cancer. Age, CVD and PD were independently associated with 30-day readmission with concordant diagnosis and kidney disease with 30-day rehospitalization with a discordant diagnosis.

Conclusions

Comorbid patients are at higher risk for 30-day readmission. Reduction of LOS, especially in elderly subjects, could increase early rehospitalization rates.

Seasonal and weekly patterns of hospital admissions for acute diverticulitis

OBJECTIVE

Onset and hospitalization of acute diseases do not occur randomly, but exhibit preferred high-risk temporal periods. The aim of this study, based on the database of hospital admissions of the Emilia-Romagna region of Italy, was to evaluate the possible existence of a seasonal or weekly pattern of hospitalization for acute diverticulitis (AD), and different rates of complications between weekend (WE) vs. weekday (WD) admissions.

PATIENTS AND METHODS

The study included all emergency hospital admissions in Emilia Romagna Region for AD between 1999 and 2011 (ICD-9-CM codes: 562.11-562.13). Day of admission was categorized, respectively, into four 3-month intervals, twelve 1-month intervals, seven 1-day intervals for statistical analysis, performed by c2 test goodness of fit and partial Fourier series on total number of cases, males and females, nonfatal or fatal cases, without and with hemorrhage.

RESULTS

The database contained records of 29,428 events of AD, relative to 24,843 different patients (mean age: 71.2 ± 13.8 years; 40.5% males). Chronobiological analysis yielded a biphasic rhythmic pattern in AD admissions, characterized by two peaks in Autumn and Spring. As for day of admission, a progressive decrease of frequency during the week was observed. In turn, a slight increase of admissions on WE was observed for hemorrhagic events.

CONCLUSIONS

An excess burden of hospitalization for AD is observed in the region Emilia-Romagna of Italy, with demonstration of a biphasic cyclical pattern with peaks in Autumn and Spring. Again, a decreasing number of Monday to Friday admissions was observed. Further studies are needed to identify possible underlying causes.

Adherence to medical treatment in inflammatory bowel disease patients

AIM

Inflammatory bowel diseases (IBD) are a group of chronic intestinal conditions characterized by unpredictable course, with periods of flare-ups and remissions suggesting poor adherence to medical therapy. On the other hand adherence is one of the most common reason of failure in the treatment of chronic disease.

METHODS

We have analyzed IBD patients' questionnaires, sent by IBD Society of Emilia-Romagna Region (Italy). The anonymous questionnaire included sex, age, qualification, management, disease duration, disease associated, previous surgery, use of homeopathy and self-medication and possible psychological support. We classified patients based on IBD type: Crohn's disease (CD) and ulcerative colitis (UC).

RESULTS

A total of 559 IBD patients were analysed (50.1% female), 52.8% were affected by CD. Patients were followed by gastroenterologist in 84.7% of cases. 17.4% of patient reported non-adherence to medical therapy; univariate analysis showed that non-adherence was more frequent in young females followed-up by general practitioners, no difference was found in educational status or type of IBD. Factors independently associated with greater adherence to medical therapy were age (OR=2.039) and follow-up by gastroenterologist (OR=3.025).

CONCLUSION

Non-adherence should be taken into account in IBD patients and especially in young female. Gastroenterologists have a major role in promoting education.

Chronobiology of acute aortic rupture or dissection: a systematic review and a meta-analysis of the literature

OBJECTIVES

Identification and quantification higher risk incidence of aortic rupture or dissection (AARD) could be of clinical interest and improve preventive strategies.

BACKGROUND

Several studies and subsequent meta-analyses have shown chronobiologic variations in the timing of occurrence of myocardial infarction, stroke, and pulmonary embolism. Conversely, such evidences are currently lacking for AARD despite a number of studies available dealing with periodicity.

METHODS

MEDLINE, EMBASE, and Google Scholar databases were searched up to July 2013. Temporal variation in the incidence of AARD was analyzed including all studies analyzing seasonal, monthly, weekly, and circadian aggregations. Two authors independently reviewed and extracted data.

