A 2017 SURVEY OF THE CLINICAL PRACTICE PATTERNS IN THE MANAGEMENT OF RELAPSING GRAVES DISEASE.

OBJECTIVE: Previous surveys from different world regions have demonstrated variations in the clinical management of Graves disease (GD). We aimed to investigate the clinical approach to GD relapse among endocrinologists. METHODS: Electronic questionnaires were e-mailed to all members of the Israeli Endocrine Society. Questionnaires included demographic data and different scenarios regarding treatment and follow-up of patients with GD relapse. RESULTS: The response rate was 49.4% (98/198). For a young male with GD relapse, 68% would restart antithyroid drug (ATD) (98% methimazole), while 32% would refer to radioactive iodine (RAI) treatment. Endocrinologists who treat >10 thyroid patients a week tended to choose ATDs over RAI ( P = .04). In the case of GD relapse with ophthalmopathy, 50% would continue ATDs, whereas 22.4% would recommend RAI treatment and 27.6% surgery. Most endocrinologists (56%) would continue ATDs for 12 to 24 months. Seventy-five percent would monitor complete blood count and liver function (39% for the first month and 36% for 6 months), and 44% would recommend a routine neck ultrasound. In a case of thyrotoxicosis due to a 3-cm hot nodule, most endocrinologists (70%) would refer to RAI ablation, 46.4% without and 23.7% with a previous fine-needle aspiration. No significant differences were found regarding gender, year of board certification, or work environment. CONCLUSION: Our survey demonstrates diverging patterns in the diagnosis and management of GD relapse that correlate well with previous surveys from other countries on GD-naïve patients and a less than optimal adherence to recently published clinical guidelines. ABBREVIATIONS: ATA = American Thyroid Association; ATD = antithyroid drug; CBC = complete blood count; GD = Graves disease; GO = Graves ophthalmopathy; LFT = liver function test; MMI = methimazole; PTU = propylthiouracil; RAI = radioactive iodine; TSI = thyroid-stimulating immunoglobulin.

Reassessment of Differentiated Thyroid Cancer Patients Using the Eighth TNM/AJCC Classification System: A Comparative Study.

BACKGROUND: Facing the prevailing concept that increased diagnosis with no change in mortality drives the increased incidence of differentiated thyroid cancer (DTC), considerable modifications have been introduced in the new edition of the tumor node metastasis (TNM)/American Joint Committee on Cancer (AJCC) staging system. The aim of this study was to compare a group of DTC patients before and after restaging, by mortality, disease severity, and disease outcomes. METHODS: DTC patients (N = 433) were restaged according to the eighth TNM/AJCC edition, and the results were compared to the seventh edition for clinicopathologic data, treatment modalities, and disease outcomes. RESULTS: When switched to the eighth edition, 97.5% of patients fell into stage I-II compared to 76.4% before, and only 11/102 patients remained in stages III-IV. Disease-specific mortality was recorded in 11/433 patients, six of whom were in stages I-II upon restaging, compared to none before (p > 0.05). In addition, more recurrences were seen in stages II (p = 0.05) and III (p = 0.03) using the eighth edition compared to the seventh edition. Stage II was affected the most, with recurrence risk increasing from 29% to 76% (p = 0.001) and persistence at last visit from 19% to 43% when switching to the eighth edition (p = 0.01). Considering stages I and II together, the recurrence risk increased from 16.7% to 28.2% (p = 0.01), lymph node metastases from 1.9% to 26.5% (p = 0.01), and persistence at last visit from 10% to 15% (p > 0.05). Of the 129 patients in the 45- to 54-year-old age group, 53 shifted to stage I (20 from stage II, 29 from stage III, and 4 from stage IV) and five shifted to stage II (all from stage IV). When comparing this age group in stage II only, the eighth edition showed more lymph node metastases (p = 0.001), more distant metastases (p = 0.003), higher recurrence risk (p = 0.002), and more persistence at the last visit (p > 0.05). CONCLUSION: The eighth TNM/AJCC edition provides a more accurate system to discriminate mortality and persistence in DTC patients. Yet, the severity of disease, especially in the 45- to 55-year-old age group and in stage II patients, should not be underestimated following the downstaging of these patients.

