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
27 OTTOBRE 2017
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°
284435: prevalence is unknown and appears in adulthood (1).The deficit is
caused by mutations of the LDHB gene (MIM *locus 150100) located in the
12p12.1 chromosome (phenotype n° 614.128). The rare cases described in
Literature relate only to a few Japanese families: an emolysis was only descri-
bed in some of the forms with complete deficiency in homozygous, while a
partial heterozygous deficit was not associated with any pathology unless
the failure LDH increase in conditions where a typical elevation should
appear. So far, eight Japanese genetic variants have been identified (2).
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-
med subsequently in response to k. breast, we extended the determination
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:
4 living brothers (+ 4 died): age 78-88, 6 cousins: age 50-60, 9 grandchildren
age 20-34 years. In this family, of three generations,10 subjects had LDH:
two males had total serum LDH values between 77 and 101 (IR: 135-225
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
analysis of serum isoenzymes in all 6 subjects showed a reduction in the
isoenzymes LDH-1(H4) and LDH-2(H3M1). In all subjects the pattern of
isoenzyme from erythrocyte emolysates provided a normal pattern (figure 1:
LDH isoenzymes electrophoretic trace of the older [*] male patient). In the
anamnesis of the family, the overall pathologies were: 4 k.breast associated
with, in one, k.colon, cerebral neoplasia, deaf-mutism, dyslipidemia, hypovi-
taminosis D, arterial hypertension, colon polyps, cholelithiasis, atrial fibrilla-
tion, disabiling arthrosis, aortic aneurysm, COPD, mild thrombocytopenia,
autoimmune hypothyroidism associated with HCV-related cryoglobulinae-
mia.The 6 subjects with LDH serum deficiency (aged 23 to 83 years) the dise-
ases reported in the anamnesis are: hypovitaminosis D in all, dyslipidemia
in three, arterial hypertension in two, impaired generalized osteoarthritis,
fibrillation cardiomyopathy, renal failure chronic and hyperuricemia in one
[*], mild thrombocytopenia in one, double neoplasia (K.breast + K.colon)
in one. The determination of LDH was performed in a clinical normal state.
It should be noted that in an 23-year-old granddaughter, during an acute
episode of infectious mononucleosis, LDH (basal 84-106 U/L) reached a
value of 658 (with AST 125 and ALT 184). It is not possible to know in the
other family members the maximum LDH value reached during acute illness.
No subjects showed signs of hemolysis or reductions of other enzymes (CPK,
transaminase, ALP, γGT,amylase). It was not possible to search for any muta-
tions in the LDHB gene for lack of technical sequencing availability of gene
sequencing.
Conclusions: LDH hereditary deficits are described in some Japanese fami-
lies. The study of this family, conducted at the level of three generations,
confirms that the decrease in enzymatic activity of LDH is due to a genetic
defect. Since this defect, has no clinical relapse, is not studied and there-
fore the type or the incidence is unknown. The analysis of the isoenzymes
reveals that the decrease is due to the LDH1(H4) isoenzyme, therefore the
defect is dependent from H subunit. The few cases described in Japan have
in common with this case the genetic origin of the defect, but some diffe-
rences indicate that this is basically a different genetic abnormality as: a)
the total activity values of LDH are much lower in the Japanese; b) in the
electrophoresis of isoenzymes there are only LAD-5 in the Japanese hou-
seholds, whereas in our case there is a decrease in LAD-1 and sometimes
LAD-2; c) in the erythrocytes electrophoresis LAD-1 and LAD-2 isoenzy-
mes are normally represented, while in Japanese there is a decrease; d) there
are no hemolysis indices in the Italian family. These genetic defects have
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
involves a lesser activity of substrate.
References:
1. Quaderni di Orphanet, dicembre 2016, Elenco delle malattie rare e sino-
nimi: in ordine alfabetico. www.orpha.net/orphacom/cahiers/docs/IT/
Elenco_malattie_rare_in_ordine_alfabetico.
2. Takatani T,Takaoka N,Tatsumi M et al. A novel missense mutation in
lactate deydrogenase B-subunit.Mol Genet Metab 2001;4:344-348.
3. Fujita K, Sato H, Kameko F et al. An immunoglobulin A1 that inhibits
lactate dehydrogenase activity, with reversal of inhibition by addition of
NADH. Ann Clin Lab Sc 2006;36:461-468.
ANALYSIS OF INTRA-HOSPITAL COMPLICATIONS AND
NEW INCIDENTAL DIAGNOSES OCCURRING AFTER
ADMISSION IN INTERNAL MEDICINE: RATE AND
IMPACT OF THESE EVENTS IN LENGHTENING THE
HOSPITALIZATION
Galassi M., Leoni S., Terzi E., Tovoli F., Piscopo M., Bolondi L. Unità
Operativa Medicina Interna Bolondi, Azienda Ospedaliero-Universitaria
S.Orsola-Malpighi, Bologna
Introduction: Advanced age, comorbidity and complex therapies fre-
quently characterize patients referred to Internal Medicine. During hospi-
talization, clinicians perform diagnostic-therapeutic algorithms aimed at
investigating and solving the clinical problem leading to hospitalization.
However, in the real life clinical practice the diagnostic and therapeutic
work-up initially planned needs to be frequently adjusted or modified due
to intra-hospital complications and/or incidental diagnosis of diseases dif-
ferent from the original admission problem.
Aims: Aims of this study were: 1) to evaluate the incidence of complications
and/or incidental diagnosis during hospitalization and the related hospitali-
zation lenghtening; 2) to evaluate the correlation between comorbidity and
incidence complications.
Methods: The clinical charts of patients consecutively admitted at Internal
Medicine Unit between 1st Jenuary 2017 and 30th April 2017 were analysed.
Exclusion criteria were: age less 18 years and death in the first 48 hours of
hospitalization.
Results: A population of 403 patients was included in the study
(M/F:187/216, mean age 73.9 years; mean and median hospitalization dura-
tion: 9.2 and 7 days); 226 patients (56%) concluded hospitalization and
were discharged without complications or new diagnosis not correlated to
the admission problem. Whereas, 177 patients (44%) had some changes
in diagnostic-therapeutic original program due to: incidental diagnosis
and complication in 29/177 (16.4%), only incidental diagnosis not corre-
lated to the admission problem in 47/177 (26.5%) and only intra-hospital
complications in 101/177 (57.1%). The median hospitalization duration of
complicated group (n=130, 32.2%; in 29/130 associated with new incidental
diagnosis) was 11 days (range 2-69 giorni) versus 5 days (range 1-24 days) of
not complicated group. Major intra-hospital complications include: hospital
acquired infections (n=51;39.2%) and delirium (n=22, 16.9%); moreover,
post-procedure (n=6) and iatrogenic (n=7) complications, other complica-
tions (n=37). In 44 pts (33.8%) more than 1 complication was described.
Comorbidity was evaluated with Charlson Index; median Charlson index
of population was 6 (range 0-15). Correlation between Charlson index ≥6
and occurrence of intra-hospital complications was statistically significant
at Chi square test (p=0,001). Correlation between intra-hospital delirium
and cognitive impairment was statistically significant (p ≤ 0,001). New inci-
5
Comunicazioni Orali
dental diagnosis were overall described in 76 pts (18.8%; in 29/76 associa-
ted with intra-hospital complications). In 18 new diagnoses, patients were
discharged without additional examinations, with mean hospitalization
duration of 8.3 days; in 58 new diagnoses, additional examinations were
required with congruous hospitalization lenghtening: 1 additional exami-
nation in 18 pts, 2 additional examinations in 12 pts and ≥ 3 additional
examinations in 28 pts, with respectively mean hospitalization duration of
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
and statistically significant correlation with Charlson index. About 18%
of patients had new incidental diagnosis not correlated to the admission
problem, generating additional examinations in more than 75% of cases and
congruous hospitalization lenghtening. These data warrant a further survey
in a large multicenter study.
THE ROULE OF MANGANESE IN HHT PATIENTS
Pinna M.1, Masala M.S.2, Vidili G.3, Turilli D.4,Pinna C.4
1
U.O. Complessa di Pronto Soccorso ed Osservazione Breve P.O. Ozieri
2
U.O. Complessa di Pronto Soccorso ed osservazione Breve P.O. Alghero
3
Dipartimento di Medicina Clinica e Sperimentale, Università Degli Studi di
Sassari 4U.O di Radiodiagnostica P.O. Ozieri
Introduction: Hereditary Hemorrhagic teleangectasia(HHT) is an heredi-
tary autosomal dominant which affects angiogenesis, causing arteriovenous
dilations, hemorrhagic teleangectasie affecting mucous membranes and
visceral shunts located predominantly in the liver, lung, and brain. Manga-
nese (Mn) is the 12th most abundant element, transition metal, pentavalent,
co-enzymatic factor (in men), whose presence is ubiquitous, responsible for
a “disease characterized by bradycinemia, amyotrophic facies, and postu-
ral instability” secondary to its toxic effect, linked to its accumulation to
predominant liver and cerebral localization with a transferrina-dependent
mechanism (DMT1), enhanced by martial deficit. The mechanism by which
Mn brain deposits may induce neurotoxicity – as well as being not clear -
may involve a toxin on the dopaminergic route, cause apoptosis or cause
endothelial dysfunction. In the literature, the evidence of Mn encephalocyte
deposits in HHT patients is found in about 30% of cases, but its diagnosis is
often misunderstood and its clinical significance underestimated. Purposes
This project aims to verify if, among sardinian patients affected by HHT,
may be found subjects with HAvms and Mn deposits and if may be linked
with Mn levels.
Materials and Methods: The study focussed on 55 sardinian patients
affected byt HHT undergoing a complete clinical screening, 28 of which
subjected to RMN brain + with study of “ poligono di Willis”+ paramagne-
tic contrast to study brain arterio-venus malformations (CAVMs).
Results: It is interesting to note that in 6 of the 28 patients undergoing
RMN encephalus, the presence of Mn deposits has been identified a carico
dei base ganglia and cerebellum’s peduncles In all patients, the Mn evi-
dence might be appreciated as an bilateral signal iperintensity in the nelle
1-weighted sequences. The mechanism is not well-known, but may depend
on the presence of port-system shunts which may also not be apparent
to imaging. A coexisting iron deficiency can contribute to increased Mn
absorption in these patients, as both of these metals have a common recep-
tor for absorption, transferrina-dependent. Starting from the assumption
that the deposition of manganese in these structures is known to increase T1
signal to magnetic resonance imaging in basal ganglia, as is usually obser-
ved in patients with hepatic impairment. In our case, the evidence in 6 cases
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,
the serum dosing in MN did not result in expected results as it was not
measurable, this could be related to the short half-life in plasma and serum
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.
In addition, 4 patients had low levels of sideremia and ferritin, while in
the other 2 cases the data were unavailable. Therefore, although liver fun-
ction indices were standard, this alteration may indicate a certain degree
of hepatic dysfunction at an early and asymptomatic stage, and indicate “at
risk” subjects to develop abnormalities related to the toxic role of this metal.
Conclusions: In addition, brain imaging through RMN study may be
useful in detecting the deposition of manganese in HHT patients also in
the subclinical phase; Starting from the assumption that the deposition of
6
118° Congresso Nazionale - Società Italiana di Medicina Interna
manganese in these structures is known to increase T1 signal to magnetic
resonance imaging in basal ganglia, as is usually observed in patients with
hepatic impairment. Manganese brain deposits may be an early indicator of
liver dysfunction in asymptomatic patients at risk of developing metal-rela-
ted toxic anomalies. Proper management of sideropenia could reduce free
transferrin levels with secondary reduction in cerebral accumulation of
manganese, which could reduce or prevent damage to neurotoxicity.
RELATIONSHIP BETWEEN AMBULATORY ARTERIAL
STIFFNESS INDEX (AASI) AND NIGHT/DAY BLOOD
PRESSURE RATIO IN ESSENTIAL HYPERTENSIVES
Musiari G.1, Di Raimondo D.1, Casuccio A.2, Miceli G.1, Tuttolomondo A.1,
Pinto A.1
1
Dipartimento Biomedico di Medicina Interna Clinica e Specialistica
- Università degli Studi di Palermo 2 Dipartimento di Biomedicina
Sperimentale e Neuroscienze Cliniche - Università degli Studi di Palermo
Introduction and Aim: Pulse Wave velocity (PWV) or the Augmentation
Index (AI), had demonstrated to discriminate surely the different extent
of arterial stiffness (AS) that features the different subgroups of hyperten-
sives in relation to the nocturnal fall of blood pressure (BP) (calculated
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
a simpler method to estimate AS. For a given increase in diastolic BP, the
increase in systolic BP is smaller in a compliant compared to a stiff artery;
the stiffer the arterial tree, the closer AASI is to 1. Only a few studies tried
to ascertain if AASI have similar ability, further validating its wide clinical
use, in addition (or alternatively) to AS with partial and conflicting Results:
In consideration of the contradictory results showed, and the almost com-
pletely absence of data regarding the ability of AASI to predict the different
degree of stiffness when hypertensives are divided into four class of dipping,
aim of the study was to clarify the potential of AASI to estimate the different
degree of AS in relation to the nocturnal BP profile.
Materials and Methods: We enrolled 816 essential hypertensives and 173
control subjects without hypertension. The study procedure included for all
subjects: a comprehensive medical history complete physical examination;
assessment of Body Mass Index (BMI), waist circumference; blood bio-
chemical examinations. Through the execution of a 24-hours ambulatory
blood pressure monitoring (ABPM), have been obtained comprehensive
data regarding 24h, diurnal and nocturnal values of BP and AASI (defined
as 1 minus the regression slope of diastolic on systolic BP values) Results:
Unadjusted AASI values of the four categories of hypertensives in relation
to night/day SBP ratio compared to control subjects. showed significantly
higher AASI for mild and reverse dippers versus control patients and
versus the other categories of dipping (p: 0.0005). The multiple regression
analysis for AASI dependent variable confirmed the association between
AASI and nocturnal dip (p: 0.015). The Multinomial Logistic Regression
Analysis after adjustment for the main confoundings: age, sex, Body Mass
Index, 24h Systolic BP, 24h Diastolic BP,confirmed the association between
AASI and dipping, but only for dipper and extreme dipper hypertensives,
losing the significance for the higher values of AASI. Conclusions:: Our
findings support the hypothesis that AASI is unable to estimate the higher
degree of AS of older hypertensive subjects with a high burden of organ and
vascular damage and several comorbidities, probably because the nocturnal
reduction of BP is a main determinant of AASI, more powerful than AS
itself. Our data do not support the clinical use of AASI as an alternative to
the PWV.
BISPHENOL-A (BPA): A PROBLEM IN HUMAN HEALTH
Lucchetta M.C.
Servizio Sanitario Emilia Romagna- Ausl Parma
Bisphenol A (4,40-isopropylidenediphenol,BPA) is a monomer used in the
manufacture of polycarbonate plastics(PV). BPA is used in diverse forms
of plastic products in the food and electronic industries (plastic container-
s,utensils,toys,water bottles,fax paper).The extensive use of BPA-containing
products has resulted in high human exposure worldwide. Many studies
reporting that more than 90% of the US population has detectable levels in
urine samples.In adults,urinary BPA concentrations are positively associated
with cardiovascular disease and diabetes.The ubiquity of BPA exposure and
its endocrine-disrupting potential raise concerns about its effects on health
118° Congresso Nazionale - Società Italiana di Medicina Interna
despite the molecule’s short half-life.However, recent animal and in vitro
studies suggest that BPA exerts additional health effects on other systems,-
such as central nervous system activity,thyroid hormone and pancreatic
β-cell function.A new american study correlates the BPA with cancers of
the liver and liver disfunction.A study on BPA-treated rats showed eleva-
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
(Bonefeld-Jorgensen et al.2007;Richter et al.2007;Rochester 2013).BPA has
the ability to bind to estrogen receptors and promote both agonist and anta-
gonist activity.BPA may be a contributing risk factor to autoimmune disease
development.The hepatic biotransformation of BPA depends on oxidation/
reduction involving glutathione.Higher BPA concentrations were associa-
ted with increased abnormal liver function tests.Animal studies demon-
strate that BPA has the ability to generate reactive oxygen species (ROS)
and reduce antioxidant reserves.BPA disruption of cytochrome P450 (CYP)
enzymes may be a potential mechanism for autoimmune pathophysiology.
The cytochrome P450 monooxygenases play a crucial role in the liver and
various other tissue.A recent cross-sectional human study of 1455 Ameri-
cans demonstrates a statistically significant association between higher BPA
concentrations and abnormal concentrations of liver enzymes: γ-glutamyl
transferase(γ-GTP),alkaline phosphatase(ALP) and LDH.The relationship
between BPA exposure and liver function remain unclear, although some
studies suggest possible mechanisms for liver damage, such as oxidative
stress and direct apoptotic activities.In 2014 the European Agency for Che-
micals(ECHA) has classified BPA in category 1b for reproductive toxicity,on
the basis of the experimental evidence.The Chemistry Council to the con-
trary, declare that BPA is safe and contrasts all the legislative proposals to
prohibit the use of BPA. The Food and Drug Administration (FDA) has pro-
duced an official document from last year to affirm the safety of BPA.Many
researchers attribute this result to the intervention of the chemical industry
lobbying.In 2006, the analysis of the literature has revealed that each of the
funded study did not find significant effects of BPA while they are present in
92% of studies not funded by industry.Based mainly on experimental data
and studies rewiewed,in 2014 the ECHA has classified BPA in category 1b
for reproductive toxicity.EFSA asserts that the diet is the main source of
exposure and that the tolerable daily intake(TDI) of BPA in food must be
lowered by a factor of 10 to 0.005 mg for kg of body weight (mg/kg b.w.)
corresponding to 4 micrograms per kilogram of body weight for day (μg/kg
b.w/day).However EFSA supports hat the total BPA inteke estimated up to
30% of the TDI for the group more exposed (teenagers).But doubts remain.
Many toxicoloy study would confirm some of the hypotheses about the role
in the alteration of hormonal balances:major damage you would have with
the lower doses, adverse effect “low dose response” typical of endocrine
disruptors (Vandenberg 2012).On the basis of the scientific evidence, in the
context of european legal standards,France has launched a national action
Comunicazioni Orali
risk reduction that certainly deserves attention on the other member States
of the E.U.In Italy,we are waiting for a law to regulate the use of BPA espe-
cially in the containers suitable for food.
Figure 1: The hepatic biotransformation of bisphenol A Datis Kharrazian
Autimmune Dis.2014
THREE-DIMENSIONAL ECHOCARDIOGRAPHIC
EVALUATION OF THE RIGHT VENTRICLE IN PATIENTS
WITH SYSTEMIC LUPUS ERYTHEMATOSUS
A. Buonauro1, M. Galderisi1, R. Esposito1, L. Nappi2, R. Sorrentino1, A.
Lobasso2, F.W. Rossi2, A. Tufano3, A. De Paulis2, G. Marone2
1
Dipartimento di Scienze Biomediche Avanzate, Università degli studi
di Napoli Federico II 2 Dipartimento di Scienze Mediche Translazionali,
Università degli studi di Napoli Federico II 3 Dipartimento di Medicina e
Chirurgia, Università degli studi di Napoli Federico II
Background: Patients with systemic lupus erythematosus (SLE) have an
increased risk of cardiovascular events, which is independent of traditional
risk factors. This higher risk has been associated with alterations of left ven-
tricular structure and function. Little is known about right ventricular (RV)
involvement in this clinical setting.
Methods: Thirty-six SLE (age 43±8 years, F/M=32/4) and 36 healthy con-
trols, matched for age and sex, were enrolled. Patients with coronary artery
disease, overt heart failure, primary cardiomyopathies, diabetes mellitus,
atrial fibrillation and primary pulmonary hypertension were excluded.
Patients and controls underwent a complete echo-Doppler exam with addi-
tional three-dimensional (3D) assessment of RV structure and function.
Echo-Doppler estimate of pulmonary arterial systolic pressure (PAPs), RV
diameters, tricuspid annular plane systolic excursion (TAPSE), tricuspid
E/A ratio and Tissue Doppler derived systolic velocity of lateral tricuspid
annulus were measured. Three-dimensional echo-derived RV end-diasto-
lic and end-systolic volumes (RV EDV and ESV respectively), RV ejection
fraction (EF) and stroke volume (SV) were determined. RV septal and
lateral longitudinal strain (SLS and LLS respectively) were estimated by
3D echo. The disease activity was evaluated by SELENA-SLEDAI score and
other inflammatory markers (reactive C protein [CRP] and erythrocyte
sedimentation rate).
Results: The two groups had comparable body mass index (BMI), heart
rate (HR), systolic and diastolic blood pressure. PAPs was marginally higher
in SLE than in controls (27.1±5.7 versus 24.6±5.0, p<0.05). Pulmonary
hypertension (PAPs > 30 mmHg) was found in 10 SLE patients (27.8%).
Standard echo-Doppler measurements of RV structure and function (RV
transverse and longitudinal diameters, TAPSE, systolic velocity of lateral
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
Comunicazioni Orali
Cardiac examination revealed tachycardia and hypotension. Laboratory
tests showed: hemoglobin 13.4 g/dl, white blood cells count 13.80 x 103/
mmÑ (neutrophils 93 %), platelet count 17 x 103/mmÑ, aspartate ami-
notransferase 67 IU/L, alanine aminotransferase 39 IU/L, total bilirubin
20.40 mg/dl (direct 15.99 mg/dl, indirect 4.41 mg/dl), creatinine 2.21 mg/dl
and azotemia 212 mg/dl. Chest radiography and electrocardiography were
normal and abdominal ultrasound revealed severe hepatomegaly with stea-
totic transformation of liver parenchyma without intra-hepatic cholestasis,
normal gallbladder and spleen, kidneys with normal total and parenchymal
measures; ascitic fluid collection was not observed. Hepatitis A, hepatitis
B, and hepatitis C viruses were excluded by hepatitis-virus-panel investi-
gation. There were no laboratory evidences of infection with Hantaan virus
and rickettsial disease. Based on history and typical laboratory findings,
icterohaemorrhagic leptospirosis (Weil’s disease) was suspected. The initial
management consisted of intravenous administration of fluids and ceftria-
xone (2 g IV once daily) was started. In the following days, the patient’s con-
dition gradually improved, jaundice decreased, renal functions improved.
The abnormalities of liver function resolved slowly within the next month,
up to which time, the bilirubin level became normal. On the twentieth day,
the patient was discharged. Micro-agglutination test (MAT) for IgM anti-
bodies against Leptospira was positive for L. icterohaemorrhagiae (titer
1: 3200; reference value ≤ 1: 100) and confirmed clinical diagnosis. Icteric
leptospirosis is a severe disease in which the clinical course is often rapidly
progressive. Severe cases often present late in the course of the disease, and
this contributes to the high mortality rate, which ranges between 5 and 15%.
The icteric form of leptospirosis occurs in 5 to 15% of all patients. Con-
sidering the patient’s history, leptospirosis, alcoholic hepatitis, or hepatic
cirrhosis were discussed in the differential diagnosis. Both conditions could
have been triggered by alcohol abuse, and are known to produce acute liver
damage accompanied by a clinical syndrome, similar to that described in
the reported case. The presentation of Weil’s disease is often atypical and
organ failures may occur 4 to 9 days after the onset of symptoms. Serum
bilirubin is frequently high and may persist for several weeks, but transami-
nases and alkaline phosphatase are usually moderately elevated. That con-
stellation was observed in this case, and serum levels of transaminases were
slightly elevated and contrasted to severe jaundice. Both slightly elevated
alkaline phosphatase levels and abdominal ultrasonography confirmed the
lack of cholestasis. In a patient which presents jaundice, if the work history
is suggestive, think about the possibility of leptospirosis.
AN UNUSUAL CALF LESION IN AN
IMMUNOCOMPROMISED PATIENT
Gili M.1, Charbonnier E. 1, Chasseur L.1, Chiacchiarini F.1, Costantini E.1,
Gallo S.1, Marinucci C.1, Morra Di Cella S.1
Porta M1 1 Dipartimento di Scienze Mediche - Università degli Studi -
Ospedale S. Giovanni Battista - Torino
A 71 year old male patient presented in October 2015 with a swollen and
tender area in his right calf. Past history: in 2006 chronic lymphatic leu-
kemia was diagnosed, which was still in progression despite many cycles
of immune- and chemotherapy. In 2014, a nodule appeared at the left pul-
monary apex, increasing in volume over the following radiograms. Further
microbial and histological investigations were inconclusive and the lesion
was interpreted as pulmonary localization of the disease. A new immu-
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
right calf, which was initially considered a spontaneous hematoma but wor-
sened over the following weeks. At the same time a skin lesion appeared on
the back, where a transcutaneous biopsy had been performed. The leg lesion
was drained and a culture revealed growth of Nocardia. Trimethoprim/
sulfamethoxazole (1200/240mg tid) was started, leading to rapid improve-
ment. A few months later the germ developed resistance to trimethoprim,
which was replaced by ceftriaxone and an aminoglycoside, obtaining com-
plete resolution of the infection. A new course of immunotherapy could be
started in May 2016. Nocardiosis: immunodeficiency states, particularly in
hematological patients, is a main risk factor for disseminated Nocardiosis.
The infection can spread to almost every tissue and, if not treated with pro-
longed appropriate antibiotic therapy, the prognosis is poor.
A 16-YEAR RETROSPECTIVE ANALYSIS OF
PRESENTATION PATTERNS, MICROBIOLOGICAL
8
118° Congresso Nazionale - Società Italiana di Medicina Interna
AETIOLOGY AND MANAGEMENT OF PYOGENIC LIVER
ABSCESSES
Serraino C. 1, Elia C. 2, Melchio R. 1, Rinaldi G.L. 1, Falcetta A. 1, Borretta V.
1
, Giraudo A. 1, Spadafora L. 1, Bracco C. 1, Silvestri A. 1, Fenoglio L.1
1
SC Medicina Interna, AO S. Croce e Carle, Cuneo; 2 Pronto Soccorso DEA,
Ospedale Regina Montis Regalis, Mondovì (CN)
Background: Pyogenic liver abscess (PLA) is a suppurating infection of the
hepatic parenchyma that is associated with a high morbidity and mortality
and develops as a complication of acute appendicitis, trauma, biliary disease;
but in a significant proportion of patients may occur without any apparent
precipitating event. Early diagnosis and treatment is a crucial step in the
management of these patients, since the presentation may be subtle and not
very specific, so currently constitutes a challenge for physicians. Escherichia
coli, Enterobacteriaceae and anaerobes cause the majority of infections, as a
consequence, broad spectrum antibiotics have been used in their treatment,
in combination with aspiration or drainage. The current study was underta-
ken to evaluate the clinical and microbiological characteristics of patients with
PLA and to recognize if the prompt aspiration or drainage could improve the
outcome.
Methods: A retrospective single-center study was conducted including 109
patients admitted to Santa Croce and Carle General Hospital, between 2000
and November 2016 with first episodes of PLA.
Results: 62 patients (56.9%) were males; mean age was 65.4 ± 14.3). The
majority of patients presented with fever, 73%; right upper abdominal pain
in 63.3%, vomiting and nausea in 28.4%. The most common laboratory
abnormality among included items was increased C-reactive protein and
fibrinogen blood levels, respectively in 98% and 93.9% of cases. Abdominal
ultrasound was the diagnostic investigation in 42.4% of cases; CT scan and
MR imaging were performed in 51.1% and 3.3% of cases respectively. The
mean size of liver abscess was 7 ± 3.5 cm. We observed blood or pus culture
study in 99 cases of which only 53.5% came with positive microbial reports.
The most common organism identified was Escherichia coli (26.5%), fol-
lowed by Enterococcus spp (11.3%). Of all PLA, in 28 cases (25.7%) the
cause was not clear: cryptogenic abscess. Biliary tract diseases, including
cholelithiasis, cholecystitis and malignancies, were identified in 55% of
cases. In 11.9% of cases the cause of PLA was assigned to be haematogenous.
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
was started at the onset of the clinical sign of infection and was changed
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
needle aspiration of PLA was performed in 13 patients (11%) and percuta-
neous abscess drainage was performed on 72 patients (67%), with median
of drainage duration of 12.6 ± 14 days. The time interval between antibio-
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
not difference in terms of outcome.
Conclusion: PLA is a diagnostically challenging problem due to non-spe-
cific presenting characteristics. The microbiological yield identified was
a typical European spectrum with a preponderance of Escherichia coli
infections. Once recognized, percutaneous drainage and antibiotic treat-
ment are the mainstay of management for PLA and earlier was the drainage
intervention, shorter was the antibiotic treatment
INCIDENCE AND CLINICAL IMPACT OF SPLENIC
EMBOLI IN A LARGE COHORT OF INFECTIVE
ENDOCARDITIS (IE) PATIENTS
Pafundi P.C., Cesaro F., Ursi M.P., Vitrone M., Andini R., Ragone E.,
Albisinni R., Zampino R., Durante-Mangoni E.
Internal Medicine, University of Campania “Luigi Vanvitelli” and Unit of
Infectious and Transplant Medicine, Monaldi Hospital, Napoli
Introduction: Embolic events (EE) represent a frequent and important com-
plication of IE (observed incidence 20-50%) and are associated with an incre-
ase in morbidity and mortality rates. Most frequent embolization sites are the
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
etiologic agents, such as S. aureus and St. bovis). However, there are very few
data on incidence and clinical consequences of splenic emboli in IE.
118° Congresso Nazionale - Società Italiana di Medicina Interna
Methods: This is a retrospective study on prospectively collected data
from 632 consecutive patients admitted to our Unit at the Monaldi Hospi-
tal between Dec ‘99 and Mar ‘17, for definite or probable IE, according to
Duke’s diagnostic criteria. Clinical data, hematochemical and microbiolo-
gical parameters, echocardiographic and other imaging examinations; sur-
gical procedures and mortality were recorded and evaluated; first compa-
ring patients with or without embolic events and then focusing on splenic
emboli risk factors.
Results: In line with the current knowlegde on EE in IE, it emerged that
patients experiencing EE were significantly younger, had significantly
higher C-reactive protein, as well as leukocytes and D-dimer values. EE
were also found mostly in subjects with left-sided IE (48.2%) and the major
etiologic agent involved was S. aureus (p = 0.0001). A more specific analysis
was performed on the group of patients with embolism (n = 254), split in
two subgroups: with splenic emboli (n=95) and with other types of emboli
(n=159). At the univariate analysis, predictive factors for a splenic embolic
event were left-sided IE location (78.9% vs 29.7%, p=0.000), community
acquired infection (77.9%, p=0.002), the type of pathogen involved, espe-
cially enterococci and streptococci (50.5%; p=0.001). Among comorbi-
dities, a prior acute myocardial infarction was more prevalent in subjects
with embolism different from splenic (4 vs 25 cases; p=0.008), whilst aortic
and mitral regurgitation were significantly higher in patients with splenic
embolism (p=0.000). These variables were included in a multivariate model,
from which IE localization (p=0.000, OR 0.589, 95% C.I.: 0.448-0.774), type
of pathogen (p=0.034; OR 1.293, 95% C.I.: 1.019–1.639) and presence of
aortic or mitral regurgitation (p=0.000; OR 3.869, 95% C.I.: 2.082–7.190
and p=0.000; OR 4.153, 95% C.I.: 2.242–7.693, respectively) but not the
type of acquisition (p=0.408; OR 0.800, 95% C.I.: 0.472-1.357), emerged as
independent predictors of the outcome.
Discussion: Embolic events are frequently observed IE complications and
impact on morbidity and mortality rates. 40.2% of our cohort experimented
EE and, among these, 37.4% involved the spleen. Hence, the identification
of patients with IE at higher risk of EE is fundamental to a better manage-
ment of the disease. Our data confirms the literature with regard to embolic
events in general in IE; however no study focused on splenic emboli in IE.
Our analyses have found, as possible predictive factors for EE in IE: endo-
carditis site, major left heart prevalence, source of infection mainly com-
munity and presence of aortic/mitral regurgitation, most involved etiologic
agents enterococci and streptococci (in general EE in IE are associated with
S. aureus infection).
SEPSIS AMONG INTERNAL MEDICINE PATIENTS:
CLINICAL CHARACTERISTICS AND PREDICTORS OF
MORTALITY
Mirijello A.1,2, Zaccone V. 1, Impagnatiello M. 1, Tosoni A. 1,
Passaro G. 1, Vallone C.V. 1, Cossari A. 3, Ventura G. 4,
Gambassi G. 1, Gasbarrini A.1, De Cosmo S. 2, Addolorato G. 1, Landolfi R. 1
& Internal Medicine Sepsis Study Group1
1
Department of Medical Sciences, Gemelli Hospital, Catholic University of
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,
Italy.
Background: Sepsis represents a major health problem among Internal
Medicine patients. Difficulties in the clinical management (e.g. early dia-
gnosis and optimal treatment) are associated with an increased rate of com-
plications and economic costs due to a prolonged inpatient stay. At present,
most of septic patients are admitted to Internal Medicine Departments.
These patients show a worse prognosis than those admitted to Intensive
Care Units. This difference seems to be due to several factors related both
to patients’ characteristics (i.e. older age, affected by chronic diseases and
on poly-pharmacotherapy), either to physicians’ characteristics (the mana-
gement of sepsis/septic shock varies depending on the specialty of the phy-
sician who handles the case), and to a general lack of literature data on this
specific population of patients (e.g. lack of validated predictive and progno-
stic scores).
Aim: Aim of the present study was to investigate the clinical characteri-
stics and prognostic factors of septic patients admitted to Internal Medi-
cine Units, by a retrospective analysis of prospectively collected data. The
primary outcome consisted in the evaluation of the mortality rate at 30-days
and 90-days from admission in order to identify significant predictors of
Comunicazioni Orali
mortality.
Methods: An active surveillance program was conducted from January
2014 to December 2014 among two Internal Medicine Inpatient Units (75
inpatient beds) of Policlinico Agostino Gemelli, Catholic University of
Rome. Every patient for whom the managing physician had requested blood
coltures collection was evaluated (screened) in order assess the presence of
SIRS criteria. Thus, a total of 226 consecutively patients were screened. The
screening program consisted in the collection of clinical characteristics
(gender, age, body mass index, risk factors for infections, risk factors for
MDR infections, co-morbidities, vital signs, mental status), clinical scores
(MEDS, SCS, REMS, SOFA), and laboratory results (blood tests, blood gas
analysis, c reactive protein, procalcitonin, lactates, D vitamin levels, beta-
D-glucane, galactomanname) at admission, at 48h and 7 days from admis-
sion. Exclusion criteria were represented by: absence of SIRS criteria, nega-
tive blood coltures. Thus, a total of 88 microbiologically-identified septic
patients were enrolled in the study. The evaluation of qSOFA was performed
retrospectively, according to SEPSIS-3 definition.
Results: Among the 88 enrolled patients, 51 (57.9%) were male, median
age 75y.o. (IR 65-82 yo, range 37-94). The median BMI was 21.6 +/- 9.3. A
total of 36 (40.9%) were immunosuppressed, 32 (35.9%) were diabetic, 35
(39.3%) were affected by neoplasms, 62 (70.4%) had received an antibio-
tic treatment in the previous 6 months, and 14 (15.9%) had had an MDR
infection in the previous 6 months. A total of 66 (75%) of patients were
carriers of vescical or central venous catheter. Finally, 21 (23.9%) were
affected by an end-stage illness. The median systolic pressure was 83 mmHg
(IR 73-90, range 51-115), mean lactate level was 2.02+/-2 mmol/l, median
PCT 2.79 (IR 0.7-19.2, range 0-100), median SCS 10.39 (IR 6-13, 63% clas-
sified as high or very high risk), mean SOFA 10.3+/-4.6, mean MEDS 10.12
+/- 4.4, REMS 7.47 +/- 3.1, mean qSOFA 1.02 +/- 0.9. Median vitamin D
levels were <7 ng/ml (IR <7-9.4, range <7-55). A total of 23 (26.1%) died
at 30-day, while 31 (35.2%) died at 90-day from admission. At multivariate
analysis, mean urinary output, age, pO2/FiO2 ratio, qSOFA score, MEDS
score, REMS score, SCS score, D vitamin levels, history of infection in the
last 6-months, end-stage illness, parenteral nutrition, hig-risk at SCS score
and a recent antibiotic treatment within the previous 6-months resulted to
be significantly associated with mortality at 30-days (p<0.01) and at 90-days
(p<0.01). After logistic regression, low D vitamin levels, low pO2/FiO2 ratio,
history of infection within previous 6-months and a high MEDS score were
independently associated with the primary outcome (p<0.01). Stepwise
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
D vitamin levels (OR 0.83 95%CI0.69-0.96, p<0.01) were independent pre-
dictors of 30-day mortality. Moreover, high MEDS scores at admission (OR
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
infection show peculiar clinical characteristics, different from those of ICU
patients. Internal Medicine patients affected by sepsis show mortality rates
in line with the literature and with ICU patients. MEDS score and D vitamin
levels could be a useful clinical predictor of mortality. Larger observational
and prospective studies are needed to confirm our data.
NON-INTENSIVE CARE UNIT ACQUIRED PNEUMONIA
IN INTERNAL MEDICINE. RETROSPECTIVE ANALYSIS OF
RISK AND OUTCOME VARIABLES IN A TWELVE-MONTH
PERIOD AT A HOSPITAL IN NORTHERN ITALY
Tricarico L., Bracco C., Brignone C., Gollè G., Serraino C.,
Melchio R., Pomero F., Mana F., Fenoglio L.
Medicina Interna ASO Santa Croce e Carle Cuneo
Background: Hospital-acquired pneumonia (HAP) is one of the leading
nosocomial infections and it is associated with high morbidity, prolongation
of hospital stay and mortality. Some authors have highlighted that the majo-
rity of studies on HAP have been conducted in patients hospitalized in the
intensive care unit (ICU), since mechanical ventilation represents a major
risk factor for nosocomial pneumonia. It is therefore necessary to study in
deep the problem for patients acquiring HAP in general wards, who may
have peculiar features and risk factors.
Methods: we conduced a retrospective study on 246 patients hospitalized
in our Internal Medicine department between January 2015 and Decem-
ber 2015. Each case of Non-Intensive Care Unit Acquired Pneumonia was
matched with patient with diagnosis at discharge of CAP o HCAP, who were
9
Comunicazioni Orali
hospitalized in the same period of time. Data on incidence, risk factors,
patient characteristics and outcomes were collected.
Results: The study group comprised 24 patients with NIAP, 68 HCAP
and 154 CAP. We analyzed some characteristics and what emerges is that:
- 22.73% of cap, 33.33% of niap and 41.18% of hcap have tumor in their
anamnesis (p 0.018) - 0% of cap and hcap and 4.17% of niap have naso-
gastric tube before the diagnosis of pneumonia (p 0.098) - 13.64% of cap,
37.50% of niap and 26.47 % of hcap have done immunosuppressive tre-
atment in the last 12 months (p 0.005) - 11.69% of cap, 25% of niap and
19.12% of hcap have done inhaled steroid therapy in the last 12 months (p
0.129), - 43.51% of cap, 87.5% of niap and 69.12% of hcap have used ppi
(p 0.000), - 14.94% of cap, 50% of niap and 22.06% of hcap died 3 months
later the diagnosis (p 0.003) - The median age was 77.87 years in patients
with CAP (sd: 12.36), 74.58 years in patients with NIAP (sd: 13.58), 78.66
years in patients with HCAP (sd: 10.36) p 0.163 - The median incubation
in NIAP is 9.66 days (sd 6.3) p 0.000 - The mean heart rate is 93.70 bpm in
patients with CAP (sd 19.48), 95.29 bpm in patients with NIAP (sd 14.09),
95.77 bpm in patients with HCAP (sd 20.36) p 0.128 - The mean breath fre-
quency is 18.42 respiratory acts per minute in patients with CAP (sd 5.43),
23.33 respiratory acts per minute in patients with NIAP (sd 4.16), 17.80
respiratory acts per minute in patients with HCAP (sd 4.13) p 0.246 - The
mean body temperature is: 37.92 °C in patients with CAP (sd 1.20), 37.46 °C
in patients with NIAP (sd 1.13), 37.53 °C in patients with HCAP (sd 1.04)
p 0.420 - The average value of Na is: 138.49 mmol/l in patients with CAP
(sd 6.96), 139.58 mmol/l in patients with NIAP (sd 6.08), 138.14 mmol/l
in patients with HCAP (sd 6.47) p 0.609 - The average value of K is: 4.17
mmol/l in patients with CAP (sd 0.61), 4.35 mmol/l in patients with NIAP
(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-
pressive therapy over the last 12 months and treatment with PPI. Immuno-
depression and the use of PPI can thus represent significant risk variables in
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
of NIAP versus CAP (this is not true, however, if the NIAP is compared with
HCAP). The mortality attributed to HAP outside the ICU in our study is
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
to NIAP on all the patients died in 2015 is 9,7%. This makes us understand
how these pneumonia are important for the patient’s prognosis and how
important is the prevention of them. It is interesting to observe the 9-day
incubation time in Non-Intensive Care Unit Acquired Pneumonia because
this leads us to consider the need to be very careful whenever possible in
prolonging the stay time hospitalization. Our study also shows that in 2015
the incidence of HAP outside the ICU was 10,95 cases per 1,000 dischar-
ges. This is a much higher value than the one reported in literature (1.6 to
3.67 cases per 1000 admissions), and that makes us understand how little
is known yet and how many studies have yet to be done on this category of
pneumonia.
ESSENTIAL TRACE ELEMENTS AND
HEPATOCARCINOMA: UNRAVELLING NOVEL
EPIGENETIC MECHANISMS INVOLVED IN LIVER
CARCINOGENESIS
Mazzi F. 1, Udali S. 1, De Santis D. 1, Ruzzenente A. 2, Moruzzi S. 1, Beschin
G. 1, Campagnaro T. 2, Pattini P. 1, Franceschi A. 1,
Olivieri O. 1, Guglielmi A. 2, Perbellini L. 3, Choi S.W. 4,5, Friso S. 1
1
Department of Medicine, University of Verona School of Medicine, Verona,
Italy 2 Department of Surgery, University of Verona School of Medicine,
Verona, Italy 3 Department of Diagnostics and Public Health, Unit of
Occupational Medicine, University of Verona School of Medicine, Verona,
Italy 4 Tufts University School of Nutrition Science and Policy, Boston, MA,
USA 5 Chaum Life Center, CHA University, Seoul, Korea
Background and Aims: Hepatocellular carcinoma (HCC) is the second
most common cause of death from cancer, worldwide. The etiology and
factors involved in its development remain, however, largely unknown.
A marked decrease in mineral trace elements is related to the genesis of
several diseases including cancer but their role in carcinogenesis, including
that of HCC, is yet not fully defined. We investigated an ample set of trace
elements amounts in serum, HCC tissues and homologous non-neoplastic
liver tissues (N) in samples of patients affected by HCC. Gene expression
and promoter DNA methylation of major element-transport proteins were
10
118° Congresso Nazionale - Società Italiana di Medicina Interna
also determined. We aimed at studying the possible involvement of DNA
methylation in trace element-linked proteins dysregulation and eventually
in HCC progression.
Methods: Cu, Zn and Se, Cd, Co were measured in liver cancer tissues and
serum of HCC patients undergoing hepatic curative surgery by Inductively
Coupled Plasma Mass Spectrometry (ICP-MS) analysis. Gene expression
profiles and DNA methylation at promoter of ZIP8, ZIP14, MT1 (MT1G,
MT1H), MT2 genes were determined by a microarray genome-wide
approach.
Results: Serum levels of Cu, Zn, Se did not show differences and were
within the reference limits among all the patients. Tissue levels of Zn, Cd, Se
and Co were, instead, markedly decreased in HCC as compared to normal
tissues; Cu levels did not differ significantly between HCC and N tissues.
There was however, a substantial increase of Cu serum levels if HCC develo-
ped in an underlying cirrhotic liver as compared with a steatosic or normal
liver. Moreover, ZIP8 and ZIP14 transporters, MT1 (MT1G, MT1H), MT2
chaperone genes were repressed with a consensual promoter hypermethyla-
tion in HCC liver tissues as compared to N tissues.
Conclusions: We show the novel finding of a significant reduction of Zn
and Cd levels in HCC tissues, together with a gene repression of ZIP8,
ZIP14, MT1, MT2 transporters linked to promoter gene hypermethylation
suggesting an early, epigenetic-based dysregulation of Zn and Cd depletion
in HCC. The lower Se in HCC tissues may have a role in cancer progression
given its ROS scavenger activity. The Cu levels increase in HCC developing
in cirrhotic liver suggests a role of Cu in early carcinogenesis phases possi-
bly through oxygen free radicals production. These evidences provide new
insights into the role of trace elements in HCC carcinogenesis.
THE ALBI GRADE PREDICTS SURVIVAL IN PATIENTS
WITH HEPATOCELLULAR CARCINOMA UNDERGOING
TRANSARTERIAL CHEMOEMBOLIZATION (TACE)
Campani C., Dragoni G., Aburas S., Inghilesi A.L., Arena U., Laffi G., Marra
F., for the Ita.Li.Ca. study group Dipartimento di Medicina Sperimentale e
Clinica, Università di Firenze
Background and Aims: The prognosis of hepatocellular carcinoma is not
solely influenced by the extent of anatomic spread of the cancer but also by
the severity of liver dysfunction. This makes the assessment of prognosis
in individual patients difficult. Child-Pugh (CPS) and model for end-stage
liver disease (MELD) scores are widely used but have considerable limita-
tions. Recently, the prognostic value of albumin-bilirubin (ALBI) grade has
been evaluated in patients undergoing resection of HCC or treatment with
different modalities. Nonetheless, its predictive role in patients undergoing
TACE has not been evaluated.
Methods: We retrospectively evaluated the prognostic significance of ALBI
in patients undergoing TACE recorded in the Ita.Li.Ca. database, and com-
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
January 2008 and December 2014 were evaluated. Patients had a median
MELD of 9 and belonged to all BCLC stages; 793 TACE were perfomed
in the BCLC-A stage, 508 in BCLC-B and 279 in BCLC-C. Median overall
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,
irrespective of the BCLC stage, the ALBI grade was a significant predictor of
overall survival (OS, P<0.0001), similar to the HAP and the mHAP scores
(P<0.0001). When patients in different BCLC stages were considered, ALBI
was a significant predictor of OS only in BCLC-A (p<0.046) and BCLC-C
(p<0.033) patients treated with TACE, whereas HAP and mHAPII predi-
cted OS across all BCLC stages. Similar data were obtained when only the
first TACE procedure was considered in each patient (total of 1143 patients,
517 BCLC-A, 313 BCLC-B and 188 BCLC-C). Considering all BCLC stages,
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-
rent BCLC stages were considered, ALBI and HAP were significant predic-
tors of OS in BCLC-C (p 0,038 and 0,03 respectively), whereas mHAPII was
not significant. Survival in the whole population was 37.5 mo. (37.9 mo. for
ALBI 1, 37.5 for ALBI 2 and 28.4 for ALBI 3).
Conclusions: ALBI provides an additional simple and objective method
of assessing liver function in HCC, and may be useful for selecting patients
more likely to survive after TACE, particularly in those belonging to the
BCLC-A and –C stages.
118° Congresso Nazionale - Società Italiana di Medicina Interna
IN ITALIAN NAFLD PATIENTS RARE CERULOPLASMIN
VARIANTS ASSOCIATE WITH DYSMETABOLIC
HYPERFERRITINEMIA AND INCREASED HEPATIC IRON
STORES: A NGS STUDY
Corradini E. 1, Bernardis I. 2, Dongiovanni P. 3, Buzzetti E. 1, Artuso L. 2,
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
Hospital of Modena, Modena, Italy 2Center for Genome Research, University
of Modena and Reggio Emilia, Modena, Italy; Department of Medical and
Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy 3
Department of Pathophysiology and Transplantation, Università degli Studi
di Milano and Internal Medicine and Metabolic Diseases, Fondazione IRCCS
Ca’ Granda Ospedale Policlinico di Milano, Milan, Italy
Background: hyperferritinemia (HyperFt) is frequent in males with dysme-
tabolism and has been associated with altered hepatic iron metabolism, incre-
ased hepatic iron stores, and worse hepatic and cardiometabolic outcomes
in patients with nonalcoholic fatty liver disease (NAFLD) and features of
metabolic syndrome. NAFLD is a multifactorial disease resulting from inte-
raction of genetic and environmental factors. Thus identification of genetic
risk factors for HyperFt and iron deposition can help understand disease
pathophysiology and improve management of patients. Aim: we aimed to
evaluate novel genetic risk variants in candidate iron genes associated with
dysmetabolic HyperFt development in NAFLD.
Matherials and Methods: from a cohort of 347 individuals with histological
NAFLD (alcohol intake < 30/20 g/day in M/F) and evaluation of circula-
ting iron metabolism, hepatic iron staining and genetic characterization, we
selected 24 cases (HyperFt) and 24 controls (NormoFt). We first excluded
patients carrying beta-thalassemia trait, persistently increased transferrin
saturation (suggesting a hemochromatosis phenotype), anemia, inflam-
mation, and female sex due to the lower representation and the possible
confounding effect of blood losses and menopause. Among patients with
positive histological iron staining, after exclusion of patients carrying HFE
genotype at risk of iron overload (C282Y+/+, C282Y/H63D, H63D+/+),
and mutations altering protein sequence of ferroportin (the only known
iron exporter in mammals), we selected 24 pts with higher ferritin levels
(>750 ng/ml) (HyperFt patients), and compared to 24 pts with negative
iron staining and lowest ferritin (NormoFt patients). Since we previously
demonstrated that HyperFt correlates with liver iron content, independently
of age and several confounders in the original NAFLD cohort, we chose
ferritin > 750 ng/ml as clinical marker of hepatic iron excess. A custom
AmpliSeq™ Next-Generation Sequencing (NGS) panel of 33 genes associa-
ted to iron homeostasis was designed and tested using Ion Torrent PGM
platform (Life Technologies). The panel was composed by genes related to
hereditary hemochromatosis, iron transport, signaling pathways regulating
the key iron hormone hepcidin, and others. Data analysis has been perfor-
med using Ion Torrent Suite™ Software (Life Technologies), Annovar, VEP,
and an in-house pipeline. Literature information and in silico predictions
(ClinVar, dbNSFP, SPIDEX, dbscSNV, HSF, NNSPLICE) were used for the
prioritization of possibly pathogenetic mutations. NGS sequencing resulted
in a mean coverage of 450X mapped reads, with 89.9% mean uniformity and
95.4% of target regions covered at least 30x (94%>50x).
Results: HyperFt patients were older (57±10 vs. 49±9 yrs, p<0.01), and
expectedly had higher ferritin (median 1099, IQR 953-1391 vs. 94, 53-122;
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%),
obesity (18% vs. 8%), hypertension (22% vs. 16%), and definite nonalcoholic
steatohepatitis (6% vs. 6%). Results showed a significantly different distribu-
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
exact test).
Ceruloplasmin (CP), a copper-protein acting as a ferroxidase whose
absence is associated with systemic iron loading leading to aceruloplami-
nemia, resulted to be the most mutated gene, with the identification of 4
different variants (harbored in heterozygosis by 6 HyperFt patients, p<0.01).
After literature review, polymorphisms reported as possibly pathogenetic
were included in the analysis (as TF c.829G>A or CP c.1652C>T) resul-
ting in 78% of HyperFt patients with variants possibly affecting iron meta-
bolism (respect to 38% of NormoFt patients, p=0.0016). Polymorphisms
reported to modulate iron phenotype were studied as well. Among these,
the TMPRSS6 A736V, which distribution was not significantly different
between IperFt and NormoFt patients. Beyond the iron-panel, patients were
checked for polymorphisms previously associated to advanced liver fibro-
sis or severe iron overload in classic HFE-hemochromatosis: respectively
Comunicazioni Orali
there was no significant difference in the frequency distribution of PCSK7
rs2369918G>C and GNPAT rs11558492 (D519G) between the two groups.
Conclusions: CP variants seem associated with dysmetabolic HyperFt
development, and likely with increased hepatic iron stores, in NAFLD.
Future studies are necessary to confirm these findings in larger cohorts and
to evaluate their clinical relevance.
LIVER CANCER (NOT ETIOLOGY, STEATOSIS OR
FIBROSIS) IS AN INDEPENDENT PREDICTOR OF
ELEVATED SERUM PERIOSTIN CONCENTRATION
AMONG CAUCASIAN PATIENTS WITH LIVER DISEASE
Mulas V.,1 Barbaglia M.N.,1 Tran Minh M.,1 Bianco S.,1 Re A.,1
Salmi L.,1 Barizzone N.,2 Camatta D.,1Sguazzotti M.,1 Daffara F.,1 Minisini
R.,1 Pirisi M.1
Dipartimenti di Medicina Traslazionale1 e Scienze della Salute2, Università
del Piemonte Orientale, Novara
Rationale and Aim: Periostin promotes liver steatosis and hypertriglyceri-
demia through downregulation of peroxisome proliferator–activated recep-
tor α, which makes this extracellular matrix protein a potential therapeutic
target for both non-alcoholic fatty liver disease (NAFLD) and dyslipide-
mia.1 Moreover, since Asian patients with NAFLD have high serum levels
of periostin compared to controls, it has been suggested that circulating
periostin may have a role as a biomarker of NAFLD.2 However, these latter
findings could not be replicated in Caucasians.3 In the present study, we
aimed to verify the possible association of serum periostin with histologi-
cally graded steatosis, stage and etiology of liver disease. Moreover, given
the abovementioned ethnic differences, we were interested in evaluating
the possible relationship between genetics of periostin and serum periostin
concentration.
Methods: N.=155 patients with either NAFLD (Group A, N.=74; in 10 cases
complicated by hepatocellular carcinoma, HCC; N.=37 males) or hepati-
tis C virus (HCV) infection (Group B, N.=81, in 7 cases complicated by
HCC; n.=40 males), as well as in N.=27 healthy controls (Group C, N.=27;
11 males), were studied. Serum periostin concentrations were measured by
the Human Periostin/OSF-2 DuoSet ELISA (R&D Systems, Inc., Minneapo-
lis, USA). Based on single nucleotide polymorphisms rs9603226, rs3829365,
and rs1029728 of the POSTN gene, haplotype analysis was carried out
both in patients and controls using the Haploview software (Broad Insti-
tute, Cambridge, USA). All cases of benign liver disease were histologically
proven and had grade and stage defined. HCC was diagnosed at imaging
and/or confirmed histologically according to the EASL-EORTC clinical
practice guideline criteria. All controls underwent transient elastography
with measure of the controlled attenuation parameter.
Results: The median (interquartile range, IQR) serum periostin concentra-
tion was 11.6 ng/ml (8.7-13.3); it was 10.9 ng/ml (7.7-14.6) in Group A,
12.0 ng/ml (9.8-16.5) in Group B, and 12.0 ng/ml (9.0-16.3) in Group C,
respectively (p=0.06). The Table presents the analysis of serum periostin
based on the severity of liver disease, categorized as absent/mild fibrosis
(Kleiner stage 1 or lower, Ishak stage 1 or lower, stiffness <5.9 kPa), mode-
rate fibrosis (Kleiner stage 2, Ishak stage 2-3), advanced fibrosis (Kleiner
stage 3 or higher, Ishak stage 4 or higher), and HCC (p values refer to Kru-
skal-Wallis test).
Serum Periostin Fibrosis  Fibrosis Fibrosis HCC
(ng/ml) minimal/absent moderate advanced
(N.=79) (N.=38) (N.=48) (N.=17)
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)
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)
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)
Group C 12.0 (9.1-16.3) - - -
Serum periostin was not associated with the degree of histologically graded
steatosis, either in Group A (p=0.409) or in Group B (p=0.899). Further-
more, it had a trend to be inversely related to body mass index (Spear-
man Rho= 0.134, p=0.086), and did not change with age (Spearman Rho
= 0.064, p=0.392). However, the serum periostin concentration increased
in inverse relationship with levels of platelet count (≥150, 100-149, <100
Å~109/L). Finally, possession of the haplotype 2 (rs9603226 = G, rs3829365
= C, rs1028728 = A; N.=116) was associated with lower serum periostin
11
Comunicazioni Orali
in comparison to all other haplotypes (haplotypes 3-6, N.=65, none had a
haplotype 1) (11.3 pg/ml, IQR 8.1-15.5 vs. 12.3, IQR 9.7-17.1, p=0.039). At
multivariate analysis, conducted having age, gender, POSTN haplotype, pla-
telet count and HCC as predictor variables, the only independent predictor
of a serum periostin concentration in the highest quartile of the study popu-
lation was HCC (OR=7.3, 95%CI 1.8-29.9, p=0.005).
Conclusions: In Caucasians, serum periostin concentrations are not
influenced by etiology of liver disease, fibrosis progression or degree of ste-
atosis. Patients with HCC have significantly higher periostin levels. Geneti-
cally determined differences may account for some of the variability obser-
ved among NAFLD populations of different ethnic origin.
References: 1.J Clin Invest 2014;124:3501-13; 2.Endocrine 2016;51:91-100;
3. Endocrine 2017;56:438-41
ADHERENCE TO MEDITERRANEAN DIET AND NON-
ALCOHOLIC FATTY LIVER DISEASE: EFFECT ON
INSULIN RESISTANCE
Pastori D. 1,2, Baratta F. 1,2, Polimeni L. 1, Bucci T. 3, Ceci F. 4, Calabrese C. 1,
Ernesti I. 5, Violi F. 1, Angelico F. 6, Del Ben M. 1
1
I Clinica Medica, Department of Internal Medicine and Medical
Specialties, Sapienza University of Rome, Italy. 2 Department of
Anatomical, Histological, Forensic Medicine and Orthopedics Sciences -
Sapienza University of Rome, Italy. 3 Department of Medical Specialties,
Salerno University of Medicine, Salerno, Italy. 4 Department of Cellular
Biotechnologies and Hematology, “La Sapienza” University, Policlinico
Umberto I Hospital, Rome, Italy. 5 Department of Experimental Medicine,
Section of Medical Pathophysiology, Endocrinology and Nutrition, Sapienza
University, Rome, Italy. 6 Department of Public Health and Infectious
Diseases, Sapienza University of Rome, Italy
Objectives: The prevalence of cardio-metabolic disorders, including non-al-
coholic fatty liver disease (NAFLD), is increasing in western countries, due
to changes in lifestyle and dietary habits. Mediterranean Diet (Med-Diet) is
effective for cardiovascular prevention, but its relationship with NAFLD has
been scarcely investigated.
Methods: We included 584 consecutive outpatients presenting with ≥1
cardiovascular risk factor such as type 2 diabetes mellitus (T2DM), arte-
rial hypertension, overweight/obesity and dyslipidaemia. Liver steatosis
was assessed by ultrasonography. Med-Diet adherence was investigated by
a validated semi-quantitative 9-item dietary questionnaire; patients were
divided into low, intermediate and high adherence. Insulin resistance was
defined by the 75th percentile of HOMA-IR (≥3.8).
Results: Mean age was 56.2±12.4 years and 38.2% were women. Liver ste-
atosis was present in 82.7%, and its prevalence decreased from low to high
adherence group (96.5% vs. 71.4%, p<0.001). In a multiple logistic regres-
sion analysis, hypertriglyceridemia (Odds Ratio (OR):2.913; p=0.002),
log(ALT) (OR:6.186; p<0.001), Med-Diet adherence (intermediate vs. low
OR:0.115; p=0.041, high vs. low OR:0.093; p=0.030), T2DM (OR:3.940;
p=0.003) and high waist circumference (OR:3.012; p<0.001) were associa-
ted with NAFLD. Among single foods, low meat intake (OR:0.178; p<0.001)
was inversely significantly associated with NAFLD. In 334 non-diabe-
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,
while Med-Diet score was inversely associated (OR:0.801, p=0.018).
Conclusions:. We found an inverse relationship between Med-Diet and
NAFLD prevalence. Among NAFLD patients, good adherence to Med-Diet
was associated with lower insulin resistance. Our findings suggest that Med-
Diet may be a beneficial nutritional approach in NAFLD patients.
FACTORS ASSOCIATED WITH OCCURRENCE/
RECURRENCE OF HEPATOCELLULAR CARCINOMA
EARLY AFTER TREATMENT OF HEPATITIS C WITH
DIRECT ANTIVIRAL AGENTS
Camatta D.,1 Mancuso G.,2 Tran Minh M.,1 Barbaglia M.N.,1 Avitabile E.,1
Ceriani E.,3 Leutner M.,3 Fangazio S.,3 Burlone M.E.,
1
Camatta D.,1 Sguazzotti M.,1 Daffara F.,1 Minisini R.,1
Boldorini R.,2 Pirisi M.
1
Dpt of Translational Medicine1 and Dpt of Health Sciences,2 Università del
Piemonte Orientale; AOU Maggiore della Carità;3 Novara
12
118° Congresso Nazionale - Società Italiana di Medicina Interna
Rationale and aim. Recently, several groups have reported a surprisingly
high rate of either de novo or recurrent hepatocellular carcinoma (HCC)
early after treatment of chronic hepatitis C with direct antiviral agents
(DAA). Both the very existence of this phenomenon and its putative expla-
nation (sudden loss of host immune control in the liver) have been questio-
ned; in fact, many believe that what has been observed is simply the result
of treating patients with far more advanced disease compared to the past,
among whom a fair number may harbor hidden HCC foci. It must be noted
that in the presence of active HCC the chances of successful anti-hepatitis
C virus therapy with DAA have been shown to be decreased. In the present
study, our aims were a) to provide further data on the rates of early HCC
occurrence/recurrence in today’s DAA era; b) to identify possibly associated
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
a DAA regimen with or without ribavirin were studied. All were free of
suspicious nodules before starting DAAs and were followed up for at least 6
months after treatment was concluded. Circulating micro RNA (miR) -122,
-373 and -155 were quantified on serum samples obtained at baseline, at
the end of treatment and at week 12 post-treatment (timing of definition
of sustained viral response, SVR12) from patients who developed HCC
(group A) and a selection of control patients (n.=30; group B) who did not,
extracted from the same population and matched for age and sex with group
A patients.
Results: During the first 24 weeks after treatment completion, de novo HCC
was detected in 9/273 patients (incidence rate 7.1% per year); recurrent
HCC was observed in 2/13 patients (incidence rate 33.4% per year). These
11/286 patients did not differ with regard to age, gender, baseline viral load
and liver biochemistry parameters from the remaining 275/286 patients.
However, as compared to the latter, they did have a significantly higher
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
107-143 vs. 140, IQR 130-151; p=0.040). Moreover, they displayed a trend
towards having higher body mass index (29.7 kg/m2, IQR 26.2-33.2 vs. 25.6,
IQR 22.9-29.4). Importantly, the intention-to-treat SVR12 rates were lower
among patients with de novo/recurrent HCC than among their counterparts
HCC-free at the end of follow up (7/11, 64% vs. 261/275, 95%; p<0.001). At
multivariate logistic regression, body mass index (OR=1.27, 95%CI 1.06-
1.51, p=0.009), previous HCC (OR=41, 95%CI 3.32-507, p=0.004) and
SVR12 (OR=0.03, 95%CI 0.004-0.30, p=0.002) were independent predictors
of HCC occurrence/recurrence. Circulating miR concentrations at baseline
were not different between group A and group B patients; however, serum
miR-122 concentrations declined between baseline, end-of-treatment and
post-treatment week 12 among group B (p=0.015) but not among group A
patients (p=0.165).
Conclusions: Advanced disease, excess body weight, and failure to clear the
virus (accompanied by relatively flat kinetics of miR-122) identify patients
who develop early HCC occurrence/recurrence following DAA treatment,
suggesting that treatment per se does not favor the emergence of HCC; on
the contrary, it is likely that undetected foci of active HCC, already present
before starting treatment, emerge. A practical implication of these findings
is that patients with the above high risk features should have counseling
and surveillance optimized before and after DAA treatment of hepatitis C.
REACTIVE HYPEREMIA INDEX (RHI) AND ARTERIAL
STIFFNESS INDEXES ARE ASSOCIATED WITH
HISTOLOGIC MARKERS OF LIVER DISEASE IN SUBJECTS
WITH NON-ALCOHOLIC FATTY LIVER DISEASE
(NAFLD) WITH AND WITHOUT NON-ALCOHOLIC
STEATOHEPATITIS (NASH)
Tuttolomondo A. 1, Petta S. 2, Casuccio A. 3, Maida C. 1,
Della Corte V. 1, Daidone M. 1, Di Raimondo D. 1, Pecoraro R. 1, Fonte R. 1,
Cirrincione A. 1, Zafonte R. 4, Cabibi D. 5, Cammà C. 2, Di Marco V. 2, Licata
A. 2, Magliozzo F. 4, Marchesini G. 6,
Merlino G. 4, Craxi A. 2, Pinto A. 1
1
U.O.C di Medicina Interna con Stroke Care, Dipartimento Biomedico di
Medicina Interna e Specialistica (Di.Bi.M.I.S), Universita` di Palermo, Italy
2
Sezione di Gastroenterologia e Epatologia, Dipartimento Biomedico di
Medicina Interna e Specialistica (Di.Bi.M.I.S), University of Palermo, Italy 3
Dipartimento di Scienze per la Promozione della Salute e Materno Infantile,
Università di Palermo, Italy. 4 Medicina Generale Palermo, Italy 5 Cattedra di
Anatomia Patologica, University of Palermo, Italy 6 Dipartimento di Scienze
Mediche e Chirurgiche, “Alma Mater Studiorum,” Università di Bologna, Italy
118° Congresso Nazionale - Società Italiana di Medicina Interna
Background: Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic
steatohepatitis (NASH) are associated with cardiovascular events and Meta-
bolic Syndrome (MetS). Some studies have reported an association between
NAFLD and cardiovascular morbidity, whereas some recent studies have
reported that subjects with NAFLD have risk factors putative to be considered
as surrogate risk factors of cardiovascular morbidity. Several useful surrogates
in clinical setting include Framingham Risk Score, carotid artery intima-me-
dia thickness, hsCRP, visceral and mediastinal fat, and coronary calcium
scores. Adjunctive surrogates for cardiovascular risk more recently valida-
ted by some studies are arterial stiffness and endothelial function indexes.
Forearm flow-mediated vasodilation (FMD) is a classical method to evaluate
endothelial dysfunction. However, findings offered by FMD can be very diffe-
rent owing to technical issues thus this technical method has been reported as
not standardized.A new method useful to measure endothelial dysfunction,
reactive hyperemia peripheral arterial tonometry (RH-PAT) has been repor-
ted by Kuvin et al. This method is noninvasive and quantitative and it offers a
digital measurement of hyperemic response. Framingham Heart Study repor-
ted RHI (reactive hyperemia index) as inversely correlated with various car-
diovascular risk factors.Augmentation pressure and PWV have been reported
as surrogate markers for cardiovascular disease strictly linked to endothelial
dysfunction. Nevertheless only a few studies analyzed arterial stiffness indexes
in NAFLD patients and a previous study analyzed endothelial dysfunction in
these subjects by means flow mediated dilation and flow-mediated vasoacti-
vity (FMV) findings reporting in NAFLD patients, a significant association
between low FMV and NASH. No study evaluated vascular health markers in
subjects with NAFLD by means of a combined analysis of reactive hyperemia
peripheral arterial tonometry (RH-PAT) and arterial stiffness indexes. Aim:
we aimed to assess whether NAFLD and its histological severity are associated
with impairment of arterial stiffness and RH-PAT indexes in a mixed cohort
of patients with biopsy-proven NAFLD.
Materials and Methods:We recruited all NAFLD patients admitted at the
Gastrointestinal & Liver Unit of Palermo University Hospital. Inclusion cri-
teria were: 1) a histological diagnosis of NAFLD on a liver biopsy obtained
less than 6 months before enrollment The Kleiner classification was used
to grade NAFLD grade. Pulse wave velocity and augmentation index were
used as markers of arterial stiffness, whereas endothelial function was eva-
luated by Endo-PAT2000 measuring reactive hyperemia index (RHI). The
Mini-Mental State Examination (MMSE) was administered to assess cogni-
tive function.
Results: 80 consecutive patients with biopsy-proven NAFLD and 83 indi-
viduals without fatty liver disease. NAFLD subjects had significantly lower
mean RHI, higher mean arterial stiffness indexes and lower mean MMSE
score. Among NAFLD subjects those with NASH showed no significant dif-
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
fibriosis grade and Kleiner inflammation grade and PWV and a significant
relationship between Kleiner fibrosis and AIX, whereas among subjects
without NASH a significant negative relationship was observed between
Kleiner inflammation and RHI.
Conclusions: our findings show how the relationship between endothelial
function expressed by RHI and histological severity of NAFLD is confined
only in non NASH subjects, whereas in more advanced stages of hepatic
damage, the relationship between histological severity and endothelial disfun-
ction has not more reported in favour of clear direact relationship with arte-
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
advanced stages of NAFLD such as NASH that it is characterized by more
evident relationship with more advanced stages of vascular damage such as
impairment of arterial stiffness. We reported that NAFLD subjects in com-
parison with control subjects showed significantly lower MMSE mean value.
Evidence from epidemiology and pathology studies indicates that damage
to the vascular system is associated with an increased risk of many types of
cognitive impairment. This finding of a lower MMSE mean scores observed
in NAFLD patients (mean MMSE 26.9) may represent a further issue confir-
ming the role of arterial stiffness and endothelial dysfunction also in clinical
setting of cognitive performance. These results suggest the potential role of
endothelial function, evaluated by measurement of endothelial function using
peripheral arterial tonometry (EndoPAT), as a possible future biomarker of
vascular pathology in NAFLD.
SUBCLINICAL CAROTID ARTERY ATHEROSCLEROSIS
PREDICTS THE PRESENCE OF COLORECTAL
ADENOMAS: A CROSS-SECTIONAL STUDY WITH A
Comunicazioni Orali
MULTIDISCIPLINARY APPROACH
1
Mancini S., 2Sena P., 1Mariani F., 1Mattei G., 1Ferrari S., 3Alboni S., 1Boarino
V., 1Merighi A., 1Roncucci L.
1
Dipartimento di Medicina Diagnostica, Clinica e di Sanità Pubblica;
2
Dipartimento di Scienze Biomediche, Metaboliche e Neuroscienze;
3
Dipartimento di Scienze della Vita; Università di Modena e Reggio Emilia,
Modena, Italy
Background: Colorectal cancer (CRC) is the second cause of cancer death
in men and the third in women worldwide. CRC arises from colonic mucosa
inflammatory changes that are susceptible of early detection and removal.
Growing evidence shows that metabolic, immunologic, and neuroregula-
tory processes can affect bowel pathophysiology. Our knowledge on the link
between metabolic, atherogenic, and psychic determinants and molecular
pathways of colorectal carcinogenesis needs to be improved.Aim: To assess
through a multidisciplinary model the association among metabolic status,
proatherogenic factors, psychological determinants, inflammatory changes in
the colorectal mucosa, and the presence of adenomas.
Methods: 64 consecutive patients (M/F 33/31) undergoing colonoscopy
were evaluated with ultrasound vascular assessment (carotid artery inti-
ma-media thickness, q-IMT© (MyLab25Gold, Esaote), and brachial artery
flow-mediated dilation, FMD), a complete lipid profile, a set of psychome-
tric tests, immunohistochemistry assay of colonic biopsies for autophagy
(LC3B-II) and myeloperoxidase (MPO) expression, matched with clinical
and anthropometric characteristics. Odds ratios (OR) for each predictor of
the presence of adenomas have been assessed. Then, multivariate statistical
analysis has been conducted among the best predictors of the presence of
colorectal adenomas. Statistical analyses were performed with SigmaPlot©
v.12 (Systat Software, Inc., San Jose, CA 95131 USA). p < 0.05 was conside-
red significant.
Results: 29 out of 64 subjects were positive for at least one colorectal
adenoma. Male sex (OR 3.76, p 0.013), BMI≥30 (OR 3.25, p 0.037), chole-
sterol levels (total and LDL, OR 4.73, p 0.004 and OR 8.67, p 0.001, respecti-
vely), elevated C-reactive protein (OR 5.56, p 0.003), as well as LC3B-II and
MPO expression in the colonic mucosa, q-IMT values, and a score among
psychometric tests (Temperament and Character Inventory-Self Tran-
scendence) resulted associated with an increased occurrence of colorectal
adenomas in univariate analyses. Multivariate analysis showed that q-IMT
remained an independent predictor of the presence of colorectal adenomas.
Conclusions: This study provides evidence that novel factors, and in par-
ticular q-IMT, could be considered for the assessment of colorectal cancer
risk.
THE IMPACT OF TROFIC EFFECTS OF MULTI STRAIN
PROBIOTIC PREPARATION ON PARACELLULAR
PERMEABILITY
Petito V.1, Laterza L.1, Graziani C.1, Lucchetti D.2, Lopetuso L.R.1, Sgambato
A.2, Scaldaferri F.1, Gasbarrini G.1, Gasbarrini A.1 1Gastroenterological
Area, Gastroenterological and Endocrino-Metabolical Sciences Department.
Catholic University of Sacred Heart of Rome-A. Gemelli Hospital 2 Pathology
Department. Catholic University of Sacred Heart of Rome-A. Gemelli
Hospital
Introduction: Probiotics are defined as live, non‐pathogenic bacteria that
confer health benefits beyond their nutritional value. Particularly VSL#3,
a probiotic mix containing 4 strains of Lactobacilli (L. paracasei, L. plan-
tarum, L. acidophilus and L. delbrueckii subsp. bulgaricus*), 3 strains of
Bifidobacteria (B. longum2, B. infantis2, B. breve) and Streptococcus ther-
mophilus, has demonstrated efficacy in the management of diseases cha-
racterized by increased intestinal permeability such as irritable bowel syn-
drome and ulcerative colitis. Several mechanisms have been postulated to
contribute to the anti‐inflammatory effect of probiotics in the gut, but few
studies exist describing in vitro effects of probiotics. (*Recently reclassified
as L. helveticus. 2Recently reclassified as B. animalis subsp. lactis.) Aims &
Methods: The aim of the present study was to evaluate the mechanism of
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-
ning media (CM) prepared using 1g of probiotic formula grown in D‐MEM
cell
culture medium (free of serum and antibiotics) at 37°C for 48 hours without
13
Comunicazioni Orali
shaking and in anaerobic conditions. The CM was be centrifuged at 4,100
rpm for 10 min to separate the bacteria, and diluted 1:10 and 1:25. The
effects of probiotic on proliferations of cells were evaluated by cell growth
curve and MTT assay. The growth curve was performed by ECIS (Electric
Cell‐Substrate Impedance Sensing) where the increase of impedance is
directly proportional to increase of cell number in the well. The MTT assay
is based on the conversion of MTT salt into insoluble formazan crystals
by living cells.The effect on apoptosis will be analyzed by cytometry using
double staining with Annexin V‐FITC and Propidium Iodide. Furthermore,
the effect on expression of tight junctions, in particular claudin‐2, occludin
and ZO‐1, was be investigated by western blot analysis.
Results: The multistrain probiotic formula, in particular the more con-
centrate CM (1:10) increases HT29 cell proliferation and the percentage of
metabolic cell activity (up 20%), together with a decrease of 90% of apopto-
tic cells in presence of CM. The expression of tight junction proteins increa-
ses in 24 hours for claudin and ZO‐1, and after 48 hours of treatment in case
of occludin. Also the densitometry and the ratio between of relative density
of protein and endogenous control (β‐actin) confirms these data. The results
are the same using two different lots.
Conclusion: These preliminary data in vitro could be able to explain how
VSL#3 works at intestinal mucosa level, in particular by secretion of factors
that enhances barrier integrity. The proliferative stimuli and the increase of
expression of tight junction proteins are consistent with an effect on mucosa
regeneration and re‐epithelization. Other experiments, also on other inte-
stinal cell line, are necessary to deeply understand the mechanism of action
of this kind of probiotic formula.
SPLENIC HYPOFUNCTION IN AUTOIMMUNE ATROPHIC
GASTRITIS
Di Sabatino A., Giuffrida P., Lenti M.V., Aronico N.,
Cococcia S., Padula D., Miceli E., Corazza G.R.
First Department of Medicine, San Matteo Hospital Foundation, University
of Pavia, Pavia, Italy
Background and Aims: Splenic hypofunction is an acquired condition
which may predispose to bacterial infections, autoimmunity or thrombo-
embolism. Immune-mediated gastrointestinal disorders, including celiac
disease and inflammatory bowel diseasem are the most frequently reported
conditions associated with hyposlenism. However, no data are available as
far as autoimmune atrophic gastritis (AAG) an immune-mediated chronic
inflammation of the gastric body and fundus, leading to hypo-achlorhydria
and vitamin B12 deficiency. We evaluated splenic function through pitted
red cell (PRC) counting, i.e. erythrocytes with membrane abnormalities
visible under interference phase microscopy as ‘pit’, in patients with AAG.
Methods: A peripheral blood sample was collected from 10 consecutive
patients (mean age 66 yrs) who had a confirmed diagnosis of AAG (corpus/
fundus atrophy with antrum sparing and positivity to anti-parietal cells
antibody). Sex- and age-matched patients with splenectomized patients
(n=20) and healthy volunteers (n=20) were also enrolled as positive and
negative control groups, respectively. PRC counting was performed with
direct-interference contrast microscope equipped with Nomarski optics
(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
the splenectomized patients had an impaired splenic function. Median PRC
values were significantly (p<0.001) higher in AAG patients (5.3%, range 3.4-
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)
in comparison to AAG patients (p<0.001), and healthy controls (p<0.0001).
Conclusions: We here reported for the first time the association between
hyposplenism and AAG. Further studies on larger series of patients are
required to assess the real prevalence of splenic hypofunction in AAG, and
to clarify the pathophysiological mechanisms underlying this association.
STUDY OF THE MICROBIOTA COMPOSITION IN
DIFFERENT FORMS OF ADULT CELIAC DISEASE
Biagi F. 1, Panelli S. 2,3, Schiepatti A. 1, Betti E. 1, Cangemi G.C. 1, Lombardo
C. 2,3, Capelli E. 2,3, Corazza G.R. 1, Ciccocioppo R. 4
1
Coeliac Centre, First Department of Internal Medicine, IRCCS Foundation
Policlinico San Matteo, University of Pavia, Pavia, Italy; 2Department
of Earth and Environmental Sciences, University of Pavia, Pavia, Italy;
14
118° Congresso Nazionale - Società Italiana di Medicina Interna
Centre for Health Technologies (C.H.T.), University of Pavia, Pavia, Italy;
3
Gastroenterology Unit, Department of Medicine, AOUI Borgo Roma,
4
University of Verona, Verona, Italy
Introduction:: Celiac disease (CD) is a chronic multifactorial enteropathy
triggered by gluten ingestion in genetically susceptible individuals. In the
last years it has emerged that gut microbiota is strongly involved in the dif-
ferentiation of intestinal epithelium, regulation of gut permeability, mucosal
immunity, development of responses to microbial and dietary antigens and
avoidance of overreactions. This is the key to understand how intestinal
dysbiosis may play a role in disrupting the immune homeostasis, thus con-
curring to the pathogenesis of some chronic inflammatory and autoimmune
conditions, including CD itself. Up to now, the relationship between shift in
the intestinal microbiota and CD has been described. However it is rather
challenging to understand whether this can be secondary to CD itself or
could have a primary role in influencing the clinical picture and severity of
the disease.
Aim: To obtain a comparative metagenomic picture of salivary, duodenal
and fecal microbiota composition in adult patients affected by different
forms of celiac disease. To compare the salivary, duodenal and fecal micro-
biota composition of CD patient with controls suffering from functional
dyspepsia. PATIENTS & METHODS: From November 2015 to June 2016
we enrolled a total of 32 CD patients divided into four groups: 8 active CD
patients (all females; mean age at diagnosis 31±4 years; 6 with a classical
presentation at diagnosis, 1 non classical, 1 silent), 20 treated CD patients
(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
by type 1 refractory CD (2F, age at diagnosis of CD 35 and 57 years old
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
and 1 male, silent, 45 years old at diagnosis). 13 patients affected by fun-
ctional dyspepsia (11 F, mean age at enrollment 51±4 year) were used as
controls. For each patient and control, DNA extraction and quantification
(Qiagen, Milan, Italy, UE), PCR production of 16S rRNA amplicons and
sequencing libraries, high-throughput sequencing of libraries on Illumina
MySeq platform (BMR Genomics, Padova, Italy, UE) were performed on
salivary, duodenal mucosa, and fecal samples. Bio-informatic analyses were
then performed on raw sequencing data (BMR Genomics). The correspon-
ding Operational Taxonomic Units (OTU) tables were produced.
Results: After polishing raw sequences, the mean number of high-quality
reads was: 55603 for feces, 103616 for saliva, 59514 for biopsies. OTU tables
show that the mean number of bacterial OTUs at 97% homology level,
corresponding to the number of bacterial species, is: 151 for feces, 286 for
saliva, 212 for biopsies. Preliminary β-diversity analyses suggest composi-
tional differences in bacterial consortia in terms of reduction of Firmicutes
and increase of Proteobacteria at level of Phyla, while a reduction of Veil-
lonella and an increase of Neisseria Genera were observed in both salivary
and mucosal samples of CD patients in comparison to controls.
Conclusion: The preliminary results of our study confirm the presence of
a dysbiosis in adulthood CD, with a substantial similarity between salivary
and mucosal data. This may also open the route for future non-invasive dia-
gnostic assessment in CD.
EMERGING ROLE OF IL-33/ST2 LEVELS IN PREDICTING
MUCOSAL RESPONSE TO ANTI-TNF THERAPY IN
ULCERATIVE COLITIS
Lopetuso L.R. 1,2, Petito V. 1, Graziani C. 1, Scannone D. 1,
Pizarro T.T. 2, Gasbarrini G. 1, Scaldaferri F. 1, Gasbarrini A 1
1
Internal Medicine, Gastroenterology Division, Catholic University of Sacred
Heart of Rome, Rome, Italy; 2Pathology, Case Western Reserve University -
School of Medicine, Cleveland, United States
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-
tor, ST2, in intestinal inflammation is incompletely understood, with both
pro-inflammatory and regulatory properties described. Recent evidence has
shown that anti-TNF is able to modulate the IL-33/ST2 axis in inflamma-
tory conditions, probably through an interplay with gut microbiota. The aim
of our study was to explore the potential role of the IL-33/ST2 axis in the
mucosal healing process mediated by anti-TNF therapy in UC.
Methods: Endoscopic MAYO score was calculated before the first anti-TNF
infusion (T0) and after 6 weeks (T2). 24 UC patients (MAYO score at T0 ≥
118° Congresso Nazionale - Società Italiana di Medicina Interna
2), grouped into 12 responders with mucosal healing (MAYO score ≤ 1) and
12 non-responders to anti-TNF at T2 (MAYO score ≥ 2) were enrolled. 10
healthy controls undergoing routine colonoscopy for tumor screening were
also enrolled. At each time point, serum samples were collected and ELISA
performed to assess IL-33/ST2 protein levels. Intestinal biopsies were also
taken from the rectum and IHC was done to evaluate mucosal IL-33/ST2
expression and localization.
Results: IL-33 protein levels were significantly increased in responders vs.
non-responders, both at T0 and T2. Among responders, IL-33 protein was
slightly reduced at T2 vs. T0, while unchanged in non-responders. Intere-
stingly, significantly higher levels of ST2 were found in responders vs. not
responders at T0, while no differences between groups were found at T2.
Among responders, ST2 levels were dramatically reduced at T2 vs. T0. No
significant differences were found in non-responders at both time points.
Healthy controls showed significantly lower levels of both IL-33 and ST2
compared with other groups. IHC confirmed these observations. In par-
ticular, IL-33 and ST2 staining was more intense within the inflamed and
ulcerated mucosa of responders compared to non-responders at T0. After 6
weeks, ST2 staining was even more evident in responders, notably localized
to the healed mucosa and in close proximity to areas of re-epithelialization.
Little to no staining for both IL-33 and ST2 was present in healthy controls.
Conclusions: Our results suggest a possible role for IL-33/ST2 in predicting
gut mucosal wound healing in patients with moderate-to-severe UC treated
with anti-TNF. A possible interplay between IL-33/ST2 axis and gut micro-
biota could partially explain these results. Further studies are underway to
determine mechanisms of action that support these findings.
INTERACTION BETWEEN LRP5 AND PERIOSTIN GENE
POLYMORPHISMS ON SERUM PERIOSTIN LEVELS AND
CORTICAL BONE MICROSTRUCTURE
Pepe J. 2, Bonnet N. 1, Herrmann F.R. 1, Biver E. 1, Rizzoli R. 1, Chevalley T. 1,
Ferrari S.L. 1
1
Division of Bone Diseases, University Hospitals and Faculty of Medicine,
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,
Geneva University Hospitals and University of Geneva,Switzerland
Purpose: To investigate the interaction between polymorphisms (SNPs) of
periostin and of other genes that modulate periostin expression on periostin
serum levels and on bone microstructure in a cohort of postmenopausal
women.
Methods: In 648 postmenopausal women from the Geneva Retirees
Cohort, we analyzed 6 periostin SNPS (rs9547952, rs9603226, rs7322993,
rs9576308, rs7338244, rs9547970) and other 149 SNPs in 14 genes, namely
BMP2, CTNNB1, ESR1,ESR2, LRP5, LRP6, PTH, SPTBN1, SOST, TGF
b1, RANK, RANKL, OPG and WNT16.Volumetric BMD and bone micro-
structure were measured by high-resolution peripheral quantitative compu-
ted tomography at distal radius and tibia.
Results: Serum periostin levels were associated with radial cortical poro-
sity, also after adjustment for age and BMI, and years since menopause
(p=0.036).Sixteen SNPs in ESR1, LRP5,OPG,SOST,SPTBN1, RANK and
RANKL genes were associated with serum periostin serum levels (p range
0.03-0.001).Twenty-six SNPs of 9 genes were associated with cortical poro-
sity at radius and/or at tibia. In particular,1 SNPs in each LRP5, ESR1 and
near RANK genes were associated with cortical porosity and with serum
periostin levels.The periostin SNP rs9547970 was also associated with cor-
tical porosity at radius and tibia (both p=0.04).We identified an interaction
between LRP5 SNP rs648438 and periostin SNP rs9547970 on serum perio-
stin levels (interaction p=0.01) and on radial cortical porosity (interaction
p=0.005).In particular, lower serum periostin levels and higher cortical
porosity were associated with periostin SNP 954790 GG and LRP5 SNP
rs648438 CC and CT.
Conclusion: If confirmed in independent cohorts, these results suggest a
role of serum periostin levels as bone cortical markers, regulated mainly by
LRP5 pathway.
MINERAL METABOLISM ABNORMALITIES IN PATIENTS
WITH PROSTATE CANCER: A SYSTEMATIC CASE
CONTROLLED STUDY
Colangelo L., Cipriani C., Pepe J., Biondi P., Cilli M., Minisola S.
Dipartimento di Medicina Interna e Specialità Mediche, Policlinico Umberto
Comunicazioni Orali
I, “Sapienza” Università di Roma
Purpose: Prostate cancer is the most common tumor in men. To the best of
our knowledge a systematic assessment of bone and mineral abnormalities
has not been performed in prostatic cancer patients consecutively enrolled.
Methods: This study was therefore carried out to investigate changes of ske-
letal and mineral metabolism in patients with prostate cancer (n = 69). A
population of patients with cancer of various origin was also investigated
as a control group (n = 53), since a comparison with non-prostate cancer
patients has not been previously reported.
Results: In the prostatic cancer group, one patient had extremely high values
of C-terminal Fibroblast Growth Factor 23, low values of tubular reabsorp-
tion of phosphate and very high values of bone alkaline phosphatase, sug-
gesting the diagnosis of oncogenic osteomalacia. We found nine patients
with primary hyperparathyroidism in the group of prostate cancer vs. only
one in cancer patients group (p < 0.026). We stratified the population on
the basis of Gleason score, prostate specific antigen and hormonal therapy.
Using a generalized linear model with a logit link to predict the probability
of developing primary hyperparathyroidism, only Gleason score, C-termi-
nal fibroblast growth factor 23 and hormonal therapy had a significant effect
(p < 0.05). Controlling for other covariates, a rise in fibroblast growth factor
23 increases the odds of developing primary hyperparathyroidism by 2% (p
= 0.017), while patients with higher values of Gleason score have a much
greater probability of developing primary hyperparathyroidism (log-odds =
3.6, p < 0.01). The probability decreases with higher values of Gleason score
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 <
0.01) decreasing the odds of developing primary hyperparathyroidism by
8%.
Conclusion: We showed a remarkable prevalence of primary hyperpara-
thyroidism in men with prostate cancer; the multivariate analysis demon-
strates that higher aggressive-ness of prostate cancer, as determined by
Gleason score, is a significant predictor of increased risk of developing
primary hyperparathyroidism.
THE EFFECT OF DENOSUMAB ON BONE MASS AND
MINERAL METABOLISM IN PATIENTS WITH SYSTEMIC
MASTOCYTOSIS
Di Stefano M. 1, Benedetti I. 1, Elena C. 2, Bergonzi M. 1,
Pesatori E.V. 1, Manfredi G.F. 1, Deamici M. 3, Grandi G. 1,
Pagani E. 1, Torre C. 3, Merante S. 2, Cazzola M. 2, Marseglia G.L. 3, Corazza
G.R. 1
1
Department of Internal Medicine, 2Department of Hematology and
3
Department of Pediatrics, IRCCS S. Matteo Hospital Foundation, University
of Pavia, Italy
Background: Mastocytosis is a rare disease characterized by abnormal
proliferation and invasion of neoplastic mast cells in many tissues with a
predominant involvement of bone marrow and skin. Bone involvement
is also very frequent and the prevalences of bone loss and bone fractures
are estimated up to 60% and 20% of cases, respectively (1,2). Bisphospho-
nate administration is considered an effective treatment of osteoporosis in
mastocytosis and a BMD yearly increase ranging from 5 to 8% was descri-
bed (3,4). Denosumab is a human monoclonal antibody against RANKL, a
pro-resorptive agent which binds to its receptor (RANK) on preosteoclasts
and osteoclasts, inducing bone resorption. Denosumab showed a significant
efficacy in the treatment of postmenopausal osteoporosis (5). Up to now, a
single case series of four patients with mastocytosis is available (6), showing
a positive effect of 1-year treatment. In five patients referred to our depart-
ment, denosumab was administered and results after one year of treatment
were reported.
Patients and Methods: Five patients (2 females, aged from 17 to 74) with
systemic mastocytosis with skin involvement and without gastrointestinal
symptoms (3 Indolent SM, 1 aggressive SM) referred to our outpatient
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,
WHO criteria). two patients had pathological fractures with vertebral col-
lapses: one patient at D5 and D7, the other patient at L1 level. The BMI
ranged from 19.2 to 26. All the patients had a previous treatment with
bisphosphonates, vitamin D and calcium supplementation. Lumbar BMD
was measured with DEXXA together with the following indices of bone and
mineral metabolism: parathyroid hormone (PTH), 25(OH)- vitamin D and
15
Comunicazioni Orali
1,25(OH)2-vitamin D, osteoprotegerin, RANK-L, telopeptide of type I col-
lagen. Denosumab 60 mg every 6 months sc was started and all the parame-
ters were evaluated again after 1 year of treatment.
Results: The treatment with denosumab improved bone mass and mineral
metabolism. Basal mean lumbar T-score increased from -1.70 ±1.56 to
-0.72±1.20. In particular, the two osteoporotic patients became osteopenic
and the three osteopenic patients normalized lumbar BMD values. None of
the patients showed the occurrence of new fractures. Basal PTH was 44±31
pg/ml and after treatment was 35±11 pg/ml; basal 25-vitaminD was 80±66
ng/ml and post-treatment value was 36±18 ng/ml; basal 1,25-vitaminD
79±25 pg/ml and post-treatment value was 73±27 pg/ml; basal osteoprote-
gerin was 4.1±2.5 pmol/l and post-treatment value was 3.1±0.9 pmol/l; basal
telopeptide was 0.55±0.3 mg/ml while post-treatment value was 0.24±0.1
mg/ml. None of the patients suffered from side effects. None of the patients
presented new fractures.
Conclusion: The administration of denosumab in patients with mastocyto-
sis and bone loss remarkably improves lumbar BMD and bone metabolism.
The high risk of fractures that characterizes this condition suggests the use
of an effective treatment and denosumab seems the best available option
both in terms of efficacy and tolerability.
References: 1. Rossini M, et al. Bone 2011;49:880–885 2. Rossini M, et al.
Immunol Allergy Clin North Am 2014; 34:383–396 3. Rossini M, et al,
AM J Med 2014; 127:1127.e-1127.e4 4. Lim AYM, et al. Ann Rheum Dis
2005;64:965-966 5. Mc Clung MR, et al. NEJM 2006;354:821-31. 6. Orsolini
G et al, Calcif Tissue Int 2017;100:595-598.
COMPUTERIZED VIDEO-CAPILLAROSCOPY
MICROCIRCULATORY ALTERATIONS RELATED TO
DIABETES MELLITUS AND ITS MICROVASCULAR
COMPLICATIONS
Lisco G., Cignarelli A., Cicco G., Garruti G., Laviola L., Giorgino F.
Section of Internal Medicine, Endocrinology, Andrology and Metabolic
Diseases, Department of Emergency and Organ Transplantation, University
of Bari Aldo Moro, Bari, Italy
Background: Diabetes mellitus (DM) is a high world prevalence chronic
disease characterized by elevated plasma glucose concentrations contribu-
ting tochronic micro- and macro-vascular complications (i.e., retinopathy,
nephropathy, neuropathy and cardiovascular diseases).
To carry out an early identification of microvascular complications, speci-
fic, standardized and inexpensive tests are urgently needed. Computerized
nailfold videocapillaroscopy (CNVC) is a tool to easily evaluate microcircu-
lation damage at the level of the fingers and could be potentially useful to
characterize the “diabetic capillaropathy”.
Material and Methods: This was a prospective study using CNVC to
examine the prevalence of capillaroscopic damage patterns in a cohort of
type 1 (T1D) and type 2 (T2D) diabetic individuals, and to assess its rela-
tionship with the level of glycometabolic control (HbA1c). From December
2016 to June 2017, we performed a CNVC examination in 63 of 70 T2D
(mean age 63±10.7; male 65,7%) and 22 of 24 T1D (mean age 44±15.9, male
50%) consecutive patients and in 37 of 38 controls without diabetes (mean
age 44.4±15.7, male 33.3%).
Results: Nailfold microcirculation alterations were found to be more pre-
valent in individuals with diabetes, including tortuosity (81.0% in T2D and
86.4% in T1D vs 43.3% in controls; p <0.01), avascular zones (38.1% in
T2D vs 9.1% in T1D and 2.7% in controls; p <0,01), and ectasiae (72.7% in
T1D and 46% in T2D versus 32,4% controls; p <0,01). At least two of these
capillary alterations were found with a higher prevalence in T2D and T1D
patients vs controls (55.6% and 72.7% vs 18.9%; p<0.01). Three different
capillaroscopic patterns were observed in the diabetic population: class 1,
composed by tortuosity plus ectasiae; class 2, composed by tortuosity plus
avascular zones; and class 3, composed by ectasiae plus tortuosity. In T2DM
patients, no difference in the prevalence of these capillaroscopic classes were
found. By contrast, a higher prevalence of capillaroscopic class 1 pattern was
found in T1D patients (in 14 of 22 examinations; p<0,001). Finally, in both
T2DM and T1DM patients, a higher prevalence of the capillaroscopic class
1 pattern was found to be associated with worse glycemic control, defined
as HbA1c >7.0% and with albumin/creatinine urinary excretion ratio >30
mg/g.
Conclusions: These preliminary data confirm the presence of a “diabetic
capillaropathy”, characterized by different damage patterns, and particularly
by class 1 abnormalities in T1D. These alterations appear to be related to the
level of metabolic control and existence of microvascular damage.
16
118° Congresso Nazionale - Società Italiana di Medicina Interna
VERTEBRAL FRACTURES COMPLICATING PREGNANCY
Sonato C., Colangelo L., Biondi P., Gianni W., Cilli M., Cipriani C., Pepe J.,
Minisola S.
Dipartimento di Medicina Interna e Specialità Mediche, Policlinico Umberto
I, Sapienza Università di Roma
A 29 year-old-woman was admitted to our Department complaining of
acute pain in lumbosacral region apparead abruptly while raising her
newborn baby from the cradle. The orthopedist had prescribed orthopedic
bust. On pathological history: one month before childbirth naturally, cur-
rently breastfeeding. No other pathology noteworth. On physical examina-
tion: general mediocre health conditions, suffering woman, BMI 18.9 kg/
m2; pain and achiness at pression in lumbar column region; absence of pal-
pable superficial lymph nodes and palpable node at the breast examination.
The patient performed column MRI that documented vertebral fractures
of D6, D10, D11 and L5. Suspecting secondary neoplastic localization, the
physician required dosage of the major tumor markers, resulting normal.
The review of the investigations performed during pregnancy highlighted:
hypercalcemia (Ca: 11.2 mg/dl), which had not been further investigated.
The patient was then re-evaluated biochemically, at our Department with
the evidence of persisted hypercalcemia (Ca++1.42 mmol /l, nv 1.17-1.33)
associated with suppressed PTH values (3 pg/ml nv 10-65) and vitamin
D values in the normal range. DEXA values showed reduced lumbar and
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)
that, together with reduced levels of estradiol and progesterone, can induce
increase in bone turnover (brain-breast-bone circuit). This is confirmed in
our patient by the increase in the serum levels of bone resorption markers
(Telopeptide C-Terminal: 2880 pg/ml, nv <1350). The biochemical and cli-
nical state was therefore attributable to pregnancy associated osteoporosis
in the absence of other secondary causes complicated by hyperproduction
of PTHrp. Our patient was advised to stop breastfeeding to achieve nor-
malization of calcium (Ca++1.31 mmol/l) and an anti-absorption drug
(Denosumab) was administered to speed up repair of skeletal damage.
In conclusion, this is a rare case of correlated PTHrp hypercalcemia that
occurred during pregnancy osteoporosis and that resolved with childbirth
and cessation of breastfeeding.
LOWER RATE OF HYPOGLYCEMIA WITH IDEGLIRA VS
INSULIN GLARGINE REGARDLESS OF DOSING TIME OR
HYPOGLYCEMIA DEFINITION IN PATIENTS WITH TYPE
2 DIABETES
G. Sesti 1, R. Chen 2, E. Jaekel 3, I. Lingvay 4, H. Jarlov 5,
L. Lehmann 5, G. Lastoria 6, S. Heller 7
Università degli Studi Magna Græcia, Catanzaro, IT,1 Concord Repatriation
General Hospital, Sydney, NSW, Australia2, Hannover Medical School,
Hannover, Germany3UT Southwestern Medical Center, Dallas, TX,
USA,4,Novo Nordisk A/S, Søborg, Denmark5 Novo Nordisk Medical Affairs
Rome, Italy6, University of Sheffield, Sheffield, United Kingdom7
In the DUAL V trial, patients assigned to insulin degludec/liraglutide
(IDegLira) had greater HbA1c reduction (end of trial [EOT] HbA1c 6.6
vs. 7.1%) versus insulin glargine (IG) with a significantly lower confirmed
hypoglycemia rate (original definition: plasma glucose [PG] <56 mg/dL or
unable to selftreat). This post hoc analysis investigated whether the lower
hypoglycemia rate with IDegLira versus IG was consistent irrespective of
dosing time (AM [00:00–11:59] or PM [12:00–23:59]) or definition of hypo-
glycemia used (overall/nocturnal confirmed, with/without symptoms, ADA
documented symptomatic). Hypoglycemia rates (episodes per patient-year
exposure [PYE]) were significantly lower with IDegLira versus IG, whether
both were dosed at AM or PM, for confirmed hypoglycemia (AM: 2.18 vs.
6.86 PYE; PM: 2.26 vs. 4.59 PYE) and for nocturnal confirmed hypoglyce-
mia (AM: 0.22 vs. 1.67 PYE; PM: 0.23 vs. 1.12 PYE) (Fig 1A). The rate of
hypoglycemia was significantly lower for IDegLira versus IG for confir-
med (2.23 vs. 5.05 PYE), confirmed symptomatic (1.56 vs. 3.75 PYE) and
ADA documented symptomatic (8.03 vs. 15.63 PYE) (Fig 1B). Nocturnal
hypoglycemia rates were significantly lower (62–84%) for IDegLira versus
IG across the different definitions used. In conclusion, despite a lower EOT
HbA1c, the hypoglycemia rate is lower with IDegLira versus IG regardless
of dosing time or hypoglycemia definition.
118° Congresso Nazionale - Società Italiana di Medicina Interna
A “COMMON” CASE OF CHRONIC DIARRHOEA
Aronico N., Giuffrida P., Di Sabatino A., Corazza G.R.
Clinica Medica I, Fondazione IRCCS Policlinico San Matteo, Università degli
Studi di Pavia, Pavia, Italia
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.
Coeliac serology, fecal calprotectin, stool culture for bacteria and parasi-
tes were negative. The patient underwent upper endoscopy with duodenal
biopsies, whose pathology report described severe villous atrophy, and HLA
typing showing a variant of DQ2. Thus, although the negativity of coeliac
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
2009 the patient experienced malabsorption so that a total parenteral nutri-
tion was commenced. From September 2016 to January 2017 she had again
diarrhoea and weight loss so that she was referred to our Centre for a reas-
sessment of the case. At that time she kept taking gluten-free diet and total
parenteral nutrition. At our Centre blood tests revealed very low levels of
IgA, IgG and IgM. Moreover, after two months of gluten challenge we repe-
ated serum anti-tissue transglutaminase and anti-endomysial antibodies,
which were confirmed negative, an upper endoscopy with duodenal biop-
sies showing severe villous atrophy, characterization of intraepithelial lym-
phocytes by flow cytometry which documented aberrant phenotype, and
PCR analysis indicative for a polyclonal rearrangement of the TCR- chain
on intestinal tissue sections. In addition, no abnormalities were found in
PET scan and entero-CT.
On this basis, we diagnosed a severe villous atrophy secondary to the
common variable immunodeficiency and leading to malabsorption and
the subsequent malnutrition. Accordingly, the patient started taking intra-
venous immunoglobulins and steroids. On the other hand, the diagnosis
of coeliac disease was still under debate. The negativity of celiac serology
and the lack of mucosal recovery after gluten-free diet would let us rule out
coeliac disease. However, the former might be secondary to immunoglobu-
lin deficiency and the latter might be induced by the concomitant common
variable immunodeficiency. Notwithstanding, the reintroduction of gluten
in the diet to be done after steroid tapering might represent a diagnostic
tool in order to establish a diagnosis of coeliac disease in case of diarrhoea
relapse. Nonetheless, even the patient is affected by coeliac disease , we
rule out refractoriness due to the absence of aberrant intraepithelial lym-
phocytes, the lack of monoclonal rearrangement of the TCR-and the nega-
tivity of PET.
WHEN HEART AND INTESTINE ARE CONNECTED: AN
EXEMPLIFYING CASE OF DIARRHEA
Molfino A., Amabile M.I., Rossi Fanelli F., Muscaritoli M.
Department of Clinical Medicine, Sapienza University of Rome, Italy
A 58-year-old woman with a 5-year history of dilated cardiomyopathy
and congestive heart failure presented to our Internal Medicine Unit in
early 2016 for dyspnea and several episodes of diarrhea. During the first
days of hospitalization, she exhibited lower extremity edema but presen-
ted well-nourished referring involuntary body weight loss of 2.5 % of the
habitual body weight. She denied any additional gastrointestinal symptoms
and the body weight remained stable during the first days of clinical obser-
vation. Anemia was not present and serum iron levels were within normal
values. In the process of the evaluation, she was noted to have markedly low
levels of albumin (2.1 g/dL) and total protein (3.2 g/dL).
Additional tests for hypoalbuminemia included a 24-h urine protein mea-
surement, serologic testing for liver function and to exclude the presence
of celiac disease and abdominal imaging performed by ultrasounds, all
resulting within normal ranges. Owing to the concerns of possible cirrhosis
related to congestive hepatopathy, evaluation of her liver showed a normal
portosystemic gradient of 2.5 mm Hg and mild sinusoidal dilation in only
one zone, but no evidence of significant fibrosis or cirrhosis described after
biopsy in the histological examination. Endoscopy was also performed
and was normal including random biopsies of the duodenum and colon.
A stool collection for fecal fat was also within normal range (2.9 g/day).
Fecal alpha-1 antitrypsin (A1AT) clearance was measured and was found
to be markedly elevated at 550 mg/10 ml (normal value: <30 mg per 100
ml) consistent with protein losing enteropathy (PLE). Additional relevant
laboratory findings included decreased level of ceruloplasmin and copper.
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-
Comunicazioni Orali
cally improve. At the end of 2016, she underwent evaluation for a cardiac
transplantation and then an uncomplicated orthotopic heart transplant was
performed. Eight weeks later, her peripheral edema had resolved, diarrhea
was not present anymore and her albumin levels reached normal values (3.8
g/dL).
DIARRHOEA AS PRESENTING SYMPTOM OF RARE
DISEASE
Parente R., De Feo G., Cardamone C., Triggiani M.
University of Salerno
Background: Behcet disease (BD) is a chronic disease with immune-me-
diated etiology, characterized by recurrent oral and genital aphtous ulcers
associated to multiorgan involvement. BD affects the gastrointestinal (GI)
tract in 3-60% of cases, expecially the ileocecal region (10-15%). Gi mani-
festations usually occur 4-6 years later than the onset of oral ulcerations.
Crohn’s disease (CD) is a chronic inflammatory bowel disease that may
affect any part of the GI tract, from mouth to anus. It presents with inte-
stinal symptoms such as abdominal pain, diarrhoea and vomiting and also
with extraintestinal manifestations (e.g. skin rashes, arthritis and ocular
inflammation).
Differential diagnosis between intestinal BD and CD could be difficult, due
to the absence of pathognomonic clinic or endoscopic findings. Systemic
corticosteroids represent the first-line therapy in both diseases.
Case Report: A 46-year-old female was admitted to our Unit with persistent
labial oedema, diarrhoea with 4 bloody discharges/die and abdominal pain.
She had a previous diagnosis of “Behcet disease” (five years ago) , based
on the evidence of oral aftosis, episcleritis and erythema nodosum; for this
reason she had started treatment with oral corticosteroids (1mg/Kg/die)
with good response. In that period she had performed a colonscopy that
showed the presence of a perianal fistula. After 2 years of treatment, when
clinicians decided to start the tapering of steroids, she referred worsening of
abdominal symptoms associated to rectal bleeding, and the onset of persi-
stent labial oedema. She did not refer fever or weight loss, neither arthralgia
nor arthritis.
At the time of admission physical examination revealed oedema of labial
mucosa, with increased consistence at palpation, not painful, and diffuse
pain at abdomen palpation.
Laboratory tests showed increased erythrocyte sedimentation rate and ele-
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
were excluded, performing stool analysis, tumour markers and a total body
computed tomography (CT scan). HLA-B51 aplotype was not detected.
Pathergy test was performed seven days after stopping steroid treatment
and the result was negative.
Abdominal ultrasound revealed minimal tickening of discending colon.
Colonscopy showed “a longitudinal rectal ulceration with active blee-
ding” and multiple biopsies were performed along the colon. The patient
underwent also an oral mucosa biopsy. Both histological findings showed a
“chronic lymphomonocytic inflammation with perivascular infiltration and
glandular architectural abnormalities” , even if no typical granulomas were
found.
Then, on the suspicious of a CD, corticosteroids treatment was restarted at
attack dosage of 1mg/Kg/die with rapid symptoms improvement: regression
of abdominal pain and rectal bleeding, but not of labial oedema.
Discussion: Intestinal BD shares many characteristics with inflammatory
bowel disease, such as CD, including genetic background, clinical manife-
stations, and therapeutic strategies. Similarities in GI and not GI symptoms
(arthropaty, ocular involvement, skin rashes, fever, weight loss) often make
the differential diagnosis between BD and CD difficult.
Although there are no specific tests for differential diagnosis, some features
could be helpful to raise the clinical suspicion of BD or CD. The presence of
non-caseating granuloma is pathognomonic of CD but these lesions could
be absent up to 75% of patients. Moreover the ulcer shape and number could
be useful to distinguish the two conditions: a focal and round ulcer is more
frequent in BD, whereas segmental and longitudinal ulcer are common in
CD.
On the other hand there is no specific diagnostic test for BD and the cur-
rently used clinical diagnostic criteria do not include intestinal symptoms.
In our patient, long-term therapy with oral corticosteroids may have contri-
buted to the diagnostic delay.
17
Comunicazioni Orali 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
KNEE OSTEOARTHRITIS
Mennuni G. 1, Serio A.2, Fontana M. 1, Nocchi S. 1, Bressanin E. 1, Conte S. 1,
Priori F. 1, Fraioli A. 1
1
UOC Medicina Interna, Terapia Medica e Medicina Termale, Scuola di
Specializzazione in Medicina Termale, Dipartimento di Medicina Interna e
Specialità Mediche, Azienda Ospedaliera Universitaria Policlinico Umberto I,
Sapienza Università di Roma 2 Università Campus Bio-Medico di Roma
(1) Number of patients in the experimental groups who participated in the studies in which a specific
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.)
(2) Calculated according to the following procedure-Value at term of therapy if the initial value was =
100 (the following is an example of the values of VAS) 29.36: 54.71 = x: 100; X = 53.66 (value found at
the end of therapy if the initial value was 100)100-53.66 = 46.34 (decrease as a percentage of
VAS value at the end of therapy) (3) TPS = Total Pain Score (4) TSS = Total Stiffness Score; (5) TPFS
= Total Physical Function score

Background: Osteoarthritis (OA) is the most common musculoskele-
tal disease worldwide. It has significant impact on patients’ quality of life,
affecting their ability to perform common daily activities. OA is found most
frequently in the elderly, although it can occur at any age and therefore
should not be considered an aging disease exclusively. Osteoarthritis can
be, for some joints, favored by specific work or sports activities, traumas,
co-morbidities such as obesity or endocrine diseases and genetic predi-
sposition. OA, and especially knee osteoarthritis, is a condition of high
socio-economic impact in terms of drug spending, hospital admissions,
work absences and temporary or permanent invalidity. Aim The aim of this
research is to evaluate literature on the efficacy of SPA-therapy (mud-pack
therapy and/or bath therapy) in the management of knee osteoarthritis.
Methods: We conducted a systematic review of the literature on spa-the-
rapy in the treatment of knee osteoarthritis. We searched the PubMed,
Medline, Cochrane Library, Web of Science databases for articles published
from 2002 through 2015 using the following key words: osteoarthritis, knee
osteoarthritis, spa therapy, mud-pack therapy, mud-bath-therapy, randomi-
zed clinical trial. Results Of the 33 studies on the use of SPA-therapy in the
ASSOCIATION OF RITUXIMAB AND MYCOPHENOLATE
MOFETIL FOR THE THERAPY OF SYSTEMIC SCLEROSIS.
ANALYSIS OF A COHORT OF PATIENTS
Fischetti C. 1, Fraticelli P. 1, Salaffi F. 2, Carotti M. 3, Pomponio G. 1, Zuliani
L. 1, Ferrarini A. 1, Gabrielli A. 1
1
Dipartimento di Medicina Interna, Ospedali Riuniti, Università Politecnica
delle Marche, Ancona; 2Clinica di reumatologia, Ospedale Carlo Urbani Jesi,
Università Politecnica delle Marche, Jesi (AN); 3Dipartimento di Radiologia,
Ospedali Riuniti, Università Politecnica delle Marche
Background: Systemic Sclerosis (SSc) is a chronic systemic disease cha-
racterized by immune abnormalities, microangiopathy and progressive
fibrosis of skin and internal organs. Only few therapeutic options have
shown a proved disease-modifying effect for skin thickening and SSc-as-
sociated interstitial lung disease. Rituximab (RTX) and Mycophenolate
Mofetil (MMF) have separately proven some evidence of efficacy and safety
in clinical trials or case series.

18
118° Congresso Nazionale - Società Italiana di Medicina Interna
Objectives: Tp assess efficacy and safety of a combination therapy, with RTX
and MMF in a cohort of SSc patients with pulmonary and cutaneous invol-
vement rapidly progressive or resistant to conventional therapy.
Methods: Eligible patients were administered with RTX in two different
regimens (1000 mg fortnightly x 2 or 375 mg/mÇ/week for 4 consecutive
weeks) at baseline and after 6 months, associated with MMF 2000 mg/day.
They received anti-infective prophylaxis with Valacyclovir 1000 mg and
Cotrimoxazole 160/800 mg alternate days. Patients underwent clinical and
laboratory evaluation every 3 months. Skin involvement was assessed by
using the modified Rodnan Skin Score (mRSS) performed by the same phy-
sician at baseline, after 3, 6 and 12 months. Chest high-resolution computed
tomography (HRCT), pulmonary function tests (PFTs) and Diffusing Capa-
city of the lung for Carbon Monoxide (DLCO) were performed at baseline,
after 6 and 12 months. The assessment of the extension of pulmonary
fibrosis (PF) was analysed with a conventional visual reader-based score
(CoVR),and with a computerized-aided method (CaM) using a DICOM
software. Statistical analysis was performed by Friedman test (GraphPa-
dPrism V5).
Results: 18 SSc patients were enrolled (F/M: 10/8, median age 51yr,
median duration of disease 1 yr, diffuse SSc 9, limited SSc 9). The analysis,
at 12 month, includes all 15 of 18 patients who completed follow-up. The
mRSS showed a statistically significant improvement (p2=0,0036). more
remarkable in patients with diffuse cutaneous SSc. For pulmonary fun-
ction tests there was a statistically significant increase of FVC (p2=0,0093),
FEV1 (p2=0,0061) with stable values of DLCO (p=0,3375). The HRCT
scan showed an improvement statistically significant evaluated with CaM
(p*=0,0331), while the CoVR showed a not significant trend toward impro-
vement. No serious adverse events were observed during the follow-up. In
two patients the MMF dose was reduced for mild neutropenia.
Conclusions: Despite preliminary and limited to a small number of
patients, our results suggest that combination therapy with RTX and MMF
is well tolerated, safe, and potentially effective for cutaneous and pulmonary
involvement in SSc patients.
PULSED ELECTROMAGNETIC FIELDS MODULATE
SCLEROSTIN LEVELS IN WOMEN WITH
POSTMENOPAUSAL OSTEOPOROSIS
Catalano A. 1, Basile G. 1, Bellone F. 1, Pecora C. 1, Loddo S. 1,
Lasco A. 1, Morabito N. 1
1
Department of Clinical and Experimental Medicine, University Hospital of
Messina, Messina, Italy; 2Spine Surgery Section, Carmona Clinic, Messina,
Italy
Object: Pulsed electromagnetic field (PEMF) could promote in vivo and in
vitro osteogenesis, and enhance bone healing with unknown mechanism.
Aim of our study was to evaluate the circulating canonical Wnt signaling
antagonists sclerostin and DKK-1 in a setting of Caucasian women with
postmenopausal osteoporosis receiving PEMFs.
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
trunk (50 min treatment session/day, 5 treatment sessions/week, for a total
of 25 times as one course of treatment), while those assigned to control
group received sham PEMF treatment with the same device. Blood sample
for evaluation of surrogate markers of bone turn-over were obtained at the
beginning and at the end of the PEMFs treatment period.
Results: At baseline, the two groups were not significantly different for
age, age since menopause, BMI, BMD, ALP, CTX and baseline sclerostin
and DKK-1 values. After treatment, sclerostin but not DKK-1 levels were
significantly reduced only in the PEMFs group (-20%, p<0.05) and this was
associated with an increase of ALP (+8%. p=0.10).
Conclusion: In women with postmenopausal osteoporosis, our preliminary
data provide the first evidence of a modulation of sclerostin levels by PEMFs
suggesting a possible explanation for PEMFs effects on bone.
MARKED HYPERFERRITINEMIA IN ADULT ONSET
STILL’S DISEASE: NOTHING NEW UNDER THE SUN?
Zanghieri G., Franchi L.
Unità Internistica Multidisciplinare, Ospedale S. Sebastiano, Correggio (RE)
Background: Ferritin is a high weight molecular iron-containing protein
Comunicazioni Orali
that functions as a iron storage compound. Under normal circumstances,
the serum ferritin concentration is usually related to the amount of body
iron stores. However, serum ferritin concentration may be elevated in pre-
sence of certain clinical conditions, including liver diseases, renal disease,
malignancies, human immunodeficiency virus (HIV) infection, non-HIV
systemic infections, chronic inflammation, chronic red-cell tranfusions and
sickle cell syndromes. Our purpose is to explain and discuss the exaggerated
ferritin response - with values > 145 times the normal upper level - in a
man with Adult Onset Still’s Disease (AOSD). An extremely elevated serum
ferritn concentration may be considered a useful criterion to diagnose this
illness.
Case Report: A 51-year-old man was admitted to our Medical Unit because
of high-spiking fever, pink-coloured skin rash, diffuse myalgias and arthral-
gias. His remote and physiological anamnesis were negative for relevant
pathologies, he took no drugs and he had no known medication allergies.
The patient had not recently travelled outside the country. On physical
examination he appeared to be suffering. The temperature was 39.4°C,
the blood pressure 122/60, the pulse 86 beats per minute, the respiration
rate was 18 breath per minute and the oxygen saturation 95% while he was
breathing ambient air. The remainder of examination was normal, except
for a diffuse erythematous skin rash. A chest radiography was normal and
abdomen ultrasound revealed splenomegaly with a longitudinal diameter
of 13.5 cm and a section area of 89.4 square centimeters. The most remar-
kable laboratory tests were: white-cell count 24.000/mmc, neutrophils 88%,
erythrocyte sedimentation rate 72 mm/h, fibrinogen 725 mg/dl, C-reactine
protein 37.91 mg/dl, procalcitonin 7.57 ng/ml, rheumatoid factor < 20 (n.v.
< 30), antistreptolysin titer 70 UI/ml (n.v. < 200). Serology for Borrelia
Burgdorferi was negative, as were tests for HBV and HCV. Renal-funcion
tests, hemoglobin and hematocrit, reticulocyte and platelet count, total
proteins, alanine and aspartate aminotrasferase, blood levels of amylase,
lipase, albumin, globilin, alkaline phosphatase, total and direct bilirubin
were within the normal range. Cultures of blood and urine were negative.
The most striking laboratory finding was an abnormal increase of ferritin:
> 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-
ria (splenomegaly and negativity of rheumatoid factor) were fulfilled. The
patient started treatment with steroids and methotrexate and was dischar-
ged from the hospital.
Discussion: AOSD is a rare sytemic inflammatory disorder of unknown
aetiology that can have serious musculoskeletal sequelae. Serum ferritin
levels are usually markedly increased in AOSD and are higher than those
found in patients with other autoimmune and inflammatory diseases. Pre-
vious studies evaluated the validity of hyperferritinemia > 1000 ng/ml (i.e.
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
very higher levels are not uncommon, as recorded in our patient, who had a
ferritin concentration more than 145 times the upper limit.
Conclusion: The usefulness of hyperferritinemia in the diagnosis of AOSD
is well-known, but sensitivity and specificity of this parameter could be
improved by fixing a threshold-level higher than those used up to date.
SCHEDULED RITUXIMAB MAINTENANCE REDUCES
RELAPSE RATE IN EOSINOPHILIC GRANULOMATOSIS
WITH POLYANGIITIS
Emmi G. 1, Rossi G.M. 2, Urban M.L. 2, Silvestri E. 1, Goldoni M. 3,
Prisco D. 1, Vaglio A. 2
1
Interdisciplinary Internal Medicine, Careggi University Hospital, Firenze,
Italy; 2Nephrology Unit, Parma University Hospital, Parma, Italy;
3
Department of Medicine and Surgery, University of Parma, Parma Italy
Objectives: Eosinophilic granulomatosis with polyangiitis (EGPA) is a
systemic vasculitis with a chronic/relapsing course. While the use of ritu-
ximab (RTX) has been largely investigated in the other anti-neutrophil
cytoplasmic antibody (ANCA)-associated vasculitides, data in patients with
EGPA are still limited.
Methods: In this retrospective, observational study, we report the outcome
of 21 EGPA patients treated with RTX induction for relapsing/refractory
disease between 2011-2017; their median follow-up was 24 months. Starting
from 2014, we protocolised RTX maintenance using a scheduled low-dose
regimen (500 mg/6 months). Results Induction with RTX was completed
by 20 patients. At the end of month 3, remission had been achieved by 15
patients (75%). RTX induction induced a statistically significant reduction
in Birmingham Vasculitis Activity Score (BVAS), prednisone dose, and eosi-
19
Comunicazioni Orali
nophil count. Among the 15 responders, 9 received protocolised RTX main-
tenance, while the remaining 6 were only retreated at the time of relapse.
Relapse-free survival was significantly longer in patients who received
protocolised RTX maintenance than in those who did not (log-rank test
p=0.0007). Treatment-related adverse events were uncommon.
Conclusions: Our results confirm that RTX effectively induces remission
in EGPA. Intriguingly, we found that a scheduled maintenance regimen of
low-dose RTX significantly reduces relapse risk in EGPA.
Figure legend:
(a) Kaplan-Meier relapse-free survival estimate of the 15 patients with eosi-
nophilic granulomatosis with polyangiitis (EGPA) who achieved remission
after induction with rituximab. (b) Comparison in relapse-free survival
20
118° Congresso Nazionale - Società Italiana di Medicina Interna
between patients who received procotolised maintenance rituximab (conti-
nuous line) and patients who did not (dashed line). (c) Birmingham Vascu-
litis Activity Score, (d) prednisone dose (or equivalent), and (e) eosinophil
counts of all patients 0, 6, 12 and 18 months after rituximab induction. Dif-
ferences in continuous variables within groups were analysed using Wil-
coxon matched-pairs signed rank test. Differences in survival curves were
analysed using the log-rank test. A p value of <0.05 was considered signifi-
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
of specific tests and / or polysomnography, in patients with resistant hyper-
tension. It would also be appropriate to carry out a complete cardiovascular
screening, considering the possible reversibility of some endothelial dysfun-
ction and atherosclerotic markers after CPAP therapy. We also recommend
118° Congresso Nazionale - Società Italiana di Medicina Interna
the use of CPET, which is not yet widely used in clinical practice, except
in specialized areas, for a complete diagnostic and prognostic evaluation
and therefore for a better therapeutic approach, mostly considering the high
cardiovascular risk of these patients.
DETECTING FAMILIAL HYPERCHOLESTEROLEMIA BY
SERUM LIPID PROFILE SCREENING IN A HOSPITAL
SETTING: CLINICAL, GENETIC AND ATHEROSCLEROTIC
BURDEN PROFILE
Scicali R.1, Di Pino A.1, Platania R. 1, Purrazzo G. 1, Ferrara V. 1, Giannone
A. 1, Urbano F. 1, Filippello A. 1, Rapisarda V. 2,
Farruggia E. 3, Piro S. 1, Rabuazzo A.M. 1, Purrello F. 1
1
Dipartimento di Medicina Clinica e Sperimentale, Università di Catania,
Italia. 2 Dipartimento di Medicina Clinica e Sperimentale, Sezione di
Medicina del Lavoro, Università di Catania, Italia. 3 Divisione di Medicina
del Lavoro, ARNAS Garibaldi, Catania, Italia
Background and Aims: Familial hypercholesterolemia (FH) is an under-
diagnosed pathology and public cholesterol screening may be useful to find
new subjects. In this study, we aim to investigate the prevalence of patients
with FH in a hospital cholesterol screening program and evaluate their athe-
rosclerotic burden using intima-media thickness (IMT) as a macroangiopa-
thic biomarker. Methods and results: We screened 1575 lipid profiles and
included for genetic analysis adults with a low-density lipoprotein (LDL)
cholesterol > 190 mg/dL and triglycerides < 200 mg/dL and first-degree
child relatives an LDL cholesterol > 160 mg/dL and triglycerides < 200 mg/
dL. The diagnosis of FH was first presumed by Dutch Lipid Clinic Network
(DLCN) criteria and then confirmed by the presence of the genetic variant.
Mean common carotid intima media thickness (IMT) was assessed using
consensus criteria. Among 56 subjects with a DLCN ≥4, 26 had an FH
genetic variant. The proportion of patients with a detected mutation having
a DLCN score of 4–5 was 17.6 %; in subjects with a DLCN score of 6–8 it
was 75 % and in individuals with a DLCN score > 8 it was 100 %. Mean IMT
was higher in FH patients compared to non FH patients (0.73 [0.61–0.83] vs
0.71 [0.60–0.75] mg/dL, p < 0.01). Moreover, multivariate analysis showed
that mean IMT was correlated with age, sex and corneal arcus (p value for
all parameters < 0.01).
Conclusions: A hospital cholesterol screening was useful to detect subjects
with FH and increased carotid atherosclerosis independently correlated
with corneal arcus.
CARDIOTOXICITY BY CHEMOTHERAPY: CORRELATION
BETWEEN EARLY INDICATORS OF CARDIAC
DYSFUNCTION AND CARDIOVASCULAR RISK FACTORS
Favuzzi A., Nicolazzi M.A., Fuorlo M., Carnicelli A., Landolfi R.
Dipartimento di Scienze Mediche, Policlinico Universitario Agostino Gemelli,
Roma
Background: The term cardiotoxicity from chemotherapy is the set of major
adverse cardiac events (left ventricular dysfunction, heart failure, arrhyth-
mias, coronary heart disease etc.) caused by anticancer drugs. In breast
cancer, the anthracycline cardiotoxicity is the most important and histo-
rically most studied, both for the frequency with which these drugs cause
adverse cardiac events, both for the high number of patients with breast
cancer undergoing treatment with anthracyclines. Sequential therapy with
trastuzumab in addition to anthracyclines increases the hazard of develo-
ping cardiotoxicity, the toxic effects of the two drugs are added up and stren-
gthen. The structural changes caused by anthracyclines may remain asymp-
tomatic until they do not sustain any event “stressors” following. Sequential
administration of anthracyclines and trastuzumab is a typical example of a
stressful event that could unmask the toxicity of anthracyclines, as well as
the presence of pre-existing cardiovascular risk factors.
Material and Methods: They were enrolled 100 women of average age 52
years underwent echocardiography before and at the end of the cytotoxic
therapy. In our population we want to recognize early and subclinic signs of
cardiac disfunction based on the modification of echocardiographic systolic
and diastolic parameters and to demonstrate correlation of the above modi-
fications with the age and pre-existing cardiovascular risk factors (hyper-
tension, cigarette smoke, diabetes, dyslipidemia, overweight and obesity).
Results: In our follow up we observed: significant reduction (p= 0,00032)
of the fraction of mitral valve ring shortening in systole (MAPSE), further
reduced in the population of patients with hypertension (p= 0,04235) at the
Comunicazioni Orali
end of the therapy compared to baseline; significant increase in left atrial
volume (p= 0,01416) and in E/e’ relationship (p=0,00113) at the end of the
therapy compared to baseline.Furthermore we demonstrated a correlation
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
cancer, and trastuzumab is usually used sequentially in patients where
HER2 receptor is overexpressed or amplified. Anthracyclines induce ultra-
structural alterations of myocardiocytes, dose-dependent and irreversible;
instead trastuzumab induces functional changes of myocardiocytes by inhi-
bition of HER2-mediated repair mechanisms, dose-independent, poten-
tially reversible. The majority of patients present asymptomatic changes
in ejection fraction, then in order to recognize early and subclinic sings
of cardiac disfunction, we studied the longitudinal systolic left ventricular
shortening using the ring mitral systolic excursion (MAPSE) as a simple,
easily obtained parameter which may contribute to the evaluation of systolic
function. Similarly to the global longitudinal strain (GLS), MAPSE explo-
res the cardiac contraction on the longitudinal axis, and was recently re-e-
valuated as easy to perform, also obtainable for bad sonographic windows
and not operator dependent.In particular MAPSE is known to detect more
subtle abnormalities of LV function which early occur, as a reduced longi-
tudinal systolic left ventricular shortening, in patients with increasing age,
myocardial hypertrophy induced by hypertension and diastolic dysfunction
with preserved ejection fraction (HFpEF), where long axis function of the
heart is already impaired while the radial function can be still preserved.
Similar to MAPSE, tissue Doppler imaging, with E/e’ relationship, is descri-
bed to be superior to conventional echocardiography in detecting early
abnormalities of the LV function and its correlation with MAPSE has been
described previously. The increase of left atrial volume can be considered as
a diastolic dysfunction index because it reflects the increase in ventricular
end-diastolic pressure. Conclusions The combined and sequential treatment
with anthracyclines and trastuzumab causes early alterations in myocardial
function even in asymptomatic patients. The heart damage consists in the
reduced contractile efficiency of the left ventricle, explored and expressed
as the reduction in MAPSE, and increased left atrial volume as a predictor
of incipient diastolic dysfunction, especially if related to cardiovascular risk
factors such as hypertension, overweight and increased age. These eviden-
ces require careful stratification of patients undergoing cytotoxic systemic
therapy based on cardiovascular risk, and therefore undertake cardiopro-
tection strategies by lifestyle modification, sartan and beta-blocking therapy
and echocardiographic monitoring during and after the end of therapy.
EFFECT OF ANAKINRA ON RECURRENT PERICARDITIS
AMONG PATIENTS WITH COLCHICINE RESISTANCE
AND CORTICOSTEROID DEPENDENCE THE AIRTRIP
RANDOMIZED CLINICAL TRIAL
Brucato A. 1, Imazio M. 2, Gattorno M. 3, Lazaros G. 4,
Maestroni S. 1, Carraro M. 2, Finetti M. 3, Cumetti D. 1,
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
M.P. 3, Belli R. 2, Gaita F. 7, Martini A. 8
1
Internal Medicine Division, Research Foundation, and Clinical
Pharmacology, Ospedale Papa Giovanni XXIII, Bergamo, Italy. 2Cardiology
Department, Maria Vittoria Hospital and Department of Public Health and
Pediatrics, University of Torino, Torino, Italy. 3IRCCS Istituto G. Gaslini,
Pediatria II, Genova, Italy. 4Cardiology Department, Maria Vittoria Hospital
and Department of Public Health and Pediatrics, University of Torino,
Torino, Italy-Department of Cardiology, University of Athens Medical School,
Hippokration Hospital, Athens, Greece. 5Clinical Immunology, Department
of Medicine, Azienda Ospedaliera-Università, Padova, Italy. 6Reumatologia,
Azienda Ospedaliero-Universitaria di Sassari, Sassari, Italy. 7University
Cardiology Division, Department of Medical Sciences, Città della Scienza e
della Salute, Torino, Italy. 8IRCCS Istituto G. Gaslini, Pediatria II, Genova,
Italy- University of Genova, Genova, Italy
Importance: Anakinra, an interleukin 1β recombinant receptor antagonist,
may have potential to treat colchicine-resistant and corticosteroid-depen-
dent recurrent pericarditis.
Objective: To determine the efficacy of anakinra for colchicine-resistant
and corticosteroid-dependent recurrent pericarditis. Design, Setting, and
Participants: The Anakinra—Treatment of Recurrent Idiopathic Pericar-
ditis (AIRTRIP) double-blind, placebo-controlled, randomized withdrawal
trial (open label with anakinra followed by a double-blind withdrawal step
with anakinra or placebo until recurrent pericarditis occurred) conducted
21
Comunicazioni Orali
among 21 consecutive patients enrolled at 3 Italian referral centers between
June and November 2014 (end of follow-up, October 2015). Included
patients had recurrent pericarditis (with_3 previous recurrences), elevation
of C-reactive protein, colchicine resistance, and corticosteroid dependence.
Interventions: Anakinra was administered at 2mg/kg per day, up to 100mg,
for 2 months, then patients who responded with resolution of pericarditis
were randomized to continue anakinra (n = 11) or switch to placebo (n =
10) for 6 months or until a pericarditis recurrence.
Main Outcomes and Measures: The primary outcomeswere recurrent peri-
carditis and time to recurrence after randomization.
Results: Eleven patients (7 female) randomized to anakinra had a mean
age of 46.5 (SD, 16.3) years; 10 patients (7 female) randomized to placebo
had a mean age of 44 (SD, 12.5) years. All patients were followed up for 12
months. Median follow-up was 14 (range, 12-17) months. Recurrent peri-
carditis occurred in 9 of 10 patients (90%; incidence rate, 2.06%of patients
per year) assigned to placebo and 2 of 11 patients (18.2%; incidence rate,
0.11% of patients per year) assigned to anakinra, for an incidence rate diffe-
rence of −1.95%(95%CI, −3.3%to −0.6%). Median flare-free survival (time
to flare) was 72 (interquartile range, 64-150) days after randomization in the
placebo group and was not reached in the anakinra group (P <.001). During
anakinra treatment, 20 of 21 patients (95.2%) experienced transient local
skin reactions: 1 (4.8%) herpes zoster, 3 (14.3%) transaminase elevation,
and 1 (4.8%) ischemic optic neuropathy. No patient permanently disconti-
nued the active drug. No adverse events occurred during placebo treatment.
Conclusion and Relevance: In this preliminary study of patients with
recurrent pericarditis with colchicine resistance and corticosteroid depen-
dence, the use of anakinra compared with placebo reduced the risk of recur-
rence over a median of 14 months. Larger studies are needed to replicate
these findings as well as to assess safety and longer-term efficacy.
FERRITIN LEVELS IN METABOLIC SYNDROME
Biferi E., Cerasi C., Stamerra C.A., De Feo M.,
Vertolli P., Properzi G., 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)
Introduction: Ferritin is one of the key proteins regulating iron homeosta-
sis and is a widely available clinical biomarker of iron status. Some studies
suggest that prevalence of atherosclerosis and insulin resistance increases
significantly with increasing serum ferritin. Metabolic syndrome (MS)
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
20 age and sex matched controls. Anthropometric parameters, blood pres-
sure, fasting serum lipid, glucose, insulin, high-sensitive C-reactive protein
(hs-CRP) and ferritin levels were evaluated in all patients. MS diagnosis was
made according to the National Cholesterol Education Program/Adult Tre-
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/
ml); (p=0.001). A positive correlation between ferritin concentrations and
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
MS group. Furthermore, mean ferritin levels raised gradually with the increa-
sing number of MS components (p=0.001).
Discussion: From the findings of our study we can conclude that MS is
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
is a powerful pro-oxidant and can cause cellular damage by producing
reactive oxygen species in different tissues of the body. Insulin producing
pancreatic β cells have been shown to be particularly susceptible to oxida-
tive injury, in part due to decreased expression of antioxidant enzymes such
as dismutase, catalase, and glutathione peroxidase. Thus iron deposition in
β cells can lead to apoptosis and consequently to decreased insulin synthe-
sis and secretion. Moreover iron deposition enhances fatty acid oxidation
and decreases glucose oxidation in skeletal muscle by inhibiting pyruvate
dehydrogenase enzyme activity thus increasing IR. Iron accumulation also
results in an abnormal increase in hepatic glucose production and inappro-
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.
22
118° Congresso Nazionale - Società Italiana di Medicina Interna
ASSOCIATION BETWEEN NECK CIRCUMFERENCE,
AORTIC AND CAROTID STIFFNESS IN HEALTHY
ADOLECENTS. THE MACISTE STUDY
Pucci G. 1, Battista F. 1, Sanesi L. 1, Bianchini E. 2, Faita F. 2, Gemignani V. 2,
D’Abbondanza M. 1, Papi F. 1, Schillaci G. 1
1
Struttura Complessa di Medicina Interna, Azienda Ospedaliera di Terni,
Dipartimento di Medicina, Università di Perugia, Terni, Italia 2 Istituto di
Fisiologia Clinica, Centro Nazionale Ricerche, Pisa, Italia
Introduction: obesity has a negative impact on arterial distensibility. Neck
circumference (NC) is a marker of upper body adiposity and unfavourable
metabolic profile among young subjects. The association between NC and
arterial stiffness is unknown. We evaluated the association between NC and
other measures of adiposity, with carotid-femoral pulse wave velocity (cf-
PWV) and carotid stiffness (CS) in healthy adolescents.
Methods: 431 individuals (mean age 16.9±1.4y, SBP/DBP 124/67±11/7
mmHg) attending the Liceo Donatelli High School in Terni, Italy, were eva-
luated. cf-PWV was measured with applanation tonometry (SphygmoCor
device, subtracted distance). CS was measured with Carotid Studio (Quipu):
a contour tracking algorithm was applied to B-mode longitudinal scans of
common carotid artery to obtain diameter changes, stroke change in lumen
area (ΔA) and lumen area (A). The cross-sectional distensibility coefficient
(DC=ΔA /(A*PP)) was converted (Bramwell-Hill equation) into a carotid
stiffness parameter (CS=(DC*ρ)-1/2, ρ=blood density) with same measure-
ment units of PWV. Carotid waveform was calibrated to brachial MAP/DBP.
Brachial MAP was derived from brachial tonometry calibrated to brachial
SBP/DBP.
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
degrees of association with both cf-PWV and CS. The association between
NC and CS was the only association which remained significant after adju-
stement for age, sex and MAP (partial R=0.13, p<0.01), and remained signi-
ficant also after further adjustment for BMI (partial R=0.10, p=0.03).
Conclusions: in healthy adolescents, NC and other measures of global and
local adiposity showed significant associations with cf-PWV and CS. The
association between NC and CS was the only correlation independent from
age, sex, MAP and BMI. Both local and systemic factors may be involved
in explaining this relationship. NC may help in identifying adolescents at
increased CS.
Table: bivariate associations between indexes of adiposity and measures of
arterial stiffness (*p<0.05, **p<0.01)
Carotid-femoral PWV Carotid stiffness
BMI 0.12** 0.21**
BMI z-score 0.07 0.18**
Waist circumference 0.17** 0.20**
Hip circumference 0.11* 0.17**
Waist/hip ratio 0.13** 0.12*
Waist/height ratio 0.08 0.11*
Neck circumference 0.25** 0.35**
ACCURACY OF A POINT SHEAR WAVE ELASTOGRAPHY
TECHNIQUE (ELASTPQ) IN THE NON-INVASIVE
ASSESSMENT OF LIVER FIBROSIS IN A LARGE COHORT
OF LIVER PATIENTS
Garcovich M. 1, Pompili M. 1, Ainora M.E. 1, Riccardi L. 1,
Grieco A. 1, Rapaccini G.L. 1, Siciliano M. 1, Gasbarrini G.B. 2, Gasbarrini
A.1, Zocco M.A. 1
1
UOC Medicina Interna, Gastroenterologia e Malattie del Fegato, Università
Cattolica del Sacro Cuore, Roma 2Professore emerito, Università Cattolica del
Sacro Cuore, Roma
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-
118° Congresso Nazionale - Società Italiana di Medicina Interna
mine the accuracy and the feasibility for the assessment of liver stiffness in a
large cohort of patients undergoing liver biopsy (LB) for various etiologies.
Methods: Consecutive patients scheduled for LB were studied by using
the iU22 Philips ultrasound system with ElastPQ technique. The correla-
tions between laboratory findings, liver stiffness and the Metavir score were
analyzed using Spearman correlation and ROC curve analyses were perfor-
med to calculate AUC for F≥2, F≥3 and F=4.
Results: We enrolled 289 patients (176/113 males/females) who underwent
LB for viral or non-viral chronic hepatitis (HCV 49%; NASH 20%; AIH/
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
PSWE showed a strong correlation with the fibrosis stage; no significant
correlation was found with the degree of necroinflammation or steatosis.
Mean kPa values in the whole cohort were 3.7 (range 2.3-4.9) for F0, 4.9
(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)
and 0.96 (±0.01), when comparing F0-F1 vs F2-F4, F0-F2 vs F3-F4 and F0-3
vs F4, respectively. The optimal cut-off values for different levels of fibrosis
were 6.0, 7,7 and 10.9 kPa for F≥2, F≥3 and F4, respectively. When analyzing
PSWE values according to different etiologies, AUROCs were 0.89 (±0.04),
0.93 (±0.29) and 0.96 (±0.03) for F≥2; 0.88 (±0.04), 0.85 (±0.03) and 0.95
(±0.03) for F≥3; 0.90 (±0.01), 0.95 (±0.01) and 0.96 (±0.01) for F4 in HCV,
NASH and AIH/PBC patients, respectively. Conclusion: To date this is the
largest case series evaluating the accuracy of ElastPQ technique. This novel
PSWE system appears to be a very useful tool for non-invasive evaluation
of liver fibrosis not only in patients with viral chronic hepatitis, but also for
patients with different liver diseases. In order to validate such a non-invasive
technique these findings need to be confirmed in larger studies comparing
different elastography devices.
EVALUATION OF THE THREE-YEARS ACTIVITY OF
ITALIAN SOCIETY OF INTERNAL MEDICINE (SIMI)
BEDSIDE ULTRASOUND SCHOOLS
Arienti V., Palmieri V.O., Domanico A., Piscaglia F., Boddi M., Fracanzani
A.L., Cogliati C., De Sio I., Parrinello G., Perrone T., Loffredo L., Testa A.,
Vidili G., Rigo L.
SIMI BEDSIDE ULTRASOUND SCHOOLS
Aim: On the occasion of the recent opening of the new SIMI Schools of
Bedside Ultrasound (BUS) this year, we wanted to assess the three-year acti-
vity (2015-2017) of the old Schools, already active.
Materials and Method: The SIMI BUS Schools already active are 13; more
details regarding the Schools are available in the SIMI web site (http://www.
simi.it/ecografia-bedside/) where the active Schools are identified with a
green check: Bari (BA), Bologna-A (BOA), Bologna-B (BOB), Firenze (FI),
Milano-C (MIC), Milano-F (MIF), Napoli (NA), Palermo (PA), Pavia (PV),
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
perform all the BUS exams of the training Course (Neck, Heart, Lung,
Abdomen, CUS)? 2) If not, for what types of BUS exam (Neck, Heart, Lung,
Abdomen, CUS) do you request the collaborations of colleagues from other
non-Internal Medicine Units or Departments? 3a) How many theoretical
BUS Courses did you organize? and 3b) how many participation certificates
did you release? 4a) How many practical BUS Courses of one week (training
in Ecoscopy) did you organize? and 4b) how many participation certificates
did you release? 5a) How many practical BUS Courses of two weeks (trai-
ning in Point Of Care US – POCUS) did you organize? and 5b) how many
participation certificates did you release? Two more questions were asked to
Comunicazioni Orali
the SIMI secretary: 6a) how many SIMI Minimaster certificates in Ecoscopy
and 6b) in Point of Care UC (POCUS) has been released.
Results: The results are summarized in Fig.1:
Conclusions: All Schools except one answered the questionnaire. The heart
is the type of BUS exam most frequently performed by colleagues from
other non-Internal Medicine Units / Departments. In spite of the remar-
kable attraction of attending the theoretical BUS Courses, there is less inte-
rest in practical training and in obtaining the SIMI certificates of Minima-
ster in Ecoscopy and / or POCUS.
THE EFFECTS OF NEW DIRECT-ACTING ANTIVIRAL
(DAA) THERAPY ON LIVER STIFFNESS MEASUREMENTS
IN PATIENTS WITH HEPATITIS C VIRUS (HCV)
INFECTION
Ainora M.E. 1., Garcovich M. 1, Lembo T. 2, Ponziani F. 1,
Funaro B. 1, Tortora A. 1, Riccardi L. 1, Siciliano M. 1, Pompili M. 1,
Gasbarrini G.B. 3, Gasbarrini A. 1, Zocco M.A. 1
1
UOC Medicina Interna, Gastroenterologia e Malattie del fegato, Università
Cattolica del Sacro Cuore Roma 2 UOC Epatologia clinica e biomolecolare,
Policlinico G. Martino Messina 3 Professore Emerito Università Cattolica del
Sacro Cuore di Roma
Background: In patients with chronic hepatitis C (HCV) the prognosis and
management largely depend on the extent and progression of liver fibro-
sis. Recent studies have reported that direct acting antivirals(DAAs) are
effective in reducing inflammatory ant fibrotic markers. Among different
non invasive methods, real-time shear wave elastography (RTE) seems to be
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
(SWE) in HCV patients undergoing DAA therapy. Secondary endpoint was
to assess the influence of different biochemical and clinical parameters on
liver stiffness modification.
Methods: We enrolled 103 patients who received different DAAs based
regimens for HCV infection between December 2014 and September
2016. Liver stiffness, evaluated by SWE, and laboratory data were assessed
before treatment (baseline), at end of treatment (EOT) and 24 weeks after
EOT (FU24). Univariate and multiple linear regression analysis was used
to determine which baseline variables were associated with improvement
in liver stiffness. Results: Liver stiffness measurements were significantly
lower at EOT (16.2 ± 9.4 vs 10.9 ± 7.6 kPa, P <0.001). Similar results were
obtained at FU24. Univariate and multivariate regression analysis showed
that failure to achieve improvement in liver stiffness measurements were
significantly associated with low necroinflammatory activity at baseline.
Conclusion: These results suggest DAA treatment resulted in a clinically
significant improvement liver stiffness and this effect is particularly evident
in patients with high inflammatory activity at baseline.
LUNG ULTRASONOGRAPHY IN SUSPECTED
PULMONARY TUBERCULOSIS: A STUDY ON
DIAGNOSTIC ACCURACY
C. Invernizzi1, P. Pini1, M. Montuori2, G. Casazza3, D. Torzillo1, F. Casella1,
S. Limonta2, G. Rizzardini4, F. Franzetti2, M. Galli2,
C. Cogliati1
1
Dipartimento di Medicina Interna, ASST-FBF-Sacco 2Dipartimento di
Scienze Biomediche e Cliniche ‘L. Sacco’, Università degli studi di Milano
e Terza Divisione di Malattie Infettive, ASST-FBF-Sacco 3Dipartimento di
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
Comunicazioni Orali
collected 101 consecutive patients from the departments of Infectious Dise-
ases of our hospital, admitted with clinical suspicion of PTB. LUS was per-
formed within 3 days after admission, by an experienced physician blinded
to the patient clinical information and radiological findings. A portable
US machine (Sonosite M-Turbo) with a convex probe was used. Patients
were examined by longitudinal, transverse and oblique scans of the ante-
rior, posterior, lateral thorax and lung apexes. Sonography was assessed for
consolidations, especially in superior quadrants and apical involvement,
subpleural micronodules (hypoechoic lesions ~10 mm in diameter), pleural
thickenings or irregularities and pleural effusion. A univariate analysis was
performed to identify significant associations between echographic findings
and the diagnosis of PTB (microbiologically or clinically defined). Variables
significantly correlated in the univariate analysis (p <.05) were entered into
a multivariate logistic regression model.
Results: PTB was confirmed in 50 patients (49.5%). Univariate analysis of
LUS findings did show significant differences in the frequency of multiple
consolidations [OR 3.11 (95% CI 1.24-7.77; p 0.0151)], apical consolida-
tions [OR 14.77 (95% CI 4.06-53.74; p <0.0001)], superior quadrant conso-
lidations [OR 5.10 (95% CI 2.19-11.89; p 0.0002)] and subpleural nodules
[OR 3.99 (95% CI 1.73-9.19; p 0.0012)]. Apical consolidation [OR 15.51
(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 the multivariate model. Sensitivity and specificity of the model were cal-
culated: the presence of both apical consolidation and subpleural nodules
had a sensitivity of 34%, specificity of 98%, and likelihood ratios (LRs) 17.34
for positive and 0.67 for negative; one of apical consolidation or subpleural
nodules had a sensitivity of 86%, specificity of 57%, LRs of 1.99 for positive
and 0.25 for negative.
Conclusions: Detection of apical consolidations and subpleural nodules
on LUS examination showed a high specificity and a good accuracy in the
diagnosis of PTB.
INFERIOR VENA CAVA RESPONSIVENESS TO
CONTROLLED ISOVOLUMETRIC RESPIRATORY
EFFORTS
Pasquero P. 1, Folino A. 2, Benzo M. 3, Laguzzi A. 1, Mesin L. 3, Messere A. 2,
Roatta S. 2, Porta M. 1
Departments of Medical Sciences1 and Neurosciences2, University of Turin.
Department of Electronics and Telecommunications, Mathematical Biology
and Physiology3, Politecnico of Turin
Objectives: Ultrasound measurement of Inferior Vena Cava (IVC) collapsi-
bility is an attractive technique for non invasive assessment of volume status
and fluid responsiveness. However, changes in IVC size are largely affected
by spontaneous breathing. This study aims at characterizing the dependence
of IVC size on controlled changes in intrathoracic pressure using a semi-au-
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
positive (+5, +10, and +15 mmHg) and negative (-5, -10, and -15 mmHg)
alveolar pressure levels. The isovolumetric constraint implies that equiva-
lent pressure changes are present at alveolar and intrathoracic level during
respiratory tasks.
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-
ratory and inspiratory efforts of increasing strength, with diaphragmatic
efforts producing larger effects than thoracic ones: -55 ±15% decrease, at
+15 mmHg of alveolar pressure (P<0.01), -80±12% at 15 mmHg diaphrag-
matic (P<0.01), 33±12% at 15 mmHg thoracic. Significant IVC changes in
size (P<0.01) and pulsatility (P<0.05), along with a non significant reduction
in the response to respiratory efforts, were also observed during the first 30
minutes of supine rest, suggesting an increase in vascular filling and taking
place after switching from the standing to the supine position.
Conclusions: This study quantified the dependence of the IVC cross-sectio-
nal area on controlled intrathoracic pressure changes and provides evidence
for a stronger influence of diaphragmatic over thoracic activity. Individual
variability in thoracic/diaphragmatic respiratory pattern should be consi-
dered in the interpretation of the respirophasic modulations of IVC size.
POINT-OF-CARE BEDSIDE ULTRASOUND (POCUS)
AND PRIMARY CARE PHYSICIANS: A PRELIMINAR
EXPERIENCE WITH THE SIMI BEDSIDE US TRAINING
PROGRAM IMPROVES DIAGNOSTIC CONFIDENCE
24
118° Congresso Nazionale - Società Italiana di Medicina Interna
AND REDUCES INAPPROPRIATE ULTRASOUND
EXAMINATIONS
Pretolani S. 1, Giovannelli C. 2, Esposito R. 3, Colla S.M. 4, Arienti V. 1
1
Centro di Ricerca ed Ecografia Clinica Ospedale Maggiore, Dipartimento
Medico, AUSL di Bologna; 2Nucleo 36 di Medicina Geberale, Dipartimento
Cure Primarie, AUSL di Bologna;3Clinica e Terapia Medica, Azienda
Ospedaliero-Universitaria di Parma, 4Corso di Formazione Specifica in
Medicina Generale, Regione Emilia-Romagna
Ultrasound examinations (US) are one of the critical issues for the evalua-
tion of the performance for local healthcare outcomes. In the recent years
the miniaturization of US instruments and the increasing evidence of the
effectiveness of bedside US for variuos clinical conditions has proposed
POCUS for the primary care physicians (PCP) and general internists (GI)1.
Reports on diagnostic appropriateness indicate that in the Emilia-Romagna
the crude US rates either for abdominal ultrasound and EcoDoppler (234 vs
188 and 137 vs 80/1000 residents respectively) are much higher compared
to other 9 Italian regions2. In 2014 the SIMI US Working group defined
the trainig program for the first and second level (POCUS) of competence
in bedisde ultrasound3. Therefore we designed a project to implement a
fruitful collaboration on US examination between PCP and the referral GI
of the local health organization. In brief, specific meetings between PCP
and referral GI have been organized to define and agree on the indications
to POCUS for the most common general medicine syndromes (abdominal
pain, leg edema, dyspnea), according to the most up-to-date guidelines. In
case of diagnostic doubt after a POCUS performed by PCP, a following ultra-
sound examination was guaranteed by e mail reservation at the reference US
Center of Maggiore Hospital in Bologna within 24-48 hours. We report here
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
of 153 POCUS were performed by one of the autors (GC) who had pre-
viuosly fully completed the second level of the SIMI bedside US training
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-
minations performed on the basis of the regular demands of ultrasound by
PGP practitioners, p<0.01) and 3/60 (5%) of the positive cases were refer-
red to the Ultrasound Center of the Ospedale Maggiore of Bologna for a
second opinion within 48 hours. In conclusion this preliminary pilot study
showed that POCUS performed by PGP trained with specific SIMI bedside
US program improves diagnostic confidence and reduces the rate of referral
to ultrasound centers. Larger studies are needed to confirm these results
between PGP of different ages and clinical experience.
1Bhagra A, et al. Mayo Clin Proc 2016; 91(12):1811-182.2Nuti S. Report
2013. Laboratorio MES, S. Anna, Pacini ed. Pisa 2014: 217-8.3Arienti V, et
al. Intern Emerg Med 2014;9(7):805-14.
RENAL INVOLVEMENT IN SYSTEMIC SCLEROSIS
Gigante A., Rosato E., Barbano B., Gasperini M.L.,Cianci R., Muscaritoli M.
Department of Clinical Medicine, Scleroderma Unit, Sapienza University of
Rome,Italy
Background: Systemic Sclerosis (SSc) is a connective tissue disease cha-
racterized by vasculopathy, deposition of collagen and fibrosis of the skin
and internal organs. Several forms of renal involvement are found in
SSc, such as asymptomatic reduction in GFR, increase in renal resistance
indices, ANCA-associated vasculitis and scleroderma renal crisis. The aim
of the study was to prospectively assess the trajectories of renal involvement
in a cohort of patients with SSc.
Methods: The study was performed at the Scleroderma Unit of the Depart-
ment of Clinical Medicine, Azienda Ospedaliera Universitaria Policlinico
Umberto I, Sapienza University of Rome Italy.One-hundred an three SSc
patients (89 F, 14 M) with mean age of 54.7 ± 13.5, duration of disease of 9 ±
6 years, were followed up for five years, from 2011 to 2016. Of these, 54 had
diffused and 49 had limited SSc form. All patients were screened annually
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
of which required dialysis. The other two patients had a favorable prognosis
and treated the acute event with high doses of ACE-inhibitors. One patient
developed ANCA-related proliferative glomerulonephritis and the other
one acute tubular necrosis. A patient has been diagnosed with renal artery
118° Congresso Nazionale - Società Italiana di Medicina Interna
stenosis secondary to arterial hypertension. The remaining 94 patients had
preserved renal function (creatinine 0.75 ± 0.19 mg/dl, CKD-EPI 92.1 ± 18
ml/min, 24h proteinuria 0.22 ± 0.13 g, uric acid 4.22 ± 1.12 mg/dl). Intra-
renal ultrasound and hemodynamic parameters documented: longitudinal
renal diameter 101.4 ± 5.6 mm, resistance index 0.70 ± 0.07, pulse rate 1.43
± 0.31 and S/D 3.52 ± 0.79.
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
implement effective preventative and therapeutic strategies which may posi-
tively impact on SSc patients’ prognosis.
GRANULOMATOUS-LYMPHOCYTIC INTERSTITIAL
LUNG DISEASE IN COMMON VARIABLE
IMMUNODEFICIENCY (CVID) A SINGLE CENTER
RETROSPECTIVE STUDY
Neri R., Gianese S., Scarpa R., Cinetto F., Agostini C.
Dipartimento di Medicina - DIMED, Università di Padova, Padova
Background: Non-infectious autoinflammatory, autoimmune, and lympho-
proliferative complications are common in patients with Common variable
immunodeficiency (CVID). Notably, 8% to 22% of CVID patients develop
an interstitial lung disease termed “granulomatous-lymphocytic intersti-
tial lung disease” (GLILD), which is associated with reduced survival. This
specific complication has been only recently described. Investigators have
used different diagnostic criteria, including diffuse radiological abnormali-
ties and/or histologic evidence of granulomatous inflammation, with lym-
phoproliferative changes characterized by histologic patterns as lymphoid
interstitial pneumonia (LIP), follicular bronchitis, and/or diffuse reactive
lymphoid hyperplasia. Impaired T-cell function leading to dysfunctional
antigen handling has been proposed as a possible underlying mechanism,
perhaps in association with reduced class-switch of memory B cells, and/or
aberrant responses to viral infection. Prior studies suggested that the deve-
lopment of GLILD is associated with an increased mortality. Management is
primarily based on what reported in small case series, and there have been
no controlled trials.
Methods: In this retrospective, single-centre study we reviewed chest
HRCT scans of a cohort of patients with diagnosis of CVID, specifically
looking for GLILD patterns. In patients with HRCT patterns consistent with
GLILD, different parameters were evaluated: pulmonary function testing
(PFTs), cell count and lymphocytes’ phenotype in bronchoalveolar lavage
fluid (BALF), serum immunoglobulin levels, clinical phenotype (including
presence of splenomegaly, hepatomegaly, autoimmune cytopenias) and
medications.
Results: A total of 89 patients with diagnosis of CVID where enrolled in
the study (mean age 48.2±11.6 years). Despite only 3/89 patients had histo-
logical diagnosis of GLILD on pulmonary biopsy, according to the current
diagnostic criteria (in 1 patient diagnosis was obtained on explanted lungs,
after bilateral lung transplantation), 16/89 patients presented radiographic
findings on chest HRCT other than bronchiectasis, raising the suspicion of
GLILD (bronchial wall thickening, nodular opacities, linear and/or irregu-
lar opacities, pulmonary consolidations, ground-glass opacities). Despite
marked radiographic abnormalities on HRCT, 15/16 patients had normal or
almost normal lung volumes (FEV1 and FVC > 70%); DLCO was reduced
(<70%) in 5/16 patients. Only 1/6 patients developed severe respiratory
failure. 9/16 patients underwent bronchoscopy; BALF analysis revealed an
increase of lymphocyte fraction in 8/9 patients, with an increased CD19+
fraction (>5%) in 3 of them (mainly lymphocytes B activated). CD4/CD8
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
in 6/16 patients, hepatomegaly in 5/16. FDG PET-CT scan was performed
in 3/16 patients, showing an increased FDG uptake in lung parenchyma,
lymph nodes, liver, spleen and bone marrow. 3/16 underwent splenectomy
due to immune thrombocytopenia (2 patients) or autoimmune haemolytic
anaemia (1 patient). 2/16 underwent liver biopsy with an evidence of
liver disease syndrome with portal hypertension and splenomegaly. 15/16
patients were treated with Ig replacement therapy at the mean dosage of
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
CVID patients support the view that GLILD represents a pulmonary mani-
festation of a generalized, multisystemic lymphoproliferative disorder with
evidence of an immune dysregulation. GLILD is often underdiagnosed, if
compared to infectious-related complications as bronchiectasis; GLILD
Comunicazioni Orali
radiological patterns should always be sought in routinely performed
HRCT scans of CVID patients, even in presence of normal pulmonary fun-
ction. Early diagnosis could indeed help addressing patients’ personalized
follow-up protocols and discovering new prognostic patterns (e.g. BALF
lymphocyte distribution), thus indentifying high risk patients that might
deserve a more aggressive therapeutic approach.
FLOW MEDIATED DILATION IS INVERSELY RELATED
TO MAST CELL PROLIFERATION IN PATIENTS WITH
MASTOCYTOSIS
Bucci T., De Feo G., Cardamone C., Triggiani M., Guerritore L., Parente R.
Department of Medicine, Division of Allergy and Clinical Immunology,
University of Salerno
Introduction: Mastocytosis is a rare disease characterized by clonal
proliferation of mast cells (MCs) in different organs. The variants of
disease include rapidly progressive (advanced) and indolent forms.
Clinical manifestations of mastocytosis are mostly due to the release
of mediators from MCs. Mediator related symptoms in these patients
could involve many organs including skin (urticaria, angioedema,
pruritus, flushing), gastrointestinal tract (diarrhea, abdominal pain,
heartburn), bone (osteoporosis/osteopenia), cardiovascular system
(anaphylaxis and hypotension). Continuous secretion of mediators by
MCs, often associated to increased oxidative stress, can influence the
endothelial function. Brachial Flow Mediated Dilatation (FMD) is a
non-invasive method to assess endothelial dysfunction and is poten-
tially related to cardiovascular events (1).
Methods: We enrolled 20 adult patients with mastocytosis (14 female,
mean age 48.9 years ±12.9). The diagnosis and the definition of
variant of disease were performed according WHO criteria. None
of the patient in this population had history of major adverse car-
diovascular event (stroke, pulmonary embolism, myocardial infarc-
tion). The ultrasound assessment of FMD was performed using a high
resolution (7.5 MHz) probe measuring both the baseline diameter of
brachial artery and the diameter after 5 minutes of arterial occlu-
sion in the upper arm. Serum tryptase, a specific indicator of MC
proliferation, was measured by immunoenzymatic method (Immuno-
CAP – Phadia). Grading of mediator related symptoms was assessed
according to Valent et al. (2).
Results: FMD was negatively correlated with age (Rs: -0.540; p=0.014),
serum tryptase (Rs=-0.870; p<0,001), serum beta 2 microglobulin (Rs=
-0.685; p=0.010) and directly correlated with female sex (Rs=0.488; p=0.029).
At multivariate regression analysis, serum tryptase showed a strong negative
association with FMD (p=0.009;β=-0.014; CI:-0.024/-0.004).No correlation
between FMD and type and grading of mediator related symptoms was
found. Advanced forms of disease showed a significantly lower FMD as
compared to indolent forms (2.1±1.1% vs 8.4±3.1; p<0,001).
Conclusions: FMD is altered in patients with mastocytosis and is
severely impaired in patients with high rate of MC proliferation and
advanced disease. Endothelial disfunction is negatively influenced by
MC proliferation rather than by the presence and severity of mediator
related symptoms.
References: 1. Yeboah, J.et al. Predictive value of brachial flow-medi-
ated dilation for incident cardiovascular events in a population-based
study: the multi-ethnic study of atherosclerosis. Circulation. 2009;
120:502-509
2. Valent P, Akin C, Escribano L, et al. Standards and standardiza-
tion in mastocytosis: consensus statements on diagnostics, treatment
recommendations and response criteria. Eur J Clin Invest. 2007;
37:435-53.
A RARE DIAGNOSIS FOR A COMMON CLINICAL
PRESENTATION
Laurelli G., Kühn M., Neri R., Cinetto F., Agostini C.
Dipartimento di Medicina DIMED, Università degli Studi di Padova
25
Comunicazioni Orali
In September 2016, a 53-year old Caucasian woman was admitted to the
Emergency Department, presenting heart palpitations and chest pain,
lasting approximately 2-3 hours. She did not present any other symptoms
and physical examination was unremarkable. She had a family history for
cardiovascular diseases and suffered from hypothyroidism treated with
levothyroxine. The ECG showed wide complex ventricular tachycardia
with a heart rate of 220 bpm, left axial deviation and right bundle branch
block aspects, promptly interrupted by electrical cardioversion. In order
to exclude possible common diagnosis (previous myocardial infarction,
chronic myocarditis, dilated cardiomyopathy and hypertrophic cardiomyo-
pathy), the following exams were performed: blood tests, including thyroid
function, resulted normal; coronary angiography and Holter ECG resul-
ted negative, whereas echocardiography showed a “moderate increased
volume of the right ventricle, significant tricuspidic insufficiency and a
discrete depression of the total systolic dynamics (EF 50%)”. She was then
discharged with the diagnosis of “Sustained ventricular tachycardia (SVT)
in cardiopathy of unknown origin”. About two weeks later, the patient pre-
sented the same symptoms that responded to electrical cardioversion. This
time, ECG was consistent with SVT but showed the presence of negative T
waves. Ecocardiography was repeated and revealed a “mild parietal hyper-
trophy of the left ventricle and a moderate dilation of the right ventricle
with diffuse hypokinesia”. To better investigate the underlying causes of the
altered kinetics and morphology, a cardiac magnetic resonance with con-
trast was performed and showed “late gadolinium enhancement (LGE) con-
sistent with myocarditis outcomes, mild pericardial and pleural effusion”.
At this point, after multidisciplinary discussion, the patient underwent an
endomyocardial biopsy that highlighted the presence of “non caseous gra-
nulomas consistent with Cardiac Sarcoidosis (CS)”. Microbiological tests on
the biopsy resulted negative. In view of the evidence that CS is a potential
cause of life-threatening arrythmias and sudden cardiac death, an ICD was
immediately implanted. To further define the staging of Sarcoidosis, specific
blood tests, High-Resolution CT of the lung, spirometry and an ophtalmo-
logic examination were performed and resulted negative. Instead, a PET/
CT showed hypermetabolism of some lymph nodes of the chest, excluding
other organ involvement. Finally, as suggested by guidelines and in order
to prevent relapse, cardiac dilation and worse prognosis, the patient was
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
SVT because this could be the first presentation of a rare but life-threatening
systemic disease, such as Sarcoidosis.
EARLY OCCURRENCE OF FATAL HHV8 AND EBV-
RELATED CASTLEMAN’S DISEASE AFTER LIVER
TRANSPLANTATION: A CASE REPORT
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,
G. Serviddio 1
1
Istituto di Medicina Interna Universitaria, Dipartimento di Scienze Mediche
e Chirurgiche, Università of Foggia, Italy 2Istituto di Anatomia Patologica
Universitaria, Dipartimento di Scienze Mediche e Chirurgiche, Università
of Foggia, Italy 3Istituto di Gastroenterologia Universitaria, Dipartimento
di Scienze Mediche e Chirurgiche, Università of Foggia, Italy; 4Istituto di
Ematologia Ospedaliera, Azienda Ospedaliero Universitaria Ospedali Riuniti
of Foggia, Italy
A 59-years-old Caucasian with hepatocellular carcinoma in alcoholic cir-
rhosis was transplanted in July 2016 and treated with ganciclovir until
November for detection of low serum CMV DNA level. In January 2017,
he was admitted to our Liver Unit for ascites, weight gain, dyspepsia, hypo-
rexia, nausea, symmetric lower limb swelling, fatigue, oliguria and lower
abdominal discomfort. Physical examination revealed paleness but preser-
ved hemodynamic and respiratory parameters. Palpable lymph nodes were
detected in the left anterior cervical region.Blood test examination showed
hemoglobin 8.2 g/dl, platelets 68.000/uL, white blood cells 3520/uL and neu-
trophils 55.6%. Liver function tests were normal whereas pseudocholineste-
rase (2448 mU/ml), alkaline phosphatase (200 IU/l), albuminemia (2.40 g/
dl) were abnormal. Renal function was preserved (GFR 90.1 ml/min) but
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
118° Congresso Nazionale - Società Italiana di Medicina Interna
whereas low serum EBV DNA was identified. Abdominal CT scan revealed
a multiple enlarged lymph nodes in the periaortic and aorto-caval region,
in the celiac-mesenteric region and in the retroperitoneal area. Because of
immunosuppression, the lack of clinical and biochemical signs of infection
and the abdominal lymphadenopathy, a diagnosis of post-transplant lym-
phoproliferative disorder was hypothesized. Bone marrow aspiration and
biopsy showed a preserved erythropoiesis and regular granulopoiesis with
no morphological involvement. 18-F-fluorodeoxyglucose positron emis-
sion tomography (18F-FDG PET) demonstrated an abnormal uptake of
the radiolabeled analogue in cervical, supraclavicular, paratracheal, axil-
lary, internal mammary, anterior mediastinal, celiac tripod, hepatic hilum,
celiac-mesenteric, retroperitoneal and inguinal lymph node stations. Node
Biopsy showed several small follicles with hyalinized germinal centers, and
a massive infiltration of interfollicular polytypic plasma cells. Such findings
were consistent with the diagnosis of Castleman’s disease (CD). Most of
plasma cells stained positively for HHV-8 antibody (clone 13B10), while
no signal was retrieved with EBV (CS1-4) antibody. However EBV DNA
sequences were detected in the formalin-fixed paraffin-embedded lymph
node tissue by real-time PCR molecular studies. Unfortunately, a rapid wor-
sening of clinical conditions occurred and patient died two days after dia-
gnosis. CD is an uncommon lymphoproliferative disorder with non-clonal
characteristics that can interest a single lymph node station or, alternati-
vely, can be diffused to multiple lymphatic stations and organs. Multicentric
Castleman’s disease (MCD) is a systemic disease that generally occurs in
patients with HIV and HHV-8 coinfection because of their disease-related
immunosuppression. This lymphoproliferative disorder often shows syste-
mic inflammatory manifestations and is characterized by high morbidity
and mortality. The natural history of MCD is extremely variable ranging
from indolent cases to fulminant disease but typically it occurs many years
after liver transplantation. In this case report we describe a case of early
and fulminant MCD occurring in a liver transplant recipient. Remarkably,
biopsy examination revealed the coexistence of both HHV-8 and EBV
infection, which is a condition rarely reported in both HIV-negative MCD
and in post-transplant lymphoproliferative disorders (PTLD). This is the
fifth case of MCD developing after liver transplantation worldwide, but the
first one caused by HHV-8 and EBV coinfection.
FIRST REPORTED CASE OF CUTANEOUS VASCULITIS,
ENTERITIS, POLYARTHRITIS AND MYOSITIS
ASSOCIATED WITH BARTONELLA HENSELAE
INFECTION
Avitabile E. 2, Strada S.2, Bonometti R.2, Bianco S.2, Sainaghi P.P. 1, Pirisi M.2
1
Department of Translational Medicine, Università del Piemonte Orientale
UPO, Novara, Italy. 2 Division of Internal Medicine, “AOU Maggiore della
Carità”, Novara, Italy
A 33-year-old male presented with fever, pretibial purpura, diarrhea (posi-
tive to fecal occult blood testing), unintentional weight loss and mono-
arthritis of the left knee despite antibiotic therapy. A clinical diagnosis of
Henoch-Schönlein vasculitis was made and treatment with a coxib started.
Five days later, the patient returned complaining of a symmetric polyar-
thritis, as well as of persisting fever and diarrhea. Investigations showed
myositis of the left calf muscles and multiple liver lesions (compatible with
microabscesses). He had had a recent contact with dog fleas, and serology
for Bartonella henselae - which can be transmitted by pet fleas - turned posi-
tive. Following treatment with azithromycin plus rifampicin, fever resolved,
general conditions improved and he was discharged. However, at a fol-
low-up visit one month later, he reported a recrudescence of his symptoms
with polyarthritis, diarrhea, weight loss and skin purpura, accompanied by
elevation of inflammatory markers, muscle necrosis indices and liver fun-
ction tests. In contrast, the focal liver lesions were reduced in both size and
number at a repeat CT scan. Suspecting a secondary vasculitis, we started
low-dose prednisone, following which all his symptoms promptly resolved
and his laboratory test results normalized. Among the increasingly reco-
gnized immune post-infectious complications associated with Bartonella
infections, this is the first case report to date of an ANCA negative vasculitis
characterized by enteritis, arthritis, myositis and skin purpura, with quick
response to corticosteroid therapy.
118° Congresso Nazionale - Società Italiana di Medicina Interna
COMUNICAZIONI ORALI
28 OTTOBRE 2017
DYSPNEA AND AUTOIMMUNE DISEASES: THE DARK
SIDE OF THE MOON
Emmi G., Vitiello G., Silvestri E., Palterer B., Dreoni L., Bensi C., Vizzutti F.,
Marra F., Laffi G., Romanelli R.G.
Dipartimento di Medicina Sperimentale e Clinica (DMSC), Università degli
Studi di Firenze, Firenze, Italia
Introduction: Dyspnea is a common symptom described as a shortness of
breath and a subjective sensation of breathing discomfort. Interstitial lung
disease (ILD) is considered to be a not so common cause of dyspnea. Even
though ILD may be idiopathic, autoimmune diseases such as anti-synthe-
tase syndrome (ASS) can present with lung involvement in about 60% of
the cases.
Case Report: A 48-year-old man was seen in the emergency department
because of increasing dyspnea for the duration of 2 weeks. In addition to
this he developed generalized asthenia, shoulder girdle weakness and pain
in his right hand. On this evaluation, a chest radiograph showed pulmonary
findings suggestive of possible bibasilar scarring or consolidation. For these
reasons, he was referred to our Department.
On evaluation, he reported increasing dyspnea and fatigue with mild
exertion during the previous 2 weeks that had required rest after normal
activities of daily living, such as climbing of one flight of stairs (Medical
Research Council [MRC] dyspnea scale 3). His past medical history was
unremarkable. He worked as a bricklayer. There was no history of allergy,
hemoptysis, sputum production, rash, Raynaud’s phenomenon or recent
fever, chills or sweats. His father had died at the age of 78 years of stroke. The
temperature was 36.4°C, the pulse was 66 and the respirations were 16. The
blood pressure was 110/70 mmHg. The oxygen saturation was 97% while
the patient was breathing ambient air. However, arterial blood gas showed
a mild hypoxemia (72.6 mmHg) with normal carbon dioxide level. Coarse
crackles were heard in both lungs. The heart sounds and the abdomen
were normal. There was no peripheral edema, the peripheral pulses were
full and there was no digital clubbing. No rash or lymphadenopathy was
noted. The neurologic examination was unremarkable. The immune-rheu-
matologic evaluation show an active arthritis of the 3° and 4° finger of the
right hand and limitation of the shoulder girdle movement. Physical exami-
nation revealed a manual muscle testing (MMT) grade 4-. Blood test exa-
minations showed elevated markers of muscular damage (creatine kinase
2559 U/L, lactate dehydrogenase 691 U/L, aldolase 51.1 U/L myoglobin
2422 ng/mL, aspartate aminotransferase 142 U/L), elevated acute phase
reactants (erythrocyte sedimentation rate 23 mm/h, c-reactive protein 23
mg/L). Blood count, liver and renal function were within the normal limits.
The electrocardiogram was unremarkable. Considering the possibility of an
infectious etiology, an intravenous broad-spectrum antibiotic therapy was
administered.
A computed tomography (CT) scan of the thorax obtained after the intra-
venous administration of contrast material revealed a ground-glass opacifi-
cation and patchy consolidations distributed in subpleural locations in the
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
monoxide (DLCO).
All blood cultures resulted negative. Screening for viruses (EBV, CMV, HBV,
HCV, HIV) and serology for Aspergillus resulted negative.
The patients underwent bronchoalveolar lavage which failed to detect any
infective etiology and the immunophenotype of the fluid collected was
unremarkable. Therefore, the antibiotic therapy was suspended.
In consideration of the lung and muscular involvement and the arthritis
of his right hand, an autoimmune disease was suspected. Sarcoidosis was
considered unlikely because of the absence of mediastinal lymph nodes at
CT scan, an angiotensin-converting enzyme within the normal range and
the results of the bronchoalveolar lavage.
Anti-nuclear antigen (ANA) antibodies on Hep-2 cells resulted negative,
nonetheless an intense cytoplasmic homogeneous fluorescence (1:2560
titer) was detected (Figure 1), indicating the possible presence of an anti-
body against a cytoplasmic antigen (anti-synthetase, anti-ribosomal or
anti-SRP antibodies). However, classical extractable nuclear antigen (ENA)
resulted negative, as well as a commercial lineblot assay for the major myosi-
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
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-
ration of the dyspnea (MRC 1). After the first three days of corticosteroid
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
ng/mL). Therefore, corticosteroid therapy was reduced to 125 mg daily for
three days and the patient was discharged the third day with prednisone 25
mg/daily and a tapering scheme of 5 mg every 7 days.
After two months, the patient showed a good muscular response, with a
complete resolution of the symptomatology and the normalization of
muscular enzymes and acute phase reactants. However, the dyspnea did not
improve further (MRC 1-2). For this reason and in accordance with a pul-
monologist consultancy, azathioprine 100 mg/daily was added to steroidal
therapy (10 mg prednisone/day).
Discussion: ASS is a heterogeneous connective tissue disease characteri-
zed by the association of inflammatory myositis, ILD and anti-synthetase
antibodies. ILD is present in about 60% of these patients and a diagnosis
of ASS-related ILD does not pose a diagnostic challenge in patients with
established diseases or when typical disease manifestations are present [skin
manifestations (Gottron’s papule, Gottron’s sign, mechanic’s hands, shawl
sign, V-sign, heliotrope rash with periorbital swelling, teleangectasias),
fever, arthritis, Raynaud’s phenomenon, generalized weakness]. The dia-
gnosis could not be so evident when dyspnea is the sole manifestation of the
disease. Indeed, dyspnea with or without acute respiratory failure is a rare
presentation of ASS and a careful multidisciplinary diagnostic approach is
needed in these patients.
In our case, the muscular weakness corroborated with the elevation of the
muscular enzymes, along with the exclusion of a cardiovascular (no pul-
monary embolism), infectious (negativity of blood culture and major viral
causes of pneumonia) and occupational (negativity of the bronchoalveolar
lavage) disease, helped us to investigate an autoimmune disease.
ANA negativity with a typical cytoplasmic fluorescence is highly indica-
tive for the presence of an anti-synthetase antibody. The negativity of the
blotting could be related to a limited sensitivity of the test. A direct immu-
nofluorescence could have helped us to recognize the presence of one of
these autoantibodies.
ASS patients often require multimodality immunosuppressive therapy to
control the muscle and/or lung manifestation of the disease. Corticoste-
roid are considered the cornerstone of the therapy. However, when ILD is
present, an additional immunosuppressive therapy is often required. Pro-
gnosis is largely determined by the extent of pulmonary involvement and
its progression. Pulmonary hypertension is a dreadful complication of this
disease and careful attention to complication of both chronic immunosup-
pressive therapy and disease-related sequelae is needed.
Conclusion: It would be prudent for clinician to keep this rare condition in
the differential diagnosis of a patient with acute onset dyspnea. Clinical exa-
mination, laboratory findings (paying attention to muscular enzymes and
pattern of the ANA fluorescence), imaging techniques (such as CT scan of
the chest) and a multidisciplinary discussion of the clinical case is needed to
obtain a prompt diagnosis and introduce an efficacious immunosuppressive
therapy.
DYSPNEA, FATIGUE, AND GENERALIZED WEAKNESS
IN A 67-YEAR-OLD MAN: APPROACH TO THE PATIENT
BETWEEN GUIDELINES AND CLINICAL JUDGMENT
Solimando A.G. 1,2, Argentiero A. 3, Kraus P. 2, Ruckdeschel A. 2, Covelli C. 4,
Einsele H. 2, Vacca A. 1
1Department of Biomedical Sciences and Human Oncology, Section of
Internal Medicine “G. Baccelli”, University of Bari Medical School, Bari,
Italy; 2Department of Internal Medicine, Hematology and Medical Oncology,
University Medical Center Würzburg, Germany; 3Department of Biomedical
Sciences and Human Oncology, Section of Medical Oncology, University
of Bari Medical School, Bari, Italy; 4Department of Emergency and Organ
Transplantation, University of Bari, Bari, Italy
We present a case of 67-year-old man with pulmonary form of mucormyco-
sis which presented as opportunistic infection post induction chemotherapy
for acute myeloid leukemia FAB M2. We treated the patient with intrave-
nous amphotericin B for 4 weeks and endobronchial resection, after which
27
Comunicazioni Orali
he clinically and radiographically improved. Overall, early consideration of
mucormycosis can lead to an earlier diagnosis, medical and surgical therapy,
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).
Mucormycosis refers to an emerging group of life-threatening fungal
infections caused by filamentous fungi of the Mucorales family. Mucor-
mycosis is most common in stem-cell transplant recipients and patients
with underlying hematologic malignancies, poorly controlled diabetes mel-
litus, trauma, neutropenia, corticosteroid and deferoxamine therapy due to
deficiency of phagocytic function, elevated serum levels of available iron
and host-pathogen interaction. The fungi penetrate blood vessels causing
endothelial damage and extensive angioinvasion with infarction, necrosis,
and thrombosis of different tissues. Mucormycosis carries a very high mor-
tality in cases of pulmonary disease, with even higher rates when there is
difficulty establishing the diagnosis.
Overall, this case is a challenging example between clinical judgment and
available validated guidelines.
Based on site localization, mucormycosis can be classified as one of 6 forms:
rhinocerebral, pulmonary, cutaneous, gastrointestinal, disseminated, and
uncommon presentations. The underlying conditions can influence clinical
presentation and outcome. This case describes a patient with main manife-
stations at pulmonary level.
Figure 1: bone marrow aspirates (left) and peripheral smear (right) showing
findings consistent with the diagnosis of AML FAB M2 (upper panel); lower
panel: necrotic endobronchial lesion (left), histopathologic slide (right) of
the endobronchial biopsy and the immunofluorescence staining evidenced
the presence of nonseptate hyphae with blood vessel invasion.
Figure 2: Chest radiograph (A) and sequential CT scans (B) before onset
28
118° Congresso Nazionale - Società Italiana di Medicina Interna
of antibiotic therapy; (C) and (D) after 6 days of empiric antibiotic therapy
demonstrating progressive inflammatory infiltrates with reversed halo sign.
AN UNUSUAL CASE OF UPSTANDING DYSPNEA
Traversa M.A., Villois P., Porta M.
Scuola di Specializzazione in Medicina Interna, Università degli Studi di
Torino
A 77-year-old woman was admitted to the Emergency Department (ED)
for sudden onset of expressive aphasia and numbness/weakness in the right
upper arm. Past medical history included hypertension, dyslipidemia and
COPD (the patient had a 15-pack month smoking history). Medications
included clonidine, omeprazole, amiloride, hydrochlorothiazide, aspirin,
and telmisartan. Continuous ECG monitoring, blood analysis, chest RX and
brain CT scan were normal. After 24h the patient was admitted to the Stroke
Unit, where a brain MR scan performed with DWI sequence demonstrated
hyperintensity in the left frontal perisylvian cortex, confirming the diagno-
sis of recent ischemia. Carotid ultrasound and trans-thoracic echocardio-
graphy did not show any abnormalities and the patient started post-stroke
rehabilitation. However, dyspnea, desaturation and low levels of pO2 appea-
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-
cut-off value of PCSK9 for CVEs (HR 2.8, p<0.001). Multivariable Cox
regression analysis showed that PCSK9 >2600 pg/ml (HR:2.536, p<0.001],
age (HR:1.083, p<0.001), female sex (HR:0.723, p=0.041) previous cerebro-
vascular (HR:1.833, p<0.001) and cardiac event (HR:1.758, p<0.001), and
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
and lipid profile. We found a significant increase of urinary TxB2 among
118° Congresso Nazionale - Società Italiana di Medicina Interna
PCSK9 groups (p<0.001). A stepwise multivariable linear regression analy-
sis showed that age (Beta=0.074, p=0.008) and log-PCSK9 (Beta=0.682,
p<0.001) were the main determinants of urinary log-TxB2.
Conclusions: Plasma PCSK9 levels are associated with an increased risk
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.
IMPACT OF RISK ASSESSMENT (PADUA AND IMPROVE
SCORES) ON VTE, MAJOR HAEMORRHAGE AND HEALTH
EXPENDITURE ASSOCIATED WITH VTE PROPHYLAXIS:
A PROSPECTIVE AND RETROSPECTIVE STUDY ON
PATIENTS HOSPITALIZED IN AN INTERNAL MEDICINE
UNIT (STIME STUDY)
De Pietri L. 1, Marietta M.2, Scarlini S. 1, Marcacci M. 1, Riva R. 1, Pietrangelo
A. 1, Ventura P. 1
1
Unit of Internal Medicine 2,2Unit of Hematology, Dept. of Medical and
Surgical Sciences for Children and Adults, Policlinico Hospital of Modena,
University of Modena and Reggio Emilia, Italy
Background: International guidelines recommend the use of pharmaco-
logical prophylaxis in hospitalized medical patients at high risk of venous
thromboembolism (VTE), by assessing individual thrombotic and haemor-
rhagic risk factors (Kahn et al, 2012). The same international guidelines
suggest the employment of standardized risk assessment models (RAMs)
when evaluating the administration of pharmacological prophylaxis in
acutely ill medical patients (Kahn et al, 2012). Padua Prediction Score (PPS)
and Improve Bleeding Score (IBS) have been indicated as the best avai-
lable models to predict thrombotic and haemorrhagic risk in hospitalized
medical patients, but it is still unknown whether their combined use can
actually lead to a reduction in thrombotic and haemorrhagic events. It is
also unclear whether their extensive use can affect to some extent health
spending associated with pharmacological prophylaxis. AIM The aim of this
study is to evaluate whether the combined use of PPS and IBS in a consecu-
tive cohort of hospitalized medical patients may influence the overall inci-
dence of thrombotic or haemorrhagic events (primary endpoint). Secondly,
health expenditure associated with pharmacological prophylaxis has also
been assessed in order to verify whether the combined use of these RAMs
may result in a reduction of prophylactic drug prescription and conse-
quently of health expenditure connected with pharmacological prophylaxis
(secondary endpoint).
Patients & Methods: All patients admitted to our internal medicine depart-
ment between May 2015 and August 2015, i.e. before the introduction and
extensive use of PPS and IBS, were consecutively enrolled (retrospective
group). Similarly, all patients admitted between November 2016 and
February 2017, once RAMs clinical use became a consolidated practice,
have also been consecutively enrolled (prospective group). The admini-
stration of pharmacological prophylaxis, the occurrence of any thrombotic
event (pulmonary embolism) or haemorrhagic complication (major blee-
ding) during hospitalization or throughout the next 90 days after hospital
discharge were progressively recorded for all enrolled patients.
Results: Compressively 210 patients were enrolled in the prospective group
and 203 patients were enrolled in the retrospective one. No differences in
baseline characteristics of the patients were observed. RAMs were available
for 100 % of prospective group patients. In the prospective group, 48% of
patients had increased VTE risk (PPS ≥ 4), 13% of patients showed increased
haemorrhagic risk (IBS ≥ 7) and only 6% of patients displayed both elevated
thrombotic and haemorrhagic risk (PPS ≥ 4 & IBS ≥ 7). Three events of
major bleeding and one event of pulmonary embolism were observed in the
prospective group; three events of major haemorrhages and two events of
pulmonary embolism were observed in the retrospective group (the statisti-
cal analysis failed to reveal significant difference between groups regarding
the primary endpoint). A statistically significant decrease of pharmacologi-
cal prophylaxis among study groups was detected: 43.3% of patients in the
prospective group and 56.7% of patients in the retrospective group received
pharmacological prophylaxis (p = 0.028), this being responsible for saving
on average 1.67 € for each patient treatment after RAMs introduction.
Conclusions: The extensive use of RAMs in our population of patients
hospitalized in an internal medicine unit did not significantly affected VTE
rate or incidence of major bleeding. A statistically significant decrease of
VTE prophylactic therapy and consequently of health spending related
to pharmacological prophylaxis has been documented, likely driven by a
more accurate stratification of individual haemorrhagic and thrombotic risk
factors. The observed decrease of prophylactic therapy administration was
Comunicazioni Orali
not accompanied by a modification of thrombotic and haemorrhagic events,
which full reassures a possible safety concern. Waiting for new clinical trials,
a broad use of RAMs may be a safe strategy for reducing health expenditure
associated with VTE prophylaxis in hospitalized medical patients.
AN ATYPICAL INFERIOR VENA CAVA THROMBOSIS
Perina L., Marchi G., Rizzi M., Sapienza E., Bellesini C.,
Dal Zotto C., Fumagalli A., Codella O.M., Girelli D.
Medicina Generale ad indirizzo Immunoematologico ed Emocoagulativo,
Università degli Studi di Verona
Presentation: A 46 year-old woman was referred to the Emergency Room
of our hospital because of incidental finding of “fluctuant thrombus” in the
inferior vena cava (IVC) during a routine abdomen US performed for the
follow-up of chronic HBV and HCV infection without evidence of active
hepatitis. The patient was essentially asymptomatic, apart from a mild bila-
teral edema of the legs, with no limitation of daily activities. Her clinical
history revealed smoking habit, previous hysteroannessiectomy for mul-
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
drug abuse. Her vital signs were normal. Her physical examination detected
only a mild bilateral edema of the legs without palpable venous cords.
ECG showed normal sinus rhythm with no S1Q3T3 pattern. CT pulmo-
nary angiography ruled out pulmonary embolism and, remarkably, lower
extremities venous Duplex US was negative for thrombosis. Laboratory tests
showed C-reactive protein, complete blood counts, renal function, PT and
aPTT within the limits. A provisional diagnosis of non datable IVC throm-
bosis was made, i.v. unfractionated heparin was started and the patient was
admitted to our department for further studies.
Differential diagnosis: Imaging studies to evaluate the extension of
thrombosis were performed, along with a more in-depth anamnesis and
biochemical exams to investigate the possible causes of inferior vena cava
thrombosis. The patient’s personal and family history was not consistent
with a hereditary thrombophilia and this hypothesis was not further inve-
stigated, as several tests (i.e. protein C and S, antithrombin III) could have
been altered by the acute episode and anticoagulant therapy. An acquired
thrombophilia was also unlikely, since the patient had no recent history
of immobilization, surgery, trauma or prolonged travel. She had no active
cancer, took no oral contraceptives, and her BMI was within the limits.
Noteworthy, D-dimer test was negative, as they were autoimmunity tests.
The patient underwent a multiphasic contrast-enhanced CT and 18F-FDG
PET to define the extension of thrombosis, and to search for a possible
abdominal neoplasia, often associated to IVC thrombosis. Indeed, abdomen
CT detected a contrast-enhanced mass of 3.5 x 3.3 cm diameter in small
pelvis with thrombus-like extension in venous vasal lumen and ascending
in inferior vena cava for 26.5 cm up to the hepatic veins (Fig. 1). 18F-FDG
PET revealed low enhancement only of the pelvic mass. The features of the
pelvic mass were compatible with a residual myoma, and a transvaginal US
also confirmed this suspect.
Diagnosis: The above findings were consistent with intravenous leiomyo-
matosis (IVL). The diagnosis was established with a re-evaluation of
the histological examination of myomas surgically removed ten months
before, which demonstrated vascular invasion of small leiomyoma nodules
distinct from the major one. After a literature review and collegial discus-
sion, we performed a contrast-enhanced abdomen MRI as the gold-stan-
dard imaging exam for IVL. This allowed a better definition of the residual
myoma, that extended as a neoplastic thrombus in the right internal iliac
vein and in the IVC up to the hepatic veins.
Treatment: Once the diagnosis of IVL was established, we suspended i.v.
unfractionated heparin and started a prophylactic dose of low molecular
weight heparin. The case was further discussed with gynecologists and
vascular surgeons. Since IVL can grow, occlude IVC or ascend up to right
atrium and cause syncope or even sudden death, a surgical intervention was
planned. The residual myoma and right internal iliac vein were resected and
IVL was removed with IVC thrombectomy (Fig. 2). The new histological
examination revealed a morphological and immunophenotypic pattern
overlapping with the previous one. No complications occurred in periope-
rative period and the patient was regularly discharged.
Fig. 1 (A-D). Longitudinal (A) and transversal view of IVL and its throm-
bus-like extension in right internal iliac vein (B, in red circle) and IVC (C)
ascending for 26.5 cm up to the hepatic veins (D), detected by multiphasic
contrast-enhanced CT.
Fig. 2. Macroscopic appearence of IVL after surgical intervention.
29
Comunicazioni Orali
Fig. 1
Fig. 2
SUBCLINICAL ATHEROSCLEROSIS IN ASYMPTOMATIC
CARRIERS OF PERSISTENT ANTIPHOSPHOLIPID
ANTIBODIES POSITIVITY: A CROSS-SECTIONAL STUDY
Di Minno M.N.D. 1, Ambrosino P. 1, Scalera A. 1, Cafaro G. 1,
Peluso R. 1, Silvestri E. 2, Di Minno G. 1, Emmi G. 2, Prisco D. 2
1
Federico II University, Naples, Italy; 2 University of Florence, Florence, Italy
Background: Whereas the relationship between subclinical atherosclerosis
and antiphospholipid syndrome (APS) has been widely investigated, little
is known about subclinical atherosclerosis in asymptomatic carriers with
isolated antiphospholipid antibodies positivity (APP).
Methods: Consecutive APP carriers, APS patients and matched controls
were enrolled. Intima-media thickness of the common carotid artery (CCA-
IMT) and of the Bulb (Bulb-IMT) and the prevalence of carotid plaques
were assessed in all enrolled subjects.
Results: A total of 104 APP carriers, 221 APS patients, and 325 matched
controls were recruited. APP carriers, APS patients and controls were com-
parable for age and gender and for the prevalence of cardiovascular risk
factors. As to the type of antiphospholipid antibodies, IgG aCL and IgG
aβ2GPI were more often found in APS patients than in APP carriers (75.1%
vs 61.5% p = 0.013 and 45.7% vs 25.0% p < 0.001, respectively). No diffe-
rence in the presence of all the other antibodies was found between APP
carriers and APS patients.
As compared with controls, APP carriers and APS patients showed a higher
CCA-IMT (0.89±0.25 vs 0.81±0.12, p=0.032 and 0.90±0.42 vs 0.81±0.12,
p=0.001, respectively), Bulb-IMT (1.10±0.45 vs 0.94±0.18, p=0.009 and
1.22±0.68 vs 0.94±0.18, p<0.001, respectively) and an increased prevalence
of carotid plaques (33.7% vs 10.2%, p<0.001 and 38.5% vs 10.2%, p<0.001,
respectively). These results were confirmed both in APP carriers and in APS
patients after adjusting for potential confounders by means of multivariate
analyses.
As compared with the 232 subjects with antibodies titer from 41 to 80
30
118° Congresso Nazionale - Società Italiana di Medicina Interna
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.
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
Tufano A. 1, Ageno W. 2, Di Micco P. 3, Monreal M. 4
1
Regional Reference Centre for Coagulation Disorders. Department of
Clinical Medicine and Surgery. “Federico II” University Hospital, Naples,
Italy. 2Research Center on Thromboembolic Disorders and Antithrombotic
Therapies, Department of Medicine and Surgery, University of Insubria,
Varese, Italy. 3Ospedale Buonconsiglio Fatebenefratelli, department of
internal medicine and emergency room, Naples, Italy. 4Department of
Internal Medicine. Hospital de Badalona Germans Trias i Pujol. Universidad
Católica de Murcia. Spain
Background: Current guidelines recommend the use of anticoagulant
therapy in patients with symptomatic splanchnic vein thrombosis (SVT)
and suggest no routine anticoagulation in those with incidental SVT.
Methods: We used the RIETE (Registro Informatizado Enfermedad Trombo
Embolica) registry to compare the rate of venous thromboembolism (VTE)
recurrences and major bleeding during anticoagulation in patients presen-
ting with symptomatic vs. incidental SVT.
Results: In March 2017, 521 patients with SVT were recruited. Of these,
212 (41%) presented with symptomatic SVT, and 309 had incidental SVT.
Most patients (94%) received anticoagulant therapy (median, 147 days).
During the course of anticoagulant therapy, 20 patients developed sympto-
matic VTE recurrences and 26 bled. Patients with symptomatic SVT had a
lower rate of VTE recurrences (hazard ratio [HR]: 0.35; 95%CI: 0.11-0.93),
a non-significantly lower rate of major bleeding (HR: 0.65; 95%CI: 0.28-
1.43) and a lower mortality rate (HR: 0.55; 95%CI: 0.33-0.91) than those
with incidental SVT. Interestingly, during the first 30 days of therapy, there
were 12 major bleeds (4 fatal bleeds) and one nonfatal VTE recurrence. On
multivariable analysis, patients with active cancer were at increased risk for
VTE recurrences (adjusted HR: 3.06; 95%CI: 1.14-8.17), while those with
anaemia (adjusted HR: 4.11; 95%CI: 1.45-11.6) or abnormal prothrombin
time (adjusted HR: 4.10; 95%CI: 1.68-10.1) at baseline were at increased
risk for major bleeding.
Conclusions: The outcome during anticoagulation in patients with sympto-
118° Congresso Nazionale - Società Italiana di Medicina Interna
matic or incidental SVT was similar. Further studies are needed to identify
which patients with SVT would benefit from anticoagulant therapy.
HIGH PLASMA CONCENTRATION OF ACTIVATED
FACTOR VII-ANTITHROMBIN COMPLEX IS ASSOCIATED
WITH AN INCREASED ACTIVATED FACTOR X
GENERATION
Tosi F. 1, Stefanoni F. 1, Baroni M. 2, Lunghi B. 2, Castagna A. 1, Ziliotto N. 2,
Minguzzi D. 1, Udali S. 1, Woodhams B. 3, Girelli D. 1, Olivieri O. 1, Bernardi
F. 2, Martinelli N. 1
1
Department of Medicine, University of Verona, Italy; 2Department of Life
Sciences and Biotechnology, University of Ferrara, Italy; 3Haemacon Ltd,
Bromley, Kent, UK
Background: activated factor VII-antithrombin (FVIIa-AT) complex has
been proposed as an indicator of tissue factor (TF) exposure to the blood,
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
coronary artery disease (CAD). Aims:to evaluate in CAD patients the rela-
tionship between FVIIa-AT levels and activated factor X generation (FXaG)
at low TF concentration, and by inhibiting tissue factor pathway inhibitor
(TFPI) or activated protein C (APC) with the aim to highlight procoagulant
components. Methods:within the framework of the Verona Heart Study
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.
FXaG in plasma was evaluated at 1 pM TF by addition of a specific FXa fluo-
rogenic substrate, and also in the presence of an anti-TFPI RNA aptamer
(TFPI-aptamer) or an anti-APC DNA aptamer (APC-aptamer).
Results: among the parameters estimated from the analysis of FXaG curves
only the area under the curve (FXa-AUC) showed a significant correlation
with FVIIa-AT levels. The FXa-AUC increased progressively across FVI-
Ia-AT quartiles, from 4031±210Rfu in the lowest to 4268±84 Rfu in the
highest (P=0.007 by ANOVA with polynomial contrasts for linear trend,
confirmed after adjustment for traditional cardiovascular risk factors).
The addition of either TFPI-aptamer or APC-aptamer produced a marked
increase of FXaG with shorter time parameters (P<0.001). The increase of
FXa-AUC across FVIIa-AT quartiles was confirmed in both TFPI-aptamer
or APC-aptamer assays (TFPI-aptamer, P=0.019; APC-aptamer, P=0.014).
Conclusion: in male CAD patients high plasma levels of FVIIa-AT are
associated with an increased FXaG at low TF concentration. The increase of
FXa-AUC across FVIIa-AT quartiles is still maintained after potentiation of
procoagulant pathways by inhibiting TFPI or APC.
AN ITALIAN SINGLE CENTER PROSPECTIVE STUDY ON
OUTCOMES IN AL AMYLOIDOSIS
Palladini G. 1, Milani P. 1, Basset M. 1, Foli A. 1, Russo F. 1,
Mussinelli R. 1, Perlini S. 2, Merlini G. 1
1
Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico
San Matteo, and Department of Molecular Medicine, University of Pavia,
Pavia, Italy 2 Internal Medicine Unit, Fondazione IRCCS Policlinico San
Matteo, and Department of Internal Medicine, University of Pavia, Pavia,
Italy
Background: In the last decade, new treatment strategies and patients
selection according to biomarkers have modified the approach to patients
with light-chain (AL) amyloidosis. However, prospective studies are hampe-
red by patient selection, short follow-up and small numbers due to the rarity
of the disease and the difficulties in enrollment.
Methods: Starting in 1994, we protocolized the collection of parameters of
clonal and organ disease at baseline and during treatment in all the 1933
patients diagnosed at our center. Here, we report the outcome of 1065
subjects enrolled after 2004, when systematic collection of cardiac biomar-
kers and FLC data started.
Results: Median age was 65 years. Involved organs were heart (77%),
kidney (66%), soft tissue (17%), liver (14%) and PNS (12%), >2 organs were
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
cutoffs), II in 44% (one of the two markers above the cutoff) and IIIa (both
markers above the cutoffs and NT-proBNP cutoff <8500 ng/L) in 20% and
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
Comunicazioni Orali
glomerular filtration rate (cutoff eGFR: 50 mL/min per 1.73 m2) was I in
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-
gic response (HR) 51%, very good partial or complete response (VGPR/
CR) 38%], cyclophosphamide-bortezomib-dexamethasone [297 patients,
HR 55%, VGPR/PR 44%), and bortezomib-MDex [132 patients, HR 64%
(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
died (13% within 3 months). Median survival in cardiac Mayo Stage I was
not reached, in stage II 58 months, in stage IIIa 17 months and in stage IIIb
6 months (P<0.001). No overall survival advantage was noted in patients
treated with upfront bortezomib based combinations compared to MDex.
Conclusion: The outcome of patients with AL amyloidosis is extremely
heterogeneous and a significant proportion of patients die before having
the chance to benefit from treatment. The extensive use of upfront bortezo-
mib ameliorates the quality of response, but does not translate in a general
improvement of overall survival.
PRELIMINARY STUDY ON DIAGNOSIS AND TREATMENT
OF ANEMIA IN INTERNAL MEDICINE DEPARTMENT: AN
OLD TOPIC OR A NEW CHALLENGE?
Santarossa C., Cosi E., Bertozzi I., Fabris F., Randi M.L.
Department of Medicine – DIMED, University of Padua, Padua, Italy
Background: Anemia is a worldwide highly prevalent disease. Several
studies show the negative impact of anemia on morbidity and mortality
in patients affected by various chronic conditions, such as myocardial
infarction, congestive heart failure, critical renal or respiratory diseases.
However, few is known about the relevance of anemia in the internal medi-
cine patients who usually suffer for numerous concomitant pathologic con-
ditions. Moreover, the available studies suggest that the detection, evalua-
tion and management of anemia are unmet medical needs. We planned a
prospective study to evaluate the incidence, the severity, the cause and the
real life adopted treatment of anemia in an internal medicine department
with the aim to define an effective algorithm to assess anemia in hospitalized
medical patients and to optimize its treatment. The data here presented refer
to a preparatory step of our project and describe the data of consecutive
patients admitted to our Department in the first 15 days of May 2017, in
order to assess the prevalence of anemia and our present ability to reco-
gnize, diagnose and treat this condition in internal medicine patients. Mate-
rial and methods: A single operator collected blood cells texts at hospital
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
(Hb) less than 120 g/L in women and less than 130 g/L in men; its severity
(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
use before or during hospitalization were registered. Statistical analysis was
performed by χ2 test and T test.
Results: Within 82 patients (42 males and 40 females, median age 77ys,
range 32-95 ys) admitted in our department, 31 (37.8%) were anemic.
Sixteen were males (38% - Hb 110,3±16,9 g/L) and 15 females (37.5% - Hb
108,1±13,1). Twenty-seven (15 males and 15 females, 87%) out of these 31
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
(25.9%) had received a treatment. Causes of anemia and adopted treatment
are summarized in the following table:
Total Treatment
Iron-deficiency anemia 8  Iron replacement in 6
Anemia of chronic inflammatory 5  none
disease
Leukemia/MDS 5  2 transfused
Microangiopathic aaemia 1  1 transfused
Beta thalassemia minor 1 none
Renal insufficiency 1 1 epoietin
Folic acid defect 1  1 vitamine supply
Multifactorial anemia 2 1 transfusion and cobalamine in both
31
Comunicazioni Orali
Discussion: Our study, though limited and preliminary, showed that, inde-
pendently from the cause of admission, almost 38% of hospitalized patients
in our internal medicine department are anemic; interestingly, most of these
patients had an already known anemia at least 12 months lasting. In agre-
ement with the data available in the literature, in less than 65% of cases the
cause of anemia was appropriately investigated and only in 40% of patients
a treatment was started. Considering the diminished quality of life and the
unfavorable clinical outcomes related to the presence of anemia, it sounds
astonishing. A recent study has pointed out that the type and severity of
anemia affects hospital re-admission and mortality in old patients. There-
fore, the definition of an effective algorithm to assess anemia in hospitalized
medical patients and to optimize its treatment results mandatory.
HFEH63D POLYMORPHISM IS COMMON IN PATIENTS
WITH IDIOPATHIC ERYTHROCYTOSIS
Biagetti G., Cosi E., Bertozzi I., Santarossa C., Fabris F., Randi M.L.
Dipartimento di Medicina - DIMED, Università di Padova, Clinica Medica 1
Background: Idiopathic erythrocytosis (IE), characterized by persistently
raised hemoglobin (Hb) and hematocrit (Ht) levels, has not a definite cause,
even after an accurate diagnostic investigation. Increased levels of ferritin
are often observed in IE and we recently found that mutations or polymor-
phisms of HFE gene are commonly found in patients with IE. Curiously,
HFE mutations were found also in IE patients with normal ferritin levels.
To better understand the relation between erythrocytosis and HFE gene, we
searched which mutations were prevalent in IE patients.
Materials and Methods: HFE mutations were searched in 33 patients with
IE (30 males and 3 females, mean age 53 ± 13 y, Hb 175,5 ± 9,2 g/dL, Ht 51,2
± 3,0 %) not carrying JAK2V617F or JAK2 exon 12 nor EPOR, VHL, PHD2
or HIF-1 alpha genes mutations. All the patients had normal serum erythro-
poietin level. None had an overt clinical diagnosis of hemochromatosis.
HFE gene mutations was performed using Lightcycler 480 on extracted
DNA Results: We found 14 HFE mutated patients (42%): 10 heterozygous
and 2 homozygous H63D and 1 H63D/C282Y. Only 1 patient carried hete-
rozygous S65C mutation. On a whole, 13 (93%) of the HFE mutated patients
have at least one H63D mutated allele. In the table we report the frequen-
cies of HFE mutations, H63D mutations and high ferritin between mutated
patients in general population, in IE patients and in the present cohort.
Italian General IE(BJH 2017) 56 IE in the present
Population patients study: 33 patients
HFE mutated  26.5%  25 (44.6%)  14 (42%)
HFEH63D  23%  17 (30.4%)  13 (39%)
High ferritin levels in
 15%  12 (48%)  9 (64%)
mutated patients
Discussion: We have recently observed that increased serum ferritin levels
and mutations of HFE are more common in IE patients than in the European
general population. The present study shows that most of the HFE mutated
patients with IE carry at least one H63D allele. HFEH63D polymorphism,
which is rarely associated with iron overload but drives an impairment in
iron metabolism, may be linked with erythrocytosis in spite of ferritin levels.
Then, it remains unclear how HFE mutations alter the supply of iron to the
erythroid tissues. Study of a large cohort of IE patients are needed to confirm
our results and to clarify the physio-pathological relation between HFE or
other molecules involved in iron metabolism and erythrocytosis.
DETERMINANTS OF CLINICAL DECISION WHEN THE
GUIDELINES ARE NOT ENOUGH: THE CASE OF A
PATIENT WITH BOTH EMORRAGIC AND THROMBOTIC
DISEASES
Passerini F., Grimaldi L.D., Ettorre C. 1, Belfiore A., Buonamico P.,
Minerva F., Pugliese S., Palmieri V.O., Portincasa P.
Clinica Medica “A. Murri”, Dipartimento di Scienze Biomediche ed
Oncologia Umana, Università di Bari “Aldo Moro” 1Centro di Emofilia e
Trombosi Azienda Ospedaliera Policlinico Bari
Patient M.F, male, 71 years old, affected by hypertension, type II diabetes
mellitus, dyslipidemia, prostatic hypertrophy, Von Willebrand disease, for
which he undergoes to periodic therapy with VIII factor enriched by von
32
118° Congresso Nazionale - Società Italiana di Medicina Interna
Willebrand component. He has also multiple-revascularized ischemic car-
diopathy, whose last intervention dates back to 2011, and paroxysmal atrial
fibrillation, for whose reasons the patient is in pharmacological treatment
both with ASA 100 mg (1cp/day) and with Dabigatran (110 mg, 1cpx2/
die). He is still in active waiting list for new coronary artery arteriography
because of the anginal symptoms even in recent months and even at rest. In
2014, LNH diagnosis with tunsillar localization with chemio-immunothe-
rapy treatment according to the R-Benda scheme, with remission of illness.
The patients is sent by Emergency Unit to our Clinic for thoracic pain and
anemia with reported episode of melena, thrombocytopenia. Laboratory
tests show: Hb 7.2 g/dl (n.v. 13.3-17.2); MCV 74.3 fl (n.v.81.2-94) for which
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
μg/dL (n.v.65-175); Ferritin 11 ng/ml (n.v. 26-388). Because of clinical and
laboratory framework, a gastropathy is suspected and the patient is planned
for an EGDS. For comorbid coexistence such as ischemic heart disease,
atrial fibrillation and congenital coagulopathy, and the difficulty in their
pharmacological treatment, which need antithetic therapies, we ask for both
cardiological and coagulological consultations. Due to high haemorrhagic
risk (CHADsVASC 6, HASBLED 5), it is decided to temporarily suspend
both anticoagulant and antiaggregant treatment with dabigatran and ASA,
although there is a very high thrombotic risk. An EGDS is then performed
which highlights a as a vegetative, ulcerated, napping bloody mass in the
duodenal bulb. Endoscopic hemostatic treatment is performed, but it is
decided not to perform a biopsy and to postpone this procedure at a time
of eventual hemoglobin stabilization. TC total body is performed which
confirms the presence of a vegetative lesion at the duodenum. At this level,
the walls appear thickened, associated with lymph nodes in the perivascular
adipose tissue. In the meantime, the patient is treated with infusion of VIII
factor enriched with von Willebrand in order to reach stable levels of HB.
Finally we plan to perform a new endoscopic examination with the specific
indication to the biopsy of the mass in the hypothesis that this could be due
to an exacerbation at this level of the LNH.
Conclusion: the interest of this very challenging case is mainly due to the
presence of two concomitant severe diseases in which relative guidelines
suggest antithetic therapeutic options. The key is represented by the pre-
sence of a neoplastic blooding mass. What to do? We chose first the proco-
agulant therapy even if it is clearly in contrast with the need of the patient
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-
rience of the physician. Once more we could say with Osler: Medicine is a
science of uncertainty and an art of probability.
A STRANGE CASE OF ANEMIA
Marcacci M. 1, Pileri F. 1, Nuzzetti M. 1, Bresciani P. 2, Pietrangelo A. 1
1
Internal Medicine 2 and Center for Hemochromatosis, University Hospital
of Modena, University of Modena and Reggio Emilia (Italy) 2 Section of
Hematology, Department of Medical and Surgical Sciences, University
Hospital of Modena, University of Modena and Reggio Emilia (Italy)
PB, a 60 year-old woman, was admitted to our hospital for mild chest pain
three days before, followed by fatigue, palpitations and dyspnea. The patient
also reported a single episode of macrohaematuria in the morning. In the
medical history of note: a mild macrocytic anemia treated with oral coba-
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
severe macrocytic anemia (Hb 7.4 g/dl, MCV 101 fl). Her pulse rate was
78 beats/minute regular, with a blood pressure of 130/70 mmHg. Oxygen
saturation at room air was 100%. Examination of the cardiovascular, respi-
ratory and abdominal systems was normal (in particular the patient did not
show lymphadenomegaly or splenomegaly). The chest pain experienced by
the patient was investigated by ECG and markers of myocardial necrosis,
all negative. In the emergency department, in consideration of macroha-
ematuria, an abdomen CT scan was performed, negative for alterations
of kidney and bladder and for intra-abdominal hematomas. There was no
family history of anemia. Indices of hemolysis showed mild reticulocyto-
sis and slight decrease of haptoglobin; cobalamin and folate levels were
low, despite supplementation, and iron assessement was consistent with
a chronic inflammatory state (ferritin 819 ng/ml, serum iron 56 microg/
dl). Before the patient underwent blood transfusion, a peripheral blood
film was performed, which revealed polychromasia, suggestive of a regene-
118° Congresso Nazionale - Società Italiana di Medicina Interna
rative anemia. Direct and indirect Coombs tests, lymphoproliferative and
lymphocyte immunopheno-typing were negative. Flow cytometry did not
detect paroxysmal nocturnal hemoglobinuria (PNH)-clones. An endosco-
pic study of the gastrointestinal tract revealed only a small 2 mm area of
gastric angiodysplasia with no active bleeding; biopsies were negative for
celiac disease and for Helicobacter pylori infection. Autoimmunity (ANA,
ANCA, anti-parietal cell and intrinsic factor antibodies), tumor markers
and celiac disease screening were negative. In order to exclude an aplastic
anemia, quantitative PCR for EBV, CMV, HHV6, HHV7, HHV8 and sero-
logy for Parvovirus B19 infection were performed, resulting negative for
recent infections. On further questioning, the patient admitted consump-
tion of large amount of broad beans the day before her symptoms began;
for this reason, glucose-6-phosphate dehydrogenase (G6PDH) assay was
performed, resulting lower than normal, despite blood transfusions (3 U/
gr.Hb, normal range 9-18). The patient was therefore advised on the medi-
cations to be avoided, and her hemoglobin rised to 12.6 g/dl after two weeks
and remained normal thereafter. G6PDH deficiency is an X linked disorder
and occurs not only in boys who are hemizygous for the X-linked G6PDH
variant gene, but may also occur in adult heterozygous women. The main
clinical manifestations are seen in hemizygous males, but heterozygous
females can also be affected in some circumstances, because of the presence
of a population of deficient cells. Female patients heterozygous for G6PDH
deficiency have two red cell populations: one with normal enzyme content
and one deficient, that explains the red cell lysis when exposed to an oxida-
tive challenge. Due to skewed X chromosome inactivation, the population
of deficient cells may be much larger, and the red cell enzyme concentra-
tion can be similar to those in hemizygous males, leading to hemolysis on
exposure to oxidant drugs or fava beans. Most individuals with G6PDH
deficiency remain clinically asymptomatic, but they are at risk of develo-
ping acute hemolytic anemia when exposed to three types of triggers: drugs,
infections and broad beans. The hemolytic attack can be self limiting, but
also very serious.
The blood film can show polychromasia, anisocytosis, poikilocytosis and
blister cells, features of acute oxidant induced hemolysis. In this case the
diagnostic difficulty was due to lack of clear signs of hemolysis at the bioche-
mical examinations and at the blood film. This case, once again, strengthens
the importance for diagnosis of collecting a detailed and accurate patient’s
history.
References: 1. Lim, F., T. Vulliamy, et al. (2005). “An Ashkenazi Jewish
woman presenting with favism.” J Clin Pathol 58(3): 317-319. 2. Luzzatto,
L., C. Nannelli, et al. (2016). “Glucose-6-Phosphate Dehydrogenase Defi-
ciency.” Hematol Oncol Clin North Am 30(2): 373-393. 3. Stockley, R., A.
Dawson, et al. (1985). “Favism in two British women.” Lancet 2(8462): 1013.
AN UNUSUAL EMOGASANALYSIS
Ciarla S., Striuli R., Petrarca M., Croce G., Parisi D., Di Michele D. U.O.C. di
Medicina Interna - Ospedale “G. Mazzini” ASL Teramo
A 32-year-old Caucasian male was admitted for acute renal failure caused by
tumor lysis syndrome. Hyperuricemia (31 mg/dl) was treated with 2 doses
of rasburicase. The day after, on physical examination cyanosis and severe
asthenia were noted. Blood pressure was 140/90 mmHg, pulse 90 beats/
min. The saturation on pulse oximeter was 40%. Arterial blood gas analysis
showed pO2 61.8 mmHg%, sO2 91.7% but 20% of methaemoglobinaemia.
At laboratory test hemoglobin was 6.9 g/dl. The anemia was associated with
hemolytic markers including marked reticulocytosis with Heinz bodies,
elevated indirect bilirubin and lactate dehydrogenase, and reduced hapto-
globin. Later blood tests confirmed glucose-6-phosphate dehydrogenase
(G6PD) deficiency. He received oxygen, ascorbic acid and blood transfu-
sion and made a complete recovery. The methaemoglobinaemia disappe-
ared after 48 hours. Rasburicase is a recombinant urate oxidase enzyme
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
monitoring is mandatory, especially in populations where G6PD deficiency
is highly prevalent. Unfortunately, the G6PD status of a patient is often
unknown at the time rasburicase therapy is contemplated. Methaemoglobi-
naemia must be suspected in case of low oxygen saturation when all other
potential causes have been ruled out.
Comunicazioni Orali
CO-ACTIVATOR-ASSOCIATED ARGININE
METHYLTRANSFERASE 1 (CARM1) IS OVEREXPRESSED
IN TYPE 2 DIABETES
Porta M., Amione C., Barutta F., 1Albano L., 1Ciccarelli M., Fornengo P.,
Merlo S., 1Ungaro P., 1Beguinot F., 2Berchialla P., 2 Cavallo F., Trento M.
Laboratory of Clinical Pedagogy, Department of Medical Sciences, University
of Turin. 1Department of Cellular and Molecular Biology and Pathology,
University Federico II, Naples. 2Department of Public Health and Paediatric
Sciences, University of Turin, Italy
Background: Type 2 diabetes (T2DM) is on the rise worldwide but the
causes for this epidemic remain to be ascertained. While several genetic
markers were described, their contribution to the total risk of developing
T2DM appears minimal. On the other hand, urbanisation has driven
dramatic changes in lifestyle and may increase risk factors for T2DM via
epigenetic mechanisms. Objective Over the years, our research interest
has focused on identifying the dimensions involved in lifestyle changes in
people with T2DM. As part of an ongoing study, we investigated the dif-
ferential expression of a panel of histone modulating enzymes in T2DM
patients and non-diabetic controls.
Patients and Methods: Patients (n=21) with T2DM, aged 40-70, treated by
diet and/or oral glucose-lowering agents and with at least 1-year attendance
in the clinic were randomly selected. Exclusion criteria were current insulin
treatment, known psychiatric conditions, cancer or other conditions with
potential impact on the epigenetic machinery. Clinical, blood chemistry,
epigenetic, inflammatory cytokines and endocrine variables were mea-
sured in the patients and in 21 non-diabetic controls matched by age and
sex. Peripheral blood leukocytes were separated and total RNA and DNA
isolated. The isolates were retro-transcribed to evaluate the expression of
a panel of 84 histone modifying enzymes by Real-Time PCR. A panel of
22 cytokines and 10 hormones involved in metabolism were measured in
serum by specific ELISA or by Bio-Plex Multiplex Immunoassay System.
Chi-square test or Fisher exact test were performed to compare groups of
categorical data, and the Mann-Whitney U test to compare continuous data.
A discrete Bayesian Network was built to explore the relationships between
all variables. Normality of distribution of continuous variables was tested by
the Shapiro-Wilk test and, since it was not satisfied, Hartemink’s Informa-
tion-Preserving Discretization was carried out. Power analysis showed that
21+21 samples allowed a statistical power of 81% to detect a 25% difference
in CARM1 expression with alpha=5% and a Bonferroni correction for 100
multiple tests.
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,
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
the groups. Of the 84 histone-modifying enzymes checked, only CARM1
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,
G-CSF, IFN γ and TNFα, and decreased levels of IP-10. Bayesian network
analysis showed that the dichotomy health/diabetes was independently
linked to plasma glucose, CARM1 and leptin. A second independent node
proceeded from IL-1b to IL-6, TNFα and IFN- γ. TNFα also clustered with
IL-7, IL-4 and IL-17.
Conclusions: This is the first report on increased expression of CARM1 in
patients with T2DM, independent of known hormonal and inflammatory
pathways. CARM1 enhances transcriptional activation of nuclear receptors
by interacting with coactivators p160 and CBP and methylation of histone
H3 at arginine 17. In particular, it is a coactivator of nuclear factor-kB and
a possible key regulator of glucose-induced insulin secretion and glucose
metabolism in the liver. Further studies will need to elucidate the conditio-
nal dependence of CARM1 expression on the presence/absence of T2DM.
TLRS EXPRESSION IN PATIENTS WITH
CARDIOVASCULAR RISK FACTORS: METABOLIC
CORRELATIONS
Perticone M. 1, Sciacqua A. 2, Hribal M. 2, Colica C. 3 Pinto A. 2, Procopio G.
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
Comunicazioni Orali
Toll Like Receptors (TLRs) are trans-membrane proteins that play a crucial
role in the innate immune response. Once activated, TLRs dimerize and
recruit a number of adaptive proteins, initiating a intracellular pathway that
culminates with the activation of Nuclear Factor kB (NFkB), a transcription
factor responsible for the transcription of inflammatory cytokines. These
cytokines generate a low-grade immune-mediated inflammatory state asso-
ciated with increased cardiometabolic risk. Systemic low-grade inflamma-
tion is also present in hypertension. The aim of this study was to evaluate
the expression of TLR2 and TLR4 and the activation of NFkB in circulating
monocytes of obese patients to assess whether the presence of hyperten-
sion worsens their risk profile. Patients were selected among the partici-
pants to the Catanzaro Metabolic Risk Factor Study (CATAMERIS). After
a complete clinical examination and laboratory tests subjects were divided
into 4 groups: 16 healthy control;18 hypertensives non-obese; 20 obese
non-hypertensive; 9 obese and hypertensive. The expression of TLRs was
evaluated by cytofluorimetry and the activation of NFkB was evaluated by
ELISA assay. There were no statistically significant differences between the
groups in terms of gender distribution and age. By design, there was a signi-
ficant difference in BMI, systolic and diastolic blood pressure(p<0.0001 for
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),
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
(p=0.003); cholesterol HDL (p=0.002); and LDL (p=0.026). By analyzing
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
both receptors levels (p <0.0001), with the worsening of the cardiometabo-
lic risk profile (from healthy subjects to hypertensive to obese); by contrast
the obese-hypertensive group presented average median levels that were
comparable to those observed in obese only subjects. To evaluate the fun-
ctional effects of the higher expression of TLRs, NFkB activity was determi-
ned in 5 healthy, 3 hypertensive, 5 obese and 2 obese-hypertensive subjects;
a not statistically significant trend of increased activity was observed with
the higher in obese subjects independently of the presence of hypertension.
In conclusion, data from this study confirm that obesity is a clinical con-
dition of high cardiovascular risk. Notably, the obese-hypertensive group
did not show any difference from obese only group, suggesting that obesity
itself accounts for the increased cardiometabolic risk in obese patients.
NT-PRO-BNP IN INSULIN-RESISTANCE MEDIATED
CONDITIONS: OVERWEIGHT/OBESITY, METABOLIC
SYNDROME AND DIABETES. THE POPULATION-BASED
CASALE MONFERRATO STUDY
Baldassarre S. 1, Fragapani S. 1, Panero A. 1, Fedele D. 1, Pinach S.1,
Lucchiari M. 2, Vitale A.R.2, Mengozzi G. 2, Gruden G.1, Bruno G 1
1
Dipartimento di scienze mediche, Università degli studi torino, Torino; 2
Laboratorio analisi cliniche, Azienda Ospedaliero-Universitaria Città della
Salute e della Scienza, Torino
Background and Aims: to examine the relationship between NT-proBNP,
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
diabetic and non-diabetic people.
Methods: The study-base were 3244 individuals aged 45-74 years, none
of whom had heart failure, 1880 without diabetes and 1364 with diabetes,
identified as part of two surveys of the population-based Casale Monfer-
rato Study. All measurements were centralized. We examined with multi-
ple linear regression the effect on NTproBNP values (dependent variable)
of a categorical variable with four levels determined by the combined
effect of diabetes (yes/no) and BMI (<25 and ≥25 kg/m2), independently
of waist circumference and after adjustment for known risk factors and
confounders (age, sex, hypertension, LDL-cholesterol, smoke, CRP, AER,
creatinine, CVD). A logistic regression analysis was also performed with
NTproBNP as a categorical variable with two levels defined by its median
value, to assess the effect of overweight/obesity, diabetes and the metabo-
lic syndrome, independently of age, sex, hypertension, LDL-cholesterol,
smoke, CRP, AER, creatinine, CVD, waist circumference. All analyses
were performed with Stata Release 10.0.
Results: Out of overall cohort of 3244 people, overweight/obesity (BMI ≥
25 kg/m2) was observed in 1,118 (59.4%) non-diabetic and 917 (67.2%)
diabetic subjects, respectively. No significant correlations between
NTproBNP and either BMI or waist circumference were found. As com-
pared to people without diabetes, subjects with diabetes showed a 2.6-
34
118° Congresso Nazionale - Società Italiana di Medicina Interna
fold increase in the adjusted-OR of having high NT-proBNP values,
while people with a BMI ≥ 25 kg/m2 had a lower adjusted-OR (0.70, 95%
CI 0.56-0.87) compared to normal-weight individuals. In people with
overweight/obesity only, the OR of having NT-proBNP levels above the
median value (34 pg/ml) was significantly lower than in normal weight
subjects (OR=0.64, 0.48-0.82). The presence of diabetes either alone or
combined with overweight/obesity or metabolic syndrome greatly enhan-
ced the OR of having NT-proBNP levels above the median value, while the
presence of metabolic syndrome alone had a more modest effect (OR=1.54,
1.18-2.01). All previous results were virtually identical after exclusion of
the subjects with CVD. Finally, we performed a separate analysis in the
non-diabetic cohort to examine the effect of HOMA-IR values above
median value (≥ 2.0) on NT-proBNP BMI ≥ 25 Kg/m2 and HOMA-IR ≥
2.0 decreased to a similar extent the ORs of having NT-proBNP above the
median value (BMI OR=0.76, 95% CI 0.60-0.95, HOMA-IR OR=0.74, 95%
CI 0.59-0.93). However, the association between overweight/obesity and
NT-proBNP was no longer significant after the inclusion into the model
of HOMA-IR). CRP was negatively associated with NT-proBNP and this
effect was evident even in the fully adjusted model.
Adjusted OR (95% CI)
Model 1 Non diabetes  1.00
Diabetes 2.60 (2.37-2.87)
BMI < 25 kg/m2 1.00
BMI ≥ 25 kg/m2 0.70 (0.56-0.87)
Model 2 Non diabetes, BMI < 25 kg/m2 1.00
Non diabetes, BMI ≥ 25 kg/m2 0.63 (0.48-0.82)
Diabetes, BMI < 25 kg/m2 5.44 (3.98-7.44)
Diabetes, BMI ≥ 25 kg/m2 4.42 (3.25-6.01)
P for trend <0.0001
Model 3 Neither Metabolic syndrome nor DM 1.00
Metabolic syndrome 1.67 (1.25-2.22)
Diabetes   7.45 (5.54-10.01)
Metabolic syndrome +Diabetes 7.56 (5.84-9.78)
P for trend <0.0001
Conclusion: Results of the Casale Monferrato population-based study
shows that NT-proBNP levels are lower in overweight/obesity, indepen-
dently of diabetes and that both insulin-resistance and chronic low-grade
inflammation are mediator of this relationship. Our findings are consistent
with the hypothesis that NPs are implicated in metabolic processes, with
impaired circulating levels of natriuretic peptides contributing to the incre-
ased cardiovascular risk of people with insulin-resistance mediated condi-
tions, obesity, MetS, and diabetes. Further intervention studies are required
to test the potential role of drugs affecting the natriuretic peptides system on
body weight and risk of diabetes.
EXENATIDE LAR IMPROVES CARDIO-METABOLIC
PARAMETERS INDEPENDENTLY OF BASELINE
ADIPONECTIN IN TYPE-2 DIABETIC PATIENTS: AN
8-MONTH PROSPECTIVE STUDY
Chianetta R. 1, Giglio R.V. 1, Nikolic D. 1, Castruccio Castracani C. 2,
Diliberto S.M. 1, Castellino G. 1, Patti A.M. 1, Mannina C. 1, Citarrella R. 1, Li
Volti G. 2, Montalto G. 1, Rizzo M. 1
1
Biomedical Department of Internal Medicine and Specialties, University of
Palermo, Italy 2Department of Biomedical and Biotechnological Sciences,
University of Catania, Italy
Background and Aims: The improvement in body composition, including
adiponectin, a known adipokine with antihyperglycemic, antiatherogenic,
and anti-inflammatory properties, has been seen after exenatide treatment.
However, the effect of exenatide once-weekly (long-acting release, LAR)
on adiponectin is largely unknown. We investigated whether the effect of
exenatide LAR on several cardio-metabolic parameters, including carotid
intima-media thickness (cIMT), endothelial function as well as cytokines
involved in endothelial function, may differ between diabetic patients with
a high and a low level of adiponectin at baseline. Materials and Methods:
Sixty subjects with T2DM (41 men and 19 women; 60±10 yrs) naïve to
118° Congresso Nazionale - Società Italiana di Medicina Interna Comunicazioni Orali

