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Coronavirus disease 2019 (COVID-19) is a new viral disease complicating with acute thrombophylic conditions, probably also via an inflammatory burden. Anticoagulants are efficacious, but their optimal preventive doses are unknown. The present study was aimed to compare different enoxaparin doses/kg of body weight in the prevention of clot complications in COVID-19 pneumonia. Retrospective data from a cohort of adult patients hospitalized for COVID-19 pneumonia, never underwent to oropharyngeal intubation before admission, were collected in an Internal Medicine environments equipped for non-invasive ventilation. Unfavorable outcomes were considered as: deep venous thrombosis, myocardial infarction, stroke, pulmonary embolism, cardiovascular death. Fourteen clinical thromboembolic events among 42 hospitalized patients were observed. Patients were divided into two group on the basis of median heparin dose (0.5 mg-or 50 IU-for kg). The decision about heparin dosing was patient by patient. Higher enoxaparin therapy (mean 0.62±0.16 mg/kg) showed a better thromboprophylactic action (HR=0.2, p=0.04) with respect to lower doses (mean 0.42±0.06 mg/kg), independently from the clinical presentation of the disease. Therefore, COVID-19 pneumonia might request higher enoxaparin doses to reduce thromboembolic events in hospitalized patients, even if outside intensive care units., Competing Interests: Competing interests: None declared., (© American Federation for Medical Research 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: In this study, we aimed to highlight the common early-stage clinical and laboratory variables independently related to the acute phase duration in patients with uncomplicated coronavirus disease (COVID-19) pneumonia., Methods: In hospitalized patients, the acute phase disease duration was followed using the Brescia-COVID respiratory severity scale. Noninvasive ventilation was administered based on clinical judgment. Patients requiring oropharyngeal intubation were excluded from the study. For parameters to be measured at the hospital entrance, age, clinical history, National Early Warning Score 2 (a multiparametric score system), partial pressure of oxygen in arterial blood/fraction of inspired oxygen (P/F ratio), C-reactive protein, and blood cell count were selected., Results: In 64 patients, age (direct relationship), P/F, and platelet number (inverse relationship) independently accounted for 43% of the acute phase duration of the disease (P < .001)., Conclusions: For the first time, the present results revealed that the acute phase duration of noncomplicated pneumonia, resulting from severe acute respiratory syndrome coronavirus 2, is independently predicted from a patient's age, as well as based on the hospital entrance values of P/F ratio and peripheral blood platelet count., (© 2020 The Authors. Journal of Medical Virology Published by Wiley Periodicals LLC.)

Background: In medical wards, to guarantee safe, sustainable and effective treatments to heterogeneous and complex patients, care should be graduated into different levels of clinical intensity based on a standardised assessment of acute-illness severity. To support this assumption, we conducted a prospective observational study on all unselected admissions of 3,381 patients to a medium size internal Italian Medicine Unit by comparing Standard Medical Care model (SMC) to a new paradigm of patient admission based on Intensity of Medical Care (IMC)., Methods: The SMC operated during 2013, while an IMC organizational model started in 2014. In SMC, patient's admission was performed according to bed availability only. In IMC, after the stratification of clinical instability performed using the National Early Warning Score (NEWS) and clinical judgment, patients were allocated to three different ward areas (high, middle, and post-acute medical care). We compared clinical and organizational outcomes of IMC patients (2015) to SMC patients (2013), performing adjusted logistic regression model., Results: We managed 1,609 and 1,772 patients using SMC and IMC, respectively. The IMC seemed to be associated to a lower risk of clinical worsening for patients. Comparing IMC to SMC, the odds ratio (aOR) for urgent transfers to intensive care units was 0.69 (p = 0.03), and for combination of urgent transfers and early deaths was 0.68 (p<0.01)., Conclusions: Redesigning the configuration of internal medicine ward to support urgency and competency of the clinical response by applying IMC paradigm based on the NEWS, improved outcomes in patients with acute illness and enhanced ward performances., Competing Interests: The authors have declared that no competing interests exist.

