Management of Hypothyroidism in Internal Medicine: Patient Profile and Effects of an Educational Programme in the Cluster-Randomized FADOI TIAMO Study

BACKGROUND AND AIMS

There is still limited knowledge regarding the clinical profile and appropriateness of treatment in patients with hypothyroidism hospitalized in Internal Medicine (IM) Departments in Italy. The aim of this study is to evaluate: 1) the characteristics of patients and possible deviations from national and international clinical practice recommendations (CPRs) in evidence-based guidelines (EBGs); 2) the improvement of patient management by means of a standardized educational programme (EP).

METHODS

A nationwide multicentre study, comprising two replications of a retrospective survey (phases 1 and 3) with an intervening EP (phase 2) in half of the centres and no EP in the other half, was conducted. The EP was based on outreach visits. Centres were assigned to the two arms of the study, labelled the training group (TG) and control group (CG) respectively, by cluster randomization. Four EBGs and 39 CPRs provided the basis on which 22 treatment management indicators were identified (7 referring to the time of hospital admission, 15 to post-admission).

RESULTS

The 21 participating centres recruited 587 hospitalized patients with hypothyroidism, 421 of which were females (71.7%, mean age 74.1 + 14.4 yrs): 318 in phase 1 and 269 in phase 3. The cause of hypothyroidism was unknown in 282 patients (48%). Evaluation at the time of admission identified satisfactory adherence to CPRs (>50%) for 63.6% of the indicators. In the phase 3, TG centres showed significant improvement vs CG in 4 of the 15 post-admission indicators, while 1 out of 15 was significantly worse.

CONCLUSIONS

The EP based on outreach visits significantly improved some indicators in the management of patients with hypothyroidism, with specific reference to appropriateness of TSH dosage and levothyroxine (LT4) treatment modality.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT05314790.

Hospitalization and mortality for acute exacerbation of chronic obstructive pulmonary disease (COPD): an Italian population-based study

OBJECTIVE

Patients with acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) have a significant mortality and morbidity. Previous studies have identified a number of independent prognostic factors. However, information on hospital admission databases is limited and data regarding short-term prognosis of these patients in Italian hospitals are lacking. Thus, we performed an epidemiological study on hospital admission for COPD acute exacerbation in Italy.

PATIENTS AND METHODS

Patients were identified using clinical Modification (ICD-9-CM) codes. Information was collected on baseline characteristics, vital status at discharge, duration of hospitalization, and up to five secondary discharge diagnoses. Comorbidity was evaluated using the Charlson comorbidity index (CCI).

RESULTS

During the observation period (2013-2014), 170,684 patients with COPD acute exacerbation were hospitalized. Mean length of hospitalization (LOH) was 9.95±8.69 days and mean in-hospital mortality was 5.30%. These data correspond to the 4.1% of all hospitalizations and to the 2.8% of all the days of hospitalization in Italy during the study period. In-hospital mortality and LOH varied among different regions (from 3.13 to 7.59% and from 8.22 to 11.28 days respectively). Old age, male gender, low discharge volume, previous hospitalization for COPD exacerbation and CCI resulted as significantly associated with higher in-hospital mortality.

CONCLUSIONS

Hospitalization for COPD exacerbation is extremely frequent even in contemporary Italian population. COPD exacerbation is clinically demanding with a not negligible short-term mortality rate and a mean LOH approaching 10 days. These latter findings were quite variable in different regions but should be further analyzed to set up appropriate health-care policies on COPD patients.

Diabetes and CoViD-19: Experience from the frontline of Internal Medicine wards in Italy

Available data suggest that the issue of CoViD-19 is particularly critical in patients with diabetes. In Italy, Internal Medicine (IM) wards have played a pivotal role in contrasting the spread of SARS-Cov2. During this pandemic, FADOI submitted a brief questionnaire to a group of its members acting as Head of IM units. Considering 38 units, 58% of beds dedicated to CoViD patients in CoViD Hospitals were in charge of IM, and globally cared for 6650 patients during a six-week period. Of these patients, 1264 (19%) had diabetes. Mortality rate in CoViD patients with or without diabetes were 20.5% and 14%, respectively (p < 0.001). Our survey seems to confirm that diabetes is a major comorbidity of CoViD-19, but it does not support an increased incidence of CoViD-19 infection in people with diabetes, if compared with the figures of patients with diabetes and hospitalized before the outbreak. On the other side, patients with diabetes appeared at a significantly increased risk of worse outcome. This finding underlines the importance of paying special attention to this patient population and its management.

The ultrathin limit of improper ferroelectricity

The secondary nature of polarization in improper ferroelectrics promotes functional properties beyond those of conventional ferroelectrics. In technologically relevant ultrathin films, however, the improper ferroelectric behavior remains largely unexplored. Here, we probe the emergence of the coupled improper polarization and primary distortive order parameter in thin films of hexagonal YMnO₃. Combining state-of-the-art in situ characterization techniques separately addressing the improper ferroelectric state and its distortive driving force, we reveal a pronounced thickness dependence of the improper polarization, which we show to originate from the strong modification of the primary order at epitaxial interfaces. Nanoscale confinement effects on the primary order parameter reduce the temperature of the phase transition, which we exploit to visualize its order-disorder character with atomic resolution. Our results advance the understanding of the evolution of improper ferroelectricity within the confinement of ultrathin films, which is essential for their successful implementation in nanoscale applications.

Evolution of improper ferroelectricity within the confinement of ultrathin films is essential for their successful implementation in nanoscale applications. Here, the authors show thickness dependence of the improper polarization originating from the strong modification of the primary order at epitaxial interfaces.

Depolarizing-Field Effects in Epitaxial Capacitor Heterostructures

We identify a transient enhancement of the depolarizing field, leading to an unexpected quench of net polarization, during the growth of a prototypical metal-ferroelectric-metal epitaxial system made of BaTiO_{3} and SrRuO_{3}. Reduced conductivity and, hence, charge screening efficiency in the early growth stage of the SrRuO_{3} top electrode promotes a breakdown of ferroelectric BaTiO_{3} into domains. We demonstrate how a thermal annealing procedure can recover the single-domain state. By tracking the polarization state in situ, using optical second harmonic generation, we bring new understanding to interface-related electrostatic effects in ferroelectric capacitors.

Early alert from the microbiology laboratory improves the outcome of elderly patients with Enterococcus spp. bloodstream infection: Results from a multicentre prospective study

OBJECTIVES

This study describes the clinical features and outcomes of patients with bloodstream infection (BSI) due to Enterococcus spp. and identified factors predictive of mortality.

METHODS

This analysis is part of a prospective multicentre observational study of consecutive hospitalised patients with BSI conducted from March 2012 to December 2012 in 31 internal medicine wards in Italy. Patients with enterococcal BSI were selected from the entire cohort. Patient characteristics, therapeutic interventions and outcome were reviewed. Cox regression analysis was performed to identify factors associated with in-hospital mortality. Hazard ratios (HRs) and 95% interval confidences (CIs) were calculated.

RESULTS

Among 533 patients with BSI, 41 (7.7%) had BSI by Enterococcus spp. (28 Enterococcus faecalis, 4 Enterococcus faecium and 3 each of Enterococcus avium, Enterococcus casseliflavus and Enterococcus gallinarum). Six BSIs (14.6%) were polymicrobial. Median (IQR) patient age was 73 (66-85.5) years. In-hospital mortality was 24.4%. Polymicrobial infection (HR = 9.100, 95% CI 1.295-63.949; P = 0.026), age (HR = 1.261, 95% CI 1.029-1.546; P = 0.025) and SOFA score (HR = 1.244, 95% CI 1.051-1.474; P = 0.011) were risk factors for in-hospital mortality. Conversely, receiving an alert from the microbiology laboratory before obtaining final antimicrobial susceptibility results was associated with survival (HR = 0.073, 95% CI 0.007-0.805; P = 0.033).

CONCLUSION

BSI due to Enterococcus spp. in elderly patients is associated with high mortality. Polymicrobial infection, age and SOFA score are factors associated with poor outcome. Conversely, early alert from the microbiology laboratory improves patient survival.

