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Background: The aim of this study was to identify which factors were associated with a risk of hospital readmission within 3 months after discharge of a sample of elderly patients admitted to internal medicine and geriatric wards. Methods: Of the 1178 patients aged 65 years or more and discharged from one of the 66 wards of the 'Registry Politerapie SIMI (REPOSI)' during 2010, 766 were followed up by phone interview 3 months after discharge and were included in this analysis. Univariate and multivariate logistic regression models were used to evaluate the association of several variables with rehospitalization within 3 months from discharge. Results: Nineteen percent of patients were readmitted at least once within 3 months after discharge. By univariate analysis in-hospital clinical adverse events (AEs), a previous hospital admission, number of diagnoses and drugs, comorbidity and severity index (according to Cumulative Illness Rating Scale-CIRS), vascular and liver diseases with a level of impairment at discharge of 3 or more at CIRS were significantly associated with risk of readmission. Multivariate logistic regression analysis showed that only AEs during hospitalization, previous hospital admission, and vascular and liver diseases were significantly associated with the likelihood of readmission. Conclusions: The results demonstrate the need for increased medical attention towards elderly patients discharged from hospital with characteristics such as AEs during the hospitalization, previous admission, vascular and liver diseases. © 2012 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Background: Atrial septal aneurysm (ASA) has been considered a potential source of cardiogenic embolism for many years. The ASA Multicenter Italian (ASA-MI) Study evaluated the prevalence and characteristics of ASA in patients with stroke and normal carotid arteries compared with control patients without stroke. The purpose of the present study was to evaluate the frequency of ASA and the association with patent foramen ovale (PFO) in the subgroup of younger patients (aged less than 55 years) included in the ASA-MI Study. Methods: The ASA-MI Study included 606 patients, enrolled between November 1990 and December 1996: 245 patients with a previous cerebral embolic attack and normal carotid study and a control group of 316 patients. They all underwent transthoracic and transesophageal echocardiography. The subgroup of younger patients aged less than 55 years included 90 patients (61 men and 29 women of mean age 49 ± 5 years) (group AY). This group was evaluated and compared with an age- and sex-matched control population (61 men; of mean age 48 ± 6 years) (group BY). Results: The prevalence of ASA was 48.8% (95% confidence interval 40–61) in group AY and 22.2% in the group BY (95% confidence interval 18–33) (χ2 = 5.968; p = 0.01). Morphological features were similar in the 2 groups of patients. ASA involved the entire septum in 52% of patients of group AY, and in 47.2% of group BY. The prevalence of PFO was 58.8% (95% confidence interval 43–62) in group AY and 28.8% in group BY (95% confidence interval 17–35) (χ2 = 5.811; p = 0.01). A strong association was found between ASA and PFO. Of the 90 younger patients with stroke, 39 of 44 (88.6%) with ASA also had PFO, compared with 14 of 46 (30.4%) without ASA (χ2 = 7.370; p = 0.007). Conclusion: We found that ASA and PFO were independent predictive factors for stroke in younger patients with stroke and normal carotid arteries and that the association between ASA and PFO bore an increased odds risk.

