Serum Uric Acid, Kidney Function and Acute Ischemic Stroke Outcomes in Elderly Patients: A Single-Cohort, Perspective Study.

Chronic kidney disease and hyperuricemia have been associated to an increased risk and a worse prognosis in acute ischemic stroke. Several mechanisms, including platelet dysfunction, coagulation disorders, endothelial dysfunction, inflammation, and an increased risk of atrial fibrillation could be implicated. The role of serum uric acid in this setting is still object of debate. We enrolled all the consecutive patients admitted to our department for acute ischemic stroke. Cox regression analysis was used to evaluate the risk of in-hospital death considering serum uric acid levels and all the comorbidities. In the overall sample, hyperuricemia was independently associated to an increased risk of in-hospital mortality. This effect was stronger in patients with chronic kidney disease while, in the group of patients with normal renal function, the relationship between hyperuricemia and increased stroke mortality was not confirmed. Hyperuricemia could be associated to higher in-hospital mortality for ischemic stroke among elderly patients when affected by kidney disease. Survival does not seem to be affected by hyperuricemia in patients with normal kidney function.

Charlson comorbidity index as a predictor of in-hospital death in acute ischemic stroke among very old patients: a single-cohort perspective study.

Chronic diseases are increasing worldwide. Association of two or more chronic conditions is related with poor health status and reduced life expectancy, particularly among elderly patients. Comorbidities represent a risk factor for adverse events in several critical illnesses. We aimed to evaluate if elderly patients are affected by multiple chronic pathologies, assessed by Charlson comorbidity index (CCI), showed a reduced in-hospital survival after ischemic stroke. In a 3-year period, we evaluated all the subjects admitted to our internal medicine department for ischemic stroke. Age, sex, NIHSS score and all the comorbidities were recorded. Days of hospitalization, hospital-related infections and in-hospital mortality were also assessed. For each patient, we evaluated CCI, obtaining four classes: group 1 (CCI: 2-3), group 2 (CCI: 4-5), group 3 (CCI: 6-7) and group 4 (CCI: ≥8). Survival was evaluated with Kaplan-Meier and Cox regression analyses. The complete model considered in-hospital death as the main outcome, days of hospitalization as the time variable and CCI as the main predictor, adjusting for NIHSS, sex and nosocomial infections. Patients in CCI group 3 and 4 had an increased risk of in-hospital mortality, independently of NIHSS, sex and nosocomial infections. Elderly patients with multiple comorbidities have higher risk of in-hospital death when affected by ischemic stroke.

Medical teleconsultation to general practitioners reduces the medical error vulnerability of internal medicine patients.

BACKGROUND: e-Health strategies are supposed to improve the performance of national health systems. Medical teleconsultation (MT) is an important component of such e-Health strategies. OBJECTIVES: The outcome of MT was evaluated with regard to the impact on the medical error vulnerability (MEV) of internal medicine patients. METHODS: A team of internal medicine doctors plus a network of forty specialists was set-up in one health district belonging to a unified and universal national health system of a country of Western Europe, in order to provide free-of-charge MT to support general practitioners in solving internal medicine cases. In this observational study, the case series of 2013 is reviewed. RESULTS: a) Only 21% of the MT fell short to the general practitioner's expectations about the case solving focus; b) throughout the medical care process of the patient, 49% of the cases met with one or more of the five MEVs, namely: 1) clinical test mishandling; 2) inaccurate differential diagnosis; 3) inadequate information flow between health providers at different levels of care (transition care); 4) poor coordination between health providers; and 5) poor reconciliation of medications or hazardous therapies. c) MT canceled or prevented MEVs in 56% and mitigate MEVs in 15% of the cases; d) MT canceled or prevented 85% of MEV caused by poor information exchange in transition care, therefore improving patient referral and counter-referral. CONCLUSIONS: MT reduces MEV and therefore, whenever implemented to a large extent, may improve the quality of health care delivery and the performance of national health systems.

CHA2DS2-VASc in the prediction of early atrial fibrillation relapses after electrical or pharmacological cardioversion.

BACKGROUND: In hemodynamically stable patients, mortality and morbidity related to atrial fibrillation are mainly due to cardioembolic disorder. No difference in the survival rate and incidence of embolic events has been described in patients undergoing rhythm or rate control if the latter is combined with an appropriate anticoagulant therapy. CHA2DS2-VASc is a score that allows clinicians to stratify embolic risk in patients affected by nonvalvular atrial fibrillation. Each item can be involved in triggering and maintaining atrial fibrillation. Thus, we hypothesized that CHA2DS2-VASc may help to predict early recurrences after cardioversion. METHODS: A total of 319 consecutive patients, admitted to our emergency department or hemodynamically stable persistent atrial fibrillation, were enrolled and treated with electrical or pharmacological sinus rhythm restoration. Outcome was defined as recurrence of atrial fibrillation 5 days after cardioversion. Predicted probability of sinus rhythm stability was assessed with an ordinal regression model using CHA2DS2-VASc as an independent variable. RESULTS: The model showed a progressive decrease in the predicted probability of sinus rhythm stability after electrical or pharmacological cardioversion along with an increase in the CHA2DS2-VASc score. A logarithmic relationship was the best-fit trend among CHA2DS2-VASc ranks and the predicted probability of sinus rhythm stability in patients undergoing both electrical and pharmacological cardioversion (r(2) = 0.98, P < 0.05 for electrical cardioversion; r(2) = 0.91, P < 0.05 for pharmacological cardioversion). CONCLUSION: Our preliminary results suggest that CHA2DS2-VASc score could be useful in evaluating the risk of early recurrence of atrial fibrillation after cardioversion. This information may have implications for disease monitoring and treatment strategies in clinical practice.

[Relationship between hypothyroidism and cholesterol out of the records of 1756 patients]. / Ipotiroidismo e colesterolo: analisi retrospettiva di una casistica trentennale di 1756 pazienti.

BACKGROUND: Subclinical hypothyroidism (SH) is settled whenever high levels of serum thyroid-stimulating hormone (TSH) are detected, whereas free thyroid hormone levels are within the normal range. Benefits and risks of therapy for SH have been debated for 2 decades. However, consensus has not yet been achieved. Besides preventing the progression to overt hypothyroidism, the decision of undertaking replacement therapy in SH is made mainly by basing on the risk of metabolic (dyslypidemia) and subsequent cardiovascular complications. MATERIALS AND METHODS: A series, made up of 1756 patients (mean age 42,8±16,8, range 0,5-94) and filed from 1984 to 2013, was studied retrospectively. 169 patients were affected by clinical (overt) hypothyroidism (IC: TSH >40). 1587 patients were affected by SH, out of whom 1121 were mild (TSH <10) and 466 medium (TSH ≥ 10 ≤40). The series of patients was properly followed-up. The mean follow-up time was 6 years. In all patients TSH, Ft4, and total cholesterol were evaluated basally and after appropriate (TSH normalized) medical therapy. RESULTS: By medical replacement treatment, clinical hypothyroidism (CI) related hypercholesterolemia decreased significantly in 28%. In SH, the baseline serum cholesterol levels were wide. However, replacement treatment did not reduce such levels. No major cardiovascular accident occurred to any patient over the follow-up period. CONCLUSIONS: Hypercholesterolemia is certainly due to CI, therapy reduces cholesterol levels that not always fall below 200 mg/dl and this condition persists over time. SH is not characterized by hypercholesterolemia. Cholesterol levels in these patients are variable equal to the normal people and can not be reduced with thyroxine.