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EVALUATION OF A STRATEGY OF ROUTINE SCREENING FOR THYROID DYSFUNCTION IN ELDERLY MEDICAL IN-PATIENTS
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Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112
Klebsiella spp were resistant to Piperacilin/Tazobactan, Ciprofloxacin, Levofloxacin, Co-trimoxazole and Fosfomicin in >20% samples. Inpatients isolates resistance to antibiotics was higher than among outpatients ones. Conclusion: Neither quinolones nor Co-trimoxazole should take place at EAT for UTI. Pseudomonas spp resistance to antibiotics raises our concern: EAT should include aminoglycosides or carbapenems. Inpatient’s decreased susceptibility to antibiotics must be taken into account when choosing. Knowing the local uropathogens and its susceptibility to antibiotics is useful to guide empiric therapy in UTI.
ASPERGILLUS TRACHEOBRONCHITIS: REPORT OF 8 CASES AND REVIEW José Tiago Silva1, Begoña de Dios2, Rafael San Juan Garrido2, Francisco Medrano2, Mario Ruiz2, Ricardo García Lujan2, José Maria Aguado2. 1 Hospital Perpetuo Socorro, Badajoz, Spain; 2Hospital Doce de Octubre, Madrid, Spain Background: In Aspergillus Tracheobronchitis (AT) the fungal infection is entirely or predominantly confined to the tracheobronchial tree. It is a rare but severe disease with a high mortality rate. Methods: We have reviewed 8 cases of AT diagnosed in our hospital in an 18-year-old period and 42 cases published in the English literature. Results: Most cases were diagnosed in neutropenic patients due to chemotherapy or hematopoietic stem-cells transplantation, immuno-suppressed solid-organ transplants and advanced AIDS. 46% of patients had fever accompanied by respiratory complaints, but up to 16% of the patients were afebrile and 10% were clinically asymptomatic. Bronchoscophy and pathological studies were diagnostic in all cases and cultures allowed the identification of the Aspergillus species in 88% of patients. Aspergillus fumigatus was responsible for most of the cases. Radiological studies were considered normal in 42% of patients. Amphotericin B was the antifungal prescribed more often (77%), especially systemic. A monotherapy regime was used in 66% of all cases. Mortality was of 54%, and occurred especially in neutropenic patients, accounting for 63% of all deaths. Conclusions: Neutropenia, lung transplantation and advanced AIDS are the primary predisposing risk factors for AT. Fever and respiratory symptoms may be absent. Radiological evaluation proves a lack of sensitivity. Bronchoscopy and histological study of biopsies and bronchoalveolar lavage leads to diagnosis in all patients and is highly specific. Aspergillus fumigatus is responsible for most cases. Voriconazole, amphotericin B and itraconazole appear to be effective against this fungal infection. AT has a considerable lower mortality than IPA.
DOUBTFUL CYSTITIS Silva Mariana, Simas Ângela, Oliveira Sónia, Rodrigues Rita, Costa Cristina, Teófilo Eugénio, Castro António. Hospital Santo António dos Capuchos-Centro Hospitalar Lisboa Central Background: Thrombosis of the major renal arteries or their branches is an important cause of deterioration of renal function, especially in the elderly. It may occur as a result of intrinsic pathology in the renal vessels or as a result of emboli originating in distant vessels. Methods: Female patient aged 83, with a history of hypertension and cronic atrial fibrillation, developed fever, hematuria, urinary urgency and confusion. Her blood tests revealed leukocytosis, high LDH (1073 U/L) and AST (62 U/L) levels and also renal dysfunction. She was admitted in our ward with the diagnosis of cystitis and acute pre-renal failure. Results: The physical exam revealed low abdominal pain. The patient started antibiotics after collection of sterile urine sample. The urine culture was negative. Abdominal pain and high LDH levels (827 U/L) persisted. In addition, high D-Dimer values (1994 U/L) were documented. She went through a CT scan which revealed renal ischemia. Oral coagulation was started. The clinical condition improved and the lab tests became normal. Conclusion: Renal ischemia is often difficult to diagnose with a large spectrum of clinical presentations depending on the time course and the extent of the occlusive event. Our patient had some of the major symptoms that may appear after acute thrombosis and infarction. We underline the importance of a high index of suspicion.
