Andrea Fontanella

Rate and duration of hospitalization for deep vein thrombosis and pulmonary embolism in real-world clinical practice

Abstract Background Current guidelines recommend initial treatment with anticoagulants at home in patients with acute deep vein thrombosis (DVT) and in patients with low-risk pulmonary embolism (PE) with adequate home circumstances. However, most of the patients with acute venous thromboembolism (VTE) are currently hospitalized regardless of their risk of short-term complications. Aim of the study To assess the proportion of outpatients with acute VTE initially treated in hospitals, to assess the mean duration of hospitalization, and to identify predictors for in-hospital or home treatment. Methods Data of Italian patients enrolled in the RIETE registry from January 2006 to December 2013 were included. Results Altogether 766 PE and 1,452 isolated DVT were included. Among PE patients, mean PESI score was 84 points (SD 35), and 56% of patients had a low-risk PESI score (<85). In all, 53.7% of DVT and 17.0% of PE were entirely treated at home, and 38.2% of DVT patients and 19.9% of PE patients were hospitalized for ≤5 days. On multivariate analysis, low PESI score was not independently associated with the hospitalization of PE patients. Conclusions One in every two patients with DVT and five in every six with PE are still hospitalized. Key Messages A significant number of patients with venous thromboembolism (VTE) are still hospitalized for the acute phase of the treatment despite current guidelines recommending initial treatment with anticoagulants at home in patients with acute deep vein thrombosis (DVT) and in patients with low-risk pulmonary embolism (PE) with adequate home circumstances.

Efficacy and safety of extended thromboprophylaxis for medically ill patients: A meta-analysis of randomised controlled trials

Compelling evidence suggests that the risk of pulmonary embolism (PE) and deep-vein thrombosis (DVT) persists after hospital discharge in acutely-ill medical patients. However, no studies consistently supported the routine use of extended-duration thromboprophylaxis (ET) in this setting. We performed a meta-analysis to assess efficacy and safety of ET in acutely-ill medical patients. Efficacy outcome was defined by the prevention of symptomatic DVT, PE, venous thromboembolism (VTE) and VTE-related mortality. Safety outcome was the occurrence of major bleeding (MB) and fatal bleeding (FB). Pooled odds ratios (ORs) and 95 % confidence intervals (95 %CI) were calculated for each outcome using a random effects model. Four RCTs for a total of 28,105 acutely-ill medical patients were included. ET was associated with a significantly lower risk of DVT (0.3 % vs 0.6 %, OR 0.504, 95 %CI: 0.287-0.885) and VTE (0.5 % vs 1.0 %, OR: 0.544, 95 %CI: 0.297-0.997); a non-significantly lower risk of PE (0.3 % vs 0.4 %, OR 0.633, 95 %CI: 0.388-1.034) and of VTE-related mortality (0.2 % vs 0.3 %, OR 0.687, 95 %CI: 0.445-1.059) and with a significantly higher risk of MB (0.8 % vs 0.4 %, OR 2.095, 95 %CI: 1.333-3.295). No difference in FB was found (0.06 % vs 0.03 %, OR 1.79, 95 %CI: 0.384-8.325). The risk benefit analysis showed that the NNT for DVT was 339, for VTE was 239, and the NNH for MB was 247. Results of our meta-analyses focused on clinical important outcomes did not support a general use of antithrombotic prophylaxis beyond the period of hospitalization in acutely-ill medical patients.

