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Cognitive-behavioral therapy (CBT) assumes that therapeutic change de-pends mainly on change of cognitive content, while, from a theoretical viewpoint, other processes are excluded. This study aims to explore standard CBT interventions using a model of therapeutic change that includes both emotional and cognitive processes, i.e., the therapeutic cycle model (TCM; Mergenthaler, 1985; 1996), which describes the pro-cesses of therapeutic change in terms of cycles involving both emotional arousal and ab-stract thinking activation. We classified standard CBT interventions in three main are-as: assessing, disputing, and reframing biased beliefs. In 10 individual cognitive therapy sessions with a 30-year-old patient affected by a panic disorder with agoraphobia (PDA), this study aimed to explore whether cognitive interventions are not only related to abstract thinking but also to the emotional activation phases of TCM. Three inde-pendent judges assessed the presence of cognitive therapeutic interventions using the Comprehensive Psychotherapeutic Interventions Rating Scale (CPIRS; Trijsburg et al., 2002). A software program measured the TCM cognitive and emotional variables. The measures revealed significant correlations between cognitive therapeutic interventions and phases of abstract thinking activation during the therapeutic process. The results clarified the role of cognitive interventions in the therapeutic process as a useful instru-ment aimed to increase reality testing.

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Immobility is a well-recognized risk factor for deep vein thrombosis (DVT) in surgical patients, whereas the level of DVT risk conferred by immobility is less defined in patients on medical wards. The aim of this study was to establish whether immobility and its duration are associated with the risk of DVT in acutely ill medical inpatients. We conducted a cohort study in acutely ill medical inpatients. Patients underwent whole leg ultrasound for suspected lower extremity DVT and were divided into two groups according to presence or absence of immobility, defined as total bed rest or sedentary without bathroom privileges. The endpoint was the detection of proximal DVT or isolated distal DVT (IDDVT). Among the 252 acutely ill medical inpatients with immobility (age 82.6 ± 10.3 years, female 63.9%), ultrasound showed 36 (14.3%) proximal DVTs and 39 (15.5%) IDDVTs, while there were 11 (4.4%) proximal DVTs and 26 (10.5%) IDDVTs among the 248 inpatients without immobility (age 73.6 ± 14.2 years, female 54.8%). The risk of proximal DVT was higher in immobile than in mobile patients (OR 3.59, 95% CI: 1.78–7.23, p = 0.0001), whereas the risk of IDDVT was similar between the two groups (OR 1.56, 95% CI: 0.92–2.66, p = 0.111). During the first 3 days of hospitalization, the frequency of all DVTs was similar in patients with and without immobility, but it was 0.26 ± 0.03 vs 0.18 ± 0.03, respectively, after 4 days. In conclusion, immobility for more than 3 days is a risk factor for proximal DVT in acutely ill medical inpatients. © The Author(s) 2021.

ObjectivesTo evaluate the frequency, clinical and etiologic features, and short- and long-term outcomes of early recurrent TIA.MethodsThis prospective observational cohort study enrolled all consecutive patients with TIA referred to our emergency department and diagnosed by a vascular neurologist. Expedited assessment and best secondary prevention were performed within 24 hours. Primary endpoints were stroke and a composite outcome including stroke, acute coronary syndrome, and vascular death at 3, 12, and, for a subset of patients, 60 months; secondary outcomes were TIA relapse, cerebral hemorrhage, new-onset atrial fibrillation, and death resulting from other causes. Concordance between index TIA and subsequent stroke etiologies was also evaluated.ResultsA total of 1,035 patients (822 with a single TIA, 213 with recurrent TIA = 21%) were enrolled from August 2010 to December 2017. Capsular warning syndrome and large artery atherosclerosis showed the strongest relationship with early recurrent TIA. The risk of stroke was significantly higher in the early recurrent TIA subgroup at each follow-up, and most stroke episodes occurred within 48 hours of index TIA. TIAs with lesion, dysarthria, and leukoaraiosis were the 3- and 12-month independent predictors of stroke incidence after early recurrent TIA subgroup. Index TIA and subsequent stroke etiologies showed substantial concordance. An ABCD3 score >6 predicted a higher risk of stroke recurrence over the entire follow-up.ConclusionsOur study evaluated long-term outcome after early recurrent TIA. Our observations support the importance of promptly detecting and treating patients with early recurrent TIAs to reduce the high early and long-term risk of poor clinical outcomes.

