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Nardi R.,Azienda USL di Bologna | Berti F.,Medicina Interna III | Greco A.,UO Geriatria | Scanelli G.,UOC Medicina Interna Ospedaliera | And 15 more authors.
Italian Journal of Medicine | Year: 2013

Internal medicine (IM) patients are mostly elderly, with multiple complex co-morbidities, usually chronic. The complexity of these patients involves the intricate entanglement of two or more systems (e.g. body and disease, family-socio-economic and environmental status, coordination of care and therapies) and this requires comprehensive, multi-dimensional assessment (MDA). Despite attempts to improve management of chronic conditions, and the availability of several MDA tools, defining the complex patient is still problematic. The complex profile of our patients can only be described through the best assessment tools designed to identify their characteristics. In order to do this, the Federation of Associations of Hospital Doctors on Internal Medicine FADOI has created its own vision of IM. This involves understanding the different needs of the patient, and analyzing diseases clusters and the possible relationships between them. By exploring the real complexity of our patients and selecting their real needs, we can exercise holistic, anthropological and appropriate choices for their treatment and care. A simpler assessment approach must be adopted for our complex patients, and alternative tools should be used to improve clinical evaluation and prognostic stratification in a hierarchical selection of priorities. Further investigation of complex patients admitted to IM wards is needed. ©Copyright R. Nardi et al., 2013.


Rosato A.,UOC di Medicina Interna | Santini C.,UOC di Medicina Interna
Italian Journal of Medicine | Year: 2012

Introduction: The traditional classification of Pneumonia as either community acquired (CAP) or hospital acquired (HAP) reflects deep differences in the etiology, pathogenesis, approach and prognosis between the two entities. Health-Care Associated Pneumonia (HCAP) develops in a heterogeneous group of patients receiving invasive medical care or surgical procedures in an outpatient setting. For epidemiology and outcomes, HCAP closely resembles HAP and possibly requires an analogous therapeutic regimen effective against multidrug-resistant pathogens. Materials and methods: We reviewed the pertinent literature and the guidelines for the diagnosis and management of HCAP to analyze the evidence for the recommended approach. Results: Growing evidence seems to confirm the differences in epidemiology and outcome between HCAP and CAP but fails to confirm any real advantage in pursuing an aggressive treatment for all HCAP and CAP patients. Discussion: Further investigations are needed to establish the optimal treatment approach according to the different categories of patients and the different illness severities. © 2011 Elsevier Srl.


Perin A.,U.O.C. di Medicina Interna | Zanatta E.,University of Padua | Pigatto E.,University of Padua | Carniello S.,U.O.C. di Medicina Interna | Cozzi Prof. F.,University of Padua
Reumatismo | Year: 2012

Objectives: Hypovitaminosis D is very common in the elderly in Italy and generally in the world, contributing to bone fractures and muscle weakness. The aim of the study was to evaluate bone metabolism in an old population of patients hospitalized not for musculo-skeletal complaints. Methods: The clinical records of 175 patients, 98 female and 77 male, aged >65 years, hospitalized in a Department of Internal Medicine (Sacile, Western Friuli) were retrospectively reviewed. Serum levels of calcium, phosphorus, alkaline phosphatase, parathyroid hormone (PTH) and 25-OH vitamin D were evaluated. Correlations between these parameters were investigate. Results: Abnormalities of bone metabolism parameters were frequently founded, particularly hypocalcemia, increased PTH and reduced 25-OH vitamin D. Hypovitaminosis D were detected in 88% of patients, low levels in 30.28% and very low levels in 57.72%. Hypovitaminosis D was related to female sex, old age of patients and high levels of PTH. Conclusions: Our data confirm that hypovitaminosis D is very common in elderly population. The study has been performed in an Italian Region where the supplementation of vitamin D in the elderly is not performed, suggesting that a awareness campaign of the doctors could be very useful to prevent bone metabolism abnormalities.


