Risk factors for hypoglycemia in patients with type 2 diabetes, hospitalized in internal medicine wards: Findings from the FADOI-DIAMOND study.

AIMS: Hypoglycemia is a potential risk in the management of patients suffering from type 2 diabetes (T2DM) and hospitalized in internal medicine units (IMUs). The aim of this analysis was to evaluate incidence of hypoglycemia and related risk factors in a group of patients admitted to IMUs. METHODS: We used the FADOI-DIAMOND study carried out in 53 Italian IMUs. The DIAMOND design included two cross-sectional surveys interspersed with an educational program. In both phases each center reviewed the charts of the last 30 hospitalized patients with known T2DM (n=3167), including information about hypoglycemia during hospital stay. The association between occurrence of hypoglycemia and potential predictors was evaluated by means of a multivariable logistic regression analysis. RESULTS: A total of 385 symptomatic hypoglycemic events were observed (rate=12%). Advanced age, cognitive dysfunction, and nephropathy were associated with hypoglycemia. Hypoglycemia occurred in 19.4% of patients treated according to the insulin sliding-scale method versus 11.4% of patients treated with basal bolus (p<0.01). More patients with hypoglycemia received sulfonylureas versus the no-hypoglycemia group (28.3% versus 20.6%, p<0.001). Significantly longer length of hospital stay and increased in-hospital mortality were found in the group with hypoglycemia compared with the no-hypoglycemia group (12.7±10.9 versus 9.6±6.5 days; 8.8% versus 4.8%, p<0.01). CONCLUSIONS: Hypoglycemia in hospitalized patients with diabetes is associated with increased length of hospitalization and in-hospital mortality. Identification of patients at increased risk of hypoglycemia may be important for optimally adapting treatment and patient management.

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

PURPOSE: Few real-world data are available on the frequency and management of pain in Internal Medicine (IM). Aims of our study were to assess the prevalence of pain in IM, and to evaluate the effects on pain management of a standardised educational programme. MATERIALS AND METHODS: The study was performed in 26 IM Units in Italy, with two cross-sectional surveys (PRE phase and POST phase) interspersed with an educational programme. In PRE phase each Centre reviewed the hospital charts of the last 100 consecutive patients hospitalised for any cause. An educational programme was conducted in each Centre by means of the 'outreach visit', a face-to-face meeting between health personnel and a trained external expert. Six months after, each Centre repeated the data collection (POST phase), specular to the PRE. RESULTS: A total of 5200 medical charts were analysed. Pain was documented in 37.5% of the patients. After the educational intervention, the intensity of pain was appropriately assessed in a higher percentage of patients (77.4% vs. 47.8%, p = 0.0001), and it was more frequently monitored during hospitalisation. Qualitative definition of pain (pathogenesis, duration, etc.) increased in POST phase (75.4% vs. 62.7%, p = 0.0001). A 73.3% increase in the use of strong opioids was detected following educational programme. CONCLUSIONS: Pain affects 4 out of 10 patients hospitalised in IM. According to our large real-world study, to implement a standardised one-shot educational programme may persistently improve the attitude of health personnel towards the characterisation and management of pain.

Combination of aprepitant, palonosetron and dexamethasone as antiemetic prophylaxis in lung cancer patients receiving multiple cycles of cisplatin-based chemotherapy.

Introduction: With repeated courses of chemotherapy, chemotherapy-induced nausea and vomiting (CINV) becomes progressively more difficult to control. The aim of this study was to evaluate whether the antiemetic efficacy of the triple combination aprepitant, palonosetron and dexamethasone could be sustained for up to six cycles of highly emetogenic chemotherapy (HEC) (cisplatin ≥ 50 mg/m(2) ). Methods: Chemotherapy-naive patients receiving cisplatin-based HEC, were treated with palonosetron 0.25 mg/i.v., dexamethasone 20 mg/i.v. and aprepitant 125 mg/p.o. 1 h before chemotherapy. Aprepitant 80 mg/p.o. and dexamethasone 4 mg/p.o. were administered on days 2-3. The primary endpoint was complete response (CR, no vomiting and no use of rescue medication), over 5 days following HEC in up to six cycles. Secondary endpoints were emesis-free and nausea-free rates. Safety was also evaluated. Results: One hundred and fifty six lung cancer patients were included in the study; the median age was 64 years and 76.9% were men. The minimum cisplatin dosage was 75 mg/m(2) , and in most patients was combined with another drug (87.4%). CR ranged from 74.4% (first cycle) to 82% (sixth cycle). More than 90% and 60% of patients were emesis-free and nausea-free during all chemotherapy cycles. The most commonly reported side effects were constipation and headache. Conclusions: The triple combination of aprepitant, palonosetron and dexamethasone enhanced not only the antiemetic protection during the first cycle, but its efficacy was also sustained for up to six cycles of cisplatin-based HEC in lung cancer patients.

