Are multiple-choice questions a good tool for the assessment of clinical competence in Internal Medicine?

There are many feasible tools for the assessment of clinical practice, but there is a wide consensus on the fact that the simultaneous use of several different methods could be strategic for a comprehensive overall judgment of clinical competence. Multiple-choice questions (MCQs) are a well-established reliable method of assessing knowledge. Constructing effective MCQ tests and items requires scrupulous care in the design, review and validation stages. Creating high-quality multiple-choice questions requires a very deep experience, knowledge and large amount of time. Hereby, after reviewing their construction, strengths and limitations, we debate their completeness for the assessment of professional competence

Noi refertiamo così… voi? Guida rapida per la valutazione sonologica della stenosi carotidea.

Da oltre quarant’anni si utilizzano gli ultrasuoni per rilevare una placca carotidea e per seguire nel tempo la sua evoluzione. I protocolli terapeutici hanno ridotto enormemente il suo impatto sulla salute delle persone ma la scelta fra terapia medica e chirurgica si fonda su una valutazione clinica e strumentale che è solo apparentemente semplice. Nei referti di un esame ultrasonografico riportiamo il più delle volte delle percentuali di stenosi, a volte puntuali, a volte in termini di range oppure ci esprimiamo con aggettivi che descrivono la gravità della stenosi ma spesso ci facciamo confondere dai numeri e dalle differenti modalità di calcolo del range di stenosi ed è indubbio che, a volte, le conclusioni risultano ambigue ed estremamente dipendenti dall’interpretazione dell’operatore. Il problema è che l’angiografia digitale, gold standard diagnostico per la stenosi carotidea, adotta delle metriche non del tutto riproducibili con gli ultrasuoni. Con questo documento vogliamo condividere la ricerca di un linguaggio comune, a partire dal referto dei nostri esami. Noi refertiamo così… voi

Old and new oral anticoagulants : food, herbal medicines and drug interactions

The most commonly prescribed oral anticoagulants worldwide are the vitamin K antagonists (VKAs) such as warfarin. Factors affecting the pharmacokinetics of VKAs are important because deviations from their narrow therapeutic window can result in bleedings due to over-anticoagulation or thrombosis because of under-anticoagulation. In addition to pharmacodynamic interactions (e.g., augmented bleeding risk for concomitant use of NSAIDs), interactions with drugs, foods, herbs, and over-the-counter medications may affect the risk/benefit ratio of VKAs. Direct oral anticoagulants (DOACs) including Factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) and thrombin inhibitor (dabigatran) are poised to replace warfarin. Phase-3 studies and real-world evaluations have established that the safety profile of DOACs is superior to those of VKAs. However, some pharmacokinetic and pharmacodynamic interactions are expected. Herein we present a critical review of VKAs and DOACs with focus on their potential for interactions with drugs, foods, herbs and over-the-counter medications

New anticoagulant drugs versus warfarin in atrial fibrillation: economic evaluation and cost-effectiveness analysis

Health care resources available for medical procedures, including pharmaceuticals, are limited worldwide. Health economic evidence is now accepted as an essential component of health technology appraisal, realizing the importance of value for money considerations for a more efficient (cost-effective) prescribing. Regulatory agencies in more and more countries perform economic evaluation and cost-effectiveness analysis in order to decide about reimbursement of a new and almost always more expensive drug. Pharmacoeconomy is now acknowledged as a science. Cost-effective analysis is just one of its approaches, measuring cost in money and benefit in terms of Quality Adjusted Life Year, a new outcome measure which combines quantity/quality of additional life-years gained with the new drug/technology. A growing body of pharmacoeconomic evidence about new anticoagulant drugs (dabigatran, rivaroxaban, apixaban) for stroke prevention in atrial fibrillation is now available. Most of this evidence comes from the National Institute of Health and Clinical Excellence (NICE) in the United Kingdom, the most referenced regulatory agency in the world. Compared to current standard therapies (warfarin), dabigatran, rivaroxaban and apixaban are cost-effective treatments for the whole population of patients with atrial fibrillation, independently of poor/good international normalized ratio control (time in therapeutic range) and risk stratification for stroke (CHADS2 score). Significant innovation and the lower rate of intracranial hemorrhage/hemorrhagic stroke coupled with the new drugs are the key drivers of these results

Haemorrhage and intestinal lymphoma

Background: The prevalence of coeliac disease is around 1% in general population but this is often unrecognised. The classical presentation of adult coeliac disease is characterized by diarrhoea and malabsorption syndrome, but atypical presentations are probably more common and are characterized by iron deficiency anaemia, weight loss, fatigue, infertility, arthralgia, peripheral neuropathy and osteoporosis. Unusual are the coagulation disorders (prevalence 20%) and these are due to vitamin K malabsorption (prolonged prothrombin time). Clinical case: A 64-year-old man was admitted to our Department for an extensive spontaneous haematoma of the right leg. He had a history of a small bowel resection for T-cell lymphoma, with a negative follow-up and he didn’t report any personal or familiar history of bleeding. Laboratory tests showed markedly prolonged prothrombin (PT) and partial-thromboplastin time (PTT), corrected by mixing studies, and whereas platelet count and liver tests was normal. A single dose (10 mg) of intravenous vitamin K normalized the PT. Several days before the patient had been exposed to a superwarfarin pesticide, but diagnostic tests for brodifacoum, bromadiolone or difenacoum were negative. Diagnosis of multiple vitamin K-dependent coagulationfactor deficiencies (II, VII, IX, X) due to intestinal malabsorption was made and coeliac disease was detected. Therefore the previous lymphoma diagnosis might be closely related to coeliac disease. Conclusions: A gluten free diet improves quality of life and restores normal nutritional and biochemical status and protects against these complications

