Fabrizio Fabris

Predictive Factors of In‐Hospital Mortality in Older Patients Admitted to a Medical Intensive Care Unit

OBJECTIVES: To identify prognostic factors that are independently predictive of in‐hospital mortality in older patients hospitalized in a medical intensive care unit (MICU).

Carotid plaque, aging, and risk factors. A study of 457 subjects.

Background and Purpose The aim of this study was to assess the prevalence of extracranial carotid artery atherosclerosis and its relation to principal cardiovascular risk factors at different ages in a sample of the general population. Methods B-mode ultrasonography was used to investigate the carotid district in 457 subjects (231 men and 226 women; mean age, 55.4±18.7 years; range, 18 to 97 years) in the metropolitan area. The ultrasonographic findings were then related to risk factors. Results Carotid plaques were found in 178 subjects (38.9%). The prevalence of atherosclerosis, number of plaques, and severity of stenosis were observed to increase with age. Age (P<.0001), cigarette smoking (P<.0001), male sex (P<.001), total cholesterol (P<.05), and, inversely, the ratio of high-density lipoprotein cholesterol to total cholesterol (P<.05) were found to be independently associated with carotid atherosclerosis. Stratified analysis by sex and age showed effect modifications by age on cigarette smoking, total cholesterol, and the ratio of high-density lipoprotein cholesterol to total cholesterol. After multivariate analysis including interaction terms, cigarette smoking and cholesterol levels were no longer found to be associated with carotid atherosclerosis in elderly subjects. Age (P<.01), total cholesterol (P<.05), and diabetes (P<.05) were positively related to the severity of vascular narrowing. Conclusions There is a high prevalence of asymptomatic carotid atherosclerosis in the general population, particularly among the very old. The association between risk factors and carotid atherosclerosis is less pronounced in the elderly than in younger subjects.

Hemorheologic and Coagulative Pattern in Hypercholesterolemic Subjects Treated with Lipid-Lowering Drugs

The effects on the coagulative and rheologic pattern of two lipid-lowering drugs, bezafibrate and simvastatin, were studied in 36 hypercholesterolemic subjects. Patients were randomly divided into two groups (18 subjects each) and received bezafibrate R 400 mg/day or simvastatin 10-40 mg/day over a twelve week period. Besides a decrease in plasma fibrinogen and fibrinopeptide A (p<0.001 both), bezafibrate induced a reduction of factor VIIc and VIIIc activity (p<0.001 both), while antithrombin 3 activity was increased (p<0.001) and the hemorheologic pattern was greatly improved (p<0.001). Simvastatin caused a slight decrease in factor VIIIc activity and a moderate reduction of beta thromboglobulin. The efficacy of bezafibrate in reducing the activation of the coagulative cascade and improving the hemorheologic pattern has been con firmed; the peculiar triglycerides- and fibrinogen-lowering effect of the drug, not observed with simvastatin, could be responsible for these modifications.

Home hospitalization service for acute uncomplicated first ischemic stroke in elderly patients: a randomized trial.

Objectives: To evaluate whether home treatment of elderly patients with acute uncomplicated first ischemic stroke is associated with different mortality rates and clinical outcomes from those of patients treated on a general medical ward (GMW).

Comparative effects of lercanidipine, lacidipine, and nifedipine gastrointestinal therapeutic system on blood pressure and heart rate in elderly hypertensive patients: The ELderly and LErcanidipine (ELLE) study

This study was conducted to compare the antihypertensive efficacy and safety of lercanidipine with those of lacidipine and nifedipine gastrointestinal therapeutic systems in patients aged 65 years or above with mild-to-moderate hypertension. Patients were randomized to receive lercanidipine 5 mg, lacidipine 2 mg, or nifedipine 30 mg for 24 weeks. After 2 weeks, the dose was doubled in non-responding patients. At 24 weeks, blood pressure was significantly reduced in the three treatment groups. The decrease in systolic blood pressure was similar in all three groups. The decrease in diastolic blood pressure in the lercanidipine group (-18.3 mmHg) was comparable to that in the nifedipine group (-17.7 mmHg), but exceeded that in the lacidipine group (-16.6 mmHg). The incidence of adverse drug reactions (ADRs) was lowest in the lercanidipine group (19.4%) compared with the nifedipine group (28.4%) and the lacidipine group (27.1%). In particular, edema was least frequent in the lercanidipine group (2.8%) compared with the lacidipine group (7.5%) and the nifedipine group (10.1%). These data demonstrate that lercanidipine is effective in lowering blood pressure in older adult hypertensive patients while maintaining a superior tolerability and safety profile.

Estimating the cost per avoided hip fracture by osteoporosis treatment in Italy

OBJECTIVES A cost-effectiveness analysis on osteoporosis treatment has been carried out as the basis for an estimate of the cost per avoided hip fracture (CPAHF) in Italy. METHODS We have assumed as correct, reported data on the efficacy of calcitonin in preventing hip fractures in European women over 50 (Mediterranean Osteoporosis Study). Health-care costs were calculated using Weinstein and Stasons equation. RESULTS Given the incidence of such fractures in Italy and their cost to the health service, we calculate that in order to prevent one hip fracture 1285 women need to be treated with calcitonin at a cost of over two million dollars. The introduction of an element of screening (bone mass measurement to select a high risk subpopulation) would reduce the CPAHF by 65%. Choice of a more effective treatment (as the hormone replacement therapy) would be cost-neutral. CONCLUSIONS Drug-related costs, selection of high risk subpopulations and drug efficacy have important implications in the estimation of optimal CPAHF.

