Papers by Daniela Tirotta
Introduction. Systemic amyloidosis AL is unusual disease that is heterogeneous in presentation. C... more Introduction. Systemic amyloidosis AL is unusual disease that is heterogeneous in presentation. Clinical case. We present a case of systemic amyloidosis AL with unusual cardiac, mesenteric, renal, peritoneal and gastrointestinal involvement, in which the diagnostic hypothesis was formulated on the basis of problem solving and ultrasound (abdomen, lung, heart US).Conclusion. This case shows that multi-organ ultrasound, associated with problem solving, may be of very helpful in the diagnosis of systemic diseases, even unusual ones and even associated to non-specific clinical aspect, avoiding a long diagnostic interval length.
Il metodo clinico rivisitato, 2006
ABSTRACT La malattia infiammatoria pelvica (PID), presente nell’1–2% delle donne sessualmente att... more ABSTRACT La malattia infiammatoria pelvica (PID), presente nell’1–2% delle donne sessualmente attive, comprende un ampio spettro di disordini del tratto genitale superiore femminile, quali una combinazione di endometriti, salpingiti, ascessi tubo-ovarici, parametriti, peritonite pelvica e periepatite (Fitz-Hugh-Curtis syndrome).
Il metodo clinico rivisitato, 2006
ABSTRACT Un ottimale assetto lipidico prevede valori di colesterolo totale (TC) < 200 mg/d... more ABSTRACT Un ottimale assetto lipidico prevede valori di colesterolo totale (TC) < 200 mg/dl, Low-Density Lipoprotein Cholesterol (LDL-C) 1, High-Density Lipoprotein Cholesterol (HDL-C) > 40 mg/dl, trigliceridi (TG) < 150 mg/dl. TL e HDL-C possono essere misurati non a digiuno, mentre TG e LDL-C sono maggiormente influenzati dal recente introito alimentare e possono essere ricavati dall’equazione di Friedewald: LDL-C= TC − (HDLC+TG/5).
Italian Journal of Medicine, 2014
Rheumatology International, 2010
For several years is described a non-random association between sarcoidosis and solid or hematolo... more For several years is described a non-random association between sarcoidosis and solid or hematological tumors. We present a case in which a patient with pulmonary sarcoidosis developed polycythemia vera few months later. A review of literature shows that sarcoidosis precedes neoplasms and tends to be a chronic active variety. Our case, by contrast, has been responsive to steroid therapy.
Digestive and Liver Disease, 2008
BMC Infectious Diseases
An amendment to this paper has been published and can be accessed via the original article.
Clinical Therapeutics, 2008
Background: Despite the high incidence of acute pyelonephritis in the community setting, there is... more Background: Despite the high incidence of acute pyelonephritis in the community setting, there is no consensus on the optimal duration of treatment. A potential reduction in the duration of the administered antibiotic regimens could contribute to avoiding further development of antimicrobial resistance. Objective: The aim of this meta-analysis was to compare short-course (7-to 14-day) with long-course (14to 42-day) treatment with the same antibiotic regimens, in terms of the effectiveness and tolerability, in acute pyelonephritis. Methods: We searched PubMed, Cochrane Central Register of Controlled Trials, and SCOPUS (January 1966-March 2008) to identify and extract data from randomized controlled trials (RCTs) comparing the effectiveness and toxicity of short-versus long-course regimens. Additionally, references of studies were searched. A publication was included if: it was an RCT; involved adult and/or adolescent patients with acute pyelonephritis; compared regimens with the same antibiotic, at the same daily dosage, that were administered for differing durations (a short course and a long course [ie, no absolute time cutoff (in days) was employed; rather, the duration of one regimen compared with another defined short-vs long-course]); and reported data regarding clinical success, bacteriologic efficacy, relapses, recurrences, and adverse events and/or patient withdrawals due to adverse events. Trials with a mixed population, including patients with acute pyelonephritis as a subset, were also included in the metaanalysis. Efficacy was assessed by evaluating clinical success, defined as resolution of symptoms and signs at the test-of-cure visit, and bacteriologic efficacy, defined as yielding sterile urine cultures or positive cultures with <10 3 colony-forming units per milliliter of urine at the test-of-cure visit. Tolerability was assessed by extracting data for adverse events. Results: According to our initial search, 205, 136, 179, and 73 potentially relevant articles were retrieved from PubMed, Cochrane Central Register of Controlled Trials, SCOPUS, and references of evaluable trials, respectively. Four RCTs were eligible for inclusion in the meta-analysis. Significant differences were not found between the short-and long-course treatment of acute pyelonephritis in terms of clinical success (odds ratio [OR], 1.27; 95% CI, 0.59-2.70), bacteriologic efficacy (OR, 0.80; 95% CI, 0.13-4.95), and relapse (OR, 0.65; 95% CI, 0.08-5.39). Also, significant differences were not found between the short-and long-course treatments regarding adverse events (OR, 0.64; 95% CI, 0.33-1.25), withdrawals due to adverse events (OR, 0.65; 95% CI, 0.28-1.55), and recurrences (OR, 1.39; 95% CI, 0.63-3.06). Conclusion: This meta-analysis failed to identify any significant differences, with regard to effectiveness and tolerability, between short-and long-course treatment with the same antibiotic.
