European Journal of Internal Medicine

Editorial Board

2012-03-01

Matrix metalloproteinases in metabolic syndrome

E. Hopps, G. Caimi — 2011-10-14

Abstract: Metabolic syndrome is commonly accompanied by an elevated cardiovascular risk with high morbidity and mortality. The alterations of the arterial vasculature begin with endothelial dysfunction and lead to micro- and macrovascular complications. The remodeling of the endothelial basal membrane, that promotes erosion and thrombosis, has a multifactorial pathogenesis that includes leukocyte activation, increased oxidative stress and also an altered matrix metalloproteinases (MMPs) expression. MMPs are endopeptidases which degrade extracellular matrix proteins, such as collagen, gelatins, fibronectin and laminin. They can be secreted by several cells within the vascular wall, but macrophages are determinant in the atherosclerotic plaques. Their activity is regulated by tissue inhibitors of MMP (TIMPs) and also by other molecules, such as plasmin. MMPs could be implicated in plaque instability predisposing to vascular complications. It has been demonstrated that an impaired MMP or TIMP expression is associated with higher risk of all-cause mortality. A large number of studies evaluated MMPs pattern in obesity, diabetes mellitus, arterial hypertension and dyslipidemia, all of which define metabolic syndrome according to several Consensus Statement (i.e. IDF, ATP III, AHA). However, few research have been carried out on subjects with metabolic syndrome. The evidences of an improvement in MMP/TIMP ratio with diet, exercise and medical therapy should encourage further investigations with the intent to contrast the atherosclerotic process and to reduce morbidity and mortality of this kind of patients.

On the nature of sarcoidosis

Jerome M. Reich — 2011-10-13

Abstract: More than 140years since its recognition as a clinical entity, sarcoidosis remains enigmatic. Its classification as a disease vs. a syndrome is uncertain. Its etiology remains undefined. The “immune paradox” (delayed type hypersensitivity anergy in a setting of exuberant systemic granulomatous response) resists explanation. Its relationship to the Kveim test is poorly understood. Its prognostic determinants and treatment indications are among the unsolved or disputed problems. Immunological investigations generated the thesis that the characterizing systemic granuloma arise as a fallback reaction to inefficient cellular immune processing, due most often to impaired myeloid dendritic cell function of unknown cause. The concept that sarcoidosis represents a (genetically conditioned) default to a more primitive immunological response provides a unifying explanation for its development in persons with a variety of antigenic exposures and in individuals with cellular immune deficiencies. It furnishes a coherent explanation for the apparent paradox that individuals exhibiting the most intense cellular response experience the most favorable outcomes and for the adverse effect of corticosteroid-suppression in recent onset sarcoidosis.

Excessive daytime sleepiness and narcolepsy — An approach to investigation and management

Ian Morrison, Renata L. Riha — 2011-10-31

Abstract: Excessive daytime sleepiness is a common presentation to physicians both in general practice and hospital settings. In this review, we provide an update on the latest theories on the pathogenesis of the condition, and discuss the approach to investigation of the sleepy patient, with particular reference to narcolepsy. Recommended therapy is reviewed for both narcolepsy and cataplexy, to provide physicians with an important reference on the investigation and management of these troubling conditions.

The frailty dilemma. Review of the predictive accuracy of major frailty scores

2011-10-03

Abstract: Background: To identify frail elderly individuals, several index or scoring systems have been developed for research purposes. The practical value of these scores for screening and diagnostic use is uncertain.Aim: The available scoring systems were reviewed to determine whether they can be used in daily practice.Methods: Literature study on relevant test instruments developed for the detection of frailty on the basis of theoretical views on the frailty concept. Data on sensitivity and specificity and predictive values were extracted.Results: Several (n=6) frailty scores were described with respect to their value as a screening or diagnostic test. Outcome of the selected test instruments is presented as a risk of negative health outcome when a test is positive. The reported AUCs of ROCs varied from 0.55 for functional decline in people admitted to an accident and emergency department to 0.87 for prediction of mortality on the basis of a co-morbidity score. As the prevalence of frailty and resulting negative health outcomes in published reports was low (5–41%), presented sensitivity and specificity values lead to low positive predictive values (6–49%) but reasonable negative predictive values (73–96%).Conclusions: As the number of false positive values of most available tests is substantial, these frailty scores are of limited value for both screening and diagnostic purposes in daily practice. As diagnostic instruments they can best be used to exclude frailty. The false-positive rate of currently available tests is too high to allow major decisions on medical care to be made on the basis of a positive test.

