Ambulatory diastolic blood pressure: a marker of comorbidity in elderly fit hypertensive individuals?

BACKGROUND: Masked diastolic hypotension is a new blood pressure (BP) pattern detected by ambulatory blood pressure monitoring (ABPM) in elderly hypertensives. The aim of this study was to relate ABPM and comorbidity in a cohort of fit elderly subjects attending an outpatient hypertension clinic. METHODS: Comorbidity was assessed by Charlson comorbidity index (CCI) and CHA2DS2VASc score. All subjects evaluated with ABPM were aged ≥ 65 years. CCI and CHA2DS2VASc score were calculated. Diastolic hypotension was defined as mean ambulatory diastolic BP < 65 mmHg and logistic regression analysis was carried out in order to detect and independent relationship between comorbidity burden and night-time diastolic BP < 65 mmHg. RESULTS: We studied 174 hypertensive elderly patients aged 72.1 ± 5.2 years, men were 93 (53.4%). Mean CCI was 0.91 ± 1.14 and mean CHA2DS2VASc score of 2.68 ± 1.22. Subjects with night-time mean diastolic values < 65 mmHg were higher in females [54.7% vs. 45.3%, P = 0.048; odds ratio (OR) = 1.914, 95% CI: 1.047-3.500]. Logistic regression analysis showed that only CHA2DS2VASc score was independently associated with night-time mean diastolic values < 65 mmHg (OR = 1.518, 95% CI: 1.161-1.985; P = 0.002), but CCI was not. CONCLUSIONS: ABPM and comorbidity evaluation appear associated in elderly fit subjects with masked hypotension. Comorbid women appear to have higher risk for low ambulatory BP.

Do Sex-Related Differences of Comorbidity Burden and/or In-Hospital Mortality Exist in Cancer Patients? A Retrospective Study in an Internal Medicine Setting.

Cancer represents important comorbidity, and data on outcomes are usually derived from selected oncologic units. Our aim was to evaluate possible sex-related differences and factors associated with in-hospital mortality (IHM) in a consecutive cohort of elderly patients with cancer admitted to internal medicine. We included all patients admitted to our department with a diagnosis of cancer during 2018. Based on the International Classification of Diseases, 9th Revision, Clinical Modification, demography, comorbidity burden, and diagnostic procedures were evaluated, with IHM as our outcome. We evaluated 955 subjects with cancer (23.9% of total hospital admissions), 42.9% were males, and the mean age was 76.4 ± 11.4 years. Metastatic cancer was diagnosed in 18.2%. The deceased group had a higher modified Elixhauser Index (17.6 ± 7.7 vs. 14 ± 7.3, p < 0.001), prevalence of cachexia (17.9% vs. 7.2%, p < 0.001), and presence of metastasis (27.8% vs. 16.3%, p = 0.001) than survivors. Females had a higher age (77.4 ± 11.4 vs. 75.5 ± 11.4, p = 0.013), and lower comorbidity (10.2 ± 5.9 vs. 12.0 ± 5.6, p < 0.001) than males. IHM was not significantly different among sex groups, but it was independently associated with cachexia and metastasis only in women. Comorbidities are highly prevalent in patients with cancer admitted to the internal medicine setting and are associated with an increased risk of all-cause mortality, especially in female elderly patients with advanced disease.

Pulmonary embolism and internal jugular vein thrombosis as evocative clues of Lemierre's syndrome: A case report and review of the literature.

Lemierre's syndrome (LS) is an uncommon condition with oropharyngeal infections, internal jugular vein thrombosis, and systemic metastatic septic embolization as the main features. Fusobacterium species, a group of strictly anaerobic Gram negative rod shaped bacteria, are advocated to be the main pathogen involved. We report a case of LS complicated by pulmonary embolism and pulmonary septic emboli that mimicked a neoplastic lung condition. A Medline search revealed 173 case reports of LS associated with internal jugular vein thrombosis that documented the type of microorganism. Data confirmed high prevalence in young males with Gram negative infections (83.2%). Pulmonary embolism was reported in 8.7% of cases mainly described in subjects with Gram positive infections (OR = 9.786; 95%CI: 2.577-37.168, P = 0.001), independently of age and gender. Only four fatal cases were reported. LS is an uncommon condition that could be complicated by pulmonary embolism, especially in subjects with Gram positive infections.

