Perception of Thromboembolism Risk: Differences between the Departments of Internal Medicine and Emergency Medicine.

The latest developments in emergency medicine (EM) have introduced new typologies of patients that have not been taken into account in previous studies of venous thromboembolism (VTE) risk. The aim of the current study was to evaluate by comparing the main international risk scores whether different perceptions of VTE risk exist in internal medicine (IM) departments and in EM departments. This cross-sectional observational study involved 23 IM and 10 EM departments of 21 different hospitals. The patient data were collected by physicians who were blinded to the purpose of the study. The data were analyzed using the main international risk scores. We analyzed 742 patients, 222 (30%) hospitalized in EM departments and the remaining 520 (70%) in IM departments. We found that fewer patients at risk for VTE were treated with low-molecular-weight heparin (LMWH) in EM departments than in IM departments. Moreover, there was significant statistical difference in the use of LMWH between IM and EM departments when the Padua score and immobilization criteria were used to assess the risk. The infrequent use of LMWH in EM patients may have several causes. For example, in EM departments, treatment of acute illness often takes higher priority than VTE risk evaluation. Moreover, immobilization criteria cannot be evaluated for all EM patients because of the intrinsic time requirements. For the aforementioned reasons, we believe that a different VTE risk score is required that takes into account the peculiarities of EM, and establishing such a score should be the object of future study.

[The overuse of thromboprophylaxis in medical patients: main clinical aspects]. / L'uso eccessivo della tromboprofilassi in pazienti medici: i principali aspetti clinici.

BACKGROUND: Overuse of thromboprophylaxis is not an infrequent behavior in internal medicine. However, differently from underuse, overuse of thromboprophylaxis is rarely taken into account, and only few studies have addressed this issue. The purpose of our study was to try to understand the reasons behind this phenomenon. METHODS: Using data from the TEVERE study, we evaluated 279 patients hospitalized in 21 hospitals of the Lazio Region in Italy. Only patients who were negative to major risk scores as established in the scientific literature were included. We assessed the frequency of thromboprophylaxis in acutely ill medical patients hospitalized in emergency and internal medicine wards, and we performed a comparative analysis for each risk factor among patients who received or not received thromboprophylaxis. RESULTS: Forty-seven patients (16.5%) with negative risk scores were given thromboprophylaxis during hospitalization. On backward stepwise logistic regression analysis, severe infection (odds ratio [OR] 2.31; 95% confidence interval [CI] 1.25-4.35) and chronic venous insufficiency (OR 3.02; 95% CI 1.96-4.67) were found to be the strongest predictors of the use of thromboprophylactic treatment with heparin. The subgroup of patients who did not exhibit risk factors was also analyzed, and age was found to be the main factor in the decision-making process regarding heparin administration in the absence of other risk factors (74.9 ± 11.8 vs 63.7 ± 18.1, p=0.002). CONCLUSIONS: Our findings suggest that thromboprophylaxis is associated with considerable uncertainty, which results in its overuse. Further research is needed to better understand thromboembolic risk factors in hospitalized medical patients.

Correlation between epicardial fat and cigarette smoking: CT imaging in patients with metabolic syndrome.