La figura dell’Hospitalist in Italia

Tra il Mito di Titone e la sindrome di Odisseo/Ulisse del Malato ComplessoA. FontanellaProfilo biosociale del paziente ospedalizzato del XXI secoloR. Nardi, G. Mathieu, M. La ReginaC’è bisogno di una nuova figura professionale?M. SilingardiAnalisi dei modelli esistenti: future hospital programF. OrlandiniAnalisi dei modelli esistenti: Acute Complex Care Model (ACCM)F. PietrantonioAnalisi dei modelli esistenti: hospitalistV. VerdianiOn being a hospitalistM. AffinatiLa nuova figura professionale italiana: profilo, attività e modelli organizzativiF. Orlandini, M. La Regina, V. Verdiani, D. ManfellottoIl percorso formativoG. Murialdo, A. Testi, G. Torre, P. Gnerre, F. OrlandiniLa certificazioneL. Marchionni, M. Campanini, C. Nozzoli, A. MazzoneHospitalist: SWOT analysisM. La Regina, F. Orlandini, V. VerdianiConsiderazioni conclusive sulla figura dell’HospitalistD. Manfellotto

Bottle-brush-shaped heterostructures of NiO-ZnO nanowires: growth study and sensing properties

We present here heterostructured ZnO-NiO nanowires (NWs), constituted by a core of single crystalline ZnO NWs, covered by poly-crystalline NiO nanorods (NRs). The bottle-brush shape was investigated by scanning electron microscopy and transmission electron microscope, confirming that a columnar growth of NiO occurred over the ZnO core, with a preferred orientation of NiO over ZnO NWs. The heterostructured devices are proposed for gas sensing application. Bare ZnO NWs and heterostructured sensors with two different thicknesses of NiO poly-crystalline NRs were analysed for acetone, ethanol, NO₂ and H₂ detection. All sensors maintained n-type sensing mechanism, with improved sensing performance for lower thickness of NiO, due to high catalytic activity of NiO. The sensing dynamic is also strongly modified by the presence of heterojunction of NiO/ZnO, with a reduction of response and recovery times towards ethanol and acetone at 400 °C.

Evaluation of the threshold value for the modified early warning score (MEWS) in medical septic patients: a secondary analysis of an Italian multicentric prospective cohort (SNOOPII study)

BACKGROUND

Due to aging and resources limitation, septic patients are often admitted to medical wards (MWs). Early warning deterioration is a relevant issue in this setting. Unfortunately, a suitable prognostic score has not been identified, yet.

AIM

To explore the ability of Modified Early Warning Score (MEWS) to predict the in-hospital mortality in septic patients admitted to MWs.

DESIGN

Secondary analysis of a multicentric prospective study.

METHODS

Consecutive septic patients with positive blood culture admitted to 31 Italian MWs were included. Baseline characteristics, clinics, isolates, rate of transfer to ICU, MEWS was collected on admission according to the study protocol. The accuracy of MEWS in predicting the in-hospital mortality was assessed with the area under the receiver-operating characteristic curves. Sensitivity, specificity, positive and negative predictive value (PPV and NPV), likelihood ratio (LR) were calculated for different MEWS cut-offs and age/comorbidities subgroups.

RESULTS

In total 526 patients were included in this analysis. Median MEWS was (range 0-11). In-hospital mortality was 14.8% and transfer to ICU 1.3%. Mortality progressively increased according to MEWS (3% in MEWS 0 vs. 27% in MEWS >5; Chi square for trend P < 0.05). The AUC of MEWS in predicting in-hospital mortality was 0.596 (95% CI, 0.524, 0.669). MEWS did not appear to have an adequate sensitivity, sensibility, PPV, NPV and LR both in the whole population and in the pre-specified subgroups.

CONCLUSIONS

Our findings do not seem to support the use of MEWS to predict the in-hospital mortality risk of sepsis in MWs.

Saper desistere per curare fino in fondo: come intraprendere il migliore percorso di assistenza nel Paziente con grave insufficienza d’organo in Medicina Interna?

<img src="/public/site/images/pgranata/rass.jpg" alt="" /><br /><p class="titolo"><strong>La futilità in medicina e le difficoltà a desistere</strong><br /><em>L. Lusiani, L. Magnani</em></p><p class="titolo"><strong>Le prospettive Slow Medicine sulla desistenza terapeutica</strong><br /><em>S. Spinsanti, S. Vernero</em></p><p class="titolo"><strong>La desistenza terapeutica: il punto di vista del magistrato</strong><br /><em>V. Castiglione, V. Pedone</em></p><p class="titolo"><strong>La <em>desistenza terapeutica</em> è giustificabile sul piano etico?</strong><br /><em>E. Furlan</em></p><p class="titolo"><strong>Il punto di vista di un credente</strong><br /><em>G. Pinna</em></p><p class="titolo"><strong>Il buon samaritano, la misericordia del medico e desistenza terapeutica: concetti fra loro compatibili?</strong><br /><em>A. Greco, M. Greco, L. Cascavilla, G. Fasanella</em></p><p class="titolo"><strong>Le grandi insufficienze d’organo <em>end stage</em>: il documento SIAARTI</strong><br /><em>G.R. Gristina, L. Riccioni</em></p><p class="titolo"><strong>I determinanti della mortalità a breve termine dei pazienti non oncologici ricoverati in medicina interna: un’esperienza sul campo</strong><br /><em>M. Tiraboschi, S. Ghidoni, A. Zucchi, A. Carobbio, A. Ghirardi, M. Casati, F. Dentali, A. Squizzato, D. Torzillo, F. De Stefano, V. Gessi, E. Tamborini Permunian, S. Moretti, A. Assolari, A. Brucato</em></p><p class="titolo"><strong>Le parole per dirlo: la comunicazione al paziente, ai familiari e al <em>caregiver</em></strong><br /><em>M. Felici, S. Lenti, L. Occhini, A. Pulerà</em></p><p class="titolo"><strong>Le alternative possibili che il medico internista può proporre alla dimissione, rispetto all’aumento di intensità di cura e l’assistenza ospedaliera ordinaria: <em>la rete di cure palliative</em></strong><br /><em>D. Valenti, F. Moggia</em></p><p class="titolo"><strong>Scompenso cardiaco avanzato: dalla terapia attiva alle cure palliative</strong><br /><em>G. Mathieu</em></p><p class="titolo"><strong>Ictus ischemico ed emorragia cerebrale: problematiche di fine vita</strong><br /><em>C. Trocino</em></p><p class="titolo"><strong>Demenza avanzata</strong><br /><em>M. Coveri</em></p><p class="titolo"><strong>La dispnea al termine della vita</strong><br /><em>M. Giorgi-Pierfranceschi, S. Orlando</em></p><p class="titolo"><strong>Dialisi</strong><br /><em>M. Meschi, S. Pioli, A. Magnano, F. Spagnoli, M. Saccò</em></p><p class="titolo"><strong>Ventilazione meccanica invasiva e non</strong><br /><em>M. La Regina, F. Orlandini</em></p><p class="titolo"><strong>Il diabete mellito</strong><br /><em>L. Morbidoni</em></p><p class="titolo"><strong>Comunicare la scelta di desistere in medicina: una esperienza sul campo</strong><br /><em>C. Bullo, G. Bordin, L. Lusiani</em></p><p class="titolo"><strong>Le prospettive future in Italia e all’interno del nostro SSN</strong><br /><em>A. Fontanella</em></p><img src="/public/site/images/pgranata/appendix.jpg" alt="" /><br /><p class="titolo"><strong>APPENDICE<br />Metodi di riconoscimento e di valutazione del paziente in fase terminale o a rischio di elevata mortalità in ospedale: le malattie più frequentemente riscontrabili in Medicina Interna</strong><br /><em>R. Nardi, G. Belmonte, P. Gnerre, G. Pinna, D. Borioni, M. Campanini, R. Gerloni, A. Fontanella</em></p>

Problematiche di fine vita: il ruolo della medicina interna ospedaliera

<img src="/public/site/images/pgranata/PREFAZIONE.jpg" alt="" /><br /><p class="titolo"><strong>Etica cristiana e malattia</strong><br /><em>E. Bianchi</em></p><img src="/public/site/images/pgranata/rass.jpg" alt="" /><br /><p class="titolo"><strong>Le problematiche di fine vita: quale consapevolezza da parte degli internisti?</strong><br /><em>M. Gambacorta, M. Campanini, R. Nardi</em></p><p class="titolo"><strong>Il concetto di terminalità: certezze e incertezze</strong><br /><em>L. Lusiani, C. Bullo</em></p><p class="titolo"><strong>Traiettorie di malattia: non sempre i pazienti e le famiglie sono informati</strong><br /><em>L. Magnani</em></p><p class="titolo"><strong>La dignità come fattore di cura: pratica clinica nel fine vita nella medicina <em>patient centered</em></strong><br /><em>M. Felici, A. Pulerà, S. Lenti</em></p><p class="titolo"><strong>L’assistenza nel fine vita: quali responsabilità? Un approccio medico-legale al tema</strong><br /><em>A. Aprile, M. Bolcato, D. Rodriguez</em></p><p class="titolo"><strong>Il paziente terminale: aspetti di tipo etico</strong><br /><em>R. Cavaliere</em></p><p class="titolo"><strong>Cure palliative, assistenza domiciliare e <em>caregiver burden</em>: il modello dell’efficienza terapeutica</strong><br /><em>L. Occhini, A. Pulerà, M. Felici</em></p><p class="titolo"><strong>Nutrizione ed idratazione nei malati terminali</strong><br /><em>R. Risicato</em></p><p class="titolo"><strong>La gestione del dolore nel paziente terminale</strong><br /><em>G. Civardi, M. Bosco, R. Bertè</em></p><p class="titolo"><strong>Sedazione di fine vita: aspetti decisionali clinici ed etici</strong><br /><em>M. Carassiti, A. De Benedictis, M. Del Prete, B. Vincenzi, V. Tambone</em></p><p class="titolo"><strong>La rimodulazione della terapia negli anziani in fase terminale</strong><br /><em>A. Cester, F. Busonera</em></p><p class="titolo"><strong>Ruolo dell’infermiere nel <em>comfort care</em> del paziente a fine vita in Medicina Interna</strong><br /><em>D. Simonazzi, M. Lince, S. Tanzi, G. Bordin</em></p><p class="titolo"><strong>Percorso di fine vita e diagnosi di terminalità: l’esperienza dell’Ausl di Modena e Reggio Emilia</strong><br /><em>G. Chesi, E. Scalabrini, P. Vacondio, G. Pinelli, G. Carrieri, G. Cioni</em></p><img src="/public/site/images/pgranata/Sezioni.jpg" alt="" /><br /><p class="titolo"><strong>APPENDICE I<br />Metodi di riconoscimento e di valutazione del paziente in fase terminale o a rischio di elevata mortalità in ospedale</strong><br /><em>R. Nardi, G. Belmonte, L. Lusiani, M. Gambacorta, G. Pinna, M. Campanini, A. Fontanella</em></p><p class="titolo"><strong>APPENDICE II<br />RECENSIONE - Riflessioni sul dolore </strong>di Umberto Eco<br /><em>R. Nardi</em></p>