RESULTS

Forty-two studies for a total of more than 80 000 patients were included. Our results showed a significantly increased incidence of AARD in Winter (Chi-square 854.92, p < 0.001), with a relative risk (RR) of 1.171 (99% CI 1.169, 1.172), in December (Chi-square 361.03, p < 0.001), RR of 1.142 (99% CI 1.141, 1.143), on Monday (Chi-square 428.09, p < 0.001), RR of 1.214 (99% CI 1.211, 1.216), and in the hours between 6 am and 12 pm (Chi-square 212.02, p < 0.001), RR of 1.585 (99% CI 1.562, 1.609). Subgroup and sensitivity analyses confirmed the results of principal analyses.

CONCLUSIONS

Our data strongly support the presence of evident rhythmic patterns in the incidence of acute aortic events, characterized by significantly higher risk in Winter, in December, on Monday and between 6 am and 12 pm. Future studies are needed to better clarify the underlying mechanisms and clinical implications.

Risk of illness, hospitalization and death in a cohort of blood donors in Italy

OBJECTIVE

The aim of this study was to determine whether blood donors (BDs), compared with non blood donors (nBDs), present significant differences in risk of illness, hospitalization and death.

METHODS

All subjects included in the database of the Association of Voluntary Italian Blood Donors of Ferrara entered the study. The analysis only included residents who donated at least once. For each BD, four age- and sex-matched non-donor controls were selected from the master archive of the Province of Ferrara. Then, all hospitalizations of BDs and controls from January 2005 to December 2010 were extracted from the hospital admission and discharge database of the region.

RESULTS

During the considered period, 26,140 hospital admissions in BDs and 98,685 in controls were recorded; 11,862 individual BDs and 43,138 nBDs. Compared with controls, BDs were characterized by older age, lower average number of admissions and diagnoses, Charlson comorbidity index score, shorter hospital length-of-stay (LOS), lower mortality rates and higher age at death. Age at death was significantly higher for BDs with longer duration and higher number of donations. In particular, blood donation was not related to an increased risk of malignancies. The main limitation of this study is potential selection bias (i.e. a healthy donor effect). Matching with the control population also has its limitations.

CONCLUSIONS

This study confirms that BDs have a lower risk of hospitalization, and, more specifically, do not have an increased risk of malignancies, leukemias, lymphomas and myeloma.

Heart and lung, a dangerous liaison-Tako-tsubo cardiomyopathy and respiratory diseases: A systematic review

AIM: To investigate the possible association between Tako-tsubo cardiomyopathy (TTC)-a reversible clinical condition mimicking an acute myocardial infarction characterized by multifactorial pathophysiologic mechanisms- and respiratory system diseases.

METHODS: We systematically searched PubMed and EMBASE medical information sources, to identify the different triggering causes, limiting our search to articles in English. The search keywords were: “tako-tsubo cardiomyopathy”, “takotsubo”, “takotsubo cardiomyopathy”, “broken heart syndrome”, “stress-induced cardiomyopathy”, “apical ballooning syndrome”, and “ampulla cardiomyopathy in combination with respiratory diseases, lung, pulmonary disease. For each kind of disease, we registered: author, year and country of study, patient sex, age, concurring situation, and outcome.

RESULTS: Out of a total of 1725 articles found, we selected 37 papers reporting a total of 38 patients. As expected, most patients were women (81.6%), mean age was 65 ± 10 years. Outcome was favorable in 100% of cases, and all the patients have been discharged uneventfully in a few days.

CONCLUSION: An association between respiratory diseases and TTC is likely to exist. Patients with severe respiratory diseases, due to the high dosages of β₂-agonists used or to the need of invasive procedures, are highly exposed to the risk of developing TTC.

Breaking heart: chronobiologic insights into takotsubo cardiomyopathy

A considerable amount of evidence has shown that the major acute cardiovascular diseases, ie, myocardial infarction, sudden cardiac death, stroke, pulmonary embolism, and rupture or dissection of aortic aneurysms do not occur randomly in time, but exhibit specific temporal patterns in their onset, according to time of day, month or season, and day of the week. This contributes to the definition of "chronorisk", where several factors, not harmful if taken alone, are capable of triggering unfavorable events when presenting all together within the same temporal window. This article reviews the actual knowledge about time of onset of takotsubo cardiomyopathy.

