Evaluation of the prevalence of dental agenesis through the use of orthopantomography in a sample of subjects residing in Lombardy and Piedmont regions

AIM

Dental agenesis is one of the most frequent dental anomalies, with a prevalence varying from 1.6% to 36.5%, depending on the populations studied. The patient's age at diagnosis, sex, and ethnic differences are considered possible influenting factors that can explain such a wide range of prevalence. The objective of the study was to define the frequency of dental agenesis in a sample of subjects living in Piedmont and Lombardy regions of Italy.

MATERIALS

X-rays, already taken for other diagnostic purposes, were collected. Orthopantomographies belonging to subjects born after 1995 and aged between 7.9 and 16.9 years were selected. It was assessed the presence of each tooth, except for third molars since they are frequently absent due to their variability. If a tooth was missing and the patient had additional radiographs, the other radiographs were evaluated to confirm the diagnosis or to rule out a delayed calcification or the presence of a malposition tooth.

Results

Orthopantomographies were collected from 1,020 subjects and 98 of them presented agenesis, with a prevalence of 5% for females and 4.61% for males. The most affected teeth were 35 and 45, followed by 12 and 22. The lower arch was more frequently involved by agenesis: there were 107 teeth absent in the mandibular arch and 83 in the maxillary arch.

Prevalence of drug-drug interactions for oral anticoagulant drugs in patients with atrial fibrillation and relationship with outcomes: a population-based cohort study

Introduction

The introduction of non-vitamin K antagonist oral anticoagulants (NOACs) changed the treatment of atrial fibrillation (AF) patients, promising a better safety profile and a lower chance of interaction with drugs than vitamin K antagoniste (VKA).

Aim

To evaluate the prevalence of possible drug-drug interactions (DDIs) in a cohort of newly anticoagulated AF patients, their impact on outcomes and possible differences between VKA and NOACs users.

Methods

We performed an analysis derived from administrative databases in Lombardy Italian region. All patients ≥40 years admitted from 01/06/2013 to 30/06/2018 with an AF diagnosis that were VKA or NOACs new users were included in this analysis. Possible DDIs were evaluated according to the prescription of OAC therapy, on the basis of current available evidence. Stroke, intracerebral hemorrhage (ICH), any bleeding and all-cause death were the study outcomes.

Results

Among the 122816 patients included in the analysis, mean (SD) age 76.3 (9.6) with 47.3% females, a mean (SD) CHA2DS2-VASc of 3.5 (1.4) was found. A total of 70180 (57.1%) patients were prescribed with VKA and 52636 (42.9%) with NOACs. A possible DDI was recorded in 63273 (51.5%). Patients exposed to DDIs were older and less likely female (both p<0.0001) and with a higher mean (SD) CHA2DS2-VASc (p<0.0001). Rate of stroke, ICH, any bleeding and all-cause death were higher in those patients exposed to DDIs (all p<0.001). After full adjustment, exposure to possible DDIs was associated with an increased risk for any bleeding (HR: 1.08, 95% CI: 1.05–1.12) and all-cause death (HR: 1.10, 95% CI: 1.07–1.13), with no differences for stroke and ICH. Comparing VKA and NOACs patients exposed to possible DDIs, we found that VKA users exposed to possible DDIs, after adjustments, were at higher risk for all the outcomes (Table).

Conclusions

In a large cohort of AF patients newly prescribed with OAC, possible DDIs were largely prevalent, in particular in VKA users. Presence of a possible DDI is associated with an increased risk of any bleeding and all-cause death. VKA users exposed to a possible DDI were at higher risk for any outcome than NOACs users exposed to a possible DDI.

Funding Acknowledgement

Type of funding source: None

A new Rayleigh-like wave in guided propagation of antiplane waves in couple stress materials

Motivated by the unexpected appearance of shear horizontal Rayleigh surface waves, we investigate the mechanics of antiplane wave reflection and propagation in couple stress (CS) elastic materials. Surface waves arise by mode conversion at a free surface, whereby bulk travelling waves trigger inhomogeneous modes. Indeed, Rayleigh waves are perturbations of the travelling mode and stem from its reflection at grazing incidence. As is well known, they correspond to the real zeros of the Rayleigh function. Interestingly, we show that the same generating mechanism sustains a new inhomogeneous wave, corresponding to a purely imaginary zero of the Rayleigh function. This wave emerges from 'reflection' of a bulk standing mode: This produces a new type of Rayleigh-like wave that travels away from, as opposed to along, the free surface, with a speed lower than that of bulk shear waves. Besides, a third complex zero of the Rayleigh function may exist, which represents waves attenuating/exploding both along and away from the surface. Since none of these zeros correspond to leaky waves, a new classification of the Rayleigh zeros is proposed. Furthermore, we extend to CS elasticity Mindlin's boundary conditions, by which partial waves are identified, whose interference lends Rayleigh-Lamb guided waves. Finally, asymptotic analysis in the thin-plate limit provides equivalent one-dimensional models.