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

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

Efficacy and safety of extended antithrombotic prophylaxis in elderly medically ill patients

Compelling evidence suggests that the risk of pulmonary embolism and deep-vein thrombosis (DVT) persists after hospital discharge in acutely ill medical patients [1]. However, results of available studies did not support the routine use of extended-duration thromboprophylaxis in this setting [2–5]. Extended antithrombotic prophylaxis beyond hospitalisation may be beneficial in elderly, medically ill patients http://ow.ly/udyj304QvNo

What We are Learning from Real World Data on Rivaroxaban for the Treatment of VTE: An Overview

Rivaroxaban is one of most common used DOACs in the treatment of VTE. Rivaroxaban has been tested in a series of premarketing studies and after it has been used in non-interventional studies and in real life studies.All studies experienced that rivaroxaban shows relevant safety concerning main outcomes of VTE therapy as recurrent VTE and major bleedings, in particular in patients that show similar clinical characteristics to those selected for EINSTEIN studies. Suggested doses of rivaroxaban seem to be safe also in real life studies while non-conventional doses may be associated to increased rate of clinical complications as recurrent VTE and major bleedings. Rivaroxaban shows also good safety when used in real life studies in patients with clinical characteristics that differ from those of patients in the EINSTEIN studies.

La figura dell’Hospitalist in Italia

Tra il Mito di Titone e la sindrome di Odisseo/Ulisse del Malato Complesso A. Fontanella Profilo biosociale del paziente ospedalizzato del XXI secolo R. Nardi, G. Mathieu, M. La Regina C’e bisogno di una nuova figura professionale? M. Silingardi Analisi dei modelli esistenti: future hospital program F. Orlandini Analisi dei modelli esistenti: Acute Complex Care Model (ACCM) F. Pietrantonio Analisi dei modelli esistenti: hospitalist V. Verdiani On being a hospitalist M. Affinati La nuova figura professionale italiana: profilo, attivita e modelli organizzativi F. Orlandini, M. La Regina, V. Verdiani, D. Manfellotto Il percorso formativo G. Murialdo, A. Testi, G. Torre, P. Gnerre, F. Orlandini La certificazione L. Marchionni, M. Campanini, C. Nozzoli, A. Mazzone Hospitalist: SWOT analysis M. La Regina, F. Orlandini, V. Verdiani Considerazioni conclusive sulla figura dell’ Hospitalist D. Manfellotto

Postprandial hyperglycemia: a new frontier in diabetes management?

Postprandial hyperglycemia is one of the earliest abnormalities of glucose homeostasis associated with type-2 diabetes and it is markedly exaggerated in diabetic patients with fasting hyperglycemia. An extensive body of data demonstrates a strong association between postprandial glucose levels and cardiovascular risk factors. Our article will focus on the concept of postprandial hyperglycemia, its physiopathology, its role on cardiovascular risk factors and the effects of new devices and a new faster insulin analog on postprandial hyperglycemia.

How to choose and become a reviewer for a scientific medical journal

Peer review is the process of subjecting an author’s scholarly work, research or ideas to the scrutiny of others who are experts in the same field. The peer review of scientific manuscripts is a cornerstone of modern science and medicine. Some journals have difficulty in finding appropriate reviewers who are able to complete reviews on time avoiding publication delay. We discuss some of the main issues involved during the peer review process. The reviewer has a direct and important impact on the quality of a scientific medical Journal. Editors select reviewers on the basis of their expertise. Reviewers are more likely to accept to review a manuscript when it is relevant to their area of interest. They should respond to ethical principles, excluding any conflict of interest condition. The reviewer has to be professional, constructive, tactful, empathetic and respectful. Structured approaches, quality indicators and step-by-step process check list formats could be useful in obtaining a good review.

Factors associated with anticoagulation prescription in elderly patients with atrial fibrillation