QJM, 2017
Background: Due to aging and resources limitation, septic patients are often admitted to medical ... more Background: Due to aging and resources limitation, septic patients are often admitted to medical wards (MWs). Early warning deterioration is a relevant issue in this setting. Unfortunately, a suitable prognostic score has not been identified, yet. Aim: To explore the ability of Modified Early Warning Score (MEWS) to predict the in-hospital mortality in septic patients admitted to MWs. Design: Secondary analysis of a multicentric prospective study. Methods: Consecutive septic patients with positive blood culture admitted to 31 Italian MWs were included. Baseline characteristics, clinics, isolates, rate of transfer to ICU, MEWS was collected on admission according to the study protocol. The accuracy of MEWS in predicting the in-hospital mortality was assessed with the area under the receiver-operating characteristic curves. Sensitivity, specificity, positive and negative predictive value (PPV and NPV), likelihood ratio (LR) were calculated for different MEWS cutoffs and age/comorbidities subgroups. Results: In total 526 patients were included in this analysis. Median MEWS was (range 0-11). In-hospital mortality was 14.8% and transfer to ICU 1.3%. Mortality progressively increased according to MEWS (3% in MEWS 0 vs. 27% in MEWS >5; Chi square for trend P < 0.05). The AUC of MEWS in predicting in-hospital mortality was 0.596 (95% CI, 0.524, 0.669). MEWS did not appear to have an adequate sensitivity, sensibility, PPV, NPV and LR both in the whole population and in the pre-specified subgroups. Conclusions: Our findings do not seem to support the use of MEWS to predict the in-hospital mortality risk of sepsis in MWs.
International Journal of Clinical and Medical Cases, 2018
The internists should utilize both their clinic experience and medical literature's evidences, me... more The internists should utilize both their clinic experience and medical literature's evidences, mediating with organizational context, patients' opinion and ethics. However, none of these components may be sufficient. In several medical sectors, we may find many and extensive grey zones in which a diagnostic intervention's effectiveness and/or its alternatives are uncertain. This cannot lead to the decision-making process's paralysis, because the evidencebased medicine requires to base any clinical decision on "the best available evidences" and not on "the best possible evidences." Clinicians should be able to extrapolate the prevailing question structuring from patients' problem (PICO: problem, intervention, confront, outcome); identify the best available evidence and synthesize it; perform critical evaluation and information transfer (critical appraisal); in clinical efficiency, evaluate any action options.
Efficacy and costs of the diagnostic process have been under extensive investigation for a long t... more Efficacy and costs of the diagnostic process have been under extensive investigation for a long time. In this study we present a detailed, retrospective analysis of the clinical and economic aspects of 347 diagnostic admissions in a teaching hospital. We have, furthermore, investigated the clinical history of a group of 50 patients, from the beginning up to one year after definitive diagnosis, through a structured questionnaire. The results shed some light onto efficacy, cost-effectiveness and cost-profit balance of diagnostic admissions. Strategies to improve efficacy and cost-effectiveness are discussed.
