SIMI - Volume Comunicazioni Orali e Poster

VOLUME
COMUNICAZIONI ORALI
E POSTER
118°
CONGRESSO
NAZIONALE
Società Italiana di Medicina Interna
Roma
27-29 Ottobre 2017
Congress Center Rome Cavalieri
INDICE
COMUNICAZIONI ORALI
VENERDÌ 27 OTTOBRE 5
SABATO 28 OTTOBRE 27
DOMENICA 29 OTTOBRE 43
POSTER
POSTER 1 - 339 70
INDICE AUTORI 192

118° Congresso Nazionale - Società Italiana di Medicina Interna Comunicazioni Orali
COMUNICAZIONI ORALI in common the fact that they have no clinical relapse. In the absence of
gene sequencing, it is currently believed that our case is attributable to the
presence of inhibitors (3), which, however, do not alter the electrophore-
sis mobility of isoenzymes, or to a modification of the catalytic site which
27 OTTOBRE 2017 involves a lesser activity of substrate.
LACTATE DEHYDROGENASE HEREDITARY DEFICIENCY:

DESCRIPTION OF THE FIRST ITALIAN FAMILY WITH
TOTAL LDH REDUCED DUE TO LOWER ACTIVITY OF
LDH-1 AND LDH-2 ISOENZYMES
Turrin M.1, Zaninotto M., Altinier S., Plebani M.

Già1 U.O.C. Medicina Interna, Ospedali Riuniti Padova Sud, Monselice (Pd),
U.O.C. Medicina di Laboratorio, Azienda Ospedaliera-Università degli Studi
di Padova
Introduction: In the ORPHANET list of rare diseases, glicogen store disease

(GSD) due to deficiency of LDH (LDH-B) subtype H (heart) appears at n° References:
284435: prevalence is unknown and appears in adulthood (1).The deficit is 1. Quaderni di Orphanet, dicembre 2016, Elenco delle malattie rare e sino-
caused by mutations of the LDHB gene (MIM *locus 150100) located in the nimi: in ordine alfabetico. www.orpha.net/orphacom/cahiers/docs/IT/
12p12.1 chromosome (phenotype n° 614.128). The rare cases described in Elenco_malattie_rare_in_ordine_alfabetico.
Literature relate only to a few Japanese families: an emolysis was only descri- 2. Takatani T,Takaoka N,Tatsumi M et al. A novel missense mutation in
bed in some of the forms with complete deficiency in homozygous, while a lactate deydrogenase B-subunit.Mol Genet Metab 2001;4:344-348.
partial heterozygous deficit was not associated with any pathology unless 3. Fujita K, Sato H, Kameko F et al. An immunoglobulin A1 that inhibits
the failure LDH increase in conditions where a typical elevation should lactate dehydrogenase activity, with reversal of inhibition by addition of
appear. So far, eight Japanese genetic variants have been identified (2). NADH. Ann Clin Lab Sc 2006;36:461-468.
Clinical Case: Twenty years ago, in a patient admitted for post-traumatic
fractures with reactive pleurisy associated, a decrease in serum LDH was
observed occasionally. From this data, initially underestimated and confir-
ANALYSIS OF INTRA-HOSPITAL COMPLICATIONS AND
med subsequently in response to k. breast, we extended the determination
NEW INCIDENTAL DIAGNOSES OCCURRING AFTER
of LDH to the brothers, and later to the nephews and the grandchildren. We
therefore took charge of a large family of Padua (23 subjects) consisting of:
ADMISSION IN INTERNAL MEDICINE: RATE AND
4 living brothers (+ 4 died): age 78-88, 6 cousins: age 50-60, 9 grandchildren
IMPACT OF THESE EVENTS IN LENGHTENING THE
age 20-34 years. In this family, of three generations,10 subjects had LDH:
HOSPITALIZATION
two males had total serum LDH values between 77 and 101 (IR: 135-225
Galassi M., Leoni S., Terzi E., Tovoli F., Piscopo M., Bolondi L. Unità
U/L) and 4 females had LDH between 80 and 106 (IR: 135-214 U/L). The
values were confirmed in two or more determinations.The electrophoretic Operativa Medicina Interna Bolondi, Azienda Ospedaliero-Universitaria
analysis of serum isoenzymes in all 6 subjects showed a reduction in the S.Orsola-Malpighi, Bologna
isoenzymes LDH-1(H4) and LDH-2(H3M1). In all subjects the pattern of
isoenzyme from erythrocyte emolysates provided a normal pattern (figure 1: Introduction: Advanced age, comorbidity and complex therapies fre-
LDH isoenzymes electrophoretic trace of the older [*] male patient). In the quently characterize patients referred to Internal Medicine. During hospi-
anamnesis of the family, the overall pathologies were: 4 k.breast associated talization, clinicians perform diagnostic-therapeutic algorithms aimed at
with, in one, k.colon, cerebral neoplasia, deaf-mutism, dyslipidemia, hypovi- investigating and solving the clinical problem leading to hospitalization.
taminosis D, arterial hypertension, colon polyps, cholelithiasis, atrial fibrilla- However, in the real life clinical practice the diagnostic and therapeutic
tion, disabiling arthrosis, aortic aneurysm, COPD, mild thrombocytopenia, work-up initially planned needs to be frequently adjusted or modified due
autoimmune hypothyroidism associated with HCV-related cryoglobulinae- to intra-hospital complications and/or incidental diagnosis of diseases dif-
mia.The 6 subjects with LDH serum deficiency (aged 23 to 83 years) the dise- ferent from the original admission problem.
ases reported in the anamnesis are: hypovitaminosis D in all, dyslipidemia Aims: Aims of this study were: 1) to evaluate the incidence of complications
in three, arterial hypertension in two, impaired generalized osteoarthritis, and/or incidental diagnosis during hospitalization and the related hospitali-
fibrillation cardiomyopathy, renal failure chronic and hyperuricemia in one zation lenghtening; 2) to evaluate the correlation between comorbidity and
[*], mild thrombocytopenia in one, double neoplasia (K.breast + K.colon) incidence complications.
in one. The determination of LDH was performed in a clinical normal state. Methods: The clinical charts of patients consecutively admitted at Internal
It should be noted that in an 23-year-old granddaughter, during an acute Medicine Unit between 1st Jenuary 2017 and 30th April 2017 were analysed.
episode of infectious mononucleosis, LDH (basal 84-106 U/L) reached a Exclusion criteria were: age less 18 years and death in the first 48 hours of
value of 658 (with AST 125 and ALT 184). It is not possible to know in the hospitalization.
other family members the maximum LDH value reached during acute illness. Results: A population of 403 patients was included in the study
No subjects showed signs of hemolysis or reductions of other enzymes (CPK, (M/F:187/216, mean age 73.9 years; mean and median hospitalization dura-
transaminase, ALP, γGT,amylase). It was not possible to search for any mutation: 9.2 and 7 days); 226 patients (56%) concluded hospitalization and
tions in the LDHB gene for lack of technical sequencing availability of gene were discharged without complications or new diagnosis not correlated to
sequencing. the admission problem. Whereas, 177 patients (44%) had some changes
Conclusions: LDH hereditary deficits are described in some Japanese fami- in diagnostic-therapeutic original program due to: incidental diagnosis
lies. The study of this family, conducted at the level of three generations, and complication in 29/177 (16.4%), only incidental diagnosis not corre-
confirms that the decrease in enzymatic activity of LDH is due to a genetic lated to the admission problem in 47/177 (26.5%) and only intra-hospital
defect. Since this defect, has no clinical relapse, is not studied and there- complications in 101/177 (57.1%). The median hospitalization duration of
fore the type or the incidence is unknown. The analysis of the isoenzymes complicated group (n=130, 32.2%; in 29/130 associated with new incidental
reveals that the decrease is due to the LDH1(H4) isoenzyme, therefore the diagnosis) was 11 days (range 2-69 giorni) versus 5 days (range 1-24 days) of
defect is dependent from H subunit. The few cases described in Japan have not complicated group. Major intra-hospital complications include: hospital
in common with this case the genetic origin of the defect, but some diffe- acquired infections (n=51;39.2%) and delirium (n=22, 16.9%); moreover,
rences indicate that this is basically a different genetic abnormality as: a) post-procedure (n=6) and iatrogenic (n=7) complications, other complica-
the total activity values of LDH are much lower in the Japanese; b) in the tions (n=37). In 44 pts (33.8%) more than 1 complication was described.
electrophoresis of isoenzymes there are only LAD-5 in the Japanese hou- Comorbidity was evaluated with Charlson Index; median Charlson index
seholds, whereas in our case there is a decrease in LAD-1 and sometimes of population was 6 (range 0-15). Correlation between Charlson index ≥6
LAD-2; c) in the erythrocytes electrophoresis LAD-1 and LAD-2 isoenzy- and occurrence of intra-hospital complications was statistically significant
mes are normally represented, while in Japanese there is a decrease; d) there at Chi square test (p=0,001). Correlation between intra-hospital delirium
are no hemolysis indices in the Italian family. These genetic defects have and cognitive impairment was statistically significant (p ≤ 0,001). New inci-
5
Comunicazioni Orali 118° Congresso Nazionale - Società Italiana di Medicina Interna
dental diagnosis were overall described in 76 pts (18.8%; in 29/76 associa- manganese in these structures is known to increase T1 signal to magnetic
ted with intra-hospital complications). In 18 new diagnoses, patients were resonance imaging in basal ganglia, as is usually observed in patients with
discharged without additional examinations, with mean hospitalization hepatic impairment. Manganese brain deposits may be an early indicator of
duration of 8.3 days; in 58 new diagnoses, additional examinations were liver dysfunction in asymptomatic patients at risk of developing metal-rela-
required with congruous hospitalization lenghtening: 1 additional exami- ted toxic anomalies. Proper management of sideropenia could reduce free
nation in 18 pts, 2 additional examinations in 12 pts and ≥ 3 additional transferrin levels with secondary reduction in cerebral accumulation of
examinations in 28 pts, with respectively mean hospitalization duration of manganese, which could reduce or prevent damage to neurotoxicity.
10.4, 11.7 and 17.1 days.
Conclusions: About 30% of patients referred to Internal Medicine is com-
plicated during hospitalization, with significant lenghtening of hospital stay RELATIONSHIP BETWEEN AMBULATORY ARTERIAL
and statistically significant correlation with Charlson index. About 18% STIFFNESS INDEX (AASI) AND NIGHT/DAY BLOOD
of patients had new incidental diagnosis not correlated to the admission
problem, generating additional examinations in more than 75% of cases and
PRESSURE RATIO IN ESSENTIAL HYPERTENSIVES
congruous hospitalization lenghtening. These data warrant a further survey
Musiari G.1, Di Raimondo D.1, Casuccio A.2, Miceli G.1, Tuttolomondo A.1,
in a large multicenter study.
Pinto A.1
1
Dipartimento Biomedico di Medicina Interna Clinica e Specialistica
- Università degli Studi di Palermo 2 Dipartimento di Biomedicina
THE ROULE OF MANGANESE IN HHT PATIENTS Sperimentale e Neuroscienze Cliniche - Università degli Studi di Palermo
Pinna M.1, Masala M.S.2, Vidili G.3, Turilli D.4,Pinna C.4 Introduction and Aim: Pulse Wave velocity (PWV) or the Augmentation
1
U.O. Complessa di Pronto Soccorso ed Osservazione Breve P.O. Ozieri Index (AI), had demonstrated to discriminate surely the different extent
2
U.O. Complessa di Pronto Soccorso ed osservazione Breve P.O. Alghero of arterial stiffness (AS) that features the different subgroups of hyperten-
3
Dipartimento di Medicina Clinica e Sperimentale, Università Degli Studi di sives in relation to the nocturnal fall of blood pressure (BP) (calculated
Sassari 4U.O di Radiodiagnostica P.O. Ozieri through the Δ N/D SBP ratio): the lower the nocturnal fall of blood pressure
(BP), the greater the PWV. Ambulatory Arterial Stiffness Index (AASI) is
Introduction: Hereditary Hemorrhagic teleangectasia(HHT) is an heredi- a simpler method to estimate AS. For a given increase in diastolic BP, the
tary autosomal dominant which affects angiogenesis, causing arteriovenous increase in systolic BP is smaller in a compliant compared to a stiff artery;
dilations, hemorrhagic teleangectasie affecting mucous membranes and the stiffer the arterial tree, the closer AASI is to 1. Only a few studies tried
visceral shunts located predominantly in the liver, lung, and brain. Manga- to ascertain if AASI have similar ability, further validating its wide clinical
nese (Mn) is the 12th most abundant element, transition metal, pentavalent, use, in addition (or alternatively) to AS with partial and conflicting Results:
co-enzymatic factor (in men), whose presence is ubiquitous, responsible for In consideration of the contradictory results showed, and the almost com-
a “disease characterized by bradycinemia, amyotrophic facies, and postu- pletely absence of data regarding the ability of AASI to predict the different
ral instability” secondary to its toxic effect, linked to its accumulation to degree of stiffness when hypertensives are divided into four class of dipping,
predominant liver and cerebral localization with a transferrina-dependent aim of the study was to clarify the potential of AASI to estimate the different
mechanism (DMT1), enhanced by martial deficit. The mechanism by which degree of AS in relation to the nocturnal BP profile.
Mn brain deposits may induce neurotoxicity – as well as being not clear - Materials and Methods: We enrolled 816 essential hypertensives and 173
may involve a toxin on the dopaminergic route, cause apoptosis or cause control subjects without hypertension. The study procedure included for all
endothelial dysfunction. In the literature, the evidence of Mn encephalocyte subjects: a comprehensive medical history complete physical examination;
deposits in HHT patients is found in about 30% of cases, but its diagnosis is assessment of Body Mass Index (BMI), waist circumference; blood bio-
often misunderstood and its clinical significance underestimated. Purposes chemical examinations. Through the execution of a 24-hours ambulatory
This project aims to verify if, among sardinian patients affected by HHT, blood pressure monitoring (ABPM), have been obtained comprehensive
may be found subjects with HAvms and Mn deposits and if may be linked data regarding 24h, diurnal and nocturnal values of BP and AASI (defined
with Mn levels. as 1 minus the regression slope of diastolic on systolic BP values) Results:
Materials and Methods: The study focussed on 55 sardinian patients Unadjusted AASI values of the four categories of hypertensives in relation
affected byt HHT undergoing a complete clinical screening, 28 of which to night/day SBP ratio compared to control subjects. showed significantly
subjected to RMN brain + with study of “ poligono di Willis”+ paramagne- higher AASI for mild and reverse dippers versus control patients and
tic contrast to study brain arterio-venus malformations (CAVMs). versus the other categories of dipping (p: 0.0005). The multiple regression
Results: It is interesting to note that in 6 of the 28 patients undergoing analysis for AASI dependent variable confirmed the association between
RMN encephalus, the presence of Mn deposits has been identified a carico AASI and nocturnal dip (p: 0.015). The Multinomial Logistic Regression
dei base ganglia and cerebellum’s peduncles In all patients, the Mn evi- Analysis after adjustment for the main confoundings: age, sex, Body Mass
dence might be appreciated as an bilateral signal iperintensity in the nelle Index, 24h Systolic BP, 24h Diastolic BP,confirmed the association between
1-weighted sequences. The mechanism is not well-known, but may depend AASI and dipping, but only for dipper and extreme dipper hypertensives,
on the presence of port-system shunts which may also not be apparent losing the significance for the higher values of AASI. Conclusions:: Our
to imaging. A coexisting iron deficiency can contribute to increased Mn findings support the hypothesis that AASI is unable to estimate the higher
absorption in these patients, as both of these metals have a common recep- degree of AS of older hypertensive subjects with a high burden of organ and
tor for absorption, transferrina-dependent. Starting from the assumption vascular damage and several comorbidities, probably because the nocturnal
that the deposition of manganese in these structures is known to increase T1 reduction of BP is a main determinant of AASI, more powerful than AS
signal to magnetic resonance imaging in basal ganglia, as is usually obser- itself. Our data do not support the clinical use of AASI as an alternative to
ved in patients with hepatic impairment. In our case, the evidence in 6 cases the PWV.
of hyperintensity of signal was not always associated with the presence of
liver shunts diagnosed with ultrasound abdomen but in all cases they were
observed by TC scan in the liver arterial phase obtained during Chest chest
to exclude artero-venus malformations of the lung (PAVMs). Furthermore,
BISPHENOL-A (BPA): A PROBLEM IN HUMAN HEALTH
the serum dosing in MN did not result in expected results as it was not
Lucchetta M.C.
measurable, this could be related to the short half-life in plasma and serum
Servizio Sanitario Emilia Romagna- Ausl Parma
of Mn resulting in indifference while the whole blood assay was diagnostic,
resulting in high Four patients taken for the second dose on whole blood.
Bisphenol A (4,40-isopropylidenediphenol,BPA) is a monomer used in the
In addition, 4 patients had low levels of sideremia and ferritin, while in
manufacture of polycarbonate plastics(PV). BPA is used in diverse forms
the other 2 cases the data were unavailable. Therefore, although liver fun-
of plastic products in the food and electronic industries (plastic container-
ction indices were standard, this alteration may indicate a certain degree
s,utensils,toys,water bottles,fax paper).The extensive use of BPA-containing
of hepatic dysfunction at an early and asymptomatic stage, and indicate “at
products has resulted in high human exposure worldwide. Many studies
risk” subjects to develop abnormalities related to the toxic role of this metal.
reporting that more than 90% of the US population has detectable levels in
Conclusions: In addition, brain imaging through RMN study may be
urine samples.In adults,urinary BPA concentrations are positively associated
useful in detecting the deposition of manganese in HHT patients also in
with cardiovascular disease and diabetes.The ubiquity of BPA exposure and
the subclinical phase; Starting from the assumption that the deposition of
its endocrine-disrupting potential raise concerns about its effects on health
6
despite the molecule’s short half-life.However, recent animal and in vitro risk reduction that certainly deserves attention on the other member States
studies suggest that BPA exerts additional health effects on other systems,- of the E.U.In Italy,we are waiting for a law to regulate the use of BPA espe-
such as central nervous system activity,thyroid hormone and pancreatic cially in the containers suitable for food.
β-cell function.A new american study correlates the BPA with cancers of Figure 1: The hepatic biotransformation of bisphenol A Datis Kharrazian
the liver and liver disfunction.A study on BPA-treated rats showed eleva- Autimmune Dis.2014
ted aspartate aminotransferase (AST),alanine aminotransferase (ALT),and
lactate dehydrogenase (LDH) levels as well as marked defects in liver
morphology. BPA has been studied extensively as an endocrine disruptor THREE-DIMENSIONAL ECHOCARDIOGRAPHIC
(Bonefeld-Jorgensen et al.2007;Richter et al.2007;Rochester 2013).BPA has EVALUATION OF THE RIGHT VENTRICLE IN PATIENTS
the ability to bind to estrogen receptors and promote both agonist and anta- WITH SYSTEMIC LUPUS ERYTHEMATOSUS
gonist activity.BPA may be a contributing risk factor to autoimmune disease
development.The hepatic biotransformation of BPA depends on oxidation/ A. Buonauro1, M. Galderisi1, R. Esposito1, L. Nappi2, R. Sorrentino1, A.
reduction involving glutathione.Higher BPA concentrations were associa- Lobasso2, F.W. Rossi2, A. Tufano3, A. De Paulis2, G. Marone2
ted with increased abnormal liver function tests.Animal studies demon- 1
Dipartimento di Scienze Biomediche Avanzate, Università degli studi
strate that BPA has the ability to generate reactive oxygen species (ROS) di Napoli Federico II 2 Dipartimento di Scienze Mediche Translazionali,
and reduce antioxidant reserves.BPA disruption of cytochrome P450 (CYP) Università degli studi di Napoli Federico II 3 Dipartimento di Medicina e
enzymes may be a potential mechanism for autoimmune pathophysiology. Chirurgia, Università degli studi di Napoli Federico II
The cytochrome P450 monooxygenases play a crucial role in the liver and
various other tissue.A recent cross-sectional human study of 1455 Ameri- Background: Patients with systemic lupus erythematosus (SLE) have an
cans demonstrates a statistically significant association between higher BPA increased risk of cardiovascular events, which is independent of traditional
concentrations and abnormal concentrations of liver enzymes: γ-glutamyl risk factors. This higher risk has been associated with alterations of left ven-
transferase(γ-GTP),alkaline phosphatase(ALP) and LDH.The relationship tricular structure and function. Little is known about right ventricular (RV)
between BPA exposure and liver function remain unclear, although some involvement in this clinical setting.
studies suggest possible mechanisms for liver damage, such as oxidative Methods: Thirty-six SLE (age 43±8 years, F/M=32/4) and 36 healthy con-
stress and direct apoptotic activities.In 2014 the European Agency for Che- trols, matched for age and sex, were enrolled. Patients with coronary artery
micals(ECHA) has classified BPA in category 1b for reproductive toxicity,on disease, overt heart failure, primary cardiomyopathies, diabetes mellitus,
the basis of the experimental evidence.The Chemistry Council to the con- atrial fibrillation and primary pulmonary hypertension were excluded.
trary, declare that BPA is safe and contrasts all the legislative proposals to Patients and controls underwent a complete echo-Doppler exam with addi-
prohibit the use of BPA. The Food and Drug Administration (FDA) has pro- tional three-dimensional (3D) assessment of RV structure and function.
duced an official document from last year to affirm the safety of BPA.Many Echo-Doppler estimate of pulmonary arterial systolic pressure (PAPs), RV
researchers attribute this result to the intervention of the chemical industry diameters, tricuspid annular plane systolic excursion (TAPSE), tricuspid
lobbying.In 2006, the analysis of the literature has revealed that each of the E/A ratio and Tissue Doppler derived systolic velocity of lateral tricuspid
funded study did not find significant effects of BPA while they are present in annulus were measured. Three-dimensional echo-derived RV end-diasto-
92% of studies not funded by industry.Based mainly on experimental data lic and end-systolic volumes (RV EDV and ESV respectively), RV ejection
and studies rewiewed,in 2014 the ECHA has classified BPA in category 1b fraction (EF) and stroke volume (SV) were determined. RV septal and
for reproductive toxicity.EFSA asserts that the diet is the main source of lateral longitudinal strain (SLS and LLS respectively) were estimated by
exposure and that the tolerable daily intake(TDI) of BPA in food must be 3D echo. The disease activity was evaluated by SELENA-SLEDAI score and
lowered by a factor of 10 to 0.005 mg for kg of body weight (mg/kg b.w.) other inflammatory markers (reactive C protein [CRP] and erythrocyte
corresponding to 4 micrograms per kilogram of body weight for day (μg/kg sedimentation rate).
b.w/day).However EFSA supports hat the total BPA inteke estimated up to Results: The two groups had comparable body mass index (BMI), heart
30% of the TDI for the group more exposed (teenagers).But doubts remain. rate (HR), systolic and diastolic blood pressure. PAPs was marginally higher
Many toxicoloy study would confirm some of the hypotheses about the role in SLE than in controls (27.1±5.7 versus 24.6±5.0, p<0.05). Pulmonary
in the alteration of hormonal balances:major damage you would have with hypertension (PAPs > 30 mmHg) was found in 10 SLE patients (27.8%).
the lower doses, adverse effect “low dose response” typical of endocrine Standard echo-Doppler measurements of RV structure and function (RV
disruptors (Vandenberg 2012).On the basis of the scientific evidence, in the transverse and longitudinal diameters, TAPSE, systolic velocity of lateral
context of european legal standards,France has launched a national action tricuspid annulus and RV E/A’ ratio) did not differ significantly between the
two groups. By 3D echo, RV ESV was greater (p=0.009) and RV EF lower
(55.4±6.2% vs. 61.7±6.0, p<0.0001) in SLE than in controls, without changes
of RV EDV and SV. RV SLS and RV LLS (-21.1±5.0% vs. -26,8 ±3.6%,
p<0.001 and -25.3±4.4% vs. -33.0 ±4.9%, p<0.0001 respectively) were both
lower in SLE. The comparison of SLE with and without pulmonary hyper-
tension did not show significant difference of standard and 3D echo RV
measurements. The subdivision of SLE according SELENA-SLEDAI (abnor-
mal) did not show significant differences in patients with abnormal vs. those
with normal values, but patients with elevated CRP (≥0.5, n=7) had lower
RV EF (p<0.02) and LLS (p<0.01) than those with normal CRP.
Conclusion: The present study shows a subclinical RV systolic myocardial
dysfunction in SLE patients. This dysfunction is unmasked only by 3D echo
and appears to be at least partially associated with infiammation activity of
disease.
AN INFECTIOUS JAUNDICE
Biferi E., Cerasi C., Stamerra C.A., De Feo M., Vertolli P., Ferri C.
University of L’Aquila - Department of Life, Health and Environmental
Sciences - Division of Internal Medicine and Nephrology - San Salvatore
Hospital of L’Aquila (Italy)
A 56 years-old Albanian man, pig farmer, was admitted to our Division for a
7-days history of fever, generalized myalgia, headache, adynamia, diarrhea,
vomiting, bloated abdomen, and one episode of hematuria. Past history
included a 20-year period of alcohol abuse. He had drunk big volumes of
alcohol until the time of admission. Physical examination was remarkable
for jaundice and large tender hepatomegaly. The spleen also was palpable.
7
Cardiac examination revealed tachycardia and hypotension. Laboratory AETIOLOGY AND MANAGEMENT OF PYOGENIC LIVER
tests showed: hemoglobin 13.4 g/dl, white blood cells count 13.80 x 103/ ABSCESSES
mmÑ (neutrophils 93 %), platelet count 17 x 103/mmÑ, aspartate ami-
notransferase 67 IU/L, alanine aminotransferase 39 IU/L, total bilirubin Serraino C. 1, Elia C. 2, Melchio R. 1, Rinaldi G.L. 1, Falcetta A. 1, Borretta V.
20.40 mg/dl (direct 15.99 mg/dl, indirect 4.41 mg/dl), creatinine 2.21 mg/dl 1
, Giraudo A. 1, Spadafora L. 1, Bracco C. 1, Silvestri A. 1, Fenoglio L.1
and azotemia 212 mg/dl. Chest radiography and electrocardiography were 1
SC Medicina Interna, AO S. Croce e Carle, Cuneo; 2 Pronto Soccorso DEA,
normal and abdominal ultrasound revealed severe hepatomegaly with stea- Ospedale Regina Montis Regalis, Mondovì (CN)
totic transformation of liver parenchyma without intra-hepatic cholestasis,
normal gallbladder and spleen, kidneys with normal total and parenchymal Background: Pyogenic liver abscess (PLA) is a suppurating infection of the
measures; ascitic fluid collection was not observed. Hepatitis A, hepatitis hepatic parenchyma that is associated with a high morbidity and mortality
B, and hepatitis C viruses were excluded by hepatitis-virus-panel investi- and develops as a complication of acute appendicitis, trauma, biliary disease;
gation. There were no laboratory evidences of infection with Hantaan virus but in a significant proportion of patients may occur without any apparent
and rickettsial disease. Based on history and typical laboratory findings, precipitating event. Early diagnosis and treatment is a crucial step in the
icterohaemorrhagic leptospirosis (Weil’s disease) was suspected. The initial management of these patients, since the presentation may be subtle and not
management consisted of intravenous administration of fluids and ceftria- very specific, so currently constitutes a challenge for physicians. Escherichia
xone (2 g IV once daily) was started. In the following days, the patient’s con- coli, Enterobacteriaceae and anaerobes cause the majority of infections, as a
dition gradually improved, jaundice decreased, renal functions improved. consequence, broad spectrum antibiotics have been used in their treatment,
The abnormalities of liver function resolved slowly within the next month, in combination with aspiration or drainage. The current study was underta-
up to which time, the bilirubin level became normal. On the twentieth day, ken to evaluate the clinical and microbiological characteristics of patients with
the patient was discharged. Micro-agglutination test (MAT) for IgM anti- PLA and to recognize if the prompt aspiration or drainage could improve the
bodies against Leptospira was positive for L. icterohaemorrhagiae (titer outcome.
1: 3200; reference value ≤ 1: 100) and confirmed clinical diagnosis. Icteric Methods: A retrospective single-center study was conducted including 109
leptospirosis is a severe disease in which the clinical course is often rapidly patients admitted to Santa Croce and Carle General Hospital, between 2000
progressive. Severe cases often present late in the course of the disease, and and November 2016 with first episodes of PLA.
this contributes to the high mortality rate, which ranges between 5 and 15%. Results: 62 patients (56.9%) were males; mean age was 65.4 ± 14.3). The
The icteric form of leptospirosis occurs in 5 to 15% of all patients. Con- majority of patients presented with fever, 73%; right upper abdominal pain
sidering the patient’s history, leptospirosis, alcoholic hepatitis, or hepatic in 63.3%, vomiting and nausea in 28.4%. The most common laboratory
cirrhosis were discussed in the differential diagnosis. Both conditions could abnormality among included items was increased C-reactive protein and
have been triggered by alcohol abuse, and are known to produce acute liver fibrinogen blood levels, respectively in 98% and 93.9% of cases. Abdominal
damage accompanied by a clinical syndrome, similar to that described in ultrasound was the diagnostic investigation in 42.4% of cases; CT scan and
the reported case. The presentation of Weil’s disease is often atypical and MR imaging were performed in 51.1% and 3.3% of cases respectively. The
organ failures may occur 4 to 9 days after the onset of symptoms. Serum mean size of liver abscess was 7 ± 3.5 cm. We observed blood or pus culture
bilirubin is frequently high and may persist for several weeks, but transami- study in 99 cases of which only 53.5% came with positive microbial reports.
nases and alkaline phosphatase are usually moderately elevated. That con- The most common organism identified was Escherichia coli (26.5%), fol-
stellation was observed in this case, and serum levels of transaminases were lowed by Enterococcus spp (11.3%). Of all PLA, in 28 cases (25.7%) the
slightly elevated and contrasted to severe jaundice. Both slightly elevated cause was not clear: cryptogenic abscess. Biliary tract diseases, including
alkaline phosphatase levels and abdominal ultrasonography confirmed the cholelithiasis, cholecystitis and malignancies, were identified in 55% of
lack of cholestasis. In a patient which presents jaundice, if the work history cases. In 11.9% of cases the cause of PLA was assigned to be haematogenous.
is suggestive, think about the possibility of leptospirosis. In 7.3% of PLA the only known risk factor for PLA was diabetes mellitus.
Intravenous antibiotic therapy started on all patients and 66.7% of cases
required intervention in different forms. An empirical antibiotic treatment
AN UNUSUAL CALF LESION IN AN was started at the onset of the clinical sign of infection and was changed
IMMUNOCOMPROMISED PATIENT upon the results of antibiotic susceptibility tests. The range of antibiotic tre-
atment duration was 29.7 ± 19.8 days (5 - 115). Ultrasound or CT-guided
Gili M.1, Charbonnier E. 1, Chasseur L.1, Chiacchiarini F.1, Costantini E.1, needle aspiration of PLA was performed in 13 patients (11%) and percuta-
Gallo S.1, Marinucci C.1, Morra Di Cella S.1 neous abscess drainage was performed on 72 patients (67%), with median
Porta M1 1 Dipartimento di Scienze Mediche - Università degli Studi - of drainage duration of 12.6 ± 14 days. The time interval between antibio-
Ospedale S. Giovanni Battista - Torino tic administration and drainage was 8.5 ± 11.7 days; later was the drainage
intervention, longer was the antibiotic treatment (p<0.001), but there was
A 71 year old male patient presented in October 2015 with a swollen and not difference in terms of outcome.
tender area in his right calf. Past history: in 2006 chronic lymphatic leu- Conclusion: PLA is a diagnostically challenging problem due to non-spe-
kemia was diagnosed, which was still in progression despite many cycles cific presenting characteristics. The microbiological yield identified was
of immune- and chemotherapy. In 2014, a nodule appeared at the left pul- a typical European spectrum with a preponderance of Escherichia coli
monary apex, increasing in volume over the following radiograms. Further infections. Once recognized, percutaneous drainage and antibiotic treat-
microbial and histological investigations were inconclusive and the lesion ment are the mainstay of management for PLA and earlier was the drainage
was interpreted as pulmonary localization of the disease. A new immu- intervention, shorter was the antibiotic treatment
notherapy cycle was then administered but the lesion enlarged. Recent
history: in September 2015 the patient reported persisting fever despite
wide spectrum antibiotics. In October a tender swelling appeared at the INCIDENCE AND CLINICAL IMPACT OF SPLENIC
right calf, which was initially considered a spontaneous hematoma but wor- EMBOLI IN A LARGE COHORT OF INFECTIVE
sened over the following weeks. At the same time a skin lesion appeared on ENDOCARDITIS (IE) PATIENTS
the back, where a transcutaneous biopsy had been performed. The leg lesion
was drained and a culture revealed growth of Nocardia. Trimethoprim/ Pafundi P.C., Cesaro F., Ursi M.P., Vitrone M., Andini R., Ragone E.,
sulfamethoxazole (1200/240mg tid) was started, leading to rapid improve- Albisinni R., Zampino R., Durante-Mangoni E.
ment. A few months later the germ developed resistance to trimethoprim, Internal Medicine, University of Campania “Luigi Vanvitelli” and Unit of
which was replaced by ceftriaxone and an aminoglycoside, obtaining com- Infectious and Transplant Medicine, Monaldi Hospital, Napoli
plete resolution of the infection. A new course of immunotherapy could be
started in May 2016. Nocardiosis: immunodeficiency states, particularly in Introduction: Embolic events (EE) represent a frequent and important com-
hematological patients, is a main risk factor for disseminated Nocardiosis. plication of IE (observed incidence 20-50%) and are associated with an incre-
The infection can spread to almost every tissue and, if not treated with pro- ase in morbidity and mortality rates. Most frequent embolization sites are the
longed appropriate antibiotic therapy, the prognosis is poor. central nervous system (>30%) and the spleen (19-36%). Several studies have
assessed incidence, risk factors and outcome of EE in IE, identifying some
general risk factors (e.g., vegetation size, mitral valve involvement, and some
A 16-YEAR RETROSPECTIVE ANALYSIS OF etiologic agents, such as S. aureus and St. bovis). However, there are very few
PRESENTATION PATTERNS, MICROBIOLOGICAL data on incidence and clinical consequences of splenic emboli in IE.
8
Methods: This is a retrospective study on prospectively collected data mortality.

from 632 consecutive patients admitted to our Unit at the Monaldi Hospi- Methods: An active surveillance program was conducted from January
tal between Dec ‘99 and Mar ‘17, for definite or probable IE, according to 2014 to December 2014 among two Internal Medicine Inpatient Units (75
Duke’s diagnostic criteria. Clinical data, hematochemical and microbiolo- inpatient beds) of Policlinico Agostino Gemelli, Catholic University of
gical parameters, echocardiographic and other imaging examinations; sur- Rome. Every patient for whom the managing physician had requested blood
gical procedures and mortality were recorded and evaluated; first compa- coltures collection was evaluated (screened) in order assess the presence of
ring patients with or without embolic events and then focusing on splenic SIRS criteria. Thus, a total of 226 consecutively patients were screened. The
emboli risk factors. screening program consisted in the collection of clinical characteristics
Results: In line with the current knowlegde on EE in IE, it emerged that (gender, age, body mass index, risk factors for infections, risk factors for
patients experiencing EE were significantly younger, had significantly MDR infections, co-morbidities, vital signs, mental status), clinical scores
higher C-reactive protein, as well as leukocytes and D-dimer values. EE (MEDS, SCS, REMS, SOFA), and laboratory results (blood tests, blood gas
were also found mostly in subjects with left-sided IE (48.2%) and the major analysis, c reactive protein, procalcitonin, lactates, D vitamin levels, beta-
etiologic agent involved was S. aureus (p = 0.0001). A more specific analysis D-glucane, galactomanname) at admission, at 48h and 7 days from admis-
was performed on the group of patients with embolism (n = 254), split in sion. Exclusion criteria were represented by: absence of SIRS criteria, nega-
two subgroups: with splenic emboli (n=95) and with other types of emboli tive blood coltures. Thus, a total of 88 microbiologically-identified septic
(n=159). At the univariate analysis, predictive factors for a splenic embolic patients were enrolled in the study. The evaluation of qSOFA was performed
event were left-sided IE location (78.9% vs 29.7%, p=0.000), community retrospectively, according to SEPSIS-3 definition.
acquired infection (77.9%, p=0.002), the type of pathogen involved, espe- Results: Among the 88 enrolled patients, 51 (57.9%) were male, median
cially enterococci and streptococci (50.5%; p=0.001). Among comorbi- age 75y.o. (IR 65-82 yo, range 37-94). The median BMI was 21.6 +/- 9.3. A
dities, a prior acute myocardial infarction was more prevalent in subjects total of 36 (40.9%) were immunosuppressed, 32 (35.9%) were diabetic, 35
with embolism different from splenic (4 vs 25 cases; p=0.008), whilst aortic (39.3%) were affected by neoplasms, 62 (70.4%) had received an antibio-
and mitral regurgitation were significantly higher in patients with splenic tic treatment in the previous 6 months, and 14 (15.9%) had had an MDR
embolism (p=0.000). These variables were included in a multivariate model, infection in the previous 6 months. A total of 66 (75%) of patients were
from which IE localization (p=0.000, OR 0.589, 95% C.I.: 0.448-0.774), type carriers of vescical or central venous catheter. Finally, 21 (23.9%) were
of pathogen (p=0.034; OR 1.293, 95% C.I.: 1.019–1.639) and presence of affected by an end-stage illness. The median systolic pressure was 83 mmHg
aortic or mitral regurgitation (p=0.000; OR 3.869, 95% C.I.: 2.082–7.190 (IR 73-90, range 51-115), mean lactate level was 2.02+/-2 mmol/l, median
and p=0.000; OR 4.153, 95% C.I.: 2.242–7.693, respectively) but not the PCT 2.79 (IR 0.7-19.2, range 0-100), median SCS 10.39 (IR 6-13, 63% clas-
type of acquisition (p=0.408; OR 0.800, 95% C.I.: 0.472-1.357), emerged as sified as high or very high risk), mean SOFA 10.3+/-4.6, mean MEDS 10.12
independent predictors of the outcome. +/- 4.4, REMS 7.47 +/- 3.1, mean qSOFA 1.02 +/- 0.9. Median vitamin D
Discussion: Embolic events are frequently observed IE complications and levels were <7 ng/ml (IR <7-9.4, range <7-55). A total of 23 (26.1%) died
impact on morbidity and mortality rates. 40.2% of our cohort experimented at 30-day, while 31 (35.2%) died at 90-day from admission. At multivariate
EE and, among these, 37.4% involved the spleen. Hence, the identification analysis, mean urinary output, age, pO2/FiO2 ratio, qSOFA score, MEDS
of patients with IE at higher risk of EE is fundamental to a better manage- score, REMS score, SCS score, D vitamin levels, history of infection in the
ment of the disease. Our data confirms the literature with regard to embolic last 6-months, end-stage illness, parenteral nutrition, hig-risk at SCS score
events in general in IE; however no study focused on splenic emboli in IE. and a recent antibiotic treatment within the previous 6-months resulted to
Our analyses have found, as possible predictive factors for EE in IE: endo- be significantly associated with mortality at 30-days (p<0.01) and at 90-days
carditis site, major left heart prevalence, source of infection mainly com- (p<0.01). After logistic regression, low D vitamin levels, low pO2/FiO2 ratio,
munity and presence of aortic/mitral regurgitation, most involved etiologic history of infection within previous 6-months and a high MEDS score were
agents enterococci and streptococci (in general EE in IE are associated with independently associated with the primary outcome (p<0.01). Stepwise
S. aureus infection). regression model allowed us to identify independent predictors of mortality
in our patients: high MEDS score at admission (OR 1.21, 95%CI 1.00-1.53,
p<0.05), low pO2/FiO2 ratio (OR 0.98, 95%CI 0.97-0.99, p<0.01) and low
SEPSIS AMONG INTERNAL MEDICINE PATIENTS: D vitamin levels (OR 0.83 95%CI0.69-0.96, p<0.01) were independent pre-
CLINICAL CHARACTERISTICS AND PREDICTORS OF dictors of 30-day mortality. Moreover, high MEDS scores at admission (OR
MORTALITY 1.24, 95%CI 1.08-1.49, p<0.01) and low D vitamin levels (OR 0.83, 95%CI
0.72-0.94, p<0.01) were independent predictors of 90-days mortality.
Conclusions: Patients admitted to Internal Medicine wards with a systemic
Mirijello A.1,2, Zaccone V. 1, Impagnatiello M. 1, Tosoni A. 1,
infection show peculiar clinical characteristics, different from those of ICU
Passaro G. 1, Vallone C.V. 1, Cossari A. 3, Ventura G. 4,
patients. Internal Medicine patients affected by sepsis show mortality rates
Gambassi G. 1, Gasbarrini A.1, De Cosmo S. 2, Addolorato G. 1, Landolfi R. 1
in line with the literature and with ICU patients. MEDS score and D vitamin
& Internal Medicine Sepsis Study Group1
levels could be a useful clinical predictor of mortality. Larger observational
1
Department of Medical Sciences, Gemelli Hospital, Catholic University of
and prospective studies are needed to confirm our data.
Rome, Rome, Italy; 2Department of Medical Sciences, IRCCS Casa Sollievo
della Sofferenza Hospital, San Giovanni Rotondo, Italy; 3Department of
Economics, Statistic and Finance, University of Calabria, Rende, Italy; 3Clinic
of Infectious Diseases, Gemelli Hospital, Catholic University of Rome, Rome, NON-INTENSIVE CARE UNIT ACQUIRED PNEUMONIA
Italy. IN INTERNAL MEDICINE. RETROSPECTIVE ANALYSIS OF
RISK AND OUTCOME VARIABLES IN A TWELVE-MONTH
Background: Sepsis represents a major health problem among Internal PERIOD AT A HOSPITAL IN NORTHERN ITALY
Medicine patients. Difficulties in the clinical management (e.g. early dia-
gnosis and optimal treatment) are associated with an increased rate of com- Tricarico L., Bracco C., Brignone C., Gollè G., Serraino C.,
plications and economic costs due to a prolonged inpatient stay. At present, Melchio R., Pomero F., Mana F., Fenoglio L.
most of septic patients are admitted to Internal Medicine Departments. Medicina Interna ASO Santa Croce e Carle Cuneo
These patients show a worse prognosis than those admitted to Intensive
Care Units. This difference seems to be due to several factors related both Background: Hospital-acquired pneumonia (HAP) is one of the leading
to patients’ characteristics (i.e. older age, affected by chronic diseases and nosocomial infections and it is associated with high morbidity, prolongation
on poly-pharmacotherapy), either to physicians’ characteristics (the mana- of hospital stay and mortality. Some authors have highlighted that the majo-
gement of sepsis/septic shock varies depending on the specialty of the phy- rity of studies on HAP have been conducted in patients hospitalized in the
sician who handles the case), and to a general lack of literature data on this intensive care unit (ICU), since mechanical ventilation represents a major
specific population of patients (e.g. lack of validated predictive and progno- risk factor for nosocomial pneumonia. It is therefore necessary to study in
stic scores). deep the problem for patients acquiring HAP in general wards, who may
Aim: Aim of the present study was to investigate the clinical characteri- have peculiar features and risk factors.
stics and prognostic factors of septic patients admitted to Internal Medi- Methods: we conduced a retrospective study on 246 patients hospitalized
cine Units, by a retrospective analysis of prospectively collected data. The in our Internal Medicine department between January 2015 and Decem-
primary outcome consisted in the evaluation of the mortality rate at 30-days ber 2015. Each case of Non-Intensive Care Unit Acquired Pneumonia was
and 90-days from admission in order to identify significant predictors of matched with patient with diagnosis at discharge of CAP o HCAP, who were
9
hospitalized in the same period of time. Data on incidence, risk factors, also determined. We aimed at studying the possible involvement of DNA
patient characteristics and outcomes were collected. methylation in trace element-linked proteins dysregulation and eventually
Results: The study group comprised 24 patients with NIAP, 68 HCAP in HCC progression.
and 154 CAP. We analyzed some characteristics and what emerges is that: Methods: Cu, Zn and Se, Cd, Co were measured in liver cancer tissues and
- 22.73% of cap, 33.33% of niap and 41.18% of hcap have tumor in their serum of HCC patients undergoing hepatic curative surgery by Inductively
anamnesis (p 0.018) - 0% of cap and hcap and 4.17% of niap have naso- Coupled Plasma Mass Spectrometry (ICP-MS) analysis. Gene expression
gastric tube before the diagnosis of pneumonia (p 0.098) - 13.64% of cap, profiles and DNA methylation at promoter of ZIP8, ZIP14, MT1 (MT1G,
37.50% of niap and 26.47 % of hcap have done immunosuppressive tre- MT1H), MT2 genes were determined by a microarray genome-wide
atment in the last 12 months (p 0.005) - 11.69% of cap, 25% of niap and approach.
19.12% of hcap have done inhaled steroid therapy in the last 12 months (p Results: Serum levels of Cu, Zn, Se did not show differences and were
0.129), - 43.51% of cap, 87.5% of niap and 69.12% of hcap have used ppi within the reference limits among all the patients. Tissue levels of Zn, Cd, Se
(p 0.000), - 14.94% of cap, 50% of niap and 22.06% of hcap died 3 months and Co were, instead, markedly decreased in HCC as compared to normal
later the diagnosis (p 0.003) - The median age was 77.87 years in patients tissues; Cu levels did not differ significantly between HCC and N tissues.
with CAP (sd: 12.36), 74.58 years in patients with NIAP (sd: 13.58), 78.66 There was however, a substantial increase of Cu serum levels if HCC develo-
years in patients with HCAP (sd: 10.36) p 0.163 - The median incubation ped in an underlying cirrhotic liver as compared with a steatosic or normal
in NIAP is 9.66 days (sd 6.3) p 0.000 - The mean heart rate is 93.70 bpm in liver. Moreover, ZIP8 and ZIP14 transporters, MT1 (MT1G, MT1H), MT2
patients with CAP (sd 19.48), 95.29 bpm in patients with NIAP (sd 14.09), chaperone genes were repressed with a consensual promoter hypermethyla-
95.77 bpm in patients with HCAP (sd 20.36) p 0.128 - The mean breath fre- tion in HCC liver tissues as compared to N tissues.
quency is 18.42 respiratory acts per minute in patients with CAP (sd 5.43), Conclusions: We show the novel finding of a significant reduction of Zn
23.33 respiratory acts per minute in patients with NIAP (sd 4.16), 17.80 and Cd levels in HCC tissues, together with a gene repression of ZIP8,
respiratory acts per minute in patients with HCAP (sd 4.13) p 0.246 - The ZIP14, MT1, MT2 transporters linked to promoter gene hypermethylation
mean body temperature is: 37.92 °C in patients with CAP (sd 1.20), 37.46 °C suggesting an early, epigenetic-based dysregulation of Zn and Cd depletion
in patients with NIAP (sd 1.13), 37.53 °C in patients with HCAP (sd 1.04) in HCC. The lower Se in HCC tissues may have a role in cancer progression
p 0.420 - The average value of Na is: 138.49 mmol/l in patients with CAP given its ROS scavenger activity. The Cu levels increase in HCC developing
(sd 6.96), 139.58 mmol/l in patients with NIAP (sd 6.08), 138.14 mmol/l in cirrhotic liver suggests a role of Cu in early carcinogenesis phases possi-
in patients with HCAP (sd 6.47) p 0.609 - The average value of K is: 4.17 bly through oxygen free radicals production. These evidences provide new
mmol/l in patients with CAP (sd 0.61), 4.35 mmol/l in patients with NIAP insights into the role of trace elements in HCC carcinogenesis.
(sd 0.83), 4.26 mmol/l in patients with HCAP (sd 0.76) p 0.030
Conclusions: our study shows that the variables significantly associated
with Non-Intensive Care Unit Acquired Pneumonia are an immunosop- THE ALBI GRADE PREDICTS SURVIVAL IN PATIENTS
pressive therapy over the last 12 months and treatment with PPI. Immuno- WITH HEPATOCELLULAR CARCINOMA UNDERGOING
depression and the use of PPI can thus represent significant risk variables in TRANSARTERIAL CHEMOEMBOLIZATION (TACE)
the development of NIAP in patients in Internal Medicine. Another intere-
sting point is that the patient’s neoplastic history is a risk factor for the onset Campani C., Dragoni G., Aburas S., Inghilesi A.L., Arena U., Laffi G., Marra
of NIAP versus CAP (this is not true, however, if the NIAP is compared with F., for the Ita.Li.Ca. study group Dipartimento di Medicina Sperimentale e
HCAP). The mortality attributed to HAP outside the ICU in our study is Clinica, Università di Firenze
50%, that does not deviate much from the mortality attributable to Vap, that
is 27% up to 43% in case of MDR agent. Instead the mortality attribuited Background and Aims: The prognosis of hepatocellular carcinoma is not
to NIAP on all the patients died in 2015 is 9,7%. This makes us understand solely influenced by the extent of anatomic spread of the cancer but also by
how these pneumonia are important for the patient’s prognosis and how the severity of liver dysfunction. This makes the assessment of prognosis
important is the prevention of them. It is interesting to observe the 9-day in individual patients difficult. Child-Pugh (CPS) and model for end-stage
incubation time in Non-Intensive Care Unit Acquired Pneumonia because liver disease (MELD) scores are widely used but have considerable limita-
this leads us to consider the need to be very careful whenever possible in tions. Recently, the prognostic value of albumin-bilirubin (ALBI) grade has
prolonging the stay time hospitalization. Our study also shows that in 2015 been evaluated in patients undergoing resection of HCC or treatment with
the incidence of HAP outside the ICU was 10,95 cases per 1,000 dischar- different modalities. Nonetheless, its predictive role in patients undergoing
ges. This is a much higher value than the one reported in literature (1.6 to TACE has not been evaluated.
3.67 cases per 1000 admissions), and that makes us understand how little Methods: We retrospectively evaluated the prognostic significance of ALBI
is known yet and how many studies have yet to be done on this category of in patients undergoing TACE recorded in the Ita.Li.Ca. database, and com-
pneumonia. pared it with other prognostic systems, including MELD, CPS, hepatoma
arterial-embolization prognostic (HAP) and mHAPII.
Results: 1508 TACE performed in 1143 consecutive patients between
ESSENTIAL TRACE ELEMENTS AND January 2008 and December 2014 were evaluated. Patients had a median
HEPATOCARCINOMA: UNRAVELLING NOVEL MELD of 9 and belonged to all BCLC stages; 793 TACE were perfomed
EPIGENETIC MECHANISMS INVOLVED IN LIVER in the BCLC-A stage, 508 in BCLC-B and 279 in BCLC-C. Median overall
CARCINOGENESIS survival in the whole population was 34,6 months (41.6 mo. for ALBI 1,
34.5 for ALBI 2 and 22.3 for ALBI 3). Considering all TACE procedures,
Mazzi F. 1, Udali S. 1, De Santis D. 1, Ruzzenente A. 2, Moruzzi S. 1, Beschin irrespective of the BCLC stage, the ALBI grade was a significant predictor of
G. 1, Campagnaro T. 2, Pattini P. 1, Franceschi A. 1, overall survival (OS, P<0.0001), similar to the HAP and the mHAP scores
Olivieri O. 1, Guglielmi A. 2, Perbellini L. 3, Choi S.W. 4,5, Friso S. 1 (P<0.0001). When patients in different BCLC stages were considered, ALBI
1
Department of Medicine, University of Verona School of Medicine, Verona, was a significant predictor of OS only in BCLC-A (p<0.046) and BCLC-C
Italy 2 Department of Surgery, University of Verona School of Medicine, (p<0.033) patients treated with TACE, whereas HAP and mHAPII predi-
Verona, Italy 3 Department of Diagnostics and Public Health, Unit of cted OS across all BCLC stages. Similar data were obtained when only the
Occupational Medicine, University of Verona School of Medicine, Verona, first TACE procedure was considered in each patient (total of 1143 patients,
Italy 4 Tufts University School of Nutrition Science and Policy, Boston, MA, 517 BCLC-A, 313 BCLC-B and 188 BCLC-C). Considering all BCLC stages,
USA 5 Chaum Life Center, CHA University, Seoul, Korea ALBI was a significant predictor of overall survival (p<0.012) similar to the
HAP and mHAPII scores (p<0,001 and p<0,012, respectively). When diffe-
Background and Aims: Hepatocellular carcinoma (HCC) is the second rent BCLC stages were considered, ALBI and HAP were significant predic-
most common cause of death from cancer, worldwide. The etiology and tors of OS in BCLC-C (p 0,038 and 0,03 respectively), whereas mHAPII was
factors involved in its development remain, however, largely unknown. not significant. Survival in the whole population was 37.5 mo. (37.9 mo. for
A marked decrease in mineral trace elements is related to the genesis of ALBI 1, 37.5 for ALBI 2 and 28.4 for ALBI 3).
several diseases including cancer but their role in carcinogenesis, including Conclusions: ALBI provides an additional simple and objective method
that of HCC, is yet not fully defined. We investigated an ample set of trace of assessing liver function in HCC, and may be useful for selecting patients
elements amounts in serum, HCC tissues and homologous non-neoplastic more likely to survive after TACE, particularly in those belonging to the
liver tissues (N) in samples of patients affected by HCC. Gene expression BCLC-A and –C stages.
and promoter DNA methylation of major element-transport proteins were
10
IN ITALIAN NAFLD PATIENTS RARE CERULOPLASMIN there was no significant difference in the frequency distribution of PCSK7
VARIANTS ASSOCIATE WITH DYSMETABOLIC rs2369918G>C and GNPAT rs11558492 (D519G) between the two groups.
HYPERFERRITINEMIA AND INCREASED HEPATIC IRON Conclusions: CP variants seem associated with dysmetabolic HyperFt
STORES: A NGS STUDY development, and likely with increased hepatic iron stores, in NAFLD.
Future studies are necessary to confirm these findings in larger cohorts and
Corradini E. 1, Bernardis I. 2, Dongiovanni P. 3, Buzzetti E. 1, Artuso L. 2, to evaluate their clinical relevance.
Pelusi S. 3, Tenedini E. 2, Tagliafico E. 2, Rametta R. 3, Fracanzani A.L. 3,
Fargion S. 3, Pietrangelo A.1,Valenti L.V. 3
1
Division of Internal Medicine 2 and Center for Hemochromatosis, University LIVER CANCER (NOT ETIOLOGY, STEATOSIS OR
Hospital of Modena, Modena, Italy 2Center for Genome Research, University FIBROSIS) IS AN INDEPENDENT PREDICTOR OF
of Modena and Reggio Emilia, Modena, Italy; Department of Medical and ELEVATED SERUM PERIOSTIN CONCENTRATION
Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy 3 AMONG CAUCASIAN PATIENTS WITH LIVER DISEASE
Department of Pathophysiology and Transplantation, Università degli Studi
di Milano and Internal Medicine and Metabolic Diseases, Fondazione IRCCS Mulas V.,1 Barbaglia M.N.,1 Tran Minh M.,1 Bianco S.,1 Re A.,1
Ca’ Granda Ospedale Policlinico di Milano, Milan, Italy Salmi L.,1 Barizzone N.,2 Camatta D.,1Sguazzotti M.,1 Daffara F.,1 Minisini
R.,1 Pirisi M.1
Background: hyperferritinemia (HyperFt) is frequent in males with dysme- Dipartimenti di Medicina Traslazionale1 e Scienze della Salute2, Università
tabolism and has been associated with altered hepatic iron metabolism, incre- del Piemonte Orientale, Novara
ased hepatic iron stores, and worse hepatic and cardiometabolic outcomes
in patients with nonalcoholic fatty liver disease (NAFLD) and features of Rationale and Aim: Periostin promotes liver steatosis and hypertriglyceri-
metabolic syndrome. NAFLD is a multifactorial disease resulting from inte- demia through downregulation of peroxisome proliferator–activated recep-
raction of genetic and environmental factors. Thus identification of genetic tor α, which makes this extracellular matrix protein a potential therapeutic
risk factors for HyperFt and iron deposition can help understand disease target for both non-alcoholic fatty liver disease (NAFLD) and dyslipide-
pathophysiology and improve management of patients. Aim: we aimed to mia.1 Moreover, since Asian patients with NAFLD have high serum levels
evaluate novel genetic risk variants in candidate iron genes associated with of periostin compared to controls, it has been suggested that circulating
dysmetabolic HyperFt development in NAFLD.
Matherials and Methods: from a cohort of 347 individuals with histological periostin may have a role as a biomarker of NAFLD.2 However, these latter
NAFLD (alcohol intake < 30/20 g/day in M/F) and evaluation of circula- findings could not be replicated in Caucasians.3 In the present study, we
ting iron metabolism, hepatic iron staining and genetic characterization, we aimed to verify the possible association of serum periostin with histologi-
selected 24 cases (HyperFt) and 24 controls (NormoFt). We first excluded cally graded steatosis, stage and etiology of liver disease. Moreover, given
patients carrying beta-thalassemia trait, persistently increased transferrin the abovementioned ethnic differences, we were interested in evaluating
saturation (suggesting a hemochromatosis phenotype), anemia, inflam- the possible relationship between genetics of periostin and serum periostin
mation, and female sex due to the lower representation and the possible concentration.
confounding effect of blood losses and menopause. Among patients with Methods: N.=155 patients with either NAFLD (Group A, N.=74; in 10 cases
positive histological iron staining, after exclusion of patients carrying HFE complicated by hepatocellular carcinoma, HCC; N.=37 males) or hepati-
genotype at risk of iron overload (C282Y+/+, C282Y/H63D, H63D+/+), tis C virus (HCV) infection (Group B, N.=81, in 7 cases complicated by
and mutations altering protein sequence of ferroportin (the only known HCC; n.=40 males), as well as in N.=27 healthy controls (Group C, N.=27;
iron exporter in mammals), we selected 24 pts with higher ferritin levels 11 males), were studied. Serum periostin concentrations were measured by
(>750 ng/ml) (HyperFt patients), and compared to 24 pts with negative the Human Periostin/OSF-2 DuoSet ELISA (R&D Systems, Inc., Minneapo-
iron staining and lowest ferritin (NormoFt patients). Since we previously lis, USA). Based on single nucleotide polymorphisms rs9603226, rs3829365,
demonstrated that HyperFt correlates with liver iron content, independently and rs1029728 of the POSTN gene, haplotype analysis was carried out
of age and several confounders in the original NAFLD cohort, we chose both in patients and controls using the Haploview software (Broad Insti-
ferritin > 750 ng/ml as clinical marker of hepatic iron excess. A custom tute, Cambridge, USA). All cases of benign liver disease were histologically
AmpliSeq™ Next-Generation Sequencing (NGS) panel of 33 genes associa- proven and had grade and stage defined. HCC was diagnosed at imaging
ted to iron homeostasis was designed and tested using Ion Torrent PGM and/or confirmed histologically according to the EASL-EORTC clinical
platform (Life Technologies). The panel was composed by genes related to practice guideline criteria. All controls underwent transient elastography
hereditary hemochromatosis, iron transport, signaling pathways regulating with measure of the controlled attenuation parameter.
the key iron hormone hepcidin, and others. Data analysis has been perfor- Results: The median (interquartile range, IQR) serum periostin concentra-
med using Ion Torrent Suite™ Software (Life Technologies), Annovar, VEP, tion was 11.6 ng/ml (8.7-13.3); it was 10.9 ng/ml (7.7-14.6) in Group A,
and an in-house pipeline. Literature information and in silico predictions 12.0 ng/ml (9.8-16.5) in Group B, and 12.0 ng/ml (9.0-16.3) in Group C,
(ClinVar, dbNSFP, SPIDEX, dbscSNV, HSF, NNSPLICE) were used for the respectively (p=0.06). The Table presents the analysis of serum periostin
prioritization of possibly pathogenetic mutations. NGS sequencing resulted based on the severity of liver disease, categorized as absent/mild fibrosis
in a mean coverage of 450X mapped reads, with 89.9% mean uniformity and (Kleiner stage 1 or lower, Ishak stage 1 or lower, stiffness <5.9 kPa), mode-
95.4% of target regions covered at least 30x (94%>50x). rate fibrosis (Kleiner stage 2, Ishak stage 2-3), advanced fibrosis (Kleiner
Results: HyperFt patients were older (57±10 vs. 49±9 yrs, p<0.01), and stage 3 or higher, Ishak stage 4 or higher), and HCC (p values refer to Kru-
expectedly had higher ferritin (median 1099, IQR 953-1391 vs. 94, 53-122; skal-Wallis test).
p<0.0001) and transferrin saturation (35±11 vs. 24±7%; p=0.0003), but had
non-significantly different prevalence of type 2 diabetes (15% vs. 10%), Serum Periostin Fibrosis Fibrosis Fibrosis HCC
obesity (18% vs. 8%), hypertension (22% vs. 16%), and definite nonalcoholic (ng/ml) minimal/absent moderate advanced
steatohepatitis (6% vs. 6%). Results showed a significantly different distribu-
(N.=79) (N.=38) (N.=48) (N.=17)
tion of potential pathogenic variants between the two clinical groups, found
in 54% of HyperFt cases and 0.04% of NormoFt patients (p=0.0001, Fisher’s Total 10.5 (8.1-15.0) 12.0 (10.8-15.5) 11.1 (8.4-13.6) 16.8 (12.3-18.9)
exact test). Group A 9.9 (6.8-13.1) 10.9 (7.1-11.3) 10.2 (7.7-14.7) 15.4 (12.1-18.3)
Ceruloplasmin (CP), a copper-protein acting as a ferroxidase whose
Group B 10.4 (7.8-14.4) 13.1 (10.9-16.5) 11.5 (8.9-18.2) 18.2 (15.4-50.1)
absence is associated with systemic iron loading leading to aceruloplami-
nemia, resulted to be the most mutated gene, with the identification of 4 Group C 12.0 (9.1-16.3) - - -
different variants (harbored in heterozygosis by 6 HyperFt patients, p<0.01).
After literature review, polymorphisms reported as possibly pathogenetic Serum periostin was not associated with the degree of histologically graded
were included in the analysis (as TF c.829G>A or CP c.1652C>T) resul- steatosis, either in Group A (p=0.409) or in Group B (p=0.899). Further-
ting in 78% of HyperFt patients with variants possibly affecting iron meta- more, it had a trend to be inversely related to body mass index (Spear-
bolism (respect to 38% of NormoFt patients, p=0.0016). Polymorphisms man Rho= 0.134, p=0.086), and did not change with age (Spearman Rho
reported to modulate iron phenotype were studied as well. Among these, = 0.064, p=0.392). However, the serum periostin concentration increased
the TMPRSS6 A736V, which distribution was not significantly different in inverse relationship with levels of platelet count (≥150, 100-149, <100
between IperFt and NormoFt patients. Beyond the iron-panel, patients were Å~109/L). Finally, possession of the haplotype 2 (rs9603226 = G, rs3829365
checked for polymorphisms previously associated to advanced liver fibro- = C, rs1028728 = A; N.=116) was associated with lower serum periostin
sis or severe iron overload in classic HFE-hemochromatosis: respectively
11
in comparison to all other haplotypes (haplotypes 3-6, N.=65, none had a Rationale and aim. Recently, several groups have reported a surprisingly
haplotype 1) (11.3 pg/ml, IQR 8.1-15.5 vs. 12.3, IQR 9.7-17.1, p=0.039). At high rate of either de novo or recurrent hepatocellular carcinoma (HCC)
multivariate analysis, conducted having age, gender, POSTN haplotype, pla- early after treatment of chronic hepatitis C with direct antiviral agents
telet count and HCC as predictor variables, the only independent predictor (DAA). Both the very existence of this phenomenon and its putative expla-
of a serum periostin concentration in the highest quartile of the study popu- nation (sudden loss of host immune control in the liver) have been questio-
lation was HCC (OR=7.3, 95%CI 1.8-29.9, p=0.005). ned; in fact, many believe that what has been observed is simply the result
Conclusions: In Caucasians, serum periostin concentrations are not of treating patients with far more advanced disease compared to the past,
influenced by etiology of liver disease, fibrosis progression or degree of ste- among whom a fair number may harbor hidden HCC foci. It must be noted
atosis. Patients with HCC have significantly higher periostin levels. Geneti- that in the presence of active HCC the chances of successful anti-hepatitis
cally determined differences may account for some of the variability obser- C virus therapy with DAA have been shown to be decreased. In the present
ved among NAFLD populations of different ethnic origin. study, our aims were a) to provide further data on the rates of early HCC
References: 1.J Clin Invest 2014;124:3501-13; 2.Endocrine 2016;51:91-100; occurrence/recurrence in today’s DAA era; b) to identify possibly associated
3. Endocrine 2017;56:438-41 factors.
Methods: N.=286 consecutive patients (N.=166 males; median age 64 years;
66% cirrhotics; N.=13 with a previous diagnosis of HCC) who received
ADHERENCE TO MEDITERRANEAN DIET AND NON- a DAA regimen with or without ribavirin were studied. All were free of
ALCOHOLIC FATTY LIVER DISEASE: EFFECT ON suspicious nodules before starting DAAs and were followed up for at least 6
INSULIN RESISTANCE months after treatment was concluded. Circulating micro RNA (miR) -122,
-373 and -155 were quantified on serum samples obtained at baseline, at
Pastori D. 1,2, Baratta F. 1,2, Polimeni L. 1, Bucci T. 3, Ceci F. 4, Calabrese C. 1, the end of treatment and at week 12 post-treatment (timing of definition
Ernesti I. 5, Violi F. 1, Angelico F. 6, Del Ben M. 1 of sustained viral response, SVR12) from patients who developed HCC
1
I Clinica Medica, Department of Internal Medicine and Medical (group A) and a selection of control patients (n.=30; group B) who did not,
Specialties, Sapienza University of Rome, Italy. 2 Department of extracted from the same population and matched for age and sex with group
Anatomical, Histological, Forensic Medicine and Orthopedics Sciences - A patients.
Sapienza University of Rome, Italy. 3 Department of Medical Specialties, Results: During the first 24 weeks after treatment completion, de novo HCC
Salerno University of Medicine, Salerno, Italy. 4 Department of Cellular was detected in 9/273 patients (incidence rate 7.1% per year); recurrent
Biotechnologies and Hematology, “La Sapienza” University, Policlinico HCC was observed in 2/13 patients (incidence rate 33.4% per year). These
Umberto I Hospital, Rome, Italy. 5 Department of Experimental Medicine, 11/286 patients did not differ with regard to age, gender, baseline viral load
Section of Medical Pathophysiology, Endocrinology and Nutrition, Sapienza and liver biochemistry parameters from the remaining 275/286 patients.
University, Rome, Italy. 6 Department of Public Health and Infectious However, as compared to the latter, they did have a significantly higher
Diseases, Sapienza University of Rome, Italy liver stiffness at transient elastography (median 21.5 kPa, IQR 17.8-34.3 vs.
14.3, IQR 10.9-22.8; p=0.029), as well as lower hemoglobin (131 g/L, IQR
Objectives: The prevalence of cardio-metabolic disorders, including non-al- 107-143 vs. 140, IQR 130-151; p=0.040). Moreover, they displayed a trend
coholic fatty liver disease (NAFLD), is increasing in western countries, due towards having higher body mass index (29.7 kg/m2, IQR 26.2-33.2 vs. 25.6,
to changes in lifestyle and dietary habits. Mediterranean Diet (Med-Diet) is IQR 22.9-29.4). Importantly, the intention-to-treat SVR12 rates were lower
effective for cardiovascular prevention, but its relationship with NAFLD has among patients with de novo/recurrent HCC than among their counterparts
been scarcely investigated. HCC-free at the end of follow up (7/11, 64% vs. 261/275, 95%; p<0.001). At
Methods: We included 584 consecutive outpatients presenting with ≥1 multivariate logistic regression, body mass index (OR=1.27, 95%CI 1.06-
cardiovascular risk factor such as type 2 diabetes mellitus (T2DM), arte- 1.51, p=0.009), previous HCC (OR=41, 95%CI 3.32-507, p=0.004) and
rial hypertension, overweight/obesity and dyslipidaemia. Liver steatosis SVR12 (OR=0.03, 95%CI 0.004-0.30, p=0.002) were independent predictors
was assessed by ultrasonography. Med-Diet adherence was investigated by of HCC occurrence/recurrence. Circulating miR concentrations at baseline
a validated semi-quantitative 9-item dietary questionnaire; patients were were not different between group A and group B patients; however, serum
divided into low, intermediate and high adherence. Insulin resistance was miR-122 concentrations declined between baseline, end-of-treatment and
defined by the 75th percentile of HOMA-IR (≥3.8). post-treatment week 12 among group B (p=0.015) but not among group A
Results: Mean age was 56.2±12.4 years and 38.2% were women. Liver ste- patients (p=0.165).
atosis was present in 82.7%, and its prevalence decreased from low to high Conclusions: Advanced disease, excess body weight, and failure to clear the
adherence group (96.5% vs. 71.4%, p<0.001). In a multiple logistic regres- virus (accompanied by relatively flat kinetics of miR-122) identify patients
sion analysis, hypertriglyceridemia (Odds Ratio (OR):2.913; p=0.002), who develop early HCC occurrence/recurrence following DAA treatment,
log(ALT) (OR:6.186; p<0.001), Med-Diet adherence (intermediate vs. low suggesting that treatment per se does not favor the emergence of HCC; on
OR:0.115; p=0.041, high vs. low OR:0.093; p=0.030), T2DM (OR:3.940; the contrary, it is likely that undetected foci of active HCC, already present
p=0.003) and high waist circumference (OR:3.012; p<0.001) were associa- before starting treatment, emerge. A practical implication of these findings
ted with NAFLD. Among single foods, low meat intake (OR:0.178; p<0.001) is that patients with the above high risk features should have counseling
was inversely significantly associated with NAFLD. In 334 non-diabe- and surveillance optimized before and after DAA treatment of hepatitis C.
tic NAFLD patients, age (OR:1.035, p=0.025), high waist circumference
(OR:7.855, p<0.001), hypertriglyceridemia (OR:2.152, p=0.011) and
Log(ALT) (OR:2.549, p=0.002) were directly associated with HOMA-IR, REACTIVE HYPEREMIA INDEX (RHI) AND ARTERIAL
while Med-Diet score was inversely associated (OR:0.801, p=0.018). STIFFNESS INDEXES ARE ASSOCIATED WITH
Conclusions:. We found an inverse relationship between Med-Diet and HISTOLOGIC MARKERS OF LIVER DISEASE IN SUBJECTS
NAFLD prevalence. Among NAFLD patients, good adherence to Med-Diet WITH NON-ALCOHOLIC FATTY LIVER DISEASE
was associated with lower insulin resistance. Our findings suggest that Med- (NAFLD) WITH AND WITHOUT NON-ALCOHOLIC
Diet may be a beneficial nutritional approach in NAFLD patients. STEATOHEPATITIS (NASH)
Tuttolomondo A. 1, Petta S. 2, Casuccio A. 3, Maida C. 1,

FACTORS ASSOCIATED WITH OCCURRENCE/ Della Corte V. 1, Daidone M. 1, Di Raimondo D. 1, Pecoraro R. 1, Fonte R. 1,
RECURRENCE OF HEPATOCELLULAR CARCINOMA Cirrincione A. 1, Zafonte R. 4, Cabibi D. 5, Cammà C. 2, Di Marco V. 2, Licata
EARLY AFTER TREATMENT OF HEPATITIS C WITH A. 2, Magliozzo F. 4, Marchesini G. 6,
DIRECT ANTIVIRAL AGENTS Merlino G. 4, Craxi A. 2, Pinto A. 1
1
U.O.C di Medicina Interna con Stroke Care, Dipartimento Biomedico di
Camatta D.,1 Mancuso G.,2 Tran Minh M.,1 Barbaglia M.N.,1 Avitabile E.,1 Medicina Interna e Specialistica (Di.Bi.M.I.S), Universita` di Palermo, Italy
Ceriani E.,3 Leutner M.,3 Fangazio S.,3 Burlone M.E.,
2
Sezione di Gastroenterologia e Epatologia, Dipartimento Biomedico di
1
Camatta D.,1 Sguazzotti M.,1 Daffara F.,1 Minisini R.,1 Medicina Interna e Specialistica (Di.Bi.M.I.S), University of Palermo, Italy 3
Boldorini R.,2 Pirisi M. Dipartimento di Scienze per la Promozione della Salute e Materno Infantile,
1
Dpt of Translational Medicine1 and Dpt of Health Sciences,2 Università del Università di Palermo, Italy. 4 Medicina Generale Palermo, Italy 5 Cattedra di
Piemonte Orientale; AOU Maggiore della Carità;3 Novara Anatomia Patologica, University of Palermo, Italy 6 Dipartimento di Scienze
Mediche e Chirurgiche, “Alma Mater Studiorum,” Università di Bologna, Italy
12
Background: Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic MULTIDISCIPLINARY APPROACH
steatohepatitis (NASH) are associated with cardiovascular events and Meta-
bolic Syndrome (MetS). Some studies have reported an association between 1
Mancini S., 2Sena P., 1Mariani F., 1Mattei G., 1Ferrari S., 3Alboni S., 1Boarino
NAFLD and cardiovascular morbidity, whereas some recent studies have V., 1Merighi A., 1Roncucci L.
reported that subjects with NAFLD have risk factors putative to be considered 1
Dipartimento di Medicina Diagnostica, Clinica e di Sanità Pubblica;
as surrogate risk factors of cardiovascular morbidity. Several useful surrogates 2
Dipartimento di Scienze Biomediche, Metaboliche e Neuroscienze;
in clinical setting include Framingham Risk Score, carotid artery intima-me- 3
Dipartimento di Scienze della Vita; Università di Modena e Reggio Emilia,
dia thickness, hsCRP, visceral and mediastinal fat, and coronary calcium Modena, Italy
scores. Adjunctive surrogates for cardiovascular risk more recently valida-
ted by some studies are arterial stiffness and endothelial function indexes. Background: Colorectal cancer (CRC) is the second cause of cancer death
Forearm flow-mediated vasodilation (FMD) is a classical method to evaluate in men and the third in women worldwide. CRC arises from colonic mucosa
endothelial dysfunction. However, findings offered by FMD can be very diffe- inflammatory changes that are susceptible of early detection and removal.
rent owing to technical issues thus this technical method has been reported as Growing evidence shows that metabolic, immunologic, and neuroregula-
not standardized.A new method useful to measure endothelial dysfunction, tory processes can affect bowel pathophysiology. Our knowledge on the link
reactive hyperemia peripheral arterial tonometry (RH-PAT) has been repor- between metabolic, atherogenic, and psychic determinants and molecular
ted by Kuvin et al. This method is noninvasive and quantitative and it offers a pathways of colorectal carcinogenesis needs to be improved.Aim: To assess
digital measurement of hyperemic response. Framingham Heart Study repor- through a multidisciplinary model the association among metabolic status,
ted RHI (reactive hyperemia index) as inversely correlated with various car- proatherogenic factors, psychological determinants, inflammatory changes in
diovascular risk factors.Augmentation pressure and PWV have been reported the colorectal mucosa, and the presence of adenomas.
as surrogate markers for cardiovascular disease strictly linked to endothelial Methods: 64 consecutive patients (M/F 33/31) undergoing colonoscopy
dysfunction. Nevertheless only a few studies analyzed arterial stiffness indexes were evaluated with ultrasound vascular assessment (carotid artery inti-
in NAFLD patients and a previous study analyzed endothelial dysfunction in ma-media thickness, q-IMT© (MyLab25Gold, Esaote), and brachial artery
these subjects by means flow mediated dilation and flow-mediated vasoacti- flow-mediated dilation, FMD), a complete lipid profile, a set of psychome-
vity (FMV) findings reporting in NAFLD patients, a significant association tric tests, immunohistochemistry assay of colonic biopsies for autophagy
between low FMV and NASH. No study evaluated vascular health markers in (LC3B-II) and myeloperoxidase (MPO) expression, matched with clinical
subjects with NAFLD by means of a combined analysis of reactive hyperemia and anthropometric characteristics. Odds ratios (OR) for each predictor of
peripheral arterial tonometry (RH-PAT) and arterial stiffness indexes. Aim: the presence of adenomas have been assessed. Then, multivariate statistical
we aimed to assess whether NAFLD and its histological severity are associated analysis has been conducted among the best predictors of the presence of
with impairment of arterial stiffness and RH-PAT indexes in a mixed cohort colorectal adenomas. Statistical analyses were performed with SigmaPlot©
of patients with biopsy-proven NAFLD. v.12 (Systat Software, Inc., San Jose, CA 95131 USA). p < 0.05 was conside-
Materials and Methods:We recruited all NAFLD patients admitted at the red significant.
Gastrointestinal & Liver Unit of Palermo University Hospital. Inclusion cri- Results: 29 out of 64 subjects were positive for at least one colorectal
teria were: 1) a histological diagnosis of NAFLD on a liver biopsy obtained adenoma. Male sex (OR 3.76, p 0.013), BMI≥30 (OR 3.25, p 0.037), chole-
less than 6 months before enrollment The Kleiner classification was used sterol levels (total and LDL, OR 4.73, p 0.004 and OR 8.67, p 0.001, respecti-
to grade NAFLD grade. Pulse wave velocity and augmentation index were vely), elevated C-reactive protein (OR 5.56, p 0.003), as well as LC3B-II and
used as markers of arterial stiffness, whereas endothelial function was eva- MPO expression in the colonic mucosa, q-IMT values, and a score among
luated by Endo-PAT2000 measuring reactive hyperemia index (RHI). The psychometric tests (Temperament and Character Inventory-Self Tran-
Mini-Mental State Examination (MMSE) was administered to assess cogni- scendence) resulted associated with an increased occurrence of colorectal
tive function. adenomas in univariate analyses. Multivariate analysis showed that q-IMT
Results: 80 consecutive patients with biopsy-proven NAFLD and 83 indi- remained an independent predictor of the presence of colorectal adenomas.
viduals without fatty liver disease. NAFLD subjects had significantly lower Conclusions: This study provides evidence that novel factors, and in par-
mean RHI, higher mean arterial stiffness indexes and lower mean MMSE ticular q-IMT, could be considered for the assessment of colorectal cancer
score. Among NAFLD subjects those with NASH showed no significant dif- risk.
ference with regard of RHI, arterial stiffness indexes and mean MMSE score
in comparison to subjects without NASH. Simple linear regression analysis
showed among NASH subjects a significant relationship between Kleiner THE IMPACT OF TROFIC EFFECTS OF MULTI STRAIN
fibriosis grade and Kleiner inflammation grade and PWV and a significant PROBIOTIC PREPARATION ON PARACELLULAR
relationship between Kleiner fibrosis and AIX, whereas among subjects PERMEABILITY
without NASH a significant negative relationship was observed between
Kleiner inflammation and RHI. Petito V.1, Laterza L.1, Graziani C.1, Lucchetti D.2, Lopetuso L.R.1, Sgambato
Conclusions: our findings show how the relationship between endothelial A.2, Scaldaferri F.1, Gasbarrini G.1, Gasbarrini A.1 1Gastroenterological
function expressed by RHI and histological severity of NAFLD is confined Area, Gastroenterological and Endocrino-Metabolical Sciences Department.
only in non NASH subjects, whereas in more advanced stages of hepatic Catholic University of Sacred Heart of Rome-A. Gemelli Hospital 2 Pathology
damage, the relationship between histological severity and endothelial disfun- Department. Catholic University of Sacred Heart of Rome-A. Gemelli
ction has not more reported in favour of clear direact relationship with arte- Hospital
rial stiffness markers.These findings are probably due to the fact that endothe-
lial dysfunction is a early pathological event not yet appreciable in more Introduction: Probiotics are defined as live, non‐pathogenic bacteria that
advanced stages of NAFLD such as NASH that it is characterized by more confer health benefits beyond their nutritional value. Particularly VSL#3,
evident relationship with more advanced stages of vascular damage such as a probiotic mix containing 4 strains of Lactobacilli (L. paracasei, L. plan-
impairment of arterial stiffness. We reported that NAFLD subjects in com- tarum, L. acidophilus and L. delbrueckii subsp. bulgaricus*), 3 strains of
parison with control subjects showed significantly lower MMSE mean value.
Evidence from epidemiology and pathology studies indicates that damage Bifidobacteria (B. longum2, B. infantis2, B. breve) and Streptococcus ther-
to the vascular system is associated with an increased risk of many types of mophilus, has demonstrated efficacy in the management of diseases cha-
cognitive impairment. This finding of a lower MMSE mean scores observed racterized by increased intestinal permeability such as irritable bowel syn-
in NAFLD patients (mean MMSE 26.9) may represent a further issue confir- drome and ulcerative colitis. Several mechanisms have been postulated to
ming the role of arterial stiffness and endothelial dysfunction also in clinical contribute to the anti‐inflammatory effect of probiotics in the gut, but few
setting of cognitive performance. These results suggest the potential role of studies exist describing in vitro effects of probiotics. (*Recently reclassified
endothelial function, evaluated by measurement of endothelial function using as L. helveticus. 2Recently reclassified as B. animalis subsp. lactis.) Aims &
peripheral arterial tonometry (EndoPAT), as a possible future biomarker of Methods: The aim of the present study was to evaluate the mechanism of
vascular pathology in NAFLD. action of VSL#3 to reduce intestinal permeability, and its effect in modu-
lating the activity on tight junctions, focusing on the effects of secreted
bioactive factors.Two different lots of VSL#3 (Manufacturer: Nutrilinea Srl,
Gallarate (VA ‐ Italy) were used. HT29 cell line was treated with a conditio-
SUBCLINICAL CAROTID ARTERY ATHEROSCLEROSIS ning media (CM) prepared using 1g of probiotic formula grown in D‐MEM
PREDICTS THE PRESENCE OF COLORECTAL cell
ADENOMAS: A CROSS-SECTIONAL STUDY WITH A culture medium (free of serum and antibiotics) at 37°C for 48 hours without
13
shaking and in anaerobic conditions. The CM was be centrifuged at 4,100 Centre for Health Technologies (C.H.T.), University of Pavia, Pavia, Italy;
3
rpm for 10 min to separate the bacteria, and diluted 1:10 and 1:25. The Gastroenterology Unit, Department of Medicine, AOUI Borgo Roma,
4
effects of probiotic on proliferations of cells were evaluated by cell growth University of Verona, Verona, Italy
curve and MTT assay. The growth curve was performed by ECIS (Electric
Cell‐Substrate Impedance Sensing) where the increase of impedance is Introduction:: Celiac disease (CD) is a chronic multifactorial enteropathy
directly proportional to increase of cell number in the well. The MTT assay triggered by gluten ingestion in genetically susceptible individuals. In the
is based on the conversion of MTT salt into insoluble formazan crystals last years it has emerged that gut microbiota is strongly involved in the dif-
by living cells.The effect on apoptosis will be analyzed by cytometry using ferentiation of intestinal epithelium, regulation of gut permeability, mucosal
double staining with Annexin V‐FITC and Propidium Iodide. Furthermore, immunity, development of responses to microbial and dietary antigens and
the effect on expression of tight junctions, in particular claudin‐2, occludin avoidance of overreactions. This is the key to understand how intestinal
and ZO‐1, was be investigated by western blot analysis. dysbiosis may play a role in disrupting the immune homeostasis, thus con-
Results: The multistrain probiotic formula, in particular the more con- curring to the pathogenesis of some chronic inflammatory and autoimmune
centrate CM (1:10) increases HT29 cell proliferation and the percentage of conditions, including CD itself. Up to now, the relationship between shift in
metabolic cell activity (up 20%), together with a decrease of 90% of apopto- the intestinal microbiota and CD has been described. However it is rather
tic cells in presence of CM. The expression of tight junction proteins increa- challenging to understand whether this can be secondary to CD itself or
ses in 24 hours for claudin and ZO‐1, and after 48 hours of treatment in case could have a primary role in influencing the clinical picture and severity of
of occludin. Also the densitometry and the ratio between of relative density the disease.
of protein and endogenous control (β‐actin) confirms these data. The results Aim: To obtain a comparative metagenomic picture of salivary, duodenal
are the same using two different lots. and fecal microbiota composition in adult patients affected by different
Conclusion: These preliminary data in vitro could be able to explain how forms of celiac disease. To compare the salivary, duodenal and fecal micro-
VSL#3 works at intestinal mucosa level, in particular by secretion of factors biota composition of CD patient with controls suffering from functional
that enhances barrier integrity. The proliferative stimuli and the increase of dyspepsia. PATIENTS & METHODS: From November 2015 to June 2016
expression of tight junction proteins are consistent with an effect on mucosa we enrolled a total of 32 CD patients divided into four groups: 8 active CD
regeneration and re‐epithelization. Other experiments, also on other inte- patients (all females; mean age at diagnosis 31±4 years; 6 with a classical
stinal cell line, are necessary to deeply understand the mechanism of action presentation at diagnosis, 1 non classical, 1 silent), 20 treated CD patients
of this kind of probiotic formula. (16 F; mean age at diagnosis 32±2 years; mean age at enrollment 37±6 years;
13 with a classical presentation at diagnosis, 6 non classical, 1 silent; median
time on a gluten free diet 2.5 years, 25°-75° 1.75-7 years), 2 patients affected
SPLENIC HYPOFUNCTION IN AUTOIMMUNE ATROPHIC by type 1 refractory CD (2F, age at diagnosis of CD 35 and 57 years old
GASTRITIS respectively, both classical) and 2 patients affected by potential celiac disease
on a gluten containing diet (1 female, non classical, 35 years old at diagnosis
Di Sabatino A., Giuffrida P., Lenti M.V., Aronico N., and 1 male, silent, 45 years old at diagnosis). 13 patients affected by fun-
Cococcia S., Padula D., Miceli E., Corazza G.R. ctional dyspepsia (11 F, mean age at enrollment 51±4 year) were used as
First Department of Medicine, San Matteo Hospital Foundation, University controls. For each patient and control, DNA extraction and quantification
of Pavia, Pavia, Italy (Qiagen, Milan, Italy, UE), PCR production of 16S rRNA amplicons and
sequencing libraries, high-throughput sequencing of libraries on Illumina
Background and Aims: Splenic hypofunction is an acquired condition MySeq platform (BMR Genomics, Padova, Italy, UE) were performed on
which may predispose to bacterial infections, autoimmunity or thrombo- salivary, duodenal mucosa, and fecal samples. Bio-informatic analyses were
embolism. Immune-mediated gastrointestinal disorders, including celiac then performed on raw sequencing data (BMR Genomics). The correspon-
disease and inflammatory bowel diseasem are the most frequently reported ding Operational Taxonomic Units (OTU) tables were produced.
conditions associated with hyposlenism. However, no data are available as Results: After polishing raw sequences, the mean number of high-quality
far as autoimmune atrophic gastritis (AAG) an immune-mediated chronic reads was: 55603 for feces, 103616 for saliva, 59514 for biopsies. OTU tables
inflammation of the gastric body and fundus, leading to hypo-achlorhydria show that the mean number of bacterial OTUs at 97% homology level,
and vitamin B12 deficiency. We evaluated splenic function through pitted corresponding to the number of bacterial species, is: 151 for feces, 286 for
red cell (PRC) counting, i.e. erythrocytes with membrane abnormalities saliva, 212 for biopsies. Preliminary β-diversity analyses suggest composi-
visible under interference phase microscopy as ‘pit’, in patients with AAG. tional differences in bacterial consortia in terms of reduction of Firmicutes
Methods: A peripheral blood sample was collected from 10 consecutive and increase of Proteobacteria at level of Phyla, while a reduction of Veil-
patients (mean age 66 yrs) who had a confirmed diagnosis of AAG (corpus/ lonella and an increase of Neisseria Genera were observed in both salivary
fundus atrophy with antrum sparing and positivity to anti-parietal cells and mucosal samples of CD patients in comparison to controls.
antibody). Sex- and age-matched patients with splenectomized patients Conclusion: The preliminary results of our study confirm the presence of
(n=20) and healthy volunteers (n=20) were also enrolled as positive and a dysbiosis in adulthood CD, with a substantial similarity between salivary
negative control groups, respectively. PRC counting was performed with and mucosal data. This may also open the route for future non-invasive dia-
direct-interference contrast microscope equipped with Nomarski optics gnostic assessment in CD.
(normal value PRC below 4%).
Results: Seven of the AAG patients had PRC values higher than 4% and
thus were diagnosed as hyposplenic. None of the 20 healthy controls and all EMERGING ROLE OF IL-33/ST2 LEVELS IN PREDICTING
the splenectomized patients had an impaired splenic function. Median PRC MUCOSAL RESPONSE TO ANTI-TNF THERAPY IN
values were significantly (p<0.001) higher in AAG patients (5.3%, range 3.4- ULCERATIVE COLITIS
12.8) than healthy controls (1.8%, range 0.5-3.6). As expected, PRC values
were significantly higher in splenectomized patients (17.2%, range 9.4-32.4) Lopetuso L.R. 1,2, Petito V. 1, Graziani C. 1, Scannone D. 1,
in comparison to AAG patients (p<0.001), and healthy controls (p<0.0001). Pizarro T.T. 2, Gasbarrini G. 1, Scaldaferri F. 1, Gasbarrini A 1
Conclusions: We here reported for the first time the association between
1
Internal Medicine, Gastroenterology Division, Catholic University of Sacred
hyposplenism and AAG. Further studies on larger series of patients are Heart of Rome, Rome, Italy; 2Pathology, Case Western Reserve University -
required to assess the real prevalence of splenic hypofunction in AAG, and School of Medicine, Cleveland, United States
to clarify the pathophysiological mechanisms underlying this association.
Background and Aim: Tumor necrosis factor (TNF) inhibitors (anti-TNF)
are considered to be effective in inducing mucosal healing in patients with
moderate-to-severe Ulcerative Colitis (UC). The role of IL-33 and its recep-
STUDY OF THE MICROBIOTA COMPOSITION IN tor, ST2, in intestinal inflammation is incompletely understood, with both
DIFFERENT FORMS OF ADULT CELIAC DISEASE pro-inflammatory and regulatory properties described. Recent evidence has
shown that anti-TNF is able to modulate the IL-33/ST2 axis in inflamma-
Biagi F. 1, Panelli S. 2,3, Schiepatti A. 1, Betti E. 1, Cangemi G.C. 1, Lombardo
tory conditions, probably through an interplay with gut microbiota. The aim
C. 2,3, Capelli E. 2,3, Corazza G.R. 1, Ciccocioppo R. 4
of our study was to explore the potential role of the IL-33/ST2 axis in the
1
Coeliac Centre, First Department of Internal Medicine, IRCCS Foundation
mucosal healing process mediated by anti-TNF therapy in UC.
Policlinico San Matteo, University of Pavia, Pavia, Italy; 2Department
Methods: Endoscopic MAYO score was calculated before the first anti-TNF
of Earth and Environmental Sciences, University of Pavia, Pavia, Italy;
infusion (T0) and after 6 weeks (T2). 24 UC patients (MAYO score at T0 ≥
14
2), grouped into 12 responders with mucosal healing (MAYO score ≤ 1) and I, “Sapienza” Università di Roma
12 non-responders to anti-TNF at T2 (MAYO score ≥ 2) were enrolled. 10
healthy controls undergoing routine colonoscopy for tumor screening were Purpose: Prostate cancer is the most common tumor in men. To the best of
also enrolled. At each time point, serum samples were collected and ELISA our knowledge a systematic assessment of bone and mineral abnormalities
performed to assess IL-33/ST2 protein levels. Intestinal biopsies were also has not been performed in prostatic cancer patients consecutively enrolled.
taken from the rectum and IHC was done to evaluate mucosal IL-33/ST2 Methods: This study was therefore carried out to investigate changes of ske-
expression and localization. letal and mineral metabolism in patients with prostate cancer (n = 69). A
Results: IL-33 protein levels were significantly increased in responders vs. population of patients with cancer of various origin was also investigated
non-responders, both at T0 and T2. Among responders, IL-33 protein was as a control group (n = 53), since a comparison with non-prostate cancer
slightly reduced at T2 vs. T0, while unchanged in non-responders. Intere- patients has not been previously reported.
stingly, significantly higher levels of ST2 were found in responders vs. not Results: In the prostatic cancer group, one patient had extremely high values
responders at T0, while no differences between groups were found at T2. of C-terminal Fibroblast Growth Factor 23, low values of tubular reabsorp-
Among responders, ST2 levels were dramatically reduced at T2 vs. T0. No tion of phosphate and very high values of bone alkaline phosphatase, sug-
significant differences were found in non-responders at both time points. gesting the diagnosis of oncogenic osteomalacia. We found nine patients
Healthy controls showed significantly lower levels of both IL-33 and ST2 with primary hyperparathyroidism in the group of prostate cancer vs. only
compared with other groups. IHC confirmed these observations. In par- one in cancer patients group (p < 0.026). We stratified the population on
ticular, IL-33 and ST2 staining was more intense within the inflamed and the basis of Gleason score, prostate specific antigen and hormonal therapy.
ulcerated mucosa of responders compared to non-responders at T0. After 6 Using a generalized linear model with a logit link to predict the probability
weeks, ST2 staining was even more evident in responders, notably localized of developing primary hyperparathyroidism, only Gleason score, C-termi-
to the healed mucosa and in close proximity to areas of re-epithelialization. nal fibroblast growth factor 23 and hormonal therapy had a significant effect
Little to no staining for both IL-33 and ST2 was present in healthy controls. (p < 0.05). Controlling for other covariates, a rise in fibroblast growth factor
Conclusions: Our results suggest a possible role for IL-33/ST2 in predicting 23 increases the odds of developing primary hyperparathyroidism by 2% (p
gut mucosal wound healing in patients with moderate-to-severe UC treated = 0.017), while patients with higher values of Gleason score have a much
with anti-TNF. A possible interplay between IL-33/ST2 axis and gut micro- greater probability of developing primary hyperparathyroidism (log-odds =
biota could partially explain these results. Further studies are underway to 3.6, p < 0.01). The probability decreases with higher values of Gleason score
determine mechanisms of action that support these findings. while on hormonal therapy; a further decrease was observed in patients on
hormonal treatment and lower values of GS. Finally, lower grade of Gleason
score without hormonal therapy have a significant protective factor (p <
INTERACTION BETWEEN LRP5 AND PERIOSTIN GENE 0.01) decreasing the odds of developing primary hyperparathyroidism by
POLYMORPHISMS ON SERUM PERIOSTIN LEVELS AND 8%.
CORTICAL BONE MICROSTRUCTURE Conclusion: We showed a remarkable prevalence of primary hyperpara-
thyroidism in men with prostate cancer; the multivariate analysis demon-
Pepe J. 2, Bonnet N. 1, Herrmann F.R. 1, Biver E. 1, Rizzoli R. 1, Chevalley T. 1, strates that higher aggressive-ness of prostate cancer, as determined by
Ferrari S.L. 1 Gleason score, is a significant predictor of increased risk of developing
1
Division of Bone Diseases, University Hospitals and Faculty of Medicine, primary hyperparathyroidism.
Geneva, Switzerland, 2Department of Internal Medicine and Medical
Disciplines,“Sapienza” University of Rome, Rome, Italy, 3Division of
Geriatrics, Department of Internal Medicine, Rehabilitation and Geriatrics, THE EFFECT OF DENOSUMAB ON BONE MASS AND
Geneva University Hospitals and University of Geneva,Switzerland MINERAL METABOLISM IN PATIENTS WITH SYSTEMIC
MASTOCYTOSIS
Purpose: To investigate the interaction between polymorphisms (SNPs) of
periostin and of other genes that modulate periostin expression on periostin Di Stefano M. 1, Benedetti I. 1, Elena C. 2, Bergonzi M. 1,
serum levels and on bone microstructure in a cohort of postmenopausal Pesatori E.V. 1, Manfredi G.F. 1, Deamici M. 3, Grandi G. 1,
women. Pagani E. 1, Torre C. 3, Merante S. 2, Cazzola M. 2, Marseglia G.L. 3, Corazza
Methods: In 648 postmenopausal women from the Geneva Retirees G.R. 1
Cohort, we analyzed 6 periostin SNPS (rs9547952, rs9603226, rs7322993, 1
Department of Internal Medicine, 2Department of Hematology and
rs9576308, rs7338244, rs9547970) and other 149 SNPs in 14 genes, namely 3
Department of Pediatrics, IRCCS S. Matteo Hospital Foundation, University
BMP2, CTNNB1, ESR1,ESR2, LRP5, LRP6, PTH, SPTBN1, SOST, TGF of Pavia, Italy
b1, RANK, RANKL, OPG and WNT16.Volumetric BMD and bone micro-
structure were measured by high-resolution peripheral quantitative compu- Background: Mastocytosis is a rare disease characterized by abnormal
ted tomography at distal radius and tibia. proliferation and invasion of neoplastic mast cells in many tissues with a
Results: Serum periostin levels were associated with radial cortical poro- predominant involvement of bone marrow and skin. Bone involvement
sity, also after adjustment for age and BMI, and years since menopause is also very frequent and the prevalences of bone loss and bone fractures
(p=0.036).Sixteen SNPs in ESR1, LRP5,OPG,SOST,SPTBN1, RANK and are estimated up to 60% and 20% of cases, respectively (1,2). Bisphospho-
RANKL genes were associated with serum periostin serum levels (p range nate administration is considered an effective treatment of osteoporosis in
0.03-0.001).Twenty-six SNPs of 9 genes were associated with cortical poro- mastocytosis and a BMD yearly increase ranging from 5 to 8% was descri-
sity at radius and/or at tibia. In particular,1 SNPs in each LRP5, ESR1 and bed (3,4). Denosumab is a human monoclonal antibody against RANKL, a
near RANK genes were associated with cortical porosity and with serum pro-resorptive agent which binds to its receptor (RANK) on preosteoclasts
periostin levels.The periostin SNP rs9547970 was also associated with cor- and osteoclasts, inducing bone resorption. Denosumab showed a significant
tical porosity at radius and tibia (both p=0.04).We identified an interaction efficacy in the treatment of postmenopausal osteoporosis (5). Up to now, a
between LRP5 SNP rs648438 and periostin SNP rs9547970 on serum perio- single case series of four patients with mastocytosis is available (6), showing
stin levels (interaction p=0.01) and on radial cortical porosity (interaction a positive effect of 1-year treatment. In five patients referred to our depart-
p=0.005).In particular, lower serum periostin levels and higher cortical ment, denosumab was administered and results after one year of treatment
porosity were associated with periostin SNP 954790 GG and LRP5 SNP were reported.
rs648438 CC and CT. Patients and Methods: Five patients (2 females, aged from 17 to 74) with
Conclusion: If confirmed in independent cohorts, these results suggest a systemic mastocytosis with skin involvement and without gastrointestinal
role of serum periostin levels as bone cortical markers, regulated mainly by symptoms (3 Indolent SM, 1 aggressive SM) referred to our outpatient
LRP5 pathway. clinic. The median duration of disease was 72 months (24-368), the median
time since osteoporosis diagnosis was 48 months (36-108 months). Three
patients had osteopenia, two patients had osteoporosis (femoral T-score,
MINERAL METABOLISM ABNORMALITIES IN PATIENTS WHO criteria). two patients had pathological fractures with vertebral col-
WITH PROSTATE CANCER: A SYSTEMATIC CASE lapses: one patient at D5 and D7, the other patient at L1 level. The BMI
CONTROLLED STUDY ranged from 19.2 to 26. All the patients had a previous treatment with
bisphosphonates, vitamin D and calcium supplementation. Lumbar BMD
Colangelo L., Cipriani C., Pepe J., Biondi P., Cilli M., Minisola S. was measured with DEXXA together with the following indices of bone and
Dipartimento di Medicina Interna e Specialità Mediche, Policlinico Umberto mineral metabolism: parathyroid hormone (PTH), 25(OH)- vitamin D and
15
1,25(OH)2-vitamin D, osteoprotegerin, RANK-L, telopeptide of type I col- VERTEBRAL FRACTURES COMPLICATING PREGNANCY
lagen. Denosumab 60 mg every 6 months sc was started and all the parame-
ters were evaluated again after 1 year of treatment. Sonato C., Colangelo L., Biondi P., Gianni W., Cilli M., Cipriani C., Pepe J.,
Results: The treatment with denosumab improved bone mass and mineral Minisola S.
metabolism. Basal mean lumbar T-score increased from -1.70 ±1.56 to Dipartimento di Medicina Interna e Specialità Mediche, Policlinico Umberto
-0.72±1.20. In particular, the two osteoporotic patients became osteopenic I, Sapienza Università di Roma
and the three osteopenic patients normalized lumbar BMD values. None of
the patients showed the occurrence of new fractures. Basal PTH was 44±31 A 29 year-old-woman was admitted to our Department complaining of
pg/ml and after treatment was 35±11 pg/ml; basal 25-vitaminD was 80±66 acute pain in lumbosacral region apparead abruptly while raising her
ng/ml and post-treatment value was 36±18 ng/ml; basal 1,25-vitaminD newborn baby from the cradle. The orthopedist had prescribed orthopedic
79±25 pg/ml and post-treatment value was 73±27 pg/ml; basal osteoprote- bust. On pathological history: one month before childbirth naturally, cur-
gerin was 4.1±2.5 pmol/l and post-treatment value was 3.1±0.9 pmol/l; basal rently breastfeeding. No other pathology noteworth. On physical examina-
telopeptide was 0.55±0.3 mg/ml while post-treatment value was 0.24±0.1 tion: general mediocre health conditions, suffering woman, BMI 18.9 kg/
mg/ml. None of the patients suffered from side effects. None of the patients m2; pain and achiness at pression in lumbar column region; absence of pal-
presented new fractures. pable superficial lymph nodes and palpable node at the breast examination.
Conclusion: The administration of denosumab in patients with mastocyto- The patient performed column MRI that documented vertebral fractures
sis and bone loss remarkably improves lumbar BMD and bone metabolism. of D6, D10, D11 and L5. Suspecting secondary neoplastic localization, the
The high risk of fractures that characterizes this condition suggests the use physician required dosage of the major tumor markers, resulting normal.
of an effective treatment and denosumab seems the best available option The review of the investigations performed during pregnancy highlighted:
both in terms of efficacy and tolerability. hypercalcemia (Ca: 11.2 mg/dl), which had not been further investigated.
References: 1. Rossini M, et al. Bone 2011;49:880–885 2. Rossini M, et al. The patient was then re-evaluated biochemically, at our Department with
Immunol Allergy Clin North Am 2014; 34:383–396 3. Rossini M, et al, the evidence of persisted hypercalcemia (Ca++1.42 mmol /l, nv 1.17-1.33)
AM J Med 2014; 127:1127.e-1127.e4 4. Lim AYM, et al. Ann Rheum Dis associated with suppressed PTH values (3 pg/ml nv 10-65) and vitamin
2005;64:965-966 5. Mc Clung MR, et al. NEJM 2006;354:821-31. 6. Orsolini D values in the normal range. DEXA values showed reduced lumbar and
G et al, Calcif Tissue Int 2017;100:595-598. femoral bone mineral density (Z-score -4.9 and -3.2 respectively). Hyper-
calcemia in this patient is due to placental (pregnancy) and breast (during
lactation) production of PTHrp (Parathyroid hormone-related protein)
COMPUTERIZED VIDEO-CAPILLAROSCOPY that, together with reduced levels of estradiol and progesterone, can induce
MICROCIRCULATORY ALTERATIONS RELATED TO increase in bone turnover (brain-breast-bone circuit). This is confirmed in
DIABETES MELLITUS AND ITS MICROVASCULAR our patient by the increase in the serum levels of bone resorption markers
COMPLICATIONS (Telopeptide C-Terminal: 2880 pg/ml, nv <1350). The biochemical and cli-
nical state was therefore attributable to pregnancy associated osteoporosis
Lisco G., Cignarelli A., Cicco G., Garruti G., Laviola L., Giorgino F. in the absence of other secondary causes complicated by hyperproduction
Section of Internal Medicine, Endocrinology, Andrology and Metabolic of PTHrp. Our patient was advised to stop breastfeeding to achieve nor-
Diseases, Department of Emergency and Organ Transplantation, University
of Bari Aldo Moro, Bari, Italy malization of calcium (Ca++1.31 mmol/l) and an anti-absorption drug
(Denosumab) was administered to speed up repair of skeletal damage.
Background: Diabetes mellitus (DM) is a high world prevalence chronic In conclusion, this is a rare case of correlated PTHrp hypercalcemia that
disease characterized by elevated plasma glucose concentrations contribu- occurred during pregnancy osteoporosis and that resolved with childbirth
ting tochronic micro- and macro-vascular complications (i.e., retinopathy, and cessation of breastfeeding.
nephropathy, neuropathy and cardiovascular diseases).
To carry out an early identification of microvascular complications, speci-
fic, standardized and inexpensive tests are urgently needed. Computerized LOWER RATE OF HYPOGLYCEMIA WITH IDEGLIRA VS
nailfold videocapillaroscopy (CNVC) is a tool to easily evaluate microcircu- INSULIN GLARGINE REGARDLESS OF DOSING TIME OR
lation damage at the level of the fingers and could be potentially useful to HYPOGLYCEMIA DEFINITION IN PATIENTS WITH TYPE
characterize the “diabetic capillaropathy”. 2 DIABETES
Material and Methods: This was a prospective study using CNVC to
examine the prevalence of capillaroscopic damage patterns in a cohort of G. Sesti 1, R. Chen 2, E. Jaekel 3, I. Lingvay 4, H. Jarlov 5,
type 1 (T1D) and type 2 (T2D) diabetic individuals, and to assess its rela- L. Lehmann 5, G. Lastoria 6, S. Heller 7
tionship with the level of glycometabolic control (HbA1c). From December Università degli Studi Magna Græcia, Catanzaro, IT,1 Concord Repatriation
2016 to June 2017, we performed a CNVC examination in 63 of 70 T2D General Hospital, Sydney, NSW, Australia2, Hannover Medical School,
(mean age 63±10.7; male 65,7%) and 22 of 24 T1D (mean age 44±15.9, male Hannover, Germany3UT Southwestern Medical Center, Dallas, TX,
50%) consecutive patients and in 37 of 38 controls without diabetes (mean USA,4,Novo Nordisk A/S, Søborg, Denmark5 Novo Nordisk Medical Affairs
age 44.4±15.7, male 33.3%). Rome, Italy6, University of Sheffield, Sheffield, United Kingdom7
Results: Nailfold microcirculation alterations were found to be more pre-
valent in individuals with diabetes, including tortuosity (81.0% in T2D and In the DUAL V trial, patients assigned to insulin degludec/liraglutide
86.4% in T1D vs 43.3% in controls; p <0.01), avascular zones (38.1% in (IDegLira) had greater HbA1c reduction (end of trial [EOT] HbA1c 6.6
T2D vs 9.1% in T1D and 2.7% in controls; p <0,01), and ectasiae (72.7% in vs. 7.1%) versus insulin glargine (IG) with a significantly lower confirmed
T1D and 46% in T2D versus 32,4% controls; p <0,01). At least two of these hypoglycemia rate (original definition: plasma glucose [PG] <56 mg/dL or
capillary alterations were found with a higher prevalence in T2D and T1D unable to selftreat). This post hoc analysis investigated whether the lower
patients vs controls (55.6% and 72.7% vs 18.9%; p<0.01). Three different hypoglycemia rate with IDegLira versus IG was consistent irrespective of
capillaroscopic patterns were observed in the diabetic population: class 1, dosing time (AM [00:00–11:59] or PM [12:00–23:59]) or definition of hypo-
composed by tortuosity plus ectasiae; class 2, composed by tortuosity plus glycemia used (overall/nocturnal confirmed, with/without symptoms, ADA
avascular zones; and class 3, composed by ectasiae plus tortuosity. In T2DM documented symptomatic). Hypoglycemia rates (episodes per patient-year
patients, no difference in the prevalence of these capillaroscopic classes were exposure [PYE]) were significantly lower with IDegLira versus IG, whether
found. By contrast, a higher prevalence of capillaroscopic class 1 pattern was both were dosed at AM or PM, for confirmed hypoglycemia (AM: 2.18 vs.
found in T1D patients (in 14 of 22 examinations; p<0,001). Finally, in both 6.86 PYE; PM: 2.26 vs. 4.59 PYE) and for nocturnal confirmed hypoglyce-
T2DM and T1DM patients, a higher prevalence of the capillaroscopic class mia (AM: 0.22 vs. 1.67 PYE; PM: 0.23 vs. 1.12 PYE) (Fig 1A). The rate of
1 pattern was found to be associated with worse glycemic control, defined hypoglycemia was significantly lower for IDegLira versus IG for confir-
as HbA1c >7.0% and with albumin/creatinine urinary excretion ratio >30 med (2.23 vs. 5.05 PYE), confirmed symptomatic (1.56 vs. 3.75 PYE) and
mg/g. ADA documented symptomatic (8.03 vs. 15.63 PYE) (Fig 1B). Nocturnal
Conclusions: These preliminary data confirm the presence of a “diabetic hypoglycemia rates were significantly lower (62–84%) for IDegLira versus
capillaropathy”, characterized by different damage patterns, and particularly IG across the different definitions used. In conclusion, despite a lower EOT
by class 1 abnormalities in T1D. These alterations appear to be related to the HbA1c, the hypoglycemia rate is lower with IDegLira versus IG regardless
level of metabolic control and existence of microvascular damage. of dosing time or hypoglycemia definition.
16
A “COMMON” CASE OF CHRONIC DIARRHOEA cally improve. At the end of 2016, she underwent evaluation for a cardiac
transplantation and then an uncomplicated orthotopic heart transplant was
Aronico N., Giuffrida P., Di Sabatino A., Corazza G.R. performed. Eight weeks later, her peripheral edema had resolved, diarrhea
Clinica Medica I, Fondazione IRCCS Policlinico San Matteo, Università degli was not present anymore and her albumin levels reached normal values (3.8
Studi di Pavia, Pavia, Italia g/dL).
A 38-year-old woman, with a history of to recurrent respiratory infections,

was referred to another Centre for diarrhoea and weight loss in 2008. DIARRHOEA AS PRESENTING SYMPTOM OF RARE
Coeliac serology, fecal calprotectin, stool culture for bacteria and parasi- DISEASE
tes were negative. The patient underwent upper endoscopy with duodenal
biopsies, whose pathology report described severe villous atrophy, and HLA Parente R., De Feo G., Cardamone C., Triggiani M.
typing showing a variant of DQ2. Thus, although the negativity of coeliac University of Salerno
serology, suspecting coeliac disease a strict gluten-free diet was started with
clinical, but not histological, benefit after 12 months of gluten-free diet. In Background: Behcet disease (BD) is a chronic disease with immune-me-
2009 the patient experienced malabsorption so that a total parenteral nutri- diated etiology, characterized by recurrent oral and genital aphtous ulcers
tion was commenced. From September 2016 to January 2017 she had again associated to multiorgan involvement. BD affects the gastrointestinal (GI)
diarrhoea and weight loss so that she was referred to our Centre for a reas- tract in 3-60% of cases, expecially the ileocecal region (10-15%). Gi mani-
sessment of the case. At that time she kept taking gluten-free diet and total festations usually occur 4-6 years later than the onset of oral ulcerations.
parenteral nutrition. At our Centre blood tests revealed very low levels of Crohn’s disease (CD) is a chronic inflammatory bowel disease that may
IgA, IgG and IgM. Moreover, after two months of gluten challenge we repe- affect any part of the GI tract, from mouth to anus. It presents with inte-
ated serum anti-tissue transglutaminase and anti-endomysial antibodies, stinal symptoms such as abdominal pain, diarrhoea and vomiting and also
which were confirmed negative, an upper endoscopy with duodenal biop- with extraintestinal manifestations (e.g. skin rashes, arthritis and ocular
sies showing severe villous atrophy, characterization of intraepithelial lym- inflammation).
phocytes by flow cytometry which documented aberrant phenotype, and Differential diagnosis between intestinal BD and CD could be difficult, due
PCR analysis indicative for a polyclonal rearrangement of the TCR- chain to the absence of pathognomonic clinic or endoscopic findings. Systemic
on intestinal tissue sections. In addition, no abnormalities were found in corticosteroids represent the first-line therapy in both diseases.
PET scan and entero-CT. Case Report: A 46-year-old female was admitted to our Unit with persistent
On this basis, we diagnosed a severe villous atrophy secondary to the labial oedema, diarrhoea with 4 bloody discharges/die and abdominal pain.
common variable immunodeficiency and leading to malabsorption and She had a previous diagnosis of “Behcet disease” (five years ago) , based
the subsequent malnutrition. Accordingly, the patient started taking intra- on the evidence of oral aftosis, episcleritis and erythema nodosum; for this
venous immunoglobulins and steroids. On the other hand, the diagnosis reason she had started treatment with oral corticosteroids (1mg/Kg/die)
of coeliac disease was still under debate. The negativity of celiac serology with good response. In that period she had performed a colonscopy that
and the lack of mucosal recovery after gluten-free diet would let us rule out showed the presence of a perianal fistula. After 2 years of treatment, when
coeliac disease. However, the former might be secondary to immunoglobu- clinicians decided to start the tapering of steroids, she referred worsening of
lin deficiency and the latter might be induced by the concomitant common abdominal symptoms associated to rectal bleeding, and the onset of persi-
variable immunodeficiency. Notwithstanding, the reintroduction of gluten stent labial oedema. She did not refer fever or weight loss, neither arthralgia
in the diet to be done after steroid tapering might represent a diagnostic nor arthritis.
tool in order to establish a diagnosis of coeliac disease in case of diarrhoea At the time of admission physical examination revealed oedema of labial
relapse. Nonetheless, even the patient is affected by coeliac disease , we mucosa, with increased consistence at palpation, not painful, and diffuse
rule out refractoriness due to the absence of aberrant intraepithelial lym- pain at abdomen palpation.
phocytes, the lack of monoclonal rearrangement of the TCR-and the nega- Laboratory tests showed increased erythrocyte sedimentation rate and ele-
tivity of PET. vated gamma globulin protein (1.98 g/dl-n.v. 0.78-1.32 g/dL). Faecal calpro-
tectin was increased (257 mg/Kg, n.v. up to 70). C3, C4 and C1INH were
normal. Parasitic, bacterial and viral infections as well as neoplastic diseases
WHEN HEART AND INTESTINE ARE CONNECTED: AN were excluded, performing stool analysis, tumour markers and a total body
EXEMPLIFYING CASE OF DIARRHEA computed tomography (CT scan). HLA-B51 aplotype was not detected.
Pathergy test was performed seven days after stopping steroid treatment
Molfino A., Amabile M.I., Rossi Fanelli F., Muscaritoli M. and the result was negative.
Department of Clinical Medicine, Sapienza University of Rome, Italy Abdominal ultrasound revealed minimal tickening of discending colon.
Colonscopy showed “a longitudinal rectal ulceration with active blee-
A 58-year-old woman with a 5-year history of dilated cardiomyopathy ding” and multiple biopsies were performed along the colon. The patient
and congestive heart failure presented to our Internal Medicine Unit in underwent also an oral mucosa biopsy. Both histological findings showed a
early 2016 for dyspnea and several episodes of diarrhea. During the first “chronic lymphomonocytic inflammation with perivascular infiltration and
days of hospitalization, she exhibited lower extremity edema but presen- glandular architectural abnormalities” , even if no typical granulomas were
ted well-nourished referring involuntary body weight loss of 2.5 % of the found.
habitual body weight. She denied any additional gastrointestinal symptoms Then, on the suspicious of a CD, corticosteroids treatment was restarted at
and the body weight remained stable during the first days of clinical obser- attack dosage of 1mg/Kg/die with rapid symptoms improvement: regression
vation. Anemia was not present and serum iron levels were within normal of abdominal pain and rectal bleeding, but not of labial oedema.
values. In the process of the evaluation, she was noted to have markedly low Discussion: Intestinal BD shares many characteristics with inflammatory
levels of albumin (2.1 g/dL) and total protein (3.2 g/dL). bowel disease, such as CD, including genetic background, clinical manife-
Additional tests for hypoalbuminemia included a 24-h urine protein mea- stations, and therapeutic strategies. Similarities in GI and not GI symptoms
surement, serologic testing for liver function and to exclude the presence (arthropaty, ocular involvement, skin rashes, fever, weight loss) often make
of celiac disease and abdominal imaging performed by ultrasounds, all the differential diagnosis between BD and CD difficult.
resulting within normal ranges. Owing to the concerns of possible cirrhosis Although there are no specific tests for differential diagnosis, some features
related to congestive hepatopathy, evaluation of her liver showed a normal could be helpful to raise the clinical suspicion of BD or CD. The presence of
portosystemic gradient of 2.5 mm Hg and mild sinusoidal dilation in only non-caseating granuloma is pathognomonic of CD but these lesions could
one zone, but no evidence of significant fibrosis or cirrhosis described after be absent up to 75% of patients. Moreover the ulcer shape and number could
biopsy in the histological examination. Endoscopy was also performed be useful to distinguish the two conditions: a focal and round ulcer is more
and was normal including random biopsies of the duodenum and colon. frequent in BD, whereas segmental and longitudinal ulcer are common in
A stool collection for fecal fat was also within normal range (2.9 g/day). CD.
Fecal alpha-1 antitrypsin (A1AT) clearance was measured and was found On the other hand there is no specific diagnostic test for BD and the cur-
to be markedly elevated at 550 mg/10 ml (normal value: <30 mg per 100 rently used clinical diagnostic criteria do not include intestinal symptoms.
ml) consistent with protein losing enteropathy (PLE). Additional relevant In our patient, long-term therapy with oral corticosteroids may have contri-
laboratory findings included decreased level of ceruloplasmin and copper. buted to the diagnostic delay.
Although we changed her diet to include a protein intake of at least 1.8-2 g/
kg/day, her albumin and total protein levels did not significantly and clini-
17
RENAL RESISTIVE INDEX REFLECTS RENAL AND management of knee osteoarthritis that were reviewed, 12 published arti-
SYSTEMIC INVOLVMENT IN SCLERODERMIC PATIENTS cles were identified for inclusion. A total of 1044 patients were enrolled in
the aforementioned studies, of which 582 belonged to experimental groups
Maestripieri V. 2, Bruni C. 1, Tesei G. 1, Chiostri M. 2, Guiducci S. 1, Bellando- while 462 belonged to control groups. The main methods used for clinical
Randone S. 1, Matucci-Cerinic M. 1, Boddi M. 2 assessment were: VAS (Visual Analogic Scale), WOMAC (Western Ontario
1
Department of Experimental and Clinical Medicine, Division of and McMaster Universities Osteoarthritis Index), Lequesne’s Index, MCII
Rheumatology, University of Florence, Firenze (Italy) 2Department (Minimal Clinic Important Improvement) AIMS (Arthritis Impact Measu-
ofExperimental and Clinical Medicine, Division of Internal Medicine, rement Scale) and SF-36 (The Short Form [36] Health Survey). In all studies
University of Florence, Firenze (Italy) the end points were evaluated at the beginning and at the end of the therapy
but in some studies additional evaluation schedules were observed. Stati-
Background: Renal Resistive Index (RRI), measured by Doppler ultra- stical analysis was performed using common tests (Student’s t test, Pear-
sound, reflects changes in both renal vascular and tubular-interstitial com- son’s X2, Wilcoxon’s test, Z value, Mann-Whitney U test). All the differences
partments and in systemic vascular compliance related to age and comorbi- between the values found before and after spa-therapy in the experimental
dities (such as hypertension, diabetes, hyperuricaemia, etc). As renal injury groups and those between experimental groups and control groups were
in younger decades may occur also for RRI <0.70, the use of this cut-off significant. Moreover, within the control groups such differences were much
may underestimate. RRI was previously investigated in small SSc samples, lower, or nonexistent, or non statistically significant. In particular, due to
although not considering possible confounding medical conditions. The the effect of spa-therapy in the patients participating in the research, the
objectives of the study were: describing RRI in our SSc population, to test score of VAS, Lequesne’s Index, and the three different WOMAC indices
both fixed 0.70 RRI cut-off and SSc-age-adjusted cut-offs in reflecting renal were respectively decreased compared to the initial value (Table). Regarding
and other organ involvement, to analyse the prognostic value of baseline the MCII index and the two health scales measuring quality of life, AIMS
RRI and RRI Δ change in predicting SSc-induced worsening. and SF-36, an improvement in clinical conditions and overall health was
Methods: SSc patients classified through ACR/EULAR 2013 criteria, ≥18 highlighted in patients after SPA treatment with a statistically significant
years were enrolled after informed consent. Baseline data on RRI, labora- difference compared to control groups.
tory, instrumental and therapeutic features were retrospectively collected. Conclusion: The research on the efficacy of spa-therapy in the treatment of
SSc-age-adjusted pathologic cut-offs were created dividing the population knee osteoarthritis confirms that by this treatment it is possible to obtain
in age quartiles and considering RRI values >75th percentile as pathologic. good results for pain, articular function and quality of life with reduction of
Results: 250 SSc patients (mean disease duration 7.2±8.3 years) were eli- disabling consequences in affected patients. Mud-bath therapy is part of an
gible for the study. RRI showed significant correlations with age (ρ=0.56, integrated and multidisciplinary approach, synergistic with other forms of
p<0.001) and creatinine clearance (ρ=-0.38, p<0.001), as well as significant therapy (pharmacological, physiotherapy, etc.), that allows to reduce phar-
associations with general population RRI determinants. When considering macological treatment dosage and/or duration, to save on healthcare system
RRI absolute value and 0.70 cut-off, only comorbidities, renal function, costs, while being associated with a lower frequency of side effects.
sPAP and E/A, DLCO and late NVC pattern were associated. Conversely,
new SSc-age-adjusted RRI cut-offs could not detect early renal damage Measuring (1) Patients Mean of detected values (c) a-b (2) Decrease
but were significantly associated with various disease related skin and lung scale %
fibrotic manifestations, as well as vasculopathic complications. After a mean
(a) before (b) after
follow-up of 3.6±2.6 years, while RRI absolute values and 0.70 RRI cut-off therapy therapy
showed no significant value, SSc-age-adjusted RRI cut-offs were signifi-
VAS 297 54,71 29,36 - 25,35 - 46,34
cantly predictive for cardiac, lung and renal worsening. On the other hand,
RRI Δ changes in 3 years (100 pts) and 5 years (60 pts), were not sensitive or Lequesne’s 140 56,61 37,49 - 19,12 - 33,78
predictive for worsening. Index
Conclusion: in clinical practice, different age-SSc-adjusted or non-adju- WOMAC – 170 21,49 13,74 - 7,75 - 36,06
sted RRI cut-offs may be used to evaluate renal and extrarenal involvement, TPS (3)
resembling DLCO for parenchymal and vascular lung involvement. These WOMAC – 126 27,78 16,98 - 10,80 - 38,87
RRI cut-offs may be considered as possible predictors of kidney, lung and TSS (4)
cardiac worsening in SSc patients. WOMAC – 387 40,26 26,71 -13,55 - 33,65
TPFS (5)
EFFICACY OF SPA-THERAPY IN THE MANAGEMENT OF (1) Number of patients in the experimental groups who participated in the studies in which a specific
KNEE OSTEOARTHRITIS measurement scale was used excluding the studies in which data were expressed in a way other than
the one normally used (eg in percentage without absolute values, in graphic form only, etc.)
Mennuni G. 1, Serio A.2, Fontana M. 1, Nocchi S. 1, Bressanin E. 1, Conte S. 1, (2) Calculated according to the following procedure-Value at term of therapy if the initial value was =
Priori F. 1, Fraioli A. 1 100 (the following is an example of the values of VAS) 29.36: 54.71 = x: 100; X = 53.66 (value found at
1
UOC Medicina Interna, Terapia Medica e Medicina Termale, Scuola di the end of therapy if the initial value was 100)100-53.66 = 46.34 (decrease as a percentage of
Specializzazione in Medicina Termale, Dipartimento di Medicina Interna e VAS value at the end of therapy) (3) TPS = Total Pain Score (4) TSS = Total Stiffness Score; (5) TPFS
Specialità Mediche, Azienda Ospedaliera Universitaria Policlinico Umberto I, = Total Physical Function score
Sapienza Università di Roma 2 Università Campus Bio-Medico di Roma
Background: Osteoarthritis (OA) is the most common musculoskele- ASSOCIATION OF RITUXIMAB AND MYCOPHENOLATE
tal disease worldwide. It has significant impact on patients’ quality of life, MOFETIL FOR THE THERAPY OF SYSTEMIC SCLEROSIS.
affecting their ability to perform common daily activities. OA is found most ANALYSIS OF A COHORT OF PATIENTS
frequently in the elderly, although it can occur at any age and therefore
should not be considered an aging disease exclusively. Osteoarthritis can Fischetti C. 1, Fraticelli P. 1, Salaffi F. 2, Carotti M. 3, Pomponio G. 1, Zuliani
be, for some joints, favored by specific work or sports activities, traumas, L. 1, Ferrarini A. 1, Gabrielli A. 1
co-morbidities such as obesity or endocrine diseases and genetic predi- 1
Dipartimento di Medicina Interna, Ospedali Riuniti, Università Politecnica
sposition. OA, and especially knee osteoarthritis, is a condition of high delle Marche, Ancona; 2Clinica di reumatologia, Ospedale Carlo Urbani Jesi,
socio-economic impact in terms of drug spending, hospital admissions, Università Politecnica delle Marche, Jesi (AN); 3Dipartimento di Radiologia,
work absences and temporary or permanent invalidity. Aim The aim of this Ospedali Riuniti, Università Politecnica delle Marche
research is to evaluate literature on the efficacy of SPA-therapy (mud-pack
therapy and/or bath therapy) in the management of knee osteoarthritis. Background: Systemic Sclerosis (SSc) is a chronic systemic disease cha-
Methods: We conducted a systematic review of the literature on spa-the- racterized by immune abnormalities, microangiopathy and progressive
rapy in the treatment of knee osteoarthritis. We searched the PubMed, fibrosis of skin and internal organs. Only few therapeutic options have
Medline, Cochrane Library, Web of Science databases for articles published shown a proved disease-modifying effect for skin thickening and SSc-as-
from 2002 through 2015 using the following key words: osteoarthritis, knee sociated interstitial lung disease. Rituximab (RTX) and Mycophenolate
osteoarthritis, spa therapy, mud-pack therapy, mud-bath-therapy, randomi- Mofetil (MMF) have separately proven some evidence of efficacy and safety
zed clinical trial. Results Of the 33 studies on the use of SPA-therapy in the in clinical trials or case series.
18
Objectives: Tp assess efficacy and safety of a combination therapy, with RTX that functions as a iron storage compound. Under normal circumstances,
and MMF in a cohort of SSc patients with pulmonary and cutaneous invol- the serum ferritin concentration is usually related to the amount of body
vement rapidly progressive or resistant to conventional therapy. iron stores. However, serum ferritin concentration may be elevated in pre-
Methods: Eligible patients were administered with RTX in two different sence of certain clinical conditions, including liver diseases, renal disease,
regimens (1000 mg fortnightly x 2 or 375 mg/mÇ/week for 4 consecutive malignancies, human immunodeficiency virus (HIV) infection, non-HIV
weeks) at baseline and after 6 months, associated with MMF 2000 mg/day. systemic infections, chronic inflammation, chronic red-cell tranfusions and
They received anti-infective prophylaxis with Valacyclovir 1000 mg and sickle cell syndromes. Our purpose is to explain and discuss the exaggerated
Cotrimoxazole 160/800 mg alternate days. Patients underwent clinical and ferritin response - with values > 145 times the normal upper level - in a
laboratory evaluation every 3 months. Skin involvement was assessed by man with Adult Onset Still’s Disease (AOSD). An extremely elevated serum
using the modified Rodnan Skin Score (mRSS) performed by the same phy- ferritn concentration may be considered a useful criterion to diagnose this
sician at baseline, after 3, 6 and 12 months. Chest high-resolution computed illness.
tomography (HRCT), pulmonary function tests (PFTs) and Diffusing Capa- Case Report: A 51-year-old man was admitted to our Medical Unit because
city of the lung for Carbon Monoxide (DLCO) were performed at baseline, of high-spiking fever, pink-coloured skin rash, diffuse myalgias and arthral-
after 6 and 12 months. The assessment of the extension of pulmonary gias. His remote and physiological anamnesis were negative for relevant
fibrosis (PF) was analysed with a conventional visual reader-based score pathologies, he took no drugs and he had no known medication allergies.
(CoVR),and with a computerized-aided method (CaM) using a DICOM The patient had not recently travelled outside the country. On physical
software. Statistical analysis was performed by Friedman test (GraphPa- examination he appeared to be suffering. The temperature was 39.4°C,
dPrism V5). the blood pressure 122/60, the pulse 86 beats per minute, the respiration
Results: 18 SSc patients were enrolled (F/M: 10/8, median age 51yr, rate was 18 breath per minute and the oxygen saturation 95% while he was
median duration of disease 1 yr, diffuse SSc 9, limited SSc 9). The analysis, breathing ambient air. The remainder of examination was normal, except
at 12 month, includes all 15 of 18 patients who completed follow-up. The for a diffuse erythematous skin rash. A chest radiography was normal and
mRSS showed a statistically significant improvement (p2=0,0036). more abdomen ultrasound revealed splenomegaly with a longitudinal diameter
remarkable in patients with diffuse cutaneous SSc. For pulmonary fun- of 13.5 cm and a section area of 89.4 square centimeters. The most remar-
ction tests there was a statistically significant increase of FVC (p2=0,0093), kable laboratory tests were: white-cell count 24.000/mmc, neutrophils 88%,
erythrocyte sedimentation rate 72 mm/h, fibrinogen 725 mg/dl, C-reactine
FEV1 (p2=0,0061) with stable values of DLCO (p=0,3375). The HRCT
protein 37.91 mg/dl, procalcitonin 7.57 ng/ml, rheumatoid factor < 20 (n.v.
scan showed an improvement statistically significant evaluated with CaM
< 30), antistreptolysin titer 70 UI/ml (n.v. < 200). Serology for Borrelia
(p*=0,0331), while the CoVR showed a not significant trend toward impro-
Burgdorferi was negative, as were tests for HBV and HCV. Renal-funcion
vement. No serious adverse events were observed during the follow-up. In
tests, hemoglobin and hematocrit, reticulocyte and platelet count, total
two patients the MMF dose was reduced for mild neutropenia.
proteins, alanine and aspartate aminotrasferase, blood levels of amylase,
Conclusions: Despite preliminary and limited to a small number of
lipase, albumin, globilin, alkaline phosphatase, total and direct bilirubin
patients, our results suggest that combination therapy with RTX and MMF
were within the normal range. Cultures of blood and urine were negative.
is well tolerated, safe, and potentially effective for cutaneous and pulmonary
The most striking laboratory finding was an abnormal increase of ferritin:
involvement in SSc patients.
> 40.000 ng/ml (n.v. 21-274 ng/ml). The clinical picture oriented to the dia-
gnosis of AOSD. In fact, all the four major Yamaguchi’s diagnostic criteria
(arthralgias, fever > 39°C, typical rash, leucocytosis) and two minor crite-
PULSED ELECTROMAGNETIC FIELDS MODULATE ria (splenomegaly and negativity of rheumatoid factor) were fulfilled. The
SCLEROSTIN LEVELS IN WOMEN WITH patient started treatment with steroids and methotrexate and was dischar-
POSTMENOPAUSAL OSTEOPOROSIS ged from the hospital.
Discussion: AOSD is a rare sytemic inflammatory disorder of unknown
Catalano A. 1, Basile G. 1, Bellone F. 1, Pecora C. 1, Loddo S. 1,
aetiology that can have serious musculoskeletal sequelae. Serum ferritin
Lasco A. 1, Morabito N. 1
levels are usually markedly increased in AOSD and are higher than those
1
Department of Clinical and Experimental Medicine, University Hospital of
found in patients with other autoimmune and inflammatory diseases. Pre-
Messina, Messina, Italy; 2Spine Surgery Section, Carmona Clinic, Messina,
vious studies evaluated the validity of hyperferritinemia > 1000 ng/ml (i.e.
Italy
five times the upper limits of normal) as a diagnostic criterion for AOSD.
This ferritin cutoff showed 80-82% sensitivity and 41-46% specificity, but
Object: Pulsed electromagnetic field (PEMF) could promote in vivo and in
very higher levels are not uncommon, as recorded in our patient, who had a
vitro osteogenesis, and enhance bone healing with unknown mechanism.
ferritin concentration more than 145 times the upper limit.
Aim of our study was to evaluate the circulating canonical Wnt signaling
Conclusion: The usefulness of hyperferritinemia in the diagnosis of AOSD
antagonists sclerostin and DKK-1 in a setting of Caucasian women with
is well-known, but sensitivity and specificity of this parameter could be
postmenopausal osteoporosis receiving PEMFs.
improved by fixing a threshold-level higher than those used up to date.
Materials and Methods: 30 participants with sufficient vitamin D and no
other diseases were recruited and randomized into two groups. PEMFs
group received PEMFs treatment by a dedicated waistcoat applied to the
SCHEDULED RITUXIMAB MAINTENANCE REDUCES
trunk (50 min treatment session/day, 5 treatment sessions/week, for a total
RELAPSE RATE IN EOSINOPHILIC GRANULOMATOSIS
of 25 times as one course of treatment), while those assigned to control
WITH POLYANGIITIS
group received sham PEMF treatment with the same device. Blood sample
for evaluation of surrogate markers of bone turn-over were obtained at the
Emmi G. 1, Rossi G.M. 2, Urban M.L. 2, Silvestri E. 1, Goldoni M. 3,
beginning and at the end of the PEMFs treatment period.
Prisco D. 1, Vaglio A. 2
Results: At baseline, the two groups were not significantly different for 1
Interdisciplinary Internal Medicine, Careggi University Hospital, Firenze,
age, age since menopause, BMI, BMD, ALP, CTX and baseline sclerostin
Italy; 2Nephrology Unit, Parma University Hospital, Parma, Italy;
and DKK-1 values. After treatment, sclerostin but not DKK-1 levels were 3
Department of Medicine and Surgery, University of Parma, Parma Italy
significantly reduced only in the PEMFs group (-20%, p<0.05) and this was
associated with an increase of ALP (+8%. p=0.10).
Objectives: Eosinophilic granulomatosis with polyangiitis (EGPA) is a
Conclusion: In women with postmenopausal osteoporosis, our preliminary
systemic vasculitis with a chronic/relapsing course. While the use of ritu-
data provide the first evidence of a modulation of sclerostin levels by PEMFs
ximab (RTX) has been largely investigated in the other anti-neutrophil
suggesting a possible explanation for PEMFs effects on bone.
cytoplasmic antibody (ANCA)-associated vasculitides, data in patients with
EGPA are still limited.
Methods: In this retrospective, observational study, we report the outcome
MARKED HYPERFERRITINEMIA IN ADULT ONSET of 21 EGPA patients treated with RTX induction for relapsing/refractory
STILL’S DISEASE: NOTHING NEW UNDER THE SUN? disease between 2011-2017; their median follow-up was 24 months. Starting
from 2014, we protocolised RTX maintenance using a scheduled low-dose
Zanghieri G., Franchi L.
regimen (500 mg/6 months). Results Induction with RTX was completed
Unità Internistica Multidisciplinare, Ospedale S. Sebastiano, Correggio (RE)
by 20 patients. At the end of month 3, remission had been achieved by 15
patients (75%). RTX induction induced a statistically significant reduction
Background: Ferritin is a high weight molecular iron-containing protein
in Birmingham Vasculitis Activity Score (BVAS), prednisone dose, and eosi-
19
nophil count. Among the 15 responders, 9 received protocolised RTX main- between patients who received procotolised maintenance rituximab (conti-
tenance, while the remaining 6 were only retreated at the time of relapse. nuous line) and patients who did not (dashed line). (c) Birmingham Vascu-
Relapse-free survival was significantly longer in patients who received litis Activity Score, (d) prednisone dose (or equivalent), and (e) eosinophil
protocolised RTX maintenance than in those who did not (log-rank test counts of all patients 0, 6, 12 and 18 months after rituximab induction. Dif-
p=0.0007). Treatment-related adverse events were uncommon. ferences in continuous variables within groups were analysed using Wil-
Conclusions: Our results confirm that RTX effectively induces remission coxon matched-pairs signed rank test. Differences in survival curves were
in EGPA. Intriguingly, we found that a scheduled maintenance regimen of analysed using the log-rank test. A p value of <0.05 was considered signifi-
low-dose RTX significantly reduces relapse risk in EGPA. cant for all analyses.
RESISTANT HYPERTENSION AND OBSTRUCTIVE SLEEP

APNEA SYNDROME IN THERAPY WITH CONTINUOUS
POSITIVE AIRWAY PRESSURE
Lai S. ,Mordenti M. 1, Mangiulli M. 2, Villani T. 1, Arcieri E. 1, Steffanina A. 1,

Di Paolo M. 1, Mastroluca D. 3, Palange P. 1
Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy;
1
Department of Public Health and Infectious Diseases, Sapienza University
of Rome, Italy; 2Department of Internal Medicine and Medical Specialities,
Sapienza University of Rome, Rome, Italy; 3Nephrology and Dialysis Unit,
Hospital ICOT Latina, Sapienza University of Rome, Italy
Introduction: Resistant hypertension is a clinical condition characterized

by the presence of pressure values above the recommended reference limits,
despite adherence to lifestyle modification and drug therapy consisting of
at least three classes of drugs at appropriate doses, one of which is a diu-
retic. Resistant hypertension can be part of the Obstructive Sleep Apnea
Syndrome (OSAS), where secondary hyperaldosteronism and greater car-
diovascular risk are present, as well as an increased risk of progression to
kidney disease.The gold standard for the diagnosis of OSAS is represented
by polysomnography, an investigation that allows classification of apnea in
central, obstructive and mixed, as well as an entity evaluation. The purpose
of our study was to evaluate the treatment of patients with resistant hyper-
tension and OSAS, after 6 months of continuous positive airway pressure
(CPAP) therapy.
Materials and Methods: 24 patients with resistant hypertension were
enrolled.andthey carried out at a polysomnography to perform diagno-
sis of OSAS. Clinical, laboratory and instrumental examinations such as
inflammatory indices, mineral metabolism, emogasalysis, and systemic
markers of atherosclerosis and endothelial dysfunction (Intima Media
Thickness, (IMT), Ankle Brachial Pressure Index (ABPI), Flow Mediated
Dilation (FMD), Renal Resistive Index (RRI), Left Ventricular Mass Index
(LVMI), as well as an assessment by Ambulatory Blood Pressure Monitoring
(ABPM) and Cardiopulmonary Exercise Testing (CPET), were performed
at T0 and after 6 months of follow up (T1).
Results: 24 patients (16 male, 8 female, mean age 59,57 ± 12,84 years), with
resistant hypertension were enrolled, with a prevalence of OSAS of 91.6%
(22/24 pz), 12 patients agreed to continue enrollment for six months of fol-
low-up with CPAP therapy. Of these 12 patients, 50% had a severe OSAS
(6/12 pts), and the remaining 50% had mild-moderate OSAS. Our study
showed a reduction in Systolic Blood Pressure (SBP), Diastolic Blood Pres-
sure (DBP), systolic and diastolic Mean Arterial Pressure (MAP) after 6
months of CPAP therapy (p<0.001, p=0.009, p=0.007, p=0.021), an incre-
ase of excretion fraction (p=0.035), and a decrease in IMT and RRI after 6
months of CPAP therapy (p =0.020, p =0.036). We also found an improve-
ment of all polysomnographic parameters (number of apnees / hypopnea
per hour (AHI), Apnea Index (AI), number of episodes of night-time hemo-
globin desaturation (ODI) (p=0.010)), an improvement in Epworth Sleepi-
ness Scale (ESS)(p = 0.03), as well as an improvement in stress tolerance to
CPET(p = 0.017), after 6 months of CPAP therapy. We also found a positive
correlations between some polysomnographic parameters (AI,AHI,ODI)
and diastolic PAM and PAPSs at the echocardiogram (p=0.049, p=0.048,
p=0.019), as well as a negative correlation between ODI and FMD (p =
0.023). CPET showed a negative correlation between patient-sustained time
(Tlim) and systolic / diastolic PAM (p=0.010, p=0.015), as well as a negative
correlation between functional capacity and ventilatory efficiency at exer-
cise (V02max%), and systolic / diastolic PAM (p = 0.024), and between the
indirect systolic output index during CPET (O2 pulse peak%) and systolic
PAM (p = 0.040).
Conclusions: OSAS is a widespread disease that can determine resistant
hypertension, as well as a progression of renal disease and higher cardio-
vascular risk, so we suggest screening through the simple administration
Figure legend: of specific tests and / or polysomnography, in patients with resistant hyper-
(a) Kaplan-Meier relapse-free survival estimate of the 15 patients with eosi- tension. It would also be appropriate to carry out a complete cardiovascular
nophilic granulomatosis with polyangiitis (EGPA) who achieved remission screening, considering the possible reversibility of some endothelial dysfun-
after induction with rituximab. (b) Comparison in relapse-free survival ction and atherosclerotic markers after CPAP therapy. We also recommend
20
the use of CPET, which is not yet widely used in clinical practice, except end of the therapy compared to baseline; significant increase in left atrial
in specialized areas, for a complete diagnostic and prognostic evaluation volume (p= 0,01416) and in E/e’ relationship (p=0,00113) at the end of the
and therefore for a better therapeutic approach, mostly considering the high therapy compared to baseline.Furthermore we demonstrated a correlation
cardiovascular risk of these patients. between the left atrial volume increase and MAPSE reduction with age and
BMI increase.
Discussion: Anthracyclines are the standard of care in patients with breast
DETECTING FAMILIAL HYPERCHOLESTEROLEMIA BY cancer, and trastuzumab is usually used sequentially in patients where
SERUM LIPID PROFILE SCREENING IN A HOSPITAL HER2 receptor is overexpressed or amplified. Anthracyclines induce ultra-
SETTING: CLINICAL, GENETIC AND ATHEROSCLEROTIC structural alterations of myocardiocytes, dose-dependent and irreversible;
BURDEN PROFILE instead trastuzumab induces functional changes of myocardiocytes by inhi-
bition of HER2-mediated repair mechanisms, dose-independent, poten-
Scicali R.1, Di Pino A.1, Platania R. 1, Purrazzo G. 1, Ferrara V. 1, Giannone tially reversible. The majority of patients present asymptomatic changes
A. 1, Urbano F. 1, Filippello A. 1, Rapisarda V. 2, in ejection fraction, then in order to recognize early and subclinic sings
Farruggia E. 3, Piro S. 1, Rabuazzo A.M. 1, Purrello F. 1 of cardiac disfunction, we studied the longitudinal systolic left ventricular
1
Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, shortening using the ring mitral systolic excursion (MAPSE) as a simple,
Italia. 2 Dipartimento di Medicina Clinica e Sperimentale, Sezione di easily obtained parameter which may contribute to the evaluation of systolic
Medicina del Lavoro, Università di Catania, Italia. 3 Divisione di Medicina function. Similarly to the global longitudinal strain (GLS), MAPSE explo-
del Lavoro, ARNAS Garibaldi, Catania, Italia res the cardiac contraction on the longitudinal axis, and was recently re-e-
valuated as easy to perform, also obtainable for bad sonographic windows
Background and Aims: Familial hypercholesterolemia (FH) is an under- and not operator dependent.In particular MAPSE is known to detect more
diagnosed pathology and public cholesterol screening may be useful to find subtle abnormalities of LV function which early occur, as a reduced longi-
new subjects. In this study, we aim to investigate the prevalence of patients tudinal systolic left ventricular shortening, in patients with increasing age,
with FH in a hospital cholesterol screening program and evaluate their athe- myocardial hypertrophy induced by hypertension and diastolic dysfunction
rosclerotic burden using intima-media thickness (IMT) as a macroangiopa- with preserved ejection fraction (HFpEF), where long axis function of the
thic biomarker. Methods and results: We screened 1575 lipid profiles and heart is already impaired while the radial function can be still preserved.
included for genetic analysis adults with a low-density lipoprotein (LDL) Similar to MAPSE, tissue Doppler imaging, with E/e’ relationship, is descri-
cholesterol > 190 mg/dL and triglycerides < 200 mg/dL and first-degree bed to be superior to conventional echocardiography in detecting early
child relatives an LDL cholesterol > 160 mg/dL and triglycerides < 200 mg/ abnormalities of the LV function and its correlation with MAPSE has been
dL. The diagnosis of FH was first presumed by Dutch Lipid Clinic Network described previously. The increase of left atrial volume can be considered as
(DLCN) criteria and then confirmed by the presence of the genetic variant. a diastolic dysfunction index because it reflects the increase in ventricular
Mean common carotid intima media thickness (IMT) was assessed using end-diastolic pressure. Conclusions The combined and sequential treatment
consensus criteria. Among 56 subjects with a DLCN ≥4, 26 had an FH with anthracyclines and trastuzumab causes early alterations in myocardial
genetic variant. The proportion of patients with a detected mutation having function even in asymptomatic patients. The heart damage consists in the
a DLCN score of 4–5 was 17.6 %; in subjects with a DLCN score of 6–8 it reduced contractile efficiency of the left ventricle, explored and expressed
was 75 % and in individuals with a DLCN score > 8 it was 100 %. Mean IMT as the reduction in MAPSE, and increased left atrial volume as a predictor
was higher in FH patients compared to non FH patients (0.73 [0.61–0.83] vs of incipient diastolic dysfunction, especially if related to cardiovascular risk
0.71 [0.60–0.75] mg/dL, p < 0.01). Moreover, multivariate analysis showed factors such as hypertension, overweight and increased age. These eviden-
that mean IMT was correlated with age, sex and corneal arcus (p value for ces require careful stratification of patients undergoing cytotoxic systemic
all parameters < 0.01). therapy based on cardiovascular risk, and therefore undertake cardiopro-
Conclusions: A hospital cholesterol screening was useful to detect subjects tection strategies by lifestyle modification, sartan and beta-blocking therapy
with FH and increased carotid atherosclerosis independently correlated and echocardiographic monitoring during and after the end of therapy.
with corneal arcus.
EFFECT OF ANAKINRA ON RECURRENT PERICARDITIS

CARDIOTOXICITY BY CHEMOTHERAPY: CORRELATION AMONG PATIENTS WITH COLCHICINE RESISTANCE
BETWEEN EARLY INDICATORS OF CARDIAC AND CORTICOSTEROID DEPENDENCE THE AIRTRIP
DYSFUNCTION AND CARDIOVASCULAR RISK FACTORS RANDOMIZED CLINICAL TRIAL
Favuzzi A., Nicolazzi M.A., Fuorlo M., Carnicelli A., Landolfi R. Brucato A. 1, Imazio M. 2, Gattorno M. 3, Lazaros G. 4,
Dipartimento di Scienze Mediche, Policlinico Universitario Agostino Gemelli, Maestroni S. 1, Carraro M. 2, Finetti M. 3, Cumetti D. 1,
Roma Carobbio A. 1, Ruperto N. 3, Marcolongo R. 5, Lorini M. 1,
Rimini A. 3, Valenti A. 1, Oppedisano I. 1, Parisi F. 1, Erre G.L. 6, Sormani
Background: The term cardiotoxicity from chemotherapy is the set of major M.P. 3, Belli R. 2, Gaita F. 7, Martini A. 8
adverse cardiac events (left ventricular dysfunction, heart failure, arrhyth- 1
Internal Medicine Division, Research Foundation, and Clinical
mias, coronary heart disease etc.) caused by anticancer drugs. In breast Pharmacology, Ospedale Papa Giovanni XXIII, Bergamo, Italy. 2Cardiology
cancer, the anthracycline cardiotoxicity is the most important and histo- Department, Maria Vittoria Hospital and Department of Public Health and
rically most studied, both for the frequency with which these drugs cause Pediatrics, University of Torino, Torino, Italy. 3IRCCS Istituto G. Gaslini,
adverse cardiac events, both for the high number of patients with breast Pediatria II, Genova, Italy. 4Cardiology Department, Maria Vittoria Hospital
cancer undergoing treatment with anthracyclines. Sequential therapy with and Department of Public Health and Pediatrics, University of Torino,
trastuzumab in addition to anthracyclines increases the hazard of develo- Torino, Italy-Department of Cardiology, University of Athens Medical School,
ping cardiotoxicity, the toxic effects of the two drugs are added up and stren- Hippokration Hospital, Athens, Greece. 5Clinical Immunology, Department
gthen. The structural changes caused by anthracyclines may remain asymp- of Medicine, Azienda Ospedaliera-Università, Padova, Italy. 6Reumatologia,
tomatic until they do not sustain any event “stressors” following. Sequential Azienda Ospedaliero-Universitaria di Sassari, Sassari, Italy. 7University
administration of anthracyclines and trastuzumab is a typical example of a Cardiology Division, Department of Medical Sciences, Città della Scienza e
stressful event that could unmask the toxicity of anthracyclines, as well as della Salute, Torino, Italy. 8IRCCS Istituto G. Gaslini, Pediatria II, Genova,
the presence of pre-existing cardiovascular risk factors. Italy- University of Genova, Genova, Italy
Material and Methods: They were enrolled 100 women of average age 52
years underwent echocardiography before and at the end of the cytotoxic Importance: Anakinra, an interleukin 1β recombinant receptor antagonist,
therapy. In our population we want to recognize early and subclinic signs of may have potential to treat colchicine-resistant and corticosteroid-depen-
cardiac disfunction based on the modification of echocardiographic systolic dent recurrent pericarditis.
and diastolic parameters and to demonstrate correlation of the above modi- Objective: To determine the efficacy of anakinra for colchicine-resistant
fications with the age and pre-existing cardiovascular risk factors (hyper- and corticosteroid-dependent recurrent pericarditis. Design, Setting, and
tension, cigarette smoke, diabetes, dyslipidemia, overweight and obesity). Participants: The Anakinra—Treatment of Recurrent Idiopathic Pericar-
Results: In our follow up we observed: significant reduction (p= 0,00032) ditis (AIRTRIP) double-blind, placebo-controlled, randomized withdrawal
of the fraction of mitral valve ring shortening in systole (MAPSE), further trial (open label with anakinra followed by a double-blind withdrawal step
reduced in the population of patients with hypertension (p= 0,04235) at the with anakinra or placebo until recurrent pericarditis occurred) conducted
21
among 21 consecutive patients enrolled at 3 Italian referral centers between ASSOCIATION BETWEEN NECK CIRCUMFERENCE,
June and November 2014 (end of follow-up, October 2015). Included AORTIC AND CAROTID STIFFNESS IN HEALTHY
patients had recurrent pericarditis (with_3 previous recurrences), elevation ADOLECENTS. THE MACISTE STUDY
of C-reactive protein, colchicine resistance, and corticosteroid dependence.
Interventions: Anakinra was administered at 2mg/kg per day, up to 100mg, Pucci G. 1, Battista F. 1, Sanesi L. 1, Bianchini E. 2, Faita F. 2, Gemignani V. 2,
for 2 months, then patients who responded with resolution of pericarditis D’Abbondanza M. 1, Papi F. 1, Schillaci G. 1
were randomized to continue anakinra (n = 11) or switch to placebo (n = 1
Struttura Complessa di Medicina Interna, Azienda Ospedaliera di Terni,
10) for 6 months or until a pericarditis recurrence. Dipartimento di Medicina, Università di Perugia, Terni, Italia 2 Istituto di
Main Outcomes and Measures: The primary outcomeswere recurrent peri- Fisiologia Clinica, Centro Nazionale Ricerche, Pisa, Italia
carditis and time to recurrence after randomization.
Results: Eleven patients (7 female) randomized to anakinra had a mean Introduction: obesity has a negative impact on arterial distensibility. Neck
age of 46.5 (SD, 16.3) years; 10 patients (7 female) randomized to placebo circumference (NC) is a marker of upper body adiposity and unfavourable
had a mean age of 44 (SD, 12.5) years. All patients were followed up for 12 metabolic profile among young subjects. The association between NC and
months. Median follow-up was 14 (range, 12-17) months. Recurrent peri- arterial stiffness is unknown. We evaluated the association between NC and
carditis occurred in 9 of 10 patients (90%; incidence rate, 2.06%of patients other measures of adiposity, with carotid-femoral pulse wave velocity (cf-
per year) assigned to placebo and 2 of 11 patients (18.2%; incidence rate, PWV) and carotid stiffness (CS) in healthy adolescents.
0.11% of patients per year) assigned to anakinra, for an incidence rate diffe- Methods: 431 individuals (mean age 16.9±1.4y, SBP/DBP 124/67±11/7
rence of −1.95%(95%CI, −3.3%to −0.6%). Median flare-free survival (time mmHg) attending the Liceo Donatelli High School in Terni, Italy, were eva-
to flare) was 72 (interquartile range, 64-150) days after randomization in the luated. cf-PWV was measured with applanation tonometry (SphygmoCor
placebo group and was not reached in the anakinra group (P <.001). During device, subtracted distance). CS was measured with Carotid Studio (Quipu):
anakinra treatment, 20 of 21 patients (95.2%) experienced transient local a contour tracking algorithm was applied to B-mode longitudinal scans of
skin reactions: 1 (4.8%) herpes zoster, 3 (14.3%) transaminase elevation, common carotid artery to obtain diameter changes, stroke change in lumen
and 1 (4.8%) ischemic optic neuropathy. No patient permanently disconti- area (ΔA) and lumen area (A). The cross-sectional distensibility coefficient
nued the active drug. No adverse events occurred during placebo treatment. (DC=ΔA /(A*PP)) was converted (Bramwell-Hill equation) into a carotid
Conclusion and Relevance: In this preliminary study of patients with stiffness parameter (CS=(DC*ρ)-1/2, ρ=blood density) with same measure-
recurrent pericarditis with colchicine resistance and corticosteroid depen- ment units of PWV. Carotid waveform was calibrated to brachial MAP/DBP.
dence, the use of anakinra compared with placebo reduced the risk of recur- Brachial MAP was derived from brachial tonometry calibrated to brachial
rence over a median of 14 months. Larger studies are needed to replicate SBP/DBP.
these findings as well as to assess safety and longer-term efficacy. Results: average NC was 33±3 cm, cf-PWV was 4.9±0.8 m/s, CS 4.3±0.6
m/s. NC, as well as other measures of adiposity (BMI, BMI z-score, waist
and hip circumferences, waist-hip ratio, waist-height ratio), showed some
FERRITIN LEVELS IN METABOLIC SYNDROME degrees of association with both cf-PWV and CS. The association between
NC and CS was the only association which remained significant after adju-
Biferi E., Cerasi C., Stamerra C.A., De Feo M., stement for age, sex and MAP (partial R=0.13, p<0.01), and remained signi-
Vertolli P., Properzi G., Ferri C. ficant also after further adjustment for BMI (partial R=0.10, p=0.03).
University of L’Aquila - Department of Life, Health and Environmental Conclusions: in healthy adolescents, NC and other measures of global and
Sciences - Division of Internal Medicine and Nephrology - San Salvatore local adiposity showed significant associations with cf-PWV and CS. The
Hospital of L’Aquila (Italy) association between NC and CS was the only correlation independent from
age, sex, MAP and BMI. Both local and systemic factors may be involved
Introduction: Ferritin is one of the key proteins regulating iron homeosta- in explaining this relationship. NC may help in identifying adolescents at
sis and is a widely available clinical biomarker of iron status. Some studies increased CS.
suggest that prevalence of atherosclerosis and insulin resistance increases Table: bivariate associations between indexes of adiposity and measures of
significantly with increasing serum ferritin. Metabolic syndrome (MS) arterial stiffness (*p<0.05, **p<0.01)
is known to be associated with increased risk of atherosclerosis as well as
insulin resistance (IR). Materials and Methods: The study group consisted
of 40 participants, (aged 22 to 66): 20 cases of metabolic syndrome and
Carotid-femoral PWV Carotid stiffness
20 age and sex matched controls. Anthropometric parameters, blood pres-
sure, fasting serum lipid, glucose, insulin, high-sensitive C-reactive protein BMI 0.12** 0.21**
(hs-CRP) and ferritin levels were evaluated in all patients. MS diagnosis was
made according to the National Cholesterol Education Program/Adult Tre- BMI z-score 0.07 0.18**
atment Panel III criteria. Results: Ferritin levels were significantly higher
in patients with (353.81±134.06 ng/ml) than without MS (117.57±84.21 ng/
Waist circumference 0.17** 0.20**
ml); (p=0.001). A positive correlation between ferritin concentrations and Hip circumference 0.11* 0.17**
HOMA-IR (r=0.64259, p=0.0022), triglycerides (r=0.47967, p=0.0323) and
low-density lipoprotein cholesterol (r=0.49190, p=0.0276) was significant in
Waist/hip ratio 0.13** 0.12*
MS group. Furthermore, mean ferritin levels raised gradually with the increa- Waist/height ratio 0.08 0.11*
sing number of MS components (p=0.001).
Discussion: From the findings of our study we can conclude that MS is Neck circumference 0.25** 0.35**
associated with significantly increased serum ferritin. These reflects iron
overload, which can lead to increase in blood glucose level due to insulin
resistance as indicated by correlation between ferritin and HOMA-IR. Iron ACCURACY OF A POINT SHEAR WAVE ELASTOGRAPHY
is a powerful pro-oxidant and can cause cellular damage by producing TECHNIQUE (ELASTPQ) IN THE NON-INVASIVE
reactive oxygen species in different tissues of the body. Insulin producing ASSESSMENT OF LIVER FIBROSIS IN A LARGE COHORT
pancreatic β cells have been shown to be particularly susceptible to oxida- OF LIVER PATIENTS
tive injury, in part due to decreased expression of antioxidant enzymes such
as dismutase, catalase, and glutathione peroxidase. Thus iron deposition in Garcovich M. 1, Pompili M. 1, Ainora M.E. 1, Riccardi L. 1,
β cells can lead to apoptosis and consequently to decreased insulin synthe- Grieco A. 1, Rapaccini G.L. 1, Siciliano M. 1, Gasbarrini G.B. 2, Gasbarrini
sis and secretion. Moreover iron deposition enhances fatty acid oxidation A.1, Zocco M.A. 1
and decreases glucose oxidation in skeletal muscle by inhibiting pyruvate 1
UOC Medicina Interna, Gastroenterologia e Malattie del Fegato, Università
dehydrogenase enzyme activity thus increasing IR. Iron accumulation also Cattolica del Sacro Cuore, Roma 2Professore emerito, Università Cattolica del
results in an abnormal increase in hepatic glucose production and inappro- Sacro Cuore, Roma
priate hepatic insulin extraction. Increased serum ferritin levels may be one
of the key elements that progresses the journey of MS to Type II diabetes. Introduction&Aims: ElastPQ is a novel point shear wave elastography
(PSWE) technique that assesses liver fibrosis by measuring liver stiffness (in
kPa) with few studies published so far. The aim of this study was to deter-
22
mine the accuracy and the feasibility for the assessment of liver stiffness in a the SIMI secretary: 6a) how many SIMI Minimaster certificates in Ecoscopy
large cohort of patients undergoing liver biopsy (LB) for various etiologies. and 6b) in Point of Care UC (POCUS) has been released.
Methods: Consecutive patients scheduled for LB were studied by using Results: The results are summarized in Fig.1:
the iU22 Philips ultrasound system with ElastPQ technique. The correla- Conclusions: All Schools except one answered the questionnaire. The heart
tions between laboratory findings, liver stiffness and the Metavir score were is the type of BUS exam most frequently performed by colleagues from
analyzed using Spearman correlation and ROC curve analyses were perfor- other non-Internal Medicine Units / Departments. In spite of the remar-
med to calculate AUC for F≥2, F≥3 and F=4. kable attraction of attending the theoretical BUS Courses, there is less inte-
Results: We enrolled 289 patients (176/113 males/females) who underwent rest in practical training and in obtaining the SIMI certificates of Minima-
LB for viral or non-viral chronic hepatitis (HCV 49%; NASH 20%; AIH/ ster in Ecoscopy and / or POCUS.
PBC 18%; other 13%). Liver stiffness measurements performed on the right
lobe were reliable in all cases but eight patients (due to morbid obesity and
narrow intercostal spaces). After univariate and multiple regression analysis THE EFFECTS OF NEW DIRECT-ACTING ANTIVIRAL
PSWE showed a strong correlation with the fibrosis stage; no significant (DAA) THERAPY ON LIVER STIFFNESS MEASUREMENTS
correlation was found with the degree of necroinflammation or steatosis. IN PATIENTS WITH HEPATITIS C VIRUS (HCV)
Mean kPa values in the whole cohort were 3.7 (range 2.3-4.9) for F0, 4.9 INFECTION
(range 2.6-9.6) for F1, 7.6 (2.8-20.7) for F2, 10.2 (6.1-19.9) for F3 and 20.4
(10.9-38.4) for F4 in the right lobe. AUROCs were 0.92 (±0.02), 0.93 (±0.02) Ainora M.E. 1., Garcovich M. 1, Lembo T. 2, Ponziani F. 1,
and 0.96 (±0.01), when comparing F0-F1 vs F2-F4, F0-F2 vs F3-F4 and F0-3 Funaro B. 1, Tortora A. 1, Riccardi L. 1, Siciliano M. 1, Pompili M. 1,
vs F4, respectively. The optimal cut-off values for different levels of fibrosis Gasbarrini G.B. 3, Gasbarrini A. 1, Zocco M.A. 1
were 6.0, 7,7 and 10.9 kPa for F≥2, F≥3 and F4, respectively. When analyzing 1
UOC Medicina Interna, Gastroenterologia e Malattie del fegato, Università
PSWE values according to different etiologies, AUROCs were 0.89 (±0.04), Cattolica del Sacro Cuore Roma 2 UOC Epatologia clinica e biomolecolare,
0.93 (±0.29) and 0.96 (±0.03) for F≥2; 0.88 (±0.04), 0.85 (±0.03) and 0.95 Policlinico G. Martino Messina 3 Professore Emerito Università Cattolica del
(±0.03) for F≥3; 0.90 (±0.01), 0.95 (±0.01) and 0.96 (±0.01) for F4 in HCV, Sacro Cuore di Roma
NASH and AIH/PBC patients, respectively. Conclusion: To date this is the
largest case series evaluating the accuracy of ElastPQ technique. This novel Background: In patients with chronic hepatitis C (HCV) the prognosis and
PSWE system appears to be a very useful tool for non-invasive evaluation management largely depend on the extent and progression of liver fibro-
of liver fibrosis not only in patients with viral chronic hepatitis, but also for sis. Recent studies have reported that direct acting antivirals(DAAs) are
patients with different liver diseases. In order to validate such a non-invasive effective in reducing inflammatory ant fibrotic markers. Among different
technique these findings need to be confirmed in larger studies comparing non invasive methods, real-time shear wave elastography (RTE) seems to be
different elastography devices. an effective and easy to perform technique for the early assessment of liver
fibrosis during antiviral treatment.
Aim: To evaluate changes in liver stiffness using shear wave elastography
EVALUATION OF THE THREE-YEARS ACTIVITY OF (SWE) in HCV patients undergoing DAA therapy. Secondary endpoint was
ITALIAN SOCIETY OF INTERNAL MEDICINE (SIMI) to assess the influence of different biochemical and clinical parameters on
BEDSIDE ULTRASOUND SCHOOLS liver stiffness modification.
Methods: We enrolled 103 patients who received different DAAs based
Arienti V., Palmieri V.O., Domanico A., Piscaglia F., Boddi M., Fracanzani regimens for HCV infection between December 2014 and September
A.L., Cogliati C., De Sio I., Parrinello G., Perrone T., Loffredo L., Testa A., 2016. Liver stiffness, evaluated by SWE, and laboratory data were assessed
Vidili G., Rigo L. before treatment (baseline), at end of treatment (EOT) and 24 weeks after
SIMI BEDSIDE ULTRASOUND SCHOOLS EOT (FU24). Univariate and multiple linear regression analysis was used
to determine which baseline variables were associated with improvement
Aim: On the occasion of the recent opening of the new SIMI Schools of in liver stiffness. Results: Liver stiffness measurements were significantly
Bedside Ultrasound (BUS) this year, we wanted to assess the three-year acti- lower at EOT (16.2 ± 9.4 vs 10.9 ± 7.6 kPa, P <0.001). Similar results were
vity (2015-2017) of the old Schools, already active. obtained at FU24. Univariate and multivariate regression analysis showed
Materials and Method: The SIMI BUS Schools already active are 13; more that failure to achieve improvement in liver stiffness measurements were
details regarding the Schools are available in the SIMI web site (http://www. significantly associated with low necroinflammatory activity at baseline.
simi.it/ecografia-bedside/) where the active Schools are identified with a Conclusion: These results suggest DAA treatment resulted in a clinically
green check: Bari (BA), Bologna-A (BOA), Bologna-B (BOB), Firenze (FI), significant improvement liver stiffness and this effect is particularly evident
Milano-C (MIC), Milano-F (MIF), Napoli (NA), Palermo (PA), Pavia (PV), in patients with high inflammatory activity at baseline.
Roma-T (RMT), Roma-V (RMV),Sassari (SS) and Verona (VR). A que-
stionnaire about retrospective activity (June 2015-May 2017) has been sent
to all active SIMI Schools including these questions: 1) Does your school LUNG ULTRASONOGRAPHY IN SUSPECTED
perform all the BUS exams of the training Course (Neck, Heart, Lung, PULMONARY TUBERCULOSIS: A STUDY ON
Abdomen, CUS)? 2) If not, for what types of BUS exam (Neck, Heart, Lung, DIAGNOSTIC ACCURACY
Abdomen, CUS) do you request the collaborations of colleagues from other
non-Internal Medicine Units or Departments? 3a) How many theoretical C. Invernizzi1, P. Pini1, M. Montuori2, G. Casazza3, D. Torzillo1, F. Casella1,
BUS Courses did you organize? and 3b) how many participation certificates S. Limonta2, G. Rizzardini4, F. Franzetti2, M. Galli2,
did you release? 4a) How many practical BUS Courses of one week (training C. Cogliati1
in Ecoscopy) did you organize? and 4b) how many participation certificates 1
Dipartimento di Medicina Interna, ASST-FBF-Sacco 2Dipartimento di
did you release? 5a) How many practical BUS Courses of two weeks (trai- Scienze Biomediche e Cliniche ‘L. Sacco’, Università degli studi di Milano
ning in Point Of Care US – POCUS) did you organize? and 5b) how many e Terza Divisione di Malattie Infettive, ASST-FBF-Sacco 3Dipartimento di
participation certificates did you release? Two more questions were asked to Scienze Biomediche e Cliniche ‘L. Sacco’, Università degli studi di Milano
4
Prima divisone di Malattie Infettive, ASST-FBF-Sacco
Introduction: The validity of lung ultrasound (LUS) in the diagnosis of

interstitial or focal lung pathologies is well documented. Nonetheless the
use of LUS has never been systematically studied in the evaluation of pul-
monary tuberculosis (PTB), where chest x-ray (CXR) remains the mainstay
for the radiological diagnosis. However, CXR for the diagnosis of active PTB
is limited by poor specificity and radiation exposure. Ultrasound is a safe,
versatile and cost-effective imaging modality with a potential role in the
evaluation and screening for PTB, reducing the delay in diagnosis where
radiological or laboratory equipment are not readily available such as in
low-resource countries.
Materials and Methods: Aim of our study is to identify sonographic signs
suggestive of PTB and assess their diagnostic accuracy. In 15 months, we
23
collected 101 consecutive patients from the departments of Infectious Dise- AND REDUCES INAPPROPRIATE ULTRASOUND
ases of our hospital, admitted with clinical suspicion of PTB. LUS was per- EXAMINATIONS
formed within 3 days after admission, by an experienced physician blinded
to the patient clinical information and radiological findings. A portable Pretolani S. 1, Giovannelli C. 2, Esposito R. 3, Colla S.M. 4, Arienti V. 1
US machine (Sonosite M-Turbo) with a convex probe was used. Patients 1
Centro di Ricerca ed Ecografia Clinica Ospedale Maggiore, Dipartimento
were examined by longitudinal, transverse and oblique scans of the ante- Medico, AUSL di Bologna; 2Nucleo 36 di Medicina Geberale, Dipartimento
rior, posterior, lateral thorax and lung apexes. Sonography was assessed for Cure Primarie, AUSL di Bologna;3Clinica e Terapia Medica, Azienda
consolidations, especially in superior quadrants and apical involvement, Ospedaliero-Universitaria di Parma, 4Corso di Formazione Specifica in
subpleural micronodules (hypoechoic lesions ~10 mm in diameter), pleural Medicina Generale, Regione Emilia-Romagna
thickenings or irregularities and pleural effusion. A univariate analysis was
performed to identify significant associations between echographic findings Ultrasound examinations (US) are one of the critical issues for the evalua-
and the diagnosis of PTB (microbiologically or clinically defined). Variables tion of the performance for local healthcare outcomes. In the recent years
significantly correlated in the univariate analysis (p <.05) were entered into the miniaturization of US instruments and the increasing evidence of the
a multivariate logistic regression model. effectiveness of bedside US for variuos clinical conditions has proposed
Results: PTB was confirmed in 50 patients (49.5%). Univariate analysis of POCUS for the primary care physicians (PCP) and general internists (GI)1.
LUS findings did show significant differences in the frequency of multiple Reports on diagnostic appropriateness indicate that in the Emilia-Romagna
consolidations [OR 3.11 (95% CI 1.24-7.77; p 0.0151)], apical consolida- the crude US rates either for abdominal ultrasound and EcoDoppler (234 vs
tions [OR 14.77 (95% CI 4.06-53.74; p <0.0001)], superior quadrant conso- 188 and 137 vs 80/1000 residents respectively) are much higher compared
lidations [OR 5.10 (95% CI 2.19-11.89; p 0.0002)] and subpleural nodules to other 9 Italian regions2. In 2014 the SIMI US Working group defined
[OR 3.99 (95% CI 1.73-9.19; p 0.0012)]. Apical consolidation [OR 15.51 the trainig program for the first and second level (POCUS) of competence
(95% CI 4.02-59.86; p <0.0001)] and subpleural nodules [OR 4.24 (95% CI
1.62-11.13; p 0.0033)] retained a significant correlation with PTB diagnosis in bedisde ultrasound3. Therefore we designed a project to implement a
in the multivariate model. Sensitivity and specificity of the model were cal- fruitful collaboration on US examination between PCP and the referral GI
culated: the presence of both apical consolidation and subpleural nodules of the local health organization. In brief, specific meetings between PCP
had a sensitivity of 34%, specificity of 98%, and likelihood ratios (LRs) 17.34 and referral GI have been organized to define and agree on the indications
for positive and 0.67 for negative; one of apical consolidation or subpleural to POCUS for the most common general medicine syndromes (abdominal
nodules had a sensitivity of 86%, specificity of 57%, LRs of 1.99 for positive pain, leg edema, dyspnea), according to the most up-to-date guidelines. In
and 0.25 for negative. case of diagnostic doubt after a POCUS performed by PCP, a following ultra-
Conclusions: Detection of apical consolidations and subpleural nodules sound examination was guaranteed by e mail reservation at the reference US
on LUS examination showed a high specificity and a good accuracy in the Center of Maggiore Hospital in Bologna within 24-48 hours. We report here
diagnosis of PTB. the preliminary results of the pilot study conducted in the geographical area
of the Nucleo 36 (which takes care of 15,000 citizens) of the local district of
Porretta in the AUSL of Bologna. From January to December 2016 a total
INFERIOR VENA CAVA RESPONSIVENESS TO of 153 POCUS were performed by one of the autors (GC) who had pre-
CONTROLLED ISOVOLUMETRIC RESPIRATORY viuosly fully completed the second level of the SIMI bedside US training
EFFORTS program. Ninety-three out of 153 (61%) US examinations were negative for
pathology (compared with a negative rate of 81% out of the total of US exa-
Pasquero P. 1, Folino A. 2, Benzo M. 3, Laguzzi A. 1, Mesin L. 3, Messere A. 2, minations performed on the basis of the regular demands of ultrasound by
Roatta S. 2, Porta M. 1 PGP practitioners, p<0.01) and 3/60 (5%) of the positive cases were refer-
Departments of Medical Sciences1 and Neurosciences2, University of Turin. red to the Ultrasound Center of the Ospedale Maggiore of Bologna for a
Department of Electronics and Telecommunications, Mathematical Biology second opinion within 48 hours. In conclusion this preliminary pilot study
and Physiology3, Politecnico of Turin showed that POCUS performed by PGP trained with specific SIMI bedside
US program improves diagnostic confidence and reduces the rate of referral
Objectives: Ultrasound measurement of Inferior Vena Cava (IVC) collapsi- to ultrasound centers. Larger studies are needed to confirm these results
bility is an attractive technique for non invasive assessment of volume status between PGP of different ages and clinical experience.
and fluid responsiveness. However, changes in IVC size are largely affected 1Bhagra A, et al. Mayo Clin Proc 2016; 91(12):1811-182.2Nuti S. Report
by spontaneous breathing. This study aims at characterizing the dependence 2013. Laboratorio MES, S. Anna, Pacini ed. Pisa 2014: 217-8.3Arienti V, et
of IVC size on controlled changes in intrathoracic pressure using a semi-au- al. Intern Emerg Med 2014;9(7):805-14.
tomated method to detect IVC cross-sectional area (CSA).
Methods: Ten healthy subjects, in supine position, performed controlled
isovolumetric respiratory efforts at functional residual capacity, attaining RENAL INVOLVEMENT IN SYSTEMIC SCLEROSIS
positive (+5, +10, and +15 mmHg) and negative (-5, -10, and -15 mmHg)
alveolar pressure levels. The isovolumetric constraint implies that equiva- Gigante A., Rosato E., Barbano B., Gasperini M.L.,Cianci R., Muscaritoli M.
lent pressure changes are present at alveolar and intrathoracic level during Department of Clinical Medicine, Scleroderma Unit, Sapienza University of
respiratory tasks. Rome,Italy
Results: The IVC cross-sectional area equal to 2.88± 0.43 cm2 at baseline
(alveolar pressure = 0 mmHg) was progressively decreased by both expi- Background: Systemic Sclerosis (SSc) is a connective tissue disease cha-
ratory and inspiratory efforts of increasing strength, with diaphragmatic racterized by vasculopathy, deposition of collagen and fibrosis of the skin
efforts producing larger effects than thoracic ones: -55 ±15% decrease, at and internal organs. Several forms of renal involvement are found in
+15 mmHg of alveolar pressure (P<0.01), -80±12% at 15 mmHg diaphrag- SSc, such as asymptomatic reduction in GFR, increase in renal resistance
matic (P<0.01), 33±12% at 15 mmHg thoracic. Significant IVC changes in indices, ANCA-associated vasculitis and scleroderma renal crisis. The aim
size (P<0.01) and pulsatility (P<0.05), along with a non significant reduction of the study was to prospectively assess the trajectories of renal involvement
in the response to respiratory efforts, were also observed during the first 30 in a cohort of patients with SSc.
minutes of supine rest, suggesting an increase in vascular filling and taking Methods: The study was performed at the Scleroderma Unit of the Depart-
place after switching from the standing to the supine position. ment of Clinical Medicine, Azienda Ospedaliera Universitaria Policlinico
Conclusions: This study quantified the dependence of the IVC cross-sectio- Umberto I, Sapienza University of Rome Italy.One-hundred an three SSc
nal area on controlled intrathoracic pressure changes and provides evidence patients (89 F, 14 M) with mean age of 54.7 ± 13.5, duration of disease of 9 ±
for a stronger influence of diaphragmatic over thoracic activity. Individual 6 years, were followed up for five years, from 2011 to 2016. Of these, 54 had
variability in thoracic/diaphragmatic respiratory pattern should be consi- diffused and 49 had limited SSc form. All patients were screened annually
dered in the interpretation of the respirophasic modulations of IVC size. for renal function by laboratory examination, ultrasound and ecocolorDop-
pler of renal arteries.
Results: In our study we observed 6 sclerodermic renal crises (3 M, 3 F), four
POINT-OF-CARE BEDSIDE ULTRASOUND (POCUS) of which required dialysis. The other two patients had a favorable prognosis
AND PRIMARY CARE PHYSICIANS: A PRELIMINAR and treated the acute event with high doses of ACE-inhibitors. One patient
EXPERIENCE WITH THE SIMI BEDSIDE US TRAINING developed ANCA-related proliferative glomerulonephritis and the other
PROGRAM IMPROVES DIAGNOSTIC CONFIDENCE one acute tubular necrosis. A patient has been diagnosed with renal artery
24
stenosis secondary to arterial hypertension. The remaining 94 patients had radiological patterns should always be sought in routinely performed
preserved renal function (creatinine 0.75 ± 0.19 mg/dl, CKD-EPI 92.1 ± 18 HRCT scans of CVID patients, even in presence of normal pulmonary fun-
ml/min, 24h proteinuria 0.22 ± 0.13 g, uric acid 4.22 ± 1.12 mg/dl). Intra- ction. Early diagnosis could indeed help addressing patients’ personalized
renal ultrasound and hemodynamic parameters documented: longitudinal follow-up protocols and discovering new prognostic patterns (e.g. BALF
renal diameter 101.4 ± 5.6 mm, resistance index 0.70 ± 0.07, pulse rate 1.43 lymphocyte distribution), thus indentifying high risk patients that might
± 0.31 and S/D 3.52 ± 0.79. deserve a more aggressive therapeutic approach.
Conclusions: Patients with SSc may develop severe kidney complications.
Early, careful and continuous assessment of renal function by means of
clinical, laboratory and instrumental evaluation is mandatory in order to FLOW MEDIATED DILATION IS INVERSELY RELATED
implement effective preventative and therapeutic strategies which may posi- TO MAST CELL PROLIFERATION IN PATIENTS WITH
tively impact on SSc patients’ prognosis. MASTOCYTOSIS
Bucci T., De Feo G., Cardamone C., Triggiani M., Guerritore L., Parente R.
GRANULOMATOUS-LYMPHOCYTIC INTERSTITIAL Department of Medicine, Division of Allergy and Clinical Immunology,
LUNG DISEASE IN COMMON VARIABLE University of Salerno
IMMUNODEFICIENCY (CVID) A SINGLE CENTER
RETROSPECTIVE STUDY Introduction: Mastocytosis is a rare disease characterized by clonal
proliferation of mast cells (MCs) in different organs. The variants of
Neri R., Gianese S., Scarpa R., Cinetto F., Agostini C.
Dipartimento di Medicina - DIMED, Università di Padova, Padova
disease include rapidly progressive (advanced) and indolent forms.
Clinical manifestations of mastocytosis are mostly due to the release
Background: Non-infectious autoinflammatory, autoimmune, and lympho- of mediators from MCs. Mediator related symptoms in these patients
proliferative complications are common in patients with Common variable could involve many organs including skin (urticaria, angioedema,
immunodeficiency (CVID). Notably, 8% to 22% of CVID patients develop pruritus, flushing), gastrointestinal tract (diarrhea, abdominal pain,
an interstitial lung disease termed “granulomatous-lymphocytic intersti- heartburn), bone (osteoporosis/osteopenia), cardiovascular system
tial lung disease” (GLILD), which is associated with reduced survival. This
specific complication has been only recently described. Investigators have
(anaphylaxis and hypotension). Continuous secretion of mediators by
used different diagnostic criteria, including diffuse radiological abnormali- MCs, often associated to increased oxidative stress, can influence the
ties and/or histologic evidence of granulomatous inflammation, with lym- endothelial function. Brachial Flow Mediated Dilatation (FMD) is a
phoproliferative changes characterized by histologic patterns as lymphoid non-invasive method to assess endothelial dysfunction and is poten-
interstitial pneumonia (LIP), follicular bronchitis, and/or diffuse reactive tially related to cardiovascular events (1).
lymphoid hyperplasia. Impaired T-cell function leading to dysfunctional Methods: We enrolled 20 adult patients with mastocytosis (14 female,
antigen handling has been proposed as a possible underlying mechanism,
perhaps in association with reduced class-switch of memory B cells, and/or
mean age 48.9 years ±12.9). The diagnosis and the definition of
aberrant responses to viral infection. Prior studies suggested that the deve- variant of disease were performed according WHO criteria. None
lopment of GLILD is associated with an increased mortality. Management is of the patient in this population had history of major adverse car-
primarily based on what reported in small case series, and there have been diovascular event (stroke, pulmonary embolism, myocardial infarc-
no controlled trials. tion). The ultrasound assessment of FMD was performed using a high
Methods: In this retrospective, single-centre study we reviewed chest resolution (7.5 MHz) probe measuring both the baseline diameter of
HRCT scans of a cohort of patients with diagnosis of CVID, specifically
looking for GLILD patterns. In patients with HRCT patterns consistent with
brachial artery and the diameter after 5 minutes of arterial occlu-
GLILD, different parameters were evaluated: pulmonary function testing sion in the upper arm. Serum tryptase, a specific indicator of MC
(PFTs), cell count and lymphocytes’ phenotype in bronchoalveolar lavage proliferation, was measured by immunoenzymatic method (Immuno-
fluid (BALF), serum immunoglobulin levels, clinical phenotype (including CAP – Phadia). Grading of mediator related symptoms was assessed
presence of splenomegaly, hepatomegaly, autoimmune cytopenias) and according to Valent et al. (2).
medications. Results: FMD was negatively correlated with age (Rs: -0.540; p=0.014),
Results: A total of 89 patients with diagnosis of CVID where enrolled in serum tryptase (Rs=-0.870; p<0,001), serum beta 2 microglobulin (Rs=
the study (mean age 48.2±11.6 years). Despite only 3/89 patients had histo- -0.685; p=0.010) and directly correlated with female sex (Rs=0.488; p=0.029).
logical diagnosis of GLILD on pulmonary biopsy, according to the current At multivariate regression analysis, serum tryptase showed a strong negative
diagnostic criteria (in 1 patient diagnosis was obtained on explanted lungs, association with FMD (p=0.009;β=-0.014; CI:-0.024/-0.004).No correlation
after bilateral lung transplantation), 16/89 patients presented radiographic between FMD and type and grading of mediator related symptoms was
findings on chest HRCT other than bronchiectasis, raising the suspicion of found. Advanced forms of disease showed a significantly lower FMD as
GLILD (bronchial wall thickening, nodular opacities, linear and/or irregu- compared to indolent forms (2.1±1.1% vs 8.4±3.1; p<0,001).
lar opacities, pulmonary consolidations, ground-glass opacities). Despite
Conclusions: FMD is altered in patients with mastocytosis and is
marked radiographic abnormalities on HRCT, 15/16 patients had normal or
almost normal lung volumes (FEV1 and FVC > 70%); DLCO was reduced severely impaired in patients with high rate of MC proliferation and
(<70%) in 5/16 patients. Only 1/6 patients developed severe respiratory advanced disease. Endothelial disfunction is negatively influenced by
failure. 9/16 patients underwent bronchoscopy; BALF analysis revealed an MC proliferation rather than by the presence and severity of mediator
increase of lymphocyte fraction in 8/9 patients, with an increased CD19+ related symptoms.
fraction (>5%) in 3 of them (mainly lymphocytes B activated). CD4/CD8 References: 1. Yeboah, J.et al. Predictive value of brachial flow-medi-
ratio was increased (> 2) in 2 patients. In 1 patient we observed a progres-
sive increase of polyclonal serum IgM (> 3 g/L). Splenomegaly was found
ated dilation for incident cardiovascular events in a population-based
in 6/16 patients, hepatomegaly in 5/16. FDG PET-CT scan was performed study: the multi-ethnic study of atherosclerosis. Circulation. 2009;
in 3/16 patients, showing an increased FDG uptake in lung parenchyma, 120:502-509
lymph nodes, liver, spleen and bone marrow. 3/16 underwent splenectomy 2. Valent P, Akin C, Escribano L, et al. Standards and standardiza-
due to immune thrombocytopenia (2 patients) or autoimmune haemolytic tion in mastocytosis: consensus statements on diagnostics, treatment
anaemia (1 patient). 2/16 underwent liver biopsy with an evidence of recommendations and response criteria. Eur J Clin Invest. 2007;
liver disease syndrome with portal hypertension and splenomegaly. 15/16
patients were treated with Ig replacement therapy at the mean dosage of
37:435-53.
397,08 mg/kg/month. 2/16 received an immunosuppressive therapy (Aza-
thioprine and Rituximab). 1/16 underwent lung transplantation for severe
respiratory failure. Conclusions: The results observed in our cohort of
A RARE DIAGNOSIS FOR A COMMON CLINICAL
CVID patients support the view that GLILD represents a pulmonary mani-
PRESENTATION
festation of a generalized, multisystemic lymphoproliferative disorder with
Laurelli G., Kühn M., Neri R., Cinetto F., Agostini C.
evidence of an immune dysregulation. GLILD is often underdiagnosed, if
Dipartimento di Medicina DIMED, Università degli Studi di Padova
compared to infectious-related complications as bronchiectasis; GLILD
25
In September 2016, a 53-year old Caucasian woman was admitted to the whereas low serum EBV DNA was identified. Abdominal CT scan revealed
Emergency Department, presenting heart palpitations and chest pain, a multiple enlarged lymph nodes in the periaortic and aorto-caval region,
lasting approximately 2-3 hours. She did not present any other symptoms in the celiac-mesenteric region and in the retroperitoneal area. Because of
and physical examination was unremarkable. She had a family history for immunosuppression, the lack of clinical and biochemical signs of infection
cardiovascular diseases and suffered from hypothyroidism treated with and the abdominal lymphadenopathy, a diagnosis of post-transplant lym-
levothyroxine. The ECG showed wide complex ventricular tachycardia phoproliferative disorder was hypothesized. Bone marrow aspiration and
with a heart rate of 220 bpm, left axial deviation and right bundle branch biopsy showed a preserved erythropoiesis and regular granulopoiesis with
block aspects, promptly interrupted by electrical cardioversion. In order no morphological involvement. 18-F-fluorodeoxyglucose positron emis-
to exclude possible common diagnosis (previous myocardial infarction, sion tomography (18F-FDG PET) demonstrated an abnormal uptake of
chronic myocarditis, dilated cardiomyopathy and hypertrophic cardiomyo- the radiolabeled analogue in cervical, supraclavicular, paratracheal, axil-
pathy), the following exams were performed: blood tests, including thyroid lary, internal mammary, anterior mediastinal, celiac tripod, hepatic hilum,
function, resulted normal; coronary angiography and Holter ECG resul- celiac-mesenteric, retroperitoneal and inguinal lymph node stations. Node
ted negative, whereas echocardiography showed a “moderate increased Biopsy showed several small follicles with hyalinized germinal centers, and
volume of the right ventricle, significant tricuspidic insufficiency and a a massive infiltration of interfollicular polytypic plasma cells. Such findings
discrete depression of the total systolic dynamics (EF 50%)”. She was then were consistent with the diagnosis of Castleman’s disease (CD). Most of
discharged with the diagnosis of “Sustained ventricular tachycardia (SVT) plasma cells stained positively for HHV-8 antibody (clone 13B10), while
in cardiopathy of unknown origin”. About two weeks later, the patient pre- no signal was retrieved with EBV (CS1-4) antibody. However EBV DNA
sented the same symptoms that responded to electrical cardioversion. This sequences were detected in the formalin-fixed paraffin-embedded lymph
time, ECG was consistent with SVT but showed the presence of negative T node tissue by real-time PCR molecular studies. Unfortunately, a rapid wor-
waves. Ecocardiography was repeated and revealed a “mild parietal hyper- sening of clinical conditions occurred and patient died two days after dia-
trophy of the left ventricle and a moderate dilation of the right ventricle gnosis. CD is an uncommon lymphoproliferative disorder with non-clonal
with diffuse hypokinesia”. To better investigate the underlying causes of the characteristics that can interest a single lymph node station or, alternati-
altered kinetics and morphology, a cardiac magnetic resonance with con- vely, can be diffused to multiple lymphatic stations and organs. Multicentric
trast was performed and showed “late gadolinium enhancement (LGE) con- Castleman’s disease (MCD) is a systemic disease that generally occurs in
sistent with myocarditis outcomes, mild pericardial and pleural effusion”. patients with HIV and HHV-8 coinfection because of their disease-related
At this point, after multidisciplinary discussion, the patient underwent an immunosuppression. This lymphoproliferative disorder often shows syste-
endomyocardial biopsy that highlighted the presence of “non caseous gra- mic inflammatory manifestations and is characterized by high morbidity
nulomas consistent with Cardiac Sarcoidosis (CS)”. Microbiological tests on and mortality. The natural history of MCD is extremely variable ranging
the biopsy resulted negative. In view of the evidence that CS is a potential from indolent cases to fulminant disease but typically it occurs many years
cause of life-threatening arrythmias and sudden cardiac death, an ICD was after liver transplantation. In this case report we describe a case of early
immediately implanted. To further define the staging of Sarcoidosis, specific and fulminant MCD occurring in a liver transplant recipient. Remarkably,
blood tests, High-Resolution CT of the lung, spirometry and an ophtalmo- biopsy examination revealed the coexistence of both HHV-8 and EBV
logic examination were performed and resulted negative. Instead, a PET/ infection, which is a condition rarely reported in both HIV-negative MCD
CT showed hypermetabolism of some lymph nodes of the chest, excluding and in post-transplant lymphoproliferative disorders (PTLD). This is the
other organ involvement. Finally, as suggested by guidelines and in order fifth case of MCD developing after liver transplantation worldwide, but the
to prevent relapse, cardiac dilation and worse prognosis, the patient was first one caused by HHV-8 and EBV coinfection.
treated with immunosuppressive therapy (Azathioprine and Prednisone).
She did not present further arrhythmic events and is currently in regular
follow-up. In conclusion, it is fundamental to exclude all possible causes of FIRST REPORTED CASE OF CUTANEOUS VASCULITIS,
SVT because this could be the first presentation of a rare but life-threatening ENTERITIS, POLYARTHRITIS AND MYOSITIS
systemic disease, such as Sarcoidosis. ASSOCIATED WITH BARTONELLA HENSELAE
INFECTION
EARLY OCCURRENCE OF FATAL HHV8 AND EBV- Avitabile E. 2, Strada S.2, Bonometti R.2, Bianco S.2, Sainaghi P.P. 1, Pirisi M.2
RELATED CASTLEMAN’S DISEASE AFTER LIVER 1
Department of Translational Medicine, Università del Piemonte Orientale
TRANSPLANTATION: A CASE REPORT UPO, Novara, Italy. 2 Division of Internal Medicine, “AOU Maggiore della
Carità”, Novara, Italy
F. Cavallone 1, R. Villani 1, F. Sanguedolce 2, A. Facciorusso 3,
G. Fioravanti 1, F. Bellanti 1, S.F. Capalbo 4, G. Vendemiale 1, A 33-year-old male presented with fever, pretibial purpura, diarrhea (posi-
G. Serviddio 1 tive to fecal occult blood testing), unintentional weight loss and mono-
1
Istituto di Medicina Interna Universitaria, Dipartimento di Scienze Mediche arthritis of the left knee despite antibiotic therapy. A clinical diagnosis of
e Chirurgiche, Università of Foggia, Italy 2Istituto di Anatomia Patologica Henoch-Schönlein vasculitis was made and treatment with a coxib started.
Universitaria, Dipartimento di Scienze Mediche e Chirurgiche, Università Five days later, the patient returned complaining of a symmetric polyar-
of Foggia, Italy 3Istituto di Gastroenterologia Universitaria, Dipartimento thritis, as well as of persisting fever and diarrhea. Investigations showed
di Scienze Mediche e Chirurgiche, Università of Foggia, Italy; 4Istituto di myositis of the left calf muscles and multiple liver lesions (compatible with
Ematologia Ospedaliera, Azienda Ospedaliero Universitaria Ospedali Riuniti microabscesses). He had had a recent contact with dog fleas, and serology
of Foggia, Italy for Bartonella henselae - which can be transmitted by pet fleas - turned posi-
tive. Following treatment with azithromycin plus rifampicin, fever resolved,
A 59-years-old Caucasian with hepatocellular carcinoma in alcoholic cir- general conditions improved and he was discharged. However, at a fol-
rhosis was transplanted in July 2016 and treated with ganciclovir until low-up visit one month later, he reported a recrudescence of his symptoms
November for detection of low serum CMV DNA level. In January 2017, with polyarthritis, diarrhea, weight loss and skin purpura, accompanied by
he was admitted to our Liver Unit for ascites, weight gain, dyspepsia, hypo- elevation of inflammatory markers, muscle necrosis indices and liver fun-
rexia, nausea, symmetric lower limb swelling, fatigue, oliguria and lower ction tests. In contrast, the focal liver lesions were reduced in both size and
abdominal discomfort. Physical examination revealed paleness but preser- number at a repeat CT scan. Suspecting a secondary vasculitis, we started
ved hemodynamic and respiratory parameters. Palpable lymph nodes were low-dose prednisone, following which all his symptoms promptly resolved
detected in the left anterior cervical region.Blood test examination showed and his laboratory test results normalized. Among the increasingly reco-
hemoglobin 8.2 g/dl, platelets 68.000/uL, white blood cells 3520/uL and neu- gnized immune post-infectious complications associated with Bartonella
trophils 55.6%. Liver function tests were normal whereas pseudocholineste- infections, this is the first case report to date of an ANCA negative vasculitis
rase (2448 mU/ml), alkaline phosphatase (200 IU/l), albuminemia (2.40 g/ characterized by enteritis, arthritis, myositis and skin purpura, with quick
dl) were abnormal. Renal function was preserved (GFR 90.1 ml/min) but response to corticosteroid therapy.
diuresis was decreased (400 ml). Low levels of tumor markers (CEA, Ca
125, Ca 15-3, Ca 19-9, PSA, α-fetoprotein) were found whereas β2-mic-
roglobulin was slightly increased (6.07 mg/L, normal range 0.80-2.70).
Inflammatory markers were abnormal (C-reactive protein 102.3 mg/L and
ESR 75 mm/h). Serum Procalcitonin level was increased (1.32 ng/ml) but
blood cultures excluded infections. CMV and BK virus PCR was negative,
26
COMUNICAZIONI ORALI tis specific antigens (Jo-1, PL-7, PL-12, EJ, OJ, SRP). Rheumatoid factor and
anti-cyclic citrullinated protein antibodies resulted negative.
Based on these findings, an atypical anti-synthetase syndrome with
unknown antibody was suspected and a pulse therapy with intravenous 250
28 OTTOBRE 2017 mg 6-methylprednisolone for three days. His conditions improved soon
after therapy onset, with a prompt resolution of the muscular weakness
(MMT 5), the resolution of the arthritis process and a subjective amelio-
DYSPNEA AND AUTOIMMUNE DISEASES: THE DARK ration of the dyspnea (MRC 1). After the first three days of corticosteroid
SIDE OF THE MOON therapy, blood examination showed a sharp decrease of creatine kinase
(from 2559 U/L to 1154 U/L) and myoglobin (from 2422 ng/mL to 913
Emmi G., Vitiello G., Silvestri E., Palterer B., Dreoni L., Bensi C., Vizzutti F., ng/mL). Therefore, corticosteroid therapy was reduced to 125 mg daily for
Marra F., Laffi G., Romanelli R.G. three days and the patient was discharged the third day with prednisone 25
Dipartimento di Medicina Sperimentale e Clinica (DMSC), Università degli mg/daily and a tapering scheme of 5 mg every 7 days.
Studi di Firenze, Firenze, Italia After two months, the patient showed a good muscular response, with a
complete resolution of the symptomatology and the normalization of
Introduction: Dyspnea is a common symptom described as a shortness of muscular enzymes and acute phase reactants. However, the dyspnea did not
breath and a subjective sensation of breathing discomfort. Interstitial lung improve further (MRC 1-2). For this reason and in accordance with a pul-
disease (ILD) is considered to be a not so common cause of dyspnea. Even monologist consultancy, azathioprine 100 mg/daily was added to steroidal
though ILD may be idiopathic, autoimmune diseases such as anti-synthe- therapy (10 mg prednisone/day).
tase syndrome (ASS) can present with lung involvement in about 60% of Discussion: ASS is a heterogeneous connective tissue disease characteri-
the cases. zed by the association of inflammatory myositis, ILD and anti-synthetase
Case Report: A 48-year-old man was seen in the emergency department antibodies. ILD is present in about 60% of these patients and a diagnosis
because of increasing dyspnea for the duration of 2 weeks. In addition to of ASS-related ILD does not pose a diagnostic challenge in patients with
this he developed generalized asthenia, shoulder girdle weakness and pain established diseases or when typical disease manifestations are present [skin
in his right hand. On this evaluation, a chest radiograph showed pulmonary manifestations (Gottron’s papule, Gottron’s sign, mechanic’s hands, shawl
findings suggestive of possible bibasilar scarring or consolidation. For these sign, V-sign, heliotrope rash with periorbital swelling, teleangectasias),
reasons, he was referred to our Department. fever, arthritis, Raynaud’s phenomenon, generalized weakness]. The dia-
On evaluation, he reported increasing dyspnea and fatigue with mild gnosis could not be so evident when dyspnea is the sole manifestation of the
exertion during the previous 2 weeks that had required rest after normal disease. Indeed, dyspnea with or without acute respiratory failure is a rare
activities of daily living, such as climbing of one flight of stairs (Medical presentation of ASS and a careful multidisciplinary diagnostic approach is
Research Council [MRC] dyspnea scale 3). His past medical history was needed in these patients.
unremarkable. He worked as a bricklayer. There was no history of allergy, In our case, the muscular weakness corroborated with the elevation of the
hemoptysis, sputum production, rash, Raynaud’s phenomenon or recent muscular enzymes, along with the exclusion of a cardiovascular (no pul-
fever, chills or sweats. His father had died at the age of 78 years of stroke. The monary embolism), infectious (negativity of blood culture and major viral
temperature was 36.4°C, the pulse was 66 and the respirations were 16. The causes of pneumonia) and occupational (negativity of the bronchoalveolar
blood pressure was 110/70 mmHg. The oxygen saturation was 97% while lavage) disease, helped us to investigate an autoimmune disease.
the patient was breathing ambient air. However, arterial blood gas showed ANA negativity with a typical cytoplasmic fluorescence is highly indica-
a mild hypoxemia (72.6 mmHg) with normal carbon dioxide level. Coarse tive for the presence of an anti-synthetase antibody. The negativity of the
crackles were heard in both lungs. The heart sounds and the abdomen blotting could be related to a limited sensitivity of the test. A direct immu-
were normal. There was no peripheral edema, the peripheral pulses were nofluorescence could have helped us to recognize the presence of one of
full and there was no digital clubbing. No rash or lymphadenopathy was these autoantibodies.
noted. The neurologic examination was unremarkable. The immune-rheu- ASS patients often require multimodality immunosuppressive therapy to
matologic evaluation show an active arthritis of the 3° and 4° finger of the control the muscle and/or lung manifestation of the disease. Corticoste-
right hand and limitation of the shoulder girdle movement. Physical exami- roid are considered the cornerstone of the therapy. However, when ILD is
nation revealed a manual muscle testing (MMT) grade 4-. Blood test exa- present, an additional immunosuppressive therapy is often required. Pro-
minations showed elevated markers of muscular damage (creatine kinase gnosis is largely determined by the extent of pulmonary involvement and
2559 U/L, lactate dehydrogenase 691 U/L, aldolase 51.1 U/L myoglobin its progression. Pulmonary hypertension is a dreadful complication of this
2422 ng/mL, aspartate aminotransferase 142 U/L), elevated acute phase disease and careful attention to complication of both chronic immunosup-
reactants (erythrocyte sedimentation rate 23 mm/h, c-reactive protein 23 pressive therapy and disease-related sequelae is needed.
mg/L). Blood count, liver and renal function were within the normal limits. Conclusion: It would be prudent for clinician to keep this rare condition in
The electrocardiogram was unremarkable. Considering the possibility of an the differential diagnosis of a patient with acute onset dyspnea. Clinical exa-
infectious etiology, an intravenous broad-spectrum antibiotic therapy was mination, laboratory findings (paying attention to muscular enzymes and
administered. pattern of the ANA fluorescence), imaging techniques (such as CT scan of
A computed tomography (CT) scan of the thorax obtained after the intra- the chest) and a multidisciplinary discussion of the clinical case is needed to
venous administration of contrast material revealed a ground-glass opacifi- obtain a prompt diagnosis and introduce an efficacious immunosuppressive
cation and patchy consolidations distributed in subpleural locations in the therapy.
lower lobes. No lymph nodes were detected. No filling defect suggesting
a pulmonary embolus was detected. Pulmonary function testing demon-
strated a slight reduction of the single-breath diffusing capacity for carbon DYSPNEA, FATIGUE, AND GENERALIZED WEAKNESS
monoxide (DLCO). IN A 67-YEAR-OLD MAN: APPROACH TO THE PATIENT
All blood cultures resulted negative. Screening for viruses (EBV, CMV, HBV, BETWEEN GUIDELINES AND CLINICAL JUDGMENT
HCV, HIV) and serology for Aspergillus resulted negative.
The patients underwent bronchoalveolar lavage which failed to detect any Solimando A.G. 1,2, Argentiero A. 3, Kraus P. 2, Ruckdeschel A. 2, Covelli C. 4,
infective etiology and the immunophenotype of the fluid collected was Einsele H. 2, Vacca A. 1
unremarkable. Therefore, the antibiotic therapy was suspended. 1Department of Biomedical Sciences and Human Oncology, Section of
In consideration of the lung and muscular involvement and the arthritis Internal Medicine “G. Baccelli”, University of Bari Medical School, Bari,
of his right hand, an autoimmune disease was suspected. Sarcoidosis was Italy; 2Department of Internal Medicine, Hematology and Medical Oncology,
considered unlikely because of the absence of mediastinal lymph nodes at University Medical Center Würzburg, Germany; 3Department of Biomedical
CT scan, an angiotensin-converting enzyme within the normal range and Sciences and Human Oncology, Section of Medical Oncology, University
the results of the bronchoalveolar lavage. of Bari Medical School, Bari, Italy; 4Department of Emergency and Organ
Anti-nuclear antigen (ANA) antibodies on Hep-2 cells resulted negative, Transplantation, University of Bari, Bari, Italy
nonetheless an intense cytoplasmic homogeneous fluorescence (1:2560
titer) was detected (Figure 1), indicating the possible presence of an anti- We present a case of 67-year-old man with pulmonary form of mucormyco-
body against a cytoplasmic antigen (anti-synthetase, anti-ribosomal or sis which presented as opportunistic infection post induction chemotherapy
anti-SRP antibodies). However, classical extractable nuclear antigen (ENA) for acute myeloid leukemia FAB M2. We treated the patient with intrave-
resulted negative, as well as a commercial lineblot assay for the major myosi- nous amphotericin B for 4 weeks and endobronchial resection, after which
27
he clinically and radiographically improved. Overall, early consideration of of antibiotic therapy; (C) and (D) after 6 days of empiric antibiotic therapy
mucormycosis can lead to an earlier diagnosis, medical and surgical therapy, demonstrating progressive inflammatory infiltrates with reversed halo sign.
and an increased survival rate. Furthermore, we provide a real example of
multiple thinking strategies, needed for a patient oriented clinical practice.
(Figure 1-2). AN UNUSUAL CASE OF UPSTANDING DYSPNEA
Mucormycosis refers to an emerging group of life-threatening fungal
infections caused by filamentous fungi of the Mucorales family. Mucor- Traversa M.A., Villois P., Porta M.
mycosis is most common in stem-cell transplant recipients and patients Scuola di Specializzazione in Medicina Interna, Università degli Studi di
with underlying hematologic malignancies, poorly controlled diabetes mel- Torino
litus, trauma, neutropenia, corticosteroid and deferoxamine therapy due to
deficiency of phagocytic function, elevated serum levels of available iron A 77-year-old woman was admitted to the Emergency Department (ED)
and host-pathogen interaction. The fungi penetrate blood vessels causing for sudden onset of expressive aphasia and numbness/weakness in the right
endothelial damage and extensive angioinvasion with infarction, necrosis, upper arm. Past medical history included hypertension, dyslipidemia and
and thrombosis of different tissues. Mucormycosis carries a very high mor- COPD (the patient had a 15-pack month smoking history). Medications
tality in cases of pulmonary disease, with even higher rates when there is included clonidine, omeprazole, amiloride, hydrochlorothiazide, aspirin,
difficulty establishing the diagnosis. and telmisartan. Continuous ECG monitoring, blood analysis, chest RX and
Overall, this case is a challenging example between clinical judgment and brain CT scan were normal. After 24h the patient was admitted to the Stroke
available validated guidelines. Unit, where a brain MR scan performed with DWI sequence demonstrated
Based on site localization, mucormycosis can be classified as one of 6 forms: hyperintensity in the left frontal perisylvian cortex, confirming the diagno-
rhinocerebral, pulmonary, cutaneous, gastrointestinal, disseminated, and sis of recent ischemia. Carotid ultrasound and trans-thoracic echocardio-
uncommon presentations. The underlying conditions can influence clinical graphy did not show any abnormalities and the patient started post-stroke
presentation and outcome. This case describes a patient with main manife- rehabilitation. However, dyspnea, desaturation and low levels of pO2 appea-
stations at pulmonary level. red upon standing up. Conversely, when laying down, the patient remained
asymptomatic with normal pO2. Spirometry and chest X-ray were normal.
Consequently, we hypothesized Platypnea-Orthodeoxia Syndrome related
to pulmonary-systemic circulation shunt. We completed the investigations
with a Trans-Cranial-Doppler and an oxygen test revealed the presence of a
right-left shunt. Contrast angiopulmonary CT scan did not show abnorma-
lities, ruling out an intra-pulmonary shunt. Transesophageal echocardio-
graphy showed a patent foramen ovale in the atrial septum, and an intrave-
nous agitated bubble study confirmed the presence of right-to-left shunting.
The final diagnosis of Cardiac Platypnea-Orthodeoxia Syndrome explained
the upstanding dyspnea with low pO2 level and the embolic origin of the
stroke. The source of embolism could not be
found, but increased pulmonary pressure due to worsening of COPD could
explain the occurrence of both Platypnea-Orthodeoxia and paradoxical
ischaemic stroke.
PCSK9, PLATELET ACTIVATION AND

CARDIOCASCULAR EVENTS IN ATRIAL FIBRILLATION
Pastori D. 1, Nocella C. 1,2, Farcomeni A. 3, Santulli S. 4,

Carnevale R. 1,2, Menichelli D. 1, Violi F. 1, Pignatelli P. 1 and the
Atherosclerosis in Atrial Fibrillation (ATHERO-AF) Study Group1
*
Mirella Saliola, Marco Antonio Casciaro, Domenico Ferro, Tommasa Vicario, Fabiana Albanese,
Francesco Cribari, Alberto Paladino, Francesco Del Sole, Marta Novo, Vittoria Cammisotto, Paola
Andreozzi, Tiziana Di Stefano, Patrizia Iannucci, Elio Sabbatini
I Clinica Medica, Department of Internal Medicine and Medical
(1)
Specialties, Sapienza University of Rome. (2) Department of Medical-Surgical

Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy. (3)
Department of Public Health and Infectious Diseases, Sapienza University,
Rome, Italy; (4) Department of Experimental Medicine, Sapienza University of
Rome, Rome, Italy
Background: Patients with atrial fibrillation (AF) display enhanced plate-

let activation but the underlying mechanism is still unclear. Objective. We
investigated 1) the association between soluble PCSK9 and CVEs in patients
with AF, 2) the relationship between soluble PCSK9 and 11-dehydro-throm-
boxane (Tx) B2, a specific marker product of platelet activation.
Methods: Prospective single-center cohort study including 907 AF patients
treated with vitamin K antagonists and followed-up for about 40 months
(3865 patients/year) to assess CVEs, including fatal/non-fatal myocardial
infarction and ischemic stroke and cardiovascular death. At admission,
plasma PCSK9 and urinary excretion of 11-dehydro-TxB2 (n=852) were
measured.
Results: Mean age was 73.5±8.2 years, and 43.0% were women. The total
number CVEs registered during follow-up was 179 (4.6%/years). By maxi-
mizing the hazard ratio (HR), we found that >2600 pg/ml was the best-
Figure 1: bone marrow aspirates (left) and peripheral smear (right) showing cut-off value of PCSK9 for CVEs (HR 2.8, p<0.001). Multivariable Cox
findings consistent with the diagnosis of AML FAB M2 (upper panel); lower regression analysis showed that PCSK9 >2600 pg/ml (HR:2.536, p<0.001],
panel: necrotic endobronchial lesion (left), histopathologic slide (right) of age (HR:1.083, p<0.001), female sex (HR:0.723, p=0.041) previous cerebro-
the endobronchial biopsy and the immunofluorescence staining evidenced vascular (HR:1.833, p<0.001) and cardiac event (HR:1.758, p<0.001), and
the presence of nonseptate hyphae with blood vessel invasion. total cholesterol/HDL ratio (HR:1.116, p<0.001) were predictive of CVEs.
In patients not treated with statins, there was no correlation between PCSK9
Figure 2: Chest radiograph (A) and sequential CT scans (B) before onset and lipid profile. We found a significant increase of urinary TxB2 among
28
PCSK9 groups (p<0.001). A stepwise multivariable linear regression analy- not accompanied by a modification of thrombotic and haemorrhagic events,
sis showed that age (Beta=0.074, p=0.008) and log-PCSK9 (Beta=0.682, which full reassures a possible safety concern. Waiting for new clinical trials,
p<0.001) were the main determinants of urinary log-TxB2. a broad use of RAMs may be a safe strategy for reducing health expenditure
Conclusions: Plasma PCSK9 levels are associated with an increased risk associated with VTE prophylaxis in hospitalized medical patients.
of CVEs in AF patients. The direct correlation between PCSK9 and TxB2
biosynthesis suggests a role for PCSK9 as a mechanism potentially implica-
ted in platelet activation. AN ATYPICAL INFERIOR VENA CAVA THROMBOSIS
Perina L., Marchi G., Rizzi M., Sapienza E., Bellesini C.,
IMPACT OF RISK ASSESSMENT (PADUA AND IMPROVE Dal Zotto C., Fumagalli A., Codella O.M., Girelli D.
SCORES) ON VTE, MAJOR HAEMORRHAGE AND HEALTH Medicina Generale ad indirizzo Immunoematologico ed Emocoagulativo,
EXPENDITURE ASSOCIATED WITH VTE PROPHYLAXIS: Università degli Studi di Verona
A PROSPECTIVE AND RETROSPECTIVE STUDY ON
PATIENTS HOSPITALIZED IN AN INTERNAL MEDICINE Presentation: A 46 year-old woman was referred to the Emergency Room
UNIT (STIME STUDY) of our hospital because of incidental finding of “fluctuant thrombus” in the
inferior vena cava (IVC) during a routine abdomen US performed for the
De Pietri L. 1, Marietta M.2, Scarlini S. 1, Marcacci M. 1, Riva R. 1, Pietrangelo follow-up of chronic HBV and HCV infection without evidence of active
A. 1, Ventura P. 1 hepatitis. The patient was essentially asymptomatic, apart from a mild bila-
1
Unit of Internal Medicine 2,2Unit of Hematology, Dept. of Medical and teral edema of the legs, with no limitation of daily activities. Her clinical
Surgical Sciences for Children and Adults, Policlinico Hospital of Modena, history revealed smoking habit, previous hysteroannessiectomy for mul-
University of Modena and Reggio Emilia, Italy tiple large myomas ten months before, and no personal or family history
of previous thrombosis. She took no daily therapy and had no history of
Background: International guidelines recommend the use of pharmaco- drug abuse. Her vital signs were normal. Her physical examination detected
logical prophylaxis in hospitalized medical patients at high risk of venous only a mild bilateral edema of the legs without palpable venous cords.
thromboembolism (VTE), by assessing individual thrombotic and haemor- ECG showed normal sinus rhythm with no S1Q3T3 pattern. CT pulmo-
rhagic risk factors (Kahn et al, 2012). The same international guidelines nary angiography ruled out pulmonary embolism and, remarkably, lower
suggest the employment of standardized risk assessment models (RAMs) extremities venous Duplex US was negative for thrombosis. Laboratory tests
when evaluating the administration of pharmacological prophylaxis in showed C-reactive protein, complete blood counts, renal function, PT and
acutely ill medical patients (Kahn et al, 2012). Padua Prediction Score (PPS) aPTT within the limits. A provisional diagnosis of non datable IVC throm-
and Improve Bleeding Score (IBS) have been indicated as the best avai- bosis was made, i.v. unfractionated heparin was started and the patient was
lable models to predict thrombotic and haemorrhagic risk in hospitalized admitted to our department for further studies.
medical patients, but it is still unknown whether their combined use can Differential diagnosis: Imaging studies to evaluate the extension of
actually lead to a reduction in thrombotic and haemorrhagic events. It is thrombosis were performed, along with a more in-depth anamnesis and
also unclear whether their extensive use can affect to some extent health biochemical exams to investigate the possible causes of inferior vena cava
spending associated with pharmacological prophylaxis. AIM The aim of this thrombosis. The patient’s personal and family history was not consistent
study is to evaluate whether the combined use of PPS and IBS in a consecu- with a hereditary thrombophilia and this hypothesis was not further inve-
tive cohort of hospitalized medical patients may influence the overall inci- stigated, as several tests (i.e. protein C and S, antithrombin III) could have
dence of thrombotic or haemorrhagic events (primary endpoint). Secondly, been altered by the acute episode and anticoagulant therapy. An acquired
health expenditure associated with pharmacological prophylaxis has also thrombophilia was also unlikely, since the patient had no recent history
been assessed in order to verify whether the combined use of these RAMs of immobilization, surgery, trauma or prolonged travel. She had no active
may result in a reduction of prophylactic drug prescription and conse- cancer, took no oral contraceptives, and her BMI was within the limits.
quently of health expenditure connected with pharmacological prophylaxis Noteworthy, D-dimer test was negative, as they were autoimmunity tests.
(secondary endpoint). The patient underwent a multiphasic contrast-enhanced CT and 18F-FDG
Patients & Methods: All patients admitted to our internal medicine depart- PET to define the extension of thrombosis, and to search for a possible
ment between May 2015 and August 2015, i.e. before the introduction and abdominal neoplasia, often associated to IVC thrombosis. Indeed, abdomen
extensive use of PPS and IBS, were consecutively enrolled (retrospective CT detected a contrast-enhanced mass of 3.5 x 3.3 cm diameter in small
group). Similarly, all patients admitted between November 2016 and pelvis with thrombus-like extension in venous vasal lumen and ascending
February 2017, once RAMs clinical use became a consolidated practice, in inferior vena cava for 26.5 cm up to the hepatic veins (Fig. 1). 18F-FDG
have also been consecutively enrolled (prospective group). The admini- PET revealed low enhancement only of the pelvic mass. The features of the
stration of pharmacological prophylaxis, the occurrence of any thrombotic pelvic mass were compatible with a residual myoma, and a transvaginal US
event (pulmonary embolism) or haemorrhagic complication (major blee- also confirmed this suspect.
ding) during hospitalization or throughout the next 90 days after hospital Diagnosis: The above findings were consistent with intravenous leiomyo-
discharge were progressively recorded for all enrolled patients. matosis (IVL). The diagnosis was established with a re-evaluation of
Results: Compressively 210 patients were enrolled in the prospective group the histological examination of myomas surgically removed ten months
and 203 patients were enrolled in the retrospective one. No differences in before, which demonstrated vascular invasion of small leiomyoma nodules
baseline characteristics of the patients were observed. RAMs were available distinct from the major one. After a literature review and collegial discus-
for 100 % of prospective group patients. In the prospective group, 48% of sion, we performed a contrast-enhanced abdomen MRI as the gold-stan-
patients had increased VTE risk (PPS ≥ 4), 13% of patients showed increased dard imaging exam for IVL. This allowed a better definition of the residual
haemorrhagic risk (IBS ≥ 7) and only 6% of patients displayed both elevated myoma, that extended as a neoplastic thrombus in the right internal iliac
thrombotic and haemorrhagic risk (PPS ≥ 4 & IBS ≥ 7). Three events of vein and in the IVC up to the hepatic veins.
major bleeding and one event of pulmonary embolism were observed in the Treatment: Once the diagnosis of IVL was established, we suspended i.v.
prospective group; three events of major haemorrhages and two events of unfractionated heparin and started a prophylactic dose of low molecular
pulmonary embolism were observed in the retrospective group (the statisti- weight heparin. The case was further discussed with gynecologists and
cal analysis failed to reveal significant difference between groups regarding vascular surgeons. Since IVL can grow, occlude IVC or ascend up to right
the primary endpoint). A statistically significant decrease of pharmacologi- atrium and cause syncope or even sudden death, a surgical intervention was
cal prophylaxis among study groups was detected: 43.3% of patients in the planned. The residual myoma and right internal iliac vein were resected and
prospective group and 56.7% of patients in the retrospective group received IVL was removed with IVC thrombectomy (Fig. 2). The new histological
pharmacological prophylaxis (p = 0.028), this being responsible for saving examination revealed a morphological and immunophenotypic pattern
on average 1.67 € for each patient treatment after RAMs introduction. overlapping with the previous one. No complications occurred in periope-
Conclusions: The extensive use of RAMs in our population of patients rative period and the patient was regularly discharged.
hospitalized in an internal medicine unit did not significantly affected VTE Fig. 1 (A-D). Longitudinal (A) and transversal view of IVL and its throm-
rate or incidence of major bleeding. A statistically significant decrease of bus-like extension in right internal iliac vein (B, in red circle) and IVC (C)
VTE prophylactic therapy and consequently of health spending related ascending for 26.5 cm up to the hepatic veins (D), detected by multiphasic
to pharmacological prophylaxis has been documented, likely driven by a contrast-enhanced CT.
more accurate stratification of individual haemorrhagic and thrombotic risk Fig. 2. Macroscopic appearence of IVL after surgical intervention.
factors. The observed decrease of prophylactic therapy administration was
29
Fig. 1 GPL/MPL, the 93 subjects with antibodies >80 GPL/MPL showed a signi-
ficantly higher CCA-IMT (0.99±0.47 vs 0.89±0.31, p = 0.028), Bulb-IMT
(1.37±0.86 vs 1.12±0.43, p = 0.001) and prevalence of carotid plaques (OR:
1.73, 95%CI: 1.06-2.82, p = 0.031). When stratifying APP carriers and APS
patients according to the number of positive antibodies, we found a pro-
gressive increase in CCA-IMT, in Bulb-IMT and in the prevalence of carotid
plaques for an increasing number of positive antibodies (Figure 1)
A higher CCA-IMT, Bulb-IMT and prevalence of carotid plaques were
also confirmed in APP carriers and in APS patients than in controls after
excluding patients with systemic lupus erythematosus or other autoimmune
diseases.
Conclusions: Similar to APS patients, APP carriers have enhanced subcli-
nical atherosclerosis, a more severe disease being observed in the presence
of high-titer antibodies and multiple antibodies positivity. These data argue
for a strict monitoring of subclinical signs of atherosclerosis and of cardio-
vascular risk factors in asymptomatic APP carriers.
Fig. 2
Figure 1. CCA-IMT, Bulb-IMT and carotid plaques in APP carriers and in

