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.

Mitochondrial DNA content: A new biomarker for sudden intrauterine unexplained death syndrome (SIUDS).

In literature there are no data related to mitochondrial DNA (mtDNA) content in sudden intrauterine unexplained death syndrome (SIUDS). To test the hypothesis that a quantitative excess of mtDNA could play a role in the pathogenesis of SIUDS, mtDNA content was measured in cerebral cortex of 9 SIUDS and in 7 controls. The median (interquartile range) mtDNA in SIUDS and controls was 14,000 (8600-33,500), 3400 (0-8500) copies per nuclear DNA, respectively (p=0.007). If mitochondria are involved in SIUDS, then higher mitochondrial DNA content may be a biomarker of this syndrome.

Natural molecules for the therapy of hyperandrogenism and metabolic disorders in PCOS.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is the most common endocrinopathy of women of reproductive age and a complex endocrine condition, due to its heterogeneity and uncertainty about its etiology. However, PCOS is also associated with other metabolic abnormalities such as insulin resistance, impaired glucose tolerance, and diabetes. There are few medications that are approved for the most common symptoms of PCOS, leading to the off-label use of medications that were approved for other indications. One of the most common medications being used off label for PCOS is metformin. Research of other effective therapeutic options has included the utility of inositol. PATIENTS AND METHODS: A systematic literature search of PubMed was performed using the following combination of terms: 'PCOS', 'hyperandrogenism' 'inositol', 'natural molecules'. Only papers published between 2000 and 2016 were included in our analysis. The present review analyzes all aspects of the choice of natural molecules in the treatment of hyperandrogenism and metabolic disorders in PCOS women. RESULTS: The rationale underlying the use of inositols as a therapeutic application in PCOS derives from their activities as insulin mimetic agents and their salutary effects on metabolism and hyperandrogenism without side effects. CONCLUSIONS: In this review will discuss the role of a number of natural associations between inositol and different substances in the treatment of hyperandrogenic symptoms in PCOS women.

[Primary adenocarcinoma of jejunum with obscure gastrointestinal bleeding]. / Adenocarcinoma primitivo del digiuno ad esteriorizzazione con enterorragia.

A case of primary small bowel adenocarcinoma is reported because of the rarity of this malignancy. Interestingly, the location of the tumour was in jejunum, instead of the most common site in duodenum. The clinical presentation was anemia, with positive fecal blood test, under antiaggregant platelet treatment for coronary heart disease, initially related to endoscopic evidence of erosive gastroduodenitis. The exacerbation of gastrointestinal bleeding during proton pump inhibitors therapy and the recurrence of abdominal pain caused careful investigation. The source of the obscure gastrointestinal bleeding had been achieved by wireless capsule endoscopy, because of not diagnostic findings of conventional upper endoscopy control, colonscopy, double contrast enteroclysis and selective arteriography. The primary definitive therapy was a radical resection of the jejunal neoplastic loop, important prognostic factor.

[Bacterial endocarditis from the stimulatory unit of a cardiac pacemaker]. / Endocardite batterica su catetere stimolatore di pacemaker cardiaco.

Cardiac device endocarditis is an infrequent complication of permanent pacemaker and implantable cardioverter-defibrillator. A personal observation had been valued noteworthy in relation to the relatively low rates and clinical features. An old man presented recurrent fevers throughout 17 months before transesophageal echocardiography detection of intracardiac vegetations. The removal and replacement of the infected device via open thoracotomy had been successful, and subsequently confirmed in a prolonged follow-up.

Use of medical resources and quality of life of patients with chronic heart failure: a prospective survey in a large Italian community hospital.

AIMS: To assess the prevalence, clinical characteristics, use of medical resources and quality of life in consecutive patients with chronic heart failure (CHF) hospitalized in a large community hospital during 3 months. METHODS AND RESULTS: The study group included 354 patients with CHF, admitted in the Departments of Internal Medicine (97%) and Cardiology. Median age was 78 years [72;85], 45% were males. CHF was the main diagnosis in 72%; 28% were in NYHA class III and 49% in class IV; 42% had atrial fibrillation. The median hospital stay was 8 days [5;14], in-hospital mortality 9% in those admitted for CHF and 19% in those admitted primarily for other diseases. Patients with CHF occupied 15% of the beds; 1330 ECGs, 389 chest X-rays, 112 echocardiograms and 10 coronary angiograms were performed. A quality of life questionnaire revealed that 82% had problems with mobility, 54% with self-care and 88% with everyday activity. Thirty-nine percent of patients had at least one hospitalization during the previous year. CONCLUSIONS: Ninety-seven percent of hospitalized patients with CHF are admitted in the Internal Medicine wards and occupy 15% of beds. The majority of the patients are 72 years or older, with severe heart failure. The frequency of rehospitalization(s) and mortality rate in this population remains high. Echocardiography is performed only in 27% of patients.

