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  • 1. European Federation of Internal MedicineAbstracts Book7 Congress thRome, Italy, Aurelia Convention Centre & Expo May, 7-10, 2008
  • 2. European Federation of Internal MedicineScientific SecretariatG. LicataG. Gasbarrini, M.D. CappelliniG. Parrinello, A. Pinto, R. Scaglione, A. TuttolomondoSocietà Italiana di Medicina Interna - SIMIViale dell’Università 25 • 00185 Rome (Italy)Phone (+39) 06 44340373 • Fax (+39) 06 44340474Presidents of the Congress Council of the Italian SocietyG. Licata Italy of Internal Medicine (SIMI)G. Gasbarrini Italy G. Abbita Erice M.D. Cappellini MilanoHonorary Presidents G.R. Corazza PaviaU. Carcassi Italy G. Crippa PiacenzaF. Dammacco Italy A. D’Avanzo AvellinoM. Sangiorgi Italy R. Lauro Roma G. Licata PalermoSteering Committee G. Mancuso Lamezia TermeW. Bauer Switzerland E. Mannarino PerugiaC. Davidson England P.M. Mannucci MilanoJ.W.F. Elte The Netherlands V. Marigliano RomaF. Ferreira Portugal M.A. Monti MilanoG. Gasbarrini Italy R. Nuti SienaG. Licata Italy M. Pagani MilanoS. Lindgren Sweden G. Palasciano BariP.M. Mannucci Italy F. Rossi Fanelli RomaD. Sereni France A. Sacco Matera M.B. Secchi MilanoEFIM Executive Committee G. Traisci PescaraW. Bauer Switzerland F. Violi RomaC. Davidson EnglandJ.W.F. Elte The Netherlands SIMI Executive SecretaryF. Ferreira Portugal F. Pepe RomaS. Lindgren SwedenD. Sereni France SIMI Administrative Secretary S. Pescetelli Roma EFIM Assistant Secretary I. Huis in t Veld The NetherlandsOrganizing SecretariatAristea GenovaSalita di Santa Caterina 4 • 16123 Genoa (Italy)Phone (+39) 010 583224 • Fax (+39) 010 5531544E-mail efim2008@aristea.com • www.aristea.com/efim2008
  • 4. Oral CommunicationsWednesday, May 7, 2008 RHEUMATOLOGY
  • 5. 1. ISCHEMIC HEART DISEASE AS THE PRESENTING FEATURE OF TAKAYASU’ 2. PROLIFERATIVE MYOSITIS ARISING IN THE STERNOCLEIDOMASTOIDARTERITIS MUSCLELorenzo Dagna, Fulvio Salvo, Emanuel Della Torre, Mattia Baldini, Enrica Bozzolo, Joaquin Campos-Franco, Nieves Mallo-Gonzalez, Raimundo Lopez-Rodriguez,Elena Baldissera, MariaGrazia Sabbadini Paula Barros Alcalde, Ihab Abdulkader, Rosario Alende-Sixto, Arturo Gonzalez-QuintelaTakayasu’s arteritis (TA) is an inflammatory disease that affects the aorta and/or its major branches. INTRODUCTION Proliferative myositis is an uncommon benign condition affecting skeletal mu-Cardiac involvement from TA is often underestimated: the heart can be directly involved by TA scle and characterized by the presence of ganglion-like giant cells within a myofibroblastic back-or be affected as a consequence of its systemic vascular manifestations. Primary cardiac involve- ground. Usually involves muscles of the trunk and extremities but the localization of this conditionment causing ischemic heart disease (IHD) can be the presenting feature of TA. We studied 60 in head and neck is rare. We report a case of proliferative myositis involving the sternocleidoma-consecutive patients (56F, 4M) with TA followed at San Raffaele Scientific Institute in Milan. Seven stoid muscle. CASE REPORT A 70-year-old woman was admitted to the hospital complaining of(6F, 1M, mean age 35.8 y) out of the 60 TA patients (11.7%) showed symptoms of IHD on pre- a five days painful mass in the neck. On physical examination, the patient was afebrile, with ansentation. Among them, 6 presented with exertion angina and 1 with an acute myocardial infar- arterial blood pressure of 115/70 mmHg, and showed a firm and painful mass of approximatelyction. A coronary angiography was performed in 6 patients and showed severe stenosis of both 2.5x1.5 cm arising from the sternal head of the right sternocleidomastoid muscle, just upon thecoronary ostia in 2 patients, whereas distal coronary artery stenoses were present in 3 patients; manubrium sterni. The rest of the physical examination was normal. A cervical and chest CT-scancoronary angiography was negative in a patient who had a positive ECG-stress test and a posi- showed a poorly demarcated enlargement of the right sternocleidomastoid muscle and there wastive stress myocardial perfusion study. The last patient had positive ECG- and myocardial perfu- no collection or lymphadenopathy. Adjacent bone was normal. A fine-needle-aspiration-biopsy ofsion imaging-stress tests, but didn’t undergo a coronary angiography. Interestingly, none of the the mass was performed and cytological smears obtained from lesion showed two populations ofpatients had known risk factors for IHD (only one was a mild smoker). Other signs and symptoms cells, fat cells and amorphous metachromatic material. The most prominent feature of the smearof TA were recognized on presentation in 4 out of 7 patients and a diagnosis of TA was consi- was a population of large polygonal cells resembling ganglion cells. The second population ofdered. In the 3 remaining patients, other signs of vascular involvement appeared later: the mean cells was composed of smaller oval to spindle-shaped cells with oval or bacillary-shaped nuclei. Thedelay in diagnosing TA was 38.7 months. Three patients were treated with CABG, 1 with a PTCA pathological diagnosis of the mass was proliferative myositis. No adjuvant therapy was admini-with stenting, 1 with a proximal aortoplasty. The other 2 patients were diagnosed with TA on pre- stered. After three weeks, the mass decreased and nearly disappeared. Actually, the patient issentation and received immunosuppressive therapy, with a marked improvement in IHD mani- asymptomatic. DISCUSSION PM is a benign tumor of the soft tissue that may mimic malignancy.festations. TA can present with signs and symptoms of IHD in many patients. Even though TA is Occur primarily in adults between 30 and 70 years and is extremely rare in children. The etio-rare, a vasculitic etiology of IHD should be considered in particular in young females with no logy is unknown, but trauma has been proposed as a possible precipitating factor suggesting anknown risk factors. An early diagnosis could allow prompt treatment and prevent possible com- inflammatory mechanism. Supporting this hypothesis, approximately one third of patients reportsplications. a history of recent trauma to the affected area. It usually appears as a solitary (exceptionally mul- tiple)rapidly growing mass that may be painful. The lesion is generally firm, non tender, fixed to muscle underneath, and without inflammatory signs. PM may present in shoulder, trunk, thigh, and head and neck. Presentation of PM as a sternocleidomastoid mass is rare and in a recent re- view considering only the English-language literature, eight cases have been described. Local ex- cision is curative and following biopsy, the lesion usually disappears as in our case. Some cases of PM were confounded with sarcoma, attributed to the unusual cellularity and alarming rate of growth, and radical surgery were performed (occasionally in conjunction with lymphadenectomy, chemotherapy and radiation therapy), even with fatal consequences. Recurrence is extremely rare. The diagnosis can be made on needle aspiration cytology alone, as many authors proposed. Re- cognition of this condition is important in order to avoid a misdiagnosis of a malignant tumor, par- ticularly high-grade sarcoma. Consultation with an experienced pathologist, conservative management and a careful clinical evaluation (watch and wait policy) can spare unnecessary sur- gery in these patients. The case described here is unusual because of its location in the sterno- cleidomastoid muscle.3. DIAGNOSTIC UTILITY OF ANTI-CYCLIC CITRULLINATED PEPTIDE AND 4. THE INFLUENCE OF ADIPOKINES ON BONE MINERAL DENSITY INANTI-MODIFIED CITRULLINATED VIMENTIN ANTIBODIES IN RHEUMATOID ELDERLY MENARTHRITIS Stefano Gonnelli, Carla Caffarelli, Katie Del Santo, Alice Cadirni, Carmine Guerriero,Goksal Keskin, Ali Inal, Lek Keskin, Aysel Pekel, Ozan Baysal, Ufuk Dizer Loredana Tanzilli, Stella Campagna, Ranuccio NutiPURPOSE: Several autoantibodies found in RA are directed to epitopes in citrullinated proteins. Body weight is commonly considered a significant predictor of bone mineral density (BMD). Adi-One of them is anti modified citrullinated vimentin (Anti-MCV). We tested the value a newly de- ponectin, an adipocyte-derived hormone, could modulate BMD. Moreover recent studies repor-veloped ELISA for the detection of antibodies againts a genetically modified citrullinated vimen- ted that ghrelin, an orexigenic peptide secreted by the stomach, is able to stimulate bonetin (anti-MCV) in comparison with an anti-CCP based ELISA system for the diagnosis of RA. formation. This study aimed to investigate whether there is any association between ghrelin levels,MATERIALS AND METHODS: Thirty-five patients with RA (mean age; 42.6 ± 10.87 years, mean adiponectine levels, body composition and BMD in elderly men. We studied 117 men aged 55disease duration; 9.37 ± 3.98 years) were enrolled in this study. Twenty –five ankylosing spondylitis years and older (mean age: 67.4 &#61617; 5.4 yrs) who were participating in an epidemiological(mean age; 35.88 ± 6.64 years, mean disease duration; 10.25 ± 4.61 years), and 19 healthy sub- study. In all subjects we evaluated ghrelin, adiponectin, parathyroid hormone (PTH), 25-hydro-jects (mean age; 40.26 ± 5.11 years) served as controls. Anti-CCP antibodies and Anti-MCV an- xyvitamin D (25OHD), bone alkaline phosphatase (B-ALP) and the carboxy-terminal telopeptidetibodies were measured using ELISA. RESULTS: In all RA patients, mean anti- CCP level was of type I collagen (CTX). BMD was assessed at lumbar spine (BMD-LS), at femoral neck (BMD-69.07 ± 90.43 U/ml and anti-MCV level was 665.77 ± 1040.19 U/ml. In patients with AS, the FN) and at total femur (BMD-TF). Body composition (fat mass and lean mass) was assessed bymean anti-CCP level was 10.7 ± 5.22 U/ml and anti-MCV level was 40.54 ± 20.15 U/ml. In he- using a DXA device (Prodigy, Lunar GE). A Food Frequency Questionnaire was used for calcula-althy controls, the mean anti-CCP level was 11.11 ± 7.65 U/ml, anti-MCV level was 23.12 ± 12.04 tion of dietary calcium intake. The values of ghrelin were lower in osteoporotic men than in osteo-U/ml. In patients with active RA, the mean serum anti-CCP level was 100.54 ± 98.07 U/ml and penic and normal men but the difference did not reach the statistical significanceanti-MCV level was 998.74 ± 1154.93 U/ml. In patients with inactive RA, the mean serum anti- (737.5&#61617;82.4; 825.3&#61617;112.5 and 853.6&#61617;136.8 pg/ml, respectively). A si-CCP level was 8.77 ± 1.55 U/ml and anti-MCV level was 27.59 ± 23.10 U/ml. According to these gnificant correlation was found between ghrelin and lean mass (r=0.20; p<0.05) but not betweenresults; In patients with RA, the mean serum anti-MCV and anti-CCP levels were significantly ghrelin and fat mass. Ghrelin showed positive correlations with BMD-FN and with BMD-F whichhigh compared to patients with AS and healthy controls (p=0.002, p=0.001, p=0.002, p=0.001 re- remained significant after adjustment for BMI and calcium intake (r= 0.24; p< 0.05 and r=0.22;spectively). The mean serum anti-MCV and anti- CCP levels were significantly higher in active pa- p<0.05, respectively). The correlation between adiponectin and BMD at all skeletal sites were ne-tients with RA than in inactive patients with RA patients (p=0.001 and p=0.001 respectively). In gative, but not significant. The correlation between adiponectin and B-ALP (r=0.249; p<0.01) re-inactive patients with RA, the mean serum anti-MCV and anti-CCP levels were similar in patients mained significant also after adjusting for confounding variables. In conclusion our study suggestswith AS and healthy controls patients (p=0.484, p=0.308, p=0.09 and p=0.222 respectively). The that in elderly men adiponectin significantly influences bone formation and that ghrelin is signifi-mean serum anti-MCV levels were correlated with DAS 28 (r=0.531, p=0.001), VAS score cantly, even though marginally, associated with BMD. Further studies are needed to elucidate(r=0.332, p=0.01), ESR (r=0.458, p=0.001), serum CRP levels (r=0.568, p=0.01), serum RF levels the role of adipokines on bone metabolism.(r=0.529, p=0.001), swollen joints number (r=0.525, p=0.001) and tender joints number (r=0.638,p=0.001). CONCLUSION: As a result; measurement of serum anti-MCV levels is useful for dia-gnosis of RA and combined use of anti-MCV and RF may be more useful prognostic factor thaneither method alone, RF and anti-CCP. 2
  • 6. 5. THE ASSESSMENT OF A GROUP OF PATIENTS WITH FIBROMYALGIA FROM 6. INTRARENAL COLOR DOPPLER SONOGRAPHY IN STUDYING PATIENTSORADEA (ROMANIA) USING THE FIBROMYALGIA IMPACT QUESTIONNAIRE AFFECTED BY SYSTEMIC SCLEROSISFelicia Tirlea, Dorina Maria Farcas, Ligia Burta, O.Burta, Corina Moldovan M. Sperandeo, G. D’Amico, G. Sperandeo, M.L. Piattelli, S. Muscarella, A. Varriale, A. De Cata, F. Prigigallo, M.A. Annese, G. VendemialeObjective: to assess the responsiveness of a group of patients with fibromyalgia from Internal Me-dicine Department of Oradea, Romania, using the Fibromyalgia Impact Questionnaire (FIQ). Ma- Systemic sclerosis is a generalized disorder which affects the connective tissue of the skin and in-terial&Methods: We studied a group of 89 patients with fibromyalgia from Medical Clinic of ternal organs and is associated with alterations of the microvasculature. Scleroderma renal crisisOradea,. The patients fulfilled the ACR criteria for fibromyalgia. All of the them underwent spe- involves almost 50% of patients with a 25% of which developing renal failure. In our study wecific treatment for 14 days including: medication(analgesics, pregabalin, tricyclic antidepressants), evaluated utility of intrarenal quantitative parameters (Resistive Index: R.I; Pulsatility Index: P.I.)kinetotherapy and massage. They were assessed with Fibromyalgia Impact Questionnaire (FIQ) during renal color Doppler sonography, as prognostic indicators of renal involvement in systemicat baseline, discharge, at 6, 12month. Effects were analysed with sensitivity statistics(effect size, ES). sclerosis. In a period of 60 mounths, we examinated 78 patients (69 females and 9 males) affec-Results: In our group of study the general score had an moderate ES=0.64 until discharge. The ted by systemic sclerosis and 92 controls. All patients underwent intrarenal color Doppler sono-effect remained moderate at 6 month(ES=0.47) and it decreased at 12 month (ES=0.38) . Con- graphy with evaluation of R.I. and P.I. every 12 mounths. We then correlated these parameters withclusion:Decreasing the pain level, fatigue, sleep disturbances and psychological distress, and also renal functional values (creatinine clearance and GFR), microalbuminuria and urine test. We foundincreasing function are the main goals for treatment in patients with fibromyalgia. Our study sho- a significantly higher R.I. (average 0.83±10) in 52 patients (51 females and 1 male) in respect towed a beneficial effect of treatment in such patients. Future research should focus on compre- controls (p<0.05). Even if our preliminary findings have to be confirmed in larger patient groups,hensive treatment programs for maintaining beneficial effects over time. our results suggest that evaluation of R.I. by color Doppler sonography in patients with systemic sclerosis could allow a selection of those patients at risk of developing renal vascular involvement and, by consequence, renal crisis as complication of systemic sclerosis.7. TAKAYASU´S ARTERITIS: ANALYSIS OF 9 PATIENTSJunco García, A.; Muñoz López de Rodas, M.C.; de Andrés Moro, F.; Sáinz Herrero, A.;Hernández Blanco, C.; del Río Ibáñez, R.; Cigüenza Gabriel, R.; Antolín Arias, J.INTRODUCTION: Takayasu´s arteritis is a chronic inflammatory disease afecting large vessels, pre-dominantly the aorta and its main branches with a prevalence of 1,2-2,6 million person. OBJEC-TIVES: 1. Review of Takayasu’s arteritis cases admitted to our hospital from 1996 to 2006. 2.Determination of the most frequent clinical manifestations. 3. Gain knowledge of the importanceof angio-Magnetic Resonance (angioMR) in the diagnosis and follow-up. 4. Analysis of the me-dical services implied in this disease. PATIENTS AND METHOD: We carried out a retrospective,descriptive, stadistical study of 9 cases of Takayasu’s arteritis admitted to the Hospital Clínico SanCarlos from January 1996 to December 2006. Data on clinical manifestations, biological tests andimage results (arteriography, angioMR, and Doppler echography) were gathered. Diagnosis wasestablished according to the classification criteria of the American College of Reumathology (ACR)in 1990. RESULTS: Anthropometric data:Women:78%;Men:22%. Media age at diagnosis was46 years (SD:14) Clinical Manifestations; Malaise:78%; Hypertension:56%; Pain in affected ves-sels:44%; Aortic insufficiency:44%; Dyspnea:44%; Atypical chest pain:33%; Acute myocardial in-faction:33%; Weight loss:33%, seasickness, syncope, acute cerebrovascular accident, heart failure,arthralgie, anorexia, Raynaud phenomenon, visual disorders:22.2%. Transient ischemic attack(TIA),abdominal pain and fever (Tª >37.8% ºC):11.1%. Biological criteria: ERS increase (>20):89%; ane-mia (Hb<12):56%; renal failure (Cr. >1.2):33%, ANA+:22% Classification criteria: abnormal arte-riography:100%, diminished brachial pulses:78%, vascular bruits:67%, claudication of lowerlimbs:67%, difference of blood pressure between arms >10mmHg:33%. Age <40:33% Abnor-mal arteriographies (parietal thickening, stenosis, occlusion and dilatation): subclavian:78%, caro-tid-vertebral:56%, infrarenal aorta-iliac:44%, mesenteric-celiac branch:44%, coronary:33%,renal:33% Distribution according to hospital services: Internal Medicine:3 cases (34%), Reuma-thology:2 cases(22%), Cardiology:2 cases (22%), Gynecology:1 case (11%), Intensive Medicine:1case (11%). Follow-up according to image tests: AngioMR:56%, Doppler echo:44%. Treatment:medical (corticoesteroids or immunossuppresives):56%; angioplasty or by-pass:11%; Combinedmedical-surgical:33%. Progression or re-stenosis:44.4% CONCLUSIONS: 1. The most frequentclinical manifestations were cardiovascular and neurological. Blood tests expressed increased ESR,anemia, and renal failure. 2. The most affected vessels were the subclavian artery, carotid andvertebral territory, infrarenal aorta-iliac and mesenteric-celiac arteries. 3. Diagnosis was establi-shed by arteriography, follow-up by angioRM and Doppler echo. 4. Admittance was carried outby Internal Medicine, Reumathology and Cardiology. Follow-up is multidisciplinary. 3
  • 7. Oral CommunicationsWednesday, May 7, 2008 PUBLIC HEALTH
  • 8. 1. PATIENTS OPINION ON THE QUALITY OF CARE OFFERED IN OUT PATIENT 2. ROUTINE ADMISSION CHEST X-RAY DOES NOT MAKE AN EFFICIENTCLINICS IN A SPANISH TEACHING HOSPITAL SETTING CONTRIBUTION TO THE DIAGNOSIS OR TREATMENT OF HOSPITALIZEDWikman Ph, Peris J.M, Safont P, Gracia M, Calabuig E, Botas M, Mj.,Monge Mj, Merino J. PATIENTS Ami Schattner Gabi Duek, , Nick Beilinson, Vladimir Neogolani, Alon Basevitz, Marina Somin,INTRODUCTION - Modern clinical practice tries to be very high in quality and has placed the Joel Cohen, Stephen Malnick.patient as the centre of all sanitary activities. That is why it is very important to know their viewon the care we offer them. This is the aim of this study, to detect our insufficiencies and then to Routine admission chest X-ray does not make an efficient contribution to the diagnosis or treat-establish an intervention program to correct them. MATERIAL/ METHODS. - Observational study ment of hospitalized patients. Oral communication. Ami Schattner Gabi Duek, , Nick Beilinson,of a random sample of patients treated in the outpatient clinics at our Hospital (n=64) through the Vladimir Neogolani, Alon Basevitz, Marina Somin, Joel Cohen, Stephen Malnick. Department oflast two terms of 2007. For this purpose we have designed a form with 14 items using a 5 steps Medicine, Kaplan Medical Centre, Rehovot and the Hebrew University Hadassah School of Me-likkert scale. The forms have been offered by a health care professional to the attending patients dicine, Jerusalem, Israel. Introduction. In many departments of medicine a chest x-ray (CXR) is per-in our out-patients clinics, to be filled out anonymously. Results are offered in percentage. Pa- formed routinely on admission. There are meager data on the diagnostic yield of routine admissiontients may choose one of the following options to evaluate:: 1. too much/very well, 2. much / CXR reflecting current changes such as the increasing age and severity of patients, the higher pre-well, 3. neutral, 4 poor/ badly, 5. very poor/ bad. 6, no answer. RESULTS .- N was 64 , 38,7% valence of immunosuppressed patients and resurgence of tuberculosis. Methods. Consecutivewere male, 61,2% women, mean age was 59,45 years, for the 26,5 % it was the first visit and 73,5 patients admitted to a single department of medicine during a two month period were studied.had been attended previously a. The waiting time to be attended has been: 0; 10.9; 46,8; 25; 7,8, The discharge summaries were screened for all relevant clinical data and then reviewed by two9,3. b. The time the doctor offered was: 7,8 ; 39; 48; 0; 0; 0; 4.6. c. the humanistic approach the senior clinicians who were not involved in the care of these patients. The clinical indication for thedoctor offered was: 62,5; 26,5; 7,8; 0; 0, 3,1. d. the technical or professional approach the doc- performance of a CXR was assessed as well as the contribution of the CXR to clinical manage-tor offered was : 62,5; 29,6; 6,2; 0; 0; 1,5. e. the information on the disease or treatment offered ment (major positive, major negative, minor positive or no contribution). Logistic regression ana-by the doctor has been: 23,4; 46,8; 23; 0;0 6,2. f. the information on complementary examina- lysis was performed with the SPSS 12 software program. Results. There were 675 patients whosetions needed was: 53,1; 32,8; 6,2; 0;0; 7,8. g. at the time of arrival at the clinic the attention re- mean age was 64.5 + 17.2 years. Their presenting complaints included chest pain (18%), dyspneaceived from other sanitary or administrative professionals was: 51,5; 20,3; 3,1; 0; 0; 25. (12%), weakness (10.5%), fever (9%), abdominal pain (8%), and neurological complaints (7.5%).COMMENTS.- This protocol is easy to carry out, and allows us to detect insufficiencies in the care In 19.6% (130 cases) the CXR was not done or the result was not obtainable. CXR findings in-we offered, so we can go forward with interventions in order to correct them. In our case the re- cluded congestion in 19.4%, an infiltrate in 12.4% and a space occupying lesion in 2.5%. The CXRsults are quite satisfactory. was reported to be normal in 38.6% of the cases. Physical examination of the chest was normal in 585 (87%) of the cases and abnormal in 87 (13%). The examination of the heart was normal in 518 (77%) and abnormal in 129 (19%). Of the 545 x-rays done, 260 (48%) were normal. In only 116 (21.5%) was there a major positive contribution of the admission CXR to diagnosis or tre- atment. In 140 (26%) it provided a minor positive contribution and in 56 (10%) - a major nega- tive contribution. In 184 patients (34%) there was no contribution of the CXR to either diagnosis or management of the patient. We found that the CXR made a major positive contribution to ma- nagement in patients for whom there was an indication for performing the x-ray (OR 10.3, p<0.0005) and in those in whom there was a finding on auscultation of the chest (OR 1.63, p=0.110). For a major negative contribution of the CXR to management, the indication for the in- vestigation was also very important (OR 72.9, p< 0.005). Conclusion. A routine admission CXR has a significant impact on patient management only in those patients in whom there are au- scultatory findings on physical examination of the chest or a clinical indication for performing the test. The policy of routine CXR on admission needs to be reassessed.3. PATIENTS CLAIMS AS A METHOD FOR SELF ASSESSEMENT OF QUALITY IN 4. QUALITY AND COMFORT OF FACILITIES OFFERED TO PATIENTS IN ANAN INTERNAL MEDICINE DEPARTMENT INTERNAL MEDICINE DEPARTMENT IN A SPANISH TEACHING HOSPITALMatarranz M , Wikman P, De Juan M A, Rugero M J., Segui Jm, , Martinez Baltanas A., Peris J., Lopez Calleja E, Wikman Ph, Peris J.M, Safont P, Gracia M, Calabuig E, Monge M J,Ramirez M I., Merino J. De Juan M A, Muela F., Merino J.BACKGROUND. - Quality of care offered, doing it in a cost efficient way and the care offered INTRODUCTION - Modern clinical practice tries to be very high in quality and has placed thebeing very sure for patients are the cornerstone of modern clinical practice. Patients self assessment patient in the centre of all sanitary activities. That is why it is very important to know about his viewof the quality in clinical practice offered is an efficient way to asses the quality of care. We have on the comfort and the quality of facilities we offer him. Looking for detecting our insufficienciescollected information about the claims presented by patients admitted in the internal medicine de- on this field and then to establish an intervention program to correct them is the aim of this study.partment the last 5 years and we analyze them to detect insufficiencies and to prepare an inter- METHODS.- Observational study on a random sample of patients cared in the outpatient clinicsvention plan to correct them. METHODS. - Descriptive study. We have elaborated a protocol to (n=64 ) or in the wards (n= 70 ) of our Hospital through the last two terms of 2007. For this pur-collect the information we find out. Claims were classified as presented verbally or in a written for pose we have designed some forms with 12 and 24 items. In some cases using a likkert scale.and we used a check list including 60 possibilities for the claims contents. The clinical activity for These have been offered to be anonymously filled by patients attending our wards and out pa-IM department was obtained from the Hospital’s Clinical Documentation Department RESULTS.- tients clinics. We include information from claims related to the items the patients have presen-The absolute number or written claims for 2003 and following years has been: 2-1-4-5 and 5; ted to the “Patient support Department” in our hospital. Results are offered in percentage ofand for verbal claims: 8-5-16-24-31. The 62% of them were presented by women: Mean age answers. RESULTS.- In out patients clinics: n 64, mean age 59,4. You consider that the facilitieswas 57,7 y: . The no. of IM claim’s in relation of those claims presented at the whole hospital have available: waiting room, clinics, material, are: very good 9,3%, good 43,75%, normal 21,8%, badbeen: for 2003: 0,34, , and for the following years: 0,19; 0,8; 0,1 and 0,9, and for oral claims: 0%, very bad 0%, n.a. 25%. In the wards: n 70, male %, mean age 57,2 y. answering patients 300,248; 0,136; 0,405;044 and 0,57. In 2007 IM written claims have been 5, related activity have % or their family 60%: n.a. 10%.. You consider inadequate the quality of: mattress: 12,8%, bedbeen: % for number of patients recovered: 0,3; % for the department’s occupancy during the year 12,8; toilet 12,8; wall painting11,4%, cleaning 7,1%; arm chair for companion 32,4% , clothes for0.038 ; and % for total of patients cared in outpatient clinics: 0,1 , There were 4 doctors and 1 bed or bath 10% , time for visiting patients 4,3%, availability to watch TV programmes 20%,nurse involved, on the remaining 12 were no sanitary professionals. This figures for verbal claims room temperature 14%. In relation with the food service: the amount was small (4,28), with fewwere: 31; 2,2 ; 0,23 and 0,6, and there were involved 7 doctors; for the remaining 77 there were variability (11,4) , to be bad prepared (8,5) , has been served cold (14,28), or in adequate timeno sanitary professionals involved. The subjects of the written claims were related courtesy, in- (4,28) , with dishes different from those you have asked for (8,57), to be bad presented (8,57),sufficient personal, non acceptance of rules, and for verbally: waiting list for clinical procedures or or it was inadequate for your disease(1,42). Information about the patient’s claims is also included.out patient clinics or bad information. COMMENTS: We underline the importance of this type COMMENTS.- This type of questionnaire allows us to get a better known on the patients viewof studies to assure quality of care. We can feel quite comfortable with our results. MATERIAL/ on the facilities available and to act for improving them.METHODS. - Observational study on a random sample of patients cared in the wards of our Ho-spital (n=70) through the last two terms of 2007. For this purpose we have designed a form with14 items using a likkert scale. The form has been offered to the patients recovered in our wardsto be anonymously filled and deposed at nurses’ desk. The 30% of the forms were filled out bypatients, 60% by their companions, (we ignore 10%). Mean age of those answering was 57, 2years. 60% of them knew their doctors name and 55, 7% knew his medical speciality. Results areoffered in percentage of answer for each item, being 1: very satisfactory, 2. satisfactory, 3. neu-tral, 4 unsatisfactory, 5. very unsatisfactory. a. The technical o professional approach by doctorshas been: 68,6; 26,9; 4,5; 0;0, b. The humanistic approach: 71,6; 24;4,5;0;0; c. The informationthey offered about patient´s disease has been: 56,2; 37,5; 4,7; 1,6,0. d. Their information on com-plementary exams patients needed: 53; 39,; 3; 4.5;0 . e. Information on treatment offered d:57,1; 34,9; 6,3; 11,6; 0. f. Nurses care has been: 52,9; 35,3; 10,3; 0,0.; Humanistic approach bynurses and other sanitary professionals : 52,2; 40,3; 4,5; 2,98; COMMENTS.- This type of que-stionnaire offers us a better understanding of how patients think about the care we offer and al-lows us to initiate intervention programs to improve the quality of our care. In our case the resultwas quite satisfactory. 5
  • 9. 5. ASSOCIATIONS BETWEEN SMOKING, NUTRITIONAL STATUS AND CLINICAL 6. SAN FRANCISCO SYNCOPE RULE, OESIL RISK SCORE AND CLINICALOUTCOME FOLLOWING ACUTE ILLNESS JUDGMENT IN THE ASSESSMENT OF SHORT TERM OUTCOME OF SYNCOPESalah Gariballa, Sarah Forster Franca Dipaola., Giorgio Costantino, Francesca Perego, Marta Borella, Andrea Galli., Giulia Cantoni, Giuseppina Pisano, Franca Barbic., Francesco Casella, Pier Giorgio Duca, Raffaello FBackground Although smokers have poor health and consequently poor dietary intake compa-red with nonsmokers no study has examined the effects of smoking on nutritional status during Objectives To compare the effectiveness of the OESIL (Osservatorio Epidemiologico sulla Sin-acute illness. Objective The aim of this study was to measure the effect, if any of smoking on nu- cope del Lazio) and SFSR (San Francisco Syncope Rule) risk scores and the Clinical Judgment intritional status in hospitalized patients. Design 434 randomly selected hospitalised patients had assessing the short-term prognosis of syncope. Methods We enrolled 488 patients consecutivelytheir nutritional status assessed from anthropometric, haematological and biochemical data within seen for syncope at 2 Emergency Department (ED) between 23rd of January and 31st of July72 hours of admission and at 6 weeks. Nutritional status was compared between current smo- 2004. Sensitivity, specificity, predictive values, positive and negative likelihood ratios (LR) for short-kers, ex-smokers and those who never smoked. Using multiple logistic regression analysis we term severe outcomes were computed for each decision rule and the Clinical Judgment. Resultsmeasured the association between smoking and nutritional status and mortality respectively after OESIL risk score was characterized by a sensitivity of 88%, specificity of 60%, negative predictiveadjusting for poor prognostic indicators including age, disability, chronic illness, medications, and value of 99%, positive and negative LR of 2.19 and 0.19, respectively. In line with OESIL score,tissue inflammation. Results Smoking status affected both anthropometric and nutritional bio- 43% of patients would have been admitted. SFSR sensitivity was 81%, specificity 63%, negativechemical measurements. For example, body weight, body mass index (BMI), mid-upper arm cir- predictive value 98%, positive LR 2.16 and negative LR 0.31. According to SFSR criteria, 40% ofcumference, Triceps skinfold thickness, serum albumin and plasma ascorbic, red-cell folate and patients seen in the ED would have been admitted. To prevent one event among discharged sub-vitamin B12 concentrations were all lower in current smokers compared with those who never jects, OESIL and SFSR risk scores would have admitted 15 and 29 more patients than clinical judg-smoked. After adjusting for age, disability and co-morbidity in a multivariate analysis, smoking sta- ment (admitted 34%). In addition, according to both decision rules no discharged patient wouldtus had a significant and independent effect on important anthropometric and biochemical nu- have died. Conclusions the OESIL and SFSR risk scales performed similarly in recognizing patientstritional assessment variables. For example, being a current smoker was associated with lower with short term high risk syncope. Both decision rules were characterized by a good sensitivity andbody weight, MUAC and plasma vitamin C concentrations by 2.5 kg, 0.87 cm and 3.8 would have identified all patients who subsequently died. However, because of a low specificity&#61549;mol/L respectively compared with those patients who never smoked. Logistic regression of OESIL and SFSR risk scales, more patients would have been admitted compared with the Cli-analysis showed that smoking and increasing age were significantly and independently related to nical Judgment.one year mortality, odds ratios (95% C.I) were 1.7 (95% C.I 1.003 – 2.87) and 3.5 (95% C.I 1.52-8.22) respectively Conclusion Smoking is independently associated with poor nutritional status inhospitalized patients. This may partly explain the poor clinical outcome associated with smoking.7. SHOULD AUTOMATED ESTIMATED GFR/CREATININE CLEARANCE BE USEDIN ALL PATIENTS BEFORE STARTING MEDICATIONSS Kadir, M Mahmood, I U DinINTRODUCTION: Kidney function is often assessed by serum creatinine alone, which howeveris insensitive in elderly. Its a known fact that equations estimating creatinine clearance/GFR basedon serum creatinine are more accurate than serum creatinine alone in predicting patients kidneyfunction, henceforth a better guide in prescription of medications. More and more hospital labo-ratories in the world are providing eGFR for their patients as a standard. METHODS: We calcu-lated estimated creatinine clearance/GFR of 74 inpatients with stable serum creatinine usingcockcroft-Gault equation via the free eGFR calculators available on the internet. To minimize anyerror, only one web calculator was used for all the patients. The medical prescriptions of all thesepatients were also reviewed and compared with British National Formulary advice along with thedoses. RESULTS: 85% of pts were above age 50. On using Serum Creatinine as a measure ofkidney function, 34%of patients had abnormal results with creatinine ranging from 111-184. Ho-wever when creatinine clearnce/GFR was used (estimated by CG equation)as a measure of kid-ney function 75% had abnormal results.More than half of these i.e 54% has moderate/severelyreduced creatinine clearnce.On reviewing their medication prescriptions 67 instances were iden-tified where these medications would have warranted a change based on calculated creatinineclearance/GFR. CONCLUSIONS: Estimated creatinine clearance/GFR should be available espe-cially when prescribing patients medications. Automated estimation of creatinine clearance/GFRshould be a standard practice in all the hospitals. A separate section on the medication charts foreGFR may help in avoiding nephrotoxic medications or nephrotoxic doses. 6
  • 10. Oral Communications Thursday, May 8, 2008CARDIOVASCULAR DISEASE
  • 11. 1. HUMAN PARAOXONASE GENE POLYMORPHISM AND CORONARY 2. PSYCHOLOGICAL FACTORS AND PROFILE ASSOCIATED WITHARTERY DISEASE RISK WHITE-COAT PHENOMENONR. Palma dos Reis, A.I. Freitas, A.C. Sousa, S. Gomes, P. Faria, A. Pereira, B. Silva, Giuseppe Crippa, Pierangelo Bertoletti, Ornella Bettinardi, Giovanna Calandra,M. Serrão, N. Santos, S. Freitas, I. Ornelas, A. Brehm, A. Cardoso Antonio Mosti and Pietro CavallottiBackground: Complex diseases such as coronary artery disease, hypertension or diabetes are White-coat phenomenon is characterised by striking increase in arterial blood pressure (BP) inusually caused by the individual susceptibility to multiple genes, environmental factors, and the hypertensive or non-hypertensive patients during BP measurement in the medical environment.interaction between them. The PON1 enzyme has been implicated in the pathogenesis of athe- This phenomenon can be detected comparing the high blood pressure value obtained in therosclerosis and coronary artery disease (CAD). Two common polymorphisms in the coding region medical environment with those obtained with a 24-hour ambulatory blood pressure monitoringof the PON1 gene which lead to a Gln (Q) /Arg (R) substitution at position192 and Leu /Met sub- (ABPM) or a series of BP measurement performed at home by the patients himself. Despite thestitution at position 55 influence PON1 activity. Aims: 1- To evaluate the PON1 polymorphisms common belief that anxious patients are prone to show this pressor response, it is unlikely that itsassociation and CAD risk. 2- To study the interaction between PON1polymorphisms and others presence, degree and duration can be routinely predict. Furthermore, no psychological variableslocated in different candidate genes. Methods: We evaluated in 298 CAD patients and 298 he- have thus far been inked to white-coat phenomenon in ad hoc designed formal analysis. To in-althy individuals the risk of CAD associated with PON1 192Q/R and 55 Leu/Met polymorphisms. vestigate the relationship between psychological profile and white coat phenomenon we haveThen, we evaluated the risk of the PON1 interaction with ECA DD; ECA 8 GG and MTHFR 1298 administered a series of validated psychometric tests to 85 subjects (46 females, mean age 52 ±AA. Finally through a regression logistics model we evaluated which variables (genetic, biochemical 12 years) undergoing ambulatory BP monitoring. Thirty-nine subjects who presented with white-and environmental) were linked, in a significant and independent way, with CAD. Results: We ve- coat phenomenon (office BP value, as measured by the physician, elevated by at least 15 % overrified that PON1 55 MM genotype, had a higher distribution in the CAD population, but did not the mean 24-hour ABPM) and 46 comparable subjects who did not disclose this alert reactionreach statistical significance as risk factor for CAD, and PON1 199 RR presented a relative risk 80% completed a series of validated psychological tests evaluating: quality of life, cognitive behaviour,higher in relation to the population without that polymorphism. The association of mutated po- hostility, cynicism, anger, anxiety, coping ability and strategies. Among the various tests, the sco-lymorphisms in the same gene belonging to the same pathophysiological systems that codify for res of three relevant scales (healthcare-related fears, mental efficiency and behavioural disenga-the same enzymatic protein, (PON 55 MM + PON 192 RR), did not increase the risk for DAC gement) resulted significantly higher (Fishers exact probability test, alpha level p< 0.05)in the(OR=1.767; p=0.057, Ns). The interaction between PON1 192 RR and MTHFR 1298 AA, sited white-coat group. No significant difference between the two groups, regarding signs and repres-in different genes, increased the risk for CAD. Similarly, the association between PON1 RR and sion of anger, cynicism, hostility, or anxiety state. Our data seem to indicate that the subjects mostECA 8 GG, was linked to an even higher risk (OR=5.6; p=0.002). After logistic regression, smo- likely to show an overt BP increase in the medical environment are those who present with heal-king habits, family history, fibrinogen, diabetes, Lp (a) and PON1 192 RR + ECA 8 GG interac- thcare-related fears and, emotional instability, but are not necessarily anxious. They disclose hightion, were kept in the regression model and proved to be an independent risk factors for CAD. coping skills addressed to the cognitive resolution of stressing situation (such as BP measurementConclusion: If separately estimated, PON1 192 RR genotype presented a relative risk for CAD in the clinical setting) but are not able to accompany these strategies with an adequate beha-80% higher than in the population without this genotype. The association with other genetic po- vioural response and involvement in the management of their clinical condition.lymorphisms sited in different genes, codifying for different enzymes and belonging to differentpathophysiological systems, always increased the risk for CAD. After correction for the other clas-sical and biochemical risk factors, PON1 192 RR + ECA 8 GG association remained a significantand independent risk factor for CAD.3. ACE DD GENOTYPE IS A CORONARY RISK FACTOR, IN THE 4. VALIDATION OF THE FRAMINGHAM AND SCORE SCORES BYPRESENCE OF OTHER RISK FACTORS “CARDIAC CTA”M.I. Mendonça, A.I. Freitas, A.C. Sousa, S. Gomes, P. Faria, A. Pereira, B. Silva, Sonia Schneer, Eli Atar, Gill Bachar, Ran Kornowski, Dana Marcovici, Victoria BeilinM. Serrão, N. Santos, S. Freitas, A. Brehm, A. Cardoso Idit Maya, Dror DickerBackground: ACE DD genotype is a risk factor of coronary artery disease in the presence of con- Background: Cardiovascular disease remains a leading cause of morbidity and mortality wor-ventional risk factors. There is some controversy on the importance of DD gene polymorphism ldwide. Recently computerized tomographic angiography (CTA) was established as a tool for earlyin cardiovascular risk in general and coronary risk in particular. Aim: The aim of this study is to detection of coronary atherosclerosis. There is disagreement as to the accuracy of “Cardiac CTA”evaluate the coronary artery disease risk in the presence (and absence) of conventional risk fac- in prediction of future cardiovascular risk, when compared to conventional clinical risks scorestors. Methodology: We performed a case control study with 305 cases and 505 controls. Cases (e.g. Framingham and Systematic Coronary Risk Evaluation [SCORE] scores). Methods: CTA ofwere coronary patients and controls normal persons without any known disease. Cases and con- coronary arteries was preformed in 190 asymptomatic patients with at least one atherogenic risktrols were similar in terms of age and sex. Percentages for the categorical variables and means ± factor as primary screening for the presence of cardiovascular disease. In these patients the Fra-standard deviation for the continuous ones, were performed. The groups were compared using mingham and SCORE scores were calculated. Statistic analysis was preformed using regressionthe Chi square test and Student T test. Afterwards, the relative risk of coronary artery disease in models. Results: 190 subjects (84% males). The mean age is 55± 9.7 years. When comparingthe DD genotype, in the presence (and absence) of the coronary risk factors was determined. Re- SCORE and Framingham risk factors we found significant correlations to calcium score (CS) andsults: The risk associated to DD genotype triplicates, when it is associated to hypertension plaque severity. SCORE calculation <2 vs.>2 was related to higher incidence of CS >100, 21.9%(OR=3.19; p<0.0001), losing significance in its absence (OR=1.34; p=Ns), the same happening vs. 42.9% respectively (OR=2.68, p=0.001). When comparing high risk SCORE (>4) vs. low riskwith dyslipidemia (OR=2.67; p<0.0001 vs. OR=1.48; p=0.024), diabetes (OR=5.95; p<0.0001 vs. (<4) CS>100 per CTA was 50% vs. 27.1% respectively (OR=2.7, p=0.001). High-risk FraminghamOR=1.46; p=0.019), smoking habits (OR=3.25; p<0.0001 vs. OR=1.32; p=Ns) or any other risk fac- score (>20) vs. low risk (<20) was related to higher incidence of CS > 100, 53.3% vs. 28.6% (ORtors studied (OR=2.61; p<0.0001 vs. OR=0.70; p<0.0001). Conclusions: We can conclude that 3.18, p=0.001). High risk SCORE vs. low risk was related to higher plaque severity (79.2% vs.ACE DD polymorphism is, in general, a risk factor of coronary artery disease (OR=1.88; p<0.001). 59.4% respectively; OR 2.6, p=0.001). High-risk Framingham score vs. low risk was also relatedThe risk increases and is significant in the presence of the conventional risk factors and decrea- to higher plaque severity (93.3% vs. 59% respectively; OR=3.18). The variables that best predic-ses loosing significance, in their absence. This work can explain the differences other authors have ted severity of plaque stenosis were age, gender, diabetes and hypertension. Conclusions: Ourfound in the evaluation of DD genotype risk. work has found the Framingham and SCORE scores to be good predictors of coronary artery di- sease when compared to cardiac CTA. In light of these exploratory findings, the use of those cli- nical scores seems to be important in identifying patients at risk for coronary atherosclerosis and treating them properly, before symptoms may develop. 8