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
Comunicazioni Orali
POOR VITAMIN STATUS IN PATIENTS WITH
SYMPTOMATIC ACUTE PORPHYRIAS: A RELIABLE
TARGET FOR TREATMENT OF SYMPTOMATIC
PATIENTS?
Ventura P., Marcacci M., Marchini S., Cuoghi C., Vaccari D., Pietrangelo A.
Unit of Internal Medicine 2, Regional Reference Centre for Porphyrias, Dept.
of Medical and Surgical Sciences for Children and Adults, Policlinico Hospital
of Modena, University of Modena and Reggio Emilia, Italy
Background: Conditions of poor nutritional status and vitamin deficiency
have been described in patients affected by porphyrias in general. In acute
porphyrias (AP), the partial enzymatic block in the heme pathway, leads to
the induction of liver delta-aminolevulic acid synthase (ALAS1), the rate
limiting step of heme biosynthesis. As ALAS1 is a vitamin B6-dependent
enzyme, its enhanced activity may result in use of abnormal high amounts
of B6, leading to different degree of B6 tissue deficiency. Interestingly, the
peripheral neuropathy observed in conditions causing B6 deficiency has
striking clinical resemblances to those observed in the AP. Moreover, any
other different micronutrients can support the heme biosynthetic pathway
through essential and non-essential co-factor roles, as well as protect the
body against oxidative stress through their antioxidant properties. Aim: to
assess vitamin B6, B12 and folates status in patients with AP and the possi-
ble association with their poor status with different clinical stage of disease
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
(symptomatic vs. asymptomatic), Vit.B6, Vit.B12, red blood cell folates and
urinary delta-aminolevulinic acid(ALA) and porphobilinogen(PBG) levels
(mean of seven seriate measurements measured outside acute attacks).
Results: As expected, symptomatic AP patients (SAP, n=18) had signifi-
cantly higher levels of urinary ALA and PBG than asymptomatic AP patients
(AAP, n=28); a significant poorer vitamin status was observed for all tested
vitamins in SAP vs. AAP group: in 6/18 (30%) vs. 0/28 (0%), p=0.001 for B6;
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
significantly higher if considering as cut-off value for vitamin status a value
below the 25th percentile of the normal range. Multiple vitamin deficiency
was also significantly frequent in SAP than in AAP group. No significant
direct correlation between vitamin plasma or RBC levels and PBG or ALA
in urine was observed, but a trend in increase of mean plasma B6 levels was
observed when stratifying patients for different levels of increase in urinary
ALA and PBG levels. Within SAP group patients undergoing a maintenance
therapy (n=14) with heme arginate, B6 status resulted significantly poorer
than that in those not undergoing a maintenance therapy (n=4) (40.7 vs.
18.8 ng/ml, respectively, p=.039), and a significant different prevalence of
B6 deficiency was observed between these two groups. B6 deficiency status
showed a significant association both with an history of recurrent acute
porphyric attacks [OR= 8.3 (95% CI 4-25.7), p=.004], and the presence of
multiple vitamin deficiency [OR= 12.9 (95% CI 3.7-51.8), p=.002], as well.
Conclusions: Patients with symptomatic AP show a significant vitamin B
group poorer status than AP asymptomatic group, particularly for B6. Con-
sidering that clinical signs of porphyric acute attacks strictly resemble those
resulting from vitamin B6 deficiency, our data suggest the importance of
assessment of vitamin status in all patients with symptomatic AP, especially
if under heme arginate maintenance therapy. A possible therapeutical role
for vitamin supplementation in these patients should be considered.
ONE HOUR POST-LOAD HYPERGLYCEMIA AND MILD
COGNITIVE IMPAIRMENT
Perticone M. 1, Arturi F. 2, Cassano V. 3, Miceli S. 4, Tramontano A. 5,
Sciacqua A. 2, Sesti G. 2, Perticone F. 2
1
Dipartimento di Medicina Sperimentale e Clinica - Università degli
Studi Magna Graecia di Catanzaro 2Dipartimento di Scienze Mediche
e Chirurgiche - Università degli Studi Magna Graecia di Catanzaro
3
Dipartimento di Scienze della Salute - Università degli Studi Magna
Graecia di Catanzaro 4Azienda Ospedaliero-Universitaria “Mater Domini” -
Catanzaro 5Università Federico II - Napoli
Insulin resistance (IR), is a well known pathogenetic factor responsible for
the appearance of many cardiometabolic disease, first of all of diabetes mel-
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
118° Congresso Nazionale - Società Italiana di Medicina Interna
motolerant subjects with 1h-post-load plasma glucose levels >155 mg/dL
(NGT 1h-high), have a cardiovascular risk similar to that of diabetics. We
hypothesized that these subjects may develop early neuropsychological alte-
rations, given their enanched IR. The aim of this study was to early detect
neuropsychological and/or neuroimaging alterations suggestive of MCI in a
group of NGT 1h-high subjects, compared with a group of subjects with 1h
post-load plasma glucose <155 mg/dL (NGT 1h-low).
Methods: We planned to enroll 30 subjects (15 NGT 1h-high and 15 NGT
1h-low), free from DM and any disease predisposing to MCI and glucose
metabolism alterations. All patients underwent 3T cerebral MRI with eva-
luation of diffusion, and complete neuropsychological assessment.
Results: These preliminary results are referred to 7 subjects (4 NGT 1h-high
and 3 NGT 1h-low), mean age 55+4 years. We observed statistically signi-
ficant differences (NGT 1h-high vs NGT 1h-low) for: 1h post-load plasma
glucose (174±14 vs 121±33 mg/dL), total cholesterol (171±29 vs 246±6 mg/
dL), and IGF-1 (114±17 vs 161±7 ng/mL). Clinically but not statistically
relevant differences were found for: insulinemia (18±13 vs 9±2 UI/mL),
and HOMA index (4±3 vs 2±1). We did not observe a significative diffe-
rence between groups with regards to neuropsychological and neuroima-
ging studies. Anyway, NGT 1-h high subjects showed a worse trend both
parameters.
Conclusion: These preliminary results, if confirmed in a greater study,
could allow to consider 1h post-load hyperglycemia as a risk factor not only
for new DM and CV events, but also for MCI.
BODY COMPOSITION ANALYSIS BY INBODY 770® IN
BREAST CANCER PATIENTS
Molfino A.1, Amabile M.I.1, 2, De Luca A.2, Ramaccini C.1,
Maceli F.2, Monti M.2, Rossi Fanelli F.1, Muscaritoli M.1
1
Department of Clinical Medicine, Sapienza - University of Rome, Rome,
Italy 2Department of Surgical Sciences, Sapienza - University of Rome, Rome,
Italy
Background and Aim: Obesity represents an under-recognized preven-
table risk factor for cancer development and recurrence, including breast
cancer (BC). Obesity is highly prevalent in western countries and it contri-
butes to almost 50% of BC in older women. However, although high body
mass index (BMI) may indicate overweight and obesity, often low muscle
mass may be present at BC diagnosis, impacting negatively on outcomes.
We aimed at assessing body composition in BC patients at the moment of
cancer diagnosis and the association between body composition and clinical
parameters.
Patients and Methods: Consecutive BC patients were enrolled before
undergoing breast surgery and any other therapy. Clinical characteristics
were collected, including BMI (weight/height2), waist circumference (cm),
while muscle mass (MM) (kg) and adiposity (kg) were assessed by bioe-
lectrical impedance analysis (InBody 770®, InBody co, Ltd., kindly provi-
ded by Caresmed, Italy). Skeletal muscle index (SMI) was calculated as MM
(kg)/ height (m)2. Parametric and non-parametric tests were performed, as
appropriate, and P <0.05 was considered statistically significant.
Results: A total of 19 BC patients were studied. Age (years) was 54.4±11.2.
BMI was 25.2±3.8 and MM was 23.3±3.2. Based on SMI cut-off values for
sarcopenia, we did not observed this condition in the patients enrolled (SMI
9.1±1.2). Eleven patients reported involuntary body weight loss (between 3
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
had a MM significantly lower with respect to patients without body weight
loss (P=0.04) and a lower phase angle value (P=0.01), as well as lower SMI
(P=0.02).
Conclusions: Besides the clinical importance of the anthropometric values,
body composition analyses revealed at the moment of BC diagnosis lower
muscularity in patients presenting involuntary body weight loss in the pre-
vious months. These preliminary results suggest that body composition
analysis should be included in the evaluation of nutritional status, since
BMI and weight loss cannot discriminate the subtle changes occurring in
body compartments in early phases of disease.
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
J, et al. Clin Nutr 2017; Fernández-Lao C, et al. Support Care Cancer 2013;
Fagherazzi G, et al. Int J Obes 2012; Han DS, et al. Sci Rep 2016.
118° Congresso Nazionale - Società Italiana di Medicina Interna
IDEGLIRA IS EFFICACIOUS ACROSS BASELINE A1C
CATEGORIES IN SUBJECTS WITH TYPE 2 DIABETES
UNCONTROLLED ON SU, GLP-1RA OR INSULIN
GLARGINE: ANALYSES FROM COMPLETED PHASE 3B
TRIALS
Piatti P. 1,Sorli C. 2, Harris S . 3, Jodar E. 4, Lingvay I. 5,
Chandarana K. 6, Langer J. 6, Lastoria G. 7, Jaeckel E. 8
San Raffaele Fondation Milane Italy1, Billings Clinic, Billings, MT, USA2,
University of Western Ontario, London, ON, Canada3. University Hospital
Quiron Salud Madrid, Madrid, Spain4, UT Southwestern Medical Center,
Dallas, TX, USA5, Novo Nordisk A/S, Soborg, Denmark6, NovoNordisk
Medical Affairs Rome, Italy7,Hannover Medical School, Hannover, Germany8
Previous analyses of phase 3a trials (DUAL I extension; DUAL II) showed
insulin degludec/liraglutide(IDegLira) is efficacious irrespective of baseline
HbA1c. This post hoc analysis aimed to confirm thisobservation in additio-
nal populations with type 2 diabetes uncontrolled on (i) a glucagon-likepep-
tide-1 receptor agonist (GLP-1RA) (DUAL III: IDegLira versus unchanged
GLP-1RA), (ii) sulfonylurea(SU) } metformin (DUAL IV: IDegLira versus
placebo) or (iii) insulin glargine (IGlar) (DUAL V: IDegLira versus con-
tinued IGlar titration). IDegLira starting dose was 10 dose steps (1 dose
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
according to baseline HbA1c; ≤7.5, >7.5–≤8.5 and >8.5%. In all trials a
higher baseline HbA1c resulted in greater HbA1c reductions. The change in
HbA1c was significantly greater with IDegLira vs. comparator in all baseline
HbA1c groups with a similar treatment difference between baseline HbA1c
groups. In all trials for all baseline HbA1c groups, IDegLira decreased mean
HbA1c to <7% at end of trial. In DUAL V, the only trial to include patients
with HbA1c >9% (mean 9.6%), HbA1cwas reduced to 6.9% with IDegLira
vs. 7.8% with IGlar. In conclusion, significant HbA1creductions occur with
IDegLira regardless of baseline HbA1c group or study population.
CHRONIC HYPOPHOSPHOREMIA: A BIOCHEMICAL
RESULT OFTEN OVERLOOKED
Colangelo L. 1, Sonato C. 1, Cilli M. 1, Gianni W. 1, Danese V.C. 1, Pepe J. 1,
Cipriani C. 1, Moreschini O. 2, Corsi A. 3, Minisola S. 1
1
Dipartimento di Medicina Interna e Specialità Mediche, Policlinico
Umberto I, Sapienza Università di Roma, 2 Dipartimento di Scienze
Anatomiche, Istologiche, Medico Legale e dell’Apparato Locomotore,
Sapienza Università di Roma, 3Dipartimento di Medicina Molecolare,
Policlinico Umberto I, Sapienza Università di Roma
A 33-year-old man with five years’ history of lumbar and pelvis pain with
multiple vertebral fractures was admitted to our hospital. His medical
history begun with fatigue markedly worsened and diffuse muscle impair-
ment which were associated with pain radiated down both legs. After a
previously examination by his physician, he was sent to a rheumatology
division for further evaluation, where ankylosing spondylitis was diagno-
sed and treated with anti-TNFa and with a low-moderate use of morphine.
On physical examination, he had severe kyphosis, proximal weakness with
difficulties in performing daily activities. He was unable to walk without
crutches. His previous laboratory results showed a chronic hypophospha-
temia. To study the unexplained hypophosphatemia, we performed an
evaluation of blood sample for phosphorus and creatinine and, at the same
time, a two-hour urine sample was collected for phosphaturia and creati-
nuria to discriminate between the factors that reduced the plasma concen-
tration of phosphorus. Nomogramm of Walton and Bijvoet helped to eva-
luate this data and showed low tubular reabsorption of phosphate (1,28 mg/
dl) despite hypophosphatemia (1,2 mg/dl). X-linked Hypophosphataemic
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
exhibited high serum FGF23 levels (673 pg/ml, ELISA LIAISON, Diasorin,
Saluggia, Italy; n.v. <95 pg/ml), which suggested that a hidden tumor was
secreting FGF23. Elevated values of bone alkaline phosphatase (58 mg/l;
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
the head of the right femur and in the right tibia, although OctreosanTM
showed an increased uptake of the tracer only in the femur. First we decided
to remove the head femur lesion and perform intra-operative FGF23 assay
to confirm tumor resection; if this had been unsuccessfully, we would have
extended the operation to excise the second bone lesion. Basal, 10, 60 and
Comunicazioni Orali
225 m’ values after excision of the right femoral head were 423, 127, 56 and
30, respectively. Starting from the 60 m’ all values were in the normal range.
The brisk fall of FGF23 values suggested that the head femur lesion was
responsible for the syndrome. On histological examination, a mesenchymal
tumor with highly vascular proliferation pattern (hemangiopericytoma-like
tumor), was diagnosed. This is the first report showing the possibility of
intra-operative FGF23 assay to monitor tumor resection in patients with
tumor induced osteomalacia. This approach could be particularly useful
to prevent incomplete resection or in case of multifocality, which has been
recently described as a cause of surgical failure. In conclusion, the presence
of a chronic hypophosphoremia should not be overlooked but must be
directed to the search for its etiology.
HIGHER INCIDENCE OF ARRHYTHMIAS IN PRIMARY
HYPERPARATHYROIDISM COMPARED TO CONTROLS
WITH TWENTY-FOUR HOUR ECG MONITORING
Pepe J., Curione M., Cipriani C., Baffa V., Colangelo L., Sonato C.,
Demafonti C., Vigna E., Biondi P., Minisola S.
Department of internal medicine and medical disciplines, “Sapienza”,
University of Rome
Background: Hypercalcemia induces arrhythmias and shortening of the
QT interval. The aim of this study was to investigate the occurrence of
arrhythmias in patients with primary hyperparathyroidism (PHPT), during
24 hour ECG monitoring.
Methods: Twenty-four PHPT postmenopausal women (age range 45-80
years) and twenty-four sex and age-matched controls underwent standard
ECG, 24 hour ECG monitoring and mineral metabolism biochemical eva-
luation. Exclusion criteria were: valvular disease, cardiac hypertrophy, pre-
vious history of arrhythmias, coronary artery disease, diabetes mellitus and
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
Bazett’s formula (QTc). QT dispersion (QTd) wascalculated as the difference
between the maximum and the minimum QT interval, respectively obtai-
ned in any of the 12 ECG leads.
Results: There were no differences concerning anthropometric parame-
ters between PHPT patients and controls. Prevalence of hypertension and
dyslipidemia were similar between PHPT and controls (hypertension: 50 vs
33.3%,dyslipidemia: 20.8 vs 16.6%). PHPT patients had mean higher total
and ionized calcium and parathyroid hormone levels compared with con-
trols (total calcium 10.87 ± 0.53 vs 9.40 ± 0.35 mg/dl, p < 0.0001, ionized
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
normal values of QTc, but significantly shorter compared with controls
(400.25 ± 15.09 vs 409.75 ± 17.12 msec, p = 0.04). In PHPT patients, an
increased occurrence of at least one supraventricular premature beats
(SVPBs) during the 24 hour ECG monitoring compared with controlswas
observed (100% vs 75 %, p = 0.0001). Moreover, in PHPT patients SVPBs
often occurred in repeating patterns as couplets (62.5 vs 29.1%, p = 0.04),
and triplets (20.8 vs 0 %, p = 0.04). Higher runs of more than four SVPBs,
lasting less than 30 second, were also observed more frequently in PHPT
compared to controls (33.3 vs 8.3%, p = 0.03). The occurrence of ventricular
premature beats (VPBs) during 24 hour monitoring was also significantly
higher in PHPT compared with controls (75% vs 29.1%, p = 0.003). In the
PHPT group, serum ionized calcium level showed a negative correlation
with QTc (r = - 0.49, p < 0.05) and a positive correlation with QTd (r = 0.46,
p < 0.05).
Conclusions: The significant higher occurrence of SVPBs and VPB in
PHPT patients is mainly related to a short QTc and hypercalcemia, thus
representing risk factors for arrhythmias.
LONG-TERM EFFECTIVENESS OF LIRAGLUTIDE FOR
TREATMENT OF TYPE 2 DIABETES IN A REAL LIFE
SETTING: A 24-MONTH NON-INTERVENTIONAL,
RETROSPECTIVE, MULTICENTRE STUDY IN ITALY
Simioni N. 1, Berra C. 2, Boemi M. 3, Bossi A.C. 4, Candido R. 5,
Di Cianni G. 6, Frontoni S. 7, Genovese S. 8, Ponzani P. 9,
Provenzano V. 10, Russo G. 11, Sciangula L. 12, Lapolla A. 1, Bette C. 14,
Nicolucci A. 15 on behalf of the NN2211-4118 Study Group.
1
Presidio Ospedaliero di Cittadella, Padova, 2 Istituto Clinico Humanitas,
Milan, 3 Ospedale INRCA, Ancona, 4 Ospedale Treviglio Caravaggio, 5
37
Comunicazioni Orali
Ass 1 Triestina, Trieste, 6 Ospedale di Livorno, 7 Ospedale S.G Calibita
Fatebenefratelli, Rome, 8 Ospedale Multimedica, Sesto San Giovanni, 9
Ospedale La Colletta, Arenzano, 10 Ospedale Civile di Partinico, Palermo, 11
Policlinico G Martino, Messina, 12 Ospedale Felice Villa, Mariano Comense, 13
University of Padua, 14 Novo Nordisk, Rome, 15 COREsearch, Pescara
Background and Aims: To evaluate the long-term effectiveness of liraglu-
tide when used in real life clinical setting in Italy.
Materials and Methods: The study population consisted in all consecutive
patients with Type 2 Diabetes Mellitus (T2DM) aged ≥18 years, initiating
liraglutide in 2011 and followed in 45 diabetes clinics in Italy. The variables
were collected for a 24-month period following liraglutide initiation. Conti-
nuous outcomes (HbA1c and weight) and categorical outcomes (reduction
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
models.
Results: Data on 1,723 patients were collected (mean age 58.9±9.5 years;
54.9% were men; diabetes duration 9.6±7.1 years, HbA1c 8.3±1.4%, weight
99.6±18.9 kg). Discontinuation rate at 24 months was 21.5%. The estima-
ted proportion of patients achieving an HbA1c reduction ≥1%-point after
12 months (primary endpoint) was 43.5% (95% Confidence Interval [CI]
40.9; 46.2). After 2 years, HbA1cwas reduced [estimated mean change from
baseline (95% CI)] by -0.78% (-0.84; -0.72; p<0.0001), body weight by -3.4
kg (-3.6; -3.1; p<0.0001), systolic blood pressure by -3.93 mmHg (-5.07;
-2.80; p<0.0001). At 24 months, an HbA1creduction of at least 1.0%-point
was achieved by 41.5% (95% CI 38.7; 44.4) of patients while 40.9% (95% CI
38.1; 43.7) achieved HbA1c ≤7.0%. A body weight reduction of at least 3%
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
reduction of ≥3% at 24 months.
Conclusions: These findings underline that the beneficial results documen-
ted in the liraglutide clinical development programme can be reproduced
when liraglutide is used in T2DM patients in a real world setting in Italy.
THE DARK SIDE OF HYPOKALEMIA
Brunelli V., Caturano A., Pontillo G., Solaro E., De Sio C.,
Acierno C., Spiezia S., Giunta R., Adinolfi L.E.
University of Campania “Luigi Vanvitelli”, Naples Division of Internal
Medicine
In March 2017, a 58 year-old patient was referred to our institution
because of asthenia, generalized malaise, insomnia and tachycardia. On
admission, vital signs were: blood pressure 140/90 mmHg, heart rate 120
bpm and regular, 98% oxygen saturation in ambient air, respiratory rate 20
breaths/min. The patient had a past history of glucose intolerance and of
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.
At the objective examination acne, flushing of the upper chest, mild facial
irsutism and fine tremors in the upper limbs were found. At the electro-
cardiogram, tachycardia and repolarization abnormalities, with elongated
t waves and presence of u waves were found; ABG revealed a severe meta-
bolic alkalosis and severe hypokalemia. Laboratory data showed diabetes
mellitus (glucose 183 mg/dL) and confirmed severe hypokalemia (K 1.9
mEq/L). Previous hormonal examinations of the patient showed an incre-
ase in ACTH (66 pg/ml) and cortisol (81.7 mcg/ml), and a reduction of
renin (<0.5 mcU/ml in clinostatism and ortostatism) and aldosterone (13
pg/ml in clinostatism and 25 pg/ml in ortostatism). The patient underwent
basal hormonal exams that confirmed the increase of ACTH (86.1 pg/ml)
and cortisol (41.5 mcg/dl) and the reduction of aldosterone and renin.
Considering that hypercortisolism could cause hypokalemia, we started to
investigate about hypercortisolism. The patient underwent cerebral MRI
that showed aspecific gliotic alterations derived from hydro-electrolytic
disequilibrium, in the absence of pituitary lesions, so a Cushing’s disease
was excluded. Urinary electrolytes were normal, so tubulopathy was
excluded. An 8 mg dexamethasone suppression test was done, confirming
‘hypercortisolism’(basal cortisol 284 ng/ml, after DMX cortisol 295 ng/
ml) and indicating that ACTH was not suppressed too (basal ACTH 131
pg/ml, after DMX ACTH 137 pg/ml), such as in Cushing’s syndrome.
At the previous hospitalization, in June 2016, the patient underwent an
abdominal MRI, which showed a globular aspect of right adrenal gland.
Hence, during the hospitalization in our facility, the patient performed a
total body CT that showed 30x35 mm nodular formation at the lower lobe
38
118° Congresso Nazionale - Società Italiana di Medicina Interna
of the left lung and a nodular lesion at the left adrenal gland. The lung
lesion was already known from 2011 and showed only a slight increase
in size compared with previous CT. A second radiological opinion was
required, indicating bilateral adrenal glands hypertrophy, excluding the
left adrenal gland nodular lesion. We performed a lung lesion FNAC, with
the histological diagnosis of low grade neuroendocrine neoplasia. So,
the patient underwent surgery to remove the lung lesion and the clinical
status clearly improved. In conclusion, the radiologic findings, associated
with the medical history, laboratory, hormonal and cytological data, led us
to a proper diagnosis. Hence, the role of the internist, as the one capable
of putting the pieces in the right place in clinical problem-solving proce-
dures, is crucial in these rare and multiple organs disease, leading a team
of specialists to diagnosis.
IMPACT OF BMI ON HbA1c REDUCTION IN RESPONSE
TO IDEGLIRA IN SUBJECTS WITH TYPE 2 DIABETES
(T2D) UNCONTROLLED ON SU, GLP-1RA OR INSULIN
GLARGINE: ANALYSES FROM COMPLETED PHASE 3B
TRIALS
S. Buscemi1, S. Harris 2, E. Jaeckel 3, E. Jodar 4, I. Lingvay 5,
K. Chandarana 6, G. Lastoria 7, T. Abrahamsen8
1
Università degli studi di Palermo, IT, 2 University of Western Ontario,
London, ON, Canada, 3Hannover Medical School, Hannover, Germany,4
University Hospital Quiron Salud Madrid, Madrid, Spain,5 UT Southwestern
Medical Center, Dallas, 6Novo Nordisk A/S, Søborg, D, 7Novo Nordisk
Medical Affairs Rome,Italy, 7 Novo Nordisk A/S, Søborg, Denmark
Previous analyses of phase 3a trials (DUAL I extension; DUAL II) showed
that insulin degludec/liraglutide. (IDegLira) is efficacious irrespective of
baseline body mass index (BMI) category in subjects with T2D who are
insulin naïve or uncontrolled on basal insulin. This post hoc analysis aimed
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-
min (DUAL IV: IDegLira versus placebo) and (iii) insulin glargine (IG)
(DUAL V: IDegLira versus continued titration of IG from pre-trial dose).
Starting dose of IDegLira was 10 dose steps [1 dose 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 for all trials. This analysis of 3 trials grouped
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 HbA1c was significantly greater with IDegLira versus comparator in all
BMI groups with a similar treatment difference between BMI groups (p=NS
for all trials). This analysis confirmed IDegLira effectively reduced HbA1c
across all baseline BMI categories when used in subjects previously treated
with SUs (as an add on), GLP-1 RA or IG (all ± other oral therapies).
RISK RECLASSIFICATION ABILITY OF URIC ACID
FOR CARDIOVASCULAR OUTCOMES IN ESSENTIAL
HYPERTENSION
Perticone M. 1, Sciacqua A. 2, Tripepi G. 3, Miceli S. 4, Cimellaro A. 2, Pinto A.
2
, Sesti G. 2, Perticone F. 2
1
Dipartimento di Medicina Sperimentale e Clinica - Università degli
Studi Magna Graecia di Catanzaro 2Dipartimento di Scienze Mediche e
Chirurgiche - Università degli Studi Magna Graecia di Catanzaro 3CNR-
IFC - Epidemiologia Clinica e Fisiopatologia delle Malattie Renali e
dell’Ipertensione - Reggio Calabria 4Azienda Ospedaliero-Universitaria
“Mater Domini” - Catanzaro
Hyperuricemia is associated with incident cardiovascular events in dif-
ferent settings of patients. We tested whether the inclusion of uric acid
(UA) in Cox models including standard risk factors allows to better stra-
tify cardiovascular risk in a cohort of 1,522 naïve hypertensives with pre-
served renal function. We used multiple Cox regression models to assess
the independent effect of UA on cardiovascular outcomes, and Harrell’C
index, Net Reclassification Index (NRI), and Integrated Discrimination
Improvement (IDI) as indicators of the additional prognostic value of UA
beyond and above that provided by standard risk factors and estimated
glomerular filtration rate (e-GFR). Study outcomes were fatal and nonfatal
cardiovascular events and fatal and nonfatal coronary outcomes/death due
to other cardiovascular events. UA resulted strongly related to both outco-
mes in unadjusted Cox regression analyses (P<0.001). Inclusion of UA
118° Congresso Nazionale - Società Italiana di Medicina Interna
into multiple Cox regression models including Framingham risk factors
and e-GFR did not affect the association between UA and outcomes (fatal
and nonfatal cardiovascular events, HR=1.44, 95% CI=1.36-1.55, P<0.001;
fatal and nonfatal coronary outcomes/death due to other cardiovascular
events, HR=1.48, 95% CI=1.36-1.61, P<0.001). Inclusion of UA into basic
Cox models provided an increase in all indexes of prognostic accuracy
for both outcomes: Harrell’C index: +5%; NRI: +24.9%; IDI: +7.6%, all
P<0.001; and Harrell’C index: +5%; NRI: +25%; IDI: +6.3%, all P<0.001,
respectively. Our data demonstrate that UA is an independent predictor
of cardiovascular outcomes and increases prognostic accuracy of Cox
models, including Framingham risk factors and e-GFR, in hypertensives
with normal renal function, allowing a risk reclassification in this setting
of patients.
THE EFFECTS OF CONTINUOUS POSITIVE AIRWAY
PRESSURE (CPAP) THERAPY ON SYMPATHOVAGAL
BALANCE IN A GROUP OF SEVERE OSAS PATIENTS
Scarpino P. 1, Perticone M. 2, Sciacqua A. 1, Siriani F. 1, Settino C. 1, Filicetti
E. 1, Sesti G. 1, Perticone F. 1
1
Dipartimento di Scienze Mediche e Chirurgiche - Università degli Studi
Magna Graecia - Catanzaro 2Dipartimento di Medicina Sperimentale e
Clinica - Università degli Studi Magna Graecia - Catanzaro
Obstructive sleep apnea syndrome (OSAS) is an independent predic-
tor of cardiovascular (CV) events and its pathogenesis recognizes both
traditional and non-traditional risk factors. Of these, the sympathetic
hyperactivity is considered one of the major mechanisms involved in the
development of CV disease in OSAS patients. Although the conservative
treatment of sleep apnea by nocturnal continuous positive airway pressure
(CPAP) is associated with improvement of heart rate variability (HRV), as
index of sympathovagal balance, its effects are still unknown. The aim of
this study was to evaluate the effect of CPAP on sympathovagal balance in
a group of severe OSAS patients after 6 months of therapy. We enrolled 92
severe OSAS patients, 80 males and 12 females, mean age 56.5+12.3 years.
All patients underwent clinical examination, measurement of creatinine,
lipid profile, insulin resistance assessed by HOMA index, uric acid and
high sensitivity C reactive protein (hs-CRP). We excluded patients with
atrial fibrillation (AF) or other cardiac arrhythmias, pacemaker rhythm,
previous history of diabetes mellitus, chronic kidney and lung disease
and respiratory failure. Estimated glomerular filtration rate (e-GFR) was
determined by CKD-EPI equation. All patients underwent nocturnal
cardiorespiratory monitoring (CRM) for the evaluation of the severity
of OSAS by the apnea-hypopnea index (AHI), the oxygen desaturation
index (ODI) and the percentage of time of saturation <90% (TC90). HRV
was assessed using 24-hour electrocardiographic monitoring. The stan-
dard deviation of all normal to normal RR intervals (SDNN), the high
and low frequency normalized powers (HF and LF) and its ratio (LF/HF)
were measured during 24 h and nocturnal period (from 12 p.m. to 6 a.m.).
Patients were prescribed with nocturnal CPAP treatment and were reeva-
luated after 6 months. All data were processed by statistic software SPSS
16.0 for Windows. Significant differences were assumed to be at P<0.05.
After 6 months of CPAP, OSAS patients presented significant differen-
ces (T6 vs T0) of: body mass index (BMI, Kg/m2 35.1+ 6.9 vs 36.4+ 7.6,
P=0.006), waist (cm, 114.5+15.4 vs 117.3+17.1 P=0.009), AHI (5.0+2.5
vs 49.2+20.0, P=0.000), ODI (6.8+3.9 vs 27.1+17.4, P=0.000), TC90 (%,
16.6+5.7 vs 22.7+ 23.8, P=0.018), systolic blood pressure (SBP, mmHg,
126.7+ 12.0 vs 134.3+ 15.2, P= 0.000), heart rate (HR, bpm, 69.4+ 7.4 vs
76.4+ 7.3, P=0.000), 24h SDNN (ms, 127.8+ 28.6 vs 91.9+ 21.8, P=000),
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),
hs-CRP (mg/L, 3.3+2.0 vs 5.8+5.7, P=0.000), uric acid (mg/dL, 5.9+1.3
vs 6.6+1.5, P=0.002), total cholesterol (mg/dL, 172.3+31.5 vs 186.5+32.3,
P=0.003), LDL-cholesterol (mg/dL, 107.6+26.6 vs 127.3+29.3, P=0.000),
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
vs 5.9+2.8, P=0.000). Linear regression analysis, performed at base-
line, demonstrated that there was a significant and inverse relationship
between all the following nocturnal parameters and different covariates:
SDNN and age (ys, r=-0.175, P=0.048), AHI (r=-0.388, P=0.000), and SBP
(r=-0.178, P=0.044); between HF and gender (r=-0.179,P=0.044) and AHI
(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-
lowing factors: SDNN and ODI (r=0.178, P=0.045), LF and AHI (r=0.448,
Comunicazioni Orali
P=0.000), HF and age (r=0.216, P=0.019),and finally between night LF/
HF ratio and AHI (r=0.544, P=0.000), and SBP (r=0.181, P=0.042). In
the multivariate model at T0, AHI resulted the strongest predictors of
all nocturnal parameters SDNN, LF,HF and LF/HF, explaining about the
15%, 20%, 21% and 29%(P=0.000), respectively of its variation. Linear
regression analysis, performed at T6, demonstrated that there was a signi-
ficant and direct relationship between Δ of nocturnal LF,LF/HF and ΔAHI
(r=0.443 and r=0.528, P=0.000 respectively). An inverse relationship was
found, instead, between Δ of nocturnal HF and ΔAHI(r=-0.329, P=0.001).
In the multivariate model at T6, Δ AHI resulted the strongest predictors
of Δ of nocturnal LF,HF and LF/HF, explaining about the 19%(P=0.000),
10%(P=0.001) and 27% (P=0.000), respectively, of its variation after
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
effects may be significantly related to decreased nocturnal sympathetic
hyperactivity in these subjects.
ENDOTHELIAL DYSFUNCTION IN CHILDREN EXPOSED
TO PASSIVE SMOKING: ROLE OF NADPH OXIDASE
Perri L. 1, Loffredo L. 1, Zicari A.M. .2, Duse M2, Occasi F. 2, Carnevale R. 1,
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”
University of Rome, Rome, Italy 2Department of Pediatrics, “Sapienza”
University of Rome, Rome, Italy
Background: Passive smoking represents an important cause of cardiova-
scular diseases. Increased oxidative stress due to passive smoke can result
in cardiovascular damage through the onset of endothelial dysfunction.
NADPH oxidase activation has been recognized as the major reactive
oxygen species source and plays a pivotal role in modulating arterial tone in
humans. Until now, there aren’t studies that have explored NADPH oxidase
activity in humans. Aim: To explore oxidative stress, the activity of NADPH
oxidase isoform Nox2 and endothelial function in children exposed to
passive smoking.
Methods: One hundred and fourteen children were consecutively enrolled
at outpatient Pediatric clinic of Sapienza University as part of routine clini-
cal controls. A questionnaire, given to the parents of the children, identified
subjects exposed to passive smoking. Matched controls were selected such
that the distribution of the age and of the relevant characteristics in this
group was similar to the distribution in the cases. A cross sectional study
was performed to compare endothelial function, assessed by flow-mediated
dilation (FMD), and oxidative stress, as assessed by blood levels of isopro-
stanes, soluble Nox2 (sNox2-dp), a marker of Nox2 activation, and serum
Nitric Oxide bioavailability, in children exposed (n=57, age: 9±3 years, 26
females and 31 males) or not exposed (n=57, age: 9±3 years, 26 females and
31 males) to passive smoking. Urinary cotinine was assessed to evaluate the
levels of exposition to nicotine.
Results: compared to controls, serum sNox2-dp and isoprostanes were
higher in children exposed to passive smoking (26±9 vs 18±9 pg/mL,
p<0.001 and 169±38 vs 150±34 pg/mL, p<0.001, respectively); conversely,
NO bioavailability and FMD were lower in children exposed to passive
smoke (59±11 vs 51±10 μM p<0.001, and 7.7±3 vs 6.1±3.6%, p<0.001,
respectively). A simple linear regression analysis showed that serum
sNox2-dp correlated with FMD (Rs:-0.221, p=0.01), (Rs:-0.221, p=0.01), NO
bioavailability (Rs:-0.547, p<0.001) and isoprostanes (Rs:-0.754, p<0.001).
Conclusions: This study suggests that NOX2-derived oxidative stress is
involved in artery dysfunction in children exposed to passive smoking.
1 HOUR POST LOAD PLASMA GLUCOSE LEVELS ARE
ASSOCIATED WITH A REDUCTION OF MYOCARDIAL
GLUCOSE UPTAKE, ESTIMATED THROUGH CARDIAC
18F-FGD-PET SCAN
Succurro E. 1, Pedace E. 1, Gangemi V. 2, Papa A. 2, Vizza P. 1,
Veltri P. 1, Cascini G.L. 2, Sesti G. 1
1
Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi
“Magna Graecia” di Catanzaro, Catanzaro, Italy 2 Dipartimento di
Medicina Sperimentale e Clinica, Università degli Studi “Magna Graecia” di
Catanzaro, Catanzaro, Italy
Introduction: Increasing evidence suggests that in subjects with normal
glucose tolerance (NGT), a plasma glucose concentration >155 mg/dl at 1
39
Comunicazioni Orali
h during an oral glucose tolerance test (OGTT) identifies subjects at incre-
ased risk for type 2 diabetes (T2DM) and an unfavorable cardiometabolic
risk profile and organ damage. It is known that, as compared to non-diabe-
tic individuals, subjects with T2DM and those with cardiovascular disease
show a reduction of myocardial glucose uptake, considered a risk factor for
the development of the cardiovascular disease. However, it is yet unknown
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.
Patients and Methods: We examined 15 subjects participating in the
CATAnzaro MEtabolic RIsk factors (CATAMERI) study, a study conducted
in a population at risk of T2DM for the presence of at least one risk factor
including family history for T2DM, overweight/obesity, hypertension, dysli-
pidemia and dysglycemia. Subjects with history of cardiovascular disease or
uncontrolled hypertension were excluded. All subjects underwent anthro-
pometrical and biochemical evaluation, and OGTT. The myocardial vitality
and glucose uptake (global MRGlu) were estimated through 18F-FGD PET
combined with euglycemic hyperinsulinemic clamp. Euglycemic hyperinsu-
linemic clamp study was performed to assess peripheral insulin sensitivity
normalized for lean body mass (Lean M) and to achieve a standardisation
of metabolic and hormonal circumstances during PET. The 18F-FGD PET
imaging procedure began after 1 h insulin infusion. The insulin-glucose
infusion continued throughout the PET imaging sequence, maintaining
euglycemia by continuous adjustment to the glucose infusion rate according
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-
1h-high (n=4), 3) impaired glucose tolerance IGT (n=6).
Results: Subjects with NGT 1h-high showed a significant increase in 2-h
glucose (p=0.004) and a reduction in HDL (p=0.001) as compared with
NGT 1h-low subjects. IGT subjects showed a significant increase in waist
circumference (p=0.03), and 2-h glucose (p<0.0001) compared to normal
subjects with 1h-low and a significant increase in 2-h glucose (p<0.0001)
and a reduction in HDL (p=0.01) than NGT 1h-high subjects, while there
was no significant differences in other parameters assessed. Both individuals
with NGT-1h-high, and those with IGT exhibited a significant reduction in
global MRGlu as compared with NGT-1h-low subjects (23.28 ± 5.89, 13.58
± 5.38 and 35.61 ± 12.73; respectively, p<0.05), while there was no signifi-
cant difference in global MRGlu between NGT-1h-high and IGT subjects.
In addition, there was a positive correlation (r = 0.586; p=0.022) between
Lean M and global MRGlu in all study subjects.
Conclusion: These results suggest that hyperglycaemia at the first hour
during OGTT is associated with a reduction in myocardial glucose uptake,
a predictor of cardiovascular disease and heart failure.
CHA2DS2-VASC AND HAS-BLED SCORES IN THE
PREDICTION OF NVAF-RELATED EVENTS IN A
POPULATION OF CRITICALLY ILL PATIENTS
Falsetti L. 1, Rucco M. 2, Nitti C. 1, Gentili T. 1, Nobili L. 1,
Zaccone V. 1, Piersantelli M.N. 1, Salvi A.1
1
Internal and Subintensive Medicine, Ospedali Riuniti di Ancona; 2
University of Camerino, School of Sciences and Technology, Computer
Science Division
Background: non-valvular atrial fibrillation (NVAF) is the most common
arrhythmia in clinical practice. Its risk increases with age and the presence
of comorbidities. NVAF-related morbility is associated to thromboembolic
events and, among patients undergoing to anticoagulant therapy, to hae-
morrhagic complications. Guidelines suggest stratifying the thrombotic risk
with CHA2DS2-VASc score and the haemorrhagic risk with HAS-BLED
score before initiating any anticoagulant treatment. These two scores share
several items, and it is common to observe patients with both an increased
thrombotic and haemorrhagic risk. This area represents a “grey zone” where
guidelines are not able to suggest any evidence-based approach.
Patients and Methods: we enrolled 519 consecutive, critically-ill subjects
affected by permanent NVAF admitted to our Subintensive Medicine
department. CHA2DS2-VASc score and HAS-BLED score were calculated
at admission. For each patient, we evaluated age, sex, admission diagnosis,
comorbidities, thromboembolic and haemorrhagic events.
Results: mean age was 75.61(±11.92) years; males represented 50.3% of the
sample; patients had a median of 2(0-6) comorbidities. We observed 38 hae-
morrhagic events and 80 thromboembolic events; HAS-BLED had a median
of 2(0-5), CHA2-DS2-VASc score had a median of 3(0-6); CHA2DS2-VASc
had an AUC of 0.56;95%CI:0.50-0:63(p=0.06); HAS-BLED had an AUC of
0.53;95%CI:0.44-0:62(p=0.53).
40
118° Congresso Nazionale - Società Italiana di Medicina Interna
Discussion: in this population of elderly patients admitted for critical
illnesses, CHA2DS2-VASc and HAS-BLED scores have a limited predictive
value for both thromboembolic and haemorrhagic events. Newer approa-
ches based on machine learning and topological data analysis could better
discriminate the risk factors of NVAF-related complications and give a more
reliable prediction of thrombotic or haemorrhagic events.
B-TYPE NATRIURETIC PEPTIDE IS A PREDICTOR OF
THIRTY-DAY MORTALITY AND THREE MONTH RE-
HOSPITALIZATION IN ELDERLY PATIENTS WITH AN
ADMISSION DIAGNOSIS OTHER THAN HEART FAILURE
Di Marca S. 1, Rando A. 1, Cataudella E. 1, Pulvirenti A. 2,
Alaimo S. 2, Terranova V. 1, Corriere T. 1, Pisano M. 1,
Di Quattro R. 1, Ronsisvalle M.L. 1, Giraffa C.M. 1, Giordano M. 3,
Stancanelli B. 1, Malatino L. 1
1
Unit of Internal Medicine, School of Emergency Medicine, Department of
Clinical and Experimental Medicine, University of Catania, c/o Cannizzaro
Hospital, Catania, Italy 2 Unit of Bioinformatics and Computer Science,
Department of Clinical and Experimental Medicine, University of Catania,
Catania, Italy 3 School of Emergency Medicine, Department of Medical,
Surgical, Neurologic, Metabolic and Geriatric Sciences, Second University of
Naples, Naples, Italy
Background: The diagnosis of heart failure (HF) in elderly patients is
often difficult because the typical clinical signs and symptoms may overlap
with those of comorbidities. Brain Natriuretic Peptide (BNP) is a reliable
predictor for diagnosis and prognosis of HF, but its role to predict short-
term prognosis in a cohort of elderly patients, with an admission diagnosis
other than HF, was so far unexplored. Design Prospective clinical study,
from September 2014 to December 2016. Setting Patients hospitalized in
the Unit of Internal Medicine, University of Catania, Catania, Italy. Parti-
cipants We prospectively recruited 404 consecutive elderly patients (aged
≥ 65 years) with an admission diagnosis other than HF. Measurements Cli-
nical examination, laboratory data, comorbidities and BNP were evaluated
at the admission. The predictive value for in-hospital mortality, thirty-day
mortality and three month re-hospitalization of BNP and other variables
was assessed. Results During hospitalization 48 patients died (12%); in
these patients BNP value >600 pg/ml did not predict mortality (OR=1.36;
CI95%:0.65-2.85;p=0.4), which was instead predicted by chronic kidney
disease (CKD) (OR=4.02; CI95%:2.1-8.27;p<0.001) and age (OR=1.08;
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;
CI95%:1.01-1.12;p=0.033) and malnutrition (OR=2.23; CI95%:1.08-
4.16;p=0.029) predicted thirty-day mortality. Re-hospitalized patients were
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
month re-hospitalization. Conclusions Our study shows that BNP value
>600 pg/ml predicts short-term prognosis in elderly patients with an admis-
sion diagnosis other than HF.
AGEING AND FAT INFILTRATION IN MUSCLE AND
LIVER
Bertolotti M., Dondi G., Lancellotti G., Mussi C.
Dipartimento di Scienze Biomediche, Metaboliche e Neuroscienze, Università
di Modena e Reggio Emilia UO di Geriatria, Azienda Ospedaliero-
Universitaria di Modena, Nuovo Ospedale Civile
Introduction: The relationship between sarcopenia and non-alcoholic fatty
liver disease (NAFLD) is relevant, considering the increasing prevalence of
the manifestations of NAFLD and non-alcoholic steatohepatitis (NASH)
worldwide, together with the overwhelming burden of aging-related con-
ditions such as sarcopenia (1). Such an association was described mainly in
Eastern Asian populations (2,3).
Methods: We completed an observational study in a cohort of 300 patients,
mostly of geriatric age (age 74.5±15.2 years, 167 males, 133 females), hospi-
talized over a 12-month period. Fat infiltration in liver and in muscle were
indirectly estimated by unenhanced spiral CT scan, by standardized analy-
sis of the attenuation coefficient (in Hounsfield Units) of pre-defined areas
of the liver and of the multifidus muscle, according to previously validated
procedures. The liver to spleen (L/S) ratio was calculated as an index of fat
accumulation in the liver whereas the multifidus/ fat (MM/F) attenuation
118° Congresso Nazionale - Società Italiana di Medicina Interna
ratio was regarded as an index of muscle infiltration (4).
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
with ongoing age (4). Age also showed a positive association with the L/S
ratio (r = 0.118, p = 0.042); in this case, the finding suggests a reduction of
hepatic fat content with aging even if the correlation is much less stringent
and therefore of questionable clinical significance. Nonetheless, such obser-
vation is consistent with epidemiological evidence describing a reduction in
the prevalence of NAFLD with ongoing age (1,5). Simple linear regression
analysis failed to disclose a significant correlation between the MM/F ratio
and the L/S index. However, considering the profound impact exerted by
age on these variables, we also performed partial correlation analysis with
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-
tive of a direct relationship between the densitometric profiles and, indi-
rectly, between the degree of fat infiltration in the two tissues.
Conclusions: Our findings confirm the association between liver and
muscle fat infiltration in an older Western population, using a densitome-
tric definition. Such an association suggests the presence of common patho-
genic mechanisms in the two conditions, among which insulin resistance
might play a role. Prospective studies specifically designed for the elderly
are welcome to confirm these hypotheses, and to provide further insight in
the pathophysiology and management of geriatric pictures such as sarco-
penia and frailty. References. 1. Bertolotti M, et al. Nonalcoholic fatty liver
disease and aging: epidemiology to management. World J Gastroenterol.
2014; 20:14185-204. 2. Lee YH, et al. Relationship between sarcopenia
and nonalcoholic fatty liver disease: the Korean Sarcopenic Obesity Study.
Hepatology. 2014; 59:1772-8. 3. Koo BK, et al. Sarcopenia is an indepen-
dent risk factor for non-alcoholic steatohepatitis and significant fibrosis. J
Hepatol. 2017; 66:123-31. 4. Kitajima Y, et al. Age-related fat deposition in
multifidus muscle could be a marker for nonalcoholic fatty liver disease.
J Gastroenterol. 2010;45:218-24. 5. Lonardo A, et al. Fatty liver, carotid
disease and gallstones: a study of age-related associations. World J Gastro-
enterol. 2006;12:5826-33.
ASSOCIATION BETWEEN PRIMARY EOSINOPHILIC
DISORDERS OF THE GASTROINTESTINAL TRACT AND
DEFECTIVE SPLEEN FUNCTION
Di Sabatino A. 1, Aronico N. 1, Giuffrida P. 1, Cococcia S. 1,
Vincenzo Lenti M. 1, Vanoli A. 2, Arfini A. 1, Guerci M. 1,
Di Stefano M. 1, Roberto Corazza G. 1
1
First Department of Medicine and 2Department of Molecular Medicine, San
Matteo Hospital Foundation, University of Pavia, Pavia, Italy
Background and Aims: Splenic hypofunction is an acquired condition,
accompanied or not by a reduction in spleen size, which may predispose to
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
inflammatory bowel disease. We recently showed the first case of primary
eosinophilic gastrointestinal disorder complicated by splenic hypofunction.
The aim of the study was to assess spleen function in a series of consecu-
tively enrolled patients affected by eosinophilic gastrointestinal disorders.
Methods: We enrolled 21 patients (mean age 43.7 years) affected by primary
eosinophilic gastrointestinal disorder (3 esophagitis, 1 gastritis, 8 gastroen-
teritis, and 9 colitis). Twenty-two healthy volunteers (mean age 42.5 years,
range 26-61) and 18 splenectomized patients (mean age 43.1 years, range
24-68) were used as negative and positive controls, respectively. Spleen fun-
ction was assessed by counting pitted red cells on peripheral blood.
Results: Eighteen out of 21 eosinophilic gastrointestinal disorder patients
(85%) were hyposplenic. Pitted red cells were significantly higher (8.0%,
range 2.1-17.2) than that of healthy volunteers (1.9%, range 0.4-4.0,
p<0.0001). A positive correlation was found between pitted red cells, cir-
culating eosinophils, and serum eosinophilic cationic protein. An 8-week
treatment with corticosteroids (topical or systemic) significantly decreased
pitted red cells (p<0.0005) in ten followed-up cases.
Conclusions: Splenic hypofunction should be investigated in patients with
primary eosinophilic gastrointestinal disorders. Corticosteroid therapy was
able to improve spleen function.
EFFECTIVE TREATMENT OF H. PYLORI INFECTION BY
THE NOVEL BISMUTH-BASED QUADRUPLE TREATMENT
IN A LARGE COHORT OF PEOPLE LIVING IN SOUTHERN
Comunicazioni Orali
ITALY. IT IS TIME TO ABANDON EMPIRIC TREATMENTS
Di Ciaula A. 1, Scaccianoce G. 2, Venerito M. 3, Zullo A. 4,
Bonfrate L. 5, Rokkas T. 6, Portincasa P. 5
1
Division of Internal Medicine, Hospital of Bisceglie, Italy; 2Gastrointestinal
Endoscopy Unit, Ospedale della Murgia “F. Perinei”, Altamura, Italy;
3
Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-
von-Guericke University Hospital, Magdeburg, Germany; 4Gastroenterology
Unit, Nuovo Regina Margherita Hospital, Rome, Italy; 5Clinica Medica “A.
Murri”, Department of Biomedical Sciences & Human Oncology, University
of Bari Medical School, Bari, Italy; 6Gastroenterology Clinic, Henry Dunant
Hospital, Athens Greece;
Background: Eradication rates following treatments for Helicobacter
pylori (HP) infection strongly depend by several factors, including the
ongoing antibiotic resistance. We explored a “real life” scenario depicting
enrolment criteria and treatment outcome in an heterogeneous group of
patients with HP-related problems. The outcomes of different approaches,
including the bismuth-based quadruple therapy (Pylera®), recently marke-
ted in Italy, were described.
Methods: Two centers in Apulia studied 2,224 subjects living in an area
with clarithromycin resistance >15%. Analyses included cause of referral,
diagnostic techniques (13C-urea breath test –UBT- or upper endoscopy-
EGDS) and outcomes of prior- or prospective eradication regimens.
Results: Over 80% of patients (60% naïve) were referred by family phy-
sicians. Asymptomatic subjects more frequently referred for noninva-
sive UBT than for EGDS (30% vs. 2%, P<0.0001). Symptoms unrelated
to H. pylori was the cause of referral in the 6% of patients, whereas 8%
of referred subjects underwent UBT only due to a familial history of
H. pylori infection. The overall infection rate was 32.5%, and similar in
patients asymptomatic (31.1%) or with HP-related symptoms/clinical
conditions (34.3%). The overall eradication rate (ER) in the 987 HP+ve
patients undergoing therapy was 80.2%, with a great variability according
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
1st-5th line regimens). Minor side effects were recorded in 5% of patients
on different eradication therapies.
Conclusions: (i) presence and characteristics of symptoms/clinical condi-
tions are not sufficient to discriminate subjects infected with H. pylori; (ii)
in a “real life” scenario, the use of heterogeneous approaches puts patients
with H. Pylori infection at risk of poor eradication outcomes and unneces-
sary procedures; (iii) the novel bismuth-based quadruple treatment yield
the highest ERs as 1st-2nd line; (iv) although sequential treatment is still
effective as 1st-line regimen, concomitant 4-drug regimen (PPI, amoxicil-
lin, metronidazole, clarithromycin) will be prefered in a geographical area
with high clarithromycin resistance. Keywords: Guidelines, Helicobacter
Pylori, Pylera
WEEKEND VERSUS WEEKDAY ADMISSION AND IN-
HOSPITAL MORTALITY FOR ACUTE ESOPHAGEAL
VARICEAL HEMORRHAGE:
A 15-YEAR RETROSPECTIVE STUDY ON THE NATIONAL
HOSPITAL DATABASE OF ITALY
Politti U., Pala M., Gallerani M.
Dipartimento di Scienze Mediche, Azienda Ospedaliero-Universitaria,
Ferrara, Italia
Previous studies have shown increased mortality for a number of medical
and surgical conditions during weekend admissions, which is known as the
“weekend effect”.
The aim of our study was to assess the association between weekday (WD)
or weekend (WE) admission and mortality for patients hospitalized with
acute esophageal variceal hemorrhage (AEVH). We analyzed routinely col-
lected hospital administrative data of all patients discharged with AEVH
demonstrated to the presence of ICD-9-CM codes of 456.0 “Esophageal
varices with bleeding”or 456.20 “ Esophageal varices in diseases classified
elsewhere” extracted from the Italian Health Ministry database (January
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
24,570 were hospitalized in urgency and the codes were in the primary or
second diagnosis. Only these were included in the study. 17.852 (72.7%)
patients were admitted on WD and 6.718 (27.3%) on WE. In-hospital mor-
41
Comunicazioni Orali
tality was slightly higher among patients under the WE (12.2 & vs 11.7)
across each study year when analyzed separately (Chi-squared = 1.402, P =
0.2365), but after adjustment for the above determinants, patients admitted
on WE were not significantly increased risk of death during hospitaliza-
tion. The mean length-of-stay (LOS) was not statistically different among
patients hospitalized during the WE compared with WD, also for deceased
patients during hospital stay. Furthermore, significant differences in the
number of therapeutic diagnostic procedures performed were not detected
among subjects with AEVH admitted during WE or WD. This study provi-
des robust confirmation that, in Italy, hospitalization for AEVH on WE is
non associated with a significantly higher mortality rate than on WD.
INTESTINAL PERMEABILITY IS INCREASED IN
PATIENTS WITH SYSTEMIC MASTOCYTOSIS WITHOUT
GASTROINTESTINAL SYMPTOMS
Di Stefano M. 1, Benedetti I. 1, Elena C. 2, Pesatori E.V. 1,
Manfredi G.F. 1, Grandi G. 1, Pagani E. 1, Merante S. 2, Cazzola M. 2,
Corazza G.R. 1
1
Department of Internal Medicine and 2Department of Hematology, IRCCS
“S.Matteo” Hospital Foundation, University of Pavia, Italy
Background: Systemic mastocytosis is a rare disease characterized by an
abnormal proliferation of neoplastic mast cells infiltrating bone marrow
and involving many organs. Gastrointestinal tract is frequently affected and
abdominal pain, diarrhea, nausea, vomiting, bloating are caused due to a
direct effect of mast cell mediators. In other conditions, mast cell media-
tors are responsible for functional gastrointestinal symptoms and intestinal
permeability alterations (Barbara G, Gastroenterology 2004). Therefore,
we measured intestinal permeability in a group of patients with systemic
mastocytosis.Patients and Methods A group of 8 patients (3 females, mean
age 54 ± 18 yrs; range 20 – 77 yrs) affected by SM were enrolled. None of
them suffered from gastrointestinal symptoms. During the 3 days before the
test, the patients were instructed to avoid foods or beverages or drugs con-
taining lactulose and mannitol. The day of the test, after an overnight fast,
a solution containing 5 g of lactulose and 1 g of mannitol in water solution
was administered. Urine was collected over the next 6 h in plastic containers
with 1 ml of 2% chlorhexidine solution, to prevent bacterial degradation
of sugars. A 20 ml urine sample was stored at -20°C until the assay. The
urinary excretion of the two sugars was measured and the lactulose and
mannitol % excretion rate was calculated. Moreover, lactulose/mannitol %
excretion rate was calculated and a value >0.03 was considered as suggestive
for altered intestinal permeability. Diamino-oxidase (DAO) and tryptase
circulating level were also determined by ELISA and FEIA, respectively.
Results: Both lactulose and mannitol excretion rates were suggestive of
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 Nazionale - Società Italiana di Medicina Interna
Hereditary Haemorrhagic Teleangiectasia (HHT), or Rendu-Osler-We-
ber syndrome. is an autosomal dominant vascular disorder, characterized
by arterio-venous malformations (AVMs), affecting nasal mucosa, oral
cavity, skin and several internal organs (lung, liver, brain, GI tract). AVMs
entail a considerable risk of severe clinical complications. HHT is caused
by mutations in endoglin (ENG) and activine A typeII-receptor-like kinase
1 (ALK1/ACVRL1) genes, responsable for HHT1 and HHT2, respectively.
The proteins encoded by ENG andALK1/ACVRL1 are involved in angioge-
nesis and vacular homeostasis regulation, through signalling transduction
of TGF-SMAD4 as principal downstream effector. as a confirmation of such
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
patients have been described thus far. While preemptive pulmonary scree-
ning complications associated to pulmonary guidelines, in light of poten-
tially adverse complications associated to pulmonary AVMs in HHT1 and
HHT2, a protocol for instrumental screening still needs standardization
for JP/HHT,a s more information regarding JP/HHT typical phenotypic
spectrum is required. Aim: To describe clinical pulmonary features of
patients affected by Juvenile polyposis/hereditary hemorrhagic telangiecta-
sia (JP/HHT) syndrome and confirmed mutations in SMAD4 gene and to
compare lung arterio-venous malformation (AVM) radiological features
with HHT1 and HHT2 patients.
Methods: The study was designed as a cross-sectional prospective survey.
Inclusion criteria: carrier of a SMAD4 mutation, completed clinical-instru-
mental screening. Phenotypic data of enrolled patients were then compared
with HHT1 and HHT2 patients’ data. Clinical-instrumental protocol inclu-
ded screening for pulmonary, hepatic and cerebral AVMs for all patients,
independent from clinical symptoms, and upper and lower endoscopy
(pancolonoscopy??) for JP/HHT patients only.
Results: A total of 5 SMAD4-mutated patients were recruited in the study.
All of the 5 patients had pulmonary AVMs (PAVMs) and GI polyps. Silent
hepatic involvement was disclosed in 4/5 patients and brain AVMs in 0/5
patients. Clinical overt manifestations secondary to PAVMs was reported by
4/5 patients, including hypoxaemia, digital clubbing, brain abscess/stroke.
Anatomical characteristics of HHT/JP, HHT1 and HHT2 PAVM-posi-
tive patients showed a trend towards more frequent bilateral involvement
(16/22, 72%, 7/17(41%), and 4/5 (80.0%), respectively, p=0,09). HHT/
JP patients had significantly higher prevalence of complex PAVMs, when
compared to HHT1 and HHT2 patients (3/5, 60.0%, 2/22, 9%, and 0/17,
0%, respectively, p<0.01), and of large (feeding artery >3 mm) PAVMs (4/5,
80%, 12/22, 54.5%, 3/17, 17.6%, respectively, p<0.02). Aggressive GI polyp
phenotype was observed as soon as in adolescence.
Conclusions: HHT/JP patients show a severe phenotype, mainly involving
pulmonary AVMs and GI polyps, which require an appropriate instrumen-
tal survey.
118° Congresso Orali
Comunicazioni Nazionale - Società Italiana di Medicina Interna
COMUNICAZIONI ORALI
29 OTTOBRE 2017
SUSTAINED VIROLOGICAL RESPONSE BY DIRECT
ANTIVIRAL AGENTS IN HCV LEADS TO AN EARLY AND
SIGNIFICANT IMPROVEMENT OF LIVER FIBROSIS
Aglitti A. 1, Masarone M. 1, Rosato V. 2, Precone D.F. 3,
Corrado M. 4, De Luna A. 5, Morisco F. 6, Camera S. 6,
Federico A. 7, Dallio M. 7, Claar E. 8, Caporaso N. 6, Persico M. 1
1
Internal Medicine and Hepatology Division, Department of Medicine
and Surgery, University of Salerno, Salerno, Italy; 1Internal Medicine and
Hepatology Department, University of Campania “Luigi Vanvitelli”, Naples,
Italy; 3Internal Medicine Department, Martiri di Villa Malta Hospital,
Sarno, Salerno, Italy; 4Infectious Diseases Department, Umberto I Hospital,
Nocera Inferiore, Salerno, Italy; 5Drug Addictions Unit, ASL Salerno DS65,
Salerno, Italy; 6Gastroenterology Unit, Department of Clinical Medicine and
Surgery, Federico II University, Naples, Italy; 7Department of Clinical and
Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples,
Italy; 8Internal Medicine Department, Hepatology Unit, Ospedale Evangelico
Villa Betania, Naples, Italy
Introduction: Direct Antiviral Agents (DAA) demonstrated high efficacy
among HCV-infected patients in registered trials. Nevertheless, the impact
of these therapies on liver stiffness measurement (LSM) and liver functio-
nality in “real-life” is not well-known. Aims: to evaluate the SVR impact
on LSM and clinical parameters of DAA-therapy on a real-life population
of HCV patients with F3/F4 fibrosis. Patients and methods: 749 HCV
genotype 1-4 patients with F3/F4 hepatitis undergoing DAA antiviral
therapy for HCV, were consecutively enrolled in four centers of Hepatology
of Italy. Clinical, biochemical and imaging data were collected at the base-
line (T0), at the End of Therapy (EoT) and after 12 weeks (SVR12). Results:
Out of 749 patients, 69.7% was F4 and 30.3% was F3. SVR12 was reached
in 97,5%. LSM significantly decreased from T0 to EoT(p<0.001) whereas it
did not from EoT to SVR12 (p:ns). Moreover, in F4 no significant differen-
ces were found in Child and MELD between T0, EoT and SVR12(p=ns).
At the univariate analysis of clinical and liver parameters, baseline high
Glucose (p<0.005), Type 2 Diabetes (p<0.001), low ALT (p<0.001), low
PLTs (p<0.005), and the presence of esophageal varices (EV) (p<0.001) were
found to be associated with a lack of a significant EoT LSM improvement.
At a multiple regression, low ALT at baseline (p<0.05), Diabetes (p<0.005)
and EV (p<0.05), were inversely associated with significant LSM reduction.
Conclusions: Virological response to DAA is associated with fibrosis
regression and recovery of liver functionality and this can be detected as
early as EoT. HCV eradication is associated with a rapid and significant cli-
nical improvement that lasts overtime and seems to be negatively influenced
by diabetes and esophageal varices.
CONTRAST ULTRASOUND LI-RADS LR-5 IDENTIFIES
HEPATOCELLULAR CARCINOMA IN CIRRHOSIS.
MULTICENTER RETROSPECTIVE STUDY OF 1006
NODULES
Terzi E. 1, Iavarone M. 2, Pompili M. 3, Veronese L. 4, Cabibbo G. 5, Fraquelli
M. 6, Riccardi L. 3, De Bonis L. 1, Sangiovanni A. 2,
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,
Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy 2A.M.
& A. Migliavacca Center for Liver Disease, Division of Gastroenterology and
Hepatology, Fondazione IRCCS Ca’ Granda Maggiore Hospital, University
of Milan, Milan, Italy 3Internal Medicine, Gastroenterology and Hepatology,
Gemelli Hospital, University of Rome, Rome, Italy 4Department of Internal
Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia,
Pavia, Italy 5Section of Gastroenterology, Biomedical Department of Internal
and Specialized Medicine (Di.Bi.M.I.S.), University of Palermo, Palermo,
Italy 6Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca’
Granda Maggiore Hospital, University of Milan, Milan, Italy 7Radiology and
Medicine, Division of Gastroenterology, University of Calgary, Canada
Background & Aims: The use of contrast enhanced ultrasound (CEUS) for
the diagnosis of hepatocellular carcinoma (HCC) in cirrhosis was questio-
43
118° Congresso Nazionale - Società ItalianaComunicazioni
di Medicina Interna
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
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
based on timing and intensity of contrast changes. Accordingly, the hepatic
lesions are subgrouped in different classes of risk of being HCC: LR-1 (defi-
nitely benign), LR-2 (probably benign), LR-3 (intermediate probability for
HCC), LR-4 (probably HCC), LR-5 (definitely HCC) and LR-M (probable
malignancy not specific for HCC). Aim of the present study was 1) to eva-
luate the CEUS LI-RADS diagnostic accuracy of LR-5 for definitely HCC
and LR-M as probable malignancy not specific for HCC and 2) to evaluate
the rate of HCC in LR-3 and LR-4 classes.
Methods: A total of 1006 nodules in 848 patients with cirrhosis at risk for
HCC collected in 5 Italian centers (Bologna, Milano, Pavia, Roma, Palermo)
were retrospectively analyzed. For the whole liver nodules a complete CEUS
pattern was available together with an accepted diagnostic method accor-
ding to noninvasive criteria reported by AASLD guidelines (CT/MRI if
typical HCC or histology if CT/MRI were inconclusive) performed within
12 weeks from the index CEUS. Patients with inconclusive CT/MRI fin-
dings and unsuitable for biopsy or with inconclusive histology pattern were
excluded from the present analysis. Arterial phase hyperenhancement was
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
(otherwise could be LR-1 or LR-M respectively). “Washout” occurrence
was defined when the lesion became hypoenhanced compared to the sur-
rounding parenchyma in the portal-venous phase. When the washout took
place it was further classified as “early” if it appeared before 60 seconds after
contrast injection (otherwise defined “late”) and “marked” when the lesion
became echofree or punched out (otherwise defined as “mild”) within 2
minutes. Nodules with arterial phase hyperenhancement and late washout
(onset ≥60 seconds after contrast injection) of mild degree were classified
as LR-5. Rim enhancement and/or early and/or marked washout quali-
fied lesions as LR-M (malignant, but not specific for HCC). Other combi-
nations qualified lesions at intermediate risk for HCC (LR-3) or probable
HCC (LR-4). Diagnostic reference standard was CT/MRI diagnosis of HCC
(=534) or histology (n=472).
Results: Median size was 2 cm. Of 1006 nodules, HCC were 820 (81%),
cholangiocarcinoma 40 (4%), regenerative nodules (±dysplastic) 116 (11%).
When compared to the AASLD hallmark pattern for the diagnosis of HCC,
the LR-5 pattern provides higher PPV (98.5% vs. 94%) with only a negli-
gible decrease in sensitivity (62% vs. 67%) and no risk of misdiagnosis for
pure cholangiocarcinoma. All LR-M nodules were malignant, the majority
of non hepatocellular origin. Over 75% cholangiocarcinomas were LR-M.
The risk of having HCC increased from LR-3 to LR-5. In particular, the
LR-3 category included 203 lesions (HCC 96=47%) and the LR-4 202 (HCC
173=87%).
Conclusions: CEUS LI-RADS classes are effective in predicting the risk of
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
approach of “atypical” nodules, all of which remain at relatively significant
risk of HCC (>50% if LR-3 or LR-4) requiring histological confirmation
whenever possible.
ASSESSMENT OF SEPSIS-3 CRITERIA IN PATIENTS WITH
CIRRHOSIS AND BACTERIAL INFECTIONS
Piano S.,1, Bartoletti M. 2, Tonon M. 1, Baldassarre M. 2,
Chies G. 1, Romano A. 1, Viale P. 2, Vettore E. 1, Domenicali M. 2, Stanco M. 1,
Pilutti C. 1, Frigo A.C. 3, Brocca A. 1, Bernardi M. 2,
Caraceni P. 2, Angeli P. 1
1
Department of Medicine – DIMED, University of Padova, Italy 2
Department of Medical and Surgical Sciences, Alma Mater Studiorum
University of Bologna, Bologna, Italy 3Department of Cardiac, Thoracic and
Vascular Sciences, University of Padova, Italy
Introduction: Patients with cirrhosis have a high risk of sepsis, which
confers a poor prognosis. SIRS criteria have several limitations in cirrho-
sis. Recently, new criteria for sepsis (Sepsis-3) have been suggested in the
general population (increase of Sequential Organ Failure Assessment[-
SOFA]≥2 points from baseline). Outside the ICU, the quick SOFA (qSOFA
[at least 2 among: alteration in mental status, systolic blood pressure≤100
43
Comunicazioni Orali
mmHg, or respiratory rate≥22/min]) was suggested to screen for sepsis.
These criteria have never been evaluated in cirrhotic patients. The aim of the
study was to assess the ability of Sepsis-3 criteria in predicting in-hospital
mortality in patients with cirrhosis and bacterial/fungal infections.
Methods: 259 consecutive patients with cirrhosis and bacterial/fungal
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
death, liver transplantation, or discharge. Findings were externally valida-
ted (197 patients).
Results: The most common infections were urinary tract infection (33%),
SBP (23%) and pneumonia (14%). SIRS, qSOFA and sepsis-3 criteria were
found in 34, 23 and 64% of patients, respectively. During the hospitaliza-
tion 19% of patients died. Sepsis-3 and qSOFA had significantly greater
discrimination for in-hospital mortality (AUROC=0.784 and 0.732,
respectively) than SIRS (AUROC=0.606;p<0.01 for both). Similar results
were observed in the validation cohort. Sepsis-3 (OR=5.71;p=0.007),
qSOFA (OR=3.11;p=0.004),CLIF-C-AD score (OR=1.05;p=0.007),C-re-
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
mortality. Patients with Sepsis-3 had higher incidence of acute-on-chronic
liver failure (36 vs 11%; p<0.001), septic shock (15 vs 0%; p<0.001) and tran-
sfer to the ICU (16 vs 2%; p=0.001) than those without Sepsis-3.
Conclusions: Sepsis-3 criteria are more accurate than SIRS criteria in pre-
dicting the severity of infections in patients with cirrhosis. qSOFA is a useful
bedside tool to assess risk for worse outcomes in these patients. Patients
with Sepsis-3 and positive qSOFA deserve more intensive management and
strict surveillance.
EFFECTS OF IFN-FREE TREATMENT ON THE
VIROLOGICAL, CLINICAL, IMMUNOLOGICAL
RESPONSE, AND QUALITY- OF- LIFE IN PATIENTS
WITH HCV-RELATED MIXED CRYOGLOBULINEMIA: A
PROSPECTIVE AND CONTROLLED STUDY
Cerretelli G., Gragnani L., Lorini S., Steidl C., Petraccia L., Sadalla S.,
Monti M., Caini P., Xheka A., Simone A., Carradori E., Arena U., Laffi G.,
Zignego A.L.
Interdepartmental Center MaSVE, Department of Experimental and Clinical
Medicine, University of Florence, Florence, Italy
Background: Antiviral therapy is the first therapeutic option for HCV
cryoglobulinemic vasculitis (CV). CV manifestations could be severe and
may compromise the patient’s quality of life (QoL). IFN-based therapy was
associated with side effects and lower virological response in CV+ than in
CV- patients. Limited data suggest that in CV patients, DAAs are safe and
associated with high rates of response (virological/clinical/immunological).
We aimed to perform, for the first time, a prospective and controlled study
on the effects of DAAs on HCV patients with cryoglobulinemia and vasculi-
tis (CV), without vasculitis (MC), and without cryoglobulinemia (controls:
HCV-Ctr).
Methods: Patients underwent standard DAA IFN-free regimens. Hepa-
to-virological data, virological and clinical response, DAAs safety and the
impact on QoL were evaluated. Immunological response (cryocrit, RF and
C4 values) were recorded together with CV symptoms in cryoglobuline-
mic patients. The Short Form Health Survey 36 (SF-36) questionnaire was
administered to obtain a physical component summary (PCS) and a mental
component summary (MCS).
Results: 182 HCV patients were consecutively treated. Following an ITT
analysis, 91,2% (166/182) patients (41/43 HCV-ctr, 48/54 CM, 77/85 CV)
achieved SVR12 and SVR24. In CV SVR patients, the clinical response pro-
gressively increased and at SVR24 was “full complete” (disappearance of
all symptoms) in 25%, “complete” (improvement of all symptoms) in 60%,
“partial” (improvement of more than 50% of symptoms) in 11.7%. Cryo-
crit levels progressively decreased from baseline to SVR24 in CM and CV
patients. Regarding QoL, the PCS values at baseline were lower in the CV
group compared to the other two groups (p<0.05). For all the groups, the
scores improved during follow-up. Adverse events, generally mild and well
tolerated, occurred in 99/182 (54.4%) 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
118° Congresso Nazionale - Società Italiana di Medicina Interna
ment is strongly suggested to increase the chances of virological and clinical
success. QoL analysis showed, for the first time, that, among HCV patients,
those with CV have a worse QoL. DAAs were effective in increasing QoL
scores in all the HCV patients, which is now considered an important goal
of therapy with an impact on CV indirect costs.
NEW DIRECT ANTIVIRAL AGENTS (DAAS) FOR
CHRONIC HCV INFECTION AND ARTERIAL STIFFNESS
Perticone M. 1, Caroleo B. 2, Sciacqua A. 3, Suraci E. 3,
Colangelo L. 3, Bencardino G. 3, Miceli S. 2, Tramontano A. 4,
Sesti G. 3, Perticone F. 3
1
Dipartimento di Medicina Sperimentale e Clinica - Università degli Studi
Magna Graecia di Catanzaro 2 Azienda Ospedaliero-Universitaria “Mater
Domini” - Catanzaro 3 Dipartimento di Scienze Mediche e Chirurgiche -
Università degli Studi Magna Graecia di Catanzaro 4 Università Federico
II - Napoli
Abnormal arterial stiffness is associated with an increased risk for various
adverse outcomes, including cardiovascular disease, stroke, and renal diseas.
Furthermore, arterial stiffness is associated with traditional cardiovascular
risk factors and metabolic alterations including obesity, impaired glucose
tolerance, and dyslipidemia. In addition, it reflects the structural arterial
wall modifications, characterizing the vascular aging. The most reliable
method to assess arterial stiffness is through pulse wave velocity (PWV)
measurement. There are several evidences demonstrating that patients
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
direct and indirect mechanisms, leading to both hepatic and extrahepatic
insulin-resistance. However, this mechanism do not fully justify the higher
cardiovascular risk of these patients. In the last few years, the new direct
antiviral agents (DAAs) for the treatment of HCV infection demonstrated
to induce a sustained viral eradication, thus contributing to minimize the
extrahepatic effects of HCV. We designed the present study to evaluate the
effect of DAAs treatment on AS in a population of patients with chronic
HCV infection. We enrolled 113 (55 M and 58 F, mean age 67,3 ± 10,2 years)
patients with chronic HCV infection, eligible for treatment with DAAs.
Patients were divided into four subgroups according with the presence of
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);
hypertensives (Group 2; n= 24, mean age 69,5 ± 6,2 yrs); diabetics (Group
3; n= 13, mean age 70,5 ± 5,9 yrs); patients with both hypertension and
T2DM (Group 4; n= 19, mean age 72,9 ± 6,8 yrs). All patients underwent
clinical and laboratory evaluation at baseline, at the end of treatment (12
or 24 weeks, depending on the treatment regimen), and at 6 months after
the end of treatment. Laboratory determinations included: qualitative and
quantitative HCV-RNA, complete blood count, serum creatinine, e-GFR,
total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride, fasting
plasma glucose, fasting plasma insulin, HOMA-index). Data are expressed
as mean value + SD and as % when appropriate. Statistical analyses were
conducted using T-test for paired data, chi-square test for nominal data,
linear regression analysis, stepwise multiple regression analysis. In the
whole study population, 6 months after the end of treatment with DAAs,
PWV decreased from 9,04 + 1,96 to 8,04 + 1,61 m/s (P<0.0001); similar
results were obtained when considering the four study group, except for
Group 4, in which there were no significant differences between PWV
values evaluated at baseline and 6 months after the end of treatment. Of
interest, when considering biochemical parameters, we observed an impro-
vement in eGFR in the whole study population before and 6 months after
treatment (90,4 + 1 vs 96,8 + 16,7 ml/min/1,73 m2; P<0.0001), as well as
an improvement in insulin resistance evaluated through HOMA index (5,1
+ 3,0 vs 3,5 + 1,08; P<0.0001). When considering the four study groups
separately, eGFR improvement before and 6 months after treatment resulted
statistically significant only in Groups 1 and 2, while HOMA index resulted
significantly reduced in all groups except that in Group 3. The findings of
this study demonstrate that HCV eradication through DAAs has important
extra-hepatic effects, in particular when considering cardio-metabolic para-
meters, thus allowing to modify the cardiovascular risk of this patients.
118° Congresso Nazionale - Società Italiana di Medicina Interna
EFFICACY AND SAFETY OF NEW DIRECT ANTIVIRAL
AGENTS IN HCV INFECTED PATIENTS WITH DIFFUSE
LARGE B CELL NON-HODGKIN LYMPHOMA
Masarone M. 1, Aglitti A. 1, Caruso R. 1, De Renzo A. 2, Selleri C. 3, Califano
C. 4, Abenavoli L. 5, Federico A. 6, Persico M. 1
1
Internal Medicine and Hepatology Unit, University of Salerno, Salerno,
Italy; 2 Hematology Department, Federico Secondo University of Naples,
Italy; 3Hematology Unit, University of Salerno, Salerno, Italy; 4Hematology
Department, Umberto I Hospital, Nocera Inferiore (Salerno), Italy;
5
Department of Health Sciences, University Magna Græcia, Catanzaro, Italy;
6
Hepatogastroenterology Division, University of Campania “Luigi Vanvitelli;
Naples, Italy
Introduction: The association of HCV with Non-Hodgkin Lymphoma
(NHL) has been demonstrated all over the world. The new interferon-free,
direct antiviral agents (DAA), showed high efficacy and safety in HCV
patients, and preliminary data seem to confirm their activity on low-grade
NHL in HCV infected patients. The question arises as whether or not -and
how- to treat the HCV positive patients suffering from diffuse large B cell
lymphomas(DLBCL). Aim of this observational study was to evaluate
whether the DAAs antiviral treatment of DLBCL/HCV-infected patients in
concomitance with chemotherapy is a safe and effective option.
Methods: 20 (13 males and 7 females), HCV1b positive subjects, undergoing
chemotherapy for DLBCL, were enrolled between June 2015 and Decem-
ber 2015. After informed consent, all the patients underwent to antiviral
therapy with sofosbuvir/ledipasvir and chemotherapy (19 R-CHOP and 1
CHOP) for DLBCL. Complete hematological (Revised European American
Lymphoma - REAL - classification, Ann-Arbor staging, and International
Prognostic Index - IPI) and hepatological (viral markers, liver stiffness and
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.
Results: DAA-treated and untreated patients were similar for sex distri-
bution, IPI score and NHL stage, and differed for age (older in treated),
chemotherapy and use of antiviral therapy. Overall-survival (OS) and dise-
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
statistically significant higher DFS was achieved in treated patients(p:0.036).
At the multivariate analysis, only IPI score and DAA were independently
correlated with a better DFS. No differences in adverse events were reported.
Conclusions: DAA-treatment in concomitance with chemotherapy showed
to be safe and effective in influencing the remission of aggressive lympho-
mas in HCV patients.
HEPATIC INVOLVEMENT AND ATRIAL FIBRILLATION
IN GERIATRIC PATIENTS WITH HEREDITARY
HAEMORRHAGIC TELANGIECTASIA
Suppressa P. 1, Valerio R. 1, Lenato G.M. 1, Lastella P. 1, Fasano D. 1, De
Vincenzo G. 1, Buonamico P. 2, Scardapane 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 “A. Murri” Internal Medicine Unit, Policlinico
Hospital, University of Bari “Aldo Moro”, Italy 3 Radiology Unit, Policlinico
Hospital, University of Bari “Aldo Moro”, Italy
Background: Hereditary Haemorrhagic Telangiectasia (HHT), or Ren-
du-Osler-Weber syndrome, is a rare autosomal dominant vascular disorder
(prevalence: 1-2:10,000), characterized by arterio-venous shunts, affecting
nasal mucosa, oral cavity, skin, and several internal organs (lung, liver,
brain, GI tract). Serious clinical complications can be associated to visce-
ral arterio-venous malformations. In particular, hepatic arterio-venous
malformations (HAVMs) are detected in 60-80% of HHT patients and may
be potentially responsible for high-output heart failure, ischemic biliary
disease, portal hypertension, and porto-systemic encephalopathy. Although
only a small percentage of HHT patients (5-8%) suffer from overt clinical
manifestations secondary to HAVMs, increased blood flow through hepatic
vascular shunts is often responsible for a subclinical hyperdynamic state.
Entering geriatric age often entails deterioration of clinical picture of these
patients, by a number of reasons, either related to progressive worsening of
HHT (lack of compensation of hyperdynamic state, increased uncontrolled
epistaxis, onset of gastrointestinal bleeding) or to emergence of concomitant
common morbidities and/or polypharmacy condition, typically associated
to geriatric age. Bearing in mind the complex frailty condition which typi-
Comunicazioni Orali
cally affects an HHT patient in geriatric age, interaction between chronic
anemia and atrial fibrillation (AF) seems to entail a considerable risk in this
population, as relative contraindication has been reported for anticoagu-
lation AF therapy, in light of the underlying bleeding phenotype. Moreo-
ver, anemia and/or significant HAVMs have been hypothesized as AF risk
factors in geriatric HHT patients, due to haemodynamic derangement wor-
sening, and subsequent atrial enlargement and/or remodelling.AIM: We
aimed to carry out an overview of HHT phenotype in geriatric age, to gain
insight into potential correlations between cardiac arrhythmias and hyper-
dynamic state secondary to HAVMs, or other HHT-related manifestations,
geriatric HHT patients.
Methods: The study was designed as a retrospective cohort study of geriatric
patients with confirmed HHT. Inclusion criteria: i) full clinical-instrumen-
tal evaluation ii) age ≥65 yrs at initial screening or subsequent monitoring.
Hepatic screening: Echo-Color Doppler examination, Multi-Slice Compu-
ted Tomography, biohumoral functional analysis. Heart rate abnormalities
were investigated by basic electrocardiography.
Results: A total of 76 patients were included in the study (mean age
70.04±4.22 yrs). Chronic anemia was present in 52/76 patients (68.4%).
Geriatric patients had a higher prevalence of hepatic AVMs and a reduced
prevalence of pulmonary and brain AVMs if compared to the global pre-
valence of our cohort. Signs of chronic atrial fibrillation were detected in
11/76 (14.4%) patients. Hepatic examination disclosed more severe haemo-
dynamic alterations, as well as significantly higher γ-GT and Alkaline Pho-
sphatase levels, and significantly more serious anoemia, in AF vs. non-AF
patients. Multiple logistic regression analysis disclosed γ-GT levels as the
only significant variable contributing to AF onset.
Conclusions: Geriatric age in HHT entails a significant association between
HAVM-related subclinical haemodynamic alterations and AF risk, with
γ-GT levels representing a potential predictor of AF onset.
4-AT DELIRIUM SCREENING TOOL IS SIGNIFICANTLY
CORRELATED WITH ROCKWOOD CLINICAL FRAILTY
SCALE IN OLDER MULTIMORBID PATIENTS ADMITTED
TO HOSPITAL WITH INFECTION
Lauretani F. 1, Ticinesi A. 1, Bastoni D. 2, Calamai S. 2,
Catalano L. 2, Catania P. 2, Cecchia M. 2, Cerundolo N. 2,
Galluzzo C. 2, Giovini M. 2, Mori G. 2, Zani MD. 2, Ciani L. 3,
Nouvenne A. 1, Maggio M. 1, Meschi T. 1
1
Dipartimento di Medicina e Chirurgia, Università di Parma - Dipartimento
Medico-Geriatrico-Riabilitativo, Azienda Ospedaliero-Universitaria di
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
Background: 4-AT is a rapid instrument for delirium assessment in hospi-
tal practice. It includes four items exploring the patient’s alertness, spatial
and temporal orientation, attention, and acute change or fluctuating clinical
course. It is validated for the diagnosis of acute delirium in older patients,
and is particularly useful in subjects with acute illness. Its correlation with
frailty and in-hospital mortality is however still unknown.
Aims: Our primary aim was to verify the correlation between the admission
4-AT score and frailty, operationalized according the Rockwood model, in
a group of elderly multimorbid patients urgently admitted to an internal
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
(LOS) in the same population.
Methods: We prospectively enrolled 158 (89 F) multimorbid (≥2 chronic
diseases) patients aged≥65 (mean 83.6±7.5) urgently admitted to Internal
Medicine and Critical Subacute Care ward of Parma University-Hospi-
tal with acute infection. 4-AT score and Rockwood Clinical Frailty Scale
(RCFS) score were calculated by trained clinicians at the moment of ward
admission. Multimorbidity burden was also assessed with the Cumulative
Illness Rating Scale (CIRS) Comorbidity Score. The associations between
4-AT and RCFS scores, and between 4-AT and LOS were verified with mul-
tiple linear regression models, considering age, sex and CIRS Comorbidity
Score as covariates. Multivariate logistic regression models were also built
to verify whether 4-AT score is a significant predictor for hospital mortality
and LOS.
Results: Medians and interquartile ranges (IQR) of 4-AT, RCFS and CIRS
Comorbidity Score were 1 [IQR 0-4], 5 [IQR 4-6], and 13 [IQR 10-15],
respectively. The median LOS was 6 days [IQR 3-10]. Twenty-nine patients
(18.3%) died during hospital stay. 4-AT score was significantly correlated
with RCFS (β±SE 1.08±0.16; age-, sex- and CIRS-adjusted p<0.001). The
45
Comunicazioni Orali
4-AT score significantly increased across different levels of frailty (fit patients
with RCFS<4: 0.9±2.3; frail patients with RCFS 4-6: 1.25±1.40; disabled
patients with RCFS>6: 6.3±3.9; p for trend<0.001). 4-AT was not correla-
ted with LOS (β±SE 0.22±0.20, p=0.27). At multivariate logistic regression
models, considering age, sex, RCFS and CIRS as confounders, 4-AT was
associated neither with inhospital mortality (OR 1.10, 95% CI 0.94-1.28,
p=0.22), nor with LOS>10 days (OR 0.97, 95% CI 0.85-1.11, p=0.68).
Conclusions: In a group of older multimorbid patients with acute infection,
the 4-AT score was significantly associated with frailty, operationalized
according to the Rockwood model. However, 4-AT was not able to predict
in-hospital mortality or LOS.
ITALIAN GUIDELINES FOR EARLY DETECTION,
DIAGNOSIS, PREVENTION AND TRATMENT OF
DELIRIUM IN THE FRAIL ELDERLY
G. Ricevuti, 1 C. Paolillo, 2 P.A. Modesti 3, M. Trabucchi 4
F. Perticone 5, N. Ferrara 6, M.P. Ruggieri 6, C. Tommasino 8,
A. Ferrari 9, P. Gnerre 10, G. Bellelli 11
1
(University Pavia, Department of Internal Medicine and Therapeutics,
Geriatrics, Pavia, Italy, Azienda Servizi alla Persona, S. Margherita Hospital,
Pavia, Italy) 2 (Emergency Department, Udine Healthcare and University
Integrated Trust, Udine, Italy, AcEMC) 3 (Dipartimento di Medicina
Sperimentale e Clinica, Università di Firenze, Italia, SIMI) 4 (Università di
Roma “Tor Vergata”, Roma, Italia, PRESIDENTE AIP), 5 (Department of
Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Italy,
PRESIDENTE SIMI), 6 (Medicina Interna e Geriatria, Università degli Studi
di Napoli “Federico II”, Napoli, Italia, PRESIDENTE SIGG ‐ Società Italiana
di Gerontologia e
Geriatria), 6 (Azienda Ospedaliera San Giovanni Addolorata della UAS,
Roma, PRESIDENTE SIMEU) 8 (Dipartimento di Scienze Biomediche,
Chirurgiche ed Odontostomatologiche, Università di Milano, ASST Santi
Paolo e Carlo Polo Universitario, Milano, Italia, SIAARTI), 9 (UOC di
Geriatria, ASMN‐ Azienda Ospedaliera di
Reggio Emilia, Italia, PRESIDENTE SIGOT), 10 (Medicina, Ospedale San
Paolo di Savona, Italia, FADOI), 11 (Università degli Studi di Milano-
Bicocca, SCC Geriatria, AO San Gerardo, Monza, Italia)
Partnering collaborative intercompany guidelines for the prevention, dia-
gnosis and treatment of delirium in the frail elderly person.
Background: Delirium or acute confusion is a clinical mis- or underdia-
gnosed condition characterized by an acute (shorter than 6 months) and
floating alteration of psychic state, with loss of attention and alteration of
consciousness, associated to an underlying organic cause. It is a serious
syndrome related to an increase of the lenght of hospitalization, the risk of
instituzionalization,the morbility and the mortality. Therefore it is crucial to
identifying it. Howeverbeing our knowledge about its mechanism limited
and having the delirium a wide range of presentations it is really difficult to
diagnose it. Delirium can be found in any medical condition and is common
in hospitalised elderly patients in his hyperactive, hypoactive and mixed
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
118° Congresso Nazionale - Società Italiana di Medicina Interna
Italian Scientific Societies (geriatricians, emergency physicians, internal
physicians, anesthesiologists, surgeons, psychiatrists and toxicologists)
shared ideas on advancing the best care practices in this field.
Conclusion: In summary, the document focused on the need of diagnosing
delirium and the opportunity of a comprensive patient-care program that
prevents delirium. A little attention was given to pharmacological therapy,
last beach only when the patient is in danger. To make the document as
widely know as possible, it will be published in the Official Journal of the
Societies in the coming months. We believe that only by involving all team
members within the hospital we can fight that so common syndrome.
A FRAILTY INDEX IN HOSPITALIZED OLDER PEOPLE: A
NEW PROPOSAL FROM THE REPOSI REGISTER
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
2
Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Université
de Toulouse III Paul Sabatier, Toulouse, France 3 Scientific Direction,
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
4
Department of Clinical Sciences and Community Health, University of
Milan, Italy
Purpose: To develop a frailty index for hospitalized older patients and test
its association with in-hospital mortality rate.
Methods: This is a cross-sectional study of people aged 65 years or more
hospitalized for at least 5 days in Italian internal medicine and geriatric
wards participating to the REPOSI register from 2010 to 2016. Frailty Index
was defined by the deficit accumulation. For the purpose of this study,
35 deficits were identified through laboratory parameters, geriatric scales
(Barthel Index, Short Blessed Test and Geriatric Depression Scale) and
comorbidities assessed at hospital admission. Association with in-hospital
mortality rate was assessed by logistic regression model adjusted for sex and
age.
Results: Among 4715 patients enrolled in the REPOSI register from 2010
to 2016, 3847 patients were hospitalized for at least 5 days in 101 internal
medicine and geriatric wards and were selected for the analyses. Nearly
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
cognitive impaired. Figure 1 shows the distribution of the Frailty Index in
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
as frail, exceeding the value of 0.5. An increasing score of Frailty Index was
associated with an increased likelihood to die during hospitalization (OR
1.05, 95%CI 1.03-1.07).
Conclusion: The development of a Frailty Index in hospitalized older
patients could represent a useful tool for internists and geriatrics in order
to improve the management of this population, which nowadays are increa-
sing more and more and are becoming the prototype of patients with whom
clinicians must deal. Moreover the correct management of frail older people
represents a great challenge for National Health System due to limited
resources.
118° Congresso Nazionale - Società Italiana di Medicina Interna
CHANGES IN FRAILTY STATUS DURING
HOSPITALIZATION AND PROGNOSTIC IMPACT IN
OLDER PATIENTS
Basile G. 1, Catalano A. 1, Mandraffino G. 2, Alibrandi A. 3, Ciancio G. 1,
Brischetto D. 1, Lasco A. 1, Cesari M. 4,5
1
Unit and School of Geriatrics, Department of Clinical and Experimental
Medicine, University of Messina, Messina, Italy; 2 Unit of Internal Medicine,
Department of Clinical and Experimental Medicine, University of Messina,
Messina, Italy; 3 Department of Economics, University of Messina, Messina,
Italy; 4 Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse,
France. 5 Université de Toulouse III Paul Sabatier, Toulouse, France
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
older hospitalized patients, 2) estimate its changes during the hospital stay,
3) determine the relationships among frailty, length of stay, and in-hospital
mortality, and 4) evaluate the predictive value of frailty for one-year morta-
lity and six-month re-hospitalization events.
Materials and Methods: Between September 2015 and April 2016, data
from 156 patients (93 women, 63 men), aged 65 years or older, and consecu-
tively admitted to Acute Geriatric Medicine Unit at the University Hospital
of Messina, Italy were collectedSetting. Geriatric Acute Care Unit. A Frailty
Index (FI) was computed taking into account 46 potential deficits collected
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
24 hours from the hospital admission (aFI) and discharge (dFI). Patients
were followed up to 12 months after the hospital discharge.
Results: The study sample had a mean age of patients was 81.5 (SD=6.2)
years, and predominantly composed by women (59%). The median aFI was
0.362 (interquartile range: 0.306-0.404). After exclusion of patients dying
during the hospital stay, a statistically significant difference was reported
between aFI (0.31, IQR 0.19-0.44) and dFI (0.29, IQR 0.19-0.40; p=0.04).
The frailest patients presented an increased risk of in-hospital death
(OR=5.9; 95% CI 2.0-17.5) and longer hospital stay (β=6.937; p=0.05). Both
the aFI and dFI were strong predictors of one year mortality and six months
re-hospitalization after discharge.
Conclusion: Frailty is a strong predictor of negative endpoints in hospitali-
zed older persons. Its assessment from routinely collected clinical data may
provide important insights about the biological age of the individual and
promote the personalization of interventions.
TAKE CARE OF THE PATIENT AND QUALITY OF
THE CARE PROCESS BY DEFINING THE CORRECT
SETTING BETWEEN HOSPITAL AND TERRITORY:
AN OBSERVATIONAL RETROSPECTIVE STUDY IN
LOMBARDY
Pietrantonio F. 1, Aperti P. 1, Tonoli L. 1, Meneghetti O. 1, Scotti E. 2, Bussi
A.R.1
1
U.O. Medicina Interna, Ospedale di Manerbio (BS) ASST-Garda 2 Unità
Operativa Medicina Generale, Istituto Neurotraumatologico Italiano (INI),
Grottaferrata (Roma)
Background: In the implementation of Lombardy socio-health care reform
(L.R. n. 23/2015), is essential to stratify patients according to clinical inten-
sity and complexity, defining care setting, personnel standards, technolo-
gical equipment and critical junctions of hospital-territory paths. Aims.
To define: 1. Internal Medicine (IM) patients’ characteristics; 2. IM role in
complex poly-pathologic patients with chronic diseases paths; 3. alternative
organizational models to improve performances, a retrospective observatio-
nal study has been realized by Manerbio IM (ASST-Garda).
Methods: After a 2000-2016 Literature review, MEWS (Modified Early
Warning Score), CIRS (Cumulative Index Rating Scale) and Care Intensity
Index (IIA) were chosen to analyze IM admitted patients. Medical records
(MR) of all patients consecutively admitted to Manerbio IM from January
1st to March 31st 2016 were analyzed.
Results: 393 patients: 199 M/194 F (total discharged: 483), median age 81
years. 93% >70 years and 37% >85 years. Critically ill patients (needing con-
tinuous monitoring): 27% (of which 10% with MEWS≥ 5, needing Intensive
Care Unit). Comorbidity (measured by CIRS-CI): 5- 6 active diseases, 53%
with CIRS 7-12. Intensity of care (IIA) high (3-4) in 46% of the patients
throughout the length of hospital stay (LOS). Average LOS: 9.35 days.
Outcome: 64% discharged at home; 10.7% deaths; 23% with social problems
Comunicazioni Orali
(transferred to sub-acute units, nursing homes-RSA, Hospices, Integrated
Home Care-ADI-activation) 2.3% referrals, voluntary resignation.
Conclusions: 1. About 27% of IM patients needs monitoring and intensive
assistance. Is currently starting-up a randomized study on use of wireless
monitoring systems in IM to demonstrate how an adequate critical patients
care improve management, reducing complication, LOS and hospitali-
zation costs. 2. About 23% of patients presents social problems for which
integrated paths could minimize LOS. 3. A pilot study is being carried out
to evaluate the pathway of patients with chronic diseases in the transition
from acute phase to low-intensity care settings to define pathways following
the subacute phase and possible experimentation of intermediate support
structures (also In public-private partnership) where to stay waiting to enter
the RSA (nursing homes with minimum intensity of care).
MULTILEVEL INTERVENTION TO IMPROVE
APPROPRIATENESS OF LABORATORY TEST REQUESTS
IN THE EMERGENCY DEPARTMENT
Fallai L. 1, NazerianP. 1, Vanni S. 1, Fanelli A. 2, Duranti C. 2,
Ognibene A. 2, Rapi S. 2, Betti L. 1, Tomaiuolo M. 3, Calamai M. 3, Grifoni S. 1
1
Dipartimento di Emergenza-Urgenza, Azienda Ospedaliero-Universitaria
Careggi, Firenze; † Laboratorio Generale, Azienda Ospedaliero-Universitaria
Careggi, Firenze; ° Amministrazione Generale, Azienda Ospedaliero-
Universitaria Careggi, Firenze
Introduction: Laboratory blood tests are part of the diagnostic investi-
gation performed in the emergency department (ED), but they are also a
potential waste in health care utilization. The aim of this study is to deter-
mine if a multilevel intervention based on optimization of test profiles and
awareness of medical staff could reduce the number of requested tests and
costs without affecting ED performances.
Methods: A before-and-after study in ED was conducted. Laboratory test
profiles were reduced from 6 to 2 and cut by 50% the number of tests in
each profile. All ED physicians were informed about the expense of labo-
ratory tests and about the appropriate use of the most frequent high cost
tests. The 8 months intervention period (1st July 2016 - 28th February 2017)
was compared with 8 months pre-intervention period (1st July 2015 - 28th
February 2016). Main outcomes were total laboratory blood tests and high-
cost tests ordered. Secondary outcomes were cost of laboratory tests and ED
and laboratory performances (patients’ waiting time, number of death in
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-
sed by 207,637 (-36.3%) with a reduction of 337.3 tests/100 patients in the
intervention period compared with pre-intervention period (p<0.05). Costs
decreased by 608,079€ (-29.6%) with a reduction of 981.2€/100 patients
(p<0.05). High-cost tests decreased by 11,457 (-27.3%) with a reduction
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
performances.
Conclusions: Multilevel intervention by modification of routine labo-
ratory test profiles and educational meetings for ED medical staff signi-
ficantly reduced laboratory test ordering and costs without affecting ED
performances.
THE ROLE OF PROCALCITONIN IN EMERGENCY
MEDICINE
Zaccone V., Falsetti L., Marchetti A., Piersantelli M.N., Nobili L., Menditto
V., Gentili T., Nitti C., Salvi A.
SOD Pronto Soccorso e Medicina D’Urgenza, Ospedali Riuniti, Ancona
Background: procalcitonin (PCT) could guide antibiotic therapy and eva-
luate its efficacy. Informations regarding the diagnostic and prognostic role
of PCT in the critically ill subject are lacking. Aim of this study was to eva-
luate the value of PCT in the diagnosis of bacterial infections and its pro-
gnostic weight in the unstable patient.
Methods: we enrolled 1063 consecutive, critically ill subjects admitted to
our Internal Subintensive Medicine Department in the period 2008-2010,
evaluating age, sex, haemodynamic parameters, blood exams, PCT and
blood cultures. In particular we collected the absolute number of peripheral
white blood cells, troponin I (TnI) and serum creatinine. Among hemody-
namic parameters, we evaluated the presence of shock (defined as systolic
blood pressure < 90 mmHg, low urine output, < 0.5 ml/kg/h and reduced
47
Comunicazioni Orali
cutaneous perfusion). The degree of severity of the pathology was assessed
with the SAPS-II score. We’ve set as outcomes mortality or intensive therapy
transfer, overall survival and length of hospital admission.
Results: We observed positive cultures in 375 subjects, whose mean PCT
levels were significantly higher than in patients without positive cultures
(0,84 ng/ml versus 0,20 ng/ml; p<0,0001). ROC curve analysis, however,
underlined a sub-optimal role of PCT in predicting bacterial isolation
(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
events among subjects with lower PCT was 44 days compared with 26 days
observed in patient with high PCT. The prognostic weight of PCT was supe-
rior than TnI, and PCT was correlated with prognosis independently from
bacterial infection. A model including SAPS2, troponin I and PCT had a
good AUC (0,734; 95%CI: 0,667-0,775) in predicting in-hospital events,
such as death or transfer to intensive-care unit.
Discussion: Procalcitonin is now a widely used marker of bacterial infection,
despite several papers confirmed its low diagnostic yeld. In our population,
we confirmed this observation by showing a low correlation between incre-
ased PCT and positive bacterial isolates (blood, sputum or urine cultures).
However, an increased PCT value was associated, independently from the
presence of sepsis or infection, to an increased rate of adverse events and a
lower event-free survival. When combined in a model including clinical and
serologic markers of severity, such as SAPS2 and troponin I, PCT showed
a good prognostic value for in-hospital death or complications by increa-
sing the AUC of the model. This derived model was able to predict adverse
event in all the critically ill patients enrolled, independently from the cause
of admission.
Conclusion: Among critically ill patients PCT has a low diagnostic yeld,
with a poor predictive value for positive bacterial cultures. PCT, however,
maintains a good prognostic significance in predicting both event-free
survival and adverse events during the hospitalization. In particular, PCT
increases the prognostic value of commonly used scores, such as SAPS2,
and well-recognised prognostic markers, as troponin I. A model including
SAPS2, troponin I and PCT is highly predictive for in-hospital adverse
events among critically ill patients, and could be used to predict the risk
of in-hospital mortality and the probability of transfer to intensive therapy
unit.
PROGNOSTIC VALUE OF HEART RATE VARIABILITY IN
ACUTE ISCHEMIC STROKE
Tobaldini E.1, Sacco R.M.1, Serafino S.2, Gallone G.P.2, Zecca B.2,
Pagnozzi G.2, Brambilla A.M.2, Montano N.1, Torgano G.2
1
Department of Internal Medicine, Fondazione IRCSS Ca’ Granda, Ospedale
Maggiore Policlinico, Milan, Italy; 2Department of Emergency Medicine,
Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Italy
Background: Acute ischemic stroke is associated with autonomic dysfun-
ction. Whether this alteration has a prognostic role is still debated. Heart
Rate Variability (HRV) is a widely used tool to assess cardiac autonomic
modulation.
Aims: To evaluate 1) the prognostic value of HRV in acute ischemic stroke,
2) the effects of reperfusion treatment (RT) on autonomic control, 3)
whether stroke localization has a role in autonomic dysfunction.
Methods: Consecutive patients with a diagnosis of acute ischemic stroke
and with sinus rhythm were enrolled in the Emergency Department (Ospe-
dale Maggiore Policlinico, Milan). Ten minutes EKG and respiration were
recorded within six hours from the event (T0) and, when applicable, after
RT (T1). Neurological deficit was assessed using NIH stroke scale (acute
phase) and modified Rankin scale (MRS), at 3 months. Spectral and symbo-
lic analyses were used to assess HRV. Spectral analysis identifies two main
components, low frequency (LF, 0.04 to 0.15 Hz), marker of sympathetic
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
2LV% and 2UV% markers of index of vagal modulation.
Results: We enrolled 38 patients (26 males, mean age 67.9 ± 13; mean
NIHSS 10,5 ± 6,3). Twenty-five of them underwent RT. As to the correla-
tion between NIHSS and autonomic parameters, we found that the group
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
outcome, the group with the worst mid-term neurological outcome (MRS
3-6) showed higher 2UV% (p<0,01) and lower 0V% (p=0,023) than patients
with better MRS 0-2. RT seemed to have no effects on HRV parameters.
48
118° Congresso Nazionale - Società Italiana di Medicina Interna
Stroke side was not found to be associated to a specific autonomic profile.
Conclusions: A decreased 0V% and an increased 2UV% may be an expres-
sion of the lost of sympathetic rhythmic oscillation with persistent respi-
ratory modulation. According to these preliminary data, in the very early
phases of acute ischemic stroke, an autonomic profile characterized by
prevalent vagal control and impaired sympathetic oscillation may predict a
poorer 3 months-outcome.
APPLICATION OF THE NOVEL SEPSIS CRITERIA IN AN
INTERNAL MEDICINE WARD: IS QSOFA EQUIVALENT TO
SIRS IN OLDER MULTIMORBID PATIENTS?
Ticinesi A. 1, Lauretani F. 1, Bastoni D. 2, Calamai S. 2,
Catalano L. 2, Catania P. 2, Cecchia M. 2, Cerundolo N. 2,
Galluzzo C. 2, Giovini M. 2, Mori G. 2, Zani M.D. 2, Ciani L. 3,
Nouvenne A. 1, Maggio M. 1, Meschi T. 1
1
Dipartimento di Medicina e Chirurgia, Università di Parma – Dipartimento
Medico-Geriatrico-Riabilitativo, Azienda Ospedaliero-Universitaria di
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
Background: In 2016, the Third International Consensus Definitions for
Sepsis and Septic Shock have recommended the implementation of a new
bedside clinical score for the diagnosis of sepsis outside the intensive care
unit. This score, termed quickSOFA (qSOFA), is composed of three clinical
criteria: respiratory rate of 22/min or greater, altered mentation measured
by Glasgow Coma Scale, and systolic blood pressure of 100 mm Hg or less.
Sepsis is present when at least 2 out of 3 criteria are fulfilled. qSOFA should
replace the old SIRS (Systemic Inflammatory Response Syndrome) criteria.
However, the validity of qSOFA over SIRS for predicting mortality in the
context of older multimorbid patients is still unknown.
Aim: To assess the non-inferiority of qSOFA over SIRS in predicting
3-month mortality in a cohort of older multimorbid patients admitted to an
academic internal medicine ward with suspected sepsis.
Methods: We prospectively enrolled 121 (66 F) multimorbid (≥2 chronic
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
treatment and biologic sample cultures. Subjects who were administered
antibiotic treatment before hospital admission and subjects with establi-
shed survival prognosis <6 months were excluded. qSOFA and SIRS scores
were calculated at the moment of ward admission, together with Cumula-
tive Illness Rating Scale (CIRS) Comorbidity Score and Rockwood Clinical
Frailty Scale (RCFS). Three months after discharge, a phone interview with
every participant’s caregiver was planned to assess mortality. Multivariate
logistic regression models including SIRS (model 1) or qSOFA (model 2)
with CIRS Comorbidity Score, RCFS, age and sex as potential confounders
were built to satisfy the aim of the study.
Results: At admission, the median and interquartile range (IQR) scores of
qSOFA, SIRS, CIRS Comorbidity Score and RCFS were 1 [IQR 0-1], 1 [IQR
1-2], 13 [IQR 10-15], and 5 [4-6], respectively. At the 3-month follow-up,
37 patients (30.5%) died. In multivariate logistic regression model 1, SIRS
was not a significant predictor of mortality (OR 1.38, 95% CI 0.87-2.17,
p=0.16), while RCFS was (OR 2.06, 95% CI 1.44-2.94, p<0.001). In model 2,
qSOFA was instead a significant predictor of 3-month mortality (OR 2.06,
95% CI 1.03-4.15, p=0.04), together with RCFS (OR 1.96, 95% CI 1.36-2.83,
p<0.001). Age, sex and CIRS Comorbidity Score were not associated with
mortality in both models.
Conclusions: In older multimorbid patients admitted to an internal medi-
cine ward with suspected sepsis, qSOFA score was a better predictor of
3-month mortality than SIRS score. Frailty, operationalized according to the
Rockwood model, was also a significant predictor of death in this setting.
HYPERLACTATEMIA, WHEN SEPSIS IS NOT ENOUGH
Traversa M. 1, Villois P., Elia F.
1
Scuola di Specializzazione in Medicina Interna, Dipartimento di Scienze
Mediche, Università degli Studi di Torino
The patient, 45 year-old, was admitted to the Intensive Care Unit with
the diagnosis of abdominal sepsis after a pancreatic surgery. Past medical
history of the patient: arterial hypertension treated with angiotensin con-
118° Congresso Nazionale - Società Italiana di Medicina Interna
verting enzyme (ACE) inhibitor, no history of smoking or alcohol abuse
and a previous abdominal surgery 6 years before for an appendicectomy.
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
tomography (CT) scan revealed a pancreatic mass, highly suspicious for a
duodenal/pancreatic cancer. Five days later he underwent a radical pancrea-
ticduodenectomy and a right emicolectomy. Histology revealed a duodenal
adenocarcinoma with local infiltration (pT4-N1-G3). Post-surgery course
was regular, canalized at day 3. After 10 days the patient developed fever
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
of the Roux-en-Y hepaticjejunostomy anastomosis and of the ileum-colic
anastomosis with a large suppurated mass within the pancreatic pouch and
around the left hepatic lobe. Blood cultures were provided from the central
venous catheter and peripheral vein and they were both found positive for
Proteus Mirabilis and Candida Glabrata. The patient underwent a second
surgery for the drainage of the intrabdominal abscess and the closure of the
dehiscent anastomosis. Antimicrobial therapy with Tigeciclin, Vancomicin
and fluconazol was started, adjusted on the antibiotic susceptibility testing
(AST). The patient required several red blood cells (RBCs) transfusions (one
every 48h) to maintain a mean 7g/dl haemoglobin level. After a few days
fever rose again along with the development of altered mentation and a pro-
gressive worsening of the clinical status. The patient was therefore moved
to our Intensive Care Unit with a severe septic shock. Physical examination
showed a severely altered mentation with a Glasgow Coma Scale (GCS) of
6/15 (E1 M3 V2), diaphoresis, invasive arterial pressure 90/50 mmHg, heart
rate 110bpm, respiratory rate 26, SpO2 98% with a Venturi Mask 40%. Tho-
racic X rays showed bilateral pleural effusion and elevated diaphragm, while
abdominal ultrasonography revealed massive intraabdominal fluid despite
the presence of three drainages. Drained fluid was found to be a bloody
corpuscular essudate. Comprehensive blood tests showed WBC 9.65, Hb
9.5, PLTS 16.000, normal blood coagulation, serum creatinine 0.5, eGFR
100 ml/min, sodium 137 and potassium 3.9. ABG pH 7.57 p02 133 pC02 23
PCT 15.38 HC03- lac 4.4. Haemocultures demonstrated an early positivity
for Gram – group KES (klebsiella-enterobacter-serratia), thus antibiotics
were switched to meropenem instead of tigeciclin. The patient was treated
with crystalloids and blood transfusions and did not require vasopressor
support. At the entrance in the ICU the SOFA score was 9; ScvO2 was 70%,
SaO2 92%, DELTA-CO2 3 (32 – 29). After a platelet transfusion, under
echografic vision, a catheter was placed with Seldinger technique in order
to take a sample of the abdominal effusion; a total 700cc of hematic fluid
was drained. The microbiological cultural exam of the ascites and the hae-
moculture revealed a positivity to Klebsiella Pneumoniae and an antibio-
tic therapy with meropenem and vancomycin was continued, based on the
antibiotic susceptibility testing. After 2 days, the haemodynamic parame-
ters improved, no more hypotension and fever vanished; the patient needed
daily transfusion for the first 4 days. At day4, most lab examinations impro-
ved: liver enzymes levels, bilirubin, coagulation, electrolytes were normal,
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
score was 7 (severely influenced by the altered mentation and the very low
platelet count). Although an improvement of the clinical status and the
blood examination, serum lactate level remained stable (around 5 mmol/l)
and the patient drowsy. Since surgery, parenteral nutrition was administe-
red under nutritional consultation. Ruled out the first idea of septic shock
and looking for other causes of lactate elevation, the hypothesis of a vitamin
deficiency was evaluated as a consequence of the lack of vitamin B1 due to
exclusive parenteral nutrition. Actually, parenteral nutrition tailored under
nutritional consultation the day after the surgery, was carefully balanced
in the percentage of fats, proteins and carbohydrates necessary for the first
days after the surgery however, it has not been changed during the patient’s
unpredictably long stay in the hospital; therefore, intravenous thiamine
replacement was associated with multivitamin complex to the parente-
ral nutrition. On the following day, serum lactate levels decreased hugely,
reaching normal level (1.3 mmol/l). After 48 hours, the patient awakened,
returning to a GCS level of 15 and fully recovered his mental status. During
the rest of the stay, the patient underwent new surgery to remove the intra-
abdominal abscess and replace the biliary drainage. One month later, after a
rehabilitation cycle, the patient was discharged to home in good condition.
In conclusion, the worsening of the patient’s clinical status, particularly the
altered mentation and the hyperlactacidemia, were not due to an abdominal
septic shock but to a Wernicke syndrome associated to thiamine deficiency.
SEVERE AUTONOMIC DYSFUNCTION DURING THE
Comunicazioni Orali
ACUTE PHASE OF SYSTEMIC CAPILLARY LEAK
SYNDROME: A CASE REPORT
Colombo R. 1, Catena E. 1, Perotti A. 1, Fossali T. 1, Wu M.A. 2, Cicardi M. 2
1
Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli
Sacco, Luigi Sacco Hospital – Polo ospedaliero, University of Milan, Milan,
Italy 2Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli
Sacco, Luigi Sacco Hospital – Polo ospedaliero, University of Milan, Milan,
Italy
Idiopathic Systemic Capillary Leak Syndrome (ISCLS) is a rare disease that
involves the endothelium and microcirculation, leading to an abrupt shift of
fluids and proteins from the intravascular to the interstitial compartment.
The consequence of the capillary leakage is a life-threatening hypovolemic
shock that can lead to lethal multiple organ dysfunction.
The autonomic nervous system (ANS) plays a central role in regulating the
cardiovascular response to hypovolemia, but ANS modulation in ISCLS has
not been investigated so far.
Here we present the case of a a 36-year-old-man admitted to our ICU for
a life-threatening ISCLS attack. During the course of the last ISCLS crisis
the patient was connected to an ICU monitor Philips IntelliVue MX800
(Philips Healthcare, Amsterdam, Netherlands) through five leads ECG
cable and invasive arterial pressure line from a 20 gauge arterial catheter
inserted into the right femoral artery. All ECG signals were sampled at 500
Hz and arterial pressure at 125 Hz with ixTrend (ixellence GmbH, Wildau,
Germany). The arterial pressure wave was resampled offline at 500 Hz with
LabChartPro 8 (AD Instruments, Dunedin, New Zealand). Autonomic
nervous system was studied non-invasively by the spectral analysis of heart
rate variability (HRV) which allowed to identify the low frequency (LF) and
high frequency (HF) components, markers of sympathetic and parasympa-
thetic modulation respectively. A spectral component was labelled as LF if
its central frequency was between 0.04 and 0.15 Hz, while it was classified as
HF if its central frequency was between 0.15 and 0.5 Hz.
During the acute phase (day 1), despite life-threatening hypotension and
severe tachycardia, the spectral analysis of HRV didn’t show any oscillatory
pattern. Total power was very low, LF band had a density of 12 msec2 and
HF band of zero msec2 respectively. At early recovery from the ISCLS crisis
(day 2), the power spectrum showed an increase of LF, and a persistently
low HF accounting for high LF/HF ratio. At the time of full recovery (Day
3) both LF and HF increased with a prevalence of the HF band, thus the LF/
HF ratio was reduced.
In conclusion, during the acute phase, our patient showed an unexpected
failure of ANS cardiovascular modulation. His HRV was totally suppres-
sed, as assessed by flattened power spectral density. Further investigation is
warranted to assess whether the ANS failure is an epiphenomenon of mul-
tiple organ dysfunction during life-threatening sickness, a compensatory
response or if it has a role in the pathogenesis of hemodynamic instability
during ISCLS crises.
APOLIPOPROTEIN C-III IS A PREDICTOR OF ACTIVATED
FACTOR VII-ANTITHROMBIN COMPLEX LEVELS: A NEW
LINK BETWEEN PLASMA LIPIDS AND COAGULATION
PATHWAY
Stefanoni F. 1, Tosi F. 1, Baroni M. 2, Castagna A. 1, Pizzolo F. 1,
Bassi A. 3, Pattini P. 1, Croce J. 1, Lunghi B. 2, Girelli D. 1,
Woodhams B. 4, Bernardi F. 2, Olivieri O. 1, Martinelli N. 1
1
Department of Medicine, University of Verona, Italy; 2Department of Life
Sciences and Biotechnology, University of Ferrara, Italy; 3Institute of Clinical
Chemistry, University Hospital of Verona, Verona, Italy; 4Haemacon Ltd,
Bromley, Kent, UK
Background: activated factor VII-antithrombin (FVIIa-AT) complex is a
potential biomarker of prothrombotic diathesis, reflecting tissue factor (TF)
exposure, and has been associated with mortality in patients with coronary
artery disease (CAD). Previous works indicated plasma lipids as predictors
of FVIIa-AT variability. Aims: to evaluate the relationships between FVI-
Ia-AT plasma concentration and lipid/apolipoprotein profile.
Methods: within the framework of the Verona Heart Study we selected 460
subjects (120 CAD-free and 340 CAD, 68.9% males, mean age 59.9±10.3
years) not taking anticoagulant drugs and for whom plasma samples were
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.
49
Comunicazioni Orali
Results: there were significant direct correlations of FVIIa-AT levels with
total and HDL cholesterol, triglyceride, Apo A-I and Apo C-III. Apo A-I
(R=0.164, P=4Å~10-4) and Apo C-III (R=0.236, P=3Å~10-7) showed the
strongest correlations. Including all the lipid parameters in an adjusted
regression model only Apo A-I and Apo C-III remained significant pre-
dictors of FVIIa-AT levels, with Apo C-III explaining 5.6% of FVIIa-AT
variability. Such results were confirmed after adjustment for sex, age, CAD
diagnosis, and renal function. The rs964184 polymorphism (tagging also
APOC3 gene locus), which has been linked with cardiovascular risk and
plasma lipids by genome-wide association studies, was associated not only
with Apo C-III levels but also with FVIIa-AT plasma concentration, being
higher in the carriers of the risk allele G (CC 81.6 [77.9-85.5], CG 90.0
[83.2-97.4], and GG 98.5 [77.8-124.6] pM, P=0.015).
Conclusion: our results indicate a strong association between Apo C-III
and FVIIa-AT levels, thereby supporting the hypothesis that Apo C-III, one
of the most important actor in lipid metabolism, may influence TF-FVIIa
pathway with prothrombotic effects.
THE DIAGNOSTIC CHALLENGE: ARE WE MISSING
PULMONARY EMBOLISM DIAGNOSIS IN PATIENTS
WITH SYNCOPE?
Campello E. 1, Rossetto V. 2, Maggiolo S. 1, Vigolo S. 3, Spiezia L. 1, Martina S.
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
Daniele del Friuli, Udine 3Dipartimento di Emergenza, Università di Padova
In the recently published Pulmonary Embolism in Syncope Italian Trial
(PESIT) that systematically evaluated 560 patients admitted to hospital with
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,
the more recent General Medicine Inpatient (GEMINI) study retrospecti-
vely evaluated 1305 patients hospitalized with a first episode of syncope
and found a diagnostic yield of VTE of 15.0% and a prevalence of VTE of
1.4%. Given such a discrepancy, it is difficult for the clinicians to grasp the
actual impact of VTE in syncope. We aimed to assess the VTE prevalence in
medical patients admitted to hospital for syncope and the occurrence of VTE
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
Department (ED) of Padua University Hospital and San Daniele del Friuli
Hospital (Italy) with a triage code of “syncope” and hospitalized between
January 2014 and December 2015. Medical records were carefully reviewed
and only patients with a diagnosis of “syncope” at discharge were enrolled.
Exclusion criteria were previous episodes of syncope, ongoing anticoagula-
tion therapy, and pregnancy. Data of patients enrolled were obtained from
medical records and information on subsequent re-admission to either
the ED or the Hospital as well as on death from any causes were recorded
for one year after the discharge from the Veneto and Friuli Venezia Giulia
Regional Health Department information systems. The following outcomes
were considered: 1. occurrence of investigation for VTE during hospitaliza-
tion and the diagnostic yield of VTE; 2. prevalence of VTE during hospitali-
zation; 3. prevalence of VTE and mortality from any causes during the one-
year follow-up after patients discharge. Out of 1169 patients hospitalized
with a triage code of “syncope”, 470 (40.2%) were excluded because the dia-
gnosis at discharge was other than syncope, 124 (10.6%) for ongoing anti-
coagulation, 119 (10.1%) for recurrence of syncope and 3 (0.26%) for both.
Out of 453 patients, 107 patients (23.6% [95% CI 19.7-27.5%) underwent
at least one imaging investigation for VTE, of whom 28 (26.1%) received
only CTPA, 52 (48.5%) only CUS and 27 (25.2%) both. Overall, 55 patients
(12.1%) underwent CTPA to confirm PE with a diagnostic yield of 30.9%
(17/55 with positive CTPA) [95%CI, 20.3-46.3%], and 79 received CUS
to confirm the presence of deep vein thrombosis (DVT) with a diagnostic
yield of 7.6% (6/79 with positive CUS) [95% CI, 1.7-13.4%]. Patients with
positive imaging were significantly older, exhibited more frequently a pre-
vious history of VTE, presented with more risk factors for VTE and a higher
1-year mortality rate. The prevalence of VTE was 5% [95% CI, 3.0-6.9%]
in the entire cohort (23/453) and 6% [95% CI, 4.8-8.4%] after exclusion of
patients with negative D-dimer and low PTP (23/380). Additionally, in 346
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
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
identified medical causes (i.e. sepsis, myocardial infarction, hearth failure,
50
118° Congresso Nazionale - Società Italiana di Medicina Interna
cancer evolution, intracranial hemorrhage) and 19 of undefined causes.
During the follow-up the overall incidence of VTE was (1.2% [95% CI, 0.1-
2.3]) in the group not investigated for PE and 0.95% [95% CI, 0.3-1.87] in
the overall population. Furthermore, we observed no significant differences
either in readmission for syncope or in mortality rates between the group
investigated and not investigated for PE. In our cohort the diagnostic yield
of VTE was 21% with a VTE prevalence of 5%. The diagnostic yield of PE
was 30.9% and the prevalence was 3.7%. The prevalence of VTE was signi-
ficantly lower in our cohort than PESIT, but significantly higher than that
found in the GEMINI study and in the general population. The prevalence
was even higher (6%) if we excluded from the analysis patients at low risk
of VTE. Consequently, PTP and D-dimer should be routinely recommen-
ded for all patients admitted to hospital for syncope and, with the excep-
tion of low-risk patients, imaging for PE should be considered, especially
in older patients with previous VTE and/or risk factors for thrombosis. In
addition, given the very low diagnostic yield of CUS for VTE in syncope,
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
and 2 patients (0.6%) died of PE, whereas no VTE event was recorded in
83 patients who received imaging. In conclusion, we can confirm that PE
has to be considered in the differential diagnosis in patients admitted for
syncope into medical wards. The diagnostic workup of PE based on PTP
and D-dimer is mandatory.
A TIME-COURSE ANALYSIS OF ACTIVATED FACTOR VII-
ANTITHROMBIN COMPLEX PLASMA CONCENTRATION
IN THE FOLLOW-UP OF PATIENTS WITH
ANGIOGRAPHICALLY-DEMONSTRATED CORONARY
ARTERY DISEASE
Stefanoni F. 1, Castagna A. 1, Baroni M. 2, Tosi F. 1, Poli G. 3,
Lunghi B. 2, Gaino S. 3, Woodhams B. 4, Lippi G. 3, Girelli D. 1, Olivieri O. 1,
Bernardi F. 2, Martinelli N. 1
1
Department of Medicine, University of Verona, Italy; 2Department of Life
Sciences and Biotechnology, University of Ferrara, Italy; 3Section of Clinical
Biochemistry, University of Verona, Italy; 4Haemacon Ltd, Bromley, Kent,
UK
Background: activated factor VII-antithrombin (FVIIa-AT) complex
reflects tissue factor exposure to the blood, thus being a biomarker of
prothrombotic diathesis, and has been associated with mortality in patients
with coronary artery disease (CAD). Aims: to evaluate FVIIa-AT plasma
concentration in CAD patients in a two-points (baseline and during the fol-
low-up) time-course analysis.
Methods: within the original prospective study showing baseline levels of
FVIIa-AT as a predictor of cardiovascular mortality, in 178 survived CAD
patients (85.4% males, mean age 58.2±8.5 years) a second blood drawn for
FVIIa-AT evaluation was performed in occasion of an ambulatory visit
(after a median follow-up of 63 months). FVIIa-AT plasma levels were mea-
sured by ELISA.
Results: during the follow-up 58 subjects reported angina symptoms, 7
had myocardial infarction (MI), and 35 underwent new coronary revascu-
larization. FVIIa-AT levels at second control were significantly correlated
with those at baseline (R=0.262, P<0.001) and were significantly higher than
those at baseline (P<0.001), except for patients having begun anticoagulant
therapy with warfarin. Neither baseline nor second control FVIIa-AT levels
were associated with angina, MI, or coronary revascularization. On the other
hand, subjects with angina had a higher increase of FVIIa-AT levels from
baseline to the second control (50.1±55.9 versus31.4±54.4 pM, P=0.035), as
well as subjects with MI (79.4±52.2 versus35.8±55.1 pM, P=0.040), while no
significant difference was found for coronary revascularization (49.9±48.8
versus34.4±56.6 pM, P=0.139). Subjects with an increase higher than the
median value (>36.4 pM) had an about two-fold increased risk of angina/
MI after adjustment for sex, age, time of follow-up, and warfarin therapy
(OR 2.05 with 95%CI 1.05-4.02).
Conclusion: in the setting of secondary prevention of CAD a larger time-re-
lated increase of FVIIa-AT levels during follow-up is associated with angina
and non-fatal MI.
ABDOMINAL PAIN: FIRST OF ALL TRUST THE PATIENT!
Mancarella M. 1, Maira D. 1, Salvatori M. 1, Migone M. , Hu C., Minonzio F.,
Braham S. 2, Cappellini M.D.
118° Congresso Nazionale - Società Italiana di Medicina Interna
Dipartimento di Medicina Interna-Fondazione IRCCS Ca’ Granda Ospedale
Maggiore Policlinico- Milano 1Scuola di specializzazione Medicina Interna-
Università degli Studi di Milano 2 Dipartimento di Emostasi e Trombosi-
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico- Milano
Introduction: We describe the case of a 43-year-old healthy woman who
repeatedly presented to Emergency department (ED) for nonspecific and
diffuse abdominal pain. CASE REPORT A 43-year-old woman was admitted
to our Internal Medicine ward in October 2016 after five days of increasing
nonspecific abdominal pain; she was a non-smoker and she was not taking
any chronic drug except for a combined hormonal contraceptive containing
0.02 mg ethinylestradiol and 3 mg drospirenone that she was taking since
8 months. The pain started suddenly and intensely, at first in epigastrium/
right upper quadrant, later spread to the entire abdomen, associated with
nausea, vomit and low grade fever. Her primary care physician prescribed
paracetamol and scopolamine with no improvement of symptoms, so she
presented to the ED of another hospital. Physical examination was normal,
with no signs of peritonitis. Laboratory tests were within the normal ranges
except for elevated C-reactive protein (8 mg/dL). Abdominal X-ray and
ultrasound revealed no abnormal findings either. She was discharged from
the ED twice, on amoxicillin/clavulanic acid twice a day for a week. Within
4 days the symptoms worsened, thus she presented to the ED of our hospi-
tal, where the abdominal ultrasound revealed a tubular hypoechogenic area
in the pancreas region. Laboratory tests confirmed high C-reactive protein
(10 mg/dL), with a normal liver and pancreatic function. She was admitted
to our Internal Medicine ward in order to undergo further tests for a better
diagnostic definition of the pancreatic finding. At admission vital signs were
stable (except for low grade fever-37.3°C), physical examination showed a
diffuse pain of abdomen, without signs suggestive of peritonitis. We admi-
nistered analgesic drugs without substantial benefit. Cholangio-MRI was
performed and revealed a inhomogeneous intraluminal hyperintense signal
in the superior mesenteric vein (SMV), suggestive for thrombosis. Both
Doppler ultrasound and Contrast-enhanced CT confirmed the presence
of thrombosis, describing an important intraluminal filling defect in the
SMV extended for 5.3 cm, involving some affluent veins too. Fortunately
no ischemic alterations of intestinal loops were observed. Contraceptive
pill was promptly discontinued and systemic anticoagulant therapy (at first
with low molecular weight heparin and then rivaroxaban) was started with a
rapid regression of the abdominal pain. In order to investigate the aetiology
of the thrombotic event, we assessed more specific tests for thrombophilia
(homocysteine, factor V Leiden, factor VIII, antithrombin III, prothrom-
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
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
event related to this drug reported in Italy. After six months of anticoagu-
lation therapy Doppler US showed complete recanalization of the superior
mesenteric vein. Rivaroxaban was interrupted and ultrasound follow-up at
2 months was still negative. DISCUSSION Mesenteric venous thrombosis
(MVT) is a rare condition accounting for 1 in 1000 ED admissions. Lack of
randomized clinical trials make controversial its management. Usual treat-
ment of MVT is unfractionated heparin or low molecular heparin followed,
in selected cases, by vitamin k antagonists. Direct oral anticoagulants have
not been studied for treatment of MVT but their use in new setting should
be evaluated. Like pulmonary embolism, MVT should be considered a
medical emergency because of the high rate risk of intestinal infarction, if
not promptly treated. Diagnosis in the early stages is very difficult because
patients usually present with nonspecific abdominal symptoms and no rele-
vant laboratory signs which must prompt to differential diagnosis of abdo-
minal pain. On the contrary our patient was repeatedly discharged from
ED and the final diagnosis was incidental. The hallmark of MVT is pain,
which is disproportional to the physical findings. A high index of suspicion
is required for the diagnosis of mesenteric venous thrombosis, especially for
patients taking hormonal contraceptive.
PELVIC VEIN THROMBOSIS AS A CAUSE OF
APPARENTLY ISOLATED PULMONARY EMBOLISM IN
WOMEN UNDER HORMONAL CONTRACEPTION
Nicolazzi M.A. 1, Carnicelli A. 1, Bonadia N. 1, Fuorlo M. 1,
Di Gennaro L. 2, Landolfi R. 1
1
Dipartimento di Scienze Mediche, Università Cattolica del Sacro Cuore,
Fondazione Policlinico Gemelli, Roma, Italia; 2 Servizio di Malattie
Emorragiche e Trombotiche, Università Cattolica del Sacro Cuore,
Comunicazioni Orali
Fondazione Policlinico Gemelli, Roma, Italia
The incidence of venous thromboembolism (VTE) among young subjects
appears to be higher in females, presumably due to hormonal factors such as
hormonal contraception (HC), pregnancy and puerperium. Several studies
show that sex hormones alter pro-coagulant protein levels, as well as pla-
telet and vessel wall functional status in a manner that may explain their
influence on thrombotic risk. The risk increase of VTE due to HC use ranges
between 2- and 6-fold the basal risk in the general population. In order to
investigate the characteristics of venous thromboses associated with HC,
we retrospectively analyzed clinical data of all women aged from 15 to 49
years discharged from the “Agostino Gemelli” University Hospital of Rome
from 2009 to 2014 with a diagnosis of VTE. Medical written records of the
hospital stay were reviewed to confirm the VTE diagnosis, to evaluate the
presence of risk factors and to assess whether the patient was taking HC
at the time of admission. In the considered timeframe, 73395 women of
childbearing age were discharged from our institution. Of those, 299 had
a codified diagnosis of VTE. After excluding venous thrombosis clearly
related to local causes (such as catheter associated thromboses or portal vein
thrombosis in liver disease) or with incomplete documentation we analyzed
168 cases. In 34 of them (20.2 %) HC use was the only VTE risk factor, 128
out of 168 (76.2%) had one or more other major risk factors while 6 (3.6 %)
had a VTE without occasional or stable risk factors. Among the 34 cases
with hormonal related VTE 8 (23.5%) women had a deep vein thrombo-
sis (DVT), 6 (17.7%) had a pulmonary embolism (PE) with concomitant
DVT, 6 (17.7%) had a cerebral vein thrombosis (CVT) and 14 (41.1%) ha
an apparently isolated pulmonary embolism without a DVT (I-PE). Seven
women of the subgroup of I-PE underwent further imaging studies, that
means full abdominal doppler ultrasound or angio-CT scan of abdomen (3
women were studied for ruling out an occult malignancy and 4 for further
investigating the cause of abdominal or pelvic symptoms). All these women
were found to have a pelvic vein thrombosis (PVT) which means thrombo-
ses of internal iliac veins with their tributaries and ovarian veins. As estro-
gen receptors (ER B) are strongly expressed on the endothelium of uterine
(endometrial and myometrial) blood vessels, we hypothesize that HC may
have a district-specific pro-thrombotic effect on pelvic vessels as well as
on cerebral vessels. Although with limitation, our findings support this
hypothesis and the need for further, specifically designed, studies. More-
over, these data suggest that clinician should not forget to investigate this
unusual site of thrombosis when dealing with hormonal contraceptive users
presenting with an apparently I-PE or with pelvic symptoms.
INTESTINAL ISCHEMIA IN HCC
Erbi A., De Gioia S., D’Andria C.,1 Milano E.,2 Sogari F.
U.O. Medicina Generale Ospedale Centrale SS Annunziata Taranto
(Direttore Dottor f. Sogari) 1SSD Allergologia e Immunologia Clinica
Ospedale SS Annunziata Taranto 2 Struttura Complessa Chirurgia Generale
Ospedale SS Annunziata Taranto
Case report: female patient, 54 years old, caucasian. Cirrhosis of tha liver
correlated HBV, complicated by HCC. On the list for liver trasplant at the
extra-regional center. Undergoig an antiviral drug treatment with Entecavir
1 mg/per day, potassium canonate 200 mg/per day, furosemide 25 mg/day
and propranolol 40 mg twice a day in secondary prevention for esophageal
varices. She reports to the Emergency Room for the rectorrhagia, which
showed at home. Hematochemical tests are urgently performed, showing
Hb values of 15 g/dL, regular white blood cells and leukocyte formula, PLT
66.000. INR 1,3. Hospitalized, the following is reported: 100/80 mm Hg
blood pressure, afebrile, eupnoica, oriented in time and space, SpO2 98%
in AA. The objective examination showed a treatable abdomen, not painful
to surface and deep palpation, lack of venous lines from collateral circles
and lack of objective signs of ascitic scum. A diagnostic program starts: the
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
recent bleeding signs and ECT abdomen confirms the splenomegaly liver
cirrhosis with HCC nodules, portal hipertention gallbladder lined with
edematoid walls containig dense bile. 2a hours after hospitalization, the
patient feels abdominal pain with localized pain in the abdominal lower
quadrants predominantly on the right, presenting a situation typical of the
acute abdomen. An abdominal TAC is performed with contrast medium,
the HCC situation was highlighted and the presence of a thrombosis of the
lower quarry vein extended for about 5 cm, whichcauses a caliber reduction
of about 55% of the lumen. On the rigth pelvic seat it shows a stretch of
51
Comunicazioni Orali
ileum with thickened, edematous walls, with appearent stretched meso, with
edemigenal semblance of the surrouding fet tissue. The patient is promptly
taken the operating theatre and undergoes ileale resection (about 40 cm)
caused be segmental ischemia of the helium. The postoperative process is
regular withaut any signs of mismatch and/or liver insufficiency. The antico-
agulant therapy with warfarin, which begins right after the surgery, resulted
in the resolution of the thrombotic condition and has subsequently allowed
the patient to undergo successfully the hepatic transplantation. The throm-
bophilic study showed the heterozygous mutation of factor v of Leiden. Np
other major alteration, except for the reduction of some coagulation factors
compatible with liver failure. The mutation of factor V of Leiden is respon-
sible for the 3-7% of portal thrombosis.
Just like many tumors, even the HCC is associated with the activation of
hemostatic processes and the incidence of portal venous thrombosis is
variable (20-65%). Since portal thrombosis is a severe limitation to liver
transplatation, the anticoagulant therapy may be addressed to patients with
total o partial portal thrombosis who risk an exclusion from the transplant
list. The case described focuses on an uncommon possibility of cirrhosis
with HCC: thrombosis of the lower cava vein. In all those subjets presen-
ting HCC, the hypotesis of a thrombotic extension to the lower caval system
should not be underestimated for the acute complications that may arise (in
our case an acute secondary abdomen with intestinal ischemia), worsening
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-
ches,which cannot be performed atan advanced phase of illness.it is obviou-
sly important to carry out a thorough research of the hereditary or acquired
prothrombotic conditions. A complete thrombophilia screening allows you
to recognize more than one risck factor over 40% of patient.
Main Points:
1) The clinical presentation of this case was insidious (rectal cancer in
patient with portal hypertention and previous incident of bleeding of the
esophageal varices) leads to a hemorragic complication.
2) The dramatic evolution in acute abdomen and the following surgical ope-
ration for intestinal ischemia, caused by thrombosis of the lower vein, has
revelaed a thrombotic complication.
3) The thrombophilic study and the presence of the heterozygous mutation
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
the search for possible additional risk factors.
SERUM-DERIVED EXTRACELLULAR VESICLES (EVS)
IMPACT ON VASCULAR REMODELING AND PREVENT
MUSCLE DAMAGE IN PERIPHERAL ARTERIAL DISEASE
(PAD)
Brizzi M.F. 1, Cavallari C. 1, Ranghino A. 1, Tapparo M. 1,
Cedrino M. 1, Figliolini F. 1, Grange C. 1, Giannachi V. 1, Garneri P. 2,
Deregibus M.C.1, Rispoli P. 2, Camussi G. 1
1
Department of Medical Sciences, 2i3T Scarl, University of Turin, Turin, Italy
2
Department of Surgical Sciences, University of Turin, Turin, Italy
Peripheral arterial disease (PAD) is a rife condition caused by the athe-
rosclerosis of the peripheral arteries. Although surgical or endovascular
intervention are still the standard therapy for improving blood flow, most
patients complain of persistent or recurring symptoms even after successful
revascularization. This implies that new therapeutic options for PAD are
very much still a major unmet need. The formation of newly born capillary
blood vessels, neovascularization, is a crucial event in rescuing tissue after
ischemia. A vast array of pre-clinical and clinical data indicates that stem
cells can contribute to the healing processes by improving vascularization.
However, the transient detection of stem cells at the site of tissue damage has
suggested that paracrine mechanisms may contribute to stem cell action.
“Exosomes”, vesicles derived from the endosomal membrane compartment
by exocytosis, and “ectosomes/microvesicles”, vesicles (EVs) generated by
the budding of cell plasma membranes are included among such paracrine
mechanisms.EVs that have been physiologically released from several cell
types can be detected in biological fluids, including blood.. As a matter of
fact, the past two decades have seen exosome also being detected in body
fluids.The EVs present in blood could therefore be an important resource
for regenerative medicine. More importanly, serum represents an abun-
dant and accessible source of circulating EVs. Therefore, serum-EV (sEV)
pro-angiogenic capability and mechanism of action were herein analyzed.
By using an in vitro assay we were able to predict sEV angiogenic poten-
tial in vivo. Effective sEVs (e-sEVs) also improved vascular remodeling and
52
118° Congresso Nazionale - Società Italiana di Medicina Interna
prevented muscle damage in a mouse model of peripheral artery disease
(PAD). e-sEV angiogenic proteomic and transcriptomic analyses show a
positive correlation with matrix metalloproteinase activation and extra-
cellular matrix organization, cytokine and chemokine signaling pathways,
Insulin-like Growth Factor and platelet pathways, and Vascular Endothelial
Growth Factor signaling. A discrete gene signature, which highlights diffe-
rences in e-sEV and ineffective-EV biological activity, was identified using
gene ontology (GO) functional analysis. An enrichment of genes associated
with the Transforming Growth Factor beta 1 (TGFb1) signaling cascade is
associated with e-sEV administration but not with ineffective-EVs. Chro-
matin immunoprecipitation analysis on the inhibitor of DNA binding
I (ID1) promoter region, and the knock-down of small mother against
decapentaplegic (SMAD)1-5 proteins confirmed GO functional analyses.
Overall, we have shown that EVs displaying pro-angiogenic potential can
be obtained from the serum of healthy donors. We have identified a simple
in vitro test to predict serum-EV angiogenic potential in vivo. The GO-ba-
sed functional analysis of ECs recovered from the capillary-like structures
formed in response to i-sEVs and e-sEVs have identified a gene signature
which sheds light on their varying biological activity. More importantly, our
data provide the scientific rationale for the use of sEVs as an alternative
therapeutic option for vascular remodeling, better local perfusion and pro-
tection against muscle damage in patients with PA.
METABOLIC SYNDROME IS AN INDEPENDENT
PREDICTOR OF ATRIAL FIBRILLATION: DATA FROM
THE “CATANZARO ATRIAL FIBRILLATION PROJECT”
Sciacqua A. 1, Perticone M. 2, Miceli S. 3, Colica C. 6, Pinto A. 1, Cassano V. 4,
Magurno M. 1, Iannello A. 1, Anastasio L. 5, Sesti G. 1, Perticone F. 1
1
Dipartimento di Scienze Mediche e Chirurgiche - Università degli Studi
Magna Graecia - Catanzaro 2Dipartimento di Medicina Sperimentale
e Clinica - Università degli Studi Magna Graecia - Catanzaro 3Azienda
Ospedaliero-Universitaria “Mater Domini” - Catanzaro 4Dipartimento di
Scienze della Salute - Università degli Studi Magna Graecia - Catanzaro
5
Azienda Ospedaliera “G. Jazzolino” - Vibo Valentia 6CNR c/o IBFM-UOS
Catanzaro
Growing evidences demonstrate that atrial fibrillation (AF) can be consi-
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
metabolic and hemodynamic disorders, may play a crucial role in the deve-
lopment of AF, by promoting subclinical organ damage, in particular renal
dysfunction with hydrosaline retention and CV damage with atrial remo-
deling. Although there are some epidemiological studies, sometimes confli-
cting, that report the association between MS and AF, it is not clear whether
MS remains an independent predictor of AF even after correction for pos-
sible confounding factors. Thus, the aim of this study was to evaluate, in a
large and well- characterized cohort, the possible association between MS
and AF appearance, even after correction for known CV risk factors, kidney
function and left atrial dimensions. We conducted a prospective popula-
tion-based study, enrolling 4322 Caucasian outpatients, aged 59.2 ± 11.7
years, with CV risk factors referred to our tertiary care setting for CV and
metabolic screening program. The diagnosis of MS was performed accor-
ding to modified ATP III criteria. Left atrial volume (LAV) was measured
by an echocardiographic examination and indexed (LAVI) for body surface,
according to the American Society of Echocardiography recommendations.
Renal function was evaluated by measurement of estimated glomerular
filtration rate (e-GFR) with CKD-Epi formula. Follow-up evaluation was
performed every 6 months and it was improved by contacting patients by
phone, or by mailing a questionnaire to family physicians. AF diagnosis was
made by standard electrocardiogram, hospital discharge diagnoses, and by
the all-clinical documentation provided by the patients. During a mean fol-
low-up of 42.8 ± 21.5 months, there were 546 new cases of AF, accounting
for an incidence of 4.5 events/100 patients-year, the AF incidence was signi-
ficantly higher in MS patients in comparison with those without (5.6 vs 2.4
events/100 patients-year, p<0.0001). In the multiple Cox regression analysis,
including all traditional CV risk factors, age (HR = 1.649, 95 %CI = 1.520–
1.789), LDL-cholesterol (HR=1.033, CI95%:1.011-1.056), body mass index
(HR= 1.031, CI95%:1.018 -1.045), LAVI (HR=1.424, CI95%:1.353 -1.499)
and MS (HR=1.573, CI95%:1.298-1.906) were retained as independent
predictors of incident AF, on the contrary e-GFR was a protective factor
(HR=0.884, CI95%:0.852 -0.918). Of interest, MS after age, was the second
strongest predictor of AF. The present study confirmed a strong association
between MS and risk of AF and demonstrated that MS remains an indepen-
118° Congresso Nazionale - Società Italiana di Medicina Interna
dent predictor even after the correction for left atrial enlargement and renal
dysfunction. The mechanisms responsible for this association are probably
represented by insulin resistance and hyperactivation of the sympathetic
nervous and renin-angiotensin system that with exaggeration of prolifera-
tive and profibrotic mechanisms, could promote morpho-functional and
electrical atrial remodeling that may justify the increased susceptibility to
AF occurrence in these patients.
A RDW-BASED CLINICAL SCORE (RE-AHF SCORE)
PREDICTS ONE-YEAR MORTALITY IN PATIENTS
HOSPITALIZED WITH ACUTE HEART FAILURE: A
DERIVATION AND VALIDATION STUDY
Melchio R., Giraudo A., Rinaldi G., Testa E., Leccardi S., Falcetta A.,
Serraino C., Bracco C., Pomero F., Silvestri A., Fenoglio L.
S.C. Medicina Interna, A.O. S. Croce e Carle, Cuneo
Background: Acute heart failure (AHF) is a leading cause of hospitalization
and increasing burden on health care systems. Accurate risk stratification
of patients hospitalized with AHF could improve clinical outcomes and
resource allocation. In a previous study we found that Red cell Distribu-
tion Width (RDW), routinely reported in complete blood cell counts, is a
powerful prognostic marker in patients with AHF. Our aim was to create
and validate a clinical score based on RDW to predict one-year mortality in
patients hospitalized for AHF.
Methods: The study consisted of a retrospective derivation cohort and a
retrospective validation cohort. Fourty-four demographic, medical history
and laboratory candidate variables were collected. In the derivation cohort,
multivariate Cox proportional hazard model was used to identify variables
associated with survival and to develop the RE-AHF score. In validation
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-
gency Department (ED) for AHF from 1th January to 31 December 2013 in
S. Croce e Carle Hospital, Cuneo were included and followed up for 1 year.
Patients from the derivation cohort had a mean age of 77,6+11 years; 52,3%
were men; 35,4% had preserved left ventricular ejection fraction. Validation
cohort consisted of 384 patients admitted from 1th January to 31th Decem-
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
fraction. All cause one-year mortality rate in the derivation and validation
cohort were respectively 26,4% and 26,6%. In the derivation cohort, Cox
multivariate analysis identified seven independent predictors for death at 1
year: age, systolic blood pressure, Charlson comorbidity score, impairment
on Activity of Daily Life scale, Red Cell Distribution (RDW)>14.5, incre-
ase RDW during hospitalization, NTproBNP (all p<0,05): this model was
used to develop the RE-AHF score. The predictive accuracy of the RE-AHF
score showed a good discrimination (c index 0,82 (95% CI 0.77-0.86) and
0,78 (95%CI 0.72-0.83) in the derivation and validation cohort respectively,
and calibration. If NTproBNP was removed from the score, overall accuracy
decreased not significantly (c index 0,79 (IC 95%: 0.74-0.84) and 0,75 (IC
95%: 0.69-0.80) in the derivation and validation cohort respectively.
Conclusions: we derived and validated a simple prognostic score that
include RDW and commonly available clinical variables in patients admit-
ted for AHF. Application of this algorithm could help identify patient who
benefit from individualized strategies or interventions.
SEX AND GENDER DIFFERENCES IN ISCHEMIC HEART
DISEASE FROM BENCH TO BEDSIDE: ENDOCRINE
VASCULAR DISEASE APPROACH (EVA) PRELIMINARY
DATA
Raparelli V. 1, Proietti M. 2, Romiti G.F. 2, Toriello F. 2, Ruscio E. 2, Sperduti
N. 2, Santangelo G. 2, Visioli G. 2, Mangieri E. 3,
Tanzilli G. 3, Lenzi A. 1- On behalf of Endocrine Vascular Approach (EVA)
Group
1
Department of Experimental Medicine, Sapienza University of Rome, Rome,
Italy 2Department of Internal Medicine and Medical Specialty, Sapienza
University of Rome, Rome, Italy 3Department of Cardiovascular, Respiratory,
Nephrologic, Anaesthesiologic and Geriatric Sciences, Sapienza University of
Rome, Rome, Italy
Introduction: Improvements in ischemic heart disease (IHD) management
have been unbalanced between sexes. Coronary microvascular dysfunction
Comunicazioni Orali
(CMD) is a putative reason for worse outcomes in women. Hypothesis: To
explore sex and gender-sensitive determinants of CMD in IHD patients.
Methods: The Endocrine Vascular disease Approach (EVA) is an
ongoing monocentric observational study (ClinicalTrials.gov Identifier:
NCT02737982), aimed to assess sex- and gender-specific interactions
between coronary circulation, hormonal status and platelet function. Con-
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-
macological and sociocultural parameters were recorded.
Results: One hundred and sixty-three patients (mean age 67±11 years;
39% women) were analyzed. The referral reason for angiography was acute
coronary syndrome in half cases, regardless sex. A previous IHD diagno-
sis was reported more frequently in men, women were less smokers, more
frequently retired and widow, less adherent to medication therapy (all,
p<0.05). The Duke Activity Status Index identified a worse performance
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,
p=0.032). CMD (defined by MBG<2) was significantly more frequently
detected in women compared to men (48% vs 31%, p=0.034). Ischemia
with no obstructive coronary disease was prevalent in women (40% vs 25%,
p= 0.017). In the subgroup of patients undergoing PCI (n=68, 41.7%) the
no-achievement of optimal microvascular reperfusion (MBG=3), despite
optimal restoration of epicardial flow, was higher in women compared to
men (86% vs 56%, p=0.015). In the multiple regression analysis, only female
sex was independently associated to CMD (OR 2.02, 95% CI 1.05-3.88,
p=0.034) and to a MBG<3 after PCI (OR 4.88, 95% CI 1.26-18.7, p=0.022).
Conclusions: Female sex is significantly associated with both CMD and
worst myocardial perfusion after PCI. The further exploration of hormonal
balance and platelet reactivity, as well as availability of outcomes data in
the EVA cohort, will provide deepen insights to analyze this phenomenon.
HLA AND KILLER CELL IMMUNOGLOBULIN-LIKE
RECEPTOR (KIRS) GENOTYPING IN PATIENTS
WITH ACUTE ISCHEMIC STROKE AS POSSIBLE
PATHOGENETIC BASIS OF STROKE SUSCEPTIBILITY
AND OF ACUTE PHASE IMMUNOINFLAMMATORY
ACTIVATION
Tuttolomondo A. 1, Pecoraro R. . 1,6, Casuccio A. 3,
Di Raimondo D. 1, Di Bona D. 5, Aiello A. 3, Accardi G. 3,
Arnao V. 4, Clemente G. 5, Della Corte V. 1, Maida C. 1,
Simonetta I. 1, Caruso C. 3, Squatrito R. 6, Pinto A. 1
1
U.O.C di Medicina Interna e Cardioangiologia, Dipartimento Biomedico
di Medicina Interna e Specialistica (Di.Bi.M.I.S), Università degli Studi
di Palermo. 2 Dipartimento di Scienze per la Promozione della Salute e
Materno Infantile “G. D’Alessandro”, Universita’ degli Studi di Palermo
(Italy). 3 Dipartimento di Biopatologia e Biotecnologie Mediche, Universita’
degli Studi di Palermo (Italy). 4 Dipartimento di BioMedicina Sperimentale e
Neuroscienze Cliniche, Università degli Studi di Palermo (Italy) 5 School and
Chair of Allergology, Dipartimento delle Emergenze e Trapianti d’Organo,
University of Bari, Bari Italy 6 Pronto Soccorso Unit, Giuseppe Giglio
Hospital, Cefalù (Italy)
Background: In humans, a major component of NK and T cell target reco-
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
surface of NK cells and T-cell subsets. Inflammation and T cell activation
have been also described as involved in pathophysiology of complications
of atherosclerosis such as acute ischemic stroke, nevertheless no study has
yet evaluated the relationship between KIR haplotypes and HLA alleles and
acute cerebrovascular disease. Aims: to implement the knowledge about the
immunological and genetic background of acute ischemic stroke suscepti-
bility in relation to the expression of the KIR and HLA alleles and to further
characterize immune-inflammatory degree of the acute phase of ischemic
stroke by means evaluation of peripheral frequency of CD28 null cells in
a sample of patients with acute stroke in comparison to subjects without
ischemic stroke and contribute to the definition of a possible risk profile of
stroke susceptibility.
Methods: Between November 2013 and July 2016, all consecutive patients
with acute ischemic stroke were recruited from Internal Medicine with
Stroke Care ward of Policlinico “P. Giaccone”, University of Palermo and
Pronto Soccorso Unit of Giuseppe Giglia Hospital, Cefalù (Palermo). As
controls we enrolled consecutive healthy subjects without acute ischemic
53
Comunicazioni Orali
stroke and without exclusion criteria (see above). Peripheral blood mono-
nuclear cells (PBMCs) have been obtained by density gradient centrifu-
gation using the Lymphocyte Separation Medium (ICN Pharmaceutical,
Costa Mesa, CA). The population of CD4+CD28null was expressed as a
percentage of CD4+ cells (CD4+CD28null and CD4+CD28+). Periphe-
ral whole blood samples was collected and genomic DNA was extracted
from leukocytes by a commercial kit. Using the polymerase chain reaction
sequence-specific primer (PCR-SSP) technique, the DNA subjects with
acute ischemic stroke and subjects without stroke were genotyped for the
presence of the 3 major KIR ligand groups, HLA-C1, HLA-C2, and HLA-
Bw4, both HLA-B and HLA-A loci.
Results: 116 patients with acute ischemic stroke were analyzed and 66
subjects without acute ischemic stroke. Subjects with acute ischemic stroke
in comparison to subjects without acute ischemic stroke showed a signifi-
cantly higher frequency of 2DL3, 2DL5B, 2DS2 and 2DS4 KIR haplotypes
and a significantly lower frequency of HLA-B-Bw4I allele. With regard of
interaction of HLA and KIR haplotypes, subjects with acute ischemic stroke
showed no significant difference with regard of frequency of co-expression
of any considered HLA and KIR haplotype, whereas subjects without acute
ischemic stroke showed a higher frequency of 2DS2 -HLAC2 co-expression.
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
2DL2-HLA-C1_A HLA-KIR interactions. We also observed an higher fre-
quency of 2DL3 and 2 DL4 KIR haplotype in subjects with LAAS subtype.
Conclusions: Our findings of a prevailing KIR phenotype of patients with
acute ischemic stroke as predominantly excitatory are consistent with fin-
dings previously reported in patients with acute coronary syndrome and
unstable atherosclerotic plaques.The higher frequency of a “proinflamma-
tory”genotype in subjects with ischemic stroke could explain the reported
immunoinflammatory activation of the acute phase of ischemic stroke
whereas the prevalent inhibitory profile observed in subjects with athero-
sclerotic (LAAS) subtype of ischemic stroke could also represent one pos-
sible explanation of a pathogenetic background as well of plaque event of
cerebral thromboembolism on the basis of recent reports indicating that
interaction of the inhibitory KIR with the HLA ligand functions not only to
inhibit NK cell activation, but also serves to prime the particular NK cell for
activation in the absence of self. This activation after initial inhibition has
been reported as “ licensing”. Future studies will be addressed to evaluate the
role of KIRs haplotypes and HLA alleles in relation of stroke outcome and of
cerebral event recurrences.
ROLE OF INTERLEUKIN 17 IN PRECLINICAL VASCULAR
DAMAGE IN METABOLIC SYNDROME
Veca V. 1, Bellofatto I. 1, Lupattelli G. 1, Siepi D. 1, Cosentino T. 1, Vacca C. 2,
Vaudo G. 1
1
Internal Medicine, Department of Medicine, University of Perugia, Italy; 2
Pharmacology Section, Department of Experimental Medicine, University of
Perugia, Italy
Objective: Clinical complications of atherosclerotic pathology such as
myocardial infarction, stroke and peripheral arterial disease represent the
primary cause of mortality and morbidity worldwide [1]. Along with tra-
ditional modifiable risk factors such as dyslipidaemia, smoking, hyperten-
sion, diabetes mellitus, obesity and alcohol, and unmistakable ones such as
familiarity, age, gender, an increasing interest has recently been placed on
so-called “emerging risk factors”. In this latter group belong metabolic syn-
drome, homocysteine, alpha lipoprotein, chronic infections and markers of
inflammation and bioumoral [2]. Interleukin 17 (IL-17), the characteristic
cytokine of the subset of T helper 17 cells [3], plays a pivotal role in pro-
tecting the host against extracellular pathogens, but acts at the same time
promoting inflammation in autoimmune diseases [4]. IL-17 is involved in
many inflammatory processes, but its role in atherosclerosis remains con-
troversial [5-7].
Methods and Results: Goal of the study was to identify the role of IL-17 in
preclinical vascular damage in metabolic syndrome. We compared 80 meta-
bolic patients (NCEP-ATP III criteria) with a sex and age-matched non-high
risk control group, evaluating in both groups functional and morphologic
vascular damage (arterial stiffness; carotid intima-media thickness; bra-
chial FVM and carotid plaque echogenicity), common cardiovascular risk
factors (dyslipidaemia, smoking, hypertension, diabetes mellitus, hypergli-
cemia, obesity), serum markers of inflammation (ESR and CRP) and levels
of IL-17. Blood level of IL-17 was determined with ELISA (enzyme-linked
immunosorbent assay). Exclusion criteria for the enrollment were age major
54
118° Congresso Nazionale - Società Italiana di Medicina Interna
of 85, neoplasia, chronic inflammatory disease, chronic infection, and all
conditions that could activate TH17-inflammatory pathways. As result we
found that there was a statistically significant difference in IL-17 plasma
levels between the groups, much higher in metabolic syndrome patients
(15.73 ± 11.84 pg/ml vs 6.54 ± 4.38 pg/ml; P= <0.01). Furthermore IL-17
levels were strictly related to the vascular damage in terms of carotid IMT
(R=0,200; P=0.03).
Conclusions:: IL-17 contributes to preclinical vascular damage, in terms
of carotid IMT, in metabolic syndrome but not to functional one. IL-17
appears to be an independent risk factor to the progression of atherosclero-
sis in metabolic syndrome.
Bibliography: [1] A.D. Lopez, C.D. Mathers, M. Ezzati, D.T. Jamison, C.J.
Murray, Global and regional burden of disease and risk factors, 2001: syste-
matic analysis of population health data, Lancet 367 (2006) 1747-1757 [2]
Salvatore Novo, Gisella Rita Amoroso e Giuseppina Novo, Aterosclerosi
preclinica e rischio cardiovascolare globale, EDIMES, Pavia 2008 [3] Gaffen
SL. Structure and signalling in the IL-17 receptor family, Nat Rev Immunol.
2009; 9:556-567 [4] Soraya Taleb, Alain Tedgui, Ziad Mallat, IL-17 and Th
17 in Atherosclerosis: Subtle and Contextual Roles, Arterioscler Thromb
Vasc Biol. 2015; 35:258-264
GASTROINTESTINAL COMPLICATIONS IN COMMON
VARIABLE IMMUNODEFICIENCY DISEASES (CVID)
Carrabba M. 1, Dellepiane R.M. 2, Lovaste S. 2, Dell’Era L. 2, Baselli L. 3,
Pietrogrande M.C. 3, Fabio G. 4
Internal Medicine Department, Fondazione IRCCS Ca’ Granda Ospedale
Maggiore Policlinico di Milano, 2Department of Pediatrics, Fondazione
IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, 3Department of
Pediatrics, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di
Milano & Università degli Studi di Milano, 4Internal Medicine Department,
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano &
Università degli Studi di Milano
Background: Common Variable Immunodeficiency Disorders (CVID) are
a group of primary immunodeficiencies characterized by lack in humoral
response and increased risk of infection. Its prevalence is estimated at 1 in
25,000 to 50,000. CVID is diagnosed if levels of at least 2 immunoglobulin
isotypes (IgG and IgA, IgM, or both) are below the normal range, together
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-
tive complications are also present in CVID. Gastrointestinal involvement
(GI) in CVID is reported in 9-20% of patients. Acute or chronic infectious
diarrhea is the most frequent manifestation. Non-infectious enteropathy
resembling Crohn’s disease, ulcerative colitis, or celiac disease occurs in 10
to 12% of CVID patients. Between 8 and 22% of CVID subjects develop
granulomatous disease in the liver or the GI tract. We describe clinical pre-
sentation of GI involvement and features of a monocentric cohort of CVID
patients.
Methods: Medical records of patients with CVID, both children and adults,
referred at Fondazione IRCCS Ca’ Granda Ospedale Policlinico in Milan
have been analyzed.
Results: CVID patients enrolled were 34, 4 children and 30 adults. Median
age is 33.5 years, ranged 11-70. The prospective follow-up mean time is 9
years (range 2-37). All patients are under immunoglobulins replacement
therapy. Gastrointestinal symptoms were present in 13 adult patients
(38.2%): 3 epigastric pain/dyspepsia, 7 chronic or relapsing diarrhea and
3 both symptoms. None of the children with CVID complained about
gastrointestinal symptoms. Five patients had stool cultures positive for
Salmonella, Campylobacter, Clostridium, Norovirus, and Rotavirus. Four
patients were diagnosed with gastritis (one H. pylori positive), 4 with celiac
disease, 5 with lymphocytic colitis and 1 with ulcerative colitis. Granulo-
matous liver disease was found in 3 patients with biopsy confirmation of
non-caseating granulomas. Two patients were found to have chronic viral
infection: Cytomegalovirus and Epstein-Barr virus. The specific treatment
to the isolated pathogen solved diarrhea only transiently. Two patients need
chronic budesonide treatment. Gluten-free diet ameliorates symptoms in
celiac disease, but diarrhea often relapses. Two patients temporary solved
symptoms with local mesalazine. All adults CVID patients are under
chronic probiotics therapy.
Conclusions: Internist and Gastroenterologist should be aware that cli-
nically and endoscopically CVID may mimic other conditions e.g. celiac
disease and IBD. However, histopathologic biopsies with few or absent
plasma cells and low intestinal IgA and IgM are features of a CVID ente-
118° Congresso Nazionale - Società Italiana di Medicina Interna
ropathy. However, despite CVID is diagnosed and replacement therapy
addressed, diagnosis of gastrointestinal involvement in CVID is challen-
ging because patients can be paucisymptomatic and pathologists need spe-
cific experience to recognize CVID histologic features. Furthermore, low
mucosal IgA levels may lead to luminal bacterial overgrowth. According to
numerous reports about the impact of alterations of the microbiota for the
pathogenesis of IBD, intestinal inflammation in CVID may also be triggered
by infectious agents. Whether or not this hypothesis can be further suppor-
ted remains to be determined.
Hence, management of chronic diarrhea is difficult, because these patients
often fail to respond to conventional therapies. The preventive use of pro-
biotics is still controversial.
A CASE OF HYPOCOMPLEMENTEMIC URTICARIAL
VASCULITIS SYNDROME (HUVS) SUCCESSFULLY
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
1
Unità di Allergologia, Università Cattolica del Sacro Cuore - Policlinico
“A. Gemelli”, Roma; 2 Unità di Immunoreumatologia, Università Campus
Bio-medico di Roma; 3 Unità di Geriatria, Università Campus Bio-medico di
Roma
We present a 47-year-old woman without relevant comorbidities who refer-
red to our University Allergy Center with a 3-year history of generalized,
itchy and burning daily flares of urticaria. She also complained arthralgia,
abdominal pain and diarrhea. On admission, physical examination revealed
diffuse vasculitic itching lesions and symmetric arthritis of second and third
proximal phalangeal and metacarpal joints. Blood tests were normal with
the exception of a strong complement depletion (C3 0.17 g/L, normal range
0.9-1.8, C4 0.24 g/L, normal range 0.1-0.4). She had no infections, no appa-
rent major organ involvement, no antibody positivity, normal IgE serum
levels, normal thyroid parameters and negative physical testing. Antihista-
mines and prednisone 8 mg/die were administered with no relief of symp-
toms and no improvement of urticaria. Colonscopy was also negative. A
skin biopsy was performed and showed perivascular and dermic eosinophi-
lic infiltrates with focal vessel damage confirming urticarial vasculitis. The
patient fulfilled diagnostic criteria for HUVS1 so antihistamines (up to four
times per day) in combination with hydroxychloroquine (200 mg/day), pre-
dnisone (0.5 mg/kg being tapered to 0.1 mg/kg) and cyclosporine A (CSA
3 mg/kg) (soon suspended for worsening of diarrhea) were administered.
A significant improvement of arthralgia was achieved with no response on
gastrointestinal involvement and urticaria (Urticarial Activity Score (UAS)
of 32 points). Omalizumab 300 mg monthly was added and after the second
injection complete remission of gastrointestinal symptoms and urticarial
(UAS of 0) was achieved and then maintained for the entire duration of
the treatment (25 weeks). Complement serum levels normalized allowing
a gradual prednisone discontinuation. One month after Omalizumab with-
drawal the patient presented a stronger exacerbation of diarrhea, abdominal
pain and urticaria (UAS of 37 points). Omalizumab 300 mg monthly was
so readministered leading to a complete remission of urticaria (UAS of 0)
and gastrointestinal symptoms. Management of HUV is very challenging:
while oral antihistamines are just palliative, hydroxychloroquine (HCQ),
colchicine and corticosteroids represent first-line therapy, with a complete
cutaneous response achieved in less than 50% patients. Other immunosup-
pressive drugs, especially Cyclosporine (CyA), cyclophosphamide (CYC)
and rituximab (RTX), have higher rates of efficacy, although they are burde-
ned, as well as steroids, by higher incidence of side effects2. Omalizumab, a
humanized anti-IgE monoclonal antibody recently approved for treatment
of chronic spontaneous urticaria (CSU)3, has been recently shown to be not
effective in a case of HUVS4. This is, to our knowledge, the first report of
successful treatment of HUVS with Omalizumab.
References: 1. Schwartz HR, McDuffie FC, Black LF, Schroeter AL, Conn
DL. Hypocomplementemic urticarial vasculitis: association with chronic
obstructive pulmonary disease. Mayo Clin Proc 1982;57:231–8. 2. Sussman
G, Hébert J, Barron C, Bian J, Caron-Guay RM, Laflamme S et al. Real-life
experiences with omalizumab for the treatment of chronic urticaria. Ann
Allergy Asthma Immunol. 2014 Feb;112(2):170-4. 3. Jachiet M, Flageul B,
Deroux A, Le Quellec A, Maurier F, Cordoliani F et al. The clinical spectrum
and therapeutic management of hypocomplementemic urticarial vasculitis:
data from a French nationwide study of fifty-seven patients. Arthritis Rheu-
matol. 2015 Feb;67(2):527-34. 4. Aurich S, Simon JC, Treudler R. Omalizu-
mab does not improve skin lesions in a patient with hypocomplementemic
urticarial vasculitis syndrome. J Eur Acad Dermatol Venereol. 2017 Mar 8.
Comunicazioni Orali
Table 1: Diagnostic criteria of hypocomplementemic urticarial vasculitis
syndrome (HUVS)
Table 1: Diagnostic criteria of hypocomplementemic urticarial vasculitis
syndrome (HUVS)
Major Criteria Minor Criteri
Recurrent urticaria  Minor Criteri
Hypocomplementemia Biopsy-proven vasculitis of dermis
Positive C1q antibodies and/or suppressed
C1q levels
Glomerulonephritis
Arthralgia/Arthritis 
Ocular Inflammation
Recurrent abdominal pain 
AN INTERESTING CASE OF ABDOMINAL PAIN
Di Stefano V. 1, Maira D. 1, Hu C. 2, Della Corte G. 2, Minonzio F. 2,
Cappellini M.D. 2
2
Dipartimento di Medicina Interna (U.O. Medicina Interna 1A) -
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico 1Scuola di
specializzazione in Medicina Interna - Università degli Studi di Milano
Introduction:. We describe a case of a woman with abdominal pain and
fever who was admitted to our Internal Medicine ward on april 2017.
Case Report: A 63 years woman presented to our Emergency Department
for intense abdominal pain associated with low grade fever. A high respira-
tory tract inflammation requiring treatment with Levofloxacin was repor-
ted in her recent medical history. Immediately after, she started to trouble
with abdominal pain without vomit or any bowel change. Because of cli-
nical suspicion of diverticulitis, she was treated with Rifaximin. Since the
worsening of symptoms and persistence of fever, she came to the hospital.
Her past medical history was significant for follicular lymphoma in remis-
sion and maintenance with Rituximab, hypertension, asymptomatic pul-
monary embolism for which she was taking Rivaroxaban.On admission to
our Internal Medicine ward the patient was alert and cooperative, her vital
signs were within normal limits, except for body temperature that was 38.4
°C. The physical examination revealed reduced breath sounds on lung bases
bilaterally. No alterations of peripheric pulses were found. Examination
of heart, skin, joints, and neurologic system was normal. During the first
days of hospitalization the patient complained of abdominal pain at night.
Fever did not recede despite empirical treatment with a broad-spectrum
antibiotic (Piperacillin/Tazobactam and Amikacin). Furthermore it was
necessary to administered low oxygen flows for desaturation. The findings
of laboratory blood analysis highlight normocitic anemia, rising of white
cells with monocytosis, PCR, procalcitonin and VES. Liver, renal function
tests, serum electrophoresis, beta2 microglobulin, complement (C3,C4) and
immunoglobulin were within normal range. CMV-DNA, EBV-DNA, HBV,
HCV, HSV1, HSV2, Syphilis, Parvovirus serology tests and quantiferon
were negative, as well as ANA, ENA and ANCA antibodies. Galactomannan
antigen was negative too. No evidence of bacterial infection was detected on
blood culture. A contrast-enhanced total body computed tomography (CT)
examination subsequently performed showed abnormal thickening (enhan-
ced postcontrast and not calcified) of the descending thoracic aorta wall
extending beyond the diaphragmatic hiatus surrounding the origin of the
celiac artery. The wall of the aortic arch was also involved but neck vessels
and all major abdominal aorta branches (except for celiac artery), including
mesentery trunks, looked spared. Aortic diameters were normal. Pleural
effusions were also observed. There was no evidence of diverticulitis or any
abdominal disease. A total body PET CT scan confirmed the diagnosis of
aortitis demonstrating FDG accumulation of thoracic and proximal abdo-
minal aorta and no uptake in any other vessels, temporal arteries included.
The patient was later studied with transesophageal echography and echo
color doppler of the supraaortic vessels and temporal arteries. Both endo-
cardial vegetations and involvement of any other vessels were excluded.
Whereas we believed that priority was to avoid the risk of aortitis compli-
cations, we speed up in starting immunosuppressive treatment so that no
histopathologic diagnosis was attempted. The patient was treated with corti-
costeroids with an amazing response: in twenty-four hours abdominal pain
and fever receded.
Conclusion: Aortitis is a general term denoting inflammation of the aortic
55
Comunicazioni Orali
wall that can occur in infectious and non-infectious conditions. Infectious
aortitis is a rare but potentially life-threatening disorder: when aortitis is
found, both laboratory test and echocardiography examination are rou-
tinely performed to exclude all major categories of infection. The most
common causes of aortitis are non-infectious and include two large vessel
vasculitis (Temporal Arteritis, also called Giant Cell Arteritis, and Takayasu
Arteritis) as well as other collagen vascular disorders such as rheumatoid
arthritis and ankylosing spondylitis. Moreover, idiopatic aortitis is a rare
entity that refers to aortitis without evident relationship to any disease. In
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?).
- Imaging showed vasculitis in early active phase, without evidence of
occlusion or other complications of aortitis. This feature was consistent with
the clinical presentation. Infact, no ischemic symptoms were present. Fur-
thermore, that is probably the reason of the rapid recovery after starting
glucocorticoid therapy. - Location of the disease and the age of the patient
may indicate a Giant Cell Arteritis, though unusual considering the absence
of other vessels involvement. Idiopathic Aortitis, while more rare, can be
another possibility. - CT imaging was essential for the diagnosis of aortitis.
We want to stress on the clinical value of performing a rapid imaging. In
fact, in the early phase of the disease treatment is generally successful and
vascular complications can be avoided.
ACTIVATION OF FIBRINOLYSIS IN IDIOPATHIC
NONHISTAMINERGIC ANGIOEDEMA: THE RATIONALE
FOR TRANEXAMIC ACID USE IN THE DISEASE
PROPHYLAXIS
Tedeschi A. 1, Trotta L. 1, Griffini S. 2, Grovetti E. 2, Lorini M. 3, Cugno M. 2
1
Medicina Interna, ASST Fatebenefratelli-Sacco, Ospedale Fatebenefratelli
e Oftalmico, Milano; 2Medicina Interna, Ospedale Maggiore Policlinico,
Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti,
Università degli Studi di Milano, Milano; 3Dipartimento di Scienze Cliniche e
di Comunità, Università degli Studi di Milano, Milano
Background: Idiopathic non-histaminergic angioedema (InHAng) is cha-
racterized by recurrent swelling of the subcutaneous and submucosal tissues
that usually occurs without weals and does not respond to H1-antihistami-
nes or corticosteroids. The pathogenesis of the disease is not well known but
there is some evidence that the bradykinin system is involved. Prolonged
treatment with tranexamic acid has been found able to prevent recurring
InHAng attacks. Some of us have previously shown that coagulation and
fibrinolysis are activated both in patients with angioedema due the heredi-
tary or acquired C1 inhibitor deficiency and in patients with chronic sponta-
neous urticaria (CSU), a disease which can be associated with angioedema.
The latter often has an autoimmune origin and in most cases responds to
H1-antihistamine treatment. In addition to the pathomechanism linked to
histamine-releasing autoantibodies, a role of coagulation and fibrinolysis in
the pathophysiology of this disorder has been hypothesized, and a good cor-
relation between the degree of activation and the severity of the disease has
been demonstrated. The observation that thrombotic risk is not increased
in patients with angioedema or CSU indicates that the activation of coagu-
lation is efficiently counterbalanced in these patients.
Methods: Aim of the present study was to investigate the activation of coa-
gulation and fibrinolysis in a group of 19 patients with InHAng, 27 patients
affected by CSU associated with angioedema (CSUAng), 38 patients with
CSU without angioedema (CSU) and 30 healthy subjects. Blood samples
were collected in a phase of disease activity in all cases. The patients with
InHAng were divided in two subgroups according to the time interval
elapsed from the last angioedema attack (less or more than one week). Using
immunoenzymatic techniques, we measured plasma levels of prothrom-
bin fragment F1+2 and D-dimer, coagulation and fibrinolysis markers,
respectively.
Results: Concentrations of F1+2 and D-dimer were more elevated in
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
191.0±8.2 ng/ml), with a significant difference for D-dimer (p<0.001).
Among InHAng patients, D-dimer, but not F1+2 concentrations were
significantly higher in the blood samples taken less than one week after
the last angioedema attack (n= 7) than in the blood samples collected
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
pmol/l vs. 407.6±183.2 pmol/l). Significantly increased levels of F1+2
and D-dimer were found in CSUAng patients (F1+2 772.2±135.5 pmol/l
56
118° Congresso Nazionale - Società Italiana di Medicina Interna
and D-dimer 1431.8±323.8 ng/ml) and in patients with CSU (F1+2
464.0±105.4 pmol/l and D-dimer 545.1±139.9 ng/ml) in comparison with
healthy subjects, confirming our previous findings.
Conclusions: These results show that coagulation cascade and fibrinolysis
are activated in InHAng and in CSU patients, in spite of different patho-
mechanisms and the predominant involvement of different mediators (bra-
dykinin and histamine, respectively). The observation of fibrinolysis activa-
tion in InHAng may support the rationale for using antifibrinolytic drugs
like tranexamic acid in InHAng prophylaxis.
QTC INTERVAL PROLONGATION IN SYSTEMIC
SCLEROSIS: EVALUATION AND CORRELATION WITH
CARDIOPULMONARY EXERCISE TEST
Gigante A. 1, Rosato E. 1, Liberatori M. 1, Sardo L. 1, Di Paolo M. 2,
Marinelli P. 2, Gasperini M.L. 1, Palange P. 2, Amoroso A. 1, Muscaritoli M. 1,
Tubani L. 1
1
Department of Clinical Medicine, Scleroderma Unit, Sapienza University of
Rome,Italy 2 Department of Public Health and Infectious Diseases, Sapienza
University of Rome, Italy
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
asymptomatic SSc patients. Also, reduced exercise tolerance was found in
SSc patients without cardiac and pulmonary involvement.The aim of the
study was to assess QTc prolongation in SSc and evaluate correlations with
cardiopulmonary exercise test (CPET) in patients without pulmonary and
cardiac manifestations.
Methods: Thirty-two patients fulfilling the American Rheumatism Associa-
tion (ARA) criteria for classification and diagnosis of SSc and twenty-three
healthy subjects were examined. For the QTc interval evaluation, 24-hour
Holter ECG recording was performed and was defined as prolonged when
>440 ms. A maximal symptom-limited CPET was performed on an electro-
nically braked cycloergometer. All subjects performed a maximal CPET as
documented by a respiratory exchange ratio (RER) higher than 1.05. Finally
nailfold videocapillaroscopy (NVC) was performed by an optical probe,
equipped with magnification 200Å~ contact lens and connected to image
analysis software. All data were expressed as median and range. The Mann–
Whitney U-test or the Kruskal–Wallis was used to test differences between
two individual study groups. Spearman’s rank order correlation coefficient
(r) was used to test for an association between numerical variables. P-values
b0.05 were considered significant.
Results: The median value of QTc is significantly (p < 0.001) increased in
SSc patients than healthy controls [457 s (397–566) vs 432 s (354–566)]. The
median value of QTc is significantly (p< 0.01) different in three capillarosco-
pic groups: early 423 (397–456), active 436 (418–465), late 469 (443–566).
A reduced exercise tolerance, defined as a V’O2 peak lower than 80% of
maximum predicted, was found in 23 out of 32 subjects (72%). A signifi-
cant negative correlation was found between QTc and all markers of exer-
cise tolerance: V’O2 peak (r= −0.41, p< 0.05,), V’O2 peak/Kg (r = −0.42, p<
0.05,), Watt max (r= −0.37, p 0.05,) and exercise time duration (r= −0.36,
p< 0.05,).
Conclusions: In the present study, QTc interval is prolonged in SSc
patients and correlates with NCV pattern. Moreover QTc prolongation
correlates with reduced exercise tolerance in the absence of cardiac and
pulmonary involvement. In SSc, myocardial fibrosis could be the major
responsible for QTc interval prolongation. Early pulmonary vasculopathy
can be evaluated with CPET, demonstrating pulmonary ventilation/per-
fusion mismatch during the effort. In SSc patients without cardiac and
pulmonary involvement, CPET and QTc interval evaluation may be used
tools for early non invasive assessment of SSc-related cardiac involvement.
ORAL DISEASE IN PATIENTS WITH CVID
Gelardi C. 1, Sparabombe S. 2, Pedini V. 1, Menghini D. 1,
Putignano A. 2, Gabrielli A. 1, Danieli M.G. 1
1
Clinica Medica, Università Politecnica delle Marche e Ospedali Riuniti,
Ancona 2 Clinica di Odontostomatologia, Università Politecnica delle Marche
e Ospedali Riuniti, Ancona
Introduction: Common variable immunodeficiency (CVID) is the most
frequent primary symptomatic immunodeficiency of the adulthood and is
characterized by reduced serum immunoglobulin levels and heterogeneous
118° Congresso Nazionale - Società Italiana di Medicina Interna
clinical phenotypes. These patients are susceptible to parodontal disease.
Aim of the study To perform a parodontal evaluation and a more precise
characterization of incidence, diagnosis and treatment of oral diseases in
patients with CVID.
Matherials and Methods: In this prospective trial we enrolled 60 patients
(30 CVID patients, 30 healthy people into the Control Group). Compilation
of medical records was done with patients’ history and data about physical
examination of the oral cavity. In the records we also reported indexes of
periodontal disease (DMFT: Decayed, Missing, Filled Teeth, PCR: plaque
control record, BOP: bleeding on probing), basing on their easy detection,
objectivity and their possible expression in alphanumeric values for stati-
stical surveys. Measure of stimulated and not stimulated salivary flow was
also reported.
Results: Recurrent aphthous stomatitis was the most frequent oral disease
(63% of CVID patients vs 3.3% of healthy people), characterized by burning
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
people) with swollen and reddened vesicles cluster on lips, caused by herpes
simplex virus type 1 (HSV-1). Angular cheilitis, an inflammatory disease
that affects corners of the mouth, often bilaterally, affected 26% of CVID
patients vs 10% healthy people. Oral candidosis (20% of CVID patients) was
the most common fungal infection of the mouth in CVID patients. Perio-
dontitis, a rare disease that affects the periodontium, the tooth-supporting
tissues, affected only 5-10% of CVID patients.
Conclusions: Patients with CVID, compared to healthy people, show a
higher rate of parodontal manifestations, such as recurrent aphthous sto-
matitis, herpes labialis, oropharyngeal candidiasis, gingivitis and early onset
aggressive periodontitis. Treatment should be initiated once the diagnosis
is done because oral disease can negatively affect patient’s quality of life.
Dental preventive treatments are therefore strictly necessary through inclu-
sion of these patients in a follow-up program, according to patient’s motiva-
tion, self-assessment and self-monitoring skills.
EXOSOMES-MEDIATE CROSSTALK IN MULTIPLE
MYELOMA PROGRESSION AND DRUG RESISTANCE
Di Marzo L. 1, Desantis V.1, Saltarella I.1, Lamanuzzi A.1, Arciuli M.1,
Annese T.1, Visino F.1, Nico B.2, Vacca A.1, Frassanito M.A.1
1
Department of Biomedical Sciences and Human Oncology (DIMO), Internal
Medicine Section, University of Bari Medical School, Bari, Italy 2Department
of Basic Medical Sciences, Neurosciences and Sense Organs, University of
Bari Medical School, Bari, Italy
Purpose: Exosomes (EXOs) mediate local and systemic cell-to-cell com-
munication and regulate cell behavior by transferring mRNA, miRNAs and
proteins to recipient cells. Recently, we demonstrated that bone marrow
(BM) cancer associated fibroblasts (CAFs) promote tumor progression and
drug resistance (DR) in multiple myeloma (MM) (1-3). In this study, we
analysed the effect of MM-derived EXOs on CAFs in MGUS to MM tran-
sition and, in turn, the effect of CAFs-derived EXOs on endothelial (ECs)
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
of cultured RPMI8226 and U266 MM cells. Electron microscopy (TEM),
dual immunofluorescence-confocal laser-scanning microscopy, western
blot (WB), flow cytometry (FC) and qRT-PCR studies were performed to
evaluate the CAFs- and MM-derived EXOs phenotypes, their miRs content
and their mutual effect.
Results: TEM analysis of CAFs- and MM-derived EXOs showed a vesi-
cles population with heterogeneous aspect, 50-100 nm sized. WB analysis
defined the expression of commonly used EXOs surface markers as CD63,
Hsp70 for CAFs and CD63, Hsp70, Alix for MM cells. Confocal micro-
scopy showed the ability both CAFs and MM cells to uptake respectively
MM- and CAFs-derived EXOs labelled with fluorescent dyes. Functional
studies showed that MM-derived EXOs induce a specific miRNA profile as
overexpression of miR-27b-3p, -125b-5p, -214-3p and activated phenotype,
as expression of FAP+ and α SMA+ antigens, in MGUS and MM CAFs. In
turn, MM CAFs released EXOs containing miR-27b-3p, -125b-5p, -214-3p
are swallowed by MM cells and ECs. Functional studies also showed that
CAFs-derived EXOs are able to stimulate angiogenic ability in ECs and to
induce bortezomib-resistance in MM cells. Discussions and
Conclusions: Overall results suggest an important exosomal crosstalk
among tumor cells, CAFs and ECs which lead to BM microenvironmental
modifications, favouring MM progression and DR.
(1) MA Frassanito et al. Leukemia. 2014; 28 (4):904-16 (2) MA Frassanito
Comunicazioni Orali
et al. Leukemia. 2016; 30:640-8 (3) Di Marzo L et al. Oncotarget. 2016
13;7(37):60698-60711
MIRNAS PROFILE OF BONE MARROW FIBROBLASTS IN
MULTIPLE MYELOMA: RELATIONSHIP WITH DISEASE
PROGRESSION AND DRUG-RESISTANCE
Desantis V.1, Di Marzo L.1, Craparotta I.2, Beltrame L.2,
Marchini S.2, Arciuli M.1, Visino F.1, D’Incalci M.2,
Frassanito M.A.1, Vacca A.1
1
Department of Biomedical Sciences and Human Oncology (DIMO),
Section of Internal Medicine and Clinical Oncology, Policlinico-Bari, Italy.
2
Department of Oncology, Pharmacological Research Institute Mario Negri,
Milan, Italy
Purpose: microRNAs (miRs) regulate gene expression at post-transcrip-
tional level modulating several biological processes. Bone marrow (BM)
fibroblasts (or cancer associated fibroblasts, CAFs) from active multiple
myeloma (MM) patients present an activated phenotype (FSP1+/FAP+/
αSMA+), with higher proliferative rate compared to monoclonal gam-
mopathy of undetermined significance (MGUS) CAFs1. BM CAFs from
bortezomib (bort)-resistant patients are resistant in vitro to the drug and
prevent bort-induced apoptosis of co-cultured MM cells2. Our purpose was
to investigate whether a specific miR profile is associated to the phenotype
and functional activities of BM CAFs in MGUS to MM transition and drug
resistance.
Methods: miRs expression was analyzed by microarray and validated by
qRT-PCR and flow cytometry on CAFs purified from BM aspirates of
MGUS and MM patients. miRs target genes were identified by interroga-
ting different tools commonly used to predict human miR gene targets and
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
profile, including 9 up-regulated and 17 down-regulated miRs. Among
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
-214-3p were FBXW7 and PTEN, respectively, involved in cell apoptosis,
proliferation and CAFs activation. Inhibition of miR-27b-3p induced the
over-expression of FBXW7, an ubiquitin ligase, which negatively modulated
the expression of MCL-1, NOTCH and Cyclin E1/2. miR-214-3p inhibition
increased PTEN levels down-regulating the AKT/GSK3 pathway and Cyclin
D1. Finally, co-cultures of MM cells with CAFs and bort treatment increa-
sed miRs expression.
Conclusions:: MGUS to MM transition and drug resistance is related to a
specific miRs profile. Over-expression of miR-27b-3p and -214-3p induces
cell proliferation and resistance to spontaneous and bort-induced apoptosis
in MM CAFs.
Bibliography:
1.       Frassanito MA et al. Leukemia 2014.
2.       Frassanito MA et al. Leukemia 2016.
DNA METHYLATION AND HYDROXYMETHYLATION
IN PRIMARY COLON CANCER AND SYNCHRONOUS
HEPATIC METASTASIS
Moruzzi S. 1, Udali S. 1, De Santis D. 1, Ruzzenente A. 2, Mazzi F. 1, Beschin
G. 1, Tammen S. 3, Campagnaro T. 2, Pattini P. 1,
Olivieri O. 1, Guglielmi A. 2, Choi S.W. 3,4 , Friso S. 1
1
Department of Medicine, University of Verona School of Medicine, Verona,
Italy 2Department of Surgery, University of Verona School of Medicine,
Verona, Italy 3Tufts University School of Nutrition Science and Policy, Boston,
MA, USA 4Chaum Life Center, CHA University, Seoul, Korea
Colorectal cancer is among the most frequent solid tumor and simultane-
ous diagnosis of primary colorectal cancer and liver metastases occurs in
about 25% of cases. Aim of the present study was to define DNA methyl-
cytosine (mCyt) and hydroxymethylcytosine (hmCyt) patterns in primary
colon cancer and synchronous hepatic metastatic tissues and to identify
a possible role for mCyt and hmCyt levels from peripheral blood mono-
nuclear cells (PBMCs) DNA as a marker of disease. Sixteen patients were
enrolled and their laboratory tests and clinical history data collected.
The mCyt and hmCyt content was determined by an LC-MS/MSmethod
in the DNA extracted from cancer tissues and from homologous can-
cer-free tissues, i.e.colon (C), liver (L) and PBMCs. Methylcytosine levels
57
Comunicazioni Orali
were similar in primary colon cancer (CCr) and liver metastasis (LM)
(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).
The difference in mCyt content between cancer and cancer-free colon
tissues were significantly different for primary colon cancer (P=0.004)
but not for liver metastasis (P=0.148) (Fig.A). Hydroxymethylcytosine
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,
P=0.905) but markedly depletedas compared to cancer-free colon (0.081%,
C.I. 0.055-0.119) with a statistically significant difference (P<0.05) for
both comparisons (Fig.B). Methylcytosine levels showed a borderline cor-
relation between PBMCs and colon cancer tissue (Pearson’s correlation
coefficient = 0.51, P=0.052). Primary colon cancer and liver metastasis
tissues have a similar epigenetic status but are significantly hypomethyla-
ted and hypohydroxymethylated as compared to homologous cancer-free
colon tissue.
NON-INVASIVE CIRCULATING TUMOR DNA
MONITORING FOR EARLY DETECTION OF RESISTANCE
OR RELAPSE TO NEOADJUVANT CHEMOTHERAPY IN
BREAST CANCER PATIENTS
Zoppoli G. 1,2, Garuti A. 2, Cirmena G. 2, Franceschelli P. 2,
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
Introduction: It has been shown that breast cancer (BC) and other neo-
plasms can release circulating tumoral DNA (ctDNA) in the peripheral
blood stream. With suitable, high-sensitivity methods, ctDNA may be
detected in plasma samples before clinically overt relapse or resistance to
chemotherapy, therefore potentially behaving as a personalized biomarker
of a patient’s health status.
Aims, Patients, and Methods: Our primary aim was to assess the propor-
tion of BC patients undergoing neoadjuvant chemotherapy (NACT) with
detectable ctDNA before surgery and absence of pathological complete
response (pCR). Secondary aims were to observe ctDNA reappearance
rate by measuring it 3 months after surgery, and every six months until
relapse or 60 months of follow-up. To detect ctDNA, a pre-NACT biopsy
was analyzed for mutations in 409 genes involved in cancer by next-gene-
ration sequencing (NGS) on a Ion Torrent TM platform. Then, an indivi-
dualized driver mutation was prioritized for each patient and measured in
plasma by droplet digital PCR (ddPCR) using the BioRad QX200® system.
Assuming an actionable mutation is found in plasma before surgery in
80% of NACT patients without pCR and < 10% of patients with pCR,
with a two-sided α =.05 and 1-β =.90, we could reject the null hypothesis
of finding ctDNA in 50% of patients regardless of pCR by enrolling and
analyzing 10 patients undergoing NACT, with a 1:1 ratio (5 with pCR and
5 without).
Results: As of May 2017, 31 patients are under active screening. NGS
and ddPCR on plasma at baseline, before and after surgery, at 6 months,
and at 12 months have been performed for 10 patients, with the post-sur-
gery pathological characteristics as previously detailed. The results for the
primary aim will be presented at the Italian Society of Internal Medicine
meeting for the first time.
PREDICTION OF RESPONSE TO NEOADJUVANT
CHEMORADIOTHERAPY IN RECTAL
ADENOCARCINOMA BY WHOLE TRANSCRIPTOME
ANALYSIS: RESULTS FROM A SINGLE CENTER,
RETROSPECTIVE PROSPECTIVE, CONSECUTIVE
58
118° Congresso Nazionale - Società Italiana di Medicina Interna
COHORT STUDY
Ferrando L. 1, Isnaldi E. 2, Garruti A. 1, Franceschelli P. 1,
Cirmena G. 1, Lia M. 2, Romairone E. 2, Scabini S. 2, Murialdo R. 2, Grillo F. 2,
Mastracci L. 2, Tixi L. 2, Ballestrero A. 2, Zoppoli G. 2
1
University of Genoa 2 Ospedale Policlinico San Martino
Introduction: In locally advanced cII/cIII rectal adenocarcinomas (LARC),
the primary treatment is surgery, together with the administration of
neoadjuvant treatment, that is a combination of radio and chemotherapy.
Tumor response to chemoradiotherapy is not uniform and shows a wide
range of responsiveness (from complete response to complete resistance).
Such complex response introduces a substantial clinical dilemma about
the benefit and the risks of the administration of neoadjuvant treatment in
LARC.
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
expression profiles. We rejected patients with intermediate response. We
identified a gene signature composed by 34 genes (p < 0.001).
Conclusion: Our results suggest that gene profiling may be used to predict
the response to neoadjuvant in LARC, but evaluation and validation of the
identied gene signature recquires extensive, prospective and multicenter
studies.
META-ANALYSIS SHOWS THAT THE USE OF METFORMIN
IN PATIENTS WITH TYPE 2 DIABETES IS ASSOCIATED
WITH SIGNIFICANTLY LOWER RISK OF COLON
NEOPLASIA
Portincasa P. 1, Rokka A. 1,2, Rokkas A. 2
1
Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human
Oncology, University of Bari “Aldo Moro” Medical School, Bari, Italy. 2
Bari English Medical Curriculum (BEMC), University of Bari “Aldo Moro”
Medical School 2Gastroenterology Clinic, Henry Dunant Hospital, Athens,
Greece
Background and Aims: Several lines of evidence suggest that biguanide
metformin, the first-line treatment of type-2 diabetes might decrease the
risk of cancer. To check this important question, we performed a meta-a-
nalysis of available studies to define the effect of metformin on colon neo-
plasia (both cancer and polyps) in the subgroup of patients with type 2
diabetes.
Methods: We searched for medical literature in human studies up to may
2017, by suitable keywords. Analyses included pooled estimates (fixed or
random-effects models); heterogeneity between studies (Cochran Q test),
likelihood of publication bias (construction of funnel plots and their sym-
metry estimated by the Begg and Mazumdar adjusted rank correlation test
and by the Egger’s regression test). Subgroup and sensitivity analyses were
also performed.
Results: 17 studies were eligible for meta-analysis [1 RCT and 16 obser-
vational studies (13 cohort and 3 case-controls)] reaching a total number
of 709,980 patients with type 2 diabetes. The risk of colon neoplasia was
significantly lower among metformin users than controls (non-metfor-
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),
Z=-3.30, p<0.001]. Conclusion: So far, the meta-analysis of available studies
shows that the use of metformin in patients with type 2 diabetes is asso-
ciated with significantly lower risk of colon neoplasia. Further studies are
urgently required to address the pathophysiological mechanisms involved
and to extend the results to additional subgroups of metformin-users.
118° Congresso Nazionale - Società Italiana di Medicina Interna
CASE MANAGEMENT IN MIGRANT POPULATION WITH
CHRONIC DISEASE: THE EXPERIENCE IN THE CLINIC
OPERA SAN FRANCESCO PER I POVERI
Villa A.M., Sardella F., Fadelli S., Abbruzzese M.G., Adamoli M., Fiammanti C.
Opera San Francesco per i Poveri, Milano
The social and economic deprivation combined with emerging chronic
diseases is well evidenced-based in our geographical area. Chronic patholo-
gies have increased with the boosting of people in poor conditions among
with, we find migrants. For them, national policies have not carried out
targeted interventions. A more planning and customization in their treat-
ment’s path should be a strategy to be implementedAccording to the more
relevant scientific literature, the case-management approach is always more
recognized in chronic diseases’ treatment. In this scientific work, it’s showed
its enforcement for poor population especially migrants. The main aims of
case-management approach are to ensure patiens’ self-management, reduce
cares fragmentation, enhance the quality of ongoing treatments, improve
patiens’ quality of life, reduce hospitatization, increase staff ’s satisfaction
also promoting a more effective resourses’ management. The Case manage-
ment project, conceived in our clinic, is planned for: - nursing activity and
health promotion with patient engagement; - counseling activities in order
to prevent more dangerous diseases with the patient’activation to a proper
lifestyle - guiding the patient within his/her therapeutical path with an help
desk supporting him/her during the treatment; - rehabilitation interven-
tions and long-term assistance in cooperation with local services; - recalling
the patiens when he/she does not go to the visit. 10% of 29.000 patients of
our clinic in the last 3 years has been worthy of such service; 600 of them
are included in the project because they are complex and stable on territory.
Patients are inserted in our electonic database as member of this project as
well as every operator knows the cure path and checks its implementation.
The case manager works in a multidisciplinary team with different medical
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
involvement and activation in the cure path: PAM 13-I card and monitoring
activation level according to the licence Insigna Helath Snc and supervision
of parameters such as weight, glycemia, blood pressure, etc) Patients are
included for their complexity and also for the eminence of cardiovascular
pathologies enabling coninuous monitoring of their pressure and glycemic
parameters; 55% of them presents three or more chronic pathologies. 28
different nationalities are involved and 8% of italian population is home-
less. The close relationship between parameters’ improvement and level of
activation also with the help of interviews between operators and patients
has showed positive evidence: 76% of the patients has improved check of
parameters and adherence to a therapy and to a lifestyle accordingly. At the
follow-up, 86% of them has showed an improvement of level of activation
and counselling effectiveness with more involvement in the cure path; lower
results for homless people.
The feedback of this aspect is fundamental for the Case-management
OSF project because it’s also a validation of this counselling methodology
towards migrant patiens with cronic diseases.
RISK OF FUTURE FRACTURE AND MORTALITY IN
OSTEOPOROTIC PATIENTS AFTER FEMORAL OR
VERTEBRAL FRACTURE IN THE VENETO REGION OF
ITALY
A. Michielin 1, S. Sella 1, A. Amabile 1, D. Braghin 1,
L. Degli Esposti 2, M. Andretta 3, F. Fabris 1, S. Giannini 1
1 Department of Medicine, University of Padova, 2 Clicon S.r.l., Ravenna, 3
Servizio Farmaceutico Regione Veneto, Venezia, Italy
Introduction: Pharmacologic therapy is recommended in osteoporotic
patients with fragility fractures in order to prevent future fracture events.
Objective The objective of this retrospective observational study was to
examine treatment prevalence among post-fracture osteoporotic patients
from a regional Italian registry and to identify possible risk factors for new
fracture events or death. Methods: Patients ≥ 50 years with a recorded
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
Comunicazioni Orali
evaluated for re-fracture event or death from any causes. Baseline comor-
bidities and medication were assessed during the year prior the fracture
event. Adherence to therapy was measured by Medication Possession Ratio
(MPR = number of pill-days available from filled prescriptions for days of
follow-up) in the 12 months following the index-date. The cumulative inci-
dence probability of experiencing a new fracture or die from any causes
was estimated by Kaplan-Meier analyses. Predictors of fracture events and
mortality were evaluated by Cox proportional hazards models.
Results: A total of 10920 patients (mean age 81.4, men 11.1%) were eligible.
Within 12 months after the index-date, 34.6% did not receive any treatment
for osteoporosis and another 33.3% received vitamin D or calcium supple-
mentation only. Only 44% of treated patients had a MPR ≥ 80%. During the
follow-up period 1015 of 10774 (9.4%) patients no previously hospitalized
for osteoporotic fracture had another fracture event (incidence rate of 41.21
per 1000 py). Osteoporotic treatment and calcium/vitamin D supplementa-
tion were associated with fewer fracture events (HR 0.707, p<0.001 and HR
0.358, p<0.001 respectively); younger patients (HR 0.983, p<0.001) and men
(HR 0.755, p=0,012) were also less likely to experience new fracture events.
3148 of the same 10774 (29.2%) patients died from any cause (incidence
rate of 118.06 per 1000 py). Osteoporotic treatment and calcium/vitamin
D supplementation were found to be inversely associated with mortality
(HR 0.664, p<0.001 and HR 0.456, p<0.001 respectively). Other predictors
of mortality were: old age, male sex, hypertension, diabetes, rheumatoid
arthritis, heart failure, dementia and BPCO. Among medications, predic-
tors of mortality were: corticosteroid systemic use, anticoagulants, analge-
sics, antipsychotics, proton pump inhibitors. Conclusion: Consistent with
the results of previous studies, most osteoporotic patients remain untreated
after fragility fracture and most of treated patients have poor compliance.
The absence of treatment is associated with a higher risk of new clinical
fractures and decreased survival, thus suggesting new efforts for implemen-
ting osteoporotic therapy prescription and challenging patient adherence
to therapy.
INTERPLAY BETWEEN BONE MARROW ENDOTHELIAL
CELLS AND CD8 T CELLS IN MULTIPLE MYELOMA
Racanelli V., Leone P., Di Lernia G., Solimando A., Saltarella I.,
Ria R., Cicco S., Vacca A.
Department of Biomedical Sciences and Human Oncology, University of Bari
Medical School, Bari, Italy
Purpose: Bone marrow (BM) endothelial cells (EC) are in close contact
with CD8 T cells that come and go across the permeable capillaries. We
analyzed the antigen presenting capacities of EC from BM of patients with
multiple myeloma (MM) and monoclonal gammopathy of undetermined
significance (MGUS).
Methods: BM EC from MGUS and MM patients were analyzed and com-
pared with regard to their frequency, expression of HLA I antigen proces-
sing-presenting molecules, capacity to present antigens to and activate CD8
T cells. Experimental procedures included flow cytometry, immunomagne-
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
class I and lymphocyte function-associated antigen 3 (LFA3) molecules,
whereas between 10 and 25% express the costimulators CD80, CD86 and
CD40, and the inducible co-stimulator ligand (ICOS-L) thus suggesting a
semi-professional antigen presenting phenotype. The EC immune/stan-
dard proteasome subunit ratio is in favor of immunoproteasome subunits
as would normally be in professional antigen presenting cells. BM EC can
present HLA class I-restricted tumor antigens to and activate tumor-speci-
fic CD8 T cells with suppressive capacity. These CD8 T cells are CD45RA-
CCR7+ and produce more IL-10 (90%) and TGF-beta (80%) than IFN-
gamma (10%). DISCUSSION Tumor-specific effector CD8 T cells in BM
of patients with MM are inefficient because of the concomitant presence
of endothelial cell-reactive tumor-specific memory CD8 T cells producing
IL-10 and TGF-beta.
Conclusions: BM EC promote MGUS-MM progression through a novel
mechanism of immune escape. BIBLIOGRAPHY Di Rosa F et al. Front
Immunol. 2016;7:51.
59
Comunicazioni Orali
MEDICINE AND MIGRATIONS
Carini L., Cantarano M.S., Cantarano M., Cantarano E.
Facolta’ Medicina e Farmacia - Universita’ Roma “Sapienza”
The medicine of migration is a branch of medical anthropology and is also
involved in the socio-cultural aspect of the immigrants about the intrica-
cies of how the health problems are addressed, lived and cared for accor-
ding to the native culture and to the destination. At the base of this disci-
pline is a conditio sine qua non: the a priori acceptance of the existence of
different medical and therapeutic practices conceptions. The message that
constantly switches between the public is that of a “health hazard” immi-
grant, the different, the foreigner, from which to defend ourselves and to
be reclaimed. By contrast, there is ample scientific literature that dismant-
les myths and scaremongering, on problems and solutions of the migra-
tion phenomenon. The applicant appealed to health emergency related to
the presence of foreign immigrants on Italian territory, has no objective
justification. The Protocol of the Ministry of Health in 2011, aimed
establishing syndromic surveillance measures in order to allow an early
warning in case of a potential emergency situation, has effectively demon-
strated the non-existence of this risk, confirming, if anything, a growing
deterioration of conditions health of the immigrant population in the
post-migration period for exposure to risk factors related to poverty and
social hardship (exhausted migrant effect). The real emergency is in how
the phenomenon of migration is dealt with in our country: widespread
ignorance, bad faith and improvisation, mixing the issue of immigration
to that of safety. Without knowledge that only an inclusive approach that
would bring the migrant paths welfare, and integrating hospitality and
health can really protect the welfare of all, migrants and the host popu-
lation. This can not and must not be found on the bank of health sector on
the contrary, to its mandate, does not discriminate anybody, does not mani-
pulate information to private-purpose, and welcomes anyone with a need,
and when necessary, care without exception and in the best possible way. By
the SIMM, the Institute of Health and the National Institute of Medicine of
Poverty and Immigration, are generated Guidelines for host health screening
protocols and any evidence-based, as well as national guidelines (in the care
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”
represented by immigrants on the annual number of new cases diagno-
sed in our country is increasing. But the number of cases of TB in immi-
grants increases much less than their numerical increase. The condition
of “immigrant” is a risk factor for developing tuberculosis especially for
vulnerable and precarious, as well as to the objective difficulties of access
to preventive services, diagnosis and care that characterize the status of ‘
immigrant. HIV-AIDS Compared with the Italian population, the foreign
resident in Italy appears to affect infection (albeit with a decrease in the
absolute of the cases) number of nearly four times higher than the Italian
population. The offer hospitality and accommodation, for the specific
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
that is extremely lethal and, in most cases causes symptomatic disease and
then death within a few days of infection. This nullifies the possibility that
an infected person who ventures into difficult journey by land and later by
sea that would take him to Italy.
Scabies and skin infections It is typical of disadvantaged social groups,
individuals homeless, people with severe psychiatric disabilities and gated
communities. There is no ethnic or geographic factors predisposing. The
absence of common policies at the international level in the sense inclu-
sive, fragmented organization and, sometimes, improvised, a political and
social debate continues, a “ collective feeling “ that you are also getting
used to preventable deaths and so cruel and unjust, they are the real emer-
gencies to deal with in a concrete and positive way.
DEMOGRAPHIC AND CLINICAL FINDINGS IN A
MONOCENTRIC COHORT OF ADULT PATIENTS WITH
PFAPA SYNDROME
Sicignano L.L., Patisso I., Cerrito L., 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: PFAPA is a likely autoimmune inflammatory syndrome cha-
racterized by recurrent febrile attacks associated with oral aphtosis, pharyn-
60
118° Congresso Nazionale - Società Italiana di Medicina Interna
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
paediatricians. Recent evidences suggested the existence of a similar picture
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-
cal characteristics of a single cohort of adult PFAPA patients.
Matherials and Methods: We selected 48 adult patients with suspected
PFAPA syndrome, performing a retrospective analysis our entire Auto-in-
flammatory Disorders database. Patients included in the study group had to
respond faithfully to the Marshall Diagnostic Criteria which were adapted for
adulthood; in particular, we deliberately neglected first criteria and we applied
the fifth one was, only retrospectively. Patients were analyzed on the basis of
disease’s onset, fever pattern characteristics, accompanying clinical manife-
stations and inflammatory index trends (VES, Protein C Reactive, Serum
Amyloid Protein).
Results: The average age of patients at the time of description was 29.7 ± 8.8
years. We observed that 30 patients had the onset of illness in childhood while
only 18 patients directly in adulthood. The average age of onset of the disease
was 14 ± 11 years. 40 patients had monthly febrile attacks; 6 patients had more
than one attack per month. The body temperature at the peak was 39.2 ± 1 °
C with a duration of attack that in 89% of patients was between 3 and 5 days.
Oral aphtosis was present in 73% of patients; the pharyngitis was found in
94% of the sample while the laterocervical adenopathy in 86% of the patients.
Regarding other manifestations of auto-inflammatory origin, abdominal pain
was present in 60% of patients, chest pain and arthritis, respectively in 19%
and 21% of analyzed cases. Skin involvement was observed in 23% of the
patients, who had predominantly pomphoid or erythematous lesions.
Conclusions: Adult PFAPA is a newly introduced auto-inflammatory syn-
drome. Clinical characteristics differ from the PFAPA of the child, which
shows an increased prevalence of oral aphtosis and a reduced prevalence of
serous manifestations. Although the incidence and prevalence of this syn-
drome have not yet been established, it is evident that rapid diagnosis and
proper treatment may have a significant impact on the quality of life of
patients. The purpose of this work is to raise the attention of the Internists
to this new nosological entity in order to reduce its diagnostic delay and, by
expanding the available case, increase its understanding.
PATTERN OF IN-HOSPITAL CHANGES IN DRUG USE IN
OLDER PEOPLE FROM 2010 TO 2016. RESULTS: FROM THE
REPOSI REGISTER
Franchi C. 1, Ardoino I. 2, Nobili A. 1, Marengoni A. 3,
Mannucci P.M. 4
1
IRCCS - Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
2
Department of Clinical Sciences and Community Health, University of Milan,
Italy 3Department of Clinical and Experimental Sciences, University of Brescia,
Italy 4Scientific Direction, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, Milan, Italy
Purpose: To assess the pattern of in-hospital changes in drug use in older
patients from 2010 to 2016.
Methods: People aged 65 years or more who were acutely hospitalized in
those internal medicine and geriatric wards that did continuously participate
to the REPOSI register from 2010 to 2016 were selected. Drugs use were cate-
gorized as: 0-1 drug (very low drug use); 2 to 4 drugs (low drug use); 5 to 9
drugs (polypharmacy) and 10 or more drugs (excessive polypharmacy). To
assess whether or not prevalence of patients in relation to drug use distribu-
tion changed overtime, adjusted prevalence ratios (PR) was estimated with
log-binomial regression models.
Results: Among 2120 patients recruited in 27 wards continuously participa-
ting to data collection, 1882 were discharged alive and included in the analy-
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
patients overtime (particularly in 2014 vs 2012, PR 1.83 95%CI 1.14-2.95).
Moreover, from 2010 to 2016 there was an increasing number of patients who
were on polypharmacy at hospital admission, which they abandoned at hospi-
tal discharge, switching to the very low drug use group.
Conclusion: These results seem to suggest that the continuous and regular
participation to the REPOSI register, specifically aimed to tackle the appro-
priateness of drug therapies in hospitalized older people with multimorbidity
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
of the therapeutic burden in this at risk population.
118° Congresso Nazionale - Società Italiana di Medicina Interna
A DIAGNOSTIC CONUNDRUM SOLVED BY SPLENIC
BIOPSY
Di Caterino M., Altruda C., Allegorico E., Galiero R., Pinotti E., Salvatore T.,
Adinolfi L.E.
Dipartimento di Medicina Interna, Università della Campania Luigi
Vanvitelli
In March 2017, a 57-year-old man was admitted due to 40-days low-grade
fever with febrile episodes up to 39.5 °C in the last week, and concomitant
weight loss, asthenia, and worsening shortness of breath. His past medical
history was significant for ankylosing spondylitis treated with adalimumab
since 7 years. Physical examination showed: GCS 15, tachypnea (RR: 30/
min), SpO2: 94% (FiO2:21%), blood pression 90/60 mmHg, tachycardia (HR:
120 bpm, regular), pirexya (38.8 °C), profuse sweating, absence of vesicular
murmur at the right lung base, epigastric tenderness and palpable spleen.
Chest X-ray documented right lung middle-basal opacity and diffuse micro-
nodular lung pattern; abdominal ultrasonography revealed mild splenomegaly
with multiple millimetric hypoechoic lesions and moderate ascites. Routine
blood analysis revealed: erythrocyte sedimentation rate 68 mm/h, C-reactive
protein 25 mg/dL, ferritin 1065 ng/mL, fibrinogen 768 mg/dl, increased α1
and α2 globulin, hypoalbuminemia, mild normochromic normocytic anemia,
lymphocitopenia (500/μL), β2microglobulin 5,9 mg/L, LDH 717 U/L. Peri-
pheral blood smear, flow cytometric immunophenotyping, and immunolo-
gical tests (ANA, ENA, ANCA, RF) were negative. Septic laboratory screen
including blood, urine, induced sputum and stool cultures, as well as serology
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-
sion and left basal pleural effusion with diffuse millimetric miliary nodules.
Abdomen tomography documented enlarged spleen characterized by many
small hypodense foci with an inconclusive contrastographic pattern. Diagno-
stic thoracentesis on the right revealed an exudate; direct bacterioscopy and
PCR for Koch bacillum (BK) were negative; cytological examination showed
neutrophilic granulocytes. Waiting for cultures, a broad spectrum antibiotic
therapy was started (Piperacillin/Tazobactam 4,5 g i.v. t.i.d. and Levofloxacin
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
contained neutrophilic granulocytes but the culture was negative for bacte-
ria and mycetes, another thoracentesis on the left was performed: cytology
was positive for T- lymphocytes CD3+; direct bacterioscopy and PCR for BK
were negative. The patient was furthermore investigated. At bronchial lavage,
culture for bacteria and mycetes, Ziehl-Neelsen stain and PCR for BK, resul-
ted negative, and the CD4/CD8 ratio normal; fundus examination didn’t show
choroid tubercles; contrast-enhanced ultrasound of splenic lesions revealed
early fast wash out suggestive of lymphomatous lesions, but also of metastasis,
pyogenic abscesses, fungal infections as well as tuberculosis. Finally, an ultra-
sonography-guided biopsy was performed. The procedure was well tolerated
and didn’t have any complications. A part of the spleen specimen was pro-
cessed to rule out mycobacterial infection: direct bacterioscopy was negative,
PCR revealed BK nucleic acid sequences, and histology showed chronic gra-
nulomatous lesions without typical caseation. A diagnosis of miliary TB in an
adalimumab treated patient was put and a standard antitubercular treatment
started which obtained an impressive clinical and laboratoristic improvement.
After 25 days in Lowenstein—Jensen medium, BK growed on spleen speci-
men but not on pleural effusion nor on BAL. Antibiogram showed sensitivity
for all first line antitubercular treatment. Pyrazinamide and ethambutol were
quieted at the end of two months, isionazid and rifampicin were planned for
additional seven months.
The case being reported is one of the very few cases reported in literature
where miliary TB diagnosis was put thanks to the splenic biopsy avoiding
other more invasive techniques. We propose this simple, effective, safe, and
bedside procedure for diagnosis of conditions which may pose a dilemma
when all other noninvasive techniques have failed.
A CASE OF “IATROGENIC” LOW BACK PAIN
Gesualdo A., Noviello M., Belfiore A., Buonamico P., Minerva F., Palmieri
V.O., Pugliese S., Portincasa P.
Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human
Oncology, University of Bari Medical School
A 47 year old male presented for evaluation of low back pain unresponsive
to antinflammatory therapy for two months. One year earlier he was dia-
gnosed with ocular seronegative myasthenia gravis wich was steroid resi-
Comunicazioni Orali
stant. Twenty days before a Nuclear Magnetic Resonance (NMR) revealed
L4-L5 spinal disc herniation. For the worsening of pain and the onset of
fever, he was admitted to our division. Neurological examination revealed
no loss of strenght in the four limbs, osteotendineous hyperreflexia and
clonic movements of the lower limbs. Back pain was exacerbated by rota-
tion of the trunk and standing position. Inflammatory markers were CRP
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-
stic hypothesis included: degenerative disease of spine, ankylosing spon-
dylarthritis, osteoporotic and pathological fracture due to chronic steroid
therapy, and spondylodiscitis. A further spine NMR confirmed the hernia-
tion beside L4-L5 spondylodiscitis with involvement of intervertebral disc,
vertebral endplates, dural sac and adjacent muscles. PET-CT scan confirmed
pathological increase of glucose metabolism (SUV max 9.1) at the L4-L5
vertebral segments suggesting local inflammation. Blood cultures were
positive for Pseudomonas Aeruginosa and specific therapy with piperacil-
lin/tazobactam was started immediately. Pain, fever and other symptoms
improved and after rehabilitation and orthopedic corset for four months a
complete resolution of symptoms and radiological findings occurred.
Conclusions: Spondylodiscitis should be considered as differential diagno-
sis of back pain. The average period between the first symptoms and diagno-
sis is about 2-6 months because symptoms are aspecific and degenerative
disc disease is more common. In this patient chronic steroid intake likely
was the predisposing factor to infection. The exact diagnostic approach and
specific antibiotic therapy, starting after positive microbiological exams led
to successful healing.
F-18-FLUORODEOXYGLUCOSE POSITRON EMISSION
TOMOGRAPHY LEADING TO A DIAGNOSIS OF
PYLEPHLEBITIS
de Sio C., Galiero R., Allegorico E., Venafro M., Di Caterino M., Pinotti E.,
Salvatore T.
Dipartimento di Medicina Interna, Università della Campania Luigi
Vanvitelli
A 52-year-old patient came to our observation because of a 3-week history
of fever (T max 40°C) preceded by intense shaking shakes unresponsiveness
to domiciliar antibiotic treatment (amoxicillin/clavulanic acid 1g t.i.d.). The
patient experienced significant weight loss (about 15 kg in the last few weeks),
intense fatigue, vague upper abdominal discomfort and lack of appetite. His
medical history was significant for uncompensated type 2 diabetes mellitus
(HbA1c 12%), hypertension and obesity class II. On examination the patient
was sweat, the temperature was 39°C, the blood pressure 115/70 mmHg, the
pulse 110 beats per minute, the respiration rate 24 breaths per minute. Abdo-
minal pain in epigastrium and right hypochondrium was evoked by palpa-
tion. Laboratory tests showed: moderate normocromic-normocytic anemia
(Hb 8.5 gr/dl), leucopenia (WBC 2700/μL) with 83% granulocytes; hypoal-
buminemia (2.6 g/dl); marked increased of ESR (120 mm/hour), CRP (20
mg/dl), fibrinogen (750 mg/dl), ferritin (1250 ng/ml),and procalcitonin (2.8
ng/ml). Coagulation, amylase and lipase were normal. All blood cultures and
a urine culture remained sterile during his hospital stay. Pheripheral blood
smear, cytofluorometry, Vidal-Wright, TORCH complex, β2-microglobulin,
Tubercolin skin test, were negative. Chest X-ray and transthoracic echocar-
diogram resulted normal. At abdominal ultrasound a thrombotic process of
right portal branch, splenic vein and spleno-mesenteric confluence was found;
furthermore, a little area of inhomogeneity at the level of the pancreas tail
emerged. Both results were confirmed by abdominal MRI which furthermore
excluded diverticulitis and other abdominal infections. Thrombophilia screen
tests and tests for autoimmune diseases (LAC screen test, ATIII, C Protein, S
Protein, Omocysteine, Leiden factor V, Factor II polymorphism, IgG anti-β2
glycoprotein, IgM-anticardiolipin, ANA, ENA, AMA, ASMA) were perfor-
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-
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
pancreatic tail. Based on these findings, non-cirrhotic pyleflebitis was diagno-
sed, likely by extensions of a peripancreatic abscess via the pancreatic-lienal
ligament. Looking for a source of infection, even a colonscopy was performed
that resulted negative. Antibiotic therapy with Imipenem 500 mg q.i.d. for
four weeks and anticoagulation therapy with Rivaroxaban were started. After
7-10 days, there was a clear improvement of symtomps and laboratory tests.
The patient was discharged in fair conditions with recommendation of taking
Rivaroxaban 20 mg o.d. At discharge, the echocolordoppler of the splancnic
61
Comunicazioni Orali
veins showed recanalization of the portal vein branches with only a suboc-
clusive thrombosis of the splenic vein. Septic thrombophlebitis (or throm-
bophlebitis suppurative of portal vein), also known as pylephlebitis, is a rare
but serious complication of an abdominal infectious process which may be
characterized by many complications (extension of the thrombus to the upper
mesenteric vein, the branches of the portal vein and the splenic vein, forma-
tion of intraepatic abscesses, sepsis and/or peritonitis). The most common
causes are diverticulitis (70% of cases), acute appendicitis, acute necrotic
pancreatitis, intestinal bowel disease. However, the presence of an infectious
focus is not always identifiable and blood cultures are positive in c. 50–80% of
pylephlebitis patients In about 80% of the cases described in the literature E.
coli, P. mirabilis, B. fragilis, K. Pneumoniae, Enterobacter and S. bovis are the
more frequently isolated germ. In our patient, the causal germ was not identi-
fied, the abdominal site of infection was only supposed to be a peripancreatic
abscess, but the FDG PET proved to be a powerful technique to identify this
infectious condition which is frequently difficult to diagnose.
GOOD ANAMNESIS (A POSTERIORI), HALF DIAGNOSIS
Trulli F., Braucci S., Caracciolo B., Cipriani E., Gianoglio O., Viscogliosi G.,
Sabetta F.
Dipartimento di Medicina, Policlinico Casilino, Roma
A 79-year-old healthy Italian man presented to our hospital with stuporous
state, fever, hematemesis and melena, jaundice and signs of multiorgan
failure (type 1 respiratory failure, hypotension, acute renal failure, elevated
transaminases and cholestatic index, hyperglycemia, increased inflamma-
tory index, thrombocytopenia, anemia and neutrophil leukocytosis; qSOFA
3). Intravenous antibiotics with piperacillin/tazobactam and supporting
therapy were initiated very quickly.
Patient underwent urgent upper endoscopy showing non-bleeding esopha-
geal erosions. Whole body CT scan showed lung bilateral basal pneumonia.
For the worsening of general conditions antibiotic therapy was modified
with vancomycin, meropenem and levofloxacin with progressive improve-
ment of clinical conditions. In the hypothesis of infectious disease, we tested
urinary pneumococcal and legionella antigen, Weil-Felix and Widal-Wri-
ght serodiagnosis, Toxoplasmosis antibodies, Hepatitis viruses and Cyto-
megalovirus antibodies, Leishmania test with negative results for recent
infections. Weak positivity for Epstein Barr virus and for Mycoplasma
pneumonae IgM antibodies was detected. After the occurrence of diarrhea,
Clostridium difficile infection was diagnosed. In suspicion of sepsis origi-
nating from the bile ducts, abdomen MR and CPRM were performed with
detection of mild common bile duct ectasia.
Patient’s hemodynamics substantially improved 15 days later and he had a
complete recovery from the disease after 40 days of hospitalization. After
improvement of clinical conditions, a careful anamnestic interview revealed
that patient had fallen into a country swamp ten days before the hospitaliza-
tion. Antibodies againstLeptospira research was made with the detection of
weak positivity of IgM at discharge and of IgG after 1 month after discharge.
Conlusions: considering his clinical presentation, his anamnesis, and the
fact that limitation of serology is that antibodies are lacking at the acute
phase of the disease, it’s highly probable that patient was affected by Lep-
tospirosis and he responded to empirical antibiotic therapy, mainly due to
meropenem and piperacillina/tazobactam, although some evidence confir-
med that fluoroquinolones were shown to be effective in reducing animal
mortality in a model of acute leptospirosis (1,2,3).
1) Ressner Ra1,Griffith ME, Beckius ML, Pimentel G, Miller RS, Mende
K, Fraser SL, Galloway RL, Hospenthal DR, Murray CK. 2008. Antimi-
crobial susceptibiities of geographically diverse clinical human isolates of
letospiras. Antimicrob Agents Chemother. Aug; 52 (8):2750-4 doi:10.1128/
aac.00044-08.
2) Matthew E. Griffith, James E. Moon, Erica N. Johnson, Kyra P. Clark,
Joshua S. Hawley, Duane R. Hospenthal and Clinton K. Murray. 2007.
Efficacy of Fluoroquinolones against lepstopira interrogans in a Hamster
Model. Model Antimicrob Agents Chemoter. 51 (7):2615-2617.
3) Musso D1, La Scola B. 2013. Laboratory diagnosis of leptospirosis: a
challenge. J Microbiol Immunol Infect. Aug;46(4):245-52.doi:10.1016/j.
jmii.0.3001 Epub Apr 29.
STREPTOCOCCUS GALLOLYTICUS INFECTION AND
COLON CANCER: A QUITE FREQUENT ASSOCIATION
De Donato M.T. 1, Marracino M. 1, De Vecchi R.M. 1, Baldi C. 2,
62
118° Congresso Nazionale - Società Italiana di Medicina Interna
La Mura G. 3, La Mura L. 4, Renis M. 5
1
UOC Medicina AOU Salerno, 2UOC Anatomia Patologica AOU Salerno,
3
Cardiologo P.O. Scafati ASL Salerno, 4Università di Napoli “Federico II”,
5
UOC Medicina P.O. Cava de’ Tirreni AOU Salerno
Introduction: Streptococcus Gallolyticus (S.G) is responsible for sepsis/
endocarditis in a particular category of patients, which may havecolo-
nic cancer, still misunderstood. In view of thisfinding, individuals with
positive blood culture for this pathogen, are currently recommended to
undergocolonscopy.
Clinical Case: F, 60. Undifferentiated diffuse colonic cancer (signet-rin-
gcells, with positivity of estrogen receptors), diagnosed a year before,
never undergone surgery, but undergone chemotherapy. Hospitalization
in Internal Medicine department for fever and severe anemia at inflam-
matory genesis (elevated inflammatory markers), then subjected to blood
transfusion. Positive blood culture for S.G. Echocardiography: aortic valve
endocarditis. Antibiotic therapy according to antibiogram: disappearance of
fever and improvement in blood counts.
Discussion: Literature has documented association between endocarditis
caused byS.G. and colon cancer, so that, in case of positive blood culture
for this pathogen, it is recommended the execution of colonoscopy for the
search of the colon cancer.
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
the recommendation; ie, in patients with colonic cancer who present sepsis,
it should be recommend to also perform an echocardiogram, as a first level
investigation, and, while waiting for the results of blood culture, it should be
recommend to practice empirical therapy against S. G.
AN UNEXPECTED AND SINGULAR GUEST
Ricci P., Stasi C., Palmieri V.O., Belfiore A., Buonamico P.,
Minerva F., Pugliese S., Portincasa P.
Dipartimento di Scienze Biomediche e Oncologia Umana, U.O. di Medicina
Interna Universitaria, Policlinico di Bari
We report a clinical case of a 79 year old woman, smoker, suffering from
osteoporosis with multiple vertebral collapse and chronic polyarthritis
treated with corticosteroids, Methotrexate, Adalimumab. She was hospi-
talized for intermittent fever (up to 39 °C), cough, asthenia, dyspnea. The
following procedures were performed: chest X-ray (documenting thicke-
ning bilateral basal parenchymal area), blood examinations showing neu-
trophilic leukocytosis (20,000/mcL), C-reactive protein (CRP, 179 mg /L),
blood cultures, urine culture (both negative). Testing on sputum showed
polymorphonuclear, filamentous branching Gram-positive bacilli, diagno-
stic of Nocardia. Whole-body CT confirmed pulmonary nocardiosis, consi-
sting of multiple consolidations and partially excavated nodules. Tubercu-
losis (TB) and other fungal infection were excluded by testing mycobacteria
in sputum, Quantiferon TB Gold and other serology tests. The patient was
successfully treated with Trimethoprim-Sulfamethoxazole (TMP-SMX, 2gr/
day) and Imipenem (2gr/day) for a month, continuing with TMP-SMX only
for another six months. Nocardiosis is a rare, opportunistic and life-thre-
atening infection, better reported in asian countries like India, while its
incidence in Europe is unknown because of its rareness. A preexisting
immunecompromised state, ranging from malignancy, organ and hemato-
poietic stem cell transplantation, chronic glucocorticoid therapy, immuno-
soppressive drugs, chemotherapy and HIV infection, have been reported
in the major part of cases. Nocardia usuallycauses pneumonia, but could
also involve any organ, especially the brain. Transcutaneous inoculation is
reported in immunocompetent individuals, causing soft tissues infection,
keratitis and endophthalmitis. Diagnosis is based on isolation of Nocar-
dia from respiratory samples, (sputum, bronchoalveolar lavage, or fluid
obtained from lung aspiration) and radiological evidence of abscesses and
nodes (with or without excavation). Whole body CT is always recommen-
ded. Sulfonamides are the drugs of choice. At the outset, both TMP (5–10
mg/kg) and SMX (25–50 mg/kg) are given twice daily. As second choice,
Minocycline and Linezolid could be used. As parenteral drug, Ceftriaxone
(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
1–2 weeks of therapy but may take longer, especially with Central Nervous
Sistem disease. After definite clinical improvement, therapy can be conti-
nued with a single oral drug, usually TMP-SMX. Brain abscesses should be
118° Congresso Nazionale - Società Italiana di Medicina Interna
aspirated, drained, or excised if the diagnosis is unclear, if an abscess is large
and accessible, or if an abscess fails to respond to chemotherapy.
A PILOT STUDY OF ULTRASONOGRAPHY-GUIDED
“SHORT” MIDLINE CATHETERS FOR DIFFICULT
VENOUS ACCESS: THE EXPERIENCE OF TRAINING
COURSE IN A UNIVERSITY SCHOOL OF INTERNAL
MEDICINE
Guidetti E., Napoli L., Leoni S., Piscaglia F., Bolondi L.
Unità Operativa Medicina Interna Bolondi, Azienda Ospedaliero-
Universitaria S. Orsola-Malpighi, Bologna
Introduction: Patients admitted to the Internal Medicine Department con-
stantly require at least one stable venous access for complex therapies. Peri-
pheral intravenous placement may be challing. Non ultrasound (US)-gui-
ded short traditional cannulas have been frequently associated with local
complication. New short midline (8- to 10 cm- long polyurethane catheters)
inserted with US guidance and direct Seldinger technique provide a reliable
vascular access option for patients with difficult venous access who would
otherwise require multiple venipunctures or lead to a delayed therapy.
Aims: To evaluate the effectiveness of a training course of US- guided short
Midline catether insertion for Internal Medicine fellows; to evaluate the
secondary advantages in terms of success rates and mean duration of the
line.
Methods: We considered the successful of “short” Midline catheters bedside
insertion program in our University School of Internal Medicine. The course
was divided in two parts, consisting of a first theoretical section (4 hours),
concerned the devices insertion tecnique and indication, and a second
practical section (8 hours), provided the placement of at least one device/
per fellow, asssisted by experts anesthesiologists. All partecipants must have
already basic US experience and competence. All the selected patients need
for stable venous access for longer than 6 days of treatment or with difficult
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
inserted, with 7 difficult inserctions (2 venipunctures); one local hematoma
was described as complication. Edema of the subcutaneous tissue, depth and
limited diameter of the vessel were the main cause of difficult venous access.
In 12/20 (52%) patients, catheters were inserted into the basilic vein (mean
diameter 3.3 mm), while in the remaining 8/20 (48%) in the brachial one
(mean diameter 4 mm). All devices have been removed after a period ranging
from 2 to 13 days (median 7 days, mean 7.8 days). The devices removal was
justified by interruption of infusional therapy (n=14), catheter displacement
(n=3), local complication (superficial thrombophlebitis, n=1), catheter occlu-
sion/malfunction without evidence of vein thrombosis confirmed by Doppler
US (n=2). No catheter-related infection have been registered in our patients.
Mean vein diameter and number of venipunctures at inserction time were
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
(40%) versus mean vein diameter 3.76 and 3/10 (30%) difficult inserctions
in the 10/20 (50%) catheters with mean life > 7 days. All internal medicine
fellows agreed that this experience with US- guided short Midline catheter
insertion and education about venous devices were positive and useful for
their clinical practice; 10% of them require more practice with tutor assistence
to menage independently device insertion.
Conclusions: Althought more experience is needed, our preliminary
data suggests that US-guided “short” Midline catethers provide a safe and
reliable kind of vascular access, especially for complex patients with diffi-
cult peripheral venous accesses. Such skills could be acquired during a trai-
ning course related to post-graduate specialization school, with good and
effective curve of learning.
ASSESSING BAVENO VI CRITERIA WITH A NEW POINT-
SHEAR WAVE ELASTOGRAPHY TECHNIQUE: THE
BAVELASTPQ STUDY
Garcovich M., Gibiino G., Ainora M.E., Annicchiarico B.E.,
Riccardi L., Pompili M., Siciliano M., Gasbarrini A., Zocco M.A.
UOC Medicina Interna, Gastroenterologia e Malattie del Fegato, Università
Cattolica del Sacro Cuore, Roma
Introduction: To date no study has explored the potential role of ElastPQ, a
novel point-SWE technique, in the assessment of clinically significant portal
Comunicazioni Orali
hypertension. The aim of our study was to determine a liver stiffness (LS)
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
value <20kPa measured by transient elastography in combination to a pla-
telet count >150,000/μl.
Aim & Methods: Data were collected on 1385 patients who underwent
ElastPQ measurement from January 2013 to January 2016 in our Depart-
ment. Inclusion criteria were a liver stiffness value of ≥7 kPa and an upper
gastrointestinal endoscopy within 12 months, with a diagnosis of compen-
sated chronic liver disease. We choose this specific liver stiffness cut-off
value in order to reasonably rule-in all patients with advanced fibrosis and
cirrhosis, based on the limited literature available on this specific elasto-
graphic technique. Exclusion criteria were history of decompensated liver
disease, evidence of porto-spleno-mesenteric vein thrombosis and non-cir-
rhotic portal hypertension. Varices were graded as low risk (grade <2) or
high risk (grade ≥2).
Results: The study included 184 patients (114 [62%] hepatitis C, and 160
[87%] Child-Pugh A). Varices were present in 36% cases, with 10% preva-
lence of high risk varices. According to ROC curve analysis liver stiffness
measurement and platelet count were evaluated as predictors of high risk
varices. Overall 74/184 (40%) met the “BAVElastPQ” criteria (that is, liver
stiffness <12 kPa and platelet count >150,000/μl). Within this group 11/63
(17%) had any grade of varices and only 1/73 (1%) had high risk varices. The
BAVElastPQ criteria gave sensitivity of 0.95, specificity of 0.44, a positive
predictive value of 0.16 and a negative predictive value of 0.98. The AUROC
for liver stiffness and platelet count was 0.81 and 0.76, respectively.
Conclusion: The BAVElastPQ criteria correctly identified 99% of patients
without high risk varices. By applying such criteria we could have poten-
tially avoided ca. 40% surveillance endoscopies in our cohort. To our know-
ledge this is the first study that evaluated the potential role of a new p-SWE
technique such as ElastPQ in the non-invasive assessment of clinically
significant portal hypertension, similarly to the recently proposed Baveno
VI criteria though using ElastPQ as an alternative to transient elastography.
EARLY ATHEROSCLEROTIC AND CARDIAC DAMAGE IN
PATIENTS UNDERGOING LIVER TRANSPLANTATION
Pisano G. 1,Oberti G. 1, Zannoni S. 1, Orlandi M. 1, Lombardi R. 1, Donato
M.F. 2, Bertelli C. 1, Porzio M. 1, Manini M. 2, Caccamo L. 3, Dondossola D. 3,
Fargion S. 1, Fracanzani A.L. 1
1
Department of Pathophysiology and Transplantation, Unit of Internal
Medicine, Ca’ Granda IRCCS Foundation, Policlinico Hospital, University
of Milan, Milan, Italy 2Division of Gastroenterology, Department of
Pathophysiology and Transplantation, Ca’ Granda IRCCS Foundation,
Policlinico Hospital, University of Milan, Milan, Italy 3Unit of Hepatic
Surgery, Department of Pathophysiology and Transplantation, Ca’ Granda
IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
Background: Improved survival after orthotopic liver transplantation
(OLT) has allowed to detect long-term consequences of liver transplan-
tation. After OLT, due to immunosuppressive drugs and increase of body
weight, patients have high risk of metabolic syndrome and of de-novo non
alcoholic fatty liver disease (NAFLD) occurrence, contributing to cardio-
vascular complications. Objective: To evaluate in a prospective study the
earliness of cardiovascular damage by echocardiographic parameters and
carotid artery alterations and the effect of metabolic modifications and
immune-suppressive therapy.
Methods:From January 2014 to March 2017we evaluated 79 patients on
waitingtransplant list, (M/F 54/25), age 54±10 years;54 were transplanted
and followed for 24 months. A complete evaluation of anthropometric, cli-
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
septum (IVSTd), left ventricular mass (LVM), left atrium (LA)) and visceral
adiposity (epicardial fat thickness (EAT)) by ultrasound and echocardio-
graphy was collected at enrollment.
Results: A significant increase of diabetes, metabolic syndrome hyperten-
sion and dyslipidemia prevalence was already evident at 6 months after
transplant, consequently a worsening of carotid damage (Quality IMT
610.4±101 vs 664.4±120, p=0.003), diastolic dysfunction (E/A 1.10±0.31 vs
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
lower progression in IMT during follow-up in patients with Tacrolimu-
stherapy than without (p= 0.04)while no relationship with the duration of
63
Comunicazioni Orali
steroid therapy was observed. In contrast the presence of diabetes was signi-
ficantly associated with carotid stiffness (p=0.02), the presence of metabo-
lic syndrome and of the use of statin with IMT (p=0.01).Fifthteen (28%)
patients received liver with histological evidence of steatosis>20%, 5/53
(9%) developed steatosis (evaluated by ultrasound) after 6 months and other
5/50 (10%) after 12 months. No significant difference in early progression of
cardiovascular damage was observed among patients who received steatotic
liver in comparison with others patients.
Conclusion: Cardiovascular alterations occur very early after liver tran-
splantation. The use of steatotic liver seems to not affect early cardiovascu-
lar damage. Therapeutic and behavior strategies aimed to prevent/delay
cardiovascular alterations should be provided in the first weeks after liver
transplant.
B-LINES IN INTERSTITIAL LUNG DISEASE: A PILOT
STUDY ON SCLERODERMIC PATIENTS
Melchio R. 1, Papaleo F. 2, Romeo N. 3, Bracco C. 1, Leccardi S. 1, Molino P. 4,
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,
Università di Torino 3S.S. Reumatologia, A.O. S. Croce e Carle, Cuneo 4S.C.
Medicina d’Urgenza, Ospedale S.Giovanni Bosco, Torino
Background: interstitial lung disease (ILD) is a common complication of
mixed connective tissue disease: in the case of scleroderma ILD is a leading
cause of morbidity and death. The extent of disease on HRCT scan, combi-
ned with spirometry, can be used to provide prognostic information. Lung
ultrasound has recently been proposed as a promising alternative method
to detect and quantify ILD in such patients, by the evaluation of B-lines, the
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.
FEASIBILITY AND PROGNOSTIC OUTCOME OF CHEST-
US IN PREHOSPITAL NON-TRAUMATIC DYSPNEIC
PATIENT
Acquistapace G. 1, Di Capua M. 1, Ruocco A.L. 1, Beretta G. 2,
Paglia S. 1
1
Dipartimento di emergenza e accettazione. Ospedale Maggiore di Lodi, Lodi
2
Emergenza extraospedaliera. Ospedale Maggiore di Lodi, Lodi
Objectives: Ultrasound (US) is the only diagnostic instrumentation avai-
lable in pre-hospital care. Despite widespread diffusion of chest-US, poor is
known about its feasibility and prognostic role in pre-hospital setting. Some
literature evidence shows that dyspnoea, as cause of pre-hospital emergency,
has a doubled mortality if compared to other pre-hospital emergencies. The
aim of our study was to assess whether chest-US has the same accuracy in
pre-hospital and hospital care and its impact on outcome of non-traumatic
dyspnoeic patients.
Methods: We conducted a retrospective study on 81 non-traumatic dysp-
noeic patients in the prehospital setting evaluated through chest-US. 157
dyspnoeic patients, age and sex matched, assessed only by clinical evalua-
tion served as control. We investigated concordance between prehospital
chest-US and emergency department (ED) performed by a different phy-
sician. We moreover evaluated 24-hours and 30-day mortality in patients
assessed by chest-US versus clinical evaluated ones.
Results: Concordance between prehospital and ED chest-US was 0.86
64
118° Congresso Nazionale - Società Italiana di Medicina Interna
showing a good accuracy when performed in prehospital setting. Moreover,
US-evaluated patients receive a diagnosis more concordant with the final
when compared to clinical evaluated ones. Anyway this difference does not
reach a statistical significance. No significant differences in 24-hour and
30-day mortality were reported in patients evaluated with or without preho-
spital US. Otherwise time management of patient and controls in prehospi-
tal care did not differ, demonstrating that use of US does not delay therapy
and transportation of patients.
Conclusion: In our study outcome was not improved in US evaluated
patients. The good concordance showed with the US performed in the ED
suggests its implementation in prehospital care to anticipate therapeutic
approach and diagnostic protocols once the patient is the ED. Prospective
studies are needed to evaluate if use of diagnostic and therapeutic protocols
in US evaluated patients could modify mortality once transported in the
ED.
PORTAL VEIN ANEURYSM: AN UNUSUAL ENTITY
DIAGNOSED BY ULTRASOUND
Berardi E., Schilardi A., Antonica G., Noia A., Sabbà C. Interdisciplinary
Department of Medicine, University of Bari School of Medicine, Bari, Italy
Portal vein aneurysm (PVA) is a rare vascular dilatation of the portal vein,
with an incidence of 0.06%. Even if the aetiology of PVA is not clearly
understood, portal hypertension, severe pancreatitis, trauma, interventio-
nal procedures and invasion of the portal vein by malignancy have been
reported as possible causative factors. Aneurysms have been described in all
parts of the portal vein; however, extrahepatic aneurysm are more common
then intrahepatic ones. One third of patients are usually asymptomatic as
PVA is an incidental finding, while approximately 50% of patients present
with non-specific abdominal pain. Gastrointestinal bleeding, portal hyper-
tension or symptoms related to the compression of adjacent organs (i.e.
abdominal swelling, jaundice) occur in less than 10% of cases.
A 86-year old male suffering from stable coronary artery disease, atrial
fibrillation and chronic kidney disease (CKD) was admitted for dyspnea.
He underwent chest-CT showing an expansive lesion at the hepatic ilus
with a maximum diameter of about 5.5 cm in the scans through the upper
abdomen. Because of CKD affecting the patient (eGFR: 22 ml/min), con-
trast medium was not employed. Hence, B-mode ultrasonography show an
anechoic cyst-like lesion (55 x 50 mm) near the porta hepatis, in continuity
with the right portal vein. That lesion had thickened walls, with concomi-
tant smoke effect that the colordoppler showed to be a circular yin-yang
flow pattern. The spleno-porto-mesenteric axis was well displayed throu-
ghout its course with normal velocity, curve with the exception of the aneu-
rysms where the flow was delayed. The inferior Vena Cava has been properly
displayed throughout its course with regulated flow pattern.
This finding conferm the hypotesis of an ilus portal vein aneurysm, in the
absence of ultrasonographic signs of portal hypertension. Different imaging
technics are used to diagnosed portal vein aneurysm. The typical B-mode
ultrasound finding is an anechoic lesion at the hepatic ilus lesion. Pulsed
wave Doppler or Color Doppler help to confirm the diagnosis by demon-
strating the presence of a non-pulsatile, monophasic or yin-yang pattern.
Color doppler, thanks to its feasibility, reproducibility and no-invasiveness,
can be considered the cornerstone for the diagnosis and follow-up of portal
vein aneurysms, even in voluminous ones, such in our case. CT and magne-
118° Congresso Nazionale - Società Italiana di Medicina Interna
tic resonance angiography for the potential iatrogenic effect of mdc may be
reserved for patients who are expected to undergo surgery.
ANXIETY LEVELS AS RISK FACTOR FOR OSTEOPOROSIS
IN POSTMENOPAUSAL WOMEN
Catalano A. 1, Martino G. 2, Bellone F. 1, Lasco A. 1, Morabito N. 1
1
Department of Clinical and Experimental Medicine, University Hospital
of Messina, Messina, Italy 2 Department of Cognitive Sciences, Psychology,
Education and Cultural Studies, University of Messina, Messina, Italy
Background: Anxiety disorders are common psychiatric diseases and
a major public health problem. Osteoporosis is the main bone metabolic
disease and is burdened by higher fracture risk. Anxiety and osteoporosis
may have consequence on quality of life and social costs. The primary aim
of our research was to investigate the association between anxiety severity
and the risk of fracture in a setting of postmenopausal women evaluated for
osteoporosis. The secondary aims were to measure depressive symptoms,
health related quality of life and their association with fracture risk.
Methods: Women were consecutively recruited at the Outpatients Clinic for
Mineral and Bone Disorder of the Department of Internal Medicine. Multi-
ple clinical risk factors (CRFs) for fractures and FRAX score, bone mineral
density (BMD) by dual-energy X-ray absorptiometry of the lumbar spine
and femur, X-ray vertebral morphometry, Hamilton Anxiety Rating Scale
(HAMA) for anxiety levels, Beck Depression Inventory for depressive symp-
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.
Results: Of the 192 recruited women (mean age 67.5±9.5 yr.), patients
falling in the lower tertile of HAMA score (HAMA-1) showed lower ten
years probability of major osteoporotic fractures, according to FRAX, in
comparison with patients in the higher one (HAMA-3) (20.44 ±9.3 vs.
24.94±13, respectively, p=0.01), and the same trend was observed when
comparing HAMA-2 and HAMA-3 tertiles. Women in HAMA-3 exhibited
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
femoral neck (-2.21±0.9 vs. -1.93±0.6, respectively, p<0.05); the same trend
for T-score measurements was observed when comparing HAMA-2 and
HAMA-3 tertiles. A significant higher rate of patients with previous fractu-
res were observed in HAMA-3 vs. HAMA-1 (p<0.05). Anxiety levels were
significantly related with age, menopausal age, years since menopause, and,
at a multiple regression analysis, were predictive of reduced BMD, after cor-
recting for other CRFs, including depressive symptoms.
SWALLOW STUDY IN PATIENTS WITH SYSTEMIC
SCLEROSIS. VIDEOFLUOROSCOPY ITEMS AND
CORRELATION WITH CLINICAL PATTERNS
Fischetti C.1, Fraticelli P. 1, Barchiesi S. 1, Romanelli G. 1, Zuliani L. 1,
Ferrarini A. 1, Pisani A.M. 2, Gabrielli A. 1
1
Clinica Medica, Dipartimento di Medicina Interna, Universita’ Politecnica
delle Marche, Ospedali Riuniti, Ancona 2Dipartimento di Radiologia,
Ospedali Riuniti, Ancona
Background: Systemic Sclerosis (SSc) is a chronic autoimmune disease cha-
racterized by proliferative vascular lesions and progressive fibrosis of skin
and internal organs, including the gastrointestinal tract. Gastrointestinal
involvement is a very frequent complication, reported in up to 90% of SSc
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
videofluoroscopy swallow study and clinical patterns of patients SSc.
Methods: 55 patients (M/F: 6/49; median age 56y; median disease 6y, lSSc /
dSSc:36/19; anti-Scl70+:21/55, ACA+:18/55, only ANA+:16/55), with a dia-
gnosis of SSc and a history of dysphagia underwent a dynamic and morpho-
logical study of the oral, pharyngeal and esophageal phases of swallowing
with videofluoroscopy. The oral and pharyngeal esophageal phases were
performed in the upright position, while the esophageal phase was perfor-
med in the prone-oblique position, after administration of contrast mate-
rial either in bolus form or diluted. Data were analyzed by radiologist with
experience in Videofluoroscopy for the evaluation of 17 videofluoroscopy
items, of which, 4 concern the oral, 4 the pharyngeal and 9 the esopha-
geal phase, respectively. Results were expressed in a binary system. Then the
main relevant videofluoroscopy findings were correlated with the principal
Comunicazioni Orali
scleroderma pattern of disease: lSSc vs dSSc; disease duration (more than 2
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
in mouth 4%. As for pharyngeal phase: stasis of bolus on pharyngeal 49%,
penetration in the laryngeal aditus 53%, post-swallowing aspiration 22%,
abnormal upper esophageal sphincter behavior 13%. Concerning esopha-
geal phase: inadequate primary peristalsis 53%, abnormal secondary peri-
stalsis 29%, non-peristaltic contractions 40%, deficit of clearance 69%,
abnormal lower esophageal sphincter behavior 76%, hiatal hernia 80%,
esophageal reflux 56%, esophagitis 82%, esophageal luminal stenosis 0%.
When we analyzed the swallowing disorders in the different pattern of dise-
ases we have not found a significant prevalence in the lSSc or in dSSc; the
dysfunctions are present in all patients particularly with more than 2 year of
disease. Finally, the correlation with autoantibodies did not show a preva-
lent pattern of autoantibodies associated with swallowing disorders
Conclusions: Our study demonstrated relevant abnormalities in swal-
lowing disorders in high number of patients with SSc. Pharyngeal and
esophageal phases are the most affected, also in the early phase of disease.
In our cohort of patients SSc, all the videofluoroscopy alterations not found
a significant prevalence in lSSc or in dSSc. An early and detailed diagno-
sis of swallowing disorders, supported by a semi-quantitative analysis with
the use of videofluoroscopy scores, may be useful to guide the appropriate
therapeutic approach, either rehabilitative or pharmacological, and finally,
to improve the patient’s quality of life. Extended studies are necessary to
confirm and transfer our data into clinical practice.
DISEASE ACTIVITY AND DAMAGE IN INFLAMMATORY
MYOPATHIES
Cardinaletti P. 1, Savore I. 1, Danieli G. 1, Lupidi F. 2, Gabrielli A. 1, Danieli
M.G. 1
1
Clinica Medica, 2Clinica Neurologica, Università Politecnica delle Marche e
Ospedali Riuniti, Ancona
Aim: To assess the disease activity, disability and damage in patients with
polymyositis (PM) and dermatomyositis (DM).
Methods: We selected 78 consecutive patients of our Internal Medi-
cine Department in which PM and DM were diagnosed according to the
Bohan and Peter’s criteria. We used a core set of functional indexes so that
disease activity, disability and damage were recorded by the MITAX (Myo-
sitis Intention to Treat Activity Index), the HAQ-DI (Health- Assessment
Questionnaire Disability Index) and the MDI (Myositis Damage Index),
respectively.
Results: Our study included 33 patients with DM, 27 with PM, 9 with can-
cer-associated myositis and 9 with connective tissue disease (CTD)-asso-
ciated myositis. Nine patients passed away during the follow-up period.
MITAX values at the onset were higher in patients with CTD-associated
myositis. MITAX values at the onset significantly correlated with succes-
sive disability as calculated with HAQ-DI and mortality rate. According
to HAQ-DI score, 28% of our patients had moderate to severe disability.
We could not find any connection between MDI and disease progression,
type, kind of involvement in myositis, disability (HAQ-DI) and mortality.
Conclusions:: Even though many international attempts have been made to
propose a core set of scores assessing disease activity and damage in myosi-
tis, our preliminary results showed only a link between MITX and disability
and mortality. In close future, international study group such as MyoNet
will certainly improve our understanding in treatment and care of inflam-
matory myopathies.
TWO FAMILY MEMBERS WITH FAMILIAL
MEDITERRANEAN FEVER CARRYING THE SAME
MUTATION SHOWED DIFFERENT CLINICAL
PRESENTATIONS
A. Grembiale, E. Corigliano, A. Franchi, M. Falbo, F. Marasco,
M.C. Calindro, G. Perrone, G.F. Mauro
U.O.C. di Medicina Interna - P.O. “San Giovanni di Dio” - Azienda Sanitaria
Provinciale di Crotone
Introduction: Familial Mediterranean fever (FMF) is the most common
auto-inflammatory disease with monogenic (Mediterranean FeVer –
MEFV gene) inherited pattern. It mainly affects ethnic groups living along
the eastern Mediterranean Sea: Turks, Sephardic Jews, Armenians, and
65
Comunicazioni Orali
Arabs. Today FMF is not rare disease in other Mediterranean ethnicities,
such as Greeks, Italians, and Iranians. It is characterized by short inflam-
matory episodes of polyserositis, and fever with irregular pattern. Amyloi-
dosis as the major cause of mortality, is the most significant complication
of FMF, and may be prevented by colchicine. The MEFV gene, associa-
ted with the disease is located on chromosome 16. This gene encodes a
781-amino-acid protein named pyrin. This protein appears to play a
pivotal role in the regulation of both inflammation and apoptosis, and
mutated pyrin lead to full-blown inflammation characterized by exces-
sive Il-1ß secretion in FMF. Mutations in the pyrin gene have been identi-
fied in the majority of FMF patients, include four conservative mis-sense
mutations (M694V, M680I, V726A, M694I), clustered in exon 10, which,
together with mutation E148Q, in exon 2, account for the vast majority
of MEFV gene abnormalities. Two mutations, hemo or heterozygotic,
confirm suffering from FMF. A few patients with more than two muta-
tions named “complex alleles mutations” have been reported. Case Report:
Here we report two young italian siblings (a man and a female) with same
heterozygotic allele mutations, but different age of onset of disease and
symptoms. A 24-year-old woman referred to our internistic outpatient
clinic with recurrent abdominal pain and fever. She had been suffering
from abdominal pain and fever once to twice a month since the age of 4
but the clinical diagnosis was just made one year previously. she had been
using 1 mg/day colchicine and has had no complaints since then. She was
compound heterozygous, bearing the M694I and R761H mutations. Her
physical examination was normal, complete blood count, electrolyte, liver
and kydney function tests, sedimentation rate, C-reactive protein (CRP),
fibrinogen and urinalysis were normal. Proteinuria and microabuminu-
ria was not present in 24-hour urine analysis. Abdominal ultrasound and
endoscopic examinations were normal. Since the patient had no symp-
toms related to amyloidosis biopsies were not performed. The brother
of the first case is a 29-year-old man who presented to the internistic
out-patient clinic with intermittent chest pain for 5 years. Initially there
was no complaint of abdominal pain or fever. Sometimes he had dyspnea
and atypical chest pain 2-3 times a year and had been evaluated by chest
diseases and cardiology departments previously and has been found to be
normal. Subsequently fever and abdominal pain appeared twice a month.
His physical examination was normal. Renal function tests, electrolytes,
liver function tests and 24-hour urine analysis were within normal limits.
The rheumatoid factor (RF), antinuclear antibody (ANA), were all nega-
tive.Abdominal ultrasound and endoscopic examinations were normal.
He underwent operation for acute appendicitis at that time. Because of
persistent abdominal pain and fever in both, FMF had been considered.
MEFV gene analysis revealed heterozygous M694I and R761H mutation.
After regularr use of 1 mg/day colchicine, his complaints were resolved.
Since the patient had no symptoms related to amyloidosis biopsies were
not performed.
Conclusion: Although our patients in this report have same mutations,
the age of onset and their clinical manifestations were different. One of
them had recurrent abdominal pain and fever, another chest pain and
dyspnea while he began to experience fever and abdominal pain a few
years later. This indicates that specific genotypic structures did not corre-
late with the same phenotypic structure. This wide clinical variability of
FMF is partly attributed to MEFV allelic heterogeneity and partly influen-
ced by environmental and genetic factors so genotype-phenotype rela-
tionship is not well established. FMF is a common disease which affects
not only the eastern Mediterranean basin countries, but also the other
western countries. It has life-threatening complications, thus the diagno-
sis of FMF is important. The occurence of FMF with atypical symptoms
should also be kept in the mind.
NEW DIGITAL ULCERS IN SISTEMIC SCLEROSIS:
MARKER OF MORTALITY FOR CARDIOVASCULAR
EVENTS
Cimino R. 1, Pintaudi C. 1, Mazzuca S. 2
1
S.O.C. Medicina Interna AOPC Catanzaro; 2Resp Medicina Interna casa di
cura Villa del Sole Catanzaro
Patients with inflammatory rheumatic disease have a heightened risk of
premature coronary heart disease and stroke. Emerging data suggest that
systemic sclerosis also is associated with an increased risk of atherosclerotic
CV events. Systemic sclerosis (SSc) is a connective tissue disease characte-
rized by excessive collagen deposition and by vascular hyperactivity and
obliteration of microvasculopathy. Vascular involvement is responsible of
some important clinical manifestations of the disease; more frequently Ray-
66
118° Congresso Nazionale - Società Italiana di Medicina Interna
naud’s phenomenon and digital ulcers (DU) with a deep impact on patients’
quality of life. Objectives: to determine the clinical burden of severe digital
vasculopathy we have reviewed hospital–based treatment for this important
complication of SSc in a single centre cohort and we aimed to elaborate risk
factors for developing new DU within six months from baseline evaluation
taking into account demographic, clinic-serological, and capillaroscopic
parameters. Moreover our aim was to evaluate the mortality by cardiova-
scular events of patients at 31 December 2016.
Methods: a total of 31 (24 Women- 7 Men) unselected consecutive SSc pts
with hystory of digital ulcers and using combined terapy (Iloprost-Bosen-
tan) were included in our study from 15 September to 31 December 2011,
and were reviewed during an 6-month period. They had mean age 51.2 years
(range 13-84), disease duration 12.2 years ± 7.5 (range 1-24). All met the
preliminary American College oh Rheumatology classification criteria for
SSc. And according skin cutaneous subsets: 18 pts (58.7%) with Limited
cutaneous SSc, 13 pts (41.3%) with diffuse cutaneous SSc. As expected all
pts suffer from Raynaud’s phenomenon and nailfold videocapillaroscopy
(NVC) was performed on all patients, and skin sclerosis was measured with
Rodnan Skin Score (mRSS). A wide patient’s anamnesis, with particular
attention to previous history of DU, was also recorded, as well as ongoing tre-
atments, mainly vasodilator or immunosuppressive therapies, and the pre-
sence of co morbidities potentially responsible for digital ischemia. Results:
During the 6-month period, 7 new DU were detected in our patients’ series
(7/31; 22.5%).(Group A with new digital ulcers 7 pts; Group B whithout
new digital ulcers 24 pts) In group A: 4 of patients were male and 3 were
female. All patients were given bosentan for a mean of 14(±10,3) months.
2 patients (F) were classified as limited and 5 (4 M /1F) as diffuse cutane-
ous SSc. Anticentromere autoantibodies (ACA) were positive in 3 patients,
anti-Scl-70 antibodies in 4 patient and antiphospholipid antibodies (APLA)
in one. There was not significant association between DU and treatment
with vasodilators and/or immunosuppressors, Complications that were
experienced in the past were mainly gangrene (30,7%), soft tissue infection
requiring systemic antibiotics (21,5%), and rarely osteomyelitis (6,4%). At
enrolment in the registry, analgesics and anti-inflammatories were admini-
stered to 25,6% of the patients, Among the topical treatments used (25,6%),
topical antibiotics were the most (15.3%), followed by non-adhering dres-
sing (6,4 %). Dry dressing was applied only in 3,2% and hydrocolloids in
3,2%. Among analyzed parameters, cutaneous SSc subsets, disease dura-
tion, history of DU in the last year, smoke, DLCO, CSURI, ESR, and CRP
showed a significantly positive association with DU. The frequency of DU
was significantly higher among the patients with diffuse cutaneous subset of
SSc compared with the patients with limited cutaneous SSc (p<0,001) More
Digital Ulcers were present at the end of the cold season from February to
May. All the 7 patients with new digital ulcers were admitted to hospital
at least once to receive intravenous prostacyclina or immunosuppressors
during the 6 month window.Four patients required multiple admissions;
with a mean duration of 9 days, which accounted for a total of 58 bed-days,
all the patients required parenteral antibiotic for infected digits and needed
opioid analgesic for DU-related pain. At the follow-ups at December 2016:
4 patients (57,1%) (group A) were died vs 1 pts (group B)(4,1%) p<0,001.
In group A, 3 patients(2 M, 69 and 62 years old- 1 F, 42 years old) were died
for coronary heart disease, one patient (F, 77 years old) for cerebrovascular
disease. In-group B one patient (F, 50 years old) for gastric cancer.
Conclusion: New Digital Ulcers in SSc are markers of mortality for car-
diovascular events. In this small series, patients with worse outcomes had
longer follow-up and late diagnosis, already with end-organ damage. More
recent patients have better results even at older ages, mirroring earlier refer-
ral and improved bundles of care.
FUO. WHEN THE SOLUTION COMES FROM THE CLINIC
Appice C. 1, Nuzzo M. 1, Buonamico P. 1, Minerva F. 1,
Palmieri V.O. 1, Pugliese S. 1, Cacciapaglia F. 2, Amati A. 3,
Belfiore A. 1, Portincasa P. 1
1
Clinica medica “A. Murri”, Dept. of Biomedical Sciences and Human
Oncology, University of Bari 2Dept. of Rheumatology, University of Bari
3
Dept. of Neurophysiopathology, University of Bari
A 64 years old patient was admitted with fever, arthralgia and myalgia at the
lower limbs starting one month earlier. He suffered from gastro-oesopha-
geal reflux disease, and had diaphragmatic relaxation. He was on a proton
pump inhibitor. During admission, the patient presented nightly fever (up
to 38°C), general and lower limbs’ weakness, muscular hypotrophy (espe-
cially of the legs). Laboratory tests showed neutrophil leukocytosis (WBC
14140/mm3; Neutrophils: 86.5%) and increase inflammatory indices
118° Congresso Nazionale - Società Italiana di Medicina Interna Comunicazioni Orali

