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BACKGROUND: Syncope due to orthostatic hypotension (OH) refers to loss of consciousness caused by hypotension induced by the upright position; it is an important risk factor for fall-related physical injuries, especially in the elderly adults. We evaluated the prevalence of OH syncope and the clinical characteristics of patients older than 65 years with syncope due to OH in the Evaluation of Guidelines in Syncope Study 2 group population. METHODS: Two hundred fifty nine patients older than 65 years consecutively admitted to the emergency department because of loss of consciousness in a period of a month were submitted to a standardized protocol approved by the European Task Force for the diagnosis of syncope; all the patients were studied by a trained physician who interacted with a central supervisor as the management of syncope was concerned, using a decision-making software. RESULTS: Prevalence of OH syncope was 12.4%. Patients with OH syncope were more likely to be affected by Parkinson's disease and by other neurological diseases. ST changes and longer values of QTc were found in OH syncope group, and they took a greater number of diuretics, nitrates, and digoxin. In multivariate analysis, Parkinson's disease (p = .001) and use of nitrates (p = .001) and diuretics (p = .020) were independently related to OH syncope. CONCLUSIONS: In patients older than 65 years, Parkinson's disease and neurological comorbidity are strictly related to OH syncope. Moreover, this study suggests the independent link between OH syncope and the use of vasoactive drugs, identifying the majority of cases as adverse drug reaction, a preventable risk factor for syncope and falls in the older population. [ABSTRACT FROM AUTHOR]

Background The guidelines of the European Society of Cardiology define the best current standard for the management of syncope Methods Prospective systematic evaluation on strict adherence to the guidelines of consecutive patients referred for syncope to the emergency departments of 11 general hospitals. In order to maximize the application, a decision making guideline-based software and the designation of trained core medical personnel – both locally in each hospital and centrally – who verified the adherence to the diagnostic pathway and eventually gave advices for its correction were utilized. Results A diagnostic work-up consistent with guidelines was completed in 465/541 patients (86%). A definite diagnosis was established in 98% (unexplained in 2%): neurally-mediated syncope was found in 66%, orthostatic hypotension in 10%, primary cardiac arrhythmias in 11%, structural cardiac or cardiopulmonary disease in 5% and non-syncopal attacks in 6%. The initial evaluation (consisting in history, physical examination and standard electrocardiogram) established a diagnosis in 50% of cases. Hospitalization for the management of syncope was appropriate in 25% and was required for other reasons in a further 13% of cases. The median in-hospital stay was 5 days (interquartile range 3-9). Apart from the initial evaluation, a total of 358 appropriate tests were performed in 193 patients (mean 1.9±1.1 per patient). Conclusion Guidelines can be implemented in the clinical practice provided that they are carefully and systematically applied. The results of this study assess the current standard for the management of syncope. [ABSTRACT FROM PUBLISHER]

Rituximab is a murine/human chimeric monoclonal antibody directed against the CD20 antigen. It is widely used in combination with polychemotherapy regimens for the treatment of hematological disorders. There is no evidence of direct cardiotoxicity of the drug but a few cases of cardiovascular adverse events have been reported in the literature. We report on two patients affected by stage IV non-Hodgkin lymphoma with bone marrow infiltration and peripheral blood involvement who experienced cardiovascular accidents temporally related to rituximab infusion. In both cases the monoclonal antibody was administered in association with a polychemotherapy regimen but administration was postponed several days later in order to avoid severe cytokine release syndrome because of the high tumor burden. The first case concerns an episode of atrial fibrillation in a patient with a diagnosis of small B-cell lymphoma. The episode happened immediately after rituximab infusion. In the second case there was an episode of chest pain associated with fever and chills during rituximab infusion in a patient with a diagnosis of mantle cell lymphoma. In both cases we noticed an unusual correlation between symptom recurrence and the speed of rituximab infusion. Both patients presented several cardiovascular risk factors but preliminary cardiac function assessment excluded signs of heart dysfunction. The pathogenesis of cardiovascular events during rituximab infusion remains unclear. A key role might be played by cytokine release from B cells as a consequence of rituximab activity. Moreover, pre-existing silent cardiac damage could be co-responsible for the clinical manifestations we reported. We consider our clinical experience relevant because it raises an issue of good clinical practice: despite rituximab's good tolerability profile, patients with cardiovascular risk factors should undergo accurate cardiac assessment so that silent heart disease can be detected. If the suspicion of cardiac damage is high, more extensive cardiac assessment is recommended.