Post-hospitalization mortality in the elderly

The level of disability and polypathology in hospitalized elderly is usually high. Multidimensional and functional assessment allows to identify risk factors for clinical and functional failure of patients. Many studies point out that identifying predictors of high-risk patients is a necessary step in accurate targeting. We evaluated 395 subjects (175 women, 202 men, mean age 77.9 year) during their hospitalization in our Geriatric ward. Baseline data included: demographics variables, medical diagnosis, functional evaluation, and laboratory values. After a 6-month follow up 80 (20.2%) subjects died. In our study, male gender, dependence at the Dependence Medical Index (DMI), low serum albumin (< 2.8 g/dl), impaired score at the Instrumental Activities of Daily Living scale (IADL), score lower than 13.7 at the acute physiology and chronic health evaluation (APACHE II) and neoplasm were independent predictors of 6-month post-hospitalization mortality. The high mortality rate of our sample could be a marker of considerable frailty among elderly patients. Our study shows that a poor functional status is a more reliable prognostic factor than type and number of admitting diagnosis. Clinical evaluation, improved with information about functional status, is a feasible and practical way of detecting risk of short term post-hospitalization mortality of elderly subjects.

Body fat and C-reactive protein levels in healthy non-obese men

BACKGROUND AND AIM The relationships between C-reactive protein (CRP) levels, adipose tissue and metabolic alterations have not been clearly established in healthy non-obese subjects. We investigated the relationships between body fat, CRP levels and metabolic variables in healthy, non-obese sons of patients affected by metabolic syndrome (MS). METHODS AND RESULTS Age, CRP and interleukin 6 (IL-6) levels, anthropometric measures (body mass index, BMI; waist circumference and waist-to-hip ratio, WHR), total and regional fat content (as determined by means of dual X-ray absorptiometry, DXA), total and LDL cholesterol, and the metabolic variables related to MS (HDL-cholesterol, triglyceride, glucose and insulin levels; the fasting insulin resistance index, FIRI; blood pressure) were evaluated in 85 healthy non-obese sons of MS patients. Linear and multiple regression analyses were used to evaluate the relationships between body fat, metabolic variables and CRP levels, and to investigate whether the association between body fat content and metabolic variables persists after adjustment for CRP levels. Body fat was associated with all of the investigated variables. CRP levels were associated with total and regional body fat, the anthropometric index of weight, age, and with some metabolic alterations (HDL-cholesterol and triglyceride levels, systolic blood pressure, and fasting insulin and LDL-cholesterol levels). The associations between total body fat and the metabolic variables did not change after adjustment for CRP levels. Total body fat was the best predictor of CRP levels (p<0.0001). CONCLUSIONS In healthy, non-obese sons of MS patients, total body fat is the best predictor of CRP levels, and remains closely associated with metabolic abnormalities after adjustment for CRP levels. These findings strongly support the hypothesis that body fat is the main determinant of metabolic abnormalities and a low inflammatory state, at least in healthy subjects.

Site-Specific Relative Risk of Fractures in the Institutionalized Elderly

A 3-year prospective study was performed to evaluate the incidence of fractures in institutionalized elderly and associated risk factors. A total of 197 subjects (47 males and 150 females, mean age 81.5 +/- 8.0 years) were included in the study. The annual fracture incidence was 7.8%. All hip fractures occurred in female subjects (annual incidence = 3.7%). As expected, the incidence of fractures is higher in walking subjects. In walking subjects (n = 128) logistic regression analysis showed falls [adjusted relative risk (RR) = 3.3; 95% confidence interval (CI) = 1.3-8.4] and age (adjusted RR = 1.7; 95% CI = 1.1-2.3) to be variables independently and significantly associated with fractures, after adjusting for baseline bone mineral density (BMD) and sex. Hip fractures were associated with age (RR = 1.6; 95% CI = 1.1-2.3), and non-hip fractures with falls (RR = 4.1; 95% CI = 1.3-13.4). The importance of low BMD as a risk factor for fractures is reduced in the institutionalized elderly. However, other fracture-site-specific risk factors exert a greater influence.

Autopsy and Multiple Pathology in the Elderly

We examined autopsy reports and the clinical diagnoses of 600 patients (200 in 1967 and 400 in 1987). For each patient we considered age, diagnostic error, main diseases and presence of multiple pathology. The number of diagnostic errors increased from 1967 to 1987. The diagnostic error was particularly high for pulmonary embolism and septic shock and significantly higher in patients > 65 than < or = 65 years old. Multiple pathology was higher in old patients: we found 4 or more diseases in 195/270 (72.2%) patients > 65 years and in only 135/330 (40.9%) patients < or = 65 years. The average period of hospitalization was directly proportional to the number of diseases present in the same patient.