L’ipotiroidismo

<p class="titolo"><img src="/public/site/images/pgranata/rass.jpg" alt="" /></p><p class="titolo"><strong>Introduzione</strong><br /><em>M. Campanini</em></p><p class="titolo"><strong>Inquadramento ed epidemiologia dell’ipotiroidismo</strong><br /><em>T.M. Attardo</em></p><p class="titolo"><strong>Ipotiroidismo e autoimmunità</strong><br /><em>P. Montanari, F. Borghi, L. Finardi</em></p><p class="titolo"><strong>L’ipotiroidismo subclinico</strong><br /><em>D. Brancato, F. Provenzano</em></p><p class="titolo"><strong>L’ipotiroidismo e la gravidanza</strong><br /><em>V. Donvito</em></p><p class="titolo"><strong>La terapia con L-tiroxina</strong><br /><em>M. Grandi, C. Sacchetti, S. Pederzoli</em></p>

Medicina interna perioperatoria - Il paziente chirurgico complesso: il ruolo dell’internista nell’ospedale snello, a misura del paziente, organizzato per intensità di cure

<p class="titolo"><img src="/public/site/images/pgranata/rass.jpg" alt="" /></p><p class="titolo"><strong>Perché l’internista è necessario nella gestione dei pazienti complessi candidati ad intervento chirurgico</strong><br /><em>F. Gilioli, G. Chesi</em></p><p class="titolo"><strong>La medicina interna nell’assistenza del paziente chirurgico complesso</strong><br /><em>M. Fabbri, S. Galli, A. Morettini</em></p><p class="titolo"><strong>Il paziente cardiopatico</strong><br /><em>G. Chesi, F. Gilioli</em></p><p class="titolo"><strong>Il paziente con broncopneumopatia cronica ostruttiva</strong><br /><em>M. Candela</em></p><p class="titolo"><strong>Il paziente diabetico</strong><br /><em>L. Morbidoni</em></p><p class="titolo"><strong>La chirurgia nel grande anziano: rischi e opportunità</strong><br /><em>A. Greco, M. Greco, G. D’Onofrio, G. Paroni, D. Sancarlo, M. Lauriola, D. Seripa</em></p><p class="titolo"><strong>Il paziente candidato ad intervento chirurgico a rischio trombo-embolico</strong><br /><em>R. Re, M. Campanini</em></p><p class="titolo"><strong>Concetto di <em>Ospedale snello</em>, <em>hospitalist</em> e di <em>co-management</em></strong><br /><em>I. Stefani, A. Mazzone</em></p><p class="titolo"><strong>L’internista nel reparto di Ortopedia: il percorso del paziente ricoverato per frattura prossimale di femore</strong><br /><em>R. Nardi, M. Mazzetti, C. Marchetti</em></p><p class="titolo"><strong>L’internista nel reparto di neurochirurgia</strong><br /><em>C. Cicognani, S. Zaccaroni</em></p><p class="titolo"><strong>L’internista nel reparto di ostetricia</strong><br /><em>A. Maina, V. Donvito, L. Balbi</em></p><p class="titolo"><strong>L’internista nel Centro Trapianti di fegato</strong><br /><em>L. Fontanella, M. Imparato</em></p><p class="titolo"><strong>La gestione del dolore post-operatorio in ambito internistico</strong><br /><em>M. Bosco, R. Bertè, G. Civardi</em></p><p class="titolo"><strong>La sindrome da rialimentazione</strong><br /><em>R. Risicato, G. Scanelli, L. Tramontano, U. Politti</em></p><p class="titolo"><strong>Terapia infusionale pre-intra-post-operatoria: solamente un problema dell’anestesista?</strong><br /><em>F. Sgambato, G. Pinna, S. Prozzo, E. Sgambato</em></p><p class="titolo"><strong>Il paziente ad elevato rischio emorragico: valutazione e management</strong><br /><em>A.M. Pizzini, I. Iori</em></p><p class="titolo"><strong>La gestione perioperatoria o periprocedurale della terapia anticoagulante-antiaggregante in elezione e in urgenza</strong><br /><em>A. Fontanella, R. Re</em></p><p class="titolo"><strong>Le complicanze mediche e gli eventi avversi indesiderabili più frequenti nel paziente internistico complesso operato</strong><br /><em>M. Silingardi</em></p><p class="titolo"><strong>Pazienti <em>chirurgici</em> ricoverati in Medicina Interna: i pazienti a rischio, selezione delle priorità e delle emergenze urgenze e pianificazione dell’assistenza</strong><br /><em>P. Gnerre, M. Gambacorta, A. Percivale</em></p><p class="titolo"><strong>Qualità, indicatori ed <em>audit</em> come strumento di miglioramento nell’assistenza del paziente complesso in chirurgia</strong><br /><em>S. De Carli, A. Montagnani</em></p><p class="titolo"><strong>Quali proposte ed evidenze per nuovi modelli organizzativi in cui l’internista può assumere un ruolo fondamentale?</strong><br /><em>A. Fontanella, M. Campanini</em></p>

La comunicazione con il paziente e tra professionisti nella gestione del paziente complesso in Medicina Interna

<p class="titolo"><img src="/public/site/images/pgranata/rass.jpg" alt="" /></p><p class="titolo"><strong>Introduzione</strong><br /><em>M. Campanini</em></p><p class="titolo"><strong>La comunicazione tra professionisti</strong><br /><em>A. Fontanella</em></p><p class="titolo"><strong>Il valore della comunicazione in medicina interna</strong><br /><em>A. Greco, M. Greco, G. D’Onofrio, D. Sancarlo</em></p><p class="titolo"><strong>Le <em>Communication Skills come Evidence Based Medicine</em></strong><br /><em>M. Felici, S. Lenti</em></p><p class="titolo"><strong>La procedura comunicativa Calgary-Cambridge</strong><br /><em>L. Sammicheli, C. Nozzoli</em></p><p class="titolo"><strong>La procedura comunicativa Macy Model</strong><br /><em>V. De Crescenzo, M. Manini</em></p><p class="titolo"><strong>La Medicina e la Ricerca <em>disease, patient </em>e<em> person-oriented</em></strong><br /><em>G. Gussoni, L. Bellesia, S. Frasson, A. Valerio, E. Zagarrì</em></p><p class="titolo"><strong>I contesti clinici e comunicativi della medicina</strong><br /><em>M. Felici, S. Lenti</em></p><p class="titolo"><strong>L’<em>illness</em> del paziente: una <em>Evidence Based Medicine</em> nella medicina della complessità</strong><br /><em>L. Occhini, A. Pulerà, M. Felici</em></p><p class="titolo"><strong><em>Illness</em> e comportamento di malattia</strong><br /><em>L. Occhini, A. Pulerà, M. Felici</em></p><p class="titolo"><strong>Il paradosso della prognosi: il dilemma della comunicazione nella prognosi in medicina interna</strong><br /><em>R. Ruggeri, L. Magnani, M. Murolo, G. Colombo, F. Colombo</em></p><p class="titolo"><strong>Il terzo incomodo, ovvero, come la tecnologia informatica ha influenzato la relazioni medico-paziente</strong><br /><em>S. De Carli, M. Rondana, V. Moretti</em></p><p class="titolo"><strong>La comunicazione efficace come strumento per aumentare l’aderenza alla terapia ovvero l’<em>alleanza terapeutica</em></strong><br /><em>A. Galanti, L. S. Martin Martin, M. Semprini, D. Terracina</em></p><p class="titolo"><strong>Il valore della comunicazione nei sistemi sanitari</strong><br /><em>M. Sandroni</em></p>

