European Journal of Internal Medicine

Editorial Board

2010-08-01

Current methods to diagnose the unresponsive and complicated forms of coeliac disease

M. Hadithi, A.S. Peña — 2010-03-02

Abstract: Coeliac disease is a common disorder. Due to the protean manifestations of the disease and the often mild but indolent course, the diagnosis is often missed. The method to diagnose this in principle reversible disease after the introduction of a gluten-free diet has attracted the attention of several scientific disciplines to find the simplest and most patient-friendly test. This has resulted in a noticeable impact on the clinical practice next to a general increased awareness of its existence, its pathogenesis, its course and recent evidence of increased mortality.Amendments made in the diagnostic criteria of coeliac disease over the last half century have simplified the diagnosis. However, the aspect most relevant to the specialist in internal medicine is related to its grave consequences when the disease fails to respond to a gluten-free diet. These refractory cases may culminate in severe complications with sombre endings and malignancy. Fortunately, current technology can offer the specialist in internal medicine more facilities to diagnose the cause of the complicated cases in order to attempt to intervene in the course of disease and hopefully save these patients.We review the available tools that now exist and their indications that can be practiced in a modern clinical setting for the diagnosis of the complicated forms of this disease.

Mechanism of hemostasis defects and management of bleeding in patients with acute coronary syndromes

Pier Mannuccio Mannucci, Massimo Franchini — 2010-04-15

Abstract: The main cause of the hemostasis defects and related bleeding complications in patients with acute coronary syndromes (ACS) are the intake of multiple antithrombotic drugs, alone or concomitantly with invasive procedures such as coronary angiography and percutaneous coronary intervention (PCI). Antithrombotic drugs that impair several phases of hemostasis (platelet function, coagulation, and fibrinolysis) are causing bleeding particularly in elderly patients, in those underweight and with comorbidities such as renal insufficiency, diabetes, hypertension and malignancy. Identification of patients at high risk of bleeding is the most important preventive strategy, because the choice and dosages of drugs may to some extent be tailored to the degree of risk. Transfusions of blood products, which may become necessary in patients with major bleeding, should be used with caution, because they are associated with adverse cardiovascular events. To reduce the need of transfusion, the hemostatic drugs that decrease blood loss and transfusion requirements in cardiac surgery (antifibrinolytic amino acids, desmopressin, and recombinant factor VIIa) might be considered. However, the efficacy of these drugs in the control of bleeding complications is not unequivocally established in ACS and there is concern for an increased risk of thrombosis. In conclusion, evidence-based recommendations for the management of bleeding in patients with ACS are currently lacking, so that prevention through accurate assessment of the individual risk is the most valid strategy.

A closer look at paroxysmal nocturnal hemoglobinuria

Saleh Rachidi, Khaled M. Musallam, Ali T. Taher — 2010-05-13

Abstract: Knowledge of the molecular mechanisms leading to the paroxysmal nocturnal hemoglobinuria (PNH) phenotypes has substantially increased in the past two decades. The associated intravascular hemolysis, hypercoagulablilty, and bone marrow failure result in a wide range of clinical sequlae. Although treatment has usually been symptomatic through several modalities and rarely curative through hematopoietic cell transplantation, recent development of the novel targeted therapeutic agent eculizumab has offered new promises for this highly morbid and fatal disease. This review summarizes current knowledge of the pathophysiology, diagnostic modalities, clinical implications, and treatment approaches of patients with PNH.

Body height and sex-related differences in incidence of venous thromboembolism: A Danish follow-up study