APS patients stratified according to the number of positive antibodies.
OUTCOME DURING ANTICOAGULATION IN PATIENTS

WITH SYMPTOMATIC VS. INCIDENTAL SPLANCHNIC
VEIN THROMBOSIS
SUBCLINICAL ATHEROSCLEROSIS IN ASYMPTOMATIC Tufano A. 1, Ageno W. 2, Di Micco P. 3, Monreal M. 4

CARRIERS OF PERSISTENT ANTIPHOSPHOLIPID 1
Regional Reference Centre for Coagulation Disorders. Department of
ANTIBODIES POSITIVITY: A CROSS-SECTIONAL STUDY Clinical Medicine and Surgery. “Federico II” University Hospital, Naples,
Italy. 2Research Center on Thromboembolic Disorders and Antithrombotic
Di Minno M.N.D. 1, Ambrosino P. 1, Scalera A. 1, Cafaro G. 1, Therapies, Department of Medicine and Surgery, University of Insubria,
Peluso R. 1, Silvestri E. 2, Di Minno G. 1, Emmi G. 2, Prisco D. 2 Varese, Italy. 3Ospedale Buonconsiglio Fatebenefratelli, department of
1
Federico II University, Naples, Italy; 2 University of Florence, Florence, Italy internal medicine and emergency room, Naples, Italy. 4Department of
Internal Medicine. Hospital de Badalona Germans Trias i Pujol. Universidad
Background: Whereas the relationship between subclinical atherosclerosis Católica de Murcia. Spain
and antiphospholipid syndrome (APS) has been widely investigated, little
is known about subclinical atherosclerosis in asymptomatic carriers with Background: Current guidelines recommend the use of anticoagulant
isolated antiphospholipid antibodies positivity (APP). therapy in patients with symptomatic splanchnic vein thrombosis (SVT)
Methods: Consecutive APP carriers, APS patients and matched controls and suggest no routine anticoagulation in those with incidental SVT.
were enrolled. Intima-media thickness of the common carotid artery (CCA- Methods: We used the RIETE (Registro Informatizado Enfermedad Trombo
IMT) and of the Bulb (Bulb-IMT) and the prevalence of carotid plaques Embolica) registry to compare the rate of venous thromboembolism (VTE)
were assessed in all enrolled subjects. recurrences and major bleeding during anticoagulation in patients presen-
Results: A total of 104 APP carriers, 221 APS patients, and 325 matched ting with symptomatic vs. incidental SVT.
controls were recruited. APP carriers, APS patients and controls were com- Results: In March 2017, 521 patients with SVT were recruited. Of these,
parable for age and gender and for the prevalence of cardiovascular risk 212 (41%) presented with symptomatic SVT, and 309 had incidental SVT.
factors. As to the type of antiphospholipid antibodies, IgG aCL and IgG Most patients (94%) received anticoagulant therapy (median, 147 days).
aβ2GPI were more often found in APS patients than in APP carriers (75.1% During the course of anticoagulant therapy, 20 patients developed sympto-
vs 61.5% p = 0.013 and 45.7% vs 25.0% p < 0.001, respectively). No diffe- matic VTE recurrences and 26 bled. Patients with symptomatic SVT had a
rence in the presence of all the other antibodies was found between APP lower rate of VTE recurrences (hazard ratio [HR]: 0.35; 95%CI: 0.11-0.93),
carriers and APS patients. a non-significantly lower rate of major bleeding (HR: 0.65; 95%CI: 0.28-
As compared with controls, APP carriers and APS patients showed a higher 1.43) and a lower mortality rate (HR: 0.55; 95%CI: 0.33-0.91) than those
CCA-IMT (0.89±0.25 vs 0.81±0.12, p=0.032 and 0.90±0.42 vs 0.81±0.12, with incidental SVT. Interestingly, during the first 30 days of therapy, there
p=0.001, respectively), Bulb-IMT (1.10±0.45 vs 0.94±0.18, p=0.009 and were 12 major bleeds (4 fatal bleeds) and one nonfatal VTE recurrence. On
1.22±0.68 vs 0.94±0.18, p<0.001, respectively) and an increased prevalence multivariable analysis, patients with active cancer were at increased risk for
of carotid plaques (33.7% vs 10.2%, p<0.001 and 38.5% vs 10.2%, p<0.001, VTE recurrences (adjusted HR: 3.06; 95%CI: 1.14-8.17), while those with
respectively). These results were confirmed both in APP carriers and in APS anaemia (adjusted HR: 4.11; 95%CI: 1.45-11.6) or abnormal prothrombin
patients after adjusting for potential confounders by means of multivariate time (adjusted HR: 4.10; 95%CI: 1.68-10.1) at baseline were at increased
analyses. risk for major bleeding.
As compared with the 232 subjects with antibodies titer from 41 to 80 Conclusions: The outcome during anticoagulation in patients with sympto-
30
matic or incidental SVT was similar. Further studies are needed to identify glomerular filtration rate (cutoff eGFR: 50 mL/min per 1.73 m2) was I in
which patients with SVT would benefit from anticoagulant therapy. 47% of patients, II in 40% and III in 13%. The median bone marrow plasma
cells infiltrate was 11% (IQR: 7-25%). Most common upfront treatments
were melphalan-dexamethasone [MDex, 367 patients, overall hematolo-
HIGH PLASMA CONCENTRATION OF ACTIVATED gic response (HR) 51%, very good partial or complete response (VGPR/
FACTOR VII-ANTITHROMBIN COMPLEX IS ASSOCIATED CR) 38%], cyclophosphamide-bortezomib-dexamethasone [297 patients,
WITH AN INCREASED ACTIVATED FACTOR X HR 55%, VGPR/PR 44%), and bortezomib-MDex [132 patients, HR 64%
GENERATION (P=0.002 compared to MDex), VGPR/PR 50%]. Median follow-up of living
patients was 42 months (IQR: 23-73 months). Fifty-six percent of patients
Tosi F. 1, Stefanoni F. 1, Baroni M. 2, Lunghi B. 2, Castagna A. 1, Ziliotto N. 2, died (13% within 3 months). Median survival in cardiac Mayo Stage I was
Minguzzi D. 1, Udali S. 1, Woodhams B. 3, Girelli D. 1, Olivieri O. 1, Bernardi not reached, in stage II 58 months, in stage IIIa 17 months and in stage IIIb
F. 2, Martinelli N. 1 6 months (P<0.001). No overall survival advantage was noted in patients
1
Department of Medicine, University of Verona, Italy; 2Department of Life treated with upfront bortezomib based combinations compared to MDex.
Sciences and Biotechnology, University of Ferrara, Italy; 3Haemacon Ltd, Conclusion: The outcome of patients with AL amyloidosis is extremely
Bromley, Kent, UK heterogeneous and a significant proportion of patients die before having
the chance to benefit from treatment. The extensive use of upfront bortezo-
Background: activated factor VII-antithrombin (FVIIa-AT) complex has mib ameliorates the quality of response, but does not translate in a general
been proposed as an indicator of tissue factor (TF) exposure to the blood, improvement of overall survival.
thus being a potential biomarker of prothrombotic diathesis. High plasma
levels of FVIIa-AT have been associated with an increased thrombin gene-
ration and predicted total and cardiovascular mortality in patients with PRELIMINARY STUDY ON DIAGNOSIS AND TREATMENT
coronary artery disease (CAD). Aims:to evaluate in CAD patients the rela- OF ANEMIA IN INTERNAL MEDICINE DEPARTMENT: AN
tionship between FVIIa-AT levels and activated factor X generation (FXaG) OLD TOPIC OR A NEW CHALLENGE?
at low TF concentration, and by inhibiting tissue factor pathway inhibitor
(TFPI) or activated protein C (APC) with the aim to highlight procoagulant Santarossa C., Cosi E., Bertozzi I., Fabris F., Randi M.L.
components. Methods:within the framework of the Verona Heart Study Department of Medicine – DIMED, University of Padua, Padua, Italy
we selected 40 male CAD patients (mean age 62.4±10.0 years) not taking
anticoagulant drugs and with data of FVIIa-AT levels measured by ELISA. Background: Anemia is a worldwide highly prevalent disease. Several
FXaG in plasma was evaluated at 1 pM TF by addition of a specific FXa fluo- studies show the negative impact of anemia on morbidity and mortality
rogenic substrate, and also in the presence of an anti-TFPI RNA aptamer in patients affected by various chronic conditions, such as myocardial
(TFPI-aptamer) or an anti-APC DNA aptamer (APC-aptamer). infarction, congestive heart failure, critical renal or respiratory diseases.
Results: among the parameters estimated from the analysis of FXaG curves However, few is known about the relevance of anemia in the internal medi-
only the area under the curve (FXa-AUC) showed a significant correlation cine patients who usually suffer for numerous concomitant pathologic con-
with FVIIa-AT levels. The FXa-AUC increased progressively across FVI- ditions. Moreover, the available studies suggest that the detection, evalua-
Ia-AT quartiles, from 4031±210Rfu in the lowest to 4268±84 Rfu in the tion and management of anemia are unmet medical needs. We planned a
highest (P=0.007 by ANOVA with polynomial contrasts for linear trend, prospective study to evaluate the incidence, the severity, the cause and the
confirmed after adjustment for traditional cardiovascular risk factors). real life adopted treatment of anemia in an internal medicine department
The addition of either TFPI-aptamer or APC-aptamer produced a marked with the aim to define an effective algorithm to assess anemia in hospitalized
increase of FXaG with shorter time parameters (P<0.001). The increase of medical patients and to optimize its treatment. The data here presented refer
FXa-AUC across FVIIa-AT quartiles was confirmed in both TFPI-aptamer to a preparatory step of our project and describe the data of consecutive
or APC-aptamer assays (TFPI-aptamer, P=0.019; APC-aptamer, P=0.014). patients admitted to our Department in the first 15 days of May 2017, in
Conclusion: in male CAD patients high plasma levels of FVIIa-AT are order to assess the prevalence of anemia and our present ability to reco-
associated with an increased FXaG at low TF concentration. The increase of gnize, diagnose and treat this condition in internal medicine patients. Mate-
FXa-AUC across FVIIa-AT quartiles is still maintained after potentiation of rial and methods: A single operator collected blood cells texts at hospital
procoagulant pathways by inhibiting TFPI or APC. admission, and throughout the whole hospitalization of the patients. More-
over, all available records in the 12 months before admission were reviewed.
Anemia was defined in accordance with WHO criteria as haemoglobin
AN ITALIAN SINGLE CENTER PROSPECTIVE STUDY ON (Hb) less than 120 g/L in women and less than 130 g/L in men; its severity
OUTCOMES IN AL AMYLOIDOSIS (mild Hb= 110-119 g/L, moderate Hb=80-109 g/L or severe Hb<80 g/L)
was also settled according to the WHO criteria. Medical history and drugs
Palladini G. 1, Milani P. 1, Basset M. 1, Foli A. 1, Russo F. 1, use before or during hospitalization were registered. Statistical analysis was
Mussinelli R. 1, Perlini S. 2, Merlini G. 1 performed by χ2 test and T test.
1
Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico Results: Within 82 patients (42 males and 40 females, median age 77ys,
San Matteo, and Department of Molecular Medicine, University of Pavia, range 32-95 ys) admitted in our department, 31 (37.8%) were anemic.
Pavia, Italy 2 Internal Medicine Unit, Fondazione IRCCS Policlinico San Sixteen were males (38% - Hb 110,3±16,9 g/L) and 15 females (37.5% - Hb
Matteo, and Department of Internal Medicine, University of Pavia, Pavia, 108,1±13,1). Twenty-seven (15 males and 15 females, 87%) out of these 31
Italy patients were yet anemic in the 12 months previous hospital admission. In
16 of them (59.3%) causes of anemia had been searched but only 7 patients
Background: In the last decade, new treatment strategies and patients (25.9%) had received a treatment. Causes of anemia and adopted treatment
selection according to biomarkers have modified the approach to patients are summarized in the following table:
with light-chain (AL) amyloidosis. However, prospective studies are hampe-
red by patient selection, short follow-up and small numbers due to the rarity
Total Treatment
of the disease and the difficulties in enrollment.
Methods: Starting in 1994, we protocolized the collection of parameters of Iron-deficiency anemia 8 Iron replacement in 6
clonal and organ disease at baseline and during treatment in all the 1933
Anemia of chronic inflammatory 5 none
patients diagnosed at our center. Here, we report the outcome of 1065 disease
subjects enrolled after 2004, when systematic collection of cardiac biomar-
kers and FLC data started. Leukemia/MDS 5 2 transfused
Results: Median age was 65 years. Involved organs were heart (77%), Microangiopathic aaemia 1 1 transfused
kidney (66%), soft tissue (17%), liver (14%) and PNS (12%), >2 organs were Beta thalassemia minor 1 none
involved in 24% of cases. Mayo stage (cutoffs: NT-proBNP= 332 ng/L and
troponin I= 0.1 ng/mL) was I in 17% of patients (both markers below the Renal insufficiency 1 1 epoietin
cutoffs), II in 44% (one of the two markers above the cutoff) and IIIa (both Folic acid defect 1 1 vitamine supply
markers above the cutoffs and NT-proBNP cutoff <8500 ng/L) in 20% and
Multifactorial anemia 2 1 transfusion and cobalamine in both
IIIb (both markers above the cutoffs and NT-proBNP cutoff >8500 ng/L)
in 19%. Renal stage, based on proteinuria (cutoff 5 g/24h) and estimated
31
Discussion: Our study, though limited and preliminary, showed that, inde- Willebrand component. He has also multiple-revascularized ischemic car-
pendently from the cause of admission, almost 38% of hospitalized patients diopathy, whose last intervention dates back to 2011, and paroxysmal atrial
in our internal medicine department are anemic; interestingly, most of these fibrillation, for whose reasons the patient is in pharmacological treatment
patients had an already known anemia at least 12 months lasting. In agre- both with ASA 100 mg (1cp/day) and with Dabigatran (110 mg, 1cpx2/
ement with the data available in the literature, in less than 65% of cases the die). He is still in active waiting list for new coronary artery arteriography
cause of anemia was appropriately investigated and only in 40% of patients because of the anginal symptoms even in recent months and even at rest. In
a treatment was started. Considering the diminished quality of life and the 2014, LNH diagnosis with tunsillar localization with chemio-immunothe-
unfavorable clinical outcomes related to the presence of anemia, it sounds rapy treatment according to the R-Benda scheme, with remission of illness.
astonishing. A recent study has pointed out that the type and severity of The patients is sent by Emergency Unit to our Clinic for thoracic pain and
anemia affects hospital re-admission and mortality in old patients. There- anemia with reported episode of melena, thrombocytopenia. Laboratory
fore, the definition of an effective algorithm to assess anemia in hospitalized tests show: Hb 7.2 g/dl (n.v. 13.3-17.2); MCV 74.3 fl (n.v.81.2-94) for which
medical patients and to optimize its treatment results mandatory. he performs trasfusional therapy with concentrated red cells; PLT 84000
(n.v. 179000-373000); PT INR 1.20 (n.v. <1.20); APTT 1.43 (n.v. <1.20);
Factor VIII 115% (n.v. 60-120) after administration of factor VIII; Iron 95
HFEH63D POLYMORPHISM IS COMMON IN PATIENTS μg/dL (n.v.65-175); Ferritin 11 ng/ml (n.v. 26-388). Because of clinical and
WITH IDIOPATHIC ERYTHROCYTOSIS laboratory framework, a gastropathy is suspected and the patient is planned
for an EGDS. For comorbid coexistence such as ischemic heart disease,
Biagetti G., Cosi E., Bertozzi I., Santarossa C., Fabris F., Randi M.L. atrial fibrillation and congenital coagulopathy, and the difficulty in their
Dipartimento di Medicina - DIMED, Università di Padova, Clinica Medica 1 pharmacological treatment, which need antithetic therapies, we ask for both
cardiological and coagulological consultations. Due to high haemorrhagic
Background: Idiopathic erythrocytosis (IE), characterized by persistently risk (CHADsVASC 6, HASBLED 5), it is decided to temporarily suspend
raised hemoglobin (Hb) and hematocrit (Ht) levels, has not a definite cause, both anticoagulant and antiaggregant treatment with dabigatran and ASA,
even after an accurate diagnostic investigation. Increased levels of ferritin although there is a very high thrombotic risk. An EGDS is then performed
are often observed in IE and we recently found that mutations or polymor- which highlights a as a vegetative, ulcerated, napping bloody mass in the
phisms of HFE gene are commonly found in patients with IE. Curiously, duodenal bulb. Endoscopic hemostatic treatment is performed, but it is
HFE mutations were found also in IE patients with normal ferritin levels. decided not to perform a biopsy and to postpone this procedure at a time
To better understand the relation between erythrocytosis and HFE gene, we of eventual hemoglobin stabilization. TC total body is performed which
searched which mutations were prevalent in IE patients. confirms the presence of a vegetative lesion at the duodenum. At this level,
Materials and Methods: HFE mutations were searched in 33 patients with the walls appear thickened, associated with lymph nodes in the perivascular
IE (30 males and 3 females, mean age 53 ± 13 y, Hb 175,5 ± 9,2 g/dL, Ht 51,2 adipose tissue. In the meantime, the patient is treated with infusion of VIII
± 3,0 %) not carrying JAK2V617F or JAK2 exon 12 nor EPOR, VHL, PHD2 factor enriched with von Willebrand in order to reach stable levels of HB.
or HIF-1 alpha genes mutations. All the patients had normal serum erythro- Finally we plan to perform a new endoscopic examination with the specific
poietin level. None had an overt clinical diagnosis of hemochromatosis. indication to the biopsy of the mass in the hypothesis that this could be due
HFE gene mutations was performed using Lightcycler 480 on extracted to an exacerbation at this level of the LNH.
DNA Results: We found 14 HFE mutated patients (42%): 10 heterozygous Conclusion: the interest of this very challenging case is mainly due to the
and 2 homozygous H63D and 1 H63D/C282Y. Only 1 patient carried hete- presence of two concomitant severe diseases in which relative guidelines
rozygous S65C mutation. On a whole, 13 (93%) of the HFE mutated patients suggest antithetic therapeutic options. The key is represented by the pre-
have at least one H63D mutated allele. In the table we report the frequen- sence of a neoplastic blooding mass. What to do? We chose first the proco-
cies of HFE mutations, H63D mutations and high ferritin between mutated agulant therapy even if it is clearly in contrast with the need of the patient
patients in general population, in IE patients and in the present cohort. to have an anticoagulant treatment for ischemic cardiac disease. This case
teaches us that the clinical decision is often the result of the relative weight
of three elements: the scientific evidence, the patient preferences, the expe-
Italian General IE(BJH 2017) 56 IE in the present
Population patients study: 33 patients rience of the physician. Once more we could say with Osler: Medicine is a
science of uncertainty and an art of probability.
HFE mutated 26.5% 25 (44.6%) 14 (42%)
HFEH63D 23% 17 (30.4%) 13 (39%)
High ferritin levels in

A STRANGE CASE OF ANEMIA
15% 12 (48%) 9 (64%)
mutated patients
Marcacci M. 1, Pileri F. 1, Nuzzetti M. 1, Bresciani P. 2, Pietrangelo A. 1
Discussion: We have recently observed that increased serum ferritin levels
1
Internal Medicine 2 and Center for Hemochromatosis, University Hospital
and mutations of HFE are more common in IE patients than in the European of Modena, University of Modena and Reggio Emilia (Italy) 2 Section of
general population. The present study shows that most of the HFE mutated Hematology, Department of Medical and Surgical Sciences, University
patients with IE carry at least one H63D allele. HFEH63D polymorphism, Hospital of Modena, University of Modena and Reggio Emilia (Italy)
which is rarely associated with iron overload but drives an impairment in
iron metabolism, may be linked with erythrocytosis in spite of ferritin levels. PB, a 60 year-old woman, was admitted to our hospital for mild chest pain
Then, it remains unclear how HFE mutations alter the supply of iron to the three days before, followed by fatigue, palpitations and dyspnea. The patient
erythroid tissues. Study of a large cohort of IE patients are needed to confirm also reported a single episode of macrohaematuria in the morning. In the
our results and to clarify the physio-pathological relation between HFE or medical history of note: a mild macrocytic anemia treated with oral coba-
other molecules involved in iron metabolism and erythrocytosis. lamin and folate supplementation (most recent blood test: Hb 12.9 g/dl,
MCV 100.6 fl, cobalamin 129 pg/ml, folate in the normal range), mild dysli-
pidemia and lower limb varicosities. Biochemical examinations showed
DETERMINANTS OF CLINICAL DECISION WHEN THE severe macrocytic anemia (Hb 7.4 g/dl, MCV 101 fl). Her pulse rate was
GUIDELINES ARE NOT ENOUGH: THE CASE OF A 78 beats/minute regular, with a blood pressure of 130/70 mmHg. Oxygen
PATIENT WITH BOTH EMORRAGIC AND THROMBOTIC saturation at room air was 100%. Examination of the cardiovascular, respi-
DISEASES ratory and abdominal systems was normal (in particular the patient did not
show lymphadenomegaly or splenomegaly). The chest pain experienced by
Passerini F., Grimaldi L.D., Ettorre C. 1, Belfiore A., Buonamico P., the patient was investigated by ECG and markers of myocardial necrosis,
Minerva F., Pugliese S., Palmieri V.O., Portincasa P. all negative. In the emergency department, in consideration of macroha-
Clinica Medica “A. Murri”, Dipartimento di Scienze Biomediche ed ematuria, an abdomen CT scan was performed, negative for alterations
Oncologia Umana, Università di Bari “Aldo Moro” 1Centro di Emofilia e of kidney and bladder and for intra-abdominal hematomas. There was no
Trombosi Azienda Ospedaliera Policlinico Bari family history of anemia. Indices of hemolysis showed mild reticulocyto-
sis and slight decrease of haptoglobin; cobalamin and folate levels were
Patient M.F, male, 71 years old, affected by hypertension, type II diabetes low, despite supplementation, and iron assessement was consistent with
mellitus, dyslipidemia, prostatic hypertrophy, Von Willebrand disease, for a chronic inflammatory state (ferritin 819 ng/ml, serum iron 56 microg/
which he undergoes to periodic therapy with VIII factor enriched by von dl). Before the patient underwent blood transfusion, a peripheral blood
film was performed, which revealed polychromasia, suggestive of a regene-
32
rative anemia. Direct and indirect Coombs tests, lymphoproliferative and CO-ACTIVATOR-ASSOCIATED ARGININE
lymphocyte immunopheno-typing were negative. Flow cytometry did not METHYLTRANSFERASE 1 (CARM1) IS OVEREXPRESSED
detect paroxysmal nocturnal hemoglobinuria (PNH)-clones. An endosco- IN TYPE 2 DIABETES
pic study of the gastrointestinal tract revealed only a small 2 mm area of
gastric angiodysplasia with no active bleeding; biopsies were negative for Porta M., Amione C., Barutta F., 1Albano L., 1Ciccarelli M., Fornengo P.,
celiac disease and for Helicobacter pylori infection. Autoimmunity (ANA, Merlo S., 1Ungaro P., 1Beguinot F., 2Berchialla P., 2 Cavallo F., Trento M.
ANCA, anti-parietal cell and intrinsic factor antibodies), tumor markers Laboratory of Clinical Pedagogy, Department of Medical Sciences, University
and celiac disease screening were negative. In order to exclude an aplastic of Turin. 1Department of Cellular and Molecular Biology and Pathology,
anemia, quantitative PCR for EBV, CMV, HHV6, HHV7, HHV8 and sero- University Federico II, Naples. 2Department of Public Health and Paediatric
logy for Parvovirus B19 infection were performed, resulting negative for Sciences, University of Turin, Italy
recent infections. On further questioning, the patient admitted consump-
tion of large amount of broad beans the day before her symptoms began; Background: Type 2 diabetes (T2DM) is on the rise worldwide but the
for this reason, glucose-6-phosphate dehydrogenase (G6PDH) assay was causes for this epidemic remain to be ascertained. While several genetic
performed, resulting lower than normal, despite blood transfusions (3 U/ markers were described, their contribution to the total risk of developing
gr.Hb, normal range 9-18). The patient was therefore advised on the medi- T2DM appears minimal. On the other hand, urbanisation has driven
cations to be avoided, and her hemoglobin rised to 12.6 g/dl after two weeks dramatic changes in lifestyle and may increase risk factors for T2DM via
and remained normal thereafter. G6PDH deficiency is an X linked disorder epigenetic mechanisms. Objective Over the years, our research interest
and occurs not only in boys who are hemizygous for the X-linked G6PDH has focused on identifying the dimensions involved in lifestyle changes in
variant gene, but may also occur in adult heterozygous women. The main people with T2DM. As part of an ongoing study, we investigated the dif-
clinical manifestations are seen in hemizygous males, but heterozygous ferential expression of a panel of histone modulating enzymes in T2DM
females can also be affected in some circumstances, because of the presence patients and non-diabetic controls.
of a population of deficient cells. Female patients heterozygous for G6PDH Patients and Methods: Patients (n=21) with T2DM, aged 40-70, treated by
deficiency have two red cell populations: one with normal enzyme content diet and/or oral glucose-lowering agents and with at least 1-year attendance
and one deficient, that explains the red cell lysis when exposed to an oxida- in the clinic were randomly selected. Exclusion criteria were current insulin
tive challenge. Due to skewed X chromosome inactivation, the population treatment, known psychiatric conditions, cancer or other conditions with
of deficient cells may be much larger, and the red cell enzyme concentra- potential impact on the epigenetic machinery. Clinical, blood chemistry,
tion can be similar to those in hemizygous males, leading to hemolysis on epigenetic, inflammatory cytokines and endocrine variables were mea-
exposure to oxidant drugs or fava beans. Most individuals with G6PDH sured in the patients and in 21 non-diabetic controls matched by age and
deficiency remain clinically asymptomatic, but they are at risk of develo- sex. Peripheral blood leukocytes were separated and total RNA and DNA
ping acute hemolytic anemia when exposed to three types of triggers: drugs, isolated. The isolates were retro-transcribed to evaluate the expression of
infections and broad beans. The hemolytic attack can be self limiting, but a panel of 84 histone modifying enzymes by Real-Time PCR. A panel of
also very serious. 22 cytokines and 10 hormones involved in metabolism were measured in
The blood film can show polychromasia, anisocytosis, poikilocytosis and serum by specific ELISA or by Bio-Plex Multiplex Immunoassay System.
blister cells, features of acute oxidant induced hemolysis. In this case the Chi-square test or Fisher exact test were performed to compare groups of
diagnostic difficulty was due to lack of clear signs of hemolysis at the bioche- categorical data, and the Mann-Whitney U test to compare continuous data.
mical examinations and at the blood film. This case, once again, strengthens A discrete Bayesian Network was built to explore the relationships between
the importance for diagnosis of collecting a detailed and accurate patient’s all variables. Normality of distribution of continuous variables was tested by
history. the Shapiro-Wilk test and, since it was not satisfied, Hartemink’s Informa-
References: 1. Lim, F., T. Vulliamy, et al. (2005). “An Ashkenazi Jewish tion-Preserving Discretization was carried out. Power analysis showed that
woman presenting with favism.” J Clin Pathol 58(3): 317-319. 2. Luzzatto, 21+21 samples allowed a statistical power of 81% to detect a 25% difference
L., C. Nannelli, et al. (2016). “Glucose-6-Phosphate Dehydrogenase Defi- in CARM1 expression with alpha=5% and a Bonferroni correction for 100
ciency.” Hematol Oncol Clin North Am 30(2): 373-393. 3. Stockley, R., A. multiple tests.
Dawson, et al. (1985). “Favism in two British women.” Lancet 2(8462): 1013. Results: BMI, plasma glucose and serum glucagon were higher in the
patients. These were all on metformin and 10 on pioglitazone, both insu-
lin-sensitizers, and most were on statins and/or other lipid-lowering drugs,
AN UNUSUAL EMOGASANALYSIS which may account for why the controls had higher total and LDL cho-
lesterol, while serum insulin and HOMA-IR index did not differ between
Ciarla S., Striuli R., Petrarca M., Croce G., Parisi D., Di Michele D. U.O.C. di the groups. Of the 84 histone-modifying enzymes checked, only CARM1
Medicina Interna - Ospedale “G. Mazzini” ASL Teramo showed a 5-fold higher median value in the patients (p<0.001), who also
had significantly higher levels of GIP, IL-4, IL-7, IL-13, IL-17, FGF basic,
A 32-year-old Caucasian male was admitted for acute renal failure caused by G-CSF, IFN γ and TNFα, and decreased levels of IP-10. Bayesian network
tumor lysis syndrome. Hyperuricemia (31 mg/dl) was treated with 2 doses analysis showed that the dichotomy health/diabetes was independently
of rasburicase. The day after, on physical examination cyanosis and severe linked to plasma glucose, CARM1 and leptin. A second independent node
asthenia were noted. Blood pressure was 140/90 mmHg, pulse 90 beats/ proceeded from IL-1b to IL-6, TNFα and IFN- γ. TNFα also clustered with
min. The saturation on pulse oximeter was 40%. Arterial blood gas analysis IL-7, IL-4 and IL-17.
showed pO2 61.8 mmHg%, sO2 91.7% but 20% of methaemoglobinaemia. Conclusions: This is the first report on increased expression of CARM1 in
At laboratory test hemoglobin was 6.9 g/dl. The anemia was associated with patients with T2DM, independent of known hormonal and inflammatory
hemolytic markers including marked reticulocytosis with Heinz bodies, pathways. CARM1 enhances transcriptional activation of nuclear receptors
elevated indirect bilirubin and lactate dehydrogenase, and reduced hapto- by interacting with coactivators p160 and CBP and methylation of histone
globin. Later blood tests confirmed glucose-6-phosphate dehydrogenase H3 at arginine 17. In particular, it is a coactivator of nuclear factor-kB and
(G6PD) deficiency. He received oxygen, ascorbic acid and blood transfu- a possible key regulator of glucose-induced insulin secretion and glucose
sion and made a complete recovery. The methaemoglobinaemia disappe- metabolism in the liver. Further studies will need to elucidate the conditio-
ared after 48 hours. Rasburicase is a recombinant urate oxidase enzyme nal dependence of CARM1 expression on the presence/absence of T2DM.
frequently used in tumor lysis syndrome. Although it is very well tolerated,
it can cause severe oxidative hemolytic anemia and methemoglobinemia in
patients with G6PD deficiency. In case of rasburicase use, a close clinical TLRS EXPRESSION IN PATIENTS WITH
monitoring is mandatory, especially in populations where G6PD deficiency CARDIOVASCULAR RISK FACTORS: METABOLIC
is highly prevalent. Unfortunately, the G6PD status of a patient is often CORRELATIONS
unknown at the time rasburicase therapy is contemplated. Methaemoglobi-
naemia must be suspected in case of low oxygen saturation when all other Perticone M. 1, Sciacqua A. 2, Hribal M. 2, Colica C. 3 Pinto A. 2, Procopio G.
potential causes have been ruled out. 2
, Suraci E. 2, Sesti G. 2, Perticone F. 2
1
Dipartimento di Medicina Sperimentale e Clinica - Università degli Studi
Magna Graecia - Catanzaro 2Dipartimento di Scienze Mediche e Chirurgiche
- Università degli Studi Magna Graecia - Catanzaro 3CNR c/o IBFM-UOS
Catanzaro
33
Toll Like Receptors (TLRs) are trans-membrane proteins that play a crucial fold increase in the adjusted-OR of having high NT-proBNP values,
role in the innate immune response. Once activated, TLRs dimerize and while people with a BMI ≥ 25 kg/m2 had a lower adjusted-OR (0.70, 95%
recruit a number of adaptive proteins, initiating a intracellular pathway that CI 0.56-0.87) compared to normal-weight individuals. In people with
culminates with the activation of Nuclear Factor kB (NFkB), a transcription overweight/obesity only, the OR of having NT-proBNP levels above the
factor responsible for the transcription of inflammatory cytokines. These median value (34 pg/ml) was significantly lower than in normal weight
cytokines generate a low-grade immune-mediated inflammatory state asso- subjects (OR=0.64, 0.48-0.82). The presence of diabetes either alone or
ciated with increased cardiometabolic risk. Systemic low-grade inflamma- combined with overweight/obesity or metabolic syndrome greatly enhan-
tion is also present in hypertension. The aim of this study was to evaluate ced the OR of having NT-proBNP levels above the median value, while the
the expression of TLR2 and TLR4 and the activation of NFkB in circulating presence of metabolic syndrome alone had a more modest effect (OR=1.54,
monocytes of obese patients to assess whether the presence of hyperten- 1.18-2.01). All previous results were virtually identical after exclusion of
sion worsens their risk profile. Patients were selected among the partici- the subjects with CVD. Finally, we performed a separate analysis in the
pants to the Catanzaro Metabolic Risk Factor Study (CATAMERIS). After non-diabetic cohort to examine the effect of HOMA-IR values above
a complete clinical examination and laboratory tests subjects were divided median value (≥ 2.0) on NT-proBNP BMI ≥ 25 Kg/m2 and HOMA-IR ≥
into 4 groups: 16 healthy control;18 hypertensives non-obese; 20 obese 2.0 decreased to a similar extent the ORs of having NT-proBNP above the
non-hypertensive; 9 obese and hypertensive. The expression of TLRs was median value (BMI OR=0.76, 95% CI 0.60-0.95, HOMA-IR OR=0.74, 95%
evaluated by cytofluorimetry and the activation of NFkB was evaluated by CI 0.59-0.93). However, the association between overweight/obesity and
ELISA assay. There were no statistically significant differences between the NT-proBNP was no longer significant after the inclusion into the model
groups in terms of gender distribution and age. By design, there was a signi- of HOMA-IR). CRP was negatively associated with NT-proBNP and this
ficant difference in BMI, systolic and diastolic blood pressure(p<0.0001 for effect was evident even in the fully adjusted model.
all). There were also significant differences for 2-hour blood glucose values
during oral glucose tolerance test (OGTT)(p=0.004); baseline (p=0.004),
Adjusted OR (95% CI)
1 hour (p=0.002) and 2 hours insulin (p=0.027); HOMA index (p=0.002);
MATSUDA index (p=<0.0001); uric acid levels (p=<0.0001); hs-PCR levels Model 1 Non diabetes 1.00
(p=0.003); cholesterol HDL (p=0.002); and LDL (p=0.026). By analyzing Diabetes 2.60 (2.37-2.87)
the mean values of TLR2 and TLR4 expression in the 4 different study
groups, it was possible to observe a progressive and significant increase of BMI < 25 kg/m2 1.00
both receptors levels (p <0.0001), with the worsening of the cardiometabo- BMI ≥ 25 kg/m2 0.70 (0.56-0.87)
lic risk profile (from healthy subjects to hypertensive to obese); by contrast Model 2 Non diabetes, BMI < 25 kg/m2 1.00
the obese-hypertensive group presented average median levels that were
comparable to those observed in obese only subjects. To evaluate the fun- Non diabetes, BMI ≥ 25 kg/m2 0.63 (0.48-0.82)
ctional effects of the higher expression of TLRs, NFkB activity was determi- Diabetes, BMI < 25 kg/m2 5.44 (3.98-7.44)
ned in 5 healthy, 3 hypertensive, 5 obese and 2 obese-hypertensive subjects;
Diabetes, BMI ≥ 25 kg/m2 4.42 (3.25-6.01)
a not statistically significant trend of increased activity was observed with
the higher in obese subjects independently of the presence of hypertension. P for trend <0.0001
In conclusion, data from this study confirm that obesity is a clinical con- Model 3 Neither Metabolic syndrome nor DM 1.00
dition of high cardiovascular risk. Notably, the obese-hypertensive group
Metabolic syndrome 1.67 (1.25-2.22)
did not show any difference from obese only group, suggesting that obesity
itself accounts for the increased cardiometabolic risk in obese patients. Diabetes 7.45 (5.54-10.01)
Metabolic syndrome +Diabetes 7.56 (5.84-9.78)
NT-PRO-BNP IN INSULIN-RESISTANCE MEDIATED P for trend <0.0001

CONDITIONS: OVERWEIGHT/OBESITY, METABOLIC
SYNDROME AND DIABETES. THE POPULATION-BASED Conclusion: Results of the Casale Monferrato population-based study
CASALE MONFERRATO STUDY shows that NT-proBNP levels are lower in overweight/obesity, indepen-
dently of diabetes and that both insulin-resistance and chronic low-grade
Baldassarre S. 1, Fragapani S. 1, Panero A. 1, Fedele D. 1, Pinach S.1, inflammation are mediator of this relationship. Our findings are consistent
Lucchiari M. 2, Vitale A.R.2, Mengozzi G. 2, Gruden G.1, Bruno G 1 with the hypothesis that NPs are implicated in metabolic processes, with
1
Dipartimento di scienze mediche, Università degli studi torino, Torino; 2 impaired circulating levels of natriuretic peptides contributing to the incre-
Laboratorio analisi cliniche, Azienda Ospedaliero-Universitaria Città della ased cardiovascular risk of people with insulin-resistance mediated condi-
Salute e della Scienza, Torino tions, obesity, MetS, and diabetes. Further intervention studies are required
to test the potential role of drugs affecting the natriuretic peptides system on
Background and Aims: to examine the relationship between NT-proBNP, body weight and risk of diabetes.
and insulin-resistance mediated conditions, overweight/obesity, metabolic
syndrome and diabetes in the Casale Monferrato Study, a population based
cohort with extensive characterization of cardiovascular risk factors in both EXENATIDE LAR IMPROVES CARDIO-METABOLIC
diabetic and non-diabetic people. PARAMETERS INDEPENDENTLY OF BASELINE
Methods: The study-base were 3244 individuals aged 45-74 years, none ADIPONECTIN IN TYPE-2 DIABETIC PATIENTS: AN
of whom had heart failure, 1880 without diabetes and 1364 with diabetes, 8-MONTH PROSPECTIVE STUDY
identified as part of two surveys of the population-based Casale Monfer-
rato Study. All measurements were centralized. We examined with multi- Chianetta R. 1, Giglio R.V. 1, Nikolic D. 1, Castruccio Castracani C. 2,
ple linear regression the effect on NTproBNP values (dependent variable) Diliberto S.M. 1, Castellino G. 1, Patti A.M. 1, Mannina C. 1, Citarrella R. 1, Li
of a categorical variable with four levels determined by the combined Volti G. 2, Montalto G. 1, Rizzo M. 1
effect of diabetes (yes/no) and BMI (<25 and ≥25 kg/m2), independently 1
Biomedical Department of Internal Medicine and Specialties, University of
of waist circumference and after adjustment for known risk factors and Palermo, Italy 2Department of Biomedical and Biotechnological Sciences,
confounders (age, sex, hypertension, LDL-cholesterol, smoke, CRP, AER, University of Catania, Italy
creatinine, CVD). A logistic regression analysis was also performed with
NTproBNP as a categorical variable with two levels defined by its median Background and Aims: The improvement in body composition, including
value, to assess the effect of overweight/obesity, diabetes and the metabo- adiponectin, a known adipokine with antihyperglycemic, antiatherogenic,
lic syndrome, independently of age, sex, hypertension, LDL-cholesterol, and anti-inflammatory properties, has been seen after exenatide treatment.
smoke, CRP, AER, creatinine, CVD, waist circumference. All analyses However, the effect of exenatide once-weekly (long-acting release, LAR)
were performed with Stata Release 10.0. on adiponectin is largely unknown. We investigated whether the effect of
Results: Out of overall cohort of 3244 people, overweight/obesity (BMI ≥ exenatide LAR on several cardio-metabolic parameters, including carotid
25 kg/m2) was observed in 1,118 (59.4%) non-diabetic and 917 (67.2%) intima-media thickness (cIMT), endothelial function as well as cytokines
diabetic subjects, respectively. No significant correlations between involved in endothelial function, may differ between diabetic patients with
NTproBNP and either BMI or waist circumference were found. As com- a high and a low level of adiponectin at baseline. Materials and Methods:
pared to people without diabetes, subjects with diabetes showed a 2.6- Sixty subjects with T2DM (41 men and 19 women; 60±10 yrs) naïve to
34
incretin-based therapies were treated with exenatide LAR as add-on to DM while increasing beta cell function and reducing visceral fat, may exert
metformin (from 1500 up to 3000 mg/day) for 8 months. Exclusion criteria additional actions on top of those anticipated for lifestyle intervention-me-
included the presence of a previous major cardiovascular event, as well as diated weight loss. Our aims were i. to characterize the inflammation/
moderate and severe renal and liver function. Fasting blood samples were pro-resolution balance of obese subjects with prediabetes or early T2DM, in
collected at baseline and after 8 months. Adiponectin was measured by order to better understand how low grade inflammation is linked to insulin
multiplex analysis using Luminex Magpix®. The cohort of patients was sub- secretion failure, insulin resistance and body fat distribution ii. to compare
divided, based on the median of adiponectin, on those with the low adipo- the effect of two different strategies, such as lifestyle changes and with lira-
nectin at baseline (≤3.1 μg/ml, n=30) and those with the high adiponectin glutide, continued until achieving the same amount of weight loss, on these
at baseline (>3.1 μg/ml, n=30), respectively. cIMT was assessed by B-mode pathophysiological events.
real-time ultrasound, while endothelial function by flow mediated dilation Methods: Forty metformin-treated obese subjects (BMI≥30) with predia-
(FMD) of the brachial artery. Results: Statistical analysis was performed by betes [impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)
paired t-test and ANOVA. After 8 months of exenatide LAR treatment, adi- or both (n=24)] or newly diagnosed T2DM (n=16), were randomized to
ponectin improved significantly (from 3.6±2.7 to 4.3±2.9 μg/ml, p=0.0393). liraglutide or lifestyle counseling until achieving a modest and comparable
Favourable effects of exenatide were found in both groups (Table). Among weight loss. Before and after loosing 7% of the initial body weight, patients
cytokines assessed, circulating p-selectin level decreased in the group with underwent a magnetic resonance imaging (MRI) of the abdominal region
lower adiponectin (from 9.9±8.3 to 6.1±4.6 ng/ml, p=0.026), that was accom- for adipose tissue (AT) distribution, and OGTT with frequent sampling to
panied by an increasing in the level of L-selectin, a cell adhesion molecule predict insulin sensitivity and β-cell function. In the context of this primary
with a key role in endothelial function (from 0.45±0.12 to 0.57±0.21 μg/ study, blood samples were available for the measurement of plasma Resolvin
ml, p=0.006). Interleukin-2 decreased significantly in the group with higher D1 and serum high-sensitivity C-reactive Protein (hs-CRP) and CTRP1 by
adiponectin only (from 8.5±5.0 to 6.5±2.3 pg/ml, p=0.047). enzyme-linked immunosorbent assays (ELISA).
Conclusion: Exenatide LAR improves several cardio-metabolic parameters, Results: At baseline, circulating levels of the Resolvin D1 and CTRP1 were
including cIMT, FMD and cytokines involved in endothelial function. Such higher in T2DM than in pre-diabetes (P=0.036 and P=0.020 respecti-
effects seem to not be influenced by baseline adiponectin. However, further vely), while hs-CRP were comparable in both groups (P=0.870). CTRP-1
investigations are required to fully elucidate these findings. was directly related to visceral AT (Rho=0.33, P=0.037), and inversely to
insulin sensitivity (Matsuda index, Rho=-0.32, P=0.041) and beta cell fun-
ction (Rho=-0.35, P=0.026). Baseline Resolvin D1 correlated directly with
Lower adiponectin at Higher adiponectin at baseline
baseline hs-CRP (Rho= 0.319, P= 0.050), and CTRP1 (Rho= 0.318, P= 0.046) and
inversely with age (Rho= -0.370, P=0.019). Due to randomization, no base-
p =
Baseline
After 8
p= Baseline
After 8
p= (between
line difference in the variables in study was detected between the two treat-
months months ment arms. After achievement of the weight loss target in the two arms, both
groups)
Weight (kg) 90±21 87±19 0.0329 88±15 85±16 0.0012 0.4690 interventions were equally effective on subcutaneous fat loss (P=0.64) and
BMI (kg/m2) 31±7 30±7 0.0298 32±6 31±5 0.0023 0.5593
HbA1c (P=0.61), whereas a significantly higher impact of liraglutide on abdo-
minal visceral fat loss (P=0.028) and improved β-cell performance (P=0.021)
Waist
circumference 109±14 106±13 0.1065 108±12 106±13 0.0122 0.8507 was reported. A comparable and significant reduction was observed for
(cm) CRP (-40.7% vs. -25.6%, P=0.32) with both interventions. In contrast, a
Fasting decrease in CTRP1 (P=0.035) was observed only in the liraglutide arm. In
glycaemia 8.8±3.1 7.2±2.4 0.0077 8.8±2.5 7.3±2.0 0.0002 0.6916 parallel, the liraglutide arm, but not the lifestyle arm, experienced a signifi-
(mmol/l) cant increase in Resolvin D1 (P=0.006). The extent of circulating Resolvin
HbA1c (%) 8.0±0.4 6.9±0.9 <0.0001 8.1±0.4 7.0±1.2 <0.0001 0.8190 D1 increase was greater among those with time-to-weight loss longer than 5
Total cholesterol
4.4±1.0 4.2±1.0 0.0717 4.4±0.8 4.2±0.8 0.0019 0.7089 months (19.1% P=0.206 vs 37.8% P=0.004). In the whole group of patients
(mmol/l) who achieved successful weight loss, regardless of the treatment arm, Resol-
HDL-cholesterol
1.1±0.2 1.2±0.3 0.0213 1.3±0.3 1.3±0.2 0.4380 0.6067 vin D1 increase significantly correlated with BMI decrease (Rho=-0.516,
(mmol/l)
P=0.020).
LDL-cholesterol Conclusions: We found that CTPR-1, reflecting visceral AT-derived inflam-
2.6±0.9 2.2±0.9 0.0106 2.5±0.8 2.3±0.9 0.0008 0.7902
(mmol/l)
mation and known to promote atherogenesis, is related to insulin sensitivity
Flow mediated
dilation (%)
5.9±1.3 7.1±1.6 <0.0001 5.6±1.3 6.5±1.6 <0.0001 0.1527 and beta cell function. In addition, Resolvin D1 levels were higher in dia-
betes rather than in prediabetes and directly correlated with both hs-CRP
Carotid IMT
(mm)
1.0±0.1 0.8±0.1 <0.0001 1.0±0.1 0.9±0.1 <0.0001 0.3554 and CTRP-1, suggesting that this pro-resolution mechanism is triggered
in response to low-grade inflammation and may be prompted by the pro-
gression of the disease as a feedback regulatory mechanism to counteract it.
Despite an equal degree of weight loss, liraglutide was more effective than
EFFECTS OF LIRAGLUTIDE VS. LIFESTYLE CHANGES
lifestyle changes in reducing CTRP1 and increasing Resolvin D1.The com-
ON RESOLVIN D1 AND C1Q/TNF-RELATED PROTEIN 1
bined effects of liraglutide on visceral obesity and insulin secretion failure,
LEVELS IN OBESE SUBJECTS WITH PREDIABETES OR
as well as on inflammation/resolution of inflammation, may provide a
TYPE 2 DIABETES AFTER COMPARABLE WEIGHT LOSS
mechanistic explanation for the reduction of cardiovascular outcomes with
liraglutide in T2DM patients, and a further rational, besides weight loss, for
Simeone P. 1, Tripaldi R. 1, Guagnano M.T. 1, Liani 1,
its use in obese subjects in an early phase of the natural history of glucose
Tartaro A. 2, Maccarone M. 2, Angelucci E. 3, Recchiuti A. 4,
control impairment.
Golato M. 3, De Cesare D. 1, Quirino A. 3, Bosco G. 1, Consoli A. 1, Davì G. 1,
Santilli F. 1
1
Department of Medicine and Aging and Center of Excellence on Aging,
University of Chieti, Italy; 2Department of Neuroscience & Imaging,
University of Chieti, Italy; 3 Medica, and Pathology, Chieti Hospital, Italy; 4
Department of Medical, Oral, and Biotechnological Sciences, G. D’Annunzio
University of Chieti-Pescara, Chieti, Italy
Background: Low-grade inflammation has a key role in the pathogenesis of

obesity and type 2 diabetes mellitus (T2DM) and their complications. The
adipokine C1q/TNF-related protein 1 (CTRP1), synthesized by the peri-
vascular adipose-tissue, is increased in patients with T2DM and has been
identified as a link between visceral fat and atheroinflammation. Resolution
of inflammation is an active program that contrasts excessive inflammation
and promotes the return to homeostasis to protect organs from damage.
Resolvin D1 is a lipid mediator with potent anti-inflammatory actions.
Objectives. We hypothesized that Liraglutide, a human glucagon-like
peptide-1 (GLP-1) analogue known to improve cardiovascular outcomes in
35
POOR VITAMIN STATUS IN PATIENTS WITH motolerant subjects with 1h-post-load plasma glucose levels >155 mg/dL
SYMPTOMATIC ACUTE PORPHYRIAS: A RELIABLE (NGT 1h-high), have a cardiovascular risk similar to that of diabetics. We
TARGET FOR TREATMENT OF SYMPTOMATIC hypothesized that these subjects may develop early neuropsychological alte-
PATIENTS? rations, given their enanched IR. The aim of this study was to early detect
neuropsychological and/or neuroimaging alterations suggestive of MCI in a
Ventura P., Marcacci M., Marchini S., Cuoghi C., Vaccari D., Pietrangelo A. group of NGT 1h-high subjects, compared with a group of subjects with 1h
Unit of Internal Medicine 2, Regional Reference Centre for Porphyrias, Dept. post-load plasma glucose <155 mg/dL (NGT 1h-low).
of Medical and Surgical Sciences for Children and Adults, Policlinico Hospital Methods: We planned to enroll 30 subjects (15 NGT 1h-high and 15 NGT
of Modena, University of Modena and Reggio Emilia, Italy 1h-low), free from DM and any disease predisposing to MCI and glucose
metabolism alterations. All patients underwent 3T cerebral MRI with eva-
Background: Conditions of poor nutritional status and vitamin deficiency luation of diffusion, and complete neuropsychological assessment.
have been described in patients affected by porphyrias in general. In acute Results: These preliminary results are referred to 7 subjects (4 NGT 1h-high
porphyrias (AP), the partial enzymatic block in the heme pathway, leads to and 3 NGT 1h-low), mean age 55+4 years. We observed statistically signi-
the induction of liver delta-aminolevulic acid synthase (ALAS1), the rate ficant differences (NGT 1h-high vs NGT 1h-low) for: 1h post-load plasma
limiting step of heme biosynthesis. As ALAS1 is a vitamin B6-dependent glucose (174±14 vs 121±33 mg/dL), total cholesterol (171±29 vs 246±6 mg/
enzyme, its enhanced activity may result in use of abnormal high amounts dL), and IGF-1 (114±17 vs 161±7 ng/mL). Clinically but not statistically
of B6, leading to different degree of B6 tissue deficiency. Interestingly, the relevant differences were found for: insulinemia (18±13 vs 9±2 UI/mL),
peripheral neuropathy observed in conditions causing B6 deficiency has and HOMA index (4±3 vs 2±1). We did not observe a significative diffe-
striking clinical resemblances to those observed in the AP. Moreover, any rence between groups with regards to neuropsychological and neuroima-
other different micronutrients can support the heme biosynthetic pathway ging studies. Anyway, NGT 1-h high subjects showed a worse trend both
through essential and non-essential co-factor roles, as well as protect the parameters.
body against oxidative stress through their antioxidant properties. Aim: to Conclusion: These preliminary results, if confirmed in a greater study,
assess vitamin B6, B12 and folates status in patients with AP and the possi- could allow to consider 1h post-load hyperglycemia as a risk factor not only
ble association with their poor status with different clinical stage of disease for new DM and CV events, but also for MCI.
and therapy with heme arginate.
Materials and Methods: 46 patients with AP (31 with Acute Intermittent
Porphyria,15 with Variegate Porphyria) were assessed for clinical status BODY COMPOSITION ANALYSIS BY INBODY 770® IN
(symptomatic vs. asymptomatic), Vit.B6, Vit.B12, red blood cell folates and BREAST CANCER PATIENTS
urinary delta-aminolevulinic acid(ALA) and porphobilinogen(PBG) levels
(mean of seven seriate measurements measured outside acute attacks). Molfino A.1, Amabile M.I.1, 2, De Luca A.2, Ramaccini C.1,
Results: As expected, symptomatic AP patients (SAP, n=18) had signifi- Maceli F.2, Monti M.2, Rossi Fanelli F.1, Muscaritoli M.1
cantly higher levels of urinary ALA and PBG than asymptomatic AP patients 1
Department of Clinical Medicine, Sapienza - University of Rome, Rome,
(AAP, n=28); a significant poorer vitamin status was observed for all tested Italy 2Department of Surgical Sciences, Sapienza - University of Rome, Rome,
vitamins in SAP vs. AAP group: in 6/18 (30%) vs. 0/28 (0%), p=0.001 for B6; Italy
4/18 (22.2%) vs. 1/28 (3.5%),.006 for B12, and 5/18 (27.7%) vs. 1/28 (3.5%),
p=.011 for RBC folates, respectively. The difference between groups resulted Background and Aim: Obesity represents an under-recognized preven-
significantly higher if considering as cut-off value for vitamin status a value table risk factor for cancer development and recurrence, including breast
below the 25th percentile of the normal range. Multiple vitamin deficiency cancer (BC). Obesity is highly prevalent in western countries and it contri-
was also significantly frequent in SAP than in AAP group. No significant butes to almost 50% of BC in older women. However, although high body
direct correlation between vitamin plasma or RBC levels and PBG or ALA mass index (BMI) may indicate overweight and obesity, often low muscle
in urine was observed, but a trend in increase of mean plasma B6 levels was mass may be present at BC diagnosis, impacting negatively on outcomes.
observed when stratifying patients for different levels of increase in urinary We aimed at assessing body composition in BC patients at the moment of
ALA and PBG levels. Within SAP group patients undergoing a maintenance cancer diagnosis and the association between body composition and clinical
therapy (n=14) with heme arginate, B6 status resulted significantly poorer parameters.
than that in those not undergoing a maintenance therapy (n=4) (40.7 vs. Patients and Methods: Consecutive BC patients were enrolled before
18.8 ng/ml, respectively, p=.039), and a significant different prevalence of undergoing breast surgery and any other therapy. Clinical characteristics
B6 deficiency was observed between these two groups. B6 deficiency status were collected, including BMI (weight/height2), waist circumference (cm),
showed a significant association both with an history of recurrent acute while muscle mass (MM) (kg) and adiposity (kg) were assessed by bioe-
porphyric attacks [OR= 8.3 (95% CI 4-25.7), p=.004], and the presence of lectrical impedance analysis (InBody 770®, InBody co, Ltd., kindly provi-
multiple vitamin deficiency [OR= 12.9 (95% CI 3.7-51.8), p=.002], as well. ded by Caresmed, Italy). Skeletal muscle index (SMI) was calculated as MM
Conclusions: Patients with symptomatic AP show a significant vitamin B (kg)/ height (m)2. Parametric and non-parametric tests were performed, as
group poorer status than AP asymptomatic group, particularly for B6. Con- appropriate, and P <0.05 was considered statistically significant.
sidering that clinical signs of porphyric acute attacks strictly resemble those Results: A total of 19 BC patients were studied. Age (years) was 54.4±11.2.
resulting from vitamin B6 deficiency, our data suggest the importance of BMI was 25.2±3.8 and MM was 23.3±3.2. Based on SMI cut-off values for
assessment of vitamin status in all patients with symptomatic AP, especially sarcopenia, we did not observed this condition in the patients enrolled (SMI
if under heme arginate maintenance therapy. A possible therapeutical role 9.1±1.2). Eleven patients reported involuntary body weight loss (between 3
for vitamin supplementation in these patients should be considered. and 6 kilograms) in the previous 6 months, whose BMI tended to be lower
(23.6±2.4) although not significantly different from the patients without
body weight loss (26.3±4.3) (P=0.07). Patients reporting body weight loss
ONE HOUR POST-LOAD HYPERGLYCEMIA AND MILD had a MM significantly lower with respect to patients without body weight
COGNITIVE IMPAIRMENT loss (P=0.04) and a lower phase angle value (P=0.01), as well as lower SMI
(P=0.02).
Perticone M. 1, Arturi F. 2, Cassano V. 3, Miceli S. 4, Tramontano A. 5, Conclusions: Besides the clinical importance of the anthropometric values,
Sciacqua A. 2, Sesti G. 2, Perticone F. 2 body composition analyses revealed at the moment of BC diagnosis lower
1
Dipartimento di Medicina Sperimentale e Clinica - Università degli muscularity in patients presenting involuntary body weight loss in the pre-
Studi Magna Graecia di Catanzaro 2Dipartimento di Scienze Mediche vious months. These preliminary results suggest that body composition
e Chirurgiche - Università degli Studi Magna Graecia di Catanzaro analysis should be included in the evaluation of nutritional status, since
3
Dipartimento di Scienze della Salute - Università degli Studi Magna BMI and weight loss cannot discriminate the subtle changes occurring in
Graecia di Catanzaro 4Azienda Ospedaliero-Universitaria “Mater Domini” - body compartments in early phases of disease.
Catanzaro 5Università Federico II - Napoli Essential References: Muscaritoli M, et al. Clin Nutr 2010; Muscaritoli M,
et al. Intern Emerg Med 2011; Molfino A, et al. Int J Mol Sci 2016; Arends
Insulin resistance (IR), is a well known pathogenetic factor responsible for J, et al. Clin Nutr 2017; Fernández-Lao C, et al. Support Care Cancer 2013;
the appearance of many cardiometabolic disease, first of all of diabetes mel- Fagherazzi G, et al. Int J Obes 2012; Han DS, et al. Sci Rep 2016.
litus (DM). Recently, it has been postuled the hypothesis of the existence
of a cerebral IR, that could be responsible of many forms of dementia and
mild cognitive impairment (MCI). It is well established that glucose nor-
36
IDEGLIRA IS EFFICACIOUS ACROSS BASELINE A1C 225 m’ values after excision of the right femoral head were 423, 127, 56 and
CATEGORIES IN SUBJECTS WITH TYPE 2 DIABETES 30, respectively. Starting from the 60 m’ all values were in the normal range.
UNCONTROLLED ON SU, GLP-1RA OR INSULIN The brisk fall of FGF23 values suggested that the head femur lesion was
GLARGINE: ANALYSES FROM COMPLETED PHASE 3B responsible for the syndrome. On histological examination, a mesenchymal
TRIALS tumor with highly vascular proliferation pattern (hemangiopericytoma-like
tumor), was diagnosed. This is the first report showing the possibility of
Piatti P. 1,Sorli C. 2, Harris S . 3, Jodar E. 4, Lingvay I. 5, intra-operative FGF23 assay to monitor tumor resection in patients with
Chandarana K. 6, Langer J. 6, Lastoria G. 7, Jaeckel E. 8 tumor induced osteomalacia. This approach could be particularly useful
San Raffaele Fondation Milane Italy1, Billings Clinic, Billings, MT, USA2, to prevent incomplete resection or in case of multifocality, which has been
University of Western Ontario, London, ON, Canada3. University Hospital recently described as a cause of surgical failure. In conclusion, the presence
Quiron Salud Madrid, Madrid, Spain4, UT Southwestern Medical Center, of a chronic hypophosphoremia should not be overlooked but must be
Dallas, TX, USA5, Novo Nordisk A/S, Soborg, Denmark6, NovoNordisk directed to the search for its etiology.
Medical Affairs Rome, Italy7,Hannover Medical School, Hannover, Germany8
Previous analyses of phase 3a trials (DUAL I extension; DUAL II) showed HIGHER INCIDENCE OF ARRHYTHMIAS IN PRIMARY
insulin degludec/liraglutide(IDegLira) is efficacious irrespective of baseline HYPERPARATHYROIDISM COMPARED TO CONTROLS
HbA1c. This post hoc analysis aimed to confirm thisobservation in additio- WITH TWENTY-FOUR HOUR ECG MONITORING
nal populations with type 2 diabetes uncontrolled on (i) a glucagon-likepep-
tide-1 receptor agonist (GLP-1RA) (DUAL III: IDegLira versus unchanged Pepe J., Curione M., Cipriani C., Baffa V., Colangelo L., Sonato C.,
GLP-1RA), (ii) sulfonylurea(SU) } metformin (DUAL IV: IDegLira versus Demafonti C., Vigna E., Biondi P., Minisola S.
placebo) or (iii) insulin glargine (IGlar) (DUAL V: IDegLira versus con- Department of internal medicine and medical disciplines, “Sapienza”,
tinued IGlar titration). IDegLira starting dose was 10 dose steps (1 dose University of Rome
step = 1 U IDeg + 0.036 mg Lira) in DUAL IV and 16 dose steps in DUAL
III and V; maximum IDegLira dose: 50 dose steps. Subjects were grouped Background: Hypercalcemia induces arrhythmias and shortening of the
according to baseline HbA1c; ≤7.5, >7.5–≤8.5 and >8.5%. In all trials a QT interval. The aim of this study was to investigate the occurrence of
higher baseline HbA1c resulted in greater HbA1c reductions. The change in arrhythmias in patients with primary hyperparathyroidism (PHPT), during
HbA1c was significantly greater with IDegLira vs. comparator in all baseline 24 hour ECG monitoring.
HbA1c groups with a similar treatment difference between baseline HbA1c Methods: Twenty-four PHPT postmenopausal women (age range 45-80
groups. In all trials for all baseline HbA1c groups, IDegLira decreased mean years) and twenty-four sex and age-matched controls underwent standard
HbA1c to <7% at end of trial. In DUAL V, the only trial to include patients ECG, 24 hour ECG monitoring and mineral metabolism biochemical eva-
with HbA1c >9% (mean 9.6%), HbA1cwas reduced to 6.9% with IDegLira luation. Exclusion criteria were: valvular disease, cardiac hypertrophy, pre-
vs. 7.8% with IGlar. In conclusion, significant HbA1creductions occur with vious history of arrhythmias, coronary artery disease, diabetes mellitus and
IDegLira regardless of baseline HbA1c group or study population. drugs that could interfere with cardiac conduction and mineral metabolism.
Patients with left bundle branch block, pacemaker carriers and patients
with ventricular pre-eccitation were also excluded. QT was corrected using
CHRONIC HYPOPHOSPHOREMIA: A BIOCHEMICAL Bazett’s formula (QTc). QT dispersion (QTd) wascalculated as the difference
RESULT OFTEN OVERLOOKED between the maximum and the minimum QT interval, respectively obtai-
ned in any of the 12 ECG leads.
Colangelo L. 1, Sonato C. 1, Cilli M. 1, Gianni W. 1, Danese V.C. 1, Pepe J. 1, Results: There were no differences concerning anthropometric parame-
Cipriani C. 1, Moreschini O. 2, Corsi A. 3, Minisola S. 1 ters between PHPT patients and controls. Prevalence of hypertension and
1
Dipartimento di Medicina Interna e Specialità Mediche, Policlinico dyslipidemia were similar between PHPT and controls (hypertension: 50 vs
Umberto I, Sapienza Università di Roma, 2 Dipartimento di Scienze 33.3%,dyslipidemia: 20.8 vs 16.6%). PHPT patients had mean higher total
Anatomiche, Istologiche, Medico Legale e dell’Apparato Locomotore, and ionized calcium and parathyroid hormone levels compared with con-
Sapienza Università di Roma, 3Dipartimento di Medicina Molecolare, trols (total calcium 10.87 ± 0.53 vs 9.40 ± 0.35 mg/dl, p < 0.0001, ionized
Policlinico Umberto I, Sapienza Università di Roma calcium 1.42 ± 0.10 vs 1.24 ± 0.03 mmol/L; parathyroid hormone 89.10
± 44.14 vs 44.7 ± 7.76 ng/L, p < 0.0001, respectively). PHPT patients had
A 33-year-old man with five years’ history of lumbar and pelvis pain with normal values of QTc, but significantly shorter compared with controls
multiple vertebral fractures was admitted to our hospital. His medical (400.25 ± 15.09 vs 409.75 ± 17.12 msec, p = 0.04). In PHPT patients, an
history begun with fatigue markedly worsened and diffuse muscle impair- increased occurrence of at least one supraventricular premature beats
ment which were associated with pain radiated down both legs. After a (SVPBs) during the 24 hour ECG monitoring compared with controlswas
previously examination by his physician, he was sent to a rheumatology observed (100% vs 75 %, p = 0.0001). Moreover, in PHPT patients SVPBs
division for further evaluation, where ankylosing spondylitis was diagno- often occurred in repeating patterns as couplets (62.5 vs 29.1%, p = 0.04),
sed and treated with anti-TNFa and with a low-moderate use of morphine. and triplets (20.8 vs 0 %, p = 0.04). Higher runs of more than four SVPBs,
On physical examination, he had severe kyphosis, proximal weakness with lasting less than 30 second, were also observed more frequently in PHPT
difficulties in performing daily activities. He was unable to walk without compared to controls (33.3 vs 8.3%, p = 0.03). The occurrence of ventricular
crutches. His previous laboratory results showed a chronic hypophospha- premature beats (VPBs) during 24 hour monitoring was also significantly
temia. To study the unexplained hypophosphatemia, we performed an higher in PHPT compared with controls (75% vs 29.1%, p = 0.003). In the
evaluation of blood sample for phosphorus and creatinine and, at the same PHPT group, serum ionized calcium level showed a negative correlation
time, a two-hour urine sample was collected for phosphaturia and creati- with QTc (r = - 0.49, p < 0.05) and a positive correlation with QTd (r = 0.46,
nuria to discriminate between the factors that reduced the plasma concen- p < 0.05).
tration of phosphorus. Nomogramm of Walton and Bijvoet helped to eva- Conclusions: The significant higher occurrence of SVPBs and VPB in
luate this data and showed low tubular reabsorption of phosphate (1,28 mg/ PHPT patients is mainly related to a short QTc and hypercalcemia, thus
dl) despite hypophosphatemia (1,2 mg/dl). X-linked Hypophosphataemic representing risk factors for arrhythmias.
rickets was excluded due to late onset age comparison, so we evaluated renal
phosphate wasting problem. Accordingly, osteomalacia caused by pho-
sphate wasting in the renal tubules was strongly suspected. The patient also LONG-TERM EFFECTIVENESS OF LIRAGLUTIDE FOR
exhibited high serum FGF23 levels (673 pg/ml, ELISA LIAISON, Diasorin, TREATMENT OF TYPE 2 DIABETES IN A REAL LIFE
Saluggia, Italy; n.v. <95 pg/ml), which suggested that a hidden tumor was SETTING: A 24-MONTH NON-INTERVENTIONAL,
secreting FGF23. Elevated values of bone alkaline phosphatase (58 mg/l; RETROSPECTIVE, MULTICENTRE STUDY IN ITALY
n.v. <17) and low-normal values of 1,25(OH)2D (26.2 ng/ml; n. v 20-67)
were also observed. A total body CT scan showed two suspicious areas in Simioni N. 1, Berra C. 2, Boemi M. 3, Bossi A.C. 4, Candido R. 5,
the head of the right femur and in the right tibia, although OctreosanTM Di Cianni G. 6, Frontoni S. 7, Genovese S. 8, Ponzani P. 9,
showed an increased uptake of the tracer only in the femur. First we decided Provenzano V. 10, Russo G. 11, Sciangula L. 12, Lapolla A. 1, Bette C. 14,
to remove the head femur lesion and perform intra-operative FGF23 assay Nicolucci A. 15 on behalf of the NN2211-4118 Study Group.
to confirm tumor resection; if this had been unsuccessfully, we would have 1
Presidio Ospedaliero di Cittadella, Padova, 2 Istituto Clinico Humanitas,
extended the operation to excise the second bone lesion. Basal, 10, 60 and Milan, 3 Ospedale INRCA, Ancona, 4 Ospedale Treviglio Caravaggio, 5
37
Ass 1 Triestina, Trieste, 6 Ospedale di Livorno, 7 Ospedale S.G Calibita of the left lung and a nodular lesion at the left adrenal gland. The lung
Fatebenefratelli, Rome, 8 Ospedale Multimedica, Sesto San Giovanni, 9 lesion was already known from 2011 and showed only a slight increase
Ospedale La Colletta, Arenzano, 10 Ospedale Civile di Partinico, Palermo, 11 in size compared with previous CT. A second radiological opinion was
Policlinico G Martino, Messina, 12 Ospedale Felice Villa, Mariano Comense, 13 required, indicating bilateral adrenal glands hypertrophy, excluding the
University of Padua, 14 Novo Nordisk, Rome, 15 COREsearch, Pescara left adrenal gland nodular lesion. We performed a lung lesion FNAC, with
the histological diagnosis of low grade neuroendocrine neoplasia. So,
Background and Aims: To evaluate the long-term effectiveness of liraglu- the patient underwent surgery to remove the lung lesion and the clinical
tide when used in real life clinical setting in Italy. status clearly improved. In conclusion, the radiologic findings, associated
Materials and Methods: The study population consisted in all consecutive with the medical history, laboratory, hormonal and cytological data, led us
patients with Type 2 Diabetes Mellitus (T2DM) aged ≥18 years, initiating to a proper diagnosis. Hence, the role of the internist, as the one capable
liraglutide in 2011 and followed in 45 diabetes clinics in Italy. The variables of putting the pieces in the right place in clinical problem-solving proce-
were collected for a 24-month period following liraglutide initiation. Conti- dures, is crucial in these rare and multiple organs disease, leading a team
nuous outcomes (HbA1c and weight) and categorical outcomes (reduction of specialists to diagnosis.
of at least 1.0%-point in HbA1c; achievement of HbA1c ≤7%; reduction of
at least 3% in body weight; reduction of at least 1.0%-point in HbA1c and
at least 3% in body weight) were analysed with hierarchical longitudinal IMPACT OF BMI ON HbA1c REDUCTION IN RESPONSE
models. TO IDEGLIRA IN SUBJECTS WITH TYPE 2 DIABETES
Results: Data on 1,723 patients were collected (mean age 58.9±9.5 years; (T2D) UNCONTROLLED ON SU, GLP-1RA OR INSULIN
54.9% were men; diabetes duration 9.6±7.1 years, HbA1c 8.3±1.4%, weight GLARGINE: ANALYSES FROM COMPLETED PHASE 3B
99.6±18.9 kg). Discontinuation rate at 24 months was 21.5%. The estima- TRIALS
ted proportion of patients achieving an HbA1c reduction ≥1%-point after
12 months (primary endpoint) was 43.5% (95% Confidence Interval [CI] S. Buscemi1, S. Harris 2, E. Jaeckel 3, E. Jodar 4, I. Lingvay 5,
40.9; 46.2). After 2 years, HbA1cwas reduced [estimated mean change from K. Chandarana 6, G. Lastoria 7, T. Abrahamsen8
baseline (95% CI)] by -0.78% (-0.84; -0.72; p<0.0001), body weight by -3.4 1
Università degli studi di Palermo, IT, 2 University of Western Ontario,
kg (-3.6; -3.1; p<0.0001), systolic blood pressure by -3.93 mmHg (-5.07; London, ON, Canada, 3Hannover Medical School, Hannover, Germany,4
-2.80; p<0.0001). At 24 months, an HbA1creduction of at least 1.0%-point University Hospital Quiron Salud Madrid, Madrid, Spain,5 UT Southwestern
was achieved by 41.5% (95% CI 38.7; 44.4) of patients while 40.9% (95% CI Medical Center, Dallas, 6Novo Nordisk A/S, Søborg, D, 7Novo Nordisk
38.1; 43.7) achieved HbA1c ≤7.0%. A body weight reduction of at least 3% Medical Affairs Rome,Italy, 7 Novo Nordisk A/S, Søborg, Denmark
was achieved by 54.0% (95% CI 51.1; 56.9) of patients and 25.5% (95% CI
23.0; 28.2) achieved an HbA1c reduction of ≥1%-point and a body weight Previous analyses of phase 3a trials (DUAL I extension; DUAL II) showed
reduction of ≥3% at 24 months. that insulin degludec/liraglutide. (IDegLira) is efficacious irrespective of
Conclusions: These findings underline that the beneficial results documen- baseline body mass index (BMI) category in subjects with T2D who are
ted in the liraglutide clinical development programme can be reproduced insulin naïve or uncontrolled on basal insulin. This post hoc analysis aimed
when liraglutide is used in T2DM patients in a real world setting in Italy. to confirm these findings in additional populations; T2D subjects uncon-
trolled on (i) glucagon-like peptide-1 receptor agonist (GLP-1 RA) (DUAL
III: IDegLira versus unchanged GLP-1 RA), (ii) sulfonylurea (SU) ± metfor-
THE DARK SIDE OF HYPOKALEMIA min (DUAL IV: IDegLira versus placebo) and (iii) insulin glargine (IG)
(DUAL V: IDegLira versus continued titration of IG from pre-trial dose).
Brunelli V., Caturano A., Pontillo G., Solaro E., De Sio C., Starting dose of IDegLira was 10 dose steps [1 dose step = 1 U IDeg + 0.036
Acierno C., Spiezia S., Giunta R., Adinolfi L.E. mg Lira] in DUAL IV and 16 dose steps in DUAL III and V; maximum
University of Campania “Luigi Vanvitelli”, Naples Division of Internal IDegLira dose: 50 dose steps for all trials. This analysis of 3 trials grouped
Medicine subjects by BMI category; <30, ≥30–<35 and ≥35 kg/m2. In all 3 trials,
change in HbA1c with IDegLira was similar between BMI groups. Change
In March 2017, a 58 year-old patient was referred to our institution in HbA1c was significantly greater with IDegLira versus comparator in all
because of asthenia, generalized malaise, insomnia and tachycardia. On BMI groups with a similar treatment difference between BMI groups (p=NS
admission, vital signs were: blood pressure 140/90 mmHg, heart rate 120 for all trials). This analysis confirmed IDegLira effectively reduced HbA1c
bpm and regular, 98% oxygen saturation in ambient air, respiratory rate 20 across all baseline BMI categories when used in subjects previously treated
breaths/min. The patient had a past history of glucose intolerance and of with SUs (as an add on), GLP-1 RA or IG (all ± other oral therapies).
sieronegative spondyloarthritis. In June 2016, the patient was hospitalized
at the department of endocrinology of our university for hypokalemia and
then discharged without a diagnostic definition of the electrolyte disorder. RISK RECLASSIFICATION ABILITY OF URIC ACID
At the objective examination acne, flushing of the upper chest, mild facial FOR CARDIOVASCULAR OUTCOMES IN ESSENTIAL
irsutism and fine tremors in the upper limbs were found. At the electro- HYPERTENSION
cardiogram, tachycardia and repolarization abnormalities, with elongated
t waves and presence of u waves were found; ABG revealed a severe meta- Perticone M. 1, Sciacqua A. 2, Tripepi G. 3, Miceli S. 4, Cimellaro A. 2, Pinto A.
bolic alkalosis and severe hypokalemia. Laboratory data showed diabetes
2
, Sesti G. 2, Perticone F. 2
mellitus (glucose 183 mg/dL) and confirmed severe hypokalemia (K 1.9
1
Dipartimento di Medicina Sperimentale e Clinica - Università degli
mEq/L). Previous hormonal examinations of the patient showed an incre- Studi Magna Graecia di Catanzaro 2Dipartimento di Scienze Mediche e
ase in ACTH (66 pg/ml) and cortisol (81.7 mcg/ml), and a reduction of Chirurgiche - Università degli Studi Magna Graecia di Catanzaro 3CNR-
renin (<0.5 mcU/ml in clinostatism and ortostatism) and aldosterone (13 IFC - Epidemiologia Clinica e Fisiopatologia delle Malattie Renali e
pg/ml in clinostatism and 25 pg/ml in ortostatism). The patient underwent dell’Ipertensione - Reggio Calabria 4Azienda Ospedaliero-Universitaria
basal hormonal exams that confirmed the increase of ACTH (86.1 pg/ml) “Mater Domini” - Catanzaro
and cortisol (41.5 mcg/dl) and the reduction of aldosterone and renin.
Considering that hypercortisolism could cause hypokalemia, we started to Hyperuricemia is associated with incident cardiovascular events in dif-
investigate about hypercortisolism. The patient underwent cerebral MRI ferent settings of patients. We tested whether the inclusion of uric acid
that showed aspecific gliotic alterations derived from hydro-electrolytic (UA) in Cox models including standard risk factors allows to better stra-
disequilibrium, in the absence of pituitary lesions, so a Cushing’s disease tify cardiovascular risk in a cohort of 1,522 naïve hypertensives with pre-
was excluded. Urinary electrolytes were normal, so tubulopathy was served renal function. We used multiple Cox regression models to assess
excluded. An 8 mg dexamethasone suppression test was done, confirming the independent effect of UA on cardiovascular outcomes, and Harrell’C
‘hypercortisolism’(basal cortisol 284 ng/ml, after DMX cortisol 295 ng/ index, Net Reclassification Index (NRI), and Integrated Discrimination
ml) and indicating that ACTH was not suppressed too (basal ACTH 131 Improvement (IDI) as indicators of the additional prognostic value of UA
pg/ml, after DMX ACTH 137 pg/ml), such as in Cushing’s syndrome. beyond and above that provided by standard risk factors and estimated
At the previous hospitalization, in June 2016, the patient underwent an glomerular filtration rate (e-GFR). Study outcomes were fatal and nonfatal
abdominal MRI, which showed a globular aspect of right adrenal gland. cardiovascular events and fatal and nonfatal coronary outcomes/death due
Hence, during the hospitalization in our facility, the patient performed a to other cardiovascular events. UA resulted strongly related to both outco-
total body CT that showed 30x35 mm nodular formation at the lower lobe mes in unadjusted Cox regression analyses (P<0.001). Inclusion of UA
38
into multiple Cox regression models including Framingham risk factors P=0.000), HF and age (r=0.216, P=0.019),and finally between night LF/
and e-GFR did not affect the association between UA and outcomes (fatal HF ratio and AHI (r=0.544, P=0.000), and SBP (r=0.181, P=0.042). In
and nonfatal cardiovascular events, HR=1.44, 95% CI=1.36-1.55, P<0.001; the multivariate model at T0, AHI resulted the strongest predictors of
fatal and nonfatal coronary outcomes/death due to other cardiovascular all nocturnal parameters SDNN, LF,HF and LF/HF, explaining about the
events, HR=1.48, 95% CI=1.36-1.61, P<0.001). Inclusion of UA into basic 15%, 20%, 21% and 29%(P=0.000), respectively of its variation. Linear
Cox models provided an increase in all indexes of prognostic accuracy regression analysis, performed at T6, demonstrated that there was a signi-
for both outcomes: Harrell’C index: +5%; NRI: +24.9%; IDI: +7.6%, all ficant and direct relationship between Δ of nocturnal LF,LF/HF and ΔAHI
P<0.001; and Harrell’C index: +5%; NRI: +25%; IDI: +6.3%, all P<0.001, (r=0.443 and r=0.528, P=0.000 respectively). An inverse relationship was
respectively. Our data demonstrate that UA is an independent predictor found, instead, between Δ of nocturnal HF and ΔAHI(r=-0.329, P=0.001).
of cardiovascular outcomes and increases prognostic accuracy of Cox In the multivariate model at T6, Δ AHI resulted the strongest predictors
models, including Framingham risk factors and e-GFR, in hypertensives of Δ of nocturnal LF,HF and LF/HF, explaining about the 19%(P=0.000),
with normal renal function, allowing a risk reclassification in this setting 10%(P=0.001) and 27% (P=0.000), respectively, of its variation after
of patients. 6 months of CPAP therapy. Our data demonstrate that in severe OSAS
patients treated by 6 months CPAP therapy, the reduction of AHI is an
independent and strong predictor of HRV improvement. Particularly, its
THE EFFECTS OF CONTINUOUS POSITIVE AIRWAY effects may be significantly related to decreased nocturnal sympathetic
PRESSURE (CPAP) THERAPY ON SYMPATHOVAGAL hyperactivity in these subjects.
BALANCE IN A GROUP OF SEVERE OSAS PATIENTS
Scarpino P. 1, Perticone M. 2, Sciacqua A. 1, Siriani F. 1, Settino C. 1, Filicetti ENDOTHELIAL DYSFUNCTION IN CHILDREN EXPOSED
E. 1, Sesti G. 1, Perticone F. 1 TO PASSIVE SMOKING: ROLE OF NADPH OXIDASE
1
Dipartimento di Scienze Mediche e Chirurgiche - Università degli Studi
Magna Graecia - Catanzaro 2Dipartimento di Medicina Sperimentale e Perri L. 1, Loffredo L. 1, Zicari A.M. .2, Duse M2, Occasi F. 2, Carnevale R. 1,
Clinica - Università degli Studi Magna Graecia - Catanzaro Battaglia S. 1, Novo M. 1, Del Ben M. 1, Angelico F. 1, Violi F. 1
1
Department of Internal Medicine and Medical Specialities, “Sapienza”
Obstructive sleep apnea syndrome (OSAS) is an independent predic- University of Rome, Rome, Italy 2Department of Pediatrics, “Sapienza”
tor of cardiovascular (CV) events and its pathogenesis recognizes both University of Rome, Rome, Italy
traditional and non-traditional risk factors. Of these, the sympathetic
hyperactivity is considered one of the major mechanisms involved in the Background: Passive smoking represents an important cause of cardiova-
development of CV disease in OSAS patients. Although the conservative scular diseases. Increased oxidative stress due to passive smoke can result
treatment of sleep apnea by nocturnal continuous positive airway pressure in cardiovascular damage through the onset of endothelial dysfunction.
(CPAP) is associated with improvement of heart rate variability (HRV), as NADPH oxidase activation has been recognized as the major reactive
index of sympathovagal balance, its effects are still unknown. The aim of oxygen species source and plays a pivotal role in modulating arterial tone in
this study was to evaluate the effect of CPAP on sympathovagal balance in humans. Until now, there aren’t studies that have explored NADPH oxidase
a group of severe OSAS patients after 6 months of therapy. We enrolled 92 activity in humans. Aim: To explore oxidative stress, the activity of NADPH
severe OSAS patients, 80 males and 12 females, mean age 56.5+12.3 years. oxidase isoform Nox2 and endothelial function in children exposed to
All patients underwent clinical examination, measurement of creatinine, passive smoking.
lipid profile, insulin resistance assessed by HOMA index, uric acid and Methods: One hundred and fourteen children were consecutively enrolled
high sensitivity C reactive protein (hs-CRP). We excluded patients with at outpatient Pediatric clinic of Sapienza University as part of routine clini-
atrial fibrillation (AF) or other cardiac arrhythmias, pacemaker rhythm, cal controls. A questionnaire, given to the parents of the children, identified
previous history of diabetes mellitus, chronic kidney and lung disease subjects exposed to passive smoking. Matched controls were selected such
and respiratory failure. Estimated glomerular filtration rate (e-GFR) was that the distribution of the age and of the relevant characteristics in this
determined by CKD-EPI equation. All patients underwent nocturnal group was similar to the distribution in the cases. A cross sectional study
cardiorespiratory monitoring (CRM) for the evaluation of the severity was performed to compare endothelial function, assessed by flow-mediated
of OSAS by the apnea-hypopnea index (AHI), the oxygen desaturation dilation (FMD), and oxidative stress, as assessed by blood levels of isopro-
index (ODI) and the percentage of time of saturation <90% (TC90). HRV stanes, soluble Nox2 (sNox2-dp), a marker of Nox2 activation, and serum
was assessed using 24-hour electrocardiographic monitoring. The stan- Nitric Oxide bioavailability, in children exposed (n=57, age: 9±3 years, 26
dard deviation of all normal to normal RR intervals (SDNN), the high females and 31 males) or not exposed (n=57, age: 9±3 years, 26 females and
and low frequency normalized powers (HF and LF) and its ratio (LF/HF) 31 males) to passive smoking. Urinary cotinine was assessed to evaluate the
were measured during 24 h and nocturnal period (from 12 p.m. to 6 a.m.). levels of exposition to nicotine.
Patients were prescribed with nocturnal CPAP treatment and were reeva- Results: compared to controls, serum sNox2-dp and isoprostanes were
luated after 6 months. All data were processed by statistic software SPSS higher in children exposed to passive smoking (26±9 vs 18±9 pg/mL,
16.0 for Windows. Significant differences were assumed to be at P<0.05. p<0.001 and 169±38 vs 150±34 pg/mL, p<0.001, respectively); conversely,
After 6 months of CPAP, OSAS patients presented significant differen- NO bioavailability and FMD were lower in children exposed to passive
ces (T6 vs T0) of: body mass index (BMI, Kg/m2 35.1+ 6.9 vs 36.4+ 7.6, smoke (59±11 vs 51±10 μM p<0.001, and 7.7±3 vs 6.1±3.6%, p<0.001,
P=0.006), waist (cm, 114.5+15.4 vs 117.3+17.1 P=0.009), AHI (5.0+2.5 respectively). A simple linear regression analysis showed that serum
vs 49.2+20.0, P=0.000), ODI (6.8+3.9 vs 27.1+17.4, P=0.000), TC90 (%, sNox2-dp correlated with FMD (Rs:-0.221, p=0.01), (Rs:-0.221, p=0.01), NO
16.6+5.7 vs 22.7+ 23.8, P=0.018), systolic blood pressure (SBP, mmHg, bioavailability (Rs:-0.547, p<0.001) and isoprostanes (Rs:-0.754, p<0.001).
126.7+ 12.0 vs 134.3+ 15.2, P= 0.000), heart rate (HR, bpm, 69.4+ 7.4 vs Conclusions: This study suggests that NOX2-derived oxidative stress is
76.4+ 7.3, P=0.000), 24h SDNN (ms, 127.8+ 28.6 vs 91.9+ 21.8, P=000), involved in artery dysfunction in children exposed to passive smoking.
nocturnal SDNN (ms, 113.6+ 26.8 vs 93.9+ 19.9 P=0.000), nocturnal LF
(n.u., 41.0+ 8.4 vs 56.7+ 15.9, P=0.000), nocturnal HF (n.u., 31.6+ 10.2 vs
26.9+ 7.9, P=0.001), nocturnal LF/HF ratio (1.4+0.6 vs 2.5+ 1.6, P=0.000), 1 HOUR POST LOAD PLASMA GLUCOSE LEVELS ARE
hs-CRP (mg/L, 3.3+2.0 vs 5.8+5.7, P=0.000), uric acid (mg/dL, 5.9+1.3 ASSOCIATED WITH A REDUCTION OF MYOCARDIAL
vs 6.6+1.5, P=0.002), total cholesterol (mg/dL, 172.3+31.5 vs 186.5+32.3, GLUCOSE UPTAKE, ESTIMATED THROUGH CARDIAC
P=0.003), LDL-cholesterol (mg/dL, 107.6+26.6 vs 127.3+29.3, P=0.000), 18F-FGD-PET SCAN
HDL-cholesterol (mg/dL, 46.7+8.9 vs 43.3+10.8, P=0.025), e-GFR (ml/
min/1,73m2, 106.7+20.1 vs 85.6+20.9, P=0.000), HOMA (4.2+2.2 Succurro E. 1, Pedace E. 1, Gangemi V. 2, Papa A. 2, Vizza P. 1,
vs 5.9+2.8, P=0.000). Linear regression analysis, performed at base- Veltri P. 1, Cascini G.L. 2, Sesti G. 1
line, demonstrated that there was a significant and inverse relationship 1
Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi
between all the following nocturnal parameters and different covariates: “Magna Graecia” di Catanzaro, Catanzaro, Italy 2 Dipartimento di
SDNN and age (ys, r=-0.175, P=0.048), AHI (r=-0.388, P=0.000), and SBP Medicina Sperimentale e Clinica, Università degli Studi “Magna Graecia” di
(r=-0.178, P=0.044); between HF and gender (r=-0.179,P=0.044) and AHI Catanzaro, Catanzaro, Italy
(r=-0.468, P=0.000); between LF/HF ratio and age (r=-0.216,P=0.019). On
the other hand, a direct relationship was found between nocturnal fol- Introduction: Increasing evidence suggests that in subjects with normal
lowing factors: SDNN and ODI (r=0.178, P=0.045), LF and AHI (r=0.448, glucose tolerance (NGT), a plasma glucose concentration >155 mg/dl at 1
39
h during an oral glucose tolerance test (OGTT) identifies subjects at incre- Discussion: in this population of elderly patients admitted for critical
ased risk for type 2 diabetes (T2DM) and an unfavorable cardiometabolic illnesses, CHA2DS2-VASc and HAS-BLED scores have a limited predictive
risk profile and organ damage. It is known that, as compared to non-diabe- value for both thromboembolic and haemorrhagic events. Newer approa-
tic individuals, subjects with T2DM and those with cardiovascular disease ches based on machine learning and topological data analysis could better
show a reduction of myocardial glucose uptake, considered a risk factor for discriminate the risk factors of NVAF-related complications and give a more
the development of the cardiovascular disease. However, it is yet unknown reliable prediction of thrombotic or haemorrhagic events.
whether NGT-1h-high subjects without history of cardiovascular disease
have alterations in myocardial glucose uptake. Aim: We evaluated myocar-
dial glucose uptake in subjects with different glucose tolerance states. B-TYPE NATRIURETIC PEPTIDE IS A PREDICTOR OF
Patients and Methods: We examined 15 subjects participating in the THIRTY-DAY MORTALITY AND THREE MONTH RE-
CATAnzaro MEtabolic RIsk factors (CATAMERI) study, a study conducted HOSPITALIZATION IN ELDERLY PATIENTS WITH AN
in a population at risk of T2DM for the presence of at least one risk factor ADMISSION DIAGNOSIS OTHER THAN HEART FAILURE
including family history for T2DM, overweight/obesity, hypertension, dysli-
pidemia and dysglycemia. Subjects with history of cardiovascular disease or Di Marca S. 1, Rando A. 1, Cataudella E. 1, Pulvirenti A. 2,
uncontrolled hypertension were excluded. All subjects underwent anthro- Alaimo S. 2, Terranova V. 1, Corriere T. 1, Pisano M. 1,
pometrical and biochemical evaluation, and OGTT. The myocardial vitality Di Quattro R. 1, Ronsisvalle M.L. 1, Giraffa C.M. 1, Giordano M. 3,
and glucose uptake (global MRGlu) were estimated through 18F-FGD PET Stancanelli B. 1, Malatino L. 1
combined with euglycemic hyperinsulinemic clamp. Euglycemic hyperinsu- 1
Unit of Internal Medicine, School of Emergency Medicine, Department of
linemic clamp study was performed to assess peripheral insulin sensitivity Clinical and Experimental Medicine, University of Catania, c/o Cannizzaro
normalized for lean body mass (Lean M) and to achieve a standardisation Hospital, Catania, Italy 2 Unit of Bioinformatics and Computer Science,
of metabolic and hormonal circumstances during PET. The 18F-FGD PET Department of Clinical and Experimental Medicine, University of Catania,
imaging procedure began after 1 h insulin infusion. The insulin-glucose Catania, Italy 3 School of Emergency Medicine, Department of Medical,
infusion continued throughout the PET imaging sequence, maintaining Surgical, Neurologic, Metabolic and Geriatric Sciences, Second University of
euglycemia by continuous adjustment to the glucose infusion rate according Naples, Naples, Italy
to the arterialized blood samples every 5 min. Subjects were divided into 3
groups: 1) 1-h post-load glucose <155 mg/dl (NGT-1h-low) (n=5), 2) NGT- Background: The diagnosis of heart failure (HF) in elderly patients is
1h-high (n=4), 3) impaired glucose tolerance IGT (n=6). often difficult because the typical clinical signs and symptoms may overlap
Results: Subjects with NGT 1h-high showed a significant increase in 2-h with those of comorbidities. Brain Natriuretic Peptide (BNP) is a reliable
glucose (p=0.004) and a reduction in HDL (p=0.001) as compared with predictor for diagnosis and prognosis of HF, but its role to predict short-
NGT 1h-low subjects. IGT subjects showed a significant increase in waist term prognosis in a cohort of elderly patients, with an admission diagnosis
circumference (p=0.03), and 2-h glucose (p<0.0001) compared to normal other than HF, was so far unexplored. Design Prospective clinical study,
subjects with 1h-low and a significant increase in 2-h glucose (p<0.0001) from September 2014 to December 2016. Setting Patients hospitalized in
and a reduction in HDL (p=0.01) than NGT 1h-high subjects, while there the Unit of Internal Medicine, University of Catania, Catania, Italy. Parti-
was no significant differences in other parameters assessed. Both individuals cipants We prospectively recruited 404 consecutive elderly patients (aged
with NGT-1h-high, and those with IGT exhibited a significant reduction in ≥ 65 years) with an admission diagnosis other than HF. Measurements Cli-
global MRGlu as compared with NGT-1h-low subjects (23.28 ± 5.89, 13.58 nical examination, laboratory data, comorbidities and BNP were evaluated
± 5.38 and 35.61 ± 12.73; respectively, p<0.05), while there was no signifi- at the admission. The predictive value for in-hospital mortality, thirty-day
cant difference in global MRGlu between NGT-1h-high and IGT subjects. mortality and three month re-hospitalization of BNP and other variables
In addition, there was a positive correlation (r = 0.586; p=0.022) between was assessed. Results During hospitalization 48 patients died (12%); in
Lean M and global MRGlu in all study subjects. these patients BNP value >600 pg/ml did not predict mortality (OR=1.36;
Conclusion: These results suggest that hyperglycaemia at the first hour CI95%:0.65-2.85;p=0.4), which was instead predicted by chronic kidney
during OGTT is associated with a reduction in myocardial glucose uptake, disease (CKD) (OR=4.02; CI95%:2.1-8.27;p<0.001) and age (OR=1.08;
a predictor of cardiovascular disease and heart failure. CI95%:1.00-1.16;p=0.012). After discharge, 54 patients died (15%) within
thirty days; in these patients BNP value >600 pg/ml (OR=2.70; CI95%:1.44-
5.05;p=0.001), CKD (OR=2.5; CI95%:1.65-3.92;p<0.001), age (OR=1.00;
CHA2DS2-VASC AND HAS-BLED SCORES IN THE CI95%:1.01-1.12;p=0.033) and malnutrition (OR=2.23; CI95%:1.08-
PREDICTION OF NVAF-RELATED EVENTS IN A 4.16;p=0.029) predicted thirty-day mortality. Re-hospitalized patients were
POPULATION OF CRITICALLY ILL PATIENTS 97 (32%); BNP value >600 pg/ml (OR=12.28; CI95%:6.05-24.93;p<0.001)
and anamnestic HF (OR=3.11; CI95%:1.513-6.44;p=0.002) predicted three
Falsetti L. 1, Rucco M. 2, Nitti C. 1, Gentili T. 1, Nobili L. 1, month re-hospitalization. Conclusions Our study shows that BNP value
Zaccone V. 1, Piersantelli M.N. 1, Salvi A.1 >600 pg/ml predicts short-term prognosis in elderly patients with an admis-
1
Internal and Subintensive Medicine, Ospedali Riuniti di Ancona; 2 sion diagnosis other than HF.
University of Camerino, School of Sciences and Technology, Computer
Science Division
AGEING AND FAT INFILTRATION IN MUSCLE AND
Background: non-valvular atrial fibrillation (NVAF) is the most common LIVER
arrhythmia in clinical practice. Its risk increases with age and the presence
of comorbidities. NVAF-related morbility is associated to thromboembolic Bertolotti M., Dondi G., Lancellotti G., Mussi C.
events and, among patients undergoing to anticoagulant therapy, to hae- Dipartimento di Scienze Biomediche, Metaboliche e Neuroscienze, Università
morrhagic complications. Guidelines suggest stratifying the thrombotic risk di Modena e Reggio Emilia UO di Geriatria, Azienda Ospedaliero-
with CHA2DS2-VASc score and the haemorrhagic risk with HAS-BLED Universitaria di Modena, Nuovo Ospedale Civile
score before initiating any anticoagulant treatment. These two scores share
several items, and it is common to observe patients with both an increased Introduction: The relationship between sarcopenia and non-alcoholic fatty
thrombotic and haemorrhagic risk. This area represents a “grey zone” where liver disease (NAFLD) is relevant, considering the increasing prevalence of
guidelines are not able to suggest any evidence-based approach. the manifestations of NAFLD and non-alcoholic steatohepatitis (NASH)
Patients and Methods: we enrolled 519 consecutive, critically-ill subjects worldwide, together with the overwhelming burden of aging-related con-
affected by permanent NVAF admitted to our Subintensive Medicine ditions such as sarcopenia (1). Such an association was described mainly in
department. CHA2DS2-VASc score and HAS-BLED score were calculated Eastern Asian populations (2,3).
at admission. For each patient, we evaluated age, sex, admission diagnosis, Methods: We completed an observational study in a cohort of 300 patients,
comorbidities, thromboembolic and haemorrhagic events. mostly of geriatric age (age 74.5±15.2 years, 167 males, 133 females), hospi-
Results: mean age was 75.61(±11.92) years; males represented 50.3% of the talized over a 12-month period. Fat infiltration in liver and in muscle were
sample; patients had a median of 2(0-6) comorbidities. We observed 38 hae- indirectly estimated by unenhanced spiral CT scan, by standardized analy-
morrhagic events and 80 thromboembolic events; HAS-BLED had a median sis of the attenuation coefficient (in Hounsfield Units) of pre-defined areas
of 2(0-5), CHA2-DS2-VASc score had a median of 3(0-6); CHA2DS2-VASc of the liver and of the multifidus muscle, according to previously validated
had an AUC of 0.56;95%CI:0.50-0:63(p=0.06); HAS-BLED had an AUC of procedures. The liver to spleen (L/S) ratio was calculated as an index of fat
0.53;95%CI:0.44-0:62(p=0.53). accumulation in the liver whereas the multifidus/ fat (MM/F) attenuation
40
ratio was regarded as an index of muscle infiltration (4). ITALY. IT IS TIME TO ABANDON EMPIRIC TREATMENTS
Results: Age was strongly correlated with the MM/F ratio (r = 0.623, p <
0.001); the correlation is consistent with an increase in muscular fat content Di Ciaula A. 1, Scaccianoce G. 2, Venerito M. 3, Zullo A. 4,
with ongoing age (4). Age also showed a positive association with the L/S Bonfrate L. 5, Rokkas T. 6, Portincasa P. 5
ratio (r = 0.118, p = 0.042); in this case, the finding suggests a reduction of 1
Division of Internal Medicine, Hospital of Bisceglie, Italy; 2Gastrointestinal
hepatic fat content with aging even if the correlation is much less stringent Endoscopy Unit, Ospedale della Murgia “F. Perinei”, Altamura, Italy;
and therefore of questionable clinical significance. Nonetheless, such obser- 3
Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-
vation is consistent with epidemiological evidence describing a reduction in von-Guericke University Hospital, Magdeburg, Germany; 4Gastroenterology
the prevalence of NAFLD with ongoing age (1,5). Simple linear regression Unit, Nuovo Regina Margherita Hospital, Rome, Italy; 5Clinica Medica “A.
analysis failed to disclose a significant correlation between the MM/F ratio Murri”, Department of Biomedical Sciences & Human Oncology, University
and the L/S index. However, considering the profound impact exerted by of Bari Medical School, Bari, Italy; 6Gastroenterology Clinic, Henry Dunant
age on these variables, we also performed partial correlation analysis with Hospital, Athens Greece;
age as the covariate; quite interestingly, with this analysis a significant asso-
ciation emerged (r = -0.134, p = 0.021). This negative association is indica- Background: Eradication rates following treatments for Helicobacter
tive of a direct relationship between the densitometric profiles and, indi- pylori (HP) infection strongly depend by several factors, including the
rectly, between the degree of fat infiltration in the two tissues. ongoing antibiotic resistance. We explored a “real life” scenario depicting
Conclusions: Our findings confirm the association between liver and enrolment criteria and treatment outcome in an heterogeneous group of
muscle fat infiltration in an older Western population, using a densitome- patients with HP-related problems. The outcomes of different approaches,
tric definition. Such an association suggests the presence of common patho- including the bismuth-based quadruple therapy (Pylera®), recently marke-
genic mechanisms in the two conditions, among which insulin resistance ted in Italy, were described.
might play a role. Prospective studies specifically designed for the elderly Methods: Two centers in Apulia studied 2,224 subjects living in an area
are welcome to confirm these hypotheses, and to provide further insight in with clarithromycin resistance >15%. Analyses included cause of referral,
the pathophysiology and management of geriatric pictures such as sarco- diagnostic techniques (13C-urea breath test –UBT- or upper endoscopy-
penia and frailty. References. 1. Bertolotti M, et al. Nonalcoholic fatty liver EGDS) and outcomes of prior- or prospective eradication regimens.
disease and aging: epidemiology to management. World J Gastroenterol. Results: Over 80% of patients (60% naïve) were referred by family phy-
2014; 20:14185-204. 2. Lee YH, et al. Relationship between sarcopenia sicians. Asymptomatic subjects more frequently referred for noninva-
and nonalcoholic fatty liver disease: the Korean Sarcopenic Obesity Study. sive UBT than for EGDS (30% vs. 2%, P<0.0001). Symptoms unrelated
Hepatology. 2014; 59:1772-8. 3. Koo BK, et al. Sarcopenia is an indepen- to H. pylori was the cause of referral in the 6% of patients, whereas 8%
dent risk factor for non-alcoholic steatohepatitis and significant fibrosis. J of referred subjects underwent UBT only due to a familial history of
Hepatol. 2017; 66:123-31. 4. Kitajima Y, et al. Age-related fat deposition in H. pylori infection. The overall infection rate was 32.5%, and similar in
multifidus muscle could be a marker for nonalcoholic fatty liver disease. patients asymptomatic (31.1%) or with HP-related symptoms/clinical
J Gastroenterol. 2010;45:218-24. 5. Lonardo A, et al. Fatty liver, carotid conditions (34.3%). The overall eradication rate (ER) in the 987 HP+ve
disease and gallstones: a study of age-related associations. World J Gastro- patients undergoing therapy was 80.2%, with a great variability according
enterol. 2006;12:5826-33. to therapeutic regimens performed outside of the referral centers or after
enrollment, with ERs ranking 59.6% (unconventional), 70.7% (7d-triple),
73.2% (undefined), 89% (10d-sequential) and 96.9% (10d-Pylera® across
ASSOCIATION BETWEEN PRIMARY EOSINOPHILIC 1st-5th line regimens). Minor side effects were recorded in 5% of patients
DISORDERS OF THE GASTROINTESTINAL TRACT AND on different eradication therapies.
DEFECTIVE SPLEEN FUNCTION Conclusions: (i) presence and characteristics of symptoms/clinical condi-
tions are not sufficient to discriminate subjects infected with H. pylori; (ii)
Di Sabatino A. 1, Aronico N. 1, Giuffrida P. 1, Cococcia S. 1, in a “real life” scenario, the use of heterogeneous approaches puts patients
Vincenzo Lenti M. 1, Vanoli A. 2, Arfini A. 1, Guerci M. 1, with H. Pylori infection at risk of poor eradication outcomes and unneces-
Di Stefano M. 1, Roberto Corazza G. 1 sary procedures; (iii) the novel bismuth-based quadruple treatment yield
1
First Department of Medicine and 2Department of Molecular Medicine, San the highest ERs as 1st-2nd line; (iv) although sequential treatment is still
Matteo Hospital Foundation, University of Pavia, Pavia, Italy effective as 1st-line regimen, concomitant 4-drug regimen (PPI, amoxicil-
lin, metronidazole, clarithromycin) will be prefered in a geographical area
Background and Aims: Splenic hypofunction is an acquired condition, with high clarithromycin resistance. Keywords: Guidelines, Helicobacter
accompanied or not by a reduction in spleen size, which may predispose to Pylori, Pylera
infections by encapsulated bacteria, autoimmunity, and thromboembolism.
Immune-mediated intestinal diseases are the most frequently reported con-
ditions associated with splenic hypofunction, including celiac disease and WEEKEND VERSUS WEEKDAY ADMISSION AND IN-
inflammatory bowel disease. We recently showed the first case of primary HOSPITAL MORTALITY FOR ACUTE ESOPHAGEAL
eosinophilic gastrointestinal disorder complicated by splenic hypofunction. VARICEAL HEMORRHAGE:
The aim of the study was to assess spleen function in a series of consecu- A 15-YEAR RETROSPECTIVE STUDY ON THE NATIONAL
tively enrolled patients affected by eosinophilic gastrointestinal disorders. HOSPITAL DATABASE OF ITALY
Methods: We enrolled 21 patients (mean age 43.7 years) affected by primary
eosinophilic gastrointestinal disorder (3 esophagitis, 1 gastritis, 8 gastroen- Politti U., Pala M., Gallerani M.
teritis, and 9 colitis). Twenty-two healthy volunteers (mean age 42.5 years, Dipartimento di Scienze Mediche, Azienda Ospedaliero-Universitaria,
range 26-61) and 18 splenectomized patients (mean age 43.1 years, range Ferrara, Italia
24-68) were used as negative and positive controls, respectively. Spleen fun-
ction was assessed by counting pitted red cells on peripheral blood. Previous studies have shown increased mortality for a number of medical
Results: Eighteen out of 21 eosinophilic gastrointestinal disorder patients and surgical conditions during weekend admissions, which is known as the
(85%) were hyposplenic. Pitted red cells were significantly higher (8.0%, “weekend effect”.
range 2.1-17.2) than that of healthy volunteers (1.9%, range 0.4-4.0, The aim of our study was to assess the association between weekday (WD)
p<0.0001). A positive correlation was found between pitted red cells, cir- or weekend (WE) admission and mortality for patients hospitalized with
culating eosinophils, and serum eosinophilic cationic protein. An 8-week acute esophageal variceal hemorrhage (AEVH). We analyzed routinely col-
treatment with corticosteroids (topical or systemic) significantly decreased lected hospital administrative data of all patients discharged with AEVH
pitted red cells (p<0.0005) in ten followed-up cases. demonstrated to the presence of ICD-9-CM codes of 456.0 “Esophageal
Conclusions: Splenic hypofunction should be investigated in patients with varices with bleeding”or 456.20 “ Esophageal varices in diseases classified
primary eosinophilic gastrointestinal disorders. Corticosteroid therapy was elsewhere” extracted from the Italian Health Ministry database (January
able to improve spleen function. 2001 to December 2015). The risk of in-hospital death was compared for
WE (including holydays) and WD admissions. In the period considered, a
total of 144,943 hospitalizations contained the coding of AEVHs, but only
EFFECTIVE TREATMENT OF H. PYLORI INFECTION BY 24,570 were hospitalized in urgency and the codes were in the primary or
THE NOVEL BISMUTH-BASED QUADRUPLE TREATMENT second diagnosis. Only these were included in the study. 17.852 (72.7%)
IN A LARGE COHORT OF PEOPLE LIVING IN SOUTHERN patients were admitted on WD and 6.718 (27.3%) on WE. In-hospital mor-
41
tality was slightly higher among patients under the WE (12.2 & vs 11.7) Hereditary Haemorrhagic Teleangiectasia (HHT), or Rendu-Osler-We-
across each study year when analyzed separately (Chi-squared = 1.402, P = ber syndrome. is an autosomal dominant vascular disorder, characterized
0.2365), but after adjustment for the above determinants, patients admitted by arterio-venous malformations (AVMs), affecting nasal mucosa, oral
on WE were not significantly increased risk of death during hospitaliza- cavity, skin and several internal organs (lung, liver, brain, GI tract). AVMs
tion. The mean length-of-stay (LOS) was not statistically different among entail a considerable risk of severe clinical complications. HHT is caused
patients hospitalized during the WE compared with WD, also for deceased by mutations in endoglin (ENG) and activine A typeII-receptor-like kinase
patients during hospital stay. Furthermore, significant differences in the 1 (ALK1/ACVRL1) genes, responsable for HHT1 and HHT2, respectively.
number of therapeutic diagnostic procedures performed were not detected The proteins encoded by ENG andALK1/ACVRL1 are involved in angioge-
among subjects with AEVH admitted during WE or WD. This study provi- nesis and vacular homeostasis regulation, through signalling transduction
des robust confirmation that, in Italy, hospitalization for AEVH on WE is of TGF-SMAD4 as principal downstream effector. as a confirmation of such
non associated with a significantly higher mortality rate than on WD. scenario, mutations in the SMAD4 gene, previously well acknowledged as
responsible for Juvenile Polyposis (JP), were reported to determine manife-
stations typical of both Combined Syndrome (JP/HHT). Only 80 JP/HHT
INTESTINAL PERMEABILITY IS INCREASED IN patients have been described thus far. While preemptive pulmonary scree-
PATIENTS WITH SYSTEMIC MASTOCYTOSIS WITHOUT ning complications associated to pulmonary guidelines, in light of poten-
GASTROINTESTINAL SYMPTOMS tially adverse complications associated to pulmonary AVMs in HHT1 and
HHT2, a protocol for instrumental screening still needs standardization
Di Stefano M. 1, Benedetti I. 1, Elena C. 2, Pesatori E.V. 1, for JP/HHT,a s more information regarding JP/HHT typical phenotypic
Manfredi G.F. 1, Grandi G. 1, Pagani E. 1, Merante S. 2, Cazzola M. 2, spectrum is required. Aim: To describe clinical pulmonary features of
Corazza G.R. 1 patients affected by Juvenile polyposis/hereditary hemorrhagic telangiecta-
1
Department of Internal Medicine and 2Department of Hematology, IRCCS sia (JP/HHT) syndrome and confirmed mutations in SMAD4 gene and to
“S.Matteo” Hospital Foundation, University of Pavia, Italy compare lung arterio-venous malformation (AVM) radiological features
with HHT1 and HHT2 patients.
Background: Systemic mastocytosis is a rare disease characterized by an Methods: The study was designed as a cross-sectional prospective survey.
abnormal proliferation of neoplastic mast cells infiltrating bone marrow Inclusion criteria: carrier of a SMAD4 mutation, completed clinical-instru-
and involving many organs. Gastrointestinal tract is frequently affected and mental screening. Phenotypic data of enrolled patients were then compared
abdominal pain, diarrhea, nausea, vomiting, bloating are caused due to a with HHT1 and HHT2 patients’ data. Clinical-instrumental protocol inclu-
direct effect of mast cell mediators. In other conditions, mast cell media- ded screening for pulmonary, hepatic and cerebral AVMs for all patients,
tors are responsible for functional gastrointestinal symptoms and intestinal independent from clinical symptoms, and upper and lower endoscopy
permeability alterations (Barbara G, Gastroenterology 2004). Therefore, (pancolonoscopy??) for JP/HHT patients only.
we measured intestinal permeability in a group of patients with systemic Results: A total of 5 SMAD4-mutated patients were recruited in the study.
mastocytosis.Patients and Methods A group of 8 patients (3 females, mean All of the 5 patients had pulmonary AVMs (PAVMs) and GI polyps. Silent
age 54 ± 18 yrs; range 20 – 77 yrs) affected by SM were enrolled. None of hepatic involvement was disclosed in 4/5 patients and brain AVMs in 0/5
them suffered from gastrointestinal symptoms. During the 3 days before the patients. Clinical overt manifestations secondary to PAVMs was reported by
test, the patients were instructed to avoid foods or beverages or drugs con- 4/5 patients, including hypoxaemia, digital clubbing, brain abscess/stroke.
taining lactulose and mannitol. The day of the test, after an overnight fast, Anatomical characteristics of HHT/JP, HHT1 and HHT2 PAVM-posi-
a solution containing 5 g of lactulose and 1 g of mannitol in water solution tive patients showed a trend towards more frequent bilateral involvement
was administered. Urine was collected over the next 6 h in plastic containers (16/22, 72%, 7/17(41%), and 4/5 (80.0%), respectively, p=0,09). HHT/
with 1 ml of 2% chlorhexidine solution, to prevent bacterial degradation JP patients had significantly higher prevalence of complex PAVMs, when
of sugars. A 20 ml urine sample was stored at -20°C until the assay. The compared to HHT1 and HHT2 patients (3/5, 60.0%, 2/22, 9%, and 0/17,
urinary excretion of the two sugars was measured and the lactulose and 0%, respectively, p<0.01), and of large (feeding artery >3 mm) PAVMs (4/5,
mannitol % excretion rate was calculated. Moreover, lactulose/mannitol % 80%, 12/22, 54.5%, 3/17, 17.6%, respectively, p<0.02). Aggressive GI polyp
excretion rate was calculated and a value >0.03 was considered as suggestive phenotype was observed as soon as in adolescence.
for altered intestinal permeability. Diamino-oxidase (DAO) and tryptase Conclusions: HHT/JP patients show a severe phenotype, mainly involving
circulating level were also determined by ELISA and FEIA, respectively. pulmonary AVMs and GI polyps, which require an appropriate instrumen-
Results: Both lactulose and mannitol excretion rates were suggestive of tal survey.
an alteration of intestinal permeability: mean lactulose excretion rate was
17.6±18,4% and mean mannitol excretion rate was 98.4±194.9%. L/M
excretion rate was >0.03 in all the patients. Mean serum DAO was 2 ± 1.5 U/
mL. Serum DAO levels were significantly correlated with lactulose % excre-
tion rate (r=0.61, p<0.05). Serum triptase levels were significantly correlated
with mannitol % excretion rate (r= 0.72, p<0.05).
Conclusion: In a group of patients with systemic mastocytosis without
gastrointestinal symptoms intestinal permeability is altered. This result sug-
gests that the effect of mast cell mediators, independently from mast cell
infiltration of gastrointestinal mucosa, could be responsible for subclinical
intestinal alterations.
SEVERE PULMONARY INVOLVEMENT OF SMAD4-

MUTATED PATIENTS WITH JUVENILE POLYPOSIS/
HEREDITARY HEMORRHAGIC TELANGIECTASIA
COMBINED SYNDROME
Lastella P. 1, Lenato G.M. 1, Suppressa P. 1, Resta N. 2, Bagnulo R. 2, Rizzi S. 3,

Marano 4, Pisani A. 3, Principi M.B. 3, Scardapane A. 4,
Di Leo A. 3, Sabbà C. 1
1
HHT Interdepartmental Center, Centro Sovraziendale per le Malattie Rare,
“Frugoni” Internal Medicine Unit, Policlinico Hospital, University of Bari
“Aldo Moro”, Bari, Italy 2 Medical Genetics Unit, HHT Interdepartmental
Center, Policlinico Hospital -University of Bari “Aldo Moro”, Italy 3
Gastroenterology Unit, HHT Interdepartmental Center, Policlinico
Hospital -University of Bari “Aldo Moro”, Italy 4 Radiology Unit, HHT
Interdepartmental Center, Policlinico Hospital -University of Bari “Aldo
Moro”, Italy
42
118° Congresso Orali
Comunicazioni Nazionale - Società Italiana di Medicina Interna 118° Congresso Nazionale - Società ItalianaComunicazioni
di Medicina Interna
Orali
COMUNICAZIONI ORALI ned for the risk of false positive diagnosis in case of cholangiocarcinoma
(CC). The American College of Radiology (ACR) – Liver Imaging Repor-
ting and Data System (LI-RADS) for CEUS is a recently released (Sep-
tember 2016) algorithm developed by a working group of American and
29 OTTOBRE 2017 international experts that, on the basis of CEUS patterns of liver nodules
in patients with cirrhosis, categorizes nodules in different classes of risk
of HCC and accounts for the characteristics differentiating HCC from CC
SUSTAINED VIROLOGICAL RESPONSE BY DIRECT based on timing and intensity of contrast changes. Accordingly, the hepatic
ANTIVIRAL AGENTS IN HCV LEADS TO AN EARLY AND lesions are subgrouped in different classes of risk of being HCC: LR-1 (defi-
SIGNIFICANT IMPROVEMENT OF LIVER FIBROSIS nitely benign), LR-2 (probably benign), LR-3 (intermediate probability for
HCC), LR-4 (probably HCC), LR-5 (definitely HCC) and LR-M (probable
Aglitti A. 1, Masarone M. 1, Rosato V. 2, Precone D.F. 3, malignancy not specific for HCC). Aim of the present study was 1) to eva-
Corrado M. 4, De Luna A. 5, Morisco F. 6, Camera S. 6, luate the CEUS LI-RADS diagnostic accuracy of LR-5 for definitely HCC
Federico A. 7, Dallio M. 7, Claar E. 8, Caporaso N. 6, Persico M. 1 and LR-M as probable malignancy not specific for HCC and 2) to evaluate
1
Internal Medicine and Hepatology Division, Department of Medicine the rate of HCC in LR-3 and LR-4 classes.
and Surgery, University of Salerno, Salerno, Italy; 1Internal Medicine and Methods: A total of 1006 nodules in 848 patients with cirrhosis at risk for
Hepatology Department, University of Campania “Luigi Vanvitelli”, Naples, HCC collected in 5 Italian centers (Bologna, Milano, Pavia, Roma, Palermo)
Italy; 3Internal Medicine Department, Martiri di Villa Malta Hospital, were retrospectively analyzed. For the whole liver nodules a complete CEUS
Sarno, Salerno, Italy; 4Infectious Diseases Department, Umberto I Hospital, pattern was available together with an accepted diagnostic method accor-
Nocera Inferiore, Salerno, Italy; 5Drug Addictions Unit, ASL Salerno DS65, ding to noninvasive criteria reported by AASLD guidelines (CT/MRI if
Salerno, Italy; 6Gastroenterology Unit, Department of Clinical Medicine and typical HCC or histology if CT/MRI were inconclusive) performed within
Surgery, Federico II University, Naples, Italy; 7Department of Clinical and 12 weeks from the index CEUS. Patients with inconclusive CT/MRI fin-
Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, dings and unsuitable for biopsy or with inconclusive histology pattern were
Italy; 8Internal Medicine Department, Hepatology Unit, Ospedale Evangelico excluded from the present analysis. Arterial phase hyperenhancement was
Villa Betania, Naples, Italy classified within the LR-3, -4 and -5 classes when the lesion became hypere-
choic in the arterial phase provided it was not globular or rim enhancement
Introduction: Direct Antiviral Agents (DAA) demonstrated high efficacy (otherwise could be LR-1 or LR-M respectively). “Washout” occurrence
among HCV-infected patients in registered trials. Nevertheless, the impact was defined when the lesion became hypoenhanced compared to the sur-
of these therapies on liver stiffness measurement (LSM) and liver functio- rounding parenchyma in the portal-venous phase. When the washout took
nality in “real-life” is not well-known. Aims: to evaluate the SVR impact place it was further classified as “early” if it appeared before 60 seconds after
on LSM and clinical parameters of DAA-therapy on a real-life population contrast injection (otherwise defined “late”) and “marked” when the lesion
of HCV patients with F3/F4 fibrosis. Patients and methods: 749 HCV became echofree or punched out (otherwise defined as “mild”) within 2
genotype 1-4 patients with F3/F4 hepatitis undergoing DAA antiviral minutes. Nodules with arterial phase hyperenhancement and late washout
therapy for HCV, were consecutively enrolled in four centers of Hepatology (onset ≥60 seconds after contrast injection) of mild degree were classified
of Italy. Clinical, biochemical and imaging data were collected at the base- as LR-5. Rim enhancement and/or early and/or marked washout quali-
line (T0), at the End of Therapy (EoT) and after 12 weeks (SVR12). Results: fied lesions as LR-M (malignant, but not specific for HCC). Other combi-
Out of 749 patients, 69.7% was F4 and 30.3% was F3. SVR12 was reached nations qualified lesions at intermediate risk for HCC (LR-3) or probable
in 97,5%. LSM significantly decreased from T0 to EoT(p<0.001) whereas it HCC (LR-4). Diagnostic reference standard was CT/MRI diagnosis of HCC
did not from EoT to SVR12 (p:ns). Moreover, in F4 no significant differen- (=534) or histology (n=472).
ces were found in Child and MELD between T0, EoT and SVR12(p=ns). Results: Median size was 2 cm. Of 1006 nodules, HCC were 820 (81%),
At the univariate analysis of clinical and liver parameters, baseline high cholangiocarcinoma 40 (4%), regenerative nodules (±dysplastic) 116 (11%).
Glucose (p<0.005), Type 2 Diabetes (p<0.001), low ALT (p<0.001), low When compared to the AASLD hallmark pattern for the diagnosis of HCC,
PLTs (p<0.005), and the presence of esophageal varices (EV) (p<0.001) were the LR-5 pattern provides higher PPV (98.5% vs. 94%) with only a negli-
found to be associated with a lack of a significant EoT LSM improvement. gible decrease in sensitivity (62% vs. 67%) and no risk of misdiagnosis for
At a multiple regression, low ALT at baseline (p<0.05), Diabetes (p<0.005) pure cholangiocarcinoma. All LR-M nodules were malignant, the majority
and EV (p<0.05), were inversely associated with significant LSM reduction. of non hepatocellular origin. Over 75% cholangiocarcinomas were LR-M.
Conclusions: Virological response to DAA is associated with fibrosis The risk of having HCC increased from LR-3 to LR-5. In particular, the
regression and recovery of liver functionality and this can be detected as LR-3 category included 203 lesions (HCC 96=47%) and the LR-4 202 (HCC
early as EoT. HCV eradication is associated with a rapid and significant cli- 173=87%).
nical improvement that lasts overtime and seems to be negatively influenced Conclusions: CEUS LI-RADS classes are effective in predicting the risk of
by diabetes and esophageal varices. HCC with LR-5 class definitely diagnostic for HCC and practically no risk
of misdiagnosis for CC. The present algorithm provides evidence for using
CEUS for an accurate diagnosis of HCC and for guiding the diagnostic
CONTRAST ULTRASOUND LI-RADS LR-5 IDENTIFIES approach of “atypical” nodules, all of which remain at relatively significant
HEPATOCELLULAR CARCINOMA IN CIRRHOSIS. risk of HCC (>50% if LR-3 or LR-4) requiring histological confirmation
MULTICENTER RETROSPECTIVE STUDY OF 1006 whenever possible.
NODULES
Terzi E. 1, Iavarone M. 2, Pompili M. 3, Veronese L. 4, Cabibbo G. 5, Fraquelli ASSESSMENT OF SEPSIS-3 CRITERIA IN PATIENTS WITH
M. 6, Riccardi L. 3, De Bonis L. 1, Sangiovanni A. 2, CIRRHOSIS AND BACTERIAL INFECTIONS
Leoni S. 1, Zocco M.A. 3, Rossi S. 4, Alessi N. 5, Wilson S.R. 7, Piscaglia F. 1
1
Department of Medical and Surgical Sciences, Division of Internal Medicine, Piano S.,1, Bartoletti M. 2, Tonon M. 1, Baldassarre M. 2,
Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy 2A.M. Chies G. 1, Romano A. 1, Viale P. 2, Vettore E. 1, Domenicali M. 2, Stanco M. 1,
& A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Pilutti C. 1, Frigo A.C. 3, Brocca A. 1, Bernardi M. 2,
Hepatology, Fondazione IRCCS Ca’ Granda Maggiore Hospital, University Caraceni P. 2, Angeli P. 1
of Milan, Milan, Italy 3Internal Medicine, Gastroenterology and Hepatology, 1
Department of Medicine – DIMED, University of Padova, Italy 2
Gemelli Hospital, University of Rome, Rome, Italy 4Department of Internal Department of Medical and Surgical Sciences, Alma Mater Studiorum
Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, University of Bologna, Bologna, Italy 3Department of Cardiac, Thoracic and
Pavia, Italy 5Section of Gastroenterology, Biomedical Department of Internal Vascular Sciences, University of Padova, Italy
and Specialized Medicine (Di.Bi.M.I.S.), University of Palermo, Palermo,
Italy 6Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca’ Introduction: Patients with cirrhosis have a high risk of sepsis, which
Granda Maggiore Hospital, University of Milan, Milan, Italy 7Radiology and confers a poor prognosis. SIRS criteria have several limitations in cirrho-
Medicine, Division of Gastroenterology, University of Calgary, Canada sis. Recently, new criteria for sepsis (Sepsis-3) have been suggested in the
general population (increase of Sequential Organ Failure Assessment[-
Background & Aims: The use of contrast enhanced ultrasound (CEUS) for SOFA]≥2 points from baseline). Outside the ICU, the quick SOFA (qSOFA
the diagnosis of hepatocellular carcinoma (HCC) in cirrhosis was questio- [at least 2 among: alteration in mental status, systolic blood pressure≤100
43 43
mmHg, or respiratory rate≥22/min]) was suggested to screen for sepsis. ment is strongly suggested to increase the chances of virological and clinical
These criteria have never been evaluated in cirrhotic patients. The aim of the success. QoL analysis showed, for the first time, that, among HCV patients,
study was to assess the ability of Sepsis-3 criteria in predicting in-hospital those with CV have a worse QoL. DAAs were effective in increasing QoL
mortality in patients with cirrhosis and bacterial/fungal infections. scores in all the HCV patients, which is now considered an important goal
Methods: 259 consecutive patients with cirrhosis and bacterial/fungal of therapy with an impact on CV indirect costs.
infections were prospectively included. Demographic, laboratory, and
microbiological data were collected at diagnosis of infection. Baseline SOFA
was assessed using preadmission data. Patients were followed-up until NEW DIRECT ANTIVIRAL AGENTS (DAAS) FOR
death, liver transplantation, or discharge. Findings were externally valida- CHRONIC HCV INFECTION AND ARTERIAL STIFFNESS
ted (197 patients).
Results: The most common infections were urinary tract infection (33%), Perticone M. 1, Caroleo B. 2, Sciacqua A. 3, Suraci E. 3,
SBP (23%) and pneumonia (14%). SIRS, qSOFA and sepsis-3 criteria were Colangelo L. 3, Bencardino G. 3, Miceli S. 2, Tramontano A. 4,
found in 34, 23 and 64% of patients, respectively. During the hospitaliza- Sesti G. 3, Perticone F. 3
tion 19% of patients died. Sepsis-3 and qSOFA had significantly greater 1
discrimination for in-hospital mortality (AUROC=0.784 and 0.732, Magna Graecia di Catanzaro 2 Azienda Ospedaliero-Universitaria “Mater
respectively) than SIRS (AUROC=0.606;p<0.01 for both). Similar results Domini” - Catanzaro 3 Dipartimento di Scienze Mediche e Chirurgiche -
were observed in the validation cohort. Sepsis-3 (OR=5.71;p=0.007), Università degli Studi Magna Graecia di Catanzaro 4 Università Federico
qSOFA (OR=3.11;p=0.004),CLIF-C-AD score (OR=1.05;p=0.007),C-re- II - Napoli
active protein (OR=1.62;p=0.014) and nosocomial infections
(OR=2.15;p=0.058),were found to be independent predictors of in-hospital Abnormal arterial stiffness is associated with an increased risk for various
mortality. Patients with Sepsis-3 had higher incidence of acute-on-chronic adverse outcomes, including cardiovascular disease, stroke, and renal diseas.
liver failure (36 vs 11%; p<0.001), septic shock (15 vs 0%; p<0.001) and tran- Furthermore, arterial stiffness is associated with traditional cardiovascular
sfer to the ICU (16 vs 2%; p=0.001) than those without Sepsis-3. risk factors and metabolic alterations including obesity, impaired glucose
Conclusions: Sepsis-3 criteria are more accurate than SIRS criteria in pre- tolerance, and dyslipidemia. In addition, it reflects the structural arterial
dicting the severity of infections in patients with cirrhosis. qSOFA is a useful wall modifications, characterizing the vascular aging. The most reliable
bedside tool to assess risk for worse outcomes in these patients. Patients method to assess arterial stiffness is through pulse wave velocity (PWV)
with Sepsis-3 and positive qSOFA deserve more intensive management and measurement. There are several evidences demonstrating that patients
strict surveillance. with chronic hepatitis C virus (HCV) infection (HCV+) have an increased
cardiovascular morbidity and mortality. These evidences have a biological
plausibility because HCV+ patients are insulin resistant as consequence of
EFFECTS OF IFN-FREE TREATMENT ON THE direct and indirect mechanisms, leading to both hepatic and extrahepatic
VIROLOGICAL, CLINICAL, IMMUNOLOGICAL insulin-resistance. However, this mechanism do not fully justify the higher
RESPONSE, AND QUALITY- OF- LIFE IN PATIENTS cardiovascular risk of these patients. In the last few years, the new direct
WITH HCV-RELATED MIXED CRYOGLOBULINEMIA: A antiviral agents (DAAs) for the treatment of HCV infection demonstrated
PROSPECTIVE AND CONTROLLED STUDY to induce a sustained viral eradication, thus contributing to minimize the
extrahepatic effects of HCV. We designed the present study to evaluate the
Cerretelli G., Gragnani L., Lorini S., Steidl C., Petraccia L., Sadalla S., effect of DAAs treatment on AS in a population of patients with chronic
Monti M., Caini P., Xheka A., Simone A., Carradori E., Arena U., Laffi G., HCV infection. We enrolled 113 (55 M and 58 F, mean age 67,3 ± 10,2 years)
Zignego A.L. patients with chronic HCV infection, eligible for treatment with DAAs.
Interdepartmental Center MaSVE, Department of Experimental and Clinical Patients were divided into four subgroups according with the presence of
Medicine, University of Florence, Florence, Italy arterial hypertension and type 2 diabetes mellitus (T2DM): patients without
hypertension and/or T2DM (Group 1; n= 57, mean age 63,9 ± 12,2 yrs);
Background: Antiviral therapy is the first therapeutic option for HCV hypertensives (Group 2; n= 24, mean age 69,5 ± 6,2 yrs); diabetics (Group
cryoglobulinemic vasculitis (CV). CV manifestations could be severe and 3; n= 13, mean age 70,5 ± 5,9 yrs); patients with both hypertension and
may compromise the patient’s quality of life (QoL). IFN-based therapy was T2DM (Group 4; n= 19, mean age 72,9 ± 6,8 yrs). All patients underwent
associated with side effects and lower virological response in CV+ than in clinical and laboratory evaluation at baseline, at the end of treatment (12
CV- patients. Limited data suggest that in CV patients, DAAs are safe and or 24 weeks, depending on the treatment regimen), and at 6 months after
associated with high rates of response (virological/clinical/immunological). the end of treatment. Laboratory determinations included: qualitative and
We aimed to perform, for the first time, a prospective and controlled study quantitative HCV-RNA, complete blood count, serum creatinine, e-GFR,
on the effects of DAAs on HCV patients with cryoglobulinemia and vasculi- total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride, fasting
tis (CV), without vasculitis (MC), and without cryoglobulinemia (controls: plasma glucose, fasting plasma insulin, HOMA-index). Data are expressed
HCV-Ctr). as mean value + SD and as % when appropriate. Statistical analyses were
Methods: Patients underwent standard DAA IFN-free regimens. Hepa- conducted using T-test for paired data, chi-square test for nominal data,
to-virological data, virological and clinical response, DAAs safety and the linear regression analysis, stepwise multiple regression analysis. In the
impact on QoL were evaluated. Immunological response (cryocrit, RF and whole study population, 6 months after the end of treatment with DAAs,
C4 values) were recorded together with CV symptoms in cryoglobuline- PWV decreased from 9,04 + 1,96 to 8,04 + 1,61 m/s (P<0.0001); similar
mic patients. The Short Form Health Survey 36 (SF-36) questionnaire was results were obtained when considering the four study group, except for
administered to obtain a physical component summary (PCS) and a mental Group 4, in which there were no significant differences between PWV
component summary (MCS). values evaluated at baseline and 6 months after the end of treatment. Of
Results: 182 HCV patients were consecutively treated. Following an ITT interest, when considering biochemical parameters, we observed an impro-
analysis, 91,2% (166/182) patients (41/43 HCV-ctr, 48/54 CM, 77/85 CV) vement in eGFR in the whole study population before and 6 months after
achieved SVR12 and SVR24. In CV SVR patients, the clinical response pro- treatment (90,4 + 1 vs 96,8 + 16,7 ml/min/1,73 m2; P<0.0001), as well as
gressively increased and at SVR24 was “full complete” (disappearance of an improvement in insulin resistance evaluated through HOMA index (5,1
all symptoms) in 25%, “complete” (improvement of all symptoms) in 60%, + 3,0 vs 3,5 + 1,08; P<0.0001). When considering the four study groups
“partial” (improvement of more than 50% of symptoms) in 11.7%. Cryo- separately, eGFR improvement before and 6 months after treatment resulted
crit levels progressively decreased from baseline to SVR24 in CM and CV statistically significant only in Groups 1 and 2, while HOMA index resulted
patients. Regarding QoL, the PCS values at baseline were lower in the CV significantly reduced in all groups except that in Group 3. The findings of
group compared to the other two groups (p<0.05). For all the groups, the this study demonstrate that HCV eradication through DAAs has important
scores improved during follow-up. Adverse events, generally mild and well extra-hepatic effects, in particular when considering cardio-metabolic para-
tolerated, occurred in 99/182 (54.4%) patients. meters, thus allowing to modify the cardiovascular risk of this patients.
Conclusions: Our data confirm the high virological, clinical and immuno-
logical success rates of DAAs in HCV-related cryoglobulinemia. Due to the
high SVR rates, no significant differences were scored between cryo+ and
cryo-. However, the majority of patients who discontinued therapy or relap-
sed had cryoglobulinemia. Similarly, patients with more severe CV belon-
ged to clinical “partial” and “non-response” groups. Therefore, early treat-
44
EFFICACY AND SAFETY OF NEW DIRECT ANTIVIRAL cally affects an HHT patient in geriatric age, interaction between chronic
AGENTS IN HCV INFECTED PATIENTS WITH DIFFUSE anemia and atrial fibrillation (AF) seems to entail a considerable risk in this
LARGE B CELL NON-HODGKIN LYMPHOMA population, as relative contraindication has been reported for anticoagu-
lation AF therapy, in light of the underlying bleeding phenotype. Moreo-
Masarone M. 1, Aglitti A. 1, Caruso R. 1, De Renzo A. 2, Selleri C. 3, Califano ver, anemia and/or significant HAVMs have been hypothesized as AF risk
C. 4, Abenavoli L. 5, Federico A. 6, Persico M. 1 factors in geriatric HHT patients, due to haemodynamic derangement wor-
1
Internal Medicine and Hepatology Unit, University of Salerno, Salerno, sening, and subsequent atrial enlargement and/or remodelling.AIM: We
Italy; 2 Hematology Department, Federico Secondo University of Naples, aimed to carry out an overview of HHT phenotype in geriatric age, to gain
Italy; 3Hematology Unit, University of Salerno, Salerno, Italy; 4Hematology insight into potential correlations between cardiac arrhythmias and hyper-
Department, Umberto I Hospital, Nocera Inferiore (Salerno), Italy; dynamic state secondary to HAVMs, or other HHT-related manifestations,
5
Department of Health Sciences, University Magna Græcia, Catanzaro, Italy; geriatric HHT patients.
6
Hepatogastroenterology Division, University of Campania “Luigi Vanvitelli; Methods: The study was designed as a retrospective cohort study of geriatric
Naples, Italy patients with confirmed HHT. Inclusion criteria: i) full clinical-instrumen-
tal evaluation ii) age ≥65 yrs at initial screening or subsequent monitoring.
Introduction: The association of HCV with Non-Hodgkin Lymphoma Hepatic screening: Echo-Color Doppler examination, Multi-Slice Compu-
(NHL) has been demonstrated all over the world. The new interferon-free, ted Tomography, biohumoral functional analysis. Heart rate abnormalities
direct antiviral agents (DAA), showed high efficacy and safety in HCV were investigated by basic electrocardiography.
patients, and preliminary data seem to confirm their activity on low-grade Results: A total of 76 patients were included in the study (mean age
NHL in HCV infected patients. The question arises as whether or not -and 70.04±4.22 yrs). Chronic anemia was present in 52/76 patients (68.4%).
how- to treat the HCV positive patients suffering from diffuse large B cell Geriatric patients had a higher prevalence of hepatic AVMs and a reduced
lymphomas(DLBCL). Aim of this observational study was to evaluate prevalence of pulmonary and brain AVMs if compared to the global pre-
whether the DAAs antiviral treatment of DLBCL/HCV-infected patients in valence of our cohort. Signs of chronic atrial fibrillation were detected in
concomitance with chemotherapy is a safe and effective option. 11/76 (14.4%) patients. Hepatic examination disclosed more severe haemo-
Methods: 20 (13 males and 7 females), HCV1b positive subjects, undergoing dynamic alterations, as well as significantly higher γ-GT and Alkaline Pho-
chemotherapy for DLBCL, were enrolled between June 2015 and Decem- sphatase levels, and significantly more serious anoemia, in AF vs. non-AF
ber 2015. After informed consent, all the patients underwent to antiviral patients. Multiple logistic regression analysis disclosed γ-GT levels as the
therapy with sofosbuvir/ledipasvir and chemotherapy (19 R-CHOP and 1 only significant variable contributing to AF onset.
CHOP) for DLBCL. Complete hematological (Revised European American Conclusions: Geriatric age in HHT entails a significant association between
Lymphoma - REAL - classification, Ann-Arbor staging, and International HAVM-related subclinical haemodynamic alterations and AF risk, with
Prognostic Index - IPI) and hepatological (viral markers, liver stiffness and γ-GT levels representing a potential predictor of AF onset.
biochemical parameters) evaluations were made. A historical retrospective
cohort of 101 DLBCL/HCV positive patients not undergone to antiviral tre-
atment was enrolled for comparison. 4-AT DELIRIUM SCREENING TOOL IS SIGNIFICANTLY
Results: DAA-treated and untreated patients were similar for sex distri- CORRELATED WITH ROCKWOOD CLINICAL FRAILTY
bution, IPI score and NHL stage, and differed for age (older in treated), SCALE IN OLDER MULTIMORBID PATIENTS ADMITTED
chemotherapy and use of antiviral therapy. Overall-survival (OS) and dise- TO HOSPITAL WITH INFECTION
ase-free-survival (DFS) were evaluated among a 52 weeks of follow-up. No
statistical difference was found in OS after 52 weeks (p:0.122), whereas a Lauretani F. 1, Ticinesi A. 1, Bastoni D. 2, Calamai S. 2,
statistically significant higher DFS was achieved in treated patients(p:0.036). Catalano L. 2, Catania P. 2, Cecchia M. 2, Cerundolo N. 2,
At the multivariate analysis, only IPI score and DAA were independently Galluzzo C. 2, Giovini M. 2, Mori G. 2, Zani MD. 2, Ciani L. 3,
correlated with a better DFS. No differences in adverse events were reported. Nouvenne A. 1, Maggio M. 1, Meschi T. 1
Conclusions: DAA-treatment in concomitance with chemotherapy showed 1
Dipartimento di Medicina e Chirurgia, Università di Parma - Dipartimento
to be safe and effective in influencing the remission of aggressive lympho- Medico-Geriatrico-Riabilitativo, Azienda Ospedaliero-Universitaria di
mas in HCV patients. Parma; 2Scuola di Specializzazione in Medicina d’Emergenza-Urgenza,
Dipartimento di Medicina e Chirurgia, Università di Parma; 3Dipartimento
di Medicina e Chirurgia, Università di Parma
HEPATIC INVOLVEMENT AND ATRIAL FIBRILLATION
IN GERIATRIC PATIENTS WITH HEREDITARY Background: 4-AT is a rapid instrument for delirium assessment in hospi-
HAEMORRHAGIC TELANGIECTASIA tal practice. It includes four items exploring the patient’s alertness, spatial
and temporal orientation, attention, and acute change or fluctuating clinical
Suppressa P. 1, Valerio R. 1, Lenato G.M. 1, Lastella P. 1, Fasano D. 1, De course. It is validated for the diagnosis of acute delirium in older patients,
Vincenzo G. 1, Buonamico P. 2, Scardapane A. 3, Sabbà C. 1 and is particularly useful in subjects with acute illness. Its correlation with
1
HHT Interdepartmental Center, Centro Sovraziendale per le Malattie frailty and in-hospital mortality is however still unknown.
Rare, “Frugoni” Internal Medicine Unit, Policlinico Hospital, University of Aims: Our primary aim was to verify the correlation between the admission
Bari “Aldo Moro”, Bari, Italy 2 “A. Murri” Internal Medicine Unit, Policlinico 4-AT score and frailty, operationalized according the Rockwood model, in
Hospital, University of Bari “Aldo Moro”, Italy 3 Radiology Unit, Policlinico a group of elderly multimorbid patients urgently admitted to an internal
Hospital, University of Bari “Aldo Moro”, Italy medicine ward with acute infection. The secondary aims were to verify
whether 4-AT is able to predict in-hospital mortality and length of stay
Background: Hereditary Haemorrhagic Telangiectasia (HHT), or Ren- (LOS) in the same population.
du-Osler-Weber syndrome, is a rare autosomal dominant vascular disorder Methods: We prospectively enrolled 158 (89 F) multimorbid (≥2 chronic
(prevalence: 1-2:10,000), characterized by arterio-venous shunts, affecting diseases) patients aged≥65 (mean 83.6±7.5) urgently admitted to Internal
nasal mucosa, oral cavity, skin, and several internal organs (lung, liver, Medicine and Critical Subacute Care ward of Parma University-Hospi-
brain, GI tract). Serious clinical complications can be associated to visce- tal with acute infection. 4-AT score and Rockwood Clinical Frailty Scale
ral arterio-venous malformations. In particular, hepatic arterio-venous (RCFS) score were calculated by trained clinicians at the moment of ward
malformations (HAVMs) are detected in 60-80% of HHT patients and may admission. Multimorbidity burden was also assessed with the Cumulative
be potentially responsible for high-output heart failure, ischemic biliary Illness Rating Scale (CIRS) Comorbidity Score. The associations between
disease, portal hypertension, and porto-systemic encephalopathy. Although 4-AT and RCFS scores, and between 4-AT and LOS were verified with mul-
only a small percentage of HHT patients (5-8%) suffer from overt clinical tiple linear regression models, considering age, sex and CIRS Comorbidity
manifestations secondary to HAVMs, increased blood flow through hepatic Score as covariates. Multivariate logistic regression models were also built
vascular shunts is often responsible for a subclinical hyperdynamic state. to verify whether 4-AT score is a significant predictor for hospital mortality
Entering geriatric age often entails deterioration of clinical picture of these and LOS.
patients, by a number of reasons, either related to progressive worsening of Results: Medians and interquartile ranges (IQR) of 4-AT, RCFS and CIRS
HHT (lack of compensation of hyperdynamic state, increased uncontrolled Comorbidity Score were 1 [IQR 0-4], 5 [IQR 4-6], and 13 [IQR 10-15],
epistaxis, onset of gastrointestinal bleeding) or to emergence of concomitant respectively. The median LOS was 6 days [IQR 3-10]. Twenty-nine patients
common morbidities and/or polypharmacy condition, typically associated (18.3%) died during hospital stay. 4-AT score was significantly correlated
to geriatric age. Bearing in mind the complex frailty condition which typi- with RCFS (β±SE 1.08±0.16; age-, sex- and CIRS-adjusted p<0.001). The
45
4-AT score significantly increased across different levels of frailty (fit patients Italian Scientific Societies (geriatricians, emergency physicians, internal
with RCFS<4: 0.9±2.3; frail patients with RCFS 4-6: 1.25±1.40; disabled physicians, anesthesiologists, surgeons, psychiatrists and toxicologists)
patients with RCFS>6: 6.3±3.9; p for trend<0.001). 4-AT was not correla- shared ideas on advancing the best care practices in this field.
ted with LOS (β±SE 0.22±0.20, p=0.27). At multivariate logistic regression Conclusion: In summary, the document focused on the need of diagnosing
models, considering age, sex, RCFS and CIRS as confounders, 4-AT was delirium and the opportunity of a comprensive patient-care program that
associated neither with inhospital mortality (OR 1.10, 95% CI 0.94-1.28, prevents delirium. A little attention was given to pharmacological therapy,
p=0.22), nor with LOS>10 days (OR 0.97, 95% CI 0.85-1.11, p=0.68). last beach only when the patient is in danger. To make the document as
Conclusions: In a group of older multimorbid patients with acute infection, widely know as possible, it will be published in the Official Journal of the
the 4-AT score was significantly associated with frailty, operationalized Societies in the coming months. We believe that only by involving all team
according to the Rockwood model. However, 4-AT was not able to predict members within the hospital we can fight that so common syndrome.
in-hospital mortality or LOS.
A FRAILTY INDEX IN HOSPITALIZED OLDER PEOPLE: A

ITALIAN GUIDELINES FOR EARLY DETECTION, NEW PROPOSAL FROM THE REPOSI REGISTER
DIAGNOSIS, PREVENTION AND TRATMENT OF
DELIRIUM IN THE FRAIL ELDERLY Franchi C. 1, Cesari M. 2, Nobili A. 1, Cortesi L. 1, Mannucci P.M. 3, Ardoino I. 4
1
IRCCS - Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
G. Ricevuti, 1 C. Paolillo, 2 P.A. Modesti 3, M. Trabucchi 4 2
Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Université
F. Perticone 5, N. Ferrara 6, M.P. Ruggieri 6, C. Tommasino 8, de Toulouse III Paul Sabatier, Toulouse, France 3 Scientific Direction,
A. Ferrari 9, P. Gnerre 10, G. Bellelli 11 Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
1
(University Pavia, Department of Internal Medicine and Therapeutics, 4
Department of Clinical Sciences and Community Health, University of
Geriatrics, Pavia, Italy, Azienda Servizi alla Persona, S. Margherita Hospital, Milan, Italy
Pavia, Italy) 2 (Emergency Department, Udine Healthcare and University
Integrated Trust, Udine, Italy, AcEMC) 3 (Dipartimento di Medicina Purpose: To develop a frailty index for hospitalized older patients and test
Sperimentale e Clinica, Università di Firenze, Italia, SIMI) 4 (Università di its association with in-hospital mortality rate.
Roma “Tor Vergata”, Roma, Italia, PRESIDENTE AIP), 5 (Department of Methods: This is a cross-sectional study of people aged 65 years or more
Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Italy, hospitalized for at least 5 days in Italian internal medicine and geriatric
PRESIDENTE SIMI), 6 (Medicina Interna e Geriatria, Università degli Studi wards participating to the REPOSI register from 2010 to 2016. Frailty Index
di Napoli “Federico II”, Napoli, Italia, PRESIDENTE SIGG ‐ Società Italiana was defined by the deficit accumulation. For the purpose of this study,
di Gerontologia e 35 deficits were identified through laboratory parameters, geriatric scales
Geriatria), 6 (Azienda Ospedaliera San Giovanni Addolorata della UAS, (Barthel Index, Short Blessed Test and Geriatric Depression Scale) and
Roma, PRESIDENTE SIMEU) 8 (Dipartimento di Scienze Biomediche, comorbidities assessed at hospital admission. Association with in-hospital
Chirurgiche ed Odontostomatologiche, Università di Milano, ASST Santi mortality rate was assessed by logistic regression model adjusted for sex and
Paolo e Carlo Polo Universitario, Milano, Italia, SIAARTI), 9 (UOC di age.
Geriatria, ASMN‐ Azienda Ospedaliera di Results: Among 4715 patients enrolled in the REPOSI register from 2010
Reggio Emilia, Italia, PRESIDENTE SIGOT), 10 (Medicina, Ospedale San to 2016, 3847 patients were hospitalized for at least 5 days in 101 internal
Paolo di Savona, Italia, FADOI), 11 (Università degli Studi di Milano- medicine and geriatric wards and were selected for the analyses. Nearly
Bicocca, SCC Geriatria, AO San Gerardo, Monza, Italia) half of them (51.5%) were females, median age was about 80 years old, 50%
had negligible dependence according to Barthel Index, and 37.9% were not
Partnering collaborative intercompany guidelines for the prevention, dia- cognitive impaired. Figure 1 shows the distribution of the Frailty Index in
gnosis and treatment of delirium in the frail elderly person. this population. The median of the score distribution was 0.29 (Interquartile
Range: 0.22-0.37). Only a paucity of patients (nearly 5%) has been identified
Background: Delirium or acute confusion is a clinical mis- or underdia- as frail, exceeding the value of 0.5. An increasing score of Frailty Index was
gnosed condition characterized by an acute (shorter than 6 months) and associated with an increased likelihood to die during hospitalization (OR
floating alteration of psychic state, with loss of attention and alteration of 1.05, 95%CI 1.03-1.07).
consciousness, associated to an underlying organic cause. It is a serious Conclusion: The development of a Frailty Index in hospitalized older
syndrome related to an increase of the lenght of hospitalization, the risk of patients could represent a useful tool for internists and geriatrics in order
instituzionalization,the morbility and the mortality. Therefore it is crucial to to improve the management of this population, which nowadays are increa-
identifying it. Howeverbeing our knowledge about its mechanism limited sing more and more and are becoming the prototype of patients with whom
and having the delirium a wide range of presentations it is really difficult to clinicians must deal. Moreover the correct management of frail older people
diagnose it. Delirium can be found in any medical condition and is common represents a great challenge for National Health System due to limited
in hospitalised elderly patients in his hyperactive, hypoactive and mixed resources.
form. This syndrome occurs in about 10 to 25% of all acute admissions to
a general hospital. The frequency in older patients is higher, 20% to 40%.
Due to the aging of the population, the absolute number may increase in
the future. The causes are the most varied and can be memorized with the
acronyms VINDICATE, I WATCH DEATH and DELIRIUM. Study Design:
These guidelines have been produced by experts indicated by many Italian
Scientific Societies. First of all, they evaluated the literature and guidelines
published by national and international scientific societies. Subsequently,
a writing group produced a first draft of the document that was circulated
between all experts and Societies for observation and integration. Finally,
it was decided not to allocate evidence levels to the recommendations that
were proposed, considering that the literature review was extended but was
not based on a systematic questioning of databases. These guidelines must
therefore be considered as a consensus of experts in all respects. Results:
Over the age of 80 years, more than one third of those in hospital will expe-
rience Delirium. Despite its high prevalence, delirium often goes undetected
and undetected delirium is associated with the highest mortality. Delirium
prevalence is not bound by specialty and crosses over to both hospital and
community settings. Given its ubiquity and its heterogeneous presentation,
delirium diagnosis and management is the responsibility of all clinicians.
To help address the need of develop a cultural movement that stressed
early identification and the immediate removal of predisposing factors that
can made an old patient more susceptible to delirium, in February 2017
an interdisciplinary group of clinicians and researcher belonging to fifteen
46
CHANGES IN FRAILTY STATUS DURING (transferred to sub-acute units, nursing homes-RSA, Hospices, Integrated
HOSPITALIZATION AND PROGNOSTIC IMPACT IN Home Care-ADI-activation) 2.3% referrals, voluntary resignation.
OLDER PATIENTS Conclusions: 1. About 27% of IM patients needs monitoring and intensive
assistance. Is currently starting-up a randomized study on use of wireless
Basile G. 1, Catalano A. 1, Mandraffino G. 2, Alibrandi A. 3, Ciancio G. 1, monitoring systems in IM to demonstrate how an adequate critical patients
Brischetto D. 1, Lasco A. 1, Cesari M. 4,5 care improve management, reducing complication, LOS and hospitali-
1
Unit and School of Geriatrics, Department of Clinical and Experimental zation costs. 2. About 23% of patients presents social problems for which
Medicine, University of Messina, Messina, Italy; 2 Unit of Internal Medicine, integrated paths could minimize LOS. 3. A pilot study is being carried out
Department of Clinical and Experimental Medicine, University of Messina, to evaluate the pathway of patients with chronic diseases in the transition
Messina, Italy; 3 Department of Economics, University of Messina, Messina, from acute phase to low-intensity care settings to define pathways following
Italy; 4 Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, the subacute phase and possible experimentation of intermediate support
France. 5 Université de Toulouse III Paul Sabatier, Toulouse, France structures (also In public-private partnership) where to stay waiting to enter
the RSA (nursing homes with minimum intensity of care).
Background: Frailty is a predictor of adverse outcomes in older subjects.
However, its assessment in the hospital setting is still scarcely explored.
Objectives. The aims of this study are to 1) measure the frailty status in MULTILEVEL INTERVENTION TO IMPROVE
older hospitalized patients, 2) estimate its changes during the hospital stay, APPROPRIATENESS OF LABORATORY TEST REQUESTS
3) determine the relationships among frailty, length of stay, and in-hospital IN THE EMERGENCY DEPARTMENT
mortality, and 4) evaluate the predictive value of frailty for one-year morta-
lity and six-month re-hospitalization events. Fallai L. 1, NazerianP. 1, Vanni S. 1, Fanelli A. 2, Duranti C. 2,
Materials and Methods: Between September 2015 and April 2016, data Ognibene A. 2, Rapi S. 2, Betti L. 1, Tomaiuolo M. 3, Calamai M. 3, Grifoni S. 1
from 156 patients (93 women, 63 men), aged 65 years or older, and consecu- 1
Dipartimento di Emergenza-Urgenza, Azienda Ospedaliero-Universitaria
tively admitted to Acute Geriatric Medicine Unit at the University Hospital Careggi, Firenze; † Laboratorio Generale, Azienda Ospedaliero-Universitaria
of Messina, Italy were collectedSetting. Geriatric Acute Care Unit. A Frailty Careggi, Firenze; ° Amministrazione Generale, Azienda Ospedaliero-
Index (FI) was computed taking into account 46 potential deficits collected Universitaria Careggi, Firenze
as part of standard clinical and laboratory parameters. Patients with an FI
>0.25 were classified as frail. For each patient, the FI was calculated within Introduction: Laboratory blood tests are part of the diagnostic investi-
24 hours from the hospital admission (aFI) and discharge (dFI). Patients gation performed in the emergency department (ED), but they are also a
were followed up to 12 months after the hospital discharge. potential waste in health care utilization. The aim of this study is to deter-
Results: The study sample had a mean age of patients was 81.5 (SD=6.2) mine if a multilevel intervention based on optimization of test profiles and
years, and predominantly composed by women (59%). The median aFI was awareness of medical staff could reduce the number of requested tests and
0.362 (interquartile range: 0.306-0.404). After exclusion of patients dying costs without affecting ED performances.
during the hospital stay, a statistically significant difference was reported Methods: A before-and-after study in ED was conducted. Laboratory test
between aFI (0.31, IQR 0.19-0.44) and dFI (0.29, IQR 0.19-0.40; p=0.04). profiles were reduced from 6 to 2 and cut by 50% the number of tests in
The frailest patients presented an increased risk of in-hospital death each profile. All ED physicians were informed about the expense of labo-
(OR=5.9; 95% CI 2.0-17.5) and longer hospital stay (β=6.937; p=0.05). Both ratory tests and about the appropriate use of the most frequent high cost
the aFI and dFI were strong predictors of one year mortality and six months tests. The 8 months intervention period (1st July 2016 - 28th February 2017)
re-hospitalization after discharge. was compared with 8 months pre-intervention period (1st July 2015 - 28th
Conclusion: Frailty is a strong predictor of negative endpoints in hospitali- February 2016). Main outcomes were total laboratory blood tests and high-
zed older persons. Its assessment from routinely collected clinical data may cost tests ordered. Secondary outcomes were cost of laboratory tests and ED
provide important insights about the biological age of the individual and and laboratory performances (patients’ waiting time, number of death in
promote the personalization of interventions. ED, re-entry and laboratory turn-around-time).
Results: Patients evaluate during the intervention and pre-intervention
period were 61,976 and 61,154 respectively. Total laboratory tests decrea-
TAKE CARE OF THE PATIENT AND QUALITY OF sed by 207,637 (-36.3%) with a reduction of 337.3 tests/100 patients in the
THE CARE PROCESS BY DEFINING THE CORRECT intervention period compared with pre-intervention period (p<0.05). Costs
SETTING BETWEEN HOSPITAL AND TERRITORY: decreased by 608,079€ (-29.6%) with a reduction of 981.2€/100 patients
AN OBSERVATIONAL RETROSPECTIVE STUDY IN (p<0.05). High-cost tests decreased by 11,457 (-27.3%) with a reduction
LOMBARDY of 18.5 tests/100 patients, and participated in costs reduction for 197,206€
(-30.5%). No significant differences were found in ED and laboratory
Pietrantonio F. 1, Aperti P. 1, Tonoli L. 1, Meneghetti O. 1, Scotti E. 2, Bussi performances.
A.R.1 Conclusions: Multilevel intervention by modification of routine labo-
1
U.O. Medicina Interna, Ospedale di Manerbio (BS) ASST-Garda 2 Unità ratory test profiles and educational meetings for ED medical staff signi-
Operativa Medicina Generale, Istituto Neurotraumatologico Italiano (INI), ficantly reduced laboratory test ordering and costs without affecting ED
Grottaferrata (Roma) performances.
Background: In the implementation of Lombardy socio-health care reform

(L.R. n. 23/2015), is essential to stratify patients according to clinical inten- THE ROLE OF PROCALCITONIN IN EMERGENCY
sity and complexity, defining care setting, personnel standards, technolo- MEDICINE
gical equipment and critical junctions of hospital-territory paths. Aims.
To define: 1. Internal Medicine (IM) patients’ characteristics; 2. IM role in Zaccone V., Falsetti L., Marchetti A., Piersantelli M.N., Nobili L., Menditto
complex poly-pathologic patients with chronic diseases paths; 3. alternative V., Gentili T., Nitti C., Salvi A.
organizational models to improve performances, a retrospective observatio- SOD Pronto Soccorso e Medicina D’Urgenza, Ospedali Riuniti, Ancona
nal study has been realized by Manerbio IM (ASST-Garda).
Methods: After a 2000-2016 Literature review, MEWS (Modified Early Background: procalcitonin (PCT) could guide antibiotic therapy and eva-
Warning Score), CIRS (Cumulative Index Rating Scale) and Care Intensity luate its efficacy. Informations regarding the diagnostic and prognostic role
Index (IIA) were chosen to analyze IM admitted patients. Medical records of PCT in the critically ill subject are lacking. Aim of this study was to eva-
(MR) of all patients consecutively admitted to Manerbio IM from January luate the value of PCT in the diagnosis of bacterial infections and its pro-
1st to March 31st 2016 were analyzed. gnostic weight in the unstable patient.
Results: 393 patients: 199 M/194 F (total discharged: 483), median age 81 Methods: we enrolled 1063 consecutive, critically ill subjects admitted to
years. 93% >70 years and 37% >85 years. Critically ill patients (needing con- our Internal Subintensive Medicine Department in the period 2008-2010,
tinuous monitoring): 27% (of which 10% with MEWS≥ 5, needing Intensive evaluating age, sex, haemodynamic parameters, blood exams, PCT and
Care Unit). Comorbidity (measured by CIRS-CI): 5- 6 active diseases, 53% blood cultures. In particular we collected the absolute number of peripheral
with CIRS 7-12. Intensity of care (IIA) high (3-4) in 46% of the patients white blood cells, troponin I (TnI) and serum creatinine. Among hemody-
throughout the length of hospital stay (LOS). Average LOS: 9.35 days. namic parameters, we evaluated the presence of shock (defined as systolic
Outcome: 64% discharged at home; 10.7% deaths; 23% with social problems blood pressure < 90 mmHg, low urine output, < 0.5 ml/kg/h and reduced
47
cutaneous perfusion). The degree of severity of the pathology was assessed Stroke side was not found to be associated to a specific autonomic profile.
with the SAPS-II score. We’ve set as outcomes mortality or intensive therapy Conclusions: A decreased 0V% and an increased 2UV% may be an expres-
transfer, overall survival and length of hospital admission. sion of the lost of sympathetic rhythmic oscillation with persistent respi-
Results: We observed positive cultures in 375 subjects, whose mean PCT ratory modulation. According to these preliminary data, in the very early
levels were significantly higher than in patients without positive cultures phases of acute ischemic stroke, an autonomic profile characterized by
(0,84 ng/ml versus 0,20 ng/ml; p<0,0001). ROC curve analysis, however, prevalent vagal control and impaired sympathetic oscillation may predict a
underlined a sub-optimal role of PCT in predicting bacterial isolation poorer 3 months-outcome.
(AUC:0,58;95% CI: 0,54-0,62). 172 patients died, and their mean PCT
values were significantly higher than survivors (2,62 ng/ml versus 0,17 ng/
ml; p<0,05). Calculating an optimal cutoff of 0,50 ng/ml, mean time without APPLICATION OF THE NOVEL SEPSIS CRITERIA IN AN
events among subjects with lower PCT was 44 days compared with 26 days INTERNAL MEDICINE WARD: IS QSOFA EQUIVALENT TO
observed in patient with high PCT. The prognostic weight of PCT was supe- SIRS IN OLDER MULTIMORBID PATIENTS?
rior than TnI, and PCT was correlated with prognosis independently from
bacterial infection. A model including SAPS2, troponin I and PCT had a Ticinesi A. 1, Lauretani F. 1, Bastoni D. 2, Calamai S. 2,
good AUC (0,734; 95%CI: 0,667-0,775) in predicting in-hospital events, Catalano L. 2, Catania P. 2, Cecchia M. 2, Cerundolo N. 2,
such as death or transfer to intensive-care unit. Galluzzo C. 2, Giovini M. 2, Mori G. 2, Zani M.D. 2, Ciani L. 3,
Discussion: Procalcitonin is now a widely used marker of bacterial infection, Nouvenne A. 1, Maggio M. 1, Meschi T. 1
despite several papers confirmed its low diagnostic yeld. In our population, 1
Dipartimento di Medicina e Chirurgia, Università di Parma – Dipartimento
we confirmed this observation by showing a low correlation between incre- Medico-Geriatrico-Riabilitativo, Azienda Ospedaliero-Universitaria di
ased PCT and positive bacterial isolates (blood, sputum or urine cultures). Parma; 2Scuola di Specializzazione in Medicina d’Emergenza-Urgenza,
However, an increased PCT value was associated, independently from the Dipartimento di Medicina e Chirurgia, Università di Parma; 3Dipartimento
presence of sepsis or infection, to an increased rate of adverse events and a di Medicina e Chirurgia, Università di Parma
lower event-free survival. When combined in a model including clinical and
serologic markers of severity, such as SAPS2 and troponin I, PCT showed Background: In 2016, the Third International Consensus Definitions for
a good prognostic value for in-hospital death or complications by increa- Sepsis and Septic Shock have recommended the implementation of a new
sing the AUC of the model. This derived model was able to predict adverse bedside clinical score for the diagnosis of sepsis outside the intensive care
event in all the critically ill patients enrolled, independently from the cause unit. This score, termed quickSOFA (qSOFA), is composed of three clinical
of admission. criteria: respiratory rate of 22/min or greater, altered mentation measured
Conclusion: Among critically ill patients PCT has a low diagnostic yeld, by Glasgow Coma Scale, and systolic blood pressure of 100 mm Hg or less.
with a poor predictive value for positive bacterial cultures. PCT, however, Sepsis is present when at least 2 out of 3 criteria are fulfilled. qSOFA should
maintains a good prognostic significance in predicting both event-free replace the old SIRS (Systemic Inflammatory Response Syndrome) criteria.
survival and adverse events during the hospitalization. In particular, PCT However, the validity of qSOFA over SIRS for predicting mortality in the
increases the prognostic value of commonly used scores, such as SAPS2, context of older multimorbid patients is still unknown.
and well-recognised prognostic markers, as troponin I. A model including Aim: To assess the non-inferiority of qSOFA over SIRS in predicting
SAPS2, troponin I and PCT is highly predictive for in-hospital adverse 3-month mortality in a cohort of older multimorbid patients admitted to an
events among critically ill patients, and could be used to predict the risk academic internal medicine ward with suspected sepsis.
of in-hospital mortality and the probability of transfer to intensive therapy Methods: We prospectively enrolled 121 (66 F) multimorbid (≥2 chronic
unit. diseases) patients aged≥65 (mean 83.2±7.6) urgently admitted to Internal
Medicine and Critical Subacute Care ward of Parma University-Hospital
with suspected sepsis, operationalized as prescription of empiric antibiotic
PROGNOSTIC VALUE OF HEART RATE VARIABILITY IN treatment and biologic sample cultures. Subjects who were administered
ACUTE ISCHEMIC STROKE antibiotic treatment before hospital admission and subjects with establi-
shed survival prognosis <6 months were excluded. qSOFA and SIRS scores
Tobaldini E.1, Sacco R.M.1, Serafino S.2, Gallone G.P.2, Zecca B.2, were calculated at the moment of ward admission, together with Cumula-
Pagnozzi G.2, Brambilla A.M.2, Montano N.1, Torgano G.2 tive Illness Rating Scale (CIRS) Comorbidity Score and Rockwood Clinical
1
Department of Internal Medicine, Fondazione IRCSS Ca’ Granda, Ospedale Frailty Scale (RCFS). Three months after discharge, a phone interview with
Maggiore Policlinico, Milan, Italy; 2Department of Emergency Medicine, every participant’s caregiver was planned to assess mortality. Multivariate
Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Italy logistic regression models including SIRS (model 1) or qSOFA (model 2)
with CIRS Comorbidity Score, RCFS, age and sex as potential confounders
Background: Acute ischemic stroke is associated with autonomic dysfun- were built to satisfy the aim of the study.
ction. Whether this alteration has a prognostic role is still debated. Heart Results: At admission, the median and interquartile range (IQR) scores of
Rate Variability (HRV) is a widely used tool to assess cardiac autonomic qSOFA, SIRS, CIRS Comorbidity Score and RCFS were 1 [IQR 0-1], 1 [IQR
modulation. 1-2], 13 [IQR 10-15], and 5 [4-6], respectively. At the 3-month follow-up,
Aims: To evaluate 1) the prognostic value of HRV in acute ischemic stroke, 37 patients (30.5%) died. In multivariate logistic regression model 1, SIRS
2) the effects of reperfusion treatment (RT) on autonomic control, 3) was not a significant predictor of mortality (OR 1.38, 95% CI 0.87-2.17,
whether stroke localization has a role in autonomic dysfunction. p=0.16), while RCFS was (OR 2.06, 95% CI 1.44-2.94, p<0.001). In model 2,
Methods: Consecutive patients with a diagnosis of acute ischemic stroke qSOFA was instead a significant predictor of 3-month mortality (OR 2.06,
and with sinus rhythm were enrolled in the Emergency Department (Ospe- 95% CI 1.03-4.15, p=0.04), together with RCFS (OR 1.96, 95% CI 1.36-2.83,
dale Maggiore Policlinico, Milan). Ten minutes EKG and respiration were p<0.001). Age, sex and CIRS Comorbidity Score were not associated with
recorded within six hours from the event (T0) and, when applicable, after mortality in both models.
RT (T1). Neurological deficit was assessed using NIH stroke scale (acute Conclusions: In older multimorbid patients admitted to an internal medi-
phase) and modified Rankin scale (MRS), at 3 months. Spectral and symbo- cine ward with suspected sepsis, qSOFA score was a better predictor of
lic analyses were used to assess HRV. Spectral analysis identifies two main 3-month mortality than SIRS score. Frailty, operationalized according to the
components, low frequency (LF, 0.04 to 0.15 Hz), marker of sympathetic Rockwood model, was also a significant predictor of death in this setting.
modulation, and high frequency (HF, 0.15-0.4 Hz), marker of parasympa-
thetic modulation and synchronous with respiration. Symbolic analysis pro-
vides three families of patterns, 0V%, index of sympathetic modulation and HYPERLACTATEMIA, WHEN SEPSIS IS NOT ENOUGH
2LV% and 2UV% markers of index of vagal modulation.
Results: We enrolled 38 patients (26 males, mean age 67.9 ± 13; mean Traversa M. 1, Villois P., Elia F.
NIHSS 10,5 ± 6,3). Twenty-five of them underwent RT. As to the correla- 1
Scuola di Specializzazione in Medicina Interna, Dipartimento di Scienze
tion between NIHSS and autonomic parameters, we found that the group Mediche, Università degli Studi di Torino
of patients with NIHSS ≥ 14 showed a prevalent parasympathetic modula-
tion compared to patients with NIHSS < 14 (p=0,025). As to the mid-term The patient, 45 year-old, was admitted to the Intensive Care Unit with
outcome, the group with the worst mid-term neurological outcome (MRS the diagnosis of abdominal sepsis after a pancreatic surgery. Past medical
3-6) showed higher 2UV% (p<0,01) and lower 0V% (p=0,023) than patients history of the patient: arterial hypertension treated with angiotensin con-
with better MRS 0-2. RT seemed to have no effects on HRV parameters.
48
verting enzyme (ACE) inhibitor, no history of smoking or alcohol abuse ACUTE PHASE OF SYSTEMIC CAPILLARY LEAK
and a previous abdominal surgery 6 years before for an appendicectomy. SYNDROME: A CASE REPORT
The patient was firstly admitted to our hospital March 10 2017 in the surgi-
cal unit with abdominal pain, loss of weight and stipsis. The first computed Colombo R. 1, Catena E. 1, Perotti A. 1, Fossali T. 1, Wu M.A. 2, Cicardi M. 2
tomography (CT) scan revealed a pancreatic mass, highly suspicious for a 1
Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli
duodenal/pancreatic cancer. Five days later he underwent a radical pancrea- Sacco, Luigi Sacco Hospital – Polo ospedaliero, University of Milan, Milan,
ticduodenectomy and a right emicolectomy. Histology revealed a duodenal Italy 2Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli
adenocarcinoma with local infiltration (pT4-N1-G3). Post-surgery course Sacco, Luigi Sacco Hospital – Polo ospedaliero, University of Milan, Milan,
was regular, canalized at day 3. After 10 days the patient developed fever Italy
with shivering, a decrease in haemoglobin’s level and a rise of the inflamma-
tion markers. A new CT scan was performed demonstrating a dehiscence Idiopathic Systemic Capillary Leak Syndrome (ISCLS) is a rare disease that
of the Roux-en-Y hepaticjejunostomy anastomosis and of the ileum-colic involves the endothelium and microcirculation, leading to an abrupt shift of
anastomosis with a large suppurated mass within the pancreatic pouch and fluids and proteins from the intravascular to the interstitial compartment.
around the left hepatic lobe. Blood cultures were provided from the central The consequence of the capillary leakage is a life-threatening hypovolemic
venous catheter and peripheral vein and they were both found positive for shock that can lead to lethal multiple organ dysfunction.
Proteus Mirabilis and Candida Glabrata. The patient underwent a second The autonomic nervous system (ANS) plays a central role in regulating the
surgery for the drainage of the intrabdominal abscess and the closure of the cardiovascular response to hypovolemia, but ANS modulation in ISCLS has
dehiscent anastomosis. Antimicrobial therapy with Tigeciclin, Vancomicin not been investigated so far.
and fluconazol was started, adjusted on the antibiotic susceptibility testing Here we present the case of a a 36-year-old-man admitted to our ICU for
(AST). The patient required several red blood cells (RBCs) transfusions (one a life-threatening ISCLS attack. During the course of the last ISCLS crisis
every 48h) to maintain a mean 7g/dl haemoglobin level. After a few days the patient was connected to an ICU monitor Philips IntelliVue MX800
fever rose again along with the development of altered mentation and a pro- (Philips Healthcare, Amsterdam, Netherlands) through five leads ECG
gressive worsening of the clinical status. The patient was therefore moved cable and invasive arterial pressure line from a 20 gauge arterial catheter
to our Intensive Care Unit with a severe septic shock. Physical examination inserted into the right femoral artery. All ECG signals were sampled at 500
showed a severely altered mentation with a Glasgow Coma Scale (GCS) of Hz and arterial pressure at 125 Hz with ixTrend (ixellence GmbH, Wildau,
6/15 (E1 M3 V2), diaphoresis, invasive arterial pressure 90/50 mmHg, heart Germany). The arterial pressure wave was resampled offline at 500 Hz with
rate 110bpm, respiratory rate 26, SpO2 98% with a Venturi Mask 40%. Tho- LabChartPro 8 (AD Instruments, Dunedin, New Zealand). Autonomic
racic X rays showed bilateral pleural effusion and elevated diaphragm, while nervous system was studied non-invasively by the spectral analysis of heart
abdominal ultrasonography revealed massive intraabdominal fluid despite rate variability (HRV) which allowed to identify the low frequency (LF) and
the presence of three drainages. Drained fluid was found to be a bloody high frequency (HF) components, markers of sympathetic and parasympa-
corpuscular essudate. Comprehensive blood tests showed WBC 9.65, Hb thetic modulation respectively. A spectral component was labelled as LF if
9.5, PLTS 16.000, normal blood coagulation, serum creatinine 0.5, eGFR its central frequency was between 0.04 and 0.15 Hz, while it was classified as
100 ml/min, sodium 137 and potassium 3.9. ABG pH 7.57 p02 133 pC02 23 HF if its central frequency was between 0.15 and 0.5 Hz.
PCT 15.38 HC03- lac 4.4. Haemocultures demonstrated an early positivity During the acute phase (day 1), despite life-threatening hypotension and
for Gram – group KES (klebsiella-enterobacter-serratia), thus antibiotics severe tachycardia, the spectral analysis of HRV didn’t show any oscillatory
were switched to meropenem instead of tigeciclin. The patient was treated pattern. Total power was very low, LF band had a density of 12 msec2 and
with crystalloids and blood transfusions and did not require vasopressor HF band of zero msec2 respectively. At early recovery from the ISCLS crisis
support. At the entrance in the ICU the SOFA score was 9; ScvO2 was 70%, (day 2), the power spectrum showed an increase of LF, and a persistently
SaO2 92%, DELTA-CO2 3 (32 – 29). After a platelet transfusion, under low HF accounting for high LF/HF ratio. At the time of full recovery (Day
echografic vision, a catheter was placed with Seldinger technique in order 3) both LF and HF increased with a prevalence of the HF band, thus the LF/
to take a sample of the abdominal effusion; a total 700cc of hematic fluid HF ratio was reduced.
was drained. The microbiological cultural exam of the ascites and the hae- In conclusion, during the acute phase, our patient showed an unexpected
moculture revealed a positivity to Klebsiella Pneumoniae and an antibio- failure of ANS cardiovascular modulation. His HRV was totally suppres-
tic therapy with meropenem and vancomycin was continued, based on the sed, as assessed by flattened power spectral density. Further investigation is
antibiotic susceptibility testing. After 2 days, the haemodynamic parame- warranted to assess whether the ANS failure is an epiphenomenon of mul-
ters improved, no more hypotension and fever vanished; the patient needed tiple organ dysfunction during life-threatening sickness, a compensatory
daily transfusion for the first 4 days. At day4, most lab examinations impro- response or if it has a role in the pathogenesis of hemodynamic instability
ved: liver enzymes levels, bilirubin, coagulation, electrolytes were normal, during ISCLS crises.
while anemia and piastrinopenia were stable with persistent haematic fluid
drainage. ABG showed pH 7.482 p02 81.6 pC02 41.5 HCO3- 30.4, and GCS
was still 10 with persistence of altered mentation and drowsiness. SOFA APOLIPOPROTEIN C-III IS A PREDICTOR OF ACTIVATED
score was 7 (severely influenced by the altered mentation and the very low FACTOR VII-ANTITHROMBIN COMPLEX LEVELS: A NEW
platelet count). Although an improvement of the clinical status and the LINK BETWEEN PLASMA LIPIDS AND COAGULATION
blood examination, serum lactate level remained stable (around 5 mmol/l) PATHWAY
and the patient drowsy. Since surgery, parenteral nutrition was administe-
red under nutritional consultation. Ruled out the first idea of septic shock Stefanoni F. 1, Tosi F. 1, Baroni M. 2, Castagna A. 1, Pizzolo F. 1,
and looking for other causes of lactate elevation, the hypothesis of a vitamin Bassi A. 3, Pattini P. 1, Croce J. 1, Lunghi B. 2, Girelli D. 1,
deficiency was evaluated as a consequence of the lack of vitamin B1 due to Woodhams B. 4, Bernardi F. 2, Olivieri O. 1, Martinelli N. 1
exclusive parenteral nutrition. Actually, parenteral nutrition tailored under 1
Department of Medicine, University of Verona, Italy; 2Department of Life
nutritional consultation the day after the surgery, was carefully balanced Sciences and Biotechnology, University of Ferrara, Italy; 3Institute of Clinical
in the percentage of fats, proteins and carbohydrates necessary for the first Chemistry, University Hospital of Verona, Verona, Italy; 4Haemacon Ltd,
days after the surgery however, it has not been changed during the patient’s Bromley, Kent, UK
unpredictably long stay in the hospital; therefore, intravenous thiamine
replacement was associated with multivitamin complex to the parente- Background: activated factor VII-antithrombin (FVIIa-AT) complex is a
ral nutrition. On the following day, serum lactate levels decreased hugely, potential biomarker of prothrombotic diathesis, reflecting tissue factor (TF)
reaching normal level (1.3 mmol/l). After 48 hours, the patient awakened, exposure, and has been associated with mortality in patients with coronary
returning to a GCS level of 15 and fully recovered his mental status. During artery disease (CAD). Previous works indicated plasma lipids as predictors
the rest of the stay, the patient underwent new surgery to remove the intra- of FVIIa-AT variability. Aims: to evaluate the relationships between FVI-
abdominal abscess and replace the biliary drainage. One month later, after a Ia-AT plasma concentration and lipid/apolipoprotein profile.
rehabilitation cycle, the patient was discharged to home in good condition. Methods: within the framework of the Verona Heart Study we selected 460
In conclusion, the worsening of the patient’s clinical status, particularly the subjects (120 CAD-free and 340 CAD, 68.9% males, mean age 59.9±10.3
altered mentation and the hyperlactacidemia, were not due to an abdominal years) not taking anticoagulant drugs and for whom plasma samples were
septic shock but to a Wernicke syndrome associated to thiamine deficiency. available for FVIIa-AT assay and for a complete lipid profile, including apo-
lipoprotein (Apo) A-I, B, C-III, and E. FVIIa-AT plasma levels were mea-
sured by ELISA.
SEVERE AUTONOMIC DYSFUNCTION DURING THE
49
Results: there were significant direct correlations of FVIIa-AT levels with cancer evolution, intracranial hemorrhage) and 19 of undefined causes.
total and HDL cholesterol, triglyceride, Apo A-I and Apo C-III. Apo A-I During the follow-up the overall incidence of VTE was (1.2% [95% CI, 0.1-
(R=0.164, P=4Å~10-4) and Apo C-III (R=0.236, P=3Å~10-7) showed the 2.3]) in the group not investigated for PE and 0.95% [95% CI, 0.3-1.87] in
strongest correlations. Including all the lipid parameters in an adjusted the overall population. Furthermore, we observed no significant differences
regression model only Apo A-I and Apo C-III remained significant pre- either in readmission for syncope or in mortality rates between the group
dictors of FVIIa-AT levels, with Apo C-III explaining 5.6% of FVIIa-AT investigated and not investigated for PE. In our cohort the diagnostic yield
variability. Such results were confirmed after adjustment for sex, age, CAD of VTE was 21% with a VTE prevalence of 5%. The diagnostic yield of PE
diagnosis, and renal function. The rs964184 polymorphism (tagging also was 30.9% and the prevalence was 3.7%. The prevalence of VTE was signi-
APOC3 gene locus), which has been linked with cardiovascular risk and ficantly lower in our cohort than PESIT, but significantly higher than that
plasma lipids by genome-wide association studies, was associated not only found in the GEMINI study and in the general population. The prevalence
with Apo C-III levels but also with FVIIa-AT plasma concentration, being was even higher (6%) if we excluded from the analysis patients at low risk
higher in the carriers of the risk allele G (CC 81.6 [77.9-85.5], CG 90.0 of VTE. Consequently, PTP and D-dimer should be routinely recommen-
[83.2-97.4], and GG 98.5 [77.8-124.6] pM, P=0.015). ded for all patients admitted to hospital for syncope and, with the excep-
Conclusion: our results indicate a strong association between Apo C-III tion of low-risk patients, imaging for PE should be considered, especially
and FVIIa-AT levels, thereby supporting the hypothesis that Apo C-III, one in older patients with previous VTE and/or risk factors for thrombosis. In
of the most important actor in lipid metabolism, may influence TF-FVIIa addition, given the very low diagnostic yield of CUS for VTE in syncope,
pathway with prothrombotic effects. it should not be performed. Patients’ outcome during the 1-year-follow-up
after discharge was also evaluated. A VTE incidence of 1.2% was found in
patients who did not receive imaging for VTE during the 1-year follow-up
THE DIAGNOSTIC CHALLENGE: ARE WE MISSING and 2 patients (0.6%) died of PE, whereas no VTE event was recorded in
PULMONARY EMBOLISM DIAGNOSIS IN PATIENTS 83 patients who received imaging. In conclusion, we can confirm that PE
WITH SYNCOPE? has to be considered in the differential diagnosis in patients admitted for
syncope into medical wards. The diagnostic workup of PE based on PTP
Campello E. 1, Rossetto V. 2, Maggiolo S. 1, Vigolo S. 3, Spiezia L. 1, Martina S. and D-dimer is mandatory.
2
, Moretti V. 2, Vettore G. 3, Simioni P. 1
1
UOSD Malattie trombotico ed emorragiche, Dipartimento di Medicina,
Università di Padova 2UOC Medicina interna, ospedale S. Antonio di San A TIME-COURSE ANALYSIS OF ACTIVATED FACTOR VII-
Daniele del Friuli, Udine 3Dipartimento di Emergenza, Università di Padova ANTITHROMBIN COMPLEX PLASMA CONCENTRATION
IN THE FOLLOW-UP OF PATIENTS WITH
In the recently published Pulmonary Embolism in Syncope Italian Trial ANGIOGRAPHICALLY-DEMONSTRATED CORONARY
(PESIT) that systematically evaluated 560 patients admitted to hospital with ARTERY DISEASE
a first episode of syncope, the diagnostic yield of venous thromboembolism
(VTE) was 41.9% and the prevalence of PE was 17.1%. On the other hand, Stefanoni F. 1, Castagna A. 1, Baroni M. 2, Tosi F. 1, Poli G. 3,
the more recent General Medicine Inpatient (GEMINI) study retrospecti- Lunghi B. 2, Gaino S. 3, Woodhams B. 4, Lippi G. 3, Girelli D. 1, Olivieri O. 1,
vely evaluated 1305 patients hospitalized with a first episode of syncope Bernardi F. 2, Martinelli N. 1
and found a diagnostic yield of VTE of 15.0% and a prevalence of VTE of 1
Department of Medicine, University of Verona, Italy; 2Department of Life
1.4%. Given such a discrepancy, it is difficult for the clinicians to grasp the Sciences and Biotechnology, University of Ferrara, Italy; 3Section of Clinical
actual impact of VTE in syncope. We aimed to assess the VTE prevalence in Biochemistry, University of Verona, Italy; 4Haemacon Ltd, Bromley, Kent,
medical patients admitted to hospital for syncope and the occurrence of VTE UK
and death during a one-year follow-up period after discharge. In this retro-
spective cohort study we selected all patients admitted to the Emergency Background: activated factor VII-antithrombin (FVIIa-AT) complex
Department (ED) of Padua University Hospital and San Daniele del Friuli reflects tissue factor exposure to the blood, thus being a biomarker of
Hospital (Italy) with a triage code of “syncope” and hospitalized between prothrombotic diathesis, and has been associated with mortality in patients
January 2014 and December 2015. Medical records were carefully reviewed with coronary artery disease (CAD). Aims: to evaluate FVIIa-AT plasma
and only patients with a diagnosis of “syncope” at discharge were enrolled. concentration in CAD patients in a two-points (baseline and during the fol-
Exclusion criteria were previous episodes of syncope, ongoing anticoagula- low-up) time-course analysis.
tion therapy, and pregnancy. Data of patients enrolled were obtained from Methods: within the original prospective study showing baseline levels of
medical records and information on subsequent re-admission to either FVIIa-AT as a predictor of cardiovascular mortality, in 178 survived CAD
the ED or the Hospital as well as on death from any causes were recorded patients (85.4% males, mean age 58.2±8.5 years) a second blood drawn for
for one year after the discharge from the Veneto and Friuli Venezia Giulia FVIIa-AT evaluation was performed in occasion of an ambulatory visit
Regional Health Department information systems. The following outcomes (after a median follow-up of 63 months). FVIIa-AT plasma levels were mea-
were considered: 1. occurrence of investigation for VTE during hospitaliza- sured by ELISA.
tion and the diagnostic yield of VTE; 2. prevalence of VTE during hospitali- Results: during the follow-up 58 subjects reported angina symptoms, 7
zation; 3. prevalence of VTE and mortality from any causes during the one- had myocardial infarction (MI), and 35 underwent new coronary revascu-
year follow-up after patients discharge. Out of 1169 patients hospitalized larization. FVIIa-AT levels at second control were significantly correlated
with a triage code of “syncope”, 470 (40.2%) were excluded because the dia- with those at baseline (R=0.262, P<0.001) and were significantly higher than
gnosis at discharge was other than syncope, 124 (10.6%) for ongoing anti- those at baseline (P<0.001), except for patients having begun anticoagulant
coagulation, 119 (10.1%) for recurrence of syncope and 3 (0.26%) for both. therapy with warfarin. Neither baseline nor second control FVIIa-AT levels
Out of 453 patients, 107 patients (23.6% [95% CI 19.7-27.5%) underwent were associated with angina, MI, or coronary revascularization. On the other
at least one imaging investigation for VTE, of whom 28 (26.1%) received hand, subjects with angina had a higher increase of FVIIa-AT levels from
only CTPA, 52 (48.5%) only CUS and 27 (25.2%) both. Overall, 55 patients baseline to the second control (50.1±55.9 versus31.4±54.4 pM, P=0.035), as
(12.1%) underwent CTPA to confirm PE with a diagnostic yield of 30.9% well as subjects with MI (79.4±52.2 versus35.8±55.1 pM, P=0.040), while no
(17/55 with positive CTPA) [95%CI, 20.3-46.3%], and 79 received CUS significant difference was found for coronary revascularization (49.9±48.8
to confirm the presence of deep vein thrombosis (DVT) with a diagnostic versus34.4±56.6 pM, P=0.139). Subjects with an increase higher than the
yield of 7.6% (6/79 with positive CUS) [95% CI, 1.7-13.4%]. Patients with median value (>36.4 pM) had an about two-fold increased risk of angina/
positive imaging were significantly older, exhibited more frequently a pre- MI after adjustment for sex, age, time of follow-up, and warfarin therapy
vious history of VTE, presented with more risk factors for VTE and a higher (OR 2.05 with 95%CI 1.05-4.02).
1-year mortality rate. The prevalence of VTE was 5% [95% CI, 3.0-6.9%] Conclusion: in the setting of secondary prevention of CAD a larger time-re-
in the entire cohort (23/453) and 6% [95% CI, 4.8-8.4%] after exclusion of lated increase of FVIIa-AT levels during follow-up is associated with angina
patients with negative D-dimer and low PTP (23/380). Additionally, in 346 and non-fatal MI.
out of 453 patients (76.3%) imaging for VTE was not performed and 9 out of
346 were excluded from follow-up because of the initiation of anticoagulant
therapy during hospital stay. Eventually, the 1-year-follow up of 337 out of ABDOMINAL PAIN: FIRST OF ALL TRUST THE PATIENT!
346 patients were considered and outcomes evaluated. Two patients (0.6%)
were readmitted for PE and 53 (15.7%) died: two of documented PE, 32 of Mancarella M. 1, Maira D. 1, Salvatori M. 1, Migone M. , Hu C., Minonzio F.,
identified medical causes (i.e. sepsis, myocardial infarction, hearth failure, Braham S. 2, Cappellini M.D.
50
Dipartimento di Medicina Interna-Fondazione IRCCS Ca’ Granda Ospedale Fondazione Policlinico Gemelli, Roma, Italia
Maggiore Policlinico- Milano 1Scuola di specializzazione Medicina Interna-
Università degli Studi di Milano 2 Dipartimento di Emostasi e Trombosi- The incidence of venous thromboembolism (VTE) among young subjects
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico- Milano appears to be higher in females, presumably due to hormonal factors such as
hormonal contraception (HC), pregnancy and puerperium. Several studies
Introduction: We describe the case of a 43-year-old healthy woman who show that sex hormones alter pro-coagulant protein levels, as well as pla-
repeatedly presented to Emergency department (ED) for nonspecific and telet and vessel wall functional status in a manner that may explain their
diffuse abdominal pain. CASE REPORT A 43-year-old woman was admitted influence on thrombotic risk. The risk increase of VTE due to HC use ranges
to our Internal Medicine ward in October 2016 after five days of increasing between 2- and 6-fold the basal risk in the general population. In order to
nonspecific abdominal pain; she was a non-smoker and she was not taking investigate the characteristics of venous thromboses associated with HC,
any chronic drug except for a combined hormonal contraceptive containing we retrospectively analyzed clinical data of all women aged from 15 to 49
0.02 mg ethinylestradiol and 3 mg drospirenone that she was taking since years discharged from the “Agostino Gemelli” University Hospital of Rome
8 months. The pain started suddenly and intensely, at first in epigastrium/ from 2009 to 2014 with a diagnosis of VTE. Medical written records of the
right upper quadrant, later spread to the entire abdomen, associated with hospital stay were reviewed to confirm the VTE diagnosis, to evaluate the
nausea, vomit and low grade fever. Her primary care physician prescribed presence of risk factors and to assess whether the patient was taking HC
paracetamol and scopolamine with no improvement of symptoms, so she at the time of admission. In the considered timeframe, 73395 women of
presented to the ED of another hospital. Physical examination was normal, childbearing age were discharged from our institution. Of those, 299 had
with no signs of peritonitis. Laboratory tests were within the normal ranges a codified diagnosis of VTE. After excluding venous thrombosis clearly
except for elevated C-reactive protein (8 mg/dL). Abdominal X-ray and related to local causes (such as catheter associated thromboses or portal vein
ultrasound revealed no abnormal findings either. She was discharged from thrombosis in liver disease) or with incomplete documentation we analyzed
the ED twice, on amoxicillin/clavulanic acid twice a day for a week. Within 168 cases. In 34 of them (20.2 %) HC use was the only VTE risk factor, 128
4 days the symptoms worsened, thus she presented to the ED of our hospi- out of 168 (76.2%) had one or more other major risk factors while 6 (3.6 %)
tal, where the abdominal ultrasound revealed a tubular hypoechogenic area had a VTE without occasional or stable risk factors. Among the 34 cases
in the pancreas region. Laboratory tests confirmed high C-reactive protein with hormonal related VTE 8 (23.5%) women had a deep vein thrombo-
(10 mg/dL), with a normal liver and pancreatic function. She was admitted sis (DVT), 6 (17.7%) had a pulmonary embolism (PE) with concomitant
to our Internal Medicine ward in order to undergo further tests for a better DVT, 6 (17.7%) had a cerebral vein thrombosis (CVT) and 14 (41.1%) ha
diagnostic definition of the pancreatic finding. At admission vital signs were an apparently isolated pulmonary embolism without a DVT (I-PE). Seven
stable (except for low grade fever-37.3°C), physical examination showed a women of the subgroup of I-PE underwent further imaging studies, that
diffuse pain of abdomen, without signs suggestive of peritonitis. We admi- means full abdominal doppler ultrasound or angio-CT scan of abdomen (3
nistered analgesic drugs without substantial benefit. Cholangio-MRI was women were studied for ruling out an occult malignancy and 4 for further
performed and revealed a inhomogeneous intraluminal hyperintense signal investigating the cause of abdominal or pelvic symptoms). All these women
in the superior mesenteric vein (SMV), suggestive for thrombosis. Both were found to have a pelvic vein thrombosis (PVT) which means thrombo-
Doppler ultrasound and Contrast-enhanced CT confirmed the presence ses of internal iliac veins with their tributaries and ovarian veins. As estro-
of thrombosis, describing an important intraluminal filling defect in the gen receptors (ER B) are strongly expressed on the endothelium of uterine
SMV extended for 5.3 cm, involving some affluent veins too. Fortunately (endometrial and myometrial) blood vessels, we hypothesize that HC may
no ischemic alterations of intestinal loops were observed. Contraceptive have a district-specific pro-thrombotic effect on pelvic vessels as well as
pill was promptly discontinued and systemic anticoagulant therapy (at first on cerebral vessels. Although with limitation, our findings support this
with low molecular weight heparin and then rivaroxaban) was started with a hypothesis and the need for further, specifically designed, studies. More-
rapid regression of the abdominal pain. In order to investigate the aetiology over, these data suggest that clinician should not forget to investigate this
of the thrombotic event, we assessed more specific tests for thrombophilia unusual site of thrombosis when dealing with hormonal contraceptive users
(homocysteine, factor V Leiden, factor VIII, antithrombin III, prothrom- presenting with an apparently I-PE or with pelvic symptoms.
bin mutation, JAK-2, C and S proteins, PNH antigen, autoimmunity tests
including antiphospholipid antibodies) that were all normal, also at the
subsequent follow-up check. Thus we concluded that the thrombotic event INTESTINAL ISCHEMIA IN HCC
was related to the use of contraceptive drug. We reported the event to the
Agenzia Italiana del Farmaco, realizing that it was the first severe adverse Erbi A., De Gioia S., D’Andria C.,1 Milano E.,2 Sogari F.
event related to this drug reported in Italy. After six months of anticoagu- U.O. Medicina Generale Ospedale Centrale SS Annunziata Taranto
lation therapy Doppler US showed complete recanalization of the superior (Direttore Dottor f. Sogari) 1SSD Allergologia e Immunologia Clinica
mesenteric vein. Rivaroxaban was interrupted and ultrasound follow-up at Ospedale SS Annunziata Taranto 2 Struttura Complessa Chirurgia Generale
2 months was still negative. DISCUSSION Mesenteric venous thrombosis Ospedale SS Annunziata Taranto
(MVT) is a rare condition accounting for 1 in 1000 ED admissions. Lack of
randomized clinical trials make controversial its management. Usual treat- Case report: female patient, 54 years old, caucasian. Cirrhosis of tha liver
ment of MVT is unfractionated heparin or low molecular heparin followed, correlated HBV, complicated by HCC. On the list for liver trasplant at the
in selected cases, by vitamin k antagonists. Direct oral anticoagulants have extra-regional center. Undergoig an antiviral drug treatment with Entecavir
not been studied for treatment of MVT but their use in new setting should 1 mg/per day, potassium canonate 200 mg/per day, furosemide 25 mg/day
be evaluated. Like pulmonary embolism, MVT should be considered a and propranolol 40 mg twice a day in secondary prevention for esophageal
medical emergency because of the high rate risk of intestinal infarction, if varices. She reports to the Emergency Room for the rectorrhagia, which
not promptly treated. Diagnosis in the early stages is very difficult because showed at home. Hematochemical tests are urgently performed, showing
patients usually present with nonspecific abdominal symptoms and no rele- Hb values of 15 g/dL, regular white blood cells and leukocyte formula, PLT
vant laboratory signs which must prompt to differential diagnosis of abdo- 66.000. INR 1,3. Hospitalized, the following is reported: 100/80 mm Hg
minal pain. On the contrary our patient was repeatedly discharged from blood pressure, afebrile, eupnoica, oriented in time and space, SpO2 98%
ED and the final diagnosis was incidental. The hallmark of MVT is pain, in AA. The objective examination showed a treatable abdomen, not painful
which is disproportional to the physical findings. A high index of suspicion to surface and deep palpation, lack of venous lines from collateral circles
is required for the diagnosis of mesenteric venous thrombosis, especially for and lack of objective signs of ascitic scum. A diagnostic program starts: the
patients taking hormonal contraceptive. haemocrome is set up, the home therapy is confirmed by adding disaccha-
rides, not responsable. SCORE MELD =13; Child-Pugg B 7. By performing
a sigmoidoscopy, it shows the presence of internal hemorrhoids, without
PELVIC VEIN THROMBOSIS AS A CAUSE OF recent bleeding signs and ECT abdomen confirms the splenomegaly liver
APPARENTLY ISOLATED PULMONARY EMBOLISM IN cirrhosis with HCC nodules, portal hipertention gallbladder lined with
WOMEN UNDER HORMONAL CONTRACEPTION edematoid walls containig dense bile. 2a hours after hospitalization, the
patient feels abdominal pain with localized pain in the abdominal lower
Nicolazzi M.A. 1, Carnicelli A. 1, Bonadia N. 1, Fuorlo M. 1, quadrants predominantly on the right, presenting a situation typical of the
Di Gennaro L. 2, Landolfi R. 1 acute abdomen. An abdominal TAC is performed with contrast medium,
1
Dipartimento di Scienze Mediche, Università Cattolica del Sacro Cuore, the HCC situation was highlighted and the presence of a thrombosis of the
Fondazione Policlinico Gemelli, Roma, Italia; 2 Servizio di Malattie lower quarry vein extended for about 5 cm, whichcauses a caliber reduction
Emorragiche e Trombotiche, Università Cattolica del Sacro Cuore, of about 55% of the lumen. On the rigth pelvic seat it shows a stretch of
51
ileum with thickened, edematous walls, with appearent stretched meso, with prevented muscle damage in a mouse model of peripheral artery disease
edemigenal semblance of the surrouding fet tissue. The patient is promptly (PAD). e-sEV angiogenic proteomic and transcriptomic analyses show a
taken the operating theatre and undergoes ileale resection (about 40 cm) positive correlation with matrix metalloproteinase activation and extra-
caused be segmental ischemia of the helium. The postoperative process is cellular matrix organization, cytokine and chemokine signaling pathways,
regular withaut any signs of mismatch and/or liver insufficiency. The antico- Insulin-like Growth Factor and platelet pathways, and Vascular Endothelial
agulant therapy with warfarin, which begins right after the surgery, resulted Growth Factor signaling. A discrete gene signature, which highlights diffe-
in the resolution of the thrombotic condition and has subsequently allowed rences in e-sEV and ineffective-EV biological activity, was identified using
the patient to undergo successfully the hepatic transplantation. The throm- gene ontology (GO) functional analysis. An enrichment of genes associated
bophilic study showed the heterozygous mutation of factor v of Leiden. Np with the Transforming Growth Factor beta 1 (TGFb1) signaling cascade is
other major alteration, except for the reduction of some coagulation factors associated with e-sEV administration but not with ineffective-EVs. Chro-
compatible with liver failure. The mutation of factor V of Leiden is respon- matin immunoprecipitation analysis on the inhibitor of DNA binding
sible for the 3-7% of portal thrombosis. I (ID1) promoter region, and the knock-down of small mother against
Just like many tumors, even the HCC is associated with the activation of decapentaplegic (SMAD)1-5 proteins confirmed GO functional analyses.
hemostatic processes and the incidence of portal venous thrombosis is Overall, we have shown that EVs displaying pro-angiogenic potential can
variable (20-65%). Since portal thrombosis is a severe limitation to liver be obtained from the serum of healthy donors. We have identified a simple
transplatation, the anticoagulant therapy may be addressed to patients with in vitro test to predict serum-EV angiogenic potential in vivo. The GO-ba-
total o partial portal thrombosis who risk an exclusion from the transplant sed functional analysis of ECs recovered from the capillary-like structures
list. The case described focuses on an uncommon possibility of cirrhosis formed in response to i-sEVs and e-sEVs have identified a gene signature
with HCC: thrombosis of the lower cava vein. In all those subjets presen- which sheds light on their varying biological activity. More importantly, our
ting HCC, the hypotesis of a thrombotic extension to the lower caval system data provide the scientific rationale for the use of sEVs as an alternative
should not be underestimated for the acute complications that may arise (in therapeutic option for vascular remodeling, better local perfusion and pro-
our case an acute secondary abdomen with intestinal ischemia), worsening tection against muscle damage in patients with PA.
the disease evolution to an unfavorable way, or by preventing treatment-
such as liver transplantation. Only an early diagnosis allows you to treat
the patient as soon as possible with more affressive therapeutic approa- METABOLIC SYNDROME IS AN INDEPENDENT
ches,which cannot be performed atan advanced phase of illness.it is obviou- PREDICTOR OF ATRIAL FIBRILLATION: DATA FROM
sly important to carry out a thorough research of the hereditary or acquired THE “CATANZARO ATRIAL FIBRILLATION PROJECT”
prothrombotic conditions. A complete thrombophilia screening allows you
to recognize more than one risck factor over 40% of patient. Sciacqua A. 1, Perticone M. 2, Miceli S. 3, Colica C. 6, Pinto A. 1, Cassano V. 4,
Main Points: Magurno M. 1, Iannello A. 1, Anastasio L. 5, Sesti G. 1, Perticone F. 1
1) The clinical presentation of this case was insidious (rectal cancer in 1
Dipartimento di Scienze Mediche e Chirurgiche - Università degli Studi
patient with portal hypertention and previous incident of bleeding of the Magna Graecia - Catanzaro 2Dipartimento di Medicina Sperimentale
esophageal varices) leads to a hemorragic complication. e Clinica - Università degli Studi Magna Graecia - Catanzaro 3Azienda
2) The dramatic evolution in acute abdomen and the following surgical ope- Ospedaliero-Universitaria “Mater Domini” - Catanzaro 4Dipartimento di
ration for intestinal ischemia, caused by thrombosis of the lower vein, has Scienze della Salute - Università degli Studi Magna Graecia - Catanzaro
revelaed a thrombotic complication. 5
Azienda Ospedaliera “G. Jazzolino” - Vibo Valentia 6CNR c/o IBFM-UOS
3) The thrombophilic study and the presence of the heterozygous mutation Catanzaro
of the factor V of the Leiden confirms that even in a HCC secondary portal
throbosis and hance due to known causes, it is necessary to avoid neglecting Growing evidences demonstrate that atrial fibrillation (AF) can be consi-
the search for possible additional risk factors. dered as a clinical manifestation in the context of the global cardiovascular
(CV) risk profile. Several clinical conditions are recognized as risk factors
for AF; in this context metabolic syndrome (MS), that represents a cluster of
SERUM-DERIVED EXTRACELLULAR VESICLES (EVS) metabolic and hemodynamic disorders, may play a crucial role in the deve-
IMPACT ON VASCULAR REMODELING AND PREVENT lopment of AF, by promoting subclinical organ damage, in particular renal
MUSCLE DAMAGE IN PERIPHERAL ARTERIAL DISEASE dysfunction with hydrosaline retention and CV damage with atrial remo-
(PAD) deling. Although there are some epidemiological studies, sometimes confli-
cting, that report the association between MS and AF, it is not clear whether
Brizzi M.F. 1, Cavallari C. 1, Ranghino A. 1, Tapparo M. 1, MS remains an independent predictor of AF even after correction for pos-
Cedrino M. 1, Figliolini F. 1, Grange C. 1, Giannachi V. 1, Garneri P. 2, sible confounding factors. Thus, the aim of this study was to evaluate, in a
Deregibus M.C.1, Rispoli P. 2, Camussi G. 1 large and well- characterized cohort, the possible association between MS
1
Department of Medical Sciences, 2i3T Scarl, University of Turin, Turin, Italy and AF appearance, even after correction for known CV risk factors, kidney
2
Department of Surgical Sciences, University of Turin, Turin, Italy function and left atrial dimensions. We conducted a prospective popula-
tion-based study, enrolling 4322 Caucasian outpatients, aged 59.2 ± 11.7
Peripheral arterial disease (PAD) is a rife condition caused by the athe- years, with CV risk factors referred to our tertiary care setting for CV and
rosclerosis of the peripheral arteries. Although surgical or endovascular metabolic screening program. The diagnosis of MS was performed accor-
intervention are still the standard therapy for improving blood flow, most ding to modified ATP III criteria. Left atrial volume (LAV) was measured
patients complain of persistent or recurring symptoms even after successful by an echocardiographic examination and indexed (LAVI) for body surface,
revascularization. This implies that new therapeutic options for PAD are according to the American Society of Echocardiography recommendations.
very much still a major unmet need. The formation of newly born capillary Renal function was evaluated by measurement of estimated glomerular
blood vessels, neovascularization, is a crucial event in rescuing tissue after filtration rate (e-GFR) with CKD-Epi formula. Follow-up evaluation was
ischemia. A vast array of pre-clinical and clinical data indicates that stem performed every 6 months and it was improved by contacting patients by
cells can contribute to the healing processes by improving vascularization. phone, or by mailing a questionnaire to family physicians. AF diagnosis was
However, the transient detection of stem cells at the site of tissue damage has made by standard electrocardiogram, hospital discharge diagnoses, and by
suggested that paracrine mechanisms may contribute to stem cell action. the all-clinical documentation provided by the patients. During a mean fol-
“Exosomes”, vesicles derived from the endosomal membrane compartment low-up of 42.8 ± 21.5 months, there were 546 new cases of AF, accounting
by exocytosis, and “ectosomes/microvesicles”, vesicles (EVs) generated by for an incidence of 4.5 events/100 patients-year, the AF incidence was signi-
the budding of cell plasma membranes are included among such paracrine ficantly higher in MS patients in comparison with those without (5.6 vs 2.4
mechanisms.EVs that have been physiologically released from several cell events/100 patients-year, p<0.0001). In the multiple Cox regression analysis,
types can be detected in biological fluids, including blood.. As a matter of including all traditional CV risk factors, age (HR = 1.649, 95 %CI = 1.520–
fact, the past two decades have seen exosome also being detected in body 1.789), LDL-cholesterol (HR=1.033, CI95%:1.011-1.056), body mass index
fluids.The EVs present in blood could therefore be an important resource (HR= 1.031, CI95%:1.018 -1.045), LAVI (HR=1.424, CI95%:1.353 -1.499)
for regenerative medicine. More importanly, serum represents an abun- and MS (HR=1.573, CI95%:1.298-1.906) were retained as independent
dant and accessible source of circulating EVs. Therefore, serum-EV (sEV) predictors of incident AF, on the contrary e-GFR was a protective factor
pro-angiogenic capability and mechanism of action were herein analyzed. (HR=0.884, CI95%:0.852 -0.918). Of interest, MS after age, was the second
By using an in vitro assay we were able to predict sEV angiogenic poten- strongest predictor of AF. The present study confirmed a strong association
tial in vivo. Effective sEVs (e-sEVs) also improved vascular remodeling and between MS and risk of AF and demonstrated that MS remains an indepen-
52
dent predictor even after the correction for left atrial enlargement and renal (CMD) is a putative reason for worse outcomes in women. Hypothesis: To
dysfunction. The mechanisms responsible for this association are probably explore sex and gender-sensitive determinants of CMD in IHD patients.
represented by insulin resistance and hyperactivation of the sympathetic Methods: The Endocrine Vascular disease Approach (EVA) is an
nervous and renin-angiotensin system that with exaggeration of prolifera- ongoing monocentric observational study (ClinicalTrials.gov Identifier:
tive and profibrotic mechanisms, could promote morpho-functional and NCT02737982), aimed to assess sex- and gender-specific interactions
electrical atrial remodeling that may justify the increased susceptibility to between coronary circulation, hormonal status and platelet function. Con-
AF occurrence in these patients. secutive IHD patients undergoing urgent or elective angiography with or
without percutaneous coronary interventions (PCI) were enrolled. CMD
was assessed using myocardial blush grade (MBG). Baseline clinical, phar-
A RDW-BASED CLINICAL SCORE (RE-AHF SCORE) macological and sociocultural parameters were recorded.
PREDICTS ONE-YEAR MORTALITY IN PATIENTS Results: One hundred and sixty-three patients (mean age 67±11 years;
HOSPITALIZED WITH ACUTE HEART FAILURE: A 39% women) were analyzed. The referral reason for angiography was acute
DERIVATION AND VALIDATION STUDY coronary syndrome in half cases, regardless sex. A previous IHD diagno-
sis was reported more frequently in men, women were less smokers, more
Melchio R., Giraudo A., Rinaldi G., Testa E., Leccardi S., Falcetta A., frequently retired and widow, less adherent to medication therapy (all,
Serraino C., Bracco C., Pomero F., Silvestri A., Fenoglio L. p<0.05). The Duke Activity Status Index identified a worse performance
S.C. Medicina Interna, A.O. S. Croce e Carle, Cuneo status in women compared to men (28.2±18 vs 38.3±17, p=0.0002). The
median in-hospital stay was longer in women (9 [6-17.5] vs 7 [4-12.5] days,
Background: Acute heart failure (AHF) is a leading cause of hospitalization p=0.032). CMD (defined by MBG<2) was significantly more frequently
and increasing burden on health care systems. Accurate risk stratification detected in women compared to men (48% vs 31%, p=0.034). Ischemia
of patients hospitalized with AHF could improve clinical outcomes and with no obstructive coronary disease was prevalent in women (40% vs 25%,
resource allocation. In a previous study we found that Red cell Distribu- p= 0.017). In the subgroup of patients undergoing PCI (n=68, 41.7%) the
tion Width (RDW), routinely reported in complete blood cell counts, is a no-achievement of optimal microvascular reperfusion (MBG=3), despite
powerful prognostic marker in patients with AHF. Our aim was to create optimal restoration of epicardial flow, was higher in women compared to
and validate a clinical score based on RDW to predict one-year mortality in men (86% vs 56%, p=0.015). In the multiple regression analysis, only female
patients hospitalized for AHF. sex was independently associated to CMD (OR 2.02, 95% CI 1.05-3.88,
Methods: The study consisted of a retrospective derivation cohort and a p=0.034) and to a MBG<3 after PCI (OR 4.88, 95% CI 1.26-18.7, p=0.022).
retrospective validation cohort. Fourty-four demographic, medical history Conclusions: Female sex is significantly associated with both CMD and
and laboratory candidate variables were collected. In the derivation cohort, worst myocardial perfusion after PCI. The further exploration of hormonal
multivariate Cox proportional hazard model was used to identify variables balance and platelet reactivity, as well as availability of outcomes data in
associated with survival and to develop the RE-AHF score. In validation the EVA cohort, will provide deepen insights to analyze this phenomenon.
cohort the predictive performance of the score was assessed by discrimina-
tion (c-index) and calibration analysis.
Results: In the derivation cohort, 436 patients admitted from the Emer- HLA AND KILLER CELL IMMUNOGLOBULIN-LIKE
gency Department (ED) for AHF from 1th January to 31 December 2013 in RECEPTOR (KIRS) GENOTYPING IN PATIENTS
S. Croce e Carle Hospital, Cuneo were included and followed up for 1 year. WITH ACUTE ISCHEMIC STROKE AS POSSIBLE
Patients from the derivation cohort had a mean age of 77,6+11 years; 52,3% PATHOGENETIC BASIS OF STROKE SUSCEPTIBILITY
were men; 35,4% had preserved left ventricular ejection fraction. Validation AND OF ACUTE PHASE IMMUNOINFLAMMATORY
cohort consisted of 384 patients admitted from 1th January to 31th Decem- ACTIVATION
ber 2015 for AHF in the same hospital from the ED: mean age was 79,3+9,4
years; 52% were men; 38,3 % of patient had preserved left ventricular ejection Tuttolomondo A. 1, Pecoraro R. . 1,6, Casuccio A. 3,
fraction. All cause one-year mortality rate in the derivation and validation Di Raimondo D. 1, Di Bona D. 5, Aiello A. 3, Accardi G. 3,
cohort were respectively 26,4% and 26,6%. In the derivation cohort, Cox Arnao V. 4, Clemente G. 5, Della Corte V. 1, Maida C. 1,
multivariate analysis identified seven independent predictors for death at 1 Simonetta I. 1, Caruso C. 3, Squatrito R. 6, Pinto A. 1
year: age, systolic blood pressure, Charlson comorbidity score, impairment 1
U.O.C di Medicina Interna e Cardioangiologia, Dipartimento Biomedico
on Activity of Daily Life scale, Red Cell Distribution (RDW)>14.5, incre- di Medicina Interna e Specialistica (Di.Bi.M.I.S), Università degli Studi
ase RDW during hospitalization, NTproBNP (all p<0,05): this model was di Palermo. 2 Dipartimento di Scienze per la Promozione della Salute e
used to develop the RE-AHF score. The predictive accuracy of the RE-AHF Materno Infantile “G. D’Alessandro”, Universita’ degli Studi di Palermo
score showed a good discrimination (c index 0,82 (95% CI 0.77-0.86) and (Italy). 3 Dipartimento di Biopatologia e Biotecnologie Mediche, Universita’
0,78 (95%CI 0.72-0.83) in the derivation and validation cohort respectively, degli Studi di Palermo (Italy). 4 Dipartimento di BioMedicina Sperimentale e
and calibration. If NTproBNP was removed from the score, overall accuracy Neuroscienze Cliniche, Università degli Studi di Palermo (Italy) 5 School and
decreased not significantly (c index 0,79 (IC 95%: 0.74-0.84) and 0,75 (IC Chair of Allergology, Dipartimento delle Emergenze e Trapianti d’Organo,
95%: 0.69-0.80) in the derivation and validation cohort respectively. University of Bari, Bari Italy 6 Pronto Soccorso Unit, Giuseppe Giglio
Conclusions: we derived and validated a simple prognostic score that Hospital, Cefalù (Italy)
include RDW and commonly available clinical variables in patients admit-
ted for AHF. Application of this algorithm could help identify patient who Background: In humans, a major component of NK and T cell target reco-
benefit from individualized strategies or interventions. gnition depends on the surveillance of human leukocyte antigen (HLA)
class I molecules by killer immunoglobulin-like receptors (KIRs), a family
of diverse activating or inhibitory receptors that are expressed on the
SEX AND GENDER DIFFERENCES IN ISCHEMIC HEART surface of NK cells and T-cell subsets. Inflammation and T cell activation
DISEASE FROM BENCH TO BEDSIDE: ENDOCRINE have been also described as involved in pathophysiology of complications
VASCULAR DISEASE APPROACH (EVA) PRELIMINARY of atherosclerosis such as acute ischemic stroke, nevertheless no study has
DATA yet evaluated the relationship between KIR haplotypes and HLA alleles and
acute cerebrovascular disease. Aims: to implement the knowledge about the
Raparelli V. 1, Proietti M. 2, Romiti G.F. 2, Toriello F. 2, Ruscio E. 2, Sperduti immunological and genetic background of acute ischemic stroke suscepti-
N. 2, Santangelo G. 2, Visioli G. 2, Mangieri E. 3, bility in relation to the expression of the KIR and HLA alleles and to further
Tanzilli G. 3, Lenzi A. 1- On behalf of Endocrine Vascular Approach (EVA) characterize immune-inflammatory degree of the acute phase of ischemic
Group stroke by means evaluation of peripheral frequency of CD28 null cells in
1
Department of Experimental Medicine, Sapienza University of Rome, Rome, a sample of patients with acute stroke in comparison to subjects without
Italy 2Department of Internal Medicine and Medical Specialty, Sapienza ischemic stroke and contribute to the definition of a possible risk profile of
University of Rome, Rome, Italy 3Department of Cardiovascular, Respiratory, stroke susceptibility.
Nephrologic, Anaesthesiologic and Geriatric Sciences, Sapienza University of Methods: Between November 2013 and July 2016, all consecutive patients
Rome, Rome, Italy with acute ischemic stroke were recruited from Internal Medicine with
Stroke Care ward of Policlinico “P. Giaccone”, University of Palermo and
Introduction: Improvements in ischemic heart disease (IHD) management Pronto Soccorso Unit of Giuseppe Giglia Hospital, Cefalù (Palermo). As
have been unbalanced between sexes. Coronary microvascular dysfunction controls we enrolled consecutive healthy subjects without acute ischemic
53
stroke and without exclusion criteria (see above). Peripheral blood mono- of 85, neoplasia, chronic inflammatory disease, chronic infection, and all
nuclear cells (PBMCs) have been obtained by density gradient centrifu- conditions that could activate TH17-inflammatory pathways. As result we
gation using the Lymphocyte Separation Medium (ICN Pharmaceutical, found that there was a statistically significant difference in IL-17 plasma
Costa Mesa, CA). The population of CD4+CD28null was expressed as a levels between the groups, much higher in metabolic syndrome patients
percentage of CD4+ cells (CD4+CD28null and CD4+CD28+). Periphe- (15.73 ± 11.84 pg/ml vs 6.54 ± 4.38 pg/ml; P= <0.01). Furthermore IL-17
ral whole blood samples was collected and genomic DNA was extracted levels were strictly related to the vascular damage in terms of carotid IMT
from leukocytes by a commercial kit. Using the polymerase chain reaction (R=0,200; P=0.03).
sequence-specific primer (PCR-SSP) technique, the DNA subjects with Conclusions:: IL-17 contributes to preclinical vascular damage, in terms
acute ischemic stroke and subjects without stroke were genotyped for the of carotid IMT, in metabolic syndrome but not to functional one. IL-17
presence of the 3 major KIR ligand groups, HLA-C1, HLA-C2, and HLA- appears to be an independent risk factor to the progression of atherosclero-
Bw4, both HLA-B and HLA-A loci. sis in metabolic syndrome.
Results: 116 patients with acute ischemic stroke were analyzed and 66 Bibliography: [1] A.D. Lopez, C.D. Mathers, M. Ezzati, D.T. Jamison, C.J.
subjects without acute ischemic stroke. Subjects with acute ischemic stroke Murray, Global and regional burden of disease and risk factors, 2001: syste-
in comparison to subjects without acute ischemic stroke showed a signifi- matic analysis of population health data, Lancet 367 (2006) 1747-1757 [2]
cantly higher frequency of 2DL3, 2DL5B, 2DS2 and 2DS4 KIR haplotypes Salvatore Novo, Gisella Rita Amoroso e Giuseppina Novo, Aterosclerosi
and a significantly lower frequency of HLA-B-Bw4I allele. With regard of preclinica e rischio cardiovascolare globale, EDIMES, Pavia 2008 [3] Gaffen
interaction of HLA and KIR haplotypes, subjects with acute ischemic stroke SL. Structure and signalling in the IL-17 receptor family, Nat Rev Immunol.
showed no significant difference with regard of frequency of co-expression 2009; 9:556-567 [4] Soraya Taleb, Alain Tedgui, Ziad Mallat, IL-17 and Th
of any considered HLA and KIR haplotype, whereas subjects without acute 17 in Atherosclerosis: Subtle and Contextual Roles, Arterioscler Thromb
ischemic stroke showed a higher frequency of 2DS2 -HLAC2 co-expression. Vasc Biol. 2015; 35:258-264
The multiple logistic regression analysis considering variables predictive of
the occurrence of acute ischemic stroke showed a protective effect of HLA-
B-Bw4I and of 2DL2-HLAC1, 2DS2-HLAC2 and a detrimental effect of GASTROINTESTINAL COMPLICATIONS IN COMMON
2DL2-HLA-C1_A HLA-KIR interactions. We also observed an higher fre- VARIABLE IMMUNODEFICIENCY DISEASES (CVID)
quency of 2DL3 and 2 DL4 KIR haplotype in subjects with LAAS subtype.
Conclusions: Our findings of a prevailing KIR phenotype of patients with Carrabba M. 1, Dellepiane R.M. 2, Lovaste S. 2, Dell’Era L. 2, Baselli L. 3,
acute ischemic stroke as predominantly excitatory are consistent with fin- Pietrogrande M.C. 3, Fabio G. 4
dings previously reported in patients with acute coronary syndrome and Internal Medicine Department, Fondazione IRCCS Ca’ Granda Ospedale
unstable atherosclerotic plaques.The higher frequency of a “proinflamma- Maggiore Policlinico di Milano, 2Department of Pediatrics, Fondazione
tory”genotype in subjects with ischemic stroke could explain the reported IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, 3Department of
immunoinflammatory activation of the acute phase of ischemic stroke Pediatrics, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di
whereas the prevalent inhibitory profile observed in subjects with athero- Milano & Università degli Studi di Milano, 4Internal Medicine Department,
sclerotic (LAAS) subtype of ischemic stroke could also represent one pos- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano &
sible explanation of a pathogenetic background as well of plaque event of Università degli Studi di Milano
cerebral thromboembolism on the basis of recent reports indicating that
interaction of the inhibitory KIR with the HLA ligand functions not only to Background: Common Variable Immunodeficiency Disorders (CVID) are
inhibit NK cell activation, but also serves to prime the particular NK cell for a group of primary immunodeficiencies characterized by lack in humoral
activation in the absence of self. This activation after initial inhibition has response and increased risk of infection. Its prevalence is estimated at 1 in
been reported as “ licensing”. Future studies will be addressed to evaluate the 25,000 to 50,000. CVID is diagnosed if levels of at least 2 immunoglobulin
role of KIRs haplotypes and HLA alleles in relation of stroke outcome and of isotypes (IgG and IgA, IgM, or both) are below the normal range, together
cerebral event recurrences. with a reduced specific antibody response to vaccination and/or frequent
infections. CVID is a B-cells defect, but also the T-cells function can be
affected. Non-infectious inflammatory, autoimmune, and lymphoprolifera-
ROLE OF INTERLEUKIN 17 IN PRECLINICAL VASCULAR tive complications are also present in CVID. Gastrointestinal involvement
DAMAGE IN METABOLIC SYNDROME (GI) in CVID is reported in 9-20% of patients. Acute or chronic infectious
diarrhea is the most frequent manifestation. Non-infectious enteropathy
Veca V. 1, Bellofatto I. 1, Lupattelli G. 1, Siepi D. 1, Cosentino T. 1, Vacca C. 2, resembling Crohn’s disease, ulcerative colitis, or celiac disease occurs in 10
Vaudo G. 1 to 12% of CVID patients. Between 8 and 22% of CVID subjects develop
1
Internal Medicine, Department of Medicine, University of Perugia, Italy; 2 granulomatous disease in the liver or the GI tract. We describe clinical pre-
Pharmacology Section, Department of Experimental Medicine, University of sentation of GI involvement and features of a monocentric cohort of CVID
Perugia, Italy patients.
Methods: Medical records of patients with CVID, both children and adults,
Objective: Clinical complications of atherosclerotic pathology such as referred at Fondazione IRCCS Ca’ Granda Ospedale Policlinico in Milan
myocardial infarction, stroke and peripheral arterial disease represent the have been analyzed.
primary cause of mortality and morbidity worldwide [1]. Along with tra- Results: CVID patients enrolled were 34, 4 children and 30 adults. Median
ditional modifiable risk factors such as dyslipidaemia, smoking, hyperten- age is 33.5 years, ranged 11-70. The prospective follow-up mean time is 9
sion, diabetes mellitus, obesity and alcohol, and unmistakable ones such as years (range 2-37). All patients are under immunoglobulins replacement
familiarity, age, gender, an increasing interest has recently been placed on therapy. Gastrointestinal symptoms were present in 13 adult patients
so-called “emerging risk factors”. In this latter group belong metabolic syn- (38.2%): 3 epigastric pain/dyspepsia, 7 chronic or relapsing diarrhea and
drome, homocysteine, alpha lipoprotein, chronic infections and markers of 3 both symptoms. None of the children with CVID complained about
inflammation and bioumoral [2]. Interleukin 17 (IL-17), the characteristic gastrointestinal symptoms. Five patients had stool cultures positive for
cytokine of the subset of T helper 17 cells [3], plays a pivotal role in pro- Salmonella, Campylobacter, Clostridium, Norovirus, and Rotavirus. Four
tecting the host against extracellular pathogens, but acts at the same time patients were diagnosed with gastritis (one H. pylori positive), 4 with celiac
promoting inflammation in autoimmune diseases [4]. IL-17 is involved in disease, 5 with lymphocytic colitis and 1 with ulcerative colitis. Granulo-
many inflammatory processes, but its role in atherosclerosis remains con- matous liver disease was found in 3 patients with biopsy confirmation of
troversial [5-7]. non-caseating granulomas. Two patients were found to have chronic viral
Methods and Results: Goal of the study was to identify the role of IL-17 in infection: Cytomegalovirus and Epstein-Barr virus. The specific treatment
preclinical vascular damage in metabolic syndrome. We compared 80 meta- to the isolated pathogen solved diarrhea only transiently. Two patients need
bolic patients (NCEP-ATP III criteria) with a sex and age-matched non-high chronic budesonide treatment. Gluten-free diet ameliorates symptoms in
risk control group, evaluating in both groups functional and morphologic celiac disease, but diarrhea often relapses. Two patients temporary solved
vascular damage (arterial stiffness; carotid intima-media thickness; bra- symptoms with local mesalazine. All adults CVID patients are under
chial FVM and carotid plaque echogenicity), common cardiovascular risk chronic probiotics therapy.
factors (dyslipidaemia, smoking, hypertension, diabetes mellitus, hypergli- Conclusions: Internist and Gastroenterologist should be aware that cli-
cemia, obesity), serum markers of inflammation (ESR and CRP) and levels nically and endoscopically CVID may mimic other conditions e.g. celiac
of IL-17. Blood level of IL-17 was determined with ELISA (enzyme-linked disease and IBD. However, histopathologic biopsies with few or absent
immunosorbent assay). Exclusion criteria for the enrollment were age major plasma cells and low intestinal IgA and IgM are features of a CVID ente-
54
ropathy. However, despite CVID is diagnosed and replacement therapy Table 1: Diagnostic criteria of hypocomplementemic urticarial vasculitis
addressed, diagnosis of gastrointestinal involvement in CVID is challen- syndrome (HUVS)
ging because patients can be paucisymptomatic and pathologists need spe-
cific experience to recognize CVID histologic features. Furthermore, low Table 1: Diagnostic criteria of hypocomplementemic urticarial vasculitis
mucosal IgA levels may lead to luminal bacterial overgrowth. According to syndrome (HUVS)
numerous reports about the impact of alterations of the microbiota for the
pathogenesis of IBD, intestinal inflammation in CVID may also be triggered
Major Criteria Minor Criteri
by infectious agents. Whether or not this hypothesis can be further suppor-
ted remains to be determined. Recurrent urticaria Minor Criteri
Hence, management of chronic diarrhea is difficult, because these patients Hypocomplementemia Biopsy-proven vasculitis of dermis
often fail to respond to conventional therapies. The preventive use of pro- Positive C1q antibodies and/or suppressed
biotics is still controversial. C1q levels
Glomerulonephritis
Arthralgia/Arthritis
A CASE OF HYPOCOMPLEMENTEMIC URTICARIAL Ocular Inflammation
VASCULITIS SYNDROME (HUVS) SUCCESSFULLY Recurrent abdominal pain
TREATED WITH OMALIZUMAB
Nucera E. 1, Basta F. 2, Buonomo A. 1, Mezzacappa S. 1, Margiotta D.P. 2,