Introduction Current guidelines for ischemic stroke prevention in atrial fibrillation or flutter (AFF) recommend Vitamin K antagonists (VKAs) for patients at high-intermediate risk and aspirin for those at intermediate-low risk. The cost-effectiveness of these treatments was demonstrated also in elderly patients. However, there are several reports that emphasize the underuse of pharmacological prophylaxis of cardio-embolism in patients with AFF in different health care settings. Aims To evaluate the adherence to current guidelines on cardio-embolic prophylaxis in elderly (> 65 years old) patients admitted with an established diagnosis of AFF to the Italian internal medicine wards participating in REPOSI registry, a project on polypathologies/polytherapies stemming from the collaboration between the Italian Society of Internal Medicine and the Mario Negri Institute of Pharmacological Research; to investigate whether or not hospitalization had an impact on guidelines adherence; to test the role of possible modifiers of VKAs prescription. Methods We retrospectively analyzed registry data collected from January to December 2008 and assessed the prevalence of patients with AFF at admission and the prevalence of risk factors for cardio-embolism. After stratifying the patients according to their CHADS 2 score the percentage of appropriateness of antithrombotic therapy prescription was evaluated both at admission and at discharge. Univariable and multivariable logistic regression models were employed to verify whether or not socio-demographic (age > 80 years, living alone) and clinical features (previous or recent bleeding, cranio-facial trauma, cancer, dementia) modified the frequency and modalities of antithrombotic drugs prescription at admission and discharge. Results Among the 1332 REPOSI patients, 247 were admitted with AFF. At admission, CHADS 2 score was ≥ 2 in 68.4% of patients, at discharge in 75.9%. Among patients with AFF 26.5% at admission and 32.8% at discharge were not on any antithrombotic therapy, and 43.7% at admission and 40.9% at discharge were not taking an appropriate therapy according to the CHADS 2 score. The higher the level of cardio-embolic risk the higher was the percentage of antiplatelet- but not of VKAs-treated patients. At admission or at discharge, both at univariable and at multivariable logistic regression, only an age > 80 years and a diagnosis of cancer, previous or active, had a statistically significant negative effect on VKAs prescription. Moreover, only a positive history of bleeding events (past or present) was independently associated to no VKA prescription at discharge in patients who were on VKA therapy at admission. If heparin was considered as an appropriate therapy for patients with indication for VKAs, the percentage of patients admitted or discharged on appropriate therapy became respectively 43.7% and 53.4%. Conclusion Among elderly patients admitted with a diagnosis of AFF to internal medicine wards, an appropriate antithrombotic prophylaxis was taken by less than 50%, with an underuse of VKAs prescription independently of the level of cardio-embolic risk. Hospitalization did not improve the adherence to guidelines.

OBJECTIVE: The aim of the study was to recognize clusters of diseases among hospitalized elderly and to identify groups of patients at risk of in-hospital death and adverse clinical events according to disease clustering. METHOD: This was a cross-sectional study conducted in 38 internal medicine and geriatric wards in Italy participating in the Registro Politerapie SIMI (REPOSI) study during 2008. The subjects were 1,332 inpatients aged 65 years or older. Clusters of diseases (i.e., two or more co-occurrent diseases) were identified using the odds ratios (OR) for the associations between pairs of conditions, followed by cluster analysis. Logistic regression models were used to evaluate the effect of disease clusters on in-hospital death and adverse clinical events. RESULTS: A total of 86.7% of the patients were discharged, 8.3% were transferred to another hospital unit, and 5.0% died during hospitalization; 36.4% of the patients had at least one adverse clinical event. Patients affected by the clusters, including heart failure (HF) and either chronic renal failure (CRF) or chronic obstructive pulmonary disease, had a significant association with in-hospital death (OR, 4.3;95% confidence interval [CI], 1.6-11.5; OR, 2.9; 95% CI, 1.1-8.3, respectively), as well as patients affected by CRF and anemia (OR, 6.1; 95% CI, 2.3-16.2). The cluster including HF and CRF was also associated with adverse clinical events (OR, 3.5; 95% CI, 1.5-7.8). The effect of both HF and CRF and anemia and CRF on in-hospital death was additive. CONCLUSION: Several groups of older patients at risk of in-hospital death and adverse clinical events were identified according to disease clustering. Knowledge of the relationship among co-occurring diseases may help developing strategies to improve clinical practice and preventative interventions.

Background: As chronicity represents one of the major challenges in the healthcare of aging populations, the understanding of how chronic diseases distribute and co-occur in this part of the population is needed. Objectives: The aims of this study were to evaluate and compare patterns of diseases identified with cluster analysis in two samples of hospitalized elderly. Methods: Data were obtained from the multicenter ‘Registry Politerapie SIMI (REPOSI)' that included people aged 65 or older hospitalized in internal medicine and geriatric wards in Italy during 2008 and 2010. The study sample from the first wave included 1,411 subjects enrolled in 38 hospitals wards, whereas the second wave included 1,380 subjects in 66 wards located in different regions of Italy. To analyze patterns of multimorbidity, a cluster analysis was performed including the same diseases (19 chronic conditions with a prevalence >5%) collected at hospital discharge during the two waves of the registry. Results: Eight clusters of diseases were identified in the first wave of the REPOSI registry and six in the second wave. Several diseases were included in similar clusters in the two waves, such as malignancy and liver cirrhosis; anemia, gastric and intestinal diseases; diabetes and coronary heart disease; chronic obstructive pulmonary disease and prostate hypertrophy. Conclusion: These findings strengthened the idea of an association other than by chance of diseases in the elderly population.