2010-04-30

Abstract: Background: Sex-related differences in incidence rate of venous thromboembolism (VTE) have been reported. It is unclear whether these differences reflect sex-related differences in the incidence of deep venous thrombosis (DVT), pulmonary embolism (PE) or both and to which extent the differences are mediated by known risk factors for VTE.Objective: To compare the incidence of DVT and PE between middle-aged men and women.Methods: We computed sex-specific incidences of VTE, DVT and PE and estimated the crude and adjusted incidence rate ratios (IRR) of VTE, DVT and PE using Cox regression for men versus women participating in the prospective study Diet, Cancer and Health. We controlled for body mass index, body height, leisure-time physical activity and smoking dose.Results: We verified 641 VTE events during a median follow-up time of 10years. The overall incidence of VTE was 1.15 [95%CI: 1.07–1.25] per thousand person years; it was higher for men than women (crude IRR: 1.55 [95%CI: 1.32–1.82]). The adjusted IRR for DVT was 1.06 [95%CI: 0.75–1.50] and for PE 0.60 [95%CI: 0.41–1.18] for men versus women. The higher rate among men appeared to be mediated mainly by body height.Conclusions: In this middle-aged population, men experienced a higher incidence of VTE due to a higher incidence of DVT. The higher incidence among men appeared to be mediated by body height. Adjusted for body height, male sex was not associated with an excess risk of either VTE or DVT but the risk of PE was notably lower compared with women.

No early signs of atherosclerotic alterations in carriers of inherited thrombophilia

2010-06-11

Abstract: Background: Congenital thrombophilia is a risk factor for venous thromboembolism (VTE). Whether it is associated with increased risk of arterial disease is today a matter of debate. We aimed to look for early signs of atherosclerotic alterations in carriers of inherited thrombophilic alterations (ITA).Methods: Between January 2006 and September 2008 ultrasonography assessment of the carotid arteries with measurement of intima-media thickness (IMT), and determination of the ankle/brachial pressure index (ABI), was performed in: a) 161 carriers of ITA (deficiency of antithrombin, protein C or S, factor V Leiden or prothrombin G20210A mutations), 84 of whom with previous VTE, and b) 180 subjects without ITA, matched for age, sex and previous VTE. All subjects were <66year old.Results: Carotid plaques were found in 8 subjects [3 (1.9%) with ITA]. Increased IMT values (>1mm) were detected in 6 subjects with and 1 without thrombophilia (p=0.055). The prevalence of IMT values>90th percentile was not different in subjects with/without thrombophilia (15.2% vs 11.6%, p=0.416). At multivariate analysis only age was significantly associated with increased odds ratios for IMT values>90th percentile. No subjects had abnormal (<0.9) ABI values.Conclusions: The present study, the first to investigate the presence of atherosclerotic markers in relatively young subjects with inherited thrombophilia, did not find a particular prevalence of signs of early atherosclerotic markers in these subjects.

Delay and misdiagnosis in sub-massive and non-massive acute pulmonary embolism

J.L. Alonso-Martínez, F.J. Anniccherico Sánchez, M.A. Urbieta Echezarreta — 2010-05-19

Abstract: Background: There is limited information about the extent and clinical importance of the delay in the diagnosis of acute pulmonary embolism.Patients and methods: Between 1998 and 2009, all consecutive patients diagnosed of acute pulmonary embolism from a registry of a single department were evaluated. We recorded the start or shift in symptoms as the beginning of pulmonary embolism and the mistaken diagnosis for which the patients had been treated. We evaluated the factors associated with the delay and misdiagnosis and their relation with mortality.Results: Overall 375 patients were evaluated. Median age was 75years, interquartile range (IQR) 15, and female 186 (49%). Median delay was 6 (IQR 12) days. Median Wells score was 4.5 (IQR 3).Delay in diagnosis was longer than 6days in 50% (95% CI 44–55) of patients, longer than 14days in 25% (95% CI 21–30) and longer than 21days in 10% (95% CI 7–13). Misdiagnosis occurred in 50% (95% CI 44–55) of patients. Higher age, more days of delay and the absence of syncope or sudden onset dyspnea were factors associated with misdiagnosis.Follow-up was carried out in 331 patients during a median of 31 (IQR 45) months. 36% (95% CI 33–43) of patients died [median 8 (IQR 29) months]. Higher age, misdiagnosis and a history of cancer were factors associated with mortality. Days of delay were not associated with mortality.Conclusions: Delay and misdiagnosis of pulmonary embolism is frequent. Elderly patients and the absence of syncope or sudden onset dyspnea favour the misdiagnosis. Delay in diagnosis does not participate in mortality.

