Community Acquired Pneumonia in Internal Medicine: A One-Year Retrospective Study Based on Pneumonia Severity Index

Community acquired pneumonia (CAP) represents the sixth cause of death and the first cause of death for an infectious disease in the USA. The aim of the present study is to evaluate how CAP is managed in a hospital setting, with particular attention to the wards of internal medicine, compared to the recommendations based and validated PSI (Pneumonia Severity Index). 42 subjects were included in the study, 25 males and 17 females. According to the PSI, nine (21%) patients were classified in class I, two (5%) in class II, ten (24%) in class III, fifteen (36%) in class IV and six (14%) in class V. Three patients died during the stay in the hospital (2 males and 1 female), all in the highest PSI class (V). According to the criteria used to evaluate the adequacy of the admission to the hospital, twentyeight patients were classified in the HRG, with an appropriate admission, whilst fourteen (33%) were in the LRG, with an inappropriate admission to the hospital. The data of the study confirm the validity of a PSI based strategy for the management of CAP since admittance to the hospital. This approach is not yet widely implemented in Italy, and a better dialogue between hospital and health system representatives would be convenient, to reduce costs and ensure the safety of patients affected by CAP.

Thromboxane and prostacyclin biosynthesis in heart failure of ischemic origin: effects of disease severity and aspirin treatment

SUMMARY BACKGROUND

Thromboembolism is a relatively common complication of chronic heart failure (HF) and the place of antiplatelet therapy is uncertain.

OBJECTIVES

We characterized the rate of thromboxane and prostacyclin biosynthesis in chronic HF of ischemic origin, with the aim of separating the influence of HF on platelet activation from that of the underlying ischemic heart disease (IHD).

PATIENTS AND METHODS

We compared urinary 11-dehydro-thromboxane (TX)B(2), 2,3 dinor 6-keto-PGF(1alpha,) 8-iso-prostaglandin (PG)F(2alpha), and plasma N-terminal pro-brain natriuretic peptide (NT-pro-BNP), asymmetric dimethylarginine (ADMA), and soluble CD40 ligand (sCD40L), in 84 patients with HF secondary to IHD, 61 patients with IHD without HF and 42 healthy subjects.

RESULTS

HF patients not on aspirin had significantly higher urinary 11-dehydro-TXB(2) as compared with healthy subjects (P < 0.0001) and IHD patients not on aspirin (P = 0.028). They also showed significantly higher 8-iso-PGF(2alpha) (P = 0.018), NT-pro-BNP (P = 0.021) and ADMA (P < 0.0001) than IHD patients not on aspirin. HF patients on low-dose aspirin had significantly lower 11-dehydro-TXB(2) (P < 0.0001), sCD40L (P = 0.007) and 2,3-dinor-6-keto-PGF(1alpha) (P = 0.005) than HF patients not treated with aspirin. HF patients in NYHA classes III and IV had significantly higher urinary 11-dehydro-TXB(2) than patients in classes I and II, independently of aspirin treatment (P < 0.05). On multiple linear regression analysis, higher NT-pro-BNP levels, lack of aspirin therapy and sCD40L, predicted 11-dehydro-TXB(2) excretion rate in HF patients (R(2) = 0.771).

CONCLUSIONS

Persistent platelet activation characterizes HF patients. This phenomenon is related to disease severity and is largely suppressable by low-dose aspirin. The homeostatic increase in prostacyclin biosynthesis is impaired, possibly contributing to enhanced thrombotic risk in this setting.

Speech perception results in children implanted with Clarion devices: Hi-Resolution and Standard Resolution modes

CONCLUSIONS

Formal testing showed that HiRes users seem to make significant use of acoustic information. Furthermore, from observations reported by experienced care-givers, for example, family, teachers and speech therapists, these children learn a lot from their surrounding environment. Incidental learning, which takes place when acquiring skills or knowledge through naturally occurring events, is a key become available to these deaf paediatric cochlear implant recipients.

OBJECTIVE

To compare speech perception skills in children with a Clarion cochlear implant using different speech coding strategies, such as continuous interleaved sampling (CIS), simultaneous analogue stimulation (SAS) and Hi-Resolution (HiRes).

