Aim
This study aimed at assessing emergency medical service (EMS) use by patients with acute myocardial infarction (AMI), factors associated with EMS use, and outcomes in the 1,200,000-inhabitant ...Italian region of Friuli Venezia Giulia.
Subject and methods
Anonymous health administrative databases were analyzed from 2010 to 2019. EMS use was assessed from Emergency Department and hospital discharge data for patients discharged with main diagnosis of AMI (ICD-9-CM 410.×1). Factors associated with EMS, likelihood of undergoing a primary percutaneous coronary intervention (pPCI) and of 30-day mortality were assessed in univariate and multivariate analyses.
Results
In 10 years, 14,900 AMI patients were hospitalized. Only half used EMS, with no changes over time. Demographic and residential factors and comorbidities affected EMS use. Although patients transported by EMS had increased 30-day mortality, undergoing pPCI decreased mortality significantly (in STEMI, OR 0.41).
Conclusion
In this region, patients transported by EMS had increased mortality, probably because of residual confounding due to AMI severity; however, undergoing pPCI halved mortality. EMS use has not increased over time and was not uniform across the region. This finding emphasizes the need of population campaigns covering all the regional geographic areas. The importance of transporting patients by EMS directly to PCI facilities should be stressed.
Background
The best policy to follow when nursing homes are massively hit by SARS-CoV2 is unclear.
Aim
To describe COVID-19 containment in a nursing home transformed into a caring center.
Methods
...Physicians and nurses were recruited. The facility was reorganized and connected with the laboratory of the reference hospital. Ultrasound was used to diagnose pneumonia. Patients needing intensive care were transferred to the reference hospital. Hydroxychloroquine/azithromycin/enoxaparin were used initially, while amiodarone/enoxaparin were used at a later phase. Under both regimens, methylprednisolone was added for severe cases. Prophylaxis was done with hydroxychloroquine initially and then with amiodarone. Period covered: March 22–July 31, 2020.
Results
The facility was reorganized in two days. Ninety-two guests of the 121 (76%) and 25 personnel of 118 (21.1%) became swab test positive. Seven swab test negative patients who developed symptoms were considered to have COVID-19. Twenty-seven patients died, 23 swab test positive, 5 of whom after full recovery. Four patients needing intensive care were transferred (3 died). Mortality, peaking in April 2020, was correlated with symptoms, comorbidities, dyspnea, fatigue, stupor/coma, high neutrophil to lymphocyte ratio, C-reactive protein, interleukin-6, pro-calcitonin, and high oxygen need (
p
≤ 0.001 for all). Among swab-positive staff, 3 had pneumonia and recovered. Although no comparison could be made between different treatment and prophylaxis strategies, potentially useful suggestions emerged. Mortality compared well with that of nursing homes of the same area not transformed into care centers.
Conclusion
Nursing homes massively hit by SARS-CoV-2 can become caring centers for patients not needing intensive care.
Background
Age‐ and sex‐specific differences exist in the treatment and outcome of ST‐elevation myocardial infarction (STEMI). We sought to describe age‐ and sex‐matched contemporary trends of ...in‐hospital management and outcome of patients with STEMI.
Methods and Results
We analyzed data from 5 Italian nationwide prospective registries, conducted between 2001 and 2014, including consecutive patients with STEMI. All the analyses were age‐ and sex‐matched, considering 4 age classes: <55, 55 to 64, 65 to 74, and ≥75 years. A total of 13 235 patients were classified as having STEMI (72.1% men and 27.9% women). A progressive shift from thrombolysis to primary percutaneous coronary intervention occurred over time, with a concomitant increase in overall reperfusion rates (P for trend <0.0001), which was consistent across sex and age classes. The crude rates of in‐hospital death were 3.2% in men and 8.4% in women (P<0.0001), with a significant increase over age classes for both sexes and a significant decrease over time for both sexes (all P for trend <0.01). On multivariable analysis, age (odds ratio 1.09, 95% CI 1.07–1.10, P<0.0001) and female sex (odds ratio 1.44, 95% CI 1.07–1.93, P=0.009) were found to be significantly associated with in‐hospital mortality after adjustment for other risk factors, but no significant interaction between these 2 variables was observed (P for interaction=0.61).
Conclusions
Despite a nationwide shift from thrombolytic therapy to primary percutaneous coronary intervention for STEMI affecting both sexes and all ages, women continue to experience higher in‐hospital mortality than men, irrespective of age.