  • 12. 5. MEDICAL CO-MORBIDITIES: AN OBSTACLE TO GUIDELINES 6. THE DIAGNOSTIC APPLICATION OF THE BIOMARKER C-REACTIVECOMPLIANCE IN ACUTE CORONARY SYNDROME? PROTEIN IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION:Manuel Sousa; Ana Rita Francisco; Pedro Amador; Sara Gonçalves; Lígia Mendes; A PROSPECTIVE STUDYFilipe Seixo; José Ferreira Santos; Carlos Perdigão Ovidiu Burta, Olivia Ligia Burta, Radu Stefan Roatis, Syed Minnatullah QadriIntroduction: Compliance with therapeutic guidelines for Acute Coronary Syndrome (ACS) is de- Objective: Acute Myocardial Infarction (AMI) is a leading cause of morbidity and mortality throu-terminant for the reduction of future events. The presence of non-cardiovascular medical co-mor- ghout the world. The purpose of this research was to investigate the possibility of using C-Reac-bidities (NCMCM) may be responsible for sub-optimal guideline adherence that many clinical tive Protein (CRP) as a potential biochemical marker in the event of an AMI in comparison toregistry show. Objective: Determine how the presence of NCMCM interferes with the treatment conventional biomarkers. Materials and Methods: The present study was undertaken by evalua-of ACS. Methods: we studied 146 consecutive in-patients (mean age 64 &#61617; 13 years; 71 ting the biochemical parameter of CRP using the nephelometric procedure “Chromatest”, on% males) admitted with the diagnosis of ACS. The prevalence of NCMCM was determined and blood samples (5ml) collected on admission with AMI. Blood samples were also collected in thethe population was divided in 2 different groups according to the presence or absence of same patients after an interval of 10 days and the procedure was repeated to determine CRP va-NCMCM. Compliance with pharmacologic treatment, including medication with acetylsalicylic lues. The subjects studied were initially excluded to bear other medical conditions that may de-acid, clopidogrel, any heparin (NFH – non fractioned heparin; LMWH – low molecular weight he- termine an increase in CRP values. In a total, the blood samples of 20 patients with AMI and 20parin), beta-blocker (BB), angiotensin converter enzyme inhibitor (ACEI) and statin, was evalua- healthy volunteers (controls) was analyzed for CRP. Results: The analysis of the patients sera forted in each group. Pharmacological compliance was defined as complete when all of the CRP values the revealed the following. The mean CRP value for both males and females collec-recommended drugs were used. Furthermore, the completion of reperfusion procedures (me- tively with AMI for the day of admission (D1) was 6.092 mg/l. The mean values for males andchanical or pharmacological) in ACS with ST elevation and the performance of coronary angio- females exclusively with AMI on D1 were 6.406 mg/l and 5.779 mg/l respectively. The meangraphy in ACS without ST elevation during hospitalization were also studied. Differences in the value for both males and females collectively with AMI after an interval of 10 days (D2) was 2.793compliance with therapeutic guidelines were analyzed in both groups. Results: 54% of the patients mg/l. The mean values of CRP exclusively for males and females with AMI on D2 were 2.495presented at least one of NCMCM (23% chronic renal failure, 20% gastrointestinal disease, 14% mg/l and 2.393 mg/l respectively. The mean value of CRP in control group on D1 for both maleschronic pulmonary disease, 9% cancer, 7% haematological disease). Compliance with therapeu- and females was 0.834 mg/l. The mean values of CRP on D1 for males and females exclusivelytic guidelines was lower in patients with NCMCM: in patients without co-morbidities there was were 0.839 mg/l and 0.824 mg/l. The mean values of CRP on D2 exclusively for males and fe-complete pharmacological compliance in 85.5% vs 69.4% in those with co-morbidities (p=0.028); males were 0.84 mg/l and 0.828 mg/l respectively. The values were studied in comparison to thein patients without co-morbidities complete pharmacological compliance plus reperfusion or co- troponin levels. Conclusion: Our study clearly shows the higher values of CRP in patients with AMIronary angiography were performed in 74.2% vs 55.6% (p=0.025). Conclusions: Compliance in comparison to normal subjects. The high values clearly indicate the detrimental effects of athe-with therapeutic guidelines established for treatment of ACS is still insufficient, particularly in pa- rosclerosis associated inflammation. CRP values remain elevated for a longer period of time intients with non-cardiovascular medical co-morbidities. comparison to other biomarkers of AMI. The values of CRP however, do not indicate any signi- ficant relationship with patient mortality as patients who died had different values of CRP in their serum samples. Males have slightly higher CRP values than females in both the control and pa- tients with AMI. The study warrants the need for further research in the potential of CRP and ac- centuates the possibility of concomitant use of CRP with other biomarkers due its reasonable efficacy and price.7. PREVALENCE OF LOWER EXTREMITY ARTERIAL DISEASE IN A 8. THE INVESTIGATION OF THE CAROTID STATE OF CORONARY ARTERYPOPULATION OF ITALIAN HOSPITALIZED PATIENTS OPERATED PATIENTSL Pasqualini, I Salvatore, D Siepi, BPR Kouadio, R Hijazi , MV Amoruso, MF Cacioni, Stefán JánosS Giaggioli, G. Schillaci, E. Mannarino Object: The comparison of the carotid US report with the coronary state, graft number, smoking,Lower Extremity Arterial Disease (LEAD), even if recognized as a crucial risk factor for cardiova- hypertension, diabetes and lipid parameters. Patients’ data.: The investigated period is 12 months:scular death, is largely underdiagnosed in clinical practice and particularly in older population. from 01.01.2006. to 31.12.2006. Patients had CABG surgery: 155, the male/female is 115 /40 /74The purpose of this study was to identify LEAD, using the ankle–brachial index (ABI) in a large %/, mean age: male 69,6 year, female : 65,7 year. Associated diseases: hypertension: 138 patients/series of hospitalized patients in a Department of Internal Medicine, and to investigate the asso- 89%/, diabetes : 65 /419%/, CRF: 2 patients, hyperlipidemia: 80 /51,6%/, smoker: 34 /21,9%/. Ca-ciation of this index with cardiovascular risk factors. We measured ABI in 829 consecutive patients rotid US report: normal: 128 patients (82,5%) non-significant stenosis :15 patients (9,6%) signifi-(462 men and 367 women) aged 50 years or older (73.2 ± 9.9 yrs). ABI, measured by an ultra- cant stenosis: 7 patients (4,5 %) , occlusion: 4 patients (2,5%) (intima/media proportion: notsound Doppler device, was considered abnormal when below 0.90. Patients with a history or examined). Carotid intervention : 7 patients, stent implantation : 6, carotid endarterectomy: 1, po-symptoms suggestive of LEAD were excluded from the study. An ABI lower than 0,90 was de- stoperative death: none, presurgical death: 1 patient. Results: by the number of grafts and se-tected in 278 patients (34%). LEAD patients were older (74.2 ± 10.4 yrs vs 70.5 ± 9.2 yrs, p<0.001) riousness of the carotid US report: normal carotid artery: mean graft number : 3, non-significantand more frequently men (60% vs 41%, p <0.001). Also sigarette smoking (57.4% vs 40.2%), dia- stenosis. 3,2, signifcant stenosis: 3,6, occlusion: 4,2 graft. The data of the patients with normal ca-betes (30.7% vs 21.5%) and hypercholesterolemia (31.3% vs 20.2%) were significantly more fre- rotid US finding / 128/ : male/female: 97/31, diabetes: 53 /41%/ , smoker: 29/23%/, hyperten-quent in patients with LEAD (all p < 0.05), whereas hypertension and obesity had no significant sion: 114/89%/, hyperlipidemia: 68/ 53%/ patients. Patients with non-significant stenosis / 15/ :relation to LEAD. In a stepwise logistic regression analysis, age, male sex, smoking, and hyper- male/female: 10/5, diabetes: 8/53%/, smoker : 2/13%/, hypertension. 13/87%/, hyperlipidemia:cholesterolemia were found to be independently associated with LEAD. A simple, bedside ABI 5/ 33%?. Patients with significant carotid artery stenosis /7/: male/female: 5/2, diabetes: 4/57%/,measurement revealed a large proportion of patients with unrecognized LEAD. These data sug- smoker: 1/17%/, hypertension: 7 (100%), hyperlipidemia: 3/43%/ patients. The data of patientsgest that ABI measurement should be included in the evaluation of cardiovascular risk in hospi- with carotid occlusion : 4 male patients, diabetes: none/!/, smoking: 2 /50%/, hypertension:4talized patients aged 50 years or older. /50%/, hyperlipidemia: 4 /100%/ patients. Conclusion: The more serious carotid state was asso- ciated with worse coronary findings. The patients with significant stenosis of the carotid artery got more periferial bypass graft . The patients with smoking, diabetes, hypertension and hyperlipide- mia have worse carotid findings and got more coronary graft. 9
  • 13. 9. EFFECTS OF LOW-GRADE SYSTEMIC INFLAMMATION ON 10. HCV INFECTION AND CAROTID ATHEROSCLEROSIS: EVIDENCE OFENDOTHELIAL MICROPARTICLE LEVELS IN SUBJECTS AT INCREASED VIRAL LOCALIZATION INSIDE THE PLAQUECARDIOVASCULAR RISK AL Zignego, R Abbate, B Chellini, R Marcucci, F Sofi, V Sollazzo, C Giannini, D Prisco,Pirro M, Vaudo G, Alaeddin A, Bagaglia F, Paoletti L, Razzi R, Mannarino MR, Schillaci M BoddiG, Mannarino E BACKGROUND. Hepatitis C virus (HCV) infection is a major health problem due to its high pre-Background and aims. Exposure to multiple cardiovascular risk factors is primarily responsible for valence and pathological sequelae including hepatic and extrahepatic disorders. It has been shownendothelial injury and contributes to activate a low-grade systemic inflammation, which in turn fur- that infection pathogens can induce macrophage foam cell formation and/or activate the immunether enhances the degree of endothelial damage. Traditional risk factors are also believed to pro- response and potentiate the immune inflammatory reaction underlying atherosclerosis. A link bet-mote endothelial release of membrane microparticles (MPs), whose generation has been ween HCV infection and increased risk of atherosclerotic disease has been recently suggested. Thisreproduced in vitro under C-reactive protein (CRP) exposure. We investigated whether activation study was aimed to evaluate the association between HCV infection and carotid atherosclerosisof a low-grade systemic inflammation under exposure to multiple traditional cardiovascular risk in 1900 patients consecutively referred to the “Center for evaluation of cardiovascular risk factors”factors has an influence on the number of circulating endothelial MPs. Methods. The total bur- of the University of Florence who showed a prevalence of anti-HCV positivity of 3,3%. METHODS.den of traditional cardiovascular risk factors, the number of circulating CD31+/CD42- endothelial In 63 HCV+ patients (34 m, 29 f, aged 71+6 yrs , range 53-82 yrs) and in 201 age-matchedMPs and plasma CRP levels have been quantified in 200 subjects without overt cardiovascular HCV – patients (140 males, 61 females, 68 &#61617; 10 yrs , range 45-80 yrs ) the status of ca-disease and at increased cardiovascular risk because of their exposure to at least 3 traditional car- rotid arteries (number of carotid plaque and carotid intima-media thickness) was studied by highdiovascular risk factors. Results. Levels of circulating endothelial MPs were positively correlated with resolution B-mode ultrasonography (Sonolayer SSA 270A equipped with a 7.5 MHz transducer).plasma CRP levels (r=0.28, p<0.05). After participants were grouped according to tertiles of the In all patients the prevalence of both traditional (smoking habit, hypertension, diabetes, dyslipi-estimated Framingham risk scores, we found that higher estimated cardiovascular risk was paral- demia, family history of premature coronary artery disease (CHD)) and new risk factors for caro-leled by increasing endothelial MPs levels. The presence of plasma CRP above the median value tid atherosclerosis (fibrinogen, C reactive protein (CRP), Lp(a) lipoprotein and homocysteine) andin the cohort further icreased the number of endothelial MPs. In a multivariate analysis plasma main liver functional parameters were also investigated. The presence of HCV RNA sequences wasCRP levels independently predicted the number of circulating endothelial MPs. Conclusions. The evaluated by high sensitive PCR-based methods in the carotid plaque tissue as well as in the cor-exposure to multiple cardiovascular risk factors contributes to injury the mature endothelium, pos- responding serum from ten HCV-positive patients who underwent carotid revascularization. RE-sibly through an increased membrane fragmentation into microparticles. Low-grade systemic in- SULTS. The prevalence of carotid lesions was significantly higher in HCV positive (80.6%) thanflammation may play a significant role in risk factor-induced endothelial MPs release. in HCV negative patients (51%, p<0.01). None of the traditional risk factors for atherosclerosis sho- wed a higher prevalence in the HCV positive than in the negative group. Interestingly, the pre- valence of smokers (6.45% vs 22.3%) and premature familiar history for CHD (16% vs 21.6%) was significantly lower in the HCV positive group (p<0.05 vs HCV negative pts). At multivariate re- gression analysis HCV infection remained as an independent risk factor for carotid atherosclero- sis. Among new risk factors , only Lp(a) and homocysteine plasma levels were significantly (p<0.01 vs HVC – pts) higher in HCV positive patients. Principal parameters of liver function did not dif- fer between the 2 groups. Interestingly, HCV RNA sequences were detected in the majority of available plaque tissues (in 7 out of 10) and frequently in the absence of serum HCV RNA, ru- ling out the possibility of samples contamination by circulating particles. CONCLUSION. Our data obtained on an Italian population strengthen the possible role of HCV infection in facilita- ting the occurrence of carotid atherosclerotic lesions, independently of the classic risk factors for atherosclerosis. A finding of special importance was the demonstration of HCV RNA sequences in carotid plaque tissues, even in the absence of serum HCV RNA positivity. Remarkably, serum markers of inflammation showed similar pattern in HCV + and HCV - populations. These data strongly suggests that HCV infection does act by a local action inside the plaque and strengthens the opportunity for further studies investigating the molecular mechanisms involved. 10
  • 14. Oral Communications Thursday, May 8, 2008 PNEUMOLOGY
  • 15. 1. ANEMIA IN COPD PATIENTS AS A PREDICTIVE FACTOR OF HOSPITALARY 2. EVALUATING THE ROLE OF INTRAVENOUS MAGNESIUM SULPHATE AS ANREADMISSION ADJUNCT TO STANDARD THERAPY IN SEVERE ACUTE ASTHMAGargallo E; Casado P; Gallego M; Szymaniec J; Gil-Sanz C. Anupam K. Singh, S.N. Gaur, Raj KumarINTRODUCTION AND OBJETIVES: Anemia is a prevalent pathology associated with many chro- Background: Though intravenous(IV) Magnesium Sulphate(MgS04) has additive effect to beta-nic diseases. COPD in industrialized countries is one of the pathologies that causes more morbi- 2 agonists, its additive benefit in face of combination tharapy with beta-2-agonists and ipratro-mortality, and consumes a great amount of health resources. We selected a group of severe pium(standard therapy of severe acute exacerbation of asthma) remains unadressed.RecentCOPD patients that were admitted at our hospital, and determine if the presence of anemia mo- Meta-analyses emphasise need for such study Aim:To evaluate the role of IV MgSO4 when useddified the number of hospitalary admissions of these patients. MATERIAL AND METHODS: 85 as an adjunct to standard therapy of severe exacerbations of asthma. Method:Randomized,singlepatients admitted at our service, diagnosed of severe COPD by spirometry during the first three blinded,placebo-controlled study was carried out in emergency department of a tertiary referralmonths of 2006 were chosen for our study. We first determine the prevalence of anemia in this centre in india.Patients aged 18-60 years presenting with acute asthma and PEFR < 100Lmingroup following the OMS criteria for anemia (levels under 13 g/dl for men, and under 12 g/dl were included All patients received IV Hydrocortisone on arrival.In group1(controls), patients werefor women). We evaluated the mortality rate of patients that had anemia, and compared if this nebulised with salbutamol and ipratropium thrice at 20 minutes interval and were given 2gm IVgroup presented more frequency of hospitalary readmission during the next 12 months. RE- MgSO4 in 200 ml normal saline at 30 minutes. In group2 patients were nebulised similarly,butSULTS: 57 of the 85 patients included were men, and 8 women. 24% (20) had anemia. 6% of were given only IV normal saline at 30 minutes for blinding. PEFR was evaluated at baseline andpatients with anemia died during the study. Hospitalary readmission was 65% in the group of ane- at 30 minutes interval.The primary efficacy end point was PEFR%predicted(pred.) at 120 mins andmia, compared with the ones that didn´t have anemia, 57%. Differrences were statistical signifi- odds ratio(O.R.) of admission.(derived from comparing proportion of groups attaining PEFRcatives (p<0.05). CONCLUSIONS: Prevelence of anemia in our study group was 24%, mainly >60%pred. at 120 minutes). Results: Both groups of 30 patients each,were matched with respectmen. Global mortality rate was 14%, and 6% in patients with COPD and anemia. Patients with to demographic and pulmonary parameters(Baseline PEFR% :32.6+4.8% in group2 vs.32.1+5.4%severe EPOC and anemia needed higher number of readmissions during the following months in group1, p=0.88).At 120 minutes,there was a higher meanPEFR%pred(66.6+4.3% vs.that continued the study. 61.7+3.3%) and %improvement from baseline (33.5+3.5% vs 29.6+3.7%), in group 2 as com- pared to group 1(MeanDifference=4.36%,C.I.2.16-6.59,p<0.001).The O.R. for admission in group 2 with respect to group1was lower and significant.(O.R=0.16,C.I.=0.05-0.77, p<0.05). Conclusion: IV MgSO4 improves pulmonary function and reduces admission rates,when used as an adjunct to standard therapy in severe acute asthma .Thus IV MgS04 should added in severe acute exa- cerbations routinely to prevent potentially fatal complications.3. SURVIVAL IN PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION ted quality of life in patients with systemic sclerosis. All our patients within three months of the-RELATED TO SYSTEMIC SCLEROSIS rapy with Iloprost and bosentan exhibited resolution of multiple fingertip ulcers and reduction ofMazzuca S, Cimino R, Iannazzo P, Paravati S, Nestico’ E, Galasso S, Giancotti S, Pintaudi C, mean number of new digital ulcers, thus opening new perspectives in the treatment of digital ul-Galasso D. cers in systemic sclerosis.Pulmonary Arterial Hypertension affects approximately 16% of patients with Systemic Sclerosis(SSc),today, is the most common cause of death in SSc. Breathlessness is common in patientswith SSc, thus SSc-associated Pulmonary Arterial Hypertension (SSc- PAH) is often diagnosed toolate for patients to derive maximum benefit from disease- modifying therapies. Objectives :Toevaluate the clinical efficacy and the effects on survival and on quality of life of Iloprost, a prosta-cycin analogue, associated with Bosentan, an endothelin receptor antagonist, in the treatment ofpatients with SSc-PAH. Materials and Methods: we performed the study on 142 consecutive pa-tients (122 W- 20 M ) with SSc from January 1998 to December 2007. The patients were selec-ted for study if they fulfilled the diagnosis of SSc according to the criteria of the American Collegeof Rheumatology and diagnosis of Limited Skin Sclerosis as defined by LeRoy (1988). The patientshad a mean age 51,2 years (range 13-84), and mean duration of disease 12,2 years ± 7,5 (range1-24 years). In 24 patients (17%) we detected pulmonary hypertension: 15 patients with SSc-PAHwithout interstizial pulmonary involvement established by HRCT, 9 patients with pulmonary hy-pertension and interstitial lung disease on HRCT defined by the presence of at least 1 of the 2following radiologic features: ground-glass opacification and honeycombing ( micro or macrocy-stic reticular pattern). From April 2004 we enrolled 8 patients (7 W-1M), mean age 50,4 ± 13,2years,2 patients with diffuse skin SSc, 6 patients with limited skin SSc and mean duration of di-sease 9,1 years , all patients affected by pulmonary arterial hypertension in absence of significantrestrictive lung disease and interstitial lung disease on HRCT. To assess PAH, we used tricuspid gra-dient detected on echocardiography and to increase the specificity, we used a threshold of pul-monary arterial systolic pressure of &#8805; 45 mmHg. All eight patients underwent therapywith Iloprost, given by intravenous infusion, at progressively increasing doses (from 0,5 to 2ng/Kg/min) over a period of 6h each day for 6 days with repeated cycles of one day at regularintervals of 14 days for 36 months, and Bosentan started at 62,5 mg twice a day and increasedto 125 mg twice a day sfter 1 month. All patients compiled Short Form -36 for Quality Life. In eightpatients we detected 28 digital ulcers. Statistical analysis were performed using Fisher’s exact testfor the comparison of frequencies, paired t-test were used for comparisons of variation in valueswithin the same individual. Univariate analysis of survival was performed by log rank test. Results:A woman, 63 years old, with diffuse skin SSc and SCL-70 positive, for hyperosmotic diabeticcoma during 12° month died. In our case series all patients developed significant improvementin exercise capacity, as documented by six minutes walking test with 351±93 m at baseline andmean increase of 44,8 m at 12° month of therapy (p<0,011) and 411±71 m (p<0,001) at 36 °month. Although pulmonary systolic pressure showed only a modest reduction, all patients si-gnificantly improved NYHA functional class from III to NYHA functional class I (p<0,02); the im-provement of the functional class occurred within three months, and was lasting for all the 36months of follow-up. Our case seris recorded clinical improvement in conjiunction with impro-vement on the six minutes walking test that has been shown to be an acceptable outcome mea-sure. By echocardiography the pulmonary arterial systolic pressure had decreased from 53±16mmHg to 50±14 mmHg at 12° month (p NS) and to 44±9 mmHg at 36° month (p<0,32); Theinstrument of Short Form-36 showed score 35±11 at baseline and 59±7,2 after 36 months of fol-low-up (p<0,002). The Short Form-36 is a valid instrument for the evaluation of the health-rela- 12
  • 16. 4. USE OF NON-INVASIVE VENTILATION FOR ACUTE RESPIRATORY FAILURE IN tient&#8217;s proper size: -ACPE Pts received CPAP (Continuous Positive Airway Pressure) withGENERAL MEDICAL WARDS a Venturi-like flow generator system (Whisper Flow, Caradine), 7.5-10 cm H2O, FiO2 to maintainFederico Lari, Germano Pilati, Gianpaolo Bragagni, Nicola Di Battista SpO2 > 92% -COPD Pts received bi-level pressure ventilation in spontaneous breathing with a ventilator (ViVo 40, Breas, Pressure Support Ventilation). Inspiratory Pressure (IPAP) was set at 14-BACKGROUND In the last years Non-Invasive Ventilation (NIV) reached an important role in 20 cm H2O (increased to the maximun tolerate), Espiratory Pressure (EPAP) 4-6 cm H2O, FiO2treatment of Acute Respiratory Failure (ARF). Prospective randomised controlled trials show im- to maintain SpO2 = 90%. Inspiratory and Espiratory triggers were set in order to minimize pa-provement in clinical features (Respiratory Rate, Neurological Score), pH and arterial blood gases tient&#8211;ventilator asynchronism. The most important parameters derived from ventilatorand in particular clinical conditions (Acute Cardiogenic Pulmonary Edema, ACPE, and acute exa- were: Respiratory Rate, Espiratory Tidal Volume (Vtesp), Lacks. A Whisper Swivel exhalation de-cerbation of Chronic Obstructive Pulmonary Disease, COPD) systematic reviews and metha-ana- vice (Respironics) was used. During bi-level ventilation Pts received aerosol therapy with short ac-lysis confirm reductions in the need for intubation and in-hospital mortality compared to standard ting beta2 agonists. -Pneumonia, ALI/ARDS Pts received CPAP or bi-level pressure ventilation ifmedical treatment. Early application and staff&#8217;s training seems to be determinant on severe hypoxemia or hypoventilation - muscle weakness were respectively prevalent. All PatientsNIV&#8217;s success. Even if the first important data on NIV come to studies performed in In- received NIV early, at the onset of respiratory failure in the ward. During the first day of treatmenttensive Care Units (ICU), subsequently these methodologies of ventilation have been used with NIV support was applied for many hours a day if necessary, with little breaks only for lunches andincreasing frequency in Emergency Departments (ED) and respiratory wards; this for several rea- personal care. During the following days, if Patient responded to treatment, NIV was decreasedsons: -increase of Elderly Patients with various chronic diseases -increase of complicated clinical adding longer breaks and then stopped. We definitively stopped NIV when Patient was able toconditions in which endo tracheal intubation (ETI) and invasive ventilation lead to poor outcomes maintain a normal respiratory pattern and normal blood gases values after 3 hours of treatment(immunodeficiency, neoplasm&#8230;) -lack of bed places in ICU However, the use of NIV in with Venturi mask. Monitoring: During the first hour of treatment a physician or a nurse were con-general medical wards is largely incomplete, and is more significant in small and middle size Ho- tinuously present at Patient&#8217;s bedside in order to verify compliance to treatment and re-spitals where the absence of ICU forces the management of ARF with NIV in general wards for assure the Patient: they controlled lacks, Patient&#8217;s tolerance of mask, clinical status. Clinicalthe first hours of treatment. AIM OF THE STUDY The study reflects our experience with NIV used parameters, arterial blood gases and pH were measured before treatment, after 1-2 hours of tre-in a general medical ward: Objective of this observational study is to verify the applicability, ef- atment, after 3-6 hour, after 12 hours, after 24 hours and more if needed, including end of NIVfectiveness and safety of non-invasive ventilation in this particular setting. METHODS Patients: We treatment. The most important clinical parameters collected were: Respiratory Rate, Neurologicalenrolled and treated with NIV 50 consecutive patients (Pts mean age 83 years, M/F 19/31) with Kelly Score, Non Invasive Blood Pressure, SpO2, Cardiac Rate, ECG, diuresis, Body Temperature.Hypoxemic or Hypercapnic ARF between June 2005 and March 2006 at Medical Division of SS Outcomes: Primary outcome of the study was NIMV failure defined as &#8220;need for intu-Salvatore Hospital of San Giovanni in Persiceto (Bologna, Italy). Nobody used NIV or oxygen for bation&#8221; (subsequent ICU transfer and invasive ventilation treatment) or &#8220;death ofchronic conditions at home and nobody received treatment for ARF in Emergency Department. Patient&#8221;. Criteria for ETI were derived from those used by Brochard and Antonelli: PatientsInclusion Criteria were the following: potential reversibility of ARF, high Respiratory Rate (>26 per were considered to have &#8220;needed intubation&#8221; if we observed worsening of clini-min), signs of respiratory distress; for Hypoxemic patients PaO2 < 60mmHg, for Hypercapnic Pa- cal status or arterial blood gases and pH during the first 3-6 hours of NIMV treatment:tients PaCO2 > 45mmHg and pH < 7.35 (but >7.10). Exclusion Criteria were controindications to &#8226;Failure to maintain PaO2 > 65 mmHg with FiO2 > 60% (PaO2/FiO2<100) &#8226;Fai-NIV: cardiac or respiratory arrest, respiratory rate <12 per min, upper airway obstruction, hemo- lure to improve PaCO2 and pH &#8226;coma or seizures disorders &#8226;difficult manage-dynamic instability or unstable cardiac arrhythmia, encephalopathy (Kelly score > 3), facial surgery ment of copious secretions &#8226;inability to correct dyspnea and respiratory distresstrauma or deformity, inability to cooperate / protect the airway, high risk of aspiration, inability to &#8226;hemodynamic or EKG instability &#8226;mask intolerance As Secondary outcomes ofclear respiratory secretions. Aetiology of ARF was determined by clinical examination, history, the study were considered: ·Differences between &#8220;responder&#8221; group andchest radiography, arterial blood gases, according to international criteria: 22 Pts (44%) were clas- &#8220;failure&#8221; group. ·Effect of NIMV on clinical parameters and arterial blood gases.sified as ACPE, 18 Pts (36%) acute exacerbation of COPD, 5 Pts (10%) Pneumonia, 5 Pts (10%) ·Evaluation of median duration of treatment, mean length of hospitalisation, complications ofAcute Lung Injury / Acute Respiratory Distress Syndrome (ALI/ARDS). Baseline characteristics of NIMV Statistical analysis: For normally distributed data results are given as means (with range),treated Pts are: mean respiratory rate 36 per min (range 28-48), mean neurological Kelly score and means were compared with Student t-test. For non-normally distributed data we used me-2.77, mean arterial blood pH 7.22 (range 7.10 &#8211; 7.50), mean PaCO2 70mmHg (range 24 dians (5th and 95th centiles). 2x2 tables were analysed by Fisher&#8217;s exact test or Chi-&#8211; 108), mean PaO2 49 mmHg (range 33 &#8211; 65). Setting: Physicians and nurses of Square test, depending on the number of data. RESULTS Nine Patients (18%) met the primarythe ward were formed since 4 years before the beginning of the study attending a specific course endpoint of the study (&#8220;failure&#8221; group): similar rates are globally reported in lite-on NIV in ARF provided by a National Scientific Society. During the following years they atten- rature both ED-ICU and ward settings (20-30%). Eight of these Patients (16%) needed endo tra-ded periodic retraining and became expert treating Patients. No Physician was pneumologist. cheal intubation (ETI), invasive mechanical ventilation, transfer to the ICU: one Patient (2%) diedConventional treatment: all Pts received conventional medical treatment, that consisted in: -ACPE: due to cardiorespiratory arrest, he was affected by Pneumonia. Three (6%) of eight Patients whointravenous vasodilators and intravenous diuretics -COPD: bronchodilator, aerosol therapy, intra- received intubation had acute exacerbations of COPD: they failed because of worsening in neu-venous steroids and antibiotics -Pneumonia: i.v. antibiotics, i.v. fluids -ALI/ARDS: i.v. antibiotics, i.v. rological score, arterial blood gases and pH values. This results in a failure rate of 16.6% in thesteroids, i.v. fluids NIV: NIV was performed with face mask paying attention to choose Pa- subgroup of Patients with COPD. The other 5 Patients who received ETI (10%) were ALI/ARDS:it was not possible to correct hypoxia, dyspnea and respiratory distress. This means that all Patients Tidal Volume and alveolar ventilation. Hypoxemic ARF related to ALI/ARDS and severe pneu-with ALI/ARDS had no success in treatment (failure rate 100%), whereas no patients with ACPE monia show a worst outcome and controversial data in literature: for this reason it is not advisa-received ETI or died (success rate 100%). The group of Patients who responded to treatment ble to manage these conditions with NIV outside the ICU and further studies are needed to(&#8220;responder&#8221; group) had no statistically significant differences versus &#8220;fai- support real advantages of NIV. NIV in addition to standard medical therapy for the treatment oflure&#8221; group in term of baseline Respiratory Rate, Kelly Score, PaO2, Blood Pressure, Heart ARF due to COPD exacerbation and ACPE is feasible, safe and effective in a general medicalRate, and NIV set up: baseline pH, PaCO2 and mean age were significantly different in these two ward if, after a correct selection of Patients, staff&#8217;s training and monitoring result appro-group. In particular &#8220;failure&#8221; group had higher pH, lower PaCO2 and lower mean priate: its early application improve clinical parameters, arterial blood gases values and can pre-age probably due to the high prevalence in this group of ALI/ARDS Patients who presented these vent ETI, ICU transfer and invasive ventilation, events related to high mortality rate, complications,features (p <0.0001). The presence of ACPE in &#8220;responder&#8221; group only, was sta- longer hospitalisation. This should encourage the diffusion of this type of ventilation in this spe-tistically significant (p 0.0027). No differences in clinical and arterial blood gases parameters were cific setting. According to strong evidences in literature, NIV should be considered a first line andpresent in &#8220;responder&#8221; versus &#8220;failure&#8221; COPD Patients. After 1- standard treatment in these clinical conditions irrespective of the setting.2 hours of treatment with NIV we registered in all patients a statistically significant improvement(p<0.05) in Respiratory Rate, Neurological Kelly Score, pH, PaCO2, PaO2 versus baseline data.These enhancements have been subsequently confirmed after 3-6 hour, 12 hours, 24 hours andmore of treatment. Median duration of treatment globally resulted 16:06 hours with significantdifferences depending on aetiology: COPD Patients required 18:54 hours (range 6-36 hours),ACPE Patients 4:15 hours (range 2-8 hours), Pneumonia 20 hours (range 6-48). As is commonknowledge ACPE Patients usually improve after few hours of CPAP treatment thanks to its he-modynamic and ventilatory effects while COPD Patients need a longer period of treatment withbilevel ventilation in order to resolve acute respiratory failure. Mean length of hospitalisation ofresponder patients resulted 8.66 days. Patients transferred to the ICU were lost so it was not pos-sible to collect further data: in other series ICU transfer and invasive ventilation lead to higherlength of hospitalisation, compications and mortality. No patients discontinued NIV treatment forside effects: NIV was substantially well tolerated. The role of nurse care in the first hours of treat-ment has been essential in order to prevent complications (as aspiration, pressure lesion, clau-strophobia&#8230;) and to enhance Patient&#8217;s comfort and compliance. DISCUSSIONResults of this study are consistent with literature&#8217;s data. Global failure rate of NIV for alltypologies of ARF (18%) is similar to those reported in important studies performed in ICU, EDand Ward setting. Also failure rate for each single condition cause of ARF is comparable with li-terature. Studies developed in ICU sometimes report slightly worse outcomes compared to stu-dies performed in General Pneumological Ward due to the need to treat more severe Pts in ICU:for example, enrolled COPD Pts present lower baseline arterial blood pH, higher baseline PaCO2.In our experience baseline characteristics of treated Pts are similar to those reported in various stu-dies performed in ICU. Aetiology remains one of the most important factor determining pro-gnosis: different pathological mechanisms sustain different clinical conditions and not in all casesthe application of positive pressures to the airways is useful. ARF due to acute exacerbation ofCOPD and ACPE is associated with a better outcome and stronger evidences in literature: the ad-dition of NIV significantly lead to lower &#8220;need for intubation&#8221; and lower morta-lity rate compared to standard medical therapy alone. In ACPE Pts CPAP and bi-level ventilationseems to be similar in effectiveness: high positive pressure inside the chest produces ventilatoryand hemodynamic useful effects such as alveolar recruitment, increase of functional residual ca-pacity (FRC), decrease of pre- and after-load. The choice to use CPAP rather than bi-level ventila-tion depend on the local experience and organisation. In COPD Pts bi-level ventilation is effectivebecause: 1- external expiratory positive pressure (EPAP or PEEP) contrast the intrinsic end expi-ratory positive pressure (iPEEP) of these Pts; 2- an higher inspiratory positive pressure (IPAP orPressure Support) decrease the work of breathing (WOB) reducing Airway Resistance, improving 13
  • 17. 5. PSORIASIS AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE:A POPULATION-BASED STUDYJacob Dreiher, Jonathan Shapiro, Batya Davidovici, Arnon D. CohenPsoriasis and Chronic Obstructive Pulmonary Disease: A Population-Based Study Oral Presenta-tion Jacob Dreiher, MD MPH, Jonathan Shapiro MD, MHA, Batya Davidovici, MD, Arnon D.Cohen, MD, MPH Southern District, Clalit Health Services, Siaal Research Center for Family Me-dicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Derma-tology Department, Rabin Medical Center, Petah Tikva, Dermatology Unit, Kaplan Medical Center,Rehovot, and Research and Health Planning Department, Health Planning and Policy Wing, Cla-lit Health Services, Tel Aviv, Israel Background: Previous reports have demonstrated an associa-tion between psoriasis and the metabolic syndrome. Chronic obstructive pulmonary disease(COPD) has also been associated with the metabolic syndrome. The goal of the study was to as-sess the association between psoriasis and COPD in a large population-based study. Methods: Across-sectional study was performed utilizing the database of a Clalit Health Services, a large he-althcare provider organization in Israel. Patients over the age of 20 years who were diagnosed withpsoriasis were compared with a sample of enrollees without psoriasis regarding the prevalenceof COPD. Data on other health-related lifestyles and co-morbidities were collected. Chi-square testsand logistic regression models were used to compare categorical parameters. Results: The studyincluded 12,502 psoriasis patients and 24,287 subjects without psoriasis. Psoriasis patients weremore likely to be male (52.1% vs. 50.2%, p<0.001) and slightly older (mean age in the psoriasisgroup: 55.8 ± 16.8, mean age of controls: 54.3 ± 17.4, p<0.001). The prevalence of COPD wassignificantly higher in psoriasis patients (5.7% vs. 3.6%, p<0.001, OR=1.63, 95% CI: 1.47-1.81). Amultivariate logistic regression model demonstrated that psoriasis was significantly associated withCOPD, after controlling for confounders, including age, gender, socioeconomic status, smokingand obesity (multivariate OR=1.27, 95% CI: 1.13-1.42, p<0.001). Conclusions: Psoriasis is associa-ted with COPD. Dermatologists taking care of patients with psoriasis should be aware of this as-sociation and advise the patients to stop smoking and reduce additional risk factors. 14
  • 18. Oral Communications Thursday, May 8, 2008 GASTROENTEROLOGY
  • 19. 1. INTRAVENOUS HIGH DOSE FUROSEMIDE PLUS SMALL VOLUME OF 2. EPIDEMIOLOGY, RISK FACTORS AND CLINICAL COURSE OF DRUG-INDUCEDHYPERTONIC SALINE SOLUTIONS (HSS) VERSUS SERIATED PARACENTESIS IN LIVER INJURYTREATMENT OF REFRACTORY ASCITES. A PILOT STUDY A. Licata, V. Calvaruso, C. Randazzo, M. Cappello, P.L. Almasio, A. CraxìPinto A, Tuttolomondo A, Di Raimondo D, Parrinello G, Di Sciacca R, Fiorello E, Paterna S, Licata G. Background & Aim. The clinical pattern of drug-induced liver injury (DILI) may range from mildBackground and Purpose: The development of ascites in patients with cirrhosis involves two major transaminases elevation to fulminant hepatitis carrying a high rate of mortality. We aimed to eva-factors: portal hypertension and renal sodium and water retention. Refractory ascites, that occurs luate the rate of severe cases of DILI on total hospital admissions and to identify the drugs mostin approximately 5% to 10% of all cases of ascites, is defined as ascites that cannot be mobilized commonly responsible of this clinical course. Methods. We retrospectively reviewed all clinical re-or the early recurrence of which cannot be prevented by medical therapy. On the basis of a pre- cords of patients with DILI admitted to our Unit from February 1996 to December 2006. A da-vious study by our group, showing efficacy of high furosemide doses+small volumes of hyperto- tabase was constructed, reporting data regarding age, sex, clinical features at onset, laboratorynic saline solutions (HSS) to treat patients with refractory heart failure, the aim of our study is to results, suspected drugs and follow-up. The diagnosis of DILI was based on the presence of at leastevaluate the safety and efficacy of this treatment in patients with liver cirrhosis complicated by re- three of the International Consensus Criteria (J Hepatol 1990). Liver damage was defined as he-fractory ascites compared to seriated paracentesis. Methods: We enrolled 84 subjects affected by patocellular, cholestatic or mixed, according to clinical and laboratory data, since histology was per-liver cirrosis with refractory ascites (59 males and 25 females) 60 subjects were treated with in- formed only in a minority of patients. All patients were negative for hepatitis A, B, C, EBV andtravenous high dose furosemide+ HSS (group A) and 24 subjects with seriated paracentesis and CMV serology and non organ-specific autoantibody screening. Results. Forty six cases out ofconventional therapy according to guidelines (Group B). Results: in group A we observed a grea- 6,134 patients received a discharge diagnose of DILI. There were 23 men and 23 women, meanter improvement in urine output, a greater loss of weight at discharge, a significant control of age was 54.2 (range 11-88 yrs), 35 patient (74%) were older than 40 years. Five patients had anascites and other signs of volume overload such as pleural effusion or leg oedema, and a better associated chronic liver disease (2 cirrhosis and 3 HCV-related chronic hepatitis). At clinical pre-Child Pugh score at discharge. On the other hand no significant differences have been observed sentation all patients had abnormal liver function tests (LFTs), 22 patients were jaundiced and 3with regard to incidence of new episodes of hepatic encephalopathy, electrolytes disorders, renal patients was admitted for hepatic failure, manifest as hepatic encephalopathy. Liver damage wasimpairment or exitus between the two groups Conclusions: the results of our study show that the- hepatocellular in 19 patients, cholestatic in 15 and mixed in 12. In 10 (22%) of cases, two or morerapy with intravenous high furosemide doses into small volumes of intravenous hypertonic saline drugs were involved. NSAIDs (n =17), psychotropic drugs (n =7) and antibiotics (n =10) were thesolutions is safe and effective in treatment of refractory ascites compared to seriated paracentesis. most commonly involved drugs, followed by anti-platelet, anti-diabetic drugs and statins. NSAIDsThis is a pilot study and further investigations are needed in a larger sample with a follow-up were involved in three cases of acute liver failure and, among them, one was listed for liver tran-stage to evaluate long term endpoint (re-admission, long term mortality, encephalopathy, renal splantation but died while on the waiting list. All patients had regular follow-up visits every threeimpairment). months for at least one year after discharge. All patients, including those with pre-existing liver di- sease had a complete normalization of LFTs at the end of follow-up. Conclusions. Severe DILI re- quiring hospital admission is very rare and appears more common in patients over 40 years. NSAIDs, psychotropic drugs and antibiotics are the most common responsible drugs. Even in se- vere cases, recovery is almost the rule and only a few patients have an unfavourable course and eventually die.3. NON-INVASIVE ASSESSMENT OF HISTOLOGICAL INFLAMMATION IN 4. CLINICAL AND EPIDEMIOLOGICAL FEATURES OF HEPATOCARCINOMA INPATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD) HEPATITIS C VIRUS INFECTED PATIENTSAlessandra Forgione, Luca Miele, Consuelo Cefalo, Anna Caprodossi, Valerio Vellone, Arnedo Diez de los Rios R. Ojeda Burgos G. Puerta Fernández S. Gavilán Carrasco JC.Simona Racco, Maria L. Gabrieli, Vittoria Vero, Marco Biolato, Fabio M. Vecchio,Giovanni Gasbarrini, Antonio Grieco Introduction. Primary heaptocarcinoma (HCC) is the fifth most frequent cause of cáncer in the world and one of the tumours with worst prognostic. Hepatitis C Virus ( HCV) infection plays anBackground: Nonalcoholic steatoepatitis (NASH) represents the most severe form of NAFLD (Non important role in its appearance. Nowadays there is not enough studies that describe the profileAlcoholic Fatty Liver Disease). The progression of NASH to most severe form of liver disease and of the HCV infected patient that develop an HCC in South Spain and the evolution of the diseasefibrosis is due to increase inflammation within the liver and serum transaminases don’t reflect the in these patients. Objectives Describe the clinical and epidemiological features of HCC in HCVseverity of liver disease. Serum Hyaluronic acid (HA), tissue inhibitor of metalloproteinase 1 infected patients in our environment. Material and Method. Type of study: Descriptive retro-(TIMP1), are reliable markers of liver fibrosis and are closely linked to the proinflammatory sta- spective study. Population: HCV infected patient´s cohort followed in Hepatitis Departament of In-tus. Aim: We aimed to build a mathematical model able to detect moderate-severe inflammation ternal Medicine Service in” Virgen de la Victoria” Hospital in Málaga, South of Spain.in biopsy proven NAFLD at different stages using the means of serum TIMP1 and HA. Patients Demographic, clinical and biological datas were analysed. Results 138 patients were included, 3%and Methods: 46 histological proven NASH (mean age 43.66 ± 14.08, male gender: 76,1%) pa- coinfected with Hepatitis B Virus ( HBV). 56% women. Medium age 50±14.3 years. The mediumtients were included in the study. Serum HA and TIMP1 were assessed by commercial ELISA follow- up period was 8±4.5 years. At the moment of diagnostic 82% were classified like Chro-kits. Difference among groups (classified according liver histology) were assessed by ANOVA. nic Hepatitis and 17.5% like Cirrhotics . We found hepatic complications during the follow-up timeDemographic, clinical, and laboratory findings were analyzed by univariate and multivariate binary in 15.2% of the cases: 3.6% ascitis, 2.2% encefalopathy, 3% varicose veins bleeding, 1.5% espon-logistic regression to build up the mathematical model. The ROC curve was used to identify the tenous bacterial peritonitis and 8% HCC. Patients with HCC were women in 63.6%, the mediumcut-off point of the mathematical model and to assess the sensitivity and specificity. Results: Mo- age was 61.7 ±8.9 years vs non HCC patients: 48.9±14.3 years, p=0.004. Medium period of ap-derate-severe histological inflammation was present in 21,7% of our population. Serum levels of pearance of HCC was 6,8±4.8 years. The most frequent reason of consult was hypertransamina-HA and TIMP1 were statistical different in patients with different stages of histological inflamma- semia (89%). Risk factor associated with HCV infection was observed in 45.5% of the cases: 80%tion, respectively with a p<0,001 and p=0,018. In the logistic regression among clinical parame- transfussion, 20% sexual risk factor. 82% of the patients had alcohol consumption under 20ters, only BMI was able to predict the moderate-severe inflammation (OR 1,666, 95%CI gr/day. 70% of the HCC was casually diagnosed, 64% by ecography control and alpha-fetopro-1,021-2,720). On the ground of these results we built a mathematical model including BMI, tein abnormal level ( medium alfafetoprotein level 15.5±5.85). The alfafetoprotein level at the be-TIMP1 and HA. The result of this model with a cut-off of 116,2522 showed good sensibility 83,3% ginning was 3.28±2 in non HCC group vs. 9.1±11 in HCC group, p < 0.05. 60% of casesand specificity: 87,5% (AUC 0,917; 95% CI 0,815-1,018; p<0.001) with a Negative Predictive Value presented an unique hepatic lession < 5cm at the time of HCC diagnostic. The hepatic transplantof 87,1% for moderate-severe inflammation. Conclusions: Our model we could exclude with a was the most frequent treatment ( 30%). 40% dindn´t receive treatment. In 12.5% of HCC casesgood accuracy the presence of moderate-severe inflammation avoiding the need of liver biopsy the lession progressed; in 62.5% didn´t grow and 25% was free of disease at the the end of thein a substantial proportion of patients. follow-up. One patient died by a non hepatic cause. Conclussions. HCC is a frequent complica- tion in HCV infected patients in our environment HCC is more frequent in the sixth decade of the life. At the moment of diagnostic the most frequent finding is a unique lession < 5cm with pathological level of alfafetoprotein Alfafetoprotein levels at the beginning of the follow-up are hi- gher in patients than later develop an HCC In our environment a high percentage of the hepa- tocarcinoma were not subsidiary of treatment but they remained stable during the followup. 16
