In-hospital symptomatic venous thromboembolism and antithrombotic prophylaxis in Internal Medicine

Hospitalised medical patients are at increased risk of venous thromboembolism (VTE), but the incidence of hospitalisation-related VTE in unselected medical inpatients has not been extensively studied, and uncertainties remain about the optimal use of thromboprophylaxis in this setting. Aims of our prospective, observational study were to assess the prevalence of VTE and the incidence of symptomatic, hospitalisation-related events in a cohort of consecutive patients admitted to 27 Internal Medicine Departments, and to evaluate clinical factors associated with the use of thromboprophylaxis. Between March and September 2006, a total of 4,846 patients were included in the study. Symptomatic VTE with onset of symptoms later than 48 hours after admission (”hospital-acquired” events, primary study end-point) occurred in 26 patients (0.55٪), while the overall prevalence of VTE (including diagnosis prior to or at admission) was 3.65٪. During hospital stay antithrombotic prophylaxis was administered in 41.6٪ of patients, and in 58.7% of those for whom prophylaxis was recommended according to the 2004 Guidelines of the American College of Chest Physicians. The choice of administering thromboprophylaxis or not appeared qualitatively adherent to indications from randomised clinical trials and international guidelines, and bed rest was the strongest determinant of the use of prophylaxis. Data from our real-world study confirm that VTE is a relevant complication in patients admitted to Internal Medicine Departments, and recommended tromboprophylaxis is still under-used, in particular in some patients groups. Further efforts are needed to better define risk profile and to optimise prophylaxis in the heterogeneous setting of medical inpatients.

[Use of rivaroxaban in real-life treatment of venous thromboembolism: results of the TEV Survey, an Italian epidemiological study]

BACKGROUND

Rivaroxaban is a direct and selective inhibitor of factor Xa. The randomized clinical trials EINSTEIN evaluated the efficacy and safety of rivaroxaban for the treatment of venous thromboembolism (VTE) proving that the drug was non-inferior to standard treatment. The aim of this survey was to describe how rivaroxaban was used in a group of "real-life" patients with VTE.

METHODS

Between June and October 2014, physicians collected aggregate data, through an online questionnaire, on consecutive patients affected by VTE and treated with rivaroxaban in the previous 6 months. Descriptive statistics were performed on the collected data.

RESULTS

A total of 345 questionnaires were filled out. The mean age of patients was 62 years, with a low prevalence of concomitant diseases and/or pharmacological treatments. Deep vein thrombosis was diagnosed in 90% of patients and pulmonary embolism in 47%; only 48% was hospitalized. Rivaroxaban was prescribed at the recommended doses and/or regimen in no more than 60% of cases. In 96% of patients, the initial therapeutic plan did not require changes. Adherence to the therapeutic plan and overall patient satisfaction with therapy were high.

CONCLUSIONS

Rivaroxaban was found easy to use and was highly appreciated by patients.

Prulifloxacin vs Levofloxacin for Exacerbation of COPD after Failure of Other Antibiotics

The chronic course and evolution of chronic obstructive pulmonary disease (COPD) is often characterized by periods of exacerbation of symptoms, which have a negative impact on the quality of life of patients, as well as on the evolution of COPD, and represent a significant cause of medical intervention and hospitalization. Very few data are available on the efficacy of rescue antibiotics in patients with acute exacerbation of COPD (AECOPD) unresponsive to previous treatment. The aim of this study was to evaluate the efficacy of two fluoroquinolones in AECOPD previously treated without success. The FADOI-FLOR study is a randomized, single-blind, non-inferiority comparison between levofloxacin and prulifloxacin. Primary end-point was "therapeutic success" at Day 10 of treatment, defined as disappearance of signs/symptoms or decrease of at least three points of a global score of symptomatology (maximum score = 15). 258 patients were enrolled (128 levofloxacin and 130 prulifloxacin), in 25 centers. A very high proportion of patients in the two groups had therapeutic success at Day-10 (levofloxacin 93.0% vs prulifloxacin 96.7%, population intention-to-treat; 94.6% vs 99.1%, population per-protocol). Earlier therapeutic success (within 7 days) was achieved in 32.0% and 36.2% of patients receiving levofloxacin or prulifloxacin, respectively. At 3-month follow-up, re-exacerbations occurred in 17.8% of patients treated with levofloxacin and 14.2% of those receiving prulifloxacin (p = 0.44). In conclusion, fluoroquinolones are very effective in the treatment of AECOPD resistant to other antibiotics.

The diagnostic pathway embolism: from the Emergency Department to the Internal Medicine Unit

The diagnostic pathway of pulmonary embolism, both in the Emergency Department and in the Medical Unit, is not a standardized one. Pulmonary embolism, often but not always complicating surgery, malignancies, different medical diseases, sometimes but not often associated with a deep vein thrombosis, is not infrequently a sudden onset life-threatening and rapidly fatal clinical condition. Most of the deaths due to pulmonary embolism occur at presentation or during the first days after admission; it is therefore of vital importance that pulmonary embolism should promptly be diagnosed and treated in order to avoid unexpected deaths; a correct risk stratification should also be made for choosing the most appropriate therapeutic options. We review the tools we dispose of for a correct clinical assessment, the existing risk scores, the advantages and limits of available diagnostic instruments. As for clinical presentation we remind the great variability of pulmonary embolism signs and symptoms and underline the importance of obtaining clinical probability scores before making requests for further diagnostic tests, in particular for pulmonary computer tomography; the Wells score is the only in-hospital validated one, but unfortunately is still largely underused. We describe our experience in two different periods of time and clinical settings in the initial evaluation of a suspected pulmonary embolism; in the first one we availed ourselves of a computerized support based on Wells score, in the second one we did not. Analysing the results we obtained in terms of diagnostic yield in these two periods, we observed that the computerized support system significantly improved our pulmonary embolism diagnostic accuracy.