Prevention of delirium in demented hospitalized patients

Marion Andro, Emmanuelle Comps, Sandrine Estivin, Armelle Gentric — 2011-06-23

Delirium, defined as an acute disruption of attention and cognition, has been recognized as the most common complication of hospitalisation for old people, occurring in 6 to 56% of the medical in-patients , reaching 89% in demented patients . Dementia is the most important risk factor for delirium . Delirium is associated with increased mortality and morbidity .

Dipeptidylpeptidase-4 (DPP-4) inhibitors are favourable to glucagon-like peptide-1 (GLP-1) receptor agonists: Yes

André J. Scheen — 2011-11-16

Abstract: The pharmacological treatment of type 2 diabetes (T2DM) is becoming increasingly complex, especially since the availability of incretin-based therapies. Compared with other glucose-lowering strategies, these novel drugs offer some advantages such as an absence of weight gain and a negligible risk of hypoglycaemia and, possibly, better cardiovascular and β-cell protection. The physician has now multiple choices to manage his/her patient after secondary failure of metformin, and the question whether it is preferable to add an oral dipeptidylpeptidase-4 (DPP-4) inhibitor (gliptin) or an injectable glucagon-like peptide-1 (GLP-1) receptor agonist will emerge. Obviously, DPP-4 inhibitors offer several advantages compared with GLP-1 receptor agonists, especially regarding easiness of use, tolerance profile and cost. However, because they can only increase endogenous GLP-1 concentrations to physiological (rather than pharmacological) levels, they are less potent to improve glucose control, promote weight reduction (“weight neutrality”) and reduce blood pressure compared to GLP-1 receptor agonists. Of note, none of the two classes have proven long-term safety and positive impact on diabetic complications yet. The role of DPP-4 inhibitors and GLP-1 receptor agonists in the therapeutic armamentarium of T2DM is rapidly evolving, but their respective potential strengths and weaknesses should be better defined in long-term head-to-head comparative controlled trials. Instead of trying to answer the question whether DPP-4 inhibitors are favourable to GLP-1 receptor agonists (or vice versa), it is probably more clinically relevant to look at which T2DM patient will benefit more from one or the other therapy considering all his/her individual clinical characteristics (“personalized medicine”).

Dipeptidyl peptidase-4 (DPP-4) inhibitors are favourable to Glucagon-Like Peptide-1 (GLP-1) agonists: No

Sten Madsbad — 2011-12-02

Abstract: Incretin-based therapies, which include the GLP-1 receptor agonists and DPP-4 inhibitors, use the antidiabetic properties of potentiating the GLP-1 receptor signalling via the regulation of insulin and glucagon secretion, inhibition of gastric emptying and suppression of appetite. Most physicians will start antidiabetic treatment with metformin, but adding a GLP-1 receptor agonist as the second drug seems to be optimal since more patients will reach an HbA1c below 7% than with a DPP-4 inhibitor or another oral antidiabetic agents and with minimal risk of hypoglycaemia. The GLP-1 receptor agonists are also more effective in weight and systolic blood pressure control than DPP-4 inhibitors. The side effects of the GLP-1 receptor agonists are primarily nausea and vomiting, which is less pronounced with the long acting agonists and often transient. A GLP-1 receptor agonist can be recommended before a DPP-4 inhibitor in obese type 2 diabetic patients, who want to lose weight. Furthermore, the GLP-1 receptor agonists cover the whole spectrum of treatment from time of diagnosis with lifestyle treatment to combination treatment with basal insulin.

The association of physical activity with novel adipokines in patients with type 2 diabetes

2011-11-30

Abstract: Background: Adipose-tissue derivatives, known as adipokines, have been involved in the inflammatory-mediated metabolic and cardiovascular disorders of type 2 diabetes mellitus (T2DM). This study examined the association between novel adipokines and self-reported physical activity, a potential anti-inflammatory mediator.Methods: We enrolled 247 men and women with T2DM, free from overt cardiovascular disease. Based on a physical activity questionnaire, patients were classified into groups: A) sedentary, who did not report any physical activity or reported light activities<2h/week and B) active, referring to low or moderate-intensity physical activities>2h/week. Among them, 88 patients were randomly selected to perform a cardiorespiratory ergocycle testing. Clinical parameters, glycemic and lipid profiles, HOMA-IR, and serum levels of visfatin, apelin, vaspin, ghrelin and adiponectin were assessed.Results: With the exception of fat-mass, our groups did not differ in anthropometric parameters and pharmaceutical regimen. Active patients showed ameliorated glucose regulation, HOMA-IR, hsCRP and exercise capacity compared to sedentary counterparts (p<0.01). Active rather than sedentary patients showed lower visfatin (10.16±5.53ng/ml vs 14.77±8.48ng/ml, p=0.013), higher apelin (1.39±0.65ng/ml vs 1.04±0.35ng/ml, p=0.018) and adiponectin (11.82±3.06μg/ml vs 7.81±2.11μg/ml, p=0.033) levels. There were non-significant differences in the rest of parameters between groups. After adjusting for age, sex and BMI, physical activity along with hsCRP and ghrelin remained independent determinants of visfatin levels (R2=0.328, p=0.032), while physical activity was independently associated with apelin (R2=0.221, p=0.022).Conclusions: Self-controlled physical activity of, even, moderate intensity ameliorates adipokines, such as visfatin, apelin and adiponectin, in patients with T2DM. Prospective interventional studies will confirm our results.The ClinicalTrials.gov identifier is: NCT00306176.