The aim of the study was to explore the association of dementia with in-hospital OBJECTIVE:The aim of the study was to explore the association of dementia with in-hospital death in acutely ill medical patients. METHODS: Thirty-four internal medicine and 4 geriatric wards in Italy participated in the Registro Politerapie SIMI-REPOSI-study during 2008. One thousand three hundred and thirty two in-patients aged 65 years or older were enrolled. Logistic regression models were used to evaluate the association of dementia with in-hospital death. Socio-demographic characteristics, morbidity (single diseases and the Charlson Index), number of drugs, and adverse clinical events during hospitalization were considered as potential confounders. RESULTS: One hundred and seventeen participants were diagnosed as being affected by dementia. Patients with dementia were more likely to be women, older, to have cerebrovascular diseases, pneumonia, and a higher number of adverse clinical events during hospitalization. The percentage of patients affected by dementia who died during hospitalization was higher than that of patients without dementia (9.4 versus 4.9%). After multiadjustment, the diagnosis of dementia was associated with in-hospital death (OR = 2.1; 95% CI = 1.0-4.5). Having dementia and at least one adverse clinical event during hospitalization showed an additive effect on in-hospital mortality (OR = 20.7; 95% CI = 6.9-61.9). CONCLUSIONS: Acutely ill elderly patients affected by dementia are more likely to die shortly after hospital admission. Having dementia and adverse clinical events during hospital stay increases the risk of death.

OBJECTIVE: The aim of the study was to recognize clusters of diseases among hospitalized elderly and to identify groups of patients at risk of in-hospital death and adverse clinical events according to disease clustering. METHOD: This was a cross-sectional study conducted in 38 internal medicine and geriatric wards in Italy participating in the Registro Politerapie SIMI (REPOSI) study during 2008. The subjects were 1,332 inpatients aged 65 years or older. Clusters of diseases (i.e., two or more co-occurrent diseases) were identified using the odds ratios (OR) for the associations between pairs of conditions, followed by cluster analysis. Logistic regression models were used to evaluate the effect of disease clusters on in-hospital death and adverse clinical events. RESULTS: A total of 86.7% of the patients were discharged, 8.3% were transferred to another hospital unit, and 5.0% died during hospitalization; 36.4% of the patients had at least one adverse clinical event. Patients affected by the clusters, including heart failure (HF) and either chronic renal failure (CRF) or chronic obstructive pulmonary disease, had a significant association with in-hospital death (OR, 4.3;95% confidence interval [CI], 1.6-11.5; OR, 2.9; 95% CI, 1.1-8.3, respectively), as well as patients affected by CRF and anemia (OR, 6.1; 95% CI, 2.3-16.2). The cluster including HF and CRF was also associated with adverse clinical events (OR, 3.5; 95% CI, 1.5-7.8). The effect of both HF and CRF and anemia and CRF on in-hospital death was additive. CONCLUSION: Several groups of older patients at risk of in-hospital death and adverse clinical events were identified according to disease clustering. Knowledge of the relationship among co-occurring diseases may help developing strategies to improve clinical practice and preventative interventions.

In order to evaluate the chronobiologic effect of nitrendipine, 27 patients with mild-to-moderate arterial essential hypertension were studied. After randomized administration of 20 mg of nitrendipine and placebo, systolic and diastolic blood pressure (SBP and DBP, respectively) and heart rate (HR) were measured for 24 h using an automatic noninvasive device. The data of the time series were statistically analyzed by single and mean cosinor methods (obtaining mesor, amplitude, and acrophase) and by ANOVA and Student's paired t test. Nitrendipine significantly reduced the SBP and DBP mesors without affecting the HR mesor, and reduced the SBP and DBP amplitudes while increasing the HR amplitude. After placebo, group circadian rhythms were observed for SBP, DBP, and HR and maintained after nitrendipine. In conclusion, a single-dose administration of nitrendipine is effective in lowering blood pressure. The increased HR amplitude is probably due to a tachycardic reaction. The preservation of the SBP, DBP, and HR group circadian rhythms agrees with the lack of interference of the drug with the neurohormonal mechanisms.