[An epidemiological study of thyroid pathology in a group of hospitalized patients]. / Valutazione epidemiologica della patologia tiroidea in una casistica ospedaliera internistica.

The epidemiological impact of thyroid disease was assessed in a group of in-patients from an area with a potential iodine deficiency. The overall frequency of thyroid disease in the three years studied was approximately 4.91%, with a prevalence of elderly patients and a bias towards the female sex of 8.14:1. Nodular, single and multiple lesions were observed in 3.74% of hospitalised patients, whereas malignant forms were limited to 1.98% of the patients with nodular pathologies. When thyrotoxic syndromes were classified it was found that there was a predominance of multinodular toxic goitres over Basedow's disease. These findings are discussed and compared to previously published data.

[Syncope in hospital internal medicine]. / La sincope nella pratica internistica ospedaliera.

BACKGROUND: Syncope and presyncope are a relatively common problem in the general population. The differential diagnosis is complex, including benign forms and potentially life-threatening syndromes. In etiological terms, a variety of causes can be diagnosed, predominantly adopting a specialist approach to the problem. The aim of this study was to assess the epidemiological and clinical impact of syncope and presyncope in an internal medicine unit. METHODS: A prospective study was performed in cases of syncope and presyncope attending an internal medicine unit. A coded diagnostic and therapeutic protocol was used. The study included the cases discharged over a 6-month period (1/5/1998-31/10/1998). RESULTS: Syncope and presyncope were present in 6.73% of cases, mainly in elderly persons, female sex and with cardiovascular forms (6.25%). Neurally mediated syndrome was the most common form, followed by cardiac and cerebrovascular diseases, in accordance with most reports. This study confirmed the diagnostic value of an accurate anamnesis and in-depth objective examination, integrated by basic ECG. It is important to underline that this global approach to the problem allowed the recognition of gastrointestinal hemorrhage and pulmonary embolism with the trait of monosymptomatic syncope and presyncope. In the absence of significant electrocardiographic data, more extensive testing in patients restricted the cases of unknown form to 7.14%. CONCLUSIONS: Syncope and presyncope represent a multidisciplinary problem, frequently found in internal medicine, which benefits from the potential advantages of a global approach.

[Mixed cryoglobulinemia and the hepatitis C virus]. / Crioglobulinemia mista e virus dell'epatite C.

Mixed cryoglobulinemia is a cryoprecipitable immune-complex mediated disease, in which cryoglobulins are type II and III of the immunochemical classification of Brouet. Essential mixed cryoglobulinemia, in opposition to secondary, is characterized by the absence of well-defined underlying disease and clinically it shows the classical triad of Meltzer and Franklin. Several reports point to the frequent, through various, liver involvement in essential-defined mixed cryoglobulinemia. Particularly, the clinical and biological evidence of liver disease is commonly soft, in spite of the common bioptic evidence of persistent or chronic active hepatitis. The problem about which comes first in this association had been widely investigated, including the possible pathogenetic role of hepatotropic viruses. Initially some studies focused attention on hepatitis B virus, but now its importance is de-emphasized because of critical epidemiological review, results of HBV-DNA in cryoprecipitates, electron microscopy data. The recent opportunity of diagnostic tests for hepatitis C virus gave proof of its great importance in apparently essential mixed cryoglobulinemia. In fact, many researches have found a variously high prevalence of anti HCV antibodies and HCV-RNA in serum and cryoprecipitates, with selective concentration in the latter. Alpha interferon treatment has been suggested as first choice drug in the management of HCV related cryoglobulinemia. The mechanism is postulated to be primarily due to its antiviral activity. Up to date optimal dose and treatment period needs to be established.

[Unusual presentation of celiac disease in adult age]. / Presentazione atipica della malattia celiaca in età adulta.

The author report the case of a 23 year old female, where a severe iron-deficiency anemia was the only clinical expression of coeliac disease. This nonspecific appearance and similar reported observations with selected intestinal malabsorption emphasize the risk of diagnostic misleading in the prospective of atypical symptoms. The subsequent result is no glutin free diet style, with its protective role against malignancy. The non invasive screening method with related antibodies determinations is stressed important diagnostic tool.

[Epidemiological assessment of thyrotoxicosis in a hospitalized population]. / Valutazione epidemiologica della tireotossicosi in una popolazione ospedalizzata.

This personal survey aims to provide further epidemiological data on thyrotoxicosis in view of the fact that reports in the literature refer solely to a limited number of geographical areas. In particular an assessment was conducted on patients admitted to Pordenone Hospital with thyrotoxicosis between 1-1-1983 and 31-12-1984. The results obtained were compared with those encountered in other studies of this pathology.

[Hospital load of bacterial intestinal infections]. / Impatto ospedaliero delle infezioni intestinali batteriche.