Quality of life in type 2 diabetes mellitus after a very low calorie diet and exercise

2011-08-18

Abstract: Objective: To evaluate whether the addition of exercise to a very low calorie diet (VLCD) has beneficial short- and long-term effects on health-related quality of life (QoL) in obese patients with type 2 diabetes mellitus (T2DM).Methods: We included 27 obese, insulin-dependent T2DM patients in a 16-week VLCD study, of whom 13 participated simultaneously in an exercise program (VLCD+E). Before, immediately after and 18months after the intervention anthropometric measurements, glucoregulation and QoL (SF-36, HADS, NHP and MFI-20) were assessed. Patients were compared to healthy lean and obese (matched for body mass index) controls matched for gender and age.Results: At baseline, T2DM patients had significantly worse QoL scores in 18 and 14 of the 22 subscales of the QoL questionnaires, compared to lean and obese controls, resp. The 16-week VLCD (n=27) decreased bodyweight (−25.4±1.3kg, p<0.0001, p=0.179 between groups), and improved glucoregulation (HbA1c −1.3±0.3%, p<0.0001, p=0.488 between groups) and 9 (VLCD-only) and 11 (VLCD+E) of the 22 subscales of QoL.After 18months, in the VLCD+E group the QoL subscales did not differ from those in obese controls and only 4 of the 22 subscales were significantly worse compared to lean controls. However, in the VLCD-only group 17 and 13 of the 22 QoL subscales were significantly worse compared to the lean and obese controls, resp.Conclusion: A 16-week VLCD induces considerable weight loss, metabolic amelioration, and major improvements in QoL in obese T2DM patients. The addition of exercise is of paramount importance for the maintenance of better QoL.

Erythrocyte mechanical fragility is increased in patients with type 2 diabetes

Giuseppe Lippi, Mariella Mercadanti, Rosalia Aloe, Giovanni Targher — 2011-12-02

Abstract: Background: Anemia is common among patients with type 2 diabetes. We determined whether type 2 diabetic patients significantly differed in erythrocyte mechanical fragility as compared with nondiabetic subjects.Methods: We recruited 25 Caucasian patients with type 2 diabetes (14 men and 11 women; mean age 58±8years) and 25 age-, race- and sex-matched nondiabetic individuals. The fragility of erythrocytes was tested by inducing mechanical hemolysis by double aspiration of K2EDTA blood through a 0.5mL insulin syringe equipped with a very thin needle. The plasma was then separated from the blood cells by centrifugation at 2000xg for 15min at room temperature. A Beckman Coulter DxC 800 was used to measure the hemolysis index by direct spectrophotometry.Results: Compared with matched nondiabetic controls, type 2 diabetic patients had a significantly increased mechanical fragility of erythrocytes (hemolysis index ratio 21±13 vs. 14±10, p=0.02). Univariable linear regression analysis revealed that there was a strong positive association between percent hemolysis and fasting plasma glucose (r=0.669, p<0.001) and hemoglobin A1c (r=0.549, p<0.005) in type 2 diabetic subjects, but not in matched nondiabetic controls.Conclusions: Our data suggest that patients with type 2 diabetes have a significantly higher erythrocyte mechanical fragility than matched nondiabetic subjects, and that fasting plasma glucose is the strongest correlate of increased mechanical fragility of erythrocytes in this patients group.

Anemia as a risk factor for low bone mineral density in postmenopausal Turkish women