Prognostic significance of platelet count changes during hospitalization for community-acquired pneumonia.

The prognostic significance of platelet count (PC) changes during hospitalization for community-acquired pneumonia (CAP) has not been investigated. For 976 adults, clinical data during hospitalization for CAP and all-cause mortality following discharge were compared according to ΔPC (PC on discharge minus PC on admission): groups A (declining PC, ΔPC < -50 × 109/l), B (stable PC, ΔPC ± 50 × 109/l), and C (rising PC, ΔPC >50 × 109/l), and according to the presence of thrombocytopenia, normal PC, and thrombocytosis on admission/discharge. Groups A, B, and C comprised 7.9%, 46.5%, and 45.6% of patients, respectively. On hospital admission/discharge, thrombocytopenia, normal PC, and thrombocytosis were observed in 12.8%/6.4%, 84.1%/84.4%, and 3.1%/9.2% of patients, respectively. The respective 90-day, 3-year, and total (median follow-up of 54 months) mortality rates were significantly higher: in group A (40.3%, 63.6%, and 72.7%), compared to groups B (12.3%, 31.5%, and 39.0%) and C (4.9%, 17.3%, and 25.4%), p < 0.001; and in patients with thrombocytopenia at discharge (27.4%, 48.4%, and 51.6%), compared to those with normal PC (10.2%, 26.9%, and 35.4%) and thrombocytosis (8.9%, 17.8%, and 24.4%) at discharge (p < 0.001). Mortality rates were comparable among groups with thrombocytopenia, normal PC, and thrombocytosis at admission (p = 0.6). In the entire sample, each 100 × 109/l increment of ΔPC strongly predicted lower mortality (p < 0.001, relative risk 0.73, 95% confidence interval 0.64-0.83). In conclusion, PC changes are common among CAP inpatients. Rising PC throughout hospitalization is a powerful predictor of better survival, while declining PC predicts poor outcome. Evaluation of PC changes during hospitalization for CAP may provide useful prognostic information.

Changes in Red Cell Distribution Width During Hospitalization for Community-Acquired Pneumonia: Clinical Characteristics and Prognostic Significance.

PURPOSE: We investigated outcomes of patients hospitalized with community-acquired pneumonia (CAP) according to the changes in red cell distribution width (RDW). METHODS: For 980 adults, clinical characteristics, outcomes during hospitalization for CAP (transfer to the intensive care unit, treatment with mechanical ventilation, prolonged hospital stay, and death), and all-cause mortality following discharge were compared: according to RDW changes versus stable RDW during hospitalization, and according to normal (≤14.7 %) versus high (>14.7 %) RDW values on admission/discharge. RESULTS: RDW changes (n = 386) during hospitalization were associated with more severe clinical and laboratory characteristics than stable RDW (n = 594). Changes in RDW strongly predicted poor in-hospital outcomes (p < 0.001). The respective 30, 90-day, and total (median follow-up 54 months) mortality rates were significantly higher (9.8, 16.0 and 43.5 %) among patients with RDW changes, compared to 4.0, 7.6 and 30.5 % among those with stable RDW (p < 0.001 for all comparisons). RDW changes, as well as high RDW (each 1 % increment) on admission and discharge, were powerful predictors of mortality (the respective relative risks 1.41, 1.13, and 1.15, and 95 % confidence intervals 1.13-1.74, 1.08-1.19, and 1.10-1.21). CONCLUSIONS: RDW changes during hospitalization for CAP are common and associated with a severe clinical profile. Time-dependent RDW changes strongly predict poor in-hospital outcomes and increased short- and long-term mortality. Repeated RDW determinations during hospitalization for CAP may provide useful prognostic information.

Prognostic significance of changes in red cell distribution width in an internal medicine ward.