For more than 20 years erythropoietin (rHEPO) has largely been used to treat anemia in myelodysplastic syndromes (MDS). Early clinical trials showed erythroid responses in no more than 15-25% of patients. In the last decade, a better selection of MDS patients suitable for a therapeutic challenge with rHEPO, alone or in combination with G-CSF, allowed for an increased response-rate, averaging around 40%. More recently, an even higher percentage of responses have been obtained using higher-doses of rHEPO (up to 80,000 IU/weekly) in lower-risk MDS patients. This treatment however, especially at such high doses, is costly and not easily affordable for prolonged periods. The aim of this study was to verify if the use of "standard" doses of rHEPO could induce a satisfying response-rate with a less expensive treatment schedule in IPSS-defined "lower-risk" MDS anemic patients. From January 2005 to December 2009 a total of 55 consecutive anemic (Hb ≤ 10 g/dL) patients (29 males, 26 females, median age 78 years) with low-intermediate-1 risk MDS were treated after informed consent with rHEPO (40,000 IU once a week subcutaneously) for at least 3 months; at the end of this period, erythroid response was assessed, and responders were allowed to continue the treatment indefinitely, whereas non-responders were considered "off study". Both efficacy and safety of the treatment were recorded and evaluated. After 3 months of treatment, 36 out of 55 (65.5%) patients achieved an erythroid response to rHEPO according to IWG 2006 criteria. Higher response-rates to rHEPO were related with both lower IPSS and particularly WPSS scores. Treatment was safe, and only 1 patient had to discontinue the treatment because of unmanageable side-effects. Among the 36 responders, 28 (77%) maintained the response after a median follow-up of 46 months. Our data indicate that standard doses of rHEPO are at least as effective as higher-doses for correcting anemia in lower-risk MDS patients; in this clinical scenario, this schedule allows for a consistent reduction of costs without precluding the achievement of a durable erythroid response., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Aims: The study hypothesis was that a decision-making approach improves diagnostic yield and reduces resource consumption for patients with syncope who present as emergencies at general hospitals., Methods and Results: This was a prospective, controlled, multi-centre study. Patients referred from 5 November to 7 December 2001 were managed according to usual practice, whereas those referred from 4 October to 5 November 2004 were managed according to a standardized-care pathway in strict adherence to the recommendations of the guidelines of the European Society of Cardiology. In order to maximize its application, a decision-making guideline-based software was used and trained core medical personnel were designated-both locally in each hospital and centrally-to verify adherence to the diagnostic pathway and give advice on its correct application. The 'usual-care' group comprised 929 patients and the 'standardized-care' group 745 patients. The baseline characteristics of the two study populations were similar. At the end of the evaluation, the standardized-care group was seen to have a lower hospitalization rate (39 vs. 47%, P=0.001), shorter in-hospital stay (7.2+/-5.7 vs. 8.1+/-5.9 days, P=0.04), and fewer tests performed per patient (median 2.6 vs. 3.4, P=0.001) than the usual-care group. More standardized-care patients had a diagnosis of neurally mediated (65 vs. 46%, P=0.001) and orthostatic syncope (10 vs. 6%, P=0.002), whereas fewer had a diagnosis of pseudo-syncope (6 vs. 13%, P=0.001) or unexplained syncope (5 vs. 20%, P=0.001). The mean cost per patient and the mean cost per diagnosis were 19 and 29% lower in the standardized-care group (P=0.001)., Conclusion: A standardized-care pathway significantly improved diagnostic yield and reduced hospital admissions, resource consumption, and overall costs.