Background: Few data are available on long-term atherothrombotic events after percutaneous transluminal angioplasty (PTA) for peripheral arterial disease (PAD). Restenosis after PTA may be a marker of a more aggressive atherothrombosis. Aim: To ascertain whether restenosis detected by duplex sonography (DUS) after PTA for iliac and femoro-popliteal disease is associated with a higher risk of cardiovascular events. Methods: We conducted a prospective cohort study of patients undergoing iliac or femoro-popliteal PTA for PAD. Patients were seen at one month, six months, one year and every year thereafter after PTA. At each visit, DUS was performed and accordingly restenosis was stratified into two categories (absent/present). The outcome was the composite of major adverse cardiovascular events (MACE). Results: Two hundred and fifty patients (aged 69 ± 11 years, male 59.2%) were enrolled. During a mean follow-up of 1207 ± 904 days, 102 (40.8%) patients developed restenosis. Restenosis was more frequent in patients with diabetes and critical limb ischaemia. MACEs (n = 76) were more frequent in the patients that developed restenosis vs. those that did not (40.2 vs. 23.6%, p =.005). Predictors of MACEs were diabetes (HR 2.02, 95%CI: 1.19–3.41, p =.009), presence of coronary heart disease at enrolment (HR 2.84, 95%CI: 1.78–4.53, p =.001) and restenosis (HR 1.87, 95%CI: 1.16–3.00, p =.010). Conclusion: Restenosis at DUS, diabetes, and coronary heart disease in patients who underwent iliac or femoro-popliteal PTA for PAD are associated with increased risk of arterial thrombotic event. Intervention trials are required to show the benefit of different therapeutic approaches in such patients at high risk of clinical deterioration.

Chest pain in children and adolescents is rarely associated with an underlying heart disease. How-ever, when it does occur, pericarditis is the most common cause. Most cases are of unknown origin (idiopathic) and mild. Up to 15-35% of paediatric patients with idiopathic pericarditis experience a recurrence during their lives and clinical management in these cases may be challenging. NSAIDs are the first-choice drugs for the treatment of acute idiopathic pericarditis. Corticosteroids should be reserved for refractory pericarditis and autoimmune or autoinflammatory disorders with peri-cardial involvement. Colchicine plays a central role for the management of recurrent forms while anakinra has recently emerged as a remedy for colchicine-resistant and corticosteroid-dependent recurrent pericarditis.

Background: Evidence provides inconsistent findings on risk factors and health outcomes associated with loneliness. The aim of this work was to grade the evidence on risk factors and health outcomes associated with loneliness, using an umbrella review approach. Methods: For each meta-analytic association, random-effects summary effect size, 95% confidence intervals (CIs), heterogeneity, evidence for small-study effect, excess significance bias and 95% prediction intervals were calculated, and used to grade significant evidence (p

Deep vein thrombosis (DVT) is an important cause of morbidity and mortality in hospitalized patients. The Wells score for DVT pretest probability (PTP) was validated in outpatients, but its utility for inpatients is unclear. The aim of this study was to establish the prevalence of inpatient proximal and distal DVT and the Wells score performance in inpatients. A single-center cross-sectional study was conducted in a university hospital. During 183days, all inpatients with suspected lower-extremity DVT were evaluated with the Wells score and whole-leg ultrasound. Among 634 inpatients (age 77.5 ± 13.8 years, males 39.3%), 507 (80.0%) were from medical wards and 127 (20.0%) from surgical wards. During the study period, there were 11,662 hospital admissions in the surgical/medical services. Whole-leg ultrasound detected 128 DVTs (20.2%); 51 (39.8%) were proximal and 77 (60.1%) were isolated distal DVTs. Estimated DVT prevalence in hospital setting was 1.09% (95% CI 0.93–1.31), and isolated distal DVT prevalence was 0.66% (95% CI 0.53–0.82). DVT frequency in low-, moderate-, and high-PTP groups was 9.8%, 24.3%, and 41.5%, respectively (p = 0.001). The area under the receiver operating characteristic curve for the Wells score was 0.67 ± 0.03 for all DVTs and 0.75 ± 0.04 for only proximal DVTs. A high PTP had a sensitivity of 24% (95% CI 14–37%) and a specificity of 93% (95% CI 91–95%) for proximal DVT diagnosis. In hospitalized patients, isolated distal DVT has a higher incidence than expected, and the Wells score accuracy for proximal DVT is similar to that found in outpatients.