BACKGROUND: The prognostic significance of red cell distribution width (RDW) during hospitalization in internal medicine wards was not sufficiently investigated. METHODS: Demographic, clinical and laboratory characteristics were collected from 586 internal medicine inpatients. Following discharge, all-cause mortality was recorded. The data were compared according to ΔRDW during hospitalization (primary endpoint), and to normal (≤14.7%) vs. high (>14.7%) RDW values on admission/discharge (secondary endpoint). RESULTS: Group A (rise in RDW, ΔRDW +0.4%), group B (nonsignificant RDW changes, ΔRDW up to 0.4%) and group C (drop in RDW, ΔRDW -0.4%) comprised 20.3%, 60.6% and 19.1% of the patients, respectively. High RDW on admission and discharge was found in 31.7% and 31.4% of patients, respectively. In-hospital mortality rates were higher in group A than in groups B and C (14.3% vs. 2.8% and 4.5%, p<0.001), whereas increased long-term (median follow-up 43 months) mortality rates were observed in group C (35.7%), compared to groups A (17.6%) and B (23.4%), p=0.009. Mortality rates were significantly higher (p<0.001) in patients with high than normal RDW on admission (51.1% vs. 20.3%) and on discharge (50.5% vs. 20.6%). Every 1% increment of RDW on admission and discharge strongly predicted mortality (relative risks 1.21 and 1.21; 95% confidence intervals 1.12-1.31 and 1.13-1.32, respectively). CONCLUSIONS: High RDW on admission and discharge predicted poor prognosis. Rising RDW throughout hospitalization was associated with higher in-hospital mortality, while an elevated long-term mortality rate was observed in patients with declining RDW. Repeated RDW measurements may improve risk stratification for internal medicine inpatients.

[Cutis verticis gyrata as an early rare presenting sign of acromegaly].

Cutis verticis gyrata (CVG) is a descriptive term for a dermal sign in which deep furrows and convoluted ridges are seen upon the scalp. They are formed due to thickening of the skin folds of the scalp and produce an appearance that resembles the gyri of the brain. The condition is classified primary when the etiology is unknown or neurologically based. CVG will be considered secondary when a definite cause, systemic or localized, is responsible for the sign. We describe a 34 year-old male who was presented with a one-month history of arthralgia in his interphalangeal joints. His physical examination revealed scalp changes compatible with CVG, which appeared 3 years earlier. Following a thorough investigation of the patient, acromegaly was diagnosed. Although CVG is a rare condition, it has been described in patients with acromegaly. The appearance of SVG as an early sign of acromegaly makes this case unique and important. In a patient developing CVG, acromegaly and other treatable disorders should always be excluded.

Clinical characteristics and prognostic significance of changes in platelet count in an internal medicine ward.

BACKGROUND: The clinical characteristics and prognostic significance of changes in platelet count (PC) during hospitalization in internal medicine wards have not been well investigated. METHODS: Demographic, clinical and laboratory data were collected from 345 patients admitted to an internal medicine ward. Following discharge, all-cause mortality was recorded. These data were compared, according to deltaPC (PC on discharge minus PC on admission): group 1 (drop in PC, deltaPC -50×10(9)/l), group 2 (no significant PC changes, deltaPC up to 50×10(9)/l) and group 3 (rise in PC, deltaPC +50×10(9)/l). RESULTS: Groups 1, 2 and 3 comprised 64 (18.5%), 200 (58%) and 81 (23.5%) patients, respectively. Patients from group 3 were younger, more likely admitted for infection and less likely for cardiovascular disorder, and less often presenting with coronary artery disease, complex nursing care and thrombocytosis on admission or thrombocytopenia on discharge than patients from groups 1 and 2. Mean platelet volume was higher in group 2 on admission and lower in group 3 on discharge. During a median follow-up of 25 months, 146 (42.3%) of 345 patients died. The survival rate was higher for group 3 (65.4%) than for groups 1 (45.3%) and 2 (58.5%), p=0.003. In the entire cohort, each 100×10(9)/l increment of deltaPC was a powerful predictor of lower mortality (p=0.03, relative risk=0.83, 95% confidence interval=0.71-0.98). CONCLUSIONS: Increased PC throughout hospitalization was associated with better prognosis than a drop or blunted rise in PC. The assessment of PC changes in an internal medicine ward may provide useful prognostic information.

