bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of the Flugelman index for identifying patients who are difficult to discharge from the hospital
Authors: Bozzano Chiara , Lancini Ilario , Mei Elena , Lucarini Maida , Mastriforti Roberta , Zuccone Nunzia , Vanni Dino , Pedace Claudio
Published: April 2013

Introduction: To evaluate the use of multidimensional assessment based on the Fluegelman Index (FI) to identify internal medicine patients who are likely to be difficult to discharge from the hospital. Materials and methods: Have been evaluated all patients admitted to the medical wards of the District General Hospital of Arezzo from September 1 to October 31, 2007. We collected data on age, sex, socioeconomic condition, cause of admission, comorbidity score preadmission functional status (Barthel Index), incontinence, feeding problems, length of hospitalization, condition at discharge, and type of discharge. The FI cut off for difficult discharge was > 17. Results: Of the 413 patients (mean age 80 + 11.37 years; percentage of women, 56.1%) included in the study, 109 (26.39%) had Flugelman Index > 17. These patients were significantly older than the patients with lower FIs (85 + 9.35 vs 78 + 11.58 years, p < 0.001), more likely to be admitted for pneumonia (22% vs. 4.9% of those with lower FIs; p < 0,001). They also had more comorbidity, loss of autonomy, cognitive impairment, social frailty, and nursing care needs. The subgroup with FIs>17 had significantly higher in-hospital mortality (30.28% vs 6.25%, p < 0.001), longer hospital stay (13 vs. 10 days, p < 0.05), and higher rates of discharge to nursing homes. Conclusions: Evaluation of internal medicine patients with the Flugelman Index may be helpful for identifying more critical patients likely to require longer hospitalization and to detect factors affecting the hospital stay. This information can be useful for more effective discharge planning.
Hospital discharge of frail, elderly patients with complex care needs: a problem or a challenge?
Authors: Silingardi Elisabetta , Lombardi Denise , Balotta Antonio
Published: April 2013

Introduction: The increase in patients with chronic disease that require on-going care is creating difficulties for the public health system, which have prompted recent attempts to remodel the system with a generalized reduction in the number of hospital beds and the implementation of services designed to promote home health care. Intermediate care is an opportunity to support timely discharge from acute-care facilities and promote functional recovery, but its efficacy requires a strong, complete and comprehensive assessment to ensure appropriate admission. Materials and methods: The Care Continuity Service of Rimini is a multiprofessional team that supplies support and counselling for acute hospital wards and training for nursing and medical professionals to develop their assessment skills. Results: A questionnaire filled out by the staff of acute-care internal medicine wards in the Greater Romagna Area has revealed ambiguities in the use of terms like ‘‘social’’ and ‘‘complex care needs.’’ It also documents difficulties in the early identification of patients likely to experience problems if they are discharged from the hospital directly to their homes. Discussion: To ensure prompt identification of these patients, we must identify/develop a screening instrument or clinical-functional method that can be used in acute-care hospital wards to plan discharges. The aims of intermediate care are to reduce hospital stays and improve continuity of care, but specific know-how and expertise are needed if these goals are to be met. Specific staff training programs and a patient-centred model are essential to ensure an acceptable cost-benefit ratio.
Agranulocytosis: an adverse effect of allopurinol treatment
Authors: Mari Elisa , Ricci Franco , Imberti Davide , Gallerani Massimo
Published: April 2013

Introduction: Allopurinol is a xanthine oxidase inhibitor that is primarily used to treat hyperuricemia and its complications. The drug is rarely associated with adverse effects, but those that occur can be significant. Hematologic side effects, including bone marrow suppression, severe anemia, thrombocytopenia, and leukopenia, have been reported in 0.2-0.6% of treated patients. Materials and methods: We report a case of agranulocytosis associated with allopurinol therapy in a patient admitted for fever.
Hyposplenism as a cause of pneumococcal meningoencephalitis in an adult patient with coeliac disease
Authors: Caraceni Paolo , Benazzi Barbara , Caio Giacono , Zaccherini Giacomo , Domenicali Marco , Volta Umberto
Published: April 2013

Introduction: Coeliac disease can be associated with hyposplenism and splenic atrophy, which may increase the patient’s risk for fatal infections caused by Streptococcus pneumoniae or Pneumococcus. It is general opinion that many more patients with coeliac disease have died from hyposplenism-related infections than those reported in literature. Case report: A 62-year-old woman with recently diagnosed coeliac disease was hospitalized with high fever, disorientation, and nuchal rigidity. Cerebral computed tomography was negative. Laboratory tests showed an elevated leukocyte count and very high levels of C reactive protein. The cerebrospinal fluid (CSF) contained an increased number of mononuclear cells associated with a low glucose level and high protein concentrations. The CSF culture was positive for Streptococcus pneumoniae. Neurological conditions rapidly deteriorated with the onset of coma, and magnetic resonance imaging of the brain revealed initial signs of encephalitis extending above and below the tentorium. Abdominal ultrasonography disclosed splenic hypotrophy that raised the suspicion of hyposplenism. The diagnosis of hyposplenism was confirmed by demonstration of Howell-Jolly bodies in a peripheral blood smear. Discussion: This is the first reported case of pneumococcal meningoencephalitis caused by splenic hypofunction in a patient with coeliac disease. When coeliac disease is diagnosed with a marked delay in an elderly patient, spleen function should always be assessed. If impaired, the patient should undergo vaccination with pneumococcal conjugate vaccine to prevent pneumococcal infections.
Apixaban
Authors: Airoldi Gianluca , Campanini Mauro
Published: April 2013

