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Eighty-five patients with asymptomatic carotid plaque—a diagnosis revealed by B-mode high-resolution echotomography—were followed up for four years; the echoplaque changes were compared with the clinical history. Eight patients died (2 from stroke, 4 from myocardial infarction, and 2 from lung tumor) and were excluded from the follow-up. Three patients underwent carotid thromboendarterectomy (TEA) (1 bilateral), and these 4 carotids were not considered in the total series. At the first echo Doppler evaluation of 150 carotids, plaques were observed in 112; 38 vessels were free of lesions. Of the 150 carotids, 8 revealed a new plaques. In regard to the echogenic pattern, 95 of the 112 plaques (84.8%) remained unchanged, 16 (14.3%) progressed, and regression of a small homogeneous plaque was observed in 1 patient (0.9%). An increase of the degree of vascular stenosis, was observed in 23 of the 150 carotids (15.3%). Cerebral ischemic symptoms occurred in 5 patients. In I patient who suffered from stroke, a new, soft, dyshomogeneous plaque in the carotid of the side of the lesion was observed. In 3 patients (2 with strokes, 1 with transient ischemic attack) the occlusion of a previous severe stenosis was observed. The fifth patient had a stroke on the side of an unchanged, ulcerated hemodynamic lesion. A valid criterion for identifying a risky plaque should be the Joint evaluation of the echostructural characteristics and the degree of stenosis. [ABSTRACT FROM AUTHOR]

METHOD: We investigated the association of total serum cholesterol concentrations and subsequent overall and coronary mortality in 304 patients aged > or =65 discharged from hospital after acute myocardial infarction. RESULTS: There was no association between total cholesterol concentrations and mortality due to either coronary heart disease or to all causes in all patients or, separately, in men, women, patients younger than 75 and patients aged 75 years and older. [ABSTRACT FROM AUTHOR]

Background: Early hospital discharge planning can help to reduce the length of stay and unplanned readmission in high-risk patients. Therefore, it is important to select patients who can benefit from a personalized discharge planning based on validated tools. The modified Blaylock Risk Assessment Screening Score (BRASS) is routinely used in the Molinette Hospital (Turin, Italy) to screen patients at high risk for discharge, but the effectiveness of the discharge planning is uncertain in intermediate-risk patients., Objective: To evaluate the best strategy for discharge planning by the Continuity of Care Hospital Unit (CCHU) in intermediate-risk patients according to modified BRASS., Design: Cluster-randomized, multiple crossover trial., Participants: Adult patients admitted in the Medicine and Neurology departments of the Molinette Hospital in Turin, Italy, between June 2018 and May 2019 with a BRASS intermediate risk., Interventions: A routine discharge planning strategy (RDP, Routine Discharge Plan), which involved the management of all intermediate-risk patients, was compared to an on-demand discharge planning strategy (DDP, on-Demand Discharge Planning), which involved only selected patients referred to the CCHU by ward staff., Main Measures: The primary outcome was the 90-day hospital readmission for any cause (HR90). Secondary outcomes included the prolonged length of stay (pLOS)., Key Results: Eight hundred two patients (median age 79 years) were included (414 RDP and 388 DDP). Comparing RDP vs. DDP periods, HR90 was 27.6% and 27.3% (OR 1.01, 90%CI 0.76-1.33, p = 0.485); and pLOS was 47 (11.4%) and 40 (10.3%) (OR 1.24, 95%CI 0.72-2.13, p = 0.447), respectively., Conclusions: This is one of the largest randomized study conducted to compare the effectiveness of two different hospital discharge planning strategies. In patients with intermediate risk of hospital discharge, a RDP offers no advantage over a DDP and results in an unnecessary increase in staff workload., Trial Registration: Clinicaltrials.gov: NCT03436940., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: In a patient-centred model of care, referral to early palliative care (EPC) depends on both the prognosis and the complexity of care needs. The PALCOM scale is a 5-domain multidimensional assessment tool developed to identify the level of complexity of palliative care needs of cancer patients. The aim of this study was to validate the PALCOM scale., Patient and Methods: We conducted a prospective cohort study of cancer patients to compare the PALCOM scale and expert empirical assessment (EA) of the complexity of palliative care needs. The EA had to categorise patients according to their complexity, considering that medium to high levels required priority attention from specialist EPC teams, while those with low levels could be managed by non-specialist teams. Systematically collected multidimensional variables were recorded in an electronic report form and stratified by level of complexity and rating system (PALCOM scale versus EA). The correlation rank (Kendall's tau test) and accuracy test (F1-score) between the two rating systems were analysed. ROC curve analysis was used to determine the predictive power of the PALCOM scale., Results: A total of 283 advanced cancer patients were included. There were no significant differences in the frequency of the levels of complexity between the EA and the PALCOM scale (low 22.3-23.7%; medium 57.2-59.0%; high 20.5-17.3%). The prevalence of high symptom burden, severe pain, functional impairment, socio-familial risk, existential/spiritual problems, 6-month mortality and in-hospital death was significantly higher ( p < 0.001) at the high complexity levels in both scoring systems. Comparative analysis showed a high correlation rank and accuracy between the two scoring systems (Kendall's tau test 0.81, F1 score 0.84). The predictive ability of the PALCOM scale was confirmed by an area under the curve in the ROC analysis of 0.907 for high and 0.902 for low complexity., Conclusions: In a patient-centred care model, the identification of complexity is a key point to appropriate referral and management of shared care with EPC teams. The PALCOM scale is a high precision tool for determining the level of complexity of palliative care needs.