Factors associated with prevention of postural hypotension by leg compression bandaging.

AIM: We evaluated the eventual effects of leg compression on seating-induced postural hypotension (PH) in the context of various relevant clinical variables. METHODS: Included were 73 hospitalized patients with various acute conditions, aged ≥ 60 years, bedridden for ≥ 8 h, with diagnosed PH [≥ 20 mmHg systolic and/or ≥ 10 mmHg diastolic blood pressure (BP) falls] at the first seating. BP, heart rhythm, dizziness and palpitations were recorded before and during 5 min of sitting. The next day, the patients were reevaluated, this time using compression bandages applied along both legs before seating. RESULTS: Compared with the non-bandaged state, PH was registered in only 53% of bandaged patients (p < 0.001). Moreover, the appearance of PH symptoms decreased (p < 0.001). On the second day (bandaged), supine diastolic BP values were higher in the persisting vs non-persisting PH group (p = 0.027). In the bandaged state, PH symptoms were significantly reduced in the non-persisting PH group (p = 0.003). Even in patients with persistent PH, the magnitude of BP decline and appearance of PH symptoms were decreased while wearing bandages (p = 0.004 and 0.002, respectively). CONCLUSION: During mobilization of inpatients, leg compression seems to reduce the seating-induced PH and relevant symptoms. Even in patients with persisting PH, bandaging may improve hemodynamics and attenuate associated symptoms.

Clinical characteristics and prognostic significance of serum albumin changes in an internal medicine ward.

BACKGROUND: The prognostic significance of hypoalbuminemia and the dynamic changes in serum albumin during hospitalization in internal medicine wards has not been sufficiently investigated. METHODS: Demographic, clinical and laboratory data were collected from 276 patients admitted to our internal medicine ward for a variety of acute disorders. Following discharge, all-cause mortality was recorded. These data were compared between patient groups, according to levels of albumin: hypoalbuminemia or normoalbuminemia (serum albumin <34 g/l and ≥ 34 g/l, respectively), on admission and discharge. RESULTS: Hypoalbuminemia on admission and on discharge was found in 46% and 54% of patients, respectively. Anemia, renal dysfunction, malignant disease, hypocholesterolemia, lymphopenia and albuminuria were more prevalent in patients with hypoalbuminemia, compared to those with normoalbuminemia (p ≤ 0.03). During a median follow-up period of 23 months, 107 of 276 patients died. Mortality was significantly higher (p<0.001) in patients with hypoalbuminemia than normoalbuminemia on admission (52.0% vs. 27.5%) and on discharge (53.7% vs. 21.2%), including those admitted with normoalbuminemia and discharged with hypoalbuminemia (43.6%). Survival rate was higher for patients admitted with hypoalbuminemia and discharged with normoalbuminemia than for those remaining with hypoalbuminemia (82.4% vs. 42.8%, p=0.004). The level of albumin on discharge (each 10 g/l decrement) was the most powerful predictor of shortened survival (relative risk 2.79, 95% confidence interval 2.04-3.70). CONCLUSIONS: Hypoalbuminemia on admission, as well as persistence or development of hypoalbuminemia throughout hospitalization, was associated with poor prognosis. Treatment aimed at increasing low albumin or maintaining its normal level may improve survival.

Atrial Fibrillation at an Internal Medicine Ward: Clinical and Prognostic Implications.