Introduction: Thromboembolic events represent the final common mechanism in the pathogenesis of the most lethal vascular diseases in the developed countries (including acute coronary syndromes, ischemic stroke, deep vein thrombosis, and pulmonary embolism). Anticoagulant drugs, such as vitamin K antagonists (VKAs), heparin, low-molecular-weight heparin (LMWH), and, more recently, fondaparinux, form the cornerstone of prevention and treatment of thromboembolic diseases, and they are among the most widely used drugs in the Western world. However, these agents have important limitations. VKAs have a narrow therapeutic range and unpredictable pharmacokinetics (PK) and pharmacodynamics (PD), which are heavily influenced by genetic factors, drug-drug interactions, and dietary intake of vitamin K. Frequent laboratory monitoring and careful dose adjustment of VKAs are needed to ensure effective anti-thrombotic protection at a reasonably low risk of bleeding. Heparin, LMWH, and fondaparinux require subcutaneous injection, which makes them unsuitable for long-term treatments. Therefore, there is a real need for new, orally active anticoagulants with predictable PK/PD profiles that can be used without laboratory monitoring. Materials and methods: In this ‘‘state of the art’’ review, the authors examine literature retrieved from a PubMed Medline search with the keyword apixaban and no limits regarding date or language of publication, type of article, or field. Results: Apixaban is an oral anticoagulant developed for the prevention and treatment of venous thromboembolism, for stroke prevention in atrial fibrillation, and for secondary prevention in ischemic heart disease. It is a potent, reversible, highly selective, direct inhibitor of free and prothrombinase-bound factor Xa. It is characterized by > 50% oral bioavailability, peak plasma concentrations 1-3 h after administration, and a 12-h terminal half-life. It also has low potential for drug-drug interactions and is eliminated through mixed renal and metabolic pathways (both CYP-mediated and CYP-independent). Apixaban has exhibited promising efficacy and safety profiles in different clinical conditions.Discussion: Apixaban is a promising new oral anticoagulant. However, additional studies on effectiveness and safety are needed to determine whether it can compete with the coumarins in the prevention and treatment of thromboembolic diseases.
The 100th anniversary of pH (1909-2009). Negative logarithms for measuring hydrogen ions: are they essential in medicine? Part I
Authors: Sgambato Francesco , Prozzo Sergio , Sgambato Ester , Sgambato Rosa , Milano Luca
Published: April 2013

Introduction: It has been 100 years since the concept of pH (1909-2009) was ‘‘invented’’ by the Danish chemist-mathematician Søren Peter Lauritz Sørensen (1868-1939) in the chemistry laboratories of the Carlsberg Brewery in Copenhagen. The anniversary provides an opportunity to examine the crucial importance in human life of acid-base balance. Materials and methods: The authors review the historical process that led to the creation of the pH scale, with citation of passages from the original work of Sørensen published 100 years ago. This is followed by a critical analysis of the debate regarding the use of logarithmstomeasure hydrogen ion concentrations based on data from scientific papers published over the past 50 years (1960-2010). Results and discussion: The authors conclude that the concept of acid-base balance can be approached and taught in a simpler, more exciting, and even pleasant fashion without using the infamous and abstruse Henderson-Hasselbalch equation. The whole rationale underlying the understanding and clinical application of this vital topic is clearly and unquestionably inherent simpler, more manageable formula introduced by Henderson (without logs), which is useful and quite adequate for use in medical education.
The hyponatremias
Authors: Elmi Giovanna , Faustini-Fustini Marco , Zaccaroni Stefania , Zoni Roberto
Published: April 2013

Introduction: Plasma sodium concentrations are commonly measured in hospitalized patients. In our department, hypernatremia (defined as a serum sodium < 135 mmol/L) is usually an incidental finding. More rarely, however, clinical manifestations of hypernatremia occur. Symptoms depend on the magnitude and rapidity of onset of the hypernatremia. When acute, severe hyponatremia develops, brain edema may occur. Considerable morbidity and mortality can be associated with hyponatremic encephalopathy per se. Moreover, rapid correction of hyponatremia also carries a risk of neurological damage related to the osmotic demyelination syndromes. This review focuses on the epidemiology, pathophysiology, and therapy of hyponatremia. Materials and methods: We carried out a search of the literature in Medline, the Cochrane Library and Clinical Evidence using the search terms hypernatremia and sodium. Conclusions: Hyponatremia is the most common electrolyte disorder encountered in clinical practice, occurring in approximately 15% to 30% of hospitalized patients, and it is not uncommon in outpatients. When faced with a hyponatremic patient, the physician has to identify the cause, treat the defect, and take care of the patient, bearing in mind that hypernatremia and its correction are associated with significant morbidity and mortality. Hyponatremic encephalopathy following acute hypernatremia is well known to be a potentially life-threatening condition, especially in patients with concomitant diseases. In contrast, chronic hypernatremia is more common, and it is often considered to be a laboratory abnormality devoid of clinical consequences. Paradoxically, however, this is just the setting in which rapid correction of plasma sodium levels can cause severe neurologic defects and death. Despite substantial progress in understanding the pathophysiology of brain damage related to hyponatremia and its treatment, optimal, safe therapies have not been well defined yet. The imminent availability of aquaretic nonpeptide arginine vasopressin receptor antagonists could provide new insights into this field. However, because of their unique effects, i.e., selective increase of solute-free water excretion by the kidney, this new class of drugs cannot be used in patients with hypovolemic hyponatremia.
Posterior reversible encephalopathy syndrome in an AIDS patient with acute renal failure and hypertension
Authors: Bargiacchi Olivia , Salerno Anna M. , Rossati Antonella , Brondolo Roberta , Brustia Diego , Rosa Felicita , Rizzo Giovanni , Garavelli Pietro L.
Published: April 2013