The association between mitral valve prolapse (MVP) and cryptogenic stroke is controversial. The Atrial Septal Aneurysm Multicenter Italian (ASA-MI) Study is a prospective multicenter study evaluating the prevalence of atrial septal aneurysm (ASA) in patients with a recent stroke and normal carotid arteries. The aim of the present research was to evaluate the frequency of ASA and its association with MVP in the stroke population and in the subgroup of young patients (55 years) included in the ASA-MI Study.The study group included 245 of the 606 patients referred for transesophageal echocardiography (168 men and 77 women, mean age 65.7 +/- 21 years). All patients were selected on the basis of a recent episode of unexplained cerebral ischemia and were included in the study if they had normal carotid arteries. The control population included 245 patients (mean age 64.7 +/- 23 years) who underwent transesophageal echocardiographic evaluation during the same period for indications other than cerebral ischemia. The subgroup of young patients (55 years) included 90 patients (61 men and 29 women, mean age 49 +/- 5 years).The prevalence of MVP was 18% (95% confidence interval 8 to 21%) in the stroke population and 15% (95% confidence interval 7 to 20%) in the control population (chi 2 = 2.1, p = NS). The prevalence of MVP did not differ between young stroke patients (28.8%) and young controls (20%) (chi 2 = 0.835, p = 0.3). MVP was not significantly associated with stroke. We found an association between ASA and MVP: there was a higher incidence of MVP in stroke patients with an ASA than in patients without stroke or an ASA (40.9 vs 25%, p0.05). There was also a higher frequency of MVP associated with ASA in the group of young patients than in all patients of the ASA-MI Study (28.8 vs 18%, chi 2 = 20.313, p0.001).We found an association between ASA and MVP in patients with recent stroke and this association bore a higher risk of cerebral events than in patients without these abnormalities.

Secondary hyperparathyroidism - a common comorbid condition in patients with chronic renal insufficiency - is considered a consequence of critical determinants such as hypocalcemia, phosphate retention and reduced levels of calcitriol production. In this complex mechanism, the skeletal apparatus and the nonskeletal targets such as vascular and heart valves are often involved, thus explaining the increased risk of cardiovascular morbidity and mortality of uremic patients. In this review we will focus on the major role played by Calcitriol deficiency as a trigger of secondary hyperparathyroidism and the crucial need for obiquitous vitamin D receptor activation in order to have an optimal PTH control and to obtain a modulation between inhibitors and inducers of soft tissue calcification. This review will also elucidate the possible role of paricalcitol - a new vitamin D analog - in conditioning morbidity and mortality of patients on renal replacement therapy (RRT).

The frequency spectrum analysis (Fourier's analysis) has recently been applied to phonocardiography. Using this mathematical approach instead of the current empirical analysis, it is possible to obtain -- on a less subjective basis -- more precise pathophysiological and diagnostic information from the acoustic cardiac phenomena. On the other hand, this refinement of the method of analysis stresses the need for better technical and methodological solutions, in order to reach the standardization of both the transduction and the recording of the acoustic signal at higher level of sensibility, fidelity and reproducibility. With this in mind, and on the basis of their experience, the Authors suggest the adoption of devices with specific technical characteristics, and propose a suitable method of application of Fourier's analysis to the phonocardiogram.

Ambulatory monitoring was used to evaluate the antihypertensive efficacy and effect on circadian rhythms of blood pressure and heart rate of a single dose and long-term administration of ramipril in 20 patients with mild to moderate essential hypertension. Patients initially were randomized to receive either placebo or a single 5-mg dose of ramipril, followed 1 week later by 5 mg of ramipril daily for 6 months. Systolic (SBP) and diastolic blood pressure (DBP) and heart rate were measured every 20 minutes for 24 hours. Single-dose ramipril reduced both SBP and DBP (P.001) without affecting heart rate. Long-term treatment produced a small additional antihypertensive effect, again without modifying heart rate. Cosinor analysis demonstrated that both administrations of ramipril effectively lowered SBP and DBP mesors (P.001), compared to placebo; circadian rhythms remained undisturbed. Heart rate also was not modified on any circadian parameter. A significant reduction (P.001) of blood pressure amplitude, however, occurred after long-term treatment and may have importance in terms of preventing cardiac damage.