Haemorrhage and intestinal lymphoma

Background: The prevalence of coeliac disease is around 1% in general population but this is often unrecognised. The classical presentation of adult coeliac disease is characterized by diarrhoea and malabsorption syndrome, but atypical presentations are probably more common and are characterized by iron deficiency anaemia, weight loss, fatigue, infertility, arthralgia, peripheral neuropathy and osteoporosis. Unusual are the coagulation disorders (prevalence 20%) and these are due to vitamin K malabsorption (prolonged prothrombin time). Clinical case: A 64-year-old man was admitted to our Department for an extensive spontaneous haematoma of the right leg. He had a history of a small bowel resection for T-cell lymphoma, with a negative follow-up and he didn’t report any personal or familiar history of bleeding. Laboratory tests showed markedly prolonged prothrombin (PT) and partial-thromboplastin time (PTT), corrected by mixing studies, and whereas platelet count and liver tests was normal. A single dose (10 mg) of intravenous vitamin K normalized the PT. Several days before the patient had been exposed to a superwarfarin pesticide, but diagnostic tests for brodifacoum, bromadiolone or difenacoum were negative. Diagnosis of multiple vitamin K-dependent coagulationfactor deficiencies (II, VII, IX, X) due to intestinal malabsorption was made and coeliac disease was detected. Therefore the previous lymphoma diagnosis might be closely related to coeliac disease. Conclusions: A gluten free diet improves quality of life and restores normal nutritional and biochemical status and protects against these complications

Spinal cord infarction: a rare cause of admission to Internal Medicine Departments but a condition with relevant systemic complications

BACKGROUND Spinal cord infarction is a rare cause of admission to Internal Medicine Departments as it is of infrequent occurrence and it is usually addressed to Neurologic Units. Diagnosis at admission however may be challenging expecially in the elderly because of several co-morbidities and variable presentation. Clinical course is often complicated by autonomic, infective and cardiovascular problems as well as a long stay-in-bed period. Outcome is poor in case of severe motor, autonomic (bladder and bowel) and sensitive impairment at presentation, it’s related to anatomic damage site and extension and it’s worse in case of anterior bilateral infarcts. CLINICAL CASE The authors describe the case of an 81- year-old woman who was admitted to an Internal Medicine Department because of cervical spinal cord infarction. The diagnostic evaluation as well as the management of cardiovascular, infective, rheumatologic and autonomic complications needed skillful internistic competence and a long in-hospital period. MR allowed a correct diagnosis a few hours after presentation, but the pathogenesis was never clearly established. The most invalidating symptoms were loss of bowel control lasting for several weeks during hospitalization and neuropathic pain still present at discharge. As for the outcome, the patient was able to go home after 3 months from admission able to walk with aids, with full bowel and bladder control and no sensitive impairment

Spinal cord infarction: a rare cause of admission to Internal Medicine Departments but a condition with relevant systemic complications

BACKGROUND Spinal cord infarction is a rare cause of admission to Internal Medicine Departments as it is of infrequent occurrence and it is usually addressed to Neurologic Units. Diagnosis at admission however may be challenging expecially in the elderly because of several co-morbidities and variable presentation. Clinical course is often complicated by autonomic, infective and cardiovascular problems as well as a long stay-in-bed period. Outcome is poor in case of severe motor, autonomic (bladder and bowel) and sensitive impairment at presentation, it’s related to anatomic damage site and extension and it’s worse in case of anterior bilateral infarcts. CLINICAL CASE The authors describe the case of an 81- year-old woman who was admitted to an Internal Medicine Department because of cervical spinal cord infarction. The diagnostic evaluation as well as the management of cardiovascular, infective, rheumatologic and autonomic complications needed skillful internistic competence and a long in-hospital period. MR allowed a correct diagnosis a few hours after presentation, but the pathogenesis was never clearly established. The most invalidating symptoms were loss of bowel control lasting for several weeks during hospitalization and neuropathic pain still present at discharge. As for the outcome, the patient was able to go home after 3 months from admission able to walk with aids, with full bowel and bladder control and no sensitive impairment

Emphysematous pancreatitis associated with penetrating duodenal ulcer

In the “proton pump inhibitors era”, a penetrating peptic ulcer (PPU) represents an exceptional cause of abdominal pain, and was more frequently observed in the past where there was not an effective antacid treatment. Ulcer-induced pancreatitis is very rare, too, and manifests with persistent, intense pain radiating to the back. A mild to severe pancreatitis with peripancreatic fluid collection can be observed at imaging. However, only a few cases of association between PPU and emphysematous pancreatitis (EP) have been published in the literature. EP is a rare but potentially fatal form of acute necrotizing pancreatitis in which gas grows in and outside the pancreas, and typically involves the whole parenchyma in diabetic individuals. Here we report an extremely rare case of a duodenal ulcer penetrating the pancreas and complicated with EP. Unlike the classic form of EP, which involves the whole parenchyma and has a poor prognosis, we found that the emphysematous involvement of the pancreas by PPU has a benign course if a conservative therapy is promptly established. Gas is confined to the site of penetration, usually the pancreatic head, and ulcers most often involve the duodenum