Subthreshold Ξ^{-} production in collisions of p(3.5 GeV)+Nb

Results on the production of the double strange cascade hyperon Ξ^{-} are reported for collisions of p(3.5  GeV)+Nb, studied with the High Acceptance Di-Electron Spectrometer (HADES) at SIS18 at GSI Helmholtzzentrum for Heavy-Ion Research, Darmstadt. For the first time, subthreshold Ξ^{-} production is observed in proton-nucleus interactions. Assuming a Ξ^{-} phase-space distribution similar to that of Λ hyperons, the production probability amounts to P_{Ξ^{-}}=[2.0±0.4(stat)±0.3(norm)±0.6(syst)]×10^{-4} resulting in a Ξ^{-}/(Λ+Σ^{0}) ratio of P_{Ξ^{-}}/P_{Λ+Σ^{0}}=[1.2±0.3(stat)±0.4(syst)]×10^{-2}. Available model predictions are significantly lower than the measured Ξ^{-} yield.

High prevalence of fragility vertebral fractures in patients hospitalised in Internal Medicine Units. Results of the POINT (Prevalence of Osteoporosis in INTernal medicine) study

BACKGROUND

Osteoporotic vertebral fractures (VFs) often go unrecognised in both healthy individuals and in pathological conditions. Few data exist on VFs in patients hospitalised in Internal Medicine Units (IMUs), who often suffer from multiple concomitant chronic disorders.

AIM OF THE STUDY

This multicentre cross-sectional study was aimed at assessing the prevalence of VFs in an unselected population of patients referring to IMUs. Correlations between VFs and the main coexisting diseases were also investigated.

METHODS

Information on demographic, clinical and laboratory findings, and on the presence of known risk factors for osteoporosis was recorded. The Genant's semi-quantitative method was used to evaluate, in a central reading centre, the presence and severity of VFs in the thoracic and lumbar spine.

RESULTS

A cohort of 995 patients was evaluated. At least one VF of any grade was found in 47.5% of patients, with similar prevalence between females (48.1%) and males (46.7%). Older age, chronic obstructive pulmonary disease, and previous diagnosis of osteoporosis showed a significant association with VFs in multivariable analysis. However, 79.7% of the VFs were observed in patients without previous diagnosis of osteoporosis. Moreover, a VF of grade 2 or greater was found in 20.8% of patients.

CONCLUSIONS

Fragility VFs is a very frequent finding in patients hospitalised in IMUs. Consequently, more attention should be devoted in this clinical setting to this comorbidity, which is known to be an additional factor for mortality and, when localised in the thoracic part of the spine, may negatively influence a concomitant respiratory insufficiency.

Identification and management of invasive mycoses in internal medicine: a road-map for physicians

Invasive mycoses are a rising problem, not only in traditional categories of patients like hematologic or neutropenic ones, but also in elderly non-neutropenic patients admitted to internal medicine wards. Patients being admitted to medical wards are usually older, have multiple comorbidities, e.g., liver cirrhosis or chronic obstructive respiratory disease, may be malnourished or receive peripheral or total parenteral nutrition, and frequently are undergoing chronic corticosteroid therapy, chemotherapy for cancer or monoclonal antibodies for autoimmune diseases. Such risk factors may be contemporarily present in a single patient increasing the risk for the development of invasive mycoses. Diagnosis of candidemia and invasive aspergillosis is particularly difficult in patients hospitalized on medical wards, since symptoms and signs have low specificity, and most diagnostic tests have been only validated in neutropenic hematologic patients, but not in those without neutropenia. Both candidemia and invasive aspergillosis carry significant morbidity and mortality. The aim of this paper is to provide a simple guide to physicians for a prompt identification and treatment of patients with possible or suspected invasive mycoses.

[A Censis survey on atrial fibrillation awareness in the general population and among general practitioners and affected patients in Italy]

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, particularly in the elderly. AF is considered an independent predictor of mortality and risk factor for stroke. AF-related stroke is usually severe and associated with a high rate of mortality and disability. Despite its prevalence, AF is a poorly known disease and it is underestimated by the general population. The aim of the Censis survey was to analyze the levels of AF knowledge and information in the Italian population and the level of AF risk awareness by general practitioners and AF patients.

METHODS

The survey included structured interviews with a sample of 1000 Italian citizens aged ≥18 years, 300 general practitioners, and 1200 AF patients.

RESULTS

The analysis confirmed low levels of knowledge of AF. In particular, the results showed that only one third of Italians know AF that is however perceived as a severe disease. In this subgroup, the risk of stroke associated with AF is known by 65%, but it is also widespread the wrong concept that AF is associated with an increased risk of myocardial infarction. The lack of knowledge of AF and its complications by the Italian population is due to educational gaps of general practitioners. In particular, only 50% of the Italian general practitioners perceive the thromboembolic risk of paroxysmal AF as comparable to that of permanent AF. In addition, there is an underuse of the scores for thromboembolic and hemorrhagic risk stratification recommended by current guidelines and a frequent use of antiplatelet therapy rather than oral anticoagulant therapy. There is also a low level of knowledge and awareness of the disease among AF patients. However, the majority of AF patients are aware of the importance of antithrombotic prophylaxis for stroke prevention.

CONCLUSIONS

This study demonstrates limited knowledge and awareness of AF in the general population and also among general practitioners and affected patients.

Complexity in hospital internal medicine departments: what are we talking about?

Internal medicine (IM) patients are mostly elderly, with multiple complex co-morbidities, usually chronic. The complexity of these patients involves the intricate entanglement of two or more systems (e.g. body and disease, family-socio-economic and environmental status, coordination of care and therapies) and this requires comprehensive, multi-dimensional assessment (MDA). Despite attempts to improve management of chronic conditions, and the availability of several MDA tools, defining the complex patient is still problematic. The complex profile of our patients can only be described through the best assessment tools designed to identify their characteristics. In order to do this, the Federation of Associations of Hospital Doctors on Internal Medicine FADOI has created its own vision of IM. This involves understanding the different needs of the patient, and analyzing diseases clusters and the possible relationships between them. By exploring the real complexity of our patients and selecting their real needs, we can exercise holistic, anthropological and appropriate choices for their treatment and care. A simpler assessment approach must be adopted for our complex patients, and alternative tools should be used to improve clinical evaluation and prognostic stratification in a hierarchical selection of priorities. Further investigation of complex patients admitted to IM wards is needed.