  • 20. 5. DUODENAL DIVERTICULA: A REVIEW OF 28 CASES 6. PRIMARY HEPATIC GIST: UNCOMMON BUT NOT IMPOSSIBLEBotas Velasco M, Robert Gates J, Peris García, J, Matarranz del Amo M, Martínez Baltanás A, Pereira S.C.; Lobão M.J.; Silva R.S.; Pereira A.Wikman Jorgensen P, Safont Gasó P, López Calleja E, Jover Díaz F, Merino J. The authors will present the clinical case of a 53 years old man diagnosed with a hepatic ga-Objetive: An analysis of the main features of the duodenal diverticula recovered in our department strointestinal stromal tumour (GIST). GISTs are neoplasm of the gastrointestinal tract, mesentery,in the last ten years. Method: We reviewed medical charts of last 28 adults diagnosed with duo- or omentum that express the protein-tyrosine kinase cKIT (CD117) and are the most common me-denal diverticula (DD) and analysed their clinical features, complications and related diseases. Re- senchymal tumour arising at these sites. Due to abdominal pain and distension, an ultrasound wassults: Mean age was 78 years (53% males). 75% were located in second part of duodenum, 17% requested, which revealed the existence of a voluminous, tumorous formation on the left liver lobe.in the third and 14% in the first. 10% were asymptomatic when diagnosed; one case had a sin- The abdominal tomography confirmed this 14,9 cm diameter lesion, which was later biopsiedgle abdominal mass. The remaining 90% had digestive symptoms due to gastrointestinal com- with ecographic guidance. The complementary study (gastro-intestinal endoscopic study and PETplications, mostly biliary (60%): cholelithiasis 20%, choledocholithiasis 20%, cholangitis 10%, acute scan) did not find any other lesion, which is consistent with the diagnosis of hepatic sarcoma/GIST.cholecistitis 10% and recurrent acute pancreatitis 28%. Acute diverticulitis developed in 3,5 %. The patient was subject to left hepatectomy and hepatic hilum lymphadenectomy on NovemberMost were associated with other digestive diseases: 39% hiatus hernia, 36% colonic diverticula 2007, and histology confirmed neuro and angioinvasive GIST with a mitotic rate of 5/10CGA. Theand 17% peptic ulceration. Neoplasic disease was found in 14%. Discussion: Duodenum is second patient is currently well, with only mild abdominal discomfort. The importance of this case lies onmost common site of diverticula along gastrointestinal tract after sigmoid colon. They usually are its rareness. With this presentation we want to alert all physicians to the unlikely possibility of alocated on pancreatic border of duodenal curve in second and third parts. In clinical practice, in- GIST being, in fact, a primary tumour.cidence is less than 6%, although in autopsy series it is 23%. DD may be single or multiple andtheir size is 1-5cm, but bigger than 10cm has been reported. DD are usually asymptomatic, al-though the most common symptom is non-specific epigastric postprandial pain. They are oftenfound coincidental with other gastrointestinal diseases, as colonic diverticula, peptic ulceration andhiatus hernia. Less than 5% have related complications; the most usual are ulceration, diverticu-litis, duodeno-colic fistula and acute and chronic pancreatitis. Gastrointestinal barium examina-tion, upper gastrointestinal endoscopy and CT scan are the gold standard for diagnosis. Definitivetreatment is diverticulectomy, although it is required in less than 1%. Conclusion: DD is an infra-diagnosed patology, due to its non-specific symptoms. We find many complications related to bi-liary tract damage, probably because in our work we only analyzed hospitalized patients; DDshould be ruled out in all cases of non-specific abdominal pain, even if other digestive diseasesare found.7. LIPOPROTEIN LIPASE ACTIVITY AND MASS, POLYMORPHISMS OF 8. ASSOCIATION BETWEEN HELICOBACTER PYLORI INFECTION AND PLASMAAPOLIPOPROTEINS E AND A5 IN PATIENTS WITH ACUTE GHRELIN LEVELS IN PATIENTS WITH GASTRITIS AND PEPTIC ULCER DISEASEHYPERTRIGLYCERIDAEMIC PANCREATITIS Nujen Colak, Baris Kosan, Erdal Eskioglu, Gonul Erden, Osman YukselInmaculada Coca Prieto, María José Ariza, José Rioja, Carlota García-Arias, Pedro Valdivielso,Gunilla Olivecrona2, Pedro González-Santos1 Introduction: Ghrelin is a recently discovered conspicuous peptide, mostly secreted from entero- endocrine cells of gastric fundus that influences gastric acid secretion and gastric motility [1,2].Objective: to analyze the catabolism of triglyceride-rich lipoproteins in patients with acute hyper- Ghrelin has effects on endocrine and non-endocrine physiologic events such as appetite, food in-triglyceridaemic pancreatitis. Material and methods: Subjects: 24 survivors of acute hypertrigly- take, body weight and growth hormone like effects [3]. Helicobacter pylori is the major cause ofceridaemic pancreatitis (cases) and 31 patients with severe hypertriglyceridaemia (controls). Main gastritis and peptic ulcers worldwide [4], therefore the pathologic results of gastric H. pylori in-outcome measures: clinical and anthropometrical data, chylomicronaemia, lipoprotein profile, po- fection may disrupt ghrelin production and secretion due to loss of the glandular cells conduc-stheparin lipoprotein lipase mass and activity, hepatic lipase activity, apolipoprotein C II and CIII ting to decreased plasma ghrelin levels [5] which can be responsible for the symptoms andmass, apo E and A5 polymorphisms. Results: five cases were found to have LPL activity deficiency. mechanism of the disease [6]. In this study we searched for the alterations in plasma ghrelin le-No cases had apolipoprotein CII deficiency. No significant differences were found between the vels of H. pylori positive and negative patients with peptic ulcer and gastritis. Methods: Patients,non-deficient LPL cases and the controls in obesity, diabetes, alcohol consumption, drug therapy, attended to our clinic with dyspeptic symptoms and had undergone upper gastrointestinal en-gender distribution, evidence of fasting chylomicronaemia, lipid levels, LPL activity and mass, he- doscopy between July to August, 2006 were searched for gastritis and peptic ulcer disease. Afterpatic lipase activity, CII and CIII mass or apo E polymorphisms. However, the SNP S19W of apo diagnosis; the patients with hepatic or renal disease, thyroid dysfunction, hyperlipidemia or dia-A5 tended to be more prevalent in cases than controls (40% vs. 23%, NS) Conclusions: primary betes were excluded. Also the gastrectomised patients, alcohol users, smokers and patients takingdefects in LPL and C-II are rare in survivors of acute hypertriglyceridaemic pancreatitis. No diffe- non steroidal anti inflammatory drugs, antibiotics, proton pump inhibitors, H2 receptor antago-rential clinical or analytical traits have been found between the group with hypertriglyceridaemic nists or bismuth were excluded. Ten patients with normal endoscopic findings were included aspancreatitis (outside the acute phase) and severe hypertriglyceridaemia group, which could let control subjects. Thirty eight patients and ten control subjects were involved in the study to be as-know which of these patients could develop hypertriglyceridaemic pancreatitis. The 19W allele of sessed for plasma ghrelin levels and H. pylori status (n=48). Mucosal biopsies were achieved fromapo A5 might be a predisposing factor for acute hypertriglyceridaemic pancreatitis. gastric fundus and corpus in order to detect histopathologic signs of H. pylori. RIA (LINCO Re- search, Missouri, USA) method was used to measure plasma ghrelin levels. Statistical analyses of the results were conducted by using software (SPSS, version 13.0) Results: Patients with dyspep- tic symptoms (n=48) consisted of 34 female and 14 male subjects. Endoscopic and histopatholo- gic findings of 21 patients revealed gastritis, 17 patients were diagnosed as peptic ulcer and 10 patients had normal endoscopy as control group. There were no significant differences between groups in terms of mean age and body mass index. Helicobacter pylori were detected in 11 of the patients with peptic ulcer, 15 of the patients with gastritis, and 5 of the control group. Ratio of genders, average age and mean body mass index did not change significantly between H. pylori positive and negative subjects. Plasma ghrelin levels of patients with peptic ulcer (40,81 ± 24,82), gastritis (27,19 ± 19,43) and normal subjects (32,32 ± 15,38) were not statistically different (p:0,14). Plasma ghrelin levels of H. pylori positive subjects (n=31) and H. pylori negative subjects (n=17) within all groups were 32,56 ± 21,97 and 34,04 ± 20,59 respectively, suggesting that there was no significant difference in ghrelin levels between groups related to H. pylori infection. Discussion: As the most common cause of gastritis and peptic ulcer disease, H. pylori infection may affect ga- stric ghrelin production which has influences on gastric acid secretion and motility. However, re- cent studies revealed conflicting data about the relation between H. pylori infection and plasma ghrelin levels [5-8]. In this study we aimed to search for any relation between H. pylori infection and plasma ghrelin levels in a group of Turkish people suffering from dyspepsia. There are many clinical situations and individual factors affecting ghrelin secretion, thus we excluded patients with diabetes, thyroid dysfunction, hyperlipidemia, hepatic or renal disease [9,10]. Other factors which can affect ghrelin secretion such as alcohol consumption, smoking and using drugs like proton pomp inhibitors, antibiotics (for H. pylori), H2 receptor antagonists, NSAID and bismuth were also excluded. Age and body mass index of the patients did not differ between groups signifi- cantly; thereby alterations of ghrelin levels due to these factors were also excluded. Insulin resi- 17
  • 21. stance is one of the factors that affect ghrelin production [9], as an unshown data we also mea- 10. HCV AND ETHANOL INDUCED ANEUPLOIDY BY DIFFERENTsured the insulin levels and HOMA index of our patients and no significant difference was found. INTRACELLULAR PATHWAYSOn the other hand, independent from H. pylori, histopathologic changes due to gastric mucosal A. Alisi, M. Ghidinelli, A. Spaziani, C. Balsanodisease was also supposed to disrupt ghrelin secretion [6]. Chronic gastritis is associated withlower ghrelin levels, as in our study, patients with gastritis had the lowest ghrelin levels (27,19 ± Hepatocellular carcinoma (HCC) is a common cancer characterized by several etiologic factors;19,43) among the patients with peptic ulcer (40,81 ± 24,82) and control subjects (32,32 ± 15,38), among these hepatitis C virus (HCV) and ethanol, alone or in association, play an important rolehowever the difference was not statistically significant (p:0,14). Chronic and atrophic changes in in HCC development and progression. During progression of HCC, hepatic cells accumulate se-the gastric mucosa due to H. pylori infection may result in decreased numbers of ghrelin produ- veral chromosomal alterations, including aneuploidy. Aneuploidy often occurs as a result of mi-cing cells and lower plasma ghrelin levels [7,9]. In contrast, there was not significant difference in tosis dysregulation. Although, HCV proteins and ethanol are directly involved in induction ofplasma ghrelin levels between H. pylori infected patients and H. Pylori uninfected patients in our aneuploidy in HCC, the mechanism remains not well defined. We have already reported the abi-study; 32,56 ± 21,97 and 34,04 ± 20,59 respectively (p:0,75), similar with another Turkish study lity of HCV core protein to lead mitotic arrest depending on unconventional activation of PKR.[8]. In conclusion, according to our results, there is not a relation between plasma ghrelin levels Thus, here we investigated, in detail, mitosis dysregulation in HepG2 polyclonal cells stably ex-and H. pylori infection. These conflicting results may be related to different H. pylori strains, as in pressing all HCV proteins or HCV core protein alone. In addition, we analyzed mitosis dysregu-Turkey the prevalence of the strains, such as CagA, that cause atrophic gastritis is lower [11]. Mo- lation in HCV polyclonal cells treated with ethanol. Our results indicate that HCV proteinsreover; differences in studied populations in terms of race, sample size, nutritional status and ha- (especially core) cause a mitosis dysregulation by a delay in mitotic exit and altering expressionbits can also affect results. Decreasing plasma ghrelin levels in H. pylori infected subjects can be of spindle-associated molecules (i.e. cyclin B1, cdk1, tubulins, Aurora A, survivin, etc) by a me-compensated by other extra gastric ghrelin producing tissues, convenient to our results. All to- chanism strictly dependent on PKR expression. In addition, HCV core protein leads to mitotic ar-gether, further studies are needed to demonstrate the association between H. pylori infection and rest, inducing nuclear localization of the cyclin B1-cdk1-PKR complex. Ethanol treatment alters theplasma ghrelin levels. References: 1. Date Y, Kojima M, Hosoda H. Ghrelin, a novel growth hor- expression of the same mitotic molecules targeted by HCV, but this phenomenon seems to bemone-releasing acylated peptide, is synthesized in a distinct endocrine cell type in the gastroin- PKR-independent.testinal tracts of rats and humans. Endocrinology. 2000 Nov;141(11):4255-61. 2. Dass NB,Munonyara M, Bassil AK. Growth hormone secretagogue receptors in rat and human gastroin-testinal tract and the effects of ghrelin. Neuroscience. 2003;120(2):443-53. 3. Ueno H, Yamagu-chi H, Kangawa K. Ghrelin: a gastric peptide that regulates food intake and energy homeostasis.Regul Pept. 2005 Mar 15;126(1-2):11-9. 4. Zhang ZW, Patchett SE, Farthing MJ. Role of Helico-bacter pylori and p53 in regulation of gastric epithelial cell cycle phase progression. Dig Dis Sci.2002 May;47(5):987-95. 5. Nwokolo CU, Freshwater DA, OHare P. Plasma ghrelin followingcure of Helicobacter pylori. Gut. 2003 May;52(5):637-40. 6. Isomoto H, Ueno H, Nishi Y. Circu-lating ghrelin levels in patients with various upper gastrointestinal diseases. Dig Dis Sci. 2005May;50(5):833-8. 7. Isomoto H, Nakazato M, Ueno H. Low plasma ghrelin levels in patients withHelicobacter pylori-associated gastritis. Am J Med. 2004 Sep 15;117(6):429-32. 8. Gokcel A, Gu-murdulu Y, Kayaselcuk F, Serin E. Helicobacter pylori has no effect on plasma ghrelin levels. Eur JEndocrinol. 2003 Apr;148(4):423-6. 9. Ukkola O. Ghrelin and insulin metabolism. Eur J Clin In-vest. 2003 Mar;33(3):183-5.106. 10. Caminos JE, Seoane LM, Tovar SA. Influence of thyroid sta-tus and growth hormone deficiency on ghrelin. Eur J Endocrinol. 2002 Jul;147(1):159-63. 11. AydinF, Kaklikkaya N, Ozgur O. Distribution of vacA alleles and cagA status of Helicobacter pylori in pep-tic ulcer disease and non-ulcer dyspepsia. Clin Microbiol Infect. 2004 Dec;10(12):1102-4. 18
  • 22. Oral Communications Thursday, May 8, 2008 HAEMATOLOGY AND ONCOLOGY
  • 23. 1. MELPHALAN-PREDNISONE-THALIDOMIDE (MP-T) DEMONSTRATES A 2. MUTATION ANALYSIS OF HEPCIDIN AND FERROPORTIN GENES:SIGNIFICANT SURVIVAL ADVANTAGE IN ELDERLY PATIENTS > 75 YEARS WITH POSSIBLE RELATIONSHIP WITH IRON OVERLOAD IN ITALIAN PROSPECTIVEMULTIPLE MYELOMA COMPARED WITH MELPHALAN-PREDNISONE (MP) IN A BLOOD-DONORSRANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL, IFM01/01 Duca Lorena, Delbini Paola, Nava Isabella, Vaja Valentina, Fiorelli Gemino,Hulin C, Decaux O, Coiteux V, Rodon P, Pegourie B, Benboubker L,Gagneux L, Dib M, Voillat L, Cappellini Maria DomenicaGuillerm G, Moreau P. Hepcidin, an antimicrobial peptide, has been shown to play a central role in homeostatic regula-Background: The MP-T combination has become the standard treatment for newly diagnosed tion of iron absorption and distribution. Hepcidin binds ferroportin, inducing its internalizationMM patients (pts) aged 65 to 75 years (Facon et al; Lancet 2007;370:1209-18). However, no and lysosomal degradation and therefore decreasing export of cellular iron to the plasma. Hep-specific therapeutic recommendation exists for pts >75 years regarding the benefit of adding tha- cidin and ferroportin dysregulation, resulting from mutations in the genes encoding these proteins,lidomide to MP. Patients older than 75 years have frequently been excluded from large clinical is implicated in the pathogenesis of several iron disorders. In this study we examined mutationstrials, although they represent more than 20% of MM pts. Methods: The IFM 01-01 trial was ini- and polymorphisms of hepcidin and ferroportin genes in italian prospective blood donors that sho-tiated in 4/2002. Pts >75 years with untreated MM were randomized to receive MP-placebo (M wed iron overload not due to HFE genotype or to other causes such as inflammation, liver disease[0.2mg/kg/d] + P [2 mg/kg/d day1-4]) x 12 courses every 6-weeks + placebo) or MP-T (MP + and abnormal ethanol consumption. Hematological and iron parameters were obtained from rou-daily thalidomide [100mg/d]). No anti-VTE prophylaxis was given. The primary end-point was tine clinical laboratory procedures. The genes of hepcidin and ferroportin were analyzed by PCRoverall survival (OS). Secondary end points were progression-free survival (PFS), response to tre- amplifications of single exons followed by mutations screening with restriction analysis with en-atment, and toxicity. Trial enrollment was prospectively planned for 258 patients. Two interim ana- donucleases or direct sequencing. From two-hundred blood-donors originating from differentlyses were performed after inclusion of 150 and 200 patients. The IFM board decided to stop areas of Italy, we identified thirty subjects (20 males and 10 females, aged 18-57 years) with in-enrollment after the second interim analysis. Results: In all, 232 pts were randomized and 3 fai- creased transferrin saturation (%TS=51±23%; normal values <45%) and/or serum ferritinled to meet inclusion criteria. In all, 229 pts were analyzed (113 MP-T; 116 MP-placebo) with a (SF=558±437 ng/mL; normal values <250 ng/mL) and normal HFE genotype. The control cohortmedian age of 78.5 years (36% >80years). No differences between the 2 groups for baseline cha- (n=50; 30 males and 20 females, aged 20-60 years) were individuals with the same geographi-racteristics were observed except for gender (p=0.03). Data were analysed on an intent-to-treat cal origin of iron-loaded carriers, normal hematological and iron parameters and negative viral andbasis. The median follow-up time was 24 months. The median OS time (se) was 45.3 (1.6) months autoimmune screening studies. No functional mutations in hepcidin gene were found in the thirtywith MP-T vs 27.7 (2.1) months with MP-placebo, the benefit was significant (p=0.03 log-rank test). blood donors with alterated iron parameters and in the healthy controls. A polymorphism in in-The median PFS time (se) was 24.1 (2) months with MP-T vs 19 (1.4) months with MP-placebo tron 2 (IVS2+7G>A) has been identified in two blood donors with iron overload: one subject had(p=0.001). Rates of at least partial response, very good partial response and complete response serum ferritin value of 488 ng/mL and normal transferrin saturation, while the other had serumwere 62%, 22% and 7% with MP-T vs 31%, 7% and 1% with MP-placebo, respectively (p<0.001). ferritin value of 617 ng/mL and 93% transferrin saturation. The last also resulted heterozygotesIn the MP-T arm, 42% of pts stopped treatment due to toxicity vs 11% in the MP-placebo arm. for two common mutations Q248H and R561G in ferroportin gene. Five common polymor-The major reasons in the MP-T arm were peripheral neuropathy (12/48), neutropenia (7/48), and phisms and one microsatellite in the promoter region of ferroportin gene were identified: 5’UTR(-DVT (7/48). Some toxicities (Grade 2-4) were significantly increased with MP-T: peripheral neu- 98)G>C, 5’UTR(-8)C>G, (CGG)n 5’UTR microsatellites, IVS1-24C>G and 977 T>C (V221V). Theropathy (20% vs 5%), neutropenia (23% vs 9%) depression (7% vs 2%). There were no signifi- -98C and -8G alleles occurred at an higher frequency in blood donors with iron overload (0.43cative differences in DVT rates for MP-T (6%) vs MP-placebo (4%) or somnolence (6% vs 3%, and 0.35, respectively) than in control group (0.06 and 0.05, respectively), whereas the promo-respectively). After relapse in the MP-placebo arm, 77% of patients received Thalidomide. Survi- ter microsatellite (CGG)7 genotype was 0.32 versus 0.20. The frequency of (CGG)9 allele wasval time after progression was similar in the 2 groups, 9.8 months after MP-placebo and 9.3 particularly high in iron-overload carriers (0.22) compared to control group (0.00). The (CGG)9months after MP-T. Conclusion: These results confirm the superiority of MP-T over MP for pro- allele was in partial linkage disequilibrium with the –98C and the –8G alleles. The intronic poly-longing OS in elderly patients with newly diagnosed MM. The toxicity was acceptable in this very morphism IVS1(-24) and the T>C substitution in exon 6 at nt 663 (V221V) were common poly-elderly population >75 years. A new era of progress is opened for these very elderly patients. morphisms that exhibited allelic frequencies significantly higher in the subjects with alterated iron parameters (0.50 and 0.70, respectively) compared to control group (0.25 and 0.08, respecti- vely). One known mutation, an A>G substitution at nt 1681 in exon 8 resulting in an amino acid change (R561G), was detected in subjects affected by iron overload at polymorphic frequencies (0.10). Heterozygosity was found in 4 individuals with moderate iron load (SF=617-779 ng/mL and TS=48-69%), while homozygosity was present in 1 out of 30 subjects and was associated with SF=1724 ng/mL and TS=63%. Through direct sequencing, a deletion of 3 base pair in exon 5 (Val162del) was detected in a subject with high serum ferritin (2750 ng/mL) and transferrin sa- turation (70%). This mutation removes a TTG unit from 780 to 791, and predicts the loss of 1 of 3 sequential valine residues 160–162. The Val162del mutation was associated to microsatellite(CGG)7, IVSI-24G and V221V in our subject. Polymorphism analysis indicated that the Val162del 3. LIVER AND HEART IRON OVERLOAD EXTIMATED BY T2* MAGNETICprobably represents a recurrent mutation due to slippage mispairing. The deletion was not found RESONANCE (MRI T2*) IN PATIENTS WITH THALASSEMIA INTERMEDIA (TI)in 50 controls. In this study an higher genetic variability of the ferroportin gene has been obser- Fasulo, Cappellini, Cesaretti, Cassinerio, Proto, Pedrotti, Pedretti, Dellegrottaglie, Roghived in blood donors with alterations in TS% and/or SF values compared to control group, asshown by high allelic frequencies of all polymorphic loci analyzed. Our studies indicate that the po- INTRODUCTION: in Thalassemia Syndromes iron overload poses significant risk of severe car-lymorphic ferroportin variants investigated could have a significant effect on iron metabolism and diac and hepatic complications which are fatal if not prevented with an adeguate iron chelationexplain the remarkable phenotypic variability that exists in non-HFE-linked iron overload. In con- therapy. MRI T2* is a new non invasive technique to assess myocardial and liver iron concentra-trast, no mutations or polymorphisms in the hepcidin gene that might be causative of iron over- tion. Several studies have been performed in Thalassemia Major whereas no data are yet availa-load were found in any of our patients. The significance of these observations are uncertain and ble in TI. AIM OF THE STUDY: to evaluate heart and liver MRI T2* in TI patients cared atfurther investigations are needed to determine if the polymorphisms of hepcidin and ferroportin Hereditary Anemia Center. METHODS: 62 TI patients (30 M and 32 F, 40 ± 8 yrs) underwentgenes affect the expression of indices of iron overload in subjects with normal HFE genotype. MRI T2* to assess myocardial and liver iron concentration. Normal heart T2* >20 ms; normal liver T2* >6.3 ms. RESULTS: cardiac T2* was abnormal (<20 ms) only in 2 of TI patients (3.2%), both females. A significant correlation (p<0.05) was found only with Hb level (p=0.0387) and IVTD of left ventricle (p=0.0182). Left ventricular ejection fraction <56% was found in 5 patients (8.1%, 1 M and 4 F), 3 of whom with normal cardiac T2*. 15 patients (24.2%, 7 M and 8 F) had left ven- tricular hypokinesis. In particular the 2 patients with cardiac T2* <20 ms had a severe/diffuse ven- tricular hypokinesis. Liver T2* was abnormal (<6.3 ms) in 38 patients (61.3%, 16 M and 22 F): 2 (3.2%, 1 M and 1 F) had severe (T2*<1.4 ms), 21 (33.9%, 9 M and 12 F) moderate (T2* between 1.4 and 2.7 ms) and 15 (24.2%, 6 M and 9 F) mild liver iron overload (T2* between 2.7 and 6.3 ms). A strong correlation was established between liver T2* and ferritin concentration (p=0.0053), AST (p=0.0136), ALT (p=0.0038) and ALP (p=0.0280) levels. CONCLUSIONS: in TI patients iron overload occurs mainly because of excess gastrointestinal absorption. According to this mecha- nism the iron overload in TI patients is mainly in the liver. Since iron per se may be responsible for severe liver diseases it is important to evaluate liver iron overload with non invasive technique and start an adeguate iron chelation therapy even in TI patients not regularly transfused. 20
  • 24. 4. B2-M-FREE HEAVY CHAIN LEVELS OF HLA-CLASS I ANTIGEN COMBINED 5. ASPIRIN-INSENSITIVE THROMBOXANE BIOSYNTHESIS INWITH SERUM IGM OR PLATELET COUNT PROVIDE TWO RELIABLE STAGING POLYCYTHEMIA VERASYSTEMS IN MULTIPLE MYELOMA Francesca Santilli, Mario Romano, Antonio Recchiuti, Alfredo Dragani, Angela Falco,Perosa F., Prete M, Sansonno L., Minoia C., E. Favoino, Racanelli V. and Dammacco F. Gianfranco Lessiani, Francesca Fioritoni, Stefano Lattanzio, Domenico Mattoscio, Bianca Rocca, Giovanni DavìWe previously showed that serum levels of beta-2-microglobulin (B2m)-free heavy chain (FHC)of HLA class I antigen have prognostic significance in multiple myeloma (MM). Univariate, mul- Polycythemia vera (PV) is a myeloproliferative disorder associated with high morbidity and mor-tivariate and tree survival analysis were used to assess the prognostic significance of FHC along tality for thrombosis. We hypothesized that in PV reduced sensitivity to aspirin may be related towith 9 continuous (age, albumin, creatinine, hemoglobin, erythrocyte sedimentation rate, B2m, cal- impairment of endothelial repair mechanisms as well as of the nitric oxide (NO) system. In 37 PVcium, IgM and platelet count) and 4 categorical (disease stage, bone lesions, Ig isotype of the M- patients on chronic low-dose aspirin, we evaluated thromboxane (TX)A2 biosynthesis, in parallelcomponent, disease activity) routinely assessed variables in a total number of 177 MM patients, with endothelial colony-forming cells (ECFCs) and plasma levels of dimethylarginine (ADMA), anof whom 146 had active disease (100 at presentation). Two staging systems (SS) emerged, namely endogenous NO inhibitor. Compared to non-aspirinated healthy subjects, PV patients showed si-the FHC/IgM and the FHC/platelet count, which allowed to assign MM patients to low (stage 1), gnificantly higher median urinary 11-dehydro-TXB2 (TXM) and plasma ADMA levels (P<0.0001),intermediate (stage II) and high risk groups (stage III). The median survival for FHC/IgM stage I, whereas they displayed a reduced number of ECFCs (P<0.0001). Multiple regression analysisII and III was 81.2, 41.5 and 27.3 months respectively, whereas that of FHC/platelet count was showed that lower ECFCs quartiles (Beta=-0.61; SE=0.13; P=0.001, R2=0.375) were the only in-89.3 (stage I), 44.1 (stage II) and 27.3 (stage III) respectively, the difference in their median sur- dependent predictors of higher TXM quartiles. These results indicate that PV patients have a pro-vival being highly significant (FHC/IgM: p<0.0001, x2= 26.37; FHC/platelet: p<0.0001, x2=23.76). found perturbation of ECFC/NO axis, which may contribute to aspirin-insensitive TXM formation.Similar results were obtained when the analysis was restricted to the 144 MM patients without Thus, additional antithrombotic strategies may be required in PV.renal insufficiency (FHC/IgM: p<0.0001, x2= 20.48; FHC/platelets: p<0.0001, x2=17.68) and to the146 patients with active disease (at diagnosis and at relapse) (FHC/IgM: p<0.0001, x2= 22.74;FHC/platelets: p<0.0001, x2=19.36). However, in the subset of 100 patients at diagnosis theFHC/IgM (p=0.001, x2=13.02) was more effective than FHC/platelet SS (p=0.04, x2=6.44) in thethree risk groups stratification. The results indicate that FHC levels, serum IgM and platelet countare independent prognostic markers of disease activity in MM and provide two easily achievableSS which are not affected by renal insufficiency and are effective for evaluating MM patients atpresentation and during follow-up.6. EFFECT OF LITHIUM ADMINISTRATION ON MUSCLE AND BODY WEIGHT 7. BETA-HYDROXY-BETA-METHYLBUTYRATE: A NEW THERAPEUTIC TOOL TOLOSS IN EXPERIMENTAL CANCER CACHEXIA COUNTERACT WEIGHT AND MUSCLE LOSS IN CANCER CACHEXIA?P.V. Sonni, S. Iannuzzi, Z. Aversa, V. Tommasi, T. Frascaria, P Costelli, F. Rossi Fanelli, P.V. Sonni, S. Iannuzzi, Z. Aversa, V. Tommasi, C. Ramaccini, G. Pinto, V.G. Minero, P. Costelli ,M. Muscaritoli F. Rossi Fanelli, M. MuscaritoliCancer cachexia (CC)-associated muscle atrophy results in an imbalance between the rates of BACKGROUND AND AIMS Beta-hydroxy-beta-methylbutyrate (HMB), a leucine metabolite,protein synthesis and breakdown. Insulin-like growth factor-1 (IGF-1) is a positive regulator of has been reported to improve muscle mass and function in cancer patients. This study aimed atskeletal muscle mass. A intracellular target in the IGF-1 pathway is glycogen synthase kinase evaluating the effects of HMB administration in an experimental in vivo model of cancer cache-(GSK-3beta) which negatively regulates the anabolic process. Indeed, GSK-3beta inhibition results xia (CC). METHODS Wistar rats were randomized to receive standard (C) or 4% HMB-enrichedin the appereance of a hypertrophic phenotype. Lithium is a natural inhibitor of GSK-3beta. The (C+HMB) chow. Rats from both groups were randomized to receive an i.p. inoculum of AH-130present study aimed at verifying if a lithium-enriched diet may prevent/attenuate muscle loss in cells (TB and TB+HMB). All rats were weighed and sacrificed at day 24. Liver, heart, and musclescancer bearing rats. Methods: Wistar rats (n=32) were randomized to receive a regular (R) or a were excised and weighed. The protein levels of p-p70, p-eIf2&#945; and p-4EB-P1 were eva-lithium-carbonate-supplemented (Li+) chow (Li2CO3 2,5g/kg/day). After 2 weeks, 8 rats/group luated by Western Blotting on gastrocnemius (GSN). RESULTS HMB significantly increased GSNreceived an intraperitoneal inoculum of 10^8 cell/2ml of AH-130 ascites hepatoma cells (tumor (p=0.002) and heart weight (p=0.001) in C. In TB+HMB body weight was significantly increasedbearing, TB). All rats were weighed and sacrificed on day 21. The state of activation of GSK-3beta (p=0.003), and GSN loss was significantly attenuated with respect to TB (p=0.03). P-eIF2&#945;(pGSK-3beta) was evaluated in the gastrocnemius muscle by western blotting analysis. Results: decreased in C+HMB, while in TB was reduced vs C, but unaffected by HMB. P-p70 was in-Treatment with Li2CO3 effectively inhibited GSK-3beta activity. Indeed, the levels of phosphory- creased by HMB in C and further increased in TB. Phosphorylated 4-EB-P1 was increased in TBlated GSK-3beta were significantly higher in Li+ than in usupplemented rats (2.23±0.47 vs but unaffected by HMB. DISCUSSION HMB attenuate weight and muscle loss in experimental1.21±1.09, p<0.05). However, both body and muscle weight loss were unaffected in TB, where CC, possibly stimulating anabolic pathways. However in this model of CC, muscle anabolic pa-pGSK-3beta levels were significantly higher than in R (1.22±0.24 vs 0.64±0.15, p<0.001). Con- thways seems not down-regulated, possibly as a compensatory response to increased muscle pro-clusions: In vivo Li2CO3 administration can modulate skeletal muscle GSK-3beta activity, but tein degradation. HMB should be promising nutritional substrate to counteract CC.cannot prevent muscle loss, at least in this experimental model of CC. 21
  • 25. 8. BALT LYMPHOMA 9. CEREBROVASCULAR ISCHEMIC EVENTS FOLLOWING CISPLATIN THERAPY.MJ Rodriguez, M Asenjo, A Cabello, F Ibañez, MJ Matías EXPERIENCE IN AN INTERNAL MEDICINE DEPARTMENT Joaquin Campos-Franco, Raimundo Lopez-Rodriguez, Nieves Mallo-Gonzalez,BACKGROUND: BALT (Bronchus-Associated Lymphoid Tissue) Lymphoma is a non-Hodgkin’s Paula Barros-Alcalde, Rosario Alende-Sixto, Arturo Gonzalez-Quintelalow grade B-cell lymphoma, arising in bronchial mucosal-associated lymphoid tissue. Pulmonarylymphomas are rare, they represent less than 1% of cases of NHL, less than 4% of extra-nodal Introduction: The neurotoxicity of cisplatin is well-known. However, cerebrovascular ischemicNHL and less than 1% of all pulmonary neoplasia. DESCRIPTION: A 49-year-old white woman events in patients receiving cisplatin-based chemotherapy have been infrequently reported. Wewas referred by her primary care physician for investigation at our hospital because of asthenia report two patients with oropharyngeal cancer whose symptoms suggest a cerebral ischemic eventof one year’s duration, an episode of erythema nodosum one year earlier and a non-investigated secondary to cisplatin chemotherapy. Case 1. A 46-year-old man with a history of squamous cellanemia that was being treated with oral iron. Pulmonary auscultation revealed fine crackles at the carcinoma of the tongue was receiving concurrent chemotherapy (cisplatin and 5-FU) and radio-bases and diffuse expiratory wheezing, the mucosae of the eyes and the skin appeared pale, therapy. Three days after the last dose, he presented to the emergency room with a generalizedotherwise physical examination was normal. Chest radiography demonstrated confluent bilateral status epilepticus. An urgent CT-scan revealed an acute infarction of the right temporal lobe. Hemacronodular infiltrates in the middle and lower lobes. A CT scan revealed bilateral mediastinal was admitted to the ICU requiring mechanical ventilation. The patient was transferred to con-adenopathies (pre-tracheal, pre-carinal and hilar) and multiple pulmonary nodes with interstitial pe- ventional hospitalization with severe disabling neurological deficits and finally died after approxi-ripheral infiltrates. The results of the full blood count were normal, excepting a MCV (mean cor- mately a 7-month course of illness. Case 2. A 65-year-old woman with a history of arterialpuscular volume) of 78 fl. Cholesterol and triglycerides were elevated. The rest of values of hypertension and squamous cell carcinoma of the tongue was receiving concurrent chemothe-biochemistry were normal. The ESR (Erythrocyte Sedimentation Rate) was 18 mm/s. CRP value rapy (cisplatin) and radiotherapy. Two days after the second course of chemotherapy, the patientwas 7.84 mg/dl (Normal CRP values vary from lab to lab. Generally, there is no CRP detectable developed severe mental status changes and finally a generalized status epilepticus. A valproic acidin the blood) and the ACE was 23 U/l (normal 8-55U/l). Serum protein electrophoresis showed infusion was started and the patient was admitted to the ICU. A cerebral MR showed hyperin-a decrease in gamma globulins. Bronchoscopy with bronchoalveolar lavage and transbronchial tense areas on T2-weighted images affecting frontotemporal lobes. These abnormalities sugge-biopsy were also performed and revealed no evidence of malignancy and yielded no acid-fast ba- sted areas of ischemic infarction. She was extubated two days later and transferred to conventionalcilli or fungal microorganisms. Our initial diagnosis was hypersensitivity pneumonitis caused by hospitalization with good neurologic recovery and at the time of the discharge she was able toinhalation of chemicals at work (she worked as a cleaner): possibly bleach, air freshener or one of make independent living. Discussion: The use of cisplatin, alone or in combination with radio-the many other products she worked with, and the finding of a lymphocytosis (40%) and low therapy and other chemotherapeutic agents has become the standard of care for the treatmentCD4/CD8 ratio in the bronchioalveolar lavage . We began treatment with high dosage cortico- of various solid tumors. Cisplatin-induced neuropathy, ototoxicity and, rarely, focal encephalopa-steroids and after a good initial response the patient relapsed with partial respiratory insufficiency thy have been described. Although rare, previous cases of ischemic stroke after cisplatin therapyand severe hypoxia. She was re-admitted. Arterial gases showed basal values of: pH 7.53, p02 54, have been reported. It has been postulated that cisplatin-induced endothelial damage in conjun-PC02 28, SBC 27, A-aD02 51; respirometry showed a restrictive pattern: FVC 70%, FEV1 74%, ction with pre-existing clotting abnormalities may be responsible for such vascular events.FEV1/FVC 90%; Pulmonary volumes as measured by plethysmography confirmed ventilatory in-sufficiency due to a restrictive disorder: TLC 73%, RV 73%, RV/TLC 99%; DLCO/VA (diffusingcapacity corrected for alveolar volume) was considerably diminished at 40% ; oxygen saturationwas 72% at 6 minutes exercise capacity test. She required domiciliary oxygen therapy until thecorrect diagnosis was reached . On her second admission, a further CT scan was performed, withsimilar results as the first one. Our subsequent differential diagnosis was sarcoidosis or lymphoma.Due to normal findings at a second bronchoscopy, with repeated bronchoalveolar lavage and atransbronchial biopsy, we then decided to perform a pulmonary biopsy that confirmed the dia-gnosis of NHL, subtype BALT. DISCUSSION: BALT lymphoma is a rare but increasingly reco-gnised clinical entity that should be considered in such difficult cases as this one. Even thoughexaminations of pleural effusion, Fine-needle Biopsy or Bronchoalveolar Lavage cytology may behelpful in arriving at a diagnosis, most cases need a surgical procedure to obtain a correct dia-gnosis by histological confirmation.10. KAPOSIS DISEASE, PENARTERITIS NODOSA AND CORTICOSTEROIDTHERAPYM Ibrir, D Hakem, K Serkhane, S Haddam, N Ouadahi, R Bab-Ahmed, A BerrahIntroduction: Kaposi’s Disease(KD)is strongly linked with acquired immodeficiency syndrome(AIDS). Its appears as sporadic or endemic(African)forms.The primen oven of this proliferation issupposed from a cell capillary.The association KD and immuno-deficiency is frequently repor-ted.The treatment using essentially immuno-suppressive therapy is local(limited skin forms)or ge-neral (extensive skin forms or/and visceral disease). Clinical case: An 55 year-old woman, sufferingof PN and treated by CS (prednisone 2mg/kg/day)develop at the sixth week of treatment an ex-tensive onichomycosis and, in the left big toe,a big tumefaction like a botryomycoma associatedin skin and violacacea lesions in the limbs rapidly extensive to the abdomen[Iconography].The ra-diography shows an osteolysis of left metatarsus.The serology of human immunodeficiency virus(HIV)is negative.Peripheral blood shows hyperleucocytosis with neutrophilic polynucleosis.Theexerese biopsy reveals a KD.Physical examination and investigations to appreciate extension arenegative (none visceral localisation found).So the patient is classed as score II A referring to IN-SERM classification of KD. Out-come: partial regression of cutaneous lesions in Bleomycine the-rapy followed by Interferon Alfa Diagnosis: The biopsy showed a fusiform cells regrouping inthick fasciculus tightly linked with vascular light,micro vascular proliferation(ectasic and tortuouscapillaries),perivascularlymphoplasmocytic infiltration and macrophages with haemosiderin inclu-sions. This aspect is typical of KD. Comments:We supposed the imputability of immunodepres-sion, inducted by strong and long term of CS therapy, in the genesis of KD. In the fact the PNappears a fortuitous event in this case report. Conclusion :KD is a neoplasm characterised by avascular proliferation localised of the skin and/or extensive in internal. KD appears as sporadic orendemic forms. The primen oven of this proliferation is supposed from a cell capillary.The asso-ciation KD and immuno-deficiency is frequently reported.The treatment using essentially immuno-suppressive therapy is local (limited skin forms) or general (extensive skin forms or/and visceraldisease). 7- Biblography: 1. Fraitag S, Roujeau JC. Maladie de Kaposi. In: Dubertret L, (Ed). Can-cers cutanés.Encyclopédie des cancers. Paris, Flammarion Médecine Sciences,1992 :345-362 2.Bournerias I. Maladie de Kaposi, chapitre 16 : 80-85. In : Le praticien face au SIDA:Serge Ker-nbaum. Médecine-Sciences. Flammarion, édition 1993. 22
  • 26. Oral Communications Thursday, May 8, 2008 CLINICAL CASES
  • 27. 1. ENCEPHALITIS EPSTEIN-BARR VIRUS INDICATING IMMUNODEFICIENCY 2. CLINICAL CASE OF CHRONIC DIARRHEA AND NON-HODGKIN´S LYMPHOMANuno Almeida; Paula Macedo; Ana Rego; Paulo Massa; Cristina Fraga; João Vasconcelos; Luís Andrade, Marco Fernandes, Ermelinda Gonçalves, Manuela BrochadoRui Mota; Rui San-Bento Introduction: The gastrointestinal tract is the predominant site of extranodal non-Hodgkins lym-This is the presentation of a clinical case involving deficiency in cellular immunity, uncovered du- phomas. Primary NHLs of the GI tract are rare, accounting for only 1 to 4 percent of malignan-ring the evaluation of encephalitis by the Epstein-Barr virus. The patient is an 18-year-old female, cies arising in the stomach, small intestine, or colon. In contrast, secondary GI involvement ishospitalized because of acute prostration, headaches, nausea, vomiting and seizures. At the age relatively common, occurring in approximately 10 percent of patients with limited stage NHL lym-of 10, she had herpes zooster with leucopenia. During hospitalization, her clinical condition wor- phomas at the time of diagnosis, and up to 60 percent of those dying from advanced NHL. De-sened and evolved very slowly, leaving her prostrated with extreme fatigue, fever, cervical lym- spite their rarity, primary NHL lymphomas of the GI tract are important, since their managementphadenopathy, hepato and splenomegaly, as well as cognitive changes. Complementary diagnosis and prognosis are distinct from that of adenocarcinomas of the GI tract. %). The incidence is ap-indicated: leucopenia (2470/&#61549;L) with lymphopenia (610/&#61549;L) and thrombocyto- proximately 2.9 /100.000 adults per year. In 40% of the situations they reveal extra-nodal invol-penia (94000/&#61549;L); minor changes of hepatic enzymes, AST 46 U/L, ALT 82 U/L, alka- vement being the gastrointestinal tract one of the most frequent affected (75%). The managementline phosphatase 150 U/L and gamma glutamyl transpeptidase 58 U/L; Computed tomography will consist of surgery and chemotherapy with survival in 5 years of 26% 73% and complete re-(CT) scan of head and cerebral magnetic resonance were normal; Lumbar puncture with eleva- mission in 40% of the cases. Clinical case: A 42 year-old man with a Gastric Non-Hodgkin´s Lym-ted protein levels (0,56 g/dl) and 6 cells/mm3 with mononuclear predominance; Electroence- phoma of B-cell origin, stage IIE-B diagnosed in October 2005 an submitted to a total gastrectomyphalography: slowed recorded activity with left front temporal focus; Excisional biopsy of cervical and 4 cycles of QT with CHOP. In remission until October 2006, he initiated epigastric pain,node indicating reactive aspects, without other relevant alterations; Positive Paul Bunnel reaction weight loss, asthenia and diarrhea. Abdominal CAT scan showed a retroperitoneal adenopathy,with subsequent serological test confirming an acute fase infection caused by the Epstein-Barr upper gastrointestinal endoscopic was normal. Suspecting of non-Hodgkin lymphoma relapsevirus; Immunoglobulins G, M and A were normal, fractions C3 and C4 of the complement were was initiated a second line chemotherapy with ESHAP (2 cycles in December and January). Thenormal, and HIV 1 and 2 serology was negative. Her clinical state improved and, to date, she has patient maintain diarrhea and he was asthenic, cachetic, desidrated with hypotension but nor-not had any infectious occurrences and has maintained superimposed levels of leucopenia and lym- mocardic, apiretic, pulmonary and cardiac auscultation normal, abdominal examination painlessphopenia. Since this was the second case of grave viral infection that she had had, she was orien- and without mass or organomegaly, moderate periphery oedema, without palpable periphericalted to an immuno-allergology evaluation, which confirmed impaired cellular immunity to antigens. adenopathy; Hb 7,2 g/dl (normocitic/normocromic), leucocyte 1900/ul with 1300/ul neutrophilThis case demonstrates a grave viral infection that is typical in situations of immunodeficiency and and 500/ul lymphocite, platelet 113.000/ul; sodium 132, potassium 2,6 and magnesium 0,6 Mgthat should alert us to further study of pathologies associated with the immune system. mmol/l; Calcium 6,4 and phosphoru 1,9 mg/dl; total protein 2,7 and albumin 1.1 mg/dl; Fecal exa- mination: bacteriologic and parasitologic negative Clostridium toxin difficile negative. Upper ga- strointestinal endoscopy: jejunal erythema, oedema and erosion. Biopsy: enteric mucosa involvement with diffuse large B-cell non-Hodgkin lymphoma. The patient was in parentheric nu- trition and one week later with correction of the analytic alteration and with better physical qua- lity was programmed chemotherapy with ESAPH that carried through the 23/03. Three days later the patient initiated neutropenia and fever, medicated with Meropenem, Amikacin and Flu- conazol but with gradual aggravation and die one week later. Conclusion: The authors present a clinical case of a sick person interned in a department of Internal Medicine.3. A CASE OF CRESCENTIC GLOMERULONEPHRITIS AND ADENOCARCINOMA 4. A CASE OF EXTRAPULMONARY TUBERCULOSIS (EPT) WITH MULTIPLE BONEOF LARGE BOWEL AND LYMPHONODAL INVOLVEMENTPreetham Boddana Alessia Rosato, Eleonora Pistella, Claudio SantiniIntroduction: Glomerular disease like crescentic glomerulonephritis may occur in systemic au- A 61 old year woman, nun living in Italy since forty years, was admitted in hospital for posteriortoimmune diseases but occasionally, malignancies may coexist and are diagnosed at the same time thoracic pain radiated to the left flank and exacerbated by standing and deep breathing, onsetas glomerular disease. We present a case of crescentic glomerulonephritis where in adenocarci- three months before. She had lost 6 kg in weight during the previous three months. She didn’tnoma of large bowel was diagnosed at the same time. Case report: A healthy 73 year male was drink alcoholics or smoke and she never was sexually active. She refers slowly resolving pneu-admitted to our renal unit after routine blood tests revealed him to be in acute renal impairment monia 20 years ago. On admission the temperature was 37.4°C , the pulse was 72 and respira-with serum creatinine measuring 350µmol/l. He had non-specific symptoms for several weeks be- tions were 20. The blood pressure was 130/80 mm Hg. Examination revealed a painless 4 cmfore being admitted, mostly revolving around new onset of constipation. CT scan of abdomen tender nodule in the left parietal area of the skull. A hard, fixed lymph node of 3 cm in diameterdone at his general hospital revealed some thickening of the terminal ileum. P-ANCA came back was palpable in the right supraclavicular region; no other palpable lymph nodes were found. Apositive at1/160, MPO /PR3 equivocal. Renal biopsy subsequently performed showed focal ne- neurologic examination, including an assessment of motor power, sensation, and reflexes in thecrotising crescentic glomerulonephritis. He was commenced on steroids and cyclophosamide. To lower extremities was normal. The hemoglobin was 11.9 g/dl, the white-cell count was 12.700 perexamine the abnormal area of bowel picked up on CT scan, he went on to have a colonoscopy cubic millimeter with 54 percent neutrophils, 35 percent lymphocytes, 4 percent monocytes, andand a biopsy was taken. Caecal biopsy report confirmed Adenocarcinoma of signet ring cell type. 3 percent eosinophils, the erythrocyte sedimentation rate was 37 mm/hr, the C reactive proteinConclusion: A number of reports have suggested an association between malignancy and cre- was 3.29. The values for urea, creatinine, electrolytes, glucose, aspartate aminotransferase, alaninescentic glomerulonephritis. Long term immunosuppression can result in haematological mali- aminotransferase, alkaline phosphatase, conjugated and total bilirubin, and amylase were normal;gnancies as well as solid organ tumours. In our case both glomerular disease and large bowel serum protein electrophoresis had a normal pattern with moderate increase of gamma globulins,malignancy were diagnosed more or less at the same time, raising possibility of association bet- urine analysis was normal.. Tuberculin skin test was strongly positive. Radiographs of the chest andween ANCA positive crescentic glomerulonephritis and malignancy. Our case is also unique in of the thoracolumbar spine were normal. Magnetic resonance imaging (MRI) scans of the thora-being probably the first case wherein crescentic glomerulonephritis and adenocarcinoma of large cic spine, obtained before and after the administration of gadopentetate dimeglumine, showed abowel (signet ring cell type) has been reported. However there is need for analysis or trials loo- soft-tissue mass causing erosion of the anterior aspect of T4 and extending to the prevertebral tis-king into prevalence and association of ANCA in cancer patients. sue, with involvement of anterior longitudinal ligament. The mass was hypointense on T1-wei- ghted images and was hyperintense on T2-weighted images, with heterogeneous enhancement. A total body computed tomographic (CT) scan showed multiple enlarged thoracic lymph nodes in the paratracheal and prevascular region, ranging up to 2 cm in diameter and numerous ab- dominal lymph nodes in the para-aortic, paracaval and iliac regions, up to 3 cm in diameter. Three osteolytic lesions were documented in T4, L4 and in the left parietal bone. The finding of multi- ple lytic bone lesions and diffuse thoracic and abdominal lymph node involvement could suggest solid malignancy, lymphoma or multiple myeloma. Endoscopic examination of upper and lower gastrointestinal tract and mammography were normal. No monoclonal component was found in serum and urine. We decided for the excisional biopsy of the palpable supraclavicular right lymph node, that revealed chronic granulomatous inflammation with epithelioid cells, giant cells, and ne- crotic material. A Ziehl–Neelsen stain for acid-fast organisms was negative. Cultures for Myco- bacterium tuberculosis resulted negative after two months. A test for antibodies to the human immunodeficiency virus (HIV) was negative. Four-drug antimycobacterial therapy with isoniazid, rifampin, pyrazinamide and streptomycin was started . After two months she was afebrile and felt much better, the thoracic pain decreased and the parietal nodule disappeared. The lung is the pri- mary site of disease in 80 percent of cases of tuberculosis and extrapulmonary localization usually occurs in patients with evidence of active or previous pulmonary disease. The most common ex- trapulmonary sites of disease are the lymph nodes, pleura, bones and joints. Extrapulmonary tu- berculosis has become more common with the advent of HIV infection. In HIV-patients extrapulmunary tuberculosis is often atypical, without evidence of pulmonary involvement; in this setting each fever of undetermined cause should be evaluated for extrapulmonary tuberculosis. Mediastinal, intraabdominal or generalized lymphadenopathy are common and often impressive, 24