Introduction: The posterior reversible encephalopathy syndrome (PRES) is a neurological entity characterized by magnetic resonance imaging (MRI) evidence of bilateral subcortical edema in the occipital regions of the brain. Case report: We report the case of a female patient with AIDS, pulmonary aspergillosis, CMV infection, and acute renal failure due to Clostridium difficile diarrhea. Her clinical course was complicated by seizures and hypertension. MRI findings were consistent with PRES. The patient was treated with anticonvulsants and antihypertensive agents with clinical improvement. Discussion and conclusions: Few cases of PRES in HIV-infected patients have been described, and it is not clear whether HIV infection is a predisposing factor for this syndrome. The article reviews the literature on PRES in HIV and discusses the role of HIV-associated endothelial damage in the pathogenesis of this syndrome.
Neurovascular alterations in chronic hepatitis C: a case-control study
Authors: Vedovetto Valentina , Bilora Franca , Chemello Liliana , Cavalletto Luisa , Rossato Alberto , Veronese Francesco , Gottardo Anna , Pagnan Antonio
Published: April 2013

Introduction: Hepatitis C is a major health problem: approximately 170 million people are infected with the hepatitis C virus worldwide. It is unclear whether chronic hepatitis C affects atherosclerosis and whether it can cause endothelial and/or autonomic nervous system (ANS) dysfunction. Materials and methods: From April 2008 through April 2009, we studied 76 patients with biopsyconfirmed chronic hepatitis C and no evidence of cirrhosis, ascites, portal hypertension, encephalopathy, or hepatocellular carcinoma. The age-, sex-, BMI- and cardiovascular risk factor- matched control group comprised 76 healthy, HCV-negative individuals with no evidence of liver, autoimmune, or immunoproliferative diseases and no history of cardiovascular events. Twenty five of the hepatitis C patients were treatment-naive; the other 51 had been treated with interferon (but only 25 had persistent virological responses). Color Doppler sonography was used to measure the intima-media-thickness (IMT) of the common and internal carotid arteries. Endothelial function was assessed in the brachial artery with the flow-mediated-dilatation (FMD) test. The ANS was assessed with the tilt, laying to standing, Valsalva, hand grip, deep breath, and stroop tests. Results: The case group (mean age 52 + 13 years) had a significantly higher internal carotid IMT (0.86 + 0.3 vs 0.67 + 0.1 mmfor controls; p = 0.002). Chronic hepatitis C was also associated with an odds ratio for carotid plaque formation (reflected by an IMT > 1.3 mm) of 2.15. Cases also had significantly reduced FMD in the brachial artery (0.46 + 0.9 vs 0.76 + 0.7 for controls; p = 0.005) and significantly altered sympathetic and parasympathetic function (p = 0.001 vs controls in the Valsalva, hand grip, deep breath, and stroop tests). Within the case group, all alterations were more severe in patients with significant viremia. Discussion: Our findings suggest that chronic hepatitis C may be a nonclassic cardiovascular risk factor since it seems to influence the onset of pre-atherosclerotic lesions and to promote atherosclerotic plaque formation in patients with pre-existing increases in carotid IMT. It also seems to cause dysfunctions of the vascular endothelium and ANS. Conclusions: Chronic hepatitis C may increase cardiovascular risk and promote ANS dysfunctions, particularly when patients have experienced treatment failure and have persistent viremia. These patients may require cardiovascular and neurologic follow-up.
Hematologic emergencies
Authors: Vallisa Daniele , Moroni Carlo F.
Published: April 2013

In recent years, the surprising progress made in other areas of hematology (advances in the understanding of leukemogenesis, improved transplant techniques) has been conspicuously absent in the management of hematologic emergencies. And yet, every step toward greater knowledge, every new treatment option will be of little value unless we are able to manage the acute complications of hematologic diseases. These complications are better defined as hematologic emergencies, and they are characterized by a high rate of mortality. This review is based on a search of the literature that was initially confined to articles published in the journal Hematology from 2000 to 2009. The search was then extended to the Cochrane Library and to Pub Med in February 2010 with the following Keywords emergencies; urgencies; hematology. The same key words were employed in a search of the archives of Blood and the New England Journal of Medicine from 2000 to 2010. The results confirm that hematologic emergencies can be caused by hematologic malignancies as well as by non-neoplastic hematologic diseases. Within the former category; this review examines the causes; manifestations; treatment and prevention of disseminated intravascular coagulation; superior vena caval syndrome; spinal cord compression; tumor lysis syndrome; hyperleukocytosis; and hypercalcemia. We also review emergency situations associated with non-neoplatic haematological diseases; such as thrombotic thrombocytopenic purpura; drug-induced hemolytic anemia; and acute sickle-cell crisis.
Clinical characteristics of italian patients with venous thromboembolism enrolled in the RIETE Registry
Authors: Di Micco Pierpaolo , Bura-Riviere Alessandra , Poggio Renzo , Tiraferri Eros , Quintavalla Roberto , Visona Adriana , Prandoni Paolo , Ciammaichella Maurizio , Barillari Giovanni , Investigators RIETE
Published: April 2013