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.

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.

Chronotype, gender and general health.

BACKGROUND: Light-dark alternation has always been the strongest external circadian "zeitgeber" for humans. Due to its growing technological preference, our society is quickly transforming toward a progressive "eveningness" (E), with consequences on personal circadian preference (chronotype), depending on gender as well. The aim of this study was to review the available evidence of possible relationships between chronotype and gender, with relevance on disturbances that could negatively impact general health, including daily life aspects. METHODS: Electronic searches of the published literature were performed in the databases MEDLINE and Web of Science, by using the Medical Subject Heading (MeSH), when available, or other specific keywords. RESULTS: Results were grouped into four general areas, i.e. (a) "General and Cardiovascular Issues", (b) "Psychological and Psychopathological Issues", (c) "Sleep and Sleep-Related Issues" and (d) "School and School-Related Issues". (a) E is associated with unhealthy and dietary habits, smoking and alcohol drinking (in younger subjects) and, in adults, with diabetes and metabolic syndrome; (b) E is associated with impulsivity and anger, depression, anxiety disorders and nightmares (especially in women), risk taking behavior, use of alcohol, coffee and stimulants, psychopathology and personality traits; (c) E has been associated, especially in young subjects, with later bedtime and wake-up time, irregular sleep-wake schedule, subjective poor sleep, school performance and motivation, health-related quality of life; (d) E was associated with lowest mood and lower overall grade point average (especially for women). CONCLUSIONS: Eveningness may impact general health, either physical or mental, sleep, school results and achievements, especially in younger age and in women. The role of family support is crucial, and parents should be deeply informed that abuse of technological devices during night hours may lead to the immature adjustment function of children's endogenous circadian pacemakers.

Reducing the risk of venous thromboembolism using apixaban - patient perspectives and considerations. Should more attention be given to females?

BACKGROUND: New oral anticoagulant agents, such as apixaban, rivaroxaban, dabigatran, or endoxaban, have recently become for patients an alternative option to conventional treatment in the therapy of venous thromboembolism (VTE). Thus, we aimed to review the available information on adverse events (AEs) of apixaban compared to conventional therapy (heparin or vitamin K antagonists) in randomized controlled trials (RCTs) on patients treated for VTE, with a particular attention to sex subgroups. METHODS: An electronic search in MEDLINE and Embase was performed by using the keywords "apixaban" and "venous thromboembolism". All RCTs focused on apixaban in the treatment and prevention of VTE were evaluated for the presence of AEs. AEs were classified as serious, bleeding, and cause of discontinuation. Moreover, we also searched by using the keywords "gender" and "venous thromboembolism" and "anticoagulants". RESULTS: Considering all subjects enrolled in the eleven RCTs as a whole to investigate the occurrence of AEs, we extrapolated an events/subjects rate of 57.8% for AEs (6,445/11,144), 7.7% for serious AEs (975/12,647), 9.1% for bleeding events (1,229/13,454), and 3.2% for discontinuation of apixaban (421/13,039). The percentage of AEs was lower in subjects treated with apixaban than in those treated with conventional VTE therapy (53% vs 56.3%, respectively). However, only one study provided data on separate analysis by sex of either efficacy or safety of apixaban. CONCLUSION: Under the patient's perspective, apixaban could represent a good choice in the treatment of VTE, due to its pharmacological, economical, and safety profile. These positive aspects are certainly present in both sexes, since the available studies include a correct percentage of women, but data with separate analyses by sex are extremely limited. Future clinical trials should include in their results on clinical impact and outcomes a stratification by sex, and studies aimed to evaluate possible sex-related differences for these drugs should be strongly encouraged.

Renal disease and accidental falls: a review of published evidence.