2011-12-12

Abstract: Background: We investigated the association of bone mineral density (BMD) by detected dual-energy X-ray absorptiometric (DXA) method and hemoglobin (Hb) levels in a large sample.Methods: The current study enrolled 371 postmenopausal women (82 anemic patients), who were screened for osteopenia or osteoporosis by DXA. Patients with osteopenia or osteoporosis (T score<−1.0 SD) were grouped as having low bone mass (LBM).Results: Anemic patients were older and had significantly higher duration of menopause. When compared with subjects with normal Hb, anemic patients had significant lower femur t score, femur BMD, femur Z score, spinal t score, spinal BMD and spinal Z score (p<0.001). Additionally, the ratio of subjects with LBM in the femur and spine were significantly high in anemic patients (p<0.002, p<0.002, respectively). There were significant correlations between Hb values and femur t score, femur BMD, spine t score, and spine BMD values of the study population in bivariate correlation analysis (r=0.150, p=0.004, r=0.148, p=0.004, r=0.160, p=0.002, r=0.164, p=0.001, respectively). Furthermore, presence of anemia was found to be an independent predictor of LBM for spine [OR: 2.483 (95% CI: 1.309–4.712), p<0.005] in logistic regression analysis. Additionally, number of anemic patients was significantly high in low femur and spine BMD groups (56 vs. 26; p=0.01, 66 vs. 16; p=0.002, respectively).Conclusion: We have found that the presence of anemia was as an independent predictor of LBM for spine after adjusting for body mass index and other confounders in postmenopausal Turkish women.

Quick diagnosis units or conventional hospitalisation for the diagnostic evaluation of severe anaemia: A paradigm shift in public health systems?

2011-03-14

Abstract: Background: Acute hospital bed utilisation is a growing concern for health care systems in most countries with public health models, as it represents a significant share of health costs. Anaemia with haemoglobin levels below 8g/l has traditionally been a criterion used to hospitalise patients in our centre for diagnosis.Methods: We conducted a longitudinal study with a prospective and retrospective cohort to investigate the usefulness of a Quick Diagnosis Unit (QDU) for the evaluation of patients with severe anaemia as compared with hospitalisation in a tertiary public hospital. We recorded pretransfusion haemoglobin and haematocrit values, Charlson comorbidity index, waiting time for the first visit, time to diagnosis (length-of-stay in hospitalised patients), final diagnosis, costs, and responses to an opinion survey.Results: QDU patients were significantly younger [65.63years (17.44)] than hospitalised patients [76.11years (12.68)] (P<.0001). No significant differences were observed regarding time to diagnosis/length-of-stay, haemoglobin concentrations and Charlson index. Iron-deficiency anaemia was the commonest type of anaemia in both cohorts and benign digestive lesions accounted for most cases. The mean cost per process (admission-discharge episode) was 2920.62 Euros in the QDU and 18,278.01 Euros in hospitalised patients. If further diagnostic tests were required, 85% of patients would prefer the QDU care model to conventional hospital admission.Conclusions: For diagnostic purposes, patients with severe anaemia can be managed similarly in a QDU or in-hospital setting, but the QDU model is more cost-saving than traditional hospitalisation. Most QDU patients preferred the QDU model to hospital admission.

Comparison of levofloxacin-containing sequential and standard triple therapies for the eradication of Helicobacter pylori

2011-03-21

Abstract: Background: There is an important concern about the success of standard triple treatment for Helicobacter pylori (H. pylori) in recent years. Better eradication rates have been reported with sequential treatment in current studies. This study aimed to compare the success of a novel levofloxacin-containing sequential regimen with standard triple therapy.Methods: H. pylori-positive patients with non-ulcer dyspepsia were randomly allocated to one of the study groups. The patients on sequential arm were given esomeprazole 40mg BID and amoxicillin 1g BID for the first week followed by esomeprazole 40mg BID, levofloxacin 500mg QD and metronidazole 500mg TID for the second week. The patients on standard triple arm were given esomeprazole 40mg BID, amoxicillin 1g BID and clarithromycin 500mg BID for 2weeks. Eradication was assessed by urea breath test on 6th weeks.Results: Seventy-five patients were enrolled in each group; 72 in sequential arm and 67 in standard arm completed the protocols. H. pylori eradication rate of per protocol was 90% in sequential versus 57% in standard treatment groups with a statistical significance (p<0.000). Both regimens were similarly well tolerated and side effects were comparable. Only one patient in sequential arm stopped the treatment because of side effects.Conclusion: The levofloxacin-containing sequential therapy is a significantly better strategy than the standard triple treatment for H. pylori eradication. Standard triple treatment is no more effective for H. pylori in our population and levofloxacin-containing sequential regimen might be used as a first-line eradication option.

