BACKGROUND: Thyroid nodules in patients with Graves' disease (GD) are common, and the incidence of coexisting thyroid carcinoma is a much debated subject, which is addressed in this study. METHODS: In order to determine the incidence rate of coexisting malignancy, a retrospective study was conducted on 103 patients who underwent surgery for GD between 1990 and 2000 at the Cliniques Universitaires Saint-Luc in Brussels, Belgium. The patients were classified into groups. Those in group I had a solitary palpable nodule (4.9%), those in group II multiple palpable nodules (12.6%), group IIIa had nodule(s) revealed by imaging techniques (incidentalomas: 17.5%), and group IIIb had diffuse non-nodular goiter (65%). RESULTS: Patients with nodules (groups I, II, and IIIa) were found to have significantly more thyroid carcinomas than those with diffuse non-nodular goiters (P=0.02), and the rate of malignancy was significantly increased when the nodules were palpable (groups I and II; P=0.03). Eight patients (7.8%) were diagnosed as having coexisting carcinomas, all but one being microcarcinomas. CONCLUSIONS: Well-differentiated papillary carcinomas are found to coexist with GD surgically treated (7.8%) and occur most frequently in GD with palpable nodular lesions (35%). Even though the majority (88%) of coexisting carcinomas are microcarcinomas, the presence of palpable nodules justifies further evaluation and follow-up.
We aimed to investigate the association between the presenting clinical manifestations of bacterial meningitis and the duration of time elapsed before lumbar puncture and start of antibiotic treatment.
Retrospective epidemiologic study using the clinical records in Barzilai Medical Center Emergency Department between 1988 and 1999.
97 patients, 72 children and 25 adults with ABM were identified. 30 of 97 (31%) were diagnosed by the primary physicians at primary care units. Acute meningitis was suspected by emergency department (ED) physicians in 51% of the referred patients. Patients with a scarce clinical picture at hospital arrival (those without fever, headache or nuchal rigidity) showed a trend toward a longer median delay until a diagnostic lumbar puncture was performed and antibiotic therapy was started (median of 14.7 h compared with 2.1 h for those with severe clinical picture) (p<0.02). Nevertheless, the clinical outcome for the total cohort did not yield a significant difference when analyzed regarding the duration of time between arrival to emergency department and antibiotic treatment initiation (p>0.3).
The interval before diagnosis of community acquired ABM in both children and adults is longer for those patients who present to the emergency department with an atypical clinical picture, mostly, without fever and without nuchal rigidity. Until bacterial meningitis can be effectively prevented, we can expect this life-threatening infection to continue to cause diagnostic and medical difficulties.
We report a retrospective study of 11 patients suffering from T-cell non-Hodgkin lymphomas preceded by immunological disorders including two chronic granulomatous diseases, one midline granuloma, four autoimmune hematologic disorders, one hypereosinophilic syndrome, two chronic lymphadenopathies, and one chronic angioedema. In the follow-up of these 11 patients, T-cell non-Hodgkin lymphomas were diagnosed. Even if we cannot exclude a fortuitous association, we feel that these conditions could constitute a 'prelymphomatous' stage.
We report the case of a 32-year-old male with hypercalcemia and recurrent nephrolithiasis as a symptom of primary hyperparathyroidism, hypoglycemia due to insulinoma, microprolactinoma, and a large, partially calcified tumor of the upper right leg. The patient underwent several surgical interventions including subtotal parathyreoidectomy, partial pancreatectomy, and percutaneous nephrolithotrypsy. Regular treatment with bromocriptine was required for normalization of serum prolactin concentration. His only sibling, a 26-year-old sister, suffered from microprolactinoma and had been treated with bromocriptine for 6 years. Their father had suffered from recurrent kidney stones and peptic ulcer and died at the age of 34. A novel 1113delC mutation within exon 7 of the menin gene was found in both siblings. This mutation results in a frame-shift with missense translation of the subsequent residual acids and preterm termination of the peptide at codon 357.
Ischemic stroke is a suddenly developing temporary or often permanent damage of the brain. Several candidate genes have been shown to have an impact in the pathogenesis of ischemic stroke. Recently, the -1131T>C polymorphism in apolipoprotein A5 (APOA5) gene has been reported to be associated with ischemic stroke in different racial groups, but no data is available currently in Han Chinese. Our study is to investigate the association between the APOA5 gene polymorphism -1131T>C and the susceptibility to ischemic stroke in Han Chinese.
310 controls and 342 patients with classified ischemic stroke were performed to detect the -1131T>C alleles genotyped by polymerase chain reaction-restriction fragment length polymorphism analysis in independent case-control study.
TG levels of subjects carrying -1131C allele were elevated compared to the subjects with -1131T allele in all ischemic stroke subgroups and in controls. The serum TC, LDL-C and HDL-C levels did not differ between subjects with T or C alleles in each group. The overall distribution of APOA5 -1131T>C genotype among stroke patients and controls was significantly different (P<0.01). Frequencies of CC homozygote and C allele were significantly higher in all stroke subgroups than those in control group. After adjustment for conventional risk factors, logistic regression analysis showed that C allele carrier (CC+CT) of -1131T>C was an independent risk factor for all stroke subgroups (P<0.05).
APOA5 gene -1131T>C polymorphism is independently associated with the development of ischemic stroke in Chinese Han population, and CC homozygote may have a promoting effect on ischemic stroke.
Background: The objective of this multicenter, parallel, double-blind, placebo-controlled clinical trial was to determine the efficacy and tolerability of the combination of ebastine 10 mg plus pseudoephedrine 120 mg once daily after 3 days of treatment in the symptomatic relief of patients with a common cold. Methods: The principal variable studied was the evaluation of overall efficacy and secondary variables were improvement of the patient, evolution of symptoms, disposition of the patient to take the medication again, and variation in nasal peak flow. Results: The percentage of subjects showing a good or excellent treatment efficacy was significantly higher in the group treated with ebastine plus pseudoephedrine (75.8%) than in the group treated with placebo (57.6%; p<0.001). Statistically significant differences were also found in favor of ebastine plus pseudoephedrine when comparing the changes in the sum of scores for nasal and ocular symptoms (p<0.006) or total symptoms (p<0.0016). The tolerability of the active treatment studied was good; that is, no significant differences were found between ebastine 10 mg plus pseudoephedrine 120 mg and placebo. Most adverse events described were slight or moderate in intensity, and no serious adverse events were reported. Conclusions: The combination of ebastine 10 mg immediate release and pseudoephedrine 120 mg sustained release was found effective in the symptomatic treatment of patients suffering from a common cold and as safe as placebo.