Guidelines and management of hospitalized patients with community-acquired pneumonia: the Italian experience of the FASTCAP study

BACKGROUND Nowadays few data are available addressing the validation of guidelines concerning diagnosis and treatment of Community-Acquired Pneumonia (CAP) in clinical practice. AIM OF THE STUDY To evaluate the impact of compliance to the recommendations issued by the Italian Federation of Internal Medicine (FADOI) in 2002 on the management of hospitalised CAP. METHODS National, multicentre, interventional, “before-after” survey, performed in 31 hospitals in Italy. All patients with CAP of Fine class IV or V (excluding those who were directly admitted to intensive care units) were included. The study was composed of three consecutive periods: 1) a retrospective phase (RP); 2) guideline implementation; 3) a prospective phase (PP). Results were expressed as Odds Ratios (OR) with 95% confidence intervals (95% CI) adjusted for risk factors and corrected for multiple comparisons in subgroups. RESULTS A significant increase in use of combinations was observed in the PP (p = 0.006). Moreover, a shift of prescription from β-lactams to fluoroquinolones as initial monotherapy was recorded. Therapies adherent to FADOI recommendations increased by 10.9% in the PP (p < 0.001). Therapeutic success improved after implementation of recommendations (73.9 vs 71.5%; OR = 0.83; 95% CI = 0.69-1.00; p = 0.049). The difference was particularly evident in Fine class V (58.0 vs 52.5%; OR = 0.71; 95% CI = 0.51-0.98; p = 0.036), where a trend towards a lower mortality occurred (23.1 vs 26.3%; OR = 0.71; 95% CI = 0.48-1.05; p = 0.090). Therapies compliant with FADOI recommendations showed a higher success rate in both study phases (76.6% vs 70.3%; OR = 0.74; 95% CI = 0.60-0.90; p = 0.004). Levofloxacin was the most clinically effective first-cycle therapy with 79.1% of success, the least effective being an antipneumococcal cephalosporin alone with 68.6% (OR = 0.72; 95% CI = 0.51-1.01; p = 0.053). Etiologic diagnosis was obtained in less than 12% of patients in both study phases. Mean lengths of hospital stay were 12.2 and 11.9 days in the RP and PP, respectively. CONCLUSIONS Implementation of FADOI therapeutic recommendations led to a significantly better outcome in terms of clinical success, especially in more severe cases of CAP. Possibly, more “aggressive” approaches towards implementation may result in further improvement in the overall management of CAP.

FASTCAP study on the management of hospitalized patients with community-acquired pneumonia: pharmacoeconomic analysis of the prospective phase

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.

A young woman with headache and seizures

CASE REPORT We describe a 31 year-old woman with headache and acute onset of seizures. Medical history and physical examination were unremarkable. She has been on therapy with oral contraceptives for many years for dysmenorrhea. A CT scan was negative, but MRI and MR-angiography showed left transverse sinus thrombosis. Screening for thrombophilia revealed hyperhomocysteinemia and Factor V Leiden heterozigousity. The patient received unfractionated heparin, followed by long-term anticoagulation with warfarin (INR 2-3). CONCLUSIONS Cerebral venous thrombosis is a rare cerebrovascular disorder, frequently in young adult (about 75% are women). The diagnosis might be difficult with consequent high long-term morbidity and mortality rate. New neuroimaging techniques (MRI and MR-angiography) and more effective treatment (anticoagulation and endovascular thrombolysis) have improved the prognosis and the natural history. The risk factors, the clinical presentation, the diagnostic evaluation and the management of cerebral venous thrombosis are reviewed.

Risk factors for venous thromboembolism and prophylaxis in medical inpatients: data from the FADOI ‘‘GEMINI’’ study

Background: Though venous thromboembolism (VTE) frequently occurs in non-surgical setting, epidemiology and risk factors for VTE in unselected medical inpatients have not been extensively studied, and uncertainties remain about the prophylactic strategy in these patients. Materials and methods: In a prospective, observational, multicenter study we aimed to contemporarily assess the epidemiology of symptomatic VTE in consecutive patients hospitalized in Internal Medicine, to evaluate the impact of potential risk factors, and the attitude of internists towards thromboprophylaxis. A total of 4,846 patients were included, during the period March-September 2006. Results: Symptomatic VTE was registered in 177 (3.65%) patients; of these, 26 cases (0.55%) occurred with onset of symptoms > 48 hours after admission (‘‘hospital-acquired’’ events, primary study end-point). Previous VTE and bed resting were significantly associated with venous thromboembolism, while a trend for increased risk was documented in cancer patients. During hospital stay antithrombotic prophylaxis was globally administered in 41.6% of patients, and in 58.4% of those for which prophylaxis was recommended according to 2004 guidelines by the American College of Chest Physicians. The choice of administering tromboprophylaxis appeared qualitatively adherent to indications from randomized trials and international guidelines, and bed rest was the strongest determinant of the use of prophylaxis. Conclusions: Data from our real-world study confirm that VTE is a quite common finding in patients admitted to Internal Medicine departments, and recommended tromboprophylaxis is still underused, in particular in some patients groups. Further efforts are needed to better define the risk profile and to optimize prophylaxis in the heterogeneous setting of medical patients.

Internal Medicine wards overcrowding and clinical risk management: structural or systemic interventions needed?

Not available

Spinal cord infarction: a rare cause of admission to Internal Medicine Departments but a condition with relevant systemic complications

BACKGROUND Spinal cord infarction is a rare cause of admission to Internal Medicine Departments as it is of infrequent occurrence and it is usually addressed to Neurologic Units. Diagnosis at admission however may be challenging expecially in the elderly because of several co-morbidities and variable presentation. Clinical course is often complicated by autonomic, infective and cardiovascular problems as well as a long stay-in-bed period. Outcome is poor in case of severe motor, autonomic (bladder and bowel) and sensitive impairment at presentation, it’s related to anatomic damage site and extension and it’s worse in case of anterior bilateral infarcts. CLINICAL CASE The authors describe the case of an 81- year-old woman who was admitted to an Internal Medicine Department because of cervical spinal cord infarction. The diagnostic evaluation as well as the management of cardiovascular, infective, rheumatologic and autonomic complications needed skillful internistic competence and a long in-hospital period. MR allowed a correct diagnosis a few hours after presentation, but the pathogenesis was never clearly established. The most invalidating symptoms were loss of bowel control lasting for several weeks during hospitalization and neuropathic pain still present at discharge. As for the outcome, the patient was able to go home after 3 months from admission able to walk with aids, with full bowel and bladder control and no sensitive impairment.