Growth differentiation factor-15, a novel biomarker related with disease severity in patients with hypertrophic cardiomyopathy

2011-09-19

Abstract: Background: The growth differentiation factor 15 (GDF-15) has been shown up-regulated in stress conditions and to have regulatory actions in myocyte hypertrophy. We hypothesized that GDF-15 could be related to disease severity and functional status in patients with hypertrophic cardiomyopathy (HCM).Methods and results: We performed a study which includes 102 consecutive outpatient HCM subjects, 73% males, aged 47.1±14.6years. A complete history and clinical examination was performed, including 12-lead electrocardiogram, echocardiography, symptom-limited treadmill exercise, 24-hour ECG-Holter monitoring, and magnetic resonance with Gadolinium. Several biomarkers, associated with myocardial remodeling and damage, were compared to GDF-15 levels. The assays were performed with commercial ELISAs or standardized methods when available. There was a significant association between GDF-15 levels and comorbidities, being higher in hypertension (p=0.001), diabetes (p=0.030), atrial fibrillation (p=0.012), dyspnea (p=0.020) and NYHA≥II functional class (p=0.037). GDF-15 levels were positively correlated with clinical variables (age, worse exercise capacity and mild renal dysfunction) and biomarkers of interstitial remodeling, such as metalloproteinase-2 (r: 0.40; p=0.009), N-terminal pro-B-type natriuretic peptide (r: 0.28; p=0.049), high-sensitivity troponin T (r: 0.30; p=0.003) and von Willebrand factor (r: 0.33; p=0.001). Multivariate analysis was assessed to estimate the involvement of these different factors in the GDF-15 levels, confirming the independent implication of severe dyspnea and functional status.Conclusions: The present results show that higher levels of GDF-15 are associated to conditions of severe disease in HCM. Hence, GDF-15 is suggested as a novel marker related to the severity and could represent a further useful tool in monitoring functional capacity of HCM patients.

Association between the polymorphism of estrogen receptor α and coronary artery disease in a Chinese population

Cheng Shen, Jianming Chen, Shizhi Fan, Zhipin Li, Yijie Hu, Qianjin Zhong — 2011-06-13

Abstract: Background: The role of estrogen receptor α (ERα) polymorphism in coronary artery disease (CAD) was investigated previously in several populations. There are few data on relation between ERa polymorphism and CAD in Chinese population. Our study was to investigate the possible association between ERα polymorphism and CAD in Chinese population.Methods: A total of 539 patients with CAD and 539 age and sex matched controls were examined for ERa polymorphism. DNA was obtained and ERa polymorphism was analyzed by the polymerase chain reaction-based restriction fragment length polymorphism (PCR-RFLP).Results: The frequencies of the PvuII C allele were significantly higher in CAD patients than in control individuals (P<0.05). Using T allele as a reference, the odds ratio for CAD patients with C allele was 1.24 (95%CI=1.03-1.48). Using TT genotype as a reference, the odds ratio for TC genotype was 1.17 (95%CI=0.90-1.50), and for CC genotype was 1.58 (95%CI=1.05-2.38). The odds ratio for CC genotype was 1.42 (95%CI=0.94-2.15) in women and 1.72 (95%CI=1.41-2.10) in men. There were no significant differences in XbaI allele and genotype between CAD patients and control individuals.Conclusions: The ERa PvuII polymorphism is associated with the increased risk of CAD in men of a Chinese population. Further research is needed to investigate the mechanism underlying the association between ERα polymorphism and CAD.

Effects of renin–angiotensin blockers/inhibitors and statins on mortality and functional impairment in polypathological patients

2011-07-11

Abstract: Background: Frail and polypathological patients (PP) are often undertreated with evidence-based cardiovascular drugs, as their benefits are uncertain in this population.Objectives: To determine the effects of treatment with renin–angiotensin system blockers/inhibitors (ACEI/ARB), statins and/or beta-blockers on survival rates and functional decline in PP with evidence-based clinical indications for treatment with any of these drug families.Method: Prospective observational multicentre cohort study with a 12-month follow-up period. We selected PP with any condition of the following: chronic heart failure, coronary heart disease, chronic renal disease, cerebrovascular disease, peripheral artery disease, diabetes mellitus with any visceral involvement, hypertension, and dyslipidaemia. Clinical, functional (Barthel index), socio-familial risk data and drug prescriptions were measured at baseline. Multivariate Cox proportional hazards and logistic regression models were used to identify variables independently associated with survival and functional decline.Results: The analysis included 1260 PP. The mean age was 79±9.5years. The mortality rate was 34.5%. Statin (aHR 0.671; P=0.001), beta-blocker plus statin (aHR 0.645; P=0.007), ACEI/ARB plus statin (aHR 0.680; P=0.002), or combined ACEI/ARB plus statin plus beta-blocker (aHR 0.541; P=0.000) prescriptions were associated with longer survival times. Additionally, PP whose Barthel index was ≥60 showed a lower risk of disability progression if treated with statins (aOR=0.476; P=0.000), or their combinations, mainly with ACEI/ARB plus beta-blockers (aOR 0.563; P=0.031).Conclusions: The prescription of statins, alone or in combination with other drugs, may impact the survival and functional decline in polypathological patients. Further prospective blinded randomised assays are needed to confirm these observations.