Patologia sistemica da virus dell'epatite C: la crioglobulinemia mista e altre manifestazioni extraepatiche

<img src="/public/site/images/pgranata/intro.jpg" alt="" /><br /><p class="titolo"><strong>La malattia o sindrome da virus dell’epatite C</strong>     1<br /><em>M. Visconti, R. Nardi</em></p><p class="titolo"><strong>Il virus C</strong>     5<br /><em>V. Iovinella, G. Iovinella</em></p><img src="/public/site/images/pgranata/crio1.jpg" alt="" /><br /><p class="titolo"><strong>Crioglobuline, crioglobulinemie e sindromi crioglobulinemiche</strong>     10<br /><em>M. Visconti, A. Salvio</em></p><p class="titolo"><strong>Patogenesi</strong>     14<br /><em>A. Ilardi</em></p><p class="titolo"><strong>La vasculite cutanea</strong>     19<br /><em>G. Monti, P. Novati, L. Castelnovo, F. Saccardo</em></p><p class="titolo"><strong>Le neuropatie periferiche</strong>     23<br /><em>R. Boni</em></p><p class="titolo"><strong>La sindrome sicca</strong>     29<br /><em>G. Italiano</em></p><p class="titolo"><strong>Il fenomeno di Raynaud</strong>     33<br /><em>F. Gallucci, A. Parisi, R. Buono</em></p><p class="titolo"><strong>La nefropatia crioglobulinemica</strong>     40<br /><em>F. Salvati</em></p><p class="titolo"><strong>I linfomi</strong>     46<br /><em>M. Laccetti</em></p><p class="titolo"><strong>La patologia articolare</strong>     52<br /><em>T. d’Errico, M. Varriale, C. Ambrosca, S. Tassinario</em></p><p class="titolo"><strong>Sindrome da iperviscosità</strong>     56<br /><em>A. Fontanella, L. Fontanella</em></p><p class="titolo"><strong>Diagnosi</strong>     60<br /><em>G. Uomo, F. Gallucci</em></p><p class="titolo"><strong>Terapia antivirale</strong>     65<br /><em>P.G. Rabitti, F. Lampasi</em></p><img src="/public/site/images/pgranata/altre11.jpg" alt="" /><br /><p class="titolo"><strong>Diabete mellito</strong>     74<br /><em>A. Maffettone, M. Rinaldi</em></p><p class="titolo"><strong>Malattie cardiovascolari</strong>     80<br /><em>R. Nardi, D. Borioni</em></p><p class="titolo"><strong>Malattie dermatologiche</strong>     86<br /><em>D. Galasso, D. D’Amico</em></p><p class="titolo"><strong>Malattie neurologiche e psichiatriche</strong>     91<br /><em>M. Imparato</em></p><p class="titolo"><strong>Correlazioni tra patologia epatica e patologia tiroidea. <br />Malattie tiroidee in corso di infezione da virus C</strong>     96<br /><em>M. Grandi, C. Sacchetti, S. Pederzoli</em></p><p class="titolo"><strong>Neoplasie extraepatiche</strong>     101<br /><em>S. Fiorino, A. Domanico, E. Accogli, D. Borioni, P. Leandri</em></p><p class="titolo"><strong>Sarcoidosi e malattie polmonari</strong>     109<br /><em>A. Zuccoli, N. Corcione, V. Nuzzo</em></p>

Magnetic gas sensing exploiting the magneto-optical Kerr effect on ZnO nanorods/Co layer system

A new system based on a Co film covered by ZnO nanorods has been fabricated with sputtering technique. It represents a promising candidate for future generation of magnetic gas sensing devices.

Aspetti clinico-organizzativi nella degenza medica ospedaliera in Italia: il ruolo della Medicina Interna nel Dipartimento Medico e continuità assistenziale

<img src="/public/site/images/pgranata/intro.jpg" alt="" /><br /><p class="titolo"><strong>Aspetti clinico-organizzativi nella degenza medica ospedaliera in Italia: il ruolo della Medicina Interna nel dipartimento medico e continuità assistenziale</strong>     499<br /><em>G. Panigada, I. Chiti</em></p><img src="/public/site/images/pgranata/Sezioni3.jpg" alt="" /><br /><p class="titolo"><strong>Organizzazione delle Medicine Interne della Toscana: analisi specifica delle criticità</strong>     503<br /><em>R. Laureano, S. Meini</em></p><p class="titolo"><strong>Risultati di una <em>survey</em> sulla complessità promossa da FADOI</strong>     509<br /><em>M. Gambacorta, A. Montagnani, P. Gnerre</em></p><p class="titolo"><strong><em>Fare di più non significa fare meglio</em>: il contributo FADOI al programma di <em>Slow Medicine</em> per una medicina sostenibile</strong>     513<br /><em>L. Lusiani, R. Frediani, A. Fortini, R. Nardi</em></p><p class="titolo"><strong>Gli effetti della riorganizzazione ospedaliera sulla comunicazione medico-paziente: un’analisi di cambiamento necessario</strong>     523<br /><em>M. Felici, S. Lenti</em></p><p class="titolo"><strong>Survey sui fabbisogni di formazione e aggiornamento degli internisti FADOI</strong>     528<br /><em>C. Canale, M. Cannone, M. La Regina, R. Risicato, M. Silingardi</em></p><img src="/public/site/images/pgranata/Sezioni21.jpg" alt="" /> <br /><p class="titolo"><strong>L’internista ospedaliero: dentro o fuori?</strong>     531<br /><em>F. Orlandini, F. Pietrantonio</em></p><p class="titolo"><strong>La telemedicina in Medicina Interna</strong>     537<br /><em>A. Sciascera</em></p><p class="titolo"><strong><em>Red flags</em> e modelli di <em>fast track</em> per accedere rapidamente alla diagnosi precoce</strong>     541<br /><em>F. Pieralli, F. Corradi</em></p><img src="/public/site/images/pgranata/Sezioni4.jpg" alt="" /><br /><p class="titolo"><strong>Sovraffollamento e qualità assistenziale in Ospedale: sono previste soluzioni nei patti per la salute?</strong>     544<br /><em>A. Fontanella</em></p><p class="titolo"><strong>L’area critica di medicina interna: stato dell’arte nella Regione Puglia. Quali motivazioni? Per quali pazienti? Secondo quali normative?</strong>     548<br /><em>F. Ventrella</em></p><p class="titolo"><strong>Il <em>medico tutor</em> nell’ospedale per intensità di cura</strong>     556<br /><em>M. Alessandri</em></p><p class="titolo"><strong>L’<em>Hospitalist</em></strong>     563<br /><em>I. Stefani, A. Mazzone</em></p><p class="titolo"><strong>Il dipartimento medico è tuttora una soluzione per il governo clinico della complessità assistenziale?</strong>     567<br /><em>G. Landini</em></p><p class="titolo"><strong>Modalità organizzative e clima interno nell’area medica</strong>     569<br /><em>S. De Carli, R. Re</em></p><p class="titolo"><strong>Malattie endocrino-metaboliche in area medica: percorsi clinico-assistenziali ed implicazioni economiche</strong>     575<br /><em>M. Cappagli, S. Barbieri, V. Scardigli, C. Rossi, L. Sanna, E. Romano</em></p><p class="titolo"><strong>Cure palliative: nuova branca specialistica o competenze da riscoprire?</strong>     583<br /><em>G. Chesi, P. Montanari, R. Nardi</em></p><p class="titolo"><strong>Strumenti di comunicazione esterna per la continuità assistenziale: dimissioni protette, percorsi integrati ospedale territorio, integrazione di servizi</strong>     588<br /><em>G. Chesi, E. Scalabrini, N. Branchetti, C. Sarti, F. Bencivenni, A. Giudici</em></p><p class="titolo"><strong><em>Integrated delivery system</em>: effetti su costi e qualità. Quale futuro?</strong>     599<br /><em>E. Desideri</em></p><p class="titolo"><strong>L’ospedale del futuro tra assistenza in acuzie e continuità di cura: il modello inglese può essere implementato anche nei nostri ospedali?</strong>     601<br /><em>P. Gnerre, M. Gambacorta, A. Montagnani</em></p><img src="/public/site/images/pgranata/concl.jpg" alt="" /><p class="titolo"><strong>Conclusioni: chi garantisce il coordinamento e la continuità delle cure?</strong>     608<br /><em>C. Nozzoli</em></p><img src="/public/site/images/pgranata/appendix.jpg" alt="" /><br /><p class="titolo"><strong>I documenti FADOI</strong>     610<br /><em>M. Campanini</em></p>