Aim: We aimed to assess the performance of the National Early Warning Score (NEWS) as tool for patient risk stratification at admission in an acute Internal Medicine ward and to ensure patient placement in ward areas with the required and most appropriate intensity of care. As secondary objective, we considered NEWS performance in two subgroups of patients: sudden cardiac events (acute coronary syndromes and arrhythmic events), and chronic respiratory insufficiency., Methods: We conducted a perspective cohort single centre study on 2,677 unselected patients consecutively admitted from July 2013 to March 2015 in the Internal Medicine ward of the hospital of Trento, Italy. The NEWS was mandatory collected on ward admission. We defined three risk categories for clinical deterioration: low score (NEWS 0-4), medium score (NEWS 5-6), and high score (NEWS≥7). Following adverse outcomes were considered: total and early (<72 hours) in-hospital mortality, urgent transfers to a higher intensity of care. A logistic regression model quantified the association between outcomes and NEWS., Results: For patients with NEWS >4 vs patients with NEWS <4, the risk of early death increased from 12 to 36 times, total mortality from 3.5 to 9, and urgent transfers from 3.5 to 7. In patients with sudden cardiac events, lower scores were significantly associated with higher risk of transfer to a higher intensity of care. In patients affected by chronic hypoxaemia, adverse outcomes occurred less in medium and high score categories of NEWS., Conclusions: National Early Warning Score assessed on ward admission may enable risk stratification of clinical deterioration and can be a good predictor of in-hospital serious adverse outcomes, although sudden cardiac events and chronic hypoxaemia could constitute some limits., (© 2017 John Wiley & Sons Ltd.)

Background: In order to evaluate the cost-effectiveness of coronary angiography performed in a low volume Center, we examined our 1-year activity., Methods: The organizational model of the multipurpose cardiac catheterization laboratory is described. In this type of facility both coronary angiographic and electrophysiological studies are performed. To evaluate the laboratory performance we examined the utilization level, the appropriateness of the studies, the complication rates and the number of studies that had to be repeated because of inadequate data or image quality. The costs were calculated for the in-house laboratory setting (the actual scenario) and for the 25 km distant laboratory setting (the historical scenario)., Results: The laboratory caseload of coronary angiography was 342 studies, 46% of the overall laboratory activity; 175 patients (51%) underwent non-pharmacological therapy, 129 patients (38%) were treated with medical therapy; the percentage of patients with normal coronary arteries was 11%. Two patients (0.58%) had vascular complications, 1 patient (0.29%) developed an acute myocardial infarction 2 hours after coronary angiography without any evidence of angiographic modifications at the repeated study. In no patient the study had to be repeated because of inadequate data or image quality. The mean cost of a coronary angiography was Lit. 512,000 (265 Euro) for the actual scenario; it would have been Lit. 694,000 (359 Euro) for the historical scenario, with Lit. 182,000 (94 Euro) saved., Conclusions: These findings are consistent with the accepted criteria of good laboratory performance and cost-effectiveness. Thus coronary angiography can be performed effectively and efficiently in a low volume Center.

Pulmonary embolism is a life-threatening condition that is accompanied by significant morbidity and mortality. In massive pulmonary embolism, where restoration of pulmonary arterial flow is urgently required, the only options available are surgical thromboembolectomy and/or thrombolytic therapy. Unfortunately, a large part of thromboembolic diseases is also considered as an absolute or relative contraindication to thrombolysis. The purpose of this paper was to emphasize the possibility of new thrombolytic agents of disregarding, according to circumstances, the contraindications to thrombolytic treatment.

Unlabelled: The aim of this paper is to report the first experience of pharmacological atrial defibrillation in humans via a temporarily occluded coronary sinus., Patients and Methods: In 6 patients (3 women, 3 men; mean age 57.8y, min 31, max 71), with clinical recurrences of atrial fibrillation, an occlusive coronary venogram was carried out in order to establish the origin of the Vein of Marshall. Atrial fibrillation was then induced by atrial pacing in all the patients and after an adequate waiting period to assure that the atrial fibrillation episode was persistent and stable, a bolus of a very low dose of an antiarrhythmic drug was delivered in 3-4 seconds into the temporarily balloon occluded coronary sinus near the orifice of the vein of Marshall. For both the venogram and the pharmacological test a Baim-Turi (USCI-Bard, Billerica MA) or a Vueport (Cardima, Fremont CA) catheter was used., Results and Comments: In five patients a single dose of 7 mg of propafenone was immediately effective in restoring the sinus rhythm. In the remaining patient 2 doses of 7mg of propafenone failed to interrupt the arrhythmia, which was subsequently interrupted by a bolus of 0.1mg of ibutilide fumarate given after a waiting period of 20 minutes. Retroperfusion of the left atrium could account for these results; in fact the Vein of Marshall has no valvular apparatus in contrast with other coronary sinus tributary veins which are equipped with an uni- or bicuspidal valve., Conclusions: Pharmacological atrial defibrillation with a minimal dose of an antiarrhythmic drug delivered near the orifice of the Vein of Marshall via the temporarily occluded coronary sinus is feasible and effective. This new pharmacological atrial defibrillation can offer interesting opportunities in developing an implantable pharmacological atrial defibrillator.