PREDICTORS OF EARLY MORTALITY IN STROKE PATIENTS Athanasios Panoutsopoulos1, Apostolos Pappas1, Ioannis Dimitriadis1, Panagiota Mylona2, Georgios Andrianopoulos1, Konstantinos Vemmos2, Eleni Koroboki2, Eleni Koufogiorga2, George Siozos1. 1Internal Medicine Department, General Hospital of Argos, Greece; 2Clinical Therapeutics Department, Alexandra General Hospital, University of Athens, Greece Background: Stroke is one of the leading causes of serious, long-term disability and death in adults. The purpose of this study was to evaluate prognostic factors related with 30-day mortality in patients with ischemic stroke. Methods: The study included 92 patients with ischemic stroke occurring between 2010 and 2011. Baseline characteristics, risk factors and follow-up data at 30 days were recorded for all patients. Results: Nine patients (9.8%) died during our study period. Univariate analysis demonstrated that compared to the survival group, non survivals had a higher percent of patients with difficulty in swallowing (88.9% vs. 22.9%), with a National Institute of Health Stroke Scale (NIHSS) score of 15 or greater (55.6% vs. 4.8%) and with a prehospital Modified Rankin Scale (MRS) score of 4 or greater (44.4% vs. 7.8%) (p<0.05). Multivariate logistic regression analysis revealed that both NIHSS score (OR=0.05, P<0.05) and prehospital MRS score (OR=0.13, P<0.05) were significantly associated with death after 30 days. Conclusion: According to our results the presence of severe neurological deficit as measured with the NIHSS score at admission and the presence of severe prehospital disability were important indicators of 30-day mortality in patients with ischemic stroke. TRANSPERINEAL TEMPLATE-GUIDED MAPPING BIOPSY FOR DETECTION OF PROSTATE CANCER AS AN INITIAL APPROACH Skouteris Vassilios1, Dounis A.1, Evagelou I.3, Metsinis M.1, Skouteris M.1, Papaioannou D.3, Papadopoulos S.3, Zacharopoulos G.2. 1Prostate Brachytherapy Center, D.T.C.A. “Hygeia”, Maroussi, Athens, Greece; 2Ultrasound Department, D.T.C.A. “Hygeia”, Maroussi, Athens, Greece; 3Pathology Department, D.T.C.A. “Hygeia”, Maroussi, Athens, Greece Background: We report our results from an alternative prostate biopsy approach (transperineal template-guided mapping biopsy or TGMB), for patients undergoing their first biopsy or after at least one negative conventional transrectal. Methods: From July 2008 through May 2011, 67 patients underwent TGMB of prostate and seminal vesicles, under constant TRUS guidance. 22 men (32.8%) had at least one prior negative transrectal biopsy. Samples were taken every 5mm throughout the entire prostate gland using a brachytherapy grid. Three cores were taken also from the base of each seminal vesicle. Every sample was labeled according to its location. Results: Median patient age was 65 years (ratio: 48–84), median PSA 6.22ng/ ml (ratio: 2.68–29) and median prostate volume 44.3 (ratio: 18-115). Median number of prostate cores was 44 (ratio: 18-75). Positive result for adenocarcinoma was found in 24 patients (36%). Gleason score was 6 in 54 patients (80.6%) and 7 in 13 patients (19.4%). From the patients that previously have been submitted to at least one negative transrectal prostate biopsy, positive were found 9 (41%). Urinary retention presented in three patients (4.5%) and a Foley catheter had to be inserted for 3-5 days. The majority of the patients developed hematuria that resolved spontaneously after 1-3 days. Conclusions: TGMB is well tolerated by patients and can be used safely for the detection and accurate staging of prostate cancer. Should be considered as next first choice in patients with rising PSA and prior negative transrectal biopsy. EVALUATION OF A STRATEGY OF ROUTINE SCREENING FOR THYROID DYSFUNCTION IN ELDERLY MEDICAL IN-PATIENTS Efstathia Soroli, Ioasaf Karafotias, Demetrios Chrysis, Marina Skopeliti, Stavros Stavrinides, Christos Charalampopoulos, Constantinos Christopoulos. First Department of Internal Medicine, “Amalia Fleming” General Hospital, Athens, Greece Background: Clinical manifestations of thyroid disease may be atypical in the elderly. The utility of routine biochemical screening of asymptomatic individuals for thyroid dysfunction is debated. We present cost-effectiveness data of a screening strategy in elderly medical in-patients.
Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112 Methods: Serum TSH and FT4 levels were measured in all patients (n=5032) older than 60 years admitted to an acute general medical unit over a period of 7 years. Cost was calculated from the Greek NHS perspective using current hospital prices. Estimates of Quality-Adjusted Life Years (QALY) were based on published Health-Related Quality of Life (HRQL) data. Results: The introduction of routine screening resulted in a significant increase in the rate of diagnoses of hypothyroidism from 3.25 cases/year to 7.57 cases/year (p=0.03 by Wilcoxon two-sample test). There was no significant impact on the frequency of diagnosis of hyperthyroidism (2 cases/year). 26 new cases of hypothyroidism (excluding subclinical disease) were diagnosed at a cost of 166,056€ (6,387€/case). Omission of FT4 estimation would have reduced the cost to 2,396€/case without compromising the diagnostic sensitivity of the strategy. Most cases had a low HRQL score due to multiple co-morbidities unrelated to the thyroid. Assuming that hypothyroidism would have remained undiagnosed for 1-2 years in the absence of screening, the cost-effectiveness index of the screening strategy was 41,870-83,740€/ QALY (15,707-31,415€/QALY in the case of measuring only TSH). Conclusion: Routine screening of elderly medical in-patients with measurement of serum TSH is cost-effective (according to WHO criteria) in the setting of the Greek NHS.
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Results: Amongst 358 patients 95.8% were men, mean age 53.1 (±12.8; range: 23-90) years. Reason for first evaluation was deranged liver function tests in a routine check up in 152 (42.4%) patients, complications of portal hypertension in 84 (23.5%), symptoms as fatigability and abdominal pain in 65 (18.1%), alcoholic hepatitis in 11 (3%), alcohol withdrawal syndrome in 7 (2%), hospitalization due to other reason in 36 (10.1%) patients and other in 3 (0.8%) patients. At presentation 178 (49.7%) had cirrhosis. A liver biopsy during the follow up in 46(12.8%) patients revealed steatosis in 37%, steatohepatitis in 13%, cirrhosis in 17.4% and other features in 32.6%. Concurrent liver diseases were reported in 82 (22.9%) of patients: viral hepatitis in 53/82 (64.6%), autoimmune or chronic cholestatic liver diseases in 24/82 (29.3%), and other in 5/82 (6.1%). During follow-up period (37.1±33.1 months), 63 (17.6%) had deterioration of liver function, including progression to cirrhosis in 17 (27%), development of cirrhosis complications related to portal hypertension in 28 (44.4%) and development of hepatocellular carcinoma in 18 (28.6%). In total, 120 (33.5%) were lost to follow-up, while 36/238 (15.1%) died from liver related causes. Conclusion: ALD comprises a significant proportion of chronic liver disease in Central Greece with significant morbidity and mortality.
COMPARISON OF MORBIDITY OF ELDERLY IN AUGUST AND NOVEMBER IN ATTICA, GREECE: A PROSPECTIVE STUDY George Theocharis1, Michael Mavros2, Evridiki Vouloumanou2, George Peppas1,2, Spyridon Barbas1, Theodore Spiropoulos1, Matthew Falagas2,3,4. 1SOS Iatroi (Doctors). Athens, Greece; 2Alfa Institute Of Biomedical Sciences (Aibs), Athens, Greece; 3Department Of Medicine, Henry Dunant Hospital, Athens, Greece; 4Department Of Medicine, Tufts University School Of Medicine, Boston, Massachusetts, USA Background: In our clinical practice, we have experienced a consistent increase in the morbidity of elderly in Greece during August. Methods: We prospectively analyzed and compared the morbidity of elderly (75 years old) between August and November of the same year (2010), using data from the SOS Doctors (a network of physicians performing house call visits). Results: We analyzed data on 739 and 738 elderly patient house-calls in August and November, respectively. Overall, the most common diagnoses were cardiovascular (17.6%), musculoskeletal (10.7%), gastrointestinal (9.5%), respiratory (8.5%), renal/genitourinary (8.1%), and neurologic/psychiatric (7.9%). In August, patients were older (p<0.01), carried a heavier burden of disease (as inferred by specific types of comorbidity and associated medical conditions), were more frequently recommended emergent hospitalization (p<0.01) and had a worse outcome of primary illness (p<0.05). Mortality of elderly visited in August was significantly higher compared to November (5% versus 2%, p<0.01). The sole independent predictor of mortality was patient’s bedridden status [adjusted odds ratio (OR)=5.59, 95% confidence intervals (CI) 2.83-11.06, p<0.001]. The identified independent