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.

Dementia and in-hospital mortality: retrospective analysis of a nationwide administrative database of elderly subjects in Italy.

AIMS:  To evaluate the relationship between comorbidity and in-hospital mortality in elderly patients affected by dementia. METHODS: Data were obtained from the Italian Ministry of Health and included all discharge records from Italian hospitals concerning subjects aged ≥ 65 years admitted to acute Internal Medicine or Geriatrics wards between January 2015 and December 2016 (3.695.278 admissions). The variables analyzed included age, sex, and in-hospital death. Twenty-five homogeneous clusters of diseases were identified in discharge codes according to the ICD-9-CM classification. RESULTS: Patients with dementia represented 7.5% of the sample (n. 278.149); they were older, more often males (51.9%), and had a higher in-hospital mortality (24.3%) compared to patients without dementia (9.7%). Dementia per se doubled the odds of death (OR 1.98; 95% CI 1.95-2.00), independent of age, sex, and comorbidities. Seven clusters of disease (pneumonia, heart failure, kidneys disease, cancer, infectious diseases, diseases of fluids/electrolytes and general symptoms) were associated with increased in-hospital mortality, independent of the presence/absence of dementia. Among patients with dementia, heart failure, pneumonia and kidney disease on their own substantially doubled/tripled mortality risk. The risk increased from 10.1% (none of selected conditions), up to 28.9% when only one of selected comorbidities was present, rising to 52.3% (OR: 9.34; p < 0.001) when two or more comorbidities were simultaneously diagnosed, besides general symptoms. CONCLUSIONS: Our study confirmed an important increase of in-hospital mortality in older subjects with dementia. Despite a different comorbidity, the conditions associated with in-hospital mortality were substantially the same in patients with or without dementia. Heart failure, pneumonia, and kidney disease identified a high risk of in-hospital mortality among subjects with dementia.

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.

Circaseptan Periodicity of Cardiovascular Diseases.

The occurrence of cardiovascular events shows a different distribution during the week, with many studies reporting a Monday peak, possibly related to the role of stress associated with commencing weekly activities. Furthermore, a higher mortality has been observed among patients hospitalized for cardiovascular and other disorders on weekends, a phenomenon known as "weekend effect." Such effect may be explained by a higher level of disease severity among patients admitted over the weekend, and/or by a poorer quality of care associated with shortage of staff, lower experience of personnel, and limited availability of therapeutic and diagnostic procedures.

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.

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.

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.

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.

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.

Discharge diagnosis and comorbidity profile in hospitalized older patients with dementia.

OBJECTIVES: The aim of this study was to investigate the principal discharge diagnosis and related comorbidity in hospitalized older patients affected by dementia. METHODS: Data from 51,838 consecutive computerized discharge records of the St. Anna University Hospital (Ferrara, Italy) were analyzed. Records included only subjects aged ≥60 years. Number of admissions, length of stay in hospital, primary and secondary discharge diagnosis (by ICD-9-CM code), number of procedures, and possible death were evaluated. RESULTS: Demented patients represented 8.6% of the sample (4466 individuals) and were older and more likely to be female patients compared with controls (47,372 individuals); they were characterized by higher number of admissions to hospital, instrumental clinical investigations, secondary diagnoses, and mortality rate. Among the primary diagnoses, a higher prevalence of cerebrovascular disease, pneumonia, and hip fracture was observed in demented patients. Furthermore, pulmonary embolism, renal failure, septicemia, and urinary infections were frequently reported in demented patients, but not in controls. As regards secondary diagnoses, dementia was associated with an increased risk of delirium, muscular atrophy and immobilization, dehydration, cystitis, and pressure ulcers, whereas the risk for other conditions, including cancer, was reduced. CONCLUSIONS: Among older patients, dementia was associated with higher rate of admissions to hospital and mortality. Discharge diagnoses were sensibly different according to the presence of dementia; in particular, a greater load and a different kind of comorbidity were observed in demented patients. On the whole, our data suggest that the adequate management of demented outpatients might help to reduce hospitalization.

Interventional approaches in VTE treatment (vena cava filters, catheter-guided thrombolysis, thrombosuction).

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular pathology after coronary disease and cerebrovascular diseases and is responsible for significant morbidity and mortality in the general population. Full-dose anticoagulation is the standard therapy for VTE, both the acute phase and the prolonged treatment. The latest guidelines of the American College of Chest Physicians recommend treatment with a full-dose of unfractionated heparin (UFH), low-molecular-weight-heparin (LMWH), fondaparinux, vitamin K antagonist (VKA), or systemically administered thrombolytics for most of the patients with objectively confirmed VTE. Catheter-guided thrombolysis and thrombosuction are interventional approaches that should be used only in selected populations; interruption of the inferior vena cava (IVC) with a filter can be performed to prevent life-threatening PE in patients with VTE and contraindications to anticoagulant treatment, bleeding complications during antithrombotic treatment, or VTE recurrences, despite optimal anticoagulation. This review summarizes the currently available literature regarding interventional approaches in VTE treatment (vena cava filters, catheter-guided thrombolysis, thrombosuction), discusses their efficacy and safety, and reviews the appropriate indications for their use in daily clinical practice.