Pneumonia in nursing home patients: is it time for a specific therapeutic strategy?

Background: Nursing home-acquired pneumonia (NHAP) was described in 1978, but only in 2005 it has been proposed as part of a new category (health care-associated pneumonia) distinct from community- or hospital-acquired infections. However, limited clinical data exist to validate this proposal. Aim of the study: To compare characteristics and outcome of patients hospitalised for pneumonia and coming from private residence or nursing home. Methods: Post-hoc analysis of the prospective phase of the FASTCAP study, performed to evaluate the impact of the Recommendations issued by the Italian Federation of Internal Medicine (FADOI) in 2002 on the management of hospitalised community-acquired pneumonia (CAP). Results: The study examined 1,219 patients coming from private residence, and 179 with NHAP. Failures of therapy were significantly more frequent in patients with NHAP (35.8% vs 24.9%; Odds Ratio 1.48; 95% confidence interval 1.05-2.09). Mortality was higher in patients coming from nursing home (24.0% vs 9.8%; OR 2.59; 95% CI 1.72-3.90). Antibiotic treatment was more frequently performed as monotherapy in case of NHAP. Conclusions: At the time of FASTCAP, NHAP was included in the category of CAP, and coherently, treatment of NHAP was not more aggressive if compared to community-acquired infections. However, our results confirm that NHAP is at increased risk for worst outcome, and probably worth considering for specific therapeutic strategies. Future studies are needed to better assess the microbiology of NHAP, and to evaluate if specific treatments, as those recommended by recent guidelines, may improve the outcome for these high-risk patients.

Internal medicine, complexity, evidence based medicine, almost ‘‘without evidences’’

Background: Internal medicine has been defined as the specialty of the adult medical complex patients. Complexity science suggests that illness (and health) results from complex, dynamic, and unique interactions between different components of the overall system. In a patient, complexity involves the intricate entanglement of two or more systems (e.g.; body-diseases, family, socioeconomic status, therapies). Aim of the study: To evaluate the real applicability of Evidence Based Medicne (EBM) in clinical Departments of Internal Medicine and its critical perspectives. Discussion: Habitually the internist takes decisions in these situations: a) certainty (the ideal decision is adopted and the corresponding strategy follows), b) risk (the more suitable alternative selected can be the determination of the probable value or mathematical hope) and c) uncertainty, in which decisions linked to triple agents: beliefs and personal values of the doctors (I) for their patients (II) in the society (III). In the medical decisions there are often different factors that go beyond the field of technical and scientific knowledge (family, social, economic problems, etc.) and demanding an ethical analysis of the decision. Conclusions: The ‘‘evidence-based medicine’’, as other models of care, has — in itself — some limitations. ‘‘No evidence in medicine’’ matters that the postulates of the EBM are not always applicable to the real patients of Internal Medicine wards, mostly elderly, frail, complex, with comorbidities and polipharmacy, often with cognitive dysfunction and limitation of autonomy, with psycho-emotional, social and economic problems. The interacting effects of overall involved diseases/factors and their management require more complex and individualised care than simply the sum of separate guideline components. Further innovation is required to resolve the need to enhance integration of evidence with our patients’ values at the ‘‘bedside and/or clinic’’ management.

Hypertriglyceridemia, a common dyslipidemia of complex definition

Background: Hypertriglyceridemia is a common biochemical finding. Depending on the triglyceride levels it can be associated with increased risk of acute pancreatitis and of cardiovascular disease. The most severe forms have a genetic basis. Clinical case: We report a case of a 60-year-old woman with very high triglycerides (800- 3,000 mg/dL) and normal cholesterol levels. The patient is a non smoker, on hypolipemic diet, non alcoholic consumer, and on regular physical exercise. Her blood pressure is normal, BMI is 20, waist circumference is 78 cm. Thyroid, renal and hepatic function are normal. She has never had acute pancreatitis or cardiovascular disease. Discussion: The diagnostic and therapeutic management of this case is discussed. Causes of primary (genetic) and secondary hypertriglyceridemia are also reviewed, together with clinical features and management on every day practice. We focused on severe hypertriglyceridemia.

Haemorrhage and intestinal lymphoma

Background: The prevalence of coeliac disease is around 1% in general population but this is often unrecognised. The classical presentation of adult coeliac disease is characterized by diarrhoea and malabsorption syndrome, but atypical presentations are probably more common and are characterized by iron deficiency anaemia, weight loss, fatigue, infertility, arthralgia, peripheral neuropathy and osteoporosis. Unusual are the coagulation disorders (prevalence 20%) and these are due to vitamin K malabsorption (prolonged prothrombin time). Clinical case: A 64-year-old man was admitted to our Department for an extensive spontaneous haematoma of the right leg. He had a history of a small bowel resection for T-cell lymphoma, with a negative follow-up and he didn’t report any personal or familiar history of bleeding. Laboratory tests showed markedly prolonged prothrombin (PT) and partial-thromboplastin time (PTT), corrected by mixing studies, and whereas platelet count and liver tests was normal. A single dose (10 mg) of intravenous vitamin K normalized the PT. Several days before the patient had been exposed to a superwarfarin pesticide, but diagnostic tests for brodifacoum, bromadiolone or difenacoum were negative. Diagnosis of multiple vitamin K-dependent coagulationfactor deficiencies (II, VII, IX, X) due to intestinal malabsorption was made and coeliac disease was detected. Therefore the previous lymphoma diagnosis might be closely related to coeliac disease. Conclusions: A gluten free diet improves quality of life and restores normal nutritional and biochemical status and protects against these complications.