Antonelli Incalzi R. 3, Schiavino D. 1 1equally contributed AN INTERESTING CASE OF ABDOMINAL PAIN
1
Unità di Allergologia, Università Cattolica del Sacro Cuore - Policlinico
“A. Gemelli”, Roma; 2 Unità di Immunoreumatologia, Università Campus Di Stefano V. 1, Maira D. 1, Hu C. 2, Della Corte G. 2, Minonzio F. 2,
Bio-medico di Roma; 3 Unità di Geriatria, Università Campus Bio-medico di Cappellini M.D. 2
Roma 2
Dipartimento di Medicina Interna (U.O. Medicina Interna 1A) -
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico 1Scuola di
We present a 47-year-old woman without relevant comorbidities who refer- specializzazione in Medicina Interna - Università degli Studi di Milano
red to our University Allergy Center with a 3-year history of generalized,
itchy and burning daily flares of urticaria. She also complained arthralgia, Introduction:. We describe a case of a woman with abdominal pain and
abdominal pain and diarrhea. On admission, physical examination revealed fever who was admitted to our Internal Medicine ward on april 2017.
diffuse vasculitic itching lesions and symmetric arthritis of second and third Case Report: A 63 years woman presented to our Emergency Department
proximal phalangeal and metacarpal joints. Blood tests were normal with for intense abdominal pain associated with low grade fever. A high respira-
the exception of a strong complement depletion (C3 0.17 g/L, normal range tory tract inflammation requiring treatment with Levofloxacin was repor-
0.9-1.8, C4 0.24 g/L, normal range 0.1-0.4). She had no infections, no appa- ted in her recent medical history. Immediately after, she started to trouble
rent major organ involvement, no antibody positivity, normal IgE serum with abdominal pain without vomit or any bowel change. Because of cli-
levels, normal thyroid parameters and negative physical testing. Antihista- nical suspicion of diverticulitis, she was treated with Rifaximin. Since the
mines and prednisone 8 mg/die were administered with no relief of symp- worsening of symptoms and persistence of fever, she came to the hospital.
toms and no improvement of urticaria. Colonscopy was also negative. A Her past medical history was significant for follicular lymphoma in remis-
skin biopsy was performed and showed perivascular and dermic eosinophi- sion and maintenance with Rituximab, hypertension, asymptomatic pul-
lic infiltrates with focal vessel damage confirming urticarial vasculitis. The monary embolism for which she was taking Rivaroxaban.On admission to
patient fulfilled diagnostic criteria for HUVS1 so antihistamines (up to four our Internal Medicine ward the patient was alert and cooperative, her vital
times per day) in combination with hydroxychloroquine (200 mg/day), pre- signs were within normal limits, except for body temperature that was 38.4
dnisone (0.5 mg/kg being tapered to 0.1 mg/kg) and cyclosporine A (CSA °C. The physical examination revealed reduced breath sounds on lung bases
3 mg/kg) (soon suspended for worsening of diarrhea) were administered. bilaterally. No alterations of peripheric pulses were found. Examination
A significant improvement of arthralgia was achieved with no response on of heart, skin, joints, and neurologic system was normal. During the first
gastrointestinal involvement and urticaria (Urticarial Activity Score (UAS) days of hospitalization the patient complained of abdominal pain at night.
of 32 points). Omalizumab 300 mg monthly was added and after the second Fever did not recede despite empirical treatment with a broad-spectrum
injection complete remission of gastrointestinal symptoms and urticarial antibiotic (Piperacillin/Tazobactam and Amikacin). Furthermore it was
(UAS of 0) was achieved and then maintained for the entire duration of necessary to administered low oxygen flows for desaturation. The findings
the treatment (25 weeks). Complement serum levels normalized allowing of laboratory blood analysis highlight normocitic anemia, rising of white
a gradual prednisone discontinuation. One month after Omalizumab with- cells with monocytosis, PCR, procalcitonin and VES. Liver, renal function
drawal the patient presented a stronger exacerbation of diarrhea, abdominal tests, serum electrophoresis, beta2 microglobulin, complement (C3,C4) and
pain and urticaria (UAS of 37 points). Omalizumab 300 mg monthly was immunoglobulin were within normal range. CMV-DNA, EBV-DNA, HBV,
so readministered leading to a complete remission of urticaria (UAS of 0) HCV, HSV1, HSV2, Syphilis, Parvovirus serology tests and quantiferon
and gastrointestinal symptoms. Management of HUV is very challenging: were negative, as well as ANA, ENA and ANCA antibodies. Galactomannan
while oral antihistamines are just palliative, hydroxychloroquine (HCQ), antigen was negative too. No evidence of bacterial infection was detected on
colchicine and corticosteroids represent first-line therapy, with a complete blood culture. A contrast-enhanced total body computed tomography (CT)
cutaneous response achieved in less than 50% patients. Other immunosup- examination subsequently performed showed abnormal thickening (enhan-
pressive drugs, especially Cyclosporine (CyA), cyclophosphamide (CYC) ced postcontrast and not calcified) of the descending thoracic aorta wall
and rituximab (RTX), have higher rates of efficacy, although they are burde- extending beyond the diaphragmatic hiatus surrounding the origin of the
ned, as well as steroids, by higher incidence of side effects2. Omalizumab, a celiac artery. The wall of the aortic arch was also involved but neck vessels
humanized anti-IgE monoclonal antibody recently approved for treatment and all major abdominal aorta branches (except for celiac artery), including
of chronic spontaneous urticaria (CSU)3, has been recently shown to be not mesentery trunks, looked spared. Aortic diameters were normal. Pleural
effective in a case of HUVS4. This is, to our knowledge, the first report of effusions were also observed. There was no evidence of diverticulitis or any
successful treatment of HUVS with Omalizumab. abdominal disease. A total body PET CT scan confirmed the diagnosis of
References: 1. Schwartz HR, McDuffie FC, Black LF, Schroeter AL, Conn aortitis demonstrating FDG accumulation of thoracic and proximal abdo-
DL. Hypocomplementemic urticarial vasculitis: association with chronic minal aorta and no uptake in any other vessels, temporal arteries included.
obstructive pulmonary disease. Mayo Clin Proc 1982;57:231–8. 2. Sussman The patient was later studied with transesophageal echography and echo
G, Hébert J, Barron C, Bian J, Caron-Guay RM, Laflamme S et al. Real-life color doppler of the supraaortic vessels and temporal arteries. Both endo-
experiences with omalizumab for the treatment of chronic urticaria. Ann cardial vegetations and involvement of any other vessels were excluded.
Allergy Asthma Immunol. 2014 Feb;112(2):170-4. 3. Jachiet M, Flageul B, Whereas we believed that priority was to avoid the risk of aortitis compli-
Deroux A, Le Quellec A, Maurier F, Cordoliani F et al. The clinical spectrum cations, we speed up in starting immunosuppressive treatment so that no
and therapeutic management of hypocomplementemic urticarial vasculitis: histopathologic diagnosis was attempted. The patient was treated with corti-
data from a French nationwide study of fifty-seven patients. Arthritis Rheu- costeroids with an amazing response: in twenty-four hours abdominal pain
matol. 2015 Feb;67(2):527-34. 4. Aurich S, Simon JC, Treudler R. Omalizu- and fever receded.
mab does not improve skin lesions in a patient with hypocomplementemic Conclusion: Aortitis is a general term denoting inflammation of the aortic
urticarial vasculitis syndrome. J Eur Acad Dermatol Venereol. 2017 Mar 8.
55
wall that can occur in infectious and non-infectious conditions. Infectious and D-dimer 1431.8±323.8 ng/ml) and in patients with CSU (F1+2
aortitis is a rare but potentially life-threatening disorder: when aortitis is 464.0±105.4 pmol/l and D-dimer 545.1±139.9 ng/ml) in comparison with
found, both laboratory test and echocardiography examination are rou- healthy subjects, confirming our previous findings.
tinely performed to exclude all major categories of infection. The most Conclusions: These results show that coagulation cascade and fibrinolysis
common causes of aortitis are non-infectious and include two large vessel are activated in InHAng and in CSU patients, in spite of different patho-
vasculitis (Temporal Arteritis, also called Giant Cell Arteritis, and Takayasu mechanisms and the predominant involvement of different mediators (bra-
Arteritis) as well as other collagen vascular disorders such as rheumatoid dykinin and histamine, respectively). The observation of fibrinolysis activa-
arthritis and ankylosing spondylitis. Moreover, idiopatic aortitis is a rare tion in InHAng may support the rationale for using antifibrinolytic drugs
entity that refers to aortitis without evident relationship to any disease. In like tranexamic acid in InHAng prophylaxis.
conclusion, we wish to focus on these interesting points of the case here
presented: - Patient medical history did not reveal any systemic disorders
that could certainly be related with the presence of aortitis (lymphoma?). QTC INTERVAL PROLONGATION IN SYSTEMIC
- Imaging showed vasculitis in early active phase, without evidence of SCLEROSIS: EVALUATION AND CORRELATION WITH
occlusion or other complications of aortitis. This feature was consistent with CARDIOPULMONARY EXERCISE TEST
the clinical presentation. Infact, no ischemic symptoms were present. Fur-
thermore, that is probably the reason of the rapid recovery after starting Gigante A. 1, Rosato E. 1, Liberatori M. 1, Sardo L. 1, Di Paolo M. 2,
glucocorticoid therapy. - Location of the disease and the age of the patient Marinelli P. 2, Gasperini M.L. 1, Palange P. 2, Amoroso A. 1, Muscaritoli M. 1,
may indicate a Giant Cell Arteritis, though unusual considering the absence Tubani L. 1
of other vessels involvement. Idiopathic Aortitis, while more rare, can be 1
Department of Clinical Medicine, Scleroderma Unit, Sapienza University of
another possibility. - CT imaging was essential for the diagnosis of aortitis. Rome,Italy 2 Department of Public Health and Infectious Diseases, Sapienza
We want to stress on the clinical value of performing a rapid imaging. In University of Rome, Italy
fact, in the early phase of the disease treatment is generally successful and
vascular complications can be avoided. Background: In systemic sclerosis (SSc) cardiac involvement may occur,
since fibrosis of the conduction system may evolve into sudden death and
autonomic dysfunction. QTc interval prolongation has been observed in
ACTIVATION OF FIBRINOLYSIS IN IDIOPATHIC asymptomatic SSc patients. Also, reduced exercise tolerance was found in
NONHISTAMINERGIC ANGIOEDEMA: THE RATIONALE SSc patients without cardiac and pulmonary involvement.The aim of the
FOR TRANEXAMIC ACID USE IN THE DISEASE study was to assess QTc prolongation in SSc and evaluate correlations with
PROPHYLAXIS cardiopulmonary exercise test (CPET) in patients without pulmonary and
cardiac manifestations.
Tedeschi A. 1, Trotta L. 1, Griffini S. 2, Grovetti E. 2, Lorini M. 3, Cugno M. 2 Methods: Thirty-two patients fulfilling the American Rheumatism Associa-
1
Medicina Interna, ASST Fatebenefratelli-Sacco, Ospedale Fatebenefratelli tion (ARA) criteria for classification and diagnosis of SSc and twenty-three
e Oftalmico, Milano; 2Medicina Interna, Ospedale Maggiore Policlinico, healthy subjects were examined. For the QTc interval evaluation, 24-hour
Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Holter ECG recording was performed and was defined as prolonged when
Università degli Studi di Milano, Milano; 3Dipartimento di Scienze Cliniche e >440 ms. A maximal symptom-limited CPET was performed on an electro-
di Comunità, Università degli Studi di Milano, Milano nically braked cycloergometer. All subjects performed a maximal CPET as
documented by a respiratory exchange ratio (RER) higher than 1.05. Finally
Background: Idiopathic non-histaminergic angioedema (InHAng) is cha- nailfold videocapillaroscopy (NVC) was performed by an optical probe,
racterized by recurrent swelling of the subcutaneous and submucosal tissues equipped with magnification 200Å~ contact lens and connected to image
that usually occurs without weals and does not respond to H1-antihistami- analysis software. All data were expressed as median and range. The Mann–
nes or corticosteroids. The pathogenesis of the disease is not well known but Whitney U-test or the Kruskal–Wallis was used to test differences between
there is some evidence that the bradykinin system is involved. Prolonged two individual study groups. Spearman’s rank order correlation coefficient
treatment with tranexamic acid has been found able to prevent recurring (r) was used to test for an association between numerical variables. P-values
InHAng attacks. Some of us have previously shown that coagulation and b0.05 were considered significant.
fibrinolysis are activated both in patients with angioedema due the heredi- Results: The median value of QTc is significantly (p < 0.001) increased in
tary or acquired C1 inhibitor deficiency and in patients with chronic sponta- SSc patients than healthy controls [457 s (397–566) vs 432 s (354–566)]. The
neous urticaria (CSU), a disease which can be associated with angioedema. median value of QTc is significantly (p< 0.01) different in three capillarosco-
The latter often has an autoimmune origin and in most cases responds to pic groups: early 423 (397–456), active 436 (418–465), late 469 (443–566).
H1-antihistamine treatment. In addition to the pathomechanism linked to A reduced exercise tolerance, defined as a V’O2 peak lower than 80% of
histamine-releasing autoantibodies, a role of coagulation and fibrinolysis in maximum predicted, was found in 23 out of 32 subjects (72%). A signifi-
the pathophysiology of this disorder has been hypothesized, and a good cor- cant negative correlation was found between QTc and all markers of exer-
relation between the degree of activation and the severity of the disease has cise tolerance: V’O2 peak (r= −0.41, p< 0.05,), V’O2 peak/Kg (r = −0.42, p<
been demonstrated. The observation that thrombotic risk is not increased 0.05,), Watt max (r= −0.37, p 0.05,) and exercise time duration (r= −0.36,
in patients with angioedema or CSU indicates that the activation of coagu- p< 0.05,).
lation is efficiently counterbalanced in these patients. Conclusions: In the present study, QTc interval is prolonged in SSc
Methods: Aim of the present study was to investigate the activation of coa- patients and correlates with NCV pattern. Moreover QTc prolongation
gulation and fibrinolysis in a group of 19 patients with InHAng, 27 patients correlates with reduced exercise tolerance in the absence of cardiac and
affected by CSU associated with angioedema (CSUAng), 38 patients with pulmonary involvement. In SSc, myocardial fibrosis could be the major
CSU without angioedema (CSU) and 30 healthy subjects. Blood samples responsible for QTc interval prolongation. Early pulmonary vasculopathy
were collected in a phase of disease activity in all cases. The patients with can be evaluated with CPET, demonstrating pulmonary ventilation/per-
InHAng were divided in two subgroups according to the time interval fusion mismatch during the effort. In SSc patients without cardiac and
elapsed from the last angioedema attack (less or more than one week). Using pulmonary involvement, CPET and QTc interval evaluation may be used
immunoenzymatic techniques, we measured plasma levels of prothrom- tools for early non invasive assessment of SSc-related cardiac involvement.
bin fragment F1+2 and D-dimer, coagulation and fibrinolysis markers,
respectively.
Results: Concentrations of F1+2 and D-dimer were more elevated in ORAL DISEASE IN PATIENTS WITH CVID
InHAng patients than in healthy subjects (mean ± ESM, respectively
424.9±137.8 pmol/l and 836.2±190.4 ng/ml vs. 145.2±6.9 pmol/l and Gelardi C. 1, Sparabombe S. 2, Pedini V. 1, Menghini D. 1,
191.0±8.2 ng/ml), with a significant difference for D-dimer (p<0.001). Putignano A. 2, Gabrielli A. 1, Danieli M.G. 1
Among InHAng patients, D-dimer, but not F1+2 concentrations were 1
Clinica Medica, Università Politecnica delle Marche e Ospedali Riuniti,
significantly higher in the blood samples taken less than one week after Ancona 2 Clinica di Odontostomatologia, Università Politecnica delle Marche
the last angioedema attack (n= 7) than in the blood samples collected e Ospedali Riuniti, Ancona
more than one week after the last angioedema attack (n= 12) (D-dimer
1713.3±268.1 ng/ml vs. 324.5±80.5 ng/ml, p<0.0001; F1+2 454.7±221.0 Introduction: Common variable immunodeficiency (CVID) is the most
pmol/l vs. 407.6±183.2 pmol/l). Significantly increased levels of F1+2 frequent primary symptomatic immunodeficiency of the adulthood and is
and D-dimer were found in CSUAng patients (F1+2 772.2±135.5 pmol/l characterized by reduced serum immunoglobulin levels and heterogeneous
56
clinical phenotypes. These patients are susceptible to parodontal disease. et al. Leukemia. 2016; 30:640-8 (3) Di Marzo L et al. Oncotarget. 2016
Aim of the study To perform a parodontal evaluation and a more precise 13;7(37):60698-60711
characterization of incidence, diagnosis and treatment of oral diseases in
patients with CVID.
Matherials and Methods: In this prospective trial we enrolled 60 patients MIRNAS PROFILE OF BONE MARROW FIBROBLASTS IN
(30 CVID patients, 30 healthy people into the Control Group). Compilation MULTIPLE MYELOMA: RELATIONSHIP WITH DISEASE
of medical records was done with patients’ history and data about physical PROGRESSION AND DRUG-RESISTANCE
examination of the oral cavity. In the records we also reported indexes of
periodontal disease (DMFT: Decayed, Missing, Filled Teeth, PCR: plaque Desantis V.1, Di Marzo L.1, Craparotta I.2, Beltrame L.2,
control record, BOP: bleeding on probing), basing on their easy detection, Marchini S.2, Arciuli M.1, Visino F.1, D’Incalci M.2,
objectivity and their possible expression in alphanumeric values for stati- Frassanito M.A.1, Vacca A.1
stical surveys. Measure of stimulated and not stimulated salivary flow was 1
Department of Biomedical Sciences and Human Oncology (DIMO),
also reported. Section of Internal Medicine and Clinical Oncology, Policlinico-Bari, Italy.
Results: Recurrent aphthous stomatitis was the most frequent oral disease 2
Department of Oncology, Pharmacological Research Institute Mario Negri,
(63% of CVID patients vs 3.3% of healthy people), characterized by burning Milan, Italy
red areas, that can evolve in bubbles and small open ulcers. Herpes labialis
was another frequent disease (43% of CVID patients vs 13.3% of healthy Purpose: microRNAs (miRs) regulate gene expression at post-transcrip-
people) with swollen and reddened vesicles cluster on lips, caused by herpes tional level modulating several biological processes. Bone marrow (BM)
simplex virus type 1 (HSV-1). Angular cheilitis, an inflammatory disease fibroblasts (or cancer associated fibroblasts, CAFs) from active multiple
that affects corners of the mouth, often bilaterally, affected 26% of CVID myeloma (MM) patients present an activated phenotype (FSP1+/FAP+/
patients vs 10% healthy people. Oral candidosis (20% of CVID patients) was αSMA+), with higher proliferative rate compared to monoclonal gam-
the most common fungal infection of the mouth in CVID patients. Perio- mopathy of undetermined significance (MGUS) CAFs1. BM CAFs from
dontitis, a rare disease that affects the periodontium, the tooth-supporting bortezomib (bort)-resistant patients are resistant in vitro to the drug and
tissues, affected only 5-10% of CVID patients. prevent bort-induced apoptosis of co-cultured MM cells2. Our purpose was
Conclusions: Patients with CVID, compared to healthy people, show a to investigate whether a specific miR profile is associated to the phenotype
higher rate of parodontal manifestations, such as recurrent aphthous sto- and functional activities of BM CAFs in MGUS to MM transition and drug
matitis, herpes labialis, oropharyngeal candidiasis, gingivitis and early onset resistance.
aggressive periodontitis. Treatment should be initiated once the diagnosis Methods: miRs expression was analyzed by microarray and validated by
is done because oral disease can negatively affect patient’s quality of life. qRT-PCR and flow cytometry on CAFs purified from BM aspirates of
Dental preventive treatments are therefore strictly necessary through inclu- MGUS and MM patients. miRs target genes were identified by interroga-
sion of these patients in a follow-up program, according to patient’s motiva- ting different tools commonly used to predict human miR gene targets and
tion, self-assessment and self-monitoring skills. validated by western blot analysis. miRs functional effects were analyzed in
CAFs transiently transfected with miRCURY LNA inhibitors and mimics.
Results and Discussion: MM and MGUS CAFs showed a different miRs
EXOSOMES-MEDIATE CROSSTALK IN MULTIPLE profile, including 9 up-regulated and 17 down-regulated miRs. Among
MYELOMA PROGRESSION AND DRUG RESISTANCE the over-expressed miRs, we focused on miRs showing a major signifi-
cant p-value: miR-27b-3p and -214-3p. Target genes of miR-27b-3p and
Di Marzo L. 1, Desantis V.1, Saltarella I.1, Lamanuzzi A.1, Arciuli M.1, -214-3p were FBXW7 and PTEN, respectively, involved in cell apoptosis,
Annese T.1, Visino F.1, Nico B.2, Vacca A.1, Frassanito M.A.1 proliferation and CAFs activation. Inhibition of miR-27b-3p induced the
1
Department of Biomedical Sciences and Human Oncology (DIMO), Internal over-expression of FBXW7, an ubiquitin ligase, which negatively modulated
Medicine Section, University of Bari Medical School, Bari, Italy 2Department the expression of MCL-1, NOTCH and Cyclin E1/2. miR-214-3p inhibition
of Basic Medical Sciences, Neurosciences and Sense Organs, University of increased PTEN levels down-regulating the AKT/GSK3 pathway and Cyclin
Bari Medical School, Bari, Italy D1. Finally, co-cultures of MM cells with CAFs and bort treatment increa-
sed miRs expression.
Purpose: Exosomes (EXOs) mediate local and systemic cell-to-cell com- Conclusions:: MGUS to MM transition and drug resistance is related to a
munication and regulate cell behavior by transferring mRNA, miRNAs and specific miRs profile. Over-expression of miR-27b-3p and -214-3p induces
proteins to recipient cells. Recently, we demonstrated that bone marrow cell proliferation and resistance to spontaneous and bort-induced apoptosis
(BM) cancer associated fibroblasts (CAFs) promote tumor progression and in MM CAFs.
drug resistance (DR) in multiple myeloma (MM) (1-3). In this study, we Bibliography:
analysed the effect of MM-derived EXOs on CAFs in MGUS to MM tran- 1. Frassanito MA et al. Leukemia 2014.
sition and, in turn, the effect of CAFs-derived EXOs on endothelial (ECs) 2. Frassanito MA et al. Leukemia 2016.
and MM cells.
Methods: EXOs isolation was performed from conditioned medium (CM)
of CAFs purified from BM aspirates of 8 active MM patients and from CM DNA METHYLATION AND HYDROXYMETHYLATION
of cultured RPMI8226 and U266 MM cells. Electron microscopy (TEM), IN PRIMARY COLON CANCER AND SYNCHRONOUS
dual immunofluorescence-confocal laser-scanning microscopy, western HEPATIC METASTASIS
blot (WB), flow cytometry (FC) and qRT-PCR studies were performed to
evaluate the CAFs- and MM-derived EXOs phenotypes, their miRs content Moruzzi S. 1, Udali S. 1, De Santis D. 1, Ruzzenente A. 2, Mazzi F. 1, Beschin
and their mutual effect. G. 1, Tammen S. 3, Campagnaro T. 2, Pattini P. 1,
Results: TEM analysis of CAFs- and MM-derived EXOs showed a vesi- Olivieri O. 1, Guglielmi A. 2, Choi S.W. 3,4 , Friso S. 1
cles population with heterogeneous aspect, 50-100 nm sized. WB analysis 1
Department of Medicine, University of Verona School of Medicine, Verona,
defined the expression of commonly used EXOs surface markers as CD63, Italy 2Department of Surgery, University of Verona School of Medicine,
Hsp70 for CAFs and CD63, Hsp70, Alix for MM cells. Confocal micro- Verona, Italy 3Tufts University School of Nutrition Science and Policy, Boston,
scopy showed the ability both CAFs and MM cells to uptake respectively MA, USA 4Chaum Life Center, CHA University, Seoul, Korea
MM- and CAFs-derived EXOs labelled with fluorescent dyes. Functional
studies showed that MM-derived EXOs induce a specific miRNA profile as Colorectal cancer is among the most frequent solid tumor and simultane-
overexpression of miR-27b-3p, -125b-5p, -214-3p and activated phenotype, ous diagnosis of primary colorectal cancer and liver metastases occurs in
as expression of FAP+ and α SMA+ antigens, in MGUS and MM CAFs. In about 25% of cases. Aim of the present study was to define DNA methyl-
turn, MM CAFs released EXOs containing miR-27b-3p, -125b-5p, -214-3p cytosine (mCyt) and hydroxymethylcytosine (hmCyt) patterns in primary
are swallowed by MM cells and ECs. Functional studies also showed that colon cancer and synchronous hepatic metastatic tissues and to identify
CAFs-derived EXOs are able to stimulate angiogenic ability in ECs and to a possible role for mCyt and hmCyt levels from peripheral blood mono-
induce bortezomib-resistance in MM cells. Discussions and nuclear cells (PBMCs) DNA as a marker of disease. Sixteen patients were
Conclusions: Overall results suggest an important exosomal crosstalk enrolled and their laboratory tests and clinical history data collected.
among tumor cells, CAFs and ECs which lead to BM microenvironmental The mCyt and hmCyt content was determined by an LC-MS/MSmethod
modifications, favouring MM progression and DR. in the DNA extracted from cancer tissues and from homologous can-
(1) MA Frassanito et al. Leukemia. 2014; 28 (4):904-16 (2) MA Frassanito cer-free tissues, i.e.colon (C), liver (L) and PBMCs. Methylcytosine levels
57
were similar in primary colon cancer (CCr) and liver metastasis (LM) COHORT STUDY
(4.69%±0.37 vs 4.77%±0.38, respectively, P=0.535) but both cancer-tissues
were hypomethylated when compared to cancer-free colon (4.98%±0.26). Ferrando L. 1, Isnaldi E. 2, Garruti A. 1, Franceschelli P. 1,
The difference in mCyt content between cancer and cancer-free colon Cirmena G. 1, Lia M. 2, Romairone E. 2, Scabini S. 2, Murialdo R. 2, Grillo F. 2,
tissues were significantly different for primary colon cancer (P=0.004) Mastracci L. 2, Tixi L. 2, Ballestrero A. 2, Zoppoli G. 2
but not for liver metastasis (P=0.148) (Fig.A). Hydroxymethylcytosine 1
University of Genoa 2 Ospedale Policlinico San Martino
content was similar in primary colon cancer as compared to liver meta-
stasis (0.035%, C.I.0.024-0.052% vs0.035%, C.I.0.021-0.058%, respectively, Introduction: In locally advanced cII/cIII rectal adenocarcinomas (LARC),
P=0.905) but markedly depletedas compared to cancer-free colon (0.081%, the primary treatment is surgery, together with the administration of
C.I. 0.055-0.119) with a statistically significant difference (P<0.05) for neoadjuvant treatment, that is a combination of radio and chemotherapy.
both comparisons (Fig.B). Methylcytosine levels showed a borderline cor- Tumor response to chemoradiotherapy is not uniform and shows a wide
relation between PBMCs and colon cancer tissue (Pearson’s correlation range of responsiveness (from complete response to complete resistance).
coefficient = 0.51, P=0.052). Primary colon cancer and liver metastasis Such complex response introduces a substantial clinical dilemma about
tissues have a similar epigenetic status but are significantly hypomethyla- the benefit and the risks of the administration of neoadjuvant treatment in
ted and hypohydroxymethylated as compared to homologous cancer-free LARC.
colon tissue. Aims, Patients and Methods: Our primary aim is to investigate the role of
pre-treatment gene expression profiling in predicting response to chemora-
diotherapy in LARC, in order to divide patients into groups of responders
or non responders. In order to predict the response to the neoadjuvant, 49
LARC biopsies were collected for gene expression profiling through Agilent
microarrays. All patients underwent the same pre-operative treatment, con-
sisting in the combination of Capecitabine and radiotherapy. We performed
class comparison to determine whether gene expression profiles differ in
the two classes (responder vs nonresponder), to identify which genes are
differentially expressed in the classes and which main pathways are involved
in the response to the neoadjuvant therapy.
Results: We performed principal components analysis, finding that the
first two principal components, selected with eigenvalue criterion, explain
respectively about 41% and 8% of the variance of the dataset. This invol-
ved subtle biological difference. However our analysis showed that the two
classes, composed by 12 nonresponder and 18 responders, differ in gene
NON-INVASIVE CIRCULATING TUMOR DNA expression profiles. We rejected patients with intermediate response. We
MONITORING FOR EARLY DETECTION OF RESISTANCE identified a gene signature composed by 34 genes (p < 0.001).
OR RELAPSE TO NEOADJUVANT CHEMOTHERAPY IN Conclusion: Our results suggest that gene profiling may be used to predict
BREAST CANCER PATIENTS the response to neoadjuvant in LARC, but evaluation and validation of the
identied gene signature recquires extensive, prospective and multicenter
Zoppoli G. 1,2, Garuti A. 2, Cirmena G. 2, Franceschelli P. 2, studies.
Isnaldi E. 1,2, Ferrando L. 2, Fregatti P. 1,2, Garlaschi A. 1,
Friedman D. 1,2, Ballestrero A. 1,2
1
Ospedale Policlinico San Martino 2 University of Genoa META-ANALYSIS SHOWS THAT THE USE OF METFORMIN
IN PATIENTS WITH TYPE 2 DIABETES IS ASSOCIATED
Introduction: It has been shown that breast cancer (BC) and other neo- WITH SIGNIFICANTLY LOWER RISK OF COLON
plasms can release circulating tumoral DNA (ctDNA) in the peripheral NEOPLASIA
blood stream. With suitable, high-sensitivity methods, ctDNA may be
detected in plasma samples before clinically overt relapse or resistance to Portincasa P. 1, Rokka A. 1,2, Rokkas A. 2
chemotherapy, therefore potentially behaving as a personalized biomarker 1
Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human
of a patient’s health status. Oncology, University of Bari “Aldo Moro” Medical School, Bari, Italy. 2
Aims, Patients, and Methods: Our primary aim was to assess the propor- Bari English Medical Curriculum (BEMC), University of Bari “Aldo Moro”
tion of BC patients undergoing neoadjuvant chemotherapy (NACT) with Medical School 2Gastroenterology Clinic, Henry Dunant Hospital, Athens,
detectable ctDNA before surgery and absence of pathological complete Greece
response (pCR). Secondary aims were to observe ctDNA reappearance
rate by measuring it 3 months after surgery, and every six months until Background and Aims: Several lines of evidence suggest that biguanide
relapse or 60 months of follow-up. To detect ctDNA, a pre-NACT biopsy metformin, the first-line treatment of type-2 diabetes might decrease the
was analyzed for mutations in 409 genes involved in cancer by next-gene- risk of cancer. To check this important question, we performed a meta-a-
ration sequencing (NGS) on a Ion Torrent TM platform. Then, an indivi- nalysis of available studies to define the effect of metformin on colon neo-
dualized driver mutation was prioritized for each patient and measured in plasia (both cancer and polyps) in the subgroup of patients with type 2
plasma by droplet digital PCR (ddPCR) using the BioRad QX200® system. diabetes.
Assuming an actionable mutation is found in plasma before surgery in Methods: We searched for medical literature in human studies up to may
80% of NACT patients without pCR and < 10% of patients with pCR, 2017, by suitable keywords. Analyses included pooled estimates (fixed or
with a two-sided α =.05 and 1-β =.90, we could reject the null hypothesis random-effects models); heterogeneity between studies (Cochran Q test),
of finding ctDNA in 50% of patients regardless of pCR by enrolling and likelihood of publication bias (construction of funnel plots and their sym-
analyzing 10 patients undergoing NACT, with a 1:1 ratio (5 with pCR and metry estimated by the Begg and Mazumdar adjusted rank correlation test
5 without). and by the Egger’s regression test). Subgroup and sensitivity analyses were
Results: As of May 2017, 31 patients are under active screening. NGS also performed.
and ddPCR on plasma at baseline, before and after surgery, at 6 months, Results: 17 studies were eligible for meta-analysis [1 RCT and 16 obser-
and at 12 months have been performed for 10 patients, with the post-sur- vational studies (13 cohort and 3 case-controls)] reaching a total number
gery pathological characteristics as previously detailed. The results for the of 709,980 patients with type 2 diabetes. The risk of colon neoplasia was
primary aim will be presented at the Italian Society of Internal Medicine significantly lower among metformin users than controls (non-metfor-
meeting for the first time. min users) [pooled RRs (95% CI)=0.75 (0.65-0.87), test for overall effect
Z=-3.95, p<0.001]. This finding applied separately for colon cancer [0.79
(0.69-0.91), Z=-3.34, p<0.001], and for colon polyps [0.58 (0.42-0.80),
PREDICTION OF RESPONSE TO NEOADJUVANT Z=-3.30, p<0.001]. Conclusion: So far, the meta-analysis of available studies
CHEMORADIOTHERAPY IN RECTAL shows that the use of metformin in patients with type 2 diabetes is asso-
ADENOCARCINOMA BY WHOLE TRANSCRIPTOME ciated with significantly lower risk of colon neoplasia. Further studies are
ANALYSIS: RESULTS FROM A SINGLE CENTER, urgently required to address the pathophysiological mechanisms involved
RETROSPECTIVE PROSPECTIVE, CONSECUTIVE and to extend the results to additional subgroups of metformin-users.
58
CASE MANAGEMENT IN MIGRANT POPULATION WITH evaluated for re-fracture event or death from any causes. Baseline comor-
CHRONIC DISEASE: THE EXPERIENCE IN THE CLINIC bidities and medication were assessed during the year prior the fracture
OPERA SAN FRANCESCO PER I POVERI event. Adherence to therapy was measured by Medication Possession Ratio
(MPR = number of pill-days available from filled prescriptions for days of
Villa A.M., Sardella F., Fadelli S., Abbruzzese M.G., Adamoli M., Fiammanti C. follow-up) in the 12 months following the index-date. The cumulative inci-
Opera San Francesco per i Poveri, Milano dence probability of experiencing a new fracture or die from any causes
was estimated by Kaplan-Meier analyses. Predictors of fracture events and
The social and economic deprivation combined with emerging chronic mortality were evaluated by Cox proportional hazards models.
diseases is well evidenced-based in our geographical area. Chronic patholo- Results: A total of 10920 patients (mean age 81.4, men 11.1%) were eligible.
gies have increased with the boosting of people in poor conditions among Within 12 months after the index-date, 34.6% did not receive any treatment
with, we find migrants. For them, national policies have not carried out for osteoporosis and another 33.3% received vitamin D or calcium supple-
targeted interventions. A more planning and customization in their treat- mentation only. Only 44% of treated patients had a MPR ≥ 80%. During the
ment’s path should be a strategy to be implementedAccording to the more follow-up period 1015 of 10774 (9.4%) patients no previously hospitalized
relevant scientific literature, the case-management approach is always more for osteoporotic fracture had another fracture event (incidence rate of 41.21
recognized in chronic diseases’ treatment. In this scientific work, it’s showed per 1000 py). Osteoporotic treatment and calcium/vitamin D supplementa-
its enforcement for poor population especially migrants. The main aims of tion were associated with fewer fracture events (HR 0.707, p<0.001 and HR
case-management approach are to ensure patiens’ self-management, reduce 0.358, p<0.001 respectively); younger patients (HR 0.983, p<0.001) and men
cares fragmentation, enhance the quality of ongoing treatments, improve (HR 0.755, p=0,012) were also less likely to experience new fracture events.
patiens’ quality of life, reduce hospitatization, increase staff ’s satisfaction 3148 of the same 10774 (29.2%) patients died from any cause (incidence
also promoting a more effective resourses’ management. The Case manage- rate of 118.06 per 1000 py). Osteoporotic treatment and calcium/vitamin
ment project, conceived in our clinic, is planned for: - nursing activity and D supplementation were found to be inversely associated with mortality
health promotion with patient engagement; - counseling activities in order (HR 0.664, p<0.001 and HR 0.456, p<0.001 respectively). Other predictors
to prevent more dangerous diseases with the patient’activation to a proper of mortality were: old age, male sex, hypertension, diabetes, rheumatoid
lifestyle - guiding the patient within his/her therapeutical path with an help arthritis, heart failure, dementia and BPCO. Among medications, predic-
desk supporting him/her during the treatment; - rehabilitation interven- tors of mortality were: corticosteroid systemic use, anticoagulants, analge-
tions and long-term assistance in cooperation with local services; - recalling sics, antipsychotics, proton pump inhibitors. Conclusion: Consistent with
the patiens when he/she does not go to the visit. 10% of 29.000 patients of the results of previous studies, most osteoporotic patients remain untreated
our clinic in the last 3 years has been worthy of such service; 600 of them after fragility fracture and most of treated patients have poor compliance.
are included in the project because they are complex and stable on territory. The absence of treatment is associated with a higher risk of new clinical
Patients are inserted in our electonic database as member of this project as fractures and decreased survival, thus suggesting new efforts for implemen-
well as every operator knows the cure path and checks its implementation. ting osteoporotic therapy prescription and challenging patient adherence
The case manager works in a multidisciplinary team with different medical to therapy.
expertise This team has created guidelines for continuous monitoring of the
healh of the patient. 787 interviews with patiens included in this project have
been done in 2016; 100 of them have experienced the tool evaluating their INTERPLAY BETWEEN BONE MARROW ENDOTHELIAL
involvement and activation in the cure path: PAM 13-I card and monitoring CELLS AND CD8 T CELLS IN MULTIPLE MYELOMA
activation level according to the licence Insigna Helath Snc and supervision
of parameters such as weight, glycemia, blood pressure, etc) Patients are Racanelli V., Leone P., Di Lernia G., Solimando A., Saltarella I.,
included for their complexity and also for the eminence of cardiovascular Ria R., Cicco S., Vacca A.
pathologies enabling coninuous monitoring of their pressure and glycemic Department of Biomedical Sciences and Human Oncology, University of Bari
parameters; 55% of them presents three or more chronic pathologies. 28 Medical School, Bari, Italy
different nationalities are involved and 8% of italian population is home-
less. The close relationship between parameters’ improvement and level of Purpose: Bone marrow (BM) endothelial cells (EC) are in close contact
activation also with the help of interviews between operators and patients with CD8 T cells that come and go across the permeable capillaries. We
has showed positive evidence: 76% of the patients has improved check of analyzed the antigen presenting capacities of EC from BM of patients with
parameters and adherence to a therapy and to a lifestyle accordingly. At the multiple myeloma (MM) and monoclonal gammopathy of undetermined
follow-up, 86% of them has showed an improvement of level of activation significance (MGUS).
and counselling effectiveness with more involvement in the cure path; lower Methods: BM EC from MGUS and MM patients were analyzed and com-
results for homless people. pared with regard to their frequency, expression of HLA I antigen proces-
The feedback of this aspect is fundamental for the Case-management sing-presenting molecules, capacity to present antigens to and activate CD8
OSF project because it’s also a validation of this counselling methodology T cells. Experimental procedures included flow cytometry, immunomagne-
towards migrant patiens with cronic diseases. tic isolation, culture and stimulation of cells, proliferation assays, immuno-
staining and microscopy.
Results: In both MGUS and MM patients, almost all BM EC express HLA
RISK OF FUTURE FRACTURE AND MORTALITY IN class I and lymphocyte function-associated antigen 3 (LFA3) molecules,
OSTEOPOROTIC PATIENTS AFTER FEMORAL OR whereas between 10 and 25% express the costimulators CD80, CD86 and
VERTEBRAL FRACTURE IN THE VENETO REGION OF CD40, and the inducible co-stimulator ligand (ICOS-L) thus suggesting a
ITALY semi-professional antigen presenting phenotype. The EC immune/stan-
dard proteasome subunit ratio is in favor of immunoproteasome subunits
A. Michielin 1, S. Sella 1, A. Amabile 1, D. Braghin 1, as would normally be in professional antigen presenting cells. BM EC can
L. Degli Esposti 2, M. Andretta 3, F. Fabris 1, S. Giannini 1 present HLA class I-restricted tumor antigens to and activate tumor-speci-
1 Department of Medicine, University of Padova, 2 Clicon S.r.l., Ravenna, 3 fic CD8 T cells with suppressive capacity. These CD8 T cells are CD45RA-
Servizio Farmaceutico Regione Veneto, Venezia, Italy CCR7+ and produce more IL-10 (90%) and TGF-beta (80%) than IFN-
gamma (10%). DISCUSSION Tumor-specific effector CD8 T cells in BM
Introduction: Pharmacologic therapy is recommended in osteoporotic of patients with MM are inefficient because of the concomitant presence
patients with fragility fractures in order to prevent future fracture events. of endothelial cell-reactive tumor-specific memory CD8 T cells producing
Objective The objective of this retrospective observational study was to IL-10 and TGF-beta.
examine treatment prevalence among post-fracture osteoporotic patients Conclusions: BM EC promote MGUS-MM progression through a novel
from a regional Italian registry and to identify possible risk factors for new mechanism of immune escape. BIBLIOGRAPHY Di Rosa F et al. Front
fracture events or death. Methods: Patients ≥ 50 years with a recorded Immunol. 2016;7:51.
hospital discharge diagnosis of vertebral or femoral fracture (index-date)
and evidence of osteoporosis at baseline (osteoporosis ICD-9 code or at least
1 prescription of drugs for osteoporosis during the previous 2 years) were
collected from the Veneto Region Health System database between January
2011 and June 2015. Patients with a history of renal disease or malignan-
cies were excluded. All eligible patients were followed-up to June 2016 and
59
MEDICINE AND MIGRATIONS gitis and laterocervical adenitis. Described for the first time by Gary Marshall
in 1987, it was considered for a long time a disease of exclusive interest for
Carini L., Cantarano M.S., Cantarano M., Cantarano E. paediatricians. Recent evidences suggested the existence of a similar picture
Facolta’ Medicina e Farmacia - Universita’ Roma “Sapienza” with onset in the adulthood. However, there are very few cases described in
Literature (2). The aim of this paper is to describe the demographic and clini-
The medicine of migration is a branch of medical anthropology and is also cal characteristics of a single cohort of adult PFAPA patients.
involved in the socio-cultural aspect of the immigrants about the intrica- Matherials and Methods: We selected 48 adult patients with suspected
cies of how the health problems are addressed, lived and cared for accor- PFAPA syndrome, performing a retrospective analysis our entire Auto-in-
ding to the native culture and to the destination. At the base of this disci- flammatory Disorders database. Patients included in the study group had to
pline is a conditio sine qua non: the a priori acceptance of the existence of respond faithfully to the Marshall Diagnostic Criteria which were adapted for
different medical and therapeutic practices conceptions. The message that adulthood; in particular, we deliberately neglected first criteria and we applied
constantly switches between the public is that of a “health hazard” immi- the fifth one was, only retrospectively. Patients were analyzed on the basis of
grant, the different, the foreigner, from which to defend ourselves and to disease’s onset, fever pattern characteristics, accompanying clinical manife-
be reclaimed. By contrast, there is ample scientific literature that dismant- stations and inflammatory index trends (VES, Protein C Reactive, Serum
les myths and scaremongering, on problems and solutions of the migra- Amyloid Protein).
tion phenomenon. The applicant appealed to health emergency related to Results: The average age of patients at the time of description was 29.7 ± 8.8
the presence of foreign immigrants on Italian territory, has no objective years. We observed that 30 patients had the onset of illness in childhood while
justification. The Protocol of the Ministry of Health in 2011, aimed only 18 patients directly in adulthood. The average age of onset of the disease
establishing syndromic surveillance measures in order to allow an early was 14 ± 11 years. 40 patients had monthly febrile attacks; 6 patients had more
warning in case of a potential emergency situation, has effectively demon- than one attack per month. The body temperature at the peak was 39.2 ± 1 °
strated the non-existence of this risk, confirming, if anything, a growing C with a duration of attack that in 89% of patients was between 3 and 5 days.
deterioration of conditions health of the immigrant population in the Oral aphtosis was present in 73% of patients; the pharyngitis was found in
post-migration period for exposure to risk factors related to poverty and 94% of the sample while the laterocervical adenopathy in 86% of the patients.
social hardship (exhausted migrant effect). The real emergency is in how Regarding other manifestations of auto-inflammatory origin, abdominal pain
the phenomenon of migration is dealt with in our country: widespread was present in 60% of patients, chest pain and arthritis, respectively in 19%
ignorance, bad faith and improvisation, mixing the issue of immigration and 21% of analyzed cases. Skin involvement was observed in 23% of the
to that of safety. Without knowledge that only an inclusive approach that patients, who had predominantly pomphoid or erythematous lesions.
would bring the migrant paths welfare, and integrating hospitality and Conclusions: Adult PFAPA is a newly introduced auto-inflammatory syn-
health can really protect the welfare of all, migrants and the host popu- drome. Clinical characteristics differ from the PFAPA of the child, which
lation. This can not and must not be found on the bank of health sector on shows an increased prevalence of oral aphtosis and a reduced prevalence of
the contrary, to its mandate, does not discriminate anybody, does not mani- serous manifestations. Although the incidence and prevalence of this syn-
pulate information to private-purpose, and welcomes anyone with a need, drome have not yet been established, it is evident that rapid diagnosis and
and when necessary, care without exception and in the best possible way. By proper treatment may have a significant impact on the quality of life of
the SIMM, the Institute of Health and the National Institute of Medicine of patients. The purpose of this work is to raise the attention of the Internists
Poverty and Immigration, are generated Guidelines for host health screening to this new nosological entity in order to reduce its diagnostic delay and, by
protocols and any evidence-based, as well as national guidelines (in the care expanding the available case, increase its understanding.
of the Ministry health) on reception, early recognition and taking care
of victims of intentional violence and torture. Some diseases have even
greater resonance media: Tuberculosis It is undeniable that the “burden” PATTERN OF IN-HOSPITAL CHANGES IN DRUG USE IN
represented by immigrants on the annual number of new cases diagno- OLDER PEOPLE FROM 2010 TO 2016. RESULTS: FROM THE
sed in our country is increasing. But the number of cases of TB in immi- REPOSI REGISTER
grants increases much less than their numerical increase. The condition
of “immigrant” is a risk factor for developing tuberculosis especially for Franchi C. 1, Ardoino I. 2, Nobili A. 1, Marengoni A. 3,
vulnerable and precarious, as well as to the objective difficulties of access Mannucci P.M. 4
to preventive services, diagnosis and care that characterize the status of ‘ 1
IRCCS - Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
immigrant. HIV-AIDS Compared with the Italian population, the foreign 2
Department of Clinical Sciences and Community Health, University of Milan,
resident in Italy appears to affect infection (albeit with a decrease in the Italy 3Department of Clinical and Experimental Sciences, University of Brescia,
absolute of the cases) number of nearly four times higher than the Italian Italy 4Scientific Direction, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
population. The offer hospitality and accommodation, for the specific Policlinico, Milan, Italy
mode of transmission of the disease, is not a risk for the resident popula-
tion. Ebola It ‘ absolutely unlikely that migrants are affected by this virus Purpose: To assess the pattern of in-hospital changes in drug use in older
that is extremely lethal and, in most cases causes symptomatic disease and patients from 2010 to 2016.
then death within a few days of infection. This nullifies the possibility that Methods: People aged 65 years or more who were acutely hospitalized in
an infected person who ventures into difficult journey by land and later by those internal medicine and geriatric wards that did continuously participate
sea that would take him to Italy. to the REPOSI register from 2010 to 2016 were selected. Drugs use were cate-
Scabies and skin infections It is typical of disadvantaged social groups, gorized as: 0-1 drug (very low drug use); 2 to 4 drugs (low drug use); 5 to 9
individuals homeless, people with severe psychiatric disabilities and gated drugs (polypharmacy) and 10 or more drugs (excessive polypharmacy). To
communities. There is no ethnic or geographic factors predisposing. The assess whether or not prevalence of patients in relation to drug use distribu-
absence of common policies at the international level in the sense inclu- tion changed overtime, adjusted prevalence ratios (PR) was estimated with
sive, fragmented organization and, sometimes, improvised, a political and log-binomial regression models.
social debate continues, a “ collective feeling “ that you are also getting Results: Among 2120 patients recruited in 27 wards continuously participa-
used to preventable deaths and so cruel and unjust, they are the real emer- ting to data collection, 1882 were discharged alive and included in the analy-
gencies to deal with in a concrete and positive way. ses. The proportion of patients with very low drug use (0-1 drug) at hospital
discharge increased overtime from 2.7% in 2010 to 9.2% in 2016. Results from
log-logistic adjusted model confirmed the increasing prevalence ratio of these
DEMOGRAPHIC AND CLINICAL FINDINGS IN A patients overtime (particularly in 2014 vs 2012, PR 1.83 95%CI 1.14-2.95).
MONOCENTRIC COHORT OF ADULT PATIENTS WITH Moreover, from 2010 to 2016 there was an increasing number of patients who
PFAPA SYNDROME were on polypharmacy at hospital admission, which they abandoned at hospi-
tal discharge, switching to the very low drug use group.
Sicignano L.L., Patisso I., Cerrito L., Stabile M., Verrecchia E., Manna R. Conclusion: These results seem to suggest that the continuous and regular
Periodic Fever and Rare Diseases Research Centre – Dipartiment of Internal participation to the REPOSI register, specifically aimed to tackle the appro-
Medicine – Policlinico “A. Gemelli” Foundation – Catholic University of priateness of drug therapies in hospitalized older people with multimorbidity
Sacred Heart - Rome and polypharmacy, did sensitize on this topic the involved clinicians, promp-
ting a medical review of prescribed drugs that is likely to have led to a decrease
Introduction: PFAPA is a likely autoimmune inflammatory syndrome cha- of the therapeutic burden in this at risk population.
racterized by recurrent febrile attacks associated with oral aphtosis, pharyn-
60
A DIAGNOSTIC CONUNDRUM SOLVED BY SPLENIC stant. Twenty days before a Nuclear Magnetic Resonance (NMR) revealed
BIOPSY L4-L5 spinal disc herniation. For the worsening of pain and the onset of
fever, he was admitted to our division. Neurological examination revealed
Di Caterino M., Altruda C., Allegorico E., Galiero R., Pinotti E., Salvatore T., no loss of strenght in the four limbs, osteotendineous hyperreflexia and
Adinolfi L.E. clonic movements of the lower limbs. Back pain was exacerbated by rota-
Dipartimento di Medicina Interna, Università della Campania Luigi tion of the trunk and standing position. Inflammatory markers were CRP
Vanvitelli 111 mg/dl (UNL 2.9), ESR 42 mm/h (NV 1-15), procalcitonin 0.21 ng/mL
(NV 0-0.05), without leukocytosis. Electromyography was normal. Diagno-
In March 2017, a 57-year-old man was admitted due to 40-days low-grade stic hypothesis included: degenerative disease of spine, ankylosing spon-
fever with febrile episodes up to 39.5 °C in the last week, and concomitant dylarthritis, osteoporotic and pathological fracture due to chronic steroid
weight loss, asthenia, and worsening shortness of breath. His past medical therapy, and spondylodiscitis. A further spine NMR confirmed the hernia-
history was significant for ankylosing spondylitis treated with adalimumab tion beside L4-L5 spondylodiscitis with involvement of intervertebral disc,
since 7 years. Physical examination showed: GCS 15, tachypnea (RR: 30/ vertebral endplates, dural sac and adjacent muscles. PET-CT scan confirmed
min), SpO2: 94% (FiO2:21%), blood pression 90/60 mmHg, tachycardia (HR: pathological increase of glucose metabolism (SUV max 9.1) at the L4-L5
120 bpm, regular), pirexya (38.8 °C), profuse sweating, absence of vesicular vertebral segments suggesting local inflammation. Blood cultures were
murmur at the right lung base, epigastric tenderness and palpable spleen. positive for Pseudomonas Aeruginosa and specific therapy with piperacil-
Chest X-ray documented right lung middle-basal opacity and diffuse micro- lin/tazobactam was started immediately. Pain, fever and other symptoms
nodular lung pattern; abdominal ultrasonography revealed mild splenomegaly improved and after rehabilitation and orthopedic corset for four months a
with multiple millimetric hypoechoic lesions and moderate ascites. Routine complete resolution of symptoms and radiological findings occurred.
blood analysis revealed: erythrocyte sedimentation rate 68 mm/h, C-reactive Conclusions: Spondylodiscitis should be considered as differential diagno-
protein 25 mg/dL, ferritin 1065 ng/mL, fibrinogen 768 mg/dl, increased α1 sis of back pain. The average period between the first symptoms and diagno-
and α2 globulin, hypoalbuminemia, mild normochromic normocytic anemia, sis is about 2-6 months because symptoms are aspecific and degenerative
lymphocitopenia (500/μL), β2microglobulin 5,9 mg/L, LDH 717 U/L. Peri- disc disease is more common. In this patient chronic steroid intake likely
pheral blood smear, flow cytometric immunophenotyping, and immunolo- was the predisposing factor to infection. The exact diagnostic approach and
gical tests (ANA, ENA, ANCA, RF) were negative. Septic laboratory screen specific antibiotic therapy, starting after positive microbiological exams led
including blood, urine, induced sputum and stool cultures, as well as serology to successful healing.
for Brucella, EBV, CMV, Leishmania, Toxoplasma, and HIV, were negative.
Tuberculin Skin Test was negative, too. The quantiferon-TB Gold test resul-
ted strongly positive. Chest tomography showed right moderate pleural effu- F-18-FLUORODEOXYGLUCOSE POSITRON EMISSION
sion and left basal pleural effusion with diffuse millimetric miliary nodules. TOMOGRAPHY LEADING TO A DIAGNOSIS OF
Abdomen tomography documented enlarged spleen characterized by many PYLEPHLEBITIS
small hypodense foci with an inconclusive contrastographic pattern. Diagno-
stic thoracentesis on the right revealed an exudate; direct bacterioscopy and de Sio C., Galiero R., Allegorico E., Venafro M., Di Caterino M., Pinotti E.,
PCR for Koch bacillum (BK) were negative; cytological examination showed Salvatore T.
neutrophilic granulocytes. Waiting for cultures, a broad spectrum antibiotic Dipartimento di Medicina Interna, Università della Campania Luigi
therapy was started (Piperacillin/Tazobactam 4,5 g i.v. t.i.d. and Levofloxacin Vanvitelli
500 mg/die). After 3 days the patient remained febrile, dyspnea got worse,
and both left and right pleural effusion increased. Since the pleural exudate A 52-year-old patient came to our observation because of a 3-week history
contained neutrophilic granulocytes but the culture was negative for bacte- of fever (T max 40°C) preceded by intense shaking shakes unresponsiveness
ria and mycetes, another thoracentesis on the left was performed: cytology to domiciliar antibiotic treatment (amoxicillin/clavulanic acid 1g t.i.d.). The
was positive for T- lymphocytes CD3+; direct bacterioscopy and PCR for BK patient experienced significant weight loss (about 15 kg in the last few weeks),
were negative. The patient was furthermore investigated. At bronchial lavage, intense fatigue, vague upper abdominal discomfort and lack of appetite. His
culture for bacteria and mycetes, Ziehl-Neelsen stain and PCR for BK, resul- medical history was significant for uncompensated type 2 diabetes mellitus
ted negative, and the CD4/CD8 ratio normal; fundus examination didn’t show (HbA1c 12%), hypertension and obesity class II. On examination the patient
choroid tubercles; contrast-enhanced ultrasound of splenic lesions revealed was sweat, the temperature was 39°C, the blood pressure 115/70 mmHg, the
early fast wash out suggestive of lymphomatous lesions, but also of metastasis, pulse 110 beats per minute, the respiration rate 24 breaths per minute. Abdo-
pyogenic abscesses, fungal infections as well as tuberculosis. Finally, an ultra- minal pain in epigastrium and right hypochondrium was evoked by palpa-
sonography-guided biopsy was performed. The procedure was well tolerated tion. Laboratory tests showed: moderate normocromic-normocytic anemia
and didn’t have any complications. A part of the spleen specimen was pro- (Hb 8.5 gr/dl), leucopenia (WBC 2700/μL) with 83% granulocytes; hypoal-
cessed to rule out mycobacterial infection: direct bacterioscopy was negative, buminemia (2.6 g/dl); marked increased of ESR (120 mm/hour), CRP (20
PCR revealed BK nucleic acid sequences, and histology showed chronic gra- mg/dl), fibrinogen (750 mg/dl), ferritin (1250 ng/ml),and procalcitonin (2.8
nulomatous lesions without typical caseation. A diagnosis of miliary TB in an ng/ml). Coagulation, amylase and lipase were normal. All blood cultures and
adalimumab treated patient was put and a standard antitubercular treatment a urine culture remained sterile during his hospital stay. Pheripheral blood
started which obtained an impressive clinical and laboratoristic improvement. smear, cytofluorometry, Vidal-Wright, TORCH complex, β2-microglobulin,
After 25 days in Lowenstein—Jensen medium, BK growed on spleen speci- Tubercolin skin test, were negative. Chest X-ray and transthoracic echocar-
men but not on pleural effusion nor on BAL. Antibiogram showed sensitivity diogram resulted normal. At abdominal ultrasound a thrombotic process of
for all first line antitubercular treatment. Pyrazinamide and ethambutol were right portal branch, splenic vein and spleno-mesenteric confluence was found;
quieted at the end of two months, isionazid and rifampicin were planned for furthermore, a little area of inhomogeneity at the level of the pancreas tail
additional seven months. emerged. Both results were confirmed by abdominal MRI which furthermore
The case being reported is one of the very few cases reported in literature excluded diverticulitis and other abdominal infections. Thrombophilia screen
where miliary TB diagnosis was put thanks to the splenic biopsy avoiding tests and tests for autoimmune diseases (LAC screen test, ATIII, C Protein, S
other more invasive techniques. We propose this simple, effective, safe, and Protein, Omocysteine, Leiden factor V, Factor II polymorphism, IgG anti-β2
bedside procedure for diagnosis of conditions which may pose a dilemma glycoprotein, IgM-anticardiolipin, ANA, ENA, AMA, ASMA) were perfor-
when all other noninvasive techniques have failed. med. All were negative.In order to better define the splanchnic venous throm-
bosis, abdominal contrast enhanced ultrasound (CEUS) was performed. The
thrombi resulted hypovascular in arterial phase, thus excluding their neopla-
A CASE OF “IATROGENIC” LOW BACK PAIN stic nature. Finally, a PET scan was performed, which demonstrated increased
strong FDG uptake at level of trombotic abdominal veins as well at level of the
Gesualdo A., Noviello M., Belfiore A., Buonamico P., Minerva F., Palmieri pancreatic tail. Based on these findings, non-cirrhotic pyleflebitis was diagno-
V.O., Pugliese S., Portincasa P. sed, likely by extensions of a peripancreatic abscess via the pancreatic-lienal
Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human ligament. Looking for a source of infection, even a colonscopy was performed
Oncology, University of Bari Medical School that resulted negative. Antibiotic therapy with Imipenem 500 mg q.i.d. for
four weeks and anticoagulation therapy with Rivaroxaban were started. After
A 47 year old male presented for evaluation of low back pain unresponsive 7-10 days, there was a clear improvement of symtomps and laboratory tests.
to antinflammatory therapy for two months. One year earlier he was dia- The patient was discharged in fair conditions with recommendation of taking
gnosed with ocular seronegative myasthenia gravis wich was steroid resi- Rivaroxaban 20 mg o.d. At discharge, the echocolordoppler of the splancnic
61
veins showed recanalization of the portal vein branches with only a suboc- La Mura G. 3, La Mura L. 4, Renis M. 5
clusive thrombosis of the splenic vein. Septic thrombophlebitis (or throm- 1
UOC Medicina AOU Salerno, 2UOC Anatomia Patologica AOU Salerno,
bophlebitis suppurative of portal vein), also known as pylephlebitis, is a rare 3
Cardiologo P.O. Scafati ASL Salerno, 4Università di Napoli “Federico II”,
but serious complication of an abdominal infectious process which may be 5
UOC Medicina P.O. Cava de’ Tirreni AOU Salerno
characterized by many complications (extension of the thrombus to the upper
mesenteric vein, the branches of the portal vein and the splenic vein, forma- Introduction: Streptococcus Gallolyticus (S.G) is responsible for sepsis/
tion of intraepatic abscesses, sepsis and/or peritonitis). The most common endocarditis in a particular category of patients, which may havecolo-
causes are diverticulitis (70% of cases), acute appendicitis, acute necrotic nic cancer, still misunderstood. In view of thisfinding, individuals with
pancreatitis, intestinal bowel disease. However, the presence of an infectious positive blood culture for this pathogen, are currently recommended to
focus is not always identifiable and blood cultures are positive in c. 50–80% of undergocolonscopy.
pylephlebitis patients In about 80% of the cases described in the literature E. Clinical Case: F, 60. Undifferentiated diffuse colonic cancer (signet-rin-
coli, P. mirabilis, B. fragilis, K. Pneumoniae, Enterobacter and S. bovis are the gcells, with positivity of estrogen receptors), diagnosed a year before,
more frequently isolated germ. In our patient, the causal germ was not identi- never undergone surgery, but undergone chemotherapy. Hospitalization
fied, the abdominal site of infection was only supposed to be a peripancreatic in Internal Medicine department for fever and severe anemia at inflam-
abscess, but the FDG PET proved to be a powerful technique to identify this matory genesis (elevated inflammatory markers), then subjected to blood
infectious condition which is frequently difficult to diagnose. transfusion. Positive blood culture for S.G. Echocardiography: aortic valve
endocarditis. Antibiotic therapy according to antibiogram: disappearance of
fever and improvement in blood counts.
GOOD ANAMNESIS (A POSTERIORI), HALF DIAGNOSIS Discussion: Literature has documented association between endocarditis
caused byS.G. and colon cancer, so that, in case of positive blood culture
Trulli F., Braucci S., Caracciolo B., Cipriani E., Gianoglio O., Viscogliosi G., for this pathogen, it is recommended the execution of colonoscopy for the
Sabetta F. search of the colon cancer.
Dipartimento di Medicina, Policlinico Casilino, Roma Conclusions: The interest of the case arises, in our opinion, by the fact that,
on the basis of this experience, you might highlight the two-way nature of
A 79-year-old healthy Italian man presented to our hospital with stuporous the recommendation; ie, in patients with colonic cancer who present sepsis,
state, fever, hematemesis and melena, jaundice and signs of multiorgan it should be recommend to also perform an echocardiogram, as a first level
failure (type 1 respiratory failure, hypotension, acute renal failure, elevated investigation, and, while waiting for the results of blood culture, it should be
transaminases and cholestatic index, hyperglycemia, increased inflamma- recommend to practice empirical therapy against S. G.
tory index, thrombocytopenia, anemia and neutrophil leukocytosis; qSOFA
3). Intravenous antibiotics with piperacillin/tazobactam and supporting
therapy were initiated very quickly. AN UNEXPECTED AND SINGULAR GUEST
Patient underwent urgent upper endoscopy showing non-bleeding esopha-
geal erosions. Whole body CT scan showed lung bilateral basal pneumonia. Ricci P., Stasi C., Palmieri V.O., Belfiore A., Buonamico P.,
For the worsening of general conditions antibiotic therapy was modified Minerva F., Pugliese S., Portincasa P.
with vancomycin, meropenem and levofloxacin with progressive improve- Dipartimento di Scienze Biomediche e Oncologia Umana, U.O. di Medicina
ment of clinical conditions. In the hypothesis of infectious disease, we tested Interna Universitaria, Policlinico di Bari
urinary pneumococcal and legionella antigen, Weil-Felix and Widal-Wri-
ght serodiagnosis, Toxoplasmosis antibodies, Hepatitis viruses and Cyto- We report a clinical case of a 79 year old woman, smoker, suffering from
megalovirus antibodies, Leishmania test with negative results for recent osteoporosis with multiple vertebral collapse and chronic polyarthritis
infections. Weak positivity for Epstein Barr virus and for Mycoplasma treated with corticosteroids, Methotrexate, Adalimumab. She was hospi-
pneumonae IgM antibodies was detected. After the occurrence of diarrhea, talized for intermittent fever (up to 39 °C), cough, asthenia, dyspnea. The
Clostridium difficile infection was diagnosed. In suspicion of sepsis origi- following procedures were performed: chest X-ray (documenting thicke-
nating from the bile ducts, abdomen MR and CPRM were performed with ning bilateral basal parenchymal area), blood examinations showing neu-
detection of mild common bile duct ectasia. trophilic leukocytosis (20,000/mcL), C-reactive protein (CRP, 179 mg /L),
Patient’s hemodynamics substantially improved 15 days later and he had a blood cultures, urine culture (both negative). Testing on sputum showed
complete recovery from the disease after 40 days of hospitalization. After polymorphonuclear, filamentous branching Gram-positive bacilli, diagno-
improvement of clinical conditions, a careful anamnestic interview revealed stic of Nocardia. Whole-body CT confirmed pulmonary nocardiosis, consi-
that patient had fallen into a country swamp ten days before the hospitaliza- sting of multiple consolidations and partially excavated nodules. Tubercu-
tion. Antibodies againstLeptospira research was made with the detection of losis (TB) and other fungal infection were excluded by testing mycobacteria
weak positivity of IgM at discharge and of IgG after 1 month after discharge. in sputum, Quantiferon TB Gold and other serology tests. The patient was
Conlusions: considering his clinical presentation, his anamnesis, and the successfully treated with Trimethoprim-Sulfamethoxazole (TMP-SMX, 2gr/
fact that limitation of serology is that antibodies are lacking at the acute day) and Imipenem (2gr/day) for a month, continuing with TMP-SMX only
phase of the disease, it’s highly probable that patient was affected by Lep- for another six months. Nocardiosis is a rare, opportunistic and life-thre-
tospirosis and he responded to empirical antibiotic therapy, mainly due to atening infection, better reported in asian countries like India, while its
meropenem and piperacillina/tazobactam, although some evidence confir- incidence in Europe is unknown because of its rareness. A preexisting
med that fluoroquinolones were shown to be effective in reducing animal immunecompromised state, ranging from malignancy, organ and hemato-
mortality in a model of acute leptospirosis (1,2,3). poietic stem cell transplantation, chronic glucocorticoid therapy, immuno-
1) Ressner Ra1,Griffith ME, Beckius ML, Pimentel G, Miller RS, Mende soppressive drugs, chemotherapy and HIV infection, have been reported
K, Fraser SL, Galloway RL, Hospenthal DR, Murray CK. 2008. Antimi- in the major part of cases. Nocardia usuallycauses pneumonia, but could
crobial susceptibiities of geographically diverse clinical human isolates of also involve any organ, especially the brain. Transcutaneous inoculation is
letospiras. Antimicrob Agents Chemother. Aug; 52 (8):2750-4 doi:10.1128/ reported in immunocompetent individuals, causing soft tissues infection,
aac.00044-08. keratitis and endophthalmitis. Diagnosis is based on isolation of Nocar-
2) Matthew E. Griffith, James E. Moon, Erica N. Johnson, Kyra P. Clark, dia from respiratory samples, (sputum, bronchoalveolar lavage, or fluid
Joshua S. Hawley, Duane R. Hospenthal and Clinton K. Murray. 2007. obtained from lung aspiration) and radiological evidence of abscesses and
Efficacy of Fluoroquinolones against lepstopira interrogans in a Hamster nodes (with or without excavation). Whole body CT is always recommen-
Model. Model Antimicrob Agents Chemoter. 51 (7):2615-2617. ded. Sulfonamides are the drugs of choice. At the outset, both TMP (5–10
3) Musso D1, La Scola B. 2013. Laboratory diagnosis of leptospirosis: a mg/kg) and SMX (25–50 mg/kg) are given twice daily. As second choice,
challenge. J Microbiol Immunol Infect. Aug;46(4):245-52.doi:10.1016/j. Minocycline and Linezolid could be used. As parenteral drug, Ceftriaxone
jmii.0.3001 Epub Apr 29. (1 - 2 gr), Imipenem (2gr) and Amikacin (5 – 7.5 mg/kg every 12 hours or 15
mg/kg every 24 hours) are usually effective. Patients with severe disease are
initially treated with a combination including TMP-SMX, Amikacin, and
Ceftriaxone or Imipenem. Clinical improvement is usually noticeable after
STREPTOCOCCUS GALLOLYTICUS INFECTION AND 1–2 weeks of therapy but may take longer, especially with Central Nervous
COLON CANCER: A QUITE FREQUENT ASSOCIATION Sistem disease. After definite clinical improvement, therapy can be conti-
nued with a single oral drug, usually TMP-SMX. Brain abscesses should be
De Donato M.T. 1, Marracino M. 1, De Vecchi R.M. 1, Baldi C. 2,
62
aspirated, drained, or excised if the diagnosis is unclear, if an abscess is large hypertension. The aim of our study was to determine a liver stiffness (LS)
and accessible, or if an abscess fails to respond to chemotherapy. cut-off value measured by ElastPQ and/or laboratory parameters that could
help identify those patients who can safely avoid screening endoscopy, simi-
larly to the recently proposed Baveno VI criteria which recommends a LS
A PILOT STUDY OF ULTRASONOGRAPHY-GUIDED value <20kPa measured by transient elastography in combination to a pla-
“SHORT” MIDLINE CATHETERS FOR DIFFICULT telet count >150,000/μl.
VENOUS ACCESS: THE EXPERIENCE OF TRAINING Aim & Methods: Data were collected on 1385 patients who underwent
COURSE IN A UNIVERSITY SCHOOL OF INTERNAL ElastPQ measurement from January 2013 to January 2016 in our Depart-
MEDICINE ment. Inclusion criteria were a liver stiffness value of ≥7 kPa and an upper
gastrointestinal endoscopy within 12 months, with a diagnosis of compen-
Guidetti E., Napoli L., Leoni S., Piscaglia F., Bolondi L. sated chronic liver disease. We choose this specific liver stiffness cut-off
Unità Operativa Medicina Interna Bolondi, Azienda Ospedaliero- value in order to reasonably rule-in all patients with advanced fibrosis and
Universitaria S. Orsola-Malpighi, Bologna cirrhosis, based on the limited literature available on this specific elasto-
graphic technique. Exclusion criteria were history of decompensated liver
Introduction: Patients admitted to the Internal Medicine Department con- disease, evidence of porto-spleno-mesenteric vein thrombosis and non-cir-
stantly require at least one stable venous access for complex therapies. Peri- rhotic portal hypertension. Varices were graded as low risk (grade <2) or
pheral intravenous placement may be challing. Non ultrasound (US)-gui- high risk (grade ≥2).
ded short traditional cannulas have been frequently associated with local Results: The study included 184 patients (114 [62%] hepatitis C, and 160
complication. New short midline (8- to 10 cm- long polyurethane catheters) [87%] Child-Pugh A). Varices were present in 36% cases, with 10% preva-
inserted with US guidance and direct Seldinger technique provide a reliable lence of high risk varices. According to ROC curve analysis liver stiffness
vascular access option for patients with difficult venous access who would measurement and platelet count were evaluated as predictors of high risk
otherwise require multiple venipunctures or lead to a delayed therapy. varices. Overall 74/184 (40%) met the “BAVElastPQ” criteria (that is, liver
Aims: To evaluate the effectiveness of a training course of US- guided short stiffness <12 kPa and platelet count >150,000/μl). Within this group 11/63
Midline catether insertion for Internal Medicine fellows; to evaluate the (17%) had any grade of varices and only 1/73 (1%) had high risk varices. The
secondary advantages in terms of success rates and mean duration of the BAVElastPQ criteria gave sensitivity of 0.95, specificity of 0.44, a positive
line. predictive value of 0.16 and a negative predictive value of 0.98. The AUROC
Methods: We considered the successful of “short” Midline catheters bedside for liver stiffness and platelet count was 0.81 and 0.76, respectively.
insertion program in our University School of Internal Medicine. The course Conclusion: The BAVElastPQ criteria correctly identified 99% of patients
was divided in two parts, consisting of a first theoretical section (4 hours), without high risk varices. By applying such criteria we could have poten-
concerned the devices insertion tecnique and indication, and a second tially avoided ca. 40% surveillance endoscopies in our cohort. To our know-
practical section (8 hours), provided the placement of at least one device/ ledge this is the first study that evaluated the potential role of a new p-SWE
per fellow, asssisted by experts anesthesiologists. All partecipants must have technique such as ElastPQ in the non-invasive assessment of clinically
already basic US experience and competence. All the selected patients need significant portal hypertension, similarly to the recently proposed Baveno
for stable venous access for longer than 6 days of treatment or with difficult VI criteria though using ElastPQ as an alternative to transient elastography.
venous access (more than two venipuntures).
Results: Twenty-one attempts for short-midline catheters positioning were
performed by Internal Medicine fellows. Twenty have been successfully EARLY ATHEROSCLEROTIC AND CARDIAC DAMAGE IN
inserted, with 7 difficult inserctions (2 venipunctures); one local hematoma PATIENTS UNDERGOING LIVER TRANSPLANTATION
was described as complication. Edema of the subcutaneous tissue, depth and
limited diameter of the vessel were the main cause of difficult venous access. Pisano G. 1,Oberti G. 1, Zannoni S. 1, Orlandi M. 1, Lombardi R. 1, Donato
In 12/20 (52%) patients, catheters were inserted into the basilic vein (mean M.F. 2, Bertelli C. 1, Porzio M. 1, Manini M. 2, Caccamo L. 3, Dondossola D. 3,
diameter 3.3 mm), while in the remaining 8/20 (48%) in the brachial one Fargion S. 1, Fracanzani A.L. 1
(mean diameter 4 mm). All devices have been removed after a period ranging 1
Department of Pathophysiology and Transplantation, Unit of Internal
from 2 to 13 days (median 7 days, mean 7.8 days). The devices removal was Medicine, Ca’ Granda IRCCS Foundation, Policlinico Hospital, University
justified by interruption of infusional therapy (n=14), catheter displacement of Milan, Milan, Italy 2Division of Gastroenterology, Department of
(n=3), local complication (superficial thrombophlebitis, n=1), catheter occlu- Pathophysiology and Transplantation, Ca’ Granda IRCCS Foundation,
sion/malfunction without evidence of vein thrombosis confirmed by Doppler Policlinico Hospital, University of Milan, Milan, Italy 3Unit of Hepatic
US (n=2). No catheter-related infection have been registered in our patients. Surgery, Department of Pathophysiology and Transplantation, Ca’ Granda
Mean vein diameter and number of venipunctures at inserction time were IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
correlated with device duration; in the 10/20 (50%) catheters with median life
< 7 days, mean vein diameter was 3,07 mm and difficult inserctions were 4/10 Background: Improved survival after orthotopic liver transplantation
(40%) versus mean vein diameter 3.76 and 3/10 (30%) difficult inserctions (OLT) has allowed to detect long-term consequences of liver transplan-
in the 10/20 (50%) catheters with mean life > 7 days. All internal medicine tation. After OLT, due to immunosuppressive drugs and increase of body
fellows agreed that this experience with US- guided short Midline catheter weight, patients have high risk of metabolic syndrome and of de-novo non
insertion and education about venous devices were positive and useful for alcoholic fatty liver disease (NAFLD) occurrence, contributing to cardio-
their clinical practice; 10% of them require more practice with tutor assistence vascular complications. Objective: To evaluate in a prospective study the
to menage independently device insertion. earliness of cardiovascular damage by echocardiographic parameters and
Conclusions: Althought more experience is needed, our preliminary carotid artery alterations and the effect of metabolic modifications and
data suggests that US-guided “short” Midline catethers provide a safe and immune-suppressive therapy.
reliable kind of vascular access, especially for complex patients with diffi- Methods:From January 2014 to March 2017we evaluated 79 patients on
cult peripheral venous accesses. Such skills could be acquired during a trai- waitingtransplant list, (M/F 54/25), age 54±10 years;54 were transplanted
ning course related to post-graduate specialization school, with good and and followed for 24 months. A complete evaluation of anthropometric, cli-
effective curve of learning. nical, biochemical and cardiovascular parameters (intima-media thickness
(IMT), arterial stiffness (cPWV) and plaques of carotid artery), cardiac
alterations (diastolic dysfunction (E/A), thickness of the interventricular
ASSESSING BAVENO VI CRITERIA WITH A NEW POINT- septum (IVSTd), left ventricular mass (LVM), left atrium (LA)) and visceral
SHEAR WAVE ELASTOGRAPHY TECHNIQUE: THE adiposity (epicardial fat thickness (EAT)) by ultrasound and echocardio-
BAVELASTPQ STUDY graphy was collected at enrollment.
Results: A significant increase of diabetes, metabolic syndrome hyperten-
Garcovich M., Gibiino G., Ainora M.E., Annicchiarico B.E., sion and dyslipidemia prevalence was already evident at 6 months after
Riccardi L., Pompili M., Siciliano M., Gasbarrini A., Zocco M.A. transplant, consequently a worsening of carotid damage (Quality IMT
UOC Medicina Interna, Gastroenterologia e Malattie del Fegato, Università 610.4±101 vs 664.4±120, p=0.003), diastolic dysfunction (E/A 1.10±0.31 vs
Cattolica del Sacro Cuore, Roma 0.85±0.27, p=0.001) and visceral obesity EAT 5.9±2.6 vs 8.1±2.8, p=0.001)
was observed, all parameterremaining stable at 12 months. A significant
Introduction: To date no study has explored the potential role of ElastPQ, a lower progression in IMT during follow-up in patients with Tacrolimu-
novel point-SWE technique, in the assessment of clinically significant portal stherapy than without (p= 0.04)while no relationship with the duration of
63
steroid therapy was observed. In contrast the presence of diabetes was signi- showing a good accuracy when performed in prehospital setting. Moreover,
ficantly associated with carotid stiffness (p=0.02), the presence of metabo- US-evaluated patients receive a diagnosis more concordant with the final
lic syndrome and of the use of statin with IMT (p=0.01).Fifthteen (28%) when compared to clinical evaluated ones. Anyway this difference does not
patients received liver with histological evidence of steatosis>20%, 5/53 reach a statistical significance. No significant differences in 24-hour and
(9%) developed steatosis (evaluated by ultrasound) after 6 months and other 30-day mortality were reported in patients evaluated with or without preho-
5/50 (10%) after 12 months. No significant difference in early progression of spital US. Otherwise time management of patient and controls in prehospi-
cardiovascular damage was observed among patients who received steatotic tal care did not differ, demonstrating that use of US does not delay therapy
liver in comparison with others patients. and transportation of patients.
Conclusion: Cardiovascular alterations occur very early after liver tran- Conclusion: In our study outcome was not improved in US evaluated
splantation. The use of steatotic liver seems to not affect early cardiovascu- patients. The good concordance showed with the US performed in the ED
lar damage. Therapeutic and behavior strategies aimed to prevent/delay suggests its implementation in prehospital care to anticipate therapeutic
cardiovascular alterations should be provided in the first weeks after liver approach and diagnostic protocols once the patient is the ED. Prospective
transplant. studies are needed to evaluate if use of diagnostic and therapeutic protocols
in US evaluated patients could modify mortality once transported in the
ED.
B-LINES IN INTERSTITIAL LUNG DISEASE: A PILOT
STUDY ON SCLERODERMIC PATIENTS
PORTAL VEIN ANEURYSM: AN UNUSUAL ENTITY
Melchio R. 1, Papaleo F. 2, Romeo N. 3, Bracco C. 1, Leccardi S. 1, Molino P. 4, DIAGNOSED BY ULTRASOUND
Serraino C. 1, Testa E. 1, Giraudo A. 1, Rinaldi G. 1, Fenoglio L.1
1
S.C. Medicina Interna, A.O. S. Croce e Carle, Cuneo 2Scuola di Medicina, Berardi E., Schilardi A., Antonica G., Noia A., Sabbà C. Interdisciplinary
Università di Torino 3S.S. Reumatologia, A.O. S. Croce e Carle, Cuneo 4S.C. Department of Medicine, University of Bari School of Medicine, Bari, Italy
Medicina d’Urgenza, Ospedale S.Giovanni Bosco, Torino
Portal vein aneurysm (PVA) is a rare vascular dilatation of the portal vein,
Background: interstitial lung disease (ILD) is a common complication of with an incidence of 0.06%. Even if the aetiology of PVA is not clearly
mixed connective tissue disease: in the case of scleroderma ILD is a leading understood, portal hypertension, severe pancreatitis, trauma, interventio-
cause of morbidity and death. The extent of disease on HRCT scan, combi- nal procedures and invasion of the portal vein by malignancy have been
ned with spirometry, can be used to provide prognostic information. Lung reported as possible causative factors. Aneurysms have been described in all
ultrasound has recently been proposed as a promising alternative method parts of the portal vein; however, extrahepatic aneurysm are more common
to detect and quantify ILD in such patients, by the evaluation of B-lines, the then intrahepatic ones. One third of patients are usually asymptomatic as
ultrasonographic marker of lung interstitial syndrome. Aim: to evaluate the
diagnostic accuracy of lung ultrasound in the screening of ILD in a cohort
of patients with systemic sclerosis (SS).
Methods: twenty consecutive patients with SS (age 59.5+12 ys), 16 (80%)
were females, underwent systematic lung ultrasonographic evaluation
within six months of a chest high resolution CT (HRCT) scan. The echo-
grapher was blinded to the HRCT scan
Results Diagnostic accuracy was evaluated by Receiver Operating Characte-
ristic (ROC) curve analysis.
Results: The prevalence of ILD as diagnosed by HRCT scan in this sample
was 50%. Mean B-lines number in patients with ILD was 32.7+11 vs
15.6+8.9 in patients without ILD (p<0.005). Receiver Operating Characteri-
stic (ROC) curve showed an AUC of 0.83 (95%CI 0.70-0.97). With a cut-off
> 7 B-lines, sensitivity was 100%, specificity 47%, and the concordance rate
was 73.5%.
Conclusions: in this pilot study, lung ultrasound by B-lines evaluation
showed a good sensitivity to detect interstitial disease in patients with SS.
Further studies are needed to better define the role of lung ultrasound on
diagnosis and follow up of ILD in such patients.
PVA is an incidental finding, while approximately 50% of patients present

FEASIBILITY AND PROGNOSTIC OUTCOME OF CHEST- with non-specific abdominal pain. Gastrointestinal bleeding, portal hyper-
US IN PREHOSPITAL NON-TRAUMATIC DYSPNEIC tension or symptoms related to the compression of adjacent organs (i.e.
PATIENT abdominal swelling, jaundice) occur in less than 10% of cases.
A 86-year old male suffering from stable coronary artery disease, atrial
Acquistapace G. 1, Di Capua M. 1, Ruocco A.L. 1, Beretta G. 2, fibrillation and chronic kidney disease (CKD) was admitted for dyspnea.
Paglia S. 1 He underwent chest-CT showing an expansive lesion at the hepatic ilus
1
Dipartimento di emergenza e accettazione. Ospedale Maggiore di Lodi, Lodi with a maximum diameter of about 5.5 cm in the scans through the upper
2
Emergenza extraospedaliera. Ospedale Maggiore di Lodi, Lodi abdomen. Because of CKD affecting the patient (eGFR: 22 ml/min), con-
trast medium was not employed. Hence, B-mode ultrasonography show an
Objectives: Ultrasound (US) is the only diagnostic instrumentation avai- anechoic cyst-like lesion (55 x 50 mm) near the porta hepatis, in continuity
lable in pre-hospital care. Despite widespread diffusion of chest-US, poor is with the right portal vein. That lesion had thickened walls, with concomi-
known about its feasibility and prognostic role in pre-hospital setting. Some tant smoke effect that the colordoppler showed to be a circular yin-yang
literature evidence shows that dyspnoea, as cause of pre-hospital emergency, flow pattern. The spleno-porto-mesenteric axis was well displayed throu-
has a doubled mortality if compared to other pre-hospital emergencies. The ghout its course with normal velocity, curve with the exception of the aneu-
aim of our study was to assess whether chest-US has the same accuracy in rysms where the flow was delayed. The inferior Vena Cava has been properly
pre-hospital and hospital care and its impact on outcome of non-traumatic displayed throughout its course with regulated flow pattern.
dyspnoeic patients. This finding conferm the hypotesis of an ilus portal vein aneurysm, in the
Methods: We conducted a retrospective study on 81 non-traumatic dysp- absence of ultrasonographic signs of portal hypertension. Different imaging
noeic patients in the prehospital setting evaluated through chest-US. 157 technics are used to diagnosed portal vein aneurysm. The typical B-mode
dyspnoeic patients, age and sex matched, assessed only by clinical evalua- ultrasound finding is an anechoic lesion at the hepatic ilus lesion. Pulsed
tion served as control. We investigated concordance between prehospital wave Doppler or Color Doppler help to confirm the diagnosis by demon-
chest-US and emergency department (ED) performed by a different phy- strating the presence of a non-pulsatile, monophasic or yin-yang pattern.
sician. We moreover evaluated 24-hours and 30-day mortality in patients Color doppler, thanks to its feasibility, reproducibility and no-invasiveness,
assessed by chest-US versus clinical evaluated ones. can be considered the cornerstone for the diagnosis and follow-up of portal
Results: Concordance between prehospital and ED chest-US was 0.86 vein aneurysms, even in voluminous ones, such in our case. CT and magne-
64
tic resonance angiography for the potential iatrogenic effect of mdc may be scleroderma pattern of disease: lSSc vs dSSc; disease duration (more than 2
reserved for patients who are expected to undergo surgery. years) and subset of autoantibody.
Results: Radiological study showed swallowing disorders for oral phase:
inadequate velar elevation 4%, leakage 15%, drooling 0% and stasis of bolus
ANXIETY LEVELS AS RISK FACTOR FOR OSTEOPOROSIS in mouth 4%. As for pharyngeal phase: stasis of bolus on pharyngeal 49%,
IN POSTMENOPAUSAL WOMEN penetration in the laryngeal aditus 53%, post-swallowing aspiration 22%,
abnormal upper esophageal sphincter behavior 13%. Concerning esopha-
Catalano A. 1, Martino G. 2, Bellone F. 1, Lasco A. 1, Morabito N. 1 geal phase: inadequate primary peristalsis 53%, abnormal secondary peri-
1
Department of Clinical and Experimental Medicine, University Hospital stalsis 29%, non-peristaltic contractions 40%, deficit of clearance 69%,
of Messina, Messina, Italy 2 Department of Cognitive Sciences, Psychology, abnormal lower esophageal sphincter behavior 76%, hiatal hernia 80%,
Education and Cultural Studies, University of Messina, Messina, Italy esophageal reflux 56%, esophagitis 82%, esophageal luminal stenosis 0%.
When we analyzed the swallowing disorders in the different pattern of dise-
Background: Anxiety disorders are common psychiatric diseases and ases we have not found a significant prevalence in the lSSc or in dSSc; the
a major public health problem. Osteoporosis is the main bone metabolic dysfunctions are present in all patients particularly with more than 2 year of
disease and is burdened by higher fracture risk. Anxiety and osteoporosis disease. Finally, the correlation with autoantibodies did not show a preva-
may have consequence on quality of life and social costs. The primary aim lent pattern of autoantibodies associated with swallowing disorders
of our research was to investigate the association between anxiety severity Conclusions: Our study demonstrated relevant abnormalities in swal-
and the risk of fracture in a setting of postmenopausal women evaluated for lowing disorders in high number of patients with SSc. Pharyngeal and
osteoporosis. The secondary aims were to measure depressive symptoms, esophageal phases are the most affected, also in the early phase of disease.
health related quality of life and their association with fracture risk. In our cohort of patients SSc, all the videofluoroscopy alterations not found
Methods: Women were consecutively recruited at the Outpatients Clinic for a significant prevalence in lSSc or in dSSc. An early and detailed diagno-
Mineral and Bone Disorder of the Department of Internal Medicine. Multi- sis of swallowing disorders, supported by a semi-quantitative analysis with
ple clinical risk factors (CRFs) for fractures and FRAX score, bone mineral the use of videofluoroscopy scores, may be useful to guide the appropriate
density (BMD) by dual-energy X-ray absorptiometry of the lumbar spine therapeutic approach, either rehabilitative or pharmacological, and finally,
and femur, X-ray vertebral morphometry, Hamilton Anxiety Rating Scale to improve the patient’s quality of life. Extended studies are necessary to
(HAMA) for anxiety levels, Beck Depression Inventory for depressive symp- confirm and transfer our data into clinical practice.
toms and the 36-Item Short Form Health Survey (SF-36) questionnaire for
quality of life were evaluated in each patient. Recruited women were consi-
dered in tertiles of HAMA scores. DISEASE ACTIVITY AND DAMAGE IN INFLAMMATORY
Results: Of the 192 recruited women (mean age 67.5±9.5 yr.), patients MYOPATHIES
falling in the lower tertile of HAMA score (HAMA-1) showed lower ten
years probability of major osteoporotic fractures, according to FRAX, in Cardinaletti P. 1, Savore I. 1, Danieli G. 1, Lupidi F. 2, Gabrielli A. 1, Danieli
comparison with patients in the higher one (HAMA-3) (20.44 ±9.3 vs. M.G. 1
24.94±13, respectively, p=0.01), and the same trend was observed when 1
Clinica Medica, 2Clinica Neurologica, Università Politecnica delle Marche e
comparing HAMA-2 and HAMA-3 tertiles. Women in HAMA-3 exhibited Ospedali Riuniti, Ancona
lower T-score vales at lumbar spine in comparison with women in HAMA-1
(-2.84±1.4 vs. -2.06±1.2, respectively, p<0.001), and lower T-score value at Aim: To assess the disease activity, disability and damage in patients with
femoral neck (-2.21±0.9 vs. -1.93±0.6, respectively, p<0.05); the same trend polymyositis (PM) and dermatomyositis (DM).
for T-score measurements was observed when comparing HAMA-2 and Methods: We selected 78 consecutive patients of our Internal Medi-
HAMA-3 tertiles. A significant higher rate of patients with previous fractu- cine Department in which PM and DM were diagnosed according to the
res were observed in HAMA-3 vs. HAMA-1 (p<0.05). Anxiety levels were Bohan and Peter’s criteria. We used a core set of functional indexes so that
significantly related with age, menopausal age, years since menopause, and, disease activity, disability and damage were recorded by the MITAX (Myo-
at a multiple regression analysis, were predictive of reduced BMD, after cor- sitis Intention to Treat Activity Index), the HAQ-DI (Health- Assessment
recting for other CRFs, including depressive symptoms. Questionnaire Disability Index) and the MDI (Myositis Damage Index),
respectively.
Results: Our study included 33 patients with DM, 27 with PM, 9 with can-
SWALLOW STUDY IN PATIENTS WITH SYSTEMIC cer-associated myositis and 9 with connective tissue disease (CTD)-asso-
SCLEROSIS. VIDEOFLUOROSCOPY ITEMS AND ciated myositis. Nine patients passed away during the follow-up period.
CORRELATION WITH CLINICAL PATTERNS MITAX values at the onset were higher in patients with CTD-associated
myositis. MITAX values at the onset significantly correlated with succes-
Fischetti C.1, Fraticelli P. 1, Barchiesi S. 1, Romanelli G. 1, Zuliani L. 1, sive disability as calculated with HAQ-DI and mortality rate. According
Ferrarini A. 1, Pisani A.M. 2, Gabrielli A. 1 to HAQ-DI score, 28% of our patients had moderate to severe disability.
1
Clinica Medica, Dipartimento di Medicina Interna, Universita’ Politecnica We could not find any connection between MDI and disease progression,
delle Marche, Ospedali Riuniti, Ancona 2Dipartimento di Radiologia, type, kind of involvement in myositis, disability (HAQ-DI) and mortality.
Ospedali Riuniti, Ancona Conclusions:: Even though many international attempts have been made to
propose a core set of scores assessing disease activity and damage in myosi-
Background: Systemic Sclerosis (SSc) is a chronic autoimmune disease cha- tis, our preliminary results showed only a link between MITX and disability
racterized by proliferative vascular lesions and progressive fibrosis of skin and mortality. In close future, international study group such as MyoNet
and internal organs, including the gastrointestinal tract. Gastrointestinal will certainly improve our understanding in treatment and care of inflam-
involvement is a very frequent complication, reported in up to 90% of SSc matory myopathies.
patients in both limited (lSSc) and diffuse (dSSc) cutaneous forms, and it is
one of the earliest events.
Objectives: Evaluate the correlation between radiological items analyzed by TWO FAMILY MEMBERS WITH FAMILIAL
videofluoroscopy swallow study and clinical patterns of patients SSc. MEDITERRANEAN FEVER CARRYING THE SAME
Methods: 55 patients (M/F: 6/49; median age 56y; median disease 6y, lSSc / MUTATION SHOWED DIFFERENT CLINICAL
dSSc:36/19; anti-Scl70+:21/55, ACA+:18/55, only ANA+:16/55), with a dia- PRESENTATIONS
gnosis of SSc and a history of dysphagia underwent a dynamic and morpho-
logical study of the oral, pharyngeal and esophageal phases of swallowing A. Grembiale, E. Corigliano, A. Franchi, M. Falbo, F. Marasco,
with videofluoroscopy. The oral and pharyngeal esophageal phases were M.C. Calindro, G. Perrone, G.F. Mauro
performed in the upright position, while the esophageal phase was perfor- U.O.C. di Medicina Interna - P.O. “San Giovanni di Dio” - Azienda Sanitaria
med in the prone-oblique position, after administration of contrast mate- Provinciale di Crotone
rial either in bolus form or diluted. Data were analyzed by radiologist with
experience in Videofluoroscopy for the evaluation of 17 videofluoroscopy Introduction: Familial Mediterranean fever (FMF) is the most common
items, of which, 4 concern the oral, 4 the pharyngeal and 9 the esopha- auto-inflammatory disease with monogenic (Mediterranean FeVer –
geal phase, respectively. Results were expressed in a binary system. Then the MEFV gene) inherited pattern. It mainly affects ethnic groups living along
main relevant videofluoroscopy findings were correlated with the principal the eastern Mediterranean Sea: Turks, Sephardic Jews, Armenians, and
65
Arabs. Today FMF is not rare disease in other Mediterranean ethnicities, naud’s phenomenon and digital ulcers (DU) with a deep impact on patients’
such as Greeks, Italians, and Iranians. It is characterized by short inflam- quality of life. Objectives: to determine the clinical burden of severe digital
matory episodes of polyserositis, and fever with irregular pattern. Amyloi- vasculopathy we have reviewed hospital–based treatment for this important
dosis as the major cause of mortality, is the most significant complication complication of SSc in a single centre cohort and we aimed to elaborate risk
of FMF, and may be prevented by colchicine. The MEFV gene, associa- factors for developing new DU within six months from baseline evaluation
ted with the disease is located on chromosome 16. This gene encodes a taking into account demographic, clinic-serological, and capillaroscopic
781-amino-acid protein named pyrin. This protein appears to play a parameters. Moreover our aim was to evaluate the mortality by cardiova-
pivotal role in the regulation of both inflammation and apoptosis, and scular events of patients at 31 December 2016.
mutated pyrin lead to full-blown inflammation characterized by exces- Methods: a total of 31 (24 Women- 7 Men) unselected consecutive SSc pts
sive Il-1ß secretion in FMF. Mutations in the pyrin gene have been identi- with hystory of digital ulcers and using combined terapy (Iloprost-Bosen-
fied in the majority of FMF patients, include four conservative mis-sense tan) were included in our study from 15 September to 31 December 2011,
mutations (M694V, M680I, V726A, M694I), clustered in exon 10, which, and were reviewed during an 6-month period. They had mean age 51.2 years
together with mutation E148Q, in exon 2, account for the vast majority (range 13-84), disease duration 12.2 years ± 7.5 (range 1-24). All met the
of MEFV gene abnormalities. Two mutations, hemo or heterozygotic, preliminary American College oh Rheumatology classification criteria for
confirm suffering from FMF. A few patients with more than two muta- SSc. And according skin cutaneous subsets: 18 pts (58.7%) with Limited
tions named “complex alleles mutations” have been reported. Case Report: cutaneous SSc, 13 pts (41.3%) with diffuse cutaneous SSc. As expected all
Here we report two young italian siblings (a man and a female) with same pts suffer from Raynaud’s phenomenon and nailfold videocapillaroscopy
heterozygotic allele mutations, but different age of onset of disease and (NVC) was performed on all patients, and skin sclerosis was measured with
symptoms. A 24-year-old woman referred to our internistic outpatient Rodnan Skin Score (mRSS). A wide patient’s anamnesis, with particular
clinic with recurrent abdominal pain and fever. She had been suffering attention to previous history of DU, was also recorded, as well as ongoing tre-
from abdominal pain and fever once to twice a month since the age of 4 atments, mainly vasodilator or immunosuppressive therapies, and the pre-
but the clinical diagnosis was just made one year previously. she had been sence of co morbidities potentially responsible for digital ischemia. Results:
using 1 mg/day colchicine and has had no complaints since then. She was During the 6-month period, 7 new DU were detected in our patients’ series
compound heterozygous, bearing the M694I and R761H mutations. Her (7/31; 22.5%).(Group A with new digital ulcers 7 pts; Group B whithout
physical examination was normal, complete blood count, electrolyte, liver new digital ulcers 24 pts) In group A: 4 of patients were male and 3 were
and kydney function tests, sedimentation rate, C-reactive protein (CRP), female. All patients were given bosentan for a mean of 14(±10,3) months.
fibrinogen and urinalysis were normal. Proteinuria and microabuminu- 2 patients (F) were classified as limited and 5 (4 M /1F) as diffuse cutane-
ria was not present in 24-hour urine analysis. Abdominal ultrasound and ous SSc. Anticentromere autoantibodies (ACA) were positive in 3 patients,
endoscopic examinations were normal. Since the patient had no symp- anti-Scl-70 antibodies in 4 patient and antiphospholipid antibodies (APLA)
toms related to amyloidosis biopsies were not performed. The brother in one. There was not significant association between DU and treatment
of the first case is a 29-year-old man who presented to the internistic with vasodilators and/or immunosuppressors, Complications that were
out-patient clinic with intermittent chest pain for 5 years. Initially there experienced in the past were mainly gangrene (30,7%), soft tissue infection
was no complaint of abdominal pain or fever. Sometimes he had dyspnea requiring systemic antibiotics (21,5%), and rarely osteomyelitis (6,4%). At
and atypical chest pain 2-3 times a year and had been evaluated by chest enrolment in the registry, analgesics and anti-inflammatories were admini-
diseases and cardiology departments previously and has been found to be stered to 25,6% of the patients, Among the topical treatments used (25,6%),
normal. Subsequently fever and abdominal pain appeared twice a month. topical antibiotics were the most (15.3%), followed by non-adhering dres-
His physical examination was normal. Renal function tests, electrolytes, sing (6,4 %). Dry dressing was applied only in 3,2% and hydrocolloids in
liver function tests and 24-hour urine analysis were within normal limits. 3,2%. Among analyzed parameters, cutaneous SSc subsets, disease dura-
The rheumatoid factor (RF), antinuclear antibody (ANA), were all negation, history of DU in the last year, smoke, DLCO, CSURI, ESR, and CRP
tive.Abdominal ultrasound and endoscopic examinations were normal. showed a significantly positive association with DU. The frequency of DU
He underwent operation for acute appendicitis at that time. Because of was significantly higher among the patients with diffuse cutaneous subset of
persistent abdominal pain and fever in both, FMF had been considered. SSc compared with the patients with limited cutaneous SSc (p<0,001) More
MEFV gene analysis revealed heterozygous M694I and R761H mutation. Digital Ulcers were present at the end of the cold season from February to
After regularr use of 1 mg/day colchicine, his complaints were resolved. May. All the 7 patients with new digital ulcers were admitted to hospital
Since the patient had no symptoms related to amyloidosis biopsies were at least once to receive intravenous prostacyclina or immunosuppressors
not performed. during the 6 month window.Four patients required multiple admissions;
Conclusion: Although our patients in this report have same mutations, with a mean duration of 9 days, which accounted for a total of 58 bed-days,
the age of onset and their clinical manifestations were different. One of all the patients required parenteral antibiotic for infected digits and needed
them had recurrent abdominal pain and fever, another chest pain and opioid analgesic for DU-related pain. At the follow-ups at December 2016:
dyspnea while he began to experience fever and abdominal pain a few 4 patients (57,1%) (group A) were died vs 1 pts (group B)(4,1%) p<0,001.
years later. This indicates that specific genotypic structures did not corre- In group A, 3 patients(2 M, 69 and 62 years old- 1 F, 42 years old) were died
late with the same phenotypic structure. This wide clinical variability of for coronary heart disease, one patient (F, 77 years old) for cerebrovascular
FMF is partly attributed to MEFV allelic heterogeneity and partly influen- disease. In-group B one patient (F, 50 years old) for gastric cancer.
ced by environmental and genetic factors so genotype-phenotype rela- Conclusion: New Digital Ulcers in SSc are markers of mortality for car-
tionship is not well established. FMF is a common disease which affects diovascular events. In this small series, patients with worse outcomes had
not only the eastern Mediterranean basin countries, but also the other longer follow-up and late diagnosis, already with end-organ damage. More
western countries. It has life-threatening complications, thus the diagno- recent patients have better results even at older ages, mirroring earlier refer-
sis of FMF is important. The occurence of FMF with atypical symptoms ral and improved bundles of care.
should also be kept in the mind.
FUO. WHEN THE SOLUTION COMES FROM THE CLINIC

NEW DIGITAL ULCERS IN SISTEMIC SCLEROSIS:
MARKER OF MORTALITY FOR CARDIOVASCULAR Appice C. 1, Nuzzo M. 1, Buonamico P. 1, Minerva F. 1,
EVENTS Palmieri V.O. 1, Pugliese S. 1, Cacciapaglia F. 2, Amati A. 3,
Belfiore A. 1, Portincasa P. 1
Cimino R. 1, Pintaudi C. 1, Mazzuca S. 2 1
Clinica medica “A. Murri”, Dept. of Biomedical Sciences and Human
1
S.O.C. Medicina Interna AOPC Catanzaro; 2Resp Medicina Interna casa di Oncology, University of Bari 2Dept. of Rheumatology, University of Bari
cura Villa del Sole Catanzaro 3
Dept. of Neurophysiopathology, University of Bari
Patients with inflammatory rheumatic disease have a heightened risk of A 64 years old patient was admitted with fever, arthralgia and myalgia at the
premature coronary heart disease and stroke. Emerging data suggest that lower limbs starting one month earlier. He suffered from gastro-oesopha-
systemic sclerosis also is associated with an increased risk of atherosclerotic geal reflux disease, and had diaphragmatic relaxation. He was on a proton
CV events. Systemic sclerosis (SSc) is a connective tissue disease characte- pump inhibitor. During admission, the patient presented nightly fever (up
rized by excessive collagen deposition and by vascular hyperactivity and to 38°C), general and lower limbs’ weakness, muscular hypotrophy (espe-
obliteration of microvasculopathy. Vascular involvement is responsible of cially of the legs). Laboratory tests showed neutrophil leukocytosis (WBC
some important clinical manifestations of the disease; more frequently Ray- 14140/mm3; Neutrophils: 86.5%) and increase inflammatory indices
66
(CRP: 175mg/mL; ESR: 62mm/h). Empirical antibiotic therapy was started

(Levofloxacin 500mg/die), without clinical improvement. Urinary cul-
tures were negative but an haemoculture was positive for Staphylococcus
Hominis and, in the light of the antibiogram, a targeted antibiotic therapy
was administered with Teicoplanin 400mg/die and echocardiogram (nega-
tive) was performed in order to exclude endocarditis. Symptoms persisted
and the next cultures were all negative. In about a month the patient had
lost weight (5 kg) so, in order to identify the cause of the fever (and in parti-
cular to rule out neoplasm), abdominal and thyroid ultrasonography, chest,
abdominal and pelvic CT-scan with contrast medium were performed
and were negative. A rheumatic disease was excluded by negative serum
auto-antibodies’. Notwithstanding phosphocreatine kinase and myoglobin
were normal, the worsening of muscular hypotrophy, fever persistence and
progressive loss of strength, prompted us to perform an electromyography
(EMG) and a magnetic resonance imaging (NMR) of the lower limbs. EMG
demonstrated a myopathic pattern while NMR showed a widespread edema
of the musculature, at the pre-insertional proximal part of the adductor
muscles, comb muscles and gluteal muscles, bilaterally. After rheumatologic
consultation, a biopsy of femoral quadriceps was performed. The histology
examination was performed by the neurophysiopathologist and pointed
to perimisional and endomysial inflammatory cells, fibers with rimmed
vacuoles, fiber with filamentous inclusions P62 positive. Data were in favor
of diagnosis of “Inclusion Body Myositis (IBM)”, an inflammatory muscle
disease characterized by two processes, one autoimmune (cloning of T cell
that appear to be driven by specific antigens to invade muscle fibers) and the
other degenerative (appearance of holes in the muscle cell vacuoles, deposits
of abnormal proteins within the cells and filamentous inclusions). Steroids
were started (Prednisone 25mg/die) and the patient gained a partial remis-
sion of symptoms.
Conclusion: we present a complex case of FUO with several normal blood
and instrumental findings, where clinical judgment was essential to drive
the final diagnosis.
EXERCISE AS PRESCRIPTION IN RENAL TRANSPLANT

RECIPIENTS:MYOCARDIAL ASSESSMENT BY GLOBAL CAN THE USE OF A SINGLE INTEGRATED UNITARY
LONGITUDINAL STRAIN FOLLOW-UP IS BETTER THAN AUTONOMIC INDEX PROVIDE EARLY CLUES FOR
SIMPLE EF EVENTUAL ELIGIBILITY FOR OLYMPIC GAMES?
Stefani L. 1,Minetti E. 2, Pedrizzetti G. 3, Pedri S. 4, Ingletto C. 2, Oggionni G. 1, Sala R. 1, Spataro A. 3, Malacarne M. 1,2, Benzi M. 3, Tamorri
Tosi B. 2, Mandoli M. 2, Galanti G.2 S. 3, Pagani M. 1, Lucini D. 1,2
1
Sports Medicine Centre- AOUC- Clinical and Experimental Department- 1
University of Milano, BIOMETRA, Milano; 2 Sezione Medicina
University Florence, Italy;2Division of Nephrology, University Hospital dell’Esercizio e Patologie Funzionali, Humanitas Clinical and Research
Careggi;3Engineering and Architectural Department-University of Center, Rozzano; 3 Sports Medicine Institute CONI, Roma
Trieste;4Medical Affairs Department – Esaote S.p.A,2Sports Medicine Center
-Clinical and Experimental Department-University of Florence-Italy Background: Optimal autonomic regulation and stress resilience might
be considered critical elements of athletic performance. Autoregressive
Purpose: A growing evidence indicates that Global Longitudinal Strain spectral analysis of heart rate variability (HRV) may represent a convenient
(GLS) by 2Dimensional Speckle Tracking Echocardiography (2DSTE) tool in order to define autonomic nervous system (ANS) control. It furni-
provides incremental and earlier information than conventional ejection shes a set of different variables and autonomic information may be une-
fraction (EF) in detecting subtle changes of myocardial contractility and venly distributed through derived indices thus impairing a friendly and
Left Ventricular (LV) function. Renal transplant recipients (RTR) maintain consistent use of the technique in clinical settings. Moreover the influence
anyway high cardiovascular risk and mortality despite in complete absence of age and gender must be accounted for a correct clinical interpretation of
of symphoms. Physical exercise is often allowed even if the potential addi- HRV derived variables. In order to overcome these problems, we develo-
tional risk. The aims is to study the role of GLS in RTR with preserved EF ped a novel unitary autonomic index for sports (ANSIs). In this study we
when involved in the exercise as prescription program. hypothesize that this Index, together with a somatic stress related symptom
Methods: The study included 40 RTR clinically stable and submitted to a score (4SQ), might help characterize athletes who were eventually selected
mixed (aerobic and resistance) exercise program, which was defined on an for the Rio 2016 Olympic Games Italian team (Rio +).
individual basis according to the ACSM guidelines. All the subjetcts were Methods: In this retrospective study we examined 778 athletes (age
evaluated by GLS. It was calculated using 2DSTE (XStrain-ESAOTE). 2D 24.4±6.7 yrs) who underwent a planned yearly pre-participation screening.
echo parameters were measured by using MyLab Seven. The EF was mea- All athletes underwent clinical, autonomic and exercise ECG evaluation.
sured using Simpson’s biplane method. RTR followed the exercise program The combination of vagal and sympathetic indices from RR variability into
prescribed at time for a period of at least 12 months during which periodical ANSIs was performed by radar plot and percent ranking of index variables.
re-evaluations of the main 2D echo parameters and of the GLS were perfor- We assessed (Rio+) versus (Rio –) athletes also after subdivision into three
med. ANOVA test was used to compare the data. sport intensity groups (low, mid and high intensity).
Results: The mean GLS at baseline was -19.2 % ±5.1 and EF was 62.7±4. Results: Overall there were no significant differences between (Rio +)
GLS was very significantly (p<0.01) higher after 6 months of exercise (GLS and (Rio -) athletes when considering single individual spectral derived
23.7 % ±4.1) and it maintained significant increase (p<0.05) after 12 M variables. Conversely, the unitary Index ANSIs was significantly higher in
(GLS: 24.4 % ±1.5) despite no significant variation of EF (62.7±4; 65.4 ±3; (Rio +) compared to (Rio-) athletes (respectively 54.5±29.5 and 47.9±28.4
64.7±5). p=0.014). This difference was particularly evident (p=0.017) in the group
Conclusions: Regular physical exercise produces positive effects on myo- of athletes characterized by both high static and dynamic components.
cardial performance in RTR as demonstrated by GLS data. GLS could Considering separately the three sport groups, 4SQ was significantly
contribute to the early detection of eventual subtile heart’s damage. This more elevated in the (Rio-) group of athletes competing in specialties
parameter might be helpful for the implementation of the 2D echo data with low or medium intensity activity levels (Low Intensity: 22.9±22.8
especially in the long term follow- up of regularly traininig. versus15.7±16.6, p=0.023; Middle intensity: 22.4±20.0 versus 15.76±18.8,
p=0.016), no difference being observed in the High intensity groups.
67
Conclusions: ANSIs, a proxy of quality of cardiac autonomic regulation different loads and playing different sports (football and cyclism).
and simple assessment of resilience to stress, may differentiate Italian athle- Material and Methods: We enrolled 47 male athletes: 23 football players
tes who were eventually selected for participation in the 2016 Rio Olympic and 24 cyclists, belonging to same football or cyclism team (mean age in
Games from those who were not, suggesting the possibility of a “winning both groups 18±3 years old). The athletes were all evaluated with echo-
functional phenotype”. The possibility to have a unitary index, which cardiography at the beginning of the sports season, after a one-month
permits to weigh the different ANS impairment associated with various cli- detraining. We assessed LV contractile function using speckle-tracking
nical conditions or different level of training, may overcome some of the echocardiographic global longitudinal strain (GLS) and global circumfe-
difficulties in the practical interpretation of different HRV variables, facili- rential strain (GCS). We also analysed right ventricular function by strain
tating a wider use of ANS evaluation in clinical settings. echocardiography.
Results: No significant differences were found in GLS data between the
two groups (23.4±0.02 in football players and 24.1±0.02 in cyclists), whereas
EARLY REPOLARIZATION AND THE TPEAK-TEND a significantly higher GCS was found in cyclists than in football players
INTERVAL: THE PREVALENCE OF SOME ECG MARKERS (31.2±0.04 and 27.2±0.05 respectively, p< 0.005). The cyclist group showed
IN A POPULATION OF YOUNG ATHLETES a significant increase in right ventricular strain compared to football players
(26.3±0.04 and 23.2±0.04, respectively, p< 0.05).
Patti A. 1, Neunhaeuserer D. 1, Boschiero F. 1, Gasperetti A. 1, Zaccaria M. 1, Conclusions: All values on contractile function were between the normal
Bergamin M. 1, Ermolao A. 1 range, although our preliminary data suggest that a dynamic exercise, which
1
Sport and Exercise Medicine Division, Department of Medicine - University involves a volume load, like cyclism, lead to a sensible increase in systolic
of Padova (Italy) function in elite athletes especially in right ventricle contractility. Further
investigation are needed to improve our sample and to correlate with other
Background: Early repolarization (ER), the Tpeak-to-Tend interval (TpTe) standard echocardiographic parameters.
and the Tpeak-Tend/QT (TpTe/QT) ratio are electrocardiographic para-
meters that seem to be associated with an increased risk of sudden cardiac
death (SCD) and arrhythmic events. The current study aimed to evaluate 20 YEARS OF HOLTER ECG MONITORING IN SPORTS
these parameters in a population of young athletes. POPULATION
Methods: Seven hundred twelve athletes between the ages of 10 and 45 years
were enrolled in the study. Some ER pattern characteristics such as J-point Ariani R., Bartoletti A., Galanti G.
morphology and amplitude and ST-segment morphology were assessed. Sport and Exercise Medicine Unit – Department of Clinical and
Furthermore, the TpTe and TpTe/QT variables were analyzed using two cut- Experimental Medicine – University of Florence - Italy
offs (100 msec and 0.25), based on values previously associated with higher
arrhythmic risk. Introduction and Aim: Arrhythmias are a common finding in the popula-
Results: Out of the total number of athletes assessed by the study, 27.4% tion that practices sports activity or in athletes and sometimes their clini-
showed ER, more frequently present in the inferior leads (40%). The majo- cal interpretation is not easy. Thus we aimed to analyze the recordings in a
rity presented a notched morphology (72.3%) and/or a horizontal/descen- group of subjects who underwent a 24-hour or weekly Holter ECG moni-
ding ST segment pattern (46.7%). Training load appeared to be associated toring in order to assess the presence of arrhythmias in a large cohort of
with an increased J-point amplitude and resulted higher in athletes with an sportives.
ascending compared to a horizontal/descending ST morphology. The mean Methods: We enrolled 6172 patients with a mean age of 35 years old with
TpTe value and TpTe/QT ratio were 66.3±9.3 msec and 0.19±0.03, respecti- a median age of 22, not selected and consecutive, since April 1997 to April
vely. Three subjects showed a TpTe interval > 100 msec, and 11 had a TpTe/ 2017. Revision analysis was performed by Holter Analysis System (Space-
QT > 0.25. labs Healthcare, LLC, California) on a sample of 10903 Holter ECG registra-
tions, focusing on the ECG features, such as arrhythmias (origin, number,
Conclusions:: Young athletes have a higher prevalence (27.4%) of ER with complexity), conduction disorders and channellopathies.
respect to the population at large. In contrast with preceding findings, our Results: The total number of patients who placed the Holter ECG was
study uncovered a majority of ER patterns that were previously correlated 6172 (68,63% male and 31,37% female). The 27,8% of subjects (n=1716)
with increased arrhythmic risk. Finally, exercise training appeared to have had a semiannual or yearly Holter ECG follow-up, composing the 58,7%
an impact on the ER patterns. The study also revealed useful data about of the total amount of recordings. The total number of registrations with
the TpTe and TpTe/QT values in a large, poorly investigated population of Sino-Atrial Block was 43, with Atrio-Ventricular Blocks (AVB) 1427, of
young athletes. Further in-depth studies investigating the clinical signifi- which I degree AVB (54%), II degree AVB type 1 (35,45%), II degree AVB
cance of ER, TpTe and the TpTe/QT ratio are warranted. type 2 (5,18%), Advanced AVB (5,74%), III degree AVB (1,61%). Branch
block’s total records were 286, of which 119 with RBBB, 64 with LBBB, 70
with bifascicular blocks, 33 with indefinite blocks, 52 with only LAFB, and
USEFULNESS OF TWO-DIMENSIONAL ECHO STRAIN 3 with LPFB. The total of subjects with ventricular pre-excitation was 199.
IN EVALUATION OF CARDIAC FUNCTION IN ELITE Those with Brugada syndrome was 17 and 8 with LQTS. The total amount
ATHLETES of recordings with supraventricular arrhythmia was 8716, of which <100 in
24h (75,95%), 100-1000 in 24h (14,82%), 1000-10000 in 24h (7,54%), >10000
Tosi B., Leone B., Toncelli L., Galanti G. (1,69%). Single ectopic beats was present in 8577 recordings, Couples in 2379,
Sport and Exercise Medicine Unit – Departement of Clinical and SVT in 1605, Atrial Fibrillation in 191, Atrial Flutter in 30. The total amount
Experimental Medicine – University of Florence - Italy of recordings with ventricular arrhythmia was 7555, of which <100 in 24h
(62,30%), 100-1000 in 24h (19,30%), 1000-10000 in 24h (14,60%),> 10000
Introduction: It has been largely showed that the cardiovascular adaptation (3,79%). Single ectopic beats were present in 7525, Couples in 1780, Triplets
to sport training is influenced by many factors, including the intensity and in 381, VTs in 183, AIVR in 214, Monomorphic in 4747, Polimorphic in 2808.
the kind of sport practiced. Classically, the so called “Morganroth hypothe- Conclusion: In the Holter recordings we examined, we found that there was
sis” was worldwide accepted in literature: static exercise, characterized by a a clear prevalence of arrhythmias (91,37%) compared to the conduction delay
pressure load to the heart, was differentiated from dynamic (isotonic) exer- (16,26%) and the channellopathies (0,41%). Analyzing in detail the features of
cise, which involves a volume load to the heart. These different loads lead to the arrhythmias we observed that a quarter of the population of the study had
different pattern of myocardial adaptation. More recent studies revisited this more than 100 beats/24h and that more than one fourth of the athletes exa-
hypothesis, showing that left ventricular (LV) remodelling pattern, obser- mined had complex supraventricular arrhythmias (28,03%) or complex ven-
ved in both resistance and endurance trained athletes, presented similar tricular arrhythmias (23,85%). This finding leads us to say that in the general
aspects. It has been shown that two-dimensional strain analysis can specifi- population arrhythmias are a common event and they are often compatible
cally study the contractile function of different myocardial regions of inte- with sports practice.
rest, quantifying intraventricular dyssynchrony and evaluating components Abbreviations and Acronyms: AIVR = Accelerated idioventricular rhythm;
of myocardial function. Although morphological modifications secondary AVB = Atrio-ventricular Block; LAFB = Left Anterior Fascicular Block; LBBB
to exercise have been largely studied, less is known on myocardial systolic = Left Bundle Branch Block; LQTS = Long QT Syndrome; LPFB = Left Poste-
function in different LV remodeling patterns in elite athletes.Aim: in this rior Fascicular Block; RBBB = Right Bundle Branch Block; SVT = Supraven-
study we aim to underline possible differences in contractile myocardial tricular Tachycardia; VT = Ventricular Tachycardia
function with strain analysis in two groups of elite athletes, trained with
68
HEART RATE VARIABILITY IN ATHLETES:

CRITICALITIES AND PITFALLS
Oggionni G. 1, Marchetti I. 1, Spataro A. 3, Malacarne M. 1,2,

Benzi M. 3, Tamorri S. 3, Sala R. 1, Pagani M. 1, Lucini D. 1,2
1
University of Milano, BIOMETRA, Milano; 2 Sezione Medicina
dell’Esercizio e Patologie Funzionali, Humanitas Clinical and Research
Center, Rozzano; 3 Sports Medicine Institute CONI, Roma
Background: The Autonomic Nervous System (ANS) plays an essential role

in the complex chain of mechanisms responsible for athletic performance
and optimal autonomic regulation is a key component for successful trai-
ning in elite athletes. The availability of non-invasive techniques permits
a relatively easy assessment of ANS regulation, allowing its inclusion in
clinical assessment of elite athletes in order to evaluate performance and
detect overtraining or overreaching. Spectral analysis of Heart Rate Varia-
bility (HRV) is a simple, non-invasive technique that is widely used in sport
to assess sympatho-vagal regulation of the heart. Its employment is increa-
sing partly due to the rising usage of wearable devices and personal internet
group Applications focusing HRV. However data acquisition using these
devices may be suboptimal because they cannot discriminate between sinus
and non-sinus beats and do not record any data regarding respiratory fre-
quency.This information is mandatory for a correct clinical interpretation
of ANS indices.
Methods: This study involved 974 elite athletes, all of them underwent a
complete autonomic assessment, by way of Autoregressive HRV analysis
using an ad-hoc Software Tool with minimal technical involvement.
Results: In 91 subjects (9% of the total population) we observed criticalities
of either cardiac rhythm or respiration. Through perusal of one-lead ECG
analysis we observed that 77 subjects had atrial or ventricular ectopy, i.e.
conditions which impair stationarity and sinus rhythm. Running anyway
autonomic nervous system analysis in this population, we observed that
RR variance and raw values of LF and HF regions are significantly higher
in arrhythmic subjects. In addition 14 subjects had slow (about 6 breath/
min, 0.1 Hz) respiration. This condition clouds the separation between LF
from HF spectral regions of RR interval variability, respectively markers of
the prevalent sympathetic and vagal modulation of SA node and of their
synergistic interaction.
Conclusions: Caution must be payed when assessing HRV with non-ECG
wearable devices. Recording ECG signal, ensuring that each QRS complex
is duly preceded by a P wave, and respiratory rate is higher than 10 breath/
min are both prerequisites for a more reliable analysis of HRV particularly
in athletes.
69
Poster 118° Congresso Nazionale - Società Italiana di Medicina Interna
POSTER G. 2, Spadaro G. 1,2, Genovese A. 1,2

1
School of Specialization in Allergology and Clinical Immunology, University
of Naples Federico II 2. Department of Translational Medical Sciences and
interdepartmental Center for Research in Basic and Clinical Immunology
Sciences, University of Naples Federico II, Naples, Italy. 3. Division of Clinical
1. AUTOSOMIC DOMINANT HYPER IGE SYNDROME – Immunology, Allergology and Rheumatology, Department of Internal
THE IPINET ADULT COHORT Medicine, University of Zagreb School of Medicine, University Hospital
Dubrava
Carrabba M. 1, Fabio G. 2, Dellepiane R.M. 3, Cossu F. 4, Specchia F. 5,
Badolato R. 6, Pietrogrande M.C. 7 Background: Angiotensin-converting enzyme inhibitor-related angioe-
1
Internal Medicine Department, Fondazione IRCCS Ca’ Granda Ospedale dema (ACEI-AAE) occurs in 0.1-0.7% of patients treated with ACE-inhi-
Maggiore Policlinico di Milano, 2Internal Medicine Department, Fondazione bitors (ACEI), with potentially serious consequences requiring immediate
IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano & Università attention. ACEI-AAE is a nonpitting edema that can affect any area of the
degli Studi, 3Department of Pediatrics, Fondazione IRCCS Ca’ Granda body, usually involving the face and upper airways. There are no speci-
Ospedale Maggiore Policlinico di Milano, 4Centro TMO Ospedale Regionale fic diagnostic biomarkers, so the diagnosis is based on exclusion of other
Microcitemie Clinica Pediatrica Università di Cagliari, 5Istituto di Clinica causes of angioedema in patients taking ACEI. In this study we present the
Pediatrica Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. clinical features of a cohort of patients(pts) with ACEI-AAE followed up at
Orsola Malpighi di Bologna, 6Clinica Pediatrica Spedali Civili di Brescia the Angioedema Centers of Universities of Naples and of Zagreb.
& Università degli Studi di Brescia, 7Department of Pediatrics, Fondazione Methods: Patients who presented to our Departments with history of angio-
IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano & Università edema without wheals after the initiation of ACEI therapy, were studied.
degli Studi di Milano C1-INH deficiency angioedema and all allergological causes were ruled out.
Patients’ demographic information, duration of ACE-I use, onset of symp-
Background: Autosomal dominant hyper-IgE syndrome (AD-HIES) or toms after starting therapy, attacks frequency and duration, symptoms and
Job’s syndrome is very rare primary immunodeficiency with a wide array anatomic sites involved, were obtained from each patient’s chart and inter-
of clinical features caused by dominant negative mutations in signal tran- view. Each patient signed informed consent.
sducer and activator of transcription 3 (STAT3). Mutations in STAT3 were Results: Thirty Caucasian patients, all affected by hypertension (46.7% F;
identified as the link between recurrent infections and connective tissue median (m.) age at symptoms onset 61.23yrs, range (r.)46-80yrs) were dia-
abnormalities. AD-HIES is characterized by eczematoid rashes, skin absces- gnosed with ACEI-AAE. The average time of symptoms onset after star-
ses, recurrent sinopulmonary infections, mucocutaneous candidiasis, and ting therapy was 4.7yrs (r.0, 08-20 yrs); 5.9 yrs was the average of therapy
malignancies. Rashes usually start within the first few weeks of life, typically duration. The estimated diagnostic delay was 1.2 yrs. Lips were the most
presenting as pustular or eczematoid eruptions on the scalp and face. Ecze- common affected site (20 pts, 66.7%); 56.7% of pts described tongue invol-
matoid dermatitis appears to be Staphylococcus aureus driven. Recurrent vement. In 8 cases there was larynx edema (21.4%). Other affected sites were
sinopulmonary and lung infections common in HIES are predominately face (30%), hands (3.3%), foot (3.3%) and genitalia (13.3%). Frequency of
caused by S. aureus, with Streptococcus pneumoniae and Haemophilus attacks varied greatly from pts to pts (m. 6.13 attacks/yr, r. 1-52 episodes/yr),
species less frequently associated. Pyogenic pneumonias result in bron- such as edema duration (m. 36, 45 hours, r. 3-168 hours). 68% of pts requi-
chiectasis and pneumatoceles frequently. Surgical resection can be neces- red hospitalization, with no endotracheal intubation. We followed up pts
sary. AD-HIES is associated with an increased risk of malignancies—most up to 10 yrs after the diagnosis. During the follow up 92.8% of pts referred
notably non-Hodgkin’s lymphoma, with the majority being of B cell origin no attacks. One patient had 1 attack/3 months during the first year; another
and aggressive histology. The pleiotropic nature of STAT3 accounts for the one had 1 attack/week during the first month and last one referred only 1
multitude of changes in HIES, not only immunological but also craniofacial, attack after the end of ACE-I. 9 pts (30%) after the beginning of symptoms
musculoskeletal, dental, and vascular abnormalities. Laboratory abnormali- switched to sartans and only one pt showed a single angioedema attack after
ties in HIES include eosinophilia and IgE usually elevated above 2, 000 IU/ 4 days from the onset of therapy (no more attacks after sartan discontinua-
uL. Patients with HIES have very little in the way of allergies or anaphylaxis tion). Before diagnosis, all pts were treated with steroids and antihistamines
to foods. This study aims to describe a cohort of adult patients with autoso- without response. 4 pts complained itching during attacks and two of them
mal dominant Hyper-IgE Syndrome (AD-HIES) with a long time follow-up presented wheals too.
recorded in the National Registry of the Italian Network for Primary Immu- Conclusion: ACEI-AAE is a rare side effect but it can be a medical emer-
nodeficiencies (IPINet). gency. Our data confirm that the majority of ACEI-AAE are severe enough
Methods: Adult AD-HIES patients recorded in the IPINet Registry with to require hospitalization. Discontinuation of ACEI can stop the edema
available follow-up have been considered. attacks but sometimes is not enough to break up symptoms. The presence of
Results: Adults HIES patients are 23 of 37 (62%). Follow up was recorded in itching and wheals may not be sufficient tips to exclude ACEI-AEE.
13 AD-HIES (8M/5F), all carriers of mutation on STAT3 gene. The average
time of follow-up is 17years (range 5-40). Age at disease onset ranged
1months-4.5years. Mean age at last follow-up was 33.5years (DS±9.96). 3. THE “RED” PATIENT: AN EXAMPLE OF DIFFERENTIAL
Onset symptoms were infections for 84.6%, dermatologic involvement for DIAGNOSIS IN INTERNAL MEDICINE
7.7%, both manifestations for 38.5% patients. Mean age at clinical diagnosis
was 22.2 years (DS±12.84). Diagnosis delay ranged 9-45 years. At diagno- Di Fino L., Mastrofilippo T., Castrovilli A., Vella F.S., Sabbà C.
sis, all the patients started prophylaxis: 92.3% antibiotics, 69.2% antifun- Department of Internal Medicine, University of Bari “Aldo Moro” - Bari
gals and 7.7% antivirals. Manifestations at clinical diagnosis were eczema (Italy)
92.3%, skin abscess 84.6%, chronic mucocandidiasis 84.6%, pneumonia
84.6%, pneumatocele 69.2%, lobectomy 53.8%, osteoporosis 23.1%, abnor- A 57-year-old man presented on December 2016 to our Medical Unit with a
mal bone fractures 30.8%. During follow-up nor lobectomy or bone fractu- diffuse cutaneous erythematous rash, oral and nasal mucositis, generalized
res were observed. At clinical diagnosis, serum IgE mean levels was 14725 edema, fever and productive cough occurring for 4-5 days, upon tapering
(DS±17514.4), at last follow-up 12101 (DS±12131.8). The 63.3% of patients of long-term steroid therapy, as he was being treated for a febrile dermatitis
had positive RAST for 70%-100% of the aero- and food allergens tested, of unknown origin.
but they had skin prick tests positive only for 8%-40% of the correspon- His past history was remarkable for Dilated Myocardiopathy with implant
ding allergens. Two patients died aged 28 and 39 years for pulmonary ble- of AICD, aortic and mitral replacement with mechanical prosthesis, Atrial
eding and cancer, respectively. Conclusions: Patients affected by AD-HIES Fibrillation, and weight loss of 12 kg in last 6 months. On June 2016 he
need to be referred to IPINet Centres because they need physicians with started therapy for hyperuricemia with allopurinol, without any relevant
expertise in these primary immunodeficiency. Indeed, promptly diagnosis, side effects. Four weeks later, a diffuse erythematous desquamative rash
prophylactic therapy improves outcome and can impact AD-HIES patients’ suddenly appeared, accompanied by fever (39°C) and oral vesicular invol-
expectation of life. vement. Laboratory tests evidenced slightly increased CRP, liver and pan-
creatic enzyme levels, mild lymphocyte and platelet count reduction, while
microbiological investigations revealed negative results. He was treated with
2. ANGIOEDEMA RELATED TO ACE I: A CASE SERIES i.v. methylprednisolone 20 mg b.i.d. with benefit. However, each attempt of
tapering corticosteroids resulted in severe re-exacerbations of clinical mani-
Carucci L. 1, Bova M. 2, Petraroli A. 2, Sutic A. 3, Morovic- Vergles J. 3, Marone festations, which ultimately prompted emergency hospitalization in our
70
118° Congresso Nazionale - Società Italiana di Medicina Interna Poster
Unit. On admission he was febrile (39°C), pulse: 80 bpm, blood pressure: ghout the body surface, for which she has taken betamethasone and chlor-
110/60 mmHg. He had a diffuse erythematous desquamative rash, peri-na- phenamine. After five days, for recurrence of hives, the primary physician
sal and peri-oral herpes-like lesions, conjunctival burning, generalized advised to suspend methimazole, which in 3% of cases is associated with
edema and onychodystrophy. He presented a vesicular murmur reduction this side effect. Propylthiourea was initiated, but daily skin manifestations
bilaterally, with diffuse rhoncus and expiratory wheezing. Laboratory inve- continued. The duration of the skin lesions lasted for 5-10 hours and resol-
stigations showed increased WBC levels (15, 2x103/uL), with evident hype- ved spontaneously. All therapy was suspended and the patient was candi-
reosinophilia (Neu 63%, Lym 21, 4%, Eo 10%), abnormal AST 401 U/L (n.v. date to radioiodine therapy. Prick test, patch test, rast test, hemocromocyto-
15-37), ALT 340 UI (n.v. 12-78), GGT 360 U/L (n.v. 15-85), ALP 197 U/L metric examination, liver and kidney function were performed which did
(n.v. 50-136), lipase 488 U/L (n.v. 73-393), amylase 96 U/L (n.v. 8-53), CRP not show any alteration or indication of allergic genesis. The total IgE was
11, 8 mg/L (n.v < 2, 9), and normal ESR (4 mm/h, n.v.<15) and electropho- 9 KUA/L, into normal range (normal values 0-200 KUA/L). The autologous
resis. Pneumonia was suspected by pulmonary X-ray; EKG showed atrial serum skin test (ASST) was positive, strongly suggesting an autoimmune
fibrillation; echocardiography highlighted an endocarditic vegetation on pathogenesis of CU. ANA-test, ENA screening, HCV, HP, celiac test were
AICD electrode. He was treated with piperacillina/tazobactam 4, 5 g thrice negative, high anti Tg-antibody and anti-TPO antibody were found (anti
a day and Metilprednisolone 40 mg/die i.v., which permitted improvement Tg antibody 170 IU/ml, normal values 0-60, anti-TPO antibody 405 IU/
of cutaneous manifestations and laboratory test normalization. Diagno- ml, normal values 0-20).The patient was then treated, with double dose of
sis of endocarditis was confirmed by Transesophageal Echocardiography third generation antihistaminic, with poor control of the sypmtoms, waiting
and blood culture positivity for S. Aureus, with a complete laboratory and to decide to undergoing therapy with Omalizumab. The young woman was
instrumental remission upon appropriate treatment with Teicoplanin (12 meanwhile undergoing to radiometabolic therapy. After one months, when
mg/kg/daily, 8 weeks) i.v. Upon a new corticosteroid tapering, severe relap- thyroid function returned to normal, urticaria was only minimally evident
sing of cutaneous and respiratory symptoms and signs occurred. Thoracic and was readily controlled by antihistaminic therapy, till the suspension.
HR-CT disclosed an interstitial pneumonia, confirmed by markedly posi- Discussion:Chronic uricaria (CU) is defined as recurrent episodes of hives
tive CMV-DNA PCR and HCMV antigenemia IFA test. Furthermore, viral for at least 6 weeks. CU is a common disorder with an estimated prevalence
panel screening detected reactivation of other herpes-viruses (HHV6 and of 0.5-5% in general population. Although there are several and numerous
HHV8). Complete remission of clinical, radiologic and laboratory abnor- systemic illness, drug or infection, no definitive cause of CU can be iden-
malities was obtained with i.v. administration of ganciclovir (5 mg/kg b.i.d., tified despite a thorough medical evaluation in 80-85% of cases. The asso-
8 weeks), methilprednisolone 40 mg/kg/daily and immunoglobulin (400 ciation between CU and various autoimmune disorders, including thyroid
mg/kg over 5 days). To gain insight into the etiological origin of recurrent disease has been recognized as indirect evidence of an autoimmune entity
febrile erythematous rash, several investigations were undertaken. Parane- of CU. The hypothesis is the presence of IgG autoantibodies direct against
oplastic syndromes were ruled out by negative Total body-CT and neopla- antibodies a subunit of the high-affinity IgE receptor. This activates blood
stic markers, as well as no sign of mycosis fungoides or Sézary syndrome basophils and cutaneous mast cells, resulting in the release of histamine.
was found by performing peripheral blood flow cytometry immunophe- While the frequency of anti-TPO antibodies is universally considered to be
notyping and cutaneous biopsy. In addition, erithrodermic psoriasis was higher in CU, there are few publications on the prevalence of ATRAs in
excluded by the absence of other cutaneous and rheumatologic features, this condition. In our case, the urticaria was secondary to multiple thyroid
despite presence of HLA-Cw6 and HLA-DR7. This complex case matched disfunction. Physicians should consider of hyperthyroidism in chronic urti-
diagnostic criteria for DRESS/DIHS (Drug Rush with Eosinophilia and caria, especially if the urticaria is refractory to standard therapy, there are
Systemic Symptoms- Drug Induced Hypersensitivity Syndrome) subse- symptoms suggestive of thyroid dysfunction or there is a family history of
quent to treatment with allopurinol. In particular, a typical DRESS/DIHS thyroid disease. The mistakes can be to confuse this manifestation as an
was diagnosed, due to the presence SCAR-J Diagnostic Criteria (7 of 8 cri- allergic cutaneous reactions of methimazole therapy. The urticaria may, in
teria positive). This “red” patient is an interesting example of differential same cases, be improved with treatment of thyroid condition.
diagnosis in internal medicine, due to the presence of multiple possible
causes of erythrodermal diffuse rash, with internal organs involvement, in
the same patient. DRESS/DIHS was unveiled after a long and complex dia- 5. A CASE OF HYPOCOMPLEMENTEMIC URTICARIAL
gnostic process with multiple confounding factors. In conclusion, DRESS/ VASCULITIS SYNDROME (HUVS) SUCCESSFULLY
DIHS should be suspected when a patient presents with unexplained recur- TREATED WITH OMALIZUMAB
rent “scratch dermatitis”. A careful medical history is mandatory, with parti-
cular attention to ongoing pharmacological treatment, since a drug-induced Nucera E. 1, Basta F. 2, Buonomo A. 1, Mezzacappa S. 1,
hypersensitivity syndrome can manifest with a flare up of disease, including Margiotta D.P. 2, Antonelli Incalzi R. 3, Schiavino D. 1
worsening liver, pancreatic or pulmonary function, which can be concealed 1
Unità di Allergologia Università Cattolica del Sacro Cuore - Policlinico “A.
by a number of confounding factors. Gemelli”, Roma 2 Unità di Immuno-reumatologia Università Campus-Bio
Medico di Roma 3 Unità di Geriatria Università Campus-Bio Medico di
Roma
4. A PRURIGINOUS THYROIDITIS
We present a 47-year-old woman without relevant comorbidities who refer-
Cerasi C., Biferi E., Vertolli P., De Feo M., Stamerra C.A., Ferri C. red to our University Allergy Center with a 3-year history of generalized,
University of L’Aquila, Department of Life, Health and Environmental itchy and burning daily flares of urticaria. She also complained arthralgia,
Sciences, Division of Internal Medicine and Nephrology, San Salvatore abdominal pain and diarrhea. On admission, physical examination revealed
Hospital, L’Aquila, Italy diffuse vasculitic itching lesions and symmetric arthritis of second and third
proximal phalangeal and metacarpal joints. Blood tests were normal with
Introduction: Graves’ disease (GD) is an autoimmune thyroid disease. the exception of a strong complement depletion (C3 0.17 g/L, normal range
Patients with GD usually present with common manifestations, in a classic 0.9-1.8, C4 0.24 g/L, normal range 0.1-0.4). She had no infections, no appa-
clinical picture. rent major organ involvement, no antibody positivity, normal IgE serum
Case Report: A 28 year-old-girl, student, was brought to our Department levels, normal thyroid parameters and negative physical testing. Antihista-
for a clinical presentation caratterized by palpitation, tremors, breathles- mines and prednisone 8 mg/die were administered with no relief of symp-
sness, anxiety and weight loss (5 Kg in 1-month period).She had no chronic toms and no improvement of urticaria. Colonscopy was also negative. A
illness and was not on any medication. No drug allergy. Her father has an skin biopsy was performed and showed perivascular and dermic eosinophi-
history of type 1 diabetes, previous hyperthyroidism, which was treated lic infiltrates with focal vessel damage confirming urticarial vasculitis. The
with radioiodine. Physical examination revealed fine tremor when arms are patient fulfilled diagnostic criteria for HUVS1 so antihistamines (up to four
extended, her heart rate was 120, her thyroid was enlarged and non-ten- times per day) in combination with hydroxychloroquine (200 mg/day), pre-
der. The patient’s vital signs, physical finding and clinical presentation were dnisone (0.5 mg/kg being tapered to 0.1 mg/kg) and cyclosporine A (CSA
suggestive of thyrotoxicosis. The diagnosis is confirmed with blood test 3 mg/kg) (soon suspended for worsening of diarrhea) were administered.
(TSH< 0.0001mIU/L (normal values 0.27-4.2), FT3 10.73 pg/ml (normal A significant improvement of arthralgia was achieved with no response on
values 2-4.4), and positivity of anti-TSH receptor antibodies (ATRAs 15 gastrointestinal involvement and urticaria (Urticarial Activity Score (UAS)
IU/L, normal values <1.5).Thyroid echography depicted goiter with hetero- of 32 points). Omalizumab 300 mg monthly was added and after the second
geneous echogenicity and increased vascularity. She received methimazole injection complete remission of gastrointestinal symptoms and urticarial
(20 mg QD) and atenolol (50 mg QD). After 10 days of therapy, following (UAS of 0) was achieved and then maintained for the entire duration of
evening meal with cheese and nuts, appeared a pruriginous urticaria throu- the treatment (25 weeks). Complement serum levels normalized allowing
71
a gradual prednisone discontinuation. One month after Omalizumab with- 1

Dept. of Internal Medicine and Clinical Oncology, 2 Dept. of Cardiac,
drawal the patient presented a stronger exacerbation of diarrhea, abdominal Thoracic, and Vascular Science, Institute of Respiratory Disease, University of
pain and urticaria (UAS of 37 points). Omalizumab 300 mg monthly was Bari Medical School, Italy
so readministered leading to a complete remission of urticaria (UAS of 0)
and gastrointestinal symptoms. Management of HUV is very challenging: Background: Obstructive Sleep Apnea (OSA) is a well-known risk factor
while oral antihistamines are just palliative, hydroxychloroquine (HCQ), for cardiovascular diseases. Several studies have shown that OSA is associa-
colchicine and corticosteroids represent first-line therapy, with a complete ted with vessel remodeling. Few studies have examined aorta in OSA.Aim:
cutaneous response achieved in less than 50% patients. Other immunosup- To analyze the link between aortic root diameter (ARD) and severity of OSA
pressive drugs, especially Cyclosporine (CyA), cyclophosphamide (CYC) or diurnal value of PaO2 and PaCO2.
and rituximab (RTX), have higher rates of efficacy, although they are burde- Methods: We studied 30 consecutive OSA patients (22 males and 8 females,
ned, as well as steroids, by higher incidence of side effects2. Omalizumab, a aged 58.5±13.2 years). All patients underwent to a morning blood gas
humanized anti-IgE monoclonal antibody recently approved for treatment analysis, a full cardiorespiratory evaluation, including nocturnal poligraphy
of chronic spontaneous urticaria (CSU)3, has been recently shown to be not and echocardiography, with measurement of ARD and aortic stiffness
effective in a case of HUVS4. This is, to our knowledge, the first report of index (ASI). Patient were divided in two groups: Group 1, non-severe OSA
successful treatment of HUVS with Omalizumab. (Apnea-Hypopnea Index - AHI - <30, 14 pts) and Group 2, severe OSA
References: (AHI >30, 16 pts). Statistical significance: p ≤0.05.
1. Schwartz HR, McDuffie FC, Black LF, Schroeter AL, Conn DL. Hypo- Results:No difference has been found between groups in ARD as absolute
complementemic urticarial vasculitis: association with chronic obstructive value (Group 1, 33, 64 ± 0, 91 mm; Group 2 33, 64 ± 1, 02, p=ns) and nor-
pulmonary disease. Mayo Clin Proc 1982;57:231–8. malized value for the body surface area – Aoi (Group 1 16, 72 ± 0, 63 mm/
2. Sussman G, Hébert J, Barron C, Bian J, Caron-Guay RM, Laflamme S et m2; Group 2, 16, 09 ± 0, 44, p=ns). Moreover, no difference has been found
al. Real-life experiences with omalizumab for the treatment of chronic urti- in ASI (Group 1, 3, 62 ± 0, 183; Group 2, 3, 51 ± 0, 19, p=ns). Conside-
caria. Ann Allergy Asthma Immunol. 2014 Feb;112(2):170-4. ring all OSA patients, AHI has shown an inverse correlation with Aoi (p=0,
3. Jachiet M, Flageul B, Deroux A, Le Quellec A, Maurier F, Cordoliani F et 018) and ASI (p=0, 0449). Moreover ASI has shown a direct correlation to
al. The clinical spectrum and therapeutic management of hypocomplemen- Aoi (p=0.01) and morning pO2 (p=0.0349) as well as an inverse correlation
temic urticarial vasculitis: data from a French nationwide study of fifty-se- to oxygen desaturation index (ODI, p=0.031) and total time of apnea and
ven patients. Arthritis Rheumatol. 2015 Feb;67(2):527-34. hypopnea (p=0.039).
4. Aurich S, Simon JC, Treudler R. Omalizumab does not improve skin Conclusion: No difference have been found between severe and not-severe
lesions in a patient with hypocomplementemic urticarial vasculitis syn- OSA in ARD. Surprisingly, data have shown that severity of OSA correla-
drome. J Eur Acad Dermatol Venereol. 2017 Mar 8. tes inversely with a ASI and Aoi. The relation between pO2 and stiffness
should be explained with a feedback mechanism that tried to overcome the
reduction of aortic elasticity due to night desaturation. These finding need
6. FLOGOSIS AND HEART INVOLVEMENT IN LARGE to be investigated in further studies on a large sample.
VESSEL VASCULITIS
Cicco S., Mersini X., Noviello S., Cirulli A., Longo S., Leone P., Battaglia S., 8. FEVER AND EPILEPSY: ALWAYS OF INFECTIVE
Dammacco F., Racanelli V.,Vacca A. ORIGIN?
Dept. of Internal Medicine and Clinical Oncology, University of Bari Medical
School Colombo G. 1, Arcudi S. 1, Rossio R. 1, Santaniello A. 1, Ferrari B. 1,2, Peyvandi
F. 1
Large vessel vasculitis (LVV) symptoms are related to increase wall thick- 1
U.O.C. di Medicina Generale - Emostasi e Trombosi, Dipartimento di
ness. Heart is usually excluded but indirect effect could determines modi- Medicina Interna, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
fications.Aim of this study was to describe heart involvement regarding Policlinico di Milano 2 Angelo Bianchi Bonomi Hemophilia and Thrombosis
common flogosis parameters. We analyzed 17 LVV (4 M, 54±20 years). All Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di
patients underwent to laboratory analysis, ultrasound and doppler of big Milano § Luigi Villa Foundation, Fondazione IRCCS Cà Granda Ospedale
arteries and heart. Maximum Blood pressure (BP) measured was conside- Maggiore Policlinico di Milano
red in this study. Left ventricular hypertrophy was present in 12 patients.
Among others, 3 present a concentric remodeling. 12 present a diastolic A 57 year-old woman was transferred to our department from another
dysfunction. Aortic root normalized for body surface area was dilated (Aoi; Hospital with a diagnosis of epilepsy and hyperpyrexia. She was recently
19.19±2.52 mm/m2) and wall thickened (3.96±0.83 mm). Aortic valve was discharged from our medicine ward for pulmonary arterial hypertension
regurgitant (AR) in 8. Framingham score was 21.69±16.09%. Other parame- (group I) for which a therapy with a phosphodiesterase inhibitor (tadalafil)
ters were: Uric Acid 4.04±1.01 mg/dl, CRP 46.30±58.33, ESR 42.86±32.38, was started. The patient, previously known for a history of undifferentiated
C3 1.19±0.26 mg/dl, Systolic BP (SBP) 125.6±21.28 mmHg and Diastolic connective tissue disease, during our recovery showed a serological evolu-
(DBP) 72.5±8.4 mmHg. A direct correlation was found with SBP and Uric tion lupus like (ANA positive (1:160), antiDNA weak positive (1/10) and
acid (p=0.04), ESR (P=0.008), diastolic dysfunction (p=0.02), and Framin- she developed symmetrical arthritis of the wrists. A therapy with cortico-
gham score (p=0.03) while was found inverse with aortic wall thickness steroid and hydroxychloroquin was begun. On admission at other hospital
(p=0.01). CRP was directly correlated to C3 (p=0.02) but inversely with an electroencephalography showed a generalized slowing of the background
aortic wall thickness (p=0.04); ESR was directly correlated to C3 (p=0.003), and epileptic activity in the right frontal region, so intravenous midazolam
Aoi (p=0.03), inversely to aortic root thickness (p=0.008). Uric Acid was was administrated successfully. A diagnosis of status epileptic was perfor-
directly correlated to diastolic dysfunction (p=0.008) and AR (p=0.01). med and therapy firstly with levetiracetam and then with topiramate and
Aortic wall thickness was directly related to Aoi (p=0.01) and inversely to phenobarbital was set up. A lumbar puncture was made and white blood
diastolic dysfunction grade (p=0.009), SBP (p=0.01), uric acid (p=0.003), cells, protein and glucose levels were normal in cerebral spinal fluid (CSF).
ESR (p=0.008), and CRP (0.049). Aoi was directly related to C3 (p=0.009) No evidence of viral, bacterial, or fungal infection was found in CSF. Brain
and to wall thickness (p=0.01). In conclusion LVV could lead an increase in magnetic resonance imaging (MRI) showed leptomeningeal enhancement
heart dimensions not related to systemic inflammation nor to blood pres- without involvement of cerebral parenchyma. For fever (T˚ 38, 5-39) she
sure. On the contrary, the reduction in diastolic function should have also was initially treated with piperacillin/tazobactam plus vancomycin. Then
an inflammatory genesis. Aortic root present an increased diameter due to for the onset of leukopiastrinopenia switched to meropenem and according
inflammatory status despite active flogosis did not appear the main actor in to the immunologist corticosteroid treatment was increased. Blood culture
wall thickning. Uric acid appear related to vasa remodeling. and urine culture were negative. Echocardiogram was negative for endocar-
ditis vegetations. Fever reappeared after suspension of antibiotic therapy.
At this point she was transferred to us to complete the investigations. In
7. ANALYSIS OF AORTIC REMODELING AND STIFFNESS our department the initial blood analyses showed: white blood cells 5.3
IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA x 103 mm3, platelet 145 x 103 mm3, hemoglobin 10.3 g/dl, normal renal
SYNDROME (OSAS): PRELIMINARY RESULTS and liver function, c-reactive protein 1.67 mg/dl, procalcitonin 0.09 ng/ml.
For fever complicated with respiratory insufficiency, a thoracic computed
S. Cicco 1, G. Castellana 2, L. Marra 2, V. Di Lecce 2, S. Dragonieri 2, tomography (CT) was performed showing a basal pneumonia. In the suspi-
P. Carratù 2, G. Ranieri 1, O. Resta 2, A. Vacca 1 cion of nosocomial pneumonia a therapy with meropenem and linezolid
72
was begun. The bronchoscopy with bronchoalveolar wash was negative manifestations has preceded the diagnosis of more than ten years, and a
for infection. Besides the broad spectrum antibiotic therapy the patient predisposition to infectious complications was present from an early age;
remains febrile. Moreover during hospitalization the neurological symp- this may suggest that further efforts are needed to raise the awareness of
toms worsened with the inability to keep the erect station and a decline of these disorders.
cognitive state with temporal space disorientation and confabulation. We
repeated autoimmunity screening: ANA test was positive (1/160), antiDNA,
antiRO, antiLA, anti sc70 were negative. In the suspicion of neurological 10. VIRAL INFECTION AND CARBAMAZEPINE
and psychiatric manifestation of systemic lupus erithematosus, discussed HYPERSENSITIVITY REACTION: FIND THE
the case with the immunologist, intravenous methylprednisolone (1 mg/ DIFFERENCENCES
kg) was initiated and then immunoglobulin and cyclofosfamide were begun
without complication. We assisted to the improvement of the neurological Ledda D., Manetti R., Filigheddu F., Cabras P., Forteleoni G.M., Valenti A.,
status with the resumption of deambulation but a mild cognitive impair- Serra C.
ment persisted. Systemic lupus erythematosus is an autoimmune disorder Dipartimento di Medicina Clinica e Sperimentale, Univerità degli Studi di
with a broad spectrum of clinical presentations. Several complications due Sassari
to the involvement of the central nervous system (CNS), peripheral nervous
system (PNS), and autonomic nervous system (ANS) along with psychiatric Clinical case: a 19-years old white girl that accessed to the Emergency
manifestations can be seen. Furthermore in neuropsychiatrics lupus erythe- Department for fever (with temperature until 40°C), a skin rash with small
matosus patients brain magnetic resonance and CSF findings were usually maculae, lymphoadenomegaly of the neck for 4 days: in this period she
normal. presented an epileptic crisis, vomit, and anuria.The blood tests showed a
pancytopenia, an increase of AST, ALT, gamma-GT, VES, PCR, creatinine.
In her history there were an autism spectrum disorder, a Poly-Cystic Ovary
9. REDUCING THE DIAGNOSTIC DELAY: A Syndrome, and a recent diagnosis of epilepsy for which she started car-
CASE REPORT OF A 61-YEARS OLD WOMAN WITH bamazepine 13 days before. She was hospitalized: the first suspect was an
RECURRENT INFECTION OF THE UPPER AND LOWER exanthematous disease of viral etiology complicated by a dehydration and a
AIRWAYS, ASTHMA, BRONCHIECTASIS AND A LATE epileptic crisis; however, because of the clinical manifestations and the time
DIAGNOSIS OF IGG3 DEFICIENCY correlation between the beginning of carbamazepine therapy and the onset
of disease, we suspected also a hypersensitivity reaction to this antiepileptic
Ledda D., Manetti R. drug. So, we searched the antibodies against Rubella virus, Measles virus,
Dipartimento di Medicina Clinica e Sperimentale - Scuola di Parvovirus, Epstein-Barr virus, Citomegalovirus, HIV, B and C hepatitis.
Specializzazione in Medicina Interna, Università degli Studi di Sassari Finally, the carbamazepine was stopped and an anti-inflammatory therapy
with methylprednisolone was started. All the antibodies searched were
Introduction: the antibody deficiencies are among the most common forms negative, with the exception of Rubella virus for which the IgG antibodies
of primary immunodeficiencies. In this group is placed the IgG subclass were positive, and the IgM antibodies were negative. However, after a few
deficiency, that may predispose to recurrent bacterial infections and also days of the beginning of corticosteroids, the clinical manifestations disap-
serious complications like bronchiectasis, asthma and chronic bronchitis. peared, and after two weeks there was a normalization of the hepatic and
We present a case of a late recognition of IgG3 deficiency, that shows how hematological profile.
these disease can still be poorly recognized. Discussion: the clinical and laboratoristical manifestations were compatible
Clinical case: a 61-years old woman that came to our attention for the first both with a viral infection and with a drug-induced hypersensitivity syn-
time on the January of 2017. The family history was negative for immuno- drome, and specifically with a entity called “anticonvulsant hypersensitivity
deficiencies or allergic diseases. From the childhood she had 2-3 episodes syndrome”. Are there tests that could help to exclude or to confirm a drug
a year of infections of upper airways; she reported two surgical interven- allergy?
tions complicated with post-surgical infections; parodontosis with multiple
dental abscesses at 45 years old.
From about 10 years she has 4-5 episodes a year of productive cough with 11. AUTOIMMUNE AND INFLAMMATORY CHRONIC
emission of thick yellow sputum, that in the last 4 years have become an URTICARIA RESISTANT TO ANTIHISTAMINES
almost daily frequency. In the 2014 she did a CT scan of the facial bones IS EFFECTIVELY TREATED WITH ANTI-IGE
that showed a pansinusitis: she had an intervention of pansinusectomy in (OMALIZUMAB)
the 2015 with poor results. In the 2015 a chest TC scan showed bronchiecta-
sis. She reported two pneumonitis in the last five years with the need of De Feo G. 1, Parente R. 1, Cardamone C. 1, Bucci T. 1, Guerritore L. 1, Triggiani
prolonged antibiotic therapy. From about 10 years she has daily episodes of M. 1
bronchospasm, for which has performed the dosing of total and specific IgE 1
Division of Allergy and Clinical Immunology, Department of Medicine,
with negative results. University of Salerno, Salerno (Italy)
Physical examination at the moment of the visit: productive cough, whee-
zing at the chest auscultation. Background: Chronic spontaneous urticaria (CSU) is characterized by the
She performed a complete blood count with differential, the lymphocyte appearance of wheals, lasting 6 weeks or more, not induced by any identi-
typing for CD3, CD4, CD8, CD19 and CD16/56 and the dosing of the com- fiable trigger. In two-thirds of cases, urticaria is associated with angioedema.
plement factors, with normal results; a serum protein electrophoresis, with CSU is a mast cell-driven condition, in which several vasoactive mediators
a percentage of gamma-globulins of 12, 1% (n.r. 9, 8-20%); the dosing of such as histamine, leukotrienes and tryptase are involved. In some patients,
IgG, IgA and IgM with IgG values at the lower limit of normal (707 mg/dl, wheals are induced by scratching the skin (dermographism, DER) or by an
n.r. 700-1600 mg/dl), IgA and IgM in the normal range (IgA 108 mg/dl, n.r. intradermal injection of autologous serum. A positive autologous serum
70-400 mg/dl; IgM 269 mg/dl, n.r. 40-280 mg/dl). skin test (ASST) defines “autoimmune urticaria”. There are no specific labo-
It was performed the assay of IgG subclasses: IgG1 570 mg/dl (n.r. 300-1140 ratory markers in CSU; however, markers of inflammation, such as C-re-
mg/dl), IgG2 150 mg/dl (n.r. 50-640 mg/dl), IgG3 10 mg/dl (n.r. 25-110 active protein (CRP), are frequently elevated. Antihistamines (anti-H1) are
mg-dl), IgG4 39 mg/dl (n.r. 8-140 mg/dl). Then it was made the diagnosis of licensed as first-line treatment of CSU, although about 40% of patients do
selective deficiency of IgG3 and was started a monthly endovenous infusion not respond to this therapy. Effective blockade of H1 receptor can be studied
of immunoglobulin. by histamine skin prick test (HSPT). Recommended treatments for anti-H1
Discussion:an early diagnosis of a IgG subclass deficiency is crucial to resistant patients include, as third-line therapy, leukotriene receptor antago-
undertake a therapy with immunoglobulin, that may obtain a reduction of nists (LTRAs), cyclosporine (CysA) and the anti-IgE monoclonal antibody,
infections, although it has not proved to significantly influence the com- omalizumab.
plications of this condition, like the bronchiectasis. Lately there has been Materials and Methods: One-hundred and four CSU patients (25M, mean
a reduction in the time between the onset of disease and the diagnosis: it age =45+/-17) received anti-H1 at recommended dose to identify respon-
is currently reported a median time for diagnosis of 4 years for the partial sive (R) and unresponsive (NR). Responsiveness was defined by achieving a
antibody deficiencies (J Clin Immunol. 2012 Oct; 32(5): 907–921.- The UAS7≤6 (range= 0-42). In NR patients, anti-H1 was up-dosed or replaced;
Spectrum of Disease Manifestations in Patients with Common Variable however, the majority of them needed third line options. In all patients cli-
Immunodeficiency Disorders and Partial Antibody Deficiency in a Univer- nical and laboratory features such as concomitant angioedema, DER, HSPT,
sity Hospital). In the case that we present the onset of the major clinical ASST, CRP and tryptase assay, were assessed.
73
Results: Two-thirds of patients responded to antihistamines at usual (I line) with a large plaque. Small enlargement of the spleen and some peripheral
or double dose (II line). Twenty-five NR patients started III line therapy: lymph nodes were detected.
6 LTRAs (R=66%), 12 CysA (R=75%) and 7 omalizumab (R=85%). In Sulfasalazine was stopped and she started with i.v. Methylprednisolone
anti-H1 responsive patients DER and HSPT remained positive in 40 % 10 mg/day for the adverse reaction and i.m. Chlorphenamine Maleate for
and 45%, respectively. Concurrent angioedema and high CRP were stron- itching. In the beginning, blood cell count showed leukocytosis only, but
gly associated with positive ASST (p<0.05). These patients responded only not hypereosinophilia. First, Scarlet fever was suspected, but pharyngeal
to omalizumab. Tryptase level did not discriminate between R and NR to swab was negative and TAS < 200 UI/ml. Some days after, blood cell count
antihistamines (5.0 vs. 5.7 ng/ml, v.n. <11, 4) but it was a good predictor showed severe leukocytosis (40 680/mm3) with hypereosinophilia (6300/
of ASST positivity and of response to omalizumab. Omalizumab induced a mm3) and monocytosis (1835/mm3). Mild inflammation was found (C-re-
mean reduction in tryptase levels of 3 ng/ml and in CRP of 5 units. active protein 42, 8 mg/dl). Other laboratory findings were as follows: high
Conclusions: Mediators other than histamine can be responsible for the lactate dehydrogenase 665 UI/L (unl < 246 UI/L), high B2 microglobulin
heterogeneous response to therapies in patients with CSU. The persistence 5.62 mg/l (unl < 2, 53 mg/l), high IgE 5430 UI/ml (unl <100 UI/l), high
of DER and HSPT in R patients indicates that, regardless of clinical impro- sign of hepatic cytolysis (ASAT 85 UI/L and ALAT 146 UI/I, and moderate
vement, other histamine receptors not blocked by anti-H1 are involved. The cholestasis (GGT 103 UI/L). No bacteria were found in blood and urine.
presence of angioedema and high levels of CRP should lead to the asses- Laboratoristic evaluations about Parvovirus, EBNA, VZV, HSV, CMV, Ente-
sment of ASST. ASST positivity is predictive of unresponsiveness to anti-H1 rovirus, Adenovirus, VDRL, TPHA, rickettsial and borreliosis were nega-
and responsiveness to omalizumab. tive. In contrast, IgM antibodies to human herpes virus type 6 (HHV6) were
positive. HHV6 DNA PCR was 87290 pg/ml. Skin biopsy showed an inflam-
mation infiltrate composed predominantly of lymphocytes and presence of
12. NODOSUM ERYTHEMA: IDIOPATHIC OR NOT? parakeratosis, acanthosis, dyskeratosis and exocytosis. Characterization of
peripheral blood lymphocytes showed normal values. No evidence of lym-
de Vincenzo G.M., Zingaro M.T., Luglio C.V., Sciancalepore D., Vella F.S., phoma or other hematological malignancies was detected by laboratory
Napoli N., Sabbà C. tests or histological studies. The diagnosis of DRESS (Drug Reaction with
Medicina Interna Universitaria “C. Frugoni”- Dipartimento Interdisciplinare Eosynophilia and Systemic Symptoms) was made.
di Medicina - Università degli Studi di Bari “A. Moro” Conclusion: In this case Sulfasalazine was the cause of DRESS, but two
weeks was necessary to achive the final lively diagnosis. The patient started
A 74-years-old Caucasian woman with 7 months history of multiple episo- infusions of Methylprednisolone 60 mg/day, the erythematous skin lesions
des of remittent nodular touchable erythematosus lesions in lower limbs was improved, the laboratory evidence of inflammation abated, and the eosi-
admitted in our hospital for diagnostic findings. She didn’t use cigarettes, nophil count normalized. The Prednisone dose was progressively tapered.
alcohol or drugs. His medical history showed an acute ischemic stroke with
focal epilepsy in 2007, essential thrombocytoma, left ventricular mixoma;
nodular tireopathy and dyslipidemia since 2013. In a previous recovery, a 14. HYPEROSINOPHILIA AND RECURRENT
biopsy of the nodular cutaneous lesions was perfomed and was diagnostic ANGIOEDEMA IN A PATIENT WITH GIANT CELL
for a septic panniculitis with morphological features of erythema nodosum. ARTERITIS: A DIAGNOSTIC “GLITCH” IN A CASE OF
At first, in order to distinguish between a idiopathic and a secondary form, GLEICH’S SYNDROME
a total body CT contrast-enhanced was performed without revealing lesions
that could justify a paraneoplastic type. Additionally, further laboratory Losa F., Firinu D., Marongiu F., Del Giacco S.R.
examinations performed were all negative: autoimmunity tests (ANA, Internal Medicine, Allergy and Clinical Immunology, Department of Medical
ANCA, AMA, Anti dsDNA, aCCP, AMA, ASMA, LKM), Quantiferon Science and Public Health, University of Cagliari, Italy
TB-Gold, parasitological and coprocoltural tests (Y. Enterocolica, H.Pylori,
Shigella, S.aureus, miceti, parasites); virological serum tests (Adenovirus, Background: Gleich’s syndrome is a rare disease characterised by the asso-
Toxoplasma, CMV, HSV1, HSV2, VZV, EBV, Parvovirus B19), urine and ciation of episodic angioedema (AE), weight gain, fever, with laboratory
blood coltures. Also we analized the lymphcytogram of peripheral venous findings such as hypereosinophilia, elevated IgE and IgMk component;
blood that was not compatible to sarcoidosis and lymphoproliferative disea- patients present a good response to corticosteroid (CS) therapy, without
ses. The complete regression of clinical symptoms treating the patients with end-organ damage. We report a case of a patient with marked chronic eosi-
Metilprednisone 4 mg 1 cp/die and Azatioprina 50 mg 1 cp X 2/die for 1 nophilia and AE previously diagnosed as Giant Cell Arteritis (GCA).
month confirmed the hypothesis that, despite the negativity of the autoan- Method and Results: A 49-years-old patient with marked eosinophilia
tibodies, it was an immunomedial form. To conclude, we formulated the since 2004 was referred in January 2014 for the occurrence of an episode
diagnose of idiopathic nodosum erythema. After 1 month-treatment above of AE of face and lids, which resolved spontaneously. In 2008 he was dia-
described, the lesions seemed almost completely regressed and ungainly, gnosed as GCA, having asymptomatic nodular thickening along the both
therefore immunosuppressive therapy was reduced with Azatioprina 50 mg temporal arteries. Since October 2014 he developed recurrences of AE and
1 cp/die. According to scientifical findings, our clinical case demonstrate erythematous, itchy skin nodules with a significant eosinophilic infiltra-
that nodosum erythema is likely idiopathic. tion into and around the vessel walls. The patient complained asthenia and
weight gain concurrent with AE. Eosinophil count was 13400/mm3 (53%).
The most common causes of hypereosinophilia were ruled out. Total serum
13. UNDRESSING” THE EFFECT OF SULFASALAZINE IN IgE were 2895 KU/l (normal < 100). Immunofixation showed an IgMk
IBD monoclonal component. We excluded myeloproliferative hypereosinophilic
syndrome (HES) variant, since chromosomal analysis did not identify any
Grimaldi L.D., Passerini F., Buonamico P., Minerva F. abnormalities. Fluorescence in situ hybridization for PDGFRβ was negative
Palmieri V.O., Pugliese S., Belfiore A., Portincasa P. and FIP1L1 gene fusion was not detected. Peripheral blood mononuclear
Clinica Medica “A. Murri”, Dept. Of Biomedical Sciences and Human cells flow cytometry revealed an abnormal T cell population with a CD3-
Oncology, University of Bari CD4+ phenotype. T-cell receptor (TCR) γ chain gene was studied by PCR,
showing a monoclonal rearrangement pattern. Gastroscopy, colonoscopy
A 73 years old woman had a 9 years history of Crohn disease treated with and cardiological evaluation did not reveal eosinophil infiltration. Reasses-
Mesalazine 800 mg b.i.d. In 2011 spondyloarthritis was diagnosed. Metho- sment of arterial biopsy showed non-giant cell granulomatous inflamma-
trexate and steroids were added. In 2013 Adalimumab 40 mg every two tion with abundant eosinophil infiltration.
weeks, was added to therapy. Conclusion: We describe a case of Gleich’s Syndrome with the atypical
One month before admission she had started Methylprednisolone 4 mg feature of eosinophilic arterial infiltration, previously mistaken as GCA.
a day and Sulfasalazine 500 mg b.i.d. After 4 week she experienced fever The arterial eosinophilic infiltration is to date an undescribed finding in this
(38°C), maculopapular rash in inguinal region, weakness, myalgia and sore disease, pointing towards other types of HES. The patient responded well to
throat. Two days later, her physician suspected tonsillitis and prescribed oral prednisolone 25 mg/day, showing normalization of eosinophilic counts
Ceftriaxone 1 gr a day, a drug she had taken several years earlier. Ceftria- and a partial control of AE. In contrast to the features associated with other
xone was stopped after two days when maculopapular rash developed over kind of HES, Gleich’s syndrome remains stable for a long time and responds
the face, trunk and proximal limbs. The same day, the patient was admit- to low dose of CS. Considered the clinical and laboratory data, a careful
ted to our department through the emergency room. Physical examination follow-up is ongoing.
showed a marked maculopapular rash with itch, fever (38, 5°C), tonsillitis
74
15. SLE OR ELSE: A NEUROPSYCHIATRIC DILEMMA a BS history from adolescenthood, developed at age 22 a severe thrombo-
sis of inferior vena cava and bilateral iliac veins. Patient had also hyperho-
Malandrino D. 1, Milia A. 1, Vitiello G. 2, Tozzetti C. 1, Parronchi P. 2, mocysteinemia and dyslipidemia and developed claudicatio intermittens
Poggesi L. 1 due to peripheral artery disease. Since first DVT episode the patient was
1
Medicina per la complessità assistenziale 3, Dipartimento DAI Emergenza under anticoagulant therapy with VKA (vitamin K anticoagulants) but with
e Accettazione, AOU-Careggi, Università degli Studi di Firenze, Firenze, low time in therapeutic range (TTR), around 45%. During the last years,
Italia 2 Unità di Medicina Interna, Immunologia e Terapia Cellulari, BS clinical manifestation were poorly controlled by different immunomo-
Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi di dulant and immunosuppressive treatment. With the aim of a steroid-spa-
Firenze, Firenze, Italia ring therapy patient started granulocyte and monocyte selective apheresis
and pharmacological treatment with cyclosporine. The patients stopped
Introduction: Systemic lupus erythematous is a multi-organ system AVK and started edoxaban 30 mg daily in order to maintain anticoagulant
autoimmune disease with clinical and serological heterogeneity. Neurop- therapy. Actually, the patient has few clinical manifestation of BS and signi-
sychiatric symptoms affect up to 90% of patients with SLE, with cognitive ficant reduction of arthritis related symptoms with a better QoL. Edoxaban
impairment, headache and mood disorder being the most commonly reco- treatment was well tolerated and any adverse drug reaction was reported.
gnized syndromes. Despite the absence of randomized controlled trials about efficacy and
Case Report: FN, a 65-year-old woman, who presented to our Emergency safety in the prophylaxis of atypical DVT in autoimmune disease, edoxaban
Department with sudden progressive right upper limb sensory-motor loss could represent a suitable treatment in this setting for its favourable safety,
associated to left dropping of the mouth and aphasia. Her clinical history drug to drug interaction profile and clear dosage reduction strategy.
was unremarkable excluding Raynaud’s phenomenon in cold periods.
Electromyography and CT scan of the head resulted negative with evidence
of non-hemodynamic extracranial atherosclerosis at CT angiography of 17. KOUNIS SYNDROME: AN UNDERDIAGNOSED
the head vessels. Investigations revealed hemolytic anemia (Hb 7.6 g/dL) DISEASE
and low platelet count (17 x 109/L) with normal liver and kidney function,
normal glycemic and electrolyte levels with high total and LDL choleste- Nardella E., De Matteis G., Casciaro A.F., Calarco R., Buonomo A.,
rol levels. No signs of viral or bacterial infections were detected. Neurop- Gambassi G.
sychological tests demonstrated intellectual impairment (MMSE=13/30) Area Medicina d‘Urgenza e Medicina Interna, Fondazione Policlinico
with an EEG which has shown paroxysmal sharp wave activity arising in Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Roma
fronto-temporal region. Rheumatologic evaluation revealed a positive
anti-nuclear antibody 1:160 with speckled pattern and positivity of anti- A 46-year-old Brazilian woman presented to our emergency department
RNP and anti-Sm specificities. Diffusion-weighted magnetic resonance with respiratory failure and subsequent syncope. The patient had a history
imaging demonstrated numerous high-intensity lesions of the white and of asthma treated with as-needed bronchodilators, but showed no symp-
grey matter. Differential Diagnosis: When evaluating patients who present toms recently, and was allergic to cat fur, penicillin and pollen. She didn’t
with symptoms suggestive for Neuropsychiatric Systemic lupus erythema- have cardiovascular risk factor, but a family history of early-age heart attack.
tous (NPSLE) careful assessment is necessary to exclude other potential She developed throat swelling, dyspnoea, blue lips, diarrhoea, facial rash
causes. In our patient, the unusual age, the sudden onset of the symptoms, with itch and oedema 20 minutes after eating anchovies fried with dill and
the possible role of a concomitant bone-marrow disease and the presence of pasta with peppery bitter. At presentation, she was sleepy and unresponsive
extracranial atherosclerosis are factors that influence the likelihood of the with severe hypotension, tachycardia, gasping respiration; arterial oxygen
disease. In support of NPSLE diagnosis, her history indicated that she met saturation was lower than 60%. The chest examination evidenced signs of
five of the American College of Rheumatology’s (ACR) clinical diagnostic severe bronchospasm with wheezing. Laboratory tests on admission showed
criteria for SLE (neurological, haematological, immunological disorders the following: creatine kinase 202 UI/l, serum cardiac troponin I (cTnI)
with positive ANA and minimal pericardial effusion). negative, no abnormalities in electrolytes, renal function, thyroid function,
Treatment and Follow-Up: Therapy with levetiracetam (1 gr bid with evi- routine blood tests, except minimal lymphocytosis; toxicology tests and
dence of therapeutic drug levels) was started awaiting the immunological serum pregnancy test were negative. An electrocardiogram (ECG) revealed
results, but the patient complained new neurological symptoms with evi- atrial fibrillation with rapid ventricular rate and ST segment depression in
dence of worsening of the EEG. A treatment with pulse intravenous steroids leads II, aVF, V4-V6. The level of cTnI two hours later admission was up
(prednisone 1 mg/Kg/die) was started along with levetiracetam and there to 0.776 ng/ml, four hours later 1.399 ng/ml. The chest x-ray showed fea-
were not been new relapses.Steroid treatment was tapered. Neuropsycolo- tures of interstitial pulmonary edema. A head computed tomography was
gical and laboratoristic assessment after 5 months demonstrated a complete negative. She was intubated and mechanically ventilated. Beta-blocker was
recovery (exception for weak positivity of Anti RNP and Sm antibody) and performed with sinus rhythm restoration and ST segment normalization.
for this reason steroid treatment was suspended and her medication was Methylprednisolone and fluid therapy were intravenously administered.
reduced to levitiracetam only. No relapses were registered after 24 months The patient was transferred to the intensive care unit and her symptoms
of follow-up. gradually improved. She became hemodynamically stable and tracheal intu-
Conclusion: Diagnosis of patients presenting with symptoms of NPSLE is bation was required for less than 48 hours. A new ECG confirmed sinus
challenging. Neuropsychiatric involvement heavily impacts patient’s health, rhythm without segment ST alteration. The level of cTnI after 24 hours was
quality of life and disease outcome. A detailed clinical evaluation with 0.088 ng/ml and the third day the value was down to normal. Transthora-
review of the medical history and appropriate laboratory analyses may allow cic echocardiography showed no wall motion abnormalities with preserved
a prompt recognition and appropriate treatment of NPSLE. ejection fraction. A chest X-ray, performed 48 hours later, revealed complete
resolution of the radiological features described above. Thus, considering
the rise and fall curve of troponin and ST segment depression during atrial
16. EDOXABAN SUITABILITY IN LONG-TERM fibrillation, we suspected a coronary artery disease. She underwent an ECG
PROPHYLAXIS OF ATYPICAL DVT ASSOCIATED WITH stress test, terminated at Stage 2 of the Bruce protocol of work due to fatigue
BEÇHET SYNDROME: A 38 YEARS-OLD MALE CASE (but the patient achieved the target heart rate of 135 beats per minute), that
REPORT showed at Stage 1 us-sloping and horizontal ST-segment depression in leads
V3-V6, which was suggestive of ischaemia. As a consequence, the patient
underwent to coronary angiography which showed normal coronary
Martini F. 1, Brunofranco M. 2, Bernardi S. 1 arteries. On the whole, these results suggested that transient ST segment
1
OU Internal Medicine, Imperia Hospital, Imperia 2 Haemostasis and Throm- depressions with elevated levels of myocardial damage marker were due to
bosis Centre, ASL. 1, Imperia coronary artery vasospasm triggered by the allergic insult. The association
of anaphylactic reaction and acute coronary syndromes was first described
Beçhet syndrome (BS) is a multi-systemic, chronic autoimmune vasculitis, in 1991 by Kounis and Zavras [1]. This condition, known as Kounis syn-
characterized by recurrent oral and genital ulcers, uveitis, arthritis and a drome or “allergic angina syndrome”, is mainly attributable to the release of
higher risk to develop deep vein thrombosis (DVT). There are no clear indi- inflammatory mediators during an allergic event. A wide variety of triggers
cations about anticoagulant prophylaxis and anticoagulant treatment dura- such as drugs, food, insect bite, environmental exposures have been reports
tion after a DVT episode in BS. DOACs (direct oral anticoagulants) could as capable of inducing it [2]. Even today this syndrome is little known and
be suitable for DVT treatment also in autoimmune disease but there is a underdiagnosed. There are no specific clinical practice guidelines about it
lack of information about their use in this setting. A 38 years-old male, with and true incidence is unknown [3]. According to the literature, it seems to
75
be essential achieving systematic troponin measurement [4] and, in patients infiltrate of the thyroid gland. leading to a gradual decrease of the thyroid
with suspicious acute myocardial injury, to perform coronary angiography function leading to hypothyroidism (1). Thyroid hormones act on the fun-
to discern three different variants of Kounis syndrome: coronary vaso- ction of many organs and tissues: oftenHashimoto’s thyroiditis patients
spasm versus coronary thrombosis versus drug-eluting stent thrombosis complain of asthenia, cold intolerance, constipation, muscle cramps, men-
[5]. In our present case, the patient likely suffered from the type 1 variant strual irregularities in women, and erectile dysfunction in males. Other
of Kounis syndrome. For this variant, the treatment of the allergic event manifestations of autoimmunity are also often present.Renal function may
alone may abolish symptoms and it seems to have the better prognosis [6]. also be compromised in patients with thyroid pathologies through different
At discharge, the patient was asymptomatic and in good clinical condi- pathogenetic mechanisms (2). Hypothyroidism causes an increase in peri-
tion. We referred her to the specialist for full allergology evaluation and pheral vascular resistance at renal levels with intraparenchymal vasoconstri-
suggested a cardiology follow up. In conclusion, physicians must be aware ction and consequent reduction of renal plasma flow, glomerular filtration
of this syndrome and suspect it whenever they face anaphylactic reaction and tubular reabsorption and excretion capacity. In the literature, however,
to timely identify and appropriately manage a potential myocardial injury. only a few cases of progressive kidney failure in the course of Hashimoto’s
Treatment of Kounis syndrome represents a double challenge because it thyroiditis are described (2, 3, 4). A 21-year-old Caucasian female, asymp-
needs to address both cardiac and allergic condition and the drugs admini- tomatic, non-smoker, with a body weight of 53Kg, height of 163 cm and
stered during the anaphylactic reaction may exacerbate heart dysfunction. BMI 19.9 Kg / m², with remote, familial and negative pharmacological
1. Kounis NG, Zavras GM. Histamine-induced coronary artery spasm: the history, came to our examination by examination Routine blood disorders
concept of allergic angina. Br J Clin Pract. 1991; 45:121–128 2. Rico Capeda of a mild and progressive increase in creatinine with values up to 1.13 mg%,
P et al. Sindrome de Kounis. Med Intensiva. 2012; 36:358-64 3. N.G. Kounis, with always normal azotemia and absence of proteinuria and albuminuria.
“Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and Pressure values 100/60 mmHg, FC 68 bpm. Nothing to point to abdomi-
therapeutic management” Clinical Chemistry and Laboratory Medicine, vol nal and pelvic ultrasound. Weak antibody positivity of antibody core anti-
54, no. 10, pp 1545-1559, 2016 4. Lippi G, Buonocore R, Schirosa F, Cervel- bodies, with negativity of ENA, anti-DNA, ANCA. The metabolic profile
lin G. Cardiac troponin I is increased in patients admitted to the emergency was normal, while the thyroid profile showed a picture of hypothyroidism:
department with severe allergic reactions. A case-control study. Int J Cardiol TSH 120.54 μUI/ml, FT3 1.30 pg / ml, FT4 0.26 pg/ml, Anti-Tireoglobulin
2015; 194:68–9. 5. Sueda S, Sasaki Y, Habara H, Kohno H. Editorial: Kounis Antibodies 147.40 IU / ml, Anti-Peroxidase Antibodies 64 IU / ml. Thyroid
syndrome (allergic angina and allergic myocardial infarction) for cardiolo- ultrasonography showed a slightly globe-shaped gland whose extension was
gists. J Cardiol Cases. 2015;12:110–12. doi: 10.1016/j.jccase.2015.07.006. 6. within the lower limits of the standard, with diffusely inhomogeneous and
Kounis NG. Coronary hypersensitivity disorder: the Kounis syndrome. Clin hypoechogenic structure. Considering ultrasonography, positivity of anti-
Ther 2013; 35:563. thyroid autoantibodies and hormonal alterations, the Hashimoto’s thyroi-
ditis was diagnosed. The patient was therefore treated with levothyrosine
(1μg/Kg/day). During therapy, progressive TSH reduction was achieved up
18. DEVELOPMENT OF HCC AFTER HCV CLEARANCE to serum TSH values of 41.39 μUI / ml at one month from the beginning of
WITH DAA-TREATMENT the treatment, with gradual renal function normalization (creatinine 0.78
mg / dl). The described
Sciancalepore D., Luglio C.V., Zingaro M.T., de Vincenzo G.M., Berardi E., Case Report: highlights the importance of TSH assay and thyroid function
Antonica G., Sabbà C., Napoli N. evaluation in patients with acute renal failure without apparent causes
Medicina Interna Universitaria “C. Frugoni”- Dipartimento Interdisciplinare even in the absence of clear symptoms of thyroid insufficiency. The case
di Medicina - Università degli Studi di Bari “A. Moro” also outlines the reversibility of plasma creatinine values with the treatment
of thyroid disease. Bibliografia 1.Santoro D, Vadalà C, Siligato r, Buemi M,
A 65-years-old Caucasian man showed a hypoechoic area in the VI-VII Benvenga S: Autoimmune Thyroiditis and Glomerulopathies; front Endo-
hepatic segment performing an abdominal US during the 24-week follow crinol (Lausanne) 2017; 8:119. 2.Papalia T, GrecoR, Mollica F., Mancuso D,
up after having been treated with hepatitis C virus (HCV) direct-acting Bonofiglio R; Acute renal failure in the course of Hashimoto’ thyroiditis;g
Antiviral (DAA).He didn’t used cigarettes, alcohol and drugs. His family ital. Nefrol 2010 Jul-Aug; 27(4); 404-8. 3.Van welsem ME, Lobatto S: Tre-
history underlined both parents affected by colorectal cancer. His medical atment of severe hypothyroidism in a patient with pregressive renal failure
history described the diagnosis of hemophilia A treated by factor VIII leads to significant improvement of renal function: Clin Nephrol 2007 Jun;
since 1982 and HCV-related liver cirrhosis (genotype 3a, fibrosis stage F4 67(6): 391-3 4.Iwazu Y, Nemoto J, Okuda K, Nakazawa e, Hashimoto A,
at Fibroscan) in absence of previous evidence of hepatocellular carcinoma Fujio Y, Sakamoto m, Ando Y, Muto s, Kusano E: A case of minimal change
(HCC). Therefore, the patients was treated by Sofosbuvir and Daclatasvir nephrotic syndrome with acute renal failure complicating Hashimotoas
for 24 weeks. The patient achieved sustained virological response (SVR) disease: Clin Nephrol 2008 Jan; 69(1):47-52.
after DAA-treatment. Laboratory tests revealed: ferritin 90 ng/ml (x0.2),
polyclonal hypergammaglobulinaemia with hypoalbuminaemia (respecti-
vely 19.5 % and 55.4%), normal transaminase levels, negative neoplastic 20. RAYNAUD’S PHENOMENON AND CAPILLAROSCOPIC
markers (CEA, AFP and CA 19.9), LDH 180 UI/l (x0.75), β2microglobul- ABNORMALITIES IN ANOREXIA NERVOSA
ine 2.8 mg/L (x1.12). An abdominal MR scan revealed a focal lesion in the
VII hepatic segment suspected of hepatocellular carcinoma (HCC). Based Sirufo M.M., De Martinis M., Ginaldi L.
on the above findings, the diagnostic hypotheses formulated were: HCC or Department of Life, Health, & Environmental Sciences, University of
occult metastatic hepatic lesions. Therefore a surgical approach was perfor- L’Aquila, L’Aquila, Italy
med by left epatectomy achieving diagnosis of HCC, (Positivity of Epar-1,
CK7; negativity of CK20 and AFP; Ki67 20%). Currently the patient is in Anorexia nervosa (AN) is an eating disorder characterized by restriction of
abdominal CT follow up with no signs of HCC recurrence. Although the energy intake and weight loss. Among peripheral vascular complications
literature references report a high risk of HCV recurrence after successful of anorexia nervosa (AN), Raynaud’s phenomenon (RP), has been descri-
DAA treatment in patients with HCV-related liver cirrhosis and previous bed.1RP is often secondary to autoimmune diseases, exhibiting typical
clinical story of HCC, this case report underlines the possibility of develo- microvascular alterations. In the absence of diseases able to cause it, RP is
ping new HCC after viral clearance due to DAA therapy. called primitive (PRP).2 Nailfold videocapillaroscopy (NVC) is a nonin-
vasive imaging technique to study microcirculation.3 An abnormal NVC
could predict the onset of an overt connective tissue disease in PRP. NVC
19. EFFECTS OF CHRONIC AUTOIMMUNE THYROIDITIS findings of AN patients with RP (ANRP) were compared with those of PRP
ON RENAL FUNCTION patients and patients with RP and anamnestic history of AN (ex-ANRP).
AN patients not suffering from RP were also included as controls. NVC was
Sirufo M.M., De Martinis M., D’Ostilio A., Ginaldi L. performed by using a x200 optical probe equipped videocapillaroscope con-
Department of Life, Health, & Environmental Sciences, University of nected to an image analyse software (VideoCap software 3.0; DS Medica,
L’Aquila, L’Aquila, Italy. Milan, Italy). According to current classifications2, 3, different NVC pat-
terns were identified: normal (N), non-specific (NS) and early scleroderma
(ES) pattern. No AN patients suffering from RP exhibited normal NVC
Hashimoto’s thyroiditis is a chronic autoimmune disease of inflammatory
findings. The percentage of ES pattern was significantly higher in ANRP
nature, due to the development of antibodies directed against cells of the
patients compared to those with PRP (p<0.01) and AN not affected by RP
thyroid gland. The disease is histologically characterized by a lymphocytic
(p<0.05), whereas no significant difference was found between ANRP and
76
ex-ANRP patients. The proportion of ex-ANRP patients exhibiting an ES establish right doses of DOACs in the treatment of juvenile VTE.
pattern was higher (p<0.05) compared to both PRP and AN. No statistically
significant difference was found in the distribution of N and NS patterns
among the groups. Our results evidenced an association between ES capilla- 22. AN UNUSUAL SHOCK WITH ELEVATED
roscopic pattern and RP in AN patients, whereas any significant association PROCALCITONIN LEVELS
was found between the three NVC patterns and the presence of autoanti-
bodies, as well as ESR and CRP values. The presence of similar capillaro- Balloni A. 1, Maceratini E. 2, Martino G.P. 3
scopic alterations also in patients with RP and anamnestic history of AN 1
Medicina e Chirurgia di Accettazione e Urgenza, Ospedale Murri Fermo
and the absence of an ES pattern in AN patients without RP, suggest that 2
Anestesia e Rianimazione, Ospedale Murri Fermo 3 Medicina Interna,
malnutrition, dysmetabolism and lifestyle are not sufficient pathogenetic Ospedale Murri Fermo
mechanisms of microvascular damage. Autoantibodies against neuropep- A 45-years-old woman was admitted to the emergency department for
tides that regulate appetite were hypothesized in AN5and an increased risk state of unconsciousness. Patients was drowsy, with pulse rate 126 beats
of autoimmune diseases in eating disorder patients has been described.6 for minute, blood pressure 80/50 mmHg, respiratory rate 20/minute and
In conclusion, our study reveals that patients with AN suffering from RP oxygen saturation of 98% at room’s air, pyretic (body temperature 39°C)
exhibit NVC findings typical of connective tissue diseases, confirming the with tremors and chills. The detection of capillar glycemia showed a severe
possibility of a link between autoimmunity and anorexia. References 1. hypoglycemic state (31 mg/dl). The emergency department physician
Sachs KV, Harnke B, Mehler PS, Krantz MJ. Cardiovascular complications started infusion of glucose solution 33% 20 ml and then glucose solution
of anorexia nervosa: a systematic review. Int J Eat Disord 2016;49(3):238- 5% 500 cc and paracetamol 1000 mg ev attending to a slow progressive reco-
248. 2. Wigley FM, Flavahan NA. Raynaud’s Phenomenon. N Engl J Med very of consciousness. After glucose infusion, patient was alert, confused
2016;375(6):556-565. 3. Maverakis E, Patel F, Kronenberg DG, et al. Inter- and disoriented, alternated drowsiness and restlessness, preferring lateral
national consensus criteria for the diagnosis of Raynaud’s phenomenon. J decubitus, without focal neurological deficits of the limbs. Clinical examina-
Autoimmun2014;48-49:60-65. 4. Yager J, Andersen AE. Clinical practice. tion showed dehydratation of skin and mucous membranes, tachycardia, no
Anorexia nervosa. N Engl J Med 2005;353(14):1481-1488. 5. Solmi M, Vero- pathologic findings at the pulmonary auscultation, diffuse moderate abdo-
nese N, Favaro A, et al. Inflammatory cytokines and anorexia nervosa: a minal pain, slight cervical stiffness. The altered mental status of the patient
meta-analysis of cross-sectional and longitudinal studies. Psychoneuroen- and the absence of relatives prevented the collection of anamnestic data.
docrinology 2015;51:237–52. 6. Raevuori A, Haukka J, Vaarala O, et al. The ECG showed sinus tachycardia with diffuse nonspecific alterations of ST-T
Increased Risk for Autoimmune Diseases in Patients with Eating Disorders. waves. Biochemistry revealed increase of leukocyte count (15.800/mmc)
PLoS One 2014;9(8): e104845. with neutrophilia (63%), C-reactive protein 14, 110 mg/L (normal value <0,
5 mg/L), potassium 3, 45 mEq/L, sodium 135 mEq/L, creatinine 3, 64 mg/dl,
urea 81 mg/dl, slight impaired coagulation (international normalized ratio
21. CAN WE TREAT JUVENILE VTE WITH EDOXABAN? 1, 3), elevated procalcitonin level at 41, 91 ng/ml (normal value < 0, 5 ng/
YES ml). Arterial blood gas analysis showed no alterations with normal lacta-
cidemia. For suspected septic shock, probably due to meningo-encephali-
Di Micco P., Amoroso L. tis, physician drew cultures of blood and urine after placement of urinary
UOC Medicina Interna, Ospedale Fatebenefratelli di Napoli, Napoli, Italia. catheter and started therapy with cristalloids and broad-spectrum antibio-
Direzione Medica, Daiichi-Sankyo Italia, Roma. tics (piperacillin/tazobactam). Before the execution of lumbar puncture
patient underwent brain-CT, negative for bleeding or intracranial hyper-
The treament of VTE with DOACs is a well known treatment. Therapeutic tension signs. The arrival of patient’s relatives after CT execution allowed
regimens and timing of treatment are well documented by international gui- the collection of medical and pharmacological hystory. Patient followed a
delines, both for initial therapy and for extended therapy. Suggested doses daily therapy with cortisone acetate and fludrocortisone, consequently the
of each drug are established after dose-finding double blind trials and then surgical removal of pituitary and bilateral adrenal adenomas. Since few
after the following phase III clinical trials. The reccomended dose of edoxa- days patient presented a pyretic gastroenteritic syndrome with vomiting
ban for treatment of VTE is 60 mg daily, but other dosages, in particular and diarrhea, with incongruous steroid therapy assumption in the latter
30 mg daily, are suggested if patients show impaired renal function and\or days. The same gastroenteritic symptoms were shared by patient’s husband
increased risk of bleeding.In literature, there are no studies concerning the and sons. The previous days she had presented generalized asthenia. After
optimal treatment with any DOACs, in particular with edoxaban for patients infusion of hydrocortisone 1000 mg ev, for suspected acute adrenocortical
aged less than 18 years old. Further information about real life studies are failure, the neurological state improved with progressive resolution of con-
missing. The off label dosage and treatment of juvenile VTE is related not only fusion and disorientation. Patient, despite slowed speech, recognized rela-
to missing data, but also to different juvenile metabolism, in particular for tives and physicians and interacted with them, showing greater collabora-
body weight & BMI, gastrointestinal absorption and renal and liver metabo- tion in the execution of simple orders. Patient was admitted in Infectology
lism. In the present article, we report a case of a 13 years old boy affected by Department with the suspected diagnosis of Addison crisis during sepsis,
post traumatic DVT occurred one week later hypomobility due to non-sur- maybe meningo-encephalitis, and treated with broad-spectrum antibiotics,
gical trauma of right lower leg. His body weight was 46 kg and his BMI was volume restoration and hydrocortisone 500 mg/die. Colture of blood, urine
lower than 19; normal function of kidney and liver were detected, none and stool and serological tests for detection of viral or bacterial infection
abnormalities of PT, aPTT and platelet count. His personal anamnesis was were negative. During the hospital stay clinical conditions recovered in
negative for other vascular diseases and similar information were given by few days and procalcitonin levels decreased until normalization. Patient
his first degree relatives. During his clinical observation, he showed inherited was discharged home with diagnosis of acute adrenocortical failure under
thrombophilia for the presence of heterozygosity of prothrombin A20210G gastroenteritis.
gene polymorphism. Neither other clotting abnormalities nor other clinical In recent years, procalcitonin has been recognized as a specific marker for
conditions inducing thrombophilia were identified. The initial treatment was bacterial infections. However, procalciton is not a perfect marker because of
based on enoxaparin 40 mg twice daily, but after the first week of treatment, the risk of false-negative and false-positive results. Acute adrenal crisis may
the patient and his parents refused to continue antithrombotic treatment with mimic a septic shock. Our patient presented some of typical and nonspecific
warfarin. So, we planned to perform an extended treatment with the reduced symptoms and signs of acute Addison disease and septic shock. The diagno-
dose of edoxaban 30 mg daily. Clinical response was good with a good tole- sis of Addisonian crisis was considered only after the collection of medical
rance of drug. After six months, we found a full recanalisation of lower limb history. In our case, as has been showed in previous few cases in literature,
DVT with a slight post- thrombotic syndrome according with Villalta score elevated procalcitonin levels were unuseful to differentiate between Addiso-
and, on the other hand, no side effects of anticoagulant therapy were found, nian crisis and septic shock. Negative culture results cannot entirely exclude
such as recurrence of VTE or minor/major bleeding. Juvenile VTE is a very the presence of a non detectable viral or bacterial infection. We can spe-
rare disease, but antithrombotic treatment in this clinical condition is very culate that in our patient the acute adrenal insufficiency was induced by
difficult because there are not any clinical studies about this topic nor inter- the sudden discontinuance of steroid therapy during an infective enteritis
national guidelines. So, modified doses of the anticoagulant therapy may be with dehydratation. No sure experimental data had yet clarified inflamma-
taken in consideration according to different BMI and juvenile metabolism. tory pathways of procalcitonin increase during adrenal insufficiency. As
We found that the reduced doses of edoxaban show a good safety concerning recently suggested by Schumm, Pfeifer et al., the deficit of cortisol under
main outcomes such as thrombotic resolution and a reduced number of com- Addison crisis may potentiate the immune response with overstimulation
plications as recurrences or bleeding. Further studies are needed in order to of macrophages and procalcitonin-producing cells increasing procalcitonin
levels. On the other hand, some recent evidences encourage the use of ste-
77
roids for the treatment of severe septic shock with impaired corticosteroids (about 30 kg), with loss of appetite and asthenia. On examination she was
response. In particular the Surviving Sepsis Campaign suggests therapy oriented with few mnesic deficits. Vital parameters were stable. A systolic
with hydrocortisone only in patients with refractory septic shock, reducing murmur (graduated 2/6) was present at the mitral auscultation area. The
mortality and improving prognosis. abdomen was tender with a palpable mass in left iliac fossa. A vascular
bruit was audible on right flank. Normochromic stool was present in rectal
ampulla. Labs examinations revealed an increased C-reactive protein, with
23. A SEVERE BRADYCARDIA IN A COLD MAN normal blood white cells count. Abdomen x-rays described multiple levels
and abdominal meteoric distention. Bowel transit was restored with rectal
Balloni A. 1, Martino G.P. 2, Maceratini E. 3 tube insertion, enemas and laxatives. Symptoms subjectively improved. On
1
Medicina E. Chirurgia Di Accettazione e Urgenza, Ospedale Murri Fermo colonoscopy, mucosa was described as hyperemic and rigid with several
2
Medicina Interna, Ospedale Murri Fermo 3 Anestesia e Rianimazione, diverticula, consistent with segmentary colitis associated with diverticulo-
Ospedale Murri Fermo sis (SCAD) pattern B. Given low arterial pressure values, antihypertensive
therapy was completely withdrawn. Rifaximin monthly cycles in association
A 89-year-old male patient, found unconscious on the floor in his home, with probiotics and laxatives were suggested and the patient was discharged.
arrived in the emergency department brought by 118 emergency service. However, in the following year she had 2 other hospital admissions because
Relatives did not have any contact from him for about 36 hours. Patient pre- of intestinal occlusion. SCAD is an infrequent presentation of diverticu-
sented with closed eyes, reacting to pain, making incomprehensible sounds. lar disease, often characterized by pain, diarrhea and bloody stool, but it
He had cold skin and dehydrated mucous membranes. A left peri-orbital can present also with intestinal occlusion. Optimal treatment has not been
hematoma and an extensive right hemi-thoracic bruising were noticed established, although literature suggests use of rifaximin and probiotics,
at body inspection. Vital signs showed hypotension (60/40 mmHg), bra- eventually associated with mesalazine and corticosteroids in more severe
dycardia (40 beats/minute), bradipnea (12 breaths/minute), Sat O2 94% in cases. In the present case the symptoms could suggest other frequent con-
oxygen therapy (FiO2 40%). Body temperature was too low to be measured ditions in elderly patients such as bowel obstruction due to fecaloma, mali-
with thermometers of our department. The capillary blood glucose was 257 gnant disease or intra-abdominal adhesions. Although prognosis of SCAD
mg/dl. He moved 4 limbs in the absence of focal neurological deficits. The is good, it can severely affect patient’s quality of life and determine frequent
patient had a history of Alzheimer’s dementia and hypertension in treat- hospital admissions, especially in elderly patients. Since constipation and
ment. Family members reported an accidental fall from the bed with head diverticular colitis may be strictly related by mutual causation, maintaining
and chest trauma two days earlier. Patient was secured with a central venous soft stool in this kind of patients could represent an important therapeutic
access in right femoral vein, starting infusion of heated 0.9% chlorinated target.
solution and dopamine, in combination with external active heating with
forced-air heating packs or blankets. ECG showed atrial fibrillation with an
average ventricular rate of 40 bpm, wide QRS with prolong QT and Osborne 25. EVERY CLOUD HAS A SILVER LINING: A
wave. Blood chemistry tests detected renal failure with creatinine 4.34 mg/ PROVIDENTIAL ABDOMINAL PAIN
dl, hyponatremia (Na 130 mEq/L) and hyperkalemia (K 5, 77 mEq/l), hypo-
calcemia (6 mEq/l), and anemia (Hb 10, 2 g/dl). Hemogasanalysis showed Bartoli G., Sola M., Casagrande S., Parrino S., Ceschia G., Barazzoni R.
metabolic acidosis with increased of lactate concentration (pH 7.155, pCO2 Struttura Complessa di Geriatria, Azienda Sanitaria Universitaria Integrata
31.9 mmHg, pO2 78.2 mmHg with FiO2 28%, HCO3 11 mmol / l, lacta- Trieste
tes 3.6 mmol / l). Brain CT scan showed a left capsular lenticular bleeding
and a frontal hygroma in the absence of intracranial hypertension signs. An 85-year-old male patient presented to Emergency Department (ED)
Ten hours later, the body temperature increased to 35.7°C and ECG reve- complaining abdominal pain. He had been well until the day before when
aled that Osborn waves disappeared, and the rhythm returned to a normal he began to perceive a dull abdominal pain with band-like pattern after a
sinus rhythm. During hypothermia cardiovascular system is concerned proteic meal. It was associated with a gastric burning sensation. The pain was
both in hemodynamic state and electrical connection. Sinus tachycardia unresponsive to magaldrate and pantoprazole which he took on as needed
and vasoconstriction with increased cardiac output are typical features in basis. In ED intravenous pantoprazole was given with subsequent subjective
early stages, but with further reduction of core body temperature they give benefit. Serum bilirubin, amylase and lipase were slightly increased. There
way to a progressive bradycardia with QT elongation, poorly responsive to was no elevation of inflammatory markers. Abdomen x-ray described signs
atropine treatment. Atrial fibrillation is the most common arrhythmia when of coprostasis. He was admitted in a Geriatric ward. Physical examination
the core temperature is less than 32°C, but at a temperature of about 28 was unremarkable. He underwent appendicectomy in his youth and bilate-
degrees pacemaker cells show a gradual reduction of spontaneous depola- ral inguinal hernia correction about thirty years earlier. He suffered from
rization in addition to a slowing of conduction system which can lead up benign prostatic hypertrophy. He reported recent onset of constipation and
to asystole, ventricular fibrillation or torsades de pointes. Osborn J wave an 8 kilos weight loss in the last 6 months; moreover, he had recent episo-
occurs more frequently at a body temperature between 28 and 32 degrees in des of self-limited abdominal pain. He drank no alcohol. He was put on
association with bradycardia, decreased consciousness leading to coma, loss fasting regimen and received enemas. The day after admission, amilase and
of airway protective reflexes with slow respiratory rate. However J waves are lipase still increased (8 times normal values) in the absence of pain. Abdo-
not pathognomonic of hypothermia. It has been reported in early repolari- minal echographic examination was hindered by significant meteorism, but
zation, Brugada Syndrome, drugs overdose, central nervous system injury didn’t reveal any sign of cholelitiasis, nor hepato-pancreatic lesions. Stool
and hypercalcaemia. Helicobacter pylori antigen was negative. Given the clinical history and the
unexplained raise of pancreatic enzymes, an abdominal CT examination
was performed. The pancreas was described as eutrophic. Between pan-
24. ODD ACRONYMS FOR A LAZY BOWEL creatic body and tail there was a 3x2 cm mass with irregular contour and
enhancement after administration of contrast agent. The lesion surrounded
Bartoli G., Sola M., Omiciuolo C., Ceschia G. splenic artery and caused a significant dilation of Wirsung duct (7 mm). An
Struttura Complessa di Geriatria, Azienda Sanitaria Universitaria Integrata ambiguous hepatic mass of 1 cm of diameter was also described. Metastases
Trieste were ruled out through an abdominal MRI and a chest CT scan. A colono-
scopy was also performed and described only colic melanosis. Given the low
A 94-years-old woman was sent to hospital by his physician because of comorbidity burden and the presence of a single pancreatic lesion he was
abdominal pain, vomit and persistent constipation. Clinical history was candidate for surgery. In the following days pancreatic enzymes spontane-
remarkable for bilateral knee arthro-prosthesis, hysterectomy, mesenteric ously dropped and the patient was discharged. Given these symptoms, the
artery stenosis, right common iliac artery aneurysm, essential hyperten- most frequent differential diagnoses could be acute or chronic pancreatitis,
sion for which she assumed ramipril. Even 3 months before our admis- intestinal subocclusion, peptic ulcer, ischemic colitis, and coledocolitiasis.
sion she went to hospital because of abdominal pain and refractory stipsis. In this case a well conducted anamnesis uncovered red flag signs (uninten-
On that occasion abdomen x-ray described multiple levels and signs of tional weight loss, previous history of abdominal pain, new onset consti-
coprostasis. A CT-scan of abdomen revealed signs of diverticulitis. Stool pation) that leaded to a second line imaging study. Pancreatic tail cancer is
transit was restored with enemas and the patient was discharged at home. usually diagnosed in advanced stage because of the paucity of symptoms. In
1 month before admission she was newly admitted to hospital after a syn- this fortunate evenience Wirsung compression caused a symptomatic onset
copal episode: therefore antihypertensive therapy was decreased. She also of the disease that has been promptly valorized and diagnosed.
reported a prominent unintentional weight loss in the last twelve months
78
all negative. Also blood culture and urine culture were negative. Empiric
26. DYSPNEA IN A HEALTHY OLD WOMAN: GHOSTS therapy with metronidazole was started. Fecal occult blood test was positive.
FROM THE PAST After 5 days from admission the patient underwent colonoscopy: this exam
identified widespread mucosal congestion and several pseudopolyps. Histo-
Sola M., Bartoli G., Ceschia G. logical analysis revealed marked inflammatory infiltration and mucosal
Struttura Complessa di Geriatria, Azienda Sanitaria Universitaria Integrata architectural distortion suggestive for ulcerative pancolitis. Mesalazine by
Trieste oral and rectal route was started. The patient was discharged after 2 weeks,
with complete resolution of initial symptoms. In first analysis from this case
In May 2016 a 79-year-old woman presented to our institution for evalua- we learnt that inflammatory bowel disease (IBD) can present at any age,
tion of progressive shortness of breath that had gradually worsened during not only in young people. Typical symptoms such as weight loss, abdominal
the previous month. She denied chest pain, back pain, or palpitations. She pain, anaemia and diarrhea may not always be present. As the clinical pre-
lived with her husband and led an active and healthy life. She took zolpidem sentation can be non-specific, particularly in the elderly, there is a long list
by oral route for chronic insomnia for several years. In 1995 she underwent of potential and more common differential diagnoses. In this patient fever
a quadrantectomy, followed by radiotherapy and hormonal therapy, for an and diarrhea could be a manifestation of diverticular disease unresponsive
adenocarcinoma in her right breast. Yearly mammograms were done until to first line treatment with rifaximin; given the clinical history, ischemic and
2010, then no other examination has been performed. Since April, because iatrogenic causes were easily ruled out; conversely, infective and neoplastic
of dyspnea, her general practitioner prescribed furosemide 25 mg oral tablet, etiologies required further examinations. In every elderly patient presenting
without clinical benefit. Furthermore, in the same period she performed a with fever and diarrhea, the differential diagnosis should include late-onset
chest radiography showing pleural effusion in middle and lower right lobes IBD. Appropriate therapy can lead to prompt control or even resolution of
with retraction of homolateral costophrenic recess, mild redistribution of related signs and symptoms.
pulmonary blood flow, normal cardiothoracic ratio, aortic arch calcifica-
tion. Labs examination revealed a slight increase of C-reactive protein and
normal white blood cells count. Physical examination revealed dullness to 28. DO NOT LOSE THE THREAD: WHEN CLINICAL
percussion and diminished breath sounds on medium and lower right lung HISTORY CAN BE MISLEADING. DIFFERENTIAL
fields; she was afebrile, there was no peripheral edema. The day after admis- DIAGNOSIS OF NEUROPSYCHIATRIC SYMPTOMS IN
sion she underwent thoracentesis with removal of 1350 cc of pale yellow AUTOIMMUNE POLYENDOCRINE DISEASE
turbid pleural liquid. Pleural fluid protein/serum protein ratio was 0, 84
and pleural fluid LDH/serum LDH ratio 0, 67, which were consistent with Di Vincenzo A. 1, Bordigato E. 1, Frascati A. 1, Bettini S. 1,
an exudative pleural effusion. Pleural fluid culture was negative, cytologic Spinazzè A. 1, Pepe V. 2, Vettor R. 1, Maffei P. 1
exam revealed papillary aggregates with atypical cells suggesting possible 1
Clinica medica 3, Dipartimento di Medicina, Azienda ospedaliera -
pleural dissemination of breast cancer. The patient was discharged without Università degli studi di Padova; 2 Clinica medica 5, Dipartimento di
dyspnea and a chest computed tomography scan with contrast agent was Medicina, Azienda ospedaliera - Università degli studi di Padova
scheduled for the following week. The exam confirmed right pleural effu-
sion associated with multiple irregular nodules on pleural wall; furthermore, A 19 year-old female was admitted to our ward due to marked asthenia,
multiple osteosclerotic lesions were present on dorsal and lumbar vertebrae fatigue, dizziness and episodes of pre-syncope for several month. Her
and tenth right rib. The patient underwent a total body bone scintigraphy medical history was complex and it was notable for central hypothyroidism,
showing multiple bone lesions (sternum, skull, ribs, dorsal and lumbar ver- central hypogonadism, growth hormone deficiency and for diabetes insipi-
tebrae, right femur and kneecap). In June she also underwent pleuroscopy dus and hyperprolactinemia, the last two conditions having been diagnosed
with biopsy of pleural lesions and chemical pleurodesis. Histologic, genetic during puberty. On suspicion of an adverse reaction of recominant GH, the
and immunohistochemistry exams were consistent with a hormone recep- patient was advised to withold r-GH whereas she kept on the remainder
tor-positive, HER2-negative ductal adenocarcinoma. In the following weeks of usual substive therapy (L-thyroxine, DDAVP, cabergoline and estrogenic
the patient was visited by the oncologist and anastrazole and zoledronic acid pills). However, there was not clinical improvement and she was referred
were started. Breast cancer is the most common cancer among women wor- to our clinic. On admission, she presented hypotension (90/50 mmHg)
ldwide. The risk of local or distant recurrence is very high during the first and bradycardia (45 beats per minute), and on neurological examination
five years following the initial treatment. Very late relapse (after 10 years or reduced strength and diffuse hyporeflexia were observed. Cardio-thoracic
more) is uncommon in breast cancer survivors. Nevertheless other cases and abdominal examination were normal. Laboratory tests initially revea-
describing prolonged disease-free survival before relapse are reported in led mild normocromic anemia (115 g/L, normal value 123-153 g/L), hypo-
literature. Most common sites of relapses are skeleton, lungs and pleura, glycaemia (41 mg/dL), hyponatraemia (131 mmol/L, n.v 136-145 mmol/L),
liver and central nervous system. The present case emphasizes the impor- hyperkaliemia (5.4 mmol/L, n.v. 3.4-4.5 mmol/L) and thrombocytopenia
tance of early detection of new symptoms in patient with a cancer history (61.000/mm3, n.v. 150-450.000/mm3). Considering her clinical history
and the significance of long life surveillance for breast cancer survivors. 2 (fatigue, asthenia), clinical findings (hypotension) and laboratory results
(anemia, ion alterations), the suspicion of an acute adrenal failure was
strong so, steroid replacement was rapidly started, with initial clinical
27. A MISLEADING DIVERTICULAR DISEASE: NOT improvement resulting in the normalization of arterial blood pressure, heart
EVERYTHING IS WHAT IT LOOKS LIKE rate and hyperkalemia. However, basal cortisol (taken before replacement
therapy) resulted in normal range, and the diagnosis of acute adrenal insuf-
Sola M., Bartoli G., Parrino S., Concollato E., Ceschia G. ficiency was not confirmed. So, we decided for the suspension of steroid
Struttura Complessa di Geriatria, Azienda Sanitaria Universitaria Integrata replacement. After withdrawal, the symptoms reappeared, and in particular,
Trieste bradycardia was more pronounced, with a heart rate of 40 bpm. On the
ECG junctional rhythm was observed, echocardiography was normal. After
A 72-year-old Italian male was admitted to our Geriatric Clinic complaining discussion with the cardiologists, therapy with aminophylline was started.
acute fever for the past 2 weeks, with mild diarrhea and asthenia. Previously After therapy was started, the heart rate was normalized, but patient remai-
he reported normal bowel habits. He lived alone in the community and his ned hypotensive, and asthenia persisted; furthermore, the patient showed
hobby was gardening. He was a nondrinker but was a former smoker. He progressive alteration of consciousness, with delirium and visual halluci-
reported no recent weight loss. Anamnesis revealed a history of diverticular nations. An urgent cerebral CT showed no alteration, whereas in EEG
disease, chronic gastritis and a colorectal adenomatous polyp removed 8 were noted irritative alterations. Head MRI was normal. Facing the threat
years earlier. He took no medication excepting tamsulosin for benign pro- of inflammatory neurological disease, cortisone therapy was reintroduced,
static hyperplasia. 7 days before hospital admission he was treated with oral with good clinical response and symptoms remission. A lumbar puncture
rifaximin which was switched to amoxicillin/clavulanic acid because of lack was performed, resulting negative for infective meningitis; however, labora-
of clinical improvement. Cardiopulmonary and abdominal examination tory tests revealed positivity for antibodies anti-glutamic acid decarboxylase
were normal, there was no hepatosplenomegaly; rectal examination did (GAD). Then, diagnosis of autoimmune limbic encephalitis was crystallized.
not reveal any blood traces. Admission labs showed elevation of inflamma- The patient was then discharged and followed up in the outpatient clinic.
tory markers, mild anemia and hypokalemia. Thyroid function tests were
normal. Chest and abdomen radiography, as well as abdominal ultrasound
imaging were performed and revealed no lesions. Stool cultures for Clo-
stridium difficile, Salmonella, Shigella, Campylobacter and parasites were
79
29. DOCTOR, I GOT SOMETHING ON MY HEAD… b) patients with poor PS and/or elevated serum LDH, with a MOS of ~4
months should be considered for a milder chemotherapy or best supportive
Brignone C., Bracco C., Pomero F., Gollè G., Cardellicchio A., Giraudo A.V., care (IIA). During response evaluation quality-of-life issues are relevant, as
Fenoglio L.M. for patients with poor-risk CUP excessive treatment-related toxicity is not
ASO S. Croce e Carle, Cuneo justified (IVB). (Annals of Oncology 26 (Supplement 5): v133–v138, 2015)
A 60-year-old woman was admitted to Internal Medicine for left inguinal

