Alessandro Cartei

Disease severity and health-related quality of life across different chronic conditions.

Measurements of health‐related quality of life (HRQL) are an essential component in overall assessment of health status, particularly in older patients. Nevertheless, how measures of HRQL relate to measures of disease severity is largely unexplored. This study was carried out to explore the relationship between a measure of HRQL and measures of severity of ischemic stroke, Parkinsons diseases (PD), or chronic coronary heart disease (CHD).

Determinants of exercise tolerance after acute myocardial infarction in older persons.

OBJECTIVES: Exercise tolerance is reduced with advancing age. Identification of potentially reversible determinants of the age‐related decrement in exercise tolerance, which remain largely unexplored in older subjects and in patients recovering from a recent myocardial infarction (MI), may have useful therapeutic implications. The objective of this study was to identify the independent determinants of exercise tolerance in older patients with a recent MI.

Compliance with therapy in hypertensive patients

ObjectiveThis study investigated pharmacological compliance in hypertensive patients recruited during a 24-month period at the Hypertension Clinic of the S. Maria Nuova Hospital.MethodsThe compliance profile scale was developed in order to classify complicance as sufficient, or poor. Compliance was evaluated according to patients’ 1) global cardiovascular risk (hypertensive) and 2) complexity of prescribed treatment at enrolment (drug, number of pills).ResultsA total of 367 patients were recruited; 82 were excluded owing to changes in therapeutic schedule or medication necessitated by other medical or surgical disease. Compliance was evaluated in 285 patients, 66% were male; the mean age was 72±12 years. Compliance was evaluated at a series of follow-ups at 3-month intervals and at 36 months of observation. Compliance at 36 months was good or sufficient in 56% of patients, but differed according to hypertensive and drug status. Compliance was better in patients with a higher level vs lower level of hypertension severity. Specifically, compliance was better in hypertensives with co-morbidity (76%) than in hypertensives without co-morbidity (37%) or hypertensives with risk factors (65%). Moreover, compliance was better in patients with a more complex therapeutic regimen (drug 1 through 3: 47, 59 and 66%).ConclusionsThese data demonstrate a relationship between disease severity and compliance, independent of the prescribed therapeutic regimen. This suggests that the most important factor for therapy adherence is disease awareness and severity, and patients with a higher level of disease are more likely to be compliant.

Aims, design and enrollment rate of the Cardiac Rehabilitation in Advanced Age (CR-AGE) randomized, controlled trial

Data regarding the efficacy of cardiac rehabilitation after acute myocardial infarction in advanced age are limited, and are derived from either controlled but non randomized trials, or observational studies. Several aspects of cardiac rehabilitation after myocardial infarction in advanced age, including its effectiveness on exercise tolerance and health-related quality of life, as well as the feasibility of rehabilitation programs, need clarification. The objectives of this randomized, controlled trial, Cardiac Rehabilitation in Advanced Age (CR-AGE), are to examine the effects of an 8-week comprehensive cardiac rehabilitation intervention, comparing 1) supervised outpatient, hospital-based cardiac rehabilitation, 2) home-based cardiac rehabilitation, and 3) usual care in each of three groups of post-myocardial infarction patients, 45–65, 66–75, and 76–85 years of age. The primary objective of the trial is to evaluate the change in physical fitness in each age group assessed by total work capacity at the end of the intervention, and during follow-up over both the medium- (6 months) and the long-term (1 and 2 years). Secondary objectives of the trial include an examination of the feasibility of cardiac rehabilitation in older patients, as well as the determination of the following: exercise complication rates; changes in peak oxygen consumption; changes in other outcome measures, such as health-related quality of life, prevalence of anxiety and depressive symptoms, fluid intelligence, body composition and mass index; incidence of new cardiac and non-cardiac events; and utilization rates of health care services. Enrollment in the CR-AGE trial is expected to be completed within the first half of 1998.

Multidisciplinary Approach to Hip Fracture in the Elderly: Florence Experience

Since September 2011 in Orthopaedic and Trauma Centre of AOU Careggi, Florence, exists a trauma area with 75 beds managed by a team with the key figure of the internal medicine specialist as coordinator of a Multidisciplinary Working Group that will include several specialists such as Anaesthesiologists, Geriatricians, Orthopaedics. Due to the high number of elderly patients, most frequently admitted for hip fracture and often suffering from multiple co-morbidities, the clinical approach is significantly more complex than in patients undergoing elective surgery. To evaluate the effectiveness of this organization model we prospectively followed the hospital course of 297 patients with hip fracture admitted to our hospital course from September 15 2012 to November 15 2012, Results were compared with an historical sample, e.g. 235 consecutive patients admitted between January 1 and March 31 2011. In the period under investigation patients treated within 48 hours raised from 36 to 80%, while early intervention was performed in historical group in only 26%. Hospital mortality was 2.3% (7/297 patients) in comparison to 3.1%. Overall incidence of severe complications has been low, less than 8% (mainly pneumonia and respiratory failure) while, despite LMWH prophylaxis, Doppler examination showed an 18% incidence of distal DVT. No proximal symptomatic DVT however was diagnosed. Mean length of hospital stay, 18.1 ± 7 days in historical sample, significantly decreased to 6.6 ± 8.9 days in September 15 2011 ± October 15 2011 and to 13.6 ± 4.7 days (p=0.0022) in November 15-December 15 2011. We suggest that an integrated evaluation at hospital arrival with careful clinical investigation, identification and stabilization of concomitant clinical problems, would allow decreasing the time to surgery, in particular in frail subjects. Moreover, clinical management by internal medicine specialists and geriatricians, other than orthopedics, should improve the ultimate outcome in patients with hip fracture.