Use and prescription appropriateness of drugs for peptic ulcer and gastrooesophageal reflux disease in hospitalized older people

PURPOSE

The aims of this study were to assess the prevalence of use and prescription appropriateness of drugs for peptic ulcer and gastrooesophageal reflux disease (GERD) at hospital admission and discharge.

METHODS

Patients aged 65 years or more hospitalized from 2010 to 2016 in 101 Italian internal medicine and geriatric wards in the context of the REPOSI register were scrutinized to assess if they were prescribed with drugs for peptic ulcer and GERD at hospital admission and discharge. Appropriateness of prescription was assessed considering the presence of specific conditions (i.e., history of peptic ulcer or gastrointestinal hemorrhages, advanced age, Helicobacter Pylori) or gastro-toxic drug combinations, according to the criteria provided by the reimbursement rules of the Agenzia Italiana del Farmaco (NOTA 1 and 48).

RESULTS

Among 4715 enrolled patients, 3899 were discharged alive. At hospital discharge, 2412 (61.9%, 95%CI: 60.3-63.4%) patients were prescribed with drugs for peptic ulcer and GERD, a 12% of increase from hospital admission. Almost half of the patients (N = 1776, 45.6%, 95%CI: 44.0-47.1%) were inappropriately prescribed or not prescribed: among the drugs for peptic ulcer and GERD users, about 60% (1444/2412) were overprescribed, and among nonusers, 22% (332/1487) were underprescribed. Among patients newly prescribed at hospital discharge, 60% (392/668) were inappropriately prescribed. The appropriateness of drugs for peptic ulcer and GERD therapy decreased by 3% from hospital admission to discharge.

CONCLUSIONS

Hospitalization missed the opportunity to improve the quality of prescription of this class of drug.

P2635Prevalence of appropriate treatment in elderly heart failure patients and impact on clinical outcomes: a subgroup analysis from REPOSI registry

Introduction

Therapeutic appropriateness in chronic diseases is a key factor in obtaining better clinical outcomes over clinical follow-up, in particular in elderly patients. Data about therapeutic appropriateness in elderly patients with heart failure (HF) are scarce.

Purpose

To describe the prevalence of appropriate treatment in elderly HF patients and its impact on clinical outcomes.

Methods

REgistro POliterapie SIMI (REPOSI) cohort was used to assess study aims. REPOSI is an Italian Nationwide Registry of elderly (≥65 years) hospitalized patients in Internal Medicine and Geriatric wards. HF diagnosis was assessed at hospital admission according to ICD-9 code 428.XX. Therapeutic appropriateness was defined according to International Guidelines.

Results

Among the 7003 patients originally enrolled, a total of 1095 (15.6%) patients reported a diagnosis of HF at hospital admission. At admission, 230 (21.0%) patients were considered as treated appropriately, with 245 (22.4%) treated appropriately during hospitalization and 249 (22.7%) at discharge (p=0.0.248). Focusing on patients aged ≥80 years, prevalence of appropriate treatment was respectively: 18.9% at admission, 20.3% during hospitalization and 21.0% at discharge (p=0.266). Among the 1095 patients with HF, 815 (74.4%) had available follow-up data. Patients appropriately treated at discharge, compared to those not treated appropriately, had a lower rate of CV death (5.1% vs. 11.9%, p=0.006) and all-cause death (7.2% vs. 26.1%, p<0.001) during follow-up, with no difference in rates of rehospitalization and CV rehospitalization. A logistic regression analysis adjusted for age, sex, risk factors, comorbidities and polypharmacy, showed that appropriate therapy at discharge was inversely associated with the risk of CV death and all-cause death (Table). In patients ≥80 years, appropriate HF treatment was inversely associated with risk of all-cause death (Table).

Logistic Regression Analysis All Patients ≥80 years OR (95% CI) OR (95% CI) CV Death 0.46 (0.23–0.94) 0.59 (0.26–1.36) All-Cause Death 0.26 (0.14–0.46) 0.27 (0.14–0.53) CI = Confidence Interval; CV = Cardiovascular; OR = Odds Ratio.

Conclusions

In elderly hospitalized HF patients, prevalence of therapeutic appropriateness was consistently low at admission, during hospitalization and at discharge, particularly in patients ≥80 years. Appropriate HF therapy was inversely associated with the risk of CV death and all-cause death in all patients and with the risk of all-cause death in patients ≥80 years.

Acknowledgement/Funding

None

P4517Heart failure in elderly and very elderly hospitalized patients: an epidemiological analysis from the REPOSI registry

Introduction

Epidemiological data about heart failure (HF) in the elderly and, in particular, very elderly patients are lacking.

Purpose

To provide the epidemiological profile of elderly and very elderly HF patients in terms of prevalence, associated clinical factors, burden of multimorbidity and functional status.