Clinical profile and predictors of in-hospital outcome in patients with heart failure: the FADOI "CONFINE" Study.

BACKGROUND: Heart failure (HF) is a major health and social problem. Internal Medicine (IM) wards admit a high proportion of patients with HF, frequently with advanced age and comorbidities. Few recent data are available in this setting, especially on predictors of in-hospital outcome. METHODS: In this observational study, we recruited patients admitted with diagnosis of HF and present in five index days, in 91 units of IM in Italy. Characteristics and management of HF, comorbidities, functional and cognitive status, and quality of life, were analyzed. RESULTS: We observed 1411 patients, with a mean age of 78.7 ± 9.6 years. At admission, 81.7% of the patients were in NYHA classes III-IV. Ninety percent of the patients had at least one comorbidity. Dementia or severely impaired functional status were registered in 21.5% and 22.8% of the patients. In 89 patients (6,3%) a negative outcome (death or clinical worsening) occurred during hospitalization. A number of variables were significantly related to negative outcome by means of univariate analysis (systolic blood pressure <100 mm Hg, pulse pressure ≥ 55 mm Hg, anaemia, brain deficit, permanent bed rest, Barthel Index ≤ 30). At multivariable analysis, significant correlation was retained by anaemia and Barthel Index ≤ 30, the latter being the strongest predictor. CONCLUSIONS: Real-world patients with HF and hospitalized in IM are frequently very old, frail and with multiple comorbidities. Functional and cognitive status significantly influence patients' outcome, and this could lead to a rethinking of the overall (in-hospital but also home-based) management of HF.

Acute limb ischemia in elderly patients: can iloprost be useful as an adjuvant to surgery? Results from the ILAILL study.

OBJECTIVES: To evaluate the effects of iloprost, in addition to surgery, on the outcome of acute lower limb ischemia (ALLI). DESIGN: Post-hoc analysis of a randomized, double-blind, placebo-controlled study. METHODS: In the context of the ILAILL (ILoprost in Acute Ischemia of Lower Limbs) study, 192 elderly patients (>70 years old) undergoing surgery for ALLI were assigned to receive perioperative iloprost (intra-arterial, intra-operative bolus of 3000 ng, plus intravenous infusion of 0.5-2.0 ng/kg/min for six hours/day for 4-7 days following surgery), or placebo (iloprost: n=100; placebo: n=92). Patients were followed-up for three-months following surgical revascularization. RESULTS: The combined incidence of death and amputation (primary study end-point) was significantly reduced in patients treated with iloprost (16.0% vs 27.2% in the placebo group; hazard ratio 1.99, 95% confidence interval 1.05-3.75, p=0.03). A statistically significant lower mortality (6.0%) was reported in patients receiving iloprost, compared to controls (15.2%) (hazard ratio 2.93, 1.11-7.71, p=0.03). The overall incidence of death and major cardiovascular events was lower in patients receiving iloprost compared to those assigned placebo (24.0% and 35.9%, respectively), at the limits of statistical significance (relative risk 1.64, 0.97-2.79, p=0.06). CONCLUSIONS: These results confirm the poor outcome in elderly patients with ALLI. Based on a subgroup analysis iloprost, as an adjuvant to surgery, appears to reduce the combined end-point of death and amputation.

Randomized trial of the effects of low-dose calcium-heparin in patients with peripheral arterial disease and claudication. Italian CAP Study Group.

PURPOSE: We performed a long-term, multicenter, randomized, double-blind trial to evaluate the efficacy and tolerability of low-dose, subcutaneous calcium-heparin (12,500 IU/day) in comparison with placebo in patients with stable peripheral arterial disease of the lower extremities. PATIENTS AND METHODS: At the end of a 2-week washout period, during which aspirin placebo was given, 201 patients were randomly assigned to receive either subcutaneous calcium-heparin or placebo for two 3-month treatment periods, each of which was followed by a 6-month period of observation. All of the patients were given low-dose aspirin (50 mg/day) throughout the 18-month study. The main efficacy variables were pain-free and maximum walking time (by standard treadmill test). Patients answered a questionnaire about pain and the limitation of daily activities. Results were analyzed by intention-to-treat. RESULTS: At the end of the study, the estimated increase in pain-free walking time was 39% in the heparin group and 23% in the placebo group (P = 0.09). The estimated increase in maximum walking time was 40% in the heparin group and 16% in the placebo group (P = 0.05). Patients treated with heparin also reported that they had to stop walking because of leg pain, or had daily activities limited by leg pain, less frequently than the placebo group (P <0.01). CONCLUSIONS: Treatment with low-dose subcutaneous calcium-heparin is safe and effective in improving walking performance and reducing physical disability in patients with stable peripheral arterial disease and claudication.