(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,
Tosi B. 2, Mandoli M. 2, Galanti G.2
1
Sports Medicine Centre- AOUC- Clinical and Experimental Department-
University Florence, Italy;2Division of Nephrology, University Hospital
Careggi;3Engineering and Architectural Department-University of
Trieste;4Medical Affairs Department – Esaote S.p.A,2Sports Medicine Center
-Clinical and Experimental Department-University of Florence-Italy
Purpose: A growing evidence indicates that Global Longitudinal Strain
(GLS) by 2Dimensional Speckle Tracking Echocardiography (2DSTE)
provides incremental and earlier information than conventional ejection
fraction (EF) in detecting subtle changes of myocardial contractility and
Left Ventricular (LV) function. Renal transplant recipients (RTR) maintain
anyway high cardiovascular risk and mortality despite in complete absence
of symphoms. Physical exercise is often allowed even if the potential addi-
tional risk. The aims is to study the role of GLS in RTR with preserved EF
when involved in the exercise as prescription program.
Methods: The study included 40 RTR clinically stable and submitted to a
mixed (aerobic and resistance) exercise program, which was defined on an
individual basis according to the ACSM guidelines. All the subjetcts were
evaluated by GLS. It was calculated using 2DSTE (XStrain-ESAOTE). 2D
echo parameters were measured by using MyLab Seven. The EF was mea-
sured using Simpson’s biplane method. RTR followed the exercise program
prescribed at time for a period of at least 12 months during which periodical
re-evaluations of the main 2D echo parameters and of the GLS were perfor-
med. ANOVA test was used to compare the data.
Results: The mean GLS at baseline was -19.2 % ±5.1 and EF was 62.7±4.
GLS was very significantly (p<0.01) higher after 6 months of exercise (GLS
23.7 % ±4.1) and it maintained significant increase (p<0.05) after 12 M
(GLS: 24.4 % ±1.5) despite no significant variation of EF (62.7±4; 65.4 ±3;
64.7±5).
Conclusions: Regular physical exercise produces positive effects on myo-
cardial performance in RTR as demonstrated by GLS data. GLS could
contribute to the early detection of eventual subtile heart’s damage. This
parameter might be helpful for the implementation of the 2D echo data
especially in the long term follow- up of regularly traininig.
Oggionni G. 1, Sala R. 1, Spataro A. 3, Malacarne M. 1,2, Benzi M. 3, Tamorri
S. 3, 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: Optimal autonomic regulation and stress resilience might
be considered critical elements of athletic performance. Autoregressive
spectral analysis of heart rate variability (HRV) may represent a convenient
tool in order to define autonomic nervous system (ANS) control. It furni-
shes a set of different variables and autonomic information may be une-
venly distributed through derived indices thus impairing a friendly and
consistent use of the technique in clinical settings. Moreover the influence
of age and gender must be accounted for a correct clinical interpretation of
HRV derived variables. In order to overcome these problems, we develo-
ped a novel unitary autonomic index for sports (ANSIs). In this study we
hypothesize that this Index, together with a somatic stress related symptom
score (4SQ), might help characterize athletes who were eventually selected
for the Rio 2016 Olympic Games Italian team (Rio +).
Methods: In this retrospective study we examined 778 athletes (age
24.4±6.7 yrs) who underwent a planned yearly pre-participation screening.
All athletes underwent clinical, autonomic and exercise ECG evaluation.
The combination of vagal and sympathetic indices from RR variability into
ANSIs was performed by radar plot and percent ranking of index variables.
We assessed (Rio+) versus (Rio –) athletes also after subdivision into three
sport intensity groups (low, mid and high intensity).
Results: Overall there were no significant differences between (Rio +)
and (Rio -) athletes when considering single individual spectral derived
variables. Conversely, the unitary Index ANSIs was significantly higher in
(Rio +) compared to (Rio-) athletes (respectively 54.5±29.5 and 47.9±28.4
p=0.014). This difference was particularly evident (p=0.017) in the group
of athletes characterized by both high static and dynamic components.
Considering separately the three sport groups, 4SQ was significantly
more elevated in the (Rio-) group of athletes competing in specialties
with low or medium intensity activity levels (Low Intensity: 22.9±22.8
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
Comunicazioni Orali
Conclusions: ANSIs, a proxy of quality of cardiac autonomic regulation
and simple assessment of resilience to stress, may differentiate Italian athle-
tes who were eventually selected for participation in the 2016 Rio Olympic
Games from those who were not, suggesting the possibility of a “winning
functional phenotype”. The possibility to have a unitary index, which
permits to weigh the different ANS impairment associated with various cli-
nical conditions or different level of training, may overcome some of the
difficulties in the practical interpretation of different HRV variables, facili-
tating a wider use of ANS evaluation in clinical settings.
EARLY REPOLARIZATION AND THE TPEAK-TEND
INTERVAL: THE PREVALENCE OF SOME ECG MARKERS
IN A POPULATION OF YOUNG ATHLETES
Patti A. 1, Neunhaeuserer D. 1, Boschiero F. 1, Gasperetti A. 1, Zaccaria M. 1,
Bergamin M. 1, Ermolao A. 1
1
Sport and Exercise Medicine Division, Department of Medicine - University
of Padova (Italy)
Background: Early repolarization (ER), the Tpeak-to-Tend interval (TpTe)
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
these parameters in a population of young athletes.
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
morphology and amplitude and ST-segment morphology were assessed.
Furthermore, the TpTe and TpTe/QT variables were analyzed using two cut-
offs (100 msec and 0.25), based on values previously associated with higher
arrhythmic risk.
Results: Out of the total number of athletes assessed by the study, 27.4%
showed ER, more frequently present in the inferior leads (40%). The majo-
rity presented a notched morphology (72.3%) and/or a horizontal/descen-
ding ST segment pattern (46.7%). Training load appeared to be associated
with an increased J-point amplitude and resulted higher in athletes with an
ascending compared to a horizontal/descending ST morphology. The mean
TpTe value and TpTe/QT ratio were 66.3±9.3 msec and 0.19±0.03, respecti-
vely. Three subjects showed a TpTe interval > 100 msec, and 11 had a TpTe/
QT > 0.25.
Conclusions:: Young athletes have a higher prevalence (27.4%) of ER with
respect to the population at large. In contrast with preceding findings, our
study uncovered a majority of ER patterns that were previously correlated
with increased arrhythmic risk. Finally, exercise training appeared to have
an impact on the ER patterns. The study also revealed useful data about
the TpTe and TpTe/QT values in a large, poorly investigated population of
young athletes. Further in-depth studies investigating the clinical signifi-
cance of ER, TpTe and the TpTe/QT ratio are warranted.
USEFULNESS OF TWO-DIMENSIONAL ECHO STRAIN
IN EVALUATION OF CARDIAC FUNCTION IN ELITE
ATHLETES
Tosi B., Leone B., Toncelli L., Galanti G.
Sport and Exercise Medicine Unit – Departement of Clinical and
Experimental Medicine – University of Florence - Italy
Introduction: It has been largely showed that the cardiovascular adaptation
to sport training is influenced by many factors, including the intensity and
the kind of sport practiced. Classically, the so called “Morganroth hypothe-
sis” was worldwide accepted in literature: static exercise, characterized by a
pressure load to the heart, was differentiated from dynamic (isotonic) exer-
cise, which involves a volume load to the heart. These different loads lead to
different pattern of myocardial adaptation. More recent studies revisited this
hypothesis, showing that left ventricular (LV) remodelling pattern, obser-
ved in both resistance and endurance trained athletes, presented similar
aspects. It has been shown that two-dimensional strain analysis can specifi-
cally study the contractile function of different myocardial regions of inte-
rest, quantifying intraventricular dyssynchrony and evaluating components
of myocardial function. Although morphological modifications secondary
to exercise have been largely studied, less is known on myocardial systolic
function in different LV remodeling patterns in elite athletes.Aim: in this
study we aim to underline possible differences in contractile myocardial
function with strain analysis in two groups of elite athletes, trained with
68
118° Congresso Nazionale - Società Italiana di Medicina Interna
different loads and playing different sports (football and cyclism).
Material and Methods: We enrolled 47 male athletes: 23 football players
and 24 cyclists, belonging to same football or cyclism team (mean age in
both groups 18±3 years old). The athletes were all evaluated with echo-
cardiography at the beginning of the sports season, after a one-month
detraining. We assessed LV contractile function using speckle-tracking
echocardiographic global longitudinal strain (GLS) and global circumfe-
rential strain (GCS). We also analysed right ventricular function by strain
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
a significantly higher GCS was found in cyclists than in football players
(31.2±0.04 and 27.2±0.05 respectively, p< 0.005). The cyclist group showed
a significant increase in right ventricular strain compared to football players
(26.3±0.04 and 23.2±0.04, respectively, p< 0.05).
Conclusions: All values on contractile function were between the normal
range, although our preliminary data suggest that a dynamic exercise, which
involves a volume load, like cyclism, lead to a sensible increase in systolic
function in elite athletes especially in right ventricle contractility. Further
investigation are needed to improve our sample and to correlate with other
standard echocardiographic parameters.
20 YEARS OF HOLTER ECG MONITORING IN SPORTS
POPULATION
Ariani R., Bartoletti A., Galanti G.
Sport and Exercise Medicine Unit – Department of Clinical and
Experimental Medicine – University of Florence - Italy
Introduction and Aim: Arrhythmias are a common finding in the popula-
tion that practices sports activity or in athletes and sometimes their clini-
cal interpretation is not easy. Thus we aimed to analyze the recordings in a
group of subjects who underwent a 24-hour or weekly Holter ECG moni-
toring in order to assess the presence of arrhythmias in a large cohort of
sportives.
Methods: We enrolled 6172 patients with a mean age of 35 years old with
a median age of 22, not selected and consecutive, since April 1997 to April
2017. Revision analysis was performed by Holter Analysis System (Space-
labs Healthcare, LLC, California) on a sample of 10903 Holter ECG registra-
tions, focusing on the ECG features, such as arrhythmias (origin, number,
complexity), conduction disorders and channellopathies.
Results: The total number of patients who placed the Holter ECG was
6172 (68,63% male and 31,37% female). The 27,8% of subjects (n=1716)
had a semiannual or yearly Holter ECG follow-up, composing the 58,7%
of the total amount of recordings. The total number of registrations with
Sino-Atrial Block was 43, with Atrio-Ventricular Blocks (AVB) 1427, of
which I degree AVB (54%), II degree AVB type 1 (35,45%), II degree AVB
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
3 with LPFB. The total of subjects with ventricular pre-excitation was 199.
Those with Brugada syndrome was 17 and 8 with LQTS. The total amount
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
(1,69%). Single ectopic beats was present in 8577 recordings, Couples in 2379,
SVT in 1605, Atrial Fibrillation in 191, Atrial Flutter in 30. The total amount
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
(3,79%). Single ectopic beats were present in 7525, Couples in 1780, Triplets
in 381, VTs in 183, AIVR in 214, Monomorphic in 4747, Polimorphic in 2808.
Conclusion: In the Holter recordings we examined, we found that there was
a clear prevalence of arrhythmias (91,37%) compared to the conduction delay
(16,26%) and the channellopathies (0,41%). Analyzing in detail the features of
the arrhythmias we observed that a quarter of the population of the study had
more than 100 beats/24h and that more than one fourth of the athletes exa-
mined had complex supraventricular arrhythmias (28,03%) or complex ven-
tricular arrhythmias (23,85%). This finding leads us to say that in the general
population arrhythmias are a common event and they are often compatible
with sports practice.
Abbreviations and Acronyms: AIVR = Accelerated idioventricular rhythm;
AVB = Atrio-ventricular Block; LAFB = Left Anterior Fascicular Block; LBBB
= Left Bundle Branch Block; LQTS = Long QT Syndrome; LPFB = Left Poste-
rior Fascicular Block; RBBB = Right Bundle Branch Block; SVT = Supraven-
tricular Tachycardia; VT = Ventricular Tachycardia
118° Congresso Nazionale - Società Italiana di Medicina Interna Comunicazioni Orali

