Is the mental health profile of immigrants changing? A national-level analysis based on hospital discharges in Italy

BACKGROUND

Among asylum seekers and refugees in European countries, several studies have shown a high burden of mental disorders, including post-traumatic stress disorder, anxiety, depression and psychoses. The present study compares hospitalization for mental disorders among migrants arriving from countries typically linked to the refugee phenomenon (putative asylum seekers), migrants arriving from other countries, and natives.

METHODS

The study is based on hospital discharge data collected at the national level by the Italian Ministry of Health. Age-standardized hospitalization rates for mental health diagnoses are calculated for the three groups during the period 2008-2015. Differences in type of admission (urgent or planned) and length of stay in hospital are also assessed.

RESULTS

Temporal trends show a general decrease of hospitalization rates for mental disorders among both immigrants and natives; however, an increase is observed among young male putative asylum seekers (from 30.3 in 2010 to 43.6 per 10,000 in 2015), mainly due to admissions for "other nonorganic psychoses".

CONCLUSION

These findings suggest that in Italy a higher burden of mental disorders might derive from the landing phenomenon, and the increase of hospitalization ascribed to "other nonorganic psychoses" (which is a general and unspecific diagnostic label) might conceal diagnostic difficulties by Italian psychiatrists to recognize atypical pictures associated with traumatic experiences.

ARRHYTHMIAS, PACING, ABLATIONC1 A DEPENDENT SYNCOPE

A 33-year-old man, ex drug addict on methadone therapy. He arrives to emergency department for syncope, reported by his wife reversion of the eyeballs and fine tremors with subsequent recovery of consciousness. A similar episode had happened a year ago. It was performed ECG: sinus bradycardia , 45 bpm, QT 600 msec, QTc 554 msec . Neurological examination performed: no motor deficits, negative Romberg. At brain CT no parenchymal tomodensitometric changes. Median line structures in axis. At the EEG: slight diffuse slow intercritical changes. Prescribed therapy with levetiracetam 500 mg. Cardiological examination and echocardiogram performed within the limits. Laboratory tests showed Trop HS 80 pg / ml. On the basis of the ECG and the slight increase of the troponin he was hospitalized in Cardiology and monitored. The following day, cardiac arrest due to torsade de pointes degenerated into ventricular fibrillation, DC shock was performed with the restoration of electrical and mechanical activity. Urgent coronary angiography was performed with evidence of coronary artery free from angiographically significant stenosis. SERT has been contacted: the patient had not been treated by them for some time and was using excessive doses of self-procuring methadone. In consideration of cardiac arrest from methadone long QT ventricular arrhythmia, ICD implantation was proposed, refused by the patient because he wanted to start detoxification therapy. During the hospitalization, progressive reduction of QT up to normalization in discharge. After a month new access to emergency department for presynopal episode, ECG showed sinus bradycardia with QTC 552 msec; the patient reports continuing to take excessive methadone doses and refuses treatment at a recovery center; considering that the ICD can be life-saving in this typ77e of patient (intractable addiction), we have re-proposed the ICD implant, rejected by the patient.

Policies for tackling health inequities in migrants in an irregular situation: learning from Italy

Issue

With increasing of numbers of people moving in Europe and around the world, the health of migrants has become a key global public-health issue. Migrants in an irregular situation (MIS) represent an important part of the migration phenomenon, whether they have become irregular by entering a country without authorisation or by overstaying a visa, including whose applied unsuccessfully for asylum.

Description of the problem

Overstaying of visas is not unusual in EU countries and during 2015 and 2016 in particular, many countries experienced a large number of unauthorised entrants. Health policies for MIS are increasingly a matter of concern. Using the 2015 Migrant Integration Policy Index Health strand (MIPEX HS) it is possible to conduct an analysis of health policies, focusing on access to health services by MIS.