Toward a sustainable and wise healthcare approach: potential contributions from hospital Internal Medicine Departments to reducing inappropriate medical spending

All countries are facing the question of how to maintain quality of care with shrinking health budgets, in the presence of a persistent increase in life expectancy, and with a significant growing demand for health care from aging populations and chronically ill patients. Current implementation of legislative measures is largely presented as a cost-cutting policy. With this political approach, there is a risk of services and the number of hospital beds being drastically reduced, mainly to detriment of the most vulnerable groups of the population and without considering the results obtained by each regional healthcare organization according to explicit evaluation markers. In our Scientific Society of Internal Medicine (the Federation of Associations of Hospital Doctors on Internal Medicine, FADOI), we want to support good medical practice because essential medicine is still a goal to be achieved throughout medical hospital care. We are looking for original ways to implement a sustainable and frugal hospital Internal Medicine policy by searching for wise and efficient clinical methodology to be applied in the care of patients admitted to internal medicine wards according to their real needs. We firmly believe that reinforcing a common agenda between medicine and public health, and sharing a common vision among professionals and decision makers in the planning of care, may be the greatest opportunity for any every health care reform. The future of the health care system cannot be restricted to mere cost reduction, but should aim to deliver better health care in relation to the money spent. Even in this period of austerity, new opportunities can still be found and doctors must lead efforts to meet this challenge.

Possible left endoventricular myxoma in a patient with deep vein thrombosis of the lower limbs: a case report

Introduction: We describe an unusual case of left ventricular myxoma associated with deep vein thrombosis (DVT). Materials and methods: A 79-year-old woman was admitted with bilateral proximal DVT that developed while she was on warfarin. The anticoagulant therapy had been started (after 2 weeks of low-molecular weight heparin) 1 month earlier in a Cardiologic Unit, where the patient had been treated for ‘‘left ventricular thrombosis associated with acute pericarditis’’. After discharge, the patient continued to experience malaise, recurrent dizziness, dyspnea, flushing, and progressively severe leg swelling despite transthoracic echocardiography (TTE) findings of normal left ventricular function. She was finally admitted to our Unit for ultrasound studies for possible DVT. On admission the INR was in the therapeutic range with increased C-reactive protein (CRP), thrombocytopenia, mild anemia, anti-PF4 antibodies, lupus anticoagulant (LAC), a positive direct Coombs test, and mildly increased anti-platelet and anticardiolipin antibody levels. Malignancy, SLE, and inherited thrombophilia were excluded by a broad-spectrum instrumental and laboratory investigation. Since heparin-induced-thrombocytopenia could not be excluded, the warfarin was replaced with fondaparinux (7.5 mg/day). Given the persistence on TTE of a ‘‘small floating mass’’ at the left ventricular apex, we suspected the previously diagnosed thrombosis was actually an unusually located myxoma, and this diagnosis was confirmed by CT and MRI. The patient also had markedly increased serum levels of interleukin 6 (IL-6), regarded by many as a marker of cardiac myxoma and the source of the constitutional symptoms and immunologic features (‘‘activity’’) of these lesions. The patient is now well except for recurrent flushing episodes. The IL-6 level is still high although the ESR, CRP, LAC have normalized. Since isolated IL-6 increases are associated with recurrence in PMR patients, we consider our patient at risk for relapse of systemic illness. Results: Three cases of cardiac myxoma associated with DVT have been reported. Myxoma production of IL-6 could explain the extracardiac symptoms and the inflammatory/autoimmune activation that caused the DVT. Discussion: Although histologic confirmation is lacking, the features of this case strongly suggest an atypical-site myxoma, in particular the concordant findings generated by the various diagnostic exams and unchanging nature of the ventricular lesion during follow-up.

The influence of physical activity performed at 20-40 years of age on cardiovascular outcomes in medical patients aged 65-75

Introduction: Several studies show that physical activity can reduce the risk of cardiovascular disease, but the vast majority of these focus on the short- to intermediate-term benefits or refer to very specific populations. This observational study was conducted to determine whether physical activity performed during the third or fourth decade of life influences the occurrence of cardiovascular events in patients aged 65-75 years. Materials and methods: We studied a cohort of 2191 unselected patients admitted to Internal Medicine Departments. Data were collected on the patients’ medical history and their physical activity level when they were 20 to 40 years old. For the latter purpose, we used a specific questionnaire to assess the levels of physical activity related to the patients’ job, daily life, leisure time, and sports. Results: Almost half (44.2%) of the patients we evaluated reported moderate-intense physical activity when they were 20-40 years old. Around one third (35.8%) of the patients had experienced at least one major cardiovascular event, and there was a slight trend towards fewer cardiovascular events in patients with histories of physical activity (mean risk reduction: 4%, multivariate analysis). More evident benefits were observed in the subgroup of patients with diabetes, where cardiovascular outcomes were much better in patients who had been physically active than in those with sedentary life-styles (mean risk reduction: 24%). Conclusions: Given its design, our study may have underestimated the cardiovascular benefits of physical activity. Nonetheless, our results suggest that moderate-intense exercise during young adulthood may have limited beneficial effects on cardiovascular disease in old age, except in specific high-risk populations (diabetic patients). More evident benefits are probably associated with regular physical activity throughout life.

Efficacy and safety of new oral anticoagulants compared with warfarin in cardioembolic prophylaxis of patients with non valvular atrial fibrillation. More lights than shadows

IntroductionThe prophylaxis of thromboembolic events represents a key point in the modern management of patients with non valvular atrial fibrillation (AF), both paroxysmal and persistent/permanent. Up to now, vitamin K antagonist (VKA) drugs are the first choice in thromboembolic prophylaxis. Their treatment limitations have lead to development and clinical experimental use of new molecules aimed to overcome their limits. The new oral anticoagulants, such as dabigatran, a direct inhibitor of thrombin or rivaroxaban and apixaban, direct inhibitors of activated factor X, have been compared to warfarin in randomized clinical phase three trials (RCTs) for thromboembolic prevention in patients with non valvular AF with the aim to demonstrate their non inferiority when compared to warfarin. The results of these trials have been recently published. In this article the authors review the results of efficacy and safety of these three more recently published large RCTs.Conclusions All RCTs, RE-LY for dabigatran, ROCKET-AF for rivaroxaban and ARISTOTLE for apixaban met the study end-points and demonstrated a good safety profile of each new oral anticoagulant, so promising a new era for thromboembolic prevention therapy in AF.