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
POSTER
1. AUTOSOMIC DOMINANT HYPER IGE SYNDROME –
THE IPINET ADULT COHORT
Carrabba M. 1, Fabio G. 2, Dellepiane R.M. 3, Cossu F. 4, Specchia F. 5,
Badolato R. 6, Pietrogrande M.C. 7
1
Internal Medicine Department, Fondazione IRCCS Ca’ Granda Ospedale
Maggiore Policlinico di Milano, 2Internal Medicine Department, Fondazione
IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano & Università
degli Studi, 3Department of Pediatrics, Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico di Milano, 4Centro TMO Ospedale Regionale
Microcitemie Clinica Pediatrica Università di Cagliari, 5Istituto di Clinica
Pediatrica Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.
Orsola Malpighi di Bologna, 6Clinica Pediatrica Spedali Civili di Brescia
& Università degli Studi di Brescia, 7Department of Pediatrics, Fondazione
IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano & Università
degli Studi di Milano
Background: Autosomal dominant hyper-IgE syndrome (AD-HIES) or
Job’s syndrome is very rare primary immunodeficiency with a wide array
of clinical features caused by dominant negative mutations in signal tran-
sducer and activator of transcription 3 (STAT3). Mutations in STAT3 were
identified as the link between recurrent infections and connective tissue
abnormalities. AD-HIES is characterized by eczematoid rashes, skin absces-
ses, recurrent sinopulmonary infections, mucocutaneous candidiasis, and
malignancies. Rashes usually start within the first few weeks of life, typically
presenting as pustular or eczematoid eruptions on the scalp and face. Ecze-
matoid dermatitis appears to be Staphylococcus aureus driven. Recurrent
sinopulmonary and lung infections common in HIES are predominately
caused by S. aureus, with Streptococcus pneumoniae and Haemophilus
species less frequently associated. Pyogenic pneumonias result in bron-
chiectasis and pneumatoceles frequently. Surgical resection can be neces-
sary. AD-HIES is associated with an increased risk of malignancies—most
notably non-Hodgkin’s lymphoma, with the majority being of B cell origin
and aggressive histology. The pleiotropic nature of STAT3 accounts for the
multitude of changes in HIES, not only immunological but also craniofacial,
musculoskeletal, dental, and vascular abnormalities. Laboratory abnormali-
ties in HIES include eosinophilia and IgE usually elevated above 2, 000 IU/
uL. Patients with HIES have very little in the way of allergies or anaphylaxis
to foods. This study aims to describe a cohort of adult patients with autoso-
mal dominant Hyper-IgE Syndrome (AD-HIES) with a long time follow-up
recorded in the National Registry of the Italian Network for Primary Immu-
nodeficiencies (IPINet).
Methods: Adult AD-HIES patients recorded in the IPINet Registry with
available follow-up have been considered.
Results: Adults HIES patients are 23 of 37 (62%). Follow up was recorded in
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).
Onset symptoms were infections for 84.6%, dermatologic involvement for
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-
sis, all the patients started prophylaxis: 92.3% antibiotics, 69.2% antifun-
gals and 7.7% antivirals. Manifestations at clinical diagnosis were eczema
92.3%, skin abscess 84.6%, chronic mucocandidiasis 84.6%, pneumonia
84.6%, pneumatocele 69.2%, lobectomy 53.8%, osteoporosis 23.1%, abnor-
mal bone fractures 30.8%. During follow-up nor lobectomy or bone fractu-
res were observed. At clinical diagnosis, serum IgE mean levels was 14725
(DS±17514.4), at last follow-up 12101 (DS±12131.8). The 63.3% of patients
had positive RAST for 70%-100% of the aero- and food allergens tested,
but they had skin prick tests positive only for 8%-40% of the correspon-
ding allergens. Two patients died aged 28 and 39 years for pulmonary ble-
eding and cancer, respectively. Conclusions: Patients affected by AD-HIES
need to be referred to IPINet Centres because they need physicians with
expertise in these primary immunodeficiency. Indeed, promptly diagnosis,
prophylactic therapy improves outcome and can impact AD-HIES patients’
expectation of life.
2. ANGIOEDEMA RELATED TO ACE I: A CASE SERIES
Carucci L. 1, Bova M. 2, Petraroli A. 2, Sutic A. 3, Morovic- Vergles J. 3, Marone
70
118° Congresso Nazionale - Società Italiana di Medicina Interna
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
Immunology, Allergology and Rheumatology, Department of Internal
Medicine, University of Zagreb School of Medicine, University Hospital
Dubrava
Background: Angiotensin-converting enzyme inhibitor-related angioe-
dema (ACEI-AAE) occurs in 0.1-0.7% of patients treated with ACE-inhi-
bitors (ACEI), with potentially serious consequences requiring immediate
attention. ACEI-AAE is a nonpitting edema that can affect any area of the
body, usually involving the face and upper airways. There are no speci-
fic diagnostic biomarkers, so the diagnosis is based on exclusion of other
causes of angioedema in patients taking ACEI. In this study we present the
clinical features of a cohort of patients(pts) with ACEI-AAE followed up at
the Angioedema Centers of Universities of Naples and of Zagreb.
Methods: Patients who presented to our Departments with history of angio-
edema without wheals after the initiation of ACEI therapy, were studied.
C1-INH deficiency angioedema and all allergological causes were ruled out.
Patients’ demographic information, duration of ACE-I use, onset of symp-
toms after starting therapy, attacks frequency and duration, symptoms and
anatomic sites involved, were obtained from each patient’s chart and inter-
view. Each patient signed informed consent.
Results: Thirty Caucasian patients, all affected by hypertension (46.7% F;
median (m.) age at symptoms onset 61.23yrs, range (r.)46-80yrs) were dia-
gnosed with ACEI-AAE. The average time of symptoms onset after star-
ting therapy was 4.7yrs (r.0, 08-20 yrs); 5.9 yrs was the average of therapy
duration. The estimated diagnostic delay was 1.2 yrs. Lips were the most
common affected site (20 pts, 66.7%); 56.7% of pts described tongue invol-
vement. In 8 cases there was larynx edema (21.4%). Other affected sites were
face (30%), hands (3.3%), foot (3.3%) and genitalia (13.3%). Frequency of
attacks varied greatly from pts to pts (m. 6.13 attacks/yr, r. 1-52 episodes/yr),
such as edema duration (m. 36, 45 hours, r. 3-168 hours). 68% of pts requi-
red hospitalization, with no endotracheal intubation. We followed up pts
up to 10 yrs after the diagnosis. During the follow up 92.8% of pts referred
no attacks. One patient had 1 attack/3 months during the first year; another
one had 1 attack/week during the first month and last one referred only 1
attack after the end of ACE-I. 9 pts (30%) after the beginning of symptoms
switched to sartans and only one pt showed a single angioedema attack after
4 days from the onset of therapy (no more attacks after sartan discontinua-
tion). Before diagnosis, all pts were treated with steroids and antihistamines
without response. 4 pts complained itching during attacks and two of them
presented wheals too.
Conclusion: ACEI-AAE is a rare side effect but it can be a medical emer-
gency. Our data confirm that the majority of ACEI-AAE are severe enough
to require hospitalization. Discontinuation of ACEI can stop the edema
attacks but sometimes is not enough to break up symptoms. The presence of
itching and wheals may not be sufficient tips to exclude ACEI-AEE.
3. THE “RED” PATIENT: AN EXAMPLE OF DIFFERENTIAL
DIAGNOSIS IN INTERNAL MEDICINE
Di Fino L., Mastrofilippo T., Castrovilli A., Vella F.S., Sabbà C.
Department of Internal Medicine, University of Bari “Aldo Moro” - Bari
(Italy)
A 57-year-old man presented on December 2016 to our Medical Unit with a
diffuse cutaneous erythematous rash, oral and nasal mucositis, generalized
edema, fever and productive cough occurring for 4-5 days, upon tapering
of long-term steroid therapy, as he was being treated for a febrile dermatitis
of unknown origin.
His past history was remarkable for Dilated Myocardiopathy with implant
of AICD, aortic and mitral replacement with mechanical prosthesis, Atrial
Fibrillation, and weight loss of 12 kg in last 6 months. On June 2016 he
started therapy for hyperuricemia with allopurinol, without any relevant
side effects. Four weeks later, a diffuse erythematous desquamative rash
suddenly appeared, accompanied by fever (39°C) and oral vesicular invol-
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
i.v. methylprednisolone 20 mg b.i.d. with benefit. However, each attempt of
tapering corticosteroids resulted in severe re-exacerbations of clinical mani-
festations, which ultimately prompted emergency hospitalization in our
118° Congresso Nazionale - Società Italiana di Medicina Interna
Unit. On admission he was febrile (39°C), pulse: 80 bpm, blood pressure:
110/60 mmHg. He had a diffuse erythematous desquamative rash, peri-na-
sal and peri-oral herpes-like lesions, conjunctival burning, generalized
edema and onychodystrophy. He presented a vesicular murmur reduction
bilaterally, with diffuse rhoncus and expiratory wheezing. Laboratory inve-
stigations showed increased WBC levels (15, 2x103/uL), with evident hype-
reosinophilia (Neu 63%, Lym 21, 4%, Eo 10%), abnormal AST 401 U/L (n.v.
15-37), ALT 340 UI (n.v. 12-78), GGT 360 U/L (n.v. 15-85), ALP 197 U/L
(n.v. 50-136), lipase 488 U/L (n.v. 73-393), amylase 96 U/L (n.v. 8-53), CRP
11, 8 mg/L (n.v < 2, 9), and normal ESR (4 mm/h, n.v.<15) and electropho-
resis. Pneumonia was suspected by pulmonary X-ray; EKG showed atrial
fibrillation; echocardiography highlighted an endocarditic vegetation on
AICD electrode. He was treated with piperacillina/tazobactam 4, 5 g thrice
a day and Metilprednisolone 40 mg/die i.v., which permitted improvement
of cutaneous manifestations and laboratory test normalization. Diagno-
sis of endocarditis was confirmed by Transesophageal Echocardiography
and blood culture positivity for S. Aureus, with a complete laboratory and
instrumental remission upon appropriate treatment with Teicoplanin (12
mg/kg/daily, 8 weeks) i.v. Upon a new corticosteroid tapering, severe relap-
sing of cutaneous and respiratory symptoms and signs occurred. Thoracic
HR-CT disclosed an interstitial pneumonia, confirmed by markedly posi-
tive CMV-DNA PCR and HCMV antigenemia IFA test. Furthermore, viral
panel screening detected reactivation of other herpes-viruses (HHV6 and
HHV8). Complete remission of clinical, radiologic and laboratory abnor-
malities was obtained with i.v. administration of ganciclovir (5 mg/kg b.i.d.,
8 weeks), methilprednisolone 40 mg/kg/daily and immunoglobulin (400
mg/kg over 5 days). To gain insight into the etiological origin of recurrent
febrile erythematous rash, several investigations were undertaken. Parane-
oplastic syndromes were ruled out by negative Total body-CT and neopla-
stic markers, as well as no sign of mycosis fungoides or Sézary syndrome
was found by performing peripheral blood flow cytometry immunophe-
notyping and cutaneous biopsy. In addition, erithrodermic psoriasis was
excluded by the absence of other cutaneous and rheumatologic features,
despite presence of HLA-Cw6 and HLA-DR7. This complex case matched
diagnostic criteria for DRESS/DIHS (Drug Rush with Eosinophilia and
Systemic Symptoms- Drug Induced Hypersensitivity Syndrome) subse-
quent to treatment with allopurinol. In particular, a typical DRESS/DIHS
was diagnosed, due to the presence SCAR-J Diagnostic Criteria (7 of 8 cri-
teria positive). This “red” patient is an interesting example of differential
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-
gnostic process with multiple confounding factors. In conclusion, DRESS/
DIHS should be suspected when a patient presents with unexplained recur-
rent “scratch dermatitis”. A careful medical history is mandatory, with parti-
cular attention to ongoing pharmacological treatment, since a drug-induced
hypersensitivity syndrome can manifest with a flare up of disease, including
worsening liver, pancreatic or pulmonary function, which can be concealed
by a number of confounding factors.
4. A PRURIGINOUS THYROIDITIS
Cerasi C., Biferi E., Vertolli P., De Feo M., Stamerra C.A., Ferri C.
University of L’Aquila, Department of Life, Health and Environmental
Sciences, Division of Internal Medicine and Nephrology, San Salvatore
Hospital, L’Aquila, Italy
Introduction: Graves’ disease (GD) is an autoimmune thyroid disease.
Patients with GD usually present with common manifestations, in a classic
clinical picture.
Case Report: A 28 year-old-girl, student, was brought to our Department
for a clinical presentation caratterized by palpitation, tremors, breathles-
sness, anxiety and weight loss (5 Kg in 1-month period).She had no chronic
illness and was not on any medication. No drug allergy. Her father has an
history of type 1 diabetes, previous hyperthyroidism, which was treated
with radioiodine. Physical examination revealed fine tremor when arms are
extended, her heart rate was 120, her thyroid was enlarged and non-ten-
der. The patient’s vital signs, physical finding and clinical presentation were
suggestive of thyrotoxicosis. The diagnosis is confirmed with blood test
(TSH< 0.0001mIU/L (normal values 0.27-4.2), FT3 10.73 pg/ml (normal
values 2-4.4), and positivity of anti-TSH receptor antibodies (ATRAs 15
IU/L, normal values <1.5).Thyroid echography depicted goiter with hetero-
geneous echogenicity and increased vascularity. She received methimazole
(20 mg QD) and atenolol (50 mg QD). After 10 days of therapy, following
evening meal with cheese and nuts, appeared a pruriginous urticaria throu-
Poster
ghout the body surface, for which she has taken betamethasone and chlor-
phenamine. After five days, for recurrence of hives, the primary physician
advised to suspend methimazole, which in 3% of cases is associated with
this side effect. Propylthiourea was initiated, but daily skin manifestations
continued. The duration of the skin lesions lasted for 5-10 hours and resol-
ved spontaneously. All therapy was suspended and the patient was candi-
date to radioiodine therapy. Prick test, patch test, rast test, hemocromocyto-
metric examination, liver and kidney function were performed which did
not show any alteration or indication of allergic genesis. The total IgE was
9 KUA/L, into normal range (normal values 0-200 KUA/L). The autologous
serum skin test (ASST) was positive, strongly suggesting an autoimmune
pathogenesis of CU. ANA-test, ENA screening, HCV, HP, celiac test were
negative, high anti Tg-antibody and anti-TPO antibody were found (anti
Tg antibody 170 IU/ml, normal values 0-60, anti-TPO antibody 405 IU/
ml, normal values 0-20).The patient was then treated, with double dose of
third generation antihistaminic, with poor control of the sypmtoms, waiting
to decide to undergoing therapy with Omalizumab. The young woman was
meanwhile undergoing to radiometabolic therapy. After one months, when
thyroid function returned to normal, urticaria was only minimally evident
and was readily controlled by antihistaminic therapy, till the suspension.
Discussion:Chronic uricaria (CU) is defined as recurrent episodes of hives
for at least 6 weeks. CU is a common disorder with an estimated prevalence
of 0.5-5% in general population. Although there are several and numerous
systemic illness, drug or infection, no definitive cause of CU can be iden-
tified despite a thorough medical evaluation in 80-85% of cases. The asso-
ciation between CU and various autoimmune disorders, including thyroid
disease has been recognized as indirect evidence of an autoimmune entity
of CU. The hypothesis is the presence of IgG autoantibodies direct against
antibodies a subunit of the high-affinity IgE receptor. This activates blood
basophils and cutaneous mast cells, resulting in the release of histamine.
While the frequency of anti-TPO antibodies is universally considered to be
higher in CU, there are few publications on the prevalence of ATRAs in
this condition. In our case, the urticaria was secondary to multiple thyroid
disfunction. Physicians should consider of hyperthyroidism in chronic urti-
caria, especially if the urticaria is refractory to standard therapy, there are
symptoms suggestive of thyroid dysfunction or there is a family history of
thyroid disease. The mistakes can be to confuse this manifestation as an
allergic cutaneous reactions of methimazole therapy. The urticaria may, in
same cases, be improved with treatment of thyroid condition.
5. A CASE OF HYPOCOMPLEMENTEMIC URTICARIAL
VASCULITIS SYNDROME (HUVS) SUCCESSFULLY
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
1
Unità di Allergologia Università Cattolica del Sacro Cuore - Policlinico “A.
Gemelli”, Roma 2 Unità di Immuno-reumatologia Università Campus-Bio
Medico di Roma 3 Unità di Geriatria Università Campus-Bio Medico di
Roma
We present a 47-year-old woman without relevant comorbidities who refer-
red to our University Allergy Center with a 3-year history of generalized,
itchy and burning daily flares of urticaria. She also complained arthralgia,
abdominal pain and diarrhea. On admission, physical examination revealed
diffuse vasculitic itching lesions and symmetric arthritis of second and third
proximal phalangeal and metacarpal joints. Blood tests were normal with
the exception of a strong complement depletion (C3 0.17 g/L, normal range
0.9-1.8, C4 0.24 g/L, normal range 0.1-0.4). She had no infections, no appa-
rent major organ involvement, no antibody positivity, normal IgE serum
levels, normal thyroid parameters and negative physical testing. Antihista-
mines and prednisone 8 mg/die were administered with no relief of symp-
toms and no improvement of urticaria. Colonscopy was also negative. A
skin biopsy was performed and showed perivascular and dermic eosinophi-
lic infiltrates with focal vessel damage confirming urticarial vasculitis. The
patient fulfilled diagnostic criteria for HUVS1 so antihistamines (up to four
times per day) in combination with hydroxychloroquine (200 mg/day), pre-
dnisone (0.5 mg/kg being tapered to 0.1 mg/kg) and cyclosporine A (CSA
3 mg/kg) (soon suspended for worsening of diarrhea) were administered.
A significant improvement of arthralgia was achieved with no response on
gastrointestinal involvement and urticaria (Urticarial Activity Score (UAS)
of 32 points). Omalizumab 300 mg monthly was added and after the second
injection complete remission of gastrointestinal symptoms and urticarial
(UAS of 0) was achieved and then maintained for the entire duration of
the treatment (25 weeks). Complement serum levels normalized allowing
71
Poster
a gradual prednisone discontinuation. One month after Omalizumab with-
drawal the patient presented a stronger exacerbation of diarrhea, abdominal
pain and urticaria (UAS of 37 points). Omalizumab 300 mg monthly was
so readministered leading to a complete remission of urticaria (UAS of 0)
and gastrointestinal symptoms. Management of HUV is very challenging:
while oral antihistamines are just palliative, hydroxychloroquine (HCQ),
colchicine and corticosteroids represent first-line therapy, with a complete
cutaneous response achieved in less than 50% patients. Other immunosup-
pressive drugs, especially Cyclosporine (CyA), cyclophosphamide (CYC)
and rituximab (RTX), have higher rates of efficacy, although they are burde-
ned, as well as steroids, by higher incidence of side effects2. Omalizumab, a
humanized anti-IgE monoclonal antibody recently approved for treatment
of chronic spontaneous urticaria (CSU)3, has been recently shown to be not
effective in a case of HUVS4. This is, to our knowledge, the first report of
successful treatment of HUVS with Omalizumab.
References:
1. Schwartz HR, McDuffie FC, Black LF, Schroeter AL, Conn DL. Hypo-
complementemic urticarial vasculitis: association with chronic obstructive
pulmonary disease. Mayo Clin Proc 1982;57:231–8.
2. Sussman G, Hébert J, Barron C, Bian J, Caron-Guay RM, Laflamme S et
al. Real-life experiences with omalizumab for the treatment of chronic urti-
caria. Ann Allergy Asthma Immunol. 2014 Feb;112(2):170-4.
3. Jachiet M, Flageul B, Deroux A, Le Quellec A, Maurier F, Cordoliani F et
al. The clinical spectrum and therapeutic management of hypocomplemen-
temic urticarial vasculitis: data from a French nationwide study of fifty-se-
ven patients. Arthritis Rheumatol. 2015 Feb;67(2):527-34.
4. Aurich S, Simon JC, Treudler R. Omalizumab does not improve skin
lesions in a patient with hypocomplementemic urticarial vasculitis syn-
drome. J Eur Acad Dermatol Venereol. 2017 Mar 8.
6. FLOGOSIS AND HEART INVOLVEMENT IN LARGE
VESSEL VASCULITIS
Cicco S., Mersini X., Noviello S., Cirulli A., Longo S., Leone P., Battaglia S.,
Dammacco F., Racanelli V.,Vacca A.
Dept. of Internal Medicine and Clinical Oncology, University of Bari Medical
School
Large vessel vasculitis (LVV) symptoms are related to increase wall thick-
ness. Heart is usually excluded but indirect effect could determines modi-
fications.Aim of this study was to describe heart involvement regarding
common flogosis parameters. We analyzed 17 LVV (4 M, 54±20 years). All
patients underwent to laboratory analysis, ultrasound and doppler of big
arteries and heart. Maximum Blood pressure (BP) measured was conside-
red in this study. Left ventricular hypertrophy was present in 12 patients.
Among others, 3 present a concentric remodeling. 12 present a diastolic
dysfunction. Aortic root normalized for body surface area was dilated (Aoi;
19.19±2.52 mm/m2) and wall thickened (3.96±0.83 mm). Aortic valve was
regurgitant (AR) in 8. Framingham score was 21.69±16.09%. Other parame-
ters were: Uric Acid 4.04±1.01 mg/dl, CRP 46.30±58.33, ESR 42.86±32.38,
C3 1.19±0.26 mg/dl, Systolic BP (SBP) 125.6±21.28 mmHg and Diastolic
(DBP) 72.5±8.4 mmHg. A direct correlation was found with SBP and Uric
acid (p=0.04), ESR (P=0.008), diastolic dysfunction (p=0.02), and Framin-
gham score (p=0.03) while was found inverse with aortic wall thickness
(p=0.01). CRP was directly correlated to C3 (p=0.02) but inversely with
aortic wall thickness (p=0.04); ESR was directly correlated to C3 (p=0.003),
Aoi (p=0.03), inversely to aortic root thickness (p=0.008). Uric Acid was
directly correlated to diastolic dysfunction (p=0.008) and AR (p=0.01).
Aortic wall thickness was directly related to Aoi (p=0.01) and inversely to
diastolic dysfunction grade (p=0.009), SBP (p=0.01), uric acid (p=0.003),
ESR (p=0.008), and CRP (0.049). Aoi was directly related to C3 (p=0.009)
and to wall thickness (p=0.01). In conclusion LVV could lead an increase in
heart dimensions not related to systemic inflammation nor to blood pres-
sure. On the contrary, the reduction in diastolic function should have also
an inflammatory genesis. Aortic root present an increased diameter due to
inflammatory status despite active flogosis did not appear the main actor in
wall thickning. Uric acid appear related to vasa remodeling.
7. ANALYSIS OF AORTIC REMODELING AND STIFFNESS
IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA
SYNDROME (OSAS): PRELIMINARY RESULTS
S. Cicco 1, G. Castellana 2, L. Marra 2, V. Di Lecce 2, S. Dragonieri 2,
P. Carratù 2, G. Ranieri 1, O. Resta 2, A. Vacca 1
72
118° Congresso Nazionale - Società Italiana di Medicina Interna
1
Dept. of Internal Medicine and Clinical Oncology, 2 Dept. of Cardiac,
Thoracic, and Vascular Science, Institute of Respiratory Disease, University of
Bari Medical School, Italy
Background: Obstructive Sleep Apnea (OSA) is a well-known risk factor
for cardiovascular diseases. Several studies have shown that OSA is associa-
ted with vessel remodeling. Few studies have examined aorta in OSA.Aim:
To analyze the link between aortic root diameter (ARD) and severity of OSA
or diurnal value of PaO2 and PaCO2.
Methods: We studied 30 consecutive OSA patients (22 males and 8 females,
aged 58.5±13.2 years). All patients underwent to a morning blood gas
analysis, a full cardiorespiratory evaluation, including nocturnal poligraphy
and echocardiography, with measurement of ARD and aortic stiffness
index (ASI). Patient were divided in two groups: Group 1, non-severe OSA
(Apnea-Hypopnea Index - AHI - <30, 14 pts) and Group 2, severe OSA
(AHI >30, 16 pts). Statistical significance: p ≤0.05.
Results:No difference has been found between groups in ARD as absolute
value (Group 1, 33, 64 ± 0, 91 mm; Group 2 33, 64 ± 1, 02, p=ns) and nor-
malized value for the body surface area – Aoi (Group 1 16, 72 ± 0, 63 mm/
m2; Group 2, 16, 09 ± 0, 44, p=ns). Moreover, no difference has been found
in ASI (Group 1, 3, 62 ± 0, 183; Group 2, 3, 51 ± 0, 19, p=ns). Conside-
ring all OSA patients, AHI has shown an inverse correlation with Aoi (p=0,
018) and ASI (p=0, 0449). Moreover ASI has shown a direct correlation to
Aoi (p=0.01) and morning pO2 (p=0.0349) as well as an inverse correlation
to oxygen desaturation index (ODI, p=0.031) and total time of apnea and
hypopnea (p=0.039).
Conclusion: No difference have been found between severe and not-severe
OSA in ARD. Surprisingly, data have shown that severity of OSA correla-
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
to be investigated in further studies on a large sample.
8. FEVER AND EPILEPSY: ALWAYS OF INFECTIVE
ORIGIN?
Colombo G. 1, Arcudi S. 1, Rossio R. 1, Santaniello A. 1, Ferrari B. 1,2, Peyvandi
F. 1
1
U.O.C. di Medicina Generale - Emostasi e Trombosi, Dipartimento di
Medicina Interna, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico di Milano 2 Angelo Bianchi Bonomi Hemophilia and Thrombosis
Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di
Milano § Luigi Villa Foundation, Fondazione IRCCS Cà Granda Ospedale
Maggiore Policlinico di Milano
A 57 year-old woman was transferred to our department from another
Hospital with a diagnosis of epilepsy and hyperpyrexia. She was recently
discharged from our medicine ward for pulmonary arterial hypertension
(group I) for which a therapy with a phosphodiesterase inhibitor (tadalafil)
was started. The patient, previously known for a history of undifferentiated
connective tissue disease, during our recovery showed a serological evolu-
tion lupus like (ANA positive (1:160), antiDNA weak positive (1/10) and
she developed symmetrical arthritis of the wrists. A therapy with cortico-
steroid and hydroxychloroquin was begun. On admission at other hospital
an electroencephalography showed a generalized slowing of the background
and epileptic activity in the right frontal region, so intravenous midazolam
was administrated successfully. A diagnosis of status epileptic was perfor-
med and therapy firstly with levetiracetam and then with topiramate and
phenobarbital was set up. A lumbar puncture was made and white blood
cells, protein and glucose levels were normal in cerebral spinal fluid (CSF).
No evidence of viral, bacterial, or fungal infection was found in CSF. Brain
magnetic resonance imaging (MRI) showed leptomeningeal enhancement
without involvement of cerebral parenchyma. For fever (T˚ 38, 5-39) she
was initially treated with piperacillin/tazobactam plus vancomycin. Then
for the onset of leukopiastrinopenia switched to meropenem and according
to the immunologist corticosteroid treatment was increased. Blood culture
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
our department the initial blood analyses showed: white blood cells 5.3
x 103 mm3, platelet 145 x 103 mm3, hemoglobin 10.3 g/dl, normal renal
and liver function, c-reactive protein 1.67 mg/dl, procalcitonin 0.09 ng/ml.
For fever complicated with respiratory insufficiency, a thoracic computed
tomography (CT) was performed showing a basal pneumonia. In the suspi-
cion of nosocomial pneumonia a therapy with meropenem and linezolid
118° Congresso Nazionale - Società Italiana di Medicina Interna
was begun. The bronchoscopy with bronchoalveolar wash was negative
for infection. Besides the broad spectrum antibiotic therapy the patient
remains febrile. Moreover during hospitalization the neurological symp-
toms worsened with the inability to keep the erect station and a decline of
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
and psychiatric manifestation of systemic lupus erithematosus, discussed
the case with the immunologist, intravenous methylprednisolone (1 mg/
kg) was initiated and then immunoglobulin and cyclofosfamide were begun
without complication. We assisted to the improvement of the neurological
status with the resumption of deambulation but a mild cognitive impair-
ment persisted. Systemic lupus erythematosus is an autoimmune disorder
with a broad spectrum of clinical presentations. Several complications due
to the involvement of the central nervous system (CNS), peripheral nervous
system (PNS), and autonomic nervous system (ANS) along with psychiatric
manifestations can be seen. Furthermore in neuropsychiatrics lupus erythe-
matosus patients brain magnetic resonance and CSF findings were usually
normal.
9. REDUCING THE DIAGNOSTIC DELAY: A
CASE REPORT OF A 61-YEARS OLD WOMAN WITH
RECURRENT INFECTION OF THE UPPER AND LOWER
AIRWAYS, ASTHMA, BRONCHIECTASIS AND A LATE
DIAGNOSIS OF IGG3 DEFICIENCY
Ledda D., Manetti R.
Dipartimento di Medicina Clinica e Sperimentale - Scuola di
Specializzazione in Medicina Interna, Università degli Studi di Sassari
Introduction: the antibody deficiencies are among the most common forms
of primary immunodeficiencies. In this group is placed the IgG subclass
deficiency, that may predispose to recurrent bacterial infections and also
serious complications like bronchiectasis, asthma and chronic bronchitis.
We present a case of a late recognition of IgG3 deficiency, that shows how
these disease can still be poorly recognized.
Clinical case: a 61-years old woman that came to our attention for the first
time on the January of 2017. The family history was negative for immuno-
deficiencies or allergic diseases. From the childhood she had 2-3 episodes
a year of infections of upper airways; she reported two surgical interven-
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
emission of thick yellow sputum, that in the last 4 years have become an
almost daily frequency. In the 2014 she did a CT scan of the facial bones
that showed a pansinusitis: she had an intervention of pansinusectomy in
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
prolonged antibiotic therapy. From about 10 years she has daily episodes of
bronchospasm, for which has performed the dosing of total and specific IgE
with negative results.
Physical examination at the moment of the visit: productive cough, whee-
zing at the chest auscultation.
She performed a complete blood count with differential, the lymphocyte
typing for CD3, CD4, CD8, CD19 and CD16/56 and the dosing of the com-
plement factors, with normal results; a serum protein electrophoresis, with
a percentage of gamma-globulins of 12, 1% (n.r. 9, 8-20%); the dosing of
IgG, IgA and IgM with IgG values at the lower limit of normal (707 mg/dl,
n.r. 700-1600 mg/dl), IgA and IgM in the normal range (IgA 108 mg/dl, n.r.
70-400 mg/dl; IgM 269 mg/dl, n.r. 40-280 mg/dl).
It was performed the assay of IgG subclasses: IgG1 570 mg/dl (n.r. 300-1140
mg/dl), IgG2 150 mg/dl (n.r. 50-640 mg/dl), IgG3 10 mg/dl (n.r. 25-110
mg-dl), IgG4 39 mg/dl (n.r. 8-140 mg/dl). Then it was made the diagnosis of
selective deficiency of IgG3 and was started a monthly endovenous infusion
of immunoglobulin.
Discussion:an early diagnosis of a IgG subclass deficiency is crucial to
undertake a therapy with immunoglobulin, that may obtain a reduction of
infections, although it has not proved to significantly influence the com-
plications of this condition, like the bronchiectasis. Lately there has been
a reduction in the time between the onset of disease and the diagnosis: it
is currently reported a median time for diagnosis of 4 years for the partial
antibody deficiencies (J Clin Immunol. 2012 Oct; 32(5): 907–921.- The
Spectrum of Disease Manifestations in Patients with Common Variable
Immunodeficiency Disorders and Partial Antibody Deficiency in a Univer-
sity Hospital). In the case that we present the onset of the major clinical
Poster
manifestations has preceded the diagnosis of more than ten years, and a
predisposition to infectious complications was present from an early age;
this may suggest that further efforts are needed to raise the awareness of
these disorders.
10. VIRAL INFECTION AND CARBAMAZEPINE
HYPERSENSITIVITY REACTION: FIND THE
DIFFERENCENCES
Ledda D., Manetti R., Filigheddu F., Cabras P., Forteleoni G.M., Valenti A.,
Serra C.
Dipartimento di Medicina Clinica e Sperimentale, Univerità degli Studi di
Sassari
Clinical case: a 19-years old white girl that accessed to the Emergency
Department for fever (with temperature until 40°C), a skin rash with small
maculae, lymphoadenomegaly of the neck for 4 days: in this period she
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
Syndrome, and a recent diagnosis of epilepsy for which she started car-
bamazepine 13 days before. She was hospitalized: the first suspect was an
exanthematous disease of viral etiology complicated by a dehydration and a
epileptic crisis; however, because of the clinical manifestations and the time
correlation between the beginning of carbamazepine therapy and the onset
of disease, we suspected also a hypersensitivity reaction to this antiepileptic
drug. So, we searched the antibodies against Rubella virus, Measles virus,
Parvovirus, Epstein-Barr virus, Citomegalovirus, HIV, B and C hepatitis.
Finally, the carbamazepine was stopped and an anti-inflammatory therapy
with methyl- prednisolone was started. All the antibodies searched were
negative, with the exception of Rubella virus for which the IgG antibodies
were positive, and the IgM antibodies were negative. However, after a few
days of the beginning of corticosteroids, the clinical manifestations disap-
peared, and after two weeks there was a normalization of the hepatic and
hematological profile.
Discussion: the clinical and laboratoristical manifestations were compatible
both with a viral infection and with a drug-induced hypersensitivity syn-
drome, and specifically with a entity called “anticonvulsant hypersensitivity
syndrome”. Are there tests that could help to exclude or to confirm a drug
allergy?
11. AUTOIMMUNE AND INFLAMMATORY CHRONIC
URTICARIA RESISTANT TO ANTIHISTAMINES
IS EFFECTIVELY TREATED WITH ANTI-IGE
(OMALIZUMAB)
De Feo G. 1, Parente R. 1, Cardamone C. 1, Bucci T. 1, Guerritore L. 1, Triggiani
M. 1
1
Division of Allergy and Clinical Immunology, Department of Medicine,
University of Salerno, Salerno (Italy)
Background: Chronic spontaneous urticaria (CSU) is characterized by the
appearance of wheals, lasting 6 weeks or more, not induced by any identi-
fiable trigger. In two-thirds of cases, urticaria is associated with angioedema.
CSU is a mast cell-driven condition, in which several vasoactive mediators
such as histamine, leukotrienes and tryptase are involved. In some patients,
wheals are induced by scratching the skin (dermographism, DER) or by an
intradermal injection of autologous serum. A positive autologous serum
skin test (ASST) defines “autoimmune urticaria”. There are no specific labo-
ratory markers in CSU; however, markers of inflammation, such as C-re-
active protein (CRP), are frequently elevated. Antihistamines (anti-H1) are
licensed as first-line treatment of CSU, although about 40% of patients do
not respond to this therapy. Effective blockade of H1 receptor can be studied
by histamine skin prick test (HSPT). Recommended treatments for anti-H1
resistant patients include, as third-line therapy, leukotriene receptor antago-
nists (LTRAs), cyclosporine (CysA) and the anti-IgE monoclonal antibody,
omalizumab.
Materials and Methods: One-hundred and four CSU patients (25M, mean
age =45+/-17) received anti-H1 at recommended dose to identify respon-
sive (R) and unresponsive (NR). Responsiveness was defined by achieving a
UAS7≤6 (range= 0-42). In NR patients, anti-H1 was up-dosed or replaced;
however, the majority of them needed third line options. In all patients cli-
nical and laboratory features such as concomitant angioedema, DER, HSPT,
ASST, CRP and tryptase assay, were assessed.
73
Poster
Results: Two-thirds of patients responded to antihistamines at usual (I line)
or double dose (II line). Twenty-five NR patients started III line therapy:
6 LTRAs (R=66%), 12 CysA (R=75%) and 7 omalizumab (R=85%). In
anti-H1 responsive patients DER and HSPT remained positive in 40 %
and 45%, respectively. Concurrent angioedema and high CRP were stron-
gly associated with positive ASST (p<0.05). These patients responded only
to omalizumab. Tryptase level did not discriminate between R and NR to
antihistamines (5.0 vs. 5.7 ng/ml, v.n. <11, 4) but it was a good predictor
of ASST positivity and of response to omalizumab. Omalizumab induced a
mean reduction in tryptase levels of 3 ng/ml and in CRP of 5 units.
Conclusions: Mediators other than histamine can be responsible for the
heterogeneous response to therapies in patients with CSU. The persistence
of DER and HSPT in R patients indicates that, regardless of clinical impro-
vement, other histamine receptors not blocked by anti-H1 are involved. The
presence of angioedema and high levels of CRP should lead to the asses-
sment of ASST. ASST positivity is predictive of unresponsiveness to anti-H1
and responsiveness to omalizumab.
12. NODOSUM ERYTHEMA: IDIOPATHIC OR NOT?
de Vincenzo G.M., Zingaro M.T., Luglio C.V., Sciancalepore D., Vella F.S.,
Napoli N., Sabbà C.
Medicina Interna Universitaria “C. Frugoni”- Dipartimento Interdisciplinare
di Medicina - Università degli Studi di Bari “A. Moro”
A 74-years-old Caucasian woman with 7 months history of multiple episo-
des of remittent nodular touchable erythematosus lesions in lower limbs was
admitted in our hospital for diagnostic findings. She didn’t use cigarettes,
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
biopsy of the nodular cutaneous lesions was perfomed and was diagnostic
for a septic panniculitis with morphological features of erythema nodosum.
At first, in order to distinguish between a idiopathic and a secondary form,
a total body CT contrast-enhanced was performed without revealing lesions
that could justify a paraneoplastic type. Additionally, further laboratory
examinations performed were all negative: autoimmunity tests (ANA,
ANCA, AMA, Anti dsDNA, aCCP, AMA, ASMA, LKM), Quantiferon
TB-Gold, parasitological and coprocoltural tests (Y. Enterocolica, H.Pylori,
Shigella, S.aureus, miceti, parasites); virological serum tests (Adenovirus,
Toxoplasma, CMV, HSV1, HSV2, VZV, EBV, Parvovirus B19), urine and
blood coltures. Also we analized the lymphcytogram of peripheral venous
blood that was not compatible to sarcoidosis and lymphoproliferative disea-
ses. The complete regression of clinical symptoms treating the patients with
Metilprednisone 4 mg 1 cp/die and Azatioprina 50 mg 1 cp X 2/die for 1
month confirmed the hypothesis that, despite the negativity of the autoan-
tibodies, it was an immunomedial form. To conclude, we formulated the
diagnose of idiopathic nodosum erythema. After 1 month-treatment above
described, the lesions seemed almost completely regressed and ungainly,
therefore immunosuppressive therapy was reduced with Azatioprina 50 mg
1 cp/die. According to scientifical findings, our clinical case demonstrate
that nodosum erythema is likely idiopathic.
13. UNDRESSING” THE EFFECT OF SULFASALAZINE IN
IBD
Grimaldi L.D., Passerini F., Buonamico P., Minerva F.
Palmieri V.O., Pugliese S., Belfiore A., Portincasa P.
Clinica Medica “A. Murri”, Dept. Of Biomedical Sciences and Human
Oncology, University of Bari
A 73 years old woman had a 9 years history of Crohn disease treated with
Mesalazine 800 mg b.i.d. In 2011 spondyloarthritis was diagnosed. Metho-
trexate and steroids were added. In 2013 Adalimumab 40 mg every two
weeks, was added to therapy.
One month before admission she had started Methylprednisolone 4 mg
a day and Sulfasalazine 500 mg b.i.d. After 4 week she experienced fever
(38°C), maculopapular rash in inguinal region, weakness, myalgia and sore
throat. Two days later, her physician suspected tonsillitis and prescribed
Ceftriaxone 1 gr a day, a drug she had taken several years earlier. Ceftria-
xone was stopped after two days when maculopapular rash developed over
the face, trunk and proximal limbs. The same day, the patient was admit-
ted to our department through the emergency room. Physical examination
showed a marked maculopapular rash with itch, fever (38, 5°C), tonsillitis
74
118° Congresso Nazionale - Società Italiana di Medicina Interna
with a large plaque. Small enlargement of the spleen and some peripheral
lymph nodes were detected.
Sulfasalazine was stopped and she started with i.v. Methylprednisolone
10 mg/day for the adverse reaction and i.m. Chlorphenamine Maleate for
itching. In the beginning, blood cell count showed leukocytosis only, but
not hypereosinophilia. First, Scarlet fever was suspected, but pharyngeal
swab was negative and TAS < 200 UI/ml. Some days after, blood cell count
showed severe leukocytosis (40 680/mm3) with hypereosinophilia (6300/
mm3) and monocytosis (1835/mm3). Mild inflammation was found (C-re-
active protein 42, 8 mg/dl). Other laboratory findings were as follows: high
lactate dehydrogenase 665 UI/L (unl < 246 UI/L), high B2 microglobulin
5.62 mg/l (unl < 2, 53 mg/l), high IgE 5430 UI/ml (unl <100 UI/l), high
sign of hepatic cytolysis (ASAT 85 UI/L and ALAT 146 UI/I, and moderate
cholestasis (GGT 103 UI/L). No bacteria were found in blood and urine.
Laboratoristic evaluations about Parvovirus, EBNA, VZV, HSV, CMV, Ente-
rovirus, Adenovirus, VDRL, TPHA, rickettsial and borreliosis were nega-
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
parakeratosis, acanthosis, dyskeratosis and exocytosis. Characterization of
peripheral blood lymphocytes showed normal values. No evidence of lym-
phoma or other hematological malignancies was detected by laboratory
tests or histological studies. The diagnosis of DRESS (Drug Reaction with
Eosynophilia and Systemic Symptoms) was made.
Conclusion: In this case Sulfasalazine was the cause of DRESS, but two
weeks was necessary to achive the final lively diagnosis. The patient started
infusions of Methylprednisolone 60 mg/day, the erythematous skin lesions
improved, the laboratory evidence of inflammation abated, and the eosi-
nophil count normalized. The Prednisone dose was progressively tapered.
14. HYPEROSINOPHILIA AND RECURRENT
ANGIOEDEMA IN A PATIENT WITH GIANT CELL
ARTERITIS: A DIAGNOSTIC “GLITCH” IN A CASE OF
GLEICH’S SYNDROME
Losa F., Firinu D., Marongiu F., Del Giacco S.R.
Internal Medicine, Allergy and Clinical Immunology, Department of Medical
Science and Public Health, University of Cagliari, Italy
Background: Gleich’s syndrome is a rare disease characterised by the asso-
ciation of episodic angioedema (AE), weight gain, fever, with laboratory
findings such as hypereosinophilia, elevated IgE and IgMk component;
patients present a good response to corticosteroid (CS) therapy, without
end-organ damage. We report a case of a patient with marked chronic eosi-
nophilia and AE previously diagnosed as Giant Cell Arteritis (GCA).
Method and Results: A 49-years-old patient with marked eosinophilia
since 2004 was referred in January 2014 for the occurrence of an episode
of AE of face and lids, which resolved spontaneously. In 2008 he was dia-
gnosed as GCA, having asymptomatic nodular thickening along the both
temporal arteries. Since October 2014 he developed recurrences of AE and
erythematous, itchy skin nodules with a significant eosinophilic infiltra-
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
IgE were 2895 KU/l (normal < 100). Immunofixation showed an IgMk
monoclonal component. We excluded myeloproliferative hypereosinophilic
syndrome (HES) variant, since chromosomal analysis did not identify any
abnormalities. Fluorescence in situ hybridization for PDGFRβ was negative
and FIP1L1 gene fusion was not detected. Peripheral blood mononuclear
cells flow cytometry revealed an abnormal T cell population with a CD3-
CD4+ phenotype. T-cell receptor (TCR) γ chain gene was studied by PCR,
showing a monoclonal rearrangement pattern. Gastroscopy, colonoscopy
and cardiological evaluation did not reveal eosinophil infiltration. Reasses-
sment of arterial biopsy showed non-giant cell granulomatous inflamma-
tion with abundant eosinophil infiltration.
Conclusion: We describe a case of Gleich’s Syndrome with the atypical
feature of eosinophilic arterial infiltration, previously mistaken as GCA.
The arterial eosinophilic infiltration is to date an undescribed finding in this
disease, pointing towards other types of HES. The patient responded well to
oral prednisolone 25 mg/day, showing normalization of eosinophilic counts
and a partial control of AE. In contrast to the features associated with other
kind of HES, Gleich’s syndrome remains stable for a long time and responds
to low dose of CS. Considered the clinical and laboratory data, a careful
follow-up is ongoing.
118° Congresso Nazionale - Società Italiana di Medicina Interna
15. SLE OR ELSE: A NEUROPSYCHIATRIC DILEMMA
Malandrino D. 1, Milia A. 1, Vitiello G. 2, Tozzetti C. 1, Parronchi P. 2,
Poggesi L. 1
1
Medicina per la complessità assistenziale 3, Dipartimento DAI Emergenza
e Accettazione, AOU-Careggi, Università degli Studi di Firenze, Firenze,
Italia 2 Unità di Medicina Interna, Immunologia e Terapia Cellulari,
Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi di
Firenze, Firenze, Italia
Introduction: Systemic lupus erythematous is a multi-organ system
autoimmune disease with clinical and serological heterogeneity. Neurop-
sychiatric symptoms affect up to 90% of patients with SLE, with cognitive
impairment, headache and mood disorder being the most commonly reco-
gnized syndromes.
Case Report: FN, a 65-year-old woman, who presented to our Emergency
Department with sudden progressive right upper limb sensory-motor loss
associated to left dropping of the mouth and aphasia. Her clinical history
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
the head vessels. Investigations revealed hemolytic anemia (Hb 7.6 g/dL)
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-
rol levels. No signs of viral or bacterial infections were detected. Neurop-
sychological tests demonstrated intellectual impairment (MMSE=13/30)
with an EEG which has shown paroxysmal sharp wave activity arising in
fronto-temporal region. Rheumatologic evaluation revealed a positive
anti-nuclear antibody 1:160 with speckled pattern and positivity of anti-
RNP and anti-Sm specificities. Diffusion-weighted magnetic resonance
imaging demonstrated numerous high-intensity lesions of the white and
grey matter. Differential Diagnosis: When evaluating patients who present
with symptoms suggestive for Neuropsychiatric Systemic lupus erythema-
tous (NPSLE) careful assessment is necessary to exclude other potential
causes. In our patient, the unusual age, the sudden onset of the symptoms,
the possible role of a concomitant bone-marrow disease and the presence of
extracranial atherosclerosis are factors that influence the likelihood of the
disease. In support of NPSLE diagnosis, her history indicated that she met
five of the American College of Rheumatology’s (ACR) clinical diagnostic
criteria for SLE (neurological, haematological, immunological disorders
with positive ANA and minimal pericardial effusion).
Treatment and Follow-Up: Therapy with levetiracetam (1 gr bid with evi-
dence of therapeutic drug levels) was started awaiting the immunological
results, but the patient complained new neurological symptoms with evi-
dence of worsening of the EEG. A treatment with pulse intravenous steroids
(prednisone 1 mg/Kg/die) was started along with levetiracetam and there
were not been new relapses.Steroid treatment was tapered. Neuropsycolo-
gical and laboratoristic assessment after 5 months demonstrated a complete
recovery (exception for weak positivity of Anti RNP and Sm antibody) and
for this reason steroid treatment was suspended and her medication was
reduced to levitiracetam only. No relapses were registered after 24 months
of follow-up.
Conclusion: Diagnosis of patients presenting with symptoms of NPSLE is
challenging. Neuropsychiatric involvement heavily impacts patient’s health,
quality of life and disease outcome. A detailed clinical evaluation with
review of the medical history and appropriate laboratory analyses may allow
a prompt recognition and appropriate treatment of NPSLE.
16. EDOXABAN SUITABILITY IN LONG-TERM
PROPHYLAXIS OF ATYPICAL DVT ASSOCIATED WITH
BEÇHET SYNDROME: A 38 YEARS-OLD MALE CASE
REPORT
Martini F. 1, Brunofranco M. 2, Bernardi S. 1
1
OU Internal Medicine, Imperia Hospital, Imperia 2 Haemostasis and Throm-
bosis Centre, ASL. 1, Imperia
Beçhet syndrome (BS) is a multi-systemic, chronic autoimmune vasculitis,
characterized by recurrent oral and genital ulcers, uveitis, arthritis and a
higher risk to develop deep vein thrombosis (DVT). There are no clear indi-
cations about anticoagulant prophylaxis and anticoagulant treatment dura-
tion after a DVT episode in BS. DOACs (direct oral anticoagulants) could
be suitable for DVT treatment also in autoimmune disease but there is a
lack of information about their use in this setting. A 38 years-old male, with
Poster
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-
mocysteinemia and dyslipidemia and developed claudicatio intermittens
due to peripheral artery disease. Since first DVT episode the patient was
under anticoagulant therapy with VKA (vitamin K anticoagulants) but with
low time in therapeutic range (TTR), around 45%. During the last years,
BS clinical manifestation were poorly controlled by different immunomo-
dulant and immunosuppressive treatment. With the aim of a steroid-spa-
ring therapy patient started granulocyte and monocyte selective apheresis
and pharmacological treatment with cyclosporine. The patients stopped
AVK and started edoxaban 30 mg daily in order to maintain anticoagulant
therapy. Actually, the patient has few clinical manifestation of BS and signi-
ficant reduction of arthritis related symptoms with a better QoL. Edoxaban
treatment was well tolerated and any adverse drug reaction was reported.
Despite the absence of randomized controlled trials about efficacy and
safety in the prophylaxis of atypical DVT in autoimmune disease, edoxaban
could represent a suitable treatment in this setting for its favourable safety,
drug to drug interaction profile and clear dosage reduction strategy.
17. KOUNIS SYNDROME: AN UNDERDIAGNOSED
DISEASE
Nardella E., De Matteis G., Casciaro A.F., Calarco R., Buonomo A.,
Gambassi G.
Area Medicina d‘Urgenza e Medicina Interna, Fondazione Policlinico
Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Roma
A 46-year-old Brazilian woman presented to our emergency department
with respiratory failure and subsequent syncope. The patient had a history
of asthma treated with as-needed bronchodilators, but showed no symp-
toms recently, and was allergic to cat fur, penicillin and pollen. She didn’t
have cardiovascular risk factor, but a family history of early-age heart attack.
She developed throat swelling, dyspnoea, blue lips, diarrhoea, facial rash
with itch and oedema 20 minutes after eating anchovies fried with dill and
pasta with peppery bitter. At presentation, she was sleepy and unresponsive
with severe hypotension, tachycardia, gasping respiration; arterial oxygen
saturation was lower than 60%. The chest examination evidenced signs of
severe bronchospasm with wheezing. Laboratory tests on admission showed
the following: creatine kinase 202 UI/l, serum cardiac troponin I (cTnI)
negative, no abnormalities in electrolytes, renal function, thyroid function,
routine blood tests, except minimal lymphocytosis; toxicology tests and
serum pregnancy test were negative. An electrocardiogram (ECG) revealed
atrial fibrillation with rapid ventricular rate and ST segment depression in
leads II, aVF, V4-V6. The level of cTnI two hours later admission was up
to 0.776 ng/ml, four hours later 1.399 ng/ml. The chest x-ray showed fea-
tures of interstitial pulmonary edema. A head computed tomography was
negative. She was intubated and mechanically ventilated. Beta-blocker was
performed with sinus rhythm restoration and ST segment normalization.
Methylprednisolone and fluid therapy were intravenously administered.
The patient was transferred to the intensive care unit and her symptoms
gradually improved. She became hemodynamically stable and tracheal intu-
bation was required for less than 48 hours. A new ECG confirmed sinus
rhythm without segment ST alteration. The level of cTnI after 24 hours was
0.088 ng/ml and the third day the value was down to normal. Transthora-
cic echocardiography showed no wall motion abnormalities with preserved
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
fibrillation, we suspected a coronary artery disease. She underwent an ECG
stress test, terminated at Stage 2 of the Bruce protocol of work due to fatigue
(but the patient achieved the target heart rate of 135 beats per minute), that
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
arteries. On the whole, these results suggested that transient ST segment
depressions with elevated levels of myocardial damage marker were due to
coronary artery vasospasm triggered by the allergic insult. The association
of anaphylactic reaction and acute coronary syndromes was first described
in 1991 by Kounis and Zavras [1]. This condition, known as Kounis syn-
drome or “allergic angina syndrome”, is mainly attributable to the release of
inflammatory mediators during an allergic event. A wide variety of triggers
such as drugs, food, insect bite, environmental exposures have been reports
as capable of inducing it [2]. Even today this syndrome is little known and
underdiagnosed. There are no specific clinical practice guidelines about it
and true incidence is unknown [3]. According to the literature, it seems to
75
Poster
be essential achieving systematic troponin measurement [4] and, in patients
with suspicious acute myocardial injury, to perform coronary angiography
to discern three different variants of Kounis syndrome: coronary vaso-
spasm versus coronary thrombosis versus drug-eluting stent thrombosis
[5]. In our present case, the patient likely suffered from the type 1 variant
of Kounis syndrome. For this variant, the treatment of the allergic event
alone may abolish symptoms and it seems to have the better prognosis [6].
At discharge, the patient was asymptomatic and in good clinical condi-
tion. We referred her to the specialist for full allergology evaluation and
suggested a cardiology follow up. In conclusion, physicians must be aware
of this syndrome and suspect it whenever they face anaphylactic reaction
to timely identify and appropriately manage a potential myocardial injury.
Treatment of Kounis syndrome represents a double challenge because it
needs to address both cardiac and allergic condition and the drugs admini-
stered during the anaphylactic reaction may exacerbate heart dysfunction.
1. Kounis NG, Zavras GM. Histamine-induced coronary artery spasm: the
concept of allergic angina. Br J Clin Pract. 1991; 45:121–128 2. Rico Capeda
P et al. Sindrome de Kounis. Med Intensiva. 2012; 36:358-64 3. N.G. Kounis,
“Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and
therapeutic management” Clinical Chemistry and Laboratory Medicine, vol
54, no. 10, pp 1545-1559, 2016 4. Lippi G, Buonocore R, Schirosa F, Cervel-
lin G. Cardiac troponin I is increased in patients admitted to the emergency
department with severe allergic reactions. A case-control study. Int J Cardiol
2015; 194:68–9. 5. Sueda S, Sasaki Y, Habara H, Kohno H. Editorial: Kounis
syndrome (allergic angina and allergic myocardial infarction) for cardiolo-
gists. J Cardiol Cases. 2015;12:110–12. doi: 10.1016/j.jccase.2015.07.006. 6.
Kounis NG. Coronary hypersensitivity disorder: the Kounis syndrome. Clin
Ther 2013; 35:563.
18. DEVELOPMENT OF HCC AFTER HCV CLEARANCE
WITH DAA-TREATMENT
Sciancalepore D., Luglio C.V., Zingaro M.T., de Vincenzo G.M., Berardi E.,
Antonica G., Sabbà C., Napoli N.
Medicina Interna Universitaria “C. Frugoni”- Dipartimento Interdisciplinare
di Medicina - Università degli Studi di Bari “A. Moro”
A 65-years-old Caucasian man showed a hypoechoic area in the VI-VII
hepatic segment performing an abdominal US during the 24-week follow
up after having been treated with hepatitis C virus (HCV) direct-acting
Antiviral (DAA).He didn’t used cigarettes, alcohol and drugs. His family
history underlined both parents affected by colorectal cancer. His medical
history described the diagnosis of hemophilia A treated by factor VIII
since 1982 and HCV-related liver cirrhosis (genotype 3a, fibrosis stage F4
at Fibroscan) in absence of previous evidence of hepatocellular carcinoma
(HCC). Therefore, the patients was treated by Sofosbuvir and Daclatasvir
for 24 weeks. The patient achieved sustained virological response (SVR)
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
markers (CEA, AFP and CA 19.9), LDH 180 UI/l (x0.75), β2microglobul-
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
on the above findings, the diagnostic hypotheses formulated were: HCC or
occult metastatic hepatic lesions. Therefore a surgical approach was perfor-
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
abdominal CT follow up with no signs of HCC recurrence. Although the
literature references report a high risk of HCV recurrence after successful
DAA treatment in patients with HCV-related liver cirrhosis and previous
clinical story of HCC, this case report underlines the possibility of develo-
ping new HCC after viral clearance due to DAA therapy.
19. EFFECTS OF CHRONIC AUTOIMMUNE THYROIDITIS
ON RENAL FUNCTION
Sirufo M.M., De Martinis M., D’Ostilio A., Ginaldi L.
Department of Life, Health, & Environmental Sciences, University of
L’Aquila, L’Aquila, Italy.
Hashimoto’s thyroiditis is a chronic autoimmune disease of inflammatory
nature, due to the development of antibodies directed against cells of the
thyroid gland. The disease is histologically characterized by a lymphocytic
76
118° Congresso Nazionale - Società Italiana di Medicina Interna
infiltrate of the thyroid gland. leading to a gradual decrease of the thyroid
function leading to hypothyroidism (1). Thyroid hormones act on the fun-
ction of many organs and tissues: oftenHashimoto’s thyroiditis patients
complain of asthenia, cold intolerance, constipation, muscle cramps, men-
strual irregularities in women, and erectile dysfunction in males. Other
manifestations of autoimmunity are also often present.Renal function may
also be compromised in patients with thyroid pathologies through different
pathogenetic mechanisms (2). Hypothyroidism causes an increase in peri-
pheral vascular resistance at renal levels with intraparenchymal vasoconstri-
ction and consequent reduction of renal plasma flow, glomerular filtration
and tubular reabsorption and excretion capacity. In the literature, however,
only a few cases of progressive kidney failure in the course of Hashimoto’s
thyroiditis are described (2, 3, 4). A 21-year-old Caucasian female, asymp-
tomatic, non-smoker, with a body weight of 53Kg, height of 163 cm and
BMI 19.9 Kg / m², with remote, familial and negative pharmacological
history, came to our examination by examination Routine blood disorders
of a mild and progressive increase in creatinine with values up to 1.13 mg%,
with always normal azotemia and absence of proteinuria and albuminuria.
Pressure values 100/60 mmHg, FC 68 bpm. Nothing to point to abdomi-
nal and pelvic ultrasound. Weak antibody positivity of antibody core anti-
bodies, with negativity of ENA, anti-DNA, ANCA. The metabolic profile
was normal, while the thyroid profile showed a picture of hypothyroidism:
TSH 120.54 μUI/ml, FT3 1.30 pg / ml, FT4 0.26 pg/ml, Anti-Tireoglobulin
Antibodies 147.40 IU / ml, Anti-Peroxidase Antibodies 64 IU / ml. Thyroid
ultrasonography showed a slightly globe-shaped gland whose extension was
within the lower limits of the standard, with diffusely inhomogeneous and
hypoechogenic structure. Considering ultrasonography, positivity of anti-
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
to serum TSH values of 41.39 μUI / ml at one month from the beginning of
the treatment, with gradual renal function normalization (creatinine 0.78
mg / dl). The described
Case Report: highlights the importance of TSH assay and thyroid function
evaluation in patients with acute renal failure without apparent causes
even in the absence of clear symptoms of thyroid insufficiency. The case
also outlines the reversibility of plasma creatinine values with the treatment
of thyroid disease. Bibliografia 1.Santoro D, Vadalà C, Siligato r, Buemi M,
Benvenga S: Autoimmune Thyroiditis and Glomerulopathies; front Endo-
crinol (Lausanne) 2017; 8:119. 2.Papalia T, GrecoR, Mollica F., Mancuso D,
Bonofiglio R; Acute renal failure in the course of Hashimoto’ thyroiditis;g
ital. Nefrol 2010 Jul-Aug; 27(4); 404-8. 3.Van welsem ME, Lobatto S: Tre-
atment of severe hypothyroidism in a patient with pregressive renal failure
leads to significant improvement of renal function: Clin Nephrol 2007 Jun;
67(6): 391-3 4.Iwazu Y, Nemoto J, Okuda K, Nakazawa e, Hashimoto A,
Fujio Y, Sakamoto m, Ando Y, Muto s, Kusano E: A case of minimal change
nephrotic syndrome with acute renal failure complicating Hashimotoas
disease: Clin Nephrol 2008 Jan; 69(1):47-52.
20. RAYNAUD’S PHENOMENON AND CAPILLAROSCOPIC
ABNORMALITIES IN ANOREXIA NERVOSA
Sirufo M.M., De Martinis M., Ginaldi L.
Department of Life, Health, & Environmental Sciences, University of
L’Aquila, L’Aquila, Italy
Anorexia nervosa (AN) is an eating disorder characterized by restriction of
energy intake and weight loss. Among peripheral vascular complications
of anorexia nervosa (AN), Raynaud’s phenomenon (RP), has been descri-
bed.1RP is often secondary to autoimmune diseases, exhibiting typical
microvascular alterations. In the absence of diseases able to cause it, RP is
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
findings of AN patients with RP (ANRP) were compared with those of PRP
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
performed by using a x200 optical probe equipped videocapillaroscope con-
nected to an image analyse software (VideoCap software 3.0; DS Medica,
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
findings. The percentage of ES pattern was significantly higher in ANRP
patients compared to those with PRP (p<0.01) and AN not affected by RP
(p<0.05), whereas no significant difference was found between ANRP and
118° Congresso Nazionale - Società Italiana di Medicina Interna
ex-ANRP patients. The proportion of ex-ANRP patients exhibiting an ES
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-
roscopic pattern and RP in AN patients, whereas any significant association
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-
scopic alterations also in patients with RP and anamnestic history of AN
and the absence of an ES pattern in AN patients without RP, suggest that
malnutrition, dysmetabolism and lifestyle are not sufficient pathogenetic
mechanisms of microvascular damage. Autoantibodies against neuropep-
tides that regulate appetite were hypothesized in AN5and an increased risk
of autoimmune diseases in eating disorder patients has been described.6
In conclusion, our study reveals that patients with AN suffering from RP
exhibit NVC findings typical of connective tissue diseases, confirming the
possibility of a link between autoimmunity and anorexia. References 1.
Sachs KV, Harnke B, Mehler PS, Krantz MJ. Cardiovascular complications
of anorexia nervosa: a systematic review. Int J Eat Disord 2016;49(3):238-
248. 2. Wigley FM, Flavahan NA. Raynaud’s Phenomenon. N Engl J Med
2016;375(6):556-565. 3. Maverakis E, Patel F, Kronenberg DG, et al. Inter-
national consensus criteria for the diagnosis of Raynaud’s phenomenon. J
Autoimmun2014;48-49:60-65. 4. Yager J, Andersen AE. Clinical practice.
Anorexia nervosa. N Engl J Med 2005;353(14):1481-1488. 5. Solmi M, Vero-
nese N, Favaro A, et al. Inflammatory cytokines and anorexia nervosa: a
meta-analysis of cross-sectional and longitudinal studies. Psychoneuroen-
docrinology 2015;51:237–52. 6. Raevuori A, Haukka J, Vaarala O, et al. The
Increased Risk for Autoimmune Diseases in Patients with Eating Disorders.
PLoS One 2014;9(8): e104845.
21. CAN WE TREAT JUVENILE VTE WITH EDOXABAN?
YES
Di Micco P., Amoroso L.
UOC Medicina Interna, Ospedale Fatebenefratelli di Napoli, Napoli, Italia.
Direzione Medica, Daiichi-Sankyo Italia, Roma.
The treament of VTE with DOACs is a well known treatment. Therapeutic
regimens and timing of treatment are well documented by international gui-
delines, both for initial therapy and for extended therapy. Suggested doses
of each drug are established after dose-finding double blind trials and then
after the following phase III clinical trials. The reccomended dose of edoxa-
ban for treatment of VTE is 60 mg daily, but other dosages, in particular
30 mg daily, are suggested if patients show impaired renal function and\or
increased risk of bleeding.In literature, there are no studies concerning the
optimal treatment with any DOACs, in particular with edoxaban for patients
aged less than 18 years old. Further information about real life studies are
missing. The off label dosage and treatment of juvenile VTE is related not only
to missing data, but also to different juvenile metabolism, in particular for
body weight & BMI, gastrointestinal absorption and renal and liver metabo-
lism. In the present article, we report a case of a 13 years old boy affected by
post traumatic DVT occurred one week later hypomobility due to non-sur-
gical trauma of right lower leg. His body weight was 46 kg and his BMI was
lower than 19; normal function of kidney and liver were detected, none
abnormalities of PT, aPTT and platelet count. His personal anamnesis was
negative for other vascular diseases and similar information were given by
his first degree relatives. During his clinical observation, he showed inherited
thrombophilia for the presence of heterozygosity of prothrombin A20210G
gene polymorphism. Neither other clotting abnormalities nor other clinical
conditions inducing thrombophilia were identified. The initial treatment was
based on enoxaparin 40 mg twice daily, but after the first week of treatment,
the patient and his parents refused to continue antithrombotic treatment with
warfarin. So, we planned to perform an extended treatment with the reduced
dose of edoxaban 30 mg daily. Clinical response was good with a good tole-
rance of drug. After six months, we found a full recanalisation of lower limb
DVT with a slight post- thrombotic syndrome according with Villalta score
and, on the other hand, no side effects of anticoagulant therapy were found,
such as recurrence of VTE or minor/major bleeding. Juvenile VTE is a very
rare disease, but antithrombotic treatment in this clinical condition is very
difficult because there are not any clinical studies about this topic nor inter-
national guidelines. So, modified doses of the anticoagulant therapy may be
taken in consideration according to different BMI and juvenile metabolism.
We found that the reduced doses of edoxaban show a good safety concerning
main outcomes such as thrombotic resolution and a reduced number of com-
plications as recurrences or bleeding. Further studies are needed in order to
Poster
establish right doses of DOACs in the treatment of juvenile VTE.
22. AN UNUSUAL SHOCK WITH ELEVATED
PROCALCITONIN LEVELS
Balloni A. 1, Maceratini E. 2, Martino G.P. 3
1
Medicina e Chirurgia di Accettazione e Urgenza, Ospedale Murri Fermo
2
Anestesia e Rianimazione, Ospedale Murri Fermo 3 Medicina Interna,
Ospedale Murri Fermo
A 45-years-old woman was admitted to the emergency department for
state of unconsciousness. Patients was drowsy, with pulse rate 126 beats
for minute, blood pressure 80/50 mmHg, respiratory rate 20/minute and
oxygen saturation of 98% at room’s air, pyretic (body temperature 39°C)
with tremors and chills. The detection of capillar glycemia showed a severe
hypoglycemic state (31 mg/dl). The emergency department physician
started infusion of glucose solution 33% 20 ml and then glucose solution
5% 500 cc and paracetamol 1000 mg ev attending to a slow progressive reco-
very of consciousness. After glucose infusion, patient was alert, confused
and disoriented, alternated drowsiness and restlessness, preferring lateral
decubitus, without focal neurological deficits of the limbs. Clinical examina-
tion showed dehydratation of skin and mucous membranes, tachycardia, no
pathologic findings at the pulmonary auscultation, diffuse moderate abdo-
minal pain, slight cervical stiffness. The altered mental status of the patient
and the absence of relatives prevented the collection of anamnestic data.
ECG showed sinus tachycardia with diffuse nonspecific alterations of ST-T
waves. Biochemistry revealed increase of leukocyte count (15.800/mmc)
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
1, 3), elevated procalcitonin level at 41, 91 ng/ml (normal value < 0, 5 ng/
ml). Arterial blood gas analysis showed no alterations with normal lacta-
cidemia. For suspected septic shock, probably due to meningo-encephali-
tis, physician drew cultures of blood and urine after placement of urinary
catheter and started therapy with cristalloids and broad-spectrum antibio-
tics (piperacillin/tazobactam). Before the execution of lumbar puncture
patient underwent brain-CT, negative for bleeding or intracranial hyper-
tension signs. The arrival of patient’s relatives after CT execution allowed
the collection of medical and pharmacological hystory. Patient followed a
daily therapy with cortisone acetate and fludrocortisone, consequently the
surgical removal of pituitary and bilateral adrenal adenomas. Since few
days patient presented a pyretic gastroenteritic syndrome with vomiting
and diarrhea, with incongruous steroid therapy assumption in the latter
days. The same gastroenteritic symptoms were shared by patient’s husband
and sons. The previous days she had presented generalized asthenia. After
infusion of hydrocortisone 1000 mg ev, for suspected acute adrenocortical
failure, the neurological state improved with progressive resolution of con-
fusion and disorientation. Patient, despite slowed speech, recognized rela-
tives and physicians and interacted with them, showing greater collabora-
tion in the execution of simple orders. Patient was admitted in Infectology
Department with the suspected diagnosis of Addison crisis during sepsis,
maybe meningo-encephalitis, and treated with broad-spectrum antibiotics,
volume restoration and hydrocortisone 500 mg/die. Colture of blood, urine
and stool and serological tests for detection of viral or bacterial infection
were negative. During the hospital stay clinical conditions recovered in
few days and procalcitonin levels decreased until normalization. Patient
was discharged home with diagnosis of acute adrenocortical failure under
gastroenteritis.
In recent years, procalcitonin has been recognized as a specific marker for
bacterial infections. However, procalciton is not a perfect marker because of
the risk of false-negative and false-positive results. Acute adrenal crisis may
mimic a septic shock. Our patient presented some of typical and nonspecific
symptoms and signs of acute Addison disease and septic shock. The diagno-
sis of Addisonian crisis was considered only after the collection of medical
history. In our case, as has been showed in previous few cases in literature,
elevated procalcitonin levels were unuseful to differentiate between Addiso-
nian crisis and septic shock. Negative culture results cannot entirely exclude
the presence of a non detectable viral or bacterial infection. We can spe-
culate that in our patient the acute adrenal insufficiency was induced by
the sudden discontinuance of steroid therapy during an infective enteritis
with dehydratation. No sure experimental data had yet clarified inflamma-
tory pathways of procalcitonin increase during adrenal insufficiency. As
recently suggested by Schumm, Pfeifer et al., the deficit of cortisol under
Addison crisis may potentiate the immune response with overstimulation
of macrophages and procalcitonin-producing cells increasing procalcitonin
levels. On the other hand, some recent evidences encourage the use of ste-
77
Poster
roids for the treatment of severe septic shock with impaired corticosteroids
response. In particular the Surviving Sepsis Campaign suggests therapy
with hydrocortisone only in patients with refractory septic shock, reducing
mortality and improving prognosis.
23. A SEVERE BRADYCARDIA IN A COLD MAN
Balloni A. 1, Martino G.P. 2, Maceratini E. 3
1
Medicina E. Chirurgia Di Accettazione e Urgenza, Ospedale Murri Fermo
2
Medicina Interna, Ospedale Murri Fermo 3 Anestesia e Rianimazione,
Ospedale Murri Fermo
A 89-year-old male patient, found unconscious on the floor in his home,
arrived in the emergency department brought by 118 emergency service.
Relatives did not have any contact from him for about 36 hours. Patient pre-
sented with closed eyes, reacting to pain, making incomprehensible sounds.
He had cold skin and dehydrated mucous membranes. A left peri-orbital
hematoma and an extensive right hemi-thoracic bruising were noticed
at body inspection. Vital signs showed hypotension (60/40 mmHg), bra-
dycardia (40 beats/minute), bradipnea (12 breaths/minute), Sat O2 94% in
oxygen therapy (FiO2 40%). Body temperature was too low to be measured
with thermometers of our department. The capillary blood glucose was 257
mg/dl. He moved 4 limbs in the absence of focal neurological deficits. The
patient had a history of Alzheimer’s dementia and hypertension in treat-
ment. Family members reported an accidental fall from the bed with head
and chest trauma two days earlier. Patient was secured with a central venous
access in right femoral vein, starting infusion of heated 0.9% chlorinated
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
wave. Blood chemistry tests detected renal failure with creatinine 4.34 mg/
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
metabolic acidosis with increased of lactate concentration (pH 7.155, pCO2
31.9 mmHg, pO2 78.2 mmHg with FiO2 28%, HCO3 11 mmol / l, lacta-
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.
Ten hours later, the body temperature increased to 35.7°C and ECG reve-
aled that Osborn waves disappeared, and the rhythm returned to a normal
sinus rhythm. During hypothermia cardiovascular system is concerned
both in hemodynamic state and electrical connection. Sinus tachycardia
and vasoconstriction with increased cardiac output are typical features in
early stages, but with further reduction of core body temperature they give
way to a progressive bradycardia with QT elongation, poorly responsive to
atropine treatment. Atrial fibrillation is the most common arrhythmia when
the core temperature is less than 32°C, but at a temperature of about 28
degrees pacemaker cells show a gradual reduction of spontaneous depola-
rization in addition to a slowing of conduction system which can lead up
to asystole, ventricular fibrillation or torsades de pointes. Osborn J wave
occurs more frequently at a body temperature between 28 and 32 degrees in
association with bradycardia, decreased consciousness leading to coma, loss
of airway protective reflexes with slow respiratory rate. However J waves are
not pathognomonic of hypothermia. It has been reported in early repolari-
zation, Brugada Syndrome, drugs overdose, central nervous system injury
and hypercalcaemia.
24. ODD ACRONYMS FOR A LAZY BOWEL
Bartoli G., Sola M., Omiciuolo C., Ceschia G.
Struttura Complessa di Geriatria, Azienda Sanitaria Universitaria Integrata
Trieste
A 94-years-old woman was sent to hospital by his physician because of
abdominal pain, vomit and persistent constipation. Clinical history was
remarkable for bilateral knee arthro-prosthesis, hysterectomy, mesenteric
artery stenosis, right common iliac artery aneurysm, essential hyperten-
sion for which she assumed ramipril. Even 3 months before our admis-
sion she went to hospital because of abdominal pain and refractory stipsis.
On that occasion abdomen x-ray described multiple levels and signs of
coprostasis. A CT-scan of abdomen revealed signs of diverticulitis. Stool
transit was restored with enemas and the patient was discharged at home.
1 month before admission she was newly admitted to hospital after a syn-
copal episode: therefore antihypertensive therapy was decreased. She also
reported a prominent unintentional weight loss in the last twelve months
78
118° Congresso Nazionale - Società Italiana di Medicina Interna
(about 30 kg), with loss of appetite and asthenia. On examination she was
oriented with few mnesic deficits. Vital parameters were stable. A systolic
murmur (graduated 2/6) was present at the mitral auscultation area. The
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
normal blood white cells count. Abdomen x-rays described multiple levels
and abdominal meteoric distention. Bowel transit was restored with rectal
tube insertion, enemas and laxatives. Symptoms subjectively improved. On
colonoscopy, mucosa was described as hyperemic and rigid with several
diverticula, consistent with segmentary colitis associated with diverticulo-
sis (SCAD) pattern B. Given low arterial pressure values, antihypertensive
therapy was completely withdrawn. Rifaximin monthly cycles in association
with probiotics and laxatives were suggested and the patient was discharged.
However, in the following year she had 2 other hospital admissions because
of intestinal occlusion. SCAD is an infrequent presentation of diverticu-
lar disease, often characterized by pain, diarrhea and bloody stool, but it
can present also with intestinal occlusion. Optimal treatment has not been
established, although literature suggests use of rifaximin and probiotics,
eventually associated with mesalazine and corticosteroids in more severe
cases. In the present case the symptoms could suggest other frequent con-
ditions in elderly patients such as bowel obstruction due to fecaloma, mali-
gnant disease or intra-abdominal adhesions. Although prognosis of SCAD
is good, it can severely affect patient’s quality of life and determine frequent
hospital admissions, especially in elderly patients. Since constipation and
diverticular colitis may be strictly related by mutual causation, maintaining
soft stool in this kind of patients could represent an important therapeutic
target.
25. EVERY CLOUD HAS A SILVER LINING: A
PROVIDENTIAL ABDOMINAL PAIN
Bartoli G., Sola M., Casagrande S., Parrino S., Ceschia G., Barazzoni R.
Struttura Complessa di Geriatria, Azienda Sanitaria Universitaria Integrata
Trieste
An 85-year-old male patient presented to Emergency Department (ED)
complaining abdominal pain. He had been well until the day before when
he began to perceive a dull abdominal pain with band-like pattern after a
proteic meal. It was associated with a gastric burning sensation. The pain was
unresponsive to magaldrate and pantoprazole which he took on as needed
basis. In ED intravenous pantoprazole was given with subsequent subjective
benefit. Serum bilirubin, amylase and lipase were slightly increased. There
was no elevation of inflammatory markers. Abdomen x-ray described signs
of coprostasis. He was admitted in a Geriatric ward. Physical examination
was unremarkable. He underwent appendicectomy in his youth and bilate-
ral inguinal hernia correction about thirty years earlier. He suffered from
benign prostatic hypertrophy. He reported recent onset of constipation and
an 8 kilos weight loss in the last 6 months; moreover, he had recent episo-
des of self-limited abdominal pain. He drank no alcohol. He was put on
fasting regimen and received enemas. The day after admission, amilase and
lipase still increased (8 times normal values) in the absence of pain. Abdo-
minal echographic examination was hindered by significant meteorism, but
didn’t reveal any sign of cholelitiasis, nor hepato-pancreatic lesions. Stool
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-
creatic body and tail there was a 3x2 cm mass with irregular contour and
enhancement after administration of contrast agent. The lesion surrounded
splenic artery and caused a significant dilation of Wirsung duct (7 mm). An
ambiguous hepatic mass of 1 cm of diameter was also described. Metastases
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
comorbidity burden and the presence of a single pancreatic lesion he was
candidate for surgery. In the following days pancreatic enzymes spontane-
ously dropped and the patient was discharged. Given these symptoms, the
most frequent differential diagnoses could be acute or chronic pancreatitis,
intestinal subocclusion, peptic ulcer, ischemic colitis, and coledocolitiasis.
In this case a well conducted anamnesis uncovered red flag signs (uninten-
tional weight loss, previous history of abdominal pain, new onset consti-
pation) that leaded to a second line imaging study. Pancreatic tail cancer is
usually diagnosed in advanced stage because of the paucity of symptoms. In
this fortunate evenience Wirsung compression caused a symptomatic onset
of the disease that has been promptly valorized and diagnosed.
118° Congresso Nazionale - Società Italiana di Medicina Interna
26. DYSPNEA IN A HEALTHY OLD WOMAN: GHOSTS
FROM THE PAST
Sola M., Bartoli G., Ceschia G.
Struttura Complessa di Geriatria, Azienda Sanitaria Universitaria Integrata
Trieste
In May 2016 a 79-year-old woman presented to our institution for evalua-
tion of progressive shortness of breath that had gradually worsened during
the previous month. She denied chest pain, back pain, or palpitations. She
lived with her husband and led an active and healthy life. She took zolpidem
by oral route for chronic insomnia for several years. In 1995 she underwent
a quadrantectomy, followed by radiotherapy and hormonal therapy, for an
adenocarcinoma in her right breast. Yearly mammograms were done until
2010, then no other examination has been performed. Since April, because
of dyspnea, her general practitioner prescribed furosemide 25 mg oral tablet,
without clinical benefit. Furthermore, in the same period she performed a
chest radiography showing pleural effusion in middle and lower right lobes
with retraction of homolateral costophrenic recess, mild redistribution of
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
percussion and diminished breath sounds on medium and lower right lung
fields; she was afebrile, there was no peripheral edema. The day after admis-
sion she underwent thoracentesis with removal of 1350 cc of pale yellow
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
an exudative pleural effusion. Pleural fluid culture was negative, cytologic
exam revealed papillary aggregates with atypical cells suggesting possible
pleural dissemination of breast cancer. The patient was discharged without
dyspnea and a chest computed tomography scan with contrast agent was
scheduled for the following week. The exam confirmed right pleural effu-
sion associated with multiple irregular nodules on pleural wall; furthermore,
multiple osteosclerotic lesions were present on dorsal and lumbar vertebrae
and tenth right rib. The patient underwent a total body bone scintigraphy
showing multiple bone lesions (sternum, skull, ribs, dorsal and lumbar ver-
tebrae, right femur and kneecap). In June she also underwent pleuroscopy
with biopsy of pleural lesions and chemical pleurodesis. Histologic, genetic
and immunohistochemistry exams were consistent with a hormone recep-
tor-positive, HER2-negative ductal adenocarcinoma. In the following weeks
the patient was visited by the oncologist and anastrazole and zoledronic acid
were started. Breast cancer is the most common cancer among women wor-
ldwide. The risk of local or distant recurrence is very high during the first
five years following the initial treatment. Very late relapse (after 10 years or
more) is uncommon in breast cancer survivors. Nevertheless other cases
describing prolonged disease-free survival before relapse are reported in
literature. Most common sites of relapses are skeleton, lungs and pleura,
liver and central nervous system. The present case emphasizes the impor-
tance of early detection of new symptoms in patient with a cancer history
and the significance of long life surveillance for breast cancer survivors. 2
27. A MISLEADING DIVERTICULAR DISEASE: NOT
EVERYTHING IS WHAT IT LOOKS LIKE
Sola M., Bartoli G., Parrino S., Concollato E., Ceschia G.
Struttura Complessa di Geriatria, Azienda Sanitaria Universitaria Integrata
Trieste
A 72-year-old Italian male was admitted to our Geriatric Clinic complaining
acute fever for the past 2 weeks, with mild diarrhea and asthenia. Previously
he reported normal bowel habits. He lived alone in the community and his
hobby was gardening. He was a nondrinker but was a former smoker. He
reported no recent weight loss. Anamnesis revealed a history of diverticular
disease, chronic gastritis and a colorectal adenomatous polyp removed 8
years earlier. He took no medication excepting tamsulosin for benign pro-
static hyperplasia. 7 days before hospital admission he was treated with oral
rifaximin which was switched to amoxicillin/clavulanic acid because of lack
of clinical improvement. Cardiopulmonary and abdominal examination
were normal, there was no hepatosplenomegaly; rectal examination did
not reveal any blood traces. Admission labs showed elevation of inflamma-
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
Poster
all negative. Also blood culture and urine culture were negative. Empiric
therapy with metronidazole was started. Fecal occult blood test was positive.
After 5 days from admission the patient underwent colonoscopy: this exam
identified widespread mucosal congestion and several pseudopolyps. Histo-
logical analysis revealed marked inflammatory infiltration and mucosal
architectural distortion suggestive for ulcerative pancolitis. Mesalazine by
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
we learnt that inflammatory bowel disease (IBD) can present at any age,
not only in young people. Typical symptoms such as weight loss, abdominal
pain, anaemia and diarrhea may not always be present. As the clinical pre-
sentation can be non-specific, particularly in the elderly, there is a long list
of potential and more common differential diagnoses. In this patient fever
and diarrhea could be a manifestation of diverticular disease unresponsive
to first line treatment with rifaximin; given the clinical history, ischemic and
iatrogenic causes were easily ruled out; conversely, infective and neoplastic
etiologies required further examinations. In every elderly patient presenting
with fever and diarrhea, the differential diagnosis should include late-onset
IBD. Appropriate therapy can lead to prompt control or even resolution of
related signs and symptoms.
28. DO NOT LOSE THE THREAD: WHEN CLINICAL
HISTORY CAN BE MISLEADING. DIFFERENTIAL
DIAGNOSIS OF NEUROPSYCHIATRIC SYMPTOMS IN
AUTOIMMUNE POLYENDOCRINE DISEASE
Di Vincenzo A. 1, Bordigato E. 1, Frascati A. 1, Bettini S. 1,
Spinazzè A. 1, Pepe V. 2, Vettor R. 1, Maffei P. 1
1
Clinica medica 3, Dipartimento di Medicina, Azienda ospedaliera -
Università degli studi di Padova; 2 Clinica medica 5, Dipartimento di
Medicina, Azienda ospedaliera - Università degli studi di Padova
A 19 year-old female was admitted to our ward due to marked asthenia,
fatigue, dizziness and episodes of pre-syncope for several month. Her
medical history was complex and it was notable for central hypothyroidism,
central hypogonadism, growth hormone deficiency and for diabetes insipi-
dus and hyperprolactinemia, the last two conditions having been diagnosed
during puberty. On suspicion of an adverse reaction of recominant GH, the
patient was advised to withold r-GH whereas she kept on the remainder
of usual substive therapy (L-thyroxine, DDAVP, cabergoline and estrogenic
pills). However, there was not clinical improvement and she was referred
to our clinic. On admission, she presented hypotension (90/50 mmHg)
and bradycardia (45 beats per minute), and on neurological examination
reduced strength and diffuse hyporeflexia were observed. Cardio-thoracic
and abdominal examination were normal. Laboratory tests initially revea-
led mild normocromic anemia (115 g/L, normal value 123-153 g/L), hypo-
glycaemia (41 mg/dL), hyponatraemia (131 mmol/L, n.v 136-145 mmol/L),
hyperkaliemia (5.4 mmol/L, n.v. 3.4-4.5 mmol/L) and thrombocytopenia
(61.000/mm3, n.v. 150-450.000/mm3). Considering her clinical history
(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
improvement resulting in the normalization of arterial blood pressure, heart
rate and hyperkalemia. However, basal cortisol (taken before replacement
therapy) resulted in normal range, and the diagnosis of acute adrenal insuf-
ficiency was not confirmed. So, we decided for the suspension of steroid
replacement. After withdrawal, the symptoms reappeared, and in particular,
bradycardia was more pronounced, with a heart rate of 40 bpm. On the
ECG junctional rhythm was observed, echocardiography was normal. After
discussion with the cardiologists, therapy with aminophylline was started.
After therapy was started, the heart rate was normalized, but patient remai-
ned hypotensive, and asthenia persisted; furthermore, the patient showed
progressive alteration of consciousness, with delirium and visual halluci-
nations. An urgent cerebral CT showed no alteration, whereas in EEG
were noted irritative alterations. Head MRI was normal. Facing the threat
of inflammatory neurological disease, cortisone therapy was reintroduced,
with good clinical response and symptoms remission. A lumbar puncture
was performed, resulting negative for infective meningitis; however, labora-
tory tests revealed positivity for antibodies anti-glutamic acid decarboxylase
(GAD). Then, diagnosis of autoimmune limbic encephalitis was crystallized.
The patient was then discharged and followed up in the outpatient clinic.
79
Poster
29. DOCTOR, I GOT SOMETHING ON MY HEAD…
Brignone C., Bracco C., Pomero F., Gollè G., Cardellicchio A., Giraudo A.V.,
Fenoglio L.M.
ASO S. Croce e Carle, Cuneo
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
at the cranial vertex. She underwent erniectomy surgery for L4-L5 discus
disease six years earlier. Chronic lumbar pain relapsing in the two years
prior to hospitalization was treated with opioid analgesics, modulators of the
GABAergic and tricyclic systems. Regular gynecological follow-up, negative
for breast or uterine pathology. She suffered from a Hashimoto thyroiditis
hesitated in hypothyroidism treated with l-thyroxine replacement therapy.
She denied musculoskeletal traumas. Approximately two weeks before the
admission, magnetic resonance imaging of the lumbosacral column and
pelvis and of the brain showed signs of previous interventions in the inter-
spinous posterior L4-L5 intersection and multiple left rooted conflicts and
presence of two parietal lesions at the intradiploic cranial vertex eroding the
bone cortical bilaterally until the dura mater. At physical examination visce-
ral obesity with BMI 31.3 was present; the lower left limb was maintained
semiflex in obligatory antalgic position; there was pain in the inguinal and
left trochanteric area with impossibility to load on the lower left limb. At the
top of the skull, there were two bumpy painless lesions of elastic consistency
covered by intact scalp. Cardiovascular, pulmonary and abdominal exami-
nation was normal. There weren’t palpable lymphadenopathies in the super-
ficial sites. In First Aid, radiographs of pelvis and left hip showed initial
bilateral coxarthrosis, while chest-radiography was normal. In addition, the
following blood tests were performed: WBC 10.57x103/mm3(N 56.2%, L
32.8%, M 10%, E 0.9%), RBC 4.67x106/mm3, Hb 14.6 g/dL, PLT 302x103/
mm3, INR 1, aPTT 37.2 sec, d-dimer 0.45 ng/mL, AST 21 U/L, ALT 41 U/L,
GGT 25 U/L, ALP 93 U/L, LDH 513 U/L, CK 33 U/L, Na+ 138.7 mEq/L,
k+ 4 mEq/L, creatinin 0.8 mg/dL, glucose 95 mg/dL, C-reactive Protein
39.6 (n.v.<10 mg/dL). Diagnostic hypothesis: multiple myeloma; occult
cancer with bone metastasis; Paget’s disease; Langerhans’ hystiocytosis. The
following laboratory tests were performed: serum protein electrophoresis
negative for monoclonal gammopathy, Ig-G 6.5 g/L, Ig-A 2.12 g/L, Ig-M
2.37 g/L, beta2-microglobulin 2.5 mg/dL, Ca2+ 1.20 mmol/L, P+ 4.7 mg/
dL, 25-hydroxyvitamin D 19.4 ng/mL, 1-84-PTH 38.2 pg/mL, TSH 4.830
μU/mL with normal free thyroxine and free triiodothyronine, fecal occult
blood test negative in three samples, normal urinalysis. The abdomen US
and the mammogram were normal. In order to better study the morpholo-
gical characterstics of the skull lesions a brain CT with iodate contrast was
performed, confirming two parietal osteolytic circle-shaped lesion without
contrast enhancement estese fino alla diploe; the radiologist’s diagnostic
hypotesis was “eosinophylic granulomas”, which are the most common and
benign form of the Langerhans cell hystiocytosis. A Tc-99m bone scan was
done to search for further osteolytic lesions eventually in sites of minor
risk for surgical biopsy. Additional bone osteolysis was shown on the left
humeral and tibial bones and on both femoral bones. CT scans of thorax,
abdomen and pelvis showed mediastinal adenopathies, a suspect left adrenal
adenoma and multiple osteolysis. The US-guided biopsy of one lesion in thi-
ghbone detected a mildly differentiated adenocarcinoma with mucosecre-
ting cells without origin-specific immunohystochemical patterns. A second
biopsy on mediastinal lymphnodes confirmed the previous result. EGDS
and pancolonoscopy were negative. A whole body 18F-FDG-PET/CT was
performed in order to identify the primary cancer: a high metabolic activity
was assessed in mediastinal lymphnodes, left adrenal gland and multiple
bone sites. A diagnosis of cancer of unknownprimary origin (CUP)was
made. Chemotherapy with Paclitaxel 175 + Carboplatin AUC 5 every 21
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-
resistance and poor outcome in patients are due to chromosomal instabi-
lity. Pathology evaluation of good quality tissue samples and meticulous
immunohistochemistry are needed to identify distinct subsets of patients. A
minority of patients (15%–20%) belong to subsets with a relatively unambi-
guous clinico-pathological findings and have a more favourable prognosis,
so they should be treated with site-specific treatment (IVB). The majority of
patients (80%–85%) do not belong to specific subsets and have only modest
sensitivity to therapy with a median overall survival (MOS) of 6–10 months.
Consequently, in this group low-toxicity chemotherapy regimens are better
indicated. Choice between a more aggressive treatment and a supportive
care could be based on the following prognostic criteria: a) patients with
a good performance status (PS) (0–1) and a normal LDH value, with a
median life expectancy of 1 year can benefit from a 2-drugs chemotherapy;
80
118° Congresso Nazionale - Società Italiana di Medicina Interna
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
care (IIA). During response evaluation quality-of-life issues are relevant, as
for patients with poor-risk CUP excessive treatment-related toxicity is not
justified (IVB). (Annals of Oncology 26 (Supplement 5): v133–v138, 2015)
30. ZOONOTIC INFECTIONS: BEWARE OF DOMESTIC
CATS
Caserza L. 1, Piatti G. 2, Del Bono V. 3, Dallegri F. 1, Montecucco F. 1
1
Department of Internal Medicine, San Martino Hospital, University of
Genoa 2Department of Microbiology, Policlinico San Martino Hospital,
University of Genoa 2Department of of Infectious Diseases, San Martino
Hospital, University of Genoa
A 92-year-old woman presented at emergency room with coma, feces loss
and fever (39.5°C), blood pressure 180/110 mmHg, respiratory rate of 25
breaths/minute and saturating 92% on room air. Personal medical history
was characterized by hypertension, mild cognitive impairment, atrial fibril-
lation, chronic heart failure, horseshoe kidney with normal renal function.
At admission in emergency room the electrocardiogram showed atrial
fibrillation with normal heart rate. Laboratory test results at admission
demonstrated white blood cell count (WBC) of 13160/mm3, lactic acid of
2, 5 mmol/l, creatinine of 0, 7 mg/dl, troponins 0, 238 ng/ml, C reactive
protein (CRP) 6, 2 mg/L, lactic dehydrogenase 252 U/L. For an uncertain
left arm and leg hyposthenia a brain CT scan with angiographic sequen-
ces was performed. It showed a complete occlusion of right intracranial
vertebral artery, diffused signs of leukoencephalopathy, no haemorrhages.
A brain Magnetic resonance was performed to exclude recent ischemia.
Hemocultures were performed and an empirical antimicrobial treatment
with piperacillin/tazobactam and meropenem was administered for four
days without a significant improvement: the patient was unconscious and
had remittent fever. At the admission in our department, the patient was
still unconscious and, at clinical examination, was reported a systolic mitra-
lic murmur and an inflamed area was detected on peri-malleolar skin of the
right leg. Both arterial-venous legs Echo-colour-Doppler and carotid ultra-
sound were negative for thrombosis and stenosis. Inflammation biomar-
kers were tested, showing elevation in procalcitonin (4, 0 μg/L), CRP was
200 mg/L; troponins were negative. Three hemocultures were positive for
Pasteurella Multocida. A specific antimicrobial therapy with ampicillin-sul-
bactam and gentamicine was started and a trans thoracic echocardiogram
was performed at day 10 of antimicrobial treatment. It didn’t show lesions
compatible with endocarditis. After one day of ampicillin-sulbactam and
gentamicin the patient was conscious and fever stopped. The patient refer-
red to her cat bite one week before the admission to hospital. A sample of
cat saliva was analyzed, it was positive for Pasteurella Multocida. The patient
was discharged after 15 days of endovenous antimicrobial therapy (ampi-
cillin-sulbactam and gentamicin) shifted to oral amoxicillin and clavulanic
acid for other 15 days.
Conclusion: Cat bites and scratches can drive many pathogenic bacteria as
Pasteurella multocida and cause a deep wound especially on legs and arms.
Usually these lesions are treated with a local approach and are often unde-
restimated by people. Only in few cases patients see a doctor for an anti-
biotic treatment. In elderly patients, especially with comorbidity, cat bites
can lead to local complications or Pasteurella multocida sespsis, an unusual
but severe condition. A wider awareness on this problem must be useful in
order to prevent life-threatening situations after pet bites. If patients present
fever after cat bites or scratches and non-compliance to antibiotic therapy is
suspected, hospitalization may be required.
31. AN UNUSUAL CASE OF APHASIA AND
HYPOTHERMIA
Dequarti A. 1, Di Vasto M.A. 1, Frigo L. 2, Minuz P. 2, Frulloni L. 1, Ciccocioppo
R. 1
1
Gastroenterology Unit, Department of Medicine, AOUI Borgo Roma,
University of Verona, Verona, Italy; 2Internal Medicine C, Department of
Medicine, AOUI Borgo Roma, University of Verona, Verona, Italy.
In December 2016, a 90-year-old woman was admitted to the Department of
Internal Medicine of the Policlinico G.B. Rossi (Verona, Italy) because of a
rapidly progressive cognitive impairment with confusing episodes lasting two
weeks, leading to global aphasia. Patient’s medical history included metabo-
lic syndrome (overweight, hypertension with hypertrophic cardiomyopathy,
118° Congresso Nazionale - Società Italiana di Medicina Interna
dyslipidemia and carotid atherosclerosis), polyarthrosis, multinodular goiter,
previous hospitalization for NSAID-related bleeding gastric ulcer, right hip
arthroplasty, and hysterectomy. Her usual therapy was: bisoprolol, oxyco-
done/naloxone, prazepam, amiloride/hydrochlorothiazide, lansoprazole.
At the admission, vital sign measurement highlighted hypotension (systolic
blood pressure 85 mmHg) and hypothermia (T 32.0°C), while blood tests
showed hyponatriemia (133 mmol/L) and hyperkaliemia (6.63 mmol/L).
The ECG showed sinus bradycardia (HR 48 bpm) with type I AV block. Neu-
rological examination pointed out that patient was vigilant, aphasic, with
myotic pupils, without deficits of motor and sensitivity function; the strength
test couldn’t be evaluated because of lack of collaboration in Mingazzini’s
test. There was also mild limb edema. Her relatives reported that she had
always been self-sufficient in housework before the present cognitive impair-
ment; however, in the last two weeks they found a progressive reduction of
autonomy in self-care and domestic works. The interpretation of this clinical
picture was challenging since several diagnostic hypotheses might be advan-
ced (such as neurological, infective, and pharmacological causes), thus the
patient was admitted in an Internal Medicine Unit. A CT scan was performed
in order to investigate possible neurological events, and no acute lesions were
found. Clinical symptoms (aphasia, hypothermia, hypotension, bradycardia)
coupled with electrolyte disorders (hyperkaliemia, hyponatriemia) made
us suspect of a possible metabolic disorder. The most likely causes include
hypothyroidism, adrenal insufficiency, and hyperammoniemia. However,
the levels of thyroid hormones, serum cortisol, ACTH, urinary free cortisol
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
no evidence of focal alteration of the signal intensity, but signs of cerebral
atrophy were carried out. Moreover, serial blood cultures and serology for
HBV, HCV, CMV, HSV-1, HSV-2, VZV, EBV, Rubella virus, Measles virus,
Mumps virus, HIV, Coxsackievirus, Borrelia Burgdorferi, Brucella, Leish-
mania, Toxoplasma Gondii, Treponema Pallidum serology resulted negative,
including urinary search of Legionella Pneumophila. Thus, a possible viral
infection of CNS was suggested and a lumbar puncture was proposed to the
Neurologist who found it inappropriate. The assessment of autoantibodies
showed ANA (1:160) and p-ANCA positivity, while ENA and anti-citrul-
line antibodies were negative, thus vasculitis or other autoimmune condi-
tion were excluded. A first 24-hour Holter ECG was carried out showing a
normal sinus rhythm (HR average 52 bpm) with type I AV block and two
significant pauses (3 and 7 seconds, respectively), whereas the second one
performed one week later, documented a normal sinus rhythm (HR average
90 bpm), type I AV block, and supraventricular tachycardia (HR max 150
bpm) that was attributed to a rebound effect of the beta-blocker withdrawal.
During the hospitalization, we witnessed a gradual cognitive improvement,
with the recovery of the speech. In addition, body temperature returned to
normal range (36.2°C), as well as systolic blood pressure (140 mmHg), and
electrolyte balance. All symptoms, therefore, disappeared after 15/20 days
without any particular therapeutic action, unless hydration and suspen-
sion of home therapy. An inappropriate (excessive) intake of domiciliary
drugs was, therefore, supposed. For this reason, a hair test was carried out
that showed very high concentration of oxycodone (516 pg/ml, negative <
3 pg/ml), and urine test that showed high benzodiazepine level (2.390 ng/
ml, negative < 200 ng/ml). It is conceivable that the oxycodone over-intake,
caused by an exacerbation of joint pain, resulted in a progressive cognitive
impairment leading, in turn, to an erroneous intake also of the other drugs,
thus causing hyponatriemia and hyperkaliemia (hydroclorothiazide/amilo-
ride) and bradycardia (beta-blocker). Thus, the final and unexpected diagno-
sis was pharmacological intoxication. This case underlines the relevance of
collecting an accurate medical history for a correct management, and how
‘less is more’.
32. A RARE CASE OF LYMPHADENOPATHY
Cioffi A., Brancato T., Coscione M., Colurcio R.
U.O. Medicina Generale, P.O. S. Maria della Pietà, Casoria (Na)
A 64 year old man was admitted in our Unit due to persisting fever, asso-
ciated with arthralgia and headache. It was relieved to some extent with
paracetamol. In his past medical history was colon polyposis treated endo-
scopically about 10 years ago as well as diabetes mellitus type 2 in treatment
with OHA and prostate hypertrophy. On examination his pulse rate was
98 bpm, blood pressure 110/70 mmHg, respiratory rate 15 breath/minute
and temperature 38.3 °C. Physical examination was unremarkable except
for tender right cervical and submandibular lymphadenopaty as well as
bilateral axillary. Laboratory tests revealed neutropenia and lymphope-
Poster
nia. LDH and GGT were elevated. Renal function tests were normal. VES,
PCR were all normal. HbsAg and anti-HCV were negative. Autoimmune
markers including anti-nuclear antibodies and anti-mitochondrial anti-
bodies were negative. Several infective agents incluging EBV, Toxoplasma,
HSV were negative. PSA was normal. Beta2microglobuline exceeds above
normal value and hypergammaglobulinemia. Positive urinoculture for
E.Coli. Chest X-ray was normal. Ultrasonography of the abdomen revealed
mild steatosis and prostate hypertrophy. Echocardiography findings revea-
led no vegetations. Furtermore a total body contrast-enhanced computed
tomography was done. The ultrasound examination of the right cervical and
submandibular revealed subverted ecostructures. Since surgical excisional
biopsy is the gold standard for diagnosis of lymphadenopaty, an excisional
biopsy of right cervical lymph node was performed. Histopathology of the
excised specimen revealed lymphadenitis with expansion of paracortical
compartmen and proliferation of extracellular histiocytes with co-expres-
sion of CD68 e MPO. A diagnosis of histocitic necrositing lymphoadenitis
(Kikuci-Fujimoto Disease) was made. The patient received antibiotics for
urinary tract infection and paracetamol for the fever and disconfort after
the procedure. KFD is a rare, benign, self limiting disease characterized by
histiocytic necrositing lymphadenitis. The cervical group of lymph nodes is
most commonly involved. Though several viral agents or an autoimmune
etiology has been proposed as causative, the exact cause remain unknown.
Long term follow up is important to monitor the development of rheumato-
logic or haematologic disease.
33. A RARE CASE OF ESSENTIAL THROMBOCYTHEMIA
ASSOCIATED WITH MASTOCYTOSIS
Cosi E. 1, Pizzi M. 2, Giannini S. 1, Bertozzi I. 1, Santarossa C. 1, Fabris F. 1,
Randi M.L. 1
1
Department of Medicine - DIMED, University of Padua, Via Giustiniani
2, 35128, Padua, Italy. 2 Surgical Pathology and Cytopathology Unit,
Department of Medicine-DIMED, University of Padova, Padova, Italy.
Introduction: Systemic mastocytosis with an associated hematological
neoplasm (SM-AHN) is the second most common subtype of SM, with a
frequency between 21 and 44%. In the majority of patients with SM-AHN,
a myeloid stem cell malignancy is diagnosed. Published descriptions of the
clinicopathologic features of SM-AHN are largely limited to individual case
reports. Clinical case: In December 2016, we evaluated in our surgery a
62 year-old man with thrombocytosis (600-750 x 10^9/L) with significant
medical history for longstanding hepato-splenomegaly. He referred skin
lesions compatible with urticaria pigmentosa treated with phototherapy.
On physical examination we confirmed a mild hepato-splenomegaly and
multiple hyperpigmented maculopapular lesions, ; no lymphadenopathy
was observed. The remaining physical examination was normal. Hemoglo-
bin and white cells count were normal; despite a normal ferritin, homozy-
gosity for HFE H63D was detected. We searched and found JAK2V617F
mutation (allele burden 9.3%). An abdomen ultrasound revealed fatty liver
and splenomegaly (largest dimension 18.7 cm). The suspicion of essential
thrombocythemia (ET) was confirmed with a bone marrow (BM) biopsy,
which showed normal cellularity with preserved M:E ratio (3:1) and normal
maturation of the myeloid and erythroid lineage; megakaryocytopoiesis
was increased (6-7 megakaryocytes/HPF) and consisted of giant mega-
caryocytes with hypersegmented nuclei, also organized in loose clusters.
Perivascular and paratrabecular aggregates of spindle-shaped mast cells
(MCs) were also present. These cells featured fine metachromatic granules
and were intermingled with eosinophils and mature-looking lymphocytes.
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-
netic analysis disclosed a normal male karyotype (46, XY). Consequently,
the medical history of the patient was accurately reconsidered. He denies
any reactions to foods, medications, especially anaesthetics, radiographic
contrast mediums, insect stings; no mast-cell mediator-related symptoms
were reported. More specific laboratory investigations were performed and
revealed elevated serum triptase level (123 ng/mL) and PTH (62, 5 pg/mL);
vitamin D insufficiency (serum 25-OH-D 50, 1 nmol/L), with normal bone
ALP (17, 4 ug/L), serum CTX (315, 7 pg/mL), serum Calcium (8, 9 mg/
dL), serum Phosphate (3, 6 mg/dL), and 24h urine calcium (174, 8 mg/24
h) and phosphate (1049, 94 mg/24 h). Molecular testing for the KITD816V
somatic mutation is ongoing. Radiographs of the spine demonstrated
multiple biconcave vertebral fractures (T7, T8, L1, L3, L5). Bone mineral
density (BMD) of the lumbar spine, measured by DXA, was significantly
reduced (T-score -3.8, BMD 0.678 g/cm2), while the total femoral (T-score
81
Poster
-1.7, BMD 0.781 g/cm2) and femoral neck BMD (T-score -2.3, BMD 0.622
g/cm2) were moderately reduced. Treatment with Acetilsalicilic Acid and
Hydroxycarbamide was started and the PLT count start to fall; furthermore
bisphosphonate was administered.
Discussion: In the published studies, SM-AHN is the second most common
subtype of SM. The myeloid malignancies most commonly associated with
SM in the literature are MDS, AML e CMML. However, cases of essential
thrombocythemia, polycythemia vera and other unclassifiable myelopro-
liferative disorders have been described as AHNs. The exact pathogenesis
of mast cell disease associated with myeloid malignancy remains unclear.
In the present case, the diagnosis were performed for both ET and SM in
agreement with WHO 2016 criteria: the patient fulfilled all 4 major criteria
for ET and the diagnosis of SM was obtained with one major criterion (mul-
tifocal compact infiltrates of MCs in bone marrow) and two minor criteria
(MCs in the bone marrow express CD25; MCs in bone marrow show an
abnormal spindle-shaped morphology). This is the first case of ET associa-
ted with SM diagnosed in agreement with the most recent WHO criteria,
showing that the use of these criteria helps in recognizing of rare associated
diseases.
34. A FEVER OF (UN)KNOWN ORIGIN?
Cufone S. 1, Bova C. 2, Vallone A. 3, Vallone G. 1
1
Department of Internal Medicine-Dipartmental structure of Interventional
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
In September 2016, a 27-year-old man was transferred from another hospi-
tal to our Department because of a worsening of his clinical conditions. He
had a history (8 days) of fever (up to 40 ° C), diarrhea and vomiting. No rele-
vant findings in his family and his physiological and past medical history
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
cm in S6 / S7) consistent with hepatic abscesses, epithelial colon estrophils,
perihepatic e celiac-mesenteric lymphoadenomegaly. He was treated with
antibiotic therapy: Meropenem, Vancomycin, Paromomycin Sulfate and
Metronidazole, without any improvement. In our hospital ward, the second
level hematochemical tests (Widal Wright, EBV IgM, Herpes Simplex 1-2
IgG and IgM, CMV - DNA, HIV test, IgM anti Parvovirus B19, Ab anti
Entamoeba histolytica, ANA) were negative as well as blood cultures, urine-
culture and coproculture for common germs and Clostridium Difficile. In
several sessions, the patient was treated with multiple ecoguidated percu-
taneous aspiration of seven hepatic abscesses. During aspiration, purulent
material was obtained. For this reason, the patient was also exposed to a
multiple local antibiotic injection (Piperacillin/Tazobactam). In addition he
was treated with a systemic antibiotic therapy (Teicoplanin, Levofloxacin,
Metronidazole) and it caused a progressive clinical improvement. During
hospitalization, after 15 days, a new clinical worsening appeared, characte-
rized by fever associated with a moderate neutropenia (WBC: 2.100/mL,
NEU: 900/mL, LIN: 700/mL), anemia (HGB: 10.5 g/dl), coagulopathy (INR:
1.52, PT: 17.6 sec 51%, and PTT: 33.9 sec). Clinical doubts: Other cause?
New sepsis focus? hepatic abscesses’ worsening? Antibiotic fever? Other?
A new abdominal TC scan was performed and the comparison with a pre-
vious test showed a clear improvement in both number and size of hepatic
abscesses. Procalcitonin and blood cultures were persistently negative; an
echocardiogram ruled out the presence of images suggestive of endocardial
vegetation. News ecoguidated percutaneous aspirations of hepatic abscesses
were performed, without purulent material emission. The aforementioned
antibiotic therapy was then replaced with Clindamycin and Gentamicin.
After the second administration of Clindamycin, the patient had a skin
rash, a new peak of fever and a worsening of bioumoral test. Despite our
worry, we decided to suspend antibiotic therapy, considering results of cul-
tures, procalcitonin test, echocardiograms, the improvement of TC exami-
nation and above all the results of new percutaneous aspiration. The patient
showed a progressive clinical improvement.
Conclusion: Gold standard therapy in patients affected by hepatic absces-
ses is represented by percutaneous ecoguided treatment (aspiration or per-
cutaneus drainage). In our patient, after the reappearance of fever, several
differential diagnoses were considered including a new sepsis focus, a wor-
sening of hepatic abscesses or an antibiotic fever. Clinical judgment drove
our choices, deciding to suspend antibiotic therapy. Clinical improvement
of patient confirmed the diagnosis: fever due to antibiotics.
82
118° Congresso Nazionale - Società Italiana di Medicina Interna
35. A STRANGE “DRESS CODE”
D’Ardes D., Marchione L., Grappasonni G., Di Febbo C.,
Rinaldi A.M.P., Carbone A.M., Chiaromonte S., Pieramati L., Angelucci E.,
Santilli F., Davi’ G.
Clinica Medica, P.o. Clinicizzato “Ss. Annunziata”, Chieti, Asl Lanciano-
Vasto-Chieti, Scuola Di Specializzazione In Medicina Interna, Universita’ “G.
D’annunzio”, Chieti
A 50-years old woman was admitted at “SS. Annunziata Hospital” of Chieti
for erythroderma, fever (with peaks of 39° C) and cough.
The patient had a history of rheumatic valvular heart disease, she had atrial
fibrillation, osteomuscolar pain and for this reason she had recently started
new drugs.
Laboratory has showed that the patient had a floating eosinophilia in asso-
ciation to erythroderma and thus she underwent to dermatological evalua-
tion e skin biopsy.
She was examined through CT scan of thorax and abdomen with evidence
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-
ciated cholecystitis.
She was evaluated in a Center of excellence for Immunology where it was
made a diagnosis of drug reaction with eosinophilia and systemic symptoms
(DRESS) successfully treated with high dose of corticosteroid.
36. THE IMPORTANCE OF MEDICAL HISTORY
Carbone A.M., Di Pizio L., Valeriani E., Grappasonni G.,
Marchione L., Santilli F., Rinaldi A.M.P., Di Febbo C.,
Angelucci E., Davì G.
U.O. Clinica Medica - Università degli Studi “G. d’Annunzio” - Chieti
A 34-year-old male patient with multiple sclerosis (MS) treated with alem-
tuzumab about twelve months before, was admitted to our department with
palpitation and asthenia. Initial clinical examination was normal except for
mild tachycardia (110 bpm). Blood test showed hemoglobin (Hgb): 5, 2 g/
dl (normal values, n.v. 13-16); hematocrit (Hct): 15% (n.v. 37-49); mean
corpuscolar volume (MCV): 83, 3 fL (n.v. 77-95); mean corpuscular hemo-
globin 28.9 pg (n.v. 25-35); mean corpuscolar hemoglobin concentration
(MCHC): 34, 7 g/dl (n.v. 33-36), white blood cells (WBC) 5, 04 x10 3/ul
(n.v. 4-10); platelets (PTL): 335 x 10 3/ uL (n.v. 150-450); potassium (K):
4, 05 mmol/L (n.v. 3.5-5.1). The patient did not report any blood loss. In
the need to transfuse, direct and indirect Coombs tests were performed.
They resulted both positive with panagglutination, so the transfusion was
impossible. The supplementary exams showed: haptoglobin < 8 mg/dl (n.v.
30-200); lactate dehydrogenase (LDH): 1114 U/L (n.v. 313-618). Renal fun-
ction was normal; total bilirubin 0, 4 mg/dl (n.v. 0.2-1.3); indirect biliru-
bin: 0, 3 mg/dl (n.v. 0-0.3). Urine analysis: pH: 6, 5 (n.v. 5.5-6.5); colour:
straw-yellow, clear; spot proteinuria: 1640 mg/dl (0-12); spot albumin: over
(0-10); bilirubin: 0.2 mg/dl (0-0); urobilinogen 1 mg/dl (0-1). According
to patient clinical conditions and in agreement with the haematologist, an
immunosuppressive therapy with intravenous (iv) methylprednisolone 1
mg/kg/d and immunoglobulin therapy (1 g/kg/d) was started. In the next
days blood exams were monitored and a further decrease of Hgb was noted
(3, 9 g/dl). Therefore two units of hemocompatible leukoreduced red blood
cells were trasfused. In agreement with the hematologist, vitamin B12, folate
and erythropoietin were added to the ongoing therapy. The steroid therapy
was increased to methylprednisolone 1 g/d and another infusion of immu-
noglobulin at the previous dose was repeated. To exclude other causes of
anemia, gastroscopy, abdominal ultrasonography (US) and bone marrow
aspiration were performed and resulted normal. The blood levels of erythro-
poietin, folate, vitamin B12 and the complete study of iron metabolism were
normal. In addition, a pneumonia caused by Micoplasma pneumoniae was
ruled out. About severe proteinuria and albuminuria found at the admission
exams, a glomerular nephropathy was suspected. However, protenuria and
albuminuria gradually normalized during the immunosuppressive therapy.
Therefore, in agreement with the nephrologist, a renal biopsy was not
performed. The patient was discharged with diagnosis of warm antibody
autoimmune haemolytic anemia and glomerular nephropathy in multiple
sclerosis treated with Alemtuzubab. He continued steroid therapy and was
directed to Hematological Unit.
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
118° Congresso Nazionale - Società Italiana di Medicina Interna
effects with the use of this drug have been reported, usually autoimmune
diseases, as thyropathies and idiopathic cytopenic purpura. These compli-
cations appear many months after the administration of the drug. Autoim-
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.
37. THE DARK SIDE OF A RECURRENT ABDOMINAL
PAIN
Di Pizio L. 1, Carbone A.M. 1, Grappasonni G. 1, Di Pizio V. 2, Pieramati L. 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 Alma
Mater Studiorum - Università di Bologna. Facoltà di Medicina e Chirurgia
A 74-year-old patient was admitted to our Unit for a symptomatology
characterized by referred abdominal pain, vomiting and diarrhea. In her
past medical history, the patient referred multiple admissions to hospital
for recurrent episodes of acute pancreatitis, described by clinical, labora-
tory and imaging features, but never associated by imaging signs suggestive
of lithiasis. She denied chronic alcohol abuse. In addition, she was affected
by Hashimoto’s chronic autoimmune thyroiditis, polymyalgia rheumatica
and allergic asthma. The patient had been cholecystectomized many years
before and had undergone a sphincterotomy of sphincter of Oddi. However,
all her past imaging examinations brought to our attention showed a mild
ectasia of the intrahepatic and common bile duct. The caliber of the pancre-
atic duct of Wirsung was at the upper limits of the normal range. In addi-
tion, a later performed duodenoscopy documented a papillitis of Vater. At
the time of the admission to our Unit, the patient was assuming pancreatic
enzyme supplementation for a chronic pancreatic failure. At the physical
examination, she showed a mild abdominal pain, poorly localized in the
epigastrium and mesogastrium. The vital signs, thoracic, cardiologic and
neurological examinations were normal. The laboratory tests documented:
amylase 715 U/l (normal values, n.v: 30-110); lipase 4293 U/l (n.v. 23-300);
white blood cells (WBC) 11.25 x 103/ul (n.v. 4-10); neutrophils 8.28 x 103/
ul (n.v. 2.8-5.25); erythrosedimentation rate 70 mm/h (n.v. 1-15); C-reactive
protein 6.85 mg/dl (n.v. 0-0.5); blood creatinine 1.45 mg/dl (n.v. 0.52-1.04).
Bilirubin, alanine transaminase (ALT), aspartate transaminase (AST),
gamma glutamyl transpeptidase (GGT), alkaline phosphatase, triglyceri-
des, thyroid-stimulating hormone (TSH) and gamma globulins were in the
normal range. An abdominal computed tomography (CT) was performed,
and there were neither signs of acute pancreatitis nor lithiasis. The duo-
denoscopy showed the signs of the past sphincterotomy. An autoimmune
cause of acute recurrent pancreatitis was suspected, and the immunoglobu-
lin G4 subclass (IgG4) were dosed and found above the upper limit of the
normal range: 150 mg/dl (n.v. 1-104). In agreement with the 2011 Interna-
tional Consensus Diagnostic Criteria (ICDC-2011), for autoimmune pan-
creatitis (AIP), this finding was consistent with a probable diagnosis of type
1 autoimmune pancreatitis (type 1 AIP). In addition to the common therapy
of acute pancreatitis (fasting and aggressive rehydratation), the patient was
treated with methylprednisolone 16 mg bis in die (bid), with benefit. She
continued the treatment per os after the discharge from our Unit, followed
by a a gradual taper (dose decrement of about 4 mg of methylprednisolone
per week), until complete discontinuation.
Discussion: Acute recurrent pancreatitis (ARP) refers to a clinical entity
characterized by episodes of acute pancreatitis which occurs on more than
one occasion. In addition to the most common causes of acute pancrea-
titis (duct stones, biliary sludge, obstruction by neoplastic causes, alcohol
abuse, hypertriglyceridemia), other possible reasons could be represented
by sphincter of Oddi dysfunction (SOD) and anatomical duct variants inter-
fering with pancreatic juice outflow. The etiology of ARP is “idiopathic” in
30% of cases. In cases of recurrent attacks of pain in patients with idiopathic
pancreatitis, we need to keep in mind that our patient may have autoim-
mune pancreatitis. The frequency is very low (about 5%). Autoimmune pan-
creatitis (AIP) is a chronic fibroinflammatory disease of the pancreas that
belongs to the spectrum of immunoglobulin G-subclass 4-related disease
(IgG4-RD). The diagnosis of AIP depends on serology, imaging, histology,
other organ involvement and reaction to steroids. Although elevated levels
of IgG4 support the diagnosis, normal levels cannot be used to exclude the
diagnosis. The initial objective for the clinician is to rule out malignancy.
In our case, the patient fulfilled the 2011 International Consensus Diagno-
stic Criteria (ICDC-2011) for a possible AIP. In addition, she responded to
the steroid therapy. However, the ARP could be due to a mechanical cause,
such as the mild ectasia of bile and pancreatic ducts, probably caused by
the previous episodes of ARP themselves. Oral pancreatic enzyme supple-
Poster
mentation is not recommended by the most used guidelines for the mana-
gement of acute pancreatitis, but they have showed some benefit in cases of
impaired pancreatic exocrine function if used early at the time of refeeding.
38. OBSCURED BY AN “ASCENDING” DISEASE
Di Pizio L. 1, Carbone A.M. 1, Grappasonni G. 1, Di Pizio V. 2,
Pepe R. 1, Chiaromonte S. 1, Dall’O’ F. 1, Marchione L. 1,
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
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
episodes of fainting (7-8 episodes in the last 48 hours). In addition, she
referred diarrhea occurred about a week before. In her clinical history, she
was affected by a conversion disorder, depression and bipolar disorder. She
was chronically treated with clozapine, clonazepam and valproic acid. At
the physical examination, she presented skin and mucous hypohydration,
sinusal tachicardia (heart rate, HR: 124 beats per minute, bpm) and pain in
the lower parts of the abdomen during the local palpation. At the neurolo-
gical examination, she showed hyposthenia of the lower limbs during the
Mingazzini test. The consciousness was preserved, but the patient showed
a poor collaboration during the whole physical examination. The body
temperature was 38.3 °C. The other vital and objective signs were normal.
The laboratory tests documented: white blood cells (WBC) 16.8 x 103/ul
(normal values, n.v: 4-10); neutrophils 13.7 x 103/ul (n.v: 2.10-7.10); C-re-
active protein 30.3 ng/ml (n.v: 0-0.5); procalcitonin 0.57 ng/ml (n.v: 0-0.5);
blood potassium 3.94 mmol/l (n.v: 3.5-5.1); blood sodium 139 ng/ml (n.v:
136-146). She had leukocyturia: urine leukocytes 15500 U/ul (n.v: 0-15). In
suspicion of an initial sepsis, we performed blood and urine cultures, chest
x-ray and a head computed tomography (CT), all of which resulted to be
normal. After about 24 hours, the patient manifested drowsiness, hyposthe-
nia of the four limbs, body temperature of 37.4 °C. The C-reactive protein
increased to 35.7 ng /ml (n.v: 0-0.5). The procalcitonin was 0.47 ng/ml (n.v.:
0-0.5), WBC 11 x 103/UL (n.v.: 4-10), neutrophils 8.9 x 103/ul (n.v.: 2.10-
7.10). A new brain CT was performed, which resulted to be normal. The
electroencephalography showed slow-wave abnormalities, with prevalence
of slow polymorphic theta (θ) waves (6-7 Hertz). The blood gas analysis
showed an hypoxemic respiratory failure, so she began oxygen therapy. As
the neurological state worsened in the following hours (the patient showed
areflexia of the four limbs), given the absence of neither a clear suspicion
of sepsis, nor the evidence of organic causes of symptoms, a lumbar pun-
cture was performed, to verify the hypothesis of Bickerstaff ’s brainstem
encephalitis (BBE) overlapping with a Guillain-Barré syndrome (GBS) and
rule out other causes of encephalitis. The cerebrospinal fluid (CSF) analysis
documented an increased protein concentration (61 mg/dl; normal range,
n.r.: 18-43), normal glucose concentration and WBC count. The blood and
CSF virological tests were negative. A therapy with intravenous immuno-
globulins (IVIg) 0.4 g/kg/d was started, with a rapid improvement of the
neurological and respiratory symptoms (recovery of the active motion of
the four limbs, level of consciousness and speech). As a diagnostic confirm,
an electroneurography was performed, which showed a decrease of F-waves
in the nerves of the lower limbs. The patient was then transferred to a spe-
cialized Centre to begin a proper neuromotor rehabilitation.
Discussion: Guillain-Barrè syndrome (GBS) is an immune-mediated disor-
der of the peripheral nerves, characterized by an acute onset of flaccid paraly-
sis associated with the loss of reflexes. In typical syndrome, rapidly progressive
bilateral weakness is the key presenting symptom in most patients. Weakness
is classically described as “ascending”, usually starting in the distal lower extre-
mities. The acute progression of limb weakness proceeds to its peak clinical
deficit in 2-4 weeks. The disease is tipically preceded by an infective episode
which often involves the respiratory or gastrointestinal tract within 4 weeks of
onset of weakness. Bickerstaff ’s brainstem encephalitis (BBE) can be defined
as a syndrome presenting acute ophtalmoplegia, ataxia and disturbance of
consciousness as its major manifestations. Not all cases present classically
with this triad of features, and absence of one does not rule out the diagnosis.
Altered sensorium is a key symptom. A considerable number of patients with
BBE developed flaccid tetraparesis, which is presumed to be a sign of overlap-
ping GBS. In fact, today the predominating opinion is doubtful that BBE is a
separate distinct clinical condition. In our patient, the confounding aspects
were the chronic anti-psychotic therapy assumed and the rapid worsening of
the clinical course. Anyhow, these features made the lumbar puncture an early
necessity. This procedure have finally confirmed our clinical suspicion.
83
Poster
39. DISSEMINATED INTRAVASCULAR COAGULATION
AND PRIMARY MYELOFIBROSIS: WHICH BEST
THERAPEUTIC STRATEGY?
Marigliano B. 1, Valli G. 2, Antonelli Incalzi R. 1, Ruggieri M.P. 2
1
U.O.C. di Medicina Interna, Università Campus Bio-Medico, Roma 2
Dipartimento Emergenza ed Accettazione, Azienda Ospedaliera S. Giovanni-
Addolorata, Roma.
Background: Disseminated intravascular coagulation (DIC) is a hemato-
logical emergency often difficult to recognize and always hard to treat as
it is the final manifestation of a number of different severe syndromes. Its
prognosis depends on the severity of the coagulopathy and on the under-
lying condition.
Case Report: The patient arrived at the emergency department (ED) for
an acute abdominal pain with caudal extension reaching both lower limbs,
associated with dysentery occurred during the two previous days with a pro-
gressive worsening trend. He was hospitalized in the cardiac rehabilitation
centre where he was admitted two weeks before to recover from heart failure
exacerbation. During hospitalization, he was treated with high doses of diu-
retics and water restriction to reduce preload and improve heart perfor-
mance. The patient had a history of diabetes mellitus not requiring insulin,
chronic obstructive pulmonary disease on long-term low flow oxygen, and a
recent laboratory diagnosis of active Primary Myelofibrosis (PM) (reported
leukocytosis > 30, 000 / uL with a gene activating mutation of the thrombo-
poietin receptor MPL gene) yet untreated (no palliation or cytoreduction).
He had first of all gone to his local rural ED where he underwent an abdomi-
nal computerized tomography (CT) scan with contrast enhancement, which
revealed extensive thrombosis spreading to the superior mesenteric artery,
and to both renal and common iliac arteries. Owing to the severe extensive
state of the thrombosis, he was transferred to our central ED with a request
for a vascular surgical and haematological consultation. At first glance, his
clinical appearance was poor. The patient arrived in a diaphoretic, hypoten-
sive, and oliguric (e.g. diuresis of less than 20ml/hour) state. Limbs were
cold, hypotrophic, and pale with a long nail bed capillary refill time and
weak peripheral pulses. Despite marked abdominal pain, his abdomen was
tractable with valid peristalsis. Thoracic evaluation revealed predominant
respiratory crackles accompanied by dyspnoea and a mild decrease in SpO2
(93% SpO2 when breathing air). Blood gas analysis showed mild hypoxa-
emia (58 mmHg pO2; 0.21 FiO2) with a severe, mixed pCO2 (48 mmHg;
pH 7.28; HCO3- 12 mEq/L). Laboratory tests revealed leukocytosis (73, 780
cells/uL), volume depletion with haemoconcentration (59.2% haematocrit,
6, 860, 000 erythrocyte cells/uL, Hb 18.4 g/dL), a tendency towards throm-
bocytosis (platelet count = 464, 000 cells/uL), acute renal damage (2.48 mg
creatinine/dl), no significant biliary or hepatocellular alteration (normal
transaminases, alkaline phosphatase and gamma-glutamyl transferase
values), and high serum osmolality (313mOsm/kg). The ultrasound scan
showed complete collapse of the inferior vena cava. He was admitted with
a diagnosis of acute abdominal pain, severe dehydration, and acute kidney
injury. Strict clinical monitoring (vital signs and urine output) was imple-
mented with telemetry equipment, along with the best possible supportive
therapy while awaiting general stabilization. Pain was relieved using opiates
(i.e. intravenous morphine). The marked hypotensive state, favoured by the
ongoing dysentery, contributory cause towards the relapse in the haema-
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
supplementation) but also of decreasing blood viscosity. The patient’s
general thrombotic state prevented any surgical approach. Unfractionated
heparin (UFH) was therefore administered to maintain haemodynamic sta-
bility and delay, without halting, the unrelenting threatening advancement
of DIC triggered by aggressive PM. Despite prompt therapeutic support,
the overt establishment of DIC, secondary to the Hyperviscosity Syndrome
(HVS) caused by PM and dehydration, went beyond clinical reversibility
and led to a multiple organ dysfunction syndrome (MODS), with secon-
dary death from septic shock the next morning. Why should an internist
be aware of this? Revising what the evidence-based medicine recommends,
the sole winning strategy is for an internist to recognize the expression of
the relapsing myeloid chronic disorder concurrently guaranteeing adequate
tissue perfusion with fluid and electrolyte equilibrium. Till date elective and
curative strategies both in PM and in DIC settings are lacking. Therefore,
if on one hand, internists (including emergency physicians) must guaran-
tee best clinical practice, on the other, hematological clinical departments
should implement preventive and therapeutic policies for thromboembolic
complications related to hematologic malignancies since their evolution, in
EDs, is not a sporadic threat.
84
118° Congresso Nazionale - Società Italiana di Medicina Interna
40. BREAKING THE STEROID WALL
1
Pettinari P., 1Romanelli G., 1Mattioli M., 1Biondi L., 1Murri M., 1Fraticelli P.,
2
Zoli A., 1Benfaremo D., 1Cardinali M., 1Gabrielli A.
1
Clinica Medica, Università Politecnica delle Marche - Azienda Ospedaliero-
Universitaria Ospedali Riuniti Ancona 2Immunologia Clinica, Azienda
Ospedaliero-Universitaria Ospedali Riuniti Ancona
Clinical scenario: A 61-year-old woman referred to the Emergency Depart-
ment (ED) complaining recurrent diffuse acute-onset abdominal pain with
cramps, nausea and vomiting (three episodes during the last 18 months).
The history of the patient was noteworthy for adrenal insufficiency, splenic
marginal zone lymphoma in follow-up from 2011 and reported gallblad-
der stones. In 2006, when Addison disease was diagnosed, the patient pre-
sented with unexplained hypotension, anemia and dehydration; she was
successfully treated with substitutive therapy, still ongoing. During the last
access to ED, an abdominal ultrasound examination revealed a mild peri-
toneal fluid amount and severe splenomegaly without other relevant patho-
logic findings: this event was suggestive for adrenal crisis and the patient
was treated with steroid boluses with benefit. Since the patient’s symptoms
worsened despite higher doses of steroids, she was admitted to our Clinical
Department.
Diagnostic work-up: Considering the pathological history, our differential
diagnosis included:
• Biliary colic;
• Adrenal crisis;
• Splenic injury (thrombotic infarction, incipient rupture);
• Angioedema attack;
• Acute intermittent porphyria.
On physical examination, Murphy sign was negative and there were no
signs of peritoneal inflammation; a severe splenomegaly was palpable. Both
total-body CT scan and abdominal-MRI scan revealed an enlargement of
spleen (19 cm of diameter) without detectable lesions, hepatomegaly and
minimal fluid in pelvic cavity; no dilatation of biliary ducts was seen. After
rehydration, laboratory tests showed moderate anemia and thrombocyto-
penia, B-cell lymphocytosis due to NHL, normal renal and hepatic function
and high CRP serum levels (4, 9 mg/dl). According to the reported instru-
mental and laboratory findings, biliary colic and splenic injury could be rea-
sonably ruled out. During the attacks, patient reported no triggering factors
(medications, alcohol, infections) and no urinary symptoms or dark urine;
therefore, porphyria was unlikely. At this point, we assessed the serum C1q
inhibitor levels that revealed a low functional activity (15% - n.v. 70-130%),
suggesting a C1q inhibitor deficiency. After discussing therapeutic options
with the hematologist and the clinical immunologist, the patient started ica-
tibant, a new bradykinin-inhibitor molecule, with no recurrence of abdomi-
nal pain at one-year follow-up period.
Conclusions: Acquired C1q esterase-inhibitor deficiency (also called
Acquired Angioedema) is a rare syndrome characterized by recurrent epi-
sodes of angioedema with cutaneous, gastrointestinal and upper airways
symptoms. The association with hematological disorders, as paraneoplastic
manifestation, is quite common, especially with lymphoproliferative disor-
ders. In the case reported, the diagnostic challenge was harder because of
the complete but transitory response to steroid therapy that masked the real
underlying disease.
41. A CASE REPORT: WITH (HEPATIC?)
ENCEPHALOPATHY
Lopetuso L., Mosoni C., Ponziani F., Addolorato G., Gasbarrini A.,
Gasbarrini G.
Istituto di Medicina Interna, Gastroenterologia e Malattie del Fegato,
Università Cattolica del Sacro Cuore, Roma
52-year-old female, affected by obesity and coeliac disease, presented to the
emergency room experiencing mental confusion and amnesia, associated
with tachyarrhythmia and severe diarrhea. Similar symptoms had occurred
also a month before. Her relatives reported a long history of alcohol abuse
(5-6 drinks/day for at least 20 years) and poor compliance to the gluten-free
diet; especially in the previous two months she had not been following the
diet. Physical examination, associated with abdominal ultrasound exam,
blood tests and a negative brain CT, allowed the diagnosis of metabolic and
alcoholic cirrhosis, complicated with grade 2 hepatic encephalopathy. We
ascribed her diarrhea to gluten consumption, considering also that gluten
consumption in a small percentage of coeliac patient can lead to neurologic
and psychiatric symptoms known as “brain fog”, which vary from transient
118° Congresso Nazionale - Società Italiana di Medicina Interna
impairment in attention and memory to ataxia and peripheral neuropathy
(Gregory W. Yelland, Dep. of Gastr., Cent. Clin. Sch., Monash Univ. and
Sch. of Hea. Sci., RMIT Univ., Melbourne, Victoria, Australia, J of gastro-
ent. and Hepatol., 2017). Treatment with branched chain amino acids and
rifaximin and a strict gluten free diet were started, with sudden improving
of the symptoms. Upon complete regression of diarrhea, we prescribed a
therapy with lactulose to prevent further encephalopathy episodes. A couple
of weeks later the patient was admitted to the hospital again, this time due
to a loss of consciousness associated with tachyarrhythmia and without
typical encephalopathy symptoms. At first we excluded a major bleeding
and a worsening in hepatic function, then we performed and ECG, which
showed persistent ST elevations in the electrocardiographic leads V1-V3
with a right bundle branch block. The patient was diagnosed with Brugada
syndrome and an implantable cardioverter defibrillator (ICD) was then
inserted. She was discharged to home in stable conditions a few days later.
A new episode of confusion and disorientation in time and space occurred
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
gluten consumption, but her symptoms had become stable and no longer
benefitted from therapy and diet. We started considering fecal microbiota
transplant (FMT) as a possible therapy of her encephalopathy symptoms,
basing on interesting data:
= Promising data suggest that FMT could play a role in hepatic encepha-
lopathy management: it is described that a 57-year-old man suffering from
grade 1-2 hepatic encephalopathy with alcohol+HCV related liver cirrhosis,
who had previously responded well to lactulose and rifaximin but could no
longer afford rifaximin, had a great benefit from FMT. (Kao D et al. Hepa-
tology 2015)
= Rising findings suggest that FMT may play a role in many disorders asso-
ciated with the alteration of gut microbiota (Cammarota G, … Gasbarrini
G, … Malfertheiner P, … Gasbarrini A et al. Gut 2017, Proc. EASL 2017)
= There is no evidence showing that microbiota modulation could play a
role in neurologic and psychiatric symptoms which can occur under gluten
consumption in coeliac patient; it seems that they should be ascribed to the
passage of gluten across the blood-brain barrier (Gasbarrini G, Mangiola
F, UE Gastro. J. 2014). However, FMT has been successfully performed in
refractory celiac disease type II complicated to enteropathy associated T
cell lymphoma, with full recovery of symptoms and intestinal mucosal villi
(Case report by van Beurden YH et al, J Gastrointest Liver Dis 2016).
42. A CHALLENGING CLINICAL PRESENTATION
Anastasio L. 1, Manno V. 1, Lentini N. 1, Chirico A. 2, Arone A. 1,
Carbone M. 1, Sofia L. 1, Topa G. 1, Grasso A. 2, Perticone M. 3, Perticone F. 4
1
UO di Medicina Interna - Ospedale “G. Jazzolino” - Vibo Valentia 2
Servizio di Gastroenterologia ed Endoscopia Digestiva - Ospedale “G.
Jazzolino” - Vibo Valentia 3 Dipartimento di Medicina Sperimentale e
Clinica - Università degli Studi Magna Graecia di Catanzaro 4 Dipartimento
di Scienze Mediche e Chirurgice - Università degli Studi Magna Graecia di
Catanzaro
A 49 years old male patient, affected by type 2 diabetes mellitus, on oral
therapy with metformin, complicated by infected diabetic foot with oste-
omyelitis of two fingers of the right foot, was admitted to emergency room
in sleepy state, with a brief history of fever in previous days. Laboratory
study revealed lactic acidosis (pH 6, 97, HCO3 3, 4 mmol/l, pCO2 14, 7
mmHg, pO2 162 mmHg, lactacidemia 10 mmol/l), acute renal impairment
(creatinine 10, 3 mg/dl, ureic nitrogen 299 mg/dl), hyperglycemia (202 mg/
dl). He was immediately admitted to Intensive Care Unit and treated with
haemodialysis by insertion of a central venous cannula. He rapidly got better
and in two days he was transferred to Internal Medicine Ward. A rehydra-
tant and empirical antibiotic treatment were started with a strictly control
of glycaemic values with basal bolus insulin protocol. A phlegmon of the
right foot was treated on the second day by incision and wadding. The acid-
base study showed moderate respiratory alchalosis. Renal function rapidly
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.
On the seventh day after admission the patient reported light dysphagia.
Examination of oropharynx revealed hyperemia and white patches in oral
cavity, resembling oral candidiasis of tongue and soft palate. Treatment with
oral antifungal gel (miconazole) was started. On the twelfth day after admis-
sion the patient had vomit of food with emission of bloody mucus. He went
to endoscopy, wich revealed “widely exulcerated esophageal mucosa, from
Poster
superior esophageal sphincter toward cardiac sphincter, that is relaxed.
Slight hyperemia of gastric antral mucosa”. The patient was placed on “nil
per os”, with parenteral nutrition and I.V. proton pump inhibitors. Therapy
with antifungal drugs (I.V. Fluconazole) and antivirals (I.V. acyclovir) was
started. The patient rapidly got subjectively better. The endoscopic biopsy
revealed “exulcerated esophageal mucosa, with necrotic leucocytes, hyphes
and fungal spores”, even if culture was negative. Endoscopy was repeated on
twentieth day, demonstrating “persistent ulcero-necrotic aspect of esopha-
geal mucosa with slight reduction of flogosis”. The patient maintained the
same therapy and the endoscopy on the 27th day demonstrated “persistent
esophageal lesions with partial regression of inflammation”. On the 40th
day, 4 weeks after clinical onset of esophageal symptoms, the endoscopic
aspect was “persistence of some longitudinal areas of necrotic mucosa, with
some bleeding erosions, with better global condition of esophageal mucosa”.
The patient was discharged in good general conditions, with a light diet and
a prescription of PPI and sucralfate.
43. A SYSTEMIC GRANULOMATOUS DISEASE IN A
PATIENT WITH MYELOFIBROSIS
Purrazzo G., Spadaro L., Giarratana F., Guiducci D., Purrello F. Department
of Clinical and Experimental Medicine, University of Catania, Ospedale
Garibaldi Nesima
Case Report: A 59-year-old woman was admitted to our department with
fever, cough, malaise and abdominal distension. Her clinical history consisted
of essential thrombocythemia evolved in myelofibrosis (MF), arterial hyper-
tension, multinodular goiter and GERD. At the time of MF diagnosis she
showed constitutional symptoms and abdominal discomfort due to massive
splenomegaly. On the basis of the ECOG score (ECOG1) and symptomato-
logy, she was enrolled in a phase III study and received the Janus Kinase (JAK)
inhibitor Ruloxitinib 20 mg twice daily. Before starting the treatment, an eva-
luation for infectious disease excluded any intercurrent or latent infection.
After 8 weeks of therapy, the patient complained of fatigue, sweat, abdominal
discomfort and fever. An abdominal ultrasound study and a computed tomo-
graphy (CT) were performed with evidence of free peritoneal fluid and multi-
focal micronodular lesions on the greater omentum and peritoneum. In addi-
tion, PET scan showed areas of increased metabolism in multiple thoracic and
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
admission the patient appeared pale, dispnoic and sweaty. Her body tempe-
rature was 38.5 °C. Laboratory test results revealed RBC 3070000 cells/mm3,
Hb 8.4 g/dL, WBC 4200 cells/mm3 (N 85.2% L 7.1% M 6.1%), PLT 229000
cells/mm3, erythrocyte sedimentation rate (ESR) 60 mm, C-reactive protein
(CRP) 5.39 mg/dL. A thoracic CT scan showed a left pleural effusion and
irregular thickening of the pleural surface. Manteaux reaction, Mycobacte-
rium tuberculosis (MT) microscopic detection in urine, emocoltures, real-
time PCR and geneXPERT for MT in pleural fluid obtained through a pleural
drainage resulted negative. QuantiFERON-TB-GOLD test resulted indeter-
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
evaluation of the obtained material reported the presence of granuloma-
tous epithelioid nodular process without necrosis with a negative Ziehl-Ne-
elsen reaction. The material then was revised to search for PCR analysis to
detect atypical mycobacteria. In particular, Nested-PCR for Mycobacterium
genus-specific (HSP65) resulted positive. So, our final diagnosis was: syste-
mic nontuberculus mycobacteriosis in a patient with post-essential throm-
bociythemia myelofibrosis treated with Ruloxitinib. Discussion: Ruloxitinib
is a Janus kinase (JAK) inhibitor widely used to decrease the constitutional
symptoms and splenomegaly in patients with myeloproliferative disease. Pre-
vious studies have showed an increased risk of tuberculosis in patients treated
with Ruloxitinib, maybe due to a depressed Th1 response and a reduced pro-
duction of gamma interferon (INF-γ). Therefore, in an apparent TB negative
case, performing additional molecular tests for atypical mycobacterium can
help to reach the diagnosis of atypical mycobacteriosis.
44. A STRANGE CASE OF EPIGASTRIC PAIN AND
NAUSEA: WHEN THE HISTORY MAKES THE DIFFERENCE
Riccardi A. 1, Esposito G. 1, Luiso V. 2, Paolillo C. 1, Sbrojavacca R. 1
1
SOC. di Pronto Soccorso e Medicina d’Urgenza, Azienda Sanitaria
Universitaria Integrata di Udine 2 Dipartimento di Medicina Interna dell’
Università degli Studi della Campania Luigi Vanvitelli
85
Poster
A 71-year-old man comes to Emergency Department (DEA) overnight
complaining of nausea and epigastric pain. She took 10 mg metoclopramide
os and an antacid without great benefits. He also reports various episodes of
vomiting in recent hours. In the history he records only a mild hypercho-
lesterolemia in simvastatin treatment. Upon arrival in DEA, the patient is
alert, oriented and collaborative, apiretic, suffering, tachycardic, and slightly
tachyptic. The abdomen is treatable with mild pain in mesogastria and with
noisy peristalsis sounds, without obvious signs of peritonism. The remai-
ning objectivity is within the normal limits. Hematochemical tests including
emocromo, electrolytes, creatinine hepatic profiles, PCRs, emogas analysis
and troponin are then required and a 40 mg pantoprazole vial is administe-
red. In the abdominal ecoscopy performed in DEA, the only abnormal signs
are an apparent gastric overexpression associated with abnormally dilated
bowel’s anse, especially in the central areas of the abdomen. In the suspect
therefore of an intestinal occlusion the patient is sent to perform an XR
abdominal exam. After about an hour the patient complains of a painful
abdominal pain with a feeling of noticeable nausea. It is therefore given 3
mg morfina with partial pain relief and a Metoclopramide iv. Hematoche-
mical examinations highlight an important neutrophil leukocytosis (18, 400
/ mcL of which 16, 190 neutrophils) with significant increase in pancreatic
amylase. EGA shows no significant alteration. Lactates are standard. There-
fore, thinking that the patient’s problem was related to acute pancreatitis, a
surgical evaluation is required. The specialist, however, before the visit asks
the result of abdomen XR exam, but it’s not ready yet. After a telephone
contact with the radiologist, the report of this exam made available: there is
no evidence of bowel anse’s dilatation or free air levels in the areas explored.
The radiologist, however, extended the investigation to the chest as well,
documenting abnormal relaxation of the gastric cavity totally dislocated in
the left chest, in relation to a likely diaphragmatic breach with consensual
dislocation of cardiomediastin. About 40 years ago, the patient had been
victimized by a violent road accident that had caused a diaphragmatic lesion
that, in his opinion, had never been symptomatic or followed in years with
clinical and instrumental follow-ups, and had therefore been omitted In
initial clinical history. At this point, to clarify the actual anatomical con-
dition of the patient, an urgent thoraco-abdominal CT exam is required
confirming the full occupation of the left chest by the gastric cavity, which
appears abnormally dilated for the stagnation of liquids, ingested and with a
large hydro levels inside. The left lung is completely collapsed with complete
lateralization of the cardiomediastin and through the large breach the chest
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
an edematous appearance as chronic pancratitis. Ultimately, the diagnostic
hypotheses of intestinal occlusion and pancreatitis have both been confir-
med CT exam, but they are been epifenomens of the dislocation of inte-
stinal thoracic viscera due to the previous traumatic diaphragmatic lesion.
The patient was therefore urgently admitted to the Department of General
Surgery to undergo multidisciplinary diaphragmatic reconstruction with
repositioning the viscera. This
Case Report: is an example of how the history is the most important
element throughout the diagnostic process
45. A STRANGE CASE OF LOW-BACK PAIN
Sgariglia R., Alessio S., Pucci G., Giuliani M., Sanesi L.
Department of Medicine, University of Perugia- Unit of Internal Medicine, S.
Maria Hospital, Terni, Italy
L.L. a 71-year-old woman came to the hospital after a month of prevalently
serotinc fever of an intermittent-remittent nature that did not respond to
FANS or empiric antibiotic therapy, and lamenting epigastric pain of a pier-
cing nature to the back. She also suffered from inappetence and unintentio-
nal weight loss. The patient had been discharged from the hospital a week
before, after undergoing vascular surgery for similar symptoms resulting in
a diagnosis of “sacciform trombotic pseudo aneurism from a piercing ulcer
in the abdominal, with the suggestion of a clinic-strumental follow-up”. The
pathological anamnesis revealed a systemic arteric hypertension - that had
been treated for the last 15 years by taking 1, 25 mg of bisoprolol once a
day and Ramipril/amlodipine 10mg/10mg 1 cp/die- and previous valvular
aortic substitution with bioprotesis (2014) for tight stenosis. A fast-abdo-
minal ultrasound did not find any indirect sign of aortic dissection. Lab
results were characterised by a relevant increase in the systemic flogotic
system values (VES 81 mm/h, PCR 8.25 mg/dl, iper-alfa2 at seroprotect
electrophoresis), neutrophilic leucocytosis, procalcitonin 0, 46 ng/ml, crea-
tinine and uraemia within the physiological range, normal emocoagulative
86
118° Congresso Nazionale - Società Italiana di Medicina Interna
values. The objective clinical exam upon entry identified warm and flushed
skin, valid pulse and isoseismics, no jugular swelling. The abdominal thora-
cic EO did not detect any significant element other than tenderness to deep
palpation in the epi-mesogastric area. No signs of peritonism were detected,
nor periumbilical bruits could be auscultated in the vascular area. Relevant
tenderness to pressure on the spinal apofisis L1-L4 limited and prevented
functionality. PA 150/70; FC 105 R; SpO2 97% in open air; T.C. 37.5°C. The
ecoculture resulted positive to the Streptococcus viridans group. Suspecting
infective spondylodiscitis as a secondary localization of bacteric endocardi-
tis, in a patient with a prosthetics aortic valve, after an electrocardiographic
exam we excluded valvular vegetations. A spinal TC revealed the presence
of multiple didascal lumbar hernias and confirmed the presence of thi-
ckened walls (21x14mm) And an aneurismatic sacciform dilatation of the
abdominal suprarenal aorta contiguous to origin of the superior mesente-
ric, in absence of signs of idroureteronefrosis. We therefore proceeded to
remove an autoimmunity panel to exclude a vasculitic lesion (negative) of
the aorta as the original cause. A PET-TC with 18-FDG was requested and
it did not find any record of a spondylodiscitis active but it displayed intense
hyper fixation of the radiochemical localised in the periaortic abdominal
area confirming the first hypothesis of flogistic/inflammatory phenomena.
The diagnosis was of “inflammatory aneurism in the suprarenal abdomi-
nal aorta”. The interposition of numerous splenetic vessels prevented a per-
cutaneous biopsy of the lesion aimed to a histologic characterisation. An
ex-adiuvantibus therapy was prescribed consisting in high dosages of cor-
ticosteroids (prednisone 25 mg x 2/die) resulting in a rapid and dramatic
improvement in symptomatic manifestations and of the clinical-laboratorial
framework (normal flogosis parameters). The patient was discharges after 7
days without fever or symptoms with the indication of a vascular follow-up
to assess a potential surgical option.
Conclusions: an analysis of the relevant literature found that aneurisms
resulting from the inflammation of the abdominal aorta only make up
between 2 and 15% of all aortic aneurisms; in most cases the problem is
localised in the infra or iuxta-renal area. This condition, that shows very
similar characteristics to idiopathic retroperitoneal fibrosis, but is often con-
sidered a nosological entity of its own, when it manifests itself in an acute
manner and, like in our patient’s case in an atpic area, (more insidious as it
doesn’t present itself within the normal clinic parameters associated to an
ab-extrinsic obstruction of contiguous areas) can appear as more common
pathology of both a surgical and medical nature.
46. WHEN MONONUCLEOSIS DOESN’T MEAN SIMPLY
A “KISS DISEASE”: ATIPICAL PRESENTATION OF A
COMMON CLINICAL CONDITION CASE REPORT
Alessio S., Giuliani M., Pucci G., Battista F., Sgariglia R., Sanesi L.
Department of Medicine, University of Perugia- Unit of Internal Medicine, S.
Maria Hospital, Terni, Italy
Case Report: A 68 -years- old woman with medical history of arterial
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-
ding events (i.e. hematuria or gastrointestinal bleeding). She didn’t take any
medication (NSAIDs, anticoagulants). At admission to our ward the vital
signs and general examination were normal, except for jaundice (in parti-
cular no hepato-splenomegaly, no superficial palpable lymphadenopathy).
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-
tes (1.5 mg/dl), severe normocytic anemia (Hb 6.7 g/dl), leucocytosis with
neutrophilia and monocytosis (leucocytes 29000/mmc, monocyte 2650/
mmc), LDH (2053 UI/l), elevation of systemic inflammation markers (CRP
5 mg/dl, VES 38 mm/h, ferritin 3000 ng/ml) with renal impairment (serum
creatinin 1.52 mg/dl, blood urea nitrogen 114 mg/dl), procalcitonin within
range (<0.05 ng/ml). Reticulocytes 9.7%. To exclude a post haemorrhagic
anemia the patient underwent endoscopic procedures (esophagogastroduo-
denoscopy and colonscopy) without detection of macroscopic pathologic
findings. Total body TC demonstrated the absence of a blood and lymphatic
system disorders (no mediastinic or abdomino-pelvic lymphadenopathy;
spleen with normal size, absense of venous pelvic or hepatic trombosis). In
consideration of elevated serum levels of unconjugates bilirubina, acute and
symptomatic anemia and high urobilinogen at urinalysis, we hypotized an
hemolytic pathogenesis. In order to investigate the etiology of acute hemoli-
sys we assessed more specific tests, including haptoglobin (27 mg/dl), direct
and indirect Coombs (negative). On the basis of conflicting radiological and
biochemical findings and after deepening her medical history, we discove-
118° Congresso Nazionale - Società Italiana di Medicina Interna
red that she complained to suffer in the previous week of a gastroenteritis
characterized by water diarrhea, abdominal pain, vomiting and fever treated
with supportive therapy. In accordance with this interesting fact and con-
sidering monocytosis at laboratory assessment, we investigated post-in-
fectious nature of the anemia: CMV and Mycoplasma Pneumoniae siero-
logy was negative, while EBV sierology turned positive for a recent primary
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
hemolityc anemia with negative direct and indirect Coombs ongoing EBV
infection was put and steroid therapy was started. She was dismissed after
4 days in good conditions, with stable haemoglobin (Hb 10 g/dl), without
need of blood transfusions.
Conclusions: In course of infectious mononucleosis in approximately 3%
patients may occur a immuno-haemolytic anemia that is associated with
anti-erythrocytes IgM detected with direct and indirect Coombs and that
develops commonly during third-fourth week. In this case, despite the pau-
ci-symptomatic clinical presentation (no deep and superficial lymphadeno-
pathy or exudative pharyngitis or hepato-splenomegaly or fever or atypical
lymphocyte, negative direct and indirect Coombs, normal liver enzyme)
that seemed initially to point towards an autoimmune/neoplastic patho-
genesis, the anamnestic element of recent “gastroenteritic syndrome” takes
a key role to suggest us the atypical presentation of mononucleosis with
hyper-hemolysis virus-related.
47. USEFULNESS OF MUSCLE MAGNETIC RESONANCE IN
INFLAMMATORY MYOPATHIES
Savore I., Gelardi C., Cardinaletti P., Pedini V., Gabrielli A.,
Danieli M.G.
Clinica Medica, Università Politecnica delle Marche & Ospedali Riuniti,
Ancona
Background: Dermatomyositis (DM) and polymyositis (PM) are the most
common idiopathic inflammatory myopathies, characterized by symmetric
proximal muscle weakness. Recently magnetic resonance imaging (MRI) has
been used in myopathies to identify affected muscles, in particular to detect
edema, which is an early sign of inflammation.
Materials and Methods: Here we describe two patients with PM, diagnosed
according to Bohan and Peter criteria. In each patient we performed MRI of
the four limbs. Two technique exist to eliminate fat interference: T2 weighted
images with fat suppression or short tau inversion recovery. Edematous areas
are hyperintense in T2 weighted images. The first case is a 51-year-old Cauca-
sian woman, with diagnosis of PM in 2008. She was treated with prednisone
(1 mg/kg/day for 4-6 weeks and then slowly tapered) and 20% subcutaneous
immunoglobulin (SCIg, at 0.1–0.2 g/kg, once a week) and after one year she
achieved remission. However, serum CPK levels remained persistently eleva-
ted, even if the muscular strength, evaluated with the MRC modified score,
was normal (MRC 88/88). MRI showed edema of proximal muscles (rotator
cuff, bilateral proximal portions of triceps, gluteus maximus and quadriceps).
After about one year physical examination revealed a compromised muscu-
lar strength with a value of MRC of 78/88 with marked hyposthenia of qua-
driceps. In the second case, a 54-year-old-man, PM was diagnosed in 2004.
He was treated with prednisone and 20%SCIg (as above), and he obtained
remission after one year with a maintaining low prednisone dose. Even in
this case, despite a good recovery with a normal MRC score, CPK levels were
persistently increased (800 U/l). MRI did not identify edematous areas. After
one year he is still in clinical and functional remission. Results: In these cases
we found a discrepancy between MRI findings and disease activity evaluated
by MRC score and CPK serum levels. In particular, these two patients with
clinical remission and persistently elevated CPK levels exhibited different pro-
gnosis with reactivation of the disease in the first case, in which MRI revea-
led edema, and stable remission in the second one, in which MRI was totally
negative. In these cases MRI could have an important role in identifying those
patients who are at risk to relapse.
Conclusion: These preliminary data open new interesting perspectives in
the use of MRI in inflammatory idiopathic myopathies. Despite the cost of
this technique and the time employed to perform the exam, MRI is useful to
identify patients who are going to relapse and to prevent it with appropriate
treatment. However, more data are necessary to define the use of MRI in these
patients.
Poster
48. AN UNSUAL CASE OF AUTOIMMUNITY SYNDROME
Benfaremo D., Pedini V., Savore I., Fraticelli P., Gabrielli A.,
Danieli M.G.
Clinica Medica, Università Politecnica delle Marche e Ospedali Riuniti,
Ancona
Introduction: A 64-year-old woman was admitted to our medical ward
for progressive fatigue and worsening of chronic anemia associated with
thrombocytopenia. History: The patient’s medical history started in 2008
when she received a diagnosis of undifferentiated connective tissue disease.
The clinical scenario at onset of symptoms included pleuropericarditis,
unspecified skin lesions, Raynaud’s phenomenon, low-titre ANA positivity
with negative anti-ENA. Corticosteroids and hydroxychloroquine were
prescribed, with a mild benefit. During the ensuing years, anemia, severe
thrombocytopenia and mild lymphopenia were invariably seen on com-
plete blood count (CBC). She underwent chest computed tomography (CT)
that showed enlarged mediastinal lymph nodes. She received a diagnosis
of systemic lupus erythematosus (SLE) and treatment with prednisone and
hydroxychloroquine was carried forward without benefit. Azathioprine was
started, but the platelet levels dropped after every steroid-tapering attempt.
Several admissions were necessary to treat the persistent severe throm-
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-
vans syndrome associated with SLE; splenomegaly had worsened (16 cm).
She was discharged after receiving treatment with corticosteroids. On June
2016 a bone marrow biopsy was suggestive of a myelodysplastic syndrome.
On December 2016 because of persistent fatigue and worsening anemia
and thrombocytopenia on blood tests, she referred to our outpatient clinic
and was admitted for further evaluation. Clinical problem: Fatigue, chronic
hemolytic anemia, thrombocytopenia, mild lymphadenopathies, marked
splenomegaly and inconstant ANA, Coombs and anti-platelet antibodies
positivity. Physical examination:Normal except for palpable severely enlar-
ged spleen, as well as multiple, soft and non tender superficial lymph nodes
on axillary and inguinal stations. Routine laboratory tests:Anemia (8 g/dl),
thrombocytopenia (about 50.000/mmc), raised LDH (388 U/l), decreased
haptoglobin, polyclonal hypergammaglobulinemia were observed. Serum
electrolytes, liver and renal function were within normal range. Differential
diagnosis:Our differential diagnosis included: 1) systemic connective tissue
disease with hematologic involvement (i.e. SLE); 2) lymphoproliferative
disorder with splenic involvement (i.e. splenic marginal zone lymphoma,
Castleman’s disease, ecc…); 3) myeloproliferative disorder (i.e. myelofibro-
sis); 4) hemophagocytic lymphohistiocytosis; 5) adult-onset Autoimmune
Lymphoproliferative Syndrome (ALPS). Work-up:The hypothesis of SLE
was unlikely since ANA, anti-ENA and nDNA-antibodies were negative. A
repeat CT scan confirmed the findings of diffuse lymphadenopathies and
marked splenomegaly (17 cm). Further blood tests showed normal triglyce-
rides level, raised serum beta2microglobulin, absence of BCR/ABL and
JAK2 mutation, elevated serum IL-10 levels (29.5 pg/ml, n.v. up to 9.1) and
the presence of higher levels of Double Negative T cells (DNT, 7.4% of total
CD3+ cells) on peripheral blood lymphocyte phenotyping. The findings
were suggestive of ALPS and a serum specimen was sent to another labora-
tory for further testing. Nevertheless, while waiting for the results, a bone
marrow biopsy was performed and the patient was referred for splenectomy
since we could not exclude a lymphoproliferative disorder.
Discussion: After surgery, the patient was well with a minimal dose of pre-
dnisone and hemolytic anemia and thrombocytopenia did not recur. The
histopathological examination of bone marrow and spleen did not reveal
anything abnormal. One month after discharge the diagnosis of adult-on-
set Autoimmune Lymphoproliferative Syndrome was confirmed with the
demonstration of higher serum levels of DNT cells with abnormal resi-
stance to Fas-induced apoptosis.
Conclusion: ALPS is an uncommon disease occurring most commonly in
children, though it may rarely present in the adulthood. It is often misdia-
gnosed due to variable phenotypic expressions and the overlap of symptoms
with many other immunological and hematological disorders. Our patient
was exceptionally old at diagnosis, but there was a diagnostic delay of almost
ten years. This case highlights the importance of a systematic differential
diagnosis, especially when facing rare diseases and therapeutic impasses.
87
Poster
49. A WEIRD CASE OF LIVER CIRRHOSIS
Vaccari D., Vegetti A., Scarlini S., Pietrangelo A., Ventura P.
Unit of Internal Medicine 2, Dept. of Medical and Surgical Science for
Children and Adults, Policlinico hospital of Modena, University of Modena
and Reggio Emilia; Italy
A 34-year-old woman was admitted to our unit due to new-onset ascites
together with hepatomegaly and slight splenomegaly. Her medical history
was notable for psoriatic arthritis, occasionally treated with NSAIDs; she
was an active smoker and denied alcohol abuse. Physical examination of the
patient showed slight jaundice, bradycardia (HR 50 bpm), severe distension of
jugular veins and abdominal expansion, with very significant hepatomegaly.
Bedside ultrasound examination revealed a severely enlarged liver, with dila-
tated, non-collapsible inferior vena cava, a moderate amount of ascites, a sli-
ghtly enlarged spleen, and severe right-sided heart enlargement with massive
regurgitation of tricuspid valve and slightly impairment of the ejection
fraction (45-50%). A standard 12-lead ECG showed a junctional rhythm with
narrow, low-voltage QRS complexes; a 1-month-earlier ECG showed a nor-
mal-rate atrial fibrillation. Blood tests showed slightly prolonged PT (INR 1.4)
and mild elevation of serum bilirubin and gamma-GT. Viral (HBV, HCV)
and autoimmune markers, as well iron blood tests and ceruloplasmin were all
within the normal range. A liver biopsy was performed, showing peri-portal
fibrosis, sinusoidal dilatation and signs of cholestasis, with no signs referable
to amyloidosis or abnormal iron/copper storage; histology showed features
at the interface between primary sclerosing cholangitis or primary biliary
cholangitis or overlap syndrome with autoimmune hepatitis, nevertheless
all autoantibodies tested (ASMA, ANCA, AMA and LKM) were negative. A
more accurate family history showed that the patient’s father died for liver
cirrhosis and congestive heart disease with severe dilatative cardiopathy
before age 40, and that her cousin was affected by Emery-Dreifuss muscular
dystrophy. Genetic testing for the LMNA gene associated with the EDMD
revealed the same mutation previously identified in the patient’s cousin. Con-
sidering the cardiac manifestations of the patient, consistent with picture
found in EDMD, an in-depth cardiologic workup was performed, including
heart MRI (which showed reduced biventricular ejection fraction and areas of
non-ischemic myocardial fibrosis) and heart catheterization (which showed
mild pulmonary artery hypertension and impaired left ventricular filling, due
to the severe dilation of right ventricle). The junctional bradycardia present
in the ECG and the inherent risk of sudden cardiac death due to ventricular
fibrillation associated with the EDMD suggested the placement of a biventri-
cular pacemaker with ICD, resulting in improved EF (70%) and synchrone
HR (70 bpm) after placement. At the moment it is yet unclear whether the
liver involvement is simply due to increased central venous pressure (i.e.
“cardiac cirrhosis”) or it has a different etiology. Hepatic vein catheterization
showed veno-venous shunts and mild portal hypertension; the results of the
liver biopsy are not entirely compatible with cardiac cirrhosis, expecially the
finding of peri-portal fibrosis. As of now, this clinical case is not closed yet.
The patient is in the process of being enlisted for heart transplantation due to
the progressive nature of the heart disease; whether she will be also subjected
to liver transplantation depends on further liver workup, including an addi-
tional liver biopsy.
50. A COMPLICATED CASE OF INTERSTITIAL
PNEUMONIA IN AN IMMUNOCOMPROMISED PATIENT
Vitrone M. 1, Mollica M. 2, Grella E. 2, Durante Mangoni E. 1
1
Internal Medicine, University of Campania Luigi Vanvitelli, Unit of
Infectious and Transplant Medicine, Monaldi Hospital, Naples, Italy;
2
Pneumology, University of Campania Luigi Vanvitelli, Unit of Pneumology,
Monaldi Hospital, Naples, Italy
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
acute type I respiratory failure. Three years before admission he had been
diagnosed with large B-cell non-Hodgkin lymphoma and treated with che-
motherapy, splenectomy, and immunotherapy with rituximab (RTX) for 2
years (last cycle 4 months before presentation). Before starting rituximab,
he had received prophylactic antiviral therapy with lamivudine 100 mg/day,
because of prior HBV infection. The patient mentioned a previous exposure
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
the prior three months that had only partially improved with several antibio-
tic courses, including beta lactams (penicillins and carbapenems) and fluo-
roquinolones. In February 2017, a chest CT scan without iv contrast showed
88
118° Congresso Nazionale - Società Italiana di Medicina Interna
bilateral upper and middle lobe consolidations, bilateral reticular-nodular
thickening of the interstitium with ground glass opacities and diffuse cal-
cified pleural plaques. At entry, the patient was mildly febrile with fatigue,
tachypnea and productive cough. Physical examination was significant for
inspiratory bilateral basal crackles and expiratory rhonchi. Labs showed Hb
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-
active protein 2.8 mg/dl, AST 0.8xULN, ALT 0.6xULN, bilirubin 0.3 mg/dL
(dir 0.1), creatinine 0.9 mg/dl, IgG 209 mg/dl, IgA 16 mg/dl, IgM <21 mg/dl.
The 12-lead electrocardiogram revealed sinus rhythm and left anterior fasci-
cular block. Severe pulmonary hypertension without left ventricular disfun-
ction (LVEF 55%) was found on transthoracic echocardiography. Resting
arterial blood gas examination showed hypoxemic hypocapnic respiratory
failure requiring oxygen supplementation with Venturi mask (FiO2 50%);
spirometry revealed a restrictive pattern and a moderate reduction in dif-
fusing capacity for carbon monoxide (DLCO). Diagnostic high-resolu-
tion computed tomography (HRCT) of the lungs showed bilateral patchy
ground glass opacities at upper and middle lobes, with signs of pneumo-
nia consolidations, parenchymal distorsions, bronchiectasis and calcified
pleural plaques compatible with pneumoconiosis. Sputum culture grew
Stenotrophomonas malthophilia, and antibiotic therapy with cotrimoxa-
zole 80/400 mg, 4 vials iv q6h, and methylprednisolone 40 mg iv q12h was
added to clarithromycin started just before hospitalization. The patient also
received iv polyclonal immunoglobulins and empirical antifungal therapy
with anidulafungin to cover for possible fungi, including Pneumocystis
jiroveci pneumonia. Candida krusei was also isolated from oropharyngeal
swab and treated with topical myconazole gel. All blood and urine cultures
were negative as well as Pneumococcal and Legionella urinary antigen tests,
polymerase chain reaction (PCR) tests on nasopharyngeal swab and serum
fungal antigens. Clinical conditions and laboratory tests improved after 12
days of antimicrobial therapy, when the antifungal agent was discontinued.
However, due to an extension of pulmonary consolidations to lower lobes
on follow up CT images, fibrobronchoscopy was performed and XDR Kle-
sbiella pneumoniae (10000 ufc/ml) isolated from bronchoalveolar lavage
(BAL) fluid. Deemed as de novo airway colonization, it did not require any
treatment. Tuberculin skin test, Quantiferon-TB gold, TB PCR and culture
on BAL fluid were all negative. Furthermore, the patient was started on gan-
ciclovir 300 mg iv q12h because of a significant reactivation of Cytomega-
lovirus (CMV-DNA 52000 gEq/mL). CT imaging 6 weeks after admission
showed a slight improvement of pulmonary consolidations with persistent
bilateral ground glass attenuation mainly at upper and middle lobes. Blood
gas analysis was also markedly improved.
Conclusions: History, physical examination, laboratory and radiologic tests
are very helpful when evaluating a patient with suspected infectious disease,
such as the one described here. However, the mainstays of infection dia-
gnosis include culture of tissues or fluids, that should be ideally collected
before the administration of antimicrobial therapy, to allow identification
of the etiologic agent and determination of antimicrobial resistance profile.
Although cultures are crucial for diagnosis, determining if their results
represent contamination rather than true infection could avoid unnecessary
treatments and testings, as in our case. Since our patient underwent immu-
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
have superimpose, due to the prolonged use of steroids for a presumed
autoimmune interstitial lung disease or Pneumocystis jiroveci pneumonia.
CMV de novo infection or reactivation in our immunocompromised host
possibly resulted in an interstitial CMV pneumonia, that had to be diffe-
rentiated from a number of other infectious and noninfectious conditions.
Finally, the history of previous RTX-exposure suggested the possibility of a
RTX-associated interstitial lung disease, that can appear at high-resolution
thoracic CT scan as diffuse bilateral ground-glass opacities.
52. DIARRHEA AND PERSISTENT OMPHALITIS IN
ADULT WOMAN
Mattioli M., Benfaremo D., Biondi L., Cardinali M., Fraticelli P., Pomponio
G., Gabrielli A.
Clinica Medica, Università Politecnica delle Marche – Ospedali Riuniti,
Ancona
Clinical scenario: A 64-year-old woman came to the Emergency Depart-
ment in March 2017 (for the fourth time during the last three months)
reporting worsening abdominal pain, started almost 6 months ago, associa-
ted to nausea and vomiting; during the last two weeks, watery diarrhea (3- 4
118° Congresso Nazionale - Società Italiana di Medicina Interna
evacuations/day) developed.Blood tests showed only moderate hypokale-
mia (2.8 mEq/l) already present during the previous hospital admissions.
An abdominal ultrasound first, and subsequently an abdominal contrast
enhanced computed tomography, were performed and showed: - wall thi-
ckening and conglomeration of many ileum loops; - hypodense nodular
formation with rough calcification in the context of approximately 3 cm,
apparently adhering and partially retraining the ileum wall that is locally
collapsed and upstream dilated with air fluid levels; - nodular “cottony”
lesions characterized by poorly enhancement of the maximum diameter
of 1.5 cm, located in mesogastric region in correspondence to the greater
omentum; - small umbilical hernia with liquid content, which reached the
skin plane; - slim wet float in Douglas. The patient was admitted to our ward
for further investigations. In-hospital: In her medical history were reported
hypertension and M-GUS, diagnosed in 2008. From November 2016, she
reported the presence of erythema, pruritus and yellow-brown secretions of
the umbilical scar, interpreted as omphalitis and treated with topic therapy
but still present. From the onset of the gastrointestinal symptoms, she
underwent a gastroscopy and a colonoscopy without detection of pathologic
features. The physical examinations confirmed the evocation of epigastric
and right abdominal pain upon palpation without signs of peritonism and
bright bowel sounds. Routine laboratory tests confirmed hypokalemia and
there was also a mild neutropenia; liver and kidney function were within
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-
tion, rough calcifications and diffuse lesions of the greater omentum, was
suspect for Sclerosing Encapsulating Peritonitis (SEP), also called Abdo-
minal Cocoon. This disease is a rare form of peritoneal inflammation that
form a membrane covering and involving the underlying organs such as
small bowel, colon or ovaries. The acquired form is etiologically divided into
idiopathic and secondary SEP; the last is associated to several conditions,
but more frequently with peritoneal dialysis, abdominal tuberculosis, drugs
(e.g. chemotherapy), autoimmune diseases, endometriosis or malignancy.
In order to evaluate for secondary SEP we performed: - Tubercolin skin
test: negative; - Complete immune serology: negative; - Neoplastic markers:
CEA, CA 19.9, CA 125, NSE, gastrin, chromogranin A: all in range; - Chest
CT scan without evidence of tuberculous exposure or neoplasms. To obtain
a histological diagnosis an exploratory laparoscopy was performed: the
definitive diagnosis was mucinous adenocarcinoma of the appendix and
inflammatory appendicular wall with peritoneal nodules; omphalitis was
due to local invasion of neoplasm.
Discussion: Appendiceal neoplasms are rare, since they account for <5%
of intestinal tumors. The recently defined appendiceal crypt cell adeno-
carcinoma (ex Goblet cell carcinoid) is an even rarer appendiceal tumor
showing both mucinous and neuroendocrine differentiation. It is a highly
aggressive tumor with a tendency for spread along peritoneal surfaces, and
limited hematogenous metastasis. In addition to their trademark histomor-
phology, these tumors also have important clinical associations. Females
are more often affected than males and patients <55 years appeared to have
more aggressive disease. They tend to be more aggressive than ordinary car-
cinoids (well-differentiated neuroendocrine tumors), frequently spreading
in a transcoelomic fashion sometimes bypassing local lymph nodes. The cli-
nical manifestations are often subtle, ranging from nonspecific symptoms to
very atypical presentations, as in developing SEP, like in our patient.
53. SEVERE DIARRHEA WITH METABOLIC ACIDOSIS,
HYPERCALCEMIA AND A PANCREATIC MASS
Falcetta A., Remo M., Testa E., Leccardi S., Bracco C., Silvestri A., Serraino
C., Fenoglio L.M.
Divisione di Medicina Interna, A.O. S. Croce e Carle, Cuneo
A 68 years old man presented to the ED in December 2016 for hypotension,
severe diarrhea, hypokalemia, hypercalcemia, acute renal failure and meta-
bolic acidosis with normal anion gap.He was admitted to the Emergency
Medicine ward and transferred two days later to the Internal Medicine ward
after hemodynamic stabilization with crystalloid and bicarbonate infusion.
He has been a wine abuser in the past, had an history of chronic obstructive
pulmonary disease and underwent a Billroth II gastrojejunostomy 15 years
before. In August 2015 he was admitted to the hospital for intestinal suboc-
clusion, an ileo-psoas abscess and a 3-cm mass lesion in the pancreatic head:
at intervention abdominal adhesions were found and a biopsy of the pancre-
atic mass showed normal pancreatic tissue. In March 2016 the patient was
readmitted in surgical ward for abdominal abscess and underwent percu-
taneous drainage and antibiotic therapy. After home discharge the patients
Poster
developed progressive fatigue, weight loss and diarrhea. In June 2016 there
was another hospital admission for severe hypokalemia. In October 2016
the patient was admitted in Infectious Disease ward for a relapse of the psoas
abscess (a microbiological colture of the drainage resulted positive for Gram
negative bacteria). Moreover a Clostridium Difficile infection was diagno-
sed and course of oral vancomycin was administered to the patient. A MRN
of abdomen showed a slight increase in the pancreatic mass dimensions (47
mm vs 32 mm), with atrophy of the body and the tail and without biliary
dilatation or focal liver disease. Oral pancreatic enzymes were started. Two
months after discharge, because of persistency of diarrhea, a colonscopy
was performed, a diagnosis of microscopic colitis was made on the basis of
histological examination and budesonide was started. At Internal Medicine
ward admission the patient was in severe compromised conditions, with
persistent severe watery diarrhea; BP was 80/50 mmHg. Severe hypokale-
mia and bicarbonate loss were difficult to manage. Because of the history,
a WDHA (Watery Diarrhea, Hypokalemia Achlorhydria) syndrome was
suspected and a 111In-Octreotide scan was performed, with confirmation
of radionuclide captation in the pancreatic mass. VIP (Vasoactive Intestinal
Polypeptide) level was measured and resulted > 120 pmol/L. Octreotide was
started with prompt resolution of symptoms, progressive amelioration of
general conditions and discharge from the hospital with scheduled surgical
intervention.
54. A CASE OF “PULMONARY” DIARRHEA
Grimaldi L. 1, Noviello M. 1, Bonfrate L. 1,2, Belfiore A. 1,
Buonamico P. 1, Minerva F. 1, Palmieri V.O. 1, Pugliese S. 1, Portincasa P. 1
1
Clinica Medica “A. Murri”, Dept. of Biomedical Sciences and Human
Oncology, University of Bari Medical School; 2 Division of Internal Medicine,
Hospital “Miulli”, Acquaviva delle Fonti, Bari
A 87-year-old woman presented to ED with a 10 days history of anorexia,
fever (38.5°C), dyspnea, cough, mild abdominal discomfort and loose stools.
History taking was rather difficult: she had hypertension, T2DM, coronary
artery disease, chronic obstructive pulmonary disease (COPD), and gastro-
esophageal reflux disease. On physical examination, she was hypotensive
(85/50 mm Hg), dehydrated, tachycardic (96 beats/min) but eupnoic (20
breaths/min). A complete blood count revealed leucocytosis (20.000/uL),
elevated creatinine (1, 7 md/dL), and increased C-Reactive Protein (200
mg/L). Intravenous fluids were initiated, a chest x-ray showed a consoli-
dation the left lower lobe suggesting pneumonia. Following admission to
Internal Medicine ward, sputum was cultured and was positive for Kleb-
siella pneumoniae infection. Antibiotic therapy was started (ceftriaxone 2
gr/die and levofloxacin 500 mg/die). Respiratory symptoms improved after
5 days but worsened from day 6 (i.e., hypovolemia, dehydration, lower
abdominal discomfort, and watery diarrhea 10/die). Further information,
collected from the family revealed that patient had been admitted to hospi-
tals five more times in the previous 2 years for “recurrent bronchitis” treated
with several regimens of antibiotics. Moreover, the last hospitalization had
been complicated by C. Difficile-related diarrhea, which was managed with
vancomycin. Thus, we scheduled a test for C. difficile toxins and antigen
which were positive. A pancolonoscopy was planned and showed pseudo-
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
masked the concomitant C. Difficile infection. However, the patient had
several risk factors for C. Difficile infection (i.e., antibiotic use, age, gastric
acid suppression, a previous diagnosis of C. Difficile infection, and hospi-
talization). C. Difficile is a Gram-positive, anaerobic, spore-forming, toxin
producing bacteria, which is responsible of antibiotic-associated colitis. C.
Difficile is a major enteric pathogen and the most frequently recorded noso-
comial pathogen. C. Difficile colonizes the large intestine and releases two
toxins leading to mucosal inflammation and damage. Antibiotics, advanced
age, gastrointestinal surgery, immunosppression and inflammatory bowel
disease represent risk factors and increase the susceptibility. The clinical
manifestation ranges from an asymptomatic carriage to fulminant colitis
with toxic megacolon. The diagnosis of C. Difficile includes laboratory stool
test for toxins, radiographic imaging of abdomen and pelvis for patients
with severe illness, and endoscopy. Initial therapy includes metronidazole
in non severe C. Difficile infection. In severe cases, vancomycin is recom-
mended. Fidaxomicin is a reasonable choice in patients who cannot tolerate
vancomycin or without benefit with previous treatment with vancomycin or
with recurrence of infection. Fidaxomicin was approved in 2011 by the US
FDA for treatment of C. Difficile and is available also in Italy, starting from
2013. Recent data have shown that fidaxomicin may be superior in preven-
89
Poster
ting recurrence of C. Difficile infection. In this case, the newer antibiotic
fidaxomicin was highly effective. The high costs of fidaxomicin (euro 1, 670
for a 10-day treatment) represent a relative limitation to the use of this drug.
Finally, C. Difficile represents a common occurence in the clinical setting of
internal medicine.
55. DERMATOMYOSITIS-RELATED INTERSTITIAL
LUNG DISEASE WITH ACUTE RESPIRATORY DISTRESS
SYNDROME AND SUCCESSFULLY TREATED WITH
RITUXIMAB AND MYCOPHENOLATE MOFETIL. A CASE
REPORT
De Luca P. 1, Solimando A.G. 1, Cirulli A. 1, Grasso S. 2, Bruno F. 2, Vacca A.
1
, Prete M. 1
1
Department of Biomedical Sciences and Human Oncology, Section of Inter-
nal Medicine “G. Baccelli”, University of Bari Medical School, Bari, Italy. 2
Department of Emergency and Organ Transplant, Section of Anesthesia and
Intensive Care.University of Bari Medical School, Bari, Italy
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
severe interstitial lung disease, which is clinically indistinguishable from an
anti-synthetase syndrome, and was successfully treated with mycophenolate
mofetil and rituximab.The patient who had a history of cigarette smoking
and nichel allergy, referred to the Internal Medicine Department for fatigue,
proximal and bilateral muscular weakness, mild periorbital edema with
erythema initially on supraorbital region, and then to the forehead and
temporal region. He suffered also of non-itchy erythematosus patchy scaly
lesion on bilateral elbows, upper of chest and metacarpophalangeal joints
with periungual erythema, hyperkeratosis on the palms and poliarthral-
gia to the hands and knees, bilaterally. The diagnosis of dermatomyositis
was formulated on the basis of the clinical symptoms, laboratory investi-
gations and after performing chest TC scan, skin/muscle and lung biopsy.
In October 2016, he started intravenous immunoglobulin (IVIG) at the
dosage of 0, 4g/kg (total dose 90 g), corticosteroids (methylprednisolone
60 mg daily) and immunosuppressive drugs with methotrexate (15 mg once
a weeks) and cyclosporine (100 mg daily) that were immediately replaced
by ciclophosphamide (50 mg daily) for clinical deterioration and iatroge-
nic hypertransaminasemia. In January 2017, he made a new admission to
Internal Medicine due to clinical worsening with fever, progressive dyspnea
at rest. For the occurrence of severe respiratory failure with the evidence of
“left pulmonary embolism, massive diffuse infiltration of both lung fields,
compatible with a framework of ARDS” (Figure 1:panel A) the patient was
transferred to the Intensive Care Unit; he was supported with high-flow
oxygen ventilation by nasal cannula (OPTIFLOW) to 40-50%, enoxaparin
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;
ANA positivity 1:80 pattern speckled, with anti-Ro52, Anti SS-B and Anti-
SSA positivity.Microbiological evaluation provided no evidence for bacte-
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
therapy with mycophenolate mofetil 1000 mg twice daily, Rituximab 300 mg
weekly for four times (total dose1200 mg). He was discharged home 6 weeks
later with tapering of metilprednisolone and mycophenolate mofetil 1000
mg twice daily. Follow up chest CT after two months showed an improve-
ment of pulmonary features (Figure 1: panel B). Interstitial lung disease is
the most common extra-muscular target in poly-dermatomyositis with a
90
118° Congresso Nazionale - Società Italiana di Medicina Interna
prevalence of approximately 40-60% and is a major risk factor for morbi-
dity and mortality. In up to one third of poly-dermatomyositis patients the
anti-synthetase syndrome will develop, characterized by dermatomyositis,
interstitial lung disease, arthritis, mechanic hands, Raynaud phenomenon
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-
sed morbidity and mortality. This case may be considered an atypical form
of anti-synthetase syndrome and offers the opportunity to discuss epide-
miology data, predictive markers, and pathogenic pathway of this rare but
severe complication of polymiosisits/dermatomyositis, in relation to the
currently available therapeutic options.
56. DYSPNEA: A SYMPTOM, SEVERAL DISEASES
Donnarumma E., Torri M., Cecioni I., Berni A., Tozzetti C.,
Poggesi L.
Medicina per la complessità assistenziale 3, AOU Careggi, Università degli
Studi di Firenze, Firenze
Woman, 42 years old presented to our hospital with slight dyspnea, chest
pain and orthopnea (symptomatology started 5-6 months earlier and pro-
gressively increased). Her past medical history was negative. Her phisical
exam and arterial blood gas revealed severe hypoxia. Blood exams showed
anemia, severe trombocitopenia and alterated coagulation tests (INR 2,
fibrinogen 31, aptt 29). A chest X-ray and computed tomography scan
revealed pleural and peritoneal effusion with diffuse micronodular and
segmentary pulmonary thromboembolism with thrombosis in right ven-
tricular. In emergency room she was treated with pigtail catheter (5 liter of
blood fluid drained), oxygen, blood and plasma transfusion and heparin
in suspicion of disseminated intravascular coagulation. Pleuric liquid was
examined. In the second day of hospitalization, her conditions deteriorated
with severe dyspnea and hypoxia (need for noninvasive ventilation), incre-
ased of pleural effusion (with insertion a second chest tube) and laboratory
findings revealed: decreased haptoglobin levels, increased ldh, schistocytes
on peripheral smear and Coombs’ test negative. Adamts 13 activity was
normal. Paraneoplastic TTP was diagnosed. Initially daily plasmaferesis
was ineffective, instead after 23 days of plasma transfusion and corticoste-
roid therapy, there was significant rise in platelet counts. Pleuric effusion
citology showed undifferentiated adenocarcinoma probably pulmonary
because other exams (stomach, skin, ovary, uterus, thyroid and breast) were
negative. After one month of therapy, laboratory tests and symptoms were
progressively better, oxygen therapy and plasma transfusion were stopped,
she continued fondaparinux (segmentary thromboembolism and ventricu-
lar thrombosis) and could start chemiotherapy.
57. “HIDE-AND-SEEK” SARCOIDOSIS: PULMONARY
FIBROSIS MASKED BY CIANOTIC HEART DISEASE –
CASE REPORT
Sgariglia R., Sanesi L., Alessio S., Giuliani M., Fioretti M., Pucci G.
Department of Medicine, University of Perugia – Unit of Internal Medicine, S.
Maria Hospital, Terni, Italy
Introduction: Pulmonary hypertension (PH) is characterized by pulmo-
nary artery medium pressure ≥25 mmHg at rest. According to new gui-
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-
118° Congresso Nazionale - Società Italiana di Medicina Interna
lagen disease, an autoimmune assay was detected. Results showed c-ANCA
and ANA positivity. A chest HRTC revealed bilateral calcified hilum lym-
phadenopathies and peri-lymphatic micronodules turning into interstitial
and subpleural thickenings, suggestive of sarcoidosis. Neither BAL nor lung
biopsy could be performed to confirm the diagnosis because of her bad cli-
nical conditions. The patient refused additional diagnostic investigation and
steroid therapy and voluntarily discharged herself from hospital.
Discussion and Conclusion: In the present clinical case, a 60-year-old
woman with long-lasting unrecognized sarcoidosis, developed severe pulmo-
nary fibrosis. We could hypothesize that the presence of ES probably masked
for years the typical clinical features of sarcoidosis. In fact, hemoptysis, as
well as dyspnea, digital clubbing and cracklings are both observable in ES
and sarcoidosis. Conjunctival injection was judged as iatrogenic disease (due
to sildenafil therapy); however, an alternative diagnosis of granulomatous
uveitis, which is very common in sarcoidosis, was not taken into considered.
PH caused by different, and sometimes overlapping, etiologies may implicate
delays in diagnosis and therapy leading to severe complications.
58. WHEN MEDICAL HISTORY MAKES THE DIFFERENCE
IN A DIFFICULT DIAGNOSIS:
CHURG-STRAUSS SYNDROME
Sanesi L., Alessio S., Sgariglia R., Giuliani M., Fioretti M., Pucci G.
Department of Medicine, University of Perugia – Unit of Internal Medicine,
“S. Maria” Hospital, Terni, Italy
Introduction: Eosinophilic granulomatosis with polyangiitis (EGPA) is a
rare systemic vasculitis with less than 2 people in a million population being
diagnosed each year, predominantly affecting small and medium sized
vessels in person with a positive history of airway allergic hypersensitivity.
Case Report: A 70 years-old-man came to the Emergency Department pre-
senting dyspnea associated with myalgias and paresthesias (numbless tin-
gling) involving right arm, progressive asthenia, fever (< 38°C) and petechiae
at lower limbs. He had a past medical history of “mild bronchial asthma”
treated with formoterol/beclomethasone (spirometry substantially normal,
with a negative reversibility test). Physical examination revealed BP 160/90
mmHg; HR 105 bpm regular, oxygen saturation, respiratory rate and body
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
involvement he underwent CT chest-abdomen that showed bibasilar pleural
effusion, pericardial and peritoneal effusion suggestive for polyserositis. The
ECG documented sinus rhythm and non-specific repolarization abnorma-
lities. An ultrasound of the abdomen was performed showing peri-hepatic
fluid. Brain CT and chest radiograph were normal. Initial laboratory asses-
sment showed leukocytosis with relevant eosinophilia (E=55%); normocytic
anemia (Hb 10.2 g/dl); CRP 8.2 mg/dl; procalcitonin was negative; urinalysis
and 24 h proteinuria were negative with preserved urine output. Stool sample
for parasites exam and tumor markers were negative. Nerve conduction
studies and electromyography of four limbs showed axonal polyneuropathy
(right ulnar and median). A working diagnosis of vasculitis was advanced,
more likely Churg-Strauss syndrome. Autoimmune panel was positive for
p-ANCA anti-myeloperoxidase (MPO 100 U/ml). With reference to Ameri-
can College of Rheumatology criteria, the concomitance of blood eosinophi-
lia, ANCA positivity, nasal polyposis, history of wheezing, multiple mono-
neuritis, a final diagnosis of eosinophilic granulomatosis with polyangitis was
made. Methotrexate at a dose of 15 mg/weekly was administered in addition
to intravenous immunoglobulins (400 mg/kg/day for 5 days) and prednisone
80 mg/day, followed by rapid improvement of patient conditions, pericardial,
pleural, peritoneal effusions and of blood counts.
Discussion and Conclusion: The clinical features of EGPA typically
develop in several sequential phases over many years. Initially, in this
patient, dyspnea associated with eosinophilia lead to a diagnosis of asthma,
although this was not confirmed by respiratory functional tests. The dia-
gnosis of EGPA syndrome was suspected after the patient developed more
complex set of signs and symptoms including paresthesia, skin lesion, poly-
serositis, elevated p-ANCA. The recognition of EGPA represents a real chal-
lenge for the clinician because of its wide variety of clinical forms.
59. A BULKY SYMPTOM
Perticone M. 1, Caroleo B. 2, Suraci E. 3, Scalise L. 3, Colangelo L. 3, Miceli S. 2,
Sciacqua A. 3, Perticone F. 3
1
Università degli Studi Magna Græcia di Catanzaro – Dipartimento di
Poster
Medicina Sperimentale e Clinica; 2 Azienda Ospedaliero-Universitaria Mater
Domini di Catanzaro; 3 Università degli Studi Magna Græcia di Catanzaro –
Dipartimento di Scienze Mediche e Chirurgiche
57-year old woman, teacher.
CHIEF COMPLIANT Shortness of breath
HISTORY OF PRESENT ILLNESS New-onset (about 1 month ago) of
fatigue and apathy and of abrupt dyspnea while at rest. She went to the
Emergency Department where she underwent chest X-ray and blood count
(referred normal). In suspicion of a panic attack, the patient was referred to
a psychiatrist, who diagnosed her with mixed mood disorder (anxious-de-
pressive) and prescribed bromazepam and vortioxetin (that she never took).
Two weeks later the patient refers the appearance of bilateral inguinal tender
lymphadenomegaly, night sweats, and weight loss. Patient was referred to
our Internal Medicine Department for evaluation and treatment.
PAST MEDICAL, SOCIAL AND FAMILY HISTORY: Nothing to report
MEDICATIONS None.
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-
galy. Temp: 36.1°C Pulse: 104 bpm BP: 104/60 mmHg RR: 32/min O2:
91% RA Laboratory tests revealed neutrophilia (85.9%) and lymphopenia
(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,
albumin 52.5%, alfa 1 8.8%, alfa 2 14%. Diagnostic examinations ECG: sinus
tachycardia with HR 108 bpm. Echocardiogram: (...) Ostium secundum
inter-atrial defect, non hemodynamically significant. (...) EF 60% Simpson.
(...) Small pericardial effusion. Thickened pericardial tissues. On the basis
of the signs and symptoms (worsening dyspnea), and of laboratory and dia-
gnostic examinations, we requested a contrast total body CT, in suspicion of
a lymphoma with consequent mediastinal involvement. The CT confirmed
the presence of “many enlarged lymph nodes in all the cervical stations. (...)
Mild right basal pleural effusion. Many confluent enlarged lymph nodes in
all the mediastinal lymph node stations (max diameter 7 cm). (...) Severely
enlarged spleen. (...) Many enlarged confluent abdominal, iliac, and ingui-
nal lymph nodes. (...)” Patient then underwent excisional biopsy of an axil-
lary lymph node, which histopathological examination documented Lymph
node localization of diffuse large B-cell lymphoma. Patient was then refer-
red to a hematologist to provide the care needed.
60. ACUTE LUPUS PNEUMONIA: A STRANGE DYSPNEA
CASE REPORT
Colombo B.M., Ricciardi E., Dallegri F.
Ospedale Policlinico San Martino, Genoa, Italy
Introduction: Respiratory system is frequently involved in systemic
lupus erythematosus, and pulmonary manifestations of this autoim-
mune disease can be very different. The most common disorders are
pleuritis and lung infections. In this case report we describe an adult
male, affected by systemic lupus erythematosus under immunosuppres-
sor therapy for years, presented with acute pneumonia.
Case Report: A 73-year-old male patient affected by systemic lupus
erythematosus presented with persistent fever, especially in the evening,
cough, dyspnea and pleuritic pain for a week, not responsive to the anti-
biotic therapy given at home. Patient’s medical history included pericar-
ditis, Hashimoto’s thyroiditis, bowel’s diverticulosis, chronic glaucoma
and systemic lupus erythematosus, for which the patient submitted at
regular ambulatory follow-up. On presentation at our department, he
had dry cough, pleuritic pain at the left back side of the thorax and he
referred fever at home, especially in the evening; he also complained a
worsening of pain and edema of the left ankle. Vital signs were good; on
examination, we only found some crackles at thorax auscultation, at the
left pulmonary upper side. Moreover the left ankle was swollen, painful
and red. Laboratory examinations showed neutrophilic leukocyto-
sis, increased C-reactive protein and procalcitonin; other values were
normal. All the blood and urinary coltures or infective disease labo-
ratory tests we collected resulted negative. Contrast chest thorax (CT)
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-
monary active lesions were detected on the right side. Subsequently, the
patient submitted at bronchoscopy with bronchoalveolar lavage (BAL);
this exam showed bronchial mucous membrane hyperemia and flogosis.
BAL was negative for research of main respiratory pathogenes bacteria.
Collaterally color-doppler ultrasound of lower limbs veins detected a
91
Poster
distal deep venous thrombosis (DVT) on the left, in a pattern of lin-
fedema and probably tendinopathy. So we collected a left leg tissues
ultrasound, that retried a voluminous fluid collect, highly corpuscolate,
with a lots of septums, extended up and down the band muscle, strictly
connected to the bone. Also the coltures from this collect were nega-
tive. At first, assuming that it were an infective disease causing the fever,
the patient was treated with empiric antibiotic therapy; we have chosen
piperacilline/tazobactam, then we switched to clindamicine and mero-
penem. However all the coltures we performed resulted negative, so we
stopped antibiotic therapy and continued steroids. During the recover
we have seen a progressive improvement of the general conditions of the
patient, and also an improvement of inflammation markers on labora-
tory tests occurred. At the moment of the discharged the patient was in
good general clinical condition, no fever and asymptomatic. Last labo-
ratory results before discharge showed a normalization of blood count
cells and C-reactive protein. On the next ambulatory control the patient
was in excellent condition, and control chest CT scan, compared to the
previous one, showed an almost complete radiologic resolution of the
pulmonary pattern.
Discussion:The clinical case is of a patient presenting fever associated to
aspecific respiratory manifestations, like dyspnea. Moreover he presen-
ted pain, edema, swallow and functional limitation at left ankle. CT scan
showed a pulmonitis process with consensual pleuric effusion, so we
thought about differential diagnosis options and we detected for bacte-
rial pulmonitis with coltural exams and BAL. Infective disease and pul-
monary embolism were substantially ruled out, and the patient impro-
ved with steroids. We related these clinical elements to his autoimmune
disease, and we discharged the patient with acute lupus pneumonia,
fasciitis and deep venous thrombosis in systemic lupus erythematosus
affected.
In patients with systemic lupus erythematosus, we have to consider several
manifestations due to the respiratory system disease involvement; the
latter can express with primary lung disorders, like parenchymal, pleural,
vascular, airways or diaphragmatic involvement, or associated lung disor-
ders. Pleuritis and pulmonary infections are the most common respiratory
manifestations in these patients. In a patient affected by systemic lupus
erythematosus, in front of a pulmonary consolidation we can suspect an
infective lung involvement or acute lung pneumonia immune-mediate. In
these patients inflammation markers are often high in both the situations,
so we have to consider other aspects. Coltures exams, procalcitonin levels
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
from steroids therapy. So, in this case the most important and interesting
aspect was the differential diagnosis in a pulmonary disorder, specifically
between an infective disease or a lung involvement directly due to syste-
mic lupus erythematosus. We focused also on the possible relationship
between respiratory manifestation and contemporary onset of leg’s fascii-
tis. Obviously, the early diagnosis has a decisive impact on the therapy and
in consequence on the prognosis, so it is important to think about and rule
out also those characteristic manifestations which can involve respiratory
system in patient affected by systemic lupus erythematosus.
On the left, image from CT scan performed during hospitalization; on the
right image from CT scan control
61. NO TREATMENT RESPONSIVE DISPNOEA AND
TACHYPNEA: SYMPTOMS DUE TO LEFT SUPERIOR CAVA
VEIN PERSISTENCE IN ELDERLY PATIENT
Nardacci M., Cicco S., Solimando A., Iodice G., Ria R., Vacca A.
Clinica Medica “G. Baccelli”, Dip. di Scienze Biomediche e Oncologia
Umana, Università di Bari, Scuola di Medicina, Policlinico di Bari
92
118° Congresso Nazionale - Società Italiana di Medicina Interna
A 83-yr-old woman, housewife, no smoker, affected by COPD, permanent
atrial fibrillation treated with NOAC and hypertension, came to our unit for
a syncope.She referred a previous dyspnea with abdominal pain occurred 5
months before, when a tumor related gut occlusion was diagnosed. Radio-
logist described a mass in right iliac fossa appearing as a gut stromal tumor
(GIST) associated to a suspected pancreatic intraductal papillary mucinous
tumor (IPMT). At the hospitalization in our ward patient was dyspnoeic,
heart rate was 100 bpm and breath rate 40/min. She complains diffuse abdo-
minal pain. At electrocardiogram hyperkinetic aritmia was found. Vascular
congestion was described at thorax X-ray. Contrast enhanced thorac CT
scan excluded a pulmunary embolism and confirmed vascular congestion
according to heart failure. Troponin as well as blood cultures were negative.
Ultrasound e CT scan of abdomen confirmed pancreatic lesion and two
masses in the last handle of small intestine but the patient refused to have
a mass biopsy. Tachycardia and tachypnea were not responsive to any tre-
atment performed (betablocker ß2 selective, digoxin, calcium-antagonist,
steroids and thinners). Hyperpyrexia and cought arise during hospitaliza-
tion. Ambulatory Blood Pressure monitoring and 24-hr ECG evaluation
were not conclusive on the tachycardia possible cause. Emogas showed a
slight hypoxia with a normal pH e pCO2, as initial COPD gas modifications.
A new contrast enhanced CT scan was performed: a mild bilateral pleural
effusion associate to a pericardial effusion but no pulmonary infection was
described. At the same time this new CT revealed a dual superior cava vein
due to the persistence of the left superior cava vein, never described in the
patient, with an enlargement of the coronary sinus. This evidence was pos-
sible as a consequence of the contrast infusion in left arm vein (while pre-
vious were performed always on the right side) that had shown a superior
cava venous vascular system filling defect. Saline contrast echocardiogram
excluded a inter atrial septum defect. Amiodarone and diuretics were given
with a promptly reduction of heart rate and a consequent reduction breath
rate. Persistent left superior cava vein is a very rare congenital anatomical
condition due to the no regression of this vessel in newborn. Dyspnea is the
most important symptom the patient complain. Cardiosurgical correction
is able to achieve a clinical remission with an excellent prognosis. However
it is mostly found in adolescent or young adult: it is extremely rare to find
this condition in elderly and, in our knowledge, there are no report about it.
Epidemiology and previous fortuitous lack of contrast infusion in left arm
are the main reason in delay of the comprehension of dyspnea cause. This
anatomical condition, at the end, should be considered as effective for lack
in treatment efficacy and symptoms resolution.
62. A RELAPSING NON USUAL INTERSTITIAL
PNEUMONIA?
Periti G., Iuculano F., Airaghi L., Fracanzani A.L., Fargion S.
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
We report a case of a 78-year-old woman who presented to our medical divi-
sion referring dyspnea for minimal efforts sneakily arisen in the prior three
weeks without cough, chest pain or fever.The patient, affected by multiple
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-
ticoid therapy with three days of one gr prednisolone boli followed by 40
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.
She was started on furosemide for the evidence of chronic cardiac failure.
During therapy, the patient repeated the HR-TC scan, displaying an impro-
vement of alveolitis and underwent pulmonary function test with diffusion
lung of CO (DLCO) and oximetry showed only a mild restrictive disease
allowing suspension of daytime O2-therapy maintaining only nighttime
supplementation. The patient finally was transferred to a respiratory reha-
bilitation ward where she continued assuming prednisone per os gradually
withdrawn in February 2016. One month after discharge, she was again
118° Congresso Nazionale - Società Italiana di Medicina Interna
admitted to our medical ward for a relapse of severe dyspnea associated with
bronchospasm episodes. She repeated the appropriated exams concluding
for an acute flare of non-UIP probably due the persistence of amiodarone
toxicity. It was hypothesized that the lipophilic nature of this widely used
antiarrhythmic drug probably led to an accumulation in subcutaneous and
abdominal fat tissue of the patient being released slowly during months,
even after the withdrawal of corticosteroid therapy. The patient restarted
prednisone remaining with a minimum dose of 12, 5 mg for six months
and slowly reducing the dosage until March 2017 for a total duration of
therapy of 9 months. The patient showed a progressive clinical improve-
ment. The patient comes again to our attention for episodes of confusion
contemporary to a new episode of severe dyspnea occurring in the last three
weeks. Also this time cough, fever and chest pain are absent. The patient had
also spontaneously diminished the dosage of diuretic therapy. The clinical
exam reveals jugular turgor, bibasilar crackles and peripheral edema. Blood
gas analysis shows a worsening of pulmonary failure with oxygen satura-
tion of 78% in ambient air and biochemical exams display mildly elevated
RPC, pro-calcitonin of 0.07 (n.v. 0.02-0.06 ng/ml) and the persistency of
mild anemia. After few days of endovenous diuretic therapy without clini-
cal benefit, the patient repeated the HR-TC which demonstrates the deve-
lopment of extensive ground glass areas and some peribronchial pseudo
nodular images compatible both with a flare of the known fibrosis or a
fungal infection. Thus, a new bronchial lavage has been performed today…
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.
Methods: We studied COPD patients which started a 3-months PR
program. Patients underwent clinical and laboratory workup and perfor-
med lung function tests before and at the end of PR. Thoracic and femoral
echography was performed by a trained technician
Results: 25 out of 47 patients ended the rehabilitation program. PR was
associated with improvement in the area of the rectus femoris (RF) and
MRC scale. There was an inverse correlation between the change in Delta
FEV1% and the change pre and post PR in thickness of the diaphragm
during quiet breathing (Delta QB) and deep breathing (Delta DB). The
change in residual volume (Delta VR) correlated with Delta QB and Delta
DB. The variation of meters in the 6MWT (Delta meters) correlated with
the variation of the area of the RF (Delta RF), with the change in FEV1
expressed as percentage of predicted (Delta FEV1) and inversely with the
change in residual volume (Delta RV). DB assessment and the area of the
RF were the only predictive factors of a good response to PR in terms of
the reduction of residual volume. The measurement of QB and DB were
predictive of the Delta meters improvement, while DB and the length of
the apposition area at FRC were predictive of FEV1% improvement
Discussion:This is the first study that evaluates the role of diaphragm
echography and of the RF in COPD patients which undergo a 12-weeks
rehabilitation program. The diaphragmatic echography can predict the
answer of a patient to a single rehabilitation cycle.
64. DIAGNOSTIC ACCURACY OF TRANSTHORACIC
ECHOCARDIOGRAPHY TO IDENTIFY INFECTIVE
ENDOCARDITIS OF NATIVE VALVES: A SYSTEMATIC
REVIEW AND META-ANALYSIS
Poster
Bonzi M. 1, Ceriani E. 1, Cernuschi G. 1, Sobiati M. 1, Giusti G. 2,
Montano M. 1
1
Internal Medicine Department, Ca Granda Foundation IRCCS, Ospedale
Maggiore Policlinico, University of Milan, Italy 2IRCCS Policlinico San
Donato Department of Paediatric Cardiology and Cardiac Surgery San
Donato Milanese, Italy.
Objective: Early diagnosis of Infective Endocarditis (IE) is crucial and
echocardiography, both transthoracic (TTE) and transesophageal (TOE),
plays a pivotal role in the diagnosis. However, the diagnostic accuracy data
of TTE reported in the guidelines are mainly derived from old studies,
published before 2000s. Aim of this study is to perform an update syste-
matic review and meta-analysis of the literature in order to assess the dia-
gnostic accuracy of TTE in detecting IE of native valves.
Methods: We performed a literature search on the electronic databases
MEDLINE and EMBASE from their inception until July 2016, with the
following entry terms: “endocarditis” AND “echocardiography”. Studies
were included if they met the following criteria: (1) enrolled ≥18 years old
patients with suspected IE on native valves; (2) all patients had TTE and
TOE performed; (3) the data about TTE diagnostic accuracy, using TOE
as gold standard, could be extracted in order to build 2 x 2 table.
Results: The search algorithm yielded 17303 records; of them 11 studies
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
0.96 (0.85-0.99) respectively. The overall diagnostic accuracy was calcula-
ted excluding from analysis patients with an indeterminate TTE.
We performed sensitivity analysis considering different scenarios in the
management of inteterminate studies. In particular, considering only
studies that contemplated indeterminate TTE results with indeterminate
examinations managed as positive, the sensitivity and specificity resulted
0.94 (0.88-0.97) and 0.57 (0.46-0.67) respectively. On the other hand, the
scenario with indeterminate examinations managed as negative showed a
sensitivity of 0.64 (0.48-0.77) and specificity of 0.98 (0.90-0.99). We per-
formed also the analysis including only studies tha did not contemplate
the presence of indeterminate resuls: the retrieved sensitivity and specifi-
city were 0.73 (0.55-0.86) and 0.94 (0.90-0.97) respectively.
Discussion:Although the retrieved pooled TTE diagnostic accuracy in
diagnosis IE on native valve is better than previously reported, a nega-
tive TTE still can exclude IE only in low pretest probability patients in a
Bayesian perspective. Thus, considering overall data, our findig support
guidelines advice to perform TOE in patiens with intermediate or high
pretest probability, also in the presence of negative TTE. However, our
findings highlights how the management of indeterminate results could
change TTE diagnostic performance. In particular a strict negative appro-
ach could ameliorate sensitivity, thus allowing the possibility to exclude
IE with a negative TTE examination also in the intermediate probability
patients. Future studies are advisable to assess if this approach could be
safe and cost-effective.
65. ECHOSTETHOSCOPE, BREAK OF AORTA-
ABDOMINAL ANEURYSMS (AAA=3A) AND THE
GENERAL PRACTITIONER (GP): “3A MANTUA PROJECT”
93
Poster
Crotti G., Castagna M.
GPs and scientific coordinators of the Eidologic Mantuan Group (EMG)
Dipartimento delle Cure Primarie ATS. Val Padana Cremona - Mantova
EMG is a group constituted by twenty general practitioners (GPs) from the
province of Mantua which completes the thoracic or abdominal medical
examination, if necessary, by using the pocket-size ultrasound imaging
system VSCAN GE (echostethoscope). Since the break of an AAA causes
6000 deaths in Italy every year, we decided to measure the diameter of the
abdominal aorta - whenever given a chance - in order to compare our data
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
and 367 women) and 110 patients whose age is included between 55 and
64 years-old (57 men and 53 women). Note: when pointing to AAA, we
mean that the diameter is superior or equal to 4 cm, while ectasia is inten-
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.
Results: 65 year-old and above patients: 10 AAA (9 men and 1 woman- 1,
2% of the total-), three of whom were urgently operated (one onset with a
left-sided renal cramping); 65 ectasias (42 men and 13 women: respectively,
9, 3% and 3, 3%), or, the 7, 8% of the total. 55-64 year-old patients: 0 AAA;
6 ectasias (4 men and 2 women, respectively, 7% and 3, 7%), or, 5, 4% of the
total. All of the AAA cases and ectasias are sub-renal. The pathologies linked
with the AAA and ectasias are: pre-existing or current tabagism (82%), arte-
rial hypertension (78%), dyslipidemia (34%), diabetes mellitus (27%). The
association between tabagism and arterial hypertension can be found in
65% of the analyzed cases.
Conclusions: The evaluation of a small percentage of Mantuan population of
the age of 55 and over seem to confirm the data of the literature, or, at least, it
does as far as the AAA is concerned. On the other hand, the presence of ecta-
sias is remarkable. Tabagism and arterial hypertension are the most valuable
risk factors, as predicted. A left-sided renal cramping can be the clue of the
presence of an AAA. Depending upon these results, it would be advantageous
that the 3A Mantua Project got proposed on a regional and national scale.
Our thanks to MDs for enlisting the patients: Abruzzino M.P., Bondavalli S.,
Botturi S.A., Bruschi B., Calabrese G., Castagna M., Crotti G., Dall’Oglio
D., Danzi R., Ferri E., Gastaldi M., Gringiani A., Imperiale D.R., Maestri T.,
Massari Q., Moreni G., Papa G., Rondelli R., Venco C., Volpi P., Zanazzi A.
66. ASSOCIATION BETWEEN THE DEGREE OF
HEART DYSFUNCTION EVALUATED THROUGH
TRANSTHORACIC ECHOCARDIOGRAM AND THE
NOCTURNAL BLOOD PRESSURE PROFILE IN 389
PATIENTS WITH ESSENTIAL HYPERTENSION
Di Raimondo D. 1, Musiari G. 1, Schimmenti C. 1, Casuccio A. 2, Miceli G. 1,
Tuttolomondo A. 1, Pinto A. 1
1
Dipartimento Biomedico di Medicina Interna Clinica e Specialistica
- Università degli Studi di Palermo 2 Dipartimento di Biomedicina
Sperimentale e Neuroscienze Cliniche - Università degli Studi di Palermo
Introduction: As previously reported, the circadian rhythm of blood pres-
sure (BP) in hypertensives is associated with the severity of organ damage,
this being the maximum for the reverse dipper profile (accompanied by
paradoxical nocturnal increase of BP levels), and gradually decreasing
towards the categories characterized by a normal circadian rhythm. In light
of the paucity of data concerning the assessment of the indices of heart
function in hypertensive patients in relation to the different nocturnal BP
profile, we designed a retrospective study ad hoc.
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-
ction. All patients were evaluated through laboratory tests, clinical data and
medical history, echocardiographic recordings, ambulatory blood pressure
monitoring (ABPM). The analysis of data was performed comparing the top
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
night) and the middle quintile, as a reference. Men and women were analy-
zed separately due to the different normal ranges of the echocardigrafic
parameters considered.
Results: We observed a less impaired cardiac function for the top quintile,
also after correction for duration of hypertension, mean systolic and diastolic
24-hour blood pressure levels, mean age, main comorbities: MEN: Left Ven-
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
94
118° Congresso Nazionale - Società Italiana di Medicina Interna
± 0.07 (top); 0.41 ± 0.05 (ref); 0.48 ± 0.11 (bottom); (p. 0.05) Left Atrium
Volume (LA Vol) (ml): 56.32 ± 12.62 (top); 58.05 ± 18.22 (ref); 73.16 ± 24.97
(bottom) (p: 0.01) Left ventricular Ejection Fraction (EF) (%): 61.8 ± 7.23
(top); 61.97 ± 6.78 (ref); 57.16 ± 9.65 (bottom) (p: 0.05) Right Atrium Area
(cm2): 14.87 ± 1.61 (top), 15.49 ± 1.66 (ref); 16.36 ± 2.74 (bottom) (p: 0.01)
Similar results for women (not enough space to display)
Conclusion: Extreme dipper hypertensives seem to have lower level of
cardiac damage (both for the left and for the right chambers) when compa-
red to the other three categories of dipping, comprising the reference one.
67. SHORT-TERM EVALUATION OF HEPATOCELLULAR
CARCINOMA AFTER LOCOREGIONAL TREATMENT:
USEFULNESS OF CONTRAST-ENHANCED
ULTRASONOGRAPHY
Ainora M.E. 1, Pompili M. 1, Garcovich M. 1, Riccardi L. 1,
Di Stasio E. 2, Ponziani F. 1, De Gaetano A.M. 3, Siciliano M. 1, Annicchiarico
B.E. 1, Gasbarrini G.B. 4, Rapaccini G.L. 1,
Gasbarrini A. 1, Zocco M.A. 1
1
UOC Medicina Interna, Gastroenterologia e Malattie del Fegato, Università
Cattolica del Sacro Cuore di Roma 2 UOC Chimica Clinica, Università
Cattolica del Sacro Cuore di Roma 3 UOC Radiodiagnostica, Università
Cattolica del Sacro Cuore di Roma 4 Professore Emerito Università Cattolica
del Sacro Cuore di Roma
Background: In patients with hepatocellular carcinoma (HCC), an accu-
rate assessment of the therapeutic response is of crucial importance in
order to schedule new treatment. Contrast-enhanced ultrasound (CEUS)
with second generation contrast agents performed 1 month after treatment
is almost as sensitive as CT in depicting the residual tumor. However, the
efficacy of CEUS performed early after the procedure is still debated. Aim:
To evaluate the diagnostic accuracy of CEUS for the assessment of tumour
response shortly after locoregional therapy in patients with unresectable
HCC.
Methods: Ninety-four patients with 104 HCC lesions who were scheduled
to receive percutaneous ethanol injection (PEI), radiofrequency ablation
(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
48 hours after the procedure in detecting residual disease was evaluated.
Sensitivity, specificity, negative predictive value (NPV), positive predictive
value (PPV) and accuracy of the avascular pattern at CEUS were calculated.
Patients were followed periodically to look for tumor or disease progres-
sion. Survival probability was estimated with the Kaplan-Meier method and
relate to CEUS responses.
Results: Based on CECT findings 43/104 lesions (41.3%) were diagnosed
as having residual viability after 1 month. CEUS performed 48 hours after
treatment detected residual tumor in 34 of the 43 nodules with treatment
failure at CECT with a sensitivity, specificity, PPV, NPV and accuracy of
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
hyperemic halo was visible in 35 lesions without a statistically significant
difference between concordant and discordant cases (p= 0.2). Responders
according to 48 hours CEUS had a significantly longer mean overall survival
and time to progression compared to non-responders (1169 vs 887 days,
and 453 vs 271 days, respectively).
Conclusion: CEUS performed 48 hours after treatment can be considered
a reliable modality for the evaluation of the real extent of necrosis and has
prognostic value in the assessment of hepatocellular carcinoma.
68. BOWEL CONTRAST-ENHANCED ULTRASOUND
PERFUSION IMAGING IN THE EVALUATION OF CROHN’S
DISEASE PATIENTS UNDERGOING BIOLOGICAL
THERAPY
Ainora M.E. 1, Garcovich M. 1, Di Stasio E. 2, Riccardi L. 1,
Scaldaferri F. 1, Armuzzi A. 1, Rapaccini G.L. 1, Pompili M. 1, Gasbarrini G.B.
3
, Gasbarrini A. 1, Zocco M.A. 1
1
UOC Medicina Interna, Gastroenterologia e Malattie del Fegato, Università
Cattolica del Sacro Cuore di Roma 2 UOC Chimica Clinica, Università
Cattolica del Sacro Cuore di Roma 3 Professore Emerito Università Cattolica
del Sacro Cuore di Roma
Introduction: Evaluation of inflammatory activity in patients with Crohn’s
118° Congresso Nazionale - Società Italiana di Medicina Interna
disease (CD) represents a crucial aspect of treatment planning and moni-
toring. High-resolution bowel ultrasound has emerged as one of the most
important imaging techniques in the diagnosis and follow up of these
patients since it is a non-invasive method that easily allows repeated exami-
nation and provides both morphological and functional analyses. In parti-
cular, microvasculature activation and angiogenesis induced by inflamma-
tion are the basis for the enhanced visualization of inflamed bowel walls
evidenced by contrast enhanced ultrasound (CEUS). Aim: To prospectively
evaluate the modification in bowel wall microvasculature of CD patients
treated with biological therapy. Material and
Methods: Twenty-eight consecutive patients (14 males and 14 females;
mean age±SD, 34±12 years) with a clinically active Crohn’s disease (Harvey
Bradshaw Index [HBI] >7) involving the terminal loop of small bowel (wall
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-
ture and contrast uptake were assessed by perfusion analysis in regions of
interest (ROI) with a quantification software (Q-Lab, Philips). Variations
between baseline and different time-points were calculated for five CEUS
functional parameters (peak intensity, PI; area under the curve, AUC; slope
of wash in, Pw, time to peak, TP and mean transit time. MTT) and were
correlated with clinical response at 14 weeks. Time-intensity curves obtai-
ned in responders (those with a decrease ≥3 in the HBI score compared
with baseline) and nonresponders were compared with Mann-Whitney test.
Results: Before the beginning of the specific treatment all patients revealed
diffuse transparietal enhancement after contrast agent injection. Among all
evalutated parameters, PI, AUC and Pw showed a significant decrease at all
examined time points from the beginning of treatment (p<0.05) and were
correlated with clinical response at 14 weeks (p<0.05). After 14 weeks, 4
patients showed a new increase in PI, Pw and AUC, even though the clini-
cal findings continued to be negative. All these patients developed clinical
recurrence within 6 months.
Conclusion: According to the preliminary results of our study, the quanti-
fication of the terminal bowel loop vascularity after contrast agent injection
might become a useful modality not only for assessing the efficacy of biolo-
gical therapy but also a reliable predictor of relapse during the follow up. In
particular, changes in perfusion parameters might suggest a closer clinical
control and treatment revaluation also for patients in clinical remission.
69. ULTRASOUND IMAGING - BASED SCORE TO ASSESS
DISEASE ACTIVITY IN INFLAMMATORY BOWEL
DISEASE
Vidili G.P. 1, Pes C. 1, Cuccuru L.M. 1, Pes G.M. 2, Dore M.P. 3
1
Internal Medicine and Ultrasonography Unit, Department of Clinical and
Experimental Medicine, University of Sassari, Sassari, Italy. 2Department
of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy.
3
Internal Medicine and Gastroenterology Unit, Department of Clinical and
Experimental Medicine, University of Sassari, Sassari, Italy.
Background: Intestinal ultrasound (US) has been shown to have high accu-
racy in the detection or exclusion of inflammatory activity in Inflammatory
Bowel Disease (IBD), contributing to the first diagnosis and follow-up of
these patients. The advantages include non-invasiveness, rapid availability,
repeatability, and low costs in comparison to other imaging or endosco-
pic techniques. However, there are no validated score systems to quantify
disease activity based on ultrasonographic parameters. Objectives. Our aim
was to assess if the score we developed, based on a multiparameter US-ima-
ging derived from available literature, correlate with clinical activity measu-
red with CDAI/Mayo score and laboratory data.
Materials and Methods: From January to June 2017, 38 patients (25 with
diagnosis of Crohn’s disease - CD, 13 of Ulcerative Colitis -UC) at our insti-
tution underwent a clinical examination including questionnaires (CDAI for
CD, Mayo partial score for UC) and laboratory exams (complete blood count,
CRP, VES, iron and albumin levels, and faecal calprotectin), followed by a full
US examination with assessment of bowel wall thickening, vascular signals
on Color-Doppler, preservation or loss of multilayer pattern and normal or
reduced motility (only for CD). All these parameters were assigned prede-
termined numerical point values in order to develop a scale which allows to
classify patients on the basis of disease severity. Then, it was compared with
symptoms and laboratory-based scoring systems. US imaging was performed
by an internist with high expertise in US bowel examination and blinded to
the clinical status. A Spearman analysis was applied to test the correlation.
Results: The US score we developed showed high correlation with clini-
cal and laboratory findings, both in CD and UC patients, providing more
Poster
detailed informations about disease activity (correlation between US-score
and CDAI: p= 0, 002; US-score and Mayo: p 0, 0001; US-score and labora-
tory-based score: p 0, 0001). Our score was not associated with age, disease
duration or lesion location.
Conclusion: The score we developed, matched with the clinical data, can
be a useful method to obtain additional informations about disease status,
helping clinicians in challenging therapeutic interventions. Currently, inte-
stinal US is spreading also among specialist internists or gastroenterologi-
sts, with appropriate training, as a component of the clinical assessment.
Together with the evolution of US equipment, a standardized system can
simplify procedure and improve examiner expertise. It deserves further
evaluation of diagnostic accuracy and performance in prospective trials to
establish the true impact on disease management.
70. PREVENTION OF RELAPSE IN TTP PATIENTS
UNDERGOING SURGERY
Arcudi S. 1, Colombo G. 1, Rossio R. 1, Pontiggia S 2, Cannavo’ N. 1,2, Ferrari B.
, Peyvandi F. 1,2
1,2
1
U.O.C. di Medicina Generale - Emostasi e Trombosi, Dipartimento di
Medicina Interna, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, Milano; 2 Angelo Bianchi Bonomi Hemophilia and Thrombosis
Center, Luigi Villa Foundation, Fondazione IRCCS Ca’ Granda Ospedale
Maggiore Policlinico, Milan, Italy
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic micro-
angiopathy, characterized by haemolytic anaemia, severe thrombocyto-
penia and ischaemic organ dysfunction due to the deposition of thrombi
in microvasculature. Acute TTP is due to a deficiency of von Willebrand
factor (VWF) cleaving protein, also known as ADAMTS13 (A Disintegrin
And Metalloproteinase with a Thrombospondin type 1 motif, member 13).
In the absence of ADAMTS13, ultra large multimers of VWF (ULVWF)
released in the bloodstream are not cleaved appropriately, thus causing
platelet aggregation in the microvasculature of brain, heart and kidneys.
The acquired form of TTP is caused by anti-ADAMTS13 autoantibodies.
Daily therapeutic plasma exchange represents the gold standard of therapy
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-
ving remission. At the cutting edge, severe ADAMTS13 deficiency (less than
10%) has been recognized as the main risk factor for TTP recurrence1, and
several conditions, including surgery, may trigger an acute episode. Thus,
a therapeutic approach may be advised to prevent relapse before exposure
to such triggers, in the presence of severely reduced ADAMTS13 activity
levels. We report three clinical cases of patients followed in our center for
recurrent acquired TTP, candidates to elective major surgery. All of them
had severe ADAMTS13 deficiency in remission phase, despite multiple
previuos therapies (including steroids and rituximab). Therefore, they were
candidated to prophylactic therapies with the aim of increasing ADAMTS13
levels before surgical procedures to prevent TTP relapse. The first patient is
a 67-year-old man, who had 5 TTP acute events before surgery. For persi-
stently low ADAMTS13 activity levels (< 10%) during remission, he conti-
nued to undergo periodic prophylactic PEX (every 40 days). He underwent
left indirect inguinal hernioplasty plus synthetic mesh. Since pre-operative
ADAMTS13 activity was < 3%, a PEX procedure was performed immedia-
tely before surgery, with increase in ADAMTS13 activity levels to 25% after
surgery; no complications were observed during the post-op and the fol-
lowing weeks.
The second patient is a 64-year-old woman, who experienced 5 TTP episo-
des in the past. She underwent two surgical procedures, namely cholecy-
stectomy and left total hip arthroplasty. Before cholecystectomy, she was
treated with 3 PEX, with a rise in ADAMTS13 activity from < 3% to 38%,
and no complications occurred after surgery. Long before undergoing left
total hip arthtroplasty, she was treated with prophylactic rituximab, obtai-
ning only a partial correction of ADAMTS13 deficiency (from <3% to 24%);
so, immediately before major surgery, she underwent prophylactic PEX,
bringing ADAMTS13 activity levels to 45%, with a subsequent safe surgical
procedure. The third patient is a 58-year-old woman, with 4 previous acute
TTP episodes. She underwent total laparoscopic hysterectomy for atypical
endometrial complex hyperplasia. Pre-operative ADAMTS13 activity was <
3%, so a prophylactic PEX was performed and ADAMTS13 activity rised to
more than 50% after surgery. No complications occurred. 7
In conclusion, we reported three cases of successful surgical procedures in
patients affected by recurrent acquired TTP, with undetectabe ADAMTS13
activity levels during remission phase. Prophylactic PEX immediately
95
Poster
before surgery could be a reasonable protocol to increase ADAMTS13 levels
and prevent relapses in such TTP patients. 1. Kremer Hovinga JA, Vesely
SK, Terrell DR, Lammle B, George JN. Survival and relapse in patients with
thrombotic thrombocytopenic purpura. Blood 2010;115:1500–11
71. ATRIAL FIBRILLATION IN PATIENTS AFFECTED
BY POLYCYTHEMIA VERA OR ESSENTIAL
THROMBOCYTHEMIA
Biagetti G., Bertozzi I., Cosi E., Santarossa C., Bogoni G., Fabris F., Randi
M.L.
Dipartimento di Medicina - DIMED, Università di Padova, Clinica Medica 1
Introduction: Atrial Fibrillation (AF) is a common cardiovascular disease
with an estimated prevalence of 0, 5 - 1% in the general population, and 2,
5-3% in over-65 people. The main complication of AF is thromboembo-
lism and therefore patients with AF are treated with anticoagulants. Also
Polycythemia Vera (PV) and Essential Thrombocytemia (ET) occur mainly
in median-advanced age and affected patients have a significant thrombo-
tic risk both in arterial and venous vessels. To prevent this risk, most of
these patients are treated with low-dose aspirin (ASA). This scenario places
a question: does a patient affected with PV/ET and AF have to receive ASA
and/or anticoagulants? Is there a preferential treatment? To answer this, we
retrospectively investigated in our large cohort of patients with PV and ET
how antithrombotic treatment has been used when AF occurred.
Methods: Within 570 PV and ET patients followed in our Department, we
found 22 patients (12 PV and 10 ET, 11 males and 11 females, mean age
72±7 years) also suffering for AF. We stratified the patients on the basis of
antiplatelet/anticoagulant treatment adopted and the occurrence of throm-
bo-hemorrhagic complications were registered. In every patient at diagnosis
of AF, CHA2DS2-VASc and HAS-BLED scores were registered.
Results: The occurrence of AF in our cohort of PV and ET patients was of
3, 9 %, and 12% for patients over 65 years. Twenty-one patients had a high
risk CHA2DS2-VASc score and 1 had a low risk; two patients had high, 20
medium and 1 had low risk HAS-BLED score. Seven patients (all with high
CHA2DS2-VASc risk) received ASA and 1 of them had a stroke; 5 out of
these 7 patients shifted to warfarin because of the occurrence of AF (during
warfarin 1 patient had a myocardial infarction). Ten patients were treated
with warfarin for AF (1 with a low and 9 with a high CHA2DS2-VASc risk)
and 2 of them had deep vein thrombosis (DVT) and 1 renal vein thrombo-
sis during treatment. In 5 patients (all with medium HAS-BLED risk) ASA
and warfarin were administered together being AF and PV or ET diagno-
sis contemporary; 1 of these patients had DVT and 1 a peripheral arterial
thrombus. Two patients had a minor bleeding during ASA therapy, 2 during
warfarin and 1 while receiving both drugs.
Discussion:Both ET/PV and AF occur mainly in the same setting of age,
making frequent the co-existence of these pathologies in the same patient.
Our data show that AF is at least as frequent in older PV and ET patients as
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,
also if associated, are able to cancel the thrombotic risk in the patients with
two prothrombotic conditions and the association of two antithrombotic
agents does not seem to represent a significant bleeding risk in our patients.
It is interesting to point how CHAD-VASC and HAS-BLED scores should
be useful in choosing the best treatment for AF in ET/PV patients. However,
the prothrombotic and pro hemorrhagic risks given by these diseases is
lacking in the scores. Prospective studies on larger cohorts of patients are
needed to answer further, and to assess appropriate guidelines.
72. THE COMPLEX MANAGEMENT OF A YOUNG WOMAN
WITH REFRACTORY IMMUNE THROMBOCYTOPENIA
Boscaro F., Bertomoro A., Di Pasquale I., Omenetto E., Fabris F.
Clinica Medica 1, Dipartimento di Medicina, Università degli Studi di
Padova
We report a case of a 28 years old Moldovan woman with a secondary,
refractory immune thrombocytopenia (ITP) diagnosed on 2002 in
Moldova. ITP is associated with hemolytic anemia (Evans Syndrome),
which required blood transfusion in childhood. Her clinical history inclu-
des post-trasfusional HCV-related hepatitis, treated in 2016 with Ledipa-
svir and Sofosbuvir with HCV eradication; Sjogren’s Syndrome with severe
dry eye and a positive titer of ANA and ENA anti-SSA; IgK MGUS without
96
118° Congresso Nazionale - Società Italiana di Medicina Interna
Bence-Jones proteinuria. Once ITP was diagnosed, the patient received a
first-line therapy with prednisone and IVIg, with no response. After, she
was unsuccessfully treated with Azatioprina. On 2006 she underwent sple-
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-
matic for epistaxis and petechiae. Platelet-associated autoantibodies against
GpIIb/IIIa and GpIb were positive; an abdominal CT was negative for acces-
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
two days), she was treated with Romiplostim (1 mcg/kg up to 3.5 mcg/kg)
administrated once a week for 26 weeks. The response to TPO-mimetic was
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
remission continued until April 2015, when at 21st week of gestation the
ITP relapsed (plts 2-5 x 10^9/L) with epistaxis, gengivoraggia and petechiae.
The patient was treated again with corticosteroids (prednisone, dexametha-
sone) and IVIg, with only a transitory response, and with Romiplostim (1
mcg/kg increased up to 10 mcg/kg once a week for 3 weeks) used off label
before delivery, without response. She underwent to elective caesarean deli-
very at 26th week of gestation, in course of platelets concentrates infusion
(plts 3 x 10^9/L). The baby did not report complication and its platelet count
was normal. Otherwise, during the post-partum period the patient deve-
loped a periuterine hematoma, requiring laparotomy for evacuation. After
the delivery, Romiplostim was administrated for other 10 weeks. Due to
fluctuating platelet count, we shifted to Eltrombopag 50 mg/die, which was
withdrawn after only one week because of sever thrombocytosis (plts 1985 x
10^9/L). The patient underwent to a new course of Rituximab, obtaining a
complete response and a stable remission with low doses of corticosteroids,
gradually tapered until suspension. In July 2016 the ITP recurred again
(plts 2 x 10^9/L), exacerbated by two infective episodes. This time throm-
bocytopenia was associated with neutropenia (N 0.32 x 10^9/L), requiring
administration of GCS-F, with benefit. The patient received once again
high dose of corticosteroids, IVIg and Eltrombopag. Platelet count rapidly
increased until 1700 x 10^9/L: TPO-mimetic was consequently withdrawn
and corticosteroid therapy was tapered. In November 2016 the ITP relap-
sed, associated with hemolytic anemia and neutropenia (plts 11 x 10^9/L,
Hb 61 g/L, N 0.40 x 10^9/L). The patient was managed with prednisone,
IVIg, Eltrombopag and Rituximab, without response. Immunosuppression
with cyclosporine A (from 50 mg x 2/die up to 100 mg x 2/die) was started
and the patient underwent 4 courses of immunoadsorption with Ig-Thera-
sorb® system, each one followed by the administration of IVIg. With this
strategy platelet count progressively increased until normal values. For the
hemolytic anemia, she was supported with blood transufusions; neutro-
penia was treated with GCS-F with benefit. In March 2017, after the 5th
relapse, the patient was treated again with immunoadsorption, this time
unsuccefully. Immunosoprression with cyclosporine A was interrupted and
we administrated high dose of chemotherapy (Cyclofosfamide, Vincristina,
Prednisone), obtaining finally a stable response.
73. FISHER-EVANS SYNDROME: CASE REPORT
Battisti P. 1, Ciammaichella M.M. 2, Maida R. 2, Petrecca I. 2,
Carfagna P. 3, Fenu S. 4, Giacomobono S. 5, Cedrone M. 4,
Pirillo S. 6
1
II Medicina, A. O. S. Giovanni-Addolorata, Roma 2 Medicina d’Urgenza,
A. O. S. Giovanni-Addolorata, Roma 3 GOICA, A. O. S. Giovanni-
Addolorata, Roma 4Ematoloogia, A. O. S. Giovanni-Addolorata, Roma
5
Immunoematologia e Medicina Trasfusionale, Policlinicio Militare Celio,
Roma 6Radiologia per il DEA, A. O. S. Giovanni-Addolorata, Roma
Introduction: The authors presented the case report of a 36-year-old Roma-
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,
PLT 2000 / mm3, neutrophilic leukocytosis related to steroid therapy, pul-
monary thickening. Therapy with endovene non-specific immunoglobulins
(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
tests:
1) ECG: RS Exposure Limits;
2) Hematochemical routine examinations show leukocytosis (between 15,
000 and 24, 000), PLTs consistently <5000 / mm3, Hb 5.7 g, PCR, which is
32 mg / dl (VN <0.6 mg / dl);
3) Primary and secondary thrombophilic screening is negative;
4) Hyperchromium, anisopoiesilocytosis, microcytosis, anulocytosis, multi-
118° Congresso Nazionale - Società Italiana di Medicina Interna
ple cysts, severe platelet and lymphopenia as well as hemolysis
5) The protidogram EF shows hypoalbuminema, hyperalpha1, hyperalpha2,
hyperbeta1, hyperbeta2, hypogamma, small monoclonal component in
gamma3;
6) Hepatitis B markers show HBS AB at 14 mUI / ml (reactive> 10 mUI /
ml);
7) Autoimmune screening shows c-ANCA positivity (unrelated to vasculi-
tis) and antinuclear antibodies (IFI title) Positivity 1: 640 Pattern speckled
8) Urine examination in the limits of sterile urinoculture and urinary tract
of the negative legionella;
9) Fibrobroncoscopy with BAL shows no acid-resistant bacilli absence,
positivity for Klebsiella Pneumoniae, BAL PCR negativity for Micobacte-
rium Tubercolosis Complex, positivity for galactogenic:
10) Serum for TORCH, legionella, EBNA, VCA, micoplasma, chlamydia is
negative;
11) Bone biopsy on the iliac crest shows increased cellularity, increased
megacaryocytes, > 2% histiocytes, diserythropoiesis, disgranulose, disme-
gacaryacytopoiesis; The histogram shows: 55% erythroblasts, 24% granulo-
blasts, 11% lymphocytes, 2% eosinophils, basophils 0, promonocytes + 2%
monocytes, 2% undifferentiated elements, 4% plasma cells, G / E 0.48. This
corresponds to hyperplasia of the erythroblastic series with series present in
all maturative phases as for hemolytic anemia in the absence of parasites or
myeloftic neoplasms;
12) TAC chest-abdomen with mdc: pulmonary consolidation with central
excavations, 7 cm DAP chin of the apical LID segment associated with
further peribronchial disomogeneous cavities, satellite nodules and bila-
teral pulmonary micronodulas, pulmonary consolidation of 33 mm at the
apical head LIS paramediastinic, material Thromboembolic in the lumen of
the taxus vessels to the lower lobes of both lungs, two lymphatic lymphatic
lesions of 24 and 25 mm, splenectomy outcomes,
13) TC Skull with mdc: Expanding characterization of 12 mm located in left
medial frontal corticosottocorticale with peripheral edema;
14) Angio-RM encephalus with mdc and ANGIO-RM of intracranial vessels
with mdc: Sequence with technique SE, FSE, FLAIR weighed in DWI T2-1
before and after paramagnetic contrast medium showing in the left frontal
nodular diameter formation Of 11 mm surrounded by edema;
15) RM Spectroscopic brain of the brainplant performed by multi-para-
meter morphology and structural technique with DWI-ADC and spectro-
scopic (CSI single-voxel) study: confirms the frontal intrasial head nodular
pseudo nodular alteration with peripheral edema, diffusion restriction: this
is due to cerebral abscess;
16) PICC is positioned by right transgigram under ultrasound guide and
the VCS positioning with RX chest is monitored; Treatment modifications:
mannitol ev, meropenem ev, colistin aerosol, emotional fusion only in case
of signs of severe hypoxia, transplantation of PLT only in cases of haemor-
rhage, acyclovir cp 800 mg, soldesam 4 mg iv, amphotericin B fl 50 mg ev,
Eltrombopag olamine. In the light of the clinical picture and repeated hema-
tologic, bronchopneumological and infectious counseling, it is located by
syndrome by Fisher-Evans.
Discussion: Autoimmune cytopenia is characterized by the selectivity of
the “target” cell in the sense that antibody action causes a specific cytope-
nia, both in peripheral and central pathogenesis or in combination. The
paradigm of this autoimmunity directed at different cells simultaneously is
Evans’s syndrome, where autoimmune hemolytic anemia is combined with
a platelet-like autoimmune pathogenesis. Both idiopathic and associated
forms of disease are known, especially in autoimmune pathogenesis, and
even after bone marrow transplantation.
Conclusions: The authors presented the case report of a patient with Fisher
- Evans syndrome.
74. A CASE OF WEAKNESS
Ciarla S., Striuli R., Petrarca M., Croce G., Parisi D., Di Michele D.
U.O.C. di Medicina Interna - Ospedale “G. Mazzini” ASL. Teramo
Case report: A 32-year-old Caucasian male was brought into the emer-
gency department because of general weakness and poor oral intake. A
week before he had previous access to first aid for the same reason and cor-
tisone was administered for submandibular and laterocervical lymphadeno-
megaly. His remote and physiological anamnesis were negative for relevant
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
vital signs were within normal limits. No significant elements were found
by a physical examination. An electrocardiogram and a chest radiography
Poster
were normal, while an abdominal ultrasonography showed nephrome-
galy and renal lithiasis. Treatment with intravenous hydration, phosphate
binders, allopurinol, and rasburicase was initiated. A chest-abdomen CT
without contrast showed subcentimetric abdominal lymph nodes. Accor-
dingly, spontaneous tumor lysis syndrome in hematologic malignancy was
suspected. Therefore, an osteomedullary biopsy was performed and showed
a T-cell lymphoblastic lymphoma.
Conclusion: Tumor lysis syndrome is an oncologic emergency that usually
occurs after chemotherapy in patients with hematologic malignancies. Ste-
roids are known to have lympholytic effects. Although steroids are widely
used, there are case reports of tumor lysis syndrome in patients with mali-
gnancies treated solely with steroids. Therefore, empirical therapy with
steroids should be avoided, especially in patients suspected of having large
tumor burdens.
75. AN INTRIGUING CLINICAL CASE OF BETA THALAS-
SEMIA UNDULY TAKEN FOR THALASSEMIA MINOR
Falconieri M. 1, Fiore G. 1, Castrovilli A. 1, Vitucci A. 2,
Palma A. 2, Pietrapertosa A. 2, Specchia G. 2, Sabbà C. 1
1
U.O. Medicina Interna Universitaria “C.Frugoni”, Dipartimento Interdisci-
plinare di Medicina, Università di Bari; 2 U.O. Ematologia con Trapianto Uni-
versitaria, Dipartimento Emergenza e Trapianti di Organi, Università di Bari
Introduction: Beta thalassemia is an hereditary autosomal recessive hae-
matological disorder caused by defects in the synthesis of globin chains
leading to reduced or absent beta (β) chains and consequently to excess of
alpha (α) chains and to decrease in hemoglobin HbA (α2β2 chains <95-
98%) and increase in HbA2 (α2δ2 >2-3%). Imbalance of β-globin chains
in heterozygous or homozygous beta thalassemia form (Minor Thalassemia
and Major Thalassemia or Cooley’s Anemia, respectively) cause haemolysis
and impair erythropoiesis with a variable grade of severity. Minor Tha-
lassemia due to mild anemia is clinically asymptomatic and exceptionally
responsible of jaundice.
Clinical Data: A 17-year-old girl with previous diagnosis of Minor Tha-
lassemia, inherited from the paternal side, was admitted to our Internal
Medicine Unit for asthenia and abdominal pain having been hospitalized
in 2015 in Surgery Unit for obstructive jaundice. The patient with a normal
constitution exhibited pale skin, weakness and positivity for Murphy’s sign
at abdominal examination.
Laboratory and Instrumental Investigations and Results: Laboratory
tests showed hypochromic and microcytic anemia (Hb 9.6 g/dl, MCV 61.6
fl, MCH 19.4 pg), normal iron profile, folic acid deficiency (2.7 ng/ml vs
n.v.>5.4), increase in indirect bilirubin (2.89 mg/dl, total 3.10 mg/dl), low
haptoglobin levels (0.31 g/l vs n.v. 0.3-2.0), negative Coombs test, normal
glucose-6-phosphate deydrogenase (G6PD) enzyme activity and negative
markers for viral hepatitis and autoimmunity. Ultrasound (US) examination
evidenced an increase in spleen volume (16.2 cm vs n.v. <12 cm) and choleli-
thiasis in absence of bile ducts dilatation. In the suspicion of a more complex
form of beta-thalassemia, an hemoglobin electrophoresis at alkaline pH on
agarose gel was performed with consequent evidence of high level of fetal
and A2 hemoglobin at a rate of 5.6 % and 5.7 %, respectively. Moreover, the
molecular study of alpha and beta DNA chains showed a β° cod 39 (C>T)
mutation and a ααα anti-3.7 triplication, both in heterozygosity. Additio-
nally, the genetic analysis of UDPG1A1 gene mutation was diagnostic for
Gilbert syndrome.
Discussion: Beta-Thalassemia Minor is a form of haemolytic microcytic
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
obstructive jaundice in a very young subject with a previous diagnosis of
Beta-Thalassemia Minor. This imposed a more-in-depth genetic hemo-
globin analysis. The finding of an increase in fetal and A2 hemoglobin
was incontrovertibly significant of Beta-Thalassemia Intermedia rather
than the harmless Beta-Thalassemia Minor. In fact, in this patient the
underlying disorder of Beta-Thalassemia Intermedia was at the base of
significant haemolysis and consequently of the massive biliary stones pro-
duction. So, when the phenotype of a presumed Beta-Thalassemia Minor
coexists with gallstones, with or without jaundice, it’s mandatory to inve-
stigate on Beta-Thalassemia Intermedia.
76. PREDICTORS OF CARDIAC EVENTS IN BETA-
THALASSEMIC ADULT PATIENTS: A PROSPECTIVE
STUDY
97
Poster
Ferrara F. 1, Riva R. 1, Ventura P. 1, Coppi F. 2, Rochira V. 3.,
Bevini M. 4., Vegetti A. 1, Corradini E. 1, Pietrangelo A. 1
1
Division of Medicine II and Center for Hemochromatosis, University
Hospital of Modena, Modena, Italy 2Division of Cardiology, University
Hospital of Modena, Modena, Italy 3Division of Endocrinology,
Sant’Agostino-Estense Hospital, Modena, Italy 4Immuno-ematology and
Transfusion Service, University Hospital of Modena, Modena, Italy
Background: β-thalassemia Major (TM) and Intermedia (TI) are characte-
rized by severe anemia early in life and iron overload both from transfu-
sion supply and from anemia itself. Prior to the advent of chelation therapy,
transfusion dependent TM patients usually died in their second decade of
life because of iron-related cardiomyopathy leading to cardiac decompen-
sation or fatal arrhythmia. Therefore, patients’ management was confined
to pediatricians. Chelation therapy since 1970s has dramatically improved
patients’ survival and made this systemic disease of interest for speciali-
sts in Internal Medicine. Although the huge improvement in expectancy
and quality of life, many patients still develop relevant complications, and
cardiac events (decompensation and arrhythmias) remain one of the prin-
cipal concern for prognosis and quality of life. Excess iron accumulation in
the heart and chronic anemia are the main determinants of cardiac events
in this population.
Aim: Aims of our study was to evaluate the incidence of cardiac events
(cardiac decompensation and arrhythmias) in a population of adult
beta-thalassemic patients and to identify possible predictors and prevention
strategies.
Population and Methods: 37 patients were included in the present study, 29
TM and 8 TI, aged 24-61, consecutively enrolled from 2011. Retrospective
data regarding diagnosis, splenectomy, cardiac history, endocrinopathies,
transfusion requirement, chelation therapy, and prospective data regarding
new-onset cardiac decompensation and arrhythmias, echocardiographic
parameters, biochemical variables (including mean pre-transfusion hemo-
globin, iron, ferritin, transferrin saturation), non transferrin-bound iron
(NTBI) and labile plasma iron (LPI), hepatic and cardiac iron deposits by
MRI T2 1, new-onset endocrinopathies and chelation therapy, were collected
through 2016 in an electronic database and analyzed on a SPSS platform.
Results: At the beginning of the study, 8 TM patients and 1 TI patient
had already experienced cardiac events, mainly cardiac decompensation.
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-
nadism, hypoparathyroidism, hypothyroidism, GH-deficiency) a signifi-
cantly higher prevalence was observed in patients who had experienced a
cardiac event although this difference failed to reach statistical significance.
No differences were observed in iron parameters, transfusion schedules
and iron chelation history in the 2 groups. During the follow-up period (72
months), 11 patients (29.7%) experienced a new cardiac event and 4 of them
had more than one event: 3 patients (8.1%) developed cardiac decompen-
sation, 5 patients had atrial fibrillation (AF), 1 patient had supraventricular
tachycardia (SVT), 1 patient had concomitant cardiac decompensation and
AF and 1 patient had AF and SVT. The onset of cardiac events was positively
correlated to: high LPI levels (OR 12.0, 95% CI 1.56-92.3, p 0.017); low mean
pre-transfusion hemoglobin (OR 0.21, 95% C.I. 0.051-0.761, p 0.21); echo-
cardiographic parameters suggestive of myocardial hypertrophy: interven-
tricular septum thickness, (OR 4.2, 95% C.I. 1.24-13.7, p 0.020), posterior
wall (OR 4.23, 95% C.I. 1.27-14.1, p 0.019), left ventricular mass (OR 1.21,
95% C.I. 1.04-1.21, p 0.005); left atrial volume (OR 1.22, 95% C.I. 1.05-1.41,
p 0.010), left ventricular tele-diastolic volume (OR 1.26, 95% C.I. 0.98-1.62,
p 0.06); QT interval prolongation (OR 7.33, 95%C.I. 1.07-50.1, p 0.04). LPI
levels were unrelated to iron deposits evaluated by hepatic and cardiac MRI
and to chelation regimen. Iron deposits measurement by MRI-T2 1 failed
to predict cardiac events. Interestingly, all patient underwent a progressive
reduction of the ejection fraction during the follow-up period although it
remained between the normal range.
Discussion and Conclusions: Our study involved a limited but well cha-
racterized number of beta-thalassemic patients affected by a severe rare
disease. We were able to identify important predictors of cardiac events,
including baseline LPI, Hb levels and echocardiographic parameters. Early
identification and treatment of endocrinologic comorbidities, improvement
of transfusion schedules and an accurate echocardiographic follow-up are
needed to reduce the risk of cardiac complications. LPI might be of clinical
utility to identify well chelated patients free from cardiac iron overload but
still at risk of cardiac events and might represent a future target for new
treatment strategies.
98
118° Congresso Nazionale - Società Italiana di Medicina Interna
77. COEXISTING HEREDITARY HEMOCHROMATOSIS
AND BETA-THALASSEMIA TRAIT: POSSIBLE
CONFOUNDERS FOR A SUBSEQUENT HEMATOLOGICAL
DIAGNOSIS
Pelusi S., Lombardi R., Iuculano F., Francione P., Valenti L., Fracanzani A.L.,
Fargion S.
Department of Pathophysiology and Transplantation, Unit of Internal
Medicine, Ca’ Granda IRCCS Foundation, Policlinico Hospital, University of
Milan, Milan, Italy
Introduction: Hereditary Hemocromathosis (HH) is a genetic disorder
in iron metabolism which causes its deposition in different organs, mainly
liver, joints, bones, and heart, causing their dysfunction. The association of
HH with hematologic disorders has been already reported, but literature is
scarce.
Case report: We report the case of a 34 year-old woman with history of
hyperferritinemia with elevated transferrin saturation (ferritin 800 ng/
ml, transferrin saturation 85%) since the youth. Moreover, she was carrier
of beta-thalassemia trait (hemoglobin levels 10-11 g/dl). Suspecting HH
the patient was genotyped for HFE gene and resulted homozygous for the
C282Y mutation. She underwent also an abdomen ultrasound (normal),
an echocardiography (impaired diastolic compliance), a bone densito-
metry (normal) and X-ray of the hands (no arthropathy). Liver biopsy
pointed out severe parenchimal siderosis with parenchymal predomi-
nantly iron deposition without significant fibrosis. She was started on
phlebotomy until iron depletion followed by maintenance phlebotomies.
After several years a progressive increase in spleen volume was observed,
followed by a splenic infarction. A trombophilic screening was obtained
and showed positivity for the V617 mutation in the JAK-2 gene, while
bone marrow biopsy diagnosed a myeloproliferative neoplasm. Therefore,
she was started with hydroxyurea and afterwards with JAK2-inhibitor. We
eventually observed a reduction in spleen volume and improvement in
blood tests.
Discussion: A longstanding abnormal erythropoiesis driven by beta-thalas-
semia trait associated with external stimuli such as phlebotomy might have
predisposed our patient to a myeloproliferative disorder and possibly have
masked and delayed its diagnosis.
78. ATYPICAL LUPUS-LIKE ANTICOAGULANT IN A
PATIENT WITH NON-HODGKIN LYMPHOMA AND HBV
INFECTION
Pina G. 1, Bucciarelli P. 2, Scopelliti F. 1, Fasola D. 1, Novembrino C. 2, Boscolo
Anzoletti M. 2, Peyvandi F. 2, Moreo G. 1
1
Internal Medicine Unit, Clinica San Carlo, Paderno Dugnano, 2Angelo
Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’
Granda Ospedale Maggiore Policlinico and University of Milan, Italy
Antiphospholipid antibodies (APA) are acquired antibodies against cel-
lular surface phospholipids that interfere with in vitro coagulation tests,
while in vivo are responsible of a thrombophilic state. Sometimes, APA
are found in patients with hematological malignancies or infections. We
describe a case of a patient with a marginal splenic B-cell non-Hodgkin
lymphoma and hepatitis B acute viral infection with an atypical presenta-
tion of APLs. A 77 years-old female patient was diagnosed with a marginal
splenic B-cell non-Hodgkin lymphoma on 2010. She was treated first with
chlorambucil and prednisone, then on 2014 with 6 cycles of rituximab
and bendamustine, achieving partial remission. Subsequently she deve-
loped acute hepatitis B viral infection and was treated with tenofovir. On
February 2017 she presented with pancytopenia (Hb 8.6 g/dL, MCV 102
fL, WBC 2800 x 103/L, platelets 82 x 103/L), ascites and leg oedema. A
marked splenomegaly was detected at visit and confirmed with CT scan
and MR (a/p diameter 19 cm). No hepatic focal lesions were found. The
patient did not have any bleeding diathesis. Liver tests were normal except
for a slight decrease of liver synthesis markers (albumin 3.0 g/dL, pChe
3290 U/L). A modest IgM lambda monoclonal gammophaty (0.04 g/dL)
was found. Prothrombin time (PT) and activated partial thromboplastin
time (APTT), previously normal, were now markedly prolonged (PT ratio
5.50, APTT ratio 2.36, respectively), and did not correct after mixing tests
with normal plasma. During the hospital stay, a PICC was inserted on the
right arm for liquid infusion, but a rapid thrombosis of its lumen occur-
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:
118° Congresso Nazionale - Società Italiana di Medicina Interna
Test Result Laboratory reference range
 PT ratio 5.50 (0.84 - 1.20)
 PT ratio mix 50/50 4.78 (0.84 - 1.20)
 APTT ratio 2.36 (0.86 - 1.20)
 APTT ratio mix 50/50  2.06 (0.86 - 1.20)
 Factor VIII 161 IU/dL  (51 - 147 IU/dL)
 Factor IX  87 IU/dL  (70 - 120 IU/dL)
 Factor VII 65 IU/dL  (62 - 138 IU/dL)
 Factor V  100 IU/dL  (70 - 134 IU/dL)
 Factor X 47 IU/dL  (66 - 126 IU/dL)
 Factor II 35 IU/dL  (73 - 113 IU/dL)
 Fibrinogen 250 mg/dL (150 - 300 mg/dL)
Plasma concentration of coagulation factors was assessed with either chro-
mogenic tests (for factors VIII and IX) or functional tests at extremely
high dilutions of patient’s plasma with buffer (up to 1:320 for factors VII,
V and X, up to 1:64 for factor II) in order to avoid as much as possible the
interference of the inhibitor on coagulation tests. In the presence of normal
plasma levels of factor V, severe liver disease was ruled out. SCT and dRVVT
tests before and after addition of phospholipids confirmed the presence of a
lupus-like inhibitor. Anticardiolipin and anti-beta2 glycoprotein 1 IgG and
IgM antibodies were negative, and cryoglobulins were absent. A diagnosis
of atypical lupus-like anticoagulant (with a marked prolongation of both
PT and APTT) was made. The patient underwent bone marrow trephyne
biopsy (5% infiltration of lymphoma cells) without any blood component
support and without bleeding complications. She is now in the waiting list
for splenectomy. Both B-cell non-Hodgkin lymphoma and HBV infection
could be responsible for the development of the atypical lupus-like anticoa-
gulant in this patient. The marked prolongation also of PT might be explai-
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
tendency) should guide doctors’ decisions. In all patients with abnormal
prolongation of both PT and APTT not explained by severe liver dysfun-
ction, the presence of APA with atypical presentation should be suspected
and accurately tested before any invasive procedure.
79. IMAGING MRI IN DIAGNOSIS OF KIDNEY
DLBCL-LYMPHOMA
1
V. Russo, 2A. Merceri, M. Gobbi
1
DIMi- Dip. Ematologia, Università degli studi di Genova, Direttore: Prof.
M. Gobbi, 2 ASST-Bergamo Est - Responsabile P.S. Osp. di Alzano L.do (BG)
Introduction: Lymphoma is the most common blood cancer. Diffuse large
B-cell lymphoma (DLBCL) is the most common form of non-Hodgkin
lymphoma (NHL), accounting for about 30% of newly diagnosed cases of
NHL in United States. The initial symptoms of DLBCL include painless
swelling in one or more lymph nodes. Some people with DLBCL develop
large tumors in the abdomen and. kidney. We report a 65-year-old man
with abdominal pain and history of chronic anemia. Abdominal MRI scan
detected hyperintense lesions in the kidney and lomboaortic nodes > 1 cm.
METHODS A 65-year-old man with history of chronic anemia was admit-
ted to our hospital for abdominal pain, light increase in serum creatinine
activity and presence of hypoechoic lesions in the kidney. Abdominal MRI
confirmed hyperintense lesions in the kidney and lomboaortic nodes > 1
cm. Bone marrow aspirate showed increased number of B lymphocytes 75%,
with dysplastic features. Immunophenotype was CD20+, CD79+, BCL-2+,
BCL-6 +, CD30-, CD15-, CD10-, CD3-. Histology of kidney lesions and
abdominal nodes prompted the diagnosis of DBCL. RESULTS The patient
was treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin,
vincristine and prednisone) obtaining a remission of symptoms. CONCLU-
SION DLBCL is an aggressive (fast-growing) lymphoma that can arise in
lymph nodes or outside of the lymphatic system, in the gastrointestinal tract
or in the kidney. A possible strategy is to perform US as the initial technique
in all patients with acute abdominal pain, with CT performed in all cases
of nondiagnostic. US data on the use of MR imaging for this indication are
still sparse. The use of conventional radiography has been surpassed; this
examination has only a possible role in the setting of bowel obstruction.
Poster
80. SPLENIC INFARCTION AND ACUTE PULMONARY
EMBOLISM (PEA) IN FOLLICULAR LYMPHOMA: A CASE
REPORT
V. Russo, 2 A. Merceri, 1 M. Gobbi
1
1
DIMi- Dip. Ematologia, Università degli studi di Genova, Direttore: Prof.
M. Gobbi, 2 ASST-Bergamo Est - Responsabile P.S. Osp. di Alzano L.do (BG)
Introduction: Follicular lymphoma (FL) is one form of lymphoma non
Hodgkin. Initial presentation of splenic FL can be given by abdominal pain.
However early diagnosis of this hematological condition can improve the
prevention of thrombotic events as PEA and splenic infarction in follicular
lymphoma (FL) patients. PEA is a relative common cardiovascular emer-
gency. PEA is a difficult diagnosis that may be missed because of non-speci-
fic clinical presentation. The initial symptoms of PEA and splenic infarction
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
chest pain. Arterial blood gas on 2 L of O2 demonstrated pH 7.46, pCO2
4.2 kPa, pO2 12.5 kPa and HCO3 22.3 mmol/L.Blood tests revealed a white
cell count of 18.2×109 /L (lymphocytes 7.5×109 /L, neutrophils 9.1×109 /L).
An urgent CTPA revealed a saddle embolus, with propagation of the clot
from the pulmonary valve extending into both main pulmonary arteries. An
abdominal ultrasound (US) shows the presence of hypoechoic lesions and
splenic infarction with blood (arrow) between the spleen and diaphragm.
Bone marrow aspirate showed increased number of B lymphocytes 72%,
with dysplastic features. Immunophenotype was CD22+, CD5-, CD23-,
CD10+. Histology of lymph nodes prompted the diagnosis of FL. RESULTS
Treatment with enoxaparin 1 mg/Kg once daily was started.
Conclusions: Thrombotic complications can be the major cause of mor-
bidity and mortality as splenic infarction and PEA in follicular lymphoma
patients. In our opinion, a multidisciplinary collaboration between haema-
tologist, radiologist and cytologist is essential in order to obtain the diagno-
sis and rapidly to start treatment.
81. SSRIS AND DOACS: A DANGEROUS ASSOCIATION? A
CASE REPORT
Bondanese M. 1,2, Boccatonda A. 1,2, Dall’o’ F. 1,2, Angelucci E. 2,
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.
2
Clinica Medica, Ospedale Clinicizzato SS. Annunziata, Chieti
Case Description: A 84-year-old Caucasian man was admitted to our
Internal Medicine Department for gastrointestinal bleeding, dehydration
and worsening of general conditions. Medical history was characterized by
severe cognitive impairment due to Alzheimer’s disease, permanent atrial
fibrillation treated with direct oral anticoagulants (DOAC) and benign
prostatic hypertrophy. At physical examination, patient was stuporous but
without focal neurologic deficits. Skin and mucous membranes were dry
and dehydrated. At chest examination, vesicular murmur was diffusely
harsh, with no pathological noises. Heart beats were muffled in arrhythmic
succession, with badly evaluable pauses. No peripheral edema was present.
Abdomen examination was normal, apparently painless. At digital rectal
examination soft stool with red blood were detected. Abdomen x-ray did
not reveal findings suggesting the origin of intestinal bleeding or intesti-
nal perforation signs. Chest x-ray did not show inflammatory parenchymal
and pleural cavities alterations. Brain CT revealed no signs of hemorrhagic
lesions or edema, and no indirect signs of intra-cranial expansive lesions.
Blood tests revealed a significant anemia and thrombocytopenia (haemo-
globin: 8.7 g/dL; platelet count: 66 x 103, Table 1). Reticulocyte absolute
count (reticulocytes %: 2.62) and reticulocyte index (2.56) were performed
in order to study anemia and thrombocytopenia, but their results did not
support the hypothesis of hyporegenerative medullar disease. All the remai-
ning causes of thrombocytopenia, including those related to drugs, were
taken into account. By the analysis of collected data, escitalopram treatment
had been introduced about one month before, due to a form of depres-
sion linked to dementia. In the literature, some SSRIs have been related to
thrombocytopenia as a detrimental side effect. Therefore, escitalopram tre-
atment was withdrawn with a progressive increase of platelet count, and the
concurrent resolution of the GI bleeding. The patient was discharged on the
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
Poster
SSRI-induced thrombocytopenia and concomitant use of anticoagulant
and/or antiplatelet therapies, in order to prevent detrimental bleedings.
Because the absolute risk of gastrointestnal bleeds with SSRIs is low, precau-
tions are probably necessary only in high-risk patients, such as those with
peptic acid disease and those with a history of bleeds.
82. LOW MOLECULAR WEIGHT HEPARIN IN VERY
ELDERLY: IS IT REALLY SAFE?
Colombo G. 1, Arcudi S. 1, Rossio R. 1, Ferrari B. 1,2, Peyvandi F. 1,2,3
1
U.O.C. di Medicina Generale - Emostasi e Trombosi, Dipartimento di
Medicina Interna, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico di Milano, 2 Angelo Bianchi Bonomi Hemophilia and Thrombosis
Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di
Milano, 3 Luigi Villa Foundation, Fondazione IRCCS Cà Granda Ospedale
Maggiore Policlinico di Milano
A 92 year-old female in good general condition presented to our department
with a diagnosis of septic and hypovolemic shock in Clostridium Difficile
enterocolitis treated with metronidazole intravenous and oral vancomicina.
She was transferred from a subacute ward to our Internal Medicine Unit.
Her history was relevant for chronic bronchitis and previous pulmonary
embolism in oral anticoagulant therapy with rivaroxaban. Furthermore
during the period of rehabilitation, the stay was complicated by two episodes
of pulmonary infections: the first treated with piperacillin/tazobactam plus
levofloxacin and the second with ceftriaxone and azithromicina. At presen-
tation the patient was pale, with mild mental confusion, blood pressure was
65/30 mmHg, pulse rate 90 beats/min, respiratory rate 28 breaths/min, body
temperature was 38 C °. In our department blood test revealed: leucocyto-
sis (11 x 103mmc), increase in c-reactive protein (11 mg/dl), hemoglobin
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
days the oral anticoagulant therapy was switched to low molecular weight
heparin at a dose adjusted for age and renal function. An episode of paroxy-
smal atrial fibrillation without hemodynamic impairment occurred. After
ten days of recovery the hospitalization was complicated by syncope during
mobilization and the blood analysis revealed a worsening of anemia (hemo-
globin 8.5 g/dl from a baseline of 11.5 g/dl) for which the patient underwent
to a single blood transfusion. The day after the patients complained abdo-
minal pain and anterior wall bruising. She developed tachycardia (heart rate
100 beats/min) and hypotension (85/60mmHg). Firstly it was suspected a
recurrence of the recent septic shock in Clostridium Difficile enterocoli-
tis, but the clinic was progressively improved during hospitalization with a
reduction of the inflammatory index and a normalization of temperature.
The blood analyses confirmed worsening anemia (hemoglobin 7.3 g/dl),
prothrombin time (1.18 s), thrompoplastin time (1.19 a), fibrinogen 159
mg/dl. The patient was stabilized with inotropes and fluids. In the suspect
of gastrointestinal bleeding an abdomen computed tomography was perfor-
med showing a bilateral hematoma of the right muscles (18 cm x 14 cm). It
was subjected to angiography with embolization of both inferior epigastric
arteries The procedure was well tolerated and the patient recovered. She
was transferred to a rehabilitation facility (at discharge haemoglobin levels
were normalized, 10.5 g/dl). Overall she was transfused with six packer reb
blood cell units. Rectus muscles hematoma (RSH) is an uncommon cause of
abdominal pain. It is the result of bleeding from damage to the superior or
inferior epigastric arteries. Anticoagulation can be a predisposing factor or
the accidental intramuscular injection of low molecular weight heparin can
directly cause rectus sheath hematoma. Although rectus sheath hematoma
are mostly self limiting, mortality can reach 25%.
83. AN UNUSUAL CASE OF THROMBOSIS: “THE
FORGOTTEN DISEASE”
Dall’o’ F. 1,2, Boccatonda A. 1,2, Bondanese M. 1,2, Angelucci E. 2,
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
2
Clinica Medica, Ospedale Clinicizzato SS. Annunziata, Chieti
Case Description: A 85-year old male was admitted to our Internal Medi-
cine Department for the onset, two days before, of dyspnoea associated with
edema, pain and functional limitation to the right antero-lateral region
of the neck. Five days before, the patient had experienced odontalgia,
100
118° Congresso Nazionale - Società Italiana di Medicina Interna
dysphagia and fever up to 39 ° C. His medical history was characterized
by multinodular toxic goiter in hormone-reductive treatment. On arrival
at our Medicine Department, a bed-side point of care ultrasound was per-
formed showing a well structured trachea and a thrombosis of the right
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
with the anonymous veins, with eccentric hypodense image also compa-
tible with thrombus. Moreover, CT scan highlighted widespread edema of
lateral epidermal tissues at the right branch of the jaw, and right muscle
edema and signs of suspected para-pharyngeal involvement. Clinically,
patients displayed an ectopic swelling in the lower right dental arch site with
erythema and cellulite, with spontaneous pus drainage. A specialized den-
tistry examination confirmed the diagnosis of granuloma of the sixth lower
right dental tooth. Subsequently, the patient underwent dental surgery with
granuloma drainage. The cultures carried out on the drained material, reve-
aled a positivity to Fusobacterium Necrophorum. An empirical antibiotic
therapy with ceftriaxone and metronidazole was established, then confir-
med by the antibiogram result. At the same time, anticoagulant therapy was
introduced, firstly with enoxaparin, followed by direct oral anticoagulant
treatment. Patient was discharged on the 8th day in good clinical conditions.
Conclusion: Lemierre syndrome is a potentially fatal pathology following
a head/neck region infection, classically described as an internal jugular
vein thrombophlebitis, associated with an infection of the cervical region
extended to the chest. The syndrome is often caused by Gram - bacteria,
in particular Fusobacterium necrophorium. The etiopathogenesis is based
on the spread of the infection from the oropharynx through the tonsillary
veins and the jugular veins inside the neighboring and distal tissues (lungs,
joints). Since the introduction of antibiotic therapy for the treatment of
pharyngitis, the incidence of the syndrome has drastically reduced, thus
erning the title “the forgotten disease.”
84. RESULTS OF A PROPHYLACTIC PROTOCOL
FOR DENTAL CARE IN A PATIENT WITH LIGNEOUS
GINGIVITIS DUE TO SEVERE PLASMINOGEN
DEFICIENCY
Di Pasquale I. 1, Boscaro F. 1, Sivolella S. 2, Saggiorato G. 3,
De Biagi M. 2, Sartori M.T. 1
1
Clinical Medicine I, Department of Medicine, University of Padua, Italy;
2
Section of Dentistry, Department of Neurosciences, University of Padua,
Italy; 3Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine,
University of Padua, Italy
Background: Severe congenital plasminogen (PLG) deficiency causes a rare
disease, known as ligneous conjunctivitis, characterized by the growth of
fibrin rich pseudomembranes on mucosal surfaces. Besides of conjunctiva,
gums are often involved, leading to ligneous gingivitis (LG). Specific therapy
for LG is not established. We describe a prophylactic protocol with enoxapa-
rin and fresh frozen plasma (FFP) for dental invasive procedures in a patient
with LG due to PLG deficiency.
Methods: A 43 years old female with LG was referred to us in 2009. She had
ligneous conjunctivitis in childhood and ligneous cervicitis refractory to
conization. PLG antigen and activity levels, and PLG genetic analysis were
carried out. In order to prevent LG recurrence after dental invasive proce-
dures, a prophylactic treatment including 10 ml/kg bw FFP before and the
day after the intervention and enoxaparin 100 U/kg bw od for 20 days was
given in addition to proper mini-invasive dentistry techniques and implant
surgery.
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
in heterozygous level. Right tooth root extraction with gum suture was
performed in 2009, left molar tooth extraction and contralateral implant
positioning in 2012, and right molar tooth extraction in 2015. PLG activity
levels raised to about 46% two hours after FFP transfusion and returned to
baseline after 48 hours. Small gingival pseudomembranes developed soon
after interventions and disappeared within one week; no bleeding complica-
tions were seen. The patient denied FFP transfusion in 2015.
Conclusions: In our patient with LG, the adoption of combined hematolo-
gical and dentistry protocols appeared to be safe and effective in preventing
abnormal gingival pseudomembranes growth after dental interventions,
maintaining a good parodontal condition.
118° Congresso Nazionale - Società Italiana di Medicina Interna
85. A RARE CAUSE OF ABDOMINAL PAIN
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
Careggi
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
history and no pharmacological therapy. She had two previous similar epi-
sodes leading up to diagnosis of gallstones and she was waiting for cholecy-
stectomy. At physical examination vital signs were normal, except for fever
(38°C); pain was localized in the right subcostal region, without tenderness,
no Murphy’s or Blumberg’s sign, and normal peristalsis. Laboratory results
showed only a slight increase in gamma-GT, ALT, AST, and PT. Abdomi-
nal Ultrasounds showed a noncontracted gallbladder without lithiasis and
normal wall thickness, no biliary dilatation but portal vein dilatation. An
abdominal CT scan showed a splenic vein thrombosis, extended to superior
mesenteric vein and portal vein, with irregular early hepatic parenchyma
enhancement. We researched both inflammatory and paraneoplastic aetio-
logy of the vein thrombosis with upper and lower gastrointestinal endo-
scopy and mammography, both negative; magnetic resonance cholangio-
pancreatography ruled out biliar cancer showing ab-estrinseco compression
of principal biliar duct from periportal edema. Despite normal blood count
values she was studied for the presence of JAK2 mutations, reported as a
marker for occult myeloproliferative disorder in patients with splanchnic
venous thrombosis, resulting absent. Patient was treated with piperacil-
lin-tazobactam and fondaparinux with a gradual regression of pain and
fever. At discharge, patient was feeling well, recanalization of thrombosis
was documentend only on superior mesenteric vein, whereas splenic and
portal veins remained obstructed, so we advised to continue anticoagula-
tion at least for 3 months, suggesting a CT scan after three months.
86. A CASE OF PULMONARY EMBOLISM IN CEREBRAL
AMYLOID ANGIOPATHY: FOCUS ON ANTICOAGULANT
THERAPY
Spampinato M.D., De Giorgi A., Fabbian F., Bagnaresi I., Pasin M.,
Manfredini R.
Medical Clinic, S. Anna-Ferrara Hospital-University Hospital
Introduction: Cerebral amyloid angiopathy (CAA) is a clinical neurolo-
gic conditions related to cerebral deposition of different types of amyloid
protein. Amyloid β-protein (Aβ)-type represent the most commonly protein
found in older individuals usually localized in the leptomeningeal and
cortical vessels. Occipital and cerebellum lobes are preferentially affected,
whereas basal ganglia, thalamus, brainstem, and white matter are uncom-
mon localization of disease. CAA is present in 25% of patients with Alzhei-
mer disease. Lobar intracerebral hemorrhage represents the catastrophic
complication CAA-related in elderly patients.Anticoagulation therapy (AT)
appears generally unsafe, even for strong indications such as non-valvular
atrial fibrillation or pulmonary thromboembolism.
Case report: 70 years malewas admittedin our internal medicine ward for
cough andfever. Medical history demonstratedhypertension, post-trauma-
tic right hip prosthesis, previous episodes of pulmonary embolism following
deep-underwater diving, ischemic cardiomyopathy, previous occipital and
parietal cerebral hemorrhage.CAA lesions in temporal-occipital-parietal
bilaterallylobes related to previous microbleedingswere shown by brain
magnetic resonance.On the other hand, physical examination was unre-
markable. Being D-dimer value high legs color-doppler ultrasound (CDU)
and computer tomography (CT) pulmonary angiography were performed.
CDU showed a posterior tibial vein (1.4 mm) and a peroneal vein (2 mm)
thrombosis, while CT pulmonary angiography documented the presence
of isolated thromboembolic lesion. Moreover, some areas of interstitial thi-
ckening characterized as micro-nodularity adjacent to bronchiectasis were
showed in the pulmonary parenchyma. In order to define usefulness of AT,
HAS-BLED score was calculated. HAS-BLED was 4 (high risk of major ble-
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
venous thromboembolism.Risk-effectiveness ratio of AT in difficult to
define in CAA patients.Further case reports are needed in order to establish
the correct AT in patients with CAA.
Poster
87. CYTOMEGALOVIRUS-ASSOCIATED SPLANCHNIC
VEIN THROMBOSIS: CASE REPORTS
Tufano A., Contaldi P., Cerbone A. M., Di Minno G.
Regional Reference Centre for Coagulation Disorders. Department of Clinical
Medicine and Surgery. “Federico II” University Hospital, Naples, Italy
Background: Splanchnic vein thrombosis (SVT) typically occurs in patients
with cirrhosis, intra-abdominal inflammatory processes, cancer, prothrom-
botic disorders, and can be clinically silent or may present with abdomi-
nal pain, fever and other non-specific symptoms. Acute cytomegalovirus
(CMV) infection has been reported to be associated with venous throm-
botic events in immunocompromised patients; these events mainly involve
the splanchnic veins, and less frequently, the lower limb deep veins, and
pulmonary circulation. However, venous thromboembolism during CMV
infection is increasingly reported in immunocompetent adults in which
thrombotic events often have acquired/inherited predisposing factors other
than the infection.
Methods: We described two young immune-competent patients who expe-
rienced an episode of SVT associated with acute CMV infection. Case I. A
40-year-old man with fever, abdominal pain and diarrhea was admitted to
our Department of Internal Medicine on 12 May 2012. He had been treated
ineffectively with antibiotics in the previous weeks. His past clinical history
included hypertension, obesity and he was carrier of beta-thalassemia. Al
admission, the patient had documented fever (>38 °C) and he complained
pain in right hip but there were no superficial lymphadenopathy on physical
examination. Blood tests revealed the presence of leukopenia with relative
lymphocytosis, elevated liver cytolysis indices, increased of lipase, amylase,
lactate dehydrogenase (LDH) and D-dimer. Chest x-ray and electrocardio-
gram were negative. A computed tomography (TC)- scan of his abdomen
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-
lipin antibodies (aCL) and lupus anticoagulant (LA), and antithrombin,
protein C, protein S, and homocysteine] was negative. Haematological
(bone marrow aspirate and JAK 2 mutation were normal) or neoplastic
diseases were excluded. Serological tests for HIV, hepatitis (A, B, C and
E), toxoplasma and EBV were normal. However, CMV serology revealed
high-titre IgM antibodies (100 IU/ml, with normal values < 12) with nega-
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
therapeutic doses of enoxaparin (8000 IU twice daily) and then warfarin.
The systemic symptoms gradually resolved without the need for gancyclo-
vir. After 6 months a complete resolution of the thrombus was showed at the
CT-scan and warfarin was discontinued. Case II. A 24 year-old female pre-
sented to the emergency room (ER) on 3 March 2011 with fever and abdo-
minal pain from a week, without changes in bowel habits. She was carrier of
beta-thalassemia and she reported a history of uterine myomas, gallbladder
stones, obesity. A biliary colic was hypothesized in a first moment, not con-
firmed at ultrasound (US) evaluation, while a urgent CT-scan of abdomen
demonstrated thrombosis of the inferior mesenteric vein, without extension
to portal and splenic veins. Use of OC was denied, hematological and neo-
plastic causes were excluded, and no other cardiovascular risk factors were
present. Serological tests for HIV, hepatitis (A, B, C and E), toxoplasma and
EBV were normal. However, CMV serology revealed high-titre IgM anti-
bodies (129 IU/ml, with normal values <12) with negative IgG antibodies,
suggesting acute infection. She was treated with low doses enoxaparin (4000
IU once daily), only for 2-3 weeks. On april 2015 the patient was referred to
our Department, because of the intention to become pregnant, and at this
time a thrombophilia work up showed heterozygous FII G20210A muta-
tion. A CT-scan of her abdomen showed resolution of the thrombus. She
was treated with enoxaparin 6000 IU once daily during pregnancy, without
thromboembolic recurrences.
Conclusions: Venous thromboembolism during CMV infection is incre-
asingly reported in immunocompetent adults and the diagnosis of SVT
in these cases should encourage the search for thrombophilic conditions
which might better guide the optimal management strategy.
88. RECURRENT PULMONARY EMBOLISM AND
Β-THALASSEMIA: A CASE REPORT
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
Poster
1
Department of Clinical Medicine and Surgery. Federico II University
Hospital, Naples, Italy 2Department of Advanced Biomedical Sciences.
Federico II University Hospital, Naples, Italy 3Department of Cardiology.
Seconda Università degli Studi, A.O.R.N. Monaldi, Napoli
Background: Adult patients with β-thalassemia are at increased risk of
thromboembolic events and pulmonary arterial hypertension (PAH), due
to a hypercoagulable state, including chronic platelet activation.
Case Report: A 54-yr-old man with β-thalassemia intermedia, splenecto-
mized 30 years earlier, and a history of unprovoked deep venous thrombosis
(DVT) complicated by pulmonary embolism (PE) at the age of 36, on long-
term vitamin K-Antagonists (VKA) during which two episodes of super-
ficial vein thrombosis (SVT) occurred, in the absence of known throm-
bophilia, was admitted to our Department in November 2016 because of
acute dyspnea. A CT-scan showed recurrent PE without DVT and at echo-
cardiography remarkably increased pulmonary arterial systolic pressure (88
mmHg) was found. VKA was stopped and the acute event was treated with
full dose enoxaparin and then apixaban (5 mg twice daily). Two months
later he was urgently re-admitted because of worsening dyspnea and PAH
(145 mmHg), with CT evidence of further PE recurrence. Cardiac catheteri-
zation confirmed chronic thromboembolic pulmonary hypertension. VKA
was reintroduced, but aspirin and riociguat were added, with symptomatic
and echocardiographic improvement during 3-mo follow-up.
Discussion: A chronic hypercoagulable state and platelet activation is
present in splenectomized patients with β-thalassemia. Thromboembolic
events and PAH represent common, yet poorly understood complications.
Data regarding the use of anticoagulants (VKA, heparins, direct oral anti-
coagulants) and antiplatelet agents to prevent/treat thromboembolic com-
plications in these patients are limited. The available evidence suggests that
adding aspirin may reduce the risk of recurrences.
89. PARANEOPLASTIC HYPOGLICEMIA: A SERIOUS
CHALLENGE FOR CLINICIANS
Boccatonda A. 1,2, Bondanese M. 1,2, Dall’o’ F. 1,2, Angelucci E. 2,
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. 2
Clinica Medica, Ospedale Clinicizzato SS. Annunziata, Chieti
Case Description: A 50 year-old woman, was admitted to our Internal
Medicine Department for recurrent and treatment-resistant hypoglycemic
crises leading to loss-of-consciousness. Medical history was characterized
by pancreatic malignant insulinoma with hepatic metastasis treated with
spleen preserving left pancreasectomy intervention and multiple liver meta-
stasectomy of III and IV hepatic segment and cholecystectomy. On admis-
sion, for the current symptoms, a re-staging total body TC was performed,
showing partially confluent secondary locations predominantly located in
the left hepatic lobe of which the largest is about 1.5 cm in diameter between
the II and III hepatic segment, and a number of secondary lesions located
in the right hepatic lobe, compared with the previous control. Initially the
patient was treated with infusion therapy of 33% and 5% glucose solutions
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.
Even this therapeutic strategy was associated with poor outcomes and poor
glycemic control. A subsequent oncologic evaluation suggested the addi-
tion of somatostatin analogue, lanreotide, on top of current therapy. There-
fore, even though the best medical therapy was set, according to literature
and guidelines, little clinical benefits were observed. For this reason, a left
hepatic lobe and branches for the IV hepatic segment chemoembolization
procedure was performed, with progressive benefit. Patient was discharged
on the eighteenth day in good clinical conditions with a good glycemic
control and sporadic hypoglycaemic episodes responding to food intake.
Discussion:The management of malignant insulinomas represents a serious
challenge for clinicians. Methods aimed at hypoglycemia prevention and tre-
atment include patient education, lifestyle modification, pharmacotherapy,
cytoreductive therapies and continuous glucose monitoring systems. When
the use pharmacotherapy is not sufficient to normalize glycemic control,
a decrease in hormonal secretion can be achieved by applying invasive
methods, i.e. debulking surgery and liver metastases chemoembolization.
102
118° Congresso Nazionale - Società Italiana di Medicina Interna
90. SINGLE ADMISSION, DOUBLE DIAGNOSIS
Brunelli V., Pirro L., Pontillo G., Pafundi P.C., Altruda C.,
Caturano A., Salvatore T., Adinolfi L.E.
University of Campania “Luigi Vanvitelli”, Naples Division of Internal
Medicine
In March 2017, a 67-year-old patient was admitted to our Division because of
subacute appearance of diplopia, asthenia and postural instability. On admis-
sion, vital signs were: blood pressure 115/65 mmHg, heart rate 62 bpm and
regular, 96% oxygen saturation, respiratory rate 16 breaths/min. The patient
had a 10-year history of type 2 diabetes mellitus, treated by dapaglifozin, and
past kidney stones. In the previous days, the patient had had fever (<38 C)
with nausea, vomiting and generalized malaise. At the physical examination,
ataxia, asymmetric finger chasing, bilateral deficit of III cranial nerves and
symmetrical areflexia of both upper and lower limbs were found. The patient
underwent a skull TC which showed a pituitary lesion of about 2-cm dia-
meter causing deformation of the sella turcica. Hence, a diagnostic lumbar
puncture, an electromyography, and a research of antibodies against gan-
gliosides were done. At the same time, the patient started immunoglobulin
therapy. The lumbar puncture showed an albumin-cytological dissociation;
electromyography documented a widespread damage of peripheral nervous
fibers, with demyelination and axonal degeneration; anti-gangliosides antibo-
dies (GM1, GM2, GM3, GD1a, GD1b, GT1b, GQ1b) resulted negative. These
data, associated with the impressive clinical improvement obtained by immu-
noglobulin treatment, led us to diagnose a Miller Fisher syndrome, a variant
of the Guillan Barré syndrome. Apart from neurological problems, the patient
presented the following clinical picture: increase of acral bones with frontal
protrusions; size growth of hands, feet and nose; enlargement of the jaw with
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
MRI, which confirmed 25 x 22 mm lesion in the sella turcica, dislocating the
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
normal IGF-1 (146.6 ng /ml; n.v. 120-246) which was confirmed by glucose
tolerance test (GH t0 9.2 ng/ml, t30 8.5, t60 8.4, t90 9.1, t120 9.4; n.v. <1). The
diagnosis of acromegaly was performed. In addition, an increase in prolactin
(89.1 ng /ml; n.v. 4.1-18.4) as a consequence of pituitary peduncle diversion
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
pg /mL, n.v. <60; cortisol 13.4 mcg /dL, n.v. 4.5-24), and thyreotropic (TSH
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.
5.2-15.8) axes due to mass effect of pituitary adenoma, were found. These
data could explain hypotension, euglycaemia and the whole clinical status
of the patient, which in part differed from that expected in the acromegaly.
After complete remission of neurological picture, the patient started a hor-
monal replacement therapy (Cortisone acetate 25 mg/die and, a week later,
Levothyroxine 50 mcg/die) prior to be submitted to neurosurgical interven-
tion. The follow up documented a very good clinical outcome. In conclusion,
the appearance of a rare neurological clinical entity such as the Miller Fisher
syndrome allowed us to diagnose even a longstanding disease that slyly may
determine serious consequences in multiple organs such as acromegaly.
91. A BITTER SWEET DISEASE
Caturano A. 1, Brunelli V. 1, Spiezia S. 1, Solaro E. 1, Acierno C. 1,
De Sio C. 1, Pontillo G. 1, Giunta R. 1, Adinolfi L.E. 1, Sasso F.C. 1
University of Campania “Luigi Vanvitelli”, Naples Division of Internal
Medicine
On March 24, 2017, at morning fasting, the patient reported an episode
of loss of consciousness preceded by shivers and sweating. At Emergency
Room, the patient was rescued and found in a state of drowsiness and hypo-
glycemic crisis (30 mg / dl), a symptomatology that quickly regressed after
administration of a glucose solution. On March 31st, she practiced a day
hospital admissions at a diabetes clinic during which was showed a modest
increase in urinary methanephrenes, normal cortisolemia, HbA1c: 3.5%.
Currently, the patient reports headache, sweating and intense asthenia.
This symptoms quickly regress after sugar intake. The physical examina-
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
118° Congresso Nazionale - Società Italiana di Medicina Interna Poster