Safety of withholding anticoagulant therapy in patients with suspected pulmonary embolism with a negative multislice computed tomography pulmonary angiography

2010-06-04

Abstract: Background: To assess the safety of withholding anticoagulant therapy in patients with clinically suspected pulmonary embolism with a negative multislice computed tomography pulmonary angiography (MCTPA).Methods: Three hundred and eighty six patients who were consecutively assessed in the emergency room of our institution for suspected pulmonary embolism were eligible for our study. Patients with either a low or an intermediate clinical probability of pulmonary embolism according to the Wells score and a negative MCTPA for pulmonary embolism were enrolled. Patients with anticoagulant therapy for other medical conditions were excluded from this study. We assessed the percentage of patients in whom venous thromboembolic events or death related to this condition within three months after the negative CT.Results: Two hundred and forty two patients were included in our series [mean age±standard deviation (SD) (63.1±18.1)]. Only one patient (0.41% [95% confidence interval −0.4%–1.22%]) showed a non-fatal pulmonary embolism during the three-month follow-up period after an initial negative CT scan (negative predictive value, 99.58%). Eleven patients died during the follow-up period due to conditions unrelated to venous thromboembolic disease (pneumonia [n=5], lung cancer [n=2], wasting syndrome [n=1], acute myocardial infarction [n=1], leiomyosarcoma [n=1], and severe pulmonary hypertension [n=1]).Conclusions: Withholding anticoagulant therapy in patients with suspected venous thromboembolic disease with a negative result on MCTPA seems to be safe in our clinical setting.

Single nucleotide polymorphisms in inflammation-related genes are associated with venous thromboembolism

2010-04-30

Abstract: Background: Various genetic risk factors are known to increase the risk of venous thromboembolism (VTE). Increasing evidence suggests a “cross-talk” between the coagulation and inflammatory cascade. Therefore, polymorphisms in genes involved in inflammation may influence susceptibility towards VTE. The aim of the study was to investigate the role of single nucleotide polymorphisms (SNPs) in inflammation genes for susceptibility towards VTE.Methods: The study group consisted of 108 (47 men and 61 women) Dutch patients with documented VTE and 325 healthy controls from the same geographical area (117 men and 208 women). Odds ratios (OR) and 95% confidence intervals (95% CI) for VTE separately and if indicated by gender were calculated to assess whether genotype and allele frequency were associated with thrombosis.Results: Heterozygosity for SNP −899C/T of the interleukin 1-alpha gene (IL1A −899C/T) was under-represented in VTE patients compared to the control group (OR=0.51, 95% CI 0.32–0.82). The IL6 −174 CC genotype was more frequent in male patients with VTE compared to male controls (OR=4.06, 95% CI 1.43–11.5). Female patients carried significantly more IL13 (intron3) TT genotype (OR=5.60, 95% CI 1.94–18.5) compared to female controls. The allelic frequency of IL4 −589 T allele was significantly increased in female patients (OR=1.72, 95% CI 1.05–2.81) in contrast to men where no differences were observed.Conclusion: Four SNPs in inflammatory-related genes of IL1A, IL4, IL6, and IL13 may be associated with VTE. These results need to be confirmed in independent groups with larger number of patients.

The tolerability and efficacy of low-dose simvastatin in statin-intolerant patients

2010-05-13

Abstract: Background/aim: Statin intolerance is increasingly recognized as a therapy limiting factor in the primary and secondary prevention of cardiovascular disease. Since vulnerability to dose related adverse events differ between subjects treated with statins we hypothesized low-dose simvastatin would be tolerated and effective in statin-intolerant patients.Method: A single center open label prospective observational study was performed assessing tolerability and efficacy of low-dose simvastatin treatment in 35 statin-intolerant patients. Statin intolerance was defined as not being able to tolerate a registered dose statin due to myalgia–myopathy, myositis, or elevation of serum liver enzyme levels. These statin-intolerant patients were treated with simvastatin with an initial dose of 2.5mg every other day. The dose was titrated upwards if possible. Tolerability was defined as remaining on treatment. Efficacy was defined as change of LDL-cholesterol compared to baseline.Results: The reached simvastatin dose ranged from 0.825 to 8.75mg/day with a mean dose of 4mg/day. Fifty-seven percent of the patients tolerated low-dose therapy and remained on treatment. Of these patients, 30% noted recurrent myalgia. Low-dose simvastatin significantly decreased mean(SD) LDL-cholesterol levels with 25.9(12.1)% (p<0.001). Eleven percent of the patients reached LDL-cholesterol target levels (<2.6mmol/l) in an intention to treat analysis and in 20% of patients that tolerated low-dose simvastatin.Conclusion: Low-dose simvastatin therapy is tolerated in a considerable proportion of statin-intolerant patients with significant lipid lowering efficacy. Low-dose statin therapy can be considered in multidrug regimens in statin-intolerant patients.