Background: Little is known about atrial fibrillation (AF) appearing during hospitalization in an Internal Medicine ward. Purpose: We aimed to investigate characteristics and prognostic significance of in-hospital onset AF. Methods: We studied 249 consecutive unselected patients admitted to this medical department with paroxysmal or persistent AF (out-of-hospital group) or AF developed during hospitalization (in-hospital group). Demographic, clinical, laboratory, electrocardiographic and echocardiographic data and all-cause mortality following discharge were recorded and compared between the groups Results: Diabetes mellitus (p=0.05), renal dysfunction (p<0.001), chronic lung disease (p=0.03) and history of stroke (p=0.01) were found more common in the in-hospital group (56 patients), compared to the out-of-hospital group (193 patients). Patients from the in-hospital group were more likely to have recurrent episodes of AF during hospitalization (p=0.002), were more frequently treated with amiodarone (p<0.001), discharged in sinus rhythm (p=0.04) and with medications for rhythm control (p=0.04). Time from onset to termination of AF (p<0.001) and hospital stay (p<0.001) were longer in the in-hospital group. On a median of 39-months follow-up, survival rate was lower in the in-hospital vs. out-of-hospital group (69.6% vs. 81.3%, p=0.025). Older age was significantly associated with shorter survival in the in-hospital group [odds ratio (OR)=1.87, 95% confidence interval (CI) 1.15-3.03, p=0.009]. In the out-of-hospital group, advanced age (OR=2.17, 95%CI 1.51-3.10, p<0.001), no prior AF episode (OR=3.41, 95%CI 1.56-7.46, p=0.002), diabetes mellitus (OR=2.22, 95%CI 1.12-4.39, p=0.006) and renal dysfunction (OR=2.44, 95%CI 1.10-5.38, p=0.049) were significantly associated with shorter survival. Conclusion: Patients developing in-hospital AF differed from subjects hospitalized for AF with respect to the severity of the clinical profile and prognosis.

Shortened erythrocyte sedimentation rate evaluation is applicable to hospitalised patients.

BACKGROUND: Westergren method, commonly used for erythrocyte sedimentation rate (ESR) determination, is simple and inexpensive. However, the 60 min required for the test are disadvantageous, especially for those departments/facilities where prompt evaluation is necessary. We investigated the possibility that earlier ESR recordings might correlate with standard 60-minute ESR and/or be predictive of the latter. METHODS: Demographic and clinical data were collected from 220 randomly chosen adult patients hospitalised for various diseases in a medical department. ESR, determined by slightly modified Westergren method, was recorded at 15, 30 and 60 min. Correlation coefficients (r) between the standard and early ESR measurements were calculated for the entire group and for the separate subgroups divided according to patient age, sex and presence of anaemia or of inflammation. RESULTS: Mean+/-SD age of the patients was 61.3+/-19.6, 55% were males; 45% had some inflammatory condition. Mean+/-SD ESR values (mm) at 15, 30 and 60 min were 9.0+/-12.1, 21.4+/-21.8 and 35.9+/-27.5, respectively. A statistically significant correlation was found between ESR measurements at 15 and 60 min (r=0.833, p<0.001). However, the strongest correlation was observed between 30 and 60 min measurements (r=0.926, p<0.001), irrespective of age, sex and presence of anaemia or of inflammation. Based on the ESR determination at 30 min (X), the predicted ESR value at 60 min (Y) could be calculated by a simple equation: Y=10.7+1.2X. CONCLUSION: Sixty-minute ESR values can be predicted by the 30-minute estimation. Shortening the test by half an hour might bear practical importance.

Anemia in diabetic patients at an internal medicine ward: clinical correlates and prognostic significance.