Acute pancreatitis and/or gallbladder disease precipitating angina pectoris, or producing arrhythmias or ST-T wave changes on electrocardiography in the absence of coronary artery disease, have frequently been mentioned. Many attempts have been made to explain the etiology of these findings. To the authors' knowledge, this report is the most dramatic expression of pathogenetic mechanisms which are still considered hypothetical.

Sixty-seven subjects with primary hypercholesterolemia were enrolled in an open study with "low dosages" of inhibitors of 3-hydroxy-3methylglutaril coenzyme A reductase. Patients were randomized in comparative and parallel study with simvastatin 10 mg (30 subjects) and pravastatin 20 mg (27 subjects) once in the evening for a treatment period of 12 months. At the end of the treatment the plasma concentrations of total and LDL cholesterol were reduced respectively by 21% (p < 0.001) and 29% (p < 0.001), plasma triglyceride concentration was reduced by 16%, high density lipoprotein (HDL) was increased by 2.9%. The efficacy of drugs was increasing during the study: at the third month 63% of subjects and at the twelfth month 89% of subjects showed a LDL < 160 mg/dL. In this study the drugs were well-tolerated, but 11 subjects showed a slight and transitory increase of CK. A treated group with simvastatin showed a similar decrease of the total cholesterol and LDL as that one treated with pravastatin. Pravastatin in comparison with simvastatin reduced significantly plasma triglycerides. There was no significant difference between the groups in the frequency of drug-related adverse effects. In conclusion "low dosages" of simvastatin and pravastatin in long term treatment were very efficacious in the reduction of total and LDL cholesterol. In our study, the decrease of total and LDL cholesterol was time-dependent, with the greatest reduction after sixth months. There were no significant differences between 10 mg of simvastatin and 20 mg of pravastatin on reduction of total and LDL cholesterol levels. Triglycerides decreased significantly only with pravastatin.

Cushing's disease and empty sella without evidence of pituitary adenoma are rarely observed. To our knowledge, there is very little documentation on long-term therapeutic follow-up with the steroidogenesis inhibitor ketoconazole. A 48-year-old woman with uncontrolled insulin-dependent diabetes mellitus, severe hypertension, and clinical findings of hypercortisolism was referred to our hospital. Endocrine evaluation of adrenocortical function evidenced hypothalamic-pituitary-hypercortisolism, and excluded adrenal tumor or an ectopic corticotropin source. Magnetic resonance imaging disclosed an empty sella turcica but not pituitary adenoma. The patient was treated with a steroidogenesis inhibitor, ketoconazole (600 mg daily) which reduced urinary cortisol excretion to within the normal range. Serum cortisol levels also returned to normal in the morning but not in the evening. The patient has continued on ketoconazole therapy for the past 7 years, with neither side effects nor tachyphylaxis. The reduction of cortisol secretion brought about significantly improved control of diabetes mellitus and hypertension, although signs of hypercortisolism have persisted. Radiographic studies of the hypophysis during follow-up have not evidenced adenoma.

In a clinical case of arterial hypertension with hypopotassiaemia and hyporeninaemic hypoaldosteronism due to the use of a dermatological cream containing 9-alpha-fluoroprednisolone, late identification of the iatrogenic cause forced attention on the differential diagnosis of the less frequent hyporeninaemic hypoaldosteronism.