Aims Acute coronary syndromes without ST-segment elevation (NSTEACS) represent an increasingly frequent cause of hospital admission. The BLITZ-2 study was planned to survey the epidemiology and ...management strategies of NSTEACS in the Italian cardiological network. Methods and results The study included 1888 patients with NSTEACS in 275 hospitals in 3 weeks. At admission, almost 20% of patients showed clinical signs of heart failure, half showed ST-segment depression, and half showed any positive biochemical myocardial necrosis marker. Patients admitted to hospitals without CathLab (n=973) were older (P=0.0005) and with higher Killip class on admission (P<0.0001) when compared with those admitted to hospitals with CathLab (n=915). During index hospitalization, 76% of the patients initially admitted to hospitals with invasive capability underwent coronary angiography and 39% percutaneous coronary intervention when compared with 39 and 17.2% of those admitted to hospitals without CathLab (P<0.001). Overall, 30-day mortality was 2.4% (2.0% in patients with invasive capability vs. 2.9% in hospitals without CathLab, P=0.2). Cardiac ischaemic events at 30 days (recurrent MI, recurrent angina, and re-hospitalization for ACS) were significantly higher in the group of patients admitted to hospitals without CathLab (OR 1.71, 95% CI 1.24–2.35). However, after multivariable adjustment, only advanced age (OR 1.043, 95% CI 1.021–1.065, P<0.0001) and Killip class >1 (OR 1.633, 95% CI 1.020–2.614, P=0.04) resulted in independent predictors of death, in-hospital MI, and re-admission for ACS, whereas the absence of an on-site CathLab did not predict an adverse outcome (OR 1.104, 95% CI 0.734–1.660). Conclusion According to this, the nationwide registry outcome is only marginally influenced by invasive procedures. Contemporary management of patients with NSTEACS in Italy is primarily driven by resource availability.
Physical activity is a mainstay (class IA) of rehabilitation programme after an acute coronary syndrome, but less than 40% of patients is physically active at one year. Home-rehabilitation, initially ...designed to manage the increasing number of patients in rehabilitation programmes, could result in a better strategy to increase adherence and persistence to physical activity.
To test such hypothesis, At Cardiac Rehabilitation Centre (Institute of Physical Medicine and Rehabilitation, Udine, Italy), physical activity adherence was compared between patients treated with a standard in-office rehabilitation programme and a cohort where home rehabilitation programme was added.
From February 2017 to February 2019, 372 patients after an acute coronary syndrome (72 were excluded according to study criteria) were included, 193 patients in standard rehabilitation and 179 in home rehabilitation. At the end of follow-up, patients of both groups were called on the telephone to collect physical activity items according to a standardized questionnaire.
At a medium follow-up of 30.1 months, there are more physically active patients in home rehabilitation than in standard, respectively 139 vs 108 patients (77,1% vs. 56%, p < 0,0001).
At multivariate analysis, including age, gender, and rehabilitation model, the probability to be fully physically active at the end of the rehabilitation programme, is 3 times higher (OR 3.0 CI 1,9-6,0 p < 0,0001) for home rehabilitation programme compared to standard one.
Home rehabilitation, when applied to selected populations, resulted in a feasible and effective strategy to promote long term physical activity in secondary prevention after an acute coronary syndrome.
Duration of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the upper respiratory tract is extremely variable, but its relation to disease severity is unknown. We investigated this ...relation in the 530 000 inhabitants of the northeastern Italian province of Udine.
We analysed real-time RT-PCR tests for SARS-CoV-2 in upper respiratory specimens conducted at the Virology Laboratory of the University Hospital of Udine, Italy (which serves the whole province) from 1 March to 30 April 2020 Specimens were from positive individuals in four groups characterized by different disease severity (critically ill patients admitted to intensive care units, patients admitted to infectious disease units, symptomatic patients visiting the emergency department and not hospitalized, and asymptomatic individuals tested during contact tracing or screening activities). Duration of viral positivity was assessed from the first positive test to the day of the first of two consecutive negative tests. Univariate and multivariate analyses were conducted to investigate differences in the four groups.
From 1 March to 30 April, 39 483 RT-PCR tests for SARS-CoV-2 were conducted on 23 778 individuals, and 974 individuals had a positive test result. Among those with multiple tests (n = 878), mean time to negativity was 23.7 days (standard error 0.3639; median 23, interquartile range 16–30 days). Mean time to negativity was longer in the group admitted to the intensive care unit than in the others, whereas no difference was observed between asymptomatic patients and those with mild disease.