Background: Assessment of metabolic energy expenditure in post-stroke patients using accelerometers is clinically important. However, understanding of the best placement of accelerometers on the body and methods for calculating activity counts are limited., Methods: Thirty hemiparetic post-stroke patients participated in this cross-sectional study. Four triaxial accelerometers were attached to the hemiplegic and contralateral sides of the waist and ankles during various activities: lying, sitting, standing, stepping in place, and walking on a treadmill (1-5 kmh -1 ). Activity counts and metabolic energy expenditure of the patients were recorded simultaneously. Simple linear regression analyses were performed between the activity counts and energy expenditure. Activities were classified according to their intensity, using the definition of energetic sedentary behavior of post-stroke patients and a low fitness level group., Results: The best estimate of energy expenditure was obtained when the accelerometer was worn on the contralateral ankle and the activity counts was calculated using the vertical and anteroposterior axes (R 2 =0.812). Six classes of activity intensity (sedentary: ≤1.5 METs, very light: 1.51-1.79, light: 1.80-2.59, moderate: 2.60-3.39, hard: 3.40-4.39, and very hard: ≥4.40) and corresponding activity counts cut-off points are presented., Conclusion: A triaxial accelerometer worn on the contralateral ankle and a method of calculating activity counts that includes at least the vertical and anteroposterior axes are recommended for estimating metabolic energy expenditure in post-stroke patients. The new activity counts cut-off points provide a significant advance in the interpretation of post-stroke monitoring in patients outside the hospital or rehabilitation center., (Copyright © 2022 Elsevier Inc. All rights reserved.)

In a context of high demand for hospital services among older people, we aimed to assess the rate and determinants of inappropriate hospitalizations of older patients, and to what extent they were associated with inappropriate hospital stay. This prospective observational multicentre study evaluated a random sample of consecutive patients aged ≥ 70 years accessing the Emergency Department (ED) of two Italian tertiary hospitals. A standardized comprehensive geriatric assessment was carried out in each patient, including the Blaylock Risk Assessment Screen Scale (BRASS) for identification of patients at risk of difficult discharge. Inappropriate hospitalization was defined by the ED physician when patients did not necessitate hospital-provided procedures but was due to social reasons or lack of an alternative care-setting. Among 1877 patients (median age 80.7 years, 50.1% male), with a high prevalence of functional dependence and social isolation (around 30% and 25%, respectively), 767 (40.9%) were hospitalized. Incidence of inappropriate hospitalization was 14.6% (95% CI 12.1%-17.1%) and was associated with moderate-high risk of difficult discharge at BRASS (OR = 1.98, 95% CI 1.16-3.39, p = 0.013) and the presence of dementia with behavioural disorders (OR = 1.79, 95% CI 1.10-2.91, p = 0.020). Compared with patients appropriately admitted, inappropriate hospitalizations had shorter length of hospital stay but accounted for 1059/9154 days of stay (11.6%). Inappropriate hospitalizations occurred in less than 15% of cases, mainly accounted for by patients no longer manageable at home, but contributed to the greatest proportion of inappropriate hospital stay. These findings highlight the need of implementing appropriate home-care services and ensuring rapid access to suitable care-facilities for community-dwelling frail older patients., (Copyright © 2021. Published by Elsevier B.V.)