Methods

Overall cohort of the REgistro POliterapie SIMI (REPOSI) was used to assess study aims. REPOSI is an Italian Nationwide Registry of elderly hospitalized patients in Internal Medicine and Geriatric wards. HF diagnosis was assessed at hospital admission according to ICD-9 code 428.XX.

Results

Among the 7003 patients originally enrolled, a total of 1095 (15.6%) patients reported a diagnosis of HF at hospital admission. Prevalence of HF progressively increased according to age strata, up to 26.8% in patients ≥90 [Figure]. A logistic regression analysis found that increasing age, body mass index and total cumulative illness rating scale (CIRS) were associated with HF (Table). Moreover, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease and polypharmacy (≥5 drugs) were associated with HF, while liver disease and neoplasm were inversely associated (Table). According to CIRS severity index and comorbidity index quartile, HF patients reported more likely values in the highest quartile than those without HF (47.4% vs. 26.6%, p<0.001 and 34.4% vs. 18.5%, p<0.001 respectively). According to short blessed test, geriatric depression scale and Barthel index, patients with HF had significantly more cognitive impairment and dementia, depression and dependent from others in daily activities than those without HF (all p<0.001).

Prevalence of HF according to Age Strata

Conclusions

In a cohort of elderly patients hospitalized in Internal Medicine and Geriatric wards HF was highly prevalent, in particular in those very elderly. HF was associated with several clinical factors, emphasizing a stronger clinical complexity. HF patients were more burdened with multimorbidity and showed an impaired functional status.

Acknowledgement/Funding

None

Inappropriate prescription of benzodiazepines in acutely hospitalized older patients

Benzodiazepines (BDZs) are widely prescribed in older people. The aims of the study are to assess the prevalence of inappropriate prescription of BZDs and the associated factors in acutely hospitalized older patients. Patients aged 65 years or more hospitalized from 2010 to 2017 in more than 100 Italian internal medicine and geriatric wards in the frame of the REPOSI register were included if prescribed with BDZs at hospital admission or discharge. Appropriateness of prescription was assessed according to the 2015 Beers criteria and their modified French and German versions. Among 4681 patients discharged from hospital, 15% (N = 710) were discharged with BDZs, and 62% of them (N = 441, 95% CI: 58.5%-65.6%) were inappropriately prescribed, being prescribed with BDZ to be always avoided in the elderly (45%), at higher doses than recommended (31%) or with no appropriate clinical conditions (19%). From admission to discharge the prevalence of inappropriate BDZ prescription decreased by 4%, but 62% of patients inappropriately prescribed at admission were still inappropriately prescribed at discharge. Among the 179 patients first prescribed at the time of discharge, half were inappropriately prescribed. Being female (OR 1.32, 95%CI 0.95-1.85), enrolled in REPOSI during the years 2016 and 2017 (OR 1.94, 95%CI 1.10-3.39; OR 1.57, 95%CI 0.95-2.58) and living in nursing homes (OR 2.04, 95%CI 0.95-4.37) were associated with an increased risk to be inappropriately prescribed. This study shows a high prevalence of inappropriate use of BDZ in acutely hospitalized older patients both at hospital admission and discharge.

Antibiotic use and associated factors in a large sample of hospitalised older people

OBJECTIVES

The aims of this study were to assess (i) the prevalence of antibiotic use, (ii) factors associated with their use and (iii) the association with in-hospital mortality in a large sample of hospitalised older people in Italy.

METHODS

Data were obtained from the 2010-2017 REPOSI register held in more than 100 internal medicine and geriatric wards in Italy. Patients aged ≥65 years with at least one antibiotic prescription during their hospitalisation were selected. Multivariable logistic regression models were used to determine factors associated with antibiotic use.

RESULTS

A total of 5442 older patients were included in the analysis, of whom 2786 (51.2%) were prescribed antibiotics during their hospitalisation. The most frequently prescribed antibiotic class was β- lactams, accounting for 50% of the total prescriptions. Poor physical independence, corticosteroid use and being hospitalised in Northern Italy were factors associated with a higher likelihood of being prescribed antibiotics. Antibiotic use was associated with an increased risk of in-hospital mortality (odds ratio=2.52, 95% confidence interval 1.82-3.48) also when accounting for factors associated with their use.

CONCLUSION

Hospitalised older people are often prescribed antibiotics. Factors related to poor physical independence and corticosteroid use are associated with increased antibiotic use. Being prescribed antibiotics is also associated with an increased risk of in-hospital death. These results demand the implementation of specific stewardship programmes to improve the correct use of antibiotics in hospital settings and to reduce the risk of antimicrobial resistance.

The Reference Site Collaborative Network of the European Innovation Partnership on Active and Healthy Ageing

Seventy four Reference Sites of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) have been recognised by the European Commission in 2016 for their commitment to excellence in investing and scaling up innovative solutions for active and healthy ageing. The Reference Site Collaborative Network (RSCN) brings together the EIP on AHA Reference Sites awarded by the European Commission, and Candidate Reference Sites into a single forum. The overarching goals are to promote cooperation, share and transfer good practice and solutions in the development and scaling up of health and care strategies, policies and service delivery models, while at the same time supporting the action groups in their work. The RSCN aspires to be recognized by the EU Commission as the principal forum and authority representing all EIP on AHA Reference Sites. The RSCN will contribute to achieve the goals of the EIP on AHA by improving health and care outcomes for citizens across Europe, and the development of sustainable economic growth and the creation of jobs.

