Mario Bo

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.

Association between the interleukin-1α gene and Alzheimer’s disease: a meta-analysis

Inflammatory processes are involved in the pathogenesis of Azheimer’s disease (AD). Several studies have addressed the effects of interleukin-1 (IL-1) genes polymorphisms on the risk of developing AD. The results are not in full agreement on whether these polymorphisms are associated with the disease. To clarify this issue, we performed a meta-analysis of all the association studies between IL-1 genes and AD. Due to the relatively small number of published articles, the meta-analysis was restricted to the association of the IL-1 −889 C/T gene polymorphism and AD. Under a random effects model, the risk for the disease was significantly higher in subjects with the T/T genotype in comparison with both C/T (OR: 1.51; 95% C.I.: 1.15–1.99) and C/C (OR: 1.49; 95% C.I.: 1.09–2.03) subjects. There was modest heterogeneity for these effect estimates. Analysis of subgroups showed a significant association in patients with early-onset AD but not in late-onset AD. Our data support a significant but modest association between the T/T genotype of the IL-1 gene and AD.

Hospital at Home for Elderly Patients With Acute Decompensation of Chronic Heart Failure A Prospective Randomized Controlled Trial

BACKGROUND Although the hospital is the standard venue for short-term medical care, it may be hazardous for older persons. This study was performed to evaluate the feasibility and effectiveness of a physician-led hospital-at-home service for selected elderly patients with acute decompensation of chronic heart failure (CHF). METHODS Prospective, single-blind, randomized controlled trial with 6-month follow-up for patients 75 years or older admitted to the hospital from April 1, 2004, through April 31, 2005, for acute decompensation of CHF. Patients were randomly assigned to the general medical ward (n = 53) or to the Geriatric Home Hospitalization Service (GHHS; n = 48). The GHHS provides diagnostic and therapeutic treatments by hospital health care professionals in the home of the patient. RESULTS Patient mortality at 6 months was 15% in the total sample, without significant differences between the 2 settings of care. The number of subsequent hospital admissions was not statistically different in the 2 groups, but the mean (SD) time to first additional admission was longer for the GHHS patients (84.3 [22.2] days vs 69.8 [36.2] days, P = .02). Only the GHHS patients experienced improvements in depression, nutritional status, and quality-of-life scores. CONCLUSIONS Substitutive hospital-at-home care is a viable alternative to traditional hospital inpatient care for elderly patients with acutely decompensated CHF. This type of care demonstrated clinical feasibility and efficacy in comparison with its alternative. Trial Registration clinicaltrials.gov Identifier: NCT00623571.

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.

Telomerase expression in B-cell chronic lymphocytic leukemia predicts survival and delineates subgroups of patients with the same igVH mutation status and different outcome

Activation of telomerase reverse transcriptase (hTERT) is essential for unlimited cell growth and plays a critical role in tumorigenesis. We investigated hTERT gene expression in 134 B-cell chronic lymphocytic leukemia (B-CLL) cases and evaluated its prognostic value with other prognostic markers (IgVH mutation status, CD38 and ZAP-70 expression). Real-time PCR assays to quantify either all hTERT transcripts (AT) or only the full length (FL) transcript encoding the functional protein were developed. hTERT-AT levels strongly correlated with hTERT-FT levels (r=0.743, P<0.0001); both inversely correlated with the percentage of IgVH mutation (P<0.005) and were significantly higher in unmutated than in mutated cases (P=0.004 and P=0.001, respectively). The hTERT values which best discriminated between the unmutated and mutated IgVH cases were 150 and 40 copies for hTERT-AT and hTERT-FL, respectively. Using these cut-off values, there was a significant difference in the survival of patients with high or low hTERT levels (P<0.0001). Unmutated cases with low hTERT levels had an overall survival close to mutated cases with high hTERT levels. Thus, this work identifies hTERT-RNA level as a new prognostic marker in B-CLL, and may be used to identify previously unrecognized patient groups with the same IgVH mutation status and different disease outcomes.

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).

The role of metals in autoimmune vasculitis: epidemiological and pathogenic study.