Use of vitamin K antagonists and risk of subarachnoid haemorrhage: A population-based case-control study

Morten Olsen, Martin Berg Johansen, Steffen Christensen, Henrik Toft Sørensen — 2010-05-31

Abstract: Background: Oral anticoagulant therapy with vitamin K antagonists is associated with an increased risk of bleeding, particularly gastrointestinal bleeding. It remains unclear, however, whether use of these medications is a risk factor for subarachnoid haemorrhage (SAH). We therefore examined the association between oral vitamin K antagonist use and risk of SAH.Methods: We conducted this population-based case-control study using medical databases in Northern Denmark (population 1,150,000). We identified 1188 patients admitted to neurologic or neurosurgical departments with a first-time diagnosis of SAH between 1996 and 2008 and 11,880 population controls. We obtained information on use of vitamin K antagonists, other medication use, and comorbidity. We used logistic regression analysis to compute odds ratios (ORs) comparing oral anticoagulant users and non-users, controlling for potential confounding factors.Results: 9 cases (0.8%) and 157 controls (1.3%) were current users of vitamin K antagonists (at least one prescription filled within 90days of the diagnosis/index date). Current use of vitamin K antagonists was not associated with increased SAH risk compared with non-use [adjusted OR=0.80 (95% CI: 0.37–1.74)]. Changing the exposure window from 90days to 120days or to 60days before the diagnosis/index date did not change the estimate substantially.Conclusion: We found no evidence to support an association between use of vitamin K antagonists and increased SAH risk.

The relationship between plasma homocysteine levels and bone mineral density in post-menopausal women

2010-04-30

Abstract: Background: Whether or not mild hyperhomocysteinemia and low serum levels of folates or vitamin B12 are risk factors for osteoporosis in the elderly is controversial.Aims and methods: To investigate whether or not plasma levels of total homocysteine (tHcy) and serum levels of folates and vitamin B12 are associated with bone mineral density (BMD), we carried out a cross-sectional study on 446 post-menopausal women (mean age: 65.1±9.4years), consecutively seen at the Siena Unit (Tuscany region, Central Italy) for BMD evaluation over a two-year period. BMD of the total femur, femoral neck and lumbar spine was detected by dual-energy X-ray absorptiometry.Results: The age-adjusted geometric mean of plasma tHcy levels (µmol/L) was 9.96±1.29 in women with normal BMD, 11.06±1.32 in those with osteopenia and 11.88±1.35 in those with osteoporosis (p<0.0001). On multiple linear regression analysis, adjusting for age, body mass index, folates, vitamin B12, creatinine clearance, smoking habit and alcohol intake, tHcy was negatively related to BMD of the total femur [β estimate for log-homocysteine: −0.050 (95% CI: −0.100 to −0.001, p=0.048; R2=0.02)], but not of femoral neck or lumbar spine. There was no significant association between BMD and serum levels of folates and vitamin B12.Conclusions: tHcy is negatively associated with BMD of the total femur. The contribution of tHcy to explain the variance of BMD is small (2% of the total variance) but clinically relevant, considering the high prevalence of osteoporosis among post-menopausal women and the possibility to lower tHcy by vitamin supplementation.

Helicobacter pylori is a major public health priority in western Balkans: An endoscopy referral center experience