In-hospital mortality for pulmonary embolism: relationship with chronic kidney disease and end-stage renal disease. The hospital admission and discharge database of the Emilia Romagna region of Italy

The impact of chronic kidney disease (CKD) on the outcome of acute pulmonary embolism (PE) is uncertain. We aimed to evaluate the effect of renal dysfunction (defined by ICD-9-CM codification) on in-hospital mortality for PE. We considered all cases of PE (first event) recorded in the database of hospital admissions for the Emilia-Romagna region, Italy, from 1999 to 2009. The inclusion criterion was the presence, as a main discharge diagnosis, of acute PE codes according to ICD-9-CM. Diagnoses of immobilization, dementia, sepsis, skeletal fractures, hypertension, heart failure, myocardial infarction, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, chronic pulmonary disease, pneumonia, malignancy, CKD and end-stage renal disease (ESRD) were also considered to evaluate comorbidity. The outcome was in-hospital mortality for PE, and multivariate logistic regression analyses was performed. We considered 24,690 cases of first episode of PE. In-hospital mortality for PE was not different in patients without renal dysfunction, with CKD, or ESRD (23.6 vs. 24 vs. 18 % p = ns). In-hospital mortality for PE was independently associated with age (OR 1.045, 95 % CI 1.042-1.048, p < 0.001), female sex (OR 1.322, 95 % CI 1.242-1.406, p < 0.001), hypertension (OR 1.096, 95 % CI 1.019-1.178, p = 0.013), diabetes mellitus (OR 1.120, 95 % CI 1.001-1.253, p = 0.049), dementia (OR 1.171, 95 % CI 1.020-1.346, p = 0.025), peripheral vascular disease (OR 1.349, 95 % CI 1.057-1.720, p = 0.016) and malignancy (OR 1.065, 95 % CI 1.016-1.116, p = 0.008). Age and comorbidity are associated with in-hospital mortality for PE, whereas CKD does not appear to be an independent predictor of adverse outcomes in patients hospitalized for PE.

Association between in-hospital mortality and renal dysfunction in 186,219 patients hospitalized for acute stroke in the Emilia-Romagna region of Italy

Using a regional Italian database, we evaluated the relationship between renal dysfunction and in-hospital mortality (IHM) in patients with acute stroke (ischemic/hemorrhagic). Patients were classified on the basis of renal damage: without renal dysfunction, with chronic kidney disease (CKD), and with end-stage renal disease (ESRD). Of a total of 186,219 patients with a first episode of stroke, 1626 (0.9%) had CKD and 819 (0.4%) had ESRD. Stroke-related IHM (total cases) was independently associated with CKD, ESRD, atrial fibrillation (AF), age, and Charlson comorbidity index (CCI). In patients with ischemic stroke (n=154,026), IHM remained independently associated with CKD, ESRD, AF, and CCI. In patients with hemorrhagic stroke (n=32,189), variables that were independently associated with IHM were CKD, ESRD, and AF. Renal dysfunction is associated with IHM related to stroke, both ischemic and hemorrhagic, with even higher odds ratios than those of other established risk factors, such as age, comorbidities, and AF.

Seasonal variation of platelets in a cohort of Italian blood donors: a preliminary report

Background

Since available data are not univocal, the aim of this study was to explore the existence of a seasonal variation in platelet count.

Methods

The study was based on the database of the Italian Association of Blood Volunteers (AVIS), section of Ferrara, Italy, 2001–2010. Hematological data (170,238 exams referring to 16,422 donors) were categorized into seasonal and monthly intervals, and conventional and chronobiological analyses were applied.

Results

Platelets and plateletcrit were significantly higher in winter-autumn, with a main peak in December-February (average +3.4% and +4.6%, respectively, P <0.001 for both).

Conclusions

Although seasonal variations have been reported for several acute cardiovascular diseases, it is extremely unlikely that such a slight increase in platelet count in winter alone may be considered as a risk factor.