marked hypoglycemia (46 mg/dL) associated with hyperinsulinaemia (17
μU/mL) and hyperC-peptidemia (4.33 ng/mL), OGGT that initially showed
an increase in glucose level, insulin and c-peptide until the end of the first
hour, but then glucose started to lower more than the other parametres and
at the third hour the values were: glucose 34 mg/dL, insulin 60.6 μU/mL,
C-Peptide 8.0 ng/mL. Patient was studied by CT with contrast material, that
highlighted at the body-tail junction of the pancreas, dorsally with respect
to the main pancreatic duct and immediately below the splenic vein, the
presence of a solid nodular formation artery perfused, with a maximum
diameter of about 14 mm, and octreoscan that could not manage to iden-
tify APUD pathology in the resolution limits. These findings, despite the
negative octreoscan, allowed us to suppose that our patient was suffering
from insulinoma, a tumor of the pancreas that is derived from beta cells
and secretes insulin. It is a rare form of a neuroendocrine tumor. Most insu-
linomas are benign in that they grow exclusively at their origin within the
pancreas. The patient was referred to surgical intervention of distal pancre-
atectomy and the insulinoma was found as we suggested. After one month
follow up, the patient had not experienced any acute hypoglycemia.
hospitalization of serum calcium values, phosphorus, PTH until normaliza-
tion predi mission. It undertakes to treatment with cinacalcet discharge cp
30 cp 1 mg / day.
Discussion: Current international guidelines focus on normalizing serum
calcium by surgery and reducing the impact of PHPT on target tissues
with preservation of renal and skeletal health. The impact of a nonsurgi-
cal approach to lowering serum calcium is thus an important considera-
tion in the medical management of PHPT among those individuals with
clinically important hypercalcemia who are not candidates for parathyroid
surgery. Thus, cinacalcet would be a useful treatment option for subjects
who have hypercalcemia and have failed surgery or are unable to proceed
with surgery. In addition, in subjects with multiple endocrine neoplasia
(MEN), cinacalcet has been shown to be useful in delaying surgery, if neces-
sary, while maintaining normocalcemia. The dose regimens of cinacalcet
required to lower serum calcium in MEN1-associated PHPT appear to be
similar to those required in sporadic PHPT.
Conclusions: The authors present a case report of primary hyperpara-
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
Poster
94. THE CONSTELLATION OF SYMPTOMS AS A WHOLE:
AN EXAMPLE OF THE INTERNISTIC METHODOLOGICAL
APPROACH IN THE FIELD OF ENDOCRINOLOGICAL
DISORDERS
D’Onofrio F., Settimo E., Belfiore A., Buonamico P., Palmieri V.O.,
Minerva F., Pugliese S., Portincasa P.
Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human
Oncology, University of Bari Medical School
A 69 year old woman came to our attention for headache, hypertension,
weight loss, marked asthenia, hypersomnia, anasarca for about 1 year.
Medical history revealed diabetes mellitus type 2 and previous laryngeal
cancer. In the last few months she underwent cardiological visits, nephro-
logical visits, nutritionistic counseling that advised diet and weight loss that
did not resolve the symptoms. At our observation: BMI 41.2 kg/m2, PA:
145/90 mmHg, Fc: 70 bpm; routine laboratory examinations and thyroid
hormones were normal as well as ECG, echocardiogram, abdomen US. In
response to high pressure values associated with headache and visual distur-
bances, antihypertensive therapy was modified obtaining normal pressure
values. Despite the good reward, headache and visual disturbances persi-
sted and we prescribed visual field examination: “incomplete peripheral
narrowing in the right eye, superior emianopsia with involvement of the left
quadrant in the left eye”. The brain magnetic resonance showed “volumi-
nous pituitary adenoma (2.23 x 2.15 cm) with solid and cystic component
compressing the optical chiasm because of an initial sovrasellar growth”. We
proceeded with diagnostic study with second-level laboratory examinations
showing hypoadrenalism and hyperprolactinaemia: prolactin 1851 mlU / L
(v.n. 132-498), vasopressin <0.1 pg / ml (v.n. 0.10-4), cortisol 5.27 mcg/dl
(v.n. 6-10); while ACTH, FSH, LH, TSH, GH appeared in the normal range.
Pharmacological therapy with corton acetate (12.5 mg/die) was initiated
and neurochirurgical evaluation was indicated for the possible removal of
adenoma. Patient is currently under follow up.
Conclusion: the attention on the obesity and hypertension as isolated
symptoms, was possibly a confounding factor for the diagnose made by the
organ specialists. Our methodological approach focused on the symptoms
as a whole and allowed us to carry out the correct diagnostic procedure.
95. AN UNCOMMON CAUSE OF CARDIAC TAMPONADE
AND RECURRENT PERICARDITIS
Fanfani G., Malandrino D., Tozzetti C., Torri M., Poggesi L. Dipartimento
DAI Emergenza ed Accettazione, AOU Careggi, Università degli studi di
Firenze
We reported a case of a 28-year-old woman presenting to the emergency
department (ER) for thoracic pain. Her past history was notable for recent
amenorrhea and a family history of Hashimoto thyroiditis. In the ER she
underwent hemodynamic instability with severe hypotension, tachycardia
and respiratory failure needing oro-tracheal intubation; a cardiac tampo-
nade was found and treated with pericardiocentesis. Further laboratory
tests, according to family history, revealed severe autoimmune hypothyroi-
dism (TSH 72 mU/L, anti-thyroglobulin 257 IU/mL, anti-peroxidase 1.207
IU/mL). Replacement therapy with levothyroxine was started.Two months
after discharge, skin hyperpigmentation, fatigue and hypotension occurred.
Further evaluation in our hospital revealed severe hyponatremia and low
serum cortisol with elevated adrenocorticotrophic hormone (ACTH 269
ng/L). Revaluation of CT scan obtained during first ER admission revealed
atrophic adrenal gland and adrenal insufficiency was diagnosed. Further-
more, the presence of elevated serum title of adrenal antibodies showed
autoimmune origin of the disease. Despite an initial improvement of clinical
conditions after hydrocortisone and fludrocortisone replacement, over the
follow up period of 3 years the patient also experienced a rare and relatively
recent described complication of Autoimmune Polyglandular Syndrome
(APS) type II: chronic recurrent pericarditis. APS type 2 (also known as Shi-
midt’s Syndrome), is a rare disorder that affects many hormone-producing
glands, described for the first time in 1926. It counts about 1.4-4.5 cases per
100.000 inhabitants and the female-to-man ratio is 3:1. It is characterized
by the obligatory occurrence of autoimmune Addison disease in combina-
tion with thyroid autoimmune diseases (Hashimoto thyroiditis) and/or type
1 diabetes mellitus; primary hypogonadism, myasthenia gravis, and celiac
disease also are commonly observed in this syndrome. The most serious
form of first manifestation is Addison’s crisis, a life threatening condition
that must be promptly recognized and treated. Regarding the imaging tech-
niques, computed tomography (CT) is able to show the involved adrenal
104
118° Congresso Nazionale - Società Italiana di Medicina Interna
glands with a remarkable improvement in the diagnosis and characteriza-
tion of adrenal insufficiency. Although cardiac tamponade and recurrent
pericarditis are not considered a key manifestations of the autoimmune
polyglandular syndrome (APS) type II, our findings, according to recent
literature, suggest that APS II should be considered in the differential dia-
gnosis of these clinical features.
96. SEVERE HYPOKALEMIA FROM HASHIMOTO
THYROIDITIS COMPLICATED BY LIFE-THREATENING
SUSTAINED VENTRICULAR TACHYCARDIA
A. Grembiale, E. Corigliano, A. Franchi, D. Siclari, M. Nocera,
A. Galdieri, R. Costa, G.F. Mauro
U.O.C. di Medicina Interna - P.O. “San Giovanni di Dio” - Azienda Sanitaria
Provinciale di Crotone
Introduction: There are a few descriptions of fatal ventricular arrhythmias
in patients with thyrotoxicosis due to Graves’ disease, but only one case
with painless thyroiditis has been published. We herein describe a rare and
lifethreatening case of Hashimoto thyroiditis that was complicated by severe
hypokalemia and ventricular tachycardia (VT).
Case Report: A 37-year-old man presented with vomiting, palpitation,
weariness and lower extremity loss of strength. His blood pressure was
120/80 mmHg, and his pulse was 110 beats/min. He had not taken any
drugs, including diuretics. There was no family history of cardiovascular
disease. He did not have diarrhea or symptoms of thyrotoxicosis, such as
goiter, weight loss, tremors, or proptosis. The medical examination did not
reveal any disease, palpation of the thyroid did not reveal either tender-
ness or nodules. Initial laboratory analysis showed the following: sodium,
143 mEq/L; potassium, 1.26 mEq/L; chloride, 107.5 mEq/L; calcium, 10,
2 mg/dL. No anemia and normal kidney function. His 24 hours urine col-
lection potassium was 1762 mEq/24h. Blood gas analysis was normal. The
initial ECG showed sinus tachycardia with depression of the ST segment,
a decrease in the amplitude of the T wave, and a prolonged QT interval.
One hour later, during electrolyte correction, the patient lost consciousness
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
rhythm with a normal QT interval (corrected QT interval =413 msec).
An echocardiogram showed normal cardiac function without evidence of
structural heart disease. His thyroid function tests showed the following
levels: thyroid-stimulating hormone (TSH), 0.07 μIU/mL (normal range
0.4 - 4.0); free thyroxine (fT4), 3.44 ng/dL (normal range 0.8-1.76); and free
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
antibody and anti-thyroglobulin antibody were normal, while Thyroid
peroxidase antibody (Ab antiTPO) was 287 IU/mL. A thyroid ultrasound
showed a non homogeneous glandular parenchyma with marked and wide-
spread increase in vascularization. We suggest Hashimoto thyroiditis as the
cause of the patient’s thyrotoxicosis. We hypothesized that the hypokalemia
was the result of potassium redistribution into the cells secondary to thyroi-
ditis and due to gastrointestinal and urinary potassium loss. The patient was
treated with oral and intravenous potassium chloride, continuous electro-
cardiograph (ECG) monitoring, and regular serum potassium level checks.
Anti-thyroid drugs were administered until euthyroidism is restored.
Brief Discussion: Hashimoto’s thyroiditis (HT) is part of the spectrum of
chronic autoimmune thyroid diseases and is associated with various degrees
of thyroid hypofunction, with thyroid autoantibodies production like the
most common, thyroid peroxidase antibodies (TPO-Ab) and thyroglobu-
lin antibodies (Tg-Ab) and with lymphocytic infiltration. The diagnosis of
Hashimoto thyroiditis is based upon clinical manifestations and laboratory
findings. In patients with hyperthyroidism and without clinical manifesta-
tions of Graves’ disease, thyroid autoimmune tests is necessary to differen-
tiate thyroiditis from Graves’ disease. Hypokalemia during the transient
thyrotoxic phase of painless thyroiditis can cause thyrotoxic paralysis and
serious polymorphic VT. There have been a few reports of fatal ventricular
arrhythmias associated with hypokalemia and thyrotoxicosis due to Graves’
disease, but only one case of painless thyroiditis and no cases of Hashimoto
thyroiditis has been described. Sustained VT is a rapid and hemodynami-
cally unstable rhythm, and urgent cardioversion is usually necessary. It may
persist and can degenerate into ventricular fibrillation, which will lead to
sudden death in the absence of prompt treatment. Severe hypokalemia can
induce ventricular arrhythmias. In the Purkinje fibers of the cardiac con-
ducting system, hypokalemia causes depolarization and leads to increased
membrane excitability and arrhythmias. Hypokalemia delays ventricular
118° Congresso Nazionale - Società Italiana di Medicina Interna
repolarization by inhibiting potassium channel activity. In this case, severe
hypokalemia during the transient thyrotoxic phase of Hashimoto thyroidi-
tis caused life-threatening sustained VT requiring urgent pharmacological
cardioversion. Physicians should therefore pay attention to the possibility of
the development of life-threatening VT associated with hypokalemia in the
setting of autoimmune thyroiditis.
97. EFFICACY AND SAFETY OF INSULIN DEGLUDEC/
LIRAGLUTIDE (IDEGLIRA) VS BASAL–BOLUS (BB)
THERAPY IN PATIENTS WITH TYPE 2 DIABETES (T2D):
DUAL VII TRIAL (NCT02420262)
Consoli A. 1, Billings L.K. 2, Doshi A. 3, Gouet D. 4, Oviedo A. 5, Rodbard H. 6,
Tentolouris N. 7, Grøn R. 8, Halladin N. 8,
G. Lastoria 9, Jodar E. 9
Università Gabriele D’Annunzio di Chieti, 1NorthShore University
HealthSystem Evanston 2, IL/University of Chicago Pritzker School of
Medicine, Chicago, IL, USA. 3, PrimeCare Medical Group, Houston, TX,
USA, 4 La Rochelle Hospital, La Rochelle, France 5, Santojanni Hospital and
Cenudiab, Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina 6,
Endocrine and Metabolic Consultants, Rockville, MD, USA. 7, National and
Kapodistrian University of Athens, Medical School, Athens, Greece 7, Novo
Nordisk, Søborg, Denmark 8,
Novo Nordisk Medical Affairs Italy 9University Hospital Quiron Salud,
Madrid, Spain 10
In a 26-wk open-label trial, 506 patients (pts) with T2D uncontrolled on
metformin and 20-50 units (U) insulin glargine U100 (IGlar) were rando-
mized 1:1 to IDegLira or BB therapy (IGlar + insulin aspart up to 4 times
a day). Mean A1C decreased from 8.2% at baseline to 6.7% at end of trial
in both arms; non-inferiority (by <0.3%) for IDegLira was confirmed
(p<0.0001; Table). A similar proportion of pts achieved A1C targets with
IDegLira vs BB (66.0% vs 67.0% for <7%/49.6% vs 44.6% for ≤6.5% respecti-
vely). Total daily insulin dose was lower for IDegLira (40.4 U) vs BB (84.1
U) (p<0.0001). Body weight decreased with IDegLira and increased with
BB (p<0.0001); the rate of hypoglycemic episodes (HEs) was lower with
IDegLira vs BB (p<0.0001). More pts achieved a triple composite endpoint
(A1C <7% with no HE in the last 12 wks and no weight gain) with IDe-
gLira vs BB (38.2% vs 6.4%; odds ratio 10.39 [5.76; 18.75] p<0.0001). Mean
pre- to postprandial plasma glucose increment decreased more with BB vs
IDegLira (p=0.0032). SF-36 (mental component summary) and TRIM-D
(total scores) improved more with IDegLira vs BB (p=0.0074 and p<0.0001
respectively). Adverse event rates were similar. In conclusion, in pts with
A1C >7% on metformin and IGlar, IDegLira vs BB resulted in similar A1C
reductions, lower insulin dose, weight loss and lower risk of HEs.
98. A RARE COMPLICATION OF THYROID FINE NEEDLE
ASPIRATION: CASE REPORT
Conte M., Carella A.M., Damone F., Modola G., Florio C.,
Di Pumpo M., Nargiso M., De Luca P., Marinelli T., Melfitano A., Benvenuto
A.
Internal Medicine Department of “T. Masselli-Mascia” Hospital - San Severo
(Fg), Italy
Introduction: Fine needle aspiration biopsy (FNAB) is procedure of choice
in the management of thyroid nodules, because easy to perform and because
of its accuracy and cost-effectiveness. FNAB is generally a safe procedural,
however serious complication can occur.
Case presentation: a 56 year old man with nontoxic multinodular goiter
history comes to our observation complaining of fever and severe anterior
neck pain. About 2 weeks before he underwent FNAB of the right (TIR
2) and left (TIR 1) dominant nodules and soon after he reported a post
FNAB-hemorrhage of the left thyroid lobe. On examination, thyroid was
enlarged and painful; laboratory tests showed PCR 101 (0-5 mg/l), TSH 0.10
(0.3-5 μUI/ml) with normal FT4, FT3, thyroid peroxidase and thyroglobu-
lin antibodies. Thyroid Ultrasound (US) showed an heterogeneous glan-
dular echotexture with poorly defined hypoechoic areas with reduction or
complete absence of blood flow so that subacute thyroiditis was diagnosed.
Corticosteroid therapy was initiated with sudden resolution of fever and
neck pain. After one month, thyroid US follow-up examination demonstra-
ted a clear improvement in glandular echotexture; laboratory tests, simulta-
neous carried out, showed normal TSH, FT4 and FT3 values.
Discussion: Thyroiditis is uncommon adverse effect of FNAB with an inci-
Poster
dence of 1% of patients underwent FNAB and it occurs with painful swel-
ling associated with US signs of glandular inflammation. The mechanism of
post FNAB-thyroiditis is unknown; the potential release of thyroglobulin,
thyroid hormone stores and cytokines can trigger inflammatory respon-
ses resulting in thyroiditis. In our case thyroid hemorrhage could be one
mechanism by which the glandular parenchyma could be primed for an
inflammatory response.
Conclusion: As thyroid nodules are more commonly diagnosed and
patients are undergoing routine FNAB evaluation, Clinicians should be
aware of this rare complication, potentially emerging after thyroid FNAB.
99. INCIDENCE OF HYPOCALCEMIA AND
HYPERCALCEMIA IN ELDERLY HOSPITALIZED
PATIENTS
Catalano A., Chilà D., Basile G., Morabito N., Lasco A.,
Benvenga S., Loddo S.
Department of Clinical and Experimental Medicine, University of Messina,
Messina, Italy
Introduction: Calcium is the most abundant mineral in the body and plays
a role in the normal functioning of nerves, muscles, bone, blood coagula-
tion and in many enzymatic processes. Disorders of calcium metabolism
are frequently encountered in routine clinical practice; however limited data
come from hospitalized patients. Our aim was to evaluate the incidence of
hypocalcemia and hypercalcemia in a setting of elderly inpatients.
Methods: This retrospective study was based on the medical records of all
hospitalized subjects aged 65 years or over, between January 1, 2011 and
August 31, 2014. Measurements of serum calcium were carried out by a
single centralized laboratory. Hypocalcemia was defined by serum calcium
levels <8.2 mg/dl and hypercalcemia by serum calcium levels >10.4 mg/dl.
Albumin correction, when albumin levels were checked, was considered to
adjust serum calcium values.
Results: A total of 4205 subjects were considered. Hypocalcemia accounted
for 45.6% and hypercalcemia for 1.9% of recruited subjects over the entire
observation period. The incidence of hypocalcemia decreased over time
with an overall reduction of 17% between the first and the last year of the
study period, while the incidence of hypercalcemia remains stable. Cases of
hypocalcemia were reduced of 5% in the female, while increased of 5% in
the male at the end of the study.
Conclusions: Hypocalcemia appears as a relevant electrolytic disorder in
elderly inpatients. Despite increased awareness about pathologic conditions
affecting calcium homeostasis, physicians have to remind to prevent and
treat hypocalcemia due to its relevant lifetreateing consequences.
100. BODY COMPOSITION OF ITALIAN SOCCER
REFEREES
Mascherini G. 1, Petri C. 1, Pizzi A. 2, Castagna C. 2, Collina P. 3, Galanti G. 1
1
SODc Medicina dello Sport e dell’Esercizio Fisico - Dipartimento di
Medicina Sperimentale e Clinica - Università degli Studi di Firenze 2
Associazione Italiana Arbitri - Federazione Italiana Giuoco Calcio 3 Direttore
Commissione Arbitrale Union of European Football Associations (UEFA)
Purpose: Soccer is an endurance sport in which players perform activities
of varying intensity over a 90-min match, is one of the most popular pasti-
mes in the world. The referee is so important for this sport that without
him there is no match. The objective of the present study was determined
the body composition of official Italian soccer referees and compare their
changes through a regular season (T1, October; T2, December; T3, May)
with a team of the first Italian league.
Methods: 22 elite soccer referees from the Italian Association of Soccer
and 18 elite Soccer players are been enrolled in this study. The variables of
body mass, height, skinfold thicknesses, body girth (waist, hip and biceps)
were collected with the purpose of estimating Sum of skinfold thicknesses,
Fat Mass (FM %), Fat Mass (FM kg), Fat Mass index (FMI kg/h) and Free-
fat mass (FFM kg).
Results: We observed statistical differences in age (SR= 39.0 ± 3.6; SP=
27.0 ± 3.5; p= ≤ 0.005). In T1, T2 and T3 evaluation are been detected sta-
tistical differences if we compare the 2 groups (Table 1). During the season
in referees group are been observed statistical difference in body mass (T1,
77.4 ± 4.2; T2 78.1 ± 4.4; T3 78.3 ± 4.2 kg; p= < 0.005), waist circumference
(T1, 76.5 ± 2.3; T2 78.1 ± 2.9; T3 77.4 ± 2.6 cm; p= < 0.005) and free-fat
mass (T1, 66.7 ± 3.8 T2 67.6 ± 4.0; T3 67.1 ± 4.0 kg; p= < 0.005). In elite
105
Poster 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
118° Congresso Nazionale - Società Italiana di Medicina Interna
1
Sports Medicine Center - AOUC-University of Florence- 2Nephrology
Division _ AOUC. -Careggi Florence - 3 Sports Medicine Center-Clinical and
Experimental Department- University of Florence
Purpose: Transplantation is the final therapy of the Chronic Kidney Disease.
After surgical treatment, the mortality is anyway high as well the sarcopenia
that can be often found. These both conditions partecipate to reduce the
quality of life in renal tranplant recipients(RTR). Regular physical exercise
regimen is actualy prescribed to contrast these aspects.The study aims to
investigate the impact of partially supervised mixed exercise after 6 months
of training.
Methods: a group of 40 RTR were submitted to the exercise prescription
program following the ACSM guidelines. They, were periodically investiga-
ted at least every 6 months, by 2D Ecocardiographic exame, ECG treadmil
test, Bioimpendance analysis, Hand-Grip test, Chair-Test, BMI analysis and
skinfolds measure. After a first short period of supervision in a gym, the
patients were free to continue the exercise program, fast walking, in a unsu-
pervised way, 3 times a week, for at least 30 min per session at moderate
intensity.
Results: BMI was reduced (from 24, 19± 5to 24, 05± 3Kg/m2); triceps (7,
88±2 to 7, 22±3mm) and bicipital (15, 10±±7 to 14, 14±6 mm) folds reduced
significantly(p<0.01) A very significant improvement was observed in the
strenght and flexibility paramters (p<0.001) of the upper limbs; TBW reduced
significantly with an improvement of water’s tissue distribution. The main
echocardogarphic parameters were normal and maintain normal for all the
observational period (LVDd 48, 1±2 mm at T0 vs 48, 0±3 mm at T6; LVSd 29,
2±2 mm at T0 up to 29, 6±4 mm at T6; CMI form 112, 6±19 gr/ m2 to 110±11
gr/ m2; EF % 61, 9 ±4at To vs 61±2 at T6).
Conclusions: Moderate mixed exercise program produces, in RTR, an
evident positive effect in the muscles’ strenght. No detrimental effect has been
observed in the myocardial function.The data are suggestive for a constant
adhesion to the protocol, despite not supervised, and support the importance
to address the patients toward a regular sports medicine follow-up.
105. DEVELOPMENT OF THE “MEDICAL ATTITUDES
TOWARDS DEPRESCRIBING QUESTIONNAIRE”
(MATD-Q)
Agosti P. 1, D’Avanzo B. 2, Damanti S. 3, Vella F.S. 1, Suppressa P. 1,
Sabbà C. 1, Mannucci P.M. 4, Nobili A. 2
1
U.O.C. Medicina Interna Universitaria “C. Frugoni”, Dipartimento
Interdisciplinare di Medicina (DIM), Policlinico di Bari, Università
degli Studi di Bari “Aldo Moro”, Bari; 2 Laboratorio di Valutazione della
Qualità delle Cure e dei Servizi per l’Anziano, IRCCS Istituto di Ricerche
Farmacologiche Mario Negri, Milano; 3 U.O.C. Geriatria, Fondazione IRCCS
Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milano; 4 Direzione
Scientifica, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di
Milano, Milano
Polypharmacy is a common problem in older patients, related to a significant
risk of prescription of potentially inappropriate medications (PIMs), drug-
drug interactions (DDI), adverse drug reactions (ADRs), reduced adherence
Poster
to treatments, falls, cognitive impairment, frailty, lower quality of life, re-ho-
spitalizations and increased mortality.In the last years, a growing interest on
deprescribing has been envisaged as a potential solution for polypharmacy
consequences. Deprescribing is defined as “the process of withdrawal of
an inappropriate medication, supervised by a health care professional with
the goal of managing polypharmacy and improving outcomes” (Reeve E et
al, 2017). Despite several criteria and tools developed in order to support
therapy reconciliation and revision, and the growing evidence about safety
of these strategies, deprescribing is little implemented in clinical practice,
yet. In order to identify obstacles to its implementation in clinical practice,
qualitative research investigated experiences and opinions of physicians
concerning deprescribing. On a whole, there is interest in applying depre-
scribing strategies and several suggestions have been proposed to make it
more practicable. To our knowledge, only one questionnaire measuring
physicians’ attitudes and experiences about deprescribing was developed
in a very specific setting of care. No questionnaire on this topic has been
developed and validated in Italy. Therefore, we have developed the “Medical
Attitudes Towards Deprescribing Questionnaire” (MATD-Q), which aims to
describe Italian physicians’ attitudes towards deprescribing in older patients
with multimorbidity and polypharmacy. The MATD-Q, thought for general
practitioners, hospital and clinics geriatricians and internists, is meant to
investigate the point of view of a wide sample of physicians coming from dif-
ferent care settings and geographical areas, in order to define the skills to be
developed in training programs, and to assess the effectiveness of these inter-
ventions on professionals’ attitudes. In agreement with widely accepted pro-
cedures about questionnaires development, we defined the survey objective,
the target population, the themes, the related variables and items, expressed
to be easily understandable and consistent, and the appropriate response
modes. Thereafter, twenty-three physicians, amongst forty invited, gave fee-
dbacks on MATD_Q concerning items completeness, comprehensiveness
and redundancy, and time necessary to fill in, by means of a content validity
structured validated questionnaire (Rowe et al, 1993; O’Brien et al, 2012). A
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-
thies (PFAPA) syndrome is a likely autoimmune inflammatory syndrome
characterized by recurrent febrile attacks associated with oral aphtosis,
pharyngitis and laterocervical adenitis. The PFAPA diagnosis is based
on 5 clinical criteria, configuring Marshall’s Criteria. It is considered the
most common cause of recurrent febrile tonsillitis in childhood, although
many cases of patients with late onset disease have been reported in the
last period. The main therapeutic options for adult PFAPA syndrome are
NSAIDs, steroids, colchicine, IL-1 antagonists and tonsillectomy. However,
there are very few cases in adulthood described in Literature and there is
no scientific evidence about effectiveness of medical and surgical therapy
in such patients. The purpose of this work is to bring the experience of
our Center about the treatment of patients with Adult PFAPA syndrome.
Matherials and Methods We selected 48 adult patients with PFAPA syn-
drome, performing a retrospective analysis of our database. Patients inclu-
ded had to respond to the adapted Marshall Criteria, where the first crite-
rion was deliberately overlooked and the fifth criterion was retrospectively
applied. Patients were analyzed on the basis of response to medical therapy
(NSAIDs, steroids, colchicine, anti-IL-1) and surgical therapy. Results We
107
Poster 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
118° Congresso Nazionale - Società Italiana di Medicina Interna
the disappearance of pulmonary valve vegetations.
Conclusion: Long-term treatment with oral fluconazole may be effective
and safe for chronic systemic candidiasis.
110. SYSTEMIC VISCERAL TUBERCULOUS
LYMPHADENOPATHY - CASE REPORT
Crescenti A. 1, Crescenti F. 1, Garufi L. 2, Crescenti R. 3
1
Primary Care Asp Messina - 2 Resident Doctor In Medical Oncology - Aou
Policlinico Messina - 3 Departement Of Internal Medicine - Ao Papardo
Messina
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),
infectious (viral: mononucleosis, CMV, AIDS, rubella; bacterial: Strep-
tococci, salmonella, brucellosis, cat scratch disease; mycoses: chlamydia;
mycobacteria: tbc; parasites: toxoplasmosis, spirochete etc.). In the diffe-
rential diagnosis of lymphadenopathies, several factors need to be consi-
dered: patient’s age, the objective characteristics and the location of the
lymph node, the associated clinical features, the medical history and the
general examination, the hematochemical examinations, the instrumen-
tal investigations (ultrasound, x-ray, CT, MRI, PET), immunophenotypic
examinations of peripheral blood or in the marrow, biopsy investigations
(lymph node, marrow). The authors present a
Case Report: on a systemic visceral tuberculous lymphadenopathy,
emblematic how allowed the exact diagnosis. Recently, other similar cases
have been described in the literature (Qingxuan Wang et al., Systemic
Lymph node tuberculosis mimicking lymphoma with 18F-FDG PET / CT-
Medicine 95, n.9, March 2016, Rui-Ln Ding et al. Lymph node tuberculo-
sis mimicking malignancy on 18F-FDG PET / CT in two patients: a case
report - Experimental and therapeutic medicine 13: 3369-3373, 2017).
In these cases, patients subjected to PET examination which suspected a
lymphoma; in the case report presented, the authors followed a reasoned
clinical-diagnostic procedure with the use of instrumental and clinical-la-
boratory tests in steps. Case report: A 63-year-old African woman with
hypertensive and ischemic heart disease, with stent positioning about 5
years ago, has been diagnosed with asthenia, dyspnoea, fever for several
months; she had a recent hospitalization with diagnosis of left pleuritis
and atrial fibrillation crisis converted to sinus rhythm with amiodarone.
Following the onset of cardiopalm and dyspnea, she was hospitalized
for implantation of bicameral PM. After a few months of coughing per-
sistence, she performed Rx chest which documented right pulmonary
thickening with smooth margins and TC chest which highlighted the
presence of multiple bulky pathological lymph nodes in all mediastinal
stations, especially subcarenal about 5 cm and preaortic about 3 cm; lungs
appeared swollen for the bulky adenopathies, with the presence of a 1 cm
nodule in the middle lobe and two consolidations in the apical bilateral
regions. A thoracic and abdominal TC with mdc showed bilateral pre-
sence of pathological lymphnodes of maximal axial diameter of about 50
mm in the hilar stations, with many other lymphadenopathies with globu-
lar morphology in almost all mediastinal lymphnodes, the largest of which
in the prevascular left station of about 30x18 and in the subcarenal region
of about 42x25 mm; there was a nodular element of about 11 mm in the
medial segment of the middle lobe and apical on both sides; there were
various lymphadenopathies increased by volume with globular morpho-
logy, to the celiac tripod, in the middle mesenteric, paraortical, paracaval,
interaortical caval with axial diameter varying from about 18 mm to about
28 mm. Meanwhile, the patient had abdominal pain and two episodes of
melena for which she was hospitalized to Hematology for suspicion of
lymphoproliferative disease. The patient appeared in mediocre conditions,
epigastric pain regressed after endovenous administration of IPP. Oste-
omyelid biopsy did not show hematologic neoplasia, echocardiogram and
thoracic surgical examination confirmed the extensive lymph node lesion
in the subcarenal tracheal region, so mediastinal biopsy was performed
with cytologic examinations of bronchial emisystems. Mediastinal lym-
phonodal agobiopsia showed: fibrotic tissue totally occupied by chronic
granulomatous inflammation, epithelioid, focally necrotizing phenomena.
This framework posed the suspicion of Tbc disease for which intrader-
malization was performed according to Mantoux, which gave a positive
result. The patient was sent to the center of infectious diseases that diagno-
sed tuberculosis of mediastinal lymph nodes for which medical therapy
was undertaken with: amikacin, isoniazid, etambutol and pyrazinamide.
The patient was subjected to clinical follow-up with clinical controls by
general medicine’s doctor and internist specialist and hematochemical
Poster
controls of renal and hepatic function every 7 days. The infectious spe-
cialist performed clinical control every 30 days. After 20-30 days of treat-
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.
Discussion and Conclusions: Tuberculosis etiology should always be
considered in the differential diagnosis of lymphoproliferative diseases in
generalized lymphadenopathy, although in the case of tbc the visceral syste-
mic lymph node interest is not frequent, since lymph node involvement is
mostly on superficial stations such as laterocervical, axillary, and so on. The
authors followed a step-by-step diagnostic procedure, where the sure dia-
gnosis derived from the agobiopsia, whithout the use of PET examination,
as emerged from the latest literature data.
111. THE ROLE OF PET IN THE DIAGNOSTIC WORK-UP
OF FUO
Tafuri F. 1, Schiavone M. 2, Arcudi S. 1, Ferrari B. 1,2, Peyvandi F. 1,3
1
U.O.C. di Medicina Generale - Emostasi e Trombosi, Dipartimento di
Medicina Interna, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, Milano, 2 U.O.C. Malattie Cardiovascolari, Fondazione IRCCS
Ca’ Granda Ospedale Maggiore Policlinico, Milano, 3 Angelo Bianchi Bonomi
Hemophilia and Thrombosis Center, Luigi Villa Foundation, Fondazione
IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
A 81 year-old patient presented to our department with fever, asthenia and
weight loss (12 kg) with no associated signs of organ dysfunction. The fever
started few months before and was previously treated with cycles of empi-
rical antibiotics and paracetamol, with initial clinical response but subse-
quent relapse of fever and asthenia. When the patient was first evaluated
in the ER, a diagnosis of urinary tract infection (UTI) was made, based on
a urine culture positive for Aerococcus urinae; hence he was discharged
with targeted antibiotic therapy (levofloxacin). Based on the poor clinical
response, the patient was subsequently readmitted to the ER and then to our
Internal Medicine Unit. His medical history was relevant for severe mitral
regurgitation (NYHA class II), approached with a surgical intervention in
transsternal thoracotomy and valve repair by Carpentier-Edwards Physio
annuloplasty ring. The intervention was performed seven months before the
admission to our ward. He also suffered from abdominal aortic aneurysm,
treated with bifurcated endoprosthesis placement. After the cardiosurgical
operation, the patient started to suffer from Mild Cognitive Impairment
(MCI) multiple domain and anxious depressive state. Notably the patient
was known for a history of rheumatic polymyalgia, Jak2+ polycythemia
vera (in treatment with hydroxycarbamide) and previous prostatic cancer,
treated with surgery, radiotherapy and hormonotherapy, with negative fol-
low-up. On admission to our ward the patient was in good general condi-
tions, febrile but with no clear clinical signs of infection nor sepsis. A broad
spectrum antibiotic therapy with piperacillin/tazobactam was started.
Serum blood tests revealed an active inflammatory state (mild leukopenia
with absolute neutrophilia, increase of CRP, fibrinogen and procalcitonin;
renal and hepatic function and coagulation tests were normal). Blood, urine
and stools cultures were performed and resulted negative. In the following
days, no clinical nor biochemical response was observed despite antibio-
tic treatment. According to the past clinical history, a wide spectrum of
differential diagnosis was considered, so other tests were carried through:
prostatic specific antigen was in the normal range, chest and abdominal
CT scan showed calcified mediastinal lymph nodes, with no other relevant
abnormalities. Quantiferon test was inconclusive, nevertheless the patient
did not showed characteristic symptoms (cough, hemoptysis), nor signs
related to tuberculosis. Since the patient complained for aspecific stiffness
and fatigue all over the body, mainly to the shoulder girdle, a relapse of
rheumatic polymyalgia was considered, but autoimmune screening was
normal. Furthermore, blood CD34 count resulted normal, so a shift from
polycythemia vera to idiopatic myelofibrosis was considered unlikely. Since
fever persisted, a diagnosis of fever of unknown origin (FUO) was made.
According to literature, FUO is defined by a body temperature >38.3°C on
several occasions, with a duration of illness of at least 3 weeks and no dia-
gnosis within 1 week of hospital admission. Since endocarditis is one of the
most relevant causes of FUO, and given the patient clinical history, a tran-
sthoracic plus transesophageal echocardiography was performed, but did
not showed valve vegetations. At this stage, a 18-FDG-PET was considered,
even if its role is still debated [1, 2]: 18-FDG accumulated at osteomedullar
level in the sternum (SUV max 10.5), so a diagnosis of sternal osteomyelitis
was made with a high degree of certainty [1]. This diagnosis was compati-
ble with the patient clinical history of previous transsternal thoracotomy,
109
Poster
with subsequent metal wires placement. A therapy with daptomicin plus
ceftriaxone was then started, based on the isolation of Bacillus clausii and
Staphylococcus epidermidis in 2 out of 9 blood cultures. The patient was
then referred to Cardiovascular Surgery for specific treatment.
According to our experience, 18-FDG-PET was crucial for correct diagnosis
and treatment. Its role should be considered in the diagnostic work-up of
FUO, and standardised to balance radiation exposure and costs versus its
advantages.
[1] J Nucl Med. 2007 Jan;48(1):35-45. [2] Clin Radiol. 2017 Jun 7.
112. THREE DIFFERENT PRESENTATIONS OF AN OLD
DISEASE
Folli C. 1, Rovellini A. 1, Piconi S. 2, Monzani V. 1
1
IRCCS Fondazione Ca’ Granda - UO Medicina Interna ad Alta Intensità di
Cura - Milano. 2 Ospedale Sacco - UO di Infettivologia - Milano
We describe three different cases of patients admitted to our division of
High-Intensity Internal Medicine with a final diagnosis of tuberculosis
(TB). First case- A 30 yrs-old woman from Eritrea had a recent history of
migratory arthritis associated with painful nodes at the legs. ERS and CRP
were elevated; autoimmune screening and viral exams were negative. The
symptoms disappeared but were followed by fever and cough; a chest X-ray
showed pneumonia and pleural effusion (treated with levofloxacin with cli-
nical benefit); a little pericardial effusion was also present. After admission
to the hospital, a TC showed a mediastinal mass, partly colliquated, and
enlarged thoracic lymph nodes. Biopsy of a supra-clavicular lymph node
showed a necrotizing lymphadenitis granulomatous, gigantocellular (rese-
arch of BK was negative, as well as DNA of mycobacterium). Haematologic
malignancy, sarcoidosis, autoimmune diseases were excluded. As the dia-
gnosis remained unclear, the lymph node was extracted. Histologic findings
were similar to the previous ones. However, DNA of Mycobacterium tuber-
culosis was finally found positive. Specific therapy was therefore started.
Second case – A 34 yrs-old man from Bangladesh was admitted to hospital
with fever and left pleural effusion. Microbiological exams were negative.
After therapy with ceftriaxone the fever disappeared. A chest TC showed
pleural thickening of uncertain origin and absence of lung involvement;
a pleural biopsy excluded neoplastic problems, showing a granulomatous,
necrotizing reaction. Search for DNA of Mycobacterium tuberculosis was
positive and four-drug therapy for tuberculosis was started. Third case - A
28-year-old woman from Bangladesh presented with a 3-month history of
neck and lumbar back pain, progressively worsening. A right supra-clavicu-
lar enlarged lymph node was present. Magnetic Resonance Imaging showed
the presence of multifocal bone spinal lesions with extensive para-spinal
soft-tissue infiltration. Blood exams showed mild normochromic anemia
and increase of ESR and CRP. An isotope bone scan revealed multiple areas
of increased uptake in the skeletal system and in the cervical and mediasti-
nal lymph nodes. A thoracic contrast-enhanced CT-scan showed multiple
mediastinal lymphadenopathies with central colliquative aspects without
pulmonary parenchymal involvement. Histopathological examination of
the laterocervical lymph node was unconclusive, showing the presence of a
granulomatous inflammation with focal areas of necrosis. Histopatological
examination of bone lesions documented epithelioid granulomas with mul-
tinucleated giant cells; PCR amplification was positive for Mycobacterium
tubercolosis. A diagnosis of disseminated extrapulmonary tubercolosis
with multifocal bone and lymphnodal involvement was established; specific
antitubercolosis treatment was started. TB is still a significant public health
problem. Extrapulmonary TB is a rare manifestation. The diagnosis is chal-
lenging because symptoms may involve any segment or mimick other disea-
ses. Diagnostic delays and missed diagnosis are relatively common and they
can sometimes lead to a wrong and dangerous therapy (i.e. with steroids).
Diagnostic test results may be impaired by several factors. Tuberculin skin
test or Interferon Gamma realease assays such as Quantiferon may result
negative because of the immune suppression due to the severity of dissemi-
nated disease. Likewise, isolation of the bacilli in the bioptic samples may be
sub-optimal and it is therefore important to obtain good-quality biopsies.
Molecular exctraction is often necessary for the diagnosis of TB, that should
always be considered, particularly in patients from TB endemic regions.
113. WORSENING PNEUMONIA DESPITE ADEQUATE
ANTIBIOTIC TREATMENT: UNCOMMON PATHOGENS
COULD REQUIRE UNCOMMON TREATMENTS!
110
118° Congresso Nazionale - Società Italiana di Medicina Interna
Graziano D. 1,2, Mirijello A. 1, de Matthaeis A. 1, Molinaro F. 1, De Cata A. 1,
Inglese M. 1, Cela P. 1, Carughi S. 1, Varriale A. 1, Vendemiale G.2,3, De Cosmo
S. 1
1
Department of Medical Sciences, Unit of Internal Medicine, “Casa Sollievo
della Sofferenza” Research Institute General Hospital, San Giovanni Rotondo,
Italy. 2Internal Medicine and Geriatrics Residency School, University of
Foggia, Foggia, Italy. 3Chair of Internal Medicine Residency School and Post
Graduate School of Geriatrics, University of Foggia, Foggia, Italy
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-
tives, in the preceding 5 days he was experimenting fever and worsening
mental status.
Three days before, he has come to the ED complaining of fever and weak-
ness. Chest X-Ray showed a lower right lobe pneumonia. Room air oxygen
saturation and blood pressure were normal, thus he was discharged with
prescription of levofloxacin 750 mg od.
Patient’s medical history was notable for epilepsy since the age of 11 treated
with carbamazepine 700mg/day and phenobarbital 150mg/day. He was
a healthcare worker of our Hospital and had a 40 pack-year history of
smoking.
At the ED he was alert but confused and restless, poorly cooperative.
Blood pressure was 85/60 mmHg, HR 81 bpm, T 38°C, SatO2 91% (I.F:
0.21), respiratory rate 20/min. Lung examination: low-medium right lobe
coarse crackles associated with reduced-absent vesicular sounds on the
right base. A 12-lead ECG showed sinus rhythm, incomplete LBB, QTc
397msec. Laboratory tests: WBC 6790/mm3; PLT 136000/mm3; Na+ 130
mmol/l; GPT 127 U/l; GOT 246 U/l; GGT 289 U/l; LDH 464 U/I; CK
3049 U/l, fibrinogen 1357 mg/dl. Head CT scan excluded hemorrages or
focal parenchymal abnormalities. Chest X-Ray documented an extensive
consolidation involving mid and lower right lobes. CURB-65 score was 2
(confusion and low blood pressure).
The patient was admitted to our Internal Medicine Department with a
provisional diagnosis of pneumonia. At admission, clinical status was
moderately deteriorated: fever, confusional state, hypoxemic respiratory
failure [pH 7.49, pO2 55, pCO2 27.7, HCO3 20.90 (F.I:0.21)], hematuria
were present. Blood, sputum and urine cultures and urinary Legionella
antigen were collected before starting empirical antibiotic treatment.
Given the apparent inefficacy of levofloxacin, the unwitnessed fall in a
patient with a history of seizures, treatment with ceftriaxone 2g od + clari-
thromycin 500mg bid was prescribed, together with oxygen at 0.35 IF. We
performed bedside POCUS to exclude subdiaphragmatic fluid collection,
liver, kidney and spleen abscesses. An echocardiogram showed slight
mitral regurgitation without vegetations. C-reactive protein was signifi-
cantly elevated 44.80 mg/dl (n.v. <0.290), as well as procalcitonin 1.8 ng/
ml (n.v. <0.05). Legionella Urinary antigen was positive.
Respiratory failure worsened in the first 24h (need for 0.5 oxygen I.F.),
thus levofloxacin 750 mg/day plus ceftriaxone was prescribed instead of
clarithromycin.
Nevertheless, patient was persistently febrile for 5 days and combined
anti-Legionella treatment with macrolide+fluoroquinolone was started
monitoring cQT at ECG (max 447 msec).
Body temperature normalized after 36h, with a gradually improvement of
patient’s mental status, regression of hematuria (day 7), fever (day 8), and
respiratory failure (at day 12). Oxygen treatment was stopped at day 15.
Patient was discharged on day 16 with prescription of levofloxacin 750 mg/
day for 7 days. According to literature, Legionella pneumophila causes 2-9%
of atypical community-acquired pneumonia (CAP) which is commonly
severe enough to require hospitalization. Although being primarily a respi-
ratory infection, Legionellosis involves central nervous system (CNS) in up
to 50% of patients. A reversible diffuse encephalopathy is the most common
neurologic complication, but focal CNS involvement can sometimes be the
initial presentation. Other common features at presentation are hyponatre-
mia, elevated liver enzymes, hematuria, ECG abnormalities. Legionnaires
disease is more common in immunocompromised persons, in smokers,
and in those with chronic lung disease. Azithromycin (500 mg orally once
daily), clarithromycin (500 mg orally twice daily), or a fluoroquinolone (eg,
levofloxacin, 750 mg orally once daily), are the drugs of choice. Combined
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
of therapy is recommended for severe diseases or immunocompromised
patients.
118° Congresso Nazionale - Società Italiana di Medicina Interna
114. A CASE OF FEVER OF UNKNOWN ORIGIN: WHEN
TIMING OF IMAGING MAKES THE DIFFERENCE
Nuzzo M. 1, Passerini F. 1, Zimatore S. 2, D’Errico E. 3, Buonamico P. 1,
Minerva F. 1, Palmieri V.O. 1, Pugliese S. 1, Belfiore A. 1, Portincasa P. 1
1
Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human
Oncology, University of Bari “Aldo Moro” Medical School, Bari, Italy; 2Unit
of Neuroradiology, Aldo Moro University, Bari, Italy; 3Neurology Unit,
Department of Basic Medical Sciences, Neurosciences and Sense Organs,
University of Bari ‘Aldo Moro’, Italy
A 77-year-old man was admitted to the Internal Medicine Division from
Emergency Room. In the last ten days he developed hypotension, fever
(37.5°C) and low back pain. Symptoms persisted despite therapy with
NSAIDs and paracetamol. He had a history of rectal cancer treated with
surgery, radiotherapy and chemotherapy, iatrogenic La Peyronie syndrome,
colonic diverticular disease, multiple cervical discopathies, acute coronary
syndrome treated with PTCA and stenting, abdominal aortic aneurysm
treated with aorto-biiliac stent grafting, recent finding of a pulmonary
lesion on computed tomography (CT) scan. Physical examination revealed
fever (37.5°C), lumbar pain, neither stiff neck nor other signs of neurologi-
cal involvement. He was alert, cooperative and oriented. Laboratory tests
showed leukocytosis (25.13×109/L; normal range <9.8×109/L) and eleva-
ted C-reactive protein level (194.0 mg/L; normal range <2.9 mg/L). A chest
x-ray did not show signs of pneumonia. Two sets of blood cultures were
obtained every time the patient showed fever over 38°C. The initial dia-
gnostic hypotheses were: urosepsis, sepsis from aortic endograft infection
and spondylodiscitis, so an empirical antibiotic therapy was started with
ceftriaxone and levofloxacin. Urine analysis revealed neither bacteriuria nor
pyuria. Echocardiography excluded endocarditis. A CT scan with contrast
did not identify any source of fever. Blood and urine cultures did not detect
any bacterial or fungal strain and virologic blood tests were negative. A total
body CT/PET (positron emission tomography) scan found high Standard
Uptake Values in the right lung (where the pulmonary lesion had been
previously described) and in the Lumbar 3-Lumbar 4 region, close to the
aortic graft, with partial involvement of Lumbar 5-Sacral 1 vertebral bodies.
A first MRI (Magnetic Resonance Imaging) scan of the spine with gadoli-
nium was performed to confirm the hypothesis of spondylodiscitis, but it
showed only signs of osteochondritis in the Lumbar 5-Sacral 1 region. A
week after the admission there was a deterioration in neurological status,
with persistence of fever and lumbar pain. Assuming a condition of sepsis,
an antibiotic therapy with meropenem, linezolid and tigeciclin was started.
Considering the hypothesis of an acute cerebrovascular disease, a brain CT
scan was performed, showing only signs of chronic vascular encephalopa-
thy. Three days later the patient showed stiff neck and positive Lasegue sign.
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.
A lumbar puncture was performed: the cerebrospinal fluid (CSF) was clear
and slightly xantochromic, it showed an increased leukocyte count (150/
mm3;45% granulocytes, 55% lymphocytes), an increased protein level
(400 mg/dL), and a decreased glucose level (CSF glucose, 18 mg/dL; blood
glucose, 80 mg/dL); no organisms were observed on Gram stain; no bacte-
rial nor fungal strain were detected on CSF cultures and virologic tests on
CSF were negative. Only RT-PCR on CSF detected b-haemolytic strepto-
coccus group B (Streptococcus agalactiae). The antibiotic therapy on course
was continued. During the following days neurological status, lumbar pain
and neck stiffness gradually improved. At discharge the patient was alert,
oriented and cooperative, he did not report lumbar pain and the signs of
meningitis had disappeared. The diagnosis of spondylodiscitis and spinal
meningitis with encephalic extension would not have been possible without
careful follow up of clinical condition, a second brain and encephalic MRI
leading to lumbar puncture and close interaction with neurological advise.
115. SERUM-ASCITES VITAMIN D GRADIENT (SADG):
A NOVEL INDEX IN SPONTANEOUS BACTERIAL
PERITONITIS
Arcopinto A. 1, Buonomo R.A. 2, Salzano A. 1, Bobbio E. 1,
D’Assante R. 3, Marra A.M. 4, Gentile I. 2, Cittadini A. 1, Borgia G. 2
1
Dipartimento di Scienze Mediche Traslazionali - Università Federico II,
Napoli 2Dipartimento di Medicina Clinica e Chirurgica, Sezione di Malattie
Infettive, Università Federico II, Napoli 3Dipartimento di Cardiochirurgia,
IRCSS. San Donato Milanese, Milano 3IRCSS. SDN, Napoli
Poster
Spontaneous bacterial peritonitis (SBP) is the most frequent infection
complicating the clinical history of end-stage liver disease with incidence
ranging from 10 to 30% in hospitalized patients and a mortality rate up
to 46%. Guidelines for SBP treatment recommend prophylaxis with oral
norfloxacin 400 mg daily or cotrimoxazole 800/160 mg daily longlife.
Whether there are factors that may help clinician to discontinue this
secondary prophylaxis is still debated. The role of vitamin D (vitD) as a
risk factor for infections in patients with cirrhosis has been largely investi-
gated. Serum vitD levels are generally lower in cirrhotic patients compa-
red with controls. For this background knowledge about vitD and PBS and
for the recognized role of vitD in modulating the immune response, we
hypothesized that the difference between serum and ascites levels of vitD
(serum-ascites vitamin D gradient (SADG)) may add valuable informa-
tion in patients with SBP. We prospectively and consecutively enrolled 54
patients with cirrhosis and ascites with clinical indication for paracentesis.
PBS was diagnosed in 16/54 (29.6%) patients. By using the normative cut
off of 20 ng/mL, vitamin D deficiency (vitDD) was observed in the vast
majority of patients (n=49/54, 90.7%) regardless of SBP diagnosis, with
51, 8% of patients (n=28) having severe vitamin D deficiency (<10 ng/
mL). No difference was found in serum or ascites vitamin D in patients
with or without PBS (p=0.16 for both) In our population, SADG values
ranged between -14 to 12, with a median value of -2 and interquartile
range of -5.0 to 1.0 ng/mL. Patients with SBP showed a SADG remarkably
reduced compared to the ones with no SBP (-5.5 (-7.4; -3.3) vs -1.4 (-3;
3.1), p=0.001. The only other variable associated to PBS was Child class
(B or C) (X2 = 9.3, p =0.002). We demonstrated that SADG is lower in
patients affected by SBP when compared to patients with cirrhosis and
ascites without SBP, whereas circulating and ascites levels of vitamin D
were not different between subgroups (see table). This is, at our knowle-
dge, the first study in which SADG is measured and a potential clinical
use proposed. This is a hypothesis-generating pilot study. The clinical que-
stions directly deriving from this preliminary study could be: 1) Is SADG
a useful index to identify patients at risk of PBS recurrence? 2) is vitamin
D supplementation a viable therapeutic strategy to prevent a first episode
or a recurrence of PBS?
PBS (n=16) No PBS  p
(n=37)
Age (years)   66.0±6.6       65.7±11.2      0.87
Child Pugh (n B/C class)   6/10 29/8     0.002
PCR levels    3.5 (2.3; 6.0)        1.5 (0.6; 3.4)        0.039    
Serum vitamin D levels    8.1±6.2        11.0±6.9        0.166    
Ascites vitamin D levels        13.7±7.5        10.7±7.1        0.164    
Serum-Ascites vit.D gradient    -5.5 (-7.4; -3.3)        -1.4 (-3; 3.1)       0.001     
(SADG)
116. INHIBITION OF NUCLEAR FACTOR (ERYTHROID-
DERIVED-2)-LIKE 2 (NRF2) PROMOTES TRANS-
DIFFERENTIATION OF HEPATOCYTE-LIKE CELLS
Bellanti F. 1, di Bello G. 1, Tamborra R. 1, Blonda M. 1, Pannone G. 2,
Vendemiale G. 1, Serviddio G. 1
1
Centre for Experimental and Regenerative Medicine, Institute of Internal
Medicine, Department of Medical and Surgical Sciences, University of
Foggia, Italy 2Pathology Unit, Department of Clinical and Experimental
Medicine, University of Foggia, Italy
Liver transplantation is still the only therapeutic option for liver failure.
There is a urgent need for liver transplants but a severe unavailability of
donor livers, which highlights the need to develop new therapeutic strate-
gies. Stem cells may be promising for patients with liver failure and cirrhosis,
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
unstable function and atypical morphology limit their usefulness. Stem cells
obtained from either adult or foetal liver are able to differentiate into hepa-
tocytes or bile duct cells. Nevertheless, their number within a normal liver is
very low, making their isolation and expansion challenging, and restricting
their application to small-scale use. The human bipotent liver progenitor
cell line HepaRG may be expanded and applied for hepatocyte differentia-
tion and transplantation testing.
Since redox-dependent signalling molecules are involved in the regulation
of stem cell self-renewal and differentiation, we studied the role of Nrf2 –
the main transcription factor involved in the oxidative stress response – in
111
Poster
the trans-differentiation process of hepatic progenitor cells. First of all, we obser-
ved that Nrf2 is active in the hepatic stem cell niche of healthy subjects, but it
seems down-regulated in patients with chronic hepatitis. We found that Nrf2 is
upregulated in undifferentiated HepaRG, which exhibit a lower mitochondrial
respiratory rate but a higher free radical production as compared to trans-diffe-
rentiated cells. Pharmacological and genetic inhibition of Nrf2 increases mito-
chondrial respiration, induces the expression of CD34, CD49a, CD49f, CD184
and EpCAM, and promotes the expression of cytochrome P450 3A4, albumin
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
cells, suggesting that this redox-dependent transcription factor may represent a
potential target to regulate the commitment of undifferentiated hepatic progeni-
tor cells into specific lineages.
117. A CASE OF SEVERE ANAEMIA
Bianchi P.I., Brocchieri A., Cagnoni F., Pasini S.M., Ferrari L., Guerrini C.,
Fugazza L.
U.O.C. di Medicina Generale, A.S.S.T. di Lodi, presidio ospedaliero di Lodi
A 65-years-old lady is admitted by the E.R. in the Internal Medicine Department
for “hypochromic anaemia”. At the entrance to the ward, the patients presents
stable, alert, orientated, pale and over-weighted (IMB 28, 9). By rectal explora-
tion normal-coloured stools are found. Recent medical history: Progressive lack
of energy and exertional dyspnoea. She already underwent to: Echocardiogram:
normal; exercise stress test: interrupted for exercise intolerance. For her skin
pallor, the Cardiologist suggested exams: Hb 4, 5 g/dL, MCV 66 fL (In 2015 Hb
was 12 g/dL, normocytic; on April 2016 Hb 9, 5, MCV 78 fL), normal white
blood cells and platelets counts, FOBT (negatives), thyroid function (normal). If
asked, she confirms episodes of black stools in the last months and fresh blood
spottings attributed to haemorrhoids. In the E.R. she also undergoes to:
- Chest X ray: mild increasing of vascular shadowing, emphysematous notes, and
obliteration of cost phrenic anterior angle.
- EKG: sinus rhythm 95 bpm
- Other blood exams: GFR 85 mL/min, PLT 123.000/mcL, INR 1, 33, PT 61%.
She is treated with 3 packed RBC transfusion, omeprazole 80 mg, crystalloids
500 mL. Past medical history: Arterial hypertension, type 2 diabetes mellitus
from 2002, COPD from 2011, hypercholesterolemia, carotid artery disease,
GERD. Never smoked, non alcohol-drinking, housewife. None familial patho-
logic history. Usual drugs: Apidra insulin 7-10-10 UI, Tresiba insulin 20 UI,
Dapaglifozin/metformin 5/1000 mg/d, ASA 100, enalapril 20, atorvastatin 10,
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
57, ALT 25, gGT 43, Al. P 67, cholinesterase 3200, LDH 231, total cholesterol
75, triglycerides 81, iron 23, transferrin 387, ferritin 3, reticulocytes 2, 45%, B12
vitamin 270, folate 6, TSH 2, 65.
- Hb 4, 7 MCV 68, Hct 17%, MCH 19, RDW 17%, PLT 104, WBC 5000 (normal
composition), proteins 6, 8 (Alb 2, 8, alfa 1 0, 1, alfa2, 0, 6, beta1, 0, 6 beta2 0, 6
gamma 2, 1 policlonal). ANA 1:80
- Upper endoscopy: oesophageal blue F1 varices. Absence of fundus varices.
Mild oedema and hyperaemic nodularities in antrum. Biopsies of antrum and
stomach body. First level research for aetiology of hepatic cirrhosis: HCV and
HbsAg (already negatives in 2014), autoimmunity, coeliac serology: all negatives
apart ANA 1:80.
- Lower endoscopy: Mild congestion of haemorrhoids of anus line.
- Enhanced CT scan of abdomen: liver presents enlarged dimensions, irregular
margins, no focal alterations. Enlarged gallbladder, in which is present a millime-
tric gallstone without biliary dilatation. Splenomegaly. By first level exams negati-
vity, there are also required: ENA abs, anti-dsDNA abs, Cuprum, ceruloplasmin,
alfa1-antitrypsin. Hepatic biopsy is under evaluation. The dosage of alfa1-anti-
trypsin shows a severe deficit. Therefore, the patients undergoes to:
- Chest HR CT scan: multiple cylindrical and varicoid bronchiectasis distribu-
ted along the whole parenchyma, especially in the poster basal left portion. The
bronchiectasis are clean. There are also some rare small cysts of airy content in
the lower lobes. No enlarged lymph nodes. No pleural or pericardial fluid.
- Spirometry and DLCO: normal volumes, except increased residual volume.
Moderate reduction of DLCO.
- 6 minutes walking test: no desaturation after a distance of 440 mts. Relief in 1
minute.
- echocardiogram to evaluated right sections: Minimum tricuspid regurgitation,
systolic PAP 20 mmHg + 0, TAPSE 22, 3. Diagnosis: Pancytopenia in hyper-
splenism and iron deficiency by portal hypertension. Child-Pugh A5 cirrhosis
and bronchiectasis associated to alfa1-antitrypsin-deficit (on going genetic defi-
112
118° Congresso Nazionale - Società Italiana di Medicina Interna
nition). The genetic test will show ZZ homozygosis.
Discussion: Usually we tend to consider less probable the diagnosis of a genetic
disease if presentation occurs in old age or incomplete form. Nevertheless
alfa1-antitrypsin-deficit is a not-so-rare cause of both hepatic cirrhosis and
COPD, with an extremely variable phenotype; in fact it can also occurs with
other pathogenic noxae and be synergic with them. Substitutive therapy impro-
ves COPD but not hepatic cirrhosis prognosis: therefore familial screening is
essential to guarantee an early diagnosis, at least for relatives.
118. HIGH PREVALENCE OF ADVANCED FIBROSIS AND
CIRRHOSIS IN TYPE 2 DIABETIC PATIENTS WITH NAFLD
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
Ospedale Maggiore Policlinico, Milano
Objective: to evaluate the prevalence and factors associated with significant-ad-
vanced fibrosis in patients with T2DM and NAFLD.
Methods: We retrospectively analyzed 87 consecutive patients, mean age 58±9
years, with biopsy proven NAFLD and T2DM from hepatology unit. Patients
underwent a complete clinical and biochemical evaluation at the time of liver
biopsy; other concomitant liver diseases were excluded.
Results: mean duration of diabetes before liver biopsy was 4.6±5.4 years; 9
patients were diagnosed with DM at the time of histology. Prevalence of NASH
was 44%, of significant-severe fibrosis (≥ F2) 60% and of cirrhosis (14%), despite
normal transaminases in 43% of patients. Patients were divided according to the
stage of fibrosis: moderate (F0-1) or significant-severe (F2-4). There were no
significant group differences regarding gender, lipid and glycemic profile, waist
circumference and BMI, platelets, fasting insulin, PNPLA3 genotype. Conver-
sely, patients with F2-F4 fibrosis had significantly higher AST (31±13 vs 43±26
UI/L, p=0.016) and age (55±8 vs 60±9 ys, p=0.006), and higher prevalence of
moderate-severe steatosis (43% vs 71%, p=0.014), NASH (20% vs 60%, p<0.001)
and metabolic syndrome (68% vs 92%, p=0.009). At logistic regression analysis
variables independently associated with significant-severe fibrosis were age (O.R.
1.068, 95%C.I. 1.005–1.134, p=0.033) and NASH (O.R. 3.836, 95% C.I. 1.304-
11.282, p=0.015).
Conclusion: NASH, significant-advanced fibrosis and cirrhosis, histologically
proven, are frequently present in patients with T2DM. Screening for diabetes in
NAFLD and viceversa is mandatory for an early diagnosis of potentially severe
liver disease, particularly with increasing age and even in presence of normal
transaminases.
119. FRAILTY INDEX IS A STRONG PREDICTOR OF
IN-HOSPITAL OUTCOMES AND MORTALITY AFTER
DISCHARGE IN CIRRHOTIC PATIENTS
Caccamo G. 1, Basile G. 2, Vadalà D. 1, Maimone S. 1, Sitajolo K. 1, Pitrone C. 1,
Squadrito G. 1, Raimondo G. 1
1
UOC di Epatologia Clinica e Biomolecolare -Dipartimento di Medicina Interna,
Azienda Ospedaliera Universitaria Policlinico G. Martino - Messina - Italia
2
UOC di Geriatria - Dipartimento di Medicina Interna, Azienda Ospedaliera
Universitaria Policlinico G. Martino - Messina - Italia
Background: Frailty is a multiply determined vulnerability state causing a higher
risk of adverse outcomes including death. Aim. To evaluate the impact of the
frailty measured by Rockwood frailty index (FI) on in-hospital outcomes and
mortality after discharge in a cohort of hospitalized cirrhotic patients.
Methods: We applied the FI to 101 cirrhotic patients (72% male; 65.6 years±12.2
SD) consecutively hospitalized from January to December 2015. Using medical,
nursing and laboratory records we estimated FI taking into account 45 potential
combinable deficits. The ratio between the number of deficits presented by each
patient and the 45 considered deficits corresponds to FI: a value >0.25 identifies
a frail patient.
Results: Cirrhosis was cryptogenic in 40% of cases; viral in 39%, alcoholic in
21%. CPT class distribution was 51A/30B/20C, median MELD score was
11.0(6.0-29.0). Thirty-five/101(34.6%) and 29/101(28.7%) patients were frail at
admission (FI-a) and discharge (FI-d), respectively. No difference was found in
FIa between CPT-B and C [16/30(53.3%) vs 15/20(75%), p=0.1]. Frail patients
had a longer in-hospital stay (17±14.8 vs 10.8±14.3 days; p=0.04); a higher pro-
bability of re-hospitalisation within 3 months [23/35(65.7%) vs 40/66(60.6%)
p=0.005]; a higher in-hospital mortality [5/35(14.3%) vs 2/66(3%), p=0.03]; a
higher mortality either at 3months [14/29 (48.3%) vs 8/72 (11.1%), p<.001],
6months [18/29(62.1%) vs 10/72(13.8%), p<.001], and 12months [18/29(62.1%)
118° Congresso Nazionale - Società Italiana di Medicina Interna Poster