Disease control measures should not be adjusted to account for differences in viral shedding according to symptomatic status.
Key Performance Indicators (KPI) regard key areas of a particular service which needs to be evaluated. Within the health system, they represent specific and measurable elements and are based on ...standards generally set by the scientific literature. KPI can be used to assess performances in different areas and achievement of goals. To develop and calculate a set of KPI in the Italian Region Friuli Venezia Giulia (1 million inhabitants) as an audit tool for the regional Emergency healthcare system, with a focus on three timedependent conditions: trauma, acute myocardial infarction, and stroke. To develop the set, a modified Delphi process was applied among Emergency care experts in Friuli Venezia Giulia. Then, the indicators were calculated from anonymous administrative health databases (Emergency Medical System, Emergency Department, hospital discharge, cardiac catheterization laboratory). Databases could be linked with each other at the individual level through a univocal stochastic key. Sensitivity analyses were conducted where different results were expected using different databases. Sixty-one indicators were calculated for the year 2018. Five indicators were summary descriptive measures, 10 were outcome measures, the others were process indicators; 20 were specific on acute myocardial infarction, 12 on trauma, 4 on stroke. Values for some indicators varied depending on the data source. These KPI provided new and interesting information and are used for periodic audit purposes in Friuli Venezia Giulia. Higher quality, completeness and richness of the administrative databases should be promoted to further increase the value of the indicators.
Background: The Italian network on acute coronary syndromes outcome (IN-ACS Outcome) study is a nationwide observational, multicenter study with the aim to describe clinical epidemiology, management, ...30-days and one-year outcomes of ACS in Italy. Methods: All consecutive patients admitted for ACS to 38 hospitals, between December 2005 and February 2007, were enrolled in the study. Patient in-hospital details and follow-up data at 30-days and one-year were collected using a web-based CRF and stored in a central database. Results: A total of 6045 patients (age 68 ± 13 years) were enrolled: 2313 patients (38.3%) had ST elevation myocardial infarction (STEMI) and 3732 (61.7%) patients had NSTE-ACS. Primary PCI was performed in 1085 (46.9%) STEMI patients, thrombolysis in 590 (25.5%) patients, whereas 638 (27.6%) patients were not reperfused. Among patients with NSTE-ACS, coronary angiography was performed in 2797 (75%) patients, PCI in 1797 (48.2%) patients and CABG in 213 (5.7%) patients. Thirty-days and one-year mortality rates were 5.8% and 9.8%, in STEMI patients and 3.1% and 8.6%, in NSTE-ACS patients. Conclusions: The IN-ACS Outcome study showed that the management of ACS is still suboptimal. Although 30-days mortality is low, the one-year mortality is still substantial.
Genetic testing identified a missense mutation in the protein kinase, AMP-activated, noncatalytic, gamma-2 (PRKAG2) gene leading to an Arg302Glu substitution.
Purpose
Over the past few years, more and more new selective molecules directed against specific cellular targets have become available for cancer therapy, leading to impressive improvements. In this ...evolving scenario, a new way of delivering older cytotoxic drugs has also been developing. Many studies demonstrated that several cytotoxic drugs have antiangiogenic properties if administered frequently and at lower doses compared with standard schedules containing maximal tolerated doses (MTD). Such a new strategy, named metronomic chemotherapy, focuses on a different target: the slowly proliferating tumour endothelial cells. About 10 years ago, metronomic chemotherapy was firstly enunciated and hereafter many clinical experiences were published related to almost any cancer disease. This review analyses available studies dealing with metronomic chemotherapy and its combination with several targeted agents in solid tumours.
Methods
A computerized literature search of MEDLINE was performed using the following search terms: metronomic OR “continuous low dose” AND chemotherapy AND cancer OR solid tumours.
Results
Satisfactory results have been achieved in diverse tumour types, such as breast and prostate cancer or paediatric sarcomas. Moreover, many studies have reported that metronomic chemotherapy determined minimal toxicity compared to MTD chemotherapy. Overall, published series on metronomic schedules are very heterogeneous often reporting on retrospective data, while only very few studies were randomized trials. These limitations still prevent to draw definitive conclusions in diverse tumour types.
Conclusions
Large well-designed studies are eagerly awaited for confirming the promises of metronomic schedules and their combinations with targeted molecules.
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