Results

Among the 34 European countries covered by the MIPEX HS, Italy’s overall score of 65 is exceeded only by Switzerland (70) and Norway (67). Averaging the indicators of access for MIS, Italy obtains the highest score (83), followed by Denmark, France, the Netherlands, Romania, Spain, Sweden and Switzerland with 67. Its score for legal entitlements to health care is 75 (the same as Sweden), while reporting of MIS to the immigration authorities is prohibited and there are no sanctions against helping them. However, legislation introduced by the new government in 2018 has restricted some of their rights.

Lessons

Current migration to Europe requires dealing with short-term health needs as well as strengthening public health and health systems in the long term. This presentation will discuss the lessons that can be learned from the comparative analysis of health policies for MIS using the MIPEX HS.

Key messages

Affordable health care is a human right, which should not be denied to any migrant. Policy analysis plays a key role in identifying interventions for promoting health equity.

ERRα promotes breast cancer cell dissemination to bone by increasing RANK expression in primary breast tumors

Bone is the most common metastatic site for breast cancer. Estrogen-related-receptor alpha (ERRα) has been implicated in cancer cell invasiveness. Here, we established that ERRα promotes spontaneous metastatic dissemination of breast cancer cells from primary mammary tumors to the skeleton. We carried out cohort studies, pharmacological inhibition, gain-of-function analyses in vivo and cellular and molecular studies in vitro to identify new biomarkers in breast cancer metastases. Meta-analysis of human primary breast tumors revealed that high ERRα expression levels were associated with bone but not lung metastases. ERRα expression was also detected in circulating tumor cells from metastatic breast cancer patients. ERRα overexpression in murine 4T1 breast cancer cells promoted spontaneous bone micro-metastases formation when tumor cells were inoculated orthotopically, whereas lung metastases occurred irrespective of ERRα expression level. In vivo, Rank was identified as a target for ERRα. That was confirmed in vitro in Rankl stimulated tumor cell invasion, in mTOR/pS6K phosphorylation, by transactivation assay, ChIP and bioinformatics analyses. Moreover, pharmacological inhibition of ERRα reduced primary tumor growth, bone micro-metastases formation and Rank expression in vitro and in vivo. Transcriptomic studies and meta-analysis confirmed a positive association between metastases and ERRα/RANK in breast cancer patients and also revealed a positive correlation between ERRα and BRCA1mut carriers. Taken together, our results reveal a novel ERRα/RANK axis by which ERRα in primary breast cancer promotes early dissemination of cancer cells to bone. These findings suggest that ERRα may be a useful therapeutic target to prevent bone metastases.

Health transition and immigration: a new challenge for Public Health

BACKGROUND

Immigration has been one of the most relevant phenomena characterizing Italy's social history of the past 30 years. Currently, there are almost 5 million non-Italian citizens in Italy, representing about 8.2% of the country's population. At the beginning of the 80s, a small health clinic, set-up by a no-profit Catholic organization called Caritas, was thus opened in Rome - managed by medical doctors and volunteer workers - aimed at providing the new migrants (often without any social rights) the sanitary support that was unavailable or difficult to find. In time, this health clinic progressively became an observatory of migrants' general health conditions, with a particular focus on the part of this population found in marginal social and legal conditions (without a residence permit).

METHODS

Data recorded in Roman Caritas Health Clinic database, belonging to patient admitted to the medical centre for the first time in 1986-1987, 2003-2004 and 2013-2014, were selected and compared. Only patients from Africa, Asia, Central and Eastern Europe and Central and Southern America were included. In addition to vital statistics, both diagnosis and prescriptions are filed according to the ICD-9.CM, 1997 in the database. Only codes 001 to 999 have been taken into consideration. The resulting sample is composed of 10741 patients. Of these, 3602 relate to 1986-1987, 4341 to 2003-2004 and 2798 to 2013-2014. The total diagnostical data processed was of 12662 (2777 in 1986-1987, 5704 in 2003-2004, 4181 in 2013-2014).

RESULTS

Over the last 30 years the most significant variable for the public health scenario is the progressively ageing population, a variable that does not occur homogeneously. Starting from 2003-2004 an upward trend for non-communicable diseases was observed, that, as suggested by this study, have patterns and determinants varying according to ethnicity.