2010-05-05

Abstract: Background: Helicobacter pylori infection is a highly prevalent community infection. The prevalence of H. pylori infection has been reported to vary worldwide by geographical area and by social and economic conditions.Aim: To investigate possible differences regarding the prevalence of H. pylori infection and related gastritis in Greek and Albanian patients undergoing routine endoscopy.Materials and methods: Single referral endoscopy center retrospective analysis for the period of 2005–2008. For each of the first 101 consecutive Albanian patients, one age and sex matched Greek patient was included. No patient was previously treated for H. pylori. Endoscopic and pathology findings were recorded for H. pylori infection and the presence of active gastritis.Results: In total 101 Albanians and 101 Greek patients were analyzed. A significantly higher prevalence of H. pylori in Albanians compared to Greeks was observed (54% vs 34%, p=0.005, OR 2.3, 95%CI 1.3–4.0). There were no differences in H. pylori prevalence among sex or age groups. Active gastritis was significantly more frequent in Albanians compared to Greeks (48% vs 32%, p=0.02, OR 2.0, 95%CI 1.3–2.6).Conclusion: This is the first attempt in western Balkans to demonstrate by routine gastroscopy and biopsy that there is a significantly higher prevalence of H. pylori and active gastritis in Albanians as compared to Greeks.

Efficacy and safety of Levofloxacin, Clarithromycin and Esomeprazol as first line triple therapy for Helicobacter pylori eradication in Middle East. Prospective, randomized, blind, comparative, multicenter study

M. Assem, G. El Azab, M. Abdel Rasheed, M. Abdelfatah, M. Shastery — 2010-06-17

Abstract: Background/aims: Antibiotic resistance and poor compliance are the main causes of Helicobacter pylori (H. pylori ) eradication failure. This study evaluated the eradication rate, tolerability, and compliance of Levofloxacin, Clarithromycin and Esomeprazol combined triple therapy for H. pylori eradication.Patients and methods: Four hundred-fifty patients from 3 centres who were diagnosed to have Helicobacter pylori infection by 13C-urea breath test were randomized into 3 equal groups; group 1 (CAE) received Clarithromycin 500mg twice daily, Amoxicillin 1000mg twice daily, plus Esomeprazol 20mg twice daily for 7days, group 2 (LAE) received Levofloxacin 500mg once daily, Amoxicillin 1000mg twice daily, plus Esomeprazol 20mg twice daily for 7days, group 3 (CLE) received Levofloxacin 500mg once daily, Clarithromycin 500mg twice daily, plus Esomeprazol 20mg twice daily for 7days. 436 patients were re-evaluated by 13C-urea breath test after 6weeks from completion of treatment.Results: H. pylori eradication (intention to treat) was successful in 136/150 (90.6%) with CLE, 127/150 (84.7%) with LAE and 118/150 (78.6%) with CAE. There was a significant difference (p<0.001) regarding treatment success between CLE and LAE when compared with CAE. There was no difference among the treatment groups with regard to the incidence and severity of adverse events reported.Conclusion: The combined Levofloxacin, and Clarithromycin and Esomeprazol based regimen as first line triple therapy for H. pylori eradication can give more significant eradication rate with same safety when compared with classic triple therapy.

Nutritional status in patients with active inflammatory bowel disease: Prevalence of malnutrition and methods for routine nutritional assessment

Dragana D. Mijač, Goran L.J. Janković, Jagoda Jorga, Miodrag N. Krstić — 2010-05-31

Abstract: Background and aim: Malnutrition is a common feature of inflammatory bowel disease (IBD). There are numerous methods for the assessment of nutritional status, but the gold standard has not yet been established. The aims of the study were to estimate the prevalence of undernutrition and to evaluate methods for routine nutritional assessment of active IBD patients.Material and methods: Twenty-three patients with active Crohn disease, 53 patients with active ulcerative colitis and 30 controls were included in the study. The nutritional status was assessed by extensive anthropometric measurements, percentage of weight loss in the past 1–6months and biochemical markers of nutrition.Results: All investigated nutritional parameters were significantly different in IBD patients compared to control subjects, except MCV, tryglicerides and serum total protein level. Serum albumin level and bodymass index (BMI) were the most predictive parameters of malnutrition. According to different assessment methods the prevalence of undernutrition and severe undernutrition in patients with active IBD were 25.0%–69.7% and 1.3%–31.6%, respectively, while in the control subjects no abnormalities have been detected. There was no statistically significant difference of nutritional parameters between UC and CD patients except lower mid-arm muscle circumference in UC group.Conclusions: Malnutrition is common in IBD patients. BMI and serum albumin are simple and convenient methods for the assessment of the nutritional status in IBD patients. Further studies with larger group of patients are necessary to elucidate the prevalence of malnutrition and the most accurate assessment methods in IBD patients.