Objectives: The primary objectives of this study were to (1) reduce pharmacy turnaround time (TAT) without compromising safety and quality and (2) reduce compounding order overload during peak hours (8:00 AM-5:00 PM). The secondary objective was to decrease patient wait time pertinent to pharmacy services., Setting: The setting was a hospital-based pharmacy., Practice Description: Pharmacy dispensing more than 1800 doses daily, 30% of which goes to outpatient cancer treatment. Patients usually receive multiple compounded medications; thus, compounding numbers are several folds higher than patient number. High compounded chemotherapy order volume overloaded pharmacy staff during peak hours and was a major contributor to patient wait time., Practice Innovation: Using Define Measure Analyze Improve Control Six Sigma and intelligent risk-taking strategies, a dedicated team identified root causes of problems and designed long-lasting solutions that would not compromise quality., Evaluation: The most effective initiative was the advanced preparation of chemotherapy for select patients (Concierge), which addressed pharmacy TAT, patient wait time, and chemotherapy order overload, all without affecting safety or quality of dispensed medications., Results: Pharmacy TAT decreased by 77% for Concierge patients and 31% for standard patients. Comparable decreases were observed for patient wait time: 67% for Concierge and 27% for standard patients. Safety and quality were maintained for all dispensations during and after implementation of Concierge. A concurrent 8% increase in patient number was observed despite no changes in physical capacity., Conclusion: The implementation of Concierge initiatives: markedly reduced pharmacy TAT without compromising safety checks performed by pharmacists; decreased chemotherapy order overload during peak hours; improved distribution of assignments for pharmacy staffand statistically significant decreased wait time for all patients, especially those selected for Concierge. Effective selection of Concierge patients minimized additional costs associated with wasted premixed chemotherapy. Improving workflow for a subset of patients affected a greater patient population, allowing additional patients to be treated daily., (Copyright © 2020 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Purpose: Radiofrequency (RF) catheter ablation of para-Hisian (P-H) and mid-septal (M-S) accessory pathways (APs) is a potentially harmful procedure due to their close location to the A-V node. Conversely, cryoablation (CA) appears safer in this setting. The aim of this study was to assess the efficacy and safety of CA of these APs using a specific protocol., Methods: Fifty-three patients undergoing CA for P-H (45) or M-S (8) APs were included. CA was performed with a 4-mm catheter at - 75 °C for 480 s in the site where conduction block over the AP was obtained by a specific cryomapping protocol. Optimal catheter-tissue contact was achieved by inferior or superior vena cava approach. In case of failure, a 6-mm catheter and/or trans-septal catheterization (TSC) were considered. Normal AV conduction was monitored throughout CA, which was interrupted in case of its inadvertent modifications., Results: In 46 patients (87%), CA was successful. Reasons for failure were as follows: lack of AP interruption (3 patients), intraprocedure AP conduction resumption (3), or transient A-H interval prolongation (1). Failure was associated with more aggressive approach including multiple procedures, greater use of 6-mm catheters, TSC, and longer CA applications. No major complications were observed. Three out of 46 patients (6.5%) experienced relapse of AP conduction during follow-up and were successfully re-treated by CA., Conclusions: CA of P-H and M-S APs is highly safe and effective and a specific protocol for cryomapping and CA could lead to a low recurrence rate at follow-up.