Introduction: The clinical characteristics, treatment strategies and outcome of patients with venous thromboembolism (VTE) may vary from country to country. Materials and methods: The RIETE (Registro Informatizado su la Enfermedad TromboEmbolica) is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic VTE. Our aim was to assess the influence of surgery and immobility for non-surgical reasons on 3-month outcomes of all Italian patients registered in the RIETE. Results: Through July 2008, 21,397 patients with acute VTE were registered in the RIETE. Of these, 896 (4.2%) were Italian, and 360 (40%) presented with pulmonary embolism (PE). Overall, 137 (15%) developed VTE after surgery; 156 (17%) developed VTE after >4 days of immobility, and 603 (67%) developed VTE in the absence of surgery or immobility. Most patients (83%) received initial therapy with low-molecular-weight heparin; 15% received unfractionated heparin. For long-term therapy, 63% of patients received vitamin K antagonists. The incidence of fatal PE during the first 3 months of therapy was 1.5% for patients with postoperative VTE, 7.7% for who developed VTE after immobility, and 1.2% for the remaining patients. The incidence of fatal bleeding among these patients was 1.5%, 1.9% and 0.3%, respectively. Of the 137 patients with postoperative VTE, 61% had received VTE prophylaxis. Of the 156 patients with recent immobility, 24% had received VTE prophylaxis. Conclusions: VTE arising after a period of immobility was associated with the highest rates of fatal PE and fatal bleeding during the first 3 months of therapy. The use of thromboprophylaxis in this population should be improved.
The ability of clinical and laboratory findings to predict in-hospital death in patients with thrombotic thrombocytopenic purpura in an internal and emergency medicine department
Authors: Pieralli Filippo , Mancini Antonio , Camaiti Alberto , Berni Giancarlo , Nozzoli Carlo
Published: April 2013

Introduction: Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening syndrome characterized by microangiopathic anemia, thrombocytopenia, diffuse microvascular thrombosis, and ischemia. It is associated with very low levels of ADAMTS-13. Measurement of ADAMTS-13 levels is used for diagnostic and prognostic purposes, but in every-day clinical practice, this type of analysis is not always readily available. In this retrospective study, we evaluated prognostic value of clinical and laboratory findings in patients with TTP. Materials and methods: We retrospectively investigated patients with clinically diagnosed TTP treated in a unit of Internal and Emergency Medicine (1996-2007). Clinical and laboratory findings were collected and analyzed in order to assess their ability to predict in-hospital death. Results: Twelve patients were identified (mean age 59 + 22 years; 58% were women). Five (42%) died during the hospitalization, and the variables significantly associated with this outcome were: a delay between diagnosis and symptom onset (HR 1.36; 95% CI 1.04-1.78; p < 0.05); a higher severity score (HR 1.48; 95%CI 1,23-3.86; p < 0.05); hemodynamic instability with hypotension and/or shock (HR 3.35; 95%CI 3.02-9.26; p < 0.01); a higher schistocyte count on blood smear (HR 1.84; 95%CI 1.04-3.27; p < 0.05); and higher lactate values (HR 1.85; 95%CI 1.08- 3.16; p < 0.05). Conclusions: TTP is a rare and potentially fatal disease with protean manifestations. Delayed diagnosis after symptom onset is a major determinant of poor outcome. Hypotension and shock are also prognostically unfavourable. Laboratory evidence of cardiocirculatory compromise (i.e., elevated lactate levels) and extension of the disease process (i.e., schistocyte count > 3) are predictive of in-hospital death, independently of the hemodynamic profile on admission.
Topiramate: use in binge eating disorder?
Authors: Gentile Mauro , Scanelli Giovanni
Published: April 2013

Introduction: Topiramate was serendipitously synthesized in 1979 during research aimed at developing a fructose-1,6-diphosphatase inhibitor that might be used in the treatment of diabetes mellitus. Some investigators have suggested it might be used in the treatment of binge eating disorder (BED). The aim of this review was to evaluate current knowledge and opinions on this topic. Materials and methods: We conducted a search of five electronic databases (PubMed, Embase, Nice, Cochrane, Cinahl) using the search strategy ‘‘topiramate’’ AND ‘‘binge’’, ‘‘binge eating disorder.’’ No time limits were applied, and only reports of randomized controlled trials were included in our analysis. Results: In clinical studies, topiramate use has been associated with significant weight loss mediated by reductions in the frequency of bingeing episodes. The most common side effects of the drug are paresthesias, but nephrolithiasis, oligohydrosis, and dizziness have also been described. Conclusions: Available data are limited, but the literature we reviewed suggests that topiramate can be useful in the medical treatment of BED, reducing both body weight and binge episodes. Side effects are not negligible. Before topiramate can be regarded as a good tool for the treatment of BED, further data must be obtained from longer, methodologically correct studies of larger populations.
Clinical management of spontaneous intracranial haemorrhage associated with oral anticoagulants: a case series
Authors: Masotti Luca , Pampana Alessandro , Pennati Paolo , Landini Giancarlo
Published: April 2013