  • 28. simulating lymphoma. Skeletal involvement is common, accounting for 35 percent of cases of ex- 5. A MYSTERIOUS CASE OF CHRONIC ITCHYtrapulmonery disease. Spinal involvement accounts for approximately half the cases, and invol- Giovita A Piccillo, Aurelio Pantò, Maurizio Nicolosi, Riccardo Polosa, Enrico GM Mondati,vement of the hip and the knee accounts for about 15 percent of them. Tuberculosis affecting the Luca Miele, Giovanni Gasbarrinispine has a long history and results in the characteristic picture of Pott’s disease. The typical pre-sentation is an initial destructive lesion in the subchondral region of the body of a lumbar or tho- INTRODUCTION Ekbom syndrome is a psychiatric disorder, first described by Thibierge in 1894racic segment that extended beneath the anterior longitudinal ligament to the adjacent segment, and recognized as Delusional Parasitosis (DP) by Ekbom in 1938, in which the patients imagineproducing a similar lesion in that bone. Multiple, axial and peripheral bone involvement is ob- the symptoms of parasitic infestation of the skin. They feel like bugs, worms, or mites that are bi-served in HIV patients, in the course of extrapulmonary or disseminated tuberculosis. Extrapul- ting, crawling, or burrowing into, under, or out of the skin. It may occur at any age but is moremonary tuberculosis has been increasingly reported also in immunocompromised patients without common in the elderly, particularly in females. It is classified in DSM IV as a non-schizophrenicHIV infection, and the risk of tuberculosis increases as immunosuppression progresses. Tubercu- delusions. Diagnosis is made excluding true infestations, contact dermatitis, allergies, alcohol/druglar reactivation has been recently reported in patients treated with infliximab for Crohn disease abuse. Therapy is based on antipsychotic agents, psychotherapy and psychoanalysis. CLINICALor rheumatoid arthritis; 40% had extrapulmonary or disseminated tuberculosis. Our patient, wi- CASE A 62 year-old man, no smoker and no drug and alcohol/abuser, affected with hyperten-thout documented immunodepressive disease, developed a form of extrapulmonary tuberculo- sion treated on enalapril, was admitted to our Dept for intense itchy, biting and rashes, due, onsis with no evidence of pulmonary localization. Massive mediastinal and intraabdominal the basis of his opinion, to parasitosis involving also the eyes. He had visited many Dermatologistslymphadenopathy and multiple ostheolytic bone lesions seemed suggestive for solid or lympha- and never it had been demonstrated a dermatological pathology. He appeared pale, tachycardictic malignancy. Extrapulmonary tuberculosis without pulmonary involvement in immunocompe- and very anxious with skin completely involved by ulcerations due to scraping. Normal were histent patients represent an emergent disease and should be considered in differential diagnosis of eyes, although he insistently complained the presence of parasites in that. BP 170/100 mmHg, HRdiffuse lymphadenopathy or multiple destructive bone lesions. 100 b/min, T 37 °C. All the laboratory data resulted within normal range. Dermatological con- sultation, scraping and skin biopsies excluded the presence of dermatological pathologies and/or parasitos, so we hypothesized a Delusional Parasitosis corfirmed by psychiatric evaluation. The patient was discharged with treatment on Pimozide and psychotherapy. DISCUSSION The pa- tient we observed is a rare case of Ekbom syndrome, a psychiatric condition difficult to diagnose, since these patients first are evaluated by Dermatologists or Internists who are often unaware of this disorder. For this reason, it is necessary a good cooperation between Internists, Dermatolo- gists and Psychiatrists to obtain an early diagnosis and choose the most effective treatment.6. BRONCHIOLITIS OBLITERANS ORGANIZING PNEUMONIA (BOOP): 7. PULMARY EMBOLISM AFTER IVIG THERAPY: A CASE REPORTA CASE REPORT Belo A, Gregório T, Silveira F, Cardoso MTPierluigi Pompili, Maria Luisa Colloca, Federico Grifalchi, Claudio Santini Intravenous immunoglobulin(IVIg) is considered a safe medication for multiple immune-media-Radiation effects in lung include early radiation pneumonitis and late effect, occurring months ted diseases.Although serious adverse reactions are rare,thrombotic events are increasingly reco-after irradiation; both are confined to the irradiated lung volume. Bronchiolitis obliterans with or- gnized.Incidence is estimated between 3-5%. A woman,34,with aquired polyneuropathy wasganizing pneumonia (BOOP) is a uncommon radiation therapy-related lung injury with lung in- submitted to a 1st treatment with IVIg and oral steroids.There was an incomplete response andfiltrates outside the radiation field. Dyspnoea is the hallmark of radiation-induced pneumonitis, she began a monthly program of IVIg 1 year later. She was hypocoagulated since 3 months be-whereas low-grade fever and non-productive cough are the features of BOOP. Radiographically, fore she had had right leg DVT.Eight months after the beginning of IVIg and 2 months after stop-BOOP presents with infiltrates in radiated areas that progress outside the portal, in 40% of cases ping hypocoagulation she had a bilateral pulmonary embolism(PE).It was noticed a right auricularbilaterally. Patients respond to steroids, but a 67% of relapse rate is reported. We present a 75 year- thrombus and an IVC filter was placed.One month later she was firstly admitted to our hospitalold woman, who underwent breast surgery for infiltrating ductal carcinoma (pT1 pN0 G2). Post in severe respiratory distress.A CAT scan of the chest showed bilateral PE.She had high levels ofoperative breast radiotherapy (50 Gy + boost 10 Gy) was given for 3 months. The patient recei- factor VIII and augmented fibrinogen.Screening for autoimmunity was negative.During her stayved hormone therapy with tamoxifene. Seven months after the end of radiotherapy, patient was she had worsening of neurological symptoms and began plasmapheresis(Pph).She was readmit-hospitalized for non-productive cough, fever (38°C) and dyspnoea. A combination of antibiotic has ted soon after with CVC infection. Hypocoagulation was reverted and CVC withdrawn.A right ju-been given for two month, without clinical improvement. Laboratory tests documented: ESR 88 gular vein thrombosis was noticed. As IVIg and Pph were suspended she progressed to flaccidmm/h, PCR 7.6 mg/dl, fibrinogen 585, alpha2globulin 18.2%; ANA and rheumatic factor were tetraplegia.Pph was restarted and she began cyclophosphamide with clinical response.With thenegative. The tine test for tuberculosis was negative. A high-resolution CT scan showed patchy, wider use of IVIg the reported rate of side effects has increased and recently received widespreadbilateral, multifocal foci of air-space consolidation, infiltration in peribronchial locations, with cha- attention.The pathophysiological basis for thrombosis is incompletely understood and specific riskracteristic migratory pattern. Arterial pO2 was 72.3 mmHg and pCO2 30.4 mmHg. Microbiolo- factors are ill defined.Thrombotic manifestations can also occur after multiple infusions without pre-gical and cytological examination of the BAL was negative. BOOP syndrome was diagnosed and vious complications and within 30 days of infusion.Comorbid conditions such as high levels of fac-treatment with prednisone (75mg/die) initiated. Dyspnoea improved and fever abated. After two tor VIII,obesity,previous venous thrombosis,oral contraceptives and the Pph CVC increased the riskweeks laboratory and radiological abnormalities resolved. The therapy was continued for seven of IVIg related thrombotic complications.This case alerts clinicians to be cautious with IVIg admi-months, tapering in the last four months. After one year the patient was well. The BOOP syn- nistration in patients with predictive factors of thrombotic complications especially those withdrome is a possible diagnosis for patients with respiratory symptoms following irradiation breast. thrombophilia. 25
  • 29. 8. ABSCESS-LIKE ONSET IN SQUAMOUS CELL LUNG CARCINOMA 9. A RARE COMPLICATION OF ANOREXIA NERVOSA: A CASE REPORTDaniela Bartos, Cristina Tirziu, Ecaterina Bontas, Ileana Simache Cátia Macedo; Rosa Soares; Rui Môço; António Furtado; José Alberto Silva; Rosário CapuchoBackground. Most lung abscesses develop as a complication of aspiration pneumonia usually cau- Spontaneous pneumomediastinum, pneumoretroperitoneum and diffuse soft-tissue emphysemased by anaerobes from the gingival breaches. In spite of all findings, lung abscesses sometimes are very rare complications associated with Anorexia Nervosa (AN). We describe the case of a 15-call awareness to a silent carcinoma that has initiated the chronic suppuration. Case presentation. year-old male patient suffering from AN, restrictive subtype, with no medical assistance so far. HeWe present a case of a sixty-nine year’s old man, heavy smoker and with no medical history ad- was admitted to our emergency service with dyspnea and asthenia. His body mass index wasmitted for malaise, right thoracic discomfort and dry cough with onset from two weeks. In kee- 14.7 Kg/m2 and he didnt’t have purgative behavior, including induced vomiting. On physicalping with this the physical examination revealed no fever, dyspnoea, rare pulmonary rales in the examination it was found an exuberant subcutaneous emphysema. Chest and abdominal com-upper part of right lung, and a right smaller, nontender and movable axillary lymphadenopathy. puted tomography scan confirmed the presence of diffuse subcutaneous emphysema, pneumo-Taken together, the clinical and biological findings with CXR - air-fluid level true cavity of upper mediastinum and pneumoretroperitoneum. Radiographic evalution of the gastrointestinal tractright pulmonary lobe, the therapy of pulmonary abscess was emerged. Further lack of favorable after barium swallowing, upper endoscopy and bronchoscopy excluded continuity’s solution. Tre-course implied pulmonary CT exam which revealed multiple mediastinal and pulmonary lym- atment involved a multidiscipline team ant it included oxygen therapy, high-caloric dietetic plan,phadenopathies. In spite of negative bronhoscopy, however the biopsy of lesion by mediastino- psychotherapy and fluoxetine. Our patient markedly improved, and his diffuse soft-tissue em-tomy confirmed the diagnosis of squamous lung carcinoma to upper right pulmonary lobe with physema, pneumomediastinum and pneumoretroperitoneum resolved spontaneously after 15metastasis. The long term outcome was negative. Discussions. By the end of the 20th century, pul- days of hospitalization. This uncommon condition is thought to be due to a diminished alveolarmonary cancer became one of the worlds leading avoidable death causes. Nonetheless, the ou- elasticity after prolonged starvation, with greater risk for rupture. An abrupt increase in intra-al-tlook is poor for most patients with lung carcinoma. The case report is attractive because of the veolar pressure may cause subclinical alveolar ruptures with air release tracked along perivascu-unusual primary lung cancer manifested as abscess with wide-spread multiple metastases through lar sheaths to the mediastinum and subcutaneous tissues. Less than 15 cases were reported in thediagnosis. Key Words: lung carcinoma, pulmonary abscess, pulmonary solitary nodule Type of literature until now.presentation: POSTER Topics: Lung Diseases10. ACUTE MYOCARDIAL INFARCTION AND BILATERAL ADRENALHEMORRHAGE CAUSED BY APLA SYNDROMEPolishchuk I., Zamir D.A 60 year old man with previous history of recurrent deep vein thrombosis and antiphospholi-pid syndrome was admitted to our department because of abdominal pain. The diagnosis of in-ferior wall myocardial infarction was made based on ECG, elevation of cardiac markers andechocardiography. His medication before admission was warfarin 5 mg daily with well controlledINR. On admission extreme prolongation of INR and PTT were found and mixed test showedonly partial correction of PT and PTT. Factors VII, IX, X all found below 5% suggesting warfarinoverdose. Abdominal CT scan revealed large bilateral adrenal hemorrhage. The patient was trea-ted with vitamin K, plasma transfusion and hydrocortisone. During the course the patient deve-loped bilateral pulmonary infiltrates with rapidly accumulated hemorrhagic pleural effusion andacute renal failure. He was treated with pulse steroid therapy for presumed catastrophic antipho-spholipid syndrome with rapid improvement. Heparin therapy was started when factors VII, IX,and X returned to normal level and subsequently switched to warfarin. The patient recovereduneventfully from myocardial infarction and renal failure, pulmonary infiltrates and pleural effu-sion resolved. Adrenal hemorrhage resulted to adrenal insufficiency that was successfully treatedwith replacement therapy. The case illustrated rare combination of both thrombotic and hemor-rhagic complications of APLA syndrome occurred in the same time. 26
  • 30. Oral Communications Thursday, May 8, 2008 PUBLIC HEALTH
  • 31. 1. NIGHT DUTIES REDUCE COGNITIVE FUNCTIONS OF INTERNS-ORAL 2. RESULTS OF AN INTERVENTION PROGRAMME TO IMPROVE THE QUALITYZamir D, Rachovitz D, Reitblat T, Polishchuk I OF THE MEDICAL RECORDS IN AN INTERNAL MEDICINE DEPARTMENT Wikman P, Safont P, Martínez A, Seguí J, Rugero M, Robert J, Merino J.Background:Night duties are part of the routine work of an intern . It was showen before that aphysician after a night duty is prone to mistakes at work and to road accidents in the way home. Introduction. The medical records are clue documents for:a) the diagnosis and follow-up of theAims:to measure whether there is real significant cognitive impairment after a night duty Me- patients, b) the evaluation of the clinical activity and the clinical management, c) for the trainingthods:25 young physicians, all during their internship underwent a computerized neuropsycho- of the becoming physicians. The end-point of this study was to improve the quality of the medi-logical assessment “CogScan” which included 15 psychologic tests: Finger Tapping Test (FTT), cal records of an internal medicine department with an intervention programme. Material and me-Inspection time (IT), Motion Perception Test (MPT), Simple Reaction Time (SRT), Choice Reaction thods. We made a descriptive and intervention study. We elaborated a questionnaire with 14 itemsTime, Immediate and Delayed Memory for Pictures, Words and Faces, Stroop test, Time-Accuracy evaluated with a likert-like scale for the evaluation of the medical records. We made a first basalTradeoff test (TATT), Digit Symbol Substitution Test (DSST), and Continuous Performance test analysis. We made the intervention that consisted of: a) Information about the results of the basal(CPT). Statistical analysis was performed using t-test for Equality of Means. Probability was esti- analysis, b) define by the staff the contents of a good medical record, c) review in real time themated (p value<0.05). This battery of tests was performed within 2 hours after duty and 6 months medical records informing about their insufficiencies. &#967;2 test was used to compare the va-later, in the same hour in the morning without a night duty before. Results:We found a remar- riables. Results. We show the percentages of the qualification very good of each item before ankable decrease in cognitive performance in most of tests after night duties. Most impairments after intervention. Legibility 50.5/ 59.7, physician´s identification 61.3/70.8, patients administrativewere subtests of motor output, selective attention (Stroop test, accuracy) and others... Conclu- data 9.0/0, admission cause 88.3/100, previous medical story 14.4/37.7, habits 20.7/46.4, aller-sion:We believe that this study defines the risk in working after night duties. A similar study is pro- gies 78.4/94.2, previous treatment 37.8/55.9, current illness 8.1/11.1, physical examination 5.4/13.9,bably required to check cognition during night duties, to check whether an intern is capable to diagnosis 3.2/13.9, evolution 53.2/89.8 and information to patients 94.6/89.7. All items were im-make right decisions after 16 hours of work, while he is still in his duty. proved in the postintervention analysis except the legibility the previous treatment and the cur- rent illness that were not modified. The differences were statistically significant with a p<0,05. Conclusions. This study has served to improve the quality of the medical records of the patients admitted to the Internal Medicine department in our hospital. We hope that that has allowed us to improve the quality of care to our patients and that it has been instructive for students and re- sidents of our department.3. DISEASE RELATED GROUPS (DRGS) ARE UNABLE TO APROPRIATELY ASSESS 4. LIMITED BENEFITS OF THE AUDIT CYCLE IN CLINICAL PRACTICETHE CLINICAL ACTIVITY OF INTERNAL MEDICINE DEPARTMENTS DEMONSTRATED THROUGH NASOGASTRIC TUBE INSERTION: STRIVING FORSegui J.M., Wikman Ph, Ramirez M I, Rugero M J, Segui J.M, Cañizares R, Gracia M, IMPROVEMENTMartinez Baltanas A, Merino J A Abdulla, U Umasankar, PM Mohamed, L OnyemaINTRODUCTION.- The DRG´s . were introduced to measure the cost of treating diseases. The Na- Introduction: Nasogastric (NG) tube insertion is a common bedside procedure carried out bytional Health Systems use them also to estimate clinical activity at hospitals, provided they allow to nursing and junior medical staff. They must have received adequate training and be competentcompare complexity of diagnosis, length of patients stay, etc…Some experts doubt that this tool in the procedure, since complications may arise (11 deaths reported in UK over 2 years). We per-is also valid to assess clinical activity if patients treated have many unrelated diseases. The aim of formed a completed audit cycle interspaced by formal teaching and practical sessions on NGthis work is to test if this tool is suitable in all type of patients. METHODS: Descriptive study. We tube placement to evaluate any changes in practice through education. Methods: Doctors and nur-have selected a random sample of the discharge documents from patients admitted in the wards ses were asked to complete a questionnaire about various aspects of tube insertion that includedof the Internal Medicine Department of our hospital in the first term of 2007. (n= 67). Their DRGs measuring the length of NG tube prior to insertion and appropriate methods to test its position.were defined depending on the clinical manifestation causing the admission, adding the co mor- A rolling training programme was then put into place using video demonstration, practical ses-bidities and diagnostic procedures done. Then we have changed the DRG either: a) selecting the sions with manequins and lecture presentations in the Academic Half-Day supported by the re-disease which caused that the patient had a longer stay, b) analysing the influence on the DRG if sults of the initial audit. A trust policy was then put into action and information was made availableduring their stay some relevant unrelated diseases to the previous diagnosis were discovered. In on the hospital website. Re-auditing was done 12 months later. Results: 25 and 45 staff comple-all cases co morbidity and clinical procedures remained unchanged. RESULTS: After new codifi- ted questionnaires in the initial audit and the reaudit, respectively. Nursing staff accounted forcation in 28 discharge documents of the 67 there was no change, but in 39 (58, 3%) the DRG 28% and 38% respectively and others were doctors. There was little improvement to show thatchanged. For a) in 13 of those 39 (33%) the difficulty index calculated by the DRG decreased: from useful dissemination of knowledge and learning has taken place. There was no change in the34, 65 to 25, 09 (difference 9, 55), this will be a mean of 0, 73 by document. In 17 (43%) the dif- percentage of respondants in the re-audit who knew how to measure the length of NG tubeficulty index by DRG increases from 25, 74 to 40, 20 (difference14, 46, this will be a mean of 0, prior to insertion (44% in both audits). Similarly, those who recommended the use of inappro-85 by document. In 21 of 39 (53,8%) a new relevant disease unrelated with that inducing DRG priate techniques such as ‘woosh test’ or ‘blue litmus paper’ to assess its position did not drop (48%was diagnosed. Initial difficulty index was 40, 31. If we calculate the index for the new diseases will and 47% respectively). Those who would turn patients onto their side and re-aspirate if the initialbe 21,28 to be added to previous 40.31, that means an increase of 0,96 by document. COMENTS: aspiration failed were a minority: 8% and 9% in both audits and those who would get a chest x-The validity of DRG´s to assess difficulties in patients suffering at the same time many unrelated ray straightaway were 84% and 87% respectively. Conclusion: Despite having an intensive edu-diseases, as usually happens in internal medicine wards, should be questioned. cational programme and availability of instructions on the hospital intranet, we were surprised to see no change in practice. This raises a serious question about the effectiveness of audit and whe- ther other means to disseminate knowledge and improve practice should be explored. 28
  • 32. 5. USE OF INTRAVENOUS ANTIBIOTHERAPY IN A DOMICILIARY 6. MANAGEMENT OF SEVERE ANAEMIA IN AN INTERNAL MEDICINE WARD:HOSPITALIZATION UNIT THINK TWICE!Hernández, A; Ibáñez, R; Ruiz, S; San Román, I; Moral, E; Fernández-Rufete, A; Ruipérez, J; HMG Martins, P Lopes, S. Lourenço, MF Puente, JAM AraújoSánchez Polo, M.T. Severe anemia (hemoglobin - Hb < 7 g/dL) may be significantly symptomatic and is often multi-The use of intravenous antimicrobial therapy at home is increasing. The aim of this work is to de- factorial. From a population of about 1700 inpatients/year we reviewed a sample of 48 who hadmonstrate the safety and efficacy of this practice. We conducted a retrospective study of the ad- Hb < 7g/dL in 2007. Nineteen patients were excluded for incomplete data (n=29). About 55%missions at our domiciliary hospitalization unit (DHU) from the 1st of January to the 31st of entered the hospital with severe anemia while 13 developed it during hospital stay. The first groupDecember 2007. We analyzed the following variables: age, sex, comorbidity index, incoming of the came for complaints of fatigue/shortness of breath or ambulatory findings of low hemoglobin va-patient, kind of infection, antibiotic administered, duration of treatment and outcomes. Of the 311 lues. In the second group most patients had come into hospital for non-anemic syndrome com-patients admitted, 187 received intravenous antibiotherapy. 99 (52.9%) were males and 88 (47.1%) plaints yet all had anemia (average Hb of 9 g/dL). GI studies and bone marrow biopsies werefemales. Mean of age was 70.24 (± 19.09 SD) years. Mean of Barthel Index of the patients was underused, and, in about 11 patients, mostly those with visible blood losses, no iron metabolism,72.52 % and Charlson Index was 4.96. 64 patients (34.2%) were admitted from emergency ser- vit B12, folate, homocisteine or eritropetin studies were asked. The study of anemia’s etiology wasvice and 123 (65.6%) from conventional hospitalization. The origin of infectious disease was: re- considered incomplete in about half of the sample, due to exams limited by clinical instability,spiratory in 108 (57.8%) cases; urinary tract 40 (21.4%) cases; skin and soft tissue 12 (6.4%), and death or anemia being attributed to “anemia of chronic diseases” with no further study. There wereothers 27 (14.4%). Antibiotics used were: ceftriaxone 75 (40.1%), quinolones 61 (35.3%), amoxi- 7 cases of iron deficit anemia (chronic blood loss and/or nutritional deficit), nine of anemia ofcillin and clavulanic 9 (4.8%), meropenem 8 (4.3%), ceftazidime 5 (2.7%), ertapenem 4 (2.1%), ce- chronic disease, 3 of a combination of both and 4 of megaloblastic anemia with deficit of folatefepime 4 (2.1%), aminoglycosides 4 (2.1%) and others 12 (6.3%). Mean treatment duration of (2) and Vit B12 (2). Final diagnoses were heterogenous: leukemia (5), sepsis status (4), nutritionalparenteral antibiotic was 5.42 days (± 4.07 SD). 173 patients (92.5%) were discharged; 13 (6.9%) deficits and new diagnosis of tuberculosis, Chron’s disease or drepanocitosis. The all-cause mor-patients required hospital readmission (3 of them because of therapeutic failure and 10 for other tality was 28%. Fourteen patients (48.3%) were followed-up as outpatients. Seven were referen-causes). Only one patient died. In our experience, those who most benefit from antibiotic treatments ced to a haematology centre, 2 for acute leukaemia. The average last known Hb was 8,9 g/dL,at home by DHU are those older, less functional state and with greater comorbidity. Treatment of with 2 patients without anaemia. Severe values of hemoglobin seem to relate to a multitude ofcommon infectious illnesses in this group of patients at DHU shortens hospital stays. The admini- etiologies and often to a mixture of chronic condition and an acute aggravator. After stabilizationstration of intravenous antibiotics at home is safe and effective. Infection disorders can be admit- and diagnose of the immediate probable cause of anemia, it is likely that in-depth investigationted and treated at these units as an efficient alternative to traditional hospitalization. and long follow-ups are needed to identify and correct a possible secondary etiology.7. SCREENING OF RISK FACTORS IN THE POPULATION OF 40 YEARS MEN AND 8. ANTIPHOSPHOLIPID’S SYNDROME AND PREGNANCY = HOW TO IMPOSEWOMEN IN NITRA REGION, REGARDING TO THE IMPORTANCE OF PRIMARY TOBACCO’S STOPPREVENTION JP Ory, C. Faure, O. MessicaMinarik p., Sirotiakova J., Hoppan M., Piesecka L. Fetal death constitutes the obstetrical complication the more frequent of antiphospholipid syn-Cardiovascular disease are the leading cause of premature mortality of women and men in Slo- drome (APS). The essential mechanics are the supervening of placental infarct. Adding pro-vak republic similar to that in other central European countries. In 2003 was established the Med- thrombin factor like tabagism is not allowable in this situation, requiring an answerable behaviourPed centrum (make early diagnosis – revent erly death) in the 2nd Internal Clinic in Nitra. We have from the patient. The case report is this of Mme L. born in 1971. The first pregnancy dates frombeen studied the cardiovacular risk factrs in the population of 40 years men and women in Nitra 1992, without particularity with birth of child weighing 3 kg 500. The diagnosis of systemic lupusregion during the period one year. It was the screening analyse with cooperation with general prac- revealed by a thrombopenia (platelets at 30000) and associated with APS is set down in 1994 an-tice doctors (GPs). The main analysed factors were: body mass index, total cholesterol, LDL-cho- tinuclear antibodies (A.C) and “native anti-DNA” antibodies very high, positive cryoglobulin, C3lesterol, HDL-cholesterol, triglycerides, blood pressure, glucose. Each person filled in a consumption of APTT at three times the reference, presence of anticardiolipin Ab (antibodies)questionnaire with personal data, data on CVD in personal and family history, including history and anticoagulant of lupus type. A corticotherapy is begun, protected by anticoagulation with lowof smooking. In our cohort study was included 259 persons. It consisted of 104 men and 155 molecular weight heparin (LMWH) and directly associated with hydroxy chloroquine (200 mg xwomen. The most frequent risk factor in both men and women groups were overweight and 2). In 1995 a first spontaneous abortion (23 weeks) happens, followed by a second one in 1995obesity (20,85%). The elevated blood presure levels were detected in 27,9% men and 9% (18 weeks). In 1997, in spite of treatment associating acetylsalicylate (100mg), LMWH (enoxapa-women. The elevation of total cholesterol was in 47.1% persons, LDL-cholesterol in 70,3%, trigly- rine) at 0.4 ml x 2, prednisone at 10 mg/day, hydroxychloroquine at 400 mg/day, delivery iscerides 18,15%. The results of our study suggest to be very important point to take a care of this very premature (six and a half months), the child weighs only 1 kg 200g. In 1999, new deliveryrisk and productive population , especially regarding to the management of primary prevention. at 33 weeks and birth of a child weighing 2kg100. Tabagism is not completely stopped. In 2004,At presence we miss special centres in our country dealing with this serious problem. new pregnancy, same therapeutic attitude and stable lupus, new successful attempt to stop tabacco ! The child will be born at 33 weeks, weighing 2 kgs. This is partially explained because of pla- centa praevia. RESULTS With pregnant woman, biological exam’s perturbations connected with tabagism, may be a means to speak firmly about tobacco. So it was in this case report. DISCUS- SION : among vascular risk’s factors, tabagism is the one which prevalence has the most increa- sed about woman, over the past three decades, becoming dominant factor about young woman. This case report permits to remind of dynaminc and precarious balance of coagulation during pre- gnancy. The presence of a greater risk’s factor like APS, requires a real participation from the pa- tient. CONCLUSION Lupus pregnancy is always difficult, all the more because associated with APS. Obtaining effective participation wich tabacco’s stop during pregnancy is an absolute ne- cessity. That’s why the information must be clear, understood, and the contract accepted. 29
  • 33. 9. PATIENTS OPINION ON THE QUALITY OF CARE OFFERED IN INTERNAL 10. AN INTERMEDIATE CARE UNIT IN INTERNAL MEDICINEMEDICINE DEPARTMENT WARDS IN AN SPANISH TEACHING HOSPITAL M. Bodro, I, Cabello, A. Riera-Mestre, A. Vidaller, A. Díaz-Prieto, R. Máñez, R. PujolWikman Ph, Peris J.M, Safont P, Gracia M, Calabuig E, Botas M, Perez Molto C, Muela F, Merino J. Aim: To describe the clinical data of patients admitted to an Intermediate Care Unit in an Inter-INTRODUCTION - Modern clinical practice tries to be very high in quality and has placed the nal Medicine Department (MICI) in a tertiary care hospital and the impact of their stay here onpatient in the centre of all sanitary activities. That is why it is very important to know about his view their health status. Patients and methods: The MICI comprises four individual rooms in a 800-bedon the care we offered him. Looking for detecting our insufficiencies and to establish an inter- teaching hospital with 50 of these beds in the ICU. The MICI serves primarily to admit patientsvention program to correct them is the aim of this study. MATERIAL/ METHODS. - Observatio- after a prolonged stay in the ICU and who require close monitoring and rehabilitation. Demo-nal study on a random sample of patients cared in the wards of our Hospital (n=70) through the graphic and clinical data of consecutive patients admitted to MICI over a 12-month period werelast two terms of 2007. For this purpose we have designed a form with 14 items using a likkert recorded. Results: 107 patients fulfilled this criterion; 71% were male. Mean age was 55.5 (18-83;scale. The form has been offered to the patients recovered in our wards to be anonymously fil- SD: 16.3) years. Main diagnoses on admission to the ICU were surgical complications (66.5%):led and deposed at nurses’ desk. The 30% of the forms were filled out by patients, 60% by their Neurosurgery (32%), Gastrointestinal (21.5%), Cardiac (5%), Thoracic (5%) and Orthopaedic Sur-companions, (we ignore 10%). Mean age of those answering was 57, 2 years. 60% of them knew gery (3%). Main medical diagnoses (33.5%) were: cardio-vascular (11%), neurological (8%) andtheir doctors name and 55, 7% knew his medical speciality. Results are offered in percentage of severe infections (8%). The mean length of ICU stay was 33 (1-105; SD: 23.4) days. Mean pre-answer for each item, being 1: very satisfactory, 2. satisfactory, 3. neutral, 4 unsatisfactory, 5. very albumin and seroalbumin levels on hospital admission were 150 (5-495; SD: 104.5) mg/L andunsatisfactory. a. The technical o professional approach by doctors has been: 68,6; 26,9; 4,5; 0;0, 26.3 (8-41; SD: 7.2) g/L, respectively. On admission to the MICI, pressure ulcers were present inb. The humanistic approach: 71,6; 24;4,5;0;0; c. The information they offered about patient´s di- 35% of patients, 74% had had a tracheotomy and 66.5% were receiving nasogastric tube fee-sease has been: 56,2; 37,5; 4,7; 1,6,0. d. Their information on complementary exams patients nee- ding. During their stay in the MICI, tracheotomy was withdrawn in 41% of patients and the na-ded: 53; 39,; 3; 4.5;0 . e. Information on treatment offered d: 57,1; 34,9; 6,3; 11,6; 0. f. Nurses sogastric tube was removed in 52%. Mean Barthel Index (BI) was 13 (0-80; SD: 17.2) on admissioncare has been: 52,9; 35,3; 10,3; 0,0.; Humanistic approach by nurses and other sanitary profes- and 33 (0-100; SD: 30.4) on discharge. The mean length of stay in the MICI was 10.2 (1-58; SD:sionals : 52,2; 40,3; 4,5; 2,98; COMMENTS.- This type of questionnaire offers us a better un- 8.8) days. On discharge, patients were transferred to Neurosurgery (26%), Gastrointestinal Sur-derstanding of how patients think about the care we offer and allows us to initiate intervention gery (17%), other Surgical Services (14%), Neurology (7%), Internal Medicine (7%), Infectious Di-programs to improve the quality of our care. In our case the result was quite satisfactory. seases (5.5%), other Medical Services (6%) and nursing home (6.5%). Six patients (5.5%) were discharged to their own home and two patients (2%) were readmitted to ICU because of acute events. Mortality rate was 3.5%. Conclusions: An Intermediate Care Unit in the Internal Medicine Department is effective in the recovery of patients discharged after a prolonged stay in the ICU. The percentage of tracheotomy and nasogastric tube withdrawals, the improvement in the BI and the low mortality rate are clear indicators of this efficacy. Internists are better able to manage pa- tients staying in these specific units. Oral comunication may be the preferred method of presen- ting abstract. 30
  • 34. Oral Communications Thursday, May 8, 2008 MISCELLANEOUS
  • 35. 1. THE FATE OF PULMONARY THROMBI AFTER PULMONARY EMBOLISM 2. PULMONARY VEIN THROMBOSISJ.L. Alonso Martínez, F.J. Anniccherico Sánchez, M. Urbieta Echezarreta, J.L. Moya Andía, R. Cavaco, S. Kaul, R. Casaretti, A. Rhrodes, R.M. GroundsV. Fernández Ladrón Introduction: Pulmonary vein thrombosis (PVT) represents a potentially fatal disease. This syn-Background. Data of a few studies have addressed the topic of thrombi resolution after pulmo- drome may clinically mimic pulmonary embolism but has a completely different investigation pat,nary embolism. Methods. Prospectively, we studied patients diagnosed of pulmonary embolism treatment and prognosis. PVT is difficult to diagnose clinically and usually requires a combination(PE) by means of thoracic computerized tomography (HCT) during 2006 and 2007. Subsequently of conventional diagnostic modalities. Treatment should be determined on the basis of the ob-a HCT was obtained in evolution in order to know the resolution or persistence of pulmonary structing pathological finding and can include antibiotic therapy, anticoagulation, thromboembo-thrombi while patients remain with anticoagulant therapy. We also searched for potential factors lectomy and/or pulmonary resection. Case report: We report a case of a 78-year-old previouslyof persistence such as clinical antecedents of thromboembolic venous disease (TEVD), thrombo- healthy female presenting with collapse and shortness of breath. Her past medical history com-philia (Myeloproliferative syndrome, antiphospholipid syndrome, Leiden factor, Prothrombin prised: type 2 Diabetes, increased uric acid and ongoing pain in right knee. Serum biochemistry20210G-A, PC, PS, Antithrombin III, Factor VIII and homocisteine), the burden of initial pulmo- revealed acute kidney injury, positive D-dimmer and increased CRP. Chest radiography showednary embolism (divided in central and peripheral pulmonary embolism), D-dimer values and volume loss in the right lung. At this time the patient was started on standard treatment for com-proBNP values on initial diagnosis, delay in diagnosis (Measured by the number of days of clini- munity acquired pneumonia and on therapeutic doses of fragmin for the hypothesis of pulmo-cal manifestations before diagnosis) and % of INR of prothtombin <2 in follow-up. Dyspnea was nary thromboembolism. In the second workout the pulmonary arteriography demonstrated aevaluated by de NYHA degree. Results. At present, we have data of 34 patients [mean age 64±17 thrombus in the pulmonary vein, with associated fibrosis and volume loss of the right lower lobe.years, male 20 (59%)]. The follow-up HCT was performed a mean of 166±64 days after initial epi- The thrombophilia screen showed decreased anti thrombin III and protein C levels. Lupic anti-sode. Thrombi in pulmonary arteries persisted in 9 (26%) patients: 1 in main pulmonary arteries, coagulant antibody and rheumatoid factor were positive. Urine protein/creatinine ratio was6 in lobar arteries, 1 in segmentary arteries and 1 in subsegmentary arteries. Dyspnea index was 553mg/mmol. Throughout patients admission we considered the possible primary cause of herI in 27 patients, II in 6 patients, and III in 1 patient. Neither age, gender, D-dimer, central or pe- PVT and whether the fibrosis was a causative event or consequence of the venous thrombosis.ripheral PE, dyspnea degree, diagnostic delay, presence of thrombophilia, proBNP or % of INR<2 Conclusion: The management of this syndrome seems dependent on the cause which is not al-were different between patients with resolved and persistent thrombi. The resolution of pulmo- ways possible to identify. No studies have been conducted regarding management of PVT, butnary thrombi was more frequent in patients without antecedents of TEVD (p<.05) Conclusions. anticoagulation, antibiotics, and, in cases of large PVT, thrombectomy or pulmonary resection inA quarter of patients treated because of pulmonary embolism fail to clear thrombi of pulmonary resectable tumours have been used.arteries during anticoagulant therapy with clinical implications on the length of anticoagulation. Al-though the factors conducting to persistence are basically unknown, the first episode goes moreoften to resolution.3. OCCIPITAL LOBE BRAIN METASTASIS FROM ADENOCARCINOMA OF 4. TIPE 1 BENIGN SYMMETRIC LIPOMATOSIS (MADELUNG’S DISEASE) ANDTHE CERVIX CHRONIC ALCOHOLISMRodriguez-Gallego López C, Blanco Moure A, Villanueva Silva M J, De La Cruz Alvarez J, Joana Goulao; Eduardo Esteves; Lisette Calado; Lourdes Tavares; Rui M. M. VictorinoJimenez-Beatty MD, Rey Barbosa A, Touza Rey FJ ,Conde Alonso C. Benign symmetric lipomatosis (BSL) is a rare metabolic disease characterised by progressive, sym-Cervical cancer characteristically spreads to adjacent structures by contigous dissemination, to pel- metrical and diffuse accumulation of nonencapsulated lipomas in the upper trunk, neck and headvic and para-aortic nodes through the lymphatic system and, late in the course of the disease, to giving rise to a characteristic pseudo-athletic appearance. It is more common in middle-aged mendistant organs by the haematogenous route. Sites most commonly affected are the lungs, liver, of Mediterranean origin with history of alcohol abuse. Type 1 involves the upper trunk, neck andand bones, in decreasing order of frequency. Metastases to the brain are extremely rare and are head and type 2 has a diffuse distribution. Lesions have an initial fast growth followed by a slow pro-usually considered incurable; only a few cases have been reported in literature. They are usually gression. Patients usually present with cosmetic complain or movement limitations. In rare casesseen a late event, and have poor outcome. Due its rarity, few reports focus the optimal manage- upper aerodigestive tract may be compromised. The aetiology is unknown but there is evidence thatment and prognosis of these patients. We report the case of a 57-year-old woman, diagnosed of the beginning of expression is associated with heavy, sustained alcohol consumption. Diagnosis isadenocarcinoma of the cervix of grade III, FIGO stage II-B in January 2004. She underwent ra- based on history and clinical findings. Imaging studies are useful to define lesion’s extent and com-diotherapy and brachytherapy. She relapsed in mediastinic nodes in November, 2006 and re- plications. Evolution is benign with extremely rare malignant transformation. There is an associationcieved 6 courses of chemotherapy (carboplatin-paclitaxel) with complete response. In December with some malignancies thought to be due to alcohol abuse. Weight reduction and alcohol absti-2007, she presented nausea, vomiting, headache and gait ataxia. On neurological examination nence are recommended but they do not stop progression. Surgery is the only effective treatmentshe presented left-sided hemiparesis and hemianopsia. A brain computed tomography (CT) re- as there is no spontaneous regression. We describe a case of a 68 years old Caucasian male heavyvealed a 4 x 4-cm right parietooccipital lesion associated with extensive brain edema. Magnetic drinker who presented with a 3 decade evolution history of multiple large disfiguring neck andresonance imaging (MRI) of the brain confirmed CT discoveries. Contrast-enhanced CT of the tho- upper trunk masses. The lesions had a rapid evolution on onset with slow growth thereafter. Hisrax, abdomen and pelvis, did not showed other metastases. In view of the localized nature of the height was 158 cm and weighted 75 Kg (body mass index of 30). Laboratory tests showed ma-lesion, surgical excision of the tumor was planned. Following a left occipital craniotomy with tumor crocytic anaemia and AST and &#947;-GT elevation. CT scan revealed neck and upper trunk ex-excision, the postoperative recovery of the patient was uneventful. Histologic examination of the tensive infiltrative nonencapsulated lipomas with no structure compression. There are approximatelymass showed metastasis from cervical adenocarcinoma. An increase in the incidence of brain me- 200 reported cases of BLS since its description in 1846. Despite the unique phenotype diagnosis istastases from cervical cancer has been noted in recent years. That may be related to a better lo- often delayed for decades as illustrated here. Obesity with this distribution requires an imaging me-coregional control due to treatment with radiochemotherapy to primary lesions and, hence, a thod to confirm the nonencapsulated lipomas that permits a diagnosis.better survival. The treatment of newer lesions are challenging due to the lack of experience insuch cases. At, present, our patient is in good health and a longer follow-up is needed to evaluatethe impact of brain metastectomy on survival. 32
  • 36. 5. WHY MAKE IT EASY WHEN YOU CAN MAKE IT DIFFICULT? 6. USING LOW COST TECHNOLOGIES TO ENHANCE DOCTOR-PATIENTGraça A., Amaral T., Rosa I., Moleiro A., Júnior J.F., Lourenço I., Alves E. COMMUNICATION IN A REGIONAL TEACHING HOSPITAL T.J. HannanAMAS, 52 year-old caucasian male, with known tabagism, periferic venous insuficiency and renallitiasis. In October 2006, was admited to our hospital pneumology´s ward for acute hypoxemic The timely availability of an adequate medical record is essential for good health care, and thetraqueobronquitis. A thoracic CT scan revealed acute massive pulmonary thromboembolism (PE) Computer-Based Patient Care Record has been defined as the ‘essential’ technology for healthand a vascular USDoppler showed rigth calf muscle flebotrombosis. Anticoagulation with warfa- care delivery. (1) It is well known that the communication between hospitals, primary care prac-rine was started. Transaminases elevation lead to the suspition of hepatic vascular compromise, titioners and patients is poor. When communication does occur (Discharge Summaries, Standardand abdominal MRI showed gallbladder lithiasis and probable inferior vena cava thrombosis. The letters) it is often not timely, accurate and does not reflect the inpatient management and the cur-patient was transfered to our Medicine ward. A ventilation-perfusion scan and pulmonary angio- rent status of the patient. (2,3) This paper describes how the use of standardised technologies ofTC excluded PE. A portal and inferior vena cava phlebography ruled out thrombosis. He was dia- MSWordR, MSExcelR and email facilities can provide effective timely reliable communication ofgnosed galblatter litiasis and calf flebothrombosis and discharged under anticoagulation. An medical record information. (4) Through the use of these technologies patients receive a copyelective colecistectomy was carried out in January 2007. One month later, the patient is re-admi- (electronic and printed) of their medical record as does the primary care physician and the ho-ted, complaining of weight loss, astenia and enlarged cervical lymph nodes. Acute renal failure, spital. Approximately 30% of patients use email for communication and 17% are over 65 yearsanemia and abnormal liver tests were detected and a progressive clinical deterioration was ob- of age. For diabetic patients a pre-formatted MSExcel worksheet provides the patient with the fa-served. A post-surgery infectious complication with sepsis was taken into account and large-spec- cility to send their Blood Sugar Readings with automatic calculation of average Blood Sugar rea-trum antibiotherapy started. An abdominal-US and CT-scan were performed, which were dings at pre-meal and bedtime and their HbA1c. This record is accessible by the author anywhereinconclusive. Attending the hypothesis of colangitis and residual cholelithiasis, the patient is sub- in the world where there in Internet access so patients remain in real-time contact with the author.mitted to ERCP, which was not possible due to extensive duodenitis. An MRI revealed possible 1. Dick R., and others. The computer-based patient record. An essential technology for healthextensive malignant disease centred in the upper abdomen. A diagnostic laparoscopy revealed care. Institute Of Medicine National Academy Press.National Academy of Sciences. 1991. 2. P.J.peritoneal carcinomatosis, a pancreatic mass and hilar liver infiltration. Progressive clinical worse- Branger, J.S.Duisterhout. Communication in Health Care. JAMIA. 1994;69-77. 3. Kripalani, Sunilning culminated in multiorganic failure. A hemorrhagic stroke superimposed leading to death. Au- MD, MSc; LeFevre, Frank MD; Phillips, Christopher O. MD, MPH; Williams, Mark V. MD; Basa-thopsy and immunohystochemical tissue studies diagnosed prostatic adenocarcinoma with viah, Preetha MD; Baker, David W. MD, MPH. Deficits in Communication and Information Tran-generalized atypical metastization. sfer Between Hospital-Based and Primary Care Physicians Implications for Patient Safety and Continuity of CareJAMA. 2007;297:831-841. 4. The Use of Existing Low-Cost Technologies to En- hance the Medical Record Documentation Using a Summary Patient Record [SPR]. Bart S, Han- nan T. Stud Health Technol Inform. 2007;129:350-3.7. ABDOMINO PELVIC MASS 8. PATTERN RECOGNITION OF KNEE JOINT VIBROACOUSTIC (VAG) BEHAVIOURIsabel Pinheiro, Agostinho Monteiro, Delfina Brito, Susana Fernandes, Rosa Ramos, USING FUZZY LOGIC ALGORITHMMaria José Metrass S. Stanciu, M. Cirmaci, M.Muresan, D. Safta, S. BlajA 26-year-old afro-woman, apparently healthy till 6 months before, since when she began to no- The point of fuzzy logic is to map an input space to an output space, and the primary mechanismtice dysuria, hypogastric pain, low grade vespertine fever, diarrhea of 2 stools per day and signi- for doing this is a list of if-then statements called rules. All rules are evaluated in parallel, and theficant weight loss (65 to 45Kg). An ultrasound revealed a pelvic mass. She was evaluated by order of the rules is unimportant. The rules themselves are useful because they refer to variablesgynecologists and hematologists and was admitted to investigate the retrosupravesical heteroge- and the adjectives that describe those variables. Before we can build a system that interprets rules,neous abdomino pelvic mass of 14x10x10cm, with irregular limits, inducing right hydronephro- we have to define all the terms we plan on using and the adjectives that describe them. If we wantsis. She was undernourished, apyretic, with painful inferior abdominal quadrants, hypogastric to see how much a knee joint is affected by arthrosis, we need to find out a normal pattern formass, vulvar edema and no adenopathies. Laboratory evaluation found microcytic anemia 8,6g/dL, VAG signals emitted by the joint, in standardized situations. This pattern has not very strictlyleukocytosis 14 300 with 57% neutrophils, C-reactive protein 15,4g/dl, erythrocyte sedimentation shape, but a range of values for defined parameters is acceptable. In this case, a ‚bad’ or a ‚good’rate 133, oligoclonal gammapathy IgG K+&#955; interpreted as inflammatory response. Anti- working knee joint must be defined by the parameters deviation from the normal range. A simi-HIV 1 and 2 were negative. The abdomino-pelvic MRI revealed a solid mass occupying the ute- lar situation could be expressed in terms of human body response to specific inputs as shocks orrus, bladder and anterior abdominal wall, with indefinition of this structures by loss of the anatomic environmental frequencies, i.e. The general idea of this work is to build a Fuzzy model in orderplans. The laparoscopy showed caseous material and multiple adherences. The Zieel Nielsen was to simulate and to evaluate the vibroacoustic behaviour of human knee joint response to differentnegative and Bacteroides fragilis was isolated. A second culture of the caseous material was per- inputs. External inputs, as impulses or frequencies, i.e., could be considerred, as well as internalformed and then a Enterobacter faecium vancomycin sensible and Candida albicans were isola- inputs, which could be, for exemple, the surface status of knee joint tissues.ted. The anatomo phatologic examination of the caseous material was suggestive of actinomycosis.Then we prescribed penicillin, vancomycin, metronidazole and fluconazole with significant cli-nico-laboratorial improvement. She is under amoxicillin for 5 months with almost normal ima-giologic studies. The diagnosis of actinomycosis is very rare nowadays and it’s easy to bemisdiagnosed as a neoplasic advanced disease but it has a good prognosis when the proper dia-gnosis and medication is performed. This extensive abdomino pelvic form of actynomicosis oc-curred in the absence of utilization of intrauterine device. 33