In Hospital and 3-Month Mortality and Functional Recovery Rate in Patients Treated for Hip Fracture by a Multidisciplinary Team.

Objectives Medical comorbidities affect outcome in elderly patients with hip fracture. This study was designed to preliminarily evaluate the usefulness of a hip-fracture unit led by an internal medicine specialist. Methods In-hospital and 3-month outcomes in patients with hip fracture were prospectively evaluated in 121 consecutive patients assessed before and followed after surgery by a multidisciplinary team led by internal medicine specialist; 337 consecutive patients were recalled from ICD-9 discharge records and considered for comparison regarding in-hospital mortality. Results In the intervention period, patients treated within 48 hours were 54% vs. 26% in the historical cohort (P<0.0001). In-hospital mortality remained stable at about 2.3 per 1000 person-days. At 3 months, 10.3% of discharged patients had died, though less than 8% of patients developed postoperative complications (mainly pneumonia and respiratory failure). The presence of more than 2 major comorbidities and the loss of 3 or more BADL were independent predictors of death. 50/105 patients recovered previous functional capacity, but no independent predictor of functional recovery could be identified. Mean length of hospital stay significantly decreased in comparison to the historical cohort (13.6± 4.7 vs 17 ± 5 days, p = 0.0001). Combined end-point of mortality and length of hospitalization < 12 days was significantly lower in study period (27 vs 34%, p <0.0132). Conclusions Identification and stabilization of concomitant clinical problems by internal medicine specialists may safely decrease time to surgery in frail subjects with hip fracture. Moreover, integrated perioperative clinical management may shorten hospital stay with no apparent increase in in-hospital mortality and ultimately improve the outcome. These results are to be confirmed by a larger study presently ongoing at our institution.

What Happens before Syncope? Study of the Time Frame Preceding Vasovagal Syncope

Objective. The events characterizing the very last part of the vasovagal crisis has not been determined. The aim of the study was to analyze the variations in respiratory pattern preceding the vaso-vagal syncope full-blown and the relationship between cardiovascular functions in order to assess the temporal sequence. Methods. Eleven consecutive patients were studied. Heart rate, arterial pressure, respiratory frequency, tidal volume, carbon dioxide, and oxygen saturation in time domain from supine and standing recordings were analyzed. Results. The respiratory activity is different in the time frame preceding syncope, both in VT and breathing rate, and that the increase of the lung ventilation does not influence the baroreflex control during the presyncopal period but may be cause of the baroreflex failure during the full-blown syncope.

Functional outcomes and mortality in geriatric and fragility hip fractures—results of an integrated, multidisciplinary model experienced by the “Florence hip fracture unit”

PurposeThe aim of this study was to evaluate the outcomes of an integrated multidisciplinary hip fracture unit through the following parameters: time to surgery, mortality, return to activities of daily living, adherence to re-fractures prevention programs.MethodsSix hundred seventy-seven consecutive patients with hip fracture were included in the study. We calculated the time to surgery as the time in hours from admission until surgery. The in-hospital mortality was calculated as the number of deaths that occurred before discharge. Each patient was then evaluated post-operatively at six weeks, three months, and one year. We studied basic activity of daily living (BADL) and the New Mobility Scale (NMS). Adherence to re-fractures prevention programs was also evaluated.Results88.9% of patients underwent surgery within two calendar days from admission. In-hospital mortality was 2.4%, and the overall mortality at one year from the intervention was 18.7%. Full mobility status or a low impairment of the mobility status was reached in 32.1% of the patients at one year and a level ≥ 3 of autonomy in BADL was reached in 62.4% (338/542) of patients. Three hundred forty-two patients were prescribed a specific therapy for secondary prevention of re-fracture.ConclusionsAn integrated, multidisciplinary model for the treatment of hip fragility fractures was effective in reducing time to surgery and mortality, increasing the level autonomy and mobility status and promoting adherence to re-fracture therapy.

Stress cardiomyopathy in hip fracture. Differential diagnosis

Received: June 02, 2017; Accepted: June 24, 2017; Published: June 26, 2017 Several studies suggest that early treatment of hip fracture is associated with a lower 30 days and long term mortality. Nevertheless patients with preoperative myocardial infarction hip surgery is associated with an high 30 day mortality (30-40%) [1]. Among 1205 patients referred to Trauma Centre of AOU Careggi Florence October 1 2011 September 3

PROPHYLAXIS OF VENOUS THROMBOEMBOLISM IN KNEE REPLACEMENT SURGERY

Venous thromboembolism (VTE) is still a frequent and sometimes severe complication after knee replacement surgery. Both pharmacological and non-pharmacological measures have been widely used to decrease VTE risk. Non pharmacological treatment include measures directed to decrease the effects of blood stasis, intermittent pneumatic compression device (IPCD) and graduated compression stockings, and mechanical devices. Pharmacological prophylaxis of venous thromboembolism (VTE) is associated with a more significant decrease in the incidence of deep venous thrombosis (DVT) and related complications after knee arthroplasty however anticoagulation may increase the risk of postoperative bleeding and related complications, in particular the need for re-intervention. Aim of present review was to suggest practical approach to DVT prophylaxis in patients undergoing knee arthroplasty. Although parenteral drugs (low dose unfractionated heparin, low molecular weight heparin and fondaparinux) are the more frequently employed agents, limited compliance may be a concern. Recent studies suggest that direct oral anticoagulants, antithrombin and anti Xa agent, might be a useful alternative although safety may limited by an higher rate of local bleeding.