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
Poster
Background and Aim: Direct-acting antivirals (DAAs) have revolutioni-
zed treatment for patients with chronic hepatitis C virus (HCV) infection,
extending the possibility of treatment to patients with cirrhosis. This study
assessed the compensation of cirrhosis after 1 year of treatment end with
DAA-based antiviral therapy in cirrhotic patients with chronic HCV
infection.
Methods: This observational multicenter cohort study included all conse-
cutive patients with chronic HCV infection and cirrhosis who underwent
antiviral therapy with second-generation DAAs. Data on all patients were
analyzed to assess compensation of cirrhosis (liver function: bilirubin,
INR, albumin, platelets, alanine aminotransferase (ALT) and MELD scores
between start of therapy to 12 months post-treatment end) and the occur-
rence of adverse outcomes (deaths, liver transplantation, hepatocellular car-
cinoma, serious decompensation events) within 1 year. Results Until June
2015, 66 cirrhotic patients (87, 8% Child-Pugh A; 18, 2% Child-Pugh B)
with chronic HCV infection started DAA-based treatment. A sustained
virological response was achieved in 93, 9% patients (62/64). After 1 year
of treatment end we observed a reduction of MELD scores [9 (6-16) vs 8
(6-19), p=0, 02], an increase in median values of albumin [4, 11 (2, 4-4, 7)
vs 4, 19 (3-3, 5), p=0.024] and a reduction in INR values [1, 1 (0, 95-1, 44)
vs 1, 05 (0, 8-1, 36), p=0.011] from baseline. These differences are not seen
when we considered the subgroup of patients with Child-Pugh B cirrho-
sis. During follow up 4/66 patients were diagnosed with an hepatocellular
carcinoma.
Conclusions: This study suggests that antiviral therapy in cirrhotic patients
with chronic HCV infection led to prolonged improvement in liver fun-
ction. If viral clearance is associated with a clinical benefit in patients with
decompensated cirrhosis (Child-Pugh B) remains to be determined.
123. UNRESECTABLE HEPATOCELLULAR CARCINOMA:
TRANSARTERIAL RADIOEMBOLIZATION VERSUS
CHEMOEMBOLIZATION
Elia C. 1, Salomone P. 2, Serraino C. 2, Cardellicchio A. 2,
Christian B. 2, Grosso M. 3, Fenoglio L. 2
1
Dipartimento di Medicina d’urgenza, ospedale Regina Montis Regalis,
ASLCN1, Mondovì, Cuneo 2Dipartimento di Medicina Interna, ospedale
Santa Croce Carle, Cuneo 3Dipartimento di Radiologia, ospedale Santa
Croce Carle, Cuneo
Hepatocellular carcinoma (HCC)- is recognized as one of the most-pre-
valent and lethal neoplasms worldwide. Prognosis and alocation of the
multiple available treatment options for patients with HCC are influenced
not only by tumour stage, but also by the degree of liver-function impair-
ment. According to theBCLC algorithm, transarterial chemoembolization
(TACE) is considered the standard treatment for intermediate-stage HCC,
Radioembolization (TARE) is a promising alternative that deserves further
prospective studies. We performed a prospective cohort study in a referral
center of all patients with unresectable HCC treated by TARE from 2010
to 2016. For comparison, one control groups of patients treated by TACE,
respectively, was also evaluated. Patients were followed up until death. The
primary outcome was survival; secondary outcomes were total hospitali-
zation time and post-treatment complications. We collected data from 390
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
TARE cohort versus TACE cohort (67% vs 48%), but the HCC in the Tare
cohort was bigger tham TACE cohort (7.8± 4, 3 vs 4.3±2.4) There was no
difference in the incidence of post-treatment nausea, vomiting, fever, or
other complications. The number of treatment sessions, the average rate of
treatment sessions per patient, total hospitalization time and rate of adverse
events were significantly higher in the TACE cohort. TARE appears to be a
safe alternative treatment to TACE with comparable complication profile,
but not for survival. Larger prospective trials, focusing on patient-reported
outcomes and cost-benefit analysis are required to consolidate these results.
124. ASSESSMENT OF VENTRICULO-ARTERIAL
COUPLING BEFORE AND AFTER ANTI-HCV THERAPY
Favretto S., De Vecchi F., Bellan M., Avitabile E., Marino P.N.,
Pirisi M.
Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale,
Novara
114
118° Congresso Nazionale - Società Italiana di Medicina Interna
Background: Growing evidence suggests a strong relationship between
HCV infection and cardiovascular disorders. Moreover, cardiovascular
abnormalities in advanced liver fibrosis (known as cirrhotic cardiomyopa-
thy, CCM) are characterized by hyperdinamic circulation featuring increa-
sed heart rate and high cardiac output, concomitant with decreased syste-
mic vascular resistance. Current criteria for cirrhotic cardiomyopathy focus
only on cardiac function without addressing the effect of hyperdynamic and
low-resistance circulation, also impaired systolic function in these patients
usually does not manifest at rest. Aims: We investigated characteristics of
the pressure-volume relationship in patients with advanced liver fibrosis
before and after anti-HCV therapy with direct antiviral agent (DAA). We
also compared the patients to a group of controls to assess wheather ventri-
culo-arterial parameters and advanced echocardiographic techniques (such
as 3D and peak longitudinal strain) were useful to describe the cardiovascu-
lar abnormalities in advanced liver cirrhosis.
Methods: We evaluated 34 consecutive cirrhotic (F4) or pre-cirrhotic (F3)
HCV patients (fibroscan>10 kPa) selected from Hepatology Clinic of the
Division “Medicina Interna 1” Ospedale Maggiore della Carità, Novara. All
the patients had compensated liver disease (CHILD A or B) and were treated
with “all oral” regimens for HCV virus (DAA) and reached sustained virolo-
gical response at 12-weeks after the end of treatment (SVR12). Patients with
history of heart failure, atrial fibrillation, cardiomiopathy, reduced left-ven-
tricular ejection fraction and significant valvular disease (more than mild
steno/insufficiency) were excluded from the study. We performed 3 echo-
cardiographic evaluation for each patient: before treatment, at the end of
therapy (ET) and at 12-weeks after the end of treatment (FU12). In addition
to the echocardiographic evaluations (as suggested by the American Society
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-
cular end-systolic elastance (Ees Sb), ventriculo-arterial coupling (EA/Ees
Sb) and cardiac work. Patients were compared to a small group of controls
(similar by age, sex, body mass index and prevalence of hypertension).
Results: Cirrotics and pre-cirrotics patients had significantly higher left
ventricular (LV) mass (p=0.004), interventricular septal (p=0.05) and LV
posterior wall thickness (p=0.03), left atrium area (p=0.05) and teledia-
stolic volume (p=0.02), while diastolic parameters (E/A ratio, deceleration
time and E/E’ ratio), LV ejection fraction and longitudinal strain were
similar to controls. Compared to controls, patients had reduced Ea/Ees
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
the ventricular-coupling variables are concerned. After DAA therapy, we
found a significant reduction in Ea/Ees sb (p<0.05) and an improvement
in myocardial efficiency (p=0.008) with a tendency towards reduction of
pressure-volume area (PVA, p=0.096) and oxygen consumption, estimated
by pressure work index (PWI). Moreover, the mean slope value of the PVA/
PWI relations, associated with chemomechanical transduction efficiencies
in a study on dogs by Wolff and colleagues, showed a change (although non
statistically significant, p=0.07) between pre-therapy and follow-up condi-
tions. Conclusions: Ventriculo-arterial coupling parameters seem to play a
role in detecting systolic cardiac impairment in the resting state in cirrhotic
patients. HCV eradication induce an improvement of myocardial efficiency
possibly by changing the ventricular-arterial coupling leading to a reduced
oxygen consumption after antiviral therapy.
125. SPLEEN DIMENSIONS ARE INVERSELY ASSOCIATED
WITH LYSOSOMAL ACID LIPASE ACTIVITY IN PATIENTS
WITH NON-ALCOHOLIC FATTY LIVER DISEASE
Baratta F. 1, Pastori D. 1, Polimeni L. 1, Tozzi G. 2, Novo M. 1,
Violi F 1, Angelico F. 3, Del Ben M. 1
1
Department of Internal Medicine and Medical Specialties, Sapienza
University, Rome, Italy; 2Unit for Neuromuscular and Neurodegenerative
Diseases, Children’s Hospital and Research Institute “Bambino Gesù”, Rome,
Italy; 3Department of Public Health and Infectious Diseases, Sapienza
University, Rome, Italy
Background: Fatty liver and splenomegaly are typical features of genetic
Lysosomal Acid Lipase (LAL) deficiency. No data in adult patients with
non-genetic reduction of LAL activity are available. We investigate the asso-
ciation between spleen dimensions and LAL activity in non-alcoholic fatty
liver disease (NAFLD) patients, in whom a reduced LAL activity has been
reported.
Methods: We included 425 consecutive patients who underwent abdominal
ultrasound to evaluate hepatic steatosis and spleen dimensions. LAL activity
118° Congresso Nazionale - Società Italiana di Medicina Interna
was measured with dried blood spot method (Lalistat2).
Results: NAFLD was present in 74.1% of screened patients. Higher median
spleen longitudinal diameter (10.6 vs. 9.9 cm; p<0.001) and spleen area
(SA) (32.7 vs. 27.7 cm2; p<0.001), together with a higher proportion of sple-
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
0.9 nmol/spot/h. LAL activity was higher in patients with SA above median
in comparison to those below median (1.0 vs. 0.8 nmol/spot/h, p<0.001).
A similar reduction was present in 56 patients with splenomegaly. At mul-
tivariable logistic regression analysis, age (OR:0.954; p=0.001), female sex
(OR:0.566; p=0.046), LAL activity below median (OR:2.064, p=0.010),
obesity (OR:2.764; p=0.001) and platelets (OR:0.995, p=0.036) were signifi-
cantly associated with SA above median. Similar results were obtained using
splenomegaly as dependent variable.
Conclusions: NAFLD patients disclose a relatively high prevalence of
spleen enlargement and splenomegaly, which were significantly associated
with a reduced LAL activity, suggesting that LAL may contribute to spleen
enlargement in this setting.
126. CEREBRAL VASCULAR RESISTANCE IS INCREASED
IN CIRRHOTIC PATIENTS WITH MINIMAL HEPATIC
ENCEPHALOPATHY AND REMAINS UNCHANGED AFTER
MEDICAL TREATMENT
Ponziani F.R. 1, Funaro B. 1, Ainora M.E. 1, Lupascu A. 2,
Riccardi L. 1, Annicchiarico B.E. 1, Garcovich M. 1, Quadarella A. 1, Siciliano
M. 1, Gasbarrini G. 3, Gasbarrini A. 1, Pompili M. 1,
Zocco M.A. 1
1
UOC di Medicina Interna, Gastroenterologia e Malattie del Fegato,
Policlinico A. Gemelli Università Cattolica del Sacro Cuore di Roma, 2UOC
di Clinica Medica e Malattie Vascolari, Policlinico A. Gemelli Università
Cattolica del sacro Cuore di Roma, 3Professore Emerito Università Cattolica
del Sacro Cuore di Roma
Background: In cirrhotic patients, cerebral vascular resistance indices (resi-
stivity index, RI and pulsatility index, PI) are good indicators of cerebral
hemodynamic abnormalities and are closely correlated with the severity of
cirrhosis, hepatic encephalopathy (HE) and ascites. However there are still
poor data about cerebral vascular indices and minimal HE (MHE). Aims:
The aim of this study was to correlate cerebral arteries resistance indices
with the presence of MHE and to evaluate their modification after treatment
with rifaximin.
Methods: 38 consecutive cirrhotic patients were enrolled in this study.
Exclusion criteria were overt HE (West Haven ≥ 1), age <18 years, active
alcohol consumption, sepsis, cerebrovascular diseases, cerebral neoplasms,
cardiac diseases, peripheral vascular diseases, treatment with rifaximin and
lactulose in the previous 30 days. Patients presenting signs of MHE at the
psychometric evaluation (TMT-A, TMT-B and DST) received rifaximin
1200 mg daily for 10 days. All patients underwent TCD for the measu-
rement of RI and PI of the mean cerebral artery (MCA) and of posterior
cerebral artery (PCA) at baseline and within 2 weeks after rifaximin treat-
ment. Median value of the right and left side arteries have been used for the
analysis. Intra-abdominal vessels (renal arteries, mesenteric artery, portal
vein) flow parameters were also assessed, and the Child-Pugh score was
calculated.
Results: Among the patients enrolled in the study 17 had MHE (44.7%).
MCA-PI, PCA-PI and RI were significantly increased in patients with MHE
compared to those without (MCA-PI 1.04 vs 1.05, p=0.05; PCA-PI 1.12 vs
0.9, p=0.02; PCA-RI 0.64 vs 0.56, p=0.01) while MCA-RI showed a trend
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
groups. Furthermore, cerebral arteries resistance indices were not associa-
ted with the Child-Pugh score. After treatment with rifaximin, TMT-A and
B and DST showed a significant improvement (p=0.05, p=0.03 and p=0.003
respectively). Only PCA-RI was ameliorated after rifaximin treatment
(p=0.024).
Conclusions: MHE is associated with increased cerebral vascular resistance
in cirrhotic patients, which remains substantially unchanged after medical
therapy.
127. LIVER STIFFNESS DECREASES IN PARALLEL
TO SERUM IP-10 CONCENTRATION FOLLOWING
TREATMENT OF HEPATITIS C WITH DIRECT ANTIVIRAL
AGENTS
Poster
Guaschino G. 1, Soddu D. 1, Tran Minh M. 1, Bellan M. 1,
Minisini R. 1, Barbaglia M. 1, Rigamonti C. 2, Pirisi M. 1,2
1
Department of Translational Medicine, Università del Piemonte Orientale, 2
Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
Rationale and Aim: It has been reported that liver stiffness measured
by transient elastography (TE, FibroScan®) decreases after direct antivi-
ral agents (DAA) treatment in patients with chronic hepatitis C (HCV);
whether this reduction reflects mainly reduced inflammation in the liver
has not been established. Interferon-gamma inducible protein 10 (IP-10) is
increased in HCV infection and correlates with hepatic inflammation. We
aimed to verify if changes in liver stiffness before and after DAA treatment
are paralleled by changes in IP10.
Methods: This retrospective study included 88 HCV patients (72% cirrho-
tics) who achieved sustained virological response (SVR) after DAA treat-
ment (started between February 2015 - May 2016) and underwent paired
TE and IP10 measurements before as well as 24 weeks after treatment with
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-
ked immunosorbent assay (normal value ≤100 pg/ml). Statistical analysis
was performed using SPSS 17.
Results: Eighty-eight patients were studied (59 males, median age 62 years)
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
kPa (range 8.8−75 kPa), 70 % had IP10 >100 pg/ml, median IP10 164 pg/
ml (20−1194pg/ml), platelet count 133000 /mcl (28000−359000/mcl). After
DAA treatment: 43% with TE >13 kPa, median TE 11 kPa (range 4.8−75
kPa), 8% with IP10 >100 pg/ml, median IP10 27 pg/ml (1−519 pg/ml), pla-
telet count 160000/mcl (33000-361 000/mcl). TE and IP10 values decreased
significantly after DAA treatment (p=0.0001), median change was -34%
(range -79 − +32%) for TE and -84 % (range -89 − +189%) for IP10. TE
decreased in 56%, increased in 2% and was stable in 42% of patients; IP10
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
IP10 were significantly correlated (r=0.23, p=0.02).Platelet count did not
significantly increase after treatment (median platelet count change +14%,
range -35 − +153%).
Conclusions: Decrease of TE after DAA treatment is paralleled by a decre-
ase in serum IP10 levels, suggesting that improvement of liver inflammation
may be a major determinant of TE reduction.
128. HARMFUL AND BENEFICIAL EFFECTS OF
ANTICOAGULATION IN PATIENTS WITH CIRRHOSIS
AND PORTAL VEIN THROMBOSIS
V. La Mura 1,2, S. Braham 3, G. Tosetti 1, F. Branchi 1, N. Bitto 2,
M. Moia 3, A.L. Fracanzani 4, M. Colombo 5, A. Tripodi 3,
M. Primignani 1
1
Division of Gastroenterology and Hepatology, IRCCS Fondazione Ospedale
Maggiore Milan 2 Internal Medicine, IRCCS San Donato, Department of
Biomedical Sciences for Health, University of Milan, San Donato Milanese,
Italy (current address for VLM) 3 Angelo Bianchi Bonomi Hemophilia and
Thrombosis Center, IRCCS Ca’ Granda Maggiore Hospital Foundation,
Department of Clinical Sciences and Community Health, University of
Milan, Milan, Italy 4 Internal Medicine, Department of Pathophysiology
and Transplantation, IRCCS Ca’ Granda Maggiore Hospital Foundation,
University of Milan, Milan, Italy 5 Department of Internal Medicine,
Humanitas Clinical and Research Center Rozzano, Italy
Background: Vitamin K antagonists (VKAs) may favor recanalization of
portal vein thrombosis (PVT) with a relative safety for upper-gastro-in-
testinal (GI) bleedings in cirrhotic patients on prophylaxis of varice-
al-hemorrhage. However, anticoagulation could be associated with other
major- and minor-bleedings that could counterbalance the benefits of
PVT-recanalization on cirrhosis. We aim to evaluate harmful and benefi-
cial effects of VKA in PVT-cirrhosis.
Patients and Methods: We Compared bleeding-risk of patients on VKA
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
of anticoagulation. One-hundred-thirty-nine cirrhotic patients not on
VKAs were controls in the analysis for any portal hypertension-rela-
ted event (LC-cohort). Survival analysis explored the impact of VKA in
115
Poster
PVT-cirrhosis.
Results: VTE- and PVT-cohort were comparable for age, gender and TTR
whereas VTE cohort had longer VKA-treatment (31.1+/-16.9 vs 23.3+/-
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%)
(p<0.05). Among major-bleedings, only those from upper-GI tract were
significantly higher in PVT- vs VTE-cohort. However, PVT- and LC-cohort
had the same upper-GI bleedings, suggesting that portal hypertension, but
not VKA, may account for the risk difference of major-bleeding between
PVT- vs VTE-cohort. Complete recanalization in PVT-patients on VKA
(n=31) independently predicted the highest portal hypertension-related
event/transplantation free-survival.
Conclusions: VKA may be responsible for a greater risk of minor-bleeding
in patients with PVT-cirrhosis compared with non-cirrhotic patients, but
this risk is counterbalanced by the benefit of PVT-recanalization.
129. IMPACT OF VONWILLEBRAND FACTOR/ADAMTS-
13 ON THE PRO-COAGULANT IMBALANCE DETECTED
IN CIRRHOSIS
La Mura V. 1, Tripodi A. 2, Bitto N. 1, Tosetti G. 3, Chantarangkul V. 2,
Baronciani L. 2, Valsecchi C. 2, Peyvandi F. 2, Salerno F. 1,
Lampertico P. 3, Colombo M. 3, Primignani M. 3
1
Internal Medicine-IRCCS San Donato, University of Milan, San Donato
Milanese (MI) 2Angelo Bianchi Bonomi Hemophilia and Thrombosis
Center-IRCCS Ca’ Granda Maggiore Hospital Foundation, Department of
Clinical Sciences and Community Health, University of Milan 3Division of
Gastroenterology and Hepatology-IRCCS Ca’ Granda Maggiore Hospital
Foundation, University of Milan
Background: Thrombomodulin-resistance (TM-R) has been associated
with the risk of de novo portal vein thrombosis and transplantation free
survival in cirrhosis. Von Willebrand factor (VWF), marker of endothelial
dysfunction, and its cleaving protease ADAMTS-13, are independent pre-
dictors of clinical outcome in cirrhosis confirming the potential pathoge-
nic role of hemostasis on liver damage. Our study aimed at exploring the
influence of VWF and ADAMTS-13 on the degree of TM-R along with the
severity of the chronic liver disease.
Patients and Methods: We prospectively collected clinical and laboratory
data of 79 patients (n° Child A/B/C = 29/35/15) (median MELD score
and range: 11; 6–28) consecutively admitted for endoscopic band ligation
of esophageal varices or paracentesis. All patients were in stable hemo-
dynamic conditions and without clinical evidence of bacterial infection.
Examinations included VWF (antigen, VWF:Ag, and activity, VWF:RCo)
(VWF:RCo/VWF:Ag was an estimate of highly active VWF), ADAMTS-
13 activity, the main pro-(FVIII, FII) and anticoagulants (antithrombin,
protein C). ETP-ratio (Endogenous thrombin Potential) with/without
thrombomodulin defined the degree of TM-R and was used to explore the
influence of VWF on pro-coagulant imbalance.
Results: Liver dysfunction was associated with high VWF:Ag, VWF:RCO
and low ADAMTS-13 (p<0.05). FVIII was the factor with the highest
degree of association with VWF:Ag, VWF:RCO independently from
MELD or Child-Pugh (multiple linear regression; p<0.001) in accor-
dance with the biological role of VWF protecting FVIII from degradation.
ADAMTS-13 negatively correlated with VWF:RCO/VWF:Ag ratio, an
indirect estimation of VWF-multimers. The thrombin generation curve
of patients with high VWF:Ag disclosed the lowest lag-time and time-
to-peak suggesting high reactivity of plasma for thrombin generation.
Interestingly, VWF positively correlated with the degree of TM-R inde-
pendently from the severity of liver dysfunction. Furthermore, it iden-
tified the highest proportion of patients with TM-R over 0.78 units, the
threshold of risk for thrombosis and severe clinical outcome. By contrary
ADAMTS-13 was not associated with TM-R.
Conclusions: VWF/ADAMTS-13 axis is impaired along with the severity
of liver dysfunction. VWF significantly influences the procoagulant imba-
lance detected in cirrhosis through high levels of FVIII.
130. A COMPLEX CASE OF ASCITES: MAY THE HEMODY-
NAMIC STUDY DISPEL OUR DOUBTS?
Triolo M. 1, Nicolini A. 2, Masarone M. 3, Caruso R. 3, Persico M. 3, Salerno F.
1
, La Mura V. 1
1
Internal Medicine, IRCCS-Policlinico San Donato, University Hospital,
Department of Biomedical Sciences for Health, University of Milan, San
116
118° Congresso Nazionale - Società Italiana di Medicina Interna
Donato Milanese (MI), Italy 2Radiology, Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico, University of Milan, Milan, Italy 3Internal
Medicine and Hepatology Unit, University of Salerno, Salerno, Italy
A 56-year-old man, active alcohol drinker of about 2 liters of wine/day for
more than ten-years and smoker of 30 cigarettes/day, presented with ascites
not responsive to diuretics in the last year. Up to 18 liters of ascites were
removed. Biochemistry disclosed a serum ascites albumin gradient (SAAG)>
1.1, total proteins 3.2 g/dL suggesting ascites secondary to post-hepatic
portal hypertension (SAAG> 1.1g/dL) with high protein content. Patient
referred the appearance of ascites after a significant weight loss (-20Kg) in
a previous period of 4 months. Biochemistry of ascites and the previous
history of weight loss called for a diagnostic work-up aimed at ruling-in/
out cirrhosis and/or other causes of ascites, among them, malignancy,
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
hypertensive gastropathy, nodular liver surface resembling cirrhosis and
partial portal vein thrombosis but normal spleen diameter. B-type natri-
uretic peptide was in the physiologic range, echocardiography negative
for systolic/diastolic dysfunction and/or indirect signs of pulmonary
hypertension. At this step, the diagnosis was: cirrhosis complicated by
ascites. MELD score was constantly 9 points. Portal vein thrombosis was
successfully treated by four months of enoxaparin 4000 U/day, however,
despite diuretic optimization, patient continued needing large volume
paracentesis every three-four weeks. The first biochemistry of ascites was
always confirmed and citology was constantly negative for malignancies.
Six months later, the patient was referred to our tertiary-care center for
transjugular intrahepatic porto-systemic shunt (TIPS) or liver transplan-
tation. The oncology work-up was repeated and confirmed negative for
any neoplastic process. CT-scan showed two interesting new data: 1) a
normal-sized spleen despite numerous periesophageal collateral circula-
tion; 2) a reduced volume pancreas with calcifications and ductal dila-
tation of Wirsung as chronic pancreatitis, compatible with the patient’s
history of chronic alcohol abuse. A nutritional counseling was requested
and an adequate dietary therapy set for suspected ascitic decompensation
at least in part due to severe pancreatic-insufficiency and malabsorption/
malnutrition. However, the dietary therapy allowed only a slight reduction
in the frequency of paracentesis, therefore, in the suspicion of a compo-
nent of post hepatic portal hypertension, a hepatic and systemic hemo-
dynamic study with transjugular biopsy were performed. The hemody-
namic study showed: liver wedge pressure 20 mmHg, hepatic vein free
pressure 11 mmHg (Hepatic Venous Pressure Gradient: 9 mmHg, below
the common threshold of clinically significant portal hypertension). The
Inferior vena cava pressure was 2 mmHg therefore the real transhepatic
gradient was 18 mmHg. The phlebographic study showed a threadlike
right hepatic vein, a well-represented but stenosed medium hepatic vein,
the catheterization of the left hepatic vein was unsuccessful. The histo-
logy showed: marked fibrotic component and cirrhotic evolution. Hence
hemodynamic and phebographic studies revealed an outflow problem of
the liver. At this point the therapeutic options were: 1) simple angiopla-
sty (PTA), 2) PTA with stenting, 3) TIPS with the aim to overcome the
stenosis by the stent allocation. At the beginning we opted for the first
approach. Manometry post-PTA showed a 50% reduction of the original
trans-hepatic pressure gradient. The patient maintained a stable weight
around 52 kg for one week after the procedure, however, weight-incre-
ase occurred again with need of two paracentesis of 10 L each in about
50 days. A TIPS was therefore positioned 2 months later by extending
the stent along the stenotic segment after PTA. A thrombophilic work-up
found a factor V Leiden mutation and finally we decided to chronically
treat the patient with enoxaparin at prophylactic dose.
Conclusion: The case allows a process of differential diagnosis of a complex
multifactorial ascites (cirrhosis, hepatic outflow obstruction, malabsorp-
tion). It confirms the orientation role for SAAG in the diagnostic work-up of
a patient with ascites and usefulness of hemodynamic+plebographic study
to go in depth of complex liver diseases.
131. ANALYSIS OF A PROSPECTIVE COHORT OF
PATIENTS WITH DRUG INDUCED LIVER INJURY AT A
SINGLE CENTRE
Licata A., Minissale M.G., Calvaruso V., Almasio P.L., Craxi A.
Gastroenterology & Hepatology Section, DIBIMIS, University of Palermo
Introduction: There are limited data about epidemiology, pathogenesis,
118° Congresso Nazionale - Società Italiana di Medicina Interna
clinical and prognostic assessment of drugs induced liver injury (DILI).
Some information comes from website or national registries such as DILIN,
Spanish, French, Japanese, and Icelander registries. We aimed to analyze
our cohort of DILI patients prospectively collected at our Department since
January 2000 to December 2016 to assess clinical features and evaluate
outcomes.
Methods: An electronic database was created to identify all suspected DILI
according to guidelines published on American College of Gastroentero-
logy. Patients after discharge were regularly followed at three-month inter-
vals for at least the first year.
Results: We detected presence of DILI in 185 patients out of 12.257 in-ho-
spital patients (females 56%; mean average age 53 years). At clinical presen-
tation, 57.8% showed liver damage of hepatocellular pattern, 18.3% chole-
static pattern and 23.2% mixed one. Among different classes of responsible
drugs, antibiotics were involved in 23.4% of cases, NSAIDs in 35.5%, immu-
nosuppressants in 10.9%, statins in 4.3%, anti-platelets and anti-psychiatric
drugs in 7.6% and other drugs in 9% (including herbal and dietary supple-
ments). In 25% of cases, two or more drugs were involved simultaneously.
One fifth of patients had concurrent chronic liver disease. We reported only
9 cases with acute liver failure (ALF): only two cases died, none was tran-
splanted but one died within waiting list. Patients with ALF were predomi-
nantly male (67%) with a mean age of 59 years. The most associated drugs
were NSAIDs (77%), and hepatocellular pattern was the most common
histological finding (78%). Six patients out of nine had previous chronic
liver disease. All patients with ALF showed jaundice, while 55% had liver
encephalopathy. Development of a chronic DILI was detected in 8% of all
patients. Among 50% of cases the culprit drugs were NSAIDs, antibiotics
were responsible for almost 40%. Among patients with chronic DILI, 16/185
(8.6%) developed drug induced autoimmune hepatitis (DIAIH). Patients
were mainly women, positive for non-organ specific autoantibodies, high
levels of transaminases and gamma-globulin, and treated with immunosup-
pression drugs for at least the first year.
Conclusions: The most common involved drugs in our DILI cohort were
antibiotics and NSAIDs, even if the increasing role of anti-platelets, psychia-
tric drugs, and herbal and dietary supplements was recorded. NSAIDs and
antibiotics were associated with poor prognosis, acute liver failure and chro-
nicity as compared to other drugs groups.
132. GLOBAL LONGITUDINAL STRAIN AS EARLY
MARKER OF CARDIOVASCULAR DAMAGE IN PATIENTS
WITH HCV-RELATED CIRRHOSIS
Minissale M.G. 1, Novo G. 2, Macaione F. 2, Giannitrapani L. 1,
Gnoffo F.P. 1, Zabara A. 1, Indovina F.S. 2, Novo S. 2, Montalto G. 1, Licata A. 1
1
Medicina Interna & Epatologia; 2Cardiologia; DIBIMIS, Università di
Palermo
Background: Patients with cirrhosis show diastolic and systolic dysfun-
ctions, which tends to manifest only under stress conditions, such as
infection, transjugular intrahepatic portosystemic shunt (TIPS) insertion,
liver or cardiac transplantation. In this study, we aim to identify, at an early
stage, a subclinical myocardial dysfunction and vascular alterations in
patients with compensated HCV-related cirrhosis to prevent decompensa-
tion of cirrhosis, heart failure and myocardial ischemia.
Methods: we compared 37 consecutive HCV-related compensated cirrho-
tic patients without previous cardiovascular events, with 32 healthy con-
trols, age and sex matched. All patients and controls underwent to clinical,
echocardiographic assessment including Global Longitudinal Strain (GLS)
to evaluate cardiac function and carotid artery scan to assess stiffness of
carotid arteries.
Results: Echocardiographic analysis showed that the left ventricle mass
index was pathologically higher in the HCV cirrhotic patients than con-
trols (111.81±25.53 vs 99.66±19.74; p = 0.037). There was an increase in
the left atrial volume index, in the right atrial volume index and in pulmo-
nary pressure in HCV cirrhotic patients as compared to controls, even if
between normal ranges (28.47±6.79vs 15.94±5.42; p <0.0001; 20.04±8.89 vs
12.74±4.70 p=0.0001; 32.49 ± 6:55 vs 27.50 ± 4.82, p<0.001 respectively).
HCV-related cirrhotic patients showed significant impairment of GLS as
compared to controls (- 18.42±2.48%, vs - 21.47±1.52 p+<0.0001), inde-
pendently associated with HCV related cirrhosis, and had a higher percen-
tage of grade I of diastolic dysfunction (50% vs 22%; p= 0.038). Concerning
vascular function, cirrhotic patients had a significantly increase of stiff-
ness index (14.35±6.16 vs. 9.03±2.52, p < 0.0001) and pulse wave velocity
(9.41±2.22 m/s vs. 7.01±1.38 m/s, p = 0.0001).
Conclusion: HCV-related cirrhotic patients present an impaired GLS,
Poster
expression of a subclinical systolic dysfunction and an increased local
vascular stiffness that may progress to vascular disease. Early detection of
these subclinical conditions might help to screen patients at high-risk to
develop heart failure and myocardial ischemia.
133. DRUG INDUCED LIVER INJURIES BY TICAGRELOR-
STATINS INTERACTION: A CASE REPORT
Minissale M.G., Serruto A., Montalto A., Soresi M., Montalto G.,
Licata A.
Internal Medicine & Hepatology, DIBIMIS, University of Palermo
Background: The anti-aggregant therapy with aspirin and inhibitor of
P2Y12 platelets receptor for ADP, such as ticagrelor, can be used to prevent
atherothrombotic events in patients with coronaric acute syndrome. Statins
are also recommended in these patients even if the safety profile is burdened
by the risk of drug interaction (CYP 3A4 inhibition by ticagrelor). Here, we
report a case of acute rabdomiolysis and hepatotoxicity in a woman with
a recent myocardial infarction treated with ticagrelor 90 mg twice daily,
aspirin 100 mg daily, atorvastatina 40 mg once daily.
Methods: We report a case of 68 old Caucasian woman with a diagnosis
of myocardial infarction and coronary percutaneous stenting treated with
ticagrelor and statins, complaining since the first month after discharging
of general illness, asthenia, nausea, myalgia, itching and epistaxis. For the
accentuation of these symptoms, in the following month she was admitted
to our Division of Internal Medicine.
Results: At admission, laboratory showed an eleveted value of CPK (100
upper normal limits), eleveted cytolytic and cholestatic values (AST/ALT
45-30 u.n.l, ggt 10 u.n.l, AP 2 u.n.l, bilirubin tot/ 4, 8 mg/dl), creatinine cle-
arance was 37, 3 mL/min/1, 73 m2. No history of alcohol or drug abuse was
reported; non-organ specific autoantibody (ANA, SMA, LKM) and viral
serology (HAV, HBV, HCV, CMV, HSV) were negative. According consen-
sus criteria for Drug Induced Liver Injury (DILI) patient was diagnosed as
suffering from a hepatocellular liver injury. RUCAM score was calculated as
11 (highly probable). Assuming an episode of interaction due to ticagrelor
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
within 15 days. Intravenous fluids and albumin were administered to avoid
acute kidney failure.
Discussion and Conclusions: Drug-drug interaction between ticagrelor
and atorvastatin caused certainly the development of muscle and liver inju-
ries. Physician should be informed of the possibility that the ticagrelor/statin
association even useful to prevent atherothrombotic events in patients with
coronaric acute syndrome could be cause muscle, liver and kidney injuries.
134. NON-INVASIVE SCREENING FOR NAFLD
AND SIGNIFICANT FIBROSIS BY TRANSIENT
ELASTOGRAPHY IN DIABETES IN PRIMARY CARE
SETTING
Lombardi R., Iuculano F., Pelusi S., Borroni V.N., Airaghi L.,
Bertelli C., Burdick L., Fatta E., Valenti L., Fargion S.,
Fracanzani A.L.
Department of Pathophysiology and Transplantation, Ca’ Granda IRCCS
Foundation, Policlinico Hospital University of Milan, Milan, Italy
Background: Diabetes is a known risk factor for the onset and progression
of non-alcoholic fatty liver disease (NAFLD) to non-alcoholic steatohe-
patitis (NASH) and liver fibrosis. Liver biopsy is the gold standard for the
staging of liver disease but it is not routinely applicable to the wide and
otherwise asymptomatic cohort of diabetic patients. We non-invasively
estimated prevalence and predictors of NAFLD and fibrosis in a cohort of
diabetic patients by using FibroScan®.
Methods: Ninety-seven consecutive patients attending the outpatient dia-
betes clinic and without any history of liver disease were enrolled over a
6-month period. All patients underwent liver ultrasound (US) and transient
elastography (FibroScan®), using the M probe or, in case of failure, the XL
probe. Controlled attenuation parameter (CAP) values >250 dB/m and liver
stiffness measurement (LSM) >7.9 kPa defined the presence of steatosis and
fibrosis, respectively. CAP values were then correlated to US steatosis.
Results: Mean age was 65± 6 years, 71% patients were males and all were on
anti diabetic therapy (oral agents in 84% and insulin in 16%). Hypertension
was present in 80%, dyslipidemia in 83%, 74% of whom on statins, overwei-
117
Poster
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
steatosis was 78% evaluated by CAP and 91% by US. CAP values significantly
correlated with US steatosis grades (p for trend=0.006) and were associated
at univariate analysis with BMI (p=0.05), ALT (p= 0.02), GGT (p=0.02) and
insulin levels (P=0.02) while at multivariate analysis only with insulin levels
(OR 1.14, 95% C.I. 1.0-1.3). Mean LSM was 5.5 ± 2 Kpa and 8 (9 %) patients
had values > 7.9. LSM values > 7.9 kPa were associated with BMI (p=0.001),
ALT (p=0.001), GGT (p=0.0001), insulin levels (p=0.001) and CAP values
(p=0.001), at age and gender adjusted analysis. Three of these patients
were classified as cirrhotics according to FibroScan® results. No association
between any anti-diabetic drugs and either steatosis or fibrosis was observed.
Conclusions: Liver damage is highly prevalent in diabetic patients as shown
by FibroScan®, which detects not only fibrosis but also steatosis. Given the
highly significant correlation between LSM values and liver tests, although
within normal ranges, studies are needed to define whether the use of
revised liver test cut-offs might increase the detection of liver damage in
these patients. A careful screening for liver disease in all diabetic patients
in primary care is mandatory also considering their high risk to develop
cirrhosis and hepatocellular carcinoma.
135. LARGE B CELLS NON-HODGKIN LYMPHOMA IN A
PATIENT WITH CHRONIC HBV INFECTION
Luglio C.V., Sciancalepore D., Sangineto M., Zingaro M.T., de Vincenzo
G.M., Perrone A., Suppressa P., Sabbà C., Napoli N.
Medicina Interna Universitaria “C. Frugoni”- Dipartimento Interdisciplinare
di Medicina - Università degli Studi di Bari “A. Moro”
A white male patient, aged 51, with a silent medical history, came to our atten-
tion complaining of cough, fever, abdominal and lumbar pain.In his family
history, it was to be noted that his father (75-year-old) died by cryptogenic
liver cirrhosis. At the physical examination, he showed a massive hard-elastic
palpable mass in right hypochondria extending up to the transverse umbilical
line, in addition to a peripheral lymphadenopathy in the latero-cervical, axil-
lary and inguinal region, bilaterally. Laboratory tests demonstrated hyperbi-
lirubinemia, mainly direct (total: 10, 86 mg/dl; direct: 8, 95 mg/dl; indirect 1,
91 mg/dl), increased values of transaminases (AST x 6.5; ALT x 4.0), gamma-
glutammiltranspeptidase -microglobulin (3, 29 mg/L). Hemoglobin (Hb =
12, 9 g/dL), platelet count (204 x 10³/uL) and total leukocyte count (5, 22 x
10³uL, neutrophils 80%, lymphocytes 10.5%) were normal. Viral serological
tests showed an active hepatitis B virus (HBV) infection as shown by the posi-
tivity for HBsAg (20133, 5 UI/mL; normal value <0.05 UI/mL), total-HBcAb,
HBeAb and HBV-DNA (8482 IU/mL). Hepatitis Delta virus (HDV), human
immunodeficiency virus (HIV) and hepatitis C virus (HCV) markers were
negative. Abdominal ultrasounds and Magnetic Resonance Imaging (MRI)
revealed massive lymphadenopathic conglomerate (diameter: 19x17 cm),
developed mainly intraperitoneal, with “casting” aspect along the mesenteric
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
the intra- and extrahepathic biliary ducts. Multiple abdominal mass biop-
sies revealed a diffuse large B cells non-Hodgkin lymphoma, fast-growing.
Positivity of CD20(+++), CD79a (+++), Bcl2(+++), Ki67>60%, Bcl6(+++),
CD10(+++), MUM-1(+-). Therefore the patient underwent to chemotherapy
with six cycles of R-CHOP (Rituximab, Ciclofosfamide, Doxorubicina, Vin-
cristina e Prednisolone) which allowed complete remission of lymphoma.
Antiviral treatment with Entecavir (0, 5 mg/day) was also started before the
onset of chermoterapy, with negativity of HBV-DNA. Up to now, two years
after chemotherapy, the patient doesn’t present any evidence of lymphoproli-
ferative disease recurrence and he is still being treated with Entecavir. Accor-
ding to the literature, our clinical case confirms the increased risk of develo-
ping B-cell NHL in chronic HBV infection and, particularelly, two subtypes:
diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL).
136. ADRENAL GLANDS MORPHOLOGY ASSESSED BY
COMPUTED TOMOGRAPHY IN STABLE CIRRHOTIC
PATIENTS
Marchisello S. 1, Privitera G. 1, Viglianesi A. 2, Paratore M. 1,
Spadaro L. 1, Purrello F. 1
1
Department of Clinical and Experimental Medicine, University of Catania,
Ospedale Garibaldi-Nesima, Catania, Italy; 2Department of Diagnostic and
Interventional Radiology, Ospedale Garibaldi-Nesima, Catania, Italy
118
118° Congresso Nazionale - Società Italiana di Medicina Interna
Background and Aims: Adrenal dysfunction has been described in liver
cirrhosis. The pathogenesis is still controversial. A structural damage of the
adrenal glands is one of the suggested pathologic mechanisms, but there are
no data about the morphology of adrenal glands in cirrhosis. The aim of our
study was to assess the morphology of the adrenal glands in cirrhotic patients
through the comparison with healthy control subjects and to investigate the
possible correlation between the features of the glands and adrenal function.
Patients and Methods: from 2014 to 2017, 66 consecutive cirrhotic patients
along with 33 healthy control subjects matched by age and gender were
enrolled for this prospectively designed study. The severity of liver disease
was evaluated by Child-Pugh and MELD score. The CT scan of the adrenal
glands was performed by a single senior radiologist “blinded” to the clinical
information. The parameters evaluated were: thickness of the glands (esti-
mated with reference to the protocol of Vincent et al.1), density (Hounsfield
Units), presence of structural abnormalities or masses. Adrenal function in
cirrhotic patients was assessed by the Standard Short Synacthen Test (SSST)
and by dosing ACTH levels.
Results: in cirrhotic population, the total thickness of the glands resulted
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,
though the difference reached the statistical significance only for the right
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
healthy controls (18.18%) we found an adrenal mass or adrenal hyperplasia.
Interestingly, there was an increase in the thickness of the adrenal glands with
the worsening of the severity of liver disease, independently from the age of
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-
lation between the total bilirubin levels and the width of the glands (r = 0.25;
p = 0.03). On the other hand, there was an inverse correlation between the
adrenal thickness and ACTH levels (r = 0.27; p = 0.03). Adrenal insufficiency
(AI) was found in 21 (31.8%) cirrhotic patients. Even though no statistically
significant difference in terms of thickness emerged in cirrhotic patients with
and without AI, patients low-responders to SSST showed higher density of
the glands (+ 22.73%).
Conclusions: for the first time in literature, to the best of our knowledge, our
study suggests that cirrhosis may influence both size and density of adrenal
glands. Specifically, these modifications are related not only to the severity
of the liver disease, but also to adrenal function, since people with AI shows
higher density of the glands. The hemodynamic changes could explain this
aspect due to possible microscopic hemorrhages. The chronic inflammatory
state typical of cirrhosis could play a role in increasing the thickness of the
glands by inducing hyperplasia or hypertrophy non ACTH-mediated. In
any event, further studies are needed.
References: 1. Vincent JM, Morrison ID, Armstrong P, et al. The size
of normal adrenal glands on computed tomography. Clin Radiol 1994;
49:453–455.
137. ORAL HEALTH EVALUATION AND TREATMENT IN
PATIENTS ELIGIBLE FOR LIVER TRANSPLANTATION: A
MONOCENTRIC EXPERIENCE
Passarelli P.C. 1, Marrone G. 2, Biolato M. 2, Liguori A. 2, Araneo C. 2,
Forte F. 2, Avolio W.A. 3, Agnes S. 3, D’Addona A. 1, Grieco A. 2
1
Department of Oral Surgery, Head and Neck Area, Fondazione
Policlinico A. Gemelli - Catholic University of the Sacred Heart, Rome
2
Gastroenterology Area, Fondazione Policlinico A. Gemelli – Catholic
University of the Sacred Heart, Rome 3 Division of General Surgery and
Organ Transplantation, Abdominal Surgery Area, Fondazione Policlinico A.
Gemelli – Catholic University of the Sacred Heart, Rome
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
preventive strategy implemented in our liver unit and leads to indication of
conservative treatment or extraction of dental elements otherwise not pre-
servable. In this study we conducted a retrospective analysis of oral health of
patients eligible for liver transplantation. Methods We enroll seventy-seven
patients eligible for liver transplantation between January 2015 and March
2017. For each patient we examined medical records, panoramic radio-
graphs and treatment performed. Results There have been carried out 420
extractions in 74/77 (96.1 %): the median of extracted teeth/patient was 8.
Dental caries afflicted 72/77 (93.5 %) of patients. At univariate analysis there
118° Congresso Nazionale - Società Italiana di Medicina Interna
was a significant association between smoking habit and number of decayed
teeth (p=0.05). In addiction the analysis showed that MELD score at time
of transplant is associated with number of teeth extracted (p=0.038) and
MELD score at time of listing for liver transplantation is associated with
number of decayed teeth (p=0.008). At last a reverse correlation was highli-
ghted between body weight and number of teeth extracted (p=0.031). Con-
clusions Oral health is a prominent need for patients eligible for liver tran-
splantation. Smoking habit is a key predictor factor of dental decay. Patients
with high MELD score and low body weight deserve particular attention
because of the higher number of dental extractions needed alongside the
higher risk both of complications and of worsening of nutritional status.
138. PREVALENCE AND SEVERITY OF LIVER INJURY
AFTER PULSED METHYLPREDNISOLONE THERAPY IN
MULTIPLE SCLEROSIS PATIENTS
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
1
Gastroenterology Area, Fondazione Policlinico A. Gemelli – Catholic
University of the Sacred Heart, Rome 2 Neuroscience Area, Fondazione
Policlinico A. Gemelli – Catholic University of the Sacred Heart, Rome
Background and Aims: Few cases of high dose pulsed methylprednisolo-
ne-related liver injury in patients with Multiple Sclerosis are reported in lite-
rature but a prospective investigation has never been performed. The aim of
the study is to evaluate the prevalence and severity of liver injury in patients
affected by Multiple Sclerosis and treated with pulsed methylprednisolone
because of clinical relapses.
Methods: Prospective observational single-center study on patients
with multiple sclerosis, in relapsing phase of the disease, treated with i.v.
methylprednisolone 1, 000 mg/day for 5 days. We tested liver function tests
(aspartate aminotransferase, alanine aminotransferase, alkaline phospha-
tase, total bilirubin) before treatment and after two weeks. In case of severe
liver injury, defined according to “Hy’s law”, a comprehensive hepatologic
work-up was performed.
Results: During 12 month observation period, we collected 251 cycles of
i.v. high dose steroid treatment from 175 patients (65.1% females, mean
age of 40.8 ± 12.2 years; mean Expanded disability status scale 2.8 ± 2.1).
After excluding 8 cycles presenting basal alteration of liver function tests,
serum aminotransferase elevation (any grade) was observed on twenty-one
cycles two weeks after methylprednisolone therapy (prevalence 8.6%). Six
of them (prevalence 2.5%) presented a severe liver injury according to Hy’s
law; after comprehensive hepatologic work-up, three out of them received a
final diagnosis of drug-induced liver injury and other three a final diagnosis
of autoimmune hepatitis.
Conclusions: Liver injury should be considered a possible adverse event
in patients with multiple sclerosis treated with pulsed methylprednisolone
therapy for clinical relapse. Aminotransferase monitoring two weeks after
pulsed methylprednisolone treatment is useful for clinical management.
139. ACUTE VIRAL HEPATITIS IN ITALY: PLEASE,
CONSIDER HEV. CASE SERIES
Marrone G. 1, Miele L. 1, Biolato M. 1, Liguori A. 1, Serricchio M.L. 1,
Bernardini F. 1, Rapaccini G.L. 1, Gasbarrini A. 1, Grieco A. 1
1
Gastroenterology Area, Fondazione Policlinico A. Gemelli – Catholic
University of the Sacred Heart, Rome
Introduction: HEV hepatitis is today considered the most common cause
of acute hepatitis worldwide. While it is endemic in developing countries,
where it is transmitted by oro-faecal route, in recent years it has been gra-
dually recognized also in developed countries. Four HEV genotypes have
been identified until now: genotype 1 and 2 are responsible of epidemic
forms in developing countries, genotype 3 and 4 are responsible of sporadic
forms in developed countries. Here we present a series of autochthonous
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
male, mean age 68.4±6.0 years. All cases denied to have travelled abroad
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
cases and right abdominal pain in one case. Pattern of presentation was
hepatocellular in 2 and cholestatic in 3 cases. Laboratory values (mean ±
Poster
standard deviation) at admission were: transaminases 2184.8±1371.2 UI/L,
bilirubin 11.6±5.2 mg/dl, INR 1.3±0.5. Laboratory values at peak were: tran-
saminases 2478.8±1214.9 UI/L, bilirubin 23.1±12.1 mg/dl and INR 1.6±0.4.
All subjects presented positive HEV IgM and IgG while only one subject
had positive serum HEV-RNA with identification of genotype 3 virus. Stool
HEV-RNA was negative in all subjects. 2 out 5 subjects had pre-existing
chronic liver disease. One of these subjects developed acute renal failure and
died from sepsis 47 days after hospital admission. The second subject is still
hospitalized for persistent jaundice 45 days after admission. The remaining
3 subjects presented complete clinical and biochemical resolution. Mean
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-
titis even in developed countries. In subjects with pre-existing liver disease,
HEV may cause acute on chronic liver failure, sometimes with severe
complications.
140. DILI: 10 YEARS OF CLINICAL EXPERIENCE IN AN
ITALIAN TERTIARY CENTER
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,
Gasbarrini A. 1, Grieco A. 1
1
Gastroenterology Area, Fondazione Policlinico A. Gemelli – Catholic
University of the Sacred Heart, Rome 2 Clinical Management, Fondazione
Policlinico A. Gemelli – Catholic University of the Sacred Heart, Rome 3
Emergency and Internal Medicine Area, Fondazione Policlinico A. Gemelli
– Catholic University of the Sacred Heart, Rome 4 Pharmacology Institute,
Fondazione Policlinico A. Gemelli – Catholic University of the Sacred Heart,
Rome 5 Division of General Surgery and Organ Transplantation, Abdominal
Surgery Area, Fondazione Policlinico A. Gemelli – Catholic University of the
Sacred Heart, Rome
Drug induced liver injury (DILI) still represents a clinical challenge. The real
incidence is difficult to assess but a range between 1/10.000 to 1/100.000 inha-
bitants appears to be reasonable. Clinical presentation is extremely variable
ranging from mild and a-specific symptoms to the dramatic manifestations
of acute liver failure requiring liver transplantation (OLT). Here we report
the experience of Policlinico Gemelli Hospital of Rome recorded by a retro-
spective study. From 1/01/2005 to 31/06/2016 clinical records of patients
discharged with ICD-9 codes of diagnosis 573.3, 570 and 571.9 (non-speci-
fied or non-infectious toxic hepatitis, massive acute or sub-acute liver necro-
sis and non-specified chronic hepatitis without alcohol mention, respectively)
were examined. The local Liver Transplant Center database has also been
consulted to identify those patients transplanted for DILI-induced acute liver
failure (ALF). Clinical and biochemical data, damage severity and patterns of
presentation, involved drugs and outcomes have been analyzed. 948 medical
records were found. After independent consultation by two expert clini-
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).
Hepatocellular pattern of damage was observed in 63% of patients, followed
by cholestatic (25%) and mixed (12%). The class of drugs mostly involved
was antibiotics (26, 9%), followed by non-steroidal anti-inflammatory drugs
(NSAIDs) (14, 4%) and immunosuppressive or chemotherapeutic agents (10,
6%). The main single agent involved resulted amoxicillin/clavulanic acid (12,
5%), followed by isoniazid (6, 7%). According to Hy’s rule 49/104 presented
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-
tion. Transplanted subjects were significantly younger than deceased subjects
(p<0.005), peak bilirubin levels were significantly higher in died and tran-
splanted subjects than in transplant-free survivors (p<0.05). DILI is a clinical
picture that requires special attention. A prompt appropriate diagnosis and an
adequate therapeutic approach, with early transplant referral while needed,
are key determinants of clinical outcome. Among laboratory data, bilirubin
levels showed the highest prognostic value.
141. ILEAL PSEUDOTUMOR IN LIVER CIRRHOSIS: LOOK
OUT ECTOPIC VARICES
Tarli C. 1, Marrone G. 1, Biolato M. 1, Liguori A. 1, Riccioni M.E. 1,
Barbaro B. 2, Gasbarrini A. 1, Grieco A. 1
1
Gastroenterology Area, Fondazione Policlinico A. Gemelli – Catholic
University of the Sacred Heart, Rome 2Diagnostic Imaging Area, Fondazione
119
Poster
Policlinico A. Gemelli – Catholic University of the Sacred Heart, Rome
Introduction: Liver cirrhosis is one of the most common causes of clini-
cally significant portal hypertension, that is defined as an elevated hepatic
venous pressure gradient (HVPG) ≥ 10 mmHg [1, 2]. Portal hypertension
leads to various mucosal abnormalities of the gastrointestinal tract, such as
the well-known esophageal/gastric varices and hemorrhoids. In some cases,
portal hypertension can determine an enteropathy (or ectopic varices)
which is discovered after the diagnosis of anemia caused by occult bleeding.
Here we report a peculiar case of ectopic varices mimicking an ileal tumor.
Case Report: A 54-year-old man with hepatitis C virus -associated liver
cirrhosis (Child A5, MELD 13) vein thrombosis at the spleno-mesenteric
confluence (on warfarin treatment) and hepatocarcinoma (waiting for liver
transplantation) was admitted to Liver Transplant Medicine Unit of Gemelli
Teaching Hospital in Rome because of fever (max 39 °C). On admission,
physical examination revealed normal vital signs. Hemoglobin level was
14.8 g/dl and blood pressure was 100/60 mmHg. A contrast enhanced
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.
A small bowel CT-scan confirmed the presence of the small endoluminal
ileum lesion. Thus, a double balloon enteroscopy revealed a big blue varice,
about 50 centimeters upstream from ileocecal valve. Thereafter, portal
hypertension treatment was optimized in the attempt to reduce bleeding
risk, waiting for the liver transplantation.
Discussion: Recognized causes of ectopic varices are intra- and extrahepa-
tic portal hypertension, surgical procedures, anomalies of venous outflow
vessels, abdominal vascular thromboses, and rare familial conditions [3]. In
portal hypertension induced by liver cirrhosis, gastrointestinal varices are
typically found in the esophagous and anorectal canal during endoscopy
and clinical rectal examination. Small bowel varices are not well-known
because this bowel tract is not usual deepen. Differential diagnosis for this
finding include cancer and for this reason, especially in patients that are
waiting for a liver transplantation, is mandatory to conduct procedures to
define and clarify the nature of these lesions.
References: [1] A. Rodriguez-Vilarrupla, M. Fernandez, J. Bosch, and J. C.
Garcia-Pagan, “Current concepts on the pathophysiology of portal hyper-
tension”, Annals of Hepatology, vol. 6, no. 1, pp. 28-36, 2007. [2] Garcia-T-
sao G, Abraldes JG, Berzigotti A, Bosch J. Portal Hypertensive Bleeding in
Cirrhosis: Risk Stratification, Diagnosis, and Management: 2016 Practice
Guidance by the American Association for the Study of Liver Diseases.
Hepatology 2017, 65(1): 310-35. [3] Helmy A, Al Kahtani K, Al Fadda M.
Updates in the pathogenesis, diagnosis and management of ectopic varices.
Hepatol Int 2008;2:322-34.
142. DIFFERENTIAL DIAGNOSIS OF NON-CIRRHOTIC
PORTAL HYPERTENSION. A CASE OF SCHISTOSOMIASIS
IN AN INTERNAL MEDICINE UNIT
Milazzo M., Lugari S., Ponz de Leon M., Pellegrini E.
Internal Medicine Unit, Dept of Internal Medicine, Endocrinology,
Metabolism and Geriatrics. University Hospital of Modena. University of
Modena and Reggio Emilia, Italy
Introduction: Schistosomiasis is one of the most prevalent though
neglected parasitic disease caused by trematode flukes of the genus Schisto-
soma affecting almost 240 million people mainly in tropical and sub-tropi-
cal areas. Clinical disease is caused by an immune response due to schisto-
some eggs lodged in host tissues and includes hepatosplenic schistosomiasis
(HSS) characterized by inflammation and portal fibrosis. We describe a case
of a man with hepatosplenomegaly where an accurate differential diagnosis
permitted to detect HSS and to initiate appropriate treatment.
Case Report: A 19-year-old man from Ghana was transferred to our
Medical ward on the grounds of hepatosplenomegaly associated with fever,
back and abdominal pain. These complaints had developed after an initial
admission in Psychiatry owing to alleged post-traumatic stress disorder
after a car accident. He had been living in Italy for one year and had not
returned to Africa recently. His clinical history was otherwise unremar-
kable. Physical examination revealed in addition diffuse abdominal tender-
ness and muscular hypotrophy. Peripheral blood examination showed mild
thrombocytopenia and hypertransaminasaemia, increased IgG and hypoal-
buminemia. Abdominal ultrasonography revealed coarse echopattern and
splenomegaly suggesting non-cirrhotic portal hypertension which was con-
firmed at Computer Tomography-scanning. Endoscopy showed esophageal
varices and congestive colitis with chronic inflammatory changes. In order
120
118° Congresso Nazionale - Società Italiana di Medicina Interna
to rule out common causes of portal hypertension tests for viral hepatitis,
hemochromatosis, A1AT-deficiency, Wilson and autoimmune disease were
performed, with negative findings. Serology tests for Plasmodium, Trepo-
nema, Leishmania and HIV were also negative. Liver biopsy showed portal
fibrosis in the absence of overt cirrhosis. Collectively, these findings, com-
patible with “cryptogenic” non-cirrhotic portal hypertension, strongly sug-
gested chronic schistosomiasis confirmed by microscopic examination of
stool samples, faecal PCR and circulating cathodic antigen urine-assay. We
thus diagnosed HSS (Schistosoma mansoni) in decompensated form cha-
racterized by fibrotic liver, splenomegaly, esophageal varices, hypoalbumi-
nemia and muscle wasting. Praziquantel treatment was immediately started.
Conclusion- Schistosomiasis, a major cause of liver fibrosis in endemic
areas, is an important diagnostic challenge in Western Countries due to
international travels and immigration. HSS should be considered in patients
with splenomegaly and portal hypertension without stigma of cirrhosis. A
high index of suspicion would permit early diagnosis and, hopefully, a more
favorable prognosis.
143. TERLIPRESSIN AND ALBUMIN FOR THE
TREATMENT OF TYPE-1 HEPATORENAL SYNDROME.
IMPACT OF ACUTE-ON-CHRONIC LIVER FAILURE
(ACLF) SEVERITY ON THERAPEUTIC RESPONSE
Piano S. 1, Schmidt 2, Ariza X. 3, Amoros A. 4, Romano A. 1,
Solà E. 3, Gerbes A. 5, Bernardi M. 6, Alessandria C. 7,
Trebicka J. 8, Gustot T. 9, Nevens F. 10, Arroyo V. 4, Gines P. 3,
Angeli P. 1
1
Department of Medicine, University of Padova, Italy 2 Klinik für
Transplantationsmedizin, Universitätsklinikum Münster, Germany 3
Hospital Clinic, IDIBAPS. and CIBEREHD, Barcelona, Spain 4 EF-CLIF.
and EASL-CLIF. Consortium, Barcelona, Spain 5 University Hospital LMU
Munich, Liver Center Munich, Munich, Germany. 6 Department of Medical
and Surgical Sciences, University of Bologna, Bologna, Italy 7 Division of
Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino,
Italy 8 Department of Internal Medicine I, University of Bonn, Bonn,
Germany 9 Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
10
University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
Background and Aims: Type-1 hepatorenal syndrome (HRS) is the most
life-threatening type of renal failure in patients with cirrhosis. The admi-
nistration of terlipressin and albumin has been shown to be effective in
treating type-1 HRS. According to the EASL-CLIF consortium definition,
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
response to treatment has never been assessed. The aims of our study
were: a) to evaluate predictors of response to treatment with terlipressin
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
mortality in these patients.
Methods: 298 patients with type-1 HRS treated with terlipressin and
albumin were included in this multicenter international study. Demo-
graphic, clinical and laboratory data were collected before the initiation of
treatment. Patients were followed-up until death, liver transplantation or
90 days.
Results: Patients were treated for a median of 8 days and response to treat-
ment was observed in 53% of patients. Response rate had a stepwise decre-
ase moving from grade 1 to grade 3 ACLF (60, 48 and 29% for grade 1, grade
2 and grade 3, respectively; p<0.001). In multivariate analysis, baseline sCr
(OR=0.23; p=0.001) and ACLF grade (OR=0.63; p=0.01) were found to be
independent predictors of response to treatment. During the 90-day follow
40% of patients died. Age (HR=1.05; p<0.001), white blood cell count
(HR=1.51; p=0.006), ACLF grade (HR=2.06; p<0.001) and response to
treatment (HR=0.41; p<0.001) were found to be independent predictors of
90-day mortality.
Conclusions: ACLF grade is a main determinant of response to terlipres-
sin and albumin in patients with type-1 HRS. ACLF grade affects survival
independently from the response to treatment. New therapeutic strategies
should be developed for patients with type-1 HRS and extrarenal organ
failures.
144. CORRELATION BETWEEN PHASE ANGLE, CHILD
PUGH CLASS AND BCLC STAGE AMONG CIRRHOTIC
PATIENTS:
118° Congresso Nazionale - Società Italiana di Medicina Interna
A NEW PROGNOSTIC TOOL IN LIVER DISEASES
Rinninella E. 1, Cintoni M. 1, Cerrito L. 2, Pizzoferrato M. 1,
Ponziani F.R. 2, Leone S. 1, Egidi G. 1, Basso L. 1, Bisciotti V. 1,
Miggiano G.A.D. 1, Pompili M. 2, Gasbarrini G. 2, Gasbarrini A. 2,
Mele M.C. 1
1
Nutrizione Clinica, Area Gastroenterologica, Polo delle Scienze
Gastroenterologiche ed Endocrino-Metaboliche, Fondazione Policlinico
Universitario Gemelli, Università Cattolica del Sacro Cuore, Roma 2
Medicina Interna e Gastroeneterologia, Area Gastroenterologica, Polo
delle Scienze Gastroenterologiche ed Endocrino-Metaboliche, Fondazione
Policlinico Universitario Gemelli, Università Cattolica del Sacro Cuore, Roma
Introduction and aim: Malnutrition in chronic liver diseases is a notewor-
thy problem (1). New prognostic factors are needed to stratify nutritional
risk in cirrhotic and HCC patients.Phase Angle (PhA), obtained by Bio-
impedeziometric Analysis (BIA) is considered as a useful tool to stratify
nutritional risk by ESPEN society (2). Recently it has been also correlated to
survival in HCC setting (3).
Material and Methods: Our Nutrition team operates in Internal Medi-
cine and Gastroenterology department and outpatient clinic. All cirrhotic
patients seen in the period between October 2016 and May 2017 were eva-
luated. For each patient anthropometric measures, lab tests and BIA, with
PhA at 50 kHz, were collected; patients were then supported with a persona-
lized diet, according to ESPEN guidelines on nutrition on cancer and liver
diseases (4-5). Data are expressed as median (IQR) for numerical variables.
Numbers (percentage) were used for categorical variables. Kruskall Wallis
was used to compare data. A p<0.05 was considered statistically significant.
Results: Eighty patients were enrolled, of which 65 (81.3%) were male.
Mean age was 64.5±12.4 years. Among all patients, 48 (60.0%) were affected
by HCC.
Etiologies were: HCV: 37 (46.3%); Alcohol: 16 (20.0%); viral + alcohol: 8
(10.0%); HBV: 6 (7.5 %); metabolic: 6 (7.5 %); other: 7 (8.7%).
Twenty-eight (35.0%) had diabetes mellitus, of which 10 (35.7% of diabe-
tics) were insulin-dependents. Thirty-nine (48.8%) were in Child A, twen-
ty-five (31.2%) in Child B and 16 (20.0%) in Child C. Three (6.3%) were in
BCLC 0, 7 (14.6%) in BCLC A, 18 (37.5%) in BCLC B, 14 (29.2%) in BCLC
C and 4 (8.3%) in BCLC D. Overall PhA was 4.1 (3.6-5.1), BMI was 25.6
(23.0-28.6).
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
stages, respectively BCLC 0: 5.2 (4.7-5.5); BCLC A: 4.1 (3.5-5.8); BCLC B:
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-
versely, BMI did not change across Child classes (Child A: 25.3 (22.7-28.2);
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
(23.0-28.6); BCLC C: 27.5 (23.7-27.9); BCLC D: 26.9 (25.5-30.4)) (p=0.89).
Conclusions: PhA, rather than BMI, correlates with Child Pugh classis in
cirrhotic patients; Furthermore, PhA correlates with BCLC classification in
HCC patients. This may be useful to stratify nutritional risk among cirrho-
tic and HCC patients. Further studies are necessary to validate these data
in larger population cohorts and to correlate nutritional risk to clinical
outcomes.
References: 1) Purnak T, Yilmaz Y. Liver disease and malnutrition. Best
Practice & Research Clinical Gastroenterology 27 (2013) 619–629 2) Kyle
UG, Bosaeus I et al. ESPEN. Bioelectrical impedance analysis-part II:
utilization in clinical practice.Clin Nutr. 2004; 23:1430-53. 3) Schütte K,
Tippelt B, Schulz C et al. Malnutrition is a prognostic factor in patients with
hepatocellular carcinoma (HCC) Clinical Nutrition 34 (2015) 1122-1127
4) Arends J, Bachmann P, Baracos V et al. ESPEN guidelines on nutrition
in cancer patients. Clin Nutr. 2017 Feb;36:11-48 5) Plautha M, Cabre´b E,
Riggio O et al. ESPEN Guidelines on Enteral Nutrition: Liver disease. Clini-
cal Nutrition (2006) 25, 285–294
145. HEPATIC INVOLVEMENT AND STIFFNESS
EVALUATION BY ELASTOGRAPHY IN HEREDITARY
HEMORRHAGIC TELANGIECTASIA
Suppressa P., Cavallo M.L., Semeraro F.P., Saracino A., Lagioia A.,
Lastella P., Buonamico P., Lenato G.M., Angarano G., Sabbà C.
1
HHT. Interdepartmental Center, Centro Sovraziendale per le Malattie
Rare, “Frugoni” Internal Medicine Unit, Policlinico Hospital, University of
Bari “Aldo Moro”, Bari, Italy Digestive Physiopathology and Celiac Disease
Poster
Centre, Dpt of Internal Medicine, “SS. Annunziata” Hospital, Taranto, Italy
Institute of Infectious Disease, Policlinico Hospital, University of Bari “Aldo
Moro”, Bari, Italy “A. Murri” Internal Medicine Unit, Policlinico Hospital,
University of Bari “Aldo Moro”, Italy
Background: Hereditary Haemorrhagic Telangiectasia (HHT), or Ren-
du-Osler-Weber syndrome, is a rare autosomal dominant vascular disor-
der (prevalence: 1-2:10, 000), characterized by arterio-venous shunts in
several organs. Serious clinical complications can be associated to visceral
arterio-venous malformations. In particular, hepatic arterio-venous mal-
formations (HAVMs) are detected in 60-80% of HHT patients and may be
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-
ciated to hyperplastic micronodular regeneration and deposition of fibrous
tissue, often not associated to clinically significant portal hypertension or
cirrhosis. Elastonography has recently been proposed as a non-invasive
effective tool to estimate liver stiffness, as a parameter for liver fibrosis. AIM:
The present study aims to investigate subclinical hepatic stiffness alterations
in HHT patients with liver involvement.
Methods: The study was designed as a prospective cohort study of patients
with either genetically or clinically confirmed HHT diagnosis. Patients were
consecutively recruited, among patients who were subjected to full clini-
cal-instrumental evaluation, independent of clinical symptoms. Hepatic
screening was performed by Echo-Color Doppler examination and Mul-
ti-Slice Computed Tomography. Stiffness evaluation was carried out by wave
elastography (echosens Fibroscan), with semiquantitative scale grading cur-
rently employed for HCV-related hepatitis.
Results: A total of 51 patients were included in the study (mean age 52
yrs). Hepatic arterio-venous malformations were detected by MSCT in
39/51 patients (76%). Elastography-based stiffness alterations were detected
in 25/47 patients (53%), 7 of which (with positive fibroscan) showed
HHT-related or unrelated concomitant hepatic disease. For the remaining
18 patients with elevated stiffness, no overt liver disease or other fibrosis
signs were evident. We found a statistically significant stiffness increase
in liver-disease vs non-liver-disease patients (9.388±5.895 and 5.30±1.85,
respectively, p<0, 019). Stiffness was positively correlated wth hepatic artery
diameter and maximum velocity.
Conclusions: Liver stiffness in HHT may be altered in certain patients, due
to diffuse hypervascularization and/or subclinical fibrotic deposition.
146. DYNAMICS AND MANAGEMENT OF ORAL
ANTICOAGULANT TREATMENT IN CHRONIC
HEPATITIS C PATIENTS UNDERGOING THERAPY WITH
DIRECT ANTIVIRAL AGENTS
Vitrone M. 1, Parrella A. 1, Ursi M.
P. 1, Andini R. 1, Ragone E. 2,
Albisinni R. 2, Zampino R. 3, Durante Mangoni E. 3
1
Internal Medicine, University of Campania ‘L. Vanvitelli’, 2 Unit of Infectious
and Transplant Medicine, 3 Internal Medicine, University of Campania ‘L.
Vanvitelli’ and Unit of Infectious and Transplant Medicine, AORN. dei Colli-
Monaldi Hospital, Naples, Italy
Direct antiviral agents (DAA) are a very effective and safe treatment for
chronic hepatitis C (CHC), but can interfere with other concurrent medica-
tions. Warfarin is still widely used as oral anticoagulant, mostly in carriers
of prosthetic cardiac valves but also in atrial fibrillation and venous throm-
boembolism. Also, warfarin is characterized per se by a high likelihood
of drug-drug interactions. Although no interaction between warfarin and
DAA is expected on the bases of preliminary studies, few real life data are
available and one case of a clinically relevant interaction in a patient treated
with paritaprevir/ritonavir/ombitasvir+dasabuvir (3D) has been recently
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
patients who were in stable treatment with warfarin (median treatment time
before DAA 17 years, IQR 10-32). Warfarin was administered because of
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
that could interfere with warfarin administered. Furthermore, liver and
renal function remained stable throughout the treatment course. All five
patients reached a sustained virological response without adverse events,
after 12 or 24 weeks of DAA treatment. According with HCV genotype and
treatment availability, 2 patients were treated with sofosbuvir-daclatasvir
121
Poster
(S-D), 2 with sofosbuvir-ledipasvir (S-L) and 1 with 3D regimen.
Figure 1 shows the dynamics of international normalized ratio (INR) and
warfarin doses before, during and after DAA treatment in the five patients.
Figure 1. INR before, during and after DAA therapy.
As shown in Figure 1, only 2 (treated with S-D and 3D, respectively) of the
5 patients experienced a drop of the INR ≤ 1.5 at week 4 of therapy; they
needed an increase of warfarin dose and a short course of supplementation
with enoxaparin waiting for the INR to return within the target range. After
stopping DAA treatment, INR remained in the therapeutic range with the
ongoing warfarin dose (no rebound was observed). The number of patients
studied is certainly very low to draw definitive conclusions. However, our
preliminary analysis shows that significant reductions in the INR can be
observed during therapy with different DAA. In contrast, there were no
cases of INR increase. Therefore, despite formal evidence of drug-drug inte-
raction between warfarin and DAA, our data suggest that a strict and careful
follow-up of INR, with adjustment of warfarin dose is needed during DAA
treatment. This policy would likely allow to avoid phases of inadequate anti-
coagulation with possible risk of thrombotic complications.
147. DIFFERENT METABOLIC FINGERPRINTS BETWEEN
HCV AND HBV PATIENTS: A POSSIBLE INTERFERENCE
OF THE TWO MAJOR HEPATITIS VIRUSES IN BASAL
METABOLISM PATHWAYS
Lorini S. 1, Gragnani L. 1, Cerretelli G. 1, Meoni G. 2, Tenori L. 2,
Monti M. 1, Corti G. 1, Luchinat C. 2, Zignego A.L. 1
1
Masve Center, Experimental and clinical medicine, University of Florence,
Florence, Italy; 2 Consorzio Interuniversitario Risonanze Magnetiche di
Metallo Proteine, University of Florence, Florence, Italy
Background: Metabolomics is the study of metabolic changes in biological
systems and may identify specific profiles associated with subtle alterations
induced by diseases. Studies performing a comparative evaluation of HCV
and HBV patients are lacking. HCV can be completely eradicated by direct
acting antivirals (DAAs). The aim of this study was to evaluate through
NMR-based metabolomic approach a group of HCV-positive patients
before and after viral eradication by DAA IFN-free regimens, comparing
their fingerprints to naïve HBV-patients and healthy donors.
Methods: Sera were collected before therapy (baseline), at SVR12, and
SVR24 time-points, from 67 HCV patients successfully treated with IFN-
free DAA regimens; as controls, we tested serum samples from 50 naive
subjects with chronic HBV infection (pathological controls; HBV) and 43
healthy donors (healthy controls; HC). Samples were analyzed using proton
nuclear magnetic resonance spectroscopy (H-NMR).
Results: MPLS analysis of HCV sera showed a significant pair-wise discri-
mination by comparing SVR12 and SVR24 with baseline samples (with 90%
and 82% of accuracy, respectively), indicating that a metabolic efficacy was
evident already at SVR12. Metabolic fingerprinting was able to distinguish
the study groups (HBV, HCV and healthy subjects) with a 75% accuracy.
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,
alanine, acetate, tyrosine, phenylalanine, formate). In detail, 2-oxoglutarate
levels progressively decreased in HCV patients from baseline to SVR24 and
122
118° Congresso Nazionale - Società Italiana di Medicina Interna
its levels were significantly higher in these patients compared to HC and to
HBV-subjects.
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
night-awakenings, weight loss of 17 kg (from 80 to 63 kg), sometimes also
vomiting, no fever, no recent travels, no domestic animals. In his medical
history: arterial hypertension, polycithemia vera, hyperuricemia, cho-
lecystectomy. No significant familial history (for cancers, enteropathies,
autoimmune diseases). He already dismissed his medicaments two months
before (ASA, olmesartan/hydrochlorothiazide, pantoprazole, atorvastatin,
phebotomies). Renal function impaired and he developed a metabolic aci-
dosis. Blood exams showed: Hb 11, 9 g/dL, MCV 84 fL, low ferritin, normal
B12 vitamin and folate, AST, 54, ALT 92 U/L, gGT 117 U/L, bilirubin 0, 7
mg/dL, normal amylases, normal TSH. Normal CEA, Ca19.9, PSA. Nega-
tive Widal-Wright, Weil-Felix, HAV, HCV, HBV, HIV serology. Negatives
ASCA, ANCA, ENA, antitransglutaminases and antiendomysium antibo-
dies. Stool exams showed negativity searching for parasites, Salmonella,
Shighella, Clostridium difficile toxin, rotavirus and adenovirus. FOBT was
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.
- Enhanced CT scan of abdomen: thickening of bladder anterior wall, no
lymph node enlargement, no thickening of gut walls. Few free liquid in
pelvic cavity. Mesalazine, rifaximin, cholestyramine and pancreatic enzymes
were started without any improvement.
- Upper endoscopy: abundant hiatal hernia. Mild reduction of duodenal
folds. HP negative. From duodenal biopsy Marsh 3b lesions are found,
with high intraepithelial lymphocytes count (60/100). As said, IgA and IgG
anti-transglutaminases and anti-endomysium antibodies were negatives,
with normal IgA levels. Total IgG and IgM also were normal. Anti ente-
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
Congo red stain of the biopsies were asked and resulted negative.
HLA typing showed the presence of a DQ2 monomer. The probability of a
complicated coeliac disease was high, because of his age, clinical and sero-
logical presentation. He was counseled to refer to an Enteropathy referral
centre but refused. He underwent also PET scan, intestinal US (normal
aspects). He started gluten free diet and budesonide 9 mg/days for 3
months. His diarrhoea stopped within two weeks. He presented again
arterial hypertension and two further episodes of ankle arthritis, and allo-
purinol and amlodipine were inserted. He started a strict follow up. He
underwent to duodenal biopsies and clinical and biochemical control after
4 months. Histology showed almost normal high of the villi, and a normal
count of IELs (< 20/100). After 2 years he weights 70 kg, he is still on strict
gluten free diet. Hb is 15, 5 g/dL. He restarted atorvastatin and controlled
calories diet. He repeated upper endoscopy with duodenal biopsies that
are still normal. The diagnosis of olmesartan-related enteropathy cannot
be totally excluded, nevertheless there are no description of an enteropa-
thy so long persisting after 2 months of drug suspension. A gluten chal-
lenge may be the most precise way to determinate whether the patients is
coeliac or not, but his major presentation on old age suggest to be carefull.
149. A RARE CAUSE OF GASTROINTESTINAL DISORDERS
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
118° Congresso Nazionale - Società Italiana di Medicina Interna
1
Department of Medical Science, Internal Medicine, ASST. Bergamo Ovest -
Treviglio (BG)
A 69-year-old male was admitted with 2 months of watery diar-
rhea, 4 kg of weight loss and severe generalized weakness. No
fever, no abdominal pain. Patient medical history included hyper-
tension, diabetes mellitus and dyslipidemia. He took Rifaximin
and probiotics. Metformin teatment was discontinued. However
he didn’t find relief. His abdomen was soft and no abdominal
masses were noted. Blood examinations showed severe metabo-
lic acidosis, mild hypokaliemia and mild anemia with folic acid
and vitamin B12 deficiency. The patient was treated with intrave-
nous rehydratation, sodium bicarbonate and potassium replace-
ment. Stool samples for Clostridium Difficile, bacteria, parasites
were negative. Colonscopy and EGDS were negative and abdo-
minal ultrasound (performed 5 days before hospital admission)
only revealed liver steatosis. During hospitalization he developed
hypovolemic and septic shock with multi-organ failure. The night
before the shock he had diarrhea of up to 10 to 12 loose bowel
movements. Blood samples were collected and we administered
intravenous antibiotic therapy and fluid replation. Treatment
with inotropic agents was initiated because of volume-resistant
hypotension. The blood cultures were positive for Enterobacter
Cloacae, susceptible to Levofloxacin. Computed tomography scan
revealed a large malignant mass in the body-tail of his pancreas,
involving spleen and stomach. A fine- needle aspiration biopsy
was performed for histologic examination (grade 2 neuroendo-
crine neoplasm). He also underwent an Octreotide radionuclide
study, which demostrated radiotracer uptake between spleen,
pancreas and the greater curvature of stomach. Tumor markers
CEA and Ca 19.9 were negative. It was not possible to test plasma
VIP levels in our laboratory or in the other hospitals in the area,
beacuse this test was not available. The patient was treated with
short-acting Octreodite and showed good control of his diar-
rhea. Then the patient underwent a distal pancreatectomy with
splenectomy and resection of posterior wall of body of stomach.
Final pathology demostrated a malignant grade 1 neuroendocrine
neoplasm of the tail of the pancreas. The mass was found to be a
VIPOMA. The patient is alive and disease- free 8 months after
surgery. VIPomas are very rare subtype of pancreatic neuroendo-
crine tumors that secrete VIP and that often elude prompt diagno-
sis. Many other conditions can mimic its presentation. VIPomas
are most often sporadic, solitary lesions greater then 3 cm in dia-
meter. They produce a clinical syndrome known as Verner-Morri-
son Syndrome, WDHA syndrome (watery diarrhea, hypokaliemia
and achlorhydria). Therapy approach involves two intercon-
nected pathways: 1- Correction of life-threatening electrolyte and
volume status abnormalities; 2- Surgical treatment. Management
with the synthetic octapeptide analog of somatosatin (Octreotide)
has proven useful in VIPoma patients with unresectable disease
and/or metastases.
150. A FURTHER CASE OF GLUTEN ATAXIA: A NOT SO
RARE DISORDER
Conti Bellocchi M.C. 1, Cavallaro T. 2, Ferrari S. 2, Cangemi G.C. 3, Zanoni G.
4
, Opri R. 4, Fabrizi G.M. 2, Frulloni L. 1, Ciccocioppo R. 1
1
Department of Medicine, University of Verona, Verona, Italy; 2Department
of Neurological Sciences, Biomedicine and Movement, University of Verona,
Verona, Italy; 3Department of Internal Medicine, IRCCS Policlinico San
Matteo Foundation, University of Pavia, Pavia, Italy; 4UOC of Immunology,
AOUI Borgo Roma, Verona, Italy
Gluten ataxia is a rare disease considered as the neurological manifestation
of gluten-related disorders, with a growing number of cases described in
the last years. Here we present the case of a young woman with progressive
idiopathic neurological impairment and a familial history of celiac disease.
Poster
Case Description: A 38-year old woman was admitted to the Neurology
Unit (AOUI Borgo Roma, Verona) because of a progressive slurring of
the speech, clumsiness of hands and unsteadiness of gait lasting one year.
She also complained head tremulousness and a tendency to sway while
walking, with occasional falls, and sometimes blurred and double vision,
in the absence of any intestinal symptom and weight loss. There was no
family history of similar conditions in the parents or siblings, except for
her two children who were suffering from celiac disease. She was under
hormone replacement for hypothyroidism and she had no addiction or
exposition to toxic substance. On physical examination, dysarthria and
tremor of voice, right deviation of the head and trunk, lightly widened
base gear with left lateropulsion, and tandem difficulty, unmodified by
eye closure were evident. Moreover, clear cerebellar signs, such as fin-
ger-nose incoordination, dis-dyakokinesia and fragmentation of tracking
movements were found, in the absence of deficit of the strength or sen-
sitivity. Laboratory tests, including metabolic and endocrinologic analy-
ses (vitamin, lactate, glucose, copper, folic acid, and iron levels), were
within normal range. Celiac serology, including anti-tissue transglutami-
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
contrast, a strong positivity of anti-Purkinje cell antibodies was evident
(1:6400) using indirect immunohistochemical test. Genetic tests for cere-
bellar ataxia syndromes were negative (SCA 1, 2, 3, 6 and FRDA), whilst
the presence of the HLA-DQ2 haplotype was found. Electromyography
was normal, whereas a slowdown of BAERS, PEV and VEMPS was docu-
mented, and a stabilometric examination showed a marked postural
instability both with opened or closed eyes. The MRI of the brain showed
a moderate cerebellar atrophy of the warm and left hemisphere, with a
hypometabolism at PET-scan. Ultrasonography of abdomen and breast,
gynecological evaluation and X-ray chest were normal, excluding the
commonest aetiology of paraneoplastic cerebellar atrophy. A mild incre-
ase of intraepithelial lymphocytes at immunohistochemistry of the duo-
denal specimens was found in the absence of villuos atrophy. Following
the suspicion of gluten ataxia, a gluten-free diet was established, leading
to clinical benefit and stability of lesions at 12 and 24 months of follow-up,
with partial improvement of stabilometric test. This is an interesting case
of gluten ataxia in a patient younger than those described in the literature.
The strong familiarity and the clinical response, as well as the negativity of
other laboratory and instrumental tests, has led to this diagnosis.
151. IS GASTROPARESIS A GASTRIC DISEASE?
Rizzoli G., Stanghellini V., Bellacosa L., De Giorgio R., Cremon C., Barbara
G., Cogliandro R.
Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi di
Bologna, Azienda Ospedialiero-Universitaria S.Orsola - Malpighi, Bologna,
Italia
Background and Aim: Gastroparesis is a digestive syndrome characte-
rized delayed gastric emptying symptoms suggestive of gastroduodenal
motor disorders (Parkman et al. Gastroenterology 2004;127;1589-91). It
recognizes three different grade of increasing severity: 1) mild gastro-
paresis with symptoms easily controlled, weight / nutrition maintained
on a regular diet; 2) compensated gastroparesis with moderate symp-
toms partially controlled by daily medications, nutrition maintained by
dietary adjustments and 3) gastric failure with refractory, uncontrolled
symptoms, inability to maintain oral nutrition, frequent physician / emer-
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-
sence of enteric dysmotility in patients with gastroparesis
Methods: One hundred two patients with digestive symptoms suggestive
of gastroparesis (84 F, 18 M; mean age 37.7 ± 15.1 yrs), consecutively
referred to the Laboratory of Functional Gastrointestinal Disorders of the
S.Orsola-Malpighi Hospital - University of Bologna to underwent both a
13C octanoic acid gastric emptying study breath test and a small bowel
stationary manometry. Relevant issues of health status were also recor-
ded for each patient according to pre-defined, validated questionnaires
at entry.
Results. Gastric emptying was delayed in 27 patients (26.5%). Small bowel
manometry showed motor abnormalities in 90 patients (88.2%), sugge-
stive of underlying enteric neuropathy, hymotility or intestinal irritability.
Among patients with abnormal small bowel manometry gastric emptying
was delayed in only 26 patients (28.9%).
Conclusions: Manometric abnormalities suggestive of enteric dysmotility
123
Poster
rather than a delayed gastric emptying are frequently recorded in patients
with gastroparesis so that intestinal and not gastric dysfunction seems to be
relevant in its pathogenesis.
152. WHAT HAPPENED FIRST: IBD OR
IMMUNODEPRESSION? A CASE OF UNUSUAL
OPPORTUNISTIC PANCOLITIS
Dell’Aera D. 1, Morea A. 2, Porretti L. 1, Tonani M. 1, Piombo M. 1, Calabretta
F. 1, Marchesi E. 1
1
SC. Medicina Generale 2, Dipartimento Area Medica, Fondazione IRCCS
Policlinico San Matteo, Pavia 2SC. Malattie Infettive, Dipartimento Area
Medica, Fondazione IRCCS Policlinico San Matteo, Pavia
Introduction: Systemic infections by Cytomegalovirus (CMV) and Epstein
Barr Virus (EBV) are usually complications of a state of immunodepression.
Patients with inflammatory bowel disease (IBD) show an increased risk of
contracting CMV infection because of immunosuppressive medication and
malnutrition. Our patient didn’t have a known condition of immunodepres-
sion, she wasn’t undergoing chemotherapy and she never had any kind of
bowel disease previously.
Case presentation: A 59-year-old woman was admitted to our institute for
rectorrhagia and asthenia. She had a history of ischemic stroke caused by
atrial fibrillation. This arrhythmia was attributed to thyrotoxicosis in an
unknown Basedow disease. She was treated with thyrostatic and anticoagula-
tion therapy (dabigatran) until she begun to complain hemorragic diarrhea.
She underwent colonoscopy and the report showed suspicious characteri-
stics of inflammatory bowel disease. Her syntomps didn’t improve even
though the administration of topical steroid and oral mesalazine: for this
reason, she presented to our hospital. We performed colonoscopy and bowel
biopsy once again: histology was consistent with severe pancolitis (intersti-
tial chronic inflammation with eosinophils and lymphocytes, neutrophilic
inflammation and crypt abscesses in 15 specimens from different locations)
and PCR (Polymerase Chain Reaction) revelead high copies of CMV and
EBV DNA in biopsies (i.e. CMV in the sigmoid colon: 6472/100000 cells;
EBV in the ascending colon: 2276/100000 cells). The other microbiological
analysis on the stool were negative, but we found high copies of CMV and
EBV DNA in peripheral blood (CMV 9540/ml; EBV 180/ml). We quickly
stopped steroid and the patient was treated with ganciclovir and metro-
nidazole. We documented: anemia (Hb 8, 2 g/dl) without leukocytosis or
lymphocytopenia, a serious malnutrition (serum albumine 1, 9 g/dl, tran-
sthyretin 8 mg/dl) with hypokalemia (K 2, 9 mEq/L) and elevated reactive
C protein (RCP 6, 95 mg/dl) and faecal calprotectin (>300 mg/kg). Blood
transfusions and parenteral nutrition were necessary. One aspect has been
left undetermined: why was our patient affected by a systemic opportuni-
stic infection? Lymphocytic phenotype analysis revealed inverted CD4/CD8
ratio compatible with CMV infection. HIV serology and autoimmunity tests
were negative. Quantitative immunoglobulins test was normal. The study
of specific immunity (IFN gamma production in vitro: spot forming units)
revealed a normal response to CMV infection (CMV pp65: 60, range 0-185)
but a lower response to EBV compared to healthy controls (EBV BZLF: 0,
range 0-236). Immunity response to PHA (phytohemoagglutinnin mitogen
stimulation of lymphocytes) was defective (PHA: 40, range 250-1200): this
discovery reinforced the argument for an immunodepressive syndrome.
Conclusions: After 4 weeks of therapy, we observed an improvement in
both diarrhea and bleeding and the resolution of malnutrition. We docu-
mented the clearance of CMV copies in peripheral blood but an elevation
of EBV copies (1080/ml). We still don’t know if this kind of opportunistic
colitis was the onset of a preexisting ulcerative colitis or the prelude to an
unknown immunodepressive syndrome. The first immunological follow-up
test confirmed a non-specific immunodepressive syndrome. Other investi-
gations are mandatory to modify clinical outcome of our patient.
153. IN AUTOIMMUNE ATROPHIC GASTRITIS
WITH MILD MUCOSAL ATROPHY, RESIDUAL ACID
PRODUCTION MAY BE RESPONSIBLE FOR ACID-
RELATED GERD
Di Stefano M., Miceli E., Benedetti I., Pisati M., Pesatori E.V., Caccia
Dominioni C., Manfredi G.F., Padula D., Grandi G.,
Lenti M., Corazza G.R.
1st Department of Internal Medicine, IRCCS “S.Matteo” Hospital
Foundation, University of Pavia, Pavia, Italy
124
118° Congresso Nazionale - Società Italiana di Medicina Interna
Background: Autoimmune atrophic gastritis (AIG) is an immune-me-
diated chronic inflammatory disorder of the gastric body and fundus,
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
hyperplasia of endocrine cells of the stomach, promoting neuroendocrine
tumors. Upper gastrointestinal symptoms, mainly dyspeptic symptoms,
are very frequent in AIG, but many AIG patients may also suffer from
reflux-related symptoms, such as heartburn and regurgitation. It was
reported that, in AIG patients, the prevalence of reflux-related symptoms
is 24% (2) and the prevalence of reflux esophagitis ranges between 12%
and 24% (2, 3). When 24-hr pH-monitoring is performed in AIG patients,
acid production is sometimes detectable and abnormal non acidic reflux
is frequently diagnosed. Since both acid and non acidic reflux may cause
heartburn, patients with AIG may run the risk to have inappropriate PPI
prescription to treat a non acidic-related heartburn. Therefore, the aim of
this observational study was the evaluation of residual acid production
capacity in AIG patients with reflux-related symptoms to define whether a
subgroup of AIG patients may be treated with PPI.
Patients and Methods: Fifteen patients (12 females, aged from 46 to 73)
with AIG, referred to our outpatient clinic due to GERD-related symp-
toms, were enrolled. Diagnosis was made on the basis of histological
criteria on perendoscopic biopsies of the gastric body and antrum (1).
The median duration of the disease was 48 months (12-120). None of the
patients were taking PPI or drugs inhibiting gastric acid production. All
patients were HP negative but 7 had a previous infection. Multifactorial
anemia was present in 2 patients. In 6 patients, autoimmune thyroidi-
tis was present, in 1 psoriasis. GERD symptoms were investigated with
24-hour multi-channel pH-impedance monitoring with two pH chan-
nels: the proximal one was positioned 5 cm above the upper margin of
the lower esophageal sphincter and the distal one was 15 cm apart, thus
in the gastric fundus. Parameters of interest were the % of time during
which fundus pH was <4, % of time during which distal esophagus pH
was <4, number of acid refluxes, number of non acidic refluxes. Results:
The exposition of gastric fundus to pH values<4 was significantly higher
in patients with mild atrophy than in patients with moderate and severe
atrophy. When severe atrophy was present, GERD-related symptoms were
associated with non acidic refluxes, but when mild atrophy was present,
the residual gastric acid production was sufficient to determine acid-re-
lated reflux disease. In particular, in the group of 8 patients with severe
mucosal atrophy the mean % of time during which fundus pH was <4 was
4.2±7.8% (0.10-22.9%), mean % of time during which distal esophagus pH
was <4 was 0.04±0.1% (0.00-0.30%), mean number of acid refluxes was
1.1±2.5 (0-7) while mean number of non acidic refluxes was 35±23 (7-75).
On the contrary, in the group of 4 patients with mild mucosal atrophy
the mean % of time during which fundus pH was <4 was 69.9±42% (7.8-
97.5%), the mean % of time during which distal esophagus pH was <4
was 0.2±0.24% (0.0-0.5%), the mean number of acid refluxes was 8.3±7.9
(0-18) while mean number of non acidic refluxes was 7±8.3 (1-19). The
severity of mucosal atrophy was significantly correlated with fundus acid
exposure (r=0.76, p<0.01).
Conclusion: In patients with AIG, the occurrence of heartburn should
be investigated with 24-hr pH-impedance monitoring to optimize treat-
ment. However, when severe atrophy is present, non acid reflux is generally
responsible for symptoms and this makes PPI treatment useless. On the
contrary, in patients with mild atrophy acid production residual capacity
may be responsible for acid-related reflux symptoms and short courses of
PPI should be the best treatment option.
References: 1.Dixon M.F. et al. Am J Surg Pathol 1996;20:1161-81. 2.Miceli
E. et al. Clinical Gastroenterol Hepatol 2012;10: 812-814 3.Tenca A. et al.
Neurogastroenterol Motil 2016; 28: 274-80.
154. AN “OVER THE COUNTER” DYSPHAGIA
Gabba M., Masotti M., Formagnana P., Bergamaschi G.,
Corazza G.R.
Dipartimento di medicina interna Clinica Medica I, Reparto 11, Policlinico
San Matteo Università degli studi di Pavia
Case Presentation: a 83 years old man came to our attention for a wasting
disease caused by dysphagia, more severe duringsolid food intake, and asso-
ciated with weight loss of nearly 20 Kg. Clinical history: prostatic hyper-
trophy treated with TURP, previous burns of lower limbs surgically treated
with skin grafts, hip and knee replacement; in 2012 diagnosis of atrofic
gastritis and erosive duodenitis. Domiciliary therapy: dutasteride, PPi, hyo-
118° Congresso Nazionale - Società Italiana di Medicina Interna
scine butylbromide for aspecific abdominal pain three times per day. Clini-
cal course: On admission the patient could eat only a special diet prescribed
for dysphagia. Abitual therapy was confirmed during hospital stay with the
only exception of hyoscine butylbromide. Blood tests performed during
hospitalization showed mild normocytic anemia with a severe deficiency
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.
A swallowing evaluation showed dysphagia due to unfunctional oral and
pharingeal phases of deglutition. During hospital stay the patient referred
progressive spontaneous improvement of dysphagia and by the time of
discharge, was able to eat normally without complaining any symptoms.
Discussion: scopolamine butylbromide has a parasympatholytic, atropi-
ne-like effect, especially peripherally, and blocks the action of acetylcholine
at parasympathetic sites in smooth muscle, secretory glands and CNS. The
major adverse effects are due to the anticholinergic action, and are dry skin
(>10%), constipation, dysphagia, (1-10%). More rarely it causes headache,
orthostatic hypotension, tachycardia. The patient is currently on gastroen-
therologic follow up with the suggestion to perform an electrophysiologic
investigation of deglutition was if symptoms relapse. However, in view of
the resolution of dysphagia after drug discontinuation, a iatrogenic damage
was strongly suspected.
Conclusion: we presented this clinical case in order to describe a possi-
ble serious side effect of an overdose of hyoscine butylbromide, an over the
counter drug.
155. EFFECTIVENESS AND SAFETY OF BISMUTH
QUADRUPLE THERAPY (PYLERA®) IN COMBINATION
WITH PPIS FOR THE ERADICATION OF H.
PYLORI INFECTION IN PATIENTS WITH DUAL
CLARITHROMYCIN AND METRONIDAZOLE
RESISTANCE
Fiorini G. 1, Saracino M.I. 1, Gatta L. 2, Vaira D. 1
1
Department of Medical and Surgical Sciences, University of Bologna,
Bologna, Italy 2Gastroenterology and Endoscopy Unit, Versilia Hospital,
Azienda USL. Toscana Nord-Ovest, Lido di Camaiore, Italy;
Background: In areas of high dual clarithromycin and metronidazole resi-
stance, bismuth quadruple therapy (BQT) is the recommended first-line
treatment for the eradication of Helicobacter pylori (H. pylori). 1 However,
the level of evidence for this recommendation is low. In combination with
proton pump inhibitors (PPIs), BQT Pylera® (a single capsule containing
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
Pylera®+ PPI regimen in H. pylori infected patients in a real clinical setting
either naïve to treatment or as a rescue treatment and to assess eradication
rates by antibiotic resistance.
Methods: Consecutive H. pylori infected patients, who underwent an
upper GI endoscopy, were enrolled. During endoscopy, biopsies were
obtained to perform culture and susceptibility test for clarithromycin
(Cla), metronidazole (Metro) and levofloxacin (Levo). H. pylori infected
patients were offered treatment with Pylera®+ full dose PPI twice daily
for 10 days. Eradication was defined as a negative 13C-UBT performed
at least 28 days after the end of the therapy. Treatment emergent adverse
events (TEAEs) were registered.
Results: From March to December 2016, 960 endoscopy were perfor-
med and 245 naïve patients were treated with the 10-day Pylera® plus PPI
regimen. Susceptibility testing was available for 78.4% of patients. 41.6%,
36.4%, and 36.1% of patients harboured strains resistant to Cla, Metro, and
Levo, respectively. 6.7% of strains were resistant to both Cla and Metro but
susceptible to Levo, whilst 13.5% of patients harboured strains resistant to all
antibiotic tested. Eradication rate according to the ITT and PP were 91.0%
(95% CI: 88.0 to 95.5) and 97.2% (95% CI: 93.7 to 98.8), respectively. 93.9%
of patients harbouring strains resistant to Cla were eradicated as well as the
94.0% of those harbouring strains resistant to Metro. Furthermore, 88.9%
of patients harbouring strains resistant to both Cla and Metro were eradi-
cated. 53.4% of patients reported TEAEs: the most frequent were asthenia
(22%), nausea (20%) and headache (18.2%). 1% of patients had to discon-
tinue therapy due to AEs. Moreover, the 10-day Pylera® plus PPI regimen
was used as rescue therapy in 116 patients with an overall eradication rate of
87.2%. 88.5% of patients with dual Cla and Metro resistance were eradicated
of the infection. Based on the number of treatments previously performed,
this regimen achieved an eradication rate of 95.1%, 82.1%, 85.7% and 77, 8%
Poster
when used as second, third, fourth and fifth line respectively.
Conclusions: 10-day Pylera® plus PPI regimen was effective to eradicate H.
pylori infected patients, in particular those harbouring strains resistant to
Cla, Metro, or both. Incidence of TEAEs was similar to that observed in the
registration trial.
156. CHOOSING WISELY FOR HELICOBACTER PYLORI
INFECTION
Gatta L. 1, Scarpignato C. 2, Fiorini G. 3, Saracino M.I. 3, Ricci C. 4,
Vaira D. 3
1
Gastroenterogy & Endoscopy Unit, Versilia Hospital, Azienda USL.
Toscana Nord Ovest, Lido di Camaiore, Italy; 2 Clinical Pharmacology and
Digestive Pathophysiology Unit, Department of Clinical and Experimental
Medicine, University of Parma, Parma, Italy; 3Department of Medical and
Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy;
4
Gastroenterology Unit, ‘Spedali Civili’ Hospital, University of Brescia,
Brescia, Italy
Background: The increasing prevalence of strains resistant to antimicrobial
agents (AGs) is a critical issue in the management of H. pylori infection. The
principal aim of this study was to assess the prevalence of primary resistan-
ces (PRs) to clarithromycin, metronidazole, and levofloxacin between 2010
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
2010 and 2015 were eligible. PRs to clarithromycin, metronidazole and
levofloxacin were evaluated with E-test, according to the EUCAST guideli-
nes. A multivariate regression analysis was performed to assess the associa-
tion between several covariates and PRs. ST and post-treatment follow-up
were offered to infected patients.
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
to 34.3), respectively. Multivariate analysis showed that PRs significantly
increased between 2010 and 2015 for clarithromycin (OR: 1.15; 95% CI:
1.08 to 1.23), metronidazole (OR: 1.11; 95% CI: 1.04 to 1.19), and levofloxa-
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.
Conclusions: In our area, PRs to antimicrobial agents tested were high,
and significantly increased between 2010 and 2015. Regular monitoring on
regional basis should be set-up to choose the better regimen and to indi-
rectly monitor the consumption of AGs. Finally, ST is able to overcome resi-
stance to clarithromycin or metronidazole.
157. GELATINE TANNATE AND TYNDALLIZED
PROBIOTICS REDUCE COLITIS SEVERITY AND
PROMOTE A FASTER RECOVERY IN DEXTRAN SODIUM
SULPHATE (DSS) MODEL OF MURINE PROLONGED
COLITIS
Lopetuso L.R., Petito V., Graziani C., Franceschi F., Cammarota G.,
Gasbarrini G., Scaldaferri F., Gasbarrini A.
Catholic University of Sacred Heart of Rome-A. Gemelli Hospital
Gastroenterological Area, Gastroenterological and Endocrino-Metabolical
Sciences Department
Background and Aim: Gelatin tannate together with a mixture of inactiva-
ted tyndallized probiotics including Lactobacilli, Bifidobacterium, Strepto-
coccus are particularly indicated in the management of moderate and pro-
longed diarrhea. No information, however, exist from in vivo studies and
no animal model has been used to confirm their efficacy or unravel specific
mechanism of action. Aim of this study was to evaluate the therapeutic effect
and mechanisms of action of the formulation containing gelatin tannate and
tyndallized probiotics in the DSS model of murine prolonged colitis.
Methods: C57BL/6 mice were exposed to three cycles of 2.5% DSS for 7
days in drinking water separated by 2 weeks of recovery with water alone
(resting period). During each cycle, after 5 days of DSS administration, mice
received the formulation containing gelatin tannate and tyndallized probio-
tics by gavage in 200 ul of drinking water (T group) for five consecutive
days. Control mice received water only (CON group). Body weight, occult
blood test and stool consistency were measured every day and used to cal-
culate the Disease Activity Index (DAI) to assess severity of colitis. Survival
was expressed as %. Mice were sacrificed 2 weeks after the third DSS cycle
and colon length was measured.
125
Poster
Results: No differences in DAI and body weight loss were found after the
first cycle of DSS between T and CON. Conversely, T group showed a signi-
ficantly reduced DAI (p<0.005) and body weight loss (p<0.005) during the
second and third DSS cycle with also a significantly faster recovery of DAI
and body weight during their respective resting periods compared to CON
group (p<0.0002 and p<0.005, respectively). No differences in mortality
were observed. At the sacrifice colon length was significantly higher in T
group vs. CON group (p<0.05).
Conclusions: Taken together our preliminary observation suggest that
the formulation containing gelatin tannate and tyndallized probiotics can
decrease the clinical severity of colitis in mice. It seems also able to promote
a faster recovery of intestinal homeostasis during prolonged colitis. Further
analyses are required to better define the mechanisms of action underlying
these findings.
158. ALMONDS AS COMPONENT OF THE
MEDITERRANEAN DIET: ORGANOLEPTIC PROFILE OF
ALMOND VARIETIES DIFFER IN RELATION TO AGE AND
BODY WEIGHT
Lorusso M.P. 1, Diella G. 2, Caggiano G. 2, Montagna M.T. 2,
Portincasa P. 1
1
Clinica Medica “A. Murri”, Department of Biomedical Sciences and
Human Oncology, University of Bari “Aldo Moro”, Italy 2Section of Hygiene,
Department of Biomedical Sciences and Human Oncology, University of Bari
“Aldo Moro”, Italy
Background and Aim: Almonds in southern Italy represent a popular compo-
nent of the “rural” Mediterranean diet bringing beneficial nutritional aspects.
The almond seed is rich in fat (≈55%, [39.4%] monounsaturated fatty acids),
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
economic and cultural value, while competing with other imported almond
varieties. Consumers’ choice, price and advertisements play a key role in this
respect. We tested organoleptic perception of two common almond varieties
according to age and body weight.
Methods: 20 lean (BMI <24.9 Kg/cm2, age 18-65 yrs), 20 obese (BMI ≥30
Kg/cm2) adults and 20 lean elderly (>65 yrs) subjects ingested almonds
blindly and randomly: A) five imported “Carmel” almonds and B) five local
“Filippo Cea” almonds. Scores were collected for olfactory, taste, chewing
and visual perceptions on a 0-100 mm Visual Analogue Scale (VAS). Before
each test the mouth was rinsed with 150 ml tap water. Drinking, smoking,
or physical exercise were prohibited 2hr before the test.
Results: Lean subjects had distinct VAS values across all domains (p<0.05
Cea vs. Carmel): olfactory [40.0 (IQR 36.3) mm vs. 55.0 (17.5) mm], taste
[50.0 (27.5) mm vs. 72.5 (30.0) mm], chewing [60.0 (28.8) mm vs. 75.0
(37.5) mm], visual [50.0 (25.0) mm vs. 75.0 (30.0) mm]. Obese subjects had
distinct visual perception [52.5 (50.0) mm Cea vs. 80 (30.0) mm Carmel;
p<0.05) while elderly subjects had distinct chewing perception [50.0 (37.5)
mm Cea vs. 65.0 (30.0) mm Carmel; p<0.05).
Conclusion: The imported Carmel and the local Cea almond varieties
provide distinct organoleptic perceptions according to age and body weight.
Mechanisms behind such differencies need to be investigated with respect to
commercial as well as pathophysiological aspects.
159. VEDOLIZUMAB IS AN EFFECTIVE AND
SAFE THERAPY IN ELDERLY PATIENTS WITH
MULTIMORBIDITY AFFECTED BY INFLAMMATORY
BOWEL DISEASE
Lenti M.V. 1, Levison S. 2, Eliadou E. 3, Willert R. 3, Kemp K. 3,
Stansfield C. 3, Assadsangabi A. 4, Singh S. 4, Crooks B. 5,
Tattersall S. 5, Kenneth C. 5, Subramanian S. 6, Probert C. 7,
Storey D. 7, Gregg B. 7, Smith P. 7, Liu E. 8, Limdi J.K. 8, Johnston A. 9,
Hamlin P.J. 2, Selinger C.P. 2
1
Department of Internal Medicine, San Matteo Hospital Foundation,
University of Pavia, Pavia, Italy 2 Leeds Gastroenterology Institute, Leeds
Teaching Hospitals, Leeds, 3 Department of Gastroenterology, Manchester
Royal Infirmary, Central Manchester University Hospitals, Manchester,
4
Department of Gastroenterology, Salford Royal Hospitals, Salford, 5
Department of Gastroenterology, Bolton NHS. Trust, Bolton, 6 Department of
Gastroenterology, Bradford Teaching Hospital, Bradford, 7 Gastroenterology
& Liver Services, The Royal Liverpool and Broadgreen University Hospitals,
126
118° Congresso Nazionale - Società Italiana di Medicina Interna
Liverpool, 8 Department of Gastroenterology, Wrightington, Wigan and Leigh
NHS. Trust, Wigan, 9 Department of Gastroenterology, The Pennine Acute
Hospitals NHS. Trust, Manchester, United Kingdom
Background and Aims: The medical therapy of inflammatory bowel disease
(IBD) poses a peculiar challenge in the elderly population with multimor-
bidity. Vedolizumab (VDZ) is a gut-selective α4β7 anti-integrin licensed
to treat Chron’s disease (CD) and ulcerative colitis (UC) that could have a
favourable safety profile in this setting. We aimed to assess clinical outcomes
and safety of VDZ in a cohort of elderly IBD patients.
Methods: We retrospectively collected data of patients treated with VDZ
at eight UK centres (August 2014-September 2016). We evaluated clinical
response at 12 and 52 weeks using the Physician Global Assessment (PGA),
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
CD, 53 UC, 2 IBD-U) and 22 elderly IBD patients (mean age 71.9 ± 4.7, 13F;
10 CD, 12 UC) were enrolled for a mean treatment period of 9.4 ± 5 months.
Nine out of 22 elderly patients (41%) had at least two associated chronic
diseases, namely essential hypertension, chronic heart failure, diabetes mel-
litus type 2, and chronic obstructive pulmonary disease. According to PGA,
78/105 (74.3%) adult CD and 44/53 (83.1%) adult UC patients had a clini-
cal response to the induction therapy, whereas 16/39 (41.1%) adult CD and
25/29 (86.2%) adult UC patients maintained response at 54 weeks. Instead,
10/10 (100%) elderly CD and 11/12 (91.7%) elderly UC patients had a cli-
nical response to the induction therapy, whereas 2/2 (100%) elderly CD
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.
Conclusions: VDZ is a safe and effective therapy even in a sub-cohort of
elderly patients with multimorbidity. Further studies are needed in order to
confirm these preliminary data.
160. ABDOMINAL PAIN IN PREGNANT WOMAN
Maringhini M. 1, Rossello M. 2, Patti R. 3, Alio W. 4, Mazzola A. 5, Spina R. 1,
Maringhini A. 3
1
U.O.C. Medicina Clinica, Respiratoria e delle Urgenze, A.O.U. Policnico
P.Giaccone di Palermo; 2Radiologia, Arnas Civico di Palermo; 3Medicina 1,
Arnas Civico di Palermo; 4Ostetricia e Ginecologia, Arnas Civico di Palermo;
5
U.O. Medicina Trasfusionale, Arnas Civico di Palermo
A 31-year-old female patient presented to the hospital at 30 weeks of her
first pregnancy. Her weight and height were 75 kg and 160 cm, respectively.
She had abdominal discomfort, vomiting and temperature of 37.5°C. Her
medically history was negative, folic acid the only drug she had been taking.
Notable physical findings included a respiratory rate of 25, blood pressure
of 100/60 mmHg, 102 bpm, and a normal gravid uterous. Vital signs were
normal. There were moderate tenderness and not rebound in abdomen. No
cervical dilatation was observed during the pelvic examination. Fetal heart
sound was 152 bpm and presentation was cefalic. There were no rupture
of membranes and uterine contraction. We ruled out the possibility of
placental abruption and uterine rupture that could happen in second half
of pregnancy. Laboratory examination revealed white blood cell count of
12500/dL (neutrophil 70%), hemoglobin 12, 6 g/dL, plateletes 180000/dL,
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
was >4425 mg/dL, cholesterol was 1328 mg/dL. No mutations in CREB3L3
was identified. Serum amylase and lypase showed no abnormality. The
results of urine tests was normal. An abdomen ultrasonography showed
normal gallbladder, no bile duct dilatation, pancreas was not seen, liver did
not show any focal lesion; nor ascites neither pleural effusion were evident.
We started conservative treatment including fasting, intravenous fluid infu-
sion(3.000 ml with glucose, , electrolytes, vitamins for 400 Kcal/die). Plasma
exchange was started: 2.000 ml of patient plasma was replaced with the same
amount of fresh frozen plasma; the procedure was repeated 3 times in 3
days. After 4 days severe upper abdominal pain with normal serum amylase
and lypase occurred. Tryglicerides and cholesterol were respectively 1106
and 296 mg/dL, PCR was 14, 16 mg/L. Ultrasonography was unchanged. An
abdominal NMR was carried out: pancreas was increased in volume, glan-
dular lobulation was lost and a thin effusion was seen all around periglandu-
lar fat. Minimal ascitic fluid was evident. Fetus still was in cefalic position.
Vital signs were stable. Omeprazole (40 mg x 2 dosage) and Piperacillin and
Tazobactam 2g/0, 25 g (2 phials, t.i.d.) were added. Several abdominal pain
was treated with paracetamole and petidin. Plasma exchange was continued
118° Congresso Nazionale - Società Italiana di Medicina Interna
according to serum tryglicerides dosage. Several ultrasound examination
were carried out during the first 2 weeks resulting in an increasing fluid
effusion in the abdomen both in the head and in the tail of the pancreas and
left pleural effusion was also demonstrated. After 9 days pain disappeared,
bowel movement restarted, antibiotics and total parenteral nutrition were
stopped and she started to eat low calories diet (400/500 Kcal/die). Anemi-
zation and iron deficiency were observed and she started iron treatment.
After 2 weeks the NMR showed an increased peripancreatic fluid collections
close to the pancreatic tail (7 cm). The patient finally delivered after Caesa-
rian section at the 33nd week. Tryglicerides dosage after delivery decreased
and she started Ezetimibe, Simvastatin and Omega3. At the dimission the
effusion took the shape of pseudocyst 7 cm in size. After 4 months of fol-
low-up the pseudocyst decreased to 4 cm and the patient was asymptomatic
with normal serum levels of cholesterol and tryglicerides.
161. INCIDENCE OF ACUTE PANCREATITIS IN WOMEN
IN CHILD-BEARING AGE. ROLE OF PREGNANCY. A
SICILIAN POPULATION-BASED COHORT STUDY
Maringhini M. 1, Dardanoni G. 2, Fantaci G. 2, Patti R. 3, Politi F. 3,
Arnone S. 4, Maringhini A. 3
1
Medicina clinica, respiratoria e delle urgenze, A.O.U. Policnico P.Giaccone
di Palermo; 2D.A.S.O.E., Assessorato Regionale Sicilia della Sanità; Medicina
1, Arnas Civico di Palermo; U.O.S. Sistema Informativo e Statistico, Arnas
Civico di Palermo
Introduction: Acute Pancreatitis (AP) is a well known complication of pre-
gnancy(1). Evidence shows gallstones and gallbladder sludge are associated
with pregnancy (2, 3) and it is known that AP is associated with gallstones
(4) and sludge (5). In hospital-based series incidence of AP has been studied
(6) but these studies may be biased by patients selection.
Methods: All DRG of childbearing age female patients admitted in all Sici-
lian hospitals between January 1st 2011 and 31st December 2015 were regi-
stered inquiring about codex CD9577.0 (AP). AP was investigated respect
to the presence of delivery (within 9 months before AP, or within 3 years
after AP) or its absence.
Results. Total 1885 AP/7493519 pts; incidence: 25.16/100000/year. AP
during pregnancy: 34/226492; 15.01/100000/year (21.2, 13.2 and 10.6
/100000/year respectively in 1st, 2nd and 3rd trimester). AP after deli-
very 287/226492; 42.24/100000/year (95.4, 30.0, 30.0, 33.6, 24.7 and
27.4/100000/year respectively in 1st, 2nd, 3rd, 4th, 5th and 6th seme-
ster). AP in women without pregnancy within 3 years, 1564/7267027;
21.52/100000/year. We stratified pts according with age: <35 yrs and >= 35
yrs. AP during pregnancy <35 yrs: 17.3/100000/year; >=35: 8.5/100000/
year. After delivery <35: 41.8/100000/year; >= 35: 43.6/100000/year. AP
in women without pregnancy, < 35 years 11.6/100000/year; >= 35 years
30.2/100000/year.
Conclusions: Pregnancy, mainly the last 2 trimester, is associated with a
lower incidence of AP respect to women without pregnancy. Postpartum
period, mainly the 1st and the 2nd semester are associated with an impres-
sive increase in incidence of AP. Women < 35 years of age have a higher
risk of AP both in pregnancy than in the postpartum period. These results
Poster
confirm the impressive modification of bile and gallbladder motility during
and after pregnancy. The increase in estrogen and progesterone production
result in elevated lithogenicity of bile and gallbladder stasis. Above all gal-
lbladder stasis prevent movement of biliary sludge and stones and reduce
AP risk. After delivery the normalization of hormone reduce bile lithogeni-
city and restore gallbladder motility. These changes determine biliary sludge
and new stones (2, 3). After delivery sludge and stones are dissolved or
moved through common bile duct to duodenum, with AP. The increase in
risk of AP in younger pregnant confirm our results in previous prospective
study on biliary sludge stones and pregnancy (2, 3) and in population–based
case control study (1).
Reference: 1. Maringhini et al. Mayo Clin Proc 2000; 75:361-4. 2. Marin-
ghini A et al J Hepatol 1987; 5: 218-23. 3. Maringhini A. et al. Ann Int Med
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
conditions.
Laboratory findings showed white blood cell count 14.69 x 109/L, C-re-
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
thrombosis. Fasting, hydration, high-dose proton pump inhibitors (PPI)
and antibiotics were started but, two days later, melena, hypotension and
oxygen desaturation appeared. An urgent oesophagogastroduodenoscopy
revealed diffused black washing-resistant pigmentation of the oesophageal
mucosa, which spared the upper 3 cm of the organ and extended down to
the LOS, associated with LOS failure and hiatal hernia. On the following day
ileus paralyticus and possible ab-ingestis pneumonia developed. The patient
died of cardiocirculatory arrest after unsuccessful resuscitation.
Conclusion: AON is a poorly described condition, with a mortality rate
of 13-35%, presenting with coffee ground vomitus, epigastric/abdominal
pain, hematemesis and/or melena. Treatment is based upon large hydration,
high-dose PPI, parenteral nutrition and resolution of underlying causes.
We suggest a pathogenic role for two toxic effects: direct acid reflux in
gastric obstruction and an indirect drop in oesophageal blood flow caused
by acid. We hypothesize that increased serum pancreatic enzymes and pan-
creatic oedema may cause respectively vessel digestion and hypovolemia,
resulting in oesophageal damage.
Literature is scanty and reports on the possible association between AP and
oesophagitis in animals, so a cause-effect relationship can only be hypothe-
sized. Gurvits et al. supposed that low-flow due to sepsis, arrhythmias, heart
failure, AP, acidosis, hypothermia or shock may lead to AON.
Naito et al. suggested that trypsin stimulates chemokines and prostaglan-
dins production by oesophageal epithelial cells, possibly leading to gastroe-
sophageal reflux disease (GERD).
Petrovic at al. emphasized the potential etiological role of LOS failure in the
simultaneous occurrence of GERD and AP, suggesting a feedback mecha-
nism. Two groups of mice underwent surgical procedures to induce AP and
oesophagitis with LOS failure, respectively. The animals with AP developed
LOS failure, whereas those with oesophagitis and LOS failure developed AP.
Other hemorrhagic complications of AP are connected with vascular lesions
caused by the inflammation and enzymatic self-digestion. These factors may
also damage the oesophagus either acting directly on the mucosal barrier or
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
Poster
during AP in our patient. However, a clear demonstration of this hypothesis
cannot be provided because of the scanty literature and the rarity of the con-
dition, and future research should help to gain further insight and develop
effective therapies for this severe pathology.
163. AUTOIMMUNE DISORDERS ASSOCIATED WITH
AUTOIMMUNE ATROPHIC GASTRITIS
Miceli E., Pisati M., Caccia Dominioni C., Lenti M.V., Padula D., Corazza
G.R.
First Department of Medicine, San Matteo Hospital Foundation, University
of Pavia, Pavia, Italy
Background and Aims: Autoimmune atrophic gastritis (AAG) is an
autoimmune disorder that affects patients of all ages causing atrophy of
the oxyntic mucosa of the stomach, progressively leading to vitamin B12
and iron deficiency. AAG has certainly an immune-mediated pathologi-
cal basis, as it was shown in both animal models and in humans, driven
by humoral and cell-mediated activation. AAG may be associated with a
number of autoimmune disorders, namely type I diabetes mellitus, viti-
ligo, Hashimoto’s thyroiditis, and Addison’s disease. We aimed to describe
all autoimmune conditions in our cohort of patients affected by AAG.
Methods: Between January 2007 and June 2017, we consecutively enrol-
led all patients diagnosed with AAG (corpus/fundus atrophy with antrum
sparing and positivity to anti-parietal cells antibody, according to the Syd-
ney-Houston classification) in our gastroenterological outpatient clinic
(Fondazione IRCCS Policlinico San Matteo). We therefore recorded the
medical history of these patients with particular regard to concurrent
associated autoimmune conditions.
Results: Within the study time span, we enrolled 287 patients suffering
from AAG (mean age 63 ± 16 years; F:M ratio 2.3:1). At least one concomi-
tant autoimmune disorder was present in 136/287 patients (47.4%; mean
age 60.3 ± 15 years, F:M ratio 2.4:1), whereas at least two autoimmune
disorders were present in 26/287 (9.6%; mean age 62.4 ± 14 years, F:M
ratio 1.9:1). In particular, the most common autoimmune disorders were
as follow: 85/287 (29.6%) Hashimoto’s thyroiditis, 13/287 (4.5%) vitiligo,
12/287 (4.2%) Grave’s disease, 11/287 (3.8%) connective tissue disorder,
9/287 (3.1%) rheumatoid arthritis, 9/287 (3.1%) psoriasis and/or psoriatic
arthritis, 6/287 (2.1%) coeliac disease, 3/287 (1.1%) inflammatory bowel
disease, 3/287 (1.1%) type I diabetes mellitus.
Conclusions: We here show that AAG is associated with other concur-
rent autoimmune conditions, namely autoimmune thyreopaties, vitiligo,
connective tissue disorders, and arthritis. These patients should be scre-
ened for AAG. Further studies are necessary to better clarify the possible
common basis of AAG and other autoimmune disorders.
164. INCREASE IN NEUROENDOCRINE CELLS IN
BIOPSIES FROM POUCH MUCOSA
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,
Luinetti L. 2, Martino M. 1, Curti M. 1, Manca R. 2, Fociani P. 5, Corazza
G.R. 1
1
Departments of 1Internal Medicine and 2Molecular Medicine, San Matteo
Hospital Foundation, University of Pavia, Pavia, Italy; 3IBD. Surgical Unit,
Divisions of 4Gastroenterology and 5Pathology, “Luigi Sacco” University
Hospital, Milan, Italy
Background and Aims: Inflammatory bowel disease (IBD) is associated
with neuroendocrine cell hyperplasia. We investigated neuroendocrine
cells in J-pouches of patients with ulcerative colitis undergoing restorative
proctocolectomy and ileal pouch-anal anastomosis.
Methods: Sections from pouch of 17 patients and ileum of 13 active IBD
patients and 11 controls were processed by immunohistochemistry for
chromogranin A (CgA) and serotonin. Mucosal tryptophan hydroxylase
(TpH)-1 and serotonin-selective reuptake transporter (SERT) transcripts
were measured by quantitative RT-PCR. TpH-1 and SERT transcripts were
detected in pouch biopsies cultured with infliximab or its isotype control,
while IL-6 and IL-8 were measured in biopsy supernatants.
Results: A significant increase in CgA-positive cells was observed in both
pouch and IBD ileum compared to control ileum, while serotonin-posi-
tive cells were significantly higher in IBD ileum, but not in pouch, com-
pared to control ileum. Significantly raised transcripts of TpH-1, but not
SERT, were found in IBD ileum in comparison to control ileum, with no
significant difference between pouch and IBD ileum. Infliximab had no
128
118° Congresso Nazionale - Società Italiana di Medicina Interna
influence on ex vivo pouch expression of TpH-1 and SERT, whereas it
significantly down-regulated IL-8.
Conclusions: We here demonstrated neuroendocrine cell hyperplasia in
pouch mucosa. Further studies are needed to clarify the pathophysiologi-
cal implication of this finding.
165. NEW INSIGHTS INTO PATHOLOGICAL
MECHANISMS UNDERLYING AUTOIMMUNE ATROPHIC
GASTRITIS
Di Sabatino A. 1, Giuffrida P. 1, Lenti M.V. 1, Cococcia S. 1,
Aronico N. 1, Vanoli A. 2, Capuano F. 2, Martino M. 1, Miceli E. 1, Corazza
G.R. 1
1
First Department of Medicine and 2Department of Molecular Medicine,
San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
Background and Aims: Autoimmune atrophic gastritis (AAG) is an
autoimmune disorder that affects patients of all ages causing atrophy of
the oxyntic mucosa of the stomach. Although the typical AAG patho-
logical features have been widely described (i.e., atrophy of the corpus/
fundus mucosa with antrum sparing), still there is a number of associated
alterations that have not clearly been characterised. In addition, apoptotic
mechanisms involving Fas/Fas ligand pathways have only been demon-
strated in vitro. We herein aimed to investigate the distribution of T lym-
phocytes and apoptotic mechanisms within the gastric mucosa of patients
with AAG.
Methods: We enrolled five patients with confirmed diagnosis of AAG
(corpus/fundus atrophy with antrum sparing and positivity to anti-parie-
tal cells antibody). Five subjects with normal gastric histology undergoing
endoscopy for functional dyspepsia were used as control group. Sections
were taken from paraffin blocks of biopsies of gastric corpus and stained
with immunoperoxidase using anti-CD3 and anti-CD8 antibodies. Apop-
totic mechanisms were assessed through TUNEL assay.
Results: CD3+ (mean 13.0±1.2 per 100 epithelial cells) and CD8+ (mean
12.5±0.7 per 100 epithelial cells) intraepithelial T lymphocytes were incre-
ased in the gastric corpus of AAG patients compared to that of control
subjects (mean 4.9±0.3 and mean 4.3±0.2 per 100 epithelial cells, respecti-
vely). TUNEL assay showed a higher grade of apoptosis in the gastric
corpus of AAG patients compared to that of control subjects.
Conclusions: We here show that intraepithelial lymphocytosis and epithe-
lial apoptosis are features of AAG. In particular, in the absence of coeliac
disease, H. pylori gastritis, and varioliform gastritis, the intraepithelial
lymphocytosis should raise the suspicion of AAG. Further studies are
necessary to better clarify the pathological mechanisms underlying AAG.
166. A RARE LESION OF THE PANCREAS
Noviello M., Gesualdo A., Bonfrate L., Belfiore A., Buonamico P., Palmieri
V.O., Pugliese S., Minerva F., Portincasa P.
Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human
Oncology, University of Bari Medical School
A 43 years old man with recurrent epigastric pain and weight loss (7 Kg)
in the last 6 months came to our attention. He suffered of hiatal hernia
and gastroesophageal reflux disease. No alcohol abuse was recorded (daily
potus 15 gr). Bioumoral tests were otherwise normal. A prior abdominal
ultrasonography (US) found a mass of the pancreatic head while the abdo-
minal computed tomography scan (CT) revealed dishomogeneity with
increased volume and a 3 cm hypodense area of the pancreatic head. The
differential diagnoses were pancreatic neoplasm or chronic pancreatitis
(i.e. autoimmune since chronic alcohol consumption was absent). Fluo-
rodeoxyglucose positron emission tomography (PET-CT) scan showed
moderate increase of glucose metabolism at the head of the pancreas with
associated hypermetabolic peripancreatic lymphadenopathy. The abdo-
minal Nuclear Magnetic Resonance (NMR) revealed cystic structures in
the space between the duodenum and the pancreas, with duodenal wall
thickening. An endoscopic US was performed and biopsy plus histology
diagnosed a chronic pancreatitis. A final diagnosis of groove pancreatitis
was made and the patient was treated conservatively (total abolition of
alcohol consumption and smoking) and followed up to 12 months, so far
(totally asymptomatic).
Conclusions: Groove pancreatitis is a rare cause of chronic pancreatitis
that affects the groove area (i.e., the anatomic space between the head of
118° Congresso Nazionale - Società Italiana di Medicina Interna
pancreas, duodenum and common bile duct). The lesion can mimic or
coexist with pancreatic carcinoma, and is still a diagnostic challenge for
clinicians. Groove pancreatitis should be considered in the differential
diagnosis of patients presenting with pancreatic head lesions. The diagno-
sis requires a complete workup to correctly manage this rare condition.
167. EFFECT OF LACTOBACILLUS REUTERI (DSM 17938)
ON METHANE PRODUCTION IN PATIENTS AFFECTED
BY FUNCTIONAL CONSTIPATION: A RETROSPECTIVE
STUDY
Ojetti V. 1, Petruzziello C. 1, Migneco A. 1, Gnarra M. 2,
Gasbarrini A. 1, Franceschi F. 1
1
Department of Medical Sciences, Division of Gastroenterology, Catholic
University of the Sacred Heart, Rome, Italy 2Dermatology Unit, Columbia
University Medical Center, NYC, NY, USA.
Objective: Constipation is a common symptom affecting up to 30% of the
Western population and is strongly associated with the presence of intestinal
methanogens, which may directly inhibit motor activity. Two recent studies
performed on adult and children affected by chronic constipation showed
that the supplementation with L. reuteri signi cantly improved bowel move-
ments. Whether its action is related to a decreasing of methane (CH4) pro-
duction has never been tested. We have therefore designed a study aimed at
testing this hypothesis.
Patients and Methods: Data of 20 adults (12 females, mean age 36.2 ± 13.7)
affected by functional constipation, treated with the probiotic L. reuteri
(DSM 17938) for 4 weeks who performed a H2/CH4 lactulose breath test
(LBT) in our institution showing a CH4 production higher than 5 ppm were
retrospectively analyzed from March to June 2015. Data recorded in their
stool diary, reporting the frequency of defecations and stool consistency
were also analysed, as well as the result of the LBT performed at the end of
the treatment with L. reuteri.
Results: Four weeks of L. reuteri administration was associated with a signi
cant decrease of mean CH4 production determined by LBT(from20.8±15
to8.9±8.6;p<0.0001CI95%) and of AUC value (from 5101.5 ± 3571.13 to
2128.4 ± 2110.8; p < 0.0001 CI 95%). Moreover, a total disappearance of
CH4 production (< 5 ppm at LBT) was observed in 11 patients, while, we
did not observe any signi cant decrease of H2 production (from 13.2 ± 8.8
to 11.4 ± 7.3, CI 95%, n.s.).
Conclusions: This study highlights for the first time the beneficial effect of
Lactobacillus reuteri (DSM 17938) on chronic constipation, via a signficant
decrease of CH4 production.
168. MAY GENDER OR ETHNICITY AFFECT DELTA OVER
BASELINE VALUES OBTAINED BY 13-C UREA BREATH
TEST?
Petruzziello C. 1, Sinatti D. 1, Gnarra M. 2, Migneco A. 1, Tesori V. 1,
Graziani C. 1, Gasbarrini A. 1, Franceschi F. 1, Ojetti V. 1
1
Department of Gastroenterology and Internal Medicine, Catholic
University, Rome, Italy 2 Dermatology Unit, Columbia University Medical
Center, NYC, USA.
Introduction: 13C-urea breath test (UBT) is a non-invasive test for
detecting active H.pylori infection. Previous studies showed a correlation
of delta over baseline (DOB) values with bacterial load, mucosal inflamma-
tion and successful eradication. Gender has been shown to affect DOB in
children. Aim of our study was to verify whether gender or ethnicity affects
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-
tient unit, from October 2015 to October 2016. Patients were divided based
on gender and ethnicity; mean DOB values were then compared.
Results: 686 pts (23.4%, 258M/428F, mean age 45±17 years) of 2922 pts
showed a positive UBT. Prevalence of H.pylori infection was significant
higher in males compared to females (29% vs 22%; p=0, 03). Females
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,
28% in those from South America and 40% in both those coming from
Africa and Asia. We found significant higher DOB values in Italians compa-
red to non-Italian (mean DOB 36±27vs69±32; p<0.0001).
Conclusion: Our study showed that in our geographic area, prevalence
H.pylori infection is higher in males. Moreover, it demonstrates for the first
Poster
time that adult females show a significant higher DOB compared to males
(p=0, 008). Whether this effect may be due to hormonal differences, able to
influence gastric emptying, bacterial load, or even the production of urease
by H.pylori, merits further investigation.
169. A CASE OF CVID-ASSOCIATED INFLAMMATORY
BOWEL DISEASE: DIAGNOSIS AND CLINICAL
MENAGEMENT
Menghini D., Danieli G., Macedoni T., Pedini V., Danieli M.G., Gabrielli A.
Clinica Medica, Università Politecnica delle Marche & Ospedali Riuniti,
Ancona
Aim of the Study: To describe our experience on the diagnosis and therapy
of Common variable immunodeficiency (CVID)-related malabsorption.
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
a weight loss of 10 kg in the last six months. Her medical history inclu-
ded psoriatic arthritis, splenectomy for an idiopathic thrombocytopenic
purpura, multifactorial anemia and osteoporosis. In the past, the diarrhoea
was considered the consequence of recurrent gastrointestinal infections in
an immunodeficient patient. On physical examination, the patient did not
have abdominal pain and was apyretic. Her weight was 33 kgs and the BMI
was 14, both indicating a severe underweight. Our first aim was to identify
the right one among the most common causes of diarrhoea and malabsorp-
tion (gastrointestinal infections, inflammatory bowel diseases, neoplasms,
pancreatic insufficiency). The patient underwent blood tests, chemical and
parasitological stool exams, coproculture, HGBT (to screen for SIBO),
gastroscopy, colonoscopy, abdominal and thoracic computed tomography.
We did not test the patient for lactose intolerance because her diet was
already lactose-free. The study showed a severe malabsorption syndrome,
with no signs of pancreatic failure, neoplasms or gastrointestinal infections.
The gastroscopy revealed a mild gastroduodenitis, negative for H. pylori.
We excluded the diagnosis of celiac disease because of the histology, the
absence of the characteristic autoantibodies and of HLA DQ-2 and DQ-8
haplotypes. The colonoscopy showed a chronic colitis, with ulcers and
inflammatory pseudopolyps. The histopathological examination revealed
crypt distortion, crypt microabscesses, a mucosal inflammatory infiltrate
composed by lymphocytes, plasma-cells and neutrophils and some aspects
resembling a collagenous colitis. We made the diagnosis of “CVID-asso-
ciated inflammatory bowel disease”, which is a typically CVID-related con-
dition similar to Crohn’s disease and ulcerative rectocolitis, but with some
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-
ment, the patient continued subcutaneous immunoglobulins (8 g/weekly)
and started a supplemental parenteral nutrition supplied by a central venous
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
the CVC and to stop adalimumab for a sepsis sustained by S. Aureus. Upon
adalimumab withdrawal, diarrhoea and psoriasis relapsed. A few months
later, the patient restarted high-dose steroids and parenteral nutrition, with
a significant improvement. We are now trying to reintroduce the anti-TNF
alfa therapy, with a particular attention to the risk of infections.
Conclusions: About 9-20% of patients with CVID may develop a CVID-as-
sociated inflammatory bowel disease. Malabsorption can be a severe com-
plication of this condition, whose treatment can be challenging, as the use
of immunosuppressants may increase the infectious risk. A supplemental
parenteral nutrition can be useful, even if it strongly increases the proba-
bility of sepsis.
170. AN UNEXPECTED BIOPTIC FINDING
Periti G. 1, Francione P. 1, Spreafico S.M. 2, Bignamini D. 2,
Airaghi L.M. 2, Fargion S. 1
1
Medicina Interna ad Indirizzo Metabolico, Università degli Studi di Milano 2
IRCCS Ospedale Maggiore Policlinico di Milano
We report a case of a 84-year-old patient who came to our attention for
persistent aqueous diarrhea of osmotic type started in the previous three
weeks, associated with a 3-Kg weight loss and tenesmus. For the persi-
stence of numerous bowel movements, 5-6/day, and rectal pain during
evacuation, the patient presented at emergency department where exams
showed mild renal failure. He reported a history of a long-standing hyper-
129
Poster
tension, treated with angiotensin II receptor blocker and beta-blocker
beside statin and glaucoma medications. He denied laxative and antibio-
tics use in the last months as well as travelling to foreign countries. He
reported that none of his family members had similar symptoms. During
hospital stay, he underwent routine examination: complete blood count
and differential leucocyte count were normal, he was mildly hypoalbu-
minemic and showed a mildly elevated RPC while aminotransferases,
alkaline phosphatase and bilirubin were normal. The physical examina-
tion was also normal.The patient did a full abdomen echo-scan, which
resulted negative, and a colonoscopy with multiple biopsy. Erythema and
granularity of the colic mucosa and eosinophilic infiltration of the lamina
propria were detected. A diagnosis of eosinophilic colitis was made and all
the possible causes were investigated (idiopathic hypereosinophilic syn-
drome, autoimmune disease, rare helminthic infections, neoplasia).
171. LIVER TRANSPLANTATION IN PATIENTS WITH
ALCOHOLIC LIVER DISEASE: A RETROSPECTIVE STUDY
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,
Di Giuda D. 4, Agnes S. 5, Grieco A. 1, Gasbarrini A. 1, Addolorato G. 1
1
Dipartimento di Medicina Interna, Gastroenterologia e Malattie del Fegato,
Università Cattolica del Sacro Cuore, Roma, Italia; 2 Dipartimento di Scienze
Mediche, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni
Rotondo, Italia; 3 Dipartimento di Medicina Interna, Università di Ghana,
Accra, Ghana; 4 Istituto di Medicina Nucleare, Università Cattolica del Sacro
Cuore, Roma, Italia; 5 Dipartimento di Chirurgia Generale, Centro Trapianti
di Fegato, Università Cattolica del Sacro Cuore, Roma, Italia
Background: Alcoholic liver disease is the most common liver disease in
the Western World. Alcohol abstinence represents the gold standard for its
treatment. When liver function fails to improve in spite of alcohol absti-
nence, liver transplantation is the treatment of for end-stage alcoholic liver
disease; however, many transplant centers are still reluctant to transplant
these group of patients because of the risk of alcohol relapse, recurrence
of the primary liver disease and associated post transplant complications.
The aim of this study was to assess survival rate, prevalence of primary liver
disease recurrence, re-transplantation and post-transplant complications
among transplanted patients for alcoholic cirrhosis compared with those
transplanted for viral cirrhosis and the associated risk for post-transplant
complications.
Methods: Clinical data of 400 consecutive patients transplanted at Gemelli
Hospital from January1995 to April 2016 were retrospectively collected.
Among them, only transplanted patients for alcoholic and viral cirrhosis
were included in the statistical analysis. Survival rate was evaluated accor-
ding to the Kaplan-Meier method. Recurrence was defined as histological
evidence of primary liver disease. Data on the onset of complication, causes
of death and graft failure after liver transplant were collected.
Results: There was no difference regarding survival rate between the
two groups. Only patients transplanted for viral cirrhosis presented with
primary liver disease recurrence. For post-transplant complications, there
was a higher rate of cancer developing in the transplanted patients for
alcoholic cirrhosis. Cancer was the major cause of death in this population.
Risk factors associated with the onset of cancer were a high MELD score at
the transplant time and smoking after transplantation.
Conclusion: Alcoholic liver disease is a good indication for liver transplan-
tation. Patients transplanted for alcoholic cirrhosis should be subjected to
regular cancer screening and they should be advised against smoking.
172. A CASE OF FOLLICULAR LYMPHOMA OF DISTAL
DUODENUM IN PATIENTS WITH FEW SYMPTOMS
Borgheresi P. 1, De Donato M.T. 2, Renis M. 3, Di Filippo F.M. 1
1
UOC Gatroenterologia e Bleeding Center AOU Salerno, 2UOC Medicina
AOU Salerno, 3UOC Medicina P.O. Cava de’ Tirreni AOU Salerno
Introduction: Follicular lymphoma is the most common subtype of indo-
lent non-Hodgkin’s lymphoma. Most patients present Ann Arbor stage III
or IV; only 5-10% patients present early stage I or II. Intestinal follicular
lymphoma have favorable clinical courses, different from their nodal coun-
terpart. Case-report: M, 60.To our observation because of gastric pain and
decrease in body weight. He underwent esophagogastroduodenoscopy
(EGDS): multiple whitish nodules in distal duodenum. Biopsy samples
showed tumor follicles with germinal center. The immunophenotyping
130
118° Congresso Nazionale - Società Italiana di Medicina Interna
showed B-cell lymphoma (BCL)2+ and CD20+ positive. The patient
underwent video-capsule enteroscopy that showed several similar lesions in
the proximal tract of small bowel and a lesser number in ileum. So he was
referred to the Hematology unit, underwent CT - PET scanning and bone
marrow examinations. He was assigned Ann Arbor stage IE.
Discussion: Intestinal follicular mainly involve duodenum. Since develop-
ment of enteroscopy devices, such as double-balloon and video-capsule
enteroscopy, we can study involvement of jejunum and ileum. Among inte-
stinal follicular lymphomas, the cases of lesions in jejunum and ileum range
from 66.7% to 100%.
Conclusions: These results emphasize the importance of enteroscopy exa-
minations to precisely evaluate the extent of intestinal lesions in follicular
lymphoma patients.Internists should be aware that follicular lymphoma
patients with gastrointestinal involvement must be investigated according
to the general guidelines for systemic follicular lymphoma.
173. OCCURRENCE OF SARCOPENIA AND FATIGUE IN
INFLAMMATORY BOWEL DISEASE PATIENTS
Scaldaferri F. 1, Pizzoferrato M. 1, Rizzatti G. 1, Ingravalle F. 1,
Poscia A. 5, Petito V. 1, Graziani C. 1, Lopetuso L.R. 1, Landi F. 3, Marzetti E. 4,
Martone A. 4, Mentella M.C. 2, Miggiano A. 2,
Mele M.C. 2, Gasbarrini G. 1, Gasbarrini A. 1
1
Catholic University of Sacred Heart of Rome-A. Gemelli
Hospital Gastroenterological Area, Gastroenterological and
Endocrino-Metabolical Sciences Department, Rome, Italy;
2
Catholic University of Sacred Heart of Rome-A. Gemelli
Hospital Nutrition Team, Rome, Italy; 3Catholic University of
Sacred Heart of Rome-A. Gemelli Hospital, Center for
Geriatric Medicine (CEMI), Institute of Internal Medicine
and Geriatrics, Rome, Italy; 4Catholic University of Sacred
Heart of Rome-A. Gemelli Hospital, Department of Geriatrics, Neurosciences
and Orthopedics, Rome, Italy; 5Catholic
University of Sacred Heart of Rome-A. Gemelli Hospital,
Institute of Hygiene, Rome, Italy
Background: Inflammatory bowel disease (IBD) are often associated with
malnutrition and variation in the body weight, mostly weight reduction,
which recognize a multifactorial etiology. In this context up to one third
of Crohn’s disease (CD) patients and up to one fourth of ulcerative colitis
(UC) patients have evidence of a muscular mass reduction of any degree
which is not caught by common body weight measures such as body mass
index (BMI). Still, data on the prevalence of sarcopenia and fatigue in these
conditions is lacking, especially in the setting of Italian IBD centers. Aim of
the study was to evaluate the incidence of chronic fatigue and sarcopenia in
inflammatory bowel disease patients followed by our center and to compare
them with a matched healthy control population.
Material and Methods: Patients with an established diagnosis of inflamma-
tory bowel disease followed at the Fondazione Policlinico A. Gemelli center
were prospectively enrolled in the study.
Disease activity was evaluated by means of the partial Mayo score for UC
and of the Harvey-Bradshaw index for CD.
A specific questionnaire was used to evaluate fatigue in IBD patients as well
as in controls which included a VAS scale (range 0-100) to evaluate percei-
ved muscular strength and questions to assess impairment in movement
abilities and in daily activities.
Sarcopenia was evaluated by means of Dual-energy X-ray absorptiometry
(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.
Sarcopenia was defined as ASMI values below 1 standard deviation (SD),
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
between groups were carried using two-tailed variance analysis with Bon-
ferroni test. Statistical significance was defined for P<0.05.
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),
the average age was 40.2 years and the average BMI was 24.98, 35% of the
patients underwent IBD-related surgery and the most common therapy was
anti-TNF alpha (42%).
For comparison purpose we also enrolled 46 healthy subjects, 47.8% (n=22)
females and 52.2% males (n=24), the average age was 36.7 years and the
average BMI was 25.7.
In terms of perceived muscular strength the average VAS score was lower for
IBD patients in comparison to healthy controls (56.7 versus 68.7 respecti-
118° Congresso Nazionale - Società Italiana di Medicina Interna
vely, p<0.05).
Movement abilities was impaired in 28% IBD patients, while only 3.6% of
the healthy controls reported an impairment (p<0.05).
IBD patients also reported a higher grade of daily activities impairment in
comparison to healthy controls (43.5% versus 10.7% respectively, p<0.05).
Sarcopenia, as defined above, was present in 44.2% of IBD patients in com-
parison to 6.5% of healthy controls (p<0.01). ASMI was significantly lower
in IBD patients in comparison to healthy controls (6.72 kg/m2 versus 7.27
kg/m2 respectively, p<0.05).
When analyzing ASMI scores in relation to IBD related therapies we found a
significant differences between patients on steroid therapy in comparison to
those not receiving steroids (ASMI 6.10 kg/m2 versus 6.96 kg/m2 respecti-
vely, p<0.05), while we did not find differences between patients with and
without anti-TNF alpha therapy.
Conclusion: Prevalence of sarcopenia and chronic fatigue is high in IBD
patients. Sarcopenia also correlate with steroid therapy while no significant
difference was found in patients with anti-TNF alpha.
174. A STRANGE CASE OF INTESTINAL
MALABSORPTION
Bellacosa L., Cogliandro R., Cremon C., Barbara G., Stanghellini V.
Department of Medical and Surgical Sciences, University of Bologna, Italy
A woman aged 67 years was referred to our Department for a 6-month
history of diarrhoea associated with abdominal bloating and severe weight
loss (13 kg). The patient has been suffering for many years of rheuma-
toid arthritis initially treated with methotrexate, stopped after a few years
because of the onset of leukopenia and anemia. After that she started tre-
atment with etanercept, also suspended after two years because of a poor
tolerance profile (onset of fever and diarrhoea).
Physical examination revealed that her abdomen was distended but not
painful at palpation, without palpable masses or hepatosplenomegaly, bowel
sounds were increased; cardiopulmonary examination was normal. Due to
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
endoscopy revealed numerous whitish patches within the distal duodenal
mucosa, and histological examination showed typical findings of Whip-
ple’s disease. Abdominal ultrasound documented a periaortic thickening
with a few small retroperitoneal lymphadenopathies and a noticeable inte-
stinal walls and mesenteric thickening. Therefore, an abdominal CT scan
was performed demonstrating inhomogeneous retroperitoneal solid tissue
widespread along the mesenteric vessels. Biopsies obtained under ultraso-
nographic control exclusively revealed fibrotic tissue and the diagnosis of
Ormond’s disease was formulated.
Retroperitoneal fibrosis, also known as Ormond’s disease, is a rare disorder
characterized by the progressive development of fibro-inflammatory tissue
in the retroperitoneum resulting in entrapment and obstruction of retrope-
ritoneal structures, notably the ureters and arteriovenous system, leading to
the clinical manifestations.
The pathophysiology of retroperitoneal fibrosis is uncertain. Among the
most common causes of this disease there is the prolonged use of certain
medications, such as antitumoral chemotherapeutics (e.g. methotrexate)
and bio-pharmaceutical agents (e.g. the tumor necrosis factor-α receptor
blocker, etanercept). Therefore, we described a case of Whipple’s disease and
retroperitoneal fibrosis, resulting in intestinal malabsorption, both related
to the use of immunomodulating drugs.
175. A MULTICENTRE, RANDOMIZED, CONTROLLED,
SINGLE-BLIND, CROSS-OVER STUDY ASSESSING THE
EFFECT OF ZESPRI GREEN KIWIFRUIT ON DIGESTIVE
FUNCTIONS IN CONSTIPATED PATIENTS
Cremon C. 1, Ansell J. 2, Pagano I. 1, Kuhn-Sherlock B. 3,
Drummond L. 4, Barbaro M.R. 1, Capelli E. 1, Belacosa L. 1, Cogliandro R. 1,
Stanghellini V. 1, Barbara G. 1
1
Università di Bologna, Policlinico S. Orsola – Malpighi, Azienda Ospedaliero
- Universitaria di Bologna 2Mt Maunganui, New Zeland 3Hamiton, New
Zeland 4Leeston, New Zeland
Digstive discomfort, including constipation, is a common condition throu-
ghout the world. Gastrointestinal discomfort and bowel habit are two target
areas for potential health claims for foods identified by EFSA. Green kiwi-
Poster
fruit is often used as natural food for the relief of constipation. We perfor-
med a multicentre, randomised, controlled, single-blind, cross over clini-
cal trial to assess the effect of green kiwifruit on digestive and gut health
functions. As a part of an international study which involved three sites
around the world using the same protocol (New Zealand, Italy, and Japan),
we enrolled three cohorts of participants: 20 healthy controls, 20 patients
with functional constipation (FC) and 20 patients with irritable bowel syn-
drome with constipation (IBS-C), according to Rome III criteria. The study
duration was a total of 16 weeks; 2-week lead in, 4-week first intervention,
4 week washout, 4-week second intervention, and final 2-week follow-up.
The cross-over design was completed using kiwifruit intervention (2 green
kiwifruit per day [Actinidia deliciosa var. Hayward]), compared to a posi-
tive control intervention of psyllium (7.5g of psyllium per day). The primary
outcome measure was quantification of complete spontaneous bowel move-
ment (CSBM). Secondary outcome measures included additional stool
frequency measures (spontaneous bowel movements [SBM], complete
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
sample collection was required for immune measures and DNA extraction
to microbial analysis. The primary outcome measure (quantification of
CBSM) was found to be significantly improved by kiwifruit as compared
with psyllium.
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-
ceptable loss of the control effect. Interestingly, better results were obtained
in patients with FC as compared with IBS-C. Similar results were obtained
for all the analysed secondary outcome measures, suggesting the non-infe-
riority of kiwifruit in comparison with psyllium. In this study we demon-
strated the efficacy and safety of kiwifruit as a food intervention for the relief
of constipation and associated symptoms in patients with FC and IBS-C,
using validated outcome measures. As empiric therapy should begin with
a fibre supplement in constipated patients, including psyllium, also kiwi-
fruit should be considered in these patients. ClinicalTrials.gov Identifier:
NCT02888392.
176. IMPACT OF LIVER STEATOSIS IN PATIENTS WITH
CELIAC DISEASE ON A GLUTEN-FREE DIET
Tovoli F., Farì R., Granito A., Faggiano C., Guidetti E., Negrini G., Bolondi L.
Department of Medical and Surgical Sciences, University of Bologna
Introduction: Recent reports suggest that patients affected by celiac disease
(CD) may be at increased risk of metabolic syndrome after beginning a glu-
ten-free diet (GFD). Also, an electronic register population study perfor-
med in Sweden suggested that CD patients are more prone at receiving a
diagnosis of non-alcoholic fatty liver disease (NAFLD) in their follow-up,
compared to the general population. Data about the prevalence of NAFLD
in CD patients obtained in a real life clinical practice are lacking and may
be helpful in improving dietary prescriptions and in better understanding
the complex gut-liver interactions of CD patients. Methods: A total of 175
CD outpatients were evaluated in our tertiary centre between February 2016
and June 2017 (inclusion criteria: CD diagnosed according to NASPGHAN
recommendations, following a strict GFD since at last 6 months; exclusion
criteria: alimentary transgressions and/or contaminations, known causes of
chronic liver disease including alcohol and drugs).
A control group of 175 matched subjects on an unrestricted diet was created
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
diabetes.
All of the patients underwent a liver ultrasound (US) examination to detect
steatosis according to the Hamaguchi criteria. The US findings were corre-
lated with clinical and laboratory data.
Results. In terms of raw prevalence, liver steatosis was found in 34.3% and
24.6% of CD and control patients, respectively (p=0.04). Analyzing only
patients with BMI<25, the gap was even more considerable (19.4 vs 4.3%,
p<0.001).
A multivariable binary logistic regression was performed using presence of
steatosis as the independent variable was performed. Independent predi-
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-
rol [Exp(B) 1.014 (95%CI 1.004-1.023), p=0.004], and alanine aminotran-
sferase [Exp(B) 1.021 (95%CI 1.004-1.037), p=0.013]. Age, sex and triglyce-
rides were not associated with liver steatosis. A further logistic regression
131
Poster
was performed in the group of CD patients: no correlations were found
between liver steatosis and pediatric age at the diagnosis (p=0.231) or dura-
tion of the GFD (p=0.310).
Conclusions: CD patients on a GFD have an increased risk of liver stea-
tosis compared to a matched population, confirming previous findings on
electronic registries. This risk is independent for other common metabo-
lic risk factors such as BMI, cholesterol and diabetes. Consistently (and
even more interestingly), steatosis was found in almost 20% of CD patients
with normal BMI. Accurate alimentary analyses and further evidences are
needed to clarify which are the most probable amongst the putative expla-
nations, which include the high-fat content of the GFD and a persistently
increased intestinal permeability.
177. PANCREATITIS IN PORTAL CAVERNOMA: AN
INUSUAL ASSOCIATION?
Zingaro M.T., de Vincenzo G.M., Sciancalepore D., Luglio C.V., Antonica G.,
Berardi E., Napoli N., Sabbà C.
Medicina Interna Universitaria “C. Frugoni - Dipartimento Interdisciplinare
di Medicina - Università degli Studi di Bari “A. Moro”
A 27-years-old Caucasian young woman with diffuse abdominal pain, diar-
rhea, fever, nausea and vomit was admitted to our hospital for diagnostic
studies. She didn’t use cigarettes, alcohol or drugs.
Her family and medical history was mute. The patient was in full well-being
until she returned from intercontinental travel in Africa showing the symp-
toms above described.
Laboratory tests underlined: PCR 94, 5 mg/L (x 32.6), Fibrinogen 604 mg/
dL (x1, 5), ESR 65 mm/h (x 3.3), increased Alpha 11, 0 % (x 2, 2) and Alpha
2 16.9 % (x 1, 4) in the serum electrophoresis, lipase 1001 UI/l(x 2.5), Pan-
creatic amylase 103 UI/l (x 1.9) negative virologic tests (CMV, EBV, Entero-
virus, Adenovirus); Widal-Wright reaction, hemoculture and coprocolture
tests were negative.
According to the clinical findings, our first diagnostic hypothesis was a pan-
creatitis due to a viral infection. We performed abdominal US that showed
slightly increased of pancreatic volume in the body and tail regions with
normal structure. Moreover, the examination revealed the presence of
massive portal cavernoma, confirmed with contrast-enhanced abdominal
CT scan., in the absence of hepatic disease.
Abdominal MR confirmed the presence of the massive portal cavernoma
and increased pancreatic volume. To exclude complications related to portal
hypertension, possibly due to the presence of the portal cavernoma, we per-
formed EGDS with no signs of esophageal varices.
We concluded that in association to a plausible viral gastroenteritis, the
occult portal cavernoma could have been caused the pancreatic dysfunction.
Antibiotic and rehydration therapies were given in addition of gabesato
mesilato (300 mg x 3/die) with rapid improvement in clinical symptoms
although pancreatic function blood tests didn’t normalize.
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
our patient, due to the portal congestion.
178. EARLY DIAGNOSIS OF DEGENERATIVE DEMENTIA
IN A YOUNG ELDERLY WITH HALLUCINATIONS: A CASE
REPORT
Camellini C., Musumeci M., Giorno A., Grassi A., Servello A., Cacciafesta
M., Ettorre E.
Dipartimento Di Scienze Cardiovascolari, Respiratorie, Nefrologiche,
Anestesiologiche E. Geriatriche, Sapienza Universita’ Di Roma
We report the case of a 65 years old patient, accompanied by his general
practitioner in our Alzheimer Evaluation Unit for the appearance since one
month of worsening visual hallucinations and insomnia.The patient did
not take any drugs and she did not report any known pathology in history;
she had already performed a brain MRI, which pointed out the presence of
rare and millimetric hyperintensis areas, localized at the white front right
substance which did not show enhancement after administration of con-
trast and therefore referable to gliotic outcome on ischemic cerebrovascular
basis. She had also performed blood analysis, which showed no significant
alterations; a carotid ultrasound, which displayed a fibro-calcified plaque
causing a 30% stenosis in the right internal carotid; and an electroencepha-
logram, which showed non-specific slow abnormalities in temporo-occipi-
132
118° Congresso Nazionale - Società Italiana di Medicina Interna
tal position bilaterally, more obvious to the right. It was performed a mul-
tidimensional geriatric assessment with administration of cognitive tests.
The Mini Mental State Examination showed that the patient was partially
oriented in time and well oriented in space, with good capacity of recording,
recall, attention, calculation and language; the test pointed out a deficit in
praxic-building skills (27/30 raw; adjusted for age and education 25.4/30).
The Montreal Cognitive Assessment demonstrated that the patient had pre-
servation of attentional capacity, naming, abstraction and verbal fluency,
with impaired ability of planning in space, visuospatial and executive abili-
ties, delayed recall (MoCA: 22/30; cut-off> 26/30). The patient had become,
in a short time, partially dependent on the basic activities of everyday life
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
to not properly understand test instructions on more than one occasion.
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
attention. The processing speed of the information was severely reduced.
She had a deficit in learning structured verbal material and visual-spatial
memory. No compromises were found in spoken language (anomies). She
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
were found in abstraction and logical reasoning.The scintigraphic investi-
gation, performed by SPECT acquisition of the skull after about four hours
later on administration e.v. of the neuroreceptorial tracer, highlighted a
severe reduction of receptitivity for the pre-synaptic dopaminergic analo-
gue in the right streaked body; a similar picture, though mild, was present
in the left streaked body. Then we provided a clinical diagnosis of Lewy
Body Dementia (LBD) and, after excluding bradycardia with an electrocar-
diogram, we prescribed therapy with rivastigmine 4, 6 mg patch/24 hours,
increasing dosage after one month to 9, 5 mg. Two months following onset
of therapy, our patient showed a remarkable improvement, with a clear
reduction in visual hallucinations.
The only other form of degenerative dementia that is more common than
LBD is Alzheimer’s disease (AD). LBD is an umbrella term for dementia
associated with the presence of Lewy bodies (abnormal deposits of a protein
called alpha-synuclein) in the brain: it refers to both Parkinson’s disease
dementia and dementia with Lewy bodies. The earliest symptoms of these
two diseases differ, but reflect the same underlying biological changes in
the brain. Over time, people with both diagnoses will develop very similar
cognitive, physical, sleep, and behavioral symptoms. Early diagnosis allows
for important early treatment that may extend quality of life and indepen-
dence. Early and accurate diagnosis is important because LBD patients may
react to certain medications differently than AD or PD patients. A variety
of drugs, as many traditional antipsychotic medications (for example, halo-
peridol, thioridazine) prescribed for individuals with Alzheimer’s disease
and other forms of dementia to control behavioral symptoms as long as hal-
lucinations, can worsen LBD symptoms. Early recognition, diagnosis and
treatment of LBD can improve the patients’ quality of life.
179. A CASE OF CORTICOBASAL DEGENERATION
PRESENTING WITH ALIEN LIMB SYNDROME AND NON-
FLUENT APHASIA
Giorno A., Camellini C., Musumeci M., Grassi A., Servello A., Cacciafesta
M., Ettorre E.
Dipartimento Di Scienze Cardiovascolari, Respiratorie, Nefrologiche,
Anestesiologiche E. Geriatriche, Sapienza Universita’ Di Roma
We report the case of a 70 years old woman, accompanied by his daughter
in our Alzheimer Evaluation Unit for the appearance since three years of
progressive difficulty in naming, initial memory deficit, non-fluent aphasia,
tremors of left hand and difficulty in controlling the movement of the limb;
she had also become depressed. In hystory: hypertension treated with val-
sartan and osteoarthritis. She had already performed a brain MRI two years
before, which showed no alterations; she had repeated a new brain MRI
before the visit, which pointed out the presence of significant dilatation of
subarachnoid liquor spaces of the vault and base in relation to cortical-sub-
cortical atrophy phenomena. Blood analysis didn’t show any abnormal
value. It was performed a multidimensional geriatric assessment with admi-
nistration of cognitive tests. The Mini Mental State Examination showed
that the patient was oriented in time and space, with good performances in
recording, oral language such as repetition, written language such as under-
standing and executing written orders, writing and short term memory; the
patient presented deficit in naming, attention, calculation and praxic-bu-
118° Congresso Nazionale - Società Italiana di Medicina Interna
ilding skills (MMSE 24/30 raw; adjusted for age and education 21.4/30).
The patient was independent in basic activities of daily living and partially
dependent in those instrumental (ADL 6/6; IADL 4/8). It was therefore per-
formed a second level analysis with neuropsychological evaluation, which
highlighted language deficits, executive function deficits and prasic-con-
structive deficits. Extensive neurological examination showed off that the
left hand limb was characterized by ideomotor apraxia, severe rigidity, bra-
dykinesia, postural tremor. There was also a parkinsonian gait. According
to all these findings we provided a clinical diagnosis of Corticobasal dege-
neration (CBD). Clinical features could be explained by involvement of the
cortical and sub-cortical structures. Cortical-related features may include
apraxia, alien limb phenomenon, focal dystonia and myoclonus. Cognitive
and behavioural problems may include non-fluent aphasia and visuospatial
impairment.
Eye movements are preserved. Involvement of sub-cortical structures results
in highly asymmetrical parkinsonism. Therefore we prescribed therapy with
levodopa/carbidopa 125/12, 5 mg twice a day, increasing dosage after one
month to 250/25 mg three times a day. Three months following onset of
therapy, our patient did not showed an improvement of the motor impair-
ment. Corticobasal degeneration is a rare and quickly progressive neuro-
degenerative disease, by unknown causes, manifesting in movement disor-
ders and cognitive impairment. Typically it appears between the sixth and
seventh decade, with equal distribution between sexes. More than one cere-
bral area is involved, in particular the parietal cortex and the ganglia of the
base. The diagnosis is difficult, especially in the early stages of the disease,
in fact it requires special attentions and accurate comparisons with other
types of dementia. Diagnosis is based upon clinical criteria; there have also
been different molecular imaging studies, even if in rather small cohorts.
The CBD has become a topic of considerable interest. Yet, despite many
reports, there are no agreed diagnostic criteria. The disease is characterized
by abnormal tau deposition that affects neurons and glial cells, including
astrocytes and oligodendroglia cells. The movement disorder is characte-
rized by asymmetrical rigidity and levodopa-resistant parkinsonism with
apraxia and variable other features, including cortical sensory loss, alien
limb phenomena, myoclonus and dystonia. Cognitive abilities are relatively
preserved. In fact, early dementia is an exclusion criterion. The response
to levodopa should be tested with at least 25/250mg of carbidopa/levo-
dopa administered three times a day for at least 2 months. The response to
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-
dual symptoms are targeted with specific medications. For example, rigi-
dity and difficulty walking may partially respond to treatments for Parkin-
son’s disease. Dystonia and myoclonus may respond to muscle relaxants or
anti-seizure medications. Memory and behavior problems may or may not
respond to treatments, such as donepezil, for Alzheimer’s disease. Depres-
sion and/or anxiety can be treated with an antidepressant, such as sertraline,
citalopram or escitalopram.
180. HEMORRHAGIC SHOCK IN HOSPITALIZED
ELDERLY PATIENTS: WHEN THE GUIDELINES MISS THE
MARK
Martino G.P. 1, Manfredi L. 2, Girotti S. 3, Benfaremo D. 3, Astorri F. 1,
Arma P. 2, Bitti G. 1, Marzan S. 1, Moriconi V. 1, Zega G. 2, Angelici S. 1
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
Ancona, SOD. Clinica Medica
Introduction: Hemorrhagic shock in the Internal Medicine ward was con-
sidered to be a rather rare occurrence, but there are no reliable data on its
actual incidence in literature. Nevertheless, it represents an insidious com-
plication and its incidence is surely increasing since elderly people affected
from several cardiovascular conditions, with multiple comorbidities (i.e. the
patients that are usually seen in Internal Medicine departments), are often
taking antithrombotic and/or anticoagulant therapy.
Case Report 1: An 89-year-old woman with a history of ischemic heart
disease (IHD) and grade III-IV chronic renal disease (CKD) was admit-
ted for heart failure and high ventricular response atrial fibrillation (AF).
During hospitalization, diuretics, antiarrhythmic and enoxaparin (4000 UI
bid) were administered. The hospitalization was complicated by hemorrha-
gic shock from spontaneous retroperitoneal hematoma replenished by a
right lumbar artery.
Case Report 2: An 83-year-old man with a history of IV grade CKD, IHD
and AF was admitted for heart failure and moderate range anemia (Hb 8.5
Poster
g/dl). He was taking acetylsalicylic acid and warfarin (with INR in thera-
peutic range in the last two months). During hospitalization, in considera-
tion of anemia, warfarin was suspended and enoxaparin (2000 U/day) was
started as a strategy for thromboembolism prophylaxis. The hospital stay
was complicated by hemorrhagic shock from a front abdominal wall hema-
toma, which was supplied by a branch of the inferior epigastric artery.
Case Report 3: A 77-year-old man with a history of degenerative cardiomio-
pathy was admitted for heart failure in non-datable AF and left basal pneu-
monia in recent orthopedic surgery for left-sided tibia-peroneal fracture.
He was taking acetylsalicylic acid. Diuretic therapy, enoxaparin (4000 UI
bid) and antibiotics were started. After 10 days of therapy, a hemorrhagic
shock occurred, presenting with severe left thoracic pain and CT evidence
of abundant left pleural effusion, probably of blood nature, atelectasis of the
homolateral pulmonary parenchyma and contralateral mediastinal devia-
tion. Upon chest drainage positioning, there was a rapid leakage of approxi-
mately 2000 ml of blood and a subsequent improvement of the patient.
Case Report 4: An 86-year-old woman with a history of advanced Par-
kinson’s disease with severe dysphagia (in enteral nutrition from a gastro-
stomy), chronic AF, IHD taking acetylsalicylic acid, levodopa + benserazide,
and a proton pump inhibitor. She was admitted for a few days of worsening
dyspnea, right lower limb swelling with superficial venous thrombosis,
hypoxemia on arterial blood gases, right heart dilation on echocardio-
gram and pulmonary infiltrates on the right base. Acetylsalicylic acid was
immediately suspended and anticoagulant therapy was started, first with
enoxaparin (6000 UI bid) and subsequently switched to apixaban (5 mg
bid). After a week of hospitalization, hemorrhagic shock occurred, presen-
ting with melena but negative gastroscopy. The patient refused to undergo
colonoscopy.
Discussion: These clinical cases of acute hemorrhage, observed over 4
months, suggest that the administration of anticoagulant or antithrombo-
tic therapy (in accordance with the treatment guidelines) can also lead to
adverse and fatal events such as hemorrhagic shock. It is well known that
the majority of clinical trials, from which the international guidelines are
drawn up, exclude elderly patients, mostly affected by multiple comorbi-
dities, which are the ones we usually deal with in our wards. In our view,
patient-tailored approaches are needed in older patients, enabling us to pre-
scribe the most appropriate therapy depending on the patient we are facing,
while not forgetting the guidelines we are requested to follow.
181. LOW-MODERATE DYSLIPIDEMIA ASSOCIATE
WITH INTOLERANCE TO STATINS AND METABOLIC
SYNDROME TREATED WITH NUTRACEUTICAL
Marchitto N., Sindona F., Fabrizio A., Mauti M., Visani N., Dalmaso S.,
Raimondi G.
1) Dr. Nicola Marchitto, Medical Director, Alfredo Fiorini Hospital,
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)
Monica Mauti, Nursing student of “Sapienza” University of Rome, Italy. 5)
Visani Nadia, Didactic Director of Nursing Course of “Sapienza” University
of Rome, Italy. 6) Dr.ssa Serenella Dalmaso, Director of ruolo, Alfredo
Fiorini Hospital, Terracina, (Latina), Italy. 7) Prof. Gianfranco Raimondi,
Associated Professor of Internal Medicine. Dept. of Medico-surgical Sciences
and Biotechnologies. “Sapienza” University of Rome, Italy
Abstract: The Metabolic Syndrome is a frequent risk factor for cardiovascu-
lar diseases and type 2 diabetes and consist of different metabolic disorders
like central obesity, insuline resistence, hypertension and dyslipidemia asso-
ciated to high value of triglycerides and low level of High-Density Lipopro-
tein. The prevalence of Metabolic Syndrome increases with age, degree of
obesity and propensity to type 2 diabetes.
Aim: The aim of this study is to evaluate the effect of Nutraceutical [1] with
Policosanoli, Berberina [4], Red yeast Rise, Cassia Nomame, Astaxantina,
Q10 Co-enzime and folic acid in patients with low to moderate dyslipide-
mia [3], intolerance to statins [8] and Metabolic Syndrome.
Methods: We have enrolled 30 patients, with range age 19 – 90 years and
Mean 71 + 19Year, ) that satisfying the NCEP:ATPIII 2001 Criteria for
Metabolic Syndrome [5]. All compliant patients were underwent to the
evaluation of Total Cholesterol (T-Chol), Low-Density Lipoprotein (LDL),
High-Density Lipoprotein (HDL), Triglycerides (TG), Heart Rate Variabi-
lity [6], T-peak to T-end index [7], QTc value and T-peak-end/QTc ratio,
and side effects before and post-administration of standard treatment with
Policosanoli, Berberina [4], Red yeast Rise, Cassia Nomane, Astaxantina,
Q10 Co-enzime and folic acid [1].
133
Poster
Results: Preliminary data shown a statistically significant change in total
cholesterol (230 mg + 33 mg vs 180 mg + 44 mg with p < 0, 001), Low-den-
sity of Lipoprotein (155 mg + 44 mg vs 116 mg + 42 mg with p < 0, 001),
High-Density Lipoprotein (43 mg + 18 mg vs 49 mg + 18 mg with p < 0,
024) and triglycerides (141 mg + 71 mg vs 124 mg + 70 mg with p < 0, 012)
with statistically significant correlation...
Conclusions: Nutraceutical [1]could be a new useful approach in the tre-
atment of patients with Metabolic Syndrome and low or moderate dyslipi-
demia [3] with intolerance to statins [8] and not responsive to non-phar-
macological treatment (lifestyle, diet, behavior modification and physical
activity) [2]. Our preliminary data gives comfortable results.
182. FE++ EDTA ADMINISTRATION IN PATIENTS WITH
SECONDARY ANEMIA. EFFECTS ON HEMOGLOBINE
VALUE, CARDIOVASCULAR RISK AND ADHERENCE TO
THERAPY
Marchitto N., Sindona F., Fusco L, Dalmaso S., Raimondi G.
1) Dr. Nicola Marchitto, Medical Director, Alfredo Fiorini Hospital,
Terracina, (Latina), Italy. 2) Dr Francesco Sindona, Specializing Doctor,
Dept. Int. Medicine. “Sapienza” University of Rome 3) Fusco Liuba, Medical
Doctor, Cardiology Department, Villa Laura, Bologna. 4) Dr.ssa Serenella
Dalmaso, Director of ruolo, Alfredo Fiorini Hospital, Terracina, (Latina),
Italy. 5) Prof. Gianfranco Raimondi, Associated Professor of Internal
Medicine. Dept. of Medico-surgical Sciences and Biotechnologies. “Sapienza”
University of Roma
Abstract: Anemia is a global problem because two billion of people are
affected by blood cells disorder. According to WHO criteria anemia id
defined as blood hemoglobin (Hb) concentration < 130 gr/L (13 gr/dl) or
hematocrit (Hct) < 39% in adult males or (Hb) concentration < 120 gr/L (12
gr/dl) or hematocrit (Hct) < 37% in adult females. In patients with coronary
heart disease, anginal episodes may increase in frequency and severity and
patients with carotid artery disease may develop light-headedness or dizzi-
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
respiratory disease. Therefore anemia evaluation and follow-up is included
in cardiovascular guidelines.
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
deficiency and or low-moderate kidney failure. We have evaluated labora-
tory value of red blood cell, Hb, and iron blood profile. We have evaluated
compliance to therapy using Morinsky Scale and have evaluated the impro-
vement of laboratory value and adherence to therapy before and post-admi-
nistration of fe++ 2 cp/24 hours.
Conclusion: Fe++ EDTA could be a valid alternative to iv therapy (gold
standard) in the treatment of secondary anemia in elderly patients. Our pre-
liminary results are comfortable but not applicable to a broad spectrum of
patients with secondary anemia without an hematological evaluation of the
different causes of anemia.
183. AS A CLEVER MIND FIGHTS THE ALZHEIMER’S
DISEASE: MARIA’S HISTORY!!!
Piccillo G.A. 1, Saitta R. 1, Mondati E.G.M. 2, Gasbarrini G.B. 3
1
Emergency Department, Cannizzaro Hospital Catania: 2Department of
Internal Medicine and Systemic Pathologies, University of Catania; 3Professor
Emeritus of Internal Medicine, Catholic University of Rome
Background Alzheimer’s disease (AD), first described by German Neurolo-
gist Alois Alzheimer in 1901, is a neurodegenerative disorder of uncertain
cause and pathogenesis which primarily affects older adults. It accounts for
more than 50% of the cases of dementia and is one of the leading sources
of morbidity and mortality in the aging population. The most essential
clinical manifestation of AD is selective memory impairment. While tre-
atments are available in order to ameliorate some symptoms of the illness,
currently there is no cure or disease-modifying therapy, and the disease
inevitably progresses in all patients. The incidence and prevalence of AD
increase exponentially after the age of 65 year, though there are rare inhe-
rited forms too (about 1%) that present before 65 y. The AD management
is still symptomatic: treatment of behavioural disturbances, environmental
manipulations to support function, and counselling with respect to safety
issues. Patients generally succumb to terminal-stage complications, such as
134
118° Congresso Nazionale - Società Italiana di Medicina Interna
dehydration, malnutrition, and infection.
Case Report: A 71 year-old woman, who had been a professor of Italian
Language and Literature, Latin and novel writer in her youth, but diagnosed
with dementia 5 years before, was admitted to our Dept for sudden crisis of
aggressiveness when her husband had tempted at home to steal her a book.
Her disease had progressed gradually and she seemed in the last months
completely nonresponsive frequently refusing her medications and being
almost totally non-communicative. In spite of her long career of profes-
sor, she said rarely a single word and often it was not appropriate. She was
almost immobile rarely rising from her wheelchair in months. It was perfor-
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
a noticeable improvement. She improved this much that she wanted to get
up and walk. She was talking some, with more sense, and she was feeding
herself again, she was interactive, reading words in books, asking questions.
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-
story and passions…. She became more talkative lately, she seemed to be
much more aware of her surroundings, she started eating by herself and
eating all of her food, her mood was very good and her clinical condition
continued to improve with old memory return and amelioration in motor
function and verbal response.
Discussion: The AD causes and pathogenesis remain unclear though it
has been hypothesized an infectious or environmental origin, but surely an
important role is played by deficit of ADAM-10 with consequent amyloid
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
not always destroyed in patients with AD. Reading can improve the patient’s
quality of life, since the meanings of written sentences can be understood
by even those who have difficulty handling verbal exchanges. People who
were literate maintain their ability to read until the end stages of dementia.
Reading requires the cooperation of several parts of the brain specialized
in language and seeing with the result to improve also the quality of life of
Alzheimer’s patients!!!
184. DRGS (DIAGNOSIS RELATED GROUPS) IN MEDICAL
AREA: CRITICAL ISSUES IN CONTROL SYSTEMS AND
VALUE
Scotti E. 1., Pietrantonio F. 2
1
Unità Operativa Medicina Generale, Istituto Neurotraumatologico Italiano
(INI), Grottaferrata (Roma); 2U.O. Medicina Interna, Ospedale di Manerbio
(BS) ASST-Garda
Background: The method used to evaluate congruity and therefore the
remunerability of hospitalizations is the PRUO (Review Protocol of Hospital
Use) method which is a remote and ex-ante control that does not take into
account the actual path of the patient with acute symptomatology leading
him to Emergency Department (ED) and requiring a diagnostic framework
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:
1. Risk of inappropriateness. The diseases treated in Internal Medicine Units
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
the admission mainly to the Medical Area to exclude acute illnesses that ED
is not able to rule out (for example, atrial fibrillation, syncope, fever, severe
anemia, complicated diabetes).
2. End stage disease. The remuneration system does not take into account
the end-stage of neoplastic and non-neoplastic pathologies, and the impact
at hospital level and in particular in the Internal Medicine Units.
3. Epidemiological transition that has resulted in an increase in mean age
and comorbidities that impact heavily on the clinical path, on therapy and
on the length of stay.
4. Progressive dismantling of the National Health System which appears
inadequate to respond effectively to the health needs of an aging population
with comorbidities that survive after repeated acute episodes.
Characteristics of the remuneration system: iso-resources and non-isoseve-
rity that would allow comorbidities valorization as, in fact, they absorb most
of resources in patients hospitalized in Internal Medicine. Repeated hospi-
talizations: they are considered inadequate and penalize Internal Medicine
Units and Internists that are the main specialists taking care of complex
polypathologic patients who are subject to ongoing exacerbations of already
diagnosed pathologies.
118° Congresso Nazionale - Società Italiana di Medicina Interna
Proposals: Adequate valorization of DRGs by using APR-DRG (All Patient
Refined DRG) taking into account the comorbidity in determining DRG
value.
Conclusions: Similarly to the tax system that applies taxation to more easily
controllable citizens such as retired and government employees, patients
admitted in Internal Medicine Units being the most numerous and most
sick are also the less valued category of reimbursement system and are
“taxed” by the system with a consequent reduction of resources allocated to
the Medical Area and subsequent reduced ability to adequately take care of
a growing slice of the population.
185. THE ROLE OF SMART CITIES AND COMMUNITIES
IN EARLY DETECTION AND PREVENTION OF FRAILTY
AND COGNITIVE IMPAIRMENT IN CITIZENS USING
UNOBTRUSIVE
METHODS:THE EXPERIENCE OF SIX INTERNATIONAL
METROPOLIS
Ricevuti G. 1, Venturini L.1, Mattiuzzo E. 1, Copelli S. 2, Paolini P. 3, Di Blas N.
3
, Mercalli F. 2
1
University Pavia, Dpt of Internal Medicine and Therapeutics, Geriatrics,
Pavia, Italy
2
MultiMed Engineers SRLS, Parma, Italy
3
Department of Electronics, Information and Bioengineering Politecnico di
Milano Milan, Italy; 2MultiMed Engineers SRLS, Parma, Italy
City4Age is a project, co-funded by the Horizon 2020 Programme of the
European Commission. It will activate urban Communities to facilitate the
role of social/health services and of families in dealing with mild cognitive
impairments and frailty in the elderly population. The challenge is to demon-
strate that Cities play a pivotal role in the unobtrusive collection of “more
data” on individual behaviours, and with “increased frequency”. This can
then greatly improve the early detection of risks through the timely analysis
of changes in these behaviours and, finally, the design of effective interven-
tions for countering these risks.Towards reaching this goal, City4Age acts
as a bridge between the European Innovation Partnerships (EIP) on Smart
Cities and Communities, on the one side, and on Active and Healthy Ageing
(EIP AHA), on the other side (Participants from both EIP’s are involved
in City4Age). More precisely City4Age focuses on the following: - Levera-
ging large amounts of personal data from individuals, collected (through
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
towards: Identifying relevant behaviours of groups or individuals, Detecting
changes that can be correlated with risks of cognitive health and frailty,
Developing ICT based interventions to mitigate these risks, Facilitating the
growth of a sustainable eco-system of services for an elderly-friendly urban
environment. The future outcome that CITY4AGE wants to reach should
be: - the development of an Integrated IT Infrastructures and Citizen servi-
ces in the health sector to evolve towards models of “age-friendly” Cities; -
the underlying factors of frailty, by exploring the association between frailty
and adverse health outcomes in older people - the better prevention and
management of the frailty syndrome and its consequences. The main stra-
tegy of City4Age is to enhance ICT tools and services that enable smart
cities to detect a wide range of data about individuals’ behaviour, in a
unobtrusive manner, in order to identify population at risk, monitor daily
life activities of identified users in a smart environment, intervene in case
a negative change of behaviour that may lead to a deterioration of their
cognitive and/or physical conditions. In order to fulfill the above strate-
gic objectives, City4Age performs research and innovation work based on
the following operational objectives: = Development of an organized set of
models and domain knowledge of MCI/Frailty symptoms. = Development
of an application ecosystem based on smart mobile devices (like phones,
watches or other unobtrusive devices) enabling the large scale collection
of personal data in home and city environments. = Setting-up a large scale
data management system enabling the real time handling of personal data
flows in a City cloud. = Development of advanced models for the detection
of risks relevant for MCI and Frailty = Test the overall approach and the
concrete results in 6 Cities (Birmingham UK, Madrid S, Lecce I, Athens G,
Singapore S). = Definition of a general sustainability model for detection
and intervention, against the risk of mild cognitive impairments and frailty.
186. THE ASSESSMENT OF THE FRAILTY IN A GERIATRIC
REHABILITATION INSTITUTE
Poster
Mattiuzzo E. , Ricevuti G., Venturini L., Rollone M., Guerriero F.,
Faruggio L., Ghiazzi J., Libertazzi A., Lorini V., Massarini G., Regina D.
University Pavia, Dpt of Internal Medicine and Therapeutics, Geriatrics,
Pavia, Italy
Italy, like most of other Western societies is characterised by a progressive
increase of average life expectancy. Following an increase in life expectancy,
age-related diseases also increase. There is good scientific evidence showing
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,
the second one as a state. During the course of the last years there have been
numerous tests aiming to define the boundaries of this entity by assessing
each of its different facets. Considered individually, such tests prove useful
as diagnostic/prognostic tools. However, they are even more useful when
combined, as they describe patients’ clinical condition in a more ample and
complete way. In fact, Frailty leads elderly people to the likelihood of deve-
loping numerous conditions with a short-term prognosis. This study aims
to assess a sample of geriatric patients at the moment of admission into a
rehabilitation centre. The purpose was that of identifying fragile patients,
and classify them through a Comprehensive Geriatric Assessment (CGA),
as well as through a comprehensive individual rehabilitation programme.
This was carried out through a series of 7 tests, plus a DXA exam for the Sar-
copenia (which was calculated using the SMI index). The data collected was
analysed individually, and later integrated into a graphic radar visualising
frail patients’ clinical characteristics in various areas. Through this study it
was possible to compare tests that are normally used in the typical CGA of
Geriatric clinical practice. A concordance was noticed between EFS, GFI,
FI, SPPB, PASE, CF in Frailty evaluation. It has been seen that SHARE-FI
and Sarcopenia do not agree with the other tests, this is most likely due to
the small number of enrolled patients (n= 47). An insufficient number of
patients does not allow to have a representative population group. The new
chance to compare multiple indexes simultaneously through a radar graph
opens new horizons in the Geriatric CGA: first of all, it is possible to have an
instrument capable of comparing multiple tests simultaneously in a single
graph, making the clinical situation of the frail patient instantly accessible;
secondly, the possibility of validating and standardizing an instrument (in
terms of the subarea) that takes into account multiple tests at the same time
could be a solution to the problem of identifying a diagnostic Gold Standard
shared by the entire Scientific Community.
187. ENDOCARDITIS TEAM: A NECESSARY REALITY
Barone M. 1, Miceli S. 2, Di Virgilio A. 2, Accoti A. 2, Caroleo B. 2,
Perticone M. 1, Naty S. 2, Parise M. 1, Perticone F. 1, Sesti G. 1
1
Department of Medical and Surgical Sciences. University Magna Graecia
of Catanzaro. Catanzaro (Italy), 2 Azienda Ospedaliera Mater Domini,
Catanzaro (Italy)
In December 2016, a 69-year-old man with a depressed mood came to our
rheumatology center for diffuse joint pain. Clinical examination showed
lower limbs edema and systolic murmur on the mitral valve. An echocardio-
gram was quickly performed and it showed the presence of vegetations on
the mitral valve and on the aortic valve associated with severe mitral insuf-
ficiency and moderate-severe aortic insufficiency. Therefore, the patient was
admitted in our Internal Medicine Unit for suspected heart failure caused
by endocarditis. No previous pathology was present in remote pathologi-
cal history, whereas in the last few months the patient reported a weight
loss (about 10 kg), back pain and fever (TC 39 ° C). The objective exami-
nation showed the presence of pallor, petechiae on lower limbs, reduction
of vesicular murmur in the basal regions and splenomegaly. Laboratory
analyses showed: hemoglobin 6.4 gr / dl; creatinine: 2.28 mg / dl; PCR: 68
mg / l. The electrocardiogram showed atrial fibrillation with high ventricu-
lar response. A context of hypoxiemic normocapnic respiratory failure was
present in arterial emogasalysis and chest X-ray showed a slight opacity in
the right lung apex and small bibasal pleural effusion. Splenic infarction
was present at the ultrasound of the spleen, as possible endocarditis embo-
lization. The patient received therapy with diuretics, heparin, beta-blocker,
oxygen therapy, and blood trasfusion. After performing 3 blood cultures
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
transoesophageal echocardiogram that confirmed the data of the first echo-
cardiogram. Blood cultures were all positive for Streptococcus gallolyticus
135
Poster
ssp gallolyticus, so we continued antibiotic therapy with ceftriaxone alone.
In the following days, patient underwent cardiac surgery: replacement
of aortic valve with biological prosthesis, curettage of anterior leaflet and
posteromedial commissure of the mitral valve, resection of P2 and repair
of posterior leaflet. Subsequently, we observed a progressive improvement
in clinical conditions. Since numerous studies in literature have shown the
association between S. gallolyticus endocarditis and colorectal cancer, we
decided to perform a PET / TC examination both to identify others loca-
lizations of embolization and to find an occult colon cancer. PET / TC
showed an increased metabolism in ascending colon and no other site of
embolization except the spleen. So we performed a colonoscopy but it was
negative. The literature suggests that a colon cancer may develop up to 4
years after the onset of an endocarditis by S.gallolyticus ssp gallolyticus so
we decided to schedule an annual endoscopic follow-up for our patient. In
conclusion, we have described a case of endocarditis that required the inter-
vention of numerous health professionals, highlighting the importance of a
multidisciplinary approach to pathology commonly known as Endocarditis
Team. Additionally, in patients with S.gallolyticus infective endocarditis, it is
important to rule out underlying tumor and, in the absence of neoplasia, to
plan the annual endoscopic follow-up.
188. BERGAMOT IMPROVES THE QUALITY OF
LIPOPROTEIN PROFILE AND SUBCLINICAL
ATHEROSCLEROSIS EQUALLY IN BOTH OBESE
AND NOT OBESE SUBJECTS WITH MODERATE
HYPERCHOLESTEROLEMIA: A 6-MONTH PROSPECTIVE
STUDY
Adamo A., Giglio R.V., Chianetta R., Nikolic D., Castellino G.,
Patti A.M., Mannina C., Galletta R., Sardo V.A., Citarrella R.,
Montalto G., Rizzo M.
Biomedical Department of Internal Medicine and Specialties, University of
Palermo, Italy
Background and Aim: Recent studies have showed that the natural extract
of bergamot has beneficial effects on the cardiometabolic parameters, inclu-
ding carotid intima-media thickness (cIMT) and atherogenic lipoproteins.
Such favorable effects were mostly attributed to the high amount of flavo-
noids. The aim of the present study was to evaluate if a bergamot-derived
extract could have different effects in obese vs not obese subjects with
moderate hypercholesterolemia. Materials and Methods: Eighty subjects
(man 42 and women 38, mean age 55±13) with moderate hypercholeste-
rolemia (LDL between 160 and 190 mg/dl) were included in the present
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,
n=29); and 2) Patients with BMI ≤30, Non Obese Group (N.O. Group,
n=51). Lipoprotein subfractions were assessed by gel electrophoresis (Lipo-
print, USA). With this methodology low density lipoprotein (LDL) are
distributed in seven bands: LDL 1 and 2 as large LDL, and LDL 3 to 7 as
small and dense LDL. Subclinical atherosclerosis was evaluated by cIMT
using B-mode ultrasound.
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
from 6.5±0.3 to 5.7±1.0, p 0.0001, respectively) and LDL-C (from 4.5±0.2
to 3.6±1.0, p=0.0002 and from 4.6±0-2 to 3.7±0.9, p 0.0001, respectively).
A statistical significance reduction of triglycerides was seen only in N.O.
Group (from 1.8±0.7 to 1.4±0.5, p=0.0020). The LDL-3, small, dense and
more atherogenic particles, decreased in both O and N.O. groups (from
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-
vely), while LDL-1, large and less atherogenic particles increased only in
N.O. subjects (from 17.0±5.0 to 19.1±4.4, p=0.0002). Bergavit® also reduced
cIMT in both groups (from 1.2±0.4 to 0.9±0.1, p=0.0110 and from 1.2±0.4
to 0.9±0.1, p 0.0001, respectively).
Conclusions: A six-month supplementation with Bergamot provided a
positive cardio-metabolic control, reducing cIMT and atherogenic lipopro-
teins in both obese and non-obese subjects. Consequently, Bergavit® may
represent a valid, alternative therapeutic approach in dyslipidemic subjects
preventing and/or reducing overall cardiometabolic risk.
189. BERGAMOT REDUCES ATHEROGENIC
LIPOPROTEIN SUBCLASSES IN DYSLIPIDEMIC SUBJECTS
WITH ELEVATED BASELINE VALUE OF CAROTID
INTIMA-MEDIA THICKNESS: A 6-MONTH PROSPECTIVE
136
118° Congresso Nazionale - Società Italiana di Medicina Interna
STUDY
Castellino G., Nikolic D., Chianetta R., Giglio R.V., Adamo A.,
Patti A.M., Mannina C., Sardo V.A., Galletta R., Bonfiglio A.,
Citarrella R., Montalto G., Rizzo M.
Biomedical Department of Internal Medicine and Specialties, University of
Palermo, Italy
Background and Aim: A search for alternative therapeutic approaches for
dyslipidemia management is increasing. A Bergamot juice derived flavo-
noid extract, Bergavit® (Bionap, Italy) contains about 28–30 % of flavonoids
(including naringin, neoeriocitrin, and neohesperidin) and its hypo-cho-
lesterolemic property is well documented. However, a recent data indica-
tes on its beneficial effects on subclinical atherosclerosis, reducing carotid
intima-media thickness (cIMT). We further evaluated whether its effect on
different cardio-metabolic parameters, including atherogenic lipoproteins,
could be different in subjects with and without subclinical atherosclerosis
and influenced by baseline value of cIMT.
Materials and Methods: Bergavit® (Bionap, Italy) was given to 80 subjects
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:
1) those with cIMT ≤0.9 mm (considered as a normal value; n = 23) and 2)
those with cIMT> 0.9 mm (considered as an abnormal value, n = 57). The
subfractions of LDLs were evaluated by electrophoresis, while cIMTs with
B-mode ultrasound.
Results: After 6 months of supplementation, Bergamot reduces the fol-
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),
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,
p<0.0001, respectively) and triglycerides (from 1.8±0.7 to 1.4±0.6, p=0.0047
and from 1.8±0.6 to 1.5±0.9, p=0.0365, respectively), whereas HDL-C
increased significantly only in subjects with cIMT> 0.9 mm (p=0.0007). In
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-
ticles increased only in the group with cIMT> 0.9 mm (from 16.5±5.4 to
18.7±5.3, p=0.0004).
Conclusions: Bergamot flavonoids supplementation significantly reduced
plasma lipids and such effects seem to not be impacted by early, subclini-
cal atherosclerosis. However, the significant improvements in the quality of
LDL-C seen only in patients with elevated levels of cIMT at baseline may, at
least in part, explain further protective effects of bergamot in these subjects.
Whether this finding may be associated with cardiovascular prevention
remains to be established by future studies.
190. SEVERE ARTERIAL HYPOTENSION IN PATIENT
WITH SYNCOPE
Cavallo M., Fornasiero A., Pujatti P.L. 1, Cecchetto M. 1, Minuz P. 2,
Paluani F. 2, Fondrieschi L. 2, Fabrizi G.M. 3, Barbieri F. 3
1
Lonigo Hospital Long-Term Care Department, Arzignano Hospital Internal
Medicine, 2 Internal Medicine C., 3 Neurology of Verona Polyclinic
Background: We describe a case of a man 65 years oldwith syncope with
trauma falling to the ground. Arrived in our Hospital Emergency Care
he presented: severe orthostatic hypotension (values lower than 50/30
mm Hg), atrial paroxysmal fibrillation disappeared spontaneously, systo-
lic overload in hypertensive heart disease with ejection fraction reduced,
radiological signs of previous ischemic stroke, hyperkalemia in chronic
renal failure. The clinical patient pathway was characterized by subsequent
hospitalization in Internal Medicine Department.Physiological History
tells of smoking, alcoholic dependence, erectile dysfunction, occupational
exposure to aromatic amines.Remote Pathological History tells of cervical
arthrosis, surgery for pyloric piercing ulceration.Next Pathological History
tells of previous lipotymes slowly ingrowing to the loss of consciousness.
Instrumental and biomorphological findings shows: a) basilar vertebral
insufficiency with left vertebral artery root loop, ectasia of the posterior
connective artery, filiform the posterior connective arteries, b)severe cer-
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
2 with non-dipper profile and severe orthostatic hypotension without
reflected tachycardia, g) hypertrophic hypertensive heart disease, FE 50%,
mild diffuse hypocynaemia, altered diastolic release. There was a severe
mixed autonomic deficiency with secondary adrenal dysfunction: adrena-
118° Congresso Nazionale - Società Italiana di Medicina Interna
line at the lower limits of standard adrenaline 12 nmol / mol / 24 hours
(vn 5-110), noradrenaline below the lower limits of standard 24 Nmol / 24
hours (vn 40-600), aldosterone in orthostatism 185 pmol / l (vn.61.2-977.8),
aldosterone clinostatism 124 pmol / l (vn 32.4-653.7), orthostatic renin
2.7 mUI / l (v.4.4- 46.1) and clinostatism 1.5 mUI / l (vn. 2.8-39.9) lower
than normal values, absent circadian cortisol curve change. Even the value
of Testosterone 3.37 mcg / ml, beta 2 microglobulin (vm. 3-4 mcg / ml),
autoantibody test, togheter with onconeuronals antibodies and adrenergic
antibodies were in the normal range, on the other side acetylcholine antibo-
dywas absent, transthyretin was negative. We find deficiency of vitamin D
5.3g / ml (14-42 ng / ml), glucouse intolerance (Hba1c 32 (vn 20-42 mmol
/ mol, glycemic curve with altered blood glucose).Specialist visits show
angiology evaluation: severe femoral venous insufficiency, with phleboge-
nic microangiopathy and cutaneous polyangiosis;neurological evaluation:
absent deficiency of sensitive nerve endings, no extrapyramidal signs; car-
diological evaluation:bradycardia in orthostatism.Clinical outcomes: The
patient initially had a beneficial effect about tiredness with therapy based on
methylprednisolone, followed by chronic therapy with fluoridrocortisone,
midodrine, captopril for the night hours, and monocollant 1° to be used
in orthostatism; in the following period the disabling autonomic pathology
was not responsive to fluoridrocortisone therapy and methylprednisolone
pains with need of repetitive intravenous Ig cycles therapy. Sudden cardio-
genic death followed.
Discussion: Clinical pictures with autonomic disorders (sensory and neuro-
motor disorders) occur with subacute episodes without any previous symp-
tomatic manifestation of illness. The disautonomia caused by post-ganglionic
sympathetic injuries are considered difficult to be treated therapeutically due
to direct axonal lesions of the nerve fibers that control the neuro-cardiogenic
function (1). In our clinical case, the concomitant neuropathy of the small
nerve fibers evaluates the hypothesis of autonomic neuropathy with direct
expression on control of pressure and heart rate. There are cases of patients
with postural tachycardia syndromes due to alterations in normal autonomic
control (2). In contrast, there are also cases of patients with very serious arte-
rial blood pressure disorders related to auto-immune ganglionic peripheral
neuronal damage (Sjogren syndrome, mixed connective tissue, LES, etc.),
amyloidosis and also lymphoproliferative diseases (3). The severity of clinical
autonomic desensitivations can go from neurocardiovascular disorders (heart
rate changes, hypo / hypertension) to severe heart rhythm disorders with
reduced heart failure, syncope and sometimes fatal collapse (4).
Conclusions: The most rooted hypothesis about the clinical picture descri-
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-
ted cycles. If this therapy is not effective, you might use steroid drugs and,
as a last resort, plasmapheresis in the most complicated patients:.Referen-
ces: 1) Akihiro u., Kunihiko A. et al.: Acute autonomic sensory and motor
neuropathy: successful treatment with iv Ig. Internal Medicine 48: 843-846,
2009. 2) Blair P. Grubb: Postural tachycardia syndrome.Circulation 117:
2814-2817, 2008.3) Edelman J., Gubbay SS.: Acute pandysautonomia due
to mixed connective tissue disease. Aust NZ. J. Med. 11: 68-70, 1981.4)
Vernino S., Phillip A.: Experimental autoimmune autonomic neuropathy. J.
Neurophysiol 90: 2053-2059, 2003.
191. HYPERTENSION AS A RISK FACTOR OF CAROTID
DOLICO ARTERIOPATHIES
Cavallo M., Fornasiero A.
U.o.s.d. Lungodegenza O.C. Lonigo, Dipartimento Scienze Mediche e
Riabilitative, Ulss8 Berica, Vicenza
Background:This study highlight a correlation between carotid dolico
arteriopathies and hypertension, unique or associated cardiometabolic
risk factor.Materials and Methods:We studied, in our Angiology Hospi-
tal Outpatient Clinic, 906 patients (429 (47%) females, 477 (53%)males).
Patients were between 50(but even less) and 81(but even more) years old.
Among them 58(6%) were less than 50 years old, 108 (12%) were 51-60
years old, 277 (31%) 61-70 years old, 281 (31%) 71-80 years old, 182 (20%)
older than 81 years old. Patient were examined with Ecocolordoppler
Toshiba Aplio XG with 7.5 MHz and 3.5 MHz probe.
Results:We found dolico arteriopathies in 361 patients (39.8%) compared
to carotid atheromatous diseases in 545 patients (60, 2%). Dolico arterio-
pathies, namely carotid course alterations, were seen as 154 (33.11%) tor-
tuosity, 113(24.3%) coiling, 198 (43%) kinking. Among 361 (39%) carotid
dolico arterio-pathies:112 (12%) were found in patients with only hyperten-
sion, 249 (27%) in patients with also others cardiometabolic risk factors. In
Poster
patients with only hypertension, dolico arteriopathies (112 pz.-12%) were
divided by age in this way:6(5%) younger than 50, 13 (12%) were 51-60
years old, 13 (12%) 61-70 years old, 56 (50%) 71-80 years old, 24 (21%) older
than 81; similarly they were divided by gender in this way:50 males (45%),
61 females (55%). In patients with also others cardiometabolic risk factors
dolico arteriopathies 249 pz. (27%) were divided by age in this way: 9 (5%)
younger than 50, 17 (7%) were 51-60 years old, 84 (33%) 61-70 years old, 81
(32%) 71-80 years old, 58 (23%) older than 81; similarly they were divide by
gender in this way: males 173 (48%), females 188 (52%). Discussion:Carotid
dolico arteriopathies (1) etiology is to date matter of discussion. Carotid
district seems to be prevalent among dolico arteriopathies (2), they may
cause cerebrovascular diseases during rotating head movements with tem-
porarily carotid blocking (3). They are correlated to several neurological
complications (vertigo, tinnitus, syncope, TIA, stroke, embolisms from
atheromatous plaques, aneurysms) (4). We must remember that hyperten-
sion may damage wall artery vessel because of the share stress by blood flow
turbolence with oxidative action on the endothelium, reduction of the tone
of elastic lamina, stretching of the muscle layer: all this explains how hyper-
tension, together with neck muscles hypotrophy, can stretch carotid axis (5)
and may cause secondary and irreversible dislocation of its course (6). Dia-
betes, dyslipidaemia, smoking, and obesity can also affect, in a different way,
the carotid course modifying blood vessel wall structure, conformation and
functionality (7). Even fibromuscolar dysplasia may cause in a lesser way
carotid course alterations (8). Furthermore there are other minor causes
of carotid course alteration among which otolaryngological intervenctions
and traumatic events (9).
Conclusion: Hypertension plays a significant and peculiar role in carotid
dolico arteriopathies development. The pharmacological control of hyper-
tension throughout life can prevent carotid course alterations and correlated
cerebrovascular diseases. A good management of other cardiometabolic risk
factors should also be garanteed.
Bibliografia: 1) Weibel J., e Fields WS. Neuroradiology 1965; 15: 7-18. 2)
Desai B., Toole JF. Stroke 1975; 6: 649-656. 3) Christodoulos S.e al.: Cir-
culation 1995; 91: 2669-2678. 4) Aleksic M., Schutz G. e al.: J. Cardiova-
scular Surg.2004; 45: 43-48. 5) Pancera P., Ribul M., Presciuttini B., Lechi
A.J.of Internal Medicine 2000; 248:7-12. 6) Del Corso L., Moruzzo D., Conte
P.e al.Angiology 1998; 49: 361-371. 7)Sacco S., Totaro R., Baldassarre M.,
Carolei A. Int. J. Angiology 2007;16(2):59-61. 8) Begelman SM., Olin JW.
Curr Opin.Rheumatol 2000; 12: 7-41. 9) Paulsen F., Tillman B.e al.: J.Ana-
tomy 2000; 197: 373-381.
192. PREDICTING THE QUALITY OF ANTICOAGULATION
CONTROL IN ATRIAL FIBRILLATION: PRELIMINARY
DATA ON THE VALIDATION OF THE SAME-TT2R2 SCORE
IN AN ITALIAN COHORT
Cheli P. 1, Proietti M. 2, Lip G.Y.H. 2, Ferri C. 1
1
Department of Life, Health and Environmental Sciences, University
of L’Aquila, L’Aquila, Italy; 1University of Birmingham, Institute of
Cardiovascular Sciences, Birmingham, United Kingdom.
Background: Despite the Introduction: of non-vitamin K oral anticoagu-
lants (NOACs), vitamin K antagonists (VKAs) still play a relevant role in
the treatment of atrial fibrillation (AF) patients. Both efficacy and safety of
VKA are strictly dependent on the quality of anticoagulation as measured
by time in therapeutic range (TTR). TTR measured by Rosendaal’s linear
interpolation has been proved to be effective in determining the quality
of anticoagulation control and strongly associated with outcomes. In this
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
anticoagulation control in patients undergoing VKA treatment in order to
assist physicians in decision-making process between VKAs and NOACs.
Objective: The aim of this study was to evaluate the SAMe-TT2R2 score in a
single-center Italian cohort of non-valvular AF patients on VKA treatment.
Methods: A cohort of consecutive patients with non-valvular AF on VKA
therapy attending the Anticoagulation Services at San Salvatore Hospital
(L’Aquila, Abruzzo, Italy) between January and May 2017 was included.
Patients with target INR range rather than 2.0-3.0 were excluded from the
study. Baseline demographic and clinical characteristics were collected.
The quality of anticoagulation control was reported as TTR by Rosenda-
al’s linear interpolation. Baseline thromboembolic risk was evaluated by the
CHA2DS2-VASc score. Likewise, baseline bleeding risk was calculated by
using the HAS-BLED scoring system. The baseline SAMe-TT2R2 score was
calculated for each patient. The study population was divided into two cate-
137
Poster
gories: patients with the SAMe-TT2R2 score 0-2 who were more likely to
achieve a good TTR and patients with the SAMe-TT2R2 score >2 who were
more likely to have a suboptimal anticoagulation control.
Results: The cohort included 215 patients diagnosed with non-valvular AF,
all Caucasian and receiving VKAs for stroke prevention. The overall mean
(SD) age was 74.3 (10) years and 131 (60.9%) were females. Permanent AF
was the most prevalent AF type (73%) and warfarin was the most used VKA
(99.1%). Hypertension was the most prevalent comorbidity (199 patients,
92.6%). 98.1% of the study population was VKA- naïve at the time of AF dia-
gnosis. The median CHA2DS2-VASC score was 4 [IQR 3-5] and the overall
median HAS-BLED score was 1 [IQR 1-2]. 165 (76.7%) patients were cate-
gorized as SAMe-TT2R2 score 0-2. The median TTR was 66.3% [IQR 53.0-
77.1]. 87 patients (59.5%) had a TTR >70 %. The median SAMe-TT2R2
score was 2 [IQR 1-2]. TTR values progressively decreased with increasing
SAMe-TT2R2 score points (p<0.001). Patients with SAMe-TT2R2 >2 had
a significantly lower median TTR value compared to patients with SAMe-
TT2R2 0-2 (TTR 71.3% and TTR 49.0% respectively, p<0.001). Linear
regression analysis showed that SAMe-TT2R2 was inversely associated
with TTR (standardized beta: - 0.673; t: -12.377; p<0.001) with a linear rela-
tionship between the score and TTR. Logistic regression analysis, adjusted
for type of AF, age, sex and eGFR between SAMe-TT2R2 groups and TTR
levels found that the SAMe-TT2R2 was inversely associated with all TTR
levels (all p< 0.001 for TTR <60%, TTR<65% and TTR >70%).
Conclusions: In this preliminary analysis, the SAMe-TT2R2 score was
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-
over, a low SAMe-TT2R2 score (0-2) was proved to be strongly predictive
of TTR >70%. Further data are still needed to validate this tool in larger
cohorts.
193. CORRELATIONS: TROPONIN-PESINDEX. “TROPESI”
STUDY: A COMPARATIVE ANALYSIS WITH STUDENT
TEST OF CONTINUOUS VARIABLES IN 30 PATIENTS
WITH VENOUS THROMBOEMBOLISM. THREE-YEAR
EXPERIENCE (2014-2016)
Maida R., Ulissi A., Ciammaichella M.M.
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
Introduction: The “TROPESI” study - an acronym derived from the letters
“TROPonin - pulmonary Embolism Severity Index”, enrolled 30 patients,
aged between 48 and 82 years with venous thromboembolism (central pul-
monary embolisms), who were hospitalized in the “Emergency Medicine”
Unit during the 3-year period January 2014-December 2016. In all of the
patients, clinical onset was characterized by severe respiratory failure (arte-
rial blood gas analysis values of pO2 < 60 mm Hg) associated with syncope,
chest pain, confusion and haemodynamic instability (SBP < 90 mm Hg).
All patients were subjected to CT CAP and pelvis with contrast medium;
pulmonary angiography with loco-regional fibrinolysis in combination
with heparin sodium, i.v. into a peripheral vein, combined with mechani-
cal thrombectomy. In all patients, the Pulmonary Embolism Severity Index
(PESI) and Troponin values were measured pre-lysis. A comparative analy-
sis was performed for continuous variables using the parametric Student
“t” test to see if there was a significant relationship between pre-lysis values
of the Troponin and the pre-lysis PES Index. PURPOSE OF STUDY: The
“TROPESI” study pursued the following objectives: to verify possible rela-
tionships between values of the pre-lysis Troponin values and pre-lysis PES
Index in 30 patients who had been enrolled in the “TROPESI” study in the
three-year period from January 2014 - December 2016; to check the statisti-
cal significance observed using the Student ‘t’ test as a bench-marking test
for continuous variables, to determine whether the relationships between
the variables under consideration were due to chance.
Materials and Methods: In the 30 patients enrolled with central pulmonary
embolism, the values of the pre-lysis Troponin values were compared with
pre-lysis PES Index values. The test therefore calculated the relative value
(RV) of the index “t” to associate with the difference found, according to
the following formula: t = (M1-M2)/√DS122 /N1 + DS22 /N2. In this way,
the “t” value obtained with Degrees of Freedom (DF) = 29 was 15.01. The
Critical Value (CV) of “t” was 3.659 with D.F. = 29 for p = 0.001, the Relative
Value (RV) of “t” was equal to 15.01 and expressed positive agreement of
co-variation between the absolute values of the two variables being consi-
dered (pre-lysis Troponin values and pre-lysis PES Index) which is highly
138
118° Congresso Nazionale - Società Italiana di Medicina Interna
significant, with p < 0.001.
Analysis of Results: When applied to the 30 patients, the Student’s “t”
test revealed a highly significant correlation (p < 0.001) between the two
variables examined (pre-lysis values of Troponin and PES Index), which,
therefore, could not be attributed to chance. In fact, the value of “t” obtained
was 15.01 and the CV (critical value) of “t” for p=0.001 was 3.659, with DF
= 29.
Discussion: The data obtained suggests that in the 30 patients enrolled in
the “TROPESI” study, the covariation of values of pre-lysis Troponin values
and pre-lysis PES Index values expressed a highly significant difference,
whose clinical significance laid in the overload of right-sided sections of
the heart, the presence of elevated blood pressure regimes caused by the
background of pulmonary embolism, which was assessed using the pre-lysis
PES Index, which followed an improvised decrease in blood flow to left-si-
ded cardiac sections and coronaric hypo-perfusion with elevated Troponin
values.
Conclusions: The “TROPESI” study showed that within this group of 30
patients with venous thrombo-embolism (central pulmonary embolisms)
there was a highly significant correlation between the two variables conside-
red: the pre-lysis Troponin values and the pre-lysis PES Index. This correla-
tion showed an absolute positive correlation under comparative Student “t”
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
in 30 patients with a central pulmonary embolism. When compared to
experiences in literature, the “TROPESI” study offers data that supplements
that provided by the study of Plasek, Nordenholz, Choi, Aujeszky and Ozsu.
194. CORRELATIONS: TROPONIN-PEINDEX. “TROPEI”
STUDY: A COMPARATIVE ANALYSIS WITH STUDENT
TEST OF CONTINUOUS VARIABLES IN 30 PATIENTS
WITH VENOUS THROMBOEMBOLISM. THREE-YEAR
EXPERIENCE (2014-2016)
Ciancio L., Ciammaichella M.M., Mida R., Ulissi A.
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
Introduction: The “TROPEI” study - an acronym derived from the letters
“TROPonin - pulmonary Embolism Index”, enrolled 30 patients, aged
between 48 and 82 years with venous thromboembolism (central pulmo-
nary embolism) who were hospitalized in the “Emergency Medicine” Unit
during the period January 2014-December 2016. In all patients, clinical
onset was characterized by severe respiratory failure (arterial blood gas
pO2 < 60 mm Hg) associated with syncope, chest pain, confusion, hae-
modynamic instability (SBP < 90 mm Hg). All patients were subjected
to CT CAP and pelvis with a contrast medium; pulmonary angiography
with loco-regional fibrinolysis in combination with heparin sodium, in a
peripheral vein, combined with mechanical thrombectomy. In all patients,
the Pulmonary Embolism Index and the Troponin values were measured
pre-lysis. A comparative analysis was performed for continuous variables
with the Student “T” parametric test to see if there was a significant rela-
tionship between pre-lysis values of Troponin and the pre-lysis PEIndex.
PURPOSE OF STUDY: The “TROPEI” study pursued the following
objectives: to verify any relationships between values of the pre-lysis Tro-
ponin values and pre-lysis PEIndex in 30 patients who were enrolled in
the “TROPEI” study in the three-year period from January 2014 - Decem-
ber 2016; to check the statistical significance observed by applying the
Student ‘t’ test as a bench-marking test for continuous variables, to deter-
mine whether the relationships between the variables considered were due
to chance.
Materials and Methods: In 30 patients enrolled with central pulmonary
embolism, the values of the pre-lysis Troponin values were compared to
values of pre-lysis PEIndex in the same 30 patients. The test therefore cal-
culated the relative value (VR) of the index “t” to associate with the diffe-
rence found, according to the following formula: t = (M1-M2)/√DS122 /N1
+ DS22 /N2. Thus the value of “t” obtained with Degrees of Freedom (DF)
= 29, was 3.65. The Critical Value (CV) of “t” is 3.659 with D.F. = 29 for p
= 0.001, the Relative Value (RV) of “t” is equal to 4.76 and expresses a posi-
tive agreement of co-variation between absolute values of the two variables
being considered (pre-lysis Troponin values and pre-lysis PEIndex) which
is highly significant with p < 0.001. ANALYSIS OF
Results: When applied to the 30 patients, the Student’s “t” test revealed
a highly significant correlation (p <0.001) of the two variables examined
(pre-lysis values of Troponin and PEIndex) which therefore could not be
attributed to chance. The value of “t” obtained was in fact 4.76 and the CV
(critical value) of “t” for p=0.001 was 3.659 with a GL=29.
118° Congresso Nazionale - Società Italiana di Medicina Interna
Discussion: The data obtained suggests that the inverse covariation of
values of the pre-lysis Troponin values and pre-lysis PEIndex values in the
30 patients enrolled in the “TROPEI” study” expressed a highly significant
difference, whose clinical significance lies in the overload of right sided
sections of the heart, in the presence of elevated blood pressure regimes
caused by the CT background of pulmonary embolism, evaluated using the
pre-lysis PEIndex, which followed an improvised decrease in blood flow to
left-sided cardiac sections and coronaric hypoperfusion.
Conclusions: The “TROPEI” study showed that within this group of 30
patients with venous thrombo-embolism (central pulmonary embolism)
there was a highly significant correlation between the two variables consi-
dered: the pre-lysis Troponin values and the pre-lysis PEIndex. This correla-
tion showed an absolute positive correlation under the comparative Student
“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-
ces in the literature, the “TROPEI” study provides data that supplements
those already provided by the studies of Plasek, Qanadli, Nural, Ghamima,
Pech.and Ozsu.
195. CORRELATIONS: TROPONIN-MILLER SCORE.
“TROPLER” STUDY: A COMPARATIVE ANALYSIS WITH
STUDENT TEST OF CONTINUOUS VARIABLES IN 30
PATIENTS WITH VENOUS THROMBOEMBOLISM.
THREE-YEAR EXPERIENCE (2014-2016)
Ciammaichella M.M., Maida R., Ulissi A.
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
Introduction: The “TROPLER” study - an acronym derived from the letters
“TROPonin – milLEr scoRe”, recruited 30 patients aged between 48 and 82
years with venous thrombo-embolism (central pulmonary embolism) who
were admitted to the “Emergency Medicine” Unit during the three year
period from January 2014 to December 2016. In all patients, clinical onset
was characterised by severe respiratory failure (arterial blood gas analysis of
pO2 < 60mmHg) associated with syncope, chest pain, confused state and
haemodynamic instability (SAP < 90 mmHg). All patients underwent: CT
scan of the chest, abdomen and pelvis with contrast medium; pulmonary
angiography with loco-regional fibrinolysis in combination with heparin
sodium IV into a peripheral vein, combined with mechanical thrombec-
tomy. In all patients, the angiographic Miller score and the Troponin values
were measured pre-lysis. A comparative analysis was performed for conti-
nuous variables using the parametric Student “t” test to see if there was a
significant relationship between pre-lysis values of the Troponin values and
the pre-lysis Miller Score. PURPOSE OF STUDY: The “TROPLER” study
pursued the following objectives: to verify possible relationships between
values of the pre-lysis Troponin and pre-lysis Miller Score in 30 patients
who were enrolled in the “TROPLER” study in the three-year period from
January 2014 - December 2016; to verify the statistical significance obser-
ved using the Student ‘t’ test as a comparative analysis test for continuous
variables, to determine whether the relationships between the variables
under consideration were due to chance.
Materials and Methods: In the 30 patients enrolled with central pulmonary
embolism, the values of the pre-lysis Troponin values were compared with
pre-lysis Miller Score values. The test therefore calculated the relative value
(RV) of the index “t” which is equal to the difference found, according to the
following formula: t = (M1-M2)/√DS12/N1 + DS22 /N2. In this way, the “t”
value obtained was 28.48 with Degrees of Freedom (DF) = 29. The Critical
Value (CV) of “t” was 3.659 with DF = 29 for p = 0.001, the Relative Value
(RV) of “t” was equal to 28.48 and expressed an absolute positive agreement
of co-variation between the values of the two variables under consideration
(pre-lysis Troponin values and pre-lysis Miller Score) which is highly signi-
ficant, with p < 0.001.
Analysis of Results: When applied to the 30 patients, the Student’s “t”
test revealed a highly significant correlation (p < 0.001) between the two
variables examined (pre-lysis values of Troponin and Miller Score), which
therefore could not be attributed to chance. The value of “t” obtained is in
fact 28.48 and the CV (critical value) of “t” for p = 0.001 is 3.659 with DF
= 29.
Discussion:: The data obtained suggests that in the 30 patients enrolled in
the “TROPLER” study, the inverse covariation of values of pre-lysis Tro-
ponin and pre-lysis Miller Score values expressed a highly significant dif-
ference, whose clinical significance lies in the overload of the right-sided
sections of the heart, in the presence of elevated blood pressure caused by
the patients’ background of pulmonary embolism, which was assessed using
Poster
the pre-lysis Miller Score, which occured after a sudden decrease in blood
flow to left-sided cardiac sections and coronaric hypoperfusion.
Conclusions: The “TROPLER” study showed that within this group of
30 patients with venous thrombo-embolism (central pulmonary emboli-
sms) there was a highly significant correlation between the two variables
considered: the pre-lysis Troponin values and the pre-lysis Miller Score.
This correlation showed an absolute positive correlation according to the
Student “t” test for comparative analysis, and did not express a random
association, but rather a close correlation between the pre-lysis Troponin
values and those of the pre-lysis Miller Score in 30 patients with a central
pulmonary embolism. When compared to experiments in the literature,
the “TROPLER” study provides data that supplements those already pro-
vided by the studies of Plasek, Nordenholz, Choi, Aujeszky and Ozsu.
196. CORRELATIONS: TROPONIN-TAPSE. “TRAPSE”
STUDY: A COMPARATIVE ANALYSIS WITH STUDENT
TEST OF CONTINUOUS VARIABLES IN 30 PATIENTS
WITH VENOUS THROMBOEMBOLISM. THREE-YEAR
EXPERIENCE (2014-2016)
Marzano M.A., Ciammaichella M.M., Maida R., Ulissi A.
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
Introduction: The “TROPSE” study - an acronym derived from “TRO-
ponin – tricuspidal anular Plane Systolic Excursion”, recruited 30 patients
aged between 48 and 82 years with venous thrombo-embolism (central pul-
monary embolism) who were admitted to the “Emergency Medicine” Unit
during the three year period from January 2014 to December 2016. In all
patients, clinical onset was characterised by severe respiratory failure (arte-
rial blood gas analysis of pO2 < 60mmHg) associated with syncope, chest
pain, confused state and haemodynamic instability (SAP < 90 mmHg). All
patients underwent: CT scan of the chest, abdomen and pelvis with con-
trast medium; pulmonary angiography with loco-regional fibrinolysis in
combination with heparin sodium IV into a peripheral vein, combined
with mechanical thrombectomy. In all patients, the Tricuspidal Anular
Plane Systolic Excursion (TAPSE VN> 2 cm) and the Troponin values were
measured pre-lysis. A comparative analysis was performed for continuous
variables using the parametric Student “t” test to see if there was a signifi-
cant relationship between pre-lysis values of the Troponin I and the pre-lysis
TAPSE.
Purpose of Study: The “TROPSE” study pursued the following objectives:
to verify any relationships between pre-lysis values of the Troponin and
TAPSE in 30 patients who were enrolled in the “TROPSE” study during
the three-years from January 201$ - December 2016; to check the statistical
significance observed by applying the Student ‘t’ test as a bench-marking
test for continuous variables, and to determine whether the relationships
between the variables being considered were due to chance.
Materials and Methods: In 30 patients enrolled with central pulmonary
embolism, the values of the pre-lysis Troponin were compared with pre-ly-
sis TAPSE values in the same 30 enrolled patients. The test therefore calcu-
lated the relative value (RV) of the index “t” which is equal to the difference
found, according to the following formula: t = (M1-M2)/√DS12/N1 + DS22
/N2. In this way, the “t” value obtained was 10, 96 with Degrees of Freedom
(DF) = 29. The Critical Value (CV) of “t” was 3.659 with DF = 29 for p
= 0.001, the Relative Value (RV) of “t” was equal to 10.96 and expressed
positive agreement of co-variation between the absolute values of the two
variables being considered (pre-lysis Troponin values and pre-lysis TAPSE)
which is highly significant, with p < 0.001.
Analysis of Results: When applied to the 30 patients, the Student’s “t”
test revealed a highly significant correlation (p < 0.001) between the two
variables examined (pre-lysis values of Troponin and TAPSE), which the-
refore could not be attributed to chance. In fact, the value of “t” is obtained
of10, 96 and the CV (critical value) of “t” for p = 0.001 is 3.659 with GL = 29.
Discussion: The data obtained suggests that the inverse co-variation of
pre-lysis Troponin values and pre-lysis TAPSE values in the 30 patients
enrolled in the “TROPSE” study, expressed a highly significant difference,
whose clinical significance lies in the overload of right-sided sections of
the heart, in the presence of elevated blood pressure regimes caused by the
background of pulmonary embolism, evaluated using the pre-lysis TAPSE,
which followed an improvised decrease in blood flow to left-sided cardiac
sections and cardiac hypoperfusion.
Conclusions: The “TROPSE” study showed that within the group of 30
patients with venous thrombo-embolism (central pulmonary embolism)
there was a highly significant correlation between the two variables conside-
red: the pre-lysis Troponin values and the pre-lysis TAPSE. This correlation
139
Poster
showed an absolute positive correlation under comparative Student “t” test
analysis, and expressed not a random association, but a close correlation
between the pre-lysis Troponin values and those of the pre-lysis TAPSE
Index in 30 patients with a central pulmonary embolism. When compared
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.
197. CORRELATIONS: TROPONIN-BNP. “TROPIDE”
STUDY: A COMPARATIVE ANALYSIS WITH STUDENT
TEST OF CONTINUOUS VARIABLES IN 30 PATIENTS
WITH VENOUS THROMBOEMBOLISM. THREE-YEAR
EXPERIENCE (2014-2016)
De Paola G., Ciammaichella M.M., Maida R., Ulissi A.
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
Introduction: The “TROPIDE” study - an acronym derived from the letters
“TROPonin - brain natriuretic peptIDE”, enrolled 30 patients aged between
48 and 82 years with venous thrombo-embolism (central pulmonary embo-
lism) who were admitted to the “Emergency Medicine” Unit during the
period January 2014-December 2016. In all patients, clinical onset was cha-
racterized by severe respiratory failure (arterial blood gas analysis of pO2 <
60 mm Hg) associated with syncope, chest pain, confusion, haemodynamic
instability (SBP < 90 mm Hg). All patients were subjected to CT CAP and
pelvis with a contrast medium; pulmonary angiography with loco-regio-
nal fibrinolysis in combination with heparin sodium, in a peripheral vein,
combined with mechanical thrombectomy. In all patients, the pre-lysis BNP
(VN = 0-100 pg/ml) and pre-lysis Troponin values were measured. A com-
parative analysis was performed for continuous variables using the para-
metric Student “t” test to see if there was a significant relationship between
pre-lysis values of the Troponin and the pre-lysis BNP.
Purpose of Study: The “TROPIDE” study pursued the following objecti-
ves: to verify any relationships between pre-lysis values of the Troponin and
BNP in 30 patients who were enrolled in the “TROPIDE” study during the
three-years from January 2014 - December 2016; to check the statistical
significance observed by applying the Student’s’t’ test as a bench-marking
test for continuous variables, and to determine whether the relationships
between the variables being considered were due to chance.
Materials and Methods: In 30 patients enrolled with central pulmonary
embolism, the values of the pre-lysis Troponin were compared with pre-ly-
sis BNP values in the same 30 enrolled patients. The test therefore calculated
the relative value (RV) of the index “t” to associate with the difference found,
according to the following formula: t = (M1-M2)/√DS122 /N1 + DS22 /N2.
Thus the value of “t” obtained with Degrees of Freedom (DF) = 29, was 8.31.
The Critical Value (CV) of “t” was 3.659 with D.F. = 29 for p = 0.001, the
Relative Value (RV) of “t” was equal to 8.31 and expressed a positive agre-
ement of co-variation between absolute values of the two variables being
considered (pre-lysis Troponin and pre-lysis BNP) which is highly signifi-
cant with p < 0.001. ANALYSIS OF
Results: When applied to the 30 patients, the Student’s “t” test revealed a
highly significant correlation (p < 0.001) between the two variables exami-
ned (pre-lysis values of Troponin and BNP), which therefore could not be
attributed to chance. In fact, the value of “t” obtained was 8.31 and the CV
(critical value) of “t” for p=0.001 was 3.659 with DF=29.
Discussion: The data obtained suggests that the inverse co-variation of
pre-lysis Troponin values and pre-lysis BNP values in the 30 patients enrol-
led in the “TROPIDE” study, expressed a highly significant difference,
whose clinical significance lies in the overload of right-sided sections of the
heart, in the presence of elevated blood pressure regimes caused by the back-
ground of pulmonary embolism, evaluated using the pre-lysis BNP, which
followed an improvised decrease in blood flow to left-sided cardiac sections
and cardiac hypoperfusion. By examining the emergent literature and the
later experiences that followed, we suggest the following. Plasek compared
the EGSYS score with the OESIL score for assessing the cardiac origin of
syncope. Sudoh, Holmes, Levin, Yoshimura, Yasue, Cotance, Dentali, Gutte,
Andresen, Wang, Dores, Pasha and Ozsu correlated BNP values with Tro-
ponin values.
Conclusions: The “TROPIDE” study showed that within the group of 30
patients with venous thrombo-embolism (central pulmonary embolism) there
was a highly significant correlation between the two variables considered: the
pre-lysis Troponin values and the pre-lysis BNP. This correlation showed an
absolute positive correlation according to comparative Student “t” test analy-
sis, and expressed not a random association, but a close correlation between
the values of pre-lysis Troponin and pre-lysis BNP values in 30 patients with a
140
118° Congresso Nazionale - Società Italiana di Medicina Interna
central pulmonary embolism. By comparing experiences in the literature, the
“TROPIDE” study offers data that supplements that provided by the studies
of Plasek, Sudoh, Holmes, Levin, Yoshimura, Yasue, Cotance, Dentali, Gutte,
Andresen, Wang, Dores, Pasha and Ozsu.
198. CORRELATIONS: TROPONIN-PAPS. “TRAPS”
STUDY: A COMPARATIVE ANALYSIS WITH STUDENT
TEST OF CONTINUOUS VARIABLES IN 30 PATIENTS
WITH VENOUS THROMBOEMBOLISM. THREE-YEAR
EXPERIENCE (2014-2016)
Puglisi L., Ciammaichella M.M., Maida R., Ulissi A.
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
Introduction: The “TRAPS” study - an acronym derived from “TRoponin -
systolic pulmonary Artery PreSsure, ” enlisted 30 patients aged between 48
and 82 years with venous thromboembolism (central pulmonary embolism)
who were admitted to the “Emergency Medicine” Unit during the period
from January 2014 to December 2016. In all patients, clinical onset was cha-
racterised by severe respiratory failure (arterial blood gas analysis of pO2 <
60mmHg) associated with syncope, chest pain, confused state and haemo-
dynamic instability (SBP < 90mmHg). All patients were subjected to a: CT
scan of the chest, abdomen and pelvis with contrast medium; pulmonary
angiography with loco-regional fibrinolysis in combination with heparin
sodium IV into a peripheral vein, associated with mechanical thrombec-
tomy. In all patients, the pre-lysis systolic pressure (sPAP) of the pulmonary
artery was measured according to the formula in mmHg as measured with
doppler: 4XTR 2 + RAP, where TRV is the speed of tricuspid regurgitation
and RAP is right atrial pressure. Recall that pulmonary hypertension is
mild if the sPAP is between 25 mmHg and 35 mmHg, moderate between 36
mmHg and 45 mmHg and severe > 46 mmHg. In all patients, the Troponin
values was measured pre-lysis. A comparative analysis was performed for
continuous variables using the parametric Student “t” test to verify if there
was a significant relationship between pre-lysis values of the Troponine and
the pre-lysis sPAP. PURPOSE OF STUDY: The “TRAPS” study pursued the
following objectives: to verify any relationships between the pre-lysis values
of the Troponine and pre-lysis values of sPAP in 30 patients who had been
enlisted in the “TRAPS” study during the three years from January 2014 to
December 2016; to check the statistical significance observed by applying the
Student ‘t’ test as a benchmarking test for continuous variables, and to deter-
mine whether the relationships between the variables being considered were
due to chance.
Materials and Methods: In the 30 patients enlisted with central pulmonary
embolism, the values of the pre-lysis Troponin were compared with pre-ly-
sis sPAP values in the same 30 enlisted patients. The test, therefore, calcu-
lated the relative value (RV) of the index “t” to associate with the difference
found, according to the following formula: t = (M1-M2)/√DS12/N1 + DS22
/N2. In this way, the “t” value obtained with Degrees of Freedom (DF) =
29 was 15, 41. The Critical Value (CV) of “t” was 3.659 with DF = 29 for
p = 0.001, the Relative Value (RV) of “t” was equal to 15.41 and expressed
positive agreement of co-variation between the absolute values of the two
variables being considered (pre-lysis Troponin values and pre-lysis sPAP)
which is highly significant, with p < 0.001.
Analysis of Results: When applied to the 30 patients, the Student’s “t”
test revealed a highly significant correlation (p < 0.001) between the two
variables examined (pre-lysis values of Troponin and sPAP), which there-
fore could not be attributed to chance. In fact, the value of “t” obtained was
15.41 and the CV (critical value) of “t” for p=0.001 was 3.659, with DF = 29.
Discussion: The data obtained suggests that the covariation of pre-lysis Tro-
ponin values and pre-lysis sPAP values in the 30 patients enlisted in the
“TRAPS” study, expressed a highly significant difference, whose clinical
significance lies in the overload of right-sided sections of the heart, in the
presence of elevated blood pressure regimes caused by the background of
pulmonary embolism, evaluated using the pre-lysis sPAP, which followed an
improvised decrease in blood flow to left-sided cardiac sections and cardiac
hypoperfusion.
Conclusions: The “TRAPS” study showed that within the group of 30 patients
with venous thromboembolism (central pulmonary embolism) there was a
highly significant correlation between the two variables considered: the
pre-lysis Troponin values and the pre-lysis sPAP. This correlation showed an
absolute positive correlation under the comparative Student “t” test analy-
sis and expressed not a random association, but a close correlation between
pre-lysis Troponin values and those of the pre-lysis sPAP in 30 patients with
a central pulmonary embolism. Compared with experiences in the literature,
the “TRAPS” study provides data that supplements those already provided by
118° Congresso Nazionale - Società Italiana di Medicina Interna
the studies by Plasek, Choi, Ghio, Zeng, Gan, Fijalkowska, Kurzyna, Kircher,
Mahan, Menyeau, Lyon, Atkinson and Ozsu.
199. CORRELATIONS: TROPONIN-RIGHT VENTRICULAR
DIAMETER. “TROPIVE” STUDY: A COMPARATIVE
ANALYSIS WITH STUDENT TEST OF CONTINUOUS
VARIABLES IN 30 PATIENTS WITH VENOUS
THROMBOEMBOLISM. THREE-YEAR EXPERIENCE
(2014-2016)
Vincentelli G.M. 1, Ciammaichella M.M. 2, Maida R. 2, Ulissi A. 2
1
Medicina d’Urgenza, A. O. S. G. Calibita Fatebenefratelli Isola Tiberina,
Roma 2Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
Introduction: The “TROPIVE” study - an acronym derived from the letters
“TROPonin – rIght VEntricular diameter”, enrolled 30 patients aged between
48 and 82 years with venous thrombo-embolism (central pulmonary embo-
lism) who were admitted to the “Emergency Medicine” Unit during the three
year period from January 2014 to December 2016. In all patients, clinical
onset was characterised by severe respiratory failure (arterial blood gas analy-
sis of pO2 < 60mmHg) associated with syncope, chest pain, confused state
and haemodynamic instability (SAP < 90 mmHg).). All patients underwent:
CT scan of the chest, abdomen and pelvis with contrast medium; pulmonary
angiography with loco-regional fibrinolysis in combination with heparin
sodium IV into a peripheral vein, combined with mechanical thrombectomy.
In all patients, the right ventricle (RV) diameter was measured pre-lysis in
diastole (<30 mm according to Kurzyna’s criteria). In all patients, the Tro-
ponin values was measured pre-lysis. A comparative analysis was performed
for continuous variables using the parametric Student “t” test to see if there
was a significant relationship between pre-lysis values of the Troponin and
the pre-lysis RV diameter.
Purpose of Study: The “TROPIVE” study pursued the following objectives:
to verify any relationships between the pre-lysis values of the Troponin and
pre-lysis values of the RV diameter in 30 patients who had been enrolled in
the “TROPIVE” study during the three year period from January 2014 to
December 2016; to verify the statistical significance observed by applying the
Student ‘t’ test as a comparative analysis test for continuous variables, in order
to determine whether or not the relationships between the variables under
consideration were due to chance.
Materials and Methods: In 30 patients enrolled with central pulmonary
embolism, the values of the pre-lysis Troponin scores were compared with
pre-lysis RV diameter values in the same 30 enrolled patients. The test the-
refore calculated the relative value (RV) of the index “t” which is equal to the
difference found, according to the following formula: t = (M1-M2)/√DS12/
N1 + DS22 /N2. In this way, the “t” value obtained was 8.57 with Degrees of
Freedom (DF) = 29. The Critical Value (CV) of “t” was 3.659 with DF=29 for p
= 0.001, thus the Relative Value (RV) of “t” equal to 8.57 expressed an absolute
positive agreement of co-variation between the values of the two variables
under consideration (pre-lysis Troponin and pre-lysis RV diameter) which
is highly significant with p < 0.001. Analysis of Results: When applied to the
30 patients, the Student’s “t” test revealed a highly significant correlation (p <
0.001) between the two variables examined (pre-lysis values of Troponin and
RV diameter), which therefore could not be attributed to chance. The value of
“t”obtained is in fact 8.57 and the CV (critical value) of “t” when p=0.001 is
3.659 with DF=29.
Discussion: The data obtained suggests that the covariation of pre-lysis Tro-
ponin values and pre-lysis RV diameter values measured in the 30 patients
enrolled in the “TROPIVE” study expresses a highly significant difference,
whose clinical significance lies in the overload of the right-sided sections of
the heart in the presence of elevated blood pressure caused by the patients’
pulmonary embolism background which occured after a sudden decrease in
blood flow to left-sided sections of the heart. This was evaluated using the
pre-lysis RV diameter and cardiac hypoperfusion.
Conclusions: The “TROPIVE” study showed that within the group of 30
patients with venous thrombo-embolism (central pulmonary embolism)
there was a highly significant correlation between the two variables conside-
red: the pre-lysis Troponin values and the pre-lysis RV diameter. This corre-
lation showed an absolute positive correlation according to the Student “t”
test for comparative analysis, and did not express a random association, but
instead a close correlation between pre-lysis Troponin values and those of
the pre-lysis RV diameter in 30 patients with a central pulmonary embolism.
When compared to experiments in the literature, the “TROPIVE” study pro-
vides data that supplements those already provided by the studies of Plasek,
Choi, Ghio, Zeng, Gan, Fijalkowska, Kurzyna, Kircher, Mahan, Menyeau,
Lyon, Atkinson and Ozsu.
Poster
200. CATHETER DIRECTED THROMBOLYSIS IN DEEP
VENOUS THROMBOSIS: ASPIREX STUDY
Aracri N. 1, Ciammaichella M.M. 1, Maida R. 1, Vagnarelli S. 2, Ambrogi C. 2
1
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma 2Radiologia
Interventistica, A. O. S. Giovanni-Addolorata, Roma
Introduction: The “ASPIREX” study, a name derived from the ASPIREX
type of vascular catheter used for loco-regional thrombolysis in deep
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-
lized in the Complex Structure “Medicine for Emergencies” in 2015-2016.
All patients had clinical signs of DVT in the common iliac-femoral axis,
less than 14 days old, with sore and tense oedema of the lower limb. A
CT scan was performed for thorax, abdomen and pelvis, with a contrast
agent that showed signs in 1 case of pulmonary embolism and confirmed
common iliac-femoral DVT as already shown in the lower limbs by ultra-
sound colour doppler imaging. The search for the primary and secondary
markers for thrombophilia was within limits. For loco-regional throm-
bolysis combined with mechanical thrombectomy the following procedure
was applied: pre-procedure removable vena cava filter; popliteal / femoral
ultrasound-guided puncture was performed with the patient prone; the
ASPIREX system of mechanical thrombectomy was applied; angioplasty
was performed with balloons of 6-8 mm; finally locoregional thromboly-
sis was performed for 24-48 h with urokinase (UK) (as amended by us at
80000 IU / h with respect to the single lysis with UK, not associated with
mechanical thrombectomy as shown by data from the National Multicen-
ter Registry of Wisconsin that provides 8000, 000 UI), by phlebographic
pre-control every 24 hours associated with therapy with heparin sodium,
PTT and fibrinogen checked every 6 hours for the duration of the throm-
bolysis, subsequently treating with oral anticoagulants until INR optimiza-
tion, according to the American College of Chest Physicians Evidence-Ba-
sed Clinical Practice Guidelines (2016 Edition); graduated elastic stocking
post-treatment. In all patients, we evaluated the degree of lysis following
treatment according to the scheme of Protack. The score is calculated in
seven venous segments: the IVC, common iliac vein, external iliac vein and
common femoral vein, the proximal portion of the superficial femoral vein,
the distal superficial femoral vein and the popliteal vein. The score is 0 when
the vein was pervious and completely devoid of thrombi, 1 when partially
occluded, and 2 when fully occluded. The total score before and after lysis
was then calculated by adding the scores for the venous segments involved
before and after thrombolysis. The difference between the scores pre- and
post-lysis is divided by the prelysis score to give a percentage of thromboly-
sis achieved. The result is a classification into three groups: grade I for lysis
under 50%, grade II for lysis at 50% -90%, and grade III for 91-100%, or
complete lysis. A comparative analysis was performed for nominal variables
with a “Q” Cochran test to check whether the degree of lysis after treatment
was statistically significant. SCOPE OF WORK: The “ASPIREX” study has
the following objectives: to assess the degree of lysis after treatment with
loco-regional UK according to the criteria of Protack in 5 patients enrolled
in the “ASPIREX” study in 2015-2016; to verify the statistical significance
observed by applying the “Q” Cochran test as a test of comparative analysis
for nominal variables to determine if the degree of lysis assumed statistical
significance.
Materials and Methods: 3 The nominal variables compared with the
designation “K conditions” were designated with the letter A (GRADE I
LYSIS), B (GRADE II LYSIS), C (GRADE III LYSIS). After the procedure,
5/5 patients (100%) presented with thrombolytic condition C (GRADE III
LYSIS). ANALYSIS OF RESULTS The Cochran Q test applied to 5 patients
shows, through comparative analysis, highly significant differences (p
<0.001), which thus cannot be attributed to chance. In fact, the value of Χ2
obtained is 10 and the CV (critical value) of Χ2 for p = 0.001 is 16.26 with
GL = 2.
Discussion:The “ASPIREX” study demonstrates how the condition C
(GRADE III LYSIS) has high statistical significance (p <0.001) and, there-
fore, shows that the lysis procedure associated with mechanical thrombec-
tomy is effective.
Conclusions: The “ASPIREX” study showed how in the group of 5 patients
with DVT, the mechanical thrombectomy procedure was extremely effective
and it was possible to reach a highly significant level of lysis.
141
Poster
201. INDICENTAL VENOUS THROMBOEMBOLISM IN 30
PATIENTS WITH CANCER: ROLE OF KHORANA SCORE.
“KHONCER” STUDY. FIVE-YEAR EXPERIENCE (2011-2016)
Ulissi A. 1., Ciammaichella M.M. 1, Maida R. 1, Martelli O. 2
1
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma 2 Oncologia
Medica, A. O. S. Giovanni-Addolorata, Roma
Introduction: The “KHONCER” study, acrostic derived from “KHOrana
score and caNCER”, enrolled 30 patients aged between 58 and 84 years
with complete incurable venous thromboembolism and cancer hospitali-
zed in the Complex “Urgency Medicine” In the five-year period January
2011-December 2016. All patients were subjected to TC-thoracadomi-
nal-pelvic CT with mdc; echocardiography; Venous ecocolordoppler lower
limbs and possibly elastompression; Thrombophilic and neoplastic markers.
In all patients, the Khorana score was measured. Therefore, a database called
“KHONCER” was created. The database contained the following fields: 1)
patient number, 2) Khorana score for each patient. All patients were analy-
zed, during recruitment, according to the above 2 fields, collected from time
to time in masks created in “structure view” and “data sheet view” as allowed
by the database program. A comparative analysis of Cochgran’s Parametric
Parametric Continuous Variables has been performed to see if there is a
significant relationship between the values of the Khorana score and the
extent of the incident venous thromboembolic manifestation (independent
variable A).
Purpose of Work: The “KHONCER” study aims to: 1) verify any existing
relationship between the Khorana score and the venous thromboembolic
manifestation in the 30 patients enrolled in the “KHONCER” study during
the five-year period January 2011 - December 2016; 2) to verify the statisti-
cal significance found by applying Cochran’s Parametric Parametric Test for
Comparative Analysis for Continuous Variables to determine whether the
relationships of the variables considered are due to the case. A comparative
analysis of Cochgran’s constant parameter variables Q was performed to see
if there is a significant relationship between the values of the Khorana score
and the magnitude of venous embolic venous manifestation (independent
variable A).
Purpose of Work: The “KHONCER” study aims to: 1) verify any existing
relationship between the values of the Khorana score and the extent of venous
embolic thrombotic event in the 30 patients enrolled in the “KHONCER”
study during the five-year period January 2011 - December 2016; 2) to verify
the statistical significance found by applying Cochran’s Parametric Parame-
tric Test for Comparative Analysis for Continuous Variables to determine
whether the relationships of the variables considered are due to the case.
Material and Method: In the 30 patients enrolled with venous thromboem-
bolism, Khorana score values were compared with the clinical manifestation
of venous thromboembolism. For the calculation of χ2 apply the following
formula: χ2 = (k-1) [(k x) -y2] / (k y) -z = 20.95. With “k” the 3 variables
considered, with “x” the total of the squares of the 3 variables considered.
“Y” indicates the total of clinical conditions. “Y2” is the square of the total
clinical condition. “Z” is the total squares of clinical conditions. The relative
value (VR) of χ2 obtained is 60 with degrees of freedom (GL) = 2. The criti-
cal value (VC) of χ2 for p = 0, 001 is 13, 816.
Results Analysis: The Cochran Q test applied to the 30 patients involved
in the “KHONCER” study shows that the clinical situation “TEV” (Full
Venous Thromboembolism) in all patients is not attributable to the case but
assumes a high statistical significance as The relative value (VR) of the χ2
obtained is 60 with degrees of freedom (GL) = 2 and the critical value (VC)
of χ2 for p = 0, 001 is 13, 816. Choice differences are, therefore, highly signi-
ficant with p <0.001.
Discussion: Data obtained in the 30 patients enrolled in the “KHONCER”
study showed statistically significant correlation in the incidental venous
thromboembolism between the Khorana score and the extent of venous
thromboembolic manifestation. Cochran’s Q testifies a highly significant
difference whose clinical significance lies in the high reliability of predicting
venous thromboembolic risk in cancer patients
Conclusions: The “KHONCER” study has shown that in a group of 30
patients with complete venous thromboembolism there is a Highly correla-
ted correlation between the Khorana score and the extent of venous throm-
boembolic manifestation according to Cochran’s “Q” test. The “KHONCER”
study demonstrates the high predictiveness of venous thromboembolic risk
in the cancer patient.
142
118° Congresso Nazionale - Società Italiana di Medicina Interna
202. POST-THROMBOTIC SYNDROME: CASE REPORT
De Angelis M. 1, Ciammaichella M.M. 2, De Paola G. 2, Maida R. 2,
Ulissi A. 2, Vagnarelli S. 3
1
Ospedale Monospecialistico Oftalmico, Roma 2 Medicina d’Urgenza, A. O.
S. Giovanni-Addolorata, Roma 3 Radiologia Interventistica, A. O. S. Giovan-
ni-Addolorata, Roma
Introduction: The authors present a case report of post-thrombophle-
tic syndrome in a 38-year-old woman who came to our observation for
persistent turgore to the lower left lobe (Figure 1-2) following deep vein
thrombosis treated 8 months earlier with other nococom. Post-thrombotic
Syndrome (SPT) is the most common complication after a deep venous
thrombosis episode (TVP). This pathology has a chronic tendency and is
often disabling by affecting the quality of life. A recent revision of literature
shows an incidence of SPT of 1-1.5%, which in 20-50% of patients appears
within two years of the thrombotic event despite the fact that adequate
anticoagulant therapy has been undertaken. In the US for a patient with
TVP who has an SPT, they spend on average $ 20, 569 compared to the
$ 15, 843 used to treat a patient with TVP who is not affection with SPT.
Case Report: We describe the case of a woman of 38 aa who came to our
observation for persistent left thigh turgor 8 months after diagnosis of deep
venous thrombosis of the left iliac-femoral axis treated with nosocomio
with LMWH embolized to ACO until optimization of Therapeutic range
of INR From anamnestic history of digestive bleeding in September 2016.
During the stay, the following examinations are performed:
1) ECG: sinus rhythm
2) hematochemical examinations: within the limits
3) Secondary thrombophilic marker markers: Negative
4) Primary Thrombophilic marker markers: Negative
5) Transverse thoracic ecgardiogram: VS in the limits, Chinese preserved,
FE 67%, diastolic dysfunction of the 1st degree, right sections in the norm,
indecent pericardial
6) Venous Ecodoppler of the lower limbs: non-occlusive segmentary throm-
bosis of the left external iliac vein with proximal tensed rhomomelous
edema
7) TC chest-abdomen with mdc: absence of opacity defects in lung arte-
ries; Subclavian thrombosis of the left ventricle iliac to the passage with the
femoral vein
8) Angio-RM abdomen: stenosis of the left and left left ventricular vein; The
stenosis originates from the inguinal ring and ends at the entrance of the
VCI with venous collateral (Figure 1)
9) Lower left lumbar articulation: left-hand transfemoral examination with
echo-guided access: documented sub occlusion of the left external limb cra-
nially to inguinal ligament, recanalization by positioning of dedicated metal
stent Cook Zilver vein 14x60 mm, dilates The stent and I check the correct
positioning with good flow inside and complete re-analysis of the left iliac
axis. The patient is discharged to ACO treatment at a therapeutic range of
INR. At discharge, the left thigh detachment is observed.
Discussion: The post-thrombotic syndrome clinic includes a series of
symptoms and signs not directly pathognomonic, but only suggestive and
potentially attributable to other pathological conditions. Therefore, we may
use the definition of “Clinical Evidence Concise” that post-thrombotic syn-
drome is: edema, ulceration, and alteration of vitality of the subcutaneous
tissue of the leg as a consequence of a deep vein thrombosis. SPT is cha-
racterized not only by the clinical manifestations of each phase of its staging,
but also by the negative impact on quality of life (worse than many chro-
nic-degenerative frameworks such as chronic obstructive pulmonary artery
disease and chronic obstructive or dysfunctions such as Diabetic disease) or
compromising it as well as more prognostic pathologies such as neoplasms,
ischemic heart disease and congestive heart failure. The diagnosis of SPT
is clinic and basically relies on an in-depth and accurate medical history,
which must primarily aim to bring out non-clinically and instrumentally
documented elements related to a venous event occurring in silent form
and on a well-conducted integrated clinical examination From ultrasonic
instrumentation. (Necessary to detect any phlebostensometric data in cli-
nostatism, ortostatism, after orthodynamics, valve incompetence for post
devolutional devaluation phenomena, thrombotic residues). However,
there are no universally validated methodologies for the diagnosis of SPTs
although some scores have been developed as tools for diagnosing and
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.
118° Congresso Nazionale - Società Italiana di Medicina Interna
203. MAY-THURNER SYNDROME: CASE REPORT
Fanfarillo F., Maida R., Ciammaichella M.M.
Medicina d’Urgenza, A. O. S: Giovanni-Addolorata, Roma
Introduction: May-Thurner syndrome is a rarely diagnosed condition in
which patients develop deep vein thrombosis (TVP) due to an anatomical
variation in which the common right iliac artery overlaps and compresses
the common left ventricular vein Against the lumbar spine We present the
case of a 40-year-old patient with turgor of the lower left limb caused by con-
tusion of the thigh and hospitalized in the Department of Urgency Medicine
for further investigation case report. The patient reaches our observation
with pain and swelling of the lower left limb after a long journey in the car.
The patient reports that the pain started at the left foot then extended to the
medial side of the thigh to radiate, finally, at the left groin. No significant
data emerge from the anamnesis collection. It assumes oral contraceptives
(drospirenone and ethinylestradiol). In the objective examination the vital
parameters were within the limits of the norm. His lower left limb was hot,
swollen, erythematosus. The arterial wrists are normally appreciable. Motri-
city and sensitivity are preserved. The chest RX does not show pleuropa-
renchymal abnormalities. Chest TC without mdc does not detect signs of
embolism. The ECG is within limits.
Complete hemocromis and baseline metabolic profile are within the limits of
the standard, PT is 14.5 seconds, PTT is 24.3 seconds, INR of 1.1, D-dimer
is 2.3 micrograms / Ml (IL method, VN <0.25 microg / ml). Primary and
secondary thrombophilia was within the limits. The lower limb venous eco-
doppler reveals the left iiaco-femoral TVP. The CT abdomen with mdc shows
left-handed TVP. Thus, the venlafying of the lower left limb confirms the
extended left popliteo-femoro-iliac thrombosis. After introducing into the left
femoral left of a catheter, French Cragg-McNamara submits the locus-regio-
nal lysis patient with 1 mg / h infusion of r-TPA in combination with systemic
anticoagulant treatment with heparin sodium, monitoring every 6 hours the
values of PTT and fibrinogen. After 24 hours, the left lower limb phonography
shows the presence of residual thrombus. Thus, mechanical thrombectomy is
performed using a Trellis device and simultaneous infusion of another 5 mg
r-TPA. A new 24-day phlebographic check is performed that documents a
partial resolution of the thrombus with residual stenosis of the common left
ventricular vein stenosis. Therefore, dilation with a balloon of 10 × 40 mm and
a stent of 14 × 40 mm is placed within the stenotic tract. Venography demon-
strates the presence of May-Thurner syndrome (MTS) on the basis of proxi-
mal TVP, common left ventricular vein stenosis in an area directly above the
lumbar spine and thrombotic residual stenosis after thrombolytic and throm-
bectomy administration. After stent placement, the patient was subjected to
warfarin therapy in heparin sodium embryo until optimization of INR values.
Twelve months after surgery, the patient had no recurrence of TVP.
Discussion: MTS was described in 1957 when it was found that 22% of the
430 autopsy corpses had an anatomical variation in which an overlapping
common iliac common artery squeezed the common left iliac vein against
the lumbar spine. Failure to correct the MTS anatomy substrate could lead
to TVP recurrence and further complications, including pulmonary embo-
lism, chronic venous stasis, and iliac vein rupture (28% of patients with ilecal
vein rupture have MTS) Anatomic defect Associated with MTS occurs in the
basin, an area that is not readily visualized by ultrasound. Consequently, if
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
24 to 48 hours. Subsequently, an intravascular stent should be inserted into
the iliac vein compression zone with post-implanted phlebographic control.
Conclusions: We have submitted a case of MTS with left ventricle TVP
treated with lysis-locoregional, mechanical thrombectomy, stent implant.
204. RETROSPECTIVE ANALYSIS ON 12
CARDIORESPIRATORY ARREST CASES IN PATIENTS
WITH MASSIVE PULMONARY EMBOLISM: CASTEV
STUDY
Ala A., Barberi S., Del Signore C., Maida R., Ciammaichella M.M.
Medicina d’Urgenza, A. O. S. Giovanni-Addolorata, Roma
Introduction: The “CASTEV” study, acrostic derived from CArdiac arreST
in patients with massiVe pulmonary embolism, enrolled between January
2017 and December 2016 12 patients with severe pulmonary embolism in
the pre-lysis period from Cardiorespiratory arrest. The clinical outbreak was
Poster
characterized by all patients with dyspnoea (arterial emo-analytical value of
pO2 <60 mmHg) associated with chest pain, hemodynamic stability (PAS
<90 mmHg) according to the American College of Chest Physicians Eviden-
ce-Based Clinical Practice Guidelines. All patients were subjected to TC-tho-
racadominal-pelvic CT with mdc; Echocardiography with systolic pulmonary
arterial pressure measurement; Venous ecocolordoppler lower limbs and pos-
sibly elastompression; Thrombophilic and neoplastic markers. In all patients,
electrocardiographic presentation rhythms were assessed at cardio-respira-
tory arrest. Therefore, a database called “CASTEV” was created. The database
contained the following fields: 1) patient number, 2) defibrillation rhythm,
3) non defibrillating rhythm (PEA or asystolia). All patients were analyzed,
during recruitment, according to the above 3 fields, collected from time to
time in masks created in “structure view” and “data sheet view” as allowed
by the database program. A comparative analysis of Cochran’s Parametric
Parametric Continuous Variables was performed to verify whether there is
a significant relationship between the cardiorespiratory arrest (independent
variable A) and the presentation rate (variable E dependent).
Purpose of Work: The CASTEV study aims to: 1) to verify any existing
relationship between cardiorespiratory arrest and electrocardiographic pre-
sentation rhythm in the 120 patients enrolled in CASTEV study during the
decade January 2007 - December 2016; 2) to verify the statistical signifi-
cance found by applying Cochran’s Parametric Parametric Test for Compa-
rative Analysis for Continuous Variables to determine whether the relation-
ships of the variables considered are due to the case.
Material and Method: A comparative analysis was conducted for conti-
nuous variables with Cochran’s Parametric Test Q to verify whether there
is a significant relationship between the variables considered: cardiorespira-
tory arrest during massive pulmonary embolism and electrocardiographic
presentation rhythm. The “Subjects” column shows the number of patients
who participated in the study. ND-A, ND-P, and D are the following in the
central column: ND-A (non-defibrillable-Asystolia), ND-P (Non-Defibril-
lable-Asystolia) D (Defibrible). In column “Y” the number of clinical situa-
tions. In the column “Y2”, the square of “Y” values. The “Total” line indicates
the total of conditions. In the “Total2” line, the squares of totals of clinical
conditions are indicated. The term “Y = 12” indicates the total of clinical
conditions. The symbol “Z = 12” indicates the square of the total clinical
condition. The symbol “Y2 = 144” indicates the square of the total clini-
cal condition. The sum of the totals in square is indicated by the following
formula: X = xND-A2 + xND-P2 + xD2 = 144 + 0 + 0 = 144. R
Esults Analysis: The Cochran Q test applied to the 12 patients involved in
retrospective analysis shows how the clinical situation “ND-A” (Not Defi-
brillable-Asistolia) highlighted in all patients is not attributable to the case
but assumes statistical significance Is high because the relative value (VR) of
the obtained χ2 is of 144 with degrees of freedom (GL) = 2 and the critical
value (VC) of χ2 for p = 0, 001 is 13, 816. Choice differences are, therefore,
highly significant with p <0.001.
Discussion: The data obtained in the 12 patients enrolled in the CASTEV
study demonstrated that the electrocardiographic rhythm of cardiorespira-
tory arrest is a non-defibrillation remedy and in particular an asystole. This
is due to severe hypoxemia and hypovolemia caused by massive pulmonary
embolism.
Conclusions: The CASTEV study showed that in the group of 12 patients
with pulmonary embolism complicated by cardiorespiratory arrest, the
electrocardiographic presentation rate is a non-defibrillative rhythm, and
in particular an asystole.
205. COMPARISON BETWEEN THREE NON-INVASIVE
TECHNIQUES OF EVALUATION MICROVASCULAR
MORPHOLOGY VS. THE GOLD-STANDARD LOCALLY
INVASIVE MICROMYOGRAPHY. PRELIMINARY DATA
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,
Sansoni G. 4, Agabiti Rosei C. 1, Trapletti V. 1, Pileri P. 1, Agabiti Rosei E. 1,
Rizzoni D. 1,5
1
Clinica Medica, Department of Clinical and Experimental Sciences,
University of Brescia, 2 Chair of Ophtalmology, University of Brescia, 3
Department of Mechanical and Industrial Engineering, University of Brescia
Brescia, Italy; 4 Department of Information Engineering, University of
Brescia, Brescia, Italy; 5 Istituto Clinico Città di Brescia, Division of Medicine,
Brescia, Italy
Objective: The evaluation of the morphological characteristics of small resi-
stance arteries in human beings is not easy. The gold standard is generally
considered to be the evaluation of the media to lumen ratio (M/L) of sub-
143
Poster 118° Congresso Nazionale - Società Italiana di Medicina Interna