  • 37. 9. MEDULLAR COMPRESSION SYNDROME 10. JACKSONIAN CRISIS ASSOCIATE WITH PARIETAL MENINGIOMAMaria Helena Brito, Rosado L., Rosado P. Maria Helena Brito, Rosado L., Rosado P.INTRODUCTION The medullar compression syndrome is a medical emergency which can swif- INTRODUCTION Cerebral tumours are persisting as the unusual causes for epilepsy and its in-tly progress into a serious neurological degradation, i.e. paraplegia, when it is not detected and cidence is thought to be affecting 16% of the patients. We report a case of a paroxysmal focal cri-treated prematurely. CASE REPORT We report the case of an eighty-three (83) year old patient, sis with a Jacksonian progression and a secondary generalisation due to a meningioma of themale, admitted to the hospital by reason of a three week evolutional lack of strength in the infe- parietal camber. CASE REPORT This case reports the clinical situation of a thirty-nine (39) yearsrior limbs as well as enuresis. The pathologic background exposed pulmonary fibrosis. During the old patient, female, who went to the emergency room with sensation and paresthesia in the left-physical examination, the patient was aware, cooperant and guided, underfeed but self-sufficient hand with progression for the arm and subsequent loss of memory. She pointed out a similar epi-for all the actions of his daily life. Giving prominence to asymmetric paraparesia, the examination sode which occurred a month ago. In her background, she had febrile crisis during her childhood.revealed: level 0/1 in the right inferior limb and 1/2 in the left inferior limb, plantar cutaneous re- The physical examination exposed facial asymmetry with a deviation to the right side of the labialflexes in bilateral extension, and non-existence of abdominal cutaneous reflexes. In addiction, in- juncture and asymmetry of the proprioceptive reactions, being clearer on the left superior mem-creased asymmetric patellar reflexes were more evident on the right side and aquilian reflexes ber. Blood analysis did not reveal any changes. Electroencephalography showed the existence ofwere absent. Although these results, the reflexes and muscular strength of the upper limbs were slow activity in the subcontinuous theta band of the right parietal-temporoccipital protuberancewithin the normal values. Painful hypoesthesia in D3-D4. Laboratorial tests indicated pancytope- on electrogenesis of very unstable base. RMN – CE Meningioma of the right parietal camber putnia, hypocalcaemia 4,4 mg/dl, phosphorus (P) 3,4 mg/dl, the prostate-specific antigen 1000 (PSA) together with an oedema having an influence upon the right frontal lobe. She was medicated, atand alkaline phosphatase 2022 IU (International Units). The Nuclear Magnetic Resonance (NMR) the very beginning, with dexametasone, carbamazepine and omeprazol which was followed byon the cervical and dorsal spine showed spinal canal stenosis and hypertrophy of the posterior ar- surgery. DISCUSSION Meningiomas are cerebral benign tumours which are more commonches D1-D2 with medullar compression but without lithic injuries. The patient began his thera- among women, revealing an assorted symptomatology according to its topographical location. Itpeutics with dexametasone, Calcium gluconate, calcitriol, bicalutamide, and his reaction to the is believed that 67% of the patients with meningioma experienced epileptic signs, being in itstreatment was good. DISCUSSION/CONCLUSION To sum up, the medullar compression syn- mainstream findings which do not follow the symptoms and these are dependent of the tumourdrome can be characterized by lumbar pain which it is not relieved by rest, sensibility alteration, position. Parietal Epilepsy is a rare type of epilepsy, with an occurrence of 5% among all typeshyporreflexia, lack of strength and, in some cases, paraparesia. The diagnosis depends on the known. Surgery is the ultimate therapeutics.level of the column where the wound is. According to the statistics, the sensitive deficit it is thoughtto be affecting 38 to 76% of the patients and it can have a primary or secondary (systemic neo-plasias) origin. It is also thought that there are two ways of metastization to the medulla and asfar it is concerned to the prostate gland’s neoplasias it is believed to be occurring throughout anextradural nonvalvular system of the Baston venous plexus. The reported patient had a diagno-sis of paraparesia with an initial symptomatology of prostate gland’s neoplasias, whose evolutionwas favourable. To finish this case report, and in the sight of this case, I would like to beseech tothe early therapeutics with corticotherapy as well as laboratorial and imagiological examination ofeach patient with a well-matched diagnosis of the medullar compression syndrome. 34
  • 38. Oral Communications Thursday, May 8, 2008 CLINICAL CASES
  • 39. 1. DESCRIPTION OF THE FOURTH CASE OF ACERULOPLASMINEMIA FOUND 2. CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY -IN ITALY PARANEOPLASTIC SYNDROMEDi Raimondo D, Pinto A, Tuttolomondo A, Miceli S, Fernandez P, La Placa S, Licata G. Jorge Ruivo, Vania Almeida, Luisa AlbuquerqueWe report the case of a 56-year-old Italian man. At the age of 40 years the patient developed in- The lymphoma-associated paraneoplastic neuropathy is due to IgM monoclonal immunoglobulinssulin-dependent diabetes mellitus. A mild degree of anemia with reduced mean corpuscular vo- with cross reactivity against neuronal antigens. Treating the underlying tumor is the only provenlume and low transferrin saturation constantly associated to high levels of ferritin without evidence measure with influence in the mortality rate, while the immunosuppressive therapy promotes a tran-of inflammatory diseases were documented since the age of 20 years. Ataxia, dystonia, mild par- sient clinical recovery in only 50% of all patients. We discuss the case of a 55 year old male patientkinsonism and dementia became evident at the age of 40 and showed a constant progression. with a lymphoma-associated chronic inflammatory demyelinating polyneuropathy (CIDP), unre-Referred to our Department we performed a bone marrow aspirate that revealed a trilineage dy- sponsive to standard immunosuppressive therapy. He described having, for 4 weeks, parasthesiasplasia with abundant iron in RE cells after Iron staining, a Brain T2-weighted Magnetic resonance in both hands, with proximal progression and to the inferior limbs. Three weeks later he complai-(MR), that showed a hypointesity consistent with paramagnetic effect due to iron deposition in the ned of symmetrical, diminished leg distal muscle strength. On neurological examination he sho-basal ganglia, dentate nucleus, thalamus, substantia nigra, and cerebral and cerebellar cortex. wed distal (grade 4) leg muscle strength, abolition of osteotendinous reflex, pain, proprioceptiveThese findings of multiorgan iron overload induced ourselves to evaluate subject’s liver. Ultraso- and vibratory hypoesthesia. The diagnostic workup revealed normocytic normochromic anaemia,nographic (US) examination of liver and spleen did not show morphologic or structural alterations; ESR 113 mm, monoclonal gammapathy IgM/K; normal CSF biochemical and cytological analysis.Liver function tests were normal. To complete the liver diagnostic evaluation a biopsy was per- Electromyogram (EMG) showed median nerve and left posterior tibial nerve demyelination. His ver-formed, which showed a normal architecture, with iron overload into the hepatocytes at Perl’s tebral bodies had an altered signal on magnetic resonance, depicting diffuse bone marrow infil-staining. Consequently to absence of common HFE mutations, copper metabolism was detected: tration. Bone marrow biopsy (BMB) was inconclusive. He was started on prednisolone withserum copper levels was reduced; serum Cp was undetectable. At fundoscopic examination the unsatisfactory response. Eight weeks after an albumin-cytological dissociation was reported in theretina showed a pigmentary degeneration as described in subjects affected by aceruloplasmine- CSF, and the EMG showed severe demyelination with distal nerve signaling blockade. By the 16thmia. Sequence analysis of the ceruloplasmin gene of the proband revealed a single homozygous week, despite immunoglobulin administration, there was a progression to tetraparesia strengthmutation: a C-T transversion at nucleotide 1948 in exon 11, causing a missense glycine->arginine grade 3 and global respiratory insufficiency, which determined invasive ventilatory support. Aftersubstitution at position 631 in the protein (G631R), already previously described. In Italy, to our repeating BMB, a lymphoplasmocytic Non-Hodgkin Lymphoma was diagnosed. He underwent 3knowledge, this is the fourth case reported, the third in adults. Hereditary aceruloplasminemia is chemotherapy pulses, including rituximab, with complete clinical and neurophysiological recovery.a rare autosomal recessive disease, firstly identified by Miyajima et al in Japan in 1987. The disease In this setting, despite de immunosuppressive treatment, the clinical recovery was only achievedis caused by the absence of an &#945;2- glycoprotein, the ceruloplasmin, a copper-containing fer- after delivery of adequate anti-neoplastic therapy directed against the underlying condition, un-roxidase, mainly synthesized in hepatocytes and widely expressed, including the central nervous derlining the importance of a thorough diagnosis and multidisciplinary treatment.system, which catalyses the oxidation of ferrous to ferric iron, a change required for release of ironto plasma transferrin. As a consequence ceruloplasmin deficiency results in iron deposition in theliver, pancreas, basal ganglia, and other organs. Patients develop diabetes mellitus, retinal pig-mentary degeneration, anemia with constant finding of high ferritin levels. Progressive neurode-generation, with dystonia, extrapyramidal signs, cerebellar ataxia, and dementia, developed inmidlife, represents often the main clinical element.3. DELAYED DIAGNOSIS OF HYPERCALCEMIA - A RARE PRESENTATION OF 4. HAEMOPHILUS AORTITIS SECONDARY TO AORTIC VALVE ENDOCARDITISSARCOIDOSIS S. Saraf ,A. Worrall, A.M. VeitchM Sagee , S Penumetsa, SRC Susarla An 86 yr old gentleman was admitted with confusion and fever. His past medical history inclu-CASE REPORT: A 79 year old lady with history of chronic renal impairment and osteoarthritis was ded ischaemic heart disease, cerebrovascular disease, renal impairment, dementia and an infra-admitted after a fall. Complete physical examination and vital signs were unremarkable. Prelimi- renal abdominal aortic aneurysm of 5.3 centimetres diameter, measured by ultrasound 2 yearsnary laboratory tests showed serum Creatinine 248, Phosphate 2.15 and a Corrected Calcium of previously. This was treated conservatively, given his co-morbidity. On admission, he was pyrexial,3.06mmol/l. She denied taking thiazide diuretics, Calcium or Vitamin D supplements and any pre- hypotensive and tachycardic. Blood tests revealed a neutrophilia of 39.7 x 109/l (normal rangeviously documented hypercalcemia. She then underwent an extensive work up to identify the 2.5 - 7.5), serum C-reactive protein levels of 148 mg/l (1 – 6), alkaline phosphatase level of 283cause of hypercalcaemia. Repeated parathormone levels were either low or normal. 24 hour uri- IU/l (38 – 126). The initial diagnosis was possible cholangitis, and he was treated with Co-amo-nary calcium excretion, Thyroid function tests, Serum immunoglobulins and protein electropho- xiclav. An abdominal ultrasound revealed echogenic sludge within a distended gall-bladder, butresis were normal. A probable diagnosis of Humoral Hypercalcemia of Malignancy was suggested with no biliary dilatation. Further imaging was arranged to investigate other sources of sepsis.but a PTHrp level was normal. Ultrasonography of the neck showed an enlarged parathyroid Computerised tomographic (CT) scanning of the abdomen revealed an 8 cm infrarenal aorticgland and although this finding was striking, low or low-normal PTH levels made the diagnosis aneurysm with a tiny pocket of air in the anterior wall which is a unique radiographic finding ofof hyperparathyroidism unlikely. Further detailed examination revealed a small lump in the upper an infected aneurysm. An echocardiogram demonstrated a 3mm diameter vegetation on the leftouter quadrant of her left breast. Mammography and ultrasound revealed an 8mm solid mass and coronary cusp of the aortic valve. Haemophilus influenzae was isolated from blood-cultures anda core biopsy confirmed an oestrogen receptor positive grade II intraductal carcinoma. Isotope the diagnosis revised to Haemophilus aortitis secondary to aortic valve endocarditis. This was trea-bone scan showed no hot spots which made a diagnosis of Hypercalcemia of Malignancy unli- ted with Co-amoxiclav and Gentamycin. He died as a result of his sepsis despite appropriate anti-kely. A whole body CT scan did not reveal metastasis. Her breast cancer was treated and she was microbial therapy.Following the advent of antibiotics, secondary aortitis has become a rarelater discharged. She was readmitted 8 weeks later with another fall and mild confusion. She had complication of native valve endocarditis, and we are aware of only one reported case of hae-a normocytic anaemia (Hb 9.6g/dL) and her corrected Calcium was 3.60mmol/L. In the view of mophilus aortitis in the recent literature.normal PTH and normocytic normochromic anaemia, a bone marrow biopsy was performed,which showed some reactive changes but with no evidence of myeloma or lymphoma. Unex-pectedly the bone marrow trephine biopsy showed multiple noncaseating granulomas, occupyingabout 80 percent of marrow. Neither acid fast bacilli nor fungi were detected. The angiotensin con-verting enzyme level at that point were found to be elevated 144U/L (normal, 0—60U/L). A dia-gnosis of Bone marrow sarcoidosis was made and she was started on prednisolone at 40mg/d.Serum calcium normalised in 6 days and her haemoglobin rose from 9.6mg/dl to 11.9mg/dl.Serum ACE level repeated in 4 weeks showed a fall to within the normal range with sustainednormocalcemia. Discussion: This is an unusual presentation of hypercalcemia. The most commoncause for an incidental finding of hypercalcemia in adults is Hyperparathyroidism. In her case, al-though initial ultrasound showed a parathyroid nodule, the PTH levels were normal. The findingof a breast nodule was another red herring. Bone scan however showed no hot spots and serumalkaline phosphatase was normal. These findings along with normal PTHrp levels excluded hu-moral hypercalcemia of malignancy as the cause. Normocytic anemia prompted a bone marrowbiopsy; the findings of which, along with raised ACE levels confirmed the diagnosis. CT scan ofthe chest did not show any evidence of pulmonary involvement making this a case of isolatedbone marrow sarcoidosis. Although bone marrow involvement is not uncommon in sarcoidosisit is exceedingly rare to have isolated bone marrow disease. Only about 10% of cases of sarcoi-dosis present with hypercalcemia and this again can be only transient, depending on disease ac-tivity. It is due to excess of 1, 25- (OH)2-D3 production from the alveolar macrophages and thesarcoid granuloma. After institution of prednisolone, there was prompt normalization of her cal-cium and ACE levels. Therefore sarcoidosis should be considered and investigated as a cause ofhypercalcemia when the preliminary investigations are non-contributory. 36
  • 40. 5. SWEET SYNDROME: CLINICAL REPORT 6. ADDISON’S DISEASE: A CLINICAL CASETeodoro M, André E, Seabra N Teodoro M, Temprano JL, André E, Seabra NIntroduction/Background: Acute febrile neutrophilic dermatose is an uncommon skin disease cha- Introduction/Background: Addison`s disease is an uncommon endocrine disorder due to primaryracterized by fever, neutrophilia, painful red papules, nodules or plaques and an infiltrate consi- adrenal failure. Autoimmune destruction of the adrenal cortex accounts for more than 80% of thesting predominantly of mature neutrophils diffusely distributed in the upper dermis. reported cases. Presentation is often insidious and non specific therefore the diagnosis at an earlyExtra-cutaneous manifestations may be present. Based on clinical setting Sweet Syndrome (SS) stage is easily missed. Case description: a 23-year-old female, with a 4 mouths history of pro-is classified as idiopathic, malignancy-associated or drug induced. The idiopathic form usually af- gressive weakness, poor appetite, depressed mood and sleep disturbances was diagnosed as ha-fects women in the fourth and fifth decades. Case description: a 80-year-old man was admitted ving a major depression by a psychiatry. She started oral antidepressants without clinicalto our hospital with a 3 weeks history of high fever (39ºC), malaise and anorexia. Besides fever, improvement. So she was admitted to our hospital to perform intravenous tricyclic therapy. Phy-physical exam was irrelevant. Laboratory data showed: anemia, neutrophilia, monocytosis and sical examination revealed increase skin pigmentation, hypotension and orthostasis. Routine abo-high ESR. Diagnostic workup included cultures, serologic tests, imagiologic exams and temporal ratory studies showed a low serum sodium (115 mmol/L) strengthen the index of suspicion ofbiopsy all negative. A small mitral regurgitation was found. One week after admission several adrenal insufficiency. Serum cortisol level was also very low (2,05 &#61549;g/dL); ACTH was 451painful nodules in the palmar face of both hands, reminding Osler nodules were found along with pg/mL. The ACTH stimulation test confirmed the diagnosis. Abdominal CT and MRI were per-a new heart murmur that revealed to be due to a severe mitral regurgitation. In spite of no ve- formed with normal results. Mantoux was negative. Only 21-hidroxilase autoantibody was posi-getations were seen, the patient started antibiotic therapy without clinical improvement. Skin tive in autoantibodies screening for type II poliglandular autoimmune syndrome. The patientbiopsy showed a neutrophilic infiltration of the dermis. He then started corticotherapy with rapid started corticoid therapy whit rapid clinic improvement. Discussion/Conclusion: With this case weclinical and laboratory improvement. 3 and 6 weeks the valvular function was markedly impro- would like to emphasize the diagnostic challenge offer by a rare condition whose unspecific pre-ved. Exams to rule out malignancy were negative. Conclusion: cases of cardiac valvular regurgi- sentation mixes the diagnoses, making it possible only in situations where the death risk is con-tation due to acute valvitis are described in SS; this possibility can`t be rule out in this patient, given siderably high like in acute adrenal crises. This is highly probably when the first symptoms arethe significant improvement in valvular function with corticoids; as the possibility of malignancy psychiatric given the prevalence of depression nowadays.remains, we keep a close fallow-up specially in older patients.7. CELIAC DISEASE ASSOCIATED WITH SJÔGRENS SYNDROME AND SYSTEMIC 8. ABCIXIMAB INDUCED THROMBOCYTOPENIA – “TWO CASES OF A KIND”LUPUS ERYTEMATOUS. A CASE REPORT Clarinda Neves, Paula Dias, Gonçalo Rocha, Fernando Friões, João Paulo Araújo, Jorge AlmeidaBen Aballah O., Ben Fredj F., Mrad B., Ben Mansour I., Toumi S., Mhiri H., Laouani Kechrid C. Abciximab is widely used in patients undergoing percutaneous coronary intervention. AlthoughIntroduction: Celiac disease is an autoimmune disease due to a hyper sensibility to gluten. It may rare, abciximab induced thrombocytopenia (AIT) may have different courses. Case 1. A 69 yearoccur with other autoimmune diseases. However the association with systemic lupus erythema- old male was admitted at the emergency department with an acute myocardial infarction andtosus (SLE) and Sjögren’s syndrome is infrequent. We report a new observation. Case report: We was submitted to angioplasty and stenting of the anterior descendent artery. A bolus of unfrac-report the case of a 31 years old woman who had a celiac disease since 7 years old with a poor tioned heparin and abciximab followed by a 12 hour infusion was administered. The platelet countcompliance for a gluten free diet, referred to our consultation for xerostomia, xerophtalmia and previous to the procedure was 303 x109/liter, and at 12 hours and day 3 was 497 and 413arthralgia. A diagnosis of Sjögren’s syndrome was made supported by an abnormal schirmer’s test, x109/liter. He was discharged on day 6 under state of the art therapy. Twelve days after the pro-a labial minor salivary gland biopsy (Chisholm III) and anti SSA, anti SSB antibodies presence. She cedure he was readmitted with malaise and a petechial rash on the lower limbs. His platelet countpresented a recent photo sensibility and mouth ulceration. We found, in the biology, an anemia, was 13 x109/liter. Peripheral blood smear and coagulation screen were normal and myelogramleucopenia and lymphopenia, proteinuria, low complement and anti DNA antibodies. So we con- suggested peripheral platelet destruction. He developed epistaxis, and on day 3 the platelet countfirmed the diagnosis of SLE associated to an APL by the presence of chronic anti beta 2 glyco- was <10 x109/liter. Platelet infusion was initiated. On day 6 he became dysartric. The CT scan sho-protein I. The patient was treated by corticotherapy, antipaludian and Sjögren’s syndrome wed a thalamic haemorrhage. He became rapidly comatose, with hydrocephaly and an externaltreatment with a stability of her autoimmune disorders; but she is not yet compliant to a gluten ventricular derivation was placed without clinical improvement. Case 2. A 71 year old male wasfree diet. Discussion: The celiac disease is an autoimmune pathology and it occurs in children ra- admitted to elective coronary angiography and submitted to angioplasty and stenting of the rightrely in adults. The association with other autoimmune diseases has been described in several stu- coronary artery. He received clopidogrel, and a bolus of heparin and abciximab followed by a 12dies essentially diabetes and thyroiditis. But the celiac disease, SLE and Sjögren’s syndrome hour infusion. The platelet count 8 hours after the procedure was 14 x109/liter. He was asym-combination is rarely reported in the literature. This association may be pathogenically explained ptomatic. The coagulation screen was normal. He remained under surveillance and the plateletby autoimmune mechanisms and a common genetic background. Conclusion: We insist to ex- count on day 1, 2 and 4 were <10, 19 and 75 x109/liter. He was discharged on day 5, withoutplore patients with autoimmune diseases to research other autoimmune disorders to improve any complications. These 2 cases demonstrate the different course of AIT. The cases of delayedtheir prognosis by specific therapies. thrombocytopenia are scarce, but raise the question of a platelet count evaluation few days after the procedure. The patients should be advised for surveillance of symptoms associated with this complication. 37
  • 41. 9. CAPTOPRIL ASSOCIATED HEPATITIS: CLINICAL AND IMMUNOLOGICAL 10. ANCYLOSTOMA DUODENALE INFESTATION PRESENTING WITHSTUDY OF 7 CASES BICITOPENIAPatrícia Howell Monteiro, Luís dos Santos Pinheiro, Adriana Albuquerque, H.M.G. Martins, S. Lourenço, J.A.M. AraújoAna Espada Sousa, Margarida Anemia is a very common clinical condition, but values below 4 g/dL are usually significantlyINTRODUCTION: Captopril (CP) is broadly used in clinical practice, with a low incidence of se- symptomatic except in slowly progressive situations. At such lower levels it is frequent that morevere adverse reactions. CP associated hepatitis is described only as individual case reports and than one factor contribute to anemia and etiologies can range from frequent GI obscure bleedingthere are no references to structured series. CP hepatotoxicity is thought to be immunological and or nutritional deficits, to bone marrow involvement, or chronic infections. Ancylostomic anemia hasT-cell mediated, but there are no published immunological studies confirming this assumption. RE- been classified into i) compensated; ii) hypocromic microcitic with reticulocitosis and iii) “aplasticPORT OF CASES: We report a series of 7 cases of CP induced hepatitis, with application of the anemia” or “irreversible type”. We present the case of a 61 year-old black male who had arrivedClinical Scale for the Diagnosis of Drug-Induced Hepatitis (CSDDIH) by Maria VAJ and Victorino from Guiné-Bissau two months before and was referred to our hospital for fatigue and an ab-RMM in parallel with the results of in vitro T-lymphocyte proliferation assays (TL-PA) with the normal hemoglobin determination. He had no relevant medical history except complaints of fa-drug. There were 4 males and 3 females, mean age 53 years. Duration of CP use and onset of tigue in the last two months and possible dietary insufficiencies. Physical examination revealedsymptoms or laboratory changes varied from 6 to 90 days in 6 cases. In 1 case CP had been used wasting and pallor. Laboratory study showed bicitopenia (Hb - 3.3g/dL, MCV - 64.6fL, MCHfor 7 years. Jaundice, pruritus, rash and fever were the most frequent symptoms. The pattern of 18.3pg; Reticulocytes – 0.02 x106/µL; Platelets – 51000/µL), serum iron - 40µg/dL and ferritinliver injury was mainly cholestatic (hepatocelular in 2 patients). Bilirrubin, g-GT and alkaline pho- 16ng/mL. Endoscopy revealed duodenitis with filariform worms and stool testing confirmed an An-sphatase averaged 12, 13 and 5 times, respectively, the upper reference limit. Time until norma- cylostoma Duodenale infestation. Inpatient treatment included 8 RBC units, mebendazole and orallisation of liver enzymes exceeded 6 months in 2 cases and severity of clinical pictures lead to iron. Patient was discharged asymptomatic, with Hb= 9.1g/dL and platelets= 37000/µL; thus, mye-hospital admission in all patients. Liver ultrasound, performed in all patients, was normal in 5. logram and bone marrow biopsy were preformed to exclude aplastic anemia. These exams wereLiver biopsy was performed in 3 patients. The CSDDIH yielded a score of probable in 3 cases and compatible with a moderately reactive marrow without iron deposits. There was a late recoverypossible in 4 for CP hepatotoxicity. In vitro TL-PA with the drug were positive in 4 cases. DI- of hemoglobin and platelets levels. A diagnosis of bicitopenia due to type 2 ancylostomic anemia,SCUSSION: Captopril associated hepatic toxicity, although not frequent, constitutes an important without reticulocitosis due to concomitant severe nutritional iron deficit is proposed. This case hi-clinical problem. Diagnosis requires a high index of suspicion and use of strict protocols for ex- ghlights the interest of exploring undiagnosed chronic conditions in migrant populations, as wellclusion of alternative causes and establishing a consistent temporal relation between drug intake as, shows that often after initial stabilization of the patient further investigation is relevant to ex-and the onset of clinical symptoms. Diagnostic clinical scales and, in selected cases, the use of TL- clude concurrent/aggravating conditions and roll out underlying severe disease.PA, are important elements in supporting the diagnosis of this situation. 38
  • 42. Oral Communications Fryday, May 9, 2008 IMMUNOLOGY
  • 43. 1. GENE VACCINATION WITH ANTI-DNA ANTIBODY CONSENSUS PEPTIDE 2. PDGF RECEPTOR TURNOVER IN SYSTEMIC SCLEROSISPREVENTS LUPUS ONSET IN LUPUS-PRONE MICE THROUGH ACTIVATION OF G. Moroncini, J. Olivieri, C. Tonnini, A. Grieco, C. Paolini, S. Mancini, M. Luchetti, S. Svegliati,CD8+CD28- TREG E. Avvedimento, A. GabrielliGilberto Filaci, Francesca Ferrera, Bevra H. Hahn, Marta Rizzi, Antonio La Cava, Francesco Indiveri BACKGROUND: Systemic sclerosis (scleroderma, SSc) is a disorder characterized by fibrosis ofIg molecules contain epitopes that can induce T cell–mediated immune responses. B cells can pro- the skin and visceral organs. We have provided evidence (1) that the serum of SSc patients con-cess and present such epitopes activating T cells. The purpose of the present study was to test the tains stimulatory autoantibodies directed to the PDGF receptor (PDGFR). PDGFR autoantibodieshypothesis that T cells that recognize an Ig consensus sequence presented by B cells will modu- stimulate in fibroblasts a signalling pathway involving Ha-Ras-ERK1/2-ROS (reactive oxygen spe-late lupus-like disease in mice. To this end, (NZB x NZW)F1 (NZB/NZW) lupus mice received so- cies), resulting in oxidative stress and collagen gene over-expression (1)(2). OBJECTIVES: To elu-matic B cell gene transfer of a DNA plasmid encoding a consensus sequence of T cell determinants cidate their mechanism of action, we tested the biological effects of these agonistic autoantibodiesof murine anti-DNA IgG or control plasmids. Treated animals were monitored for the production on PDGFR biological activity and stability. METHODS: We challenged normal human primary fi-of antibody, the development of renal disease, and the phenotype, number, and function of T cells. broblasts for 5-120 minutes with PDGF or IgGs purified from serum of SSc patients (SSc-IgGs)Treatment of mice with Ig consensus plasmid induced TGF&#61538;–producing CD8+CD28– T or healthy controls. Additional experiments were performed in presence of selective inhibitors ofcells that suppressed the antigen-specific stimulation of CD4+ T cells in a cell contact– indepen- the molecules involved in the PDGFR signalling, including a specific inhibitor of PDGFR auto-dent manner, reduced antibody production, retarded the development of nephritis, and impro- phosphorylation. After incubation, cells were subjected to FACS and Western Blot analysis of cellved survival. Significantly, adoptive transfer of CD8+CD28– T cells from protected mice into surface and total PDGFR protein levels, respectively. To discriminate between transcriptional andhypergammaglobulinemic NZB/NZW mice effectively protected the transferred mice from the post-translational effects, the experiments were also performed in the presence of cycloheximide,development of renal disease. These data suggest that gene expression of anti-DNA Ig consen- an inhibitor of translation. To duplicate the effects of ROS, we also treated cells with H2O2 withinsus sequence induces immunoregulatory T cells that delay the development of lupus nephritis by the same time frame. RESULTS: We found that PDGF rapidly down-regulated PDGFR. SSc-IgGssuppressing hypergammaglobulinemia and renal disease. prevented PDGFR down-regulation maintaining PDGFR on the cell surface up to 120 minutes. Between 60 and 120 minutes, SSc-IgGs further increased PDGFR protein levels. This increase was inhibited by cycloheximide. The effect of SSc-IgGs on PDGFR turnover was reversed by pre-in- cubating the cells with inhibitors of i)PDGFR signalling or ii)Ha-Ras farnesylation or iii)ERK pho- sphorylation or iv)ROS generation. Exposure of cells to H2O2 replicated the effects of SSc-IgGs on cell surface and total PDGFR levels. In addition we found that, upon SSc-IgG binding, the rate of PDGFR polyubiquitination was significantly lower compared to that induced by PDGF. CON- CLUSIONS: PDGF down-regulates the membrane receptor by inducing its degradation. The agonistic PDGFR autoantibodies, isolated from scleroderma patients, stabilize the receptor on the cell membrane by reducing the ubiquitin-dependent degradation and stimulating eventually (60- 120 minutes) de novo synthesis of the protein. This results in a persistent stimulation of PDGFR signalling. The stabilization of the receptor by the autoantibodies is mediated by ROS. These data provide a pathogenic link between the agonistic PDGFR autoantibodies and the phenotype of sy- stemic sclerosis. REFERENCES: 1) Baroni SS, Santillo MR, Bevilacqua F, Luchetti M, Spadoni T, Mancini M, Fraticelli P, Sambo P, Funaro A, Kazlauskas A, Avvedimento EV, Gabrielli A. Stimula- tory autoantibodies to the PDGF receptor in systemic sclerosis (scleroderma). N Engl J Med 2006; 354: 2667-76. 2) Svegliati S, Cancello R, Sambo P, Luchetti M, Paroncini P, Orlandini G, Disce- poli G, Paterno’ R, Santillo MR, Cozzo I, Cassano S, Avvedimento EV, Gabrielli A. PDGF and re- active oxygen species (ROS) regulate Ras protein levels in primary human fibroblasts via ERK 1-2. Amplification of ROS-ERK-Ras signalling in scleroderma fibroblasts. J Biol Chem 2005; 280: 36474-82.3. EFFECTS OF DEPLETION OF B-CELLS BY ANTI-CD20 MONOCLONAL 4. ROLE OF THE CHEMOKINE CXCL13 IN HEPATITIS C VIRUS-RELATEDANTIBODY IN HCV+ MIXED CRYOGLOBULINEMIA (MC) AND LIVER CIRRHOSIS CRYOGLOBULINEMIC VASCULITISAntonio Petrarca, Luigi Rigacci, Carlo Giannini, Umberto Arena, Stefano Colagrande, Felicia Anna Tucci, Laura Troiani, Vincenza Conteduca, Gianfranco Lauletta, Loredana Sansonno,Paolo Romagnoli, Roberto Caporale, Laura Gragnani, Paolo Montalto, Alessando Natali, Michele Montrone, Domenico Sansonno, Franco DammaccoAlberto Bosi, Giacomo Laffi, Anna Linda Zignego Background and Aims. Lymphoid structures resembling secondary lymphoid organs in tissuesBackground. Antiviral therapy is the first therapeutic option in HCV-related MC; however, pa- targeted by chronic inflammatory processes have a major role in maintaining immune responsestients are frequently excluded due to contraindications. The effectiveness of B-cell depletion by against persistent antigens. Chemokine CXCL13, also known as BCA-1 (B-cell attracting chemo-anti-CD20mAb (Rituximab) was described, but the possibility of an immunodepression-related in- kine-1) or BLC (B-lymphocyte chemoattractant) is a major regulator of B cell trafficking. It was plan-crease in viral replication and ALT limits its use in cirrhosis. MC patients frequently have cirrhosis. ned to explore the role of CXCL13 in chronic hepatitis C virus (HCV) infection that frequentlyPatients. 14 HCV+ patients (3males, mean age: 59yrs.) with invalidating MC and liver cirrhosis, associates with lymphoid neogenesis in the liver and B cell dysfunction and lymphoproliferativewho were excluded from antiviral therapy, were treated with Rituximab (4weekly infusions of 375 disorders, including mixed cryoglobulinemia (MC). Methods. RT-PCR and quantitative real-timemg/m2) and followed-up for 6months. Results. Pre-treatment MC included, in addition to pur- RT-PCR were used for the analyses of CXCL13 gene expression in skin and in portal tracts isola-pura, arthropathy, and weakness, sensory-motor polyneuropaty in 12, nephropathy in 2, and leg ted from liver biopsies with laser capture microdissection (LCM) technique. ELISA and immuno-ulcers in 2 cases. Cirrhosis was class A in 10, class B in 3, and class C in 1 patient (Child-Pugh clas- fluorescence were carried out to detect CXCL13 protein in sera and in skin and liver tissues of 20sification). Four patients showed ascitic decompensation. A consistent improvement of MC sym- and 26 chronically HCV-infected patients with and without MC, respectively Results. Serum le-ptoms and biohumoral data was evident at the end-of-treatment (EOT) and end-of-follow-up vels of CXCL13 in chronically HCV-infected patients with MC were significantly higher than in(EOFU), with disappearance of purpura and leg ulcers and improvement/disappearance of we- those without MC and healthy controls, while the highest levels strongly correlated with activeakness, arthralgias, polyneuropaty and nephropathy. Some modification in mean viral titres cryoglobulinemic cutaneous vasculitis. CXCL13 gene expression on portal tracts showed enhan-(2.6x106, 4.2x106 and 2.5x106 IU/mL at admission, EOT and EOFU, respectively) and in mean ced levels of specific mRNA in MC patients with active cutaneous vasculitis compared with thoseALT values (54.9, 45,8 and 66.3IU/L) were observed. Improvement of liver protidosyntetic acti- with non-active vasculitis and HCV-infected patients without MC. Specific CXCL13 gene mRNAvity, protrombin time, ascites, portal hypertension, and encephalopathy was observed at EOT and espression was also up-regulated in skin tissue samples of MC patients with vasculitis. These fin-EOFU, especially in advanced cases. The Child-Pugh score improved from C11 to B7, B8 to A6, dings paralleled specific liver and skin deposits of CXCL13 protein. CXCL13 levels did not changeB7 to A5 and B9 to B7 respectively in patients with Child-Pugh >A. Conclusions. This study con- after a successful response to antiviral therapy or B-cell depletion treatment. By contrast, they de-firms the effectiveness and safety of Rituximab in MC and shows its safety also in patients with clined significantly during and after the resolution of cutaneous vasculitis with corticosteroids.advanced cirrhosis. Moreover, the Rituximab-related depletion of CD20+B-cells was followed by Conclusions. Up-regulation of CXCL13 gene expression is a distinctive feature of HCV-infectedcirrhosis improvement in spite of a moderate and inconstant increase of both viraemia and ALT patients. CXCL13 is expressed at the site of liver and skin in MC patients where it could play avalues. The mechanisms involved are unknown. Interesting working hypotheses may implicate a major role in the pathogenesis of tissue damage.role played by direct B-cell hepatotoxicity with the contribution of B-cell infiltrates in conditioningliver damage. The improvement of Kuppfer cell function due to the cryocrit value reduction mightalso play a role. 40
  • 44. 5. ORAL SPECIFIC DESENSITIZATION IN FOOD ALLERGIC PATIENTS 6. EOSINOPHIL-DERIVED TISSUE FACTOR AS POTENTIAL ACTIVATOR OFBuonomo A, Nucera E, Pollastrini E, De Pasquale T, Lombardo C, Pecora V, Roncallo C, COAGULATION IN PATIENTS WITH CHRONIC URTICARIAMusumeci S, Sabato V, Colagiovanni A, Rizzi A, Aruanno A, Schiavino D, Patriarca G Massimo Cugno, Alberto Tedeschi, Angelo V. Marzano, Riccardo AseroAccording to our group’s experience, an oral specific desensitizing treatment is the only effective Background. Frequently, chronic urticaria (CU) is associated with histamine-releasing autoantibo-way to treat food allergic patients. This treatment should be taken in consideration when the re- dies and thus it is considered an autoimmune disorder. In addition, we have demonstrated acti-sponsible food is an essential component of the diet (such as milk or eggs, especially in children), vation of blood coagulation via tissue factor (TF) and generation of the fibrin fragment D-dimerwhen food avoidance is difficult or when an elimination diet does not induce a spontaneous de- in several patients with CU. Coagulation activation paralleled the severity of the disease. Eosinophils,sensitization. We studied 90 patients (59 were children, aged less than 17 years) with food allergy which are involved in CU skin lesions, have been recently demonstrated as the major source of TFwho underwent an oral specific desensitizing treatment according to standardized protocols. 104 in human blood. Aims of the study. We assessed whether eosinophils are the cellular source of TFtreatments were performed since some patients were allergic to more than one food. The dia- in CU skin lesions. Methods. Ten patients with severe CU were studied. Skin biopsy specimens weregnosis of food allergy was made up through the medical history and an allergological work up: taken from wheals of more recent onset. The control group consisted of 10 biopsy specimens ofskin prick tests, detection of serum specific IgE and the double-blind, placebo-controlled food perilesional normal skin from different types of skin tumours. TF expression was evaluated by im-challenge. By stratifying patients on the basis patients on the basis of food allergy, results can be munohistochemical methods using an anti-TF monoclonal antibody. Co-localization of TF and eo-summarized as follows: cow milk: the treatment was completed in 25 cases out of 36 in 3-12 sinophil cationic protein (ECP), a classic cell marker of eosinophils, was investigated by doublemonths; whole egg: the treatment was completed in 19 cases out of 29 in 3-8 months; cod fish: staining studies using two specific monoclonal antibodies in the 4 specimens showing the highestthe treatment was completed in 9 cases out of 12; in the remaining 27 cases the treatment was TF reactivity scores. Results. All specimens from patients with CU clearly showed TF expression thatperformed with sheep milk, mixed milk (cow and sheep), egg albumen, mixed fish (codfish and was absent in all normal control specimens (P = 0.0001). The double staining experiments for TFsoil), soil, wheat, corn, apple, bean, orange, peanut, peach and lettuce and it was successful in 20 and ECP clearly showed that the TF-positive cells were eosinophils. Conclusions. Eosinophils are thecases. Totally the treatment was abandoned in 14 cases because of lack of compliance. In the re- main source of TF in CU lesional skin. This finding highlights the role of these cells in the patho-maining ones it was successfully completed (patients could eat again the food they were allergic physiology of CU and might pave the way for new therapeutic strategies.to) in 73 cases (82%), in 14 (15.8%) the treatment was stopped because of the occurrence of ad-verse reactions and in 2 (2.2%) patients achieved a partial tolerance to the food. In about half thecases some mild side-effects, such as urticaria, abdominal pain and vomiting occurred and oralantihistamines or steroids were used; in these cases the treatment was continued till the end usingsodium cromolyn or antihistamines prophylactically. During the oral desensitizing treatment weobserved a significant decrease of specific IgE and a significant increase of specific IgG4 after 6,12 and 18 months. In one patient we also found a decrease in IL-4 and an increase in IFN-g pro-duction by T lymphocytes, both spontaneously and after induction by allergen or mitogen. Thesedata let us hypothesize that during the treatment a switch from a Th2 to Th1 response occurred.Even if further studies are needed, an oral specific desensitizing treatment can be considered aneffective and quietly safe therapeutic approach to food allergy.7. LUPUS RELATED MYELOPATHYSoy E., Guasch B. , Laguillo G, Carmona C., Clemente C.Transverse myelitis is a rare but well recognised neurological manifestation of systemic lupus ery-thematosus (SLE). We describe a woman 31 years old, with known SLE, lasting ten years, who de-veloped an acute cord lesion. She was admited to our hospital for fever artromyalgies andheadache and the inicial treatment was hidroxycloroquine 200mg twice day and prednisona 7.5mg daily. She was tested for ANA, DNA, Ro and La that were positive. Antiphospholipid antibo-dies and lupus anticoagulant were negative. Blood cultures and infectious serology were negative.The second day appeared severe low back pain, urinary retention for voiding disturbance and gaitdifficulty. Nor other sphincter disturbances nor sensory level. Motor function was preserved andhyperreflexia was obtained on legs. Cerebroespinal fluid analysis showed increased proteins (85.5mg/dl), decreased glucose (46.8 mg/dl) and pleocytosis (10 white blood cells). Cerebroespinalfluid’s Gram stain, India ink stain and microbiologicals cultures ( for bacteria, acid-fast bacilli andfungi) were negative. Magnetic resonance imaging demonstrated an enlarged and hyperintensecord (T2-STIR) from D8 to L1 suggesting transverse myelitis at this level (Figure1.). Oral predni-sone was increased to 1 mg/Kg and was added 1000 mg daily of mycophenolate mofetil. Afterthis, six days later, she recovered sphincter control and fever and headache dissapeared. The gaitprogressively improved to complete recovery in 1 month. She was mantained with the same doseof mycophenolate mofetil and prednisona was tapered to low maintenances doses. Lasting threemonths the transverse myelitis has not relapsed. Magnetic resonance imaging showed that cordswelling and hyperintensity disappeared (Figure 2.). Conclusions: Lupus related myelopathy is apoorly understood entity, in our case no associated with anti phospholipid antibodies. There is agood relation ship between symptomes and magnetic resonance imaging. Outcome might bemore favourable than previously suggested. Mycophelonate mofetil may be useful for lupus re-lated myelopathy. 41
  • 45. Oral Communications Fryday, May 9, 2008 STROKE