Hepatic granuloma (HG) is a well defined histopathological finding with an heterogenous clinical presentation. Diagnosis of a specific clinical entity is not possible every time. Descriptive studies may shed light on the various etiologies also common and distinctive findings among these patients.
We reviewed the results of the liver biopsies of 592 patients. Characteristics of the patients with HG were extracted from the hospital charts. Laboratory studies included biochemical tests, hepatitis C virus (HCV) antibody, Brucella agglutination tests, tuberculin skin test. According to the diagnostic clues further tests (thoracic computed tomography (CT), ultrasonography, organ biopsy in addition to liver, antimitochondrial antibody, hepatitis B surface (HBs) antigen, venereal disease research laboratory (VDRL)) were performed.
HG was found in 13 of the 592 patients (2.2%). Primary biliary cirrhosis (three cases) was the most frequent cause followed by sarcoidosis, miliary tuberculosis and BCGitis (Bacillus Calmette Guerin) (two cases each). Two patients with HG could not be diagnosed. Only three patients had remarkable physical examination findings. Alkaline phosphatase and gamma-glutamyl transpeptidase were the most frequently elevated enzymes. Abdominal ultrasonography provided no specific diagnostic clue in any patient. Localization of the HGs was portal in 6 patients, parenchymal in 5 patients and both portal and parenchymal in 2 patients. Three exitus were due to BCGitis, miliary tuberculosis and fungal infection.
Tuberculosis is still among the most common etiologic factors. BCGitis has a fulminant rather than an indolent course. Abdominal ultrasonography could be used to rule out obstructive jaundice rather than to reach a specific diagnosis. Involvement of portal area by HG in most of the cases might cause obstruction of the biliary canaliculi and elevation of the cholestatic enzymes. Follow up of the difficult cases may be the best approach since the presence of HG was not proved as a bad prognostic factor for any disease.
BACKGROUND: The aim of this retrospective study was to determine the clinical, laboratory, and radiological features of all adult patients with varicella-zoster virus pneumonia (VZVP) treated in our departments during the last 5 years. Important therapeutic and evolutionary features are also reported. METHODS: Fourteen patients (11 males and 3 females, mean age OF 36.4 and 34.3 years, respectively), diagnosed as suffering from VZVP, were included in this study. The antecedents of previous contact with patients with varicella, smoking, pregnancy, and underlying diseases were evaluated. In all cases, the diagnosis of pneumonia was established by clinical and radiological criteria in the course of varicella infection. RESULTS: All but one patient had had previous contact with a varicella patient. Eleven of them (78.57%) were smokers. None of the patients was immunocompromised. All patients had the characteristic rash of the disease, fever, and cough. Only six (43%) had bilateral sparse rales on auscultation. Arterial blood gas analysis at the onset of VZVP revealed hypoxemia in seven patients (50%) and hypocapnia in six (43%). Mean PaO(2) was 55 mmHg (range of 42-68 mmHg) and mean PaCO(2) was 34 mmHg (range of 27-36 mmHg). Chest radiographs showed ill-defined nodular or reticular densities of various sizes scattered throughout both lung fields. A CT scan of the chest, performed in seven patients (50%), confirmed the radiological findings and marked out patchy ground-glass attenuation in three patients and coalescence of lesions in two others. After diagnosis, all patients were immediately started on acyclovir 5-10 mg/kg every 8 h. Five patients (36%) were admitted to the ICU due to acute hypoxemic respiratory failure. Two patients received noninvasive positive pressure ventilation via a facemask and the other three patients with a clinical diagnosis of ARDS were intubated and ventilated mechanically. The duration of patient hospitalization was 16+/-10 days. One patient (8%) died in the ICU on the third day after admission due to multiple organ dysfunction (MOF). All of the other patients recovered completely without any sequelae. CONCLUSIONS: Adult patients with severe VZVP must be admitted and treated in the ICU. The use of intravenous acyclovir may be lifesaving, preventing progressive respiratory failure and reducing the high mortality rate of the disease.
Hepatitis B virus infection has decreased in Italy. The aims of this study were to identify changes, if any, in the epidemiological pattern of HBV infection in a southern Italian town first surveyed in 1996 and to assess the effectiveness of vaccination campaign against hepatitis B.
In 2010, subjects were selected from the census by a systematic 1:4 random sampling procedure. Hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B core antigen (anti-HBc) were detected by ELISA. Associations (odds ratios) linking exposure to hepatitis B virus infection to potential risk factors were estimated by univariate and multivariate analyses.
Of the 1100 eligible subjects, 1020 (92.0%) agreed to participate. The prevalences of HBsAg (0.6%) and anti-HBc (15.2%) were significantly lower than in 1996 (0.8% and 21.5%) (p<0.01). No subject below 30 years of age (those that had been targeted for compulsory immunization) had been exposed to HBV infection. At multiple logistic regression analysis, age>45 years (OR=9.8; 95% CI=5.1-18.7) and past use of glass syringes (OR=1.9; 95% CI=1.2-3.1) independently predicted the likelihood of anti-HBc positivity.
These results, albeit obtained in a small town and thus not generalizable, confirm the continuous decreasing trend of HBV infection and demonstrate the effectiveness of the Italian hepatitis B vaccination program.
This study aimed to compare the efficacy and safety of bismuth-included standard regimen and modified sequential treatments in Turkey, where the success rate of standard triple therapy is very low.
One-hundred and sixty patients with dyspeptic complaints and naïve Helicobacter pylori infection were randomized into four groups: 41 patients received standard 14-day quadruple treatment (STD) (Rabeprazole 20mg-bid, bismuth subcitrate (120mg-qid), Tetracycline 500mg-qid, Metronidazole 500mg-tid) for 2weeks. The modified sequential therapy groups received 20mg rabeprazole and 1g amoxicillin, twice daily for the first 5days, followed by Rabeprazole 20mg-bid, bismuth subcitrate (120mg-qid), Tetracycline 500mg-qid, Metronidazole 500mg-tid for the remaining 5 (10day sequential therapy group-10S) (42 patients), 7 (12day sequential therapy group-12S) (42 patients) and 9 (14day sequential therapy group-14S) (41 patients) days.