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

144
118° Congresso Nazionale - Società Italiana di Medicina Interna
posterior pararenal spaces and in pelvic cavity, prominent azygous/hemi-azy-
gous veins, and bilateral iliofemoral-popliteal DVT. From the fourth day of
admission, the patient developed bilateral lower limb swelling. He was treated
with compression stockings and anticoagulant therapy and discharged home
after three weeks in a markedly improved condition. The patient was recom-
mended 6 months of anticoagulation with apixaban. A CT scan performed 3
months after admission showed recanalization of the obstructed venous seg-
ments. Congenital anomalies of the IVC are often associated with DVT, espe-
cially in young, healthy individuals without other DVT risk factors. In these
cases DVT may not present with typical symptoms. There is no consensus in
literature about the duration of the anticoagulant treatment. Some authors
recommend life-long anticoagulation even when thrombophilia investigation
is negative in order to reduce the recurrence risk.
Finally, it is worth emphasizing that young patients with DVT that is not
associated with classical risk factors should undergo a complete investigation,
including IVC imaging methods, with the objective of excluding possible con-
genital venous anomalies.
209. NON-SURGICAL PERIODONTAL TREATMENT
IMPROVES CARDIOVASCULAR ADAPTATION TO
ORTHOSTATIC CHALLENGE IN THE SHORT-TERM
Del Pinto R., Pietropaoli D., Barone A., Monaco A., Ferri C.,
Giannoni M.
University of L’Aquila, Department of Life, Health and Environmental
Sciences, L’Aquila, ITALY.
Background: Periodontal health status influences systemic health, and
periodontal treatment (PT) has been shown to improve systemic inflam-
mation and endothelial dysfunction. The latter has been associated to
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-
tion overall compared to the basal condition. Seven days after treatment, a
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-
statism (SBP -6.22mmHg, p=0.01; HR -4.33bpm, p=0.03). Orthostatic
DBP decreased, without reaching statistical significance (DBP -1.05mmHg,
p=0.59). No statistical difference was observed in the acute or late effects on
CV parameters between treatments.
Conclusions: NSPT determined an acute, non-significant increase in BP
and a significant reduction in BP and HR in the short-term that persisted
after orthostatic challenge, irrespective of treatment. These results are in line
with previous findings on endothelial-mediated effects of NSPT. Longer fol-
low-up is needed in order to verify any longer persistence of these effects
and their potential impact on CV health.
210. CLUSTERS OF COMORBIDITIES AND IN-HOSPITAL
MORTALITY IN ELDERLY PATIENTS AFFECTED
BY ACUTE HEART FAILURE: A SINGLE-COHORT
PROSPECTIVE STUDY
Capeci W. 1, Falsetti L. 2, Tarquinio N. 3, Viticchi G. 4, Fioranelli A. 5,
Di Pentima C. 3, Zoppi F. 3, Pellegrini F. 3, Burattini M. 3
Poster
1
Neurosurgery Unit, Ospedali Riuniti di Ancona; 2Internal and Subintensive
Medicine Department, Ospedali Riuniti di Ancona; 3Internal Medicine
Department, Ospedale “S.S. Benvenuto e Rocco”, Osimo (Ancona);
4
Neurology Clinic, Università Politecnica delle Marche, Ancona; 5Cardiology
Clinic, Università Politecnica delle Marche, Ancona
Background: acute heart failure (AHF) is negatively affected by the presence of
comorbidities. We aimed to evaluate if different associations of comorbidities
could differently affect in-hospital mortality for AHF in a cohort of elderly
patients.
Materials and Methods: we enrolled all the consecutive patients admitted
to our Internal Medicine department in the years 2014-2017 for AHF
investigating age, sex, in-hospital mortality and presence of 16 common
internistic comorbidities. Association of chronic pathologies was explored
with Pearson’s bivariate test, selecting only clusters of ≥2 significantly
associated comorbidities. Then, we obtained ROC curves predicting
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
sample. In-hospital mortality was 13%. We obtained 11 different clusters, 6
of which predicting significantly in-hospital mortality. The first (anaemia,
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-
0.821;p=0.037. The third (dyslipidaemia, AF, PAD, CVD, haematologic
disorders) had AUC:0.716;95%CI:0.564-0.868;p=0.009.The fourth (AF,
anaemia, dyslipidaemia, diabetes, CVD, IPB) had AUC:0.764;95%CI:0.658-
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,
IPB) had AUC:0.695;95%CI:0.565-0.825;p=0.019.
Discussion: In this small sample, some clusters of comorbidities were not
associated to an increased risk of in-hospital mortality in AHF. However, we
identified some patterns which are strongly associated to in-hospital death.
These cluster deserve the best clinical attention and the most extensive therapy.
211. THE ROLE OF FRAMINGHAM RISK SCORE IN THE
PROGRESSION FROM MILD COGNITIVE IMPAIRMENT
TO DEMENTIA
Falsetti L. 1, Viticchi G. 2, Buratti L. 2, Provinciali L. 2, Silvestrini M. 2
1
Internal and Subintensive Medicine, Ospedali Riuniti di Ancona, Italy;
2
Neurological Clinic, Marche Polytechnic University, Ancona, Italy
Background: Mild cognitive impairment (MCI) often represents the clini-
cal manifestation of cognitive deterioration preceding Alzheimer’s disease
(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
cardiovascular risk profile (FCRP) could be useful to identify patients at the
highest risk of conversion from MCI to AD.
Methods: Patients with aMCI were carefully investigated to assess their
vascular risk profile. They were also submitted to a comprehensive neurop-
sychological evaluation. FCRP was calculated for each patient and apoli-
poprotein E (ApoE) genotype was determined from peripheral blood cells.
The main outcome was defined as a conversion to AD within 24 months
145
Poster
after inclusion.
Results: 385 consecutive aMCI subjects were included. Age, FCRP, and
vascular age showed a fairly predictive value on conversion to AD. Selecting
the subpopulation of ApoE ε4 carriers, we observed that FCRP had an
increased performance in predicting the conversion. The rate of conversion
increased from 12.5% in the FCRP low-risk group to 43.2% in the high-risk
group (p < 0.0001). ApoE ε4 carriers had a 3.7-times increased probability
of conversion with respect to the other subjects (p < 0.0001).
Conclusions: FCRP assessment could be considered a reliable approach
to predict conversion to AD in aMCI subjects. The presence of ApoE ε4
increases significantly the risk of conversion. These data confirm the narrow
relationship between genetic and vascular risk factors in influencing the
evolution of cognitive impairment.
212. TAKO-TSUBO SYNDROME AFTER PACE-MAKER
IMPLANTATION: A CASE REPORT
Fanfani G., Calcagno E., Tozzetti C., Torri M., Poggesi L.
Dipartimento DAI Emergenza ed Accettazione, AOU Careggi, Università
degli studi di Firenze
Case Report: We described the case of a 84-year old man suffering of sudden
reduction of left ventricular systolic function after pace-maker implanta-
tion. His medical history was notable for hypertensive heart disease, per-
manent atrial fibrillation and moderate pulmonary hypertension. His phar-
macological-therapy included digoxin and an ace-inhibitor. The patient
underwent pace-maker implantation because junctional rhythm due to Sick
Sinus Syndrome. The procedure was completely free from complications
and the patient didn’t experience clinical signs or symptoms of heart failure,
but the echocardiogram after the implantation showed apical ballooning
and a sudden reduction of ejection fraction (EF 36%) with mild increase of
Troponin I. The electrocardiogram showed ventricular rhythm induced by
the pace-maker, without any changes compared to the previous one. After
24 hours, a new echocardiogram showed an increase of EF to 52%, without
administration of pharmacological therapy.
Tako-Tsubo cardiomyopathy is a relatively common acute and reversible myo-
cardial dysfunction that typically occurs after an emotional or physical stress.
It has been largely approved that this syndrome is associated with increased
plasmatic levels of catecholamines triggering myocardial stunning. TakoT-
subo cardiomyopathy occurs in more than 90% of cases in postmenopausal
women. In fact, estrogens are involved in the expression of beta-adrenergic
receptors in myocardial tissue enhancing transcription of cardioprotective
factors. Lack of estrogens, catecholamine-induced cardiotoxicity and micro-
vascular dysfunction are the main supported theories. Pace-maker implan-
tation related stress is a rare cause to take into account. In literature there
are few cases, describing tipically postmenopausal women who underwent
pace-maker implantation for severe bradycardia due to atrioventricular block.
We found only one case of Tako-Tsubo cardiomyopathy described in a man.
213. ACUTE HEART FAILURE AND INFECTIONS: A
RETROSPECTIVE STUDY
Folli C., Rovellini A., Accordino S., Billi F., Monzani V.
IRCCS Fondazione Ca’ Granda - UO di Medicina Interna ad Alta Intensità
di Cura - Milano
Heart failure is one of the leading causes of hospital admission, especially
in elderly patients, with an estimated prevalence > 10% in patients aged
more than 70 yrs. Infections are not only another major cause of admis-
sion to hospital divisions but also a frequent and threatening complication
in patients hospitalized for different medical causes. The relation between
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
chronic heart failure, with an increased risk of in-hospital death. Aim of the
study was to evaluate a cohort of consecutive patients admitted to the Divi-
sion of Acute Internal Medicine for heart failure, with or without infections
(community- or hospital-acquired) and to identify the risk factors for the
development of infections and mortality. Secondary aim was to evaluate
the site of infection and the most frequently involved bacteria. 626 patients
with heart failure consecutively admitted to our division were enrolled in
the study (334 females; mean age 82.9±9.5 yrs) from January 1st, 2013 to
December 31st, 2015. 375 (60%) had a diagnosis of infection (at admission
or during in-hospital stay). The majority of patients (86.4%) was admitted
146
118° Congresso Nazionale - Società Italiana di Medicina Interna
directly from the Emergency Room, 7.5% was transferred from other hospi-
tal divisions and 6.1% was transferred from Residences for Elderly Patients.
Mean in-hospital stay was 13.8 days in the whole population, significantly
higher in patients with infections (p<0.001). 39.3% of patients had at least
one previous episode ho hospitalization for heart failure. In 78% of the
375 patients, the infection was community-acquired (mostly respiratory),
in 22% hospital-acquired (mostly urinary). Germs most frequently invol-
ved were E.coli, S.aureus, E.faecalis. Mortality in the whole population was
12.5% (significantly different in patients with or without infections, 16.6%
vs 6.2%, p<0.001). Risk factors for the development of infections were male
sex and COPD. Risk factors for mortality were advanced age and cognitive
impairment, as well as renal failure, lattacidemia and hyponatremia. Low
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
these patients, often as a cause precipitating heart failure or as a compli-
cation, worsening the prognosis. Multi-drug resistant germs are frequently
involved and antibiotic therapy should be carefully evaluated.
214. PREVALENCE OF DYSLIPIDEMIA AND EVALUATION
OF LIPID PROFILE AND LIPID-LOWERING THERAPY IN
A POPULATION OF HYPERTENSIVES
Giulietti F., Spannella F., Cocci G., Balietti P., Landi L., Bordoni V., Sarzani
R.
Internal Medicine and Geriatrics, ESH. Hypertension Excellence Centre,
Università Politecnica delle Marche, IRCCS-INRCA, Ancona, Italy
Background: Dyslipidemia and hypertension are the most prevalent modi-
fiable cardiovascular (CV) risk factors and they often coexist. Aim of the
study: analyze the prevalence of dyslipidemia and evaluate the lipid profile
and lipid-lowering drugs in a population of hypertensives who underwent
a 24h ambulatory blood pressure monitoring (ABPM), to underline the
relevance of this association and possible lacks in the management of
dyslipidemia.
Methods: Retrospective study on 1440 hypertensives referred to our Hyper-
tension Centre between 2010 and 2015. Blood pressure profiles and control
rates were evaluated using ABPM. Dyslipidemia was defined by the pre-
sence of at least one of these characteristics: total cholesterol (TC) ≥200 mg/
dL, high levels of calculated LDL cholesterol (cLDL), based on individual
CV risk (according to 2016 ESC/EAS guidelines), HDL cholesterol <40 mg/
dl in males and <50 mg/dl in females, triglycerides (TG) ≥150 mg/dl.
Results: Mean age: 55.9 ± 13.4 years. Males: 57.2%. Dyslipidemia: 82.6%.
Overweight/Obesity: 68%. Smoking: 18.1%. Diabetes Mellitus: 10.7%.
Peripheral arterial disease (PAD): 23.7%. Mean eGFR: 75.0 ± 15.6 ml/
min/1.73m2. Mean TC: 205.9 ± 39.7 mg/dl. Mean cLDL: 129.2 ± 34.5 mg/
dl. Mean HDL: 51.8 ± 13.7 mg/dl. Median TG: 111 mg/dl (82-157). Patient
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.
Diabetics not treated with lipid-lowering drugs: 56.4%. Diabetics treated
with lipid-lowering drugs without reaching cLDL target: 56.5%. Patients
with PAD not treated with lipid-lowering drugs: 78.3%. Statin prevalences:
simvastatin (38.9%), atorvastatin (31.7%), rosuvastatin (15.0%), pravasta-
tin (11.9%), others (2.5%). Patients taking high intensity statins: 2%. Blood
pressure control rates: 29.9%. Blood pressure and lipid control rates: 12%.
Conclusion: Our data showed a poor management of dyslipidemia in
hypertensive patients, who referred to our Hypertension Centre. In par-
ticular, patients at higher CV risk were often not treated with lipid-lowe-
ring drugs or they were treated with low intensity statins, without reaching
the recommended target. An appropriate management of dyslipidemia is
needed, to improve the CV prevention.
215. RENAL RESISTIVE INDEX IN THE ACUTE
MYOCARDIAL INFARCTION STEMI AND NSTEMI,
CORRELATIONS WITH METABOLIC, INFLAMMATORY
AND ATEROSCLEROTIC MARKERS
Lai S. 1, Iorio R. 2, Asllanaj B. 3, Molfino A. 1, Perrotta A. 1,
Mangiulli M. 4, Barillà F. 2, Mariotti A. 5
1
Department of Clinical Medicine, Sapienza University of Rome, Italy; 2
Department of Cardiovascular, Respiratory, Nephrological, Anaesthetic
and Geriatric Sciences, Sapienza University of Rome, Rome, Italy 3
Specialistläkare, Falu Lasarett, Falun, Svezia; 4Department of Internal
118° Congresso Nazionale - Società Italiana di Medicina Interna
Medicine and Medical Specialities, Sapienza University of Rome, Rome, Italy;
5
UOC Nephrology and Dialysis, A.Perrino Hospital, Brindisi
Introduction: Coronary heart disease is one of the main causes of death
in the world, particularly in patients with chronic kidney disease (CKD), a
disease with a worldwide prevalence of 8-13% and with high cardiovascular
morbidity and mortality. Patients with ischemic coronary heart disease are
subdivided into STsegment elevation Myocardial Infarction (STEMI), or
non- ST segment elevation Myocardial Infarction (NSTEMI). The purpose
of our study was to evaluate the use of Renal Resistive Index (RRI) as a
marker of cardiovascular risk in patients with acute myocardial infarction
STEMI and NSTEMI and possible correlations with renal function, metabo-
lic and inflammatory indices, and atherosclerotic markers.
Materials and Methods: 40 patients (34 males and 6 females, mean age
59.47 ± 10.95 years), with acute myocardial infarction STEMI and NSTEMI
were enrolled, and we have made an assessment of estimated glomerular
filtration rate (eGFR), mineral metabolism and inflammatory (C-reactive
protein, CRP) and metabolic indices (homeostatic model assessment,
HOMA-IR). In addition, Intima Media Thickness (IMT), Ankle-Brachial
Pressure Index (ABPI) and RRI markers were evaluated.
Results: In our study we showed a significant negative correlation between
RRI and eGFR (r = -0.47; p-value = 0.0282), and a significant positive corre-
lation between RRI and CRP (r = 0.539; p-value = 0.042), while we found a
positive correlation but to the limits of statistical significance, between RRI
and IMT (r = 0.415; p-value = 0.098).
Conclusions: The Renal Resistance Index (RRI) is a hemodynamic measure
that reflects both the resistance and the arterial compliance of the renal
vessels. It is considered to be one of the most sensitive parameters of renal
plasma flow alterations and a systemic index of endothelial dysfunction.
From the results of our study, RRI appears to be an useful cardiovascular
risk marker, correlating with inflammation, that has a key role in athe-
rosclerosis, particularly in CKD. Furthermore, the positive correlation,
found in our study between RRI and eGFR, suggests the use of the first as
an integrative marker to better assess the progression of CKD in patients
with coronary heart disease. Indeed, RRI is considered to be a very sensitive
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.
References: 1) Inflammation, Atherosclerosis, and Coronary Artery
Disease Göran K. Hansson, M.D., Ph.D. Review Article. N Engl J Med
2005;352:1685-95
2) Third universal definition of myocardial infarction. European Heart
Journal (2012) 33, 2551-2567.
3) Parolini C, Noce A, Staffolani E, Giarrizzo GF, Costanzi S, Splendiani G
(2009) Renal resistive index and long-term outcome in chronic nephropa-
thies. Radiology 252:888–896
4) Hashimoto J, Ito S (2011) Central pulse pressure and aortic stiffness
determine renalhemodynamics: Pathophysiological implication for micro-
albuminuria in hypertension Hypertension 58:839
216. FOLLOWING YOUR HEART OR TRUSTING YOUR
GUT? A CASE OF A MISLEADING CHEST PAIN
Piombo M. 1, Merati G. 1, Dell’Aera D. 1, Perrone T. 1, Mugellini A. 1, Corazza
G.R. 1
1
Dipartimento Area Medica, SC. Medicina Generale 1, Fondazione IRCCS
Policlinico San Matteo, Pavia
Introduction: A variety of non cardiac conditions could show with chest
pain and electrocardiographic (ECG) changes mimicking ischemic heart
disease. In literature, non specific ECG changes have been reported with
pericarditis, pancreatitis, acute stroke, subarachnoid hemorrhage, myocar-
dium neoplasm, hypothermia, gastric distention and cholecystitis.
Case Report: On June 2017 a 86-year-old woman was admitted to the
Emergency Department of our hospital for chest pain, nausea and vomiting.
She had a history of gallstone disease, massive hiatal hernia, arterial hyper-
tension, stage 3 of chronic kidney disease and she was recently discharged
from another medical department with a diagnosis of acute coronary syn-
drome (ACS) undergoing to conservative treatment. Physical examination
revealed normal vital signs, a grade 3 systolic murmur on cardiac auscul-
tation and a normal pulmonary and abdominal exam. Biochemical results
demonstrated neutrophilic leukocytosis and a slight increase in the tro-
ponin I (TnI) level. The ECG showed a sinus tachycardia with left bundle
branch block (LBBB), which was already known, and a chest CT scan with
contrast excluded pulmonary embolism and aortic dissection. The patient
was admitted to our department for a reacutization of ACS managed with a
Poster
conservative therapy. In the second day of recovery she developed fever and
abdominal pain with guarding and rebound tenderness on palpation of epi-
gastric and right upper quadrant region. Chemistry revealed worsening of
leukocytosis, increased procalcitonin and C-reactive protein (CRP) levels,
elevated creatinine level and unchanged troponin value with normal range
of transaminases and cholestasis index. After microbiological examinations,
bowel rest, fluid support and empiric antibiotic therapy with piperacillin-ta-
zobactam were started. The ultrasound finding were suggestive of acute cho-
lecystitis with gallstones and revealed an anechoic collection of fluid with
poorly defined borders in epigastric region suspect for abscess. Therefore an
abdomen CT scan with contrast was done in which the diagnosis of acute
calculous cholecystitis complicated by pericholecystic abscess was confir-
med. A surgical consult was requested but, taking into consideration the
age and the multiple comorbidities, a conservative approach was preferred.
A second line antibiotic therapy with metronidazole and meropenem was
started obtaining apyrexia, improvement of pain and of physical examina-
tion and also progressive decrease of leucocytes, CRP and procalcitonin
levels. Meanwhile, ECG was unchanged, TnI level continued being slightly
increased and echocardiography demonstrated a normal left ventricular
ejection fraction with antero- septal hypokinesis and posterior-basal akyne-
sis, already shown by a previous exam.
Discussion:We report a case of a 86-year-old woman with a chest pain and
clinical features suggestive of ACS disguising an acute complicated cholecy-
stitis. Several studies confirmed the association between gallbladder disease
and ECG alterations, even if the exact pathophysiological mechanism of this
correlation remains unclear. In our case the presence of a previous LBBB
probably masked acute ECG changes, but the persistent slight elevation of
TnI, without features of an acute myocardial infarction, and the absence of
new alterations on echocardiography allowed to rule out the hypothesis of
an ACS.
Conclusion: The presence of chest pain and ECG changes should be
managed with particular attention to all the possible differential diagnosis,
in order to ensure an early and appropriate treatment, especially in elderly
in which the clinical presentation could be misleading.
217. KIDNEY DYSFUNCTION IS ASSOCIATED WITH
THE BURDEN OF CORONARY ATHEROSCLEROSIS,
INDEPENDENTLY OF DIABETES
D’Errico M.M. 1,2, Mangiacotti A. 1, Graziano D. 1,2, Massa V. 1,2,
Piscitelli P. 1, Mirijello A. 1, Marchese N. 3, Vendemiale G. 2,
Russo A. 3, Vigna C. 3, De Cosmo S. 1
1
Department of Medical Sciences, Unit of Internal Medicine, “Casa Sollievo
della Sofferenza” Research Institute General Hospital, San Giovanni Rotondo,
Italy. 2Internal Medicine and Geriatrics Residency School, University of
Foggia, Foggia, Italy. 3Department of Cardiovascular Sciences, Unit of
Cardiololgy, “Casa Sollievo della Sofferenza” Research Institute General
Hospital San Giovanni Rotondo
Background: Kidney dysfunction is associated with an increased risk
of coronary artery disease (CAD). Aim of our study was to describe the
burden of coronary atherosclerosis associated with the components of
chronic kidney disease, i.e. low glomerular filtration rate or albuminuria.
Patients and Methods: We enrolled 208 (M165/F43) consecutive patients
with mean age of 69.3+10.5 yrs old, who underwent percutaneous coro-
nary intervention (PCI) for stable or acute coronary syndrome. Glomeru-
lar filtration rate has been estimated from serum creatinine by CKD-EPI,
albuminuria has been measured by urinary albumin creatinine ratio(ACR).
Coronary disease was defined by the presence of coronary stenosis >50%.
Results: Clinical features of patients recruited were the following: BMI:
28.5+29 Kg/m2, systolic blood pressure: 136+16 mmHg, diastolic blood
pressure: 75+10 mmHg, triglycerides: 159+95 mg/dl, HDL-chol: 43.4+13
mg/dl, LDL-chol: 100+38 mg/dl. Estimated glomerular filtration rate
(eGFR): 69.3+23.3 ml/min/1.73m2 and ACR: median 1.49, range 0.33-831
mg/mmol. Ninety-seven (47%) had type 2 diabetes (9% diet, 52% OHA,
39% Insulin+ OHA). One-hundred-sixty-eight (81%) were dyslipidemic,
183 (88%) had arterial hypertension and 57 (27%) were smokers. Regar-
ding the burden of coronary disease, 56 (27%) patients had single vessel
disease (S-VD), 67 (32%) 2-vessels disease (2-VD) and 85 (41%) 3-vessels
disease (3-VD). EGFR progressively decreased with the increase of the
number of coronary vessels involved: 76.4+22.1, 69.3+23.6, 64.6+22.9 ml/
min/1.72m2 in patients with S-VD, 2VD or 3VD, respectively (p=0.026,
adjusted by age, gender). The significance did not change when presence/
absence of diabetes was added in the model (p=0.033). Albuminuria signi-
ficantly increased only in patients with 3VD (1.36, 0.44-781; 1.23, 036-135;
147
Poster
2.26, 033-831 mg/mmol, in patients with S-VD, 2-VD or 3-VD, respectively;
3VD vs SVD+2VD p=0.005 adjusted for age, gender). Also in this case, the
significance did not change when presence/absence of diabetes was added
in the model (p=0.018).
Conclusions: In our sample, we describe a strong and linear association
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
of diabetes.
218. ENDOTHELIAL PROGENITOR CELLS AND MARKERS
OF VASCULAR DAMAGE IN HYPERTENSIVE PATIENTS
Sciacqua A. 1, Perticone M. 2, Hrabal M. 1, Pinto A. 1, Miceli S. 3,
Cassano V. 4, Bencardino G. 1, Magurno M. 1, Grillo N. 1, Sesti G. 1,
Perticone F. 1
1
Dipartimento di Scienze Mediche e Chirurgiche - Università degli Studi
Magna Graecia - Catanzaro 2Dipartimento di Medicina Sperimentale
e Clinica - Università degli Studi Magna Graecia - Catanzaro 3Azienda
Ospedaliero-Universitaria “Mater Domini” - Catanzaro 4Dipartimento di
Scienze della Salute - Università degli Studi Magna Graecia - Catanzaro
The endothelial progenitor cells (EPCs), produced by the bone marrow in
response to different exogenous and endogenous stimuli, present the ability
to differentiate into mature endothelial cells and may contribute to neova-
scularization after endothelial injury. Several studies have reported that the
presence of cardiovascular (CV) risk factors or other pathological condi-
tions affecting both the number and the functions of EPCs. In particular,
there is a negative relationship between CV risk factors and the circulating
EPCs number and migratory activity. Of interest, low levels of EPCs are
associated with CV morbidity and mortality. It is well known that early
indicators of vascular damage such as endothelial dysfunction, increased
arterial stiffness (AS) and carotid intima-media thickness (c-IMT), repre-
sent independent predictors of poor CV prognosis. The aim of this study
was to evaluate the possible association of EPCs circulating levels with both
functional and structural vascular damage indexes in a group of uncom-
plicated and untreated hypertensive patients. We enrolled 60 Caucasian
subjects (33 men and 27 women, mean age 46.3+13.5 years). Endothelial
function was estimated by a peripheral arterial tonometer (PAT) with the
measurement of reactive hyperemia index (RHI, Itamar-Medical, Cae-
sarea, Israel). AS was evaluated with the measurement of carotid-femoral
pulse wave velocity (PWV) by applanation tonometry (SphygmoCor) and
c-IMT by a high-resolution ultrasound B-mode system. Insulin resistance
was assessed by HOMA index and renal function by measurement of esti-
mated glomerular filtration rate (e-GFR) according to CKD-Epi formula.
Pool of circulating EPCs was determined by cytometric analysis of the fol-
lowing specific surface antigens: CD34, CD133, VEGFR2(KDR) and plasma
cytokine’s network (IL6, IL1β, TNFα) by chemiluminescence. Patients were
evaluated at baseline (cross-sectional analysis) and after a mean follow-up
of 3.0 ± 0.6 years. At baseline, a linear regression analysis was performed
to test the correlation among vascular assessment parameters, as depen-
dent variables, and different covariates. RHI was significantly correlated
with EPCs (r=0.585, P<0.0001) and inversely related with HOMA (r=
-0.468, P<0.0001), TNF-α (r= -0.344, P=0.004), IL-6 (r= -0.316, P=0.007),
hs-CRP (r= -0.313, P=0.007) and IL-1β (r= -0.278, P=0.016). PWV was
significantly related with HOMA (r=0.460, P<0.0001), TNF-α (r=0.379,
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
and EPCs (r= -0.357, P=0.003) and with e-GFR (r= -0.393, P=0.011), but
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
and smoking as dichotomic values, were inserted in a stepwise multivariate
linear regression model to determine the independent predictors of RHI,
PWV and c-IMT. EPCs were the major predictor of RHI, explaining a 34.2
% of its variation, HOMA added another 8.4%. Similarly, EPCs were the
strongest predictor of PWV, explaining 32.1% and HOMA justified another
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
14.8%. Follow up data collection shows that the pharmacological treatment
induced a significant improvement in endothelial function and AS, but not
for c-IMT. After correction for vascular indexes basal values, EPCs justified
17% (P=0.001), 27.7% (P<0.0001) and 10.6% (P=0.006) of the variation of
Δ RHI, Δ PWV and Δ c-IMT at follow-up, respectively. In conclusion, the
present study strengthens the association between circulating EPCs and
148
118° Congresso Nazionale - Società Italiana di Medicina Interna
morpho-functional vascular damage indicators in hypertensives, demon-
strating a greater association with functional parameters (endothelial fun-
ction and AS). Moreover, circulating EPCs may predict variation in vascular
parameters during follow-up, thus the need for antihypertensive drugs not
only able to lower blood pressue values but also to improve EPCs levels.
219. BIOMARKERS OF LEFT VENTRICULAR MASS IN
HYPERTENSIVE PATIENTS
Miceli S. 1, Perticone M. 2, Sciacqua A. 3, Grillo N. 3, Falbo T. 3,
Sesti G. 3, Perticone F. 3
1
Azienda Ospedaliero-Universitaria “Mater Domini” - Catanzaro
2
Dipartimento di Medicina Sperimentale e Clinica - Università degli Studi
Magna Graecia - Catanzaro 3Dipartimento di Scienze Mediche e Chirurgiche
- Università degli Studi Magna Graecia - Catanzaro
Left ventricular mass (LVM) is an independent cardiovascular (CV) risk
factor, that recognizes a multifactorial pathophysiology. Raised blood pres-
sure explains only a 10-25% of LVH variation, thus suggesting the existence
of other not hemodynamic factors such as obesity, obstructive sleep apnea
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
patients with known CV risk factors, in comparison with a control group.
We performed an observational study enrolling 512 caucasian outpatients
(228 males and 284 females, median age 50.9 ± 10.8 years). The study
population was divided into three groups: Group I (n= 184; normotensive/
normal weight; 83 males and 101 females), Group II (n= 238; hypertensive/
normal weight; 104 males and 134 females), and the Group III (n=90; obese/
hypertensive; 40 males and 50 females). All patients underwent measure-
ment of the following parameters: weight, height, body mass index (BMI),
heart rate (HR), fasting plasma glucose, fasting insulin, HOMA index, cre-
atinine, estimated glomerular filtration rate (e-GFR) using the CKD-EPI
equation, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceri-
des, uric acid, hs-PCR, 25(OH)D and PTH. LVM was determined through
Echocardiogram as Devereux formula and indexed both for body surface
area (LVM/SC) and for height2.7 (LVM/h2.7). Linear regression analysis
was performed to assess the correlation between2.7 and the different LVMs
indexed variable h2, 7 throughout the population and in the three groups
separately. Then, variables that reached statistical significance were inser-
ted in a stepwise multiple regression model where the dependent variable
was LVM/h2.7. In whole population insulin resulted the main predictor of
LVM indexed (LVMI) explaining the 23.8% of its variation; other indepen-
dent predictors were uric acid, hs-PCR and HR, adding another 4.8%, 3%
and 0.4% of its variation, respectively. In Group II the main predictor of
LVM variability was insulin, which explained a 19.4% of its variation; other
independent predictors were uric acid and hs-PCR, explaining another
4.1% and 1.7% of its variation, respectively. In Group III the main predi-
ctor of LVMI insulin, explaining a 41.1% of its variation, anduric acid and
HR added a 12.1% and 3.1% of its variation, respectively. The results of
this study demonstrate that, beyond blood pressure, age and gender, other
factors act in the determinism of LVM both in normal weight and in obese
hypertensive patients. In our population the primary biomarker of LVM
was insulin, both in the whole study population and in the three groups
separately. Another important evidence emerged from our study is that in
obese patients cardiac mass indexed for h2.7 helps to better stratify the CV
risk profile in this setting of patients.
220. RIGHT VENTRICULAR FUNCTION IN PATIENTS
WITH TYPE 2 DIABETES MELLITUS
Miceli S. 1, Perticone M. 2, Sciacqua A. 3, Falbo T. 3, Grillo N. 3,
Bencardino G. 3, Sesti G. 3, Perticone F. 3
1
Azienda Ospedaliero-Universitaria “Mater Domini” - Catanzaro
2
Dipartimento di Medicina Sperimentale e Clinica - Università degli Studi
Magna Graecia - Catanzaro 3Dipartimento di Scienze Mediche e Chirurgiche
- Università degli Studi Magna Graecia - Catanzaro
The right ventricle is a chamber capable of tolerating high volume loads
with modest increases in blood pressure. However, in the event of a pressure
overload, it becomes quickly unable to support the additional load resulting
in a drop in the cardiac output (afterload mismatch). Diabetic cardiomyo-
pathy can manifest itself as subclinical organ damage. It is characterized
by structural and functional anomalies of ventricular and atrial contractile
myocardium. Most studies on diabetes-induced alterations focused on the
118° Congresso Nazionale - Società Italiana di Medicina Interna
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
outpatients (261 males and 177 females), divided into two groups: group 1
included non-diabetic patients; group 2 newly diagnosed diabetic patients.
We measured the following antropometric and clinical parameters: height,
weight, body mass index, heart rate, systolic and diastolic blood pressure.
All patients underwent measurement of the following laboratory para-
meters: fasting plasma glucose, fasting insulin, HOMA index, creatinine,
e-GFR (CKD-EPI), total-, HDL- and LDL cholesterol, triglycerides, uric
acid, hs-PCR. In all patients we performed an echocardiographic evalua-
tion of the main morphological and functional parameters: VASI, MVSI,
RVOT, TAPSe, PAPs, TAPSe/PAps, E/A (RV e LV), E/e’ (RV e LV), IPM,
RVP, TAPSe/RVP (Evdx). As regards to the right sections, diabetic patients
did not show differences in morphological parameters, but showed higher
levels of MPI (50.5 vs. 36.1, P <0.000), lower ventricular efficiency (EVdx:
11.07 vs 14.6, P = 0.001) and higher values of pulmonary systolic pressure
(PAP: 31.9 vs. 27, P = 0.028), compared to control subjects. A linear regres-
sion analysis was conducted to see the related parameters with dependent
variables (EVdx and IPM). Therefore, all parameters that reached statistical
significance were included in a multiple regression model, thus detecting the
predictive factors for MPI and EVdx. The main predictors for EVdx resulted
HOMA index and SBP. The main predictors for MPI resulted HOMA index,
VASI, SBP and hs-PCR. Newly diagnosed diabetic patients have subclini-
cal functional alterations that precede the morphological alterations of the
right chambers. Myocardial performance index (MPI) and right ventricular
efficiency (expression of the relationship between TAPSe /RVP), are early
markers of subclinical organ damage to the right heart.
221. HEART FAILURE AND IRON STATUS
Perticone M. 1, Sciacqua A. 2, Miceli S. 3, Zito R. 2, Falbo T. 2,
Cassano V. 4, 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 3Azienda Ospedaliero-
Universitaria “Mater Domini” - Catanzaro 4Dipartimento di Scienze della
Salute - Università degli Studi Magna Graecia - Catanzaro
Heart failure (HF) is a chronic disease showing an increasing prevalence
due to the aging of the population; Iron deficiency (ID) is a clinical condi-
tion often observed in HF patients. Recent evidence has shown that patients
with both HF and anemia have, compared to non-anemic patients, lower left
ventricular ejection fraction (LVEF), a worse NYHA class, most commonly
left ventricular hypertrophy and a worse quality of life. Furthermore, it has
been also demonstrated a high prevalence of ID in patients with reduced
ejection fraction (HF-REF) that, regardless of the simultaneous presence of
anemia, was associated with an increase in hospitalization, mortality and
poor quality of life of the patient. The aim of this study was to evaluate, in a
cohort of patients with HF, stratified by both reduced (<40%) and preserved
EF, the possible relationship between the iron status and cardiac function.
We enrollwed 206 Caucasian patients (114 males and 92 females, mean
age o75.34 ± 10.59 yrs). All subjects had a diagnosis of HF, NYHA I-IV
functional class. In all subjects a careful history was collected and a com-
plete cardiovascular examination was performed with arterial blood pres-
sure, heart rate and major anthropometric parameters; In particular: waist,
weight, height and body mass index (BMI). A blood sampling was obtained
for the determination of lipid profile, fasting plasma glucose, uric acid, cre-
atinine, serum iron, emocromocytometric examination and renal function.
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,
PAPs). Measurements of the ejection fraction, EF (Simpson method, %),
was also obtained from the telediastolic and telesisthetic ventricular volume
measurements. Values of P<0.05 were considered statistically significant.
Patients with with EF < 40% showed, in comparison to patients with EF >
40% inferior plasmatic levels of iron (57.31±22.06 vs 85.10±30.0 mcg/dL,
p<0.0001). In addition, with EF<40% compared to patients with preserved
EF also showed lower haemoglobin levels (12.27 ± 1.46 vs 13.35 ± 1.47 g/dL,
p<0.0001). Our results demonstrated that the reduction of iron levels signi-
ficantly correlated with low EF whereas there is no significance between
serum iron and patients with EF>40%. Despite the strong evidence of the
benefits of iron therapy on symptoms and hospitalizations of HF patients,
this is rarely used in current clinical practice, even if it could be a good
approach to improve the quality of life of patients with chronic HF.
Poster
222. EFFICACY AND SAFETY OF TOCILIZUMAB IV
ADMINISTRATION IN ADULT ONSET STILL DISEASE
Cardinali M., Benfaremo D., Biondi L., Mattioli M., Olivari D.,
Angeletti A., Manfredi L., Pomponio G., Fraticelli P., Gabrielli A.
Dipartimento di scienze cliniche e molecolari - SOD. clinica Medica -
Ospedali riuniti di Ancona
Background: Adult Still’s disease (ASD) is a rare inflammatory disorder
where patients complain about recurrent and dramatic spikes of fevers,
arthralgia with sometimes frank arthritis, sudden onset of evanescent rash.
A severe pharyngitis is common in ASD. There is equal occurrence between
the sexes, with two peaks, one between 15 and 25 and the second between
the ages of 36 and 46, with older patients sometimes reported. There aren’t
defined diagnostic criteria, but Yamaguchi criteria have the highest sensiti-
vity in patients with a definite diagnosis of ASD. The four major Yamaguchi
criteria are: fever at least 39° lasting at least one week; arthralgia or arthritis
lasting two weeks or longer; a non-pruritic erythematous skin rash typically
salmon-coloured found over the trunk or extremities; Leucocytosis with
at least 80 percent granulocytes. Minor Yamaguchi criteria include: sore
throat; lymphadenopathy; hepatomegaly or splenomegaly; abnormal eleva-
tion of aspartate and alanine aminotransferase and lactate dehydrogenase;
negative test for ANA and Rheumatoid factor. Therapy aims to control phy-
sical signs and symptoms of inflammation and prevents end organ damage.
While mild-disease patients only need a low dose of glucocorticoid therapy,
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
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
such as tocilizumab are described in case series as effective for disease resi-
stant to other medications.
Introduction: In this small case series, we observed the effectiveness and
safety of an 8 mg/kg monthly tocilizumab (IL-6 inhibitor) intravenous
administration in patients with adult Still’s disease. Our patients were 4, one
male and three females with a mean age of 50.5 years and a mean disease
duration of 3.25 years at the point of observation (April 2017). Main symp-
toms complained were recurrent and debilitating fever along with arthralgia.
Results: After administration of intravenous Tocilizumab (mean number
of infusions: 24) all patients had remission of symptoms for most of the
time between the administrations; we also observed a mean DAS28 (PCR)
reduction of 2.41 points and a mean PCR reduction of 7.16 mg/dl. Use of
intravenous tocilizumab allowed reduction in daily glucocorticoid therapy
of 29.17 mg of prednisone. The administration of tocilizumab did not
provoke major side effects, and all patients are currently on therapy. At April
2017 one patient switched to Tocilizumab SC for a better control of arthral-
gia recurring the last week before infusion.
Discussion and Conclusions: Since Tocilizumab introduction a couple
of studies were available about its use in adult onset Still disease. In many
cases those were retrospective studies or case reports, generally including
patients who were refractory to conventional treatment. However, the effi-
cacy and safety of this treatment is broadly described, except two reports of
macrophage activation syndrome (MAS). Actually, Still disease could also
exacerbate MAS, and it may be difficult to distinguish if this is an adverse
effect or part of the disease. While randomized control trials are required to
compare different therapies available, this case series demonstrates safety
and effectiveness of tocilizumab even in moderate forms of disease, parti-
cularly as
223. GLOBAL LONGITUDINAL STRAIN ASSESSMENT IN A
COHORT OF PATIENTS WITH SYSTEMIC SCLEROSIS. AN
EARLY PREDICTOR OF SISTOLIC DISFUNCTION
Fischetti C. 1, Ferrarini A. 1, Zuliani L. 1, Guerra F. 2, Stronati G. 2,
Fraticelli P. 1, Danieli M.G. 1, Capucci A. 2, Gabrielli A. 1
1
Clinica Medica, Dipartimento Di Medicina Interna, Universita’ Politecnica
Delle Marche, Ospedali Riuniti, Ancona 2 Clinica Di Cardiologia E.
Aritmologia, Universita’ Politecnica Delle Marche, Ospedali Riuniti, Ancona
Background: Systemic sclerosis (SSc) is chronic disease characterized by
vascular abnormality and progressive fibrosis of skin and internal organs
such as lung, gastro-intestinal tract, kidney and heart. While commonly
undetected by standard echocardiography, recent advances in speck-
149
Poster
le-tracking analysis could potentially aid in detecting subclinical heart
organ damage in SSc patients. Aim of our study was to evaluate echo-deri-
ved, speckle-tracking global longitudinal strain (GLS) as a marker of subcli-
nical right and left ventricular dysfunction in SSc patients.
Methods: We studied 51 SSc patients (8 males, 18 diffuse subgroup,
mean age 54±16 years) and 51 age- and gender-matched controls in a 1:1
fashion. A standard echocardiographic exam according to current guide-
lines was performed for each subject. Bi-dimensional, speckle-tracking
derived global and segmental longitudinal strain rate were compared
between cases and control. Moreover, info on SSc variant, anticorpal
pattern, cardiovascular risk factors, and other organ systems involvement
were collected for each patient.
Results: Left ventricle and right ventricle GLS were significantly impai-
red in patients with SSc when compared to healthy controls (-19.2% vs.
-20.3%; p=0.007 and -21.0% vs. -23.6%; p=0.029 respectively). Using -20%
as a cut-off for GLS, SSc patients had a 3.5-fold increased risk of sub-
clinical left ventricle systolic impairment and a 4.1-fold increased risk of
subclinical right ventricle systolic impairment when compared with age
and gender matched controls (OR 3.5; 95% CI 1.1-16.2; p=0.032). The
reduction in GLS in SSc is homogeneous and widespread to both ven-
tricles, with no segments significantly more involved than others and a
preserved apex-base and epicardium-endocardium gradient.
Conclusion: While traditional echo parameters are ineffective in detecting
subclinical systolic impairment, a reduced GLS is more common in patients
with SSc and is significant for both left and right ventricles. As the GLS
impairment seems similar in both chambers, our findings could be explai-
ned by diffuse and progressive myocardial fibrosis rather than changes in
arterial pulmonary pressures due to lung involvement.
224. AN UNUSUAL CASE OF BREATHLESSNESS: WHAT
COULD BE HIDING BEHIND DYSPNEA?
Maira D. 1, Di Stefano V. 1, Migone De Amicis M. 1, Minonzio F. 2,
Hu C. 2, Gerosa M. 3, Cappellini M.D. 2
1
Scuola di specializzazione in Medicina Interna - Università degli Studi
di Milano 2Dipartimento di Medicina Interna (U.O. Medicina Interna
1A) - Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico 3
Dipartimento di Reumatologia – Istituto Gaetano Pini
Introduction: We describe the peculiar case of a female adult patient with
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
Department with a 4-week history of increasing breathlessness and persi-
stent dry cough. Dyspnea occurred with mild exertion and was associated
with a feeling of chest tightness and nonspecific chest pain, especially on
the right side. Approximately 5 days before admission she developed fever
and a concomitant worsening of coughing and fatigue, so that she sought
medical attention. The patient was a nonsmoker. She was diagnosed with
SLE 5 years before. Since then she experienced 3 hospitalizations due to
flares with SLE-related articular, nephrologic and neuropsychiatric invol-
vement. However, her rheumatologic disorder was referred to be in good
control during the last year. At the time of admission the patient was on
low-dose steroid (prednisone 5 mg od) associated with low-dose metho-
trexate (7.5 mg weekly). On admission to our Internal Medicine ward the
patient was alert and comfortable at rest, afebrile, her vital signs were stable.
Her oxygen saturation was 98% on 35% Venturi mask at 8 l/min, her respi-
ratory rate was 28 breaths/min. Chest examination revealed fine inspiratory
basal crackles on the left side and dimished breath sounds on the right side.
Examination of the heart, abdomen and neurologic system was normal. She
complained of severe pain in her fingers, wrists, knees and ankles which
were not swollen but tender to the touch and slightly reddened. A purpu-
ric non pruritic rash was noted on her right hand. Laboratory tests showed
mild anemia, leukopenia with lymphopenia, elevated C-reactive protein
and erythrocyte sedimentation rate. Renal and hepatic function tests were
normal. Immunological investigations revealed an abnormal titer of ANA
(1/320), with positivity of anti-dsDNA antibodies;antiphospholipid antibo-
dies were negative. C3 levels were depressed, while C4 levels were normal.
In the suspect of respiratory tract infection, empiric antimicrobial treatment
with piperacillin/tazobactam was started and methotrexate was temporarily
stopped. In fact, chest X-ray showed a marked right hemidiaphragm eleva-
tion with severe homolateral lung volume reduction and basal linear ate-
lectasis in the absence of definite parenchimal infiltrates. A contrast-enhan-
ced chest CT was obtained to further define the nature of these findings,
confirming basal bilateral atelectasis and small right lung volume, minimal
150
118° Congresso Nazionale - Società Italiana di Medicina Interna
pleural and pericardic effusion. Pneumonia was ruled out; there was no
evidence of interstitial or vascular disease. Results of PFT were abnormal,
showing a restrictive ventilatory defect with a reduced TLC (49% of predi-
cted capacity), RV (75%) and FVC (45%). DLCO was not assessed due to
the patient’s inability in performing the test. During the first days of hospi-
tal stay the purpuric rash worsened, extending on the patient’s left leg and
right breast area. Moreover she developed painful mucositis on both of her
lips. The clinical features of the patient, the radiologic and functional chest
findings and the serologic evidence of SLE flare, together with a review of
current literature and case reports, allowed us to suspect SLE-related pul-
monary involvement. A diagnosis of shrinking lung syndrome (SLS) was
made.
Conclusion: Shrinking lung syndrome is a rare complication mainly associa-
ted with SLE, although it has also been reported in patients with other con-
nective tissue diseases. Respiratory involvement in SLE patients is common
(60–80%), consisting mostly of pleuritis, PE, pulmonary hypertension,
acute pneumonitis and chronic interstitial lung disease. The estimated pre-
valence of SLE-associated SLS is 0.6-1%. It occurs months to years after the
diagnosis. It is characterized by progressive exertional dyspnea of variable
severity with or without pleuritic chest pain, associated with reduced lung
volumes as demonstrated by elevated hemidiaphragms on chest X ray and a
restrictive defect on PFT, with no evidence of parenchymal lung disease or
vascular pathology on imaging findings.The underlying physiopathologic
mechanism is unknown: chronic pleural inflammation has been hypothe-
sized to promote the reduction in diaphragmatic mobility inhibiting deep
inspiration by neural reflexes. This could result in chronic lung hypoinfla-
tion, leading to parenchymal remodelling with changes in elasticity, thus
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
agents have also been used either if the patient fails to improve or since the
beginning of the treatment. Theophylline and beta-agonists have been sug-
gested in order to increase diaphragmatic strength. Long-term prognosis is
good: improvement and stabilization is achieved in most cases.Our patient
was started on metilprednisolone 40 mg iv daily and antibiotic therapy was
discontinued, obtaining a reduction in the need of oxygen supply and in
the inflammatory markers. We observed a prompt regression of the pur-
puric rash, while the mucositis diminuished without totally disappearing.
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).
Rheumatologic and pneumologic follow-up were planned.
225. THE UNLUCKY HISTORY OF AN UNFORGETTABLE
PAINTER AFFLICTED WITH STILL’S DISEASE
Piccillo G.A. 1, Saitta R. 1, Mondati E.G.M. 2, Gasbarrini G.B. 3
1
Emergency Department, Cannizzaro Hospital Catania; 2Department of
Internal Medicine and Systemic Pathologies, University of Catania; 3Professor
Emeritus of Internal Medicine, Catholic University of Rome
Introduction: Adult onset Still’s disease (AOSD) is a very rare systemic
inflammatory disorder found worldwide, first described by Doctor Still a
British Paediatrician in children, and predominantly affecting young adults
16-35 years old, with increased frequency of HLA B-35, clinically characte-
rised by high spiking fever (>39°C), usually in the evening, popular or
macula-papular, salmon pink in colour, evanescent rash in the trunk and
proximal extremities and mildly pruritic, arthritis with intense arthralgia
and involvement of the distal interphalangeal joints of the hand, myalgia
and multi-organ involvement. Currently its prevalence globally is unknown.
Case Report: A very good painter 33-year-old woman, neither smoker,
nor alcoholand drug user, was admitted to our Department due to onset
of fever, abdominal pain, nausea and vomiting. She had a 2-year history of
evanescent rash at limbs and trunk. She had been suffering with weakness
and weight loss in the last months and headache and vomiting in previous
20 days. At clinical examination, she appeared very pale and suffering with
headache, vomiting, itchy to lower limbs and severe hand arthralgia, and
overall she was very preoccupied for the strong trouble to use her right hand
in order to paint!!!. The evaluation of her skin, disclosed the presence of
multiple erythematous spots and areas of hyperpigmentation. Laboratory
analysis revealed normocytic anemia, leukocytosis (15.000 WBC mainly
neutrophiles) and thrombocytosis, rise of phlogosis indexes (C-reactive
protein, ferritin, fibrinogen and ESR and transaminases. Autoimmune
panel was negative, except for low titer ANA. Blood cultures and serology
for viruses were collected hypothesizing a bacterial or viral infection and
broad-spectrum antibiotic therapy was started without clinical benefit. All
118° Congresso Nazionale - Società Italiana di Medicina Interna
the cultures were subsequently negative. CT-scan revealed the presence of
inflammatory interstitial lung infiltrates, splenomegaly, lymphadenopa-
thy. In order to exclude malignancies the patient underwent to PET which
showed hypermetabolism in lungs, spleen and lymph nodes. Skin biopsies
pointed out a leukocytoclastic vasculitis. Given all this, since all the investi-
gations executed ruled out an infective, autoimmune or neoplastic disease,
final diagnosis of AOSD was made. So, she started therapy on high dose of
prednisone with progressive clinic, laboratory and radiological benefit. She,
despite the deep pain to her hands, bravely continued to paint her fantastic
pictures!!!! A month later at the follow up visit the patient was dramati-
cally improved, so the steroid therapy was gradually reduced with no any
complication.
Discussion:The clinical presentation of AOSD is really heterogeneous and
the spectrum of differential diagnoses (infectious, neoplastic, and autoim-
mune disorders) is wide and for this reason the diagnosis of AOSD can be
challenging. We here presented the unlucky case of a young woman with a
clinical presentation of skin rash and hand arthralgia, who, though struck
by strong pain to her hands, courageously faced the disease and continued
to make her nice paintings.....we only helped her to chase her dream!!!
226. COMBINED SERUM DEFICIENCY OF ALKALINE
PHOSPHATASE AND LACTATE DEHYDROGENASE:
CLINICAL REBUS IN AN OLIGOSYMPTOMATIC ADULT
PATIENT
Turrin M. 1, Altinier S., Zaninotto M., Plebani M.
già 1 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: A persistent reduction in serum activityof ALP (persi-
stent hypophosphatasemia) is characteristic of hypophosphatasia (HPP).
A sporadic hypophosphatasemia is caused by: severe hypothyroidism,
Cushing’s disease, bisphosphonate therapy, renal osteodystrophy, milk-
alkali syndrome, vitamin D intoxication, Wilson’s disease, vitamin C defi-
ciency, hypomagnesemia, hypoglycemia, celiac disease, pernicious anemia,
hypozincemia, radioactive heavy metal contamination, Kikuchi-Fujimoto
disease. Six major clinical forms of HPP have been described: lethal peri-
natal, benign prenatal, infantile, juvenile, adult, and odontohypophospha-
tasia.The diagnosis of HPP in the adult is determined by the combination
of suggestive bone manifestations, low ALPactivity, high serum concentra-
tions of pyridoxal-5’-phosphate (PLP) or in urine phosphoethanolamine
(PEA).The genetic defect is confirmed by the positive finding of ALPL gene
mutations that encode for TNSALP (tissue-non-specific[liver/bone/kidney]
isoenzyme of ALP). A serum LDH deficiency in H subunit was described
in the 1980s and 1990s in some Japanese families without clinically relevant
consequences (MIM 614128).
Clinical case: A 39years old man came to our attention because he com-
plained for a few months of pain and sense of heaviness in his elbows, arms,
calf and wrist. He assumed NSAID with good outcome. For the force deficit
in the first closure and paresthesia at the fingers of the hands performed a
EMG compatible with the minimum grade carpal tunnel syndrome. Labora-
torytests were normal for: blood glucose, creatininemia, eGFR, ALT, hemo-
chrome, ferritin, serum protein electrophoresis, triglycerides, cholesterol.
Anamnesis evidenced: smoker, regular lifestyles, no allergies;moderate sco-
liosisof the cervical and thoracolumbar vertebrae, C6-C7 intervertebral disk
protrusion, bilateral epicondylitis.The results of biochemical investigations
showed: ALP: 40 U/L (nv: 56-119), 25(OH) D3: 30 ng/mL (insufficiency:
<75), uricemia: 0.45 mmol/L (nv: <0.42). Normal: inflammatory indices,
calcium, phosphorus, CPK, TSH, creatinine clearance, urinary calcium,
phosphate, and uric acid, serum magnesium, zinc, RF, PTH, CTX.Two
months later the low ALP value was confirmed (42 U/L) together with a to
tal LDH of 91 U/L (nv: 135-225), which was also confirmed in subsequent
control. A lumbar and femoral bone densitometry highlighted a bone mass
framework within the limits.Adult hypophosphatasia suspect, suggested
by persistently low ALP activity, was not inagreement with normal bone
metabolism and BMD. The patient also had no dental problems. Pharmaco-
logical interferences responsible for a decrease in ALP have been excluded:
azathioprine, clofibrate, vitamin D intoxication, danazol, estrogen, oral con-
traceptives and bisphosphonates.The LDH isoenzymes showed: LAD-1:12%
(nv:15-25), LAD-2:24% (nv:32-41), LAD-3: 36% (nv:18-26), LAD-4: 15%
(nv:7-14), LAD-5: 13% (nv:5-16). Decrease in 1 and 2 isoenzyme was found
in serum but not in red blood cells.The ALP bone isoenzyme (BSALP) was
normal as well as the vitamin B6 dose on the blood (21.7 μg/L, nv: <27.2).
Family members (parents, siblings, grandchildren)have been tested, and
Poster
with the exception of hypovitaminosis D, they showed normal values of
both ALP and LDH. Molecular analysis by direct sequencing of the ALPL
gene coding regions (NM_000478.4), located in chromosome 1p36.1-p34,
did not highlight the presence of genetic variants of importance for diagno-
stic purposes. It was not possible to search for any mutations in the LDHB
gene (MIM150100, chromosome 12p12.1) for lack of technical availability
of gene sequencing.
Conclusions: In the patient described, despite of moderate osteo-articu-
lar symptoms and persistently low ALP value, normal vitamin B6 and no
ALPL gene mutations were found. These mutations are more than 335:
the number and diversity of these variants justify the high variability of
the phenotypic expression of the HPP. Such evidences leads us to believe
that our case represents anoccult or oligosymptomatic form of hypopho-
sphatasia.The practical consequences consist in clinical and biochemical
parameter monitoring and avoiding the use of bisphosphonates and excess
vitamin D. Regarding in serum LDH-1 and LDH-2 deficiency (and not in
erythrocytes), we find it plausible, in the absence of LDHB gene sequen-
cing, two hypotheses:the presence of a circulating immune globulin that
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
described in Literature.
227. BURDEN OF COMORBIDITY IN ELDERLY PATIENTS
WITH ATRIAL FIBRILLATION: INSIGHTS FROM THE
REPOSI STUDY
Proietti M. 1, Nobili A. 2, Mannucci P.M. 3, Lip G.Y. 4
1
Institute of Cardiovascular Sciences, University of Birmingham,
Birmingham, United Kingdom; Department of Neuroscience, Laboratory
of Quality Assessment of Geriatric Therapies and Services, IRCCS – Istituto
di Ricerche Farmacologiche “Mario Negri”, Milan, Italy; 2Department of
Neuroscience, Laboratory of Quality Assessment of Geriatric Therapies and
Services, IRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”, Milan,
Italy; 3Scientific Direction, IRCCS Ca’ Granda Maggiore Policlinico Hospital
Foundation, Milan Italy; 4Institute of Cardiovascular Sciences, University of
Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research
Unit, Department of Clinical Medicine, Aalborg University, Aalborg,
Denmark;
Background: Patients with atrial fibrillation (AF) are often elderly and have
multiple comorbidities. The latter can be assessed using various clinical
severity scales. The burden of comorbidity has been associated with worse
outcomes in several clinical conditions, including patients with cardiova-
scular disease. Purpose: To analyze the relationship between the burden of
comorbidity and outcomes in elderly patients with AF from the REPOSI
Study. REPOSI study is an on-going observational registry of elderly (≥65
years) hospitalized patients.
Methods: Comorbidity severity was quantified according to Cumulative
Illness Rating Scale Index of Comorbidity (CIRS-IC). Based on the median
CIRS-IC, AF patients were categorized as ‘low’ and ‘high’ comorbidity. All
patients with an AF diagnosis enrolled from 2010, 2012, 2014 and 2015
REPOSI cohorts with available CIRS-IC and follow-up data were conside-
red for the analysis.
Results: In the 735 patients, available for this analysis, median [IQR]
CIRS-IC was 3 [2-5]: thus, 373(50.7%) had low comorbidity while
362(49.3%) had high comorbidity. Increased cognitive dysfunction (defined
using the short Blessed test) (p=0.005), and polypharmacy (p=0.001) were
independently associated with high comorbidity, as well as several clini-
cal conditions [Table]. CHA2DS2-VASc was higher in patients with high
comorbidity compared to low comorbidity (p<0.001). At follow-up, rates of
cardiovascular (CV) death and all-cause death were higher in patients with
high comorbidity compared to low comorbidity (11.0% vs. 5.9%, p=0.012
and 23.8% vs. 14.5%, p=0.001 respectively). Kaplan-Meier curves analysis
showed that patients with high comorbidity had a higher risk for both CV
death (Log-Rank: 4.891, p=0.027) and all-cause death (Log-Rank: 7.765,
p=0.005). Multivariate Cox regression analysis, found that high comorbi-
dity was independently associated with both CV death (hazard ratio [HR]:
1.77, 95% confidence interval [CI]: 1.05-2.98) and all-cause death (HR: 1.50,
95% CI: 1.09-1.40). A further Cox model, computed using CIRS-IC as con-
tinuous variable, again confirmed the association with CV-death (HR: 1.23,
95% CI: 1.09-1.40) and all-cause death (HR: 1.17, 95% CI: 1.07-1.27).
Conclusions: In elderly AF patients, high comorbidity is independently
associated with an increased risk for CV death and all-cause death.
Table: Factors Independently Associated with High Comorbidity
151
Poster
OR  95% CI   p
Short Blessed Test (per point) 1.03  1.01-1.06  0.005 
Hypertension  2.84  1.65-4.89  <0.001 
Hypercholesterolemia  2.41  1.19-4.87  0.014 
Peripheral Arterial Disease  3.26  1.09-9.71  0.034 
Diabetes Mellitus  2.35  1.57-3.50  <0.001 
Chronic Kidney Disease  3.06  2.03-4.63  <0.001 
Chronic Obstructive 1.63  1.07-2.49  0.022 
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-
Legend: CI= confidence interval; OR= odds ratio.
228. EFFECT OF LOW DOSE OF SACUBITRIL/VALSARTAN
IN PATIENTS WITH CHRONIC SEVERE HEART FAILURE
ON BODY COMPOSITION, BIOIMPEDENZIOMETRY,
HEART RATE VARIABILITY AND T-PEAK-TO T-END
INDEX
Raimondi G. 1, Sindona F. 1, Mobilia P. 2, Dalmaso S. 2, Visani N. 2,
Marchitto N. 2
1
Dept. of Medico-surgical Sciences and Biotechnologies. “Sapienza”
University of Roma. Faculty of Pharmacy and Medicine 1 1ASL. Latina “A.
Fiorini” Hospital
Chronic Heart Failure is definied as an abnormality of the cardiac
structure and/or function resulting in clinical symptom (dyspnea) and
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
Sacubitril/Valsartan in elderly patients with reduced FE < 35% (HFrFE)
on Heart rate variability, T-peak to T-end index, fat mass, free fat mass
and total body water.
Methods: We have enrolled 12 elderly patients 9 males (range age 70 –
87 years and mean value of 77 years) and 2 females (range age 50 – 71
years and mean value of 60.5 years) with HFrFE < 35%. Four patients have
chronic kidney failure and four patients have diabetes. All patients have
hypertension. We have evaluated kidney function, glucose, BNP, Heart
Rate Variability, T-peak to T-end index and Bioimpedenziometry. Only
1 patient did not complete the follow-up because of adverse events due to
orthostatic hypotension.
Results: Our preliminary data underlines that the treatment with Sacu-
bitril/Valsartan in elderly patients with reduced FE < 35%, improves the
redistribution of body water like ECM (19.4 Kg/m + 3 Kg/m vs 18.4 Kg/m
+ 2.6 Kg/m with p = 0.001), body weight (81.2 kg + 8.0 kg vs 78.1 Kg +
8.0 Kg/m with p = 0.002) and improves clinical outcomes. There are no
significant difference in the kidney failure (Creatinine: 1.582 mg/dl + 0.72
mg/dl vs 1.524 mg/dl + 0.65 mg/dl with p = 0.550), diabetes (Glycemia:
123.8 mg/dl + 42, 3 mg/dl vs 124.6 mg/dl + 58, 3 mg/dl with p = 0.92). The
BNP showed a consistent reduction even if not significantly (1513 pg/ml
+ 936.9 pg/ml vs 1122 pg/ml + 935.4 pg/ml with p = 0, 082). HRV indices
did not show significant variations: RR (858.2 + 145.8 ms vs 772.1 + 145.8
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).
Conclusion: This experience led us to prescribe Sacubitril/Valsartan
24/26 mg bis in die in elderly patients with HFrFE because it was effective
and well-tolerated when used in routine clinical practice. Sacubitril/Val-
sartan could be a new useful approach in the treatment of elderly patients
with Chronic heart failure with reduced ejection fraction < 35% without
influence in renal failure, diabetes and HRV. Our preliminary data gives
comfortable results but, for now, we have enrolled few patients to give
conclusive results.
229. A RARE CAUSE OF MYOCARDITIS: MYASTHENIA
GRAVIS
La Mura L. 1, De Donato M.T. 2, Renis M. 3, La Mura G. 4
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
Scafati ASL. Salerno
Introduction: Myasthenia gravis is an autoimmune disorder characterized
152
118° Congresso Nazionale - Società Italiana di Medicina Interna
by skeletal muscle involvement.
Clinical Case: F, 78, previous partial thyroidectomy, was hospitalized in
Neurosurgery for ptosis, deficits of the sixth cranial nerve, double vision,
dysphagia for solids and tetraipostenia. During hospitalization: sudden
onset of dyspnea associated with ECG-graphical changes (T wave inversion
in anteroseptal) and elevation of cardiac necrosis enzymes. Physical exa-
mination: chest presence of rales at the bases; BP = 130/90 mmHg, HR 96.
Echocardiogram: Left ventricle and left atrium dilated, EF = 22%. Akinesia
of the apex. Mild tricuspidle failure (PAPs 30 mmHg). So the patient was
bodies to acetylcholine receptor. Diagnosis: “Myasthenia gravis”. Terapy:
Immunoglobulin i.v, pyridostigmine bromide cp 60 mg, prednisone 50
mg/day. Ten days later: cardiac and neurological involvement hadalmost
solved.
Discussion: It is conceivable acute myocardial involvement during active
myasthenia gravis phase, regressed completely and in a short time, as a
result of immunosuppressive therapy
Conclusions: This case is particularly significant because, although in lite-
rature is described that cardiac involvement in myasthenia gravis may take
several forms (from asymptomatic ECG changes to ventricular tachycardia,
myocarditis, heart failure and sudden death), only few cases are reported.
230. EXERCISE TESTING: A NOT RISK-FREE TEST
La Mura L. 1, La Mura G. 2, De Donato M.T. 3, Renis M. 4
1
Università “Federico II” Napoli, 2 Cardiologo PO Scafati ASL. Salerno, 3UOC
Medicina AOU Salerno, 4UOC Medicina P.O. Cava de’ Tirreni AOU Salerno
Introduction: Exercise testing is a cardiovascular stress test that uses tre-
admill bicycle exercise with ECG and blood pressure monitoring. It is fre-
quently used, especially for the diagnosis of ischemic heart disease.
Clinical case: F, 62; familiarity for CAD; risk factors (smoking, family
mixed dyslipidemia, hypertension);she turns to a cardiologist for fatigue
and palpitations. Current therapy: ramipril HCT5/25; verapamil 120,
rosuvastatin 10 Echocardiography: normal; ECG: ST segment depressio-
nin V 4-6, like ventricular overload (not present before). 19/01/16:100 W
exercise test (H.R. 150/min.) suspended because of Run of ventricular
tachycardia and accentuation of the depression. No angina and/or increa-
sed pressure. Assuming CAD, while waiting for myocardial scintigraphy,
the patient undergoes therapeutic change (perindopril/indapamide/amlo-
dipine 5/1, 25/5; ranolazine 374 BID; ASA 100; Bisoprolol 1.25). 21/01/16:
myocardial scintigraphy at rest and after effort (75 W; 137/min): accentua-
tion of alterations like ventricular overload, in the absence of perfusion
deficits, induced by the effort. 25/01/16: detection of hypokalemia (K = 1,
7) and metabolic alkalosis!
Discussion: Probably so serious electrolyte disorders had corroborated
an ischemic heart disease path.The patient had no pharmacological and
clinical elements which could indicate serious electrolyte disorders.
Conclusions: Exercise testing is an invasive examination, not without any
risks, and always requires, in our opinion, preliminary clinical evaluation
with lab test (electrolytes, heart enzymes and hemoglobin).
231. RDW AS A PROGNOSTIC FACTOR OF MORTALITY
IN PATIENTS HOSPITALIZED FOR THE FIRST TIME FOR
HEART FAILURE
Salvatori M. 1,2,3, González R.M. 4, Migone De Amicis M.1,2,3,
Chivite D. 4, Corbella X. 4,5, Formiga F. 4, Cappellini M.D. 1,2,3
1
Università degli Studi di Milano, Scuola di Specializzazione
in Medicina Interna, Milano, Italy 2 Fondazione IRCCS
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
Interna, Hospital Universitari de Bellvitge-IDIBELL,
L’Hospitalet de Llobregat, Barcelona, Spain. 5 Facultad de
Medicina y Ciencias de la Salud, Universitat Internacional
de Catalunya, Barcelona, Spain
Objective: Red blood cell distribution width (RDW) is a numerical measure
of the variability in size of circulating erythrocytes. Recent studies linked
elevated RDW with poor cardiovascular outcome in several distinct popu-
lations, included patients affected by heart failure (HF). Our purpose is to
118° Congresso Nazionale - Società Italiana di Medicina Interna Poster

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
Poster
may represent a safe and efficacious alternative strategy to long-term OAC
therapy in HHT patients with AF-induced high stroke risk and poor tole-
rance for OAC.
234. VENTRICULAR ARRHYTHMIAS IN YOUNG
ATHLETES: A PREDICTIVE SCORE
Toncelli L., Chiostri M., Bartolini A., Ciullini G., Vono M.C.R.,
Tosi B., Modesti P.A., Galanti G.
Sport and Exercise Medicine Unit Department of Clinical and Experimental
Medicine – University of Florence - Italy
Inroduction and Aim: The significance and long- term outcome of ven-
tricular arrhythmias, specially frequent and complex, in apparently healthy
athletes is often controversial. Ventricular ectopy in young athletes often has
a left bundle-branch block morphology originating from the right ventricle
(RV). Arrhythmias can be the clinical expression of an initial underlying
cardiovascular disease that may not be easily detected in the growing age.
The present study was thus designed to investigate the right ventricle mor-
phology and function with echocardiography in young athletes presenting
ventricular arrhythmias originating from right ventricle. Subjects Studied
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-
mias originating from right ventricle at baseline EKG which did not disap-
pear nor decrease during exercise test, and group B (n=168) without any
arrhythmias.
Methods: In all athletes an echocardiogram has been performed, focused
on right ventricle, according to the guidelines of the American Society of
Echocardiography. Statistical Analysis A multivariate logistic regression
analysis was performed in order to identify adjusted predictors of arrhyth-
mias. The coefficients obtained were used to develop a scoring system to
calculate the risk of arrhythmia.
Results: No sex differences were found. At echocardiography the measures
were all between the normal range though the athletes with arrhythmias
were older, heavier and taller.
Group A had different RV systolic function indexes, namely a lower TAPSE,
a higher MPI index and more positive values of strain; moreover, they had
lower RV longitudinal dimensions and higher RV end diastolic area (both
absolute and indexed for subject’s height).
Conclusions: The likelihood of arrhythmia increases with age, with the
decrease in systolic function parameters and with a more “glossy” aspect of
right ventricle. This score seems reliable in predicting the development of
frequent and complex extrasistolia in young athletes (65% sensitivity, 86%
specificity). Sports people with score ≥ 250 should be more closely followed
with EKG Holter and accurate echocardiographic study of right ventricle in
order to detect early signs of cardiac disease.
235. RETRO-PROSPECTIVE STUDY ON THE UTILITY OF
CARDIOVASCULAR SCREENING IN YOUNG ATHLETES
Tosi B., Vono M.C.R., Galanti G.
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
118° Congresso Nazionale - Società Italiana di Medicina Interna
luation carried out following the judgment of non-eligibility. Patients who
gave the consent, underwent a new cardiologic examination to confirm the
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-
ble. During 2015 and 2016 the total number of visits per year was around
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
non–eligible for cardiovascular causes: arrhythmias 30%, cardiomyopathies
27%, pre-excitatory pathways 11%, T-wave abnormalities 6%, valvulopathy
6%, only 3% for coronary artery disease and hypertension, 10% refused to
undergo further investigations.
Our preliminary data showed that around 20% were rehabilitated to sport
practice. Some non-eligible athletes or their family chose not to participate
to our study for the emotional stress caused by the new diagnosis.
Conclusions: The most extensive SCD prevention campaign in Italy, to
date, is the mandatory cardiovascular screening to obtain eligibility for both
agonistic and non-agonistic sports in athletes. Our preliminary data showed
that cardiac disorders were found for the first time in almost the majority of
athletes during the sport medicine visit. The cardiovascular screening seems
to be useful for the early diagnosis of cardiac disorders associated with an
higher risk of SCD that would remain otherwise undetected.
236. CHA2DS2VASC SCORE IS A PREDICTOR OF LEFT
ATRIAL ENLARGEMENT IN NON-VALVULAR ATRIAL
FIBRILLATION: THE NEAFI ECHO REGISTRY
Lo Iudice F. 1, De Roberto A.M. 1, Petitto M. 1, Buonauro A. 1,
Luciano F. 1, Esposito R. 1, Tufano A. 2, Trimarco B. 1, Galderisi M. 1
1
Department of Advanced Biomedical Sciences. Federico II University
Hospital – Naples (Italy) 2Department of Clinical Medicine and Surgery.
Federico II University Hospital – Naples (Italy)
Background: In atrial fibrillation (AF), thromboembolic (TE) risk evalua-
tion is based on CHA2DS2VASc risk score which relies on clinical parame-
ters. The evidence of transthoracic echo parameters in predicting TE risk
is not sufficiently strong. The NeAFi-Echo registry is a single-center obser-
vational registry created for collecting echo-Doppler measurements and
clinical/anamnestic data in AF patients referring to our Echo-lab.Purpose:
Our aim was to assess relationships between left atrial (LA) size and TE
risk evaluated by CHA2DS2VASc in non-valvular AF(nvAF) patients of
NeAfi-Echo Registry using echo-Doppler and Speckle Tracking Echocar-
diography (STE).
Methods: In the first year, NeAfi registry enrolled 194 AF patients, 186
affected by nvAF (mean age 69 years, 106 males). Among nvAF patients,
110 had permanent/persistent AF and 76 paroxysmal AF. All patients
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
systolic strain (GLS). GLS was considered as “positive” (sign +).
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/
m²; T3= LAVI >50.5 mL/m². CHA2DS2VASc was lower in T1 than in T2
118° Congresso Nazionale - Società Italiana di Medicina Interna
(p=0.006) and T3 (p<0.0001), and in T2 than in T3 (p=0.03) (Figure). Con-
sidering T2 and T3 as a single group (LAVI T2/T3), LV mass index, E/e’ ratio
(both p<0.0001) were greater but EF (p<0.0001) and GLS (p=0.018) lower
in LAVI T2/T3 than in LAVI T1. In the pooled nvAF population, CHA2D-
S2VASc was positively correlated with LAVi (r=0.34, p<0.0001), E/e’ ratio
(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
adjusting for LVMi, E/e’ ratio and EF, CHA2DS2VASc was an independent
predictor of LAVi T2/T3 (beta=0.280, p=0.03).
Conclusion: LA dilation, LV diastolic/systolic dysfunction, and increased
LV mass characterize TE risk profile as evaluated by CHA2DS2VASC score.
A LAVi³ 37.8 mL/m² is associated with higher CHA2DS2VASc score inde-
pendent on EF, LV mass and E/e’. CHA2DS2VASc is a marker of cardiac
organ damage in nvAF.
237. A CASE OF NECROTIZING FASCIITIS BETWEEN
NEW ETIOLOGIC AGENTS AND DIAGNOSTIC
CONTROVERSIES
Amaradio M.D. 1, Esposito G. 2, Riccardi A. 2, Sbrojavacca R. 2
1
UO Medicina Interna e D’Urgenza, Dipartimento di Medicina Clinica e
Sperimentale, Azienda Ospedaliero-Universitaria “Policlinico-V. Emanuele”,
Università di Catania; 2S.O.C. Pronto Soccorso e Medicina d’Urgenza,
Azienda Sanitaria Universitaria Integrata di Udine
Overnight, a 72 years old man was admitted to our Emergency Department,
with fever and altered state of consciousness.
He had an history of type 2 diabetes mellitus, arterious hypertension,
dyslipidemy, obesity and ventricle peritoneal shunt for hypertensive
hydrocephalus.
He appeared partially orientated, tachipnoeic (30 breaths/min) with
SpO2:89% in room air. Blood pressure: 150/80 mmHg, pulse rate: 130 beats/
min and body temperature: 39.5°C. Heart sounds, vescicular murmur ad
abdominal objectivity were normal. The lower left limb showed obvious
signs of flogosis, as by erisypelas. qSOFA was 2 and so blood sample analysis
and emocultures were done. Hydration was started immediately. Empirical
antibiotic therapy (amoxicillin/clavulanate and clindamycin) was infused
after blood samples analysis. Arterial lactate was 3.3 mmol/l. Later, lab tests
showed moderate upward inflammatory markers (WBC 13.000x10³/μL,
PCR 22mg/L) and muscle lysis enzymes (CPK 636U/L). SOFA score was
5. Patient was so admitted in the semi-intensive care unit with diagnosis of
“Soft tissue sepsis”.
The next morning, the objectivity of the left lower limb worsened: numerous
large bullae appeared in the distal third. The pain increased. So, we started
a more aggressive therapy (meropenem and daptomicina), and simultane-
ously, a surgical debridement of the injured limb was programmed. In the
meantime, the TC of left leg revealed diffuse oedema of skin and subcu-
taneous tissue, thin liquid film on fascial planes with no sign of necroti-
zing fasciitis. On the contrary, the day after, the fasciotomy highlighted the
necrosis of the fascial tissue mainly in the posteromedial side. On the third
day, blood cultural exams showed growth of Vibrio Parahaemolyticus, a
very rare bacteria in our country. After a more detailed medical interview it
emerged that the patient fished on bare feet in marshland areas. Antibiotic
therapy was simplified (amoxicillin-clavulanate). After twenty days of anti-
biotic therapy and periodic medications of the lesion, the patient’s condi-
tions gradually improved and he was discharged to home with diagnosis of:
“Necrotizing fasciitis due to Vibrio parahaemolyticus”.
Necrotizing fasciitis (NF) is a rare but serious infection of the skin and soft
tissue, which tend to progress through the fascia planes, rapidly destructing
deep tissue. Even if the incidence is rising for the overheating of waters and
the selection of new clonal groups, NF due to Vibrio Parahaemolyticus
remains an extremely infrequent infection. In fact, searching “necrotizing
fasciitis” AND “vibrio parahaemolyticus” on PubMed only 9 items have
been found (comprising Vibrio Vulnificus cases). The Vibrio species are
short, oxidase-positive, and gram-negative bacilli that are actively motile.
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.
However, mortality rates approaching 3% are reported. V. parahaemolyticus
NF did not differ clinically from necrotizing soft-tissue infections caused by
other members of the Vibrionaceae family, consisting of the classic triad of
swelling, erythema and intense pain. Patients with liver disease and diabetes
mellitus have a higher risk of developing sepsis. Beyond the rarity of etio-
Poster
logy, this case demonstrates that imaging does not always help diagnosis, in
fact only surgical debridement locate the sign of NF (not demonstrated by
TC scan). The gold standard for confirming diagnosis, when it is equivocal,
is the combination of surgical exploration and microbiological and histopa-
thological analysis of 1 cm3 of soft tissue.
238. SYNCOPE BY COMPLETE HEART BLOCK
Astazi P., Palmieri P.
Azienda Regionale Emergenza Sanitaria 118 - Regione Lazio
New-onset third-degree atrioventricular (AV) block is a medical emergency
common in the elderly, in which the impulse generated in the sinoatrial
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
blood flow to the brain.
Case Report: Emergency Medical Service’s A.R.E.S. 118 – Regione LAZIO
team managed an 84-years-old patient presenting with an acute hemodyna-
mic compromise caused by bradycardia and possible episodes of asystole.
On examination pale and sweaty patient was lying on the ground, con-
scious, normal breathing, very small cardiac pulse, bradycardia at 20 beats/
min, systolic blood pressure < 60 mmHg (at potential risk of asystole), the
ECG 12 leads showed broad P wave with a regular P-to-P interval (it repre-
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
of complete heart block there was lack of any apparent relationship between
P waves and QRS complexes.
Clinical history examination revealed 3 milder episodes of dizziness, weak-
ness and palpitations during the previous days, for which he had not sought
medical attention. Patient was in drug therapy for diabetes, hypertension
and hypercholesterolemia, assuming oral antidiabetic, beta blocker and
statin. Patient was immediately considered for temporary external transcu-
taneous cardiac pacing. This approach certainly offers a “bridge” to trans
venous approach, if necessary. It is accomplished by delivering pulses of
electric current through the patient’s chest, which stimulates the heart to
contract. During transcutaneous pacing, pads were placed on the patient’s
chest, in the anterior/lateral position. The pads were then attached to a
monitor/defibrillator, a heart rate of 60 beats/min was selected, and current
(90 milliamps) was increased until electrical capture (characterized by a
wide QRS complex with tall, broad T wave on the ECG) was obtained, with
a corresponding normal pulse. Before patient pacing, sedation was obtained
by administering an anxiolytic. Promptly hemodynamic conditions of the
patient were stabilized. Discussion: Treatment of third-degree AV block is
based on the level of the block. Immediate pacing is indicated especially
when the block is at or below the His-Purkinje level with very low ven-
tricular rate and insufficient blood pressure. Brady-arrhythmias requiring
cardiac pacing can be caused by a variety of etiologies (adverse drug effects,
acute myocardial infarction, electrolyte disorders) and the early identifi-
cation of a potentially reversible cause is the first step towards treatment.
Elderly patients with sustained or frequent bradyarrhythmia are often
symptomatic. Easy fatigability, reduced exercise capacity and symptoms of
HF are common in persistent bradyarrhythmia. Subtle symptoms are irrita-
bility, lassitude, inability to concentrate, apathy, forgetfulness and dizziness.
Dizziness, pre-syncope and syncope are common symptoms with intermit-
tent severe forms of brady-arrhythmias and are due to a sudden decrease in
cerebral blood flow.
Conclusions: Even death in patients with untreated AV block may occur,
due not only to heart failure secondary to low cardiac output, but also to
sudden cardiac death caused by prolonged asystole or bradycardia-triggered
ventricular tachyarrhythmia. A.R.E.S. 118 – Regione LAZIO medical inter-
vention is essential to decide on the need for cardiac pacing therapy, to treat
immediately at home and to allow to reduce propensity for life-threatening
brady-dysrhythmias, before permanent pacemaker can be implanted into
these individuals to increase adequate heart rate and maintain blood flow
to the brain.
239. AN INTEGRATED ULTRASOUND APPROACH TO
ACUTE DYSPNEA IN EMERGENCY DEPARTMENT
Carlino M.V. 1, Mancusi C. 1, Sforza A. 2, de Simone G. 1,
Paladino F. 2
1
Hypertension Research Center, UOC Emergency Medicine, Federico II
University Hospital, Naples. 2Emergency Department, Cardarelli Hospital,
155
Poster 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
118° Congresso Nazionale - Società Italiana di Medicina Interna
243. USE OF 4AT TEST IN SCREENING FOR DELIRIUM
IN GERIATRIC MEDICAL PATIENT: A PILOT STUDY IN
EMERGENCY DEPARTMENT
Paolillo C., Castiglia G., Riccardi A., Pozzi D., Esposito G., Sbrojavacca R.
SOC. di Pronto Soccorso e Medicina d’urgenza, Azienda Sanitaria
Universitaria Integrata di Udine (ASUIUD)
Delirium is an acute and fluctuating disorder of attention and cognitive
functioning, which is almost always triggered by underlying medical causes
and is often accompanied by abnormal arousal and perceptual disturbances.
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, prolonged
hospitalization, increased cost of care, higher distress for patients and heal-
thcare professionals. The emergency department (ED) may be a strategic
place to detect this disorder and initiate clinical management. There are
few studies that examine delirium in elderly ED patients: Lewis, Wofford
and Naughton found a prevalence of 5-17% of delirium in ED patients. The
apparently low rate of detection of delirium may be because ED physicians
do not record this diagnosis. Thus the goal of our study were to determine
the prevalence of delirium in elderly ED patients using the 4AT test (4 Rapid
Assessment Test for delirium).
Methods: This study was carried out at S. Maria della Misericordia Hospital
Center, Udine, an hospital university integrated trust. All patient aged 75
years and older who were screened for eligibility had presented consecu-
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-
ded. Eligible patients were approached and the 4AT test was administered.
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
78 male, median age was 85, 3. Eighty-three cases of delirium were dia-
gnosed with 4AT. The prevalence of delirium was 41, 3%. Hypoactive was
the common subtype (74/200 patients, 37%), followed by mixed and hype-
ractive. Sepsis (16%), polipharmacy (18%), urinary retention (7%) and fecal
impaction (6%) were associated with delirium.
Conclusions: Our sample size was very small. However our small model
achieved that delirium occurred in about four aged patients every ten
visited in ED. and that the hypoactive subtypes was the most frequent. Fur-
thermore the 4AT. proved to be an easy and brief clinical instrument for
delirium detection in ED. The ED. may be a strategic place to detect this
disorder. Earlier detection of delirium in the ED. could improve the benefits
of treatment and the prognosis.
Bibliography: G. Bellelli: “Delirium Day”: a nationwide point prevalence
study of delirium in older hospitalized patients using an easy standardized
diagnostic tool. BMC. Medicine 2016 14:106.
JH. Han: Delirium in the older emergency department patient: a quiet epi-
demic. Emerg Med Clin N. Am 2010 28 611-631.
KM. Terrell: Quality indicators for geriatric emergency care. Acad Emerg
Med 2009 16:441-449
244. AN “ATYPICAL “ LEGIONELLOSIS
Pricoco G. 1, Esposito G. 2, Sbrojavacca R. 2
1
UO medicina Interna e d’ Urgenza, dipartimento di medicina clinica e
sperimentale, Azienda Ospedaliero Universitaria “ Policlinico Vittorio
Emanuele “ Catania 2 SOC. di Pronto Soccorso e Medicina d’Urgenza,
Azienda Sanitaria Universitaria Integrata Udine (ASUIUD)
Legionnaires’ disease is an acute pneumonia caused by inhalation or aspi-
ration of aerosols contaminated with Legionella bacteria. The majority
(>90%) of Legionnaires’ disease cases are caused by the species of Legio-
nella pneumophila, and about 85% more specifically by L. pneumophila.
We report the case of a 46-year-old man, with a history of tetraparesis fol-
lowing a road accident and secondary focal epilepsy, who presented to our
department with a nine day history of fever (up to 38.5°C), mild dyspnoea
and ingrown dysphagya. In the previous 7 days the patient was treated in
a medicine department of his town with amoxi-clavulanate in the first 3
days, then switched, due to poor clinical improvement, to dual empiric
therapy with piperacillin-tazobactam (13.5 g/24h) and clarithromycin
(500 mg twice a day). Upon arrival at our department, on physical exa-
mination the patient had a body temperature of 37.6ºC, was tachycardic
Poster
and tachypneic with respiratory rate at 30/min. Blood pressure was 90/60
mm Hg and oxygen saturation on room air was 91%. Absolute dysphagia
required positioning of nasogastric probe. Inspiratory crackles were heard
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
and lower limbs did not reveal any anomalies. Laboratory studies revealed
a white blood cell count of 6030/mmc with 85% neutrophils, C-reactive
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
coagulation studies all were normal. Ultrasound lung features of diffuse
interstitial syndrome with spared areas were observed and Chest X-ray
showed pulmonary consolidations in both right and left middle lobes of
the lungs. Subsequent tests found the patient to have a positive urinary
Legionella Antigen for which piperacillin-tazobactam was discontinued
and only claritromicyn therapy (500 mg twice a day) was continued with
progressive improvement of clinical and radiographic features. Therapy
with a quinolone was not considered due to the history of epilepsy of
the patient. Legionnaires’disease is a significant health problem in many
countries, largely because Legionella pneumophila is a frequent cause of
both community and hospital-acquired pneumonia. Smoking, chronic
obstructive lung disease, diabetes, chronic corticosteroid therapy and
immuno-compromised status are known risk factors for Legionnaires’di-
sease. Although the most popular theory is that Legionella is inhalated in
aerosolized droplets of water, this case shows that rarely, in patients with
swallowing disorders, Legionnaires’ disease can be acquired by accidental
aspiration of drinking water, with the secretions getting past the choking
reflex and mistakenly entering the lungs.
245. SCINTIGRAPHY IN PULMONARY EMBOLISM: BACK
TO THE FUTURE
Montaldo L. 1, Esposito G. 1, Barboni E. 2, Sbrojavacca R. 1
1
SOC. di Pronto Soccorso e Medicina d’urgenza, Azienda Sanitaria
Universitaria Integrata di Udine (ASUIUD) 2 SOC. di Medicina 2, Azienda
Sanitaria Universitaria Integrata di Udine (ASUIUD)
The diagnosis of pulmonary embolism (PE) has always been a challenge,
because the clinical presentation of the disease is extremely heterogeneous:
from asymptomatic shapes to the obstuctive shock. The diagnosis is often
difficult since symptoms and signs are non specific.(1)
For many years, the ventilation/perfusion scintigraphy (V/Q scan) has
been the gold standard in PE diagnosis, but in the Emergency Depart-
ment setting, Multi-detector computed tomography (MDCT), has replaced
the V/Q scan as the initial imaging study in the work up of suspected PE.
MDCT offers significant improvements in spatial and temporal resolution,
faster scan times, and and the ability to identify an alternative diagnosis.
These advancements allow routine visualization of subsegmental pulmo-
nary emboli, but this kind of PE has an uncertain clinical meaning, and may
represent “normal” embolic activity originating from the lower extremity
venous valves (2).
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
long-term anticoagulant therapy are not marginal.
The radiation dose of CT is higher than VQ scan. The Radiation risk varies
with sex, age, and organ (it is higher in female, young and breast tissue), so
that the role of VQ scan could be particularly relevant in: Young patients,
pregnant women and women in general, expecially to reduce breasts expo-
sition. In the 1990s, the scintigraphy report followed the PIOPED criteria
(4). PIOPED criteria have two limits: The first, the elaborate response in
five categories (normal, very low probability, low probability, intermediate
probability and high probability), The second, The high number of non
diagnostic exams (about 70%). Subsequently, new interpretation criteria
were elaborated: PISAPED (5) and PIOPED II (modified) (6). Both criteria
propose to perform chest radiography before the scintigraphy. In this way,
a normal (or almost normal) chest x-ray allows to eliminate the ventilation
component of the exams, because in the presence of a normal x-ray, any
defect of perfusion is considered a mismatch. Finally, the new diagnostic
criteria, reduce only three categories (non-diagnostic, probable and unpro-
bable) the results of the exam.
We aimed to establish whether a “PE diagnostic algorithm” based on chest
X-ray and perfusion scan was reliable in the our Emergency Room (ER).
Prior to the X-ray, we also established the pre-test probability of PE, using
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
Poster
Suspected PE, haemodynamic stability, chest X-ray read as negative accor-
ding to PIOPED II criteria. These patients were then subjected to perfusion
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
PE in 5 cases, . 4 out 16 patients with negative scan for PE, came back to
the ER in the following days, but no one had symptoms or signs suggestive
for PE. In our study We had no false negative results and no scan was read
as non diagnostic. The numbers are certainly very limited, but the return
of pulmonary scintigraphy in the diagnosis of pulmonary embolism gives
a real chance of limiting “overdiagnosis” and is a good example of “less is
more”.
(1). Cecilia Becattini and Giancarlo Agnelli. Risk stratification and
management of acute pulmonary embolism - Hematology 2016, Dec
2;2016(1):404-412.
(2). Jane M. Suh J.M. et al - Dots are not clots: the over-diagnosis and
over-treatment of PE - Emerg Radiol (2010) 17:347–352
(3). Wiener R.S. et al -Time trends in pulmonary embolism in the united
states: evidence of overdiagnosis.- arch intern med. 2011;171(9):831-837
(4). Gottschalk A. et al, Ventilation-perfusion scintigraphy in the PIOPED
study. II. Evaluation of criteria and interpretations. J Nucl Med 1993; 34:
1119- 1126.
(5). Miniati M, Pistolesi M Et Al -Value of the perfusion lung scan in
the diagnosis of pulmonary embolism. Am J Respir Crit Care Med.
1996;154:1387–1393.
(6). Sostman H. D. et al - Sensitivity and Specificity of Perfusion Scinti-
graphy Combined with Chest Radiography for Acute Pulmonary Embolism
in PIOPED II.- J Nucl Med 2008; 49:1741–1748
246. ACUTE TUBULAR NECROSIS: A CLINICAL CASE OF
ETHYLENE GLYCOL INTOXICATION
Mastropasqua M., Di Vincenzo M.G., Legramante J. M.,
Malatesta M., Noja M., Petrilli C., Susi B.
Dipartimento di Pronto Soccorso-Medicina d’Urgenza Policlinico Tor
Vergata, Roma
Ethylene glycol is a bivalent alcohol used as antifreeze in the automotive
industry (airport slopes, locks, etc.). It is also used in condensers and
heat exchangers, lacquers and glues. Ethylene glycol is absorbed from the
gastrointestinal tract rapidly, after ingestion(blood peak within 1-4 hours
after ingestion). Initially it exerts an action on the central nervous system,
stimulating and then narcotic, subsequently causing cardiovascular disor-
ders and metabolism alterations, and renal impairment to kidney failure. It
is metabolized at the liver level and generates acid metabolites with higher
toxicity than the starting compound, such as glycol aldehyde, glycolic acid
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
to arrival in the Department of Emergency. The patient appeared sleeply,
confused, with contracted diuresis. At emogas-analysis, metabolic acidosis
(lactate 8 mmol / L) was present, the hepato-renal function was normal at
the beginning. The patient was subjected to EGDS (“no esophagus-gastric
stenosis lesions”) and TAC chest-abdomen (“no perforations”). Pavia’s CAV
colleagues indicated that the patient was subjected to hydration(approxi-
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-
peutic range 120-150) followed by 2 ml /kg/h, dosage of ethanolemia and
renal chemistry performed every two hours).Because of persistence of oli-
go-anuria, as the volume of distribution of ethylene glycol low (less than 1L
/ Kg) and the linkage to almost absent plasma proteins, it was indication
for urgent hemodialysis.The high dosage of ethylene glycol (laboratory test
carried out at CAV in Pavia) has confirmed the intoxication. The patient
was subjected to serious lactate evaluations, hepato-renal function, etha-
nolemia and urine examination with progressive improvement in clinical
and laboratory conditions and subsequently hospitalized at SPDC for the
appropriate treatment. Ethylene glycol, after ingestion, is metabolised by
glycolaldehyde alcohol-dehydrogenase, which is metabolized to glycolic
acid, glycosilic acid and ac. oxalic acid, which together with lactic acid are
responsible for metabolic acidosis and organ damage resulting from the
precipitation of insoluble oxalate crystals together with calcium (calcium
oxalate). The prompt administration of the antidote and hemodialysis has
allowed a rapid recovery (48 hours of hospitalization in Department of
Emergency) of the clinical and laboratory picture.
158
118° Congresso Nazionale - Società Italiana di Medicina Interna
247. NECROTIZING FASCIITIS: A CASE REPORT
Mazziotti M.A. 1, Esposito G. 2, Onorato P. 2, Sbrojavacca R. 2
1
Istituto di Clinica Medica e Geriatria, Fondazione Policlinico Universitario
Agostino Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy; 2 SOC.
di Pronto Soccorso e Medicina d’Urgenza, Azienda Sanitaria Universitaria
Integrata Udine (ASUIUD), Italy
A 73-year-old woman presented to our Emergency Department complai-
ning of severe pain in the left inguinal region, started two days before
and worsening during the last night. She denied history of trauma. Her
medical history included hypertension, osteoporosis, chronic hepatitis C
virus and a cerebral venous cavernous hemangioma. There was no evi-
dence for any allergies or drug abuse. At the initial clinical examination
she presented intensely suffering, alert and afebrile. The examination of
the region didn’t reveale any inflammation sign. Compression ultraso-
nography excluded a deep venous thrombosis. Over the next few hours,
the patient’s clinical situation progressively deteriorated. She started to be
febrile, hypoperfused, tachycardic and tachypneic. Blood tests were consi-
stent with severe sepsis and multiorgan dysfunction. An abdominal-pelvic
CT scan found a pronounced cutaneous and subcutaneous edema of the
inguinal region together with an effusion spread along anterior fascia of
pelvic and thigh muscles. A multidisciplinary assessment was carried out
together with infectivologists, general and vascolar surgeons, gynecologi-
sts, orthopedics and anesthetists and the decision to perform immediate
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
the intensive care unit for post-operative care and supportive measures.
Tissue and blood cultures returned a positive result for group A beta-he-
molytic Streptococcus. The patient was discharged home after 78 days
from her admission.
Necrotizing fasciitis is a rare soft-tissue infection primarily involving the
superficial fascia of skeletal muscle. Predisposing factors include diabetes,
immunosuppression and traumatic wounds but it can manifest in otherwise
healty people as well. The affected area usually shows skin changes but they
can be initially absent. Laboratory findings and imaging studies are useful
in the diagnosis but it can be often definitively established only by surgical
exploration. A bacterial etiology is usually found. Treatment consists of early
and complete surgical debridement of necrotic tissue, combined with bro-
ad-spectrum antibiotic therapy and hemodynamic support if necessary. This
case demonstrates that even in young and previously overall healthy patients,
necrotizing fasciitis can be a rapidly progressive and life-threatening condi-
tion. Prompt diagnosis and rapid surgical intervention are crucial and can
mean the difference between life and death in these critically ill patients.
248. NEW MODEL OF ACUTE OBSTRUCTIVE JAUNDICE
MANAGEMENT IN THE EMERGENCY DEPARTMENT
Ojetti V. 1, Sinatti D. 1, Perri V. 2, Petruzziello C. 1, Tringali A. 1, Gasbarrini A.
1
, Costamagna G. 2, Franceschi F. 1
1
Department of Emergency and Internal Medicine, Catholic University,
Rome, Italy 1 Department of Endoscopy, Catholic University, Rome, Italy
Introduction: Obstructive jaundice is a frequent cause of access in Emer-
gency Department (ED) and requires a rapid management with hospitali-
zation, in order to perform ERCP. To reduce the problem of overcrowding,
in Italian’s ED were introduced Brief Observation Units (BOUs), in which
patients are treated for 48-72h with a significant decrease of hospitaliza-
tions. Aim of our study was evaluate the efficacy of a new model of mana-
ging obstructive acute jaundice directly from BOU.
Patients and Methods: We evaluated, from September 2014 to November
2016, 162 patients (79M/83F, mean age 65±16, 8 years) who came to our ED
with an acute obstructive jaundice, confirmed by ultrasound or CT scan. All
patients had the indication to perform ERCP.
Results: 92, 6% (150 out of 162) patients were discharged, directly from
BOU, the day after the procedure or within 48 hours from admission, with
a higher discharge rate in in those with choledocholithiasis (94%), biliary
stent clogging (97%) and pancreatic prosthesis (100%). In the table below
are shown ERCP findings, with relative discharge rates.
118° Congresso Nazionale - Società Italiana di Medicina Interna Poster