Seasonal variation in the occurrence of delirium in patients admitted to medical units of a general hospital in Italy

OBJECTIVE

Delirium syndrome is common in the hospitalised population. However, data on its aetiological factors are scarce. Clinical observations suggest a relationship between delirium occurrence and seasons. The aim of study was to determine whether a seasonal variation exists in the occurrence of delirium events in-hospital patients.

METHODS

The study included all admissions to the medical units of the Hospital of Ferrara, Italy, between January 2002 and December 2010. On the basis of date admission, cases have been analysed for seasonal variation (four 3-month intervals by seasons) by means of conventional statistics. Moreover, cases categorised into twelve 1-month intervals were also analysed by means of a validated chronobiologic inferential method (single cosinor) to search for cyclic variability.

RESULTS

During the analysed period, the hospital database contained 74 379 records referring to 42 625 subjects (52.7% females). Delirium diagnoses were 1300 (1.7% of total sample), 668 of whom in females (51.4%) and 632 in males (48.6%). Events of delirium were more frequent in winter and autumn (26.6 and 26.5%, respectively) than in spring (23.5%) and summer (23.4%). Chronobiological analysis yielded a significant peak of delirium events in January, when considering both the total raw number of cases and the percent of admissions.

CONCLUSIONS

The study seems to indicate in patients hospitalised in medical units, a higher rate of occurrence of delirium in autumn-winter, similar to that reported for acute medical diseases. The role of possible underlying favouring or triggering factors deserves further research.

Chronobiology in aortic diseases - "is this really a random phenomenon?"

Although acute aortic rupture or dissection is relatively uncommon, it ranks in third position among necropsy-confirmed causes of out-of-hospital sudden death in the general population. Similar to other acute cardiovascular events (e.g., acute myocardial infarction, sudden death, stroke, and pulmonary embolism) there is a growing body of evidence regarding temporal patterns in onset, characterized by circadian, seasonal and weekly variations for aortic aneurysms. On one hand, it is possible that these cardiovascular diseases share common underlying pathophysiologic mechanisms, e.g., increase in blood pressure, heart rate, sympathetic activity, basal vascular tone, vasoconstrictive hormones, and prothrombotic tendency. On the other hand, the possibility exists that the connecting link is an internal disruption (dyssynchrony) of some molecular mechanisms intrinsic to the peripheral biological clock (that of cardiomyocyte is the most widely investigated). Such disruption may contribute to cardiovascular disease and biological rhythms - an intriguing hypothesis for future research.

Thyroid diseases and pregnancy

BACKGROUND Thyroid diseases and diabetes mellitus are the most common endocrine diseases during pregnancy. Internal Medicine doctors could be involved in the management of pregnant women affected by thyroid diseases, in particular if an Endocrine Unit lacks in the hospital; it is mandatory that they have the skills to cope with these diseases. METHODS In this work authors describe the most common thyroid abnormalities that can occur during pregnancy: hypothyroidism (clinical and subclinical), hyperthyroidism (clinical and sub-clinical), autoimmune thyroiditis (in particular the so called post-partum thyroiditis), nodular diseases and cancer. They discuss moreover the peculiar pathophysiologic mechanisms by which these diseases appear, the diagnostic tools and the therapies, according to their own experience and the more recent international guidelines. RESULTS AND CONCLUSIONS It is important to evaluate thyroid function tests before and during pregnancy, at 16th and 28th gestational week; it is mandatory to cure also the “sub-clinical” hypothyroidism during pregnancy, when TSH level are higher than 5 μIU/mL; the optimal dose of levo-thyroxine during pregnancy is, average, 30-50% higher than that used before pregnancy; it is not correct to treat mild or sub-clinical hyperthyroidism; propylthyouracil is the best drug to treat hyperthyroidism during pregnancy; the post-partum thyroiditis is generally transient, so that a careful monitoring of thyroid function is advisable, in particular after 9-12 months of therapy; thyroid cancer, if discovered during pregnancy, generally has no negative effects on the outcome of the pregnancy; it would be better to treat surgically thyroid cancer during the last trimester of the pregnancy.