pain not controlled by analgesics and the appearance of two skull injuries 30. ZOONOTIC INFECTIONS: BEWARE OF DOMESTIC
at the cranial vertex. She underwent erniectomy surgery for L4-L5 discus CATS
disease six years earlier. Chronic lumbar pain relapsing in the two years
prior to hospitalization was treated with opioid analgesics, modulators of the Caserza L. 1, Piatti G. 2, Del Bono V. 3, Dallegri F. 1, Montecucco F. 1
GABAergic and tricyclic systems. Regular gynecological follow-up, negative 1
Department of Internal Medicine, San Martino Hospital, University of
for breast or uterine pathology. She suffered from a Hashimoto thyroiditis Genoa 2Department of Microbiology, Policlinico San Martino Hospital,
hesitated in hypothyroidism treated with l-thyroxine replacement therapy. University of Genoa 2Department of of Infectious Diseases, San Martino
She denied musculoskeletal traumas. Approximately two weeks before the Hospital, University of Genoa
admission, magnetic resonance imaging of the lumbosacral column and
pelvis and of the brain showed signs of previous interventions in the inter- A 92-year-old woman presented at emergency room with coma, feces loss
spinous posterior L4-L5 intersection and multiple left rooted conflicts and and fever (39.5°C), blood pressure 180/110 mmHg, respiratory rate of 25
presence of two parietal lesions at the intradiploic cranial vertex eroding the breaths/minute and saturating 92% on room air. Personal medical history
bone cortical bilaterally until the dura mater. At physical examination visce- was characterized by hypertension, mild cognitive impairment, atrial fibril-
ral obesity with BMI 31.3 was present; the lower left limb was maintained lation, chronic heart failure, horseshoe kidney with normal renal function.
semiflex in obligatory antalgic position; there was pain in the inguinal and At admission in emergency room the electrocardiogram showed atrial
left trochanteric area with impossibility to load on the lower left limb. At the fibrillation with normal heart rate. Laboratory test results at admission
top of the skull, there were two bumpy painless lesions of elastic consistency demonstrated white blood cell count (WBC) of 13160/mm3, lactic acid of
covered by intact scalp. Cardiovascular, pulmonary and abdominal exami- 2, 5 mmol/l, creatinine of 0, 7 mg/dl, troponins 0, 238 ng/ml, C reactive
nation was normal. There weren’t palpable lymphadenopathies in the super- protein (CRP) 6, 2 mg/L, lactic dehydrogenase 252 U/L. For an uncertain
ficial sites. In First Aid, radiographs of pelvis and left hip showed initial left arm and leg hyposthenia a brain CT scan with angiographic sequen-
bilateral coxarthrosis, while chest-radiography was normal. In addition, the ces was performed. It showed a complete occlusion of right intracranial
following blood tests were performed: WBC 10.57x103/mm3(N 56.2%, L vertebral artery, diffused signs of leukoencephalopathy, no haemorrhages.
32.8%, M 10%, E 0.9%), RBC 4.67x106/mm3, Hb 14.6 g/dL, PLT 302x103/ A brain Magnetic resonance was performed to exclude recent ischemia.
mm3, INR 1, aPTT 37.2 sec, d-dimer 0.45 ng/mL, AST 21 U/L, ALT 41 U/L, Hemocultures were performed and an empirical antimicrobial treatment
GGT 25 U/L, ALP 93 U/L, LDH 513 U/L, CK 33 U/L, Na+ 138.7 mEq/L, with piperacillin/tazobactam and meropenem was administered for four
k+ 4 mEq/L, creatinin 0.8 mg/dL, glucose 95 mg/dL, C-reactive Protein days without a significant improvement: the patient was unconscious and
39.6 (n.v.<10 mg/dL). Diagnostic hypothesis: multiple myeloma; occult had remittent fever. At the admission in our department, the patient was
cancer with bone metastasis; Paget’s disease; Langerhans’ hystiocytosis. The still unconscious and, at clinical examination, was reported a systolic mitra-
following laboratory tests were performed: serum protein electrophoresis lic murmur and an inflamed area was detected on peri-malleolar skin of the
negative for monoclonal gammopathy, Ig-G 6.5 g/L, Ig-A 2.12 g/L, Ig-M right leg. Both arterial-venous legs Echo-colour-Doppler and carotid ultra-
2.37 g/L, beta2-microglobulin 2.5 mg/dL, Ca2+ 1.20 mmol/L, P+ 4.7 mg/ sound were negative for thrombosis and stenosis. Inflammation biomar-
dL, 25-hydroxyvitamin D 19.4 ng/mL, 1-84-PTH 38.2 pg/mL, TSH 4.830 kers were tested, showing elevation in procalcitonin (4, 0 μg/L), CRP was
μU/mL with normal free thyroxine and free triiodothyronine, fecal occult 200 mg/L; troponins were negative. Three hemocultures were positive for
blood test negative in three samples, normal urinalysis. The abdomen US Pasteurella Multocida. A specific antimicrobial therapy with ampicillin-sul-
and the mammogram were normal. In order to better study the morpholo- bactam and gentamicine was started and a trans thoracic echocardiogram
gical characterstics of the skull lesions a brain CT with iodate contrast was was performed at day 10 of antimicrobial treatment. It didn’t show lesions
performed, confirming two parietal osteolytic circle-shaped lesion without compatible with endocarditis. After one day of ampicillin-sulbactam and
contrast enhancement estese fino alla diploe; the radiologist’s diagnostic gentamicin the patient was conscious and fever stopped. The patient refer-
hypotesis was “eosinophylic granulomas”, which are the most common and red to her cat bite one week before the admission to hospital. A sample of
benign form of the Langerhans cell hystiocytosis. A Tc-99m bone scan was cat saliva was analyzed, it was positive for Pasteurella Multocida. The patient
done to search for further osteolytic lesions eventually in sites of minor was discharged after 15 days of endovenous antimicrobial therapy (ampi-
risk for surgical biopsy. Additional bone osteolysis was shown on the left cillin-sulbactam and gentamicin) shifted to oral amoxicillin and clavulanic
humeral and tibial bones and on both femoral bones. CT scans of thorax, acid for other 15 days.
abdomen and pelvis showed mediastinal adenopathies, a suspect left adrenal Conclusion: Cat bites and scratches can drive many pathogenic bacteria as
adenoma and multiple osteolysis. The US-guided biopsy of one lesion in thi- Pasteurella multocida and cause a deep wound especially on legs and arms.
ghbone detected a mildly differentiated adenocarcinoma with mucosecre- Usually these lesions are treated with a local approach and are often unde-
ting cells without origin-specific immunohystochemical patterns. A second restimated by people. Only in few cases patients see a doctor for an anti-
biopsy on mediastinal lymphnodes confirmed the previous result. EGDS biotic treatment. In elderly patients, especially with comorbidity, cat bites
and pancolonoscopy were negative. A whole body 18F-FDG-PET/CT was can lead to local complications or Pasteurella multocida sespsis, an unusual
performed in order to identify the primary cancer: a high metabolic activity but severe condition. A wider awareness on this problem must be useful in
was assessed in mediastinal lymphnodes, left adrenal gland and multiple order to prevent life-threatening situations after pet bites. If patients present
bone sites. A diagnosis of cancer of unknownprimary origin (CUP)was fever after cat bites or scratches and non-compliance to antibiotic therapy is
made. Chemotherapy with Paclitaxel 175 + Carboplatin AUC 5 every 21 suspected, hospitalization may be required.
days was begun and a whole body CT-scan is now ongoing for re-staging.
Attending the ESMO guidelines of 2015, CUPs account for 3%–5% of all
malignancies. It is thought that uncommon clinical presentation, chemo- 31. AN UNUSUAL CASE OF APHASIA AND
resistance and poor outcome in patients are due to chromosomal instabi- HYPOTHERMIA
lity. Pathology evaluation of good quality tissue samples and meticulous
immunohistochemistry are needed to identify distinct subsets of patients. A Dequarti A. 1, Di Vasto M.A. 1, Frigo L. 2, Minuz P. 2, Frulloni L. 1, Ciccocioppo
minority of patients (15%–20%) belong to subsets with a relatively unambi- R. 1
guous clinico-pathological findings and have a more favourable prognosis, 1
Gastroenterology Unit, Department of Medicine, AOUI Borgo Roma,
so they should be treated with site-specific treatment (IVB). The majority of University of Verona, Verona, Italy; 2Internal Medicine C, Department of
patients (80%–85%) do not belong to specific subsets and have only modest Medicine, AOUI Borgo Roma, University of Verona, Verona, Italy.
sensitivity to therapy with a median overall survival (MOS) of 6–10 months.
Consequently, in this group low-toxicity chemotherapy regimens are better In December 2016, a 90-year-old woman was admitted to the Department of
indicated. Choice between a more aggressive treatment and a supportive Internal Medicine of the Policlinico G.B. Rossi (Verona, Italy) because of a
care could be based on the following prognostic criteria: a) patients with rapidly progressive cognitive impairment with confusing episodes lasting two
a good performance status (PS) (0–1) and a normal LDH value, with a weeks, leading to global aphasia. Patient’s medical history included metabo-
median life expectancy of 1 year can benefit from a 2-drugs chemotherapy; lic syndrome (overweight, hypertension with hypertrophic cardiomyopathy,
80
dyslipidemia and carotid atherosclerosis), polyarthrosis, multinodular goiter, nia. LDH and GGT were elevated. Renal function tests were normal. VES,
previous hospitalization for NSAID-related bleeding gastric ulcer, right hip PCR were all normal. HbsAg and anti-HCV were negative. Autoimmune
arthroplasty, and hysterectomy. Her usual therapy was: bisoprolol, oxyco- markers including anti-nuclear antibodies and anti-mitochondrial anti-
done/naloxone, prazepam, amiloride/hydrochlorothiazide, lansoprazole. bodies were negative. Several infective agents incluging EBV, Toxoplasma,
At the admission, vital sign measurement highlighted hypotension (systolic HSV were negative. PSA was normal. Beta2microglobuline exceeds above
blood pressure 85 mmHg) and hypothermia (T 32.0°C), while blood tests normal value and hypergammaglobulinemia. Positive urinoculture for
showed hyponatriemia (133 mmol/L) and hyperkaliemia (6.63 mmol/L). E.Coli. Chest X-ray was normal. Ultrasonography of the abdomen revealed
The ECG showed sinus bradycardia (HR 48 bpm) with type I AV block. Neu- mild steatosis and prostate hypertrophy. Echocardiography findings revea-
rological examination pointed out that patient was vigilant, aphasic, with led no vegetations. Furtermore a total body contrast-enhanced computed
myotic pupils, without deficits of motor and sensitivity function; the strength tomography was done. The ultrasound examination of the right cervical and
test couldn’t be evaluated because of lack of collaboration in Mingazzini’s submandibular revealed subverted ecostructures. Since surgical excisional
test. There was also mild limb edema. Her relatives reported that she had biopsy is the gold standard for diagnosis of lymphadenopaty, an excisional
always been self-sufficient in housework before the present cognitive impair- biopsy of right cervical lymph node was performed. Histopathology of the
ment; however, in the last two weeks they found a progressive reduction of excised specimen revealed lymphadenitis with expansion of paracortical
autonomy in self-care and domestic works. The interpretation of this clinical compartmen and proliferation of extracellular histiocytes with co-expres-
picture was challenging since several diagnostic hypotheses might be advan- sion of CD68 e MPO. A diagnosis of histocitic necrositing lymphoadenitis
ced (such as neurological, infective, and pharmacological causes), thus the (Kikuci-Fujimoto Disease) was made. The patient received antibiotics for
patient was admitted in an Internal Medicine Unit. A CT scan was performed urinary tract infection and paracetamol for the fever and disconfort after
in order to investigate possible neurological events, and no acute lesions were the procedure. KFD is a rare, benign, self limiting disease characterized by
found. Clinical symptoms (aphasia, hypothermia, hypotension, bradycardia) histiocytic necrositing lymphadenitis. The cervical group of lymph nodes is
coupled with electrolyte disorders (hyperkaliemia, hyponatriemia) made most commonly involved. Though several viral agents or an autoimmune
us suspect of a possible metabolic disorder. The most likely causes include etiology has been proposed as causative, the exact cause remain unknown.
hypothyroidism, adrenal insufficiency, and hyperammoniemia. However, Long term follow up is important to monitor the development of rheumato-
the levels of thyroid hormones, serum cortisol, ACTH, urinary free cortisol logic or haematologic disease.
and ammonia were found within normal range. Serum calcium alterations
were also excluded. In the meantime, an EEG showing slow traces associated
with bilateral electrical abnormalities, and an MRI brain examination with 33. A RARE CASE OF ESSENTIAL THROMBOCYTHEMIA
no evidence of focal alteration of the signal intensity, but signs of cerebral ASSOCIATED WITH MASTOCYTOSIS
atrophy were carried out. Moreover, serial blood cultures and serology for
HBV, HCV, CMV, HSV-1, HSV-2, VZV, EBV, Rubella virus, Measles virus, Cosi E. 1, Pizzi M. 2, Giannini S. 1, Bertozzi I. 1, Santarossa C. 1, Fabris F. 1,
Mumps virus, HIV, Coxsackievirus, Borrelia Burgdorferi, Brucella, Leish- Randi M.L. 1
mania, Toxoplasma Gondii, Treponema Pallidum serology resulted negative, 1
Department of Medicine - DIMED, University of Padua, Via Giustiniani
including urinary search of Legionella Pneumophila. Thus, a possible viral 2, 35128, Padua, Italy. 2 Surgical Pathology and Cytopathology Unit,
infection of CNS was suggested and a lumbar puncture was proposed to the Department of Medicine-DIMED, University of Padova, Padova, Italy.
Neurologist who found it inappropriate. The assessment of autoantibodies
showed ANA (1:160) and p-ANCA positivity, while ENA and anti-citrul- Introduction: Systemic mastocytosis with an associated hematological
line antibodies were negative, thus vasculitis or other autoimmune condi- neoplasm (SM-AHN) is the second most common subtype of SM, with a
tion were excluded. A first 24-hour Holter ECG was carried out showing a frequency between 21 and 44%. In the majority of patients with SM-AHN,
normal sinus rhythm (HR average 52 bpm) with type I AV block and two a myeloid stem cell malignancy is diagnosed. Published descriptions of the
significant pauses (3 and 7 seconds, respectively), whereas the second one clinicopathologic features of SM-AHN are largely limited to individual case
performed one week later, documented a normal sinus rhythm (HR average reports. Clinical case: In December 2016, we evaluated in our surgery a
90 bpm), type I AV block, and supraventricular tachycardia (HR max 150 62 year-old man with thrombocytosis (600-750 x 10^9/L) with significant
bpm) that was attributed to a rebound effect of the beta-blocker withdrawal. medical history for longstanding hepato-splenomegaly. He referred skin
During the hospitalization, we witnessed a gradual cognitive improvement, lesions compatible with urticaria pigmentosa treated with phototherapy.
with the recovery of the speech. In addition, body temperature returned to On physical examination we confirmed a mild hepato-splenomegaly and
normal range (36.2°C), as well as systolic blood pressure (140 mmHg), and multiple hyperpigmented maculopapular lesions, ; no lymphadenopathy
electrolyte balance. All symptoms, therefore, disappeared after 15/20 days was observed. The remaining physical examination was normal. Hemoglo-
without any particular therapeutic action, unless hydration and suspen- bin and white cells count were normal; despite a normal ferritin, homozy-
sion of home therapy. An inappropriate (excessive) intake of domiciliary gosity for HFE H63D was detected. We searched and found JAK2V617F
drugs was, therefore, supposed. For this reason, a hair test was carried out mutation (allele burden 9.3%). An abdomen ultrasound revealed fatty liver
that showed very high concentration of oxycodone (516 pg/ml, negative < and splenomegaly (largest dimension 18.7 cm). The suspicion of essential
3 pg/ml), and urine test that showed high benzodiazepine level (2.390 ng/ thrombocythemia (ET) was confirmed with a bone marrow (BM) biopsy,
ml, negative < 200 ng/ml). It is conceivable that the oxycodone over-intake, which showed normal cellularity with preserved M:E ratio (3:1) and normal
caused by an exacerbation of joint pain, resulted in a progressive cognitive maturation of the myeloid and erythroid lineage; megakaryocytopoiesis
impairment leading, in turn, to an erroneous intake also of the other drugs, was increased (6-7 megakaryocytes/HPF) and consisted of giant mega-
thus causing hyponatriemia and hyperkaliemia (hydroclorothiazide/amilo- caryocytes with hypersegmented nuclei, also organized in loose clusters.
ride) and bradycardia (beta-blocker). Thus, the final and unexpected diagno- Perivascular and paratrabecular aggregates of spindle-shaped mast cells
sis was pharmacological intoxication. This case underlines the relevance of (MCs) were also present. These cells featured fine metachromatic granules
collecting an accurate medical history for a correct management, and how and were intermingled with eosinophils and mature-looking lymphocytes.
‘less is more’. By immunohistochemistry, MCs were positive for triptase and CD117,
with aberrant expression of CD25 and CD2. An increase in bone marrow
reticulin fibers (MF grade 2) was present in MC-infiltrated areas. Cytoge-
32. A RARE CASE OF LYMPHADENOPATHY netic analysis disclosed a normal male karyotype (46, XY). Consequently,
the medical history of the patient was accurately reconsidered. He denies
Cioffi A., Brancato T., Coscione M., Colurcio R. any reactions to foods, medications, especially anaesthetics, radiographic
U.O. Medicina Generale, P.O. S. Maria della Pietà, Casoria (Na) contrast mediums, insect stings; no mast-cell mediator-related symptoms
were reported. More specific laboratory investigations were performed and
A 64 year old man was admitted in our Unit due to persisting fever, asso- revealed elevated serum triptase level (123 ng/mL) and PTH (62, 5 pg/mL);
ciated with arthralgia and headache. It was relieved to some extent with vitamin D insufficiency (serum 25-OH-D 50, 1 nmol/L), with normal bone
paracetamol. In his past medical history was colon polyposis treated endo- ALP (17, 4 ug/L), serum CTX (315, 7 pg/mL), serum Calcium (8, 9 mg/
scopically about 10 years ago as well as diabetes mellitus type 2 in treatment dL), serum Phosphate (3, 6 mg/dL), and 24h urine calcium (174, 8 mg/24
with OHA and prostate hypertrophy. On examination his pulse rate was h) and phosphate (1049, 94 mg/24 h). Molecular testing for the KITD816V
98 bpm, blood pressure 110/70 mmHg, respiratory rate 15 breath/minute somatic mutation is ongoing. Radiographs of the spine demonstrated
and temperature 38.3 °C. Physical examination was unremarkable except multiple biconcave vertebral fractures (T7, T8, L1, L3, L5). Bone mineral
for tender right cervical and submandibular lymphadenopaty as well as density (BMD) of the lumbar spine, measured by DXA, was significantly
bilateral axillary. Laboratory tests revealed neutropenia and lymphope- reduced (T-score -3.8, BMD 0.678 g/cm2), while the total femoral (T-score
81
-1.7, BMD 0.781 g/cm2) and femoral neck BMD (T-score -2.3, BMD 0.622 35. A STRANGE “DRESS CODE”
g/cm2) were moderately reduced. Treatment with Acetilsalicilic Acid and
Hydroxycarbamide was started and the PLT count start to fall; furthermore D’Ardes D., Marchione L., Grappasonni G., Di Febbo C.,
bisphosphonate was administered. Rinaldi A.M.P., Carbone A.M., Chiaromonte S., Pieramati L., Angelucci E.,
Discussion: In the published studies, SM-AHN is the second most common Santilli F., Davi’ G.
subtype of SM. The myeloid malignancies most commonly associated with Clinica Medica, P.o. Clinicizzato “Ss. Annunziata”, Chieti, Asl Lanciano-
SM in the literature are MDS, AML e CMML. However, cases of essential Vasto-Chieti, Scuola Di Specializzazione In Medicina Interna, Universita’ “G.
thrombocythemia, polycythemia vera and other unclassifiable myelopro- D’annunzio”, Chieti
liferative disorders have been described as AHNs. The exact pathogenesis
of mast cell disease associated with myeloid malignancy remains unclear. A 50-years old woman was admitted at “SS. Annunziata Hospital” of Chieti
In the present case, the diagnosis were performed for both ET and SM in for erythroderma, fever (with peaks of 39° C) and cough.
agreement with WHO 2016 criteria: the patient fulfilled all 4 major criteria The patient had a history of rheumatic valvular heart disease, she had atrial
for ET and the diagnosis of SM was obtained with one major criterion (mul- fibrillation, osteomuscolar pain and for this reason she had recently started
tifocal compact infiltrates of MCs in bone marrow) and two minor criteria new drugs.
(MCs in the bone marrow express CD25; MCs in bone marrow show an Laboratory has showed that the patient had a floating eosinophilia in asso-
abnormal spindle-shaped morphology). This is the first case of ET associa- ciation to erythroderma and thus she underwent to dermatological evalua-
ted with SM diagnosed in agreement with the most recent WHO criteria, tion e skin biopsy.
showing that the use of these criteria helps in recognizing of rare associated She was examined through CT scan of thorax and abdomen with evidence
diseases. of lung infiltration and mediastinal lymphadenopathy, thus she underwent
to bronchoscopy and bronchial biopsy.
At the same time the patient showed an episode of cardiac failure with asso-
34. A FEVER OF (UN)KNOWN ORIGIN? ciated cholecystitis.
She was evaluated in a Center of excellence for Immunology where it was
Cufone S. 1, Bova C. 2, Vallone A. 3, Vallone G. 1 made a diagnosis of drug reaction with eosinophilia and systemic symptoms
1
Department of Internal Medicine-Dipartmental structure of Interventional (DRESS) successfully treated with high dose of corticosteroid.
ultrasound, Azienda Ospedaliera Annunziata-Mariano Santo-Cosenza, Italy
1
; Internal Medicine- Azienda Ospedaliera Annunziata-Mariano Santo-
Cosenza, Italy 2; Infectious diseases-Jazzolino Hospital Vibo Valentia, Italy 3 36. THE IMPORTANCE OF MEDICAL HISTORY
In September 2016, a 27-year-old man was transferred from another hospi- Carbone A.M., Di Pizio L., Valeriani E., Grappasonni G.,
tal to our Department because of a worsening of his clinical conditions. He Marchione L., Santilli F., Rinaldi A.M.P., Di Febbo C.,
had a history (8 days) of fever (up to 40 ° C), diarrhea and vomiting. No rele- Angelucci E., Davì G.
vant findings in his family and his physiological and past medical history U.O. Clinica Medica - Università degli Studi “G. d’Annunzio” - Chieti
were present. An abdominal CT scan, performed in the other hospital, had
showed the presence of seven liver expansive lesions (axial diameter up to 6 A 34-year-old male patient with multiple sclerosis (MS) treated with alem-
cm in S6 / S7) consistent with hepatic abscesses, epithelial colon estrophils, tuzumab about twelve months before, was admitted to our department with
perihepatic e celiac-mesenteric lymphoadenomegaly. He was treated with palpitation and asthenia. Initial clinical examination was normal except for
antibiotic therapy: Meropenem, Vancomycin, Paromomycin Sulfate and mild tachycardia (110 bpm). Blood test showed hemoglobin (Hgb): 5, 2 g/
Metronidazole, without any improvement. In our hospital ward, the second dl (normal values, n.v. 13-16); hematocrit (Hct): 15% (n.v. 37-49); mean
level hematochemical tests (Widal Wright, EBV IgM, Herpes Simplex 1-2 corpuscolar volume (MCV): 83, 3 fL (n.v. 77-95); mean corpuscular hemo-
IgG and IgM, CMV - DNA, HIV test, IgM anti Parvovirus B19, Ab anti globin 28.9 pg (n.v. 25-35); mean corpuscolar hemoglobin concentration
Entamoeba histolytica, ANA) were negative as well as blood cultures, urine- (MCHC): 34, 7 g/dl (n.v. 33-36), white blood cells (WBC) 5, 04 x10 3/ul
culture and coproculture for common germs and Clostridium Difficile. In (n.v. 4-10); platelets (PTL): 335 x 10 3/ uL (n.v. 150-450); potassium (K):
several sessions, the patient was treated with multiple ecoguidated percu- 4, 05 mmol/L (n.v. 3.5-5.1). The patient did not report any blood loss. In
taneous aspiration of seven hepatic abscesses. During aspiration, purulent the need to transfuse, direct and indirect Coombs tests were performed.
material was obtained. For this reason, the patient was also exposed to a They resulted both positive with panagglutination, so the transfusion was
multiple local antibiotic injection (Piperacillin/Tazobactam). In addition he impossible. The supplementary exams showed: haptoglobin < 8 mg/dl (n.v.
was treated with a systemic antibiotic therapy (Teicoplanin, Levofloxacin, 30-200); lactate dehydrogenase (LDH): 1114 U/L (n.v. 313-618). Renal fun-
Metronidazole) and it caused a progressive clinical improvement. During ction was normal; total bilirubin 0, 4 mg/dl (n.v. 0.2-1.3); indirect biliru-
hospitalization, after 15 days, a new clinical worsening appeared, characte- bin: 0, 3 mg/dl (n.v. 0-0.3). Urine analysis: pH: 6, 5 (n.v. 5.5-6.5); colour:
rized by fever associated with a moderate neutropenia (WBC: 2.100/mL, straw-yellow, clear; spot proteinuria: 1640 mg/dl (0-12); spot albumin: over
NEU: 900/mL, LIN: 700/mL), anemia (HGB: 10.5 g/dl), coagulopathy (INR: (0-10); bilirubin: 0.2 mg/dl (0-0); urobilinogen 1 mg/dl (0-1). According
1.52, PT: 17.6 sec 51%, and PTT: 33.9 sec). Clinical doubts: Other cause? to patient clinical conditions and in agreement with the haematologist, an
New sepsis focus? hepatic abscesses’ worsening? Antibiotic fever? Other? immunosuppressive therapy with intravenous (iv) methylprednisolone 1
A new abdominal TC scan was performed and the comparison with a pre- mg/kg/d and immunoglobulin therapy (1 g/kg/d) was started. In the next
vious test showed a clear improvement in both number and size of hepatic days blood exams were monitored and a further decrease of Hgb was noted
abscesses. Procalcitonin and blood cultures were persistently negative; an (3, 9 g/dl). Therefore two units of hemocompatible leukoreduced red blood
echocardiogram ruled out the presence of images suggestive of endocardial cells were trasfused. In agreement with the hematologist, vitamin B12, folate
vegetation. News ecoguidated percutaneous aspirations of hepatic abscesses and erythropoietin were added to the ongoing therapy. The steroid therapy
were performed, without purulent material emission. The aforementioned was increased to methylprednisolone 1 g/d and another infusion of immu-
antibiotic therapy was then replaced with Clindamycin and Gentamicin. noglobulin at the previous dose was repeated. To exclude other causes of
After the second administration of Clindamycin, the patient had a skin anemia, gastroscopy, abdominal ultrasonography (US) and bone marrow
rash, a new peak of fever and a worsening of bioumoral test. Despite our aspiration were performed and resulted normal. The blood levels of erythro-
worry, we decided to suspend antibiotic therapy, considering results of cul- poietin, folate, vitamin B12 and the complete study of iron metabolism were
tures, procalcitonin test, echocardiograms, the improvement of TC exami- normal. In addition, a pneumonia caused by Micoplasma pneumoniae was
nation and above all the results of new percutaneous aspiration. The patient ruled out. About severe proteinuria and albuminuria found at the admission
showed a progressive clinical improvement. exams, a glomerular nephropathy was suspected. However, protenuria and
Conclusion: Gold standard therapy in patients affected by hepatic absces- albuminuria gradually normalized during the immunosuppressive therapy.
ses is represented by percutaneous ecoguided treatment (aspiration or per- Therefore, in agreement with the nephrologist, a renal biopsy was not
cutaneus drainage). In our patient, after the reappearance of fever, several performed. The patient was discharged with diagnosis of warm antibody
differential diagnoses were considered including a new sepsis focus, a wor- autoimmune haemolytic anemia and glomerular nephropathy in multiple
sening of hepatic abscesses or an antibiotic fever. Clinical judgment drove sclerosis treated with Alemtuzubab. He continued steroid therapy and was
our choices, deciding to suspend antibiotic therapy. Clinical improvement directed to Hematological Unit.
of patient confirmed the diagnosis: fever due to antibiotics. Discussion: Alemtuzumab is an anti-CD52 monoclonal antibody which
causes profound B- and T-lymphocyte depletion. It is a primary indica-
tion for active relapsing-remitting multiple sclerosis (MS). Several adverse
82
effects with the use of this drug have been reported, usually autoimmune mentation is not recommended by the most used guidelines for the mana-
diseases, as thyropathies and idiopathic cytopenic purpura. These compli- gement of acute pancreatitis, but they have showed some benefit in cases of
cations appear many months after the administration of the drug. Autoim- impaired pancreatic exocrine function if used early at the time of refeeding.
mune haemolytic anemia and glomerular nephropathy by anti-glomerular
basement membrane antibodies has been reported as extremely rare. In our
case, the patient showed both this rare adverse effects. 38. OBSCURED BY AN “ASCENDING” DISEASE
Di Pizio L. 1, Carbone A.M. 1, Grappasonni G. 1, Di Pizio V. 2,

37. THE DARK SIDE OF A RECURRENT ABDOMINAL Pepe R. 1, Chiaromonte S. 1, Dall’O’ F. 1, Marchione L. 1,
PAIN Rinaldi A.M.P. 1, Santilli F. 1, Di Febbo C. 1, Angelucci E. 1, Davì G. 1
1
U.O. Clinica Medica - Università degli Studi “G. d’Annunzio” - Chieti 2
Di Pizio L. 1, Carbone A.M. 1, Grappasonni G. 1, Di Pizio V. 2, Pieramati L. 1, Alma Mater Studiorum - Università di Bologna. Facoltà di Medicina e
Santilli F. 1, Di Febbo C. 1, Angelucci E. 1, Davì G. 1 Chirurgia.
1
U.O. Clinica Medica - Università degli Studi “G. d’Annunzio” Chieti 2 Alma
Mater Studiorum - Università di Bologna. Facoltà di Medicina e Chirurgia A 58-year-old female patient came to our attention for a symptomatology
characterized by dizziness, hyposthenia of the lower limbs, and multiple
A 74-year-old patient was admitted to our Unit for a symptomatology episodes of fainting (7-8 episodes in the last 48 hours). In addition, she
characterized by referred abdominal pain, vomiting and diarrhea. In her referred diarrhea occurred about a week before. In her clinical history, she
past medical history, the patient referred multiple admissions to hospital was affected by a conversion disorder, depression and bipolar disorder. She
for recurrent episodes of acute pancreatitis, described by clinical, labora- was chronically treated with clozapine, clonazepam and valproic acid. At
tory and imaging features, but never associated by imaging signs suggestive the physical examination, she presented skin and mucous hypohydration,
of lithiasis. She denied chronic alcohol abuse. In addition, she was affected sinusal tachicardia (heart rate, HR: 124 beats per minute, bpm) and pain in
by Hashimoto’s chronic autoimmune thyroiditis, polymyalgia rheumatica the lower parts of the abdomen during the local palpation. At the neurolo-
and allergic asthma. The patient had been cholecystectomized many years gical examination, she showed hyposthenia of the lower limbs during the
before and had undergone a sphincterotomy of sphincter of Oddi. However, Mingazzini test. The consciousness was preserved, but the patient showed
all her past imaging examinations brought to our attention showed a mild a poor collaboration during the whole physical examination. The body
ectasia of the intrahepatic and common bile duct. The caliber of the pancre- temperature was 38.3 °C. The other vital and objective signs were normal.
atic duct of Wirsung was at the upper limits of the normal range. In addi- The laboratory tests documented: white blood cells (WBC) 16.8 x 103/ul
tion, a later performed duodenoscopy documented a papillitis of Vater. At (normal values, n.v: 4-10); neutrophils 13.7 x 103/ul (n.v: 2.10-7.10); C-re-
the time of the admission to our Unit, the patient was assuming pancreatic active protein 30.3 ng/ml (n.v: 0-0.5); procalcitonin 0.57 ng/ml (n.v: 0-0.5);
enzyme supplementation for a chronic pancreatic failure. At the physical blood potassium 3.94 mmol/l (n.v: 3.5-5.1); blood sodium 139 ng/ml (n.v:
examination, she showed a mild abdominal pain, poorly localized in the 136-146). She had leukocyturia: urine leukocytes 15500 U/ul (n.v: 0-15). In
epigastrium and mesogastrium. The vital signs, thoracic, cardiologic and suspicion of an initial sepsis, we performed blood and urine cultures, chest
neurological examinations were normal. The laboratory tests documented: x-ray and a head computed tomography (CT), all of which resulted to be
amylase 715 U/l (normal values, n.v: 30-110); lipase 4293 U/l (n.v. 23-300); normal. After about 24 hours, the patient manifested drowsiness, hyposthe-
white blood cells (WBC) 11.25 x 103/ul (n.v. 4-10); neutrophils 8.28 x 103/ nia of the four limbs, body temperature of 37.4 °C. The C-reactive protein
ul (n.v. 2.8-5.25); erythrosedimentation rate 70 mm/h (n.v. 1-15); C-reactive increased to 35.7 ng /ml (n.v: 0-0.5). The procalcitonin was 0.47 ng/ml (n.v.:
protein 6.85 mg/dl (n.v. 0-0.5); blood creatinine 1.45 mg/dl (n.v. 0.52-1.04). 0-0.5), WBC 11 x 103/UL (n.v.: 4-10), neutrophils 8.9 x 103/ul (n.v.: 2.10-
Bilirubin, alanine transaminase (ALT), aspartate transaminase (AST), 7.10). A new brain CT was performed, which resulted to be normal. The
gamma glutamyl transpeptidase (GGT), alkaline phosphatase, triglyceri- electroencephalography showed slow-wave abnormalities, with prevalence
des, thyroid-stimulating hormone (TSH) and gamma globulins were in the of slow polymorphic theta (θ) waves (6-7 Hertz). The blood gas analysis
normal range. An abdominal computed tomography (CT) was performed, showed an hypoxemic respiratory failure, so she began oxygen therapy. As
and there were neither signs of acute pancreatitis nor lithiasis. The duo- the neurological state worsened in the following hours (the patient showed
denoscopy showed the signs of the past sphincterotomy. An autoimmune areflexia of the four limbs), given the absence of neither a clear suspicion
cause of acute recurrent pancreatitis was suspected, and the immunoglobu- of sepsis, nor the evidence of organic causes of symptoms, a lumbar pun-
lin G4 subclass (IgG4) were dosed and found above the upper limit of the cture was performed, to verify the hypothesis of Bickerstaff ’s brainstem
normal range: 150 mg/dl (n.v. 1-104). In agreement with the 2011 Interna- encephalitis (BBE) overlapping with a Guillain-Barré syndrome (GBS) and
tional Consensus Diagnostic Criteria (ICDC-2011), for autoimmune pan- rule out other causes of encephalitis. The cerebrospinal fluid (CSF) analysis
creatitis (AIP), this finding was consistent with a probable diagnosis of type documented an increased protein concentration (61 mg/dl; normal range,
1 autoimmune pancreatitis (type 1 AIP). In addition to the common therapy n.r.: 18-43), normal glucose concentration and WBC count. The blood and
of acute pancreatitis (fasting and aggressive rehydratation), the patient was CSF virological tests were negative. A therapy with intravenous immuno-
treated with methylprednisolone 16 mg bis in die (bid), with benefit. She globulins (IVIg) 0.4 g/kg/d was started, with a rapid improvement of the
continued the treatment per os after the discharge from our Unit, followed neurological and respiratory symptoms (recovery of the active motion of
by a a gradual taper (dose decrement of about 4 mg of methylprednisolone the four limbs, level of consciousness and speech). As a diagnostic confirm,
per week), until complete discontinuation. an electroneurography was performed, which showed a decrease of F-waves
Discussion: Acute recurrent pancreatitis (ARP) refers to a clinical entity in the nerves of the lower limbs. The patient was then transferred to a spe-
characterized by episodes of acute pancreatitis which occurs on more than cialized Centre to begin a proper neuromotor rehabilitation.
one occasion. In addition to the most common causes of acute pancrea- Discussion: Guillain-Barrè syndrome (GBS) is an immune-mediated disor-
titis (duct stones, biliary sludge, obstruction by neoplastic causes, alcohol der of the peripheral nerves, characterized by an acute onset of flaccid paraly-
abuse, hypertriglyceridemia), other possible reasons could be represented sis associated with the loss of reflexes. In typical syndrome, rapidly progressive
by sphincter of Oddi dysfunction (SOD) and anatomical duct variants inter- bilateral weakness is the key presenting symptom in most patients. Weakness
fering with pancreatic juice outflow. The etiology of ARP is “idiopathic” in is classically described as “ascending”, usually starting in the distal lower extre-
30% of cases. In cases of recurrent attacks of pain in patients with idiopathic mities. The acute progression of limb weakness proceeds to its peak clinical
pancreatitis, we need to keep in mind that our patient may have autoim- deficit in 2-4 weeks. The disease is tipically preceded by an infective episode
mune pancreatitis. The frequency is very low (about 5%). Autoimmune pan- which often involves the respiratory or gastrointestinal tract within 4 weeks of
creatitis (AIP) is a chronic fibroinflammatory disease of the pancreas that onset of weakness. Bickerstaff ’s brainstem encephalitis (BBE) can be defined
belongs to the spectrum of immunoglobulin G-subclass 4-related disease as a syndrome presenting acute ophtalmoplegia, ataxia and disturbance of
(IgG4-RD). The diagnosis of AIP depends on serology, imaging, histology, consciousness as its major manifestations. Not all cases present classically
other organ involvement and reaction to steroids. Although elevated levels with this triad of features, and absence of one does not rule out the diagnosis.
of IgG4 support the diagnosis, normal levels cannot be used to exclude the Altered sensorium is a key symptom. A considerable number of patients with
diagnosis. The initial objective for the clinician is to rule out malignancy. BBE developed flaccid tetraparesis, which is presumed to be a sign of overlap-
In our case, the patient fulfilled the 2011 International Consensus Diagno- ping GBS. In fact, today the predominating opinion is doubtful that BBE is a
stic Criteria (ICDC-2011) for a possible AIP. In addition, she responded to separate distinct clinical condition. In our patient, the confounding aspects
the steroid therapy. However, the ARP could be due to a mechanical cause, were the chronic anti-psychotic therapy assumed and the rapid worsening of
such as the mild ectasia of bile and pancreatic ducts, probably caused by the clinical course. Anyhow, these features made the lumbar puncture an early
the previous episodes of ARP themselves. Oral pancreatic enzyme supple- necessity. This procedure have finally confirmed our clinical suspicion.
83
39. DISSEMINATED INTRAVASCULAR COAGULATION 40. BREAKING THE STEROID WALL

AND PRIMARY MYELOFIBROSIS: WHICH BEST
THERAPEUTIC STRATEGY? 1
Pettinari P., 1Romanelli G., 1Mattioli M., 1Biondi L., 1Murri M., 1Fraticelli P.,
2
Zoli A., 1Benfaremo D., 1Cardinali M., 1Gabrielli A.
Marigliano B. 1, Valli G. 2, Antonelli Incalzi R. 1, Ruggieri M.P. 2 1
Clinica Medica, Università Politecnica delle Marche - Azienda Ospedaliero-
1
U.O.C. di Medicina Interna, Università Campus Bio-Medico, Roma 2 Universitaria Ospedali Riuniti Ancona 2Immunologia Clinica, Azienda
Dipartimento Emergenza ed Accettazione, Azienda Ospedaliera S. Giovanni- Ospedaliero-Universitaria Ospedali Riuniti Ancona
Addolorata, Roma.
Clinical scenario: A 61-year-old woman referred to the Emergency Depart-
Background: Disseminated intravascular coagulation (DIC) is a hemato- ment (ED) complaining recurrent diffuse acute-onset abdominal pain with
logical emergency often difficult to recognize and always hard to treat as cramps, nausea and vomiting (three episodes during the last 18 months).
it is the final manifestation of a number of different severe syndromes. Its The history of the patient was noteworthy for adrenal insufficiency, splenic
prognosis depends on the severity of the coagulopathy and on the under- marginal zone lymphoma in follow-up from 2011 and reported gallblad-
lying condition. der stones. In 2006, when Addison disease was diagnosed, the patient pre-
Case Report: The patient arrived at the emergency department (ED) for sented with unexplained hypotension, anemia and dehydration; she was
an acute abdominal pain with caudal extension reaching both lower limbs, successfully treated with substitutive therapy, still ongoing. During the last
associated with dysentery occurred during the two previous days with a pro- access to ED, an abdominal ultrasound examination revealed a mild peri-
gressive worsening trend. He was hospitalized in the cardiac rehabilitation toneal fluid amount and severe splenomegaly without other relevant patho-
centre where he was admitted two weeks before to recover from heart failure logic findings: this event was suggestive for adrenal crisis and the patient
exacerbation. During hospitalization, he was treated with high doses of diu- was treated with steroid boluses with benefit. Since the patient’s symptoms
retics and water restriction to reduce preload and improve heart perfor- worsened despite higher doses of steroids, she was admitted to our Clinical
mance. The patient had a history of diabetes mellitus not requiring insulin, Department.
chronic obstructive pulmonary disease on long-term low flow oxygen, and a Diagnostic work-up: Considering the pathological history, our differential
recent laboratory diagnosis of active Primary Myelofibrosis (PM) (reported diagnosis included:
leukocytosis > 30, 000 / uL with a gene activating mutation of the thrombo- • Biliary colic;
poietin receptor MPL gene) yet untreated (no palliation or cytoreduction). • Adrenal crisis;
He had first of all gone to his local rural ED where he underwent an abdomi- • Splenic injury (thrombotic infarction, incipient rupture);
nal computerized tomography (CT) scan with contrast enhancement, which • Angioedema attack;
revealed extensive thrombosis spreading to the superior mesenteric artery, • Acute intermittent porphyria.
and to both renal and common iliac arteries. Owing to the severe extensive On physical examination, Murphy sign was negative and there were no
state of the thrombosis, he was transferred to our central ED with a request signs of peritoneal inflammation; a severe splenomegaly was palpable. Both
for a vascular surgical and haematological consultation. At first glance, his total-body CT scan and abdominal-MRI scan revealed an enlargement of
clinical appearance was poor. The patient arrived in a diaphoretic, hypoten- spleen (19 cm of diameter) without detectable lesions, hepatomegaly and
sive, and oliguric (e.g. diuresis of less than 20ml/hour) state. Limbs were minimal fluid in pelvic cavity; no dilatation of biliary ducts was seen. After
cold, hypotrophic, and pale with a long nail bed capillary refill time and rehydration, laboratory tests showed moderate anemia and thrombocyto-
weak peripheral pulses. Despite marked abdominal pain, his abdomen was penia, B-cell lymphocytosis due to NHL, normal renal and hepatic function
tractable with valid peristalsis. Thoracic evaluation revealed predominant and high CRP serum levels (4, 9 mg/dl). According to the reported instru-
respiratory crackles accompanied by dyspnoea and a mild decrease in SpO2 mental and laboratory findings, biliary colic and splenic injury could be rea-
(93% SpO2 when breathing air). Blood gas analysis showed mild hypoxa- sonably ruled out. During the attacks, patient reported no triggering factors
emia (58 mmHg pO2; 0.21 FiO2) with a severe, mixed pCO2 (48 mmHg; (medications, alcohol, infections) and no urinary symptoms or dark urine;
pH 7.28; HCO3- 12 mEq/L). Laboratory tests revealed leukocytosis (73, 780 therefore, porphyria was unlikely. At this point, we assessed the serum C1q
cells/uL), volume depletion with haemoconcentration (59.2% haematocrit, inhibitor levels that revealed a low functional activity (15% - n.v. 70-130%),
6, 860, 000 erythrocyte cells/uL, Hb 18.4 g/dL), a tendency towards throm- suggesting a C1q inhibitor deficiency. After discussing therapeutic options
bocytosis (platelet count = 464, 000 cells/uL), acute renal damage (2.48 mg with the hematologist and the clinical immunologist, the patient started ica-
creatinine/dl), no significant biliary or hepatocellular alteration (normal tibant, a new bradykinin-inhibitor molecule, with no recurrence of abdomi-
transaminases, alkaline phosphatase and gamma-glutamyl transferase nal pain at one-year follow-up period.
values), and high serum osmolality (313mOsm/kg). The ultrasound scan Conclusions: Acquired C1q esterase-inhibitor deficiency (also called
showed complete collapse of the inferior vena cava. He was admitted with Acquired Angioedema) is a rare syndrome characterized by recurrent epi-
a diagnosis of acute abdominal pain, severe dehydration, and acute kidney sodes of angioedema with cutaneous, gastrointestinal and upper airways
injury. Strict clinical monitoring (vital signs and urine output) was imple- symptoms. The association with hematological disorders, as paraneoplastic
mented with telemetry equipment, along with the best possible supportive manifestation, is quite common, especially with lymphoproliferative disor-
therapy while awaiting general stabilization. Pain was relieved using opiates ders. In the case reported, the diagnostic challenge was harder because of
(i.e. intravenous morphine). The marked hypotensive state, favoured by the the complete but transitory response to steroid therapy that masked the real
ongoing dysentery, contributory cause towards the relapse in the haema- underlying disease.
tological disorder, was countered by increasing fluids. Suitable hydration
was implemented with saline infusion with the aim not only of ensuring
adequate blood circulation (together with bicarbonate infusion and oxygen 41. A CASE REPORT: WITH (HEPATIC?)
supplementation) but also of decreasing blood viscosity. The patient’s ENCEPHALOPATHY
general thrombotic state prevented any surgical approach. Unfractionated
heparin (UFH) was therefore administered to maintain haemodynamic sta- Lopetuso L., Mosoni C., Ponziani F., Addolorato G., Gasbarrini A.,
bility and delay, without halting, the unrelenting threatening advancement Gasbarrini G.
of DIC triggered by aggressive PM. Despite prompt therapeutic support, Istituto di Medicina Interna, Gastroenterologia e Malattie del Fegato,
the overt establishment of DIC, secondary to the Hyperviscosity Syndrome Università Cattolica del Sacro Cuore, Roma
(HVS) caused by PM and dehydration, went beyond clinical reversibility
and led to a multiple organ dysfunction syndrome (MODS), with secon- 52-year-old female, affected by obesity and coeliac disease, presented to the
dary death from septic shock the next morning. Why should an internist emergency room experiencing mental confusion and amnesia, associated
be aware of this? Revising what the evidence-based medicine recommends, with tachyarrhythmia and severe diarrhea. Similar symptoms had occurred
the sole winning strategy is for an internist to recognize the expression of also a month before. Her relatives reported a long history of alcohol abuse
the relapsing myeloid chronic disorder concurrently guaranteeing adequate (5-6 drinks/day for at least 20 years) and poor compliance to the gluten-free
tissue perfusion with fluid and electrolyte equilibrium. Till date elective and diet; especially in the previous two months she had not been following the
curative strategies both in PM and in DIC settings are lacking. Therefore, diet. Physical examination, associated with abdominal ultrasound exam,
if on one hand, internists (including emergency physicians) must guaran- blood tests and a negative brain CT, allowed the diagnosis of metabolic and
tee best clinical practice, on the other, hematological clinical departments alcoholic cirrhosis, complicated with grade 2 hepatic encephalopathy. We
should implement preventive and therapeutic policies for thromboembolic ascribed her diarrhea to gluten consumption, considering also that gluten
complications related to hematologic malignancies since their evolution, in consumption in a small percentage of coeliac patient can lead to neurologic
EDs, is not a sporadic threat. and psychiatric symptoms known as “brain fog”, which vary from transient
84
impairment in attention and memory to ataxia and peripheral neuropathy superior esophageal sphincter toward cardiac sphincter, that is relaxed.
(Gregory W. Yelland, Dep. of Gastr., Cent. Clin. Sch., Monash Univ. and Slight hyperemia of gastric antral mucosa”. The patient was placed on “nil
Sch. of Hea. Sci., RMIT Univ., Melbourne, Victoria, Australia, J of gastro- per os”, with parenteral nutrition and I.V. proton pump inhibitors. Therapy
ent. and Hepatol., 2017). Treatment with branched chain amino acids and with antifungal drugs (I.V. Fluconazole) and antivirals (I.V. acyclovir) was
rifaximin and a strict gluten free diet were started, with sudden improving started. The patient rapidly got subjectively better. The endoscopic biopsy
of the symptoms. Upon complete regression of diarrhea, we prescribed a revealed “exulcerated esophageal mucosa, with necrotic leucocytes, hyphes
therapy with lactulose to prevent further encephalopathy episodes. A couple and fungal spores”, even if culture was negative. Endoscopy was repeated on
of weeks later the patient was admitted to the hospital again, this time due twentieth day, demonstrating “persistent ulcero-necrotic aspect of esopha-
to a loss of consciousness associated with tachyarrhythmia and without geal mucosa with slight reduction of flogosis”. The patient maintained the
typical encephalopathy symptoms. At first we excluded a major bleeding same therapy and the endoscopy on the 27th day demonstrated “persistent
and a worsening in hepatic function, then we performed and ECG, which esophageal lesions with partial regression of inflammation”. On the 40th
showed persistent ST elevations in the electrocardiographic leads V1-V3 day, 4 weeks after clinical onset of esophageal symptoms, the endoscopic
with a right bundle branch block. The patient was diagnosed with Brugada aspect was “persistence of some longitudinal areas of necrotic mucosa, with
syndrome and an implantable cardioverter defibrillator (ICD) was then some bleeding erosions, with better global condition of esophageal mucosa”.
inserted. She was discharged to home in stable conditions a few days later. The patient was discharged in good general conditions, with a light diet and
A new episode of confusion and disorientation in time and space occurred a prescription of PPI and sucralfate.
a month later, in association with severe diarrhea; blood tests, including
ammonia, were normal, and the patient’s relatives reported to us that she
completely quitted the gluten free diet. We recommended to her to avoid 43. A SYSTEMIC GRANULOMATOUS DISEASE IN A
gluten consumption, but her symptoms had become stable and no longer PATIENT WITH MYELOFIBROSIS
benefitted from therapy and diet. We started considering fecal microbiota
transplant (FMT) as a possible therapy of her encephalopathy symptoms, Purrazzo G., Spadaro L., Giarratana F., Guiducci D., Purrello F. Department
basing on interesting data: of Clinical and Experimental Medicine, University of Catania, Ospedale
= Promising data suggest that FMT could play a role in hepatic encepha- Garibaldi Nesima
lopathy management: it is described that a 57-year-old man suffering from
grade 1-2 hepatic encephalopathy with alcohol+HCV related liver cirrhosis, Case Report: A 59-year-old woman was admitted to our department with
who had previously responded well to lactulose and rifaximin but could no fever, cough, malaise and abdominal distension. Her clinical history consisted
longer afford rifaximin, had a great benefit from FMT. (Kao D et al. Hepa- of essential thrombocythemia evolved in myelofibrosis (MF), arterial hyper-
tology 2015) tension, multinodular goiter and GERD. At the time of MF diagnosis she
= Rising findings suggest that FMT may play a role in many disorders asso- showed constitutional symptoms and abdominal discomfort due to massive
ciated with the alteration of gut microbiota (Cammarota G, … Gasbarrini splenomegaly. On the basis of the ECOG score (ECOG1) and symptomato-
G, … Malfertheiner P, … Gasbarrini A et al. Gut 2017, Proc. EASL 2017) logy, she was enrolled in a phase III study and received the Janus Kinase (JAK)
= There is no evidence showing that microbiota modulation could play a inhibitor Ruloxitinib 20 mg twice daily. Before starting the treatment, an eva-
role in neurologic and psychiatric symptoms which can occur under gluten luation for infectious disease excluded any intercurrent or latent infection.
consumption in coeliac patient; it seems that they should be ascribed to the After 8 weeks of therapy, the patient complained of fatigue, sweat, abdominal
passage of gluten across the blood-brain barrier (Gasbarrini G, Mangiola discomfort and fever. An abdominal ultrasound study and a computed tomo-
F, UE Gastro. J. 2014). However, FMT has been successfully performed in graphy (CT) were performed with evidence of free peritoneal fluid and multi-
refractory celiac disease type II complicated to enteropathy associated T focal micronodular lesions on the greater omentum and peritoneum. In addi-
cell lymphoma, with full recovery of symptoms and intestinal mucosal villi tion, PET scan showed areas of increased metabolism in multiple thoracic and
(Case report by van Beurden YH et al, J Gastrointest Liver Dis 2016). mediastinal lymph node stations, in the stomach, at gynecological level and in
the lungs. A laparoscopic biopsy of the omental lesions showed not necroti-
zing granulomatous inflammation with a negative Ziehl-Neelsen reaction. On
42. A CHALLENGING CLINICAL PRESENTATION admission the patient appeared pale, dispnoic and sweaty. Her body tempe-
rature was 38.5 °C. Laboratory test results revealed RBC 3070000 cells/mm3,
Anastasio L. 1, Manno V. 1, Lentini N. 1, Chirico A. 2, Arone A. 1, Hb 8.4 g/dL, WBC 4200 cells/mm3 (N 85.2% L 7.1% M 6.1%), PLT 229000
Carbone M. 1, Sofia L. 1, Topa G. 1, Grasso A. 2, Perticone M. 3, Perticone F. 4 cells/mm3, erythrocyte sedimentation rate (ESR) 60 mm, C-reactive protein
1
UO di Medicina Interna - Ospedale “G. Jazzolino” - Vibo Valentia 2 (CRP) 5.39 mg/dL. A thoracic CT scan showed a left pleural effusion and
Servizio di Gastroenterologia ed Endoscopia Digestiva - Ospedale “G. irregular thickening of the pleural surface. Manteaux reaction, Mycobacte-
Jazzolino” - Vibo Valentia 3 Dipartimento di Medicina Sperimentale e rium tuberculosis (MT) microscopic detection in urine, emocoltures, real-
Clinica - Università degli Studi Magna Graecia di Catanzaro 4 Dipartimento time PCR and geneXPERT for MT in pleural fluid obtained through a pleural
di Scienze Mediche e Chirurgice - Università degli Studi Magna Graecia di drainage resulted negative. QuantiFERON-TB-GOLD test resulted indeter-
Catanzaro minate. On the basis of these findings and of the patient’s history we decided
to request a pleuroscopy with biopsies of the pleural lesions. The hystologic
A 49 years old male patient, affected by type 2 diabetes mellitus, on oral evaluation of the obtained material reported the presence of granuloma-
therapy with metformin, complicated by infected diabetic foot with oste- tous epithelioid nodular process without necrosis with a negative Ziehl-Ne-
omyelitis of two fingers of the right foot, was admitted to emergency room elsen reaction. The material then was revised to search for PCR analysis to
in sleepy state, with a brief history of fever in previous days. Laboratory detect atypical mycobacteria. In particular, Nested-PCR for Mycobacterium
study revealed lactic acidosis (pH 6, 97, HCO3 3, 4 mmol/l, pCO2 14, 7 genus-specific (HSP65) resulted positive. So, our final diagnosis was: syste-
mmHg, pO2 162 mmHg, lactacidemia 10 mmol/l), acute renal impairment mic nontuberculus mycobacteriosis in a patient with post-essential throm-
(creatinine 10, 3 mg/dl, ureic nitrogen 299 mg/dl), hyperglycemia (202 mg/ bociythemia myelofibrosis treated with Ruloxitinib. Discussion: Ruloxitinib
dl). He was immediately admitted to Intensive Care Unit and treated with is a Janus kinase (JAK) inhibitor widely used to decrease the constitutional
haemodialysis by insertion of a central venous cannula. He rapidly got better symptoms and splenomegaly in patients with myeloproliferative disease. Pre-
and in two days he was transferred to Internal Medicine Ward. A rehydra- vious studies have showed an increased risk of tuberculosis in patients treated
tant and empirical antibiotic treatment were started with a strictly control with Ruloxitinib, maybe due to a depressed Th1 response and a reduced pro-
of glycaemic values with basal bolus insulin protocol. A phlegmon of the duction of gamma interferon (INF-γ). Therefore, in an apparent TB negative
right foot was treated on the second day by incision and wadding. The acid- case, performing additional molecular tests for atypical mycobacterium can
base study showed moderate respiratory alchalosis. Renal function rapidly help to reach the diagnosis of atypical mycobacteriosis.
improved, without further need of dialysis. Hemodynamic condition was
stable with onset of polyuria up to 4.5 litres/day, treated with water and ele-
crolytes replacement by intravenous infusions and oral intake by the patient. 44. A STRANGE CASE OF EPIGASTRIC PAIN AND
On the seventh day after admission the patient reported light dysphagia. NAUSEA: WHEN THE HISTORY MAKES THE DIFFERENCE
Examination of oropharynx revealed hyperemia and white patches in oral
cavity, resembling oral candidiasis of tongue and soft palate. Treatment with Riccardi A. 1, Esposito G. 1, Luiso V. 2, Paolillo C. 1, Sbrojavacca R. 1
oral antifungal gel (miconazole) was started. On the twelfth day after admis- 1
SOC. di Pronto Soccorso e Medicina d’Urgenza, Azienda Sanitaria
sion the patient had vomit of food with emission of bloody mucus. He went Universitaria Integrata di Udine 2 Dipartimento di Medicina Interna dell’
to endoscopy, wich revealed “widely exulcerated esophageal mucosa, from Università degli Studi della Campania Luigi Vanvitelli
85
A 71-year-old man comes to Emergency Department (DEA) overnight values. The objective clinical exam upon entry identified warm and flushed
complaining of nausea and epigastric pain. She took 10 mg metoclopramide skin, valid pulse and isoseismics, no jugular swelling. The abdominal thora-
os and an antacid without great benefits. He also reports various episodes of cic EO did not detect any significant element other than tenderness to deep
vomiting in recent hours. In the history he records only a mild hypercho- palpation in the epi-mesogastric area. No signs of peritonism were detected,
lesterolemia in simvastatin treatment. Upon arrival in DEA, the patient is nor periumbilical bruits could be auscultated in the vascular area. Relevant
alert, oriented and collaborative, apiretic, suffering, tachycardic, and slightly tenderness to pressure on the spinal apofisis L1-L4 limited and prevented
tachyptic. The abdomen is treatable with mild pain in mesogastria and with functionality. PA 150/70; FC 105 R; SpO2 97% in open air; T.C. 37.5°C. The
noisy peristalsis sounds, without obvious signs of peritonism. The remai- ecoculture resulted positive to the Streptococcus viridans group. Suspecting
ning objectivity is within the normal limits. Hematochemical tests including infective spondylodiscitis as a secondary localization of bacteric endocardi-
emocromo, electrolytes, creatinine hepatic profiles, PCRs, emogas analysis tis, in a patient with a prosthetics aortic valve, after an electrocardiographic
and troponin are then required and a 40 mg pantoprazole vial is administe- exam we excluded valvular vegetations. A spinal TC revealed the presence
red. In the abdominal ecoscopy performed in DEA, the only abnormal signs of multiple didascal lumbar hernias and confirmed the presence of thi-
are an apparent gastric overexpression associated with abnormally dilated ckened walls (21x14mm) And an aneurismatic sacciform dilatation of the
bowel’s anse, especially in the central areas of the abdomen. In the suspect abdominal suprarenal aorta contiguous to origin of the superior mesente-
therefore of an intestinal occlusion the patient is sent to perform an XR ric, in absence of signs of idroureteronefrosis. We therefore proceeded to
abdominal exam. After about an hour the patient complains of a painful remove an autoimmunity panel to exclude a vasculitic lesion (negative) of
abdominal pain with a feeling of noticeable nausea. It is therefore given 3 the aorta as the original cause. A PET-TC with 18-FDG was requested and
mg morfina with partial pain relief and a Metoclopramide iv. Hematoche- it did not find any record of a spondylodiscitis active but it displayed intense
mical examinations highlight an important neutrophil leukocytosis (18, 400 hyper fixation of the radiochemical localised in the periaortic abdominal
/ mcL of which 16, 190 neutrophils) with significant increase in pancreatic area confirming the first hypothesis of flogistic/inflammatory phenomena.
amylase. EGA shows no significant alteration. Lactates are standard. There- The diagnosis was of “inflammatory aneurism in the suprarenal abdomi-
fore, thinking that the patient’s problem was related to acute pancreatitis, a nal aorta”. The interposition of numerous splenetic vessels prevented a per-
surgical evaluation is required. The specialist, however, before the visit asks cutaneous biopsy of the lesion aimed to a histologic characterisation. An
the result of abdomen XR exam, but it’s not ready yet. After a telephone ex-adiuvantibus therapy was prescribed consisting in high dosages of cor-
contact with the radiologist, the report of this exam made available: there is ticosteroids (prednisone 25 mg x 2/die) resulting in a rapid and dramatic
no evidence of bowel anse’s dilatation or free air levels in the areas explored. improvement in symptomatic manifestations and of the clinical-laboratorial
The radiologist, however, extended the investigation to the chest as well, framework (normal flogosis parameters). The patient was discharges after 7
documenting abnormal relaxation of the gastric cavity totally dislocated in days without fever or symptoms with the indication of a vascular follow-up
the left chest, in relation to a likely diaphragmatic breach with consensual to assess a potential surgical option.
dislocation of cardiomediastin. About 40 years ago, the patient had been Conclusions: an analysis of the relevant literature found that aneurisms
victimized by a violent road accident that had caused a diaphragmatic lesion resulting from the inflammation of the abdominal aorta only make up
that, in his opinion, had never been symptomatic or followed in years with between 2 and 15% of all aortic aneurisms; in most cases the problem is
clinical and instrumental follow-ups, and had therefore been omitted In localised in the infra or iuxta-renal area. This condition, that shows very
initial clinical history. At this point, to clarify the actual anatomical con- similar characteristics to idiopathic retroperitoneal fibrosis, but is often con-
dition of the patient, an urgent thoraco-abdominal CT exam is required sidered a nosological entity of its own, when it manifests itself in an acute
confirming the full occupation of the left chest by the gastric cavity, which manner and, like in our patient’s case in an atpic area, (more insidious as it
appears abnormally dilated for the stagnation of liquids, ingested and with a doesn’t present itself within the normal clinic parameters associated to an
large hydro levels inside. The left lung is completely collapsed with complete ab-extrinsic obstruction of contiguous areas) can appear as more common
lateralization of the cardiomediastin and through the large breach the chest pathology of both a surgical and medical nature.
is occupied by some small intestine, transverse colon, colon descending
and pancreas body. It is also evident that a liquid spill in the left parieto-
colic space near the thing of the pancreas still in the abdomen, which has 46. WHEN MONONUCLEOSIS DOESN’T MEAN SIMPLY
an edematous appearance as chronic pancratitis. Ultimately, the diagnostic A “KISS DISEASE”: ATIPICAL PRESENTATION OF A
hypotheses of intestinal occlusion and pancreatitis have both been confir- COMMON CLINICAL CONDITION CASE REPORT
med CT exam, but they are been epifenomens of the dislocation of inte-
stinal thoracic viscera due to the previous traumatic diaphragmatic lesion. Alessio S., Giuliani M., Pucci G., Battista F., Sgariglia R., Sanesi L.
The patient was therefore urgently admitted to the Department of General Department of Medicine, University of Perugia- Unit of Internal Medicine, S.
Surgery to undergo multidisciplinary diaphragmatic reconstruction with Maria Hospital, Terni, Italy
repositioning the viscera. This
Case Report: is an example of how the history is the most important Case Report: A 68 -years- old woman with medical history of arterial
element throughout the diagnostic process hypertension and past peptic ulcer was admitted to our Medical Division for
severe asthenia, fatigue, jaundice and tachycardia developed in the previous
few days associated with emission of dark urine. Patient denied any blee-
45. A STRANGE CASE OF LOW-BACK PAIN ding events (i.e. hematuria or gastrointestinal bleeding). She didn’t take any
medication (NSAIDs, anticoagulants). At admission to our ward the vital
Sgariglia R., Alessio S., Pucci G., Giuliani M., Sanesi L. signs and general examination were normal, except for jaundice (in parti-
Department of Medicine, University of Perugia- Unit of Internal Medicine, S. cular no hepato-splenomegaly, no superficial palpable lymphadenopathy).
Maria Hospital, Terni, Italy BP 100/60 mmHg, HR 110 bpm R, SatO2 98% room air, TC 36.6 °C. Blood
laboratory tests revealed hyperbilirubinemia (2.2 mg/dl) mostly unconjuga-
L.L. a 71-year-old woman came to the hospital after a month of prevalently tes (1.5 mg/dl), severe normocytic anemia (Hb 6.7 g/dl), leucocytosis with
serotinc fever of an intermittent-remittent nature that did not respond to neutrophilia and monocytosis (leucocytes 29000/mmc, monocyte 2650/
FANS or empiric antibiotic therapy, and lamenting epigastric pain of a pier- mmc), LDH (2053 UI/l), elevation of systemic inflammation markers (CRP
cing nature to the back. She also suffered from inappetence and unintentio- 5 mg/dl, VES 38 mm/h, ferritin 3000 ng/ml) with renal impairment (serum
nal weight loss. The patient had been discharged from the hospital a week creatinin 1.52 mg/dl, blood urea nitrogen 114 mg/dl), procalcitonin within
before, after undergoing vascular surgery for similar symptoms resulting in range (<0.05 ng/ml). Reticulocytes 9.7%. To exclude a post haemorrhagic
a diagnosis of “sacciform trombotic pseudo aneurism from a piercing ulcer anemia the patient underwent endoscopic procedures (esophagogastroduo-
in the abdominal, with the suggestion of a clinic-strumental follow-up”. The denoscopy and colonscopy) without detection of macroscopic pathologic
pathological anamnesis revealed a systemic arteric hypertension - that had findings. Total body TC demonstrated the absence of a blood and lymphatic
been treated for the last 15 years by taking 1, 25 mg of bisoprolol once a system disorders (no mediastinic or abdomino-pelvic lymphadenopathy;
day and Ramipril/amlodipine 10mg/10mg 1 cp/die- and previous valvular spleen with normal size, absense of venous pelvic or hepatic trombosis). In
aortic substitution with bioprotesis (2014) for tight stenosis. A fast-abdo- consideration of elevated serum levels of unconjugates bilirubina, acute and
minal ultrasound did not find any indirect sign of aortic dissection. Lab symptomatic anemia and high urobilinogen at urinalysis, we hypotized an
results were characterised by a relevant increase in the systemic flogotic hemolytic pathogenesis. In order to investigate the etiology of acute hemoli-
system values (VES 81 mm/h, PCR 8.25 mg/dl, iper-alfa2 at seroprotect sys we assessed more specific tests, including haptoglobin (27 mg/dl), direct
electrophoresis), neutrophilic leucocytosis, procalcitonin 0, 46 ng/ml, crea- and indirect Coombs (negative). On the basis of conflicting radiological and
tinine and uraemia within the physiological range, normal emocoagulative biochemical findings and after deepening her medical history, we discove-
86
red that she complained to suffer in the previous week of a gastroenteritis 48. AN UNSUAL CASE OF AUTOIMMUNITY SYNDROME
characterized by water diarrhea, abdominal pain, vomiting and fever treated
with supportive therapy. In accordance with this interesting fact and con- Benfaremo D., Pedini V., Savore I., Fraticelli P., Gabrielli A.,
sidering monocytosis at laboratory assessment, we investigated post-in- Danieli M.G.
fectious nature of the anemia: CMV and Mycoplasma Pneumoniae siero- Clinica Medica, Università Politecnica delle Marche e Ospedali Riuniti,
logy was negative, while EBV sierology turned positive for a recent primary Ancona
infection (IgM 37, 10 U/ml –VR: <20 negative, 20-40 doubt, >40 positive
– IgG VCA 750 U/ml –VR:>=20 positive). A final diagnosis of self-limiting Introduction: A 64-year-old woman was admitted to our medical ward
hemolityc anemia with negative direct and indirect Coombs ongoing EBV for progressive fatigue and worsening of chronic anemia associated with
infection was put and steroid therapy was started. She was dismissed after thrombocytopenia. History: The patient’s medical history started in 2008
4 days in good conditions, with stable haemoglobin (Hb 10 g/dl), without when she received a diagnosis of undifferentiated connective tissue disease.
need of blood transfusions. The clinical scenario at onset of symptoms included pleuropericarditis,
Conclusions: In course of infectious mononucleosis in approximately 3% unspecified skin lesions, Raynaud’s phenomenon, low-titre ANA positivity
patients may occur a immuno-haemolytic anemia that is associated with with negative anti-ENA. Corticosteroids and hydroxychloroquine were
anti-erythrocytes IgM detected with direct and indirect Coombs and that prescribed, with a mild benefit. During the ensuing years, anemia, severe
develops commonly during third-fourth week. In this case, despite the pau- thrombocytopenia and mild lymphopenia were invariably seen on com-
ci-symptomatic clinical presentation (no deep and superficial lymphadeno- plete blood count (CBC). She underwent chest computed tomography (CT)
pathy or exudative pharyngitis or hepato-splenomegaly or fever or atypical that showed enlarged mediastinal lymph nodes. She received a diagnosis
lymphocyte, negative direct and indirect Coombs, normal liver enzyme) of systemic lupus erythematosus (SLE) and treatment with prednisone and
that seemed initially to point towards an autoimmune/neoplastic patho- hydroxychloroquine was carried forward without benefit. Azathioprine was
genesis, the anamnestic element of recent “gastroenteritic syndrome” takes started, but the platelet levels dropped after every steroid-tapering attempt.
a key role to suggest us the atypical presentation of mononucleosis with Several admissions were necessary to treat the persistent severe throm-
hyper-hemolysis virus-related. bocytopenia with high-dose pulse steroids; a further treatment attempt
with belimumab was also disappointing. In April 2016 she was admitted to
another Internal Medicine ward where she received a diagnosis of Fischer-E-
47. USEFULNESS OF MUSCLE MAGNETIC RESONANCE IN vans syndrome associated with SLE; splenomegaly had worsened (16 cm).
INFLAMMATORY MYOPATHIES She was discharged after receiving treatment with corticosteroids. On June
2016 a bone marrow biopsy was suggestive of a myelodysplastic syndrome.
Savore I., Gelardi C., Cardinaletti P., Pedini V., Gabrielli A., On December 2016 because of persistent fatigue and worsening anemia
Danieli M.G. and thrombocytopenia on blood tests, she referred to our outpatient clinic
Clinica Medica, Università Politecnica delle Marche & Ospedali Riuniti, and was admitted for further evaluation. Clinical problem: Fatigue, chronic
Ancona hemolytic anemia, thrombocytopenia, mild lymphadenopathies, marked
splenomegaly and inconstant ANA, Coombs and anti-platelet antibodies
Background: Dermatomyositis (DM) and polymyositis (PM) are the most positivity. Physical examination:Normal except for palpable severely enlar-
common idiopathic inflammatory myopathies, characterized by symmetric ged spleen, as well as multiple, soft and non tender superficial lymph nodes
proximal muscle weakness. Recently magnetic resonance imaging (MRI) has on axillary and inguinal stations. Routine laboratory tests:Anemia (8 g/dl),
been used in myopathies to identify affected muscles, in particular to detect thrombocytopenia (about 50.000/mmc), raised LDH (388 U/l), decreased
edema, which is an early sign of inflammation. haptoglobin, polyclonal hypergammaglobulinemia were observed. Serum
Materials and Methods: Here we describe two patients with PM, diagnosed electrolytes, liver and renal function were within normal range. Differential
according to Bohan and Peter criteria. In each patient we performed MRI of diagnosis:Our differential diagnosis included: 1) systemic connective tissue
the four limbs. Two technique exist to eliminate fat interference: T2 weighted disease with hematologic involvement (i.e. SLE); 2) lymphoproliferative
images with fat suppression or short tau inversion recovery. Edematous areas disorder with splenic involvement (i.e. splenic marginal zone lymphoma,
are hyperintense in T2 weighted images. The first case is a 51-year-old Cauca- Castleman’s disease, ecc…); 3) myeloproliferative disorder (i.e. myelofibro-
sian woman, with diagnosis of PM in 2008. She was treated with prednisone sis); 4) hemophagocytic lymphohistiocytosis; 5) adult-onset Autoimmune
(1 mg/kg/day for 4-6 weeks and then slowly tapered) and 20% subcutaneous Lymphoproliferative Syndrome (ALPS). Work-up:The hypothesis of SLE
immunoglobulin (SCIg, at 0.1–0.2 g/kg, once a week) and after one year she was unlikely since ANA, anti-ENA and nDNA-antibodies were negative. A
achieved remission. However, serum CPK levels remained persistently eleva- repeat CT scan confirmed the findings of diffuse lymphadenopathies and
ted, even if the muscular strength, evaluated with the MRC modified score, marked splenomegaly (17 cm). Further blood tests showed normal triglyce-
was normal (MRC 88/88). MRI showed edema of proximal muscles (rotator rides level, raised serum beta2microglobulin, absence of BCR/ABL and
cuff, bilateral proximal portions of triceps, gluteus maximus and quadriceps). JAK2 mutation, elevated serum IL-10 levels (29.5 pg/ml, n.v. up to 9.1) and
After about one year physical examination revealed a compromised muscu- the presence of higher levels of Double Negative T cells (DNT, 7.4% of total
lar strength with a value of MRC of 78/88 with marked hyposthenia of qua- CD3+ cells) on peripheral blood lymphocyte phenotyping. The findings
driceps. In the second case, a 54-year-old-man, PM was diagnosed in 2004. were suggestive of ALPS and a serum specimen was sent to another labora-
He was treated with prednisone and 20%SCIg (as above), and he obtained tory for further testing. Nevertheless, while waiting for the results, a bone
remission after one year with a maintaining low prednisone dose. Even in marrow biopsy was performed and the patient was referred for splenectomy
this case, despite a good recovery with a normal MRC score, CPK levels were since we could not exclude a lymphoproliferative disorder.
persistently increased (800 U/l). MRI did not identify edematous areas. After Discussion: After surgery, the patient was well with a minimal dose of pre-
one year he is still in clinical and functional remission. Results: In these cases dnisone and hemolytic anemia and thrombocytopenia did not recur. The
we found a discrepancy between MRI findings and disease activity evaluated histopathological examination of bone marrow and spleen did not reveal
by MRC score and CPK serum levels. In particular, these two patients with anything abnormal. One month after discharge the diagnosis of adult-on-
clinical remission and persistently elevated CPK levels exhibited different pro- set Autoimmune Lymphoproliferative Syndrome was confirmed with the
gnosis with reactivation of the disease in the first case, in which MRI revea- demonstration of higher serum levels of DNT cells with abnormal resi-
led edema, and stable remission in the second one, in which MRI was totally stance to Fas-induced apoptosis.
negative. In these cases MRI could have an important role in identifying those Conclusion: ALPS is an uncommon disease occurring most commonly in
patients who are at risk to relapse. children, though it may rarely present in the adulthood. It is often misdia-
Conclusion: These preliminary data open new interesting perspectives in gnosed due to variable phenotypic expressions and the overlap of symptoms
the use of MRI in inflammatory idiopathic myopathies. Despite the cost of with many other immunological and hematological disorders. Our patient
this technique and the time employed to perform the exam, MRI is useful to was exceptionally old at diagnosis, but there was a diagnostic delay of almost
identify patients who are going to relapse and to prevent it with appropriate ten years. This case highlights the importance of a systematic differential
treatment. However, more data are necessary to define the use of MRI in these diagnosis, especially when facing rare diseases and therapeutic impasses.
patients.
87
49. A WEIRD CASE OF LIVER CIRRHOSIS bilateral upper and middle lobe consolidations, bilateral reticular-nodular
thickening of the interstitium with ground glass opacities and diffuse cal-
Vaccari D., Vegetti A., Scarlini S., Pietrangelo A., Ventura P. cified pleural plaques. At entry, the patient was mildly febrile with fatigue,
Unit of Internal Medicine 2, Dept. of Medical and Surgical Science for tachypnea and productive cough. Physical examination was significant for
Children and Adults, Policlinico hospital of Modena, University of Modena inspiratory bilateral basal crackles and expiratory rhonchi. Labs showed Hb
and Reggio Emilia; Italy 13 g/dL, WBC 16990/uL, Neu 8360/uL, lymphocytes 8140/uL, CD4/CD8
ratio 0.2 (1-2.5), NK lymphocytes 4.9 (5-15), B lymphocytes 1.3(5-15), C-re-
A 34-year-old woman was admitted to our unit due to new-onset ascites active protein 2.8 mg/dl, AST 0.8xULN, ALT 0.6xULN, bilirubin 0.3 mg/dL
together with hepatomegaly and slight splenomegaly. Her medical history (dir 0.1), creatinine 0.9 mg/dl, IgG 209 mg/dl, IgA 16 mg/dl, IgM <21 mg/dl.
was notable for psoriatic arthritis, occasionally treated with NSAIDs; she The 12-lead electrocardiogram revealed sinus rhythm and left anterior fasci-
was an active smoker and denied alcohol abuse. Physical examination of the cular block. Severe pulmonary hypertension without left ventricular disfun-
patient showed slight jaundice, bradycardia (HR 50 bpm), severe distension of ction (LVEF 55%) was found on transthoracic echocardiography. Resting
jugular veins and abdominal expansion, with very significant hepatomegaly. arterial blood gas examination showed hypoxemic hypocapnic respiratory
Bedside ultrasound examination revealed a severely enlarged liver, with dila- failure requiring oxygen supplementation with Venturi mask (FiO2 50%);
tated, non-collapsible inferior vena cava, a moderate amount of ascites, a sli- spirometry revealed a restrictive pattern and a moderate reduction in dif-
ghtly enlarged spleen, and severe right-sided heart enlargement with massive fusing capacity for carbon monoxide (DLCO). Diagnostic high-resolu-
regurgitation of tricuspid valve and slightly impairment of the ejection tion computed tomography (HRCT) of the lungs showed bilateral patchy
fraction (45-50%). A standard 12-lead ECG showed a junctional rhythm with ground glass opacities at upper and middle lobes, with signs of pneumo-
narrow, low-voltage QRS complexes; a 1-month-earlier ECG showed a nor- nia consolidations, parenchymal distorsions, bronchiectasis and calcified
mal-rate atrial fibrillation. Blood tests showed slightly prolonged PT (INR 1.4) pleural plaques compatible with pneumoconiosis. Sputum culture grew
and mild elevation of serum bilirubin and gamma-GT. Viral (HBV, HCV) Stenotrophomonas malthophilia, and antibiotic therapy with cotrimoxa-
and autoimmune markers, as well iron blood tests and ceruloplasmin were all zole 80/400 mg, 4 vials iv q6h, and methylprednisolone 40 mg iv q12h was
within the normal range. A liver biopsy was performed, showing peri-portal added to clarithromycin started just before hospitalization. The patient also
fibrosis, sinusoidal dilatation and signs of cholestasis, with no signs referable received iv polyclonal immunoglobulins and empirical antifungal therapy
to amyloidosis or abnormal iron/copper storage; histology showed features with anidulafungin to cover for possible fungi, including Pneumocystis
at the interface between primary sclerosing cholangitis or primary biliary jiroveci pneumonia. Candida krusei was also isolated from oropharyngeal
cholangitis or overlap syndrome with autoimmune hepatitis, nevertheless swab and treated with topical myconazole gel. All blood and urine cultures
all autoantibodies tested (ASMA, ANCA, AMA and LKM) were negative. A were negative as well as Pneumococcal and Legionella urinary antigen tests,
more accurate family history showed that the patient’s father died for liver polymerase chain reaction (PCR) tests on nasopharyngeal swab and serum
cirrhosis and congestive heart disease with severe dilatative cardiopathy fungal antigens. Clinical conditions and laboratory tests improved after 12
before age 40, and that her cousin was affected by Emery-Dreifuss muscular days of antimicrobial therapy, when the antifungal agent was discontinued.
dystrophy. Genetic testing for the LMNA gene associated with the EDMD However, due to an extension of pulmonary consolidations to lower lobes
revealed the same mutation previously identified in the patient’s cousin. Con- on follow up CT images, fibrobronchoscopy was performed and XDR Kle-
sidering the cardiac manifestations of the patient, consistent with picture sbiella pneumoniae (10000 ufc/ml) isolated from bronchoalveolar lavage
found in EDMD, an in-depth cardiologic workup was performed, including (BAL) fluid. Deemed as de novo airway colonization, it did not require any
heart MRI (which showed reduced biventricular ejection fraction and areas of treatment. Tuberculin skin test, Quantiferon-TB gold, TB PCR and culture
non-ischemic myocardial fibrosis) and heart catheterization (which showed on BAL fluid were all negative. Furthermore, the patient was started on gan-
mild pulmonary artery hypertension and impaired left ventricular filling, due ciclovir 300 mg iv q12h because of a significant reactivation of Cytomega-
to the severe dilation of right ventricle). The junctional bradycardia present lovirus (CMV-DNA 52000 gEq/mL). CT imaging 6 weeks after admission
in the ECG and the inherent risk of sudden cardiac death due to ventricular showed a slight improvement of pulmonary consolidations with persistent
fibrillation associated with the EDMD suggested the placement of a biventri- bilateral ground glass attenuation mainly at upper and middle lobes. Blood
cular pacemaker with ICD, resulting in improved EF (70%) and synchrone gas analysis was also markedly improved.
HR (70 bpm) after placement. At the moment it is yet unclear whether the Conclusions: History, physical examination, laboratory and radiologic tests
liver involvement is simply due to increased central venous pressure (i.e. are very helpful when evaluating a patient with suspected infectious disease,
“cardiac cirrhosis”) or it has a different etiology. Hepatic vein catheterization such as the one described here. However, the mainstays of infection dia-
showed veno-venous shunts and mild portal hypertension; the results of the gnosis include culture of tissues or fluids, that should be ideally collected
liver biopsy are not entirely compatible with cardiac cirrhosis, expecially the before the administration of antimicrobial therapy, to allow identification
finding of peri-portal fibrosis. As of now, this clinical case is not closed yet. of the etiologic agent and determination of antimicrobial resistance profile.
The patient is in the process of being enlisted for heart transplantation due to Although cultures are crucial for diagnosis, determining if their results
the progressive nature of the heart disease; whether she will be also subjected represent contamination rather than true infection could avoid unnecessary
to liver transplantation depends on further liver workup, including an addi- treatments and testings, as in our case. Since our patient underwent immu-
tional liver biopsy. ne-suppressive treatments, he could reactivate multiple pathogens, inclu-
ding bacteria, viruses and fungi. It was critical to assess his immune status
and give iv immunoglobulin replacement. Iatrogenic immune defects could
50. A COMPLICATED CASE OF INTERSTITIAL have superimpose, due to the prolonged use of steroids for a presumed
PNEUMONIA IN AN IMMUNOCOMPROMISED PATIENT autoimmune interstitial lung disease or Pneumocystis jiroveci pneumonia.
CMV de novo infection or reactivation in our immunocompromised host
Vitrone M. 1, Mollica M. 2, Grella E. 2, Durante Mangoni E. 1 possibly resulted in an interstitial CMV pneumonia, that had to be diffe-
1
Internal Medicine, University of Campania Luigi Vanvitelli, Unit of rentiated from a number of other infectious and noninfectious conditions.
Infectious and Transplant Medicine, Monaldi Hospital, Naples, Italy; Finally, the history of previous RTX-exposure suggested the possibility of a
2
Pneumology, University of Campania Luigi Vanvitelli, Unit of Pneumology, RTX-associated interstitial lung disease, that can appear at high-resolution
Monaldi Hospital, Naples, Italy thoracic CT scan as diffuse bilateral ground-glass opacities.
A 74 year old man came to our observation in March 2017 due to recent
fever (up to 39.5°C), productive cough with purulent sputum, dyspnea and 52. DIARRHEA AND PERSISTENT OMPHALITIS IN
acute type I respiratory failure. Three years before admission he had been ADULT WOMAN
diagnosed with large B-cell non-Hodgkin lymphoma and treated with che-
motherapy, splenectomy, and immunotherapy with rituximab (RTX) for 2 Mattioli M., Benfaremo D., Biondi L., Cardinali M., Fraticelli P., Pomponio
years (last cycle 4 months before presentation). Before starting rituximab, G., Gabrielli A.
he had received prophylactic antiviral therapy with lamivudine 100 mg/day, Clinica Medica, Università Politecnica delle Marche – Ospedali Riuniti,
because of prior HBV infection. The patient mentioned a previous exposure Ancona
to asbestos; he denied use of illicit drugs or cigarette smoking. He complai-
ned of recurrent productive cough, fever (38-38.5°C) and dyspnea during Clinical scenario: A 64-year-old woman came to the Emergency Depart-
the prior three months that had only partially improved with several antibio- ment in March 2017 (for the fourth time during the last three months)
tic courses, including beta lactams (penicillins and carbapenems) and fluo- reporting worsening abdominal pain, started almost 6 months ago, associa-
roquinolones. In February 2017, a chest CT scan without iv contrast showed ted to nausea and vomiting; during the last two weeks, watery diarrhea (3- 4
88
evacuations/day) developed.Blood tests showed only moderate hypokale- developed progressive fatigue, weight loss and diarrhea. In June 2016 there
mia (2.8 mEq/l) already present during the previous hospital admissions. was another hospital admission for severe hypokalemia. In October 2016
An abdominal ultrasound first, and subsequently an abdominal contrast the patient was admitted in Infectious Disease ward for a relapse of the psoas
enhanced computed tomography, were performed and showed: - wall thi- abscess (a microbiological colture of the drainage resulted positive for Gram
ckening and conglomeration of many ileum loops; - hypodense nodular negative bacteria). Moreover a Clostridium Difficile infection was diagno-
formation with rough calcification in the context of approximately 3 cm, sed and course of oral vancomycin was administered to the patient. A MRN
apparently adhering and partially retraining the ileum wall that is locally of abdomen showed a slight increase in the pancreatic mass dimensions (47
collapsed and upstream dilated with air fluid levels; - nodular “cottony” mm vs 32 mm), with atrophy of the body and the tail and without biliary
lesions characterized by poorly enhancement of the maximum diameter dilatation or focal liver disease. Oral pancreatic enzymes were started. Two
of 1.5 cm, located in mesogastric region in correspondence to the greater months after discharge, because of persistency of diarrhea, a colonscopy
omentum; - small umbilical hernia with liquid content, which reached the was performed, a diagnosis of microscopic colitis was made on the basis of
skin plane; - slim wet float in Douglas. The patient was admitted to our ward histological examination and budesonide was started. At Internal Medicine
for further investigations. In-hospital: In her medical history were reported ward admission the patient was in severe compromised conditions, with
hypertension and M-GUS, diagnosed in 2008. From November 2016, she persistent severe watery diarrhea; BP was 80/50 mmHg. Severe hypokale-
reported the presence of erythema, pruritus and yellow-brown secretions of mia and bicarbonate loss were difficult to manage. Because of the history,
the umbilical scar, interpreted as omphalitis and treated with topic therapy a WDHA (Watery Diarrhea, Hypokalemia Achlorhydria) syndrome was
but still present. From the onset of the gastrointestinal symptoms, she suspected and a 111In-Octreotide scan was performed, with confirmation
underwent a gastroscopy and a colonoscopy without detection of pathologic of radionuclide captation in the pancreatic mass. VIP (Vasoactive Intestinal
features. The physical examinations confirmed the evocation of epigastric Polypeptide) level was measured and resulted > 120 pmol/L. Octreotide was
and right abdominal pain upon palpation without signs of peritonism and started with prompt resolution of symptoms, progressive amelioration of
bright bowel sounds. Routine laboratory tests confirmed hypokalemia and general conditions and discharge from the hospital with scheduled surgical
there was also a mild neutropenia; liver and kidney function were within intervention.
normal range and there were no systemic signs of inflammation.
Diagnostic work-up: The clinical evidence of intermittent and partial
small bowel obstruction and the radiological signs of ileum conglomera- 54. A CASE OF “PULMONARY” DIARRHEA
tion, rough calcifications and diffuse lesions of the greater omentum, was
suspect for Sclerosing Encapsulating Peritonitis (SEP), also called Abdo- Grimaldi L. 1, Noviello M. 1, Bonfrate L. 1,2, Belfiore A. 1,
minal Cocoon. This disease is a rare form of peritoneal inflammation that Buonamico P. 1, Minerva F. 1, Palmieri V.O. 1, Pugliese S. 1, Portincasa P. 1
form a membrane covering and involving the underlying organs such as 1
Clinica Medica “A. Murri”, Dept. of Biomedical Sciences and Human
small bowel, colon or ovaries. The acquired form is etiologically divided into Oncology, University of Bari Medical School; 2 Division of Internal Medicine,
idiopathic and secondary SEP; the last is associated to several conditions, Hospital “Miulli”, Acquaviva delle Fonti, Bari
but more frequently with peritoneal dialysis, abdominal tuberculosis, drugs
(e.g. chemotherapy), autoimmune diseases, endometriosis or malignancy. A 87-year-old woman presented to ED with a 10 days history of anorexia,
In order to evaluate for secondary SEP we performed: - Tubercolin skin fever (38.5°C), dyspnea, cough, mild abdominal discomfort and loose stools.
test: negative; - Complete immune serology: negative; - Neoplastic markers: History taking was rather difficult: she had hypertension, T2DM, coronary
CEA, CA 19.9, CA 125, NSE, gastrin, chromogranin A: all in range; - Chest artery disease, chronic obstructive pulmonary disease (COPD), and gastro-
CT scan without evidence of tuberculous exposure or neoplasms. To obtain esophageal reflux disease. On physical examination, she was hypotensive
a histological diagnosis an exploratory laparoscopy was performed: the (85/50 mm Hg), dehydrated, tachycardic (96 beats/min) but eupnoic (20
definitive diagnosis was mucinous adenocarcinoma of the appendix and breaths/min). A complete blood count revealed leucocytosis (20.000/uL),
inflammatory appendicular wall with peritoneal nodules; omphalitis was elevated creatinine (1, 7 md/dL), and increased C-Reactive Protein (200
due to local invasion of neoplasm. mg/L). Intravenous fluids were initiated, a chest x-ray showed a consoli-
Discussion: Appendiceal neoplasms are rare, since they account for <5% dation the left lower lobe suggesting pneumonia. Following admission to
of intestinal tumors. The recently defined appendiceal crypt cell adeno- Internal Medicine ward, sputum was cultured and was positive for Kleb-
carcinoma (ex Goblet cell carcinoid) is an even rarer appendiceal tumor siella pneumoniae infection. Antibiotic therapy was started (ceftriaxone 2
showing both mucinous and neuroendocrine differentiation. It is a highly gr/die and levofloxacin 500 mg/die). Respiratory symptoms improved after
aggressive tumor with a tendency for spread along peritoneal surfaces, and 5 days but worsened from day 6 (i.e., hypovolemia, dehydration, lower
limited hematogenous metastasis. In addition to their trademark histomor- abdominal discomfort, and watery diarrhea 10/die). Further information,
phology, these tumors also have important clinical associations. Females collected from the family revealed that patient had been admitted to hospi-
are more often affected than males and patients <55 years appeared to have tals five more times in the previous 2 years for “recurrent bronchitis” treated
more aggressive disease. They tend to be more aggressive than ordinary car- with several regimens of antibiotics. Moreover, the last hospitalization had
cinoids (well-differentiated neuroendocrine tumors), frequently spreading been complicated by C. Difficile-related diarrhea, which was managed with
in a transcoelomic fashion sometimes bypassing local lymph nodes. The cli- vancomycin. Thus, we scheduled a test for C. difficile toxins and antigen
nical manifestations are often subtle, ranging from nonspecific symptoms to which were positive. A pancolonoscopy was planned and showed pseudo-
very atypical presentations, as in developing SEP, like in our patient. membranes. Treatment with the macrocyclic fidaxomicin (200 mg cp b.i.d
for 10 days) was started leading to rapid resolution of symptoms and fre-
quency of diarrhea.In this case, the initial predominant respiratory picture
53. SEVERE DIARRHEA WITH METABOLIC ACIDOSIS, masked the concomitant C. Difficile infection. However, the patient had
HYPERCALCEMIA AND A PANCREATIC MASS several risk factors for C. Difficile infection (i.e., antibiotic use, age, gastric
acid suppression, a previous diagnosis of C. Difficile infection, and hospi-
Falcetta A., Remo M., Testa E., Leccardi S., Bracco C., Silvestri A., Serraino talization). C. Difficile is a Gram-positive, anaerobic, spore-forming, toxin
C., Fenoglio L.M. producing bacteria, which is responsible of antibiotic-associated colitis. C.
Divisione di Medicina Interna, A.O. S. Croce e Carle, Cuneo Difficile is a major enteric pathogen and the most frequently recorded noso-
comial pathogen. C. Difficile colonizes the large intestine and releases two
A 68 years old man presented to the ED in December 2016 for hypotension, toxins leading to mucosal inflammation and damage. Antibiotics, advanced
severe diarrhea, hypokalemia, hypercalcemia, acute renal failure and meta- age, gastrointestinal surgery, immunosppression and inflammatory bowel
bolic acidosis with normal anion gap.He was admitted to the Emergency disease represent risk factors and increase the susceptibility. The clinical
Medicine ward and transferred two days later to the Internal Medicine ward manifestation ranges from an asymptomatic carriage to fulminant colitis
after hemodynamic stabilization with crystalloid and bicarbonate infusion. with toxic megacolon. The diagnosis of C. Difficile includes laboratory stool
He has been a wine abuser in the past, had an history of chronic obstructive test for toxins, radiographic imaging of abdomen and pelvis for patients
pulmonary disease and underwent a Billroth II gastrojejunostomy 15 years with severe illness, and endoscopy. Initial therapy includes metronidazole
before. In August 2015 he was admitted to the hospital for intestinal suboc- in non severe C. Difficile infection. In severe cases, vancomycin is recom-
clusion, an ileo-psoas abscess and a 3-cm mass lesion in the pancreatic head: mended. Fidaxomicin is a reasonable choice in patients who cannot tolerate
at intervention abdominal adhesions were found and a biopsy of the pancre- vancomycin or without benefit with previous treatment with vancomycin or
atic mass showed normal pancreatic tissue. In March 2016 the patient was with recurrence of infection. Fidaxomicin was approved in 2011 by the US
readmitted in surgical ward for abdominal abscess and underwent percu- FDA for treatment of C. Difficile and is available also in Italy, starting from
taneous drainage and antibiotic therapy. After home discharge the patients 2013. Recent data have shown that fidaxomicin may be superior in preven-
89
ting recurrence of C. Difficile infection. In this case, the newer antibiotic prevalence of approximately 40-60% and is a major risk factor for morbi-
fidaxomicin was highly effective. The high costs of fidaxomicin (euro 1, 670 dity and mortality. In up to one third of poly-dermatomyositis patients the
for a 10-day treatment) represent a relative limitation to the use of this drug. anti-synthetase syndrome will develop, characterized by dermatomyositis,
Finally, C. Difficile represents a common occurence in the clinical setting of interstitial lung disease, arthritis, mechanic hands, Raynaud phenomenon
internal medicine. and presence of circulating anti-transfer RNA synthetase antibodies (eg.
Anti-Jo1). Apart from dermatomyositis, interstitial lung disease is the most
frequent and dominant organ involvement in this syndrome with increa-
55. DERMATOMYOSITIS-RELATED INTERSTITIAL sed morbidity and mortality. This case may be considered an atypical form
LUNG DISEASE WITH ACUTE RESPIRATORY DISTRESS of anti-synthetase syndrome and offers the opportunity to discuss epide-
SYNDROME AND SUCCESSFULLY TREATED WITH miology data, predictive markers, and pathogenic pathway of this rare but
RITUXIMAB AND MYCOPHENOLATE MOFETIL. A CASE severe complication of polymiosisits/dermatomyositis, in relation to the
REPORT currently available therapeutic options.
De Luca P. 1, Solimando A.G. 1, Cirulli A. 1, Grasso S. 2, Bruno F. 2, Vacca A.

1
, Prete M. 1 56. DYSPNEA: A SYMPTOM, SEVERAL DISEASES
1
Department of Biomedical Sciences and Human Oncology, Section of Inter-
nal Medicine “G. Baccelli”, University of Bari Medical School, Bari, Italy. 2 Donnarumma E., Torri M., Cecioni I., Berni A., Tozzetti C.,
Department of Emergency and Organ Transplant, Section of Anesthesia and Poggesi L.
Intensive Care.University of Bari Medical School, Bari, Italy Medicina per la complessità assistenziale 3, AOU Careggi, Università degli
Studi di Firenze, Firenze
Here we present the case of a 42-year old man, affected by dermatomyositis,
who developed an acute respiratory distress syndrome as complication of a Woman, 42 years old presented to our hospital with slight dyspnea, chest
severe interstitial lung disease, which is clinically indistinguishable from an pain and orthopnea (symptomatology started 5-6 months earlier and pro-
anti-synthetase syndrome, and was successfully treated with mycophenolate gressively increased). Her past medical history was negative. Her phisical
mofetil and rituximab.The patient who had a history of cigarette smoking exam and arterial blood gas revealed severe hypoxia. Blood exams showed
and nichel allergy, referred to the Internal Medicine Department for fatigue, anemia, severe trombocitopenia and alterated coagulation tests (INR 2,
proximal and bilateral muscular weakness, mild periorbital edema with fibrinogen 31, aptt 29). A chest X-ray and computed tomography scan
erythema initially on supraorbital region, and then to the forehead and revealed pleural and peritoneal effusion with diffuse micronodular and
temporal region. He suffered also of non-itchy erythematosus patchy scaly segmentary pulmonary thromboembolism with thrombosis in right ven-
lesion on bilateral elbows, upper of chest and metacarpophalangeal joints tricular. In emergency room she was treated with pigtail catheter (5 liter of
with periungual erythema, hyperkeratosis on the palms and poliarthral- blood fluid drained), oxygen, blood and plasma transfusion and heparin
gia to the hands and knees, bilaterally. The diagnosis of dermatomyositis in suspicion of disseminated intravascular coagulation. Pleuric liquid was
was formulated on the basis of the clinical symptoms, laboratory investi- examined. In the second day of hospitalization, her conditions deteriorated
gations and after performing chest TC scan, skin/muscle and lung biopsy. with severe dyspnea and hypoxia (need for noninvasive ventilation), incre-
In October 2016, he started intravenous immunoglobulin (IVIG) at the ased of pleural effusion (with insertion a second chest tube) and laboratory
dosage of 0, 4g/kg (total dose 90 g), corticosteroids (methylprednisolone findings revealed: decreased haptoglobin levels, increased ldh, schistocytes
60 mg daily) and immunosuppressive drugs with methotrexate (15 mg once on peripheral smear and Coombs’ test negative. Adamts 13 activity was
a weeks) and cyclosporine (100 mg daily) that were immediately replaced normal. Paraneoplastic TTP was diagnosed. Initially daily plasmaferesis
by ciclophosphamide (50 mg daily) for clinical deterioration and iatroge- was ineffective, instead after 23 days of plasma transfusion and corticoste-
nic hypertransaminasemia. In January 2017, he made a new admission to roid therapy, there was significant rise in platelet counts. Pleuric effusion
Internal Medicine due to clinical worsening with fever, progressive dyspnea citology showed undifferentiated adenocarcinoma probably pulmonary
at rest. For the occurrence of severe respiratory failure with the evidence of because other exams (stomach, skin, ovary, uterus, thyroid and breast) were
“left pulmonary embolism, massive diffuse infiltration of both lung fields, negative. After one month of therapy, laboratory tests and symptoms were
compatible with a framework of ARDS” (Figure 1:panel A) the patient was progressively better, oxygen therapy and plasma transfusion were stopped,
transferred to the Intensive Care Unit; he was supported with high-flow she continued fondaparinux (segmentary thromboembolism and ventricu-
oxygen ventilation by nasal cannula (OPTIFLOW) to 40-50%, enoxaparin lar thrombosis) and could start chemiotherapy.
8, 000 IU twice daily and 100 mg daily of Methylprednisolone. Laboratory
tests showed: increased C-Reactive Protein and erythrocyte sedimentation
rate (59.8 mg/L and 65 mm/1h, respectively). D-Dimer test up to 5745; 57. “HIDE-AND-SEEK” SARCOIDOSIS: PULMONARY
ANA positivity 1:80 pattern speckled, with anti-Ro52, Anti SS-B and Anti- FIBROSIS MASKED BY CIANOTIC HEART DISEASE –
SSA positivity.Microbiological evaluation provided no evidence for bacte- CASE REPORT
rial, fungal or viral infection. Based on these data a diagnosis of acute inter-
stitial lung disease was made and the patient started an immunosuppressive Sgariglia R., Sanesi L., Alessio S., Giuliani M., Fioretti M., Pucci G.
therapy with mycophenolate mofetil 1000 mg twice daily, Rituximab 300 mg Department of Medicine, University of Perugia – Unit of Internal Medicine, S.
weekly for four times (total dose1200 mg). He was discharged home 6 weeks Maria Hospital, Terni, Italy
later with tapering of metilprednisolone and mycophenolate mofetil 1000
mg twice daily. Follow up chest CT after two months showed an improve- Introduction: Pulmonary hypertension (PH) is characterized by pulmo-
ment of pulmonary features (Figure 1: panel B). Interstitial lung disease is nary artery medium pressure ≥25 mmHg at rest. According to new gui-
the most common extra-muscular target in poly-dermatomyositis with a delines, it could be due to a primary increase in the pulmonary arterial
system (GROUP1) or secondary to congenital and acquired heart diseases
(GROUP2), lung diseases (GROUP3), pulmonary artery thromboembolism
(GROUP4) and others (GROUP5), including hematological, systemic and
metabolic disorders.
Case Report: A 60-year-old woman affected by Eisenmenger Syndrome
(ES) due to ventricular septal defect with right-to-left shunting, presented
palpable purpura to lower limbs and worsening of dyspnea; she also referred
episodes of hemoptysis and chest pain. Conjunctival injection was obser-
ved at the examination and attributed to sildenafil-induced ocular vasodi-
lation. She had also acrocyanosis and digital clubbing; pulse oximetry was
74%. BP was 145/80 mmHg; HR 90 bpm; body temperature 36°C. At the
cardiac auscultation, a fixed split S2 was heard; at chest auscultation, sym-
metric bilateral cracklings were present. The ECG showed sinus rhythm,
pulmonary P wave, right axial deviation and complete right bundle branch
block. Blood test showed severe polyglobulia (Hb 22 g/dL), thrombocytope-
nia (PTL 93.000/mmc) and hypercalcemia (11 mg/dL). ESR, CRP, liver and
kidney functions were all normal. In suspicion of systemic vasculitis or col-
90
lagen disease, an autoimmune assay was detected. Results showed c-ANCA Medicina Sperimentale e Clinica; 2 Azienda Ospedaliero-Universitaria Mater
and ANA positivity. A chest HRTC revealed bilateral calcified hilum lym- Domini di Catanzaro; 3 Università degli Studi Magna Græcia di Catanzaro –
phadenopathies and peri-lymphatic micronodules turning into interstitial Dipartimento di Scienze Mediche e Chirurgiche
and subpleural thickenings, suggestive of sarcoidosis. Neither BAL nor lung 57-year old woman, teacher.
biopsy could be performed to confirm the diagnosis because of her bad cli- CHIEF COMPLIANT Shortness of breath
nical conditions. The patient refused additional diagnostic investigation and HISTORY OF PRESENT ILLNESS New-onset (about 1 month ago) of
steroid therapy and voluntarily discharged herself from hospital. fatigue and apathy and of abrupt dyspnea while at rest. She went to the
Discussion and Conclusion: In the present clinical case, a 60-year-old Emergency Department where she underwent chest X-ray and blood count
woman with long-lasting unrecognized sarcoidosis, developed severe pulmo- (referred normal). In suspicion of a panic attack, the patient was referred to
nary fibrosis. We could hypothesize that the presence of ES probably masked a psychiatrist, who diagnosed her with mixed mood disorder (anxious-de-
for years the typical clinical features of sarcoidosis. In fact, hemoptysis, as pressive) and prescribed bromazepam and vortioxetin (that she never took).
well as dyspnea, digital clubbing and cracklings are both observable in ES Two weeks later the patient refers the appearance of bilateral inguinal tender
and sarcoidosis. Conjunctival injection was judged as iatrogenic disease (due lymphadenomegaly, night sweats, and weight loss. Patient was referred to
to sildenafil therapy); however, an alternative diagnosis of granulomatous our Internal Medicine Department for evaluation and treatment.
uveitis, which is very common in sarcoidosis, was not taken into considered. PAST MEDICAL, SOCIAL AND FAMILY HISTORY: Nothing to report
PH caused by different, and sometimes overlapping, etiologies may implicate MEDICATIONS None.
delays in diagnosis and therapy leading to severe complications. PHYSICAL EXMINATION Shortness of breath, heart palpitations; hard
to get a breath in, shortness of breath, no cough; changes in mood (she
feel anxious and depressed); teneder bilateral inguinal lymphadenome-
58. WHEN MEDICAL HISTORY MAKES THE DIFFERENCE galy. Temp: 36.1°C Pulse: 104 bpm BP: 104/60 mmHg RR: 32/min O2:
IN A DIFFICULT DIAGNOSIS: 91% RA Laboratory tests revealed neutrophilia (85.9%) and lymphopenia
CHURG-STRAUSS SYNDROME (6.3%); fibrinogen 443 mg/dl, hsCRP 71.60 mg/l, AST 64 UI/l, iron 23 mcg/
dl, LDH 1150 UI/l; beta-2 microglobulin 5.03 mg/L, ferritin 248.3 ng/ml,
Sanesi L., Alessio S., Sgariglia R., Giuliani M., Fioretti M., Pucci G. albumin 52.5%, alfa 1 8.8%, alfa 2 14%. Diagnostic examinations ECG: sinus
Department of Medicine, University of Perugia – Unit of Internal Medicine, tachycardia with HR 108 bpm. Echocardiogram: (...) Ostium secundum
“S. Maria” Hospital, Terni, Italy inter-atrial defect, non hemodynamically significant. (...) EF 60% Simpson.
(...) Small pericardial effusion. Thickened pericardial tissues. On the basis
Introduction: Eosinophilic granulomatosis with polyangiitis (EGPA) is a of the signs and symptoms (worsening dyspnea), and of laboratory and dia-
rare systemic vasculitis with less than 2 people in a million population being gnostic examinations, we requested a contrast total body CT, in suspicion of
diagnosed each year, predominantly affecting small and medium sized a lymphoma with consequent mediastinal involvement. The CT confirmed
vessels in person with a positive history of airway allergic hypersensitivity. the presence of “many enlarged lymph nodes in all the cervical stations. (...)
Case Report: A 70 years-old-man came to the Emergency Department pre- Mild right basal pleural effusion. Many confluent enlarged lymph nodes in
senting dyspnea associated with myalgias and paresthesias (numbless tin- all the mediastinal lymph node stations (max diameter 7 cm). (...) Severely
gling) involving right arm, progressive asthenia, fever (< 38°C) and petechiae enlarged spleen. (...) Many enlarged confluent abdominal, iliac, and ingui-
at lower limbs. He had a past medical history of “mild bronchial asthma” nal lymph nodes. (...)” Patient then underwent excisional biopsy of an axil-
treated with formoterol/beclomethasone (spirometry substantially normal, lary lymph node, which histopathological examination documented Lymph
with a negative reversibility test). Physical examination revealed BP 160/90 node localization of diffuse large B-cell lymphoma. Patient was then refer-
mmHg; HR 105 bpm regular, oxygen saturation, respiratory rate and body red to a hematologist to provide the care needed.
temperature all normal; at chest examination, there was evidence of bibasilar
dullness on percussion with a relative absence of sound over the same region;
diffuse tenderness and muscle weakness of right arm. To evaluate pulmonary 60. ACUTE LUPUS PNEUMONIA: A STRANGE DYSPNEA
involvement he underwent CT chest-abdomen that showed bibasilar pleural CASE REPORT
effusion, pericardial and peritoneal effusion suggestive for polyserositis. The
ECG documented sinus rhythm and non-specific repolarization abnorma- Colombo B.M., Ricciardi E., Dallegri F.
lities. An ultrasound of the abdomen was performed showing peri-hepatic Ospedale Policlinico San Martino, Genoa, Italy
fluid. Brain CT and chest radiograph were normal. Initial laboratory asses-
sment showed leukocytosis with relevant eosinophilia (E=55%); normocytic Introduction: Respiratory system is frequently involved in systemic
anemia (Hb 10.2 g/dl); CRP 8.2 mg/dl; procalcitonin was negative; urinalysis lupus erythematosus, and pulmonary manifestations of this autoim-
and 24 h proteinuria were negative with preserved urine output. Stool sample mune disease can be very different. The most common disorders are
for parasites exam and tumor markers were negative. Nerve conduction pleuritis and lung infections. In this case report we describe an adult
studies and electromyography of four limbs showed axonal polyneuropathy male, affected by systemic lupus erythematosus under immunosuppres-
(right ulnar and median). A working diagnosis of vasculitis was advanced, sor therapy for years, presented with acute pneumonia.
more likely Churg-Strauss syndrome. Autoimmune panel was positive for Case Report: A 73-year-old male patient affected by systemic lupus
p-ANCA anti-myeloperoxidase (MPO 100 U/ml). With reference to Ameri- erythematosus presented with persistent fever, especially in the evening,
can College of Rheumatology criteria, the concomitance of blood eosinophi- cough, dyspnea and pleuritic pain for a week, not responsive to the anti-
lia, ANCA positivity, nasal polyposis, history of wheezing, multiple mono- biotic therapy given at home. Patient’s medical history included pericar-
neuritis, a final diagnosis of eosinophilic granulomatosis with polyangitis was ditis, Hashimoto’s thyroiditis, bowel’s diverticulosis, chronic glaucoma
made. Methotrexate at a dose of 15 mg/weekly was administered in addition and systemic lupus erythematosus, for which the patient submitted at
to intravenous immunoglobulins (400 mg/kg/day for 5 days) and prednisone regular ambulatory follow-up. On presentation at our department, he
80 mg/day, followed by rapid improvement of patient conditions, pericardial, had dry cough, pleuritic pain at the left back side of the thorax and he
pleural, peritoneal effusions and of blood counts. referred fever at home, especially in the evening; he also complained a
Discussion and Conclusion: The clinical features of EGPA typically worsening of pain and edema of the left ankle. Vital signs were good; on
develop in several sequential phases over many years. Initially, in this examination, we only found some crackles at thorax auscultation, at the
patient, dyspnea associated with eosinophilia lead to a diagnosis of asthma, left pulmonary upper side. Moreover the left ankle was swollen, painful
although this was not confirmed by respiratory functional tests. The dia- and red. Laboratory examinations showed neutrophilic leukocyto-
gnosis of EGPA syndrome was suspected after the patient developed more sis, increased C-reactive protein and procalcitonin; other values were
complex set of signs and symptoms including paresthesia, skin lesion, poly- normal. All the blood and urinary coltures or infective disease labo-
serositis, elevated p-ANCA. The recognition of EGPA represents a real chal- ratory tests we collected resulted negative. Contrast chest thorax (CT)
lenge for the clinician because of its wide variety of clinical forms. scan performed in our department detected a pulmonary consolidation
area at the upper left lobe, described as “hepatizzation-like”, with two
minimal pulmonary abscesses and consensual pleural effusion. No pul-
59. A BULKY SYMPTOM monary active lesions were detected on the right side. Subsequently, the
patient submitted at bronchoscopy with bronchoalveolar lavage (BAL);
Perticone M. 1, Caroleo B. 2, Suraci E. 3, Scalise L. 3, Colangelo L. 3, Miceli S. 2, this exam showed bronchial mucous membrane hyperemia and flogosis.
Sciacqua A. 3, Perticone F. 3 BAL was negative for research of main respiratory pathogenes bacteria.
1
Università degli Studi Magna Græcia di Catanzaro – Dipartimento di Collaterally color-doppler ultrasound of lower limbs veins detected a
91
distal deep venous thrombosis (DVT) on the left, in a pattern of lin- A 83-yr-old woman, housewife, no smoker, affected by COPD, permanent
fedema and probably tendinopathy. So we collected a left leg tissues atrial fibrillation treated with NOAC and hypertension, came to our unit for
ultrasound, that retried a voluminous fluid collect, highly corpuscolate, a syncope.She referred a previous dyspnea with abdominal pain occurred 5
with a lots of septums, extended up and down the band muscle, strictly months before, when a tumor related gut occlusion was diagnosed. Radio-
connected to the bone. Also the coltures from this collect were nega- logist described a mass in right iliac fossa appearing as a gut stromal tumor
tive. At first, assuming that it were an infective disease causing the fever, (GIST) associated to a suspected pancreatic intraductal papillary mucinous
the patient was treated with empiric antibiotic therapy; we have chosen tumor (IPMT). At the hospitalization in our ward patient was dyspnoeic,
piperacilline/tazobactam, then we switched to clindamicine and mero- heart rate was 100 bpm and breath rate 40/min. She complains diffuse abdo-
penem. However all the coltures we performed resulted negative, so we minal pain. At electrocardiogram hyperkinetic aritmia was found. Vascular
stopped antibiotic therapy and continued steroids. During the recover congestion was described at thorax X-ray. Contrast enhanced thorac CT
we have seen a progressive improvement of the general conditions of the scan excluded a pulmunary embolism and confirmed vascular congestion
patient, and also an improvement of inflammation markers on labora- according to heart failure. Troponin as well as blood cultures were negative.
tory tests occurred. At the moment of the discharged the patient was in Ultrasound e CT scan of abdomen confirmed pancreatic lesion and two
good general clinical condition, no fever and asymptomatic. Last labo- masses in the last handle of small intestine but the patient refused to have
ratory results before discharge showed a normalization of blood count a mass biopsy. Tachycardia and tachypnea were not responsive to any tre-
cells and C-reactive protein. On the next ambulatory control the patient atment performed (betablocker ß2 selective, digoxin, calcium-antagonist,
was in excellent condition, and control chest CT scan, compared to the steroids and thinners). Hyperpyrexia and cought arise during hospitaliza-
previous one, showed an almost complete radiologic resolution of the tion. Ambulatory Blood Pressure monitoring and 24-hr ECG evaluation
pulmonary pattern. were not conclusive on the tachycardia possible cause. Emogas showed a
Discussion:The clinical case is of a patient presenting fever associated to slight hypoxia with a normal pH e pCO2, as initial COPD gas modifications.
aspecific respiratory manifestations, like dyspnea. Moreover he presen- A new contrast enhanced CT scan was performed: a mild bilateral pleural
ted pain, edema, swallow and functional limitation at left ankle. CT scan effusion associate to a pericardial effusion but no pulmonary infection was
showed a pulmonitis process with consensual pleuric effusion, so we described. At the same time this new CT revealed a dual superior cava vein
thought about differential diagnosis options and we detected for bacte- due to the persistence of the left superior cava vein, never described in the
rial pulmonitis with coltural exams and BAL. Infective disease and pul- patient, with an enlargement of the coronary sinus. This evidence was pos-
monary embolism were substantially ruled out, and the patient impro- sible as a consequence of the contrast infusion in left arm vein (while pre-
ved with steroids. We related these clinical elements to his autoimmune vious were performed always on the right side) that had shown a superior
disease, and we discharged the patient with acute lupus pneumonia, cava venous vascular system filling defect. Saline contrast echocardiogram
fasciitis and deep venous thrombosis in systemic lupus erythematosus excluded a inter atrial septum defect. Amiodarone and diuretics were given
affected. with a promptly reduction of heart rate and a consequent reduction breath
In patients with systemic lupus erythematosus, we have to consider several rate. Persistent left superior cava vein is a very rare congenital anatomical
manifestations due to the respiratory system disease involvement; the condition due to the no regression of this vessel in newborn. Dyspnea is the
latter can express with primary lung disorders, like parenchymal, pleural, most important symptom the patient complain. Cardiosurgical correction
vascular, airways or diaphragmatic involvement, or associated lung disor- is able to achieve a clinical remission with an excellent prognosis. However
ders. Pleuritis and pulmonary infections are the most common respiratory it is mostly found in adolescent or young adult: it is extremely rare to find
manifestations in these patients. In a patient affected by systemic lupus this condition in elderly and, in our knowledge, there are no report about it.
erythematosus, in front of a pulmonary consolidation we can suspect an Epidemiology and previous fortuitous lack of contrast infusion in left arm
infective lung involvement or acute lung pneumonia immune-mediate. In are the main reason in delay of the comprehension of dyspnea cause. This
these patients inflammation markers are often high in both the situations, anatomical condition, at the end, should be considered as effective for lack
so we have to consider other aspects. Coltures exams, procalcitonin levels in treatment efficacy and symptoms resolution.
and antibiotic therapy’s reactions are some important aspects to look for;
we can suspect acute lupus pneumonia if the clinical condition do not
improve under antibiotic therapy as expected, and more benefits we have 62. A RELAPSING NON USUAL INTERSTITIAL
from steroids therapy. So, in this case the most important and interesting PNEUMONIA?
aspect was the differential diagnosis in a pulmonary disorder, specifically
between an infective disease or a lung involvement directly due to syste- Periti G., Iuculano F., Airaghi L., Fracanzani A.L., Fargion S.
mic lupus erythematosus. We focused also on the possible relationship Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
between respiratory manifestation and contemporary onset of leg’s fascii-
tis. Obviously, the early diagnosis has a decisive impact on the therapy and We report a case of a 78-year-old woman who presented to our medical divi-
in consequence on the prognosis, so it is important to think about and rule sion referring dyspnea for minimal efforts sneakily arisen in the prior three
out also those characteristic manifestations which can involve respiratory weeks without cough, chest pain or fever.The patient, affected by multiple
system in patient affected by systemic lupus erythematosus. pathologies, had a BMI of 41.6 kg/m2, a history of chronic atrial fibrilla-
tion in long lasting treatment with amiodarone, calcium channel blocker
treated hypertension, chronic renal insufficiency, mild microcytic anemia
and depressive syndrome. She had also urine coltures persistently posi-
tive for E. coli infection. One year ago she was diagnosed with non usual
interstitial pneumonia (UIP) related to the use of amiodarone determining
chronic respiratory failure. In that occasion the patient stopped amiodarone
therapy and underwent multiple exams. The high-resolution TC scan (HR-
TC), performed after a short wide-spectrum antibiotic course and diuretic
therapy, showed persistent ground-glass areas with alveolitis and pleural
effusion; broncoalveolar lavage was completely normal and nocturnal oxi-
metry was frankly positive showing a hypoxia index of 51 %. Concluding
for amiodarone induced pulmonary fibrosis, the patient started a glucocor-
On the left, image from CT scan performed during hospitalization; on the ticoid therapy with three days of one gr prednisolone boli followed by 40
right image from CT scan control mg daily. The patient also completed the work-up with echocardiography
which revealed severe hypertrophy of left ventricle associated with aortic
steno-insufficiency, severe dilatation of both atria and a PAPs of 51 mmHg.
61. NO TREATMENT RESPONSIVE DISPNOEA AND She was started on furosemide for the evidence of chronic cardiac failure.
TACHYPNEA: SYMPTOMS DUE TO LEFT SUPERIOR CAVA During therapy, the patient repeated the HR-TC scan, displaying an impro-
VEIN PERSISTENCE IN ELDERLY PATIENT vement of alveolitis and underwent pulmonary function test with diffusion
lung of CO (DLCO) and oximetry showed only a mild restrictive disease
Nardacci M., Cicco S., Solimando A., Iodice G., Ria R., Vacca A. allowing suspension of daytime O2-therapy maintaining only nighttime
Clinica Medica “G. Baccelli”, Dip. di Scienze Biomediche e Oncologia supplementation. The patient finally was transferred to a respiratory reha-
Umana, Università di Bari, Scuola di Medicina, Policlinico di Bari bilitation ward where she continued assuming prednisone per os gradually
withdrawn in February 2016. One month after discharge, she was again
92
admitted to our medical ward for a relapse of severe dyspnea associated with Bonzi M. 1, Ceriani E. 1, Cernuschi G. 1, Sobiati M. 1, Giusti G. 2,
bronchospasm episodes. She repeated the appropriated exams concluding Montano M. 1
for an acute flare of non-UIP probably due the persistence of amiodarone 1
Internal Medicine Department, Ca Granda Foundation IRCCS, Ospedale
toxicity. It was hypothesized that the lipophilic nature of this widely used Maggiore Policlinico, University of Milan, Italy 2IRCCS Policlinico San
antiarrhythmic drug probably led to an accumulation in subcutaneous and Donato Department of Paediatric Cardiology and Cardiac Surgery San
abdominal fat tissue of the patient being released slowly during months, Donato Milanese, Italy.
even after the withdrawal of corticosteroid therapy. The patient restarted
prednisone remaining with a minimum dose of 12, 5 mg for six months Objective: Early diagnosis of Infective Endocarditis (IE) is crucial and
and slowly reducing the dosage until March 2017 for a total duration of echocardiography, both transthoracic (TTE) and transesophageal (TOE),
therapy of 9 months. The patient showed a progressive clinical improve- plays a pivotal role in the diagnosis. However, the diagnostic accuracy data
ment. The patient comes again to our attention for episodes of confusion of TTE reported in the guidelines are mainly derived from old studies,
contemporary to a new episode of severe dyspnea occurring in the last three published before 2000s. Aim of this study is to perform an update syste-
weeks. Also this time cough, fever and chest pain are absent. The patient had matic review and meta-analysis of the literature in order to assess the dia-
also spontaneously diminished the dosage of diuretic therapy. The clinical gnostic accuracy of TTE in detecting IE of native valves.
exam reveals jugular turgor, bibasilar crackles and peripheral edema. Blood Methods: We performed a literature search on the electronic databases
gas analysis shows a worsening of pulmonary failure with oxygen satura- MEDLINE and EMBASE from their inception until July 2016, with the
tion of 78% in ambient air and biochemical exams display mildly elevated following entry terms: “endocarditis” AND “echocardiography”. Studies
RPC, pro-calcitonin of 0.07 (n.v. 0.02-0.06 ng/ml) and the persistency of were included if they met the following criteria: (1) enrolled ≥18 years old
mild anemia. After few days of endovenous diuretic therapy without clini- patients with suspected IE on native valves; (2) all patients had TTE and
cal benefit, the patient repeated the HR-TC which demonstrates the deve- TOE performed; (3) the data about TTE diagnostic accuracy, using TOE
lopment of extensive ground glass areas and some peribronchial pseudo as gold standard, could be extracted in order to build 2 x 2 table.
nodular images compatible both with a flare of the known fibrosis or a Results: The search algorithm yielded 17303 records; of them 11 studies
fungal infection. Thus, a new bronchial lavage has been performed today… were included, for a total of 2209 patients, studies mean age 27-62 years
old. The pooled TTE sensitivity and specificity were 0.87 (0.66-0.96) and
63. ECHOGRAPHIC ASSESSMENT OF DIAPHRAGM AND

RECTUS FEMORIS IN COPD PATIENTS BEFORE AND
AFTER A PULMONARY REHABILITATION PROGRAM
Augelletti T., Ferri S., Campisi R., Sorrentino R., Genco S.,
Heffler E., Ragusa A., Crimi N.
Istituto di Pneumologia Riabilitativa, Azienda Ospedaliera Universitaria
Policlinico Vittorio Emanuele, Catania
Introduction: Chronic Obstructive Pulmonary Disease (COPD) is cha-

racterized by chronic airways inflammation and progressive airflow limi-
tation with an increasing morbidity and mortality worldwide A non-phar-
macological approach, such us pulmonary rehabilitation (PR), may help
contrast dynamic hyperinflation and its deleterious clinical effects in
COPD. Recently, some studies have demonstrated the possible role of
ultrasound measurement of diaphragm thickness and thickening at the
zone of apposition. Ultrasound assessment of the diaphragm provide a
rapid, reliable, radiation-free and relatively easy to use approach to eva-
luate diaphragmatic function.
Thus, we hypothesized that studying the US variation of diaphragm mobi-
lity (zone of apposition) and thickness before and post a PR program may
be a good marker of the effects of a successful PR program. 0.96 (0.85-0.99) respectively. The overall diagnostic accuracy was calcula-
Methods: We studied COPD patients which started a 3-months PR ted excluding from analysis patients with an indeterminate TTE.
program. Patients underwent clinical and laboratory workup and perfor- We performed sensitivity analysis considering different scenarios in the
med lung function tests before and at the end of PR. Thoracic and femoral management of inteterminate studies. In particular, considering only
echography was performed by a trained technician studies that contemplated indeterminate TTE results with indeterminate
Results: 25 out of 47 patients ended the rehabilitation program. PR was examinations managed as positive, the sensitivity and specificity resulted
associated with improvement in the area of the rectus femoris (RF) and 0.94 (0.88-0.97) and 0.57 (0.46-0.67) respectively. On the other hand, the
MRC scale. There was an inverse correlation between the change in Delta scenario with indeterminate examinations managed as negative showed a
FEV1% and the change pre and post PR in thickness of the diaphragm sensitivity of 0.64 (0.48-0.77) and specificity of 0.98 (0.90-0.99). We per-
during quiet breathing (Delta QB) and deep breathing (Delta DB). The formed also the analysis including only studies tha did not contemplate
change in residual volume (Delta VR) correlated with Delta QB and Delta the presence of indeterminate resuls: the retrieved sensitivity and specifi-
DB. The variation of meters in the 6MWT (Delta meters) correlated with city were 0.73 (0.55-0.86) and 0.94 (0.90-0.97) respectively.
the variation of the area of the RF (Delta RF), with the change in FEV1 Discussion:Although the retrieved pooled TTE diagnostic accuracy in
expressed as percentage of predicted (Delta FEV1) and inversely with the diagnosis IE on native valve is better than previously reported, a nega-
change in residual volume (Delta RV). DB assessment and the area of the tive TTE still can exclude IE only in low pretest probability patients in a
RF were the only predictive factors of a good response to PR in terms of Bayesian perspective. Thus, considering overall data, our findig support
the reduction of residual volume. The measurement of QB and DB were guidelines advice to perform TOE in patiens with intermediate or high
predictive of the Delta meters improvement, while DB and the length of pretest probability, also in the presence of negative TTE. However, our
the apposition area at FRC were predictive of FEV1% improvement findings highlights how the management of indeterminate results could
Discussion:This is the first study that evaluates the role of diaphragm change TTE diagnostic performance. In particular a strict negative appro-
echography and of the RF in COPD patients which undergo a 12-weeks ach could ameliorate sensitivity, thus allowing the possibility to exclude
rehabilitation program. The diaphragmatic echography can predict the IE with a negative TTE examination also in the intermediate probability
answer of a patient to a single rehabilitation cycle. patients. Future studies are advisable to assess if this approach could be
safe and cost-effective.
64. DIAGNOSTIC ACCURACY OF TRANSTHORACIC

ECHOCARDIOGRAPHY TO IDENTIFY INFECTIVE 65. ECHOSTETHOSCOPE, BREAK OF AORTA-
ENDOCARDITIS OF NATIVE VALVES: A SYSTEMATIC ABDOMINAL ANEURYSMS (AAA=3A) AND THE
REVIEW AND META-ANALYSIS GENERAL PRACTITIONER (GP): “3A MANTUA PROJECT”
93
Crotti G., Castagna M. ± 0.07 (top); 0.41 ± 0.05 (ref); 0.48 ± 0.11 (bottom); (p. 0.05) Left Atrium
GPs and scientific coordinators of the Eidologic Mantuan Group (EMG) Volume (LA Vol) (ml): 56.32 ± 12.62 (top); 58.05 ± 18.22 (ref); 73.16 ± 24.97
Dipartimento delle Cure Primarie ATS. Val Padana Cremona - Mantova (bottom) (p: 0.01) Left ventricular Ejection Fraction (EF) (%): 61.8 ± 7.23
EMG is a group constituted by twenty general practitioners (GPs) from the (top); 61.97 ± 6.78 (ref); 57.16 ± 9.65 (bottom) (p: 0.05) Right Atrium Area
province of Mantua which completes the thoracic or abdominal medical (cm2): 14.87 ± 1.61 (top), 15.49 ± 1.66 (ref); 16.36 ± 2.74 (bottom) (p: 0.01)
examination, if necessary, by using the pocket-size ultrasound imaging Similar results for women (not enough space to display)
system VSCAN GE (echostethoscope). Since the break of an AAA causes Conclusion: Extreme dipper hypertensives seem to have lower level of
6000 deaths in Italy every year, we decided to measure the diameter of the cardiac damage (both for the left and for the right chambers) when compa-
abdominal aorta - whenever given a chance - in order to compare our data red to the other three categories of dipping, comprising the reference one.
with the ones shown by the literature.
Materials and Methods: between 2015 and 2016 we analyzed the diameter
of the abdominal aorta of 830 patients of the age of 65 and above (463 men 67. SHORT-TERM EVALUATION OF HEPATOCELLULAR
and 367 women) and 110 patients whose age is included between 55 and CARCINOMA AFTER LOCOREGIONAL TREATMENT:
64 years-old (57 men and 53 women). Note: when pointing to AAA, we USEFULNESS OF CONTRAST-ENHANCED
mean that the diameter is superior or equal to 4 cm, while ectasia is inten- ULTRASONOGRAPHY
ded when the diameter is inferior to 4 cm, inferior or equal to the 50% more
than the diameter of the aorta at the proximal neck. Ainora M.E. 1, Pompili M. 1, Garcovich M. 1, Riccardi L. 1,
Results: 65 year-old and above patients: 10 AAA (9 men and 1 woman- 1, Di Stasio E. 2, Ponziani F. 1, De Gaetano A.M. 3, Siciliano M. 1, Annicchiarico
2% of the total-), three of whom were urgently operated (one onset with a B.E. 1, Gasbarrini G.B. 4, Rapaccini G.L. 1,
left-sided renal cramping); 65 ectasias (42 men and 13 women: respectively, Gasbarrini A. 1, Zocco M.A. 1
9, 3% and 3, 3%), or, the 7, 8% of the total. 55-64 year-old patients: 0 AAA; 1
6 ectasias (4 men and 2 women, respectively, 7% and 3, 7%), or, 5, 4% of the Cattolica del Sacro Cuore di Roma 2 UOC Chimica Clinica, Università
total. All of the AAA cases and ectasias are sub-renal. The pathologies linked Cattolica del Sacro Cuore di Roma 3 UOC Radiodiagnostica, Università
with the AAA and ectasias are: pre-existing or current tabagism (82%), arte- Cattolica del Sacro Cuore di Roma 4 Professore Emerito Università Cattolica
rial hypertension (78%), dyslipidemia (34%), diabetes mellitus (27%). The del Sacro Cuore di Roma
association between tabagism and arterial hypertension can be found in
65% of the analyzed cases. Background: In patients with hepatocellular carcinoma (HCC), an accu-
Conclusions: The evaluation of a small percentage of Mantuan population of rate assessment of the therapeutic response is of crucial importance in
the age of 55 and over seem to confirm the data of the literature, or, at least, it order to schedule new treatment. Contrast-enhanced ultrasound (CEUS)
does as far as the AAA is concerned. On the other hand, the presence of ecta- with second generation contrast agents performed 1 month after treatment
sias is remarkable. Tabagism and arterial hypertension are the most valuable is almost as sensitive as CT in depicting the residual tumor. However, the
risk factors, as predicted. A left-sided renal cramping can be the clue of the efficacy of CEUS performed early after the procedure is still debated. Aim:
presence of an AAA. Depending upon these results, it would be advantageous To evaluate the diagnostic accuracy of CEUS for the assessment of tumour
that the 3A Mantua Project got proposed on a regional and national scale. response shortly after locoregional therapy in patients with unresectable
Our thanks to MDs for enlisting the patients: Abruzzino M.P., Bondavalli S., HCC.
Botturi S.A., Bruschi B., Calabrese G., Castagna M., Crotti G., Dall’Oglio Methods: Ninety-four patients with 104 HCC lesions who were scheduled
D., Danzi R., Ferri E., Gastaldi M., Gringiani A., Imperiale D.R., Maestri T., to receive percutaneous ethanol injection (PEI), radiofrequency ablation
Massari Q., Moreni G., Papa G., Rondelli R., Venco C., Volpi P., Zanazzi A. (RFA), transarterial chemoembolization (TACE) or combined treatment
were enrolled in this study. With contrast-enhanced computed tomography
(CECT) at 1 month as the reference standard, the ability of CEUS performed
66. ASSOCIATION BETWEEN THE DEGREE OF 48 hours after the procedure in detecting residual disease was evaluated.
HEART DYSFUNCTION EVALUATED THROUGH Sensitivity, specificity, negative predictive value (NPV), positive predictive
TRANSTHORACIC ECHOCARDIOGRAM AND THE value (PPV) and accuracy of the avascular pattern at CEUS were calculated.
NOCTURNAL BLOOD PRESSURE PROFILE IN 389 Patients were followed periodically to look for tumor or disease progres-
PATIENTS WITH ESSENTIAL HYPERTENSION sion. Survival probability was estimated with the Kaplan-Meier method and
relate to CEUS responses.
Di Raimondo D. 1, Musiari G. 1, Schimmenti C. 1, Casuccio A. 2, Miceli G. 1, Results: Based on CECT findings 43/104 lesions (41.3%) were diagnosed
Tuttolomondo A. 1, Pinto A. 1 as having residual viability after 1 month. CEUS performed 48 hours after
1
Dipartimento Biomedico di Medicina Interna Clinica e Specialistica treatment detected residual tumor in 34 of the 43 nodules with treatment
- Università degli Studi di Palermo 2 Dipartimento di Biomedicina failure at CECT with a sensitivity, specificity, PPV, NPV and accuracy of
Sperimentale e Neuroscienze Cliniche - Università degli Studi di Palermo 79.1%, 96.7%, 94.4%, 86.8% and 89% respectively. There was a high degree
of concordance between CEUS and CECT (kappa coefficient=0.78). An
Introduction: As previously reported, the circadian rhythm of blood pres- hyperemic halo was visible in 35 lesions without a statistically significant
sure (BP) in hypertensives is associated with the severity of organ damage, difference between concordant and discordant cases (p= 0.2). Responders
this being the maximum for the reverse dipper profile (accompanied by according to 48 hours CEUS had a significantly longer mean overall survival
paradoxical nocturnal increase of BP levels), and gradually decreasing and time to progression compared to non-responders (1169 vs 887 days,
towards the categories characterized by a normal circadian rhythm. In light and 453 vs 271 days, respectively).
of the paucity of data concerning the assessment of the indices of heart Conclusion: CEUS performed 48 hours after treatment can be considered
function in hypertensive patients in relation to the different nocturnal BP a reliable modality for the evaluation of the real extent of necrosis and has
profile, we designed a retrospective study ad hoc. prognostic value in the assessment of hepatocellular carcinoma.
Materials and Methods: We enrolled 389 patients with essential hyperten-
sion. Main exclusion criteria were the evidence of secondary hypertension
or any concurrent condition able to influence heart structure and/or fun- 68. BOWEL CONTRAST-ENHANCED ULTRASOUND
ction. All patients were evaluated through laboratory tests, clinical data and PERFUSION IMAGING IN THE EVALUATION OF CROHN’S
medical history, echocardiographic recordings, ambulatory blood pressure DISEASE PATIENTS UNDERGOING BIOLOGICAL
monitoring (ABPM). The analysis of data was performed comparing the top THERAPY
quintile (38 patients with the greatest fall in blood pressure at night), the
bottom quintile (comprising 38 patients with minor or no pressure drop at Ainora M.E. 1, Garcovich M. 1, Di Stasio E. 2, Riccardi L. 1,
night) and the middle quintile, as a reference. Men and women were analy- Scaldaferri F. 1, Armuzzi A. 1, Rapaccini G.L. 1, Pompili M. 1, Gasbarrini G.B.
zed separately due to the different normal ranges of the echocardigrafic 3
, Gasbarrini A. 1, Zocco M.A. 1
parameters considered. 1
Results: We observed a less impaired cardiac function for the top quintile, Cattolica del Sacro Cuore di Roma 2 UOC Chimica Clinica, Università
also after correction for duration of hypertension, mean systolic and diastolic Cattolica del Sacro Cuore di Roma 3 Professore Emerito Università Cattolica
24-hour blood pressure levels, mean age, main comorbities: MEN: Left Ven- del Sacro Cuore di Roma
tricular Mass (g/m2.7): 41.51 ± 7.94 (top); 44.48 ± 10.69 (ref); 51.24 ± 14.90
(bottom) (p: 0.001) Left ventricular Relative Wall Thickness (RWT): 0.39 Introduction: Evaluation of inflammatory activity in patients with Crohn’s
94
disease (CD) represents a crucial aspect of treatment planning and moni- detailed informations about disease activity (correlation between US-score
toring. High-resolution bowel ultrasound has emerged as one of the most and CDAI: p= 0, 002; US-score and Mayo: p 0, 0001; US-score and labora-
important imaging techniques in the diagnosis and follow up of these tory-based score: p 0, 0001). Our score was not associated with age, disease
patients since it is a non-invasive method that easily allows repeated exami- duration or lesion location.
nation and provides both morphological and functional analyses. In parti- Conclusion: The score we developed, matched with the clinical data, can
cular, microvasculature activation and angiogenesis induced by inflamma- be a useful method to obtain additional informations about disease status,
tion are the basis for the enhanced visualization of inflamed bowel walls helping clinicians in challenging therapeutic interventions. Currently, inte-
evidenced by contrast enhanced ultrasound (CEUS). Aim: To prospectively stinal US is spreading also among specialist internists or gastroenterologi-
evaluate the modification in bowel wall microvasculature of CD patients sts, with appropriate training, as a component of the clinical assessment.
treated with biological therapy. Material and Together with the evolution of US equipment, a standardized system can
Methods: Twenty-eight consecutive patients (14 males and 14 females; simplify procedure and improve examiner expertise. It deserves further
mean age±SD, 34±12 years) with a clinically active Crohn’s disease (Harvey evaluation of diagnostic accuracy and performance in prospective trials to
Bradshaw Index [HBI] >7) involving the terminal loop of small bowel (wall establish the true impact on disease management.
thickness > 5 mm), were enrolled in this study. Clinical assessment, labo-
ratory tests and CEUS were performed at baseline and after 2 (T1), 6 (T2)
and 14 (T3) weeks of treatment with infliximab. Bowel wall microvascula- 70. PREVENTION OF RELAPSE IN TTP PATIENTS
ture and contrast uptake were assessed by perfusion analysis in regions of UNDERGOING SURGERY
interest (ROI) with a quantification software (Q-Lab, Philips). Variations
between baseline and different time-points were calculated for five CEUS Arcudi S. 1, Colombo G. 1, Rossio R. 1, Pontiggia S 2, Cannavo’ N. 1,2, Ferrari B.
functional parameters (peak intensity, PI; area under the curve, AUC; slope , Peyvandi F. 1,2
1,2
of wash in, Pw, time to peak, TP and mean transit time. MTT) and were 1
correlated with clinical response at 14 weeks. Time-intensity curves obtai- Medicina Interna, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
ned in responders (those with a decrease ≥3 in the HBI score compared Policlinico, Milano; 2 Angelo Bianchi Bonomi Hemophilia and Thrombosis
with baseline) and nonresponders were compared with Mann-Whitney test. Center, Luigi Villa Foundation, Fondazione IRCCS Ca’ Granda Ospedale
Results: Before the beginning of the specific treatment all patients revealed Maggiore Policlinico, Milan, Italy
diffuse transparietal enhancement after contrast agent injection. Among all
evalutated parameters, PI, AUC and Pw showed a significant decrease at all Thrombotic thrombocytopenic purpura (TTP) is a thrombotic micro-
examined time points from the beginning of treatment (p<0.05) and were angiopathy, characterized by haemolytic anaemia, severe thrombocyto-
correlated with clinical response at 14 weeks (p<0.05). After 14 weeks, 4 penia and ischaemic organ dysfunction due to the deposition of thrombi
patients showed a new increase in PI, Pw and AUC, even though the clini- in microvasculature. Acute TTP is due to a deficiency of von Willebrand
cal findings continued to be negative. All these patients developed clinical factor (VWF) cleaving protein, also known as ADAMTS13 (A Disintegrin
recurrence within 6 months. And Metalloproteinase with a Thrombospondin type 1 motif, member 13).
Conclusion: According to the preliminary results of our study, the quanti- In the absence of ADAMTS13, ultra large multimers of VWF (ULVWF)
fication of the terminal bowel loop vascularity after contrast agent injection released in the bloodstream are not cleaved appropriately, thus causing
might become a useful modality not only for assessing the efficacy of biolo- platelet aggregation in the microvasculature of brain, heart and kidneys.
gical therapy but also a reliable predictor of relapse during the follow up. In The acquired form of TTP is caused by anti-ADAMTS13 autoantibodies.
particular, changes in perfusion parameters might suggest a closer clinical Daily therapeutic plasma exchange represents the gold standard of therapy
control and treatment revaluation also for patients in clinical remission. in acute phase, with a dramatic increase of overall survival rates from 10%
to 80-85%. Nonetheless, refractory disease and fatal outcomes still occur,
and almost one third of patients will experience TTP relapse after achie-
69. ULTRASOUND IMAGING - BASED SCORE TO ASSESS ving remission. At the cutting edge, severe ADAMTS13 deficiency (less than
DISEASE ACTIVITY IN INFLAMMATORY BOWEL 10%) has been recognized as the main risk factor for TTP recurrence1, and
DISEASE several conditions, including surgery, may trigger an acute episode. Thus,
a therapeutic approach may be advised to prevent relapse before exposure
Vidili G.P. 1, Pes C. 1, Cuccuru L.M. 1, Pes G.M. 2, Dore M.P. 3 to such triggers, in the presence of severely reduced ADAMTS13 activity
1
Internal Medicine and Ultrasonography Unit, Department of Clinical and levels. We report three clinical cases of patients followed in our center for
Experimental Medicine, University of Sassari, Sassari, Italy. 2Department recurrent acquired TTP, candidates to elective major surgery. All of them
of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy. had severe ADAMTS13 deficiency in remission phase, despite multiple
3
Internal Medicine and Gastroenterology Unit, Department of Clinical and previuos therapies (including steroids and rituximab). Therefore, they were
Experimental Medicine, University of Sassari, Sassari, Italy. candidated to prophylactic therapies with the aim of increasing ADAMTS13
levels before surgical procedures to prevent TTP relapse. The first patient is
Background: Intestinal ultrasound (US) has been shown to have high accu- a 67-year-old man, who had 5 TTP acute events before surgery. For persi-
racy in the detection or exclusion of inflammatory activity in Inflammatory stently low ADAMTS13 activity levels (< 10%) during remission, he conti-
Bowel Disease (IBD), contributing to the first diagnosis and follow-up of nued to undergo periodic prophylactic PEX (every 40 days). He underwent
these patients. The advantages include non-invasiveness, rapid availability, left indirect inguinal hernioplasty plus synthetic mesh. Since pre-operative
repeatability, and low costs in comparison to other imaging or endosco- ADAMTS13 activity was < 3%, a PEX procedure was performed immedia-
pic techniques. However, there are no validated score systems to quantify tely before surgery, with increase in ADAMTS13 activity levels to 25% after
disease activity based on ultrasonographic parameters. Objectives. Our aim surgery; no complications were observed during the post-op and the fol-
was to assess if the score we developed, based on a multiparameter US-ima- lowing weeks.
ging derived from available literature, correlate with clinical activity measu- The second patient is a 64-year-old woman, who experienced 5 TTP episo-
red with CDAI/Mayo score and laboratory data. des in the past. She underwent two surgical procedures, namely cholecy-
Materials and Methods: From January to June 2017, 38 patients (25 with stectomy and left total hip arthroplasty. Before cholecystectomy, she was
diagnosis of Crohn’s disease - CD, 13 of Ulcerative Colitis -UC) at our insti- treated with 3 PEX, with a rise in ADAMTS13 activity from < 3% to 38%,
tution underwent a clinical examination including questionnaires (CDAI for and no complications occurred after surgery. Long before undergoing left
CD, Mayo partial score for UC) and laboratory exams (complete blood count, total hip arthtroplasty, she was treated with prophylactic rituximab, obtai-
CRP, VES, iron and albumin levels, and faecal calprotectin), followed by a full ning only a partial correction of ADAMTS13 deficiency (from <3% to 24%);
US examination with assessment of bowel wall thickening, vascular signals so, immediately before major surgery, she underwent prophylactic PEX,
on Color-Doppler, preservation or loss of multilayer pattern and normal or bringing ADAMTS13 activity levels to 45%, with a subsequent safe surgical
reduced motility (only for CD). All these parameters were assigned prede- procedure. The third patient is a 58-year-old woman, with 4 previous acute
termined numerical point values in order to develop a scale which allows to TTP episodes. She underwent total laparoscopic hysterectomy for atypical
classify patients on the basis of disease severity. Then, it was compared with endometrial complex hyperplasia. Pre-operative ADAMTS13 activity was <
symptoms and laboratory-based scoring systems. US imaging was performed 3%, so a prophylactic PEX was performed and ADAMTS13 activity rised to
by an internist with high expertise in US bowel examination and blinded to more than 50% after surgery. No complications occurred. 7
the clinical status. A Spearman analysis was applied to test the correlation. In conclusion, we reported three cases of successful surgical procedures in
Results: The US score we developed showed high correlation with clini- patients affected by recurrent acquired TTP, with undetectabe ADAMTS13
cal and laboratory findings, both in CD and UC patients, providing more activity levels during remission phase. Prophylactic PEX immediately
95
before surgery could be a reasonable protocol to increase ADAMTS13 levels Bence-Jones proteinuria. Once ITP was diagnosed, the patient received a
and prevent relapses in such TTP patients. 1. Kremer Hovinga JA, Vesely first-line therapy with prednisone and IVIg, with no response. After, she
SK, Terrell DR, Lammle B, George JN. Survival and relapse in patients with was unsuccessfully treated with Azatioprina. On 2006 she underwent sple-
thrombotic thrombocytopenic purpura. Blood 2010;115:1500–11 nectomy, obtaining a complete response and a stable remission with low
dose of corticosteroids.She came at our attention in 2013, when the ITP
recurred for the first time with a platelet count of 4-9 x 10^9/L, sympto-
71. ATRIAL FIBRILLATION IN PATIENTS AFFECTED matic for epistaxis and petechiae. Platelet-associated autoantibodies against
BY POLYCYTHEMIA VERA OR ESSENTIAL GpIIb/IIIa and GpIb were positive; an abdominal CT was negative for acces-
THROMBOCYTHEMIA sory spleen, and bone marrow examination was normal. Since the patient
was refractory to full doses of prednisone (1 mg/kg) and IVIg (1 g/kg for
Biagetti G., Bertozzi I., Cosi E., Santarossa C., Bogoni G., Fabris F., Randi two days), she was treated with Romiplostim (1 mcg/kg up to 3.5 mcg/kg)
M.L. administrated once a week for 26 weeks. The response to TPO-mimetic was
Dipartimento di Medicina - DIMED, Università di Padova, Clinica Medica 1 fluctuating (plts 800 – 4 x 10^9/L) so, in April 2014, the patient received
a course of Rituximab (375 mg/m x 4 doses) with complete response. The
Introduction: Atrial Fibrillation (AF) is a common cardiovascular disease remission continued until April 2015, when at 21st week of gestation the
with an estimated prevalence of 0, 5 - 1% in the general population, and 2, ITP relapsed (plts 2-5 x 10^9/L) with epistaxis, gengivoraggia and petechiae.
5-3% in over-65 people. The main complication of AF is thromboembo- The patient was treated again with corticosteroids (prednisone, dexametha-
lism and therefore patients with AF are treated with anticoagulants. Also sone) and IVIg, with only a transitory response, and with Romiplostim (1
Polycythemia Vera (PV) and Essential Thrombocytemia (ET) occur mainly mcg/kg increased up to 10 mcg/kg once a week for 3 weeks) used off label
in median-advanced age and affected patients have a significant thrombo- before delivery, without response. She underwent to elective caesarean deli-
tic risk both in arterial and venous vessels. To prevent this risk, most of very at 26th week of gestation, in course of platelets concentrates infusion
these patients are treated with low-dose aspirin (ASA). This scenario places (plts 3 x 10^9/L). The baby did not report complication and its platelet count
a question: does a patient affected with PV/ET and AF have to receive ASA was normal. Otherwise, during the post-partum period the patient deve-
and/or anticoagulants? Is there a preferential treatment? To answer this, we loped a periuterine hematoma, requiring laparotomy for evacuation. After
retrospectively investigated in our large cohort of patients with PV and ET the delivery, Romiplostim was administrated for other 10 weeks. Due to
how antithrombotic treatment has been used when AF occurred. fluctuating platelet count, we shifted to Eltrombopag 50 mg/die, which was
Methods: Within 570 PV and ET patients followed in our Department, we withdrawn after only one week because of sever thrombocytosis (plts 1985 x
found 22 patients (12 PV and 10 ET, 11 males and 11 females, mean age 10^9/L). The patient underwent to a new course of Rituximab, obtaining a
72±7 years) also suffering for AF. We stratified the patients on the basis of complete response and a stable remission with low doses of corticosteroids,
antiplatelet/anticoagulant treatment adopted and the occurrence of throm- gradually tapered until suspension. In July 2016 the ITP recurred again
bo-hemorrhagic complications were registered. In every patient at diagnosis (plts 2 x 10^9/L), exacerbated by two infective episodes. This time throm-
of AF, CHA2DS2-VASc and HAS-BLED scores were registered. bocytopenia was associated with neutropenia (N 0.32 x 10^9/L), requiring
Results: The occurrence of AF in our cohort of PV and ET patients was of administration of GCS-F, with benefit. The patient received once again
3, 9 %, and 12% for patients over 65 years. Twenty-one patients had a high high dose of corticosteroids, IVIg and Eltrombopag. Platelet count rapidly
risk CHA2DS2-VASc score and 1 had a low risk; two patients had high, 20 increased until 1700 x 10^9/L: TPO-mimetic was consequently withdrawn
medium and 1 had low risk HAS-BLED score. Seven patients (all with high and corticosteroid therapy was tapered. In November 2016 the ITP relap-
CHA2DS2-VASc risk) received ASA and 1 of them had a stroke; 5 out of sed, associated with hemolytic anemia and neutropenia (plts 11 x 10^9/L,
these 7 patients shifted to warfarin because of the occurrence of AF (during Hb 61 g/L, N 0.40 x 10^9/L). The patient was managed with prednisone,
warfarin 1 patient had a myocardial infarction). Ten patients were treated IVIg, Eltrombopag and Rituximab, without response. Immunosuppression
with warfarin for AF (1 with a low and 9 with a high CHA2DS2-VASc risk) with cyclosporine A (from 50 mg x 2/die up to 100 mg x 2/die) was started
and 2 of them had deep vein thrombosis (DVT) and 1 renal vein thrombo- and the patient underwent 4 courses of immunoadsorption with Ig-Thera-
sis during treatment. In 5 patients (all with medium HAS-BLED risk) ASA sorb® system, each one followed by the administration of IVIg. With this
and warfarin were administered together being AF and PV or ET diagno- strategy platelet count progressively increased until normal values. For the
sis contemporary; 1 of these patients had DVT and 1 a peripheral arterial hemolytic anemia, she was supported with blood transufusions; neutro-
thrombus. Two patients had a minor bleeding during ASA therapy, 2 during penia was treated with GCS-F with benefit. In March 2017, after the 5th
warfarin and 1 while receiving both drugs. relapse, the patient was treated again with immunoadsorption, this time
Discussion:Both ET/PV and AF occur mainly in the same setting of age, unsuccefully. Immunosoprression with cyclosporine A was interrupted and
making frequent the co-existence of these pathologies in the same patient. we administrated high dose of chemotherapy (Cyclofosfamide, Vincristina,
Our data show that AF is at least as frequent in older PV and ET patients as Prednisone), obtaining finally a stable response.
in general population. The use of antiplatelet and/or anticoagulant therapy
in the present cohort of patients with PV/ET and AF is apparently chosen
only on the basis of the physician experience. Nor ASA neither warfarin, 73. FISHER-EVANS SYNDROME: CASE REPORT
also if associated, are able to cancel the thrombotic risk in the patients with
two prothrombotic conditions and the association of two antithrombotic Battisti P. 1, Ciammaichella M.M. 2, Maida R. 2, Petrecca I. 2,
agents does not seem to represent a significant bleeding risk in our patients. Carfagna P. 3, Fenu S. 4, Giacomobono S. 5, Cedrone M. 4,
It is interesting to point how CHAD-VASC and HAS-BLED scores should Pirillo S. 6
be useful in choosing the best treatment for AF in ET/PV patients. However, 1
II Medicina, A. O. S. Giovanni-Addolorata, Roma 2 Medicina d’Urgenza,
the prothrombotic and pro hemorrhagic risks given by these diseases is A. O. S. Giovanni-Addolorata, Roma 3 GOICA, A. O. S. Giovanni-
lacking in the scores. Prospective studies on larger cohorts of patients are Addolorata, Roma 4Ematoloogia, A. O. S. Giovanni-Addolorata, Roma
needed to answer further, and to assess appropriate guidelines. 5
Immunoematologia e Medicina Trasfusionale, Policlinicio Militare Celio,
Roma 6Radiologia per il DEA, A. O. S. Giovanni-Addolorata, Roma
72. THE COMPLEX MANAGEMENT OF A YOUNG WOMAN Introduction: The authors presented the case report of a 36-year-old Roma-
WITH REFRACTORY IMMUNE THROMBOCYTOPENIA nian citizen who came to our observation for fever, headache, and confu-
sion. CASE REPORT: High blood pressure (Hb 5.7 g), Coombs positive test,
Boscaro F., Bertomoro A., Di Pasquale I., Omenetto E., Fabris F. PLT 2000 / mm3, neutrophilic leukocytosis related to steroid therapy, pul-
Clinica Medica 1, Dipartimento di Medicina, Università degli Studi di monary thickening. Therapy with endovene non-specific immunoglobulins
Padova (30 gr / day) is initiated for 5 days and then it is started with eltrormbopag
olamine therapy. During the stay the patient is subjected to the following
We report a case of a 28 years old Moldovan woman with a secondary, tests:
refractory immune thrombocytopenia (ITP) diagnosed on 2002 in 1) ECG: RS Exposure Limits;
Moldova. ITP is associated with hemolytic anemia (Evans Syndrome), 2) Hematochemical routine examinations show leukocytosis (between 15,
which required blood transfusion in childhood. Her clinical history inclu- 000 and 24, 000), PLTs consistently <5000 / mm3, Hb 5.7 g, PCR, which is
des post-trasfusional HCV-related hepatitis, treated in 2016 with Ledipa- 32 mg / dl (VN <0.6 mg / dl);
svir and Sofosbuvir with HCV eradication; Sjogren’s Syndrome with severe 3) Primary and secondary thrombophilic screening is negative;
dry eye and a positive titer of ANA and ENA anti-SSA; IgK MGUS without 4) Hyperchromium, anisopoiesilocytosis, microcytosis, anulocytosis, multi-
96
ple cysts, severe platelet and lymphopenia as well as hemolysis were normal, while an abdominal ultrasonography showed nephrome-
5) The protidogram EF shows hypoalbuminema, hyperalpha1, hyperalpha2, galy and renal lithiasis. Treatment with intravenous hydration, phosphate
hyperbeta1, hyperbeta2, hypogamma, small monoclonal component in binders, allopurinol, and rasburicase was initiated. A chest-abdomen CT
gamma3; without contrast showed subcentimetric abdominal lymph nodes. Accor-
6) Hepatitis B markers show HBS AB at 14 mUI / ml (reactive> 10 mUI / dingly, spontaneous tumor lysis syndrome in hematologic malignancy was
ml); suspected. Therefore, an osteomedullary biopsy was performed and showed
7) Autoimmune screening shows c-ANCA positivity (unrelated to vasculi- a T-cell lymphoblastic lymphoma.
tis) and antinuclear antibodies (IFI title) Positivity 1: 640 Pattern speckled Conclusion: Tumor lysis syndrome is an oncologic emergency that usually
8) Urine examination in the limits of sterile urinoculture and urinary tract occurs after chemotherapy in patients with hematologic malignancies. Ste-
of the negative legionella; roids are known to have lympholytic effects. Although steroids are widely
9) Fibrobroncoscopy with BAL shows no acid-resistant bacilli absence, used, there are case reports of tumor lysis syndrome in patients with mali-
positivity for Klebsiella Pneumoniae, BAL PCR negativity for Micobacte- gnancies treated solely with steroids. Therefore, empirical therapy with
rium Tubercolosis Complex, positivity for galactogenic: steroids should be avoided, especially in patients suspected of having large
10) Serum for TORCH, legionella, EBNA, VCA, micoplasma, chlamydia is tumor burdens.
negative;
11) Bone biopsy on the iliac crest shows increased cellularity, increased
megacaryocytes, > 2% histiocytes, diserythropoiesis, disgranulose, disme- 75. AN INTRIGUING CLINICAL CASE OF BETA THALAS-
gacaryacytopoiesis; The histogram shows: 55% erythroblasts, 24% granulo- SEMIA UNDULY TAKEN FOR THALASSEMIA MINOR
blasts, 11% lymphocytes, 2% eosinophils, basophils 0, promonocytes + 2%
monocytes, 2% undifferentiated elements, 4% plasma cells, G / E 0.48. This Falconieri M. 1, Fiore G. 1, Castrovilli A. 1, Vitucci A. 2,
corresponds to hyperplasia of the erythroblastic series with series present in Palma A. 2, Pietrapertosa A. 2, Specchia G. 2, Sabbà C. 1
all maturative phases as for hemolytic anemia in the absence of parasites or 1
U.O. Medicina Interna Universitaria “C.Frugoni”, Dipartimento Interdisci-
myeloftic neoplasms; plinare di Medicina, Università di Bari; 2 U.O. Ematologia con Trapianto Uni-
12) TAC chest-abdomen with mdc: pulmonary consolidation with central versitaria, Dipartimento Emergenza e Trapianti di Organi, Università di Bari
excavations, 7 cm DAP chin of the apical LID segment associated with
further peribronchial disomogeneous cavities, satellite nodules and bila- Introduction: Beta thalassemia is an hereditary autosomal recessive hae-
teral pulmonary micronodulas, pulmonary consolidation of 33 mm at the matological disorder caused by defects in the synthesis of globin chains
apical head LIS paramediastinic, material Thromboembolic in the lumen of leading to reduced or absent beta (β) chains and consequently to excess of
the taxus vessels to the lower lobes of both lungs, two lymphatic lymphatic alpha (α) chains and to decrease in hemoglobin HbA (α2β2 chains <95-
lesions of 24 and 25 mm, splenectomy outcomes, 98%) and increase in HbA2 (α2δ2 >2-3%). Imbalance of β-globin chains
13) TC Skull with mdc: Expanding characterization of 12 mm located in left in heterozygous or homozygous beta thalassemia form (Minor Thalassemia
medial frontal corticosottocorticale with peripheral edema; and Major Thalassemia or Cooley’s Anemia, respectively) cause haemolysis
14) Angio-RM encephalus with mdc and ANGIO-RM of intracranial vessels and impair erythropoiesis with a variable grade of severity. Minor Tha-
with mdc: Sequence with technique SE, FSE, FLAIR weighed in DWI T2-1 lassemia due to mild anemia is clinically asymptomatic and exceptionally
before and after paramagnetic contrast medium showing in the left frontal responsible of jaundice.
nodular diameter formation Of 11 mm surrounded by edema; Clinical Data: A 17-year-old girl with previous diagnosis of Minor Tha-
15) RM Spectroscopic brain of the brainplant performed by multi-para- lassemia, inherited from the paternal side, was admitted to our Internal
meter morphology and structural technique with DWI-ADC and spectro- Medicine Unit for asthenia and abdominal pain having been hospitalized
scopic (CSI single-voxel) study: confirms the frontal intrasial head nodular in 2015 in Surgery Unit for obstructive jaundice. The patient with a normal
pseudo nodular alteration with peripheral edema, diffusion restriction: this constitution exhibited pale skin, weakness and positivity for Murphy’s sign
is due to cerebral abscess; at abdominal examination.
16) PICC is positioned by right transgigram under ultrasound guide and Laboratory and Instrumental Investigations and Results: Laboratory
the VCS positioning with RX chest is monitored; Treatment modifications: tests showed hypochromic and microcytic anemia (Hb 9.6 g/dl, MCV 61.6
mannitol ev, meropenem ev, colistin aerosol, emotional fusion only in case fl, MCH 19.4 pg), normal iron profile, folic acid deficiency (2.7 ng/ml vs
of signs of severe hypoxia, transplantation of PLT only in cases of haemor- n.v.>5.4), increase in indirect bilirubin (2.89 mg/dl, total 3.10 mg/dl), low
rhage, acyclovir cp 800 mg, soldesam 4 mg iv, amphotericin B fl 50 mg ev, haptoglobin levels (0.31 g/l vs n.v. 0.3-2.0), negative Coombs test, normal
Eltrombopag olamine. In the light of the clinical picture and repeated hema- glucose-6-phosphate deydrogenase (G6PD) enzyme activity and negative
tologic, bronchopneumological and infectious counseling, it is located by markers for viral hepatitis and autoimmunity. Ultrasound (US) examination
syndrome by Fisher-Evans. evidenced an increase in spleen volume (16.2 cm vs n.v. <12 cm) and choleli-
Discussion: Autoimmune cytopenia is characterized by the selectivity of thiasis in absence of bile ducts dilatation. In the suspicion of a more complex
the “target” cell in the sense that antibody action causes a specific cytope- form of beta-thalassemia, an hemoglobin electrophoresis at alkaline pH on
nia, both in peripheral and central pathogenesis or in combination. The agarose gel was performed with consequent evidence of high level of fetal
paradigm of this autoimmunity directed at different cells simultaneously is and A2 hemoglobin at a rate of 5.6 % and 5.7 %, respectively. Moreover, the
Evans’s syndrome, where autoimmune hemolytic anemia is combined with molecular study of alpha and beta DNA chains showed a β° cod 39 (C>T)
a platelet-like autoimmune pathogenesis. Both idiopathic and associated mutation and a ααα anti-3.7 triplication, both in heterozygosity. Additio-
forms of disease are known, especially in autoimmune pathogenesis, and nally, the genetic analysis of UDPG1A1 gene mutation was diagnostic for
even after bone marrow transplantation. Gilbert syndrome.
Conclusions: The authors presented the case report of a patient with Fisher Discussion: Beta-Thalassemia Minor is a form of haemolytic microcytic
- Evans syndrome. anemia clinically silent. However, exceptionally, it may represent the
clinic epiphenomenon of a heavier hemoglobin genetic disorder. In this
clinical case, it was surprising the finding of cholelithiasis complicated by
74. A CASE OF WEAKNESS obstructive jaundice in a very young subject with a previous diagnosis of
Beta-Thalassemia Minor. This imposed a more-in-depth genetic hemo-
Ciarla S., Striuli R., Petrarca M., Croce G., Parisi D., Di Michele D. globin analysis. The finding of an increase in fetal and A2 hemoglobin
U.O.C. di Medicina Interna - Ospedale “G. Mazzini” ASL. Teramo was incontrovertibly significant of Beta-Thalassemia Intermedia rather
than the harmless Beta-Thalassemia Minor. In fact, in this patient the
Case report: A 32-year-old Caucasian male was brought into the emer- underlying disorder of Beta-Thalassemia Intermedia was at the base of
gency department because of general weakness and poor oral intake. A significant haemolysis and consequently of the massive biliary stones pro-
week before he had previous access to first aid for the same reason and cor- duction. So, when the phenotype of a presumed Beta-Thalassemia Minor
tisone was administered for submandibular and laterocervical lymphadeno- coexists with gallstones, with or without jaundice, it’s mandatory to inve-
megaly. His remote and physiological anamnesis were negative for relevant stigate on Beta-Thalassemia Intermedia.
pathologies. Serum biochemistry tests showed anemia, elevated creatinine
and increasing levels of potassium, phosphorus and uric acid. Therefore, he
was admitted to internal Medicine Unit for acute renal failure. The patient’s 76. PREDICTORS OF CARDIAC EVENTS IN BETA-
vital signs were within normal limits. No significant elements were found THALASSEMIC ADULT PATIENTS: A PROSPECTIVE
by a physical examination. An electrocardiogram and a chest radiography STUDY
97
Ferrara F. 1, Riva R. 1, Ventura P. 1, Coppi F. 2, Rochira V. 3., 77. COEXISTING HEREDITARY HEMOCHROMATOSIS
Bevini M. 4., Vegetti A. 1, Corradini E. 1, Pietrangelo A. 1 AND BETA-THALASSEMIA TRAIT: POSSIBLE
1
Division of Medicine II and Center for Hemochromatosis, University CONFOUNDERS FOR A SUBSEQUENT HEMATOLOGICAL
Hospital of Modena, Modena, Italy 2Division of Cardiology, University DIAGNOSIS
Hospital of Modena, Modena, Italy 3Division of Endocrinology,
Sant’Agostino-Estense Hospital, Modena, Italy 4Immuno-ematology and Pelusi S., Lombardi R., Iuculano F., Francione P., Valenti L., Fracanzani A.L.,
Transfusion Service, University Hospital of Modena, Modena, Italy Fargion S.
Department of Pathophysiology and Transplantation, Unit of Internal
Background: β-thalassemia Major (TM) and Intermedia (TI) are characte- Medicine, Ca’ Granda IRCCS Foundation, Policlinico Hospital, University of
rized by severe anemia early in life and iron overload both from transfu- Milan, Milan, Italy
sion supply and from anemia itself. Prior to the advent of chelation therapy,
transfusion dependent TM patients usually died in their second decade of Introduction: Hereditary Hemocromathosis (HH) is a genetic disorder
life because of iron-related cardiomyopathy leading to cardiac decompen- in iron metabolism which causes its deposition in different organs, mainly
sation or fatal arrhythmia. Therefore, patients’ management was confined liver, joints, bones, and heart, causing their dysfunction. The association of
to pediatricians. Chelation therapy since 1970s has dramatically improved HH with hematologic disorders has been already reported, but literature is
patients’ survival and made this systemic disease of interest for speciali- scarce.
sts in Internal Medicine. Although the huge improvement in expectancy Case report: We report the case of a 34 year-old woman with history of
and quality of life, many patients still develop relevant complications, and hyperferritinemia with elevated transferrin saturation (ferritin 800 ng/
cardiac events (decompensation and arrhythmias) remain one of the prin- ml, transferrin saturation 85%) since the youth. Moreover, she was carrier
cipal concern for prognosis and quality of life. Excess iron accumulation in of beta-thalassemia trait (hemoglobin levels 10-11 g/dl). Suspecting HH
the heart and chronic anemia are the main determinants of cardiac events the patient was genotyped for HFE gene and resulted homozygous for the
in this population. C282Y mutation. She underwent also an abdomen ultrasound (normal),
Aim: Aims of our study was to evaluate the incidence of cardiac events an echocardiography (impaired diastolic compliance), a bone densito-
(cardiac decompensation and arrhythmias) in a population of adult metry (normal) and X-ray of the hands (no arthropathy). Liver biopsy
beta-thalassemic patients and to identify possible predictors and prevention pointed out severe parenchimal siderosis with parenchymal predomi-
strategies. nantly iron deposition without significant fibrosis. She was started on
Population and Methods: 37 patients were included in the present study, 29 phlebotomy until iron depletion followed by maintenance phlebotomies.
TM and 8 TI, aged 24-61, consecutively enrolled from 2011. Retrospective After several years a progressive increase in spleen volume was observed,
data regarding diagnosis, splenectomy, cardiac history, endocrinopathies, followed by a splenic infarction. A trombophilic screening was obtained
transfusion requirement, chelation therapy, and prospective data regarding and showed positivity for the V617 mutation in the JAK-2 gene, while
new-onset cardiac decompensation and arrhythmias, echocardiographic bone marrow biopsy diagnosed a myeloproliferative neoplasm. Therefore,
parameters, biochemical variables (including mean pre-transfusion hemo- she was started with hydroxyurea and afterwards with JAK2-inhibitor. We
globin, iron, ferritin, transferrin saturation), non transferrin-bound iron eventually observed a reduction in spleen volume and improvement in
(NTBI) and labile plasma iron (LPI), hepatic and cardiac iron deposits by blood tests.
MRI T2 1, new-onset endocrinopathies and chelation therapy, were collected Discussion: A longstanding abnormal erythropoiesis driven by beta-thalas-
through 2016 in an electronic database and analyzed on a SPSS platform. semia trait associated with external stimuli such as phlebotomy might have
Results: At the beginning of the study, 8 TM patients and 1 TI patient predisposed our patient to a myeloproliferative disorder and possibly have
had already experienced cardiac events, mainly cardiac decompensation. masked and delayed its diagnosis.
Patients with previous cardiac events were more frequently male and had
more endocrine complications, diabetes (44.4 vs 7.1%, p 0.02) and IGF1
deficiency (33 vs 0%, p 0.01). For other endocrine complications (hypogo- 78. ATYPICAL LUPUS-LIKE ANTICOAGULANT IN A
nadism, hypoparathyroidism, hypothyroidism, GH-deficiency) a signifi- PATIENT WITH NON-HODGKIN LYMPHOMA AND HBV
cantly higher prevalence was observed in patients who had experienced a INFECTION
cardiac event although this difference failed to reach statistical significance.
No differences were observed in iron parameters, transfusion schedules Pina G. 1, Bucciarelli P. 2, Scopelliti F. 1, Fasola D. 1, Novembrino C. 2, Boscolo
and iron chelation history in the 2 groups. During the follow-up period (72 Anzoletti M. 2, Peyvandi F. 2, Moreo G. 1
months), 11 patients (29.7%) experienced a new cardiac event and 4 of them 1
Internal Medicine Unit, Clinica San Carlo, Paderno Dugnano, 2Angelo
had more than one event: 3 patients (8.1%) developed cardiac decompen- Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’
sation, 5 patients had atrial fibrillation (AF), 1 patient had supraventricular Granda Ospedale Maggiore Policlinico and University of Milan, Italy
tachycardia (SVT), 1 patient had concomitant cardiac decompensation and
AF and 1 patient had AF and SVT. The onset of cardiac events was positively Antiphospholipid antibodies (APA) are acquired antibodies against cel-
correlated to: high LPI levels (OR 12.0, 95% CI 1.56-92.3, p 0.017); low mean lular surface phospholipids that interfere with in vitro coagulation tests,
pre-transfusion hemoglobin (OR 0.21, 95% C.I. 0.051-0.761, p 0.21); echo- while in vivo are responsible of a thrombophilic state. Sometimes, APA
cardiographic parameters suggestive of myocardial hypertrophy: interven- are found in patients with hematological malignancies or infections. We
tricular septum thickness, (OR 4.2, 95% C.I. 1.24-13.7, p 0.020), posterior describe a case of a patient with a marginal splenic B-cell non-Hodgkin
wall (OR 4.23, 95% C.I. 1.27-14.1, p 0.019), left ventricular mass (OR 1.21, lymphoma and hepatitis B acute viral infection with an atypical presenta-
95% C.I. 1.04-1.21, p 0.005); left atrial volume (OR 1.22, 95% C.I. 1.05-1.41, tion of APLs. A 77 years-old female patient was diagnosed with a marginal
p 0.010), left ventricular tele-diastolic volume (OR 1.26, 95% C.I. 0.98-1.62, splenic B-cell non-Hodgkin lymphoma on 2010. She was treated first with
p 0.06); QT interval prolongation (OR 7.33, 95%C.I. 1.07-50.1, p 0.04). LPI chlorambucil and prednisone, then on 2014 with 6 cycles of rituximab
levels were unrelated to iron deposits evaluated by hepatic and cardiac MRI and bendamustine, achieving partial remission. Subsequently she deve-
and to chelation regimen. Iron deposits measurement by MRI-T2 1 failed loped acute hepatitis B viral infection and was treated with tenofovir. On
to predict cardiac events. Interestingly, all patient underwent a progressive February 2017 she presented with pancytopenia (Hb 8.6 g/dL, MCV 102
reduction of the ejection fraction during the follow-up period although it fL, WBC 2800 x 103/L, platelets 82 x 103/L), ascites and leg oedema. A
remained between the normal range. marked splenomegaly was detected at visit and confirmed with CT scan
Discussion and Conclusions: Our study involved a limited but well cha- and MR (a/p diameter 19 cm). No hepatic focal lesions were found. The
racterized number of beta-thalassemic patients affected by a severe rare patient did not have any bleeding diathesis. Liver tests were normal except
disease. We were able to identify important predictors of cardiac events, for a slight decrease of liver synthesis markers (albumin 3.0 g/dL, pChe
including baseline LPI, Hb levels and echocardiographic parameters. Early 3290 U/L). A modest IgM lambda monoclonal gammophaty (0.04 g/dL)
identification and treatment of endocrinologic comorbidities, improvement was found. Prothrombin time (PT) and activated partial thromboplastin
of transfusion schedules and an accurate echocardiographic follow-up are time (APTT), previously normal, were now markedly prolonged (PT ratio
needed to reduce the risk of cardiac complications. LPI might be of clinical 5.50, APTT ratio 2.36, respectively), and did not correct after mixing tests
utility to identify well chelated patients free from cardiac iron overload but with normal plasma. During the hospital stay, a PICC was inserted on the
still at risk of cardiac events and might represent a future target for new right arm for liquid infusion, but a rapid thrombosis of its lumen occur-
treatment strategies. red. Due to this clinical presentation and a marked prolongation of both
PT and APTT, with the need of invasive procedures, a more detailed coa-
gulation pattern was performed, as shown in the following Table:
98
Test Result Laboratory reference range 80. SPLENIC INFARCTION AND ACUTE PULMONARY
EMBOLISM (PEA) IN FOLLICULAR LYMPHOMA: A CASE
PT ratio 5.50 (0.84 - 1.20)
REPORT
PT ratio mix 50/50 4.78 (0.84 - 1.20)
APTT ratio 2.36 (0.86 - 1.20)

V. Russo, 2 A. Merceri, 1 M. Gobbi
1
1
DIMi- Dip. Ematologia, Università degli studi di Genova, Direttore: Prof.
APTT ratio mix 50/50 2.06 (0.86 - 1.20) M. Gobbi, 2 ASST-Bergamo Est - Responsabile P.S. Osp. di Alzano L.do (BG)
Factor VIII 161 IU/dL (51 - 147 IU/dL)
Introduction: Follicular lymphoma (FL) is one form of lymphoma non
Factor IX 87 IU/dL (70 - 120 IU/dL)
Hodgkin. Initial presentation of splenic FL can be given by abdominal pain.
Factor VII 65 IU/dL (62 - 138 IU/dL) However early diagnosis of this hematological condition can improve the
Factor V 100 IU/dL (70 - 134 IU/dL) prevention of thrombotic events as PEA and splenic infarction in follicular
lymphoma (FL) patients. PEA is a relative common cardiovascular emer-
Factor X 47 IU/dL (66 - 126 IU/dL)
gency. PEA is a difficult diagnosis that may be missed because of non-speci-
Factor II 35 IU/dL (73 - 113 IU/dL) fic clinical presentation. The initial symptoms of PEA and splenic infarction
Fibrinogen 250 mg/dL (150 - 300 mg/dL) may include dyspnea, chest pain, painless and abdominal pain. We present
a 67 year-old man with abdominal pain and dyspnea. METHODS A 67
year-old man was admitted to our hospital for abdominal pain, dyspnea and
Plasma concentration of coagulation factors was assessed with either chro-
chest pain. Arterial blood gas on 2 L of O2 demonstrated pH 7.46, pCO2
mogenic tests (for factors VIII and IX) or functional tests at extremely
4.2 kPa, pO2 12.5 kPa and HCO3 22.3 mmol/L.Blood tests revealed a white
high dilutions of patient’s plasma with buffer (up to 1:320 for factors VII,
cell count of 18.2×109 /L (lymphocytes 7.5×109 /L, neutrophils 9.1×109 /L).
V and X, up to 1:64 for factor II) in order to avoid as much as possible the
An urgent CTPA revealed a saddle embolus, with propagation of the clot
interference of the inhibitor on coagulation tests. In the presence of normal
from the pulmonary valve extending into both main pulmonary arteries. An
plasma levels of factor V, severe liver disease was ruled out. SCT and dRVVT
abdominal ultrasound (US) shows the presence of hypoechoic lesions and
tests before and after addition of phospholipids confirmed the presence of a
splenic infarction with blood (arrow) between the spleen and diaphragm.
lupus-like inhibitor. Anticardiolipin and anti-beta2 glycoprotein 1 IgG and Bone marrow aspirate showed increased number of B lymphocytes 72%,
IgM antibodies were negative, and cryoglobulins were absent. A diagnosis with dysplastic features. Immunophenotype was CD22+, CD5-, CD23-,
of atypical lupus-like anticoagulant (with a marked prolongation of both CD10+. Histology of lymph nodes prompted the diagnosis of FL. RESULTS
PT and APTT) was made. The patient underwent bone marrow trephyne Treatment with enoxaparin 1 mg/Kg once daily was started.
biopsy (5% infiltration of lymphoma cells) without any blood component Conclusions: Thrombotic complications can be the major cause of mor-
support and without bleeding complications. She is now in the waiting list bidity and mortality as splenic infarction and PEA in follicular lymphoma
for splenectomy. Both B-cell non-Hodgkin lymphoma and HBV infection patients. In our opinion, a multidisciplinary collaboration between haema-
could be responsible for the development of the atypical lupus-like anticoa- tologist, radiologist and cytologist is essential in order to obtain the diagno-
gulant in this patient. The marked prolongation also of PT might be explai- sis and rapidly to start treatment.
ned by the possible activity of this APA against prothrombin.This finding
may challenge invasive procedures for the fear of bleeding. However, the
clinical pattern of the patient (characterized, in this case, by a thrombotic 81. SSRIS AND DOACS: A DANGEROUS ASSOCIATION? A
tendency) should guide doctors’ decisions. In all patients with abnormal CASE REPORT
prolongation of both PT and APTT not explained by severe liver dysfun-
ction, the presence of APA with atypical presentation should be suspected Bondanese M. 1,2, Boccatonda A. 1,2, Dall’o’ F. 1,2, Angelucci E. 2,
and accurately tested before any invasive procedure. Davi’ G. 1,2, Santilli F. 1,2
1
Department of Medicine and Aging, and Center of Aging Science and
Translational Medicine (CESI-Met), Via Luigi Polacchi, Chieti, 66100, Italy.
79. IMAGING MRI IN DIAGNOSIS OF KIDNEY 2
Clinica Medica, Ospedale Clinicizzato SS. Annunziata, Chieti
DLBCL-LYMPHOMA
Case Description: A 84-year-old Caucasian man was admitted to our
1
V. Russo, 2A. Merceri, M. Gobbi Internal Medicine Department for gastrointestinal bleeding, dehydration
1
DIMi- Dip. Ematologia, Università degli studi di Genova, Direttore: Prof. and worsening of general conditions. Medical history was characterized by
M. Gobbi, 2 ASST-Bergamo Est - Responsabile P.S. Osp. di Alzano L.do (BG) severe cognitive impairment due to Alzheimer’s disease, permanent atrial
Introduction: Lymphoma is the most common blood cancer. Diffuse large fibrillation treated with direct oral anticoagulants (DOAC) and benign
B-cell lymphoma (DLBCL) is the most common form of non-Hodgkin prostatic hypertrophy. At physical examination, patient was stuporous but
lymphoma (NHL), accounting for about 30% of newly diagnosed cases of without focal neurologic deficits. Skin and mucous membranes were dry
NHL in United States. The initial symptoms of DLBCL include painless and dehydrated. At chest examination, vesicular murmur was diffusely
swelling in one or more lymph nodes. Some people with DLBCL develop harsh, with no pathological noises. Heart beats were muffled in arrhythmic
large tumors in the abdomen and. kidney. We report a 65-year-old man succession, with badly evaluable pauses. No peripheral edema was present.
with abdominal pain and history of chronic anemia. Abdominal MRI scan Abdomen examination was normal, apparently painless. At digital rectal
detected hyperintense lesions in the kidney and lomboaortic nodes > 1 cm. examination soft stool with red blood were detected. Abdomen x-ray did
METHODS A 65-year-old man with history of chronic anemia was admit- not reveal findings suggesting the origin of intestinal bleeding or intesti-
ted to our hospital for abdominal pain, light increase in serum creatinine nal perforation signs. Chest x-ray did not show inflammatory parenchymal
activity and presence of hypoechoic lesions in the kidney. Abdominal MRI and pleural cavities alterations. Brain CT revealed no signs of hemorrhagic
confirmed hyperintense lesions in the kidney and lomboaortic nodes > 1 lesions or edema, and no indirect signs of intra-cranial expansive lesions.
cm. Bone marrow aspirate showed increased number of B lymphocytes 75%, Blood tests revealed a significant anemia and thrombocytopenia (haemo-
with dysplastic features. Immunophenotype was CD20+, CD79+, BCL-2+, globin: 8.7 g/dL; platelet count: 66 x 103, Table 1). Reticulocyte absolute
BCL-6 +, CD30-, CD15-, CD10-, CD3-. Histology of kidney lesions and count (reticulocytes %: 2.62) and reticulocyte index (2.56) were performed
abdominal nodes prompted the diagnosis of DBCL. RESULTS The patient in order to study anemia and thrombocytopenia, but their results did not
was treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, support the hypothesis of hyporegenerative medullar disease. All the remai-
vincristine and prednisone) obtaining a remission of symptoms. CONCLU- ning causes of thrombocytopenia, including those related to drugs, were
SION DLBCL is an aggressive (fast-growing) lymphoma that can arise in taken into account. By the analysis of collected data, escitalopram treatment
lymph nodes or outside of the lymphatic system, in the gastrointestinal tract had been introduced about one month before, due to a form of depres-
or in the kidney. A possible strategy is to perform US as the initial technique sion linked to dementia. In the literature, some SSRIs have been related to
in all patients with acute abdominal pain, with CT performed in all cases thrombocytopenia as a detrimental side effect. Therefore, escitalopram tre-
of nondiagnostic. US data on the use of MR imaging for this indication are atment was withdrawn with a progressive increase of platelet count, and the
still sparse. The use of conventional radiography has been surpassed; this concurrent resolution of the GI bleeding. The patient was discharged on the
examination has only a possible role in the setting of bowel obstruction. sixth day in good clinical conditions, and DOAC therapy was reintroduced
with good clinical outcome.
Conclusion: Clinicians should be aware of the possible association between
99
SSRI-induced thrombocytopenia and concomitant use of anticoagulant dysphagia and fever up to 39 ° C. His medical history was characterized
and/or antiplatelet therapies, in order to prevent detrimental bleedings. by multinodular toxic goiter in hormone-reductive treatment. On arrival
Because the absolute risk of gastrointestnal bleeds with SSRIs is low, precau- at our Medicine Department, a bed-side point of care ultrasound was per-
tions are probably necessary only in high-risk patients, such as those with formed showing a well structured trachea and a thrombosis of the right
peptic acid disease and those with a history of bleeds. internal jugular vein. Subsequently, a neck and thorax CT scan confirmed
the thrombosis of the right internal jugular vein in the intracranial tract
and its irregular opacification in the distal tract, close to the confluence
82. LOW MOLECULAR WEIGHT HEPARIN IN VERY with the anonymous veins, with eccentric hypodense image also compa-
ELDERLY: IS IT REALLY SAFE? tible with thrombus. Moreover, CT scan highlighted widespread edema of
lateral epidermal tissues at the right branch of the jaw, and right muscle
Colombo G. 1, Arcudi S. 1, Rossio R. 1, Ferrari B. 1,2, Peyvandi F. 1,2,3 edema and signs of suspected para-pharyngeal involvement. Clinically,
1
U.O.C. di Medicina Generale - Emostasi e Trombosi, Dipartimento di patients displayed an ectopic swelling in the lower right dental arch site with
Medicina Interna, Fondazione IRCCS Ca’ Granda Ospedale Maggiore erythema and cellulite, with spontaneous pus drainage. A specialized den-
Policlinico di Milano, 2 Angelo Bianchi Bonomi Hemophilia and Thrombosis tistry examination confirmed the diagnosis of granuloma of the sixth lower
Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di right dental tooth. Subsequently, the patient underwent dental surgery with
Milano, 3 Luigi Villa Foundation, Fondazione IRCCS Cà Granda Ospedale granuloma drainage. The cultures carried out on the drained material, reve-
Maggiore Policlinico di Milano aled a positivity to Fusobacterium Necrophorum. An empirical antibiotic
therapy with ceftriaxone and metronidazole was established, then confir-
A 92 year-old female in good general condition presented to our department med by the antibiogram result. At the same time, anticoagulant therapy was
with a diagnosis of septic and hypovolemic shock in Clostridium Difficile introduced, firstly with enoxaparin, followed by direct oral anticoagulant
enterocolitis treated with metronidazole intravenous and oral vancomicina. treatment. Patient was discharged on the 8th day in good clinical conditions.
She was transferred from a subacute ward to our Internal Medicine Unit. Conclusion: Lemierre syndrome is a potentially fatal pathology following
Her history was relevant for chronic bronchitis and previous pulmonary a head/neck region infection, classically described as an internal jugular
embolism in oral anticoagulant therapy with rivaroxaban. Furthermore vein thrombophlebitis, associated with an infection of the cervical region
during the period of rehabilitation, the stay was complicated by two episodes extended to the chest. The syndrome is often caused by Gram - bacteria,
of pulmonary infections: the first treated with piperacillin/tazobactam plus in particular Fusobacterium necrophorium. The etiopathogenesis is based
levofloxacin and the second with ceftriaxone and azithromicina. At presen- on the spread of the infection from the oropharynx through the tonsillary
tation the patient was pale, with mild mental confusion, blood pressure was veins and the jugular veins inside the neighboring and distal tissues (lungs,
65/30 mmHg, pulse rate 90 beats/min, respiratory rate 28 breaths/min, body joints). Since the introduction of antibiotic therapy for the treatment of
temperature was 38 C °. In our department blood test revealed: leucocyto- pharyngitis, the incidence of the syndrome has drastically reduced, thus
sis (11 x 103mmc), increase in c-reactive protein (11 mg/dl), hemoglobin erning the title “the forgotten disease.”
11.5 g/dl, platelet 200 x103mmc, normal renal and hepatic function. Beside
antibiotic therapy, hydratation and dopamine support (with renal dosage)
were introduced with rapid improvement of clinical condition. In the next 84. RESULTS OF A PROPHYLACTIC PROTOCOL
days the oral anticoagulant therapy was switched to low molecular weight FOR DENTAL CARE IN A PATIENT WITH LIGNEOUS
heparin at a dose adjusted for age and renal function. An episode of paroxy- GINGIVITIS DUE TO SEVERE PLASMINOGEN
smal atrial fibrillation without hemodynamic impairment occurred. After DEFICIENCY
ten days of recovery the hospitalization was complicated by syncope during
mobilization and the blood analysis revealed a worsening of anemia (hemo- Di Pasquale I. 1, Boscaro F. 1, Sivolella S. 2, Saggiorato G. 3,
globin 8.5 g/dl from a baseline of 11.5 g/dl) for which the patient underwent De Biagi M. 2, Sartori M.T. 1
to a single blood transfusion. The day after the patients complained abdo- 1
Clinical Medicine I, Department of Medicine, University of Padua, Italy;
minal pain and anterior wall bruising. She developed tachycardia (heart rate 2
Section of Dentistry, Department of Neurosciences, University of Padua,
100 beats/min) and hypotension (85/60mmHg). Firstly it was suspected a Italy; 3Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine,
recurrence of the recent septic shock in Clostridium Difficile enterocoli- University of Padua, Italy
tis, but the clinic was progressively improved during hospitalization with a
reduction of the inflammatory index and a normalization of temperature. Background: Severe congenital plasminogen (PLG) deficiency causes a rare
The blood analyses confirmed worsening anemia (hemoglobin 7.3 g/dl), disease, known as ligneous conjunctivitis, characterized by the growth of
prothrombin time (1.18 s), thrompoplastin time (1.19 a), fibrinogen 159 fibrin rich pseudomembranes on mucosal surfaces. Besides of conjunctiva,
mg/dl. The patient was stabilized with inotropes and fluids. In the suspect gums are often involved, leading to ligneous gingivitis (LG). Specific therapy
of gastrointestinal bleeding an abdomen computed tomography was perfor- for LG is not established. We describe a prophylactic protocol with enoxapa-
med showing a bilateral hematoma of the right muscles (18 cm x 14 cm). It rin and fresh frozen plasma (FFP) for dental invasive procedures in a patient
was subjected to angiography with embolization of both inferior epigastric with LG due to PLG deficiency.
arteries The procedure was well tolerated and the patient recovered. She Methods: A 43 years old female with LG was referred to us in 2009. She had
was transferred to a rehabilitation facility (at discharge haemoglobin levels ligneous conjunctivitis in childhood and ligneous cervicitis refractory to
were normalized, 10.5 g/dl). Overall she was transfused with six packer reb conization. PLG antigen and activity levels, and PLG genetic analysis were
blood cell units. Rectus muscles hematoma (RSH) is an uncommon cause of carried out. In order to prevent LG recurrence after dental invasive proce-
abdominal pain. It is the result of bleeding from damage to the superior or dures, a prophylactic treatment including 10 ml/kg bw FFP before and the
inferior epigastric arteries. Anticoagulation can be a predisposing factor or day after the intervention and enoxaparin 100 U/kg bw od for 20 days was
the accidental intramuscular injection of low molecular weight heparin can given in addition to proper mini-invasive dentistry techniques and implant
directly cause rectus sheath hematoma. Although rectus sheath hematoma surgery.
are mostly self limiting, mortality can reach 25%. Results: The patient’s PLG antigen and activity levels were 25 ug/ml and
27%, respectively, and genetic analysis showed a c.112A>G p.K38E muta-
tion in exon 2 and c.1256+1G>A substitution at donor site of exon 10, each
83. AN UNUSUAL CASE OF THROMBOSIS: “THE in heterozygous level. Right tooth root extraction with gum suture was
FORGOTTEN DISEASE” performed in 2009, left molar tooth extraction and contralateral implant
positioning in 2012, and right molar tooth extraction in 2015. PLG activity
Dall’o’ F. 1,2, Boccatonda A. 1,2, Bondanese M. 1,2, Angelucci E. 2, levels raised to about 46% two hours after FFP transfusion and returned to
Davi’ G. 1,2, Santilli F. 1,2 baseline after 48 hours. Small gingival pseudomembranes developed soon
1
Department of Medicine and Aging, and Center of Aging Science and after interventions and disappeared within one week; no bleeding complica-
Translational Medicine (CESI-Met), Via Luigi Polacchi, Chieti, 66100, Italy tions were seen. The patient denied FFP transfusion in 2015.
2
Clinica Medica, Ospedale Clinicizzato SS. Annunziata, Chieti Conclusions: In our patient with LG, the adoption of combined hematolo-
gical and dentistry protocols appeared to be safe and effective in preventing
Case Description: A 85-year old male was admitted to our Internal Medi- abnormal gingival pseudomembranes growth after dental interventions,
cine Department for the onset, two days before, of dyspnoea associated with maintaining a good parodontal condition.
edema, pain and functional limitation to the right antero-lateral region
of the neck. Five days before, the patient had experienced odontalgia,
100
85. A RARE CAUSE OF ABDOMINAL PAIN 87. CYTOMEGALOVIRUS-ASSOCIATED SPLANCHNIC