BMC Infectious Diseases
Background The burden of cardiovascular (CV) complications in patients hospitalised for community... more Background The burden of cardiovascular (CV) complications in patients hospitalised for community-acquired pneumonia (CAP) is still uncertain. Available studies used different designs and different criteria to define CV complications. We assessed the cumulative incidence of acute of CV complications during hospitalisation for CAP in Internal Medicine Units (IMUs). Methods This was a prospective study carried out in 26 IMUs, enrolling patients consecutively hospitalised for CAP. Defined CV complications were: newly diagnosed heart failure, acute coronary syndrome, new onset of supraventricular or ventricular arrhythmias, new onset hemorrhagic or ischemic stroke or transient ischemic attack. Outcome measures were: in-hospital and 30-day mortality, length of hospital stay and rate of 30-day re-hospitalisation. Results A total of 1266 patients were enrolled, of these 23.8% experienced at least a CV event, the majority (15.5%) represented by newly diagnosed decompensated heart failure, a...
SN Comprehensive Clinical Medicine
Cat scratch disease (CSD) is a disease usually characterized by self-limited lymphadenopathy of t... more Cat scratch disease (CSD) is a disease usually characterized by self-limited lymphadenopathy of the young man. Rarely CSD, however, can manifest itself as an unusual hepatosplenic form (HS-CSD) in immunocompetent patients. HS-CSD diagnosis is generally based on clinical features, imaging, and serologies, but sensitivity of serologies is very variable, like that of other diagnostic methods, as Warthin-Starry silver stain and isthology. Also there are no specific markers for the follow-up. The use of the CEUS (abdominal contrast-enhanced ultrasound) in HS-CSD is not previously described in literature examined, but we think that CEUS can be of help to diagnosis and follow-up of these patients, even after an initial CT scan, because it is a sensitive method, as seen in other diseases associated with granulomas, such as sarcoidosis. We describe 2 new cases of HS-CSD, and we performed a systematic review of the clinical cases reported in the past 10 years in the literature associated to an analysis of clinical, diagnostic, and therapeutic aspects of the disease. Keywords Cat scratch disease. Immunocompetent patient. Hepatosplenic cat scratch disease. Abdominal contrast-enhanced ultrasound. Diagnosis. Follow-up This article is part of the Topical Collection on Medicine
Italian Journal of Medicine
Celiac disease (CD) is a complex polygenic disorder, which involves genetic factors human leukocy... more Celiac disease (CD) is a complex polygenic disorder, which involves genetic factors human leukocyte complex (HLA) and non-HLA genes, environmental factors, innate and adoptive immunity, and a robust chronic T-mediated autoimmune component. The main goal of the present monograph is to define a methodological approach for the disease, characterized by frequent late diagnosis, in order for the physician to become aware of the disease management, the diversity of the clinical presentation itself and in different patients. A unique attention is payed to the specific diagnostic tests to define a correct and accurate application of them, and in addition, to disease follow-up and possible complications. Moreover, a dedicated space is assigned to refractory CD, to potential CD and non-celiac gluten sensitivity. Legislative aspects of the celiac disease in Italy are addressed, too. The celiac disease guidelines and their evaluation by means of Appraisal of Guidelines, Research and Evaluation ...
Italian Journal of Medicine
Edema is defined as a palpable swelling caused by an increase in interstitial fluid volume. Leg e... more Edema is defined as a palpable swelling caused by an increase in interstitial fluid volume. Leg edema is a common problem with a wide range of possible causes and is the result of an imbalance in the filtration system between the capillary and interstitial spaces. Major causes of edema include venous obstruction, increased capillary permeability and increased plasma volume secondary to sodium and water retention. In both hospital and general practice, the patient with a swollen leg presents a common dilemma in diagnosis and treatment. The cause may be trivial or life-threatening and it is often difficult to determine the clinical pathway. The diagnosis can be narrowed by categorizing the edema according to its duration, distribution (unilateral or bilateral) and accompanying symptoms. This work provides clinically oriented recommendations for the management of leg edema in adults.