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.

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.

Temporal variation of heart failure hospitalization: does it exist?

Congestive heart failure (CHF) is the end stage of many cardiac diseases, and one of the leading causes of mortality and morbidity around the world. Coronary heart disease and hypertension (either singly or together) are the main etiology for CHF. It has been reported that major acute cardiovascular events (myocardial infarction, sudden death, cardiac arrest, ischemic and hemorrhagic stroke, pulmonary embolism, rupture/dissection of aortic aneurysms) do not occur randomly through time, but exhibit a specific temporal periodicity characterized by seasonal (winter), weekly (Monday), and circadian (morning) patterns of onset. Thus, because the major causes of CHF present a temporal pattern, in the past several years some studies have investigated the temporal variation of CHF hospitalization and mortality, with results indicating the possibility of a preference for winter months, Mondays, and nighttime, respectively.

Seasonal pattern of peptic ulcer hospitalizations: analysis of the hospital discharge data of the Emilia-Romagna region of Italy.

BACKGROUND: Previous studies have reported seasonal variation in peptic ulcer disease (PUD), but few large-scale, population-based studies have been conducted. METHODS: To verify whether a seasonal variation in cases of PUD (either complicated or not complicated) requiring acute hospitalization exists, we assessed the database of hospital admissions of the region Emilia Romagna (RER), Italy, obtained from the Center for Health Statistics, between January 1998 and December 2005. Admissions were categorized by sex, age (<65, 65-74, > or = 75 yrs), site of PUD lesion (stomach or duodenum), main complication (hemorrhage or perforation), and final outcome (intended as fatal outcome: in-hospital death; nonfatal outcome: patient discharged alive). Temporal patterns in PUD admissions were assessed in two ways, considering a) total counts per single month and season, and b) prevalence proportion, such as the monthly prevalence of PUD admissions divided by the monthly prevalence of total hospital admissions, to assess if the temporal patterns in the raw data might be the consequence of seasonal and annual variations in hospital admissions per se in the region. For statistical analysis, the chi2 test for goodness of fit and inferential chronobiologic method (Cosinor and partial Fourier series) were used. RESULTS: Of the total sample of PUD patients (26,848 [16,795 males, age 65 +/- 16 yrs; 10,053 females, age 72 +/- 15 yrs, p < 0.001)], 7,151 were < 65 yrs of age, 8,849 between 65 and 74 yrs of age, and 10,848 > or = 75 yrs of age. There were more cases of duodenal (DU). (89.8%) than gastric ulcer (GU) (3.6%), and there were 1,290 (4.8%) fatal events. Data by season showed a statistically difference with the lowest proportion of PUD hospital admissions in summer (23.3%) (p < 0.001), for total cases and rather all subgroups. Chronobiological analysis identified three major peaks of PUD hospitalizations (September-October, January-February, and April-May) for the whole sample (p = 0.035), and several subgroups, with nadir in July. Finally, analysis of the monthly prevalence proportions yielded a significant (p = 0.025) biphasic pattern with a main peak in August-September-October, and a secondary one in January-February. CONCLUSIONS: A seasonal variation in PUD hospitalization, characterized by three peaks of higher incidence (Autumn, Winter, and Spring) is observed. When data corrected by monthly admission proportions are analyzed, late summer-autumn and winter are confirmed as higher risk periods. The underlying pathophysiologic mechanisms are unknown, and need further studies. In subjects at higher risk, certain periods of the year could deserve an appropriate pharmacological protection to reduce the risk of PUD hospitalization.

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.

Seasonal and weekly patterns of hospital admissions for nonfatal and fatal myocardial infarction.

OBJECTIVE: This retrospective study, based on the database of hospital admissions of the region Emilia-Romagna [RER], Italy, was aimed to confirm the existence of a seasonal or weekly pattern of hospital admission of acute myocardial infarction (AMI) and to verify possible differences between nonfatal or fatal cases. METHODS: The study included all cases of patients with AMI hospitalized between 1998 and 2006. Day of admission was categorized, respectively, into four 3-month intervals, into twelve 1-month intervals, and into seven 1-day intervals for statistical analysis, performed by chi(2) test goodness of fit and partial Fourier series on total cases, males, females, and nonfatal and fatal cases. RESULTS: The database included 64 191 cases of AMI (62.9% males, 12.3% fatal). Acute myocardial infarction was most frequent in winter and least in summer (P < .0001). The highest number of cases was recorded in January and the lowest in July (P < .0001). Chronobiologic analysis showed winter peaks for total cases (January, P = .035), females (December, P = .009), and fatal cases (January, P < .001). Acute myocardial infarction was most frequent on Monday and least on Sunday (P < .0001). Comparing observed vs expected events, there was a significantly higher frequency of cases on weekdays and reduced on weekends, for total (P < .0001), nonfatal (P < .0001), and fatal cases (P = .0001). CONCLUSIONS: This study confirms a significantly higher frequency of AMI admissions in winter and on a Monday. No difference in the frequency of nonfatal vs fatal events, depending of patients' admissions on weekdays or weekends, was found.