 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
Poster
Comorbidity: 4; CIRS CI severity: 2. Most frequent DRG 127 (heart failure).
Reduction of time spent by the nurse in vital parameters monitoring: from
33 to 41 min / day / patient. 42% of patients have a Blaylock Risk Assessment
Screening Score (BRASS) ≥20, indicating frail patients who need adequate
taking in charge and continuity of care from hospital to territory.
Conclusion: Preliminary results of the LIMS study show the feasibility
of using wireless systems in daily practice and in the management of the
chronic and frail patients. Considering that about 1/4 of the IM patients
presents, in addition to the acute clinical problem, also social problems, it
would be useful to extend the use of remote monitoring systems also in the
territory, both in residential facilities and at home. The advantage of using
wireless monitoring systems in IM is that the measurement of critical para-
meters and the resulting alarms are detected by mobile devices (smartpho-
nes and tablets) operated by doctors and nurses in the department with
considerable reduction of management costs. The extension of the use of
these systems in the patients’monitoring in low intensity structures and at
home would provide qualified assistance to the patient even after hospital
discharge, reducing ED access and overcrowding of the Internal Medicine
Units. For an appropriate patient’s data flow management, a multidiscipli-
nary team can respond in real time to patient needs properly framed with
a constant monitoring.
252. DIAGNOSTIC ROLE OF HOSPITAL INTERNAL
MEDICINE. A RETROSPECTIVE OBSERVATIONAL
STUDY COMPARING THE EMERGENCY DEPARTMENT
INITIAL DIAGNOSIS AND THE INTERNAL MEDICINE
DISCHARGE DIAGNOSIS
Scotti E. 1, Pietrantonio F. 2, Alessi E. 1, Leardi M.G. 1, Gerardi F. 1,
Rainone M. 1, Vesprini E. 1
1
Unità Operativa Medicina Generale, Istituto Neurotraumatologico Italiano
(INI), Grottaferrata (Roma) 2Unità Operativa di Medicina Interna, Ospedale
di Manerbio, Manerbio (BS) ASST-Garda
Background: Despite the central role of Internal Medicine (IM) in emergency
admissions management, both users and health programmers seems don’t
know the distinctive features of IM activities. According to Literature, IM role
is characterized by: 1. Acute, critical, poly-pathologic and complex patients
management; 2. Difficult clinical diagnosis; 3. Priorities’ identification; 4.
Hospital-territory paths promotion integrating different specialists activities.
Objective. To determine the proportion of correct and missed emergency
department (ED) diagnoses compared to IM discharge diagnoses.
Methods: ED diagnoses and hospital IM discharge diagnoses were compa-
red. By using consensus among experts method a diagnosis evaluation grid
was realized. Diagnosis has been defined as follows: 1. The “gold standard”
diagnosis (correct diagnosis), according to ICD9 (9th International Classifi-
cation of Diseases and Related Health Problems), carried out independently
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
acceptance or transfer record to the Internal Medicine Unit; 3. Wrong Prio-
rity: the correct diagnosis appears as a secondary diagnosis in the ED diagno-
sis; 4. Incomplete diagnosis: diagnostic orientation without a precise diagno-
sis; 5. Wrong Diagnosis: the correct diagnosis was not performed in ED. The
first 13 diagnoses made in ED are defined as most frequent in number within
the sample being examined.
Results: 317 nontrauma patients presenting to the ED from June to September
2016 and admitted to INI (Italian Neurotraumatologic Institute) IM depart-
ment were included for final analysis. The final diagnosis at IM discharge was
taken to be the correct “gold standard” diagnosis. In 180 patients (56, 7%)
corresponded to the primary ED diagnosis, in 104 patients (32, 8%) were
missed, the remaining 10.5% of the diagnosis (33 patients) was incomplete or
with wrong priority. The most frequent final diagnoses were cardiac failure (n
=53), pneumonia (n= 43), TIA (Transient Ischemic Attack) (n=31); respira-
tory failure (n=28); COPD (Chronic Obstructive Pulmonary Disease) (n=21),
correctly diagnosed at the ED in 37, 26, 19, 20, and 11 patients, respectively.
Conclusion: Patients presenting in ED with acute symptoms represent a dia-
gnostic challenge that in 43.3% of cases is explained by the clinical activity
done by the Internal Medicine specialist during hospitalization. The study
confirms the central role of Internal Medicine in defining the correct diagno-
sis in acute and complex patients. It is probably time to promote awareness
campaigns for patients and policy makers on the central role of Internal Medi-
cine in hospital organization and hospital-territory integration and to give the
right weight to the IM complex activitiy through an appropriate DRGs (Dia-
gnosis Related Groups) valorization in Medical Area.
160
118° Congresso Nazionale - Società Italiana di Medicina Interna
253. SHORT-TERM BLOOD PRESSURE VARIABILITY AND
CIRCADIAN BLOOD PRESSURE PROFILE IN SUBJECTS
WITH HYPERTENSIVE URGENCIES
Ricci S. 1, Battista F. 1, Sgariglia R. 1, Crocetti A. 2, Tilocca G. 2,
Perlini S. 3, Pucci G. 1
1
Struttura Complessa di Medicina Interna, Azienda Ospedaliera di Terni,
Dipartimento di Medicina, Università di Perugia, Terni, Italia 2 Struttura
Complessa di Cardiologia, Azienda Ospedaliera di Terni, Dipartimento di
Medicina, Università di Perugia, Terni, Italia 3 Dipartimento di Medicina
Interna e Terapia Medica, Policlinico “S.Matteo”, Università di Pavia, Italia
Introduction: Hypertensive Urgencies (HU), classified as abrupt blood
pressure (BP) increases above 190/110 mmHg without acute organ damage,
could be theoretically conceived as an expression of increased short-term BP
variability (BPV). However, few studies systematically explored this asso-
ciation. It is also unknown if subjects experiencing HU are characterized
by abnormal BP circadian profiles. We evaluated the association between
HU, measures of short-term BP variability, and nocturnal BP dipping in a
case-control study.
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.
All subjects underwent Ambulatory Blood Pressure Monitoring (ABPM)
within 5 days from admission. Subjects with hypertensive emergencies
(at admission or during the following days) were excluded. Controls were
selected in order to be well matched with HU subjects for sex, age, 24-h
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
(SD-SBP), Systolic BP Average Real Variability (ARV), and weighted 24-h
SD of SBP (wSD) were taken as measures of BPV. All subjects were managed
according to Guidelines for Good Clinical Practice.
Results: 62 subjects with HU (60±16 years, office BP 190/101±21/10
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-
time SBP/DBP, number of anti-hypertensive drugs, and degree of noctur-
nal BP fall. Subjects with HU had increased wSD (12.0±3 vs 9.2±3 mmHg,
p=0.02) and night-time SD-SBP (9±3 vs 8±2 mmHg, p=0.01) as compared
to controls. Differences in ARV (8.5±3 vs 6.9±3 mmHg, p=0.29) and day-
time SD-SBP (12±4 vs 12±3, p=0.22) were not significant.
Conclusions: as compared to hypertensive patients without HU, subjects
referring to the ED for HU showed increased indexes of short-term BPV,
expressed as increased wSD and nocturnal SD-SBP. We did not found any
differences between groups in terms of nocturnal BP dipping. Our results
therefore suggest a possible functional link between increased BPV and the
occurrence of HU in hypertensive patients.
254. NEUROCARDIOLOGY: TAKO TSUBO SYNDROME
Suppa M., Colzi M., Millarelli F.R., Fazzi V., Mazzocchitti A.M.,
Coppola A., Gradini R.
1
Dipartimento di Emergenza - Università degli Studi di Roma “ Sapienza”,
1
Dipartimento di Medicina Sperimentale - Università degli Studi di Roma
“Sapienza”
Introduction: Neurocardiology refers to the interplay between the nervous
system and the cardiovascular system. Stress-related cardiomyopathy exem-
plifies the brain-heart connection and occurs in several conditions with
acute brain injury that share sympathetic activation. The brain’s influen-
ces on heart can include elevated cardiac repolarization abnormalities on
electrocardiogram, myocardial necrosis, and autonomic dysfunction. The
aim of this study was to evaluate this in the takotsubo syndrome (TTS) that
generally presents as an acute myocardial infarction characterized by severe
left ventricular dysfunction.
Materials and Methods: Between 2015 and 2016, five consecutive patients,
aged between 70 and 75 years, four woman e one man, were enrolled in
the study. All patients were hospitalized in the Emergency Department with
abrupt-onset chest pain or dyspnea and suspected takotsubo syndrome.
Blood samples were drawn immediately after admission by direct venipun-
cture of an antecubital vein, applying a minimum of stasis. Ordinary labora-
tory data included myoglobin, troponin T, CK-MB, and electrocardiogram
(ECG). All patients underwent angiography procedure.
Results: In two patient there was sone psychiological stress in the family
in the previous days, in the others a strenuous physical activity preceded
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,
118° Congresso Nazionale - Società Italiana di Medicina Interna
particularly in the anterior and lateral leads, in one patient the ECG was
normal. All patients manifested modest increases in creatine kinase-MB
and cardiac troponin T concentrations. Coronary angiography showed
either normal coronary arteries or nonobstructive coronary artery disease.
The diagnosis of TTS was suggested by the area of dysfunction detected on
left ventricular (LV) angiography.
Conclusion: There is general consensus that this “brain-cardiac” process
occurs via the β-adrenoceptor–mediated cAMP-dependent proteinkinase
pathway. Regional differences in adrenoceptor density might explain the
pattern of LV dysfunction often seen in TTS. Experimental data have shown
that β2- adrenoceptors are more frequently expressed in apical than in basal
segments of the LV, whereas a reverse distribution is present for norepine-
phrine β1-adrenoceptors and sympathetic nerve terminals of the neuro-car-
diac axis, which are expressed much more at the base rather than at the
apex of the LV. The high prevalence in postmenopausal women suggests
that estrogen deprivation may play a facilitating role, probably mediated by
endothelial dysfunction.
255. THE ROLE OF PROCALCITONIN IN THE DIAGNOSIS
OF ACUTE CORONARY SYNDROME
Suppa M., Granato T. 1, Anastasi E. 2, Colzi M., Millarelli F.R.,
Mazzocchitti A.M, Millarelli F., Fazzi V., Gradini R. 3
Dipartimento Emergenza -Università degli Studi “Sapienza” - Roma, 1IBPM/
CNR. - Roma, 2Dipartimento Medicina Molecolare - Università degli Studi “
Sapienza”- Roma, 3Dipartimento di Medicina Sperimentale Università degli
Studi “Sapienza”- Roma
Introduction: Cardiovascular diseases represent the leading cause of mor-
tality and morbidity both in men and women, and include both heart and
blood vessels conditions. Sometimes patients with chest pain have typical
symptoms and other undiagnosed symptoms due to other concomitant
pathologies making the diagnosis more difficult. Cardiac troponin is a
well-established biomarker of myocardial injury and it is clinically used
to guide diagnosis and management of patients suspected of having acute
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-
nary syndrome (ACS) and to investigate their possible correlation with the
release of troponin T, myoglobin and CK-MB.
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
years) were enrolled in the study. The patients were 83 % Caucasian and 17
% Asian. All patients were hospitalized in the Emergency Department with
chest pain and suspected ACS. The total patient population was divided into
two subgroup, females (n=8) and males (n=40), respectively. Blood samples
were drawn immediately after admission by direct venipuncture of an ante-
cubital vein, applying a minimum of stasis. Ordinary laboratory data inclu-
ded procalcitonin, creatinine, sodium, potassium, calcium, glucose, CRP,
blood count, troponin T, CK-MB, cholesterol, triglycerides, HDL.
Results: Among the 48 patients included in the study, chest pain was descri-
bed in 25 % patients with unstable angina (UA), 12, 5 % patients with ST
elevation myocardial infarction (STEMI) and 62, 5% with no ST elevation
myocardial infarction (NSTEMI). The clinical characteristics of the patients
included in the study presented the following parameters: 58, 3 % hyper-
lipidemia, 70.8% hypertension, 16.6% diabetes, 29.1 % previous coronary
artery disease. All patients have been submitted to angiography procedure.
79% of patients were eligible to percutaneous coronary intervention (PCI)
and stenting and 17 % were submitted to coronary artery bypass surgery.
After coronary angiography one patient has not been referred to any tre-
atment. Serum electrolytes, sodium, potassium, calcium levels and pro-
calcitonin were within the normal range. All patients were evaluated with
echocardiogram and had a good ejection fraction: 71% was > 45% and 29%
was < 40%.
Conclusion: Studies on the use of this marker in ACS diagnosis, an inflam-
matory process indicate its usability; but some other studies emphasize its
inefficiency in diagnosis and see it only as a predictor of heart patients’ sur-
vival. in the present study the results show that there is no significance.
Poster
256. VITAMIN D LEVELS IN PATIENTS WITH GAUCHER
DISEASE: BASAL AND AFTER ORAL SUPPLEMENTATION
EVALUATION
Molisso A. 1, Barbato A. 1, Sibilio M. 2, Rendina D. 1, Tuzzi R. 3,
Strazzullo P. 1
1
Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli
“Federico II”; 2Divisione di Pediatria, Ospedale “Moscati” di Aversa (CE),
Italia; 3Dipartimento di Scienze Mediche Traslazionali, Università di Napoli
“Federico II”
Background: Gaucher disease (GD) is the most prevalent lysosomal storage
disease due to accumulation of glucosylceramide in cells of the reticu-
lo-endothelial system and is often associated with bone impairment. The
present study aims to evaluate the 25-hydroxyvitamin D (25[OH]D) levels
in outpatients with GD before and after oral supplementation according to
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
technique. All patients found to have a 25[OH]D level lower than 30 ng/ml
were prescribed oral cholecalciferol (vitamin D3) supplementation in order
to normalize their vitamin D status.
Results: At basal examination all patients, except one, showed serum
25[OH]D levels lower than 30 ng/ml. According to the Holick protocol, the
patients were treated with different dosage of cholecalciferol according to
basal 25[OH]D levels. In 27 patients, after a mean of 21 months (range: 9 to
36 months) of oral supplementation with cholecalciferol (vitamin D3) only
3 patients normalized their 25[OH]D levels.
Conclusion: In this group of GD patients, living in southern Italy, we
detected low serum levels of 25[OH]D similarly to what reported in other
GD populations. To our knowledge, this was the first analysis looking at
the effect of oral vitamin D supplementation in GD patients in real life.
Despite the correct therapeutic approach, only about 10% of the patients
undergoing treatment reached normal serum 25[OH]D levels (>30 ng/ml).
Among possible reasons for this unsatisfactory outcome, poor compliance
of patients or defects in vitamin D absorption are the most likely.
257. EFFECTS OF DARK CHOCOLATE ON ENDOTHELIAL
FUNCTION IN PATIENTS WITH NON-ALCOHOLIC
STEATOHEPATITIS
Battaglia S., Loffredo L., Perri L., Polimeni L., Carnevale R.,
Baratta F., Novo M., Del Ben M., Angelico F., Violi F.
Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma
Sapienza
Background: Oxidative stress plays a pivotal role to determine endothe-
lial dysfunction in patients with non-alcoholic fatty liver disease (NAFLD).
Polyphenols could reduce oxidative stress and improve endothelial function
by inhibiting the nicotinamide-adenine-dinucleotide-phosphate (NADPH)
oxidase isoform Nox2. Aim: The aim of this study was to analyze the effect
of cocoa polyphenols on endothelial function, assessed by flow-mediated
dilation (FMD), in a population affected by non-alcoholic steatohepatitis
(NASH).
Methods: In a cross-sectional study we analyzed FMD and oxidative stress,
as assessed by Nox2 activation, serum isoprostanes and nitric oxide bioa-
vailability (NOx), in patients with NASH (n=19), simple fatty liver disease
(FLD) (n=19) and controls (n=19). Then, we performed a randomized,
cross-over study in 19 subjects with NASH comparing the effect of 14-days
administration of 40 g of chocolate at high (dark chocolate, cocoa>85%)
versus low content (milk chocolate, cocoa <35%) of polyphenols on artery
dilation and oxidative stress.
Results: Compared to controls, NASH and FLD patients had higher Nox2
activity and isoprostanes levels and lower FMD and nitric oxide bioavailabi-
lity, with a significant gradient between FLD and NASH. The interventional
study showed that, compared to baseline, FMD and NOx increased (from
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,
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
Poster
258. CARDIOVASCULAR RISK IN PATIENTS WITH
TYPE 2 DIABETES MELLITUS: ROLE OF THE SPECIFIC
DETERMINANTS OF DISEASE SEVERITY
Pellegrini E. 1, Peli L. 1, D’Amico R. 2, Carulli L. 1, Mussi C. 1,
Bertolotti M. 1
1
Dept of Biomedical, Metabolic and Neural Sciences and 2Dept of Diagnostic
and Clinical Medicine and Public Health, University of Modena and Reggio
Emilia and University Hospital of Modena, Modena, Italy
Introduction: Diabetes mellitus represents an important cardiovascular
and coronary risk factor, and is currently considered a coronary disease
equivalent regardless of the degree of severity and metabolic control. Several
algorithms have been devised to estimate cardiovascular risk, most of which
non-specific for diabetics and hardly applicable to Mediterranean countries.
AIM of this study was to investigate the variables associated with cardiova-
scular risk in a population of type 2 diabetes in the Emilia Romagna area.
Methods: We longitudinally analyzed the documentation of Diabetes Clinic
patients, aged 35-65 without previous events, in the period 1991-2001. The
occurrence of cardiovascular events in the subsequent 10 years was recorded
and correlated with the main risk factors, including a number of variables
specific for diabetes; standard statistical analysis was performed.
Results: 3629 patients were eligible (2071 males, 1558 females). 546 of these
(15.0%) presented an event at 10 years. According to Kaplan-Meier survival
curves, the variables statistically associated with the occurrence of cardio-
vascular events were established risk factors such as age, gender, smoking,
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
DIABETES
Boccatonda A. 1, Vadini F. 2, Simeone P. 1, Tartaro A. 3, Consoli A. 1,
Davi’ G. 1, Santilli F. 1
1
Department of Medicine and Aging, and Center of Aging Science and
Translational Medicine (CESI-Met), Via Luigi Polacchi, Chieti, 66100,
Italy; 2Psychoinfectivology Service, Pescara General Hospital, Pescara, Italy;
3
Department of Neuroscience & Imaging, University of Chieti, Italy
Background: Diabetes is an acknowledged risk factor for cognitive impair-
ment and dementia later in life. A novel class of antidiabetic drugs, gluca-
gon-like peptide-1 (GLP-1) analogues, approved for the treatment of type
2 diabetes (T2DM) and obesity, has been shown in animal models to exert
a neuroprotective effect by influencing the GLP-1 receptors in the central
nervous system.
Aims and Methods: Sixty-two metformin-treated obese subjects with pre-
diabetes [impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)
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
intervention and exercise training) until achieving a modest and comparable
weight loss (-7% of initial body weight), to assess i. the baseline relationship
between cognitive performance and cardiometabolic variables, such as sub-
cutaneous (SAT) and visceral (VAT) adipose tissue distribution (assessed
by MRI), insulin sensitivity (Matsuda Index, HOMA-IR) and beta cell per-
formance (by Insulin Secretion-Sensitivity Index-2 (ISSI-2) during multiple
sampling OGTT; ii. whether, at equal degree of weight loss, a treatment by a
GLP-1 receptor agonist might exert a greater impact than lifestyle changes on
cognitive functions (memory and attention). A detailed neuropsychological
assessment (NP) was performed through a battery consisting of 7 tests. Stan-
dardized neuropsychological z scores (NPZ) were calculated by subtracting
the appropriate normative mean from the raw score and then dividing by
the normative standard deviation. In order to have distinct cognitive areas,
a composite domain z score for the attention tests (NPZ-A: sustained atten-
tion, and visual search test), memory tests (NPZ-M, including short term,
162
118° Congresso Nazionale - Società Italiana di Medicina Interna
working memory and long-term, visuographic memory), and executive
functions (NPZ-E: task-switching), were calculated. Results. At baseline, in
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
(rho= 0.409, p=0.001), ISSI-2 (rho=0.290, p=0.022), The composite memory
score NPZ-M correlated with insulin sensitivity, as reflected by Matsuda
index (rho= 0.394, p= 0.002) and HOMA-IR (rho= -0.382, p= 0.002), beta
cell function, as reflected by ISSI-2 (rho= 0.277, p= 0.029), VAT (rho= -0.260,
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
NPZ-M (Beta =0.307, SEM=0.002, P=0.015), independently of VAT, NAFLD,
Matsuda index, IL1-RA. Selective attention and composite index of attention
tests correlated with waist circumference (rho=0.27, p=0.037 and rho=0.30,
p=0.019), fasting plasma glucose (rho=0.28, p=0.025 and rho=0.27, p=0.035)
and ISSI-2 (rho=-0.326, p=0.010 and rho=0. 35, p=0.005, respectively). After
exclusion of patients not achieving the weight loss goal within 15 months or
lost-to-follow-up, final outcome status was ascertained for 40 patients (20
per arm). After achievement of the weight loss target, a significant increase
in long-term, visuographic memory (p=0.002) and the composite index of
memory tests (NPZ-M) was observed in the liraglutide arm (P=0.029)(Figure
1), but not in the lifestyle arm. In parallel, a significantly greater improvement
in beta cell function, as assessed by ISSI-2 (81.3% vs. 27.4%, p=0.006) and
reduction in VAT (-15.3% vs. -9% median decrease, P=0.028) was observed
after liraglutide-associated weight loss, as compared with lifestyle-associated
weight loss. In the lifestyle arm, there was an improvement in sustained atten-
tion (p<0.0001), selective attention (p=0.001) and NPZ-A (p=0.002).
Conclusions: In obese subjects with prediabetes or early T2DM, cognitive
performance is associated with cardiometabolic variables. At equal degree
of weight loss, liraglutide improves memory performance, whereas lifestyle
changes seem to be a promising non-pharmacogical strategy to contrast or
delay the development of cognitive impairment, with particular reference
to attentive functions. Therefore, it is plausible that a therapeutic approach
involving diet, physical activity and incretin analogues might be beneficial
against cognitive deficits occurring in patients in early, and possibly precli-
nical phases of diabetes.
260. BENEFICIAL EFFECTS OF HYPOCALORIC
MEDITERRANEAN DIET ON VISCERAL FAT AS AND
METABOLIC PATTERNS IN OBESE SUBJECTS
Bonfrate L., Minerva F., Cappabianca M., de Bari O., Portincasa P.
Department of Biomedical Sciences and Human Oncology, Clinica Medica
“A. Murri”, Policlinico Hospital, University of Bari Medical School, Bari, Italy
Background: the expansion of visceral adipose tissue (VAT) is closely asso-
ciated with metabolic abnormalities and increased risk of several chronic
diseases. Increased VAT is also a marker of ectopic fat deposition in the
liver and the heart, while decreased VAT can represent a marker of success
during dietary plan. We therefore evaluated the correlation beetwen VAT
and metabolic patterns in obese subjects undergoing an hypocaloric typical
mediterranean controlled diet.
Methods: over a 6 mo. period, 87 obese (BMI>30 Kg/m2) subjects (53 F:34
M, age 51yrs±1.4 SE and 56.4±1.1yrs, respectively) entered an hypocaloric
mediteranean diet program. The following measurements were performed
at baseline and at the end of the protocol: BMI, waist circumference, biou-
moral exams (i.e., insulinemia, total-, LDL- and HDL-cholesterol, triglyce-
rides, fasting glycemia, GPT, uric acid), ultrasonographic measurements of
fat (liver steatosis, subcutaneous and visceral fat) by Hitachi equipment.
Results: at baseline M displayed greater metabolic abnormalities than F.
Subcutaneous fat positively correlated with BMI while visceral fat correlated
118° Congresso Nazionale - Società Italiana di Medicina Interna
with BMI, fasting glycemia, insulinemia, HDL, total-C, triglycerides, and
degree of liver steatosis. The 6 mo. hypocaloric mediteranean alimentary
program was associated with significant improvement of anthropometric,
ultrasonografic and bioumoral outcomes.
Conclusions: Visceral fat is a metabollically active tissue. VAT correlates
with the metabolic profile of patients and can be used as marker in evalua-
ting the efficacy of targeted alimentary programs in metabolically abnormal
subjects.
261. AN UNEXPECTED CAUSE OF HYPOGLICEMIA
Bontempelli E., Cagnoni F., Besozzi A., Dognini G.P., Destro M.
Department of Medical Science, Internal Medicine, ASST. Bergamo Ovest,
Treviglio - Italy
A 59-year-old male was admitted with episodes of weakness, sweating and
loss of consciousness. These symptoms occurred both fasting and postpran-
dial. Patient medical history included hypertension, dyslipidemia and
recent episode of Herpes Zoster Ophthalmicus treated with Aciclovir. His
blood examinations at the time of admission were notable for: hypoglyce-
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-
lating hormone level was 3.200 μIU/l, cortisol and ACTH were normal. His
plasma serum insulin was high (47 μU/ml) and C-peptide was 12 ng/ml
(normal value 0.9-7.1 ng/ml). Computed tomography scan of the abdomen
revealed no abnormal lesion in the pancreas. All immunologic tests and
the determination of urine sulfonylurea were negative. Glucose infusion
was administered multiple times because of persistent hypoglycemia with
the need of infusion of highly concentrated (33%) glucose solutions. Upon
further examination, the patient revealed that, in addition to Aciclovir, he
had taken a multivitaminic formula containing α-lipoic agent (ALA) 400
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
high titer of anti-insulin antibodies, a diagnosis of Insulin Autoimmune
Syndrome (Hirata Syndrome) was made. The patient was treated with Pre-
dnisone 1mg/kg and showed normalized blood glucose levels after 5 days of
treatment. α-Lipoic agent treatment had already been suspended since the
day of admission.
The dose of Prednisone was slowly tapered and the patient remained asymp-
tomatic with normal blood glucose levels. Anti-insulin antibodies decre-
ased in the following months. Hirata Syndrome or Insulin Autoimmune
Syndrome was initially reported by Hirata in 1970 and it is a rare cause
of hypoglicemia. Most of cases are reported in Japan, only few in Western
Countries. It is characterized by serious hypoglicemia, high levels of blood
insulin and insulin autoantibodies in the absence of exogenous insulin
administration.
The cause of this syndrome is unclear, but insulin autoantibody formation is
considered to be associeted with autoimmune disease (Graves disease, rheu-
matoid arthritis) or with assumption of drugs containing a sulfhydryl group
(methimazole, carbimazole, penicillamine, captopril, penicillin, metima-
zole, imipenem, isoniazide, idralazine and procainamide).
There is a significant genetic predisposition to this disease and it is strongly
correlated with HLA class II (HLA-DRB1 1403, DRB1 10406). In our case
HLA tiping demostrated the presence of HLA-DRB1 1403. α – Lipoic acid
is a sulfhydryl-containing compound used to as nutritional supplement and
used to treat peripheral neuropathy; assumption of ALA can be the cause of
this syndrome in patients with genetic predisposition.
262. METABOLIC SYNDROME AND COPD: NOVEL
RELATION BETWEEN SMOKING, INSULIN RESISTANCE
AND VITAMIN D LEVELS
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
1
Department of Internal Medicine, University of Bari “Aldo Moro” - Bari
(Italy), 2 Institute of Respiratory Disease, University of Bari “Aldo Moro” –
Bari (Italy)
Introduction: Metabolic Syndrome (MetS) and Chronic Obstructive Pul-
monary Disease (COPD) are two emerging clinical conditions characteri-
zed by a persistent systemic inflammation. Aim To evaluate and compare
risk factors, clinical and metabolic characteristics of patients affected with
Poster
MetS, COPD or both diseases.
Methods: We recruited 96 patients, 48 from “Metabolic Disorders” and 48
from “COPD” outpatient clinic of Bari University Hospital. Patients were
divided in: MetS (n=37 group 1), COPD (n=21 group 2), MetS+COPD
(n=38 group 3). Clinical, instrumental e laboratory parameters were evalua-
ted. Results The prevalence of COPD among patients with MetS was 23%;
58% of COPD patients met “armonized” criteria for MetS diagnosis. In
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
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
observed in all smokers, especially in current smokers (p=0, 001; R= 0, 626);
moreover, a negative correlation was found between vitamin D and C-pep-
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
in current smokers (p=0, 001; R=-0, 714).
Conclusions: These preliminary results confirm and stress the strict link
existing between MetS and COPD. Moreover, the novel relation pointed
out between pack/years, vitamin D and development of insulin-resistance
opens up new prospects that require to be further investigated.
263. LIRAGLUTIDE IMPROVES CAROTID INTIMA-MEDIA
THICKNESS IN PRE-ELDERLY AND ELDERLY PATIENTS
WITH TYPE-2 DIABETES: AN 18-MONTH PROSPECTIVE,
REAL LIFE STUDY
Mannina C., Castellino G., Patti A., Giglio R.V., Chianetta R.,
Nikolic D., Bonfiglio A., Sardo V.A., Galletta R., Catalfio R.,
Citarrella R., Montalto G., Rizzo M.
Biomedical Department of Internal Medicine and Specialties, University of
Palermo, Italy
Background and Aims: Liraglutide exerts cardio-protective effects beyond
of those on glucose metabolism, affecting several cardio-metabolic parame-
ters, such as subclinical atherosclerosis. However, it is not known if those
effects differ in the long-term between pre-elderly and elderly subjects with
type-2 diabetes (T2DM).
Materials and Methods: We included 135 subjects with T2DM divided in
2 groups: 1) 71 pre-elderly subjects (46 men and 25 women, 55±7 years),
and 2) 64 elderly subjects (33 men and 31 women, 70±5 years). All subjects
were naïve to incretin-based therapies and treated with liraglutide as add-on
to metformin, 0.6 mg/day for two weeks, followed by a dose of 1.2 mg/day.
At baseline and every 6 months fasting samples were taken for labora-
tory analyses and carotid-intima media thickness (cIMT) was assessed by
B-mode ultrasound. Statistical analysis was performed by ANOVA and the
Spearman correlation method.
Results: After18 months of liraglutide therapy HbA1creduced signifi-
cantly in both groups (from 9.02±1.06 to 6.93±1.25 and from 8.50±0.71
to 6.74±0.90 %, respectively) as well as fasting glycemia (from 9.57±3.33
to 7.16±2.83 mmol/L; and from 9.14±3.71 to 7.28±2.29 mmol/L, p<0.0001
for all). Anthropometric parameters changed although not significantly.
Lipids, with the exception of HDL-cholesterol, reduced significantly only
in pre-elderly subjects (triglycerides from 1.94±1.48 to 1.57±0.80 mmol/L,
p=0.0458; total cholesterol from 4.90±1.57 to 4.27±1.04 mmol/L, p=0.0025;
LDL-cholesterol from 2.92±1.44 to 2.34±0.91 mmol/L, p=0.0054. cIMT
significantly decreased in both groups (from 0.96±0.18 to 0.78±0.20 mm;
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)
groups.
Conclusion: Liraglutide significantly reduced cIMT in both pre-elderly and
elderly subjects with T2DM, beyond glycemic control.
264. LIRAGLUTIDE IMPROVES METABOLIC
PARAMETERS AND REDUCES INTIMA-MEDIA
THICKNESS IN OBESE PATIENTS WITH TYPE 2
DIABETES: 18-MONTH PROSPECTIVE STUDY
Giglio R.V., Patti A.M., Castellino G., Mannina C., Nikolic D., Chianetta R.,
Galletta R., Sardo V.A., Bonfiglio A., Catalfio R., Citarrella R., Montalto G.,
Rizzo M.
Biomedical Department of Internal Medicine and Specialties, University of
163
Poster 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
Department of Clinical and Experimental Medicine, University Hospital of
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
Department of Clinical and Experimental Medicine, University Hospital of
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
118° Congresso Nazionale - Società Italiana di Medicina Interna
was administered below. At a distance of 1 hour and 2 hours after the
intake, the PA, FC, FMD, PWV and PWA measurements were again per-
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
T60’(p = 0.007); FC showed a statistically significant reduction in baseline
values: 76.10 ± 11.63 bpm; T60’: 67.40 ± 7.47 bpm (p = 0.001); T120’:
68.32 ± 9.98 bpm (p = 0.007); there was a reduction in PWV, although not
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.
and baseline AP values: 4.60 ± 2.45 mmHg; T60’ 3.96 ± 3.55 mmHg; T120’
3.84 ± 2.98 mmHg; n.s. Metabolic monitoring showed a statistically signi-
ficant increase in mean values of cutanea - basal temperature: 31.37 ± 0.98
°C; T60’: 32.25 ± 2.34 °C (p = 0.045); T120: 33.12 ± 0.87 (p = 0.00000001);
the difference in the values recorded in T120’ and T60’ is also statistically
significant (p = 0.044); a statistically significant increase in mean tempe-
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
also an increase in mean - baseline energy expenditure: 1.20 ± 0.20 cal;
T60’: 1.27 ± 0.25cal; T120’: 1.21 ± 0.21cal; n.s. Correlated with the incre-
ase in mean - basal METs: 1.11 ± 0.13; T60’ 1.17 ± 0.24; T120’ 1.12 ± 0.13;
n.s. The data reported in our study suggests that the intake of diosmin in
combination with other flavonoids has positive effects on: FMD, PWV,
PWA thermogenesis and metabolism in the healthy subject. Increasing
endothelial function, reducing arterial wall stiffness, and beneficial effects
on the healthy subject’s metabolism allow us to hypothesize that the addi-
tion of rich diosmine and other flavonoid supplements in daily diet can
be a further potential benefit in prevention and cardiovascular protection.
268. LIRAGLUTIDE 3.0 MG IN OBESE/OVERWEIGHT
ADULTS WITH OR WITHOUT PREDIABETES WITH
BASELINE BMI <35 VS. ≥35 KG/M2 IN THE SCALE
OBESITY AND PREDIABETES 56-WEEK RANDOMISED,
DOUBLE‑BLIND, PLACEBO-CONTROLLED TRIAL
Vettor R. 1, Greenway F. 2, le Roux C.W. 3, McGowan B. 4,
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
Rouge, LA, USA; 3 University College Dublin, Ireland; 4 Guy’s & St Thomas’
NHS. Foundation Trust, London, UK; 5 Columbia University, New York, NY,
USA; 6 Novo Nordisk A/S, Søborg, Denmark; 7 Novo Nordisk SpA, Rome,
Italy; 8 Antwerp University Hospital, Antwerp, Belgium
Background: The 3-year SCALE Obesity and Prediabetes trial
(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
adjunct to diet and exercise for 160 weeks.
Methods: This post hoc analysis compared efficacy and safety of liraglutide
for adults with prediabetes and BMI < vs ≥35 kg/m² at baseline. Treatment
effect of liraglutide across BMI subgroups was evaluated by statistical testing
of interaction between treatment and BMI subgroup.
Results: BL characteristics were similar between liraglutide and placebo
BMI subgroups (< vs ≥35 kg/m2) except weight-related characteristics
(weight, BMI, waist circumference) and history of dyslipidemia (more
common for liraglutide BMI <35 kg/m2). At 160 weeks, significantly greater
mean and categorical weight losses (WLs) were seen with liraglutide vs
PBO for BMI < and ≥35 kg/m2 (mean WL [%]: −6.4, −6.0 vs −1.7, −2.0; %
achieved ≥5% WL: 51.1, 48.9 vs 19.7, 25.0; >10% WL: 25.7, 23.7 vs 8.9, 9.8;
>15% WL: 8.1, 8.0 vs 2.5, 2.2) as well as greater improvements in glycemic
parameters and quality of life endpoints; these treatment effects appeared to
be independent of baseline BMI (interaction p>0.05). While on treatment
at 160 weeks, more people with liraglutide vs placebo regressed to normo-
glycemia, irrespective of baseline BMI: 66.1, 65.8% vs 34.9, 36.9%. Rates
of adverse events (AEs), and serious/severe AEs were generally comparable
across BMI subgroups. Rates of gallbladder-related AEs were similar for
liraglutide < and ≥35 kg/m2 (24 events [2.4 events/100 years’ observation],
69 [3.1]) but higher than placebo (6 [1.3], 12 [1.2]). Rates of pancreatitis
were low, similar between BMI < and ≥35 kg/m2 but higher with liraglutide
vs placebo (2 [0.2], 8 [0.3] vs 1 [0.2], 1 [0.1]), as were breast neoplasms (2
[0.3], 8 [0.4] vs 0 for placebo).
Conclusions: After 56 weeks, there was no evidence thetreatment effects of
liraglutide 3.0 mg as adjunct to diet and exercise on weight loss, glycaemic
parameters, and blood pressure differed across the baseline BMI subgroups
Poster
(<35 vs. ≥35 kg/m2). The safety and tolerability of liraglutide 3.0 mg were
comparable in baseline BMI subgroups (<35 vs. ≥35 kg/m2).
269. C REACTIVE PROTEIN INCREASE IS ASSOCIATED
WITH HIGH CORONARY AND PERIPHERAL
ATHEROSCLEROTIC BURDEN IN SUBJECTS WITH
VISCERAL OBESITY
Ferrara V. 1, Scicali R. 1, Di Pino A. 1, Gallo A., Piro S. 1,
Rosenbaum D. 2, Rabuazzo A.M. 1, Giral P. 2, Bruckert E. 2,
Purrello F. 1
1
Dipartimento di Medicina Clinica e Sperimentale, Università degli
Studi di Catania, Catania, Italia. 2 Cardiovascular Prevention Unit and
Endocrinology Service, Paris Hospital Public Assistance, Pitie-Salpetriere
Hospital Group, Pierre et Marie Curie University, Paris, France
Background and Aims: The association of visceral obesity with an incre-
ased risk of developing cardiovascular disease is unclear. In these subjects,
inflammation plays a central role in developing atherosclerosis. Our
objective was to examine the cardiovascular (CV) risk profile of visceral
obesity patients with and without inflammation according to high sensiti-
vity C reactive protein (CRP), using macroangiopathic imaging biomarkers.
Methods: Our population consisted of 140 patients aged between 40 and
70 years, with a waist circumference ≥ 88 for women and ≥ 102 for men
and at least 1 CV risk factor. Exclusion criteria were prior history of CV
disease or clinical evidence of advanced renal disease. Inflammation was
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
< 0.05). Visceral obesity subjects with inflammation had higher mean IMT
than non-exposed subjects (0.62 ± 0.18 vs. 0.56 ± 0.11 mm, p < 0.05). In
addition, in a multiple linear regression, CAC was associated with inflam-
mation (p < 0.05) and age (p < 0.001).
Conclusions: Among patients with abdominal obesity, CRP increase is
associated with higher coronary and peripheral atherosclerotic burden in
visceral obesity patients.
270. CHANGES IN GLUCOSE METABOLISM AFTER
CLEARANCE OF HEPATITIS C VIRUS: A PROSPECTIVE
STUDY WITH SERIATED OGTTS
Gualerzi A., Bianco S., De Benedittis C., Tran Minh M., Bellan M.,
Carnevale Schianca G.P., Pirisi M.
A.O.U. Maggiore della Carità di Novara - S.C.D.U. Medicina Interna 1
Rationale and Aim: It has been shown that hepatitis C virus (HCV) car-
riers with diabetes who have their infection cleared by antiviral treatment
improve their glycemic control, mainly because of lowered insulin resistance
(IR); whether this mechanism applies to HCV carriers with normal glucose
tolerance (NGT) and prediabetes has not been studied yet. The present study
aimed to fill this gap.
Methods: Sixty-one HCV patients (35 males, 26 females; mean age 64±12;
mean body mass index 25, 8±3, 8 kg/m2; 31 with cirrhosis) underwent a dual
oral glucose tolerance test (OGTT) with simultaneous measure of plasma
insulin concentration (at baseline and after 60 and 120 min) plus HbA1c,
both prior the initiation of direct oral antiviral (DAA) treatment and at the
end of treatment (EOT). We categorized patients based on the glucose tole-
rance status and calculated OGTT-derived indices of IR and insulin-sensiti-
vity (HOMA-IR, ISI Belfiore), insulin-secretion (EFP Stumvoll) and beta cell
function (Disposition Index). The indices above were related to the clinical
and laboratory characteristics of the study population.
Results: At baseline, 32/61 patients (52, 5%) showed glucose metabolism
abnormalities (including 24 with prediabetes and 8 who satisfied OGTT
criteria for diabetes). At EOT, 14/32 patients (44%) reversed to NGT status
while in 18/32 the alteration of glucose metabolism persisted (54%, inclu-
ding 5 diabetics), despite a global reduction in glycemic levels at G0’ (decre-
ased by 4%, p=0, 018), G60’ and G120’ (respectively decreased by 15%, p>0,
001). The decrease in HOMA IR was statistically significant (p<0.001) and
equal to 26%. ISI was increased by 39, 6% (p<0.001) and this data is confir-
med also analyzing the NGTs alone. There were no significant differences in
insulin-secretion (p=0.301), while the Disposition Index increased by 29%
(p<0.001). Excluding 19 patients who received ribavirin (a drug known to
cause hemolysis) the reduction of HbA1c was also statistically significant
165
Poster
(p=0.025), being reduced of 1, 8%. From the multivariate analysis emerged
as single independent predictor of HOMA-IR improvement the presence of
a low viral load (<106 UI/ml) at baseline.
Conclusions: Among chronically HCV infected patients, treatment-indu-
ced changes in insulin sensitivity occur early, being already present at the
end of antiviral therapy, and concern the entire spectrum of glucose meta-
bolism abnormalities.
271. ABDOMINAL DEPOTS IN THE EVALUATION OF
CARDIOVASCULAR RISK IN WOMEN UNDERGOING
ASSISTED REPRODUCTIVE TECHNOLOGY (ART)
Fatini C., Cirillo M., Cosentino E., Crociani A., Donnarumma E.,
Fabbri M., Fallai L., Lunardi S., Maestripieri V., Boddi M.
Dipartimento di Medicina Sperimentale e Clinica, AOU
Careggi, Firenze
Background: Overweight and obesity are reported to impair fertility in
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-
sed cardiovascular risk, nevertheless this topic is object of debate.
Methods: We investigated, in a model of 27 overweight or obese women
(mean age 40.7yrs), who underwent ART and had referred to the Vascular
166
118° Congresso Nazionale - Società Italiana di Medicina Interna
Women Disorders Clinic, AOU Careggi, anthropometric, bio-humoral and
ultrasound/imaging markers, in order to frame their cardiovascular risk.
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/
dL (7.2 mmol/L), defined as the upper limit of the recommended premeal
PG goal based on the 2015 ADA Standards of Medical Care in Diabetes,
at each visit during the maintenance period, as well as doing so without
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
occurring between 00:01 and 05:59, inclusive. Patients (T1D or T2D) from
seven open-label, randomized, treat-to-target trials treated with either IDeg
(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
maintenance period, as well as doing so without experiencing nocturnal
confirmed hypoglycemia, compared with IGlar. These results were similar
across the three patient populations; T1D, T2D insulin treated and T2D
insulin naïve. In conclusion, more patients treated with IDeg can achieve
target FPG without nocturnal confirmed hypoglycemia compared with
IGlar.
273. META-ANALYSIS COMPARING HYPOGLYCEMIA
RATES OF INSULIN DEGLUDEC WITH INSULIN
GLARGINE ACROSS CLINICAL TRIALS WITH UP TO 2
YEARS’ DURATION
118° Congresso Nazionale - Società Italiana di Medicina Interna
Montano N. 1, Philis-Tsimikas A. 2, Bode B. 3, Del Prato S. 4,
Gross J. 5, Mathieu C. 6, Troelsen L. 7, Leeuwen M.V. 7, Zinman B. 8, Mancuso
M. 9
1
Department of Clinical Sciences and Community Health, University of
Milan, Milan, Italy 2 Scripps Whittier Diabetes Institute, San Diego, USA, 3
Atlanta Diabetes Associates, Atlanta, GA, USA, 4 University of Pisa, Pisa, 5
Universidade Federal do Rio Grande de Sul, Porto Alegre, Br, 6 UZ LEUVEN,
Leuven, Belgium, 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 with low day-to-day variability. A comparison of the
rate of hypoglycemia with IDeg versus insulin glargine (IGlar) across
phase 3a trials, including all available trial extensions (n=4) plus one new
trial was performed post hoc; IDeg: n=3454; IGlar: n=1709; T1D: 2 trials;
T2D: 6 trials. Hypoglycemia was defined as rates of self-reported confir-
med hypoglycemia (BG <56 mg/dL or severe hypoglycemia requiring assi-
stance) and nocturnal confirmed hypoglycemia (00:01–05:59 both incl.).
Rates were analyzed with a negative binomial regression model on patient
level data. IDeg resulted in statistically significantly lower rates of con-
firmed and nocturnal confirmed hypoglycemia versus IGlar in T2D, and
for nocturnal confirmed hypoglycemia in T1D (Table). Analyses of the
maintenance period (from 16 weeks onwards), demonstrated more pro-
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
of additional trial data for up to two years’ duration, the lower rates of
both overall (T2D) and nocturnal confirmed (T1D and T2D, respectively)
hypoglycemia with IDeg versus IGlar are maintained.
274. THE IMPACT OF BASELINE BMI AND HBA1C ON
GLYCEMIC CONTROL AFTER TREATMENT WITH FAST-
ACTING INSULIN ASPART IN INDIVIDUALS WITH TYPE
2 DIABETES
Perticone F. 1, Bowering K. 2, Bode B. 3, Harris S. 4, Piletic M. 5,
Babu V. 6, Dethlefsen C. 6, Rodbard H.W. 7, Mancuso M. 8
1
Magna Graecia University, Catanzaro, Italy 2University of Alberta,
Edmonton, Canada 3Atlanta Diabetes Associates, Atlanta, Georgia, USA.
4
Western University, London, Ontario, Canada 5General Hospital, Novo
Mesto, Slovenia 6Novo Nordisk A/S, Søborg, Denmark 6Claus Dethlefsen
Novo Nordisk A/S, Søborg, Denmark 7 Endocrine and Metabolic Consultants,
Rockville, Maryland, USA. 8Novo Nordisk SpA, Rome, Italy
Baseline characteristics related to severity of disease can be predictors of
the HbA1c-lowering effect of a treatment. The impact of baseline BMI and
HbA1c on the efficacy and safety of mealtime fast-acting insulin aspart
(faster aspart) in type 2 diabetes (T2D) was assessed in a post hoc analysis of
two randomized phase 3a trials: a 26-week, double-blind, treat-to-target trial
with mealtime insulin aspart (IAsp) in a basal–bolus regimen as the com-
parator (onset 2), and an 18-week, open-label trial with basal insulin alone
as the comparator (onset 3). All individuals were also taking metformin. In
this analysis, individuals were grouped by baseline BMI (<25, 25–30, ≥30
kg/m2) or HbA1c (≤7.5, >7.5–<8.0, ≥8.0%). In onset 2, the overall change
in HbA1c was non-inferior to faster aspart (n=345) vs. IAsp (n=344), with
an estimated treatment difference (ETD) (95% CI) of −0.02% (−0.15;0.10).
In onset 3, overall change in HbA1c was superior with faster aspart (n=116)
vs. basal insulin alone (n=120), with an ETD of −0.94% (−1.17;−0.72). The
ETD for change in HbA1c in each trial was similar for all BMI and HbA1c
subgroups. No major differences between treatments were observed in risk
of hypoglycemia (Table) or insulin dose across subgroups in either trial.
Neither baseline HbA1c nor BMI altered the glycemic response to faster
aspart in individuals with T2D.
275. 1, 5-ANHYDROGLUCITOL CORRELATES WITH
POSTPRANDIAL GLUCOSE IN SUBJECTS WITH TYPE
1 DIABETES IRRESPECTIVE OF HBA1C RESPONDER
STATUS
G. Tonolo 1, S. Heller 2, K. Bowering 3, P. Raskin 4, Liebl 5,
K. Buchholtz 6, D.M. Bretler 6, T. Pieber 7, M. Mancuso 8
1
Diabetologia Asl 2, Olbia, Italy 2University of Sheffield, Sheffield, UK,
3
University of Alberta, Edmonton, AB, Canada, 4University of Texas
Poster
Southwestern Medical Center, Dallas, TX, USA, 5Fachklinik Bad Heilbrunn,
Bad Heilbrunn, Germany, 6Novo Nordisk, Søborg, Denmark, 7Medical
University of Graz, Graz, Austria, 8Novo Nordisk spA, Rome, Italy
Serum 1, 5-anhydroglucitol (1, 5-AG) decreases during periods of hyper-
glycemia (>180 mg/dL) and reflects postprandial plasma glucose (PPG)
control over the previous 1–2 weeks. The extent 1, 5-AG reflects PPG
control may also depend on overall glycemic control. This was assessed in a
post hoc analysis of onset 1, a 26-week, randomized, phase 3 trial in subjects
with type 1 diabetes evaluating mealtime (MT) fast-acting insulin aspart
(faster aspart), 20 min post-meal (PT) faster aspart and MT insulin aspart
(IAsp), each with insulin detemir. Subjects (n=990) were pooled to examine
the correlation between absolute values of 1, 5-AG and 2-h PPG from 7-9-7
self-measured plasma glucose profiles at week 26 according to HbA1c (<7%
or ≥7%) at week 26. HbA1c was reduced in all treatment arms. Primary
endpoint in onset 1 was HbA1c change from baseline (est. treatment dif-
ference [ETD] [95% CI]: MT faster aspart vs. IAsp −0.15% [−0.23;−0.07];
PT faster aspart vs. IAsp 0.04% [−0.04;0.12]). Glycemic differences were
reflected in 1, 5-AG change from baseline (ETD [95% CI]: MT faster aspart
vs. IAsp 0.50 μg/mL [0.24;0.76]; PT faster aspart vs. IAsp –0.16 μg/mL
[–0.42;0.10]). 1, 5-AG correlated with 2-h PPG, in subjects with HbA1c
<7% and HbA1c ≥7%. These results are consistent with the usefulness of
1, 5-AG as a marker of short-term glycemic control, irrespective of HbA1c
responder status.
276. EFFICACY AND SAFETY OF FAST-ACTING
INSULIN ASPART ARE MAINTAINED OVER 52 WEEKS:
COMPARISON WITH INSULIN ASPART IN ONSET 1
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,
M. Mancuso 9
1
Unità Funzionale, Ospedale San Raffaele di Milano, Milan, Italy 2Clinical
and Experimental Endocrinology, UZ Leuven, Leuven, Belgium, 3Atlanta
Diabetes Associates, Atlanta, GA, USA, 4 Mossakowski Medical Research
Center, Polish Academy of Sciences & Central Clinical Hospital MSWiA,
Warsaw, Poland, 5Scripps Whittier Diabetes Institute, San Diego, CA, USA,
6
Diabetes Research Center, Münster, Germany, 7Novo Nordisk, Søborg,
Denmark, 8Royal Surrey County Hospital, Guildford, UK, 9Novo Nordisk
SpA, Rome, Italy
Onset 1 was a phase 3a trial evaluating fast-acting insulin aspart (FA) in
adults with type 1 diabetes (T1D) over 52 weeks in two 26-week periods.
Subjects were randomized to double-blind mealtime FA, insulin aspart
(IAsp) or open-label post-meal FA, each with insulin detemir for the first
26 weeks. Subjects on mealtime FA (n=381) and IAsp (n=380) continued
to the additional 26-week period, aimed to assess long-term safety and effi-
cacy. After 52 weeks, HbA1c change from baseline (−0.08% [FA] vs. +0.01%
[IAsp]) showed a significant estimated treatment difference (ETD) [95%
confidence interval (CI)] favoring FA (ETD: −0.10% [−0.19;−0.00]). Change
from baseline in 1-h postprandial plasma glucose (PPG) increment after meal
test was −1.05 mmol/L (FA) vs. −0.14 mmol/L (IAsp) (ETD: −0.91 mmol/L
[−1.40;−0.43]; −16.48 mg/dL [−25.17;−7.80]). A similar trend toward better
efficacy with FA vs. IAsp was seen in change from baseline in 2-h PPG incre-
ment after meal test (ETD [95% CI]: −0.42 mmol/L [−1.11;0.27]; −7.60 mg/
dL [−19.98;4.78]). Mean 7-9-7-point self-measured plasma glucose profiles
were significant in favor of FA (ETD: −0.23 mmol/L [−0.46;−0.00]; −4.14
mg/dL [−8.23;−0.06]). Median total insulin dose was 0.77 U/kg (FA) vs. 0.83
U/kg (IAsp). No difference was observed for body weight change (+1.18 kg
[FA] vs. +1.05 kg [IAsp]; ETD: 0.13 kg [−0.38;0.65]). After 52 weeks, adverse
events were similar between FA and IAsp and as expected for IAsp. Severe or
blood glucose-confirmed hypoglycemia rates (plasma glucose <3.1 mmol/L
[56 mg/dL]) were similar with FA (53.29 events/patient-year) vs. IAsp (53.19
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
physiology with FA achieves lower PPG and HbA1c in T1D compared with
IAsp.
277. POSTPRANDIAL PLASMA GLUCOSE IN TARGET
RANGE WITH FASTER ASPART BASAL–BOLUS THERAPY
C. Irace 1, H.W. Rodbard 2, K. Bowering 3, M. Piletič 4,
M. Demissie 5, S. Klim 6, T.R. Pieber 7, M. Mancuso 8
167
Poster
1
Magna Graecia University, Catanzaro, Italy 2Endocrine and Metabolic
Consultants, Rockville, MD, USA, 3Department of Medicine, University
of Alberta, Edmonton, AB, Canada, 4General Hospital Novo Mesto, Novo
Mesto, Slovenia, 5Novo Nordisk, Søborg, Denmark, 6Novo Nordisk, Bagsværd,
Denmark, 7Medical University of Graz, Graz, Austria 8Novo Nordisk SpA,
Rome, Italy
Fast-acting insulin aspart (faster aspart) aims to reduce postprandial
plasma glucose (PPG) levels by mimicking physiological insulin secre-
tion. onset 3 was an 18-week, 1:1-randomized, open-label trial evaluating
adding and titrating mealtime faster aspart to basal insulin therapy vs. a
basal-only regimen, both in combination with metformin in patients with
type 2 diabetes (T2D). This post hoc analysis (n=236) explored the two tre-
atments’ ability to achieve 2-h PPG in range at 6, 12 and 18 weeks (end
of trial [EOT]). Response was defined as maintaining nine postprandial
self-measured plasma glucose (SMPG) measurements taken during 3 days
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
non-responders. With faster aspart basal–bolus, the odds of achieving 2-h
PPG within the defined ranges were already significantly higher by 6 weeks
relative to basal-only treatment, and this increased through EOT. The faster
aspart basal–bolus group showed superior HbA1c reduction (ETD −0.94%
[95% CI: −1.17;−0.72]). Concomitant with improved blood glucose control,
the rate of hypoglycemia increased at EOT (Table). In conclusion, 2-h PPG
was more consistently in target range with faster aspart basal–bolus therapy
compared with basal insulin alone in patients with T2D.
278. EVALUATION OF EARLY POSTPRANDIAL
SUPPRESSION OF ENDOGENOUS GLUCOSE
PRODUCTION WITH FASTER ASPART VERSUS INSULIN
ASPART
C. Irace 1, A. Basu 2, T.R. Pieber 3, A.K. Hansen 4, S. Sach-Friedl 3,
K.M.D. Thomsen 4, R. Basu 1, H. Haahr 4, M. Mancuso 5
1
Magna Graecia University, Catanzaro, Italy 2Mayo Clinic, Rochester, MN,
USA, 3Medical University of Graz, Graz, Austria, 4Novo Nordisk, Søborg,
Denmark, 5Novo Nordisk SpA, Rome, Italy
Background and Aims: Fast-acting insulin aspart (faster aspart) is insulin
aspart (IAsp) in a new formulation containing two well-known additional
excipients, L-arginine and niacinamide, which result in a stable formula-
tion with accelerated initial absorption after subcutaneous administration.
Previous clinical trials have shown that faster aspart provides greater early
absorption leading to improved postprandial glucose control compared
with IAsp. The aim of the present trial was to investigate the mechanisms
behind the lower postprandial glucose achieved with faster aspart versus
IAsp.
Materials and Methods: In a randomised, double-blind, crossover trial
design, subjects with type 1 diabetes (N=40; 21 women/19 men; mean±SD
168
118° Congresso Nazionale - Società Italiana di Medicina Interna
age 42±12 years, BMI 24.1±2.2 kg/m2, HbA1c 7.3±0.7%) received identi-
cal subcutaneous single doses of faster aspart and IAsp (individualised by
subject; 0.06-0.28 U/kg) at the start of a standardised mixed meal (contai-
ning 75 g carbohydrate labelled with [1-13C] glucose). Postprandial glucose
turnover was assessed by the triple-tracer meal method using continuous,
variable [6-3H] glucose and [6, 6-2H2] glucose infusion.
Results: Early insulin exposure (AUCIAsp, 0-30min and AUCIAsp, 0-1h)
was greater for faster aspart versus IAsp, leading to smaller postprandial
glucose increment at 1 hour (ΔPG1h) (Table). The smaller ΔPG1h with
faster aspart was due to greater suppression of endogenous glucose pro-
duction (EGP) and higher glucose disappearance (ΔAUCRd) with faster
aspart versus IAsp during the first hour post-dose. Suppression of free fatty
acid levels (AOCFFA, 0-1h) was 36% greater for faster aspart versus IAsp.
Conclusion: Faster aspart provides improved postprandial glucose control
compared with IAsp partly through earlier and greater suppression of endo-
genous glucose production.
279. VISION-RELATED QUALITY OF LIFE AND LOCUS
OF CONTROL IN TYPE 1 DIABETES. A MULTICENTRE
OBSERVATIONAL STUDY
Trento M., Durando O., Merlo S., Fornengo P., Amione C.,
1
Bertello S., 1Oleandri S., 2Picca P., 3Donati M.C., 3Virgili,
4
Bandello F., 4Lattanzio R., 4Aragona E., 5Scoccianti L., 6Perilli R.,
7
Casati S., 7Gusson E., 8Charrier L., 8Cavallo F., Porta M.
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
3
Eye and Pathophysiological Clinic. Azienda Ospedaliera Universitaria
Careggi. Florence 4 Department of Ophthalmology, Scientific Institute San
Raffaele, University Vita-Salute, Milan. 5 Diabetic Retinopathy Centre and
Laser Treatment. Institute of Ophthalmology, Parma 6 Department of Social
Ophthalmology. Azienda Ospedaliera Universitaria. Pescara. 7 Department
of Neurosciences and Biomedicine. Azienda Ospedaliera Universitaria.
Verona. 8 Department of Public Health and Paediatric Sciences, University of
Turin, Italy. Diabetic Retinopathy Centre, Department of Medical Sciences,
University of Turin, Italy
Introduction: Vision plays an important role in the ability of people to
process information from their environment and to participate in everyday
activities. Diabetic Retinopathy (DR) is considered to remain asymptoma-
tic until it reaches its late stages. However, subtle changes in vision related
quality of life (QoL) may occur even in mild DR and their perception may
be related to a patient’s locus of control (LoC) of his/her disease.
Objective. To evaluate vision-related QoL and LoC in patients with Type 1
Diabetes and different stages of DR.
Patients and Methods: The 25-item National Eye Institute Visual Fun-
ctioning (NEI VFQ-25) and Locus of Control (LoC) questionnaires were
self-administered to 258 patients between January 2014 and March 2017 in
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.
118° Congresso Nazionale - Società Italiana di Medicina Interna
280. DYNAMIC ASSESSMENT OF THE STANDARD ORAL
GLUCOSE TOLERANCE TEST THROUGH CALCULATION
OF THE PERCENTAGE GLYCEMIC INCREMENT AT 120
MIN (PG%): A NOVEL INTERPRETATION OF NORMAL
GLUCOSE TOLERANCE
Merlotti E. 1, Carnevale Schianca G.P. 2, Momo E. 1, Rossini A. 1, Celasco M. 1,
Fra G.P. 2, Brustia F. 1, Pirisi M. 1
1
Dipartimento di Medicina Traslazionale, Università del Piemonte
Orientale, Novara, 2SCDU Medicina Interna 1, Azienda Ospedaliero-
Universitaria “Maggiore della Carità”, Novara
Rationale and Aim: It is conceivable that subjects with more efficient
glucose utilization at a certain time point in their life will show lower risk
of progression to prediabetes and diabetes along the years. Based on this
hypothesis, we studied subjects who at a baseline standard oral glucose
tolerance test (OGTT) had normal glucose tolerance (NGT) by repeating
the OGTT at the end of follow-up. Our aim was to define the value of the
percentage increment of the 2-hour plasma glucose with respect to fasting
plasma glucose (PG%) as a predictor of future abnormalities of glucose
metabolism.
Methods: The study population included 353 subjects, 131 males (37.1%)
median age 53 years. For each subject, age, body mass index (BMI), waist
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)
and disposition index (DI) were recorded at baseline. Factors associated
with persistence of the NGT status over time were identified at univariate
and multivariate time-to-event analysis, along an average follow up that
lasted 12 years (min 1 years, max 12 years).
Results: At baseline, 226 (64.1%) subjects had a PG% < 20 (Group A) and
127 (35.9%) a PG% ≥ 20 (Group B). Subjects belonging to Group B differed
from subjects in Group A with regard to age (52 years vs. 55 years, p<0.02),
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
2.3, p<0.001), BMI (25.6 Kg/h2 vs 27.6 Kg/h2, p<0.05), EISI (10.4 vs 7.9,
p<0.0001), DI (8.9 vs 8.2, p<0.0001), PG% (-2.2% vs 32.3%, p<0.0001),
HbA1c (5.4% vs 5.5%, p<0.001). There was a strong linear correlation
between PG% and HOMA (r= 0.18, p <0.01), EISI (r= -0.88, p<0.001) and
DI (r= -0.45, p<0.0001). Group B subjects were less likely to remain in the
NGT state along time (p<0.0001). Finally, in a Cox proportional hazards
model in which the outcome variable was loss of NGT status and the predi-
ctive variables were age, PG%, familiarity with DM, BMI, CV, HbA1c, the
two only independent predictors were age and PG% (respectively OR 2.41,
IC95% 1.32-4.4, OR 4.53, IC95% 2.65-7.74).
Conclusions: At an OGTT, the closer the 2-hour plasma glucose is to
fasting plasma glucose, the higher is insulin sensitivity and the lower is
insulin secretion. The PG% is a simplie and economic tool and promises to
expand prognostic power of the OGTT into the NGT range, not only as a
surrogate index of β cell function but, more importantly, as a predictor of
the ability to remain in the NGT state over time.
281. ASSOCIATION BETWEEN PHOSPHATASE AND
TENSIN HOMOLOGUE (PTEN) EXPRESSION, GLUCOSE
CONTROL AND CALORIES SUPPLEMENTED IN
CRITICALLY ILL PATIENTS
Molfino A. 1, Amabile M.I. 1, Alessandri F. 2, Farcomeni A. 3,
Dell’Utri D. 2, Mosillo P. 4, Rossi Fanelli F. 1, Muscaritoli M. 1,
Laviano A. 1
1
Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
2
Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and
Geriatric Sciences, Sapienza University of Rome, Rome, Italy 3Department of
Public Health and Infectious Diseases, Sapienza University of Rome, Rome,
Italy 4Department of Physiology and Pharmacology “Vittorio Erspamer”,
Sapienza University of Rome, Rome, Italy
Background and Aim: Phosphatase and tensin homologue (PTEN) reduces
insulin sensitivity and its expression increases during sepsis. Considering
that critically ill patients present insulin resistance, we investigated the role
of PTEN expression on glucose control and clinical outcome(s) in patients
hospitalized in an intensive care unit (ICU) receiving artificial nutrition.
Patients and Methods: This was an observational, single-center study
recruiting adult patients hospitalized in ICU for trauma. Plasma glucose
Poster
levels and its variability were recorded in these patients. PTEN expression
via western blotting analysis was measured and the associations between
PTEN, plasma glucose levels and glycemic variability were investigated, as
well as between PTEN and calories administered. Parametric and non-pa-
rametric tests were performed, as appropriate, and P <0.05 was considered
statistically significant.
Results: Twenty patients (13 men, mean age of 37.3 ± 12.7 years) were
considered. No correlation between plasma glucose and PTEN was docu-
mented (r= -0.15, P= 0.55), neither between glycemic variability and PTEN
expression (r= -0.00, P= 0.99). However, total kcal/day administered and
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
with PTEN above the median (P=0.048). This association was more pro-
nounced when adjusted for body weight (P= 0.03) and for the average of
insulin daily administered (P= 0.02).
Conclusions: PTEN expression might contribute to glucose homeostasis
and disposal in critically ill patients receiving artificial nutrition.
Essential References:
NICE-SUGAR Study Investigators. N Engl J Med2009
Grinder-Hansen L, et al. Diabetes Metab2016
Laviano A, et al. Nat Rev Endocrinol2010
Stles BL, et al. Mol Cell Biol2006
Van den Berghe G, et al. N Engl J Med2006
282. DIABETIC KETOACIDOSIS DURING SGLT2
INHIBITORS TREATMENT
Nardella E. 1, D’Addio S. 1, De Vito F. 1, Soldato M. 1, Caramazza D. 2,
Pedone Anchora L. 2, Gallucci V. 2, Bartoccioni E. 3, Pitocco D. 1, Manna R. 1
1
Area Medicina d‘Urgenza e Medicina Interna; 2 Area Salute della Donna; 3
Area Diagnostica di Laboratorio e Malattie Infettive Fondazione Policlinico
Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Roma
A 57-year-old woman was admitted for an elective laparoscopic sacrocol-
popexy because of genitourinary prolapse recurrence. The patient had a
10-year history of diabetes mellitus, diagnosed as type 2 (T2DM), although
she had never been overweight. She had also hypertension, Hashimoto’s
thyroiditis, and vitiligo developed in the last two years. Medications inclu-
ded levothyroxine, bisoprolol, cilazapril/hydrochlorothiazide and simvasta-
tin. Diabetes had been initially treated with metformin associated to short
and long acting insulins. Because of hypoglycaemic crisis she discontinued
insulin aspart. Two months before admission empagliflozin was added and
she followed a carbohydrate-restricted diet with weight loss, good glycaemic
control and reduction of insulin glargine need. At admission, the body mass
index (BMI) was 21.2 kg/m2. On the third postoperative day, the patient
suddenly developed shortness of breath, epigastric pain and nausea without
vomiting. On examination, she was upset but conscious, afebrile, normoten-
sive, with marked Kussmaul breathing. An electrocardiogram showed sinus
tachycardia. Blood gas analysis revealed severe metabolic acidosis with a
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.
There were no physical or laboratory findings of infection and renal fun-
ction was normal. In the setting of recent abdominal surgery, the hypocap-
nia could suggest pulmonary embolism, although the patient wasn’t hypoxic
and oxygen saturation was normal. Indeed, a chest computed tomography
scan was negative. Therefore, a diagnosis of diabetic ketoacidosis (DKA)
with only minor hyperglycaemia was established and standard treatment
was initiated with intravenous insulin, fluids and bicarbonate obtaining
clinical and laboratory improvement. In this patient, despite previous dia-
gnosis of T2DM, the history of autoimmune diseases and the presence of
a normal BMI suggested a latent autoimmune diabetes of adults (LADA).
Indeed, laboratory studies revealed antiglutamic acid decarboxylase auto-
antibodies (> 200 IU/ml) and undetectable C peptide levels. At discharge,
empagliflozin and metformin were discontinued and the patient was swi-
tched to insulin therapy, and she is in good clinical condition with good
glycaemia control. In May 2015, the Food and Drug Administration (FDA)
issued a drug safety communication which reported that Sodium-glucose
cotransporter 2 (SGLT-2) inhibitors may lead to DKA also without a sub-
stantial increase in blood glucose levels [1]. These drugs decrease plasma
glucose by blocking the reabsorption of glucose at the proximal tubule [2].
Factors associated with DKA development include low insulin-producing
capacity in the pancreas, a sudden drop in a patient’s insulin dose, increased
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
Poster
with LADA may be misdiagnosed as T2DM. This would lead to insufficient
insulin levels specially in stress condition. Moreover in our present case, the
weight reduction could suggest a β-cell mass loss and in this setting a surgery,
during empagliflozin treatment, has been a trigger of DKA. European Medi-
cines Agency (EMA) recommended temporarily stopping SGLT2 inhibitors
in patients who are undergoing major surgery or are in hospital due to serious
illness. In conclusion, SGLT-2 might be safely used in patients with T2DM
who have endogenous insulin production. In conditions where there is little
or no insulin production such as T1DM, LADA, pancreatitis, we should con-
sider the development of complications [4]. Thus, it is essential to establish a
correct diagnosis of the diabetes type: a LADA misdiagnosed may be a terri-
ble mistake for patients, because SGLT-2 inhibitors treatment without insulin
introduction could increase the risk of ketoacidosis.
1. FDA Drug Safety Communication. FDA warns that SGLT2 inhibitors for
diabetes may result in a serious condition of too much acid in the blood.
May 15, 2015
2. Tahrani AA, Barnett AH, Bailey CJ. SGLT inhibitors in management of
diabetes. Lancet Diabetes Endocrinol 2013;1:140-51.
3. EMA European Medicines Agency. EMA confirms recommendations to
minimise ketoacidosis risk with SGLT2 inhibitors for diabetes. February 25,
2016
4. Clement M, Senior P. Euglycemic diabetic ketoacidosis with canagliflozin:
Not-so-sweet but avoidable complication of sodium-glucose cotranspor-
ter-2 inhibitor use. Canadian Family Physician. 2016;62(9):725-728
283. A RESIDUAL, YET SIGNIFICANT, RISK
Cecchini M., Panizon E., Vinci P.A., Biolo G.
Clinica Medica, Dipartimento di Medicina, Ospedale di Cattinara, Azienda
Sanitaria Universitaria integrata di TS.
In a 73 years old woman, affected by heterozygous familial hyperchole-
sterolemia, hypertension and severe peripheral artery disease (stenting of
the right internal carotid artery, endarterectomy of the left internal carotid
artery and percutaneous-trans-catheter angioplasty of both iliac arteries),
Lipoprotein (a) level was tested and found to be elevated (139 mg/dL).
At the beginning of statin treatment (in 2009) she developed statin-related
myopathy (CK level > 1000 U/L). She was therefore treated with ezetimibe
with unsatisfactory results. We therefore initiated bimonthly treatment
with with LDL apheresis. In March 2016 she has begun treatment with a
novel PCSK9 inhibitor, evolocumab 140 mg/14 days. An optimal LDL
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-
sclerotic disease, despite an optimized control of LDL cholesterol, i.e., 36, 8
mg/dL. The patient was then re-evaluated for residual cardiovascular risk.
Blood pressure was well controlled, homocysteine, glucose and C-reactive
protein levels were normal. The patient had normal body weigh and did
not smoke. We therefore decided to reevaluate Lp(a) levels (137 mg/dL)
which appeared not have been affected by evolocumab. It is well known
that Lp(a) greatly increases cardiovascular risk, however there is not clear
consensus about Lp(a) lowering strategies. LDL apheresis is the only pro-
cedure that has been demonstrated effective in decreasing Lp(a). However,
this technique is only available for a very limited number of patients. In
case of increased Lp(a), current clinical guidelines usually recommend to
optimize control of LDL cholesterol. New PCSK9 inhibitors are considered
promising tools to achieve such goal. [J Thorac Dis. 2017 Jan;9(1):E78-E82.
Doi: 10.21037/jtd.2017.01.40].
In our patients, guideline suggestion was not effective in preventing progres-
sion of atherosclerosis despite the very low LDL cholesterol level achieved
during evolocumab administration. Thus, despite very low LDL-choleste-
rol, given the high Lp(a) levels associated with atherosclerosis progression,
we decided to resume LDL-apheresis aimed at reducing Lp(a) [Curr Opin
Lipidol 2016 Aug;27(4):351-8. Doi:10.1097/MOL.0000000000000319].
After LDL-apheresis, Lp(a) level was decreased to 31 mg/dL.
284. A VERY RARE CAUSE OF RELAPSING
HYPOGLYCAEMIA: THE HIRATA SYNDROME!!!
Piccillo G.A. 1, Saitta R. 1, Mondati E.G.M. 2, Gasbarrini G.B. 3
1
Emergency Department, Cannizzaro Hospital Catania; 2Department of
Internal Medicine and Systemic Pathologies, University of Catania; 3Professor
Emeritus of Internal Medicine, Catholic University of Rome
170
118° Congresso Nazionale - Società Italiana di Medicina Interna
Introduction: Insulin autoimmune syndrome (IAS), first described in 1973
by Hirata, is clinically characterised by recurrent spontaneous postprandial
hypoglycaemia. Serum insulin is extremely high with elevated insulin auto-
antibodies. The disease has a significant genetic predisposition as suggested
by its association with specific HLA class II alleles and it is often associated
with previous exposure to drugs with a sulphydryl group in their chemical
structures. Nowadays there are more than 170 cases reported worldwide the
majority of which are reported in Japan, while the syndrome is very rare in
Caucasian population.
Case Report: A 34-year old Sicilian woman with 6 month history of inter-
mittent, late postprandial diaphoresis, tremors, palpitations, dizziness
and confusion with no headache, nausea nor vomiting, was admitted to
our Emergency Department due to a new episode of severe hypoglycae-
mia. Symptoms had ever improved with sugary drinks and other caloric
intake resulting in weight gain of 5 kg in the last months. Her past medical
history was not meaningful and she had previously taken only medications
for seasonal asthma due to allergy. She denied any history of alcoholism
or drug addiction. At presentation the patient appeared alert and oriented
to person and time and her vital signs were stable. Her blood glucose level
(BGL) was 52 mg/dl and required 50% dextrose to maintain her BGL >70
mg/dl. Serum insulin was >2400 mU/l (normal <27), C-peptide 11.7 nmol/l
(0.4–1.5) and sulphonylurea screening was negative. Initially we suspected
an insulinoma, thus abdominal CT, MRI and PET scan were done in order
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
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-
over we took patient’s blood samples for HLA Class II typing with positive
result. She was treated on fractionated, normocaloric diet (5 meals/day) and
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
symptomatology, with no need of insulin therapy.
Discussion:Mechanism of IAS is that antibodies against insulin binds and
releases insulin asynchronously. Free insulin levels are normal though
bound (total) are high. Luckily, the major part of IAS patients (80%) spon-
taneously remit. The disease is more present in Asiatic populations while
insulinomas are the most prevalent cause of hyperinsulinemic hypoglyca-
emia in Caucasians in whom investigation is focused on localization fol-
lowed by surgery. We wish here to emphasize the importance of differential
diagnosis for hypoglycaemia and the need to measure insulin antibodies in
order to avoid unnecessary surgery.
285. 1-HOUR DURING OGTT INCREASED RISK OF
CARDIOVASCULAR DAMAGE IN OBESE AND NON OBESE
SUBJECTS
Succurro E., Pedace E., Andreozzi F., Miceli S., Bencardino G.,
Sciacqua A., Perticone F., Sesti G.
Dipartimento di Scienze Mediche e Chirurgiche, Università “Magna Graecia”
di Catanzaro, Catanzaro, Italia
Recent studies have suggested that a plasma glucose concentration >155 mg/
dl at 1 hour during OGTT (1h-NGT-high) identifies subjects with a worse
metabolic and cardiovascular risk profile and with increased risk of type
2 diabetes (DM2). However, individuals with1 h post load hyperglycaemia
exhibited higher adiposity as compared with subjects with glucose concen-
tration at 1h <155 mg / dl (1h-NGT-low), Therefore, it is not clear whether
the increased cardiovascular organ damage observed in 1h-NGT-high indi-
viduals is due to increased body weight. To elucidate this issue, we exami-
ned 1680 subjects aged between 20 and 65, participating to the CATAMERI
study, an observational study conducted in a population at risk of DM2 for
the presence of at least one risk factor including family history of DM2,
overweight/obesity, hypertension, dysglycaemia and dyslipidaemia. The
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
carotid arteries, thickness of the interventricular septum (IVS) evaluated by
echocardiogram, and arterial stiffness evaluated by pulse pressure. Accor-
ding to the BMI and the value of the plasma glucose at 1h during OGTT,
subjects were divided into 4 groups: 1) non obese (BMI <27 Kg/m2) with
glucose concentration at 1h <155 mg / dl (1h-NGT-low) (N = 477), 2) non
obese (BMI <27 Kg/m2) with 1h-NGT-high (n = 268), 3) obese (BMI> 30
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
118° Congresso Nazionale - Società Italiana di Medicina Interna
waist circumference (p<0.001), but not BMI (p=ns), systolic (p<0.0001) and
diastolic blood pressure (p=0.003), LDL cholesterol (p=0.02), triglycerides
(p<0.001), HOMA-IR (p<0.0001), fasting plasma glucose (FPG) (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-
ficant increase in pulse pressure (p=0.003), IMT (p<0.001), SIV (p<0.001),
and rate pressure product (p<0.001) compared to 1h-NGT-low. 1h-N-
GT-high non-obese showed a significant increase in BMI (p=0.04), waist
circumference (p=0.006), systolic (p<0.0001) and diastolic blood pressure
(p=0.004), LDL cholesterol (p=0.01), triglycerides (p=0.003), HOMA-IR
(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,
1h-NGT-high non-obese showed a significant increase in pulse pressure
(p<0.0001), IMT (p<0.0001), SIV (p<0.0001) and rate pressure product
(p<0.0001) as compared with 1h-NGT-low non-obese. In a logistic regres-
sion model, 1h-NGT-high obese showed a significantly increased risk of
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,
1h-NGT-high non-obese displayed a significantly increased risk of having
a composite endpoint of cardiovascular organ damage as compared with
1h-NGT-low non-obese (OR 2.084, 95% CI 1.14-3.79, p <0.01). These results
suggest that hyperglycaemia at the first hour during OGTT aggravates the
risk of subclinical organ damage in both obese and non-obese subjects.
286. CHRONIC SUBCLINICAL INFLAMMATION IN META-
BOLICALLY HEALTHY BUT OBESE (MHO) SUBJECTS AND
OBESE INSULIN RESISTANT SUBJECTS
Pedace E., Succurro E., Fiorentino T.V., Andreozzi F., Sesti G.
Dipartimento di Scienze Mediche e Chirurgiche, Università “Magna Graecia”
di Catanzaro, Catanzaro, Italy
Introduction: It is known that chronic subclinical inflamma-
tion is a predictor of type 2 diabetes (T2DM) and cardiovascular
disease (CVD). Among markers of subclinical inflammation, the
most reliable for clinical use is high-sensitivity C-reactive protein
(hsCRP), but other markers, such as erytrocyte sedimentation
rate (ESR), fibrinogen, C3 complement (C3), and white blood
cells (WBC), have been associated with T2DM. A subset of obese
subjects, termed “metabolically healthy but obese” (MHO) indivi-
duals, has been identified to have a favorable cardiovascular risk
profile as compared with insulin-resistant obese (IRO) individuals,
but whether MHO subjects have a worse inflammatory profile
as compared with nonobese normal subjects is not known. Aim:
To evaluate the inflammatory profile in metabolically healthy but
obese (MHO) and in insulin-resistant obese (IRO) as compared
with nonobese normal subjects. Patients and
Methods: The study group consisted of 810 non-diabetic subjects,
with a normal glucose tolerance (fasting plasma glucose <100 mg/
dl and 2-h post-challenge glucose <140 mg/dl), participating to the
CATAnzaro MEtabolic RIsk factors (CATAMERI) Study, an obser-
vational study recruiting individuals at risk of T2DM. All subjects
underwent anthropometrical and biochemical evaluation and 75 g
oral glucose tolerance test (OGTT). The ISI index, derived from the
OGTT, was used to estimate insulin sensitivity. We aimed to quan-
tify the inflammatory state using an Inflammatory Score, generated
by attributing one point for a value greater than the median of the
study sample for each of the five measured inflammation markers
(fibrinogen, ESR, hsCRP, C3, and WBC) and ranged from 1 (lowest
median value for each of the five inflammatory markers) to 6
(highest median value for each of the five inflammatory markers).
Participants were defined as nonobese normal subjects if they had
a BMI<27 Kg/m2 (n = 394) and obese if they had a BMI >30 Kg/
m2 e <45 Kg/m2 (n = 416). According to ISI, the obese subjects
were stratified into quartiles and defined as being MHO if their ISI
was in the upper quartile and IRO if their ISI was in the two lower
quartiles.
Results: MHO subjects exhibited significantly lower triglycerides,
HbA1c, uric acid, FPG, and 2-h glucose and significantly higher
Poster
HDL cholesterol as compared with IRO subjects. MHO subjects
also showed significantly lower ESR, hsPCR, C3, and WBC as com-
pared with IRO subjects (p=0, 005, p<0, 0001, p<0, 0001, p<0, 0001,
respectively). As compared with nonobese normal subjects, MHO
subjects exhibited significantly higher waist circumference, uric
acid, fibrinogen, and C3, and significantly lower HDL cholesterol
and IGF-1, while there were no significant differences between the
other inflammatory and metabolic parameters assessed. In contrast,
IRO subjects showed significantly higher waist circumference, sBP,
dBP, triglycerides, HbA1c, uric acid, FPG, 2-h glucose, and all of
the five inflammatory markers measured and significantly lower
Matsuda index, HDL cholesterol and IGF-1 as compared with
nonobese normal subjects. Subjects were classified in six categories
according to their Inflammation Score. A greater proportion of IRO
(18, 2%) had the highest value of the Inflammation Score compa-
red to nonobese normal subjects (2, 7%; p<0, 0001) and MHO (8,
6%; p=0, 004). In a logistic regression model, both IRO and MHO
subjects showed an increased risk (OR 8, 061, 95% C.I. 3, 967-16,
378; p<0, 0001; and OR 3, 398, 95% C.I. 1, 346-8, 574, p<0, 0061,
respectively) of having the highest value of the Inflammatory Score
as compared with nonobese normal subjects.
Conclusion: Our data indicated that MHO subjects showed a better inflam-
matory risk profile as compared with insulin resistant obese subjects.
287. PERICARDIAL EFFUSION IN ANOREXIA NERVOSA
IS ASSOCIATED WITH LOWER BMI: A RETROSPECTIVE
STUDY
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
1
U.O. Medicina II, 2U.O. Psichiatria, 3U.O. Cardiologia e UTIC, Ospedale
San Paolo, Milano; Università degli Studi di Milano
Background: Anorexia nervosa (AN) is a psychiatric disease that can lead
to many medical complications, including cardiovascular disorders such
as bradycardia, hypotension, arrhythmias and heart failure. Among these
complications, of interest is silent pericardial effusion (PE), especially in
patients with lower BMI: a few publications have reported PE in patients
with AN, but only rare cases of acute life-threatening cardiac tamponade
are described.
Subjects, Methods and Results: We performed a retrospective study to
collect data of AN patients visited in the San Paolo’s Hospital Psychiatric
Unit from January 1, 2015 to May 31, 2017. The data of 138 patients (9
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-
trist and an internist. 42 out of 138 patients were submitted to at least one
transthoracic echocardiogram during the follow-up period. This subgroup
of patients differed from the others for lower BMI (p=0.001), lower WBC
(p=0.02), higher AST and ALT levels (p=0.03 and 0.001 respectively), lower
albumin levels (p=0.03). 19 out of 42 patients (45.2%) showed a mild to
moderate PE (< 2 cm) without hemodynamic impairment, not requiring
intervention. Bradycardia and aspecific abnormalities of repolarization
were seen at ECG of these patients, but in none of them we found abnor-
malities suspected for PE. Patient with PE appeared to be the ones with the
lowest BMI.
Conclusions: This study supports the association between AN and clini-
cally silent PE, which may represent an early sign of cardiovascular involve-
ment. In particular, there is a correlation between PE and BMI: the lower the
BMI, the higher the prevalence of PE.
288. MEDITERRANEAN DIET IN PATIENTS WITH
ACUTE ISCHEMIC STROKE: RELATIONSHIPS BETWEEN
MEDITERRANEAN DIET SCORE, DIAGNOSTIC SUBTYPE,
AND STROKE SEVERITY INDEX
Tuttolomondo A. 1, Casuccio A. 2, Di Raimondo D. 1, Buttà C. 1,
Pecoraro R. 1, Della Corte V. 1, Arnao V. 4, Clemente G. 1, Maida C. 1,
Simonetta I. 1, Miceli G. 1, Cirrincione A. 1, Corpora F. 1, Pinto A. 1
1
Internal Medicine and Cardio-Angiology Ward, Biomedical Department
of Internal and Specialistic Medicine, University of Palermo, Italy. ²Sciences
171
Poster
for Health Promotion and Mother-Child Care Department, University of
Palermo, Italy
Background: The heart-healthy Mediterranean diet (Me-Di)) is a healthy
eating plan based on typical foods and recipes of Mediterranean-style
cooking A recent randomized trial showed that the risk of stroke was
reduced significantly in the two Me-Di groups. This is consistent with epi-
demiologic studies that showed an inverse association between Me-Di and
stroke incidence. Furthermore a recent study sought to assess the longitu-
dinal association between greater adherence to MeD and risk of incident
stroke reporting how adherence to MeD seems to be associated with a
lower risk of incident ischemic stroke. Nevertheless, no study has addres-
sed the association of adherence to a Me-Di in subjects with acute ische-
mic stroke and diagnostic subtype and severity of stroke. Thus we con-
ducted a retrospective study to evaluate the association between Me-Di
adherence evaluated by means of the calculation of Mediterranean Diet
Score (MeDi score) and stroke subtype, severity index, and outcome of
ischemic stroke. Aim: The primary outcome in this study was to evaluate
differences in mean Me-Di score between patients with acute ischemic
stroke and subjects without acute ischemic stroke. Secondary outcomes
were: evaluation of a relationship between TOAST subtypes of ischemic
stroke and mean Me-Di score, and between severity index of acute ische-
mic stroke and mean Me-Di score. Methods: The type of acute ischemic
stroke was classified according to the TOAST criteria. All patients admit-
ted to our ward with acute ischemic stroke completed a 137-item vali-
dated food-frequency questionnaire adapted to the Sicilian population.
A scale indicating the degree of adherence to the traditional Mediter-
ranean diet was used (Me-Di score: range 0-9). All patients admitted to
our ward with acute ischemic stroke (or their relatives) completed a 137-
item validated food-frequency questionnaire (17) adapted to the Sicilian
population. A scale indicating the degree of adherence to the traditional
Mediterranean diet was constructed by Trichopoulou et al.. A value of 0
or 1 was assigned to each of nine indicated components with the use of
the sex-specific median as the cutoff. For beneficial components (vege-
tables, legumes, fruits, nuts, cereal, and fish), individuals whose consu-
mption was below the median were assigned a value of 0, and individuals
whose consumption was at or above the median were assigned a value
of 1. For components presumed to be detrimental (meat, poultry, dairy
products), individuals whose consumption was below the median were
assigned a value of 1, and individuals whose consumption was at or above
the median were assigned a value of 0. Results: 198 subjects with acute
ischemic stroke the stroke subjects had a lower mean Mediterranean diet
score compared to 100 controls without stroke. We observed a signifi-
cant positive correlation between Me-Di score and SSS score, whereas we
observed a negative relationship between Me-Di score and NIHSS and
Rankin scores. Subjects with atherosclerotic (LAAS) stroke subtype had a
lower mean Me-Di score compared to subjects with other subtypes.Multi-
nomial logistic regression analysis in the simple model showed a negative
relationship between Me-Di score and LAAS subtype vs. lacunar subtype
(OR=2.226 CI95%; 1.66-2.98; P=<0.0005) and LAAS vs. cardio-embolic
subtype (OR: 2.180 CI95%: 1.68-2.83; P<0.0005). Multivariable regression
model conducted by evaluation of all different variables even not signifi-
cant, between TOAST subgroups such as NIHSS score, SSS score, AF and
diabetes, LAAS subtype vs. lacunar subtype maintained a significant nega-
tive relations with MeDi score (and the same relationship was maintained
also for LAAS vs. cardio-embolic subtype and Me-Di score By means of
ROC curve analysis we found good sensitivity and specificity of mean
MeDi score to predict ischemic stroke subtype, in the case of lacunar vs.
LAAS (AUC=0.829).
Conclusions: Our study shows that low adherence to a Mediterranean
diet is associated with higher stroke prevalence, with LAAS stroke subtype
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
risk profile linked to a low adherence to a Mediterranean Diet style. Thus
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
atherosclerotic events such as atherosclerotic strokes. However, patients
with acute ischemic stroke and lower adherence to Me-Di could be cha-
racterized by a higher inflammatory background with higher immune-in-
flammatory responses after acute ischemic stroke more likely to be athe-
rosclerotic. This interpretation, although biologically plausible, needs to
be confirmed by further studies aimed at evaluating different degrees of
immune-inflammatory activation of the acute post-stroke phase in rela-
tion to different nutritional profiles with particular attention to adherence
to a Me-Di diet.
172
118° Congresso Nazionale - Società Italiana di Medicina Interna
289. A CASE OF ACARBOSE-INDUCED ACUTE
HEPATOTOXICITY IN A YOUNG WOMAN AFFECTED
BY LATENT AUTOIMMUNE DIABETES OF THE ADULTS
(LADA)
Valvo B., Lovati E., Lucotti P., Corazza G.R.
First Department of Medicine, Scientific Institute St. Matteo Hospital,
University of Pavia, Pavia
Introduction: Acarbose is an oligosaccharide obtained from fermentation
of Actinoplanes utahensis which acts as an alpha-glucosidase inhibitor,
resulting in delayed carbohydrates digestion and thus in lower post-pran-
dial glucose blood concentration. It is a useful therapy in the management
of type 2 diabetes and can be sometimes adopted as an adjunctive therapy
on the top of insulin in type 1 diabetic patients. Its most common side
effect is bowel discomfort due to carbohydrate malabsorption so that acar-
bose is contraindicated in patients with chronic entheropathies as well as
in renal failure and cirrhosis. Acarbose is known to be associated with a
statistically significant dose-dependent risk (OR 6.86, 95%, CI 2.50-18.80)
in asympothomatic transaminase increase (over three-fold the upper limit
of normal) as reported in a recent meta-analysis (Zhang et al. 2016) inve-
stigating alpha glucosidase inhibitors-associated hepatotoxicity in type-2
diabetes. Acarbose-induced liver injury is generally mild and self-limited
after drug withdrawal but few sporadic cases of acute hepatotoxicity asso-
ciated with acarbose treatment have been described (Hsiao et al. 2006).
Case Report: A 27-year-old woman presented to our outpatient clinic in
November 2016. She was diagnosed with Latent Autoimmune Diabetes
of the Adults (LADA) and was treated with long acting insulin (detemir
0.2 UI/Kg) at bedtime. Due to inadequate postprandial glycemic control,
albeit mild, acarbose (50 mg two times daily) was added to the treatment
in February 2017. Two months later she developed progressive asthenia,
nausea and abdominal discomfort. Physical examination was unremar-
kable, apart from hepatomegaly. Laboratory examination revealed high
aminotransferases (AST 545 mU/ml and ALT 703 mU/ml; upper refe-
rence values 39 e 34 respectively) and cholestasis indices (GGT 425 mU/
ml, and ALP 179 mU/ml; upper reference values 53 e 150 respectively),
with mild increase in total bilirubin. Results of serological tests for viral
infections hepatitis were negative and biliary obstructions were excluded
by abdominal ultrasound. In suspicion of a drug-induced hepatotoxicity,
acarbose treatment was promptly discontinued and patient was admit-
ted to hospital. Workup for acute hepatitis did not reveal any underlying
infectious or autoimmune process and patient’s symptoms resolved as
her transaminases improved by discontinuation of acarbose. Serum liver
enzymes concentrations were within the normal range six weeks after
acarbose was stopped.
Discussion:In the present case, temporal relation between acarbose tre-
atment initiation and liver damage onset, in addition to the complete
recovery following drug withdrawal, make the acarbose-induced hepato-
toxicity a reliable diagnosis. According to the Italian Pharmacovigilance
Drug Agency, from January 2001 to June 2017 only six cases of hepatobi-
liar adverse events related to acarbose therapy have been reported (which
account for 5.7% of all acarbose-related reports), including five acute
hepatitis (two of which defined as cholestatic), one case of hypertransa-
minasemia and one unspecified drug-induced hepatic injury. The cause
of liver injury during acarbose treatment is not known. An immunologi-
cal reaction to this bacterially derived oligosaccharide molecule has been
supposed as an etiopathogenic mechanism since it is minimally absorbed
from the intestine. Although rare, the eventuality of a severe acarbose-in-
duced hepatotoxicity must be considered, so that monitoring of serum
liver enzymes during acarbose treatment may be careful to prevent this
unpredictable but potentially fatal complication.
290. CHANGING TRENDS IN SERUM 25-OH-VITAMIN D
LEVELS, YEARS 2005-2016, IN PADOVA (ITALY)
A. Amabile, S. Sella, M. Zaninotto, A. Michielin, D. Braghin,
M. Fusaro, A. Aghi, F. Fabris, M. Plebani, S. Giannini
Department of Medicine-DIMED, University of Padova, Italy
Background: It is well-known that hypovitaminosis D is very common in
the general population. In the elderly, this condition is far more frequent
and associated with remarkable skeletal morbidity, such as increased risk
of fragility fractures and falls. In the past, its prevalence has been found
to be very high in Italy. However, no recent studies have been carried out
to evaluate whether trends in serum vitamin D levels are changing over
118° Congresso Nazionale - Società Italiana di Medicina Interna
time in our Country. Objective: The purpose of this study was to evaluate
the possible changes over time in 25-OH-vitamin D serum levels in the
population of Padova, Italy, years 2005 to 2016.
Methods: Subjects were included in the study if they were males or
females, aged 1-100 years and had at least one determination of serum
25-OH-vitamin D at the Unit of Laboratory Medicine, University Hospital
of Padova, Italy, over the period January 1st, 2005 to December 31st, 2016.
114, 492 patients were included in the study, 65.4% female with median
age 64 (52, 74); 34.6% male with median age 53 (35, 69). Data were also
analyzed according to the following categories: year of assay, gender,
cohorts of age (0-18, 18-49, 50-59, 60-69, 70-79, 80-89, 90+), vitamin D
status (deficiency <30 nmol/L; insufficiency: 30-75 nmol/L; sufficiency: >
75 nmol/L).
Results: The table below shows the median values of serum vitamin levels
D per year in the whole population sample during the period considered.
Serum 25-OH-vitamin D levels significantly increased over time. When
divided by gender, median levels of vitamin D were higher in females (i.e.
in year 2016: F 78 (56-100) nmol/L vs M 65 (43-87) nmol/L, p<0, 001).
Females were also less frequently deficient (i.e. in 2016: F 20% vs M 31%,
p<0.001) and more frequently sufficient (i.e. in 2016: F 54% vs M 39%,
p<0.001) than males. A more evident improvement in vitamin D levels
was observed in older subjects (i.e. 80-89 yrs: 32 (17-56) nmol/L in 2005,
56 (24-84) nmol/L in 2010 and 76 (48-99) nmol/L in 2016, p<0.001). A
similar trend, although less important, was observed in young cohorts
(0-18 yy: 55 (35-92) nmol/L in 2005, 63 (40-91) nmol/L in 2010 and 69
(50-91) nmol/L in 2016, p<0.001). At the same time, the prevalence of
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,
37% in 2010 and 24% in 2016, p<0.001).
Conclusions: This study demonstrates a significant improvement over time
in serum vitamin D levels in a large population sample, particularly evident
in the elderly. Further studies aimed to assess the true current prevalence of
low serum vitamin D levels are warranted.
Variable 2005 2006 2007 2008 2009
Vitamin D (nmol/l)  44(29,67)  39(25,59  45(27,67) 56(34,80) 62(36,86)
2011 2012 2013 2014 2015
Vitamin D (nmol/l) 64(39,89) 61(40,81) 64(42,85) 63(40,84) 63(41,85)
291. CHYLOTHORAX: A CASE OF PLEURAL EFFUSION IN
A PATIENT WITH SARCOIDOSIS
Calcagno E., Alesini M., Tozzetti C., Poggesi L.
Dipartimento DAI emergenza ed accettazione, Degenza Medicina C, AOU
Careggi Firenze
We describe a case of a 76 years-old-woman with a previous histological
diagnosis of sarcoidosis (with pulmonary, cutaneous and adrenal involve-
ment) in remission at last follow-up on February 2017, who acceded to our
emergency department (ED) because of worsening dyspnea and onset of
peripheral oedema. Her medical history was remarkable for atrial fibrilla-
tion, severe smoke exposure, COPD and pulmonary thromboembolism,
therefore her home therapy was corticosteroids, diuretics and vitamin K
antagonist. Blood tests showed NT-proBNP 19.398 pg/mL, creatinine 1.56
mg/dL, sodium 127 mEq/L, procalcitonin 0.14 ng/dL, normal WBC. The
arterial blood gas showed type II respiratory failure. The echocardiogram
highlighted a right heart enlargement and a severe pulmonary hyperten-
sion (sPAP 65 mmHg) with a normal left ejection fraction (EF 60%). A CT
pulmonary angiography excluded acute thromboembolism, revealing the
presence of bilateral pleural effusion greater in the right side (75 mm) with
underlying atelectasis of the parenchyma; moreover there was evidence of
sarcoidotic lung parenchymal involvement, stable in comparison to the last
chest CT, and a little increase in mediastinal lynphoadenopathy dimension
(ilar, pre- and para-tracheal).Suspecting right heart failure in a patient with
chronic pulmonary heart disease related to COPD, parenchimal sarcoidosis
and history of pulmonary thromboembolism, she was treated with conti-
nuous furosemide infusion and bi-level positive airway pressure (BiPAP)
non-invasive ventilation. Despite of an initial consistent diuretic response,
there was neither any improvement in pleural effusion extent (echografically
evaluated), nor in respiratory dynamic. Therefore, a diagnostic thoracente-
sis was performed and 1000 mL of milky fluid were drained. Pleural fluid
analysis showed 1.309 mg/dL triglycerides, 79 mg/dL cholesterol, 186 g/L
glucose, 123 U/L LDH, 38 g/L proteins and numerous mature lymphocytes
without morphological alterations. Any bacterial growth (including M.
Poster
tubercolosis) was revealed and cytologic analysis was normal. Blood exams
showed lymphopenia (lymphocytes: 330/mm3) and a chitotriosidase level
lower than a previous check (116.2 U/L Vs 400 U/L, the sample was with-
drawn during corticosteroids therapy). Excluding other possible etiologies,
we diagnosed chylothorax in sarcoidosis. A conservative management was
choosen, so a fat-free diet with medium chain triglyceride oil and high-dose
methylprednisolone therapy were started; besides, a pleural pigtail catheter
was inserted with daily gradual reduction of chyle drainage. Nevertheless,
due to overlapping of infective complications, in particular toxic megacolon
induced by Clostridium difficile and fungal pneumonia, the patient died in
Intensive Care Unit. Chilothorax is a collection of chyle (fluid consisting of
lymph and fats, especially triglicerides, coming from the small intestine)
in the pleural cavity, due to a damage (destruction or obstruction) of the
thoracic duct. It could be traumatic (54, 8%), sub-classified as iatrogenic
and non-iatrogenic, or not traumatic (38, 1%), including malignancy (lym-
phoma, lung cancer, luekemia, stomach cancer), tubercolosis, amyloidosis,
thyroid goitre, superior vena cava thrombosis, benign tumor, sarcoidosis,
diseases of the lymph vessels and congenital duct abnormalities; a small
amount of cases remains of unknown etiology (10-15%). Nevertheless its
rarity, chylothorax has an extreme clinical relevance because of the high
mortality associated (75%), related to malnutrition, immunosoppression
and hemodynamic involvement. In literature the association between
chylothorax and sarcoidosis is rarely reported (we found only 5 cases in
MEDLINE): in all cases, there was a mediastinal adenopathic involve-
ment of the sarcoidotic disease (chronic or recrudescent) and a right-sided
chylothorax.
292. A BRIEF HISTORY OF BIOETHICS
Carini L. 1, Cantarano M.S., Cantarano M., Cantarano E.
1
Facolta’ Medicina E. Farmacia - Universita’ Roma “Sapienza”
Bioethics is characterized by a strong anthropological pluralism that pits
2010
the various different nodes ethical reasons and solutions. There could be no
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-
sance” of practical philosophy determined by the progress of technology
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
essential moment for the practice of the doctor, however, we are witnes-
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
of Bioethics, highlighting the rational formation and main objectives. The
birth of bioethics has its ideological roots in the ruins of World War II. The
tragedy of global proportions, and the horrendous crimes, to which man
had come, stimulated consciences to a deep reflection, in an attempt to
establish the boundaries of ethics and behavior, that they applied for every
man and in every historical moment. Multiply and become more pressing,
from that moment forward, the declarations of various international organi-
zations setting forth the statutory rights of every man. Simultaneously with
this type lodging “legal” was born a philosophical reflection aims to justify
the rationality and ethics of established propositions.
It is not enough, in fact, state the human rights by the will of the majority,
but it is necessary to justify them with philosophical investigation: in other
words, is not enough to affirm the right to life, but we need the “philosophy”
of the right to life. The tumultuous development of medicine and, in a wider
overview, scientific discoveries, have given man a potential ability to change
the life of the planet and cause the destruction of his own kind. Such situa-
tions have heightened the need for ethics in the biomedical field, based on
reason and the objective value of life and of the person. In the Catholic
Church Pope Pius XII gives a decisive impulse to the rapid development
of a medical moral able to deal with new ethical problems that arise in the
practice of medicine. The moral proposed by the Pope’ solutions have often
found acceptance even beyond the ecclesial boundaries, contributing to the
achievement of a world cultural situation that deepens the action of man by
man problems in the biomedical field. It must therefore be Bioethics: term
coined by Van Resselaer Potter in 1970.
Potter pointed out that in the past ethics, understood as a reflection on
human values and ideals of human characteristics, he had been conside-
red one of the humanities sector, destined to pass, for the most part, within
philosophical disputes. The development achieved by biotechnology now
required to release the ethics from the beautiful but barren theoretical isola-
tion, to combine it with the reality and practice of biological fact. Bioethics,
in the idea of its founder, therefore, is an attempt to heal the separation
173
Poster
between natural science (biology) and spiritual science (ethics), in outlining
a future livable for humans and draw a “bridge to the future”.
If this is bioethics according Potter must be added that the “movement” bio-
ethical even born before him. In the second half of the 60s some US scholars
deepen the ethical issues of abortion and the sanctity of life, contributing
greatly to the medical del’etica rebirth.
In 1969 D. Callahan co-founded the first center the first Institute for Society,
Ethics and the Life Sciences in Hastingson-Hudson. It is proposed, beyond
any ideology and religion, to face and provide a solution to the ethical issues
raised by the new achievements in the biomedical field and is characterized
by the strong political-pedagogical purpose.
In 1971 he established the The Kennedy Institute of Ethics at Georgetown
University in Washington which aims to promote a concept of bioethics,
understood as “moral anthropology” based on research of what is univer-
sally human, and led research in the Encyclopedia of Bioethics, published in
1978: the most comprehensive and authoritative tool for those dealing with
bioethical issues.
Since then this “discipline” was introduced in the new University. It was
established in 1985 in Italy the first Chair of Bioethics at the Faculty of
Medicine of the Catholic University of Rome. The authoritative Encyclo-
pedia of Bioethics, New York in 1978, defines bioethics as “the systematic
study of human conduct in the life sciences and health care, as this conduct
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.
It is therefore rational elaboration regarding the ethical aspect (the lawful
and non-lawful) in the vast and important field of medical sciences.
293. CONSIDERATION OF PAIN
Carini L. 1, Cantarano M.S., Cantarano M., Cantarano E. 1
Facolta’ Madicina E. Farmacia - Universita’ Roma “Sapienza”
Epiphenomenon of the disease is, in general, suffering or pain.
This, like any other sensation, has, first and foremost, a physical, bodily con-
notation as a perceived alarm signal directly without cognitive mediation of
memories, words or representations. We share it with all living beings. But
it can also appear as a psychic suffering with all those consciousness and
unconscious that the psyche itself constitutes.
This pain does not affect other animals, but only the upper mammals. It has
a motivational dimension - affective and affects previous experiences. Both
the first type and the second, are experiences that tend to close themselves,
activate all systems to repair the damage or injury and escape them as soon
as possible to ensure survival. There is then the “mental” pain that embraces
the past, lives in the present and projects itself in the future. It is experienced
in a cognitive dimension - evaluative dependent on the personal and cultu-
ral evolution of the person who lives it.
It is the exclusive experience of Man as a dimension of his existence rather
than his survival and does not exhaust his function by repairing the damage
but leads to the opening to the other, to growth, to maturity. It assumes a
high symbolic value as a sign of a profound and personal experience. The
questions about pain characterize every man’s life of inevitable crossroads.
These questions are strictly personal as the answers: every man will put it,
until the end of human history, seeking an answer that will always be his
answer! The boundaries of pain have a personal nature. When we come
in contact with the suffering of another, we can do it only as this affects
our existence, hurt our sensitivity, interprets our intelligence, and evokes
unconscious resonances. The different “levels” of pain and the reciprocal
interactions between them make possible epiphenomenon, otherwise
incomprehensible, associated with the uniqueness and unrepeatability of
the human being’s personality: do not experience suffering from bodily
injuries or, on the contrary, suffer from Intensely for unrealistic stimuli or
transforming atrocious physical pain into a testimony of altruistic love, ... It
remains, however, certain that no matter how much empathy, no one can
suffer in the place of another, at most it can suffer near (rapport or mirro-
ring) to a Another, by means of an ad - ation, a competent assistant. Pain,
in fact, being one of the most universal forms of “communication” has a
feature that makes it not perfectly integrable in the 5 axioms of the Human
Communication of the School of Palo Alto (California): while having an
analogous syntax is devoid of Grammar ie alphanumeric connotations that
would make “transmission” and “understanding” easy. Moreover, suffering
is conditioned by his own idea of suffering and the latter is the debtor of the
cultural experience of his time and environment.
For those who are in charge of assistance understanding the bond that a
man has with his pain is more relevant than not knowing which physiologi-
174
118° Congresso Nazionale - Società Italiana di Medicina Interna
cal and pathological dynamics are underlying it. This understanding refers
to human skills far more than to those, albeit relevant, technical-scientific.
It is at first that reference should be made, in the light of the second, to
attempt to clarify the mysterious questions raised by pain and its meaning,
to give them a sense and try to give an answer. The patient seeks and urges
the person who cares for him, who is, therefore, called to work with the
sick, responsibly, with competence and personal suffering, a motivation and
a meaning. The answer must be outlined on several “systemically” related
plans: intellectual, psychological and metaphysical, to the extent that it
develops, subtle and corroding, feelings of anguish and fear of abandonment
and negation of assistance until the “desire of death” Pain, but fear! Fear is a
“simple” or “primary” emotion pervasive, perhaps the most pervasive in the
world. It relates to the body and its precariousness, but it generates, for this
reason, “resilience” rather than “resistance”. It is a powerful driving force in
human history. The fear of death is a constant presence in history, so that
for some, it would be at the center of every fear! However, it would not be
universal and invincible since it is dominated by other emotions and values
and has always been.
The nature of the fear of death changed over the centuries.
Religious myths, which terrorized believers with the threat of the most
horrid punishments after death, have been supplanted by other less mislea-
ding myths, including that of the “immortality” promised by science!
294. THE “PIES” OF FLORENCE NIGHTINGALE
Carini L. 1, Cantarano M.S., Cantarano M., Cantarano E. 1
Facolta’ Medicina E. Farmacia - Universita’ Roma “Sapienza”
A good and innovative recipe for health statistics: the “pies” of Florence
Nightingale.
As we know, the Crimean War, at that time called the East War, was a con-
flict fought from 4 October 1853 to 1 February 1856 between the Russian
Empire and an alliance of Ottoman Empire, France, England and the
Kingdom of Sardinia. The dramatic conditions of abandoning the wounded
and sick British (for the French there were the Sisters of Charity and for the
Russians the 300 Nurses “Sisters of the Exaltation of the Cross” by Grand
Duchess Elena Pavlovna born Carlotta of Wurttemberg) during the war
operations.
Quoted on the Times as the first war reporter, prompted the British gover-
nment to intervene under the rapidly growing pressures of public opinion
that had always been very much heard and powerful.
There was no pre-established Organization that was up to the task in an
area, among other things, very impervious and unhealthy. At the end
Angel Band was sent: 38 nurses at F. Nightingale’s orders. Nightingale was
English, born in Italy, and had two possible solutions to face the difficult
task of “Latin” and “Teutonic”. The first epiphenomenon of Roman Catholic
anthropology provided a “human” preparation, perhaps, but certainly not
“professional”. The nurse, humble and submissive to the physician, could
not have any autonomous or responsible role! The second, as an expression
of “reformed” anthropology, provided for a theoretical - practical training
that would make the nurse a true “care manager” ante litteram! Florence
made his choice and went to study in Germany at the Kaiserwerth School
of Nursing Diacones founded in 1836. On her return, she was facing the
difficult problem of choosing her women to be employed in field care. She
did not want either “prettiest prostitutes or volunteer ladies”! All of them
had to be nurses! “By unanimous consent (except that of military com-
mands that will oppose them fiercely, struggling, according to their usual
traditions, even against the evidence!). The action of nurses on the field was
resolved even for the Conducting war operations! One of the lucid insights
of Nightingale led her to document, for the first time in the history of health
care, statistically, mathematically, the positive and negative results of various
activities and welfare techniques. Through the elaboration of pie charts, a
method widely used in descriptive statistics for graphical representations
of quantitative variables measured on categories of classes in order to avoid
establishing, even involuntarily, an order that does not exist in the catego-
ries themselves, Nightingale provided. Especially to the unbelievers and
the opponents, absolutely incontrovertible data that, beyond all reasonable
doubt, demonstrated the objective results of his / her welfare activities!
The general health conditions of sick and / or injured soldiers improved
and dropped mortality for infections from 42.7% to 2, 2% in 6 months, and
psychological support was offered to all. On her return was celebrated as a
heroine, she and her mission inspired a sentimental literature to cover the
hardness of working reality. Funds, fame and prestige allowed him to set
up a school despite the strong opposition from the medical class. Through
the application of statistics and appropriate field research, he worked to
118° Congresso Nazionale - Società Italiana di Medicina Interna
improve civil hospitals. The British government started a nursing school
reform that included practical internships at certified hospitals! She was
asked, also overseas, not only as a healthcare expert, but also as an intel-
ligent counselor on health care. He died at 90 years after giving nursing an
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
theory, according to the Nightingale, there was necessarily the environment:
microclimate, hygiene and diet, were the factors on which the nurse (skilled,
prepared, vigilant and persevering) had to act so as not to hinder the vis
medicatrix Naturae stimulating the possible “passivity” of the “patient” to
cooperate in healing. “The woman had found her place in the health system,
but a subordinate place. Doctors, initially hostile, will end up willingly
accepting his obedient and submissive collaboration.
She, however, opposed bacteriology and feminism, and the limits of her
theory were those of the socio-cultural context of reference summed up in
the axiom that “Every woman is a nurse.”
She adopted masked and Victorian models of wife, mother, and housewife
roles transplanting them into nursing reality!
295. AN ANCIENT EXAMPLE OF HEALTH MANAGEMENT:
THE SACRED INFIRMARY OF MALTA
Carini L. 1, Cantarano M.S., Cantarano M., Cantarano E. 1
Facolta’ Medicina E. Farmacia - Universita’ Studi Roma “Sapienza”
For centuries, the disease has been considered synonymous with moral guilt.
Evil was to blame the sinner and therefore a recipient of a social instance of
“charity” of Christianity and of his specific attention to the attitude of the
“medical” Christ or the duty of mercy to the body too: “I was ill and I You
have visited me”(Mt 25: 36). This particular type of “charity”, however, requi-
red a special organization and management to make it an effective, efficient
and “economic” one. Few have given the merit of the Institution, which can be
regarded as the precursor of the hospital management: the Hospital Order of
St. John of Jerusalem, known as Rhodes and Malta. In a landscape that saw the
strong opposition between Islam and Christianity, with class divisions within
the “faiths” themselves, the initiatives of Sacred Infermeria in the case of
rescue and service to “our Lord the Sick” can be definitive “revolutionary”.In
fact, the institution’s raison d’etre, from its birth, was to accommodate pilgrims
and sick people who came to the holy places for Christians. After the end of
the Latin Dominions in the Holy Land, after the expulsion from Rhodes and
the transfer to the island of Malta, the Knights invested their fruits of race war
on the Mediterranean, in the works of assistance and rescue by building the
hospital structure more large in Europe: 155 meters long for 10, 5 meters wide
for 11 meters in height.
Young leaves of the Most Noble Houses in Europe, had as their first task to
cleanse the plagues of poor derelicts served with silverware in respect to “Our
Lord the Sick”, but also an expression of practical knowledge by the Sanitary
Of Order: silver had powerful bacteriostatic qualities.
Already in 1679, the patients considered infectious were isolated from the
others, linens and kitchenware had to be strictly separate from the one used to
others and marked specially. Within the Sacred Infirmary, each patient could
have a single bed provided with wool mattresses with canopies and colorful
curtains.
The Infirmary welcomed sick people belonging to any social class, nationality
and belief. Towards the end of the eighteenth century, the number of patients
admitted to the hospital was almost 4, 000 every year, with a mortality of 8%
(against 20% of Illuminati’s welfare institutions in Europe). In the Sacred
Infirmary the Sick was divided according to the manifested, medical or surgi-
cal, acute or chronic pathology. There were beds for mental illnesses.
Since 1725, the medical-surgical team consisted of Professionals who had
been trained in Italy and France. At the Infirmary there was a very good
Pharmacy. In 1676 the University School of Anatomy and Surgery was born,
which became one of the most renowned in Europe (and one of the oldest).
In this school, the first lessons and first experiments on corpses of modern
history were performed and here the “first degree” doctor will be “graduated”
and will be allowed to practice the surgeon’s profession. The Regulation of the
Sacred Infirmary was strongly pioneered by the Grand Master Manuel Pinto
de Fonseca in 1725.
In 1787 the Sacred Infirmary complex was able to ordinarily accommodate
563 people, compared to the 350/400 of 60 years earlier.
In the event of an emergency, capacity climbed to 914.
To sick people was given the opportunity to make anonymous complaints,
faults reports, abuse reports through a closed box with two different keys in
which anyone could submit their comments and complaints. As well as being
Poster
an antenatal agent for hospitalization, the Melitense care system is a very early
example of many bioethics that were absolutely unthinkable in that period
and only later were referred to by authors considered to be great bioethical
pioneers of the 18th century as Peter Frank or John Gregory. 2
296. GENDERS PATHOLOGY
Carini L., Cantarano M.S., Cantarano M., Cantarano E.
Facoltà di Farmacia e Medicina Università di Roma Sapienza
The term “gender” refers to the “man” and “woman” categories, not only
based on biological differences but also influenced by environmental, social
and cultural factors, as well as by the experience of the individual. The term
“sex” refers more simply to the individual’s biological characterization. The
World Health Organization has paid particular attention to the diversity
with which many pathologies, once considered typically male, They are
manifested in the female population by making specific recommendations.
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.
The gender approach is now considered a reality that can not be ignored and
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.
At 65 years of age there is a positive evolution of average survival, currently
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
reduction of mortality for circulatory diseases and malignant tumors, which
together account for over 70% of all deaths in Italy, which has allowed to
increase the average life of 2.1 years in both genera. The increase in survival
has resulted in both sexes, a slight increase in years of unhealthy health. It
has been found that longer life expectancy is not accompanied by an impro-
vement in the same quality of survival.
Women are more attentive to their health and are subjected more frequently
to prevention controls than men. Women are also the first in drug use, but
they are poorly represented in clinical or pharmacological trials. Here too,
genetic prejudices, which consider the cause of the disease almost exclu-
sively based on hormonal variability, delay the path of pharmacological
research and the search for socio-environmental risk factors and primary
prevention.
According to international statistics, cardiovascular disease, considered
increasing in humans, is the number one killer for women between the ages
of 44 and 59 and far exceeds all the causes of death. Diagnosis also occurs at
a more advanced stage than men, the prognosis is more severe for the same
age. Endometriosis is a dislocation of the glandular tissue outside the uterus.
Like the endometrium of the uterus, these shoots are also influenced by
hormonal variations, so that each cycle is congested with blood, proliferate
and break out, causing pain, inflammation and then adherence between the
tissues.
Endometriosis may affect the woman at the first menstruation and accom-
pany her until menopause. It can develop regardless of whether or not you
have had a pregnancy. The disease has a prevalence of about 10 to 15% of
women in reproductive age and affects about 30-50% of infertile women
or who have difficulty conceiving. It is often underestimated (it is estima-
ted that at least 9 years of diagnosis are required) and disabling, it causes
a serious state of psycho-physical suffering in the woman. In Italy, women
with concurrent diagnosis of endometriosis are at least 3 million. The social
cost of the illness exceeds 4 billion euros. Breast cancer is the most frequent
cancer and the cause of death for cancer most important for women.
The National Plan for Prevention, the organization of screening programs
has achieved significant results, but strong territorial differences and social
inequalities persist. In southern Italy, over 60% of women in the target popu-
lation are still not offered in organized programs. Lung tumor is a growing
cancer among women determined by lifestyle modification in relation to
smoking and urges information campaigns and a gender-oriented primary
prevention action.
Of the injuries and occupational illnesses of women, until a few years ago it
was only for the period of pregnancy, in relation to the risks of the unborn.
Compared to working conditions, the characteristics of the male worker
were considered for the most part. Even less attention is given to patholo-
gical events related to domestic work, particularly accidents. Pathological
stress is associated exclusively with productive work without considering
the greatest psychosocial risk affecting women and is given by the double
workload.
In June 2017, the 59 Deans of Medicine degrees decided that everyone
would have the teaching of Gender Medicine within their disciplines.
175
Poster
297. CRONOBIOLOGY
Carini L., Cantarano M.S., Cantarano M., Cantarano E.
Facoltà di Farmacia e Medicina, Università Sapienza Roma
Life on Earth has evolved in a context characterized by impressive environ-
mental variations, some of which are cyclical. Most living organisms have
evolved into environments that have chosen adaptations to oscillations of
environmental parameters in different temporal domains by modifying
their metabolism and behavior and thus avoiding passively fluctuations.
Chronobiology deals with the study of these genetic, molecular and phy-
siological endogenous oscillators. In Mammals, the organization of the
circadian oscillators is hierarchical and consists of numerous peripheral
oscillators distributed in various organs such as the liver, the lungs, the
spleen, the heart, and a central circadian clock, located in the brain at the
suprachiasmatic nuclei of the Hypothalamus, which plays an important role
in coordinating the activities of peripheral oscillators and is essential for
converting luminous Zeitgeber, coming from the retino-hypothalamic tract,
into cascade signals synchronizing peripheral oscillators.
The genes whose expression is controlled by the central clock and peripheral
oscillators represent a significant portion of the genome and are largely dif-
ferent in the different oscillators. In fact, it has been shown that the fraction
of RNA messengers that are transcribed with a circadian kinetics repre-
sent up to 10% of total messengers, whereas transcripts whose oscillation
occurs in more than one tissue generally do not reach 1% of the total. This
information, suggests that different peripheral oscillators contribute to the
regulation of tissue-specific rhythmic phenotypes, which probably reflect
the peculiarity of the functions exponent by different organs. However, in
Mammals, genomic duplication events produced a redundancy of genetic
information, resulting in multiple copies of multiple clock genes (eg, Per1,
Per2, and Per3, Cry1 and Cry2). This phenomenon has led to an increase in
complexity in the organization of the circadian oscillators of mammals. In
addition, although conserved in the course of evolution, some watch pro-
teins appear to have assumed different roles within the molecular device
that generates oscillation.
It is the case of CRY protein, which in the central oscillator is the blue light
photoreceptor and is involved in clock synchronization, while in mammals
stabilizes PER’s proteins in the cytoplasm forming complexes entering the
nucleus and regulating by negative feedback. The clock genes Per and Cry.
CRY does not seem to be implicated in the circadian Mammalian photore-
ception; It is believed that this role is performed by other photopigments
in the retina. Additionally, the role of the Timeless gene in the Mammalian
circadian clock is still under Discussion: A set of disorders and syndromes
(cronopathologies) originate from alterations in the physiological processes
of an organism usually due to desynchronization of the circadian biological
clock.
The most serious and lasting is the pathologies that can be attributed to chro-
nically working jobs that are subject to shift-work schemes. Recently, some
mutations have been discovered, with genes encoding components of the
circadian clock that cause inherited syndromes such as the Familial Advan-
ced Sleep Phase (FASPS) syndrome due to a point mutation in the clock
gene Period 2, which abolishes a phosphorylation site in the corresponding
protein, or in the Ck1-ε gene encoding one of the kinases involved in pho-
sphorylation of Period 2 protein. Even central nervous system anatomy and
cognitive deficits can manifest. Seasonal affective disorder (SAD) is known,
related to the worsening of the synchronizing effect of natural light, which
accompanies the advent of autumn and winter, and which becomes particu-
larly important in populations living at latitudes high. The treatment of cir-
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
crono-pharmacological approach is currently in an experimental phase and
based on molecules such as melatonin and its analogs.
Understanding the mechanisms of action of circadian clocks and their phy-
siological and metabolic effects is of great importance in the pharmacolo-
gical treatments of many diseases, for which the optimal time intervals for
drug administration are identified, so as to increase their effectiveness and
minimize unwanted effects.
298. COMUNICATE HEALT
Carini L., Cantarano M.S., Cantarano M., Cantarano E.
Facoltà di Farmacia e Medicina, Università Sapienza Roma
There is a gap in communication between those who produce life-saving
176
118° Congresso Nazionale - Società Italiana di Medicina Interna
drugs and vaccines and an ever-increasing humanity in the shadow of the
disease despite the invasion, even in this absolutely private and personal,
mass media and network and other systems of Global communication, and
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-
ting dangerous misunderstandings of serious global health risks.
It must be filled with corporate social responsibility and “true” communi-
cation efforts, which in some cases go hand in hand with slicing of profit
from the industry. Willing to expand the breed and suicide of humankind,
or rather, the large-scale application of the paradox that continues to break
down child mortality with vaccinations in developing countries, while in
the industrialized world Increasing the rate of family education increases
escape from vaccines and spread epidemics that were believed to have been
eradicated for some time. The debate is about why advanced societies do
not fully believe in advances of medicine, particularly “allopathic”, right now
that industry products save lives more than before, starting with active prin-
ciples against severe and disabling diseases such as hepatitis or new lines
for some cancers and for autoimmune diseases. It seems that twenty years
ago, when the time devoted to TV comparisons on health issues was greater
and better organized, dialectical conflicts between doctors and families
refusing therapies were less unmistakable. Transverse studies confirm the
importance of “time-factor” in the relationship between trust and patient:
a British investigation links the litigation (number of claims) to the dura-
tion of medical visits. Below fatigues of 13 minutes and 20 seconds it would
be maximum, while, on the contrary, would tend to swing fast above 18
minutes. Would be far inferior. It seems that “only good communication
with the physician” lights up “Patient-listening brain minded in his fears.
But the problem is that Health Services are not equipped to give the Doctor
too much time to persuade or listen.”
And we come to the drug industry. Immediately after the Second World
War, their reputation was “second only to that of God and the Marines,
today things have changed despite progress and the hundreds of thousands
of dollars spent in communication” as if they were ashamed to say that
they are industries And generate profits, because there’s someone on the
web who cries not to trust.” The fear is that science and Internet wizards
are on the same level, no more than the scientific evidence of effectiveness
against ignorance or simply a thought made less lucid than the illness due to
apprehension. But it is so?
And again, if there are remedies for doctors such as roles in which the Camice
is in the Patient, what communication strategies have to adopt industries and
health systems in the face of struggles against time, such as that in Italy to
eradicate the new Morbid epidemic that led to the Decree on the Obligation
of Vaccines in a “no-vax vs pro-vax” climate even if the former are only 3%
of the population and undecided by a 17%? It is likely that only with the law
obligations tout court, certain resistances do not crawl as if by magic. Rather!
And here, however, is the element that would not have been expected in the
US as in Italy: hesitant to keep or abandon vaccines are communities with a
higher education rate, California white collar workers than farmers in Mid-
West. Because? “It is not superstition or reliance on the magician the main
note of this dissolution in the scientific world, but a credibility deficit of this
world, which instead of being represented by the Nobel Prize, should exalt
the social function of its efforts and give less of the ‘ Idea of living on profits.”
Attempts are there. In Greece, pharmaceutical industries have begun to pay
for care. In addition, some of them, with blockbusters, have earned several
thousand times the cost of the investment.
Now, “it is necessary to give the realistic idea that those who work in health
work for the common good and are at the side of the weak, who are more
and more”.
299. A CASE OF POSTERIOR REVERSIBLE
ENCEPHALOPATHY SYNDROME IN INTERNAL
MEDICINE SETTING
D. Dell’Aera, L. Porretti, F. Calabretta, M. Piombo, A. Martignoni,
S. Perlini
SC Medicina Generale 2, Dipartimento Area Medica, Fondazione IRCCS
Policlinico San Matteo, Pavia
Introduction: Posterior reversible encephalopathy syndrome (PRES) is an
acute neurological syndrome increasingly recognized in patients with renal
failure, hypertension, sepsis, autoimmune disorders, eclampsia and under-
going chemotherapy, i.e. patients admitted in the Internal Medicine setting.
PRES is reversible if promptly treated.
Case presentation: A 74-year-old man undergoing neurorehabilitation
after an ischemic stroke, was transferred to our institution with acute
118° Congresso Nazionale - Società Italiana di Medicina Interna
renal failure (eGFR by MDRD: 7ml/min) and a GCS (Glasgow Coma
Scale) equal to 5. He had an aortic endoprosthesis obstructing the ostium
of the left renal artery, hypertension (that was initially treated with ACE
inhibitors), oliguria and generalized myoclonic seizures. Head CT scan
revealed bilateral cerebellar hypodensities. Serum glucose, ammonia,
thyroid-stimulating hormone and electrolyte levels were normal; urine
cultures were negative and blood cultures were positive for Citrobacter
koseri. Findings on brain MRI were consistent with PRES. Dialysis was
not performed since kalemia, azotemia and volemia were normal. Paren-
teral fluid support, dopamine infusion, meropenem and antihypertensive
drugs were initiated. After 72 hours we observed a complete resolution of
the neurological symptoms.
Conclusions: PRES can be easily misdiagnosed as stroke or toxic-meta-
bolic encephalopathy. Two coexisting physiopathological mechanisms
are involved: hyperperfusion from hypertensive encephalopathy and
endothelial dysfunction induced by cytokines. Early diagnosis and treat-
ment are essential for complete recovery.
300. EXTREME DIPPER HYPERTENSIVES HAVE A LOWER
LEVEL OF SYMPATHETIC TONE EVALUATED THROUGH
THE CALCULATION OF THE HEART RATE VARIABILITY
WHEN COMPARED WITH THE OTHER PATIENTS WITH
HIGHER NIGHT/DAY BLOOD PRESSURE RATIO
Miceli G. 1, Di Raimondo D. 1, Casuccio A. 2, Musiari G. 1,
Buttà C. 1, Tuttolomondo A. 1, Pinto A. 1
1
Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.M.I.S)
- Università degli Studi di Palermo 2 Dipartimento di Biomedicina
Sperimentale e Neuroscienze Cliniche - Università degli Studi di Palermo
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
(0.9<ratio 1.0) and reverse dippers (ratio 1.0). Reverse and mild dipper
hypertensives have poorer prognoses compared with the physiological
dipper profile, but the prognostic relevance of the extreme dipper profile
remains uncertain. The evaluation of heart rate variability (HRV), obtained
by 24-h Holter ECG monitoring, is the most frequently used noninvasive
form of assessment of the activity of the autonomic nervous system. Reverse
and mild dipper hypertensives have reduced HRV, indicating an overacti-
vation of the sympathetic nervous system (SNS); however, the HRV beha-
vior in extreme dippers is still controversial. The goal of this study was to
compare HRV indexes of extreme vs. reverse dipper essential hypertensives
measured on the basis of time domains.
Methods and Results: We enrolled 125 hypertensive subjects, excluding
patients with secondary hypertension, supraventricular arrhythmias,
holders of permanent intracardiac pacemaker, medical conditions contrain-
dicating the performance of dynamic ECG and/or the ambulatory blood
pressure monitoring (ABPM). Hypertensives subjects were divided in 4
quartiles accoding to night/day BP ratios. The upper and lower quartiles (31
subjects per quartile) were compared; 30 normotensive subjects were enrol-
led as a control group. Time domain HRV parameters of the three groups
revealed a higher degree of sympathetic activation in the lower quartile
(reverse dipper) vs. the upper quartile (extreme) and normotensive con-
trols. HRV parameters related to parasympathetic tone did not show any
significant variations among the three groups.
Conclusion: when hypertensive subjects are classified in relation to the
extent of the nocturnal decline of blood pressure, the measure of HRV allows
to discriminate different degrees of sympathetic tone and of sympatho-vagal
balance. The category of patients with the highest degree of nocturnal fall of
BP (extreme dipper) seems to be the one with the lower level of sympathetic
tone, even if is compared with the dipper profile, that is the physiological
one. In our opinion, this peculiar feature of the extreme dipper hypertensi-
ves could be considered an element prognostically favourable.
301. BLOOD PRESSURE AND METABOLIC PROFILES IN
OVERWEIGHT/OBESE PATIENTS WITH OBSTRUCTIVE
SLEEP APNEA SYNDROME BEFORE AND AFTER
3-MONTH CPAP THERAPY
Giulietti F., Spannella F., Di Pentima C., Lombardi F.E., Borioni E.,
Rosettani G., Bernardi B., Iacoacci C., Giordano P., Sarzani R.
Internal Medicine and Geriatrics, ESH. Hypertension Excellence Centre,
Università Politecnica delle Marche, IRCCS-INRCA, Ancona, Italy
Poster
Background: Obstructive sleep apnea syndrome (OSAS) is closely related
to hypertension and altered glucose and lipid metabolism. Overweight is
a crucial risk factor for OSAS. Aim: to describe the blood pressure (BP)
and metabolic changes in overweight/obese adults with moderate to severe
OSAS before and after 3-month CPAP therapy.
Methods: Prospective observational study on 56 patients (T1) of whom
13 were re-evaluated after 3-month CPAP therapy (T2). Inclusion criteria:
BMI ≥25 kg/m², age ≥18 years, CPAP therapy indication (AHI ≥15). Instru-
mental examinations: home sleep apnea polygraphy, 24h ambulatory BP
monitoring, 72h metabolic monitoring (Sensewear Armband ®). Laboratory
examinations: glycemia, insulinemia, total cholesterol, HDL cholesterol, tri-
glycerides. Insulin resistance (IR) was evaluated by HOMA-index.
Results: Evaluation at T1: mean age 57.2 ± 10.4 years. Males: 49 (89%).
Mean BMI: 31 ± 4 kg/m²; mean waist: 110.8 ± 7.7 cm. Mean AHI: 44 ±
15. Prevalence of hypertension: 87.5%; prevalence of dyslipidemia: 67.9%;
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
having IR than patients with AHI ≥15 (OR = 4.5, p = 0.047). Considering
13 patients re-evaluated at T2, there were no significant variations of either
BMI or glycemic and lipid profile. There was a reduction in baseline meta-
bolism (p = ns), which correlated significantly with ODI and SpO2 nadir at
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-
sting for antihypertensive therapy.
Conclusion: Overweight/obese patients with OSAS are also often affected
by hypertension and altered glucose and lipid metabolism. CPAP therapy
has a positive impact on nighttime BP, which affects cardiovascular risk.
CPAP may reduce basal metabolism but does not significantly affect body
weight nor glucose and lipid profile, unless coupled with lifestyle changes.
302. ALCOHOL ABUSE AND EMOTIONAL SELF-
REGULATION: A PRELIMINARY CLINICAL STUDY
Renzetti D. 1, Laforgia V. 2
1
Responsabile Unità Operativa di Medicina Interna e Medicina Generale,
Mater Dei Hospital Bari; 2 Psicologo Clinico, Mater Dei Hospital Bari
This work is based on the opportunity to present the psychological evalua-
tion of the patients involved in the Department of Internal Medicine of the
Mater Dei Hospital (Bari), hospitalized for alcohol abstinence syndrome,
alcohol detoxication and organ damage evaluation. In addition to medical
assessment and individual diagnostic-instrumental and therapeutic plan,
the assessment protocol for patients with a diagnosis of alcohol dependence
includes the clinical interview with the psychologist specialist and psycho-
metric assessment for the evaluation of the emotional state (STATE TRAIT
ANXYETY INVENTORY in versions 1 and 2), mood (BECK DEPRES-
SION INVENTORY II) and symptomatology (SYMTOM CHECK LIST
90 REVISED). This evaluation is performed during the stay period in
hospital. The aim of the psychological and psychodiagnostic evaluation
is twofold: to evaluate the emotional, cognitive, behavioral and social
conditions of the patients during hospitalization and to motivate them to
change and to continue the treatment after hospital discharge.
According to the literature, an important aspect in evaluating and treating
addicted patients concerns emotional self-regulation skills, understood as
the set of processes through which individuals control and influence their
emotions, the time to experience them and the way in which to expe-
rience and express them. During clinical observation, patients frequently
refer to use alcohol as a useful substance for regulating emotions. Emo-
tionally intense events associated with frequent mood swings in patients
with difficulty adjusting emotions, according to clinical assessments of the
authors of this work, lead patients to increase the frequency and quan-
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
daily by the patients until the time of the hospitalization. In other words,
the intention was to check whether more volumes of alcohol consumed
in grams of alcohol consumed per day were more noticeable in the scale
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
between 26 and 70 (average 48.25, ds 9.51), with an average of 11.3 years
of school attendance (min.5 years max.19 years; ds 3.52). For each patient
was calculated the average daily alcohol consumption (grams of alcohol
/ day) up to the time of hospitalization. The data were analyzed by linear
177
Poster
regression. Statistical analysis did not show statistically significant values
in any of the scales and dimensions considered (p> 0.05). In other words,
the levels of daily alcohol consumption in the patients being examined are
not related to major and more pronounced alterations in the emotional,
mood and symptomatic status of the subjects involved in the study. Accor-
ding to the authors’ view, the use of psychodiagnostic tests and measures
capable of studying in a more specific and detailed way the dimensions
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.
303. HOW TO GOVERN THE REQUEST FOR HEALTH
CARE WHEN THE PATIENT BECOMES A CONSUMER?
Lucchetta M.C., Davì R.
Servizio Sanitario Emilia Romagna, Ausl Parma
What is the right thing to do in medicine?What is well to do in medici-
ne?What is right to provide or not to provide?The choice is between to
“do all it can” and to”do as little as possible”.This question is especially
important today because physicians’s decisions influence not only the
health of people but also the power of the market that turns the patients
into consumers of health.“Do all it can”ensures to the physician juridical
impunity and unexceptionable ethical position, but this practice opens
the doors to the incorrect use of the health care resources.”Do as little
as possible”could induce the patient to accept the evidence that health
is an unavailable right, that medicine is not an exact science and that
it is necessary to come to terms with the peculiar limits of the human
condition.The correct medical practice, probably, tands between two
extremes.”You can make a lot of money by telling at healthy people that
are sick”.This statement of the BMJ is an indictment addressed against
the phenomenon of the “medicalization” of health which manipulates the
person’s ability to feel himself healthy or sick.This objective is pursued
with the marketing strategies cleverly disguised (disease mongering).The
market of healthcare extend by increasing the number of subjects that
you “feel” sick.So born the”Creative Epidemiology” which must selldi-
seases.The “doctor Knock” was the precursor of the modern ability of
the market to expand the “supply” of medical services and create false
“request” for health.And his story as timely as ever.Consumerism lionizes
personal choice and raises the expectation that desires can and will be
satisfied.Grows dramatically the number of healthy subjects who “feel”
sick, “consumers of health” greedy to receive visits and to get prescribe
examinations, medications and treatments.Perhaps, today the real chal-
lenge in healthcare sistem is not only the optimization of resources and
the precise observance of the prescriptive’s appropriateness.The real
challenge is raising public awareness, public consciousness and critical
scrutiny.The citizen must know that the commodification of health, the
promotion of a free market of healthcare, coupled with the doctor-patient
relationship threatened and discouraged, is dangerous for his freedom,
his rights and his health rights.It is necessary to redefine the boundaries
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
do more or do less, but “do better” or “know how to do better”, expertise
that can not be separated from the “quality” and background of the physi-
cian.The Charter of Medical Professionalism (elaborated by the European
Federation of Internal Medicine and the American College of Physicians)
suggests:to provide efficient patient care (guiding principle:“the good of
the patient”), to respect the patient as an autonomous person (principle
of “self-determination”)and ensure that all citizens have the same oppor-
tunities (principle of “non-discrimination”/“fairness”).But the good phy-
sician should keep as a guide the two cardinal principles of hippocratic
medical ethics: do not do things that are harmful to the patient (“primum
non nocere”) and choose treatments with proven effectiveness (based on
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
know what is appropriate for the patient.It is the responsibility of the
physician to determine the judgment on the limit.The growing tendency
nowadays to sue physicians debase the ethical orientation that gives to
the physician the judgment about the limit, opening the way, not only,
to “triumph of medicine” of doctor Knock but especially to “triumph of
defensive medicine”.The physician may not be free to treat and respecting
the ethics of care without adequate legal protection.It would be asking
him for daily heroism.The healthcare organization have to consider the
“satisfaction” of those who receive treatment in Public Health Service.The
178
118° Congresso Nazionale - Società Italiana di Medicina Interna
satisfaction must be in agreement with the ethical requirements.Also in
the dissatisfaction of the patient/customer, user of services, must grapple
with the ethical issues.The quality of the organisation of health care ser-
vices lies in the ability to integrate and reconcile the different instances.
The complexity of medicine requires the” know-be” and the “know-do”
of physician and the awareness of citizen.Both must be able to measure
with the limit of science.
304. A MAN WITH SYMMETRIC LOWER LIMBS
WEAKNESS
Maestripieri V. 1, Fallai L. 1, Tozzetti C. 2, Torri M. 2, Poggesi L. 1
1
Università degli Studi di Firenze 2 Medicina per la Complessità Assistenziale
3, AOU Careggi
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-
toms. His medical history was notable for diabetes mellitus, hypertension,
coronary artery disease, COPD, prostatectomy for heteroplasia and a mul-
tifactorial lower limbs polyneuropathy diagnosed in 2007 with electromyo-
graphy (EMG) due to diabetes and B12 deficit in history of alcohol abuse.
His medications included calcium antagonists, diuretics and aspirin.
At physical examination he correctly performed Mingazzini I and showed
slight symmetrical weakness in Mingazzini II, conserved symmetrical
tendon reflexes and no deficit of sensibility (pallestesic and thermo-dolo-
rific); he was able to walk without support. The EMG showed axonal poly-
neuropathy without denervation’s sign. Biochemical examination showed
vitamin B12 deficit. He was discharged with vitamin B12 supplement
therapy and ambulatory follow up. 7 days after discharge he presented to
ER unable to walk with sensibility deficit of lower limbs, slight weakness
of upper limbs and no tendon reflexes. He also presented acute urinary
retention treated with catheterization and respiratory failure necessitating
oxygen support. EMG showed initial signs of denervation. A lumbar pun-
cture with CSF analysis showed albumin-cytological dissociation, sugge-
sting Guillain-Barré Syndrome (GBS) with subacute onset.
The patient was treated with intravenous immunoglobulins with improve-
ment of muscular strength both in upper and lower limbs and after a week
of hospitalization was transferred to a rehabilitation hospital.
GBS is a rapid-onset muscle weakness caused by the immune system
damaging the peripheral nervous system. The initial symptoms are typi-
cally changes in sensation or pain along with muscle weakness, beginning
in the feet and hands. This often spreads to the arms and upper body with
both sides being involved. The symptoms develop over hours to a few
weeks. The diagnosis of GBS depends on findings such as rapid develop-
ment of muscle paralysis, absent reflexes, absence of fever, and a likely
cause. Cerebrospinal fluid analysis (through a lumbar spinal puncture)
and nerve conduction studies are supportive investigations commonly
performed in the diagnosis of GBS. In those with severe weakness, prompt
treatment with intravenous immunoglobulins or plasmapheresis, together
with supportive care, will lead to good recovery in the majority.
305. VITAMIN D, PARATHORMONE AND
CARDIOVASCULAR RISK: THE GOOD, THE BAD AND
THE UGLY
Pascale A.V. 1, Giannotti R. 1, Finelli R. 1, Fabbricatore D. 1, Visco V. 1,
Matula I. 1, Mazzeo P. 1, Ragosa N. 2, Massari A. 3, Di Sevo M.G. 4,
Ciccarelli M. 1, Iaccarino G. 1
1
Dipartimento di Medicina e Chirurgia, Università degli Studi di Salerno
2
Dipartimento di Cardiologia, P. O. “San Luca”, Vallo della Lucania (SA)
3
Dipartimento di Patologia Clinica, A.O.U. San Giovanni di Dio e Ruggi
d’Aragona, Salerno 4Dipartimento di Patologia Clinica, P.O. “Luigi Curto”,
Polla (SA)
25OH Vitamin D (VitD) insufficiency and increased cardiovascular risk
(CVR) association is still debated. The VitD dependendent paratohormone
(PTH), is considered as the possible actuator of VitD effects on CVR. In
an overall population observational study, we assessed the role of PTH in
predicting CVR. We recruited 412 persons during the World Hyperten-
sion Day, in the area of Salerno, Southern Italy. Through means of dedica-
ted questionnaires, blood pressure measurements and a blood draught, we
collected dietary habits, anamnestic, clinical and metabolic data. CVR was
calculated according to the Framingham CVR charts. The overall popula-
tion mean age±SD was 49.9±20 yrs, and female sex was slightly prevalent
118° Congresso Nazionale - Società Italiana di Medicina Interna
(53.2%). VitD deficiency (<20 uMol/ml) was most frequent (65.4%). In this
population VitD and CVR did not correlate. VitD and PTH inversely cor-
related (r=-0.236, p<0.001) as expected. PTH was in direct linear regres-
sion with CVR (F=14, 982, p<0.0001). Elevated PTH (>=56 mg/dl) levels
identify a population with higher CVR (11.9±6.2 vs 9.2±7.1, p<0.01) and
larger prevalence of cardiovascular events (10, 2 vs 4.1, p<0, 04). Since PTH
increases with age and kidney function, we selected a 41-60 years old popu-
lation (N=150). Also in this homogenous group, people with elevated PTH
present a larger cardiovascular risk (8.4±10.5 vs 4.1±4.8, p<0, 01) due to
higher systolic blood pressure (137.2±20.4 vs 130.1±16.0, p<0.05). In con-
clusion, VitD deficiency causes PTH elevation that in the overall population
increases the CVR. Our data let hypothesize that VitD supplementation may
represent a major presidium to reduce PTH level and consequently CVR.
306. MYOTONIC DYSTROPHY AND
HYPOGAMMAGLOBULINEMIA: CASE SERIES
Pedini V., Menghini D., Cardinaletti P., Gabrielli A., Danieli M.G.
Clinica Medica, Università Politecnica delle Marche & Ospedali Riuniti,
Ancona
Background: Hypogammaglobulinemia is frequently described in patients
with myotonic dystrophy. Mechanisms involved in this association are not
completely clear, but an increased immunoglobulin catabolism is recogni-
zed in these patients. In most cases, hypogammaglobulinemia affects only
the IgG class and does not become clinically manifest.
Case Series: We describe three patients with myotonic dystrophy and
hypogammaglobulinemia. The first case is a 44-year-old man with myo-
tonic dystrophy type 1, who came to our attention for a history of recur-
rent infections of the upper respiratory tract. At the laboratory exams, we
documented hypogammaglobulinemia with low serum IgG levels (449 mg/
dl), normal IgA and IgM levels and protective antibodies against tetanus.
He also had a history of recurrent infections by Helicobacter Pylori, with
eradication after two antibiotic cycles. Due to the recurrent infections,
we decided to start replacement therapy with intravenous immunoglobu-
lin (0.4 g/kg monthly), switched one year ago to facilitated subcutaneous
immunoglobulin with a significant reduction of infectious episodes and the
achievement of protective serum IgG levels (> 600 mg/dl). The second case
is a 49-year-old man with a recent history of recurrent upper respiratory
tract infections, which required monthly antibiotic therapy. Laboratory tests
revealed hypogammaglobulinemia, with mildly reduced serum IgG levels.
He has been recently studied for a chronic myopathy, with the diagnosis
of myotonic dystrophy type 2. The third case is a 59-year-old man with a
complex clinical history, characterized by vitiligo, leucopenia (with lym-
phopenia), autoimmune thyroiditis, long-lasting hypogammaglobulinemia
and a previous diagnosis of probable polymyositis treated with low-dose
steroids. In 2015 he repeated electromyography, which revealed a myoto-
nic pattern. Genetic analysis was performed and diagnosis of myotonic
dystrophy type 2 was confirmed.
Conclusions: Hypogammaglobulinemia is frequently reported in patients
with myotonic dystrophy. Most cases described in literature are not associa-
ted to clinical manifestations, like recurrent infections. In our cases, patients
were symptomatic. For the first patient, we decided to start an Ig replace-
ment therapy with benefit.
307. VIDEOCAPILLAROSCOPY IN SARDINIAN HHT
PATIENTS
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
Sassari 3U.O Complessa di Pronto Soccorso e Osservazione Breve del P.O di
Alghero
Hereditary Hemorrhagic Teleangectasia(HHT) is an hereditary autoso-
mal dominant which affects angiogenesis, causing arteriovenous dilations,
hemorrhagic teleangectasie affecting mucous membranes and visceral
shunts located predominantly in the liver, lung, and brain.
Skin-mucous teleangectasia is small flat or lightly detectable, red-violet
color, consisting of dilated and convoluted capillaries, which begin to appear
in the third decade of life and tend to increase in number and size. The
earliest alteration of telangiectasia is the focal dilation of the post-capillary
venules; Such a lesion with time tends to increase in size to affect, through
Poster
the capillaries, also the arterial segments thus hesitating in the formation of
artery-venous fistula.
The teleangectal engagement of the skin-mucous microcirculation can be
evaluated, as well as clinically, with the aid of the videocapillaroscope. Vide-
ocapillaroscopy (VCL) is a non-invasive diagnostic method used to define
morphological and functional anomalies of microcirculation, which plays a
very important role in the diagnostic and prognostic approach to Systemic
Sclerosis (SSc). VCL is commonly performed at the level of the nail bed, but
it can also be used to study microcirculation at the lab and skin.
This is the first experimental, comparative case-control study that aims to
evaluate systematically the characteristics and prevalence of microcircula-
tion alterations in patients with HHT and aims to understand whether VCL’s
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-
rosis (SSc) and healthy controls (CS) evaluating the following parameters
of digital dyscalculia at VCL: morphology Of the capillary; -diameter of the
capillary gills; - Giant capillaries, - Neo-angiogenesis, -little-hemorrhage,
-little anuerysm -Difference of Capillaries, -Avascular Aces, -Hemoserine
Deposits.
28 patients with HHT who were admitted to the UH clinics of Internal
Medicine 2 of the Department of Clinical and Experimental Medicine of
AOU of Sassari from April to June 2016 were enrolled.
As a control population they were enrolled in the study:-28 SSc patients
afflicted to UOC Clinic and Experimental Rheumatology Clinics of Sassari.-
28 healthy subjects: blood donors associated with the Transfusion Center
of the Hospital-University Hospital in Sassari (CS).The VideoCAP DS-Me-
dica® capillaroscopic system was equipped with 20x and 200x magnifica-
tion optics. The microcirculation of the following districts was analyzed: 8
ungual beds (excluding I fingerprints of my finger).
Statistical analysis was conducted using the Fisher test, used to compare
the prevalence of individual capillaroscopic alterations between two groups
(HHT vs SSc and HHT vs. CS) and the ANOVA employed between multiple
groups (HHT vs SSc vs CS). A value of p was less than or equal to 0.05 We
have identified capillaroscopic characteristics that allow us to differentiate
the HHT picture from the pathological picture of patients with systemic
sclerosis and thus from the normal picture of healthy controls. The capil-
laries of HHT patients are more “similar” to those of healthy subjects and
certainly dissimilar to those of subjects with SSc.
The diameter of the capillary branches is not conserved in HHT patientsto
a little lesser extent than patients with SSC.The presence of rare and fre-
quent microaneurysms is more frequent in patients with HHT compared to
patients with systemic sclerosis (frequent: 31.6% VS 23.5%, rare: 68.4% VS
47.1 %), So this aspect may be typical of HHT patients.
The presence of rare microaneurysms was more frequently detected in capil-
laries of HHT patients than in SSc patients, we may say that its relief could
be a typical element for altering the microcirculation in HHT patients.The
prevalent changes in microcirculation in HHT patients were: capillaries
with twisted pincers 78.6%, dm of the branches preserved with rare ectasie
39.3%, microaneurism presence 67.8% (rare: 30% Frequent: 68%).In con-
clusion, we can say that globally the capillaroscopic appearance of patients
with HHT differs from the typical picture of systemic sclerosis.
VLC could be used as a diagnostic aid in differentiating patients with
dubious HHT diagnoses from healthy, with regard to the evidence of rare
microanurysm and differentiating them from subjects with SSc regarding
capillary morphology and capillaroscopic pattern, being dissimilar In the
two control groups.
Further comparative studies based on a higher sample size will be requi-
red and directed to the study of bodily districts other than that of the nail
microcirculation, as the severity of the sample could cause distortion of the
obtained results.
308. WHEN THE EXCESS OF MINERALCORTICOID
HORMONES IS ONLY APPARENT
Renis M. 1, La Mura G. 2, De Donato M.T. 3, La Mura L. 4
1
UOC Medicina P.O. Cava de’ Tirreni AOU Salerno, 2 Cardiologo PO Scafati
ASL. Salerno, 3UOC Medicina AOU Salerno, 4Università “Federico II” Napoli
Introduction: Sometimes we find clinical and electrolyte abnormalities
similar to hyperaldosteronism, without mineralocorticoid excess. Clinical
case:F, 62, is hospitalized in department of Internal Medicine for muscle
aches and fatigue. History: smoking, dyslipidemia and well controlled
hypertension. Current therapy: ramipril/HCT; rosuvastatin 10, verapa-
mil, fluconazole 50 mg BID for 10 days (two months before). ECG: ST
179
Poster
segment depression like ventricular overload. Laboratory tests: K: 1.7; Na:
146; CPK: 11971; PH: 7, 56; HCO3- 55.5; urinary potassium 40.3 mEq/24
hours; aldosterone, renin, cortisol, ACTH: limits. Abdominal ultrasound
and abdominal TC, and renal arteries Doppler: limits. The patient under-
goes KCL i.v., potassium kanreonate, acetazolamide. Gradual normaliza-
tion of clinical and laboratory parameters. Subsequent re-evaluation after
discharge (ongoing therapy: barnidipine, rosuvastatin 5, ezetimibe): normal
Electrolytes and ECG.
Discussion: The severe hypokalemia with alkalosis and rhabdomyolysis,
puts etiopathogenetic open questions (in our opinion, it can not just be
attributed to ramipril/HCT and to rosuvastatin, assumed for years without
noticeable electrolytic and CPK alterations) Rhabdomyolysis may be secon-
dary to severe electrolyte imbalance.
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
function (similar to some rare genetic diseases characterized by enhanced
tubular Na/K exchange).
309. AN UNUSUAL CAUSE OF PSYCHIATRIC DISORDERS
Renis M. 1, De Vecchi R.M. 2, Marracino M. 2, La Mura G. 3,
La Mura L. 4, De Donato M.T. 2
1
UOC Medicina P.O. Cava de’ Tirreni AOU Salerno, 2UOC Medicina AOU
Salerno, 3 Cardiologo PO Scafati ASL. Salerno, 4Università “Federico II “
Napoli
Introduction: Proton pump inhibitors drugs (PPIs) are widely used. They
often have some misunderstood or underestimated side effects.
Clinical case: F, 76. Hypertensive heart disease, WPW syndrome. Therapy:
clopidogrel, beta-blockers, ACE inhibitors, statins, PPIs, occasionally diu-
retics. Repeated previous hospitalizations, both in Internal Medicine and in
Neurology department, complaining tremors, ataxia and acute psychiatric
disorders, with a finding of hypocalcemia and hypokalemia, never adequa-
tely investigated. A week before our observation: fast clinic deterioration
after taking thiazide diuretic, following a cardiological control. November
2016: ataxia, delirium with hallucinations, generalized tremors. Admission
to Neurology department. She came to our observation in consulting. She
showed low values of calcium, potassium and magnesium. Hypothesis:chro-
nically taken PPI can cause hypomagnesemia, first cause of complex and
persistent electrolytic disorder. Stop to PPI: resolution of symptoms and
normalization of electrolytes.
Discussion: This clinical case emphasizes the following highlights: • Often
neuropsychiatric manifestations are due to metabolic and/or electrolytic
disorders;
• We should always evaluate all electrolytes, not only Na and K, particularly
in presence of persistent neurological symptoms;
• Electrolyte disorders can often be iatrogenic, sometimes due to PPIs.
Conclusions: PPIs are prescribed too frequently, even outside of guidelines,
being deemed not harmful. Conversely, they often have some misunder-
stood and underestimated side effects.
310. FOCUS ON QUALITY OF LIFE IN PATIENTS WITH
COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)
Romeo A., Risicato R., Grasso O., Marturana S., Intravaia S., Platania S.,
Giacalone S., Cristaldi E.
U.O.C. Medicina Interna P.O. “Muscatello” di Augusta (SR)
Purpose and scope of the study: Quality of life can be severely impaired
in patients with COPD. Purpose of this research is to identify the impact
of COPD on the quality of life of hospidalized patients and to examine its
relationship with the severity of the disease.
Research Method: through the survey SAT-P (Satisfation Profile) it has
been measured the physical wellbeing of the patients. The SAT-P is a self-re-
port questionnaire and the 32 item survey the subjective satisfaction in
daily life. Are enrolled 15 patients (13 males, 2 females), average age is 71,
all affected by moderated COPD. In that group were not included patients
affected by senile dementia, psychiatric disorders, major impaired cognitive
ability, neoplasms, major depression and anxiety (frequently associated with
COPD). 12 subjects has been submitted to the second control group. Are
asked to evaluate their own satisfaction concerning the last month. Results
of the Reasearch: From the scoring is clear how the group affected by COPD
has a score of 57, 8 while in the clinical control group the scoring go up
180
118° Congresso Nazionale - Società Italiana di Medicina Interna
to 74, 3. As consequence the group of patients affected by COPD shows a
minor satisfation about life quality. It also makes many feel frustrated and
angry about not being able to do the things they want to. The study focused
on single factors analysis in terms of capability:
- Psycological / physical / working / social / sleep
- Sleep / feeding / spare time Each of this factor has been perceived as less
satisfying in particular emotional stability, self-confidence, psychological
autonomy.
Conclusion: the results of the research confirms a considerable reduction of
life quality in the patients affected by COPD. Clearly emerges that a multidi-
sciplinary approach is necessary. That approach should include psychologist
support as part of the treatment to increase the compliance to the treat-
ments and the rehabilitation programs.
311. A CASE OF CAPD-RELATED CRYPTOCOCCUS
NEOFORMANS PERITONITIS
Cabibbe M., Brunati C., Grotti M., Montoli A.
ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy. Divisione di
Nefrologia, dialisi e trapianto renale
Objectives: Cryptococcal peritonitis is uncommon, with only 61 cases
reported between 1951 and 2012. Peritoneal dialysis (PD) patients account
for 25% of cases. Diagnosis is often difficult while prompt treatment is
required.
Methods: A 80 -year-old man with severe atherosclerosis and chronic renal
disease related to nephrolithiasis and ischemic nephropathy gradually deve-
loped diabetes and uremia six years after receiving a kidney transplant.
Immunosuppression included rapamycin 1 mg qd, mycophenolic acid 500
mg qd and prednisone 2.5 mg qd. A peritoneal dialysis catheter was inser-
ted, and CAPD (Continuous Ambulatory Peritoneal Disease) started two
months later. Only low dose prednisone was maintained to preserve residual
kidney function. Thirty days into CAPD, the patient presented with fever
(38.4°C): the abdomen was tender, the PD catheter exit site was healthy, the
peritoneal fluid was clear. Chest, abdomen and brain imaging were negative.
He had blood (17.340/mm3, ) and peritoneal fluid (190/mm3) leukocyto-
sis. CRP was 10.2 mg/dl. Blood, urine and peritoneal effluent cultures were
collected. I.V. ceftriaxone 2 g qd was administered. Three days later the
fever had disappeared but CRP increased to 17.8 mg/dl and peritoneal fluid
leukocytes rose to 600/mm3. Intraperitoneal cefotaxime was added (1g/2
L bag). On day 6 the peritoneal effluent culture collected at presentation
grew Cryptococcus Neoformans var. Grubii. Serum cryptococcal antigen
was negative.
Results: intravenous liposomal Amphotericine B 200 mg and Flucytosine
2.5 g were administered for 4 weeks, with prompt clinical improvement. The
PD catheter was removed, and hemodialysis was initiated.
Conclusions: Fungal peritonitis is almost always associated with both
recent antibacterial use and multiple episodes of bacterial peritonitis. Our
patient had a particularly high risk, being an immunosuppressed bearer of a
failing kidney transplant. A high index of clinical suspicion and prolonged
cultures of the peritoneal effluent are needed since fungi may require weeks
to emerge and some case present as culture negative peritonitis.
312. TIRED OF BEING TIRED
Cardinali M., Benfaremo D., Mattioli M., Biondi L., Festa A, Gabrielli A.
SOD. Clinica Medica, Ospedali riuniti di Ancona/ Università politecnica
delle marche, dipartimento di scienze cliniche e molecolari
A 58-year-old man was admitted to our ward in April 2017 for a 5-month
history of worsening fatigue, numbness, confusion and onset of frequent
cramps, particularly severe in his lower limbs. These symptoms were present
all day long, not elicited by any behaviour, occurring even at rest. There were
no signs of systemic infection such as fever, cough or dysuria. The patient
had no relevant comorbidities, except for occasional episodes of gastritis.
He was not taking any drug. After one week from the onset of the symp-
toms blood tests were performed as outpatient: complete blood count was
normal, biomarkers of inflammation, hepatic and renal function were unre-
markable, CPK and LDH levels were normal; a moderate hypokalemia with
mild hypomagnesaemia was present. Administration of oral potassium and
magnesium supplement for some weeks was beneficial but upon treatment
discontinuation the symptoms recurred.
Physical examination: no significant remarks. Normal blood pressure
(130/85 mmHg).
118° Congresso Nazionale - Società Italiana di Medicina Interna Poster

Laboratory tests: No significant abnormalities except low serum potassium
(2.9 mEq/L), low 24-hour urinary calcium excretion and 24-hour urinary
cortisol excretion at upper bound. Arterial blood gas: pH 7.48, PO2 80
mmHg, PCO2 44 mmHg, HCO3 32.8 mmol/l, satO2 99.1%
Imaging: a computed tomography of chest and abdomen was negative.
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-
sion of a massive and prolonged loss of gastrointestinal secretions. Rarely
hypokalemia could be the consequence of a renal potassium wasting due
to tubular injury, increased mineralocorticoid activity or tubular transport
proteins mutations. Our patient was not taking any drug and did not report
a history of prolonged vomiting or diarrhoea. We therefore focused on the
renal potassium wasting hypothesis. Tubular injury was unlikely, as there
were no signs of reflux nephropathy or interstitial nephritis, as was the
hypothesis of increased mineralocorticoid activity, since renin-angiotensin
system was normal. The combination of hypokalaemia, metabolic alkalo-
sis and normal blood pressure prompted us to consider a tubular transport
protein mutation: the concurrent presence of hypocalciuria drove us to the
diagnosis of Gitelman Syndrome (GS). GS is an autosomal recessive disease,
with mutations in each gene coding for the thiazide-sensitive Na-Cl cotran-
sporter (NCC) in the distal tubule. Reduced NCC activity mimics the effects
of persistent thiazide diuretic action, which include volume contraction,
renal potassium wasting and hypokalaemia, renal magnesium wasting and
hypomagnesemia, and low urinary calcium excretion.
Management: The tubular defects in Gitelman syndrome cannot be cor-
rected (except by renal transplantation). So, the treatment aims to correct
the volume deficit and electrolyte abnormalities. In GS an increase in renal
prostaglandin E2 (PGE2) production is usually present, although urinary
PGE2 excretion is lower compared with the strictly related Bartter Syn-
drome; in some patients NSAIDs may effectively raise the serum potassium.
In addition, a drug that blocks distal tubule sodium-potassium exchange,
such as spironolactone, eplerenone, or amiloride, is usually administe-
red, frequently in higher-than-usual doses. This drug combination can
raise the serum potassium, correct the metabolic alkalosis, and partially
reduce degree of hypomagnesemia. Most patients require oral potassium
and magnesium supplementation since therapy with NSAIDs and drugs
that block distal tubule sodium-potassium exchange is often incompletely
effective. Angiotensin-converting enzyme (ACE) inhibitors reduce the pro-
duction of angiotensin II and aldosterone and may be a useful adjunctive
therapy. Our patient was dismissed with a potassium supplement and spi-
ronolactone 100 mg/die.
313. CIRCULATING SCLEROSTIN AND DICKKOPF-1
CORRELATE WITH VASCULAR CALCIFICATIONS IN
NON-DIALYSIS CHRONIC KIDNEY DISEASE
Catalano A. 1, Ferro C. 1, Faraci B. 1, Basile G. 1, Ricciardi C.A. 1, Donato R. 2,
Santoro D. 1, Lasco A. 1
1
Department of Clinical and Experimental Medicine, University of Messina,
Messina, Italy; 2Department of Radiological Sciences, University of Messina,
Messina, Italy
DKK-1 was independently associated with previous cardiovascular events
(OR=1.0007, 95% CI (1.0000 to 1.0013), p=0.04.
Conclusions: Wnt signaling inhibitors sclerostin and DKK-1 are associated
with vascular calcification detected by TC, and may represent new valuable
biomarkers of cardiovascular risk in in CKD patients.
314. PROGNOSTIC RELEVANCE OF DIFFERENT GFR
EVALUATING EQUATIONS IN ELDERLY HOSPITALIZED
PATIENTS
Gallo P., De Vincentis A., Vespasiani-Gentilucci U., Galati G.,
Pedone C., Picardi A., Antonelli Incalzi R.
Campus Bio-Medico University of Rome
Background and Aims: The estimated glomerular filtration rate (eGFR) is
a predictor of important outcomes such as in-hospital mortality, hospital
readmission and death within 3 months. Its reduction has been associated
with the risk of all-causes mortality and cardiovascular mortality in both
general population and elderly patients. Moreover, while reduced renal fun-
ction is common in older people, the best method for estimating the GFR
remains unclear and a reliable assessment is a challenge especially in an
acute care setting where significant short-time changes are common. Finally,
most studies analyzing the accuracy of GFR estimation in the elderly were
carried out in an ambulatory or outpatient setting. In the last years, new
GFR-estimating equations (Modification of Diet in Renal Disease, MDRD;
Chronic Kidney Disease Epidemiology Collaboration, CKD-EPI; Berlin
Initiative Study, Berlin Initiative Study BIS) have been validated but only
one in older population (BIS, data from the Berlin Initiative Study, with only
persons aged 70 and older). Therefore, we aimed to compare the progno-
stic value of these new formulas in comparison to Cockcroft-Gault (CG), in
predicting the risk of in-hospital mortality and mortality within 3 months
from discharge.
Materials and Methods: Data were extracted from a validated database
employed by internal and geriatrics medical wards participating in the form
of “Registro Politerapia SIMI (REPOSI)” which is a registry including hospi-
talized patients aged more than 65 years and organized by the Italian Society
of Internal Medicine and IRCCS - Mario Negri Institute of Pharmacological
Research of Milan. Patients with available creatinine values at hospital admis-
sion were selected and eGFR was calculated according to CG, CKD-EPI,
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%
confidence intervals (95%CI). Therefore, the discriminatory performances
of different eGFR equations were compared calculating the area under the
receiver operating characteristics (AUC) of the above mentioned regression
models.
Results: 4621 patients were included in the analysis (mean age 79.4 +/- 7.5
years, 48.8% males). Among these, 4.2% and 9.9% died during hospitalization
and within 3 months from discharge, respectively. CG showed the greatest
association with both in-hospital and 3 months mortality (Table 1).

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
Poster
Accordingly, the model including CG had the best discriminative perfor-
mance compared to the others (Figure 1, left). This superiority was not con-
firmed if correcting for a proxy of nutritional status, such as albumin levels
(Figure 1, right).
Conclusions: Even though multiple studies showed CG to retain poor accu-
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
elderly and its known association with a poor outcome.
315. MULTIDIMENSIONAL PROGNOSTIC INDEX IN
OLDER ADULT PATIENTS WITH CHRONIC KIDNEY
DISEASE UNDERGOING RENAL REPLACEMENT
THERAPY OR CONSERVATIVE MANAGEMENT
Lai S., Molfino A., Amabile M.I., Innico G. 1, Mangiulli M. 2,
Esposito Y. 2, Coppola B. 3, Perrotta A., Protopapa P., Galani A. 4,
Aucella F. 5, Brunori G. 6, Russo G.E. 7
Study Group on Geriatric Nephrology of the Italian Society of Nephrology
(SIN) Department of Clinical Medicine, Sapienza University of Rome,
Rome, Italy. 1Department of Medicine DIMED, School of Specialization in
Nephrology, University of Padova, Padova, Italy; 2Department of Internal
Medicine and Medical Specialities, Sapienza University of Rome, 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).
Materials and Methods: A total of 173CKD patients, on conservative and
replacement therapy were consecutively included. All patients underwent
an assessment with MPI and divided into 3 risk classes, assessing morta-
lity rate (number of deaths / population number), the rate of hospitaliza-
tion (number of admissions / total population numbers), in addition to the
days of hospitalization and number of annual admissions, in the two years
of follow up, Clinical, laboratory and instrumental examinations such as
anthropometric parameters (Body Mass Index, BMI; Bioimpedance Analy-
sis (BIA)), inflammatory indices, mineral metabolism and markers of athe-
rosclerosis (Intima Media Thickness, IMT), Ankle Brachial Pressure Index
(ABPI)) were performed at T0, and after 2 years, at T1 from enrollment.
Results: A total of 173 patients (107 male, 66 female), with a mean age of
74.65 ± 8.43, affected by CKD (stage 3/5 KDOQI), on conservative (104
patients) and replacement therapy (34 patients on HD, 35 patients on PD)
were consecutively included. Our study showed a significant association
between mortality rate and MPI for risk classes (2=58, 871, p <0, 0001), and
the statistical analysis of standardized residues, showed that the differences
are statistically significant in each group with r <1.96 or r >1.96 (p<0.05).
There was also a positive correlation between the MPI value and the number
of hospitalizations per year (p <0.001), and the days of hospitalization (p
<0.001), in addition to age (p = 0.003). Moreover we found another posi-
tive correlation between MPI and extracellular water (ECW) at T0 (r=0.234;
p=0, 013).
Conclusions: Predicting life expectancy is essential to identify the most
appropriate clinical decision-making for management, treatment and pre-
vention as well as for patients and family members to have realistic expecta-
tions. In our study, we showed a significant association between MPI and
mortality rate and hospitalization, in CKD patients on conservative and
replacement therapy. Therefore, our results suggest that MPI may be very
useful to assess the prognosis of older adults with CKD on conservative and
replacement therapy, and that multidimensional and multidisciplinary eva-
luation through MPI should be considered in this population. Moreover, in
our study we found a positive correlation between MPI and ECW, therefore,
182
118° Congresso Nazionale - Società Italiana di Medicina Interna
considering that fluid overload is an important element of progression to
adverse clinical outcome in CKD patients, we suggest a careful monito-
ring of fluid status, indeed the low cost, non-invasiveness and availability
of BIA could make it an adequate tool for fluid evaluation in a large CKD
population.
316. MAGNETIC RESONANCE IMAGING 3T AND TOTAL
FIBROTIC VOLUME IN AUTOSOMAL DOMINANT
POLYCYSTIC KIDNEY DISEASE
Lai S., Mastroluca D. 1, Letizia C. 2, Petramala L. 2, Perrotta A.,
Di Gaeta A. 3, Ferrigno L. 4, Panebianco V. 3, Mangiulli M. 5,
Esposito Y. 5, Pintus G., D’Angelo A.R. 6
Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy:
1
Nephrology and Dialysis Unit, Hospital ICOT. Latina, Sapienza University
of Rome, Italy; 2Department of Internal Medicine and Medical Specialities,
Sapienza University of Rome, Rome; 3Department of Radiological,
Oncological and Pathological Sciences, Sapienza University of Rome, Italy;
4
National Centre for Epidemiology, Surveillance and Health Promotion,
National Institute of Health, Rome; 5Department of Internal Medicine and
Medical Specialities, Sapienza University of Rome, Rome, Italy; 6Department
of Obstetrical-Gynecological Sciences and Urologic Sciences, Sapienza
University of Rome, Italy
Introduction: Autosomal dominant polycystic kidney disease (ADPKD)
is the most common renal hereditary disorder. In the last years, several
authors have attempted to identify a kidney damage marker for predicting
the prognosis, and the effectiveness of therapy in ADPKD.
Aim: The aim of this study was to identify and quantify, through a novel MR
protocol with 3 Tesla (MRI 3Tesla), the presence in ADPKD, of parenchy-
mal fibrotic tissue, at an early stage of disease, able to correlate the glomeru-
lar filtrate and to predict the loss of the function renal.
Material and Methods: 15 ADPKD patients were undergone to renal MRI
3Tesla at T0 and at follow up (T1, 52.8 months). Moreover we have evalua-
ted renal function, plasma aldosterone concentration (PAC), Homeostasis
Model Assessment-insulin resistance (HOMA-IR), and markers of athe-
rosclerosis (carotid intima media thickness (IMT), ankle/brachial index
(ABI), left ventricular mass index (LVMI).
Results: Our study showed a significant negative correlation between total
kidney volume (TKV) and eGFR during the follow up, at T1 (r=-0.059,
p<0.02). We showed, also, a negative correlation between eGFR and Total
Fibrotic Volume (TFV) (r=-0.61, p<0.04), and between eGFR and Total
Perfusion Volume/Total kidney Volume (TPV/TKV%) (r=-0.59, p<0.02)
always during the follow up, at T1. Instead, TKV (r=0.37, p=0.16) and
TPV/TKV% (r=-0.16, p=0.56) not showed a significant correlation with
the monthly slope of the decline of eGFR. Moreover, TFV was correlated
positively with PAC (r=0.50, p<0.05), insulin values (r=0.49, p<0.05), ABI
(r=0.51, p <0.05) and the LVMI (r=0.63, p<0.01).
Conclusions: The MRI 3Tesla, could be useful in the evaluation of fibro-
tic tissue, correlating it with the eGFR. Despite the high costs, therefore it
would be advisable to carry out a study with MRI 3Tesla, to evaluate the pro-
gression of the disease and the effectiveness of new therapeutic strategies, in
addition to the early cardiovascular screening and PAC dosage.
References: 1) Torres VE, Harris PC, Pirson Y. Autosomal dominant
polycystic kidney disease. Lancet 2007;369:1287–1301. 2) Caroli A, Antiga
L, Conti S, Sonzogni A, Fasolini G, Ondei P, Perico N, Remuzzi G, Remuzzi
A. Intermediate volume on computed tomography imaging defines a fibro-
tic compartment that predicts glomerular filtration rate decline in auto-
118° Congresso Nazionale - Società Italiana di Medicina Interna
somal dominant polycystic kidney disease patients. Am J Pathol. 2011
Aug;179(2):619-27. 3) Jill Norman: Fibrosis and progression of Autosomal
Dominant Polycystic Kidney Disease (ADPKD): Biochim Biophys Acta.
2011 October; 1812(10): 1327–1336. 4) Liu Y. Renal fibrosis: New insights
into pathogenesis and therapeutics. Kidney Int. 2006; 69:213–217. 5) Naka-
mura T, Ushiyama C, Suzuki S, Ebihara I, Shimada N, Koide H. Elevation of
serum levels of metalloproteinase-1, tissue inhibitor of metalloproteinase-1
and type IV collagen, and plasma levels of metalloproteinase-9 in polycy-
stic kidney disease. Am. J. Nephrol. 2000; 20:32–36. 6) Irazabal MV, Rangel
LJ, Bergstralh EJ, Osborn SL, Harmon AJ, Sundsbak JL, Bae KT, Chapman
AB, Grantham JJ, Mrug M, Hogan MC, El-Zoghby ZM, Harris PC, Erick-
son BJ, King BF, Torres VE8; CRISP Investigators. Imaging classification of
autosomal dominant polycystic kidney disease: a simple model for selecting
patients for clinical trials. J Am Soc Nephrol. 2015 Jan;26(1):160-72. 7) Pei
Y, Obaji J, Dupuis A, Paterson AD, Magistroni R, Dicks E, Parfrey P, Cramer
B, Coto E, Torra R, San Millan JL, Gibson R, Breuning M, Peters D, Ravine
D. Unified criteria for ultrasonographic diagnosis of ADPKD. J Am Soc
Nephrol. 2009 Jan;20(1):205-12. 8) Lai S, Petramala L, Mastroluca D, Petra-
glia E, Di Gaeta A, Indino E, Panebianco V, Ciccariello M, Shahabadi HH,
Galani A, Letizia C, D’Angelo AR.Hyperaldosteronism and cardiovascular
risk in patients with autosomal dominant polycystic kidney disease. Medi-
cine (Baltimore). 2016 9) Bhutani H, Smith V, Rahbari-Oskoui F, Mittal A,
Grantham JJ, Torres VE, Mrug M, Bae KT, Wu Z, Ge Y, Landslittel D, Gibbs
P, O’Neill WC, Chapman AB1; CRISP Investigators. A comparison of ultra-
sound and magnetic resonance imaging shows that kidney length predicts
chronic kidney disease in autosomal dominant polycystic kidney disease.
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.
317. VASCULAR ENDOTHELIAL GROWTH FACTOR
INHIBITOR THERAPY AND CARDIOVASCULAR AND
RENAL DAMAGE IN RENAL CELL CARCINOMA
Lai S., Molfino A., Mangiulli M. 1, Esposito Y. 1, Innico G. 2,
Coppola B. 3, Mastroluca D. 4, Galani A. 5, Mariotti A. 6
Study Group on Geriatric Nephrology of the Italian Society of Nephrology
(SIN) Department of Clinical Medicine, Sapienza University of Rome, Rome,
Italy; 1Department of Internal Medicine and Medical Specialities, Sapienza
University of Rome, Rome, Italy; 2Department of Medicine DIMED, School of
Specialization in Nephrology, University of Padova, Padova, Italy.; 3Dialysis
Unit, San Giovanni Evangelista Hospital, Tivoli, Italy; 4Nephrology and
Dialysis Unit, ICOT. Hospital, Latina, Sapienza University of Rome, Italy.;
5
Department of Clinical and Experimental Sciences, University of Brescia,
Brescia, Italy; 6UOC Nephrology and Dialysis, A.Perrino Hospital, Brindisi
Background: Renal cell carcinoma (RCC) represents 2-3% of all adult
malignancies, with >210 000 new cases and 100 000 deaths annually; the
highest peak incidence is between 60 to 70 years of age. Recently, inhibi-
tion of tumour angiogenesis has been the focus of anticancer treatments.
Members of the vascular endothelial growth factor (VEGF) family and their
receptors (tyrosine kinase), were identified as regulators of angiogenesis,
and their overexpression is critical to tumour growth, including metastasis.
Angiogenesis inhibition, as a therapeutic strategy against malignancies, was
initially proposed by Folkman in 1971, and the findings observed have led
to the development of VEGF-targeted agents, either as monoclonal antibo-
dies against VEGF, or small tyrosine kinase inhibitors, that currently are the
most commonly used drugs, and have shown excellent results with signi-
ficant efficacy and safety. In particular, sunitinib malate, an oral multitar-
geted receptor tyrosine kinase inhibitor, known to inhibit VEGF receptors
(VEGFR1, 2 and 3), platelet-derived growth factor receptors (PDGFR a and
b), stem-cell factor receptor (c-KIT), Fms-like tyrosine kinase 3 receptor
(FLT3) and receptor encoded by the ret proto-oncogene, is approved for
the first- and second-line treatment of advanced and/or metastatic RCC.
The reported renal adverse effects of sunitinib were hypertension, protei-
nuria, renal insufficiency, and thrombotic microangiopathy, even if with a
very variable incidence, of renal failure, 12.4-65.6% (57% in patients with
pre-existing chronic kidney disease (CKD)), proteinuria, 41-63%, and
hypertension, 40-60%. Moreover, sunitinib, could be also associated with
cardiac toxicity, in particular with left ventricular dysfunction and car-
diomyocyte hypertrophy, but currently, knowledge on the effect of sunitinib
on cardiovascular risk and renal damage is limited. The aim of the study was
to evaluate, renal and cardiovascular damage, at baseline (T0) and after 3
months (T1) from initiating sunitinib therapy in patients with RCC.
Materials and Methods: Patients with metastatic RCC treated with suniti-
Poster
nib were enrolled. This population was evaluated before starting treatment
(T0) and after 3 months (T1). Laboratory and instrumental parameters,
including renal function, proteinuria, mineral metabolism, blood pressure,
interventricular septum (IVS) and left ventricular mass index (LVMI) were
recorded before and after treatment.
Results: Thirty-two patients (13 female, 19 male, mean age 62.7±9.9 years)
were enrolled. We observed overtime, a significant reduction in estimated
glomerular filtration rate (eGFR) (p=0.01), haemoglobin (Hb) (p=0.04)
and 25-hydroxyvitamin D (25-OH-VitD) (p=0.002), in association with a
significant increase in serum phosphorus (p<0.001), systolic blood pressure
(SBP) (p<0.001), diastolic blood pressure (DBP) (p<0.001), IVS (p=0.03)
and proteinuria (p<0.001); while we showed no significant differences in
glycosuria, phosphaturia, serum uric acid, intact parathormone, and LVMI.
Conclusion: Molecular targeting drugs are the new generation of cancer
chemotherapeutic agents aimed to interfere with proteins that are mainly
responsible for tumour growth or progression. In this study we found a
significant change in renal function, BP, proteinuria and some important
cardiovascular risk factors, such as anaemia, vitamin D deficiency, hyper-
phosphatemia and IVS, while we have no evidence of renal tubulopathy
indices. Therefore we recommend a careful assessment of renal function,
mineral metabolism, hemoglobin, and accurate monitoring of proteinu-
ria and blood pressure, in addition to an evaluation of echocardiographic
parameters, such as IVS and LVMI, should be performed at initiation of
sunitinib therapy and monitored regularly, in particular in patients who had
significant cardiovascular risk factors, including underlying hypertension,
dyslipidaemia, older age and CKD.
318. NEUROLOGICAL AND PSYCHOLOGICAL CHANGES
IN HEMODIALYSIS PATIENTS BEFORE AND AFTER THE
TREATMENT
Lai S., Molfino A., Mecarelli O. 1, Pulitano P. 1, Mastroluca D. 2,
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,
Mariotti A. 7
Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy;
1
Department of Neurology and Psychiatry, Sapienza University of Rome,
Rome, Italy; 2 Nephrology and Dialysis Unit, Hospital ICOT. Latina, Sapienza
University of Rome, Italy; 3Department of Neurology and Psychiatry, Catholic
University of Sacred Heart, Rome, Italy; 4Regina Elena National Cancer
Institute, Center for Tumor-related Epilepsy, UOSD. Neurology; 5Department
of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy;
6
Department of Internal Medicine and Medical Specialities, Sapienza
University of Rome, Rome, Italy, 7UOC Nephrology and Dialysis, A.Perrino
Hospital, Brindisi
Introduction: The prevalence of chronic kidney disease (CKD) is growing
in the world such as the number of patients needing dialysis. In ESRD the
morbility and mortality are higher than in the general population, and neu-
rological, psychological and cognitive disorders, could greatly contribute to
the morbidity, and poor quality of life of these patients.
Aim of the Study: The aim of this study was to assess the neurological
changes in haemodialysis (HD) patients, cognitive and psychological asses-
sment, and the correlation with risk factors associated to CKD.
Materials and Methods: 16 clinically stable patients on HD, and 15 healthy
controls (HC) matched for age and sex were enrolled. Clinical, laboratory
and instrumental examinations, as renal function, inflammatory markers
and mineral metabolism indexes, psychological (MMPI-2, SatP) and
cognitive tests (NPZ5) were carried out. Electroencephalogram (EEG) was
carried out before (T0) and after (T1) HD treatment.
Results: The patients showed significant differences between T0 and T1 in
theta/alpha index (p<0.001), in the absolute and relative power of delta and
theta band, and in absolute power of Beta 1 band of EEG respect to HC.
Moreover these patients showed significant difference respect to HC, for
inflammatory indexes (CRP and ESV; p<0.001, p<0.001), mineral metabo-
lism indexes, as parathormone (iPTH), 1-25 dihydroxyvitamin D3 (1, 25–
(OH)2D3) (p<0.001, p<0.001) serum uric acid (p=0.003), and hemoglobin
(Hb) (p<0.001). MMPI-2 clinical scales showed a significant difference
between two groups, in Depression (p<0.001), Paranoia (p<0.001), Hyste-
ria (p=0.037) and Psycopatic deviate (p=0.010), while MMPI-2 content
scale showed a significant difference in Cynism (p=0.005), Health Con-
cerns (p=0.053) and Family Problems (p=0.032). Also SAT P test showed
a significant difference between two groups in Factor I (psychological fun-
ctioning), Factor II (physical functioning) and Factor III (work), (p=0.045,
p<0.001, p=0.014). Moreover NPZ5 showed a significant difference between
183
Poster
HD patients and HC in Rey Auditory Verbal Learning test (RAVL test)
(List A and B, p<0.001, p=0.0145; respectively), digit span test (DS test)
(backword, p=0.0034), and Symbol Digit Modalities Test (SDMT test) (120
sec, p=0.0145).
Conclusions: This study showed that the EEG abnormalities improve, but not
significantly after HD, with a significant reduction in the Theta/Alpha index,
which could represent a reliable index of cerebrovascular damage, or indicate
a border, between normality and brain disfunction, being implicated in the
corticotherapy-cortical retroactivation mechanism. However, in our study,
the Theta/Alpha index has significantly improved after HD, but remained
significantly higher than HC. treatment, and persists significant differences
compared to HC. Even qualitative EEG data showed a more regular and
stable EEG after HD therapy but with persistent and significant differences
compared to HC, also in PCR, iPTH, Vitamin D, hemoglobin and uricemia
values. Moreover, our study showed cognitive and psycological difficulty, with
reduced quality of life in these patients. A routine assessment of neuropsycho-
logical features, in patients on HD, with a multidisciplinary approach could
contribute to make an early diagnosis with eventual proper treatment.
319. SARCOPENIA IN CHRONIC KIDNEY DISEASE
ON CORSERVATIVE AND REPLACEMENT THERAPY-
PRELIMINARY STUDY
Lai S., Muscaritoli M., Amabile M.I., Ettorre E. 1, Andreozzi P. 1,
Sgreccia S. 1, De Leo S., Mangiulli M. 2, Esposito Y. 2, Protopapa P.,
Perrotta A., Pintus G., Spagnoli A. 3, Molfino A.
Study Group on Geriatric Nephrology of the Italian Society of Nephrology
(SIN). MIOSIN. Study, preliminary results. Department of Clinical Medicine,
Sapienza University of Rome, Italy; 1Department of Cardiovascular,
Respiratory, Nephrological, Anaesthetic and Geriatric Sciences, Sapienza
University of Rome, Rome, Italy; 2Department of Internal Medicine and
Medical Specialities, Sapienza University of Rome, Rome, Italy; 3Department
of Statistics Sciences, Sapienza University of Rome, Italy
Background: Chronic kidney disease (CKD) is a common condition with a
high cardiovascular morbidity and mortality, associated with emerging risk
factors, such as sarcopenia and dynapenia. Several conditions may affect
muscle mass in CKD, including metabolic, nutritional and inflammatory
changes, leading to worse cardiovascular outcomes and cognitive function
in this population. AIM: To evaluate the prevalence of sarcopenia (based on
European Working Group on Sarcopenia criteria), dynapenia and sarcope-
nic obestity in CKD patients on conservative therapy (stage 3-5 KDOQI)
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
dysfunction and with psychological and cognitive function.
Materials and Methods: A total of 77 patients (32 male), with a mean age
of 69.57 ± 9.84 years, were consecutively included. Clinical, laboratory and
instrumental examinations, including Bioimpedance Analysis (BIA), Hand
Grip Strenght, Intima Media Thickness (IMT), Ankle Brachial Pressure
Index (ABPI), Flow Mediated Dilation (FMD) and evaluation of epicar-
dial adipose tissue (EAT) were performed, as well as analysis of psycho-
logical and cognitive status by Montreal Cognitive Assessment (MoCA),
Mini-Mental State Examination (MMSE), and Geriatric Depression Scale
(GDS).
Results: The prevalence of sarcopenia was of 49.4% (44, 7% in HD, 10, 5%
in DP, 13, 2% in KT patients and 31.6% in patients on conservative therapy),
while the prevalence of dynapenia and sarcopenic obesity in the entire
population was 10.4% and 2.6%, respectively. Patients with sarcopenia
showed higher IMT (p=0.03), EAT (p=0.003) values with respect to non
sarcopenic patients, and lower FMD (p=0.003), total cholesterol (p=0.006),
HDL (p=0.004), base excess (BE) (p=0.048) bicarbonate (HCO3) (p=0.04),
Vitamin D (p=0.047) and lower estimated basal metabolism rate (p=0.03).
Using cognitive tests, we found in sarcopenic patients lower MOCA values
(p=0.029) e higher GDS score (p=0.05), whereas we did not find differences
between the 2 groups in MMSE (p=0.096).
Conclusion: In our study, we found a high prevalence of sarcopenia in CKD
patients and in patients on replacement therapy with a significant change
in early systemic markers of atherosclerosis and endothelial dysfunction.
Sarcopenic patients showed alterations in cognitive function and in mood.
Sarcopenia is often an underestimated condition in patients with reduced
renal function and a systematic assessment of the muscular component,
by simple, inexpensive and non-invasive methods, may be useful to better
define the prognosis and the cardiovascular risk in these patients.
184
118° Congresso Nazionale - Società Italiana di Medicina Interna
320. EFFECTS OF UNDERLYING RENAL DISEASE ON
NUTRITIONAL AND METABOLIC PROFILE IN OLDER
ADULTS WITH REDUCED RENAL FUNCTION
Molfino A. 1, Lai S. 1, Amabile M.I. 1, Altieri S. 2, Mastroluca D. 3,
Lai C. 4, Aceto P. 5, Crudo M. 6, Rossi Fanelli F. 1, Muscaritoli M. 1
1
Department of Clinical Medicine, Sapienza University of Rome, Rome,
Italy 2Department of Clinical and Molecular Medicine, Sapienza University
of Rome, Sant’Andrea Hospital, Rome, Italy. 3Department of Internal
Medicine and Medical Specialties, Sapienza University of Rome, Rome,
Italy. 4Department of Dynamic and Clinic Psychology, Sapienza University
of Rome, Rome, Italy 5Department of Anesthesiology and Intensive Care,
Catholic University of Sacred Heart, Rome, Italy 6Software House INTECS.
S.p.A., Rome, Italy
Background and Aim: Chronic kidney disease (CKD) is highly prevalent
among older adults and increased risk of cardiovascular disease is frequent
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
without known renal disease.
Patients and Methods: Consecutive outpatients aged ≥65 years with
reduced renal function were enrolled and divided into 2 groups: Group A
(patients with history of renal disease) and Group B (patients with unknown
renal disease). Nutritional and metabolic parameters, including involuntary
body weight loss (BWL) in the previous 6 months, mineral metabolism,
inflammatory indices, and left ventricular mass index (LVMI), were deter-
mined. Parametric and non-parametric tests were performed as appro-
priate, and P < 0.05 was considered statistically significant.
Results: Seventy-six consecutive patients were enrolled. Group A (n = 39,
M: 24) showed greater BWL with a significant reduction of 25-hydroxyvita-
min D, transferrin, cholinesterase, albumin, and greater LVMI with respect
to Group B (P < 0.01). In addition, Group A showed significantly increased
intact parathyroid hormone, total cholesterol, low-density lipoprotein, tri-
glycerides, and C-reactive protein when compared to Group B (P < 0.05).
Conclusions: The positive history of renal disease may negatively impact on
several nutritional and metabolic parameters related to increased cardiova-
scular risk among older adults.
Essential References:
Hallan SI, et al. Nephron Clin Pract 2010
Muscaritoli M, et al. Curr Opin Clin Nutr Metab Care 2009
Lai S, et al. Ren Fail 2014
Molfino A, et al. J Cachexia Sarcopenia Muscle 2014
321. A URINARY CAUSE OF ENCEPHALOPATHY
Struglia M. 1, Di Giosia P. 1, Halmagy S.A. 1, Boni M.. 2,
Calcinaro F. 1
1
UOC Medicina Interna, Ospedale “Mazzoni”, Ascoli Piceno 2UOC
Nefrologia, Ospedale “Mazzoni”, Ascoli Piceno
A 42-year-old woman was referred to our Department with a decreased
level of consciousness of unknown cause. Her previous medical history was
unremarkable except for of congenital bladder exstrophy treated with ure-
terosigmoidostomy as a child. She presented gradual onset of drowsiness
and confusion. She was afebrile, semicomatose and exhibited myoclonic
movements of her limbs. Within few hours she became deeply comatose
(Glasgow coma scale = 3). Toxicology screen was negative and brain CT
scan was normal. Blood test revealed severe hyperammonemia and meta-
bolic acidosis. Other biochemical values including renal and liver function
tests were normal. The electroencephalogram did not show any seizures,
but showed severe encephalopathic changes with triphasic waves consi-
stent with metabolic encephalopathy. The patient underwent continuous
venous hemofiltration for two consecutive days with sustained correction
of ammonia levels. Urea cycle disorders were ruled out by serum amino
acid chromatography and abdominal CT scan excluded hepatic failure and
portosystemic shunt. Blood cultures were negative. Patient was treated
with protein restriction, lactulose therapy and sodium/potassium citrate.
She improved clinically and returned to her premorbid functional status.
Otherwise, laboratory and clinical examinations during follow-up at our
department were unremarkable. In this moment, we are considering the
conversion of urinary diversion to an ileal conduit in order to normalize
ammonia levels and to avoid the risk of relapses. The above case presenta-
tion illustrates a rare yet potentially fatal complication of urinary diversion.
It should alert the readers to consider the diagnosis of hyperammonemia in
118° Congresso Nazionale - Società Italiana di Medicina Interna
any patient with a urinary diversion who presents acutely confusion, agita-
tion, stupor and decreased levels of consciousness. Rapid recognition and
treatment can prevent serious complications such as encephalopathic coma
and death.
322. DIALYTIC TECHNIQUES AND CARDIOVASCULAR
COMPLICATIONS
Raimondi G. 1, Marchitto N. 2, Sindona F. 1, Stranges V. 2,
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.
Fiorini” Hospital
Cardiovascular disease remains the leading cause of death in end-stage renal
endothelial (ESRD) patients, coupled with a reduction in haemodialysis
tolerability. Cardiovascular instability, expressed as intradial hypotension
(IDH), represents the most frequent clinical complication and significantly
affects morbidity and mortality of patients, leading to numerous cardiova-
scular complications. It can also contribute to chronic hyperhydration due
to inability to reach the dry weight and lead to sub dialysis.
Two are the most widely used dialysis techniques: standard (HD) diffusion -
and hemodiafiltration (HDF) - convective - in its variants.
Aim: The aim was to compare the effects of the two purification methods
on removing uremic toxins, cardiovascular stability and haemoglobin levels
in order to evaluate their effectiveness on improving clinical conditions
and reducing cardiovascular risk. Material and Methods: The study was
longitudinal, multicentre, prospective and non-randomized, from 2015 to
2017. 52 subjects (36 M, 16 F) from two Dialysis Centers in the province
of Latina, aged 35 to 92, with good vascular access (Qb> 250 ml/min) were
examined. Subjects with a dialysis age less than one year were excluded. We
compared the values at time zero (T0) and six months (T6) of 26 patients
with mean age 68.7 (16 M, mean age 67.3 - 10 F, mean age 71.1) in HD and
26 Patients with mean age 72.8 (20 M, mean age 71.95 - 6 F, mean age 75.3)
in convective treatment (HDF online, HDF Evolution, HDF Aequilibrium).
The parameters considered were: KT/V, Azotemia, Haemoglobin, Sodium,
Potassium, Calcium, SAP, DAP and HR. Statistical analysis has been perfor-
med by SigmaStat. 3.5 software.
Results: The main parameter considered was the Kt/V index of purity dialy-
sis: both in T0 and T6 there was a statistically significant difference (1.28 ±
0.28 vs 1.51 ± 0.17 1, 1.28 ± 0.27 vs. 1.54 ± 0.25 1). As well as K post dialysis
(4.73 ± 0 vs. 3.98 ± 0.24 1, 4.53 ± 0.35 vs. 3.44 ± 0.007 2 mmol/l) while Ca
showed a significant difference only to T6 (8.64 ± 0.59 versus 9, 38 ± 1.03
1
mg/dl). Hemodynamic parameters showed greater stability both of the
systolic and diastolic and FC rates although they did not achieve statistical
significance as well as sodiemia. Post-dialysis haemoglobin values tend to
be more stable in HDF.
Discussion: In this study, the best hemodialytic method was evaluated in
the management of cardiovascular complications as well as other hydro-e-
lectrolytic-metabolic aspects. HDF has shown to mprove intradial hemo-
dynamic stability with respect to HD, allowing at the same time a better
purification and allowing the ideal weight to be achieved by effectively
subtracting liquids without abuse of increased conductivity. The results
allow to confirm the higher effectiveness of HDF than HD in cardiovascular
management among these subjects. It is currently being evaluated for the
hydration status by bio-impedance, which will provide an interesting data
for evaluation of bodily fluids.
Conclusion: We observed results highlighting HDF advantage in terms
of lower cardiovascular complications, this allowing incidence reduction
without causing any significant increase in natrium and at the same time
improving dialysis purification. These results agree with major studies sug-
gesting high flow synthetic membranes usage and high exchange convective
methodology as a technique to obtain the best results about uremic toxins
removal and hemodynamic stability improvement.
323. PREVALENCE OF ELECTROLYTE DISORDERS IN
INTERNAL MEDICINE: COMORBIDITY AND RISK
FACTORS
Castellino P., Scuto S., Murabito A.R., Reale S., Ferrigno C.,
Zanoli L.
Dipartimento di medicina clinica e sperimentale, Università di Catania,
Policlinico di Catania, UO Medicina Interna
Poster
The electrolyte disorders are the most frequent disease in hospitalized
patients in Internal Medicine. Disorders of Sodium and Potassium are asso-
ciated to worse prognosis if not promptly recognized and treated. In this
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,
hearth failure, arterial hypertension in management with diuretics and far-
macologic polytheraphy (> 5 drugs). In conclusion, the electrolyte disorders
are frequent in Internal Medicine and are very important a prompt diagno-
sis and management.
324. A CASE OF NEPHROTIC SYNDROME IN A WOMEN
Serra C., Valenti A., Cabras P., Filigheddu F., Manetti R.
Istituto Clinica e Terapia Medica Sperimentale, Università degli studi di
Sassari
We report the case of a 44 years old woman with obesity, osteoporosis and
chronic venous insufficiency, who was admitted to our department for oli-
guria, dyspnoea and massive peripheral edema. She also reported a history
of recurrent cystitis, the last episode one month before hospitalization.
One week before hospital admission she had noted progressive diuresis
reduction, until only one concentrated urination per day, lumbosacral pain,
mild dysuria, weight gain and edema, especially of the face and of upper
and lower extremities. For this reason, she had started a domiciliary treat-
ment with ciprofloxacin, suspecting an urinary tract infection (UTI). Phy-
sical examination showed generalized edema and vesicular breathing quite
decreased inferiorly at the chest examination; the other clinical features were
normal; body weight was 124 kg (from her previous 115 kg), blood pres-
sure and other vital signs were normal; the first line laboratory evaluation
suggested a nephrotic syndrome with increased level of serum Creatinine
(1, 86 mg/dl), albumin deficiency (1, 8 g/dl), hyperlipoproteinemia (total
Cholesterol 369 mg/dl, HDL. 60 mg/dl; triglycerides 169 mg/dl); at the uri-
nalysis: microscopic haematuria, heavy proteinuria (20 g/day), white blood
cells and a sediment of hyaline and granular casts. Creatinine clearance was
54.9 ml/min. There was also mild hyponatremia (serum sodium level = 132
mEq/L), hypokaliemia (serum potassium level = 3.3 mEq/L); serum protein
electrophoresis was normal; urine culture was negative for UTI. Chest X-ray
confirmed pleural bilateral effusion, the echocardiogram was substantially
normal. Abdominal ultrasound showed a renal cortex with increased echo-
genicity but no other pathogenic findings. Considering the hypothesis of a
neoplastic disorder, a screening for malignancies (including mammography,
colonoscopy and HRCT) was done with negative results. Because of the
presence of high level of Ca 125, pelvic echotomography and gynecological
examination were performed, again with negative findings. Autoimmunity
tests were negative; the study of coagulation profile did not detect defects,
except low protein S. levels. Due to technical problems we could perform a
renal biopsy only after 16 days from the beginning of symptomatology: it
showed a mild form of mesangial glomerulonephritis, with poor intersti-
tial inflammation and possible focal glomerulosclerosis; immunoflorescent
assays did not identify definite granular deposits. After urinary catheterisa-
tion a diuretic bolus treatment with furosemide 20 mg i.v. four times a day
and potassium canreonate 100 mg once a day were started, strengthened by
fluid restriction and decreased salt intake, with an improvement of diuresis
(about 1500 ml/24 h); it was administered a prophylactic anticoagulation
and the patient didn’t receive steroids. After nephrology consultation, with
a daily continuous infusion of furosemide 125 mg, albumine 20 g and bicar-
bonates 20 mEq, diuresis increased and we observed a progressive reduction
of peripheral edema. 2 weeks after the admission the body weight was 113
kg and the diuresis was about 4000 ml/day; we then switched to oral furo-
semide 25 mg twice a day and potassium canrenoate 50 mg a day. Labora-
tory testing revealed progressive normalization of renal function (Serum
Creatinine: 0, 84 mg/dl; normal electrolytes levels; important reduction on
proteinuria). Ambulatory follow-up showed total normalization of pro-
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
of Minimal change disease (MCD), a major cause of nephrotic syndrome
in both children and adults. In particular MCD. accounts for 10 to 25%
of cases of nephrotic syndrome in adults. Regarding the pathogenesis, its
underlying cause is not clear but studies suggest that systemic T. cell dysfun-
ction results in the production of a glomerular permeability factor (many
data suggest the role of Interleukin 13), resulting in alteration of podocytes:
electron microscopy shows the characteristic histological lesion, the efface-
ment or “fusion” of the podocyte’s foot processes. On the other hand, it is
185
Poster
important to underline glomeruli normal appearance on light microscopy
and the absence of complement or Ig deposits on immunofluorescence.
While most cases are idiopathic, secondary MCD. is associated with drugs
(NSAIDs and antimicrobial use), malignancies (particularly hematologic
like Hodgkin Lymphoma, rarely solid tumors), infections (like tubercolosis
or hepatitis virus), allergies to multiple allergens and autoimmune condi-
tions. Clinical manifestations are: sudden onset over days to some weeks
of a nephrotic syndrome with proteinuria (usually 3.5-4 g/day, occasionally
more than 15 to 20 g/day) and microscopic hematuria, edema, hyperten-
sion, hyperlipidemia, modest increase in serum creatinine concentration.
Possible complications are: increased risk of thromboembolism and suscep-
tibility to infection, while acute renal failure is infrequent. Generally, a renal
biopsy is essential in adults who present the nephropathy syndrome to guide
diagnosis and therapy; differential diagnosis includes Focal Segmental Glo-
merulosclerosis (FSGS). First line therapy is a low-sodium diet and diuretics
for fluid removal, glucorticoid theraphy is the treatment of choice, leading
to a complete remission in over 85 to 90 % of cases; ACE. inhibitors/ARBs or
statin therapy are not necessary in normo-tensive patient. Untreated cases
of MCD. are associated with a high risk of mortality, but the spontaneous
remission is possible (5 to 10%). End-stage renal disease is rare; 50 to 65% of
adults will have a relapse within 1 or 2 years, especially after viral infection.
325. UNDERNEATH CHRONIC PAIN: TWO CASE
REPORTS
Gabba M., Masotti M., Formagnana P., Bergamaschi G.,
Corazza G.R.
Dipartimento di Medicina Interna Clinica Medica I, Reparto 11, Policlinico
San Matteo Università degli studi di Pavia
Introduction: Pulmonary carcinomas are malignancies highly prevalent
throughout the world. They are characterized by biological aggressivity,
insidious onset, difficulty in early detection, early metastatic spread and
poor prognosis at the time of presentation. The most frequent symptoms of
presentation are cough, weight loss, dyspnea and chest pain; also hemopty-
sis, fatigue and paraneoplastic syndromes such as inappropriate ADH secre-
tion, Lambert Eaton or ectopic ACTH production can be associated. Most
lung cancers do not cause any symptoms until they have spread, and about
30% to 40% of people with lung cancer have some symptoms or signs of
metastatic disease. Lung cancer most often spreads to the liver, the adrenal
glands, the bones, and the brain. We here present two case reports in which
the unusual presentation (osteoarticular pain) delayed the diagnosis.
Case presentation 1: a 66 years old man admitted for long standing right
shoulder pain, treated but non responsive to NSAIDs. Clinical history:
Active smoker, vasculopathy complicated with PAOD. Treated for a few
months for calcific tendinopathy of shoulder cuff with infiltrative therapy
and steroids with scant benefits.
Clinical course: At time of admission patient presented with edematous
right arm. Vascular EcoDoppler showed deep venous thrombosis of sub-
clavian and axillary veins; a CT scan showed segmental and subsegmental
pulmonary embolism of the right lower lobe. A colliquative expansive mass
at the right thoracic inlet was also detected, together with bone metasta-
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
therefore addressed to oncologic follow up.
Clinical presentation 2: 55 years old female patient admitted for aggra-
vating left leg pain described in sciatic syndrome features and treated by
general practitioner with high doses of NAIDs for a few months with no
benefits. Clinical history: Active smoker, essential arterial hypertension.
Clinical course: At time of admission patient appeared severely sarcopenic
and suffering. When CT scan was obtained, an expansive pulmonary lesion
with speculated margins and satellite micronodules was disclosed, together
with multiple disease localizations involving liver and bones, particularly
vertebral bodies and causing multiple vertebral collapses, including L4.
Bronchoscopic examination was performed in order to obtained an histo-
logic typization of the neoplasia, but the procedure was non conclusive due
to the localization of the primary lesion. In consideration of the extremely
advanced stage of the disease and severely compromised organic status of
the patient, pain- control therapy with opioids was assessed. Patient died
due to massive pulmonary effusion causing respiratory failure three weeks
after hospitalization.
Conclusion: we report these clinical cases in order to describe two unusual
and misleading presentation of lung cancer.
186
118° Congresso Nazionale - Società Italiana di Medicina Interna
326. RARE ABDOMINAL MASS: A CASE REPORT
Mastropierro V. 1, Perrone A. 1, Mazzoccoli C. 1,
Castiglione Minischetti M. 1, Ingravallo G. 2, Cimmino A. 2,
Minerva F. 3, Sabbà C. 1
1
“Frugoni” Internal Medicine Unit, Policlinico Hospital, University of Bari
“Aldo Moro”, Bari, Italy 2 Pathological Anatomy Unit, Policlinico Hospital,
University of Bari “Aldo Moro”, Italy 3 “A. Murri” Internal Medicine Unit,
Policlinico Hospital, University of Bari “Aldo Moro”, Italy
Numerous nosological entities can manifest with an abdominal mass,
including bulky lymphoma and solid neoplasms affecting liver, kidney, or
gastrointestinal tract. Some of these entities usually arise in adulthood, while
other diseases are characteristic of pediatric age. A young male patient, 23
years old, presented to our observation on April 2017 at “Frugoni” Inter-
nal Medicine Unit of our Institution, with abdominal pain, arising ten days
earlier, not associated with fever, nausea or vomiting. The patient had no
relevant personal history.
The patient reported appearance of an abdominal mass in para-umbilical
region, two months before, with increasing volume, initially neglected by
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
through umbilical, hypogastric, and right iliac regions, and appearing hard,
firm and not painful at palpation. Lymph nodes, spleen and liver were not
palpable. Laboratory tests revealed normal blood count, liver and renal fun-
ction, inflammation and neoplastic markers. Abdominal ultrasound (US)
showed a solid inhomogeneous pseudonodular formation in umbilical
region, displacing intestinal loops. Total-body CT investigation disclosed
multiple focal areas in parietal peritoneum, mild endoabdominal effusion,
and retroperitoneal multiple solid iso-hypoechoic formations, measuring
up to 13 cm, and signs of hepatic infiltration.
Upon US-guided transabdominal needle aspiration, bioptic specimen
was obtained and directed to histologic exam, with evidence of morpho-
logical and immunophenotypic features (NSE +, EMA+, cytokeratin pool
+, desmin +, WT1c +, vimentin +) clearly indicating desmoplastic small
round cell tumor (DSRCT). Molecular characterization revealed EWSR1
gene rearrangement.
The patient was subjected to chemiotherapy treatment course (cyclopho-
sphamide-epidoxorubicin-vincristin- ifosfamide-etoposide), aiming to
reduce tumor mass size, and to permit subsequent surgical excision.
DSRCT is a rare malignancy, belonging soft-tissue sarcoma family, with less
of 1, 000 cases insofar described. It is a highly aggressive tumor, which affect
males in 90% of cases, usually young, and typically shows typical regional
localization (abdominal and pelvic). Prognosis is poor (44% global 3-years
survival). No environmental/familial risk factors or definitive therapeutic
approaches have been identified, despite variable combinations of surgery,
chemotherapy, radiotherapy and molecular therapy. In conclusion, in pre-
sence of an unexplained abdominal mass in a young male patient, diffe-
rential diagnosis should take into account this rare malignancy, which is
often characterized by a delayed diagnosis, due to usually silent, albeit fast-
growth, course. Early diagnosis can prompt appropriate and timely thera-
peutic approach.
327. EARLY EVALUATION OF ANOREXIA AND NUTRIENT
INTAKE IN CANCER PATIENTS
Molfino A. 1, Nuglio. C. 2, Emerenziani S. 2, Falco S. 1,
Trillo M.L.A. 2, Ferravante F. 2, Cicala M. 2, Amabile M.I. 1,
Rossi Fanelli F. 1, Muscaritoli M. 1
1
Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
2
Gastroenterology Unit, University Campus Bio-Medico di Roma, Rome, Italy
Background and Aim: Anorexia, i.e. the loss of the desire to eat, reduced
food intake (hypophagia) and body weight loss (WL) are very common in
advanced cancer patients and may lead to nutritional impairment, in turn
negatively affecting morbidity and mortality. The aim of the present study
was to early evaluate the prevalence of anorexia, hypophagia, energy and
protein intakes in patients with gastrointestinal and lung cancer at first
oncology visit. Material and Methods: Seventy patients (37 M, aged 62±12
years) were enrolled. Body mass index (BMI: kg/m2), 6-months WL (%),
pre-cachexia, cachexia and serum C-reactive protein (CRP) were assessed.
Anorexia was assessed by two specific questionnaires. Energy (kcal/kg/day)
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-
118° Congresso Nazionale - Società Italiana di Medicina Interna
vely) (Table1). Hypophagia was defined for energy and protein intakes ≤
70% of the recommendations. Prism 5.0®software was used for statistical
analysis.
Results: BMI was 22±4 kg/m2; WL was 11±7%. Fourteen patients (21%)
were pre-cachectic and 54 (78%) were cachectic. The highest prevalence
of anorexia (80%) and hypophagia (80%) were present in gastro-esopha-
geal cancer and higher in patients with elevated CRP levels (77%). Table 1.
Recommended vs actual energy and protein intakes
Conclusions: Anorexia and inadequate nutritional intake were highly pre-
valent in cancer patients at first oncology visit. Energy and protein intakes
were significantly lower that recommended in pancreatic and gastro-e-
sophageal cancer patients. This study strengthens the view that nutritional
abnormalities may be present at the onset of cancer disease and therefore
supports the need of early and appropriate nutritional interventions in order
to prevent or treat cancer cachexia and its negative consequences.
328. MILIARY PULMONARY OPACITIES:
A CHALLENGE FOR CLINICIANS
Rossio R. 1, Fares R. 1, Ferrari B. 1, Andrisani M.C. 2, Peyvandi F. 1
1
Fondazione IRCCS Ca granda Ospedale Maggiore Policlinico, Dipartimento
di Medicina Interna, UOC di Medicina generale-Emostasi e Trombosi 2
U.O. Radiologia, Dipartimento dei Servizi, area Diagnostica per immagini.
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
A 80 year-old Caucasian man presented to the emergency department with
worsening dyspnoea on exertion, peripheral oedema, cough and fever in
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
120/60 mmHg, pulse rate 61 beats/min, respiratory rate 30 breaths/min and
oxygen saturation 88 % on room air. On chest examination, bibasilar inspi-
ratory crackles were present. Chest X-ray showed bilateral increased lung
markings, more evident at the right periilar region with diffuse bilateral
reticulo-nodular interstitial pattern. Blood analysis showed normal levels
of total white blood cells and C-reactive protein. High resolution computed
tomography (HRCT) confirmed a right apical mass with irregular margins,
multiple micronodules spread throughout both lungs and a right pleural
effusion. Both thoracentesis and bronchoscopy with bronchoalveolar lavage
excluded bacterial, fungal and tubercular infections; cytologic analysis
showed reactive mesotelial cells. 18F-fluorodeoxyglucose-Positron Emis-
sion Tomography (18FDG-PET) showed increased glucose metabolism in
the pulmonary nodules (with Standardized Uptake Value - SUV- of 6, 5) in
the right pulmonary mass, in the right supraclavicular lymph nodes and in
the fourth thoracic vertebra. A lymph node biopsy was performed, revealing
metastatic pulmonary carcinoma localization. Based on age and comorbidi-
ties, the patient underwent chemotherapy. Despite when lung micronodular
miliary pattern is detected, pulmonary tuberculosis (i.e. tubercoloma with
miliary tuberculosis) is usually suspected, it is necessary to consider a dif-
ferential diagnosis with lung cancer and haematogenous metastases. Less
frequently, this pattern can be detected in fungal infections (histoplasmosis,
coccidioidomycosis, etc), in silicosis and in histiocytosis x. In addition to
clinical clues (physical signs and symptoms, comorbidities, risk factors and
environmental exposures), the HRCT of the lungs represents a crucial tool
for differential diagnosis, through identifying and differentiating the pattern
of distribution of the pulmonary micronodules. In our patient, the first dia-
gnostic hypotheses was a tuberculoma, due to the typical localization of the
pulmonary consolidation in the apical segment of the upper lobes, radiating
to hilum, associated to a miliary tuberculotic spread and pleural effusion.
The differential diagnosis with a primary lung cancer of the right upper lobe
with diffuse hematogenous dissemination was also considered, despite the
presence of hundreds small metastases scattered throughout both lungs is
very rare in patients with primary lung cancer. The tissue biopsy was indeed
essential for correct diagnosis.
329. THIS IS NOT PULMONARY EMBOLISM
Stasi C., Capurso M., Belfiore A., Minerva F., Palmieri V.O.,
Pugliese S., Buonamico P., Portincasa P.
Clinica Medica “A. Murri”, Department of Biomedical Sciences and Human
Oncology, University of Bari “Aldo Moro” Medical School, Bari, Italy
A 71-years-old woman, smoker, suffering from blood hypertension and
depression was admitted to Emergency Department. In the last month she
Poster
suffered of transient global amnesia, lack of attention, ataxia, dizziness,
dyspnea and chest pain. Blood analyses showed hypoxemia, hypocapnia
(pO2: 70 mmHg, pCO2: 30 mmHg), hyponatremia (120 mEq/L) and incre-
ased D-dimers (744 μg/L). These features were highly suggestive of pulmo-
nary embolism, considering neurological symptoms justified by hypoxia,
hypotension and electrolyte squilibrium. A perfusion lung scan performed
urgently (due to allergic diathesis) displayed perfusion deficit at the upper
segment of the lower left lobe, and suggested the diagnosis of pulmonary
embolism. After admission to Internal Medicine Division, a neurological
evaluation and CT scanning of the head were negative, chest X-ray showed
mediastinum flaring, while echocardiography highlighted dilatation of pul-
monary artery and its main branches with mild to moderate pulmonary
hypertension. Anticoagulation with LMWH and rehydration therapy with
saline solution were started. Because no improvement of both natriemia and
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-
chus and infiltrating the left branch of the pulmonary artery with compres-
sion of the superior vena cava. Histology, performed on pulmonary biopsy
by broncoscopic sonography concluded for small-cell lung cancer (SCLC),
likely responsible for paraneoplastic syndrome of inappropriate antidiuretic
hormone secretion (SIADH).
Conclusion: We describe a misleading case of “pulmonary embolism”. This
first diagnosis was not supported because of persistent hyponatremia and
initial therapeutic failure. The ultimate diagnosis (small-cell lung cancer and
paraneoplastic syndrome) relied on chest CT. When considering the dia-
gnosis of pulmonary embolism by lung perfusion scan, if deep vein throm-
bosis is excluded, chest CT has a key role to address the final diagnosis.
330. PULMONARY TUMOR WITH PLEURAL
INVOLVEMENT.TIA.PERSISTENT ATRIAL FIBRILLATION.
HYPERTENSIVE CARDIOPATHY.MILD MITRAL
INSUFFICIENCY.CHRONIC CEREBRAL VASCULOPATHY.
OBESITY.VSA ATHEROSCLEROSIS. POST-SURGICAL
HYPOTHYROIDISM IN SUBSTITUTION THERAPY
1
Stellitano E., 1Aronne V., 1Caserta C., 1Carerj B., Fulgido A.,
1
Lipari P., 1Meduri G., 1Scordo A., 1Tarzia I., 2Stellitano A.,
1
U.O.C. 2U.O.C. Geriatria P.O. Ospedale S.Anna- San Fermo della Battaglia
-ASST. Lariana Como. Medicina interna P.O. Melito Porto Salvo(RC) –ASP.
Reggio Calabria
Female patient, 76y.o. Hypertension in treatment, pre-existing thyroidec-
tomy with substitution therapy, previous right safenectomy. Episodes of
paroxysmal atrial fibrillation for years. Persistent atrial fibrillation for a week.
Hypertensive crisis since three days before hospitalization.She is hospitaliz-
sed for strength deficit at right hand and loss of sensitivity. B.P.140/80, ECG:
AF, HR84b/m.Patientalert. ChestPE: negative. Cardiac P.E.: arrhythmias,
A(rterial) B(lood) G(as): normal, normal haematochemical examinations,
Brain CT: periventricular white hypodensity for chronic cerebrovascular
suffering without signs of focallesions.
Treatment: LMWH, Antihypertensive, atorvastatin, eutrirox.Echodop-
pler:atherosclerosis of Supra-aortic Vessels. Echocardiography: hyperten-
sive cardiopathy, Mitral Insufficiency.
Brain CT control does not show any modifications. Chest RX: nodular
image with sharp outlines adherent to the posterior parietal pleura in the left
mid-subclavian field.Chest CAT with contrast: solid nodular formation with
probably heteroplasic uneven impregnation, about 6cm diameter, localized
to the upper segment of the Left Lower Lobe adherent to parietal pleura with
contiguity and continuity relationships with the back arch of the sixth rib,
where an areola of 11 mm diameter oval osteolysis and a cortical interruption
are present, no hilar and mediastinal lymphoadenomegalies, no focal lesions
due to the remaining parenchyma. Improvement of the clinical picture, no
strength deficit, no paresthesia in the right arm.
331. NOT TYPED LEFT UPPER PULMONARY
HETEROPLASY. COPD. OSAS. DILATATIVE
MYOCARDIOPATHY
1
Stellitano E., 1Aronne V., 1Caserta C., 1Carerj B., Fulgido A.,
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
Calabria; 2U.O.C. Geriatria P.O. Ospedale S.Anna- San Fermo della
Battaglia -ASST. Lariana Como
187
Poster
Male patient, 76 years old; hospitalised on 04/02/2017 for ingravescent
dyspnea, reduced diuresis, dysuria and widespread arthritis. Smoker
suffering from severe COPD with home LTOT, hypertensive dilated car-
diomyopathy, permanent AF in NOAC therapy, severe obesity, OSAS,
sigma diverticulosis.In 2016 chest RX: Left lung thickening. CT total body
without and with contrast: neoplastic pulmonary mass in the upper apical
left lobe segment, irregular and spliced margins with striations towards
the pleura and the scissure, multiple lymphadenopathies, pulmonary
micro-nodules in all segments. Hepatic nodular lesion, lymph nodes at
the gastric bend level, left ventricular nodular lesion at suprarenal level.
PET: presence of proliferative pulmonary primitive pathology and secon-
dary proliferative localization at lymphonodular, adrenal, liver, peritoneal,
osteo-medullary level. Hematochemical routine examinations within
standard limits, with the exception of increased transaminases, gamma-gt,
LDH. Some tumor markers (CEA, CA125, CA15.3) have increased. Cor-
ticosteroid therapy with improved dyspnea, pain therapy and O2 therapy.
On the fifth day the patient is discharged against doctors’ opinion. Male
patient, 76 years old; hospitalised on 04/02/2017 for ingravescent dyspnea,
reduced diuresis, dysuria and widespread arthritis. Smoker suffering from
severe COPD with home LTOT, hypertensive dilated cardiomyopathy,
permanent AF in NOAC therapy, severe obesity, OSAS, sigma diverticu-
losis.In 2016 chest RX: Left lung thickening. CT total body without and
with contrast: neoplastic pulmonary mass in the upper apical left lobe
segment, irregular and spliced margins with striations towards the pleura
and the scissure, multiple lymphadenopathies, pulmonary micro-nodules
in all segments. Hepatic nodular lesion, lymph nodes at the gastric bend
level, left ventricular nodular lesion at suprarenal level. PET: presence of
proliferative pulmonary primitive pathology and secondary proliferative
localization at lymphonodular, adrenal, liver, peritoneal, osteo-medullary
level. Hematochemical routine examinations within standard limits, with
the exception of increased transaminases, gamma-gt, LDH. Some tumor
markers (CEA, CA125, CA15.3) have increased. Corticosteroid therapy
with improved dyspnea, pain therapy and O2 therapy. On the fifth day
the patient is discharged against doctors’ opinion. Male patient, 76 years
old; hospitalised on 04/02/2017 for ingravescent dyspnea, reduced diure-
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
RX: Left lung thickening. CT total body without and with contrast: neo-
plastic pulmonary mass in the upper apical left lobe segment, irregular
and spliced margins with striations towards the pleura and the scissure,
multiple lymphadenopathies, pulmonary micro-nodules in all segments.
Hepatic nodular lesion, lymph nodes at the gastric bend level, left ven-
tricular nodular lesion at suprarenal level. PET: presence of proliferative
pulmonary primitive pathology and secondary proliferative localiza-
tion at lymphonodular, adrenal, liver, peritoneal, osteo-medullary level.
Hematochemical routine examinations within standard limits, with the
exception of increased transaminases, gamma-gt, LDH. Some tumor
markers (CEA, CA125, CA15.3) have increased. Corticosteroid therapy
with improved dyspnea, pain therapy and O2 therapy. On the fifth day
the patient is discharged against doctors’ opinion. Male patient, 76 years
old; hospitalised on 04/02/2017 for ingravescent dyspnea, reduced diure-
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
RX: Left lung thickening. CT total body without and with contrast: neo-
plastic pulmonary mass in the upper apical left lobe segment, irregular
and spliced margins with striations towards the pleura and the scissure,
multiple lymphadenopathies, pulmonary micro-nodules in all segments.
Hepatic nodular lesion, lymph nodes at the gastric bend level, left ven-
tricular nodular lesion at suprarenal level. PET: presence of proliferative
pulmonary primitive pathology and secondary proliferative localization at
lymphonodular, adrenal, liver, peritoneal, osteo-medullary level. Hemato-
chemical routine examinations within standard limits, with the exception
of increased transaminases, gamma-gt, LDH. Some tumor markers (CEA,
CA125, CA15.3) have increased. Corticosteroid therapy with improved
dyspnea, pain therapy and O2 therapy. On the fifth day the patient is
discharged against doctors’ opinion.
188
118° Congresso Nazionale - Società Italiana di Medicina Interna
333. BRONCHIECTASIS AND ASTHMA: ONLY A
COMORBIDITY OR A NEW PHENOTYPE?
Ferri S., Campisi R., Sorrentino R., Genco S., Heffler E., Crimi N., Augelletti T.
Istituto di Pneumologia Riabilitativa, Azienda Ospedaliera Universitaria
Policlinico Vittorio Emanuele, Catania
Introduction: Bronchiectasis (BE) is a chronic disease associated with high
morbidity e mortality. Several studies have enlightened pathophysiology,
microbiology and epidemiology of the disease, but few is known about its
phenotypes. We aimed to study the correlation between asthma and BE as
a new phenotype.
Methods: We consecutively enrolled all adult patients with a CT diagnosis
of noncystic fibrosis BE and treated asthma presenting to our Outpatients
Clinic in a 6-months period. Patients with traction BE were excluded. All
included patients underwent clinical and laboratory workup, lung function
tests and microbiological analysis of sputum. Asthma control test (ACT) was
submitted at the recruitment visit. We collected blood and sputum samples
and skin prick tests were conducted in order to define asthma phenotype.
Results: 16 patients (6 males/10 females; 1 current smoker, 4 ex smokers
and 11 non smokers) were enrolled into the study. BE were cylindric in 87%
and both cystic and cylindric in only 2 cases. 50% patients had BE in 4 lobes,
30% in 6 lobes and 20% in 2 lobes. Radiologically, 11 and 5 patients were
defined as mild and moderate respectively. None was found with severe BE.
The main hallmark was frequent, non-seasonal exacerbations (mean 4, 18/
year), with productive cough and non purulent phlegm. Microbiological
analysis was lead in sputum samples. Pseudomonas Aeruginosa was found
in 4 patients while no pathogens were found in the remaining samples. All
patients were negative for allergic bronchopulmonary aspergillosis (ABPA).
Mean ACT was 14.2. 50% of patients had both peripherical and sputum
eosinophilia. Lung function tests were normal or mildly obstructive in 81%
of patients, only 3 were moderate.
Conclusions: Asthma/BE patients seems to have worse symptoms in spite
of mild radiological and lung functional findings. We suppose that the asso-
ciation between Asthma and BE can play a role as a trigger for exacerbations
and it may be a new phenotype for both diseases.
334. JUST A PNEUMONIA?
Cabras P., Filigheddu F., Manetti R., Serra C., Valenti A., Ledda D.
Dipartimento di Medicina Clinica e Sperimentale, scuola di specializzazione
in Medicina Interna, Università di Sassari
We report the case of a 71 years old white man with progressively worse-
ning dyspnea, fever and productive cough. The arterial hemogasanalysis
showed a severe respiratory failure (pH 7.43, pO2 38.3 mmHg, pCO2 30.3
mmHg, Lactate 3.9 mmol/ L, bicarbonate 21.4 mmol/L). The patient was
dyspnotic, cyanotic, sweaty, tachycardic, with rales and velchro sound
spread throughout the lungs. He had a history of COPD (ex-strong
smoker), atrial fibrillation, diabetes mellitus, essential hypertension.
In the emergency department, a chest Rx was performed showing focal
bronchopneumonia and an important accentuation of interstitium. In our
department, we administered high flow oxygen (8l/min with 40% Venturi
mask), antibiotic therapy (Piperacillin/tazobactam and clarithromycin),
cortisone, diuretic and aerosol therapy. Blood and urine cultures were
negative, while sputum culture was positive. Cardiac ultrasound showed
pulmonary hypertension (PAPS 63 mmHg). A chest CT revealed incre-
ased interstitial markings with associated bronchiectasie, honeycomb
and ground-glass areas and calcific lung nodules. To better investigate
the nature of this interstitiopathy, we screened for autoimmune diseases,
viruses and uncommon germs, HIV, quantiferon which were all negative.
After seven days, the patient had a new CT-HR that showed improvement
in the picture; spirometry + DLCO showed a mild ventilatory restriction
deficiency and a severe reduction in the alveolo-capillary diffusion of the
gases. According to pneumological consult, the patient performed a bron-
choscopy that showed important inflammation in the whole bronchial
tree. Considering the improvement in symptomatology, laboratory and
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-
118° Congresso Nazionale - Società Italiana di Medicina Interna
Figure 1
gressive lung fibrosis which is anatomically and pathologically characterized
by a particular type of lung injury, which is defined as a pattern of common
interstitial pneumonia. A genetic basis and a relationship with smoke have
been suspected, but the causes of the disease have not yet been identified.
People affected by idiopathic pulmonary fibrosis are cured with cortisone
(which reduces the inflammation) and in some cases with drugs that lower
immune defenses and reduce connective tissue growth (such as azathioprine
and cyclophosphamide). Research has led to the recent approval of two drugs:
pirfenidone, with anti-proliferative, anti-inflammatory and anti-oxidant pro-
perties and nintedanib that inhibits the activity of certain tyrosine kinases.
Unfortunately it seems that the diagnosis generally occurs very late (about
one to two years after the first symptoms) and that death occurs in 50% of
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
questions: could this disease be diagnosed at the beginning, before irreversible
lung injury? When is the best timing to start experimental therapies? Does the
patient have to take prophylactic antibiotic therapy cycles?
335. CLINICAL ASSESSMENT OF ENDOTHELIAL
FUNCTION IN PATIENTS WITH CHRONIC OBSTRUCTIVE
PULMONARY DISEASE: A SYSTEMATIC REVIEW WITH
META-ANALYSIS
Ambrosino P. 1, Lupoli R., 1 Iervolino S., 2 De Felice A., 2 Pappone N., 2
Storino A. 3, Di Minno M.N.D. 4
1
Department of Clinical Medicine and Surgery, Federico II University, Naples,
Italy; 2ICS. Maugeri SpA. SB, Scientific Institute of Telese Terme - IRCCS,
Telese Terme (BN), Italy; 3Department of Public Health, Federico II University,
Naples, Italy; 4Department of Advanced Biomedical Sciences, Division of
Cardiology, Federico II University, Naples, Italy
Background: Patients with chronic obstructive pulmonary disease (COPD)
have an increased cardiovascular morbidity and mortality. Flow-mediated
(FMD) and nitrate-mediated dilation (NMD) are considered non-invasive
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
Poster
336. SUBCLINICAL CAROTID ATHEROSCLEROSIS IN
PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY
DISEASE: A META-ANALYSIS OF LITERATURE STUDIES
Ambrosino P. 1, Lupoli R. 1, Cafaro G. 1, Iervolino S. 2, Carone M. 3,
Pappone N. 2, Di Minno M.N.D. 4
1
Department of Clinical Medicine and Surgery, Federico II University,
Naples, Italy; 2ICS. Maugeri SpA. SB, Scientific Institute of Telese Terme
- IRCCS, Telese Terme (BN), Italy; 3ICS. Maugeri SpA. SB, Scientific
Institute of Cassano delle Murge - IRCCS, Cassano delle Murge (BA), Italy;
4
Department of Advanced Biomedical Sciences, Division of Cardiology,
Federico II University, Naples, Italy
Background: Chronic obstructive pulmonary disease (COPD) patients
have an increased cardiovascular (CV) morbidity and mortality. Common
carotid intima-media thickness (CCA-IMT) and carotid plaques are sur-
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
impact of COPD on CCA-IMT and on the prevalence of carotid plaques
were systematically searched.
Results. Twenty studies (2, 082 COPD patients and 4, 844 controls) were
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
carotid plaques (1, 231 COPD patients and 4, 222 controls). Compared to
controls, COPD patients showed a significantly higher CCA-IMT (mean
difference [MD]: 0.201 mm; 95%CI: 0.142, 0.260; P<0.001. Figure 1),
and an increased prevalence of carotid plaques (Odds Ratio [OR]: 2.503;
95%CI: 1.333, 2.175; P<0.0001). Meta-regression models showed a direct
association between disease severity [as expressed by Global Initiative for
Chronic Obstructive Lung Disease (GOLD) class] and the difference in
the risk of carotid plaques presence between COPD patients and controls.
Conclusions: COPD is significantly associated with subclinical athero-
sclerosis. These findings may be useful to plan adequate CV prevention
strategies.
189
Poster
337. ENDOTHELIAL FUNCTION IN PATIENTS WITH
CHRONIC OBSTRUCTIVE PULMONARY DISEASE: THE
EFFECT OF PULMONARY REHABILITATION
Ambrosino P. 1 Lupoli R., 1 Iervolino S., 2 De Felice A., 2 Pappone N., 2
Storino A. 3, Di Minno M.N.D. 4
1
Department of Clinical Medicine and Surgery, Federico II University,
Naples, Italy; 2ICS. Maugeri SpA. SB, Scientific Institute of Telese Terme -
IRCCS, Telese Terme (BN), Italy; 3Department of Public Health, Federico
II University, Naples, Italy; 4Department of Advanced Biomedical Sciences,
Division of Cardiology, Federico II University, Naples, Italy
Background: COPD is associated with subclinical atherosclerosis and
endothelial dysfunction. The effect of pulmonary rehabilitation (PR) on
markers of CV risk in COPD has not been extensively investigated. In the
present study, we tested the hypothesis that PR is able to improve endothelial
function assessed by flow-mediated dilation (FMD) in patients with COPD.
Methods: Consecutive COPD patients referred to ICS Maugeri, IRCCS,
Scientific Institute of Telese Terme, Benevento, Italy between June 2016 and
December 2016 for a comprehensive 40-session PR program were screened
for inclusion in the present study. All the major demographic and clinical
data were collected for each patient. Laboratory and lung function parame-
ters were assessed at admission (T0) and after completing the PR program
(T1).
Results: A total of 80 patients with COPD had full data collected before and
after PR. FMD significantly and substantially changed after the PR program
(Δ%FMD=3.5%), increasing from 7.1% ± 3.7 to 10.6% ± 4.8 (P<0.001).
Changes in FMD (Δ%FMD) following PR were positively correlated with
changes in FEV1 (Δ%FEV1) (r=0.33; P=0.003, Figure 1). After adjusting
for all potential confounders by means of multivariate analyses, Δ%FEV1
was an independent predictor of Δ%FMD (β=0.287; 95%CI: 0.248-1.350;
P=0.001). In particular, for each 1% increase in FEV1 a ≈ 6% probability of
FMD improvement was found (OR: 1.06; 95%CI: 1.01-1.12). In addition, we
found that patients experiencing an improvement in GOLD class more fre-
quently reported an improvement in FMD (OR: 7.86; 95%CI: 1.21-51.10).
Conclusions: Results of our prospective study suggest that endothelial fun-
ction could significantly improve after PR in COPD patients. Thus, PR could
be seen as an opportunity to modify the CV risk profile of these patients.
Figure 1. Relationship between changes in flow-mediated dilation (FMD)
and changes in forced expiratory volume in 1 second (FEV1) following
pulmonary rehabilitation.
338. CHRONIC OBSTRUCTIVE PULMONARY DISEASE
AND COMORBIDITIES: DATA FROM A LARGE COHORT
OF SOUTH ITALIAN PATIENTS
Sciacqua A. 1, Perticone M. 2, Falbo T. 1, Miceli S. 3, Iannello A. 1,
Bencardino G. 1, Cassano V. 4, Sesti G. 1, Perticone F. 1
1
Dipartimento di Scienze Mediche e Chirurgiche - Università degli Studi
Magna Graecia - Catanzaro 2Dipartimento di Medicina Sperimentale
e Clinica - Università degli Studi Magna Graecia - Catanzaro 3Azienda
Ospedaliero-Universitaria “Mater Domini” - Catanzaro 4Dipartimento di
Scienze della Salute - Università degli Studi Magna Graecia - Catanzaro
Chronic obstructive pulmonary disease (COPD) is a common public
190
118° Congresso Nazionale - Società Italiana di Medicina Interna
health problem worldwide, characterized by irreversible progressive airway
obstruction and systemic inflammation as a result of exposure to smoking,
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
COPD frequently suffer from comorbidities, such as cardiovascular disease
(CVD) and diabetes. Previous reports have shown that >60% of deaths in
patients with COPD are caused by comorbidities rather than by COPD
itself. The aim of this cross-sectional study was to evaluate, in a large group
of patients with COPD, the prevalence of associated comorbidities and to
identify clinic and biochemical characteristics able to phenotypically cha-
racterize affected patients. From 2010 to 2016, 893 outpatients, affected by
several comorbidities and referring to Geriatric Cardiovascular Disease
Unit, were enrolled. All patients underwent complete collection of clinical
history and physical examination and determination of biochemical para-
meters. Renal function was evaluated by measurement of estimated glome-
rular filtration rate (e-GFR) with CKD-Epi formula. COPD diagnosis was
defined by a standard spirometry according to the joint American Thora-
cic Society and European Respiratory Society Guidelines. Among enrol-
led patients, 603 were affected by COPD [COPD (+)], 441 males and 168
females, a 67% showed GOLD stage 1-2, 33% GOLD stage 3 and another
4.9% GOLD stage 4. In comparison with COPD (-) patients, those COPD
(+) were older (64.4+12.7 vs 58.9+12.4, p<0.0001), with higher prevalence
of males (77% vs 37%, p<0.0001) and smokers (62% vs 20%, p<0.0001).
They showed increased values of both systolic (140.7+18.2 vs 133.7+15.7,
p<0.0001) and diastolic blood pressure (82.1+10.5 vs 79.8+10.5, p<0.0001)
and lower values of body mass index (29.5+5.5 vs 31.2+6.2, p<0.0001),
HDL-cholesterol (48.1+13.2 vs 52.3+13.6, p<0.0001) and e-GFR (84.8+27.7
vs 115.2+36.1, p<0.0001). Of interest, levels of uric acid (6.1+1.6 vs 5.3+1.4,
p<0.0001), fibrinogen (340.1+75.1 vs 312.2+74.5, p<0.0001) and high sen-
sitivity-C reactive protein (hs-CRP) (6.1+3.1 vs 3.1+1.1, p<0.0001) were
significantly increased in COPD (+) patients, thus showing an increased
inflammatory burden. Regarding comorbidities, COPD (+) patients pre-
sented higher prevalence of diabetes (49.7% vs 11.2%, p<0.0001), atrial
fibrillation (24.1% vs 3.8%, p<0.0001) and chronic kidney disease (18.1%
vs 8.8%, p=0.002). Moreover, statistical analysis performed in COPD (+)
patients and according with gender, although not reaching statistical signi-
ficance, showed a greater prevalence of comorbidities in females than in
males. Present data confirm that patients with COPD have many comor-
bidities with possible gender-related differences. The link with COPD may
be explained by chronic systemic inflammation, so as demonstrated by the
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
affect autonomic profile; however, this association has never been investiga-
ted in detail. Analysis of heart rate variability (HRV) is a simple, noninvasive
tool to study autonomic nervous system.
Aims: To investigate the effects of lung transplantation on CAC using two
different types of analysis of HRV.
Methods: Consecutive adult lung transplant candidates referred to our
transplant center (Ospedale Maggiore Policlinico, Milan) were enrolled
between July 2016 and June 2017. Ten minutes EKG and respiration were
recorded before and 15 days after the intervention. Clinically stable condi-
tions and sinus rhythm on EKG were demanded. Autonomic cardiovascular
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),
marker of sympathetic modulation and high frequency (HF, 0.15-0.4 Hz),
118° Congresso Nazionale - Società Italiana di Medicina Interna Poster

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
Indice Autori 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
118° Congresso Nazionale - Società Italiana di Medicina Interna Indice Autori

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
Indice Autori 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
118° Congresso Nazionale - Società Italiana di Medicina Interna Indice Autori

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
Indice Autori 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
118° Congresso Nazionale - Società Italiana di Medicina Interna Indice Autori

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
Indice Autori 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
118° Congresso Nazionale - Società Italiana di Medicina Interna Indice Autori

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
Indice Autori 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
118° Congresso Nazionale - Società Italiana di Medicina Interna Indice Autori

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
Indice Autori 118° Congresso Nazionale - Società Italiana di Medicina Interna

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
118° Congresso Nazionale - Società Italiana di Medicina Interna Indice Autori

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
Indice Autori 118° Congresso Nazionale - Società Italiana di Medicina Interna

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

Società Italiana di Medicina Interna

Viale dell’Università, 25 • 00185 Roma
Tel. 06 44340373 • Fax 06 44340474
Email info@simi.it • Web www.simi.it

Segreteria Organizzativa

Via Roma, 10 • 16121 Genova

Tel. 010 553591 • Fax 010 5535970
Email simi@aristea.com • Web www.aristea.com

WWW.SIMI.IT - WWW.ARISTEA.COM/SIMI