BACKGROUND A possible relationship between Silica (Si) exposure and antineutrophil cytoplasm antibodies (ANCA)-associated vasculitis has been reported. Furthermore, tuberculosis (TBC) has been frequently described in patients with silicosis, and TBC infection shares with ANCA-associated vasculitis the formation of granulomas. Therefore, an intriguing network including Silica, Vasculitis, TBC and ANCA might be hypothesized. The aim of this work was to further investigate these correlations using both epidemiological and pathogenic approaches. METHODS Study I--epidemiological study. A case-control study to compare the occupational histories of 31 cases of biopsy proven vasculitis (18 pauci-immune crescentic glomerulonephritis, 9 microscopic polyangitis, 4 Wegeners granulomatosis) with those of 58 age, sex and residence-matched controls (affected by other kidney diseases), was performed. Occupational Health physicians designed an appropriate questionnaire in order to evaluate a wide spread of exposures and calculate their entity by the product of Intensity x Frequency x Duration. Study II--tuberculosis association. A case-control study to evaluate the frequency of a previous history of tuberculosis (TBC) in 45 patients with vasculitis and 45 controls were performed. Study III--ANCA positivity. A case-control study to evaluate the presence of ANCA was performed by testing blood samples of 64 people with previous professional exposure and 65 sex/age matched patients hospitalized in a General Medicine Unit. Furthermore, the same evaluation was made in a pilot study in 16 patients with ongoing or previous TBC. Study IV--experimental study. The oxygen free radicals (OFR) and IL-12 production (both involved in the pathogenesis of vasculitis) from human phagocytic cells stimulated with an amorphous (diatomaceous earth) and a crystalline (quartz) form of Si at the doses of 10 and 100 microg ml(-1) was evaluated. RESULTS Study I--a positive history of exposure to Si resulted in significantly more present in cases (14/31 = 45%) than in controls (14/58 = 24%, P = 0.04, OR = 2.4) and no other significant exposure association was found (including asbestos, mineral oil, formaldehyde, diesel and welding fumes, grain and wood dust, leather, solvents, fungicides, bitumen, lead and paint). Study II--past TBC infection was significantly more present in patients with vasculitis (12/45 = 26%) than in controls (4/45 = 8%, P < 0.05). Study III--ANCA was present in 2/64 exposed people (vs. 0/65 controls, P = NS) and 0/16 patients with TBC. Study IV--both amorphous and crystalline Si forms represented a stimulus for OFR and IL-12 production, but quartz resulted as a greater inductor. CONCLUSIONS We conclude that Si exposure might be a risk factor for ANCA-associated vasculitis, possibly enhancing endothelial damage by phagocyte generation of oxygen free radicals and Th1 differentiation by an excessive IL-12 phagocyte production. Frequency of TBC was significantly higher in vasculitis patients. ANCA was not frequent in the preliminary examination of people with previous professional exposure or patients with TBC, but the number of samples evaluated is too small to allow conclusions.

Risk of cognitive decline in older patients after carotid endarterectomy: an observational study.

OBJECTIVES: To determine whether patients undergoing carotid endarterectomy (CE) for symptomatic left internal carotid artery (LICA) stenosis have greater risk of cognitive decline than patients with asymptomatic LICA disease or right internal carotid artery (RICA) disease.

Malnutrition in an elderly demented population living at home

Malnutrition is a frequent complication for elderly demented patients even if they live at their own home with the assistance of a caregiver. The present study evaluates nutritional characteristics of a population of 130 non-institutionalized demented patients. The results show that the mini nutritional assessment (MNA) total score is inversely related with the neuro-psychiatric inventory (NPI) score and that the level of cognitive impairment is related with the nutritional status: patients with mild cognitive impairment (MCI) showed a mean MNA score higher than patients affected by Alzheimers disease (AD) or vascular dementia (VaD). Moreover, patients depressed, with hallucinations or with behavioral disturbs are more exposed to underfeeding than only cognitively impaired subjects. In conclusion, an appropriated evaluation of nutritional status could prevent and treat nutrition-related problems even in the elderly demented patients living at home.