IDIOPATHIC VENOUS THROMBOEMBOLISM: RISK FACTORS OF RECURRENCE AND OPTIMAL DURATION OF ANTICOAGULANT THERAPY

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Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112

Results: Seventy-eight patients, 65.5 +/- 4.4 years old (age range: 31 to 84 years), with 34 women (43.6%) were included. 43 patients (55.1%) fulfilled diagnostic criteria of the syndrome. Increased waist/hip circumference ratio was observed in 38 patients (48.7%). Twenty-five patients fulfilled 3 diagnostic criteria (58.1%), 10 patients 4 diagnostic criteria (23.3%) and 8 patients fulfilled all the diagnostic criteria (18.6%). Prevalence of VRF: 43.6% for obesity (BMI > 30 Kg/m2), 68.4% arterial hypertension, 65.4% smoking, 58.9% elevated cholesterol levels, 53.8% sedentarism, 45.9% diabetes mellitus and 44.9% elevated triglycerides. MS was associated with the occurrence of an acute coronary syndrome (p < .01). Conclusions: Patients hospitalized for an acute coronary syndrome have an elevated prevalence of vascular risk factors and the metabolic syndrome. This syndrome, in spite of the discrepancies on its prognostic significance, is associated with an increased risk for an acute coronary syndrome. CERVICOFACIAL ACTINOMYCOSIS Victor Romero, Ramón Guitart, Ruben Blanco, Juan Agramonte, Victor Romero Nieves, Jorge Peraza. Miramar Polyclinic Palma de Mallorca, Spain Background: Actinomycosis is an uncommon, chronic bacterial infection caused by Actinomyces species, normal inhabitants in the oral cavity, respiratory and digestive tracts. This is characterized by suppuration, abscess formation, tissue fibrosis and granuloma formation. Actinomyces species are anaerobic bacteria that cannot penetrate healthy tissue. It has three main forms cervicofacial, pulmonary and abdominal. Actinomyces israelii is the most common pathogen. It is diagnosed by examining the exudates and infected tissue. Gram staining reveals gram positive long-branching filaments. The histologic and microscopic diagnoses are made by the finding of sulfur granules in the specimens; incisional biopsy is often undertaken to determine a diagnosis. Prolonged antimicrobial therapy with penicillin has typically been recommended. Case Report: We present the case of 50 years old, female, with personal history of Diabetes Mellitus type I, who was admitted to our hospital because fever of 38° C and painful right submaxilar mass, six weeks before admission the patient had suffered dental manipulation. At physical examination we found a painful, hard, red, and hot right sub maxilar mass of about 3 cms of diameter running to right lateral cervical region. Lab test shown severe leukocytosis, hyperglycaemia and raised ESR and CRP. Cervicofacial CT scanner shown bulky and heterogenic right laterocervical mass. Cytology and the culture of material obtained shown Actinomyces radingae. Incision and drainage of abscess, following of Penicillin G 24 millions U/d IV daily was the treatment with an excellent clinical response. ALCOHOL USE DISORDERS AND ITS DETECTION AMONG MEDICAL INPATIENTS IN EUROPE. THE ALCHIMIE STUDY. FIRST PHASE DATA Beatriz Rosón1, Jan Vaclavik2, Rudolf Stauber3, Ieva Ruza4, Pascal Perney5, José Barata6, Alexander Arutyunov7, and the ALCHIMIE STUDY GROUP. 1 Hospital Universitari De Bellvitge; 2University Hospital Olomouc; 3Medical University of Graz; 4Riga East Clinical University Hospital. Hospital Linezers; 5CH du Bassin de Thau; 6Hospital García Orta; 7City Clinical Hospital n°4 Background: This project aims to investigate the prevalence of alcohol use disorders (AUDs) in medical wards across Europe and to assess its recognition by physicians. Methods: Point-prevalence, multicentre study performed in 8 European countries. Patients were screened with the AUDIT-C and the SIAC questionnaires. Drinking patterns were determined using ICD-10 criteria. Medical records were reviewed to collect information about recording of alcohol use. Results: We interviewed 2123 (79%) inpatients [1114 (52%) men; mean age (SD) 67.9±17.3 years]. Reasons for admission were not alcohol-related in 2031 (95%) patients. Overall, 300 (14%) patients had current AUDs. Drinking patterns were: non-drinkers 984 (46%), low-risk 773 (36%), harzardous 163 (8%), harmful 63 (3%), dependent 74 (3%), former-dependent 47 (2%), and unknown pattern 19 (1%). There were significant differences in the prevalence of AUDs between countries with range of 22% for France and 8% for Estonia. We reviewed 2100 (98%) medical records. Alcohol consumption was recorded in 920 (44%) patients. Recording was more frequently performed in patients

