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.

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.

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.

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.

Emergency reversal of anticoagulation with vitamin K antagonists with 3-factor prothrombin complex concentrates in patients with major bleeding.

Major bleeding is a serious and potentially fatal complication of treatment with vitamin K antagonists (VKAs). Prothrombin complex concentrates (PCCs) can substantially shorten the time needed to reverse VKA effects. To determine the efficacy and safety of 3-factor PCCs for the rapid reversal of VKAs in patients with major bleeding. Patients receiving VKAs and suffering from acute major bleeding were eligible for this prospective cohort study if their international normalized ratio (INR) was higher than or equal to 2.0. Stratified 35-50 IU kg(-1) PCC doses were infused based on initial INR. A total of 126 patients (62 males; mean age: 74 years, range 37-96 years) were enrolled. The mean INR at presentation was 3.3 (range 2-11). At 30 min after PCC administration the mean INR was 1.4 (range: 0.9-3.1), declining to less than or equal to 1.5 in 75 % of patients. The benefit of PCC was maintained for a long time, since in 97 % of all post-infusion time points through 96 h the mean INR remained lower than or equal to 1.5 (mean: 1.19; range: 0.9-2.3). During hospitalization neither thrombotic complications nor significant adverse events were observed and 12 patients died (10 %); none of the deaths was judged to be related to PCC administration. 3-factor PCC administration is an effective, rapid ad safe treatment for the urgent reversal of VKAs in patients with acute major bleeding. Broader use of PCC in this clinical setting appears to be appropriate.

Quadriplegia due to pachymeningitis, vasculitis and sepsis in a patient with rheumatoid arthritis: a case report.

We report the case of a 84-year-old man, with history of rheumatoid arthritis, admitted the Hospital for a fall and complaining of dysaesthesia and pain located to the cervical spine and arms. Within a few hours after admission, fever and acute, progressive, ascendant quadriplegia became evident. Magnetic resonance imaging (MRI) of cervical spine showed spinal canal stenosis between C4-C6 with spinal cord compression. Hemocultures resulted positive for Staphylococcus aureus. The clinical picture rapidly evolved to sepsis with a fatal multi-organ failure. An autopsy found a osteosclerosis narrowing the neurocanal at the level of C3-C6, and recent cervical medulla infarction. A histological exam revealed the presence of a suppurative pachymeningitis with local phenomenas of periradiculitis, vasculitis and thrombosis of the anterior medullar artery, associated with coagulative necrosis of the neural tissue.

High output heart failure due to an iatrogenic arterio-venous fistula after lumbar disc surgery.

Vascular injury is a rare but not uncommon complication of spinal surgery and associated with dramatic consequences. Congestive heart failure secondary to a hyperkinetic circulation can occur in systemic diseases and in arterio-venous fistulae. A 57-year-old man was admitted to hospital complaining of dyspnoea and oedema of the left leg. Eight days previously he had undergone a discectomy at L4-L5. On auscultation a systolic-diastolic murmur was noted over the entire abdomen. An echocardiogram demonstrated an enlarged right atrium, severe mitral and tricuspid regurgitation and increased pulmonary artery pressure. An abdominal CT demonstrated irregular dilatation of the left common iliac vein and through a fistula and simultaneous opacification of the right common iliac artery; subsequently, this was also confirmed by angiography. The patient underwent an emergency endovascular stent-graft of the right common iliac artery with normalization of the venous return pressure and quick resolution of the heart failure. It is important for the physician involved in clinical work to keep in mind all the possible post-surgical complications that can occur in symptomatic patients who have recently undergone an intervention.

Seasonal variation in onset of acute appendicitis.

PURPOSE: Several acute diseases exhibit a circannual pattern. The present study was aimed to verify the possible existence of a seasonal variability in the onset of acute appendicitis (AA). PATIENTS AND METHODS: All cases of AA diagnosed at the St Anna Hospital of Ferrara, Italy, from 1998 to 2004, were considered. The total sample was divided into subgroups by gender, age (< or = 19 and > or = 20 years), and ICD9-CM code. For statistical analysis, the distribution of symptom onset was tested for uniformity by the chi2 test for goodness of fit, and chronobiological analysis was performed by applying partial Fourier series. RESULTS: In the 7-year period analysis, 1331 consecutive cases of AA (673 males) were observed. The analysis showed, for total population, a seasonal variation with a peak in summer and a nadir in spring. Subjects < or = 19 years (n = 654) showed a higher frequency of events in winter (winter = 191 cases, 29.2%; spring = 154 cases, 23.5%, summer = 142 cases, 21.7%, autumn = 167 cases, 25.5%, chi2 = 8.07 p = 0.046), whereas subjects > or = 20 years (n = 677) showed a higher frequency in summer (winter = 150, 22.2%, spring = 151, 22.3%, summer = 214, 31.6%, autumn = 162, 23.9%, chi2 = 16.33 p = 0.001; difference between the two groups: chi2: 19.2, p < 0.001). Cases of AA with peritonitis (ICD-9 540.0, n = 90), were more frequent in summer (winter = 18, 20%, spring = 19, 21.17%, summer = 38, 42.2%, autumn = 15, 16.7%, chi2 = 14.22, p = 0.002), and chronobiological analysis found a statistically significant peak of higher incidence in July (PR 68.2, 95%CL: May-September, p = 0.006). CONCLUSIONS: The existence of a seasonal pattern in the onset of AA is confirmed, with differences in relation to age.

Chronobiology of rupture and dissection of aortic aneurysms.