The overall compliance and H. pylori eradication rate among the 160 patients who completed the H. pylori eradication regimens were 86.9% (139/160) and 78.1% (125/160), respectively. The results were not statistically different between groups in the eradication rates. Per-protocol eradication rates were 76.5% in STD, 71.4% in 10S, 82.4% in 12S and 83.3% in 14S groups (p=0.7). Intention-to-treatment rates were 77.5% in STD, 72.5% in 10S, 82.5% in 12S and 80.0% in 14S groups (p=0.5).
The eradication rates of standard 14-day and different sequential quadruple treatment regimens are comparable and much more higher than with standard 14-day triple H. pylori eradication treatment that has been reported previously in Turkey.
BACKGROUND: Procalcitonin (PCT) is a recently described inflammatory marker that has been shown to increase significantly in patients with severe systemic bacterial infections or sepsis. Reports on the diagnostic and predictive value of PCT in systemic fungal infections are limited. METHODS: In order to evaluate the role of PCT in systemic mycosis, 14 patients (mean age 40 years) with proven or probable systemic fungal infections were investigated. Blood samples were collected on days 1, 3, 5, and 10 after the onset of signs and symptoms of systemic fungal infection (clinical and/or laboratory diagnosis and/or radiographic evidence). PCT measurements were performed using an immunoluminometric assay. RESULTS: In five patients with severe fungal infection and an unfavorable course (patient group 2), PCT levels were moderately elevated on day 3 (0.5-1.0 ng/ml), whereas they were normal in the patients who recovered (patient group 1). High PCT levels (>/=1.11 ng/ml) were detected on the 10th day of the course of the illness in patient group 2. A normal or moderate elevation of PCT on day 10 was observed in patient group 1. The difference in mean PCT levels in patient groups 1 and 2 on days 3 and 10 were statistically significant. CONCLUSIONS: PCT levels seem to correlate with the severity and outcome of systemic fungal infection. If this finding can be confirmed in a larger number of patients, it could serve as a prognostic indicator.
Background: Big cities were particularly affected by tuberculosis in the 1990s. Methods: We studied 141 cases of extrapulmonary tuberculosis in patients not infected by HIV in the northeastern suburbs of Paris. Results: A total of 84 men and 57 women were included in the study. Their average age at diagnosis was 42.2 years. Some 73.6% of the patients were foreign-born. A total of 182 sites were identified in 141 patients. There was an association with pulmonary tuberculosis in 38 cases. The sites were: lymph node (48.9%), pleural (25.5%), skeletal (22.7%), genitourinary (5.7%), and meninges (5%). Unfavorable social conditions were frequently observed. The average duration of treatment was 10 months. Twenty-four adverse drug effects were noted. Sixty-eight strains of Mycobacterium tuberculosis were isolated. Five cases of primary resistance to at least one antituberculous drug and only one case of multidrug resistance were observed. Some 95.7% of the 93 patients who were not lost to follow up were cured. Conclusion: Independently of HIV infection, extrapulmonary tuberculosis is still present, particularly in the suburbs of big cities, where social conditions are poor. The significant number of patients lost to follow-up demands that measures be adapted for the therapeutic management of these patients.
BACKGROUND: Although several randomized, control trials (RTC) suggest that oral anticoagulation (OAC) benefits patients with atrial fibrillation (AF), this might not be true for hospitalized patients with co-morbid conditions. If the results of the RTCs are valid, then how many patients in AF admitted to an acute medical unit will benefit from OAC? METHODS: An RCT-based decision analysis model calculated the quality-adjusted life expectancy (QALE) gain from OAC for 141 unselected consecutive patients over 65 years of age with AF admitted to an acute medical unit. RESULTS: If treated with aspirin, all 141 patients were predicted to gain QALE compared with placebo. If the quality of life adjustment (QoLA) on OAC was the same as placebo, then 104 patients were predicted to benefit from OAC compared with aspirin, while 63 patients were predicted to benefit at a QoLA of 0.99 (overall benefit 0.13+/-0.15 QALYs, range 0.01-0.88 QALYs). These 63 patients were more likely to have had a stroke, diabetes, hypertension, heart failure or heart attack, and less likely to have impaired renal function than those predicted not to benefit. The 78 patients predicted not to benefit from OAC included 11 younger patients without heart failure, hypertension, diabetes or cerebrovascular disease; the remaining 67 patients, however, were older, more likely to have heart failure and/or renal impairment and were at high risk of both stroke and bleeding. CONCLUSION: An RCT-based decision analysis model suggests that more than half the patients in AF admitted to a small rural hospital with acute medical conditions are unlikely to benefit from OAC, while all will benefit from aspirin.
To determine the usefulness of Ca 15.3 as a candidate biomarker in systemic sclerosis (SSc) patients with interstitial lung disease (ILD).
Two-hundred-twenty-one SSc patients with Ca 15.3 determinations were considered; 168 had evidence of interstitial lung involvement on high-resolution computed tomography (HRCT); digitalized scans were available for scoring in 84 subjects. Discrimination between patients with or without ILD, was assessed by receiving operating characteristics (ROC) analysis; correlations between HRCT scores and Ca 15.3 were performed. Survival and serial pulmonary function tasting (PFT) data were used for prognostication.
Ca 15.3 serum levels strongly correlated with HRCT scores (r=0.734, p<0.0001) which were predictors of survival at the 20% threshold (p=3.1∗10(-4)). Ca 15.3 had an area under ROC to detect the meaningful 20% fibrosis extent equal to 0.927 and abnormal Ca 15.3 values were capable of differentiating between patients at hi- or low-risk for progression in the group with undetermined disease extent (HR=3.209, confidence interval [CI95]=1.56-6.602, p=0.002). Ca 15.3 outperformed other PFT measures in providing a separation of survival estimates where HRCT scans are unavailable. The combined use of HRCT scores and Ca 15.3 in SSc-ILD patients was more discriminatory (HR=4.824, CI95=2.612-8.912, p<0.0001) than the staging system based on HRCT scores plus FVC (HR=2.657, CI95=1.703-4.147, p<0.0001) and characterized by lower prediction errors (0.2134 vs 0.2234).
Ca 15.3 is a rapid and inexpensive candidate biomarker for SSc-ILD being proportional to the extent of lung injury and specific and sensitive in assessing meaningful extents of the disease with prognostic significance.