predictors of recommendation for emergent hospitalization were patient’s sedation [OR=2.88 (1.80, 4.59), p<0.001], fever [OR=2.55 (1.84, 3.54), p<0.001], heat stroke [OR=2.08 (1.19, 3.64), p=0.01], Alzheimer’s disease [OR=1.77 (1.15, 2.72), p=0.01], and bedridden status [OR=1.45 (1.07, 1.97), p<0.05]. Conclusion: Morbidity and mortality of elderly patients was significantly higher in August compared to November, substantiating the informal term “Augustitis” for the Greek elderly. Large, prospective population-based studies are warranted to further enlighten this field. Keywords: older individuals, age, geriatrics, primary care, seasonality EPIDEMIOLOGICAL CHARACTERISTICS AND BURDEN OF ALCOHOLIC LIVER DISEASE IN CENTRAL GREECE Aggelos Stefos, Kalliopi Zachou, Georgia Papadamou, Eirini I. Rigopoulou, George N. Dalekos. Department of Medicine and Academic Liver Unit, University of Thessaly, Larissa, Greece Backround: Alcohol abuse is the third more frequent risk factor for chronic disease burden in developed countries. This study portrays descriptive epidemiology features of alcoholic liver disease (ALD) in a referral tertiary centre in Central Greece. Methods: We retrospectively evaluated medical files from 358 patients with ALD seen at our outpatient liver clinic between 2002 and 2009 and recorded their main epidemiological characteristics.
CELLULAR-HUMORAL THEORY OF PATHONOMIA: NEW INSIGHTS IN THE FOUNDATIONS OF INTERNAL MEDICINE Konstantin Sukhov. Russian Scientific Center of Restorative Medicine and Balneology, Ministry of Health and Social Development of the Russian Federation, Moscow, Russia Background: In recent years, the failure of the cellular theory of pathonomia generally accepted in the internal medicine becomes increasingly evident. A rapidly developing scientific and technical progress offers novel and more complex techniques for patient examination; the pharmaceutical industry manufactures medicaments, which are increasingly expensive and potent. But, all achievements in this field do not allow improving in principle the treatment of human internal diseases and thereby do not allow medicine to rise to a brand new level of its development. Methods: Such trends of modern medicine worry deeply the whole community of physicians. We consider that one should bottom the reasons for this in the foundations of our perceptions of the causes of contraction and progress of a disease. While dealing with hirudotherapy (medicinal leech therapy) over a period of years, we paid attention to a remarkable efficacy of this method in the treatment of various therapeutic, surgical, gynecologic, and many other diseases. This brings up the question: “If so wide spectrum of diseases can be treated by hirudotherapy, probably, all these diseases share some similarities in their pathogenesis?”, and, at the same time, to the answer: “If we would know the underlying principles of action of medical leeches, we will also know the basic principles of progress of the most of diseases!” Results: Our experience shows that the foundation for the therapeutic application of medical leeches consists in the systemic effect (anticoagulant and thrombolytic actions, and decrease in the blood viscosity) and local effect (anti-inflammatory action and considerable tissue lymphatic efflux). Taking into account the obtained results and based on the physiological principles of the vital activity of a body, we suggest to consider the cellular-humoral theory of pathonomia: The vital activity of an organism is the sum of the vital activities of individual cells combined therein. The life of an organism and its life quality depend on the state of the total sum of the life and life quality of each individual cell. The life of a cell and its life quality depends directly on the state of the liquid circulation in an organism, viz., its afflux and efflux, and the direct effect of any factor on the cell itself. The qualitative state of liquid circulation in a body is provided by the blood circulation system: arterial part provides a cell with the necessary affluxion of nutrients, while the removal of metabolic products from a cell (effluxion) is provided by the drainage system with two constituents - venous circulation and lymphatic system of a body. The direct effect on a cell can be physical, chemical (toxic, endocrine), biological (bacterial, viral) etc. Conclusion: The suggested theory is incompletely exhaustive, but allows one to look in a new light at the main problems of medicine, such as contraction and progress of diseases, and, primarily, at the possibilities of their treatments.
Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112
Klebsiella spp were resistant to Piperacilin/Tazobactan, Ciprofloxacin, Levofloxacin, Co-trimoxazole and Fosfomicin in >20% samples. Inpatients isolates resistance to antibiotics was higher than among outpatients ones. Conclusion: Neither quinolones nor Co-trimoxazole should take place at EAT for UTI. Pseudomonas spp resistance to antibiotics raises our concern: EAT should include aminoglycosides or carbapenems. Inpatient’s decreased susceptibility to antibiotics must be taken into account when choosing. Knowing the local uropathogens and its susceptibility to antibiotics is useful to guide empiric therapy in UTI.
ASPERGILLUS TRACHEOBRONCHITIS: REPORT OF 8 CASES AND REVIEW José Tiago Silva1, Begoña de Dios2, Rafael San Juan Garrido2, Francisco Medrano2, Mario Ruiz2, Ricardo García Lujan2, José Maria Aguado2. 1 Hospital Perpetuo Socorro, Badajoz, Spain; 2Hospital Doce de Octubre, Madrid, Spain Background: In Aspergillus Tracheobronchitis (AT) the fungal infection is entirely or predominantly confined to the tracheobronchial tree. It is a rare but severe disease with a high mortality rate. Methods: We have reviewed 8 cases of AT diagnosed in our hospital in an 18-year-old period and 42 cases published in the English literature. Results: Most cases were diagnosed in neutropenic patients due to chemotherapy or hematopoietic stem-cells transplantation, immuno-suppressed solid-organ transplants and advanced AIDS. 46% of patients had fever accompanied by respiratory complaints, but up to 16% of the patients were afebrile and 10% were clinically asymptomatic. Bronchoscophy and pathological studies were diagnostic in all cases and cultures allowed the identification of the Aspergillus species in 88% of patients. Aspergillus fumigatus was responsible for most of the cases. Radiological studies were considered normal in 42% of patients. Amphotericin B was the antifungal prescribed more often (77%), especially systemic. A monotherapy regime was used in 66% of all cases. Mortality was of 54%, and occurred especially in neutropenic patients, accounting for 63% of all deaths. Conclusions: Neutropenia, lung transplantation and advanced AIDS are the primary predisposing risk factors for AT. Fever and respiratory symptoms may be absent. Radiological evaluation proves a lack of sensitivity. Bronchoscopy and histological study of biopsies and bronchoalveolar lavage leads to diagnosis in all patients and is highly specific. Aspergillus fumigatus is responsible for most cases. Voriconazole, amphotericin B and itraconazole appear to be effective against this fungal infection. AT has a considerable lower mortality than IPA.
DOUBTFUL CYSTITIS Silva Mariana, Simas Ângela, Oliveira Sónia, Rodrigues Rita, Costa Cristina, Teófilo Eugénio, Castro António. Hospital Santo António dos Capuchos-Centro Hospitalar Lisboa Central Background: Thrombosis of the major renal arteries or their branches is an important cause of deterioration of renal function, especially in the elderly. It may occur as a result of intrinsic pathology in the renal vessels or as a result of emboli originating in distant vessels. Methods: Female patient aged 83, with a history of hypertension and cronic atrial fibrillation, developed fever, hematuria, urinary urgency and confusion. Her blood tests revealed leukocytosis, high LDH (1073 U/L) and AST (62 U/L) levels and also renal dysfunction. She was admitted in our ward with the diagnosis of cystitis and acute pre-renal failure. Results: The physical exam revealed low abdominal pain. The patient started antibiotics after collection of sterile urine sample. The urine culture was negative. Abdominal pain and high LDH levels (827 U/L) persisted. In addition, high D-Dimer values (1994 U/L) were documented. She went through a CT scan which revealed renal ischemia. Oral coagulation was started. The clinical condition improved and the lab tests became normal. Conclusion: Renal ischemia is often difficult to diagnose with a large spectrum of clinical presentations depending on the time course and the extent of the occlusive event. Our patient had some of the major symptoms that may appear after acute thrombosis and infarction. We underline the importance of a high index of suspicion.