Activated lymphoid cells in human gliomas: morphofunctional and cytochemical evidence.

To study defensive infiltrating cells, smear preparation from 20 fresh gliomas and autologous normal peritumoural brain tissue, used as control, were analysed. May-Grünwald Giemsa staining and cytochemical reaction markers of cellular functions [acid phosphatase (AP), dihydrofolate reductase (DHFR), dipeptidilpeptidase (DAP IV) and serine esterase BLT-dependent (SE)], were employed to characterize the cells. The extent of the leukocytic infiltration and the percentage of activated lymphocytes ("hand mirror" shape lymphocytes: HMS; lymphocytes binding tumor: LBT) were also studied. In addition serum levels of T cell growth factor interleukin-2 (IL-2) and of the soluble IL-2 receptor (sIL-2R) were determined in the affected patients. In tumoural imprints, mostly in astrocytomas, we observed an increased percentage of DHFR and DAP IV positive lymphocytes, of HMS lymphocytes and of lymphocytes binding tumoral cells. Serum levels of IL-2 were significantly increased in all patients whilst sIL-2R levels, were high only in glioblastoma. These findings indicate that in malignant gliomas there is stimulation of the immune system as witnessed by the presence of activated cells inside tumor tissue and soluble activating factors in serum.

Telemetry monitoring of hemodynamic effects induced over time by adenosine agonists in spontaneously hypertensive rats.

Using the telemetry system in spontaneously hypertensive rats (SHR), we evaluated the hemodynamic effects of four adenosine analogs having different selectivity for A1 and A2a adenosine receptor subtypes. The selective A2a agonists, 2-hexynyl-5'-N-ethylcarboxamidoadenosine (2HE-NECA) and 2-[4-(2-carboxyethyl)-phenethylamino]-5'-N-ethylcarboxamidoaden osi ne (CGS 21680), the selective A1 agonist, 2-chloro-N6-cyclopentyl-adenosine (CCPA) and the nonselective agonist, 5'-N-ethyl-carboxamidoadenosine (NECA), were administered i.p. to conscious spontaneously hypertensive rats. For comparison, the calcium channel blocker, felodipine, was included. CCPA and 2HE-NECA were tested also by the oral route. Systolic and diastolic blood pressure and heart rate were recorded every 5 min for 24 hr after drug administration. Data were analyzed using the curve fitting model recently elaborated. All compounds caused dose-dependent antihypertensive effects. The i.p. dose inducing a decrease of 50 mm Hg (ED50) was calculated for both systolic and diastolic blood pressure. As regards diastolic blood pressure, ED50 values were: CCPA, 0.019 (0.013-0.027) mg/kg, 2HE-NECA, 0.009 (0.002-0.03) mg/kg, CGS 21680, 0.155 (0.084-0.246) mg/kg, NECA, 0.008 (0.004-0.016) mg/kg and felodipine, 5.16 (4.18-7.18) mg/kg. At equiactive doses, the antihypertensive effects of adenosine agonists were shorter lasting [t1/2 for DBP were: CCPA, 54 (44-76) min, 2HE-NECA, 57 (46-71) min, CGS 21680, 45 (21-94) min, NECA, 61(38-97) min] than those of felodipine [t1/2 = 233 (182-274) min]. After oral administration (0.3, 1 and 3 mg/kg), hypotension induced by 2HE-NECA was longer lasting than that of CCPA. 2HE-NECA, CGS 21680 and felodipine caused tachycardia.(ABSTRACT TRUNCATED AT 250 WORDS)

Modeling hemodynamic profiles by telemetry in the rat. A study with A1 and A2a adenosine agonists.