Hepatitis B virus (HBV) reactivation is a fatal complication in patients who receive chemotherapy or immunosuppressive therapy. We examined the effect of preventive entecavir (ETV), a new nucleoside analogue on HBV reactivation during chemotherapy or immunosuppressive therapy.
Between February 2007 and September 2009, sixteen nucleoside analogue treatment-naive patients with chronic HBV infection (HB surface antigen [HBsAg] positive) who required chemotherapy or immunosuppressive therapy were enrolled. Referring to some guidelines, the patients received preventive ETV to reduce incidence of HBV reactivation, and were closely monitored for HBV markers.
HBV reactivation did not occur in any of the 16 patients and the indispensable treatments for their underlying diseases could be continued. However, HBV relapsed after preventive ETV was discontinued in 2 patients.
This study suggests that ETV is a useful option for preventing HBV reactivation in patients with chronic HBV infection.
We present an atypical case of myelofibrosis developing into secondary leukemia FAB subtype M4, with inversion of chromosome 16, FLT3/D835 point mutation and diffuse osteolytic lesions accompanied by elevated TNF-alpha. The simultaneous occurrence of these mutations reflects the progressive association of genetic lesions developing into secondary leukemia with a relatively benign course.
BACKGROUND: To date, the studies that have been done on fever of unknown origin have mostly been descriptive. Therefore, we know the etiogical spectrum and how it has changed since 1966 for many regions of the world. However, we do not know if there are clinical or laboratory predictors of severe outcome. Being able to estimate the severity of the disease early on would allow one to determine how intensive the diagnostic work-up should be. METHODS: A multicenter cohort study was carried out on 164 consecutive patients who met the classic, modified criteria of fever of unknown origin. The study lasted 2 years (1997-1998) and included a follow-up period of another 2 years. The main outcome measured was the final diagnosis established at the end of follow-up. RESULTS: When the white cell count was abnormal, the relative risk for a serious disease was 1.49 (CI: 1.15-1.94; p=0.004), when anemia was present, the relative risk was 1.55 (CI: 1.21-1.98; p=0.003), and for high alanine aminotransferase (ALAT), bilirubin, or lactate dehydrogenase (LDH), the relative risks were 1.57 (CI: 1.21-2.02; p=0.010), 1.57 (CI: 1.18-2.08; p=0.007), and 3.43 (CI: 1.81-6.48; p=0.0002), respectively. In multivariate analysis, the odds ratios for serious diseases were 2.7 (CI: 1.17-6.4; p=0.02) for abnormal white cell count, 2.8 (CI: 1.14-7.16; p=0.02) for anemia, 4.3 (CI: 1.6-11.5; p=0.003) for high serum bilirubin, and 5.3 (1.5-18.6; p=0.009) for high serum ALAT. CONCLUSIONS: In patients having a fever of unknown origin, anemia, abnormal white cell count, and high ALAT and bilirubin are independent predictors of severe outcome.
Interleukin-17 (IL-17) is a CD4 T-cell-derived mediator of angiogenesis that stimulates vascular endothelial cell migration and regulates the production of a variety of proangiogenic factors, such as tumor necrosis factor-alpha (TNF-alpha) and vascular endothelial cell growth factor (VEGF). Angiogenesis is implicated in the progression of multiple myeloma (MM).
We measured serum levels of IL-17, TNF-alpha, and VEGF, as well as microvessel density (MVD) in 40 untreated MM patients.
Levels of IL-17 in the sera of patients with MM were higher than those in matched controls; however, the difference did not reach statistical significance. Serum levels of both TNF-alpha and VEGF in MM patients were significantly higher than those in controls (p<0.001 in both instances). Levels of IL-17 in MM patients, both stage II and stage III, were significantly higher than those of stage I patients (p=0.001 and p<0.001, respectively). Similarly, higher values of VEGF (p<0.001), TNF-alpha (p<0.001), and MVD (p<0.035) were associated with advanced disease stage. Serum values of IL-17 in MM patients correlated positively not only with VEGF (Spearman's rho=0.606) and TNF-alpha (r=0.552; p<0.001 in both instances), but also with MVD (r=0.385, p=0.014). In addition, a positive correlation was found between serum values of VEGF and TNF-alpha (r=0.657, p<0.001), MVD and VEGF (r=0.353, p=0.026), and between MVD and TNF-alpha (r=0.506, p=0.001) in MM patients.
These results suggest that IL-17 plays a role in the promotion of angiogenesis and associated disease progression in MM.
Lupus erythematosus (LE) is a heterogeneous disease with broad clinical spectrum from cutaneous to visceral and systemic inflammation. IL-17 isoforms (IL-17A and IL-17F) are proinflammatory cytokines with unclear implications in lupus erythematosus pathogenesis. In this study we focused upon IL-17 in normal and modified lupus skin with a correlative study between local and serological expression.
89 subjects were recruited and divided in 5 groups-10 patients with psoriasis (disease control group), 13 healthy controls, 26 with discoid chronic lupus (DLE), 23 with systemic lupus erythematosus (SLE) and 17 with subacute lupus erythematosus (SCLE). Blood samples and skin punched-biopsy specimens were performed. Serum IL-17A, IL-17F, and IL-23 concentrations were determined by ELISA. Skin IL-17A and CD4 expression were evaluated by immunohistochemistry.
Immunohistochemical expression of IL-17A was higher in DLE, SCLE and SLE patients than in negative control subjects (all p<0.05). Serum IL-17A concentrations were higher in DLE and SLE patients than in negative controls (p<0.05). Serum IL-17A levels were similar in SCLE and negative controls (p>0.05). Serum IL-17F concentrations were higher in DLE, SCLE and SLE patients than in healthy controls (all p<0.05). In DLE, SCLE, SLE patients and healthy controls we observed comparable levels of IL-23 (p>0.05). Serum anti Ro antibodies correlate with IL-17A+ lymphocytes from SCLE lesion and SLE normal skin (all p<0.05).
IL-17 isoforms (IL-17A and IL-17F) are implicated in SLE but also in DLE and SCLE immunopathogenesis.
Long-term prognoses of Wegener granulomatosis (WG) and Churg-Strauss syndrome (CSS) are known; however, few data exist on long-term prognoses for microscopic polyangiitis (MPA). Our aim was to analyse the prognoses of MPA.