The objective of the study is to evaluate the efficacy of corticosteroids in Sydenham chorea. This is a retrospective observational study. Clinical information of children with Sydenham chorea were collected. Outcome of Sydenham chorea was evaluated in consideration of presence or absence of corticosteroid therapy. Thirty patients were enrolled. A total of 15 were treated with prednisone, 15 received symptomatic drugs or no treatment. Patients who were treated with prednisone showed faster improvement (4 vs 16 days; p = 0.002) and shorter median time of remission (30 vs 135 days; p < 0.001). Conclusion: Our study showed that corticosteroid therapy is an effective treatment of Sydenham chorea. What is Known: Steroid treatment in Sydenham chorea is widely used but it is not standardized. Few manuscript report a beneficial use of steroids in Sydenham chorea if compared with no treatment. What is New: Steroid treatment seems to be effective in both clinical remission and clinical improvement of symptoms among patients with Sydenham chorea. Steroid treatment seems to be superior to conventional treatment.

The aim of this exploratory study was to investigate the correlation between cultural and psychological factors in relation to predicting eating disorders in two different non-clinical Italian (n = 61) and Swedish (n = 31) female populations, thought to have different cultures and lifestyles. The Swedish sample would reflect an emancipated model of women pursuing autonomy and freedom but also an ideal of thinness, while the Italian sample would reflect a difficult transition from traditional submissiveness to modern autonomy. Both groups completed self-report instruments assessing cultural values (e.g., collectivism and individualism) and features of eating disorders (e.g., drive for thinness, bulimia, body dissatisfaction, self-esteem, parental criticism and perfectionism). Swedish women were found to display higher levels of bulimia, perfectionism, and individualism than Italian women, while regression analysis showed that in the Italian sample high levels of collectivism were correlated with measures of EDs. The results support the hypothesis that EDs are linked with both modern values of autonomy, independence and emancipation, and situations of cultural transition in which women are simultaneously exposed to traditional models of submission and opportunities for emancipation and autonomy.

Background: Rapid management can reduce the short stroke risk after transient ischaemic attack (TIA), but the long-term effect is still little known. We evaluated 3-year vascular outcomes in patients with TIA after urgent care. Methods: We prospectively enrolled all consecutive patients with TIA diagnosed by a vascular neurologist and referred to our emergency department (ED). Expedited assessment and best secondary prevention was within 24 h. Endpoints were stroke within 90 days, and stroke, myocardial infarction, and vascular death at 12, 24 and 36 months. Results: Between August 2010 and July 2013, we evaluated 686 patients with suspected TIA; 433 (63%) patients had confirmed TIA. Stroke at 90 days was 2.07% (95% confidence interval (CI), 1.1-3.9) compared with the ABCD2-predicted risk of 9.1%. The long-term stroke risk was 2.6% (95% CI, 1.1-4.2), 3.7% (95% CI, 1.6-5.9) and 4.4% (95% CI, 1.9-6.8) at 12, 24 and 36 months, respectively. The composite outcome of stroke, myocardial infarction, and vascular death was 3.5% (95% CI, 1.7-5.1), 4.9% (95% CI, 2.5-7.4), and 5.6% (95% CI, 2.8-8.3) at 12, 24, and 36 months, respectively. Conclusions: TIA expedited management driven by vascular neurologists was associated with a marked reduction in the expected early stroke risk and low long-term risk of stroke and other vascular events.