CONCLUSIONS

The progressive modification of the socio-demographic profile of the migrant population determined the health transition already seen in the local population. It has also presented itself among foreigners due to the increase in their average age, as well as their provenance from countries with high risk of certain metabolic pathologies, and the acquisition of inadequate lifestyles and eating habits. This epidemiologic shift has had necessary implications on the organization of services and on the activation of eventual specific courses of action.

Alkaline phosphatase protects against renal inflammation through dephosphorylation of lipopolysaccharide and adenosine triphosphate

BACKGROUND AND PURPOSE

Recently, two phase-II trials demonstrated improved renal function in critically ill patients with sepsis-associated acute kidney injury treated with the enzyme alkaline phosphatase. Here, we elucidated the dual active effect on renal protection of alkaline phosphatase.

EXPERIMENTAL APPROACH

The effect of human recombinant alkaline phosphatase (recAP) on LPS-induced renal injury was studied in Sprague-Dawley rats. Renal function was assessed by transcutaneous measurement of FITC-sinistrin elimination in freely moving, awake rats. The mechanism of action of recAP was further investigated in vitro using conditionally immortalized human proximal tubular epithelial cells (ciPTEC).

KEY RESULTS

In vivo, LPS administration significantly prolonged FITC-sinistrin half-life and increased fractional urea excretion, which was prevented by recAP co-administration. Moreover, recAP prevented LPS-induced increase in proximal tubule injury marker, kidney injury molecule-1 expression and excretion. In vitro, LPS-induced production of TNF-α, IL-6 and IL-8 was significantly attenuated by recAP. This effect was linked to dephosphorylation, as enzymatically inactive recAP had no effect on LPS-induced cytokine production. RecAP-mediated protection resulted in increased adenosine levels through dephosphorylation of LPS-induced extracellular ADP and ATP. Also, recAP attenuated LPS-induced increased expression of adenosine A2A receptor. However, the A2A receptor antagonist ZM-241385 did not diminish the effects of recAP.

CONCLUSIONS AND IMPLICATIONS

These results indicate that the ability of recAP to reduce renal inflammation may account for the beneficial effect observed in septic acute kidney injury patients, and that dephosphorylation of ATP and LPS are responsible for this protective effect.

Prevalence of HIV infections in hospitalised immigrants in Clinics of Infectious Diseases in Italy: a multicentric survey

Our aim was to evaluate the prevalence of HIV infection in immigrants hospitalised in infectious disease settings in Italy during 2002. Each participating centre filled in a CRF which regarded the number of immigrants hospitalised in ordinary regime or in day-hospital during 2002 and, for HIV-positive patients only, some demographic (age, sex, origin) and clinical features (only HIV positivity or AIDS, new diagnosis or not, diagnosis of opportunistic infections). A total of 46 Infectious Diseases Units participated in the study and a total number of 2255 patients were tested for anti-HIV, irrespective of the cause of hospitalization, with 378 (16%) cases of positivity. Women accounted for 47.9%; the mean age of the population was 34.5 years. African patients showed a higher prevalence of HIV infections than subjects from other geographical areas (61.9% of all cases). Most HIV-infected patients were unaware of their positivity. In conclusion, HIV infection represents one of the main health problems among immigrants, particularly of African origin.

Simit epidemiological multicentric study on hospitalized immigrants in Italy during 2002

The aim of this article is to retrospectively evaluate the patient characteristics and the most common infectious diseases in immigrant patients hospitalized in 46 Italian infectious disease clinics during 2002. The main Italian infectious disease clinics were invited to fill in a questionnaire that regarded the number and type of hospital admissions, the country of origin, and demographic features (age, sex, and resident state) of immigrants. A total of 46 clinics including 2255 patients participated in the study. Most patients were men (63%) with an age between 16 and 40 years (63.4%) covered by the National Health Service (71%) and coming from Africa (44.3%). The main infectious diseases observed were: 378 (16.76%) cases of HIV infection, 303 (13.43%) cases of tuberculosis diseases, 282 (12.5%) cases of various forms of viral hepatitis, 177 (7.84%) cases of respiratory diseases, and 196 (8.69%) gastrointestinal diseases. Tropical diseases found were 134 (5.94%) including 95 cases of malaria (70.9%). In conclusion, a broad range of diseases was noted in immigrants which were directly correlated with conditions of poverty. Only a few tropical diseases were diagnosed and therefore the immigrant should not be considered as an infectious disease carrier.