Cohort study with retrospective selection of patients. Twenty-two patients admitted to our Hospital (1990-2006) with biopsy-proven MPA were studied. The start date for entry into the study was the date of diagnosis. Statistical analysis was performed to look for prognostic factors for survival.
MPA patients were followed-up for a median of 78 (5-131) months. MPA patients were treated with cyclophosphamide (Cy) plus corticosteroid (Cs) (59%) or Cs alone (41%). Seven MPA patients died. Cumulative MPA patient survival at 1, 5, and 10 years were 85% (75-95%), 85% (75-95%), and 74% (60-88%) in those treated with Cy plus Cs and 50% (32-68%), 36% (14-58%), and 0% (0-30%) in those treated with Cs alone, respectively (P=0.04). Disease extent index <5 (P=0.02) and age <65 years (P=0.02) were associated with improved survival rates in MPA patients treated with Cy. Five MPA (23%) patients relapsed after a median of 54 months (35-93). No variables were related to relapses. Despite treatment, 11MPA (50%) patients developed end-stage renal disease after a median of 9 months (0-53).
Most MPA patients had life-threatening renal or lung involvement at diagnosis. Patients not treated with immunosuppressants had a poorer prognosis. The long-term prognosis of MPA patients who survived 6 months post diagnosis was good, although renal survival rates are low.
Our aim was to compare the sensitivity of various diagnostic criteria for adult Still's disease in 17 patients with established adult Still's disease who were followed in a department of internal medicine over a mean period of 7 years. The median age of the 17 patients was 27 years and the sex ratio M:F was 1:4. The patients had essentially systemic manifestations with fever (n=14), inflammation and leukocytosis (n=16), and moderate liver dysfunction (n=13) that disappeared after a mean of 21 days (range 8-48 days). In the first week of hospitalization, the sensitivities of the criteria proposed by Yamaguchi, Reginato, and Kahn were 94, 18, and 23%, respectively. One month later, the sensitivity was 100% for Yamaguchi's diagnostic criteria versus only 88% for Reginato's and Kahn's criteria. This study confirms that Yamaguchi's diagnostic criteria are more sensitive and are met earlier than Reginato's and Kahn's criteria in patients followed in internal medicine.
The authors analyzed 704 transthoracic echocardiographic (TTE) examinations, performed routinely to all admitted patients to a general 16-bed Intensive Care Unit (ICU) during an 18-month period. Data acquisition and prevalence of abnormalities of cardiac structures and function were assessed, as well as the new, previously unknown severe diagnoses. A TTE was performed within the first 24 h of admission on 704 consecutive patients, with a mean age of 61.5+/-17.5 years, ICU stay of 10.6+/-17.1 days, APACHE II 22.6+/-8.9, and SAPS II 52.7+/-20.4. In four patients, TTE could not be performed. Left ventricular (LV) dimensions were quantified in 689 (97.8%) patients, and LV function in 670 (95.2%) patients. Cardiac output (CO) was determined in 610 (86.7%), and mitral E/A in 399 (85.9% of patients in sinus rhythm). Echocardiographic abnormalities were detected in 234 (33%) patients, the most common being left atrial (LA) enlargement (n=163), and LV dysfunction (n=132). Patients with these alterations were older (66+/-16.5 vs 58.1+/-17.4, p<0.001), presented a higher APACHE II score (24.4+/-8.7 vs 21.1+/-8.9, p<0.001), and had a higher mortality rate (40.1% vs 25.4%, p<0.001). Severe, previously unknown echocardiographic diagnoses were detected in 53 (7.5%) patients; the most frequent condition was severe LV dysfunction. Through a multivariate logistic regression analysis, it was determined that mortality was affected by tricuspid regurgitation (p=0.016, CI 1.007-1.016) and ICU stay (p<0.001, CI 1-1.019). We conclude that TTE can detect most cardiac structures in a general ICU. One-third of the patients studied presented cardiac structural or functional alterations and 7.5% severe previously unknown diagnoses.
Computed tomography (CT)-guided liver biopsy using large-caliber cutting needles allows the recovery of larger tissue specimens that are more suitable for establishing histological diagnosis. Yet, large-caliber needles are associated with higher rates of post-biopsy bleeding. The aim of this prospective study was to assess the efficacy and safety of the method, when all of the procedures were performed by experienced radiologists and all patients were carefully evaluated and treated, when needed, before the biopsy.
A total of 767 consecutive patients with focal hepatic lesions underwent CT-guided liver biopsy during a 5-year period. The procedures were performed in a single center using 18-gauge automated biopsy guns with a 2-cm cutting edge by a team of experienced radiologists (>100 procedures performed by each one before the initiation of the study). Before the procedure, abnormal coagulation indices were corrected, ascites was treated and, in all cases, an adequate parenchymal cuff of normal tissue between the lesion and the capsule was retained.
In all cases the extracted specimens were adequate for diagnosis. No major complications (i.e., death or complications requiring surgery, chest tube, or blood transfusions) were observed. Minor complications (i.e., those not requiring medical intervention) were observed in three patients.
Percutaneous CT-guided liver biopsy using an 18-gauge automated needle is a safe and effective procedure. Careful pre-biopsy evaluation and treatment, when needed, and maintenance of an adequate parenchymal cuff between the lesion and the capsule contribute to the safety of the method.
Positron emission tomography (PET) was developed in the mid-1970, and its initial applications were for heart and brain imaging research. Nowadays, this technology is aimed mainly at staging or restaging tumours as it allows the assessment of biochemical processes that are either specific or associated with tumour biology. The full appreciation of PET potentials and limitations among general practitioners and internists cannot be considered achieved and the appropriate use of PET especially when coupled to X-ray computed tomography (CT) is still suboptimal. The majority of PET studies rely on the use of fluorodeoxyglucose labelled with fluorine-18 (FDG), which is a radiopharmaceutical specific for glucose transport and metabolism. PET with FDG is amenable for studying most type of tumours, including those of the head and neck, lung, oesophagus, colo-rectal, gastrointestinal stromal tumours, pancreas, some types of lymphomas and melanoma, whereas in some tumours, including those of the reproductive system, brain, breast and bones, there is a limited role for PET and there is no substantial role for FDG-PET for the bronchoalveolar, hepatocellular, urinary system, testicular, neuroendocrine, carcinoids and adrenal tumours, differentiated thyroid cancers, and several subtypes of malignant lymphoma. Thus, the limits of FDG have stimulated the use and development of other radiopharmaceuticals. These tracers represent the opportunity for expanding the use of PET to other areas in oncology in the near future.