Background: Long QT and use of QT-prolonging drugs are common among older patients receiving polytherapies, but real-world evidence on their impact in clinical practice is controversial. We investigated prevalence, variables associated and clinical implications of prolonged corrected QT (QTc) among patients from the Syncope and Dementia study., Methods: Observational, prospective, multicenter study. Patients≥65 years with dementia and fall suspected for syncope in the previous three months were enrolled. Several clinical variables and the complete list of medications were recorded for each patient. A 12‑lead ECG was obtained and corrected QT was calculated by the Bazett's formula. One-year followup for death and recurrent syncope was performed., Results: Prolonged QTc was observed in 25% of the 432 enrolled patients (mean age 83.3), and was significantly associated with male gender (OR 2.09; 95% CI 1.34-3.26) and diuretics use (OR 1.85; 95% CI 1.18-2.90). At one-year 23.3% of patients died and 30.4% reported at least one recurrent event. Variables associated with one-year mortality were: age, male gender, atrial fibrillation (AF), use of calcium channel blockers and prolonged QTc (OR 1.80; 95% CI 1.01-3.20). Among patients with prolonged QTc a significant interaction for mortality was found with AF. Recurrent events were associated with the use of antiplatelets, cholinesterase. inhibitors and antipsychotics, but not with prolonged QTc., Conclusions: We documented a high prevalence of prolonged QTc, that was associated with male gender and diuretics but not with psychoactive medications. Patients with prolonged QTc had higher one-year mortality, that was four-fold increased in those with concomitant AF., (Copyright © 2018 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Aim: To evaluate the prevalence and predictors of potentially inappropriate medications (PIM) and potential prescribing omissions (PPO) in hospital-discharged older patients, according to the recently updated Screening Tool of Older People's Prescriptions and Screening Tool to Alert to Right Treatment version 2 criteria., Methods: This was a multicenter prospective observational study of patients aged ≥65 years consecutively discharged from geriatric and internal medicine wards. Each patient underwent a comprehensive geriatric assessment, and PIM and PPO at discharge were determined according to the Screening Tool of Older People's Prescriptions and Screening Tool to Alert to Right Treatment version 2 criteria. A multivariate logistic regression was carried out to identify variables independently associated with PIM and PPO., Results: Among 726 participants (mean age 81.5 years, 47.8% women), the prevalence of PIM and PPO were 54.4% and 44.5%, respectively. Benzodiazepines and proton-pump inhibitors were the drugs most frequently involved with PIM, whereas PPO were often related to 5-alpha reductase inhibitors, angiotensin-converting enzyme inhibitors, statins and drugs for osteoporosis. The number of medications (OR 1.22, 95% CI 1.15-1.28) and discharge from geriatric units (OR 0.55, 95% CI 0.40-0.75) were associated with PIM, whereas PPO were independently associated with discharge from geriatric wards (OR 0.44, 95% CI 0.31-0.62), age (OR 1.04, 95% CI 1.02-1.07), comorbidities (OR 1.17, 95% CI 1.04-1.30) and the number of drugs (OR 1.12, 95% CI 1.05-1.18)., Conclusions: Inappropriate prescribing is highly prevalent among hospital-discharged older patients, and is associated with polypharmacy and discharge from internal medicine departments. Geriatr Gerontol Int 2019; 19: 5-11., (© 2018 Japan Geriatrics Society.)

Background: Blood pressure variability (BPV) may have prognostic implications for cardiovascular risk and cognitive decline; however, BPV has yet to be studied in old and very old people., Aims: Aim of the present study was to evaluate the extent of BPV and to identify variables associated with BPV among older subjects., Methods: A retrospective study of patients aged ≥ 65 years who underwent 24-h ambulatory blood pressure monitoring (ABPM) was carried out. Three different BPV indexes were calculated for systolic and diastolic blood pressure (SBP and DBP): standard deviation (SD), coefficient of variation (CV), and average real variability (ARV). Demographic variables and use of antihypertensive medications were considered., Results: The study included 738 patients. Mean age was 74.8 ± 6.8 years. Mean SBP and DBP SD were 20.5 ± 4.4 and 14.6 ± 3.4 mmHg. Mean SBP and DBP CV were 16 ± 3 and 20 ± 5%. Mean SBP and DBP ARV were 15.7 ± 3.9 and 11.8 ± 3.6 mmHg. At multivariate analysis older age, female sex and uncontrolled mean blood pressure were associated with both systolic and diastolic BPV indexes. The use of calcium channel blockers and alpha-adrenergic antagonists was associated with lower systolic and diastolic BPV indexes, respectively., Conclusions: Among elderly subjects undergoing 24-h ABPM, we observed remarkably high indexes of BPV, which were associated with older age, female sex, and uncontrolled blood pressure values.

Aim: Potentially inappropriate prescriptions (PIP) have been highly reported in older patients, but few studies have investigated their association with adverse clinical outcomes. The present study aimed to evaluate the prevalence and predictors of PIP in hospital-discharged older adults, and to explore the association of PIP with death and rehospitalization., Methods: We carried out a multicenter prospective cohort study on hospital-discharged patients aged ≥65 years. Each patient underwent a comprehensive geriatric assessment, and the prevalence of PIP was obtained by applying Beers Criteria 2015 to discharge documents. Telephone follow up was carried out at 6 months., Results: The prevalence of PIP was 63%, and was associated with psychiatric-behavioral disorders (OR 1.64), the number of daily taken medications (OR 1.08) and long-term care discharge (OR 1.91), whereas better functional performance was protective (OR 0.93). Neither the presence nor the number of PIP were associated with rehospitalization or mortality at 6 months. However, insulin sliding scale (OR 4.97) and use of drugs inappropriate in heart failure (OR 4.64) were associated with an increased risk of rehospitalization, whereas prescription of digoxin ≥0.125 mg/daily (OR 1.77) and antipsychotics (OR 1.65) were associated with a higher risk of mortality., Conclusions: Among older hospital-discharged patients, we documented a high prevalence of PIP that was significantly associated with polytherapy, the presence of psychiatric-behavioral disorders and discharge to long-term care facilities. Although the presence and the number of PIP were not associated with adverse outcomes, some specific inappropriate prescriptions were associated with a higher risk of hospital readmission and death. Geriatr Gerontol Int 2018; 18: 561-568., (© 2017 Japan Geriatrics Society.)