Serum vitamin B12 and folate status in patients with inflammatory bowel diseases

Mustafa Yakut, Yusuf Üstün, Gökhan Kabaçam, Irfan Soykan — 2010-06-07

Abstract: Background: The aims of this study were to investigate the prevalence of serum vitamin B12 and folate abnormalities in patients with inflammatory bowel diseases (IBD) and to identify risk factors associated with B12 and folate abnormalities in this entity.Methods: 138 patients with IBD (45 Crohn's disease and 93 ulcerative colitis) and 53 healthy subjects were enrolled into the study. Fasting serum B12 and folic acid levels were measured and clinical data regarding inflammatory bowel diseases were gathered.Results: While the mean serum B12 concentration in CD patients was 281±166pg/ml, the mean serum vitamin B12 concentration in UC patients was 348±218pg/ml (p=0.224). The number of patients with vitamin B12 deficiency in the CD group was greater than the number of patients with UC [n=10 (22%) vs. n=4 (7.5%), p=0.014]. The number of patients (n=10, 22%) with B12 deficiency in the CD group was also greater than controls (n=4, 7.5%) (p=0.039). With regard to folate levels, the median serum folate level was 7.7±5.3ng/ml in CD patients, 8.6±8.3ng/ml in UC patients and 9.9±3.3ng/ml in the control group (p=n.s.). Patients with a prior ileocolonic resection had an abnormal B12 concentration compared to patients without surgery (p=0.008). In CD patients, ileal involvement was the only independent risk factor for having a low folate level.Conclusion: Serum vitamin B12 and folate deficiencies are common in patients with CD compared to UC patients and controls. In CD patients, prior small intestinal surgery is an independent risk factor for having a low serum vitamin B12 level.

Prevalence of irritable bowel syndrome in Italian rural and urban areas

2010-06-17

Abstract: Background/aims: No comparative studies are available, as yet, in Italy, concerning the prevalence of irritable bowel syndrome (IBS) in urban and rural areas. The aim is to compare the prevalence of IBS in Italian urban and rural areas.Methods: 950 subjects were randomly selected from each area and completed a questionnaire regarding demographic data and the Rome II questionnaire.Results: The prevalence of IBS was significantly (p<0.05) higher in the urban (9.9%), than in the rural area (4.4%). In the urban area, a significantly higher prevalence of IBS was observed in females than in males, 67/490 (13.7%) vs 27/460 (5.9%) (p<0.05), while no gender differences were present in the rural population.Conclusion: In the urban area, we found a higher prevalence of IBS, and a significantly higher prevalence of IBS in females than in males, while no gender differences were present in the rural population.

Under-recognized renal insufficiency in hospitalized patients: Implications for care

2010-05-31

Abstract: Background: The consequences of undetected low glomerular filtration rate (GFR) are important in hospitalized patients who receive potentially nephrotoxic drugs or undergo major surgery. This study estimated the prevalence of estimated GFR (eGFR) <60mL/min/1.73m2 in hospitalized patients.Methods: This cross-sectional descriptive study included 14,658 adults hospitalized at 10 centers in Spain. Serum samples were analyzed for hemoglobin, creatinine, albumin and urea nitrogen. eGFR was estimated using Modification of Diet in Renal Disease (MDRD) 4 or MDRD IDMS, and MDRD 6 when serum albumin and BUN were included (n=8611). Individuals were classified as having GFR≥60mL/min/1.73m2, stages 3, 4 and 5 (GFR 30–59, 15–29 and <15mL/min/1.73m2, respectively). Additionally, stages 3a and 3b (GFR 45–59 and 30–44mL/min/1.73m2, respectively) were assessed.Results: MDRD 4 eGFR showed that 28.3% of patients had renal insufficiency stages 3–5 and 14.2% had stages 3b, 4 or 5, which represents important-severe renal deterioration. Forty-three percent of patients with stages 3–5 had hemoglobin ≤11g/dL, compared with 27.9% of patients with eGFR≥60mL/min/1.73m2. A good correlation was observed between eGFR MDRD 4 and MDRD 6.Conclusions: A high percentage of hospitalized patients in Spain have deteriorated renal function stages 3–5. Using eGFR equations to assess eGFR could identify more hospitalized patients with renal insufficiency, potentially leading to improved care.