[A vaccination campaign for gypsy children in Rome]

Several studies conducted in Rome have shown low levels of vaccination coverage in gypsy communities. Thus a vaccination campaign targeting to 2400 gypsy children aged 0-13 years, present in 32 settlements in Rome, was conducted in 2002. The campaign was related to vaccinations required and recommended in Italy: diphtheria, tetanus, hepatitis B, pertussis (whooping cough), haemophilus influenzae and measles. In the majority of cases it was decided to carry out the vaccinations directly in the gypsy settlements, in accordance with the methods of pulse immunisation. In the case of small settlements a strategy for reorienting the population to vaccination centres was adopted. Around 2000 children were vaccinated, equivalent to 80% of the paediatric population present during the period. The number of children who have never been vaccinated has decreased from 40% prior to the campaign to 9% after the third week. Vaccination coverage in medium- and small-sized settlements (<200 inhabitants) after the campaign shows values of over 70%; in the large settlements, more modest increases have been recorded and coverage has rarely exceeded 50%. This experience has highlighted the importance of networking between public healthcare institutions and non-profit organisations. The mobilisation of a wide range of competences has thus enabled the attainment of a high level of effectiveness.

[Epidemiologic multicenter study of the prevalence of hepatitis in hospitalised immigrants in Italy in the year 2002]

AIM

To retrospectively evaluate the prevalence of hepatitis in immigrant patients hospitalised in 48 Italian Operative Unit of Infectious Diseases during 2002.

METHODS AND PATIENTS

in our study we included the clinical data of 2255 immigrated patients hospitalised, during the period between 01/01/2002-31/12/2002, in ordinary admission or in Day Hospital in Infectious Diseases O.U. and we have evaluated the prevalence of hepatitis in this population.

RESULTS

282 patients affected by hepatitis has been evidenced (12.5% of total hospitalised patients). The prevalent form was HBV-related (41.6% in chronic forms and 48.4% in acute), while the rate for HCV were less (37.5% in chronic and 3% in acute). The most part of patient were men (59.6%), with a mean age of 34.2 years and come from east-European countries (34.39%).

CONCLUSION

Viral hepatitis are the third infectious diseases evidenced in immigrated population. HBV-chronic hepatitis is the prevalent form in immigrated patients, as expression of absence of vaccine prophylaxis in many countries. HCV-form was less frequent and it is particularly presents in east-European patients, probably as expression of endogenous drug abuse.

Acute hepatitis induced by cyproterone acetate

OBJECTIVE

To report a case of acute hepatitis resulting from the use of cyproterone acetate, an adjuvant treatment for prostate cancer.

CASE SUMMARY

An 87 year-old white man, admitted to surgery for prostate cancer, received cyproterone acetate 300 mg/d orally and developed acute hepatitis, which initially was diagnosed clinically. A liver biopsy showed changes suggestive of acute cholestatic hepatitis. Cyprotorone was stopped immediately, and the patient was subsequently treated with corticosteroids. He then improved rapidly.

DISCUSSION

Cyproterone acetate is thought to be well tolerated, but some authors have reported severe hepatic reactions, in particular acute hepatitis, fatal fulminant hepatic failure, and hepatocellular carcinoma. The above-mentioned hepatotoxicity represents an idiosyncratic drug reaction, probably due to the hepatomitogen action of cyproterone, causing an increase of hepatocytes expressing placental glutathione S-transferase, which are considered preneoplastic elements.