Dispersion of elastic waves in a layer interacting with a Winkler foundation

Dispersion of plane harmonic waves in an elastic layer interacting with a one- or two-sided Winkler foundation is analyzed. The long-wave low-frequency polynomial approximations of the full transcendental dispersion relations are derived for a relatively soft foundation. The validity of the conventional engineering formulation of a Kirchhoff plate resting on an elastic foundation is investigated. It is shown that this formulation has to be refined near the cutoff frequency of bending waves. The associated near cutoff expansion is obtained for both cases. A simple explicit formula demonstrating veering of bending and extensional waves is presented for a one-sided foundation.

Implementation of the Frailty Index in hospitalized older patients: Results from the REPOSI register

BACKGROUND

Frailty is a state of increased vulnerability to stressors, associated to poor health outcomes. The aim of this study was to design and introduce a Frailty Index (FI; according to the age-related accumulation of deficit model) in a large cohort of hospitalized older persons, in order to benefit from its capacity to comprehensively weight the risk profile of the individual.

METHODS

Patients aged 65 and older enrolled in the REPOSI register from 2010 to 2016 were considered in the present analyses. Variables recorded at the hospital admission (including socio-demographic, physical, cognitive, functional and clinical factors) were used to compute the FI. The prognostic impact of the FI on in-hospital and 12-month mortality was assessed.

RESULTS

Among the 4488 patients of the REPOSI register, 3847 were considered eligible for a 34-item FI computation. The median FI in the sample was 0.27 (interquartile range 0.21-0.37). The FI was significantly predictive of both in-hospital (OR 1.61, 95%CI 1.38-1.87) and overall (HR 1.46, 95%CI 1.32-1.62) mortality, also after adjustment for age and sex.

CONCLUSIONS

The FI confirms its strong predictive value for negative outcomes. Its implementation in cohort studies (including those conducted in the hospital setting) may provide useful information for better weighting the complexity of the older person and accordingly design personalized interventions.

Disability, and not diabetes, is a strong predictor of mortality in oldest old patients hospitalized with pneumonia

BACKGROUND

Pneumonia causes more deaths than any other infectious disease, especially in older patients with multiple chronic diseases. Recent studies identified a low functional status as prognostic factor for mortality in elderly patients with pneumonia while contrasting data are available about the role of diabetes. The aim of this study was to evaluate the in-hospital, 3-month and 1-year mortality in elderly subjects affected by pneumonia enrolled in the RePoSi register.

METHODS

We retrospectively analyzed the data collected on hospitalized elderly patients in the frame of the REPOSI project. We analyzed the socio-demographic, laboratory and clinical characteristics of subjects with pneumonia. Multivariate logistic analysis was used to explore the relationship between variables and mortality.

RESULTS

Among 4714 patients 284 had pneumonia. 52.8% were males and the mean age was 80 years old. 19.8% of these patients had a Barthel Index ≤40 (p ˂ 0.0001), as well as 43.2% had a short blessed test ≥10 (p ˂ 0.0117). In these subjects a significant CIRS for the evaluation of severity and comorbidity indexes (p ˂ 0.0001) were present. Although a higher fasting glucose level was identified in people with pneumonia, in the multivariate logistic analysis diabetes was not independently associated with in-hospital, 3-month and 1-year mortality, whereas patients with lower Barthel Index had a higher mortality risk (odds ratio being 9.45, 6.84, 19.55 in hospital, at 3 and 12 months).

CONCLUSION

Elderly hospitalized patients affected by pneumonia with a clinically significant disability had a higher mortality risk while diabetes does not represent an important determinant of short and long-term outcome.

Under-detection of delirium and impact of neurocognitive deficits on in-hospital mortality among acute geriatric and medical wards

BACKGROUND

Delirium is a neuropsychiatric disorder, triggered by medical precipitants causes. Study aims were to describe the prevalence and impact on in-hospital mortality of delirium identified through ICD-9 codes as well as evidence of neurocognitive deficits demonstrated in a population of older patients admitted to acute medical wards.

METHODS

This was a prospective cohort multicenter study of 2521 older patients enrolled in the "Registro Politerapie SIMI (REPOSI)" during the years 2010 and 2012. The diagnosis of delirium was obtained by ICD-9 codes. Cognitive function was evaluated with the Short Blessed Test (SBT) and single SBT items were used as measures of deficits in attention, orientation and memory. Combination of deficits in SBT items was used as a proxy for delirium. Logistic regression was used to evaluate the association with in-hospital mortality of delirium and combined deficits in SBT items.