Introduction: Intracranial haemorrhage (ICH) is associated with high mortality and morbidity, and for this reason it is the most feared complication of oral anticoagulant therapy (OAT). Recommendations are available for the immediate reversal of OAT, but these measures are not always used uniformly and rapidly. The aim of this study was to critically review the treatment of spontaneous OAT-related ICH in our hospital. Materials and methods: We retrospectively analyzed the medical records of patients admitted to our ward between January 2006 and January 2010 for spontaneous OAT-related ICH. Results: In the analyzed period, 15 patients were hospitalized for OAT-related ICH (supratentorial in 66.5%, infratentorial in 20%, acute subdural hematoma in 13.5%). In 66.5% of the patients, the INR on arrival was within the therapeutic range. In 60% of the cases, the Glasgow Coma Scale (GCS) on arrival was > 8/15. Three-factor prothrombin complex concentrate (PCC) was administered in 80% of the cases, and 30% of patients received fresh frozen plasma (FFP) and recombinant activated factor VII (FVIIra). One patient received PCC plus PFC, and another received PCC with FVIIra. FFP alone was used in 13.5% of the patients. All of the patients received intravenously administered vitamin K1. Treatment was started in the Emergency Room in 33.5% of the cases; in the other 66.5% it began on our ward. In 66.5% of the patients, the treatment was effective in reversing OATwithin 8 hours. In 2 cases, the hematoma was surgically evacuated, and the patients survived. Total mortality for OAT-related ICH was 46.5% (32.9% in non-OAT-related ICH). In 71.5% of the patients with OAT-related haemorrhages, death occurred within 48 hours of arrival. Sixty percent of the patients with ICH > 60 cm3 (20% in patients with ICH < 60 cm3) and 100% of those with GCS < 7/15 died. For survivors, the median modified Rankin Scale at discharge was 3. All survivors were still alive at 3 months after discharge. Conclusions: Our study shows that in ICH associated with OAT, mortality is related to the size of the hematoma and to the GCS. Our study confirms that treatment of OAT-related ICH varies and is sometimes delayed. Management protocols for ICH-OATshould be implemented in clinical settings.
Cutaneous reactions to heparin therapy: when are they caused by heparin allergy?
Authors: Zisa Giuliana , Riccobono Francesca , Galimberti Maurizio
Published: April 2013

Introduction: Little is known about the incidence and causes of heparin-induced skin lesions. The most commonly reported causes are delayed-type hypersensitivity reactions. We describe 3 patients who were referred to our staff between March and October 2009 for suspected heparin allergies. All were scheduled to undergo major surgery (cardiovascular or orthopedic). Materials and methods: All 3 patients reported the development of itchy, erythematous rashes a few days after the subcutaneous administration of heparin (nadroparin calcium in cases 1 and 2, unspecified in case 3). Each of them underwent a diagnostic work-up for heparin allergy, which included prick and intradermal tests with commonly used heparins and patch testing with undiluted heparins and disinfectants. Results: Patch tests with disinfectants were negative in all 3 cases. In case 2, all allergological tests were negative. In cases 1 and 3, delayed positivity emerged for nadroparin calcium and at least one other heparin tested. Intravenous and/or subcutaneous provocation testing was done with an alternative heparin which produced negative results in skin tests (heparin sodium in case 1, pentasaccharide fondaparinux in case 3). In both cases the alternative drug was tolerated. After our evaluation, all 3 patients underwent surgery with no heparin-related complications. Discussion: The presenting clinical features in these 3 cases provided no information on which reactions were likely to be allergic: all 3 patients presented with similar local delayed reaction. The allergic reactions were identified only after cutaneous testing.
De Quervain’s thyroiditis: current concepts and a report of four cases
Authors: Boni Roberto , Rabitti Pier G.
Published: April 2013

Introduction: De Quervain’s subacute thyroiditis is a self-limiting granulomatous inflammatory disorder, which is thought to be virally induced in genetically predisposed individuals. It is characterized by thyroid pain and thyrotoxicosis, as well as by systemic symptoms like fever, hepatic cytolysis, and an elevated erythrocyte sedimentation rate. It is often mistaken for an upper respiratory tract infection. Materials and methods: The authors review recent advances in the understanding of the pathogenesis and pathophysiology of De Quervain’s subacute thyroiditis; risk factors for complications, with emphasis on relapses and end-stage hypothyroidism; differential diagnosis and the exclusion of other subtypes of thyroiditis; and current treatment options. Four cases of De Quervain’s thyroiditis are then analyzed and compared with cases in the literature. Discussion: In three of the patients, onset occurred in June and was probably related to a small, seasonal epidemic cluster. These cases were quite different from the fourth one, which occurred in October, suggesting that two distinct viruses might be involved. One of the patients presented a very rare complication, vocal-cord paralysis, which responded well to glucocorticoid therapy. Another presented with an even rarer post-partum form of painful thyroiditis.
Hospital organization based on intensity of care: potential errors to avoid
Authors: NardI Roberto , Arienti Vincenzo , Nozzoli Carlo , Mazzone Antonino
Published: April 2013