CONCLUSION

This case suggests the possibility of hepatotoxicity from cyproterone.

Hyperuricemia and gout in thyroid endocrine disorders

OBJECTIVE

A significant correlation between thyroid function and purine nucleotide metabolism has been established in hypothyroidism. On the contrary, the relationship between hyperthyroidism and purine metabolism is more controversial. The present study evaluates the prevalence of hyperuricemia and gout in patients affected by primary hypothyroidism and hyperthyroidism.

METHODS

We studied 28 patients with primary hypothyroidism and 18 patients with primary hyperthyroidism, all hospitalized because of endocrine dysfunction. All underwent a series of clinical, biochemical and instrumental evaluations; in particular, thyroid-stimulatin hormone (TSH), free thyroxine (fT4), blood urea, serum creatinine, creatinine clearance, serum and urinary uric acid levels were measured.

RESULTS

In comparison to the prevalence reported in the general population, a significant increase of both hyperuricemia and gout was found in the hypothyroid patients, and of hyperuricemia in the hyperthyroid patients. In hyperthyroidism the hyperuricemia is due to the increased urate production, while in hypothyroidism the hyperuricemia is secondary to a decreased renal plasma flow and impaired glomerular filtration.

CONCLUSIONS

Ourfindings confirm the data in the literature concerning the high prevalence of hyperuricemia and gout in hypothyroidism. It shows that hyperthyroidism can cause a significant increase in serum uric acid, as well, although lower than the hyperuricemia due to thyroid hormone deficiency.

Acute hepatitis induced by cyproterone acetate

OBJECTIVE

To report a case of acute hepatitis resulting from the use of cyproterone acetate, an adjuvant treatment for prostate cancer.

CASE SUMMARY

An 87 year-old white man, admitted to surgery for prostate cancer, received cyproterone acetate 300 mg/d orally and developed acute hepatitis, which initially was diagnosed clinically. A liver biopsy showed changes suggestive of acute cholestatic hepatitis. Cyprotorone was stopped immediately, and the patient was subsequently treated with corticosteroids. He then improved rapidly.

DISCUSSION

Cyproterone acetate is thought to be well tolerated, but some authors have reported severe hepatic reactions, in particular acute hepatitis, fatal fulminant hepatic failure, and hepatocellular carcinoma. The above-mentioned hepatotoxicity represents an idiosyncratic drug reaction, probably due to the hepatomitogen action of cyproterone, causing an increase of hepatocytes expressing placental glutathione S-transferase, which are considered preneoplastic elements.

CONCLUSION

This case suggests the possibility of hepatotoxicity from cyproterone.

[Usefulness of online bibliographic research in biomedical research, with an application to the epidemiologic study of genetic osteopathy]

The bibliographic research online is an useful means of recovering information in all the subjects, particularly in the field of biomedicine. In fact, this instrument allows researchers to get information in a rapid, complete and up-to-date way. The aim of the present review is to describe the usefulness of the bibliographical research online in the field of the genetic osteopathies. These are rare disorders: so, their own rarity makes the bibliographical research online necessary to carry out a large and effective comparison of experiences. The obtained results are amply reported in the manuscript. For instance, we verified that chondrodysplasias are the diseases most represented in the literature, while melorheostosis the disorder less mentioned. Moreover, we evidenced that some hereditary disorders of connective tissue, such as Marfan's syndrome, osteogenesis imperfecta and Ehlers-Danlos syndrome, are strongly influenced by race, sex and age.

[Evaluation of early biomarkers of cartilage degeneration in the diagnosis and clinico-therapeutic monitoring of primary osteoarthrosis]

It is known that in the course of osteoarthritis (OA), articular cartilage develops biochemical and structural changes. In the last years, serum and urinary markers of both the synthesis and destruction of cartilage have been dosed, above all in order to carry out an early diagnosis of OA. Among them, the urinary excretion of pyridinoline seems to correlate with the entity of the degradation of cartilage. The aim of the present study is to evaluate the above mentioned markers in OA patients compared to control subjects. Moreover, the possible influence on cartilage of two different non steroidal antiinflammatory drugs (NSAIDs), in particular Nabumetone and Piroxicam, has been verified. The study shows that the urinary excretion of pyridinoline is able to express the severity of OA. At last, the study shows that the tested drugs do not interfere with the metabolism of cartilage.