VEIN THROMBOSIS: CASE REPORTS
Fallai L. 1, Maestripieri V. 1, Tozzetti C. 2, Torri M. 2, Poggesi L. 1
1
Università degli Studi di Firenze; 2 Azienda Ospedaliero-Universitaria Tufano A., Contaldi P., Cerbone A. M., Di Minno G.
Careggi Regional Reference Centre for Coagulation Disorders. Department of Clinical
Medicine and Surgery. “Federico II” University Hospital, Naples, Italy
We present a case of a 56 years-old woman with epigastric and right hypo-
chondrial pain and one episode of vomit. She reported no significant medical Background: Splanchnic vein thrombosis (SVT) typically occurs in patients
history and no pharmacological therapy. She had two previous similar epi- with cirrhosis, intra-abdominal inflammatory processes, cancer, prothrom-
sodes leading up to diagnosis of gallstones and she was waiting for cholecy- botic disorders, and can be clinically silent or may present with abdomi-
stectomy. At physical examination vital signs were normal, except for fever nal pain, fever and other non-specific symptoms. Acute cytomegalovirus
(38°C); pain was localized in the right subcostal region, without tenderness, (CMV) infection has been reported to be associated with venous throm-
no Murphy’s or Blumberg’s sign, and normal peristalsis. Laboratory results botic events in immunocompromised patients; these events mainly involve
showed only a slight increase in gamma-GT, ALT, AST, and PT. Abdomi- the splanchnic veins, and less frequently, the lower limb deep veins, and
nal Ultrasounds showed a noncontracted gallbladder without lithiasis and pulmonary circulation. However, venous thromboembolism during CMV
normal wall thickness, no biliary dilatation but portal vein dilatation. An infection is increasingly reported in immunocompetent adults in which
abdominal CT scan showed a splenic vein thrombosis, extended to superior thrombotic events often have acquired/inherited predisposing factors other
mesenteric vein and portal vein, with irregular early hepatic parenchyma than the infection.
enhancement. We researched both inflammatory and paraneoplastic aetio- Methods: We described two young immune-competent patients who expe-
logy of the vein thrombosis with upper and lower gastrointestinal endo- rienced an episode of SVT associated with acute CMV infection. Case I. A
scopy and mammography, both negative; magnetic resonance cholangio- 40-year-old man with fever, abdominal pain and diarrhea was admitted to
pancreatography ruled out biliar cancer showing ab-estrinseco compression our Department of Internal Medicine on 12 May 2012. He had been treated
of principal biliar duct from periportal edema. Despite normal blood count ineffectively with antibiotics in the previous weeks. His past clinical history
values she was studied for the presence of JAK2 mutations, reported as a included hypertension, obesity and he was carrier of beta-thalassemia. Al
marker for occult myeloproliferative disorder in patients with splanchnic admission, the patient had documented fever (>38 °C) and he complained
venous thrombosis, resulting absent. Patient was treated with piperacil- pain in right hip but there were no superficial lymphadenopathy on physical
lin-tazobactam and fondaparinux with a gradual regression of pain and examination. Blood tests revealed the presence of leukopenia with relative
fever. At discharge, patient was feeling well, recanalization of thrombosis lymphocytosis, elevated liver cytolysis indices, increased of lipase, amylase,
was documentend only on superior mesenteric vein, whereas splenic and lactate dehydrogenase (LDH) and D-dimer. Chest x-ray and electrocardio-
portal veins remained obstructed, so we advised to continue anticoagula- gram were negative. A computed tomography (TC)- scan of his abdomen
tion at least for 3 months, suggesting a CT scan after three months. demonstrated an extensive thrombus of splenic vein and superior mesen-
teric vein. The screening for inherited/acquired thrombophilia [including
FVL and prothrombin (FII) G20210A gene polymorphisms, anti-cardio-
86. A CASE OF PULMONARY EMBOLISM IN CEREBRAL lipin antibodies (aCL) and lupus anticoagulant (LA), and antithrombin,
AMYLOID ANGIOPATHY: FOCUS ON ANTICOAGULANT protein C, protein S, and homocysteine] was negative. Haematological
THERAPY (bone marrow aspirate and JAK 2 mutation were normal) or neoplastic
diseases were excluded. Serological tests for HIV, hepatitis (A, B, C and
Spampinato M.D., De Giorgi A., Fabbian F., Bagnaresi I., Pasin M., E), toxoplasma and EBV were normal. However, CMV serology revealed
Manfredini R. high-titre IgM antibodies (100 IU/ml, with normal values < 12) with nega-
Medical Clinic, S. Anna-Ferrara Hospital-University Hospital tive IgG antibodies, and a low IgG avidity index: 0.122 (reference range <0.2:
low), suggesting acute infection. The patient was anti-coagulated with full
Introduction: Cerebral amyloid angiopathy (CAA) is a clinical neurolo- therapeutic doses of enoxaparin (8000 IU twice daily) and then warfarin.
gic conditions related to cerebral deposition of different types of amyloid The systemic symptoms gradually resolved without the need for gancyclo-
protein. Amyloid β-protein (Aβ)-type represent the most commonly protein vir. After 6 months a complete resolution of the thrombus was showed at the
found in older individuals usually localized in the leptomeningeal and CT-scan and warfarin was discontinued. Case II. A 24 year-old female pre-
cortical vessels. Occipital and cerebellum lobes are preferentially affected, sented to the emergency room (ER) on 3 March 2011 with fever and abdo-
whereas basal ganglia, thalamus, brainstem, and white matter are uncom- minal pain from a week, without changes in bowel habits. She was carrier of
mon localization of disease. CAA is present in 25% of patients with Alzhei- beta-thalassemia and she reported a history of uterine myomas, gallbladder
mer disease. Lobar intracerebral hemorrhage represents the catastrophic stones, obesity. A biliary colic was hypothesized in a first moment, not con-
complication CAA-related in elderly patients.Anticoagulation therapy (AT) firmed at ultrasound (US) evaluation, while a urgent CT-scan of abdomen
appears generally unsafe, even for strong indications such as non-valvular demonstrated thrombosis of the inferior mesenteric vein, without extension
atrial fibrillation or pulmonary thromboembolism. to portal and splenic veins. Use of OC was denied, hematological and neo-
Case report: 70 years malewas admittedin our internal medicine ward for plastic causes were excluded, and no other cardiovascular risk factors were
cough andfever. Medical history demonstratedhypertension, post-trauma- present. Serological tests for HIV, hepatitis (A, B, C and E), toxoplasma and
tic right hip prosthesis, previous episodes of pulmonary embolism following EBV were normal. However, CMV serology revealed high-titre IgM anti-
deep-underwater diving, ischemic cardiomyopathy, previous occipital and bodies (129 IU/ml, with normal values <12) with negative IgG antibodies,
parietal cerebral hemorrhage.CAA lesions in temporal-occipital-parietal suggesting acute infection. She was treated with low doses enoxaparin (4000
bilaterallylobes related to previous microbleedingswere shown by brain IU once daily), only for 2-3 weeks. On april 2015 the patient was referred to
magnetic resonance.On the other hand, physical examination was unre- our Department, because of the intention to become pregnant, and at this
markable. Being D-dimer value high legs color-doppler ultrasound (CDU) time a thrombophilia work up showed heterozygous FII G20210A muta-
and computer tomography (CT) pulmonary angiography were performed. tion. A CT-scan of her abdomen showed resolution of the thrombus. She
CDU showed a posterior tibial vein (1.4 mm) and a peroneal vein (2 mm) was treated with enoxaparin 6000 IU once daily during pregnancy, without
thrombosis, while CT pulmonary angiography documented the presence thromboembolic recurrences.
of isolated thromboembolic lesion. Moreover, some areas of interstitial thi- Conclusions: Venous thromboembolism during CMV infection is incre-
ckening characterized as micro-nodularity adjacent to bronchiectasis were asingly reported in immunocompetent adults and the diagnosis of SVT
showed in the pulmonary parenchyma. In order to define usefulness of AT, in these cases should encourage the search for thrombophilic conditions
HAS-BLED score was calculated. HAS-BLED was 4 (high risk of major ble- which might better guide the optimal management strategy.
eding). Only prophylaxis dose of heparinwas started with an indication to
wear elastic stockings. Six monthslater no clinical complications (thrombo-
tic or hemorrhagic) were reported.
Discussion: Our case is the first one reporting association between CAAand 88. RECURRENT PULMONARY EMBOLISM AND
venous thromboembolism.Risk-effectiveness ratio of AT in difficult to Β-THALASSEMIA: A CASE REPORT
define in CAA patients.Further case reports are needed in order to establish
the correct AT in patients with CAA. Tufano A. 1, Gianno A. 1, Franco N. 1, Alcidi G. 1, Nardo A. 1, Polimeno M. 1,
Ricciardi E. 1, Cerbone A.M. 1, Galderisi M. 2, D’Alto M. 3, Coppola A. 1, Di
Minno G. 1
101
1
Department of Clinical Medicine and Surgery. Federico II University 90. SINGLE ADMISSION, DOUBLE DIAGNOSIS
Hospital, Naples, Italy 2Department of Advanced Biomedical Sciences.
Federico II University Hospital, Naples, Italy 3Department of Cardiology. Brunelli V., Pirro L., Pontillo G., Pafundi P.C., Altruda C.,
Seconda Università degli Studi, A.O.R.N. Monaldi, Napoli Caturano A., Salvatore T., Adinolfi L.E.
University of Campania “Luigi Vanvitelli”, Naples Division of Internal
Background: Adult patients with β-thalassemia are at increased risk of Medicine
thromboembolic events and pulmonary arterial hypertension (PAH), due
to a hypercoagulable state, including chronic platelet activation. In March 2017, a 67-year-old patient was admitted to our Division because of
Case Report: A 54-yr-old man with β-thalassemia intermedia, splenecto- subacute appearance of diplopia, asthenia and postural instability. On admis-
mized 30 years earlier, and a history of unprovoked deep venous thrombosis sion, vital signs were: blood pressure 115/65 mmHg, heart rate 62 bpm and
(DVT) complicated by pulmonary embolism (PE) at the age of 36, on long- regular, 96% oxygen saturation, respiratory rate 16 breaths/min. The patient
term vitamin K-Antagonists (VKA) during which two episodes of super- had a 10-year history of type 2 diabetes mellitus, treated by dapaglifozin, and
ficial vein thrombosis (SVT) occurred, in the absence of known throm- past kidney stones. In the previous days, the patient had had fever (<38 C)
bophilia, was admitted to our Department in November 2016 because of with nausea, vomiting and generalized malaise. At the physical examination,
acute dyspnea. A CT-scan showed recurrent PE without DVT and at echo- ataxia, asymmetric finger chasing, bilateral deficit of III cranial nerves and
cardiography remarkably increased pulmonary arterial systolic pressure (88 symmetrical areflexia of both upper and lower limbs were found. The patient
mmHg) was found. VKA was stopped and the acute event was treated with underwent a skull TC which showed a pituitary lesion of about 2-cm dia-
full dose enoxaparin and then apixaban (5 mg twice daily). Two months meter causing deformation of the sella turcica. Hence, a diagnostic lumbar
later he was urgently re-admitted because of worsening dyspnea and PAH puncture, an electromyography, and a research of antibodies against gan-
(145 mmHg), with CT evidence of further PE recurrence. Cardiac catheteri- gliosides were done. At the same time, the patient started immunoglobulin
zation confirmed chronic thromboembolic pulmonary hypertension. VKA therapy. The lumbar puncture showed an albumin-cytological dissociation;
was reintroduced, but aspirin and riociguat were added, with symptomatic electromyography documented a widespread damage of peripheral nervous
and echocardiographic improvement during 3-mo follow-up. fibers, with demyelination and axonal degeneration; anti-gangliosides antibo-
Discussion: A chronic hypercoagulable state and platelet activation is dies (GM1, GM2, GM3, GD1a, GD1b, GT1b, GQ1b) resulted negative. These
present in splenectomized patients with β-thalassemia. Thromboembolic data, associated with the impressive clinical improvement obtained by immu-
events and PAH represent common, yet poorly understood complications. noglobulin treatment, led us to diagnose a Miller Fisher syndrome, a variant
Data regarding the use of anticoagulants (VKA, heparins, direct oral anti- of the Guillan Barré syndrome. Apart from neurological problems, the patient
coagulants) and antiplatelet agents to prevent/treat thromboembolic com- presented the following clinical picture: increase of acral bones with frontal
plications in these patients are limited. The available evidence suggests that protrusions; size growth of hands, feet and nose; enlargement of the jaw with
adding aspirin may reduce the risk of recurrences. prognathism; hepatomegaly; muscular hypotrophy prevalent in the lower
limbs. Furthermore, during the hospitalization the patient resulted euglyce-
mic even without antidiabetic treatment. So, the patient underwent a cerebral
89. PARANEOPLASTIC HYPOGLICEMIA: A SERIOUS MRI, which confirmed 25 x 22 mm lesion in the sella turcica, dislocating the
CHALLENGE FOR CLINICIANS optic chiasm and the pituitary peduncle, as in pituitary macroadenoma. Basal
hormonal examinations showed an increase of GH (8.9 ng /ml; n. v. < 5) with
Boccatonda A. 1,2, Bondanese M. 1,2, Dall’o’ F. 1,2, Angelucci E. 2, normal IGF-1 (146.6 ng /ml; n.v. 120-246) which was confirmed by glucose
Davi’ G. 1,2, Santilli F. 1,2 tolerance test (GH t0 9.2 ng/ml, t30 8.5, t60 8.4, t90 9.1, t120 9.4; n.v. <1). The
1
Department of Medicine and Aging, and Center of Aging Science and diagnosis of acromegaly was performed. In addition, an increase in prolactin
Translational Medicine (CESI-Met), Via Luigi Polacchi, Chieti, 66100, Italy. 2 (89.1 ng /ml; n.v. 4.1-18.4) as a consequence of pituitary peduncle diversion
Clinica Medica, Ospedale Clinicizzato SS. Annunziata, Chieti and a deficiency in the gonadotropic (FSH 0.5 UI /L, n.v. 1.3-118; LH 0.2 UI
/L, n.v. 2.8-6.8; testosterone 8 ng /dL, n.v. 195-895), corticotropic (ACTH 3.8
Case Description: A 50 year-old woman, was admitted to our Internal pg /mL, n.v. <60; cortisol 13.4 mcg /dL, n.v. 4.5-24), and thyreotropic (TSH
Medicine Department for recurrent and treatment-resistant hypoglycemic 0.429 mUI/ml, n.v.0.4-4; FT3 0.8 pg /mL, n.v. 1.5-5.9; FT4 4.5 pg /mL, n.v.
crises leading to loss-of-consciousness. Medical history was characterized 5.2-15.8) axes due to mass effect of pituitary adenoma, were found. These
by pancreatic malignant insulinoma with hepatic metastasis treated with data could explain hypotension, euglycaemia and the whole clinical status
spleen preserving left pancreasectomy intervention and multiple liver meta- of the patient, which in part differed from that expected in the acromegaly.
stasectomy of III and IV hepatic segment and cholecystectomy. On admis- After complete remission of neurological picture, the patient started a hor-
sion, for the current symptoms, a re-staging total body TC was performed, monal replacement therapy (Cortisone acetate 25 mg/die and, a week later,
showing partially confluent secondary locations predominantly located in Levothyroxine 50 mcg/die) prior to be submitted to neurosurgical interven-
the left hepatic lobe of which the largest is about 1.5 cm in diameter between tion. The follow up documented a very good clinical outcome. In conclusion,
the II and III hepatic segment, and a number of secondary lesions located the appearance of a rare neurological clinical entity such as the Miller Fisher
in the right hepatic lobe, compared with the previous control. Initially the syndrome allowed us to diagnose even a longstanding disease that slyly may
patient was treated with infusion therapy of 33% and 5% glucose solutions determine serious consequences in multiple organs such as acromegaly.
and endovenous high dose steroid therapy, with concurrent tight glycemic
monitoring. Despite this, patient continued to experience severe hypo-
glycaemia, which prompted us to introduce diazoside at maximum doses. 91. A BITTER SWEET DISEASE
Even this therapeutic strategy was associated with poor outcomes and poor
glycemic control. A subsequent oncologic evaluation suggested the addi- Caturano A. 1, Brunelli V. 1, Spiezia S. 1, Solaro E. 1, Acierno C. 1,
tion of somatostatin analogue, lanreotide, on top of current therapy. There- De Sio C. 1, Pontillo G. 1, Giunta R. 1, Adinolfi L.E. 1, Sasso F.C. 1
fore, even though the best medical therapy was set, according to literature University of Campania “Luigi Vanvitelli”, Naples Division of Internal
and guidelines, little clinical benefits were observed. For this reason, a left Medicine
hepatic lobe and branches for the IV hepatic segment chemoembolization
procedure was performed, with progressive benefit. Patient was discharged On March 24, 2017, at morning fasting, the patient reported an episode
on the eighteenth day in good clinical conditions with a good glycemic of loss of consciousness preceded by shivers and sweating. At Emergency
control and sporadic hypoglycaemic episodes responding to food intake. Room, the patient was rescued and found in a state of drowsiness and hypo-
Discussion:The management of malignant insulinomas represents a serious glycemic crisis (30 mg / dl), a symptomatology that quickly regressed after
challenge for clinicians. Methods aimed at hypoglycemia prevention and tre- administration of a glucose solution. On March 31st, she practiced a day
atment include patient education, lifestyle modification, pharmacotherapy, hospital admissions at a diabetes clinic during which was showed a modest
cytoreductive therapies and continuous glucose monitoring systems. When increase in urinary methanephrenes, normal cortisolemia, HbA1c: 3.5%.
the use pharmacotherapy is not sufficient to normalize glycemic control, Currently, the patient reports headache, sweating and intense asthenia.
a decrease in hormonal secretion can be achieved by applying invasive This symptoms quickly regress after sugar intake. The physical examina-
methods, i.e. debulking surgery and liver metastases chemoembolization. tion showed mitral heart murmur 2/6 according to Levin scale and reduced
vesicular murmur to the pulmonary bases. Furthermore, during the hospi-
talization the patient exhibited a marked glycemic variability, so we investi-
gated the endocrine aspects both laboratory and imaging. From the labora-
tory point of view, the patient underwent 72 hour fast test, interrupted by
102
marked hypoglycemia (46 mg/dL) associated with hyperinsulinaemia (17 hospitalization of serum calcium values, phosphorus, PTH until normaliza-
μU/mL) and hyperC-peptidemia (4.33 ng/mL), OGGT that initially showed tion predi mission. It undertakes to treatment with cinacalcet discharge cp
an increase in glucose level, insulin and c-peptide until the end of the first 30 cp 1 mg / day.
hour, but then glucose started to lower more than the other parametres and Discussion: Current international guidelines focus on normalizing serum
at the third hour the values were: glucose 34 mg/dL, insulin 60.6 μU/mL, calcium by surgery and reducing the impact of PHPT on target tissues
C-Peptide 8.0 ng/mL. Patient was studied by CT with contrast material, that with preservation of renal and skeletal health. The impact of a nonsurgi-
highlighted at the body-tail junction of the pancreas, dorsally with respect cal approach to lowering serum calcium is thus an important considera-
to the main pancreatic duct and immediately below the splenic vein, the tion in the medical management of PHPT among those individuals with
presence of a solid nodular formation artery perfused, with a maximum clinically important hypercalcemia who are not candidates for parathyroid
diameter of about 14 mm, and octreoscan that could not manage to iden- surgery. Thus, cinacalcet would be a useful treatment option for subjects
tify APUD pathology in the resolution limits. These findings, despite the who have hypercalcemia and have failed surgery or are unable to proceed
negative octreoscan, allowed us to suppose that our patient was suffering with surgery. In addition, in subjects with multiple endocrine neoplasia
from insulinoma, a tumor of the pancreas that is derived from beta cells (MEN), cinacalcet has been shown to be useful in delaying surgery, if neces-
and secretes insulin. It is a rare form of a neuroendocrine tumor. Most insu- sary, while maintaining normocalcemia. The dose regimens of cinacalcet
linomas are benign in that they grow exclusively at their origin within the required to lower serum calcium in MEN1-associated PHPT appear to be
pancreas. The patient was referred to surgical intervention of distal pancre- similar to those required in sporadic PHPT.
atectomy and the insulinoma was found as we suggested. After one month Conclusions: The authors present a case report of primary hyperpara-
follow up, the patient had not experienced any acute hypoglycemia. thyroidism in a 78 aa woman came to our attention by state stupor and
severe hypercalcemia.
92. PRIMITIVE HYPERPARATHYROIDISM: CASE REPORT

93. COMORBIDITIES ASSOCIATED WITH
Pignata D. 1, Ciammaichella M.M. 1, De Paola G. 1, Maida R. 1, HYPOPARATHYROIDISM: AN 8-YEAR REGISTER-BASED
Ulissi A. 1, Puglisi L. 1, Petrecca I. 1, Marzano M.A. 1, Ala A. 1, STUDY IN ITALY
Ciancio L. 1,Fanfarillo F. 1, Spada A. 2, Santonati A. 2, Santini E. 3
1
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma 2 Cipriani C. 1, Pepe J. 1 Manai R. 1, Biamonte F. 1, Baffa V. 1,
Endocrinologia, A. O. S. Giovanni-Addolorata, Roma 3 Servizio di Occhiuto M. 1, Danese V. 1, Nieddu L. 2, Minisola S. 1
Radiologia, Artemisia, Roma 1
Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma
“Sapienza” 2Facoltà di Economia, Università degli Studi Internazionali di
Introduction: The authors present a case report of primary hyperpara- Roma
thyroidism in a 78 aa woman came to our attention by state stupor and
severe hypercalcemia. Primary hyperparathyroidism (PHPT) is diagnosed Purpose: To assess the prevalence of comorbidities associated with hypopara-
by the presence of hypercalcemia and an elevated or nonsuppressed para- thyroidism among hospitalized patients in Italy during an 8-year period.
thyroid hormone (PTH) level. PHPT is caused by a solitary adenoma in 85% Methods: We retrieved data from the ‘‘Record of Hospital Discharge’’ (SDO) of
of cases, with multi-glandular disease occurring in up to 15% of cases. Para- the Italian Health Ministry, from the year 2006 to 2013 and analyzed the codes
thyroid carcinoma is rare. Following the introduction of the multiple-chan- corresponding to hypoparathyroidism-related diagnoses. We observed a mean
nel biochemical analyzers in the early 1970s, the clinical presentation of prevalence of hypoparathyroidism of 5.3/100, 000 inhabitants/year among
PHPT changed from a symptomatic condition (e.g., renal stones, fragility inpatients and retrieved the data corresponding to cardiovascular, infectious,
fractures, and significant hypercalcemia) to a largely asymptomatic condi- urinary tract and psychiatric disease, cerebral calcifications, epilepsy, skin,
tion (4). With parathyroid surgery, PHPT may be cured, with normalization cataract, fracture and cancer. The codes corresponding to cancer of the neck
of both serum calcium and PTH. Surgery is both safe and effective in expe- region were excluded as hypoparathyroidsm can result from neck surgery in
rienced hands with surgical success rates typically O95%. In subjects with these cases.
symptomatic PHPT, surgery is indicated. At the 3rd and, more recently, the Results: Table 1 shows the prevalence of diagnoses of the aforementioned com-
4th International Workshops on the management of asymptomatic PHPT, plications, demographic data and days of stay in the period 2006-2013.
amended guidelines were developed to identify which patients may be safely
followed without surgery. The recommendations from these workshops also
provide a set of guidelines for appropriate monitoring and medical fol- Comorbitidities n (%) of Sex Age (years; Days of stay
hospitalitazions (F/M ratio) mean±SD) (mean±SD)
low-up in those who do not meet surgical guidelines as well as those who
are unable or unwilling to undergo parathyroidectomy. Cardiovascular 3600 (31.4) 2.8:1 64.4±16.7 11±11.4
Case Report: The authors present a case reportof primary hyperparathyroi- Infectious 903 (7.9) 2.8:1 51.9±23.2 12.7±11.7
dism in a 78 aa woman came to our attention by state stupor and severe
hypercalcemia. In history we record BBS, high blood pressure, multi-infarct Urinary tract 955 (8.3) 2.2:1 64.6±16 10.9±10.3
encephalopathy with cognitive impairment During the stay the following Psychiatric 595 (5.2) 3.1:1 55±22.9 10.3±11.4
tests are performed:
Epilepsy 252 (2.2) 2.1:1 52.2±23.4 12±11.8
1) ECG: sinus rhythm, BBS with short QT interval
2) ECG sec. Holter: constant RS, BBS, absence of significant breaks 3) Blood Cerebral 46 (0.4) 1.4:1 57.5±18.7 14.5±11.3
calcifications
tests: thyroid function within the limits, Ca 16 mg / dL (8.1 to 11.0 NV),
Phosphorus 2.0 (2.7 to 4.5 NV), calciuria 830.30 mg / 24h (NV 100-400), pg Skin 197 (1.7) 3.5:1 51±25.4 10.8±12.5
/ ml 148, 00 PTH (NV 12-72) Cramps and 214 (1.9) 3.9:1 50±23 8.2±8.9
4) Search secondary thrombophilia markers: negative tetany
5) Search primary thrombophilia markers: negative
Cataract 18 (0.2) 1:1 58.2±16.9 8.3±8.5
6) Trans-thoracic echocardiogram: VS limits, Chinese preserved, FE 57%,
diastolic dysfunction of first-degree, right-wing sections in the standard, Fracture 94 (0.8) 2.7:1 66.5±220.2 16.2±11.8
pericardium unscathed Cancer 898 (7.8) 2.2:1 59.5±15.7 9.2±9.8
7) Abdominal ultrasound: spot kidney hyperechoic
8) Ultrasound thyroid and parathyroid: thyroid limits, 2 nodules in the left
Conclusions: Our preliminary results demonstrate that there is a high preva-
lobe in the upper middle third of the diameter of 8 mm, hyperechoic and
lence of cardiovascular, infectious, urinary tract, psychiatric diseases and cancer
solid each, 5 mm calcific the other
in association with the diagnosis of hypoparathyroidism in Italy in the period
9) Chest X-ray. cardiomegaly
2006-2013. Comorbidities are more frequent in the sixth-seventh decade of
10) CT skull. Leukoencephalopathy chronic ischemic hypoxic
life and in women than men. It is interesting to note the low rate of hospita-
11) Parathyroid scintigraphy with Tc 99 sestamibi and in terms of image
lization for fracture among patients with hypoparathyroidism. More data on
subtraction: differential wash-out between thyroid gland and parathyroid
factors possibly associated with the epidemiology and clinical manifestation of
adenoma: a) early phase scintigram shows a focus of increate activity in the
the comorbidities are needed. In particular, results need to be validated by the
middle of the left thyroid lobe; b) two-hour scintigram shows persistence
comparison with a control population in order to define the prevalence of the
of the focus, a finding consistent with parathyroid adenoma It undertakes
aforementioned comorbidities in association with hypoparathyroidism.
moisturizing therapy, phosphonates, cortisone, diuretici.Si monitor during
103
94. THE CONSTELLATION OF SYMPTOMS AS A WHOLE: glands with a remarkable improvement in the diagnosis and characteriza-
AN EXAMPLE OF THE INTERNISTIC METHODOLOGICAL tion of adrenal insufficiency. Although cardiac tamponade and recurrent
APPROACH IN THE FIELD OF ENDOCRINOLOGICAL pericarditis are not considered a key manifestations of the autoimmune
DISORDERS polyglandular syndrome (APS) type II, our findings, according to recent
literature, suggest that APS II should be considered in the differential dia-
D’Onofrio F., Settimo E., Belfiore A., Buonamico P., Palmieri V.O., gnosis of these clinical features.
Minerva F., Pugliese S., Portincasa P.
Oncology, University of Bari Medical School 96. SEVERE HYPOKALEMIA FROM HASHIMOTO
THYROIDITIS COMPLICATED BY LIFE-THREATENING
A 69 year old woman came to our attention for headache, hypertension, SUSTAINED VENTRICULAR TACHYCARDIA
weight loss, marked asthenia, hypersomnia, anasarca for about 1 year.
Medical history revealed diabetes mellitus type 2 and previous laryngeal A. Grembiale, E. Corigliano, A. Franchi, D. Siclari, M. Nocera,
cancer. In the last few months she underwent cardiological visits, nephro- A. Galdieri, R. Costa, G.F. Mauro
logical visits, nutritionistic counseling that advised diet and weight loss that U.O.C. di Medicina Interna - P.O. “San Giovanni di Dio” - Azienda Sanitaria
did not resolve the symptoms. At our observation: BMI 41.2 kg/m2, PA: Provinciale di Crotone
145/90 mmHg, Fc: 70 bpm; routine laboratory examinations and thyroid
hormones were normal as well as ECG, echocardiogram, abdomen US. In Introduction: There are a few descriptions of fatal ventricular arrhythmias
response to high pressure values associated with headache and visual distur- in patients with thyrotoxicosis due to Graves’ disease, but only one case
bances, antihypertensive therapy was modified obtaining normal pressure with painless thyroiditis has been published. We herein describe a rare and
values. Despite the good reward, headache and visual disturbances persi- lifethreatening case of Hashimoto thyroiditis that was complicated by severe
sted and we prescribed visual field examination: “incomplete peripheral hypokalemia and ventricular tachycardia (VT).
narrowing in the right eye, superior emianopsia with involvement of the left Case Report: A 37-year-old man presented with vomiting, palpitation,
quadrant in the left eye”. The brain magnetic resonance showed “volumi- weariness and lower extremity loss of strength. His blood pressure was
nous pituitary adenoma (2.23 x 2.15 cm) with solid and cystic component 120/80 mmHg, and his pulse was 110 beats/min. He had not taken any
compressing the optical chiasm because of an initial sovrasellar growth”. We drugs, including diuretics. There was no family history of cardiovascular
proceeded with diagnostic study with second-level laboratory examinations disease. He did not have diarrhea or symptoms of thyrotoxicosis, such as
showing hypoadrenalism and hyperprolactinaemia: prolactin 1851 mlU / L goiter, weight loss, tremors, or proptosis. The medical examination did not
(v.n. 132-498), vasopressin <0.1 pg / ml (v.n. 0.10-4), cortisol 5.27 mcg/dl reveal any disease, palpation of the thyroid did not reveal either tender-
(v.n. 6-10); while ACTH, FSH, LH, TSH, GH appeared in the normal range. ness or nodules. Initial laboratory analysis showed the following: sodium,
Pharmacological therapy with corton acetate (12.5 mg/die) was initiated 143 mEq/L; potassium, 1.26 mEq/L; chloride, 107.5 mEq/L; calcium, 10,
and neurochirurgical evaluation was indicated for the possible removal of 2 mg/dL. No anemia and normal kidney function. His 24 hours urine col-
adenoma. Patient is currently under follow up. lection potassium was 1762 mEq/24h. Blood gas analysis was normal. The
Conclusion: the attention on the obesity and hypertension as isolated initial ECG showed sinus tachycardia with depression of the ST segment,
symptoms, was possibly a confounding factor for the diagnose made by the a decrease in the amplitude of the T wave, and a prolonged QT interval.
organ specialists. Our methodological approach focused on the symptoms One hour later, during electrolyte correction, the patient lost consciousness
as a whole and allowed us to carry out the correct diagnostic procedure. and a run of sustained ventricular tachycardia began. We injected intrave-
nous lidocaine with successfully restoring sinus rhythm and consciousness.
After serum potassium levels were corrected, the ECG showed normal sinus
95. AN UNCOMMON CAUSE OF CARDIAC TAMPONADE rhythm with a normal QT interval (corrected QT interval =413 msec).
AND RECURRENT PERICARDITIS An echocardiogram showed normal cardiac function without evidence of
structural heart disease. His thyroid function tests showed the following
Fanfani G., Malandrino D., Tozzetti C., Torri M., Poggesi L. Dipartimento levels: thyroid-stimulating hormone (TSH), 0.07 μIU/mL (normal range
DAI Emergenza ed Accettazione, AOU Careggi, Università degli studi di 0.4 - 4.0); free thyroxine (fT4), 3.44 ng/dL (normal range 0.8-1.76); and free
Firenze triiodothyronine (fT3) 8, 65 pg/mL (normal range 1.80 - 4.20). These results
were suggestive of thyrotoxicosis. The patient’s levels of the TSH receptor
We reported a case of a 28-year-old woman presenting to the emergency antibody and anti-thyroglobulin antibody were normal, while Thyroid
department (ER) for thoracic pain. Her past history was notable for recent peroxidase antibody (Ab antiTPO) was 287 IU/mL. A thyroid ultrasound
amenorrhea and a family history of Hashimoto thyroiditis. In the ER she showed a non homogeneous glandular parenchyma with marked and wide-
underwent hemodynamic instability with severe hypotension, tachycardia spread increase in vascularization. We suggest Hashimoto thyroiditis as the
and respiratory failure needing oro-tracheal intubation; a cardiac tampo- cause of the patient’s thyrotoxicosis. We hypothesized that the hypokalemia
nade was found and treated with pericardiocentesis. Further laboratory was the result of potassium redistribution into the cells secondary to thyroi-
tests, according to family history, revealed severe autoimmune hypothyroi- ditis and due to gastrointestinal and urinary potassium loss. The patient was
dism (TSH 72 mU/L, anti-thyroglobulin 257 IU/mL, anti-peroxidase 1.207 treated with oral and intravenous potassium chloride, continuous electro-
IU/mL). Replacement therapy with levothyroxine was started.Two months cardiograph (ECG) monitoring, and regular serum potassium level checks.
after discharge, skin hyperpigmentation, fatigue and hypotension occurred. Anti-thyroid drugs were administered until euthyroidism is restored.
Further evaluation in our hospital revealed severe hyponatremia and low Brief Discussion: Hashimoto’s thyroiditis (HT) is part of the spectrum of
serum cortisol with elevated adrenocorticotrophic hormone (ACTH 269 chronic autoimmune thyroid diseases and is associated with various degrees
ng/L). Revaluation of CT scan obtained during first ER admission revealed of thyroid hypofunction, with thyroid autoantibodies production like the
atrophic adrenal gland and adrenal insufficiency was diagnosed. Further- most common, thyroid peroxidase antibodies (TPO-Ab) and thyroglobu-
more, the presence of elevated serum title of adrenal antibodies showed lin antibodies (Tg-Ab) and with lymphocytic infiltration. The diagnosis of
autoimmune origin of the disease. Despite an initial improvement of clinical Hashimoto thyroiditis is based upon clinical manifestations and laboratory
conditions after hydrocortisone and fludrocortisone replacement, over the findings. In patients with hyperthyroidism and without clinical manifesta-
follow up period of 3 years the patient also experienced a rare and relatively tions of Graves’ disease, thyroid autoimmune tests is necessary to differen-
recent described complication of Autoimmune Polyglandular Syndrome tiate thyroiditis from Graves’ disease. Hypokalemia during the transient
(APS) type II: chronic recurrent pericarditis. APS type 2 (also known as Shi- thyrotoxic phase of painless thyroiditis can cause thyrotoxic paralysis and
midt’s Syndrome), is a rare disorder that affects many hormone-producing serious polymorphic VT. There have been a few reports of fatal ventricular
glands, described for the first time in 1926. It counts about 1.4-4.5 cases per arrhythmias associated with hypokalemia and thyrotoxicosis due to Graves’
100.000 inhabitants and the female-to-man ratio is 3:1. It is characterized disease, but only one case of painless thyroiditis and no cases of Hashimoto
by the obligatory occurrence of autoimmune Addison disease in combina- thyroiditis has been described. Sustained VT is a rapid and hemodynami-
tion with thyroid autoimmune diseases (Hashimoto thyroiditis) and/or type cally unstable rhythm, and urgent cardioversion is usually necessary. It may
1 diabetes mellitus; primary hypogonadism, myasthenia gravis, and celiac persist and can degenerate into ventricular fibrillation, which will lead to
disease also are commonly observed in this syndrome. The most serious sudden death in the absence of prompt treatment. Severe hypokalemia can
form of first manifestation is Addison’s crisis, a life threatening condition induce ventricular arrhythmias. In the Purkinje fibers of the cardiac con-
that must be promptly recognized and treated. Regarding the imaging tech- ducting system, hypokalemia causes depolarization and leads to increased
niques, computed tomography (CT) is able to show the involved adrenal membrane excitability and arrhythmias. Hypokalemia delays ventricular
104
repolarization by inhibiting potassium channel activity. In this case, severe dence of 1% of patients underwent FNAB and it occurs with painful swel-
hypokalemia during the transient thyrotoxic phase of Hashimoto thyroidi- ling associated with US signs of glandular inflammation. The mechanism of
tis caused life-threatening sustained VT requiring urgent pharmacological post FNAB-thyroiditis is unknown; the potential release of thyroglobulin,
cardioversion. Physicians should therefore pay attention to the possibility of thyroid hormone stores and cytokines can trigger inflammatory respon-
the development of life-threatening VT associated with hypokalemia in the ses resulting in thyroiditis. In our case thyroid hemorrhage could be one
setting of autoimmune thyroiditis. mechanism by which the glandular parenchyma could be primed for an
inflammatory response.
Conclusion: As thyroid nodules are more commonly diagnosed and
97. EFFICACY AND SAFETY OF INSULIN DEGLUDEC/ patients are undergoing routine FNAB evaluation, Clinicians should be
LIRAGLUTIDE (IDEGLIRA) VS BASAL–BOLUS (BB) aware of this rare complication, potentially emerging after thyroid FNAB.
THERAPY IN PATIENTS WITH TYPE 2 DIABETES (T2D):
DUAL VII TRIAL (NCT02420262)
99. INCIDENCE OF HYPOCALCEMIA AND
Consoli A. 1, Billings L.K. 2, Doshi A. 3, Gouet D. 4, Oviedo A. 5, Rodbard H. 6, HYPERCALCEMIA IN ELDERLY HOSPITALIZED
Tentolouris N. 7, Grøn R. 8, Halladin N. 8, PATIENTS
G. Lastoria 9, Jodar E. 9
Università Gabriele D’Annunzio di Chieti, 1NorthShore University Catalano A., Chilà D., Basile G., Morabito N., Lasco A.,
HealthSystem Evanston 2, IL/University of Chicago Pritzker School of Benvenga S., Loddo S.
Medicine, Chicago, IL, USA. 3, PrimeCare Medical Group, Houston, TX, Department of Clinical and Experimental Medicine, University of Messina,
USA, 4 La Rochelle Hospital, La Rochelle, France 5, Santojanni Hospital and Messina, Italy
Cenudiab, Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina 6,
Endocrine and Metabolic Consultants, Rockville, MD, USA. 7, National and Introduction: Calcium is the most abundant mineral in the body and plays
Kapodistrian University of Athens, Medical School, Athens, Greece 7, Novo a role in the normal functioning of nerves, muscles, bone, blood coagula-
Nordisk, Søborg, Denmark 8, tion and in many enzymatic processes. Disorders of calcium metabolism
Novo Nordisk Medical Affairs Italy 9University Hospital Quiron Salud, are frequently encountered in routine clinical practice; however limited data
Madrid, Spain 10 come from hospitalized patients. Our aim was to evaluate the incidence of
hypocalcemia and hypercalcemia in a setting of elderly inpatients.
In a 26-wk open-label trial, 506 patients (pts) with T2D uncontrolled on Methods: This retrospective study was based on the medical records of all
metformin and 20-50 units (U) insulin glargine U100 (IGlar) were rando- hospitalized subjects aged 65 years or over, between January 1, 2011 and
mized 1:1 to IDegLira or BB therapy (IGlar + insulin aspart up to 4 times August 31, 2014. Measurements of serum calcium were carried out by a
a day). Mean A1C decreased from 8.2% at baseline to 6.7% at end of trial single centralized laboratory. Hypocalcemia was defined by serum calcium
in both arms; non-inferiority (by <0.3%) for IDegLira was confirmed levels <8.2 mg/dl and hypercalcemia by serum calcium levels >10.4 mg/dl.
(p<0.0001; Table). A similar proportion of pts achieved A1C targets with Albumin correction, when albumin levels were checked, was considered to
IDegLira vs BB (66.0% vs 67.0% for <7%/49.6% vs 44.6% for ≤6.5% respecti- adjust serum calcium values.
vely). Total daily insulin dose was lower for IDegLira (40.4 U) vs BB (84.1 Results: A total of 4205 subjects were considered. Hypocalcemia accounted
U) (p<0.0001). Body weight decreased with IDegLira and increased with for 45.6% and hypercalcemia for 1.9% of recruited subjects over the entire
BB (p<0.0001); the rate of hypoglycemic episodes (HEs) was lower with observation period. The incidence of hypocalcemia decreased over time
IDegLira vs BB (p<0.0001). More pts achieved a triple composite endpoint with an overall reduction of 17% between the first and the last year of the
(A1C <7% with no HE in the last 12 wks and no weight gain) with IDe- study period, while the incidence of hypercalcemia remains stable. Cases of
gLira vs BB (38.2% vs 6.4%; odds ratio 10.39 [5.76; 18.75] p<0.0001). Mean hypocalcemia were reduced of 5% in the female, while increased of 5% in
pre- to postprandial plasma glucose increment decreased more with BB vs the male at the end of the study.
IDegLira (p=0.0032). SF-36 (mental component summary) and TRIM-D Conclusions: Hypocalcemia appears as a relevant electrolytic disorder in
(total scores) improved more with IDegLira vs BB (p=0.0074 and p<0.0001 elderly inpatients. Despite increased awareness about pathologic conditions
respectively). Adverse event rates were similar. In conclusion, in pts with affecting calcium homeostasis, physicians have to remind to prevent and
A1C >7% on metformin and IGlar, IDegLira vs BB resulted in similar A1C treat hypocalcemia due to its relevant lifetreateing consequences.
reductions, lower insulin dose, weight loss and lower risk of HEs.
100. BODY COMPOSITION OF ITALIAN SOCCER

98. A RARE COMPLICATION OF THYROID FINE NEEDLE REFEREES
ASPIRATION: CASE REPORT
Mascherini G. 1, Petri C. 1, Pizzi A. 2, Castagna C. 2, Collina P. 3, Galanti G. 1
Conte M., Carella A.M., Damone F., Modola G., Florio C., 1
SODc Medicina dello Sport e dell’Esercizio Fisico - Dipartimento di
Di Pumpo M., Nargiso M., De Luca P., Marinelli T., Melfitano A., Benvenuto Medicina Sperimentale e Clinica - Università degli Studi di Firenze 2
A. Associazione Italiana Arbitri - Federazione Italiana Giuoco Calcio 3 Direttore
Internal Medicine Department of “T. Masselli-Mascia” Hospital - San Severo Commissione Arbitrale Union of European Football Associations (UEFA)
(Fg), Italy
Purpose: Soccer is an endurance sport in which players perform activities
Introduction: Fine needle aspiration biopsy (FNAB) is procedure of choice of varying intensity over a 90-min match, is one of the most popular pasti-
in the management of thyroid nodules, because easy to perform and because mes in the world. The referee is so important for this sport that without
of its accuracy and cost-effectiveness. FNAB is generally a safe procedural, him there is no match. The objective of the present study was determined
however serious complication can occur. the body composition of official Italian soccer referees and compare their
Case presentation: a 56 year old man with nontoxic multinodular goiter changes through a regular season (T1, October; T2, December; T3, May)
history comes to our observation complaining of fever and severe anterior with a team of the first Italian league.
neck pain. About 2 weeks before he underwent FNAB of the right (TIR Methods: 22 elite soccer referees from the Italian Association of Soccer
2) and left (TIR 1) dominant nodules and soon after he reported a post and 18 elite Soccer players are been enrolled in this study. The variables of
FNAB-hemorrhage of the left thyroid lobe. On examination, thyroid was body mass, height, skinfold thicknesses, body girth (waist, hip and biceps)
enlarged and painful; laboratory tests showed PCR 101 (0-5 mg/l), TSH 0.10 were collected with the purpose of estimating Sum of skinfold thicknesses,
(0.3-5 μUI/ml) with normal FT4, FT3, thyroid peroxidase and thyroglobu- Fat Mass (FM %), Fat Mass (FM kg), Fat Mass index (FMI kg/h) and Free-
lin antibodies. Thyroid Ultrasound (US) showed an heterogeneous glan- fat mass (FFM kg).
dular echotexture with poorly defined hypoechoic areas with reduction or Results: We observed statistical differences in age (SR= 39.0 ± 3.6; SP=
complete absence of blood flow so that subacute thyroiditis was diagnosed. 27.0 ± 3.5; p= ≤ 0.005). In T1, T2 and T3 evaluation are been detected sta-
Corticosteroid therapy was initiated with sudden resolution of fever and tistical differences if we compare the 2 groups (Table 1). During the season
neck pain. After one month, thyroid US follow-up examination demonstra- in referees group are been observed statistical difference in body mass (T1,
ted a clear improvement in glandular echotexture; laboratory tests, simulta- 77.4 ± 4.2; T2 78.1 ± 4.4; T3 78.3 ± 4.2 kg; p= < 0.005), waist circumference
neous carried out, showed normal TSH, FT4 and FT3 values. (T1, 76.5 ± 2.3; T2 78.1 ± 2.9; T3 77.4 ± 2.6 cm; p= < 0.005) and free-fat
Discussion: Thyroiditis is uncommon adverse effect of FNAB with an inci- mass (T1, 66.7 ± 3.8 T2 67.6 ± 4.0; T3 67.1 ± 4.0 kg; p= < 0.005). In elite
105
soccer players don’t are been found statistical differences. Methods: We enrolled 32 soccer players (CA) and 24 cyclists (CI) of same age
Conclusion: Considering the results of the present study we may conclude (soccer players 18, 4±0, 9 years, cyclists 19, 9±1, 1 years; p=NS) belonging to
that official football referees presented an amount of body fat higher of same team in order to obtain same kind of training. Athletes were subjected
that observed in football players. Therefore, the nutritional habits must to an evaluation of body composition through anthropometric measure-
be adapted to their daily physical activities, short training periods and ments, bioelectrical impedance analysis (BIA) and dual-energy X-ray absor-
moderate energy intensity physical activity, on average, during match refe- btiometry (DXA). Once established the reduction of BMD, cyclists were also
reeing, to obtain better performance. subjected to blood samplings for vitamin D and calcium concentration (T0).
These blood exams were re++peated after two months (T1) of Cholecalciferol
T1 T2 T3 supplementation (T2) and after three more moths (T2).
Refe- Foot- p value Refe- Foot- p Refe- Foot- p Results: Main differences between these two groups relate to bone health
rees ballers rees ballers value rees ballers value specifically in BMD (CA: 1, 2±0, 2 g/cm2, CI: 1, 0±0, 1g/cm2; p=0, 001) and
Z-score (CA: 0, 4 ±1, 3 DS, CI: -2, 3±-0, 7 DS; p=0, 02). Serum vitamin D and
Sum of 78,0 48.9 <0.005 74.4 47.8 <0.005 80.0 47.9 <0.005 calcium at first blood sampling (26, 49±3, 901 ng/mL and 8, 89±0, 421 mg/
thick- ±19.4 ±7.9 ±17.1 ±2.8 ±17.0 ±3.3
nesses dL) are at the lower level of range of normality. At the end of supplementation
FM % 13.6 8.8 <0.005 13.2 9.0 <0.005 13.9 8.8 <0.005 vitamin D concentration is normal (32, 5±3, 9 ng/mL), while calcium is back
±3.0 ±1.7 ±2.7 ±1.8 ±2.9 ±1.6 in range of normality after five months from the beginning of supplementa-
FM Kg 10.7 7.2 <0.005 10.6 7.5 <0.005 11.1 7.3 <0.005 tion (9, 4±0, 4 mg/dL).
± 2.2 ±1.5 ±2.0 ±1.6 ±2.1 ±1.2 Conclusion: Body compositions confirms a reduced bone health in cyclists.
FM/h 5.8 3.9 <0.005 5.7 4.1 <0.005 6.0 3.9 <0.005 The supplementation shows efficiency raising serum vitamin D and calcium
± 1.2 ±0.8 ±1.1 ±0.9 ±1.1 ±0.6
levels. Mostly in young athletes, a first level approach could be based on
FFM 66.7 72.7 <0.005 67.6 72.7 <0.005 67.1 72.9 <0.005
Kg ±3.8 ±4.7 ±4.0 ±4.6 ±4.0 ±5.2
nutrition and a weight-bearing physical activity. It is clear the necessity of
paying attention at bone health in cyclists, especially in young age in order
to avoid an impairment of bone mass peak which could lead to a bone frailty
101. LINK BETWEEN BODY CELLULAR MASS AND LEFT in adulthood.
VENTRICULAR HYPERTROPHY IN FEMALE AND MALE
ATHLETES
103. ONE YEAR FOLLOW UP EFFECTIVENESS OF HOME
Mascherini G., Petri C., Galanti G. BASED EXERCISE IN BREAST CANCER
SODc Medicina dello Sport e dell’Esercizio Fisico - CISMEG. - AOU Careggi
– Firenze - Italia Mascherini G., Tosi B., Degli Innocenti S., Grifoni E., Petri C., Galanti G.
SODc Medicina dello Sport e dell’Esercizio Fisico - CISMEG. - AOU Careggi –
Purpose: Cardiac adaptation to intense physical training is determined by Firenze - Italia
many factors. Eliminate the fat mass from the indexing of left ventricular
parameters seems to better explain some heart modifications, characteri- Purpose: Prevention strategies and improved therapy increased the number
zing the so-called “athlete’s heart. Differences between sexes in the left ven- of women survivors of breast cancer. However it tends to gain weight expo-
tricle parameters are well established, however, both sport activity and body sing again himself to the risk of recurrence. Exercise is shown to be a drug
composition analysis seem to eliminate them. The aim of this study is a sex that can be used in this context. Supervised exercise has shown remarkable
comparison of athletes’ hearts with an indexation of body cell mass in elite effectiveness, but is associated to poor compliance at long term. In this study,
soccer players. we aimed to verify whether a home-based exercise program is effective for 1
Methods: 18 females were matched with 18 elite male soccer players of the year in physical fitness related to health parameters management of a cohort
same age (female=26.2±2.4, male 26.9±2.5; p=NS). An accurate body com- of breast cancer survivors.
position analysis and an echocardiography were performed in the morning Methods: Experimental cohort observational study. We enrolled 53 women
on athletes group who were in a rest condition, having not exercised in the (age 49.1±5.5, height 163±7.3 cm) survivors to a breast cancer. At baseline
previous 12 hours and having fasted for breakfast. were assessed the lifestyle in term of physical activity with accelerometer and
Results: Body composition show higher values in females for hip circu- physical fitness related to health in term of aerobic capacity by 6 Minutes
mference/height (female:0.55±0.03, male: 0.52±0.02; p<0.01) and fat mass Walking Test (6MWT), flexibility (Sit & Reach), grip and lower limbs stren-
index (female: 3.7±0.7 kg/m2, male: 2.4±0.4 kg/m2; p<0.001), while there gth (Hand Grip and 30’’ Chair Test) and body composition (anthropometrics
is no difference in extra cellular mass index (female: 7.1±1.2 kg/m2, male: parameters, skinfold thickness and bio impedance). Home based exercise was
7.6±0.4 kg/m2; p=NS). There are no differences in systo-diastolic parame- prescribe for 1 year with a 2 months follow up. Parameters of physical fitness
ters between sex. Absolute values of the left ventricular dimension shows related to health were compared (ANOVA test).
higher values in male, when these parameters are indexed with body Results: The levels of physical activity before the program show a moderately
composition they present their own development with the left ventricular active sample (PAL = 1.5) and an overweight condition (BMI = 26.5). The
mass being higher in males also with the indexed body cell mass (female: comparison shows a general trend of improvement of all recorded parame-
126.62±16.08 g/m2, male: 142.87±13.48 g/m2; p<0.001). There are no sexes ters, statistically significant changes were:
differences with this indexation for the inter ventricular septum. - waist circumference, T0= 91.1 ± 9.2; T 12= 85.2 ± 8.4 cm; p <0.05,
Conclusion: Sport activity seems to slightly reduce the differences in body - Reduction in Total Body Water, RZ: T0=539.0±67.0; T12= 591.1±64.0 Ω;
composition and in left ventricular parameters. The different hormonal sta- p<0.05,
tuses play an important role in the adaption also with the same physical - 6 MWT, T0= 496.4 ± 141.3; T12= 593.6 ±41.7 m; p <0.05, - 30 ‘’ Chair test,
effort. T0=15.7 ± 3.9; T 12=19.1 ± 6.0 rep.; p <0.05,
- Sit & Reach, T0= 3.3± 9.9; T12= 11.0 ± 4.8 cm; p<0.05,
- Diastolic blood pressure after 6 MWT, T0= 78.4±10.1; T12= 72, 5±14.8
mmhg; p<0.005.
102. BODY MINERAL DENSITY AS A HEALTH INDEX IN Conclusion: Home-based unsupervised exercise in breast cancer survivors
ATHLETES yielded 1 year efficacy. Lifestyle change, in terms of physical activity, it is
necessary in this kind of patients and this model appear allows long-term
Mascherini G., Bocci M., Petri C., Tempesti G., Galanti G.
therapeutic efficacy. Unsupervised approach, in comparison with supervised
SODc Medicina dello Sport e dell’Esercizio Fisico - Dipartimento di Medicina
one, allow a reduction of the cost related to the treatment of not communi-
Sperimentale e Clinica - Università degli Studi di Firenze – Italia
cable disease with exercise therapy.
Purpose: The amount of bone accrued during the growing years is a major
104. UNSUPERVISED PHYSICAL EXERCISE CONTRASTS
determinant of the risk of fractures in later life. Weight bearing physical acti-
SARCOPENIA AND MAINTAIN CARDIOVASCULAR
vity is a modifiable determinant of peak bone mineral accrual. Vitamin D con-
PERFORMANCE IN RENAL TRANSPLANT RECIPIENTS
tributes to bone strength primarily by facilitating the absorption of calcium
from the small intestine and inhibiting PTH activity to prevent the loss of
Stefani L. 1, Minetti E. 2, Conti C. 1, Ingletto C. 1, Mandoli M. 1, Mascherini G.
calcium from bone. We aimed to verify the Body Mineral Density (BMD) in a 1
, Petri C. 1, Corezzi M. 1, Palmerini D. 1,
group formed by young cyclists and measured the level of Vitamin D.
Galanti G. 3
106
1
Sports Medicine Center - AOUC-University of Florence- 2Nephrology to treatments, falls, cognitive impairment, frailty, lower quality of life, re-ho-
Division _ AOUC. -Careggi Florence - 3 Sports Medicine Center-Clinical and spitalizations and increased mortality.In the last years, a growing interest on
Experimental Department- University of Florence deprescribing has been envisaged as a potential solution for polypharmacy
consequences. Deprescribing is defined as “the process of withdrawal of
Purpose: Transplantation is the final therapy of the Chronic Kidney Disease. an inappropriate medication, supervised by a health care professional with
After surgical treatment, the mortality is anyway high as well the sarcopenia the goal of managing polypharmacy and improving outcomes” (Reeve E et
that can be often found. These both conditions partecipate to reduce the al, 2017). Despite several criteria and tools developed in order to support
quality of life in renal tranplant recipients(RTR). Regular physical exercise therapy reconciliation and revision, and the growing evidence about safety
regimen is actualy prescribed to contrast these aspects.The study aims to of these strategies, deprescribing is little implemented in clinical practice,
investigate the impact of partially supervised mixed exercise after 6 months yet. In order to identify obstacles to its implementation in clinical practice,
of training. qualitative research investigated experiences and opinions of physicians
Methods: a group of 40 RTR were submitted to the exercise prescription concerning deprescribing. On a whole, there is interest in applying depre-
program following the ACSM guidelines. They, were periodically investiga- scribing strategies and several suggestions have been proposed to make it
ted at least every 6 months, by 2D Ecocardiographic exame, ECG treadmil more practicable. To our knowledge, only one questionnaire measuring
test, Bioimpendance analysis, Hand-Grip test, Chair-Test, BMI analysis and physicians’ attitudes and experiences about deprescribing was developed
skinfolds measure. After a first short period of supervision in a gym, the in a very specific setting of care. No questionnaire on this topic has been
patients were free to continue the exercise program, fast walking, in a unsu- developed and validated in Italy. Therefore, we have developed the “Medical
pervised way, 3 times a week, for at least 30 min per session at moderate Attitudes Towards Deprescribing Questionnaire” (MATD-Q), which aims to
intensity. describe Italian physicians’ attitudes towards deprescribing in older patients
Results: BMI was reduced (from 24, 19± 5to 24, 05± 3Kg/m2); triceps (7, with multimorbidity and polypharmacy. The MATD-Q, thought for general
88±2 to 7, 22±3mm) and bicipital (15, 10±±7 to 14, 14±6 mm) folds reduced practitioners, hospital and clinics geriatricians and internists, is meant to
significantly(p<0.01) A very significant improvement was observed in the investigate the point of view of a wide sample of physicians coming from dif-
strenght and flexibility paramters (p<0.001) of the upper limbs; TBW reduced ferent care settings and geographical areas, in order to define the skills to be
significantly with an improvement of water’s tissue distribution. The main developed in training programs, and to assess the effectiveness of these inter-
echocardogarphic parameters were normal and maintain normal for all the ventions on professionals’ attitudes. In agreement with widely accepted pro-
observational period (LVDd 48, 1±2 mm at T0 vs 48, 0±3 mm at T6; LVSd 29, cedures about questionnaires development, we defined the survey objective,
2±2 mm at T0 up to 29, 6±4 mm at T6; CMI form 112, 6±19 gr/ m2 to 110±11 the target population, the themes, the related variables and items, expressed
gr/ m2; EF % 61, 9 ±4at To vs 61±2 at T6). to be easily understandable and consistent, and the appropriate response
Conclusions: Moderate mixed exercise program produces, in RTR, an modes. Thereafter, twenty-three physicians, amongst forty invited, gave fee-
evident positive effect in the muscles’ strenght. No detrimental effect has been dbacks on MATD_Q concerning items completeness, comprehensiveness
observed in the myocardial function.The data are suggestive for a constant and redundancy, and time necessary to fill in, by means of a content validity
adhesion to the protocol, despite not supervised, and support the importance structured validated questionnaire (Rowe et al, 1993; O’Brien et al, 2012). A
to address the patients toward a regular sports medicine follow-up. final version of MATD_Q was defined, consisting in 30 items, common to
all physicians, four more for general practitioners and clinics geriatricians
and internists, and five more for hospital ones. Twenty-five items measure
medical awareness of polypharmacy and inappropriateness problems, per-
ception of the need to implement corrective strategies and of patients’ atti-
tude to reduce drugs, personal attitude and behavior related to deprescribing.
The specialty-specific items mainly concern personal behavior and experien-
ces in deprescribing. Answers for all these items go from “strongly agree”
to “strongly disagree” and the maximum score is attributed to the answer
considered as the most deprescribing-oriented. A final section of five que-
stions ask doctors to assign a priority order and, not included in the total
score, aims to provide information on the factors potentially influencing
the implementation of these strategies in clinical practice. MATD_Q will be
validated for internal consistency and test-retest reliability after Ethics Com-
mittee approval.
106. FOCUS ON THERAPY OF ADULT PFAPA SYNDROME:

A SINGLE CENTRE EXPERIENCE
Sicignano L.L., Patisso I., Stabile M., Verrecchia E., Manna R.

Periodic Fever and Rare Diseases Research Centre – Dipartiment of Internal
Medicine – Policlinico “A. Gemelli” Foundation – Catholic University of
Sacred Heart - Rome
Introduction: Periodic Fever, Aphtas, Pharyngitis and cervical Adenopa-

105. DEVELOPMENT OF THE “MEDICAL ATTITUDES thies (PFAPA) syndrome is a likely autoimmune inflammatory syndrome
TOWARDS DEPRESCRIBING QUESTIONNAIRE” characterized by recurrent febrile attacks associated with oral aphtosis,
(MATD-Q) pharyngitis and laterocervical adenitis. The PFAPA diagnosis is based
on 5 clinical criteria, configuring Marshall’s Criteria. It is considered the
Agosti P. 1, D’Avanzo B. 2, Damanti S. 3, Vella F.S. 1, Suppressa P. 1, most common cause of recurrent febrile tonsillitis in childhood, although
Sabbà C. 1, Mannucci P.M. 4, Nobili A. 2 many cases of patients with late onset disease have been reported in the
1
U.O.C. Medicina Interna Universitaria “C. Frugoni”, Dipartimento last period. The main therapeutic options for adult PFAPA syndrome are
Interdisciplinare di Medicina (DIM), Policlinico di Bari, Università NSAIDs, steroids, colchicine, IL-1 antagonists and tonsillectomy. However,
degli Studi di Bari “Aldo Moro”, Bari; 2 Laboratorio di Valutazione della there are very few cases in adulthood described in Literature and there is
Qualità delle Cure e dei Servizi per l’Anziano, IRCCS Istituto di Ricerche no scientific evidence about effectiveness of medical and surgical therapy
Farmacologiche Mario Negri, Milano; 3 U.O.C. Geriatria, Fondazione IRCCS in such patients. The purpose of this work is to bring the experience of
Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milano; 4 Direzione our Center about the treatment of patients with Adult PFAPA syndrome.
Scientifica, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Matherials and Methods We selected 48 adult patients with PFAPA syn-
Milano, Milano drome, performing a retrospective analysis of our database. Patients inclu-
Polypharmacy is a common problem in older patients, related to a significant ded had to respond to the adapted Marshall Criteria, where the first crite-
risk of prescription of potentially inappropriate medications (PIMs), drug- rion was deliberately overlooked and the fifth criterion was retrospectively
drug interactions (DDI), adverse drug reactions (ADRs), reduced adherence applied. Patients were analyzed on the basis of response to medical therapy
(NSAIDs, steroids, colchicine, anti-IL-1) and surgical therapy. Results We
107
observed that 66% of patients had used NSAIDs; of these, only 59% showed in immunocompetent subjects, difficult to treat and leading to invalidating
partial benefits from these drugs, especially in terms of fever reduction. Ste- and/or life-threatening consequences. The diagnostic process is complica-
roids were used by 57% of patients; 75% of these showed complete remission ted and requires a multidisciplinary approach.
of symptoms, while 25% only a partial remission. Colchicine was chroni- Methods: Over the last two years, 4 cases of IS were diagnosed in our depart-
cally taken by 71% of patients with a full response in 53% of cases, while ment. All patients were female and aged 44 to 80 yrs. They were admitted for
other 47% showed only a partial reduction of symptoms. IL-1 inhibitors severe back pain with motion limitation and hyperpyrexia. Increased white
(anakinra and canakinumab) were used in 4 patients with complete resolu- blood cell count, increased inflammation markers and multiple comorbidi-
tion of the symptoms. Regarding surgical therapy, we observed that, among ties were observed in all affected patients (see table).
patients with pediatric onset, 85% had had tonsillectomy in childhood; in Results:
remaining 22 patients, only 9 (41%) underwent surgical intervention in name age localization isolated pathogen treatment comorbidities
adulthood. None of the patients achieved complete resolution of the disease. N.T. 44 Lumbar with mul- Staphylococcus Oxacillin Previous vertebral
Patients reported only a partial benefit in terms of elongating inter-criti- tiple paravertebral Aureus Rifampicin surgery, anemia
cal intervals and reducing the intensity of the disease. Conclusions Adult abscesses Linezolid
PFAPA syndrome, although clinically very similar, differs significantly from D.G.F. 64 Dorsal (D9-D10) E. Coli Ertapenem Previous ovaric
pediatric disease in response to medical and surgical therapy. In our case, cancer, relapsing
urinary tract
adult patients showed reduced sensitivity to steroids, compared to pediatric infections, type II
patients. We confirmed the therapeutic validity of colchicine in prevention diabetes
of fever attacks, with a response rate greater than 70% of the case. However, A.M. 70 Dorsal (D4) No isolated patho- Isoniazide Rifam- Type II diabetes,
the most interesting thing was to note that none of the patients in the study gen (high suspi- picin Pirazinamide hypertension,
cion for tubercular Ethambutol Coronary artery
group had fully benefited from surgical therapy; This is an absolutely diffe- infection disease, vertebral
rent data from the available PFAPA literature on child where tonsillectomy osteoporosis
is offered, in some work, as resolution therapy in majority of cases. B.C. 80 Dorsal (D8) Streptococcus Linezolid Chronic heart
mitis Meropenem failure, chronic
kidney failure, ver-
tebral osteoporosis
107. PERSISTENT AND SEVERE HYPOGLYCEMIA
ASSOCIATED WITH TRIMETHOPRIM- In all patients, CT. scan and MR. were performed and were diagnostic
SULFAMETHOXAZOLE IN A FRAIL DIABETIC MAN ON
for spondylodiscitis. In three patients the aspiration of infected mate-
POLYPHARMACY
rial was possible and led to the isolation of the involved microorga-
Rossio R. 1, Arcudi S. 1, Colombo G. 1, Ferrari B. 1, Piconi S. 2, Peyvandi F. 1 nism (see table).
1
Fondazione IRCCS Ca granda Ospedale Maggiore Policlinico, Dipartimento Conclusions: Three patients underwent specific antibiotic treatment
di Medicina Interna, UOC di Medicina generale-Emostasi e Tromvosi, 2 based on antibiogram. The fourth one (A.M.) underwent antitubercu-
Infectious Department AO FBF. Luigi Sacco, Milano lar therapy according to a positive Quantiferon test and to highly sug-
gestive CT. and MR. findings of Pott’s disease. Despite the specific the-
A 85-year-old man resident in a nursing home was admitted to the emer- rapies and prolonged care, the two oldest patients (A.M. and B.C.) with
gency room (ER) for refractory hypoglycemia (capillary blood glucose a worst prognosis due to severe comorbidities died in two months. In
36). He had a history of dementia, type 2 diabetes mellitus, moderate renal the youngest patient (N.T.) the antibiotic treatment was able to reduce
insufficiency (creatinine clearance 40 ml/min) and chronic ischemic heart the extent of vertebral involvement. The fourth patient (D.G.F.) had a
disease. His glycemia was well controlled by means of 30 daily units of complete regression of the infection after one year treatment.
standard insulin. Multiple medications were levothyroxine, esomeprazole,
amiodarone, ramipril, bisoprolol, aspirin, clopidogrel. He was found to be
on treatment with co-trimoxazole 960 mg (800 mg sulfamethoxazole/160 109. LONG-TERM ORAL FLUCONAZOLE FOR CHRONIC
mg trimethoprim) added twice daily 7 days before due an urinary tract SYSTEMIC CANDIDIASIS: DO NOT LOSE SIGHT OF IT
infection. On examination he was pale, with fluctuating levels of consciou-
sness and with signs of dehydration. Laboratory investigations showed urea Biondi L. 1, Benfaremo D. 1, Mattioli M. 1, Cardinali M. 1,
52 mg/dl, creatinine 1.79 mg/dl (clearance 28 ml/min). After administration
Fraticelli P. 2, Gabrielli A. 1
of 10 ml of a 33% glucose solution and 1000 ml of 10% solution, glucose 1
Clinica Medica, Dipartimento di scienze cliniche e molecolari,
raised temporarily (110 mg/dl) but quickly dropped, after 6 additional hours
Università Politecnica della Marche, Ancona, Italy 2Clinica Medica,
of glucose infusion, were 67 mg/dl. Hypoglycemia persisted despite aggres-
Dipartimento di medicina interna, Ospedali Riuniti Ancona, Italy
sive support, blood glucose being 42 mg/dl 12 hours after admission to ER.
It was started a continuous infusion of 10% glucose until normalization 32
hours after admission. Hypoglycemia was still present when the glucose Introduction: A 75-year-old Caucasian man was discharged from our
solution was subsequently stopped, so the patient was admitted to our ward. department one year ago with a diagnosis of systemic candidiasis with
Therapy with co-trimoxazole was discontinued, because it was thought that eyes, pulmonary valve and lung involvement.
hypoglycemia was induced by this drug, and an intravenous therapy with Therapeutic approach: During the hospitalization the patient was
1000 ml per day of 5% glucose solution was continued until normalization readily treated with an anti-fungal regimen that included amphotericin
of glucose levels three days after starting this therapy. Blood insulin levels (8, B (3 mg/kg/die) and 5-fluorocytosine (25 mg/kg/day) for 6 weeks, as
8 uUI/ml n.v [2.6-25]) and C-peptide levels (4, 57 ng/ml n.v. [1.1-4.4]) were suggested by published recommendations, with improvement of fever,
inappropriated raised. A diagnosis of hypoglycemia induced mainly by the inflammatory markers and radiologic findings but inefficacy on the
antimicrobial agent was made, with added contribution from multiple other ocular and the cardiac involvement. The patient was therefore refer-
drugs. This case illustrates the importance of prescription appropriateness red to the cardiac surgeon for consultation, but he was not considered
in elderly multimorbid patients in terms of type and dosage of drugs, in eligible for surgery due to the clinical conditions and the possibility
order to avoid serious adverse reactions. of systemic fungal dissemination during Extra Corporeal Membrane
Oxygenation (ECMO), along with the concrete risk of prosthetic valve
reinfection. After a multidisciplinary discussion, that included the
108. BACK PAIN IN THE INTERNAL MEDICINE patient and his family, we decided to discharge the patient with oral
DEPARTMENT: INFECTIOUS SPONDYLODISCITIS, WE fluconazole (400 mg/day), aiming to achieve a stable chronic systemic
SHOULD THINK ABOUT IT infection and deferring surgery to the eventuality of clinical worsening.
Follow-up: During the first twelve months of follow-up, the patient
Perna L. 1, Barbato A. 1, Venetucci P. 2, De Pascale F. 1, Molisso A. 1, reported no improvement of visual impairment but a good quality
Galletti F. 1, D’Elia L. 1, Strazzullo P. 1 of life with only one episode of fever due to a probable concomitant
1
Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli viral infection. Blood tests were negative for systemic inflammation
“Federico II”; 2 Dipartimento di Scienze Biomediche Avanzate, Università di and there were no signs of drug toxicity. Repeated follow-up chest CTs
Napoli “Federico II” showed gradual but consistent improvement of the pulmonary infiltra-
tes and a transthoracic echocardiogram performed ten months after
Background: Infectious spondylodiscitis (IS) is a relatively rare condition the first presentation showed
108
the disappearance of pulmonary valve vegetations. controls of renal and hepatic function every 7 days. The infectious spe-
Conclusion: Long-term treatment with oral fluconazole may be effective cialist performed clinical control every 30 days. After 20-30 days of treat-
and safe for chronic systemic candidiasis. ment, the patient had an improvement in general condition with regres-
sion of dyspnoea. After three months, radiographic examinations (Rx and
TC) documented the regression of systemic lymphadenopathy.
110. SYSTEMIC VISCERAL TUBERCULOUS Discussion and Conclusions: Tuberculosis etiology should always be
LYMPHADENOPATHY - CASE REPORT considered in the differential diagnosis of lymphoproliferative diseases in
generalized lymphadenopathy, although in the case of tbc the visceral syste-
Crescenti A. 1, Crescenti F. 1, Garufi L. 2, Crescenti R. 3 mic lymph node interest is not frequent, since lymph node involvement is
1
Primary Care Asp Messina - 2 Resident Doctor In Medical Oncology - Aou mostly on superficial stations such as laterocervical, axillary, and so on. The
Policlinico Messina - 3 Departement Of Internal Medicine - Ao Papardo authors followed a step-by-step diagnostic procedure, where the sure dia-
Messina gnosis derived from the agobiopsia, whithout the use of PET examination,
as emerged from the latest literature data.
Systemic lymphadenopathies can be traced back to different etiologies:
immunologic, neoplastic (Hodgkin or non Hodgkin lymphoma, acute or
chronic leukemia, malignant histiocytosis, metastasis from solid tumors), 111. THE ROLE OF PET IN THE DIAGNOSTIC WORK-UP
infectious (viral: mononucleosis, CMV, AIDS, rubella; bacterial: Strep- OF FUO
tococci, salmonella, brucellosis, cat scratch disease; mycoses: chlamydia;
mycobacteria: tbc; parasites: toxoplasmosis, spirochete etc.). In the diffe- Tafuri F. 1, Schiavone M. 2, Arcudi S. 1, Ferrari B. 1,2, Peyvandi F. 1,3
rential diagnosis of lymphadenopathies, several factors need to be consi- 1
dered: patient’s age, the objective characteristics and the location of the Medicina Interna, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
lymph node, the associated clinical features, the medical history and the Policlinico, Milano, 2 U.O.C. Malattie Cardiovascolari, Fondazione IRCCS
general examination, the hematochemical examinations, the instrumen- Ca’ Granda Ospedale Maggiore Policlinico, Milano, 3 Angelo Bianchi Bonomi
tal investigations (ultrasound, x-ray, CT, MRI, PET), immunophenotypic Hemophilia and Thrombosis Center, Luigi Villa Foundation, Fondazione
examinations of peripheral blood or in the marrow, biopsy investigations IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
(lymph node, marrow). The authors present a
Case Report: on a systemic visceral tuberculous lymphadenopathy, A 81 year-old patient presented to our department with fever, asthenia and
emblematic how allowed the exact diagnosis. Recently, other similar cases weight loss (12 kg) with no associated signs of organ dysfunction. The fever
have been described in the literature (Qingxuan Wang et al., Systemic started few months before and was previously treated with cycles of empi-
Lymph node tuberculosis mimicking lymphoma with 18F-FDG PET / CT- rical antibiotics and paracetamol, with initial clinical response but subse-
Medicine 95, n.9, March 2016, Rui-Ln Ding et al. Lymph node tuberculo- quent relapse of fever and asthenia. When the patient was first evaluated
sis mimicking malignancy on 18F-FDG PET / CT in two patients: a case in the ER, a diagnosis of urinary tract infection (UTI) was made, based on
report - Experimental and therapeutic medicine 13: 3369-3373, 2017). a urine culture positive for Aerococcus urinae; hence he was discharged
In these cases, patients subjected to PET examination which suspected a with targeted antibiotic therapy (levofloxacin). Based on the poor clinical
lymphoma; in the case report presented, the authors followed a reasoned response, the patient was subsequently readmitted to the ER and then to our
clinical-diagnostic procedure with the use of instrumental and clinical-la- Internal Medicine Unit. His medical history was relevant for severe mitral
boratory tests in steps. Case report: A 63-year-old African woman with regurgitation (NYHA class II), approached with a surgical intervention in
hypertensive and ischemic heart disease, with stent positioning about 5 transsternal thoracotomy and valve repair by Carpentier-Edwards Physio
years ago, has been diagnosed with asthenia, dyspnoea, fever for several annuloplasty ring. The intervention was performed seven months before the
months; she had a recent hospitalization with diagnosis of left pleuritis admission to our ward. He also suffered from abdominal aortic aneurysm,
and atrial fibrillation crisis converted to sinus rhythm with amiodarone. treated with bifurcated endoprosthesis placement. After the cardiosurgical
Following the onset of cardiopalm and dyspnea, she was hospitalized operation, the patient started to suffer from Mild Cognitive Impairment
for implantation of bicameral PM. After a few months of coughing per- (MCI) multiple domain and anxious depressive state. Notably the patient
sistence, she performed Rx chest which documented right pulmonary was known for a history of rheumatic polymyalgia, Jak2+ polycythemia
thickening with smooth margins and TC chest which highlighted the vera (in treatment with hydroxycarbamide) and previous prostatic cancer,
presence of multiple bulky pathological lymph nodes in all mediastinal treated with surgery, radiotherapy and hormonotherapy, with negative fol-
stations, especially subcarenal about 5 cm and preaortic about 3 cm; lungs low-up. On admission to our ward the patient was in good general condi-
appeared swollen for the bulky adenopathies, with the presence of a 1 cm tions, febrile but with no clear clinical signs of infection nor sepsis. A broad
nodule in the middle lobe and two consolidations in the apical bilateral spectrum antibiotic therapy with piperacillin/tazobactam was started.
regions. A thoracic and abdominal TC with mdc showed bilateral pre- Serum blood tests revealed an active inflammatory state (mild leukopenia
sence of pathological lymphnodes of maximal axial diameter of about 50 with absolute neutrophilia, increase of CRP, fibrinogen and procalcitonin;
mm in the hilar stations, with many other lymphadenopathies with globu- renal and hepatic function and coagulation tests were normal). Blood, urine
lar morphology in almost all mediastinal lymphnodes, the largest of which and stools cultures were performed and resulted negative. In the following
in the prevascular left station of about 30x18 and in the subcarenal region days, no clinical nor biochemical response was observed despite antibio-
of about 42x25 mm; there was a nodular element of about 11 mm in the tic treatment. According to the past clinical history, a wide spectrum of
medial segment of the middle lobe and apical on both sides; there were differential diagnosis was considered, so other tests were carried through:
various lymphadenopathies increased by volume with globular morpho- prostatic specific antigen was in the normal range, chest and abdominal
logy, to the celiac tripod, in the middle mesenteric, paraortical, paracaval, CT scan showed calcified mediastinal lymph nodes, with no other relevant
interaortical caval with axial diameter varying from about 18 mm to about abnormalities. Quantiferon test was inconclusive, nevertheless the patient
28 mm. Meanwhile, the patient had abdominal pain and two episodes of did not showed characteristic symptoms (cough, hemoptysis), nor signs
melena for which she was hospitalized to Hematology for suspicion of related to tuberculosis. Since the patient complained for aspecific stiffness
lymphoproliferative disease. The patient appeared in mediocre conditions, and fatigue all over the body, mainly to the shoulder girdle, a relapse of
epigastric pain regressed after endovenous administration of IPP. Oste- rheumatic polymyalgia was considered, but autoimmune screening was
omyelid biopsy did not show hematologic neoplasia, echocardiogram and normal. Furthermore, blood CD34 count resulted normal, so a shift from
thoracic surgical examination confirmed the extensive lymph node lesion polycythemia vera to idiopatic myelofibrosis was considered unlikely. Since
in the subcarenal tracheal region, so mediastinal biopsy was performed fever persisted, a diagnosis of fever of unknown origin (FUO) was made.
with cytologic examinations of bronchial emisystems. Mediastinal lym- According to literature, FUO is defined by a body temperature >38.3°C on
phonodal agobiopsia showed: fibrotic tissue totally occupied by chronic several occasions, with a duration of illness of at least 3 weeks and no dia-
granulomatous inflammation, epithelioid, focally necrotizing phenomena. gnosis within 1 week of hospital admission. Since endocarditis is one of the
This framework posed the suspicion of Tbc disease for which intrader- most relevant causes of FUO, and given the patient clinical history, a tran-
malization was performed according to Mantoux, which gave a positive sthoracic plus transesophageal echocardiography was performed, but did
result. The patient was sent to the center of infectious diseases that diagno- not showed valve vegetations. At this stage, a 18-FDG-PET was considered,
sed tuberculosis of mediastinal lymph nodes for which medical therapy even if its role is still debated [1, 2]: 18-FDG accumulated at osteomedullar
was undertaken with: amikacin, isoniazid, etambutol and pyrazinamide. level in the sternum (SUV max 10.5), so a diagnosis of sternal osteomyelitis
The patient was subjected to clinical follow-up with clinical controls by was made with a high degree of certainty [1]. This diagnosis was compati-
general medicine’s doctor and internist specialist and hematochemical ble with the patient clinical history of previous transsternal thoracotomy,
109
with subsequent metal wires placement. A therapy with daptomicin plus Graziano D. 1,2, Mirijello A. 1, de Matthaeis A. 1, Molinaro F. 1, De Cata A. 1,
ceftriaxone was then started, based on the isolation of Bacillus clausii and Inglese M. 1, Cela P. 1, Carughi S. 1, Varriale A. 1, Vendemiale G.2,3, De Cosmo
Staphylococcus epidermidis in 2 out of 9 blood cultures. The patient was S. 1
then referred to Cardiovascular Surgery for specific treatment. 1
Department of Medical Sciences, Unit of Internal Medicine, “Casa Sollievo
According to our experience, 18-FDG-PET was crucial for correct diagnosis della Sofferenza” Research Institute General Hospital, San Giovanni Rotondo,
and treatment. Its role should be considered in the diagnostic work-up of Italy. 2Internal Medicine and Geriatrics Residency School, University of
FUO, and standardised to balance radiation exposure and costs versus its Foggia, Foggia, Italy. 3Chair of Internal Medicine Residency School and Post
advantages. Graduate School of Geriatrics, University of Foggia, Foggia, Italy
[1] J Nucl Med. 2007 Jan;48(1):35-45. [2] Clin Radiol. 2017 Jun 7.
A 58-year-old white Caucasian man came to our Emergency Department
for an unwitnessed fall and altered mental status. According to patient’s rela-
112. THREE DIFFERENT PRESENTATIONS OF AN OLD tives, in the preceding 5 days he was experimenting fever and worsening
DISEASE mental status.
Three days before, he has come to the ED complaining of fever and weak-
Folli C. 1, Rovellini A. 1, Piconi S. 2, Monzani V. 1 ness. Chest X-Ray showed a lower right lobe pneumonia. Room air oxygen
1
IRCCS Fondazione Ca’ Granda - UO Medicina Interna ad Alta Intensità di saturation and blood pressure were normal, thus he was discharged with
Cura - Milano. 2 Ospedale Sacco - UO di Infettivologia - Milano prescription of levofloxacin 750 mg od.
Patient’s medical history was notable for epilepsy since the age of 11 treated
We describe three different cases of patients admitted to our division of with carbamazepine 700mg/day and phenobarbital 150mg/day. He was
High-Intensity Internal Medicine with a final diagnosis of tuberculosis a healthcare worker of our Hospital and had a 40 pack-year history of
(TB). First case- A 30 yrs-old woman from Eritrea had a recent history of smoking.
migratory arthritis associated with painful nodes at the legs. ERS and CRP At the ED he was alert but confused and restless, poorly cooperative.
were elevated; autoimmune screening and viral exams were negative. The Blood pressure was 85/60 mmHg, HR 81 bpm, T 38°C, SatO2 91% (I.F:
symptoms disappeared but were followed by fever and cough; a chest X-ray 0.21), respiratory rate 20/min. Lung examination: low-medium right lobe
showed pneumonia and pleural effusion (treated with levofloxacin with cli- coarse crackles associated with reduced-absent vesicular sounds on the
nical benefit); a little pericardial effusion was also present. After admission right base. A 12-lead ECG showed sinus rhythm, incomplete LBB, QTc
to the hospital, a TC showed a mediastinal mass, partly colliquated, and 397msec. Laboratory tests: WBC 6790/mm3; PLT 136000/mm3; Na+ 130
enlarged thoracic lymph nodes. Biopsy of a supra-clavicular lymph node mmol/l; GPT 127 U/l; GOT 246 U/l; GGT 289 U/l; LDH 464 U/I; CK
showed a necrotizing lymphadenitis granulomatous, gigantocellular (rese- 3049 U/l, fibrinogen 1357 mg/dl. Head CT scan excluded hemorrages or
arch of BK was negative, as well as DNA of mycobacterium). Haematologic focal parenchymal abnormalities. Chest X-Ray documented an extensive
malignancy, sarcoidosis, autoimmune diseases were excluded. As the dia- consolidation involving mid and lower right lobes. CURB-65 score was 2
gnosis remained unclear, the lymph node was extracted. Histologic findings (confusion and low blood pressure).
were similar to the previous ones. However, DNA of Mycobacterium tuber- The patient was admitted to our Internal Medicine Department with a
culosis was finally found positive. Specific therapy was therefore started. provisional diagnosis of pneumonia. At admission, clinical status was
Second case – A 34 yrs-old man from Bangladesh was admitted to hospital moderately deteriorated: fever, confusional state, hypoxemic respiratory
with fever and left pleural effusion. Microbiological exams were negative. failure [pH 7.49, pO2 55, pCO2 27.7, HCO3 20.90 (F.I:0.21)], hematuria
After therapy with ceftriaxone the fever disappeared. A chest TC showed were present. Blood, sputum and urine cultures and urinary Legionella
pleural thickening of uncertain origin and absence of lung involvement; antigen were collected before starting empirical antibiotic treatment.
a pleural biopsy excluded neoplastic problems, showing a granulomatous, Given the apparent inefficacy of levofloxacin, the unwitnessed fall in a
necrotizing reaction. Search for DNA of Mycobacterium tuberculosis was patient with a history of seizures, treatment with ceftriaxone 2g od + clari-
positive and four-drug therapy for tuberculosis was started. Third case - A thromycin 500mg bid was prescribed, together with oxygen at 0.35 IF. We
28-year-old woman from Bangladesh presented with a 3-month history of performed bedside POCUS to exclude subdiaphragmatic fluid collection,
neck and lumbar back pain, progressively worsening. A right supra-clavicu- liver, kidney and spleen abscesses. An echocardiogram showed slight
lar enlarged lymph node was present. Magnetic Resonance Imaging showed mitral regurgitation without vegetations. C-reactive protein was signifi-
the presence of multifocal bone spinal lesions with extensive para-spinal cantly elevated 44.80 mg/dl (n.v. <0.290), as well as procalcitonin 1.8 ng/
soft-tissue infiltration. Blood exams showed mild normochromic anemia ml (n.v. <0.05). Legionella Urinary antigen was positive.
and increase of ESR and CRP. An isotope bone scan revealed multiple areas Respiratory failure worsened in the first 24h (need for 0.5 oxygen I.F.),
of increased uptake in the skeletal system and in the cervical and mediasti- thus levofloxacin 750 mg/day plus ceftriaxone was prescribed instead of
nal lymph nodes. A thoracic contrast-enhanced CT-scan showed multiple clarithromycin.
mediastinal lymphadenopathies with central colliquative aspects without Nevertheless, patient was persistently febrile for 5 days and combined
pulmonary parenchymal involvement. Histopathological examination of anti-Legionella treatment with macrolide+fluoroquinolone was started
the laterocervical lymph node was unconclusive, showing the presence of a monitoring cQT at ECG (max 447 msec).
granulomatous inflammation with focal areas of necrosis. Histopatological Body temperature normalized after 36h, with a gradually improvement of
examination of bone lesions documented epithelioid granulomas with mul- patient’s mental status, regression of hematuria (day 7), fever (day 8), and
tinucleated giant cells; PCR amplification was positive for Mycobacterium respiratory failure (at day 12). Oxygen treatment was stopped at day 15.
tubercolosis. A diagnosis of disseminated extrapulmonary tubercolosis Patient was discharged on day 16 with prescription of levofloxacin 750 mg/
with multifocal bone and lymphnodal involvement was established; specific day for 7 days. According to literature, Legionella pneumophila causes 2-9%
antitubercolosis treatment was started. TB is still a significant public health of atypical community-acquired pneumonia (CAP) which is commonly
problem. Extrapulmonary TB is a rare manifestation. The diagnosis is chal- severe enough to require hospitalization. Although being primarily a respi-
lenging because symptoms may involve any segment or mimick other disea- ratory infection, Legionellosis involves central nervous system (CNS) in up
ses. Diagnostic delays and missed diagnosis are relatively common and they to 50% of patients. A reversible diffuse encephalopathy is the most common
can sometimes lead to a wrong and dangerous therapy (i.e. with steroids). neurologic complication, but focal CNS involvement can sometimes be the
Diagnostic test results may be impaired by several factors. Tuberculin skin initial presentation. Other common features at presentation are hyponatre-
test or Interferon Gamma realease assays such as Quantiferon may result mia, elevated liver enzymes, hematuria, ECG abnormalities. Legionnaires
negative because of the immune suppression due to the severity of dissemi- disease is more common in immunocompromised persons, in smokers,
nated disease. Likewise, isolation of the bacilli in the bioptic samples may be and in those with chronic lung disease. Azithromycin (500 mg orally once
sub-optimal and it is therefore important to obtain good-quality biopsies. daily), clarithromycin (500 mg orally twice daily), or a fluoroquinolone (eg,
Molecular exctraction is often necessary for the diagnosis of TB, that should levofloxacin, 750 mg orally once daily), are the drugs of choice. Combined
always be considered, particularly in patients from TB endemic regions. treatment with macrolide plus fluoroquinolones could be used in life-threa-
tening disease, although there is no robust evidence to support this practice.
Duration of therapy should be at least 10-14 days, although a 21-days course
113. WORSENING PNEUMONIA DESPITE ADEQUATE of therapy is recommended for severe diseases or immunocompromised
ANTIBIOTIC TREATMENT: UNCOMMON PATHOGENS patients.
COULD REQUIRE UNCOMMON TREATMENTS!
110
114. A CASE OF FEVER OF UNKNOWN ORIGIN: WHEN

TIMING OF IMAGING MAKES THE DIFFERENCE Spontaneous bacterial peritonitis (SBP) is the most frequent infection
complicating the clinical history of end-stage liver disease with incidence
Nuzzo M. 1, Passerini F. 1, Zimatore S. 2, D’Errico E. 3, Buonamico P. 1, ranging from 10 to 30% in hospitalized patients and a mortality rate up
Minerva F. 1, Palmieri V.O. 1, Pugliese S. 1, Belfiore A. 1, Portincasa P. 1 to 46%. Guidelines for SBP treatment recommend prophylaxis with oral
1
Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human norfloxacin 400 mg daily or cotrimoxazole 800/160 mg daily longlife.
Oncology, University of Bari “Aldo Moro” Medical School, Bari, Italy; 2Unit Whether there are factors that may help clinician to discontinue this
of Neuroradiology, Aldo Moro University, Bari, Italy; 3Neurology Unit, secondary prophylaxis is still debated. The role of vitamin D (vitD) as a
Department of Basic Medical Sciences, Neurosciences and Sense Organs, risk factor for infections in patients with cirrhosis has been largely investi-
University of Bari ‘Aldo Moro’, Italy gated. Serum vitD levels are generally lower in cirrhotic patients compa-
red with controls. For this background knowledge about vitD and PBS and
A 77-year-old man was admitted to the Internal Medicine Division from for the recognized role of vitD in modulating the immune response, we
Emergency Room. In the last ten days he developed hypotension, fever hypothesized that the difference between serum and ascites levels of vitD
(37.5°C) and low back pain. Symptoms persisted despite therapy with (serum-ascites vitamin D gradient (SADG)) may add valuable informa-
NSAIDs and paracetamol. He had a history of rectal cancer treated with tion in patients with SBP. We prospectively and consecutively enrolled 54
surgery, radiotherapy and chemotherapy, iatrogenic La Peyronie syndrome, patients with cirrhosis and ascites with clinical indication for paracentesis.
colonic diverticular disease, multiple cervical discopathies, acute coronary PBS was diagnosed in 16/54 (29.6%) patients. By using the normative cut
syndrome treated with PTCA and stenting, abdominal aortic aneurysm off of 20 ng/mL, vitamin D deficiency (vitDD) was observed in the vast
treated with aorto-biiliac stent grafting, recent finding of a pulmonary majority of patients (n=49/54, 90.7%) regardless of SBP diagnosis, with
lesion on computed tomography (CT) scan. Physical examination revealed 51, 8% of patients (n=28) having severe vitamin D deficiency (<10 ng/
fever (37.5°C), lumbar pain, neither stiff neck nor other signs of neurologi- mL). No difference was found in serum or ascites vitamin D in patients
cal involvement. He was alert, cooperative and oriented. Laboratory tests with or without PBS (p=0.16 for both) In our population, SADG values
showed leukocytosis (25.13×109/L; normal range <9.8×109/L) and eleva- ranged between -14 to 12, with a median value of -2 and interquartile
ted C-reactive protein level (194.0 mg/L; normal range <2.9 mg/L). A chest range of -5.0 to 1.0 ng/mL. Patients with SBP showed a SADG remarkably
x-ray did not show signs of pneumonia. Two sets of blood cultures were reduced compared to the ones with no SBP (-5.5 (-7.4; -3.3) vs -1.4 (-3;
obtained every time the patient showed fever over 38°C. The initial dia- 3.1), p=0.001. The only other variable associated to PBS was Child class
gnostic hypotheses were: urosepsis, sepsis from aortic endograft infection (B or C) (X2 = 9.3, p =0.002). We demonstrated that SADG is lower in
and spondylodiscitis, so an empirical antibiotic therapy was started with patients affected by SBP when compared to patients with cirrhosis and
ceftriaxone and levofloxacin. Urine analysis revealed neither bacteriuria nor ascites without SBP, whereas circulating and ascites levels of vitamin D
pyuria. Echocardiography excluded endocarditis. A CT scan with contrast were not different between subgroups (see table). This is, at our knowle-
did not identify any source of fever. Blood and urine cultures did not detect dge, the first study in which SADG is measured and a potential clinical
any bacterial or fungal strain and virologic blood tests were negative. A total use proposed. This is a hypothesis-generating pilot study. The clinical que-
body CT/PET (positron emission tomography) scan found high Standard stions directly deriving from this preliminary study could be: 1) Is SADG
Uptake Values in the right lung (where the pulmonary lesion had been a useful index to identify patients at risk of PBS recurrence? 2) is vitamin
previously described) and in the Lumbar 3-Lumbar 4 region, close to the D supplementation a viable therapeutic strategy to prevent a first episode
aortic graft, with partial involvement of Lumbar 5-Sacral 1 vertebral bodies. or a recurrence of PBS?
A first MRI (Magnetic Resonance Imaging) scan of the spine with gadoli-
nium was performed to confirm the hypothesis of spondylodiscitis, but it PBS (n=16) No PBS p
showed only signs of osteochondritis in the Lumbar 5-Sacral 1 region. A (n=37)
week after the admission there was a deterioration in neurological status, Age (years) 66.0±6.6 65.7±11.2 0.87
with persistence of fever and lumbar pain. Assuming a condition of sepsis, Child Pugh (n B/C class) 6/10 29/8 0.002
an antibiotic therapy with meropenem, linezolid and tigeciclin was started. PCR levels 3.5 (2.3; 6.0) 1.5 (0.6; 3.4) 0.039
Considering the hypothesis of an acute cerebrovascular disease, a brain CT Serum vitamin D levels 8.1±6.2 11.0±6.9 0.166
scan was performed, showing only signs of chronic vascular encephalopa- Ascites vitamin D levels 13.7±7.5 10.7±7.1 0.164
thy. Three days later the patient showed stiff neck and positive Lasegue sign. Serum-Ascites vit.D gradient -5.5 (-7.4; -3.3) -1.4 (-3; 3.1) 0.001
(SADG)
After neurological evaluation, a second brain and spinal MRI scan with
gadolinium was performed. This time the exam showed signs of spondylo-
discitis of the L5-S1 region and spinal meningitis with encephalic extension. 116. INHIBITION OF NUCLEAR FACTOR (ERYTHROID-
A lumbar puncture was performed: the cerebrospinal fluid (CSF) was clear DERIVED-2)-LIKE 2 (NRF2) PROMOTES TRANS-
and slightly xantochromic, it showed an increased leukocyte count (150/ DIFFERENTIATION OF HEPATOCYTE-LIKE CELLS
mm3;45% granulocytes, 55% lymphocytes), an increased protein level
(400 mg/dL), and a decreased glucose level (CSF glucose, 18 mg/dL; blood Bellanti F. 1, di Bello G. 1, Tamborra R. 1, Blonda M. 1, Pannone G. 2,
glucose, 80 mg/dL); no organisms were observed on Gram stain; no bacte- Vendemiale G. 1, Serviddio G. 1
rial nor fungal strain were detected on CSF cultures and virologic tests on 1
Centre for Experimental and Regenerative Medicine, Institute of Internal
CSF were negative. Only RT-PCR on CSF detected b-haemolytic strepto- Medicine, Department of Medical and Surgical Sciences, University of
coccus group B (Streptococcus agalactiae). The antibiotic therapy on course Foggia, Italy 2Pathology Unit, Department of Clinical and Experimental
was continued. During the following days neurological status, lumbar pain Medicine, University of Foggia, Italy
and neck stiffness gradually improved. At discharge the patient was alert,
oriented and cooperative, he did not report lumbar pain and the signs of Liver transplantation is still the only therapeutic option for liver failure.
meningitis had disappeared. The diagnosis of spondylodiscitis and spinal There is a urgent need for liver transplants but a severe unavailability of
meningitis with encephalic extension would not have been possible without donor livers, which highlights the need to develop new therapeutic strate-
careful follow up of clinical condition, a second brain and encephalic MRI gies. Stem cells may be promising for patients with liver failure and cirrhosis,
leading to lumbar puncture and close interaction with neurological advise. and the identification of their regulatory networks is determinant for organ
regeneration. Mesenchymal, embryonic and pluripotent stem cells have
been investigated as potential sources for hepatic differentiation, but their
115. SERUM-ASCITES VITAMIN D GRADIENT (SADG): unstable function and atypical morphology limit their usefulness. Stem cells
A NOVEL INDEX IN SPONTANEOUS BACTERIAL obtained from either adult or foetal liver are able to differentiate into hepa-
PERITONITIS tocytes or bile duct cells. Nevertheless, their number within a normal liver is
very low, making their isolation and expansion challenging, and restricting
Arcopinto A. 1, Buonomo R.A. 2, Salzano A. 1, Bobbio E. 1, their application to small-scale use. The human bipotent liver progenitor
D’Assante R. 3, Marra A.M. 4, Gentile I. 2, Cittadini A. 1, Borgia G. 2 cell line HepaRG may be expanded and applied for hepatocyte differentia-
1
Dipartimento di Scienze Mediche Traslazionali - Università Federico II, tion and transplantation testing.
Napoli 2Dipartimento di Medicina Clinica e Chirurgica, Sezione di Malattie Since redox-dependent signalling molecules are involved in the regulation
Infettive, Università Federico II, Napoli 3Dipartimento di Cardiochirurgia, of stem cell self-renewal and differentiation, we studied the role of Nrf2 –
IRCSS. San Donato Milanese, Milano 3IRCSS. SDN, Napoli the main transcription factor involved in the oxidative stress response – in
111
the trans-differentiation process of hepatic progenitor cells. First of all, we obser- nition). The genetic test will show ZZ homozygosis.
ved that Nrf2 is active in the hepatic stem cell niche of healthy subjects, but it Discussion: Usually we tend to consider less probable the diagnosis of a genetic
seems down-regulated in patients with chronic hepatitis. We found that Nrf2 is disease if presentation occurs in old age or incomplete form. Nevertheless
upregulated in undifferentiated HepaRG, which exhibit a lower mitochondrial alfa1-antitrypsin-deficit is a not-so-rare cause of both hepatic cirrhosis and
respiratory rate but a higher free radical production as compared to trans-diffe- COPD, with an extremely variable phenotype; in fact it can also occurs with
rentiated cells. Pharmacological and genetic inhibition of Nrf2 increases mito- other pathogenic noxae and be synergic with them. Substitutive therapy impro-
chondrial respiration, induces the expression of CD34, CD49a, CD49f, CD184 ves COPD but not hepatic cirrhosis prognosis: therefore familial screening is
and EpCAM, and promotes the expression of cytochrome P450 3A4, albumin essential to guarantee an early diagnosis, at least for relatives.
and gamma-glutamyl transpeptidase.
To conclude, we show that the inhibition of Nrf2 leads to morphological, phe-
notypical and functional patterns characteristic of trans-differentiated HepaRG 118. HIGH PREVALENCE OF ADVANCED FIBROSIS AND
cells, suggesting that this redox-dependent transcription factor may represent a CIRRHOSIS IN TYPE 2 DIABETIC PATIENTS WITH NAFLD
potential target to regulate the commitment of undifferentiated hepatic progeni-
tor cells into specific lineages. Borroni V. 1, Lombardi R. 1, Spreafico S.M. 1, Airaghi L.M. 1,
Fargion S. 1, Fracanzani A.L. 1
Dipartimento di Fisiopatologia e dei Trapianti, Fondazione IRCCS Ca’ Granda
117. A CASE OF SEVERE ANAEMIA Ospedale Maggiore Policlinico, Milano
Bianchi P.I., Brocchieri A., Cagnoni F., Pasini S.M., Ferrari L., Guerrini C., Objective: to evaluate the prevalence and factors associated with significant-ad-
Fugazza L. vanced fibrosis in patients with T2DM and NAFLD.
U.O.C. di Medicina Generale, A.S.S.T. di Lodi, presidio ospedaliero di Lodi Methods: We retrospectively analyzed 87 consecutive patients, mean age 58±9
years, with biopsy proven NAFLD and T2DM from hepatology unit. Patients
A 65-years-old lady is admitted by the E.R. in the Internal Medicine Department underwent a complete clinical and biochemical evaluation at the time of liver
for “hypochromic anaemia”. At the entrance to the ward, the patients presents biopsy; other concomitant liver diseases were excluded.
stable, alert, orientated, pale and over-weighted (IMB 28, 9). By rectal explora- Results: mean duration of diabetes before liver biopsy was 4.6±5.4 years; 9
tion normal-coloured stools are found. Recent medical history: Progressive lack patients were diagnosed with DM at the time of histology. Prevalence of NASH
of energy and exertional dyspnoea. She already underwent to: Echocardiogram: was 44%, of significant-severe fibrosis (≥ F2) 60% and of cirrhosis (14%), despite
normal; exercise stress test: interrupted for exercise intolerance. For her skin normal transaminases in 43% of patients. Patients were divided according to the
pallor, the Cardiologist suggested exams: Hb 4, 5 g/dL, MCV 66 fL (In 2015 Hb stage of fibrosis: moderate (F0-1) or significant-severe (F2-4). There were no
was 12 g/dL, normocytic; on April 2016 Hb 9, 5, MCV 78 fL), normal white significant group differences regarding gender, lipid and glycemic profile, waist
blood cells and platelets counts, FOBT (negatives), thyroid function (normal). If circumference and BMI, platelets, fasting insulin, PNPLA3 genotype. Conver-
asked, she confirms episodes of black stools in the last months and fresh blood sely, patients with F2-F4 fibrosis had significantly higher AST (31±13 vs 43±26
spottings attributed to haemorrhoids. In the E.R. she also undergoes to: UI/L, p=0.016) and age (55±8 vs 60±9 ys, p=0.006), and higher prevalence of
- Chest X ray: mild increasing of vascular shadowing, emphysematous notes, and moderate-severe steatosis (43% vs 71%, p=0.014), NASH (20% vs 60%, p<0.001)
obliteration of cost phrenic anterior angle. and metabolic syndrome (68% vs 92%, p=0.009). At logistic regression analysis
- EKG: sinus rhythm 95 bpm variables independently associated with significant-severe fibrosis were age (O.R.
- Other blood exams: GFR 85 mL/min, PLT 123.000/mcL, INR 1, 33, PT 61%. 1.068, 95%C.I. 1.005–1.134, p=0.033) and NASH (O.R. 3.836, 95% C.I. 1.304-
She is treated with 3 packed RBC transfusion, omeprazole 80 mg, crystalloids 11.282, p=0.015).
500 mL. Past medical history: Arterial hypertension, type 2 diabetes mellitus Conclusion: NASH, significant-advanced fibrosis and cirrhosis, histologically
from 2002, COPD from 2011, hypercholesterolemia, carotid artery disease, proven, are frequently present in patients with T2DM. Screening for diabetes in
GERD. Never smoked, non alcohol-drinking, housewife. None familial patho- NAFLD and viceversa is mandatory for an early diagnosis of potentially severe
logic history. Usual drugs: Apidra insulin 7-10-10 UI, Tresiba insulin 20 UI, liver disease, particularly with increasing age and even in presence of normal
Dapaglifozin/metformin 5/1000 mg/d, ASA 100, enalapril 20, atorvastatin 10, transaminases.
esomeprazole 20, Tiotropium, levosulpiride 25 mg.
During the hospital stay: ASA is interruped.
-Standard blood exams: Na 137, K 3, 73, creatinine 0, 57, bilirubin 0, 7/0, 3, AST 119. FRAILTY INDEX IS A STRONG PREDICTOR OF
57, ALT 25, gGT 43, Al. P 67, cholinesterase 3200, LDH 231, total cholesterol IN-HOSPITAL OUTCOMES AND MORTALITY AFTER
75, triglycerides 81, iron 23, transferrin 387, ferritin 3, reticulocytes 2, 45%, B12 DISCHARGE IN CIRRHOTIC PATIENTS
vitamin 270, folate 6, TSH 2, 65.
- Hb 4, 7 MCV 68, Hct 17%, MCH 19, RDW 17%, PLT 104, WBC 5000 (normal Caccamo G. 1, Basile G. 2, Vadalà D. 1, Maimone S. 1, Sitajolo K. 1, Pitrone C. 1,
composition), proteins 6, 8 (Alb 2, 8, alfa 1 0, 1, alfa2, 0, 6, beta1, 0, 6 beta2 0, 6 Squadrito G. 1, Raimondo G. 1
gamma 2, 1 policlonal). ANA 1:80 1
UOC di Epatologia Clinica e Biomolecolare -Dipartimento di Medicina Interna,
- Upper endoscopy: oesophageal blue F1 varices. Absence of fundus varices. Azienda Ospedaliera Universitaria Policlinico G. Martino - Messina - Italia
Mild oedema and hyperaemic nodularities in antrum. Biopsies of antrum and 2
UOC di Geriatria - Dipartimento di Medicina Interna, Azienda Ospedaliera
stomach body. First level research for aetiology of hepatic cirrhosis: HCV and Universitaria Policlinico G. Martino - Messina - Italia
HbsAg (already negatives in 2014), autoimmunity, coeliac serology: all negatives
apart ANA 1:80. Background: Frailty is a multiply determined vulnerability state causing a higher
- Lower endoscopy: Mild congestion of haemorrhoids of anus line. risk of adverse outcomes including death. Aim. To evaluate the impact of the
- Enhanced CT scan of abdomen: liver presents enlarged dimensions, irregular frailty measured by Rockwood frailty index (FI) on in-hospital outcomes and
margins, no focal alterations. Enlarged gallbladder, in which is present a millime- mortality after discharge in a cohort of hospitalized cirrhotic patients.
tric gallstone without biliary dilatation. Splenomegaly. By first level exams negati- Methods: We applied the FI to 101 cirrhotic patients (72% male; 65.6 years±12.2
vity, there are also required: ENA abs, anti-dsDNA abs, Cuprum, ceruloplasmin, SD) consecutively hospitalized from January to December 2015. Using medical,
alfa1-antitrypsin. Hepatic biopsy is under evaluation. The dosage of alfa1-anti- nursing and laboratory records we estimated FI taking into account 45 potential
trypsin shows a severe deficit. Therefore, the patients undergoes to: combinable deficits. The ratio between the number of deficits presented by each
- Chest HR CT scan: multiple cylindrical and varicoid bronchiectasis distribu- patient and the 45 considered deficits corresponds to FI: a value >0.25 identifies
ted along the whole parenchyma, especially in the poster basal left portion. The a frail patient.
bronchiectasis are clean. There are also some rare small cysts of airy content in Results: Cirrhosis was cryptogenic in 40% of cases; viral in 39%, alcoholic in
the lower lobes. No enlarged lymph nodes. No pleural or pericardial fluid. 21%. CPT class distribution was 51A/30B/20C, median MELD score was
- Spirometry and DLCO: normal volumes, except increased residual volume. 11.0(6.0-29.0). Thirty-five/101(34.6%) and 29/101(28.7%) patients were frail at
Moderate reduction of DLCO. admission (FI-a) and discharge (FI-d), respectively. No difference was found in
- 6 minutes walking test: no desaturation after a distance of 440 mts. Relief in 1 FIa between CPT-B and C [16/30(53.3%) vs 15/20(75%), p=0.1]. Frail patients
minute. had a longer in-hospital stay (17±14.8 vs 10.8±14.3 days; p=0.04); a higher pro-
- echocardiogram to evaluated right sections: Minimum tricuspid regurgitation, bability of re-hospitalisation within 3 months [23/35(65.7%) vs 40/66(60.6%)
systolic PAP 20 mmHg + 0, TAPSE 22, 3. Diagnosis: Pancytopenia in hyper- p=0.005]; a higher in-hospital mortality [5/35(14.3%) vs 2/66(3%), p=0.03]; a
splenism and iron deficiency by portal hypertension. Child-Pugh A5 cirrhosis higher mortality either at 3months [14/29 (48.3%) vs 8/72 (11.1%), p<.001],
and bronchiectasis associated to alfa1-antitrypsin-deficit (on going genetic defi- 6months [18/29(62.1%) vs 10/72(13.8%), p<.001], and 12months [18/29(62.1%)
112
vs 16/72(22.2%), p<.001]. Patients with a FI-d>0.25 had a risk of mortality higher Agostino Gemelli Hospital, Rome, Italy; 5 Histopathology, Agostino Gemelli
than that predicted by CPT and MELD. Hospital, Rome, Italy; 6 Liver Transplant Surgery, Agostino Gemelli Hospital,
Conclusion: FI strongly predicts in-hospital outcomes and mortality after Rome, Italy
discharge in hospitalized cirrhotic patients.
Introduction: BCLC-C stage hepatocellular carcinoma (HCC) includes a
wide spectrum of tumour and patients’ characteristics. Aim: To investigate
the prognostic factors for survival of BCLC-C stage HCC patients in a real-
life setting.
Patients and Methods: Consecutive caucasian cirrhotic patients with
BCLC-C stage HCC were included in the analysis. Pre-treatment (Child-
Pugh score, performance status (PS), number and maximum size of lesions,
vascular invasion, metastases, the combination of vascular invasion and
extrahepatic spread, alpha-fetoprotein (AFP) levels, NIACE score) and
post-treatment (number of treatments after the progression to BCLC-C
120. AN UNEXPECTED CASE OF CIRRHOSIS IN A stage and disease control (DC) considering stable+partial+complete
QUIESCENT CASE OF CROHN’S DISEASE response as the best treatment outcome) variables were considered as pro-
gnostic factors.
Calcagno E., Fanfani G., Tozzetti C., Torri M., Poggesi L. Results: 116 patients were included in the analysis. Median survival was
Dipartimento DAI emergenza ed accettazione, Degenza Medicina C, AOU 13.4 months (95%CI 10.6-17). At the univariate analysis, tumour size,
Careggi Firenze vascular invasion with or without extrahepatic spread, and AFP>200 ng/
mL as pre-treatment factors and DC as post-treatment variable were asso-
We describe a case of a 54-year-old man affected by Crohn’s disease in remis- ciated with survival. However, multivariable cox regression revealed that
sion phase for about 13 years, under mantainence treatment with mesalazine the influence of these factors was not homogeneous during time. Indeed,
(800 mg bid) and cyclic exposure to metronidazole; he underwent to several in the early period AFP>200 ng/mL was an independent predictor of worse
bowel resections because of local complications and was treated in the past outcome (at <6 months: HR 5.073, 95%CI 2.159-11.916, p=0.0002). As
with oral glucocorticoids and azathioprine. He presented to the Emergency expected, in the multivariable post-treatment prognostic model DC was
Department of our hospital because of melena and severe anemia (Hb 7.6 g/ associated with a better longterm survival (at >1 year: HR 0.110, 95%CI
dL) requiring blood transfusions. An esophagogastroduodenoscopy (EGD) 0.038-0.314, p=<0.0001).
revealed esophageal varices with signs of recent (but not active) bleeding Conclusions: In patients with BCLC C HCC, AFP>200 ng/mL is a strong
and clots, impeding to visualize gastric funds and making variceal ligation. unfavorable prognostic factor in the early period, while DC is associated
Moved to our Internal Medicine Department, first of all we echographi- with long-term patients’ survival.
cally excluded the possibility of a portal vein thrombosis, with the collateral
evidence of heterogeneous liver parenchyma, suggestive for cirrhosis. The
evaluation of liver stiffness with ultrasound-based elastography (Fibroscan)
showed a Metavir fibrosis score of F4. Blood tests showed a fair hepatic fun-
ctional balance, with 111.000/mm3 platelets, 0.3 mg/dL total bilirubin, 3.45
g/dL albumin, 28 U/L ALT, 30 U/L gammaGT, 77 U/L alcalin phosphatase,
INR 1.1 (CHILD PUGH score 6, class A)). Hepatotropic viruses, desialed
transferrin and anti-mithocondrial antibody (AMA) were negative. Second
line investigations excluded autoimmune hepatitis, hemocromatosis and
Wilson’s disease too. Drug induced hepatotoxicity was ruled out because of
the long latent period from azathioprine treatment; in literature azathioprine
could induce hepatic damage within few months of treatment discontinua-
tion, and cirrhosis is a really rare complication developed during treatment.
A deeper analysis of his past medical history, revealed the presence of hepatic
steatosis in a three-year-ago MRI and the concomitant presence of hyperbi-
lirubinemia (total bilirubin: 2.03 mg/dL), a light increase in transaminase
levels (ALT: 71 U/L, AST: 69 U/L), normal triglycerides and cholesterol levels
(164 mg/dL and 147 mg/dL respectively). Therefore, an exclusion diagno-
sis of cirrhosis as evolution of a non-alcoholic steatohepatitis (NASH) was
done. Variceal ligation and TIPSS were made after clinical stabilization and a
therapy with bisoprolol, pantoprazole and mesalazine was set up. Hepato-bi-
liary tract is a frequent extraintestinal localization in intestinal bowel disea-
ses (IBD), especially in patients affected by ulcerative colitis (UC). The pre-
valence of liver test alterations, usually transient, reaches up to 50% during
the course of IBD. Non-alcoholic fatty liver disease (NAFLD) is the most
common cause of elevated liver enzymes in IBD patients and it sensitizes
the liver to injury. On the other hand, NAFDL is often asymptomatic and it
is less frequently associated with metabolic risk factors in IBD patients than
in general population, so it could be underestimate in its prognostic implica-
tions, that include liver fibrosis.
121. TIME DEPENDENT EFFECT OF PROGNOSTIC

FACTORS IN PATIENTS WITH BCLC-C STAGE
HEPATOCELLULAR CARCINOMA: A REAL-LIFE
EXPERIENCE
Ponziani F.R. 1, Spinelli 1, Rinninella E. 1, Cerrito L. 1, Saviano A. 1,
Riccardi L. 1, Zocco M.A. 1, Annicchiarico B.E. 1, Garcovich M. 1, Siciliano M. 122. ANTIVIRAL THERAPY WITH SECOND-GENERATION
1
, Giuliante F. 2, De Gaetano A.M. 3, Iezzi R. 3, Basso M.4, DIRECT-ACTING ANTIVIRALS IN CIRRHOTIC PATIENTS
Miele L. 1, Vecchio F.M. 5, Avolio A.W. 6, Agnes S. 6, Gasbarrini G.B. 1, WITH CHRONIC HCV INFECTION. 1 YEAR FOLLOW UP
Rapaccini G.L. 1, Grieco A. 1, Gasbarrini A. 1, Pompili M. 1
1
Internal Medicine, Gastroenterology, Hepatology, Agostino Gemelli Cesario V. 1, Ponziani F. 2, Tortora A. 2, Fornaciari G. 2, Pompili M. 2,
Hospital, Roma, Italy; 2 Hepatobiliary Surgery, Agostino Gemelli Hospital, Siciliano M. 2
Rome, Italy; 3 Radiology, Agostino Gemeli Hospital, Rome, Italy; 4 Oncology,
1
Dipartimento di Medicina, ASMN, Reggio Emilia, 2Dipartimento di
Medicina, UCSC, Roma
113
Background and Aim: Direct-acting antivirals (DAAs) have revolutioni- Background: Growing evidence suggests a strong relationship between
zed treatment for patients with chronic hepatitis C virus (HCV) infection, HCV infection and cardiovascular disorders. Moreover, cardiovascular
extending the possibility of treatment to patients with cirrhosis. This study abnormalities in advanced liver fibrosis (known as cirrhotic cardiomyopa-
assessed the compensation of cirrhosis after 1 year of treatment end with thy, CCM) are characterized by hyperdinamic circulation featuring increa-
DAA-based antiviral therapy in cirrhotic patients with chronic HCV sed heart rate and high cardiac output, concomitant with decreased syste-
infection. mic vascular resistance. Current criteria for cirrhotic cardiomyopathy focus
Methods: This observational multicenter cohort study included all conse- only on cardiac function without addressing the effect of hyperdynamic and
cutive patients with chronic HCV infection and cirrhosis who underwent low-resistance circulation, also impaired systolic function in these patients
antiviral therapy with second-generation DAAs. Data on all patients were usually does not manifest at rest. Aims: We investigated characteristics of
analyzed to assess compensation of cirrhosis (liver function: bilirubin, the pressure-volume relationship in patients with advanced liver fibrosis
INR, albumin, platelets, alanine aminotransferase (ALT) and MELD scores before and after anti-HCV therapy with direct antiviral agent (DAA). We
between start of therapy to 12 months post-treatment end) and the occur- also compared the patients to a group of controls to assess wheather ventri-
rence of adverse outcomes (deaths, liver transplantation, hepatocellular car- culo-arterial parameters and advanced echocardiographic techniques (such
cinoma, serious decompensation events) within 1 year. Results Until June as 3D and peak longitudinal strain) were useful to describe the cardiovascu-
2015, 66 cirrhotic patients (87, 8% Child-Pugh A; 18, 2% Child-Pugh B) lar abnormalities in advanced liver cirrhosis.
with chronic HCV infection started DAA-based treatment. A sustained Methods: We evaluated 34 consecutive cirrhotic (F4) or pre-cirrhotic (F3)
virological response was achieved in 93, 9% patients (62/64). After 1 year HCV patients (fibroscan>10 kPa) selected from Hepatology Clinic of the
of treatment end we observed a reduction of MELD scores [9 (6-16) vs 8 Division “Medicina Interna 1” Ospedale Maggiore della Carità, Novara. All
(6-19), p=0, 02], an increase in median values of albumin [4, 11 (2, 4-4, 7) the patients had compensated liver disease (CHILD A or B) and were treated
vs 4, 19 (3-3, 5), p=0.024] and a reduction in INR values [1, 1 (0, 95-1, 44) with “all oral” regimens for HCV virus (DAA) and reached sustained virolo-
vs 1, 05 (0, 8-1, 36), p=0.011] from baseline. These differences are not seen gical response at 12-weeks after the end of treatment (SVR12). Patients with
when we considered the subgroup of patients with Child-Pugh B cirrho- history of heart failure, atrial fibrillation, cardiomiopathy, reduced left-ven-
sis. During follow up 4/66 patients were diagnosed with an hepatocellular tricular ejection fraction and significant valvular disease (more than mild
carcinoma. steno/insufficiency) were excluded from the study. We performed 3 echo-
Conclusions: This study suggests that antiviral therapy in cirrhotic patients cardiographic evaluation for each patient: before treatment, at the end of
with chronic HCV infection led to prolonged improvement in liver fun- therapy (ET) and at 12-weeks after the end of treatment (FU12). In addition
ction. If viral clearance is associated with a clinical benefit in patients with to the echocardiographic evaluations (as suggested by the American Society
decompensated cirrhosis (Child-Pugh B) remains to be determined. of Echocardiography), we performed non invasive evaluation of ventricu-
lar-arterial coupling (using sigle-beat technique) with continuous recording
of blood pressure (Finapres ®): arterial elastance (Ea), single-beat left-ventri-
123. UNRESECTABLE HEPATOCELLULAR CARCINOMA: cular end-systolic elastance (Ees Sb), ventriculo-arterial coupling (EA/Ees
TRANSARTERIAL RADIOEMBOLIZATION VERSUS Sb) and cardiac work. Patients were compared to a small group of controls
CHEMOEMBOLIZATION (similar by age, sex, body mass index and prevalence of hypertension).
Results: Cirrotics and pre-cirrotics patients had significantly higher left
Elia C. 1, Salomone P. 2, Serraino C. 2, Cardellicchio A. 2, ventricular (LV) mass (p=0.004), interventricular septal (p=0.05) and LV
Christian B. 2, Grosso M. 3, Fenoglio L. 2 posterior wall thickness (p=0.03), left atrium area (p=0.05) and teledia-
1
Dipartimento di Medicina d’urgenza, ospedale Regina Montis Regalis, stolic volume (p=0.02), while diastolic parameters (E/A ratio, deceleration
ASLCN1, Mondovì, Cuneo 2Dipartimento di Medicina Interna, ospedale time and E/E’ ratio), LV ejection fraction and longitudinal strain were
Santa Croce Carle, Cuneo 3Dipartimento di Radiologia, ospedale Santa similar to controls. Compared to controls, patients had reduced Ea/Ees
Croce Carle, Cuneo sb (p=0.03), increased stroke volume (p=0.03) ed increased cardiac work
(p=0.018). We found no differences between F4 and F3 patients as far as
Hepatocellular carcinoma (HCC)- is recognized as one of the most-pre- the ventricular-coupling variables are concerned. After DAA therapy, we
valent and lethal neoplasms worldwide. Prognosis and alocation of the found a significant reduction in Ea/Ees sb (p<0.05) and an improvement
multiple available treatment options for patients with HCC are influenced in myocardial efficiency (p=0.008) with a tendency towards reduction of
not only by tumour stage, but also by the degree of liver-function impair- pressure-volume area (PVA, p=0.096) and oxygen consumption, estimated
ment. According to theBCLC algorithm, transarterial chemoembolization by pressure work index (PWI). Moreover, the mean slope value of the PVA/
(TACE) is considered the standard treatment for intermediate-stage HCC, PWI relations, associated with chemomechanical transduction efficiencies
Radioembolization (TARE) is a promising alternative that deserves further in a study on dogs by Wolff and colleagues, showed a change (although non
prospective studies. We performed a prospective cohort study in a referral statistically significant, p=0.07) between pre-therapy and follow-up condi-
center of all patients with unresectable HCC treated by TARE from 2010 tions. Conclusions: Ventriculo-arterial coupling parameters seem to play a
to 2016. For comparison, one control groups of patients treated by TACE, role in detecting systolic cardiac impairment in the resting state in cirrhotic
respectively, was also evaluated. Patients were followed up until death. The patients. HCV eradication induce an improvement of myocardial efficiency
primary outcome was survival; secondary outcomes were total hospitali- possibly by changing the ventricular-arterial coupling leading to a reduced
zation time and post-treatment complications. We collected data from 390 oxygen consumption after antiviral therapy.
consecutive patients with unresectable HCC. A total of 300 underwent
TACE and 90 underwent TARE. Median ages were 70, 9 and 64 years for
TACE and TARE, respectively. The one-year-survival was higher in the 125. SPLEEN DIMENSIONS ARE INVERSELY ASSOCIATED
TARE cohort versus TACE cohort (67% vs 48%), but the HCC in the Tare WITH LYSOSOMAL ACID LIPASE ACTIVITY IN PATIENTS
cohort was bigger tham TACE cohort (7.8± 4, 3 vs 4.3±2.4) There was no WITH NON-ALCOHOLIC FATTY LIVER DISEASE
difference in the incidence of post-treatment nausea, vomiting, fever, or
other complications. The number of treatment sessions, the average rate of Baratta F. 1, Pastori D. 1, Polimeni L. 1, Tozzi G. 2, Novo M. 1,
treatment sessions per patient, total hospitalization time and rate of adverse Violi F 1, Angelico F. 3, Del Ben M. 1
events were significantly higher in the TACE cohort. TARE appears to be a 1
Department of Internal Medicine and Medical Specialties, Sapienza
safe alternative treatment to TACE with comparable complication profile, University, Rome, Italy; 2Unit for Neuromuscular and Neurodegenerative
but not for survival. Larger prospective trials, focusing on patient-reported Diseases, Children’s Hospital and Research Institute “Bambino Gesù”, Rome,
outcomes and cost-benefit analysis are required to consolidate these results. Italy; 3Department of Public Health and Infectious Diseases, Sapienza
University, Rome, Italy
124. ASSESSMENT OF VENTRICULO-ARTERIAL Background: Fatty liver and splenomegaly are typical features of genetic
COUPLING BEFORE AND AFTER ANTI-HCV THERAPY Lysosomal Acid Lipase (LAL) deficiency. No data in adult patients with
non-genetic reduction of LAL activity are available. We investigate the asso-
Favretto S., De Vecchi F., Bellan M., Avitabile E., Marino P.N., ciation between spleen dimensions and LAL activity in non-alcoholic fatty
Pirisi M. liver disease (NAFLD) patients, in whom a reduced LAL activity has been
Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, reported.
Novara Methods: We included 425 consecutive patients who underwent abdominal
ultrasound to evaluate hepatic steatosis and spleen dimensions. LAL activity
114
was measured with dried blood spot method (Lalistat2). Guaschino G. 1, Soddu D. 1, Tran Minh M. 1, Bellan M. 1,
Results: NAFLD was present in 74.1% of screened patients. Higher median Minisini R. 1, Barbaglia M. 1, Rigamonti C. 2, Pirisi M. 1,2
spleen longitudinal diameter (10.6 vs. 9.9 cm; p<0.001) and spleen area 1
Department of Translational Medicine, Università del Piemonte Orientale, 2
(SA) (32.7 vs. 27.7 cm2; p<0.001), together with a higher proportion of sple- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
nomegaly (17.8 vs. 5.5%, p=0.001), was present in patients with NAFLD
compared to those without. In NAFLD patients, median LAL activity was Rationale and Aim: It has been reported that liver stiffness measured
0.9 nmol/spot/h. LAL activity was higher in patients with SA above median by transient elastography (TE, FibroScan®) decreases after direct antivi-
in comparison to those below median (1.0 vs. 0.8 nmol/spot/h, p<0.001). ral agents (DAA) treatment in patients with chronic hepatitis C (HCV);
A similar reduction was present in 56 patients with splenomegaly. At mul- whether this reduction reflects mainly reduced inflammation in the liver
tivariable logistic regression analysis, age (OR:0.954; p=0.001), female sex has not been established. Interferon-gamma inducible protein 10 (IP-10) is
(OR:0.566; p=0.046), LAL activity below median (OR:2.064, p=0.010), increased in HCV infection and correlates with hepatic inflammation. We
obesity (OR:2.764; p=0.001) and platelets (OR:0.995, p=0.036) were signifi- aimed to verify if changes in liver stiffness before and after DAA treatment
cantly associated with SA above median. Similar results were obtained using are paralleled by changes in IP10.
splenomegaly as dependent variable. Methods: This retrospective study included 88 HCV patients (72% cirrho-
Conclusions: NAFLD patients disclose a relatively high prevalence of tics) who achieved sustained virological response (SVR) after DAA treat-
spleen enlargement and splenomegaly, which were significantly associated ment (started between February 2015 - May 2016) and underwent paired
with a reduced LAL activity, suggesting that LAL may contribute to spleen TE and IP10 measurements before as well as 24 weeks after treatment with
enlargement in this setting. DAA. The predefined limits to consider significant a change were: TE value
≥30% increase/decrease from baseline, IP10 value ≥20% increase/decrease
from baseline. IP-10 was measured in serum samples using the enzyme-lin-
126. CEREBRAL VASCULAR RESISTANCE IS INCREASED ked immunosorbent assay (normal value ≤100 pg/ml). Statistical analysis
IN CIRRHOTIC PATIENTS WITH MINIMAL HEPATIC was performed using SPSS 17.
ENCEPHALOPATHY AND REMAINS UNCHANGED AFTER Results: Eighty-eight patients were studied (59 males, median age 62 years)
MEDICAL TREATMENT 57% HCV genotype 1, 57% with endoscopic signs of portal hypertension
at baseline. Before DAA treatment: 70% with TE >13 kPa, median TE 18.2
Ponziani F.R. 1, Funaro B. 1, Ainora M.E. 1, Lupascu A. 2, kPa (range 8.8−75 kPa), 70 % had IP10 >100 pg/ml, median IP10 164 pg/
Riccardi L. 1, Annicchiarico B.E. 1, Garcovich M. 1, Quadarella A. 1, Siciliano ml (20−1194pg/ml), platelet count 133000 /mcl (28000−359000/mcl). After
M. 1, Gasbarrini G. 3, Gasbarrini A. 1, Pompili M. 1, DAA treatment: 43% with TE >13 kPa, median TE 11 kPa (range 4.8−75
Zocco M.A. 1 kPa), 8% with IP10 >100 pg/ml, median IP10 27 pg/ml (1−519 pg/ml), pla-
1
UOC di Medicina Interna, Gastroenterologia e Malattie del Fegato, telet count 160000/mcl (33000-361 000/mcl). TE and IP10 values decreased
Policlinico A. Gemelli Università Cattolica del Sacro Cuore di Roma, 2UOC significantly after DAA treatment (p=0.0001), median change was -34%
di Clinica Medica e Malattie Vascolari, Policlinico A. Gemelli Università (range -79 − +32%) for TE and -84 % (range -89 − +189%) for IP10. TE
Cattolica del sacro Cuore di Roma, 3Professore Emerito Università Cattolica decreased in 56%, increased in 2% and was stable in 42% of patients; IP10
del Sacro Cuore di Roma decreased in 94 %, increased in 4% and was stable in 2% of patients; 53% of
patients showed decrease of both TE and IP10. Delta % change of TE and
Background: In cirrhotic patients, cerebral vascular resistance indices (resi- IP10 were significantly correlated (r=0.23, p=0.02).Platelet count did not
stivity index, RI and pulsatility index, PI) are good indicators of cerebral significantly increase after treatment (median platelet count change +14%,
hemodynamic abnormalities and are closely correlated with the severity of range -35 − +153%).
cirrhosis, hepatic encephalopathy (HE) and ascites. However there are still Conclusions: Decrease of TE after DAA treatment is paralleled by a decre-
poor data about cerebral vascular indices and minimal HE (MHE). Aims: ase in serum IP10 levels, suggesting that improvement of liver inflammation
The aim of this study was to correlate cerebral arteries resistance indices may be a major determinant of TE reduction.
with the presence of MHE and to evaluate their modification after treatment
with rifaximin.
Methods: 38 consecutive cirrhotic patients were enrolled in this study. 128. HARMFUL AND BENEFICIAL EFFECTS OF
Exclusion criteria were overt HE (West Haven ≥ 1), age <18 years, active ANTICOAGULATION IN PATIENTS WITH CIRRHOSIS
alcohol consumption, sepsis, cerebrovascular diseases, cerebral neoplasms, AND PORTAL VEIN THROMBOSIS
cardiac diseases, peripheral vascular diseases, treatment with rifaximin and
lactulose in the previous 30 days. Patients presenting signs of MHE at the V. La Mura 1,2, S. Braham 3, G. Tosetti 1, F. Branchi 1, N. Bitto 2,
psychometric evaluation (TMT-A, TMT-B and DST) received rifaximin M. Moia 3, A.L. Fracanzani 4, M. Colombo 5, A. Tripodi 3,
1200 mg daily for 10 days. All patients underwent TCD for the measu- M. Primignani 1
rement of RI and PI of the mean cerebral artery (MCA) and of posterior 1
Division of Gastroenterology and Hepatology, IRCCS Fondazione Ospedale
cerebral artery (PCA) at baseline and within 2 weeks after rifaximin treat- Maggiore Milan 2 Internal Medicine, IRCCS San Donato, Department of
ment. Median value of the right and left side arteries have been used for the Biomedical Sciences for Health, University of Milan, San Donato Milanese,
analysis. Intra-abdominal vessels (renal arteries, mesenteric artery, portal Italy (current address for VLM) 3 Angelo Bianchi Bonomi Hemophilia and
vein) flow parameters were also assessed, and the Child-Pugh score was Thrombosis Center, IRCCS Ca’ Granda Maggiore Hospital Foundation,
calculated. Department of Clinical Sciences and Community Health, University of
Results: Among the patients enrolled in the study 17 had MHE (44.7%). Milan, Milan, Italy 4 Internal Medicine, Department of Pathophysiology
MCA-PI, PCA-PI and RI were significantly increased in patients with MHE and Transplantation, IRCCS Ca’ Granda Maggiore Hospital Foundation,
compared to those without (MCA-PI 1.04 vs 1.05, p=0.05; PCA-PI 1.12 vs University of Milan, Milan, Italy 5 Department of Internal Medicine,
0.9, p=0.02; PCA-RI 0.64 vs 0.56, p=0.01) while MCA-RI showed a trend Humanitas Clinical and Research Center Rozzano, Italy
towards the increase (0.65 vs 0.61, p=0.07). No significant difference was
found in the intra-abdominal vessels flow parameters between the two Background: Vitamin K antagonists (VKAs) may favor recanalization of
groups. Furthermore, cerebral arteries resistance indices were not associa- portal vein thrombosis (PVT) with a relative safety for upper-gastro-in-
ted with the Child-Pugh score. After treatment with rifaximin, TMT-A and testinal (GI) bleedings in cirrhotic patients on prophylaxis of varice-
B and DST showed a significant improvement (p=0.05, p=0.03 and p=0.003 al-hemorrhage. However, anticoagulation could be associated with other
respectively). Only PCA-RI was ameliorated after rifaximin treatment major- and minor-bleedings that could counterbalance the benefits of
(p=0.024). PVT-recanalization on cirrhosis. We aim to evaluate harmful and benefi-
Conclusions: MHE is associated with increased cerebral vascular resistance cial effects of VKA in PVT-cirrhosis.
in cirrhotic patients, which remains substantially unchanged after medical Patients and Methods: We Compared bleeding-risk of patients on VKA
therapy. for de novo PVT-cirrhosis (PVT-cohort, n=63) vs non-cirrhosis patients
with venous thromboembolism (VTE-cohort, n=160) during four years of
follow-up. Time in therapeutic range (TTR) of INR indicated the quality
127. LIVER STIFFNESS DECREASES IN PARALLEL of anticoagulation. One-hundred-thirty-nine cirrhotic patients not on
TO SERUM IP-10 CONCENTRATION FOLLOWING VKAs were controls in the analysis for any portal hypertension-rela-
TREATMENT OF HEPATITIS C WITH DIRECT ANTIVIRAL ted event (LC-cohort). Survival analysis explored the impact of VKA in
AGENTS
115
PVT-cirrhosis. Donato Milanese (MI), Italy 2Radiology, Fondazione IRCCS Ca’ Granda
Results: VTE- and PVT-cohort were comparable for age, gender and TTR Ospedale Maggiore Policlinico, University of Milan, Milan, Italy 3Internal
whereas VTE cohort had longer VKA-treatment (31.1+/-16.9 vs 23.3+/- Medicine and Hepatology Unit, University of Salerno, Salerno, Italy
16.2 months, p=0.002). The actuarial probability of major/minor blee-
ding was higher in PVT-cohort (21%/30%) than VTE-cohort (7%/20%) A 56-year-old man, active alcohol drinker of about 2 liters of wine/day for
(p<0.05). Among major-bleedings, only those from upper-GI tract were more than ten-years and smoker of 30 cigarettes/day, presented with ascites
significantly higher in PVT- vs VTE-cohort. However, PVT- and LC-cohort not responsive to diuretics in the last year. Up to 18 liters of ascites were
had the same upper-GI bleedings, suggesting that portal hypertension, but removed. Biochemistry disclosed a serum ascites albumin gradient (SAAG)>
not VKA, may account for the risk difference of major-bleeding between 1.1, total proteins 3.2 g/dL suggesting ascites secondary to post-hepatic
PVT- vs VTE-cohort. Complete recanalization in PVT-patients on VKA portal hypertension (SAAG> 1.1g/dL) with high protein content. Patient
(n=31) independently predicted the highest portal hypertension-related referred the appearance of ascites after a significant weight loss (-20Kg) in
event/transplantation free-survival. a previous period of 4 months. Biochemistry of ascites and the previous
Conclusions: VKA may be responsible for a greater risk of minor-bleeding history of weight loss called for a diagnostic work-up aimed at ruling-in/
in patients with PVT-cirrhosis compared with non-cirrhotic patients, but out cirrhosis and/or other causes of ascites, among them, malignancy,
this risk is counterbalanced by the benefit of PVT-recanalization. liver vascular diseases, right heart failure. Total body CT-scan, positron-e-
mission-tomography, colon- and upper gastro-intestinal endoscopy were
negative for cancer but positive for small esophageal varices, mild portal
129. IMPACT OF VONWILLEBRAND FACTOR/ADAMTS- hypertensive gastropathy, nodular liver surface resembling cirrhosis and
13 ON THE PRO-COAGULANT IMBALANCE DETECTED partial portal vein thrombosis but normal spleen diameter. B-type natri-
IN CIRRHOSIS uretic peptide was in the physiologic range, echocardiography negative
for systolic/diastolic dysfunction and/or indirect signs of pulmonary
La Mura V. 1, Tripodi A. 2, Bitto N. 1, Tosetti G. 3, Chantarangkul V. 2, hypertension. At this step, the diagnosis was: cirrhosis complicated by
Baronciani L. 2, Valsecchi C. 2, Peyvandi F. 2, Salerno F. 1, ascites. MELD score was constantly 9 points. Portal vein thrombosis was
Lampertico P. 3, Colombo M. 3, Primignani M. 3 successfully treated by four months of enoxaparin 4000 U/day, however,
1
Internal Medicine-IRCCS San Donato, University of Milan, San Donato despite diuretic optimization, patient continued needing large volume
Milanese (MI) 2Angelo Bianchi Bonomi Hemophilia and Thrombosis paracentesis every three-four weeks. The first biochemistry of ascites was
Center-IRCCS Ca’ Granda Maggiore Hospital Foundation, Department of always confirmed and citology was constantly negative for malignancies.
Clinical Sciences and Community Health, University of Milan 3Division of Six months later, the patient was referred to our tertiary-care center for
Gastroenterology and Hepatology-IRCCS Ca’ Granda Maggiore Hospital transjugular intrahepatic porto-systemic shunt (TIPS) or liver transplan-
Foundation, University of Milan tation. The oncology work-up was repeated and confirmed negative for
any neoplastic process. CT-scan showed two interesting new data: 1) a
Background: Thrombomodulin-resistance (TM-R) has been associated normal-sized spleen despite numerous periesophageal collateral circula-
with the risk of de novo portal vein thrombosis and transplantation free tion; 2) a reduced volume pancreas with calcifications and ductal dila-
survival in cirrhosis. Von Willebrand factor (VWF), marker of endothelial tation of Wirsung as chronic pancreatitis, compatible with the patient’s
dysfunction, and its cleaving protease ADAMTS-13, are independent pre- history of chronic alcohol abuse. A nutritional counseling was requested
dictors of clinical outcome in cirrhosis confirming the potential pathoge- and an adequate dietary therapy set for suspected ascitic decompensation
nic role of hemostasis on liver damage. Our study aimed at exploring the at least in part due to severe pancreatic-insufficiency and malabsorption/
influence of VWF and ADAMTS-13 on the degree of TM-R along with the malnutrition. However, the dietary therapy allowed only a slight reduction
severity of the chronic liver disease. in the frequency of paracentesis, therefore, in the suspicion of a compo-
Patients and Methods: We prospectively collected clinical and laboratory nent of post hepatic portal hypertension, a hepatic and systemic hemo-
data of 79 patients (n° Child A/B/C = 29/35/15) (median MELD score dynamic study with transjugular biopsy were performed. The hemody-
and range: 11; 6–28) consecutively admitted for endoscopic band ligation namic study showed: liver wedge pressure 20 mmHg, hepatic vein free
of esophageal varices or paracentesis. All patients were in stable hemo- pressure 11 mmHg (Hepatic Venous Pressure Gradient: 9 mmHg, below
dynamic conditions and without clinical evidence of bacterial infection. the common threshold of clinically significant portal hypertension). The
Examinations included VWF (antigen, VWF:Ag, and activity, VWF:RCo) Inferior vena cava pressure was 2 mmHg therefore the real transhepatic
(VWF:RCo/VWF:Ag was an estimate of highly active VWF), ADAMTS- gradient was 18 mmHg. The phlebographic study showed a threadlike
13 activity, the main pro-(FVIII, FII) and anticoagulants (antithrombin, right hepatic vein, a well-represented but stenosed medium hepatic vein,
protein C). ETP-ratio (Endogenous thrombin Potential) with/without the catheterization of the left hepatic vein was unsuccessful. The histo-
thrombomodulin defined the degree of TM-R and was used to explore the logy showed: marked fibrotic component and cirrhotic evolution. Hence
influence of VWF on pro-coagulant imbalance. hemodynamic and phebographic studies revealed an outflow problem of
Results: Liver dysfunction was associated with high VWF:Ag, VWF:RCO the liver. At this point the therapeutic options were: 1) simple angiopla-
and low ADAMTS-13 (p<0.05). FVIII was the factor with the highest sty (PTA), 2) PTA with stenting, 3) TIPS with the aim to overcome the
degree of association with VWF:Ag, VWF:RCO independently from stenosis by the stent allocation. At the beginning we opted for the first
MELD or Child-Pugh (multiple linear regression; p<0.001) in accor- approach. Manometry post-PTA showed a 50% reduction of the original
dance with the biological role of VWF protecting FVIII from degradation. trans-hepatic pressure gradient. The patient maintained a stable weight
ADAMTS-13 negatively correlated with VWF:RCO/VWF:Ag ratio, an around 52 kg for one week after the procedure, however, weight-incre-
indirect estimation of VWF-multimers. The thrombin generation curve ase occurred again with need of two paracentesis of 10 L each in about
of patients with high VWF:Ag disclosed the lowest lag-time and time- 50 days. A TIPS was therefore positioned 2 months later by extending
to-peak suggesting high reactivity of plasma for thrombin generation. the stent along the stenotic segment after PTA. A thrombophilic work-up
Interestingly, VWF positively correlated with the degree of TM-R inde- found a factor V Leiden mutation and finally we decided to chronically
pendently from the severity of liver dysfunction. Furthermore, it iden- treat the patient with enoxaparin at prophylactic dose.
tified the highest proportion of patients with TM-R over 0.78 units, the Conclusion: The case allows a process of differential diagnosis of a complex
threshold of risk for thrombosis and severe clinical outcome. By contrary multifactorial ascites (cirrhosis, hepatic outflow obstruction, malabsorp-
ADAMTS-13 was not associated with TM-R. tion). It confirms the orientation role for SAAG in the diagnostic work-up of
Conclusions: VWF/ADAMTS-13 axis is impaired along with the severity a patient with ascites and usefulness of hemodynamic+plebographic study
of liver dysfunction. VWF significantly influences the procoagulant imba- to go in depth of complex liver diseases.
lance detected in cirrhosis through high levels of FVIII.
131. ANALYSIS OF A PROSPECTIVE COHORT OF

130. A COMPLEX CASE OF ASCITES: MAY THE HEMODY- PATIENTS WITH DRUG INDUCED LIVER INJURY AT A
NAMIC STUDY DISPEL OUR DOUBTS? SINGLE CENTRE
Triolo M. 1, Nicolini A. 2, Masarone M. 3, Caruso R. 3, Persico M. 3, Salerno F. Licata A., Minissale M.G., Calvaruso V., Almasio P.L., Craxi A.
1
, La Mura V. 1 Gastroenterology & Hepatology Section, DIBIMIS, University of Palermo
1
Internal Medicine, IRCCS-Policlinico San Donato, University Hospital,
Department of Biomedical Sciences for Health, University of Milan, San Introduction: There are limited data about epidemiology, pathogenesis,
116
clinical and prognostic assessment of drugs induced liver injury (DILI). expression of a subclinical systolic dysfunction and an increased local
Some information comes from website or national registries such as DILIN, vascular stiffness that may progress to vascular disease. Early detection of
Spanish, French, Japanese, and Icelander registries. We aimed to analyze these subclinical conditions might help to screen patients at high-risk to
our cohort of DILI patients prospectively collected at our Department since develop heart failure and myocardial ischemia.
January 2000 to December 2016 to assess clinical features and evaluate
outcomes.
Methods: An electronic database was created to identify all suspected DILI 133. DRUG INDUCED LIVER INJURIES BY TICAGRELOR-
according to guidelines published on American College of Gastroentero- STATINS INTERACTION: A CASE REPORT
logy. Patients after discharge were regularly followed at three-month inter-
vals for at least the first year. Minissale M.G., Serruto A., Montalto A., Soresi M., Montalto G.,
Results: We detected presence of DILI in 185 patients out of 12.257 in-ho- Licata A.
spital patients (females 56%; mean average age 53 years). At clinical presen- Internal Medicine & Hepatology, DIBIMIS, University of Palermo
tation, 57.8% showed liver damage of hepatocellular pattern, 18.3% chole-
static pattern and 23.2% mixed one. Among different classes of responsible Background: The anti-aggregant therapy with aspirin and inhibitor of
drugs, antibiotics were involved in 23.4% of cases, NSAIDs in 35.5%, immu- P2Y12 platelets receptor for ADP, such as ticagrelor, can be used to prevent
nosuppressants in 10.9%, statins in 4.3%, anti-platelets and anti-psychiatric atherothrombotic events in patients with coronaric acute syndrome. Statins
drugs in 7.6% and other drugs in 9% (including herbal and dietary supple- are also recommended in these patients even if the safety profile is burdened
ments). In 25% of cases, two or more drugs were involved simultaneously. by the risk of drug interaction (CYP 3A4 inhibition by ticagrelor). Here, we
One fifth of patients had concurrent chronic liver disease. We reported only report a case of acute rabdomiolysis and hepatotoxicity in a woman with
9 cases with acute liver failure (ALF): only two cases died, none was tran- a recent myocardial infarction treated with ticagrelor 90 mg twice daily,
splanted but one died within waiting list. Patients with ALF were predomi- aspirin 100 mg daily, atorvastatina 40 mg once daily.
nantly male (67%) with a mean age of 59 years. The most associated drugs Methods: We report a case of 68 old Caucasian woman with a diagnosis
were NSAIDs (77%), and hepatocellular pattern was the most common of myocardial infarction and coronary percutaneous stenting treated with
histological finding (78%). Six patients out of nine had previous chronic ticagrelor and statins, complaining since the first month after discharging
liver disease. All patients with ALF showed jaundice, while 55% had liver of general illness, asthenia, nausea, myalgia, itching and epistaxis. For the
encephalopathy. Development of a chronic DILI was detected in 8% of all accentuation of these symptoms, in the following month she was admitted
patients. Among 50% of cases the culprit drugs were NSAIDs, antibiotics to our Division of Internal Medicine.
were responsible for almost 40%. Among patients with chronic DILI, 16/185 Results: At admission, laboratory showed an eleveted value of CPK (100
(8.6%) developed drug induced autoimmune hepatitis (DIAIH). Patients upper normal limits), eleveted cytolytic and cholestatic values (AST/ALT
were mainly women, positive for non-organ specific autoantibodies, high 45-30 u.n.l, ggt 10 u.n.l, AP 2 u.n.l, bilirubin tot/ 4, 8 mg/dl), creatinine cle-
levels of transaminases and gamma-globulin, and treated with immunosup- arance was 37, 3 mL/min/1, 73 m2. No history of alcohol or drug abuse was
pression drugs for at least the first year. reported; non-organ specific autoantibody (ANA, SMA, LKM) and viral
Conclusions: The most common involved drugs in our DILI cohort were serology (HAV, HBV, HCV, CMV, HSV) were negative. According consen-
antibiotics and NSAIDs, even if the increasing role of anti-platelets, psychia- sus criteria for Drug Induced Liver Injury (DILI) patient was diagnosed as
tric drugs, and herbal and dietary supplements was recorded. NSAIDs and suffering from a hepatocellular liver injury. RUCAM score was calculated as
antibiotics were associated with poor prognosis, acute liver failure and chro- 11 (highly probable). Assuming an episode of interaction due to ticagrelor
nicity as compared to other drugs groups. and atorvatastin, we withdrawn immediately atorvastatin and continued
ticagrelor with ASA. There was a clinical and biochemical improvement,
with decrease of creatinkinase and aminotransferases till normal values
132. GLOBAL LONGITUDINAL STRAIN AS EARLY within 15 days. Intravenous fluids and albumin were administered to avoid
MARKER OF CARDIOVASCULAR DAMAGE IN PATIENTS acute kidney failure.
WITH HCV-RELATED CIRRHOSIS Discussion and Conclusions: Drug-drug interaction between ticagrelor
and atorvastatin caused certainly the development of muscle and liver inju-
Minissale M.G. 1, Novo G. 2, Macaione F. 2, Giannitrapani L. 1, ries. Physician should be informed of the possibility that the ticagrelor/statin
Gnoffo F.P. 1, Zabara A. 1, Indovina F.S. 2, Novo S. 2, Montalto G. 1, Licata A. 1 association even useful to prevent atherothrombotic events in patients with
1
Medicina Interna & Epatologia; 2Cardiologia; DIBIMIS, Università di coronaric acute syndrome could be cause muscle, liver and kidney injuries.
Palermo
Background: Patients with cirrhosis show diastolic and systolic dysfun- 134. NON-INVASIVE SCREENING FOR NAFLD
ctions, which tends to manifest only under stress conditions, such as AND SIGNIFICANT FIBROSIS BY TRANSIENT
infection, transjugular intrahepatic portosystemic shunt (TIPS) insertion, ELASTOGRAPHY IN DIABETES IN PRIMARY CARE
liver or cardiac transplantation. In this study, we aim to identify, at an early SETTING
stage, a subclinical myocardial dysfunction and vascular alterations in
patients with compensated HCV-related cirrhosis to prevent decompensa- Lombardi R., Iuculano F., Pelusi S., Borroni V.N., Airaghi L.,
tion of cirrhosis, heart failure and myocardial ischemia. Bertelli C., Burdick L., Fatta E., Valenti L., Fargion S.,
Methods: we compared 37 consecutive HCV-related compensated cirrho- Fracanzani A.L.
tic patients without previous cardiovascular events, with 32 healthy con- Department of Pathophysiology and Transplantation, Ca’ Granda IRCCS
trols, age and sex matched. All patients and controls underwent to clinical, Foundation, Policlinico Hospital University of Milan, Milan, Italy
echocardiographic assessment including Global Longitudinal Strain (GLS)
to evaluate cardiac function and carotid artery scan to assess stiffness of Background: Diabetes is a known risk factor for the onset and progression
carotid arteries. of non-alcoholic fatty liver disease (NAFLD) to non-alcoholic steatohe-
Results: Echocardiographic analysis showed that the left ventricle mass patitis (NASH) and liver fibrosis. Liver biopsy is the gold standard for the
index was pathologically higher in the HCV cirrhotic patients than con- staging of liver disease but it is not routinely applicable to the wide and
trols (111.81±25.53 vs 99.66±19.74; p = 0.037). There was an increase in otherwise asymptomatic cohort of diabetic patients. We non-invasively
the left atrial volume index, in the right atrial volume index and in pulmo- estimated prevalence and predictors of NAFLD and fibrosis in a cohort of
nary pressure in HCV cirrhotic patients as compared to controls, even if diabetic patients by using FibroScan®.
between normal ranges (28.47±6.79vs 15.94±5.42; p <0.0001; 20.04±8.89 vs Methods: Ninety-seven consecutive patients attending the outpatient dia-
12.74±4.70 p=0.0001; 32.49 ± 6:55 vs 27.50 ± 4.82, p<0.001 respectively). betes clinic and without any history of liver disease were enrolled over a
HCV-related cirrhotic patients showed significant impairment of GLS as 6-month period. All patients underwent liver ultrasound (US) and transient
compared to controls (- 18.42±2.48%, vs - 21.47±1.52 p+<0.0001), inde- elastography (FibroScan®), using the M probe or, in case of failure, the XL
pendently associated with HCV related cirrhosis, and had a higher percen- probe. Controlled attenuation parameter (CAP) values >250 dB/m and liver
tage of grade I of diastolic dysfunction (50% vs 22%; p= 0.038). Concerning stiffness measurement (LSM) >7.9 kPa defined the presence of steatosis and
vascular function, cirrhotic patients had a significantly increase of stiff- fibrosis, respectively. CAP values were then correlated to US steatosis.
ness index (14.35±6.16 vs. 9.03±2.52, p < 0.0001) and pulse wave velocity Results: Mean age was 65± 6 years, 71% patients were males and all were on
(9.41±2.22 m/s vs. 7.01±1.38 m/s, p = 0.0001). anti diabetic therapy (oral agents in 84% and insulin in 16%). Hypertension
Conclusion: HCV-related cirrhotic patients present an impaired GLS, was present in 80%, dyslipidemia in 83%, 74% of whom on statins, overwei-
117
ght in 75% of patients (27% of these obese). Deranged AST, ALT and GGT
were present in 1%, 6% and 7% of patients, respectively. Prevalence of hepatic Background and Aims: Adrenal dysfunction has been described in liver
steatosis was 78% evaluated by CAP and 91% by US. CAP values significantly cirrhosis. The pathogenesis is still controversial. A structural damage of the
correlated with US steatosis grades (p for trend=0.006) and were associated adrenal glands is one of the suggested pathologic mechanisms, but there are
at univariate analysis with BMI (p=0.05), ALT (p= 0.02), GGT (p=0.02) and no data about the morphology of adrenal glands in cirrhosis. The aim of our
insulin levels (P=0.02) while at multivariate analysis only with insulin levels study was to assess the morphology of the adrenal glands in cirrhotic patients
(OR 1.14, 95% C.I. 1.0-1.3). Mean LSM was 5.5 ± 2 Kpa and 8 (9 %) patients through the comparison with healthy control subjects and to investigate the
had values > 7.9. LSM values > 7.9 kPa were associated with BMI (p=0.001), possible correlation between the features of the glands and adrenal function.
ALT (p=0.001), GGT (p=0.0001), insulin levels (p=0.001) and CAP values Patients and Methods: from 2014 to 2017, 66 consecutive cirrhotic patients
(p=0.001), at age and gender adjusted analysis. Three of these patients along with 33 healthy control subjects matched by age and gender were
were classified as cirrhotics according to FibroScan® results. No association enrolled for this prospectively designed study. The severity of liver disease
between any anti-diabetic drugs and either steatosis or fibrosis was observed. was evaluated by Child-Pugh and MELD score. The CT scan of the adrenal
Conclusions: Liver damage is highly prevalent in diabetic patients as shown glands was performed by a single senior radiologist “blinded” to the clinical
by FibroScan®, which detects not only fibrosis but also steatosis. Given the information. The parameters evaluated were: thickness of the glands (esti-
highly significant correlation between LSM values and liver tests, although mated with reference to the protocol of Vincent et al.1), density (Hounsfield
within normal ranges, studies are needed to define whether the use of Units), presence of structural abnormalities or masses. Adrenal function in
revised liver test cut-offs might increase the detection of liver damage in cirrhotic patients was assessed by the Standard Short Synacthen Test (SSST)
these patients. A careful screening for liver disease in all diabetic patients and by dosing ACTH levels.
in primary care is mandatory also considering their high risk to develop Results: in cirrhotic population, the total thickness of the glands resulted
cirrhosis and hepatocellular carcinoma. significantly increased compared to healthy people (right side: 18.71 ±3.05
mm vs 16.17 ± 4.37 mm, p= 0.01; left side: 21.85 ± 5.46 mm vs 18.66 ± 4.95
mm, p = 0.01). Moreover, the density of the glands was higher in cirrhosis,
135. LARGE B CELLS NON-HODGKIN LYMPHOMA IN A though the difference reached the statistical significance only for the right
PATIENT WITH CHRONIC HBV INFECTION gland (right gland: 24.16 ±10.5 HU vs 17.7 ± 10.1 HU, p= 0.03; left gland: 22.4
± 8.8 HU vs 19.9 ± 7.5 HU, p = NS). In one cirrhotic patient (6%) and in six
Luglio C.V., Sciancalepore D., Sangineto M., Zingaro M.T., de Vincenzo healthy controls (18.18%) we found an adrenal mass or adrenal hyperplasia.
G.M., Perrone A., Suppressa P., Sabbà C., Napoli N. Interestingly, there was an increase in the thickness of the adrenal glands with
Medicina Interna Universitaria “C. Frugoni”- Dipartimento Interdisciplinare the worsening of the severity of liver disease, independently from the age of
di Medicina - Università degli Studi di Bari “A. Moro” patients, showing a correlation between the thickness and the MELD score
and the Child-Pugh score (r = 0.28; p = 0.02). In particular, there was a corre-
A white male patient, aged 51, with a silent medical history, came to our atten- lation between the total bilirubin levels and the width of the glands (r = 0.25;
tion complaining of cough, fever, abdominal and lumbar pain.In his family p = 0.03). On the other hand, there was an inverse correlation between the
history, it was to be noted that his father (75-year-old) died by cryptogenic adrenal thickness and ACTH levels (r = 0.27; p = 0.03). Adrenal insufficiency
liver cirrhosis. At the physical examination, he showed a massive hard-elastic (AI) was found in 21 (31.8%) cirrhotic patients. Even though no statistically
palpable mass in right hypochondria extending up to the transverse umbilical significant difference in terms of thickness emerged in cirrhotic patients with
line, in addition to a peripheral lymphadenopathy in the latero-cervical, axil- and without AI, patients low-responders to SSST showed higher density of
lary and inguinal region, bilaterally. Laboratory tests demonstrated hyperbi- the glands (+ 22.73%).
lirubinemia, mainly direct (total: 10, 86 mg/dl; direct: 8, 95 mg/dl; indirect 1, Conclusions: for the first time in literature, to the best of our knowledge, our
91 mg/dl), increased values of transaminases (AST x 6.5; ALT x 4.0), gamma- study suggests that cirrhosis may influence both size and density of adrenal
glutammiltranspeptidase -microglobulin (3, 29 mg/L). Hemoglobin (Hb = glands. Specifically, these modifications are related not only to the severity
12, 9 g/dL), platelet count (204 x 10³/uL) and total leukocyte count (5, 22 x of the liver disease, but also to adrenal function, since people with AI shows
10³uL, neutrophils 80%, lymphocytes 10.5%) were normal. Viral serological higher density of the glands. The hemodynamic changes could explain this
tests showed an active hepatitis B virus (HBV) infection as shown by the posi- aspect due to possible microscopic hemorrhages. The chronic inflammatory
tivity for HBsAg (20133, 5 UI/mL; normal value <0.05 UI/mL), total-HBcAb, state typical of cirrhosis could play a role in increasing the thickness of the
HBeAb and HBV-DNA (8482 IU/mL). Hepatitis Delta virus (HDV), human glands by inducing hyperplasia or hypertrophy non ACTH-mediated. In
immunodeficiency virus (HIV) and hepatitis C virus (HCV) markers were any event, further studies are needed.
negative. Abdominal ultrasounds and Magnetic Resonance Imaging (MRI) References: 1. Vincent JM, Morrison ID, Armstrong P, et al. The size
revealed massive lymphadenopathic conglomerate (diameter: 19x17 cm), of normal adrenal glands on computed tomography. Clin Radiol 1994;
developed mainly intraperitoneal, with “casting” aspect along the mesenteric 49:453–455.
vessels, hepatic hilum, in the celiac and perigastric area and in retroperitoneal
space. The mass itself displaced the gallbladder and the pancreas, compres-
sing “extrinsic” common bile duct and causing either a modest expansion of 137. ORAL HEALTH EVALUATION AND TREATMENT IN
the intra- and extrahepathic biliary ducts. Multiple abdominal mass biop- PATIENTS ELIGIBLE FOR LIVER TRANSPLANTATION: A
sies revealed a diffuse large B cells non-Hodgkin lymphoma, fast-growing. MONOCENTRIC EXPERIENCE
Positivity of CD20(+++), CD79a (+++), Bcl2(+++), Ki67>60%, Bcl6(+++),
CD10(+++), MUM-1(+-). Therefore the patient underwent to chemotherapy Passarelli P.C. 1, Marrone G. 2, Biolato M. 2, Liguori A. 2, Araneo C. 2,
with six cycles of R-CHOP (Rituximab, Ciclofosfamide, Doxorubicina, Vin- Forte F. 2, Avolio W.A. 3, Agnes S. 3, D’Addona A. 1, Grieco A. 2
cristina e Prednisolone) which allowed complete remission of lymphoma. 1
Department of Oral Surgery, Head and Neck Area, Fondazione
Antiviral treatment with Entecavir (0, 5 mg/day) was also started before the Policlinico A. Gemelli - Catholic University of the Sacred Heart, Rome
onset of chermoterapy, with negativity of HBV-DNA. Up to now, two years 2
Gastroenterology Area, Fondazione Policlinico A. Gemelli – Catholic
after chemotherapy, the patient doesn’t present any evidence of lymphoproli- University of the Sacred Heart, Rome 3 Division of General Surgery and
ferative disease recurrence and he is still being treated with Entecavir. Accor- Organ Transplantation, Abdominal Surgery Area, Fondazione Policlinico A.
ding to the literature, our clinical case confirms the increased risk of develo- Gemelli – Catholic University of the Sacred Heart, Rome
ping B-cell NHL in chronic HBV infection and, particularelly, two subtypes:
diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL). AASLD guidelines recommend dental evaluation of patients eligible for liver
transplantation in order to identify any cavities, oral infections or root frag-
ments. Collaboration between hepatologists and dentists is the basis of the
136. ADRENAL GLANDS MORPHOLOGY ASSESSED BY preventive strategy implemented in our liver unit and leads to indication of
COMPUTED TOMOGRAPHY IN STABLE CIRRHOTIC conservative treatment or extraction of dental elements otherwise not pre-
PATIENTS servable. In this study we conducted a retrospective analysis of oral health of
patients eligible for liver transplantation. Methods We enroll seventy-seven
Marchisello S. 1, Privitera G. 1, Viglianesi A. 2, Paratore M. 1, patients eligible for liver transplantation between January 2015 and March
Spadaro L. 1, Purrello F. 1 2017. For each patient we examined medical records, panoramic radio-
1
Department of Clinical and Experimental Medicine, University of Catania, graphs and treatment performed. Results There have been carried out 420
Ospedale Garibaldi-Nesima, Catania, Italy; 2Department of Diagnostic and extractions in 74/77 (96.1 %): the median of extracted teeth/patient was 8.
Interventional Radiology, Ospedale Garibaldi-Nesima, Catania, Italy Dental caries afflicted 72/77 (93.5 %) of patients. At univariate analysis there
118
was a significant association between smoking habit and number of decayed standard deviation) at admission were: transaminases 2184.8±1371.2 UI/L,
teeth (p=0.05). In addiction the analysis showed that MELD score at time bilirubin 11.6±5.2 mg/dl, INR 1.3±0.5. Laboratory values at peak were: tran-
of transplant is associated with number of teeth extracted (p=0.038) and saminases 2478.8±1214.9 UI/L, bilirubin 23.1±12.1 mg/dl and INR 1.6±0.4.
MELD score at time of listing for liver transplantation is associated with All subjects presented positive HEV IgM and IgG while only one subject
number of decayed teeth (p=0.008). At last a reverse correlation was highli- had positive serum HEV-RNA with identification of genotype 3 virus. Stool
ghted between body weight and number of teeth extracted (p=0.031). Con- HEV-RNA was negative in all subjects. 2 out 5 subjects had pre-existing
clusions Oral health is a prominent need for patients eligible for liver tran- chronic liver disease. One of these subjects developed acute renal failure and
splantation. Smoking habit is a key predictor factor of dental decay. Patients died from sepsis 47 days after hospital admission. The second subject is still
with high MELD score and low body weight deserve particular attention hospitalized for persistent jaundice 45 days after admission. The remaining
because of the higher number of dental extractions needed alongside the 3 subjects presented complete clinical and biochemical resolution. Mean
higher risk both of complications and of worsening of nutritional status. hospital stay was 26.4±18.1 days.
Conclusions: HEV infection appears to be not so rare in our country.
Accordingly, HEV infection has to be considered in presence of acute hepa-
138. PREVALENCE AND SEVERITY OF LIVER INJURY titis even in developed countries. In subjects with pre-existing liver disease,
AFTER PULSED METHYLPREDNISOLONE THERAPY IN HEV may cause acute on chronic liver failure, sometimes with severe
MULTIPLE SCLEROSIS PATIENTS complications.
Biolato M. 1, Nociti V. 2, Marrone G. 1, Liguori A. 1, De Fino C. 2, Bianco A. 2,

Mirabella M. 2, Grieco A. 1 140. DILI: 10 YEARS OF CLINICAL EXPERIENCE IN AN
1
Gastroenterology Area, Fondazione Policlinico A. Gemelli – Catholic ITALIAN TERTIARY CENTER
University of the Sacred Heart, Rome 2 Neuroscience Area, Fondazione
Policlinico A. Gemelli – Catholic University of the Sacred Heart, Rome Marrone G. 1, Liguori A. 1, Biolato M. 1, Araneo C. 1, Volpe M. 2, Racco S. 3,
Miele L. 1, Mores N. 4, Avolio A.W. 5, Agnes S. 5,
Background and Aims: Few cases of high dose pulsed methylprednisolo- Gasbarrini A. 1, Grieco A. 1
ne-related liver injury in patients with Multiple Sclerosis are reported in lite-
1
rature but a prospective investigation has never been performed. The aim of University of the Sacred Heart, Rome 2 Clinical Management, Fondazione
the study is to evaluate the prevalence and severity of liver injury in patients Policlinico A. Gemelli – Catholic University of the Sacred Heart, Rome 3
affected by Multiple Sclerosis and treated with pulsed methylprednisolone Emergency and Internal Medicine Area, Fondazione Policlinico A. Gemelli
because of clinical relapses. – Catholic University of the Sacred Heart, Rome 4 Pharmacology Institute,
Methods: Prospective observational single-center study on patients Fondazione Policlinico A. Gemelli – Catholic University of the Sacred Heart,
with multiple sclerosis, in relapsing phase of the disease, treated with i.v. Rome 5 Division of General Surgery and Organ Transplantation, Abdominal
methylprednisolone 1, 000 mg/day for 5 days. We tested liver function tests Surgery Area, Fondazione Policlinico A. Gemelli – Catholic University of the
(aspartate aminotransferase, alanine aminotransferase, alkaline phospha- Sacred Heart, Rome
tase, total bilirubin) before treatment and after two weeks. In case of severe
liver injury, defined according to “Hy’s law”, a comprehensive hepatologic Drug induced liver injury (DILI) still represents a clinical challenge. The real
work-up was performed. incidence is difficult to assess but a range between 1/10.000 to 1/100.000 inha-
Results: During 12 month observation period, we collected 251 cycles of bitants appears to be reasonable. Clinical presentation is extremely variable
i.v. high dose steroid treatment from 175 patients (65.1% females, mean ranging from mild and a-specific symptoms to the dramatic manifestations
age of 40.8 ± 12.2 years; mean Expanded disability status scale 2.8 ± 2.1). of acute liver failure requiring liver transplantation (OLT). Here we report
After excluding 8 cycles presenting basal alteration of liver function tests, the experience of Policlinico Gemelli Hospital of Rome recorded by a retro-
serum aminotransferase elevation (any grade) was observed on twenty-one spective study. From 1/01/2005 to 31/06/2016 clinical records of patients
cycles two weeks after methylprednisolone therapy (prevalence 8.6%). Six discharged with ICD-9 codes of diagnosis 573.3, 570 and 571.9 (non-speci-
of them (prevalence 2.5%) presented a severe liver injury according to Hy’s fied or non-infectious toxic hepatitis, massive acute or sub-acute liver necro-
law; after comprehensive hepatologic work-up, three out of them received a sis and non-specified chronic hepatitis without alcohol mention, respectively)
final diagnosis of drug-induced liver injury and other three a final diagnosis were examined. The local Liver Transplant Center database has also been
of autoimmune hepatitis. consulted to identify those patients transplanted for DILI-induced acute liver
Conclusions: Liver injury should be considered a possible adverse event failure (ALF). Clinical and biochemical data, damage severity and patterns of
in patients with multiple sclerosis treated with pulsed methylprednisolone presentation, involved drugs and outcomes have been analyzed. 948 medical
therapy for clinical relapse. Aminotransferase monitoring two weeks after records were found. After independent consultation by two expert clini-
pulsed methylprednisolone treatment is useful for clinical management. cians, 104 records were identified as eligible for the analysis with diagnosis
of probable or definite DILI. The population consisted of 61 females (59%)
and 43 males (41%). Median age was 56 years (interquartile range 44-67 y).
139. ACUTE VIRAL HEPATITIS IN ITALY: PLEASE, Hepatocellular pattern of damage was observed in 63% of patients, followed
CONSIDER HEV. CASE SERIES by cholestatic (25%) and mixed (12%). The class of drugs mostly involved
was antibiotics (26, 9%), followed by non-steroidal anti-inflammatory drugs
Marrone G. 1, Miele L. 1, Biolato M. 1, Liguori A. 1, Serricchio M.L. 1, (NSAIDs) (14, 4%) and immunosuppressive or chemotherapeutic agents (10,
Bernardini F. 1, Rapaccini G.L. 1, Gasbarrini A. 1, Grieco A. 1 6%). The main single agent involved resulted amoxicillin/clavulanic acid (12,
1
Gastroenterology Area, Fondazione Policlinico A. Gemelli – Catholic 5%), followed by isoniazid (6, 7%). According to Hy’s rule 49/104 presented
University of the Sacred Heart, Rome a severe liver damage (ALT ≥ 3xULN and Total Bilirubin ≥ 2xULN). 6/104
patients (5, 7%) died and 3/104 (2, 9%) received orthotropic liver transplanta-
Introduction: HEV hepatitis is today considered the most common cause tion. Transplanted subjects were significantly younger than deceased subjects
of acute hepatitis worldwide. While it is endemic in developing countries, (p<0.005), peak bilirubin levels were significantly higher in died and tran-
where it is transmitted by oro-faecal route, in recent years it has been gra- splanted subjects than in transplant-free survivors (p<0.05). DILI is a clinical
dually recognized also in developed countries. Four HEV genotypes have picture that requires special attention. A prompt appropriate diagnosis and an
been identified until now: genotype 1 and 2 are responsible of epidemic adequate therapeutic approach, with early transplant referral while needed,
forms in developing countries, genotype 3 and 4 are responsible of sporadic are key determinants of clinical outcome. Among laboratory data, bilirubin
forms in developed countries. Here we present a series of autochthonous levels showed the highest prognostic value.
Italian cases with acute HEV hepatitis observed at Fondazione Policlinico
Universitario A. Gemelli in Rome.
Case series: From April 2015 to June 2017 we have observed five cases, 4/5 141. ILEAL PSEUDOTUMOR IN LIVER CIRRHOSIS: LOOK
male, mean age 68.4±6.0 years. All cases denied to have travelled abroad OUT ECTOPIC VARICES
before admission while 2/5 reported consumption of uncooked meat and
raw fish. Onset symptoms were flu like symptoms in 2 case, jaundice in 2 Tarli C. 1, Marrone G. 1, Biolato M. 1, Liguori A. 1, Riccioni M.E. 1,
cases and right abdominal pain in one case. Pattern of presentation was Barbaro B. 2, Gasbarrini A. 1, Grieco A. 1
hepatocellular in 2 and cholestatic in 3 cases. Laboratory values (mean ±
1
University of the Sacred Heart, Rome 2Diagnostic Imaging Area, Fondazione
119
Policlinico A. Gemelli – Catholic University of the Sacred Heart, Rome to rule out common causes of portal hypertension tests for viral hepatitis,
hemochromatosis, A1AT-deficiency, Wilson and autoimmune disease were
Introduction: Liver cirrhosis is one of the most common causes of clini- performed, with negative findings. Serology tests for Plasmodium, Trepo-
cally significant portal hypertension, that is defined as an elevated hepatic nema, Leishmania and HIV were also negative. Liver biopsy showed portal
venous pressure gradient (HVPG) ≥ 10 mmHg [1, 2]. Portal hypertension fibrosis in the absence of overt cirrhosis. Collectively, these findings, com-
leads to various mucosal abnormalities of the gastrointestinal tract, such as patible with “cryptogenic” non-cirrhotic portal hypertension, strongly sug-
the well-known esophageal/gastric varices and hemorrhoids. In some cases, gested chronic schistosomiasis confirmed by microscopic examination of
portal hypertension can determine an enteropathy (or ectopic varices) stool samples, faecal PCR and circulating cathodic antigen urine-assay. We
which is discovered after the diagnosis of anemia caused by occult bleeding. thus diagnosed HSS (Schistosoma mansoni) in decompensated form cha-
Here we report a peculiar case of ectopic varices mimicking an ileal tumor. racterized by fibrotic liver, splenomegaly, esophageal varices, hypoalbumi-
Case Report: A 54-year-old man with hepatitis C virus -associated liver nemia and muscle wasting. Praziquantel treatment was immediately started.
cirrhosis (Child A5, MELD 13) vein thrombosis at the spleno-mesenteric Conclusion- Schistosomiasis, a major cause of liver fibrosis in endemic
confluence (on warfarin treatment) and hepatocarcinoma (waiting for liver areas, is an important diagnostic challenge in Western Countries due to
transplantation) was admitted to Liver Transplant Medicine Unit of Gemelli international travels and immigration. HSS should be considered in patients
Teaching Hospital in Rome because of fever (max 39 °C). On admission, with splenomegaly and portal hypertension without stigma of cirrhosis. A
physical examination revealed normal vital signs. Hemoglobin level was high index of suspicion would permit early diagnosis and, hopefully, a more
14.8 g/dl and blood pressure was 100/60 mmHg. A contrast enhanced favorable prognosis.
abdomen CT-scan confirmed hepatocarcinoma lesions and the presence of
liver abscesses (blood cultures were found later positive for E. Coli); in addi-
ction, the presence of a 16 mm ileum node of uncertain origin was reported. 143. TERLIPRESSIN AND ALBUMIN FOR THE
A small bowel CT-scan confirmed the presence of the small endoluminal TREATMENT OF TYPE-1 HEPATORENAL SYNDROME.
ileum lesion. Thus, a double balloon enteroscopy revealed a big blue varice, IMPACT OF ACUTE-ON-CHRONIC LIVER FAILURE
about 50 centimeters upstream from ileocecal valve. Thereafter, portal (ACLF) SEVERITY ON THERAPEUTIC RESPONSE
hypertension treatment was optimized in the attempt to reduce bleeding
risk, waiting for the liver transplantation. Piano S. 1, Schmidt 2, Ariza X. 3, Amoros A. 4, Romano A. 1,
Discussion: Recognized causes of ectopic varices are intra- and extrahepa- Solà E. 3, Gerbes A. 5, Bernardi M. 6, Alessandria C. 7,
tic portal hypertension, surgical procedures, anomalies of venous outflow Trebicka J. 8, Gustot T. 9, Nevens F. 10, Arroyo V. 4, Gines P. 3,
vessels, abdominal vascular thromboses, and rare familial conditions [3]. In Angeli P. 1
portal hypertension induced by liver cirrhosis, gastrointestinal varices are 1
Department of Medicine, University of Padova, Italy 2 Klinik für
typically found in the esophagous and anorectal canal during endoscopy Transplantationsmedizin, Universitätsklinikum Münster, Germany 3
and clinical rectal examination. Small bowel varices are not well-known Hospital Clinic, IDIBAPS. and CIBEREHD, Barcelona, Spain 4 EF-CLIF.
because this bowel tract is not usual deepen. Differential diagnosis for this and EASL-CLIF. Consortium, Barcelona, Spain 5 University Hospital LMU
finding include cancer and for this reason, especially in patients that are Munich, Liver Center Munich, Munich, Germany. 6 Department of Medical
waiting for a liver transplantation, is mandatory to conduct procedures to and Surgical Sciences, University of Bologna, Bologna, Italy 7 Division of
define and clarify the nature of these lesions. Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino,
References: [1] A. Rodriguez-Vilarrupla, M. Fernandez, J. Bosch, and J. C. Italy 8 Department of Internal Medicine I, University of Bonn, Bonn,
Garcia-Pagan, “Current concepts on the pathophysiology of portal hyper- Germany 9 Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
tension”, Annals of Hepatology, vol. 6, no. 1, pp. 28-36, 2007. [2] Garcia-T- 10
University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
sao G, Abraldes JG, Berzigotti A, Bosch J. Portal Hypertensive Bleeding in
Cirrhosis: Risk Stratification, Diagnosis, and Management: 2016 Practice Background and Aims: Type-1 hepatorenal syndrome (HRS) is the most
Guidance by the American Association for the Study of Liver Diseases. life-threatening type of renal failure in patients with cirrhosis. The admi-
Hepatology 2017, 65(1): 310-35. [3] Helmy A, Al Kahtani K, Al Fadda M. nistration of terlipressin and albumin has been shown to be effective in
Updates in the pathogenesis, diagnosis and management of ectopic varices. treating type-1 HRS. According to the EASL-CLIF consortium definition,
Hepatol Int 2008;2:322-34. patients with type-1 HRS meet ACLF criteria, a syndrome characterized
by organ failures and high short term mortality in patients with an acute
decompensation of cirrhosis. However, the impact of ACLF grade on the
142. DIFFERENTIAL DIAGNOSIS OF NON-CIRRHOTIC response to treatment has never been assessed. The aims of our study
PORTAL HYPERTENSION. A CASE OF SCHISTOSOMIASIS were: a) to evaluate predictors of response to treatment with terlipressin
IN AN INTERNAL MEDICINE UNIT and albumin in patients with type 1 HRS (reduction in serum creatinine
[sCr]<1.5 mg/dl at the end of treatment); b) to evaluate predictors of 90-day
Milazzo M., Lugari S., Ponz de Leon M., Pellegrini E. mortality in these patients.
Internal Medicine Unit, Dept of Internal Medicine, Endocrinology, Methods: 298 patients with type-1 HRS treated with terlipressin and
Metabolism and Geriatrics. University Hospital of Modena. University of albumin were included in this multicenter international study. Demo-
Modena and Reggio Emilia, Italy graphic, clinical and laboratory data were collected before the initiation of
treatment. Patients were followed-up until death, liver transplantation or
Introduction: Schistosomiasis is one of the most prevalent though 90 days.
neglected parasitic disease caused by trematode flukes of the genus Schisto- Results: Patients were treated for a median of 8 days and response to treat-
soma affecting almost 240 million people mainly in tropical and sub-tropi- ment was observed in 53% of patients. Response rate had a stepwise decre-
cal areas. Clinical disease is caused by an immune response due to schisto- ase moving from grade 1 to grade 3 ACLF (60, 48 and 29% for grade 1, grade
some eggs lodged in host tissues and includes hepatosplenic schistosomiasis 2 and grade 3, respectively; p<0.001). In multivariate analysis, baseline sCr
(HSS) characterized by inflammation and portal fibrosis. We describe a case (OR=0.23; p=0.001) and ACLF grade (OR=0.63; p=0.01) were found to be
of a man with hepatosplenomegaly where an accurate differential diagnosis independent predictors of response to treatment. During the 90-day follow
permitted to detect HSS and to initiate appropriate treatment. 40% of patients died. Age (HR=1.05; p<0.001), white blood cell count
Case Report: A 19-year-old man from Ghana was transferred to our (HR=1.51; p=0.006), ACLF grade (HR=2.06; p<0.001) and response to
Medical ward on the grounds of hepatosplenomegaly associated with fever, treatment (HR=0.41; p<0.001) were found to be independent predictors of
back and abdominal pain. These complaints had developed after an initial 90-day mortality.
admission in Psychiatry owing to alleged post-traumatic stress disorder Conclusions: ACLF grade is a main determinant of response to terlipres-
after a car accident. He had been living in Italy for one year and had not sin and albumin in patients with type-1 HRS. ACLF grade affects survival
returned to Africa recently. His clinical history was otherwise unremar- independently from the response to treatment. New therapeutic strategies
kable. Physical examination revealed in addition diffuse abdominal tender- should be developed for patients with type-1 HRS and extrarenal organ
ness and muscular hypotrophy. Peripheral blood examination showed mild failures.
thrombocytopenia and hypertransaminasaemia, increased IgG and hypoal-
buminemia. Abdominal ultrasonography revealed coarse echopattern and
splenomegaly suggesting non-cirrhotic portal hypertension which was con- 144. CORRELATION BETWEEN PHASE ANGLE, CHILD
firmed at Computer Tomography-scanning. Endoscopy showed esophageal PUGH CLASS AND BCLC STAGE AMONG CIRRHOTIC
varices and congestive colitis with chronic inflammatory changes. In order PATIENTS:
120
A NEW PROGNOSTIC TOOL IN LIVER DISEASES Centre, Dpt of Internal Medicine, “SS. Annunziata” Hospital, Taranto, Italy
Institute of Infectious Disease, Policlinico Hospital, University of Bari “Aldo
Rinninella E. 1, Cintoni M. 1, Cerrito L. 2, Pizzoferrato M. 1, Moro”, Bari, Italy “A. Murri” Internal Medicine Unit, Policlinico Hospital,
Ponziani F.R. 2, Leone S. 1, Egidi G. 1, Basso L. 1, Bisciotti V. 1, University of Bari “Aldo Moro”, Italy
Miggiano G.A.D. 1, Pompili M. 2, Gasbarrini G. 2, Gasbarrini A. 2,
Mele M.C. 1 Background: Hereditary Haemorrhagic Telangiectasia (HHT), or Ren-
1
Nutrizione Clinica, Area Gastroenterologica, Polo delle Scienze du-Osler-Weber syndrome, is a rare autosomal dominant vascular disor-
Gastroenterologiche ed Endocrino-Metaboliche, Fondazione Policlinico der (prevalence: 1-2:10, 000), characterized by arterio-venous shunts in
Universitario Gemelli, Università Cattolica del Sacro Cuore, Roma 2 several organs. Serious clinical complications can be associated to visceral
Medicina Interna e Gastroeneterologia, Area Gastroenterologica, Polo arterio-venous malformations. In particular, hepatic arterio-venous mal-
delle Scienze Gastroenterologiche ed Endocrino-Metaboliche, Fondazione formations (HAVMs) are detected in 60-80% of HHT patients and may be
Policlinico Universitario Gemelli, Università Cattolica del Sacro Cuore, Roma potentially responsible for a number of clinical consequences in a small per-
centage of HHT patients (5-8%). Hepatic involvement in HHT can be asso-
Introduction and aim: Malnutrition in chronic liver diseases is a notewor- ciated to hyperplastic micronodular regeneration and deposition of fibrous
thy problem (1). New prognostic factors are needed to stratify nutritional tissue, often not associated to clinically significant portal hypertension or
risk in cirrhotic and HCC patients.Phase Angle (PhA), obtained by Bio- cirrhosis. Elastonography has recently been proposed as a non-invasive
impedeziometric Analysis (BIA) is considered as a useful tool to stratify effective tool to estimate liver stiffness, as a parameter for liver fibrosis. AIM:
nutritional risk by ESPEN society (2). Recently it has been also correlated to The present study aims to investigate subclinical hepatic stiffness alterations
survival in HCC setting (3). in HHT patients with liver involvement.
Material and Methods: Our Nutrition team operates in Internal Medi- Methods: The study was designed as a prospective cohort study of patients
cine and Gastroenterology department and outpatient clinic. All cirrhotic with either genetically or clinically confirmed HHT diagnosis. Patients were
patients seen in the period between October 2016 and May 2017 were eva- consecutively recruited, among patients who were subjected to full clini-
luated. For each patient anthropometric measures, lab tests and BIA, with cal-instrumental evaluation, independent of clinical symptoms. Hepatic
PhA at 50 kHz, were collected; patients were then supported with a persona- screening was performed by Echo-Color Doppler examination and Mul-
lized diet, according to ESPEN guidelines on nutrition on cancer and liver ti-Slice Computed Tomography. Stiffness evaluation was carried out by wave
diseases (4-5). Data are expressed as median (IQR) for numerical variables. elastography (echosens Fibroscan), with semiquantitative scale grading cur-
Numbers (percentage) were used for categorical variables. Kruskall Wallis rently employed for HCV-related hepatitis.
was used to compare data. A p<0.05 was considered statistically significant. Results: A total of 51 patients were included in the study (mean age 52
Results: Eighty patients were enrolled, of which 65 (81.3%) were male. yrs). Hepatic arterio-venous malformations were detected by MSCT in
Mean age was 64.5±12.4 years. Among all patients, 48 (60.0%) were affected 39/51 patients (76%). Elastography-based stiffness alterations were detected
by HCC. in 25/47 patients (53%), 7 of which (with positive fibroscan) showed
Etiologies were: HCV: 37 (46.3%); Alcohol: 16 (20.0%); viral + alcohol: 8 HHT-related or unrelated concomitant hepatic disease. For the remaining
(10.0%); HBV: 6 (7.5 %); metabolic: 6 (7.5 %); other: 7 (8.7%). 18 patients with elevated stiffness, no overt liver disease or other fibrosis
Twenty-eight (35.0%) had diabetes mellitus, of which 10 (35.7% of diabe- signs were evident. We found a statistically significant stiffness increase
tics) were insulin-dependents. Thirty-nine (48.8%) were in Child A, twen- in liver-disease vs non-liver-disease patients (9.388±5.895 and 5.30±1.85,
ty-five (31.2%) in Child B and 16 (20.0%) in Child C. Three (6.3%) were in respectively, p<0, 019). Stiffness was positively correlated wth hepatic artery
BCLC 0, 7 (14.6%) in BCLC A, 18 (37.5%) in BCLC B, 14 (29.2%) in BCLC diameter and maximum velocity.
C and 4 (8.3%) in BCLC D. Overall PhA was 4.1 (3.6-5.1), BMI was 25.6 Conclusions: Liver stiffness in HHT may be altered in certain patients, due
(23.0-28.6). to diffuse hypervascularization and/or subclinical fibrotic deposition.
PhA was worse in higher classes of Child, respectively: 4.4 (3.8-5.5) for
Child A, 4.07 (3.6-4.9) for Child B and 3.8 (2.9-4.3) for Child C (p=0.02).
Regarding HCC patients, PhA was significantly lower in higher BCLC 146. DYNAMICS AND MANAGEMENT OF ORAL
stages, respectively BCLC 0: 5.2 (4.7-5.5); BCLC A: 4.1 (3.5-5.8); BCLC B: ANTICOAGULANT TREATMENT IN CHRONIC
4.0 (3.6-4.4); BCLC C: 4.3 (3.8-4.7); BCLC D: 2.9 (2.5-3.3) (p=0.02). Con- HEPATITIS C PATIENTS UNDERGOING THERAPY WITH
versely, BMI did not change across Child classes (Child A: 25.3 (22.7-28.2); DIRECT ANTIVIRAL AGENTS
Child B 27.0 (23.2-30.6); Child C: 24.8 (23.2-28.7)) (p=0.74) and BCLC
stages (BCLC 0: 29.4 (24.0-34.9); BCLC A: 25.5 (24.0-28.3); BCLC B: 26.5 Vitrone M. 1, Parrella A. 1, Ursi M.
(23.0-28.6); BCLC C: 27.5 (23.7-27.9); BCLC D: 26.9 (25.5-30.4)) (p=0.89). P. 1, Andini R. 1, Ragone E. 2,
Conclusions: PhA, rather than BMI, correlates with Child Pugh classis in Albisinni R. 2, Zampino R. 3, Durante Mangoni E. 3
cirrhotic patients; Furthermore, PhA correlates with BCLC classification in 1
Internal Medicine, University of Campania ‘L. Vanvitelli’, 2 Unit of Infectious
HCC patients. This may be useful to stratify nutritional risk among cirrho- and Transplant Medicine, 3 Internal Medicine, University of Campania ‘L.
tic and HCC patients. Further studies are necessary to validate these data Vanvitelli’ and Unit of Infectious and Transplant Medicine, AORN. dei Colli-
in larger population cohorts and to correlate nutritional risk to clinical Monaldi Hospital, Naples, Italy
outcomes.
References: 1) Purnak T, Yilmaz Y. Liver disease and malnutrition. Best Direct antiviral agents (DAA) are a very effective and safe treatment for
Practice & Research Clinical Gastroenterology 27 (2013) 619–629 2) Kyle chronic hepatitis C (CHC), but can interfere with other concurrent medica-
UG, Bosaeus I et al. ESPEN. Bioelectrical impedance analysis-part II: tions. Warfarin is still widely used as oral anticoagulant, mostly in carriers
utilization in clinical practice.Clin Nutr. 2004; 23:1430-53. 3) Schütte K, of prosthetic cardiac valves but also in atrial fibrillation and venous throm-
Tippelt B, Schulz C et al. Malnutrition is a prognostic factor in patients with boembolism. Also, warfarin is characterized per se by a high likelihood
hepatocellular carcinoma (HCC) Clinical Nutrition 34 (2015) 1122-1127 of drug-drug interactions. Although no interaction between warfarin and
4) Arends J, Bachmann P, Baracos V et al. ESPEN guidelines on nutrition DAA is expected on the bases of preliminary studies, few real life data are
in cancer patients. Clin Nutr. 2017 Feb;36:11-48 5) Plautha M, Cabre´b E, available and one case of a clinically relevant interaction in a patient treated
Riggio O et al. ESPEN Guidelines on Enteral Nutrition: Liver disease. Clini- with paritaprevir/ritonavir/ombitasvir+dasabuvir (3D) has been recently
cal Nutrition (2006) 25, 285–294 reported (Puglisi GM, J Clin Pharm Ther 2017). At the Unit of Infectious
& Transplant Medicine, AORN Ospedali dei Colli-Monaldi, University of
Campania “L. Vanvitelli”, we treated with DAA 5 chronically infected HCV
145. HEPATIC INVOLVEMENT AND STIFFNESS patients who were in stable treatment with warfarin (median treatment time
EVALUATION BY ELASTOGRAPHY IN HEREDITARY before DAA 17 years, IQR 10-32). Warfarin was administered because of
HEMORRHAGIC TELANGIECTASIA either carriage of prosthetic cardiac valves (n= 5) or atrial fibrillation (n=1).
During DAA treatment, no diet change was prescribed nor any other drug
Suppressa P., Cavallo M.L., Semeraro F.P., Saracino A., Lagioia A., that could interfere with warfarin administered. Furthermore, liver and
Lastella P., Buonamico P., Lenato G.M., Angarano G., Sabbà C. renal function remained stable throughout the treatment course. All five
1
HHT. Interdepartmental Center, Centro Sovraziendale per le Malattie patients reached a sustained virological response without adverse events,
Rare, “Frugoni” Internal Medicine Unit, Policlinico Hospital, University of after 12 or 24 weeks of DAA treatment. According with HCV genotype and
Bari “Aldo Moro”, Bari, Italy Digestive Physiopathology and Celiac Disease treatment availability, 2 patients were treated with sofosbuvir-daclatasvir
121
(S-D), 2 with sofosbuvir-ledipasvir (S-L) and 1 with 3D regimen. its levels were significantly higher in these patients compared to HC and to
Figure 1 shows the dynamics of international normalized ratio (INR) and HBV-subjects.
warfarin doses before, during and after DAA treatment in the five patients. Conclusion: H-NMR proved a significant discrimination for all groups
(HCV-baseline, SVR12, SVR24, naïve HBV, HC) and the fingerprints of
HCV patients after SVR progressively approached to the ones recorded in
HC. Also, fingerprints of untreated HCV and HBV patients can be discrimi-
nated with a high accuracy even in the unsupervised analysis, indicating the
existence of virus-specific interactions with different metabolic pathways.
Finally, a direct role of HCV in altering basal metabolism pathways could
help to explain the association with some extrahepatic disease; i.e. previous
works reported high levels of 2-oxoglutarate in serum of patients with heart
failure and, in this light, our finding could explain the relationship between
HCV and an increased risk of cardiovascular disease.
148. A MAJOR PRESENTATION ENTEROPATHY
Bianchi P.I., Guerrini C., Minoja G., Sartori M., De Paduanis G.A., Fugazza L.
U.O.C. di Medicina Generale, A.S.S.T. di Lodi, presidio ospedaliero di Lodi
A 65-years-old male was admitted on March 2015 in the Internal Medi-

cine ward of Lodi for chronic diarrhea, suddenly begun two months before.
He refers 10 liquid stool evacuations/day, without blood, also causing
Figure 1. INR before, during and after DAA therapy. night-awakenings, weight loss of 17 kg (from 80 to 63 kg), sometimes also
As shown in Figure 1, only 2 (treated with S-D and 3D, respectively) of the vomiting, no fever, no recent travels, no domestic animals. In his medical
5 patients experienced a drop of the INR ≤ 1.5 at week 4 of therapy; they history: arterial hypertension, polycithemia vera, hyperuricemia, cho-
needed an increase of warfarin dose and a short course of supplementation lecystectomy. No significant familial history (for cancers, enteropathies,
with enoxaparin waiting for the INR to return within the target range. After autoimmune diseases). He already dismissed his medicaments two months
stopping DAA treatment, INR remained in the therapeutic range with the before (ASA, olmesartan/hydrochlorothiazide, pantoprazole, atorvastatin,
ongoing warfarin dose (no rebound was observed). The number of patients phebotomies). Renal function impaired and he developed a metabolic aci-
studied is certainly very low to draw definitive conclusions. However, our dosis. Blood exams showed: Hb 11, 9 g/dL, MCV 84 fL, low ferritin, normal
preliminary analysis shows that significant reductions in the INR can be B12 vitamin and folate, AST, 54, ALT 92 U/L, gGT 117 U/L, bilirubin 0, 7
observed during therapy with different DAA. In contrast, there were no mg/dL, normal amylases, normal TSH. Normal CEA, Ca19.9, PSA. Nega-
cases of INR increase. Therefore, despite formal evidence of drug-drug inte- tive Widal-Wright, Weil-Felix, HAV, HCV, HBV, HIV serology. Negatives
raction between warfarin and DAA, our data suggest that a strict and careful ASCA, ANCA, ENA, antitransglutaminases and antiendomysium antibo-
follow-up of INR, with adjustment of warfarin dose is needed during DAA dies. Stool exams showed negativity searching for parasites, Salmonella,
treatment. This policy would likely allow to avoid phases of inadequate anti- Shighella, Clostridium difficile toxin, rotavirus and adenovirus. FOBT was
coagulation with possible risk of thrombotic complications. positive (1/3) and calprotectin was borderline (70 mg/g). He underwent to:
- Lower endoscopy, until ileum: some diverticula of the sigma. Histology:
chronic mild inflammation of small intestine and colon mucosa.
147. DIFFERENT METABOLIC FINGERPRINTS BETWEEN - Enhanced CT scan of abdomen: thickening of bladder anterior wall, no
HCV AND HBV PATIENTS: A POSSIBLE INTERFERENCE lymph node enlargement, no thickening of gut walls. Few free liquid in
OF THE TWO MAJOR HEPATITIS VIRUSES IN BASAL pelvic cavity. Mesalazine, rifaximin, cholestyramine and pancreatic enzymes
METABOLISM PATHWAYS were started without any improvement.
- Upper endoscopy: abundant hiatal hernia. Mild reduction of duodenal
Lorini S. 1, Gragnani L. 1, Cerretelli G. 1, Meoni G. 2, Tenori L. 2, folds. HP negative. From duodenal biopsy Marsh 3b lesions are found,
Monti M. 1, Corti G. 1, Luchinat C. 2, Zignego A.L. 1 with high intraepithelial lymphocytes count (60/100). As said, IgA and IgG
1
Masve Center, Experimental and clinical medicine, University of Florence, anti-transglutaminases and anti-endomysium antibodies were negatives,
Florence, Italy; 2 Consorzio Interuniversitario Risonanze Magnetiche di with normal IgA levels. Total IgG and IgM also were normal. Anti ente-
Metallo Proteine, University of Florence, Florence, Italy rocytes antibodies were asked, a confirm of the anti jejunal antibodies was
asked to a referral centre and they were confirmed negatives. PAS stain and
Background: Metabolomics is the study of metabolic changes in biological Congo red stain of the biopsies were asked and resulted negative.
systems and may identify specific profiles associated with subtle alterations HLA typing showed the presence of a DQ2 monomer. The probability of a
induced by diseases. Studies performing a comparative evaluation of HCV complicated coeliac disease was high, because of his age, clinical and sero-
and HBV patients are lacking. HCV can be completely eradicated by direct logical presentation. He was counseled to refer to an Enteropathy referral
acting antivirals (DAAs). The aim of this study was to evaluate through centre but refused. He underwent also PET scan, intestinal US (normal
NMR-based metabolomic approach a group of HCV-positive patients aspects). He started gluten free diet and budesonide 9 mg/days for 3
before and after viral eradication by DAA IFN-free regimens, comparing months. His diarrhoea stopped within two weeks. He presented again
their fingerprints to naïve HBV-patients and healthy donors. arterial hypertension and two further episodes of ankle arthritis, and allo-
Methods: Sera were collected before therapy (baseline), at SVR12, and purinol and amlodipine were inserted. He started a strict follow up. He
SVR24 time-points, from 67 HCV patients successfully treated with IFN- underwent to duodenal biopsies and clinical and biochemical control after
free DAA regimens; as controls, we tested serum samples from 50 naive 4 months. Histology showed almost normal high of the villi, and a normal
subjects with chronic HBV infection (pathological controls; HBV) and 43 count of IELs (< 20/100). After 2 years he weights 70 kg, he is still on strict
healthy donors (healthy controls; HC). Samples were analyzed using proton gluten free diet. Hb is 15, 5 g/dL. He restarted atorvastatin and controlled
nuclear magnetic resonance spectroscopy (H-NMR). calories diet. He repeated upper endoscopy with duodenal biopsies that
Results: MPLS analysis of HCV sera showed a significant pair-wise discri- are still normal. The diagnosis of olmesartan-related enteropathy cannot
mination by comparing SVR12 and SVR24 with baseline samples (with 90% be totally excluded, nevertheless there are no description of an enteropa-
and 82% of accuracy, respectively), indicating that a metabolic efficacy was thy so long persisting after 2 months of drug suspension. A gluten chal-
evident already at SVR12. Metabolic fingerprinting was able to distinguish lenge may be the most precise way to determinate whether the patients is
the study groups (HBV, HCV and healthy subjects) with a 75% accuracy. coeliac or not, but his major presentation on old age suggest to be carefull.
Also, 34 metabolites emerged from the analysis, some of them significantly
differed between HCV group and HS and between HCV group and HBV
group (i.e. 2-oxoglutarate, 3-hydroxybutyrate, creatine, choline, valine, 149. A RARE CAUSE OF GASTROINTESTINAL DISORDERS
alanine, acetate, tyrosine, phenylalanine, formate). In detail, 2-oxoglutarate
levels progressively decreased in HCV patients from baseline to SVR24 and Bontempelli E. 1, Valabrega E. 1, Suardi M.G. 1, Cagnoni F. 1,
Dognini G.P. 1, Besozzi A. 1, Belotti Masserini A. 1, Destro M. 1
122
1
Department of Medical Science, Internal Medicine, ASST. Bergamo Ovest - Case Description: A 38-year old woman was admitted to the Neurology
Treviglio (BG) Unit (AOUI Borgo Roma, Verona) because of a progressive slurring of
the speech, clumsiness of hands and unsteadiness of gait lasting one year.
A 69-year-old male was admitted with 2 months of watery diar- She also complained head tremulousness and a tendency to sway while
rhea, 4 kg of weight loss and severe generalized weakness. No walking, with occasional falls, and sometimes blurred and double vision,
in the absence of any intestinal symptom and weight loss. There was no
fever, no abdominal pain. Patient medical history included hyper- family history of similar conditions in the parents or siblings, except for
tension, diabetes mellitus and dyslipidemia. He took Rifaximin her two children who were suffering from celiac disease. She was under
and probiotics. Metformin teatment was discontinued. However hormone replacement for hypothyroidism and she had no addiction or
he didn’t find relief. His abdomen was soft and no abdominal exposition to toxic substance. On physical examination, dysarthria and
masses were noted. Blood examinations showed severe metabo- tremor of voice, right deviation of the head and trunk, lightly widened
lic acidosis, mild hypokaliemia and mild anemia with folic acid base gear with left lateropulsion, and tandem difficulty, unmodified by
eye closure were evident. Moreover, clear cerebellar signs, such as fin-
and vitamin B12 deficiency. The patient was treated with intrave- ger-nose incoordination, dis-dyakokinesia and fragmentation of tracking
nous rehydratation, sodium bicarbonate and potassium replace- movements were found, in the absence of deficit of the strength or sen-
ment. Stool samples for Clostridium Difficile, bacteria, parasites sitivity. Laboratory tests, including metabolic and endocrinologic analy-
were negative. Colonscopy and EGDS were negative and abdo- ses (vitamin, lactate, glucose, copper, folic acid, and iron levels), were
minal ultrasound (performed 5 days before hospital admission) within normal range. Celiac serology, including anti-tissue transglutami-
only revealed liver steatosis. During hospitalization he developed nase (TTG)6 dosage both in the blood and liquor, was negative, as the
ANA, ENA, GAD-Ab, ANNA1, ANNA2, Yo, amfifisina, Ma1-2, CV2. By
hypovolemic and septic shock with multi-organ failure. The night contrast, a strong positivity of anti-Purkinje cell antibodies was evident
before the shock he had diarrhea of up to 10 to 12 loose bowel (1:6400) using indirect immunohistochemical test. Genetic tests for cere-
movements. Blood samples were collected and we administered bellar ataxia syndromes were negative (SCA 1, 2, 3, 6 and FRDA), whilst
intravenous antibiotic therapy and fluid replation. Treatment the presence of the HLA-DQ2 haplotype was found. Electromyography
with inotropic agents was initiated because of volume-resistant was normal, whereas a slowdown of BAERS, PEV and VEMPS was docu-
hypotension. The blood cultures were positive for Enterobacter mented, and a stabilometric examination showed a marked postural
instability both with opened or closed eyes. The MRI of the brain showed
Cloacae, susceptible to Levofloxacin. Computed tomography scan a moderate cerebellar atrophy of the warm and left hemisphere, with a
revealed a large malignant mass in the body-tail of his pancreas, hypometabolism at PET-scan. Ultrasonography of abdomen and breast,
involving spleen and stomach. A fine- needle aspiration biopsy gynecological evaluation and X-ray chest were normal, excluding the
was performed for histologic examination (grade 2 neuroendo- commonest aetiology of paraneoplastic cerebellar atrophy. A mild incre-
crine neoplasm). He also underwent an Octreotide radionuclide ase of intraepithelial lymphocytes at immunohistochemistry of the duo-
study, which demostrated radiotracer uptake between spleen, denal specimens was found in the absence of villuos atrophy. Following
the suspicion of gluten ataxia, a gluten-free diet was established, leading
pancreas and the greater curvature of stomach. Tumor markers to clinical benefit and stability of lesions at 12 and 24 months of follow-up,
CEA and Ca 19.9 were negative. It was not possible to test plasma with partial improvement of stabilometric test. This is an interesting case
VIP levels in our laboratory or in the other hospitals in the area, of gluten ataxia in a patient younger than those described in the literature.
beacuse this test was not available. The patient was treated with The strong familiarity and the clinical response, as well as the negativity of
short-acting Octreodite and showed good control of his diar- other laboratory and instrumental tests, has led to this diagnosis.
rhea. Then the patient underwent a distal pancreatectomy with
splenectomy and resection of posterior wall of body of stomach. 151. IS GASTROPARESIS A GASTRIC DISEASE?
Final pathology demostrated a malignant grade 1 neuroendocrine
neoplasm of the tail of the pancreas. The mass was found to be a Rizzoli G., Stanghellini V., Bellacosa L., De Giorgio R., Cremon C., Barbara
VIPOMA. The patient is alive and disease- free 8 months after G., Cogliandro R.
surgery. VIPomas are very rare subtype of pancreatic neuroendo- Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi di
crine tumors that secrete VIP and that often elude prompt diagno- Bologna, Azienda Ospedialiero-Universitaria S.Orsola - Malpighi, Bologna,
Italia
sis. Many other conditions can mimic its presentation. VIPomas
are most often sporadic, solitary lesions greater then 3 cm in dia- Background and Aim: Gastroparesis is a digestive syndrome characte-
meter. They produce a clinical syndrome known as Verner-Morri- rized delayed gastric emptying symptoms suggestive of gastroduodenal
son Syndrome, WDHA syndrome (watery diarrhea, hypokaliemia motor disorders (Parkman et al. Gastroenterology 2004;127;1589-91). It
and achlorhydria). Therapy approach involves two intercon- recognizes three different grade of increasing severity: 1) mild gastro-
nected pathways: 1- Correction of life-threatening electrolyte and paresis with symptoms easily controlled, weight / nutrition maintained
on a regular diet; 2) compensated gastroparesis with moderate symp-
volume status abnormalities; 2- Surgical treatment. Management toms partially controlled by daily medications, nutrition maintained by
with the synthetic octapeptide analog of somatosatin (Octreotide) dietary adjustments and 3) gastric failure with refractory, uncontrolled
has proven useful in VIPoma patients with unresectable disease symptoms, inability to maintain oral nutrition, frequent physician / emer-
and/or metastases. gency department visits, hospitalizations. Gastric emptying abnormalities
are only partially related to the type and severity of symptoms and other
pathophysiological mechanisms may be involved. We investigated the pre-
150. A FURTHER CASE OF GLUTEN ATAXIA: A NOT SO sence of enteric dysmotility in patients with gastroparesis
RARE DISORDER Methods: One hundred two patients with digestive symptoms suggestive
of gastroparesis (84 F, 18 M; mean age 37.7 ± 15.1 yrs), consecutively
Conti Bellocchi M.C. 1, Cavallaro T. 2, Ferrari S. 2, Cangemi G.C. 3, Zanoni G. referred to the Laboratory of Functional Gastrointestinal Disorders of the
4
, Opri R. 4, Fabrizi G.M. 2, Frulloni L. 1, Ciccocioppo R. 1 S.Orsola-Malpighi Hospital - University of Bologna to underwent both a
1
Department of Medicine, University of Verona, Verona, Italy; 2Department 13C octanoic acid gastric emptying study breath test and a small bowel
of Neurological Sciences, Biomedicine and Movement, University of Verona, stationary manometry. Relevant issues of health status were also recor-
Verona, Italy; 3Department of Internal Medicine, IRCCS Policlinico San ded for each patient according to pre-defined, validated questionnaires
Matteo Foundation, University of Pavia, Pavia, Italy; 4UOC of Immunology, at entry.
AOUI Borgo Roma, Verona, Italy Results. Gastric emptying was delayed in 27 patients (26.5%). Small bowel
manometry showed motor abnormalities in 90 patients (88.2%), sugge-
Gluten ataxia is a rare disease considered as the neurological manifestation stive of underlying enteric neuropathy, hymotility or intestinal irritability.
of gluten-related disorders, with a growing number of cases described in Among patients with abnormal small bowel manometry gastric emptying
the last years. Here we present the case of a young woman with progressive was delayed in only 26 patients (28.9%).
idiopathic neurological impairment and a familial history of celiac disease. Conclusions: Manometric abnormalities suggestive of enteric dysmotility
123
rather than a delayed gastric emptying are frequently recorded in patients Background: Autoimmune atrophic gastritis (AIG) is an immune-me-
with gastroparesis so that intestinal and not gastric dysfunction seems to be diated chronic inflammatory disorder of the gastric body and fundus,
relevant in its pathogenesis. leading to mucosal atrophy and presence of pyloric or intestinal metapla-
sia (1). This condition is responsible for a progressive reduction of gastric
acid secretion with consequent up regulation of gastrin production and
152. WHAT HAPPENED FIRST: IBD OR hyperplasia of endocrine cells of the stomach, promoting neuroendocrine
IMMUNODEPRESSION? A CASE OF UNUSUAL tumors. Upper gastrointestinal symptoms, mainly dyspeptic symptoms,
OPPORTUNISTIC PANCOLITIS are very frequent in AIG, but many AIG patients may also suffer from
reflux-related symptoms, such as heartburn and regurgitation. It was
Dell’Aera D. 1, Morea A. 2, Porretti L. 1, Tonani M. 1, Piombo M. 1, Calabretta reported that, in AIG patients, the prevalence of reflux-related symptoms
F. 1, Marchesi E. 1 is 24% (2) and the prevalence of reflux esophagitis ranges between 12%
1
SC. Medicina Generale 2, Dipartimento Area Medica, Fondazione IRCCS and 24% (2, 3). When 24-hr pH-monitoring is performed in AIG patients,
Policlinico San Matteo, Pavia 2SC. Malattie Infettive, Dipartimento Area acid production is sometimes detectable and abnormal non acidic reflux
Medica, Fondazione IRCCS Policlinico San Matteo, Pavia is frequently diagnosed. Since both acid and non acidic reflux may cause
heartburn, patients with AIG may run the risk to have inappropriate PPI
Introduction: Systemic infections by Cytomegalovirus (CMV) and Epstein prescription to treat a non acidic-related heartburn. Therefore, the aim of
Barr Virus (EBV) are usually complications of a state of immunodepression. this observational study was the evaluation of residual acid production
Patients with inflammatory bowel disease (IBD) show an increased risk of capacity in AIG patients with reflux-related symptoms to define whether a
contracting CMV infection because of immunosuppressive medication and subgroup of AIG patients may be treated with PPI.
malnutrition. Our patient didn’t have a known condition of immunodepres- Patients and Methods: Fifteen patients (12 females, aged from 46 to 73)
sion, she wasn’t undergoing chemotherapy and she never had any kind of with AIG, referred to our outpatient clinic due to GERD-related symp-
bowel disease previously. toms, were enrolled. Diagnosis was made on the basis of histological
Case presentation: A 59-year-old woman was admitted to our institute for criteria on perendoscopic biopsies of the gastric body and antrum (1).
rectorrhagia and asthenia. She had a history of ischemic stroke caused by The median duration of the disease was 48 months (12-120). None of the
atrial fibrillation. This arrhythmia was attributed to thyrotoxicosis in an patients were taking PPI or drugs inhibiting gastric acid production. All
unknown Basedow disease. She was treated with thyrostatic and anticoagula- patients were HP negative but 7 had a previous infection. Multifactorial
tion therapy (dabigatran) until she begun to complain hemorragic diarrhea. anemia was present in 2 patients. In 6 patients, autoimmune thyroidi-
She underwent colonoscopy and the report showed suspicious characteri- tis was present, in 1 psoriasis. GERD symptoms were investigated with
stics of inflammatory bowel disease. Her syntomps didn’t improve even 24-hour multi-channel pH-impedance monitoring with two pH chan-
though the administration of topical steroid and oral mesalazine: for this nels: the proximal one was positioned 5 cm above the upper margin of
reason, she presented to our hospital. We performed colonoscopy and bowel the lower esophageal sphincter and the distal one was 15 cm apart, thus
biopsy once again: histology was consistent with severe pancolitis (intersti- in the gastric fundus. Parameters of interest were the % of time during
tial chronic inflammation with eosinophils and lymphocytes, neutrophilic which fundus pH was <4, % of time during which distal esophagus pH
inflammation and crypt abscesses in 15 specimens from different locations) was <4, number of acid refluxes, number of non acidic refluxes. Results:
and PCR (Polymerase Chain Reaction) revelead high copies of CMV and The exposition of gastric fundus to pH values<4 was significantly higher
EBV DNA in biopsies (i.e. CMV in the sigmoid colon: 6472/100000 cells; in patients with mild atrophy than in patients with moderate and severe
EBV in the ascending colon: 2276/100000 cells). The other microbiological atrophy. When severe atrophy was present, GERD-related symptoms were
analysis on the stool were negative, but we found high copies of CMV and associated with non acidic refluxes, but when mild atrophy was present,
EBV DNA in peripheral blood (CMV 9540/ml; EBV 180/ml). We quickly the residual gastric acid production was sufficient to determine acid-re-
stopped steroid and the patient was treated with ganciclovir and metro- lated reflux disease. In particular, in the group of 8 patients with severe
nidazole. We documented: anemia (Hb 8, 2 g/dl) without leukocytosis or mucosal atrophy the mean % of time during which fundus pH was <4 was
lymphocytopenia, a serious malnutrition (serum albumine 1, 9 g/dl, tran- 4.2±7.8% (0.10-22.9%), mean % of time during which distal esophagus pH
sthyretin 8 mg/dl) with hypokalemia (K 2, 9 mEq/L) and elevated reactive was <4 was 0.04±0.1% (0.00-0.30%), mean number of acid refluxes was
C protein (RCP 6, 95 mg/dl) and faecal calprotectin (>300 mg/kg). Blood 1.1±2.5 (0-7) while mean number of non acidic refluxes was 35±23 (7-75).
transfusions and parenteral nutrition were necessary. One aspect has been On the contrary, in the group of 4 patients with mild mucosal atrophy
left undetermined: why was our patient affected by a systemic opportuni- the mean % of time during which fundus pH was <4 was 69.9±42% (7.8-
stic infection? Lymphocytic phenotype analysis revealed inverted CD4/CD8 97.5%), the mean % of time during which distal esophagus pH was <4
ratio compatible with CMV infection. HIV serology and autoimmunity tests was 0.2±0.24% (0.0-0.5%), the mean number of acid refluxes was 8.3±7.9
were negative. Quantitative immunoglobulins test was normal. The study (0-18) while mean number of non acidic refluxes was 7±8.3 (1-19). The
of specific immunity (IFN gamma production in vitro: spot forming units) severity of mucosal atrophy was significantly correlated with fundus acid
revealed a normal response to CMV infection (CMV pp65: 60, range 0-185) exposure (r=0.76, p<0.01).
but a lower response to EBV compared to healthy controls (EBV BZLF: 0, Conclusion: In patients with AIG, the occurrence of heartburn should
range 0-236). Immunity response to PHA (phytohemoagglutinnin mitogen be investigated with 24-hr pH-impedance monitoring to optimize treat-
stimulation of lymphocytes) was defective (PHA: 40, range 250-1200): this ment. However, when severe atrophy is present, non acid reflux is generally
discovery reinforced the argument for an immunodepressive syndrome. responsible for symptoms and this makes PPI treatment useless. On the
Conclusions: After 4 weeks of therapy, we observed an improvement in contrary, in patients with mild atrophy acid production residual capacity
both diarrhea and bleeding and the resolution of malnutrition. We docu- may be responsible for acid-related reflux symptoms and short courses of
mented the clearance of CMV copies in peripheral blood but an elevation PPI should be the best treatment option.
of EBV copies (1080/ml). We still don’t know if this kind of opportunistic References: 1.Dixon M.F. et al. Am J Surg Pathol 1996;20:1161-81. 2.Miceli
colitis was the onset of a preexisting ulcerative colitis or the prelude to an E. et al. Clinical Gastroenterol Hepatol 2012;10: 812-814 3.Tenca A. et al.
unknown immunodepressive syndrome. The first immunological follow-up Neurogastroenterol Motil 2016; 28: 274-80.
test confirmed a non-specific immunodepressive syndrome. Other investi-
gations are mandatory to modify clinical outcome of our patient.
154. AN “OVER THE COUNTER” DYSPHAGIA
153. IN AUTOIMMUNE ATROPHIC GASTRITIS Gabba M., Masotti M., Formagnana P., Bergamaschi G.,
WITH MILD MUCOSAL ATROPHY, RESIDUAL ACID Corazza G.R.
PRODUCTION MAY BE RESPONSIBLE FOR ACID- Dipartimento di medicina interna Clinica Medica I, Reparto 11, Policlinico
RELATED GERD San Matteo Università degli studi di Pavia
Di Stefano M., Miceli E., Benedetti I., Pisati M., Pesatori E.V., Caccia Case Presentation: a 83 years old man came to our attention for a wasting
Dominioni C., Manfredi G.F., Padula D., Grandi G., disease caused by dysphagia, more severe duringsolid food intake, and asso-
Lenti M., Corazza G.R. ciated with weight loss of nearly 20 Kg. Clinical history: prostatic hyper-
1st Department of Internal Medicine, IRCCS “S.Matteo” Hospital trophy treated with TURP, previous burns of lower limbs surgically treated
Foundation, University of Pavia, Pavia, Italy with skin grafts, hip and knee replacement; in 2012 diagnosis of atrofic
gastritis and erosive duodenitis. Domiciliary therapy: dutasteride, PPi, hyo-
124
scine butylbromide for aspecific abdominal pain three times per day. Clini- when used as second, third, fourth and fifth line respectively.
cal course: On admission the patient could eat only a special diet prescribed Conclusions: 10-day Pylera® plus PPI regimen was effective to eradicate H.
for dysphagia. Abitual therapy was confirmed during hospital stay with the pylori infected patients, in particular those harbouring strains resistant to
only exception of hyoscine butylbromide. Blood tests performed during Cla, Metro, or both. Incidence of TEAEs was similar to that observed in the
hospitalization showed mild normocytic anemia with a severe deficiency registration trial.
of cianocobalamin; inflammatory markers were in the normal range. An
abdominal US examination performed to lok for a neoplastic disease was
negative; an EGDS showed atrophic gastropathy and esophageal dyscinesia. 156. CHOOSING WISELY FOR HELICOBACTER PYLORI
A swallowing evaluation showed dysphagia due to unfunctional oral and INFECTION
pharingeal phases of deglutition. During hospital stay the patient referred
progressive spontaneous improvement of dysphagia and by the time of Gatta L. 1, Scarpignato C. 2, Fiorini G. 3, Saracino M.I. 3, Ricci C. 4,
discharge, was able to eat normally without complaining any symptoms. Vaira D. 3
Discussion: scopolamine butylbromide has a parasympatholytic, atropi- 1
Gastroenterogy & Endoscopy Unit, Versilia Hospital, Azienda USL.
ne-like effect, especially peripherally, and blocks the action of acetylcholine Toscana Nord Ovest, Lido di Camaiore, Italy; 2 Clinical Pharmacology and
at parasympathetic sites in smooth muscle, secretory glands and CNS. The Digestive Pathophysiology Unit, Department of Clinical and Experimental
major adverse effects are due to the anticholinergic action, and are dry skin Medicine, University of Parma, Parma, Italy; 3Department of Medical and
(>10%), constipation, dysphagia, (1-10%). More rarely it causes headache, Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy;
orthostatic hypotension, tachycardia. The patient is currently on gastroen- 4
Gastroenterology Unit, ‘Spedali Civili’ Hospital, University of Brescia,
therologic follow up with the suggestion to perform an electrophysiologic Brescia, Italy
investigation of deglutition was if symptoms relapse. However, in view of
the resolution of dysphagia after drug discontinuation, a iatrogenic damage Background: The increasing prevalence of strains resistant to antimicrobial
was strongly suspected. agents (AGs) is a critical issue in the management of H. pylori infection. The
Conclusion: we presented this clinical case in order to describe a possi- principal aim of this study was to assess the prevalence of primary resistan-
ble serious side effect of an overdose of hyoscine butylbromide, an over the ces (PRs) to clarithromycin, metronidazole, and levofloxacin between 2010
counter drug. and 2015. A secondary aim was to evaluate the effectiveness of sequential
therapy (ST) in strains resistant to clarithromycin and/or metronidazole.
Methods: naïve H. pylori positive patients referred for endoscopy between
155. EFFECTIVENESS AND SAFETY OF BISMUTH 2010 and 2015 were eligible. PRs to clarithromycin, metronidazole and
QUADRUPLE THERAPY (PYLERA®) IN COMBINATION levofloxacin were evaluated with E-test, according to the EUCAST guideli-
WITH PPIS FOR THE ERADICATION OF H. nes. A multivariate regression analysis was performed to assess the associa-
PYLORI INFECTION IN PATIENTS WITH DUAL tion between several covariates and PRs. ST and post-treatment follow-up
CLARITHROMYCIN AND METRONIDAZOLE were offered to infected patients.
RESISTANCE Results: PRs to clarithromycin, metronidazole, and levofloxacin were 36.1%
(95%CI: 30.4 to 41.9), 38.5% (95%CI: 33.6 to 43.6), and 28.7% (95%CI: 23.5
Fiorini G. 1, Saracino M.I. 1, Gatta L. 2, Vaira D. 1 to 34.3), respectively. Multivariate analysis showed that PRs significantly
1
Department of Medical and Surgical Sciences, University of Bologna, increased between 2010 and 2015 for clarithromycin (OR: 1.15; 95% CI:
Bologna, Italy 2Gastroenterology and Endoscopy Unit, Versilia Hospital, 1.08 to 1.23), metronidazole (OR: 1.11; 95% CI: 1.04 to 1.19), and levofloxa-
Azienda USL. Toscana Nord-Ovest, Lido di Camaiore, Italy; cin (OR: 1.15; 95% CI: 1.08 to 1.25). ST eradicated >87% of strains resistant
to clarithromycin or metronidazole and 83% of those resistant to both AGs.
Background: In areas of high dual clarithromycin and metronidazole resi- Conclusions: In our area, PRs to antimicrobial agents tested were high,
stance, bismuth quadruple therapy (BQT) is the recommended first-line and significantly increased between 2010 and 2015. Regular monitoring on
treatment for the eradication of Helicobacter pylori (H. pylori). 1 However, regional basis should be set-up to choose the better regimen and to indi-
the level of evidence for this recommendation is low. In combination with rectly monitor the consumption of AGs. Finally, ST is able to overcome resi-
proton pump inhibitors (PPIs), BQT Pylera® (a single capsule containing stance to clarithromycin or metronidazole.
bismuth subcitrate potassium, metronidazole and tetracycline hydrochlo-
ride) can be used as first line treatment or as rescue therapy to eradicate
H. pylori infection.Aim: To assess the effectiveness and safety of a 10-day 157. GELATINE TANNATE AND TYNDALLIZED
Pylera®+ PPI regimen in H. pylori infected patients in a real clinical setting PROBIOTICS REDUCE COLITIS SEVERITY AND
either naïve to treatment or as a rescue treatment and to assess eradication PROMOTE A FASTER RECOVERY IN DEXTRAN SODIUM
rates by antibiotic resistance. SULPHATE (DSS) MODEL OF MURINE PROLONGED
Methods: Consecutive H. pylori infected patients, who underwent an COLITIS
upper GI endoscopy, were enrolled. During endoscopy, biopsies were
obtained to perform culture and susceptibility test for clarithromycin Lopetuso L.R., Petito V., Graziani C., Franceschi F., Cammarota G.,
(Cla), metronidazole (Metro) and levofloxacin (Levo). H. pylori infected Gasbarrini G., Scaldaferri F., Gasbarrini A.
patients were offered treatment with Pylera®+ full dose PPI twice daily Catholic University of Sacred Heart of Rome-A. Gemelli Hospital
for 10 days. Eradication was defined as a negative 13C-UBT performed Gastroenterological Area, Gastroenterological and Endocrino-Metabolical
at least 28 days after the end of the therapy. Treatment emergent adverse Sciences Department
events (TEAEs) were registered.
Results: From March to December 2016, 960 endoscopy were perfor- Background and Aim: Gelatin tannate together with a mixture of inactiva-
med and 245 naïve patients were treated with the 10-day Pylera® plus PPI ted tyndallized probiotics including Lactobacilli, Bifidobacterium, Strepto-
regimen. Susceptibility testing was available for 78.4% of patients. 41.6%, coccus are particularly indicated in the management of moderate and pro-
36.4%, and 36.1% of patients harboured strains resistant to Cla, Metro, and longed diarrhea. No information, however, exist from in vivo studies and
Levo, respectively. 6.7% of strains were resistant to both Cla and Metro but no animal model has been used to confirm their efficacy or unravel specific
susceptible to Levo, whilst 13.5% of patients harboured strains resistant to all mechanism of action. Aim of this study was to evaluate the therapeutic effect
antibiotic tested. Eradication rate according to the ITT and PP were 91.0% and mechanisms of action of the formulation containing gelatin tannate and
(95% CI: 88.0 to 95.5) and 97.2% (95% CI: 93.7 to 98.8), respectively. 93.9% tyndallized probiotics in the DSS model of murine prolonged colitis.
of patients harbouring strains resistant to Cla were eradicated as well as the Methods: C57BL/6 mice were exposed to three cycles of 2.5% DSS for 7
94.0% of those harbouring strains resistant to Metro. Furthermore, 88.9% days in drinking water separated by 2 weeks of recovery with water alone
of patients harbouring strains resistant to both Cla and Metro were eradi- (resting period). During each cycle, after 5 days of DSS administration, mice
cated. 53.4% of patients reported TEAEs: the most frequent were asthenia received the formulation containing gelatin tannate and tyndallized probio-
(22%), nausea (20%) and headache (18.2%). 1% of patients had to discon- tics by gavage in 200 ul of drinking water (T group) for five consecutive
tinue therapy due to AEs. Moreover, the 10-day Pylera® plus PPI regimen days. Control mice received water only (CON group). Body weight, occult
was used as rescue therapy in 116 patients with an overall eradication rate of blood test and stool consistency were measured every day and used to cal-
87.2%. 88.5% of patients with dual Cla and Metro resistance were eradicated culate the Disease Activity Index (DAI) to assess severity of colitis. Survival
of the infection. Based on the number of treatments previously performed, was expressed as %. Mice were sacrificed 2 weeks after the third DSS cycle
this regimen achieved an eradication rate of 95.1%, 82.1%, 85.7% and 77, 8% and colon length was measured.
125
Results: No differences in DAI and body weight loss were found after the Liverpool, 8 Department of Gastroenterology, Wrightington, Wigan and Leigh
first cycle of DSS between T and CON. Conversely, T group showed a signi- NHS. Trust, Wigan, 9 Department of Gastroenterology, The Pennine Acute
ficantly reduced DAI (p<0.005) and body weight loss (p<0.005) during the Hospitals NHS. Trust, Manchester, United Kingdom
second and third DSS cycle with also a significantly faster recovery of DAI
and body weight during their respective resting periods compared to CON Background and Aims: The medical therapy of inflammatory bowel disease
group (p<0.0002 and p<0.005, respectively). No differences in mortality (IBD) poses a peculiar challenge in the elderly population with multimor-
were observed. At the sacrifice colon length was significantly higher in T bidity. Vedolizumab (VDZ) is a gut-selective α4β7 anti-integrin licensed
group vs. CON group (p<0.05). to treat Chron’s disease (CD) and ulcerative colitis (UC) that could have a
Conclusions: Taken together our preliminary observation suggest that favourable safety profile in this setting. We aimed to assess clinical outcomes
the formulation containing gelatin tannate and tyndallized probiotics can and safety of VDZ in a cohort of elderly IBD patients.
decrease the clinical severity of colitis in mice. It seems also able to promote Methods: We retrospectively collected data of patients treated with VDZ
a faster recovery of intestinal homeostasis during prolonged colitis. Further at eight UK centres (August 2014-September 2016). We evaluated clinical
analyses are required to better define the mechanisms of action underlying response at 12 and 52 weeks using the Physician Global Assessment (PGA),
these findings. comparing elderly (≥ 65 years) with adult (< 65 years) patients. Safety issues
were also recorded.
Results: A total of 160 adult IBD patients (mean age 36.5 ± 11.9, 95F; 105
158. ALMONDS AS COMPONENT OF THE CD, 53 UC, 2 IBD-U) and 22 elderly IBD patients (mean age 71.9 ± 4.7, 13F;
MEDITERRANEAN DIET: ORGANOLEPTIC PROFILE OF 10 CD, 12 UC) were enrolled for a mean treatment period of 9.4 ± 5 months.
ALMOND VARIETIES DIFFER IN RELATION TO AGE AND Nine out of 22 elderly patients (41%) had at least two associated chronic
BODY WEIGHT diseases, namely essential hypertension, chronic heart failure, diabetes mel-
litus type 2, and chronic obstructive pulmonary disease. According to PGA,
Lorusso M.P. 1, Diella G. 2, Caggiano G. 2, Montagna M.T. 2, 78/105 (74.3%) adult CD and 44/53 (83.1%) adult UC patients had a clini-
Portincasa P. 1 cal response to the induction therapy, whereas 16/39 (41.1%) adult CD and
1
Clinica Medica “A. Murri”, Department of Biomedical Sciences and 25/29 (86.2%) adult UC patients maintained response at 54 weeks. Instead,
Human Oncology, University of Bari “Aldo Moro”, Italy 2Section of Hygiene, 10/10 (100%) elderly CD and 11/12 (91.7%) elderly UC patients had a cli-
Department of Biomedical Sciences and Human Oncology, University of Bari nical response to the induction therapy, whereas 2/2 (100%) elderly CD
“Aldo Moro”, Italy and 6/7 (85.7%) elderly UC patients maintained response at 54 weeks. No
adverse events, nor infectious diseases were reported in the elderly cohort.
Background and Aim: Almonds in southern Italy represent a popular compo- Conclusions: VDZ is a safe and effective therapy even in a sub-cohort of
nent of the “rural” Mediterranean diet bringing beneficial nutritional aspects. elderly patients with multimorbidity. Further studies are needed in order to
The almond seed is rich in fat (≈55%, [39.4%] monounsaturated fatty acids), confirm these preliminary data.
vit. E, Mg+, Cu++, P, fibers, riboflavin, proteins, phenols and polyphenols. As
other nuts, almonds contribute to prevention of cardiovascular disease and
diabetes. Almond crops are widely distributed in Apulia and add important 160. ABDOMINAL PAIN IN PREGNANT WOMAN
economic and cultural value, while competing with other imported almond
varieties. Consumers’ choice, price and advertisements play a key role in this Maringhini M. 1, Rossello M. 2, Patti R. 3, Alio W. 4, Mazzola A. 5, Spina R. 1,
respect. We tested organoleptic perception of two common almond varieties Maringhini A. 3
according to age and body weight. 1
U.O.C. Medicina Clinica, Respiratoria e delle Urgenze, A.O.U. Policnico
Methods: 20 lean (BMI <24.9 Kg/cm2, age 18-65 yrs), 20 obese (BMI ≥30 P.Giaccone di Palermo; 2Radiologia, Arnas Civico di Palermo; 3Medicina 1,
Kg/cm2) adults and 20 lean elderly (>65 yrs) subjects ingested almonds Arnas Civico di Palermo; 4Ostetricia e Ginecologia, Arnas Civico di Palermo;
blindly and randomly: A) five imported “Carmel” almonds and B) five local 5
U.O. Medicina Trasfusionale, Arnas Civico di Palermo
“Filippo Cea” almonds. Scores were collected for olfactory, taste, chewing
and visual perceptions on a 0-100 mm Visual Analogue Scale (VAS). Before A 31-year-old female patient presented to the hospital at 30 weeks of her
each test the mouth was rinsed with 150 ml tap water. Drinking, smoking, first pregnancy. Her weight and height were 75 kg and 160 cm, respectively.
or physical exercise were prohibited 2hr before the test. She had abdominal discomfort, vomiting and temperature of 37.5°C. Her
Results: Lean subjects had distinct VAS values across all domains (p<0.05 medically history was negative, folic acid the only drug she had been taking.
Cea vs. Carmel): olfactory [40.0 (IQR 36.3) mm vs. 55.0 (17.5) mm], taste Notable physical findings included a respiratory rate of 25, blood pressure
[50.0 (27.5) mm vs. 72.5 (30.0) mm], chewing [60.0 (28.8) mm vs. 75.0 of 100/60 mmHg, 102 bpm, and a normal gravid uterous. Vital signs were
(37.5) mm], visual [50.0 (25.0) mm vs. 75.0 (30.0) mm]. Obese subjects had normal. There were moderate tenderness and not rebound in abdomen. No
distinct visual perception [52.5 (50.0) mm Cea vs. 80 (30.0) mm Carmel; cervical dilatation was observed during the pelvic examination. Fetal heart
p<0.05) while elderly subjects had distinct chewing perception [50.0 (37.5) sound was 152 bpm and presentation was cefalic. There were no rupture
mm Cea vs. 65.0 (30.0) mm Carmel; p<0.05). of membranes and uterine contraction. We ruled out the possibility of
Conclusion: The imported Carmel and the local Cea almond varieties placental abruption and uterine rupture that could happen in second half
provide distinct organoleptic perceptions according to age and body weight. of pregnancy. Laboratory examination revealed white blood cell count of
Mechanisms behind such differencies need to be investigated with respect to 12500/dL (neutrophil 70%), hemoglobin 12, 6 g/dL, plateletes 180000/dL,
commercial as well as pathophysiological aspects. blood glucose was 145 mg/dL, urea 35 mg/dL, serum creatinine 1, 0 mg/dL;
functional test of liver and coagulation were normal as well as electrolytes.
Arterial blood gases were normal. Blood sample was milky and triglyceride
159. VEDOLIZUMAB IS AN EFFECTIVE AND was >4425 mg/dL, cholesterol was 1328 mg/dL. No mutations in CREB3L3
SAFE THERAPY IN ELDERLY PATIENTS WITH was identified. Serum amylase and lypase showed no abnormality. The
MULTIMORBIDITY AFFECTED BY INFLAMMATORY results of urine tests was normal. An abdomen ultrasonography showed
BOWEL DISEASE normal gallbladder, no bile duct dilatation, pancreas was not seen, liver did
not show any focal lesion; nor ascites neither pleural effusion were evident.
Lenti M.V. 1, Levison S. 2, Eliadou E. 3, Willert R. 3, Kemp K. 3, We started conservative treatment including fasting, intravenous fluid infu-
Stansfield C. 3, Assadsangabi A. 4, Singh S. 4, Crooks B. 5, sion(3.000 ml with glucose, , electrolytes, vitamins for 400 Kcal/die). Plasma
Tattersall S. 5, Kenneth C. 5, Subramanian S. 6, Probert C. 7, exchange was started: 2.000 ml of patient plasma was replaced with the same
Storey D. 7, Gregg B. 7, Smith P. 7, Liu E. 8, Limdi J.K. 8, Johnston A. 9, amount of fresh frozen plasma; the procedure was repeated 3 times in 3
Hamlin P.J. 2, Selinger C.P. 2 days. After 4 days severe upper abdominal pain with normal serum amylase
1
Department of Internal Medicine, San Matteo Hospital Foundation, and lypase occurred. Tryglicerides and cholesterol were respectively 1106
University of Pavia, Pavia, Italy 2 Leeds Gastroenterology Institute, Leeds and 296 mg/dL, PCR was 14, 16 mg/L. Ultrasonography was unchanged. An
Teaching Hospitals, Leeds, 3 Department of Gastroenterology, Manchester abdominal NMR was carried out: pancreas was increased in volume, glan-
Royal Infirmary, Central Manchester University Hospitals, Manchester, dular lobulation was lost and a thin effusion was seen all around periglandu-
4
Department of Gastroenterology, Salford Royal Hospitals, Salford, 5 lar fat. Minimal ascitic fluid was evident. Fetus still was in cefalic position.
Department of Gastroenterology, Bolton NHS. Trust, Bolton, 6 Department of Vital signs were stable. Omeprazole (40 mg x 2 dosage) and Piperacillin and
Gastroenterology, Bradford Teaching Hospital, Bradford, 7 Gastroenterology Tazobactam 2g/0, 25 g (2 phials, t.i.d.) were added. Several abdominal pain
& Liver Services, The Royal Liverpool and Broadgreen University Hospitals, was treated with paracetamole and petidin. Plasma exchange was continued
126
according to serum tryglicerides dosage. Several ultrasound examination confirm the impressive modification of bile and gallbladder motility during
were carried out during the first 2 weeks resulting in an increasing fluid and after pregnancy. The increase in estrogen and progesterone production
effusion in the abdomen both in the head and in the tail of the pancreas and result in elevated lithogenicity of bile and gallbladder stasis. Above all gal-
left pleural effusion was also demonstrated. After 9 days pain disappeared, lbladder stasis prevent movement of biliary sludge and stones and reduce
bowel movement restarted, antibiotics and total parenteral nutrition were AP risk. After delivery the normalization of hormone reduce bile lithogeni-
stopped and she started to eat low calories diet (400/500 Kcal/die). Anemi- city and restore gallbladder motility. These changes determine biliary sludge
zation and iron deficiency were observed and she started iron treatment. and new stones (2, 3). After delivery sludge and stones are dissolved or
After 2 weeks the NMR showed an increased peripancreatic fluid collections moved through common bile duct to duodenum, with AP. The increase in
close to the pancreatic tail (7 cm). The patient finally delivered after Caesa- risk of AP in younger pregnant confirm our results in previous prospective
rian section at the 33nd week. Tryglicerides dosage after delivery decreased study on biliary sludge stones and pregnancy (2, 3) and in population–based
and she started Ezetimibe, Simvastatin and Omega3. At the dimission the case control study (1).
effusion took the shape of pseudocyst 7 cm in size. After 4 months of fol- Reference: 1. Maringhini et al. Mayo Clin Proc 2000; 75:361-4. 2. Marin-
low-up the pseudocyst decreased to 4 cm and the patient was asymptomatic ghini A et al J Hepatol 1987; 5: 218-23. 3. Maringhini A. et al. Ann Int Med
with normal serum levels of cholesterol and tryglicerides. 1993; 119: 116-20. 4. Moreau JA et al. Mayo Clinc Proc 1988; 63: 466-73.
%. 5. Lee SP et al, N Eng J Med 1992; 326-:589-93. 6. Eddy JJ et al. Obstet
Gynecol 2008; 112: 1075-81
162. A POSSIBLE ASSOCIATION BETWEEN ACUTE