Aims: The guidelines of the European Society of Cardiology (ESC) define the current standard for the management of syncope, but are still incompletely applied in the clinical setting., Methods and Results: Prospective systematic evaluation, on strict adherence to the guidelines, of consecutive patients referred for syncope to the emergency departments of 11 general hospitals. In order to maximize the application, a decision-making guideline-based software was used and trained core medical personnel were designated-both locally in each hospital and centrally-to verify adherence to the diagnostic pathway and give advice on its correction. A diagnostic work-up consistent with the guidelines was completed in 465/541 patients (86%). A definite diagnosis was established in 98% (unexplained in 2%): neurally mediated syncope accounted for 66% of diagnosis, orthostatic hypotension 10%, primary arrhythmias 11%, structural cardiac or cardiopulmonary disease 5%, and non-syncopal attacks 6%, respectively. The initial evaluation (consisting of history, physical examination, and standard electrocardiogram) established a diagnosis in 50% of cases. Hospitalization for the management of syncope was appropriate in 25% and was required for other reasons in a further 13% of cases. The median in-hospital stay was 5.5 days (interquartile range, 3-9). Apart from the initial evaluation, a mean of 1.9+/-1.1 appropriate tests per patient was performed in 193 patients and led to a final diagnosis in 182 of these (94%)., Conclusion: The results of this study assess the current standard for the management of syncope on the basis of a rigorous adherence to guidelines of the ESC and provide a frame of reference for daily activity when dealing with syncope.

Unlabelled: OBJECTIVE; To evaluate the results of a large cohort of non-responder or relapsing responder patients with chronic hepatitis C retreated with various schedules of interferon (IFN)., Methods: Our study included 276 patients (158 non-responders and 118 relapsing responders) who underwent IFN retreatments. Among the non-responder group, 158 patients underwent further courses of IFN. In particular, 108 patients underwent one course of IFN retreatment, 40 patients underwent two courses, eight patients underwent three courses, and two patients underwent four courses. Regarding the relapsing responder group, the 118 patients were retreated with the same dosage for varying periods. In particular, 50 patients were treated for 6 months, 43 patients for 12 months, and 25 for 24 months. Patients in the subgroups of IFN retreatment were homogeneous as far as age and gender distribution, as well as virological and histological characteristics, are concerned. Qualitative and quantitative HCV-RNA was evaluated at baseline, at the end of treatment and at the last check-up of follow-up. HCV genotype was determined on baseline serum samples. Alanine transaminase (ALT) levels were tested monthly., Results: Long-term biochemical (normal ALT levels) and virological (HCV-RNA negative) response was obtained in 2.6% of non-responder retreated patients, and in 33.9% of relapsing responder retreated patients. Evaluation of response on the basis of the duration of treatment showed that 48%, 19% and 16% of relapsing responder patients retreated for 24, 12 and 6 months, respectively, obtained long-term biochemical and virological response., Conclusion: Non-responder patient retreatment is inefficient especially in cirrhotic and/or genotype 1 b patients. IFN retreatment is warranted in relapsing responder patients. In particular, 24-month therapy induces significant long-term biochemical and virological response.

In order to assess the efficacy of alpha-2b interferon (r-IFN) in the treatment of non-A non-B chronic hepatitis, 30 patients were randomised to receive r-IFN (3 MU subcutaneously three times a week for 24 weeks) or no therapy. A total of 21 males and 9 females, aged between 24-66 years old and who had had increased transaminase levels for at least one year, were included in the study. Three patients were ex-drug addicts and 6 had received blood transfusions whereas the cause of the infection in the remaining 21 patients was unknown. Hepatic biopsies performed prior to the study revealed persistent chronic hepatitis in 7 patients, active chronic hepatitis (ACH) in 19 patients and ACH with hepatic cirrhosis in 4 patients. Anti-HCV antibodies were present in 21 patients (70%). Transaminase values returned to normal in 11 (73%) of the 15 patients treated and remained unchanged in controls after 6 months of therapy. During the 18-month follow-up following the suspension of r-IFN treatment, transaminase values rose again to pre-treatment levels in 4 patients. Anti-HCV antibodies did not disappear in any of the patients who responded to therapy.

The present study was designed to evaluate the patients with transient loss of consciousness who are seen in the emergency room and the ways in which they are currently triaged and evaluated, to determine the risk factors influencing their prognosis, and to analyze the aspects of diagnostic evaluation that are most useful. We made a retrospective study of 391 patients with transient loss of consciousness seen at the emergency room of S. Martino hospital. The causes of loss of consciousness, admission decision, diagnostic tests ordered, initial and final diagnoses and mortality are evaluated. The admission decision was influenced by three factors: cause of loss of consciousness, presence of chronic disease, and patient age. The same factors were shown to influence mortality. Full concordance between initial and final diagnosis was only 50 per cent. In 18.6 per cent of patients the cause of loss of consciousness was not identified at dismissal. The history and physical examination were crucial elements in the evaluation of most patients, and only in selected cases did tests such as electrocardiogram, Holter monitoring, electroencephalogram, computerized tomography scan provide diagnostic information.