Background: Uncertainties about efficacy and safety of oral anticoagulant therapy (OAT) among older and frail medical patients with atrial fibrillation (AF) largely contribute to under-prescription of these drugs., Aims: In this prospective observational cohort study, we investigated mortality, and ischemic and hemorrhagic events, in hospital-discharged older patients with AF., Methods: Stroke and bleeding risk were evaluated using CHA2DS2-VASC and HAS-BLED scores. Comorbidity, frailty, cognitive and nutritional status and functional autonomy were evaluated using standardized scales. Independent associations between clinical variables, including OAT use, and all-cause mortality, fatal and non-fatal ischemic and hemorrhagic events, were evaluated. Further clinical outcomes comparison between patients treated with OAT and those untreated was performed after adjustment for significant differences in patient baseline characteristics with propensity score matching., Results: Of 452 patients included (mean age 81.6 years, 54.9 % women, roughly 30 % cognitively impaired and/or functionally dependent, mean CHA2DS2-VASC and HAS-BLED scores 4.6 and 2.8, respectively), 151 (33.4 %) died during a mean follow-up period of 300.5 days; ischemic and hemorrhagic stroke occurred in 4.0 and 0.4 % of patients, respectively, and major bleedings in 6.2 %., Discussion: After multivariate analysis, OAT at discharge was associated with lower overall mortality and reduced occurrence of ischemic stroke, the first finding being confirmed in propensity score matched analysis., Conclusions: Among older vulnerable AF patients with high post discharge death rate, OAT was associated, among other multiple factors, with reduced mortality and lower occurrence of ischemic stroke.

Aim: The aim of the present study was to investigate the prevalence of geriatric syndromes among older medical inpatients with atrial fibrillation, and their association with use of vitamin K antagonists., Methods: A retrospective study of patients aged ≥65 years discharged with a diagnosis of atrial fibrillation from the Acute Geriatric Ward was carried out. Stroke and bleeding risk were evaluated according to the CHA 2 DS 2 -VASC and HAS-BLED scores. Comorbidity, cognitive status, functional autonomy and contraindications to vitamin K antagonists were also considered., Results: Atrial fibrillation was documented in 1078 of 3650 patients (29.5%, mean age 83.4 ± 6.6 years, 60.3% women). Contraindications to vitamin K antagonists were documented in 24.9% of patients. Prescription of vitamin K antagonists at discharge was 37.8% and 47.9%, in the overall sample and in those without contraindications, respectively. In the overall sample, prescription of vitamin K antagonists was associated with younger age, permanent/persistent atrial fibrillation, home discharge, less comorbidity, higher hemoglobin levels, better functional independence, known atrial fibrillation at admission and lower HAS-BLED score. Among patients without contraindications to vitamin K antagonists, their use at discharge was independently associated with younger age, permanent/persistent atrial fibrillation, home discharge, higher hemoglobin levels and CHA2DS2-VASC score, better functional autonomy, and greater number of drugs., Conclusions: We showed a high prevalence of atrial fibrillation among older medical inpatients, who have a poor health status and a high prevalence of geriatric syndromes. Vitamin K antagonists were prescribed in less than half of the patients; underuse was mainly accounted for by a high prevalence of comorbidities/contraindications, poor health status and limited functional autonomy. Geriatr Gerontol Int 2017; 17: 416-423., (© 2016 Japan Geriatrics Society.)

Aim: To characterize elderly medical patients and identify factors associated with prolonged length of stay., Methods: The present prospective observational study evaluated consecutive patients aged ≥65 years admitted in acute geriatric and medical wards. A comprehensive assessment including demographic, clinical, functional and cognitive variables was carried out. Delayed discharge was defined when patients were discharged later than the date they were deemed medically ready for discharge by physicians. The analysis was initially carried out on the total sample and subsequently according to whether hospital admission had been from home, or from intermediate or long-term facilities., Results: Among 1568 patients (age 81.3 ± 7.3 years, 712 men), we observed a high prevalence of functional dependence, cognitive impairment, chronic immobilization and frailty (50%, 25%, 20% and 40%, respectively). Overall, delayed discharge occurred in 442 cases - resulting in 2637 days of prolonged hospital stay - and was independently associated with impairment in activities of daily living, frailty, high comorbidity and inappropriate admission. Among patients admitted from home (roughly 90% of the sample), delayed discharge occurred in 392 patients, and was independently associated with cognitive impairment, functional dependence, low severity of comorbidity and inappropriate admission (OR 3.39). Among patients admitted from intermediate or long-term facilities, lower cognitive impairment and greater severity of functional dependence were independently associated with prolonged stay., Conclusions: Poor health conditions and high prevalence of geriatric syndromes are extremely common among older medical inpatients. Delayed discharge was mainly observed in patients admitted from home, and associated with cognitive impairment (OR 1.12) and functional dependence (OR 1.49)., (© 2015 Japan Geriatrics Society.)