IntroductionThe extreme variability of clinical severity in medical admitted patients is diluted in a “average” standard of care, that may be stronger than the real needs for someone, but clearly inadequate, sometimes even dangerous, for other ones, critically ill.DiscussionThe model of a differentiated intensity of hospital care can be defined as the organizational model structured to areas/sectors dedicated to patients with homogeneous needs of care. The intermediate care unit (“High dependency units”, “sub-intensive care areas” – “high care units”) are particularly suitable for patients who have a lower risk compared to patients treated in intensive care, but liable to develop complications and needing a close monitoring much more than the “standard”, “routine” care. The implementation of the a new organizational model must be careful and consider the possible enlargement errors that can be made. The analysis of the context is necessary for assess prerequisites, excluding the elements opposed to the success of the proposed model (i.e.: wards congestion and overcrowding, with a consequential with increased risk of adverse events). Before implementing and admitting patients in new “models”, we have to define the epidemiological population characteristics, their level of complexity/criticality/instability and the current assessment tools.ConclusionsAny new proposal of hospital management change has, as first obligation, to explicit the basic visions and primary goals for “the added value” resulting to the patient and the whole organization, with the evidence of an “health technology assessment” approach, for the professional hospital overall governance. But without the presumption, or worse, the apodictic assertion, to proclaim the implementation of structures with “differentiated intensity of hospital care” organizations that are not.
End-of-life care for cancer patients in an Internal Medicine department
Authors: Lusiani Luigi , Bordin Gabriella , Mantineo Giovanni , Roncato Pietro , Favaro Lionella , Tessaro Leopoldo , Sandonà Lorena , Bordin Francesca
Published: April 2013

Introduction Many cancer patients die in the hospital, in spite of their preference to end their lives at home. Internal Medicine wards are poorly equipped to care for dying patients. Staff members have no specific training in palliative care, and the organization of the ward lacks flexibility. The entire staff (physicians and nurses) of the Internal Medicine ward of our hospital took part in a specially designed training program, and a protocol for end-of-life care (EOL-care) was implemented to improve the comfort of patients with terminal cancer. The aim of this study was to analyze the impact of this protocol on clinical practice in the ward, in terms of the number of interventions and the degree of control of key symptoms. Materials and methods The EOL-care protocol, which was established in cooperation with the Sue Ryder Foundation, was a modified version of the Liverpool Care Pathway. The main objective was to ensure the comfort of the dying patient through judicious discontinuation of all non-essential medications and interventions, frequent and systematic assessment of the key symptoms, and greater emphasis on communication with the patient and his/her caregivers. We compared 82 unselected cases managed with conventional care, representing the 20% of the deaths that occurred in 2007-2008 in our ward (controls), and 27 consecutive cancer patients cared for with the EOL-care protocol between May 2009 and February 2010 (cases). Results Patients in the case group received fewer interventions than controls (catheterization rate: 0% vs 19.4%; invasive procedure rate: 0% vs 8.5%; parenteral nutrition: 0% vs 3.6%), but they obtained almost complete relief of symptoms (pain, dyspnea, respiratory tract obstruction by secretions, agitation, nausea/vomiting). The most prominent result was pain relief: systematic checks revealed persistent pain in only 2.9% of the EOL-care group versus 59.7% of the controls during the last 48 hours of life. Discussion This observational study provides evidence that the quality of EOL-care for cancer patients can be improved, even in non-specialized departments, through organizational rather than technological interventions.
Lower limb ischemia in a thrombophilic woman during ovarian stimulation for assisted reproduction techniques
Authors: Strina Ida , De Placido Giuseppe , D’Uva Maristella , Romano Ilaria Jane , Di Micco Pierpaolo
Published: April 2013

Introduction Women receiving hormone therapy as part of assisted reproduction protocols are at increased risk for thrombosis. Controlled ovarian stimulation may be a risk factor for thrombotic events, and thrombophilic subjects are more prone to develop thrombosis during hormone therapies. Materials and methods We report a case of arterial thrombosis of the iliacofemuropopliteal axis, which occurred in a young woman with Factor V Leiden-related thrombophilia, who was receiving recombinant follicle-stimulating hormone and leuprorelin in preparation for in vitro fertilization and embryo transfer, and pharmacological thromboprophylaxis with enoxaparin. Results The thrombosis resulted in critical limb ischemia whose clinical evolution is described. Discussion Further research is needed to identify the best strategy for reducing the thrombotic risk associated with assisted reproduction protocols and to determine whether these women should receive pharmacological thromboprophylaxis.
Ortner's syndrome: a rare case of cardiovocal hoarseness
Authors: Belmonte Gelorma , Leandri Paolo , Reta Massimo , Orlandi Paolo Emilio , Ciorba Andrea , Aimoni Claudia , Scanelli Giovanni , Nardi Roberto
Published: April 2013