BACKGROUND: Infectious diarrhea is a worldwide problem, with differences from country to country, and it is an important cause of infant morbidity and mortality in the underdeveloped countries. METHODS: The present study is a retrospective assessment on bacterial intestinal infections, referring to a hospital survey during the 1995-1996 period. The aim of the work is to verify epidemiological and clinical weight of this diseases. The total number of notifications appears rather small, although the limit relating to non-inclusion of paediatric admissions and Clostridium difficile infections. With regard to this problem, it must be emphasized that non-serious and speed recovering clinical pictures probably escape hospitalization. RESULTS: In the personal research it has been proved the clear supremacy of the group D Salmonella, as referred in other Italian studies. In our investigation, the greater number of cases occurred in summer and the suspected vehicle of infection was frequently foul eggs. The analysis of case reports proved that no importance was ascribed to the research of fecal leucocytes in the diagnostics of diarrhea. With regard to this easy examination, it must be stressed the non-specific role as a screening test for bacterial enteroinvasive infections. CONCLUSIONS: The treatment effected constantly involved the maintenance of adequate fluid-electrolyte balance. However the use of an antimicrobical agent recurred frequently, with preference for ciprofloxacin. In relation to the literature reports, this specifical therapeutic approach is discussed.

[The SCOOP II trial in heart failure]. / Lo studio SCOOP II (Scompenso nell'Ospedalizzazione Pubblica): proposta di un modello.

BACKGROUND: The aim of this study was to evaluate the effectiveness of a health education intervention aimed at improving therapeutic compliance and quality of life of patients with chronic heart failure (CHF). In this 1100 bed Community hospital 97% of patients with CHF admitted to the Internal Medicine Unit have a high rate of readmission, mortality and negative quality of life. METHODS: Two hundred patients (123 males, 77 females, mean age 75 years) were enrolled and randomized. CHF patients admitted to the Internal Medicine Unit were randomly assigned to usual care (n=100) or intervention group (n=100), which consisted of a nurse-guided education program, facilitated telephone communication and regularly scheduled follow-up visits with an internist. The primary endpoints were quality of life and quality of service improvement, and improved compliance with the heart failure guidelines. All patients were submitted to echocardiography. RESULTS: Ejection fraction is available for 87% of them. Baseline quality of life is similar in both groups. Final data will be available after April 2001.

[Association of hyponatremia and eosinophilia: correlated idiopathic hypereosinophilic syndrome and SIADH or adrenal insufficiency with secondary eosinophilia]. / Associazione di iponatriemia ed eosinofilia: sindrome ipereosinofila idiopatica e SIADH correlata o insufficienza surrenalica con eosinofilia secondaria?

A 56 year old man was admitted cause he had increasing symptoms as weakness, lethargy, disorientation. The total eosinophil count was 3000/mm3, the serum sodium concentration was 120 mmol per litre. In spite of severe hyponatriemia, urinary sodium excretion was not suppressed and serum osmolality (240 mOsm/Kg was lower than urine osmolality (488 mOsm/Kg). SIADH and Idiopathic Hypereosinophilic Syndrome was diagnosed because we found systemic failure signs due to hypereosinophilia (hepatitis, gastritis, pulmonary hypertension, and encefalopathy). Cortisonic treatment was started with symptoms improving, natriemia, eosynophil count and hepatitis signs normalization. After treatment stopping, reappeared asymptomatic hypereosinophilia, than we choosed Idrossiurea but, non-standing hypereosinophilia disappeared, appeared signs of preexisting adrenal insufficiency, emphasized by stopping cortisone therapy. A RMN showed an hypofiseal adenoma. Many cases of SIADH and Hypereosinophilia hiding adrenocortical insufficiency are reported with severe and unusual hypereosinophilia.

[Artificial nutrition and hydration: basic care or medical therapy]. / Considerazioni su un caso di sindrome neurolettica maligna da olanzapina.

The development of the healthcare systems has spread the use of artificial nutrition, both parenteral and enteral, as a solution for all the problems related to those diseases that prevent oral nutrition. The need for hydration and nutrition is a basic one for humans and its fulfilment is generally considered an ordinary care, always due, however the techniques of artificial nutrition raise the question whether they can be considered therapy that can be with holded or withdrawed according to criteria that avoid useless abuses (therapeutic fury). From an ethical point of view it is very important to define the futility (a term that comprises the evaluation of the proportionality, the adequacy and the ordinariness) of the means that medicine can offer. In the reviewed clinical studies the resort to artificial nutrition and hydration is justified only as a means of improving the quality of life, while the medical decision making on the usefulness or uselessness of a treatment must take into account the efficacy of the cure from a clinical point of view and its endurance by the patient and the caregiver. The adequacy and the proportionality of the cure or of the nutritional therapy do not depend thus on the disease or its stage, but on the clinical situation of the patient, on his caregivers and on the competence of the medical staff.