[Molecular genetics and bone diseases]

The authors describe the molecular mechanisms determining some skeletal diseases, in particular those due to a well-defined, single genic defect. In fact, they examine the hereditary disorders due to mutations in the genes encoding the different collagen types and the hereditary diseases secondary to the defects in: a) the structural proteins of cartilage; b) the enzymes and the sulfate transporters of proteoglycans; c) the transcription factors; d) the growth factors. At the end, the authors emphasize the importance of the genetic studies on animal models, for understanding the etiopathogenesis of many human hereditary disorders.

Immigration and health: the Italian National Focal Point experience

This report is a description of the situation of migrant populations in Italy. It was written by a committed team of experts from public institutions, non-governmental organisations (NGO) and volunteer associations that for three years have been part of the Italian National Focal Point (NFP) within the European Project "AIDS & Mobility", which is being co-ordinated by the Netherlands Institute for Health Promotion and Disease Prevention (the Netherlands) and financed by the European Commission DG/V. This year the Italian National Focal Point, co-ordinated by the Telefono Verde AIDS of the Istituto Superiore di Sanità, has produced a second report (the first one was published in 1998) on health issues related to migrant populations. Besides providing an updated picture on the presence of foreigners in Italy, such report illustrates the present legislative situation within the sanitary area and some interventions regarding prevention, treatment and rehabilitation provided by each structure in the Italian NFP to foreign citizens. The initiatives carried out during the year 1999 by public institutions, NGO and volunteer associations are also reported in order to detect the psycho-social-sanitary needs of immigrants and target prevention programmes to their particular and specific needs.

[Sexually transmitted diseases among immigrants in Italy]

In Italy, most foreign residents are between the ages of 19 and 40 years and are sexually active. Data from the Italian national STD surveillance system, a nationwide network of public STD clinics, show that over 10% of the reported cases of STD are diagnosed among these individuals. Furthermore, the mobility of foreign populations and problems with access to health care facilities can contribute to the spread of these diseases. This report presents data on over 4000 STD patients and on 1103 AIDS patients among foreign residents in Italy and includes a discussion of strategies for providing adequate STD care and for promoting prevention.

Immigration and health: the Italian situation. Italian National Focal Point (NFP) of the AIDS & Mobility Project

This report is a description of the situation of migrant populations in Italy. It was written as part of the European project "AIDS & Mobility", which is being co-ordinated by the Netherlands Institute for Health Promotion and Disease Prevention and financed by the European Union (EU). The report was written by the Italian National Focal Point (NFP) of the AIDS & Mobility Project, which consists of a committed team of experts from public institutions, non-governmental organizations, volunteer associations, and researchers from the Telefono Verde AIDS (National AIDS Help-line of Italy) of the Centro Operativo AIDS (COA, National AIDS Unit of Italy) of the Istituto Superiore di Sanità. The report illustrates the phenomenon of immigration in Italy, with demographic data (updated at 31 December 1997) on the presence of non-Italians and a review of the current laws pertinent to this phenomenon, with particular reference to health care laws. Moreover, epidemiological data on HIV/AIDS and on sexually transmitted diseases are provided, particularly as they relate to drug addiction and prostitution. Finally, following an accurate analysis of the situation and in light of the experience gained, the report includes proposals for identifying needs, objectives to pursue, and strategies to adopt, with respect to confronting the issue of immigration.