Calf deep vein thrombosis (CDVT) ultrasound diagnostic criteria are still debated. A clot >= 3.5 mm may be an appropriate threshold for CDVT diagnosis. Six week heparin treatment is associated with recanalization in half of patients with CDVT. Objective/Background: Calf deep vein thrombosis (CDVT) is frequently found in symptomatic outpatients, but CDVT ultrasound diagnostic criteria are still debated. It has been proposed that only clots with >= 5 mm maximum diameter can be considered as CDVT. Aims: To assess clot diameters and characteristics of CDVT, and to assess the recanalization rate of CDVT after anticoagulant treatment. Methods: In a prospective, multicenter cohort study symptomatic outpatients in whom CDVT was diagnosed by ultrasound were enrolled. Posterior tibial, fibular, medial and lateral gastrocnemius, and soleal veins were compressed transversally over their entire length. Clot diameter was measured during maximum compression and ultrasound was repeated after 6 weeks of low molecular weight heparin treatment. Results: In 172 patients (age 70 +/- 1 y, male 32%) CDVT was detected in 132 (76.7%) muscle veins only, and in 24 (14%) axial veins only, while 16 (9.3%) patients had both muscular and axial CDVT. A total of 212 clots were found with a diameter of 5.8 +/- 1.8 mm (IQR 4.5-6.8 mm) with the 10th percentile being >= 3.5 mm. A cut off value of >= 5 mm had a sensitivity of 0.76 (95% CI 0.69-0.82), whereas a value of >= 3.5 mm had a sensitivity of 0.94 (95% CI 0.89-0.97). Recanalization (i.e. residual vein obstruction = 5 mm is found in only 76% of CDVT patients and a clot diameter >= 3.5 mm may be more appropriate as a threshold for CDVT. After 6 weeks of anticoagulant treatment, half of CDVT patients had recanalization and recanalization was not correlated with clot characteristics at enrolment, but with mobility of the patients. (C) 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Background The risk of heparin induced thrombocytopenia (HIT) associated with low molecular weight heparin (LMWH) for treatment of superficial vein thrombosis (SVT) is uncertain. As a result the necessity of platelet count monitoring is unclear in this setting. Aims To assess the risk of HIT in outpatients treated with LMWH for SVT. Methods In a prospective single centre study we included all symptomatic outpatients in whom a real-time B-mode and color Doppler ultrasonography examination revealed SVT without DVT. Patients treated with vitamin K antagonists or fondaparinux were excluded. Patients received full dose enoxaparin for 1 week followed by half therapeutic dose for 3 weeks or parnaparin 8500 UI aXa for 10 days followed by 6400 UI aXa once daily for 20 days. Platelet count was performed on the day of diagnosis (D0) and 7 (D7), and 14 (D14) days afterward. Primary outcomes were the rate of thromboembolic events and of HIT during a 3-month follow-up. Results 678 outpatients (age: 64.7 ± 16.2 years, male: 42.0%) were evaluated. During follow-up, 7 venous thrombo-embolic events were recorded (1.03% CI 95%: 0.50–2.11%), while no major bleeding was observed (0.0% CI 95%: 0.0–0.56%). Platelet count was 255 ± 93 × 109/L at D0, 245 ± 93 × 109/L at D7 (p = 0.204 vs. D0) and 261 ± 116 × 109/L at D14 (p = 0.405 vs. D0). No fall in platelet count > 50% and no case of HIT were recorded (HR 0.0% CI 95%: 0–0.56%). Conclusions A 4-week LMWH treatment for SVT is associated with an incidence of HIT lower than 0.6% and platelet count monitoring may be omitted in this setting.

Background and objectives: To assess the predictive value of D-dimer (D-d) and Factor VIII (FVIII) in combination for recurrent venous thromboembolism (VTE) after vitamin K antagonist (VKA) therapy suspension. Design and methods: Consecutive outpatients with a first episode of idiopathic proximal deep vein thrombosis of the lower limbs were enrolled on the day of VKA suspension. After 30+/−10 days, D-d (cut-off value: 500 ng/mL), chromogenic FVIII activity and inherited thrombophilia were determined. Follow-up was 2 years. Results: Overall recurrence rate was 16.4% (55/336; 95% CI:13–21%). The multivariate hazard ratio (HR) for recurrence was 2.45 (95% CI: 1.24–4.99) for abnormal D-d and 2.76 (95% CI:1.57–4.85) for FVIII above the 75th percentile (2.42 U/mL) after adjustment for age, sex, thrombophilia, VKA duration and residual venous obstruction. When compared with normal D-d and FVIII, the multivariate HR was 4.5 (95% CI: 1.7–12.2) for normal D-d with FVIII above 2.42 U/mL and 2.7 (95% CI: 1.2–6.6) and 7.1 (95% CI:2.8–17.6) for abnormal D-d with FVIII, respectively, below and above 2.42 U/mL. Interpretation and conclusions: D-d and FVIII at 30+/−10 days after VKA withdrawal are independent risk factors for recurrent VTE.

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