Incidence and predictors of venous thromboembolism in post-acute care patients. A prospective cohort study

Few studies have addressed the topic of venous thromboembolism (VTE) in patients hospitalised in rehabilitation facilities. This patient population is rapidly growing, and data aimed to better define VTE risk in this setting are needed. Primary aim of this prospective observational study was to evaluate the frequency of symptomatic, objectively confirmed VTE in a cohort of unselected consecutive patients admitted to rehabilitation facilities, after medical diseases or surgery. Further objectives were to assess overall mortality, to identify risk factors for VTE and mortality, and to assess the attitude of physicians towards thromboprophylaxis. A total of 3,039 patients were included in the study, and the median duration of hospitalisation was 26 days. Seventy-two patients (2.4%) had symptomatic VTE. The median time to VTE from admission to the long-term care unit was 13 days. According to multivariable analysis, previous VTE (hazard ratio 5.67, 95% confidence interval 3.30-9.77) and cancer (hazard ratio 2.26, 95% confidence interval 1.36-3.75) were significantly associated to the occurrence of VTE. Overall in-hospital mortality was 15.1%. Age over 75 years, male gender, disability, cancer, and the absence of thromboprophylaxis were significantly associated to an increased risk of death (multivariable analysis). In-hospital antithrombotic prophylaxis was administered to 75.1% of patients, and low-molecular-weight heparin was the most widely used agent. According to our study, patients admitted to rehabilitation facilities remain at substantially increased risk for VTE. Because this applies to the majority of these patients, there is a great need for clinical trials assessing optimal prophylactic strategies.

Deep subthreshold Xi;{-} production in Ar + KCl reactions at 1.76A GeV

We report first results on a deep subthreshold production of the doubly strange hyperon Xi;{-} in a heavy-ion reaction. At a beam energy of 1.76A GeV the reaction Ar + KCl was studied with the High Acceptance Di-Electron Spectrometer at SIS18/GSI. A high-statistics and high-purity Lambda sample was collected, allowing for the investigation of the decay channel Xi;{-} --> Lambdapi;{-}. The deduced Xi;{-}/(Lambda + Sigma;{0}) production ratio of (5.6 +/- 1.2_{-1.7};{+1.8}) x 10;{-3} is significantly larger than available model predictions.

[Infected pressure ulcers: evaluation and management]

Pressure ulcers in elderly individuals can cause significant morbidity and mortality and are a major economic burden to the health care system. Prevention should be the ultimate objective of pressure ulcer care, and it requires an understanding of the pathophysiology leading to pressure ulcers and the means of reducing both intrinsic and extrinsic risk factors. Clinical examination often underestimates the degree of deep-tissue involvement, and its findings are inadequate for the detection of associated osteomyelitis. Microbiological data, if obtained from deep-tissue biopsy, are useful for directing antimicrobial therapy, but they are insufficient as the sole criterion for the diagnosis of infection. Imaging studies, such as computed tomography and magnetic resonance imaging, are useful, but bone biopsy and histopathological evaluation remain the "gold standard" for the detection of osteomyelitis. The goals of treatment of pressure ulcers should be resolution of infection and promotion of wound healing. A combination of surgical debridement and medical interventions may be required. Systemic antimicrobial therapy should be used for patients with serious pressure ulcers infections, including those with spreading cellulitis, bacteremia or osteomyelitis.

[Skin and soft tissue infections: classification and epidemiology]

In the present review, authors take into consideration the classification and the epidemiology of the skin and soft tissue infections (SSTIs), a set of commonly observed pathologies, which can present different features, relatively to site and localization, clinical characteristics, and aetiological agent, their severity being related to the depth of the interested sites. Given the variable presentation of SSTIs, an assessment of their incidence and prevalence is difficult. In general, the incidence of SSTIs has increased due to the ageing of the general population, the increased number of critically ill patients, the increased number of immunocompromised patients (HIV, cancer and organ transplant patients) and the recent emergence of multi-drug resistant pathogens.

In-hospital symptomatic venous thromboembolism and antithrombotic prophylaxis in Internal Medicine. Findings from a multicenter, prospective study

Hospitalised medical patients are at increased risk of venous thromboembolism (VTE), but the incidence of hospitalisation-related VTE in unselected medical inpatients has not been extensively studied, and uncertainties remain about the optimal use of thromboprophylaxis in this setting. Aims of our prospective, observational study were to assess the prevalence of VTE and the incidence of symptomatic, hospitalisation-related events in a cohort of consecutive patients admitted to 27 Internal Medicine Departments, and to evaluate clinical factors associated with the use of thromboprophylaxis. Between March and September 2006, a total of 4,846 patients were included in the study. Symptomatic VTE with onset of symptoms later than 48 hours after admission ("hospital-acquired" events, primary study end-point) occurred in 26 patients (0.55%), while the overall prevalence of VTE (including diagnosis prior to or at admission) was 3.65%. During hospital stay antithrombotic prophylaxis was administered in 41.6% of patients, and in 58.7% of those for whom prophylaxis was recommended according to the 2004 Guidelines of the American College of Chest Physicians. The choice of administering thromboprophylaxis or not appeared qualitatively adherent to indications from randomised clinical trials and international guidelines, and bed rest was the strongest determinant of the use of prophylaxis. Data from our real-world study confirm that VTE is a relevant complication in patients admitted to Internal Medicine Departments, and recommended tromboprophylaxis is still under-used, in particular in some patients groups. Further efforts are needed to better define risk profile and to optimise prophylaxis in the heterogeneous setting of medical inpatients.

Survey of cardiovascular risk factors in overweight and obese patients (SCOOP study) six-month changes in risk factor levels and cardiovascular risk

BACKGROUND

Obesity is considered a major threat to health worldwide, and its treatment is difficult. The SCOOP project is aimed at describing the effects of treating obesity in everyday clinical practice, following a standard protocol of weight reduction.

METHODS

A total of 2472 obese or overweight men and women (with a body mass index of 27 units or more), aged between 35 and 74, were enrolled in different clinical facilities. Treatment included a 25% average reduction in caloric intake and a recommendation to take a brisk walk for at least 150 min per week. After 6 months, a second survey was then carried out.