BACKGROUND: Characteristics and prognostic significance of anemia in hospitalized diabetic patients are unknown. METHODS: We studied 3145 unselected patients admitted to two Internal Medicine Departments, 872 (27.7%) of whom were diabetic. Forty diabetic patients died during the first hospitalization period. Out of the remaining 832 patients, 334 (40.2%) were anemic and evaluated for survival. In 87 diabetic patients, the cause of anemia was evident on admission, whereas the other 247 had to be further investigated for etiology of anemia. RESULTS: Compared to non-anemic diabetic patients, the diabetic anemic patients were older (mean age 71.4 vs. 64.4 years, P<.001) and predominantly females (52.4% vs. 44.4%, P<.02). Of the 247 evaluated patients, 38% were deficient in iron, 12% in vitamin B(12) and/or folate, 54% had anemia of chronic disease, 47% suffered from heart failure, 39% had renal dysfunction and 22% were complex nursing care patients and/or had diabetic foot. On median follow-up of 19.2 months, mortality rate was higher in anemic compared to non-anemic diabetic patients (17.3% vs. 4%, P<.001), the main cause of death being infection. Male sex (P=.03), albuminuria (P=.01) and heart failure (P=.06) were associated with shorter survival, male sex being the most significant (OR 2.02, 95% CI 1.04-4.00). CONCLUSION: Frequency of anemia was increased in diabetic patients admitted to the Internal Medicine Departments, compared to the studies performed on ambulatory patient populations. Anemia was multifactorial and associated with higher mortality, predominantly from infections. Males with albuminuria and heart failure were at higher risk of death.

Application of HRV-CD for estimation of life expectancy in various clinical disorders.

BACKGROUND: Low heart rate variability (HRV) was found in various medical conditions including heart failure and acute myocardial infarction. Decreased HRV in these conditions predicted poor prognosis. METHODS: HRV was estimated in 133 unselected inpatients with relevant clinical bedside conditions by non-linear analysis derived from chaos theory, which calculates the correlation dimension (CD) of the cardiac electrophysiologic system (HRV-CD). RESULTS: Mean HRV-CD in the entire group was 3.75+/-0.45. Heart failure, coronary artery disease, cardiac arrhythmia, low serum potassium, renal dysfunction, and diabetes mellitus were significantly associated with reduced HRV-CD compared to their counterparts [3.6 vs. 3.9 (P<.001), 3.65 vs. 3.87 (P=.005), 3.58 vs. 3.8 (P=.01), 3.38 vs. 3.81 (P=.02), 3.59 vs. 3.8 (P=.04), and 3.66 vs. 3.82 (P=.04), respectively]. Stepwise logistic regression showed heart failure to be the condition most significantly associated with low HRV-CD (odds ratio 4.2, 95% confidence interval 1.90-9.28, P<.001). In the entire group, decreased HRV-CD (< or =3.75 vs. >3.75) was associated with lower survival (P=.01). Mortality of diabetic patients with HRV-CD < or =3.75 exceeded the mortality in patients with HRV-CD >3.75 (P=.02). Heart failure, renal dysfunction or age over 70 combined with HRV-CD < or =3.75 also appeared to be associated with augmented mortality. CONCLUSIONS: Diminished HRV-CD is associated with heart failure, coronary artery disease, cardiac arrhythmia, renal dysfunction, diabetes mellitus and low serum potassium. Among the latter, heart failure is most significantly associated with decreased HRV-CD. Decreased HRV-CD values, especially in diabetics, are also associated with lower survival.

Clinical variables affecting survival in patients with decompensated diastolic versus systolic heart failure.

BACKGROUND: The impact of various clinical variables on long-term survival of patients with acutely decompensated diastolic heart failure (DHF) compared to systolic heart failure (SHF) has not been sufficiently investigated. METHODS: Clinical, laboratory, electrocardiographic and echocardiographic data were collected and analyzed for all-cause mortality in 473 furosemide-treated patients aged >or=60 years, hospitalized for acutely decompensated HF. RESULTS: Diastolic heart failure patients (n = 183) were more likely to be older, female, hypertensive, obese, with shorter preexisting HF duration, atrial fibrillation, lower New York Heart Association (NYHA) class, lower maintenance furosemide dosages, and to receive calcium antagonists. The SHF group (290 patients) demonstrated prevailing coronary artery disease, nitrate or digoxin treatment, and electrocardiographic conduction disturbances (P

Seating-induced postural hypotension is common in older patients with decompensated heart failure and may be prevented by lower limb compression bandaging.