A 34-year man was admitted to the hospital with symptoms of hypoglycemia. The endocrine investigations indicated adrenocortical insufficiency secondary to isolated ACTH deficiency: low ACTH and cortisol plasma levels, significant increase of cortisol following prolonged stimulation with depot tetracosactrin, normal secretory reserve of other anterior pituitary hormones. The absence of ACTH-response after corticotropin releasing hormone and insulin tolerance tests suggested a primary impairment of corticotropin cells.

AGAPE (Computer-based Outpatients' Clinic Programme) is a programme for IBM-compatible microcomputers realised by physicians for the management of hypertensive patients. The programme is planned to make the operators' work complete and expeditious while, at the same time, respecting the standard formulation of the clinical approach to the patient. The collection, organisation, recording and communication of data are handled on line by the programme under the operator's control. Special attention has been given to the control of the quality of the data collected as well as to their easy use for clinical, research and statistical purposes. This programme was used for 52 months in a hypertension clinic where physicians and nurses work jointly. Up to April 1989, 1924 new patient visits and 10,639 control visits together with 3,375 groups of lab tests were inserted. The mean training time for new operators was 3.2 hours; the mean data insertion time was 12.5 minutes for the first visit, 3 minutes for the subsequent visits and 2.5 minutes for lab tests. The drop-outs, evaluated at one-year follow-up on each 250 patients before and after the introduction of the computerized system, were 84/250 and 64/250 respectively (p less than 0.05), with a trend to wards the better control of hypertension (diastolic blood pressure less than 90 mmHg, 128/250 vs 143/250, n.s.).

Serum calcitonin (CT) concentrations were determined in 96 heroin addicts. CT levels were assayed by radioimmunological method employing two antisera, one vs. the 17-32 fraction (IMN) of the human CT, the other vs. the 11-32 fraction (B7). In heroin addicts the CT mean values were significantly higher (P less than 0.001) than in normal subjects (141 +/- 16.0 and 292 +/- 21.7 pg/ml with IMN-antiserum and with B7-antiserum, respectively, in heroin addicts; 64 +/- 7.8 and 189 +/- 21.7 pg/ml in controls). Serum CT levels assayed with B7-antiserum were notably higher (P less than 0.001) both in controls and in heroin addicts. Our results draw attention to the heterogeneity of high ICT values found in heroin addicts.

Serum calcitonin (CT) and prolactin (PRL) levels were determined in 21 heroin addicts in hospital treatment with methadone. After withdrawal of heroin the values of CT 112.4 +/- 62.9 pg/ml, and PRL 19.1 +/- 10.1 ng/ml were both significantly higher (P less than 0.001) than in normal controls (62.2 +/- 43.8 pg/ml and 9.1 +/- 3.5 ng/ml, respectively). After withdrawal of methadone, i.e. 12 +/- 3.7 days after heroin withdrawal, CT values were 76.6 +/- 32.7 ng/ml (a significant level of P less than 0.02 towards initial values). No correlation was noted between CT and PRL values.

Prolactin (PRL) and thyrotropin (TSH) serum levels were determined in a group of young female heroin addicts treated in hospital with methadone in tapered doses. At admission, from 24 to 3 h after the last dose of 'street' heroin, basal PRL values were 21 +/- 2.6 ng/ml, i.e. significantly higher (P less than 0.001) than in controls: 9.8 +/- 0.7; there was no significant differences of basal TSH values between heroin addicts and normal subjects: 2.5 +/- 0.2 vs. 2.2 +/- 0.1 mu units/ml, respectively. The day after admission, when methadone treatment was begun, the PRL and TSH pituitary response to thyrotropin releasing hormone (TRH) 200 micrograms i.v. in 12 patients was studied. The PRL response was significantly reduced (P less than 0.001) in heroin addicts vs. controls, the mean values of highest percent increments over basal were 368 +/- 41.8 and 847 +/- 80.7, respectively. The TSH response in the two groups was similar, the mean highest per cent increment over basal 393 +/- 53.4 in heroin addicts vs. 367 +/- 39.2 in controls. The increase of the PRL basal concentration and its decreased pituitary response following TRH were probably related to a change in the tuberoinfundibolar dopaminergic system (TIDA) because of a chronic intake of opiates whereas the impaired function of the dopaminergic system did not alter the thyrotropin pituitary secretion.