To evaluate the value of (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in monitoring disease activity and predicting treatment response in idiopathic retroperitoneal fibrosis (iRPF).
This prospective study was approved by the institutional review board. Informed consent was obtained from all patients. Twenty-six patients with iRPF receiving tamoxifen monotherapy underwent repeated FDG-PET (baseline and, if positive, at 3 months) and computed tomographic (CT) scanning (baseline, 4 and 8 months). Maximal RPF mass thickness in 3 different view directions was measured on each CT scan; FDG-uptake was semi-quantified using a visual 4-point scale. Initial and follow-up PET scan results were correlated with clinical, laboratory and CT scan follow-up data. Treatment outcome was the aggregate measure of clinical, laboratory and CT-documented response to tamoxifen.
FDG-PET was positive in 20 patients. Patients with positive PET scan result had higher C-reactive protein level (P=0.02) and larger mass size (P=0.01) compared with patients with negative PET scan result. Visual PET score correlated with C-reactive protein level (P=0.002) and CT-documented mass thickness (P=0.04). Visual PET score decreased following treatment (P<0.01). This decrease correlated with decrease in ESR (P<0.001) but not with CT-documented mass regression. Positive predicting value (PPV) of initial positive PET scan result was 0.63; PPV of negative follow-up PET scan result in patients with initial positive PET scan result was 0.66.
FDG-PET is valuable in detecting (recurrent) disease activity. Short-term follow-up with FDG-PET cannot be routinely recommended for the therapeutic evaluation of RPF disease in tamoxifen-treated patients.
To identify analytical and clinical variables that may improve the effectiveness of temporal artery biopsy (TAB) for the diagnosis of giant cell arteritis (GCA).
A retrospective study of TABs conducted between 1989 and 2007 at the 450-bed Hospital Parc Taulí, Sabadell. Demographic data, clinical manifestations, analytical data prior to the biopsy and final diagnoses were recorded, including only those cases in which these data were reflected in the clinical history.
In this period, 278 TABs were conducted in 181 women (65.1%) and 97 men (mean age 74 years). Seventy-nine (28.4%) were positive (GCA+) and 199 (71.5%) negative (TAB-). The most frequent final diagnoses in the TAB- group were: polymyalgia rheumatica (PMR) (18.6%), giant cell arteritis plus negative TAB (GCA-) (13.6%), tension headache (7.5%), infection (7.5%), other vasculitis (7.5%), and neoplasm (6.0%). The GCA+ group was compared with the TAB- group, the GCA- group and the PMR group. In the multivariate analysis only headache (RR 3.6), jaw claudication (RR 2.9) and abnormal temporal artery on palpation (RR 2.5) revealed statistical differences between the GCA+ and TAB- groups.
One third of the biopsies performed at our centre were positive for GCA. The clinical variables that best predicted a positive TAB in our series were headache, jaw claudication, and abnormal temporal artery on palpation.
A 22-year-old man was admitted to our hospital with a palpable mass in the left upper quadrant. He had a history of blunt abdominal trauma. Computer tomography showed a large splenic cyst. Another finding was a markedly elevated concentration of the tumor marker CA 19-9 in his serum and cystic fluid. After surgical removal of the cyst this concentration decreased to a nearly normal level. Because no cellular lining of the cyst was found at histological examination, the cyst could have been regarded as 'false' or a 'pseudocyst'. However, since several cases of epithelial splenic cysts in combination with a high serum CA 19-9 have been described recently, our diagnosis was of an epithelial 'true' cyst. We assume that, for some reason, in primary splenic cysts, the thin cellular lining can be released before histological examination is performed.
For years, CA 19-9 has been proposed as a marker for epithelial-type gastrointestinal cancers, even though it is well known that its diagnostic specificity is low. Here we describe cases of extremely high CA 19-9 levels in benign biliary tract diseases. The first case involved a 77-year-old male patient with choledocholithiasis and jaundice who was found to have CA 19-9 levels of 98,628 UI/ml. The second case was a 63-year-old male patient with autoimmune cholangitis and a CA 19-9 level of 250 IU/ml. The third case was a 74-year-old male patient with cholelithiasis and choledocholithiasis who developed acute cholangitis. CA 19-9 levels were elevated to 14,950 UI/ml during the episode. The fourth case involved a 73-year-old man with biliary colic and jaundice following an acute open cholecystectomy procedure who had a transient 100-fold increase in CA 19-9 (2230 IU/ml).
Our objective was to learn about the incidence of hospitalization for venous thromboembolism (VTE) in the public health care system in Andalusia and to define the profile of the patients, with special reference to the Department of Internal Medicine.
We analyzed the discharged data set of 32 hospitals in the Andalusian Health Care Service between 1998 and 2001, identifying the cases in whom the diagnosis was VTE. The age, sex, length of stay, outcome, number of diagnoses, diagnosis-related group (DRG), and coded procedures were studied.
During the period studied, there were 2,228,894 discharges, 19,170 of which involved VTE. In 8494 of these, VTE was the cause of the admission. Some 3961 patients (46.6%) were admitted for pulmonary embolism (PE); 45% were discharged from internal medicine, 41% from pneumology, and 14% from other departments. The average patient age was 65, the length of stay 13.8 days, and the global in-hospital mortality rate 13%. Some 4533 cases (53.4%) were admitted due to deep vein thrombosis (DVT): 38.5% to internal medicine, 21.30% to general surgery, 12.35% to angiology, and the remainder to other departments. The length of stay was 10.6 days with an in-hospital mortality rate of 2.20%. In 7721 cases, VTE was the secondary diagnosis (after excluding 2955 cases of superficial thrombophlebitis of the upper limbs); 74% was associated with a medical DRG.
VTE is a frequent pathology in our hospitals. It shows a great variability in clinical practice although there are differences between patients treated by different specialists. VTE as secondary diagnosis was more frequent in medical inpatients.
This study aims to analyse trends in heart failure mortality for England and Wales from 1950 to 2003.
A retrospective observational study was conducted using death certificate and population data from the Office for National Statistics.