Italian Journal of Medicine, Sep 11, 2017
Edema is defined as a palpable swelling caused by an increase in interstitial fluid volume. Leg e... more Edema is defined as a palpable swelling caused by an increase in interstitial fluid volume. Leg edema is a common problem with a wide range of possible causes and is the result of an imbalance in the filtration system between the capillary and interstitial spaces. Major causes of edema include venous obstruction, increased capillary permeability and increased plasma volume secondary to sodium and water retention. In both hospital and general practice, the patient with a swollen leg presents a common dilemma in diagnosis and treatment. The cause may be trivial or life-threatening and it is often difficult to determine the clinical pathway. The diagnosis can be narrowed by categorizing the edema according to its duration, distribution (unilateral or bilateral) and accompanying symptoms. This work provides clinically oriented recommendations for the management of leg edema in adults.
Italian Journal of Medicine, Nov 28, 2017
Definition Celiac disease (from Greek κοιλια, abdomen, belly) is a permanent autoimmune food into... more Definition Celiac disease (from Greek κοιλια, abdomen, belly) is a permanent autoimmune food intolerance, which is triggered, in genetically predisposed subjects, by gluten ingestion 1 of the protein wheat fraction alcohol-soluble. The main gluten protein is gliadin, distinguished into 4 different types, based on the electrophoretic mobility (α, β, γ, ω). The disease consists of an immune reaction against gluten, which mainly strikes the small intestine of the genetically predisposed subjects and usually disappears with gluten-free diet. 2 In 2012 the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines highlighted the CD definition change through the years, from a rare enteropathy to a frequent multi-organ and multi-factor disease, characterized by a genetic predisposition related to human leukocyte complex (HLA)-DQ2 and HLA-DQ8 histocompatibility complex. 3 Gastrointestinal (abdominal pain, constipation and/or diarrhea, nausea and vomit, abdominal re
Italian Journal of Medicine
Our study is a benchmarking on acute pancreatitis, managed in three different Medical Units. The ... more Our study is a benchmarking on acute pancreatitis, managed in three different Medical Units. The aim of benchmarking is to optimize time and resources by comparing sufficiently homogeneous reality, to identify areas for improvement and to plan appropriate strategies correction. The observation of heterogeneity in terms of clinical aspects and costs in our hospitals, performed through <em>benchmarking</em>, despite our limited case histories, might provide new ideas for future implementation.
Clinical Management Issues, 2009
Idiopathic thrombocytopenic purpura (ITP) is a disorder characterized by accelerated destruction ... more Idiopathic thrombocytopenic purpura (ITP) is a disorder characterized by accelerated destruction of platelets. About 25 to 30% of patients with ITP are resistant to standard treatment. Recent reports suggest that rituximab may be useful in treating chronic refractory ITP. We report a case of a 72-year-old woman with ITP resistant to standard treatment with steroids (prednisone 2 mg/kg for 2 weeks, followed by prednisone 1 mg/kg) and intravenous immunoglobulin (0,5 mg/kg for 5 days). An infection by Helicobacter pylori was eradicated; afterwards she was treated with rituximab 375 mg/m2, once weekly for four weeks, resulting in a complete long-lasting response. Rituximab could represent a satisfactory alternative to the splenectomia in the adults with ITP; in our case the remission is complete (stable platelets > 200 x 109 after 8 months), early (before the fourth dose) and sustained (follow-up 18 months).
Italian Journal of Medicine, 2016
Delirium is a neuropsychiatric sindrome characterized by acute onset, a fluctuating course, an al... more Delirium is a neuropsychiatric sindrome characterized by acute onset, a fluctuating course, an altered level of consciousness, disturbances in orientation, memory, attention, thinking, perception and behaviour. One third of patients aged 70 or older were admitted to the general medical service of an acute care hospital experience delirium. The development of delirium is associated with worse outcome increased a 10-fold risk for death and a 3- to 5-fold risk for nosocomial complications, prolonged length of stay, and greater need for nursing home placement after discharge. Therefore patients with delirium have higher morbidity and mortality rates, higher re-admission rates, and a greater risk of long term institutionalization care, thereby having a significant impact on both health and social care expenditure. The cost of delirium to the health-care system is then substantial. Despite its clinical importance and health-related costs, it often remains under-recognized and inadequately...
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Papers by Daniela Tirotta