BACKGROUND: The aim of our study was to assess the relationship between cigarette smoking and epicardial fat in a cohort of patients with metabolic syndrome (MetS) at risk for coronary artery disease. METHODS: We studied, in primary prevention, 54 subjects diagnosed with MetS. According to their smoking habits, the subjects were divided into two groups: smokers and non-smokers. Besides anthropometric characterization and screening laboratory tests, the subjects had a multidetector computerized tomography scan, which allowed epicardial fat quantification and calcium score (CS) evaluation. RESULTS: Compared with non-smokers, smokers showed older age (61.6 ± 1.8 vs 56.8 ± 1.2 yrs; p < 0.05). Also, the smokers displayed increased epicardial fat volume (138 [123; 150] vs 101[79; 130] ml; p < 0.01) as well as higher CS (94 [3; 301.5] vs 0 [0;10.2]; p < 0.001), in comparison with non-smokers. Notably, CS was positively correlated with smoking habit (rs 0.469; p < 0.01), epicardial fat (rs 0.377; p < 0.01), age (rs 0.502; p < 0.001) and uric acid (rs 0.498; p < 0.01). Accordingly, the associations between both CS or epicardial fat and cigarette smoking were still maintained after adjustment for age (r 0.317; p < 0.05; r 0.427; p < 0.01). Finally, multiple regression analysis showed that smoke was the variable that best predicted CS (R(2) 0.131; ß 0.362; p < 0.05) and epicardial fat (R(2) 0.177; ß 0.453; p = 0.01). CONCLUSIONS: Our findings suggest that, in subjects with MetS, cigarette smoking is an independent predictor of increased epicardial fat volume and higher CS.

Serum interferon (IFN)-neutralizing antibodies and bioactivities of IFNs in patients with severe type II essential mixed cryoglobulinemia.

The efficacy of alpha interferon (IFN-alpha) in the treatment of severe type II essential mixed cryoglobulinemia (EMC) has been reported previously. In some patients, the development of neutralizing antibodies to recombinant IFN-alpha (rIFN-alpha) can affect the clinical response achieved with rIFN-alpha; a second treatment with natural IFN-alpha preparations may reinduce the clinical response. In the present study the ability of leukocyte IFN (LeIFN) to restore the response was investigated from a pharmacodynamic viewpoint. Specifically, the pharmacodynamic profiles of different IFN-alpha preparations were studied by measuring the serum neopterin levels and the levels of expression of protein MxA mRNA in in vivo peripheral blood mononuclear cells in two patients with EMC whose resistance to rIFN-alpha2a treatment increased concomitantly with the development of neutralizing antibodies. These markers were measured before injection and at 24 and 48 h after a single injection of rIFN-alpha2a, consensus IFN [(C)IFN], or LeIFN. No increase or only a slight increase in MxA mRNA levels was detectable after administration of rIFN-alpha2a or (C)IFN, whereas a significant increase (>/=10-fold) in MxA mRNA expression was recorded following administration of LeIFN. The neutralizing antibodies to rIFN-alpha2a cross-react with (C)IFN. Sera from these patients neutralized most but not all of the subtypes present in the natural IFN-alpha (LeIFN) mixture, and no significant increase in neopterin levels was observed after these patients were switched to LeIFN treatment. In summary, the data demonstrate that the problem of neutralizing antibodies still exists and that LeIFN may induce an increase in the level of MxA mRNA expression but not an increase in neopterin levels in patients who are resistant to treatment with rIFN-alpha2a or (C)IFN.

Influence of age and autoimmunity on liver disease in HCV-associated type II mixed cryoglobulinemia.

It has been suggested that hepatitis C virus (HCV) infected patients with type II mixed cryoglobulinemia have less extensive liver damage than patients without cryoglobulinemia. We retrospectively evaluated 35 patients with type II mixed cryoglobulinemia associated with HCV infection, seeking for factors associated with normal alanine aminotransferase (ALT) values. The presence of anti-GOR and of other autoantibodies, including the recently described anti-LAG-3.1, was specifically investigated. Fifty-four percent of patients had anti-GOR, 46% anti-LAG-3.1, 40% anti-smooth muscle, 17% anti-nuclear, and 11% anti-liver-kidney microsome 1 antibodies. Anti-GOR was significantly (p = 0.037) associated with anti-LAG-3.1 but not with other autoantibodies. Persistently abnormal ALT levels were observed in 54% of patients. By univariate analyses, abnormal ALT was significantly associated with anti-GOR positivity (p = 0.018) and younger age (p = 0.03). Multivariate regression analysis confirmed that these variables were independently associated with abnormal ALT. Our data suggest that the presence of autoimmune manifestations as well as unidentified age-related host factor(s) may protect from liver injury in HCV-associated cryoglobulinemia.