BACKGROUND: Postural hypotension induced by transition from supine to sitting position and measures for its prevention in heart failure has not been investigated. OBJECTIVE: Our purpose was to evaluate the prevalence of postural hypotension and associated clinical manifestations as well as the contribution of various risk factors for postural hypotension on transition from lying to sitting in older patients with decompensated heart failure, and to study the eventual preventive effect of leg bandaging. METHODS: Seating-induced postural hypotension (>or=20 mm Hg systolic and/or >or=10 mm Hg diastolic blood pressure fall) was assessed on the first study day in 108 patients aged >or=60 years, hospitalized for acutely decompensated heart failure. On the next day, in patients manifesting postural hypotension, compression bandages were applied along both legs before seating. Blood pressure, heart rate, O(2) saturation, and the occurrence of dizziness or palpitations were recorded prior to and 1, 3 and 5 min following seating. RESULTS: Postural hypotension occurred in 49.1% of patients. Dizziness and/or palpitations manifested in 25%. Diastolic (36.1%) versus systolic (23.1%) postural hypotension prevailed (p=0.05). On univariate analysis, postural hypotension was associated with female sex (p=0.03), more severe heart failure (p=0.05), longer bedrest (p=0.04), higher supine systolic (p=0.01) or diastolic (p=0.002) blood pressure, nonischemic heart failure (p=0.002), and not using nitrates (p = 0.01). On multivariate analysis, longer bedrest (OR=1.58, 95% CI=1.13-2.2, p<0.001), higher supine diastolic blood pressure (OR=1.33, 95% CI=1.1-1.61, p=0.001), and nonischemic heart failure (OR=3.48, 95% CI=1.4-8.63, p=0.009) were the most predictive of postural hypotension. Compression bandages prevented postural hypotension in 21 of 49 patients and decreased the degree of postural blood pressure fall (p<0.001). CONCLUSION: Seating-induced postural hypotension is common among older inpatients with decompensated heart failure, especially with longer bedrest, higher supine diastolic blood pressure and non-ischemic etiology. Leg compression bandaging may be useful for the prevention of postural hypotension in these patients.

Splenic vein thrombosis following abdominal compression and vibration: a case report.

The authors describe a 46-year-old man with isolated splenic vein thrombosis (SVT) that developed after concrete drilling, which caused significant compression and vibration of the abdominal wall. Methyltetrahydrofolate reductase (MTHFR) deficiency-related hyperhomocysteinemia, which was subsequently diagnosed, predisposed him to this event. To the best of the knowledge of authors, this is the first report of isolated splenic vein thrombosis caused by compression and vibration of the abdomen. Relevant aspects of isolated post-traumatic splenic vein thrombosis in this context are discussed.

Effect of various clinical variables on total intracellular magnesium in hospitalized normomagnesemic diabetic patients before discharge.

Deficiency of intracellular magnesium (icMg) may coexist with normal serum Mg levels. Little is known about clinical and pharmacological factors affecting icMg in normomagnesemic patients with diabetes mellitus (DM). Moreover, no information exists regarding the icMg state in diabetic patients after acute illness and before hospital discharge. We have evaluated the effect of antihyperglycemic medications and other relevant clinical variables on icMg in 119 such patients. Total icMg was measured in peripheral blood mononuclear cells. Twenty healthy volunteers served as controls. IcMg content (microg/mg cell protein) was lower in DM compared to controls (1.74 +/- 0.44 vs 2.4 +/- 0.39, p < 0.001). It was also significantly lower in patients treated with insulin (1.57 +/- 0.31 vs 1.8 +/- 0.46, p = 0.01), while metformin treatment was associated with higher icMg (1.86 +/- 0.49 vs 1.63 +/- 0.35, p = 0.003). After adjustment for age, gender, and concomitant use of other hypoglycemic drugs, only treatment with metformin was independently associated with increased icMg (p = 0.03). No statistically significant association or correlation was found between icMg content and age, causes of hospitalization, comorbid conditions, treatment with other drugs, concentrations of HbA1c, serum glucose, Mg, or creatinine. In conclusion, icMg is depleted in normomagnesemic DM patients. Insulin treatment is associated with worsening of icMg status, while metformin treatment may confer protective effect.