Entecavir is an optional agent to prevent hepatitis B virus (HBV) reactivation: A review of 16 patients

2010-05-31

Abstract: Background: 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.Methods: 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.Results: 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.Conclusions: This study suggests that ETV is a useful option for preventing HBV reactivation in patients with chronic HBV infection.

Obesity, hypertension and home sphygmomanometer cuffs

Tekin Akpolat — 2010-05-31

Abstract: Background: Since the increasing prevalence of obesity leads to a larger mean arm circumferences in the hypertensive population and appropriate cuff size is essential for accurate measurement of blood pressure, overweight and obese patients often require automated home sphygmomanometers with large- or extra large-sized cuffs. The aims of this study were to evaluate the information about cuff size on automated upper arm home sphygmomanometer packing boxes and compare the findings with wrist device boxes.Methods: One hundred twelve different device boxes (49 automated upper arm, 5 semi-automatic, and 58 wrist) produced by 40 manufacturers were investigated.Results: Three different types of information were observed (written, graphical, or a combination of both). There was not any information about cuff size on 49 (44%) device boxes. Most of the information expressed on the boxes was not attractive or informative for the patients.Conclusion: This study showed that the information regarding cuff size on most of the device boxes was obtuse and the patients are not warned sufficiently about appropriate cuff size. Physicians and health care providers should inform and train their patients about appropriate cuff size.

Heart involvement in Churg–Strauss syndrome: Retrospective study in French Burgundy population in past 10years

2010-06-14

Abstract: Introduction: Heart manifestations of Churg–Strauss syndrome (CSS) are varied. In the early stages of the disease, it is difficult to distinguish between lesions that are specific to CSS and those of other etiologies. The aim of our work was to compare the characteristics of patients with heart manifestations linked or not to Churg–Strauss syndrome.Material and methods: We recorded all clinical symptoms of patients with CSS hospitalized between 1998 and 2008 in Burgundy, France, and determined the possible relationships between heart symptoms and CSS.Results: From a cohort of 31 patients, we found 20 with heart lesions. When heart lesions were present, we noted fewer initial symptoms of digestive disorders (p<0.05), lower levels of lung infiltrates and fewer anti-MPO pANCA (p<0.05). Heart lesions were linked to CSS in 75% of cases. Their patients were thus younger than those in the other cardiac patients (p<0.05), were more likely to have clinical manifestations of heart involvement at diagnosis, were less likely to have lung infiltrates on the X-ray at diagnosis and during flare-ups and less likely to have lung abnormalities on X-rays during flare-ups (p<0.05) and higher level of leucocytes and eosinophils at diagnosis.Conclusion: Heart lesions directly attributable to CSS are frequent, severe and probably underestimated. A specific physiopathology that is not mediated by ANCA seems to be involved in the genesis of CSS-related heart lesions.

A 3-factor epistatic model predicts digital ulcers in Italian scleroderma patients

2010-06-24

Abstract: Background: The genetic background may predispose systemic sclerosis (SSc) patients to the development of digital ulcers (DUs).Methods: Twenty-two functional cytokine single nucleotide polymorphisms (SNPs) and 3 HLA class I and II antigens were typed at the genomic level by polymerase chain reaction in 200 Italian SSc patients. Associations with DUs were sought by parametric models and with the Multifactor Dimensionality Reduction (MDR) algorithm to depict the presence of epistasis. Biological models consistent with MDR results were built by means of Petri nets to describe the metabolic significance of our findings.Results: On the exploratory analysis, the diffuse cutaneous subset (dcSSc) was the only single factor statistically associated with DUs (p=0.045, ns after Bonferroni correction). Gene–gene analysis showed that a 3-factor model comprising the IL-6 C-174G, the IL-2 G-330T SNPs and the HLA-B*3501 allele was predictive for the occurrence of DUs in our population (testing accuracy=66.9%; p<0.0001, permutation testing).Conclusion: Biological interpretation via Petri net showed that IL-6 is a key factor in determining DUs occurrence and that this cytokines may synergise with HLA-B*3501 to determine DUs onset. Owing to the limited number of patients included in the study, future research are needed to replicate our statistical findings as well as to better determine their functional meaning.

