Pain prevalence and management in an internal medicine setting in Italy.

Background. Since data on pain evaluation and management in patients admitted to internal medicine wards (IMWs) are limited, we aimed to evaluate these aspects in a cohort of internistic patients. Methods. We considered all patients consecutively admitted from June to December 2011 to our unit. Age, gender, and length-of-hospital-stay (LOS) were recorded. Comorbidities were arbitrarily defined, and pain severity was evaluated by Numeric Rating Scale (NRS) on admission and discharge. Results. The final sample consisted of 526 patients (mean age 74 ± 14 years; 308 women). Significant pain (NRS ≥ 3) was detected in 63% of cases, and severe (NRS ≥ 7) in 7.6%. Pain was successfully treated, and NRS decreased from 4.65 ± 2.05 to 0.89 ± 1.3 (P < 0.001). Compared with subjects with NRS < 3, those with significant pain were older (75.5 ± 13.9 versus 72.9 ± 14.5 years, P = 0.038), and had a higher LOS (7.9 ± 6.1 versus 7.3 ± 6.8, P = 0.048). Significant pain was independently associated with age (OR 0.984, P = 0.018), cancer (OR 3.347, P < 0.001), musculoskeletal disease (OR 3.054, P < 0.0001), biliary disease (OR 3.100, P < 0.01), and bowel disease (OR 3.100, P < 0.003). Conclusion. In an internal medicine setting, multiple diseases represent significant cause of pain. Prompt pain evaluation and management should be performed as soon as possible, in order to avoid patients' suffering and reduce the need of hospital stay.

Circadian rhythms and medical diseases: does it matter when drugs are taken?

BACKGROUND: Chronobiology is devoted to the study of biological rhythms. It is possible that a given medication may be therapeutic and safe when administered at some time, but subtherapeutic or poorly tolerated at another. METHODS: We focused on some classes of drugs, widely used by the internists, performing a PubMed search with the single drugs associated with the MeSH terms "Chronotherapy", "Circadian rhythm", and "Chronobiology, phenomena". Among the studies found, we considered only those provided with discrete numerosity or clearly stated methodological characteristics. RESULTS: The results of available studies were given, along with a series of short take-home messages at the end of each mini-chapter devoted to: antihypertensives, statins, anticoagulants, analgesics, drugs for acid-related disorders, and anti-asthmatic drugs. In particular, evidence of morning vs. evening administration, when applicable, was given for each medication. CONCLUSIONS: Adequate evidence seems to support that at least ACE-inhibitors or angiotensin receptor blockers, simvastatin, corticosteroids (slow-release formulation) for arthritic patients, and ranitidine should preferably be administered in the evening. Morning dosing could be better for proton pump inhibitors, whereas time of administration is not crucial for asthma inhalation drugs. Studies are available for other drugs, but not so strong enough to draw definite conclusions. For now, we need prospective intervention trials specifically designed to investigate the long-term effects of a temporal approach to medical therapy. However, since switching to morning-evening administration or vice versa is simple and inexpensive, in some cases it could be considered, remembering that, in any case, adherence remains the crucial point.

In-hospital mortality in patients with renal dysfunction admitted for myocardial infarction: the Emilia-Romagna region of Italy database of hospital admissions.

BACKGROUND: In-hospital mortality of patients with myocardial infarction (MI) in different European populations and renal dysfunction is variable. We aimed to evaluate in-hospital mortality for MI in chronic kidney disease (CKD), in end-stage renal disease (ESRD), and in subjects admitted for MI without renal dysfunction living in the Emilia-Romagna region of Italy. METHODS: We considered all cases of MI (first event) recorded in the database of hospital admissions of the region Emilia-Romagna of Italy, from January 1999 to December 2009. The criterion for inclusion was the presence, as a first discharge diagnosis, of acute MI (International Classification of Diseases, 9th Revision, Clinical Modification). The Charlson comorbidity index (CCI), with the exclusion of CKD, was calculated. The outcome variable was in-hospital mortality for MI, and its association with comorbidities, CKD and ESRD, was analyzed. RESULTS: During the considered period, 88,014 cases of first MI were recorded. The percentage of patients admitted with MI and died during hospitalization were higher in patients with ESRD (38.3 %) and CKD (16.5 %) than in those without renal dysfunction (14 %) (p < 0.01). In CKD and ESRD patients, data of in-hospital mortality for MI exhibited a twofold increase in the analyzed period. In-hospital mortality for MI was independently associated with age (OR 1.077, 95 % CI 1.075-1.080, p < 0.001), CCI excluding CKD (OR 1.101, 95 % CI 1.069-1.134, p < 0.001), cerebrovascular disease (OR 1.450, 95 % CI 1.349-1.557, p < 0.001), malignancy (OR 1.234, 95 % CI 1.153-1.320, p < 0.001), and ESRD (OR 4.137, 95 % CI 3.511-4.875, p < 0.001). CONCLUSIONS: As for the Emilia-Romagna region of Italy, in-hospital mortality for MI is increasing over the last years, and mortality seems to be related with patients' comorbidities and presence of advanced stages of CKD.

[Falls and renal function: a dangerous association]. / Cadute e funzione renale: un'associazione pericolosa.

Falls are an important health problem and the risk of falling increases with age. The costs due to falls are related to the progressive decline of patients' clinical conditions, with functional inability inducing increasing social costs, morbidity and mortality. Renal dysfunction is mostly present in elderly people who often have several comorbidities. Risk factors for falls have been classified as intrinsic and extrinsic, and renal dysfunction is included among the former. Chronic kidney disease per se is an important risk factor for falls, and the risk correlates negatively with creatinine clearance. Vitamin D deficiency, dysfunction of muscles and bones, nerve degeneration, cognitive decline, electrolyte imbalance, anemia, and metabolic acidosis have been reported to be associated with falls. Falls seem to be very frequent in dialysis patients: 44% of subjects on hemodialysis fall at least once a year with a 1-year mortality due to fractures of 64%. Male sex, comorbidities, predialysis hypotension, and a history of previous falls are the main risk factors, together with events directly related to renal replacement therapy such as biocompatibility of the dialysis membrane, arrhythmias, fluid overload and length of dialysis treatment. Peripheral nerve degeneration and demyelination as well as altered nerve conduction resulting in muscular weakness and loss of peripheral sensitivity are frequent when the glomerular filtration rate is less than 12 mL/min. Moreover, depression and sleep disorders can also increase the risk of falls. Kidney function is an important parameter to consider when evaluating the risk of falls in the elderly, and the development of specific guidelines for preventing falls in the uremic population should be considered.