Unadjusted heart failure deaths rose by a factor of more than four between 1950 and 1974 and then fell by a quarter by 2003. When standardised for changes in the age, sex and size of the population, there was a tripling in mortality rate from 1950 to the mid-1970s and since then, a sustained decline in mortality rate of 50% by 2003. The unadjusted female heart failure death rate has been between 1.5-2 times that of males since the early 1970s, but this is much less marked when the differences in the age distribution and sizes of the male and female populations are taken into account. Heart failure mortality trends are similar to those of coronary heart disease (CHD), but the peak is about 10 years earlier, and the male/female ratios are reversed. There is a continuing rise in deaths from both heart failure and CHD in the very elderly (>85 years).
Unlike hospital trends, deaths from heart failure in the community in England and Wales show a decline since the early 1970s, in spite of an ageing population. This may reflect genuine changes in heart failure incidence, or parallel changes in CHD.
This study is a survey of cardiovascular risk factors in Sardinia in the years 1999-2001 and allows us to update previously observed trends of such factors and to compare them with those in the Italian mainland.
Random samples of free living population of the Mediterranean island of Sardinia, Italy, were collected. Overall, 6818 subjects, 50% of each sex, and aged 20-80+ years constituted the sample. Personal and family data were collected using a semiquantitative questionnaire of frequencies. Blood biochemical variables related to risk for atherosclerosis were measured. In particular, serum total cholesterol, HDL-cholesterol, triglycerides, Apo A-1, Apo B, Lp(a), uric acid, blood glucose and plasma homocysteine were analyzed in each subject enrolled.
In the age classes 20-59 years, during a 30 year period, prevalence of smoking among males continued to decrease from 58 to 24% (p for trend <0.001), and, for the first time, prevalence of smoking among females decreased as well: from 31% in 1995 to 20% in 2001 (p for trend <0.001). In contrast, a steady increase in TC (mg/dl) (189, 206, 215, 216, p for trend <0.05 in males and 184 197, 212, 217, p for trend <0.05 in females), and LDL-C (136, 143, 138, 144, p for tend <0.05 in males and 127, 139, 136, 135, p for trend <0.05 in females) was observed. HDL-C showed a steady increase (p for trend <0.01 in males and females). Lp(a) values were high in both sexes, a finding linked to the ethnic influence on them. Systolic and diastolic blood pressure values (mm Hg) increased with age. In the present survey (population aged 20-80+ years, current smokers were 17.5% among males and 13.8% among females. Total and HDL-cholesterol were higher than in other parts of Italy (209 vs 205 in males, and 211 vs 204 in females), while systolic and diastolic blood pressure were lower.
Overall, total- and LDL-cholesterol showed an increasing trend, while blood pressure and smoking habits had a decreasing tendency. The increase in blood cholesterol follows the trend in other areas of the world, mainly due to changing dietary habits. Therefore, a campaign of eating information and education (population strategy) could favourably modify cardiovascular risk, as occurred in Sardinia during the past decade with the Regional ATS-Sardegna Campaign.
Background: The mortality rate from bacteraemia is one of the highest among infections in hospitals, especially in the intensive care unit (ICU). Recently, an increase in nosocomial bacteraemia caused by gram-negative resistant pathogens has been observed. In this work we review the clinical and laboratory findings of adult patients with Acinetobacter bacteraemia in order to identify risk factors associated with mortality. Methods: A retrospective review of the medical records of patients with Acinetobacter bacteraemia identified by blood cultures from the Diagnostic Microbiology Laboratory was conducted between January 1989 and March 1998. Results: We identified 59 cases of Acinetobacter bacteraemia. Most of the infections (71%) were nosocomial; the majority occurred in the Department of Internal Medicine (28.8%), followed by Haematology (27%) and the ICU (23%). A. lwoffii was isolated in 52.5% of cases and A. baumannii in 47.5%. The related mortality was 17%. Staying in the ICU was associated with A. baumannii bacteraemia (P<0.004). An intravascular catheter was the leading source of infection (37%). Main risk factors were mechanical ventilation (28%), parenteral nutrition (23%) and the presence of a urinary catheter (22%). In the multivariate analysis the independent prognostic factors for mortality were the presence of shock (P<0.05) and the severity of the underlying disease, according to the classification of McCabe (P<0.05). Conclusions: The incidence of Acinetobacter bacteraemia has increased in the last decade, mainly since 1995. The development of septic shock and the severity of the underlying disease appear to be associated with an increase in mortality.
Background: The risk of infection with transfusion-transmitted viruses has been reduced remarkably. A zero-risk blood supply, however, remains a popular goal. A 3-year prospective donor study was conducted in the Epirus region of Greece to determine the prevalence of human immunodeficiency virus (HIV), human T-lymphotropic virus (HTLV), hepatitis B virus, and hepatitis C virus (HCV). Herein, we report the prevalence of HIV, HTLV, and HCV infection markers in this area. Methodology: Between January 1, 1995 and December 31, 1997, 6696 donors were investigated for the presence of anti-HIV, anti-HTLV, and anti-HCV antibodies using standard enzyme immunoassays (EIA). Every sample with anti-HCV reactivity by third-generation EIA was further investigated using a third-generation recombinant immunoblot assay (RIBA 3.0) and HCV-RNA by a combination of polymerase chain reaction (PCR) and DNA EIA. Results: None of the donors tested positive for anti-HIV or anti-HTLV antibodies. In contrast, anti-HCV was detected in 41 donors (0.61%). Using a RIBA 3.0 test, eight donors tested positive and eight had indeterminate results, while 25 tested negative. Seven of the eight donors with both EIA and RIBA 3.0 reactivity had increased levels of aminotransferases and detectable serum HCV-RNA. The remaining 34 donors had repeatedly normal aminotransferases and three times negative HCV-RNA. Liver biopsy was performed in anti-HCV/HCV-RNA-positive donors (7/41). The lesions were compatible with chronic hepatitis C in all of them. Conclusion: A zero prevalence of HIV and HTLV infection markers was found. Although the number of annual donations in this study was relatively low, the negative data for HIV and HTLV clearly indicate that rates of these infections are low in our region and that infected donors will be seen infrequently. HCV infection in blood donors remains very low in our region and is similar to the data reported in other industrialized countries. In fact, the prevalence of definite HCV infection seems to be very low (7/6696; 0.1%). However, a significant proportion of anti-HCV-reactive donors by third-generation EIA (33/41) had indeterminate or negative results by the RIBA 3.0. The latter donors were repeatedly negative for HCV-RNA. This finding may indicate that some donors tested false-positive for anti-HCV, although the possibility of true HCV infection contracted in the distant past cannot be excluded. In our opinion, close attention to mandatory principles of transfusion medicine, along with the screening of plasma donors using nucleic acid amplification technology, are the only methods that can further ensure the safety of our blood supply.