Routinely adding ultrasound examinations by pocket-sized ultrasound devices improves inpatient diagnostics in a medical department

2011-11-11

Abstract: Background: We aimed to investigate the potential benefit of adding a routine cardiac and abdominal diagnostic examination by pocket-sized ultrasound device in patients admitted to a medical department.Methods: A random sample of 196 patients admitted to the medical department at a non-university hospital in Norway between March and September 2010 was studied. The patients underwent cardiac and abdominal screening with a pocket-sized ultrasound device with B-mode and color flow imaging after a principal diagnosis was set. Three internists/cardiologists experienced in ultrasonography performed the examinations. Diagnostic corrections were made and findings were confirmed by high-end echocardiography and examinations at the radiologic department.Results: 196 patients were included (male=56.6%, mean±SD; 68.1±15.0years old). The time spent doing the ultrasound screening was mean±SD 4.3±1.6min for the cardiac screening and 2.5±1.1min for the abdominal screening. In 36 (18.4%) patients this examination resulted in a major change in the primary diagnosis. In 38 (19.4%) patients the diagnosis was verified and in 18 (9.2%) patients an important additional diagnosis was made.Conclusion: By adding a pocket-sized ultrasound examination of <10min to usual care, we corrected the diagnosis in almost 1 of 5 patients admitted to a medical department, resulting in a completely different treatment strategy without delay in many of the patients. Routinely adding a cardiac and abdominal ultrasound screening has the potential to rearrange inpatients workflow and diagnosis.

An observational study on bloodstream extended-spectrum beta-lactamase infection in critical care unit: Incidence, risk factors and its impact on outcome

Prashant Nasa, Deven Juneja, Omender Singh, Rohit Dang, Akhilesh Singh — 2011-08-01

Abstract: Background: The incidence of nosocomial infections caused by extended-spectrum beta-lactamase (ESBL) producing microbes is increasing rapidly in the last few years. However, the clinical significance of infections caused by ESBL-producing bacteria in ICU patients remains unclear. We did a prospective study to look for incidence, risk factors and outcome of these infections in ICU patients.Methods: Consecutive isolates of Escherichia coli and Klebsiella pneumoniae in blood cultures were included for the analysis. Patients were divided into two groups based on the production of ESBL. Primary outcome measure was ICU mortality. Logistic regression analysis was done to identify risk factors for ESBL production.Results: Among the 95 isolates tested, 73 (76.8%) produced ESBL. Transfer from other hospitals or wards (OR 3.65; 95% CI: 1.3–10.1 and RR 1.35; 95% CI: 1.05–1.73) and previous history of antibiotics usage (OR 3.54; 95% CI: 1.04–11.97 and RR 1.5; 95% CI: 0.89–2.5) were risk factors for ESBL production. There was no significant difference in ICU mortality (p=0.588), need for organ support between two groups.Conclusion: There is a high incidence of ESBL producing organisms causing blood stream infections in critically ill patients. Transfer from other hospitals and previous antibiotic usage are important risk factors for ESBL production. However ESBL production may not be associated with a poorer outcome if appropriate early antibiotic therapy is instituted.

Serum osmolarity as an outcome predictor in hospital emergency medical admissions

Trevor Nicholson, Kathleen Bennett, Bernard Silke — 2011-08-03

Abstract: Background: To determine whether the serum osmolarity, calculated at the time of an emergency medical presentation, alone or combined with other predictors, could identify patients at low and high risks of an inpatient death by day 30.Methods: A retrospective analysis of all emergency medical patients admitted to St. James's Hospital (SJH), Dublin between the 1st of January 2002 and the 31st of December 2009, using the hospital in-patient enquiry (HIPE) system, linked to the patient administration system, and laboratory datasets. Hospital inpatient mortality (30days) was obtained from a database of deaths over the same period. Multivariate logistic regression was used to derive the best predictive model, with goodness of fit and Area Under the Receiver Operator Curves (AUROC) assessing the predictive accuracy.Results: Univariate analysis identified two quantiles of <10% and >75% of the osmolarity distribution as being at an increased mortality risk. Their respective mortality rates were 13.7% and 15.7% respectively, with unadjusted odds rate that were 1.66 (1.47, 1.88): p<0.0001 and 3.14 (2.87, 3.43): p<0.0001. After adjustment for other outcome predictors, a significant association with increased mortality remained, with OR=1.82 (1.61, 2.06), p<0.0001. Although the calculated osmolarity alone was not sufficiently predictive with AUROC=0.74 (95% CI: 0.73, 0.76), when combined with other predictors, the AUROC increased to 0.86 (95% CI: 0.84, 0.88).Conclusion: Admission osmolarity, a simple calculation, is associated with the risk of mortality in acutely ill medical patients; deviations outside the normal range are relevant. A useful clinical predictive algorithm requires the incorporation of additional predictors.