Introduction Ortner's syndrome, also known as cardiovocal syndrome, is a rare clinical entity with hoarseness due to left recurrent laryngeal nerve (RLN) palsy owing to a cardiovascular disease. Norbert Ortner ascribed hoarseness of voice RLN palsy in patients with several mitral stenosis, postulating that an enlarged left atrium could be responsible for the recurrent laryngeal nerve palsy. Case report A 63-year-old man with a history of progressive hoarseness of voice developed since over three months. Flexible laryngoscopy revealed a fixed left vocal cord in the paramedian position. The chest enhanced axial computed tomography confirmed a large left ventricular aneurysm. Conclusions Hoarseness has significant public health implications. Patients suffer from social deprivation, depression and a poor quality of life. Several underlying conditions are associated with the cardiovocal syndrome, including iatrogenic, congenital, mitral valve disorders, aortic and ventricular aneurysms. Laryngoscopy is indicated for the assessment of hoarseness if symptoms fail to improve or resolve within three months, or at any time when the clinician suspects a serious underlying disorder.
Clinimetric criteria of rheumatoid arthritis
Authors: Galasso Domenico , L’Andolina Massimo , Marigliano Norma M. , Galasso Salvatore , Forte Giovanni
Published: April 2013

Rheumatoid arthritis is a systemic autoimmune disease, mainly poli-artycular, among wide-spread chronic inflammatory diseases, that cause pain, functional limitation, damage and joints deformations, and disability. It is characterized by turns of active inflammation and remission phases. Inflammation degree and persistence are associated to a bad functional prognosis and progressive joint disability. These patients management require a continuous valuation of inflammatory activity index of disease both therapeutic management and to prevent disablement process. We focus on many valuation index of joint disability and functional damage. Very important are both the scales of auto-values concerning the pain and the joint swelling and clinical data get by physician to valuate activity index of disease as defined by DAS28. Significant data come by health-related quality of life, disability and by AIMS2 (Arthritis Impact Measurement Scale).
Sarcoidosis: old certainties and new perspectives
Authors: Tana Claudio , Tana Marco , Mezzetti Andrea , Schiavone Cosima
Published: April 2013

Introduction Sarcoidosis is the paradigm of the internistic disease. It virtually affects every organ and tissue and is characterized by the presence of noncaseating granulomas. A holistic view is needed for the diagnosis and treatment of the disease. The authors provide an overview on several recently published studies, which pose new perspectives on the approach to the disease.Materials and methods The authors reviewed the scientific literature focusing on new etiopathogenetic, diagnostic and therapeutic data.Results and discussion A multimodal approach is appropriate and effective in the diagnosis and treatment of systemic diseases such as sarcoidosis. In this context, the internist plays a key role more than any other specialist.
Proton pump inhibitor use in a university teaching hospital
Authors: Meli Maria , Malta Renato , Aprea Luigi , Pasquale Andrea , La Seta Concetta , Di Rosa Salvatore , D’Alessandro Natale
Published: April 2013

Introduction Proton pump inhibitors (PPIs) are highly prescribed drugs in Italy and in particular in the Sicilian region but little is known about their use in the hospital setting.Materials and methods PPI utilization and related costs were reviewed retrospectively by examining the pharmaceutical records of drug dispensation to the various wards of the Policlinico Universitario P. Giaccone of Palermo in 2010. Differences in the prescribing rates and drug preferences among the different clinical wards were analyzed.Results A total of 20,420 patients were hospitalized at the Policlinico of Palermo in 2010. Overall, the consumption of PPIs was 120 DDD/100 bed-days for the year 2010 with a total cost of 42,780 euros. Omeprazole and esomeprazole were the most commonly prescribed molecules accounting for over 70% of all prescriptions: nevertheless, wide differences in drug choices were noted even within the same ward. As expected, greater utilization rates were registered in the Internal Medicine and General Surgery departments. In particular, the highest consumption was observed in the Oncology, Geriatry and Obesity Surgery wards, with about 250 DDD/100 bed-days. All wards reported intravenous PPI administration suggesting some inappropriate use.Discussion From our data, PPIs appear to be moderately over-used at the Policlinico of Palermo. This practice may lead to the inappropriate continuation of therapy in primary care, further increasing costs and risks of adverse events. A survey evaluating in more detail the appropriateness of prescriptions is advisable.
Crowned dens syndrome
Authors: Belfiore Norma , Privitera Vito , Carmosino Giampaolo , Doveri Giulio
Published: April 2013

Introduction Microcrystalline deposition in peri-odontoid articular structures is mainly responsible for acute or chronic cervical pain and is known as “crowned dens syndrome”.Materials and methods We described two cases of acute cervical pain associated with onset of fever and peripheral acute monoarthritis. Cervical computed tomography (CT) scan showed linear calcification of the retrodens ligament and calcium pyrophosphate dehydrate (CPPD) crystals were found in synovial fluid of inflamed joints. Both patients were treated with anti-inflammatory drugs and colchicine.Discussion Calcium depositions around the odontoid process of the axis can be occasionally detected by radiological studies. They are frequently asymptomatic but sometimes can be associated with severe neurological abnormalities, fever and acute neck pain. CPPD crystals are usually deposited in joints and bursae but occasionally can disrupt these anatomical confines and deposit in periarticular tissues, sometimes forming large masses confused with tumours.Conclusions Acute onset of cervical neck pain associated with elevation of inflammatory indicators and/or signs of cervical myelopathy should suggest CT scans searching for microcrystal depositions in the peryodonthoid tissue. Differential diagnosis of fever of unknown origin (FUO) should include crowned dens syndrome specially in the elderly after exclusion of several endocrine or metabolic disorders, infection diseases (meningitis), arthritis (psoriatic arthritis and ankylosing spondylitis) and tumours (chordoma, meningioma, osteoblastoma).
A strange weakness: a case-report of dilated cardiomyopathy in a young patient with spontaneous coronary dissection
Authors: Bartolomucci Francesco , Cipriani Francesco , Valente Giovanni , Curci Serafino , Deluca Giovanni
Published: April 2013