  • 46. 1. IMMUNO-INFLAMMATORY PREDICTORS OF STROKE IN PATIENTS WITH 2. CD40 LIGAND AND MCP-1 LEVELS AS PREDICTORS OF CARDIOVASCULARCHRONIC NON VALVULAR ATRIAL FIBRILLATION (NVAF) EVENTS IN LACUNAR AND NON-LACUNAR STROKESPinto A, Di Raimondo D, Tuttolomondo A, Casuccio A, Di Sciacca R, Fernandez P, Licata G Santilli F, Tuttolomondo A, Basili S, Ferrante E, Di Raimondo D, Pinto A, Davì G, Licata GIntroduction: Atrial fibrillation (AF) is the most common of the serious cardiac rhythm disturban- Background and purpose. Upregulation of soluble CD40 ligand (CD40L) and of the monocyteces and is responsible for substantial morbidity and mortality in the general population. It is well- chemoattractant protein-1 (MCP-1) has been found in patients with acute cerebral ischemia. Weestablished that patients with nonvalvular atrial fibrillation (NVAF) are at risk for embolism, asked whether (i) the two molecules are similarly upregulated among non-lacunar and lacunarespecially when their conditions are complicated with risk factors for embolism. Moreover in- strokes and (ii) CD40L and/or MCP-1 may predict the risk of cardiovascular events in the two sub-flammation and hypercoagulability markers are present in patients with NVAF. On this basis we types of ischemic stroke. Methods. Ninety patients with type 2 diabetes mellitus presenting withhypothesized that increased plasma levels of citokines, selectins, adhesion molecules and Von an acute ischemic stroke (compared with 45 control subjects) were evaluated on admission andWillebrand factor would be associated with an increased risk of stroke in patients with NVAF. To up to 36 months (median 24 months) after the event. Results. Patients with acute stroke had hi-test our hypothesis, we undertook a prospective study to determine rates of stroke in patients gher plasma CD40L and MCP-1 than controls (p<0.0001), with no significant differences amongwith non valvular atrial fibrillation and compared plasma levels of these inflammatory variables to lacunar and non-lacunar ones. On multiple regression analysis only higher sCD40L quartiles andthe occurrence of stroke during a three years follow-up. Matherials and methods: Patients with older age were associated with higher MCP-1 quartiles. Forty-eight % patients experienced va-chronic NVAF admitted to our Department of Internal Medicine from 2000 to 2006 were con- scular events. Cox regression analysis showed that only the presence of higher sCD40L valuessecutively enrolled. Blood samples were drawn within 72 hours from admission. We evaluated pla- independently predicted the recurrence of vascular events. Conclusions. Platelet-monocyte inte-sma levels of IL-1&#946;, TNF-&#945;, IL-6, IL-10, E-selectin, P-selectin, ICAM-1 and VCAM-1. raction, through upregulation of inflammatory molecules such as CD40L and MCP-1, is involvedPatient events (stroke at follow-up) were monitored. Results: We enrolled 373 (M/F: 237/136) in the advanced stage of atherosclerotic cerebro-vascular disease.consecutive patients with chronic NVAF. IL6, TNF-&#945;, vWF and IL1&#946; plasma levels atadmission were significantly associated with new onset stroke at follow-up. At multivariate analy-sis high levels of IL6, TNF-&#945; and vWF remained a significant predictor of an higher risk toexperience ischemic stroke at follow-up. Moreover plasma values of TNF-&#61537; , IL6 andvWF showed a significative area under the ROC curve Discussion: In our study we showed as ba-seline plasma levels of TNF-&#946;, IL-6 and vWF are predictors of new onset ischemic stroke atfollow-up in patients with chronic non valvular atrial fibrillation (NVAF) with a significatively higherpredictive value than other laboratory and clinical variables. Atrial fibrillation (AF) is a major causeof morbidity and mortality from stroke and thromboembolism, usually due to embolization ofthrombus formed within the fibrillating left atrium and its appendage. Atrial fibrillation is associa-ted with a prothrombotic or hypercoagulable state, with evidence of abnormal hemostasis, en-dothelial damage/dysfunction, and platelet activation. Inflammatory mechanisms, includingC-reactive protein (CRP) and interleukin-6 (IL-6), are suspected to play a role in arterial throm-bogenesis but their association with the prothrombotic state of AF has studied only in few studiesthat analyzed the role of vWF. There is an apparent link between thrombogenesis and inflam-mation. In our study univariate and multivariate analysis showed a significative predictive value ofsome cytokines plasma levels with regard of new stroke onset at a three years follow-up and thisfinding, in our opinion, could represent a further clear confirmation of the role of inflammation inthromboembolism pathogenesis in atrial fibrillation.3. SILENT PULMONARY ARTERIOVENOUS MALFORMATIONS IN HEREDITARY sion and occur in up to 30% of HHT patients. Although they can produce pulmonary symptomsHAEMORRHAGIC TELANGIECTASIA: A PREVENTABLE CAUSE OF EMBOLIC related to right to left shunt or haemorrhage inside the pleura or the lung, most usually they re-CEREBRAL EVENTS main clinically silent and they are diagnosed when a neurological embolic event, such a transientA. Fernández-Rufete; E. Moral; G. Poza; R. Ibáñez; A. Hernández; I. San Román; S. Ruiz ischemic attack, stroke or brain abscess, occurs, sometimes with fatal consequences. They can ap- pear at any age and are not related to the severity of epistaxis or skin telangiectasias. Patient inINTRODUCTION Hereditary haemorrhagic telangiectasia (HHT) (Osler-Weber-Rendu syndrome) case 1 had been diagnosed of HHT since childhood because of affected siblings, recurrent epi-is a rare genetic autosomal-dominant multi-system disorder characterized by vascular abnorma- staxis and telangiectasias. Neurological complications (transient ischemic attack, left median ce-lities. Most common clinical manifestation include epistaxis, mucocutaneous telangiectasias, ga- rebral artery stroke) due to paradoxical embolism occurred at an advance age and perhaps wasstrointestinal bleeding and iron deficiency anaemia but visceral lesions can occur in many organs. the cause of the PAVM delayed diagnosis. Patient in case 2 presented with haemoptysis and a pul-We present two patients with HHT who presented with embolic complications of clinically silent, monary nodule at an early age, but at that time he didn’t fulfil criteria for HHT (epistaxis but noundiagnosed PAVMs. PRESENTATION OF THE CASES CASE 1. A 74-year-old woman was ad- telangiectasia nor family history). In this case, the diagnosis of PAVMs was also made after a neu-mitted to our hospital because of iron deficiency anaemia. She was diagnosed of HHT on the basis rological complication such as a cerebral abscess occurred . The absence of family history and theof family history, recurrent nose bleeding from childhood and mucocutaneous teleangiectasias. late appereance of mucocutaneous teleangiectasia could possibly lead to a delayed diagnosis ofFive years earlier she related a transient loss of strength in her left arm and clopidrogel was pre- HHT and PAVMs. No screening method was applied in any of the patients or their relatives to dia-scribed. Six months before admission she had a complete left middle cerebral artery stroke with gnose PAVMs. Once detected, PAVMs were treated with transcatheter embolization with good re-right hemiplegia and aphasia and was admitted at another hospital. She had no other known car- sults and no complications. Patients with HHT are at risk of thromboembolic complications. Bothdiovascular risk factors than age. Laboratory tests, electrocardiography, chest radiograph, and patients had serious thromboembolic events (high risk because of HHT and inmmobility due totransthoracic echocardiography were normal and an ultrasonography of the carotid arteries sho- neurological damage) that carried many therapeutical problems. CONCLUSIONS: 1. PAVMSwed no significant stenosis. One year after she was admitted to our hospital because of iron de- ARE AN IMPORTANT AND UNRECOGNISED CAUSE OF MORBILITY IN PATIENTS WITHficiency anaemia. Gastroscopy showed multiple gastric angiectasia and barium enema was normal. HHT. 2. DIAGNOSIS OF PAVMS IS USUALLY DELAYED, AFTER AN EMBOLIC EVENT HASThe existence of an embolic cerebral event of unknown origin in a patient with THH lead the su- OCCURRED- 3. ALL HHT PATIENTS SHOULD BE SCREENED FOR PAMVS. 4.IN OUR EX-spicion of an occult PAVM. A computed tomography of the chest revealed a 1, 5 cm PAVM in the PERIENCE, TREATMENT WITH TRANSCATHETER EMBOLIZATION IS A SAFE AND EFFEC-left lower lobe. Cerebral MRI showed a extensive area of necrosis but no AVM were detectec. Pre- TIVE THERAPEUTIC PROCEDURE OF PAVM.embolization pulmonary angiography confirmed the PAVM and also showed a thrombosis of theinferior cava vein. Transcatheter embolization of the PAVm was performed without any compli-cations and she was discharged with prophylactic low molecular heparin and oral iron therapy.After 6 months the patient remains well, with no new vascular events and no anaemia. CASE 2.A 41-year-old man was admitted because of changes in behaviour, headache and an acute cen-tral right facial paralysis. He related frequent epistaxis since childhood and for the last ten yearsmultiple telangiectasias had progressively appeared on his face, mouth and lips . Iron deficiencyanaemia had been diagnosed a year ago. He had no family history of HHT. Fifteen years earlierhe underwent a chest CT scan because of hemoptysis and a nodule was found in the right upperlobe. After a thorough study that included a bronchoscopy and lung biopsy no diagnosis wasmade. Other than the epistaxis he had been well until two weeks before admission when his wifenoticed changes in his behaviour and confusion. Cranial CT scan showed ring contrast enhancedhipodense lesions in the left basal ganglia that were suggestive of brain abscesses. Chest CT scanwas also performed and multiple lung nodules were seen in the upper and lower right lobe, andleft lower lobe that were diagnosed as PAVMs. After prolonged antibiotic treatment and surgicaldrainage he showed a progressive neurological improvement. Transcatheter embolization of thePAVM located in the ritght left lower was done. Two days after the procedure he had a right fe-moral vein thrombosis and a silent bilateral lung embolism and he was anticoagulated. After 6months the patient is able to walk, has no cognitive sequeale and no other pulmonary symptons,and a new CT scan shows no new PAVMs and of no signs of pulmonary embolism. DISCUSSIONIn clinical practice diagnosis of HHT is made according to the Curaçao criteria. The two patientsdescribed meet the criteria of definite HHT (epistaxis, multiple mucocutaneous telangiectasias, vi-sceral lesions in both of them and family history in case 1). PAVMs is the commonest visceral le- 43
  • 47. 4. TELEMEDICINE FOR ACUTE STROKE CARE: 1 YEAR OF EXPERIENCE 5. IMMUNO-INFLAMMATORY AND THROMBOTIC/PHYBRINOLYTIC MARKERSA. Pedragosa, M. Ribó, P. Ferràs, O. Mascaró, C. Sanclemente, M. Martín, J. Álvarez-Sabin, AS A DIAGNOSTIC PANEL OF ACUTE ISCHEMIC STROKEJ. Vilaró Tuttolomondo A, Di Raimondo D, Corrao S, Di Sciacca R, Fernandez P, Pinto A, Licata G.Background telemedicine allows evaluation of acute stroke patients in hospitals where an expert Introduction: Accumulating evidences suggest that inflammation plays an important role in the de-neurologist is not available. We aim to study the feasibility and impact of a telestroke evaluation velopment of cardiovascular and cerebrovascular disease. The aim of this study is to evaluate thesystem in the acute care of stroke patients admited to a community hospital (ComH). Methods predictive value of a bound of candidate serum immunoinflammatory and thrombotic/phybrino-The system allows high quality image teleconference between the patient and treating physician litic moleculae towards acute ischemic stroke diagnosis. Materials and Methods : were enrolledat the emergency room in the ComH and an expert neurologist at the reference central hospital 120 consecutive patients with a diagnosis of acute ischemic stroke and 123 consecutive hospita-(RefH) (70 km / 60 minutes away). The neurologist has also remote access to brain CT-scans. We lized control patients without a diagnosis of acute ischemic stroke. Were evaluated plasma levelsprospectively recorded all patients admitted to the ComH with suspected acute stroke during the of IL-1b, TNF-a, IL-6 and IL-10, E-selectin, P-selectin, sICAM-1 and sVCAM-1 as markers of im-first year after “telestroke” system activation. Demographic and clinical data were recorded, neu- munoinflammatory activation, vWF plasma levels as a marker of endothelial dysfunction, TPA an-rological status was assessed with the NIHSS scale. We also recorded the physicians degree of tigen and PAI-1 plasma levels as a marker of a prothrombotic state. Results: TNF-alfa, PAI-1 andsatisfaction. Results During one year the system was activated in 75 patients, 66% of acute stroke TPA on bivariate logistic regression were highly correlated to stroke diagnosis. Among the otheradmissions were remotely evaluated by the neurologist: mean age 69 years, median NIHSS: 9, variables maintained in the final model IL1beta, Selectin E, were significantly associated with acutemean time from onset 151 minutres. Urgent transfer to RefH was decided in only 22 patients ischemic stroke diagnosis , whereas IL-6 , VICAM-1, ICAM-1 and neutrophil percentage showed(19%), thombolytic treatment with tPA was administrated in 8 patients (7%) (4 of them in the only a slight or no association with stroke diagnosis . Furthermore the continuous values of TNF-ComH). The main reasons for not consulting the remote neurologist was previous disability and a, PAI-1 and TPA showed a significative predictive value, likelihood ratio, with an area under theonset time > 6 hours. The number of transfers considered unnecessary was dramatically reduced ROC curve respectively of 98,6%, 97,1% and 99,9%. Discussion: Our findings could suggest theaccording to the previous year (50% to 18%). Physicians felt that the system helped in advancing possible high diagnostic power of these immunoinflammatory and thrombotic/phybrinolitic va-therapeutic measures and improved the accuracy of diagnosis. The overall degree of satisfaction riables in patients with acute ischemic stroke Although our results are encouraging, additionalwas good. Conclusions Telemedicine helped delivering urgent specialized care to patients with studies are needed to establish the validity of this approach and samples are expected to en-acute stroke in a hospital lacking a neurologist on call. Time to initiation of specific therapies was hance our control population for marker panel analysisreduced and thombolytic treatment was started in the ComH under the supervision of an expertstroke team.6. STROKE PROPHYLAXIS IN ATRIAL FIBRILLATION: IS IT REALLY DONE?Gonçalves,J.; Iglesias, A.B.Aims: Underuse of warfarin for stroke prophylaxis in atrial fibrillation (AF) is extensive and repre-sents a major problem in clinical practice. Methods : Retrospective study of population that con-sisted of resident discharged AF patients in Internal Medicine and Cardiology Departments inone Portuguese hospital (Castelo Branco) in 2006. Medical records were examined. The study wasbased in risk factors for stroke that favours anticoagulation in AF patients and its contraindications.We settled the number of patients who had indication for treatment or not and if it was prescri-bed or not, according to international guidelines. Results: The study ( 326 patients ) verified: - Riskstratification was not complete to include patients for prophylaxis of stroke in 43 % of cases. - Un-deruse of warfarine ( 59 %) in patients with indication for the treatment, and no apparent con-traindications. Suggestion: Reach a better use of international guidelines for stroke prophylaxis inAF patients. 44
  • 48. Oral Communications Fryday, May 9, 2008 HEART FAILURE
  • 49. 1. CHANGES IN NATRIURETIC PEPTIDES AND CYTOKINES PLASMA LEVELS 2. IS THERE STILL A GAP BETWEEN GUIDELINES AND CLINICAL PRACTICE ININ PATIENTS WITH HEART FAILURE, AFTER HIGH DOSE OF FUROSEMIDE HEART FAILURE?PLUS SMALL VOLUME SALINE SOLUTIONS (HSS) AND AFTER AN ACUTE Joana Mascarenhas, Cristiana Paulo, Patrícia Lourenço, Joana Pimenta, Ana Azevedo,SALINE LOADING Paulo BettencourtPinto A, Tuttolomondo A, Di Raimondo D, Di Sciacca R, Parrinello G, Paterna S, Fernandez P,Licata G Background: Underuse of recommended medications in the treatment of patients with heart fai- lure (HF) is well known. We aimed to determine prescription rates of HF drugs at discharge afterIntroduction: Over the last years, it has been acknowledged that neuroendocrine activation is of pa- an acute episode of HF and to identify predictors of drug prescription in two cohorts of patientsthophysiological and prognostic importance in patients with heart failure (HF). Moreover, it is now evaluated 4 years apart. Methods: We prospectively evaluated 224 patients (71.4±12.6 years,clear that in the HF state, activation of the inflammatory system occurs, resulting in release of proin- 33.5% women) discharged after an episode of acute HF in 2006/07-group 1. Data concerningflammatory cytokines as well as adhesion molecules that may perpetuate the inflammatory state this sample was compared with that of the 273 patients (72.7±11.8 years, 54.9% women) di-and play an important role in modulating the left ventricular dysfunction. Our group previously sho- scharged after an episode of acute HF in 2002/03-group 2. Time to death or readmission withinwed that the combination of high dose furosemide associated with small-volume hypertonic saline 3 months was compared between the two cohorts using Cox regression. Logistic regression wassolution (HSS) infusion is safe and tolerable (10,11) and that this combination in patients with se- performed to identify variables related to drug prescription. Results: In group 2, loop diureticsvere CHF determined a significant reduction of hospitalization time, the maintenance of the achie- were prescribed to 94.3% of patients, ACE-inhibitors to 82.7% [89.4% in patients with left ven-ved New York Heart Association (NYHA) at discharge, the reduction of readmissions to hospital tricular systolic dysfunction (LVSD) and 69.2% in the remaining (p=0.001)], beta-blockers (Bb) tofor CHF worsening and a significant mortality rate reduction. More recently our group also re- 39.7% and spironolactone to 32.9%, independently of LVSF. In group 1, 97.8% patients were di-ported that HSS group reached dry weight more rapidly, a significantly faster reduction in BNP le- scharged on loop diuretics, 65.2% on Bb [with significant differences between patients withvels, shorter hospitalization length of staying and lower incidence in readmissions in the 30 day (71.4%) and without (51.1%) LVSD (p=0.018)], 69.2% on ACEIs and 32.1% on spironolactone, in-study period. On this basis, the aim of this study was to evaluate the effects of high-dose furose- dependently of LVSF. ACEIs or ARBs were prescribed to 79.9% of patients in group 1. No patientmide treatment plus HSS on natriuretic peptides and immunoinflammatory markers levels in pa- in group 2 was treated with ARBs. In multivariate analysis, LVSD and lower creatinine levels weretients with heart failure and to analyze the response to acute saline loading at the end of treatment independent predictors of ACEI prescription, respectively for men and women, in group 2. Inperiod in terms of natriuretic peptides and inflammatory marker levels. Methods : 120 consecutive group 1, increasing age and higher creatinine levels were negatively and independently associa-patients with heart failure treated with high dose furosemide+HSS, 30 HF controls treated with high ted with ACEI prescription. When considering ACEIs or ARBs together, only worse renal functiondose furosemide without HSS, 30 controls with asymptomatic left ventricular dysfunction (ALVD) was associated with under-prescription. In stratified analysis, higher heart rate at admission andand 30 healthy controls. We evaluated plasma levels of BNP, ANP, IL-1&#946;, TNF-&#945;, IL- LVSD were the most important predictors of Bb prescription in men of group 1. No predictors6, IL-10, E-selectin, P-selectin, ICAM-1 and VCAM-1 respectively in baseline conditions after treat- were identified for women. Men were more likely treated with Bb in group 2. Spironolactone usement (in cases and HF controls) and after an acute saline load (in cases and controls). Results: At was inversely associated with age in group 2 and with worse renal function in men of group 1.admission, patients with heart failure showed low-level of serum and urinary sodium. They also sho- We didn´t find any predictive variable for treatment with diuretics. The event rate was not diffe-wed high plasma levels of ANP, BNP, TNF-&#945;, IL-1&#946; and IL-6. After 8 days of treat- rent between the two groups (hazard ratio=1.01; 95% CI 0.81-1.49, p=0.54). Conclusion: Bb pre-ment with high dose furosemide and small volume of HSS, patients with ALVD or CHF a significant scription increased between 2003 and 2007, suggesting that clinicians are more aware ofincrease of daily diuresis, serum and urinary sodium, a significant lowering of weight , SBP HR and guidelines. ACE-inhibitors and/or ARBs are frequently considered in the treatment of HF, althoughof ANP, BNP, IL-1&#946;, TNF-&#945;, IL-6 plasma values. Until the end of treatment period was renal dysfunction is still a limiting factor in their use. Spironolactone use remains very low, renalreached, after the acute saline load, patients with CHF or left ventricular dysfunction showed higher, dysfunction being the major limiting factor. Although the gap between guidelines and clinicalthough not statistically significant, plasma levels of ANP and significatively higher plasma levels of practice can partially be attributed to comorbidities, major improvements have occurred at our in-BNP, IL-1&#946; and TNF-&#945;, in comparison with values observed immediately after the stitution.treatment period in the same patients, nevertheless these plasma values remained lower in com-parison with admission values. Moreover, patients with HF treated with i.v. high dose furosemide+ HSS showed, after acute saline load, a lower absolute change of ANP, BNP, TNF-&#945;, IL-1&#946;, IL-6 E-Selectin, P-Selectin plasma levels with respect to the values observed, in the samepatients, at the end of treatment period in comparison respectively to the absolute change obser-ved in control subjects (healthy and ALVD subjects), after a saline load, whereas no significant dif-ference was observed between case and controls in absolute change of IL-10, ICAM-1 andV-CAM-1 plasma levels. Conclusion: Treatment with high dose furosemide and HSS, by loweringvolume overloading could be responsible for a stretching relief that could influence natriuretic pep-tides and immunoinflammatory marker plasma levels after treatment and after an acute saline load.3. PROGNOSTIC VALUE OF THORACIC FLUID CONTENT AFTER AN EPISODE OF 4. THE METABOLIC SYNDROME (METS) IN SYMPTOMATIC HEART FAILURE:ACUTE HEART FAILURE PREVALENCE AND CLINICAL ASPECTSCristiana Paulo, Joana Mascarenhas, Patrícia Lourenço, Helena Silva, Joana Pimenta, Daniela Toporan, Cristina Tanaseanu, Marius VintilaAna Azevedo, Paulo Bettencourt Background.The association of MetS components in chronic heart failure (HF) elderly patients andBackground: Impedance cardiography is an emerging non invasive method of monitoring he- its clinical significance has not been yet clearly established. Objective. To analyze the prevalencemodynamic parameters. Limited information is available concerning the use of impedance car- of MetS (diagnosed according to National Cholesterol Education Program Adult Treatment Paneldiography as a prognostic marker in heart failure (HF) patients. Methods: We conducted a III – NCEP ATP III criteria and, respectively, International Diabetes Federation – IDF criteria) in pa-prospective cohort study with 187 patients admitted to the hospital with diagnosis of acute HF. De- tients with symptomatic heart failure; to correlate the presence of the metabolic risk factors withmographic, clinical, echocardiographic and laboratorial data were collected. Patients had a bioim- the type and severity of left ventricular dysfunction. Methods. We studied the impact of MetS onpedance cardiography performed at discharge. Treatment was instituted according to the 630 patients, aged >65 yrs (mean age 75 yrs), women 65%, admitted to our hospital with clini-attending physician. Patients were followed up for three months. The primary end point was all- cal syndrome of HF. 52% of patients had class IV NYHA (New York Heart Association) HF, 21%cause death or readmission. Prognosis was compared between groups using Cox proportional ha- had class III, 15% met class II and 12% class I. All patients underwent a measurement of ejectionzards regression. Multivariate Cox regression was performed to adjust for the effect of fraction (EF) by the quantitative 2D (biplane Simpson) method and a Doppler examination of mi-confounders. Results: We analyzed data from 57 (30.5%) women, with a median age of 75 years, tral inflow for a complete, systolic and diastolic, left ventricular function (LVF) evaluation. An EFand 130 men (69.5%), with a median age of 69 years. Ischemic etiology was present in 92 pa- >50% defined a preserved systolic LVF. HF had, as underlying disease, 51% coronary artery di-tients (49.2%), 37(22.3%) patients had preserved left ventricular function and 85 patients (51.2%) sease, 12% valve disease, 8% dilated cardiomiopathy and 29% arterial hypertension. The patientshad severe left ventricular dysfunction. Ninety-eight (52.4%) patients had atrial fibrillation and 75 in atrial fibrillation and flutter were excluded. Student’s t and chi-square tests were used for stati-(40.1%) had diabetes. The mean (standard deviation) number of previous admissions due to HF stical analyzed. Results.The prevalence of the MetS was 27,2% (171 cases) by classical ATP III cri-was 0.62 (1.17) per patient. In univariate analysis for the identification of predictors of adverse out- teria and 34,1% (215 patients) by applying IDF criteria ( subjects are required to have centralcome after discharge we found a significant higher hazard of death or re-hospitalization for pa- obesity – waist circumference >94 cm for males and >80 cm for females plus any two of the fol-tients with higher levels of thoracic fluid content (on the third tertile in comparison to the first) (HR lowing: triglyceride level >150 mg/dl, HDL-cholesterol level <40 mg/dl for males and <50 mg/dl3.36; 95% CI, 1.75 to 6.46, p<0.001) and for patients with chronic HF vs patients with new-onset for females, blood pressure >130/80 mm Hg and blood glucose level >100 mg/dl). About 16%HF, number of previous hospital admissions due to HF, coronary heart disease, diabetes mellitus, of cases with MetS (including 2 or 3 components)had HF class I and II NYHA,with preserved EFsystolic and diastolic blood pressure at admission and values of hemoglobin, albumin, B-type na- and diastolic dysfunction. 180 patients (84%) with MetS (including 4 or 5 components) weretriuretic peptide (BNP) and C reactive protein at admission and discharge, and cholesterol levels older, more often women, in more severe NYHA class (III and IV), with systolic (LVEF <40%) andat discharge. Taking into account the effect of other prognostic factors that are associated with hi- diastolic dysfunction. Compare with patients in HF without MetS, cases with MetS had more fre-gher thoracic fluid content, in multivariate analysis, TFC maintained prognostic value (HR 3.26 CI quently both coronary heart disease and hypertension, longer duration of diabetes, use of insu-95% 1.50 to 6.70, p=0.001) independently of number of hospital admissions, new-onset vs chro- lin, severe mixed dyslipidemia and higher creatinin level. The hospitalization was longer for thesenic HF or BNP at discharge. Conclusions: The results suggest that thoracic fluid content evalua- patients, with more ischemic heart events and with a slower regression of HF symptoms and signsted by impedance cardiography allows the identification of patients at higher risk of adverse events under maximal conventional treatment. Conclusions. The prevalence of MetS in elderly with HFand might help clinicians in planning discharge of HF patients. is higher according to the new IDF recommendations (approximately one third -34,1%, respect of one quarter –27,2% according to ATP III criteria). The presence of few components of MetS is associated with a stable clinical HF and with an echocardio-graphic LV diastolic dysfunction. The cluster of more metabolic risk factors encompasses by the MetS in one case seems to be a heavy burner on patients in HF, given the high risk for development a severe LV systolic and diastolic dysfunction and a more complicate evolution. Enhancing knowledge about the clinical impor- tance of MetS is a priority future research. At present, an aggressive and uncompromising ap- proach and management of MetS is require in order to avoid the high risk for progression to a severe form of HF. 46
  • 50. 5. FACTORS PROTECTING OR FAVOURING FEAR IN CARDIAC HEART FAILURE 6. BIOELECTRICAL IMPEDANCE ANALYSIS FOR PREDICTION OF HOSPITALPATIENTS ADMISSION DUE TO CARDIAC DECOMPENSATION IN AMBULATORY HEARTQuiles I, Diaz M, Alfaro R., Llorens P, Wikman P, Segui Jm, Martinez Baltanas A., Safont P., FAILURE: A FOLLOW-UP STUDYMerino J. Daniele Torres, Gaspare Parrinello, Salvatore Paterna, Pietro Di Pasquale, Manuela Mezzero, Antonio Fatta, Karin Trapanese, Alessia Torres, Giuseppe LicataINTRODUCTION - Diseases could trigger fears provide they induced organic and psychologicalchanges in the way of living and alter life expectancies. In this work we try to define the factors Background: During the progression of heart failure (HF), phases of chronic compensation andfavouring or protecting cardiac heart failure patients (CHF) of suffering of fears. METHODS - De- acute decompensation are characterized by fluid accumulation. It is not always apparent, beco-scriptive study in which for evaluating fears we use a modification of P. Arranz questionnaire. The ming evident only when the symptoms/signs are manifest. We evaluate the predictive value offorms have been filled by a random sample of CHF patients (all of which accomplished Framin- Whole-Body (WB) and Segmental (Seg) Bioelectrical Impedance Analysis (BIA), useful in hydra-gham criteria), willing to participate and admitted in the Internal Medicine wards of our hospital tion status evaluation, for hospital admission due to cardiac decompensation in ambulatory HF.through the two first terms of 2007. We study 34 different factors, all probably related with fear Methods and Results: 62 patients (67.1±8.1 yr, 32 F) with compensated HF (LVEF 36&#61617;&#6in these patients. Statistical analysis was the percentage of each factor in the sample, and then 1494;%, NYHA class 2,4) referred to our Heart Failure Centre and followed-up for a median ofOdds ratio was calculated with a bi variable and multivariable analysis. RESULTS - We included 522 days. 25 healthy subjects were controls. Clinical data, BIA measurements (Resistance R, Re-42 patients, mean age 73,6+_14,5 years, 54,8% of which were women, Many factors seem to be actance Xc) using BIA-101 pletismograph (Akern Srl) were taken at recruitment and at intervalsrelated in the bi variate analysis but lost their effect in the multivariate analysis (MA).The final fin- of about 45 days. The end point was hospitalization due to cardiac decompensation. At the enddings were: Favouring the appearance of fears: a) unwilling loneliness: pain scale values (OR 1, of the study an expert team blinded to BIA parameters, subdivided the subjects into two groups44 p< 0.03), to have dead brothers (14,2, p=0,04); b) having an incurable disease: number of chil- (A group 42 stable patients; B group 14 hospitalized patients) estimating the predictive accuracydren (OR 1,34, p=0,04); c) of being judged: presence of anxiety (OR 8,57 p > 0,05); d) of orga- of BIA. Hospitalized patients had a statistically significant reduction (p<0,001) of bioelectrical datanic pain: being male (OR 4,9, p=0,02); e) of possible psychological adverse effects of used drugs, before hospitalization (A: Seg R 60,5±8,6, Seg Xc 5,2±3,7, Seg PA 0,43±0,05, WB R 512.7+56.8,(OR 3,67 p=0,05) ; f) of possible organic adverse effects with the drugs used: number of drugs WB Xc 44,3±5,8,; B: Seg R 40,2±7,7 Seg Xc 3,1±2,9 Seg PA 0,23±0,02 WB R 438.1+53.4 WB(OR 0,74 p=0,05); g) of the impossibility of being cared by their family: number of brothers (OR Xc 34±8,7 Ohm) and significantly lower LV ejection fraction and serum sodium level, higher C-1,69 p=0,01), number or previous admissions (OR 0,6 p=0,05) and the presence of anxiety (OR reactive protein and a reduced compliance to medical recommendations. In a multivariate analy-16,3 p=0,004); h) the need to be institutionalized: to be male (OR 8,59 p= 0,02), Protecting for sis BIA was the most significant independent predictor for hospitalization (p=.012). Conclusion: BIAthe appearance of fears: a) of loose of self control: to be practising catholic (OR 0,04, p0 0,02) is low-cost, easy, non-invasive, rapid method to predict hospital admission due to HF exacerba-and to be under benzodiacepine treatment (OR 0,029, 0= 0,0004); and b) of the possibility to tion among ambulatory patients. It may be prospectively a useful tool in monitoring HF: the ear-suffer sanitary errors: to be practising catholic (0R 0,2 p=0,03). COMMENTS - We find very few lier evaluation of pre-clinical state of hyperhydration suggests to tailor medical treatment andmodifiable factors able to protect against fears. dietary recommendations.7. NON-INVASIVE DETECTION OF PCWP IN DECOMPENSATED HEART FAILUREPATIENTS TREATED WITH INTRAVENOUS HIGH-DOSE FUROSEMIDE ANDSMALL-VOLUME HYPERTONIC SALINE SOLUTION: RELATIONSHIP WITH BNPAND BIOIMPEDANCEDaniele Torres, Antonio Fatta, Manuela Mezzero, Marina Pomilla, Caterina Trapanese,Valentina Siragusa, Gaspare Parrinello, Salvatore Paterna, Pietro Di Pasquale, Giuseppe LicataBackground: Decompansated heart failure (DHF) is a broad of spectrum of signs and symptomscharacterized by fluid’s accumulation in the interstitial space of the lungs and whole body. We eva-luate the non-invasive detection of pulmonary capillary wedge pressure (PCWP) by Tissue Dop-pler Analysis DHF patients underwent treatment with intravenous high-dose furosemide andsmall-volume hypertonic saline solution (HSS). Moreover we investigate its relationship with chan-ges of BNP plasma levels and Whole-body (WB) and segmental (Seg) bioelectrical impedance ana-lysis (BIA), a non-invasive tool useful to estimate the hydration status and fluid distribution.Methods and Results: 66 consecutive patients (63 to 82 yr, 43 men) admitted for DHF (EF<45%,NYHA class III-IV) underwent tailored therapy with intravenous furosemide and HSS were en-rolled. 22 patients with compensated left ventricular dysfunction and 22 healthy subjects were con-sidered as controls. WB and Seg BIA parameters were drawn at hospital entry and after clinicalstabilization with treatment. At discharge there was a significant reduction of PCWP (-7 mmHg,p<.001) as BNP levels (p<.001) and significant increase of BIA parameters (p<.001) in DHF patients.Furthermore significant correlations of PCWP with BNP serum levels (p<.001) and BIA parame-ters (p<.001) and of BNP levels and BIA parameters (p<.001) at baseline and at clinical stabiliza-tion correlation were found. Conclusion: our data suggest that non-invasive evaluation of PCWPis a valuable and useful way in management of DHF. Moreover it is related to neuro-hormonalactivation and whole-body and pulmonary fluid accumulation in these patients. High-dose of in-travenous furosemide plus HSS are well tolerated and improve the in-hospital outcome with aneffective hemodynamic stabilization, the normalization of hydration status and a positive neuro-hormonal modulation. 47
  • 51. Oral Communications Fryday, May 9, 2008 HYPERTENSION
  • 52. 1. AMBULATORY BLOOD PRESSURE 24-HOUR MONITORING TO EVALUATE 2. WHITE COAT HYPERTENSION IS HIGHLY PREVALENT IN FRAIL ELDERLYEFFECTS ON BLOOD PRESSURE OF PHYSICAL ACTIVITY IN HYPERTENSIVE ADMITTED IN NURSING HOME. RESULTS OF A STUDY CONDUCTED WITHPATIENTS AMBULATORY BLOOD PRESSURE MONITORINGDi Raimondo D, Pinto A, Tuttolomondo A, Di Gati M, Licata G Fedeli A., Zanieri S., Belladonna M., Pecchioni S., Pepe G., Lambertucci L., Lotti E., Masotti G, Marchionni N, Ungar A.Objective: Hypertension is one of the most important risk factors for cardiovascular disease andischemic stroke. Several studies have demonstrated that physical exercise reduces blood pressure Aim: The elderly population living in nursing home is quite peculiar because of its high preva-(BP) levels in hypertensive subjects and improves controls of several well-known risk factors for lence of comorbidity, disability and incidence of cognitive impairment. At present there are no dataatherosclerosis such as diabetes mellitus, blood lipid profile and obesity. On this basis our group on the specific effects of hypertension in this population. Aim of the study was to verify the pre-tried to evaluate if an exercise program based on periodic controlled fast walking sessions would valence of hypertension in patients living in nursing homes and to evaluate the relation betweenreduce blood pressure levels in hypertensive subjects already in therapy with antihypertensive clinical blood pressure and ambulatory blood pressure monitoring in this population (ABPM).drugs, evaluating BP variations through 24 hour ambulatory blood pressure monitoring (ABPM). Methods: study population was composed by 273 patients (mean age 81 years) divided in threeDesign and Methods: were enrolled 189 hypertensive subjects (101 men and 88 women, mean groups: Group A: composed by hypertensive outpatients (N=100); Group B: frail elderly admit-age 55.7 ± 10.8 years) already under pharmacological therapy, not suffering from obesity (Body ted in nursing home (N=100) Group C: patients admitted to the rehabilitation ward of the sameMass Index < 30) and without any pathological condition resulting in reduced mobility. A main centre (N=73). Clinical and pharmacological data were collected for all patients as well as clinicalinclusion criterion was the evidence of stage I hypertension, according to the Guidelines for Hy- blood pressure (OBP) and 24 hour ABPM (Spacelabs 90207). Definitions: “White coat hyper-pertension Treatment of the European Society of Hypertension (ESH) and the European Society tension”: OBP&#8805;140/90 and ABPM <135/85 mmHg; “masked hypertension”:of Cardiology (ESC), as an average value obtained with a 24-hour ABPM performed on admis- OBP<140/90 mmHg and ABPM&#8805;135/85 mmHg). Results: Patients of group A had thesion. These subjects uderwent to a six weeks program of exercise, based on fast walking, super- higher prevalence of clinical hypertension (Group A 71%, Group B 51%; Group C 70%). Wevised by experienced physiotherapists. The walking velocity was setted on the “self-selected” found a good correlation between blood pressure values measured clinically an with ABPM onlyspeed, that is the walking speed considered comfortable for every subject, added to a mean of in Group A (PAS: r=0,54; p=< 0,001; PAD r=0,70, p=<0,001), while the correlation was poor in40 %, to obtain a value comparable to fast walking for every subject. 168 patients of 189 com- Group B (PAS: r=0,3 and p=0,02; PAD: r=0,11 and p=0,2). In Group C the correlation was inter-pleted the training period. Results: mean 24 h systolic blood pressure (SBP) changed from 143.1 mediate (PAS: r=0,62; p=<0,001;PAD0,44; r<0,001). The prevalence of white coat hypertensionto 135.5 mmHg (p < 0.001), mean 24 h diastolic blood pressure (DBP) changed from 91.1 to was 14% in Group A, 57% in Group C and of 70% in Group B. Circadian rhythm analysis was84.8 mmHg (p < 0.001). Statistically significance reductions were evident also in everyone of the preserved only in 22% both in Groups B and C. In Group A we found a higher percentage ofthree periods in which daytime was divided. No differences were found in BP values during sleep patients with preserved circadian rhythm (33%). Conclusions: This study demonstrated a poor cor-between baseline and after exercise. No differences were found on mean values of heart rate. relation between clinical and ambulatory blood pressure, with an high prevalence of white coatConclusions: This significant reduction of SBP and DBP, yet evident after a short period of exer- hypertension. The hypertensive patient in nursing home is very peculiar and deserves a carefulcise therapy, evaluated with ABPM, confirms that physical exercise should be a main element in management for what concerns diagnosis and treatment.lifestyle changes for the management of hypertension both in untreated hypertensive patients orhigh-risk subjects for hypertension, and also in hypertensive patients in association with pharma-cological therapy, especially when blood pressure targets are not reached.In our study, further,ABPM confirms its major role in providing useful informations regarding therapeutic follow-up ofhypertensive subjects.3. EFFECT OF MINERALCORTICOID RECEPTOR ANTAGONISM ON 4. USEFULNESS OF A SERIES OF REPEATED IN-OFFICE BLOOD PRESSUREENDOTHELIAL DYSFUNCTION IN ESSENTIAL HYPERTENSION (ROBP) MEASUREMENTS FOR THE DIAGNOSIS OF WHITE-COATCirenza G., Daniele GP, Cioffi A, Corsini F, Di Palma G, Raele G, Torella R, Salvatore T HYPERTENSION Giuseppe Crippa, Antonino Cassi, Claudio Venturi, Elena Bravi, Pietro CavallottiEndothelial dysfunction is a characteristic feature of arterial hypertension and a pivotal early eventin the development of atherosclerosis. Aldosterone seems to play a role independent from renin White-coat hypertension is usually defined as an elevated office blood pressure (OBP) level asso-angiotensin system (RAS) on the pathophysiology of endothelial dysfunction and organ impair- ciated with normal home blood pressure (HBP) or ambulatory blood pressure (ABP). However,ment. In the present study, we examined the effect on endothelial dysfunction of adding a mi- from the one hand, not all subjects are candidate for HBP measurements since this procedureneral corticoid receptor antagonist to the angiotensin-converting enzyme inhibitor in the treatment needs a certain ability and should be avoided in anxious, incompliant and unreliable individuals.of essential hypertension. Twenty patients with new diagnosis of moderate to severe essential hy- From the other hand, the routine use of ABP monitoring is limited by its still insufficient availabi-pertension based on the WHO/ISH guidelines were treated with either ramipril (10 mg/d) alone lity, its cost, and the discomfort that it can generate in some patient. Aim of this study was to as-(group I : 10 patients, 6 men and 4 women, mean age 51.3+/-3.2 yrs) or ramipril (10 mg/d) plus sess whether a series of repeated office blood pressure (ROBP) measurements was able topotassium canrenoate (50 mg/d) (group II: 10 patients, 5 men and 5 women, mean age 50.0+/- discriminate white-coat from sustained hypertensive subjects. We considered one hundred and3.5 yrs). Flow-mediated vasodilatation (FMD) of the brachial artery was measured in the two tre- twenty-two pharmacologically untreated subjects (mean age 58 ± 19, 67 females) referred to ouratment groups and in 14 normotensive control subjects (8 men and 6 women, mean age Hypertension Unit by their general practitioner with the main indication of confirming the clini-49.5+/-3.2 yrs) before and after al least 14.2+/-2.7 weeks. Basal FMD was significantly lower in cal diagnosis of hypertension through an ABP monitoring. After a 20 minute resting in a com-hypertensive patients with respect to control subjects (4.9+/-2.4 vs 7.8+/-3.0%; p<0.01). Antihy- fortable armchair, all subjects underwent ROBP measurement performed by using an automatedpertensive therapy restored blood pressure to normal (group I: 128+/-11/80+/-8 vs 155+/- oscillometric device set to obtain 10 readings at 2.5 minute intervals. After the first reading the exa-12/98+/-9 mmHg; group II: 125+/-7/78+/-10 vs 158+/-13/103+/-7 mmHg) and significantly im- mined subject remained alone in the doctor’s office. Few minutes after the end of the series of 10proved the FMD (group I: 8.2+/-5.1 vs 4.9+/-2.4%, p <0.05; group II: 8.0+/-2.8 vs 4.6+/-2.1%, p measurements (ROBP), an ABP monitoring was mounted. The average of the last six measure-<0.05) without significant differences between the two groups for either the parameters. Results ments obtained with ROBP was compared with mean daytime (from 8 a.m. to 10 p.m.) ABP va-suggest that adding potassium canrenoate has no advantage on endothelial dysfunction in patients lues. Eighty-one, out of the 122 individuals considered for the analysis, showed daytime ABPwith essential hypertension who are receiving an angiotensin-converting enzyme inhibitor. patterns compatible with the diagnosis of sustained hypertension (systolic BP > 130 and/or dia- stolic BP > 80 mmHg) while 41 subjects presented with normal ABP values, suggesting white-coat hypertension. ROBP measurement predicted the white-coat phenomenon in all but one subjects. The average of the sixth-to-tenth values (122/76 ± 7/8 mmHg)obtained with ROBP practically overlapped daytime ABP values (121/75 ± 7/8 mmHg) in those subjects and the correlation was tight and significant (systolic r: 0.84, p<0.001, diastolic r: 0.96, p<0.001, Pearsons correlation test). In the group of 81 subjects, identified by ABP monitoring as sustained hypertensive patients, ROBP measurement disclosed systolic and/or diastolic values higher than normal (mean ROBP 147/85 ± 12/7, mean daytime ABP 146/85 ± 11/8 mmHg) as well, and a good correlation with daytime mean ABP values was found (systolic r: 0.81, p<0.001, diastolic r: 0.91, p<0.001). In con- clusion, our data indicate that ROBP measurements, performed under standardised condition, may be helpful for the diagnosis of white-coat hypertension. Also in patients with sustained hy- pertension a very good correlation between morning ROBP measurement and mean daytime ABP values was found indicating that, in dipper patients at least, ROBP represents a reliable tool for taking treatment decision. 49
  • 53. 5. ASSOCIATION OF ENDOTHELIAL DYSFUNCTION, LOW-GRADE 6. INFLAMMATION AFFECTS TUBULOINTERSTITIAL DAMAGE IN ESSENTIALINFLAMMATION AND PLATELET ACTIVATION IN HYPERTENSIVE PATIENTS HYPERTENSIONWITH MICROALBUMINURIA Savino A, Berni A, Torri M, Poggesi L, Cecioni I, Berardino S, Boddi MFrancesca Santilli, Patrizia Ferroni, Maria Teresa Guagnano, Angela Falco, Vincenzo Paoletti,Maria Rosaria Manigrasso, Noemi Michetti, Fiorella Guadagni, Stefania Basili, Giovanni Davì Background: The role played by vascular inflammation in development of hypertensive-target organ damage is still under debate. Recently, hypertension-induced inflammation was reportedObjectives. To analyze the relationship among platelet activation, endothelial dysfunction low- not to be related with glomerular damage investigated by microalbuminuria. However, relation-grade inflammation and sCD40L in hypertensive patients with or without microalbuminuria (MA). ship between inflammation and the involvement of the tubulointerstitial compartment was neverPatients and methods. A cross-sectional comparison of sCD40L levels was performed in 25 pa- investigated. Renal resistive index (RRI) was shown to early detect tubulointerstitial damage whentients with essential hypertension and MA (MH) pair-matched for gender and age with 25 patients renal function is still preserved. This study was aimed to investigate if in essential hypertension,with essential hypertension (EH) and 25 healthy normotensive subjects. Circulating C-reactive tubulointerstitial damage was affected by the level of inflammatory markers. Methods: We inve-protein (CRP, marker of inflammation), sP-selectin (marker of in vivo platelet activation), asym- stigated 24 hypertensive patients (HP) (aged 62±14 years, 14M/10F) and 35 age-matched heal-metric dimetylarginine (ADMA) and von Willebrand Factor (vWF)(markers of endothelial dysfun- thy subjects (21M/14F). All subjects had a fasting glucose <110 mg/dL, ejection fraction >50%,ction) levels were analyzed in each subject. Results. sCD40L levels were increased in MH patients creatinine <1.2 mg/dL or creatinine clearance >60 mL/min, and uricemia <6 mg/dL. Patients withcompared to either EH (p<0.001) or HS (p<0.0001). A highly significant correlation between pla- cardiovascular events in the previous 6 months, secondary hypertension, or major inflammatorysma sCD40L and sP-selectin (p<0.0001), vWF (p<0.001) or CRP levels (p<0.05) was observed in disease were excluded. No subject was on anti-inflammatory drugs. Levels of fibrinogen, alpha-MH patients. Multivariate regression analysis showed that sP-selectin was the strongest indepen- 2-globulin, erythrocytes sedimentation rate (ESR), total white blood cell and neutrophil countsdent predictor of sCD40L levels (p<0.0001) in MH patients. Hypertensive patients with both vWF were assayed as inflammatory markers. RRI ([peak systolic velocity—end-diastolic velocity]/peak sy-and CRP levels above the median had the highest sCD40L levels (p< 0.0001). Factorial ANOVA stolic velocity) was calculated by the analysis of the Doppler flow wave obtained from the inter-analysis of all hypertensive subjects confirmed that only MH patients with low-grade inflamma- lobar arteries at superior, medium, inferior poles in each kidney as the mean of six measurements,tion had elevated levels of sCD40L. Conclusions. sCD40L levels appear to discriminate a subset and was considered normal when <0.70. Results: In HP, mean levels of inflammatory markersof patients characterized by microalbuminuria and low-grade inflammation, suggesting that inhi- were significantly higher than in controls (fibrinogen 433±132 mg/dL, alpha-2-globulin 13±2.4%,bition of the CD40/CD40L system may represent a potential therapeutic target in hypertensive ESR 37±23 mm/h, p<0.05 vs control for all). Total white blood cell and neutrophil counts did notsubjects at high risk for cardiovascular events. differ between HP and controls. RRI values resulted &#8805;0.70 in 11/24 HP, with a mean value of 0.68±0.07 (p<0.02 vs control). In HP, RRI was significantly correlated with levels of ESR (r=0.42, p=0.04), fibrinogen (r=0.43, p=0.03) and alpha-2-globulin (r=0.44, p=0.04). Conclusions: Inflammation is associated with and seems to facilitate the renal damage of the tubulointerstitial compartment in essential hypertension. 50
  • 54. Oral Communications Fryday, May 9, 2008 INFECTIOUS DISEASE