RESULTS

Delirium was coded in 2.9%, while deficits in attention, orientation, and memory were found in 35.4%, 29.7% and 77.5% of patients. Inattention and either disorientation or memory deficits were found in 14.1%, while combination of the 3 deficits in 19.8%. Delirium, as per ICD-9 codes, was not a predictor of in-hospital mortality. In contrast, objective deficits of inattention, in combination with orientation and memory disorders, were stronger predictors after adjusting for covariates.

CONCLUSIONS

The documentation of delirium is poor in medical wards of Italian acute hospitals. Neurocognitive deficits on objective testing (in a pattern suggestive of undiagnosed delirium) should be used to raise awareness of delirium, given their association with in-hospital mortality.

Brain and kidney, victims of atrial microembolism in elderly hospitalized patients? Data from the REPOSI study

BACKGROUND

It is well known that atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with a higher risk of stroke, and new evidence links AF to cognitive impairment, independently from an overt stroke (CI). Our aim was to investigate, assuming an underlying role of atrial microembolism, the impact of CI and CKD in elderly hospitalized patients with AF.

METHODS

We retrospectively analyzed the data collected on elderly patients in 66 Italian hospitals, in the frame of the REPOSI project. We analyzed the clinical characteristics of patients with AF and different degrees of CI. Multivariate logistic analysis was used to explore the relationship between variables and mortality.

RESULTS

Among the 1384 patients enrolled, 321 had AF. Patients with AF were older, had worse CI and disability and higher rates of stroke, hypertension, heart failure, and CKD, and less than 50% were on anticoagulant therapy. Among patients with AF, those with worse CI and those with lower estimated glomerular filtration rate (eGFR) had a higher mortality risk (odds ratio 1.13, p=0.006). Higher disability levels, older age, higher systolic blood pressure, and higher eGFR were related to lower probability of oral anticoagulant prescription. Lower mortality rates were found in patients on oral anticoagulant therapy.

CONCLUSIONS

Elderly hospitalized patients with AF are more likely affected by CI and CKD, two conditions that expose them to a higher mortality risk. Oral anticoagulant therapy, still underused and not optimally enforced, may afford protection from thromboembolic episodes that probably concur to the high mortality.

Acute focal brain damage alters mitochondrial dynamics and autophagy in axotomized neurons

Mitochondria are key organelles for the maintenance of life and death of the cell, and their morphology is controlled by continual and balanced fission and fusion dynamics. A balance between these events is mandatory for normal mitochondrial and neuronal function, and emerging evidence indicates that mitochondria undergo extensive fission at an early stage during programmed cell death in several neurodegenerative diseases. A pathway for selective degradation of damaged mitochondria by autophagy, known as mitophagy, has been described, and is of particular importance to sustain neuronal viability. In the present work, we analyzed the effect of autophagy stimulation on mitochondrial function and dynamics in a model of remote degeneration after focal cerebellar lesion. We provided evidence that lesion of a cerebellar hemisphere causes mitochondria depolarization in axotomized precerebellar neurons associated with PTEN-induced putative kinase 1 accumulation and Parkin translocation to mitochondria, block of mitochondrial fusion by Mfn1 degradation, increase of calcineurin activity and dynamin-related protein 1 translocation to mitochondria, and consequent mitochondrial fission. Here we suggest that the observed neuroprotective effect of rapamycin is the result of a dual role: (1) stimulation of autophagy leading to damaged mitochondria removal and (2) enhancement of mitochondria fission to allow their elimination by mitophagy. The involvement of mitochondrial dynamics and mitophagy in brain injury, especially in the context of remote degeneration after acute focal brain damage, has not yet been investigated, and these findings may offer new target for therapeutic intervention to improve functional outcomes following acute brain damage.

Understanding adverse drug reactions in older adults through drug-drug interactions

AIMS

The aims of this study are to evaluate prevalence and characteristics of adverse drug reactions (ADRs) and to evaluate the potential contribution of specific medications, therapeutic categories and drug-drug interactions (DDIs) in older adults.

METHODS

All ADR reporting forms of persons aged 65+ years collected by the pharmacovigilance of one of the main hospitals in Italy during 2013 were evaluated. DDIs were analysed by a computerized prescription system (INTERCheck) and based on the interactions' database managed by the Istituto di Ricerche Farmacologiche Mario Negri. DDIs were classified according to their clinical relevance as contraindicated, major, and moderate.

RESULTS

Amongst all the ADR reporting forms (n=1014) collected during 2013, 343 affected older adults. The most frequent ADRs were: haemorrhages (n=122, 35.5%), allergic reactions (n=56, 16.3%), and elevated International Normalized Ratio (INR>6, n=54, 15.7%). The specific medications that contributed to ADRs were warfarin (42.5%), acenocumarol (9%), and allopurinol (8.5%); while the therapeutic categories were haematological agents (67%) and proton pump inhibitors (13%). A total of 912 DDIs were found; one third of them were contraindicated or major and 31.5% of them potentially contributed to ADRs; of these, the most frequent were: warfarin and heparin (contraindicated, n=5); warfarin and a statin (major, n=38); warfarin and a proton pump inhibitor (moderate, n=40). At least one DDI contributed to 66 haemorrhages out of 122 (54%) and to 41 elevated INR out of 54 (76%).