PANCREATITIS AND ACUTE OESOPHAGEAL NECROSIS:
A CASE REPORT
Marinucci C., Zardo F., Raviolo A., Gili M., Gallo S.,
Morra Di Cella S., Porta M.
Department of Internal Medicine, San Giovanni Battista Hospital of Turin
Introduction: Acute oesophageal necrosis (AON), also known as “black

oesophagus”, is a rare clinical disorder defined by endoscopic evidence
of black circumferential pigmentation of the oesophagus associated with
mucosal necrosis at histology. We propose an association between AON
and acute pancreatitis (AP), supposing a relationship between pancreatic
enzymes and sphincteric failure.
Materials and Methods: We report on a case of association between AP and
AON and a literature analysis, suggesting a possible feedback between incre-
ased pancreatic enzymes and lower oesophageal sphincter (LOS) failure.
Results: A 86 year-old woman was admitted for epigastric pain, diarrhoea
and coffee ground vomitus. She reported weekly bouts of diarrhoea over
the past year, hypertension and osteoporosis and she was in good general
161. INCIDENCE OF ACUTE PANCREATITIS IN WOMEN conditions.
IN CHILD-BEARING AGE. ROLE OF PREGNANCY. A Laboratory findings showed white blood cell count 14.69 x 109/L, C-re-
SICILIAN POPULATION-BASED COHORT STUDY active protein 3.9 mg/l, amylase 2500 U/L, AST 878 U/L, ALT 437 U/L.
A CT-scan showed acute pancreatitis, abdominal fluid and splenic vein
Maringhini M. 1, Dardanoni G. 2, Fantaci G. 2, Patti R. 3, Politi F. 3, thrombosis. Fasting, hydration, high-dose proton pump inhibitors (PPI)
Arnone S. 4, Maringhini A. 3 and antibiotics were started but, two days later, melena, hypotension and
1
Medicina clinica, respiratoria e delle urgenze, A.O.U. Policnico P.Giaccone oxygen desaturation appeared. An urgent oesophagogastroduodenoscopy
di Palermo; 2D.A.S.O.E., Assessorato Regionale Sicilia della Sanità; Medicina revealed diffused black washing-resistant pigmentation of the oesophageal
1, Arnas Civico di Palermo; U.O.S. Sistema Informativo e Statistico, Arnas mucosa, which spared the upper 3 cm of the organ and extended down to
Civico di Palermo the LOS, associated with LOS failure and hiatal hernia. On the following day
ileus paralyticus and possible ab-ingestis pneumonia developed. The patient
Introduction: Acute Pancreatitis (AP) is a well known complication of pre- died of cardiocirculatory arrest after unsuccessful resuscitation.
gnancy(1). Evidence shows gallstones and gallbladder sludge are associated Conclusion: AON is a poorly described condition, with a mortality rate
with pregnancy (2, 3) and it is known that AP is associated with gallstones of 13-35%, presenting with coffee ground vomitus, epigastric/abdominal
(4) and sludge (5). In hospital-based series incidence of AP has been studied pain, hematemesis and/or melena. Treatment is based upon large hydration,
(6) but these studies may be biased by patients selection. high-dose PPI, parenteral nutrition and resolution of underlying causes.
Methods: All DRG of childbearing age female patients admitted in all Sici- We suggest a pathogenic role for two toxic effects: direct acid reflux in
lian hospitals between January 1st 2011 and 31st December 2015 were regi- gastric obstruction and an indirect drop in oesophageal blood flow caused
stered inquiring about codex CD9577.0 (AP). AP was investigated respect by acid. We hypothesize that increased serum pancreatic enzymes and pan-
to the presence of delivery (within 9 months before AP, or within 3 years creatic oedema may cause respectively vessel digestion and hypovolemia,
after AP) or its absence. resulting in oesophageal damage.
Results. Total 1885 AP/7493519 pts; incidence: 25.16/100000/year. AP Literature is scanty and reports on the possible association between AP and
during pregnancy: 34/226492; 15.01/100000/year (21.2, 13.2 and 10.6 oesophagitis in animals, so a cause-effect relationship can only be hypothe-
/100000/year respectively in 1st, 2nd and 3rd trimester). AP after deli- sized. Gurvits et al. supposed that low-flow due to sepsis, arrhythmias, heart
very 287/226492; 42.24/100000/year (95.4, 30.0, 30.0, 33.6, 24.7 and failure, AP, acidosis, hypothermia or shock may lead to AON.
27.4/100000/year respectively in 1st, 2nd, 3rd, 4th, 5th and 6th seme- Naito et al. suggested that trypsin stimulates chemokines and prostaglan-
ster). AP in women without pregnancy within 3 years, 1564/7267027; dins production by oesophageal epithelial cells, possibly leading to gastroe-
21.52/100000/year. We stratified pts according with age: <35 yrs and >= 35 sophageal reflux disease (GERD).
yrs. AP during pregnancy <35 yrs: 17.3/100000/year; >=35: 8.5/100000/ Petrovic at al. emphasized the potential etiological role of LOS failure in the
year. After delivery <35: 41.8/100000/year; >= 35: 43.6/100000/year. AP simultaneous occurrence of GERD and AP, suggesting a feedback mecha-
in women without pregnancy, < 35 years 11.6/100000/year; >= 35 years nism. Two groups of mice underwent surgical procedures to induce AP and
30.2/100000/year. oesophagitis with LOS failure, respectively. The animals with AP developed
Conclusions: Pregnancy, mainly the last 2 trimester, is associated with a LOS failure, whereas those with oesophagitis and LOS failure developed AP.
lower incidence of AP respect to women without pregnancy. Postpartum Other hemorrhagic complications of AP are connected with vascular lesions
period, mainly the 1st and the 2nd semester are associated with an impres- caused by the inflammation and enzymatic self-digestion. These factors may
sive increase in incidence of AP. Women < 35 years of age have a higher also damage the oesophagus either acting directly on the mucosal barrier or
risk of AP both in pregnancy than in the postpartum period. These results indirectly with gastric and/or duodenal vessel erosion leading to localized
ischemia. We propose that the same mechanism(s) may have led to AON
127
during AP in our patient. However, a clear demonstration of this hypothesis influence on ex vivo pouch expression of TpH-1 and SERT, whereas it
cannot be provided because of the scanty literature and the rarity of the con- significantly down-regulated IL-8.
dition, and future research should help to gain further insight and develop Conclusions: We here demonstrated neuroendocrine cell hyperplasia in
effective therapies for this severe pathology. pouch mucosa. Further studies are needed to clarify the pathophysiologi-
cal implication of this finding.
163. AUTOIMMUNE DISORDERS ASSOCIATED WITH

AUTOIMMUNE ATROPHIC GASTRITIS 165. NEW INSIGHTS INTO PATHOLOGICAL
MECHANISMS UNDERLYING AUTOIMMUNE ATROPHIC
Miceli E., Pisati M., Caccia Dominioni C., Lenti M.V., Padula D., Corazza GASTRITIS
G.R.
First Department of Medicine, San Matteo Hospital Foundation, University Di Sabatino A. 1, Giuffrida P. 1, Lenti M.V. 1, Cococcia S. 1,
of Pavia, Pavia, Italy Aronico N. 1, Vanoli A. 2, Capuano F. 2, Martino M. 1, Miceli E. 1, Corazza
G.R. 1
Background and Aims: Autoimmune atrophic gastritis (AAG) is an 1
First Department of Medicine and 2Department of Molecular Medicine,
autoimmune disorder that affects patients of all ages causing atrophy of San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
the oxyntic mucosa of the stomach, progressively leading to vitamin B12
and iron deficiency. AAG has certainly an immune-mediated pathologi- Background and Aims: Autoimmune atrophic gastritis (AAG) is an
cal basis, as it was shown in both animal models and in humans, driven autoimmune disorder that affects patients of all ages causing atrophy of
by humoral and cell-mediated activation. AAG may be associated with a the oxyntic mucosa of the stomach. Although the typical AAG patho-
number of autoimmune disorders, namely type I diabetes mellitus, viti- logical features have been widely described (i.e., atrophy of the corpus/
ligo, Hashimoto’s thyroiditis, and Addison’s disease. We aimed to describe fundus mucosa with antrum sparing), still there is a number of associated
all autoimmune conditions in our cohort of patients affected by AAG. alterations that have not clearly been characterised. In addition, apoptotic
Methods: Between January 2007 and June 2017, we consecutively enrol- mechanisms involving Fas/Fas ligand pathways have only been demon-
led all patients diagnosed with AAG (corpus/fundus atrophy with antrum strated in vitro. We herein aimed to investigate the distribution of T lym-
sparing and positivity to anti-parietal cells antibody, according to the Syd- phocytes and apoptotic mechanisms within the gastric mucosa of patients
ney-Houston classification) in our gastroenterological outpatient clinic with AAG.
(Fondazione IRCCS Policlinico San Matteo). We therefore recorded the Methods: We enrolled five patients with confirmed diagnosis of AAG
medical history of these patients with particular regard to concurrent (corpus/fundus atrophy with antrum sparing and positivity to anti-parie-
associated autoimmune conditions. tal cells antibody). Five subjects with normal gastric histology undergoing
Results: Within the study time span, we enrolled 287 patients suffering endoscopy for functional dyspepsia were used as control group. Sections
from AAG (mean age 63 ± 16 years; F:M ratio 2.3:1). At least one concomi- were taken from paraffin blocks of biopsies of gastric corpus and stained
tant autoimmune disorder was present in 136/287 patients (47.4%; mean with immunoperoxidase using anti-CD3 and anti-CD8 antibodies. Apop-
age 60.3 ± 15 years, F:M ratio 2.4:1), whereas at least two autoimmune totic mechanisms were assessed through TUNEL assay.
disorders were present in 26/287 (9.6%; mean age 62.4 ± 14 years, F:M Results: CD3+ (mean 13.0±1.2 per 100 epithelial cells) and CD8+ (mean
ratio 1.9:1). In particular, the most common autoimmune disorders were 12.5±0.7 per 100 epithelial cells) intraepithelial T lymphocytes were incre-
as follow: 85/287 (29.6%) Hashimoto’s thyroiditis, 13/287 (4.5%) vitiligo, ased in the gastric corpus of AAG patients compared to that of control
12/287 (4.2%) Grave’s disease, 11/287 (3.8%) connective tissue disorder, subjects (mean 4.9±0.3 and mean 4.3±0.2 per 100 epithelial cells, respecti-
9/287 (3.1%) rheumatoid arthritis, 9/287 (3.1%) psoriasis and/or psoriatic vely). TUNEL assay showed a higher grade of apoptosis in the gastric
arthritis, 6/287 (2.1%) coeliac disease, 3/287 (1.1%) inflammatory bowel corpus of AAG patients compared to that of control subjects.
disease, 3/287 (1.1%) type I diabetes mellitus. Conclusions: We here show that intraepithelial lymphocytosis and epithe-
Conclusions: We here show that AAG is associated with other concur- lial apoptosis are features of AAG. In particular, in the absence of coeliac
rent autoimmune conditions, namely autoimmune thyreopaties, vitiligo, disease, H. pylori gastritis, and varioliform gastritis, the intraepithelial
connective tissue disorders, and arthritis. These patients should be scre- lymphocytosis should raise the suspicion of AAG. Further studies are
ened for AAG. Further studies are necessary to better clarify the possible necessary to better clarify the pathological mechanisms underlying AAG.
common basis of AAG and other autoimmune disorders.
166. A RARE LESION OF THE PANCREAS

164. INCREASE IN NEUROENDOCRINE CELLS IN
BIOPSIES FROM POUCH MUCOSA Noviello M., Gesualdo A., Bonfrate L., Belfiore A., Buonamico P., Palmieri
V.O., Pugliese S., Minerva F., Portincasa P.
Di Sabatino A. , Giuffrida P. , Vanoli A. , Biletta E. , Aronico N. ,
1 1 2 2 1
Lenti M.V. 1, Bergamaschi G. 1, Sampietro G.M. 3, Ardizzone S. 4, Oncology, University of Bari Medical School
Luinetti L. 2, Martino M. 1, Curti M. 1, Manca R. 2, Fociani P. 5, Corazza
G.R. 1 A 43 years old man with recurrent epigastric pain and weight loss (7 Kg)
1
Departments of 1Internal Medicine and 2Molecular Medicine, San Matteo in the last 6 months came to our attention. He suffered of hiatal hernia
Hospital Foundation, University of Pavia, Pavia, Italy; 3IBD. Surgical Unit, and gastroesophageal reflux disease. No alcohol abuse was recorded (daily
Divisions of 4Gastroenterology and 5Pathology, “Luigi Sacco” University potus 15 gr). Bioumoral tests were otherwise normal. A prior abdominal
Hospital, Milan, Italy ultrasonography (US) found a mass of the pancreatic head while the abdo-
Background and Aims: Inflammatory bowel disease (IBD) is associated minal computed tomography scan (CT) revealed dishomogeneity with
with neuroendocrine cell hyperplasia. We investigated neuroendocrine increased volume and a 3 cm hypodense area of the pancreatic head. The
cells in J-pouches of patients with ulcerative colitis undergoing restorative differential diagnoses were pancreatic neoplasm or chronic pancreatitis
proctocolectomy and ileal pouch-anal anastomosis. (i.e. autoimmune since chronic alcohol consumption was absent). Fluo-
Methods: Sections from pouch of 17 patients and ileum of 13 active IBD rodeoxyglucose positron emission tomography (PET-CT) scan showed
patients and 11 controls were processed by immunohistochemistry for moderate increase of glucose metabolism at the head of the pancreas with
chromogranin A (CgA) and serotonin. Mucosal tryptophan hydroxylase associated hypermetabolic peripancreatic lymphadenopathy. The abdo-
(TpH)-1 and serotonin-selective reuptake transporter (SERT) transcripts minal Nuclear Magnetic Resonance (NMR) revealed cystic structures in
were measured by quantitative RT-PCR. TpH-1 and SERT transcripts were the space between the duodenum and the pancreas, with duodenal wall
detected in pouch biopsies cultured with infliximab or its isotype control, thickening. An endoscopic US was performed and biopsy plus histology
while IL-6 and IL-8 were measured in biopsy supernatants. diagnosed a chronic pancreatitis. A final diagnosis of groove pancreatitis
Results: A significant increase in CgA-positive cells was observed in both was made and the patient was treated conservatively (total abolition of
pouch and IBD ileum compared to control ileum, while serotonin-posi- alcohol consumption and smoking) and followed up to 12 months, so far
tive cells were significantly higher in IBD ileum, but not in pouch, com- (totally asymptomatic).
pared to control ileum. Significantly raised transcripts of TpH-1, but not Conclusions: Groove pancreatitis is a rare cause of chronic pancreatitis
SERT, were found in IBD ileum in comparison to control ileum, with no that affects the groove area (i.e., the anatomic space between the head of
significant difference between pouch and IBD ileum. Infliximab had no
128
pancreas, duodenum and common bile duct). The lesion can mimic or time that adult females show a significant higher DOB compared to males
coexist with pancreatic carcinoma, and is still a diagnostic challenge for (p=0, 008). Whether this effect may be due to hormonal differences, able to
clinicians. Groove pancreatitis should be considered in the differential influence gastric emptying, bacterial load, or even the production of urease
diagnosis of patients presenting with pancreatic head lesions. The diagno- by H.pylori, merits further investigation.
sis requires a complete workup to correctly manage this rare condition.
169. A CASE OF CVID-ASSOCIATED INFLAMMATORY

167. EFFECT OF LACTOBACILLUS REUTERI (DSM 17938) BOWEL DISEASE: DIAGNOSIS AND CLINICAL
ON METHANE PRODUCTION IN PATIENTS AFFECTED MENAGEMENT
BY FUNCTIONAL CONSTIPATION: A RETROSPECTIVE
STUDY Menghini D., Danieli G., Macedoni T., Pedini V., Danieli M.G., Gabrielli A.
Clinica Medica, Università Politecnica delle Marche & Ospedali Riuniti,
Ojetti V. 1, Petruzziello C. 1, Migneco A. 1, Gnarra M. 2, Ancona
Gasbarrini A. 1, Franceschi F. 1
1
Department of Medical Sciences, Division of Gastroenterology, Catholic Aim of the Study: To describe our experience on the diagnosis and therapy
University of the Sacred Heart, Rome, Italy 2Dermatology Unit, Columbia of Common variable immunodeficiency (CVID)-related malabsorption.
University Medical Center, NYC, NY, USA. CASE-REPORT: A 41-year-old Caucasian woman affected by CVID came
to our attention on March 2016 for a flare-up of her chronic diarrhoea and
Objective: Constipation is a common symptom affecting up to 30% of the a weight loss of 10 kg in the last six months. Her medical history inclu-
Western population and is strongly associated with the presence of intestinal ded psoriatic arthritis, splenectomy for an idiopathic thrombocytopenic
methanogens, which may directly inhibit motor activity. Two recent studies purpura, multifactorial anemia and osteoporosis. In the past, the diarrhoea
performed on adult and children affected by chronic constipation showed was considered the consequence of recurrent gastrointestinal infections in
that the supplementation with L. reuteri signi cantly improved bowel move- an immunodeficient patient. On physical examination, the patient did not
ments. Whether its action is related to a decreasing of methane (CH4) pro- have abdominal pain and was apyretic. Her weight was 33 kgs and the BMI
duction has never been tested. We have therefore designed a study aimed at was 14, both indicating a severe underweight. Our first aim was to identify
testing this hypothesis. the right one among the most common causes of diarrhoea and malabsorp-
Patients and Methods: Data of 20 adults (12 females, mean age 36.2 ± 13.7) tion (gastrointestinal infections, inflammatory bowel diseases, neoplasms,
affected by functional constipation, treated with the probiotic L. reuteri pancreatic insufficiency). The patient underwent blood tests, chemical and
(DSM 17938) for 4 weeks who performed a H2/CH4 lactulose breath test parasitological stool exams, coproculture, HGBT (to screen for SIBO),
(LBT) in our institution showing a CH4 production higher than 5 ppm were gastroscopy, colonoscopy, abdominal and thoracic computed tomography.
retrospectively analyzed from March to June 2015. Data recorded in their We did not test the patient for lactose intolerance because her diet was
stool diary, reporting the frequency of defecations and stool consistency already lactose-free. The study showed a severe malabsorption syndrome,
were also analysed, as well as the result of the LBT performed at the end of with no signs of pancreatic failure, neoplasms or gastrointestinal infections.
the treatment with L. reuteri. The gastroscopy revealed a mild gastroduodenitis, negative for H. pylori.
Results: Four weeks of L. reuteri administration was associated with a signi We excluded the diagnosis of celiac disease because of the histology, the
cant decrease of mean CH4 production determined by LBT(from20.8±15 absence of the characteristic autoantibodies and of HLA DQ-2 and DQ-8
to8.9±8.6;p<0.0001CI95%) and of AUC value (from 5101.5 ± 3571.13 to haplotypes. The colonoscopy showed a chronic colitis, with ulcers and
2128.4 ± 2110.8; p < 0.0001 CI 95%). Moreover, a total disappearance of inflammatory pseudopolyps. The histopathological examination revealed
CH4 production (< 5 ppm at LBT) was observed in 11 patients, while, we crypt distortion, crypt microabscesses, a mucosal inflammatory infiltrate
did not observe any signi cant decrease of H2 production (from 13.2 ± 8.8 composed by lymphocytes, plasma-cells and neutrophils and some aspects
to 11.4 ± 7.3, CI 95%, n.s.). resembling a collagenous colitis. We made the diagnosis of “CVID-asso-
Conclusions: This study highlights for the first time the beneficial effect of ciated inflammatory bowel disease”, which is a typically CVID-related con-
Lactobacillus reuteri (DSM 17938) on chronic constipation, via a signficant dition similar to Crohn’s disease and ulcerative rectocolitis, but with some
decrease of CH4 production. key differences. Treatment with high-dose steroid therapy obtained clinical
remission, which was maintained with the instroduction of adalimumab,
which was also beneficial for the psoriatic arthritis. As supporting treat-
168. MAY GENDER OR ETHNICITY AFFECT DELTA OVER ment, the patient continued subcutaneous immunoglobulins (8 g/weekly)
BASELINE VALUES OBTAINED BY 13-C UREA BREATH and started a supplemental parenteral nutrition supplied by a central venous
TEST? catheter. After six months, the patient gained 7 kg in weight and the diarrhea
was in remission. However, on September 2016 it was necessary to remove
Petruzziello C. 1, Sinatti D. 1, Gnarra M. 2, Migneco A. 1, Tesori V. 1, the CVC and to stop adalimumab for a sepsis sustained by S. Aureus. Upon
Graziani C. 1, Gasbarrini A. 1, Franceschi F. 1, Ojetti V. 1 adalimumab withdrawal, diarrhoea and psoriasis relapsed. A few months
1
Department of Gastroenterology and Internal Medicine, Catholic later, the patient restarted high-dose steroids and parenteral nutrition, with
University, Rome, Italy 2 Dermatology Unit, Columbia University Medical a significant improvement. We are now trying to reintroduce the anti-TNF
Center, NYC, USA. alfa therapy, with a particular attention to the risk of infections.
Conclusions: About 9-20% of patients with CVID may develop a CVID-as-
Introduction: 13C-urea breath test (UBT) is a non-invasive test for sociated inflammatory bowel disease. Malabsorption can be a severe com-
detecting active H.pylori infection. Previous studies showed a correlation plication of this condition, whose treatment can be challenging, as the use
of delta over baseline (DOB) values with bacterial load, mucosal inflamma- of immunosuppressants may increase the infectious risk. A supplemental
tion and successful eradication. Gender has been shown to affect DOB in parenteral nutrition can be useful, even if it strongly increases the proba-
children. Aim of our study was to verify whether gender or ethnicity affects bility of sepsis.
DOB in adults.
Patients and Methods: We retrospectively analyzed data of 2922 patients
(1024M/1898F mean age 47±15 years) that underwent UBT in our outpa- 170. AN UNEXPECTED BIOPTIC FINDING
tient unit, from October 2015 to October 2016. Patients were divided based
on gender and ethnicity; mean DOB values were then compared. Periti G. 1, Francione P. 1, Spreafico S.M. 2, Bignamini D. 2,
Results: 686 pts (23.4%, 258M/428F, mean age 45±17 years) of 2922 pts Airaghi L.M. 2, Fargion S. 1
showed a positive UBT. Prevalence of H.pylori infection was significant
1
Medicina Interna ad Indirizzo Metabolico, Università degli Studi di Milano 2
higher in males compared to females (29% vs 22%; p=0, 03). Females IRCCS Ospedale Maggiore Policlinico di Milano
showed a significant higher mean DOB (34±25 vs 27, 6±22; p=0, 008). The
prevalence of H.pylori infection is 32% in those from Eastern Countries, We report a case of a 84-year-old patient who came to our attention for
28% in those from South America and 40% in both those coming from persistent aqueous diarrhea of osmotic type started in the previous three
Africa and Asia. We found significant higher DOB values in Italians compa- weeks, associated with a 3-Kg weight loss and tenesmus. For the persi-
red to non-Italian (mean DOB 36±27vs69±32; p<0.0001). stence of numerous bowel movements, 5-6/day, and rectal pain during
Conclusion: Our study showed that in our geographic area, prevalence evacuation, the patient presented at emergency department where exams
H.pylori infection is higher in males. Moreover, it demonstrates for the first showed mild renal failure. He reported a history of a long-standing hyper-
129
tension, treated with angiotensin II receptor blocker and beta-blocker showed B-cell lymphoma (BCL)2+ and CD20+ positive. The patient
beside statin and glaucoma medications. He denied laxative and antibio- underwent video-capsule enteroscopy that showed several similar lesions in
tics use in the last months as well as travelling to foreign countries. He the proximal tract of small bowel and a lesser number in ileum. So he was
reported that none of his family members had similar symptoms. During referred to the Hematology unit, underwent CT - PET scanning and bone
hospital stay, he underwent routine examination: complete blood count marrow examinations. He was assigned Ann Arbor stage IE.
and differential leucocyte count were normal, he was mildly hypoalbu- Discussion: Intestinal follicular mainly involve duodenum. Since develop-
minemic and showed a mildly elevated RPC while aminotransferases, ment of enteroscopy devices, such as double-balloon and video-capsule
alkaline phosphatase and bilirubin were normal. The physical examina- enteroscopy, we can study involvement of jejunum and ileum. Among inte-
tion was also normal.The patient did a full abdomen echo-scan, which stinal follicular lymphomas, the cases of lesions in jejunum and ileum range
resulted negative, and a colonoscopy with multiple biopsy. Erythema and from 66.7% to 100%.
granularity of the colic mucosa and eosinophilic infiltration of the lamina Conclusions: These results emphasize the importance of enteroscopy exa-
propria were detected. A diagnosis of eosinophilic colitis was made and all minations to precisely evaluate the extent of intestinal lesions in follicular
the possible causes were investigated (idiopathic hypereosinophilic syn- lymphoma patients.Internists should be aware that follicular lymphoma
drome, autoimmune disease, rare helminthic infections, neoplasia). patients with gastrointestinal involvement must be investigated according
to the general guidelines for systemic follicular lymphoma.
171. LIVER TRANSPLANTATION IN PATIENTS WITH

ALCOHOLIC LIVER DISEASE: A RETROSPECTIVE STUDY 173. OCCURRENCE OF SARCOPENIA AND FATIGUE IN
INFLAMMATORY BOWEL DISEASE PATIENTS
Vassallo G.A. 1, Tarli C. 1, Rando M.M. 1, Mosoni C. 1, Mirijello A. 2,
Agyei-Nkansah A. 3, Antonelli M. 1, Sestito L. 1, Perotti G. 4, Scaldaferri F. 1, Pizzoferrato M. 1, Rizzatti G. 1, Ingravalle F. 1,
Di Giuda D. 4, Agnes S. 5, Grieco A. 1, Gasbarrini A. 1, Addolorato G. 1 Poscia A. 5, Petito V. 1, Graziani C. 1, Lopetuso L.R. 1, Landi F. 3, Marzetti E. 4,
1
Dipartimento di Medicina Interna, Gastroenterologia e Malattie del Fegato, Martone A. 4, Mentella M.C. 2, Miggiano A. 2,
Università Cattolica del Sacro Cuore, Roma, Italia; 2 Dipartimento di Scienze Mele M.C. 2, Gasbarrini G. 1, Gasbarrini A. 1
Mediche, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni 1
Catholic University of Sacred Heart of Rome-A. Gemelli
Rotondo, Italia; 3 Dipartimento di Medicina Interna, Università di Ghana, Hospital Gastroenterological Area, Gastroenterological and
Accra, Ghana; 4 Istituto di Medicina Nucleare, Università Cattolica del Sacro Endocrino-Metabolical Sciences Department, Rome, Italy;
Cuore, Roma, Italia; 5 Dipartimento di Chirurgia Generale, Centro Trapianti 2
Catholic University of Sacred Heart of Rome-A. Gemelli
di Fegato, Università Cattolica del Sacro Cuore, Roma, Italia Hospital Nutrition Team, Rome, Italy; 3Catholic University of
Sacred Heart of Rome-A. Gemelli Hospital, Center for
Background: Alcoholic liver disease is the most common liver disease in Geriatric Medicine (CEMI), Institute of Internal Medicine
the Western World. Alcohol abstinence represents the gold standard for its and Geriatrics, Rome, Italy; 4Catholic University of Sacred
treatment. When liver function fails to improve in spite of alcohol absti- Heart of Rome-A. Gemelli Hospital, Department of Geriatrics, Neurosciences
nence, liver transplantation is the treatment of for end-stage alcoholic liver and Orthopedics, Rome, Italy; 5Catholic
disease; however, many transplant centers are still reluctant to transplant University of Sacred Heart of Rome-A. Gemelli Hospital,
these group of patients because of the risk of alcohol relapse, recurrence Institute of Hygiene, Rome, Italy
of the primary liver disease and associated post transplant complications.
The aim of this study was to assess survival rate, prevalence of primary liver Background: Inflammatory bowel disease (IBD) are often associated with
disease recurrence, re-transplantation and post-transplant complications malnutrition and variation in the body weight, mostly weight reduction,
among transplanted patients for alcoholic cirrhosis compared with those which recognize a multifactorial etiology. In this context up to one third
transplanted for viral cirrhosis and the associated risk for post-transplant of Crohn’s disease (CD) patients and up to one fourth of ulcerative colitis
complications. (UC) patients have evidence of a muscular mass reduction of any degree
Methods: Clinical data of 400 consecutive patients transplanted at Gemelli which is not caught by common body weight measures such as body mass
Hospital from January1995 to April 2016 were retrospectively collected. index (BMI). Still, data on the prevalence of sarcopenia and fatigue in these
Among them, only transplanted patients for alcoholic and viral cirrhosis conditions is lacking, especially in the setting of Italian IBD centers. Aim of
were included in the statistical analysis. Survival rate was evaluated accor- the study was to evaluate the incidence of chronic fatigue and sarcopenia in
ding to the Kaplan-Meier method. Recurrence was defined as histological inflammatory bowel disease patients followed by our center and to compare
evidence of primary liver disease. Data on the onset of complication, causes them with a matched healthy control population.
of death and graft failure after liver transplant were collected. Material and Methods: Patients with an established diagnosis of inflamma-
Results: There was no difference regarding survival rate between the tory bowel disease followed at the Fondazione Policlinico A. Gemelli center
two groups. Only patients transplanted for viral cirrhosis presented with were prospectively enrolled in the study.
primary liver disease recurrence. For post-transplant complications, there Disease activity was evaluated by means of the partial Mayo score for UC
was a higher rate of cancer developing in the transplanted patients for and of the Harvey-Bradshaw index for CD.
alcoholic cirrhosis. Cancer was the major cause of death in this population. A specific questionnaire was used to evaluate fatigue in IBD patients as well
Risk factors associated with the onset of cancer were a high MELD score at as in controls which included a VAS scale (range 0-100) to evaluate percei-
the transplant time and smoking after transplantation. ved muscular strength and questions to assess impairment in movement
Conclusion: Alcoholic liver disease is a good indication for liver transplan- abilities and in daily activities.
tation. Patients transplanted for alcoholic cirrhosis should be subjected to Sarcopenia was evaluated by means of Dual-energy X-ray absorptiometry
regular cancer screening and they should be advised against smoking. (DXA). The appendicular skeletal muscle index (ASMI), defined as the ratio
between the appendicular muscular mass in kg and the square of the height
in meters was calculated.
172. A CASE OF FOLLICULAR LYMPHOMA OF DISTAL Sarcopenia was defined as ASMI values below 1 standard deviation (SD),
DUODENUM IN PATIENTS WITH FEW SYMPTOMS in particular for men we used an ASMI <7.23 kg/m2 while an ASMI <5.76
Kg/m2 was used in women. Results were expressed as average. Comparison
Borgheresi P. 1, De Donato M.T. 2, Renis M. 3, Di Filippo F.M. 1 between groups were carried using two-tailed variance analysis with Bon-
1
UOC Gatroenterologia e Bleeding Center AOU Salerno, 2UOC Medicina ferroni test. Statistical significance was defined for P<0.05.
AOU Salerno, 3UOC Medicina P.O. Cava de’ Tirreni AOU Salerno Results: A total of 43 IBD patients were enrolled in the study, 51% CD
(n=22) and 49% UC (n=21), 44% females (n=19) and 56% males (n=24),
Introduction: Follicular lymphoma is the most common subtype of indo- the average age was 40.2 years and the average BMI was 24.98, 35% of the
lent non-Hodgkin’s lymphoma. Most patients present Ann Arbor stage III patients underwent IBD-related surgery and the most common therapy was
or IV; only 5-10% patients present early stage I or II. Intestinal follicular anti-TNF alpha (42%).
lymphoma have favorable clinical courses, different from their nodal coun- For comparison purpose we also enrolled 46 healthy subjects, 47.8% (n=22)
terpart. Case-report: M, 60.To our observation because of gastric pain and females and 52.2% males (n=24), the average age was 36.7 years and the
decrease in body weight. He underwent esophagogastroduodenoscopy average BMI was 25.7.
(EGDS): multiple whitish nodules in distal duodenum. Biopsy samples In terms of perceived muscular strength the average VAS score was lower for
showed tumor follicles with germinal center. The immunophenotyping IBD patients in comparison to healthy controls (56.7 versus 68.7 respecti-
130
vely, p<0.05). fruit is often used as natural food for the relief of constipation. We perfor-
Movement abilities was impaired in 28% IBD patients, while only 3.6% of med a multicentre, randomised, controlled, single-blind, cross over clini-
the healthy controls reported an impairment (p<0.05). cal trial to assess the effect of green kiwifruit on digestive and gut health
IBD patients also reported a higher grade of daily activities impairment in functions. As a part of an international study which involved three sites
comparison to healthy controls (43.5% versus 10.7% respectively, p<0.05). around the world using the same protocol (New Zealand, Italy, and Japan),
Sarcopenia, as defined above, was present in 44.2% of IBD patients in com- we enrolled three cohorts of participants: 20 healthy controls, 20 patients
parison to 6.5% of healthy controls (p<0.01). ASMI was significantly lower with functional constipation (FC) and 20 patients with irritable bowel syn-
in IBD patients in comparison to healthy controls (6.72 kg/m2 versus 7.27 drome with constipation (IBS-C), according to Rome III criteria. The study
kg/m2 respectively, p<0.05). duration was a total of 16 weeks; 2-week lead in, 4-week first intervention,
When analyzing ASMI scores in relation to IBD related therapies we found a 4 week washout, 4-week second intervention, and final 2-week follow-up.
significant differences between patients on steroid therapy in comparison to The cross-over design was completed using kiwifruit intervention (2 green
those not receiving steroids (ASMI 6.10 kg/m2 versus 6.96 kg/m2 respecti- kiwifruit per day [Actinidia deliciosa var. Hayward]), compared to a posi-
vely, p<0.05), while we did not find differences between patients with and tive control intervention of psyllium (7.5g of psyllium per day). The primary
without anti-TNF alpha therapy. outcome measure was quantification of complete spontaneous bowel move-
Conclusion: Prevalence of sarcopenia and chronic fatigue is high in IBD ment (CSBM). Secondary outcome measures included additional stool
patients. Sarcopenia also correlate with steroid therapy while no significant frequency measures (spontaneous bowel movements [SBM], complete
difference was found in patients with anti-TNF alpha. bowel movements [CBM], bowel movements [BM]), the Gastrointestinal
Symptom Rating Scale (GSRS), the IBS-QoL questionnaire, together with
objective measures of gastrointestinal transit times using Smart Pills. Faecal
174. A STRANGE CASE OF INTESTINAL sample collection was required for immune measures and DNA extraction
MALABSORPTION to microbial analysis. The primary outcome measure (quantification of
CBSM) was found to be significantly improved by kiwifruit as compared
Bellacosa L., Cogliandro R., Cremon C., Barbara G., Stanghellini V. with psyllium.
Department of Medical and Surgical Sciences, University of Bologna, Italy In particular, analysing the data for all the constipated patients, we showed
that the test product, kiwifruit, is effective and adequately rules out an unac-
A woman aged 67 years was referred to our Department for a 6-month ceptable loss of the control effect. Interestingly, better results were obtained
history of diarrhoea associated with abdominal bloating and severe weight in patients with FC as compared with IBS-C. Similar results were obtained
loss (13 kg). The patient has been suffering for many years of rheuma- for all the analysed secondary outcome measures, suggesting the non-infe-
toid arthritis initially treated with methotrexate, stopped after a few years riority of kiwifruit in comparison with psyllium. In this study we demon-
because of the onset of leukopenia and anemia. After that she started tre- strated the efficacy and safety of kiwifruit as a food intervention for the relief
atment with etanercept, also suspended after two years because of a poor of constipation and associated symptoms in patients with FC and IBS-C,
tolerance profile (onset of fever and diarrhoea). using validated outcome measures. As empiric therapy should begin with
Physical examination revealed that her abdomen was distended but not a fibre supplement in constipated patients, including psyllium, also kiwi-
painful at palpation, without palpable masses or hepatosplenomegaly, bowel fruit should be considered in these patients. ClinicalTrials.gov Identifier:
sounds were increased; cardiopulmonary examination was normal. Due to NCT02888392.
the late onset of symptoms, an organic disease was suspected and the relative
diagnostic work-up implemented. Laboratory evaluations revealed elevated
inflammatory markers. Colonoscopy was negative. Upper gastrointestinal 176. IMPACT OF LIVER STEATOSIS IN PATIENTS WITH
endoscopy revealed numerous whitish patches within the distal duodenal CELIAC DISEASE ON A GLUTEN-FREE DIET
mucosa, and histological examination showed typical findings of Whip-
ple’s disease. Abdominal ultrasound documented a periaortic thickening Tovoli F., Farì R., Granito A., Faggiano C., Guidetti E., Negrini G., Bolondi L.
with a few small retroperitoneal lymphadenopathies and a noticeable inte- Department of Medical and Surgical Sciences, University of Bologna
stinal walls and mesenteric thickening. Therefore, an abdominal CT scan
was performed demonstrating inhomogeneous retroperitoneal solid tissue Introduction: Recent reports suggest that patients affected by celiac disease
widespread along the mesenteric vessels. Biopsies obtained under ultraso- (CD) may be at increased risk of metabolic syndrome after beginning a glu-
nographic control exclusively revealed fibrotic tissue and the diagnosis of ten-free diet (GFD). Also, an electronic register population study perfor-
Ormond’s disease was formulated. med in Sweden suggested that CD patients are more prone at receiving a
Retroperitoneal fibrosis, also known as Ormond’s disease, is a rare disorder diagnosis of non-alcoholic fatty liver disease (NAFLD) in their follow-up,
characterized by the progressive development of fibro-inflammatory tissue compared to the general population. Data about the prevalence of NAFLD
in the retroperitoneum resulting in entrapment and obstruction of retrope- in CD patients obtained in a real life clinical practice are lacking and may
ritoneal structures, notably the ureters and arteriovenous system, leading to be helpful in improving dietary prescriptions and in better understanding
the clinical manifestations. the complex gut-liver interactions of CD patients. Methods: A total of 175
The pathophysiology of retroperitoneal fibrosis is uncertain. Among the CD outpatients were evaluated in our tertiary centre between February 2016
most common causes of this disease there is the prolonged use of certain and June 2017 (inclusion criteria: CD diagnosed according to NASPGHAN
medications, such as antitumoral chemotherapeutics (e.g. methotrexate) recommendations, following a strict GFD since at last 6 months; exclusion
and bio-pharmaceutical agents (e.g. the tumor necrosis factor-α receptor criteria: alimentary transgressions and/or contaminations, known causes of
blocker, etanercept). Therefore, we described a case of Whipple’s disease and chronic liver disease including alcohol and drugs).
retroperitoneal fibrosis, resulting in intestinal malabsorption, both related A control group of 175 matched subjects on an unrestricted diet was created
to the use of immunomodulating drugs. enrolling outpatient evaluated for internistic symptoms at our Day Service
in the same timelapse. Matching factors included age, body mass index
(BMI), hypercholesterolemia, hypertrygliceridemia, hypertension and
175. A MULTICENTRE, RANDOMIZED, CONTROLLED, diabetes.
SINGLE-BLIND, CROSS-OVER STUDY ASSESSING THE All of the patients underwent a liver ultrasound (US) examination to detect
EFFECT OF ZESPRI GREEN KIWIFRUIT ON DIGESTIVE steatosis according to the Hamaguchi criteria. The US findings were corre-
FUNCTIONS IN CONSTIPATED PATIENTS lated with clinical and laboratory data.
Results. In terms of raw prevalence, liver steatosis was found in 34.3% and
Cremon C. 1, Ansell J. 2, Pagano I. 1, Kuhn-Sherlock B. 3, 24.6% of CD and control patients, respectively (p=0.04). Analyzing only
Drummond L. 4, Barbaro M.R. 1, Capelli E. 1, Belacosa L. 1, Cogliandro R. 1, patients with BMI<25, the gap was even more considerable (19.4 vs 4.3%,
Stanghellini V. 1, Barbara G. 1 p<0.001).
1
Università di Bologna, Policlinico S. Orsola – Malpighi, Azienda Ospedaliero A multivariable binary logistic regression was performed using presence of
- Universitaria di Bologna 2Mt Maunganui, New Zeland 3Hamiton, New steatosis as the independent variable was performed. Independent predi-
Zeland 4Leeston, New Zeland ctos of steatosis included: CD group [Exp(B) 3.650 (95%CI 1.911-6.972),
p<0.001], BMI [Exp(B) 1.468 (95%CI 1.320-1.620), p<0.001], total choleste-
Digstive discomfort, including constipation, is a common condition throu- rol [Exp(B) 1.014 (95%CI 1.004-1.023), p=0.004], and alanine aminotran-
ghout the world. Gastrointestinal discomfort and bowel habit are two target sferase [Exp(B) 1.021 (95%CI 1.004-1.037), p=0.013]. Age, sex and triglyce-
areas for potential health claims for foods identified by EFSA. Green kiwi- rides were not associated with liver steatosis. A further logistic regression
131
was performed in the group of CD patients: no correlations were found tal position bilaterally, more obvious to the right. It was performed a mul-
between liver steatosis and pediatric age at the diagnosis (p=0.231) or dura- tidimensional geriatric assessment with administration of cognitive tests.
tion of the GFD (p=0.310). The Mini Mental State Examination showed that the patient was partially
Conclusions: CD patients on a GFD have an increased risk of liver stea- oriented in time and well oriented in space, with good capacity of recording,
tosis compared to a matched population, confirming previous findings on recall, attention, calculation and language; the test pointed out a deficit in
electronic registries. This risk is independent for other common metabo- praxic-building skills (27/30 raw; adjusted for age and education 25.4/30).
lic risk factors such as BMI, cholesterol and diabetes. Consistently (and The Montreal Cognitive Assessment demonstrated that the patient had pre-
even more interestingly), steatosis was found in almost 20% of CD patients servation of attentional capacity, naming, abstraction and verbal fluency,
with normal BMI. Accurate alimentary analyses and further evidences are with impaired ability of planning in space, visuospatial and executive abili-
needed to clarify which are the most probable amongst the putative expla- ties, delayed recall (MoCA: 22/30; cut-off> 26/30). The patient had become,
nations, which include the high-fat content of the GFD and a persistently in a short time, partially dependent on the basic activities of everyday life
increased intestinal permeability. and totally dependent on those instrumental (ADL 3/6; IADL 0/8). Accor-
ding to all these findings we decided to submit our patient to do a neurop-
sychological evaluation and a SPECT. She collaborated on the trial, showing
177. PANCREATITIS IN PORTAL CAVERNOMA: AN to not properly understand test instructions on more than one occasion.
INUSUAL ASSOCIATION? The insight was adequate (grade = 4/4). We found out that immediate atten-
tion was preserved, while there was a serious lack of selective and sustained
Zingaro M.T., de Vincenzo G.M., Sciancalepore D., Luglio C.V., Antonica G., attention. The processing speed of the information was severely reduced.
Berardi E., Napoli N., Sabbà C. She had a deficit in learning structured verbal material and visual-spatial
Medicina Interna Universitaria “C. Frugoni - Dipartimento Interdisciplinare memory. No compromises were found in spoken language (anomies). She
di Medicina - Università degli Studi di Bari “A. Moro” showed deficit in the performance of the clock design test, the copy of a
complex figure and the copy of simple geometric shapes. No abnormalities
A 27-years-old Caucasian young woman with diffuse abdominal pain, diar- were found in abstraction and logical reasoning.The scintigraphic investi-
rhea, fever, nausea and vomit was admitted to our hospital for diagnostic gation, performed by SPECT acquisition of the skull after about four hours
studies. She didn’t use cigarettes, alcohol or drugs. later on administration e.v. of the neuroreceptorial tracer, highlighted a
Her family and medical history was mute. The patient was in full well-being severe reduction of receptitivity for the pre-synaptic dopaminergic analo-
until she returned from intercontinental travel in Africa showing the symp- gue in the right streaked body; a similar picture, though mild, was present
toms above described. in the left streaked body. Then we provided a clinical diagnosis of Lewy
Laboratory tests underlined: PCR 94, 5 mg/L (x 32.6), Fibrinogen 604 mg/ Body Dementia (LBD) and, after excluding bradycardia with an electrocar-
dL (x1, 5), ESR 65 mm/h (x 3.3), increased Alpha 11, 0 % (x 2, 2) and Alpha diogram, we prescribed therapy with rivastigmine 4, 6 mg patch/24 hours,
2 16.9 % (x 1, 4) in the serum electrophoresis, lipase 1001 UI/l(x 2.5), Pan- increasing dosage after one month to 9, 5 mg. Two months following onset
creatic amylase 103 UI/l (x 1.9) negative virologic tests (CMV, EBV, Entero- of therapy, our patient showed a remarkable improvement, with a clear
virus, Adenovirus); Widal-Wright reaction, hemoculture and coprocolture reduction in visual hallucinations.
tests were negative. The only other form of degenerative dementia that is more common than
According to the clinical findings, our first diagnostic hypothesis was a pan- LBD is Alzheimer’s disease (AD). LBD is an umbrella term for dementia
creatitis due to a viral infection. We performed abdominal US that showed associated with the presence of Lewy bodies (abnormal deposits of a protein
slightly increased of pancreatic volume in the body and tail regions with called alpha-synuclein) in the brain: it refers to both Parkinson’s disease
normal structure. Moreover, the examination revealed the presence of dementia and dementia with Lewy bodies. The earliest symptoms of these
massive portal cavernoma, confirmed with contrast-enhanced abdominal two diseases differ, but reflect the same underlying biological changes in
CT scan., in the absence of hepatic disease. the brain. Over time, people with both diagnoses will develop very similar
Abdominal MR confirmed the presence of the massive portal cavernoma cognitive, physical, sleep, and behavioral symptoms. Early diagnosis allows
and increased pancreatic volume. To exclude complications related to portal for important early treatment that may extend quality of life and indepen-
hypertension, possibly due to the presence of the portal cavernoma, we per- dence. Early and accurate diagnosis is important because LBD patients may
formed EGDS with no signs of esophageal varices. react to certain medications differently than AD or PD patients. A variety
We concluded that in association to a plausible viral gastroenteritis, the of drugs, as many traditional antipsychotic medications (for example, halo-
occult portal cavernoma could have been caused the pancreatic dysfunction. peridol, thioridazine) prescribed for individuals with Alzheimer’s disease
Antibiotic and rehydration therapies were given in addition of gabesato and other forms of dementia to control behavioral symptoms as long as hal-
mesilato (300 mg x 3/die) with rapid improvement in clinical symptoms lucinations, can worsen LBD symptoms. Early recognition, diagnosis and
although pancreatic function blood tests didn’t normalize. treatment of LBD can improve the patients’ quality of life.
Although literature findings do not unlight a clinical correlation between
portal cavernoma and pancreatic alteration, we supposed that portal caver-
noma could be probably the cause of the pancreatic alterations shown by 179. A CASE OF CORTICOBASAL DEGENERATION
our patient, due to the portal congestion. PRESENTING WITH ALIEN LIMB SYNDROME AND NON-
FLUENT APHASIA
178. EARLY DIAGNOSIS OF DEGENERATIVE DEMENTIA Giorno A., Camellini C., Musumeci M., Grassi A., Servello A., Cacciafesta
IN A YOUNG ELDERLY WITH HALLUCINATIONS: A CASE M., Ettorre E.
REPORT Dipartimento Di Scienze Cardiovascolari, Respiratorie, Nefrologiche,
Anestesiologiche E. Geriatriche, Sapienza Universita’ Di Roma
Camellini C., Musumeci M., Giorno A., Grassi A., Servello A., Cacciafesta
M., Ettorre E. We report the case of a 70 years old woman, accompanied by his daughter
Dipartimento Di Scienze Cardiovascolari, Respiratorie, Nefrologiche, in our Alzheimer Evaluation Unit for the appearance since three years of
Anestesiologiche E. Geriatriche, Sapienza Universita’ Di Roma progressive difficulty in naming, initial memory deficit, non-fluent aphasia,
tremors of left hand and difficulty in controlling the movement of the limb;
We report the case of a 65 years old patient, accompanied by his general she had also become depressed. In hystory: hypertension treated with val-
practitioner in our Alzheimer Evaluation Unit for the appearance since one sartan and osteoarthritis. She had already performed a brain MRI two years
month of worsening visual hallucinations and insomnia.The patient did before, which showed no alterations; she had repeated a new brain MRI
not take any drugs and she did not report any known pathology in history; before the visit, which pointed out the presence of significant dilatation of
she had already performed a brain MRI, which pointed out the presence of subarachnoid liquor spaces of the vault and base in relation to cortical-sub-
rare and millimetric hyperintensis areas, localized at the white front right cortical atrophy phenomena. Blood analysis didn’t show any abnormal
substance which did not show enhancement after administration of con- value. It was performed a multidimensional geriatric assessment with admi-
trast and therefore referable to gliotic outcome on ischemic cerebrovascular nistration of cognitive tests. The Mini Mental State Examination showed
basis. She had also performed blood analysis, which showed no significant that the patient was oriented in time and space, with good performances in
alterations; a carotid ultrasound, which displayed a fibro-calcified plaque recording, oral language such as repetition, written language such as under-
causing a 30% stenosis in the right internal carotid; and an electroencepha- standing and executing written orders, writing and short term memory; the
logram, which showed non-specific slow abnormalities in temporo-occipi- patient presented deficit in naming, attention, calculation and praxic-bu-
132
ilding skills (MMSE 24/30 raw; adjusted for age and education 21.4/30). g/dl). He was taking acetylsalicylic acid and warfarin (with INR in thera-
The patient was independent in basic activities of daily living and partially peutic range in the last two months). During hospitalization, in considera-
dependent in those instrumental (ADL 6/6; IADL 4/8). It was therefore per- tion of anemia, warfarin was suspended and enoxaparin (2000 U/day) was
formed a second level analysis with neuropsychological evaluation, which started as a strategy for thromboembolism prophylaxis. The hospital stay
highlighted language deficits, executive function deficits and prasic-con- was complicated by hemorrhagic shock from a front abdominal wall hema-
structive deficits. Extensive neurological examination showed off that the toma, which was supplied by a branch of the inferior epigastric artery.
left hand limb was characterized by ideomotor apraxia, severe rigidity, bra- Case Report 3: A 77-year-old man with a history of degenerative cardiomio-
dykinesia, postural tremor. There was also a parkinsonian gait. According pathy was admitted for heart failure in non-datable AF and left basal pneu-
to all these findings we provided a clinical diagnosis of Corticobasal dege- monia in recent orthopedic surgery for left-sided tibia-peroneal fracture.
neration (CBD). Clinical features could be explained by involvement of the He was taking acetylsalicylic acid. Diuretic therapy, enoxaparin (4000 UI
cortical and sub-cortical structures. Cortical-related features may include bid) and antibiotics were started. After 10 days of therapy, a hemorrhagic
apraxia, alien limb phenomenon, focal dystonia and myoclonus. Cognitive shock occurred, presenting with severe left thoracic pain and CT evidence
and behavioural problems may include non-fluent aphasia and visuospatial of abundant left pleural effusion, probably of blood nature, atelectasis of the
impairment. homolateral pulmonary parenchyma and contralateral mediastinal devia-
Eye movements are preserved. Involvement of sub-cortical structures results tion. Upon chest drainage positioning, there was a rapid leakage of approxi-
in highly asymmetrical parkinsonism. Therefore we prescribed therapy with mately 2000 ml of blood and a subsequent improvement of the patient.
levodopa/carbidopa 125/12, 5 mg twice a day, increasing dosage after one Case Report 4: An 86-year-old woman with a history of advanced Par-
month to 250/25 mg three times a day. Three months following onset of kinson’s disease with severe dysphagia (in enteral nutrition from a gastro-
therapy, our patient did not showed an improvement of the motor impair- stomy), chronic AF, IHD taking acetylsalicylic acid, levodopa + benserazide,
ment. Corticobasal degeneration is a rare and quickly progressive neuro- and a proton pump inhibitor. She was admitted for a few days of worsening
degenerative disease, by unknown causes, manifesting in movement disor- dyspnea, right lower limb swelling with superficial venous thrombosis,
ders and cognitive impairment. Typically it appears between the sixth and hypoxemia on arterial blood gases, right heart dilation on echocardio-
seventh decade, with equal distribution between sexes. More than one cere- gram and pulmonary infiltrates on the right base. Acetylsalicylic acid was
bral area is involved, in particular the parietal cortex and the ganglia of the immediately suspended and anticoagulant therapy was started, first with
base. The diagnosis is difficult, especially in the early stages of the disease, enoxaparin (6000 UI bid) and subsequently switched to apixaban (5 mg
in fact it requires special attentions and accurate comparisons with other bid). After a week of hospitalization, hemorrhagic shock occurred, presen-
types of dementia. Diagnosis is based upon clinical criteria; there have also ting with melena but negative gastroscopy. The patient refused to undergo
been different molecular imaging studies, even if in rather small cohorts. colonoscopy.
The CBD has become a topic of considerable interest. Yet, despite many Discussion: These clinical cases of acute hemorrhage, observed over 4
reports, there are no agreed diagnostic criteria. The disease is characterized months, suggest that the administration of anticoagulant or antithrombo-
by abnormal tau deposition that affects neurons and glial cells, including tic therapy (in accordance with the treatment guidelines) can also lead to
astrocytes and oligodendroglia cells. The movement disorder is characte- adverse and fatal events such as hemorrhagic shock. It is well known that
rized by asymmetrical rigidity and levodopa-resistant parkinsonism with the majority of clinical trials, from which the international guidelines are
apraxia and variable other features, including cortical sensory loss, alien drawn up, exclude elderly patients, mostly affected by multiple comorbi-
limb phenomena, myoclonus and dystonia. Cognitive abilities are relatively dities, which are the ones we usually deal with in our wards. In our view,
preserved. In fact, early dementia is an exclusion criterion. The response patient-tailored approaches are needed in older patients, enabling us to pre-
to levodopa should be tested with at least 25/250mg of carbidopa/levo- scribe the most appropriate therapy depending on the patient we are facing,
dopa administered three times a day for at least 2 months. The response to while not forgetting the guidelines we are requested to follow.
levodopa is considered poor when the extrapyramidal features fail to show
marked improvement, or the therapeutic effect is transient (ie, lasts less than
a year). At this time, there is no specific treatment for CBD. Instead indivi- 181. LOW-MODERATE DYSLIPIDEMIA ASSOCIATE
dual symptoms are targeted with specific medications. For example, rigi- WITH INTOLERANCE TO STATINS AND METABOLIC
dity and difficulty walking may partially respond to treatments for Parkin- SYNDROME TREATED WITH NUTRACEUTICAL
son’s disease. Dystonia and myoclonus may respond to muscle relaxants or
anti-seizure medications. Memory and behavior problems may or may not Marchitto N., Sindona F., Fabrizio A., Mauti M., Visani N., Dalmaso S.,
respond to treatments, such as donepezil, for Alzheimer’s disease. Depres- Raimondi G.
sion and/or anxiety can be treated with an antidepressant, such as sertraline, 1) Dr. Nicola Marchitto, Medical Director, Alfredo Fiorini Hospital,
citalopram or escitalopram. Terracina, (Latina), Italy. 2) Dr. Francesco Sindona., Specializing Doctor,
Dept. of Internal Medicine. “Sapienza” University of Rome, Italy. 3) Fabrizio
Alessandra, Nursing student of “Sapienza” University of Rome, Italy 4)
180. HEMORRHAGIC SHOCK IN HOSPITALIZED Monica Mauti, Nursing student of “Sapienza” University of Rome, Italy. 5)
ELDERLY PATIENTS: WHEN THE GUIDELINES MISS THE Visani Nadia, Didactic Director of Nursing Course of “Sapienza” University
MARK of Rome, Italy. 6) Dr.ssa Serenella Dalmaso, Director of ruolo, Alfredo
Fiorini Hospital, Terracina, (Latina), Italy. 7) Prof. Gianfranco Raimondi,
Martino G.P. 1, Manfredi L. 2, Girotti S. 3, Benfaremo D. 3, Astorri F. 1, Associated Professor of Internal Medicine. Dept. of Medico-surgical Sciences
Arma P. 2, Bitti G. 1, Marzan S. 1, Moriconi V. 1, Zega G. 2, Angelici S. 1 and Biotechnologies. “Sapienza” University of Rome, Italy
1
Asur Marche-Area Vasta 4 Fermo, U.O. Medicina Interna 2 Asur Marche-
Area Vasta 4 Fermo, U.O. Medicina Amandola 3AOU Ospedali Riuniti di Abstract: The Metabolic Syndrome is a frequent risk factor for cardiovascu-
Ancona, SOD. Clinica Medica lar diseases and type 2 diabetes and consist of different metabolic disorders
like central obesity, insuline resistence, hypertension and dyslipidemia asso-
Introduction: Hemorrhagic shock in the Internal Medicine ward was con- ciated to high value of triglycerides and low level of High-Density Lipopro-
sidered to be a rather rare occurrence, but there are no reliable data on its tein. The prevalence of Metabolic Syndrome increases with age, degree of
actual incidence in literature. Nevertheless, it represents an insidious com- obesity and propensity to type 2 diabetes.
plication and its incidence is surely increasing since elderly people affected Aim: The aim of this study is to evaluate the effect of Nutraceutical [1] with
from several cardiovascular conditions, with multiple comorbidities (i.e. the Policosanoli, Berberina [4], Red yeast Rise, Cassia Nomame, Astaxantina,
patients that are usually seen in Internal Medicine departments), are often Q10 Co-enzime and folic acid in patients with low to moderate dyslipide-
taking antithrombotic and/or anticoagulant therapy. mia [3], intolerance to statins [8] and Metabolic Syndrome.
Case Report 1: An 89-year-old woman with a history of ischemic heart Methods: We have enrolled 30 patients, with range age 19 – 90 years and
disease (IHD) and grade III-IV chronic renal disease (CKD) was admit- Mean 71 + 19Year, ) that satisfying the NCEP:ATPIII 2001 Criteria for
ted for heart failure and high ventricular response atrial fibrillation (AF). Metabolic Syndrome [5]. All compliant patients were underwent to the
During hospitalization, diuretics, antiarrhythmic and enoxaparin (4000 UI evaluation of Total Cholesterol (T-Chol), Low-Density Lipoprotein (LDL),
bid) were administered. The hospitalization was complicated by hemorrha- High-Density Lipoprotein (HDL), Triglycerides (TG), Heart Rate Variabi-
gic shock from spontaneous retroperitoneal hematoma replenished by a lity [6], T-peak to T-end index [7], QTc value and T-peak-end/QTc ratio,
right lumbar artery. and side effects before and post-administration of standard treatment with
Case Report 2: An 83-year-old man with a history of IV grade CKD, IHD Policosanoli, Berberina [4], Red yeast Rise, Cassia Nomane, Astaxantina,
and AF was admitted for heart failure and moderate range anemia (Hb 8.5 Q10 Co-enzime and folic acid [1].
133
Results: Preliminary data shown a statistically significant change in total dehydration, malnutrition, and infection.
cholesterol (230 mg + 33 mg vs 180 mg + 44 mg with p < 0, 001), Low-den- Case Report: A 71 year-old woman, who had been a professor of Italian
sity of Lipoprotein (155 mg + 44 mg vs 116 mg + 42 mg with p < 0, 001), Language and Literature, Latin and novel writer in her youth, but diagnosed
High-Density Lipoprotein (43 mg + 18 mg vs 49 mg + 18 mg with p < 0, with dementia 5 years before, was admitted to our Dept for sudden crisis of
024) and triglycerides (141 mg + 71 mg vs 124 mg + 70 mg with p < 0, 012) aggressiveness when her husband had tempted at home to steal her a book.
with statistically significant correlation... Her disease had progressed gradually and she seemed in the last months
Conclusions: Nutraceutical [1]could be a new useful approach in the tre- completely nonresponsive frequently refusing her medications and being
atment of patients with Metabolic Syndrome and low or moderate dyslipi- almost totally non-communicative. In spite of her long career of profes-
demia [3] with intolerance to statins [8] and not responsive to non-phar- sor, she said rarely a single word and often it was not appropriate. She was
macological treatment (lifestyle, diet, behavior modification and physical almost immobile rarely rising from her wheelchair in months. It was perfor-
activity) [2]. Our preliminary data gives comfortable results. med a brain CT-scan to determine any possible further anatomical damage
with no any evidence. Thus, we decided to observe the patient’s behaviour
with books and newspapers let her to read them. Two days later we reported
182. FE++ EDTA ADMINISTRATION IN PATIENTS WITH a noticeable improvement. She improved this much that she wanted to get
SECONDARY ANEMIA. EFFECTS ON HEMOGLOBINE up and walk. She was talking some, with more sense, and she was feeding
VALUE, CARDIOVASCULAR RISK AND ADHERENCE TO herself again, she was interactive, reading words in books, asking questions.
THERAPY She was like super relaxed especially after we bring her the adorable books
of Latin and Italian literature. At the end, she came back to her youth, life-
Marchitto N., Sindona F., Fusco L, Dalmaso S., Raimondi G. story and passions…. She became more talkative lately, she seemed to be
1) Dr. Nicola Marchitto, Medical Director, Alfredo Fiorini Hospital, much more aware of her surroundings, she started eating by herself and
Terracina, (Latina), Italy. 2) Dr Francesco Sindona, Specializing Doctor, eating all of her food, her mood was very good and her clinical condition
Dept. Int. Medicine. “Sapienza” University of Rome 3) Fusco Liuba, Medical continued to improve with old memory return and amelioration in motor
Doctor, Cardiology Department, Villa Laura, Bologna. 4) Dr.ssa Serenella function and verbal response.
Dalmaso, Director of ruolo, Alfredo Fiorini Hospital, Terracina, (Latina), Discussion: The AD causes and pathogenesis remain unclear though it
Italy. 5) Prof. Gianfranco Raimondi, Associated Professor of Internal has been hypothesized an infectious or environmental origin, but surely an
Medicine. Dept. of Medico-surgical Sciences and Biotechnologies. “Sapienza” important role is played by deficit of ADAM-10 with consequent amyloid
University of Roma β deposition in the brain and neuritic plaques. In spite of common beliefs
many Alzheimer’s patients find comfort in books. Luckily, reading ability is
Abstract: Anemia is a global problem because two billion of people are not always destroyed in patients with AD. Reading can improve the patient’s
affected by blood cells disorder. According to WHO criteria anemia id quality of life, since the meanings of written sentences can be understood
defined as blood hemoglobin (Hb) concentration < 130 gr/L (13 gr/dl) or by even those who have difficulty handling verbal exchanges. People who
hematocrit (Hct) < 39% in adult males or (Hb) concentration < 120 gr/L (12 were literate maintain their ability to read until the end stages of dementia.
gr/dl) or hematocrit (Hct) < 37% in adult females. In patients with coronary Reading requires the cooperation of several parts of the brain specialized
heart disease, anginal episodes may increase in frequency and severity and in language and seeing with the result to improve also the quality of life of
patients with carotid artery disease may develop light-headedness or dizzi- Alzheimer’s patients!!!
ness. All causes of anemia give impaired of hemoglobin level and red blood
cells value. This hematological problem have an hight impact about quality
of life in older patients in particular if affected of cronic heart failure and or 184. DRGS (DIAGNOSIS RELATED GROUPS) IN MEDICAL
respiratory disease. Therefore anemia evaluation and follow-up is included AREA: CRITICAL ISSUES IN CONTROL SYSTEMS AND
in cardiovascular guidelines. VALUE
Methods: We have enrolled 8 elderly patients (2 males and 6 females, range
age 43 – 97 years) with recent diagnosis of secondary anemia due to iron Scotti E. 1., Pietrantonio F. 2
deficiency and or low-moderate kidney failure. We have evaluated labora- 1
Unità Operativa Medicina Generale, Istituto Neurotraumatologico Italiano
tory value of red blood cell, Hb, and iron blood profile. We have evaluated (INI), Grottaferrata (Roma); 2U.O. Medicina Interna, Ospedale di Manerbio
compliance to therapy using Morinsky Scale and have evaluated the impro- (BS) ASST-Garda
vement of laboratory value and adherence to therapy before and post-admi-
nistration of fe++ 2 cp/24 hours. Background: The method used to evaluate congruity and therefore the
Conclusion: Fe++ EDTA could be a valid alternative to iv therapy (gold remunerability of hospitalizations is the PRUO (Review Protocol of Hospital
standard) in the treatment of secondary anemia in elderly patients. Our pre- Use) method which is a remote and ex-ante control that does not take into
liminary results are comfortable but not applicable to a broad spectrum of account the actual path of the patient with acute symptomatology leading
patients with secondary anemia without an hematological evaluation of the him to Emergency Department (ED) and requiring a diagnostic framework
different causes of anemia. and a series of examinations that will determine only at the end of the path
whether the patient needed or not the hospitalization.
Main issues:
183. AS A CLEVER MIND FIGHTS THE ALZHEIMER’S 1. Risk of inappropriateness. The diseases treated in Internal Medicine Units
DISEASE: MARIA’S HISTORY!!! are the ones most likely to be unsuitable for hospitalization, as they have a
major impact on the ED activity and is the First Aid physician that decides
Piccillo G.A. 1, Saitta R. 1, Mondati E.G.M. 2, Gasbarrini G.B. 3 the admission mainly to the Medical Area to exclude acute illnesses that ED
1
Emergency Department, Cannizzaro Hospital Catania: 2Department of is not able to rule out (for example, atrial fibrillation, syncope, fever, severe
Internal Medicine and Systemic Pathologies, University of Catania; 3Professor anemia, complicated diabetes).
Emeritus of Internal Medicine, Catholic University of Rome 2. End stage disease. The remuneration system does not take into account
the end-stage of neoplastic and non-neoplastic pathologies, and the impact
Background Alzheimer’s disease (AD), first described by German Neurolo- at hospital level and in particular in the Internal Medicine Units.
gist Alois Alzheimer in 1901, is a neurodegenerative disorder of uncertain 3. Epidemiological transition that has resulted in an increase in mean age
cause and pathogenesis which primarily affects older adults. It accounts for and comorbidities that impact heavily on the clinical path, on therapy and
more than 50% of the cases of dementia and is one of the leading sources on the length of stay.
of morbidity and mortality in the aging population. The most essential 4. Progressive dismantling of the National Health System which appears
clinical manifestation of AD is selective memory impairment. While tre- inadequate to respond effectively to the health needs of an aging population
atments are available in order to ameliorate some symptoms of the illness, with comorbidities that survive after repeated acute episodes.
currently there is no cure or disease-modifying therapy, and the disease Characteristics of the remuneration system: iso-resources and non-isoseve-
inevitably progresses in all patients. The incidence and prevalence of AD rity that would allow comorbidities valorization as, in fact, they absorb most
increase exponentially after the age of 65 year, though there are rare inhe- of resources in patients hospitalized in Internal Medicine. Repeated hospi-
rited forms too (about 1%) that present before 65 y. The AD management talizations: they are considered inadequate and penalize Internal Medicine
is still symptomatic: treatment of behavioural disturbances, environmental Units and Internists that are the main specialists taking care of complex
manipulations to support function, and counselling with respect to safety polypathologic patients who are subject to ongoing exacerbations of already
issues. Patients generally succumb to terminal-stage complications, such as diagnosed pathologies.
134
Proposals: Adequate valorization of DRGs by using APR-DRG (All Patient

Refined DRG) taking into account the comorbidity in determining DRG Mattiuzzo E. , Ricevuti G., Venturini L., Rollone M., Guerriero F.,
value. Faruggio L., Ghiazzi J., Libertazzi A., Lorini V., Massarini G., Regina D.
Conclusions: Similarly to the tax system that applies taxation to more easily University Pavia, Dpt of Internal Medicine and Therapeutics, Geriatrics,
controllable citizens such as retired and government employees, patients Pavia, Italy
admitted in Internal Medicine Units being the most numerous and most
sick are also the less valued category of reimbursement system and are Italy, like most of other Western societies is characterised by a progressive
“taxed” by the system with a consequent reduction of resources allocated to increase of average life expectancy. Following an increase in life expectancy,
the Medical Area and subsequent reduced ability to adequately take care of age-related diseases also increase. There is good scientific evidence showing
a growing slice of the population. that the multiple co-morbidities among elderly people are part of a broader
entity called “elderly Frailty”. Such nosological entity Is still being defined, as
there are two schools of thought: the first one considers Frailty as a syndrome,
185. THE ROLE OF SMART CITIES AND COMMUNITIES the second one as a state. During the course of the last years there have been
IN EARLY DETECTION AND PREVENTION OF FRAILTY numerous tests aiming to define the boundaries of this entity by assessing
AND COGNITIVE IMPAIRMENT IN CITIZENS USING each of its different facets. Considered individually, such tests prove useful
UNOBTRUSIVE as diagnostic/prognostic tools. However, they are even more useful when
METHODS:THE EXPERIENCE OF SIX INTERNATIONAL combined, as they describe patients’ clinical condition in a more ample and
METROPOLIS complete way. In fact, Frailty leads elderly people to the likelihood of deve-
loping numerous conditions with a short-term prognosis. This study aims
Ricevuti G. 1, Venturini L.1, Mattiuzzo E. 1, Copelli S. 2, Paolini P. 3, Di Blas N. to assess a sample of geriatric patients at the moment of admission into a
3
, Mercalli F. 2 rehabilitation centre. The purpose was that of identifying fragile patients,
1
University Pavia, Dpt of Internal Medicine and Therapeutics, Geriatrics, and classify them through a Comprehensive Geriatric Assessment (CGA),
Pavia, Italy as well as through a comprehensive individual rehabilitation programme.
2
MultiMed Engineers SRLS, Parma, Italy This was carried out through a series of 7 tests, plus a DXA exam for the Sar-
3
Department of Electronics, Information and Bioengineering Politecnico di copenia (which was calculated using the SMI index). The data collected was
Milano Milan, Italy; 2MultiMed Engineers SRLS, Parma, Italy analysed individually, and later integrated into a graphic radar visualising
frail patients’ clinical characteristics in various areas. Through this study it
City4Age is a project, co-funded by the Horizon 2020 Programme of the was possible to compare tests that are normally used in the typical CGA of
European Commission. It will activate urban Communities to facilitate the Geriatric clinical practice. A concordance was noticed between EFS, GFI,
role of social/health services and of families in dealing with mild cognitive FI, SPPB, PASE, CF in Frailty evaluation. It has been seen that SHARE-FI
impairments and frailty in the elderly population. The challenge is to demon- and Sarcopenia do not agree with the other tests, this is most likely due to
strate that Cities play a pivotal role in the unobtrusive collection of “more the small number of enrolled patients (n= 47). An insufficient number of
data” on individual behaviours, and with “increased frequency”. This can patients does not allow to have a representative population group. The new
then greatly improve the early detection of risks through the timely analysis chance to compare multiple indexes simultaneously through a radar graph
of changes in these behaviours and, finally, the design of effective interven- opens new horizons in the Geriatric CGA: first of all, it is possible to have an
tions for countering these risks.Towards reaching this goal, City4Age acts instrument capable of comparing multiple tests simultaneously in a single
as a bridge between the European Innovation Partnerships (EIP) on Smart graph, making the clinical situation of the frail patient instantly accessible;
Cities and Communities, on the one side, and on Active and Healthy Ageing secondly, the possibility of validating and standardizing an instrument (in
(EIP AHA), on the other side (Participants from both EIP’s are involved terms of the subarea) that takes into account multiple tests at the same time
in City4Age). More precisely City4Age focuses on the following: - Levera- could be a solution to the problem of identifying a diagnostic Gold Standard
ging large amounts of personal data from individuals, collected (through shared by the entire Scientific Community.
new sensing technologies) both at home and public spaces - Managing the
personal data flows following a privacy-aware linked open data paradigm -
Providing basic reasoning and learning mechanisms for different purposes 187. ENDOCARDITIS TEAM: A NECESSARY REALITY
towards: Identifying relevant behaviours of groups or individuals, Detecting
changes that can be correlated with risks of cognitive health and frailty, Barone M. 1, Miceli S. 2, Di Virgilio A. 2, Accoti A. 2, Caroleo B. 2,
Developing ICT based interventions to mitigate these risks, Facilitating the Perticone M. 1, Naty S. 2, Parise M. 1, Perticone F. 1, Sesti G. 1
growth of a sustainable eco-system of services for an elderly-friendly urban 1
Department of Medical and Surgical Sciences. University Magna Graecia
environment. The future outcome that CITY4AGE wants to reach should of Catanzaro. Catanzaro (Italy), 2 Azienda Ospedaliera Mater Domini,
be: - the development of an Integrated IT Infrastructures and Citizen servi- Catanzaro (Italy)
ces in the health sector to evolve towards models of “age-friendly” Cities; -
the underlying factors of frailty, by exploring the association between frailty In December 2016, a 69-year-old man with a depressed mood came to our
and adverse health outcomes in older people - the better prevention and rheumatology center for diffuse joint pain. Clinical examination showed
management of the frailty syndrome and its consequences. The main stra- lower limbs edema and systolic murmur on the mitral valve. An echocardio-
tegy of City4Age is to enhance ICT tools and services that enable smart gram was quickly performed and it showed the presence of vegetations on
cities to detect a wide range of data about individuals’ behaviour, in a the mitral valve and on the aortic valve associated with severe mitral insuf-
unobtrusive manner, in order to identify population at risk, monitor daily ficiency and moderate-severe aortic insufficiency. Therefore, the patient was
life activities of identified users in a smart environment, intervene in case admitted in our Internal Medicine Unit for suspected heart failure caused
a negative change of behaviour that may lead to a deterioration of their by endocarditis. No previous pathology was present in remote pathologi-
cognitive and/or physical conditions. In order to fulfill the above strate- cal history, whereas in the last few months the patient reported a weight
gic objectives, City4Age performs research and innovation work based on loss (about 10 kg), back pain and fever (TC 39 ° C). The objective exami-
the following operational objectives: = Development of an organized set of nation showed the presence of pallor, petechiae on lower limbs, reduction
models and domain knowledge of MCI/Frailty symptoms. = Development of vesicular murmur in the basal regions and splenomegaly. Laboratory
of an application ecosystem based on smart mobile devices (like phones, analyses showed: hemoglobin 6.4 gr / dl; creatinine: 2.28 mg / dl; PCR: 68
watches or other unobtrusive devices) enabling the large scale collection mg / l. The electrocardiogram showed atrial fibrillation with high ventricu-
of personal data in home and city environments. = Setting-up a large scale lar response. A context of hypoxiemic normocapnic respiratory failure was
data management system enabling the real time handling of personal data present in arterial emogasalysis and chest X-ray showed a slight opacity in
flows in a City cloud. = Development of advanced models for the detection the right lung apex and small bibasal pleural effusion. Splenic infarction
of risks relevant for MCI and Frailty = Test the overall approach and the was present at the ultrasound of the spleen, as possible endocarditis embo-
concrete results in 6 Cities (Birmingham UK, Madrid S, Lecce I, Athens G, lization. The patient received therapy with diuretics, heparin, beta-blocker,
Singapore S). = Definition of a general sustainability model for detection oxygen therapy, and blood trasfusion. After performing 3 blood cultures
and intervention, against the risk of mild cognitive impairments and frailty. we started empirical therapy with ceftriaxone and daptomycin, the antibio-
tic dosage was adjusted for renal function and GFR estimated by CKD-EPI
was 28 ml/min/1.73 m2. The cardiac surgeon suggested the execution of a
186. THE ASSESSMENT OF THE FRAILTY IN A GERIATRIC transoesophageal echocardiogram that confirmed the data of the first echo-
REHABILITATION INSTITUTE cardiogram. Blood cultures were all positive for Streptococcus gallolyticus
135
ssp gallolyticus, so we continued antibiotic therapy with ceftriaxone alone. STUDY

In the following days, patient underwent cardiac surgery: replacement
of aortic valve with biological prosthesis, curettage of anterior leaflet and Castellino G., Nikolic D., Chianetta R., Giglio R.V., Adamo A.,
posteromedial commissure of the mitral valve, resection of P2 and repair Patti A.M., Mannina C., Sardo V.A., Galletta R., Bonfiglio A.,
of posterior leaflet. Subsequently, we observed a progressive improvement Citarrella R., Montalto G., Rizzo M.
in clinical conditions. Since numerous studies in literature have shown the Biomedical Department of Internal Medicine and Specialties, University of
association between S. gallolyticus endocarditis and colorectal cancer, we Palermo, Italy
decided to perform a PET / TC examination both to identify others loca-
lizations of embolization and to find an occult colon cancer. PET / TC Background and Aim: A search for alternative therapeutic approaches for
showed an increased metabolism in ascending colon and no other site of dyslipidemia management is increasing. A Bergamot juice derived flavo-
embolization except the spleen. So we performed a colonoscopy but it was noid extract, Bergavit® (Bionap, Italy) contains about 28–30 % of flavonoids
negative. The literature suggests that a colon cancer may develop up to 4 (including naringin, neoeriocitrin, and neohesperidin) and its hypo-cho-
years after the onset of an endocarditis by S.gallolyticus ssp gallolyticus so lesterolemic property is well documented. However, a recent data indica-
we decided to schedule an annual endoscopic follow-up for our patient. In tes on its beneficial effects on subclinical atherosclerosis, reducing carotid
conclusion, we have described a case of endocarditis that required the inter- intima-media thickness (cIMT). We further evaluated whether its effect on
vention of numerous health professionals, highlighting the importance of a different cardio-metabolic parameters, including atherogenic lipoproteins,
multidisciplinary approach to pathology commonly known as Endocarditis could be different in subjects with and without subclinical atherosclerosis
Team. Additionally, in patients with S.gallolyticus infective endocarditis, it is and influenced by baseline value of cIMT.
important to rule out underlying tumor and, in the absence of neoplasia, to Materials and Methods: Bergavit® (Bionap, Italy) was given to 80 subjects
plan the annual endoscopic follow-up. with moderate hypercholesterolemia (LDL-C between 160 and 190 mg / dL)
(42 men and 38 women, age: 55 ± 13) at a dose of 2 pills/day (150 mg of fla-
vonoids) for 6 months. The cohort of patients was subdivided into 2 groups:
188. BERGAMOT IMPROVES THE QUALITY OF 1) those with cIMT ≤0.9 mm (considered as a normal value; n = 23) and 2)
LIPOPROTEIN PROFILE AND SUBCLINICAL those with cIMT> 0.9 mm (considered as an abnormal value, n = 57). The
ATHEROSCLEROSIS EQUALLY IN BOTH OBESE subfractions of LDLs were evaluated by electrophoresis, while cIMTs with
AND NOT OBESE SUBJECTS WITH MODERATE B-mode ultrasound.
HYPERCHOLESTEROLEMIA: A 6-MONTH PROSPECTIVE Results: After 6 months of supplementation, Bergamot reduces the fol-
STUDY lowing parameters in both groups: total cholesterol (from 6.6±0.4 to
5.8±1.2, p=0.0047 and from 6.6±0.4 to 5.7±1.0, p<0.0001, respectively),
Adamo A., Giglio R.V., Chianetta R., Nikolic D., Castellino G., LDL-C (from 4.6±0.1 to 3.8±1.0, p=0.0044 and from 4.5±0.2 to 3.6±0.9,
Patti A.M., Mannina C., Galletta R., Sardo V.A., Citarrella R., p<0.0001, respectively) and triglycerides (from 1.8±0.7 to 1.4±0.6, p=0.0047
Montalto G., Rizzo M. and from 1.8±0.6 to 1.5±0.9, p=0.0365, respectively), whereas HDL-C
Biomedical Department of Internal Medicine and Specialties, University of increased significantly only in subjects with cIMT> 0.9 mm (p=0.0007). In
Palermo, Italy addition, small, dense and more atherogenic LDL-3 particles reduced (from
6.1±4.0 to 3.1±1.2, p<0.0001), while large and less atherogenic LDL-1 par-
Background and Aim: Recent studies have showed that the natural extract ticles increased only in the group with cIMT> 0.9 mm (from 16.5±5.4 to
of bergamot has beneficial effects on the cardiometabolic parameters, inclu- 18.7±5.3, p=0.0004).
ding carotid intima-media thickness (cIMT) and atherogenic lipoproteins. Conclusions: Bergamot flavonoids supplementation significantly reduced
Such favorable effects were mostly attributed to the high amount of flavo- plasma lipids and such effects seem to not be impacted by early, subclini-
noids. The aim of the present study was to evaluate if a bergamot-derived cal atherosclerosis. However, the significant improvements in the quality of
extract could have different effects in obese vs not obese subjects with LDL-C seen only in patients with elevated levels of cIMT at baseline may, at
moderate hypercholesterolemia. Materials and Methods: Eighty subjects least in part, explain further protective effects of bergamot in these subjects.
(man 42 and women 38, mean age 55±13) with moderate hypercholeste- Whether this finding may be associated with cardiovascular prevention
rolemia (LDL between 160 and 190 mg/dl) were included in the present remains to be established by future studies.
study. Bergamot-derived extract (Bergavit®, Italy) was given at a dose of 2
pills daily (150mg of flavonoids) for 6 months. The cohort of patients was
subdivided in 2 groups: 1) Patients with BMI ≥30, Obese Group (O. Group, 190. SEVERE ARTERIAL HYPOTENSION IN PATIENT
n=29); and 2) Patients with BMI ≤30, Non Obese Group (N.O. Group, WITH SYNCOPE
n=51). Lipoprotein subfractions were assessed by gel electrophoresis (Lipo-
print, USA). With this methodology low density lipoprotein (LDL) are Cavallo M., Fornasiero A., Pujatti P.L. 1, Cecchetto M. 1, Minuz P. 2,
distributed in seven bands: LDL 1 and 2 as large LDL, and LDL 3 to 7 as Paluani F. 2, Fondrieschi L. 2, Fabrizi G.M. 3, Barbieri F. 3
small and dense LDL. Subclinical atherosclerosis was evaluated by cIMT 1
Lonigo Hospital Long-Term Care Department, Arzignano Hospital Internal
using B-mode ultrasound. Medicine, 2 Internal Medicine C., 3 Neurology of Verona Polyclinic
Results: After 6 months, in both groups, O. and N.O., bergamot-derived
extract reduced total cholesterol (from 6.7±0.5 to 5.8±1.2, p=0.0008 and Background: We describe a case of a man 65 years oldwith syncope with
from 6.5±0.3 to 5.7±1.0, p 0.0001, respectively) and LDL-C (from 4.5±0.2 trauma falling to the ground. Arrived in our Hospital Emergency Care
to 3.6±1.0, p=0.0002 and from 4.6±0-2 to 3.7±0.9, p 0.0001, respectively). he presented: severe orthostatic hypotension (values lower than 50/30
A statistical significance reduction of triglycerides was seen only in N.O. mm Hg), atrial paroxysmal fibrillation disappeared spontaneously, systo-
Group (from 1.8±0.7 to 1.4±0.5, p=0.0020). The LDL-3, small, dense and lic overload in hypertensive heart disease with ejection fraction reduced,
more atherogenic particles, decreased in both O and N.O. groups (from radiological signs of previous ischemic stroke, hyperkalemia in chronic
6.2±0.4 to 4.4±0.2, p=0.0171 and from 5.6±3.0 to 2.8±1.0, p 0.0001, respecti- renal failure. The clinical patient pathway was characterized by subsequent
vely), while LDL-1, large and less atherogenic particles increased only in hospitalization in Internal Medicine Department.Physiological History
N.O. subjects (from 17.0±5.0 to 19.1±4.4, p=0.0002). Bergavit® also reduced tells of smoking, alcoholic dependence, erectile dysfunction, occupational
cIMT in both groups (from 1.2±0.4 to 0.9±0.1, p=0.0110 and from 1.2±0.4 exposure to aromatic amines.Remote Pathological History tells of cervical
to 0.9±0.1, p 0.0001, respectively). arthrosis, surgery for pyloric piercing ulceration.Next Pathological History
Conclusions: A six-month supplementation with Bergamot provided a tells of previous lipotymes slowly ingrowing to the loss of consciousness.
positive cardio-metabolic control, reducing cIMT and atherogenic lipopro- Instrumental and biomorphological findings shows: a) basilar vertebral
teins in both obese and non-obese subjects. Consequently, Bergavit® may insufficiency with left vertebral artery root loop, ectasia of the posterior
represent a valid, alternative therapeutic approach in dyslipidemic subjects connective artery, filiform the posterior connective arteries, b)severe cer-
preventing and/or reducing overall cardiometabolic risk. vical spondylodiscoarthrosis with narrow cervical spinal canal, c) alcoholic
hepatitis, d) peripheral neuropathic damage, e) double renal kidney region
with 50% renal artery stenosis, f) clinostatism arterial hypertension grade
189. BERGAMOT REDUCES ATHEROGENIC 2 with non-dipper profile and severe orthostatic hypotension without
LIPOPROTEIN SUBCLASSES IN DYSLIPIDEMIC SUBJECTS reflected tachycardia, g) hypertrophic hypertensive heart disease, FE 50%,
WITH ELEVATED BASELINE VALUE OF CAROTID mild diffuse hypocynaemia, altered diastolic release. There was a severe
INTIMA-MEDIA THICKNESS: A 6-MONTH PROSPECTIVE mixed autonomic deficiency with secondary adrenal dysfunction: adrena-
136
line at the lower limits of standard adrenaline 12 nmol / mol / 24 hours patients with only hypertension, dolico arteriopathies (112 pz.-12%) were
(vn 5-110), noradrenaline below the lower limits of standard 24 Nmol / 24 divided by age in this way:6(5%) younger than 50, 13 (12%) were 51-60
hours (vn 40-600), aldosterone in orthostatism 185 pmol / l (vn.61.2-977.8), years old, 13 (12%) 61-70 years old, 56 (50%) 71-80 years old, 24 (21%) older
aldosterone clinostatism 124 pmol / l (vn 32.4-653.7), orthostatic renin than 81; similarly they were divided by gender in this way:50 males (45%),
2.7 mUI / l (v.4.4- 46.1) and clinostatism 1.5 mUI / l (vn. 2.8-39.9) lower 61 females (55%). In patients with also others cardiometabolic risk factors
than normal values, absent circadian cortisol curve change. Even the value dolico arteriopathies 249 pz. (27%) were divided by age in this way: 9 (5%)
of Testosterone 3.37 mcg / ml, beta 2 microglobulin (vm. 3-4 mcg / ml), younger than 50, 17 (7%) were 51-60 years old, 84 (33%) 61-70 years old, 81
autoantibody test, togheter with onconeuronals antibodies and adrenergic (32%) 71-80 years old, 58 (23%) older than 81; similarly they were divide by
antibodies were in the normal range, on the other side acetylcholine antibo- gender in this way: males 173 (48%), females 188 (52%). Discussion:Carotid
dywas absent, transthyretin was negative. We find deficiency of vitamin D dolico arteriopathies (1) etiology is to date matter of discussion. Carotid
5.3g / ml (14-42 ng / ml), glucouse intolerance (Hba1c 32 (vn 20-42 mmol district seems to be prevalent among dolico arteriopathies (2), they may
/ mol, glycemic curve with altered blood glucose).Specialist visits show cause cerebrovascular diseases during rotating head movements with tem-
angiology evaluation: severe femoral venous insufficiency, with phleboge- porarily carotid blocking (3). They are correlated to several neurological
nic microangiopathy and cutaneous polyangiosis;neurological evaluation: complications (vertigo, tinnitus, syncope, TIA, stroke, embolisms from
absent deficiency of sensitive nerve endings, no extrapyramidal signs; car- atheromatous plaques, aneurysms) (4). We must remember that hyperten-
diological evaluation:bradycardia in orthostatism.Clinical outcomes: The sion may damage wall artery vessel because of the share stress by blood flow
patient initially had a beneficial effect about tiredness with therapy based on turbolence with oxidative action on the endothelium, reduction of the tone
methylprednisolone, followed by chronic therapy with fluoridrocortisone, of elastic lamina, stretching of the muscle layer: all this explains how hyper-
midodrine, captopril for the night hours, and monocollant 1° to be used tension, together with neck muscles hypotrophy, can stretch carotid axis (5)
in orthostatism; in the following period the disabling autonomic pathology and may cause secondary and irreversible dislocation of its course (6). Dia-
was not responsive to fluoridrocortisone therapy and methylprednisolone betes, dyslipidaemia, smoking, and obesity can also affect, in a different way,
pains with need of repetitive intravenous Ig cycles therapy. Sudden cardio- the carotid course modifying blood vessel wall structure, conformation and
genic death followed. functionality (7). Even fibromuscolar dysplasia may cause in a lesser way
Discussion: Clinical pictures with autonomic disorders (sensory and neuro- carotid course alterations (8). Furthermore there are other minor causes
motor disorders) occur with subacute episodes without any previous symp- of carotid course alteration among which otolaryngological intervenctions
tomatic manifestation of illness. The disautonomia caused by post-ganglionic and traumatic events (9).
sympathetic injuries are considered difficult to be treated therapeutically due Conclusion: Hypertension plays a significant and peculiar role in carotid
to direct axonal lesions of the nerve fibers that control the neuro-cardiogenic dolico arteriopathies development. The pharmacological control of hyper-
function (1). In our clinical case, the concomitant neuropathy of the small tension throughout life can prevent carotid course alterations and correlated
nerve fibers evaluates the hypothesis of autonomic neuropathy with direct cerebrovascular diseases. A good management of other cardiometabolic risk
expression on control of pressure and heart rate. There are cases of patients factors should also be garanteed.
with postural tachycardia syndromes due to alterations in normal autonomic Bibliografia: 1) Weibel J., e Fields WS. Neuroradiology 1965; 15: 7-18. 2)
control (2). In contrast, there are also cases of patients with very serious arte- Desai B., Toole JF. Stroke 1975; 6: 649-656. 3) Christodoulos S.e al.: Cir-
rial blood pressure disorders related to auto-immune ganglionic peripheral culation 1995; 91: 2669-2678. 4) Aleksic M., Schutz G. e al.: J. Cardiova-
neuronal damage (Sjogren syndrome, mixed connective tissue, LES, etc.), scular Surg.2004; 45: 43-48. 5) Pancera P., Ribul M., Presciuttini B., Lechi
amyloidosis and also lymphoproliferative diseases (3). The severity of clinical A.J.of Internal Medicine 2000; 248:7-12. 6) Del Corso L., Moruzzo D., Conte
autonomic desensitivations can go from neurocardiovascular disorders (heart P.e al.Angiology 1998; 49: 361-371. 7)Sacco S., Totaro R., Baldassarre M.,
rate changes, hypo / hypertension) to severe heart rhythm disorders with Carolei A. Int. J. Angiology 2007;16(2):59-61. 8) Begelman SM., Olin JW.
reduced heart failure, syncope and sometimes fatal collapse (4). Curr Opin.Rheumatol 2000; 12: 7-41. 9) Paulsen F., Tillman B.e al.: J.Ana-
Conclusions: The most rooted hypothesis about the clinical picture descri- tomy 2000; 197: 373-381.
bed by the patient may be a severe orthostatic arterial hypotension based
on a seronegative autoimmune ganglionopathic form that, in most patients,
find a beneficial effect in immunoglobulin indovenous therapy for repea- 192. PREDICTING THE QUALITY OF ANTICOAGULATION
ted cycles. If this therapy is not effective, you might use steroid drugs and, CONTROL IN ATRIAL FIBRILLATION: PRELIMINARY
as a last resort, plasmapheresis in the most complicated patients:.Referen- DATA ON THE VALIDATION OF THE SAME-TT2R2 SCORE
ces: 1) Akihiro u., Kunihiko A. et al.: Acute autonomic sensory and motor IN AN ITALIAN COHORT
neuropathy: successful treatment with iv Ig. Internal Medicine 48: 843-846,
2009. 2) Blair P. Grubb: Postural tachycardia syndrome.Circulation 117: Cheli P. 1, Proietti M. 2, Lip G.Y.H. 2, Ferri C. 1
2814-2817, 2008.3) Edelman J., Gubbay SS.: Acute pandysautonomia due 1
Department of Life, Health and Environmental Sciences, University
to mixed connective tissue disease. Aust NZ. J. Med. 11: 68-70, 1981.4) of L’Aquila, L’Aquila, Italy; 1University of Birmingham, Institute of
Vernino S., Phillip A.: Experimental autoimmune autonomic neuropathy. J. Cardiovascular Sciences, Birmingham, United Kingdom.
Neurophysiol 90: 2053-2059, 2003.
Background: Despite the Introduction: of non-vitamin K oral anticoagu-
lants (NOACs), vitamin K antagonists (VKAs) still play a relevant role in
191. HYPERTENSION AS A RISK FACTOR OF CAROTID the treatment of atrial fibrillation (AF) patients. Both efficacy and safety of
DOLICO ARTERIOPATHIES VKA are strictly dependent on the quality of anticoagulation as measured
by time in therapeutic range (TTR). TTR measured by Rosendaal’s linear
Cavallo M., Fornasiero A. interpolation has been proved to be effective in determining the quality
U.o.s.d. Lungodegenza O.C. Lonigo, Dipartimento Scienze Mediche e of anticoagulation control and strongly associated with outcomes. In this
Riabilitative, Ulss8 Berica, Vicenza contest, predicting the TTR is crucial. With this purpose, the SAMe-TT2R2
score has been developed in 2013 as a manageable tool to predict quality of
Background:This study highlight a correlation between carotid dolico anticoagulation control in patients undergoing VKA treatment in order to
arteriopathies and hypertension, unique or associated cardiometabolic assist physicians in decision-making process between VKAs and NOACs.
risk factor.Materials and Methods:We studied, in our Angiology Hospi- Objective: The aim of this study was to evaluate the SAMe-TT2R2 score in a
tal Outpatient Clinic, 906 patients (429 (47%) females, 477 (53%)males). single-center Italian cohort of non-valvular AF patients on VKA treatment.
Patients were between 50(but even less) and 81(but even more) years old. Methods: A cohort of consecutive patients with non-valvular AF on VKA
Among them 58(6%) were less than 50 years old, 108 (12%) were 51-60 therapy attending the Anticoagulation Services at San Salvatore Hospital
years old, 277 (31%) 61-70 years old, 281 (31%) 71-80 years old, 182 (20%) (L’Aquila, Abruzzo, Italy) between January and May 2017 was included.
older than 81 years old. Patient were examined with Ecocolordoppler Patients with target INR range rather than 2.0-3.0 were excluded from the
Toshiba Aplio XG with 7.5 MHz and 3.5 MHz probe. study. Baseline demographic and clinical characteristics were collected.
Results:We found dolico arteriopathies in 361 patients (39.8%) compared The quality of anticoagulation control was reported as TTR by Rosenda-
to carotid atheromatous diseases in 545 patients (60, 2%). Dolico arterio- al’s linear interpolation. Baseline thromboembolic risk was evaluated by the
pathies, namely carotid course alterations, were seen as 154 (33.11%) tor-
CHA2DS2-VASc score. Likewise, baseline bleeding risk was calculated by
tuosity, 113(24.3%) coiling, 198 (43%) kinking. Among 361 (39%) carotid
dolico arterio-pathies:112 (12%) were found in patients with only hyperten- using the HAS-BLED scoring system. The baseline SAMe-TT2R2 score was
sion, 249 (27%) in patients with also others cardiometabolic risk factors. In calculated for each patient. The study population was divided into two cate-
137
gories: patients with the SAMe-TT2R2 score 0-2 who were more likely to significant, with p < 0.001.
achieve a good TTR and patients with the SAMe-TT2R2 score >2 who were Analysis of Results: When applied to the 30 patients, the Student’s “t”
more likely to have a suboptimal anticoagulation control. test revealed a highly significant correlation (p < 0.001) between the two
Results: The cohort included 215 patients diagnosed with non-valvular AF, variables examined (pre-lysis values of Troponin and PES Index), which,
all Caucasian and receiving VKAs for stroke prevention. The overall mean therefore, could not be attributed to chance. In fact, the value of “t” obtained
(SD) age was 74.3 (10) years and 131 (60.9%) were females. Permanent AF was 15.01 and the CV (critical value) of “t” for p=0.001 was 3.659, with DF
was the most prevalent AF type (73%) and warfarin was the most used VKA = 29.
(99.1%). Hypertension was the most prevalent comorbidity (199 patients, Discussion: The data obtained suggests that in the 30 patients enrolled in
92.6%). 98.1% of the study population was VKA- naïve at the time of AF dia- the “TROPESI” study, the covariation of values of pre-lysis Troponin values
gnosis. The median CHA2DS2-VASC score was 4 [IQR 3-5] and the overall and pre-lysis PES Index values expressed a highly significant difference,
median HAS-BLED score was 1 [IQR 1-2]. 165 (76.7%) patients were cate- whose clinical significance laid in the overload of right-sided sections of
the heart, the presence of elevated blood pressure regimes caused by the
gorized as SAMe-TT2R2 score 0-2. The median TTR was 66.3% [IQR 53.0- background of pulmonary embolism, which was assessed using the pre-lysis
77.1]. 87 patients (59.5%) had a TTR >70 %. The median SAMe-TT2R2 PES Index, which followed an improvised decrease in blood flow to left-si-
score was 2 [IQR 1-2]. TTR values progressively decreased with increasing ded cardiac sections and coronaric hypo-perfusion with elevated Troponin
SAMe-TT2R2 score points (p<0.001). Patients with SAMe-TT2R2 >2 had values.
a significantly lower median TTR value compared to patients with SAMe- Conclusions: The “TROPESI” study showed that within this group of 30
TT2R2 0-2 (TTR 71.3% and TTR 49.0% respectively, p<0.001). Linear patients with venous thrombo-embolism (central pulmonary embolisms)
regression analysis showed that SAMe-TT2R2 was inversely associated there was a highly significant correlation between the two variables conside-
with TTR (standardized beta: - 0.673; t: -12.377; p<0.001) with a linear rela- red: the pre-lysis Troponin values and the pre-lysis PES Index. This correla-
tionship between the score and TTR. Logistic regression analysis, adjusted tion showed an absolute positive correlation under comparative Student “t”
for type of AF, age, sex and eGFR between SAMe-TT2R2 groups and TTR test analysis, and expressed not a random association, but a close correlation
between the pre-lysis Troponin values and those of the pre-lysis PES Index
levels found that the SAMe-TT2R2 was inversely associated with all TTR in 30 patients with a central pulmonary embolism. When compared to
levels (all p< 0.001 for TTR <60%, TTR<65% and TTR >70%). experiences in literature, the “TROPESI” study offers data that supplements
Conclusions: In this preliminary analysis, the SAMe-TT2R2 score was that provided by the study of Plasek, Nordenholz, Choi, Aujeszky and Ozsu.
found to be effective in predicting the quality of anticoagulation control in
our cohort of Italian non-valvular AF patients on VKAs with TTR values
progressively decreasing at increasing of SAMe-TT2R2 score points. More- 194. CORRELATIONS: TROPONIN-PEINDEX. “TROPEI”
over, a low SAMe-TT2R2 score (0-2) was proved to be strongly predictive STUDY: A COMPARATIVE ANALYSIS WITH STUDENT
of TTR >70%. Further data are still needed to validate this tool in larger TEST OF CONTINUOUS VARIABLES IN 30 PATIENTS
cohorts. WITH VENOUS THROMBOEMBOLISM. THREE-YEAR
EXPERIENCE (2014-2016)
193. CORRELATIONS: TROPONIN-PESINDEX. “TROPESI” Ciancio L., Ciammaichella M.M., Mida R., Ulissi A.
STUDY: A COMPARATIVE ANALYSIS WITH STUDENT Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
TEST OF CONTINUOUS VARIABLES IN 30 PATIENTS
WITH VENOUS THROMBOEMBOLISM. THREE-YEAR Introduction: The “TROPEI” study - an acronym derived from the letters
EXPERIENCE (2014-2016) “TROPonin - pulmonary Embolism Index”, enrolled 30 patients, aged
between 48 and 82 years with venous thromboembolism (central pulmo-
Maida R., Ulissi A., Ciammaichella M.M. nary embolism) who were hospitalized in the “Emergency Medicine” Unit
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma during the period January 2014-December 2016. In all patients, clinical
onset was characterized by severe respiratory failure (arterial blood gas
Introduction: The “TROPESI” study - an acronym derived from the letters pO2 < 60 mm Hg) associated with syncope, chest pain, confusion, hae-
“TROPonin - pulmonary Embolism Severity Index”, enrolled 30 patients, modynamic instability (SBP < 90 mm Hg). All patients were subjected
aged between 48 and 82 years with venous thromboembolism (central pul- to CT CAP and pelvis with a contrast medium; pulmonary angiography
monary embolisms), who were hospitalized in the “Emergency Medicine” with loco-regional fibrinolysis in combination with heparin sodium, in a
Unit during the 3-year period January 2014-December 2016. In all of the peripheral vein, combined with mechanical thrombectomy. In all patients,
patients, clinical onset was characterized by severe respiratory failure (arte- the Pulmonary Embolism Index and the Troponin values were measured
rial blood gas analysis values of pO2 < 60 mm Hg) associated with syncope, pre-lysis. A comparative analysis was performed for continuous variables
chest pain, confusion and haemodynamic instability (SBP < 90 mm Hg). with the Student “T” parametric test to see if there was a significant rela-
All patients were subjected to CT CAP and pelvis with contrast medium; tionship between pre-lysis values of Troponin and the pre-lysis PEIndex.
pulmonary angiography with loco-regional fibrinolysis in combination PURPOSE OF STUDY: The “TROPEI” study pursued the following
with heparin sodium, i.v. into a peripheral vein, combined with mechani- objectives: to verify any relationships between values of the pre-lysis Tro-
cal thrombectomy. In all patients, the Pulmonary Embolism Severity Index ponin values and pre-lysis PEIndex in 30 patients who were enrolled in
(PESI) and Troponin values were measured pre-lysis. A comparative analy- the “TROPEI” study in the three-year period from January 2014 - Decem-
sis was performed for continuous variables using the parametric Student ber 2016; to check the statistical significance observed by applying the
“t” test to see if there was a significant relationship between pre-lysis values Student ‘t’ test as a bench-marking test for continuous variables, to deter-
of the Troponin and the pre-lysis PES Index. PURPOSE OF STUDY: The mine whether the relationships between the variables considered were due
“TROPESI” study pursued the following objectives: to verify possible rela- to chance.
tionships between values of the pre-lysis Troponin values and pre-lysis PES Materials and Methods: In 30 patients enrolled with central pulmonary
Index in 30 patients who had been enrolled in the “TROPESI” study in the embolism, the values of the pre-lysis Troponin values were compared to
three-year period from January 2014 - December 2016; to check the statisti- values of pre-lysis PEIndex in the same 30 patients. The test therefore cal-
cal significance observed using the Student ‘t’ test as a bench-marking test culated the relative value (VR) of the index “t” to associate with the diffe-
for continuous variables, to determine whether the relationships between rence found, according to the following formula: t = (M1-M2)/√DS122 /N1
the variables under consideration were due to chance. + DS22 /N2. Thus the value of “t” obtained with Degrees of Freedom (DF)
Materials and Methods: In the 30 patients enrolled with central pulmonary = 29, was 3.65. The Critical Value (CV) of “t” is 3.659 with D.F. = 29 for p
embolism, the values of the pre-lysis Troponin values were compared with = 0.001, the Relative Value (RV) of “t” is equal to 4.76 and expresses a posi-
pre-lysis PES Index values. The test therefore calculated the relative value tive agreement of co-variation between absolute values of the two variables
(RV) of the index “t” to associate with the difference found, according to being considered (pre-lysis Troponin values and pre-lysis PEIndex) which
the following formula: t = (M1-M2)/√DS122 /N1 + DS22 /N2. In this way, is highly significant with p < 0.001. ANALYSIS OF
the “t” value obtained with Degrees of Freedom (DF) = 29 was 15.01. The Results: When applied to the 30 patients, the Student’s “t” test revealed
Critical Value (CV) of “t” was 3.659 with D.F. = 29 for p = 0.001, the Relative a highly significant correlation (p <0.001) of the two variables examined
Value (RV) of “t” was equal to 15.01 and expressed positive agreement of (pre-lysis values of Troponin and PEIndex) which therefore could not be
co-variation between the absolute values of the two variables being consi- attributed to chance. The value of “t” obtained was in fact 4.76 and the CV
dered (pre-lysis Troponin values and pre-lysis PES Index) which is highly (critical value) of “t” for p=0.001 was 3.659 with a GL=29.
138
Discussion: The data obtained suggests that the inverse covariation of the pre-lysis Miller Score, which occured after a sudden decrease in blood
values of the pre-lysis Troponin values and pre-lysis PEIndex values in the flow to left-sided cardiac sections and coronaric hypoperfusion.
30 patients enrolled in the “TROPEI” study” expressed a highly significant Conclusions: The “TROPLER” study showed that within this group of
difference, whose clinical significance lies in the overload of right sided 30 patients with venous thrombo-embolism (central pulmonary emboli-
sections of the heart, in the presence of elevated blood pressure regimes sms) there was a highly significant correlation between the two variables
caused by the CT background of pulmonary embolism, evaluated using the considered: the pre-lysis Troponin values and the pre-lysis Miller Score.
pre-lysis PEIndex, which followed an improvised decrease in blood flow to This correlation showed an absolute positive correlation according to the
left-sided cardiac sections and coronaric hypoperfusion. Student “t” test for comparative analysis, and did not express a random
Conclusions: The “TROPEI” study showed that within this group of 30 association, but rather a close correlation between the pre-lysis Troponin
patients with venous thrombo-embolism (central pulmonary embolism) values and those of the pre-lysis Miller Score in 30 patients with a central
there was a highly significant correlation between the two variables consi- pulmonary embolism. When compared to experiments in the literature,
dered: the pre-lysis Troponin values and the pre-lysis PEIndex. This correla- the “TROPLER” study provides data that supplements those already pro-
tion showed an absolute positive correlation under the comparative Student vided by the studies of Plasek, Nordenholz, Choi, Aujeszky and Ozsu.
“t” test analysis, and expressed not a random association, but a close correla-
tion between pre-lysis Troponin values and those of the pre-lysis PEIndex in
30 patients with a central pulmonary embolism. Compared with experien- 196. CORRELATIONS: TROPONIN-TAPSE. “TRAPSE”
ces in the literature, the “TROPEI” study provides data that supplements STUDY: A COMPARATIVE ANALYSIS WITH STUDENT
those already provided by the studies of Plasek, Qanadli, Nural, Ghamima, TEST OF CONTINUOUS VARIABLES IN 30 PATIENTS
Pech.and Ozsu. WITH VENOUS THROMBOEMBOLISM. THREE-YEAR
EXPERIENCE (2014-2016)
195. CORRELATIONS: TROPONIN-MILLER SCORE. Marzano M.A., Ciammaichella M.M., Maida R., Ulissi A.
“TROPLER” STUDY: A COMPARATIVE ANALYSIS WITH Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
STUDENT TEST OF CONTINUOUS VARIABLES IN 30
PATIENTS WITH VENOUS THROMBOEMBOLISM. Introduction: The “TROPSE” study - an acronym derived from “TRO-
THREE-YEAR EXPERIENCE (2014-2016) ponin – tricuspidal anular Plane Systolic Excursion”, recruited 30 patients
aged between 48 and 82 years with venous thrombo-embolism (central pul-
Ciammaichella M.M., Maida R., Ulissi A. monary embolism) who were admitted to the “Emergency Medicine” Unit
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma during the three year period from January 2014 to December 2016. In all
patients, clinical onset was characterised by severe respiratory failure (arte-
Introduction: The “TROPLER” study - an acronym derived from the letters rial blood gas analysis of pO2 < 60mmHg) associated with syncope, chest
“TROPonin – milLEr scoRe”, recruited 30 patients aged between 48 and 82 pain, confused state and haemodynamic instability (SAP < 90 mmHg). All
years with venous thrombo-embolism (central pulmonary embolism) who patients underwent: CT scan of the chest, abdomen and pelvis with con-
were admitted to the “Emergency Medicine” Unit during the three year trast medium; pulmonary angiography with loco-regional fibrinolysis in
period from January 2014 to December 2016. In all patients, clinical onset combination with heparin sodium IV into a peripheral vein, combined
was characterised by severe respiratory failure (arterial blood gas analysis of with mechanical thrombectomy. In all patients, the Tricuspidal Anular
pO2 < 60mmHg) associated with syncope, chest pain, confused state and Plane Systolic Excursion (TAPSE VN> 2 cm) and the Troponin values were
haemodynamic instability (SAP < 90 mmHg). All patients underwent: CT measured pre-lysis. A comparative analysis was performed for continuous
scan of the chest, abdomen and pelvis with contrast medium; pulmonary variables using the parametric Student “t” test to see if there was a signifi-
angiography with loco-regional fibrinolysis in combination with heparin cant relationship between pre-lysis values of the Troponin I and the pre-lysis
sodium IV into a peripheral vein, combined with mechanical thrombec- TAPSE.
tomy. In all patients, the angiographic Miller score and the Troponin values Purpose of Study: The “TROPSE” study pursued the following objectives:
were measured pre-lysis. A comparative analysis was performed for conti- to verify any relationships between pre-lysis values of the Troponin and
nuous variables using the parametric Student “t” test to see if there was a TAPSE in 30 patients who were enrolled in the “TROPSE” study during
significant relationship between pre-lysis values of the Troponin values and the three-years from January 201$ - December 2016; to check the statistical
the pre-lysis Miller Score. PURPOSE OF STUDY: The “TROPLER” study significance observed by applying the Student ‘t’ test as a bench-marking
pursued the following objectives: to verify possible relationships between test for continuous variables, and to determine whether the relationships
values of the pre-lysis Troponin and pre-lysis Miller Score in 30 patients between the variables being considered were due to chance.
who were enrolled in the “TROPLER” study in the three-year period from Materials and Methods: In 30 patients enrolled with central pulmonary
January 2014 - December 2016; to verify the statistical significance obser- embolism, the values of the pre-lysis Troponin were compared with pre-ly-
ved using the Student ‘t’ test as a comparative analysis test for continuous sis TAPSE values in the same 30 enrolled patients. The test therefore calcu-
variables, to determine whether the relationships between the variables lated the relative value (RV) of the index “t” which is equal to the difference
under consideration were due to chance. found, according to the following formula: t = (M1-M2)/√DS12/N1 + DS22
Materials and Methods: In the 30 patients enrolled with central pulmonary /N2. In this way, the “t” value obtained was 10, 96 with Degrees of Freedom
embolism, the values of the pre-lysis Troponin values were compared with (DF) = 29. The Critical Value (CV) of “t” was 3.659 with DF = 29 for p
pre-lysis Miller Score values. The test therefore calculated the relative value = 0.001, the Relative Value (RV) of “t” was equal to 10.96 and expressed
(RV) of the index “t” which is equal to the difference found, according to the positive agreement of co-variation between the absolute values of the two
following formula: t = (M1-M2)/√DS12/N1 + DS22 /N2. In this way, the “t” variables being considered (pre-lysis Troponin values and pre-lysis TAPSE)
value obtained was 28.48 with Degrees of Freedom (DF) = 29. The Critical which is highly significant, with p < 0.001.
Value (CV) of “t” was 3.659 with DF = 29 for p = 0.001, the Relative Value Analysis of Results: When applied to the 30 patients, the Student’s “t”
(RV) of “t” was equal to 28.48 and expressed an absolute positive agreement test revealed a highly significant correlation (p < 0.001) between the two
of co-variation between the values of the two variables under consideration variables examined (pre-lysis values of Troponin and TAPSE), which the-
(pre-lysis Troponin values and pre-lysis Miller Score) which is highly signi- refore could not be attributed to chance. In fact, the value of “t” is obtained
ficant, with p < 0.001. of10, 96 and the CV (critical value) of “t” for p = 0.001 is 3.659 with GL = 29.
Analysis of Results: When applied to the 30 patients, the Student’s “t” Discussion: The data obtained suggests that the inverse co-variation of
test revealed a highly significant correlation (p < 0.001) between the two pre-lysis Troponin values and pre-lysis TAPSE values in the 30 patients
variables examined (pre-lysis values of Troponin and Miller Score), which enrolled in the “TROPSE” study, expressed a highly significant difference,
therefore could not be attributed to chance. The value of “t” obtained is in whose clinical significance lies in the overload of right-sided sections of
fact 28.48 and the CV (critical value) of “t” for p = 0.001 is 3.659 with DF the heart, in the presence of elevated blood pressure regimes caused by the
= 29. background of pulmonary embolism, evaluated using the pre-lysis TAPSE,
Discussion:: The data obtained suggests that in the 30 patients enrolled in which followed an improvised decrease in blood flow to left-sided cardiac
the “TROPLER” study, the inverse covariation of values of pre-lysis Tro- sections and cardiac hypoperfusion.
ponin and pre-lysis Miller Score values expressed a highly significant dif- Conclusions: The “TROPSE” study showed that within the group of 30
ference, whose clinical significance lies in the overload of the right-sided patients with venous thrombo-embolism (central pulmonary embolism)
sections of the heart, in the presence of elevated blood pressure caused by there was a highly significant correlation between the two variables conside-
the patients’ background of pulmonary embolism, which was assessed using red: the pre-lysis Troponin values and the pre-lysis TAPSE. This correlation
139
showed an absolute positive correlation under comparative Student “t” test central pulmonary embolism. By comparing experiences in the literature, the
analysis, and expressed not a random association, but a close correlation “TROPIDE” study offers data that supplements that provided by the studies
between the pre-lysis Troponin values and those of the pre-lysis TAPSE of Plasek, Sudoh, Holmes, Levin, Yoshimura, Yasue, Cotance, Dentali, Gutte,
Index in 30 patients with a central pulmonary embolism. When compared Andresen, Wang, Dores, Pasha and Ozsu.
to experiments in the literature, the “TROPSE” study provides data that sup-
plements those already provided by the studies of Plasek, Calcutteea, Yang,
Lopez-Candales, Zanobetti and Ozsu. 198. CORRELATIONS: TROPONIN-PAPS. “TRAPS”
STUDY: A COMPARATIVE ANALYSIS WITH STUDENT
197. CORRELATIONS: TROPONIN-BNP. “TROPIDE” WITH VENOUS THROMBOEMBOLISM. THREE-YEAR
STUDY: A COMPARATIVE ANALYSIS WITH STUDENT EXPERIENCE (2014-2016)
WITH VENOUS THROMBOEMBOLISM. THREE-YEAR Puglisi L., Ciammaichella M.M., Maida R., Ulissi A.
EXPERIENCE (2014-2016) Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
De Paola G., Ciammaichella M.M., Maida R., Ulissi A. Introduction: The “TRAPS” study - an acronym derived from “TRoponin -
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma systolic pulmonary Artery PreSsure, ” enlisted 30 patients aged between 48
and 82 years with venous thromboembolism (central pulmonary embolism)
Introduction: The “TROPIDE” study - an acronym derived from the letters who were admitted to the “Emergency Medicine” Unit during the period
“TROPonin - brain natriuretic peptIDE”, enrolled 30 patients aged between from January 2014 to December 2016. In all patients, clinical onset was cha-
48 and 82 years with venous thrombo-embolism (central pulmonary embo- racterised by severe respiratory failure (arterial blood gas analysis of pO2 <
lism) who were admitted to the “Emergency Medicine” Unit during the 60mmHg) associated with syncope, chest pain, confused state and haemo-
period January 2014-December 2016. In all patients, clinical onset was cha- dynamic instability (SBP < 90mmHg). All patients were subjected to a: CT
racterized by severe respiratory failure (arterial blood gas analysis of pO2 < scan of the chest, abdomen and pelvis with contrast medium; pulmonary
60 mm Hg) associated with syncope, chest pain, confusion, haemodynamic angiography with loco-regional fibrinolysis in combination with heparin
instability (SBP < 90 mm Hg). All patients were subjected to CT CAP and sodium IV into a peripheral vein, associated with mechanical thrombec-
pelvis with a contrast medium; pulmonary angiography with loco-regio- tomy. In all patients, the pre-lysis systolic pressure (sPAP) of the pulmonary
nal fibrinolysis in combination with heparin sodium, in a peripheral vein, artery was measured according to the formula in mmHg as measured with
combined with mechanical thrombectomy. In all patients, the pre-lysis BNP doppler: 4XTR 2 + RAP, where TRV is the speed of tricuspid regurgitation
(VN = 0-100 pg/ml) and pre-lysis Troponin values were measured. A com- and RAP is right atrial pressure. Recall that pulmonary hypertension is
parative analysis was performed for continuous variables using the para- mild if the sPAP is between 25 mmHg and 35 mmHg, moderate between 36
metric Student “t” test to see if there was a significant relationship between mmHg and 45 mmHg and severe > 46 mmHg. In all patients, the Troponin
pre-lysis values of the Troponin and the pre-lysis BNP. values was measured pre-lysis. A comparative analysis was performed for
Purpose of Study: The “TROPIDE” study pursued the following objecti- continuous variables using the parametric Student “t” test to verify if there
ves: to verify any relationships between pre-lysis values of the Troponin and was a significant relationship between pre-lysis values of the Troponine and
BNP in 30 patients who were enrolled in the “TROPIDE” study during the the pre-lysis sPAP. PURPOSE OF STUDY: The “TRAPS” study pursued the
three-years from January 2014 - December 2016; to check the statistical following objectives: to verify any relationships between the pre-lysis values
significance observed by applying the Student’s’t’ test as a bench-marking of the Troponine and pre-lysis values of sPAP in 30 patients who had been
test for continuous variables, and to determine whether the relationships enlisted in the “TRAPS” study during the three years from January 2014 to
between the variables being considered were due to chance. December 2016; to check the statistical significance observed by applying the
Materials and Methods: In 30 patients enrolled with central pulmonary Student ‘t’ test as a benchmarking test for continuous variables, and to deter-
embolism, the values of the pre-lysis Troponin were compared with pre-ly- mine whether the relationships between the variables being considered were
sis BNP values in the same 30 enrolled patients. The test therefore calculated due to chance.
the relative value (RV) of the index “t” to associate with the difference found, Materials and Methods: In the 30 patients enlisted with central pulmonary
according to the following formula: t = (M1-M2)/√DS122 /N1 + DS22 /N2. embolism, the values of the pre-lysis Troponin were compared with pre-ly-
Thus the value of “t” obtained with Degrees of Freedom (DF) = 29, was 8.31. sis sPAP values in the same 30 enlisted patients. The test, therefore, calcu-
The Critical Value (CV) of “t” was 3.659 with D.F. = 29 for p = 0.001, the lated the relative value (RV) of the index “t” to associate with the difference
Relative Value (RV) of “t” was equal to 8.31 and expressed a positive agre- found, according to the following formula: t = (M1-M2)/√DS12/N1 + DS22
ement of co-variation between absolute values of the two variables being /N2. In this way, the “t” value obtained with Degrees of Freedom (DF) =
considered (pre-lysis Troponin and pre-lysis BNP) which is highly signifi- 29 was 15, 41. The Critical Value (CV) of “t” was 3.659 with DF = 29 for
cant with p < 0.001. ANALYSIS OF p = 0.001, the Relative Value (RV) of “t” was equal to 15.41 and expressed
Results: When applied to the 30 patients, the Student’s “t” test revealed a positive agreement of co-variation between the absolute values of the two
highly significant correlation (p < 0.001) between the two variables exami- variables being considered (pre-lysis Troponin values and pre-lysis sPAP)
ned (pre-lysis values of Troponin and BNP), which therefore could not be which is highly significant, with p < 0.001.
attributed to chance. In fact, the value of “t” obtained was 8.31 and the CV Analysis of Results: When applied to the 30 patients, the Student’s “t”
(critical value) of “t” for p=0.001 was 3.659 with DF=29. test revealed a highly significant correlation (p < 0.001) between the two
Discussion: The data obtained suggests that the inverse co-variation of variables examined (pre-lysis values of Troponin and sPAP), which there-
pre-lysis Troponin values and pre-lysis BNP values in the 30 patients enrol- fore could not be attributed to chance. In fact, the value of “t” obtained was
led in the “TROPIDE” study, expressed a highly significant difference, 15.41 and the CV (critical value) of “t” for p=0.001 was 3.659, with DF = 29.
whose clinical significance lies in the overload of right-sided sections of the Discussion: The data obtained suggests that the covariation of pre-lysis Tro-
heart, in the presence of elevated blood pressure regimes caused by the back- ponin values and pre-lysis sPAP values in the 30 patients enlisted in the
ground of pulmonary embolism, evaluated using the pre-lysis BNP, which “TRAPS” study, expressed a highly significant difference, whose clinical
followed an improvised decrease in blood flow to left-sided cardiac sections significance lies in the overload of right-sided sections of the heart, in the
and cardiac hypoperfusion. By examining the emergent literature and the presence of elevated blood pressure regimes caused by the background of
later experiences that followed, we suggest the following. Plasek compared pulmonary embolism, evaluated using the pre-lysis sPAP, which followed an
the EGSYS score with the OESIL score for assessing the cardiac origin of improvised decrease in blood flow to left-sided cardiac sections and cardiac
syncope. Sudoh, Holmes, Levin, Yoshimura, Yasue, Cotance, Dentali, Gutte, hypoperfusion.
Andresen, Wang, Dores, Pasha and Ozsu correlated BNP values with Tro- Conclusions: The “TRAPS” study showed that within the group of 30 patients
ponin values. with venous thromboembolism (central pulmonary embolism) there was a
Conclusions: The “TROPIDE” study showed that within the group of 30 highly significant correlation between the two variables considered: the
patients with venous thrombo-embolism (central pulmonary embolism) there pre-lysis Troponin values and the pre-lysis sPAP. This correlation showed an
was a highly significant correlation between the two variables considered: the absolute positive correlation under the comparative Student “t” test analy-
pre-lysis Troponin values and the pre-lysis BNP. This correlation showed an sis and expressed not a random association, but a close correlation between
absolute positive correlation according to comparative Student “t” test analy- pre-lysis Troponin values and those of the pre-lysis sPAP in 30 patients with
sis, and expressed not a random association, but a close correlation between a central pulmonary embolism. Compared with experiences in the literature,
the values of pre-lysis Troponin and pre-lysis BNP values in 30 patients with a the “TRAPS” study provides data that supplements those already provided by
140
the studies by Plasek, Choi, Ghio, Zeng, Gan, Fijalkowska, Kurzyna, Kircher,
Mahan, Menyeau, Lyon, Atkinson and Ozsu.
199. CORRELATIONS: TROPONIN-RIGHT VENTRICULAR 200. CATHETER DIRECTED THROMBOLYSIS IN DEEP
DIAMETER. “TROPIVE” STUDY: A COMPARATIVE VENOUS THROMBOSIS: ASPIREX STUDY
ANALYSIS WITH STUDENT TEST OF CONTINUOUS
VARIABLES IN 30 PATIENTS WITH VENOUS Aracri N. 1, Ciammaichella M.M. 1, Maida R. 1, Vagnarelli S. 2, Ambrogi C. 2
THROMBOEMBOLISM. THREE-YEAR EXPERIENCE 1
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma 2Radiologia
(2014-2016) Interventistica, A. O. S. Giovanni-Addolorata, Roma
Vincentelli G.M. 1, Ciammaichella M.M. 2, Maida R. 2, Ulissi A. 2 Introduction: The “ASPIREX” study, a name derived from the ASPIREX
1
Medicina d’Urgenza, A. O. S. G. Calibita Fatebenefratelli Isola Tiberina, type of vascular catheter used for loco-regional thrombolysis in deep
Roma 2Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma venous thrombosis (DVT), enrolled 5 patients (4 men and 1 woman),
aged between 45 and 72 years old, with DVT of the lower limbs, hospita-
Introduction: The “TROPIVE” study - an acronym derived from the letters lized in the Complex Structure “Medicine for Emergencies” in 2015-2016.
“TROPonin – rIght VEntricular diameter”, enrolled 30 patients aged between All patients had clinical signs of DVT in the common iliac-femoral axis,
48 and 82 years with venous thrombo-embolism (central pulmonary embo- less than 14 days old, with sore and tense oedema of the lower limb. A
lism) who were admitted to the “Emergency Medicine” Unit during the three CT scan was performed for thorax, abdomen and pelvis, with a contrast
year period from January 2014 to December 2016. In all patients, clinical agent that showed signs in 1 case of pulmonary embolism and confirmed
onset was characterised by severe respiratory failure (arterial blood gas analy- common iliac-femoral DVT as already shown in the lower limbs by ultra-
sis of pO2 < 60mmHg) associated with syncope, chest pain, confused state sound colour doppler imaging. The search for the primary and secondary
and haemodynamic instability (SAP < 90 mmHg).). All patients underwent: markers for thrombophilia was within limits. For loco-regional throm-
CT scan of the chest, abdomen and pelvis with contrast medium; pulmonary bolysis combined with mechanical thrombectomy the following procedure
angiography with loco-regional fibrinolysis in combination with heparin was applied: pre-procedure removable vena cava filter; popliteal / femoral
sodium IV into a peripheral vein, combined with mechanical thrombectomy. ultrasound-guided puncture was performed with the patient prone; the
In all patients, the right ventricle (RV) diameter was measured pre-lysis in ASPIREX system of mechanical thrombectomy was applied; angioplasty
diastole (<30 mm according to Kurzyna’s criteria). In all patients, the Tro- was performed with balloons of 6-8 mm; finally locoregional thromboly-
ponin values was measured pre-lysis. A comparative analysis was performed sis was performed for 24-48 h with urokinase (UK) (as amended by us at
for continuous variables using the parametric Student “t” test to see if there 80000 IU / h with respect to the single lysis with UK, not associated with
was a significant relationship between pre-lysis values of the Troponin and mechanical thrombectomy as shown by data from the National Multicen-
the pre-lysis RV diameter. ter Registry of Wisconsin that provides 8000, 000 UI), by phlebographic
Purpose of Study: The “TROPIVE” study pursued the following objectives: pre-control every 24 hours associated with therapy with heparin sodium,
to verify any relationships between the pre-lysis values of the Troponin and PTT and fibrinogen checked every 6 hours for the duration of the throm-
pre-lysis values of the RV diameter in 30 patients who had been enrolled in bolysis, subsequently treating with oral anticoagulants until INR optimiza-
the “TROPIVE” study during the three year period from January 2014 to tion, according to the American College of Chest Physicians Evidence-Ba-
December 2016; to verify the statistical significance observed by applying the sed Clinical Practice Guidelines (2016 Edition); graduated elastic stocking
Student ‘t’ test as a comparative analysis test for continuous variables, in order post-treatment. In all patients, we evaluated the degree of lysis following
to determine whether or not the relationships between the variables under treatment according to the scheme of Protack. The score is calculated in
consideration were due to chance. seven venous segments: the IVC, common iliac vein, external iliac vein and
Materials and Methods: In 30 patients enrolled with central pulmonary common femoral vein, the proximal portion of the superficial femoral vein,
embolism, the values of the pre-lysis Troponin scores were compared with the distal superficial femoral vein and the popliteal vein. The score is 0 when
pre-lysis RV diameter values in the same 30 enrolled patients. The test the- the vein was pervious and completely devoid of thrombi, 1 when partially
refore calculated the relative value (RV) of the index “t” which is equal to the occluded, and 2 when fully occluded. The total score before and after lysis
difference found, according to the following formula: t = (M1-M2)/√DS12/ was then calculated by adding the scores for the venous segments involved
N1 + DS22 /N2. In this way, the “t” value obtained was 8.57 with Degrees of before and after thrombolysis. The difference between the scores pre- and
Freedom (DF) = 29. The Critical Value (CV) of “t” was 3.659 with DF=29 for p post-lysis is divided by the prelysis score to give a percentage of thromboly-
= 0.001, thus the Relative Value (RV) of “t” equal to 8.57 expressed an absolute sis achieved. The result is a classification into three groups: grade I for lysis
positive agreement of co-variation between the values of the two variables under 50%, grade II for lysis at 50% -90%, and grade III for 91-100%, or
under consideration (pre-lysis Troponin and pre-lysis RV diameter) which complete lysis. A comparative analysis was performed for nominal variables
is highly significant with p < 0.001. Analysis of Results: When applied to the with a “Q” Cochran test to check whether the degree of lysis after treatment
30 patients, the Student’s “t” test revealed a highly significant correlation (p < was statistically significant. SCOPE OF WORK: The “ASPIREX” study has
0.001) between the two variables examined (pre-lysis values of Troponin and the following objectives: to assess the degree of lysis after treatment with
RV diameter), which therefore could not be attributed to chance. The value of loco-regional UK according to the criteria of Protack in 5 patients enrolled
“t”obtained is in fact 8.57 and the CV (critical value) of “t” when p=0.001 is in the “ASPIREX” study in 2015-2016; to verify the statistical significance
3.659 with DF=29. observed by applying the “Q” Cochran test as a test of comparative analysis
Discussion: The data obtained suggests that the covariation of pre-lysis Tro- for nominal variables to determine if the degree of lysis assumed statistical
ponin values and pre-lysis RV diameter values measured in the 30 patients significance.
enrolled in the “TROPIVE” study expresses a highly significant difference, Materials and Methods: 3 The nominal variables compared with the
whose clinical significance lies in the overload of the right-sided sections of designation “K conditions” were designated with the letter A (GRADE I
the heart in the presence of elevated blood pressure caused by the patients’ LYSIS), B (GRADE II LYSIS), C (GRADE III LYSIS). After the procedure,
pulmonary embolism background which occured after a sudden decrease in 5/5 patients (100%) presented with thrombolytic condition C (GRADE III
blood flow to left-sided sections of the heart. This was evaluated using the LYSIS). ANALYSIS OF RESULTS The Cochran Q test applied to 5 patients
pre-lysis RV diameter and cardiac hypoperfusion. shows, through comparative analysis, highly significant differences (p
Conclusions: The “TROPIVE” study showed that within the group of 30 <0.001), which thus cannot be attributed to chance. In fact, the value of Χ2
patients with venous thrombo-embolism (central pulmonary embolism) obtained is 10 and the CV (critical value) of Χ2 for p = 0.001 is 16.26 with
there was a highly significant correlation between the two variables conside- GL = 2.
red: the pre-lysis Troponin values and the pre-lysis RV diameter. This corre- Discussion:The “ASPIREX” study demonstrates how the condition C
lation showed an absolute positive correlation according to the Student “t” (GRADE III LYSIS) has high statistical significance (p <0.001) and, there-
test for comparative analysis, and did not express a random association, but fore, shows that the lysis procedure associated with mechanical thrombec-
instead a close correlation between pre-lysis Troponin values and those of tomy is effective.
the pre-lysis RV diameter in 30 patients with a central pulmonary embolism. Conclusions: The “ASPIREX” study showed how in the group of 5 patients
When compared to experiments in the literature, the “TROPIVE” study pro- with DVT, the mechanical thrombectomy procedure was extremely effective
vides data that supplements those already provided by the studies of Plasek, and it was possible to reach a highly significant level of lysis.
Choi, Ghio, Zeng, Gan, Fijalkowska, Kurzyna, Kircher, Mahan, Menyeau,
Lyon, Atkinson and Ozsu.
141
201. INDICENTAL VENOUS THROMBOEMBOLISM IN 30 202. POST-THROMBOTIC SYNDROME: CASE REPORT

PATIENTS WITH CANCER: ROLE OF KHORANA SCORE.
“KHONCER” STUDY. FIVE-YEAR EXPERIENCE (2011-2016) De Angelis M. 1, Ciammaichella M.M. 2, De Paola G. 2, Maida R. 2,
Ulissi A. 2, Vagnarelli S. 3
Ulissi A. 1., Ciammaichella M.M. 1, Maida R. 1, Martelli O. 2 1
Ospedale Monospecialistico Oftalmico, Roma 2 Medicina d’Urgenza, A. O.
1
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma 2 Oncologia S. Giovanni-Addolorata, Roma 3 Radiologia Interventistica, A. O. S. Giovan-
Medica, A. O. S. Giovanni-Addolorata, Roma ni-Addolorata, Roma
Introduction: The “KHONCER” study, acrostic derived from “KHOrana Introduction: The authors present a case report of post-thrombophle-
score and caNCER”, enrolled 30 patients aged between 58 and 84 years tic syndrome in a 38-year-old woman who came to our observation for
with complete incurable venous thromboembolism and cancer hospitali- persistent turgore to the lower left lobe (Figure 1-2) following deep vein
zed in the Complex “Urgency Medicine” In the five-year period January thrombosis treated 8 months earlier with other nococom. Post-thrombotic
2011-December 2016. All patients were subjected to TC-thoracadomi- Syndrome (SPT) is the most common complication after a deep venous
nal-pelvic CT with mdc; echocardiography; Venous ecocolordoppler lower thrombosis episode (TVP). This pathology has a chronic tendency and is
limbs and possibly elastompression; Thrombophilic and neoplastic markers. often disabling by affecting the quality of life. A recent revision of literature
In all patients, the Khorana score was measured. Therefore, a database called shows an incidence of SPT of 1-1.5%, which in 20-50% of patients appears
“KHONCER” was created. The database contained the following fields: 1) within two years of the thrombotic event despite the fact that adequate
patient number, 2) Khorana score for each patient. All patients were analy- anticoagulant therapy has been undertaken. In the US for a patient with
zed, during recruitment, according to the above 2 fields, collected from time TVP who has an SPT, they spend on average $ 20, 569 compared to the
to time in masks created in “structure view” and “data sheet view” as allowed $ 15, 843 used to treat a patient with TVP who is not affection with SPT.
by the database program. A comparative analysis of Cochgran’s Parametric Case Report: We describe the case of a woman of 38 aa who came to our
Parametric Continuous Variables has been performed to see if there is a observation for persistent left thigh turgor 8 months after diagnosis of deep
significant relationship between the values of the Khorana score and the venous thrombosis of the left iliac-femoral axis treated with nosocomio
extent of the incident venous thromboembolic manifestation (independent with LMWH embolized to ACO until optimization of Therapeutic range
variable A). of INR From anamnestic history of digestive bleeding in September 2016.
Purpose of Work: The “KHONCER” study aims to: 1) verify any existing During the stay, the following examinations are performed:
relationship between the Khorana score and the venous thromboembolic 1) ECG: sinus rhythm
manifestation in the 30 patients enrolled in the “KHONCER” study during 2) hematochemical examinations: within the limits
the five-year period January 2011 - December 2016; 2) to verify the statisti- 3) Secondary thrombophilic marker markers: Negative
cal significance found by applying Cochran’s Parametric Parametric Test for 4) Primary Thrombophilic marker markers: Negative
Comparative Analysis for Continuous Variables to determine whether the 5) Transverse thoracic ecgardiogram: VS in the limits, Chinese preserved,
relationships of the variables considered are due to the case. A comparative FE 67%, diastolic dysfunction of the 1st degree, right sections in the norm,
analysis of Cochgran’s constant parameter variables Q was performed to see indecent pericardial
if there is a significant relationship between the values of the Khorana score 6) Venous Ecodoppler of the lower limbs: non-occlusive segmentary throm-
and the magnitude of venous embolic venous manifestation (independent bosis of the left external iliac vein with proximal tensed rhomomelous
variable A). edema
Purpose of Work: The “KHONCER” study aims to: 1) verify any existing 7) TC chest-abdomen with mdc: absence of opacity defects in lung arte-
relationship between the values of the Khorana score and the extent of venous ries; Subclavian thrombosis of the left ventricle iliac to the passage with the
embolic thrombotic event in the 30 patients enrolled in the “KHONCER” femoral vein
study during the five-year period January 2011 - December 2016; 2) to verify 8) Angio-RM abdomen: stenosis of the left and left left ventricular vein; The
the statistical significance found by applying Cochran’s Parametric Parame- stenosis originates from the inguinal ring and ends at the entrance of the
tric Test for Comparative Analysis for Continuous Variables to determine VCI with venous collateral (Figure 1)
whether the relationships of the variables considered are due to the case. 9) Lower left lumbar articulation: left-hand transfemoral examination with
Material and Method: In the 30 patients enrolled with venous thromboem- echo-guided access: documented sub occlusion of the left external limb cra-
bolism, Khorana score values were compared with the clinical manifestation nially to inguinal ligament, recanalization by positioning of dedicated metal
of venous thromboembolism. For the calculation of χ2 apply the following stent Cook Zilver vein 14x60 mm, dilates The stent and I check the correct
formula: χ2 = (k-1) [(k x) -y2] / (k y) -z = 20.95. With “k” the 3 variables positioning with good flow inside and complete re-analysis of the left iliac
considered, with “x” the total of the squares of the 3 variables considered. axis. The patient is discharged to ACO treatment at a therapeutic range of
“Y” indicates the total of clinical conditions. “Y2” is the square of the total INR. At discharge, the left thigh detachment is observed.
clinical condition. “Z” is the total squares of clinical conditions. The relative Discussion: The post-thrombotic syndrome clinic includes a series of
value (VR) of χ2 obtained is 60 with degrees of freedom (GL) = 2. The criti- symptoms and signs not directly pathognomonic, but only suggestive and
cal value (VC) of χ2 for p = 0, 001 is 13, 816. potentially attributable to other pathological conditions. Therefore, we may
Results Analysis: The Cochran Q test applied to the 30 patients involved use the definition of “Clinical Evidence Concise” that post-thrombotic syn-
in the “KHONCER” study shows that the clinical situation “TEV” (Full drome is: edema, ulceration, and alteration of vitality of the subcutaneous
Venous Thromboembolism) in all patients is not attributable to the case but tissue of the leg as a consequence of a deep vein thrombosis. SPT is cha-
assumes a high statistical significance as The relative value (VR) of the χ2 racterized not only by the clinical manifestations of each phase of its staging,
obtained is 60 with degrees of freedom (GL) = 2 and the critical value (VC) but also by the negative impact on quality of life (worse than many chro-
of χ2 for p = 0, 001 is 13, 816. Choice differences are, therefore, highly signi- nic-degenerative frameworks such as chronic obstructive pulmonary artery
ficant with p <0.001. disease and chronic obstructive or dysfunctions such as Diabetic disease) or
Discussion: Data obtained in the 30 patients enrolled in the “KHONCER” compromising it as well as more prognostic pathologies such as neoplasms,
study showed statistically significant correlation in the incidental venous ischemic heart disease and congestive heart failure. The diagnosis of SPT
thromboembolism between the Khorana score and the extent of venous is clinic and basically relies on an in-depth and accurate medical history,
thromboembolic manifestation. Cochran’s Q testifies a highly significant which must primarily aim to bring out non-clinically and instrumentally
difference whose clinical significance lies in the high reliability of predicting documented elements related to a venous event occurring in silent form
venous thromboembolic risk in cancer patients and on a well-conducted integrated clinical examination From ultrasonic
Conclusions: The “KHONCER” study has shown that in a group of 30 instrumentation. (Necessary to detect any phlebostensometric data in cli-
patients with complete venous thromboembolism there is a Highly correla- nostatism, ortostatism, after orthodynamics, valve incompetence for post
ted correlation between the Khorana score and the extent of venous throm- devolutional devaluation phenomena, thrombotic residues). However,
boembolic manifestation according to Cochran’s “Q” test. The “KHONCER” there are no universally validated methodologies for the diagnosis of SPTs
study demonstrates the high predictiveness of venous thromboembolic risk although some scores have been developed as tools for diagnosing and
in the cancer patient. determining the severity of the syndrome (CEAP, VCSS, Widmer, Brandjes,
Ginsberg, Villalta)
Conclusions: The authors presented a case of posttraumatic syndrome
treated with PTA + venous stent.
142
characterized by all patients with dyspnoea (arterial emo-analytical value of

pO2 <60 mmHg) associated with chest pain, hemodynamic stability (PAS
203. MAY-THURNER SYNDROME: CASE REPORT <90 mmHg) according to the American College of Chest Physicians Eviden-
ce-Based Clinical Practice Guidelines. All patients were subjected to TC-tho-
Fanfarillo F., Maida R., Ciammaichella M.M. racadominal-pelvic CT with mdc; Echocardiography with systolic pulmonary
Medicina d’Urgenza, A. O. S: Giovanni-Addolorata, Roma arterial pressure measurement; Venous ecocolordoppler lower limbs and pos-
sibly elastompression; Thrombophilic and neoplastic markers. In all patients,
Introduction: May-Thurner syndrome is a rarely diagnosed condition in electrocardiographic presentation rhythms were assessed at cardio-respira-
which patients develop deep vein thrombosis (TVP) due to an anatomical tory arrest. Therefore, a database called “CASTEV” was created. The database
variation in which the common right iliac artery overlaps and compresses contained the following fields: 1) patient number, 2) defibrillation rhythm,
the common left ventricular vein Against the lumbar spine We present the 3) non defibrillating rhythm (PEA or asystolia). All patients were analyzed,
case of a 40-year-old patient with turgor of the lower left limb caused by con- during recruitment, according to the above 3 fields, collected from time to
tusion of the thigh and hospitalized in the Department of Urgency Medicine time in masks created in “structure view” and “data sheet view” as allowed
for further investigation case report. The patient reaches our observation by the database program. A comparative analysis of Cochran’s Parametric
with pain and swelling of the lower left limb after a long journey in the car. Parametric Continuous Variables was performed to verify whether there is
The patient reports that the pain started at the left foot then extended to the a significant relationship between the cardiorespiratory arrest (independent
medial side of the thigh to radiate, finally, at the left groin. No significant variable A) and the presentation rate (variable E dependent).
data emerge from the anamnesis collection. It assumes oral contraceptives Purpose of Work: The CASTEV study aims to: 1) to verify any existing
(drospirenone and ethinylestradiol). In the objective examination the vital relationship between cardiorespiratory arrest and electrocardiographic pre-
parameters were within the limits of the norm. His lower left limb was hot, sentation rhythm in the 120 patients enrolled in CASTEV study during the
swollen, erythematosus. The arterial wrists are normally appreciable. Motri- decade January 2007 - December 2016; 2) to verify the statistical signifi-
city and sensitivity are preserved. The chest RX does not show pleuropa- cance found by applying Cochran’s Parametric Parametric Test for Compa-
renchymal abnormalities. Chest TC without mdc does not detect signs of rative Analysis for Continuous Variables to determine whether the relation-
embolism. The ECG is within limits. ships of the variables considered are due to the case.
Complete hemocromis and baseline metabolic profile are within the limits of Material and Method: A comparative analysis was conducted for conti-
the standard, PT is 14.5 seconds, PTT is 24.3 seconds, INR of 1.1, D-dimer nuous variables with Cochran’s Parametric Test Q to verify whether there
is 2.3 micrograms / Ml (IL method, VN <0.25 microg / ml). Primary and is a significant relationship between the variables considered: cardiorespira-
secondary thrombophilia was within the limits. The lower limb venous eco- tory arrest during massive pulmonary embolism and electrocardiographic
doppler reveals the left iiaco-femoral TVP. The CT abdomen with mdc shows presentation rhythm. The “Subjects” column shows the number of patients
left-handed TVP. Thus, the venlafying of the lower left limb confirms the who participated in the study. ND-A, ND-P, and D are the following in the
extended left popliteo-femoro-iliac thrombosis. After introducing into the left central column: ND-A (non-defibrillable-Asystolia), ND-P (Non-Defibril-
femoral left of a catheter, French Cragg-McNamara submits the locus-regio- lable-Asystolia) D (Defibrible). In column “Y” the number of clinical situa-
nal lysis patient with 1 mg / h infusion of r-TPA in combination with systemic tions. In the column “Y2”, the square of “Y” values. The “Total” line indicates
anticoagulant treatment with heparin sodium, monitoring every 6 hours the the total of conditions. In the “Total2” line, the squares of totals of clinical
values of PTT and fibrinogen. After 24 hours, the left lower limb phonography conditions are indicated. The term “Y = 12” indicates the total of clinical
shows the presence of residual thrombus. Thus, mechanical thrombectomy is conditions. The symbol “Z = 12” indicates the square of the total clinical
performed using a Trellis device and simultaneous infusion of another 5 mg condition. The symbol “Y2 = 144” indicates the square of the total clini-
r-TPA. A new 24-day phlebographic check is performed that documents a cal condition. The sum of the totals in square is indicated by the following
partial resolution of the thrombus with residual stenosis of the common left formula: X = xND-A2 + xND-P2 + xD2 = 144 + 0 + 0 = 144. R
ventricular vein stenosis. Therefore, dilation with a balloon of 10 × 40 mm and Esults Analysis: The Cochran Q test applied to the 12 patients involved in
a stent of 14 × 40 mm is placed within the stenotic tract. Venography demon- retrospective analysis shows how the clinical situation “ND-A” (Not Defi-
strates the presence of May-Thurner syndrome (MTS) on the basis of proxi- brillable-Asistolia) highlighted in all patients is not attributable to the case
mal TVP, common left ventricular vein stenosis in an area directly above the but assumes statistical significance Is high because the relative value (VR) of
lumbar spine and thrombotic residual stenosis after thrombolytic and throm- the obtained χ2 is of 144 with degrees of freedom (GL) = 2 and the critical
bectomy administration. After stent placement, the patient was subjected to value (VC) of χ2 for p = 0, 001 is 13, 816. Choice differences are, therefore,
warfarin therapy in heparin sodium embryo until optimization of INR values. highly significant with p <0.001.
Twelve months after surgery, the patient had no recurrence of TVP. Discussion: The data obtained in the 12 patients enrolled in the CASTEV
Discussion: MTS was described in 1957 when it was found that 22% of the study demonstrated that the electrocardiographic rhythm of cardiorespira-
430 autopsy corpses had an anatomical variation in which an overlapping tory arrest is a non-defibrillation remedy and in particular an asystole. This
common iliac common artery squeezed the common left iliac vein against is due to severe hypoxemia and hypovolemia caused by massive pulmonary
the lumbar spine. Failure to correct the MTS anatomy substrate could lead embolism.
to TVP recurrence and further complications, including pulmonary embo- Conclusions: The CASTEV study showed that in the group of 12 patients
lism, chronic venous stasis, and iliac vein rupture (28% of patients with ilecal with pulmonary embolism complicated by cardiorespiratory arrest, the
vein rupture have MTS) Anatomic defect Associated with MTS occurs in the electrocardiographic presentation rate is a non-defibrillative rhythm, and
basin, an area that is not readily visualized by ultrasound. Consequently, if in particular an asystole.
MTS is suspected, venography, magnetic resonance imaging or intravascular
ultrasound should be performed. It is recommended that, after the initial coa-
gulation lysis, the infusion of thrombolytic should be continued for a further 205. COMPARISON BETWEEN THREE NON-INVASIVE
24 to 48 hours. Subsequently, an intravascular stent should be inserted into TECHNIQUES OF EVALUATION MICROVASCULAR
the iliac vein compression zone with post-implanted phlebographic control. MORPHOLOGY VS. THE GOLD-STANDARD LOCALLY
Conclusions: We have submitted a case of MTS with left ventricle TVP INVASIVE MICROMYOGRAPHY. PRELIMINARY DATA
treated with lysis-locoregional, mechanical thrombectomy, stent implant.
Coschignano M.A. 1, Caletti S. 1, De Ciuceis C. 1, Rossini C. 1,
Duse S. 2, Docchio F. 3, Pasinetti S. 3, Zambonardi F. 3, Semeraro F. 2,
204. RETROSPECTIVE ANALYSIS ON 12 Sansoni G. 4, Agabiti Rosei C. 1, Trapletti V. 1, Pileri P. 1, Agabiti Rosei E. 1,
CARDIORESPIRATORY ARREST CASES IN PATIENTS Rizzoni D. 1,5
WITH MASSIVE PULMONARY EMBOLISM: CASTEV 1
Clinica Medica, Department of Clinical and Experimental Sciences,
STUDY University of Brescia, 2 Chair of Ophtalmology, University of Brescia, 3
Department of Mechanical and Industrial Engineering, University of Brescia
Ala A., Barberi S., Del Signore C., Maida R., Ciammaichella M.M. Brescia, Italy; 4 Department of Information Engineering, University of
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma Brescia, Brescia, Italy; 5 Istituto Clinico Città di Brescia, Division of Medicine,
Brescia, Italy
Introduction: The “CASTEV” study, acrostic derived from CArdiac arreST
in patients with massiVe pulmonary embolism, enrolled between January Objective: The evaluation of the morphological characteristics of small resi-
2017 and December 2016 12 patients with severe pulmonary embolism in stance arteries in human beings is not easy. The gold standard is generally
the pre-lysis period from Cardiorespiratory arrest. The clinical outbreak was considered to be the evaluation of the media to lumen ratio (M/L) of sub-
143
cutaneous small vessels obtained by local biopsies and evaluated by wire or 0.03). cDC was unchanged at follow-up. Patients with accelerated athero-
pressure micromyiography. However, non-invasive techniques for the evalua- sclerosis (n = 16) had significantly higher serum creatinine and lower glo-
tion of retinal arterioles were recently proposed, in particular two approaches merular filtration rate (eGFR) at baseline. In multiple logistic regression,
seem to provide interesting information: scanning laser Doppler flowmetry only eGFR and the presence of syndesmophytes were associated with an
(SLDF) and adaptive optics (AO); both of them provide an estimation of the accelerated atherosclerosis, independent of traditional cardiovascular risk
wall to lumen ratio (WLR) of retinal arterioles. A non-invasive measurement factors.
of basal and total capillary density may be obtained by videomicroscopy/ Conclusions: In patients with SpA without overt CV disease, a decrease in
capillaroscopy. No direct comparison of the three non-invasive techniques in renal function and radiographic damage are conditions associated with the
the same population was previously performed, in particular AO was never development of subclinical accelerated atherosclerosis. Longitudinal asses-
validated against micromyography. sment of cIMT could be useful to better evaluate the individual CV risk of
Design and Methods:In the present study we enrolled 11 normotensive these patients improving their prognostic stratification.
lean subject, 8 hypertensive lean patients, 9 normotensive obese patients
and 8 hypertensive obese patients undergoing an election surgical inter-
vention. All subjects and patients (=36) underwent a biopsy of subcutane- 207. OMEGA-6 FATTY ACIDS IN ERYTHROCYTE
ous fat during surgery. Subcutaneous small resistance artery structure was MEMBRANES ARE INVERSELY ASSOCIATED WITH
assessed by wire myography and the M/L was calculated. WLR of retinal FEATURES OF THE METABOLIC SYNDROME IN A
arterioles was obtained by Scanning Laser Doppler Flowmetry and AO SAMPLE OF OBESE CHILDREN
(SLDF, Heidelberg Engineering, Heidelberg, Germany and RTX-1, Imagine
Eyes, Orsay, France). Functional (basal) and structural (total) microvascular Bonafini S. 1, Dalbeni A. 1, Tagetti A. 1, Gaudino R. 2, Cavarzere P. 2,
density were evaluated by capillaroscopy (Videocap 3, DS Medica, Milan, Montagnana M. 3, Danese E. 3, Ramaroli D. 2, Raimondi S. 2, Giontella A. 1,
Italy) before and after venous congestion. Mantovani A. 1, Donato A. 1, Minuz P. 1,
Results: The results are summarized in the Table (slope of the relation: Antoniazzi F. 2, Maffeis C. 2, Fava C. 1
p<0.01 RTX-1 vs. SLDF). 1
University of Verona, Department of Medicine, Verona 2 University of
Conclusion: Our data suggest that AO has a substantial advantage over Verona, Department of Surgery, Dentistry, Paediatrics and Gynaecology,
SLDF in terms of evaluation of microvascular morphology, since it is more Verona 3University of Verona, Department of Neuroscience, Biomedicine and
closely correlated with the M/L of subcutaneous small arteries, considered Movement Science, Verona
a gold-standard approach but limited in its clinical application by the local
invasiveness of the procedure. Background: Obesity leads to the clustering of cardiovascular (CV) risk
factors and the metabolic syndrome (MetS) also in children and is often
accompanied by non-alcoholic fatty liver disease. Quality of dietary fat,
Basal capillary Total capillary Basal capillary Total capillary
density in the density in the density in the density in the beyond the quantity, can influence CV risk profile and in particular omega-3
nailfold / M/L nailfold / M/L dorsum of the dorsum of the fatty acids (FA) have been proposed as beneficial in this setting.
finger / M/L finger / M/L Objective: The aim of the study was to evaluate the associations of indivi-
Correlation 0.49, r2= 0.24, 0.53, r2=0.28, 0.026, r2=0.0006, 0.05, r2=0.0025, dual CV risk factors, characterizing the MetS, with erythrocyte membrane
coefficients p<0.001 p<0.001 p=NS p=NS
(n=36)
FA, markers of average intake, in a group of 70 obese children.
Basal capillary Total capillary
Design: We conducted an observational study. Erythrocyte membrane FA
density in the density in the were measured by gas chromatography.
forearm/ M/L forearm/ M/L Results: Mean content of Omega-3 FA was low (Omega-3 Index =
Correlation 0.011, r2 =0.001 0.027, 2=0.0007 4.7±0.8%). Non omega-3 FA but omega-6 FA, in particular arachidonic acid
coefficients p=NS p=NS (AA), were inversely associated with several features of the MetS: AA resul-
(n=36)
ted inversely correlated with waist circumference (rS = -0.352), triglycerides
W/L retinal arte- W/L retinal arte- W/L retinal
rioles (SLDF)/ rioles (RTX-1) arterioles (rS = -0.379), fasting insulin (rS = -0.337), 24-hour-SBP (rS = -0.313), dayti-
M/L / M/L (SLDF)/ W/L me-SBP (rS = -0.267), nighttime-SBP (rS = -0, 245) and nighttime-DBP (rS
retinal arterioles = -0.344). Total amount of saturated FA (SFA) and specifically, palmitic acid,
(RTX-1)
correlated positively with waist circumference (rS = 0.354), triglycerides (rS
Correlation 0.55, r2=0.30 0.84, r2=0.81 0.52, r2=0.27
coefficients p<0.001 p<0.001 p<0.001
= 0.400) and fasting insulin (rS = 0.287). Fatty Liver Index (FLI), a pre-
(n=36) dictive score of steatosis based on GGT, triglycerides and anthropometric
indexes, was directly correlated to palmitic acid (rS = 0.515) and inversely
to AA (rS = -0.472).
206. FACTORS ASSOCIATED WITH ACCELERATED Conclusions: Our data suggest that omega-6 FA, and especially AA, could
SUBCLINICAL ATHEROSCLEROSIS IN PATIENTS be protective toward CV risk factors featuring the MetS and also to indexes
WITH SPONDYLOARTHRITIS WITHOUT OVERT of hepatic steatosis in obese children, whereas SFA seems to exert opposite
CARDIOVASCULAR DISEASE effects.
Dalbeni A. 1, Giollo A. 2, Tagetti A. 1, Mantovani A. 1, Cioffi G. 3, Ognimbeni F.

3
, Gatti D. 2, Idolazzi L. 2; Orsolini G. 2, Rossini M. 2, 208. CONGENITAL ANOMALIES OF THE INFERIOR VENA
Minuz P. 1, Fava C. 1, Viapiana O. 2 CAVA AND DEEP VEIN THROMBOSIS: A CASE REPORT
1
divisione di Medicina Interna, dipartimento di Medicina, Univeristà di
Verona, VERONA. 2divisione di reumatologia, dipartimento di Medicina, De Feo M., Vertolli P., Stamerra C.A., Cerasi C., Cervelli N.,
Univeristà di Verona, VERONA. 3 dipartimento di Cardiologia, Ospedale De Santis V., Biferi E., Di Giosia P., Viscido A., Moscardelli S., Grassi D.,
Villa Bianca, TRENTO Ferri C.
Università degli Studi dell’Aquila - Dipartimento di Medicina Clinica, Sanità
Objective: Data on the progression of atherosclerosis in spondyloarthritis Pubblica, Scienze della Vita e dell’Ambiente
(SpA) are scarce, despite a high burden of cardiovascular diseases (CVD).
The aim of this study was to identify the predictors of an accelerated subcli- Congenital anomalies of the inferior vena cava (IVC) are rare and repre-
nical atherosclerosis in patients with SpA. sent a predisposition for deep vein thrombosis (DVT). A 39 year old man
Methods: Study participants were 66 patients free of CVD classified accor- was admitted to hospital after suffering from 10 days of fever, pleuritic chest
ding to ASAS criteria. The patients were evaluated at baseline and after 13.5 pain and shortness of breath. He experienced low back pain and stayed at
± 3.6 months. Ultrasound measurements of carotid intima-media thickness home in bed a week prior. He was a non-smoker and past history revealed
(cIMT) and distensibility coefficient (cDC) were used to assess the extent of a right saphenectomy at age 19. A physical examination was unremarkable.
subclinical atherosclerosis. cIMT progression rate was calculated dividing His inflammatory parameters and D-dimer were markedly raised. Blood
the cIMT change by the time between the scans. Accelerated atherosclerosis and urine cultures and testing for viral infections, hypercoagulable states and
was defined as the top cIMT progression rate quartile. autoimmune diseases were negative. Inflammatory markers and fever did not
Results: At baseline, the mean Framingham Risk Score was 14 ± 11 %. At respond to empiric antibiotic treatment, corticosteroids and paracetamol. CT
follow-up, cIMT increased in 39 patients (59%; mean difference 0.01 ± 0.10; scan, performed to search for pulmonary embolism, revealed a congenital
p =.334). Mean cIMT progression rate was 0.01 mm/year (95 % CI -0.02 to absence of infra-renal segment of IVC with venous ectasias in perirenal and
144
posterior pararenal spaces and in pelvic cavity, prominent azygous/hemi-azy- 1

Neurosurgery Unit, Ospedali Riuniti di Ancona; 2Internal and Subintensive
gous veins, and bilateral iliofemoral-popliteal DVT. From the fourth day of Medicine Department, Ospedali Riuniti di Ancona; 3Internal Medicine
admission, the patient developed bilateral lower limb swelling. He was treated Department, Ospedale “S.S. Benvenuto e Rocco”, Osimo (Ancona);
with compression stockings and anticoagulant therapy and discharged home 4
Neurology Clinic, Università Politecnica delle Marche, Ancona; 5Cardiology
after three weeks in a markedly improved condition. The patient was recom- Clinic, Università Politecnica delle Marche, Ancona
mended 6 months of anticoagulation with apixaban. A CT scan performed 3
months after admission showed recanalization of the obstructed venous seg- Background: acute heart failure (AHF) is negatively affected by the presence of
ments. Congenital anomalies of the IVC are often associated with DVT, espe- comorbidities. We aimed to evaluate if different associations of comorbidities
cially in young, healthy individuals without other DVT risk factors. In these could differently affect in-hospital mortality for AHF in a cohort of elderly
cases DVT may not present with typical symptoms. There is no consensus in patients.
literature about the duration of the anticoagulant treatment. Some authors Materials and Methods: we enrolled all the consecutive patients admitted
recommend life-long anticoagulation even when thrombophilia investigation to our Internal Medicine department in the years 2014-2017 for AHF
is negative in order to reduce the recurrence risk. investigating age, sex, in-hospital mortality and presence of 16 common
Finally, it is worth emphasizing that young patients with DVT that is not internistic comorbidities. Association of chronic pathologies was explored
associated with classical risk factors should undergo a complete investigation, with Pearson’s bivariate test, selecting only clusters of ≥2 significantly
including IVC imaging methods, with the objective of excluding possible con- associated comorbidities. Then, we obtained ROC curves predicting
genital venous anomalies. in-hospital mortality for AHF from binary logistic regressions adopting each
cluster as predictor.
Results: Mean age was 82.56(±8, 92), females representing 53.7% of the
209. NON-SURGICAL PERIODONTAL TREATMENT sample. In-hospital mortality was 13%. We obtained 11 different clusters, 6
IMPROVES CARDIOVASCULAR ADAPTATION TO of which predicting significantly in-hospital mortality. The first (anaemia,
ORTHOSTATIC CHALLENGE IN THE SHORT-TERM dementia, diabetes, AF) had AUC:0.678;95%CI:0.585-0.810;p=0.032.
The second (hypertension, CKD, CVD) had AUC:0.673;95%CI:0.525-
Del Pinto R., Pietropaoli D., Barone A., Monaco A., Ferri C., 0.821;p=0.037. The third (dyslipidaemia, AF, PAD, CVD, haematologic
Giannoni M. disorders) had AUC:0.716;95%CI:0.564-0.868;p=0.009.The fourth (AF,
University of L’Aquila, Department of Life, Health and Environmental anaemia, dyslipidaemia, diabetes, CVD, IPB) had AUC:0.764;95%CI:0.658-
Sciences, L’Aquila, ITALY. 0.870;p=0.002.The fifth (CVD, OSAS, dyslipidaemia, AF, PAD, rheumatologic
diseases) had AUC:0.687;95%CI:0.557-0.818;p=0.024.The last (OSAS, AF,
Background: Periodontal health status influences systemic health, and IPB) had AUC:0.695;95%CI:0.565-0.825;p=0.019.
periodontal treatment (PT) has been shown to improve systemic inflam- Discussion: In this small sample, some clusters of comorbidities were not
mation and endothelial dysfunction. The latter has been associated to associated to an increased risk of in-hospital mortality in AHF. However, we
orthostatic intolerance. We hypothesized that single-stage scaling (SSS) and
full mouth disinfection (FMD) may affect cardiovascular (CV) response to
orthostatic challenge in otherwise healthy subjects who needed non-surgi-
cal PT (NSPT).
Methods: Twenty age-sex-BMI-matched patients (10M;10F) aged 42.3±13.9
years who needed NSPT underwent SSS (n.12) or FMD (2 sessions 48h
apart; n.8) based on the severity of the disease. Systolic and diastolic BP
(SBP, DBP; mmHg) and heart rate (HR; beats per minute, bpm) were mea-
sured with a validated automatic device (Omron M6 Comfort It) in clino-
(3x) and orthostatism (within 1’ after standing) before and after each treat-
ment and 7 days after completion of treatment. Within- and between-group
analyses were performed. Data were expressed as mean±standard deviation
(SD). Significance level was set at p<0.05.
Results: In the population overall, baseline CV parameters were as follows:
SBP 120.2±13.9mmHg, DBP 74.6±11.6mmHg, HR 70.1±11.6bpm in clino-
statism; SBP 126.8±14.5mmHg, DBP 82.2± 7.8mmHg, HR 77.7±12.3bpm
in orthostatism. No statistical difference was observed in CV parameters
at baseline between groups. Soon after each treatment session, a non-si-
gnificant increase in BP, both in clinostatism (SBP + 1.18mmHg, p=0.52;
DBP +2.05mmHg, p=0.18) and in orthostatism (SBP +3.25mmHg, p=0.26;
DBP +3.1mmHg, p=0.11), and a reduction in HR (clinostatism -4.93bpm,
p=0.0001; orthostatism: -2.15bpm, p=0.07), were observed in the popula- identified some patterns which are strongly associated to in-hospital death.
tion overall compared to the basal condition. Seven days after treatment, a These cluster deserve the best clinical attention and the most extensive therapy.
significant decrease in the CV parameters compared to the basal condition
was observed in the population overall, both in clino- (SBP -5.48mmHg,
p=0.03; DBP -4.27mmHg, p=0.01; HR -4-48bpm, p=0.002) and in ortho- 211. THE ROLE OF FRAMINGHAM RISK SCORE IN THE
statism (SBP -6.22mmHg, p=0.01; HR -4.33bpm, p=0.03). Orthostatic PROGRESSION FROM MILD COGNITIVE IMPAIRMENT
DBP decreased, without reaching statistical significance (DBP -1.05mmHg, TO DEMENTIA
p=0.59). No statistical difference was observed in the acute or late effects on
CV parameters between treatments. Falsetti L. 1, Viticchi G. 2, Buratti L. 2, Provinciali L. 2, Silvestrini M. 2
Conclusions: NSPT determined an acute, non-significant increase in BP 1
Internal and Subintensive Medicine, Ospedali Riuniti di Ancona, Italy;
and a significant reduction in BP and HR in the short-term that persisted 2
Neurological Clinic, Marche Polytechnic University, Ancona, Italy
after orthostatic challenge, irrespective of treatment. These results are in line
with previous findings on endothelial-mediated effects of NSPT. Longer fol- Background: Mild cognitive impairment (MCI) often represents the clini-
low-up is needed in order to verify any longer persistence of these effects cal manifestation of cognitive deterioration preceding Alzheimer’s disease
and their potential impact on CV health. (AD). Currently, there are no reliable approaches for an objective evaluation
of the risk of developing AD in patients affected by amnestic MCI (aMCI).
Objective: The aim of this study was to verify whether the Framingham
210. CLUSTERS OF COMORBIDITIES AND IN-HOSPITAL cardiovascular risk profile (FCRP) could be useful to identify patients at the
MORTALITY IN ELDERLY PATIENTS AFFECTED highest risk of conversion from MCI to AD.
BY ACUTE HEART FAILURE: A SINGLE-COHORT Methods: Patients with aMCI were carefully investigated to assess their
PROSPECTIVE STUDY vascular risk profile. They were also submitted to a comprehensive neurop-
sychological evaluation. FCRP was calculated for each patient and apoli-
Capeci W. 1, Falsetti L. 2, Tarquinio N. 3, Viticchi G. 4, Fioranelli A. 5, poprotein E (ApoE) genotype was determined from peripheral blood cells.
Di Pentima C. 3, Zoppi F. 3, Pellegrini F. 3, Burattini M. 3 The main outcome was defined as a conversion to AD within 24 months
145
after inclusion. directly from the Emergency Room, 7.5% was transferred from other hospi-
Results: 385 consecutive aMCI subjects were included. Age, FCRP, and tal divisions and 6.1% was transferred from Residences for Elderly Patients.
vascular age showed a fairly predictive value on conversion to AD. Selecting Mean in-hospital stay was 13.8 days in the whole population, significantly
the subpopulation of ApoE ε4 carriers, we observed that FCRP had an higher in patients with infections (p<0.001). 39.3% of patients had at least
increased performance in predicting the conversion. The rate of conversion one previous episode ho hospitalization for heart failure. In 78% of the
increased from 12.5% in the FCRP low-risk group to 43.2% in the high-risk 375 patients, the infection was community-acquired (mostly respiratory),
group (p < 0.0001). ApoE ε4 carriers had a 3.7-times increased probability in 22% hospital-acquired (mostly urinary). Germs most frequently invol-
of conversion with respect to the other subjects (p < 0.0001). ved were E.coli, S.aureus, E.faecalis. Mortality in the whole population was
Conclusions: FCRP assessment could be considered a reliable approach 12.5% (significantly different in patients with or without infections, 16.6%
to predict conversion to AD in aMCI subjects. The presence of ApoE ε4 vs 6.2%, p<0.001). Risk factors for the development of infections were male
increases significantly the risk of conversion. These data confirm the narrow sex and COPD. Risk factors for mortality were advanced age and cognitive
relationship between genetic and vascular risk factors in influencing the impairment, as well as renal failure, lattacidemia and hyponatremia. Low
evolution of cognitive impairment. levels of albumin and hemoglobin were risk factors for both end-points. A
high percentage of patients admitted to Medicine divisions for acute heart
failure is represented by elderly, frail patients. Infections are frequent in
212. TAKO-TSUBO SYNDROME AFTER PACE-MAKER these patients, often as a cause precipitating heart failure or as a compli-
IMPLANTATION: A CASE REPORT cation, worsening the prognosis. Multi-drug resistant germs are frequently
involved and antibiotic therapy should be carefully evaluated.
Fanfani G., Calcagno E., Tozzetti C., Torri M., Poggesi L.
Dipartimento DAI Emergenza ed Accettazione, AOU Careggi, Università
degli studi di Firenze 214. PREVALENCE OF DYSLIPIDEMIA AND EVALUATION
OF LIPID PROFILE AND LIPID-LOWERING THERAPY IN
Case Report: We described the case of a 84-year old man suffering of sudden A POPULATION OF HYPERTENSIVES
reduction of left ventricular systolic function after pace-maker implanta-
tion. His medical history was notable for hypertensive heart disease, per- Giulietti F., Spannella F., Cocci G., Balietti P., Landi L., Bordoni V., Sarzani
manent atrial fibrillation and moderate pulmonary hypertension. His phar- R.
macological-therapy included digoxin and an ace-inhibitor. The patient Internal Medicine and Geriatrics, ESH. Hypertension Excellence Centre,
underwent pace-maker implantation because junctional rhythm due to Sick Università Politecnica delle Marche, IRCCS-INRCA, Ancona, Italy
Sinus Syndrome. The procedure was completely free from complications
and the patient didn’t experience clinical signs or symptoms of heart failure, Background: Dyslipidemia and hypertension are the most prevalent modi-
but the echocardiogram after the implantation showed apical ballooning fiable cardiovascular (CV) risk factors and they often coexist. Aim of the
and a sudden reduction of ejection fraction (EF 36%) with mild increase of study: analyze the prevalence of dyslipidemia and evaluate the lipid profile
Troponin I. The electrocardiogram showed ventricular rhythm induced by and lipid-lowering drugs in a population of hypertensives who underwent
the pace-maker, without any changes compared to the previous one. After a 24h ambulatory blood pressure monitoring (ABPM), to underline the
24 hours, a new echocardiogram showed an increase of EF to 52%, without relevance of this association and possible lacks in the management of
administration of pharmacological therapy. dyslipidemia.
Tako-Tsubo cardiomyopathy is a relatively common acute and reversible myo- Methods: Retrospective study on 1440 hypertensives referred to our Hyper-
cardial dysfunction that typically occurs after an emotional or physical stress. tension Centre between 2010 and 2015. Blood pressure profiles and control
It has been largely approved that this syndrome is associated with increased rates were evaluated using ABPM. Dyslipidemia was defined by the pre-
plasmatic levels of catecholamines triggering myocardial stunning. TakoT- sence of at least one of these characteristics: total cholesterol (TC) ≥200 mg/
subo cardiomyopathy occurs in more than 90% of cases in postmenopausal dL, high levels of calculated LDL cholesterol (cLDL), based on individual
women. In fact, estrogens are involved in the expression of beta-adrenergic CV risk (according to 2016 ESC/EAS guidelines), HDL cholesterol <40 mg/
receptors in myocardial tissue enhancing transcription of cardioprotective dl in males and <50 mg/dl in females, triglycerides (TG) ≥150 mg/dl.
factors. Lack of estrogens, catecholamine-induced cardiotoxicity and micro- Results: Mean age: 55.9 ± 13.4 years. Males: 57.2%. Dyslipidemia: 82.6%.
vascular dysfunction are the main supported theories. Pace-maker implan- Overweight/Obesity: 68%. Smoking: 18.1%. Diabetes Mellitus: 10.7%.
tation related stress is a rare cause to take into account. In literature there Peripheral arterial disease (PAD): 23.7%. Mean eGFR: 75.0 ± 15.6 ml/
are few cases, describing tipically postmenopausal women who underwent min/1.73m2. Mean TC: 205.9 ± 39.7 mg/dl. Mean cLDL: 129.2 ± 34.5 mg/
pace-maker implantation for severe bradycardia due to atrioventricular block. dl. Mean HDL: 51.8 ± 13.7 mg/dl. Median TG: 111 mg/dl (82-157). Patient
We found only one case of Tako-Tsubo cardiomyopathy described in a man. on lipid-lowering therapy: 19% (statins 87.6%, ezetimibe 8.2%, others
4.2%). Target cLDL levels, based on individual CV risk: 39% (all patients),
42.9% (treated patients). Females had a worse lipid profile than males.
213. ACUTE HEART FAILURE AND INFECTIONS: A Diabetics not treated with lipid-lowering drugs: 56.4%. Diabetics treated
RETROSPECTIVE STUDY with lipid-lowering drugs without reaching cLDL target: 56.5%. Patients
with PAD not treated with lipid-lowering drugs: 78.3%. Statin prevalences:
Folli C., Rovellini A., Accordino S., Billi F., Monzani V. simvastatin (38.9%), atorvastatin (31.7%), rosuvastatin (15.0%), pravasta-
IRCCS Fondazione Ca’ Granda - UO di Medicina Interna ad Alta Intensità tin (11.9%), others (2.5%). Patients taking high intensity statins: 2%. Blood
di Cura - Milano pressure control rates: 29.9%. Blood pressure and lipid control rates: 12%.
Conclusion: Our data showed a poor management of dyslipidemia in
Heart failure is one of the leading causes of hospital admission, especially hypertensive patients, who referred to our Hypertension Centre. In par-
in elderly patients, with an estimated prevalence > 10% in patients aged ticular, patients at higher CV risk were often not treated with lipid-lowe-
more than 70 yrs. Infections are not only another major cause of admis- ring drugs or they were treated with low intensity statins, without reaching
sion to hospital divisions but also a frequent and threatening complication the recommended target. An appropriate management of dyslipidemia is
in patients hospitalized for different medical causes. The relation between needed, to improve the CV prevention.
sepsis and heart failure is well known and the coexistence of both patho-
logies leads to a worse prognosis, mainly in elderly subjects. Low respira-
tory tract infections have a prevalence of >15% in hospitalized patients with 215. RENAL RESISTIVE INDEX IN THE ACUTE
chronic heart failure, with an increased risk of in-hospital death. Aim of the MYOCARDIAL INFARCTION STEMI AND NSTEMI,
study was to evaluate a cohort of consecutive patients admitted to the Divi- CORRELATIONS WITH METABOLIC, INFLAMMATORY
sion of Acute Internal Medicine for heart failure, with or without infections AND ATEROSCLEROTIC MARKERS
(community- or hospital-acquired) and to identify the risk factors for the
development of infections and mortality. Secondary aim was to evaluate Lai S. 1, Iorio R. 2, Asllanaj B. 3, Molfino A. 1, Perrotta A. 1,
the site of infection and the most frequently involved bacteria. 626 patients Mangiulli M. 4, Barillà F. 2, Mariotti A. 5
with heart failure consecutively admitted to our division were enrolled in 1
Department of Clinical Medicine, Sapienza University of Rome, Italy; 2
the study (334 females; mean age 82.9±9.5 yrs) from January 1st, 2013 to Department of Cardiovascular, Respiratory, Nephrological, Anaesthetic
December 31st, 2015. 375 (60%) had a diagnosis of infection (at admission and Geriatric Sciences, Sapienza University of Rome, Rome, Italy 3
or during in-hospital stay). The majority of patients (86.4%) was admitted Specialistläkare, Falu Lasarett, Falun, Svezia; 4Department of Internal
146
Medicine and Medical Specialities, Sapienza University of Rome, Rome, Italy; conservative therapy. In the second day of recovery she developed fever and
5
UOC Nephrology and Dialysis, A.Perrino Hospital, Brindisi abdominal pain with guarding and rebound tenderness on palpation of epi-
Introduction: Coronary heart disease is one of the main causes of death gastric and right upper quadrant region. Chemistry revealed worsening of
in the world, particularly in patients with chronic kidney disease (CKD), a leukocytosis, increased procalcitonin and C-reactive protein (CRP) levels,
disease with a worldwide prevalence of 8-13% and with high cardiovascular elevated creatinine level and unchanged troponin value with normal range
morbidity and mortality. Patients with ischemic coronary heart disease are of transaminases and cholestasis index. After microbiological examinations,
subdivided into STsegment elevation Myocardial Infarction (STEMI), or bowel rest, fluid support and empiric antibiotic therapy with piperacillin-ta-
non- ST segment elevation Myocardial Infarction (NSTEMI). The purpose zobactam were started. The ultrasound finding were suggestive of acute cho-
of our study was to evaluate the use of Renal Resistive Index (RRI) as a lecystitis with gallstones and revealed an anechoic collection of fluid with
marker of cardiovascular risk in patients with acute myocardial infarction poorly defined borders in epigastric region suspect for abscess. Therefore an
STEMI and NSTEMI and possible correlations with renal function, metabo- abdomen CT scan with contrast was done in which the diagnosis of acute
lic and inflammatory indices, and atherosclerotic markers. calculous cholecystitis complicated by pericholecystic abscess was confir-
Materials and Methods: 40 patients (34 males and 6 females, mean age med. A surgical consult was requested but, taking into consideration the
59.47 ± 10.95 years), with acute myocardial infarction STEMI and NSTEMI age and the multiple comorbidities, a conservative approach was preferred.
were enrolled, and we have made an assessment of estimated glomerular A second line antibiotic therapy with metronidazole and meropenem was
filtration rate (eGFR), mineral metabolism and inflammatory (C-reactive started obtaining apyrexia, improvement of pain and of physical examina-
protein, CRP) and metabolic indices (homeostatic model assessment, tion and also progressive decrease of leucocytes, CRP and procalcitonin
HOMA-IR). In addition, Intima Media Thickness (IMT), Ankle-Brachial levels. Meanwhile, ECG was unchanged, TnI level continued being slightly
Pressure Index (ABPI) and RRI markers were evaluated. increased and echocardiography demonstrated a normal left ventricular
Results: In our study we showed a significant negative correlation between ejection fraction with anteroseptal hypokinesis and posterior-basal akyne-
RRI and eGFR (r = -0.47; p-value = 0.0282), and a significant positive corre- sis, already shown by a previous exam.
lation between RRI and CRP (r = 0.539; p-value = 0.042), while we found a Discussion:We report a case of a 86-year-old woman with a chest pain and
positive correlation but to the limits of statistical significance, between RRI clinical features suggestive of ACS disguising an acute complicated cholecy-
and IMT (r = 0.415; p-value = 0.098). stitis. Several studies confirmed the association between gallbladder disease
Conclusions: The Renal Resistance Index (RRI) is a hemodynamic measure and ECG alterations, even if the exact pathophysiological mechanism of this
that reflects both the resistance and the arterial compliance of the renal correlation remains unclear. In our case the presence of a previous LBBB
vessels. It is considered to be one of the most sensitive parameters of renal probably masked acute ECG changes, but the persistent slight elevation of
plasma flow alterations and a systemic index of endothelial dysfunction. TnI, without features of an acute myocardial infarction, and the absence of
From the results of our study, RRI appears to be an useful cardiovascular new alterations on echocardiography allowed to rule out the hypothesis of
risk marker, correlating with inflammation, that has a key role in athe- an ACS.
rosclerosis, particularly in CKD. Furthermore, the positive correlation, Conclusion: The presence of chest pain and ECG changes should be
found in our study between RRI and eGFR, suggests the use of the first as managed with particular attention to all the possible differential diagnosis,
an integrative marker to better assess the progression of CKD in patients in order to ensure an early and appropriate treatment, especially in elderly
with coronary heart disease. Indeed, RRI is considered to be a very sensitive in which the clinical presentation could be misleading.
parameter for any alterations in renal microcirculation, it also has a low
cost, is readily reproducible, and has no side effects, so it can be easily used
in CKD patients. 217. KIDNEY DYSFUNCTION IS ASSOCIATED WITH
References: 1) Inflammation, Atherosclerosis, and Coronary Artery THE BURDEN OF CORONARY ATHEROSCLEROSIS,
Disease Göran K. Hansson, M.D., Ph.D. Review Article. N Engl J Med INDEPENDENTLY OF DIABETES
2005;352:1685-95
2) Third universal definition of myocardial infarction. European Heart D’Errico M.M. 1,2, Mangiacotti A. 1, Graziano D. 1,2, Massa V. 1,2,
Journal (2012) 33, 2551-2567. Piscitelli P. 1, Mirijello A. 1, Marchese N. 3, Vendemiale G. 2,
3) Parolini C, Noce A, Staffolani E, Giarrizzo GF, Costanzi S, Splendiani G Russo A. 3, Vigna C. 3, De Cosmo S. 1
(2009) Renal resistive index and long-term outcome in chronic nephropa- 1
Department of Medical Sciences, Unit of Internal Medicine, “Casa Sollievo
thies. Radiology 252:888–896 della Sofferenza” Research Institute General Hospital, San Giovanni Rotondo,
4) Hashimoto J, Ito S (2011) Central pulse pressure and aortic stiffness Italy. 2Internal Medicine and Geriatrics Residency School, University of
determine renalhemodynamics: Pathophysiological implication for micro- Foggia, Foggia, Italy. 3Department of Cardiovascular Sciences, Unit of
albuminuria in hypertension Hypertension 58:839 Cardiololgy, “Casa Sollievo della Sofferenza” Research Institute General
Hospital San Giovanni Rotondo
216. FOLLOWING YOUR HEART OR TRUSTING YOUR Background: Kidney dysfunction is associated with an increased risk
GUT? A CASE OF A MISLEADING CHEST PAIN of coronary artery disease (CAD). Aim of our study was to describe the
burden of coronary atherosclerosis associated with the components of
Piombo M. 1, Merati G. 1, Dell’Aera D. 1, Perrone T. 1, Mugellini A. 1, Corazza chronic kidney disease, i.e. low glomerular filtration rate or albuminuria.
G.R. 1 Patients and Methods: We enrolled 208 (M165/F43) consecutive patients
1
Dipartimento Area Medica, SC. Medicina Generale 1, Fondazione IRCCS with mean age of 69.3+10.5 yrs old, who underwent percutaneous coro-
Policlinico San Matteo, Pavia nary intervention (PCI) for stable or acute coronary syndrome. Glomeru-
lar filtration rate has been estimated from serum creatinine by CKD-EPI,
Introduction: A variety of non cardiac conditions could show with chest albuminuria has been measured by urinary albumin creatinine ratio(ACR).
pain and electrocardiographic (ECG) changes mimicking ischemic heart Coronary disease was defined by the presence of coronary stenosis >50%.
disease. In literature, non specific ECG changes have been reported with Results: Clinical features of patients recruited were the following: BMI:
pericarditis, pancreatitis, acute stroke, subarachnoid hemorrhage, myocar- 28.5+29 Kg/m2, systolic blood pressure: 136+16 mmHg, diastolic blood
dium neoplasm, hypothermia, gastric distention and cholecystitis. pressure: 75+10 mmHg, triglycerides: 159+95 mg/dl, HDL-chol: 43.4+13
Case Report: On June 2017 a 86-year-old woman was admitted to the mg/dl, LDL-chol: 100+38 mg/dl. Estimated glomerular filtration rate
Emergency Department of our hospital for chest pain, nausea and vomiting. (eGFR): 69.3+23.3 ml/min/1.73m2 and ACR: median 1.49, range 0.33-831
She had a history of gallstone disease, massive hiatal hernia, arterial hyper- mg/mmol. Ninety-seven (47%) had type 2 diabetes (9% diet, 52% OHA,
tension, stage 3 of chronic kidney disease and she was recently discharged 39% Insulin+ OHA). One-hundred-sixty-eight (81%) were dyslipidemic,
from another medical department with a diagnosis of acute coronary syn- 183 (88%) had arterial hypertension and 57 (27%) were smokers. Regar-
drome (ACS) undergoing to conservative treatment. Physical examination ding the burden of coronary disease, 56 (27%) patients had single vessel
revealed normal vital signs, a grade 3 systolic murmur on cardiac auscul- disease (S-VD), 67 (32%) 2-vessels disease (2-VD) and 85 (41%) 3-vessels
tation and a normal pulmonary and abdominal exam. Biochemical results disease (3-VD). EGFR progressively decreased with the increase of the
demonstrated neutrophilic leukocytosis and a slight increase in the tro- number of coronary vessels involved: 76.4+22.1, 69.3+23.6, 64.6+22.9 ml/
ponin I (TnI) level. The ECG showed a sinus tachycardia with left bundle min/1.72m2 in patients with S-VD, 2VD or 3VD, respectively (p=0.026,
branch block (LBBB), which was already known, and a chest CT scan with adjusted by age, gender). The significance did not change when presence/
contrast excluded pulmonary embolism and aortic dissection. The patient absence of diabetes was added in the model (p=0.033). Albuminuria signi-
was admitted to our department for a reacutization of ACS managed with a ficantly increased only in patients with 3VD (1.36, 0.44-781; 1.23, 036-135;
147
2.26, 033-831 mg/mmol, in patients with S-VD, 2-VD or 3-VD, respectively; morpho-functional vascular damage indicators in hypertensives, demon-
3VD vs SVD+2VD p=0.005 adjusted for age, gender). Also in this case, the strating a greater association with functional parameters (endothelial fun-
significance did not change when presence/absence of diabetes was added ction and AS). Moreover, circulating EPCs may predict variation in vascular
in the model (p=0.018). parameters during follow-up, thus the need for antihypertensive drugs not
Conclusions: In our sample, we describe a strong and linear association only able to lower blood pressue values but also to improve EPCs levels.
between eGFR and burden of coronary atherosclerosis. Albuminuria signi-
ficantly increases only in patients with 3-VD. The association between
kidney damage and coronary atherosclerosis is independent by the presence 219. BIOMARKERS OF LEFT VENTRICULAR MASS IN
of diabetes. HYPERTENSIVE PATIENTS
Miceli S. 1, Perticone M. 2, Sciacqua A. 3, Grillo N. 3, Falbo T. 3,

218. ENDOTHELIAL PROGENITOR CELLS AND MARKERS Sesti G. 3, Perticone F. 3
OF VASCULAR DAMAGE IN HYPERTENSIVE PATIENTS 1
Azienda Ospedaliero-Universitaria “Mater Domini” - Catanzaro
2
Sciacqua A. 1, Perticone M. 2, Hrabal M. 1, Pinto A. 1, Miceli S. 3, Magna Graecia - Catanzaro 3Dipartimento di Scienze Mediche e Chirurgiche
Cassano V. 4, Bencardino G. 1, Magurno M. 1, Grillo N. 1, Sesti G. 1, - Università degli Studi Magna Graecia - Catanzaro
Perticone F. 1
1
Dipartimento di Scienze Mediche e Chirurgiche - Università degli Studi Left ventricular mass (LVM) is an independent cardiovascular (CV) risk
Magna Graecia - Catanzaro 2Dipartimento di Medicina Sperimentale factor, that recognizes a multifactorial pathophysiology. Raised blood pres-
e Clinica - Università degli Studi Magna Graecia - Catanzaro 3Azienda sure explains only a 10-25% of LVH variation, thus suggesting the existence
Ospedaliero-Universitaria “Mater Domini” - Catanzaro 4Dipartimento di of other not hemodynamic factors such as obesity, obstructive sleep apnea
Scienze della Salute - Università degli Studi Magna Graecia - Catanzaro syndrome (OSAS). The aim of this study was to evaluate role of biomar-
kers on the determinism of LVM in a population never-treated hypertensive
The endothelial progenitor cells (EPCs), produced by the bone marrow in patients with known CV risk factors, in comparison with a control group.
response to different exogenous and endogenous stimuli, present the ability We performed an observational study enrolling 512 caucasian outpatients
to differentiate into mature endothelial cells and may contribute to neova- (228 males and 284 females, median age 50.9 ± 10.8 years). The study
scularization after endothelial injury. Several studies have reported that the population was divided into three groups: Group I (n= 184; normotensive/
presence of cardiovascular (CV) risk factors or other pathological condi- normal weight; 83 males and 101 females), Group II (n= 238; hypertensive/
tions affecting both the number and the functions of EPCs. In particular, normal weight; 104 males and 134 females), and the Group III (n=90; obese/
there is a negative relationship between CV risk factors and the circulating hypertensive; 40 males and 50 females). All patients underwent measure-
EPCs number and migratory activity. Of interest, low levels of EPCs are ment of the following parameters: weight, height, body mass index (BMI),
associated with CV morbidity and mortality. It is well known that early heart rate (HR), fasting plasma glucose, fasting insulin, HOMA index, cre-
indicators of vascular damage such as endothelial dysfunction, increased atinine, estimated glomerular filtration rate (e-GFR) using the CKD-EPI
arterial stiffness (AS) and carotid intima-media thickness (c-IMT), repre- equation, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceri-
sent independent predictors of poor CV prognosis. The aim of this study des, uric acid, hs-PCR, 25(OH)D and PTH. LVM was determined through
was to evaluate the possible association of EPCs circulating levels with both Echocardiogram as Devereux formula and indexed both for body surface
functional and structural vascular damage indexes in a group of uncom- area (LVM/SC) and for height2.7 (LVM/h2.7). Linear regression analysis
plicated and untreated hypertensive patients. We enrolled 60 Caucasian was performed to assess the correlation between2.7 and the different LVMs
subjects (33 men and 27 women, mean age 46.3+13.5 years). Endothelial indexed variable h2, 7 throughout the population and in the three groups
function was estimated by a peripheral arterial tonometer (PAT) with the separately. Then, variables that reached statistical significance were inser-
measurement of reactive hyperemia index (RHI, Itamar-Medical, Cae- ted in a stepwise multiple regression model where the dependent variable
sarea, Israel). AS was evaluated with the measurement of carotid-femoral was LVM/h2.7. In whole population insulin resulted the main predictor of
pulse wave velocity (PWV) by applanation tonometry (SphygmoCor) and LVM indexed (LVMI) explaining the 23.8% of its variation; other indepen-
c-IMT by a high-resolution ultrasound B-mode system. Insulin resistance dent predictors were uric acid, hs-PCR and HR, adding another 4.8%, 3%
was assessed by HOMA index and renal function by measurement of esti- and 0.4% of its variation, respectively. In Group II the main predictor of
mated glomerular filtration rate (e-GFR) according to CKD-Epi formula. LVM variability was insulin, which explained a 19.4% of its variation; other
Pool of circulating EPCs was determined by cytometric analysis of the fol- independent predictors were uric acid and hs-PCR, explaining another
lowing specific surface antigens: CD34, CD133, VEGFR2(KDR) and plasma 4.1% and 1.7% of its variation, respectively. In Group III the main predi-
cytokine’s network (IL6, IL1β, TNFα) by chemiluminescence. Patients were ctor of LVMI insulin, explaining a 41.1% of its variation, anduric acid and
evaluated at baseline (cross-sectional analysis) and after a mean follow-up HR added a 12.1% and 3.1% of its variation, respectively. The results of
of 3.0 ± 0.6 years. At baseline, a linear regression analysis was performed this study demonstrate that, beyond blood pressure, age and gender, other
to test the correlation among vascular assessment parameters, as depen- factors act in the determinism of LVM both in normal weight and in obese
dent variables, and different covariates. RHI was significantly correlated hypertensive patients. In our population the primary biomarker of LVM
with EPCs (r=0.585, P<0.0001) and inversely related with HOMA (r= was insulin, both in the whole study population and in the three groups
-0.468, P<0.0001), TNF-α (r= -0.344, P=0.004), IL-6 (r= -0.316, P=0.007), separately. Another important evidence emerged from our study is that in
hs-CRP (r= -0.313, P=0.007) and IL-1β (r= -0.278, P=0.016). PWV was obese patients cardiac mass indexed for h2.7 helps to better stratify the CV
significantly related with HOMA (r=0.460, P<0.0001), TNF-α (r=0.379, risk profile in this setting of patients.
P=0.001), IL-6 (r=0.296, P=0.011), IL-1β (r=0.237, P=0.034) and hs-CRP
(r=0.224, P=0.042); and it was inversely related with EPCs (r= -0.567,
P<0.0001). Finally, an inverse relationship was observed between c-IMT 220. RIGHT VENTRICULAR FUNCTION IN PATIENTS
and EPCs (r= -0.357, P=0.003) and with e-GFR (r= -0.393, P=0.011), but WITH TYPE 2 DIABETES MELLITUS
a positive relationship with age (r=0.248, P=0.028) and LDL-cholesterol
(r=0.254, P=0.025). Variables reaching statistical significance, and gender Miceli S. 1, Perticone M. 2, Sciacqua A. 3, Falbo T. 3, Grillo N. 3,
and smoking as dichotomic values, were inserted in a stepwise multivariate Bencardino G. 3, Sesti G. 3, Perticone F. 3
linear regression model to determine the independent predictors of RHI, 1
Azienda Ospedaliero-Universitaria “Mater Domini” - Catanzaro
PWV and c-IMT. EPCs were the major predictor of RHI, explaining a 34.2 2
% of its variation, HOMA added another 8.4%. Similarly, EPCs were the Magna Graecia - Catanzaro 3Dipartimento di Scienze Mediche e Chirurgiche
strongest predictor of PWV, explaining 32.1% and HOMA justified another - Università degli Studi Magna Graecia - Catanzaro
8.3% of PWV variation. On the other hand, e-GFR was the strongest pre-
dictor of c-IMT explaining 15.4% of its variation, but EPCs added another The right ventricle is a chamber capable of tolerating high volume loads
14.8%. Follow up data collection shows that the pharmacological treatment with modest increases in blood pressure. However, in the event of a pressure
induced a significant improvement in endothelial function and AS, but not overload, it becomes quickly unable to support the additional load resulting
for c-IMT. After correction for vascular indexes basal values, EPCs justified in a drop in the cardiac output (afterload mismatch). Diabetic cardiomyo-
17% (P=0.001), 27.7% (P<0.0001) and 10.6% (P=0.006) of the variation of pathy can manifest itself as subclinical organ damage. It is characterized
Δ RHI, Δ PWV and Δ c-IMT at follow-up, respectively. In conclusion, the by structural and functional anomalies of ventricular and atrial contractile
present study strengthens the association between circulating EPCs and myocardium. Most studies on diabetes-induced alterations focused on the
148
left ventricle. We have designed this observational study to evaluate right

ventricular function in patients with new diagnosis of diabetes mellitus with
the intention of highlighting any early signs of dysfunction. We enrolled 438 222. EFFICACY AND SAFETY OF TOCILIZUMAB IV
outpatients (261 males and 177 females), divided into two groups: group 1 ADMINISTRATION IN ADULT ONSET STILL DISEASE
included non-diabetic patients; group 2 newly diagnosed diabetic patients.
We measured the following antropometric and clinical parameters: height, Cardinali M., Benfaremo D., Biondi L., Mattioli M., Olivari D.,
weight, body mass index, heart rate, systolic and diastolic blood pressure. Angeletti A., Manfredi L., Pomponio G., Fraticelli P., Gabrielli A.
All patients underwent measurement of the following laboratory para- Dipartimento di scienze cliniche e molecolari - SOD. clinica Medica -
meters: fasting plasma glucose, fasting insulin, HOMA index, creatinine, Ospedali riuniti di Ancona
e-GFR (CKD-EPI), total-, HDL- and LDL cholesterol, triglycerides, uric
acid, hs-PCR. In all patients we performed an echocardiographic evalua- Background: Adult Still’s disease (ASD) is a rare inflammatory disorder
tion of the main morphological and functional parameters: VASI, MVSI, where patients complain about recurrent and dramatic spikes of fevers,
RVOT, TAPSe, PAPs, TAPSe/PAps, E/A (RV e LV), E/e’ (RV e LV), IPM, arthralgia with sometimes frank arthritis, sudden onset of evanescent rash.
RVP, TAPSe/RVP (Evdx). As regards to the right sections, diabetic patients A severe pharyngitis is common in ASD. There is equal occurrence between
did not show differences in morphological parameters, but showed higher the sexes, with two peaks, one between 15 and 25 and the second between
levels of MPI (50.5 vs. 36.1, P <0.000), lower ventricular efficiency (EVdx: the ages of 36 and 46, with older patients sometimes reported. There aren’t
11.07 vs 14.6, P = 0.001) and higher values of pulmonary systolic pressure defined diagnostic criteria, but Yamaguchi criteria have the highest sensiti-
(PAP: 31.9 vs. 27, P = 0.028), compared to control subjects. A linear regres- vity in patients with a definite diagnosis of ASD. The four major Yamaguchi
sion analysis was conducted to see the related parameters with dependent criteria are: fever at least 39° lasting at least one week; arthralgia or arthritis
variables (EVdx and IPM). Therefore, all parameters that reached statistical lasting two weeks or longer; a non-pruritic erythematous skin rash typically
significance were included in a multiple regression model, thus detecting the salmon-coloured found over the trunk or extremities; Leucocytosis with
predictive factors for MPI and EVdx. The main predictors for EVdx resulted at least 80 percent granulocytes. Minor Yamaguchi criteria include: sore
HOMA index and SBP. The main predictors for MPI resulted HOMA index, throat; lymphadenopathy; hepatomegaly or splenomegaly; abnormal eleva-
VASI, SBP and hs-PCR. Newly diagnosed diabetic patients have subclini- tion of aspartate and alanine aminotransferase and lactate dehydrogenase;
cal functional alterations that precede the morphological alterations of the negative test for ANA and Rheumatoid factor. Therapy aims to control phy-
right chambers. Myocardial performance index (MPI) and right ventricular sical signs and symptoms of inflammation and prevents end organ damage.
efficiency (expression of the relationship between TAPSe /RVP), are early While mild-disease patients only need a low dose of glucocorticoid therapy,
markers of subclinical organ damage to the right heart. patients with life-threatening organ involvement require high-dose gluco-
corticoid therapy and early intervention with a biologic agent. While there
aren’t randomized trials to compare drug choices, first-line biologic therapy
221. HEART FAILURE AND IRON STATUS is based on IL-1 inhibitors, an effective therapy which may minimize or
avoid entirely the need for glucocorticoids in most patients. IL-6 inhibitors
Perticone M. 1, Sciacqua A. 2, Miceli S. 3, Zito R. 2, Falbo T. 2, such as tocilizumab are described in case series as effective for disease resi-
Cassano V. 4, Sesti G. 2, Perticone F. 2 stant to other medications.
1
Dipartimento di Medicina Sperimentale e Clinica - Università degli Studi Introduction: In this small case series, we observed the effectiveness and
Magna Graecia - Catanzaro 2Dipartimento di Scienze Mediche e Chirurgiche safety of an 8 mg/kg monthly tocilizumab (IL-6 inhibitor) intravenous
- Università degli Studi Magna Graecia - Catanzaro 3Azienda Ospedaliero- administration in patients with adult Still’s disease. Our patients were 4, one
Universitaria “Mater Domini” - Catanzaro 4Dipartimento di Scienze della male and three females with a mean age of 50.5 years and a mean disease
Salute - Università degli Studi Magna Graecia - Catanzaro duration of 3.25 years at the point of observation (April 2017). Main symp-
toms complained were recurrent and debilitating fever along with arthralgia.
Heart failure (HF) is a chronic disease showing an increasing prevalence Results: After administration of intravenous Tocilizumab (mean number
due to the aging of the population; Iron deficiency (ID) is a clinical condi- of infusions: 24) all patients had remission of symptoms for most of the
tion often observed in HF patients. Recent evidence has shown that patients time between the administrations; we also observed a mean DAS28 (PCR)
with both HF and anemia have, compared to non-anemic patients, lower left reduction of 2.41 points and a mean PCR reduction of 7.16 mg/dl. Use of
ventricular ejection fraction (LVEF), a worse NYHA class, most commonly intravenous tocilizumab allowed reduction in daily glucocorticoid therapy
left ventricular hypertrophy and a worse quality of life. Furthermore, it has of 29.17 mg of prednisone. The administration of tocilizumab did not
been also demonstrated a high prevalence of ID in patients with reduced provoke major side effects, and all patients are currently on therapy. At April
ejection fraction (HF-REF) that, regardless of the simultaneous presence of 2017 one patient switched to Tocilizumab SC for a better control of arthral-
anemia, was associated with an increase in hospitalization, mortality and gia recurring the last week before infusion.
poor quality of life of the patient. The aim of this study was to evaluate, in a Discussion and Conclusions: Since Tocilizumab introduction a couple
cohort of patients with HF, stratified by both reduced (<40%) and preserved of studies were available about its use in adult onset Still disease. In many
EF, the possible relationship between the iron status and cardiac function. cases those were retrospective studies or case reports, generally including
We enrollwed 206 Caucasian patients (114 males and 92 females, mean patients who were refractory to conventional treatment. However, the effi-
age o75.34 ± 10.59 yrs). All subjects had a diagnosis of HF, NYHA I-IV cacy and safety of this treatment is broadly described, except two reports of
functional class. In all subjects a careful history was collected and a com- macrophage activation syndrome (MAS). Actually, Still disease could also
plete cardiovascular examination was performed with arterial blood pres- exacerbate MAS, and it may be difficult to distinguish if this is an adverse
sure, heart rate and major anthropometric parameters; In particular: waist, effect or part of the disease. While randomized control trials are required to
weight, height and body mass index (BMI). A blood sampling was obtained compare different therapies available, this case series demonstrates safety
for the determination of lipid profile, fasting plasma glucose, uric acid, cre- and effectiveness of tocilizumab even in moderate forms of disease, parti-
atinine, serum iron, emocromocytometric examination and renal function. cularly as
All pazients underwent standard echocardiographic examinations both in
M mode and two-dimensional: to evaluate left ventricular mass indexed
(LVMI), right and left atrial diameters (VASI), right function (TAPSE, 223. GLOBAL LONGITUDINAL STRAIN ASSESSMENT IN A
PAPs). Measurements of the ejection fraction, EF (Simpson method, %), COHORT OF PATIENTS WITH SYSTEMIC SCLEROSIS. AN
was also obtained from the telediastolic and telesisthetic ventricular volume EARLY PREDICTOR OF SISTOLIC DISFUNCTION
measurements. Values of P<0.05 were considered statistically significant.
Patients with with EF < 40% showed, in comparison to patients with EF > Fischetti C. 1, Ferrarini A. 1, Zuliani L. 1, Guerra F. 2, Stronati G. 2,
40% inferior plasmatic levels of iron (57.31±22.06 vs 85.10±30.0 mcg/dL, Fraticelli P. 1, Danieli M.G. 1, Capucci A. 2, Gabrielli A. 1
p<0.0001). In addition, with EF<40% compared to patients with preserved 1
Clinica Medica, Dipartimento Di Medicina Interna, Universita’ Politecnica
EF also showed lower haemoglobin levels (12.27 ± 1.46 vs 13.35 ± 1.47 g/dL, Delle Marche, Ospedali Riuniti, Ancona 2 Clinica Di Cardiologia E.
p<0.0001). Our results demonstrated that the reduction of iron levels signi- Aritmologia, Universita’ Politecnica Delle Marche, Ospedali Riuniti, Ancona
ficantly correlated with low EF whereas there is no significance between
serum iron and patients with EF>40%. Despite the strong evidence of the Background: Systemic sclerosis (SSc) is chronic disease characterized by
benefits of iron therapy on symptoms and hospitalizations of HF patients, vascular abnormality and progressive fibrosis of skin and internal organs
this is rarely used in current clinical practice, even if it could be a good such as lung, gastro-intestinal tract, kidney and heart. While commonly
approach to improve the quality of life of patients with chronic HF. undetected by standard echocardiography, recent advances in speck-
149
le-tracking analysis could potentially aid in detecting subclinical heart pleural and pericardic effusion. Pneumonia was ruled out; there was no
organ damage in SSc patients. Aim of our study was to evaluate echo-deri- evidence of interstitial or vascular disease. Results of PFT were abnormal,
ved, speckle-tracking global longitudinal strain (GLS) as a marker of subcli- showing a restrictive ventilatory defect with a reduced TLC (49% of predi-
nical right and left ventricular dysfunction in SSc patients. cted capacity), RV (75%) and FVC (45%). DLCO was not assessed due to
Methods: We studied 51 SSc patients (8 males, 18 diffuse subgroup, the patient’s inability in performing the test. During the first days of hospi-
mean age 54±16 years) and 51 age- and gender-matched controls in a 1:1 tal stay the purpuric rash worsened, extending on the patient’s left leg and
fashion. A standard echocardiographic exam according to current guide- right breast area. Moreover she developed painful mucositis on both of her
lines was performed for each subject. Bi-dimensional, speckle-tracking lips. The clinical features of the patient, the radiologic and functional chest
derived global and segmental longitudinal strain rate were compared findings and the serologic evidence of SLE flare, together with a review of
between cases and control. Moreover, info on SSc variant, anticorpal current literature and case reports, allowed us to suspect SLE-related pul-
pattern, cardiovascular risk factors, and other organ systems involvement monary involvement. A diagnosis of shrinking lung syndrome (SLS) was
were collected for each patient. made.
Results: Left ventricle and right ventricle GLS were significantly impai- Conclusion: Shrinking lung syndrome is a rare complication mainly associa-
red in patients with SSc when compared to healthy controls (-19.2% vs. ted with SLE, although it has also been reported in patients with other con-
-20.3%; p=0.007 and -21.0% vs. -23.6%; p=0.029 respectively). Using -20% nective tissue diseases. Respiratory involvement in SLE patients is common
as a cut-off for GLS, SSc patients had a 3.5-fold increased risk of sub- (60–80%), consisting mostly of pleuritis, PE, pulmonary hypertension,
clinical left ventricle systolic impairment and a 4.1-fold increased risk of acute pneumonitis and chronic interstitial lung disease. The estimated pre-
subclinical right ventricle systolic impairment when compared with age valence of SLE-associated SLS is 0.6-1%. It occurs months to years after the
and gender matched controls (OR 3.5; 95% CI 1.1-16.2; p=0.032). The diagnosis. It is characterized by progressive exertional dyspnea of variable
reduction in GLS in SSc is homogeneous and widespread to both ven- severity with or without pleuritic chest pain, associated with reduced lung
tricles, with no segments significantly more involved than others and a volumes as demonstrated by elevated hemidiaphragms on chest X ray and a
preserved apex-base and epicardium-endocardium gradient. restrictive defect on PFT, with no evidence of parenchymal lung disease or
Conclusion: While traditional echo parameters are ineffective in detecting vascular pathology on imaging findings.The underlying physiopathologic
subclinical systolic impairment, a reduced GLS is more common in patients mechanism is unknown: chronic pleural inflammation has been hypothe-
with SSc and is significant for both left and right ventricles. As the GLS sized to promote the reduction in diaphragmatic mobility inhibiting deep
impairment seems similar in both chambers, our findings could be explai- inspiration by neural reflexes. This could result in chronic lung hypoinfla-
ned by diffuse and progressive myocardial fibrosis rather than changes in tion, leading to parenchymal remodelling with changes in elasticity, thus
arterial pulmonary pressures due to lung involvement. being responsible for decreased lung compliance. Nowadays no standardi-
zed guidelines for the treatment of SLS are available. Patients are usually
treated with medium or high doses of glucocorticoids. Immunosuppressive
224. AN UNUSUAL CASE OF BREATHLESSNESS: WHAT agents have also been used either if the patient fails to improve or since the
COULD BE HIDING BEHIND DYSPNEA? beginning of the treatment. Theophylline and beta-agonists have been sug-
gested in order to increase diaphragmatic strength. Long-term prognosis is
Maira D. 1, Di Stefano V. 1, Migone De Amicis M. 1, Minonzio F. 2, good: improvement and stabilization is achieved in most cases.Our patient
Hu C. 2, Gerosa M. 3, Cappellini M.D. 2 was started on metilprednisolone 40 mg iv daily and antibiotic therapy was
1
Scuola di specializzazione in Medicina Interna - Università degli Studi discontinued, obtaining a reduction in the need of oxygen supply and in
di Milano 2Dipartimento di Medicina Interna (U.O. Medicina Interna the inflammatory markers. We observed a prompt regression of the pur-
1A) - Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico 3 puric rash, while the mucositis diminuished without totally disappearing.
Dipartimento di Reumatologia – Istituto Gaetano Pini The patient was discharged with oral prednisone (50 mg od), to be slowly
tapered. Methotrexate was started again at her usual dose (7.5 mg weekly).
Introduction: We describe the peculiar case of a female adult patient with Rheumatologic and pneumologic follow-up were planned.
systemic lupus erythematosus (SLE) who was admitted to our Internal
Medicine ward in May 2017 complaining shortness of breath.
Case Report: A 49-year-old Peruvian woman presented to our Emergency 225. THE UNLUCKY HISTORY OF AN UNFORGETTABLE
Department with a 4-week history of increasing breathlessness and persi- PAINTER AFFLICTED WITH STILL’S DISEASE
stent dry cough. Dyspnea occurred with mild exertion and was associated
with a feeling of chest tightness and nonspecific chest pain, especially on Piccillo G.A. 1, Saitta R. 1, Mondati E.G.M. 2, Gasbarrini G.B. 3
the right side. Approximately 5 days before admission she developed fever 1
Emergency Department, Cannizzaro Hospital Catania; 2Department of
and a concomitant worsening of coughing and fatigue, so that she sought Internal Medicine and Systemic Pathologies, University of Catania; 3Professor
medical attention. The patient was a nonsmoker. She was diagnosed with Emeritus of Internal Medicine, Catholic University of Rome
SLE 5 years before. Since then she experienced 3 hospitalizations due to
flares with SLE-related articular, nephrologic and neuropsychiatric invol- Introduction: Adult onset Still’s disease (AOSD) is a very rare systemic
vement. However, her rheumatologic disorder was referred to be in good inflammatory disorder found worldwide, first described by Doctor Still a
control during the last year. At the time of admission the patient was on British Paediatrician in children, and predominantly affecting young adults
low-dose steroid (prednisone 5 mg od) associated with low-dose metho- 16-35 years old, with increased frequency of HLA B-35, clinically characte-
trexate (7.5 mg weekly). On admission to our Internal Medicine ward the rised by high spiking fever (>39°C), usually in the evening, popular or
patient was alert and comfortable at rest, afebrile, her vital signs were stable. macula-papular, salmon pink in colour, evanescent rash in the trunk and
Her oxygen saturation was 98% on 35% Venturi mask at 8 l/min, her respi- proximal extremities and mildly pruritic, arthritis with intense arthralgia
ratory rate was 28 breaths/min. Chest examination revealed fine inspiratory and involvement of the distal interphalangeal joints of the hand, myalgia
basal crackles on the left side and dimished breath sounds on the right side. and multi-organ involvement. Currently its prevalence globally is unknown.
Examination of the heart, abdomen and neurologic system was normal. She Case Report: A very good painter 33-year-old woman, neither smoker,
complained of severe pain in her fingers, wrists, knees and ankles which nor alcoholand drug user, was admitted to our Department due to onset
were not swollen but tender to the touch and slightly reddened. A purpu- of fever, abdominal pain, nausea and vomiting. She had a 2-year history of
ric non pruritic rash was noted on her right hand. Laboratory tests showed evanescent rash at limbs and trunk. She had been suffering with weakness
mild anemia, leukopenia with lymphopenia, elevated C-reactive protein and weight loss in the last months and headache and vomiting in previous
and erythrocyte sedimentation rate. Renal and hepatic function tests were 20 days. At clinical examination, she appeared very pale and suffering with
normal. Immunological investigations revealed an abnormal titer of ANA headache, vomiting, itchy to lower limbs and severe hand arthralgia, and
(1/320), with positivity of anti-dsDNA antibodies;antiphospholipid antibo- overall she was very preoccupied for the strong trouble to use her right hand
dies were negative. C3 levels were depressed, while C4 levels were normal. in order to paint!!!. The evaluation of her skin, disclosed the presence of
In the suspect of respiratory tract infection, empiric antimicrobial treatment multiple erythematous spots and areas of hyperpigmentation. Laboratory
with piperacillin/tazobactam was started and methotrexate was temporarily analysis revealed normocytic anemia, leukocytosis (15.000 WBC mainly
stopped. In fact, chest X-ray showed a marked right hemidiaphragm eleva- neutrophiles) and thrombocytosis, rise of phlogosis indexes (C-reactive
tion with severe homolateral lung volume reduction and basal linear ate- protein, ferritin, fibrinogen and ESR and transaminases. Autoimmune
lectasis in the absence of definite parenchimal infiltrates. A contrast-enhan- panel was negative, except for low titer ANA. Blood cultures and serology
ced chest CT was obtained to further define the nature of these findings, for viruses were collected hypothesizing a bacterial or viral infection and
confirming basal bilateral atelectasis and small right lung volume, minimal broad-spectrum antibiotic therapy was started without clinical benefit. All
150
the cultures were subsequently negative. CT-scan revealed the presence of with the exception of hypovitaminosis D, they showed normal values of
inflammatory interstitial lung infiltrates, splenomegaly, lymphadenopa- both ALP and LDH. Molecular analysis by direct sequencing of the ALPL
thy. In order to exclude malignancies the patient underwent to PET which gene coding regions (NM_000478.4), located in chromosome 1p36.1-p34,
showed hypermetabolism in lungs, spleen and lymph nodes. Skin biopsies did not highlight the presence of genetic variants of importance for diagno-
pointed out a leukocytoclastic vasculitis. Given all this, since all the investi- stic purposes. It was not possible to search for any mutations in the LDHB
gations executed ruled out an infective, autoimmune or neoplastic disease, gene (MIM150100, chromosome 12p12.1) for lack of technical availability
final diagnosis of AOSD was made. So, she started therapy on high dose of of gene sequencing.
prednisone with progressive clinic, laboratory and radiological benefit. She, Conclusions: In the patient described, despite of moderate osteo-articu-
despite the deep pain to her hands, bravely continued to paint her fantastic lar symptoms and persistently low ALP value, normal vitamin B6 and no
pictures!!!! A month later at the follow up visit the patient was dramati- ALPL gene mutations were found. These mutations are more than 335:
cally improved, so the steroid therapy was gradually reduced with no any the number and diversity of these variants justify the high variability of
complication. the phenotypic expression of the HPP. Such evidences leads us to believe
Discussion:The clinical presentation of AOSD is really heterogeneous and that our case represents anoccult or oligosymptomatic form of hypopho-
the spectrum of differential diagnoses (infectious, neoplastic, and autoim- sphatasia.The practical consequences consist in clinical and biochemical
mune disorders) is wide and for this reason the diagnosis of AOSD can be parameter monitoring and avoiding the use of bisphosphonates and excess
challenging. We here presented the unlucky case of a young woman with a vitamin D. Regarding in serum LDH-1 and LDH-2 deficiency (and not in
clinical presentation of skin rash and hand arthralgia, who, though struck erythrocytes), we find it plausible, in the absence of LDHB gene sequen-
by strong pain to her hands, courageously faced the disease and continued cing, two hypotheses:the presence of a circulating immune globulin that
to make her nice paintings.....we only helped her to chase her dream!!! decreases the activity of the enzyme without interfering with its synthesis
or a modification of the catalytic site with lower substrateaffinity. A serum
ALP deficiency associated with Lactate Dehydrogenase B deficiency is not
226. COMBINED SERUM DEFICIENCY OF ALKALINE described in Literature.
PHOSPHATASE AND LACTATE DEHYDROGENASE:
CLINICAL REBUS IN AN OLIGOSYMPTOMATIC ADULT
PATIENT 227. BURDEN OF COMORBIDITY IN ELDERLY PATIENTS
WITH ATRIAL FIBRILLATION: INSIGHTS FROM THE
Turrin M. 1, Altinier S., Zaninotto M., Plebani M. REPOSI STUDY
già 1 U.O.C. Medicina Interna, Ospedali Riuniti Padova Sud, Monselice (Pd),
U.O.C. Medicina di Laboratorio, Azienda Ospedaliera-Università degli Studi Proietti M. 1, Nobili A. 2, Mannucci P.M. 3, Lip G.Y. 4
di Padova 1
Institute of Cardiovascular Sciences, University of Birmingham,
Birmingham, United Kingdom; Department of Neuroscience, Laboratory
Introduction: A persistent reduction in serum activityof ALP (persi- of Quality Assessment of Geriatric Therapies and Services, IRCCS – Istituto
stent hypophosphatasemia) is characteristic of hypophosphatasia (HPP). di Ricerche Farmacologiche “Mario Negri”, Milan, Italy; 2Department of
A sporadic hypophosphatasemia is caused by: severe hypothyroidism, Neuroscience, Laboratory of Quality Assessment of Geriatric Therapies and
Cushing’s disease, bisphosphonate therapy, renal osteodystrophy, milk- Services, IRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”, Milan,
alkali syndrome, vitamin D intoxication, Wilson’s disease, vitamin C defi- Italy; 3Scientific Direction, IRCCS Ca’ Granda Maggiore Policlinico Hospital
ciency, hypomagnesemia, hypoglycemia, celiac disease, pernicious anemia, Foundation, Milan Italy; 4Institute of Cardiovascular Sciences, University of
hypozincemia, radioactive heavy metal contamination, Kikuchi-Fujimoto Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research
disease. Six major clinical forms of HPP have been described: lethal peri- Unit, Department of Clinical Medicine, Aalborg University, Aalborg,
natal, benign prenatal, infantile, juvenile, adult, and odontohypophospha- Denmark;
tasia.The diagnosis of HPP in the adult is determined by the combination
of suggestive bone manifestations, low ALPactivity, high serum concentra- Background: Patients with atrial fibrillation (AF) are often elderly and have
tions of pyridoxal-5’-phosphate (PLP) or in urine phosphoethanolamine multiple comorbidities. The latter can be assessed using various clinical
(PEA).The genetic defect is confirmed by the positive finding of ALPL gene severity scales. The burden of comorbidity has been associated with worse
mutations that encode for TNSALP (tissue-non-specific[liver/bone/kidney] outcomes in several clinical conditions, including patients with cardiova-
isoenzyme of ALP). A serum LDH deficiency in H subunit was described scular disease. Purpose: To analyze the relationship between the burden of
in the 1980s and 1990s in some Japanese families without clinically relevant comorbidity and outcomes in elderly patients with AF from the REPOSI
consequences (MIM 614128). Study. REPOSI study is an on-going observational registry of elderly (≥65
Clinical case: A 39years old man came to our attention because he com- years) hospitalized patients.
plained for a few months of pain and sense of heaviness in his elbows, arms, Methods: Comorbidity severity was quantified according to Cumulative
calf and wrist. He assumed NSAID with good outcome. For the force deficit Illness Rating Scale Index of Comorbidity (CIRS-IC). Based on the median
in the first closure and paresthesia at the fingers of the hands performed a CIRS-IC, AF patients were categorized as ‘low’ and ‘high’ comorbidity. All
EMG compatible with the minimum grade carpal tunnel syndrome. Labora- patients with an AF diagnosis enrolled from 2010, 2012, 2014 and 2015
torytests were normal for: blood glucose, creatininemia, eGFR, ALT, hemo- REPOSI cohorts with available CIRS-IC and follow-up data were conside-
chrome, ferritin, serum protein electrophoresis, triglycerides, cholesterol. red for the analysis.
Anamnesis evidenced: smoker, regular lifestyles, no allergies;moderate sco- Results: In the 735 patients, available for this analysis, median [IQR]
liosisof the cervical and thoracolumbar vertebrae, C6-C7 intervertebral disk CIRS-IC was 3 [2-5]: thus, 373(50.7%) had low comorbidity while
protrusion, bilateral epicondylitis.The results of biochemical investigations 362(49.3%) had high comorbidity. Increased cognitive dysfunction (defined
showed: ALP: 40 U/L (nv: 56-119), 25(OH) D3: 30 ng/mL (insufficiency: using the short Blessed test) (p=0.005), and polypharmacy (p=0.001) were
<75), uricemia: 0.45 mmol/L (nv: <0.42). Normal: inflammatory indices, independently associated with high comorbidity, as well as several clini-
calcium, phosphorus, CPK, TSH, creatinine clearance, urinary calcium, cal conditions [Table]. CHA2DS2-VASc was higher in patients with high
phosphate, and uric acid, serum magnesium, zinc, RF, PTH, CTX.Two comorbidity compared to low comorbidity (p<0.001). At follow-up, rates of
months later the low ALP value was confirmed (42 U/L) together with a to cardiovascular (CV) death and all-cause death were higher in patients with
tal LDH of 91 U/L (nv: 135-225), which was also confirmed in subsequent high comorbidity compared to low comorbidity (11.0% vs. 5.9%, p=0.012
control. A lumbar and femoral bone densitometry highlighted a bone mass and 23.8% vs. 14.5%, p=0.001 respectively). Kaplan-Meier curves analysis
framework within the limits.Adult hypophosphatasia suspect, suggested showed that patients with high comorbidity had a higher risk for both CV
by persistently low ALP activity, was not inagreement with normal bone death (Log-Rank: 4.891, p=0.027) and all-cause death (Log-Rank: 7.765,
metabolism and BMD. The patient also had no dental problems. Pharmaco- p=0.005). Multivariate Cox regression analysis, found that high comorbi-
logical interferences responsible for a decrease in ALP have been excluded: dity was independently associated with both CV death (hazard ratio [HR]:
azathioprine, clofibrate, vitamin D intoxication, danazol, estrogen, oral con- 1.77, 95% confidence interval [CI]: 1.05-2.98) and all-cause death (HR: 1.50,
traceptives and bisphosphonates.The LDH isoenzymes showed: LAD-1:12% 95% CI: 1.09-1.40). A further Cox model, computed using CIRS-IC as con-
(nv:15-25), LAD-2:24% (nv:32-41), LAD-3: 36% (nv:18-26), LAD-4: 15% tinuous variable, again confirmed the association with CV-death (HR: 1.23,
(nv:7-14), LAD-5: 13% (nv:5-16). Decrease in 1 and 2 isoenzyme was found 95% CI: 1.09-1.40) and all-cause death (HR: 1.17, 95% CI: 1.07-1.27).
in serum but not in red blood cells.The ALP bone isoenzyme (BSALP) was Conclusions: In elderly AF patients, high comorbidity is independently
normal as well as the vitamin B6 dose on the blood (21.7 μg/L, nv: <27.2). associated with an increased risk for CV death and all-cause death.
Family members (parents, siblings, grandchildren)have been tested, and Table: Factors Independently Associated with High Comorbidity
151
by skeletal muscle involvement.