Agranulocytosis: an adverse effect of allopurinol treatment

Introduction: Allopurinol is a xanthine oxidase inhibitor that is primarily used to treat hyperuricemia and its complications. The drug is rarely associated with adverse effects, but those that occur can be significant. Hematologic side effects, including bone marrow suppression, severe anemia, thrombocytopenia, and leukopenia, have been reported in 0.2-0.6% of treated patients. Materials and methods: We report a case of agranulocytosis associated with allopurinol therapy in a patient admitted for fever.

Retrievable vena cava filters: a clinical review

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism (PE), is a major cause of morbidity and mortality. Parenteral anticoagulant treatment with full-dose unfractioned heparin, low-molecular-weight-heparin, or fondaparinux, followed by oral treatment with the vitamin K antagonists, is recommended for the majority of patients. However, in the presence of contraindications to anticoagulant treatment, bleeding complications during antithrombotic treatment, or VTE recurrences despite optimal anticoagulation, interruption of the inferior vena cava with a filter is a potential option aimed to prevent life-threatening PE. Currently, the vast majority of filters implanted worldwide are of the permanent type, but their use is associated with a number of long term complications. Non-permanent filters represent an important alternative, and in particular retrievable filters are an attractive option because they may be either left in place permanently or safely retrieved after a quite long period when they become unnecessary. In this review, we summarize the currently available literature regarding retrievable vena cava filters and we discuss current evidences on their efficacy and safety. Moreover, the appropriate indications for their use in daily clinical practice are reviewed.

Risperidone and pulmonary embolism: a harmful association? Case series and review of the literature

Gallerani M, Imberti D, Mari E, Marra A, Manfredini R. Risperidone and pulmonary embolism: a harmful association? Case series and review of the literature.

Objective: Risperidone is an atypical antipsychotic drug used to treat a number of psychiatric diseases, such as schizophrenia, schizoaffective and bipolar disorders and irritability in children with autism. Moreover, it is also often administered for short-term treatment of persistent aggression in people with moderate-to-severe Alzheimer's dementia. A possible association between risperidone and venous thromboembolism (VTE) has been described. We intended to verify the dimension of the problem in our hospital setting.

Methods: We considered all consecutive patients hospitalised in our Internal Medicine Department from January 2004 to December 2010, who were treated with risperidone and presented pulmonary embolism (PE).

Results: Four cases of patients, apparently free from the well-known major risk factors for VTE (i.e. cancer, prolonged immobilisation, acute cardiac and respiratory failure, infections), who presented PE associated with risperidone therapy, were reported in details.

Conclusions: A review of the available literature, discussing the possible different pathogenic reasons for this increased risk of VTE, is provided.

Therapeutic potential of apixaban in the prevention of venous thromboembolism in patients undergoing total knee replacement surgery

Anticoagulant prophylaxis for preventing venous thromboembolism (VTE) is a worldwide established procedure in hip and knee replacement surgery. Despite available anticoagulant prophylaxis, patients who undergo total knee arthroplasty (TKA) have a high incidence of venous VTE. In spite of their proven efficacy, the currently available anticoagulants have limitations that driven to develop new oral agents that directly target specific factors in the coagulation cascade, such as direct thrombin inhibitors and direct Factor Xa inhibitors, in an attempt to overcome some of the drawbacks with the traditional agents. Apixaban is a potent, selective direct inhibitor of the coagulation factor Xa, recently approved in Europe for the prevention of venous thromboembolism (VTE) in adult patients after total hip replacement (THR) or total knee replacement (TKR) surgery. Apixaban has been extensively studied worldwide in about 12,000 patients in four clinical studies that have demonstrated the efficacy and safety of apixaban respect to enoxaparin for the prevention of thromboembolism after major orthopedic surgery. Three of these trials involved 7,337 patients who undergo TKR: one phase II trial (APROPOS Study) and two large phase III trials (ADVANCE 1 and ADVANCE 2 Studies). ADVANCE 1 demonstrated that when compared with enoxaparin 30 mg twice daily for efficacy, apixaban did not meet the prespecified statistical criteria for noninferiority, but its use was associated with lower rates of clinically relevant bleeding. ADVANCE 2 showed that apixaban was superior to the European standard dose of enoxaparin of 40 mg once daily in term of efficacy, with a similar incidence of major bleeding. This review focuses the clinical efficacy and tolerability of oral apixaban for the prevention of VTE in adult patients following TKR surgery.