Introduction Atherosclerosis is the most common cause of coronary affections, but coronary dissection is certainly more insidious. This is the separation of the media apart from the other layers of the vessel wall, with or without intimal tear. Spontaneous coronary dissection is a rare event, especially in young men: only 150 cases were reported till 1986 and over 300 till date. The main consequence is an acute coronary occlusion with myocardial infarction and sudden death.Case report We report the case of a 28-year-old man, presented with a mild symptomatic spontaneous coronary dissection, consisting of a strange weakness, remained undetected until fortuitous medical analyses suggested the opportunity of further investigations. A clinical examination and an EKG showed the opportunity to perform a bidimensional echocardiogram at first, a low-dose dobutamine stress echocardiogram, then a regional myocardial perfusion and a non-invasive coronary flow reserve assessment. The patient has been properly and quickly screened and is now enlisted for cardiac transplantation.Conclusions In such cases the immediate identification and treatment of the affection can be crucial. In our experience the basic and advanced echocardiography allowed a sooner diagnosis than the usual proceeding based on coronarographic examination.
Acute infectious mononucleosis presenting with palpebral and periorbital edema
Authors: Puntorieri Elvira , Postorino Adele , Di Bartolo Concetta Elisabetta , Leonardi Valentina , Zagari Domenico , Mileto Giuseppe
Published: April 2013

Introduction Almost all organs can be involved in the infection by Epstein–Barr virus and consequently, the beginning symptoms of infectious mononucleosis may be different.Materials and methods We report a case of infection by Epstein–Barr virus in a 17-year-old girl whose primary manifestation was an initially monolateral and subsequently bilateral dacryoadenitis.Results The incidence of acute dacryoadenitis by Epstein–Barr virus is valued around one case per million people per year, but it is probably underestimated: it is due to infiltration of the lacrimal gland by activated lymphocytes.Discussion An acute dacryoadenitis, especially when it affects a young adult and when bilateral, should guide the diagnostic and haematochemical and serological investigations towards a systemic disease such as infectious mononucleosis. It is almost always responsive to a systemic corticosteroid therapy, but in some cases it can progress towards a dacryocystitis and exceptionally towards the Sjögren syndrome. Appropriate and timely treatment will be able to reduce any subsequent complications.
Chronic pancreatitis: from guidelines to clinical practice
Authors: Uomo Generoso , Ventrucci Maurizio
Published: April 2013

Introduction The paucity of specific standardized criteria leads to uncertainties in clinical practice regarding the management of chronic pancreatitis (CP).Objectives This paper reports some of the systematic guidelines for the diagnosis and treatment of CP recently elaborated by an Italian multicenter study group. We review recommendations on clinical and nutritional aspects of the disease, assessment of pancreatic function, treatment of exocrine pancreatic failure and secondary diabetes, treatment of pain, and prevention of painful relapses. The review also looks at the role of endoscopy in the management of pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications; the appropriate use of various imaging techniques, including endoscopic ultrasound; and the indications for and techniques used in surgical management of CP.
Area of admission and short-term care: an integral part of the internal medicine ward organized to intensive care
Authors: Serafini Francesco , Bonanni Luca , Zancanaro Andrea , Fricano Giuseppina , Giannoccaro Marco , Zulian Elisa , Dalla Vestra Michele , Atanasio Paola , Conton Pierantonio , De Riva Carlo , Fantin Giuseppe , Presotto Fabio
Published: April 2013

Introduction The analysis of the production related to health care activities in the Medicine ward of dell’Angelo Hospital (Mestre-Venezia, Italy) in the year 2010 reveals that the short-term hospitalization, less than 3 days, corresponds to 18% of all inpatient admissions.Objectives The short-term hospitalization approach need to be “governed”, both in terms of effectiveness and efficiency. In our department we have identified an area called “Admission and Short Stay Area”, where the discharge follows a comprehensive diagnostic and therapeutic pathway. Accordingly, we plan to extend the number of beds dedicated to the short stay in hospital, in order to decrease the average duration of stay avoiding the risk of increasing the readmissions, to share new pathways between health care workers.Materials and methods Within the department we have identified 8 beds for patients admitted from the emergency room. In the same beds triage is performed. In these beds the maximum duration of stay is 3 days. To achieve this goal we used clinical pathways shared between health workers, and bedside diagnostic procedures such as ultrasounds.Results In 2011 than to year 2010 there was an increased rate of short-term hospitalization (22–18%). Despite that the mean hospital stay was unchanged (10.3–10.6 days). The number of readmission within 90 days was also unchanged when we considered the most common diseases. More than 90% of health care workers followed the pre-established clinical care pathways.Conclusions The presence of a small number of beds within the medicine ward was dedicated to perform triage that allows to identify clinical care the needs of the patient. Among these some can be resolved in 3 days, rewarding patients and saving human and financial resources. To achieve this goal it is necessary that health care providers share clinical pathways, and that the bedside ultrasound is accessible.