Annali italiani di medicina interna : organo ufficiale della Societa italiana di medicina interna最新文献

Juvenile idiopathic arthritis represents a heterogeneous group of autoimmune diseases. It arises before 16 years of age and lasts more than 6 months. We can distinguish many arthritis sub-types. A serious problem in juvenile idiopathic arthritis is skeletal growth retardation, osteopenia and greater risk of developing fractures. Juvenile idiopathic arthritis diagnosis is an exclusion diagnosis. Many conditions can simulate it. First-choice drugs in juvenile idiopathic arthritis treatment are nonsteroidal anti-inflammatory drugs, analgesic and antipyretic drugs. The second-choice drugs are "slow-acting" antirheumatic drugs, like methotrexate. The use of glucocorticoids is strongly influenced by their side effects, in particular the inhibition of statural growth and the premature appearance of osteoporosis. Recent findings on the central role of tumor necrosis factor-alpha, in particular damage pathogenesis in the course of juvenile idiopathic arthritis, have permitted the development of new therapeutic strategies (infliximab, etanercept), aimed at blocking this cytokine.

Cardiovascular disease and depression, which is frequently encountered in developed countries, are unexpectedly linked and someway interdependent. Although it has been proven that major depression is a risk factor for cardiovascular disease, it is also true that cardiovascular disease may often cause depression. This article provides epidemiological data regarding this phenomenon and focuses on the mechanisms and causes that link these apparently unrelated pathologies. The diagnosis of depression and the difficulty in recognizing it as such are reviewed and several tests useful for this purpose are presented. Finally, the most common antidepressants particularly suitable for cardiac patients are examined along with any possible interactions between these drugs and those currently used for treatment of cardiovascular disease.

Skin and soft tissue infections that usually follow minor traumatic events or surgical procedures are caused by a wide spectrum of bacteria. We describe a soft tissue infection caused by a Mycobacterium chelonae in an immunocompetent patient who underwent liposculpture and lipofilling of the gluteal-trochanteric region, emphasizing the importance of clinical suspicion and effective treatment of infection.

A 67-year-old woman was hospitalized with recurrent fever, arthralgia and erythema of the arms and legs. She had suffered from bronchiectasis for the previous 4 years, and Pseudomonas was persistently detected in her sputum. During the course of her illness, she developed distal sensitive and motor polyneuropathy. Serum test was positive for myeloperoxidase and bactericidal/permeability-increasing protein antineutrophil cytoplasmic antibodies. Nerve biopsy showed vasculitis infiltration of the vasa nervorum. She started immunoglobulin therapy, and after methylprednisolone and pulse cyclophosphamide therapy once monthly for 6 months she showed a good response and a reduction in symptoms.

The antiphospholipid syndrome is associated with complications of pregnancy or venous or arterial thrombosis in the presence of antiphospholipid antibodies. Venous thromboembolism is the most common clinical feature. Pathogenetic mechanisms underlying the syndrome are not completely understood and several hypotheses have been raised. Secondary prophylaxis after venous thromboembolism episodes requires oral anticoagulants (prothrombin time-international normalized ratio 2-3) for 6 to 12 months. More intensive anticoagulant regimens are indicated in case of recurrence. A longer or life-long course of treatment is indicated in patients with recurrent or life-threatening events or in the presence of high titers of antiphospholipid antibodies. Among risk factors for venous thromboembolism, inherited thrombophilia is recently described, such as defects of the physiological coagulation inhibitors, genetic mutations of factor V and factor II of the coagulation cascade and hyperhomocysteinemia. High levels of factor VIII, factor IX and lipoprotein(a) have recently been proposed as new risk factors for venous thromboembolism. The coexistence of inherited thrombophilia seems to enhance the thrombogenic risk, in particular in the venous vascular bed. The new insights into the diagnosis of inherited thrombophilia could allow a better evaluation of the thrombotic risk, leading to tailor the prophylactic strategy.

The aim of this study was to describe the characteristics of institutionalized patients, the patterns of admission, hospital stay and discharge and the extent of resource utilization before, during and after hospitalization, in an Acute Division of Internal Medicine of a university hospital. All adult patients admitted to the division were consecutively enrolled during a 3-month study period. Patients underwent a multidimensional assessment and data collection concerning admission and discharge patterns, resource utilization, and discharge diagnosis. Three hundred and eighteen patients, with an average age of 73.8 years, entered in the study; the rate of patients both affected by severe cognitive and functional impairment was high (29.9%); 3-4 comorbidity classes were estimated in 70.8% of patients; the most frequent diagnoses at discharge were gastrointestinal (major diagnostic category 6), liver and pancreas diseases (major diagnostic category 7); despite the high rate of comorbidity and severity of illness, the average diagnosis-related groups was low (1.15 +/- 0.59) and also the levels of nursing and personal care provided in the hospital were low (21 +/- 15 and 19 +/- 16, respectively). Median length of stay was 9 days and 3-4 comorbidity classes significantly prolonged hospitalization (p < 0.01). The main critical aspects concerning hospital admissions were the low rates of general practitioner requests of admission (26.7%), the high rates of unplanned readmissions (17.9%) and inappropriate recovery (12.6%). Concerning discharge, only 18.5% of patients had assisted discharges despite the high rates of patients with functional impairment; difficulties at discharge were estimated in 15.0% of patients. Our data suggest to improve the relation between hospital and primary health services in order to assure appropriateness of patient care and optimal use of a specialistic division.