CONCLUSION

DDIs significantly contribute to the onset of ADRs in older adults and intervention programmes, e.g., the employment of a computerized system, may reduce the burden of iatrogenic illnesses in the elderly.

Gender-differences in disease distribution and outcome in hospitalized elderly: data from the REPOSI study

BACKGROUND AND PURPOSE

Women live longer and outnumber men. On the other hand, older women develop more chronic diseases and conditions such as arthritis, osteoporosis and depression, leading to a greater number of years of living with disabilities. The aim of this study was to describe whether or not there are gender differences in the demographic profile, disease distribution and outcome in a population of hospitalized elderly people.

METHODS

Retrospective observational study including all patients recruited for the REPOSI study in the year 2010. Analyses are referred to the whole group and gender categorization was applied.

RESULTS

A total of 1380 hospitalized elderly subjects, 50.5% women and 49.5% men, were considered. Women were older than men, more often widow and living alone or in nursing homes. Disease distribution showed that malignancy, diabetes, coronary artery disease, chronic kidney disease and chronic obstructive pulmonary disease were more frequent in men, but hypertension, osteoarthritis, anemia and depression were more frequent in women. Severity and comorbidity indexes according to the Cumulative Illness Rating Scale (CIRS-s and CIRS-c) were higher in men, while cognitive impairment evaluated by the Short Blessed Test (SBT), mood disorders by the Geriatric Depression Scale (GDS) and disability in daily life measured by Barthel Index (BI) were worse in women. In-hospital and 3-month mortality rates were higher in men.

CONCLUSIONS

Our study showed a gender dimorphism in the demographic and morbidity profiles of hospitalized elderly people, emphasizing once more the need for a personalized process of healthcare.

E-learning to improve the drug prescribing in the hospitalized elderly patients: the ELICADHE feasibility pilot study

BACKGROUND

E-learning is an efficient and cost-effective educational method.

AIMS

This study aimed at evaluating the feasibility of an educational e-learning intervention, focused on teaching geriatric pharmacology and notions of comprehensive geriatric assessment, to improve drug prescribing to hospitalized elderly patients.

METHODS

Eight geriatric and internal medicine wards were randomized to intervention (e-learning educational program) or control. Clinicians of the two groups had to complete a specific per group e-learning program in 30 days. Then, ten patients (aged ≥75 years) had to be consecutively enrolled collecting clinical data at hospital admission, discharge, and 3 months later. The quality of prescription was evaluated comparing the prevalence of potentially inappropriate medications through Beer's criteria and of potential drug-drug interactions through a specific computerized database.

RESULTS

The study feasibility was confirmed by the high percentage (90 %) of clinicians who completed the e-learning program, the recruitment, and follow-up of all planned patients. The intervention was well accepted by all participating clinicians who judged positively (a mean score of >3 points on a scale of 5 points: 0 = useless; 5 = most useful) the specific contents, the methodology applied, the clinical relevance and utility of e-learning contents and tools for the evaluation of the appropriateness of drug prescribing.

CONCLUSIONS

The pilot study met all the requested goals. The main study is currently ongoing and is planned to finish on July 2015.

Prevalence of potentially inappropriate medications and risk of adverse clinical outcome in a cohort of hospitalized elderly patients: results from the REPOSI Study

WHAT IS KNOWN AND OBJECTIVE

Inappropriate prescribing is highly prevalent for older people and has become a global healthcare concern because of its association with negative health outcomes including ADEs, hospitalization and resource utilization. Beers' criteria are widely utilized for evaluating the appropriateness of medications, and an up-to-date version has recently been published. To assess the prevalence of patients exposed to PIMs at hospital discharge according to the 2003 and 2012 versions of Beers' criteria and to evaluate the risk of adverse clinical events, re-hospitalization and all-cause mortality at 3-month follow-up.

METHODS

This cross-sectional study was held in 66 Italian internal medicine and geriatric wards. The sample included 1380 inpatients aged 65 years or older. Prescriptions of PIM were analysed at hospital discharge. We considered all patients with complete 3-month follow-up.

RESULTS AND DISCUSSION

The prevalence of patients receiving at least one PIM was 20·1% and 23·5% according to the 2003 and 2012 versions of the Beers' criteria, respectively. The 2012 Beers' criteria identified more patients with at least one PIM than the 2003 version, although a high percentage of those patients (72·2%) were also identified by the criteria updated in 2003. The main difference in the prevalence of patients receiving a PIM according to the two versions of Beers' criteria involved prescriptions of benzodiazepines for insomnia or agitation, chronic use of non-benzodiazepine hypnotics, prescription of antipsychotics in people with dementia and oral iron at dosage higher than 325 mg/day. Prescription of PIMs was not associated with a higher risk of adverse clinical events, re-hospitalization and all-cause mortality at 3-month follow-up in both univariate and multivariate analysis, after adjusting for age, sex and CIRS comorbidity index.