In-hospital mortality in patients with renal dysfunction admitted for myocardial infarction: the Emilia-Romagna region of Italy database of hospital admissions

BACKGROUND

In-hospital mortality of patients with myocardial infarction (MI) in different European populations and renal dysfunction is variable. We aimed to evaluate in-hospital mortality for MI in chronic kidney disease (CKD), in end-stage renal disease (ESRD), and in subjects admitted for MI without renal dysfunction living in the Emilia-Romagna region of Italy.

METHODS

We considered all cases of MI (first event) recorded in the database of hospital admissions of the region Emilia-Romagna of Italy, from January 1999 to December 2009. The criterion for inclusion was the presence, as a first discharge diagnosis, of acute MI (International Classification of Diseases, 9th Revision, Clinical Modification). The Charlson comorbidity index (CCI), with the exclusion of CKD, was calculated. The outcome variable was in-hospital mortality for MI, and its association with comorbidities, CKD and ESRD, was analyzed.

RESULTS

During the considered period, 88,014 cases of first MI were recorded. The percentage of patients admitted with MI and died during hospitalization were higher in patients with ESRD (38.3 %) and CKD (16.5 %) than in those without renal dysfunction (14 %) (p < 0.01). In CKD and ESRD patients, data of in-hospital mortality for MI exhibited a twofold increase in the analyzed period. In-hospital mortality for MI was independently associated with age (OR 1.077, 95 % CI 1.075-1.080, p < 0.001), CCI excluding CKD (OR 1.101, 95 % CI 1.069-1.134, p < 0.001), cerebrovascular disease (OR 1.450, 95 % CI 1.349-1.557, p < 0.001), malignancy (OR 1.234, 95 % CI 1.153-1.320, p < 0.001), and ESRD (OR 4.137, 95 % CI 3.511-4.875, p < 0.001).

CONCLUSIONS

As for the Emilia-Romagna region of Italy, in-hospital mortality for MI is increasing over the last years, and mortality seems to be related with patients' comorbidities and presence of advanced stages of CKD.

Higher mortality in patients hospitalized for acute aortic rupture or dissection during weekends

BACKGROUND

The management of acute aortic aneurysm rupture or dissection (AARD) requires specific medical expertise, diagnostic techniques, and therapeutic options, not always available in all hospitals through the entire week. The aim of our study was to evaluate whether an association exists between weekday (WD) or weekend (WE) admission and mortality for patients with ARRD.

METHODS

Based on the database of routinely collected hospital admissions of the region of Emilia Romagna (RER) of Italy, we examined the discharge sheets of all patients with AARD (January 1999 to December 2009). The risk of in-hospital death was calculated for admissions on the WE compared with the admissions during a WD.

RESULTS

The analysis considered 4559 events in 4461 patients. AARD admissions were most frequent on Monday (14.7%) and Friday (14.8%) and less frequent on Saturday (12.6%). The percentage of events admitted on Sunday/holiday was 15.0%, whereas the distribution of death rate with respect to day of admission was significantly different (χ(2) = 23.472; P < .001) with the highest frequency peak on Sunday/holiday (17.4%) and the lowest on Tuesday (12.9%). WE admissions were associated with significantly higher in-hospital mortality (43.4%) than WD admissions (36.9%, P < .001). Multivariate regression analysis showed that WE admission was an independent risk factor for increased in-hospital mortality odds ratio 1.318; 95% confidence interval, 1.144-1.517; P < .001).

CONCLUSIONS

Our findings show that hospitalization for AARD on WE is associated with a significantly higher mortality rate than hospitalization on WD. Further studies are needed to investigate whether ensuring optimal diagnostic and therapeutic approaches during the entire week might improve the overall survival of patients with ARRD.