Malago R.,Instituto Of Radiologia | Pezzato A.,Instituto Of Radiologia | Barbiani C.,Instituto Of Radiologia | Tavella D.,U.O. Cardiologia | And 4 more authors.
Radiologia Medica | Year: 2013

Purpose. This study evaluated the incremental value and cost-effectiveness ratio of introducing coronary angiography (CA) with multidetector computed tomography (MDCT-CA) in the diagnostic management of patients with suspected coronary artery disease (CAD) compared with the traditional diagnostic workup. Material and methods. Five hundred and fifty consecutive patients who underwent MDCT-CA between January 2009 and June 2011 were considered. Patients with atypical chest pain and suspected obstructive CAD were directed to one of two diagnostic pathways: the traditional protocol (examination, stress test, CA) and the current protocol (examination, stress test, MDCT-CA, and CA, if necessary). The costs of each protocol and for the individual method were calculated. Based on the results, the cost-effectiveness ratio of the two diagnostic pathways was compared. A third, modified, diagnostic pathway has been proposed with its relative cost-effectiveness ratio (examination, MDCT-CA, stress test, and CA, if necessary). Results. Stress test vs. MDCT-CA had an accuracy of 66%, a sensitivity and specificity of 21% and 87%, respectively, and a positive (PPV) and negative (NPV) predictive value of 40% and 70%, respectively. Comparison between conventional CA (CCA) and MDCT-CA showed a sensitivity and specificity of 92% and 89%, respectively, a PPV and NPV of 89%, and an accuracy of 92%. The traditional protocol has higher costs than the second protocol: 1,645 euro against 322 euro (mean), but it shows a better cost-effectiveness ratio. The new proposed protocol has lower costs, mean 261 euro, with a better costeffectiveness ratio than the traditional protocol. Conclusions. The diagnostic protocol for patients with suspected CAD has been modified by the introduction of MDCT-CA. Our study confirms the greater diagnostic performance of MDCT-CA compared with stress test and its similar accuracy to CCA. The use of MDCT-CA to select patients for CCA has a favourable cost-effectiveness profile. © Springer-Verlag 2013.


Bonsignore L.,UOC di Medicina Interna | Cardillo R.,UOC di Medicina Interna | Leotta S.,UOC di Medicina Interna | Pavone S.,UOC di Medicina Interna | And 5 more authors.
Italian Journal of Medicine | Year: 2013

Still's disease is a disease of unknown etiology that was identified for the first time in 1897 by George Still who noted the association of fever, arthralgias and cutaneous rash in a group of 22 children. In 1971, Bywaters noticed that this symptomatology could also be found in adult patients. High fever, arthralgias, a diffuse cutaneous rash with sore throat, increased spleen volume and lymph nodes are the clinical manifestations of this disease. However, it shows high variability in its clinical presentation (monocyclic, polycyclic and chronic forms). Blood tests show high levels of white blood cells, increased ferritin levels, and negative autoantibodies and rheumatoid factor. We examined 2 clinical cases that strongly suggested adult Still's disease: a 38-year old woman and a 30-year old man. The woman came to our attention because of the following symptomatology: fever for more than eleven days before hospitalization and polyarthralgias. Blood tests showed high inflammatory markers (ferritin >35,000), low platelets and increased white blood cells. A diffuse rash and oral aphthae were then observed. The second case presented the following symptoms: fever (38.4°C), cutaneous rash, polyarthralgias, and sore throat. Blood tests showed high levels of inflammatory markers and blood cell count showed an increase in neutrophil levels. Abdominal ultrasonography showed hepatosplenomegaly. Concentrating on these elements allowed us to formulate the diagnosis of adult Still's disease, both patients showing a highly suggestive clinical profile. Yamaguchi's criteria were satisfied and different diseases could be excluded according to the pharmacological response to anti-inflammatory drugs. This strengthened our diagnostic hypothesis and allowed us to focus our attention on this unknown disease, often unrecognized because of the problems of diagnosis. In fact, the clinical characters are initially aspecific (sore throat and fever). Furthermore, there is a large inter-individual variability during the disease course that could lead to misunderstanding. However, satisfaction of Yamagouchi's criteria and the pharmacological response to corticosteroid drugs suggested adult Still's disease. © Copyright L. Bonsignore et al., 2013.