PREDICTORS OF EARLY MORTALITY IN STROKE PATIENTS Athanasios Panoutsopoulos1, Apostolos Pappas1, Ioannis Dimitriadis1, Panagiota Mylona2, Georgios Andrianopoulos1, Konstantinos Vemmos2, Eleni Koroboki2, Eleni Koufogiorga2, George Siozos1. 1Internal Medicine Department, General Hospital of Argos, Greece; 2Clinical Therapeutics Department, Alexandra General Hospital, University of Athens, Greece Background: Stroke is one of the leading causes of serious, long-term disability and death in adults. The purpose of this study was to evaluate prognostic factors related with 30-day mortality in patients with ischemic stroke. Methods: The study included 92 patients with ischemic stroke occurring between 2010 and 2011. Baseline characteristics, risk factors and follow-up data at 30 days were recorded for all patients. Results: Nine patients (9.8%) died during our study period. Univariate analysis demonstrated that compared to the survival group, non survivals had a higher percent of patients with difficulty in swallowing (88.9% vs. 22.9%), with a National Institute of Health Stroke Scale (NIHSS) score of 15 or greater (55.6% vs. 4.8%) and with a prehospital Modified Rankin Scale (MRS) score of 4 or greater (44.4% vs. 7.8%) (p<0.05). Multivariate logistic regression analysis revealed that both NIHSS score (OR=0.05, P<0.05) and prehospital MRS score (OR=0.13, P<0.05) were significantly associated with death after 30 days. Conclusion: According to our results the presence of severe neurological deficit as measured with the NIHSS score at admission and the presence of severe prehospital disability were important indicators of 30-day mortality in patients with ischemic stroke. TRANSPERINEAL TEMPLATE-GUIDED MAPPING BIOPSY FOR DETECTION OF PROSTATE CANCER AS AN INITIAL APPROACH Skouteris Vassilios1, Dounis A.1, Evagelou I.3, Metsinis M.1, Skouteris M.1, Papaioannou D.3, Papadopoulos S.3, Zacharopoulos G.2. 1Prostate Brachytherapy Center, D.T.C.A. “Hygeia”, Maroussi, Athens, Greece; 2Ultrasound Department, D.T.C.A. “Hygeia”, Maroussi, Athens, Greece; 3Pathology Department, D.T.C.A. “Hygeia”, Maroussi, Athens, Greece Background: We report our results from an alternative prostate biopsy approach (transperineal template-guided mapping biopsy or TGMB), for patients undergoing their first biopsy or after at least one negative conventional transrectal. Methods: From July 2008 through May 2011, 67 patients underwent TGMB of prostate and seminal vesicles, under constant TRUS guidance. 22 men (32.8%) had at least one prior negative transrectal biopsy. Samples were taken every 5mm throughout the entire prostate gland using a brachytherapy grid. Three cores were taken also from the base of each seminal vesicle. Every sample was labeled according to its location. Results: Median patient age was 65 years (ratio: 48–84), median PSA 6.22ng/ ml (ratio: 2.68–29) and median prostate volume 44.3 (ratio: 18-115). Median number of prostate cores was 44 (ratio: 18-75). Positive result for adenocarcinoma was found in 24 patients (36%). Gleason score was 6 in 54 patients (80.6%) and 7 in 13 patients (19.4%). From the patients that previously have been submitted to at least one negative transrectal prostate biopsy, positive were found 9 (41%). Urinary retention presented in three patients (4.5%) and a Foley catheter had to be inserted for 3-5 days. The majority of the patients developed hematuria that resolved spontaneously after 1-3 days. Conclusions: TGMB is well tolerated by patients and can be used safely for the detection and accurate staging of prostate cancer. Should be considered as next first choice in patients with rising PSA and prior negative transrectal biopsy. EVALUATION OF A STRATEGY OF ROUTINE SCREENING FOR THYROID DYSFUNCTION IN ELDERLY MEDICAL IN-PATIENTS Efstathia Soroli, Ioasaf Karafotias, Demetrios Chrysis, Marina Skopeliti, Stavros Stavrinides, Christos Charalampopoulos, Constantinos Christopoulos. First Department of Internal Medicine, “Amalia Fleming” General Hospital, Athens, Greece Background: Clinical manifestations of thyroid disease may be atypical in the elderly. The utility of routine biochemical screening of asymptomatic individuals for thyroid dysfunction is debated. We present cost-effectiveness data of a screening strategy in elderly medical in-patients.
Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112 Methods: Serum TSH and FT4 levels were measured in all patients (n=5032) older than 60 years admitted to an acute general medical unit over a period of 7 years. Cost was calculated from the Greek NHS perspective using current hospital prices. Estimates of Quality-Adjusted Life Years (QALY) were based on published Health-Related Quality of Life (HRQL) data. Results: The introduction of routine screening resulted in a significant increase in the rate of diagnoses of hypothyroidism from 3.25 cases/year to 7.57 cases/year (p=0.03 by Wilcoxon two-sample test). There was no significant impact on the frequency of diagnosis of hyperthyroidism (2 cases/year). 26 new cases of hypothyroidism (excluding subclinical disease) were diagnosed at a cost of 166,056€ (6,387€/case). Omission of FT4 estimation would have reduced the cost to 2,396€/case without compromising the diagnostic sensitivity of the strategy. Most cases had a low HRQL score due to multiple co-morbidities unrelated to the thyroid. Assuming that hypothyroidism would have remained undiagnosed for 1-2 years in the absence of screening, the cost-effectiveness index of the screening strategy was 41,870-83,740€/ QALY (15,707-31,415€/QALY in the case of measuring only TSH). Conclusion: Routine screening of elderly medical in-patients with measurement of serum TSH is cost-effective (according to WHO criteria) in the setting of the Greek NHS.
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Results: Amongst 358 patients 95.8% were men, mean age 53.1 (±12.8; range: 23-90) years. Reason for first evaluation was deranged liver function tests in a routine check up in 152 (42.4%) patients, complications of portal hypertension in 84 (23.5%), symptoms as fatigability and abdominal pain in 65 (18.1%), alcoholic hepatitis in 11 (3%), alcohol withdrawal syndrome in 7 (2%), hospitalization due to other reason in 36 (10.1%) patients and other in 3 (0.8%) patients. At presentation 178 (49.7%) had cirrhosis. A liver biopsy during the follow up in 46(12.8%) patients revealed steatosis in 37%, steatohepatitis in 13%, cirrhosis in 17.4% and other features in 32.6%. Concurrent liver diseases were reported in 82 (22.9%) of patients: viral hepatitis in 53/82 (64.6%), autoimmune or chronic cholestatic liver diseases in 24/82 (29.3%), and other in 5/82 (6.1%). During follow-up period (37.1±33.1 months), 63 (17.6%) had deterioration of liver function, including progression to cirrhosis in 17 (27%), development of cirrhosis complications related to portal hypertension in 28 (44.4%) and development of hepatocellular carcinoma in 18 (28.6%). In total, 120 (33.5%) were lost to follow-up, while 36/238 (15.1%) died from liver related causes. Conclusion: ALD comprises a significant proportion of chronic liver disease in Central Greece with significant morbidity and mortality.
COMPARISON OF MORBIDITY OF ELDERLY IN AUGUST AND NOVEMBER IN ATTICA, GREECE: A PROSPECTIVE STUDY George Theocharis1, Michael Mavros2, Evridiki Vouloumanou2, George Peppas1,2, Spyridon Barbas1, Theodore Spiropoulos1, Matthew Falagas2,3,4. 1SOS Iatroi (Doctors). Athens, Greece; 2Alfa Institute Of Biomedical Sciences (Aibs), Athens, Greece; 3Department Of Medicine, Henry Dunant Hospital, Athens, Greece; 4Department Of Medicine, Tufts University School Of Medicine, Boston, Massachusetts, USA Background: In our clinical practice, we have experienced a consistent increase in the morbidity of elderly in Greece during August. Methods: We prospectively analyzed and compared the morbidity of elderly (75 years old) between August and November of the same year (2010), using data from the SOS Doctors (a network of physicians performing house call visits). Results: We analyzed data on 739 and 738 elderly patient house-calls in August and November, respectively. Overall, the most common diagnoses were cardiovascular (17.6%), musculoskeletal (10.7%), gastrointestinal (9.5%), respiratory (8.5%), renal/genitourinary (8.1%), and neurologic/psychiatric (7.9%). In August, patients were older (p<0.01), carried a heavier burden of disease (as inferred by specific types of comorbidity and associated medical conditions), were more frequently recommended emergent hospitalization (p<0.01) and had a worse outcome of primary illness (p<0.05). Mortality of elderly visited in August was significantly higher compared to November (5% versus 2%, p<0.01). The sole independent predictor of mortality was patient’s bedridden status [adjusted odds ratio (OR)=5.59, 95% confidence intervals (CI) 2.83-11.06, p<0.001]. The identified independent