Prevalence of thoracic vertebral fractures in Spanish patients hospitalized in Internal Medicine Departments. Assessment of the clinical inertia. (PREFRAMI study)

2011-12-23

Abstract: Purpose: To study the prevalence of vertebral fractures (VF), the associated risk factors and the degree of diagnosis and prescription upon discharge in a series of hospitalized medical patients ≥50years of age.Methods: A cross-sectional, multicentre and observational study in which a prevalence cut-off was carried out concerning patients admitted to six Internal Medicine departments in Malaga (Spain). The main variables were the existence of a fracture in the spine lateral x-ray, the inclusion of the diagnosis of a fracture in the discharge report, and the establishment of anti-osteoporotic treatment at discharge.Results: 254 patients were included (mean age 66.4±14.9years). The prevalence of VF was of 14.2% (36 cases). Patients with VF presented with a higher mean age, compared to those without VF (70.14 vs. 65.7years) (p=0.035). The means contrast for the FRAX index variable (major osteoporotic and hip fracture), grouping according to the presence of VF, did not show any statistical significance (p=0.369 and p=0.788, respectively). Only in 8.3% of the discharge reports of patients with VF had the diagnosis of VF and/or osteoporosis been recorded and the prescription of anti-osteoporotic drugs been included.Conclusions: A high prevalence of asymptomatic VF is verified in medical inpatients ≥50years of age. The FRAX index did not turn out to be predictive of the presence of VF in this population. There is an underdiagnosis of osteoporotic VF in the coding at hospital discharge. Action protocols are necessary to avoid clinical inactivity regarding this entity.

The prevalence of Neurally Mediated Syncope in older patients presenting with unexplained falls

Mahesan Anpalahan, Stephen Gibson — 2011-11-21

Abstract: Aims: To determine the prevalence and clinical significance of carotid sinus syndrome (CSS) and vasovagal syncope (VVS), the two common types of Neurally Mediated Syncope (NMS), in a cohort of older patients with unexplained falls.Methods: Patients presenting with unexplained and accidental falls were identified from 200 consecutive admissions of falls in patients aged 65years and older admitted to the Rapid Assessment Medical Unit (RAMU) in a teaching hospital. A sample of unexplained and accidental fallers underwent carotid sinus massage (CSM) and tilt table testing (TTT) as per a standardised protocol. Baseline characteristics, clinical variables and the prevalence of NMS were compared between the two groups.Results: Falls were unexplained in 26% of patients. The prevalence of NMS was 24% (5/21) among patients with unexplained falls who underwent assessment for NMS, whereas it was nil (0/17) in patients with accidental falls (P=0.050). The prevalence of previous falls was significantly higher in patients with unexplained falls (P=0.0025), but all other baseline characteristics were similar between the two groups.Conclusion: Falls are unexplained in a significant number of older patients presenting to acute hospitals. The assessment of unexplained fallers for NMS is clinically important as this may be aetiologically related in nearly a quarter of these patients.

Emergency visits and hospital admissions in aged people living close to a gas-fired power plant

Agostino Di Ciaula — 2011-10-24

Abstract: Background: Combustion of natural gas for energy generation produces less pollutants than coke/oil. However, little is known about the short-term effect of pollution generated by gas-fired power plants on the health of elderly people.Methods: During three months, daily emergency visits/hospital admissions of subjects living within 3km from a gas-fueled power plant were counted and related to ambient concentrations of nitrogen dioxide (NO2) and particulate matter of median aerometric diameter <10μm (PM10). A generalized additive model served to correlate visits/hospital admissions to pollutants, controlling for meteorological confounders.Results: Mean air concentrations of PM10 and NO2 were higher after-than before the start of operation of the plant, with the highest concentrations recorded within 1km. Although pollutants were below the limits set by the European legislation, in elderly people there was a positive correlation between the number of emergency visits and daily air concentrations of PM10 and NO2, as measured at 1 and 3km from the plant. In subjects aged 70years or more, the number of hospital admissions was positively correlated with PM10 levels measured within 3km from the power plant, whereas in older subjects (≥80year) it was also significantly linked with the lowest air concentration of PM10 (measured at 6km from the plant).Discussion: Combustion of natural gas for energy generation produces a rise in air concentration of PM10 and NO2 close to the plant, with a concentration-dependent increment of daily emergency visits and hospital admissions in elderly people, and with an age-dependent susceptibility.

