The impact of compliance with Italian guidelines on the outcome of hospitalised community-acquired pneumonia (CAP) in internal medicine departments was evaluated. All Fine class IV or V CAP patients ...were included in this multicentre, interventional, before-and-after study, composed of three phases: 1) a retrospective phase (RP; 1,443 patients); 2) a guideline implementation phase; and 3) a prospective phase (PP; 1,404 patients). Antibiotic prescription according to the guidelines increased significantly in the PP. The risk of failure at the end of the firstline therapy was significantly lower in the PP versus the RP (odds ratio (OR) 0.83, 95% confidence interval (CI) 0.69-1.00), particularly in Fine class V patients (OR 0.71, 95% CI 0.51-0.98). Analysis of outcome in the overall population (2,847 patients) showed a statistically significant advantage for compliant versus noncompliant therapies in terms of failure rate (OR 0.74, 95% CI 0.60-0.90) and an advantage in terms of mortality (OR 0.77, 95% CI 0.58-1.04). Antipneumococcal cephalosporin monotherapy was associated with a low success rate (68.6%) and the highest mortality (16.2%); levofloxacin alone and the combination of cephalosporin and macrolide resulted in higher success rates (79.1 and 76.7%, respectively) and significantly lower mortalities (9.1 and 5.7%, respectively). Overall, a low compliance with guidelines in the prospective phase (44%) was obtained, indicating the need for future more aggressive and proactive approaches.
Abstract Background Heart failure (HF) is a major health and social problem. Internal Medicine (IM) wards admit a high proportion of patients with HF, frequently with advanced age and comorbidities. ...Few recent data are available in this setting, especially on predictors of in-hospital outcome. Methods In this observational study, we recruited patients admitted with diagnosis of HF and present in five index days, in 91 units of IM in Italy. Characteristics and management of HF, comorbidities, functional and cognitive status, and quality of life, were analyzed. Results We observed 1411 patients, with a mean age of 78.7 ± 9.6 years. At admission, 81.7% of the patients were in NYHA classes III–IV. Ninety percent of the patients had at least one comorbidity. Dementia or severely impaired functional status were registered in 21.5% and 22.8% of the patients. In 89 patients (6,3%) a negative outcome (death or clinical worsening) occurred during hospitalization. A number of variables were significantly related to negative outcome by means of univariate analysis (systolic blood pressure < 100 mmHg, pulse pressure ≥ 55 mmHg, anaemia, brain deficit, permanent bed rest, Barthel Index ≤ 30). At multivariable analysis, significant correlation was retained by anaemia and Barthel Index ≤ 30, the latter being the strongest predictor. Conclusions Real-world patients with HF and hospitalized in IM are frequently very old, frail and with multiple comorbidities. Functional and cognitive status significantly influence patients' outcome, and this could lead to a rethinking of the overall (in-hospital but also home-based) management of HF.
A macro-scale approach to R/C modeling is proposed in this paper by formulating a comprehensive model, that describes R/C behavior in the uncracked stage (solid concrete) and in the cracked stage, ...the latter with either unidirectional cracking (primary cracks) or with bidirectional cracking (primary and secondary cracks) or even multi-directional cracking. The secant stiffness matrix is formulated by means of a direct procedure, based on the assumption that the solid concrete and the reinforcement work in parallel, while the solid concrete between the cracks and the cracks themselves work in series. The resistant mechanisms active at the crack interface are introduced by means of their highly nonlinear laws, that are taken from the literature and are based on well-documented tests. The reliability and accuracy of the proposed model are checked against a few well-documented tests on 2D R/C members failing past the formation of secondary cracks.
An experimental indication of negative heat capacity in excited nuclear systems is inferred from the event by event study of energy fluctuations in Au quasi-projectile sources formed in Au+Au ...collisions at 35 A.MeV. Equilibrated events are selected and the excited source configuration is reconstructed through a calorimetric analysis of its de-excitation products. Fragment partitions show signs of a critical behavior at about 4.5 A.MeV excitation energy. Around this value the heat capacity shows a negative branch providing a direct evidence of a first order liquid gas phase transition.
A method is proposed for the analysis of the nonlinear behavior up to failure of reinforced-concrete membrane elements. The approach considers a linear elastic behavior for concrete before cracking; ...after cracking, the cracks are assumed as having a fixed direction and uniform spacing and cracked reinforced concrete is modeled as an orthotropic material. The basic element of cracked reinforced-concrete membrane is defined and the related stiffness matrix is proposed. The quantities that govern the problem are the opening and the sliding of the crack lips, as well as the strain of the concrete struts that are located between cracks. Applied to a local analysis of cracked reinforced concrete, the above variables allow for the effective modeling of compatibility and equilibrium conditions and take into account phenomena such as aggregate interlock, tension stiffening, and dowel action. To verify the reliability and capability of the proposed method, some comparisons with experimental observations of relevant tests are made.