In this retrospective cohort observational study, we investigated mortality, ischemic, and hemorrhagic events in patients ≥65 years with atrial fibrillation consecutively discharged from an Acute Geriatric Ward in the period 2010 to 2013. Stroke and bleeding risk were evaluated using CHA2DS2-VASC (congestive heart failure/left ventricular dysfunction, hypertension, aged ≥75 years, diabetes mellitus, stroke/transient ischemic attack/systemic embolism, vascular disease, aged 65 to 74 years, gender category) and HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly) scores. Co-morbidity, cognitive status, and functional autonomy were evaluated using standardized scales. Independent associations among clinical variables, including use of vitamin K antagonist-based oral anticoagulant therapy (OAT), all-cause mortality, and fatal and nonfatal ischemic and hemorrhagic events, were evaluated. Further clinical outcomes comparison between patients treated with OAT and those untreated was performed after adjustment for significant differences in patient baseline characteristics with propensity score matching. Of 980 patients discharged (mean age 83 years, 60% women, roughly 30% cognitively impaired or functionally dependent, mean CHA2DS2-VASC and HAS-BLED scores 4.8 and 2.1, respectively), 505 (51.5%) died during a mean follow-up period of 571 days; ischemic and hemorrhagic stroke occurred in 82 (12.3%) and 13 patients (1.3%), respectively, and major bleedings in 43 patients (4.4%). Vitamin K antagonists' use was independently associated with reduced mortality (odds ratio 0.524) and with a nonsignificant reduction in incidence of ischemic stroke, without excess in bleeding risk. Similar findings were observed in the 2 propensity score-matched cohorts of patients. In conclusion, among vulnerable patients with atrial fibrillation ≥65 years with high post-discharge death rate, OAT was associated, among other multiple factors, with reduced mortality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Lymphoma is a common malignancy observed in companion animals. This type of naturally occurring neoplasia has been uncommonly reported in great apes. Diffuse large B-cell lymphoma was diagnosed in an 8-yr-old captive orangutan (Pongo pygmaeus) with gastrointestinal disease by histologic and immunohistochemical methodologies. The orangutan was treated with three cycles of combination chemotherapy (intravenous Rituxan, cyclophosphamide, doxorubicin, and vincristine). The primate has been in good health and exhibiting normal behaviors for more than 15 mo following treatment.

Objectives: Increasing evidence has mounted in recent years on the potential prognostic role of biomarkers out of cardiac-specific medical settings. We aimed to test whether cardiac and inflammatory biomarkers are independently associated with in-hospital mortality in older unselected medical inpatients undergoing standardized multidimensional evaluation., Design: Observational study conducted in a metropolitan university-teaching hospital. A standardized, multidimensional analysis was carried out on all patients by using medical and hospital discharge documentation and interview results integrated with information collected from family members or caregivers., Participants and Setting: Patients older than 65 years consecutively admitted to the acute geriatric ward and to 2 acute medical wards of the hospital., Results: Male sex; low systolic blood pressure; APACHE score; functional impairment in activities of daily living (ADLs), instrumental ADLs, and Short Physical Performance Battery (SPPB); cognitive impairment; malnutrition; low albumin values; and elevated values of inflammatory and cardiac biomarkers were significantly associated with in-hospital mortality at univariate analysis. After multivariate analysis, male sex, low systolic blood pressure values at entry, severe cognitive impairment, and low functional performance measured by the SPPB resulted to be independently associated with in-hospital mortality., Conclusions: The main finding of the present study is that these biomarkers, although associated with in-hospital mortality, do not have independent predictive significance when a comprehensive and multidimensional evaluation is conducted. The main clinical implication is that our findings should discourage the indiscriminate recourse to measurement of cardiac and inflammatory biomarkers, at least in older medical inpatients, thereby reducing a patient's hospital cost and potentially minimizing further unnecessary diagnostic procedures., (Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