WHAT IS NEW AND CONCLUSIONS

This study found no significant effect of inappropriate drug use according to Beers' criteria on health outcomes among older adults 3 month after discharge. Even though these criteria have been suggested as helpful in promoting appropriate prescribing, reducing drug-related adverse events and associated healthcare costs, to date there is no clear evidence that their application can achieve objective and quantifiable improvements in clinical outcomes. A possible explanation is that both versions of the Beers' criteria have several recognized limitations, one of the main ones being the restricted availability of some drugs in Europe or their limited prescription in everyday clinical practice.

Elevated risk of death and major cardiovascular events in subjects with newly diagnosed diabetes: findings from an administrative database

AIMS

To investigate the incidence of major cardiovascular complications and mortality in the first years of follow-up in patients with newly diagnosed diabetes.

METHODS AND RESULTS

We examined incidence rates of hospitalization for cardiovascular reasons and death among new patients with diabetes using the administrative health database of the nine million inhabitants of Lombardy followed from 2002 to 2007. Age and sex-adjusted rates were calculated and hazard ratios (HR) were estimated with a matched population without diabetes of the same sex, age (± 1 year) and general practitioner. There were 158,426 patients with newly diagnosed diabetes and 314,115 subjects without diabetes. Mean follow-up was 33.0 months (SD ± 17.5). 9.7% of patients with diabetes were hospitalized for cardiovascular events vs. 5.4% of subjects without diabetes; mortality rate was higher in patients with diabetes (7.7% vs. 4.4%). The estimated probability of hospitalization during the follow up was higher in patients with diabetes than in subjects without for coronary heart disease (HR 1.4, 95% CI 1.3-1.4), cerebrovascular disease (HR 1.3.95% CI 1.2-1.3), heart failure (HR 1.4, 95% CI 1.3-1.4) as was mortality (HR 1.4, 95% CI 1.4-1.4). Younger patients with diabetes had a risk of death or hospital admission for cardio-cerebrovascular events similar to subjects without diabetes ten years older.

CONCLUSIONS

The elevated morbidity and mortality risks were clear since the onset of diabetes and rose over time. These data highlight the importance of prompt and comprehensive patients care in addition to anti-diabetic therapy in patients with newly diagnosed diabetes.

Validation of healthcare administrative data for the diagnosis of epilepsy

BACKGROUND

Administrative databases have become an important tool to monitor diseases. Patients with epilepsy could be traced using disease-specific codes and prescriptions, but formal validation is required to obtain an accurate case definition. The aim of the study was to correlate administrative data on epilepsy with an independent source of patients with epilepsy in a district of Lombardy, Northern Italy, from 2000 to 2008.

METHODS

Data of nearly 320 600 inhabitants in the district of Lecco collected from the Drug Administrative Database of the Lombardy Region were analysed. Among them were included patients who fulfilled the International Classification of Diseases 9 (ICD-9) codes and/or the disease-specific exemption code for epilepsy and those who had at least one EEG record and took antiepileptic drugs (AEDs) as monotherapy or in variable combinations. To ascertain epilepsy cases, 11 general practitioners (GPs) with 15 728 affiliates were contacted. Multiple versions of the diagnostic algorithm were developed using different logistic regression models and all combinations of the four independent variables.

RESULTS

Among the GP affiliates, 71 (4.5/1000) had a gold standard diagnosis of epilepsy. The best and most conservative algorithm included EEG and selected treatment schedules and identified 61/71 patients with epilepsy (sensitivity 85.9%, CI 76.0% to 92.2%) and 15 623/15 657 patients without epilepsy (specificity 99.8%,CI 99.7% to 99.8%). The positive and negative predictive values were 64.2% and 99.9%. Sensitivity (86.7%) and the positive predictive value (68.4%) increased only slightly when patients with single seizures were included.

CONCLUSIONS

A diagnostic algorithm including EEG and selected treatment schedules is only moderately sensitive for the detection of epilepsy and seizures. These findings apply only to the Northern Italian scenario.

Emerging role of mitochondria dysfunction in the onset of neurodegenerative diseases

Mitochondria play a pivotal role in a number of biochemical processes in the neuron including energy metabolism and ATP production, intracellular Ca2+ homeostasis and cell signalling which are all implicated in the regulation of neuronal excitability. For this reason, it is not surprising that alterations in mitochondrial function have emerged as a hallmark of aging and various age-related neurodegenerative diseases in which a progressive functional decline of mitochondria has been described. The evidence that mitochondria are concentrated in synapses, together with the observation that synaptic dysfunction identifies an early forerunner of a later neurodegeneration, strongly suggests that significant alterations to synaptic mitochondrial localization, number, morphology, or function can be detrimental to synaptic transmission and might characterize the early stages of many neurological diseases. Thus, the characterization of both molecular players and pathway involved in mitochondria dysfunction will provide new chances to identify pharmacological target for new mitochondria-based drugs aimed at interrupting or slowing down pathological processes and/or ameliorating symptoms of neurological disorders. In this review we provide a current view on the role of mitochondria for neuronal function and how mitochondrial functions impinge on neurological diseases.

