Background: Few studies evaluated the clinical outcomes of Community Acquired Pneumonia (CAP), Hospital-Acquired Pneumonia (HAP) and Health Care-Associated Pneumonia (HCAP) in relation to the adherence of antibiotic treatment to the guidelines of the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) in hospitalized elderly people (65 years or older). Methods: Data were obtained from REPOSI, a prospective registry held in 87 Italian internal medicine and geriatric wards. Patients with a diagnosis of pneumonia (ICD-9 480-487) or prescribed with an antibiotic for pneumonia as indication were selected. The empirical antibiotic regimen was defined to be adherent to guidelines if concordant with the treatment regimens recommended by IDSA/ATS for CAP, HAP, and HCAP. Outcomes were assessed by logistic regression models. Results: A diagnosis of pneumonia was made in 317 patients. Only 38.8% of them received an empirical antibiotic regimen that was adherent to guidelines. However, no significant association was found between adherence to guidelines and outcomes. Having HAP, older age, and higher CIRS severity index were the main factors associated with in-hospital mortality. Conclusions: The adherence to antibiotic treatment guidelines was poor, particularly for HAP and HCAP, suggesting the need for more adherence to the optimal management of antibiotics in the elderly with pneumonia

A, Ciabattoni G, Patrono C. Thromboxane and prostacyclin biosynthesis in heart failure of ischemic origin: effects of disease severity and aspirin treatment. J Thromb Haemost 2010; 8: 914-22.Summary. Background: Thromboembolism is a relatively common complication of chronic heart failure (HF) and the place of antiplatelet therapy is uncertain. Objectives: We characterized the rate of thromboxane and prostacyclin biosynthesis in chronic HF of ischemic origin, with the aim of separating the influence of HF on platelet activation from that of the underlying ischemic heart disease (IHD). Patients and Methods: We compared urinary 11-dehydro-thromboxane (TX)B 2 , 2,3 dinor 6-keto-PGF 1a, 8-iso-prostaglandin (PG)F 2a , and plasma N-terminal pro-brain natriuretic peptide (NT-pro-BNP), asymmetric dimethylarginine (ADMA), and soluble CD40 ligand (sCD40L), in 84 patients with HF secondary to IHD, 61 patients with IHD without HF and 42 healthy subjects. Results: HF patients not on aspirin had significantly higher urinary 11-dehydro-TXB 2 as compared with healthy subjects (P < 0.0001) and IHD patients not on aspirin (P = 0.028). They also showed significantly higher 8-iso-PGF 2a (P = 0.018), NT-pro-BNP (P = 0.021) and ADMA (P < 0.0001) than IHD patients not on aspirin. HF patients on low-dose aspirin had significantly lower 11-dehydro-TXB 2 (P < 0.0001), sCD40L (P = 0.007) and 2,3-dinor-6-keto-PGF 1a (P = 0.005) than HF patients not treated with aspirin. HF patients in NYHA classes III and IV had significantly higher urinary 11-dehydro-TXB 2 than patients in classes I and II, independently of aspirin treatment (P < 0.05). On multiple linear regression analysis, higher NT-pro-BNP levels, lack of aspirin therapy and sCD40L, predicted 11-dehydro-TXB 2 excretion rate in HF patients (R 2 = 0.771). Conclusions: Persistent platelet activation characterizes HF patients. This phenomenon is related to disease severity and is largely suppressable by lowdose aspirin. The homeostatic increase in prostacyclin biosynthesis is impaired, possibly contributing to enhanced thrombotic risk in this setting.

A rate-control strategy is the most widely used among elderly AF patients with multiple comorbidities and polypharmacy. No differences were evident in CV death and all-cause death at follow-up.

In this in-hospital cohort, the use of lipid-lowering agents was mainly driven by patients' clinical history, most notably the presence of clinically overt manifestations of atherosclerosis. Increasing age seems to be associated with lower prescription rates. This might be indicative of cautious behavior towards a potentially toxic treatment regimen.

The Italian Society of Internal Medicine has developed a voluntary program of professional accreditation of the medical units run by its constituency. Participation in the program, which is meant to foster staff involvement in clinical governance, includes all the medical personnel and nurses. Accreditation is awarded provided the candidate unit is able to adhere to a pre-established set of quality standards, meet a number of clinical and organizational requirements and monitor specific indicators. Self-evaluation is the first step in the program, followed by a site visit by a team of peer internists experienced in quality auditing. The program, which has involved so far 19 units, has considered a number of clinical requirements related to the three most frequent diseases in Italian internal medicine wards: chronic heart failure (CHF), exacerbation of chronic obstructive pulmonary disease (COPD) and hepatic cirrhosis with ascites (HCA). The comparison between self- and peer-evaluation witnessed less discrepancies for disease-related than for organizational requirements, the latter being met to a smaller degree by most units. In particular, concordance was higher for requirements and indicators pertaining to CHF and HCA than to COPD. This program of professional accreditation developed by the Italian Society of Internal Medicine has the potential to describe, monitor and improve clinical and organizational performances in internal medicine. It should also be seen as a contribution to implement the strategy of professional governance in hospitals.