This study aimed to make a profile of patients at highest risk of developing contrast induced nephropathy (CIN) in order to take appropriate prevention measures. 591 patients undergoing coronary procedures were divided into two groups: patients with (CIN-group) and without (no-CIN) an increase in creatinine level equal or more than 25% from baseline values within 24-48 h after the coronary procedure. All patients underwent an accurate anamnesis, objective exam, hematochemical measurements, and diagnostic exams. The results of this study while confirming that, average age (p = 0.01), diabetes mellitus (p < 0.0001), base line renal insufficiency (p = 0.0001), diuretic therapy (p = 0.002), higher contrast doses (p = 0.01), are associated with a higher risk of contrast-induced nephropathy, also demonstrated that both clinical (p = 0.01) and subclinical (p < 0.0001) atherosclerosis, and higher preprocedural high sensitive C-reactive protein levels (hs- CRP) (p = 0.02) are risk factors for CIN., (Copyright © 2012. Published by Elsevier B.V.)

Background: Blood pressure (BP) variations occurring after hospital discharge in a population of older hypertensives have not been previously investigated., Design: elderly (≥65 years) hypertensives admitted to the geriatric acute ward of a university-teaching hospital were enrolled in this prospective observational study., Methods: Exclusion criteria were terminal illness, discharge to institution, and changes in antihypertensive regimen. BP was recorded in the emergency room, at ward admission, daily during hospital stay, and at discharge. Home self blood pressure measurement was performed after discharge., Results: The study population included 106 patients. There was a significant decrease in systolic BP (SBP) and diastolic BP (DBP) throughout the study time points. SBP and DBP decreased after discharge (from 135.1 ± 15.0 to 131.5 ± 16.1 mmHg and from 77.2 ± 8.4 to 71.6 ± 8.7 mmHg, respectively), the difference being significant only for DBP (p = 0.000). We further observed higher prevalence of critically low BP values (SBP <120 mmHg and DBP <70 mmHg) at home (23.6% and 48.1%, respectively) compared to discharge (8.5% and 9.4%, p = 0.006 and p = 0.000, respectively)., Conclusions: We observed a decrease in BP values, and particularly DBP values, after hospital discharge, in a sample of older hypertensives. Critically low BP values were observed at home in a high proportion of subjects, suggesting wise use of antihypertensive therapy at discharge and early monitoring of BP values at home.

Background: Parkinson's disease is a neurodegenerative disorder involving the basal ganglia. Type-2 Diabetes Mellitus is an important risk factor for Alzheimer disease and vascular dementia. However, the association between Parkinson's disease and Diabetes Mellitus is controversial., Objective: To investigate glucose metabolism abnormalities in 110 Parkinson's disease patients with and without dementia., Subjects and Methods: We evaluated Insulin Resistance, glucose and insulin levels after a 2-h-oral-glucose-tolerance-test in 53 Parkinson's disease with dementia and 57 with Parkinson's disease without dementia, with normal fasting glucose., Results: BMI, waist circumference, fasting glucose and insulin values, HbA1c, triglycerides, blood lipid profile, depression rating, educational levels, levodopa-dosage and antipsychotic use were similar in both groups. Disease duration and motor impairment were higher in patients with Parkinson's disease and dementia group. After 2-h-oral-glucose-tolerance-test, the prevalence of glucose metabolism abnormalities was significantly higher in group with Parkinson's disease and dementia group (p=0.03). The insulin resistance was present in 62% patients with Parkinson's disease with dementia, of whom 30% had also impaired glucose tolerance, 5,6% newly diagnosed Diabetes Mellitus and 26% only Insulin Resistance. These percentages were significantly higher in group with Parkinson's disease and dementia, also after adjustment for disease duration and motor disability., Conclusions: Our study suggests that PD patients with dementia are two times more likely to have insulin resistance than patients with PD., (Copyright © 2011 Elsevier B.V. All rights reserved.)

A follow-up program to help patients suffering from severe osteoporosis during their therapy with teriparatide or PTH(1-84) has been designed and performed. The objective of this study was to evaluate the 18-month persistence on these therapies in patients participating in the program. We enrolled 382 patients who started teriparatide or PTH(1-84) following this program and compared them with a historical cohort of 398 patients treated with the same therapies but who did not participate in any follow-up program. At the beginning of the therapy, nurses trained patients on self-injection. Patients received one phone call per week during the first month, then one phone call per month and per 3 months during the following 5 and 12 months, respectively. In every call, nurses helped patients to resolve any possible issues and collected adverse event information. The persistence rate of the group following the program was 85.6%, 8.2% higher than that of the group not following any program (77.4%). The log-rank test on persistence rates on therapy in patients enrolled and not enrolled in the program was performed; the difference was statistically significant (P = 0.006). Discontinuation in the follow-up program group occurred mainly at early stages of the treatment due to adverse events. Our results show that patients suffering from severe osteoporosis treated with teriparatide or PTH(1-84) and enrolled in a follow-up program have higher persistence rates than patients not following the program.