Comparison of disease clusters in two elderly populations hospitalized in 2008 and 2010

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.

Prevalence, incidence and mortality of diagnosed diabetes: evidence from an Italian population-based study

AIMS

To describe trends in diagnosed diabetes prevalence, incidence and mortality from 2000 to 2007 in the most heavily populated Italian region.

METHODS

We examined the prevalence and incidence rates of Type 1 and Type 2 diabetes and yearly mortality rates among individuals with diabetes from 2000 to 2007 using an administrative health database of prescription, disease-specific exemption and hospitalization records of more than 9 million inhabitants of Lombardy. Age- and sex-specific rates were calculated and temporal trends for subjects aged ≥ 30 years were analysed.

RESULTS

The crude point diabetes prevalence rose from 3.0% in 2000 to 4.2% in 2007, a 40% increase. The incidence remained stable during the study period with a rate of 4/1000 per year. Overall mortality declined from 43.2/1000 in 2001 to 40.3/1000 in 2007 (6.7% decrease) at a rate slightly higher than that of the general population (4.8% decrease). Our projection in subjects aged ≥ 30 years indicates that the prevalence will rise continuously over the next years, reaching 11.1% in 2030.

CONCLUSIONS

The prevalence of diabetes increased substantially between 2000 and 2007, mainly because there are more patients with a new diagnosis each year than those who die. The increase observed by 2007 almost reached the World Health Organization prediction for 2030. Our analyses suggest that the increase will continue over the next few decades. These data are important for defining the burden of diabetes in the near future, to help in planning health services and ensure proper allocation of resources.

In-hospital death according to dementia diagnosis in acutely ill elderly patients: the REPOSI study

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.

Prevalence and appropriateness of drug prescriptions for peptic ulcer and gastro-esophageal reflux disease in a cohort of hospitalized elderly

BACKGROUND

Proton pump inhibitors (PPI) are among the most commonly prescribed medicines and their overuse is widespread in both primary and secondary care. Inappropriate prescription is of particular concern among elderly patients, who have often multiple comorbidities and need many drugs.

METHODS

We evaluate the appropriateness of drugs for peptic ulcer or gastro-esophageal reflux disease (GERD) in a sample of elderly patients (65 years old or older) at admission and discharge in 38 internal medicine wards between January 2008 and December 2008, according to the presence of specific conditions or gastro-toxic drug combinations.

RESULTS

Among 1155 patients eligible for the analysis, 466 (40.3%) were treated with drugs for GERD or peptic ulcer were at hospital admission and 647 (56.0%) at discharge; 62.4% of patients receiving a drug for peptic ulcer or GERD at admission and 63.2% at discharge were inappropriately treated. Among these, the number of other drugs prescribed was associated with greater use of drugs for peptic ulcer or GERD, even after adjustment for age, sex and number of diagnoses at admission (OR 95% CI=1.26 (1.18-1.34), p=.0001) or discharge (OR 95% CI=1.11 (1.05-1.18), p=0.0003).

CONCLUSIONS

Prevalence of inappropriate prescription of drugs for peptic ulcer or GERD remained almost the same at admission and discharge. Inappropriate use of these drugs is related to the concomitant use of other drugs. Careful assessment of clinical conditions and stricter adherence to evidence-based guidelines are essential for a rational and cost-effective use of drugs for peptic ulcer or GERD.

In-hospital death and adverse clinical events in elderly patients according to disease clustering: the REPOSI study

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.

Factors affecting adherence to guidelines for antithrombotic therapy in elderly patients with atrial fibrillation admitted to internal medicine wards

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 >80years, 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.

A surveillance-oriented medical record as a source of data for both drug and quality of care surveillance

The medical record for hospitalized patients has been modified in order to orient it towards two types of surveillance: adverse drug reactions (ADRs) and the quality of medical care. The modification consists of an adaptation of the progress notes; the transfer of the information to a special database is facilitated by the use of a simple system of codes that identify and correlate the items necessary for surveillance purposes. During the 6 months of observation of the 1103 pediatric patients included in the study, 35 clinically important suspected ADRs were noted by physicians. For the quality of medical care surveillance, all drug prescriptions were evaluated and areas in which to intervene in order to improve the appropriateness of prescriptions were identified. Quality surveillance was also extended to the monitoring of 'unexplained' adverse events for which no particular cause was attributable. We consider it advantageous to carry out these two types of surveillance simultaneously because they require many common items of information. The use of an oriented medical record as a source of data makes it possible to integrate surveillance with everyday ward activities.