OR 95% CI p Clinical Case: F, 78, previous partial thyroidectomy, was hospitalized in
Neurosurgery for ptosis, deficits of the sixth cranial nerve, double vision,
Short Blessed Test (per point) 1.03 1.01-1.06 0.005
dysphagia for solids and tetraipostenia. During hospitalization: sudden
Hypertension 2.84 1.65-4.89 <0.001
onset of dyspnea associated with ECG-graphical changes (T wave inversion
Hypercholesterolemia 2.41 1.19-4.87 0.014
in anteroseptal) and elevation of cardiac necrosis enzymes. Physical exa-
Peripheral Arterial Disease 3.26 1.09-9.71 0.034
mination: chest presence of rales at the bases; BP = 130/90 mmHg, HR 96.
Diabetes Mellitus 2.35 1.57-3.50 <0.001
Echocardiogram: Left ventricle and left atrium dilated, EF = 22%. Akinesia
Chronic Kidney Disease 3.06 2.03-4.63 <0.001
Chronic Obstructive 1.63 1.07-2.49 0.022
of the apex. Mild tricuspidle failure (PAPs 30 mmHg). So the patient was
Pulmonary Disease transferred to the cardiology department. Coronary angiography: epicar-
Neoplasm 2.20 1.25-3.88 0.006 dial arteries without angiographic lesions. We investigated autoimmune
Polypharmacy 2.23 1.37-3.65 0.001 or paraneoplastic causes. Laboratory tests: ESR 86 mm; positivity of anti-
bodies to acetylcholine receptor. Diagnosis: “Myasthenia gravis”. Terapy:
Legend: CI= confidence interval; OR= odds ratio. Immunoglobulin i.v, pyridostigmine bromide cp 60 mg, prednisone 50
mg/day. Ten days later: cardiac and neurological involvement hadalmost
solved.
228. EFFECT OF LOW DOSE OF SACUBITRIL/VALSARTAN Discussion: It is conceivable acute myocardial involvement during active
IN PATIENTS WITH CHRONIC SEVERE HEART FAILURE myasthenia gravis phase, regressed completely and in a short time, as a
ON BODY COMPOSITION, BIOIMPEDENZIOMETRY, result of immunosuppressive therapy
HEART RATE VARIABILITY AND T-PEAK-TO T-END Conclusions: This case is particularly significant because, although in lite-
INDEX rature is described that cardiac involvement in myasthenia gravis may take
several forms (from asymptomatic ECG changes to ventricular tachycardia,
Raimondi G. 1, Sindona F. 1, Mobilia P. 2, Dalmaso S. 2, Visani N. 2, myocarditis, heart failure and sudden death), only few cases are reported.
Marchitto N. 2
1
Dept. of Medico-surgical Sciences and Biotechnologies. “Sapienza”
University of Roma. Faculty of Pharmacy and Medicine 1 1ASL. Latina “A. 230. EXERCISE TESTING: A NOT RISK-FREE TEST
Fiorini” Hospital
La Mura L. 1, La Mura G. 2, De Donato M.T. 3, Renis M. 4
Chronic Heart Failure is definied as an abnormality of the cardiac
1
Università “Federico II” Napoli, 2 Cardiologo PO Scafati ASL. Salerno, 3UOC
structure and/or function resulting in clinical symptom (dyspnea) and Medicina AOU Salerno, 4UOC Medicina P.O. Cava de’ Tirreni AOU Salerno
sign (edema), poor quality of life and shortened survival.
Aim: The aim of this study is to evaluate the role of the new therapy with Introduction: Exercise testing is a cardiovascular stress test that uses tre-
Sacubitril/Valsartan in elderly patients with reduced FE < 35% (HFrFE) admill bicycle exercise with ECG and blood pressure monitoring. It is fre-
on Heart rate variability, T-peak to T-end index, fat mass, free fat mass quently used, especially for the diagnosis of ischemic heart disease.
and total body water. Clinical case: F, 62; familiarity for CAD; risk factors (smoking, family
Methods: We have enrolled 12 elderly patients 9 males (range age 70 – mixed dyslipidemia, hypertension);she turns to a cardiologist for fatigue
87 years and mean value of 77 years) and 2 females (range age 50 – 71 and palpitations. Current therapy: ramipril HCT5/25; verapamil 120,
years and mean value of 60.5 years) with HFrFE < 35%. Four patients have rosuvastatin 10 Echocardiography: normal; ECG: ST segment depressio-
chronic kidney failure and four patients have diabetes. All patients have nin V 4-6, like ventricular overload (not present before). 19/01/16:100 W
hypertension. We have evaluated kidney function, glucose, BNP, Heart exercise test (H.R. 150/min.) suspended because of Run of ventricular
Rate Variability, T-peak to T-end index and Bioimpedenziometry. Only tachycardia and accentuation of the depression. No angina and/or increa-
1 patient did not complete the follow-up because of adverse events due to sed pressure. Assuming CAD, while waiting for myocardial scintigraphy,
orthostatic hypotension. the patient undergoes therapeutic change (perindopril/indapamide/amlo-
Results: Our preliminary data underlines that the treatment with Sacu- dipine 5/1, 25/5; ranolazine 374 BID; ASA 100; Bisoprolol 1.25). 21/01/16:
bitril/Valsartan in elderly patients with reduced FE < 35%, improves the myocardial scintigraphy at rest and after effort (75 W; 137/min): accentua-
redistribution of body water like ECM (19.4 Kg/m + 3 Kg/m vs 18.4 Kg/m tion of alterations like ventricular overload, in the absence of perfusion
+ 2.6 Kg/m with p = 0.001), body weight (81.2 kg + 8.0 kg vs 78.1 Kg + deficits, induced by the effort. 25/01/16: detection of hypokalemia (K = 1,
8.0 Kg/m with p = 0.002) and improves clinical outcomes. There are no 7) and metabolic alkalosis!
significant difference in the kidney failure (Creatinine: 1.582 mg/dl + 0.72 Discussion: Probably so serious electrolyte disorders had corroborated
mg/dl vs 1.524 mg/dl + 0.65 mg/dl with p = 0.550), diabetes (Glycemia: an ischemic heart disease path.The patient had no pharmacological and
123.8 mg/dl + 42, 3 mg/dl vs 124.6 mg/dl + 58, 3 mg/dl with p = 0.92). The clinical elements which could indicate serious electrolyte disorders.
BNP showed a consistent reduction even if not significantly (1513 pg/ml Conclusions: Exercise testing is an invasive examination, not without any
+ 936.9 pg/ml vs 1122 pg/ml + 935.4 pg/ml with p = 0, 082). HRV indices risks, and always requires, in our opinion, preliminary clinical evaluation
did not show significant variations: RR (858.2 + 145.8 ms vs 772.1 + 145.8 with lab test (electrolytes, heart enzymes and hemoglobin).
ms with P= 0, 322), LF/HF (0.335 + 0.225 vs 0.373 + 0.41 with P= 0.821).
T-peak to T-end (89.6 + 18.5 ms vs 97.1 + 16, 3 ms with P= 0.340) and Qtc
(367.2 + 34.6 ms vs 353.1 + 35.3 ms with P= 0.64). 231. RDW AS A PROGNOSTIC FACTOR OF MORTALITY
Conclusion: This experience led us to prescribe Sacubitril/Valsartan IN PATIENTS HOSPITALIZED FOR THE FIRST TIME FOR
24/26 mg bis in die in elderly patients with HFrFE because it was effective HEART FAILURE
and well-tolerated when used in routine clinical practice. Sacubitril/Val-
sartan could be a new useful approach in the treatment of elderly patients Salvatori M. 1,2,3, González R.M. 4, Migone De Amicis M.1,2,3,
with Chronic heart failure with reduced ejection fraction < 35% without Chivite D. 4, Corbella X. 4,5, Formiga F. 4, Cappellini M.D. 1,2,3
influence in renal failure, diabetes and HRV. Our preliminary data gives
1
Università degli Studi di Milano, Scuola di Specializzazione
comfortable results but, for now, we have enrolled few patients to give in Medicina Interna, Milano, Italy 2 Fondazione IRCCS
conclusive results. Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy 3 Dipartimento di
Scienze Cliniche e di Comunità, Università
degli Studi di Milano, Milano, Italy 4 Servicio de Medicina
229. A RARE CAUSE OF MYOCARDITIS: MYASTHENIA Interna, Hospital Universitari de Bellvitge-IDIBELL,
GRAVIS L’Hospitalet de Llobregat, Barcelona, Spain. 5 Facultad de
Medicina y Ciencias de la Salud, Universitat Internacional
La Mura L. 1, De Donato M.T. 2, Renis M. 3, La Mura G. 4 de Catalunya, Barcelona, Spain
1
Università di Napoli “ Federico II”, 2 UOC Medicina Interna AOU Salerno,
3
UOC Medicina Interna P.O. Cava de’ Tirreni AOU Salerno, 4Cardiologo PO Objective: Red blood cell distribution width (RDW) is a numerical measure
Scafati ASL. Salerno of the variability in size of circulating erythrocytes. Recent studies linked
elevated RDW with poor cardiovascular outcome in several distinct popu-
Introduction: Myasthenia gravis is an autoimmune disorder characterized lations, included patients affected by heart failure (HF). Our purpose is to
152
analyze the prognostic value of RDW in patients admitted for the first time score calculation to assess disease severity and ABI index determination.
for an episode of acute HF, focusing on 1-year-mortality. Results. The AUROCs for each CV risk factor were consistently larger in
Material and Methods: We retrospectively retrieved administrative data magnitude for ULLA score compared with ABI; the comparisons were sta-
regarding all admissions within a 24 month-period (January 2013 – Decem- tistically significant for age, male gender, smoking status, hypertension, dia-
ber 2014) at Bellvitge University Hospital, a 750-bed tertiary-care public betes and previous cardiovascular events (Table 1).
hospital from Barcelona (Spain), with HF as primary discharge diagno- Conclusions: Our results demonstrate that ultrasonography is a better
sis. Following this first selection we reviewed all medical records of these method to screen PAD in order to identify all disease stages. We thing
patients in order to select only those who truly fulfilled clinical criteria for that this new overview of PAD is necessary in particular to include PAD
acute HF and were experiencing the first ever admission due to a first episode as organ damage marker in CV risk stratification.
of acute HF. We also excluded from the analysis those patients younger than
65 years of age, patients whose acute HF was secondary to an acute coronary Table 1. Associations between ULLA and ABI scores and cardiovascular
syndrome, patients in stage V chronic kidney disease (CKD) undergoing risk factors.
kidney replacement therapies, patients who had received a kidney or heart
transplant, and patients with advanced disease considered to be in termi- ULLA SCORE ULLA SCORE ABI ABI
nal phase. We divided patients in two subgroups depending on the RDW OR AUROC OR AUROC p-
value (minor or superior to 15%), comparing their demographic, clinical (95% CI) (95% CI) (95% CI) (95% CI) value
and treatment characteristics. We calculated mortality rate during hospita- Age≥ 60 years 1.68 (1.31, 2.16) 0.69 (0.61, 0.77) 1.04 (0.65, 1.66) 0.51 (0.45, 0.58) <0.001
lization and 1-year-mortality rate in both subgroups. Finally we utilized Cox Male gender 1.76 (1.48, 2.10) 0.71 (0.66, 0.77) 1.71 (1.17, 2.50) 0.59 (0.54, 0.63) <0.001
multivariable regression analysis to evaluate what variables present at the BMI ≥ 25 kg/m2 0.87 (0.74, 1.02) 0.55 (0.48, 0.62) 0.98 (0.68, 1.42) 0.51 (0.46, 0.56) 0.20
admission were associated to a significant 1-year-mortality risk. Smoking status 1.43 (1.21, 1.69) 0.64 (0.58, 0.70) 1.40 (0.95, 2.07) 0.56 (0.52, 0.61) 0.010
Results: A total of 897 patients were included in the study: mean age was Hypertension 1.54 (1.27, 1.85) 0.66 (0.60, 0.73) 1.25 (0.83, 1.89) 0.54 (0.49, 0.59) <0.001
80.25 ± 7.6 years and 507 (56.5%) of them were female, with higher preva- Diabetes 1.38 (1.17, 1.63) 0.63 (0.57, 0.70) 1.23 (0.86, 1.75) 0.55 (0.49, 0.60) 0.003
lence of preserved ejection fraction (58%). RDW was superior to 15 in 474 Dyslipidemia 1.10 (0.94, 1.28) 0.54 (0.48, 0.61) 0.67 (0.47, 0.96) 0.54, 0.49, 0.59) 0.90
(52.8%) patients. CV family history 1.00 (0.83, 1.21) 0.50 (0.42, 0.58) 0.82 (0.55, 1.21) 0.53 (0.47, 0.59) 0.64
The multivariate analysis confirmed a significant and independent rela- Sedentary 1.25 (1.05, 1.48) 0.59 (0.53, 0.66) 0.96 (0.65, 1.43) 0.51 (0.46, 0.56) 0.11
tionship between RDW > 15 and a prior diagnosis of diabetes (OR 1.48 - CV events 1.59 (1.32, 1.91) 0.68 (0.61, 0.75) 1.64 (1.13, 2.36) 0.62 (0.56, 0.68) 0.038
IC95% 1.111- 1.973) plus higher sodium concentration (OR 1.047 - IC95%
1.015- 1.081). ULLA: ultrasonographic lower limbs atherosclerosis. ABI: ankle-brachial
During the index admission 32 (6, 8%) patients with RDW > 15 and 16 (3, index. OR: odds ratio; CI: confidence interval. AUROCs: areas under the
8%) patients with RDW <15 died (p= 0, 049). receiver operating characteristic. BMI: body mass index. CV: cardiovascular.
1-year-mortality was significantly associated with RDW > 15 at the time of
admission (Log-rank test 5, 502; p=0, 019).
Multivariate analysis confirmed that presence of RDW > 15 at the time of 233. HEREDITARY HAEMORRHAGIC TELANGIECTASIA
index admission was actually associated with a higher risk of one-year mor- AND ORAL ANTICOAGULATION: EFFICACY OF
tality (HR 1.411 - IC95% 1.050-1.895). Other factors independently associa- PERCUTANEOUS LEFT ATRIAL APPENDAGE OCCLUSION
ted with this risk were older age (HR 1.081 - IC95% 1, 059-1, 103), a higher IN PATIENTS WITH NON-VALVULAR ATRIAL
comorbidity measured by the ChI (HR 1, 134 - IC95% 1, 052-1, 224), and FIBRILLATION
higher potassium blood concentration (HR 1, 424 - IC95% 1, 119-1, 811).
Discussion: The presence of altered RDW ad admission is a common con- Suppressa P. 1, De Cillis E. 2, Acquaviva T. 2, Lenato G.M. 1,
dition among patients admitted for the first time for acute HF, and is more Lastella P. 1, Dani E. 1, Rizzi L. 1, Bortone A.S. 2, Sabbà C. 1
frequent among diabetic patients, patients with a previous diagnosis of 1
HHT. Interdepartmental Center, Centro Sovraziendale per le Malattie
anemia and patients with elevated Charlson comorbility index. RDW> 15 is Rare, “Frugoni” Internal Medicine Unit, Policlinico Hospital, University of
associated with statistic relevance with higher 1-year-mortality risk in this Bari “Aldo Moro”, Bari, Italy 2 Interventional lab, Cardio-Thoracic Surgery
subgroup of patients affected by HF. Unit, Department of Emergency and Organs Transplantation, HHT.
Conclusions: Our study confirms that RDW>15 at admission in patients Interdepartmental Center, Policlinico Hospital, University of Bari “Aldo
admitted for the first time for acute HF is frequent, and that its presence Moro”, Bari, Italy
confers higher significant and independent 1-year-mortality risk in this
population affected by HF. Background: Hereditary Haemorrhagic Telangiectasia (HHT), or Ren-
du-Osler-Weber syndrome, is a rare autosomal dominant vascular disorder,
with a prevalence of 1-2:10, 000. Nosebleeds and GI bleeding, secondary to
232. ASSOCIATION BETWEEN PERIPHERAL ARTERIAL rupturing arterio-venous shunts, are often responsible for chronic iron-de-
DISEASE AND CARDIOVASCULAR RISK FACTORS: ROLE ficiency anemia. Visceral arterio-venous malformations can be detected in
OF ULTRASONOGRAPHY VERSUS ANKLE-BRACHIAL lung, liver, brain. Objective: Severity of epistaxis in Hereditary Hemorrhagic
INDEX Telangiectasia (HHT) varies widely, from mild, self-limited nosebleeds to
severe, life-threatening nasal hemorrhage. In Patients with severe grade of
Santoro L. 1, Flex A. 1, Nesci A. 1, Ferraro P.M. 2, De Matteis G. 1, epistaxis, gastrointestinal bleeding and life-threatening bleeding from visce-
Di Giorgio A. 1, Gambaro G. 2, Gasbarrini A. 1, Santoliquido A. 1 ral arteriovenous malformations, oral anticoagulation (OAC) therapy may
1
Dipartimento di Medicina Interna, Università Cattolica del Sacro Cuore often result unsustainable. However, some of these patients are affected by
- Roma, Italia 2 Divisione di Nefrologia e Dialisi, Università Cattolica del atrial fibrillation (AF). In this particular high stroke risk setting, percuta-
Sacro Cuore - Roma, Italia neous closure of left atrial appendage (LAA) may represent a viable and
efficacious alternative strategy to long-term (OAC).
Background and Aims: It is well known that most studies on atheroscle- Methods: Between 2009 and 2016, five consecutive patients with non-val-
rotic processes include peripheral arterial disease (PAD) diagnosis only vular AF-related high thromboembolic risk, CHA2DS2-VASc ≥2, and
if patients report symptoms suggestive of PAD and/or an instrumental severe epistaxis, underwent percutaneous closure of LAA with Amplatzer
demonstration of lower limb perfusion deficit is provided, rather than cardiac plug device.
the sole presence of atherosclerotic lesions localized at lower limbs. This The procedure was performed percutaneously using a trans-septal approach
attitude has led to ignore early stages of PAD, in a time period in which under transesophageal echocardiography and fluoroscopy guidance.
evaluation of subclinical vascular lesions, as a measure of vascular target Procedure- and device-related major adverse events (MAEs) were defined
organ damage, represents a topic of great interest, as happened for carotid as the composite of death, stroke, major or life-threatening bleeding, serious
intima-media thickness and arterial stiffness. The aim of this study is to pericardial effusion, device embolization, major access-site vascular com-
compare ultrasonography versus ankle-brachial index (ABI) evaluation plication, or need for cardiovascular surgery within 30 days following the
in the association between PAD and cardiovascular (CV) risk factors. intervention. Results Early procedural success was complete and no MAEs
Methods: 320 subjects >18 years undergoing lower limbs vascular evalua- occurred in all patients. At 12 months follow-up no thromboembolic event
tion because of symptoms suggestive of PAD or presence of known CV risk occurred in HHT treated patients. Follow-up transesophageal echocardio-
factors were enrolled. All these subjects were submitted to ultrasonographic graphy showed complete LAA sealing in all patients with no residual leaks
evaluation with ULLA (Ultrasonographic Lower Limbs Atherosclerosis) and no device embolization. Conclusions: Percutaneous closure of LAA
153
may represent a safe and efficacious alternative strategy to long-term OAC luation carried out following the judgment of non-eligibility. Patients who
therapy in HHT patients with AF-induced high stroke risk and poor tole- gave the consent, underwent a new cardiologic examination to confirm the
rance for OAC. previous diagnosis in our ambulatory.
Results: In Tuscany the number of visits for sport eligibility is increa-
sing over the years with a parallel decrease of athletes judged non-eligi-
234. VENTRICULAR ARRHYTHMIAS IN YOUNG ble. During 2015 and 2016 the total number of visits per year was around
ATHLETES: A PREDICTIVE SCORE 160.000, non-eligible athletes were 154 and 121 respectively, around 70%
of whom were below 50 years of age. Nearly 90% of these were judged
Toncelli L., Chiostri M., Bartolini A., Ciullini G., Vono M.C.R., non–eligible for cardiovascular causes: arrhythmias 30%, cardiomyopathies
Tosi B., Modesti P.A., Galanti G. 27%, pre-excitatory pathways 11%, T-wave abnormalities 6%, valvulopathy
Sport and Exercise Medicine Unit Department of Clinical and Experimental 6%, only 3% for coronary artery disease and hypertension, 10% refused to
Medicine – University of Florence - Italy undergo further investigations.
Our preliminary data showed that around 20% were rehabilitated to sport
Inroduction and Aim: The significance and long- term outcome of ven- practice. Some non-eligible athletes or their family chose not to participate
tricular arrhythmias, specially frequent and complex, in apparently healthy to our study for the emotional stress caused by the new diagnosis.
athletes is often controversial. Ventricular ectopy in young athletes often has Conclusions: The most extensive SCD prevention campaign in Italy, to
a left bundle-branch block morphology originating from the right ventricle date, is the mandatory cardiovascular screening to obtain eligibility for both
(RV). Arrhythmias can be the clinical expression of an initial underlying agonistic and non-agonistic sports in athletes. Our preliminary data showed
cardiovascular disease that may not be easily detected in the growing age. that cardiac disorders were found for the first time in almost the majority of
The present study was thus designed to investigate the right ventricle mor- athletes during the sport medicine visit. The cardiovascular screening seems
phology and function with echocardiography in young athletes presenting to be useful for the early diagnosis of cardiac disorders associated with an
ventricular arrhythmias originating from right ventricle. Subjects Studied higher risk of SCD that would remain otherwise undetected.
Two hundred sixty-five white young athletes were recruited, aged 9 to 18
years, 158 male and 107 female. Subjects were then divided in two groups:
group A(n=97) presenting frequent and/or complex ventricular arrhyth- 236. CHA2DS2VASC SCORE IS A PREDICTOR OF LEFT
mias originating from right ventricle at baseline EKG which did not disap- ATRIAL ENLARGEMENT IN NON-VALVULAR ATRIAL
pear nor decrease during exercise test, and group B (n=168) without any FIBRILLATION: THE NEAFI ECHO REGISTRY
arrhythmias.
Methods: In all athletes an echocardiogram has been performed, focused Lo Iudice F. 1, De Roberto A.M. 1, Petitto M. 1, Buonauro A. 1,
on right ventricle, according to the guidelines of the American Society of Luciano F. 1, Esposito R. 1, Tufano A. 2, Trimarco B. 1, Galderisi M. 1
Echocardiography. Statistical Analysis A multivariate logistic regression 1
Department of Advanced Biomedical Sciences. Federico II University
analysis was performed in order to identify adjusted predictors of arrhyth- Hospital – Naples (Italy) 2Department of Clinical Medicine and Surgery.
mias. The coefficients obtained were used to develop a scoring system to Federico II University Hospital – Naples (Italy)
calculate the risk of arrhythmia.
Results: No sex differences were found. At echocardiography the measures Background: In atrial fibrillation (AF), thromboembolic (TE) risk evalua-
were all between the normal range though the athletes with arrhythmias tion is based on CHA2DS2VASc risk score which relies on clinical parame-
were older, heavier and taller. ters. The evidence of transthoracic echo parameters in predicting TE risk
Group A had different RV systolic function indexes, namely a lower TAPSE, is not sufficiently strong. The NeAFi-Echo registry is a single-center obser-
a higher MPI index and more positive values of strain; moreover, they had vational registry created for collecting echo-Doppler measurements and
lower RV longitudinal dimensions and higher RV end diastolic area (both clinical/anamnestic data in AF patients referring to our Echo-lab.Purpose:
absolute and indexed for subject’s height). Our aim was to assess relationships between left atrial (LA) size and TE
Conclusions: The likelihood of arrhythmia increases with age, with the risk evaluated by CHA2DS2VASc in non-valvular AF(nvAF) patients of
decrease in systolic function parameters and with a more “glossy” aspect of NeAfi-Echo Registry using echo-Doppler and Speckle Tracking Echocar-
right ventricle. This score seems reliable in predicting the development of diography (STE).
frequent and complex extrasistolia in young athletes (65% sensitivity, 86% Methods: In the first year, NeAfi registry enrolled 194 AF patients, 186
specificity). Sports people with score ≥ 250 should be more closely followed affected by nvAF (mean age 69 years, 106 males). Among nvAF patients,
with EKG Holter and accurate echocardiographic study of right ventricle in 110 had permanent/persistent AF and 76 paroxysmal AF. All patients
order to detect early signs of cardiac disease. underwent clinical history and physical exam to calculate CHA2DS2VASc
score, Echo-Doppler including evaluation of left ventricular (LV) geome-
try, systolic and diastolic function and STE-derived LV global longitudinal
235. RETRO-PROSPECTIVE STUDY ON THE UTILITY OF systolic strain (GLS). GLS was considered as “positive” (sign +).
CARDIOVASCULAR SCREENING IN YOUNG ATHLETES Results: The population of nvAF patients was divided into 3 LA volume
index (LAVi) tertiles: T1= <37.8 LAVi mL/m²; T2= LAVi 37.8 – 50.5 mL/
Tosi B., Vono M.C.R., Galanti G. m²; T3= LAVI >50.5 mL/m². CHA2DS2VASc was lower in T1 than in T2
Sport and Exercise Medicine Unit – Department of Clinical and
Experimental Medicine – University of Florence - Italy
Introduction: Prevention of Sudden Cardiac Death (SCD) still remains a

challenging point in Public Health. SCD annually account for an estimated
350.000 deaths in the US, 700.000 in Europe. The annual incidence in Italy
is more than 1.000 people under 40 years of age. SCD in young athletes is
usually caused by complex ventricular arrhythmias whose pathological sub-
strates are very wide and sometimes remain unknown. The early diagnosis
of cardiovascular diseases that can expose young people to an increased risk
of SCD is therefore crucial.
Aim: Aim of our study is to analyze the utility of mandatory cardiovascu-
lar screening in athletes and to evaluate the demographic and clinical cha-
racteristics of athletes judged non-eligible to sport practice for cardiova-
scular causes in Tuscany. We also intend to improve the identification of
young people with high risk of SCD in order to direct them in a long-term
follow-up.
Materials and Methods: 50 athletes below 50 years of age, judged non-eligi-
ble to sport practice for cardiovascular cause during the years 2015 and 2016
were enrolled. The athletes were submitted to a questionnaire with familiar,
physiological, pharmacological, sportive and pathological history before
and after the judgment of non-eligibility. We also stored any cardiologic eva-
154
(p=0.006) and T3 (p<0.0001), and in T2 than in T3 (p=0.03) (Figure). Con- logy, this case demonstrates that imaging does not always help diagnosis, in
sidering T2 and T3 as a single group (LAVI T2/T3), LV mass index, E/e’ ratio fact only surgical debridement locate the sign of NF (not demonstrated by
(both p<0.0001) were greater but EF (p<0.0001) and GLS (p=0.018) lower TC scan). The gold standard for confirming diagnosis, when it is equivocal,
in LAVI T2/T3 than in LAVI T1. In the pooled nvAF population, CHA2D- is the combination of surgical exploration and microbiological and histopa-
S2VASc was positively correlated with LAVi (r=0.34, p<0.0001), E/e’ ratio thological analysis of 1 cm3 of soft tissue.
(r=0.41, p<0.0001) and LV mass index (LVMi) (r=0.24, p<0.001). A nega-
tive correlation of CHA2DS2VASc was found with EF (r=-0.39, p<0.0001)
and GLS (r=-0.23, p<0.01). By a multiple logistic regression analysis, after 238. SYNCOPE BY COMPLETE HEART BLOCK
adjusting for LVMi, E/e’ ratio and EF, CHA2DS2VASc was an independent
predictor of LAVi T2/T3 (beta=0.280, p=0.03). Astazi P., Palmieri P.
Conclusion: LA dilation, LV diastolic/systolic dysfunction, and increased Azienda Regionale Emergenza Sanitaria 118 - Regione Lazio
LV mass characterize TE risk profile as evaluated by CHA2DS2VASC score.
A LAVi³ 37.8 mL/m² is associated with higher CHA2DS2VASc score inde- New-onset third-degree atrioventricular (AV) block is a medical emergency
pendent on EF, LV mass and E/e’. CHA2DS2VASc is a marker of cardiac common in the elderly, in which the impulse generated in the sinoatrial
organ damage in nvAF. node does not propagate to the ventricles. Patients can experience syncope
with falling to the ground by bradycardia as result of several types of AV
blocks. This is mandatorily caused by decreased cardiac output with reduced
237. A CASE OF NECROTIZING FASCIITIS BETWEEN blood flow to the brain.
NEW ETIOLOGIC AGENTS AND DIAGNOSTIC Case Report: Emergency Medical Service’s A.R.E.S. 118 – Regione LAZIO
CONTROVERSIES team managed an 84-years-old patient presenting with an acute hemodyna-
mic compromise caused by bradycardia and possible episodes of asystole.
Amaradio M.D. 1, Esposito G. 2, Riccardi A. 2, Sbrojavacca R. 2 On examination pale and sweaty patient was lying on the ground, con-
1
UO Medicina Interna e D’Urgenza, Dipartimento di Medicina Clinica e scious, normal breathing, very small cardiac pulse, bradycardia at 20 beats/
Sperimentale, Azienda Ospedaliero-Universitaria “Policlinico-V. Emanuele”, min, systolic blood pressure < 60 mmHg (at potential risk of asystole), the
Università di Catania; 2S.O.C. Pronto Soccorso e Medicina d’Urgenza, ECG 12 leads showed broad P wave with a regular P-to-P interval (it repre-
Azienda Sanitaria Universitaria Integrata di Udine sents the first rhythm), the QRS complexes with a regular R-to-R interval
represent the second rhythm. The PR interval was variable, as the hallmark
Overnight, a 72 years old man was admitted to our Emergency Department, of complete heart block there was lack of any apparent relationship between
with fever and altered state of consciousness. P waves and QRS complexes.
He had an history of type 2 diabetes mellitus, arterious hypertension, Clinical history examination revealed 3 milder episodes of dizziness, weak-
dyslipidemy, obesity and ventricle peritoneal shunt for hypertensive ness and palpitations during the previous days, for which he had not sought
hydrocephalus. medical attention. Patient was in drug therapy for diabetes, hypertension
He appeared partially orientated, tachipnoeic (30 breaths/min) with and hypercholesterolemia, assuming oral antidiabetic, beta blocker and
SpO2:89% in room air. Blood pressure: 150/80 mmHg, pulse rate: 130 beats/ statin. Patient was immediately considered for temporary external transcu-
min and body temperature: 39.5°C. Heart sounds, vescicular murmur ad taneous cardiac pacing. This approach certainly offers a “bridge” to trans
abdominal objectivity were normal. The lower left limb showed obvious venous approach, if necessary. It is accomplished by delivering pulses of
signs of flogosis, as by erisypelas. qSOFA was 2 and so blood sample analysis electric current through the patient’s chest, which stimulates the heart to
and emocultures were done. Hydration was started immediately. Empirical contract. During transcutaneous pacing, pads were placed on the patient’s
antibiotic therapy (amoxicillin/clavulanate and clindamycin) was infused chest, in the anterior/lateral position. The pads were then attached to a
after blood samples analysis. Arterial lactate was 3.3 mmol/l. Later, lab tests monitor/defibrillator, a heart rate of 60 beats/min was selected, and current
showed moderate upward inflammatory markers (WBC 13.000x10³/μL, (90 milliamps) was increased until electrical capture (characterized by a
PCR 22mg/L) and muscle lysis enzymes (CPK 636U/L). SOFA score was wide QRS complex with tall, broad T wave on the ECG) was obtained, with
5. Patient was so admitted in the semi-intensive care unit with diagnosis of a corresponding normal pulse. Before patient pacing, sedation was obtained
“Soft tissue sepsis”. by administering an anxiolytic. Promptly hemodynamic conditions of the
The next morning, the objectivity of the left lower limb worsened: numerous patient were stabilized. Discussion: Treatment of third-degree AV block is
large bullae appeared in the distal third. The pain increased. So, we started based on the level of the block. Immediate pacing is indicated especially
a more aggressive therapy (meropenem and daptomicina), and simultane- when the block is at or below the His-Purkinje level with very low ven-
ously, a surgical debridement of the injured limb was programmed. In the tricular rate and insufficient blood pressure. Brady-arrhythmias requiring
meantime, the TC of left leg revealed diffuse oedema of skin and subcu- cardiac pacing can be caused by a variety of etiologies (adverse drug effects,
taneous tissue, thin liquid film on fascial planes with no sign of necroti- acute myocardial infarction, electrolyte disorders) and the early identifi-
zing fasciitis. On the contrary, the day after, the fasciotomy highlighted the cation of a potentially reversible cause is the first step towards treatment.
necrosis of the fascial tissue mainly in the posteromedial side. On the third Elderly patients with sustained or frequent bradyarrhythmia are often
day, blood cultural exams showed growth of Vibrio Parahaemolyticus, a symptomatic. Easy fatigability, reduced exercise capacity and symptoms of
very rare bacteria in our country. After a more detailed medical interview it HF are common in persistent bradyarrhythmia. Subtle symptoms are irrita-
emerged that the patient fished on bare feet in marshland areas. Antibiotic bility, lassitude, inability to concentrate, apathy, forgetfulness and dizziness.
therapy was simplified (amoxicillin-clavulanate). After twenty days of anti- Dizziness, pre-syncope and syncope are common symptoms with intermit-
biotic therapy and periodic medications of the lesion, the patient’s condi- tent severe forms of brady-arrhythmias and are due to a sudden decrease in
tions gradually improved and he was discharged to home with diagnosis of: cerebral blood flow.
“Necrotizing fasciitis due to Vibrio parahaemolyticus”. Conclusions: Even death in patients with untreated AV block may occur,
Necrotizing fasciitis (NF) is a rare but serious infection of the skin and soft due not only to heart failure secondary to low cardiac output, but also to
tissue, which tend to progress through the fascia planes, rapidly destructing sudden cardiac death caused by prolonged asystole or bradycardia-triggered
deep tissue. Even if the incidence is rising for the overheating of waters and ventricular tachyarrhythmia. A.R.E.S. 118 – Regione LAZIO medical inter-
the selection of new clonal groups, NF due to Vibrio Parahaemolyticus vention is essential to decide on the need for cardiac pacing therapy, to treat
remains an extremely infrequent infection. In fact, searching “necrotizing immediately at home and to allow to reduce propensity for life-threatening
fasciitis” AND “vibrio parahaemolyticus” on PubMed only 9 items have brady-dysrhythmias, before permanent pacemaker can be implanted into
been found (comprising Vibrio Vulnificus cases). The Vibrio species are these individuals to increase adequate heart rate and maintain blood flow
short, oxidase-positive, and gram-negative bacilli that are actively motile. to the brain.
The infection occurs through ingestion of raw molluscs or through trauma-
tic injury in marine environments. Wound infections due to Vibrio paraha-
emolyticus associated with exposure to brackish water are typically mild. 239. AN INTEGRATED ULTRASOUND APPROACH TO
However, mortality rates approaching 3% are reported. V. parahaemolyticus ACUTE DYSPNEA IN EMERGENCY DEPARTMENT
NF did not differ clinically from necrotizing soft-tissue infections caused by
other members of the Vibrionaceae family, consisting of the classic triad of Carlino M.V. 1, Mancusi C. 1, Sforza A. 2, de Simone G. 1,
swelling, erythema and intense pain. Patients with liver disease and diabetes Paladino F. 2
mellitus have a higher risk of developing sepsis. Beyond the rarity of etio-
1
Hypertension Research Center, UOC Emergency Medicine, Federico II
University Hospital, Naples. 2Emergency Department, Cardarelli Hospital,
155
Naples sion with hydro-air levels of the loops of the small intestine for a mechanical
obstruction”. We place a nasogastric tube and we hospitalize the patient in
Background: Acute dyspnea is one of the main reasons for admission to the surgery with the following diagnosis: “intestinal occlusion in a patient with
Emergency Department (ED). The availability of ultra-miniaturized pocket breast cancer, gastritis, hypertension, hypercholesterolemia”. The patient
ultrasound devices (PUD) adds diagnostic power to the clinical examina- undergoes surgery during which runs a resection of part of the small inte-
tion. The aim of this study is to identify an integrated ultrasound flow chart stine and a biopsy of the lymphnodes of gastric region. Histological exami-
for diagnosis of cardiogenic dyspnea (CD), using PUD and combining eva- nation: “extended secondary localization on the walls of the small intestine
luation from lung, heart and inferior vena cava (IVC). of poorly differentiated gastric carcinoma of diffuse type; the neoplasia is
Methods: We included 102 patients presenting to the ED of “Antonio present on either surgical resection margin intestinal segments; massive
Cardarelli” Hospital in Naples (Italy) for acute dyspnea (AD). All patients lymphnode metastatis of poorly differentiated gastric carcinoma” Conlu-
underwent integrated ultrasound examination (IUE) of lung-heart-IVC, sions: often gastric cancer is associated with breast cancer, especially in the
using PUD. The gold standard was the FINAL diagnosis determined by case of gastric linitis plastica. Diagnosis is often difficult because the gastric
two expert reviewers: cardiogenic dyspnea (CD) or dyspnea of non-cardiac mucosa is spared from the neoplasm and biopsy is needed. In this case
origin (non-CD). We used 2 × 2 contingency tables to analyze sensitivity, report due to metastatic invasion, the patient was initiated for chemothe-
specificity, positive and negative predictive value and accuracy of the three rapy; the prognosis is unfavorable due to the dissemination to the lymph
ultrasonic methods and their combinations for the diagnosis of CD, compa- nodes and peritoneum.
ring with the FINAL diagnosis.
Results: Lung ultrasound (LUS) alone exhibited a good sensitivity (100%)
and specificity (82%) and had the highest accuracy (89%) among single 241. CHINA SYNDROME
modalities (heart and IVC) for the diagnosis of CD. The highest accuracy
(96%) was obtained with the combination of positive LUS AND either D’Alessio A., Nanni V., Cucinotta F., Furi E., Mangani I.,
dilated left atrium or EF ≤ 40% or both on heart examination (all p<0.01 vs Cristiano G., Romano C.P. 1, Giunta R. 1, Giannasi G.
single modalities). Nuovo Ospedale S.g.di Dio-Ausl Toscana Centro- Firenze Aou-Universita’
Conclusion: In patients presenting to ED, IUE using PUD is a useful exten- Luigi Vanvitelli Di Napoli 1
sion of clinical examination and has a reliable diagnostic discriminant
ability in the evaluation of acute dyspnea. In April 2016, a 25-year-old Chinese man was admitted to the our emer-
gency department for severe, worsening asthenia. His past medical history
was unremarkable. He denied alcohol abuse and use of illicit drugs. Phy-
Parameter Sensitivity Specificity PPV (%) NPV (%) Accuracy (%)
(%) (%) (95% CI) (95% CI) sical examination of nervous, cardiovascular, and respiratory sistems was
(95% CI) (95% CI) normal, with the exception of light tremor in the upper limbs. ECG revealed
Chest X-ray 64.9 88.5 77.4 80.6 79.6 90 heart rate, low T waves and long QTc. ABG was within normal limits.
(47.4-79.3) (77.2-94.9) (58.5-89.7) (68.8-88.8) Laboratory tests showed severe hypokaliemia and hypomagnesemia. CPK
NT-pro-BNP 80 69.7 73.7 76.7 75 was normal. A provisional diagnosis of hypokalemic periodic paralysis
(62.5-90.9) (51.1- 83.8) (56.6-86.0) (57.3-89.4)
was made and the patient was transferred to the internal medicine ward
Bilateral IS and/ 100 82 78 100 89
or effusion (88.8-100) (69.6-90.2) (63.7-88.0) (91.1-100)
for further diagnostic investigations. Eventually, the patient was diagnosed
Dilated left 92.3 77.0 72.0 94.0 83
with hypokalemic periodic paralysis, in the context of thyrotoxicosis, and
atrium (78.0-98.0) (64.2-86.5) (57.3-83.3) (82.5-98.4) discharged with potassium supplements and tapazole, with good control of
EF ≤ 40% 59.00 90.2 79.3 77.5 78 disease. Hypokalemic periodic paralysis is a channelopathy primarily due
(42.2-74.0) (79.1-95.9) (59.7-91.3) (65.7-86.2) to a defect in a voltage-gated calcium channel, is most commonly found in
IVC dilated and/ 69.2 70.5 60 78.2 70 males of Asian ethnicity, and may be a complication of thyrotoxicosis.
or not collapsing (52.3-82.5) (57.3-81.1) (44.4-73.9) (64.6-87.8)
Bilateral IS and/ 100 93.4 90.7 100 96
or effusion AND (88.8-100) (83.3- 97.9) (76.9-97) (92.1-100)
either dilated left 242. USE OF ULTRASOUND GUIDED LONG PERIPHERAL
atrium or EF ≤ INTRAVENOUS DEVICES IN EMERGENCY DEPARTMENT:
40% or both A SINGLE CENTRE EXPERIENCE
Parameter Area under 95% CI p Giustivi D., Di Capua M., Ruocco A.L., Paglia S.
curve (AUC) Dipartimento di emergenza e accettazione. Ospedale Maggiore di Lodi, Lodi
Bilateral IS and/or effusion AND either 0,968 0,912-0,993 -
dilated left atrium or EF ≤ 40% or both
Approximately 60% to 90% of hospitalized patients require an IV catheter
Bilateral IS and/or effusion 0,911 0,838-0,959 0,0053
during their hospital stay. Therefore, even the most rigorously performed
Dilated left atrium 0,841 0,754-0,906 0,0001
studies indicate that the overall IV catheter failure rate lies between 35% and
EF ≤ 40% 0,746 0,650-0,828 0,0001
50%. Until recently, the dwell time limit for an inserted catheter was restri-
cted to 72 to 96 hours, a limit based on observational data suggesting that
the risk of thrombophlebitis and infection increased the longer a catheter
240. STOMACH AND BREAST, A CASUAL CONNECTION
was left in place and used. Even in major clinical centers with dedicated IV
NEVER
teams performing careful prospective randomized studies, the IV catheter
failure rate is as high as 63%, with a mean and median across studies of
Castorani L. 1, Lattanzio F. 2, Dipaola G. 1, Cannito C.D. 1
46% and 43%, respectively. The main causes of peripheral IV catheter failure
1
U.O. Medicina e Chirurgia d’accettazione e d’urgenza PO “Mons. Dimiccoli”
are: phlebitis, infiltration and occlusion. Some evidence suggests that use
Barletta, ASL. BT,
of ultrasound inserted long peripheral intravenous devices (LPIV) could
2
U.O. Chirurgia Generale PO “Mons. Dimiccoli” Barletta, ASL. BT.
reduce failure rate, infiltration of drugs in soft tissues and catheter related
blood stream infections. We conducted an observational study on 164 US
A 61-year-old patient arrives at the Hospital for epigastric pain and vomi-
inserted LPIV in the emergency department to evaluate the catheter failure
ting. The patient reports for some months vomiting, weight loss, hunger
rate compared to literature data. In six months we placed 164 LPIV in the
reduction, and constipation. She is affected by hypertension, hyperchole-
emergency department (18 3-French catheter and 146 4-Frech catheter) in
sterolemia and a previous breast cancer (8 years earlier). Five months ago,
patient with difficult vein access. The mean dwell time was 10.83 days for
a gastroenterology examination and a gastroscopy (“A grade esophagitis,
the 3-french LPIVs and 12.46 days for the 4-french ones. Rate of failure
hiatal hernia, antrum gastritis”, no gastric biopsies) were submitted. The
was 4/18 (22.2%) in the 3-French LPIV (2 dislocation and 2 phlebitis) and
patient has flat abdomen with Blumberg positive in epigastrium and in
13/146 (8.9%) in the 4-French LPIV (5 dislocation, 1 phlebitis, 7 occlusion).
the right abdominal quadrants. We undergo FAST ultrasound: “conside-
No catheter related blood stream infection was evident. In our experience
rable distension of the small intestine (especially duodenum and jejunal)
the use of US-LPIV in emergency department is a feasible choice with a
with abdominal effusion. Blood exam: microcytic anemia (Hb: 11.2 g / dl;
lower failure rate if compared to literature data of IV catheter. Prospective
MCV: 79 fl). The patient underwent to TC abdomen for acute abdomen
studies are needed to confirm our data and to find out if the use of LPIV in
by bowel obstruction. The TC reports: “... modest abdominal effusion; the
ED is not only safer and better accepted for the patient but probably also
gastric walls appear thickened for edema; there is a significant fluid disten-
cost-effective.
156
and tachypneic with respiratory rate at 30/min. Blood pressure was 90/60
243. USE OF 4AT TEST IN SCREENING FOR DELIRIUM mm Hg and oxygen saturation on room air was 91%. Absolute dysphagia
IN GERIATRIC MEDICAL PATIENT: A PILOT STUDY IN required positioning of nasogastric probe. Inspiratory crackles were heard
EMERGENCY DEPARTMENT in the middle and basal zones of both lungs and percussion revealed dul-
lness at the base of right lung. A careful examination of the skin, abdomen
Paolillo C., Castiglia G., Riccardi A., Pozzi D., Esposito G., Sbrojavacca R. and lower limbs did not reveal any anomalies. Laboratory studies revealed
SOC. di Pronto Soccorso e Medicina d’urgenza, Azienda Sanitaria a white blood cell count of 6030/mmc with 85% neutrophils, C-reactive
Universitaria Integrata di Udine (ASUIUD) protein value of 151 mg/L. PCT was of 1, 10 ng/ml. Also a mild hypona-
tremia (130 mEq/L) was shown. Results of liver, kidney function tests and
Delirium is an acute and fluctuating disorder of attention and cognitive coagulation studies all were normal. Ultrasound lung features of diffuse
functioning, which is almost always triggered by underlying medical causes interstitial syndrome with spared areas were observed and Chest X-ray
and is often accompanied by abnormal arousal and perceptual disturbances. showed pulmonary consolidations in both right and left middle lobes of
Over the age of 80 years, more than one third of those in hospital will expe- the lungs. Subsequent tests found the patient to have a positive urinary
rience delirium. Despite its high prevalence, delirium often goes undetected Legionella Antigen for which piperacillin-tazobactam was discontinued
and undetected delirium is associated with the highest mortality, prolonged and only claritromicyn therapy (500 mg twice a day) was continued with
hospitalization, increased cost of care, higher distress for patients and heal- progressive improvement of clinical and radiographic features. Therapy
thcare professionals. The emergency department (ED) may be a strategic with a quinolone was not considered due to the history of epilepsy of
place to detect this disorder and initiate clinical management. There are the patient. Legionnaires’disease is a significant health problem in many
few studies that examine delirium in elderly ED patients: Lewis, Wofford countries, largely because Legionella pneumophila is a frequent cause of
and Naughton found a prevalence of 5-17% of delirium in ED patients. The both community and hospital-acquired pneumonia. Smoking, chronic
apparently low rate of detection of delirium may be because ED physicians obstructive lung disease, diabetes, chronic corticosteroid therapy and
do not record this diagnosis. Thus the goal of our study were to determine immuno-compromised status are known risk factors for Legionnaires’di-
the prevalence of delirium in elderly ED patients using the 4AT test (4 Rapid sease. Although the most popular theory is that Legionella is inhalated in
Assessment Test for delirium). aerosolized droplets of water, this case shows that rarely, in patients with
Methods: This study was carried out at S. Maria della Misericordia Hospital swallowing disorders, Legionnaires’ disease can be acquired by accidental
Center, Udine, an hospital university integrated trust. All patient aged 75 aspiration of drinking water, with the secretions getting past the choking
years and older who were screened for eligibility had presented consecu- reflex and mistakenly entering the lungs.
tively at the ED. All patients able to comunicate in Italian and for whom
consent could be obtained were enrolled. Critically ill patients (uncon-
sciouss, with unstable cardiorespiratory status or severe trauma) were exclu- 245. SCINTIGRAPHY IN PULMONARY EMBOLISM: BACK
ded. Eligible patients were approached and the 4AT test was administered. TO THE FUTURE
Results: A total of 200 patients aged 75 years and over presented to the ED
from April 2017 to May 2017 were eligible for this study. 122 female and Montaldo L. 1, Esposito G. 1, Barboni E. 2, Sbrojavacca R. 1
78 male, median age was 85, 3. Eighty-three cases of delirium were dia-
1
SOC. di Pronto Soccorso e Medicina d’urgenza, Azienda Sanitaria
gnosed with 4AT. The prevalence of delirium was 41, 3%. Hypoactive was Universitaria Integrata di Udine (ASUIUD) 2 SOC. di Medicina 2, Azienda
the common subtype (74/200 patients, 37%), followed by mixed and hype- Sanitaria Universitaria Integrata di Udine (ASUIUD)
ractive. Sepsis (16%), polipharmacy (18%), urinary retention (7%) and fecal
impaction (6%) were associated with delirium. The diagnosis of pulmonary embolism (PE) has always been a challenge,
Conclusions: Our sample size was very small. However our small model because the clinical presentation of the disease is extremely heterogeneous:
achieved that delirium occurred in about four aged patients every ten from asymptomatic shapes to the obstuctive shock. The diagnosis is often
visited in ED. and that the hypoactive subtypes was the most frequent. Fur- difficult since symptoms and signs are non specific.(1)
thermore the 4AT. proved to be an easy and brief clinical instrument for For many years, the ventilation/perfusion scintigraphy (V/Q scan) has
delirium detection in ED. The ED. may be a strategic place to detect this been the gold standard in PE diagnosis, but in the Emergency Depart-
disorder. Earlier detection of delirium in the ED. could improve the benefits ment setting, Multi-detector computed tomography (MDCT), has replaced
of treatment and the prognosis. the V/Q scan as the initial imaging study in the work up of suspected PE.
Bibliography: G. Bellelli: “Delirium Day”: a nationwide point prevalence MDCT offers significant improvements in spatial and temporal resolution,
study of delirium in older hospitalized patients using an easy standardized faster scan times, and and the ability to identify an alternative diagnosis.
diagnostic tool. BMC. Medicine 2016 14:106. These advancements allow routine visualization of subsegmental pulmo-
JH. Han: Delirium in the older emergency department patient: a quiet epi- nary emboli, but this kind of PE has an uncertain clinical meaning, and may
demic. Emerg Med Clin N. Am 2010 28 611-631. represent “normal” embolic activity originating from the lower extremity
KM. Terrell: Quality indicators for geriatric emergency care. Acad Emerg venous valves (2).
Med 2009 16:441-449 Since the introduction of CT, an 81% increase in PE diagnosis was recorde-
red, but no variation in mortality occurred (3): it‘s, therefore, likely that CT
can cause “overdiagnosis” and consequencely “overtreatment”. The effects of
244. AN “ATYPICAL “ LEGIONELLOSIS long-term anticoagulant therapy are not marginal.
The radiation dose of CT is higher than VQ scan. The Radiation risk varies
Pricoco G. 1, Esposito G. 2, Sbrojavacca R. 2 with sex, age, and organ (it is higher in female, young and breast tissue), so
1
UO medicina Interna e d’ Urgenza, dipartimento di medicina clinica e that the role of VQ scan could be particularly relevant in: Young patients,
sperimentale, Azienda Ospedaliero Universitaria “ Policlinico Vittorio pregnant women and women in general, expecially to reduce breasts expo-
Emanuele “ Catania 2 SOC. di Pronto Soccorso e Medicina d’Urgenza, sition. In the 1990s, the scintigraphy report followed the PIOPED criteria
Azienda Sanitaria Universitaria Integrata Udine (ASUIUD) (4). PIOPED criteria have two limits: The first, the elaborate response in
five categories (normal, very low probability, low probability, intermediate
Legionnaires’ disease is an acute pneumonia caused by inhalation or aspi- probability and high probability), The second, The high number of non
ration of aerosols contaminated with Legionella bacteria. The majority diagnostic exams (about 70%). Subsequently, new interpretation criteria
(>90%) of Legionnaires’ disease cases are caused by the species of Legio- were elaborated: PISAPED (5) and PIOPED II (modified) (6). Both criteria
nella pneumophila, and about 85% more specifically by L. pneumophila. propose to perform chest radiography before the scintigraphy. In this way,
We report the case of a 46-year-old man, with a history of tetraparesis fol- a normal (or almost normal) chest x-ray allows to eliminate the ventilation
lowing a road accident and secondary focal epilepsy, who presented to our component of the exams, because in the presence of a normal x-ray, any
department with a nine day history of fever (up to 38.5°C), mild dyspnoea defect of perfusion is considered a mismatch. Finally, the new diagnostic
and ingrown dysphagya. In the previous 7 days the patient was treated in criteria, reduce only three categories (non-diagnostic, probable and unpro-
a medicine department of his town with amoxi-clavulanate in the first 3 bable) the results of the exam.
days, then switched, due to poor clinical improvement, to dual empiric We aimed to establish whether a “PE diagnostic algorithm” based on chest
therapy with piperacillin-tazobactam (13.5 g/24h) and clarithromycin X-ray and perfusion scan was reliable in the our Emergency Room (ER).
(500 mg twice a day). Upon arrival at our department, on physical exa- Prior to the X-ray, we also established the pre-test probability of PE, using
mination the patient had a body temperature of 37.6ºC, was tachycardic either a validated scores (Well’s score, Geneva score) or The “Gestalt “, and
dosed the D-dimer (when probability was low). The inclusion criteria were:
157
Suspected PE, haemodynamic stability, chest X-ray read as negative accor-

ding to PIOPED II criteria. These patients were then subjected to perfusion 247. NECROTIZING FASCIITIS: A CASE REPORT
scintigraphy to exclude or confirm PE. We recruited 23 patients, 16 females
and 7 males. The mean age was 46.2 years. Scintigraphy was diagnostic for Mazziotti M.A. 1, Esposito G. 2, Onorato P. 2, Sbrojavacca R. 2
PE in 5 cases, . 4 out 16 patients with negative scan for PE, came back to 1
Istituto di Clinica Medica e Geriatria, Fondazione Policlinico Universitario
the ER in the following days, but no one had symptoms or signs suggestive Agostino Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy; 2 SOC.
for PE. In our study We had no false negative results and no scan was read di Pronto Soccorso e Medicina d’Urgenza, Azienda Sanitaria Universitaria
as non diagnostic. The numbers are certainly very limited, but the return Integrata Udine (ASUIUD), Italy
of pulmonary scintigraphy in the diagnosis of pulmonary embolism gives
a real chance of limiting “overdiagnosis” and is a good example of “less is A 73-year-old woman presented to our Emergency Department complai-
more”. ning of severe pain in the left inguinal region, started two days before
(1). Cecilia Becattini and Giancarlo Agnelli. Risk stratification and and worsening during the last night. She denied history of trauma. Her
management of acute pulmonary embolism - Hematology 2016, Dec medical history included hypertension, osteoporosis, chronic hepatitis C
2;2016(1):404-412. virus and a cerebral venous cavernous hemangioma. There was no evi-
(2). Jane M. Suh J.M. et al - Dots are not clots: the over-diagnosis and dence for any allergies or drug abuse. At the initial clinical examination
over-treatment of PE - Emerg Radiol (2010) 17:347–352 she presented intensely suffering, alert and afebrile. The examination of
(3). Wiener R.S. et al -Time trends in pulmonary embolism in the united the region didn’t reveale any inflammation sign. Compression ultraso-
states: evidence of overdiagnosis.- arch intern med. 2011;171(9):831-837 nography excluded a deep venous thrombosis. Over the next few hours,
(4). Gottschalk A. et al, Ventilation-perfusion scintigraphy in the PIOPED the patient’s clinical situation progressively deteriorated. She started to be
study. II. Evaluation of criteria and interpretations. J Nucl Med 1993; 34: febrile, hypoperfused, tachycardic and tachypneic. Blood tests were consi-
1119- 1126. stent with severe sepsis and multiorgan dysfunction. An abdominal-pelvic
(5). Miniati M, Pistolesi M Et Al -Value of the perfusion lung scan in CT scan found a pronounced cutaneous and subcutaneous edema of the
the diagnosis of pulmonary embolism. Am J Respir Crit Care Med. inguinal region together with an effusion spread along anterior fascia of
1996;154:1387–1393. pelvic and thigh muscles. A multidisciplinary assessment was carried out
(6). Sostman H. D. et al - Sensitivity and Specificity of Perfusion Scinti- together with infectivologists, general and vascolar surgeons, gynecologi-
graphy Combined with Chest Radiography for Acute Pulmonary Embolism sts, orthopedics and anesthetists and the decision to perform immediate
in PIOPED II.- J Nucl Med 2008; 49:1741–1748 explorative surgery was made. The patient underwent an emergency inci-
sion with surgical debridement of necrotic tissues and a broad-spectrum
IV antibiotic therapy was started. The patient was then transferred to
246. ACUTE TUBULAR NECROSIS: A CLINICAL CASE OF the intensive care unit for post-operative care and supportive measures.
ETHYLENE GLYCOL INTOXICATION Tissue and blood cultures returned a positive result for group A beta-he-
molytic Streptococcus. The patient was discharged home after 78 days
Mastropasqua M., Di Vincenzo M.G., Legramante J. M., from her admission.
Malatesta M., Noja M., Petrilli C., Susi B. Necrotizing fasciitis is a rare soft-tissue infection primarily involving the
Dipartimento di Pronto Soccorso-Medicina d’Urgenza Policlinico Tor superficial fascia of skeletal muscle. Predisposing factors include diabetes,
Vergata, Roma immunosuppression and traumatic wounds but it can manifest in otherwise
healty people as well. The affected area usually shows skin changes but they
Ethylene glycol is a bivalent alcohol used as antifreeze in the automotive can be initially absent. Laboratory findings and imaging studies are useful
industry (airport slopes, locks, etc.). It is also used in condensers and in the diagnosis but it can be often definitively established only by surgical
heat exchangers, lacquers and glues. Ethylene glycol is absorbed from the exploration. A bacterial etiology is usually found. Treatment consists of early
gastrointestinal tract rapidly, after ingestion(blood peak within 1-4 hours and complete surgical debridement of necrotic tissue, combined with bro-
after ingestion). Initially it exerts an action on the central nervous system, ad-spectrum antibiotic therapy and hemodynamic support if necessary. This
stimulating and then narcotic, subsequently causing cardiovascular disor- case demonstrates that even in young and previously overall healthy patients,
ders and metabolism alterations, and renal impairment to kidney failure. It necrotizing fasciitis can be a rapidly progressive and life-threatening condi-
is metabolized at the liver level and generates acid metabolites with higher tion. Prompt diagnosis and rapid surgical intervention are crucial and can
toxicity than the starting compound, such as glycol aldehyde, glycolic acid mean the difference between life and death in these critically ill patients.
and oxalates. We describe the case of young man, A.D. of 27 years, we
came to our observation for ingestion of about three glasses of antifreeze
and bleach (not more precisely specified), about six to eight hours prior 248. NEW MODEL OF ACUTE OBSTRUCTIVE JAUNDICE
to arrival in the Department of Emergency. The patient appeared sleeply, MANAGEMENT IN THE EMERGENCY DEPARTMENT
confused, with contracted diuresis. At emogas-analysis, metabolic acidosis
(lactate 8 mmol / L) was present, the hepato-renal function was normal at Ojetti V. 1, Sinatti D. 1, Perri V. 2, Petruzziello C. 1, Tringali A. 1, Gasbarrini A.
the beginning. The patient was subjected to EGDS (“no esophagus-gastric 1
, Costamagna G. 2, Franceschi F. 1
stenosis lesions”) and TAC chest-abdomen (“no perforations”). Pavia’s CAV 1
Department of Emergency and Internal Medicine, Catholic University,
colleagues indicated that the patient was subjected to hydration(approxi- Rome, Italy 1 Department of Endoscopy, Catholic University, Rome, Italy
mately 7 L / 24 h), administration of antidote (95% ethanol, 5 fl in SF 500
cc, with a first dose of 10 ml / kg in 30-40 min, ethanolemia dosing (thera- Introduction: Obstructive jaundice is a frequent cause of access in Emer-
peutic range 120-150) followed by 2 ml /kg/h, dosage of ethanolemia and gency Department (ED) and requires a rapid management with hospitali-
renal chemistry performed every two hours).Because of persistence of oli- zation, in order to perform ERCP. To reduce the problem of overcrowding,
go-anuria, as the volume of distribution of ethylene glycol low (less than 1L in Italian’s ED were introduced Brief Observation Units (BOUs), in which
/ Kg) and the linkage to almost absent plasma proteins, it was indication patients are treated for 48-72h with a significant decrease of hospitaliza-
for urgent hemodialysis.The high dosage of ethylene glycol (laboratory test tions. Aim of our study was evaluate the efficacy of a new model of mana-
carried out at CAV in Pavia) has confirmed the intoxication. The patient ging obstructive acute jaundice directly from BOU.
was subjected to serious lactate evaluations, hepato-renal function, etha- Patients and Methods: We evaluated, from September 2014 to November
nolemia and urine examination with progressive improvement in clinical 2016, 162 patients (79M/83F, mean age 65±16, 8 years) who came to our ED
and laboratory conditions and subsequently hospitalized at SPDC for the with an acute obstructive jaundice, confirmed by ultrasound or CT scan. All
appropriate treatment. Ethylene glycol, after ingestion, is metabolised by patients had the indication to perform ERCP.
glycolaldehyde alcohol-dehydrogenase, which is metabolized to glycolic Results: 92, 6% (150 out of 162) patients were discharged, directly from
acid, glycosilic acid and ac. oxalic acid, which together with lactic acid are BOU, the day after the procedure or within 48 hours from admission, with
responsible for metabolic acidosis and organ damage resulting from the a higher discharge rate in in those with choledocholithiasis (94%), biliary
precipitation of insoluble oxalate crystals together with calcium (calcium stent clogging (97%) and pancreatic prosthesis (100%). In the table below
oxalate). The prompt administration of the antidote and hemodialysis has are shown ERCP findings, with relative discharge rates.
allowed a rapid recovery (48 hours of hospitalization in Department of
Emergency) of the clinical and laboratory picture.
158
FINDINGS N° OF PATIENTS (%) DISCHARGE RATE At history she had experimented many admissions to various hospitals
pancreatic cancer 6 (3,7%) 5 (83%) ever presenting with the same clinical picture until her deep worsening
cancer of the bile duct 4 (2,5%) 3 (75%) due to a respiratory failure which needed intubation ventilator and inotro-
choledocholitiasis 97 (60,8%) 91 (94%) pic support in Intensive care unit and renal failure treated on dyalisis for
prothesis obstruction 37 (22,8%) 36 (97%) prerenal acute kidney injury. Unluckily, although she had experimented
pancreatic prosthesis 8 (4,9%) 8 (100%) many similar episodes with various admissions to Hospital, the patient had
benign strictures 7 (4,3%) 6 (86%) had not yet any diagnosis. During each admission she had been hemo-
others 3 (1,9%) 1 (33%) concentrated, hypoalbuminemic, but never there was been evidence of
sepsis signs. At admission to our Dept, she presented alert and oriented
Discussion and Conclusions: Our study showed, for the first time, the but tachycardic and hypotese with HR of 125 b/min and BP 85/50 mmHg.
effectiveness of BOU in the managing of patients with acute obstructive jau- Laboratory data pointed out an hypoalbuminemia (22g/L), rise of creati-
ndice, with a high percentage of discharge (92, 6%), in particular in patients nine 3.2 mg/dL) and presence of proteins in urine (+--) and large numbers
with choledocholithiasis, biliary stent clogging and pancreatic prosthesis. of hyaline casts and low urine output, CRP (12 mg/dL) elevation, normal
The definition of a subset of patients with acute obstructive jaundice who serum protein electrophoresis and negative screen for sepsis. Normal was
could be efficacy managed in BOU, is the essential approach to decrease troponin, EKG and echocardiogram with normal left ventricular function.
unnecessary inpatients’ admissions. On the grounds of clinical picture and history and overall since the cardiac
performance was good with normal systolic function, we suspected a case
of Clarkson disease (Systemic capillary leak syndrome) and treated our
249. NEW MODEL OF CHOLEDOCHOLITHIASIS patient on intravenous crystalloid solution, oral theophylline and terbuta-
MANAGEMENT IN THE EMERGENCY DEPARTMENT line, albumin, glucocorticoids and diuretics with progressive improvement
of her clinical picture blood pressure normalization and normal urine
Ojetti V. 1, Sinatti D. 1, Perri V. 2, Petruzziello C. 1, Tringali A. 1, Gasbarrini A. output and was discharged 7 days later.
1
, Costamagna G. 2, Franceschi F. 1 Discussion:Clarkson’s disease is a very rare, sneaky and potentially fatal
1
Department of Emergency and Internal Medicine, Catholic University, disease the causes of which are unknown difficult to diagnose. As possible
Rome, Italy 1 Department of Endoscopy, Catholic University, Rome, Italy causes it has been suggested drug adverse effects (interleukins-monoclonal
antibodies, gentamicine), sepsis, graft versus host disease, ovarian hyper-
Introduction: Choledocholitiasis is one of the most common cause of access stimulation syndrome, viral hemorrhagic fevers, autoimmune diseases,
in Emergency Department (ED), and requires a rapid treatment with ERCP snakebite. Physiopathology seems to recognize two steps: capillary leak
and hospitalization. To reduce the problem of overcrowding and elevated phase and recruitment phase. Urgent therapy consists in prompt admini-
hospital admissions, in Italian’s ED was introduced Brief Observation Unit stration of beta-2-stimulants as terbutaline and theophylline, albumin, col-
(BOU), in which patients are treated for 48-72h, with a significant decrease of loids, glucocorticoids to reduce or stop the capillary leak and diuretics in
regular admission costs. Aim of our study was evaluate the efficacy of a new the second stage in order to help the patients to discharge the accumulated
model of managing patients with acute choledocholitiasis directly from BOU. fluids quickly.
Patients and Methods: We evaluated, from September 2014 to November
2016, 97 patients (55M/42F mean age 66, 2±17, 8 yrs) who came to our
ED of “Gemelli” Hospital with acute choledocholitiasis, confirmed by ultra- 251. LIMS (LIGHT MONITOR STUDY): HOW TO
sound or CT scan. All patients had the indication to perform ERCP. IMPROVE OUTCOMES, LENGTH OF STAY AND COSTS
Results: In the table are shown characteristics of patients, with discharge OF CRITICALLY ILL PATIENTS IN INTERNAL MEDICINE
rate. UNITS WITH WIRELESS MONITORING SYSTEMS
FINDINGS TOTAL PATIENTS DISCHARGE RATE FROM BOU
Pietrantonio F. 1, Bussi A.R. 1, Amadasi S. 1, Bresciani E. 1,
Cholelitiasis 22/97 18/22 (82%)
Caldonazzo A. 1, Colombini P. 1, Giovannini M.S. 1, Lanzini L. 1, Migliorati P.
with cholecystectomy 53/97 52/53 (98%) 1
, Perini P. 1, Politi A. 1, Soldati F. 1, Meneghetti O. 1, Bellocco R. 2, D’Amico R. 3
acalculous gallbladder 22/97 21/22 (95,4%) 1
U.O. Medicina Interna P.O. Manerbio (BS) ASST-Garda, 2 Università di
94% of patients (91 out of 97) were treated and directly discharged from Milano-Bicocca, Cattedra di Statistica Medica, 3 Università di Modena e
BOU. Reggio Emilia, Cattedra di Statistica Medica
Discussion and Conclusions: Our study showed, for the first time, the
effectiveness of BOU in managing patients with choledocholitiasis, with Background: Continuous monitoring of ASST-Garda’s activity data showed
a high percentage of discharge (94%). In particular, we reached greater an increasing trend in access to Emergency Department (ED) and subse-
results for patients with previous cholecystectomy or acalculous gallblad- quent hospitalizations for patients over 65 years with chronic diseases in the
der, respectively 98% and 95, 4%. The definition of a subset of patients with acute phase, that remains constant regardless of seasonal factors. ED access
choledocholitiasis who could be efficacy managed in BOU, is the essential data in the first quarter of 2017 compared to the same 2016 period, showed
approach to decrease unnecessary inpatients’ admissions. an increase of 1% of ED accesses with a corresponding growing of Internal
Medicine (IM) admissions by approximately 10%, resulting in overcrow-
ding of ED and IM Department. A recent retrospective study carried out in
250. A MYSTERIOUS CASE OF HYPOALBUMINEMIA DUE the Internal Medicine Unit of Manerbio Hospital also showed that critical
TO….THE TOO OFTEN MISDIAGNOSED CLARKSON patients (with need for continuous monitoring and high technology) admit-
SYNDROME!!! ted to IM are 27% (10% with intensive care transfer criteria: MEWS≥ 5)
and present between 5 and 6 active pathologies.The 23%, however, predomi-
Piccillo G.A. 1, Saitta R. 1, Mondati E.G.M. 2, Gasbarrini G.B. 3 nantly, presents socio-sanitary problems and the need to activate integrated
1
Emergency Department, Cannizzaro Hospital Catania; 2Department of hospital-territory pathways.
Internal Medicine and Systemic Pathologies, University of Catania; 3Professor Methods: In order to evaluate the usefulness of wireless monitoring systems
Emeritus of Internal Medicine, Catholic University of Rome in the management of critical patients in Internal Medicine, provide data on
the impact of acute and critical patients in IM and economic data that will
Introduction: Clarkson’s disease (also known as Systemic Capillary Leak help quantify the relative cost of a situation of acute in-hospital admission, a
Syndrome- SCLS), first described by B. Clarkson in 1960, is an extremely pilot perspective controlled randomized open-label single-center study with
rare medical condition characterized by self-reversing episodes during WIN @ Hospital wearable and wireless system was started (LIMS Study).
which the endothelial cells which line the capillaries are thought to separate Patients with Early Warning Score (MEWS) ≥ 3 and / or NEWS (National
for a few days, allowing for a leakage of fluid from the circulatory system to Early Warning Score)≥ 5 were subjected to wireless monitoring versus tra-
the interstitial space, resulting in a dangerous hypotension, hemoconcen- ditional monitoring in the first 72 h of hospitalization. Primary End Point:
tration, and hypoalbuminemia. It is a life-threatening illness because each Reduction of major complications that, early treated, allow the improve-
episode has the potential to cause damage to, or the failure of, vital organs ment of critical patient outcomes. Secondary endpoints: Length of Stay
due to limited perfusion. Moreover, unfortunately, it is often misdiagnosed (LOS) reduction; reduced monitoring nurse’s time; patients’ stratification
as other diseases. and end stage definition. Preliminary Results: From March 21st to today, 31
Case Report: A 42 year old woman was admitted to our Department due patients have been recruited. Average age: 80, 5 years; Average LOS: 9 days;
to dyspnoea and diarrhea and oedema to her mid-calves since few days. Re-hospitalization within 21 days: 8 paz (25%); Deaths: 5; CIRS Average
159
Comorbidity: 4; CIRS CI severity: 2. Most frequent DRG 127 (heart failure). 253. SHORT-TERM BLOOD PRESSURE VARIABILITY AND
Reduction of time spent by the nurse in vital parameters monitoring: from CIRCADIAN BLOOD PRESSURE PROFILE IN SUBJECTS
33 to 41 min / day / patient. 42% of patients have a Blaylock Risk Assessment WITH HYPERTENSIVE URGENCIES
Screening Score (BRASS) ≥20, indicating frail patients who need adequate
taking in charge and continuity of care from hospital to territory. Ricci S. 1, Battista F. 1, Sgariglia R. 1, Crocetti A. 2, Tilocca G. 2,
Conclusion: Preliminary results of the LIMS study show the feasibility Perlini S. 3, Pucci G. 1
of using wireless systems in daily practice and in the management of the 1
Struttura Complessa di Medicina Interna, Azienda Ospedaliera di Terni,
chronic and frail patients. Considering that about 1/4 of the IM patients Dipartimento di Medicina, Università di Perugia, Terni, Italia 2 Struttura
presents, in addition to the acute clinical problem, also social problems, it Complessa di Cardiologia, Azienda Ospedaliera di Terni, Dipartimento di
would be useful to extend the use of remote monitoring systems also in the Medicina, Università di Perugia, Terni, Italia 3 Dipartimento di Medicina
territory, both in residential facilities and at home. The advantage of using Interna e Terapia Medica, Policlinico “S.Matteo”, Università di Pavia, Italia
wireless monitoring systems in IM is that the measurement of critical para-
meters and the resulting alarms are detected by mobile devices (smartpho- Introduction: Hypertensive Urgencies (HU), classified as abrupt blood
nes and tablets) operated by doctors and nurses in the department with pressure (BP) increases above 190/110 mmHg without acute organ damage,
considerable reduction of management costs. The extension of the use of could be theoretically conceived as an expression of increased short-term BP
these systems in the patients’monitoring in low intensity structures and at variability (BPV). However, few studies systematically explored this asso-
home would provide qualified assistance to the patient even after hospital ciation. It is also unknown if subjects experiencing HU are characterized
discharge, reducing ED access and overcrowding of the Internal Medicine by abnormal BP circadian profiles. We evaluated the association between
Units. For an appropriate patient’s data flow management, a multidiscipli- HU, measures of short-term BP variability, and nocturnal BP dipping in a
nary team can respond in real time to patient needs properly framed with case-control study.
a constant monitoring. Methods: we analysed all subjects consecutively admitted to the Emergency
Department of the “S. Maria” University Hospital, Terni, with a diagnosis of
HU, and subsequently evaluated in the Hypertension Unit by a specialist.
252. DIAGNOSTIC ROLE OF HOSPITAL INTERNAL All subjects underwent Ambulatory Blood Pressure Monitoring (ABPM)
MEDICINE. A RETROSPECTIVE OBSERVATIONAL within 5 days from admission. Subjects with hypertensive emergencies
STUDY COMPARING THE EMERGENCY DEPARTMENT (at admission or during the following days) were excluded. Controls were
INITIAL DIAGNOSIS AND THE INTERNAL MEDICINE selected in order to be well matched with HU subjects for sex, age, 24-h
DISCHARGE DIAGNOSIS SBP/DBP, and number of anti-hypertensive drugs. All controls had a nega-
tive history for HU. Day-time and night-time standard deviation of SBP
Scotti E. 1, Pietrantonio F. 2, Alessi E. 1, Leardi M.G. 1, Gerardi F. 1, (SD-SBP), Systolic BP Average Real Variability (ARV), and weighted 24-h
Rainone M. 1, Vesprini E. 1 SD of SBP (wSD) were taken as measures of BPV. All subjects were managed
1
Unità Operativa Medicina Generale, Istituto Neurotraumatologico Italiano according to Guidelines for Good Clinical Practice.
(INI), Grottaferrata (Roma) 2Unità Operativa di Medicina Interna, Ospedale Results: 62 subjects with HU (60±16 years, office BP 190/101±21/10
di Manerbio, Manerbio (BS) ASST-Garda mmHg, 24-h BP 122/73±13/9 mmHg), were compared with 177 controls.
Both groups did not differ in terms of 24-h SBP/DBP, day-time and night-
Background: Despite the central role of Internal Medicine (IM) in emergency time SBP/DBP, number of anti-hypertensive drugs, and degree of noctur-
admissions management, both users and health programmers seems don’t nal BP fall. Subjects with HU had increased wSD (12.0±3 vs 9.2±3 mmHg,
know the distinctive features of IM activities. According to Literature, IM role p=0.02) and night-time SD-SBP (9±3 vs 8±2 mmHg, p=0.01) as compared
is characterized by: 1. Acute, critical, poly-pathologic and complex patients to controls. Differences in ARV (8.5±3 vs 6.9±3 mmHg, p=0.29) and day-
management; 2. Difficult clinical diagnosis; 3. Priorities’ identification; 4. time SD-SBP (12±4 vs 12±3, p=0.22) were not significant.
Hospital-territory paths promotion integrating different specialists activities. Conclusions: as compared to hypertensive patients without HU, subjects
Objective. To determine the proportion of correct and missed emergency referring to the ED for HU showed increased indexes of short-term BPV,
department (ED) diagnoses compared to IM discharge diagnoses. expressed as increased wSD and nocturnal SD-SBP. We did not found any
Methods: ED diagnoses and hospital IM discharge diagnoses were compa- differences between groups in terms of nocturnal BP dipping. Our results
red. By using consensus among experts method a diagnosis evaluation grid therefore suggest a possible functional link between increased BPV and the
was realized. Diagnosis has been defined as follows: 1. The “gold standard” occurrence of HU in hypertensive patients.
diagnosis (correct diagnosis), according to ICD9 (9th International Classifi-
cation of Diseases and Related Health Problems), carried out independently 254. NEUROCARDIOLOGY: TAKO TSUBO SYNDROME
by two experienced IM specialists and reported in the discharge letter. 2. ED
diagnosis performed by the First Aid Physician and reported in the patient Suppa M., Colzi M., Millarelli F.R., Fazzi V., Mazzocchitti A.M.,
acceptance or transfer record to the Internal Medicine Unit; 3. Wrong Prio- Coppola A., Gradini R.
rity: the correct diagnosis appears as a secondary diagnosis in the ED diagno- 1
Dipartimento di Emergenza - Università degli Studi di Roma “ Sapienza”,
sis; 4. Incomplete diagnosis: diagnostic orientation without a precise diagno- 1
Dipartimento di Medicina Sperimentale - Università degli Studi di Roma
sis; 5. Wrong Diagnosis: the correct diagnosis was not performed in ED. The “Sapienza”
first 13 diagnoses made in ED are defined as most frequent in number within
the sample being examined. Introduction: Neurocardiology refers to the interplay between the nervous
Results: 317 nontrauma patients presenting to the ED from June to September system and the cardiovascular system. Stress-related cardiomyopathy exem-
2016 and admitted to INI (Italian Neurotraumatologic Institute) IM depart- plifies the brain-heart connection and occurs in several conditions with
ment were included for final analysis. The final diagnosis at IM discharge was acute brain injury that share sympathetic activation. The brain’s influen-
taken to be the correct “gold standard” diagnosis. In 180 patients (56, 7%) ces on heart can include elevated cardiac repolarization abnormalities on
corresponded to the primary ED diagnosis, in 104 patients (32, 8%) were electrocardiogram, myocardial necrosis, and autonomic dysfunction. The
missed, the remaining 10.5% of the diagnosis (33 patients) was incomplete or aim of this study was to evaluate this in the takotsubo syndrome (TTS) that
with wrong priority. The most frequent final diagnoses were cardiac failure (n generally presents as an acute myocardial infarction characterized by severe
=53), pneumonia (n= 43), TIA (Transient Ischemic Attack) (n=31); respira- left ventricular dysfunction.
tory failure (n=28); COPD (Chronic Obstructive Pulmonary Disease) (n=21), Materials and Methods: Between 2015 and 2016, five consecutive patients,
correctly diagnosed at the ED in 37, 26, 19, 20, and 11 patients, respectively. aged between 70 and 75 years, four woman e one man, were enrolled in
Conclusion: Patients presenting in ED with acute symptoms represent a dia- the study. All patients were hospitalized in the Emergency Department with
gnostic challenge that in 43.3% of cases is explained by the clinical activity abrupt-onset chest pain or dyspnea and suspected takotsubo syndrome.
done by the Internal Medicine specialist during hospitalization. The study Blood samples were drawn immediately after admission by direct venipun-
confirms the central role of Internal Medicine in defining the correct diagno- cture of an antecubital vein, applying a minimum of stasis. Ordinary labora-
sis in acute and complex patients. It is probably time to promote awareness tory data included myoglobin, troponin T, CK-MB, and electrocardiogram
campaigns for patients and policy makers on the central role of Internal Medi- (ECG). All patients underwent angiography procedure.
cine in hospital organization and hospital-territory integration and to give the Results: In two patient there was sone psychiological stress in the family
right weight to the IM complex activitiy through an appropriate DRGs (Dia- in the previous days, in the others a strenuous physical activity preceded
gnosis Related Groups) valorization in Medical Area. the onset. In two patient there was also a stroke at entrance the emergency
department. In four patients ECG presented with diffuse T-wave inversion,
160
particularly in the anterior and lateral leads, in one patient the ECG was 256. VITAMIN D LEVELS IN PATIENTS WITH GAUCHER
normal. All patients manifested modest increases in creatine kinase-MB DISEASE: BASAL AND AFTER ORAL SUPPLEMENTATION
and cardiac troponin T concentrations. Coronary angiography showed EVALUATION
either normal coronary arteries or nonobstructive coronary artery disease.
The diagnosis of TTS was suggested by the area of dysfunction detected on Molisso A. 1, Barbato A. 1, Sibilio M. 2, Rendina D. 1, Tuzzi R. 3,
left ventricular (LV) angiography. Strazzullo P. 1
Conclusion: There is general consensus that this “brain-cardiac” process 1
Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli
occurs via the β-adrenoceptor–mediated cAMP-dependent proteinkinase “Federico II”; 2Divisione di Pediatria, Ospedale “Moscati” di Aversa (CE),
pathway. Regional differences in adrenoceptor density might explain the Italia; 3Dipartimento di Scienze Mediche Traslazionali, Università di Napoli
pattern of LV dysfunction often seen in TTS. Experimental data have shown “Federico II”
that β2- adrenoceptors are more frequently expressed in apical than in basal
segments of the LV, whereas a reverse distribution is present for norepine- Background: Gaucher disease (GD) is the most prevalent lysosomal storage
phrine β1-adrenoceptors and sympathetic nerve terminals of the neuro-car- disease due to accumulation of glucosylceramide in cells of the reticu-
diac axis, which are expressed much more at the base rather than at the lo-endothelial system and is often associated with bone impairment. The
apex of the LV. The high prevalence in postmenopausal women suggests present study aims to evaluate the 25-hydroxyvitamin D (25[OH]D) levels
that estrogen deprivation may play a facilitating role, probably mediated by in outpatients with GD before and after oral supplementation according to
endothelial dysfunction. the Holick protocol.
Methods: In 30 adult patients with GD (age, mean (range): 46.5 yrs (18
to 68 yrs)), the serum 25[OH]D levels were measured with standardized
255. THE ROLE OF PROCALCITONIN IN THE DIAGNOSIS technique. All patients found to have a 25[OH]D level lower than 30 ng/ml
OF ACUTE CORONARY SYNDROME were prescribed oral cholecalciferol (vitamin D3) supplementation in order
to normalize their vitamin D status.
Suppa M., Granato T. 1, Anastasi E. 2, Colzi M., Millarelli F.R., Results: At basal examination all patients, except one, showed serum
Mazzocchitti A.M, Millarelli F., Fazzi V., Gradini R. 3 25[OH]D levels lower than 30 ng/ml. According to the Holick protocol, the
Dipartimento Emergenza -Università degli Studi “Sapienza” - Roma, 1IBPM/ patients were treated with different dosage of cholecalciferol according to
CNR. - Roma, 2Dipartimento Medicina Molecolare - Università degli Studi “ basal 25[OH]D levels. In 27 patients, after a mean of 21 months (range: 9 to
Sapienza”- Roma, 3Dipartimento di Medicina Sperimentale Università degli 36 months) of oral supplementation with cholecalciferol (vitamin D3) only
Studi “Sapienza”- Roma 3 patients normalized their 25[OH]D levels.
Conclusion: In this group of GD patients, living in southern Italy, we
Introduction: Cardiovascular diseases represent the leading cause of mor- detected low serum levels of 25[OH]D similarly to what reported in other
tality and morbidity both in men and women, and include both heart and GD populations. To our knowledge, this was the first analysis looking at
blood vessels conditions. Sometimes patients with chest pain have typical the effect of oral vitamin D supplementation in GD patients in real life.
symptoms and other undiagnosed symptoms due to other concomitant Despite the correct therapeutic approach, only about 10% of the patients
pathologies making the diagnosis more difficult. Cardiac troponin is a undergoing treatment reached normal serum 25[OH]D levels (>30 ng/ml).
well-established biomarker of myocardial injury and it is clinically used Among possible reasons for this unsatisfactory outcome, poor compliance
to guide diagnosis and management of patients suspected of having acute of patients or defects in vitamin D absorption are the most likely.
coronary syndromes. This has led to improved decision-making process in
this type of novel biomarkers in cardiac patients as Procalcitonin (PCT).
The aim of this study was to determine the levels of PCT in acute coro- 257. EFFECTS OF DARK CHOCOLATE ON ENDOTHELIAL
nary syndrome (ACS) and to investigate their possible correlation with the FUNCTION IN PATIENTS WITH NON-ALCOHOLIC
release of troponin T, myoglobin and CK-MB. STEATOHEPATITIS
Materials and Methods: Between November 2015 and March 2016, 48 con-
secutive patients, aged between 40 and 70 years (mean 61.5 range 43-77 Battaglia S., Loffredo L., Perri L., Polimeni L., Carnevale R.,
years) were enrolled in the study. The patients were 83 % Caucasian and 17 Baratta F., Novo M., Del Ben M., Angelico F., Violi F.
% Asian. All patients were hospitalized in the Emergency Department with Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma
chest pain and suspected ACS. The total patient population was divided into Sapienza
two subgroup, females (n=8) and males (n=40), respectively. Blood samples
were drawn immediately after admission by direct venipuncture of an ante- Background: Oxidative stress plays a pivotal role to determine endothe-
cubital vein, applying a minimum of stasis. Ordinary laboratory data inclu- lial dysfunction in patients with non-alcoholic fatty liver disease (NAFLD).
ded procalcitonin, creatinine, sodium, potassium, calcium, glucose, CRP, Polyphenols could reduce oxidative stress and improve endothelial function
blood count, troponin T, CK-MB, cholesterol, triglycerides, HDL. by inhibiting the nicotinamide-adenine-dinucleotide-phosphate (NADPH)
Results: Among the 48 patients included in the study, chest pain was descri- oxidase isoform Nox2. Aim: The aim of this study was to analyze the effect
bed in 25 % patients with unstable angina (UA), 12, 5 % patients with ST of cocoa polyphenols on endothelial function, assessed by flow-mediated
elevation myocardial infarction (STEMI) and 62, 5% with no ST elevation dilation (FMD), in a population affected by non-alcoholic steatohepatitis
myocardial infarction (NSTEMI). The clinical characteristics of the patients (NASH).
included in the study presented the following parameters: 58, 3 % hyper- Methods: In a cross-sectional study we analyzed FMD and oxidative stress,
lipidemia, 70.8% hypertension, 16.6% diabetes, 29.1 % previous coronary as assessed by Nox2 activation, serum isoprostanes and nitric oxide bioa-
artery disease. All patients have been submitted to angiography procedure. vailability (NOx), in patients with NASH (n=19), simple fatty liver disease
79% of patients were eligible to percutaneous coronary intervention (PCI) (FLD) (n=19) and controls (n=19). Then, we performed a randomized,
and stenting and 17 % were submitted to coronary artery bypass surgery. cross-over study in 19 subjects with NASH comparing the effect of 14-days
After coronary angiography one patient has not been referred to any tre- administration of 40 g of chocolate at high (dark chocolate, cocoa>85%)
atment. Serum electrolytes, sodium, potassium, calcium levels and pro- versus low content (milk chocolate, cocoa <35%) of polyphenols on artery
calcitonin were within the normal range. All patients were evaluated with dilation and oxidative stress.
echocardiogram and had a good ejection fraction: 71% was > 45% and 29% Results: Compared to controls, NASH and FLD patients had higher Nox2
was < 40%. activity and isoprostanes levels and lower FMD and nitric oxide bioavailabi-
Conclusion: Studies on the use of this marker in ACS diagnosis, an inflam- lity, with a significant gradient between FLD and NASH. The interventional
matory process indicate its usability; but some other studies emphasize its study showed that, compared to baseline, FMD and NOx increased (from
inefficiency in diagnosis and see it only as a predictor of heart patients’ sur- 2.9±2.4 to 7.2±3.0% p<0.001 and from 15.9±3.6 to 20.6±4.9 μM, p<0.001,
vival. in the present study the results show that there is no significance. respectively) in subjects given dark but not in those given milk chocolate. A
simple linear regression analysis showed that Δ (expressed by difference of
values between before and after 14 days of chocolate assumption) of FMD
was associated with Δ of Nox2 activity (Rs=-0.323; p=0.04), serum isopro-
stanes (Rs: -0.553; p<0.001) and NOx (Rs: 0.557; p<0.001).
Conclusions: Cocoa polyphenols improve endothelial function via Nox 2
down-regulation in NASH patients.
161
258. CARDIOVASCULAR RISK IN PATIENTS WITH working memory and long-term, visuographic memory), and executive
TYPE 2 DIABETES MELLITUS: ROLE OF THE SPECIFIC functions (NPZ-E: task-switching), were calculated. Results. At baseline, in
DETERMINANTS OF DISEASE SEVERITY the whole group of patients (n=62), working memory correlated with VAT
(rho=-0.277, p=0.03), HOMA-IR (rho=-0.354, p=0.004), Matsuda index
Pellegrini E. 1, Peli L. 1, D’Amico R. 2, Carulli L. 1, Mussi C. 1, (rho= 0.409, p=0.001), ISSI-2 (rho=0.290, p=0.022), The composite memory
Bertolotti M. 1 score NPZ-M correlated with insulin sensitivity, as reflected by Matsuda
1
Dept of Biomedical, Metabolic and Neural Sciences and 2Dept of Diagnostic index (rho= 0.394, p= 0.002) and HOMA-IR (rho= -0.382, p= 0.002), beta
and Clinical Medicine and Public Health, University of Modena and Reggio cell function, as reflected by ISSI-2 (rho= 0.277, p= 0.029), VAT (rho= -0.260,
Emilia and University Hospital of Modena, Modena, Italy p=0.041), NAFLD (rho= -0.262, p= 0.040), IL1-RA (rho= -0.280p= 0.028).
On multiple regression analysis, ISSI-2 was the only significant predictor of
Introduction: Diabetes mellitus represents an important cardiovascular NPZ-M (Beta =0.307, SEM=0.002, P=0.015), independently of VAT, NAFLD,
and coronary risk factor, and is currently considered a coronary disease Matsuda index, IL1-RA. Selective attention and composite index of attention
equivalent regardless of the degree of severity and metabolic control. Several tests correlated with waist circumference (rho=0.27, p=0.037 and rho=0.30,
algorithms have been devised to estimate cardiovascular risk, most of which p=0.019), fasting plasma glucose (rho=0.28, p=0.025 and rho=0.27, p=0.035)
non-specific for diabetics and hardly applicable to Mediterranean countries. and ISSI-2 (rho=-0.326, p=0.010 and rho=0. 35, p=0.005, respectively). After
AIM of this study was to investigate the variables associated with cardiova- exclusion of patients not achieving the weight loss goal within 15 months or
scular risk in a population of type 2 diabetes in the Emilia Romagna area. lost-to-follow-up, final outcome status was ascertained for 40 patients (20
Methods: We longitudinally analyzed the documentation of Diabetes Clinic per arm). After achievement of the weight loss target, a significant increase
patients, aged 35-65 without previous events, in the period 1991-2001. The in long-term, visuographic memory (p=0.002) and the composite index of
occurrence of cardiovascular events in the subsequent 10 years was recorded memory tests (NPZ-M) was observed in the liraglutide arm (P=0.029)(Figure
and correlated with the main risk factors, including a number of variables 1), but not in the lifestyle arm. In parallel, a significantly greater improvement
specific for diabetes; standard statistical analysis was performed. in beta cell function, as assessed by ISSI-2 (81.3% vs. 27.4%, p=0.006) and
Results: 3629 patients were eligible (2071 males, 1558 females). 546 of these reduction in VAT (-15.3% vs. -9% median decrease, P=0.028) was observed
(15.0%) presented an event at 10 years. According to Kaplan-Meier survival after liraglutide-associated weight loss, as compared with lifestyle-associated
curves, the variables statistically associated with the occurrence of cardio- weight loss. In the lifestyle arm, there was an improvement in sustained atten-
vascular events were established risk factors such as age, gender, smoking, tion (p<0.0001), selective attention (p=0.001) and NPZ-A (p=0.002).
systolic arterial pressure, HDL-cholesterol, and also specific indicators of
diabetes severity like glycated hemoglobin and diabetes duration. Cox mul-
tivariate risk modeling yielded similar results.
Conclusions: In diabetic patients, disease severity and the degree of meta-
bolic control should be considered for global risk evaluation and, in per-
spective, for the definition of treatment targets. Specific risk functions
should be designed; the algorithm derived from these data will be utilized for
a prospective evaluation of cardiovascular risk in our Regional population.
Grant Support: The present work was partly supported by the Regione
Emilia Romagna within the Programma di Ricerca Regione-Università
2007-2009: Research for Clinical Governance.
259. LIRAGLUTIDE IMPROVES MEMORY PERFORMANCE

INDEPENDENTLY FROM WEIGHT LOSS IN OBESE
PATIENTS WITH PREDIABETES OR EARLY TYPE 2 Conclusions: In obese subjects with prediabetes or early T2DM, cognitive
DIABETES performance is associated with cardiometabolic variables. At equal degree
of weight loss, liraglutide improves memory performance, whereas lifestyle
Boccatonda A. 1, Vadini F. 2, Simeone P. 1, Tartaro A. 3, Consoli A. 1, changes seem to be a promising non-pharmacogical strategy to contrast or
Davi’ G. 1, Santilli F. 1 delay the development of cognitive impairment, with particular reference
1
Department of Medicine and Aging, and Center of Aging Science and to attentive functions. Therefore, it is plausible that a therapeutic approach
Translational Medicine (CESI-Met), Via Luigi Polacchi, Chieti, 66100, involving diet, physical activity and incretin analogues might be beneficial
Italy; 2Psychoinfectivology Service, Pescara General Hospital, Pescara, Italy; against cognitive deficits occurring in patients in early, and possibly precli-
3
Department of Neuroscience & Imaging, University of Chieti, Italy nical phases of diabetes.
Background: Diabetes is an acknowledged risk factor for cognitive impair-

ment and dementia later in life. A novel class of antidiabetic drugs, gluca- 260. BENEFICIAL EFFECTS OF HYPOCALORIC
gon-like peptide-1 (GLP-1) analogues, approved for the treatment of type MEDITERRANEAN DIET ON VISCERAL FAT AS AND
2 diabetes (T2DM) and obesity, has been shown in animal models to exert METABOLIC PATTERNS IN OBESE SUBJECTS
a neuroprotective effect by influencing the GLP-1 receptors in the central
nervous system. Bonfrate L., Minerva F., Cappabianca M., de Bari O., Portincasa P.
Aims and Methods: Sixty-two metformin-treated obese subjects with pre- Department of Biomedical Sciences and Human Oncology, Clinica Medica
diabetes [impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) “A. Murri”, Policlinico Hospital, University of Bari Medical School, Bari, Italy
or both (n=41)] or newly diagnosed T2DM (n=21), were randomized to the
GLP-receptor agonist liraglutide (1.8 mg/d) or lifestyle counseling (dietary Background: the expansion of visceral adipose tissue (VAT) is closely asso-
intervention and exercise training) until achieving a modest and comparable ciated with metabolic abnormalities and increased risk of several chronic
weight loss (-7% of initial body weight), to assess i. the baseline relationship diseases. Increased VAT is also a marker of ectopic fat deposition in the
between cognitive performance and cardiometabolic variables, such as sub- liver and the heart, while decreased VAT can represent a marker of success
cutaneous (SAT) and visceral (VAT) adipose tissue distribution (assessed during dietary plan. We therefore evaluated the correlation beetwen VAT
by MRI), insulin sensitivity (Matsuda Index, HOMA-IR) and beta cell per- and metabolic patterns in obese subjects undergoing an hypocaloric typical
formance (by Insulin Secretion-Sensitivity Index-2 (ISSI-2) during multiple mediterranean controlled diet.
sampling OGTT; ii. whether, at equal degree of weight loss, a treatment by a Methods: over a 6 mo. period, 87 obese (BMI>30 Kg/m2) subjects (53 F:34
GLP-1 receptor agonist might exert a greater impact than lifestyle changes on M, age 51yrs±1.4 SE and 56.4±1.1yrs, respectively) entered an hypocaloric
cognitive functions (memory and attention). A detailed neuropsychological mediteranean diet program. The following measurements were performed
assessment (NP) was performed through a battery consisting of 7 tests. Stan- at baseline and at the end of the protocol: BMI, waist circumference, biou-
dardized neuropsychological z scores (NPZ) were calculated by subtracting moral exams (i.e., insulinemia, total-, LDL- and HDL-cholesterol, triglyce-
the appropriate normative mean from the raw score and then dividing by rides, fasting glycemia, GPT, uric acid), ultrasonographic measurements of
the normative standard deviation. In order to have distinct cognitive areas, fat (liver steatosis, subcutaneous and visceral fat) by Hitachi equipment.
a composite domain z score for the attention tests (NPZ-A: sustained atten- Results: at baseline M displayed greater metabolic abnormalities than F.
tion, and visual search test), memory tests (NPZ-M, including short term, Subcutaneous fat positively correlated with BMI while visceral fat correlated
162
with BMI, fasting glycemia, insulinemia, HDL, total-C, triglycerides, and MetS, COPD or both diseases.
degree of liver steatosis. The 6 mo. hypocaloric mediteranean alimentary Methods: We recruited 96 patients, 48 from “Metabolic Disorders” and 48
program was associated with significant improvement of anthropometric, from “COPD” outpatient clinic of Bari University Hospital. Patients were
ultrasonografic and bioumoral outcomes. divided in: MetS (n=37 group 1), COPD (n=21 group 2), MetS+COPD
Conclusions: Visceral fat is a metabollically active tissue. VAT correlates (n=38 group 3). Clinical, instrumental e laboratory parameters were evalua-
with the metabolic profile of patients and can be used as marker in evaluated. Results The prevalence of COPD among patients with MetS was 23%;
ting the efficacy of targeted alimentary programs in metabolically abnormal 58% of COPD patients met “armonized” criteria for MetS diagnosis. In
subjects. particular, 77% of all patients were smokers (pack/years>0), 34% of whom
current smokers. Excluding patients in metformin treatment (to avoid con-
founding factors), C-peptide levels were found to be significantly higher
261. AN UNEXPECTED CAUSE OF HYPOGLICEMIA in patients with both diseases as compared with the other 2 groups (p=0,
03). A positive relation between pack/years (P/Y) and C-peptide levels was
Bontempelli E., Cagnoni F., Besozzi A., Dognini G.P., Destro M. observed in all smokers, especially in current smokers (p=0, 001; R= 0, 626);
Department of Medical Science, Internal Medicine, ASST. Bergamo Ovest, moreover, a negative correlation was found between vitamin D and C-pep-
Treviglio - Italy tide (p= 0, 023; R= -0, 479). Strikingly, a negative relation was also observed
between P/Y and vitamin D levels and, also in this case, it was more evident
A 59-year-old male was admitted with episodes of weakness, sweating and in current smokers (p=0, 001; R=-0, 714).
loss of consciousness. These symptoms occurred both fasting and postpran- Conclusions: These preliminary results confirm and stress the strict link
dial. Patient medical history included hypertension, dyslipidemia and existing between MetS and COPD. Moreover, the novel relation pointed
recent episode of Herpes Zoster Ophthalmicus treated with Aciclovir. His out between pack/years, vitamin D and development of insulin-resistance
blood examinations at the time of admission were notable for: hypoglyce- opens up new prospects that require to be further investigated.
mia (35 mg/dl), normal liver and kindey function and mild anemia. He had
never taken insulin or oral hypoglycemic agents before.
Thyroid and adrenal cortical function tests were performed: thyroid stimu- 263. LIRAGLUTIDE IMPROVES CAROTID INTIMA-MEDIA
lating hormone level was 3.200 μIU/l, cortisol and ACTH were normal. His THICKNESS IN PRE-ELDERLY AND ELDERLY PATIENTS
plasma serum insulin was high (47 μU/ml) and C-peptide was 12 ng/ml WITH TYPE-2 DIABETES: AN 18-MONTH PROSPECTIVE,
(normal value 0.9-7.1 ng/ml). Computed tomography scan of the abdomen REAL LIFE STUDY
revealed no abnormal lesion in the pancreas. All immunologic tests and
the determination of urine sulfonylurea were negative. Glucose infusion Mannina C., Castellino G., Patti A., Giglio R.V., Chianetta R.,
was administered multiple times because of persistent hypoglycemia with Nikolic D., Bonfiglio A., Sardo V.A., Galletta R., Catalfio R.,
the need of infusion of highly concentrated (33%) glucose solutions. Upon Citarrella R., Montalto G., Rizzo M.
further examination, the patient revealed that, in addition to Aciclovir, he Biomedical Department of Internal Medicine and Specialties, University of
had taken a multivitaminic formula containing α-lipoic agent (ALA) 400 Palermo, Italy
mg twice a day as treatment for Herpes Zoster. Anti-insulin antibodies were
present in high titer. Considering the recent assumption of ALA and the Background and Aims: Liraglutide exerts cardio-protective effects beyond
high titer of anti-insulin antibodies, a diagnosis of Insulin Autoimmune of those on glucose metabolism, affecting several cardio-metabolic parame-
Syndrome (Hirata Syndrome) was made. The patient was treated with Pre- ters, such as subclinical atherosclerosis. However, it is not known if those
dnisone 1mg/kg and showed normalized blood glucose levels after 5 days of effects differ in the long-term between pre-elderly and elderly subjects with
treatment. α-Lipoic agent treatment had already been suspended since the type-2 diabetes (T2DM).
day of admission. Materials and Methods: We included 135 subjects with T2DM divided in
The dose of Prednisone was slowly tapered and the patient remained asymp- 2 groups: 1) 71 pre-elderly subjects (46 men and 25 women, 55±7 years),
tomatic with normal blood glucose levels. Anti-insulin antibodies decre- and 2) 64 elderly subjects (33 men and 31 women, 70±5 years). All subjects
ased in the following months. Hirata Syndrome or Insulin Autoimmune were naïve to incretin-based therapies and treated with liraglutide as add-on
Syndrome was initially reported by Hirata in 1970 and it is a rare cause to metformin, 0.6 mg/day for two weeks, followed by a dose of 1.2 mg/day.
of hypoglicemia. Most of cases are reported in Japan, only few in Western At baseline and every 6 months fasting samples were taken for labora-
Countries. It is characterized by serious hypoglicemia, high levels of blood tory analyses and carotid-intima media thickness (cIMT) was assessed by
insulin and insulin autoantibodies in the absence of exogenous insulin B-mode ultrasound. Statistical analysis was performed by ANOVA and the
administration. Spearman correlation method.
The cause of this syndrome is unclear, but insulin autoantibody formation is Results: After18 months of liraglutide therapy HbA1creduced signifi-
considered to be associeted with autoimmune disease (Graves disease, rheu- cantly in both groups (from 9.02±1.06 to 6.93±1.25 and from 8.50±0.71
matoid arthritis) or with assumption of drugs containing a sulfhydryl group to 6.74±0.90 %, respectively) as well as fasting glycemia (from 9.57±3.33
(methimazole, carbimazole, penicillamine, captopril, penicillin, metima- to 7.16±2.83 mmol/L; and from 9.14±3.71 to 7.28±2.29 mmol/L, p<0.0001
zole, imipenem, isoniazide, idralazine and procainamide). for all). Anthropometric parameters changed although not significantly.
There is a significant genetic predisposition to this disease and it is strongly Lipids, with the exception of HDL-cholesterol, reduced significantly only
correlated with HLA class II (HLA-DRB1 1403, DRB1 10406). In our case in pre-elderly subjects (triglycerides from 1.94±1.48 to 1.57±0.80 mmol/L,
HLA tiping demostrated the presence of HLA-DRB1 1403. α – Lipoic acid p=0.0458; total cholesterol from 4.90±1.57 to 4.27±1.04 mmol/L, p=0.0025;
is a sulfhydryl-containing compound used to as nutritional supplement and LDL-cholesterol from 2.92±1.44 to 2.34±0.91 mmol/L, p=0.0054. cIMT
used to treat peripheral neuropathy; assumption of ALA can be the cause of significantly decreased in both groups (from 0.96±0.18 to 0.78±0.20 mm;
this syndrome in patients with genetic predisposition. and from 0.98±0.17 to 0.79±0.20 mm, respectively; p<0.0001 for both).
Changes in cIMT were positively associated only with changes in triglyceri-
des in both pre-elderly (r=0.245, p=0.0398) and elderly (r=0.566, p<0.0001)
262. METABOLIC SYNDROME AND COPD: NOVEL groups.
RELATION BETWEEN SMOKING, INSULIN RESISTANCE Conclusion: Liraglutide significantly reduced cIMT in both pre-elderly and
AND VITAMIN D LEVELS elderly subjects with T2DM, beyond glycemic control.
Candigliota M. 1, Castrovilli A. 1, Piazzolla G. 1, Liotino V. 2,

Vulpi M. 2, Oliva V. 1, Resta O. 2, Tortorella C. 1, Sabbà C. 1 264. LIRAGLUTIDE IMPROVES METABOLIC
1
Department of Internal Medicine, University of Bari “Aldo Moro” - Bari PARAMETERS AND REDUCES INTIMA-MEDIA
(Italy), 2 Institute of Respiratory Disease, University of Bari “Aldo Moro” – THICKNESS IN OBESE PATIENTS WITH TYPE 2
Bari (Italy) DIABETES: 18-MONTH PROSPECTIVE STUDY
Introduction: Metabolic Syndrome (MetS) and Chronic Obstructive Pul- Giglio R.V., Patti A.M., Castellino G., Mannina C., Nikolic D., Chianetta R.,
monary Disease (COPD) are two emerging clinical conditions characteri- Galletta R., Sardo V.A., Bonfiglio A., Catalfio R., Citarrella R., Montalto G.,
zed by a persistent systemic inflammation. Aim To evaluate and compare Rizzo M.
risk factors, clinical and metabolic characteristics of patients affected with Biomedical Department of Internal Medicine and Specialties, University of
163
Palermo, Italy 0.98, CI 95% 0.87-1.10) and Dkk-1 (OR 1.73, CI 95% 0.91-3.30) were not
associated with GDM onset.
Introduction: It is well known that Liraglutide, in addition to good glyce- Conclusion: Sclerostin and Dkk-1 levels were not associated with an
mic control, has cardioprotective effects influencing various cardio-meta- adverse metabolic control in pregnant women and probably do not play a
bolic parameters, such as subclinical atherosclerosis. Data on long-term significant role in the pathophysiology of GDM.
effects of Liraglutide are limited, especially in obese patients who are at
higher cardiovascular risk and represent the majority of patients with type
2 diabetes mellitus (T2DM). 266. MULTIPLE OSTEOPOROTIC FRACTURES
Materials and Methods: In an18-month prospective study, we evaluated 72 COMPLICATING WOLFRAM SYNDROME
subjects (43 men and 29 women; mean age: 61±10 years), who were obese
(BMI 35±5) with T2DM, naïve to incretin based therapies and treated with Catalano A. 1, Bellone F. 1, Cicala G. 2, Giandalia A. 1, Morabito N. 1,
metformin only. Liraglutide was given, on top of metformin (1500 mg/day), Cucinotta D. 1, Russo G.T. 1
at a fixed dose of 1.2 mg/day throughout the duration of the study. Fasting 1
plasma samples were collected for laboratory analyses (from baseline and Messina, Messina, Italy; 2Orthopedics and Traumatology Unit, University
every 6 months). Carotid-intima media thickness (cIMT) was assessed by Hospital of Messina, Messina, Italy
color doppler ultrasound. Statistical analysis was performed by ANOVA.
Results: Liraglutide significantly improves all metabolic parameters studied Objective: Wolfram Syndrome (WS) is a rare and lethal disease characte-
with the exception of triglycerides and high-density lipoproteins cholesterol rized by optic atrophy, diabetes mellitus, diabetes insipidus, and hearing
(HDL) (Table). loss. To date, osteoporotic related fractures have not been reported in
affected patients. We describe the case of a man affected by WS compli-
baseline 6 months 12 months 18 months P=(for trend) cated by several bone fragility fractures. Methods and Results: A 50 year-
Weight (kg) 96±17 91±16 91±17 90±17 0.192 old Caucasian man was hospitalized because of tibia and fibula fractures.
BMI kg/m2 35±5 34±5 33±5 33±5 0.042 His clinical features included diabetes mellitus, diabetes insipidus, optic
Waist circumference 116±15 113±12 112±12 109±15 0.024 atrophy and deafness that were consistent with an unrecognized WS dia-
(cm) gnosis, which was confirmed by the identification of a specific mutation in
Fasting glycaemia 9.58±3.23 7.42±2.54 7.23±2.05 7.30±2.75 <0.0001 gene WFS1 encoding wolframin. Because of multiple fractures, the patient
(mmol/l) also underwent a complete workout for osteoporosis. Bedside quantitative
HbA1c (%) 8.76±0.96 6.87±1.41 6.80±1.06 6.85±1.23 <0.0001 ultrasound (QUS) at the proximal phalangeal metaphysis of the last four
Total cholesterol 4.70±1.46 4.33±1.05 4.19±0.91 4.17±1.02 0.020 fingers of the non-dominant hand measured Amplitude Dependent Speed
(mmol/l)
of Sound (AD-SoS), Bone Transmission Time (BTT), Fast Wave Ampli-
Triglycerides 1.86±0.78 1.57±0.73 1.62±0.85 1.59±0.78 0.100
(mmol/l) tude (FWA), Signal Dynamic (SDy), and, finally, Ultrasound Bone Profile
LDL-cholesterol 2.72±1.40 2.43±0.95 2.28±0.86 2.20±0.90 0.018 Index (UBPI). Serum levels of surrogate markers of bone remodeling were
(mmol/l) determined, revealing a high bone turnover, with elevated levels of the bone
HDL- cholesterol 1.14±0.27 1.19±0.27 1.18±0.31 1.23±0.31 0.310 resorption marker C-telopeptide of type 1 collagen (CTX) and the bone
(mmol/l) formation marker osteocalcin (BGP); moreover, a secondary hyperpara-
cIMT (mm) 0.97±0.17 0.88±0.13 0.82±0.13 0.78±0.22 <0.0001 thyroidism resulting from the combination of vitamin D deficit and inci-
pient renal failure (eGFR: 45 ml/min) in addition to referred low dietary
Conclusions: Liraglutide seems to have a long-term beneficial effect on calcium intake was also observed. All these exams indicated a reduced bone
several cardio-metabolic risk factors in obese patients with T2DM. These density and impaired bone metabolism consistent with severe osteoporosis
effects could further contribute to an effective cardiovascular risk preven- with elevated bone turnover. Previously unidentified rib fractures were also
tion and/or reduction in such subjects. detected.
Conclusions: To the best of our knowledge, this is the first report of osteo-
porotic related fractures in a patient affected by WS. Although no effective
265. SCLEROSTIN AND DICKKOPF-1 IN PREGNANT treatments are currently available to delay the progression of the disease,
WOMEN WITH GESTATIONAL DIABETES this
Case Report: suggests to evaluate fracture risk in the diagnostic work-up
Catalano A. 1, Morabito N. 1, Pintaudi B. 2, Giunta L. 1, Loddo S. 1, of WS.
Corrado F. 3, D’Anna R. 3, Lasco A. 1, Di Benedetto A. 1
1
Messina, Messina, Italy; 2SSD. Diabetology, Ca’Granda Niguarda Hospital, 267. FLAVONOIDS, VASCULAR FUNCTION AND METABO-
Milan, Italy; 3Department of Pediatric, Gynecological, Microbiological and LISM: NEW EVIDENCE IN THE HEALTHY SUBJECT
Biomedical Sciences, Messina, Italy
Cervelli N., Grassi D., Di Placido F., De Feo M., Stamerra C.A.,
Objective: In animal models, Wnt/β-catenin signaling pathway has been Mai F., Proietti I., Leone S., Ferri C.
shown to contribute to the modulation of insulin secretion, β-cell function Università degli Studi dell’Aquila, Dipartimento di Medicina Clinica, Sanità
and insulin signaling in skeletal muscle. Sclerostin and Dkk-1 are soluble Pubblica, Scienze della Vita e dell’Ambiente
antagonists of Wnt signaling, and sclerostin has been associated with an
adverse metabolic profile. No data exist on the association between scle- Nitric oxide plays a pivotal role in regulating vascular tone. Different
rostin and Dkk-1 with the main clinical features in pregnant women with studies show that endothelial function is impaired in subjects with patho-
gestational diabetes (GDM). Our aim was to investigate the possible role of logies associated with high cardiovascular risk such as hypertension,
sclerostin and Dkk-1 in pregnant women with GDM. hypercholesterolemia, diabetes and obesity. An ever-increasing number of
Materials and Methods: We recruited thirty-five consecutive women with evidence suggests both in vitro and in vivo flavonoids improve endothe-
GDM, identified between the 24th and 28th week of gestation by the 75 g lial function, increasing nitric oxide production, acting on oxidative stress
oral glucose tolerance test (OGTT), according to International Association and resulting in significant endothelial and vascular benefit. However,
of Diabetes and Pregnancy Study Groups criteria; a group of normal glucose data on the effects of diosmine in combination with other flavonoids on
tolerance (NGT) (n=36) pregnant women were considered as healthy con- the arterial system and metabolism are poor; in particular there are no
trols. For each women, levels of sclerostin and Dkk-1 were assessed the same acute studies to assess such effects on healthy subjects. Based on these
day of OGTT. All the participants were followed until delivery, and several considerations, in this study we aimed to investigate for the first time the
maternal and newborn’s features were recorded. acute effects of a combination of high concentration flavonoids on (1)
Results: No significant differences were detected for age, height, family flow-mediated dilation; (2) blood pressure and heart rate; (3) stiffness
history of diabetes, history of previous GDM, sclerostin and Dkk-1 levels index and (4) metabolism and thermogenesis. 25 healthy volunteers (8
when women affected by GDM were compared with NGT women. More- males, 31.0 ± 4.3 years) were enrolled among students and young workers
over, no significant differences were observed between GDM and NGT in the city of L’Aquila. With supine volunteers metabolic monitoring was
women as for pregnancy outcomes, i.e. gestational week at delivery, cesa- applied throughout the duration of the examination; baseline measure-
rean section rate, newborns’ gender, neonatal weight and APGAR scores at ments of PA, FC, FMD, PWV and PWA were also carried out. A tablet
1 and at 5 minutes. Finally, at a multiple regression analysis, sclerostin (OR containing a combination of diosmine/diosmethane with other flavonoids
164
was administered below. At a distance of 1 hour and 2 hours after the (<35 vs. ≥35 kg/m2). The safety and tolerability of liraglutide 3.0 mg were
intake, the PA, FC, FMD, PWV and PWA measurements were again per- comparable in baseline BMI subgroups (<35 vs. ≥35 kg/m2).
formed. The administration of diosmin in combination with other flavo-
noids resulted in an increase in FMD - basal: 6.90 ± 3.25%; T60’: 9.93 ±
4.93%; T120’: 7.77 ± 3.91%; this increase was statistically significant in 269. C REACTIVE PROTEIN INCREASE IS ASSOCIATED
T60’(p = 0.007); FC showed a statistically significant reduction in baseline WITH HIGH CORONARY AND PERIPHERAL
values: 76.10 ± 11.63 bpm; T60’: 67.40 ± 7.47 bpm (p = 0.001); T120’: ATHEROSCLEROTIC BURDEN IN SUBJECTS WITH
68.32 ± 9.98 bpm (p = 0.007); there was a reduction in PWV, although not VISCERAL OBESITY
statistically significant - basal: 6.19 ± 0.78 m/sec; T60’: 6.00 ± 0.72 m/sec,
AIx - basal 15.32 ± 7.45%; T60’: 12.72 ± 11.45%; T120’: 12.24 ± 9.42%; n.s. Ferrara V. 1, Scicali R. 1, Di Pino A. 1, Gallo A., Piro S. 1,
and baseline AP values: 4.60 ± 2.45 mmHg; T60’ 3.96 ± 3.55 mmHg; T120’ Rosenbaum D. 2, Rabuazzo A.M. 1, Giral P. 2, Bruckert E. 2,
3.84 ± 2.98 mmHg; n.s. Metabolic monitoring showed a statistically signi- Purrello F. 1
ficant increase in mean values of cutanea - basal temperature: 31.37 ± 0.98 1
Dipartimento di Medicina Clinica e Sperimentale, Università degli
°C; T60’: 32.25 ± 2.34 °C (p = 0.045); T120: 33.12 ± 0.87 (p = 0.00000001); Studi di Catania, Catania, Italia. 2 Cardiovascular Prevention Unit and
the difference in the values recorded in T120’ and T60’ is also statistically Endocrinology Service, Paris Hospital Public Assistance, Pitie-Salpetriere
significant (p = 0.044); a statistically significant increase in mean tempe- Hospital Group, Pierre et Marie Curie University, Paris, France
rature values found close to the body - basal: 31.24 ± 1.01 °C; T60’: 32.60
± 1.01 °C (p = 0.0001) T120’: 33.00 ± 0.90 °C (p = 0.00000002). There was Background and Aims: The association of visceral obesity with an incre-
also an increase in mean - baseline energy expenditure: 1.20 ± 0.20 cal; ased risk of developing cardiovascular disease is unclear. In these subjects,
T60’: 1.27 ± 0.25cal; T120’: 1.21 ± 0.21cal; n.s. Correlated with the incre- inflammation plays a central role in developing atherosclerosis. Our
ase in mean - basal METs: 1.11 ± 0.13; T60’ 1.17 ± 0.24; T120’ 1.12 ± 0.13; objective was to examine the cardiovascular (CV) risk profile of visceral
n.s. The data reported in our study suggests that the intake of diosmin in obesity patients with and without inflammation according to high sensiti-
combination with other flavonoids has positive effects on: FMD, PWV, vity C reactive protein (CRP), using macroangiopathic imaging biomarkers.
PWA thermogenesis and metabolism in the healthy subject. Increasing Methods: Our population consisted of 140 patients aged between 40 and
endothelial function, reducing arterial wall stiffness, and beneficial effects 70 years, with a waist circumference ≥ 88 for women and ≥ 102 for men
on the healthy subject’s metabolism allow us to hypothesize that the addi- and at least 1 CV risk factor. Exclusion criteria were prior history of CV
tion of rich diosmine and other flavonoid supplements in daily diet can disease or clinical evidence of advanced renal disease. Inflammation was
be a further potential benefit in prevention and cardiovascular protection. defined as a CRP value ≥ 2. Coronary artery calcium (CAC) score as well as
mean common carotid intima media thickness (IMT) were assessed using
consensus criteria. Results: CAC score was higher in inflammation group
compared to non-exposed group (60.74 ± 159.57 vs 50.74 ± 179.68 AU, p
268. LIRAGLUTIDE 3.0 MG IN OBESE/OVERWEIGHT < 0.05). Visceral obesity subjects with inflammation had higher mean IMT
ADULTS WITH OR WITHOUT PREDIABETES WITH than non-exposed subjects (0.62 ± 0.18 vs. 0.56 ± 0.11 mm, p < 0.05). In
BASELINE BMI <35 VS. ≥35 KG/M2 IN THE SCALE addition, in a multiple linear regression, CAC was associated with inflam-
OBESITY AND PREDIABETES 56-WEEK RANDOMISED, mation (p < 0.05) and age (p < 0.001).
DOUBLE‑BLIND, PLACEBO-CONTROLLED TRIAL Conclusions: Among patients with abdominal obesity, CRP increase is
associated with higher coronary and peripheral atherosclerotic burden in
Vettor R. 1, Greenway F. 2, le Roux C.W. 3, McGowan B. 4,
visceral obesity patients.
Pi-Sunyer X. 5, Cancino A.P. 6, Shapiro Manning L. 7,
Donnarumma G. 7, Van Gaal L. 8
1
University of Padua, Padua, Italy; 2 Pennington Biomedical Center, Baton
270. CHANGES IN GLUCOSE METABOLISM AFTER
Rouge, LA, USA; 3 University College Dublin, Ireland; 4 Guy’s & St Thomas’
CLEARANCE OF HEPATITIS C VIRUS: A PROSPECTIVE
NHS. Foundation Trust, London, UK; 5 Columbia University, New York, NY,
STUDY WITH SERIATED OGTTS
USA; 6 Novo Nordisk A/S, Søborg, Denmark; 7 Novo Nordisk SpA, Rome,
Italy; 8 Antwerp University Hospital, Antwerp, Belgium
Gualerzi A., Bianco S., De Benedittis C., Tran Minh M., Bellan M.,
Carnevale Schianca G.P., Pirisi M.
Background: The 3-year SCALE Obesity and Prediabetes trial
A.O.U. Maggiore della Carità di Novara - S.C.D.U. Medicina Interna 1
(NCT01272219) randomized 2254 adults with prediabetes (female 76%;
mean: age 48 years; BMI 39 kg/m²) 2:1 to liraglutide 3.0 mg or placebo as
Rationale and Aim: It has been shown that hepatitis C virus (HCV) car-
adjunct to diet and exercise for 160 weeks.
riers with diabetes who have their infection cleared by antiviral treatment
Methods: This post hoc analysis compared efficacy and safety of liraglutide
improve their glycemic control, mainly because of lowered insulin resistance
for adults with prediabetes and BMI < vs ≥35 kg/m² at baseline. Treatment
(IR); whether this mechanism applies to HCV carriers with normal glucose
effect of liraglutide across BMI subgroups was evaluated by statistical testing
tolerance (NGT) and prediabetes has not been studied yet. The present study
of interaction between treatment and BMI subgroup.
aimed to fill this gap.
Results: BL characteristics were similar between liraglutide and placebo
Methods: Sixty-one HCV patients (35 males, 26 females; mean age 64±12;
BMI subgroups (< vs ≥35 kg/m2) except weight-related characteristics
mean body mass index 25, 8±3, 8 kg/m2; 31 with cirrhosis) underwent a dual
(weight, BMI, waist circumference) and history of dyslipidemia (more
oral glucose tolerance test (OGTT) with simultaneous measure of plasma
common for liraglutide BMI <35 kg/m2). At 160 weeks, significantly greater
insulin concentration (at baseline and after 60 and 120 min) plus HbA1c,
mean and categorical weight losses (WLs) were seen with liraglutide vs
both prior the initiation of direct oral antiviral (DAA) treatment and at the
PBO for BMI < and ≥35 kg/m2 (mean WL [%]: −6.4, −6.0 vs −1.7, −2.0; %
end of treatment (EOT). We categorized patients based on the glucose tole-
achieved ≥5% WL: 51.1, 48.9 vs 19.7, 25.0; >10% WL: 25.7, 23.7 vs 8.9, 9.8;
rance status and calculated OGTT-derived indices of IR and insulin-sensiti-
>15% WL: 8.1, 8.0 vs 2.5, 2.2) as well as greater improvements in glycemic
vity (HOMA-IR, ISI Belfiore), insulin-secretion (EFP Stumvoll) and beta cell
parameters and quality of life endpoints; these treatment effects appeared to
function (Disposition Index). The indices above were related to the clinical
be independent of baseline BMI (interaction p>0.05). While on treatment
and laboratory characteristics of the study population.
at 160 weeks, more people with liraglutide vs placebo regressed to normo-
Results: At baseline, 32/61 patients (52, 5%) showed glucose metabolism
glycemia, irrespective of baseline BMI: 66.1, 65.8% vs 34.9, 36.9%. Rates
abnormalities (including 24 with prediabetes and 8 who satisfied OGTT
of adverse events (AEs), and serious/severe AEs were generally comparable
criteria for diabetes). At EOT, 14/32 patients (44%) reversed to NGT status
across BMI subgroups. Rates of gallbladder-related AEs were similar for
while in 18/32 the alteration of glucose metabolism persisted (54%, inclu-
liraglutide < and ≥35 kg/m2 (24 events [2.4 events/100 years’ observation],
ding 5 diabetics), despite a global reduction in glycemic levels at G0’ (decre-
69 [3.1]) but higher than placebo (6 [1.3], 12 [1.2]). Rates of pancreatitis
ased by 4%, p=0, 018), G60’ and G120’ (respectively decreased by 15%, p>0,
were low, similar between BMI < and ≥35 kg/m2 but higher with liraglutide
001). The decrease in HOMA IR was statistically significant (p<0.001) and
vs placebo (2 [0.2], 8 [0.3] vs 1 [0.2], 1 [0.1]), as were breast neoplasms (2
equal to 26%. ISI was increased by 39, 6% (p<0.001) and this data is confir-
[0.3], 8 [0.4] vs 0 for placebo).
med also analyzing the NGTs alone. There were no significant differences in
Conclusions: After 56 weeks, there was no evidence thetreatment effects of
insulin-secretion (p=0.301), while the Disposition Index increased by 29%
liraglutide 3.0 mg as adjunct to diet and exercise on weight loss, glycaemic
(p<0.001). Excluding 19 patients who received ribavirin (a drug known to
parameters, and blood pressure differed across the baseline BMI subgroups
cause hemolysis) the reduction of HbA1c was also statistically significant
165
(p=0.025), being reduced of 1, 8%. From the multivariate analysis emerged Women Disorders Clinic, AOU Careggi, anthropometric, bio-humoral and
as single independent predictor of HOMA-IR improvement the presence of ultrasound/imaging markers, in order to frame their cardiovascular risk.
a low viral load (<106 UI/ml) at baseline. Weight, height and waist/hip circumferences were measured, and BMI, and
waist to hip ratio (WHR) were calculated; ultrasound evaluation of abdomi-
nal fat depots (liver according to a semiquantitative score from 0-8;visceral,
subcutaneous and right perirenal adipose thickness) were performed, and a
14-item Mediterranean Diet Assessment Tool was administered.
Results: Fifteen women were overweight and 12 obese; we found a nega-
tive correlation between BMI, weight and waist circumferences and the
adherence to the 14-item Mediterranean Diet Score (p < 0.01, and p<0.05,
respectively). An altered lipid profile and elevated Lp(a) levels (mean value
405.7 mg/L) were observed in all women investigated, as well as increased
PCR-hs (mean value 4.5 mg/L) values. A positive and significant relation-
ship between PCR-hs levels and overweight/obesity was observed (p<0.05).
As concerns the abdominal liver depots, 23 women had moderate (>3) and
4 women severe (>6) Non-Alcoholic Fat Liver Disease (NAFLD); when sub-
cutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and perirenal
depots were considered, we found that 18 women had SAT > 20mm, 11
women had VAT > 55 mm, and 15 women had perirenal depots >20 mm.
By analysing abdominal depots according to the Mediterranean Diet Score,
we observed a negative but not significant correlation for each depot inve-
stigated. A significant correlation was found between increased perirenal fat
depots and lower HDL levels (p=0.004); SAT was associated with both high
total cholesterol levels and high LDL-C (p=0.04 and p=0.03, respectively);
and VAT was positively and significantly correlated with high PCR-hs values
(p=0.03).
Comments: Our data highlighted that in a group of women who underwent
ART, homogeneous for both increased BMI and moderate or severe
NAFLD, increased abdominal fat depots could identify subgroups with a
more marked dysmetabolism and low grade inflammation. The improve-
ment in both adherence to the Mediterranean Diet model, and physical
activity could reduce abdominal fat depots, thus inducing a better ART’s
outcome.
272. ACHIEVING FPG TARGET WITHOUT

HYPOGLYCEMIA: A META-ANALYSIS OF INSULIN
DEGLUDEC VERSUS INSULIN GLARGINE
Simioni N. 1, Meneghini L. 2, Atkin S. 3, Jain R. 4, Mathieu C. 5, Philis-

Tsimikas A. 6, Bardtrum L. 7, Tutkunkardas M.D. 7,
Zinman B. 8, Mancuso M. 9
1
U.O. Medicina Interna, Ulss 15 Alta Padovana, Cittadella, Italy 2 University
of Texas Southwestern Medical Center and Parkland Health & Hospital
System, Dallas, TX, USA, 3 Weill Cornell Medicine in Qatar, Doha, Qatar, 4
Aurora Health Care, Milwaukee, WI, USA, 5 UZ Leuven, Leuven, Belgium,
6
Scripps Whittier Diabetes Institute, San Diego, CA, USA, 7 Novo Nordisk
A/S, Søborg, Denmark, 8 Mount Sinai Hospital, University of Toronto,
Toronto, ON, Canada, 9 Novo Nordisk SpA, Rome, Italy
Insulin degludec (IDeg) is a basal insulin with a long and stable gluco-
se-lowering effect and low day-to-day intra-patient variability compared
with insulin glargine (IGlar). This meta-analysis investigated the propor-
tion of patients meeting the laboratory-measured FPG target of <130 mg/
Conclusions: Among chronically HCV infected patients, treatment-indu- dL (7.2 mmol/L), defined as the upper limit of the recommended premeal
ced changes in insulin sensitivity occur early, being already present at the PG goal based on the 2015 ADA Standards of Medical Care in Diabetes,
end of antiviral therapy, and concern the entire spectrum of glucose meta- at each visit during the maintenance period, as well as doing so without
bolism abnormalities. experiencing nocturnal hypoglycemia. The maintenance period is defined
as all visits from week 16 onwards. Nocturnal hypoglycemia was defined
as any confirmed (BG <56 mg/dL [3.1 mmol/L]) self-monitored event
271. ABDOMINAL DEPOTS IN THE EVALUATION OF occurring between 00:01 and 05:59, inclusive. Patients (T1D or T2D) from
CARDIOVASCULAR RISK IN WOMEN UNDERGOING seven open-label, randomized, treat-to-target trials treated with either IDeg
ASSISTED REPRODUCTIVE TECHNOLOGY (ART) (n=2501) or IGlar (n=1256) were included. Use of IDeg resulted in signifi-
cantly more patients reaching the FPG target at each visit throughout the
Fatini C., Cirillo M., Cosentino E., Crociani A., Donnarumma E., maintenance period, as well as doing so without experiencing nocturnal
Fabbri M., Fallai L., Lunardi S., Maestripieri V., Boddi M. confirmed hypoglycemia, compared with IGlar. These results were similar
Dipartimento di Medicina Sperimentale e Clinica, AOU across the three patient populations; T1D, T2D insulin treated and T2D
Careggi, Firenze insulin naïve. In conclusion, more patients treated with IDeg can achieve
target FPG without nocturnal confirmed hypoglycemia compared with
Background: Overweight and obesity are reported to impair fertility in IGlar.
women; moreover, increasing age in getting pregnant and physiological
lowering in ovarian function, could explain the higher percentage of women
undergoing ART. Overweight or obese ART women could have an increa- 273. META-ANALYSIS COMPARING HYPOGLYCEMIA
sed cardiovascular risk, nevertheless this topic is object of debate. RATES OF INSULIN DEGLUDEC WITH INSULIN
Methods: We investigated, in a model of 27 overweight or obese women GLARGINE ACROSS CLINICAL TRIALS WITH UP TO 2
(mean age 40.7yrs), who underwent ART and had referred to the Vascular YEARS’ DURATION
166
Montano N. 1, Philis-Tsimikas A. 2, Bode B. 3, Del Prato S. 4, Southwestern Medical Center, Dallas, TX, USA, 5Fachklinik Bad Heilbrunn,
Gross J. 5, Mathieu C. 6, Troelsen L. 7, Leeuwen M.V. 7, Zinman B. 8, Mancuso Bad Heilbrunn, Germany, 6Novo Nordisk, Søborg, Denmark, 7Medical
M. 9 University of Graz, Graz, Austria, 8Novo Nordisk spA, Rome, Italy
1
Department of Clinical Sciences and Community Health, University of
Milan, Milan, Italy 2 Scripps Whittier Diabetes Institute, San Diego, USA, 3 Serum 1, 5-anhydroglucitol (1, 5-AG) decreases during periods of hyper-
Atlanta Diabetes Associates, Atlanta, GA, USA, 4 University of Pisa, Pisa, 5 glycemia (>180 mg/dL) and reflects postprandial plasma glucose (PPG)
Universidade Federal do Rio Grande de Sul, Porto Alegre, Br, 6 UZ LEUVEN, control over the previous 1–2 weeks. The extent 1, 5-AG reflects PPG
Leuven, Belgium, 7 Novo Nordisk A/S, Søborg, Denmark, 8 Mount Sinai control may also depend on overall glycemic control. This was assessed in a
Hospital, University of Toronto, Toronto, ON, Canada, 9 Novo Nordisk SpA, post hoc analysis of onset 1, a 26-week, randomized, phase 3 trial in subjects
Rome, Italy with type 1 diabetes evaluating mealtime (MT) fast-acting insulin aspart
(faster aspart), 20 min post-meal (PT) faster aspart and MT insulin aspart
Insulin degludec (IDeg) is a basal insulin with a long and stable gluco- (IAsp), each with insulin detemir. Subjects (n=990) were pooled to examine
se-lowering effect with low day-to-day variability. A comparison of the the correlation between absolute values of 1, 5-AG and 2-h PPG from 7-9-7
rate of hypoglycemia with IDeg versus insulin glargine (IGlar) across self-measured plasma glucose profiles at week 26 according to HbA1c (<7%
phase 3a trials, including all available trial extensions (n=4) plus one new or ≥7%) at week 26. HbA1c was reduced in all treatment arms. Primary
trial was performed post hoc; IDeg: n=3454; IGlar: n=1709; T1D: 2 trials; endpoint in onset 1 was HbA1c change from baseline (est. treatment dif-
T2D: 6 trials. Hypoglycemia was defined as rates of self-reported confir- ference [ETD] [95% CI]: MT faster aspart vs. IAsp −0.15% [−0.23;−0.07];
med hypoglycemia (BG <56 mg/dL or severe hypoglycemia requiring assi- PT faster aspart vs. IAsp 0.04% [−0.04;0.12]). Glycemic differences were
stance) and nocturnal confirmed hypoglycemia (00:01–05:59 both incl.). reflected in 1, 5-AG change from baseline (ETD [95% CI]: MT faster aspart
Rates were analyzed with a negative binomial regression model on patient vs. IAsp 0.50 μg/mL [0.24;0.76]; PT faster aspart vs. IAsp –0.16 μg/mL
level data. IDeg resulted in statistically significantly lower rates of con- [–0.42;0.10]). 1, 5-AG correlated with 2-h PPG, in subjects with HbA1c
firmed and nocturnal confirmed hypoglycemia versus IGlar in T2D, and <7% and HbA1c ≥7%. These results are consistent with the usefulness of
for nocturnal confirmed hypoglycemia in T1D (Table). Analyses of the 1, 5-AG as a marker of short-term glycemic control, irrespective of HbA1c
maintenance period (from 16 weeks onwards), demonstrated more pro- responder status.
nounced benefits with IDeg versus IGlar in both T1D and T2D. In conclu-
sion, this post hoc meta-analysis confirms and extends the outcomes of a
previously published pre-specified meta-analysis. Even with the inclusion 276. EFFICACY AND SAFETY OF FAST-ACTING
of additional trial data for up to two years’ duration, the lower rates of INSULIN ASPART ARE MAINTAINED OVER 52 WEEKS:
both overall (T2D) and nocturnal confirmed (T1D and T2D, respectively) COMPARISON WITH INSULIN ASPART IN ONSET 1
hypoglycemia with IDeg versus IGlar are maintained.
P. Piatti 1, C. Mathieu 2, B. Bode 3, E. Franek 4, A. Philis-Tsimikas 5,
L. Rose 6, T. Graungaard 7, A.B. Østerskov 7, D. Russell-Jones 8,
274. THE IMPACT OF BASELINE BMI AND HBA1C ON M. Mancuso 9
GLYCEMIC CONTROL AFTER TREATMENT WITH FAST- 1
Unità Funzionale, Ospedale San Raffaele di Milano, Milan, Italy 2Clinical
ACTING INSULIN ASPART IN INDIVIDUALS WITH TYPE and Experimental Endocrinology, UZ Leuven, Leuven, Belgium, 3Atlanta
2 DIABETES Diabetes Associates, Atlanta, GA, USA, 4 Mossakowski Medical Research
Center, Polish Academy of Sciences & Central Clinical Hospital MSWiA,
Perticone F. 1, Bowering K. 2, Bode B. 3, Harris S. 4, Piletic M. 5, Warsaw, Poland, 5Scripps Whittier Diabetes Institute, San Diego, CA, USA,
Babu V. 6, Dethlefsen C. 6, Rodbard H.W. 7, Mancuso M. 8 6
Diabetes Research Center, Münster, Germany, 7Novo Nordisk, Søborg,
1
Magna Graecia University, Catanzaro, Italy 2University of Alberta, Denmark, 8Royal Surrey County Hospital, Guildford, UK, 9Novo Nordisk
Edmonton, Canada 3Atlanta Diabetes Associates, Atlanta, Georgia, USA. SpA, Rome, Italy
4
Western University, London, Ontario, Canada 5General Hospital, Novo
Mesto, Slovenia 6Novo Nordisk A/S, Søborg, Denmark 6Claus Dethlefsen Onset 1 was a phase 3a trial evaluating fast-acting insulin aspart (FA) in
Novo Nordisk A/S, Søborg, Denmark 7 Endocrine and Metabolic Consultants, adults with type 1 diabetes (T1D) over 52 weeks in two 26-week periods.
Rockville, Maryland, USA. 8Novo Nordisk SpA, Rome, Italy Subjects were randomized to double-blind mealtime FA, insulin aspart
(IAsp) or open-label post-meal FA, each with insulin detemir for the first
Baseline characteristics related to severity of disease can be predictors of 26 weeks. Subjects on mealtime FA (n=381) and IAsp (n=380) continued
the HbA1c-lowering effect of a treatment. The impact of baseline BMI and to the additional 26-week period, aimed to assess long-term safety and effi-
HbA1c on the efficacy and safety of mealtime fast-acting insulin aspart cacy. After 52 weeks, HbA1c change from baseline (−0.08% [FA] vs. +0.01%
(faster aspart) in type 2 diabetes (T2D) was assessed in a post hoc analysis of [IAsp]) showed a significant estimated treatment difference (ETD) [95%
two randomized phase 3a trials: a 26-week, double-blind, treat-to-target trial confidence interval (CI)] favoring FA (ETD: −0.10% [−0.19;−0.00]). Change
with mealtime insulin aspart (IAsp) in a basal–bolus regimen as the com- from baseline in 1-h postprandial plasma glucose (PPG) increment after meal
parator (onset 2), and an 18-week, open-label trial with basal insulin alone test was −1.05 mmol/L (FA) vs. −0.14 mmol/L (IAsp) (ETD: −0.91 mmol/L
as the comparator (onset 3). All individuals were also taking metformin. In [−1.40;−0.43]; −16.48 mg/dL [−25.17;−7.80]). A similar trend toward better
this analysis, individuals were grouped by baseline BMI (<25, 25–30, ≥30 efficacy with FA vs. IAsp was seen in change from baseline in 2-h PPG incre-
kg/m2) or HbA1c (≤7.5, >7.5–<8.0, ≥8.0%). In onset 2, the overall change ment after meal test (ETD [95% CI]: −0.42 mmol/L [−1.11;0.27]; −7.60 mg/
in HbA1c was non-inferior to faster aspart (n=345) vs. IAsp (n=344), with dL [−19.98;4.78]). Mean 7-9-7-point self-measured plasma glucose profiles
an estimated treatment difference (ETD) (95% CI) of −0.02% (−0.15;0.10). were significant in favor of FA (ETD: −0.23 mmol/L [−0.46;−0.00]; −4.14
In onset 3, overall change in HbA1c was superior with faster aspart (n=116) mg/dL [−8.23;−0.06]). Median total insulin dose was 0.77 U/kg (FA) vs. 0.83
vs. basal insulin alone (n=120), with an ETD of −0.94% (−1.17;−0.72). The U/kg (IAsp). No difference was observed for body weight change (+1.18 kg
ETD for change in HbA1c in each trial was similar for all BMI and HbA1c [FA] vs. +1.05 kg [IAsp]; ETD: 0.13 kg [−0.38;0.65]). After 52 weeks, adverse
subgroups. No major differences between treatments were observed in risk events were similar between FA and IAsp and as expected for IAsp. Severe or
of hypoglycemia (Table) or insulin dose across subgroups in either trial. blood glucose-confirmed hypoglycemia rates (plasma glucose <3.1 mmol/L
Neither baseline HbA1c nor BMI altered the glycemic response to faster [56 mg/dL]) were similar with FA (53.29 events/patient-year) vs. IAsp (53.19
aspart in individuals with T2D. events/patient-year) (estimated ratio: 1.01 [95% CI: 0.88;1.15]). No long-
term safety issues were identified with FA. Glycemic control was significantly
improved after 52 weeks with FA vs. IAsp. Approaching a profile closer to
275. 1, 5-ANHYDROGLUCITOL CORRELATES WITH physiology with FA achieves lower PPG and HbA1c in T1D compared with
POSTPRANDIAL GLUCOSE IN SUBJECTS WITH TYPE IAsp.
1 DIABETES IRRESPECTIVE OF HBA1C RESPONDER
STATUS
277. POSTPRANDIAL PLASMA GLUCOSE IN TARGET
G. Tonolo 1, S. Heller 2, K. Bowering 3, P. Raskin 4, Liebl 5, RANGE WITH FASTER ASPART BASAL–BOLUS THERAPY
K. Buchholtz 6, D.M. Bretler 6, T. Pieber 7, M. Mancuso 8
1
Diabetologia Asl 2, Olbia, Italy 2University of Sheffield, Sheffield, UK, C. Irace 1, H.W. Rodbard 2, K. Bowering 3, M. Piletič 4,
3
University of Alberta, Edmonton, AB, Canada, 4University of Texas M. Demissie 5, S. Klim 6, T.R. Pieber 7, M. Mancuso 8
167
1
Magna Graecia University, Catanzaro, Italy 2Endocrine and Metabolic age 42±12 years, BMI 24.1±2.2 kg/m2, HbA1c 7.3±0.7%) received identi-
Consultants, Rockville, MD, USA, 3Department of Medicine, University cal subcutaneous single doses of faster aspart and IAsp (individualised by
of Alberta, Edmonton, AB, Canada, 4General Hospital Novo Mesto, Novo subject; 0.06-0.28 U/kg) at the start of a standardised mixed meal (contai-
Mesto, Slovenia, 5Novo Nordisk, Søborg, Denmark, 6Novo Nordisk, Bagsværd, ning 75 g carbohydrate labelled with [1-13C] glucose). Postprandial glucose
Denmark, 7Medical University of Graz, Graz, Austria 8Novo Nordisk SpA, turnover was assessed by the triple-tracer meal method using continuous,
Rome, Italy variable [6-3H] glucose and [6, 6-2H2] glucose infusion.
Results: Early insulin exposure (AUCIAsp, 0-30min and AUCIAsp, 0-1h)
Fast-acting insulin aspart (faster aspart) aims to reduce postprandial was greater for faster aspart versus IAsp, leading to smaller postprandial
plasma glucose (PPG) levels by mimicking physiological insulin secre- glucose increment at 1 hour (ΔPG1h) (Table). The smaller ΔPG1h with
tion. onset 3 was an 18-week, 1:1-randomized, open-label trial evaluating faster aspart was due to greater suppression of endogenous glucose pro-
adding and titrating mealtime faster aspart to basal insulin therapy vs. a duction (EGP) and higher glucose disappearance (ΔAUCRd) with faster
basal-only regimen, both in combination with metformin in patients with aspart versus IAsp during the first hour post-dose. Suppression of free fatty
type 2 diabetes (T2D). This post hoc analysis (n=236) explored the two tre- acid levels (AOCFFA, 0-1h) was 36% greater for faster aspart versus IAsp.
atments’ ability to achieve 2-h PPG in range at 6, 12 and 18 weeks (end Conclusion: Faster aspart provides improved postprandial glucose control
of trial [EOT]). Response was defined as maintaining nine postprandial compared with IAsp partly through earlier and greater suppression of endo-
self-measured plasma glucose (SMPG) measurements taken during 3 days genous glucose production.
of profiling within two specified ranges: ≥3.9–≤10 mmol/L (≥70–≤180 mg/
dL) and ≥3.1–≤10 mmol/L (≥56–≤180 mg/dL); individuals with ≥1 SMPG
measurement (from a total of nine) outside target range were labelled 279. VISION-RELATED QUALITY OF LIFE AND LOCUS
non-responders. With faster aspart basal–bolus, the odds of achieving 2-h OF CONTROL IN TYPE 1 DIABETES. A MULTICENTRE
PPG within the defined ranges were already significantly higher by 6 weeks OBSERVATIONAL STUDY
relative to basal-only treatment, and this increased through EOT. The faster
aspart basal–bolus group showed superior HbA1c reduction (ETD −0.94% Trento M., Durando O., Merlo S., Fornengo P., Amione C.,
[95% CI: −1.17;−0.72]). Concomitant with improved blood glucose control, 1
Bertello S., 1Oleandri S., 2Picca P., 3Donati M.C., 3Virgili,
the rate of hypoglycemia increased at EOT (Table). In conclusion, 2-h PPG 4
Bandello F., 4Lattanzio R., 4Aragona E., 5Scoccianti L., 6Perilli R.,
was more consistently in target range with faster aspart basal–bolus therapy 7
Casati S., 7Gusson E., 8Charrier L., 8Cavallo F., Porta M.
compared with basal insulin alone in patients with T2D. Laboratory of Clinical Pedagogy, Department of Medical Sciences, University
of Turin. 1 Service of Endocrinology and Diabetology. Azienda Ospedaliera.
Cuneo 2 Service of Endocrinology. Azienda Ospedaliera Universitaria. Foggia
278. EVALUATION OF EARLY POSTPRANDIAL 3
Eye and Pathophysiological Clinic. Azienda Ospedaliera Universitaria
SUPPRESSION OF ENDOGENOUS GLUCOSE Careggi. Florence 4 Department of Ophthalmology, Scientific Institute San
PRODUCTION WITH FASTER ASPART VERSUS INSULIN Raffaele, University Vita-Salute, Milan. 5 Diabetic Retinopathy Centre and
ASPART Laser Treatment. Institute of Ophthalmology, Parma 6 Department of Social
Ophthalmology. Azienda Ospedaliera Universitaria. Pescara. 7 Department
C. Irace 1, A. Basu 2, T.R. Pieber 3, A.K. Hansen 4, S. Sach-Friedl 3, of Neurosciences and Biomedicine. Azienda Ospedaliera Universitaria.
K.M.D. Thomsen 4, R. Basu 1, H. Haahr 4, M. Mancuso 5 Verona. 8 Department of Public Health and Paediatric Sciences, University of
1
Magna Graecia University, Catanzaro, Italy 2Mayo Clinic, Rochester, MN, Turin, Italy. Diabetic Retinopathy Centre, Department of Medical Sciences,
USA, 3Medical University of Graz, Graz, Austria, 4Novo Nordisk, Søborg, University of Turin, Italy
Denmark, 5Novo Nordisk SpA, Rome, Italy
Introduction: Vision plays an important role in the ability of people to
Background and Aims: Fast-acting insulin aspart (faster aspart) is insulin process information from their environment and to participate in everyday
aspart (IAsp) in a new formulation containing two well-known additional activities. Diabetic Retinopathy (DR) is considered to remain asymptoma-
excipients, L-arginine and niacinamide, which result in a stable formula- tic until it reaches its late stages. However, subtle changes in vision related
tion with accelerated initial absorption after subcutaneous administration. quality of life (QoL) may occur even in mild DR and their perception may
Previous clinical trials have shown that faster aspart provides greater early be related to a patient’s locus of control (LoC) of his/her disease.
absorption leading to improved postprandial glucose control compared Objective. To evaluate vision-related QoL and LoC in patients with Type 1
with IAsp. The aim of the present trial was to investigate the mechanisms Diabetes and different stages of DR.
behind the lower postprandial glucose achieved with faster aspart versus Patients and Methods: The 25-item National Eye Institute Visual Fun-
IAsp. ctioning (NEI VFQ-25) and Locus of Control (LoC) questionnaires were
Materials and Methods: In a randomised, double-blind, crossover trial self-administered to 258 patients between January 2014 and March 2017 in
design, subjects with type 1 diabetes (N=40; 21 women/19 men; mean±SD 9 DR screening centres. The NEI VFQ-25 explores 12 dimensions: General
Health (GH), General Vision (GV), Ocular Pain (OP), Near Activities (NA),
Distance Activities (DA), Visual Specific Social Functioning (VSSF), Mental
Health (VSMH), Role Difficulties (VSRD), Dependency (VSD), Driving
(D), Colour Vision (CV) and Peripheral Vision (PV). The LoC question-
naire includes 18 items assessing 3 areas: Internal Control of disease, the
role of Chance and trust in Others (family members, health operators). Data
on socio-anagraphic variables and presence of DR, cataract and previous
laser treatment (LT) were collected.
Results. Patients included 124 women and 134 men aged 42.0±12.4 years
and with 28.0±12.4 disease duration. DR was absent (n=74), mild-moderate
(n=75), severe (n=96) and laser treated (n=13). DR severity was directly
associated with disease duration (p<0.001) and measuring blood glucose
less than 4 times a day (p=0.013). Smoking showed a trend to protect
from DR. The patients with no DR had better scores for General Health
(p=0.0008), General Vision (p=0.0007), CV (p=0.045) and Peripheral
Vision (p=0.0001) than those with mild and more severe DR. There were no
differences in any of the LoC areas.
Conclusions: Even in mild asymptomatic stages, DR is associated with
impaired perception of vision related quality of life, with specific reference
to general health, general vision, colour vision and peripheral vision, inde-
pendently of personality traits explored by the LoC tool. The possible pro-
tective effect of smoking confirms previous reports and requires further
investigation.
168
280. DYNAMIC ASSESSMENT OF THE STANDARD ORAL levels and its variability were recorded in these patients. PTEN expression
GLUCOSE TOLERANCE TEST THROUGH CALCULATION via western blotting analysis was measured and the associations between
OF THE PERCENTAGE GLYCEMIC INCREMENT AT 120 PTEN, plasma glucose levels and glycemic variability were investigated, as
MIN (PG%): A NOVEL INTERPRETATION OF NORMAL well as between PTEN and calories administered. Parametric and non-pa-
GLUCOSE TOLERANCE rametric tests were performed, as appropriate, and P <0.05 was considered
statistically significant.
Merlotti E. 1, Carnevale Schianca G.P. 2, Momo E. 1, Rossini A. 1, Celasco M. 1, Results: Twenty patients (13 men, mean age of 37.3 ± 12.7 years) were
Fra G.P. 2, Brustia F. 1, Pirisi M. 1 considered. No correlation between plasma glucose and PTEN was docu-
1
Dipartimento di Medicina Traslazionale, Università del Piemonte mented (r= -0.15, P= 0.55), neither between glycemic variability and PTEN
Orientale, Novara, 2SCDU Medicina Interna 1, Azienda Ospedaliero- expression (r= -0.00, P= 0.99). However, total kcal/day administered and
Universitaria “Maggiore della Carità”, Novara PTEN expression significantly correlated (r= 0.56, P= 0.01). Also, patients
with PTEN levels below the median value received less kcal/day than those
Rationale and Aim: It is conceivable that subjects with more efficient with PTEN above the median (P=0.048). This association was more pro-
glucose utilization at a certain time point in their life will show lower risk nounced when adjusted for body weight (P= 0.03) and for the average of
of progression to prediabetes and diabetes along the years. Based on this insulin daily administered (P= 0.02).
hypothesis, we studied subjects who at a baseline standard oral glucose Conclusions: PTEN expression might contribute to glucose homeostasis
tolerance test (OGTT) had normal glucose tolerance (NGT) by repeating and disposal in critically ill patients receiving artificial nutrition.
the OGTT at the end of follow-up. Our aim was to define the value of the Essential References:
percentage increment of the 2-hour plasma glucose with respect to fasting NICE-SUGAR Study Investigators. N Engl J Med2009
plasma glucose (PG%) as a predictor of future abnormalities of glucose Grinder-Hansen L, et al. Diabetes Metab2016
metabolism. Laviano A, et al. Nat Rev Endocrinol2010
Methods: The study population included 353 subjects, 131 males (37.1%) Stles BL, et al. Mol Cell Biol2006
median age 53 years. For each subject, age, body mass index (BMI), waist Van den Berghe G, et al. N Engl J Med2006
circumference (CV), glycated hemoglobin (HbA1c), PG% and surrogate
indices of β cell function such as homeostasis model assessment (HOMA),
insulin sensitivity index (EISIStumvoll), insulin secretion (EFPStumvoll) 282. DIABETIC KETOACIDOSIS DURING SGLT2
and disposition index (DI) were recorded at baseline. Factors associated INHIBITORS TREATMENT
with persistence of the NGT status over time were identified at univariate
and multivariate time-to-event analysis, along an average follow up that Nardella E. 1, D’Addio S. 1, De Vito F. 1, Soldato M. 1, Caramazza D. 2,
lasted 12 years (min 1 years, max 12 years). Pedone Anchora L. 2, Gallucci V. 2, Bartoccioni E. 3, Pitocco D. 1, Manna R. 1
Results: At baseline, 226 (64.1%) subjects had a PG% < 20 (Group A) and
1
Area Medicina d‘Urgenza e Medicina Interna; 2 Area Salute della Donna; 3
127 (35.9%) a PG% ≥ 20 (Group B). Subjects belonging to Group B differed Area Diagnostica di Laboratorio e Malattie Infettive Fondazione Policlinico
from subjects in Group A with regard to age (52 years vs. 55 years, p<0.02), Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Roma
G120’ (87 mg/dl vs. 121 mg/dl, p<0.0001), I0’ (8.05 mcU/ml vs 10.2 mcU/
ml, p<0.001), I120 (36.4 mcU/ml vs 68 mcU/ml, p<0.0001), HOMA (1.7 vs A 57-year-old woman was admitted for an elective laparoscopic sacrocol-
2.3, p<0.001), BMI (25.6 Kg/h2 vs 27.6 Kg/h2, p<0.05), EISI (10.4 vs 7.9, popexy because of genitourinary prolapse recurrence. The patient had a
p<0.0001), DI (8.9 vs 8.2, p<0.0001), PG% (-2.2% vs 32.3%, p<0.0001), 10-year history of diabetes mellitus, diagnosed as type 2 (T2DM), although
HbA1c (5.4% vs 5.5%, p<0.001). There was a strong linear correlation she had never been overweight. She had also hypertension, Hashimoto’s
between PG% and HOMA (r= 0.18, p <0.01), EISI (r= -0.88, p<0.001) and thyroiditis, and vitiligo developed in the last two years. Medications inclu-
DI (r= -0.45, p<0.0001). Group B subjects were less likely to remain in the ded levothyroxine, bisoprolol, cilazapril/hydrochlorothiazide and simvasta-
NGT state along time (p<0.0001). Finally, in a Cox proportional hazards tin. Diabetes had been initially treated with metformin associated to short
model in which the outcome variable was loss of NGT status and the predi- and long acting insulins. Because of hypoglycaemic crisis she discontinued
ctive variables were age, PG%, familiarity with DM, BMI, CV, HbA1c, the insulin aspart. Two months before admission empagliflozin was added and
two only independent predictors were age and PG% (respectively OR 2.41, she followed a carbohydrate-restricted diet with weight loss, good glycaemic
IC95% 1.32-4.4, OR 4.53, IC95% 2.65-7.74). control and reduction of insulin glargine need. At admission, the body mass
Conclusions: At an OGTT, the closer the 2-hour plasma glucose is to index (BMI) was 21.2 kg/m2. On the third postoperative day, the patient
fasting plasma glucose, the higher is insulin sensitivity and the lower is suddenly developed shortness of breath, epigastric pain and nausea without
insulin secretion. The PG% is a simplie and economic tool and promises to vomiting. On examination, she was upset but conscious, afebrile, normoten-
expand prognostic power of the OGTT into the NGT range, not only as a sive, with marked Kussmaul breathing. An electrocardiogram showed sinus
surrogate index of β cell function but, more importantly, as a predictor of tachycardia. Blood gas analysis revealed severe metabolic acidosis with a
the ability to remain in the NGT state over time. pH of 6.88, pCO2 of 9 mmHg, bicarbonate level 1.7 mmol/L, anion gap
19.3, and an increased base excess (-31.5 mmol/L). Blood glucose was 298
mg/dL, and urinalysis revealed glucose >30.0 g/L and presence of ketones.
281. ASSOCIATION BETWEEN PHOSPHATASE AND There were no physical or laboratory findings of infection and renal fun-
TENSIN HOMOLOGUE (PTEN) EXPRESSION, GLUCOSE ction was normal. In the setting of recent abdominal surgery, the hypocap-
CONTROL AND CALORIES SUPPLEMENTED IN nia could suggest pulmonary embolism, although the patient wasn’t hypoxic
CRITICALLY ILL PATIENTS and oxygen saturation was normal. Indeed, a chest computed tomography
scan was negative. Therefore, a diagnosis of diabetic ketoacidosis (DKA)
Molfino A. 1, Amabile M.I. 1, Alessandri F. 2, Farcomeni A. 3, with only minor hyperglycaemia was established and standard treatment
Dell’Utri D. 2, Mosillo P. 4, Rossi Fanelli F. 1, Muscaritoli M. 1, was initiated with intravenous insulin, fluids and bicarbonate obtaining
Laviano A. 1 clinical and laboratory improvement. In this patient, despite previous dia-
1
Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy gnosis of T2DM, the history of autoimmune diseases and the presence of
2
Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and a normal BMI suggested a latent autoimmune diabetes of adults (LADA).
Geriatric Sciences, Sapienza University of Rome, Rome, Italy 3Department of Indeed, laboratory studies revealed antiglutamic acid decarboxylase auto-
Public Health and Infectious Diseases, Sapienza University of Rome, Rome, antibodies (> 200 IU/ml) and undetectable C peptide levels. At discharge,
Italy 4Department of Physiology and Pharmacology “Vittorio Erspamer”, empagliflozin and metformin were discontinued and the patient was swi-
Sapienza University of Rome, Rome, Italy tched to insulin therapy, and she is in good clinical condition with good
glycaemia control. In May 2015, the Food and Drug Administration (FDA)
Background and Aim: Phosphatase and tensin homologue (PTEN) reduces issued a drug safety communication which reported that Sodium-glucose
insulin sensitivity and its expression increases during sepsis. Considering cotransporter 2 (SGLT-2) inhibitors may lead to DKA also without a sub-
that critically ill patients present insulin resistance, we investigated the role stantial increase in blood glucose levels [1]. These drugs decrease plasma
of PTEN expression on glucose control and clinical outcome(s) in patients glucose by blocking the reabsorption of glucose at the proximal tubule [2].
hospitalized in an intensive care unit (ICU) receiving artificial nutrition. Factors associated with DKA development include low insulin-producing
Patients and Methods: This was an observational, single-center study capacity in the pancreas, a sudden drop in a patient’s insulin dose, increased
recruiting adult patients hospitalized in ICU for trauma. Plasma glucose insulin requirement (due to illness, surgery or alcohol abuse) or conditions
that can restrict food intake or lead to severe dehydration [3]. Some patients
169
with LADA may be misdiagnosed as T2DM. This would lead to insufficient Introduction: Insulin autoimmune syndrome (IAS), first described in 1973
insulin levels specially in stress condition. Moreover in our present case, the by Hirata, is clinically characterised by recurrent spontaneous postprandial
weight reduction could suggest a β-cell mass loss and in this setting a surgery, hypoglycaemia. Serum insulin is extremely high with elevated insulin auto-
during empagliflozin treatment, has been a trigger of DKA. European Medi- antibodies. The disease has a significant genetic predisposition as suggested
cines Agency (EMA) recommended temporarily stopping SGLT2 inhibitors by its association with specific HLA class II alleles and it is often associated
in patients who are undergoing major surgery or are in hospital due to serious with previous exposure to drugs with a sulphydryl group in their chemical
illness. In conclusion, SGLT-2 might be safely used in patients with T2DM structures. Nowadays there are more than 170 cases reported worldwide the
who have endogenous insulin production. In conditions where there is little majority of which are reported in Japan, while the syndrome is very rare in
or no insulin production such as T1DM, LADA, pancreatitis, we should con- Caucasian population.
sider the development of complications [4]. Thus, it is essential to establish a Case Report: A 34-year old Sicilian woman with 6 month history of inter-
correct diagnosis of the diabetes type: a LADA misdiagnosed may be a terri- mittent, late postprandial diaphoresis, tremors, palpitations, dizziness
ble mistake for patients, because SGLT-2 inhibitors treatment without insulin and confusion with no headache, nausea nor vomiting, was admitted to
introduction could increase the risk of ketoacidosis. our Emergency Department due to a new episode of severe hypoglycae-
1. FDA Drug Safety Communication. FDA warns that SGLT2 inhibitors for mia. Symptoms had ever improved with sugary drinks and other caloric
diabetes may result in a serious condition of too much acid in the blood. intake resulting in weight gain of 5 kg in the last months. Her past medical
May 15, 2015 history was not meaningful and she had previously taken only medications
2. Tahrani AA, Barnett AH, Bailey CJ. SGLT inhibitors in management of for seasonal asthma due to allergy. She denied any history of alcoholism
diabetes. Lancet Diabetes Endocrinol 2013;1:140-51. or drug addiction. At presentation the patient appeared alert and oriented
3. EMA European Medicines Agency. EMA confirms recommendations to to person and time and her vital signs were stable. Her blood glucose level
minimise ketoacidosis risk with SGLT2 inhibitors for diabetes. February 25, (BGL) was 52 mg/dl and required 50% dextrose to maintain her BGL >70
2016 mg/dl. Serum insulin was >2400 mU/l (normal <27), C-peptide 11.7 nmol/l
4. Clement M, Senior P. Euglycemic diabetic ketoacidosis with canagliflozin: (0.4–1.5) and sulphonylurea screening was negative. Initially we suspected
Not-so-sweet but avoidable complication of sodium-glucose cotranspor- an insulinoma, thus abdominal CT, MRI and PET scan were done in order
ter-2 inhibitor use. Canadian Family Physician. 2016;62(9):725-728 to investigate this possibility but they failed to identify it. Endoscopic
ultrasound no pointed out pancreatic lesions. Calcium stimulation study
showed high insulin without a gradient. As we excluded all the other causes
283. A RESIDUAL, YET SIGNIFICANT, RISK of hypoglycaemia, we suspected a case of Hirata disease and our diagnosis
was confirmed by the elevated insulin autoantibodies >50 U/l (<0.3). More-
Cecchini M., Panizon E., Vinci P.A., Biolo G. over we took patient’s blood samples for HLA Class II typing with positive
Clinica Medica, Dipartimento di Medicina, Ospedale di Cattinara, Azienda result. She was treated on fractionated, normocaloric diet (5 meals/day) and
Sanitaria Universitaria integrata di TS. experienced a significant relief of symptoms. The patient, despite her low
level of C peptide, is still in good conditions 16 months after the onset of
In a 73 years old woman, affected by heterozygous familial hyperchole- symptomatology, with no need of insulin therapy.
sterolemia, hypertension and severe peripheral artery disease (stenting of Discussion:Mechanism of IAS is that antibodies against insulin binds and
the right internal carotid artery, endarterectomy of the left internal carotid releases insulin asynchronously. Free insulin levels are normal though
artery and percutaneous-trans-catheter angioplasty of both iliac arteries), bound (total) are high. Luckily, the major part of IAS patients (80%) spon-
Lipoprotein (a) level was tested and found to be elevated (139 mg/dL). taneously remit. The disease is more present in Asiatic populations while
At the beginning of statin treatment (in 2009) she developed statin-related insulinomas are the most prevalent cause of hyperinsulinemic hypoglyca-
myopathy (CK level > 1000 U/L). She was therefore treated with ezetimibe emia in Caucasians in whom investigation is focused on localization fol-
with unsatisfactory results. We therefore initiated bimonthly treatment lowed by surgery. We wish here to emphasize the importance of differential
with with LDL apheresis. In March 2016 she has begun treatment with a diagnosis for hypoglycaemia and the need to measure insulin antibodies in
novel PCSK9 inhibitor, evolocumab 140 mg/14 days. An optimal LDL order to avoid unnecessary surgery.
cholesterol target was then achieved. LDL apheresis was discontinued. In
February 2017, an evaluation of the right ICA by angio-CT and arterio-
graphy demonstrated stent restenosis and clear progression of the athero- 285. 1-HOUR DURING OGTT INCREASED RISK OF
sclerotic disease, despite an optimized control of LDL cholesterol, i.e., 36, 8 CARDIOVASCULAR DAMAGE IN OBESE AND NON OBESE
mg/dL. The patient was then re-evaluated for residual cardiovascular risk. SUBJECTS
Blood pressure was well controlled, homocysteine, glucose and C-reactive
protein levels were normal. The patient had normal body weigh and did Succurro E., Pedace E., Andreozzi F., Miceli S., Bencardino G.,
not smoke. We therefore decided to reevaluate Lp(a) levels (137 mg/dL) Sciacqua A., Perticone F., Sesti G.
which appeared not have been affected by evolocumab. It is well known Dipartimento di Scienze Mediche e Chirurgiche, Università “Magna Graecia”
that Lp(a) greatly increases cardiovascular risk, however there is not clear di Catanzaro, Catanzaro, Italia
consensus about Lp(a) lowering strategies. LDL apheresis is the only pro-
cedure that has been demonstrated effective in decreasing Lp(a). However, Recent studies have suggested that a plasma glucose concentration >155 mg/
this technique is only available for a very limited number of patients. In dl at 1 hour during OGTT (1h-NGT-high) identifies subjects with a worse
case of increased Lp(a), current clinical guidelines usually recommend to metabolic and cardiovascular risk profile and with increased risk of type
optimize control of LDL cholesterol. New PCSK9 inhibitors are considered 2 diabetes (DM2). However, individuals with1 h post load hyperglycaemia
promising tools to achieve such goal. [J Thorac Dis. 2017 Jan;9(1):E78-E82. exhibited higher adiposity as compared with subjects with glucose concen-
Doi: 10.21037/jtd.2017.01.40]. tration at 1h <155 mg / dl (1h-NGT-low), Therefore, it is not clear whether
In our patients, guideline suggestion was not effective in preventing progres- the increased cardiovascular organ damage observed in 1h-NGT-high indi-
sion of atherosclerosis despite the very low LDL cholesterol level achieved viduals is due to increased body weight. To elucidate this issue, we exami-
during evolocumab administration. Thus, despite very low LDL-choleste- ned 1680 subjects aged between 20 and 65, participating to the CATAMERI
rol, given the high Lp(a) levels associated with atherosclerosis progression, study, an observational study conducted in a population at risk of DM2 for
we decided to resume LDL-apheresis aimed at reducing Lp(a) [Curr Opin the presence of at least one risk factor including family history of DM2,
Lipidol 2016 Aug;27(4):351-8. Doi:10.1097/MOL.0000000000000319]. overweight/obesity, hypertension, dysglycaemia and dyslipidaemia. The
After LDL-apheresis, Lp(a) level was decreased to 31 mg/dL. subjects underwent anthropometric assessment, oral glucose tolerance test
(OGTT), and measurement of various cardiovascular organ damage inclu-
ding intima-media thickness (IMT) assessed by ultrasound of the common
284. A VERY RARE CAUSE OF RELAPSING carotid arteries, thickness of the interventricular septum (IVS) evaluated by
HYPOGLYCAEMIA: THE HIRATA SYNDROME!!! echocardiogram, and arterial stiffness evaluated by pulse pressure. Accor-
ding to the BMI and the value of the plasma glucose at 1h during OGTT,
Piccillo G.A. 1, Saitta R. 1, Mondati E.G.M. 2, Gasbarrini G.B. 3 subjects were divided into 4 groups: 1) non obese (BMI <27 Kg/m2) with
1
Emergency Department, Cannizzaro Hospital Catania; 2Department of glucose concentration at 1h <155 mg / dl (1h-NGT-low) (N = 477), 2) non
Internal Medicine and Systemic Pathologies, University of Catania; 3Professor obese (BMI <27 Kg/m2) with 1h-NGT-high (n = 268), 3) obese (BMI> 30
Emeritus of Internal Medicine, Catholic University of Rome Kg/m2) with 1h-NGT-low (n = 457), 4) obese (BMI> 30 Kg/m2) with 1h-N-
GT-high (n = 478). 1h-NGT-high obese showed a significant increase in
170
waist circumference (p<0.001), but not BMI (p=ns), systolic (p<0.0001) and HDL cholesterol as compared with IRO subjects. MHO subjects
diastolic blood pressure (p=0.003), LDL cholesterol (p=0.02), triglycerides also showed significantly lower ESR, hsPCR, C3, and WBC as com-
(p<0.001), HOMA-IR (p<0.0001), fasting plasma glucose (FPG) (p<0.0001) pared with IRO subjects (p=0, 005, p<0, 0001, p<0, 0001, p<0, 0001,
and 2-h glucose (p<0.0001) and a reduction in HDL (p=0.02), compared to
obese subjects with 1h-NGT-low. 1h-NGT-high obese also showed a signi- respectively). As compared with nonobese normal subjects, MHO
ficant increase in pulse pressure (p=0.003), IMT (p<0.001), SIV (p<0.001), subjects exhibited significantly higher waist circumference, uric
and rate pressure product (p<0.001) compared to 1h-NGT-low. 1h-N- acid, fibrinogen, and C3, and significantly lower HDL cholesterol
GT-high non-obese showed a significant increase in BMI (p=0.04), waist and IGF-1, while there were no significant differences between the
circumference (p=0.006), systolic (p<0.0001) and diastolic blood pressure other inflammatory and metabolic parameters assessed. In contrast,
(p=0.004), LDL cholesterol (p=0.01), triglycerides (p=0.003), HOMA-IR
IRO subjects showed significantly higher waist circumference, sBP,
(p=0.05), FPG (p<0.0001) and 2-h glucose (p<0.0001) and a reduction in
HDL (p=0.02) as compared with 1h-NGT-low non-obese. Additionally, dBP, triglycerides, HbA1c, uric acid, FPG, 2-h glucose, and all of
1h-NGT-high non-obese showed a significant increase in pulse pressure the five inflammatory markers measured and significantly lower
(p<0.0001), IMT (p<0.0001), SIV (p<0.0001) and rate pressure product Matsuda index, HDL cholesterol and IGF-1 as compared with
(p<0.0001) as compared with 1h-NGT-low non-obese. In a logistic regres- nonobese normal subjects. Subjects were classified in six categories
sion model, 1h-NGT-high obese showed a significantly increased risk of according to their Inflammation Score. A greater proportion of IRO
having a composite endpoint of cardiovascular organ damage as compared
with 1h-NGT-low obese (OR 1.78, 95% CI 1.12-2.85, p <0.01). Similarly,
(18, 2%) had the highest value of the Inflammation Score compa-
1h-NGT-high non-obese displayed a significantly increased risk of having red to nonobese normal subjects (2, 7%; p<0, 0001) and MHO (8,
a composite endpoint of cardiovascular organ damage as compared with 6%; p=0, 004). In a logistic regression model, both IRO and MHO
1h-NGT-low non-obese (OR 2.084, 95% CI 1.14-3.79, p <0.01). These results subjects showed an increased risk (OR 8, 061, 95% C.I. 3, 967-16,
suggest that hyperglycaemia at the first hour during OGTT aggravates the 378; p<0, 0001; and OR 3, 398, 95% C.I. 1, 346-8, 574, p<0, 0061,
risk of subclinical organ damage in both obese and non-obese subjects. respectively) of having the highest value of the Inflammatory Score
as compared with nonobese normal subjects.
286. CHRONIC SUBCLINICAL INFLAMMATION IN META- Conclusion: Our data indicated that MHO subjects showed a better inflam-
BOLICALLY HEALTHY BUT OBESE (MHO) SUBJECTS AND matory risk profile as compared with insulin resistant obese subjects.
OBESE INSULIN RESISTANT SUBJECTS
Pedace E., Succurro E., Fiorentino T.V., Andreozzi F., Sesti G. 287. PERICARDIAL EFFUSION IN ANOREXIA NERVOSA
Dipartimento di Scienze Mediche e Chirurgiche, Università “Magna Graecia” IS ASSOCIATED WITH LOWER BMI: A RETROSPECTIVE
di Catanzaro, Catanzaro, Italy STUDY
Introduction: It is known that chronic subclinical inflamma- Tamagni M.E. 1, Pizzi R. 1, Fanin A. 1, Bertelli S. 2, Massironi L. 3,
Lucreziotti S. 3, Scarone S. 2, Carugo S. 3, Pontiroli A.E. 1, Benetti A. 1
tion is a predictor of type 2 diabetes (T2DM) and cardiovascular 1
U.O. Medicina II, 2U.O. Psichiatria, 3U.O. Cardiologia e UTIC, Ospedale
disease (CVD). Among markers of subclinical inflammation, the San Paolo, Milano; Università degli Studi di Milano
most reliable for clinical use is high-sensitivity C-reactive protein
(hsCRP), but other markers, such as erytrocyte sedimentation Background: Anorexia nervosa (AN) is a psychiatric disease that can lead
rate (ESR), fibrinogen, C3 complement (C3), and white blood to many medical complications, including cardiovascular disorders such
cells (WBC), have been associated with T2DM. A subset of obese as bradycardia, hypotension, arrhythmias and heart failure. Among these
complications, of interest is silent pericardial effusion (PE), especially in
subjects, termed “metabolically healthy but obese” (MHO) indivi-
patients with lower BMI: a few publications have reported PE in patients
duals, has been identified to have a favorable cardiovascular risk with AN, but only rare cases of acute life-threatening cardiac tamponade
profile as compared with insulin-resistant obese (IRO) individuals, are described.
but whether MHO subjects have a worse inflammatory profile Subjects, Methods and Results: We performed a retrospective study to
as compared with nonobese normal subjects is not known. Aim: collect data of AN patients visited in the San Paolo’s Hospital Psychiatric
To evaluate the inflammatory profile in metabolically healthy but Unit from January 1, 2015 to May 31, 2017. The data of 138 patients (9
obese (MHO) and in insulin-resistant obese (IRO) as compared M/129 F, age 24± 3 years, BMI 14 ± 3.1 kg/m2, Mean ±SD) were analyzed,
including blood tests, electrocardiogram (ECG), evaluation by a psychia-
with nonobese normal subjects. Patients and trist and an internist. 42 out of 138 patients were submitted to at least one
Methods: The study group consisted of 810 non-diabetic subjects, transthoracic echocardiogram during the follow-up period. This subgroup
with a normal glucose tolerance (fasting plasma glucose <100 mg/ of patients differed from the others for lower BMI (p=0.001), lower WBC
dl and 2-h post-challenge glucose <140 mg/dl), participating to the (p=0.02), higher AST and ALT levels (p=0.03 and 0.001 respectively), lower
CATAnzaro MEtabolic RIsk factors (CATAMERI) Study, an obser- albumin levels (p=0.03). 19 out of 42 patients (45.2%) showed a mild to
vational study recruiting individuals at risk of T2DM. All subjects moderate PE (< 2 cm) without hemodynamic impairment, not requiring
intervention. Bradycardia and aspecific abnormalities of repolarization
underwent anthropometrical and biochemical evaluation and 75 g
were seen at ECG of these patients, but in none of them we found abnor-
oral glucose tolerance test (OGTT). The ISI index, derived from the malities suspected for PE. Patient with PE appeared to be the ones with the
OGTT, was used to estimate insulin sensitivity. We aimed to quan- lowest BMI.
tify the inflammatory state using an Inflammatory Score, generated Conclusions: This study supports the association between AN and clini-
by attributing one point for a value greater than the median of the cally silent PE, which may represent an early sign of cardiovascular involve-
study sample for each of the five measured inflammation markers ment. In particular, there is a correlation between PE and BMI: the lower the
(fibrinogen, ESR, hsCRP, C3, and WBC) and ranged from 1 (lowest BMI, the higher the prevalence of PE.
median value for each of the five inflammatory markers) to 6
(highest median value for each of the five inflammatory markers). 288. MEDITERRANEAN DIET IN PATIENTS WITH
Participants were defined as nonobese normal subjects if they had ACUTE ISCHEMIC STROKE: RELATIONSHIPS BETWEEN
a BMI<27 Kg/m2 (n = 394) and obese if they had a BMI >30 Kg/ MEDITERRANEAN DIET SCORE, DIAGNOSTIC SUBTYPE,
m2 e <45 Kg/m2 (n = 416). According to ISI, the obese subjects AND STROKE SEVERITY INDEX
were stratified into quartiles and defined as being MHO if their ISI
Tuttolomondo A. 1, Casuccio A. 2, Di Raimondo D. 1, Buttà C. 1,
was in the upper quartile and IRO if their ISI was in the two lower Pecoraro R. 1, Della Corte V. 1, Arnao V. 4, Clemente G. 1, Maida C. 1,
quartiles. Simonetta I. 1, Miceli G. 1, Cirrincione A. 1, Corpora F. 1, Pinto A. 1
Results: MHO subjects exhibited significantly lower triglycerides, 1
Internal Medicine and Cardio-Angiology Ward, Biomedical Department
HbA1c, uric acid, FPG, and 2-h glucose and significantly higher of Internal and Specialistic Medicine, University of Palermo, Italy. ²Sciences
171
for Health Promotion and Mother-Child Care Department, University of 289. A CASE OF ACARBOSE-INDUCED ACUTE
Palermo, Italy HEPATOTOXICITY IN A YOUNG WOMAN AFFECTED
BY LATENT AUTOIMMUNE DIABETES OF THE ADULTS
Background: The heart-healthy Mediterranean diet (Me-Di)) is a healthy (LADA)
eating plan based on typical foods and recipes of Mediterranean-style
cooking A recent randomized trial showed that the risk of stroke was Valvo B., Lovati E., Lucotti P., Corazza G.R.
reduced significantly in the two Me-Di groups. This is consistent with epi- First Department of Medicine, Scientific Institute St. Matteo Hospital,
demiologic studies that showed an inverse association between Me-Di and University of Pavia, Pavia
stroke incidence. Furthermore a recent study sought to assess the longitu-
dinal association between greater adherence to MeD and risk of incident Introduction: Acarbose is an oligosaccharide obtained from fermentation
stroke reporting how adherence to MeD seems to be associated with a of Actinoplanes utahensis which acts as an alpha-glucosidase inhibitor,
lower risk of incident ischemic stroke. Nevertheless, no study has addres- resulting in delayed carbohydrates digestion and thus in lower post-pran-
sed the association of adherence to a Me-Di in subjects with acute ische- dial glucose blood concentration. It is a useful therapy in the management
mic stroke and diagnostic subtype and severity of stroke. Thus we con- of type 2 diabetes and can be sometimes adopted as an adjunctive therapy
ducted a retrospective study to evaluate the association between Me-Di on the top of insulin in type 1 diabetic patients. Its most common side
adherence evaluated by means of the calculation of Mediterranean Diet effect is bowel discomfort due to carbohydrate malabsorption so that acar-
Score (MeDi score) and stroke subtype, severity index, and outcome of bose is contraindicated in patients with chronic entheropathies as well as
ischemic stroke. Aim: The primary outcome in this study was to evaluate in renal failure and cirrhosis. Acarbose is known to be associated with a
differences in mean Me-Di score between patients with acute ischemic statistically significant dose-dependent risk (OR 6.86, 95%, CI 2.50-18.80)
stroke and subjects without acute ischemic stroke. Secondary outcomes in asympothomatic transaminase increase (over three-fold the upper limit
were: evaluation of a relationship between TOAST subtypes of ischemic of normal) as reported in a recent meta-analysis (Zhang et al. 2016) inve-
stroke and mean Me-Di score, and between severity index of acute ische- stigating alpha glucosidase inhibitors-associated hepatotoxicity in type-2
mic stroke and mean Me-Di score. Methods: The type of acute ischemic diabetes. Acarbose-induced liver injury is generally mild and self-limited
stroke was classified according to the TOAST criteria. All patients admit- after drug withdrawal but few sporadic cases of acute hepatotoxicity asso-
ted to our ward with acute ischemic stroke completed a 137-item vali- ciated with acarbose treatment have been described (Hsiao et al. 2006).
dated food-frequency questionnaire adapted to the Sicilian population. Case Report: A 27-year-old woman presented to our outpatient clinic in
A scale indicating the degree of adherence to the traditional Mediter- November 2016. She was diagnosed with Latent Autoimmune Diabetes
ranean diet was used (Me-Di score: range 0-9). All patients admitted to of the Adults (LADA) and was treated with long acting insulin (detemir
our ward with acute ischemic stroke (or their relatives) completed a 137- 0.2 UI/Kg) at bedtime. Due to inadequate postprandial glycemic control,
item validated food-frequency questionnaire (17) adapted to the Sicilian albeit mild, acarbose (50 mg two times daily) was added to the treatment
population. A scale indicating the degree of adherence to the traditional in February 2017. Two months later she developed progressive asthenia,
Mediterranean diet was constructed by Trichopoulou et al.. A value of 0 nausea and abdominal discomfort. Physical examination was unremar-
or 1 was assigned to each of nine indicated components with the use of kable, apart from hepatomegaly. Laboratory examination revealed high
the sex-specific median as the cutoff. For beneficial components (vege- aminotransferases (AST 545 mU/ml and ALT 703 mU/ml; upper refe-
tables, legumes, fruits, nuts, cereal, and fish), individuals whose consu- rence values 39 e 34 respectively) and cholestasis indices (GGT 425 mU/
mption was below the median were assigned a value of 0, and individuals ml, and ALP 179 mU/ml; upper reference values 53 e 150 respectively),
whose consumption was at or above the median were assigned a value with mild increase in total bilirubin. Results of serological tests for viral
of 1. For components presumed to be detrimental (meat, poultry, dairy infections hepatitis were negative and biliary obstructions were excluded
products), individuals whose consumption was below the median were by abdominal ultrasound. In suspicion of a drug-induced hepatotoxicity,
assigned a value of 1, and individuals whose consumption was at or above acarbose treatment was promptly discontinued and patient was admit-
the median were assigned a value of 0. Results: 198 subjects with acute ted to hospital. Workup for acute hepatitis did not reveal any underlying
ischemic stroke the stroke subjects had a lower mean Mediterranean diet infectious or autoimmune process and patient’s symptoms resolved as
score compared to 100 controls without stroke. We observed a signifi- her transaminases improved by discontinuation of acarbose. Serum liver
cant positive correlation between Me-Di score and SSS score, whereas we enzymes concentrations were within the normal range six weeks after
observed a negative relationship between Me-Di score and NIHSS and acarbose was stopped.
Rankin scores. Subjects with atherosclerotic (LAAS) stroke subtype had a Discussion:In the present case, temporal relation between acarbose tre-
lower mean Me-Di score compared to subjects with other subtypes.Multi- atment initiation and liver damage onset, in addition to the complete
nomial logistic regression analysis in the simple model showed a negative recovery following drug withdrawal, make the acarbose-induced hepato-
relationship between Me-Di score and LAAS subtype vs. lacunar subtype toxicity a reliable diagnosis. According to the Italian Pharmacovigilance
(OR=2.226 CI95%; 1.66-2.98; P=<0.0005) and LAAS vs. cardio-embolic Drug Agency, from January 2001 to June 2017 only six cases of hepatobi-
subtype (OR: 2.180 CI95%: 1.68-2.83; P<0.0005). Multivariable regression liar adverse events related to acarbose therapy have been reported (which
model conducted by evaluation of all different variables even not signifi- account for 5.7% of all acarbose-related reports), including five acute
cant, between TOAST subgroups such as NIHSS score, SSS score, AF and hepatitis (two of which defined as cholestatic), one case of hypertransa-
diabetes, LAAS subtype vs. lacunar subtype maintained a significant nega- minasemia and one unspecified drug-induced hepatic injury. The cause
tive relations with MeDi score (and the same relationship was maintained of liver injury during acarbose treatment is not known. An immunologi-
also for LAAS vs. cardio-embolic subtype and Me-Di score By means of cal reaction to this bacterially derived oligosaccharide molecule has been
ROC curve analysis we found good sensitivity and specificity of mean supposed as an etiopathogenic mechanism since it is minimally absorbed
MeDi score to predict ischemic stroke subtype, in the case of lacunar vs. from the intestine. Although rare, the eventuality of a severe acarbose-in-
LAAS (AUC=0.829). duced hepatotoxicity must be considered, so that monitoring of serum
Conclusions: Our study shows that low adherence to a Mediterranean liver enzymes during acarbose treatment may be careful to prevent this
diet is associated with higher stroke prevalence, with LAAS stroke subtype unpredictable but potentially fatal complication.
and a worse stroke clinical profile evaluated by means of NIHSS and
Rankin score.our finding concerning a lower mean MeDi score in stroke
patients compared to controls can be related to a different cerebrovascular 290. CHANGING TRENDS IN SERUM 25-OH-VITAMIN D
risk profile linked to a low adherence to a Mediterranean Diet style. Thus LEVELS, YEARS 2005-2016, IN PADOVA (ITALY)
it is plausible to hypothesize that unlike patients with higher adherence
to Me-Di, patients with lower Me-Di score are more likely to develop A. Amabile, S. Sella, M. Zaninotto, A. Michielin, D. Braghin,
atherosclerotic events such as atherosclerotic strokes. However, patients M. Fusaro, A. Aghi, F. Fabris, M. Plebani, S. Giannini
with acute ischemic stroke and lower adherence to Me-Di could be cha- Department of Medicine-DIMED, University of Padova, Italy
racterized by a higher inflammatory background with higher immune-in-
flammatory responses after acute ischemic stroke more likely to be athe- Background: It is well-known that hypovitaminosis D is very common in
rosclerotic. This interpretation, although biologically plausible, needs to the general population. In the elderly, this condition is far more frequent
be confirmed by further studies aimed at evaluating different degrees of and associated with remarkable skeletal morbidity, such as increased risk
immune-inflammatory activation of the acute post-stroke phase in rela- of fragility fractures and falls. In the past, its prevalence has been found
tion to different nutritional profiles with particular attention to adherence to be very high in Italy. However, no recent studies have been carried out
to a Me-Di diet. to evaluate whether trends in serum vitamin D levels are changing over
172
time in our Country. Objective: The purpose of this study was to evaluate tubercolosis) was revealed and cytologic analysis was normal. Blood exams
the possible changes over time in 25-OH-vitamin D serum levels in the showed lymphopenia (lymphocytes: 330/mm3) and a chitotriosidase level
population of Padova, Italy, years 2005 to 2016. lower than a previous check (116.2 U/L Vs 400 U/L, the sample was with-
Methods: Subjects were included in the study if they were males or drawn during corticosteroids therapy). Excluding other possible etiologies,
females, aged 1-100 years and had at least one determination of serum we diagnosed chylothorax in sarcoidosis. A conservative management was
25-OH-vitamin D at the Unit of Laboratory Medicine, University Hospital choosen, so a fat-free diet with medium chain triglyceride oil and high-dose
of Padova, Italy, over the period January 1st, 2005 to December 31st, 2016. methylprednisolone therapy were started; besides, a pleural pigtail catheter
114, 492 patients were included in the study, 65.4% female with median was inserted with daily gradual reduction of chyle drainage. Nevertheless,
age 64 (52, 74); 34.6% male with median age 53 (35, 69). Data were also due to overlapping of infective complications, in particular toxic megacolon
analyzed according to the following categories: year of assay, gender, induced by Clostridium difficile and fungal pneumonia, the patient died in
cohorts of age (0-18, 18-49, 50-59, 60-69, 70-79, 80-89, 90+), vitamin D Intensive Care Unit. Chilothorax is a collection of chyle (fluid consisting of
status (deficiency <30 nmol/L; insufficiency: 30-75 nmol/L; sufficiency: > lymph and fats, especially triglicerides, coming from the small intestine)
75 nmol/L). in the pleural cavity, due to a damage (destruction or obstruction) of the
Results: The table below shows the median values of serum vitamin levels thoracic duct. It could be traumatic (54, 8%), sub-classified as iatrogenic
D per year in the whole population sample during the period considered. and non-iatrogenic, or not traumatic (38, 1%), including malignancy (lym-
Serum 25-OH-vitamin D levels significantly increased over time. When phoma, lung cancer, luekemia, stomach cancer), tubercolosis, amyloidosis,
divided by gender, median levels of vitamin D were higher in females (i.e. thyroid goitre, superior vena cava thrombosis, benign tumor, sarcoidosis,
in year 2016: F 78 (56-100) nmol/L vs M 65 (43-87) nmol/L, p<0, 001). diseases of the lymph vessels and congenital duct abnormalities; a small
Females were also less frequently deficient (i.e. in 2016: F 20% vs M 31%, amount of cases remains of unknown etiology (10-15%). Nevertheless its
p<0.001) and more frequently sufficient (i.e. in 2016: F 54% vs M 39%, rarity, chylothorax has an extreme clinical relevance because of the high
p<0.001) than males. A more evident improvement in vitamin D levels mortality associated (75%), related to malnutrition, immunosoppression
was observed in older subjects (i.e. 80-89 yrs: 32 (17-56) nmol/L in 2005, and hemodynamic involvement. In literature the association between
56 (24-84) nmol/L in 2010 and 76 (48-99) nmol/L in 2016, p<0.001). A chylothorax and sarcoidosis is rarely reported (we found only 5 cases in
similar trend, although less important, was observed in young cohorts MEDLINE): in all cases, there was a mediastinal adenopathic involve-
(0-18 yy: 55 (35-92) nmol/L in 2005, 63 (40-91) nmol/L in 2010 and 69 ment of the sarcoidotic disease (chronic or recrudescent) and a right-sided
(50-91) nmol/L in 2016, p<0.001). At the same time, the prevalence of chylothorax.
vitamin D deficiency decreased more markedly in older people (eg 80-89
yrs: 73% in 2005, 44% in 2010 and 26% in 2016, p<0.001). This trend was
similar in the young cohorts, though less obvious (0-18 yrs: 44% in 2005, 292. A BRIEF HISTORY OF BIOETHICS
37% in 2010 and 24% in 2016, p<0.001).
Conclusions: This study demonstrates a significant improvement over time Carini L. 1, Cantarano M.S., Cantarano M., Cantarano E.
in serum vitamin D levels in a large population sample, particularly evident 1
Facolta’ Medicina E. Farmacia - Universita’ Roma “Sapienza”
in the elderly. Further studies aimed to assess the true current prevalence of
low serum vitamin D levels are warranted. Bioethics is characterized by a strong anthropological pluralism that pits
Variable 2005 2006 2007 2008 2009 2010
the various different nodes ethical reasons and solutions. There could be no
Vitamin D (nmol/l) 44(29,67) 39(25,59 45(27,67) 56(34,80) 62(36,86) 62(37,84)
agreement, therefore, even on the start and on the nature of bioethics. There
are those who fit the traditional ethics nell’alveo bioethics with a “renais-
2011 2012 2013 2014 2015 sance” of practical philosophy determined by the progress of technology
Vitamin D (nmol/l) 64(39,89) 61(40,81) 64(42,85) 63(40,84) 63(41,85) and medicine that creates new problems.
Others see in bioethics a new discipline that is detached from ‘medical to
rise to new tasks and new definitions. Although ethics has always been an
291. CHYLOTHORAX: A CASE OF PLEURAL EFFUSION IN essential moment for the practice of the doctor, however, we are witnes-
A PATIENT WITH SARCOIDOSIS sing a renewed commitment to ethical and philosophical reflection in the
medical field. It may be useful to summarize the key stages of the journey
Calcagno E., Alesini M., Tozzetti C., Poggesi L. of Bioethics, highlighting the rational formation and main objectives. The
Dipartimento DAI emergenza ed accettazione, Degenza Medicina C, AOU birth of bioethics has its ideological roots in the ruins of World War II. The
Careggi Firenze tragedy of global proportions, and the horrendous crimes, to which man
had come, stimulated consciences to a deep reflection, in an attempt to
We describe a case of a 76 years-old-woman with a previous histological establish the boundaries of ethics and behavior, that they applied for every
diagnosis of sarcoidosis (with pulmonary, cutaneous and adrenal involve- man and in every historical moment. Multiply and become more pressing,
ment) in remission at last follow-up on February 2017, who acceded to our from that moment forward, the declarations of various international organi-
emergency department (ED) because of worsening dyspnea and onset of zations setting forth the statutory rights of every man. Simultaneously with
peripheral oedema. Her medical history was remarkable for atrial fibrilla- this type lodging “legal” was born a philosophical reflection aims to justify
tion, severe smoke exposure, COPD and pulmonary thromboembolism, the rationality and ethics of established propositions.
therefore her home therapy was corticosteroids, diuretics and vitamin K It is not enough, in fact, state the human rights by the will of the majority,
antagonist. Blood tests showed NT-proBNP 19.398 pg/mL, creatinine 1.56 but it is necessary to justify them with philosophical investigation: in other
mg/dL, sodium 127 mEq/L, procalcitonin 0.14 ng/dL, normal WBC. The words, is not enough to affirm the right to life, but we need the “philosophy”
arterial blood gas showed type II respiratory failure. The echocardiogram of the right to life. The tumultuous development of medicine and, in a wider
highlighted a right heart enlargement and a severe pulmonary hyperten- overview, scientific discoveries, have given man a potential ability to change
sion (sPAP 65 mmHg) with a normal left ejection fraction (EF 60%). A CT the life of the planet and cause the destruction of his own kind. Such situa-
pulmonary angiography excluded acute thromboembolism, revealing the tions have heightened the need for ethics in the biomedical field, based on
presence of bilateral pleural effusion greater in the right side (75 mm) with reason and the objective value of life and of the person. In the Catholic
underlying atelectasis of the parenchyma; moreover there was evidence of Church Pope Pius XII gives a decisive impulse to the rapid development
sarcoidotic lung parenchymal involvement, stable in comparison to the last of a medical moral able to deal with new ethical problems that arise in the
chest CT, and a little increase in mediastinal lynphoadenopathy dimension practice of medicine. The moral proposed by the Pope’ solutions have often
(ilar, pre- and para-tracheal).Suspecting right heart failure in a patient with found acceptance even beyond the ecclesial boundaries, contributing to the
chronic pulmonary heart disease related to COPD, parenchimal sarcoidosis achievement of a world cultural situation that deepens the action of man by
and history of pulmonary thromboembolism, she was treated with conti- man problems in the biomedical field. It must therefore be Bioethics: term
nuous furosemide infusion and bi-level positive airway pressure (BiPAP) coined by Van Resselaer Potter in 1970.
non-invasive ventilation. Despite of an initial consistent diuretic response, Potter pointed out that in the past ethics, understood as a reflection on
there was neither any improvement in pleural effusion extent (echografically human values and ideals of human characteristics, he had been conside-
evaluated), nor in respiratory dynamic. Therefore, a diagnostic thoracente- red one of the humanities sector, destined to pass, for the most part, within
sis was performed and 1000 mL of milky fluid were drained. Pleural fluid philosophical disputes. The development achieved by biotechnology now
analysis showed 1.309 mg/dL triglycerides, 79 mg/dL cholesterol, 186 g/L required to release the ethics from the beautiful but barren theoretical isola-
glucose, 123 U/L LDH, 38 g/L proteins and numerous mature lymphocytes tion, to combine it with the reality and practice of biological fact. Bioethics,
without morphological alterations. Any bacterial growth (including M. in the idea of its founder, therefore, is an attempt to heal the separation
173
between natural science (biology) and spiritual science (ethics), in outlining cal and pathological dynamics are underlying it. This understanding refers
a future livable for humans and draw a “bridge to the future”. to human skills far more than to those, albeit relevant, technical-scientific.
If this is bioethics according Potter must be added that the “movement” bio- It is at first that reference should be made, in the light of the second, to
ethical even born before him. In the second half of the 60s some US scholars attempt to clarify the mysterious questions raised by pain and its meaning,
deepen the ethical issues of abortion and the sanctity of life, contributing to give them a sense and try to give an answer. The patient seeks and urges
greatly to the medical del’etica rebirth. the person who cares for him, who is, therefore, called to work with the
In 1969 D. Callahan co-founded the first center the first Institute for Society, sick, responsibly, with competence and personal suffering, a motivation and
Ethics and the Life Sciences in Hastingson-Hudson. It is proposed, beyond a meaning. The answer must be outlined on several “systemically” related
any ideology and religion, to face and provide a solution to the ethical issues plans: intellectual, psychological and metaphysical, to the extent that it
raised by the new achievements in the biomedical field and is characterized develops, subtle and corroding, feelings of anguish and fear of abandonment
by the strong political-pedagogical purpose. and negation of assistance until the “desire of death” Pain, but fear! Fear is a
In 1971 he established the The Kennedy Institute of Ethics at Georgetown “simple” or “primary” emotion pervasive, perhaps the most pervasive in the
University in Washington which aims to promote a concept of bioethics, world. It relates to the body and its precariousness, but it generates, for this
understood as “moral anthropology” based on research of what is univer- reason, “resilience” rather than “resistance”. It is a powerful driving force in
sally human, and led research in the Encyclopedia of Bioethics, published in human history. The fear of death is a constant presence in history, so that
1978: the most comprehensive and authoritative tool for those dealing with for some, it would be at the center of every fear! However, it would not be
bioethical issues. universal and invincible since it is dominated by other emotions and values
Since then this “discipline” was introduced in the new University. It was and has always been.
established in 1985 in Italy the first Chair of Bioethics at the Faculty of The nature of the fear of death changed over the centuries.
Medicine of the Catholic University of Rome. The authoritative Encyclo- Religious myths, which terrorized believers with the threat of the most
pedia of Bioethics, New York in 1978, defines bioethics as “the systematic horrid punishments after death, have been supplanted by other less mislea-
study of human conduct in the life sciences and health care, as this conduct ding myths, including that of the “immortality” promised by science!
is examined in the light of moral values and principles”.
Bioethics can be conceived then as “that part of moral philosophy that has
the object and scope of man on man action in the biomedical field. 294. THE “PIES” OF FLORENCE NIGHTINGALE
It is therefore rational elaboration regarding the ethical aspect (the lawful
and non-lawful) in the vast and important field of medical sciences. Carini L. 1, Cantarano M.S., Cantarano M., Cantarano E. 1
Facolta’ Medicina E. Farmacia - Universita’ Roma “Sapienza”
293. CONSIDERATION OF PAIN A good and innovative recipe for health statistics: the “pies” of Florence
Nightingale.
Carini L. 1, Cantarano M.S., Cantarano M., Cantarano E. 1 As we know, the Crimean War, at that time called the East War, was a con-
Facolta’ Madicina E. Farmacia - Universita’ Roma “Sapienza” flict fought from 4 October 1853 to 1 February 1856 between the Russian
Empire and an alliance of Ottoman Empire, France, England and the
Epiphenomenon of the disease is, in general, suffering or pain. Kingdom of Sardinia. The dramatic conditions of abandoning the wounded
This, like any other sensation, has, first and foremost, a physical, bodily con- and sick British (for the French there were the Sisters of Charity and for the
notation as a perceived alarm signal directly without cognitive mediation of Russians the 300 Nurses “Sisters of the Exaltation of the Cross” by Grand
memories, words or representations. We share it with all living beings. But Duchess Elena Pavlovna born Carlotta of Wurttemberg) during the war
it can also appear as a psychic suffering with all those consciousness and operations.
unconscious that the psyche itself constitutes. Quoted on the Times as the first war reporter, prompted the British gover-
This pain does not affect other animals, but only the upper mammals. It has nment to intervene under the rapidly growing pressures of public opinion
a motivational dimension - affective and affects previous experiences. Both that had always been very much heard and powerful.
the first type and the second, are experiences that tend to close themselves, There was no pre-established Organization that was up to the task in an
activate all systems to repair the damage or injury and escape them as soon area, among other things, very impervious and unhealthy. At the end
as possible to ensure survival. There is then the “mental” pain that embraces Angel Band was sent: 38 nurses at F. Nightingale’s orders. Nightingale was
the past, lives in the present and projects itself in the future. It is experienced English, born in Italy, and had two possible solutions to face the difficult
in a cognitive dimension - evaluative dependent on the personal and cultu- task of “Latin” and “Teutonic”. The first epiphenomenon of Roman Catholic
ral evolution of the person who lives it. anthropology provided a “human” preparation, perhaps, but certainly not
It is the exclusive experience of Man as a dimension of his existence rather “professional”. The nurse, humble and submissive to the physician, could
than his survival and does not exhaust his function by repairing the damage not have any autonomous or responsible role! The second, as an expression
but leads to the opening to the other, to growth, to maturity. It assumes a of “reformed” anthropology, provided for a theoretical - practical training
high symbolic value as a sign of a profound and personal experience. The that would make the nurse a true “care manager” ante litteram! Florence
questions about pain characterize every man’s life of inevitable crossroads. made his choice and went to study in Germany at the Kaiserwerth School
These questions are strictly personal as the answers: every man will put it, of Nursing Diacones founded in 1836. On her return, she was facing the
until the end of human history, seeking an answer that will always be his difficult problem of choosing her women to be employed in field care. She
answer! The boundaries of pain have a personal nature. When we come did not want either “prettiest prostitutes or volunteer ladies”! All of them
in contact with the suffering of another, we can do it only as this affects had to be nurses! “By unanimous consent (except that of military com-
our existence, hurt our sensitivity, interprets our intelligence, and evokes mands that will oppose them fiercely, struggling, according to their usual
unconscious resonances. The different “levels” of pain and the reciprocal traditions, even against the evidence!). The action of nurses on the field was
interactions between them make possible epiphenomenon, otherwise resolved even for the Conducting war operations! One of the lucid insights
incomprehensible, associated with the uniqueness and unrepeatability of of Nightingale led her to document, for the first time in the history of health
the human being’s personality: do not experience suffering from bodily care, statistically, mathematically, the positive and negative results of various
injuries or, on the contrary, suffer from Intensely for unrealistic stimuli or activities and welfare techniques. Through the elaboration of pie charts, a
transforming atrocious physical pain into a testimony of altruistic love, ... It method widely used in descriptive statistics for graphical representations
remains, however, certain that no matter how much empathy, no one can of quantitative variables measured on categories of classes in order to avoid
suffer in the place of another, at most it can suffer near (rapport or mirro- establishing, even involuntarily, an order that does not exist in the catego-
ring) to a Another, by means of an ad - ation, a competent assistant. Pain, ries themselves, Nightingale provided. Especially to the unbelievers and
in fact, being one of the most universal forms of “communication” has a the opponents, absolutely incontrovertible data that, beyond all reasonable
feature that makes it not perfectly integrable in the 5 axioms of the Human doubt, demonstrated the objective results of his / her welfare activities!
Communication of the School of Palo Alto (California): while having an The general health conditions of sick and / or injured soldiers improved
analogous syntax is devoid of Grammar ie alphanumeric connotations that and dropped mortality for infections from 42.7% to 2, 2% in 6 months, and
would make “transmission” and “understanding” easy. Moreover, suffering psychological support was offered to all. On her return was celebrated as a
is conditioned by his own idea of suffering and the latter is the debtor of the heroine, she and her mission inspired a sentimental literature to cover the
cultural experience of his time and environment. hardness of working reality. Funds, fame and prestige allowed him to set
For those who are in charge of assistance understanding the bond that a up a school despite the strong opposition from the medical class. Through
man has with his pain is more relevant than not knowing which physiologi- the application of statistics and appropriate field research, he worked to
174
improve civil hospitals. The British government started a nursing school an antenatal agent for hospitalization, the Melitense care system is a very early
reform that included practical internships at certified hospitals! She was example of many bioethics that were absolutely unthinkable in that period
asked, also overseas, not only as a healthcare expert, but also as an intel- and only later were referred to by authors considered to be great bioethical
ligent counselor on health care. He died at 90 years after giving nursing an pioneers of the 18th century as Peter Frank or John Gregory. 2
immeasurable contribution, mainly by changing the public image. Nursing
culture has been deeply influenced by its works: health education, training,
professionalization, autonomy, independence. At the base of the nursing 296. GENDERS PATHOLOGY
theory, according to the Nightingale, there was necessarily the environment:
microclimate, hygiene and diet, were the factors on which the nurse (skilled, Carini L., Cantarano M.S., Cantarano M., Cantarano E.
prepared, vigilant and persevering) had to act so as not to hinder the vis Facoltà di Farmacia e Medicina Università di Roma Sapienza
medicatrix Naturae stimulating the possible “passivity” of the “patient” to
cooperate in healing. “The woman had found her place in the health system, The term “gender” refers to the “man” and “woman” categories, not only
but a subordinate place. Doctors, initially hostile, will end up willingly based on biological differences but also influenced by environmental, social
accepting his obedient and submissive collaboration. and cultural factors, as well as by the experience of the individual. The term
She, however, opposed bacteriology and feminism, and the limits of her “sex” refers more simply to the individual’s biological characterization. The
theory were those of the socio-cultural context of reference summed up in World Health Organization has paid particular attention to the diversity
the axiom that “Every woman is a nurse.” with which many pathologies, once considered typically male, They are
She adopted masked and Victorian models of wife, mother, and housewife manifested in the female population by making specific recommendations.
roles transplanting them into nursing reality! In the light of these clarifications, we are moving from a biological study
between men and women to a more complex study that does not neglect
the social, psychological, political and cultural implications of the person.
295. AN ANCIENT EXAMPLE OF HEALTH MANAGEMENT: The gender approach is now considered a reality that can not be ignored and
THE SACRED INFIRMARY OF MALTA hopes to soon Andard of the best European countries. Overall According
to Istat reports, women have a life expectancy of 84.5 years while men 79.4.
Carini L. 1, Cantarano M.S., Cantarano M., Cantarano E. 1 At 65 years of age there is a positive evolution of average survival, currently
Facolta’ Medicina E. Farmacia - Universita’ Studi Roma “Sapienza” 21.9 years for women and 18.4 for men, in all geographical allocations and
with reductions in gender and territorial differences; It is attributed to the
For centuries, the disease has been considered synonymous with moral guilt. reduction of mortality for circulatory diseases and malignant tumors, which
Evil was to blame the sinner and therefore a recipient of a social instance of together account for over 70% of all deaths in Italy, which has allowed to
“charity” of Christianity and of his specific attention to the attitude of the increase the average life of 2.1 years in both genera. The increase in survival
“medical” Christ or the duty of mercy to the body too: “I was ill and I You has resulted in both sexes, a slight increase in years of unhealthy health. It
have visited me”(Mt 25: 36). This particular type of “charity”, however, requi- has been found that longer life expectancy is not accompanied by an impro-
red a special organization and management to make it an effective, efficient vement in the same quality of survival.
and “economic” one. Few have given the merit of the Institution, which can be Women are more attentive to their health and are subjected more frequently
regarded as the precursor of the hospital management: the Hospital Order of to prevention controls than men. Women are also the first in drug use, but
St. John of Jerusalem, known as Rhodes and Malta. In a landscape that saw the they are poorly represented in clinical or pharmacological trials. Here too,
strong opposition between Islam and Christianity, with class divisions within genetic prejudices, which consider the cause of the disease almost exclu-
the “faiths” themselves, the initiatives of Sacred Infermeria in the case of sively based on hormonal variability, delay the path of pharmacological
rescue and service to “our Lord the Sick” can be definitive “revolutionary”.In research and the search for socio-environmental risk factors and primary
fact, the institution’s raison d’etre, from its birth, was to accommodate pilgrims prevention.
and sick people who came to the holy places for Christians. After the end of According to international statistics, cardiovascular disease, considered
the Latin Dominions in the Holy Land, after the expulsion from Rhodes and increasing in humans, is the number one killer for women between the ages
the transfer to the island of Malta, the Knights invested their fruits of race war of 44 and 59 and far exceeds all the causes of death. Diagnosis also occurs at
on the Mediterranean, in the works of assistance and rescue by building the a more advanced stage than men, the prognosis is more severe for the same
hospital structure more large in Europe: 155 meters long for 10, 5 meters wide age. Endometriosis is a dislocation of the glandular tissue outside the uterus.
for 11 meters in height. Like the endometrium of the uterus, these shoots are also influenced by
Young leaves of the Most Noble Houses in Europe, had as their first task to hormonal variations, so that each cycle is congested with blood, proliferate
cleanse the plagues of poor derelicts served with silverware in respect to “Our and break out, causing pain, inflammation and then adherence between the
Lord the Sick”, but also an expression of practical knowledge by the Sanitary tissues.
Of Order: silver had powerful bacteriostatic qualities. Endometriosis may affect the woman at the first menstruation and accom-
Already in 1679, the patients considered infectious were isolated from the pany her until menopause. It can develop regardless of whether or not you
others, linens and kitchenware had to be strictly separate from the one used to have had a pregnancy. The disease has a prevalence of about 10 to 15% of
others and marked specially. Within the Sacred Infirmary, each patient could women in reproductive age and affects about 30-50% of infertile women
have a single bed provided with wool mattresses with canopies and colorful or who have difficulty conceiving. It is often underestimated (it is estima-
curtains. ted that at least 9 years of diagnosis are required) and disabling, it causes
The Infirmary welcomed sick people belonging to any social class, nationality a serious state of psycho-physical suffering in the woman. In Italy, women
and belief. Towards the end of the eighteenth century, the number of patients with concurrent diagnosis of endometriosis are at least 3 million. The social
admitted to the hospital was almost 4, 000 every year, with a mortality of 8% cost of the illness exceeds 4 billion euros. Breast cancer is the most frequent
(against 20% of Illuminati’s welfare institutions in Europe). In the Sacred cancer and the cause of death for cancer most important for women.
Infirmary the Sick was divided according to the manifested, medical or surgi- The National Plan for Prevention, the organization of screening programs
cal, acute or chronic pathology. There were beds for mental illnesses. has achieved significant results, but strong territorial differences and social
Since 1725, the medical-surgical team consisted of Professionals who had inequalities persist. In southern Italy, over 60% of women in the target popu-
been trained in Italy and France. At the Infirmary there was a very good lation are still not offered in organized programs. Lung tumor is a growing
Pharmacy. In 1676 the University School of Anatomy and Surgery was born, cancer among women determined by lifestyle modification in relation to
which became one of the most renowned in Europe (and one of the oldest). smoking and urges information campaigns and a gender-oriented primary
In this school, the first lessons and first experiments on corpses of modern prevention action.
history were performed and here the “first degree” doctor will be “graduated” Of the injuries and occupational illnesses of women, until a few years ago it
and will be allowed to practice the surgeon’s profession. The Regulation of the was only for the period of pregnancy, in relation to the risks of the unborn.
Sacred Infirmary was strongly pioneered by the Grand Master Manuel Pinto Compared to working conditions, the characteristics of the male worker
de Fonseca in 1725. were considered for the most part. Even less attention is given to patholo-
In 1787 the Sacred Infirmary complex was able to ordinarily accommodate gical events related to domestic work, particularly accidents. Pathological
563 people, compared to the 350/400 of 60 years earlier. stress is associated exclusively with productive work without considering
In the event of an emergency, capacity climbed to 914. the greatest psychosocial risk affecting women and is given by the double
To sick people was given the opportunity to make anonymous complaints, workload.
faults reports, abuse reports through a closed box with two different keys in In June 2017, the 59 Deans of Medicine degrees decided that everyone
which anyone could submit their comments and complaints. As well as being would have the teaching of Gender Medicine within their disciplines.
175
297. CRONOBIOLOGY drugs and vaccines and an ever-increasing humanity in the shadow of the
disease despite the invasion, even in this absolutely private and personal,
Carini L., Cantarano M.S., Cantarano M., Cantarano E. mass media and network and other systems of Global communication, and
Facoltà di Farmacia e Medicina, Università Sapienza Roma always fearful of being left behind especially in the protection of their rights.
The gap between scientific world and diffident users runs the risk of genera-
Life on Earth has evolved in a context characterized by impressive environ- ting dangerous misunderstandings of serious global health risks.
mental variations, some of which are cyclical. Most living organisms have It must be filled with corporate social responsibility and “true” communi-
evolved into environments that have chosen adaptations to oscillations of cation efforts, which in some cases go hand in hand with slicing of profit
environmental parameters in different temporal domains by modifying from the industry. Willing to expand the breed and suicide of humankind,
their metabolism and behavior and thus avoiding passively fluctuations. or rather, the large-scale application of the paradox that continues to break
Chronobiology deals with the study of these genetic, molecular and phy- down child mortality with vaccinations in developing countries, while in
siological endogenous oscillators. In Mammals, the organization of the the industrialized world Increasing the rate of family education increases
circadian oscillators is hierarchical and consists of numerous peripheral escape from vaccines and spread epidemics that were believed to have been
oscillators distributed in various organs such as the liver, the lungs, the eradicated for some time. The debate is about why advanced societies do
spleen, the heart, and a central circadian clock, located in the brain at the not fully believe in advances of medicine, particularly “allopathic”, right now
suprachiasmatic nuclei of the Hypothalamus, which plays an important role that industry products save lives more than before, starting with active prin-
in coordinating the activities of peripheral oscillators and is essential for ciples against severe and disabling diseases such as hepatitis or new lines
converting luminous Zeitgeber, coming from the retino-hypothalamic tract, for some cancers and for autoimmune diseases. It seems that twenty years
into cascade signals synchronizing peripheral oscillators. ago, when the time devoted to TV comparisons on health issues was greater
The genes whose expression is controlled by the central clock and peripheral and better organized, dialectical conflicts between doctors and families
oscillators represent a significant portion of the genome and are largely dif- refusing therapies were less unmistakable. Transverse studies confirm the
ferent in the different oscillators. In fact, it has been shown that the fraction importance of “time-factor” in the relationship between trust and patient:
of RNA messengers that are transcribed with a circadian kinetics repre- a British investigation links the litigation (number of claims) to the dura-
sent up to 10% of total messengers, whereas transcripts whose oscillation tion of medical visits. Below fatigues of 13 minutes and 20 seconds it would
occurs in more than one tissue generally do not reach 1% of the total. This be maximum, while, on the contrary, would tend to swing fast above 18
information, suggests that different peripheral oscillators contribute to the minutes. Would be far inferior. It seems that “only good communication
regulation of tissue-specific rhythmic phenotypes, which probably reflect with the physician” lights up “Patient-listening brain minded in his fears.
the peculiarity of the functions exponent by different organs. However, in But the problem is that Health Services are not equipped to give the Doctor
Mammals, genomic duplication events produced a redundancy of genetic too much time to persuade or listen.”
information, resulting in multiple copies of multiple clock genes (eg, Per1, And we come to the drug industry. Immediately after the Second World
Per2, and Per3, Cry1 and Cry2). This phenomenon has led to an increase in War, their reputation was “second only to that of God and the Marines,
complexity in the organization of the circadian oscillators of mammals. In today things have changed despite progress and the hundreds of thousands
addition, although conserved in the course of evolution, some watch pro- of dollars spent in communication” as if they were ashamed to say that
teins appear to have assumed different roles within the molecular device they are industries And generate profits, because there’s someone on the
that generates oscillation. web who cries not to trust.” The fear is that science and Internet wizards
It is the case of CRY protein, which in the central oscillator is the blue light are on the same level, no more than the scientific evidence of effectiveness
photoreceptor and is involved in clock synchronization, while in mammals against ignorance or simply a thought made less lucid than the illness due to
stabilizes PER’s proteins in the cytoplasm forming complexes entering the apprehension. But it is so?
nucleus and regulating by negative feedback. The clock genes Per and Cry. And again, if there are remedies for doctors such as roles in which the Camice
CRY does not seem to be implicated in the circadian Mammalian photore- is in the Patient, what communication strategies have to adopt industries and
ception; It is believed that this role is performed by other photopigments health systems in the face of struggles against time, such as that in Italy to
in the retina. Additionally, the role of the Timeless gene in the Mammalian eradicate the new Morbid epidemic that led to the Decree on the Obligation
circadian clock is still under Discussion: A set of disorders and syndromes of Vaccines in a “no-vax vs pro-vax” climate even if the former are only 3%
(cronopathologies) originate from alterations in the physiological processes of the population and undecided by a 17%? It is likely that only with the law
of an organism usually due to desynchronization of the circadian biological obligations tout court, certain resistances do not crawl as if by magic. Rather!
clock. And here, however, is the element that would not have been expected in the
The most serious and lasting is the pathologies that can be attributed to chro- US as in Italy: hesitant to keep or abandon vaccines are communities with a
nically working jobs that are subject to shift-work schemes. Recently, some higher education rate, California white collar workers than farmers in Mid-
mutations have been discovered, with genes encoding components of the West. Because? “It is not superstition or reliance on the magician the main
circadian clock that cause inherited syndromes such as the Familial Advan- note of this dissolution in the scientific world, but a credibility deficit of this
ced Sleep Phase (FASPS) syndrome due to a point mutation in the clock world, which instead of being represented by the Nobel Prize, should exalt
gene Period 2, which abolishes a phosphorylation site in the corresponding the social function of its efforts and give less of the ‘ Idea of living on profits.”
protein, or in the Ck1-ε gene encoding one of the kinases involved in pho- Attempts are there. In Greece, pharmaceutical industries have begun to pay
sphorylation of Period 2 protein. Even central nervous system anatomy and for care. In addition, some of them, with blockbusters, have earned several
cognitive deficits can manifest. Seasonal affective disorder (SAD) is known, thousand times the cost of the investment.
related to the worsening of the synchronizing effect of natural light, which Now, “it is necessary to give the realistic idea that those who work in health
accompanies the advent of autumn and winter, and which becomes particu- work for the common good and are at the side of the weak, who are more
larly important in populations living at latitudes high. The treatment of cir- and more”.
cadian clock dysfunctions is largely based on light therapy and on the adop-
tion of time tables of physical and social activities that are able to enhance
endogenous rhythm and to synchronize it with the external environment. A 299. A CASE OF POSTERIOR REVERSIBLE
crono-pharmacological approach is currently in an experimental phase and ENCEPHALOPATHY SYNDROME IN INTERNAL
based on molecules such as melatonin and its analogs. MEDICINE SETTING
Understanding the mechanisms of action of circadian clocks and their phy-
siological and metabolic effects is of great importance in the pharmacolo- D. Dell’Aera, L. Porretti, F. Calabretta, M. Piombo, A. Martignoni,
gical treatments of many diseases, for which the optimal time intervals for S. Perlini
drug administration are identified, so as to increase their effectiveness and SC Medicina Generale 2, Dipartimento Area Medica, Fondazione IRCCS
minimize unwanted effects. Policlinico San Matteo, Pavia
Introduction: Posterior reversible encephalopathy syndrome (PRES) is an