Magnesium and C-reactive protein in heart failure: an anti-inflammatory effect of magnesium administration?

BACKGROUND: Little is known about the relationship between serum magnesium (Mg) and C-reactive protein (CRP) in heart failure (HF). AIM OF THE STUDY: To investigate the relationship, if any, between serum Mg and CRP in HF patients and, concomitantly, to test a hypothesis that Mg supplementation might affect serum CRP levels. METHODS: Serum Mg and CRP were evaluated in 68 patients with chronic systolic HF leading to hospital admission and 65 patients requiring hospitalization for other causes. Following 5 weeks, serum Mg, CRP and intracellular Mg were reevaluated in 17 HF patients after administration of oral Mg citrate 300 mg/day (group A), and 18 untreated HF patients (group B). In order to obtain Gaussian distribution, logarithmic transformation of CRP was performed. RESULTS: Inverse correlation was found between serum Mg and log CRP (r = -0.28, P = 0.002). Compared to controls, patients with HF demonstrated higher baseline CRP levels, independent of coexisting conditions, and lower serum Mg values. Following Mg treatment, log CRP decreased from 1.4 +/- 0.4 to 0.8 +/- 0.3 in group A (P < 0.001). No significant changes in log CRP were demonstrable in group B. Serum Mg (mmol/l) rose significantly in group A (0.74 +/- 0.04-0.88 +/- 0.08, P < 0.001), and to a lesser extent in group B (0.82 +/- 0.08-0.88 +/- 0.08, P = 0.04). Intracellular Mg significantly increased only in Mg-treated group A (P = 0.01). CONCLUSIONS: Oral Mg supplementation to HF patients significantly attenuates blood levels of CRP, a biomarker of inflammation. Targeting the inflammatory cascade by Mg administration might prove a useful tool for improving the prognosis in HF.

Patient-dependent variables affecting treatment and prediction of acute coronary syndrome are age-related. A study performed in Israel.

BACKGROUND: Acute coronary syndrome (ACS) prevails in older patients and is associated with higher morbidity and mortality. Little is known about patient-related variables that may affect course and treatment of ACS in older vs. younger with acute chest pain. METHODS: Situational, circumstantial, and other patient-related variables were assessed in 1000 unselected consecutive older (> or =70 years) and younger (<70 years) patients admitted with chest pain and possible ACS. RESULTS: In 182 older vs. 818 younger patients, prevalence of females, those not speaking the local language, living alone, lower education level, non-smokers, diabetes, hypertension, preexisting coronary artery disease, and attempting some form of self-treatment before seeking medical help were significantly greater (P<0.001). Interval from chest pain onset to emergency department arrival was longer (P=0.05), and a higher proportion of the older considered hospitalization mandatory, suspecting ACS (P<0.001). ACS eventually developed in 19.1% of younger and 39% of older patients (P<0.001). On multivariate analysis, most predictive of ACS in the younger group were: preexisting coronary artery disease (OR 5.27; 95% CI 3.44-8.07, P<0.001), current smoking (OR 1.78; 95% CI 1.16-2.75, P=0.002), male sex (OR 1.57; 95% CI 1.0-2.59, P=0.07), and older age (OR 1.25; 95% CI 1.11-1.42, P=0.005). In the older group, these were: not speaking the local language (OR 2.39; 95% CI 1.19-4.79, P=0.005), preexisting coronary artery disease (OR 1.95; 95% CI 1.0-3.87, P=0.026), direct emergency department arrival (OR 1.9; 95% CI 1.0-3.77, P=0.066), and diabetes (OR 1.84; 95% CI 1.0-3.56, P=0.079). CONCLUSIONS: We defined age-associated differences in patient-related variables that may predict ACS and affect treatment negatively. These variables might improve risk stratification upon hospitalization.