La ventilazione non invasiva in Medicina Interna

<p class="titolo"><strong>Legenda delle più comuni abbreviazioni e acronimi</strong>     391</p><p class="titolo"><strong>Prefazione</strong>     393<br /><em>P. Navalesi</em></p><p class="titolo"><strong>Presentazione</strong>     395<br /><em>M. Campanini</em></p><img src="/public/site/images/pgranata/intro.jpg" alt="" /><br /><p class="titolo"><strong>La NIV in Medicina Interna</strong>     396<br /><em>F. Lari</em></p><img src="/public/site/images/pgranata/rass.jpg" alt="" /><br /><p class="titolo"><strong>Il ventilatore e i suoi componenti</strong>     399<br /><em>F. Lari</em></p><p class="titolo"><strong>Maschere ed interfacce</strong>     407<br /><em>F. Lari</em></p><p class="titolo"><strong>Sistemi CPAP (pressione positiva continua applicata alle vie aeree)</strong>     411<br /><em>F. Lari</em></p><p class="titolo"><strong>Principi e tecniche di ventilazione meccanica</strong>     417<br /><em>F. Giostra, E. Di Flaviano</em></p><p class="titolo"><strong>Insufficienza respiratoria acuta cardiogena - ruolo della ventilazione non invasiva</strong>     427<br /><em>F. Ventrella</em></p><p class="titolo"><strong>Riacutizzazione di broncopneumopatia cronica ostruttiva</strong>     443<br /><em>M. La Regina, F. Orlandini</em></p><p class="titolo"><strong>Altre indicazioni alla ventilazione meccanica non invasiva</strong>     451<br /><em>F. Pieralli, O. Para, C. Nozzoli</em></p><p class="titolo"><strong>Le apnee del sonno: competenza multidisciplinare e ruolo dell’internista</strong>     456<br /><em>F. Lari</em></p><p class="titolo"><strong>La ventilazione meccanica non invasiva nella palliazione del paziente oncologico terminale</strong>     462<br /><em>S. Orlando, M. Giorgi-Pierfranceschi</em></p><p class="titolo"><strong>La NIV nel paziente con insufficienza respiratoria cronica, la gestione domiciliare - Competenza specialistica nelle patologie pneumologiche pure</strong>     465<br /><em>A. Marchioni, E.M. Clini, B. Beghé</em></p><p class="titolo"><strong>Approccio al paziente internistico, candidato alla ventilazione meccanica non invasiva: <em>key messages</em></strong>     475<br /><em>M. Giorgi Pierfranceschi</em></p><img src="/public/site/images/pgranata/concl.jpg" alt="" /><p class="titolo"><strong>La ventilazione meccanica non invasiva: conclusioni</strong>     482<br /><em>M. Errico, A. Greco</em></p><img src="/public/site/images/pgranata/appendix.jpg" alt="" /><br /><p class="titolo"><strong>NIV in Medicina Interna: sono necessari sistemi di monitoraggio emodinamico?</strong>     484<br /><em>N. Di Battista, F. Savelli</em></p>

II ruolo degli omega-3 nel paziente pluripatologico complesso: dalle evidenze alla pratica clinica in Medicina Interna

<img src="/public/site/images/pgranata/intro.jpg" alt="" /><br /><p class="titolo"><strong>II ruolo degli omega-3 nel paziente pluripatologico complesso</strong>     241<br /><em>M. Campanini, R. Nardi</em></p><img src="/public/site/images/pgranata/rass.jpg" alt="" /><br /><p class="titolo"><strong>II ruolo degli omega-3 nella prevenzione dell’ipertrigliceridemia pura e iperlipemia combinata, ma non solo: dalle evidenze alla pratica clinica</strong>     247<br /><em>P. Gnerre, O. Para, G. Balbi</em></p><p class="titolo"><strong>Gli omega-3 nell’obesità e nell’insulino-resistenza</strong>     260<br /><em>M. Poggiano</em></p><p class="titolo"><strong>Gli omega-3 nel diabete mellito di tipo 2</strong>     262<br /><em>M. Poggiano</em></p><p class="titolo"><strong>Gli effetti degli omega-3 sulle aritmie</strong>     265<br /><em>C. Cenci</em></p><p class="titolo"><strong>Gli effetti degli omega-3 nella prevenzione dell’infarto miocardico</strong>     269<br /><em>R. Gerloni</em></p><p class="titolo"><strong>Omega-3 e scompenso cardiaco</strong>     274<br /><em>R. Gerloni</em></p><p class="titolo"><strong>I prodotti naturali: una possibile alternativa alle statine per la riduzione del colesterolo</strong>     279<br /><em>M.C. Pasquini</em></p><p class="titolo"><strong>Nutrizione, omega-3 e cancro</strong>     288<br /><em>A. Mazza, G. Rubello, G. Mazza</em></p><p class="titolo"><strong>Gli omega-3: trigliceridi naturali o esteri etilici?</strong>     301<br /><em>P. Zuccheri, C. Iacono, G. Benini</em></p><img src="/public/site/images/pgranata/concl.jpg" alt="" /><p class="titolo"><strong>II ruolo degli omega-3 nel paziente pluripatologico complesso: dalle evidenze alla pratica clinica in Medicina Interna</strong>     306<br /><em>A. Fontanella</em></p>

Lorentz microscopy sheds light on the role of dipolar interactions in magnetic hyperthermia

Monodispersed Fe3O4 nanoparticles with comparable size distributions have been synthesized by two different synthesis routes, co-precipitation and thermal decomposition. Thanks to the different steric stabilizations, the described samples can be considered as a model system to investigate the effects of magnetic dipolar interactions on the aggregation states of the nanoparticles. Moreover, the presence of magnetic dipolar interactions can strongly affect the nanoparticle efficiency as a hyperthermic mediator. In this paper, we present a novel way to visualize and map the magnetic dipolar interactions in different kinds of nanoparticle aggregates by the use of Lorentz microscopy, an easy and reliable in-line electron holographic technique. By exploiting Lorentz microscopy, which is complementary to the magnetic measurements, it is possible to correlate the interaction degrees of magnetic nanoparticles with their magnetic behaviors. In particular, we demonstrate that Lorentz microscopy is successful in visualizing the magnetic configurations stabilized by dipolar interactions, thus paving the way to the comprehension of the power loss mechanisms for different nanoparticle aggregates.

Tuning the radial structure of core–shell silicon carbide nanowires

By varying the growth conditions in chemical vapour deposition synthesis we demonstrate the possible tuning of the core–shell ratio of SiC/SiO₂ nanowires.

Pain management in internal medicine and effects of a standardised educational intervention: the FADOI-DOMINO study

PURPOSE

Few real-world data are available on the frequency and management of pain in Internal Medicine (IM). Aims of our study were to assess the prevalence of pain in IM, and to evaluate the effects on pain management of a standardised educational programme.

MATERIALS AND METHODS

The study was performed in 26 IM Units in Italy, with two cross-sectional surveys (PRE phase and POST phase) interspersed with an educational programme. In PRE phase each Centre reviewed the hospital charts of the last 100 consecutive patients hospitalised for any cause. An educational programme was conducted in each Centre by means of the 'outreach visit', a face-to-face meeting between health personnel and a trained external expert. Six months after, each Centre repeated the data collection (POST phase), specular to the PRE.

RESULTS

A total of 5200 medical charts were analysed. Pain was documented in 37.5% of the patients. After the educational intervention, the intensity of pain was appropriately assessed in a higher percentage of patients (77.4% vs. 47.8%, p = 0.0001), and it was more frequently monitored during hospitalisation. Qualitative definition of pain (pathogenesis, duration, etc.) increased in POST phase (75.4% vs. 62.7%, p = 0.0001). A 73.3% increase in the use of strong opioids was detected following educational programme.

CONCLUSIONS

Pain affects 4 out of 10 patients hospitalised in IM. According to our large real-world study, to implement a standardised one-shot educational programme may persistently improve the attitude of health personnel towards the characterisation and management of pain.

Cytocompatibility and cellular internalization mechanisms of SiC/SiO2 nanowires

First evidence of in vitro cytocompatibility of SiC/SiO2 core-shell nanowires is reported. Different internalization mechanisms by adenocarcinomic alveolar basal epithelial cells, monocytic cell line derived from an acute monocytic leukemia, breast cancer cells, and normal human dermal fibroblasts are shown. The internalization occurs mainly for macropinocytosis and sporadically by direct penetration in all cell models considered, whereas it occurred for phagocytosis only in monocytic leukemia cells. The cytocompatibility of the nanowires is proved by the analysis of cell proliferation, cell cycle progression, and oxidative stress on the cells treated with NWs as compared to controls. Reactive oxygen species generation was detected as an early event that then quickly run out with a rapid decrease only in adenocarcinomic alveolar basal epithelial and human dermal fibroblasts cells. In all the cell lines, the intracellular presence of NWs induce the same molecular events but to a different extent: peroxidation of membrane lipids and oxidation of proteins. The NWs do not elicit either midterm (72 h) or long-term (10 days) cytotoxic activity leading to irreversible cellular damages or death. Our results are important in view of a possible use of SiC/SiO2 core-shell structures acting as biomolecule-delivery vectors or intracellular electrodes.

Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators

BACKGROUND Pulmonary embolism (PE) is a potentially fatal disease. Diagnosis is challenging for clinicians because clinical presentation is variable and there is no diagnostic test that combines sufficiently high sensitivity and specificity to be used alone in clinically suspected PE. AIM OF THE STUDY PIOPED II investigators have formulated recommendations for the diagnostic approach to patients with suspected PE based on randomized trials. METHODS Diagnostic work-up recommendations were formulated based on the results of the Prospective Investigation of Pulmonary Embolism Diagnosis II and outcomes studies. RESULTS In many patients that present the combination of low or moderate clinical probability with negative D-dimer PE can be safely excluded. In other patients with suspected PE and positive D-dimer a CT angiography in combination with CT venography is recommended. PIOPED II investigators have also formulated recommendations for patients with suspected PE and allergy to iodinated contrast medium, with impaired renal function, and for women at fertile age and during pregnancy. In patients with discordant findings between clinical assessment and CTA o CTA/CTV, and with segmental or sub-segmental EP, further evaluation may be necessary and the diagnosis should be re-assessed. DISCUSSION AND CONCLUSIONS PIOPED II recommendations are of particular interest because consider, after the right clinical evaluation necessary for risk stratification of PE, the most recent, sensitive and specific imaging techniques for definitive diagnosis, such as CTA and CTV. D-dimer evaluation is recommended but, however, its low specificity is not underlined. The importance of combining CTA and CTV for a complete evaluation of the deep venous system is stated, but the difficulties of a routinary similar approach are not considered and alternative techniques, like compressive ultrasound and Colour Doppler ultrasound, are not proposed. The study faces also the issue of segmental and sub-segmental embolism, that presents a difficult clinical interpretation: the recommendations are, before starting the therapy, to re-evaluate and confirm the diagnosis, to avoid the risk of overtreatment.

Fondaparinux

AIM OF THE STUDY To review the best evidence-based knowledge about the clinical pharmacology and use of fondaparinux. DESIGN OF THE STUDY Narrative review. RESULTS Fondaparinux is a synthetic pentasaccharide anticoagulant that binds selectively with high affinity to antithrombin and catalyses the inactivation of factor Xa, which results in a dose-dependent inhibition of thrombin generation. Fondaparinux does not bind to platelets or inhibit platelet aggregation, does not cross-react with antibodies to heparin-PF4 complexes (HIT antibodies) and has no effects on the activated partial thromboplastin time, prothrombin time and antithrombin levels. Fondaparinux shows a linear and highly predictable pharmacokinetic profile in humans, with very limited intraindividual and interindividual variability, which makes routine monitoring and dose adjustments unnecessary for the majority of the population. After subcutaneous iniection fondaparinux undergoes complete and dose-independent absorption; it is not significantly metabolized by the liver and does not interfere with cytochrome P450-mediated transformation of other drugs. Fondaparinux is almost entirely excreted unchanged in the urine with a half-life of approximately 17 hours, allowing for once-daily dosing. Its plasma clearance is reduced in patients with moderate or severe renal insufficiency. In the clinical trials and post-marketing surveillance fondaparinux shows an excellent tolerability profile, with a low incidence of major bleeding across a wide dose range and no cases of severe thrombocytopenia or heparin-induced thrombocytopenia (HIT). CONCLUSIONS Fondaparinux has been approved in many countries for use in thromboprophylaxis after major orthopedic surgery and in medical patients, and for the treatment of sintomatic venous thromboembolism (deep venous thrombosis and hemodynamically stable pulmonary embolism) and acute coronary syndromes (unstable angina, and acute miocardial infartion, with or without ST elevation). In these clinical settings fondaparinux is at least as effective and safe as unfractionated heparin or low molecular weight heparins, and may be easier to use.

Cardiovascular risk and inhibition of cyclooxygenase: traditional nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors

BACKGROUND The development of non-selective nonsteroidal anti-inflammatory drugs (tNSAIDs) and, more recently, of selective inhibitors of the cycloooxygenase-2 isoform (COXIBs), has contributed greatly towards the effective management of patients with arthritis and pain complaints. Although COXIBs have demonstrated an improved gastrointestinal tolerability compared with tNSAIDs, the cardiovascular effects of the two drugs types are much controversial. By blocking prostacyclin formation but leaving platelet-derived thromboxane A2 generation unopposed, the potential gastrointestinal benefit of COXIBs may come at cost of increased thrombotic risk. AIM OF THE STUDY This review aims at analysing the cardiovascular effects of the tNSAIDs and COXIBs. METHOD This review addresses the controversy of effects of COXIBs and tNSAIDs in 4 segments. It begins with a discussion about pathophysiological effects of cyclooxygenase inhibition on cardiovascular system. This is followed by a systematic review and meta-analysis of a control, randomized, double blind study and population-based matched case-control study to compare the risk of serious cardiovascular events with tNSAIDs and COXIBs. Then it answers to key questions with the aim to assist the clinicians for a systematic approach to evaluate the risk-benefit-ratio of NSAIDs in the clinical practice. Finally we analyse the open questions associated with the use of NSAIDs and the cardiovascular events. RESULTS The use of rofecoxib demonstrated an increase in adverse cardiovascular events. This toxic effect is not dose-related. The relationship between celecoxib and cardiovascular risk is less clear. The results of different clinical trials are conflicting: some didn’t demonstrate increase in cardiovascular toxicity but the APC study and recently a metanalysis reported a significant incidence of adverse cardiovascular events. Also valdecoxib and parecoxib appear to have increased risk for cardiovascular toxicity. Eterocoxib is still the object of three ongoing clinical trials. The TARGET study demonstrated for lumiracoxib a low increase in cardiovascular events compared with ibuprofen and naproxen. Also the use of ibuprofen (800 mg t.i.d.), diclofenac (75 mg b.i.d.) and indomethacin is reported to cause adverse cardiovascular events. The use of naprosen shows a better profile regarding cardiovascular toxicity. tNSAIDSs can worse clinical condition of patients affected by chronic cardiac failure and rofecoxib but not celecoxib can disclose clinical cardiac failure. A politherapy with both tNSAIDs and rofecoxib demonstrated an increase of blood arterial pressure and peripheral oedema. CONCLUSIONS This review confirms the findings from randomized trials, meta-analysis and observational studies regarding the risk of cardiovascular events with rofecoxib, valdecoxib e parecoxib, whereas the evidence for other COXIBs is not so clear. Also in the class of tNSAID some drugs (diclofenac and ibuprofen) can have an increased cardiovascular toxicity.

A randomized controlled trial of rituximab for the treatment of severe cryoglobulinemic vasculitis

OBJECTIVE

To conduct a long-term, prospective, randomized controlled trial evaluating rituximab (RTX) therapy for severe mixed cryoglobulinemia or cryoglobulinemic vasculitis (CV).

METHODS

Fifty-nine patients with CV and related skin ulcers, active glomerulonephritis, or refractory peripheral neuropathy were enrolled. In CV patients who also had hepatitis C virus (HCV) infection, treatment of the HCV infection with antiviral agents had previously failed or was not indicated. Patients were randomized to the non-RTX group (to receive conventional treatment, consisting of 1 of the following 3: glucocorticoids; azathioprine or cyclophosphamide; or plasmapheresis) or the RTX group (to receive 2 infusions of 1 gm each, with a lowering of the glucocorticoid dosage when possible, and with a second course of RTX at relapse). Patients in the non-RTX group who did not respond to treatment could be switched to the RTX group. Study duration was 24 months.

RESULTS

Survival of treatment at 12 months (i.e., the proportion of patients who continued taking their initial therapy), the primary end point, was statistically higher in the RTX group (64.3% versus 3.5% [P < 0.0001]), as well as at 3 months (92.9% versus 13.8% [P < 0.0001]), 6 months (71.4% versus 3.5% [P < 0.0001]), and 24 months (60.7% versus 3.5% [P < 0.0001]). The Birmingham Vasculitis Activity Score decreased only after treatment with RTX (from a mean ± SD of 11.9 ± 5.4 at baseline to 7.1 ± 5.7 at month 2; P < 0.001) up to month 24 (4.4 ± 4.6; P < 0.0001). RTX appeared to be superior therapy for all 3 target organ manifestations, and it was as effective as conventional therapy. The median duration of response to RTX was 18 months. Overall, RTX treatment was well tolerated.

CONCLUSION

RTX monotherapy represents a very good option for severe CV and can be maintained over the long term in most patients.

Venous thromboembolism in patients hospitalized in internal medicine wards

Venous thromboembolism (VTE) is one of the main causes of morbility and mortality in the ospedalized patients. Epidemiologist studies have also demonstrated that VTE is an important and frequent problems in medical patients. In surgical patients is done with greater frequency, but in medical patients prophylaxis is not completely codified and less often less practiced. This review shows epidemiological data, risk factors and classification of the risk of VTE in patients with medical pathologies. Then meta-analyses studies and main studies such as Medenox, Prevent and Artemis, that have examined the prophylaxis of VTE in medical patients are described and discussed, along with their results concerning morbility and mortality. The current problems of prophylaxis in medical patients are reviewed , such as duration of treatment, optimal dosage of the low molecular weight heparin (LMWH) and the correct risk assessment of VTE. EXCLAIM Study has showed the benefit of extended prophylaxis with statistically significant reduction in VTE events.

