[Evaluation of the workload resulting from iatrogenic pathology in a medical ward in a regional hospital]. / Valutazione del carico di lavoro dovuto a patologia iatrogena in un Reparto di Medicina di un Ospedale Regionale.

OBJECTIVES: 1) To estimate the burden to diagnose and treat iatrogenic disorders out of all the activities of a referral hospital's medical ward. 2) To investigate about the main causes making the iatrogenic disorders arouse. DESIGN AND SUBJECTS: The entire series of iatrogenic disorder bearing patients (in- and out-), treated in the Institute of Medical Pathology of Ancona throughout a period of two years, were studied retrospectively. The low therapeutic index treatments (i.e. antiproliferative drugs, therapies under emergency, surgical amputations) were ruled out. The data to address the objectives were gathered. RESULTS AND CONCLUSIONS: 1) Highly probable iatrogenic disorders were diagnosed in 84/1620 patients (5.2%). 2) For this task 108/2763 medical performances were carried out (3.9%); 3) iatrogenic disorders were Slight in 20 (24%), Moderate in 44 (52%) and Severe in 20 (24%) patients. 4) Some facilitaters (poor monitoring of adverse drug reactions, primary disease incorrect treatment, poor accuracy of primary disease diagnosis, incoordination among therapists) were detected in 32, 25, 14, and 7%. 5) The most commonly occurring facilitaters were detected more frequently in Severe rather than Non Severe iatrogenic disorder bearing patients. 6) Severe iatrogenic disorders and the serious consequences of them, such as death and permanent serious harm, occur more often, when there are combinations of facilitaters; 7) Costs were minor in 69% and major in 31%.

Paraneoplastic syndromes in 68 cases of resectable non-small cell lung carcinoma: can they help in early detection?

The aim of this study was to assess the importance of paraneoplastic syndromes as an early sign of non-small cell lung cancer (NSCLC). A procedure for searching paraneoplastic syndromes, based on 40 years of reports in the literature, was established and the prevalence of paraneoplastic syndromes estimated in 68 patients with resectable NSCLC. Stages I and II were considered eligible for surgery straight away. Patients in Stage IIIA underwent surgery if partially or completely responsive to three courses of neo-adjuvant chemotherapy. Paraneoplastic syndromes were assessed and confirmed in nine patients (13%). Motor-sensory neuropathy, arthritis and arthralgias to the knees, periarthritis to the shoulder, hypertrophic osteopathy, clubbing, pruritus were observed. Only three patients with painful osteoarthropathies were diagnosed with NSCLC by tracing their paraneoplastic syndrome, whereas most of them (36/68) were diagnosed incidentally through a chest radiograph taken for tumour-unrelated symptoms. A careful research of paraneoplastic syndromes in high risk patients may guide the doctor to a resectable NSCLC diagnosis. Recent onset arthritis and arthralgias, which cannot be explained otherwise, should be considered to be early clues of lung cancer.

[Diagnosis of fever of unknown origin: use of Bayes theorem]. / La diagnosi di febbre di origine oscura: applicazione del teorema di Bayes.

Sophisticated tests and time are needed to establish the diagnosis of fever of unknown origin (FUO). Bayes theorem can guide the clinician to early probabilistic diagnosis. The authors had estimated the a priori probabilities in a previous study yet. In this paper the diagnostic probabilities of four clinical signs (arthralgias, myalgias, splenomegaly, multiple micro-lymphoadenopathies) and the probabilities of abnormalities of some routine laboratory tests (neutrophils count, lymphocytes count, platelets count, hemoglobin, lactic-dehydrogenase, C3 and C4 complement subunits and fibrinogen plasma concentrations, erythrocyte sedimentation rate) and of the positive bacterial cultures, were estimated in the main groups of FUO disease (indefinite, aspecific bacteria infections, non-bacterial or specific bacteria infections, neoplasias, connective tissue diseases, miscellaneous group). The data suggest that the a priori probability is not affected by the clinical signs. Arthralgias increase the probability of connective tissue diseases. Normal erythrocyte sedimentation rate and plasma fibrinogen concentrations increase the probability of paraneoplastic and indefinite fever. Thrombocytosis increases the probability of paraneoplastic fever. Over 1200 U/l serum lactic-dehydrogenase serum concentrations guide to non-bacterial or specific bacteria infectious diseases and to malignancies. Neutrophilia decreases the probability of indefinite diagnosis, even though it is not specific. The heterogeneity of the miscellaneous group makes the interpretations of the data very hard.