Background: All over Europe, an increased use of public health services has been noticed, particularly referring to access and hospitalization among elderly in the emergency department (ED)., Methods: Prospective study at a university teaching hospital in Turin, northern Italy, recruiting subjects aged >65 years consecutively attending the medical ED during 1 month. Demography, functional and cognitive status, comorbidity, severity of acute critical illness, previous ED accesses and hospitalization, diagnosis and other relevant data for ED admission and hospitalization were considered., Results: Data were collected for 1632 patients (average age 77.6 years), 89% of the 1834 older subjects who attended the ED during the study period (29.3% of the patients attending the ED). Six hundred and fifty older subjects were admitted to the hospital (62.2% of the hospital admissions). Severity of acute critical illness, presence of chronic obstructive pulmonary disease and heart failure, a high number of drugs being taken, functional dependence and advanced age were independently associated with hospital admission. One-third of the patients appeared to be frequent users of health services with more than two visits/admissions. Higher comorbidity, partial or complete functional dependence, chronic diseases (arrhythmia, pulmonary neoplasm, diseases of the large intestine) and politherapy were associated either with frequent use of the ED and multiple admissions., Conclusions: Elderly account for a high proportion of hospitalizations, mainly determined by critical health conditions, advanced age and functional dependence. Poor health conditions (high comorbidity and presence of chronic multi-organ diseases), functional dependence but not critical social factors were the main determinants of multiple hospital admissions.

We aimed to evaluate the efficacy and safety of oxycodone/acetaminophen (O/A) and codeine/acetaminophen (C/A) vs. conventional therapy (CT) without opioids in older women suffering from osteoarthritis (OA)-related pain, sub-optimally responsive to prior conventional treatments. We performed a 6 week, randomized, single blind, controlled study in three nursing homes. We enrolled 154 women with painful OA. They were assigned to treatment with O/A (n=52) and C/A (n=52) vs. CT (n=50). We evaluated at baseline and at week 6: average pain in the last week (mean pain, MeP), pain at rest (RP), pain in movement (MP) (numeric rating scale, NRS); depressive symptoms (Beck Depression Inventory-II, BDI-II); functional status (activities of daily living, ADL) and cognitive status (mini mental state evaluation, MMSE). We considered the adverse events (AEs) in the study period. At week 6, MeP, RP and MP were significantly reduced in all three groups (p<0.001); compared to CT, O/A and C/A were associated with greater reductions in MeP (p<0.001 and p=0.004, respectively), in RP (p=0.028 and p=0.032, respectively) in MP (p<0.001 and p=0.002, respectively) and with significant improvement in BDI-II score (p=0.05 and p=0.04, respectively) and ADL value (p=0.04 and p=0.05, respectively). AE rates did not differ between groups.

Background: Low (< or = 90) Ankle Brachial Index (ABI) values identify patients at high risk for cardiovascular (CV) disease and mortality. Implications for CV risk classification from routinely measuring ABI in the context of a Lipid Clinic have not been fully investigated. We aimed to evaluate whether and to what extent routine ABI determination on top of conventional risk prediction models may modify CV risk classification., Methods: Consecutive asymptomatic non-diabetic individuals free from previous CV events attending for a first visit at a Lipid Clinic underwent routine ABI determination and conventional CV risk classification according either to national CUORE model (including age, gender, smoking, total and high density lipoprotein cholesterol, systolic blood pressure and current use of blood pressure lowering drugs) and SCORE model for low risk countries., Results: In the overall sample (320 subjects, mean age 64.8 years) 77 subjects (24.1%) were found to have low ABI value. Forty-two of 250 subjects (16.8%) and 47 of 215 individuals (21.3%) at low or moderate risk according to the CUORE and SCORE models, respectively, were found to have low ABI values, and should be reclassified at high risk., Conclusion: In a series of consecutive asymptomatic individuals in a Lipid Clinic, we observed a high prevalence of low ABI values among subjects deemed at low or moderate risk on conventional prediction models, leading to CV high-risk reclassification of roughly one fifth of patients. These findings reinforce recommendations for routine determination of ABI at least within referral primary prevention settings.