Predictors of major in-hospital ischemic complications and length of hospital stay after coronary stenting

Although recent data show that coronary stenting reduces procedural complications and late restenosis, major concern has been expressed about the greater hospital cost associated with the use of this device as compared to conventional coronary angioplasty. Since length of hospital stay after surgical procedures is a major determinant of resource use, the identification of variables associated with an excessively long hospital stay after intracoronary stent placement may have important practical consequences. The purpose of this study was to assess factors responsible for the occurrence of in-hospital complications and prolonged hospital stay after coronary stenting in 939 consecutive patients enrolled in the Registro Impianto Stent Endocoronarico (RISE Study Group). Consecutive patients undergoing coronary stent implantation at 16 medical centers in Italy were prospectively enrolled in the Registry. Clinical data, qualitative and quantitative angiographic findings were obtained from data collected in case report forms at each investigator site. Major ischemic complications were considered death, Q-wave myocardial infarction, emergency bypass surgery and emergency repeat angioplasty. The study group consisted of 939 patients (781 men, 158 women with a mean age of 59 years) in whom 1392 stents were implanted in 1006 lesions and expanded at a maximal inflation pressure of 14.7 +/- 3 atmospheres. The great majority of patients (92%) received only antiplatelet drugs after coronary stenting. During hospitalization, there were 45 major ischemic complications in 39 patients (4.2%): 13 events were related to acute or subacute thrombosis (1.4%). On multivariate logistic regression analysis, the following factors were predictive of in-hospital complications: increasing age (OR 2.19, 95% CI 1.18-4.07), unplanned stenting (OR 3.46, 95% CI 1.65-7.23) and maximal inflation pressure (OR 0.83, 95% CI 0.75-0.93). Mean hospital stay after stent implantation was 4.1 +/- 4.4 days and was related, by multivariate regression analysis, to female sex (p = 0.0001), prior bypass surgery (p = 0.03), non-elective stenting (p = 0.0001), use of anticoagulation (p = 0.0001) and development of major ischemic complications (p = 0.0001). This Registry shows that in an unselected population of patients undergoing coronary stenting, major ischemic complications occur at a relatively low rate (4.2%) and thrombotic events can be kept at 1.4%, despite the omission of anticoagulation in the great majority of patients. Length of hospital stay was affected by the occurrence of major ischemic complications, unplanned stenting, use of anticoagulation, female sex and prior bypass surgery. Accumulating experience, further reduction in complications and complete omission of anticoagulation may decrease length of hospital stay, thus reducing the use of resources after coronary stenting.

Multiple cocaine-induced seizures and corresponding cocaine and metabolite concentrations

The etiology of seizures associated with cocaine use is unclear. Because cocaine seizures are relatively uncommon, they should be diagnosed by exclusion and a neurological workup to rule out central nervous system (CNS) catastrophe should be made. This report describes the clinical findings, treatment, and blood cocaine and metabolite concentrations in a patient who, on two separate occasions, had seizures associated with crack cocaine ingestion. Approximately 1 hour after the ingestion incidents, the patient had multiple, generalized seizures that abated spontaneously. His workup for CNS bleeding, infection, and trauma was negative. Cocaine concentrations on the first incident peaked at 2.48 mg/L and on the second incident peaked at 3.9 mg/L. Other clinical findings included tachycardia, hypertension, diaphoresis, and disorientation. Blood cocaine and metabolite analysis revealed extremely high concentrations. Other than the incident of seizures and transient cardiovascular aberrations, these high concentrations were tolerated by the patient without further sequelae. A review of cocaine-induced seizures and treatment is included.

[Diagnostic imaging of current pulmonary tuberculosis. Clinical significance of the presentation patterns and particular aspects in HIV-positive and HIV-negative subjects]

PURPOSE

We compared two groups of risk patients to try to identify different radiologic patterns in pulmonary tuberculosis.

MATERIALS AND METHODS

74 subjects, divided into two groups (HIV+:27; HIV-:47) were included since 1993. The patients were examined with chest X-ray (CXR) and CT.