Suspected acute allergic reactions: analysis of admissions to the Emergency Department of the AOU Maggiore della Carità Hospital in Novara from 2003 to 2007

OBJECTIVE OF THE STUDY

The aim of our work is to ascertain the frequency and the impact of acute allergic reactions on the routine of a highly-specialized Emergency Department collecting information on the admission, the typology of symptoms and the degree of severity calculating the incidence and the outcomes of the events.

MATERIALS AND METHODS

The study started the 1 July 2006 and the records of the Emergency Department of the Maggiore della Carità Hospital in Novara were consulted retrospectively in the period between the 1 January 2003 and the 31 December 2006, and prospectively up to the 31 December 2007, using keywords that could identify admission for suspected allergic reactions. Information relating to internal medicine and/or pediatric cases were examined, excluding all surgical and/or trauma cases. The number ofadmissions per year was considered broken down by clinical signs, triage assessment upon admission and discharge outcome.

RESULTS

Admissions to the Emergency Department during the period under consideration were 165,120 with 6107 suspected cases of allergic reactions. The symptoms most frequently reported both in adults (A) and children (C < or =18 years old), were: hives 37%, asthma 20.65 (A)% and 27.4% (C); drug allergy 7.5% (A) and 6.1% (C). Reactions to Hymenoptera venom were less frequent, 4.7% (A) and 1.27% (C); the frequency of angioedema, conjunctivitis and rhinitis was between 1 and 4%. The incidence of food allergies (1.4%) and anaphylaxis (0.8%) was comparable for all ages. The triage assessment showed a significant percentage of "yellow" and "red" codes, with 362 cases (5.9%) and 71 cases (1.16%) respectively. A total of 151 patients was hospitalized, no one classified as "white" code. Death occurred in 7 cases: 4 "yellow" codes and 3 "red" codes, respectively. A more detailed specialistic evaluation was recommended in only 10% of the patients.

CONCLUSIONS

Admissions to the Emergency Department for suspected allergic reaction are proportional to the number of overall admissions for internal medicine cases and do not appear to be related to the general increase of allergies in the population. This led us to focus our attention on how allergic diseases impact the work of an Emergency Department and how to describe the discharge diagnosis better. A significant number of descriptive diagnoses also turned out to be inaccurate and did not allow the syndrome to be identified properly. The analysis of this information aims to be a stimulus to improve the emergency clinical approach used for allergic diseases and to plan the adequate management ofallergic patients after they have been treated in hospital.

[Hemorrhagic syndrome during high-dose ampicillin treatment]

In high doses, the beta-lactams--particularly cephalosporins--can cause bleeding from impairment of prothrombin formation. We report a case of hemorrhagic syndrome in a 63-year-old woman during therapy with high doses of ampicillin for Listeria monocytogenes meningitis.

[Hepatosplenic cat-scratch disease in the immunocompetent adult]

Atypical manifestations of cat-scratch disease have been described in children and immunosuppressed adults. We report the first case of hepatosplenic cat-scratch disease in an immunocompetent subject, demonstration of diversity of this infection. A 33-year-old man presented with prolonged fever, lymphadenopathy and multiple hypodense lesions of liver and spleen in ultrasonographic imaging. The hepatic biopsy showed non-specific inflammatory reactions including granulomata and stellate necrosis. Anti-Bartonella antibodies have been found. The therapy with clarithromycin and doxycycline for many weeks was effective for hepatic lesions. A month ago a history of a cat contact with the presence of a skin lesion has been reported.

Flare and tumor lysis syndrome with atypical features after letrozole therapy in advanced breast cancer. A case report

Tumor lysis syndrome, which develops after effective therapy of malignant conditions and leads to hyperuricemia, hyperkaliemia, hyperphosphatemia, hypocalcemia and elevated lactate dehydrogenase, is uncommon in solid tumors. In breast carcinoma it can be associated with tamoxifen flare, i.e. a transient increase in symptoms, mainly bone pain, observed shortly after the start of tamoxifen therapy. We report the case of a patient with advanced breast carcinoma involving the pleural space, unresponsive to combined chemotherapy, who experienced rapid worsening after the initiation of letrozole. Her symptoms included shock, bilateral pleural effusion, cardiac tamponade and oliguria. Laboratory parameters disclosed elevated transaminase, lactate dehydrogenase, uric acid and D-dimer blood levels. The patient was in critical condition for nearly 2 weeks. She improved progressively and has remained well and in complete remission for 20 months. This clinical picture suggests increased damage to the pleura (and probably the pericardium) and rapid leakage of tumor products, following the start of endocrine therapy. Letrozole is a non-steroidal aromatase inhibitor which is used in advanced breast cancer, resistant to first-line endocrine/chemotherapeutic treatment. Our review of the literature did not disclose any other descriptions of flare and tumor lysis syndrome after aromatase inhibitor therapy. Moreover, this case was characterized by atypical and complex clinical features. The aim of this presentation is to point out the practical significance, in neoplastic patients, of the differential diagnosis between symptoms due to tumor progression and those associated with anomalous reactions to therapy.

Familial clustering of IgA nephropathy: further evidence in an Italian population

Several lines of evidence suggest that genetic factors have an important role in the pathogenesis of immunoglobulin A (IgA) nephropathy. We report the prevalence of familial IgA nephropathy in a referral center in northern Italy and present the data on HLA genotypes in the families identified. Twenty-six of 185 patients (14%) with IgA nephropathy investigated in Brescia, Italy, were related to at least one other patient with the disease. Restriction fragment length polymorphism (RFLP) analysis of HLA-DR beta and HLA-DQ alpha and beta genes, as well as polymerase chain reaction-based oligonucleotide typing, was performed in family members. The 26 patients with IgA nephropathy belonged to 10 families. Familial relationships between the patients varied greatly, ranging from parent-child to sib-pair to more distant familial relationships. No common nephrotoxic factor was identified in the families. The intervals separating the apparent onset of disease in relatives with IgA nephropathy varied from 8 months to 13 years. In patients with a family history of IgA nephropathy, there was an increased incidence of HLA-DRB1*08 compared with those with sporadic IgA nephropathy. The study shows that a significant number of the patients with IgA nephropathy followed up in Brescia had a family history of disease. The fact that the Italian population, an ethnic group not previously examined, also presents an increased familial susceptibility to IgA nephropathy suggests that familial predisposition is a very common finding for IgA nephropathy. Thus, clinicians should become aware that IgA nephropathy may aggregate within families in a substantial number of cases. In addition, this subgroup of patients with IgA nephropathy offers an ideal opportunity to elucidate the molecular genetics of this disease.

[Lipid metabolic disorders in obesity: their epidemiology, physiopathology and clinico-therapeutic implications]

The centralization of body fat, particularly in abdominal or visceral depots, is associated with qualitative and quantitative lipid abnormalities. Examples of these qualitative alterations include changes in low density lipoprotein composition, namely an increased number of small or dense low density lipoprotein particles, which seem to be prone to increased lipid oxidation. Oxidative modification of low density lipoproteins is involved in atherosclerotic development of the arterial wall. Alterations of lipid composition often arise in a context of insulin resistance with hyperinsulinism. Genetic features, such as apolipoprotein E polymorphism, also play a significant role in lipoprotein metabolism. The principle treatment of obesity and associated dyslipidemia is to reduce energy intake through diet. Moderate exercise is effective, especially in patients with insulin resistance. Drug therapy is considered primarily for patients who refuse to make behavioral changes.

Portal and mesenteric thrombosis in protein S (pS) deficiency

Portal and/or mesenteric thrombosis is a rare occurrence, and often an underlying hypercoagulable state can be found. We describe a case in which a mesenteric infarction due to mesenteric venous thrombosis occurred as the first manifestation of an inherited type I deficiency of protein S, whereas signs of portal thrombosis emerged later.

Which treatment for which patient in the future? Possible modifications in CAPD

On 578 unselected new patients followed from 1981 through 1993, 51% on CAPD and 49% on HD, long-term patient and method survivals, cause of death, and drop-out in the two methods were compared. Survival, adjusted for patient selection biases, was not different on CAPD and HD up to 10 years. 50% of the patients were still in their first treatment after 3.5 years on CAPD and after 7 years on HD, and 5 and 28% respectively, after 10 years. Patient survival on CAPD was not falsely improved by drop-outs. Drop-out is increasing for CAPD, mainly due to patient/partner burn-out, which should be relieved by a more liberal application of automated PD. Malnutrition is more frequent on CAPD than on HD but not for the elderly. In a 3 year prospective study on 60 CAPD and 34 HD patients serum albumin, nPCR and nutritional status, as assessed by SGA did not influence survival in each modality. Survival was similar with K(p,r)t/V > or = 1.7/week on CAPD and Kt/V > or = 1/treatment on HD, and worse below these values. On CAPD, a Kp,rt/V > or = 1.96 gave better survivals.