A growing body of evidence suggests that the occurrence of cardiovascular events is not evenly distributed over time, but shows peculiar temporal patterns that vary with time of day, day of the week, and month (season) of the year. These patterns coincide with the temporal variation in the pathophysiologic mechanisms that trigger cardiovascular events and the physiologic changes in body rhythms. These two factors in combination contribute to the periodicity in susceptibility to acute cardiovascular events. The classic assumption of epidemiologic studies that there is a constancy in risk for disease during the various time domains has now been challenged by the emerging new concept of chronorisk. In the last two decades temporal patterns (circadian, weekly, seasonal) have been identified for several acute cardiovascular diseases, such as acute myocardial infarction, sudden death, pulmonary embolism, and stroke, with peak incidence for most in the morning and during winter. One of the most life-threatening cardiovascular emergencies, aortic aneurysm rupture or dissection, also demonstrates periodicity, characterized by a similar temporal distribution, which suggests a common pathophysiologic mechanism or triggers similar to other cardiovascular acute emergencies. We review the data on chronobiology of acute aortic rupture or dissection, and discuss various pathophysiologic mechanisms that account for this variability. It is likely that identification of consistent recurring patterns in the underlying risk mechanisms could provide potential new insights for more precise diagnosis and efficacious therapeutic intervention.

Risk of hospitalization for upper gastrointestinal tract bleeding.

OBJECTIVE: This study evaluates the hospitalization risk for upper gastrointestinal bleeding (UGIB) with reference to the clinical characteristics of patients and drugs taken before admission. METHODS: This study is based on the GIFA (Italian Group for the Pharmacosurveillance in the Elderly) database. Cases with an ICD-9 code of esophagus, stomach or duodenum bleeding, or acute esophago-gastroduodenal disease associated with anemia have been classified as UGIB. Sex, age, year of observation, drugs taken at home, comorbidity, smoking, alcohol, and use of gastroprotectants have been also taken into account. Statistical analysis has been conducted using multivariate logistic regression models. RESULTS: 32,388 patients have been enrolled, 940 of which presented UGIB. Age, comorbidity, use of smoke and alcohol, hospitalization duration, and mortality during hospitalization were significantly higher in UGIB than nonUGIB patients. Increased UGIB risk has been found in patients taking NSAIDs (both when aspirin was included or excluded), acetaminophen, constipating agents, iron, ethacrynic acid, propranolol. Reduced UGIB risk has been found in patients taking nitrates. CONCLUSIONS: UGIB risk appears to correlate with clinical characteristics of the patient: it increases with age, comorbidity, and smoke and alcohol consumption. Among drugs, NSAIDs are associated with the highest UGIB risk, while nitrates with a reduction of risk.

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 < 0.001), 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.

Cystocerebral syndrome: a case report and literature review.

Delirium is a frequent cause of hospitalization in the elderly patient, and can be sustained by several factors, which are not always evident. In 1990 Blackburn and Dunn described a clinical picture characterized by the presence of acute urinary retention presenting as delirium, and named it "cystocerebral syndrome". In 1991 Liem and Carter advanced a possible pathophysiological explanation for this phenomenon, suggesting that adrenergic tension might increase in the central nervous system when micturition cannot occur at the usual threshold. The consequent increase in catecholamines level might produce delirium. We report the case of a very old subject with delirium and acute urinary retention, suggestive of the "cystocerebral syndrome", in order to call the attention of geriatricians to acute urinary retention as a possible precipitating factor of delirium.

[Epistaxis and circadian rhythm]. / Epistassi e ritmi circadiani.

It is known that many physiological variables show a rhythmic variability along a time span, e.g.: day, week, month or year. It is possible that the temporal overlapping of a constellation of factors may act as favouring and/or triggering factors for the onset of several acute diseases. Among these, epistaxis shows a circadian variability too. Such pattern, characterised by a prevalent peak in the morning and a secondary one in the evening, strictly resembles that of arterial blood pressure. The lack of differences between the temporal pattern of hypertensive and normotensive subjects suggests that the physiological pattern of blood pressure, and not strictly a condition of hypertension, may play a favouring role in certain hours of the day, probably together other local factors.

Circadian differences in the individual sensitivity to opiate overdose.

OBJECTIVE: The aim of the present study was to test whether circadian differences in the response to opiates exist in humans and, if so, whether they are synchronized with the well-known circadian variations in overdose frequency. DESIGN: Daily variations in opiate overdose frequency, total amount of naloxone necessary to treat the comatose state, and frequency of hospitalization were examined in pure, nonlethal, consecutive cases of opiate (presumably intravenous heroin) overdoses. Furthermore, daily variations in the frequency of lethal overdoses were examined in all cases observed during the same period. SETTING: An 8-yr prospective, observational study in the city and suburban area of Ferrara, Italy. PATIENTS: A total of 518 consecutive cases of nonlethal opiate overdoses in 327 different patients, plus 110 consecutive cases of lethal opiate overdoses with precise or presumptive time of death. RESULTS: Analysis of the circadian distribution of nonlethal overdoses showed a significant peak in the afternoon to early evening. Analysis of the distribution of the hourly average amount of naloxone used to rescue patients from coma showed an opposite circadian variation, with a significant peak in the early morning. The hospitalization risk was also significantly higher from 3:00 to 8:59 am. However, in a subset of representative cases, plasma morphine concentrations did not change significantly in different hours of the day. Analysis of circadian distribution of lethal overdoses showed a significant peak in the evening hours. The death risk (calculated as the percentage of lethal events in the total number of intoxications within a given time frame) was significantly higher from 3:00 to 8:59 am. CONCLUSION: The present data provide evidence for the existence of circadian variations in the individual sensitivity to opiate overdose.