BACKGROUND: The pathogenesis of falling is complex, and identification of risk factors may be essential for prevention. The relationship between renal disease and falls is unclear, and the goal of this study was to collect the available evidence and investigate the relationship between accidental falls and renal dysfunction. METHODS: Electronic searches were performed in the MEDLINE, Scopus, Ovid SP and Web of Science databases to identify the appropriate literature. The themes used were: falls (combined in the title/abstract fall or falls or falling or faller* or fallen or slip* or trip* or (MeSH) accidental falls) and renal insufficiency (chronic or renal insufficiency or kidney diseases combined in title/abstract renal disease* or kidney disease* or renal insufficiency or kidney insufficiency or kidney failure or renal failure or MeSH renal insufficiency, chronic or renal insufficiency or kidney diseases). The incidence, risk factors, complications, and characteristics of the falls were analyzed. RESULTS: Eight prospective cohorts including five cross-sectional studies, and one case-control study were identified. No randomized controlled studies were found. The incidence of falls in chronic kidney disease patients ranged between 1.18 and 1.60 fall/patient year. These were frequent in frail older adults on hemodialysis treatment. Falling relapses in the same group of patients caused serious consequences. Data on pre-end stage renal disease (ESRD) were scarce. CONCLUSIONS: The risk of falling appears to be common in patients with renal dysfunction especially in older adults undergoing hemodialysis. On the other hand, we could not find any conclusive data on pre-ESRD patients.

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.

A possible relationship between renal impairment and complications development in type 2 diabetes mellitus: a prospective, observational study in Italy.

BACKGROUND: We investigated the relationship between complications development and estimated glomerular filtration rate (eGFR), in a cohort of type 2 diabetes mellitus (T2DM) outpatients. METHODS: This observational study considered 1284 T2DM outpatients, who had been followed-up for 4.5 ± 1.6 years. eGFR was estimated using Chronic Kidney Disease Epidemiology Collaboration equation. The independent relationship between development of complications and clinical data was evaluated, and hazard ratio (HR) by Cox regression analysis calculated. RESULTS: Mean age of the population was 66.8 ± 10.4 years; mean serum creatinine and eGFR were 1.05 ± 0.36 mg/dl and 71.6 ± 21.6 ml/min/1.73 m(2), respectively. Complications including death (14.2% of the whole population) were recorded in 504 subjects (39.3%). Patients with complications were older and more frequently male with history of hypertension, coronary heart disease, congestive heart disease, retinopathy, nephropathy and had higher levels of glycated hemoglobin. At Cox regression analysis, eGFR was the major risk factor for development of complications, and the HR increased according with lower eGFR (HR 1.53 and 1.86, for eGFR<45 and<30 ml/min/1.73 m(2), respectively). CONCLUSIONS: In our cohort of T2DM outpatients, a reduced eGFR was associated with an increased risk of complications development.

Diurnal and twenty-four hour patterning of human diseases: cardiac, vascular, and respiratory diseases, conditions, and syndromes.

Various medical conditions, disorders, and syndromes exhibit predictable-in-time diurnal and 24 h patterning in the signs, symptoms, and grave nonfatal and fatal events, e.g., respiratory ones of viral and allergic rhinorrhea, reversible (asthma) and non-reversible (bronchitis and emphysema) chronic obstructive pulmonary disease, cystic fibrosis, high altitude pulmonary edema, and decompression sickness; cardiac ones of atrial premature beats and tachycardia, paroxysmal atrial fibrillation, 3rd degree atrial-ventricular block, paroxysmal supraventricular tachycardia, ventricular premature beats, ventricular tachyarrhythmia, symptomatic and non-symptomatic angina pectoris, Prinzmetal vasospastic variant angina, acute (non-fatal and fatal) incidents of myocardial infarction, sudden cardiac arrest, in-bed sudden death syndrome of type-1 diabetes, acute cardiogenic pulmonary edema, and heart failure; vascular and circulatory system ones of hypertension, acute orthostatic postprandial, micturition, and defecation hypotension/syncope, intermittent claudication, venous insufficiency, standing occupation leg edema, arterial and venous branch occlusion of the eye, menopausal hot flash, sickle cell syndrome, abdominal, aortic, and thoracic dissections, pulmonary thromboembolism, and deep venous thrombosis, and cerebrovascular transient ischemic attack and hemorrhagic and ischemic stroke. Knowledge of these temporal patterns not only helps guide patient care but research of their underlying endogenous mechanisms, i.e., circadian and others, and external triggers plus informs the development and application of effective chronopreventive and chronotherapeutic strategies.