Behaviour of Listeria monocytogenes during the maturation of naturally and artificially contaminated salami: effect of lactic-acid bacteria starter cultures

The antimicrobial activity of a bacteriocin-producing Lactobacillus plantarum MCS strain against Listeria monocytogenes in naturally and artificially contaminated salami was evaluated in comparison with that of other non bacteriocin-producing lactic-acid bacteria (i.e., L. plantarum MCS1 mutant strain and two commercial starter cultures). In salami not inoculated with lactic-acid bacteria, moderate L. monocytogenes growth was observed after 7-14 days. The addition of the starter cultures prevented growth, but not always the survival of Listeria. During the maturation of artificially-contaminated salami, Listeria counts tended to decrease, but no significant differences were observed between samples inoculated with L. plantarum MCS or with the MCS1 bacteriocin-negative mutant strain. However, at the end of the maturation period, in naturally-contaminated salami, differences in the survival of Listeria (recovered by enrichment) were observed in the batches inoculated with the different lactic-acid bacteria: Listeria appeared to be absent only in salami inoculated with the L. plantarum MCS strain.

[Microalbuminuria: theoretical bases and new applications]

The constant presence of albumin, as detected by common biochemical methods, in multiple urine samples of a patient, was first considered by Bright, in 1836, as a cardinal sign of renal disease ("clinical proteinuria"). Since then this view was widely adopted for studying the clinical evolution of the patients with diabetes mellitus, whose high risk to develop proteinuria and subsequently a progressive decline of renal function was well known. Thus the finding of "clinical proteinuria" by traditional, merely biochemical techniques, has been considered for more than one century as the opening event in the onset of diabetic nephropathy, and a distinctive sign of glomerulopathy in general. More recently, this view has been deeply criticized, mainly because it lies on the implicit assumption that the sensitivity limits of the biochemical tests for the detection of urinary protein concentrations (about 300 mg/dl), coincide with the ones that can distinguish non nephropathic from nephropathic patients (either diabetic or not). Indeed new techniques, that detect urinary proteins down to 1 microgram/ml, have shown that the upper limit of protein excretion in healthy people is well below the minimum concentration detectable by all the traditional tests. Therefore a new clinical entity, named "microproteinuria" has been defined, meaning the urinary excretion rate ranging between the "physiological" and the "clinical" proteinuria; its pathophysiologic, diagnostic and prognostic significance has been extensively evaluated in the last 20 years. Microproteinuria has been shown to represent a crucial event in the natural history of the diabetic nephropathy; in diabetic patients it is strictly related to the risk of future (months to years) development of overt nephropathy and chronic renal failure, and it may predict the risk of macroangiopathic complications. More recently new settings have been proposed for the study of microproteinuria, as an early and sensitive marker of cardiovascular diseases in hypertensive non diabetic patients and even in non hypertensive non diabetic elderly people. The role of microproteinuria in the diagnosis and follow-up of many non-diabetic glomerulopathies is a very interesting though still unexplored field.

Hepatotoxicity of hydroxy-methyl-glutaryl-coenzyme A reductase inhibitors

The first clinical studies on hydroxy-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors reported a low incidence of liver toxicity. The personal observation of a case of simvastatin-induced acute cholestatic hepatitis prompted us to evaluate the true incidence of hepatic side effects of these drugs in a large Italian population. One hundred patients taking simvastatin and ninety patients treated with pravastatin were followed-up six months with periodical evaluation of serum lipid levels and liver function test. In 5% of simvastatin-treated patients and 4.5% of pravastatin-treated patients significant liver toxicity was observed, which required drug discontinuation. The mechanism of liver damage was direct, idiosyncratic, but immunological features of drug toxicity could be hypothesized in one patient.

[Current aspects of the diagnosis of arterial hypertension]

Arterial blood pressure (BP) is widely believed to be a main risk factor for cardiovascular diseases. The chance to develop some kind of vascular injury is almost exponentially and continuously related to BP values at a given age. In accordance, the WHO stated the upper limits for diastolic and systolic BP beyond which it is reasonable to anticipate a clear statistic advantage from the hypotensive treatment (of either pharmacologic or other kind). However many studies have shown that the relation coefficient between BP values and the occurrence of cardiovascular diseases is on the whole quite weak, even under rigorously controlled conditions. This could be, at least in part, due to the fact that the severity of the cardiovascular damage depends on the "global" hypertensive load continuously charging the patient's cardiovascular system along the whole life: the "random" measurement of the BP is indeed a poor statistical index of such load because of the wide variability of BP with time. Thus many sources of BP variability have been studied, in order to develop multiple-measurement methods of BP monitoring hopefully with more prognostic power. In this article we review the major problems inherent to the methodological development of the serial full-automatic sphygmomanometric ambulatory BP monitoring, such as its concordance with different more traditional techniques, the statistic effectiveness of intermittent (versus continuous) sampling, the psychological impact of multiple cuff inflations during the day and the night.(ABSTRACT TRUNCATED AT 250 WORDS)

[IgE-mediated allergy to ethylene oxide in hemodialyzed patients]

Ethylene oxide (ETO) is widely employed in sterilization of hemodialysis materials. Many studies have shown that ETO may act as an antigenic compound when bound to human albumin, therefore eliciting allergic reactions during hemodialysis. In the present study, we investigated in 93 patients undergoing long-term hemodialysis the prevalence of sensitization to ETO. All the patients were investigated for the presence of allergic or pseudo allergic reactions during the treatment. Specific IgE to ETO were found in sera of 3 patients: 1 suffered from urticaria and 1 from glottic edema and hypotension during the dialysis. The third one had non symptoms. The employ of a gamma-rays sterilized filter determined the disappearance of clinical manifestations in the two symptomatic patients, therefore suggesting a pathogenetic role of the specific IgE to ETO in determining the clinical manifestations.

[Heart involvement in anorexia nervosa: an electrocardiographic, functional and morphological study]

Mental anorexia (MA) is the most frequent condition of malnutrition in industrialized countries. Sudden death in MA is not infrequent. Furthermore, the role of nutritional state as an important determinant of myocardial function is known. Cardiovascular function was studied in 9 patients with MA. Blood electrolytes and thyroid function were assessed, basal and dynamic ECG, chest roentgenogram, M-mode echocardiography, ergometric test, cardiac output measurement and, in two cases, magnetic nuclear resonance (MNR) were performed. Our data confirm the ECG changes which were preeminent in the clinical context, as predictors of possible major, life-threatening arrhythmic events. The correct QT interval was normal in all patients. In 4 cases with heart rate less than 40 b/min, Holter ECG showed ventricular and atrial extrasystolic beats. In one case S-A blocks with idioventricular substitutive beats were recorded; the normal performance under maximal strain stands for a normal functional reserve. Blood electrolytes were in the normal range. The hypothalamic-pituitary axis can be considered as a cocausal factor by means of autonomic nervous system modulations. Echocardiography revealed only a mild reduction of ventricular wall thickness. Scattered degenerative myocardial involvement as shown by MNR imaging, could be the anatomical counterpart of a clinically emerging cardiomyopathy with potentially severe arrhythmias.

Acute cholestatic hepatitis during simvastatin administration

Simvastatin, recently introduced in clinical practice for pharmacological treatment of hypercholesterolemia, has been found to cause minor and reversible elevations of serum transaminases. We report a case of acute cholestatic hepatitis during simvastatin therapy. Clinical, biochemical, immunological, and histological findings were consistent with a simvastatin-induced liver damage through an immunological-mediated mechanism. This case suggests a careful monitoring of liver function tests during simvastatin therapy, and caution in continuing simvastatin administration when elevations of serum transaminases take place.

[Lipoprotein (a)]

Lipoprotein(a) [Lp(a)] is a high molecular weight plasma protein structurally related to low density lipoprotein (LDL), but with distinct metabolic and biologic features. Six different isotypes may be found among the general population; they are inherited as a codominant autosomic monogenic trait. Lp(a) levels in the blood are strictly conditioned by the isotype and much less, if at all, by other environmental or metabolic factors. The Lp(a) catabolic rate is very similar among different individuals and comes from the balance of two complementary pathways: uptake from blood by tissue cells via LDL-receptors, and non-receptor macrophagic internalization at the level of the reticulo-endothelial system. Its high content in lysolecithins and cholesterol, and the close structural similarity of its peptidic component to plasminogen, make Lp(a) a crucial "meeting point" of two main physiopathologic elements of atherogenesis:lipoprotein metabolism and fibrinolysis. This particular role would seem to explain the experimental finding of a close relation between Lp(a) plasmatic levels and the severity of atheromatous processes. Deep understanding of Lp(a) physiopathology is therefore expected to be a powerful tool for the creation of a comprehensive and practical model of atherogenesis and to enable us to deal with prognostic, preventive and therapeutic problems in this field from a new view point.