with AUDs than in the other patients (58% vs 41%). Quantitative recording was performed in 119 (13%) with significant differences among countries ranging from 46% of medical records in Austria to 0% in Latvia. Conclusion: AUDs are frequent among European patients hospitalized for reasons not alcohol-related. They are frequently undetected during hospitalization. Adequate quantification of alcohol intake is rarely performed. We stress the need to implement measures to increase and improve the detection and recording of alcohol use among hospitalized patients. NECROTISING PNEUMONIA WITH STAPHYLOCOCCUS AUREUS CARRYING PANTON-VALENTINE LEUKOCIDIN GENES: AN UNDERESTIMATED GRAVITY? Xavier Roux1, Bruno Soullié1, Fabrice Camou2, Christophe Rapp3, Patrick Imbert3, Frédéric Mechaï3, Jean Louis Koeck1. 1Service de biologie clinique, Hôpital d’instruction des armées Robert Picqué; 2Service de réanimation, Hôpital St André / CHU de Bordeaux; 3Service de pathologies infectieuses et tropicales, Hôpital d’instruction des armées Begin Background: Panton Valentine Leukocidin (PVL) associated staphylococcal pneumonia is a distinct clinical entity affecting healthy young people. Its physiopathology is well known and its clinicical specifications were recently described. Our study aims to assess the clinical, biological and radiological features of S. aureus pneumonia due to PVL. Methods: Our study reports a serie of ten retrospective cases of PVLassociated staphylococcal pneumonia. We studied the clinical, biological and radiological features with a standardized questionnaire. We compared our data with a serie of ten S. aureus pneumonia without leucocidine by a statistical analysis. Results: We report on 8 men and 2 women without any immunodepression. Four of them had an influenza-like syndrom a few days before. The median age was 29,5 years for the PVL-positive patients and 64,2 years (59·2–81·4) for the others (p=0·001). No clinical difference was found beetween PVL positive and PVL negative pneumonia. A neutropenia (p=0,039) and a higher level of C reactive protein (p=0,012) was found in PVL positive pneumonia. SAPS2 (Simplified Acute Physiology Score) and PSI (pneumonia severity index) scores in PVL pneumonia were lower than in PVL negative pneumonia. Conclusions: PVL-producing S aureus causes rapidly progressive, haemorrhagic, necrotising pneumonia, mainly in healthy children and young adults. In 40% of the cases, the pneumonia is preceded by influenza-like symptoms. There is no clinical distinction in our study. A neutropenia must alarm the physician. In our study, the gravity scores seem to under-estimate the risk of unfavourable evolution in spite of a high letality rate. IDIOPATHIC VENOUS THROMBOEMBOLISM: RISK FACTORS OF RECURRENCE AND OPTIMAL DURATION OF ANTICOAGULANT THERAPY Pedro Ruiz-Artacho, Jose Maria Pedrajas-Navas, Angel Molino-Gonzalez, Vanesa Sendín-Martin, Nike Sanchez-Martinez, Belen Gonzalez-Casanova, Emilio Agrela-Rojas, Vanesa Lopez-Pelaez, Angeles Martin-Serrat, Isabel Jimenez, Ruth Velarde, Pedro Gonzalez-deLara. Hospital Clínico San Carlos Background: Unprovoked venous thromboembolism (VTE) has a high incidence of recurrence. The optimal duration of secondary prophylaxis is not established. Predictors for recurrent VTE in these patients are unknown. Our objectives were to identify factors involved to recurrence of thromboembolism and the optimal duration of anticoagulant therapy in patients with idiopathic venous thromboembolism (VTE) and to assess the cumulative probability of recurrence after 18 months. Methods: Registro Informatizado de Enfermedad TromboEmbólica (RIETE) is an ongoing, prospective registry of consecutively enrolled patients with objectively confirmed, symptomatic, acute VTE. We determined independent predictive factors (clinical and analytics) for recurrent venous thromboembolism (VTE) after stopping anticoagulation, including duration of anticoagulation. Results: Between January 2001 and March 2010, 30949 were included in RIETE. 8939 (28,9%) were unprovoked venous thromboembolism. 2294 were followed after stopping anticoagulation for a median of 5,4 months (IR 2,512,0), and had been treated for a median of 6,2 months of anticoagulation (IR 4,1-8,5). Cumulative probability of recurrence, until 18 months of follow up, was 17,5%. There were no significant independent predictor factors for recurrent VTE, including duration of anticoagulation.

Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112

when we use the recommended values by the ADA. Results of HbA1c are shown in Table 1.

Table 1 Effect of duration of anticoagulation in recurrent VTE (adjusted) Months of anticoagulation <3 3–5 6–12 >12

S83

HR

CI 95%

1.11 1.11 1.15

0.60–2.04 0.69–1.78 0.74–1.80

P

0.944

IDF (< 6.5%) NICE(6.57.5%) ADA (<7%)

Good control

Bad control

47 (35.3%) 47 (35.3%) 73 (54.9%)

86 (64.7%) 86 (64.7%) 60 (45.1%)

Conclusions: Unprovoked venous thromboembolism has a high risk of recurrence after stopping anticoagulation. Three months of treatment achieves a similar risk of recurrent venous thromboembolism to a longer course of treatment. There are no other factors which help to predict a high or low risk of recurrence after stopping anticoagulation.

Conclusion: Prevalence of DM in patients admitted in IMD is high (37.4%). Regardless of the criteria consulted, the percentage of patients with good control of their illness is very poor, however it varies from 54.9 % (ADA) to 35.3% (IDF and NICE). The difference of gradation between these guidelines may influence the therapeutic decision during the clinical practice.

USEFULNESS OF HBA1C DETERMINATION IN DIAGNOSIS OF DIABETES MELLITUS IN PATIENTS ADMITTED TO INTERNAL MEDICINE

AL AMYLOIDOSIS MANIFESTING AS ISOLATED CARDIAC DISEASE – CASE REPORT AND THE REVIEW OF CASES OF PRIMARY AMYLOIDOSIS

Leticia Ruiz-Rivera, Andrés Ruiz-Sancho, Clara Lahoz García, Alfonso Lluna Carrascosa, Manuela Moreno Higueras, Marta García Morales, Jorge Parra Ruiz, Antonio Díez Ruiz. Department of Internal Medicine. San Cecilio University Hospital. Granada. Spain

Vânia Sá-Araújo1, Joaquim Andrade2, Teresa Antunes1. 1São João Hospital – Department of Internal Medicine, Porto, Portugal; 2São João Hospital – Department of Hematology, Porto, Portugal

Background: To identify non-diabetic patients admitted to in Internal Medicine (IM) Department fulfilling diagnostic criteria for diabetes mellitus (DM) or at high risk of DM by HBA1c determination. Methods: As part of a prospective study of early identification of people at risk of developing DM (which is currently ongoing), we have included all hospitalized patients in an IM ward. We elaborated an initial analysis of the data obtained from April to December 2010. HbA1c was determined in all of them. Patients with known history of DM were excluded. The rest of the patients were stratified in three groups according to HbA1c values. Results: until December 2010, 356 patients were screened and 223 (62.6%) were enrolled. Most of the patients (53.4%) were male with an average of 67.6 years of age. Results of HbA1c values are shown in the following table: HbA1c <5.7% 5.7-6.4% >6.5%