Perimyocarditis following streptococcal group A infection: From clinical cases to bioinformatics analysis

2010-06-07

Abstract: Background: Streptococcal infection is known to be associated with non-suppurative complications, including rheumatic fever. A less well recognized complication is perimyocarditis.Methods: We report 4 cases of myocarditis in young males associated with acute streptoccal infection. Following this clinical observation we employed bioinformatic techniques to identify common epitopes between Streptococcus group A and human muscle proteins. We used Blast to search all the proteome (1697 proteins) of the Streptococcus pyogenes M1 GAS against the human proteome of 34,180 proteins.Results: 4 patients with streptococcal A related myocarditis were treated and made a complete recovery. One cardiac protein, ATP2A2 (NP_733765.1)), a cardiac Ca2+ ATPase, shared an epitope with Streptococcus group A and a high probability of being presented on a MHC Class II molecule.Conclusion: Streptococcal myocarditis may be a commoner entity than previously appreciated. Bioinformatic techniques have identified a suspected common epitope between the streptococcal proteins and a cardiac Ca2+ ATPase.

Parallel communication in the wards

Ami Schattner — 2010-05-11

Patient–physician communication is almost exclusively pragmatic. Nowhere more so than in the overcrowded hospital wards attending to older, more complex patients whose length of stay is steadily decreasing. Indeed, patients would not want to trespass on physicians' time; and doctors were primarily instructed in obtaining as much clinical information as possible pertaining to symptoms and their characteristics and the more practical aspects of patient care. The same is true for clinical teachers. Too often, they speak about patients but rarely speak to them as people .

Relationship between anemia and cognitive functions in the geriatric population

Nishant Tageja — 2010-06-07

Recent years have witnessed a renewed interest in the debate about anemia and its adverse clinical effects on the geriatric population, with a number of studies reporting associations between mild anemia and physical conditioning, aerobic fitness and executive–cognitive abilities. The recently published study by Terekeci et al. was well-conducted and adds to our present fund of knowledge on the subject. However, a few key issues may need attention before further prospective studies are undertaken.

European Journal of Internal Medicine

Editorial Board

Contents

Current methods to diagnose the unresponsive and complicated forms of coeliac disease

Mechanism of hemostasis defects and management of bleeding in patients with acute coronary syndromes

A closer look at paroxysmal nocturnal hemoglobinuria

Body height and sex-related differences in incidence of venous thromboembolism: A Danish follow-up study

No early signs of atherosclerotic alterations in carriers of inherited thrombophilia

Delay and misdiagnosis in sub-massive and non-massive acute pulmonary embolism

Safety of withholding anticoagulant therapy in patients with suspected pulmonary embolism with a negative multislice computed tomography pulmonary angiography

Single nucleotide polymorphisms in inflammation-related genes are associated with venous thromboembolism

The tolerability and efficacy of low-dose simvastatin in statin-intolerant patients

Use of vitamin K antagonists and risk of subarachnoid haemorrhage: A population-based case-control study

The relationship between plasma homocysteine levels and bone mineral density in post-menopausal women

Helicobacter pylori is a major public health priority in western Balkans: An endoscopy referral center experience

Efficacy and safety of Levofloxacin, Clarithromycin and Esomeprazol as first line triple therapy for Helicobacter pylori eradication in Middle East. Prospective, randomized, blind, comparative, multicenter study

Nutritional status in patients with active inflammatory bowel disease: Prevalence of malnutrition and methods for routine nutritional assessment

Serum vitamin B12 and folate status in patients with inflammatory bowel diseases

Prevalence of irritable bowel syndrome in Italian rural and urban areas

Under-recognized renal insufficiency in hospitalized patients: Implications for care

Entecavir is an optional agent to prevent hepatitis B virus (HBV) reactivation: A review of 16 patients

Obesity, hypertension and home sphygmomanometer cuffs

Heart involvement in Churg–Strauss syndrome: Retrospective study in French Burgundy population in past 10years

A 3-factor epistatic model predicts digital ulcers in Italian scleroderma patients

Perimyocarditis following streptococcal group A infection: From clinical cases to bioinformatics analysis

Parallel communication in the wards

Relationship between anemia and cognitive functions in the geriatric population