Diurnal and twenty-four hour patterning of human diseases: acute and chronic common and uncommon medical conditions.

The symptom intensity and mortality of human diseases, conditions, and syndromes exhibit diurnal or 24 h patterning, e.g., skin: atopic dermatitis, urticaria, psoriasis, and palmar hyperhidrosis; gastrointestinal: esophageal reflux, peptic ulcer (including perforation and hemorrhage), cyclic vomiting syndrome, biliary colic, hepatic variceal hemorrhage, and proctalgia fugax; infection: susceptibility, fever, and mortality; neural: frontal, parietal, temporal, and occipital lobe seizures, Parkinson's and Alzheimer's disease, hereditary progressive dystonia, and pain (cancer, post-surgical, diabetic neuropathic and foot ulcer, tooth caries, burning mouth and temporomandibular syndromes, fibromyalgia, sciatica, intervertebral vacuum phenomenon, multiple sclerosis muscle spasm, and migraine, tension, cluster, hypnic, and paroxysmal hemicranial headache); renal: colic and nocturnal enuresis and polyuria; ocular: bulbar conjunctival redness, keratoconjunctivitis sicca, intraocular pressure and anterior ischemic optic neuropathy, and recurrent corneal erosion syndrome; psychiatric/behavioral: major and seasonal affective depressive disorders, bipolar disorder, parasuicide and suicide, dementia-associated agitation, and addictive alcohol, tobacco, and heroin cravings and withdrawal phenomena; plus autoimmune and musculoskeletal: rheumatoid arthritis, osteoarthritis, axial spondylarthritis, gout, Sjögren's syndrome, and systemic lupus erythematosus. Knowledge of these and other 24 h patterns of human pathophysiology informs research of their underlying circadian and other endogenous mechanisms, external temporal triggers, and more effective patient care entailing clinical chronopreventive and chronotherapeutic strategies.

All-cause mortality and estimated renal function in type 2 diabetes mellitus outpatients: Is there a relationship with the equation used?

BACKGROUND: We investigated the relationship between serum creatinine (SCr) and estimated glomerular filtration rate (eGFR), evaluated by different formulae, and all-cause mortality (ACM) in type 2 diabetes mellitus (T2DM) outpatients. METHODS: This observational cohort study considered 1365 T2DM outpatients, who had been followed up for a period of up to 11 years. eGFR was estimated using several equations. RESULTS: Seventy subjects (5.1%) died after a follow-up of 9.8 ± 3 years. Univariate analysis showed that diagnosis of nephropathy (odds ratio (OR): 2.554, 95% confidence interval (CI): 1.616-4.038, p < 0.001) and microvascular complications (OR: 2.281, 95% CI: 1.449-3.593, p < 0.001) were associated with ACM. Receiving operating characteristic (ROC) curves showed that the areas under the curve for ACM were similar using the different eGFR equations. eGFR values were predictors of ACM, and the hazard ratios (HRs) of the different equations for eGFR estimation were similar. CONCLUSION: In our cohort of T2DM outpatients, different eGFR equations perform similarly in predicting ACM, whereas SCr did not.

Takotsubo cardiomyopathy and acute infectious diseases: a mini-review of case reports.

Takotsubo cardiomyopathy (TTC), also defined as "stress cardiomyopathy," is characterized by a systolic dysfunction localized in the apical and medial left ventricles. Takotsubo cardiomyopathy is more prevalent in females and it is usually related to an event triggered by physical or emotional stress. We systematically explored PubMed and Embase medical information source to identify case reports showing association between infection and TTC. For each kind of infection, we collected a set of data, including pathogen, site of infection, clinical outcome, patient age and sex, and author and year of publication. We found 26 articles dealing with 27 case reports (74% women). The mean age was 61.4 ± 13.7 years and bacterial infections were more frequent (n = 23, 85.2%). In 14 cases, there was a culture-based definition of the bacterial strain: gram+ in 8 cases (57.1%) and gram- in 6 cases (42.9%). Clinical outcome was always favorable.