n

%

134 67 22

60.1 30 9,9

Conclusions: Among patients with no history of diabetes, 9.9% (22 persons) showed diagnostic criteria for DM (HbA1c > 6.5%) and 67 (30%) were at high risk of diabetes. Improving diagnostic accuracy, classification and therapy of DM in those patients would be translated into considerable clinical benefits. ADA recently included the HbA1c values as a diagnostic criteria of DM, as well as scoreboard of risk of future diabetes and cardiovascular disease. Routine determination of HbA1c would identify most of those patients at risk. GLYCATED HAEMOGLOBIN MONITORING IN A COHORT OF PATIENTS WITH DIABETES MELLITUS ADMITTED IN AN INTERNAL MEDICINE DEPARTMENT Andrés Ruiz-Sancho, Leticia Ruiz-Rivera, Alfonso Lluna Carrascosa, Clara Lahoz García, César Magro-Checa, Antonio Díez Ruiz. Department of Internal Medicine, Hospital Universitario San Cecilio. Granada, Spain. Background: HbA1c is the most widely used measure of chronic glycaemia. Several therapeutic guidelines on type 2 diabetes have been published in the last years. Objective: To assess the impact of three of these guidelines in the HbA1c on a group of Type 2 diabetic patients admitted in an Internal Medicine Department (IMD). Methods: We gathered clinical and laboratory data, including HbA1c and mean glucose levels, from 356 consecutive patients admitted in our IMD between April and December 2010 admitted under different reasons. For a correct metabolic control, classification was made according to recommended values by ADA, IDF and NICE guides. Results: Patients without history of DM were excluded and 133 patients were selected (37.4%); the average age was 76.43 years old and 57.1% of patients were female. According to IDF and NICE guides, only 35.3% of our patients had a good control of their illness; however this proportion rises to 54.9%

Background: Amyloidosis AL is an uncommon systemic disease characterized by deposition of insoluble fibrillar protein in different organs. It has been estimated that 5% of patients experience clinically isolated cardiac involvement. Methods: The authors present a case report of cardiac amyloidosis and review the cases of primary amyloidosis followed at our institution between 2000 and 2010. Results: A 76-year-old female patient presented to the emergency department with exertional dyspnea, in which a pericardial effusion was diagnosed. The investigation study was negative and as the symptoms improved, the patient was discharged. Two weeks later, she was admitted with acute heart failure. Electrocardiogram and echocardiogram raised the hypothesis of cardiac amyloidosis and the diagnosis was confirmed through endomyocardial biopsy. Laboratory parameters included an increase in cardiac biomarkers and a presence of a monoclonal gammopathy in immunoelectrophoresis. The patient was managed by chemotherapy associating bortezomid and dexamethasone. This entity gave reason for a review of the cases diagnosed at our department with primary amyloidosis. The study group included 18 men and 14 women with a mean age of 69 years. The most frequent presentation feature was renal. Cardiac involvement was suspected in 16 patients, but only 5 were confirmed through endomyocardial biopsy (8 patients are dead). Conclusion: Clinical signs of heart failure can be the presenting feature of amyloidosis, however, it remain undiagnosed due to the rarity and lack of suspicion on part of physician. Cardiac involvement represents the most important prognostic determinant, with a median survival of one year from diagnosis. AN OVERVIEW OF FAMILIAR TULAREMIA IN KOSOVO Izet Sadiku1, Arjan Harxhi2, Muharrem Bajrami1, Albina Ponosheci1, Merita Emini3. 1University Clinical Center of Kosovo,Clinic for Infection Disease,Prishtina,Kosovo; 2University Clinical Center of Albania, Clinic for Infection Disease,Tirana, Albania; 3University Clinical Center of Kosovo,Clinic for Internal Diseases,Prishtina, Kosovo Background: In 1999/2000 epidemic of tularemia was established for the first time in Kosovo and 22 cases were reported. Aim of our study is presentation of the familiar epidemics’ of tularemia in Kosovo during 2010-2011 and analysis of epidemiological, clinical, and treatment of tularemia in Kosovo. Methods: We have analyzed 4 family cases (included 8 patients) which were from the endemic regions of Kosovo. All the cases were from rural areas. We have analyzed data from their medical histories included anamnesis, physical examination, laboratory analyses and treatment. Results: 3 family cases were supplied with water only from wells one was supplied from two sources: form well and from city water supply. Mean age of patients was 21.25 years. Clinical manifestation were: lymphadenopathy, temperature, neck pain, neck lymphadenopathy, axillary and supraclavicular lymphadenopathy. Erythrocyte sedimentation rate was increased in all patients and hemogram was in normal values. The other biochemical analy-