  • 55. 1. MEASURES TO ERRADICATE A NOROVIRUS ACUTE GASTROENTERITIS 2. CLOSTRIDIUM DIFFICILE ASSOCIATED DIARRHOEA: AN OUTBREAK IN ANOUTBREAK IN A INTERNAL MEDICINE WARD INTERNAL MEDICINE WARDJ.R. Muñoz, M.A. Asencio, J. Alonso, I. Márquez, M. Jiménez Patrícia Howell Monteiro, Tiago Nolasco, Luís dos Santos Pinheiro, Maria João Nunes da Silva, Dulce Oliveira, José Melo Cristino, Thomas Hanscheid, Margarida Lucas, Rui M.M. VictorinoBackground. Norovirus, former Norwalk-like-virus, belong to Caliciviridae (RNA-viruses), can pro-voke outbreaks of acute gastroenteritis in institutions and are spread through contaminated food INTRODUCTION: Clostridium difficile associated diarrhoea (CDAD) is a nosocomial infection ofand water, and especially by hands. Not only in hospitals, norovirus ocurr in day care centers, re- growing importance. Hospital outbreaks of CDAD have been described with growing severitystaurants, cruise ships, school and other setting. Objetive.The aim of this study was to dercribe an and recurrence rates, with new risk factors identified. In these outbreaks a new strain of Clostri-outbreak in a internal medicine ward, and detailing the actions to erradicate this helth corcern. Me- dium difficile (CD) was isolated with increased virulence and pathogenicity. Little information onthods. In april 2007 a gastroenteritis outbreak occurr in a hospital ward during the weekend. Three this issue is published in Portugal and Southern Europe. CLINICAL CASES: We describe an out-days later, it begins in a internal medicine ward, a similar outbreak involving 9 patients, 6 workers break of 8 cases of CDAD in an Internal Medicine ward during a 3 week period, diagnosed byand at least 4 visitors. In order to avoid secundary cases we recommend to limit the visits and we the detection of toxin A in faeces. All patients were treated with oral metronidazole. The patientsencourage the nursery to mantein strict personal hygiene, specially handwashing with soap. We mean age was 78 years, 6 were men and 75% initiated diarrhoea inhospital. The mean time bet-clean and desinfect rooms, baths and corredors and other environment surfaces. Water supplies ween admission and diarrhoea was 19 days. Mean duration of diarrhoea was 10 days. After ini-are changed. Foodhanders were advised to extrem their measures and the exclusion of ill handers. tiating antibiotic, diarrhoea resolved in an average of 5 days. Before developing CDAD all patientsAll the stools samples from patients were sent to laboratory. Results After an average incubation had been on antibiotics (average 2,4 per patient) and the most frequent was piperacillin-tazo-period of 20-24 hours and lasts no more than two days, our surveys reveal mild symtoms with few bactam (50%), followed by gentamicin, vancomycin and ciprofloxacin. The classes involved were:vomiting, diarrhoea, without fever, frecuently watery stools. 17,5 % of patients were involved. The penicillins (75%), aminoglycosides (50%), vancomycin (38%) and cephalosporins, quinolones andoutbreak last from 8-12 days. The laboratory of Microbiology rules out pathogens bacteria, rotavi- carbapenems (25%). Both before and during the outbreak, there was no change in the practicesrus, adenovirus, Criptosporidium sp. Clostridium difficile and protozoos. The first four samples were of health professionals and in the patients’ profile. Detailed microbiological studies to characterizeshipped to National Microbiology Center and they detected norovirus by electron microscopy in the strain are ongoing. DISCUSSION: In our hospital during 2006 only 13 cases of CDAD werethree samples. Conclusions 1. Efforts to encourage hygiene measures were definitive to erradicate diagnosed in 43400 admissions. This outbreak has the particularity of a large number of cases inthe outbreak in order to avoid health and financial problems. 2. Stools specimens should be sent a small unit of 21 beds in a short period of time in a Hospital where the previous number of re-to laboratory as soon as possible to detect the etiological agent, to extrem mesaures and to erra- ported cases was low. We hypothesize that, as in recent publications, a particularly virulent straindicate the outbreak. J Background. Norovirus, former Norwalk-like-virus, belong to Caliciviridae may be in the origin of the outbreak. The occurrence of this outbreak emphasizes the importance(RNA-viruses), can provoke outbreaks of acute gastroenteritis in institutions and are spread through of CDAD as a nosocomial infection of increasing prevalence and severity.contaminated food and water, or by hands. Not only in hospitals, norovirus ocurr in day care cen-ters, restaurants, cruise ships, school and other setting. Objetive.The aim of this study was to der-cribe an outbreak in a internal medicine ward, and detailing the actions to erradicate the helthcorcern. Methods. In april 2007 a gastroenteritis outbreak occurr in a hospital ward during theweekend. Three days later, it begins in a internal medicine ward, a similar outbreak involving 9 pa-tients, 6 workers and at least 4 visitors. In order to avoid secundary cases we recommend to limitthe visits and we encourage the nursery to mantein strict personal hygiene, specially handwashingwith soap. We clean and desinfect rooms, baths and corredors and other environment surfaces.Water supplies are changed. Foodhanders were advised to extrem their measures and the exclu-sion of ill handers.All the stools samples from patients were sent to laboratory. Results After an ave-rage incubation period of 20-24 hours and lasts no more than two days. Our surveys reveal mildsymtoms with few vomiting, diarrhoea, without fever, frecuently watery stools. 17,5 % of patientswere involved. The outbreak last from 8-12 days. The laboratory of Microbiology rules out the pre-sence in stools samples of pathogens bacterias, rotavirus, adenovirus, Criptosporidium sp. Clostri-dium difficile and protozoos. The first four samples were shipped to National Microbiology Centerwhere they detected norovirus by electron microscopy in three samples. Conclusions 1. Efforts toencourage hygiene measures were definitive to erradicate the outbreak in order to avoid health andfinancial problems. 2. Stools specimens should be sent to laboratory as soon as possible to detectthe etiological agent, to extrem mesaures and to erradicate the outbreak. and to be quietsus usua-rios y a los responsables sanitarios.3. BRUCELLOSIS - A RETROSPECTIVE STUDY 4. TUBERCULOUS PERITONITIS: AN EMERGING UNCOMMONA. Fidalgo, C. Mendonça, A. Baptista, P. Proença, L. Almeida, I. Mendonça, P. Silva EXTRAPULMONARY INFECTION CAUSED BY MYCOBACTERIUM TUBERCULOSIS Guisado Vasco P, Calleja Lopez JL, Ruedas Lopez A, Trueba Vicente A, Egea Simon M, MialdeaINTRODUCTION – Brucellosis is a zoonosis provoked by bacteria of Brucella gender. There are M, Moreno Cobo MA, Rodríguez Fernández E, Perez Corral Fmany Brucella species being. The species Brucella Melitensis (ovine and caprine), Brucella Suis(suine), Brucella Abotus (bovine), and Brucella canis (dogs). In our country the prevalent species Background: tuberculous peritonitis is a main differential diagnose in patients affected with fever, asci-is Brucella Melitensis and the disease is presented with assymmetric changes related to farm ani- tes and abdominal pain of uncertain origin. It is frequently associated to immunocompromised status.mal growing and tadings being northeast the district with highest incidence rate. OBJECTIVE – Our objective is to describe the clinical variability presentation and usefulness of imaging and micro-population analysis of patients with Brucellosis according to clinical onset and course, diagnostic biological techniques. Method: we found 8 cases found in the clinical database from the departmentapproach and therapy. MATERIAL AND METHODS – retrospective study of the clinical files of of internal medicine of the University Hospital Ramón y Cajal. All selected patients were HIV negativediseased with diagnosis of Brucellosis and admitted in our Hospital during the period from January and non-cirrhotic. Material: fever and diffusely distended tender abdomen was the most common pre-2000 to December 2005. Age, sex, occupation, form of presentation, infective source and focus, senting feature (n=7). These symptoms were associated in decrease order of frequency to: weight lossduration of treatment and its complications were considered. RESULTS – a total of 33 cases were of 2.5 kg/per month (n=6), anorexia and asthenia (n=3), cough (n=2), legs swelling or constipation. Tworegisted, with average age of 47 years old (ranking from 16 to 74 years old) being more frequent patients previously had pulmonary tuberculosis and one case suffered from erythema nodosum (onein male gender (67%). CONCLUSION – Brucellosis continues to be an endemic zoonosis in our year before abdominal pain onset). Two patients had the initial presumption diagnoses of peritoneal car-country mostly associated with growing farm animals; it should always be considered in the dif- cinomatosis. Symptoms arose in most patients in an average of 28 days (range between 7 and 112 days).ferential diagnosis of a febrile syndrome. Those patients who were born in Spain (n=5) were older (seventh and eighth decade of life), in contrast to those who came from endemic areas, Africa and South America, with a mean age of 24 years. Rou- tine laboratory test showed mild normochromic normocytic anemia (n=7), high erythrocyte sedimen- tation rate (n=3), polyclonal hypergammaglobulinemia (n=4) and a cholestasis hypertransaminasemia pattern (n=4). CA-125 level was high in two cases. One case had moderate to severe hypercalcemia due to ectopic synthesis of 1,25 hydroxi-vitamin D3. Tuberculin test with purified protein derivative (PPD) was positive in four patients. Chest X-ray and thorax computer tomography (CT) showed residual tubercu- losis patterns in just one patient (pleural thickening). Active tuberculosis was found in half of the cases (pleural effusion or apex infiltration). An abdominal and pelvic enhanced CT was made in all cases. It showed ascites (n=6), hypodense centre’s lymph nodes with mesenteric fat engrossment and omental caking (n=3). Splenomegaly was detected in 2 cases. Peritoneal fluid analysis could only be made in two cases, showing relative lymphocytic pleocytosis. Adenosine deaminase was elevated in one case (69 U/L). Examination of acid fast stained smears of ascites fluid was negative in all cases. In five patientswas performed a laparoscopic abdomen examination. It showed peritoneal thickening and multiple whitish nodules. Hystologic examination of parietal peritoneum and lymph nodes biopsies showed necrotizing granulomas in all cases. Auramin stains of tissue biopsies detected bacilli in three cases. Nucleic acid am- plification (NAA) through MTD method to detect Mycobacterium Tuberculosis genome was done n fove patients. It showed positive results in four cases. Culture made on Coletsos and Lowenstein Jensen of tissue biopsies, ascites or pleural effusion was positive in three cases. Tuberculostatic multidrug therapy was started in all patients. On a regular basis, fever withdrew in the first week and progressive general improvement began after 4 weeks of treatment. All patients had a good clinical outcome, except one who died due to urine Gram-negative sepsis. Conclusions: acute abdominal tenderness and fever should be considered as an initial manifestation of tuberculous peritonitis. In young patients who came from endemic areas with abdominal tenderness, fever and ascites, tuberculous peritonitis should be early ruled out. The inland patients are most commonly elders. CT imaging described appropriately main fea- tures of this disease (ascites, omental caking, lymph nodes). Laparoscopic exploration of the abdomen and puncture under radiological control are the most reliable techniques to both microbiological and pathological diagnosis. Pleural effusion is the most affected site of disease extension. Good clinical out- come could be achieved in immunocompetent patients affected by tuberculous peritonitis, on the basis of an early and accurate diagnosis. 52
  • 56. 5. ACUTE BACTERIAL MENINGITIS IN ADULTS: TEMPORAL ASSOCIATION 6. CARDIOVASCULAR RISK ASSOCIATED TO HIV INFECTION IN MADRIDBETWEEN INITIATION OF PARENTERAL ANTIBIOTIC THERAPY AND Fernández Amago M.T., Torres do Rego A., Sanchez Conde M., Lopez Bernaldo de Quiros J.C.CEREBROSPINAL FLUID STERILISATIONBrian F. Menezes, Gavin Francis, Thomas Solomon BACKGROUND: The incidence of acute myocardial infarction (AMI) has experimented an im- portant increase during last years in HIV infected patients comparing to the non-infected onesIntroduction We attempted to evaluate cerebrospinal fluid(CSF) sterilisation after commencement where the incidence is decreasing. The antiretroviral treatment (ART) has changed the prognosisof parenteral antibiotic therapy in meningitis in adults, particularly in those with high likelihood of of HIV disease, increasing the survival rate and improving life quality for patients. Nevertheless re-acute bacterial meningitis(ABM), and to ascertain causes of delay in lumbar puncture(LP). Methods ciently have been published some data associating ART with an increase in peripheral artery andPatients discharged from a hospital over 3 years with a diagnosis of meningitis were identified and coronary disease, specially in those patients receiving Protease Inhibitors treatment that are asso-records of those fitting the following case definitions were retrospectively reviewed- Adult me- ciated with an increase in the incidence of methabolic changes and body changes than in gene-ningitis: Clinically meningitic patients aged >/=15years with CSF pleocytosis(>4leucocytes/ml), Li- ral population are related to an increase of cardiovascular risk In recient studies it´s suggestedkely bacterial meningitis: Adult meningitis cases fitting criteria of Chavanet et al for meningitis of that HIV virus can participate in the develope of atherosclerosis independently than other car-likely bacterial aetiology, Culture positive ABM: Adult meningitis cases with positive CSF cultures. diovascular risk factors. OBJETIVE: To describe the Cardiovascular Risk Factors associated to ische-Results 92 cases of adult meningitis confirmed by CSF analysis were identified, 16 being culture mic cardiopathy in HIV infected patients as well as calculate and compare the Framingham tenpositive ABM. All culture positive cases were detected when LP was performed <8 hours of the years cardiovascular risk between these patients. MATERIAL AND METHODS.: Sample of 244first parenteral antibiotic dose and >/=8 hours later, no culture positive cases were identified. 24 HIV-infected outpatients followed up in our consults in Gregorio Marañon Hospital.. We selectedcases of likely bacterial meningitis were detected. 8 of these cases had sterile CSF. However, 6 of patients without ischemic cardiopathy history and they were invited to voluntarily fill a form. Wethese were noted to have had LP >/=8 hours after initiating parenteral antibiotic therapy (statisti- used Framingham score risk table to calculate the patients ten years cardiovascular risk . RESULTS:cally significant). The commonest reason for delay in LP was performance of cranial computeri- We analyzed 244 patients, 176 (72,1%) were males, medium age 49,14 years old, 125 ( 51,22%)sed tomography(CT). However, in 68% of these, it was not clinically indicated. CT was normal in sexually infected, 55 (22,5%) patients C stage, average CD4 504, 188 patients (77%) with inde-nearly all who underwent inappropriate scanning. Conclusions When meningitis is suspected, LP tectable viral load, 196 patients on ART. 4,9% were diabetic, total cholesterol 202,37, HDL 52 ,should be performed within 8 hours of initiating parenteral antibiotics to prevent missed diagno- LDL 106,7 and triglicerides 161,04. 64,8% tobacco smokers. The 4% of patients had Framinghamsis due to early CSF sterilisation. Inappropriately requested CT delays LP and is invariably normal. risk >15%, the 33% had cardiovascular risk between 5-15% and the rest 63% had <5% risk. A value of Framingham risk &#8805;5% is significantly associated to the age, male sex and high cholesterol levels. There are not significant differences in cardiovascular risk between patients on ART or without ART, and we didn´t find differences in cardiovascular risk between patients trea- ted with Protease Inhibitors or with Non Nucleosides. CONCLUSION: Cardiovascular risk in HIV infected patients in Madrid is high. There are not significant differences in cardiovascular risk bet- ween patients on the different antiretroviral regimens. However there are significant differences related to the age, male sex and high cholesterol level.7. CLINICAL FEATURES AND OUTCOME OF PATIENTS WITH VASCULAR 8. HEALTHCARE-ASSOCIATED PNEUMONIA AS A NEW CLINICAL ENTITY:PROSTHESES INFECTION RESULTS OF A PROSPECTIVE, OBSERVATIONAL, MULTICENTER STUDYEmanuele Durante-Mangoni, Cristina Caianiello, Enrico Ragone, Daniela Pinto, Rosina Albisinni, FROM ITALYFrancesco Crispi, Riccardo Utili Marco Falcone, Mario Venditti, Salvatore Corrao, Giuseppe Licata, Pietro SerraThe growing number of vascular prosthesis implants has been paralleled by an alarming increase Background: Traditionally, pneumonias have been classified as community or hospital acquiredof prosthesis infection rates. Besides single case reports, there are no meaningful case series de- (CAP or HAP, respectively). Health care–associated pneumonia (HCAP) has been recently pro-scribing etiology, clinical course and complications of vascular prosthesis infection. From Jan 04 posed as a new category of respiratory infection. However, limited data exist to validate this en-to Dec 07, 10 pts with vascular prosthesis infection (6 abdominal aorta, 2 ascending aorta, 2 iliac tity. Aim of this study was to ascertain the epidemiology and outcome of CAP, HCAP, and HAPartery) were admitted to our referral centre for cardiovascular infections. Median age was 71 y. in patients hospitalized in Internal Medicine wards. Methods: Data from all patients with CAP,(37-81), all were males. The median time from implant to onset was 3 y. (0.2-31). 80% had ische- HCAP, and HAP hospitalized in medical wards of 55 Italian hospitals during an active 1-week sur-mic heart disease, 20% dilated cardiomiopathy. CV risk factors were: hypertension 90%; diabe- veillance performed from January 22 to January 29 and June 25 to July 2, 2007, were prospec-tes 20%; impaired fasting glucose 30%; dislipidemia 40%; obesity 20%. Cultures were positive tively collected. Patients who had recent contact with the health care system through nursingin 9 pts, the infection was polymicrobial in 5. Blood cultures were positive in 90% cases. Culture homes, hemodialysis clinics, or prior hospitalization were considered to have HCAP. Results: Du-of explanted material showed the same bacteremic pathogen in 75% of operated pts. Gram-po- ring the periods of study, 362 episodes of pneumonia were observed. Of these, 223 patientssitive organisms were grown in all pts, gram-negatives were found in a third of them, a multi-drug (61.6%) had CAP, 90 (24.9%) had HCAP, and 49 (13.5%) had HAP. Compared to CAP patients,resistant organism in 1 case. Diagnosis was corroborated by a positive leucocyte or PET scan in HCAP patients were more commonly classified into high-risk pneumonia severity index classes40% and 20% of cases, respectively. Multislice CT or GI-endoscopy disclosed aorto-enteric fistu- (p< 0.01), had a higher incidence of malnutrition (p<0.01), a more frequent bilateral involvementlas in 4/8 intra-abdominal infections. The therapeutic approach was conservative with targeted, at radiographic examination (p= 0.01), received more frequently a gastric acid-reducing agent orlong-term suppressive antibiotic treatment in 50% of cases, mostly due to high operative risk aerosolized drugs (p<0.01), and were less frequently febrile at admission (p= 0.01). The occur-owing to pre-existing heart disease. None of these pts died during a median follow up of 18 mo rences of S aureus in the HCAP and HAP groups were significantly higher than in the CAP group,(6-36). Urgent/elective surgery was performed in 5 patients, 2 of whom (40%) died intraopera- while predominated S. pneumoniae. HCAP patients were more likely to receive an unadequatetively. Vascular prosthetic infections are potentially lethal complications believed to require pro- antimicrobial therapy (p<0.01), and had a length of hospital stay (LHS) significantly higher thansthesis removal for cure. A satisfactory outcome was obtained with conservative treatment, and CAP patients (p<0.01). Mortality rates associated with HCAP (17.7%) and HAP (18.3%) were notthere were no major antibiotic-resistance issues. When antibiotics fail to control sepsis or there is significantly different from each other. Both were significantly higher than that of CAP (6.7%, p<impending rupture in the GI tract, the high risk surgical option seems justified. 0.01). Conclusions: HCAP should be considered as a new single entity that is associated with a higher severity of disease, a greater LHS, and a higher mortality rate. 53
  • 57. 9. DIARRHEAS CAUSED BY CLOSTRIDIUM DIFFICILE. A FIVE YEARS 10. PLEURAL SPACE INFECTIONSRETROSPECTIVE STUDY (2003-2007) FJ Fernández-Fernández, L González-Vázquez, R Puerta-Louro, J de la Cruz-Álvarez,A. Carrero Gra , M. Cepeda González, E. Ferreira Pasos, S. Hernando Rea, P. Carrero González, S Pérez-Fernández, J de la Fuente-AguadoI. León Gaitán, J. Elízaga Corrales, J. Moreno. Palomares, B. García López Introduction: Parapneumonic effusion is any pleural effusion secondary to pneumonia or lungOBJECTIVES: To describe the epidemiological characteristics of Clostridium difficile colitis during abscess. Complicated parapneumonic effusion is characterized by fibrin deposition, and it diffe-five years in the General hospital of Segovia and the general outcome of our patients with anti- rentiates from uncomplicated effusion on the basis of pleural fluid analysis. Empyema is definedbiotic therapy. MATHERIAL AND METHODS: We reviewed all the requests done to our Mi- by the presence of pus in the pleural space; it can develop as a complication of pneumonia, orcrobiology laboratory during those five years. They had registered 700 forms, 61 of them had may follow surgery, trauma or other causes. We describe the clinical aspects of complicated pleu-been positive. The diagnosis method use in our laboratory is the detection of Toxin A and B by ral infections, focusing on their presentation and management. Methods: Retrospective and de-inmunoassys tests. We did a formulary to pick up the facts that were relevant and we analysed scriptive study of the medical records of all patients diagnosed of complicated parapneumonicjust the case histories of patients with a positive result in the test for C. difficile. All our results were effusion or empyema in POVISA between 2002 and 2007. Patients were included if they had anyanalysed by SPSS, the statistics program. RESULTS: The 61 positive results that we got were of these characteristics: pleural fluid with pus, pH <7.2, glucose <60 mg/dl, positive Gram stain orfrom 57 patients and we were able to complete in an appropriate way the form in 41 cases. The positive culture. Patients with tuberculous pleural effusion were excluded. Results: Forty-eight pa-rest were from non hospitalised patients or data were incomplete. The 56% of the sample were tients (38 males, mean age 53) were included. An underlying disease was present in 48%: can-women and the 44% were men. 78 years was the age average (SD 17.5). 10% of the requests cer in 10, neurological disease in 6, diabetes mellitus in 4 and injection drug use in 3 patients. Ofwere from ambulance patients, the majority of the rest ones were from medical services (75%) the 48 patients, 71% were parapneumonic, trauma was the cause in 12% and 8% were posto-and just the 14% were from surgical services. Community infections were diagnosed in 32% pa- perative. The most frequent clinical manifestations at diagnosis were fever (60%), thoracic paintients and nosocomial ones in 68% (more than 72 hours hospitalised). 41%patients had fever and (60%), cough (39%) and dyspnea (31%), with a mean duration before diagnosis of 10 days. Leu-just 12% had leukocytosis. The majority of cases were catalogued as inespecific colitis. We just kocytosis was present in 94%, and erythrocyte sedimentation rate and C-reactive protein were ele-had two cases of fulminate colitis. 40% of patients had history of serious disease (oncological pa- vated in 100% of the evaluated patients. Pleural fluid showed the following results: pus in 65%,thology) and 51% were inmunosupressed patients (15% were being treated with chemotherapy, pH <7.2 in 80%, glucose <40 mg/dl in 62% and <60 in 81%, LDH >1 000 IU/L in 78%, mean14% were receiving corticosteroid therapy, the 38% were diabetic, 19% were being treated with cell count 52 368 (median 12 250), and positive Gram stain in 11 patients. The agent etiologicimmunosuppressant drugs…) Just the 7.3% had inflammatory bowel disease. Half of our patients was identified in 23 patients. Pleural fluid culture was positive in 49%, and blood cultures in 10%.had been hospitalised for more then 15 days when they were diagnosed. More than 50% were Isolated pathogens were gram-positive cocci in 16 patients (streptococci in 10), anaerobic bacte-being treated with inhibitors of proton bomb. 83% had received antibiotic therapy, 67% of these ria in 6 and gram-negative bacilli in 5 patients. Antimicrobial therapy with resistance <20% werewith one antibiotic and the rest ones had received 2 or more. About patients treated just with cefotaxime, imipenem, piperacillin-tazobactam, clindamycin and aminoglycosides. Tube thora-one drug, in the 35% it was with penicillin (Carbapenem, cephalosporim and betalactamic alone scostomy (8- to 10-F pigtail) was performed in 47 patients, and intrapleural fibrinolytics were ad-or with betalactamasas). The combination of antibiotics more used was penicillin with quinolo- ministered in 22 patients, always for loculated parapneumonic effusions. Decortication wasnes. Intravenous way was used 67%. 75% of patients received specific treatment with metroni- performed in 11 patients. Mortality rate was 6% and there were no poor prognostic factors iden-dazole and in 82% of cases the responsible drug was retired. Antiperistaltic drugs were used just tified. Conclusions: Most of complicated pleural space infections are secondary to pneumonia,in 14% cases. We had few complications, just 4 cases, 3 of them were an acute abdomen and and usually they occur in patients with debilitation and comorbid diseases. Most frequently in-1 paralytic ileous. In 20% of cases an endoscope were done. CONCLUSIONS: Our register is volved pathogens are microaerophilic streptococci and anaerobes. Antimicrobial therapy associa-very similar to the ones describe in other series. Its majority is about patients than were recei- ted with drainage of the complicated effusion, usually by small tube thoracostomy, has improvedving wide spectrum antibiotic therapy. They had a good outcome with specific treatment and we the prognosis. The association of third-generation cephalosporins with clindamycin may be hi-had a few number of complications. ghly effective as empiric initial therapy. 54
  • 58. Oral Communications Fryday, May 9, 2008 GERIATRICS
  • 59. 1. CENTER FOR RESEARCH AND CARE OF AGING: A STRATEGY FOR AN 2. THE CONTRIBUTION OF CEREBRO-VASCULAR PATHOLOGY TO THEINTEGRATE APPROACH PATTERN OF COGNITIVE FUNCTIONING IN ELDERLY WITH MILD COGNITIVEMari D, Fatti L, Micale G, Ogliari G IMPAIRMENT (MCI) L. Bergamaschini, G. Mosca M. Zanetti, C. Abbate, A. Casè, C. Bilotta, C. VerganiThe effects of longevity, real revolution of this century, are producing a significant impact on so-cial and public health programs, on family life, economy, job placements and training of health Microvascular brain injury, typically measured by reduced cerebral blood flow and vasomotor re-care employees. Center for Research and Care of Aging is an organical structure which tries to activity (systolic peak velocity before and after maximal breath-hold, minimum 15 seconds) (CO2-face up to preventive medicine with a close connection with Family Medicine, through a broad VMR), is believed to be an important determinant of cognitive impairment in the elderly. Aim. Inrange of innovative and comprehensive programs in clinical care and education, closely related study was to determine whether CO2-VMR, as measured by transcranial Doppler sonographyto biomedical research. The structure is an University Training Center for junior faculty of Medi- (TCD), may contribute to a better characterization of MCI subtypes in elderly. Method. In thiscine, Nursing , Biotechnology and for Postgraduate students in Geriatric Medicine . Continuing cross-sectional study 11 subjects with amnesic MCI (aMCI) and 54 with multiple domains MCIMedical Education (CME) program in Geriatric Medicine and in Geriatric Rehabilitation is yearly (mcdMCI) underwent clinical, neuropsychological, neuroradiological and CO2-VMR evaluations.planned. The organical stucture extends for 30.000 sq.m. downtown in Milan, provides at the Seventy subjects without cognitive impairment, with (n=50) or without (n=20) vascular risk factorsground floor a variety of clinical services, radiology, an ambulatory care center with over 3000 pa- (VRF), served as controls. Results. Controls: CO2-VMR test was normal (+ 20%. or more, of basaltients weekly (80% are over 65 years old; at the first floor are simmetrically located a 12-bed in- value) in subjects without VRF and it was significantly higher (p < 0.01) than the values measu-patient Acute Care for the Elderly Unit and 4-bed and DH 18-bed inpatients Rehabilitation Unit red (+10% or less, of the basal value) in subjects with VFR. Patients: CO2-VMR was normal or sli-and 15-bed DH.Long-term care services are provided three floors up, in a 160-bed teaching nur- ghtly reduced in patients with aMCI; in 36/54 (66%) mcdMCI subjects CO2-VMR was below thesing home with high standard of medical care. Patients with requiring intensive care can be ad- normal value, and was similar to the values measured in control subjects with VRF; in those pa-mitted to Coronary Care Unit and Stroke Unit in the same hospital. This structure also provides tients reduced C02-VMR was associated with worse performance in tests of executive functions.4000 sq.m. of laboratories dedicated to diagnostic assays and to research on neurobiology, en- Normal C02-VMR was found in the remaining 18/54 (33%) mcdMCI patients, of whose 9 (50%)docrinology and metabolism, cardiovascular diseases, immunological disesases and longevity lin- had memory impairment as major tool (amnesic mcdMCI). Conclusions. 1) C02-VMR is reducedked to both a clinical department and a basic science department, to promote our goal of building in mcdMCI patients and can be readily seen at an early stage of disease; 2) C02-VMR evaluationa strong basic science program devoted to the study of clinically-relevant issues related to aging. may provide data suitable for discriminating vascular from degenerative MCI; 3) decreased C02-Clinical geriatric researchers are working on search adequate tools for a good management of VMR may be a key element in disease evolution.older patients with multiple chronic conditions, to better define diagnostic and therapeutic cour-ses of a given individual. Electronic health records (EHR) are being developed to improve com-munication as health information follows patients from one care setting to another (Acute care andRehabilitation Unit, Nursing home) reducing fragmentation of services for seniors transitioningfrom one level of care to another and from one health care system to another. EHR systems mustaccommodate information germane to a senior frail population, including, but not limited to, fun-ctional assessments, cognitive assessments, and information on advance directives to correctlychoose location and practice setting of patients. The EHR should provide prompts on preventionrelevant to seniors and on potential errors, e.g. drug-drug interactions or excessive dosing, spe-cific for older adults. References: Frist WH, Health Care in the 21st Century. N Engl J Med2005;352:267-72.3. COMPLEX DIAGNOSIS IS FREQUENT IN THE ELDERLY PATIENTS WITH 4. AN AUDIT OF THE MANAGEMENT OF IRON DEFICIENCY IN AN ELDERLYYNCOPE. RESULTS OF AN OBSERVATIONAL STUDY ON OUTPATIENTS POPULATIONWITH SYNCOPE EVALUATED WITH NEUROAUTONOMIC TESTS Adrian Blundell, Adam GordonA. Morrione, A. Landi, A. Maraviglia, F. Caldi, T. Cellai, M. Ciompi, C. Golzio, M. Rafanelli,V. Chisciotti, N. Marchionni, G. Masotti, A. Ungar Introduction The British Society of Gastroenterologists has developed guidelines for the mana- gement of iron deficiency anaemia (IDA). They suggest that all older patients with proven IDA (wi-Aims: to evaluate diagnostic value of autonomic tests in relation with age, to evaluate predictors thout overt blood loss) should be fully investigated while appreciating that the appropriateness ofof neuromediated syncope and the presence of complex diagnosis in patients with syncope unex- such investigations in patients with severe co-morbidities and advancing age needs to be carefullyplained after initial evaluation. Methods: indication to neuroautonomic evaluation were: 1. first considered. Our aim was to determine if these guidelines were being followed appropriately inline evaluation - history, physical examination and ECG – suggestive of neurally-mediated syn- an elderly population. Method Retrospective case note review of iron deficient patients (ferritincope; 2. first line evaluation suggestive of cardiac syncope excluded after specific diagnostic tests; <30&#61549;mg/L) over a 12 month period. Results 46 cases reviewed (39 female). Mean age3. none certain or suspected diagnostic criteria after the first line evaluation. All patients were eva- 81 (range 65-97). 34 patients admitted from home, 9 from residential home and 3 from nursingluated with neuroautonomic tests: Tilt Table Test (TTT) potentiated with sublingual nitro-glyce- home. 34 asymptomatic patients and 24 prescribed aspirin. Mean Hb 10.37 (range 4.7-15.1).rine, Carotid Sinus Massage (CSM) in supine and up-right position and Orthostatic Hypotension Only 22 (48%) patients were offered some form of investigation. 6 (13%) patients had clear do-(OH). Results: we enrolled 873 consecutive patients (373 men and 500 women, mean age cumentation that further investigation was inappropriate and 7 (15%) had investigation deferred66,5&#61617;18 years). 584 (mean age 77,2±7 years) were aged 65 and older. Neuroautonomic (commenced on iron supplementation). 11 (24%) patients had no investigations. 16 patients hadevaluation was diagnostic in 64,3% of the cases (64,7% in younger vs 64,2% in older, p=ns). upper GI tract visualised but only 9 had bowel imaging and only 8 had coeliac serology checked.TTT was diagnostic in 50,4% of the cases, CSM was diagnostic in 11,8% and OH was present in Only 1 cancer was detected. Conclusion The BSG guidelines were not followed in 24 (52%)19,9% of the cases. Vasovagal syncope had a similar distribution in any decades of age. Predic- cases. In 11 of these patients there was no documentation of the rationale for deviating from gui-tors of a positive response to TTT were the presence of prodromic symptoms and a typical si- delines. It is clearly not always appropriate to intensively investigate elderly patients with iron de-tuational syncope. The presence of a positive response to CSM increased with age; age and ficiency anaemia but decisions regarding this must be considered carefully and documentedabnormal ECG were predictors of a positive response to CSM. Venous incontinence and alpha appropriately. Using ferritin as the only marker of iron deficiency in our cohort detected a largeblockers, nitrates and benzodiazepines therapy resulted associated with the presence of OH. 129 number of asymptomatic individuals with only one malignancy found. We intend to institute a local(23%) patients presented a complex diagnosis. The most frequent association resulted the coe- policy of documenting decisions regarding iron deficiency anaemia clearly and will incorporate tea-xistence of vasovagal syncope and OH (15,8% of the cases). Complex diagnosis was present in ching on BSG guidelines into the postgraduate curriculum. The audit will be repeated annually.42,9% in patients aged 80 and older; age was the strongest predictor of complex diagnosis. Con-clusions: neuroautonomic diagnostic tests are very useful in patients with unexplained syncopeafter initial evaluation, both in young and older. Complex neuromediated diagnosis is very fre-quent in older patients. 56
  • 60. 5. PULMONARY EMBOLISM IN ELDERLY 6. DETRIMENTAL EFFECT OF LOOP DIURETIC THERAPY IN A GERIATRICR Castelli, L. Bergamaschini, F Porro, G. Pantaleo A. Guariglia POPULATION Franco Carmassi, Ferdinando de Negri, Antonio De Giorgi, Ferdinando PentimoneThe risk of venous thromboembolism increases with age. Pulmonary embolism (PE)on the otherhand, can be difficult to diagnose in the elderly. We compare risk factors, clinical features in two Standard treatment of heart failure relies on loop diuretics and ACE inhibitors; evidence suggestsage groups (< 65 and > 65) of patients with suspected PE in the emergency department (ED). First that the joined use of aldosterone antagonists and beta blockers decreases morbidity and mor-level evaluation (including risk factors, clinical presentation, Wells score and Cumulative Illness tality in patients in NYHA class III-IV. However, the increase of angiotensin 2 and aldosterone ob-Rating Scale [CIRS]), second level examinations (including four-slice spiral computed tomography served during chronic use of loop diuretics quenches the sodiuretic effect because of[sCT] in most patients), in-hospital mortality and three month follow-up, were retrospectively com- sodium-sparing forces arising in the volume-deprived kidney. Because of dehydration and tissuepared in < 65 and > 65 yrs old patients with suspected PE visited in ED. 582 patients were stu- hypoperfusion a prothrombotic state and overt ischemic events are seldom detectable in elderlydied, of whom 180 aged < 65, with PE confirmed: 31.6% and 402 > 65, with PE in 43,7% of cases. patients under therapy for heart failure. We evaluated the neurohormonal profile and cardiacAge was directly related to the diagnosis of PE (p <0.007), with observed probability > expected ejection fraction in 20 elderly (age >65 yrs) patients with chronic heart failure (NYHA class II-IV),probability in the 70-79 year subgroup. CIRS score increased as a function of both age (p<0.001) assuming loop diuretics, ACE inhibitors, beta-blockers and low doses of spironolactone. The neu-and PE (p< 0.007). Dyspnea, syncope and jugular distension were more frequently observed in rohormonal profile (serum epinephrine, norepinephrine, renin, aldosterone, angiotensin 2; urinaryolder patients. Malignancy was related to PE in young patients (p< 0.05), previous thromboem- aldosterone) was evaluated basally and 5 weeks and 6 months after loop diuretic interruption. Atbolism in the old ones (p< 0.03). In-hospital mortality rate among the elderly and younger patients the same interval thrombotic markers (thrombin-antithrombin complexes, F1+2 fragment and D-was respectively 2% and 0.2% Age > 65 and comorbidity are risk factors for PE in ED patients. dimer) were assayed. NYHA class and ejection fraction were evaluated after 6 months. Serum le-Dyspnea, syncope and jugular distension are observed more frequently in older patients with vels of renin, angiotensin-2, aldosterone, epinephrine, norepinephrine, as well as 24-h urinaryPE.In-hospital mortality due to venous thromboembolism increases in advanced age patients . aldosterone excretion were significantly reduced (p<0.01 vs basal levels) 5 weeks as well 6 months since diuretic interruption. An almost normalization of thrombotic markers was also observed. A relevant improvement of NYHA class and ejection fraction was evident after 6 months in all pa- tients. The results show that an inappropriate diuretic therapy may induce a neurohormonal acti- vation, which is not completely quenched by the aldosterone antagonist spironolactone. The increased levels of cathecholamines, angiotensin and aldosterone are associated with a pro- thrombotic state, which improves with the suppression of neurohormonal activation.7. SHORT-STAY UNITS AS AN ALTERNATIVE TO INTERNAL MEDICINE FOR 8. GLOBAL GERIATRIC ASSESSMENT OF VERY OLD PATIENTS IN AELDERLY PATIENTS WITH DECOMPENSATED HEART FAILURE MEDICINE WARDChivite D, Salazar A, Pujol R, Alonso J S. Duque, J. Silvestre, P. Freitas, I. Reis, A. Martins, C. Vieira, F. Grenho, A. Lourenço, V. Batalha, L. CamposBACKGROUND: For patients with acute, decompensated heart failure (DHF) Short-Stay Unit(SSU) admissions have become complementary to those to conventional Internal Medicine Ser- Introduction: The prevalence of very old patients (pts) admitted in the infirmaries is growing, whichvices (IMS) However, whether admissions to a SSU because of DHF pose a risk towards an in- stresses the importance of a multidimensional global geriatric assessment (GGA). Previous studiescrease in morbimortality, readmission or poor disease control remains unknown. AIMS: to have demonstrated the effectiveness of GGA at identifying pts at risk, so as to prevent their fun-compare the in-hospital process of care and short – to mid- term outcomes of patients admitted ctional and cognitive deterioration, and an eventual re-admission. Objectives: GGA of very old ptsto a SSU because of DHF with those of patients admitted to an IMS for the same reason. ME- (&#8805;85 years) admitted to a Medicine ward of a central hospital. Methods: in a cross-sec-THODS: randomized observational study. Patients evaluated at the Emergency Unit of the Ho- tional study, a GGA was performed for 3 months through the application of the following scales:spital Universitari de Bellvitge because of DHF who fulfilled admission criteria to the SSU (acute Charlson Index (CI), Barthel (BS), Lawton & Brody (LBS), Yesavage Geriatric Depression (YGDS),DHF not complicated, clinical stability, moderate comorbidity, moderate disability) were randomly and Mini Mental State Examination (MMSE). Clinical and sociodemographic characterization. Re-distributed at the time of admission between the SSU and the IMS. Baseline and process-of-care sults: 18 pts were included, 2 excluded. The prevalence of very old pts was 23% (20/86); 78%data were recorded during the index admission. Both cohorts were prospectively followed during were female, average age 89 years. The average length of hospital stay was of 60 days; 28% hada year – data regarding morbimortality, functional status, quality of life, exercise capacity and con- a prolonged stay due to social problems, with an average additional 45 days. Respiratory infec-trol and knowledge of the disease were collected. Index admission plus follow-up costs were also tion (44%) and cerebral vascular accident (33%) constituted the main reasons for admission. 39evaluated. RESULTS: within a 10-month period 140 patients (SSU=70, IMS=69) were included in % had CI 1, 22% - 2, 22% - 3, 17%&#8805;4. Concerning BS, 61% presented mild dependencythe study – no relevant differences were found neither in their baseline status (demographic data, for daily life activities (DLA), and 11% were totally dependent. According to LBS, most of the ptscomorbidities, HF story, cognitive and functional status), nor in the characteristics of the DHF epi- presented a great dependence for instrumental DLA (iDLA) (LBS &#8804;2). Through the YGDS,sode (precipitating factors, admission features, complications, in-hospital mortality, readiness for 13% had severe depression, 47% mild depression and 40% without depression. According todischarge) except for a higher number of examinations performed during admission to the SMI the MMSE 53% did not present cognitive defect. The level of dependency for the DLA correla-(4.04 vs 8.97 days, p < 0.05), as were total hospital costs (633.48 vs 2081.28 €/patient, p < 0.05)patients. SSU patients’ length of stay was significantly lower than that of those admitted to the IMS ted with the comorbidity and cognitive defect. Conclusions: It was verified that the prevalence of admitted very old pts was elevated. Most pts had high comorbidity, preserved cognitive functions,During the follow-up, a trend towards higher readmission rates was found among patients di- depressive mood, and dependency in iDLA with compromised autonomy. The use of screeningscharged from the SSI (proportion of patients with at least one or more readmissions: 16% at 28 scales allows for the identification of risk groups and the implementation of preventive strategies.days, 29% at 3 months, 41% at 6 months and 46% at 12 months vs 10, 23, 30 i 39% for IMSpatients, respectively). No other significant differences were found during the follow-up regar-ding mortality, quality of life, functional status, exercise capacity, quality of care, or disease kno-wledge and self-care abilities, or outpatient and readmission costs. CONCLUSIONS: for elderlyheart failure patients with rather preserved social, cognitive and clinical status presenting with anuncomplicated decompensation, admission to the SSU because of DHF is safe and cost – effec-tive, and may be considered a good complement to conventional admissions to the IMS. 57
  • 61. 9. INFLUENCE OF GERIATRIC INPATIENTS’ DELIRIUM ON 12-MONTH’S 10. STUDY ABOUT THE ACCEPTANCE OF INFLUENZA VACCINES BY CAREMORTALITY GIVERS IN A GERIATRIC AND LONG-TERM-CARE INSTITUTION: FOR THEParra N, Cerdà M, Contreras O, Sort D, Carral E, Lozano A, Rosell F IMPROVEMENT OF VACCINATION COVERAGE AMONG HEALTHCARE PROFESSIONALSObjective: to evaluate the influence of geriatric inpatients’ delirium on 12-month mortality po- P. Pina, A.L. Moreau, O. Sadeg, A. Teixeirastdischarge. Methods: a prospective cohort study on 235 geriatric inpatients admitted to our Uni-versity Hospital during the first quarter of 2006 has been undertaken. Baseline-measurements Introduction: seasonal influenza is a viral transmissible infectious disease causing increased mor-included data about functional, emotional, cognitive and socio-economical status, as well as sco- bidity or mortality in frail subjects, especially those living in institutions. Efforts to prevent the im-res for severity of chronic and acute illness through an accorded protocol for complete geriatric pact of infectious diseases were proposed based on the use of influenza vaccination amongassessment. Likewise, the presence of delirium was screened by means of an adaptation of the healthcare professionals. We wanted to evaluate the acceptance of our institutional vaccination pro-Confusion Assessment Method. Patients developing delirium during the first 48 hours after ad- cedure initiated in 2005 and the possibility of its improvement. Methods : a questionnaire wasmission and those who died during hospitalization were excluded. After discharge patients were delivered in May 2007 to all healthcare professionals (n = 730) to identify their current vaccinefollowed up for one year. Mortality during the 12 months after enrollment was analysed with the status in 2006, and their opinion concerning the vaccination against influenza in 2007. Results :Cox proportional hazards model. Statistics were performed using SPSS 12.0. Results: during ad- 369 (50.2 %) responses were obtained. 31.7 % of those responding were vaccinated in 2006, 77.8mission 28 patients developed delirium (11.9%). Out of them, 12 (42.9%) died during the follo- % using the institutional procedure. 221 (87.7 %) non-vaccinated healthcare professionals indi-wing 12 months. Mortality in non-delirious patients during the observation period was 14.0% (29 cated their position concerning influenza vaccination: 37 % of them will accept the vaccination inpatients). Unadjusted hazard ratio (HR) of delirium with mortality was 4.6 (CI 95% 2.0 – 10.7) and 2007 (on the condition that our current institutional procedure would be improved), 63 % ofthe adjusted HR was 2.6 (CI 95% 1.0 – 6.8). Among patients without dementia, the effect of de- them will refuse influenza vaccines in spite of any improvement. Conclusion : our study empha-lirium on mortality after adjusting for covariates was stronger (HR 3.3; CI 95% 1.2 – 7.1) than in sizes that the use of an adapted procedure of influenza vaccination among healthcare professio-demented patients (HR 2.2; CI 95% 1.9 – 5.3), although in both cases the relationship was si- nals could improve vaccine coverage. It also emphasizes that a margin of those professionals isgnificant (p<0.05). Conclusions: geriatric inpatients´ delirium is a significant predictor of postdi- still reluctant to vaccination.scharge 12-month’s mortality. Based on our experience, mortality risk is threefold increased indelirious non-demented patients than in patients with neither delirium nor dementia. This rela-tionship is weaker in demented patients. Infradiagnosis of delirium in demented patients mightcontribute to this fact. 58