The newly developed radiotelemetry system offers a number of advantages for the measurement of blood pressure and heart rate in laboratory animals. However, no available statistical methods permit valid use of the many data gathered with this continuous recording of hemodynamic parameters. This study describes elaboration and testing of mathematical functions as applied to the measurement of the effects of drugs on blood pressure and heart rate in spontaneously hypertensive rats. We used parametric functions analogous to those for pharmacokinetic studies. Curve fitting is in fact the only approach that provides reasonable estimates of hemodynamic kinetic constants. Nonlinear functions were assessed by analyzing telemetric hemodynamic effects induced by three adenosine receptor agonists with different selectivity for the A1 or A2a receptor. After acute administration in conscious rats, the A1 agonist 2-chloro-N6-cyclopentyladenosine induced dose-related hypotension (eg, 0.03 mg/kg; peak, -70 mm Hg; time to peak, 0.34 hour) and bradycardia (eg, 0.03 mg/kg; peak, -186 beats per minute [bpm]; time to peak, 0.38 hour). The A2a agonist 2-hexynyl-5'-N-ethylcarboxamidoadenosine induced dose-related hypotension (eg, 0.003 mg/kg; peak, -36 mm Hg; time to peak, 0.32 hour) with reflex tachycardia (eg, 0.003 mg/kg; peak, 152 bpm; time to peak, 0.35 hour). The nonselective adenosine agonist 5'-N-ethylcarboxamidoadenosine (0.1 mg/kg) induced hypotension (peak, -75 mm Hg; time to peak, 2.2 hours) and bradycardia followed by tachycardia (first peak, -131 bpm; time to peak, 1.26 hours; second peak, 123 bpm; time to peak, 13.9 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Repeated administration of selective adenosine A1 and A2 receptor agonists in the spontaneously hypertensive rat: tolerance develops to A1-mediated hemodynamic effects.

We investigated the effects of the selective A1 adenosine receptor agonist 2-chloro-N6-cyclopentyladenosine (CCPA), the selective A2 adenosine agonists 2-hexynyl-5'-N-ethyl-carboxamidoadenosine(2-hexynyl-NECA) and 2-[p-(2-carboxyethyl)-phenethylamino]-5'-N-ethylcarboxamidoadenosi ne (CGS 21680), and the nonselective adenosine agonist 5'-N-ethylcarboxamidoadenosine (NECA) on systolic blood pressure (SBP), heart rate (HR) and receptor binding characteristics. The drugs were studied after acute and repeated i.p. administration in conscious, spontaneously hypertensive rats (SHRs). SBP and HR were recorded by the tail-cuff method. In acute studies the drugs induced a dose-dependent antihypertensive effect with the following order of potency: 2-hexynyl-NECA > NECA > CCPA = CGS 21680. As expected, the A1 agonist CCPA induced a dose-dependent bradycardia, whereas the A2 agonists had minimal influence on HR, and the nonselective agonist NECA induced bradycardia only at the two highest doses. In chronic experiments, the compounds were administered twice daily at equihypotensive doses. 2-Hexynyl-NECA, CGS 21680 and NECA maintained their antihypertensive effects throughout the experimental period. After 21 days, SBP levels were -32, -38 and -28% vs. baseline, respectively. HR was slightly affected. Conversely, tolerance developed to both hypotensive and bradycardic effects of CCPA: at day 21 SBP regained the pretreatment value (+2% vs. baseline), and HR also recovered (-14% vs. baseline). Binding studies were performed on cerebral tissues: no differences were observed between treated and control rats in number and affinity of either A1 and A2 receptors.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential effects of dopamine D-1 and D-2 receptor antagonist antipsychotics on sleep-wake patterns in the rat.

A series of antipsychotics having different selectivity for dopamine (DA) D-1 and D-2 receptors were studied for their effects on sleep stages in the rat. Electroencephalographic activity was recorded and classified according to the stages of wakefulness, rapid eye movement (REM) sleep and non-REM sleep. Total sleep duration, non-REM and REM latencies, number and duration of REM episodes were calculated. The DA D-1 antagonists, SCH 23390 (0.001-0.1 mg/kg s.c.), SCH 39166 (0.01-0.3 mg/kg s.c.) and NNC-756 (0.003-0.1 mg/kg s.c.), enhanced markedly the time spent in sleep through a significant increase of both non-REM and REM. Enhancement of REM was due to an increase in the number of episodes. The selective DA D-2 antagonists, raclopride (0.03-1 mg/kg s.c.) and remoxipride (1-10 mg/kg s.c.), did not affect sleep stages. Haloperidol (0.1-3 mg/kg p.o.) increased the duration of total sleep through an increase of non-REM, leaving REM unmodified. The nonselective DA antagonists, chlorpromazine (0.3-3 mg/kg s.c.) and clozapine (0.3-3 mg/kg s.c.) produced either no effect or slightly increased non-REM, respectively. Both drugs reduced REM duration by lowering the number and duration of episodes. The data show that there are differences between DA D-1 and D-2 antagonists with regard to their effects on sleep and wakefulness. Concomitant enhancement of both total sleep and REM appears to be a peculiar feature which clearly distinguishes DA D-1 antagonists from the other DA receptor blockers.(ABSTRACT TRUNCATED AT 250 WORDS)