Malta R.,University of Palermo | Di Rosa S.,UOC di Medicina Interna | D'Alessandro N.,University of Palermo
Italian Journal of Medicine | Year: 2010

Introduction: Antibacterial prescribing practices between 2004 and 2008 were investigated in the P. Giaccone University Hospital in Palermo, Italy to provide a foundation for critical analysis of the appropriateness of health-care resource usage. Materials and methods: Antibiotic prescribing practices between 2004 and 2008 were analyzed in the hospital as a whole and in different specialty areas. Results were expressed as defined daily doses (DDD) as a function of bed-days, number of admissions, and Diagnosis Related Group (DRG) points. Results: During the study period, increases were observed in the overall DDD per 100 bed-days (68.7 vs. 91.3) and the DDD per admission (4.53 vs. 5.54), but less variation was observed in the DDD/DRG score (3.55 vs. 3.63). Use of metronidazole, carbapenems, and glycopeptides increased, while use of third-generation cephalosporins, quinolones, and oral penicillins remained fairly stable. The drugs most commonly used in 2008 were (% of total DDD): levofloxacin (18.08%), amoxicillin + clavulanic acid (13.32%), ceftriaxone (9.01%), ciprofloxacin (8.21%), clarithromycin (5.74%), metronidazole (5.36%), ceftazidime (5.16%), amoxicillin (4.92%), gentamicin (1.88%), and meropenem (1.80%). An overall trend toward the prescription of newer wide-spectrum antibacterial agents was noted. National guidelines on chemoprophylaxis in surgery were observed in only 3/17 (17.7%) units. The prevalence of nosocomial infections was lower than those reported in the literature. Discussion: Although the cases treated in the hospital have become more complex over the years, the DDD documented in our study are far too high with respect to the actual clinical needs. These findings point to a trend toward the practice of excessively defensive medicine. Greater responsibility among physicians and the promotion of primary and secondary measures of preventive hygiene are fundamental to reduce the prescriptive pressure, a goal that should also have beneficial effects on health-care costs. © 2010 Elsevier Srl. All rights reserved.


Fiaccadori E.,University of Parma | Parenti E.,University of Parma | Regolisti G.,University of Parma | Detrenis S.,U.O.C. di Medicina Interna | And 3 more authors.
Giornale Italiano di Cardiologia | Year: 2010

The utilization of renal replacement therapies in cardiac patients has received increasing attention in recent years. In fact, isolated ultrafiltration has been proposed in patients with heart failure as a means for rapidly relieving fluid overload while preserving renal function; moreover, periprocedural hemofiltration (HF) has been suggested for radiocontrast-induced nephropathy (RCIN) prophylaxis. As a matter of fact fluid overload, with the ensuing systemic and pulmonary congestion, remains a major problem in patients with heart failure, and diuretic resistance is not an uncommon feature in the more advanced stages of the syndrome. In the same way, RCIN is increasingly indicated as a major complication of the use of iodinated contrast media, accounting for a significant number of hospital-acquired acute kidney injury episodes; moreover, it is thought to be associated with short- and long-term adverse effects on patient prognosis and increased economic burden. This article is aimed at reviewing the background of renal replacement therapies in the clinical context of cardiology wards, with special regard to isolated ultrafiltration and HF, as well as the current evidence regarding the safety and efficacy of these procedures, and their economic impact. From a theoretical point of view, isolated ultrafiltration could have a number of potential heart- and kidney-related advantages if compared to standard therapy (mainly diuretics). However, currently available clinical evidence does not support these concepts for its widespread utilization. Thus, isolated ultrafiltration should be reserved for selected patients with advanced heart failure and diuretic resistance, as part of a more complex strategy devoted to the control of fluid retention. There is currently no sound evidence for routinely recommending periprocedural HF in coronary angiography procedures, even in patients at high risk for RCIN. © 2010 AIM Publishing Srl.

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