298. COMUNICATE HEALT acute neurological syndrome increasingly recognized in patients with renal
failure, hypertension, sepsis, autoimmune disorders, eclampsia and under-
Carini L., Cantarano M.S., Cantarano M., Cantarano E. going chemotherapy, i.e. patients admitted in the Internal Medicine setting.
Facoltà di Farmacia e Medicina, Università Sapienza Roma PRES is reversible if promptly treated.
Case presentation: A 74-year-old man undergoing neurorehabilitation
There is a gap in communication between those who produce life-saving after an ischemic stroke, was transferred to our institution with acute
176
renal failure (eGFR by MDRD: 7ml/min) and a GCS (Glasgow Coma

Scale) equal to 5. He had an aortic endoprosthesis obstructing the ostium Background: Obstructive sleep apnea syndrome (OSAS) is closely related
of the left renal artery, hypertension (that was initially treated with ACE to hypertension and altered glucose and lipid metabolism. Overweight is
inhibitors), oliguria and generalized myoclonic seizures. Head CT scan a crucial risk factor for OSAS. Aim: to describe the blood pressure (BP)
revealed bilateral cerebellar hypodensities. Serum glucose, ammonia, and metabolic changes in overweight/obese adults with moderate to severe
thyroid-stimulating hormone and electrolyte levels were normal; urine OSAS before and after 3-month CPAP therapy.
cultures were negative and blood cultures were positive for Citrobacter Methods: Prospective observational study on 56 patients (T1) of whom
koseri. Findings on brain MRI were consistent with PRES. Dialysis was 13 were re-evaluated after 3-month CPAP therapy (T2). Inclusion criteria:
not performed since kalemia, azotemia and volemia were normal. Paren- BMI ≥25 kg/m², age ≥18 years, CPAP therapy indication (AHI ≥15). Instru-
teral fluid support, dopamine infusion, meropenem and antihypertensive mental examinations: home sleep apnea polygraphy, 24h ambulatory BP
drugs were initiated. After 72 hours we observed a complete resolution of monitoring, 72h metabolic monitoring (Sensewear Armband ®). Laboratory
the neurological symptoms. examinations: glycemia, insulinemia, total cholesterol, HDL cholesterol, tri-
Conclusions: PRES can be easily misdiagnosed as stroke or toxic-meta- glycerides. Insulin resistance (IR) was evaluated by HOMA-index.
bolic encephalopathy. Two coexisting physiopathological mechanisms Results: Evaluation at T1: mean age 57.2 ± 10.4 years. Males: 49 (89%).
are involved: hyperperfusion from hypertensive encephalopathy and Mean BMI: 31 ± 4 kg/m²; mean waist: 110.8 ± 7.7 cm. Mean AHI: 44 ±
endothelial dysfunction induced by cytokines. Early diagnosis and treat- 15. Prevalence of hypertension: 87.5%; prevalence of dyslipidemia: 67.9%;
ment are essential for complete recovery. prevalence of diabetes mellitus: 14.3% (IR: 78.3%); prevalence of peripheral
arterial disease: 33.9%; prevalence of atrial fibrillation: 8.9%. Patients with
non-dipper BP profile: 58.9%. Patients with AHI ≥30 had higher risk of
300. EXTREME DIPPER HYPERTENSIVES HAVE A LOWER having IR than patients with AHI ≥15 (OR = 4.5, p = 0.047). Considering
LEVEL OF SYMPATHETIC TONE EVALUATED THROUGH 13 patients re-evaluated at T2, there were no significant variations of either
THE CALCULATION OF THE HEART RATE VARIABILITY BMI or glycemic and lipid profile. There was a reduction in baseline meta-
WHEN COMPARED WITH THE OTHER PATIENTS WITH bolism (p = ns), which correlated significantly with ODI and SpO2 nadir at
HIGHER NIGHT/DAY BLOOD PRESSURE RATIO T1 (p = 0.007, p = 0.038, respectively). There was also a significant reduction
in nighttime BP (-8 / -5 mmHg, p = 0.012 and p = 0.019), even after adju-
Miceli G. 1, Di Raimondo D. 1, Casuccio A. 2, Musiari G. 1, sting for antihypertensive therapy.
Buttà C. 1, Tuttolomondo A. 1, Pinto A. 1 Conclusion: Overweight/obese patients with OSAS are also often affected
1
Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.M.I.S) by hypertension and altered glucose and lipid metabolism. CPAP therapy
- Università degli Studi di Palermo 2 Dipartimento di Biomedicina has a positive impact on nighttime BP, which affects cardiovascular risk.
Sperimentale e Neuroscienze Cliniche - Università degli Studi di Palermo CPAP may reduce basal metabolism but does not significantly affect body
weight nor glucose and lipid profile, unless coupled with lifestyle changes.
Background and Aims: When evaluating the ‘night/day BP ratio’, both
hypertensives and normotensives can be arbitrarily classified into four
groups: extreme dippers (ratio 0.8), dippers (0.8<ratio 0.9), mild dippers 302. ALCOHOL ABUSE AND EMOTIONAL SELF-
(0.9<ratio 1.0) and reverse dippers (ratio 1.0). Reverse and mild dipper REGULATION: A PRELIMINARY CLINICAL STUDY
hypertensives have poorer prognoses compared with the physiological
dipper profile, but the prognostic relevance of the extreme dipper profile Renzetti D. 1, Laforgia V. 2
remains uncertain. The evaluation of heart rate variability (HRV), obtained 1
Responsabile Unità Operativa di Medicina Interna e Medicina Generale,
by 24-h Holter ECG monitoring, is the most frequently used noninvasive Mater Dei Hospital Bari; 2 Psicologo Clinico, Mater Dei Hospital Bari
form of assessment of the activity of the autonomic nervous system. Reverse
and mild dipper hypertensives have reduced HRV, indicating an overacti- This work is based on the opportunity to present the psychological evalua-
vation of the sympathetic nervous system (SNS); however, the HRV beha- tion of the patients involved in the Department of Internal Medicine of the
vior in extreme dippers is still controversial. The goal of this study was to Mater Dei Hospital (Bari), hospitalized for alcohol abstinence syndrome,
compare HRV indexes of extreme vs. reverse dipper essential hypertensives alcohol detoxication and organ damage evaluation. In addition to medical
measured on the basis of time domains. assessment and individual diagnostic-instrumental and therapeutic plan,
Methods and Results: We enrolled 125 hypertensive subjects, excluding the assessment protocol for patients with a diagnosis of alcohol dependence
patients with secondary hypertension, supraventricular arrhythmias, includes the clinical interview with the psychologist specialist and psycho-
holders of permanent intracardiac pacemaker, medical conditions contrain- metric assessment for the evaluation of the emotional state (STATE TRAIT
dicating the performance of dynamic ECG and/or the ambulatory blood ANXYETY INVENTORY in versions 1 and 2), mood (BECK DEPRES-
pressure monitoring (ABPM). Hypertensives subjects were divided in 4 SION INVENTORY II) and symptomatology (SYMTOM CHECK LIST
quartiles accoding to night/day BP ratios. The upper and lower quartiles (31 90 REVISED). This evaluation is performed during the stay period in
subjects per quartile) were compared; 30 normotensive subjects were enrol- hospital. The aim of the psychological and psychodiagnostic evaluation
led as a control group. Time domain HRV parameters of the three groups is twofold: to evaluate the emotional, cognitive, behavioral and social
revealed a higher degree of sympathetic activation in the lower quartile conditions of the patients during hospitalization and to motivate them to
(reverse dipper) vs. the upper quartile (extreme) and normotensive con- change and to continue the treatment after hospital discharge.
trols. HRV parameters related to parasympathetic tone did not show any According to the literature, an important aspect in evaluating and treating
significant variations among the three groups. addicted patients concerns emotional self-regulation skills, understood as
Conclusion: when hypertensive subjects are classified in relation to the the set of processes through which individuals control and influence their
extent of the nocturnal decline of blood pressure, the measure of HRV allows emotions, the time to experience them and the way in which to expe-
to discriminate different degrees of sympathetic tone and of sympatho-vagal rience and express them. During clinical observation, patients frequently
balance. The category of patients with the highest degree of nocturnal fall of refer to use alcohol as a useful substance for regulating emotions. Emo-
BP (extreme dipper) seems to be the one with the lower level of sympathetic tionally intense events associated with frequent mood swings in patients
tone, even if is compared with the dipper profile, that is the physiological with difficulty adjusting emotions, according to clinical assessments of the
one. In our opinion, this peculiar feature of the extreme dipper hypertensi- authors of this work, lead patients to increase the frequency and quan-
ves could be considered an element prognostically favourable. tity of alcohol content. The hypothesis of this clinical study was to check
whether the presence of marked emotional, humoral and symptomatic
changes had significant correlations with the amount of alcohol taken
301. BLOOD PRESSURE AND METABOLIC PROFILES IN daily by the patients until the time of the hospitalization. In other words,
OVERWEIGHT/OBESE PATIENTS WITH OBSTRUCTIVE the intention was to check whether more volumes of alcohol consumed
SLEEP APNEA SYNDROME BEFORE AND AFTER in grams of alcohol consumed per day were more noticeable in the scale
3-MONTH CPAP THERAPY and size considered by the questionnaires given during the evaluation.
The subjects were evaluated in a total of 40 (30 men and 10 women) aged
Giulietti F., Spannella F., Di Pentima C., Lombardi F.E., Borioni E., between 26 and 70 (average 48.25, ds 9.51), with an average of 11.3 years
Rosettani G., Bernardi B., Iacoacci C., Giordano P., Sarzani R. of school attendance (min.5 years max.19 years; ds 3.52). For each patient
Internal Medicine and Geriatrics, ESH. Hypertension Excellence Centre, was calculated the average daily alcohol consumption (grams of alcohol
Università Politecnica delle Marche, IRCCS-INRCA, Ancona, Italy / day) up to the time of hospitalization. The data were analyzed by linear
177
regression. Statistical analysis did not show statistically significant values satisfaction must be in agreement with the ethical requirements.Also in
in any of the scales and dimensions considered (p> 0.05). In other words, the dissatisfaction of the patient/customer, user of services, must grapple
the levels of daily alcohol consumption in the patients being examined are with the ethical issues.The quality of the organisation of health care ser-
not related to major and more pronounced alterations in the emotional, vices lies in the ability to integrate and reconcile the different instances.
mood and symptomatic status of the subjects involved in the study. Accor- The complexity of medicine requires the” know-be” and the “know-do”
ding to the authors’ view, the use of psychodiagnostic tests and measures of physician and the awareness of citizen.Both must be able to measure
capable of studying in a more specific and detailed way the dimensions with the limit of science.
of emotional self-regulation will give us in the future more information
about the link between levels of alcohol consumption and patient abilities
of emotional self-regulation. 304. A MAN WITH SYMMETRIC LOWER LIMBS
WEAKNESS
303. HOW TO GOVERN THE REQUEST FOR HEALTH Maestripieri V. 1, Fallai L. 1, Tozzetti C. 2, Torri M. 2, Poggesi L. 1
CARE WHEN THE PATIENT BECOMES A CONSUMER? 1
Università degli Studi di Firenze 2 Medicina per la Complessità Assistenziale
3, AOU Careggi
Lucchetta M.C., Davì R.
Servizio Sanitario Emilia Romagna, Ausl Parma A 77 years old man presented at the ER for symmetric distal lower limbs,
paraesthesia and back pain began 1 week before. He referred no other symp-
What is the right thing to do in medicine?What is well to do in medici- toms. His medical history was notable for diabetes mellitus, hypertension,
ne?What is right to provide or not to provide?The choice is between to coronary artery disease, COPD, prostatectomy for heteroplasia and a mul-
“do all it can” and to”do as little as possible”.This question is especially tifactorial lower limbs polyneuropathy diagnosed in 2007 with electromyo-
important today because physicians’s decisions influence not only the graphy (EMG) due to diabetes and B12 deficit in history of alcohol abuse.
health of people but also the power of the market that turns the patients His medications included calcium antagonists, diuretics and aspirin.
into consumers of health.“Do all it can”ensures to the physician juridical At physical examination he correctly performed Mingazzini I and showed
impunity and unexceptionable ethical position, but this practice opens slight symmetrical weakness in Mingazzini II, conserved symmetrical
the doors to the incorrect use of the health care resources.”Do as little tendon reflexes and no deficit of sensibility (pallestesic and thermo-dolo-
as possible”could induce the patient to accept the evidence that health rific); he was able to walk without support. The EMG showed axonal poly-
is an unavailable right, that medicine is not an exact science and that neuropathy without denervation’s sign. Biochemical examination showed
it is necessary to come to terms with the peculiar limits of the human vitamin B12 deficit. He was discharged with vitamin B12 supplement
condition.The correct medical practice, probably, tands between two therapy and ambulatory follow up. 7 days after discharge he presented to
extremes.”You can make a lot of money by telling at healthy people that ER unable to walk with sensibility deficit of lower limbs, slight weakness
are sick”.This statement of the BMJ is an indictment addressed against of upper limbs and no tendon reflexes. He also presented acute urinary
the phenomenon of the “medicalization” of health which manipulates the retention treated with catheterization and respiratory failure necessitating
person’s ability to feel himself healthy or sick.This objective is pursued oxygen support. EMG showed initial signs of denervation. A lumbar pun-
with the marketing strategies cleverly disguised (disease mongering).The cture with CSF analysis showed albumin-cytological dissociation, sugge-
market of healthcare extend by increasing the number of subjects that sting Guillain-Barré Syndrome (GBS) with subacute onset.
you “feel” sick.So born the”Creative Epidemiology” which must selldi- The patient was treated with intravenous immunoglobulins with improve-
seases.The “doctor Knock” was the precursor of the modern ability of ment of muscular strength both in upper and lower limbs and after a week
the market to expand the “supply” of medical services and create false of hospitalization was transferred to a rehabilitation hospital.
“request” for health.And his story as timely as ever.Consumerism lionizes GBS is a rapid-onset muscle weakness caused by the immune system
personal choice and raises the expectation that desires can and will be damaging the peripheral nervous system. The initial symptoms are typi-
satisfied.Grows dramatically the number of healthy subjects who “feel” cally changes in sensation or pain along with muscle weakness, beginning
sick, “consumers of health” greedy to receive visits and to get prescribe in the feet and hands. This often spreads to the arms and upper body with
examinations, medications and treatments.Perhaps, today the real chal- both sides being involved. The symptoms develop over hours to a few
lenge in healthcare sistem is not only the optimization of resources and weeks. The diagnosis of GBS depends on findings such as rapid develop-
the precise observance of the prescriptive’s appropriateness.The real ment of muscle paralysis, absent reflexes, absence of fever, and a likely
challenge is raising public awareness, public consciousness and critical cause. Cerebrospinal fluid analysis (through a lumbar spinal puncture)
scrutiny.The citizen must know that the commodification of health, the and nerve conduction studies are supportive investigations commonly
promotion of a free market of healthcare, coupled with the doctor-patient performed in the diagnosis of GBS. In those with severe weakness, prompt
relationship threatened and discouraged, is dangerous for his freedom, treatment with intravenous immunoglobulins or plasmapheresis, together
his rights and his health rights.It is necessary to redefine the boundaries with supportive care, will lead to good recovery in the majority.
of a medical practice in order to benefit the health of person.Few medical
treatments are a problem but many cares also.Can be problematic both
positions: doing too much as do less.Maybe the very problem is not to 305. VITAMIN D, PARATHORMONE AND
do more or do less, but “do better” or “know how to do better”, expertise CARDIOVASCULAR RISK: THE GOOD, THE BAD AND
that can not be separated from the “quality” and background of the physi- THE UGLY
cian.The Charter of Medical Professionalism (elaborated by the European
Federation of Internal Medicine and the American College of Physicians) Pascale A.V. 1, Giannotti R. 1, Finelli R. 1, Fabbricatore D. 1, Visco V. 1,
suggests:to provide efficient patient care (guiding principle:“the good of Matula I. 1, Mazzeo P. 1, Ragosa N. 2, Massari A. 3, Di Sevo M.G. 4,
the patient”), to respect the patient as an autonomous person (principle Ciccarelli M. 1, Iaccarino G. 1
of “self-determination”)and ensure that all citizens have the same oppor- 1
Dipartimento di Medicina e Chirurgia, Università degli Studi di Salerno
tunities (principle of “non-discrimination”/“fairness”).But the good phy- 2
Dipartimento di Cardiologia, P. O. “San Luca”, Vallo della Lucania (SA)
sician should keep as a guide the two cardinal principles of hippocratic 3
Dipartimento di Patologia Clinica, A.O.U. San Giovanni di Dio e Ruggi
medical ethics: do not do things that are harmful to the patient (“primum d’Aragona, Salerno 4Dipartimento di Patologia Clinica, P.O. “Luigi Curto”,
non nocere”) and choose treatments with proven effectiveness (based on Polla (SA)
the principle of “benefit”).This setting can be accused of being a “physi-
cian-centric”:Only the doctor has the scientific skills that allow him to 25OH Vitamin D (VitD) insufficiency and increased cardiovascular risk
know what is appropriate for the patient.It is the responsibility of the (CVR) association is still debated. The VitD dependendent paratohormone
physician to determine the judgment on the limit.The growing tendency (PTH), is considered as the possible actuator of VitD effects on CVR. In
nowadays to sue physicians debase the ethical orientation that gives to an overall population observational study, we assessed the role of PTH in
the physician the judgment about the limit, opening the way, not only, predicting CVR. We recruited 412 persons during the World Hyperten-
to “triumph of medicine” of doctor Knock but especially to “triumph of sion Day, in the area of Salerno, Southern Italy. Through means of dedica-
defensive medicine”.The physician may not be free to treat and respecting ted questionnaires, blood pressure measurements and a blood draught, we
the ethics of care without adequate legal protection.It would be asking collected dietary habits, anamnestic, clinical and metabolic data. CVR was
him for daily heroism.The healthcare organization have to consider the calculated according to the Framingham CVR charts. The overall popula-
“satisfaction” of those who receive treatment in Public Health Service.The tion mean age±SD was 49.9±20 yrs, and female sex was slightly prevalent
178
(53.2%). VitD deficiency (<20 uMol/ml) was most frequent (65.4%). In this the capillaries, also the arterial segments thus hesitating in the formation of
population VitD and CVR did not correlate. VitD and PTH inversely cor- artery-venous fistula.
related (r=-0.236, p<0.001) as expected. PTH was in direct linear regres- The teleangectal engagement of the skin-mucous microcirculation can be
sion with CVR (F=14, 982, p<0.0001). Elevated PTH (>=56 mg/dl) levels evaluated, as well as clinically, with the aid of the videocapillaroscope. Vide-
identify a population with higher CVR (11.9±6.2 vs 9.2±7.1, p<0.01) and ocapillaroscopy (VCL) is a non-invasive diagnostic method used to define
larger prevalence of cardiovascular events (10, 2 vs 4.1, p<0, 04). Since PTH morphological and functional anomalies of microcirculation, which plays a
increases with age and kidney function, we selected a 41-60 years old popu- very important role in the diagnostic and prognostic approach to Systemic
lation (N=150). Also in this homogenous group, people with elevated PTH Sclerosis (SSc). VCL is commonly performed at the level of the nail bed, but
present a larger cardiovascular risk (8.4±10.5 vs 4.1±4.8, p<0, 01) due to it can also be used to study microcirculation at the lab and skin.
higher systolic blood pressure (137.2±20.4 vs 130.1±16.0, p<0.05). In con- This is the first experimental, comparative case-control study that aims to
clusion, VitD deficiency causes PTH elevation that in the overall population evaluate systematically the characteristics and prevalence of microcircula-
increases the CVR. Our data let hypothesize that VitD supplementation may tion alterations in patients with HHT and aims to understand whether VCL’s
represent a major presidium to reduce PTH level and consequently CVR. performance can provide useful information for the diagnosis of Disease
and, if any, statistically significant differences in microcirculation between
HHT patients and two-arm control population: patients with systemic scle-
306. MYOTONIC DYSTROPHY AND rosis (SSc) and healthy controls (CS) evaluating the following parameters
HYPOGAMMAGLOBULINEMIA: CASE SERIES of digital dyscalculia at VCL: morphology Of the capillary; -diameter of the
capillary gills; - Giant capillaries, - Neo-angiogenesis, -little-hemorrhage,
Pedini V., Menghini D., Cardinaletti P., Gabrielli A., Danieli M.G. -little anuerysm -Difference of Capillaries, -Avascular Aces, -Hemoserine
Clinica Medica, Università Politecnica delle Marche & Ospedali Riuniti, Deposits.
Ancona 28 patients with HHT who were admitted to the UH clinics of Internal
Medicine 2 of the Department of Clinical and Experimental Medicine of
Background: Hypogammaglobulinemia is frequently described in patients AOU of Sassari from April to June 2016 were enrolled.
with myotonic dystrophy. Mechanisms involved in this association are not As a control population they were enrolled in the study:-28 SSc patients
completely clear, but an increased immunoglobulin catabolism is recogni- afflicted to UOC Clinic and Experimental Rheumatology Clinics of Sassari.-
zed in these patients. In most cases, hypogammaglobulinemia affects only 28 healthy subjects: blood donors associated with the Transfusion Center
the IgG class and does not become clinically manifest. of the Hospital-University Hospital in Sassari (CS).The VideoCAP DS-Me-
Case Series: We describe three patients with myotonic dystrophy and dica® capillaroscopic system was equipped with 20x and 200x magnifica-
hypogammaglobulinemia. The first case is a 44-year-old man with myo- tion optics. The microcirculation of the following districts was analyzed: 8
tonic dystrophy type 1, who came to our attention for a history of recur- ungual beds (excluding I fingerprints of my finger).
rent infections of the upper respiratory tract. At the laboratory exams, we Statistical analysis was conducted using the Fisher test, used to compare
documented hypogammaglobulinemia with low serum IgG levels (449 mg/ the prevalence of individual capillaroscopic alterations between two groups
dl), normal IgA and IgM levels and protective antibodies against tetanus. (HHT vs SSc and HHT vs. CS) and the ANOVA employed between multiple
He also had a history of recurrent infections by Helicobacter Pylori, with groups (HHT vs SSc vs CS). A value of p was less than or equal to 0.05 We
eradication after two antibiotic cycles. Due to the recurrent infections, have identified capillaroscopic characteristics that allow us to differentiate
we decided to start replacement therapy with intravenous immunoglobu- the HHT picture from the pathological picture of patients with systemic
lin (0.4 g/kg monthly), switched one year ago to facilitated subcutaneous sclerosis and thus from the normal picture of healthy controls. The capil-
immunoglobulin with a significant reduction of infectious episodes and the laries of HHT patients are more “similar” to those of healthy subjects and
achievement of protective serum IgG levels (> 600 mg/dl). The second case certainly dissimilar to those of subjects with SSc.
is a 49-year-old man with a recent history of recurrent upper respiratory The diameter of the capillary branches is not conserved in HHT patientsto
tract infections, which required monthly antibiotic therapy. Laboratory tests a little lesser extent than patients with SSC.The presence of rare and fre-
revealed hypogammaglobulinemia, with mildly reduced serum IgG levels. quent microaneurysms is more frequent in patients with HHT compared to
He has been recently studied for a chronic myopathy, with the diagnosis patients with systemic sclerosis (frequent: 31.6% VS 23.5%, rare: 68.4% VS
of myotonic dystrophy type 2. The third case is a 59-year-old man with a 47.1 %), So this aspect may be typical of HHT patients.
complex clinical history, characterized by vitiligo, leucopenia (with lym- The presence of rare microaneurysms was more frequently detected in capil-
phopenia), autoimmune thyroiditis, long-lasting hypogammaglobulinemia laries of HHT patients than in SSc patients, we may say that its relief could
and a previous diagnosis of probable polymyositis treated with low-dose be a typical element for altering the microcirculation in HHT patients.The
steroids. In 2015 he repeated electromyography, which revealed a myoto- prevalent changes in microcirculation in HHT patients were: capillaries
nic pattern. Genetic analysis was performed and diagnosis of myotonic with twisted pincers 78.6%, dm of the branches preserved with rare ectasie
dystrophy type 2 was confirmed. 39.3%, microaneurism presence 67.8% (rare: 30% Frequent: 68%).In con-
clusion, we can say that globally the capillaroscopic appearance of patients
Conclusions: Hypogammaglobulinemia is frequently reported in patients
with HHT differs from the typical picture of systemic sclerosis.
with myotonic dystrophy. Most cases described in literature are not associa-
VLC could be used as a diagnostic aid in differentiating patients with
ted to clinical manifestations, like recurrent infections. In our cases, patients
dubious HHT diagnoses from healthy, with regard to the evidence of rare
were symptomatic. For the first patient, we decided to start an Ig replace-
microanurysm and differentiating them from subjects with SSc regarding
ment therapy with benefit.
capillary morphology and capillaroscopic pattern, being dissimilar In the
two control groups.
Further comparative studies based on a higher sample size will be requi-
307. VIDEOCAPILLAROSCOPY IN SARDINIAN HHT red and directed to the study of bodily districts other than that of the nail
PATIENTS microcirculation, as the severity of the sample could cause distortion of the
obtained results.
Pinna M. 1, Mura S. 2, Masala M.S. 3, Vidili G. 2, Erre G. 2
1
U.O. Complessa di Pronto Soccorso e Osservazione Breve del P.O. Ozieri
2
Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di 308. WHEN THE EXCESS OF MINERALCORTICOID
Sassari 3U.O Complessa di Pronto Soccorso e Osservazione Breve del P.O di HORMONES IS ONLY APPARENT
Alghero
Renis M. 1, La Mura G. 2, De Donato M.T. 3, La Mura L. 4
Hereditary Hemorrhagic Teleangectasia(HHT) is an hereditary autoso- 1
UOC Medicina P.O. Cava de’ Tirreni AOU Salerno, 2 Cardiologo PO Scafati
mal dominant which affects angiogenesis, causing arteriovenous dilations, ASL. Salerno, 3UOC Medicina AOU Salerno, 4Università “Federico II” Napoli
hemorrhagic teleangectasie affecting mucous membranes and visceral
shunts located predominantly in the liver, lung, and brain. Introduction: Sometimes we find clinical and electrolyte abnormalities
Skin-mucous teleangectasia is small flat or lightly detectable, red-violet similar to hyperaldosteronism, without mineralocorticoid excess. Clinical
color, consisting of dilated and convoluted capillaries, which begin to appear case:F, 62, is hospitalized in department of Internal Medicine for muscle
in the third decade of life and tend to increase in number and size. The aches and fatigue. History: smoking, dyslipidemia and well controlled
earliest alteration of telangiectasia is the focal dilation of the post-capillary hypertension. Current therapy: ramipril/HCT; rosuvastatin 10, verapa-
venules; Such a lesion with time tends to increase in size to affect, through mil, fluconazole 50 mg BID for 10 days (two months before). ECG: ST
179
segment depression like ventricular overload. Laboratory tests: K: 1.7; Na: to 74, 3. As consequence the group of patients affected by COPD shows a
146; CPK: 11971; PH: 7, 56; HCO3- 55.5; urinary potassium 40.3 mEq/24 minor satisfation about life quality. It also makes many feel frustrated and
hours; aldosterone, renin, cortisol, ACTH: limits. Abdominal ultrasound angry about not being able to do the things they want to. The study focused
and abdominal TC, and renal arteries Doppler: limits. The patient under- on single factors analysis in terms of capability:
goes KCL i.v., potassium kanreonate, acetazolamide. Gradual normaliza- - Psycological / physical / working / social / sleep
tion of clinical and laboratory parameters. Subsequent re-evaluation after - Sleep / feeding / spare time Each of this factor has been perceived as less
discharge (ongoing therapy: barnidipine, rosuvastatin 5, ezetimibe): normal satisfying in particular emotional stability, self-confidence, psychological
Electrolytes and ECG. autonomy.
Discussion: The severe hypokalemia with alkalosis and rhabdomyolysis, Conclusion: the results of the research confirms a considerable reduction of
puts etiopathogenetic open questions (in our opinion, it can not just be life quality in the patients affected by COPD. Clearly emerges that a multidi-
attributed to ramipril/HCT and to rosuvastatin, assumed for years without sciplinary approach is necessary. That approach should include psychologist
noticeable electrolytic and CPK alterations) Rhabdomyolysis may be secon- support as part of the treatment to increase the compliance to the treat-
dary to severe electrolyte imbalance. ments and the rehabilitation programs.
Conclusions: We supposed a drug interaction between verapamil and flu-
conazole (as rosuvastatin has only little action on hepatic cytochromes) with
reduced catabolism of steroid hormones or a transient action on kidney 311. A CASE OF CAPD-RELATED CRYPTOCOCCUS
function (similar to some rare genetic diseases characterized by enhanced NEOFORMANS PERITONITIS
tubular Na/K exchange).
Cabibbe M., Brunati C., Grotti M., Montoli A.
ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy. Divisione di
309. AN UNUSUAL CAUSE OF PSYCHIATRIC DISORDERS Nefrologia, dialisi e trapianto renale
Renis M. 1, De Vecchi R.M. 2, Marracino M. 2, La Mura G. 3, Objectives: Cryptococcal peritonitis is uncommon, with only 61 cases
La Mura L. 4, De Donato M.T. 2 reported between 1951 and 2012. Peritoneal dialysis (PD) patients account
1
UOC Medicina P.O. Cava de’ Tirreni AOU Salerno, 2UOC Medicina AOU for 25% of cases. Diagnosis is often difficult while prompt treatment is
Salerno, 3 Cardiologo PO Scafati ASL. Salerno, 4Università “Federico II “ required.
Napoli Methods: A 80 -year-old man with severe atherosclerosis and chronic renal
disease related to nephrolithiasis and ischemic nephropathy gradually deve-
Introduction: Proton pump inhibitors drugs (PPIs) are widely used. They loped diabetes and uremia six years after receiving a kidney transplant.
often have some misunderstood or underestimated side effects. Immunosuppression included rapamycin 1 mg qd, mycophenolic acid 500
Clinical case: F, 76. Hypertensive heart disease, WPW syndrome. Therapy: mg qd and prednisone 2.5 mg qd. A peritoneal dialysis catheter was inser-
clopidogrel, beta-blockers, ACE inhibitors, statins, PPIs, occasionally diu- ted, and CAPD (Continuous Ambulatory Peritoneal Disease) started two
retics. Repeated previous hospitalizations, both in Internal Medicine and in months later. Only low dose prednisone was maintained to preserve residual
Neurology department, complaining tremors, ataxia and acute psychiatric kidney function. Thirty days into CAPD, the patient presented with fever
disorders, with a finding of hypocalcemia and hypokalemia, never adequa- (38.4°C): the abdomen was tender, the PD catheter exit site was healthy, the
tely investigated. A week before our observation: fast clinic deterioration peritoneal fluid was clear. Chest, abdomen and brain imaging were negative.
after taking thiazide diuretic, following a cardiological control. November He had blood (17.340/mm3, ) and peritoneal fluid (190/mm3) leukocyto-
2016: ataxia, delirium with hallucinations, generalized tremors. Admission sis. CRP was 10.2 mg/dl. Blood, urine and peritoneal effluent cultures were
to Neurology department. She came to our observation in consulting. She collected. I.V. ceftriaxone 2 g qd was administered. Three days later the
showed low values of calcium, potassium and magnesium. Hypothesis:chro- fever had disappeared but CRP increased to 17.8 mg/dl and peritoneal fluid
nically taken PPI can cause hypomagnesemia, first cause of complex and leukocytes rose to 600/mm3. Intraperitoneal cefotaxime was added (1g/2
persistent electrolytic disorder. Stop to PPI: resolution of symptoms and L bag). On day 6 the peritoneal effluent culture collected at presentation
normalization of electrolytes. grew Cryptococcus Neoformans var. Grubii. Serum cryptococcal antigen
Discussion: This clinical case emphasizes the following highlights: • Often was negative.
neuropsychiatric manifestations are due to metabolic and/or electrolytic Results: intravenous liposomal Amphotericine B 200 mg and Flucytosine
disorders; 2.5 g were administered for 4 weeks, with prompt clinical improvement. The
• We should always evaluate all electrolytes, not only Na and K, particularly PD catheter was removed, and hemodialysis was initiated.
in presence of persistent neurological symptoms; Conclusions: Fungal peritonitis is almost always associated with both
• Electrolyte disorders can often be iatrogenic, sometimes due to PPIs. recent antibacterial use and multiple episodes of bacterial peritonitis. Our
Conclusions: PPIs are prescribed too frequently, even outside of guidelines, patient had a particularly high risk, being an immunosuppressed bearer of a
being deemed not harmful. Conversely, they often have some misunder- failing kidney transplant. A high index of clinical suspicion and prolonged
stood and underestimated side effects. cultures of the peritoneal effluent are needed since fungi may require weeks
to emerge and some case present as culture negative peritonitis.
310. FOCUS ON QUALITY OF LIFE IN PATIENTS WITH

COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE) 312. TIRED OF BEING TIRED
Romeo A., Risicato R., Grasso O., Marturana S., Intravaia S., Platania S., Cardinali M., Benfaremo D., Mattioli M., Biondi L., Festa A, Gabrielli A.
Giacalone S., Cristaldi E. SOD. Clinica Medica, Ospedali riuniti di Ancona/ Università politecnica
U.O.C. Medicina Interna P.O. “Muscatello” di Augusta (SR) delle marche, dipartimento di scienze cliniche e molecolari
Purpose and scope of the study: Quality of life can be severely impaired A 58-year-old man was admitted to our ward in April 2017 for a 5-month
in patients with COPD. Purpose of this research is to identify the impact history of worsening fatigue, numbness, confusion and onset of frequent
of COPD on the quality of life of hospidalized patients and to examine its cramps, particularly severe in his lower limbs. These symptoms were present
relationship with the severity of the disease. all day long, not elicited by any behaviour, occurring even at rest. There were
Research Method: through the survey SAT-P (Satisfation Profile) it has no signs of systemic infection such as fever, cough or dysuria. The patient
been measured the physical wellbeing of the patients. The SAT-P is a self-re- had no relevant comorbidities, except for occasional episodes of gastritis.
port questionnaire and the 32 item survey the subjective satisfaction in He was not taking any drug. After one week from the onset of the symp-
daily life. Are enrolled 15 patients (13 males, 2 females), average age is 71, toms blood tests were performed as outpatient: complete blood count was
all affected by moderated COPD. In that group were not included patients normal, biomarkers of inflammation, hepatic and renal function were unre-
affected by senile dementia, psychiatric disorders, major impaired cognitive markable, CPK and LDH levels were normal; a moderate hypokalemia with
ability, neoplasms, major depression and anxiety (frequently associated with mild hypomagnesaemia was present. Administration of oral potassium and
COPD). 12 subjects has been submitted to the second control group. Are magnesium supplement for some weeks was beneficial but upon treatment
asked to evaluate their own satisfaction concerning the last month. Results discontinuation the symptoms recurred.
of the Reasearch: From the scoring is clear how the group affected by COPD Physical examination: no significant remarks. Normal blood pressure
has a score of 57, 8 while in the clinical control group the scoring go up (130/85 mmHg).
180
Laboratory tests: No significant abnormalities except low serum potassium DKK-1 was independently associated with previous cardiovascular events
(2.9 mEq/L), low 24-hour urinary calcium excretion and 24-hour urinary (OR=1.0007, 95% CI (1.0000 to 1.0013), p=0.04.
cortisol excretion at upper bound. Arterial blood gas: pH 7.48, PO2 80 Conclusions: Wnt signaling inhibitors sclerostin and DKK-1 are associated
mmHg, PCO2 44 mmHg, HCO3 32.8 mmol/l, satO2 99.1% with vascular calcification detected by TC, and may represent new valuable
Imaging: a computed tomography of chest and abdomen was negative. biomarkers of cardiovascular risk in in CKD patients.
Differential diagnosis: There are many causes of persistent hypokalemia in
adults. Mostly this electrolytic alteration occurs because of a drug adverse
event, typically diuretics. In second instance, hypokalemia could be expres- 314. PROGNOSTIC RELEVANCE OF DIFFERENT GFR
sion of a massive and prolonged loss of gastrointestinal secretions. Rarely EVALUATING EQUATIONS IN ELDERLY HOSPITALIZED
hypokalemia could be the consequence of a renal potassium wasting due PATIENTS
to tubular injury, increased mineralocorticoid activity or tubular transport
proteins mutations. Our patient was not taking any drug and did not report Gallo P., De Vincentis A., Vespasiani-Gentilucci U., Galati G.,
a history of prolonged vomiting or diarrhoea. We therefore focused on the Pedone C., Picardi A., Antonelli Incalzi R.
renal potassium wasting hypothesis. Tubular injury was unlikely, as there Campus Bio-Medico University of Rome
were no signs of reflux nephropathy or interstitial nephritis, as was the
hypothesis of increased mineralocorticoid activity, since renin-angiotensin Background and Aims: The estimated glomerular filtration rate (eGFR) is
system was normal. The combination of hypokalaemia, metabolic alkalo- a predictor of important outcomes such as in-hospital mortality, hospital
sis and normal blood pressure prompted us to consider a tubular transport readmission and death within 3 months. Its reduction has been associated
protein mutation: the concurrent presence of hypocalciuria drove us to the with the risk of all-causes mortality and cardiovascular mortality in both
diagnosis of Gitelman Syndrome (GS). GS is an autosomal recessive disease, general population and elderly patients. Moreover, while reduced renal fun-
with mutations in each gene coding for the thiazide-sensitive Na-Cl cotran- ction is common in older people, the best method for estimating the GFR
sporter (NCC) in the distal tubule. Reduced NCC activity mimics the effects remains unclear and a reliable assessment is a challenge especially in an
of persistent thiazide diuretic action, which include volume contraction, acute care setting where significant short-time changes are common. Finally,
renal potassium wasting and hypokalaemia, renal magnesium wasting and most studies analyzing the accuracy of GFR estimation in the elderly were
hypomagnesemia, and low urinary calcium excretion. carried out in an ambulatory or outpatient setting. In the last years, new
Management: The tubular defects in Gitelman syndrome cannot be cor- GFR-estimating equations (Modification of Diet in Renal Disease, MDRD;
rected (except by renal transplantation). So, the treatment aims to correct Chronic Kidney Disease Epidemiology Collaboration, CKD-EPI; Berlin
the volume deficit and electrolyte abnormalities. In GS an increase in renal Initiative Study, Berlin Initiative Study BIS) have been validated but only
prostaglandin E2 (PGE2) production is usually present, although urinary one in older population (BIS, data from the Berlin Initiative Study, with only
PGE2 excretion is lower compared with the strictly related Bartter Syn- persons aged 70 and older). Therefore, we aimed to compare the progno-
drome; in some patients NSAIDs may effectively raise the serum potassium.
stic value of these new formulas in comparison to Cockcroft-Gault (CG), in
In addition, a drug that blocks distal tubule sodium-potassium exchange,
predicting the risk of in-hospital mortality and mortality within 3 months
such as spironolactone, eplerenone, or amiloride, is usually administe-
from discharge.
red, frequently in higher-than-usual doses. This drug combination can
Materials and Methods: Data were extracted from a validated database
raise the serum potassium, correct the metabolic alkalosis, and partially
employed by internal and geriatrics medical wards participating in the form
reduce degree of hypomagnesemia. Most patients require oral potassium
of “Registro Politerapia SIMI (REPOSI)” which is a registry including hospi-
and magnesium supplementation since therapy with NSAIDs and drugs
talized patients aged more than 65 years and organized by the Italian Society
that block distal tubule sodium-potassium exchange is often incompletely
effective. Angiotensin-converting enzyme (ACE) inhibitors reduce the pro- of Internal Medicine and IRCCS - Mario Negri Institute of Pharmacological
duction of angiotensin II and aldosterone and may be a useful adjunctive Research of Milan. Patients with available creatinine values at hospital admis-
therapy. Our patient was dismissed with a potassium supplement and spi- sion were selected and eGFR was calculated according to CG, CKD-EPI,
ronolactone 100 mg/die. MDRD and BIS formulas. The association between eGFR according to diffe-
rent equations and in-hospital and 3-months mortality was estimated through
log-normal regression models and expressed as risk ratios (RRs) with 95%
313. CIRCULATING SCLEROSTIN AND DICKKOPF-1 confidence intervals (95%CI). Therefore, the discriminatory performances
CORRELATE WITH VASCULAR CALCIFICATIONS IN of different eGFR equations were compared calculating the area under the
NON-DIALYSIS CHRONIC KIDNEY DISEASE receiver operating characteristics (AUC) of the above mentioned regression
models.
Catalano A. 1, Ferro C. 1, Faraci B. 1, Basile G. 1, Ricciardi C.A. 1, Donato R. 2, Results: 4621 patients were included in the analysis (mean age 79.4 +/- 7.5
Santoro D. 1, Lasco A. 1 years, 48.8% males). Among these, 4.2% and 9.9% died during hospitalization
1
Department of Clinical and Experimental Medicine, University of Messina, and within 3 months from discharge, respectively. CG showed the greatest
Messina, Italy; 2Department of Radiological Sciences, University of Messina, association with both in-hospital and 3 months mortality (Table 1).
Messina, Italy
Background: Vascular calcifications (VC) represent a common finding in

chronic kidney disease (CKD), leading to increased cardiovascular mor-
bidity and mortality. The Wnt signaling pathway may play a pivotal role
in vascular impairment seen in CKD. Aim of the study: The aim of this
study was to investigate the possible association of VC with the circulating
Wnt signaling inhibitors sclerostin and DKK-1 in patients suffering from
non-dialysis CKD and to explore their predictive role in relation to cardio-
vascular events.
Methods: 82 patients (74 M, 8 F; mean age 72.25 ± 10.8 yr) with CKD
stages 3 to 5 were studied. Non-contrast computed tomography (CT) scan
was used to assess vascular calcification of aorta (thoracic and abdominal
tracts), coronary arteries and cardiac valves. BMD was measured by DXA at
the lumbar spine and femoral neck. Sclerostin and DKK-1 were measured.
Results: Sclerostin levels were significantly associated with creatinine cle-
arance (r= 0.32, p=0.008) and positively associated with BMD at lumbar
spine and femoral neck (r=0.3, p=0.02; and r=0.49, p<0.001, respectively).
When the entire population was divided in tertiles of calcium score, higher
levels of sclerostin, but not DKK-1, were observed in the tertiles of higher
coronary calcium score. At stepwise multiple regression analyses, after
multiple adjustments for age, BMI, diabetes, hypertension, smoking habit,
CKD-stage and sclerostin level, DKK-1 was an independent predictor of
the total arterial calcium weight (β=166.51, SE=29.09, p<0.0001), moreover
181
Accordingly, the model including CG had the best discriminative perfor- considering that fluid overload is an important element of progression to
mance compared to the others (Figure 1, left). This superiority was not con- adverse clinical outcome in CKD patients, we suggest a careful monito-
firmed if correcting for a proxy of nutritional status, such as albumin levels ring of fluid status, indeed the low cost, non-invasiveness and availability
(Figure 1, right). of BIA could make it an adequate tool for fluid evaluation in a large CKD
Conclusions: Even though multiple studies showed CG to retain poor accu- population.
racy in estimating eGFR, our results shed light on its prognostic role in older
people. Probably, the weight of nutritional status and age in this formula
explain this relationship considering the high prevalence of malnutrition in 316. MAGNETIC RESONANCE IMAGING 3T AND TOTAL
elderly and its known association with a poor outcome. FIBROTIC VOLUME IN AUTOSOMAL DOMINANT
POLYCYSTIC KIDNEY DISEASE
315. MULTIDIMENSIONAL PROGNOSTIC INDEX IN Lai S., Mastroluca D. 1, Letizia C. 2, Petramala L. 2, Perrotta A.,
OLDER ADULT PATIENTS WITH CHRONIC KIDNEY Di Gaeta A. 3, Ferrigno L. 4, Panebianco V. 3, Mangiulli M. 5,
DISEASE UNDERGOING RENAL REPLACEMENT Esposito Y. 5, Pintus G., D’Angelo A.R. 6
THERAPY OR CONSERVATIVE MANAGEMENT Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy:
1
Nephrology and Dialysis Unit, Hospital ICOT. Latina, Sapienza University
Lai S., Molfino A., Amabile M.I., Innico G. 1, Mangiulli M. 2, of Rome, Italy; 2Department of Internal Medicine and Medical Specialities,
Esposito Y. 2, Coppola B. 3, Perrotta A., Protopapa P., Galani A. 4, Sapienza University of Rome, Rome; 3Department of Radiological,
Aucella F. 5, Brunori G. 6, Russo G.E. 7 Oncological and Pathological Sciences, Sapienza University of Rome, Italy;
Study Group on Geriatric Nephrology of the Italian Society of Nephrology
4
National Centre for Epidemiology, Surveillance and Health Promotion,
(SIN) Department of Clinical Medicine, Sapienza University of Rome, National Institute of Health, Rome; 5Department of Internal Medicine and
Rome, Italy. 1Department of Medicine DIMED, School of Specialization in Medical Specialities, Sapienza University of Rome, Rome, Italy; 6Department
Nephrology, University of Padova, Padova, Italy; 2Department of Internal of Obstetrical-Gynecological Sciences and Urologic Sciences, Sapienza
Medicine and Medical Specialities, Sapienza University of Rome, Rome, Italy; University of Rome, Italy
3
Dialysis Unit, San Giovanni Evangelista Hospital, Tivoli, Italy; 4Department
of Clinical and Experimental Sciences, University of Brescia, Brescia,
Italy; 5Nephrology and Dialysis, IRCCS “Casa Sollievo della Sofferenza”,
San Giovanni Rotondo, Foggia, Italy; 6Division of Nephrology, Hospital
“S.Chiara”, APSS, Trento; 7Department of Obstetrical-Gynecological Sciences
and Urologic Sciences, Sapienza University of Rome, Italy
Introduction: The prevalence of chronic kidney disease (CKD) is increa-

sing in older adults worldwide, such as the number of older adults requiring
dialysis. The prognostic evaluation of older adults with CKD plays a key role
in decision-making of treatment processes. It is increasingly evident that
the prognosis of older adults with CKD is strongly influenced by functio-
nal and cognitive status, body composition and nutritional status, as well as
comorbidities and treatments. In this study, we evaluated the effectiveness
of the Multidimensional Prognostic Index (MPI), in predicting mortality
risk and hospitalization, and association with nutritional, metabolic indices
and markers of atherosclerosis in older adults with CKD on conservative
and replacemente therapy (hemodialysis (HD) and peritoneal dialysis (PD). Introduction: Autosomal dominant polycystic kidney disease (ADPKD)
Materials and Methods: A total of 173CKD patients, on conservative and is the most common renal hereditary disorder. In the last years, several
replacement therapy were consecutively included. All patients underwent authors have attempted to identify a kidney damage marker for predicting
an assessment with MPI and divided into 3 risk classes, assessing morta- the prognosis, and the effectiveness of therapy in ADPKD.
lity rate (number of deaths / population number), the rate of hospitaliza- Aim: The aim of this study was to identify and quantify, through a novel MR
tion (number of admissions / total population numbers), in addition to the protocol with 3 Tesla (MRI 3Tesla), the presence in ADPKD, of parenchy-
days of hospitalization and number of annual admissions, in the two years mal fibrotic tissue, at an early stage of disease, able to correlate the glomeru-
of follow up, Clinical, laboratory and instrumental examinations such as lar filtrate and to predict the loss of the function renal.
anthropometric parameters (Body Mass Index, BMI; Bioimpedance Analy- Material and Methods: 15 ADPKD patients were undergone to renal MRI
sis (BIA)), inflammatory indices, mineral metabolism and markers of athe- 3Tesla at T0 and at follow up (T1, 52.8 months). Moreover we have evalua-
rosclerosis (Intima Media Thickness, IMT), Ankle Brachial Pressure Index ted renal function, plasma aldosterone concentration (PAC), Homeostasis
(ABPI)) were performed at T0, and after 2 years, at T1 from enrollment. Model Assessment-insulin resistance (HOMA-IR), and markers of athe-
Results: A total of 173 patients (107 male, 66 female), with a mean age of rosclerosis (carotid intima media thickness (IMT), ankle/brachial index
74.65 ± 8.43, affected by CKD (stage 3/5 KDOQI), on conservative (104 (ABI), left ventricular mass index (LVMI).
patients) and replacement therapy (34 patients on HD, 35 patients on PD) Results: Our study showed a significant negative correlation between total
were consecutively included. Our study showed a significant association kidney volume (TKV) and eGFR during the follow up, at T1 (r=-0.059,
between mortality rate and MPI for risk classes (2=58, 871, p <0, 0001), and p<0.02). We showed, also, a negative correlation between eGFR and Total
the statistical analysis of standardized residues, showed that the differences Fibrotic Volume (TFV) (r=-0.61, p<0.04), and between eGFR and Total
are statistically significant in each group with r <1.96 or r >1.96 (p<0.05). Perfusion Volume/Total kidney Volume (TPV/TKV%) (r=-0.59, p<0.02)
There was also a positive correlation between the MPI value and the number always during the follow up, at T1. Instead, TKV (r=0.37, p=0.16) and
of hospitalizations per year (p <0.001), and the days of hospitalization (p TPV/TKV% (r=-0.16, p=0.56) not showed a significant correlation with
<0.001), in addition to age (p = 0.003). Moreover we found another posi- the monthly slope of the decline of eGFR. Moreover, TFV was correlated
tive correlation between MPI and extracellular water (ECW) at T0 (r=0.234; positively with PAC (r=0.50, p<0.05), insulin values (r=0.49, p<0.05), ABI
p=0, 013). (r=0.51, p <0.05) and the LVMI (r=0.63, p<0.01).
Conclusions: Predicting life expectancy is essential to identify the most Conclusions: The MRI 3Tesla, could be useful in the evaluation of fibro-
appropriate clinical decision-making for management, treatment and pre- tic tissue, correlating it with the eGFR. Despite the high costs, therefore it
vention as well as for patients and family members to have realistic expecta- would be advisable to carry out a study with MRI 3Tesla, to evaluate the pro-
tions. In our study, we showed a significant association between MPI and gression of the disease and the effectiveness of new therapeutic strategies, in
mortality rate and hospitalization, in CKD patients on conservative and addition to the early cardiovascular screening and PAC dosage.
replacement therapy. Therefore, our results suggest that MPI may be very References: 1) Torres VE, Harris PC, Pirson Y. Autosomal dominant
useful to assess the prognosis of older adults with CKD on conservative and polycystic kidney disease. Lancet 2007;369:1287–1301. 2) Caroli A, Antiga
replacement therapy, and that multidimensional and multidisciplinary eva- L, Conti S, Sonzogni A, Fasolini G, Ondei P, Perico N, Remuzzi G, Remuzzi
luation through MPI should be considered in this population. Moreover, in A. Intermediate volume on computed tomography imaging defines a fibro-
our study we found a positive correlation between MPI and ECW, therefore, tic compartment that predicts glomerular filtration rate decline in auto-
182
somal dominant polycystic kidney disease patients. Am J Pathol. 2011 nib were enrolled. This population was evaluated before starting treatment
Aug;179(2):619-27. 3) Jill Norman: Fibrosis and progression of Autosomal (T0) and after 3 months (T1). Laboratory and instrumental parameters,
Dominant Polycystic Kidney Disease (ADPKD): Biochim Biophys Acta. including renal function, proteinuria, mineral metabolism, blood pressure,
2011 October; 1812(10): 1327–1336. 4) Liu Y. Renal fibrosis: New insights interventricular septum (IVS) and left ventricular mass index (LVMI) were
into pathogenesis and therapeutics. Kidney Int. 2006; 69:213–217. 5) Naka- recorded before and after treatment.
mura T, Ushiyama C, Suzuki S, Ebihara I, Shimada N, Koide H. Elevation of Results: Thirty-two patients (13 female, 19 male, mean age 62.7±9.9 years)
serum levels of metalloproteinase-1, tissue inhibitor of metalloproteinase-1 were enrolled. We observed overtime, a significant reduction in estimated
and type IV collagen, and plasma levels of metalloproteinase-9 in polycy- glomerular filtration rate (eGFR) (p=0.01), haemoglobin (Hb) (p=0.04)
stic kidney disease. Am. J. Nephrol. 2000; 20:32–36. 6) Irazabal MV, Rangel and 25-hydroxyvitamin D (25-OH-VitD) (p=0.002), in association with a
LJ, Bergstralh EJ, Osborn SL, Harmon AJ, Sundsbak JL, Bae KT, Chapman significant increase in serum phosphorus (p<0.001), systolic blood pressure
AB, Grantham JJ, Mrug M, Hogan MC, El-Zoghby ZM, Harris PC, Erick- (SBP) (p<0.001), diastolic blood pressure (DBP) (p<0.001), IVS (p=0.03)
son BJ, King BF, Torres VE8; CRISP Investigators. Imaging classification of and proteinuria (p<0.001); while we showed no significant differences in
autosomal dominant polycystic kidney disease: a simple model for selecting glycosuria, phosphaturia, serum uric acid, intact parathormone, and LVMI.
patients for clinical trials. J Am Soc Nephrol. 2015 Jan;26(1):160-72. 7) Pei Conclusion: Molecular targeting drugs are the new generation of cancer
Y, Obaji J, Dupuis A, Paterson AD, Magistroni R, Dicks E, Parfrey P, Cramer chemotherapeutic agents aimed to interfere with proteins that are mainly
B, Coto E, Torra R, San Millan JL, Gibson R, Breuning M, Peters D, Ravine responsible for tumour growth or progression. In this study we found a
D. Unified criteria for ultrasonographic diagnosis of ADPKD. J Am Soc significant change in renal function, BP, proteinuria and some important
Nephrol. 2009 Jan;20(1):205-12. 8) Lai S, Petramala L, Mastroluca D, Petra- cardiovascular risk factors, such as anaemia, vitamin D deficiency, hyper-
glia E, Di Gaeta A, Indino E, Panebianco V, Ciccariello M, Shahabadi HH, phosphatemia and IVS, while we have no evidence of renal tubulopathy
Galani A, Letizia C, D’Angelo AR.Hyperaldosteronism and cardiovascular indices. Therefore we recommend a careful assessment of renal function,
risk in patients with autosomal dominant polycystic kidney disease. Medi- mineral metabolism, hemoglobin, and accurate monitoring of proteinu-
cine (Baltimore). 2016 9) Bhutani H, Smith V, Rahbari-Oskoui F, Mittal A, ria and blood pressure, in addition to an evaluation of echocardiographic
Grantham JJ, Torres VE, Mrug M, Bae KT, Wu Z, Ge Y, Landslittel D, Gibbs parameters, such as IVS and LVMI, should be performed at initiation of
P, O’Neill WC, Chapman AB1; CRISP Investigators. A comparison of ultra- sunitinib therapy and monitored regularly, in particular in patients who had
sound and magnetic resonance imaging shows that kidney length predicts significant cardiovascular risk factors, including underlying hypertension,
chronic kidney disease in autosomal dominant polycystic kidney disease. dyslipidaemia, older age and CKD.
Kidney Int. 2015 Jul;88(1):146-51. 10) Mao Z, Xie G, Ong AC.Metabolic
abnormalities in autosomal dominant polycystic kidney disease. Nephrol
Dial Transplant. 2015 Feb;30(2):197-203. 318. NEUROLOGICAL AND PSYCHOLOGICAL CHANGES
IN HEMODIALYSIS PATIENTS BEFORE AND AFTER THE
TREATMENT
317. VASCULAR ENDOTHELIAL GROWTH FACTOR
INHIBITOR THERAPY AND CARDIOVASCULAR AND Lai S., Molfino A., Mecarelli O. 1, Pulitano P. 1, Mastroluca D. 2,
RENAL DAMAGE IN RENAL CELL CARCINOMA Romanello R. 3, Zarabla A. 4, Galani A. 5, Pintus G., Currado A.C.,
D’Ambrosio V., Mangiulli M. 6, Esposito Y. 6, Frassetti N. 6,
Lai S., Molfino A., Mangiulli M. 1, Esposito Y. 1, Innico G. 2, Mariotti A. 7
Coppola B. 3, Mastroluca D. 4, Galani A. 5, Mariotti A. 6 Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy;
Study Group on Geriatric Nephrology of the Italian Society of Nephrology 1
Department of Neurology and Psychiatry, Sapienza University of Rome,
(SIN) Department of Clinical Medicine, Sapienza University of Rome, Rome, Rome, Italy; 2 Nephrology and Dialysis Unit, Hospital ICOT. Latina, Sapienza
Italy; 1Department of Internal Medicine and Medical Specialities, Sapienza University of Rome, Italy; 3Department of Neurology and Psychiatry, Catholic
University of Rome, Rome, Italy; 2Department of Medicine DIMED, School of University of Sacred Heart, Rome, Italy; 4Regina Elena National Cancer
Specialization in Nephrology, University of Padova, Padova, Italy.; 3Dialysis Institute, Center for Tumor-related Epilepsy, UOSD. Neurology; 5Department
Unit, San Giovanni Evangelista Hospital, Tivoli, Italy; 4Nephrology and of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy;
Dialysis Unit, ICOT. Hospital, Latina, Sapienza University of Rome, Italy.; 6
Department of Internal Medicine and Medical Specialities, Sapienza
5
Department of Clinical and Experimental Sciences, University of Brescia, University of Rome, Rome, Italy, 7UOC Nephrology and Dialysis, A.Perrino
Brescia, Italy; 6UOC Nephrology and Dialysis, A.Perrino Hospital, Brindisi Hospital, Brindisi
Background: Renal cell carcinoma (RCC) represents 2-3% of all adult Introduction: The prevalence of chronic kidney disease (CKD) is growing
malignancies, with >210 000 new cases and 100 000 deaths annually; the in the world such as the number of patients needing dialysis. In ESRD the
highest peak incidence is between 60 to 70 years of age. Recently, inhibi- morbility and mortality are higher than in the general population, and neu-
tion of tumour angiogenesis has been the focus of anticancer treatments. rological, psychological and cognitive disorders, could greatly contribute to
Members of the vascular endothelial growth factor (VEGF) family and their the morbidity, and poor quality of life of these patients.
receptors (tyrosine kinase), were identified as regulators of angiogenesis, Aim of the Study: The aim of this study was to assess the neurological
and their overexpression is critical to tumour growth, including metastasis. changes in haemodialysis (HD) patients, cognitive and psychological asses-
Angiogenesis inhibition, as a therapeutic strategy against malignancies, was sment, and the correlation with risk factors associated to CKD.
initially proposed by Folkman in 1971, and the findings observed have led Materials and Methods: 16 clinically stable patients on HD, and 15 healthy
to the development of VEGF-targeted agents, either as monoclonal antibo- controls (HC) matched for age and sex were enrolled. Clinical, laboratory
dies against VEGF, or small tyrosine kinase inhibitors, that currently are the and instrumental examinations, as renal function, inflammatory markers
most commonly used drugs, and have shown excellent results with signi- and mineral metabolism indexes, psychological (MMPI-2, SatP) and
ficant efficacy and safety. In particular, sunitinib malate, an oral multitar- cognitive tests (NPZ5) were carried out. Electroencephalogram (EEG) was
geted receptor tyrosine kinase inhibitor, known to inhibit VEGF receptors carried out before (T0) and after (T1) HD treatment.
(VEGFR1, 2 and 3), platelet-derived growth factor receptors (PDGFR a and Results: The patients showed significant differences between T0 and T1 in
b), stem-cell factor receptor (c-KIT), Fms-like tyrosine kinase 3 receptor theta/alpha index (p<0.001), in the absolute and relative power of delta and
(FLT3) and receptor encoded by the ret proto-oncogene, is approved for theta band, and in absolute power of Beta 1 band of EEG respect to HC.
the first- and second-line treatment of advanced and/or metastatic RCC. Moreover these patients showed significant difference respect to HC, for
The reported renal adverse effects of sunitinib were hypertension, protei- inflammatory indexes (CRP and ESV; p<0.001, p<0.001), mineral metabo-
nuria, renal insufficiency, and thrombotic microangiopathy, even if with a lism indexes, as parathormone (iPTH), 1-25 dihydroxyvitamin D3 (1, 25–
very variable incidence, of renal failure, 12.4-65.6% (57% in patients with (OH)2D3) (p<0.001, p<0.001) serum uric acid (p=0.003), and hemoglobin
pre-existing chronic kidney disease (CKD)), proteinuria, 41-63%, and (Hb) (p<0.001). MMPI-2 clinical scales showed a significant difference
hypertension, 40-60%. Moreover, sunitinib, could be also associated with between two groups, in Depression (p<0.001), Paranoia (p<0.001), Hyste-
cardiac toxicity, in particular with left ventricular dysfunction and car- ria (p=0.037) and Psycopatic deviate (p=0.010), while MMPI-2 content
diomyocyte hypertrophy, but currently, knowledge on the effect of sunitinib scale showed a significant difference in Cynism (p=0.005), Health Con-
on cardiovascular risk and renal damage is limited. The aim of the study was cerns (p=0.053) and Family Problems (p=0.032). Also SAT P test showed
to evaluate, renal and cardiovascular damage, at baseline (T0) and after 3 a significant difference between two groups in Factor I (psychological fun-
months (T1) from initiating sunitinib therapy in patients with RCC. ctioning), Factor II (physical functioning) and Factor III (work), (p=0.045,
Materials and Methods: Patients with metastatic RCC treated with suniti- p<0.001, p=0.014). Moreover NPZ5 showed a significant difference between
183
HD patients and HC in Rey Auditory Verbal Learning test (RAVL test) 320. EFFECTS OF UNDERLYING RENAL DISEASE ON
(List A and B, p<0.001, p=0.0145; respectively), digit span test (DS test) NUTRITIONAL AND METABOLIC PROFILE IN OLDER
(backword, p=0.0034), and Symbol Digit Modalities Test (SDMT test) (120 ADULTS WITH REDUCED RENAL FUNCTION
sec, p=0.0145).
Conclusions: This study showed that the EEG abnormalities improve, but not Molfino A. 1, Lai S. 1, Amabile M.I. 1, Altieri S. 2, Mastroluca D. 3,
significantly after HD, with a significant reduction in the Theta/Alpha index, Lai C. 4, Aceto P. 5, Crudo M. 6, Rossi Fanelli F. 1, Muscaritoli M. 1
which could represent a reliable index of cerebrovascular damage, or indicate 1
Department of Clinical Medicine, Sapienza University of Rome, Rome,
a border, between normality and brain disfunction, being implicated in the Italy 2Department of Clinical and Molecular Medicine, Sapienza University
corticotherapy-cortical retroactivation mechanism. However, in our study, of Rome, Sant’Andrea Hospital, Rome, Italy. 3Department of Internal
the Theta/Alpha index has significantly improved after HD, but remained Medicine and Medical Specialties, Sapienza University of Rome, Rome,
significantly higher than HC. treatment, and persists significant differences Italy. 4Department of Dynamic and Clinic Psychology, Sapienza University
compared to HC. Even qualitative EEG data showed a more regular and of Rome, Rome, Italy 5Department of Anesthesiology and Intensive Care,
stable EEG after HD therapy but with persistent and significant differences Catholic University of Sacred Heart, Rome, Italy 6Software House INTECS.
compared to HC, also in PCR, iPTH, Vitamin D, hemoglobin and uricemia S.p.A., Rome, Italy
values. Moreover, our study showed cognitive and psycological difficulty, with
reduced quality of life in these patients. A routine assessment of neuropsycho- Background and Aim: Chronic kidney disease (CKD) is highly prevalent
logical features, in patients on HD, with a multidisciplinary approach could among older adults and increased risk of cardiovascular disease is frequent
contribute to make an early diagnosis with eventual proper treatment. in renal impairment. Metabolic and nutritional derangements are asso-
ciated with CKD. We aimed at comparing the metabolic, nutritional, and
cardiovascular impact of reduced renal function between patients with and
319. SARCOPENIA IN CHRONIC KIDNEY DISEASE without known renal disease.
ON CORSERVATIVE AND REPLACEMENT THERAPY- Patients and Methods: Consecutive outpatients aged ≥65 years with
PRELIMINARY STUDY reduced renal function were enrolled and divided into 2 groups: Group A
(patients with history of renal disease) and Group B (patients with unknown
Lai S., Muscaritoli M., Amabile M.I., Ettorre E. 1, Andreozzi P. 1, renal disease). Nutritional and metabolic parameters, including involuntary
Sgreccia S. 1, De Leo S., Mangiulli M. 2, Esposito Y. 2, Protopapa P., body weight loss (BWL) in the previous 6 months, mineral metabolism,
Perrotta A., Pintus G., Spagnoli A. 3, Molfino A. inflammatory indices, and left ventricular mass index (LVMI), were deter-
Study Group on Geriatric Nephrology of the Italian Society of Nephrology mined. Parametric and non-parametric tests were performed as appro-
(SIN). MIOSIN. Study, preliminary results. Department of Clinical Medicine, priate, and P < 0.05 was considered statistically significant.
Sapienza University of Rome, Italy; 1Department of Cardiovascular, Results: Seventy-six consecutive patients were enrolled. Group A (n = 39,
Respiratory, Nephrological, Anaesthetic and Geriatric Sciences, Sapienza M: 24) showed greater BWL with a significant reduction of 25-hydroxyvita-
University of Rome, Rome, Italy; 2Department of Internal Medicine and min D, transferrin, cholinesterase, albumin, and greater LVMI with respect
Medical Specialities, Sapienza University of Rome, Rome, Italy; 3Department to Group B (P < 0.01). In addition, Group A showed significantly increased
of Statistics Sciences, Sapienza University of Rome, Italy intact parathyroid hormone, total cholesterol, low-density lipoprotein, tri-
glycerides, and C-reactive protein when compared to Group B (P < 0.05).
Background: Chronic kidney disease (CKD) is a common condition with a Conclusions: The positive history of renal disease may negatively impact on
high cardiovascular morbidity and mortality, associated with emerging risk several nutritional and metabolic parameters related to increased cardiova-
factors, such as sarcopenia and dynapenia. Several conditions may affect scular risk among older adults.
muscle mass in CKD, including metabolic, nutritional and inflammatory Essential References:
changes, leading to worse cardiovascular outcomes and cognitive function Hallan SI, et al. Nephron Clin Pract 2010
in this population. AIM: To evaluate the prevalence of sarcopenia (based on Muscaritoli M, et al. Curr Opin Clin Nutr Metab Care 2009
European Working Group on Sarcopenia criteria), dynapenia and sarcope- Lai S, et al. Ren Fail 2014
nic obestity in CKD patients on conservative therapy (stage 3-5 KDOQI) Molfino A, et al. J Cachexia Sarcopenia Muscle 2014
and in patients on replacement therapy, including hemodialysis (HD), peri-
toneal dialysis (PD) and after kidney transplantation (KT), and the asso-
ciations between sarcopenia and markers of atherosclerosis, endothelial 321. A URINARY CAUSE OF ENCEPHALOPATHY
dysfunction and with psychological and cognitive function.
Materials and Methods: A total of 77 patients (32 male), with a mean age Struglia M. 1, Di Giosia P. 1, Halmagy S.A. 1, Boni M.. 2,
of 69.57 ± 9.84 years, were consecutively included. Clinical, laboratory and Calcinaro F. 1
instrumental examinations, including Bioimpedance Analysis (BIA), Hand 1
UOC Medicina Interna, Ospedale “Mazzoni”, Ascoli Piceno 2UOC
Grip Strenght, Intima Media Thickness (IMT), Ankle Brachial Pressure Nefrologia, Ospedale “Mazzoni”, Ascoli Piceno
Index (ABPI), Flow Mediated Dilation (FMD) and evaluation of epicar-
dial adipose tissue (EAT) were performed, as well as analysis of psycho- A 42-year-old woman was referred to our Department with a decreased
logical and cognitive status by Montreal Cognitive Assessment (MoCA), level of consciousness of unknown cause. Her previous medical history was
Mini-Mental State Examination (MMSE), and Geriatric Depression Scale unremarkable except for of congenital bladder exstrophy treated with ure-
(GDS). terosigmoidostomy as a child. She presented gradual onset of drowsiness
Results: The prevalence of sarcopenia was of 49.4% (44, 7% in HD, 10, 5% and confusion. She was afebrile, semicomatose and exhibited myoclonic
in DP, 13, 2% in KT patients and 31.6% in patients on conservative therapy), movements of her limbs. Within few hours she became deeply comatose
while the prevalence of dynapenia and sarcopenic obesity in the entire (Glasgow coma scale = 3). Toxicology screen was negative and brain CT
population was 10.4% and 2.6%, respectively. Patients with sarcopenia scan was normal. Blood test revealed severe hyperammonemia and meta-
showed higher IMT (p=0.03), EAT (p=0.003) values with respect to non bolic acidosis. Other biochemical values including renal and liver function
sarcopenic patients, and lower FMD (p=0.003), total cholesterol (p=0.006), tests were normal. The electroencephalogram did not show any seizures,
HDL (p=0.004), base excess (BE) (p=0.048) bicarbonate (HCO3) (p=0.04), but showed severe encephalopathic changes with triphasic waves consi-
Vitamin D (p=0.047) and lower estimated basal metabolism rate (p=0.03). stent with metabolic encephalopathy. The patient underwent continuous
Using cognitive tests, we found in sarcopenic patients lower MOCA values venous hemofiltration for two consecutive days with sustained correction
(p=0.029) e higher GDS score (p=0.05), whereas we did not find differences of ammonia levels. Urea cycle disorders were ruled out by serum amino
between the 2 groups in MMSE (p=0.096). acid chromatography and abdominal CT scan excluded hepatic failure and
Conclusion: In our study, we found a high prevalence of sarcopenia in CKD portosystemic shunt. Blood cultures were negative. Patient was treated
patients and in patients on replacement therapy with a significant change with protein restriction, lactulose therapy and sodium/potassium citrate.
in early systemic markers of atherosclerosis and endothelial dysfunction. She improved clinically and returned to her premorbid functional status.
Sarcopenic patients showed alterations in cognitive function and in mood. Otherwise, laboratory and clinical examinations during follow-up at our
Sarcopenia is often an underestimated condition in patients with reduced department were unremarkable. In this moment, we are considering the
renal function and a systematic assessment of the muscular component, conversion of urinary diversion to an ileal conduit in order to normalize
by simple, inexpensive and non-invasive methods, may be useful to better ammonia levels and to avoid the risk of relapses. The above case presenta-
define the prognosis and the cardiovascular risk in these patients. tion illustrates a rare yet potentially fatal complication of urinary diversion.
It should alert the readers to consider the diagnosis of hyperammonemia in
184
any patient with a urinary diversion who presents acutely confusion, agita- The electrolyte disorders are the most frequent disease in hospitalized
tion, stupor and decreased levels of consciousness. Rapid recognition and patients in Internal Medicine. Disorders of Sodium and Potassium are asso-
treatment can prevent serious complications such as encephalopathic coma ciated to worse prognosis if not promptly recognized and treated. In this
and death. study we recruited consecutively 381 patients hospitalized in Internal Medi-
cina in a period from 1 June 2016 to 30 April 2017. 22.4% of these patients
are affected by electrolyte disorders. The fundamental causes were CKD,
322. DIALYTIC TECHNIQUES AND CARDIOVASCULAR hearth failure, arterial hypertension in management with diuretics and far-
COMPLICATIONS macologic polytheraphy (> 5 drugs). In conclusion, the electrolyte disorders
are frequent in Internal Medicine and are very important a prompt diagno-
Raimondi G. 1, Marchitto N. 2, Sindona F. 1, Stranges V. 2, sis and management.
Taurisano S. 2, Visani N. 2, Mobilia P. 2
1
Dept. of Medico-surgical Sciences and Biotechnologies. “Sapienza”
University of Roma. Faculty of Pharmacy and Medicine 1 1ASL. Latina “A. 324. A CASE OF NEPHROTIC SYNDROME IN A WOMEN
Fiorini” Hospital
Serra C., Valenti A., Cabras P., Filigheddu F., Manetti R.
Cardiovascular disease remains the leading cause of death in end-stage renal Istituto Clinica e Terapia Medica Sperimentale, Università degli studi di
endothelial (ESRD) patients, coupled with a reduction in haemodialysis Sassari
tolerability. Cardiovascular instability, expressed as intradial hypotension
(IDH), represents the most frequent clinical complication and significantly We report the case of a 44 years old woman with obesity, osteoporosis and
affects morbidity and mortality of patients, leading to numerous cardiova- chronic venous insufficiency, who was admitted to our department for oli-
scular complications. It can also contribute to chronic hyperhydration due guria, dyspnoea and massive peripheral edema. She also reported a history
to inability to reach the dry weight and lead to sub dialysis. of recurrent cystitis, the last episode one month before hospitalization.
Two are the most widely used dialysis techniques: standard (HD) diffusion - One week before hospital admission she had noted progressive diuresis
and hemodiafiltration (HDF) - convective - in its variants. reduction, until only one concentrated urination per day, lumbosacral pain,
Aim: The aim was to compare the effects of the two purification methods mild dysuria, weight gain and edema, especially of the face and of upper
on removing uremic toxins, cardiovascular stability and haemoglobin levels and lower extremities. For this reason, she had started a domiciliary treat-
in order to evaluate their effectiveness on improving clinical conditions ment with ciprofloxacin, suspecting an urinary tract infection (UTI). Phy-
and reducing cardiovascular risk. Material and Methods: The study was sical examination showed generalized edema and vesicular breathing quite
longitudinal, multicentre, prospective and non-randomized, from 2015 to decreased inferiorly at the chest examination; the other clinical features were
2017. 52 subjects (36 M, 16 F) from two Dialysis Centers in the province normal; body weight was 124 kg (from her previous 115 kg), blood pres-
of Latina, aged 35 to 92, with good vascular access (Qb> 250 ml/min) were sure and other vital signs were normal; the first line laboratory evaluation
examined. Subjects with a dialysis age less than one year were excluded. We suggested a nephrotic syndrome with increased level of serum Creatinine
compared the values at time zero (T0) and six months (T6) of 26 patients (1, 86 mg/dl), albumin deficiency (1, 8 g/dl), hyperlipoproteinemia (total
with mean age 68.7 (16 M, mean age 67.3 - 10 F, mean age 71.1) in HD and Cholesterol 369 mg/dl, HDL. 60 mg/dl; triglycerides 169 mg/dl); at the uri-
26 Patients with mean age 72.8 (20 M, mean age 71.95 - 6 F, mean age 75.3) nalysis: microscopic haematuria, heavy proteinuria (20 g/day), white blood
in convective treatment (HDF online, HDF Evolution, HDF Aequilibrium). cells and a sediment of hyaline and granular casts. Creatinine clearance was
The parameters considered were: KT/V, Azotemia, Haemoglobin, Sodium, 54.9 ml/min. There was also mild hyponatremia (serum sodium level = 132
Potassium, Calcium, SAP, DAP and HR. Statistical analysis has been perfor- mEq/L), hypokaliemia (serum potassium level = 3.3 mEq/L); serum protein
med by SigmaStat. 3.5 software. electrophoresis was normal; urine culture was negative for UTI. Chest X-ray
Results: The main parameter considered was the Kt/V index of purity dialy- confirmed pleural bilateral effusion, the echocardiogram was substantially
sis: both in T0 and T6 there was a statistically significant difference (1.28 ± normal. Abdominal ultrasound showed a renal cortex with increased echo-
genicity but no other pathogenic findings. Considering the hypothesis of a
0.28 vs 1.51 ± 0.17 1, 1.28 ± 0.27 vs. 1.54 ± 0.25 1). As well as K post dialysis
neoplastic disorder, a screening for malignancies (including mammography,
(4.73 ± 0 vs. 3.98 ± 0.24 1, 4.53 ± 0.35 vs. 3.44 ± 0.007 2 mmol/l) while Ca colonoscopy and HRCT) was done with negative results. Because of the
showed a significant difference only to T6 (8.64 ± 0.59 versus 9, 38 ± 1.03 presence of high level of Ca 125, pelvic echotomography and gynecological
1
mg/dl). Hemodynamic parameters showed greater stability both of the examination were performed, again with negative findings. Autoimmunity
systolic and diastolic and FC rates although they did not achieve statistical tests were negative; the study of coagulation profile did not detect defects,
significance as well as sodiemia. Post-dialysis haemoglobin values tend to except low protein S. levels. Due to technical problems we could perform a
be more stable in HDF. renal biopsy only after 16 days from the beginning of symptomatology: it
Discussion: In this study, the best hemodialytic method was evaluated in showed a mild form of mesangial glomerulonephritis, with poor intersti-
the management of cardiovascular complications as well as other hydro-e- tial inflammation and possible focal glomerulosclerosis; immunoflorescent
lectrolytic-metabolic aspects. HDF has shown to mprove intradial hemo- assays did not identify definite granular deposits. After urinary catheterisa-
dynamic stability with respect to HD, allowing at the same time a better tion a diuretic bolus treatment with furosemide 20 mg i.v. four times a day
purification and allowing the ideal weight to be achieved by effectively and potassium canreonate 100 mg once a day were started, strengthened by
subtracting liquids without abuse of increased conductivity. The results fluid restriction and decreased salt intake, with an improvement of diuresis
allow to confirm the higher effectiveness of HDF than HD in cardiovascular (about 1500 ml/24 h); it was administered a prophylactic anticoagulation
management among these subjects. It is currently being evaluated for the and the patient didn’t receive steroids. After nephrology consultation, with
hydration status by bio-impedance, which will provide an interesting data a daily continuous infusion of furosemide 125 mg, albumine 20 g and bicar-
for evaluation of bodily fluids. bonates 20 mEq, diuresis increased and we observed a progressive reduction
Conclusion: We observed results highlighting HDF advantage in terms of peripheral edema. 2 weeks after the admission the body weight was 113
of lower cardiovascular complications, this allowing incidence reduction kg and the diuresis was about 4000 ml/day; we then switched to oral furo-
without causing any significant increase in natrium and at the same time semide 25 mg twice a day and potassium canrenoate 50 mg a day. Labora-
improving dialysis purification. These results agree with major studies sug- tory testing revealed progressive normalization of renal function (Serum
gesting high flow synthetic membranes usage and high exchange convective Creatinine: 0, 84 mg/dl; normal electrolytes levels; important reduction on
methodology as a technique to obtain the best results about uremic toxins proteinuria). Ambulatory follow-up showed total normalization of pro-
removal and hemodynamic stability improvement. teinuria 8 weeks after discharge; today, after 9 months the patient is still
asymptomatic and has persistent normal renal function. Considering all the
characteristics above illustrated, our clinical case seems to be an example
323. PREVALENCE OF ELECTROLYTE DISORDERS IN of Minimal change disease (MCD), a major cause of nephrotic syndrome
INTERNAL MEDICINE: COMORBIDITY AND RISK in both children and adults. In particular MCD. accounts for 10 to 25%
FACTORS of cases of nephrotic syndrome in adults. Regarding the pathogenesis, its
underlying cause is not clear but studies suggest that systemic T. cell dysfun-
Castellino P., Scuto S., Murabito A.R., Reale S., Ferrigno C., ction results in the production of a glomerular permeability factor (many
Zanoli L. data suggest the role of Interleukin 13), resulting in alteration of podocytes:
Dipartimento di medicina clinica e sperimentale, Università di Catania, electron microscopy shows the characteristic histological lesion, the efface-
Policlinico di Catania, UO Medicina Interna ment or “fusion” of the podocyte’s foot processes. On the other hand, it is
185
important to underline glomeruli normal appearance on light microscopy 326. RARE ABDOMINAL MASS: A CASE REPORT
and the absence of complement or Ig deposits on immunofluorescence.
While most cases are idiopathic, secondary MCD. is associated with drugs Mastropierro V. 1, Perrone A. 1, Mazzoccoli C. 1,
(NSAIDs and antimicrobial use), malignancies (particularly hematologic Castiglione Minischetti M. 1, Ingravallo G. 2, Cimmino A. 2,
like Hodgkin Lymphoma, rarely solid tumors), infections (like tubercolosis Minerva F. 3, Sabbà C. 1
or hepatitis virus), allergies to multiple allergens and autoimmune condi- 1
“Frugoni” Internal Medicine Unit, Policlinico Hospital, University of Bari
tions. Clinical manifestations are: sudden onset over days to some weeks “Aldo Moro”, Bari, Italy 2 Pathological Anatomy Unit, Policlinico Hospital,
of a nephrotic syndrome with proteinuria (usually 3.5-4 g/day, occasionally University of Bari “Aldo Moro”, Italy 3 “A. Murri” Internal Medicine Unit,
more than 15 to 20 g/day) and microscopic hematuria, edema, hyperten- Policlinico Hospital, University of Bari “Aldo Moro”, Italy
sion, hyperlipidemia, modest increase in serum creatinine concentration.
Possible complications are: increased risk of thromboembolism and suscep- Numerous nosological entities can manifest with an abdominal mass,
tibility to infection, while acute renal failure is infrequent. Generally, a renal including bulky lymphoma and solid neoplasms affecting liver, kidney, or
biopsy is essential in adults who present the nephropathy syndrome to guide gastrointestinal tract. Some of these entities usually arise in adulthood, while
diagnosis and therapy; differential diagnosis includes Focal Segmental Glo- other diseases are characteristic of pediatric age. A young male patient, 23
merulosclerosis (FSGS). First line therapy is a low-sodium diet and diuretics years old, presented to our observation on April 2017 at “Frugoni” Inter-
for fluid removal, glucorticoid theraphy is the treatment of choice, leading nal Medicine Unit of our Institution, with abdominal pain, arising ten days
to a complete remission in over 85 to 90 % of cases; ACE. inhibitors/ARBs or earlier, not associated with fever, nausea or vomiting. The patient had no
statin therapy are not necessary in normo-tensive patient. Untreated cases relevant personal history.
of MCD. are associated with a high risk of mortality, but the spontaneous The patient reported appearance of an abdominal mass in para-umbilical
remission is possible (5 to 10%). End-stage renal disease is rare; 50 to 65% of region, two months before, with increasing volume, initially neglected by
adults will have a relapse within 1 or 2 years, especially after viral infection. the patient. He reported no significant appetite loss or digestive disturban-
ces, despite weight loss of 10 kg in the last six months. Physical examination
evidenced a large solid abdominal mass of 15 cm in diameter, extending
325. UNDERNEATH CHRONIC PAIN: TWO CASE through umbilical, hypogastric, and right iliac regions, and appearing hard,
REPORTS firm and not painful at palpation. Lymph nodes, spleen and liver were not
palpable. Laboratory tests revealed normal blood count, liver and renal fun-
Gabba M., Masotti M., Formagnana P., Bergamaschi G., ction, inflammation and neoplastic markers. Abdominal ultrasound (US)
Corazza G.R. showed a solid inhomogeneous pseudonodular formation in umbilical
Dipartimento di Medicina Interna Clinica Medica I, Reparto 11, Policlinico region, displacing intestinal loops. Total-body CT investigation disclosed
San Matteo Università degli studi di Pavia multiple focal areas in parietal peritoneum, mild endoabdominal effusion,
and retroperitoneal multiple solid iso-hypoechoic formations, measuring
Introduction: Pulmonary carcinomas are malignancies highly prevalent up to 13 cm, and signs of hepatic infiltration.
throughout the world. They are characterized by biological aggressivity, Upon US-guided transabdominal needle aspiration, bioptic specimen
insidious onset, difficulty in early detection, early metastatic spread and was obtained and directed to histologic exam, with evidence of morpho-
poor prognosis at the time of presentation. The most frequent symptoms of logical and immunophenotypic features (NSE +, EMA+, cytokeratin pool
presentation are cough, weight loss, dyspnea and chest pain; also hemopty- +, desmin +, WT1c +, vimentin +) clearly indicating desmoplastic small
sis, fatigue and paraneoplastic syndromes such as inappropriate ADH secre- round cell tumor (DSRCT). Molecular characterization revealed EWSR1
tion, Lambert Eaton or ectopic ACTH production can be associated. Most gene rearrangement.
lung cancers do not cause any symptoms until they have spread, and about The patient was subjected to chemiotherapy treatment course (cyclopho-
30% to 40% of people with lung cancer have some symptoms or signs of sphamide-epidoxorubicin-vincristin- ifosfamide-etoposide), aiming to
metastatic disease. Lung cancer most often spreads to the liver, the adrenal reduce tumor mass size, and to permit subsequent surgical excision.
glands, the bones, and the brain. We here present two case reports in which DSRCT is a rare malignancy, belonging soft-tissue sarcoma family, with less
the unusual presentation (osteoarticular pain) delayed the diagnosis. of 1, 000 cases insofar described. It is a highly aggressive tumor, which affect
Case presentation 1: a 66 years old man admitted for long standing right males in 90% of cases, usually young, and typically shows typical regional
shoulder pain, treated but non responsive to NSAIDs. Clinical history: localization (abdominal and pelvic). Prognosis is poor (44% global 3-years
Active smoker, vasculopathy complicated with PAOD. Treated for a few survival). No environmental/familial risk factors or definitive therapeutic
months for calcific tendinopathy of shoulder cuff with infiltrative therapy approaches have been identified, despite variable combinations of surgery,
and steroids with scant benefits. chemotherapy, radiotherapy and molecular therapy. In conclusion, in pre-
Clinical course: At time of admission patient presented with edematous sence of an unexplained abdominal mass in a young male patient, diffe-
right arm. Vascular EcoDoppler showed deep venous thrombosis of sub- rential diagnosis should take into account this rare malignancy, which is
clavian and axillary veins; a CT scan showed segmental and subsegmental often characterized by a delayed diagnosis, due to usually silent, albeit fast-
pulmonary embolism of the right lower lobe. A colliquative expansive mass growth, course. Early diagnosis can prompt appropriate and timely thera-
at the right thoracic inlet was also detected, together with bone metasta- peutic approach.
tic disease involving clavicle, sternal manubrium and first costal bone. A
CT- guided biopsy was later obtained and further histologic examination
was conclusive for undifferentiated pulmonary carcinoma, the patient was 327. EARLY EVALUATION OF ANOREXIA AND NUTRIENT
therefore addressed to oncologic follow up. INTAKE IN CANCER PATIENTS
Clinical presentation 2: 55 years old female patient admitted for aggra-
vating left leg pain described in sciatic syndrome features and treated by Molfino A. 1, Nuglio. C. 2, Emerenziani S. 2, Falco S. 1,
general practitioner with high doses of NAIDs for a few months with no Trillo M.L.A. 2, Ferravante F. 2, Cicala M. 2, Amabile M.I. 1,
benefits. Clinical history: Active smoker, essential arterial hypertension. Rossi Fanelli F. 1, Muscaritoli M. 1
Clinical course: At time of admission patient appeared severely sarcopenic 1
Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
and suffering. When CT scan was obtained, an expansive pulmonary lesion 2
Gastroenterology Unit, University Campus Bio-Medico di Roma, Rome, Italy
with speculated margins and satellite micronodules was disclosed, together
with multiple disease localizations involving liver and bones, particularly Background and Aim: Anorexia, i.e. the loss of the desire to eat, reduced
vertebral bodies and causing multiple vertebral collapses, including L4. food intake (hypophagia) and body weight loss (WL) are very common in
Bronchoscopic examination was performed in order to obtained an histo- advanced cancer patients and may lead to nutritional impairment, in turn
logic typization of the neoplasia, but the procedure was non conclusive due negatively affecting morbidity and mortality. The aim of the present study
to the localization of the primary lesion. In consideration of the extremely was to early evaluate the prevalence of anorexia, hypophagia, energy and
advanced stage of the disease and severely compromised organic status of protein intakes in patients with gastrointestinal and lung cancer at first
the patient, pain- control therapy with opioids was assessed. Patient died oncology visit. Material and Methods: Seventy patients (37 M, aged 62±12
due to massive pulmonary effusion causing respiratory failure three weeks years) were enrolled. Body mass index (BMI: kg/m2), 6-months WL (%),
after hospitalization. pre-cachexia, cachexia and serum C-reactive protein (CRP) were assessed.
Conclusion: we report these clinical cases in order to describe two unusual Anorexia was assessed by two specific questionnaires. Energy (kcal/kg/day)
and misleading presentation of lung cancer. and protein (g/kg/day) intakes were recorded by 3-day dietary recall and
compared to ESPEN guidelines-recommended intakes (30 and 1.2, respecti-
186
vely) (Table1). Hypophagia was defined for energy and protein intakes ≤ suffered of transient global amnesia, lack of attention, ataxia, dizziness,
70% of the recommendations. Prism 5.0®software was used for statistical dyspnea and chest pain. Blood analyses showed hypoxemia, hypocapnia
analysis. (pO2: 70 mmHg, pCO2: 30 mmHg), hyponatremia (120 mEq/L) and incre-
Results: BMI was 22±4 kg/m2; WL was 11±7%. Fourteen patients (21%) ased D-dimers (744 μg/L). These features were highly suggestive of pulmo-
were pre-cachectic and 54 (78%) were cachectic. The highest prevalence nary embolism, considering neurological symptoms justified by hypoxia,
of anorexia (80%) and hypophagia (80%) were present in gastro-esopha- hypotension and electrolyte squilibrium. A perfusion lung scan performed
geal cancer and higher in patients with elevated CRP levels (77%). Table 1. urgently (due to allergic diathesis) displayed perfusion deficit at the upper
Recommended vs actual energy and protein intakes segment of the lower left lobe, and suggested the diagnosis of pulmonary
Conclusions: Anorexia and inadequate nutritional intake were highly pre- embolism. After admission to Internal Medicine Division, a neurological
valent in cancer patients at first oncology visit. Energy and protein intakes evaluation and CT scanning of the head were negative, chest X-ray showed
were significantly lower that recommended in pancreatic and gastro-e- mediastinum flaring, while echocardiography highlighted dilatation of pul-
sophageal cancer patients. This study strengthens the view that nutritional monary artery and its main branches with mild to moderate pulmonary
abnormalities may be present at the onset of cancer disease and therefore hypertension. Anticoagulation with LMWH and rehydration therapy with
supports the need of early and appropriate nutritional interventions in order saline solution were started. Because no improvement of both natriemia and
to prevent or treat cancer cachexia and its negative consequences. chest pain occurred in the following hours, an angiography chest CT scan
was requested. Unexpectedly a massive dishomogeneous plurilobated lesion
was detected in the left lung hilum, causing stenosis of the main left bron-
328. MILIARY PULMONARY OPACITIES: chus and infiltrating the left branch of the pulmonary artery with compres-
A CHALLENGE FOR CLINICIANS sion of the superior vena cava. Histology, performed on pulmonary biopsy
by broncoscopic sonography concluded for small-cell lung cancer (SCLC),
Rossio R. 1, Fares R. 1, Ferrari B. 1, Andrisani M.C. 2, Peyvandi F. 1 likely responsible for paraneoplastic syndrome of inappropriate antidiuretic
1
Fondazione IRCCS Ca granda Ospedale Maggiore Policlinico, Dipartimento hormone secretion (SIADH).
di Medicina Interna, UOC di Medicina generale-Emostasi e Trombosi 2 Conclusion: We describe a misleading case of “pulmonary embolism”. This
U.O. Radiologia, Dipartimento dei Servizi, area Diagnostica per immagini. first diagnosis was not supported because of persistent hyponatremia and
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy initial therapeutic failure. The ultimate diagnosis (small-cell lung cancer and
paraneoplastic syndrome) relied on chest CT. When considering the dia-
A 80 year-old Caucasian man presented to the emergency department with gnosis of pulmonary embolism by lung perfusion scan, if deep vein throm-
worsening dyspnoea on exertion, peripheral oedema, cough and fever in bosis is excluded, chest CT has a key role to address the final diagnosis.
the last few days. He was a former smoker, affected by Parkinson disease,
previous hospitalizations for heart failure and recent placement of pace-
maker for total atrioventricular block. At presentation, blood pressure was 330. PULMONARY TUMOR WITH PLEURAL
120/60 mmHg, pulse rate 61 beats/min, respiratory rate 30 breaths/min and INVOLVEMENT.TIA.PERSISTENT ATRIAL FIBRILLATION.
oxygen saturation 88 % on room air. On chest examination, bibasilar inspi- HYPERTENSIVE CARDIOPATHY.MILD MITRAL
ratory crackles were present. Chest X-ray showed bilateral increased lung INSUFFICIENCY.CHRONIC CEREBRAL VASCULOPATHY.
markings, more evident at the right periilar region with diffuse bilateral OBESITY.VSA ATHEROSCLEROSIS. POST-SURGICAL
reticulo-nodular interstitial pattern. Blood analysis showed normal levels HYPOTHYROIDISM IN SUBSTITUTION THERAPY
of total white blood cells and C-reactive protein. High resolution computed
tomography (HRCT) confirmed a right apical mass with irregular margins, 1
Stellitano E., 1Aronne V., 1Caserta C., 1Carerj B., Fulgido A.,
multiple micronodules spread throughout both lungs and a right pleural 1
Lipari P., 1Meduri G., 1Scordo A., 1Tarzia I., 2Stellitano A.,
effusion. Both thoracentesis and bronchoscopy with bronchoalveolar lavage 1
U.O.C. 2U.O.C. Geriatria P.O. Ospedale S.Anna- San Fermo della Battaglia
excluded bacterial, fungal and tubercular infections; cytologic analysis -ASST. Lariana Como. Medicina interna P.O. Melito Porto Salvo(RC) –ASP.
showed reactive mesotelial cells. 18F-fluorodeoxyglucose-Positron Emis- Reggio Calabria
sion Tomography (18FDG-PET) showed increased glucose metabolism in
the pulmonary nodules (with Standardized Uptake Value - SUV- of 6, 5) in Female patient, 76y.o. Hypertension in treatment, pre-existing thyroidec-
the right pulmonary mass, in the right supraclavicular lymph nodes and in tomy with substitution therapy, previous right safenectomy. Episodes of
the fourth thoracic vertebra. A lymph node biopsy was performed, revealing paroxysmal atrial fibrillation for years. Persistent atrial fibrillation for a week.
metastatic pulmonary carcinoma localization. Based on age and comorbidi- Hypertensive crisis since three days before hospitalization.She is hospitaliz-
ties, the patient underwent chemotherapy. Despite when lung micronodular sed for strength deficit at right hand and loss of sensitivity. B.P.140/80, ECG:
miliary pattern is detected, pulmonary tuberculosis (i.e. tubercoloma with AF, HR84b/m.Patientalert. ChestPE: negative. Cardiac P.E.: arrhythmias,
miliary tuberculosis) is usually suspected, it is necessary to consider a dif- A(rterial) B(lood) G(as): normal, normal haematochemical examinations,
ferential diagnosis with lung cancer and haematogenous metastases. Less Brain CT: periventricular white hypodensity for chronic cerebrovascular
frequently, this pattern can be detected in fungal infections (histoplasmosis, suffering without signs of focallesions.
coccidioidomycosis, etc), in silicosis and in histiocytosis x. In addition to Treatment: LMWH, Antihypertensive, atorvastatin, eutrirox.Echodop-
clinical clues (physical signs and symptoms, comorbidities, risk factors and pler:atherosclerosis of Supra-aortic Vessels. Echocardiography: hyperten-
environmental exposures), the HRCT of the lungs represents a crucial tool sive cardiopathy, Mitral Insufficiency.
for differential diagnosis, through identifying and differentiating the pattern Brain CT control does not show any modifications. Chest RX: nodular
of distribution of the pulmonary micronodules. In our patient, the first dia- image with sharp outlines adherent to the posterior parietal pleura in the left
gnostic hypotheses was a tuberculoma, due to the typical localization of the mid-subclavian field.Chest CAT with contrast: solid nodular formation with
pulmonary consolidation in the apical segment of the upper lobes, radiating probably heteroplasic uneven impregnation, about 6cm diameter, localized
to hilum, associated to a miliary tuberculotic spread and pleural effusion. to the upper segment of the Left Lower Lobe adherent to parietal pleura with
The differential diagnosis with a primary lung cancer of the right upper lobe contiguity and continuity relationships with the back arch of the sixth rib,
with diffuse hematogenous dissemination was also considered, despite the where an areola of 11 mm diameter oval osteolysis and a cortical interruption
presence of hundreds small metastases scattered throughout both lungs is are present, no hilar and mediastinal lymphoadenomegalies, no focal lesions
very rare in patients with primary lung cancer. The tissue biopsy was indeed due to the remaining parenchyma. Improvement of the clinical picture, no
essential for correct diagnosis. strength deficit, no paresthesia in the right arm.
329. THIS IS NOT PULMONARY EMBOLISM 331. NOT TYPED LEFT UPPER PULMONARY
HETEROPLASY. COPD. OSAS. DILATATIVE
Stasi C., Capurso M., Belfiore A., Minerva F., Palmieri V.O., MYOCARDIOPATHY
Pugliese S., Buonamico P., Portincasa P.
Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human 1
Stellitano E., 1Aronne V., 1Caserta C., 1Carerj B., Fulgido A.,
Oncology, University of Bari “Aldo Moro” Medical School, Bari, Italy 1
Lipari P., 1Meduri G.,1Scordo A., 1Tarzia I., 2Stellitano A.
1
U.O.C. Medicina interna P.O. Melito Porto Salvo(RC) –ASP. Reggio
A 71-years-old woman, smoker, suffering from blood hypertension and Calabria; 2U.O.C. Geriatria P.O. Ospedale S.Anna- San Fermo della
depression was admitted to Emergency Department. In the last month she Battaglia -ASST. Lariana Como
187
Male patient, 76 years old; hospitalised on 04/02/2017 for ingravescent 333. BRONCHIECTASIS AND ASTHMA: ONLY A
dyspnea, reduced diuresis, dysuria and widespread arthritis. Smoker COMORBIDITY OR A NEW PHENOTYPE?
suffering from severe COPD with home LTOT, hypertensive dilated car-
diomyopathy, permanent AF in NOAC therapy, severe obesity, OSAS, Ferri S., Campisi R., Sorrentino R., Genco S., Heffler E., Crimi N., Augelletti T.
sigma diverticulosis.In 2016 chest RX: Left lung thickening. CT total body Istituto di Pneumologia Riabilitativa, Azienda Ospedaliera Universitaria
without and with contrast: neoplastic pulmonary mass in the upper apical Policlinico Vittorio Emanuele, Catania
left lobe segment, irregular and spliced margins with striations towards Introduction: Bronchiectasis (BE) is a chronic disease associated with high
the pleura and the scissure, multiple lymphadenopathies, pulmonary morbidity e mortality. Several studies have enlightened pathophysiology,
micro-nodules in all segments. Hepatic nodular lesion, lymph nodes at microbiology and epidemiology of the disease, but few is known about its
the gastric bend level, left ventricular nodular lesion at suprarenal level. phenotypes. We aimed to study the correlation between asthma and BE as
PET: presence of proliferative pulmonary primitive pathology and secon- a new phenotype.
dary proliferative localization at lymphonodular, adrenal, liver, peritoneal, Methods: We consecutively enrolled all adult patients with a CT diagnosis
osteo-medullary level. Hematochemical routine examinations within of noncystic fibrosis BE and treated asthma presenting to our Outpatients
standard limits, with the exception of increased transaminases, gamma-gt, Clinic in a 6-months period. Patients with traction BE were excluded. All
LDH. Some tumor markers (CEA, CA125, CA15.3) have increased. Cor- included patients underwent clinical and laboratory workup, lung function
ticosteroid therapy with improved dyspnea, pain therapy and O2 therapy. tests and microbiological analysis of sputum. Asthma control test (ACT) was
On the fifth day the patient is discharged against doctors’ opinion. Male submitted at the recruitment visit. We collected blood and sputum samples
patient, 76 years old; hospitalised on 04/02/2017 for ingravescent dyspnea, and skin prick tests were conducted in order to define asthma phenotype.
reduced diuresis, dysuria and widespread arthritis. Smoker suffering from Results: 16 patients (6 males/10 females; 1 current smoker, 4 ex smokers
severe COPD with home LTOT, hypertensive dilated cardiomyopathy, and 11 non smokers) were enrolled into the study. BE were cylindric in 87%
permanent AF in NOAC therapy, severe obesity, OSAS, sigma diverticu- and both cystic and cylindric in only 2 cases. 50% patients had BE in 4 lobes,
losis.In 2016 chest RX: Left lung thickening. CT total body without and 30% in 6 lobes and 20% in 2 lobes. Radiologically, 11 and 5 patients were
with contrast: neoplastic pulmonary mass in the upper apical left lobe defined as mild and moderate respectively. None was found with severe BE.
segment, irregular and spliced margins with striations towards the pleura The main hallmark was frequent, non-seasonal exacerbations (mean 4, 18/
and the scissure, multiple lymphadenopathies, pulmonary micro-nodules year), with productive cough and non purulent phlegm. Microbiological
in all segments. Hepatic nodular lesion, lymph nodes at the gastric bend analysis was lead in sputum samples. Pseudomonas Aeruginosa was found
level, left ventricular nodular lesion at suprarenal level. PET: presence of in 4 patients while no pathogens were found in the remaining samples. All
proliferative pulmonary primitive pathology and secondary proliferative patients were negative for allergic bronchopulmonary aspergillosis (ABPA).
localization at lymphonodular, adrenal, liver, peritoneal, osteo-medullary Mean ACT was 14.2. 50% of patients had both peripherical and sputum
level. Hematochemical routine examinations within standard limits, with eosinophilia. Lung function tests were normal or mildly obstructive in 81%
the exception of increased transaminases, gamma-gt, LDH. Some tumor of patients, only 3 were moderate.
markers (CEA, CA125, CA15.3) have increased. Corticosteroid therapy Conclusions: Asthma/BE patients seems to have worse symptoms in spite
with improved dyspnea, pain therapy and O2 therapy. On the fifth day of mild radiological and lung functional findings. We suppose that the asso-
the patient is discharged against doctors’ opinion. Male patient, 76 years ciation between Asthma and BE can play a role as a trigger for exacerbations
old; hospitalised on 04/02/2017 for ingravescent dyspnea, reduced diure- and it may be a new phenotype for both diseases.
sis, dysuria and widespread arthritis. Smoker suffering from severe COPD
with home LTOT, hypertensive dilated cardiomyopathy, permanent AF in
NOAC therapy, severe obesity, OSAS, sigma diverticulosis.In 2016 chest 334. JUST A PNEUMONIA?
RX: Left lung thickening. CT total body without and with contrast: neo-
plastic pulmonary mass in the upper apical left lobe segment, irregular Cabras P., Filigheddu F., Manetti R., Serra C., Valenti A., Ledda D.
and spliced margins with striations towards the pleura and the scissure, Dipartimento di Medicina Clinica e Sperimentale, scuola di specializzazione
multiple lymphadenopathies, pulmonary micro-nodules in all segments. in Medicina Interna, Università di Sassari
Hepatic nodular lesion, lymph nodes at the gastric bend level, left ven-
tricular nodular lesion at suprarenal level. PET: presence of proliferative We report the case of a 71 years old white man with progressively worse-
pulmonary primitive pathology and secondary proliferative localiza- ning dyspnea, fever and productive cough. The arterial hemogasanalysis
tion at lymphonodular, adrenal, liver, peritoneal, osteo-medullary level. showed a severe respiratory failure (pH 7.43, pO2 38.3 mmHg, pCO2 30.3
Hematochemical routine examinations within standard limits, with the mmHg, Lactate 3.9 mmol/ L, bicarbonate 21.4 mmol/L). The patient was
exception of increased transaminases, gamma-gt, LDH. Some tumor dyspnotic, cyanotic, sweaty, tachycardic, with rales and velchro sound
markers (CEA, CA125, CA15.3) have increased. Corticosteroid therapy spread throughout the lungs. He had a history of COPD (ex-strong
with improved dyspnea, pain therapy and O2 therapy. On the fifth day smoker), atrial fibrillation, diabetes mellitus, essential hypertension.
the patient is discharged against doctors’ opinion. Male patient, 76 years In the emergency department, a chest Rx was performed showing focal
old; hospitalised on 04/02/2017 for ingravescent dyspnea, reduced diure- bronchopneumonia and an important accentuation of interstitium. In our
sis, dysuria and widespread arthritis. Smoker suffering from severe COPD department, we administered high flow oxygen (8l/min with 40% Venturi
with home LTOT, hypertensive dilated cardiomyopathy, permanent AF in mask), antibiotic therapy (Piperacillin/tazobactam and clarithromycin),
NOAC therapy, severe obesity, OSAS, sigma diverticulosis.In 2016 chest cortisone, diuretic and aerosol therapy. Blood and urine cultures were
RX: Left lung thickening. CT total body without and with contrast: neo- negative, while sputum culture was positive. Cardiac ultrasound showed
plastic pulmonary mass in the upper apical left lobe segment, irregular pulmonary hypertension (PAPS 63 mmHg). A chest CT revealed incre-
and spliced margins with striations towards the pleura and the scissure, ased interstitial markings with associated bronchiectasie, honeycomb
multiple lymphadenopathies, pulmonary micro-nodules in all segments. and ground-glass areas and calcific lung nodules. To better investigate
Hepatic nodular lesion, lymph nodes at the gastric bend level, left ven- the nature of this interstitiopathy, we screened for autoimmune diseases,
tricular nodular lesion at suprarenal level. PET: presence of proliferative viruses and uncommon germs, HIV, quantiferon which were all negative.
pulmonary primitive pathology and secondary proliferative localization at After seven days, the patient had a new CT-HR that showed improvement
lymphonodular, adrenal, liver, peritoneal, osteo-medullary level. Hemato- in the picture; spirometry + DLCO showed a mild ventilatory restriction
chemical routine examinations within standard limits, with the exception deficiency and a severe reduction in the alveolo-capillary diffusion of the
of increased transaminases, gamma-gt, LDH. Some tumor markers (CEA, gases. According to pneumological consult, the patient performed a bron-
CA125, CA15.3) have increased. Corticosteroid therapy with improved choscopy that showed important inflammation in the whole bronchial
dyspnea, pain therapy and O2 therapy. On the fifth day the patient is tree. Considering the improvement in symptomatology, laboratory and
discharged against doctors’ opinion. instrumental examinations and normalization of arterial hemogasanalysis
without oxygen supply, the patient was discharged with the diagnosis of
idiopathic pulmonary fibrosis. He was then was referred to pneumologists
for experimental therapy with Pirfenidone. Before the new therapy began,
the patient was admitted again for pneumonia and severe respiratory
failure. He was transferred to the intensive care unit and he was intubated.
Now the patient is at home with oxygen and cortisone therapy. The patient
is suffering from idiopathic pulmonary fibrosis, a rare illness, which causes
irreversible damage to the lungs. It is a specific form of chronic and pro-
188
Figure 1
gressive lung fibrosis which is anatomically and pathologically characterized 336. SUBCLINICAL CAROTID ATHEROSCLEROSIS IN
by a particular type of lung injury, which is defined as a pattern of common PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY
interstitial pneumonia. A genetic basis and a relationship with smoke have DISEASE: A META-ANALYSIS OF LITERATURE STUDIES
been suspected, but the causes of the disease have not yet been identified.
People affected by idiopathic pulmonary fibrosis are cured with cortisone Ambrosino P. 1, Lupoli R. 1, Cafaro G. 1, Iervolino S. 2, Carone M. 3,
(which reduces the inflammation) and in some cases with drugs that lower Pappone N. 2, Di Minno M.N.D. 4
immune defenses and reduce connective tissue growth (such as azathioprine 1
Department of Clinical Medicine and Surgery, Federico II University,
and cyclophosphamide). Research has led to the recent approval of two drugs: Naples, Italy; 2ICS. Maugeri SpA. SB, Scientific Institute of Telese Terme
pirfenidone, with anti-proliferative, anti-inflammatory and anti-oxidant pro- - IRCCS, Telese Terme (BN), Italy; 3ICS. Maugeri SpA. SB, Scientific
perties and nintedanib that inhibits the activity of certain tyrosine kinases. Institute of Cassano delle Murge - IRCCS, Cassano delle Murge (BA), Italy;
Unfortunately it seems that the diagnosis generally occurs very late (about 4
Department of Advanced Biomedical Sciences, Division of Cardiology,
one to two years after the first symptoms) and that death occurs in 50% of Federico II University, Naples, Italy
cases two to three years after the diagnosis. Often the only solution is pul-
monary transplantation. Through this case, we invite you to reflect on some Background: Chronic obstructive pulmonary disease (COPD) patients
questions: could this disease be diagnosed at the beginning, before irreversible have an increased cardiovascular (CV) morbidity and mortality. Common
lung injury? When is the best timing to start experimental therapies? Does the carotid intima-media thickness (CCA-IMT) and carotid plaques are sur-
patient have to take prophylactic antibiotic therapy cycles? rogate markers of subclinical atherosclerosis and predictors of CV events.
Methods: We performed a meta-analysis to evaluate the association
between COPD and subclinical atherosclerosis. Studies evaluating the
335. CLINICAL ASSESSMENT OF ENDOTHELIAL impact of COPD on CCA-IMT and on the prevalence of carotid plaques
FUNCTION IN PATIENTS WITH CHRONIC OBSTRUCTIVE were systematically searched.
PULMONARY DISEASE: A SYSTEMATIC REVIEW WITH Results. Twenty studies (2, 082 COPD patients and 4, 844 controls) were
META-ANALYSIS included, 12 studies with data on CCA-IMT (13 data-sets on 1, 180 COPD
patients and 2, 312 controls) and 12 studies reporting on the prevalence of
Ambrosino P. 1, Lupoli R., 1 Iervolino S., 2 De Felice A., 2 Pappone N., 2 carotid plaques (1, 231 COPD patients and 4, 222 controls). Compared to
Storino A. 3, Di Minno M.N.D. 4 controls, COPD patients showed a significantly higher CCA-IMT (mean
1
Department of Clinical Medicine and Surgery, Federico II University, Naples, difference [MD]: 0.201 mm; 95%CI: 0.142, 0.260; P<0.001. Figure 1),
Italy; 2ICS. Maugeri SpA. SB, Scientific Institute of Telese Terme - IRCCS, and an increased prevalence of carotid plaques (Odds Ratio [OR]: 2.503;
Telese Terme (BN), Italy; 3Department of Public Health, Federico II University, 95%CI: 1.333, 2.175; P<0.0001). Meta-regression models showed a direct
Naples, Italy; 4Department of Advanced Biomedical Sciences, Division of association between disease severity [as expressed by Global Initiative for
Cardiology, Federico II University, Naples, Italy Chronic Obstructive Lung Disease (GOLD) class] and the difference in
the risk of carotid plaques presence between COPD patients and controls.
Background: Patients with chronic obstructive pulmonary disease (COPD) Conclusions: COPD is significantly associated with subclinical athero-
have an increased cardiovascular morbidity and mortality. Flow-mediated sclerosis. These findings may be useful to plan adequate CV prevention
(FMD) and nitrate-mediated dilation (NMD) are considered non-invasive strategies.
methods to assess endothelial function and surrogate markers of subclinical
atherosclerosis. We performed a systematic review with meta-analysis and
meta-regression to evaluate the impact of COPD on FMD and NMD.
Methods: Studies were systematically searched in the PubMed, Web of
Science, Scopus and EMBASE databases. The random-effect method was
used to take into account the variability among included studies.
Results: A total of eight studies were included in the final analysis, 8 with data
on FMD (334 COPD patients) and 2 on NMD (104 COPD patients). Com-
pared to controls, COPD patients showed a significantly lower FMD (MD:
-3.15%; 95%CI: -4.89, -1.40; P<0.001. Figure 1) and NMD (MD: -3.53%;
95%CI: -7.04, -0.02; P=0.049). Sensitivity analyses substantially confirmed
results. Meta-regression models showed that a more severe degree of airway
obstruction is associated with a more severe FMD impairment in COPD
patients than in controls. Regression analyses confirmed that the associa-
tion between COPD and endothelial dysfunction is independent of baseline
smoking status and most traditional cardiovascular risk factors.
Conclusions: COPD is significantly and independently associated with
endothelial dysfunction. These findings may be useful to plan adequate car-
diovascular prevention strategies in this clinical setting, with particular regard
to patients with a more severe disease
189
337. ENDOTHELIAL FUNCTION IN PATIENTS WITH health problem worldwide, characterized by irreversible progressive airway
CHRONIC OBSTRUCTIVE PULMONARY DISEASE: THE obstruction and systemic inflammation as a result of exposure to smoking,
EFFECT OF PULMONARY REHABILITATION noxious gases, and particles. It is associated with high mortality and mor-
bidity, with heavy health care costs. A relevant aspect is that patients with
Ambrosino P. 1 Lupoli R., 1 Iervolino S., 2 De Felice A., 2 Pappone N., 2 COPD frequently suffer from comorbidities, such as cardiovascular disease
Storino A. 3, Di Minno M.N.D. 4 (CVD) and diabetes. Previous reports have shown that >60% of deaths in
1
Department of Clinical Medicine and Surgery, Federico II University, patients with COPD are caused by comorbidities rather than by COPD
Naples, Italy; 2ICS. Maugeri SpA. SB, Scientific Institute of Telese Terme - itself. The aim of this cross-sectional study was to evaluate, in a large group
IRCCS, Telese Terme (BN), Italy; 3Department of Public Health, Federico of patients with COPD, the prevalence of associated comorbidities and to
II University, Naples, Italy; 4Department of Advanced Biomedical Sciences, identify clinic and biochemical characteristics able to phenotypically cha-
Division of Cardiology, Federico II University, Naples, Italy racterize affected patients. From 2010 to 2016, 893 outpatients, affected by
several comorbidities and referring to Geriatric Cardiovascular Disease
Background: COPD is associated with subclinical atherosclerosis and Unit, were enrolled. All patients underwent complete collection of clinical
endothelial dysfunction. The effect of pulmonary rehabilitation (PR) on history and physical examination and determination of biochemical para-
markers of CV risk in COPD has not been extensively investigated. In the meters. Renal function was evaluated by measurement of estimated glome-
present study, we tested the hypothesis that PR is able to improve endothelial rular filtration rate (e-GFR) with CKD-Epi formula. COPD diagnosis was
function assessed by flow-mediated dilation (FMD) in patients with COPD. defined by a standard spirometry according to the joint American Thora-
Methods: Consecutive COPD patients referred to ICS Maugeri, IRCCS, cic Society and European Respiratory Society Guidelines. Among enrol-
Scientific Institute of Telese Terme, Benevento, Italy between June 2016 and led patients, 603 were affected by COPD [COPD (+)], 441 males and 168
December 2016 for a comprehensive 40-session PR program were screened females, a 67% showed GOLD stage 1-2, 33% GOLD stage 3 and another
for inclusion in the present study. All the major demographic and clinical 4.9% GOLD stage 4. In comparison with COPD (-) patients, those COPD
data were collected for each patient. Laboratory and lung function parame- (+) were older (64.4+12.7 vs 58.9+12.4, p<0.0001), with higher prevalence
ters were assessed at admission (T0) and after completing the PR program of males (77% vs 37%, p<0.0001) and smokers (62% vs 20%, p<0.0001).
(T1). They showed increased values of both systolic (140.7+18.2 vs 133.7+15.7,
Results: A total of 80 patients with COPD had full data collected before and p<0.0001) and diastolic blood pressure (82.1+10.5 vs 79.8+10.5, p<0.0001)
after PR. FMD significantly and substantially changed after the PR program and lower values of body mass index (29.5+5.5 vs 31.2+6.2, p<0.0001),
(Δ%FMD=3.5%), increasing from 7.1% ± 3.7 to 10.6% ± 4.8 (P<0.001). HDL-cholesterol (48.1+13.2 vs 52.3+13.6, p<0.0001) and e-GFR (84.8+27.7
Changes in FMD (Δ%FMD) following PR were positively correlated with vs 115.2+36.1, p<0.0001). Of interest, levels of uric acid (6.1+1.6 vs 5.3+1.4,
changes in FEV1 (Δ%FEV1) (r=0.33; P=0.003, Figure 1). After adjusting p<0.0001), fibrinogen (340.1+75.1 vs 312.2+74.5, p<0.0001) and high sen-
for all potential confounders by means of multivariate analyses, Δ%FEV1 sitivity-C reactive protein (hs-CRP) (6.1+3.1 vs 3.1+1.1, p<0.0001) were
was an independent predictor of Δ%FMD (β=0.287; 95%CI: 0.248-1.350; significantly increased in COPD (+) patients, thus showing an increased
P=0.001). In particular, for each 1% increase in FEV1 a ≈ 6% probability of inflammatory burden. Regarding comorbidities, COPD (+) patients pre-
FMD improvement was found (OR: 1.06; 95%CI: 1.01-1.12). In addition, we sented higher prevalence of diabetes (49.7% vs 11.2%, p<0.0001), atrial
found that patients experiencing an improvement in GOLD class more fre- fibrillation (24.1% vs 3.8%, p<0.0001) and chronic kidney disease (18.1%
quently reported an improvement in FMD (OR: 7.86; 95%CI: 1.21-51.10). vs 8.8%, p=0.002). Moreover, statistical analysis performed in COPD (+)
Conclusions: Results of our prospective study suggest that endothelial fun- patients and according with gender, although not reaching statistical signi-
ction could significantly improve after PR in COPD patients. Thus, PR could ficance, showed a greater prevalence of comorbidities in females than in
be seen as an opportunity to modify the CV risk profile of these patients. males. Present data confirm that patients with COPD have many comor-
Figure 1. Relationship between changes in flow-mediated dilation (FMD) bidities with possible gender-related differences. The link with COPD may
and changes in forced expiratory volume in 1 second (FEV1) following be explained by chronic systemic inflammation, so as demonstrated by the
pulmonary rehabilitation. higher levels of hs-CRP in COPD (+) patients, who are also characterized by
a worse hemodynamic and biochemical profile.
339. AUTONOMIC CARDIOVASCULAR CONTROL

BEFORE AND AFTER LUNG TRANSPLANTATION:
A PILOT STUDY
Tobaldini E. 1, Coti Zelati G. 1, Monti A. 1, Rossetti V. 2,

Morlacchi L.C. 2, Briganti D.F. 2, Henchi S. 2, Tarsia P. 2, Righi I. 3,
Mantero M. 2, Aliberti S. 2, Montano N. 1, Blasi F. 2
1
Departments of Internal Medicine, and Clinical Sciences and Community
Health, University of Milan, Fondazione IRCCS Ca’ Granda, Ospedale
Maggiore Policlinico, Via F. Sforza 35, Milan, Italy; 2 Department of
Pathophysiology and Transplantation, University of Milan, Fondazione
IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan,
Italy; 3 Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS
Cà Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
Background: Abnormalities in cardiac autonomic control (CAC) are known

to be present in patients with chronic obstructive, restrictive and mixed pul-
monary diseases; such alterations are associated with a poor prognosis in
cardiovascular and non-cardiovascular disorders. Lung transplantation may
338. CHRONIC OBSTRUCTIVE PULMONARY DISEASE affect autonomic profile; however, this association has never been investiga-
AND COMORBIDITIES: DATA FROM A LARGE COHORT ted in detail. Analysis of heart rate variability (HRV) is a simple, noninvasive
OF SOUTH ITALIAN PATIENTS tool to study autonomic nervous system.
Aims: To investigate the effects of lung transplantation on CAC using two
Sciacqua A. 1, Perticone M. 2, Falbo T. 1, Miceli S. 3, Iannello A. 1, different types of analysis of HRV.
Bencardino G. 1, Cassano V. 4, Sesti G. 1, Perticone F. 1 Methods: Consecutive adult lung transplant candidates referred to our
1
Dipartimento di Scienze Mediche e Chirurgiche - Università degli Studi transplant center (Ospedale Maggiore Policlinico, Milan) were enrolled
Magna Graecia - Catanzaro 2Dipartimento di Medicina Sperimentale between July 2016 and June 2017. Ten minutes EKG and respiration were
e Clinica - Università degli Studi Magna Graecia - Catanzaro 3Azienda recorded before and 15 days after the intervention. Clinically stable condi-
Ospedaliero-Universitaria “Mater Domini” - Catanzaro 4Dipartimento di tions and sinus rhythm on EKG were demanded. Autonomic cardiovascular
Scienze della Salute - Università degli Studi Magna Graecia - Catanzaro control was assessed using spectral and symbolic analysis of HRV. Spectral
analysis identifies two main oscillations, low frequency (LF, 0.04 to 0.15 Hz),
Chronic obstructive pulmonary disease (COPD) is a common public marker of sympathetic modulation and high frequency (HF, 0.15-0.4 Hz),
190
synchronous with respiration and marker of parasympathetic modulation.

Total variance, the sum of the different oscillatory components, can be cal-
culated as well. Symbolic analysis is a new non-linear method that identifies
three families of patterns, 0V%, index of sympathetic modulation, 2LV and
2UV%, index of parasympathetic modulation.
Results: Sixteen patients were enrolled (9 males, mean age 39.56 ± 14.66,
mean LAS 38.45 ± 10.76). Out of them, ten patients had a diagnosis of Cystic
Fibrosis (CF), one patient had Non Specific Interstitial Pneumonia (NSIP),
one patient had Chronic Obstructive Pulmonary Disease (COPD), two
patients had Idiopathic Pulmonary Fibrosis (IPF), one patient had COPD
plus IPF and one patient had a Pulmonary Graft Versus Host Disease after
hematopoietic stem cells transplant. Comparing HRV parameters before
and after lung transplantation, there was no significant difference in heart
rate (85 ± 15 bpm vs 87 ± 12 bpm, p= 0.63); total variability was significantly
lower after the intervention (135 ± 153 ms2 vs 682 ± 433 ms2, p < 0, 001)
while 0V % significantly increased after the Tx (42 ± 22 vs 25 ± 18, p= 0,
041).
Conclusions: According to these preliminary data, results showed that
transplantation was able to induce a marked decrease of total variability,
likely to be related to a partial cardiac denervation, although associated with
an increased sympathetic rhythmic modulation. Whether these data could
have a prognostic role in this setting warrant further investigations.
191
Indice Autori 118° Congresso Nazionale - Società Italiana di Medicina Interna
INDICE AUTORI Altruda C. 61, 102 Arnone S. 127

Amabile A. 59 Arone A. 85
Amabile, A. 172 Aronico N. 14, 17, 41, 128
A Amabile M.I. 17, 36, 169, 182, 184, 186 Aronne V. 187
Amadasi S. 159 Arroyo V. 120
Amaradio M.D. 155 Arturi F. 36
Abbruzzese M.G. 59
Amati A. 66 Artuso L. 11
Abenavoli L. 45
Ambrogi C. 141 Asllanaj B. 146
Abrahamsen T. 38
Ambrosino P. 30, 189, 190 Assadsangabi A. 126
Aburas S. 10
Amione C. 33, 168 Astazi P. 155
Accardi G. 53
Amoros A. 120 Astorri F. 133
Accordino S. 146
Amoroso A. 56 Atkin S. 166
Accoti A. 135
Amoroso L. 77 Aucella F. 182
Aceto P. 184
Anastasi E. 161 Augelletti T. 93, 188
Acierno C. 38, 102
Anastasio L. 52, 85 Avitabile E. 12, 26, 114
Acquaviva T. 153
Andini R. 8, 121 Avolio A.W. 113, 119
Acquistapace G. 64
Andreozzi F. 170, 171 Avolio W.A. 118
Adamo A. 136
Andreozzi P. 184
Adamoli M. 59
Andretta M. 59
Addolorato G. 9, 84, 130
Andrisani M.C. 187
B
Adinolfi L.E. 38, 61, 102
Angarano G. 121
Agabiti Rosei C. 143
Angeletti A. 149
Agabiti Rosei E. 143 Babu V. 167
Angelici S. 133
Ageno W. 30 Badolato R. 70
Angelico F. 12, 39, 114, 161
Aghi, A. 172 Baffa V. 37, 103
Angeli P. 43, 120
Aglitti A. 43, 45 Bagnaresi I. 101
Angelucci E. 35, 82, 83, 99, 100, 102
Agnes S. 113, 118, 119, 130 Bagnulo R. 42
Annese T. 57
Agostini C. 25 Baldassarre M. 43
Annicchiarico B.E. 63, 94, 113, 115
Agosti P. 107 Baldassarre S. 34
Ansell J. 131
Agyei-Nkansah A. 130 Baldi C. 62
Antonelli Incalzi R. 55, 71, 84, 181
Aiello A. 53 Balietti P. 146
Antonelli M. 130
Ainora M.E. 22, 23, 63, 94, 115 Ballestrero A. 58
Antoniazzi F. 144
Airaghi L. 92, 117 Balloni A. 77, 78
Antonica G. 64, 76, 132
Airaghi L.M. 112, 129 Bandello F. 168
Aperti P. 47
Ala A. 103, 143 Baratta F. 12, 114, 161
Appice C. 66
Alaimo S. 40 Barazzoni R. 78
Aracri N. 141
Albano L. 33 Barbaglia M. 115
Aragona E. 168
Albisinni R. 8, 121 Barbaglia M.N. 11, 12
Araneo C. 118, 119
Alboni S. 13 Barbano B. 24
Arcieri E. 20
Alcidi G. 101 Barbara G. 123, 131
Arciuli M. 57
Alesini M. 173 Barbaro B. 119
Arcopinto A. 111
Alessandria C. 120 Barbaro M.R. 131
Arcudi S. 72, 95, 100, 108, 109
Alessandri F. 169 Barbato A. 108, 161
Ardizzone S. 128
Alessi E. 160 Barberi S. 143
Ardoino I. 46, 60
Alessi N. 43 Barbieri F. 136
Arena U. 10, 44
Alessio S. 86, 90, 91 Barboni E. 157
Arfini A. 41
Aliberti S. 190 Barchiesi S. 65
Argentiero A. 27
Alibrandi A. 47 Bardtrum L. 166
Ariani R. 68
Alio W. 126 Barillà F. 146
Arienti V. 23, 24
Allegorico E. 61 Barizzone N. 11
Ariza X. 120
Almasio P.L. 116 Baronciani L. 116
Arma P. 133
Altieri S. 184 Barone A. 145
Armuzzi A. 94
Altinier S. 5, 151 Barone M. 135
Arnao V. 53, 171
192
118° Congresso Nazionale - Società Italiana di Medicina Interna Indice Autori
Baroni M. 31, 49, 50 Bernardi F. 31, 49, 50 Bonafini S. 144

Bartoccioni E. 169 Bernardi M. 43, 120 Bondanese M. 99, 100, 102
Bartoletti A. 68 Bernardini F. 119 Bonfiglio A. 136, 163
Bartoletti M. 43 Bernardi S. 75 Bonfrate L. 41, 89, 128, 162
Bartoli G. 78, 79 Bernardis I. 11 Boni M.V. 184
Bartolini A. 154 Berni A. 90 Bonnet N. 15
Barutta F. 33 Berra C. 37 Bonometti R. 26
Baselli L. 54 Bertelli C. 63, 117 Bontempelli E. 122, 163
Basile G. 19, 47, 105, 112, 181 Bertelli S. 171 Bonzi M. 93
Basset M. 31 Bertello S. 168 Bordigato E. 79
Bassi A. 49 Bertolotti M. 40, 162 Bordoni V. 146
Basso L. 121 Bertomoro A 96 Borgheresi P. 130
Basso M. 113 Bertozzi I. 31, 32, 81, 96 Borgia G. 111
Basta F. 55, 71 Beschin G. 10, 57 Borioni E. 177
Bastoni D. 45, 48 Besozzi A. 122, 163 Borretta V. 8
Basu A. 168 Bette C. 37 Borroni V. 112
Basu R. 168 Betti E. 14 Borroni V.N. 117
Battaglia S. 39, 72, 161 Betti L. 47 Bortone A.S. 153
Battista F. 22, 86, 160 Bettini S. 79 Boscaro F. 96, 100
Battisti P. 96 Bevini M. 98 Boschiero F. 68
Beguinot F. 33 Biagetti G. 32, 96 Bosco G. 35
Belacosa L. 131 Biagi F. 14 Boscolo Anzoletti M. 98
Belfiore A. 32, 61, 62, 66, 74, 89, 104, 111, Biamonte F. 103 Bossi A.C. 37
128, 187 Bianchini E. 22 Bova C. 82
Bellacosa L. 123, 131 Bianchi P.I. 112, 122 Bova M. 70
Bellando-Randone S. 18 Bianco A. 119 Bowering K. 167
Bellan M. 114, 115, 165 Bianco S. 11, 26, 165 Bracco C. 8, 9, 53, 64, 80, 89
Bellanti F. 26, 111 Biferi E. 7, 22, 71, 144 Braghin, D. 172
Bellelli G. 46 Bignamini D. 129 Braham S. 50, 115
Bellesini C. 29 Biletta E. 128 Brambilla A.M. 48
Belli R. 21 Billi F. 146 Brancato T. 81
Bellocco R. 159 Billings L.K. 105 Branchi F. 115
Bellofatto I. 54 Biolato M. 118, 119 Braucci S. 62
Bellone F. 19, 65, 164 Biolo G. 170 Bresciani E. 159
Belotti Masserini A. 122 Biondi L. 84, 88, 108, 149, 180 Bresciani P. 32
Beltrame L. 57 Biondi P. 15, 16, 37 Bressanin E. 18
Bencardino G. 44, 148, 170, 190 Bisciotti V. 121 Bretler D.M. 167
Benedetti I. 15, 42, 124 Bitti G. 133 Briganti D.F. 190
Benetti A. 171 Bitto N. 115, 116 Brignone C. 9, 80
Benfaremo D. 84, 87, 88, 108, 133, 149, Biver E. 15 Brischetto D. 47
180 Blasi F. 190 Brizzi M.F. 52
Bensi C. 27 Blonda M. 111 Brocca A. 43
Benvenga S. 105 Boarino V. 13 Brocchieri A. 112
Benvenuto A. 105 Bobbio E. 111 Brucato A. 21
Benzi M. 67, 69 Boccatonda A. 99, 100, 102, 162 Bruckert E. 165
Benzo M. 24 Bocci M. 106 Brunati C. 180
Berardi E. 64, 76, 132 Boddi M. 18, 23, 166 Brunelli V. 38, 102
Berchialla P. 33 Bode B. 167 Bruni C. 18
Beretta G. 64 Boemi M. 37 Bruno F. 90
Bergamaschi G. 124, 128, 186 Bogoni G. 96 Brunofranco M. 75
Bergamin M. 68 Boldorini R. 12 Bruno G. 34
Bergonzi M. 15 Bolondi L. 5, 63, 131 Brunori G 182
Bernardi B. 177 Bonadia N. 51 Brustia F. 169
193
Bucciarelli P. 98 Campello E. 50 Casati S. 168

Bucci T. 12, 25, 73 Campisi R. 93, 188 Casazza G. 23
Buchholtz K. 167 Camussi G. 52 Casciaro A.F. 75
Buonamico P. 32, 45, 61, 62, 66, 74, 89, Cancino A.P. 165 Cascini G.L. 39
104, 111, 121, 128, 187 Candido R. 37 Casella F. 23
Buonauro A. 7, 154 Candigliota M. 163 Caserta C. 187
Buonomo A. 55, 71, 75 Cangemi G.C. 14, 123 Caserza L. 80
Buonomo R.A. 111 Cannavo’ N. 95 Cassano V. 36, 52, 148, 149, 190
Buratti L. 145 Cannito C.D. 156 Castagna A. 31, 49, 50
Burattini M. 145 Cantarano E. 60, 173, 174, 175, 176 Castagna C. 105
Burdick L. 117 Cantarano M. 60, 173, 174, 175, 176 Castagna M. 94
Burlone M.E. 12 Cantarano M.S. 60, 173, 174, 175, 176 Castellana G. 72
Buscemi S. 38 Capalbo S.F. 26 Castellino G. 34, 136, 163
Bussi A.R. 47, 159 Capeci W. 145 Castellino P. 185
Buttà C. 171, 177 Capelli E. 14, 131 Castiglia G. 157
Buzzetti E. 11 Caporaso N. 43 Castiglione Minischetti M. 186
Cappabianca M. 162 Castorani L. 156
Cappellini M.D. 50, 55, 150 Castrovilli A. 70, 97, 163
C Capuano F. 128 Castruccio Castracani C. 34
Capucci A. 149 Casuccio A. 6, 12, 53, 94, 171, 177
Capurso M. 187 Catalano A. 19, 47, 65, 105, 164, 181
Cabibbe M. 180
Caracciolo B. 62 Catalano L. 45, 48
Cabibbo G. 43
Caraceni P. 43 Catalfio R. 163
Cabibi D. 12
Caramazza D. 169 Catania P. 45, 48
Cabras P. 73, 185, 188
Carbone A.M. 82, 83 Cataudella E. 40
Caccamo G. 112
Carbone M. 85 Catena E. 49
Caccamo L. 63
Cardamone C. 17, 25, 73 Caturano A. 38, 102
Caccia Dominioni C. 124, 128
Cardellicchio A. 80, 114 Cavallari C. 52
Cacciafesta M. 132
Cardinaletti P. 65, 87, 179 Cavallaro T. 123
Cacciapaglia F. 66
Cardinali M. 84, 88, 108, 149, 180 Cavallo F. 33, 168
Cafaro G. 30, 189
Carella A.M. 105 Cavallo M. 136, 137
Caggiano G. 126
Carerj B. 187 Cavallo M.L. 121
Cagnoni F. 112, 122, 163
Carfagna P. 96 Cavallone F. 26
Caini P. 44
Carini L. 60, 173, 174, 175, 176 Cavarzere P. 144
Calabrese C. 12
Carlino M.V. 155 Cazzola M. 15, 42
Calabretta F. 124, 176
Carnevale R. 28, 39, 161 Cecchetto M. 136
Calamai M. 47
Carnevale Schianca G.P. 165, 169 Cecchia M. 45, 48
Calamai S. 45, 48
Carnicelli A. 21, 51 Cecchini M. 170
Calarco R. 75
Carobbio A. 21 Ceci F. 12
Calcagno E. 113, 146, 173
Caroleo B. 44, 91, 135 Cecioni I. 90
Calcinaro F. 184
Carone M. 189 Cedrino M. 52
Caldonazzo A. 159
Carotti M. 18 Cedrone M. 96
Caletti S. 143
Carrabba M. 54, 70 Cela P. 110
Califano C. 45
Carradori E. 44 Celasco M. 169
Calindro M.C. 65
Carraro M. 21 Cerasi C. 7, 22, 71, 144
Calvaruso V. 116
Carratù P. 72 Cerbone A. M. 101
Camatta D. 11, 12
Carucci L. 70 Cerbone A.M. 101
Camellini C. 132
Carughi S. 110 Ceriani E. 12, 93
Camera S. 43
Carugo S. 171 Cernuschi G. 93
Cammà C. 12
Carulli L. 162 Cerretelli G. 44, 122
Cammarota G. 125
Caruso C. 53 Cerrito L. 60, 113, 121
Campagnaro T. 10, 57
Caruso R. 45, 116 Cerundolo N. 45, 48
Campani C. 10
Casagrande S. 78 Cervelli N. 144, 164
194
Cesari M. 46, 47 Claar E. 43 Covelli C. 27

Cesario V. 113 Clemente G. 53, 171 Craparotta I. 57
Cesaro F. 8 Cocci G. 146 Craxi A. 12, 116
Ceschia G. 78, 79 Cococcia S. 14, 41, 128 Cremon C. 123, 131
Chandarana K. 37, 38 Codella O.M. 29 Crescenti A. 109
Chantarangkul V. 116 Cogliandro R. 123, 131 Crescenti F. 109
Charbonnier E. 8 Cogliati C. 23 Crescenti R. 109
Charrier L. 168 Colangelo L. 15, 16, 37, 44, 91 Crimi N. 93, 188
Chasseur L. 8 Colica C 52 Cristaldi E. 180
Cheli P. 137 Colica C. 33 Cristiano G. 156
Chen R. 16 Colla S.M. 24 Croce G. 33, 97
Chevalley T. 15 Collina P. 105 Croce J. 49
Chiacchiarini F. 8 Colombini P. 159 Crocetti A. 160
Chianetta R. 34, 136, 163 Colombo B.M. 91 Crociani A. 166
Chiaromonte S. 82, 83 Colombo G. 72, 95, 100, 108 Crooks B. 126
Chies G. 43 Colombo M. 115, 116 Crotti G. 94
Chilà D. 105 Colombo R. 49 Crudo M. 184
Chiostri M. 18, 154 Colurcio R. 81 Cuccuru L.M. 95
Chirico A. 85 Colzi M. 160, 161 Cucinotta D. 164
Choi S.W. 10, 57 Concollato E. 79 Cucinotta F. 156
Christian B. 114 Consoli A. 35, 105, 162 Cufone S. 82
Ciammaichella M.M. 96, 103, 138, 139, Contaldi P. 101 Cugno M. 56
140, 141, 142, 143 Conte M. 105 Cumetti D. 21
Ciancio G. 47 Conte S. 18 Cuoghi C. 36
Ciancio L. 103, 138 Conti Bellocchi M.C. 123 Curione M. 37
Cianci R. 24 Conti C. 106 Currado A.C. 183
Ciani L. 45, 48 Copelli S. 135 Curti M. 128
Ciarla S. 33, 97 Coppi F. 98
Cicala G. 164 Coppola A. 101, 160
Cicala M. 186 Coppola B. 182, 183
D
Cicardi M. 49 Corazza G.R. 14, 15, 17, 42, 124, 128, 147,
Ciccarelli M. 33, 178 172, 186
D’Abbondanza M. 22
Ciccocioppo R. 14, 80, 123 Corezzi M. 106
D’Addio S. 169
Cicco G. 16 Corigliano E. 65, 104
D’Addona A. 118
Cicco S. 59, 72, 92 Corpora F. 171
Daffara F. 11, 12
Cignarelli A. 16 Corradini E. 11, 98
Daidone M. 12
Cilli M. 15, 16, 37 Corrado F. 164
Dalbeni A. 144
Cimellaro A. 38 Corrado M. 43
D’Alessio A. 156
Cimino R. 66 Corriere T. 40
Dallegri F. 80, 91
Cimmino A. 186 Corsi A. 37
Dallio M. 43
Cinetto F. 25 Cortesi L. 46
Dall’o’ F. 83, 99, 100, 102
Cintoni M. 121 Corti G. 122
Dalmaso S. 133, 134, 152
Cioffi A. 81 Coschignano M.A. 143
D’Alto M. 101
Cioffi G. 144 Coscione M. 81
Dal Zotto C. 29
Cipriani C. 15, 16, 37, 103 Cosentino E. 166
Damanti S. 107
Cipriani E. 62 Cosentino T. 54
D’Ambrosio V. 183
Cirillo M. 166 Cosi E. 31, 32, 81, 96
D’Amico R. 159, 162
Cirmena G. 58 Cossari A. 9
Dammacco F. 72
Cirrincione A. 12, 171 Cossu F. 70
Damone F. 105
Cirulli A. 72, 90 Costamagna G. 158, 159
D’Andria C. 51
Citarrella R. 34, 136, 163 Costantini E. 8
Danese E. 144
Cittadini A. 111 Costa R. 104
Danese V. 103
Ciullini G. 154 Coti Zelati G. 190
195
Danese V.C. 37 De Martinis M. 76 Di Micco P. 30, 77

D’Angelo A.R. 182 De Matteis G. 75, 153 Di Michele D. 33, 97
Dani E. 153 de Matthaeis A. 110 Di Minno G. 30, 101
Danieli G. 65, 129 Demissie M. 167 Di Minno M.N.D. 30, 189
Danieli M.G. 56, 65, 87, 129, 149, 179 De Paduanis G.A. 122 D’Incalci M. 57
D’Anna R. 164 De Paola G. 103, 140, 142 Dipaola G. 156
Dardanoni G. 127 De Pascale F. 108 Di Paolo M. 20, 56
D’Ardes D. 82 De Paulis A. 7 Di Pasquale I. 96, 100
D’Assante R. 111 De Pietri L. 29 Di Pentima C. 145, 177
D’Avanzo B. 107 Dequarti A. 80 Di Pino A. 21, 165
Davì G. 35, 82, 83, 99, 100, 102, 162 Deregibus M.C. 52 Di Pizio L. 82, 83
Davì R. 178 De Renzo A. 45 Di Pizio V. 83
D. Braghin 59 De Roberto A.M. 154 Di Placido F. 164
Deamici M. 15 D’Errico E. 111 Di Pumpo M. 105
De Angelis M. 142 D’Errico M.M. 147 Di Quattro R. 40
de Bari O. 162 De Santis D. 10, 57 Di Raimondo D. 6, 12, 53, 94, 171, 177
De Benedittis C. 165 Desantis V. 57 Di Sabatino A. 14, 17, 41, 128
De Biagi M. 100 De Santis V. 144 Di Sevo M.G. 178
De Bonis L. 43 de Simone G. 155 Di Stasio E. 94
De Cata A. 110 De Sio C. 38, 61, 102 Di Stefano M. 15, 41, 42, 124
De Cesare D. 35 De Sio I. 23 Di Stefano V. 55, 150
De Cillis E. 153 Destro M. 122, 163 Di Vasto M.A. 80
De Ciuceis C. 143 Dethlefsen C. 167 Di Vincenzo A. 79
De Cosmo S. 9, 110, 147 De Vecchi F. 114 Di Vincenzo M.G. 158
De Donato M.T. 62, 130, 152, 179, 180 De Vecchi R.M. 62, 180 Di Virgilio A. 135
De Felice A. 189, 190 De Vincentis A. 181 Docchio F. 143
De Feo G. 17, 25, 73 De Vincenzo G. 45 Dognini G.P. 122, 163
De Feo M. 7, 22, 71, 144, 164 de Vincenzo G.M. 74, 76, 118, 132 Domanico A. 23
De Fino C. 119 De Vito F. 169 Domenicali M. 43
De Gaetano A.M. 94, 113 di Bello G. 111 Donati M.C. 168
De Gioia S. 51 Di Benedetto A. 164 Donato A. 144
De Giorgi A. 101 Di Blas N. 135 Donato M.F. 63
De Giorgio R. 123 Di Bona D. 53 Donato R. 181
Degli Esposti L. 59 Di Capua M. 64, 156 Dondi G. 40
Degli Innocenti S. 106 Di Caterino M. 61 Dondossola D. 63
Del Ben M. 12, 39, 114, 161 Di Cianni G. 37 Dongiovanni P. 11
Del Bono V. 80 Di Ciaula A. 41 Donnarumma E. 90, 166
De Leo S. 184 Diella G. 126 Donnarumma G. 165
Del Giacco S.R. 74 Di Febbo C. 82, 83 D’Onofrio F. 104
D’Elia L. 108 Di Filippo F.M. 130 Dore M.P. 95
Della Corte G. 55 Di Fino L. 70 Doshi A. 105
Della Corte V. 12, 53, 171 Di Gaeta A. 182 D’Ostilio A. 76
Dell’Aera D. 124, 147, 176 Di Gennaro L. 51 Dragonieri S. 72
Dellepiane R.M. 54, 70 Di Giorgio A. 153 Dragoni G. 10
Dell’Era L. 54 Di Giosia P. 144, 184 Dreoni L. 27
Dell’Utri D. 169 Di Giuda D. 130 Drummond L. 131
Del Pinto R. 145 Di Lecce V. 72 Durando O. 168
Del Prato S. 167 Di Leo A. 42 Durante Mangoni E. 88, 121
Del Signore C. 143 Di Lernia G. 59 Durante-Mangoni E. 8
De Luca A. 36 Diliberto S.M. 34 Duranti C. 47
De Luca P. 90, 105 Di Marca S. 40 Duse M. 39
De Luna A. 43 Di Marco V. 12 Duse S. 143
Demafonti C. 37 Di Marzo L. 57
196
E Fargion S. 11, 63, 92, 98, 112, 117, 129 Foli A. 31

Farì R. 131 Folino A. 24
Farruggia E. 21 Folli C. 110, 146
Egidi G. 121 Faruggio L. 135 Fondrieschi L. 136
Einsele H. 27 Fasano D. 45 Fontana M. 18
Elena C. 15, 42 Fasola D. 98 Fonte R. 12
Elia C. 8, 114 Fatini C. 166 Formagnana P. 124, 186
Eliadou E. 126 Fatta E. 117 Fornaciari G. 113
Elia F. 48 Fava C. 144 Fornasiero A. 136, 137
Emerenziani S. 186 Favretto S. 114 Fornengo P. 33, 168
Emmi G. 19, 27, 30 Favuzzi A. 21 Forte F. 118
Erbi A. 51 Fazzi V. 160, 161 Forteleoni G.M. 73
Ermolao A. 68 Fedele D. 34 Fossali T. 49
Ernesti I. 12 Federico A. 43, 45 Fracanzani A.L. 11, 23, 63, 92, 98, 112,
Erre G. 179 Fenoglio L. 8, 9, 53, 64, 114 115, 117
Erre G.L. 21 Fenoglio L.M. 80, 89 Fragapani S. 34
Esposito G. 85, 155, 157, 158 Fenu S. 96 Fra G.P. 169
Esposito R. 7, 24, 154 Ferrando L. 58 Fraioli A. 18
Esposito Y. 182, 183, 184 Ferrara F. 98 Franceschelli P. 58
Ettorre C. 32 Ferrara, N. 46 Franceschi A. 10
Ettorre E. 132, 184 Ferrara V. 21, 165 Franceschi F. 125, 129, 158, 159
Ferrari, A. 46 Franchi, A. 65, 104
Ferrari B. 72, 95, 100, 108, 109, 187 Franchi C. 46, 60
F
Ferrari L. 112 Franchi L. 19
Ferrarini A. 18, 65, 149 Francione P. 98, 129
Fabbian F. 101 Ferrari S. 13, 123 Franco N. 101
Fabbricatore D. 178 Ferrari S.L. 15 Franek E. 167
Fabbri M. 166 Ferraro P.M. 153 Franzetti F. 23
Fabio G. 54, 70 Ferravante F. 186 Fraquelli M. 6 43
Fabris F. 31, 32, 59, 81, 96, 172 Ferri C. 7, 22, 71, 137, 144, 145, 164 Frascati A. 79
Fabrizi G.M. 123, 136 Ferrigno C. 185 Frassanito M.A 57
Fabrizio A. 133 Ferrigno L. 182 Frassanito M.A. 57
Facciorusso A. 26 Ferri S. 93, 188 Frassetti N. 183
Fadelli S. 59 Ferro C. 181 Fraticelli P. 18, 65, 84, 87, 88, 108, 149
Faggiano C. 131 Festa A 180 Fregatti P. 58
Faita F. 22 Fiammanti C. 59 Friedman D. 58
Falbo, M. 65 Figliolini F. 52 Frigo A.C. 43
Falbo T. 148, 149, 190 Filicetti E. 39 Frigo L. 80
Falcetta A. 8, 53, 89 Filigheddu F. 73, 185, 188 Friso S. 10, 57
Falconieri M. 97 Filippello A. 21 Frontoni S. 37
Falco S. 186 Finelli R. 178 Frulloni L. 80, 123
Fallai L. 47, 101, 166, 178 Finetti M. 21 Fugazza L. 112, 122
Falsetti L. 40, 47, 145 Fioranelli A. 145 Fulgido A. 187
Fanelli A. 47 Fioravanti G. 26 Fumagalli A. 29
Fanfani G. 104, 113, 146 Fiore G. 97 Funaro B. 23, 115
Fanfarillo F. 103, 143 Fiorentino T.V. 171 Fuorlo M. 21, 51
Fangazio S. 12 Fioretti M. 90, 91 Furi E. 156
Fanin A. 171 Fiorini G. 125 Fusaro M. 172
Fantaci G. 127 Firinu D. 74 Fusco L 134
Faraci B. 181 Fischetti C. 18, 65, 149
Farcomeni A. 28, 169 Flex A. 153
Florio C. 105
G
Fares R. 187
Fociani P. 128
197
Gabba M. 124, 186 Gerardi F. 160 Golato M. 35

Gabrielli A. 18, 56, 65, 84, 87, 88, 108, 129, Gerbes A. 120 Goldoni M. 19
149, 179, 180 Gerosa M. 150 Gollè G. 9, 80
Gaino S. 50 Gesualdo A. 61, 128 Gouet D. 105
Gaita F. 21 Ghiazzi J. 135 Gradini R. 160, 161
Galani A. 182, 183 Giacalone S. 180 Gragnani L. 44, 122
Galanti G. 67, 68, 105, 106, 154 Giacomobono S. 96 Granato T. 161
Galassi M. 5 Giandalia A. 164 Grandi G. 15, 42, 124
Galati G. 181 Gianese S. 25 Grange C. 52
Galderisi M. 101, 154 Giannachi V. 52 Granito A. 131
Galderisi, M. 7 Giannasi G. 156 Grappasonni G. 82, 83
Galdieri, A. 104 Giannini S. 59, 81, 172 Grassi A. 132
Galiero R. 61 Giannitrapani L. 117 Grassi D. 144, 164
Gallerani M. 41 Gianni W. 16, 37 Grasso A. 85
Galletta R. 136, 163 Gianno A. 101 Grasso O. 180
Galletti F. 108 Giannone A. 21 Grasso S. 90
Galli M. 23 Giannoni M. 145 Graungaard T. 167
Gallo A. 165 Giannotti R. 178 Graziani C. 13, 14, 125, 129, 130
Gallone G.P. 48 Gianoglio O. 62 Graziano D. 110, 147
Gallo P. 181 Giarratana F. 85 Greenway F. 165
Gallo S. 8, 127 Gibiino G. 63 Gregg B. 126
Gallucci V. 169 Gigante A. 24, 56 Grella E. 88
Galluzzo C. 45, 48 Giglio R.V. 34, 136, 163 Grembiale A. 65, 104
Gambaro G. 153 Gili M. 8, 127 Grieco A. 22, 113, 118, 119, 130
Gambassi G. 9, 75 Ginaldi L. 76 Griffini S. 56
Gangemi V. 39 Gines P. 120 Grifoni E. 106
Garcovich M. 22, 23, 63, 94, 113, 115 Giollo A. 144 Grifoni S. 47
Garlaschi A. 58 Giontella A. 144 Grillo F. 58
Garneri P. 52 Giordano M. 40 Grillo N. 148
Garruti A. 58 Giordano P. 177 Grimaldi L. 89
Garruti G. 16 Giorgino F. 16 Grimaldi L.D. 32, 74
Garufi L. 109 Giorno A. 132 Grøn R. 105
Garuti A. 58 Giovannelli C. 24 Gross J. 167
Gasbarrini A. 9, 13, 14, 22, 23, 63, 84, 94, Giovannini M.S. 159 Grosso M. 114
113, 115, 119, 121, 125, 129, 130, Giovini M. 45, 48 Grotti M. 180
153, 158, 159 Giraffa C.M. 40 Grovetti E. 56
Gasbarrini G. 13, 14, 84, 115, 121, 125, Giral P. 165 Gruden G. 34
130 Giraudo A. 8, 53, 64 Guagnano M.T. 35
Gasbarrini G.B. 22, 23, 94, 113, 134, 150, Giraudo A.V. 80 Gualerzi A. 165
159, 170 Girelli D. 29, 31, 49, 50 Guaschino G. 115
Gasperetti A. 68 Girotti S. 133 Guerci M. 41
Gasperini M.L. 24, 56 Giuffrida P. 14, 17, 41, 128 Guerra F. 149
Gatta L. 125 Giuliani M. 86, 90, 91 Guerrini C. 112, 122
Gatti D. 144 Giuliante F. 113 Guerritore L. 25, 73
Gattorno M. 21 Giulietti F. 146, 177 Guglielmi A. 10, 57
Gaudino R. 144 Giunta L. 164 Guidetti E. 63, 131
Gelardi C. 56, 87 Giunta R. 38, 102, 156 Guiducci D. 85
Gemignani V. 22 Giusti G. 93 Guiducci S. 18
Genco S. 93, 188 Giustivi D. 156 Gusson E. 168
Genovese A. 70 Gnarra M. 129 Gustot T. 120
Genovese S. 37 Gnerre, P. 46
Gentile I. 111 Gnoffo F.P. 117
Gentili T. 40, 47 Gobbi M. 99
H
198
Haahr H. 168 K Lentini N. 85

Halladin N. 105 Lenzi A. 53
Halmagy S.A. 184 Leone B. 68
Hamlin P.J. 126 Kemp K. 126 Leone P. 59, 72
Hansen A.K. 168 Kenneth C. 126 Leone S. 121, 164
Harris S. 37, 38, 167 Klim S. 167 Leoni S. 5, 43, 63
Heffler E. 93, 188 Kraus P. 27 le Roux C.W. 165
Heller S. 16, 167 Kühn M. 25 Letizia C. 182
Henchi S. 190 Kuhn-Sherlock B. 131 Leutner M. 12
Herrmann F.R. 15 Levison S. 126
Hrabal M. 148 Lia M. 58
L
Hribal M. 33 Liani 35
Hu C. 50, 55, 150 Liberatori M. 56
Laffi G. 10, 27, 44 Libertazzi A. 135
Laforgia V. 177 Licata A. 12, 116, 117
I Liebl 167
Lagioia A. 121
Laguzzi A. 24 Liguori A. 118, 119
Lai C. 184 Limdi J.K. 126
Iaccarino G. 178
Lai S. 20, 146, 182, 183, 184 Limonta S. 23
Iacoacci C. 177
Lamanuzzi A. 57 Lingvay I. 16, 37, 38
Iannello A. 52, 190
Lampertico P. 116 Liotino V. 163
Iavarone M. 43
La Mura G. 62, 152, 179, 180 Lipari P. 187
Idolazzi L. 144
La Mura L. 62, 152, 179, 180 Lip G.Y. 151
Iervolino S. 189, 190
La Mura V. 115, 116 Lip G.Y.H. 137
Iezzi R. 113
Lancellotti G. 40 Lippi G. 50
Imazio M. 21
Landi F. 130 Lisco G. 16
Impagnatiello M. 9
Landi L. 146 Liu E. 126
Indovina F.S. 117
Landolfi R. 9, 21, 51 Li Volti G. 34
Inghilesi A.L. 10
Langer J. 37 Lobasso A. 7
Inglese M. 110
Lanzini L. 159 Loddo S. 19, 105, 164
Ingletto C. 67, 106
Lapolla A. 37 Loffredo L. 23, 39, 161
Ingravalle F. 130
Lasco A. 19, 47, 65, 105, 164, 181 Lo Iudice F. 154
Ingravallo G. 186
Lastella P. 42, 45, 121, 153 Lombardi F.E. 177
Innico G. 182, 183
Lastoria G. 16, 37, 38, 105 Lombardi R. 63, 98, 112, 117
Intravaia S. 180
Laterza L. 13 Lombardo C. 14
Invernizzi C. 23
Lattanzio F. 156 Longo S. 72
Iodice G. 92
Lattanzio R. 168 Lopetuso L. 84
Iorio R. 146
Laurelli G. 25 Lopetuso L.R. 13, 14, 125, 130
Irace C. 167, 168
Lauretani F. 45, 48 Lorini M. 21, 56
Isnaldi E. 58
Laviano A. 169 Lorini S. 44, 122
Iuculano F. 92, 98
Laviola L. 16 Lorini V. 135
Lazaros G. 21 Lorusso M.P. 126
J Leardi M.G. 160 Losa F. 74
Leccardi S. 53, 64, 89 Lovaste S. 54
Ledda D. 73, 188 Lovati E. 172
Jaeckel E. 37, 38 L. Rose 167
Leeuwen M.V. 167
Jaekel E. 16 Lucchetta M.C. 6, 178
Legramante J. M. 158
Jain R. 166 Lucchetti D. 13
Lehmann L. 16
Jarlov H. 16 Lucchiari M. 34
Lembo T. 23
Jodar E. 37, 38, 105 Luchinat C. 122
Lenato G.M. 42, 45, 121, 153
Johnston A. 126 Luciano F. 154
Lenti M. 124
Lenti M.V. 14, 128 Lucini D. 67, 69
Lucotti P. 172
199
Lucreziotti S. 171 Mangani I. 156 Martino M. 128

Lugari S. 120 Mangiacotti A. 147 Martone A. 130
Luglio C.V. 74, 76, 118, 132 Mangieri E. 53 Marturana S. 180
Luinetti L. 128 Mangiulli M. 20, 146, 182, 183, 184 Marzano M.A. 103, 139
Luiso V. 85 Manini M. 63 Marzan S. 133
Lunardi S. 166 Manna R. 60, 107, 169 Marzetti E. 130
Lunghi B. 31, 49, 50 Mannina C. 34, 136, 163 Masala M.S. 6, 179
Lupascu A. 115 Manno V. 85 Masarone M. 43, 45, 116
Lupattelli G. 54 Mannucci P.M. 46, 60, 107, 151 Mascherini G. 105, 106
Lupidi F. 65 Mantero M. 190 Masotti M. 124, 186
Lupoli R. 189 Mantovani A. 144 Massari A. 178
Marano 42 Massarini G. 135
Marasco, F. 65 Massa V. 147
M Marcacci M. 29, 32, 36 Massironi L. 171
Marchese N. 147 Mastracci L. 58
Marchesi E. 124 Mastrofilippo T. 70
Macaione F. 117
Marchesini G. 12 Mastroluca D. 20, 182, 183, 184
Maccarone M. 35
Marchetti A. 47 Mastropasqua M. 158
Macedoni T. 129
Marchetti I. 69 Mastropierro V. 186
Maceli F. 36
Marchi G. 29 Mathieu C. 166, 167
Maceratini E. 77, 78
Marchini S. 36, 57 Mattei G. 13
Maestripieri V. 18, 101, 166, 178
Marchione L. 82, 83 Mattioli M. 84, 88, 108, 149, 180
Maestroni S. 21
Marchisello S. 118 Mattiuzzo E. 135
Maffei P. 79
Marchitto N. 133, 134, 152, 185 Matucci-Cerinic M. 18
Maffeis C. 144
Marcolongo R. 21 Matula I. 178
Maggiolo S. 50
Marengoni A. 60 Mauro, G.F. 65, 104
Maggio M. 45, 48
Margiotta D.P. 55, 71 Mauti M. 133
Magliozzo F. 12
Mariani F. 13 Mazzeo P. 178
Magurno M. 52, 148
Marietta M. 29 Mazzi F. 10, 57
Maida C. 12, 53, 171
Marigliano B. 84 Mazziotti M.A. 158
Maida R. 96, 103, 138, 139, 140, 141, 142,
Marinelli P. 56 Mazzocchitti A.M 161
143
Marinelli T. 105 Mazzocchitti A.M. 160
Mai F. 164
Maringhini A. 126, 127 Mazzoccoli C. 186
Maimone S. 112
Maringhini M. 126, 127 Mazzola A. 126
Maira D. 50, 55, 150
Marino P.N. 114 Mazzuca S. 66
Malacarne M. 67, 69
Marinucci C. 8, 127 McGowan B. 165
Malandrino D. 75, 104
Mariotti A. 146, 183 Mecarelli O. 183
Malatesta M. 158
Marone G. 7, 70 Meduri G. 187
Malatino L. 40
Marongiu F. 74 Melchio R. 8, 9, 53, 64
Mana F. 9
Marra A.M. 111 Mele M.C. 121, 130
Manai R. 103
Marracino M. 62, 180 Melfitano A. 105
Manca R. 128
Marra F. 10, 27 Menditto V. 47
Mancarella M. 50
Marra L. 72 Meneghetti O. 47, 159
Mancini S. 13
Marrone G. 118, 119 Meneghini L. 166
Mancusi C. 155
Marseglia G.L. 15 Menghini D. 56, 129, 179
Mancuso G. 12
Martelli O. 142 Mengozzi G. 34
Mancuso M. 166, 167, 168
Martignoni, A. 176 Menichelli D. 28
Mandoli M. 67, 106
Martina S. 50 Mennuni G. 18
Mandraffino G. 47
Martinelli N. 31, 49, 50 Mentella M.C. 130
Manetti R. 73, 185, 188
Martini A. 21 Meoni G. 122
Manfredi G.F. 15, 42, 124
Martini F. 75 Merante S. 15, 42
Manfredi L. 133, 149
Martino G. 65 Merati G. 147
Manfredini R. 101
Martino G.P. 77, 78, 133 Mercalli F. 135
200
Merceri A. 99 Monaco A. 145 Nappi L. 7

Merighi A. 13 Mondati E.G.M. 134, 150, 159, 170 Nardacci M. 92
Merlini G. 31 Monreal M. 30 Nardella E. 75, 169
Merlino G. 12 Montagna M.T. 126 Nardo A. 101
Merlo S. 33, 168 Montagnana M. 144 Nargiso M. 105
Merlotti E. 169 Montaldo L. 157 Naty S. 135
Mersini X. 72 Montalto A. 117 Nazerian P. 47
Meschi T. 45, 48 Montalto G. 34, 117, 136, 163 Negrini G. 131
Mesin L. 24 Montano M. 93 Neri R. 25
Messere A. 24 Montano N. 48, 167, 190 Nesci A. 153
Mezzacappa S. 55, 71 Montecucco F. 80 Neunhaeuserer D. 68
Miceli E. 14, 124, 128 Monti A. 190 Nevens F. 120
Miceli G. 6, 94, 171, 177 Monti M. 36, 44, 122 Nico B. 57
Miceli S. 36, 38, 44, 52, 91, 135, 148, 149, Montoli A. 180 Nicolazzi M.A. 21, 51
170, 190 Montuori M. 23 Nicolini A. 116
Michielin A. 59, 172 Monzani V. 110, 146 Nieddu L. 103
Mida R. 138 Morabito N. 19, 65, 105, 164 Nikolic D. 34, 136, 163
Miele L. 113, 119 Mordenti M. 20 Nitti C. 40, 47
Miggiano A. 130 Morea A. 124 Nobili A. 46, 60, 107, 151
Miggiano G.A.D. 121 Moreo G. 98 Nobili L. 40, 47
Migliorati P. 159 Moreschini O. 37 Nocchi S. 18
Migneco A. 129 Mores N. 119 Nocella C. 28
Migone De Amicis M. 150 Moretti V. 50 Nocera, M. 104
Migone M. 50 Moriconi V. 133 Nociti V. 119
Milani P. 31 Mori G. 45, 48 Noia A. 64
Milano E. 51 Morisco F. 43 Noja M. 158
Milazzo M. 120 Morlacchi L.C. 190 Nouvenne A. 45, 48
Milia A. 75 Morovic-Vergles J. 70 Novembrino C. 98
Millarelli F. 161 Morra Di Cella S. 8, 127 Noviello M. 61, 89, 128
Millarelli F.R. 160, 161 Moruzzi S. 10, 57 Noviello S. 72
Minerva F. 32, 61, 62, 66, 74, 89, 104, 111, Moscardelli S. 144 Novo G. 117
128, 162, 186, 187 Mosillo P. 169 Novo M. 39, 114, 161
Minetti E. 67, 106 Mosoni C. 84, 130 Novo S. 117
Minguzzi D. 31 Mugellini A. 147 Nucera E. 55, 71
Minisini R. 11, 12, 115 Mulas V. 11 Nuglio. C. 186
Minisola S. 15, 16, 37, 103 Murabito A.R. 185 Nuzzetti M. 32
Minissale M.G. 116, 117 Mura S. 179 Nuzzo M. 66, 111
Minoja G. 122 Murialdo R. 58
Minonzio F. 50, 55, 150 Murri M. 84
Minuz P. 80, 136, 144 Muscaritoli M. 17, 24, 36, 56, 169, 184,
O
Mirabella M. 119 186
Mirijello A. 9, 110, 130, 147 Musiari G. 6, 94, 177
Oberti G. 63
Mobilia P. 152, 185 Mussi C. 40, 162
Occasi F. 39
Modesti P.A. 46, 154 Mussinelli R. 31
Occhiuto M. 103
Modola G. 105 Musumeci M. 132
Oggionni G. 67, 69
Moia M. 115
Ognibene A. 47
Molfino A. 17, 36, 146, 169, 182, 183, 184,
186
N Ognimbeni F. 144
Ojetti V. 129, 158, 159
Molinaro F. 110
Oleandri S. 168
Molino P. 64
Nanni V. 156 Olivari D. 149
Molisso A. 108, 161
Napoli L. 63 Oliva V. 163
Mollica M. 88
Napoli N 76 Olivieri O. 10, 31, 49, 50, 57
Momo E. 169
Napoli N. 74, 118, 132 Omenetto E. 96
201
Omiciuolo C. 78 Pasini S.M. 112 Petitto M. 154

Onorato P. 158 Pasin M. 101 Petraccia L. 44
Oppedisano I. 21 Pasquero P. 24 Petramala L. 182
Opri R. 123 Passarelli P.C. 118 Petrarca M. 33, 97
Orlandi M. 63 Passaro G. 9 Petraroli A. 70
Orsolini G. 144 Passerini F. 32, 74, 111 Petrecca I. 96, 103
Østerskov A.B. 167 Pastori D. 12, 28, 114 Petri C. 105, 106
Oviedo A. 105 Patisso I. 60, 107 Petrilli C. 158
Patti A. 68, 163 Petruzziello C. 129, 158, 159
Patti A.M. 34, 136, 163 Petta S. 12
P Pattini P. 10, 49, 57 Pettinari P. 84
Patti R. 126, 127 Peyvandi F. 72, 95, 98, 100, 108, 109, 116,
Pecora C. 19 187
Padula D. 14, 124, 128
Pecoraro R. 12, 171 Philis-Tsimikas A. 166, 167
Pafundi P.C. 8, 102
Pecoraro R. . 53 Piano S. 43, 120
Pagani E. 15, 42
Pedace E. 39, 170, 171 Piatti G. 80
Pagani M. 67, 69
Pedini V. 56, 87, 129, 179 Piatti P. 37, 167
Pagano I. 131
Pedone Anchora L. 169 Piazzolla G. 163
Paglia S. 64, 156
Pedone C. 181 Picardi A. 181
Pagnozzi G. 48
Pedri S. 67 Picca P. 168
Paladino F. 155
Pedrizzetti G. 67 Piccillo G.A. 134, 150, 159, 170
Pala M. 41
Peli L. 162 Piconi S. 108, 110
Palange P. 20, 56
Pellegrini E. 120, 162 Pieber T. 167
Palladini G. 31
Pellegrini F. 145 Pieber T.R. 167, 168
Palma A. 97
Pelusi S. 11, 98, 117 Pieramati L. 82, 83
Palmerini D. 106
Peluso R. 30 Piersantelli M.N. 40, 47
Palmieri P. 155
Pepe J. 15, 16, 37, 103 Pietrangelo A. 11, 29, 32, 36, 88, 98
Palmieri V.O. 23, 32, 61, 62, 66, 74, 89,
Pepe R. 83 Pietrantonio F. 47, 134, 159, 160
104, 111, 128, 187
Pepe V. 79 Pietrapertosa A. 97
Palterer B. 27
Perbellini L. 10 Pietrogrande M.C. 54, 70
Paluani F. 136
Perilli R. 168 Pietropaoli D. 145
Panebianco V. 182
Perina L. 29 Pignata D. 103
Panelli S. 14
Perini P. 159 Pignatelli P. 28
Panero A. 34
Periti G. 92, 129 Pileri F. 32
Panizon E. 170
Perlini S. 31, 160, 176 Pileri P. 143
Pannone G. 111
Perna L. 108 Piletič M. 167
Paolillo C. 46, 85, 157
Perotti A. 49 Pilutti C. 43
Paolini P. 135
Perotti G. 130 Pinach S. 34
Papa A. 39
Perri L. 39, 161 Pina G. 98
Papaleo F. 64
Perri V. 158, 159 Pini P. 23
Papi F. 22
Perrone A. 118, 186 Pinna C. 6
Pappone N. 189, 190
Perrone, G. 65 Pinna M. 6, 179
Paratore M. 118
Perrone T. 23, 147 Pinotti E. 61
Parente R. 17, 25, 73
Perrotta A. 146, 182, 184 Pintaudi B. 164
Parise M. 135
Persico M. 43, 45, 116 Pintaudi C. 66
Parisi D. 33, 97
Perticone F. 33, 36, 38, 39, 44, 46, 52, 85, Pinto A. 6, 12, 33, 38, 52, 53, 94, 148, 171,
Parisi F. 21
91, 135, 148, 149, 167, 170, 190 177
Parrella A. 121
Perticone M. 33, 36, 38, 39, 44, 52, 85, 91, Pintus G. 182, 183, 184
Parrinello G. 23
135, 148, 149, 190 Piombo M. 124, 147
Parrino S. 78, 79
Pesatori E.V. 15, 42, 124 Piombo, M. 176
Parronchi P. 75
Pes C. 95 Pirillo S. 96
Pascale A.V. 178
Pes G.M. 95 Pirisi M. 11, 12, 26, 114, 115, 165, 169
Pasinetti S. 143
Petito V. 13, 14, 125, 130 Piro S. 21, 165
202
Pirro L. 102 Principi M.B. 42 Rapi S. 47

Pisani A. 42 Priori F. 18 Rapisarda V. 21
Pisani A.M. 65 Prisco D. 19, 30 Raskin P. 167
Pisano G. 63 Privitera G. 118 Raviolo A. 127
Pisano M. 40 Probert C. 126 Re A. 11
Pisati M. 124, 128 Procopio G. 33 Reale S. 185
Piscaglia F. 23, 43, 63 Proietti I. 164 Recchiuti A 35
Piscitelli P. 147 Proietti M. 53, 137, 151 Regina D. 135
Piscopo M. 5 Properzi G. 22 Remo M. 89
Pi-Sunyer X. 165 Protopapa P. 182, 184 Rendina D. 161
Pitocco D. 169 Provenzano V. 37 Renis M. 62, 130, 152, 179, 180
Pitrone C. 112 Provinciali L. 145 Renzetti D. 177
Pizarro T.T. 14 Pucci G. 22, 86, 90, 91, 160 Resta N. 42
Pizzi A. 105 Pugliese S. 32, 61, 62, 66, 74, 89, 104, 111, Resta O. 72, 163
Pizzi M. 81 128, 187 Ria R. 59, 92
Pizzi R. 171 Puglisi L. 103, 140 Riccardi A. 85, 155, 157
Pizzoferrato M. 121, 130 Pujatti P.L. 136 Riccardi L. 22, 23, 43, 63, 94, 113, 115
Pizzolo F. 49 Pulitano P. 183 Ricciardi C.A. 181
Platania R. 21 Pulvirenti A. 40 Ricciardi E. 91, 101
Platania S. 180 Purrazzo G. 21, 85 Ricci C. 125
Plebani M. 5, 151 Purrello F. 21, 85, 118, 165 Riccioni M.E. 119
Plebani, M. 172 Putignano A. 56 Ricci P. 62
Poggesi L. 75, 90, 101, 104, 113, 146, 173, Ricci S. 160
178 Ricevuti G. 135
Poli G. 50
Q Ricevuti, G. 46
Polimeni L. 12, 114, 161 Rigamonti C. 115
Polimeno M. 101 Righi I. 190
Quadarella A. 115
Politi A. 159 Rigo L. 23
Quirino A. 35
Politi F. 127 Rimini A. 21
Politti U. 41 Rinaldi A.M.P. 82, 83
Pomero F. 9, 53, 80 R Rinaldi G. 53, 64
Pompili M. 22, 23, 43, 63, 94, 113, 115, 121 Rinaldi G.L. 8
Pomponio G. 18, 88, 149 Rinninella E. 113, 121
Pontiggia S 95 Rabuazzo A.M. 21, 165 Risicato R. 180
Pontillo G. 38, 102 Racanelli V. 59, 72 Rispoli P. 52
Pontiroli A.E. 171 Racco S. 119 Riva R. 29, 98
Ponzani P. 37 Ragone E. 8, 121 Rizzardini G. 23
Ponz de Leon M. 120 Ragosa N. 178 Rizzatti G. 130
Ponziani F. 23, 84, 94, 113 Ragusa A. 93 Rizzi L. 153
Ponziani F.R. 113, 115, 121 Raimondi G. 133, 134, 152, 185 Rizzi M. 29
Porretti L. 124 Raimondi S. 144 Rizzi S. 42
Porretti, L. 176 Raimondo G. 112 Rizzoli G. 123
Porta M. 24, 28, 33, 127, 168 Rainone M. 160 Rizzoli R. 15
Portincasa P. 32, 41, 58, 61, 62, 66, 74, 89, Ramaccini C. 36 Rizzo M. 34, 136, 163
104, 111, 126, 128, 162, 187 Ramaroli D. 144 Rizzoni D. 143
Porzio M. 63 Rametta R. 11 Roatta S. 24
Poscia A. 130 Randi M.L. 31, 32, 81, 96 Roberto Corazza G. 41
Pozzi D. 157 Rando A. 40 Rochira V. 98
Precone D.F. 43 Rando M.M. 130 Rodbard H. 105
Prete M. 90 Ranghino A. 52 Rodbard H.W. 167
Pretolani S. 24 Ranieri G. 72 Rokka A. 58
Pricoco G. 157 Rapaccini G.L. 22, 94, 113, 119 Rokkas A. 58
Primignani M. 115, 116 Raparelli V. 53 Rokkas T. 41
203
Rollone M. 135 Sadalla S. 44 Scarpignato C. 125

Romairone E. 58 Saggiorato G. 100 Scarpino P. 39
Romanelli G. 65, 84 Sainaghi P.P. 26 Schiavino D. 55, 71
Romanelli R.G. 27 Saitta R. 134, 150, 159, 170 Schiavone M. 109
Romanello R. 183 Salaffi F. 18 Schiepatti A. 14
Romano A. 43, 120 Sala R. 67, 69 Schilardi A. 64
Romano C.P. 156 Salerno F. 116 Schillaci G. 22
Romeo A. 180 Salmi L. 11 Schimmenti C. 94
Romeo N. 64 Salomone P. 114 Schmidt 120
Romiti G.F. 53 Saltarella I. 57, 59 Sciacqua A. 33, 36, 38, 39, 44, 52, 91, 148,
Roncucci L. 13 Salvatore T. 61, 102 149, 170, 190
Ronsisvalle M.L. 40 Salvatori M. 50 Sciancalepore D. 74, 76, 118, 132
Rosato E. 24, 56 Salvi A. 40, 47 Sciangula L. 37
Rosato V. 43 Salzano A. 111 Scicali R. 21, 165
Rosenbaum D. 165 Sampietro G.M. 128 Scoccianti L. 168
Rosettani G. 177 Sanesi L. 22, 86, 90, 91 Scopelliti F. 98
Rossello M. 126 Sangineto M. 118 Scordo A. 187
Rossetti V. 190 Sangiovanni A. 43 Scotti E. 47, 134, 160
Rossetto V. 50 Sanguedolce F. 26 Scuto S. 185
Rossi Fanelli F. 17, 36, 169, 184, 186 Sansoni G. 143 Selinger C.P. 126
Rossi F.W. 7 Santangelo G. 53 Sella S. 59, 172
Rossi G.M. 19 Santaniello A. 72 Selleri C. 45
Rossini A. 169 Santarossa C. 31, 32, 81, 96 Semeraro F. 143
Rossini C. 143 Santilli F. 35, 82, 83, 99, 100, 102, 162 Semeraro F.P. 121
Rossini M. 144 Santini E. 103 Sena P. 13
Rossio R. 72, 95, 100, 108, 187 Santoliquido A. 153 Serafino S. 48
Rossi S. 43 Santonati A. 103 Serio A. 18
Rovellini A. 110, 146 Santoro D. 181 Serra C. 73, 185, 188
Rucco M. 40 Santoro L. 153 Serraino C. 8, 9, 53, 64, 89, 114
Ruckdeschel A. 27 Santulli S. 28 Serricchio M.L. 119
Ruggieri M.P. 84 Sapienza E. 29 Serruto A. 117
Ruggieri, M.P. 46 Saracino A. 121 Servello A. 132
Ruocco A.L. 64, 156 Saracino M.I. 125 Serviddio G. 26, 111
Ruperto N. 21 Sardella F. 59 Sesti G. 16, 33, 36, 38, 39, 44, 52, 135, 148,
Ruscio E. 53 Sardo L. 56 149, 170, 171, 190
Russell-Jones D. 167 Sardo V.A. 136, 163 Sestito L. 130
Russo A. 147 Sartori M. 122 Settimo E. 104
Russo F. 31 Sartori M.T. 100 Settino C. 39
Russo G. 37 Sarzani R. 146, 177 Sforza A. 155
Russo G.E. 182 Sasso F.C. 102 Sgambato A. 13
Russo G.T. 164 Saviano A. 113 Sgariglia R. 86, 90, 91, 160
Russo V. 99 Savore I. 65, 87 Sgreccia S. 184
Ruzzenente A. 10, 57 Sbrojavacca R. 85, 155, 157, 158 Sguazzotti M. 11, 12
Scabini S. 58 Shapiro Manning L. 165
Scaccianoce G. 41 Sibilio M. 161
S Scaldaferri F. 13, 14, 94, 125, 130 Sicignano L.L. 60, 107
Scalera A. 30 Siciliano M. 22, 23, 63, 94, 113, 115
Scalise L. 91 Siclari, D. 104
Sabbà C. 42, 45, 64, 70, 74, 76, 97, 107,
Scannone D. 14 Siepi D. 54
118, 121, 132, 153, 163, 186
Scardapane A. 42, 45 Silvestri A. 8, 53, 89
Sabetta F. 62
Scarlini S. 29, 88 Silvestri E. 19, 27, 30
Sacco R.M. 48
Scarone S. 171 Silvestrini M. 145
Sach-Friedl S. 168
Scarpa R. 25 Simeone P. 35, 162
204
Simioni N. 37, 166 Stanghellini V. 123, 131 Tesei G. 18

Simioni P. 50 Stansfield C. 126 Tesori V. 129
Simone A. 44 Stasi C. 62, 187 Testa A. 23
Simonetta I. 53, 171 Stefani L. 67, 106 Testa E. 53, 64, 89
Sinatti D. 129, 158, 159 Stefanoni F. 31, 49, 50 Thomsen K.M.D. 168
Sindona F. 133, 134, 152, 185 Steffanina A. 20 Ticinesi A. 45, 48
Singh S. 126 Steidl C. 44 Tilocca G. 160
Siriani F. 39 Stellitano A. 187 Tixi L. 58
Sirufo M.M. 76 Stellitano E. 187 Tobaldini E. 48, 190
Sitajolo K. 112 Storey D. 126 Tomaiuolo M. 47
Sivolella S. 100 Storino A. 189, 190 Tommasino C. 46
Smith P. 126 Strada S. 26 Tonani M. 124
Sobiati M. 93 Stranges V. 185 Toncelli L. 68, 154
Soddu D. 115 Strazzullo P. 108, 161 Tonoli L. 47
Sofia L. 85 Striuli R. 33, 97 Tonolo G. 167
Sogari F. 51 Stronati G. 149 Tonon M. 43
Solà E. 120 Struglia M. 184 Topa G. 85
Sola M. 78, 79 Suardi M.G. 122 Torgano G. 48
Solaro E. 38, 102 Subramanian S. 126 Toriello F. 53
Soldati F. 159 Succurro E. 39, 170, 171 Torre C. 15
Soldato M. 169 Suppa M. 160, 161 Torri M. 90, 101, 104, 113, 146, 178
Solimando A. 59, 92 Suppressa P. 42, 45, 107, 118, 121, 153 Tortora A. 23, 113
Solimando A.G. 27, 90 Suraci E. 33, 44, 91 Tortorella C. 163
Sonato C. 16, 37 Susi B. 158 Torzillo D. 23
Soresi M. 117 Sutic A. 70 Tosetti G. 115, 116
Sorli C. 37 Tosi B. 67, 68, 106, 154
Sormani M.P. 21 Tosi F. 31, 49, 50
Sorrentino R. 93, 188
T Tosoni A. 9
Sorrentino, R. 7 Tovoli F. 5, 131
Spada A. 103 Tozzetti C. 75, 90, 101, 104, 113, 146, 173,
Tafuri F. 109
Spadafora L. 8 178
Tagetti A. 144
Spadaro G. 70 Tozzi G. 114
Tagliafico E. 11
Spadaro L. 85, 118 Trabucchi M. 46
Tamagni M.E. 171
Spagnoli A. 184 Tramontano A. 36, 44
Tamborra R. 111
Spampinato M.D. 101 Tran Minh M. 11, 12, 115, 165
Tammen S. 57
Spannella F. 146, 177 Trapletti V. 143
Tamorri S. 67, 69
Sparabombe S. 56 Traversa M. 48
Tanzilli G. 53
Spataro A. 67, 69 Traversa M.A. 28
Tapparo M. 52
Specchia F. 70 Trebicka J. 120
Tarli C. 119, 130
Specchia G. 97 Trento M. 33, 168
Tarquinio N. 145
Sperduti N. 53 Tricarico L. 9
Tarsia P. 190
Spiezia L. 50 Triggiani M. 17, 25, 73
Tartaro A. 35, 162
Spiezia S. 38, 102 Trillo M.L.A. 186
Tarzia I. 187
Spina R. 126 Trimarco B. 154
Tattersall S. 126
Spinazzè A. 79 Tringali A. 158, 159
Taurisano S. 185
Spinelli 113 Triolo M. 116
Tedeschi A. 56
Spreafico S.M. 112, 129 Tripaldi R. 35
Tempesti G. 106
Squadrito G. 112 Tripepi G. 38
Tenedini E. 11
Squatrito R. 53 Tripodi A. 115, 116
Tenori L. 122
Stabile M. 60, 107 Troelsen L. 167
Tentolouris N. 105
Stamerra C.A. 7, 22, 71, 144, 164 Trotta L. 56
Terranova V. 40
Stancanelli B. 40 Trulli F. 62
Terzi E. 5, 43
Stanco M. 43 Tubani L. 56
205
Tufano A. 7, 30, 101, 154 Vendemiale G. 26, 110, 111, 147 Willert R. 126
Turilli D. 6 Venerito M. 41 Wilson S.R. 43
Turrin M. 5, 151 Venetucci P. 108 Woodhams B. 31, 49, 50
Tutkunkardas M.D. 166 Ventura G. 9 Wu M.A. 49
Tuttolomondo A. 6, 12, 53, 94, 171, 177 Ventura P. 29, 36, 88, 98
Tuzzi R. 161 Venturini L. 135
Veronese L. 43
X
Verrecchia E. 60, 107
U Vertolli P. 7, 22, 71, 144
Xheka A. 44
Vespasiani-Gentilucci U. 181
Vesprini E. 160
Udali S. 10, 31, 57
Ulissi A. 103, 138, 139, 140, 141, 142
Vettore E. 43 Z
Vettore G. 50
Ungaro P. 33
Vettor R. 79, 165
Urban M.L. 19 Zabara A. 117
Viale P. 43
Urbano F. 21 Zaccaria M. 68
Viapiana O. 144
Ursi M.P. 8, 121 Zaccone V. 9, 40, 47
Vidili G. 6, 23, 179
Vidili G.P. 95 Zafonte R. 12
V Viglianesi A. 118 Zambonardi F. 143
Vigna C. 147 Zampino R. 8, 121
Vigna E. 37 Zanghieri G. 19
Vacca A. 27, 57, 59, 72, 90, 92 Vigolo S. 50 Zani M.D. 45, 48
Vacca C. 54 Villa A.M. 59 Zaninotto M. 5, 151, 172
Vaccari D. 36, 88 Villani R. 26 Zannoni S. 63
Vadalà D. 112 Villani T. 20 Zanoli L. 185
Vadini F. 162 Villois P. 28, 48 Zanoni G. 123
Vaglio A. 19 Vincentelli G.M. 141 Zarabla A. 183
Vagnarelli S. 141, 142 Vincenzo Lenti M. 41 Zardo F. 127
Vaira D. 125 Vinci P.A. 170 Zecca B. 48
Valabrega E. 122 Violi F 114 Zega G. 133
Valenti A. 21, 73, 185, 188 Violi F. 12, 28, 39, 161 Zicari A.M. 39
Valenti L. 98, 117 Virgili 168 Zignego A.L. 44, 122
Valenti L.V. 11 Visani N. 133, 152, 185 Ziliotto N. 31
Valeriani E. 82 Viscido A. 144 Zimatore S. 111
Valerio R. 45 Viscogliosi G. 62 Zingaro M.T. 74, 76, 118, 132
Valli G. 84 Visco V. 178 Zinman B. 166, 167
Vallone A. 82 Visino F. 57 Zito R. 149
Vallone C.V. 9 Visioli G. 53 Zocco M.A. 22, 23, 43, 63, 94, 113, 115
Vallone G. 82 Vitale A.R. 34 Zoli A. 84
Valsecchi C. 116 Viticchi G. 145 Zoppi F. 145
Valvo B. 172 Vitiello G. 27, 75 Zoppoli G. 58
Van Gaal L. 165 Vitrone M. 8, 88, 121 Zuliani L. 18, 65, 149
Vanni S. 47 Vitucci A. 97 Zullo A. 4 41
Vanoli A. 41, 128 Vizza P. 39
Varriale A. 110 Vizzutti F. 27
Vassallo G.A. 130 Volpe M. 119
Vaudo G. 54 Vono M.C.R. 154
Veca V. 54 Vulpi M. 163
Vecchio F.M. 113
Vegetti A. 88, 98
Vella F.S. 70, 74, 107 W
Veltri P. 39
Venafro M. 61
206
Segreteria Scientifica
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VOLUME

INDICE AUTORI 192

LACTATE DEHYDROGENASE HEREDITARY DEFICIENCY:

Turrin M.1, Zaninotto M., Altinier S., Plebani M.

Introduction: In the ORPHANET list of rare diseases, glicogen store disease

Methods: This is a retrospective study on prospectively collected data mortality.

Tuttolomondo A. 1, Petta S. 2, Casuccio A. 3, Maida C. 1,

A 38-year-old woman, with a history of to recurrent respiratory infections,

RESISTANT HYPERTENSION AND OBSTRUCTIVE SLEEP

Lai S. ,Mordenti M. 1, Mangiulli M. 2, Villani T. 1, Arcieri E. 1, Steffanina A. 1,

Introduction: Resistant hypertension is a clinical condition characterized

EFFECT OF ANAKINRA ON RECURRENT PERICARDITIS

Introduction: The validity of lung ultrasound (LUS) in the diagnosis of

PCSK9, PLATELET ACTIVATION AND

Pastori D. 1, Nocella C. 1,2, Farcomeni A. 3, Santulli S. 4,

Specialties, Sapienza University of Rome. (2) Department of Medical-Surgical

Background: Patients with atrial fibrillation (AF) display enhanced plate-

Figure 1. CCA-IMT, Bulb-IMT and carotid plaques in APP carriers and in

OUTCOME DURING ANTICOAGULATION IN PATIENTS

SUBCLINICAL ATHEROSCLEROSIS IN ASYMPTOMATIC Tufano A. 1, Ageno W. 2, Di Micco P. 3, Monreal M. 4

HFEH63D 23% 17 (30.4%) 13 (39%)

High ferritin levels in

Metabolic syndrome +Diabetes 7.56 (5.84-9.78)

NT-PRO-BNP IN INSULIN-RESISTANCE MEDIATED P for trend <0.0001

Background: Low-grade inflammation has a key role in the pathogenesis of

SEVERE PULMONARY INVOLVEMENT OF SMAD4-

Lastella P. 1, Lenato G.M. 1, Suppressa P. 1, Resta N. 2, Bagnulo R. 2, Rizzi S. 3,

A FRAILTY INDEX IN HOSPITALIZED OLDER PEOPLE: A

Background: In the implementation of Lombardy socio-health care reform

Nucera E. 1, Basta F. 2, Buonomo A. 1, Mezzacappa S. 1, Margiotta D.P. 2,

PVA is an incidental finding, while approximately 50% of patients present

FUO. WHEN THE SOLUTION COMES FROM THE CLINIC

(CRP: 175mg/mL; ESR: 62mm/h). Empirical antibiotic therapy was started

EXERCISE AS PRESCRIPTION IN RENAL TRANSPLANT

HEART RATE VARIABILITY IN ATHLETES:

Oggionni G. 1, Marchetti I. 1, Spataro A. 3, Malacarne M. 1,2,

Background: The Autonomic Nervous System (ANS) plays an essential role

POSTER G. 2, Spadaro G. 1,2, Genovese A. 1,2

a gradual prednisone discontinuation. One month after Omalizumab with- 1

A 60-year-old woman was admitted to Internal Medicine for left inguinal

Di Pizio L. 1, Carbone A.M. 1, Grappasonni G. 1, Di Pizio V. 2,

39. DISSEMINATED INTRAVASCULAR COAGULATION 40. BREAKING THE STEROID WALL

De Luca P. 1, Solimando A.G. 1, Cirulli A. 1, Grasso S. 2, Bruno F. 2, Vacca A.

63. ECHOGRAPHIC ASSESSMENT OF DIAPHRAGM AND

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is cha-

64. DIAGNOSTIC ACCURACY OF TRANSTHORACIC

APTT ratio 2.36 (0.86 - 1.20)

85. A RARE CAUSE OF ABDOMINAL PAIN 87. CYTOMEGALOVIRUS-ASSOCIATED SPLANCHNIC

92. PRIMITIVE HYPERPARATHYROIDISM: CASE REPORT

100. BODY COMPOSITION OF ITALIAN SOCCER

106. FOCUS ON THERAPY OF ADULT PFAPA SYNDROME:

Sicignano L.L., Patisso I., Stabile M., Verrecchia E., Manna R.

Introduction: Periodic Fever, Aphtas, Pharyngitis and cervical Adenopa-

114. A CASE OF FEVER OF UNKNOWN ORIGIN: WHEN

121. TIME DEPENDENT EFFECT OF PROGNOSTIC

131. ANALYSIS OF A PROSPECTIVE COHORT OF

Biolato M. 1, Nociti V. 2, Marrone G. 1, Liguori A. 1, De Fino C. 2, Bianco A. 2,

148. A MAJOR PRESENTATION ENTEROPATHY

A 65-years-old male was admitted on March 2015 in the Internal Medi-