BACKGROUND The economic evaluation of guide-lines based hospital management of Community- Acquired Pneumonia (CAP) with antibiotic therapy is rarely reported in literature. AIM OF THE STUDY To ...compare costs and effectiveness of 5 different antibiotic courses administered to Fine IV and V class patients with CAP, hospitalized in 31 Italian Internal Medicine (IM) Departments and enrolled in the prospective phase of the multicentre FASTCAP study after the implementation of the Italian Federation of Internal Medicine (FADOI) recommendations on the management of patients with CAP admitted to IM. METHODS 5 main antibiotic courses, administered to 786 patients, were considered (3 monotherapies: levofloxacin, 213 patients; amoxycillin/clavulanate, 134 patients; ceftriaxone, 166 patients; 2 combination therapies: amoxycillin/clavulanate + advanced macrolide, 137 patients; ceftriaxone + advanced macrolide, 136 patients). A cost analysis and two cost/effectiveness analyses (comparing, after the 1st cycle of therapy, cost to outcome for both Fine IV and V classes and cost to avoided mortality during hospitalization for Fine V class only) were carried out adopting the hospital viewpoint. Health care cost, reported in euros 2007, included: drugs acquisition; nursing time; devices for ev administration; hospitalization in inpatient setting. RESULTS The least and the most costly therapies are levofloxacin (3,032.19 ± 2,045.34 euros) and ceftriaxone (3,666.95 ± 2,389.46 euros) in Fine IV class and amoxycillin/clavulanate (2,989.37 ± 2,242.15 euros) and ceftriaxone + advanced macrolide (4,633.59 ± 2,491.57 euros) in Fine V class. As far as the therapeutic outcome is concerned, levofloxacin dominates comparators in Fine IV class, whereas amoxycillin/clavulanate + advanced macrolide is both the most costly (3,433.16 ± 1,725.63 euros) and the most effective option (69.6%; 95% CI: 54.3-82.3%) in Fine V class. In Fine V class ceftriaxone + advanced macrolide reports both the highest cost and the highest proportion of avoided mortality during hospitalization (95.1%; 95% CI: 83.5-99.4%). Sensitivity analysis confirmed the robustness of primary findings. DISCUSSION Our pharmacoeconomic results are consistent with the FADOI recommendations. CONCLUSIONS Levofloxacin outperforms other antibiotic courses among Fine IV class patients, whereas the cost/effectiveness of ceftriaxone or amoxycillin/clavulanate both + advanced macrolide depends upon per patient available budget in Fine V class.
BACKGROUND AND AIM OF THE STUDY Optimal duration of oral anticoagulant therapy (OAT) in idiopathic venous thromboembolism (VTE) is unknown. Indefinite OAT carries an unacceptable risk of major ...bleeding and prospective studies have demonstrated that OAT is no longer protective after its withdrawal. How to identify the patients at risk for recurrence? D-dimer is a marker of thrombin activity. Early prospective studies showed that elevated D-dimer levels after anticoagulation had a highly predictive value for a recurrent episode. Does D-dimer assay have a role in gauging the appropriate duration of anticoagulant therapy? The PROLONG study tries to answer this question.
METHOD D-dimer assay was performed one month after stopping anticoagulation. Patiens with normal D-dimer levels did not resume anticoagulation while patients with elevated D-dimer levels were randomized to discontinue or resume anticoagulation. Study end-points was the composite of recurrent VTE and major bleeding during an average follow-up of 1.4 years.
RESULTS The rate of recurrence is significantly higher in patients with elevated D-dimer levels who discontinued anticoagulation. Resuming anticoagulation in this cohort of patients markedly reduces recurrent events without increasing major bleeding.
DISCUSSION AND CONCLUSIONS PROLONG study is provocative, because D-dimer assay is simple, thus not requiring dedicated laboratory facilities. D-dimer test has otherwise high sensitivity but low specificity in VTE diagnosis. Aspecifically elevated D-dimer levels are available in the elderly and the majority of patients included in the study were > 65 years old, thus introducing a possible selection bias. Nonetheless the results of the study are useful for the clinician. Prolongation of vitamin K antagonists in patients with elevated D-dimer levels one month after discontinuation of OAT for a first unprovoked episode of VTE results in a favourable risk-benefit relationship. Probably this conclusion is even more appropriate for young patients.
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