RESULTS

At the entry examination, patients exhibited high levels of most cardiovascular risk factors and estimated cardiovascular risks, and a high prevalence of cardiovascular diseases (14.1% in men; 6.3% in women), diabetes (30.5% in men; 25.2% in women) and metabolic syndrome (25.6% in men; 22.8% in women). After 6 months, 69% of all enrolled patients reported for a final examination. Levels of all cardiovascular risk factors were significantly reduced, including estimated cardiovascular risks (-20.4% in men and -12.6% in women). A targeted 10% reduction in body weight was achieved by 19% of patients. Changes in weight and cardiovascular risk factors were highly correlated with the self-reported compliance to prescriptions, and graded with the observed weight reduction. Benefits should be lowered by 30% if it is assumed that the patients who did not show up at the follow-up did not change their characteristics.

CONCLUSION

Short term positive effects of treatment of obesity can be obtained in everyday clinical practice using a simple protocol.

Isotopic dependence of the nuclear caloric curve

The A/Z dependence of projectile fragmentation at relativistic energies has been studied with the ALADIN forward spectrometer at SIS. A stable beam of (124)Sn and radioactive beams of (124)La and (107)Sn at 600 MeV per nucleon have been used in order to explore a wide range of isotopic compositions. Chemical freeze-out temperatures are found to be nearly invariant with respect to the A/Z of the produced spectator sources, consistent with predictions for expanded systems. Small Coulomb effects (DeltaT approximately 0.6 MeV) appear for residue production near the onset of multifragmentation.

Can CAP guideline adherence improve patient outcome in internal medicine departments?

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.

Co-morbidity does not reflect complexity in internal medicine patients

Internal medicine patients are mostly elderly; they have multiple co-morbidities, which are usually chronic, rather than self-limiting or acute diseases. Neither administrative indicators nor co-morbidity indexes, though validated in elderly patients, are able to completely define these "complex" patients or to allow physicians to correctly "cope" with them. For the complex patients found in internal medicine wards, internists need not only to find the best diagnosis and treatment, but also to apply a complex intervention (i.e., a comprehensive assessment and both continuous and multi-disciplinary care) in order to maintain their health and ability to function and to prevent or delay disability, frailty, and displacement from home and community. The aim of this review is to underscore the differences between the concepts of co-morbidity and complexity, to discuss instruments for their measurement, and to highlight related implications, areas of uncertainty, and the responsibilities of internists in the assessment and management of inpatients of their wards. The conclusion we come to is that it is mandatory to shift from a finance/administrative-based management system to a clinical process model (clinical governance) driven by the quality of the medical outcome and the cost of achieving that outcome. From a "complexity theory" standpoint, patient-centered care and collaboration can be seen as simple rules that guide desirable behaviors in a complex system. By exploring the real complexity of our patients, we exercise the holistic, anthropologic medicine of the person that is internal medicine.

The assessment of complexity in internal medicine patients. The FADOI Medicomplex Study

BACKGROUND

Although the number of elderly people is progressively increasing in the world, old and very old patients have been under-represented and understudied in trials evaluating the efficacy of chronic illness management models. The usual hospital indicators and practice guidelines do not consider the effects of complexity - co-morbidity, social support, functional and cognitive status, patient adherence to therapy, risk of adverse drug reactions - in these subjects. The aim of this observational, multi-centric cohort study was to carefully assess factors contributing to the complexity of care for patients admitted to internal medicine wards. This was done by evaluating the severity of disease and degree of stability at admission, co-morbidity, age-related impairments, and the need for discharge planning plus post-discharge support.

METHODS

A total of 386 patients from 11 internal medicine wards in Emilia-Romagna and Marche, Italy, enrolled in a given week were evaluated. At admission, the following variables were recorded: demographic characteristics, medical history, global clinical-social prognostic evaluation, co-morbidity, severity of illness, presence of shock or hemodynamic instability, coma, and frequencies and causes of unscheduled hospital re-admission.

RESULTS

Cancer, congestive heart failure, pneumonia, stroke, and chronic obstructive pulmonary disease were the most frequent primary diagnoses. The complexity of our case study was characterized by several concomitant diseases. Over 50% of the patients were considered severe or more than severe, and over 20% extremely severe, with very high co-morbidity indices and illness severity scores. Some 55% of our patients were in need of partial or total care; 10% had some speech impairment, and 63% needed in-home health care after hospital discharge.

CONCLUSIONS

The increasing numbers of elderly patients admitted to internal medicine departments suggests the need for a chronic illness management model, integrating gerontological and geriatric care to improve outcomes. For effective care, future protocols need to take a multi-dimensional, interdisciplinary approach to these patients and to develop a coordinated, integrated plan for treatment and long-term follow-up.

Dielectron production in 12C+12C collisions at 2A GeV with the HADES spectrometer

The invariant-mass spectrum of e+e- pairs produced in 12C+12C collisions at an incident energy of 2 GeV per nucleon has been measured for the first time. The measured pair production probabilities span over 5 orders of magnitude from the pi(0)-Dalitz to the rho/omega invariant-mass region. Dalitz decays of pi(0) and eta account for all the yield up to 0.15 GeV/c(2), but for only about 50% above this mass. A comparison with model calculations shows that the excess pair yield is likely due to baryon-resonance and vector-meson decays. Transport calculations based on vacuum spectral functions fail, however, to describe the entire mass region.

Time trends in three triennial surveys of cardiovascular risk factors and their treatment among patients discharged from divisions of internal medicine The FAPOI-1, FADOI-2, and FADOI-3 studies

BACKGROUND: There is increasing interest in monitoring cardiovascular risk factor levels and their treatment. We decided to study this in patients discharged from Divisions of Internal Medicine. METHODS: In three studies conducted in 1996, 1999, and 2002, data was collected on diagnoses of cardiovascular diseases and cardiovascular risk factor levels and treatment in 5904, 7476, and 9649 patients, respectively, aged 35 years or older, who were discharged within a week from 235, 345, and 517 Divisions of Internal Medicine in Italy. RESULTS: Between the first and third surveys, a relative decrease in atherosclerotic cardiovascular diseases was recorded, but heart failure showed a definite increase, reaching 11% of all cases. Mean levels of most cardiovascular risk factors decreased significant; only obesity did not. The proportion of treated hypertensives increased slightly (from 65% to 83% among men, and from 69% to 85% among women). The proportion of controlled hypertensives also rose, reaching around 37%. The proportion of treated dyslipidemics increased from 10% to 28% in men and from 12% to 25% in women, due to an increase in the use of statins. CONCLUSIONS: It is essential to focus attention on cardiovascular risk factors in order to optimize their treatment and to reduce cardiovascular disease.