MATERIAL AND METHODS

The study population comprised 40 children, 17 implanted with a Clarion Hi-Focus 1.2 and 23 with a Clarion CII. All children were pre-lingually deaf and differed in terms of age and cause of deafness. All children had undergone a trial (minimum 6 months) with hearing aids before implantation. Children implanted with a Clarion 1.2 were either CIS or SAS users [Standard Resolution mode (SRM) group]; children implanted with a Clarion CII were Hi-Resolution users [Hi-Resolution mode (HRM) group]. Findings were assessed according to-Erber's hierarchical model (detection, discrimination, identification, recognition and comprehension), making use of a battery of speech perception tests calibrated to the age of the child. Further information concerning use of the implant in everyday situations was obtained by means of the Meaningful Auditory Integration Scale (MAIS) questionnaire, which was administered to the parents. Tests were carried out prior to each fitting session, at switch-on and then at 3, 6, 9 and 12 months. Findings at pre-implantation and at 12 months follow-up were collected for both the SRM and HRM groups. Speech perception results were analysed for the SRM and HRM groups, independent of age at implantation, for five subgroups of children according to the paediatric test battery in use and for two subgroups of children, one < and one > 5 years of age.

RESULTS

Clarion-implanted children using the Hi-Resolution strategy can develop better speech perception skills at 12 months post-implantation compared to children fitted with the SAS or CIS strategy. SAS or CIS users implanted before the age of 5 years tend to achieve better results at 1 year follow-up than children implanted later. In contrast, in Hi-Resolution users, a trend towards better results for recognition and comprehension tasks was observed in children implanted after 5 years of age.

[Ascites as preeminent manifestation of primary hypothyroidism. Clinical case]

The case of an adult male who came to clinical evaluation because of an abundant ascites without any obvious cardiac or hepatic explanation is reported. The exudative characteristics of the ascitic fluid, the elevated serum-ascites albumin gradient, some electrocardiographic anomalies, hypercholesterolemia and a slight macrocytic anemia prompted a clinical diagnosis of probable hypothyroidism. This was also due to an anamnesis of remote antithyroid radiometabolic treatment. The serum hormone levels and the ultrasonogram of the gland confirmed the diagnosis. Hormonal substitutive therapy led to thyroid-stimulating hormone normalization and to a progressive decrease of the ascites, that eventually disappeared. This case, which involves a rare manifestation of hypothyroidism, underscores the need to consider thyroid diseases in the differential diagnosis of ascites and to include thyroid-stimulating hormone dosage among the laboratory tests to be ordered when suspicious clinical or biochemical data are present (mainly, the exudative aspect of the ascites).

[Castleman's disease with isolated renal location: clinical case]

In a review of the literature the authors delineate the present nosographic and descriptive characteristics of Castleman's disease. They then report the case of an adult woman who came to their attention because of persistent, low-grade fever, sweating, malaise and polyarthralgia. Laboratory data evidenced increased acute-phase reactants, polyclonal hypergammaglobulinemia, and anemia due to "chronic disease". Diagnostic imaging documented a right renal mass. A nephrectomy was performed. Histopathological studies confirmed hyaline-vascular type Castleman's disease with monoclonal B-cell lymphoproliferation. The clinical and laboratory anomalies regressed after surgery and continue to be absent after 1 year of follow-up. The authors conclude their presentation by pointing out the peculiarities of this case that do not correspond with the traditional distinctive features of the disease.

Antithrombin III Pescara: a defective AT III variant with no alterations of plasma crossed immunoelectrophoresis, but with an abnormal crossed immunoelectrofocusing pattern

An abnormal AT III variant was found in five members from a family where a high incidence of thromboembolism occurred. In all the affected subjects AT III antigen concentration was normal, whereas antithrombin and antifactor Xa progressive activities as well as heparin cofactor activities were low. Crossed immunoelectrophoresis performed either in absence or in presence of heparin showed a normal plasma pattern. Further chromatographic investigations showed a normal affinity to heparin. An abnormal plasma pattern was evidentiated by crossed immunoelectrofocusing throughout all the AT III pH range. These data are consistent with the presence of an abnormal AT III variant with a defective binding to serine proteases and clearly identifiable only by crossed immunoelectrofocusing. This variant appeared different from the other qualitative AT III defects so far described and was named 'Antithrombin III Pescara'.