Human papillomavirus detected in esophageal squamous cell carcinoma in Iran

2011-11-14

Abstract: Introduction: Considering the different results obtained regarding the association of HPV with the development of esophageal squamous cell carcinoma (ESCC) in different populations, we aimed to determine the frequency of HPV infection and its subtypes in ESCC in Iranian patients.Method: A total of 100 paraffin-embedded tissue samples of ESCC diagnosed during 1991 and 2005 in the Institute of Cancer affiliated to Tehran University of Medical Sciences were selected. Seven out of 100 samples were excluded due to low quality of extracted DNA from paraffin-embedded specimens. Thus, 93 samples were included for HPV genotyping.Result: All samples were examined using SPF10 primers for HPV detection. HPV DNA was positive in 8 out of 93 (8.6%) ESCC specimens. Using INNO-LiPA genotyping system we detected the genotypes of 5 out of 8 HPV-positive samples. Both HPV types 16 and 6 were detected in 3 specimens; one sample was positive for HPV type 18 and 2 samples were co-infected with two HPV types. There were no statistically significant differences between HPV-positive and HPV-negative cases with regard to clinical and pathologic findings. Three samples were positive for SPF10 indicating HPV infection; however, the exact HPV type could not be clarified using INNO-LiPA genotyping .Conclusion: In conclusion, the present study showed that a small proportion of ESCC specimens from Iran harbor HPV16, 18 genome using a highly sensitive method. As different rates have been reported from Iran, a more widespread study with more precise definition of geographical differences could delineate the potential involvement of HPV in the development of ESCC in Iranian population.

Countering health threats by chemicals with a potential terrorist background — creating a rapid alert system for Europe

2011-10-28

Abstract: Background: The acronym "ASHT" stands for "Alerting System and Development of a Health Surveillance System for the Deliberate Release of Chemicals by Terrorists". Imagine this scenario: 15 patients with respiratory symptoms following a concert in Rome and 12 patients coughing after lunch in a cafeteria in the Czech Republic; are these events related? Today these events would never be connected as there is no mechanism to allow EU Member States to share this type of information effectively. The main objective of the ASHT project was to improve data sharing between EU Member States. In part, this was achieved by an internet accessible EU-wide alerting system with the aim to detect the deliberate (i.e. criminal or terrorist) or accidental release of chemicals. Nevertheless more information from police, fire brigades and health professionals is needed.Methods: Description of the design, development, functionality and testing of the relational database system called "RAS-CHEM" (Rapid Alert System for Chemicals).Results: A database structure appropriate for the description of "events" with sophisticated retrieval functions was developed. For evaluation purposes 37 events were entered into the database including 29 scenarios and 8 historical mass intoxications. The alert level was "background information" for 21 events, "suspected mass intoxication" for 6 cases and "confirmed mass intoxication" for 10 events.Conclusion: The RAS-CHEM database works and will be integrated into the Health Emergency Operations Facility (HEOF) with other European Rapid Alert Systems. Poisons centres receive a large number of enquiries and could be important sentinels in this field of toxicovigilance.

Vitamin D deficiency and peripheral diabetic neuropathy

S. Skalli, M. Muller, S. Pradines, S. Halimi, N. Wion-Barbot — 2011-12-12

Vitamin D deficiency has been associated with musculoskeletal diseases for many years. Accumulating evidence suggests that low Vitamin D levels are also associated with numerous pathologies such as cancer, microbial and metabolic diseases, including type 2 diabetes . Peripheral diabetic neuropathy affects more than 50% of type 2 diabetic patients and is considered a major diabetic complication . Vitamin D might be implicated in its pathophysiology via its potential influence on nerve function . Association between Vitamin D and self-reported peripheral neuropathy symptoms was recently described in diabetic patients from 2001 to 2004 NHANES . The purpose of our study was to investigate the prevalence of low Vitamin D levels in type 2 diabetic patients with peripheral diabetic neuropathy.

Vaccination against influenza a virus (H1N1) among Spanish healthcare workers

Julián Olalla, Fernando de Ory, Inmaculada Casas, Nicolás Benítez — 2011-12-23

After the first cases of H1N1 influenza A in 2009, the World Health Organization recommended the vaccination of healthcare workers (HCWs) as a matter of priority . HCWs are at occupational risk of influenza exposure . In the case of the influenza A (H1N1) pandemic in 2009, a significant barrier to vaccination was the fear of vaccine side effects and doubts about its effectiveness, despite scientific evidence in its support. There were marked geographic differences, ranging from the vaccination of 85% of Dutch general practitioners to just 22.2% of the HCWs in a Spanish hospital . In this paper, we propose to determine the percentage of workers vaccinated among a large sample of HCWs nationwide, and to identify differences according to professional status and the hospital services in which they work.

Initiation treatment with imiglucerase every 3weeks in type 1 Gaucher disease