predictors of recommendation for emergent hospitalization were patient’s sedation [OR=2.88 (1.80, 4.59), p<0.001], fever [OR=2.55 (1.84, 3.54), p<0.001], heat stroke [OR=2.08 (1.19, 3.64), p=0.01], Alzheimer’s disease [OR=1.77 (1.15, 2.72), p=0.01], and bedridden status [OR=1.45 (1.07, 1.97), p<0.05]. Conclusion: Morbidity and mortality of elderly patients was significantly higher in August compared to November, substantiating the informal term “Augustitis” for the Greek elderly. Large, prospective population-based studies are warranted to further enlighten this field. Keywords: older individuals, age, geriatrics, primary care, seasonality EPIDEMIOLOGICAL CHARACTERISTICS AND BURDEN OF ALCOHOLIC LIVER DISEASE IN CENTRAL GREECE Aggelos Stefos, Kalliopi Zachou, Georgia Papadamou, Eirini I. Rigopoulou, George N. Dalekos. Department of Medicine and Academic Liver Unit, University of Thessaly, Larissa, Greece Backround: Alcohol abuse is the third more frequent risk factor for chronic disease burden in developed countries. This study portrays descriptive epidemiology features of alcoholic liver disease (ALD) in a referral tertiary centre in Central Greece. Methods: We retrospectively evaluated medical files from 358 patients with ALD seen at our outpatient liver clinic between 2002 and 2009 and recorded their main epidemiological characteristics.
CELLULAR-HUMORAL THEORY OF PATHONOMIA: NEW INSIGHTS IN THE FOUNDATIONS OF INTERNAL MEDICINE Konstantin Sukhov. Russian Scientific Center of Restorative Medicine and Balneology, Ministry of Health and Social Development of the Russian Federation, Moscow, Russia Background: In recent years, the failure of the cellular theory of pathonomia generally accepted in the internal medicine becomes increasingly evident. A rapidly developing scientific and technical progress offers novel and more complex techniques for patient examination; the pharmaceutical industry manufactures medicaments, which are increasingly expensive and potent. But, all achievements in this field do not allow improving in principle the treatment of human internal diseases and thereby do not allow medicine to rise to a brand new level of its development. Methods: Such trends of modern medicine worry deeply the whole community of physicians. We consider that one should bottom the reasons for this in the foundations of our perceptions of the causes of contraction and progress of a disease. While dealing with hirudotherapy (medicinal leech therapy) over a period of years, we paid attention to a remarkable efficacy of this method in the treatment of various therapeutic, surgical, gynecologic, and many other diseases. This brings up the question: “If so wide spectrum of diseases can be treated by hirudotherapy, probably, all these diseases share some similarities in their pathogenesis?”, and, at the same time, to the answer: “If we would know the underlying principles of action of medical leeches, we will also know the basic principles of progress of the most of diseases!” Results: Our experience shows that the foundation for the therapeutic application of medical leeches consists in the systemic effect (anticoagulant and thrombolytic actions, and decrease in the blood viscosity) and local effect (anti-inflammatory action and considerable tissue lymphatic efflux). Taking into account the obtained results and based on the physiological principles of the vital activity of a body, we suggest to consider the cellular-humoral theory of pathonomia: The vital activity of an organism is the sum of the vital activities of individual cells combined therein. The life of an organism and its life quality depend on the state of the total sum of the life and life quality of each individual cell. The life of a cell and its life quality depends directly on the state of the liquid circulation in an organism, viz., its afflux and efflux, and the direct effect of any factor on the cell itself. The qualitative state of liquid circulation in a body is provided by the blood circulation system: arterial part provides a cell with the necessary affluxion of nutrients, while the removal of metabolic products from a cell (effluxion) is provided by the drainage system with two constituents - venous circulation and lymphatic system of a body. The direct effect on a cell can be physical, chemical (toxic, endocrine), biological (bacterial, viral) etc. Conclusion: The suggested theory is incompletely exhaustive, but allows one to look in a new light at the main problems of medicine, such as contraction and progress of diseases, and, primarily, at the possibilities of their treatments.