[Fever of unknown origin. Comparison of the diagnostic spectrum of 53 cases in a medical ward in an Italian hospital with those of other 9 countries]. / Febbre di origine ignota. Confronto tra lo spettro diagnostico di 53 casi di un Reparto di Medicina di un ospedale italiano con quello di altri nove Paesi.

In the Institute of Medical Pathology of Ancona University, 53 cases of fever of unknown origin (FUO) were reviewed. In 44 cases (83%) the diagnosis was certainly stated. The diagnostic spectrum of the diagnosed cases was: 31 infectious (58%), 3 neoplastic (6%), 8 autoimmune (15%), 2 miscellaneous diseases (4%). Nine cases (17%) were undiagnosed. The mortality rate of the diagnosed cases was 16% within 16 months. The diagnostic spectrum, compared with the FUO series from nine countries, is unlike because of a higher rate of infectious diseases and a lower rate of neoplastic diseases. The methods, successfully used to achieve the final diagnosis were: laboratory tests, including bacteriologic studies, in 39%, evaluation of the clinical course and follow-up in 25%, imaging scan tests, including radionuclide, ultrasound, magnetic resonance, computed tomography, in 23%, and anatomopathological studies in 13%. A three years' follow-up was successfully carried out in 7 out of the 9 undiagnosed patients: 5 were healed without any treatment, 1 healed through a course of non steroid anti-inflammatory drugs and only one died because of the FUO carrying disease. None was persistently sick. The data are discussed through a comparison with the series of FUO bearing patients from other 9 countries.

Plasma atrial natriuretic peptide and natriuretic peptide receptor gene expression in adipose tissue of normotensive and hypertensive obese patients.

OBJECTIVE: Human and rat adipose tissue contain very high levels of natriuretic peptides clearance receptor messenger (m)RNA, and fasting inhibits its gene expression in adipose tissue. In this study we evaluated plasma atrial natriuretic peptide (ANP) and gene expression of biologically active type A natriuretic peptide receptor (NPr-A) and clearance natriuretic peptide receptor (NPr-C) in adipose tissue of obese hypertensive and obese normotensive patients. DESIGN AND METHODS: We studied 27 untreated obese hypertensives, 26 obese normotensives (body mass index > or = 30 kg/m2), 24 non-obese essential hypertensives and 23 lean healthy subjects (body mass index < or = 25 kg/m2). Blood samples were withdrawn for ANP, plasma renin activity and aldosterone radioimmunoassays. Subcutaneous peri-umbilical adipose tissue samples were obtained, by needle aspiration, in 13 obese hypertensives and in 12 obese normotensives and used for RNA extraction. Then, complementary synthesis and semiquantitative polymerase chain reaction (PCR) with primers complementary to sequences of different exons of the genes encoding for NPr-A, NPr-C and beta-actin, were performed. 32P-labeled PCR products were separated by electrophoresis, blotted onto nylon membranes, and the exposed autoradiographic films were analysed by densitometry. NPr signals were normalized by the beta-actin expression level. RESULTS: Plasma ANP was lower in obese hypertensives than in obese normotensives (37.5+/-7 versus 43.2+/-6 pg/ml, P< 0.05), but was higher in non-obese hypertensives than in non-obese normotensives. In contrast, plasma renin activity and aldosterone were higher in the obese hypertensives. Although NPr-A and NPr-C expression were not statistically different between the two obese groups, the NPr-A: NPr-C mRNA ratios were significantly lower in obese hypertensives (P < 0.03). CONCLUSIONS: Our data suggest that in obese hypertensives compared to obese normotensives, the lower NPr-A: NPr-C ratio might determine decreased biological activity and/or an increased clearance of natriuretic peptide in adipose tissue, suggesting that the natriuretic peptide and its receptor system may be important in obesity-related hypertension where ANP levels are lower.