RESULTS

In the HIV+ group we observed 40 radiologic alterations, with 6 cases of bilateral lung involvement and 9 of atypical localizations; particularly: 11 consolidations, 8 cavitations, 5 miliary diseases, 9 hilar or mediastinal adenopathies, 3 extrapulmonary localizations and 4 negative CXRs. In the HIV- group we found 53 radiologic alterations, with 6 cases of bilateral lung involvement and 3 of atypical localizations; particularly: 12 consolidations, 25 cavitations, 5 nodular patterns, 1 miliary disease, 5 nodal disease, 4 pleural diseases and 1 negative CRX.

DISCUSSION AND CONCLUSIONS

In HIV- patients lung consolidations and tysiogen patterns are significantly prevalent, while miliary diseases, mediastinal diseases and atypical localizations and negative CRXs are more frequent in HIV+ patients. We found miliary diseases, mediastinal diseases and extrapulmonary localizations also in HIV- patients with heavily impaired social, economic and sanitary conditions. This alterations indicate compromised host resistance, independent of the causes and modalities of immunodeficiency. The distinction between primary and secondary tuberculosis is currently not mandatory.

Determinants of tuberculosis in an immigrant population in Rome: a case-control study

SETTING

An out-patient clinic for immigrants in Rome, Italy.

OBJECTIVE

To determine risk factors for tuberculosis among immigrants in Italy.

DESIGN

Case-control study. Cases comprised 44 individuals aged 15-55 years who had a first diagnosis of tuberculosis between 1989 and 1994 at the clinic. Controls comprised 264 individuals randomly recruited among immigrants who attended the clinic for other reasons within seven days before or after the case was diagnosed. Subject information included country of origin, date of first arrival in Italy, level of education, knowledge of the Italian language, and legal resident status.

RESULTS

An increase of tuberculosis risk was observed with increasing tuberculosis incidence in the country of origin. Multivariate analysis showed an increased risk for those coming from Central and South America (odds ratio [OR] 5.5; 95% confidence interval [CI] 1.6-18.7). The adjusted odds ratio by time since entry in Italy increased during the second year of residence (OR 2.8; 95% CI 1.1-7.0), but decreased after that period. A trend toward increasing risk with decreasing educational level was observed.

CONCLUSIONS

These results demonstrate the need for a public health policy in Italy for tuberculosis control among immigrants which includes screening, prophylaxis and treatment.

[Lung tuberculosis in HIV positive patients. Clinico-radiologic correlations]

We investigated the radiologic features of pulmonary tuberculosis in HIV+ patients.

SUBJECTS AND METHODS

24 cases of pulmonary tuberculosis in HIV+ patients were studied (17 men and 7 women, average age: 38 years). The study includes 19 drug addicts, 3 homosexuals, 1 polytransfused subject and 1 patient not belonging to the categories considered at risk). Three subgroups were identified by the CD4/mm3 cell count (< 200, 200-500, > 500).

RESULTS

In our 24 patients, we identified 37 radiologic manifestations (in 13 cases associated in the same patient), with 6 cases of bilateral pulmonary and 9 atypical localizations. In detail: 10 consolidations, 7 productive (miliary) cavitations, 8 mediastinal lymphadenitis, 3 extrapulmonary forms and 4 cases with no chest X-ray alterations. There is a major frequency of consolidations and cavitations in the patients with CD4 > 200 and a major frequency of productive forms, lymphadenitis and extrapulmonary localizations in the subjects with CD4 < 200. We observed no cases of tuberculosis in patients with CD4 > 500. The medical therapy is usually more effective in the more immunocompetent subjects and, anyway, in the exudative forms, improving in 35% of cases, than in the productive and disseminated forms improving in 6% of cases only.

DISCUSSION AND CONCLUSIONS

Only the severely immunodeficient HIV+ patients (CD4 < 500) are affected with tuberculosis. There exists a significant rate of parenchymal consolidations and tisiogenic forms in subjects with CD4 > 200 and a high rate of miliary forms, lymphadenitis and extrapulmonary localizations in patients with low cell count (< 200). The medical therapy is more effective in the more immunocompetent subjects and, anyway, in the exudative forms, than in the productive and disseminated forms. Finally, atypical localization of pulmonary tuberculosis are frequent in HIV patients.