Factor V Leiden and prothrombin gene G20210A mutations in Italian patients with Behçet's disease and deep vein thrombosis

OBJECTIVE

To evaluate the frequency and type of vascular lesions and to study the association of factor V gene G1691A (Leiden) and prothrombin gene G20210A polymorphisms with venous thrombosis in Italian patients with Behçet's disease (BD).

METHODS

Included were 118 consecutive Italian BD patients followed over a 3-year period (1997-1999) who satisfied the International Study Group criteria for BD. The control group consisted of 132 healthy Italian blood donors. All BD patients and controls were genotyped by polymerase chain reaction and allele-specific restriction enzyme techniques for factor V Leiden and prothrombin gene G20210A polymorphisms.

RESULTS

Vascular lesions were observed in 37 (31.4%) patients. The 2 most common lesions were subcutaneous thrombophlebitis (10.2%) and deep vein thrombosis (DVT) of the legs (22.8%). No significant demographic and clinical differences between patients with and without DVT were present. The distribution of allele and genotype frequencies of prothrombin gene G20210A and factor V Leiden polymorphisms did not differ significantly between BD patients and healthy controls. The frequencies of carriage rates of prothrombin gene G20210A and factor V Leiden polymorphisms in BD patients with and without DVT were similar. However, the frequency of 20210A allele was significantly higher in BD patients with ocular disease than in those without, particularly in the patients with posterior uveitis/retinal vasculitis.

CONCLUSIONS

The frequency and types of vascular lesions in Italian BD patients were similar to those reported in studies from other countries. No association between factor V Leiden mutation and G20210A mutation in the 3'-untranslated region of the prothrombin gene with DVT was found. However, a prothrombin gene G20210A mutation may influence the development and severity of ocular involvement in BD.

Trends in cardiovascular risk factors and their treatment among patients discharged from divisions of internal medicine. The FAPOI-1 and FADOI-2 studies

BACKGROUND

There is an increasing interest in monitoring cardiovascular risk factor levels and their treatment. Two studies were run in patients discharged from Divisions of Internal Medicine.

METHODS

Two studies, respectively conducted in 1996 and 1999, have collected data on the diagnoses of cardiovascular diseases and cardiovascular risk factor levels and treatment in 6450 and 8133 patients (age > or = 35 years) discharged during 1 week from 235 and 345 Italian Divisions of Internal Medicine.

RESULTS

The second survey revealed: a relative increase in heart failure and cerebrovascular disease diagnoses; lower serum levels of total cholesterol and triglycerides, lower systolic and diastolic blood pressure mean levels, and a decreased incidence of the habit of smoking among males. The proportion of treated hypertensives (blood pressure > or = 140/90 mmHg, or the use of antihypertensive drugs) increased slightly (65 to 68% among men and 69 to 71% among women). A reduction in the use of ACE-inhibitors was observed, balanced by an increase in the use of angiotensin II antagonists. The proportion of treated dyslipidemic patients (total cholesterol levels > or = 250 mg/dl, or HDL cholesterol levels < 35 mg/dl or triglyceride levels > or = 200 mg/dl or the use of hypolipidemic drugs) significantly increased from 10 to 25% among males and from 12 to 25% among females, due to a substantial increase in the use of statins.

CONCLUSIONS

During a 3-year period increasing attention for cardiovascular risk factors and their treatment among patients discharged from Divisions of Internal Medicine has been documented. In particular, there has been a large increase in the use of statins, although large segments of patients may need further attention and drug treatment.

Is duplex ultrasonography useful for the diagnosis of giant-cell arteritis?

BACKGROUND

Evidence of a dark halo on ultrasonography has been considered a specific sign of giant-cell arteritis and may replace temporal artery biopsy for the diagnosis of giant-cell arteritis in patients with typical clinical manifestations.

OBJECTIVE

To assess the usefulness of temporal artery duplex ultrasonography and to compare this mode of ultrasonography with physical examination of temporal arteries for the diagnosis of giant-cell arteritis in patients with suspected giant-cell arteritis or polymyalgia rheumatica.

DESIGN

Diagnostic test study.

SETTING

Several divisions of Reggio Emilia Hospital, Reggio Emilia, Italy.

PATIENTS

86 consecutive patients with a suspected diagnosis of giant-cell arteritis or polymyalgia rheumatica identified over a 22-month period.

MEASUREMENTS

The temporal arteries were examined in all 86 patients. Duplex ultrasonography of the temporal arteries was then performed by two ultrasonographers who were unaware of the clinical diagnosis. Before corticosteroid therapy was started, temporal artery biopsies were performed in all patients at the site targeted by the ultrasonographer.

RESULTS

A hypoechoic halo around the lumen of the temporal arteries had a sensitivity of only 40% (95% CI, 16% to 68%) and a specificity of 79% (CI, 68% to 88%) for the diagnosis of biopsy-proven giant-cell arteritis. The negative likelihood ratio was 0.8 (CI, 0.5 to 1.2), and the positive likelihood ratio was 1.9 (CI, 0.9 to 4.1). When the thickness of the halo was at least 1 mm, specificity increased to 93% (CI, 84% to 98%) and the positive likelihood ratio increased to 5.7 (CI, 2.0 to 16.2); however, sensitivity remained low at 40% (CI, 16% to 68%). On physical examination, temporal artery abnormalities had a higher sensitivity of 67% (CI, 38% to 88%), a higher specificity of 99% (CI, 92% to 100%), and a higher positive likelihood ratio of 47.3 (CI, 6.5 to 342.4) than did ultrasonographic findings. None of the patients with giant-cell arteritis had a normal temporal artery inspection and a hypoechoic halo on ultrasonography.

CONCLUSION

Evidence on ultrasonography of a halo around temporal arteries, either any halo or a halo 1 mm or greater in thickness, only modestly increased the probability of biopsy-proven giant-cell arteritis but did not improve the diagnostic accuracy of a careful physical examination.