The aim of this study is to evaluate the experience of a single coeliac centre over a 15-year-long study period (between November of 1997 and September of 2011).
Patients and methods:
Charts of 178 patients (139 females) with coeliac disease were retrospectively evaluated. Tests performed: multiple duodenal biopsies, anti-tissue transglutaminase and anti-endomysium antibodies, body mass index calculation, osteodensitometry, evaluation of disorders associated with coeliac disease, and implementation of family screening.
Histological samples were available in 133 cases, distribution according to Marsh-Oberhuber classification: M0 in 7%, M1-M2 in 4%, M3a in 26%, M3b in 13%, and M3c in 50% of cases, respectively. Anti-tissue transglutaminase and anti-endomysium antibody tests were available in 158 cases, 132/158 showed seropositivity. Mean body mass index values were 23.05kg/m(2) for males, and 21.07kg/m(2) for females, respectively. Osteodensitometry showed normal values in 46%, osteopenia in 36%, and osteoporosis in 18% of cases, respectively. Coeliac disease associated disorders was present in 63/178 (35%) patients. Ninety coeliacs brought 197 first degree relatives for screening, with 47/197 (23%) relatives proving to have coeliac disease. Correlations between anti-tissue transglutaminase antibody titres and Marsh-Oberhuber classification, and anti-tissue transglutaminase antibody titres and bone mineral density values were found to be statistically significant (p=0.0011, and p=0.001, respectively).
Coeliac disease can become overt at any age. Female predominance is significant. Histology usually showed advanced villous atrophy. Mean body mass index values were within normal range. The high prevalence of associated disorders is also noted. The prevalence of 24% of coeliac disease among first degree relatives underlines the necessity of family screening.
The objective of the study is to determine the frequency and the clinical significance of autoantibodies to the pericentromeric heterochromatin protein 1 (HP1). So far this antinuclear antibody specificity has been mainly reported in patients with the CREST syndrome.
We screened the sera of 199 individuals, including patients suffering from various autoimmune disorders (Group I, n=145) and non autoimmune diseases (Group II, n=44 patients) as well as healthy individuals (Group III, n=30). The sera were systematically tested by Western blot and ELISA using a GST-HP1α fusion protein as an antigen.
Anti-HP1 antibodies were detected in 32% of patients in Group I, 11.3% in Group II and 3.3% of individuals in Group III. They could be detected in sera containing or not antinuclear antibodies detectable by indirect immunofluorescence. Anti-HP1 antibodies were mostly associated with the CREST and Sjogren's syndromes (70% and 44.4%, respectively). They could also be detected in 22.2% of patients suffering from various other autoimmune diseases. However, their negative predictive value was 94% in the CREST syndrome.
Anti-HP1 autoantibodies are associated with a large spectrum of disorders. However, they have a diagnostic value in the CREST syndrome.
Dioxin-type chemicals produce a variety of toxic and biochemical changes, some of which occur at very low doses and last for long periods of time. The most consistent toxin effect is body weight loss. In animals, the histopathologic changes, which are hyperplastic and hypertrophic, affect the gastrointestinal mucosa and the urinary track epithelium. In contrast, atrophic responses are seen in the thymus. Both hyperplasia and necrosis are observed in the liver. The administration of 2,3,7,8-tetrachlorodibenzo-p-dioxin also produces endocrine effects and changes in carbohydrate and lipid metabolism. The most serious toxic effects and the biochemical background of the lesions are reviewed.
Acute heart failure has a poor prognosis and the presence of anemia may increase the risk of adverse outcomes. However, the clinical and laboratory characteristics of anemia in acute heart failure are poorly known. We aimed to assess the causes and the clinical and laboratory correlates of anemia in patients with acute cardiogenic pulmonary edema (ACPE).
This observational study, performed in an Emergency Unit, enrolled 200 patients treated with medical therapy and continuous positive airway pressure.
Anemia was found in 36% of patients (38.5% of females and 32.5% of males) and was severe (hemoglobin <9 g/dL) in 6.9% of cases. The most frequent causes of anemia were chronic renal failure (27.8%), chronic inflammatory states (27.8%) and the clustering of multiple factors (18.1%). A wider spectrum of etiological factors was found in females than in males. Microcytic anemia was observed only in females (20% of those anemic), mainly due to iron deficiency/chronic blood loss. Glomerular filtration rate, serum iron, serum albumin, total cholesterol and diastolic blood pressure were independently associated with hemoglobin levels.
The etiology of anemia in ACPE is heterogeneous, with several causal factors besides impaired renal function. The pattern of anemia is different between genders, suggesting that sex-specific diagnostic and therapeutic targets should be implemented.
While socioeconomic gradients in cardiovascular disease have been well established in high-income countries, this relationship is not well understood in middle-income countries.
Data from Demographic Health Surveys collected in Albania (2008-09), Armenia (2005), Azerbaijan (2006) and Ukraine (2007) were used to estimate age-adjusted differences in systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), hypertension (HTN), elevated blood pressure, and optimal blood pressure across a standardized wealth index, level of educational attainment, and urban versus rural residence.
The wealthiest Albanian females had lower average SBP, DBP, PP (all p<0.01) and HTN status (odds ratio [OR]=0.3, CI: 0.2-0.5, p<0.001) compared to the poorest; similar education gradients were also found. Such disparities also existed for Albanian men. Among Armenian women, urban (OR=1.4, 1.1-1.8, p<0.01), more educated (OR=0.7, CI: 0.6-0.9, p<0.01), and wealthier (OR=1.8, 1.4-2.4, p<0.001) women were more likely to have optimal blood pressure. Urban Armenian men were also more likely to have optimal blood pressure (OR=1.8, 1.2-2.9, p<0.01). Wealthier and urban Azerbaijani had lower risk of elevated blood pressure and Azerbaijani women displayed strong wealth gradients with higher quintiles of wealth associated with lower continuous blood pressure measures. There were no socioeconomic gradients for Ukrainian males or females.
There is compelling evidence that wealth and education gradients affect the probability of HTN for women in Albania, Armenia, and Azerbaijan, and for men in Albania.