Dear Editor, Atrial fibrillation (AF) has a high prevalence in patients older than 75 years. Oral anticoagulants are likely to be beneficial in elderly patients with AF for preventing thromboembolism despite their increased risk of bleeding. However, in daily practice these patients are undertreated, but reasons for this clinical approach are still under debate. To date only a few studies have evaluated the rate of prescription of oral anticoagulants in patients 80 years old and data on the factors associated with lack of anticoagulant treatment in this population are not compelling. Furthermore, information on AF patients 85 years and 90 years is even more limited. The aim of our study was to evaluate the rate of prescription of anticoagulant therapy and the factor associated with prescription in elderly patients enrolled in the Italian multicentre, observational study AntiThrombotic Agents in Atrial Fibrillation (ATA-AF), that included a total of 7148 non-selected patients with AF referred to a representative sample of cardiology and internal medicine units. This secondary analysis provided separate data in different ages categories (80–84 years, 85–89 years and 90 years). Our results showed that from 31 May–1 July 2010, 2617 patients> 80 years were observed in 360 Italian centres (196 internal medicine units and 164 cardiology units); they were affected by AF with no mechanical prosthetic valves or another indication for anticoagulation: 1335 (51%) were between 80–84 years, 927 (35%) between 85–90 years and 355 (14%) were over 90 years old. One thousand and sixty-three patients (40%) were already anticoagulated and 775 (29%) were on antiplatelet treatment at admission. Oral anticoagulant treatment was prescribed in 1213 of 2617 patients (46%) at discharge and this was significantly different in different age categories being 58% in patients between 80–84 years, 40% in patients between 85–90 years and 20% in patients> 90 years (p< 0.001). Of note, at least one antiplatelet drug was prescribed in 985 patients (37%), and two antiplatelet drugs were prescribed in 181 patients (6%). Several other factors resulted significantly associated with anticoagulation prescription at univariate analysis. At multivariate analysis the subgroup of patients > 90 years remained inversely associated with anticoagulation treatment at discharge (odds ratio (OR) 0.382 (confidence interval (CI) 0.250–0.583) p< 0.001). Furthermore, cancer, history of falls, dementia and the use of antiplatelet drugs were significantly associated with a lower prescription of anticoagulants in our elderly patients. Conversely patients with no need of assistance, or who live alone, and those who

PM10 exposure is associated with increased hospitalizations for respiratory syncytial virus bronchiolitis among infants in Lombardy, Italy

ABSTRACT Respiratory syncytial virus (RSV) is the primary cause of acute lower respiratory infections in children, bronchiolitis in particular. Airborne particulate matter (PM) may influence the childrens immune system and foster the spread of RSV infection. We aimed to verify whether PM10 exposure is associated with hospitalization due to RSV bronchiolitis. We selected hospital discharge records (HRD) with ICD‐9‐CM code 466.11 of infants < 1 year of age, occurring in the epidemic seasons of two years (2012–2013) in Lombardy, Italy. Cases were assigned daily PM10 and apparent temperature levels of the capital city of their residential province. Different exposure windows were considered: single days preceding hospitalization (lag 0 to 30), their average estimates (lag 0–1 to 0–30), and the four weeks preceding hospitalization (week 1 to 4). Negative binomial regression models adjusted for apparent temperature and season were applied to the daily counts of hospitalizations in each province. Results were expressed as incidence rate ratios (IRR) and 95% confidence intervals (95%CI) per 10 &mgr;g/m3 increase in PM10 concentration. Random effects meta‐analyses of province‐specific IRR were performed to obtain regional estimates. 2814 HRD met our inclusion criteria; males represented about 55% of the cases. A 6% increased risk of hospitalization (95%CI: 1.03–1.10) was found at lag 0 and an almost overlapping 7% increase at lag 1. IRR ranged from 1.03 to 1.05 between lags 2 and 11. No increased risk was observed from lag 12. When considering averaged daily lags, risk estimates gradually increased in the two weeks preceding hospitalization from 1.08 (1.04–1.12) at lag 0–1 to 1.15 (1.08–1.23) between lags 0–11 and 0–13. Analyses on weekly lags showed a risk increase of 6% (1.01–1.12) during week 1 and of 7% (1.02–1.13) during week 2. Our study found a clear association between short‐ and medium‐term PM10 exposures and increased risk of hospitalization due to RSV bronchiolitis among infants. HighlightsRespiratory syncytial virus bronchiolitis (RSV‐B) might be influenced by air pollution.PM10 was associated with RSV‐B hospitalizations among infants in Lombardy, Italy.The most relevant exposure windows were the 2 weeks preceding hospitalization.