  • 62. Oral Communications Fryday, May 9, 2008 GASTROENTEROLOGY
  • 63. 1. HEPATIC EXPRESSION OF CYCLOOXYGENASE-2 IN NON-ALCOHOLIC FATTY 2. OXYSTEROLS PLASMA LEVELS CORRELATE WITH CHRONIC LIVER DISEASESLIVER DISEASE E. Mici, S. Petta, V. Diurni, A. Craxì, C. BalsanoL. Giannitrapani, S. Ingrao, M. Soresi, S. Petta, A.M. Florena, V. Di Marco, M. Cervello,G. Montalto BACKGROUND AND AIMS: Hepatic steatosis is a characteristic histological feature of patients with chronic hepatitis C. Steatosis is observed in about 70% of patients with chronic hepatitis C.Background and aims: Non alcoholic fatty liver disease (NAFLD) is a spectrum of disorders ran- Several studies confirm the existence of a relationship between chronic hepatitis C and steatosisging from steatosis to steatohepatitis (NASH), which in turn can progress to cirrhosis, but the mo- and suggest a direct role of the HCV core protein in inducing liver steatosis. Increasing experi-lecular mechanisms influencing the disease progression are still poorly understood. mental data suggest an important role of oxidative stress in chronic liver diseases. HCV infectionCiclooxygenase-2 (COX-2), the inducible isoform of the enzymes that catalyse the prostaglandin is characterized by increased markers of oxidative stress, such as oxysterols, which could be in-synthesis from arachidonic acid, has been described to be overexpressed in the livers of mice volved in the evolution of liver damage. Oxysterols, generated from peroxidation of cholesterolwith methionine- and choline-deficient (MCD) diet-induced steatohepatitis and in patients with are sensitive and specific markers of enhanced oxidative stress. Oxysterols bind to orphan nuclearchronic hepatitis C associated steatosis. The aim of this study was to evaluate the expression of receptors like Liver X Receptors (LXR) alpha (is expressed at particularly high levels in liver) andCOX-2 in a population of subjects with NAFLD/NASH to confirm its possible role as pro-inflam- beta. These receptors form heterodimers with the Retinoid X Receptor (RXR), thus regulatingmatory mediator in metabolic forms of fatty liver disease. Methods: We used 47 formalin-fixed, lipid and lipoprotein metabolism. In the liver, LXR-alpha regulate expression of a number of pro-paraffin-embedded liver tissue samples obtained by needle biopsies from patients with teins involved in cholesterol and fatty acid metabolism, including CYP7A and sterol regulatory bin-NAFLD/NASH (10F/37M), scored for hepatic steatosis, grading and staging according to Brunt. ding element protein 1c (SREBP-1c). In addition, LXR-alpha controls the transcription of severalFive histologically normal livers obtained during surgery of biliary tracts, after receiving written in- genes involved in cellular cholesterol efflux including ATP-binding cassette (ABC)A1, ABC(G1), andformed consent from the patient, were used as controls. The expression of COX-2 was investi- apolipoprotein E. We investigate the relationship between HCV-related steatosis and oxysterolgated by immunohistochemistry. The positive signals for COX-2 were observed in the cytoplasm plasma levels, using a recently developed specific and sensitive mass spectrometry assay to mea-of hepatocytes and scored on the basis of: 1) maximum intensity (i.e. the maximum level among sure oxysterols (7-beta-hydroxycholesterol and 7-ketocholesterol) in patients with HCV infectionall positive cells); 2) dominant intensity (i.e. the level observed in the majority of positive cells); and and steatosis. Patients with HBV infection and liver steatosis have been considered as controls. ME-3) extensiveness (by percentage population) of positively stained cells. The score of each speci- THODS: A Gas-Chromatography/Mass-Spectrometry technique was used for the dosage of oxy-men was the sum of the three parameters (sum of the scores). Results: No hepatic expression of sterol plasma concentration in 30 patients affected by HCV or HBV infection or NAFLD (10COX-2 was shown in the healthy liver. A positive staining for COX-2, ranging from slight to more patients for each group). RESULTS: HCV infection causes a significant increase in plasma oxysterolintense, was shown in almost all the pathologic livers. A significant correlation between higher he- concentration as compared with controls. Plasma oxysterol concentration correlates with liver eco-patic expression of COX-2 (evaluated as sum of the scores) and higher percentage of histologi- genicity (evaluated by ultrasound) and grading and staging of liver fibrosis (revealed by biopsies),cal steatosis (rho=0.31; p<0.05) and with ALT levels (rho=0.48, p<0.001), was found. No significant in HCV-positive patients independently of sex, age and BMI. CONCLUSIONS: The study of thecorrelation was observed between the sum of the scores and grading (rho= 0.29, p=0.056), sta- relationship between HCV and oxidative stress will improve our knowledge on the progressionging, total and HDL-cholesterol, triglycerides, BMI and HOMA. Conclusions: The positive corre- of chronic liver disease, indicating new parameters to be considered when HCV patients undergolation between the expression of COX-2 and ALT levels, even if not paralleled by a similar antiviral therapy.relationship with histological grading, let us hypothesize a possible role of COX-2 as pro-inflam-matory mediator in NAFLD/NASH which may deserve further studies for its use as a marker ofdisease progression.3. EMODIN INHIBITS CELL INVASIVENESS INDUCED BY HCV 4. CLINICAL COURSE OF NIMESULIDE-INDUCED LIVER INJURYB.Buchetti, A.Spaziani , A. Alisi, S. Anticoli, C. Balsano A. Licata, V. Calvaruso, M. Cappello, D. Cabibi, V. Di Marco, C. Randazzo, A. Tuttolomondo, P.L. Almasio, G. Licata, A. Craxì.BACKGROUND AND AIMS: there are several clinical and basic reports about intrahepatic spreadof transformed cells during hepatocellular carcinoma course (HCC). Hepatitis C virus (HCV) is Background & Aim. Nimesulide has been shown to cause a wide range of liver injuries, from mil-the major causative viral agent of cirrhosis and hepatocarcinoma. Systemic chemotherapy for un- dly abnormal liver tests to severe liver damage, including fulminant hepatic failure. We report theresectable or metastatic HCC are quite ineffective. The metastatic capability is related to the mo- clinical course of patients with nimesulide-induced liver injury and evaluate predictors of suscep-dulation of cell adhesion and motility and since the molecular and cellular mechanisms controlling tibility or hypersensivity to the drug. Methods. We reviewed all clinical records of patients with dia-these events are not completely understood we decided to analye them in depth in HCV-related gnosis of drug-induced liver injury (DILI) admitted to our Department from January 2001 toHCC. METHODS: Cells invasiveness was examined by a migration and adhesion assay. We per- October 2005, and constructed a database of data on age, sex, clinical features at onset, bioche-formed western blotting, immunoprecipitation and immuno-fluorescence assays, silencing gene mistry and follow-up. Diagnosis of DILI was based on the presence of at least three of the Inter-expression with specific siRNA molecules for HCV core protein and FAK. Emodin, the cancer cell national Consensus Criteria (J. Hepatol, 1990). DILI was classified as hepatocellular, cholestatic ormigration and invasion inhibitor, was purchased by Sigma. RESULTS: HepG2 cells were used to mixed, mainly according to clinical and laboratory data and liver biopsy was performed only in aestablish HCV-wt (entire genome) and HCV core stable polyclones. Both HCV-wt and HCV core minority of patients. All patients were tested for HAV, HBV, HCV, EBV, CMV serology and for nonprotein induced paxillin and beta1-integrin expression levels increase; no changes were observed organ-specific autoantibodies, ceruloplasmin and ferritin. Results. Forty six patients were dischar-in alpha-actinin expression. IF assay showed a spread beta1-integrin distribution in the cytosol and ged with diagnosis of DILI. 17 of them were considered to be linked to nimesulide. Seven werealpha actinin delocalization from the cytosol to the perinuclear region, in HCV-wt polyclones. HCV men and 10 women, mean age was 58,3 (range 27-87 yrs). Two patient had pre-existing chro-core protein silencing by a specific siRNA completely abrogated HCV-related effects. In addition, nic liver disease, one viral-related chronic hepatitis and one cryptogenic cirrhosis. Eleven out 16Focal Adhesion Kinases (FAK) expression and activity was increased in HCV wt policlones and patients had jaundice at the diagnosis; all patients had elevated ALT ranging from 3 to 80 u.n.l.;HCV core protein; HCV core siRNA re-estabilished FAK basal levels in these cells. Interestingly, 3 out of 17 patients developed severe hepatic failure with encephalopathy and/or ascites. All pa-FAK siRNA targeting only partially reverted the HCV focal adhesion deregulation, whereas emo- tients had hepatocellular or mixed liver damage. Liver biopsies in 5 patients showed centrilobu-din completely abrogated it. CONCLUSIONS: Emodin counteracting HCV related adhesion mo- lar or panlobular bridging necrosis with mild intrahepatic cholestasis. Nimesulide-inducedlecules alterations could be considered as a valid alternative to the therapeutic approaches to date autoimmunity (diffuse ANA 1:160, M2 AMA 1:320) was found in one women. One patient withavailable. liver failure died while on waiting list for liver transplant. In all other patients, liver tests returned to normal values within follow-up period (mean 22 months, range 12-48). Conclusions. Nimesu- lide is a common cause of DILI, which is usually reversible upon discontinuation of the drug but occasionally it may progress to severe hepatic failure. Even in cases with long-lasting clinical course, nimesulide-induced liver damage does not progress to cirrhosis but its clinical outcome cannot be predicted by pre-existing liver disease. 60
  • 64. 5. AUTOIMMUNE CHRONIC ACTIVE HEPATITIS: ANATOMOCLINIC’S STUDY OF 6. LOSARTAN INCREASES IL-10 IN CHRONIC LIVER DISEASE13 PATIENTS Szantova M, Turecky L, Petrakovicova Z, Uhlikova E.Ilhem BenJazia, Mabrouk Khalifa, Neirouz Ghannouchi, Wissem Hachfi, Ahlem Brahem,Amel Letaief, Fethi Bahri Aim of the study: To study the effect of losartan on liver fibrosis markers in chronic liver disease. Pa- tients and methods: Twenty patients with steatohepatitis and early stage of liver cirrhosis were in-Background: Our aim was to assess the anatomoclinic, therapeutic and evolutive features of Tu- cluded. Hylauronic acid, TIMP-1, PIIIP, MMP-1, IL-10 and TNF-&#945; were examined before andnisian patients with autoimmune hepatitis treated in our hospital.Patients and methods: we re- after 9 months of treatment with losartan. Results: No significant differences were found in rutinetrospectively included 13 patients with autoimmune hepatitis diagnosed at the unit of Infectious biochemical, hematological parameters including proteosynthetic function. Markers of liver fibrosisdiseases and Internal medicine of Farhat Hached hospital in Sousse, central Tunisia, from January (hyaluronic acid, TIMP-1, PIIIP, MMP-1) and TNF-&#945; were without significant differences, too.2000 to February 2007. The diagnostic of autoimmune hepatitis is established to the recom- The level of antiinflammatory cytokine IL-10 significantly increased after treatment. Discussion: Si-mendations of the score of the International Autoimmune Hepatitis Group. A definite diagnosis of gnificant increase of IL-10 after treatment with losartan indicates on stimulation of antiinflammatoryautoimmune hepatitis based in these criteria required a pretreatment score exceeding 15. Results: response. Stimulation of antiinflammatory mechanisms is the key factor for avoiding of progressionthe mean age was 42 years (16-69) with a clear female predominance (12 female, 1 male). In of inflammation and fibrosis. So as our group of patients had liver disease in the mild stage without30.7% of cases autoimmune hepatitis was revealed by abnormalities test hepatic on medical chec- liver fibrosis, we couldn´t find differences in fibrosis markers. Conclusion: The study confirmed, thatkup. The most common clinical symptoms and signs were asthenia (38.5%), right upper abdomi- losartan is safe in patients with early stage of liver disease. It opened an area for larger clinical stu-nal pain (23%) and ascite (23%). 15% of patients were diagnosed as acute –onset autoimmune dies in patients with reversible stage of liver disease, especially in steatohepatitis.hepatitis (serum alanine aminotransferase lever higher than 10 fold the upper normal limits). Au-toimmune extrahepatic manifestations were associated in 38.4%. The autoimmune hepatitis typeI has been noted in 92% and type II in 8%. All patients had antinuclear antibody or anti smoothmuscle antibody positive (a serum titer higher than 1/40). Liver biopsy showed necrotic-inflam-matory activity in 49% and cirrhosis in 46%. The treatment (azathioprine and corticosteroid) wasprescribed in 77%. This treatment was discontinued in 40% of patients because appearance of theside effects of the treatment. Follow-up: 23% died because cirrhosis’s complication (2 cases) failurehepatic (1 case). Conclusion: the diagnostic of autoimmune hepatitis must be established early foreach patient with chronic liver disease particularly in those are supposed as a cryptogenetic hepa-titis. The prognosis is compromised by delayed diagnosis and by the complication of the cirrhosis.7. MASSIVE AND RECURRENT RECTAL BLEEDING 8. INVOLVEMENT OF THE CD40/CD40 LIGAND PATHWAY IN COELIAC DISEASEDiogo Cruz, Sofia Neto, Pedro Guedes, Luis Correia, Francisco Araújo, J.L. Ducla Soares Antonio Di Sabatino, Laura Rovedatti, Laura Cantoro, Stefania Vetrano, Paolo Biancheri, Paolo Cazzola, Elena Strada, Francesco Broglia, Silvio Danese, Gino Roberto CorazzaDieulafoy’s lesion is an uncommon cause of gastrointestinal (GI) bleeding. It consists of an ano-malous enlargement of submucosal blood vessels, leading to epithelial erosion in the absence of Background & Aims: The CD40/CD40 ligand (CD40L) system is crucially invoved in immunity.an ulcer. This lesion is most commonly located in the lesser curve of the stomach, although it can Cognate interaction between CD40, expressed on immune (monocytes, macrophages, dendriticrarely be found elsewhere in the GI tract, manifesting itself through haemorrhage, usually self-li- cells) and non-immune cells (fibroblasts, epithelial and endothelial cells), and CD40L, mainly ex-mited and showing a tendency for recurrence. Dieulafoy’s can also be an occasional cause of pressed by activated T cells, results in up-regulation of a number of cell surface and soluble mo-massive GI bleeding. Diagnostic and therapeutic procedures are conducted via endoscopy, which lecules which ultimately induce inflammation. To determine if CD40/CD40L pathway is involvedmust be performed in the presence of active haemorrhage. The case this article refers to reports in the pathogenesis of coeliac disease (CD), we explored the effect of CD40L blockade on T hel-of a 90-year-old hypertensive man, admitted to the hospital with massive rectal bleeding. His per cell type 1 (Th1) cytokine production and expression of T-bet, a T-box transcription factor re-haemoglobin levels had dropped 4 g/dl, although he showed no signs of haemodynamic com- quired for Th1 differentiation, in treated CD biopsies grown ex vivo. Methods: Multiplepromise. On the patient’s first day in the hospital, he underwent an upper endoscopy, showing perendoscopic duodenal biopsies were collected from 11 treated CD patients (mean age 34.6 yrs,no abnormalities. On the same day, a colonoscopy was also performed, which revealed multiple range 21-57). Biopsies were placed on iron grids in the central well of an organ culture dish in adiverticula and no active bleeding. During his stay, he had another episode, and this time there tight container with 95% O2/5% CO2 at 37°C, and cultured for 24h with or without 1mg/ml pep-was evident haemodynamic repercussion. This prompted two urgent proctosigmoidoscopies, both tic-tryptic digest of gliadin (PT-gliadin) in the presence or absence of 10 mcg/ml anti-CD40L neu-of which failed to show the source of bleeding. The haemorrhage eventually ceased and the pa- tralising antibody or its isotype matched control (mouse IgG). After culture, interferontient was discharged. Eight days later he was readmitted with a similar bleeding episode. The pa- (IFN)-gamma and interleukin (IL)-17 were measured in the organ culture supernatants by ELISA.tient underwent another colonoscopy, which showed a bleeding lesion suggestive of Dieulafoy’s. T-bet was determined in mucosal homogenates by immunoblotting and normalised for &#946;-After successful haemostasis was reached, clinical improvement ensued and the patient has had actin. Results: Supernatants of coeliac biopsies cultured with PT-gliadin showed significantly higherno other episodes ever since. levels of IFN-gamma (mean 183.6±68.6 pg/ml; p<0.001) and IL-17 (mean 54.8±21.4 pg/ml; p<0.005) in comparison to biopsies treated with control IgG (mean 102.4 ± 36.2 and 16.2±5.7 pg/ml, respectively). The addition of the anti-CD40L neutralising antibody significantly (p<0.001) inhibited the PT-gliadin-induced up-regulation of both IFN-gamma (mean 98.3±29.1 pg/ml) and IL-17 (18.5±8.1 pg/ml). Mucosal T-bet expression was significantly (p<0.001) down-regulated when coeliac biopsies were treated with anti-CD40L antibody. Conclusions: Our results indicate that CD40/CD40L pathway plays a key pathogenic role in CD. Disruption of CD40/CD40L interac- tions through monoclonal antibodies against CD40 or CD40L may offer a therapeutic alternative to gluten-free diet in CD. 61
  • 65. 9. A KEY ROLE FOR THE ENDOCANNABINOID SYSTEM IN INFLAMMATORY 10. CD4+CD25HIGHFOXP3+ T-REGULATORY CELLS IN CROHN’S DISEASEBOWEL DISEASE PATIENTS TREATED WITH INFLIXIMABAntonio Di Sabatino, Natalia Battista, Paolo Biancheri, Paolo Cazzola, Alessandro Vanoli, Antonio Di Sabatino, Manuela Rosado, Paolo Biancheri, Paolo Cazzola, Laura Rovedatti,Costanza Alvisi, Maurizio Perego, Giuseppe Astarita, Daniele Piomelli, Mauro Maccarrone, Alessandro Vanoli, Laura Cantoro, Rita Carsetti, Gino Roberto CorazzaGino Roberto Corazza Background & Aims. In animal models of intestinal inflammation, CD4+CD25highFoxp3+ T-re-Background & Aims. Activation of cannabinoid receptors 1 (CB1) and 2 (CB2) by endocannabi- gulatory cells (Treg) exert a potent anti-inflammatory action. Moreover, depletion of Treg has beennoids impacts on a number of gastrointestinal functions. Recent data indicate that treatment of reported in active inflammatory bowel disease. Tumor necrosis factor (TNF)-alpha, which is cen-mice with a CB1 receptor agonist reduces LPS-induced colitis, thus suggesting a role for the en- trally involved in the pathogenesis of Crohn’s disease (CD), down-modulates the function of Treg.dogenous cannabinoid agonist anandamide in protecting against inflammation in the gut. Here We here investigated both in in vivo and in vitro experiments the influence of anti-TNF therapywe examined the role of the endogenous cannabinoid system in inflammatory bowel disease on Treg in CD. Methods. Sixteen steroid-refractory or fistulising CD patients were treated with in-(IBD) by evaluating the mucosal expression of anandamide, palmitoylethanolamide (PEA), 2-ara- fliximab administered at week 0, 2 and 6 in a dose of 5 mg/kg. Peripheral blood samples werechidonoyl-glycerol (2-AG), and the activity of fatty acid amide hydrolase (FAAH), degrading anan- collected immediately before the first infusion and after 10 weeks. Multicolor flow cytometry wasdamide and 2-AG, and N-acylethanolamine-hydrolyzing acid amidase (NAAA), degrading PEA. performed to analyse circulating CD4+CD25highFoxp3+Treg. Foxp3 transcripts were determi-We further investigated the in vitro effect of the synthetic anandamide analogue methanandamide ned by quantitative RT-PCR in isolated peripheral blood lymphocytes (PBLs). Serum levels of tran-on T helper cell type 1 (Th1) immune response. Methods. Biopsies were collected from inflamed sforming growth factor (TGF)-beta and interleukin (IL)-10 were measured by ELISA. Laminacolonic mucosa of patients affected by Crohn’s disease (n=11) and ulcerative colitis (n=12), and propria mononuclear cells (LPMCs) were isolated from inflamed CD areas, cultured for 48h withfrom normal mucosa (n=15). Endocannabinoid levels were determined by high performance li- increasing concentrations of infliximab (10 and 100 µg/ml) or its isotype matched control (humanquid chromatography-tandem mass spectrometry. Activity of FAAH and NAAA was assessed by IgG1), and analysed by flow cytometry for Treg determination. Results. A substantial clinical im-a radiochromatographic method. Biopsies or anti-CD3/CD28-stimulated lamina propria mono- provement in 9 of the 16 CD patients was associated to a significant increase of the percentagenuclear cells were cultured for 48h with increasing concentrations of methanandamide (0.1, 1 and of Treg (from mean 3.9 ± 1.1% to 12.5 ± 4.8%, p<0.05). The restoration of the Treg pool was ac-10&#956;M) in the presence or absence of CB1 and CB2 antagonists. Released cytokines, i.e. in- companied by a parallel increase of serum TGF-beta (from mean 715.1 ± 235.6 to 1702.9 ± 445.3terferon (IFN)-&#947; and tumor necrosis factor (TNF)-&#945;, were measured in the culture su- pg/ml, p<0.0005) and IL-10 (from mean 37.9 ± 16.6 to 296 ± 102 pg/ml, p<0.0005) in the sub-pernatants by ELISA. Results. Anandamide and PEA, but not 2-AG, were significantly decreased group of responder patients. Foxp3 transcripts were significantly (p<0.005) higher in PBLs col-in IBD mucosa in comparison to normal mucosa. A lower activity of FAAH, but not NAAA, was lected after 10 week treatment in comparison to PBLs collected before treatment. No significantfound in IBD patients when compared to controls. Methanandamide induced a significant dose- change of either Treg, Foxp3 transcripts or serum cytokine levels was found in the subgroup ofdependent decrease of IFN-&#947; and TNF-&#945; concentrations both in organ and cell cul- non-responder CD patients. In in vitro experiments, infliximab significantly (p<0.001) increased theture supernatants. CB1 and CB2 receptor antagonists neutralised the down-regulatory effect of mean percentage of CD mucosal Treg in a dose-dependent manner (IgG1: 1.2 ± 0.4%; 10 µg/mlmethanandamide on Th1 cytokine production. No appreciable difference between Crohn’s disease infliximab: 6.7 ± 2.9%; 100 µg/ml infliximab: 11.7 ± 4.7%). Conclusions. Our findings suggest thatand ulcerative colitis samples was observed in all the experiments. Conclusions. Endocannabi- an additional mechanism whereby infliximab exerts its therapeutic action in CD is restoring thenoids are reduced in IBD inflamed mucosa. Activation of CB1 and CB2 receptors plays a crucial Treg pool. This might occur via up-regulation of TGF-beta and IL-10.role in dampening the Th1-mediated immune response in the gut. Our results point on the en-dogenous cannabinoid system as a promising therapeutic target for the treatment of IBD. 62
  • 66. Oral Communications Fryday, May 9, 2008 ENDOCRINOLOGY, DIABETES, NUTRITION
  • 67. 1. MIDNIGHT SALIVARY CORTISOL FOR DIAGNOSIS OF SUBCLINICAL 2. ACTIVATION OF THE ENDOGENOUS CANNABINOID SYSTEM STIMULATESCUSHING’S SYNDROME IN PATIENTS WITH CLINICALLY INAPPARENT ADIPOGENESIS IN HUMAN ADIPOSE TISSUEADRENOCORTICAL ADENOMA Vettor Roberto, Pagano Claudio, Pilon Catia, Calcagno Alessandra, Urbanet Riccardo,Giuseppe Reimondo, Silvia Bovio, Ilaria Micossi, Barbara Zaggia, Barbara Allasino, Fulvia Daffara, Rossato Marco, Milan Gabriella, Bianchi Katiuscia, Rizzuto Rosario, Bernante Paolo,Arianna Ardito, Angela Termine, Chiara Sciolla, Alberto Angeli, Massimo Terzolo Federspil GiovanniMidnight salivary cortisol (MSC) is regarded as a promising test for the evaluation of Cushing’s The endogenous cannabinoid system participates in the regulation of energy balance, and its dy-syndrome. However, MSC has never been employed to evaluate subclinical Cushing’syndrome sregulation may be implicated in the pathogenesis of obesity. Adipose tissue endocannabinoids(SCS) associated with clinically inapparent adrenal adenoma (AA). Aim of the present study was may produce metabolic and endocrine effects, but very few data are available in human adiposeto assess the value of MSC in the diagnosis of SCS. A prospective study was carried out on 87 tissue. We measured expression of type 1 and type 2 cannabinoid receptors (CB), enzymes of can-patients (54 women and 33 men aged 38-74 years, median 62) with AA detected serendipitou- nabinoids synthesis and degradation in human omental, sc abdominal, and gluteal adipose tissuesly during 2003-2007 at our center in the diagnostic work-up of non-adrenal diseases in patients from lean and obese subjects. Activation of CB1 increases lipoprotein lipase activitiy in adipocy-without classic cushingoid features. The patients underwent a standard endocrine work-up. A tes and this would augment the flux of free fatty acids to adipocytes for triglycerides synthesis. Fur-group of 179 healthy subjects served as controls for MSC. The upper level of normalcy for MSC thermore, we assessed the effect of CB1 stimulation on glucose uptake and intracellularwas set at 3 mcg/L (the 97th percentile of controls). MSC was significantly higher in patients with transduction mechanisms in primary human adipocytes. Then we assessed the reciprocal regu-AI than in controls (2.1 ± 1.5 vs 1.4 ± 0.8 mcg/L, p<0.0001) and in 16 patients (18.4%) MSC was lation between CB1 and peroxisome proliferator-activated receptor-gamma (PPAR &#947;). Fi->3 mcg/L. Forty-eight patients (55.2%) did not suppress cortisol <1.8 mcg/dl after 1-mg DST (only nally, we tested whether leptin and adiponectin are regulated by CB1 in human adipocytes. We4 patients did not suppress <5.0 mcg/dl), 24 patients (27.6%) had ACTH <10 pg/ml and 4 (4.6%) found that most genes of the endocannabinoid system are down-regulated in gluteal fat and up-had UFC >150 mcg/24h. A combination of 2 altered results was found in 17 patients (19.5%) who regulated in visceral and sc abdominal adipose tissue of obese patients. Treatment of adipocytespresented MSC >3 mcg/l more frequently than the remainders (41% vs. 13%, p=0.02). Hyper- with rosiglitazone markedly down-regulated CB1 expression, whereas Win 55,212 increases thetension was observed in 52 patients (59.7%), obesity in 20 (22.9%) and hyperglycemia in 41 mRNA expression of PPAR&#947;. Win 55,212 increased (+50%) glucose uptake, the transloca-(47.1%). MSC did not correlate with age, BMI, waist and mass size and the patients with MSC >3 tion of glucose transporter 4, and intracellular calcium in fat cells. All these effects were inhibitedmcg/L showed a trend toward higher frequency of hypertension and hyperglicemia (69% vs. by SR141716 and wortmannin and by removing extracellular calcium. Win 55,212 and SR14171658% and 56% vs. 45%, respectively). In summary, MSC is able to reveal the functional auto- had no effect on expression of adiponectin and leptin. These results indicate that CB1 activationnomy of AA but a few patients have a relevant hypercortisolism (MSC >97th centile of controls), by endogenous cannabinoids stimulates PPAR&#947; thus promoting adipogenesis. Local en-at least when using a RIA assay of MSC. This may hamper detection of any endocrine-phenotype docannabinoids favour glucose and lipid utilization in human adipocytes thus promoting lipoge-correlations. On the other hand, occurrence of post-DST cortisol >1.8 mcg/dl seems a finding too nesis. These data suggest a role of endocannabinoids-CB1 activation in channeling excess energyaspecific for diagnostic purposes. fuels to adipose tissue in obese humans.3. NAFLD ABD TYPE 2 DIABETES: A GENETIC OR METABOLIC ISSUE? 4. SERUM LIVER ENZYMES IN UNDERWEIGHT PATIENTS WITH EATINGCarulli L, Rondinella S, Rudilosso A, Ganazzi D, Bertolotti M, Loria P, Carulli N DISORDERS C. Montagnese, A. Signorini, E. De Filippo, C. De Caprio, F. Contaldo, F. Pasanisi, L. ScalfiBackground Type 2 diabetes (T2D) seems to be a risk factor for the development of Non Alco-holic Fatty Liver Disease (NAFLD) and for its progression to fibrosis. The pathogenesis of the Background: Data on serum liver enzymes in patients with anorexia nervosa still remain contra-NAFLD-T2D association is not known. Recent data have shown that hyperinsulinemia and insu- dictory and inconsistent, whereas no information is available on underweight patients with atypi-linresistance (IR) may be the primary phenomenon in NAFLD as well as inflammation. Aim of the cal eating disorders, who may also be considered at risk for poor nutritional status. Subjects andstudy was to evaluate the prevalence of NAFLD in T2D, to correlate NAFLD with the Metabolic methods: 163 underweight patients were identified among the female subjects aged >17 yrs whoSyndrome (MetS) features and with T2D therapy, to evaluate the relation between NAFLD and consecutively afferred to the outpatient clinic for eating disorders (2000-2004): 97 patients hadgenetic polymorphisms associated to IR, PC-1 K121Q, and inflammation, IL-6–174 C/G. Methods anorexia nervosa (AN) and 66 patients suffered from atypical eating disorders (AED). An age-mat-80 diabetic subjects were enrolled and underwent blood sample and medical history to ruled out ched control group was also studied Fasting blood samples were collected at 08:00-08:30. Hae-alcohol consumption and other liver diseases aetiology. Steatosis was defined according to stan- moglobin, serum albumin, cholesterol, triglycerides, alanine aminotransferase (ALT), aspartatedardized ultrasonographic criteria and a score for each criterion was assigned like indicator of the aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyltransferase (GGT), lactate de-severity of fatty liver infiltration (Fatty liver indicator, FLI). Results The subjects studied were over- hydrogenase (LDH), and choline esterase (CHE) were all determined using routine laboratoryweight with BMI=28.60 (25°÷ 75°=25.35÷ 32.95), had normal lipid profile and uric acid and had methods. Results: In the AN patients transaminases and GGT were higher while ALP and CHEhigher GPT levels (25°÷ 75°; GOT: 7.00÷ 27.25 and GPT: 21.00÷38.00) 22.5% subjects had no were lower in comparison to control women. Similar differences were also observed In AED pa-steatosis whereas 77.5% had different severity of fatty liver infiltration FLI did correlate significan- tients for AST, GGT and CHE. Hypertransaminasemia (ALT and/or AST above normal values) oc-tly with BMI (p< 0.01), total Cholesterol (p<0.01), glycosilated haemoglobin (p<0.05) and TG curred in 14.4% of the AN patients and 15.2% of the ATD patients. A high prevalence of abnormal(p<0.01) No correlation was found between T2D therapy and severity of NAFLD. No significant values was also observed in both groups for ALP (15.5 and 22.7%) and CHE (28.2 and 13.6%)difference in polymorphisms prevalence was observed when NAFLD subjects were compared to In the anorectic group there was a significant association of AST, ALP and GGT with BMI whilea control group. Discussion Our data show that T2D patients have a very high prevalence of ALT, AST, GGT, ALP, LDH and CK did not correlate with haemoglobin, albumin, total protein andNAFLD which is probably related to hyperinsulinism and IR. This is further supported by the po- cholesterol. A relationship with trygliceride levels was found for AST, GGT and LDH while CHEsitive correlation of NAFLD with BMI and TG. The lipogenic effects of insulin may underlie such was significantly related to glycaemia and total serum proteins. Conclusion: Serum enzyme ab-relationship. In our population NAFLD associates with some features of MetS whereas no signifi- normalities are quite frequent not only in AN but also in underweight patients with AED. In par-cant genetic component is present. ticular, low CHE values also occur in patients with a relatively small BMI decrease. 64
  • 68. 5. IMPACT OF HYPERGLYCEMIA ON CLINICAL OUTCOME IN PATIENTS 6. VISCERAL AND SUBCUTANEUS FAT CHANGES FOLLOWING 10% AND 25%UNDERGOING PERCUTANEOUS CORONARY INTERVENTION(PCI) FOR WEIGHT LOSS IN SEVERE OBESE PATIENTS TREATED WITH LAPAROSCOPICST-SEGMENT ELEVATION MYOCARDIAL INFARCTION(STEMI) GASTRIC BYPASSAriella De Monte, Andrea Perkan, Giancarlo Vitrella, Serena Rakar, Erica Della Grazia, F del Genio, I De Sio, G del Genio, C Finelli, F Pasanisi, F ContaldoAlessandro Salvi, Gianfranco Sinagra Bariatric surgery is considered the most effective treatment for reducing excess weight and main-Background and aims: non diabetic patients with STEMI and hyperglycemia at hospital admission taining weight loss in patients with clinically severe obesity. There are limited data evaluating me-have a higher prevalence of cardiac morbidity and mortality, but there are very few data from li- tabolic and fat changes following bariatric surgery in severely obese patients. We evaluated 22terature. The aims of this study are to assess the prevalence of acute hyperglycemia in non dia- patients (13 M, 9 F; age 42.6±5.6 years; BMI 49.3±6.0 kg/m2), undergoing laparoscopic gastricbetic patients with STEMI undergoing PCI (primary or rescue) and its prognostic impact on bypass, before surgery and following 10% and 25% weight loss (WL), obtained on average sixreperfusion and clinical outcome. Methods: 184 patients with STEMI undergone to PCI were en- and thirty weeks after surgery respectively. Visceral and subcutaneous fat were assessed with ul-rolled from PCI registry of Trieste (wich contains anamnestic, clinical, angiographic, echocardio- trasound. Weight (138.5±24.9 vs. 121.8± 21.3 vs. 104.6±20.4 kg; p=0.001), BMI (49.3±6.0 vs.graphic and therapeutic data) between December 1,2004, and July 31,2006.Follow-up at 1 month 43.4±5.0 vs. 37.1±4.5 kg/m2; p=0.001) and waist circumference (142.6±15.5 vs. 133.0±14.1 vs.is being conducted to quantify patients’postdischarge outcomes. Glycemia was considered nor- 117.8±14.1 cm; p=0.001) statistically decreased following 10 and 25% WL. Mean glucosemal if &#61603;110 mg/dl. The group was divided in 3 subgroups: non diabetic normoglycemic (102.1±25.4 vs. 87.8±8.2 vs. 76.9±7.8 mg/dl; p=0.001), triglyceridemia (174.9±106.3 vs.patients (n=22;12%), non diabetic hyperglycaemic patients (n=104;57%) e diabetic patients 130.9±52.7 vs. 103.6±37.7 mg/dl; p=0.005), HDL-cholesterolemia (46.1±11.5 vs. 39.9±8.0 vs.(n=58;31%). Results: in this study main parameters of hyperglycemic non diabetic patients have 49.1±9.6 mg/dl; p=NS), AST (22.5±5.3 vs. 29.6±12.1 vs.21.9±9.5 U/ml; p=NS), ALT (33.2±12.9a intermediate trend between non diabetic normoglycemic and diabetic groups. The hypergly- vs. 34.6±19.2 vs. 20.4±11.2 U/ml; p=0.01), &#947;GT (36.8±29.9 vs. 21.8±11.5 vs. 15.7±8.1 U/ml;cemic non diabetic group had a double risk of death compared to normoglycemic one. The group p=0.01) and HOMA (6.2±4.0 vs. 2.3±1.2 vs. 1.6±0.8; p=0.001) improved after surgery with si-of hyperglycemic non diabetic subjects had an increased impaired fasting glucose (IFG) at 1 gnificantly reduction at 25% WL. Visceral fat (8.9±3.2 vs. 6.5±2.2 vs. 4.5±1.3 cm; p=0.001) andmonth follow-up compared to non diabetic normoglycemic group (24.8% vs 9.1%, p=0.001). subcutaneous fat (3.4±1.1 vs. 2.9±0.7 vs. 2.1±0.8 cm; p=0.01 vs. baseline) both significantly de-Subgroups Normoglycemic Hyperglycemic Diabetic p Age 62&#61617;12 64&#61617;12 creased following 25% WL after surgery. Following WL visceral fat thickness progressively de-69&#61617;13 <0,05 Peripheral vascular disease 13% 19% 36% <0,05 TIMI Risk Score creased paralleling metabolic improvements. Further investigations are needed to evaluate long3,2&#61617;1,6 3,9&#61617;2,3 5,0&#61617;2,3 <0,05 Ischemia time 91&#61617;77 term effects of metabolic changes in patients undergoing laparoscopic bariatric surgery.134&#61617;117 197&#61617;227 <0,05 TIMI post PCI 2,9&#61617;0,4 2,8&#61617;0,72,6&#61617;0,7 <0,05 Heart failure 17% 21% 38% <0,05 30 days mortality 4% 10% 15% NSConclusions: in this study acute hyperglycemia prevalence in non diabetic patients with STEMI ishighest of all data from literature (57%). Acute hyperglycemia is associated with a worse outcomealso in non diabetic subjects and detects an intermediate risk class between non diabetic and dia-betic patients with STEMI, which could benefit by therapy. Acute hyperglycemia is predictive ofIFG suggesting a metabolic stadiation in order of a better therapeutic strategy of secondary pre-vention of ischemic cardiopathy.7. THE EFFECT OF PHEOCHROMOCYTOMA TREATMENT ON SUBCLINICALINFLAMMATION AND ENDOCRINE FUNCTION OF ADIPOSE TISSUEBosanska L., Petrak O., Zelinka T., Mraz M., Widimsky J., Haluzik M.Patients with a catecholamine-secreting tumor (e.g. pheochromocytoma) may suffer from earlyprogression of atherosclerosis and higher risk of cardiovascular diseases, although the exact me-chanism of accelerated atherosclerosis in these patients is only partially understood. Previous invitro studies have demonstrated that increased catecholamine levels can markedly modulate theendocrine function of adipose tissue. It is also known, that numerous hormones of adipose tissuesuch as adiponectin and resistin, may be directly or indirectly involved in the etiopathogenesis ofatherosclerosis. The aim of our study was to evaluate the influence of surgical removal of pheo-chromocytoma on the endocrine function of adipose tissue and subclinical inflammation as mea-sured by circulating C-reactive protein (CRP) levels. 18 patients with newly diagnosedpheochromocytoma were included into study. Anthropometric measures, biochemical parameters,serum CRP, leptin, adiponectin and resistin levels were measured at the time of diagnosis and 6months after surgical removal of pheochromocytoma, respectively. Surgical removal of pheochro-mocytoma significantly increased body weight, decreased both systolic and diastolic blood pressure,fasting blood glucose and glycated hemoglobin levels. Serum CRP levels were decreased by 50% 6 months after surgical removal of pheochromocytoma (0.49 ± 0.12 mg/l vs. 0.23 ± 0.05 mg/l,p < 0.05) despite a significant increase in body weight. Serum leptin, adiponectin and resistin le-vels were not affected by the surgery. We conclude that increased body weight in patients after sur-gical removal of pheochromocytoma is accompanied by a paradoxical attenuation of subclinicalinflammation. We failed to demonstrate an involvement of the changes of circulating leptin, adi-ponectin or resistin levels in this process. Supported by MZO 000064165 a IGA 8302-5. 65
  • 69. Oral Communications Saturday, May 10, 2008 ENDOCRINOLOGY, DIABETES, NUTRITION
  • 70. 1. SUBCUTANEOUS SMALL RESISTANCE ARTERY REMODELING IN PATIENTS 2. LIVER FUNCTION TEST DURING METFORMIN THERAPY IN PATIENTS WITHWITH CUSHING´S SYNDROME POLYCYSTIC OVARY SYNDROME (PCOS)Gianluca E.M. Boari, Carolina De Ciuceis, Enzo Porteri, Nicola Rizzardi, Caterina Platto, Luca Miele,Consuelo Cefalo, Daniela Martinez, Alessandra Forgione, Maurizio Pompili,Silvia Paiardi, Guido A.M. Tiberio, Stefano M. Giulini, Damiano Rizzoni, Enrico Agabiti Rosei Francesca Sagnella, Simona Racco, Rosanna Apa, Giovanni Gasbarrini, Antonio GriecoObjectives: Structural alterations of small resistance arteries in essential hypertensives (EH) are mo- Background: Polycystic ovary syndrome (PCOS) is considered one of the most common form ofstly characterized by inward eutrophic remodeling. However, we observed hypertrophic remode- ovarian disease in young women. PCOS shares several features of Metabolic Syndrome (MS) withling in patients with renovascular hypertension, in those with acromegaly as well as in patients with nonalcoholic fatty liver disease (NAFLD). Metformin therapy is the standard of care for insulin re-noninsulin-dependent diabetes mellitus, suggesting a relevant effect of humoral growth factors on sistance (IR) in these patients. Aim: to evaluate the prevalence of NAFLD and the effect of standardvascular structure, even in addition to the hemodynamic load. Cortisol may stimulate the renin-an- therapy with Metformin on non-invasive fibrosis markers in patients with PCOS and hyperinsuli-giotensin system, and induce cardiac hypertrophy. However, no data are presently available about naemia. Patients and Methods: We enrolled 50 non-diabetic consecutive patients with PCOS.small artery structure in patients with Cushing’s syndrome. Methods: We have investigated the NAFLD was assessed by abdominal ultrasound (US). Anthropometric variables, OGTT, serum li-structure of subcutaneous small resistance arteries in 12 normotensive (NT) subjects, in 12 EH sub- pids and aminotransferases, and HOMA index were determined at basal visit and after 6 monthsjects, and in 7 patients with Cushing’s syndrome (CS). Small arteries from subcutaneous fat were of therapy with Metformin (1500 mg/die for 24 weeks). ATPIII criteria were used for defining me-diassected and mounted on a micromyograph. The normalized internal diameter (ID), media thick- tabolic syndrome (MS). The Wilcoxon paired test was used to assess the modification after treat-ness (MT), media-to-lumen ratio (ML) and the media cross-sectional area (MCSA) were measured. ment, p=0.05 was considered significant. Results 13 patients (age: 25.69± 7.38 years; BMI: 30.96±Results: Demographic variables were similar in the three groups, except for clinic blood pressure 8.23) completed the treatment. At the entry basal visit 30.8 % (4/13) showed MS. NAFLD at US(BP, 127/79±2.4/2.1 mm Hg in NT vs 169/99±1.5/1.7 and 160/90±5.4/3.9 mm Hg in EH and CS, was decteted in 10/13 (76.9%) subjects with PCOS. Subjects with PCOS and NAFLD were youn-p<0.01/p<0.001 and p<0.01/p<0.05, respectively) and 24-hour urinary cortisol levels (CS: 1.540±40 ger than subjects without NAFLD (24.10±6.84 VS 31±7.81) with higher waist-hip-ratio (0.87 ±0.09nmol/day). M/L was significantly greater in EH and CS compared with NT (0.099±0.003 and vs 0.73 ± 0.04, p<0.05). The only adverse event reported was the diarrhoea in 6/13 (46.2%) but0.0916±0.004 versus 0.0684±0.004, p<0.001 and p<0.01, respectively). No difference was obser- in all cases it did not lead to the discontinuation of therapy. After 6 months of Metformin therapyved between EH and CS. The media cross-sectional area was significantly greater in CS compared the AUC was significantly improved in all subject (18730.50± 8105.35 vs 12531.81± 6515.14, p:with EH and with NT. Conclusion: Our results suggest the presence of hypertrophic remodeling 0,002), HDL-Cholesterol significantly increased (45.83± 11.08 vs 49.53± 9.41, p<0.05) and theof subcutaneous small resistance arteries of CS, probably as a consequence of growth promoting AST/ALT ratio was significantly improved (0.90±0.39 vs 0.72±0.32, p:0.028) even if a significantor profibrotic properties of circulating cortisol and/or other hormones. reduction of the ultrasound degree of steatosis was not observed. Discussion: Six months therapy with Metformin in patients with PCOS was able to improve severity of liver disease assessed by AST/ALT ratio even if we did not observed a significant modification of steatosis at US. The re- duction of IR incidence and the increase the HDL Cholesterol levels could lead to a reduction of cardiovascular risk and improving liver function tests in women with PCOS.3. HYPOTHYROIDISM DUE TO HASHIMOTO’S DISEASE, RADIOIODINE 4. L-CARNITINE ADMINISTRATION IMPROVES INSULIN SENSITIVITY INTHERAPY AND POST THYROIDECTOMY: ARE THERE ANY DIFFERENCES IN PATIENTS WITH IMPAIRED GLUCOSE METABOLISMCARDIOVASCULARY RISK? A. Molfino, A. Cascino, C. Ramaccini, C. Conte, F. Rossi Fanelli, A. LavianoCemil Bilir, Hakan Cinemre, Feyzi Gokosmanoglu, Ramazan Büyükkay , Necip Aytug RATIONALE: Insulin resistance and type II diabetes are characterized by hyperglycemia and hy-Objective: The most common cause of hypothyroidism is chronic autoimmune thyroiditis,radioio- perinsulinemia. Insulin resistance may be associated with mitochondrial dysfunction. L-carnitine,dine treatment and thyroidectomy.Hypothyroidism is a cardiovascular risk factor.We investigated the an intramitochondrial carrier of acylic groups, is a molecule involved in lipids and carbohydratespossible differences in cardiovascular risk between different etiology of hypothyroidism.Methods:116 metabolism. L-carnitine therefore may modulate cell energy metabolism. We designed a study topatients (28 male,88 female) hypothroid patients who presented to our outpatient clinic from Feb, investigate the effects of oral L-carnitine administration on plasma glycemic and insulinemic pro-2007 to Aug, 2007 were included. Patients with a history of diabetes mellitus, hypertension, renal file in patients with impaired fasting glucose or diabetes mellitus type II. METHODS: The effect offailure, dyslipidemia, have 10- year Framingham risk score> 5%, previous or current use of medi- L-carnitine was investigated in 16 patients (12 males and 4 females); the mean age ± SD wascations effect carotid intima media and thyroid hormone levels excluded.32 patients were dia- 66.69±13.37 y. Patients were randomly assigned to two groups. The first group (LC, n=8; 5 M andgnosed as Hashimoto’s disease according to antithyroid antibody levels and/ or thyroid 3 F) received L-carnitine (4 grams/day) and 1200 or 1400 Kcal/day standard diet for women or menultrasonography.19 pateints had hypothyroidism due to thyroid surgery and 8 were hypothyroid respectively, for 10 consecutive days. The second group (C, n=8; 7 M and 1 F) received only 1200because of radioiodine therapy.Remaining 59 patients were evaluated for carotis intima media or 1400 Kcal/day standard diet for women or men respectively, for 10 consecutive days. Oral glu-thickness (CIMT) using carotid duplex ultrasonography.Age and sex matched 67 healty subjects cose tolerance test (OGTT, basal and 2 hours), fasting plasma insulin levels and Homeostasis Modelwere selected as controls.All measurements were performed by the same radiologist who is ex- Assessment (HOMA-IR) were assessed in each group before and after treatment. RESULTS: Fastingperienced in the area.Results:CIMT was found to be 0.71 mm (0.45-1.14) in Hashimoto group, plasma glucose levels were not statistically different in the two groups after treatment. OGTT-20.70 mm (0.53-1.02 ) in the post surgical group and 0.71mm (0.55-1.3) in the post radioiodine thre- hours significantly improved after treatment both in LC (232.62±64.75 mg/dl vs 146.25±59.04atment group while measured as 0.52 mm (0.39-0.76) in controls.CIMT were found to be very mg/dl, p=0.015) and C group (193.25±64.11 mg/dl vs 128±53.29 mg/dl, p=0.04). Interestingly, wesignificantly higher in all three groups compared to the controls( p= 0.0001).No statistically signi- observed a significant improvement in plasma insulin levels and HOMA-IR after treatment in LCficant difference were found between three groups(p=0.80).CIMT were measured as mean 0.74 group (7.04±2.6 &#956;U/ml vs 4.51±1.79 &#956;U/ml, p=0.04; 1.95±0.79 vs 1.17±0.51, p=0.03).mm and 0.72 mm in antithyroid antibody positive and negative patients, respectively (p=0.82).Con- No significant differences in plasma insulin levels and HOMA-IR were observed in C group. CON-clusion: This is the first study evaluating possible differences in CIMT as a cardiovascular risk fac- LCUSIONS: L-carnitine in association with low calorie diet significantly ameliorates OGTT-2 hours,tor among hypothyroidism patients related to three major etiologies as well as antithyroid antibody reduces plasma insulin levels and diminishes insulin resistance, as indicated by HOMA-IR impro-positivity. Further studies might be needed to evaluate other cardiovascular risk factors. vement. 67
  • 71. 5. THE MOTILITY OF THE ESOPHAGEAL BODY: COMPARISON BETWEEN TYPE 2 6. THE ASSOCIATION OF IRON STORES AND DIABETES MELLITUS TYPE IIDIABETICS PATIENTS AN HEALTHY INDIVIDUALS Patiakas Stefanos, Eirini Vasileiou, Vardakis Zaharias, Tsoukis EvangelosJorge JX; Coelho A; Panão EA; Simões C; Almeida CC AIM: The evaluation and comparison of iron stores in patients with Diabetes Mellitus type II as wellIntroduction: The influence of diabetes Mellitus on the esophageal motility is not well known. Some as in healthy individuals METHODS: During the year 2005, 200 patients, with Diabetes Mellitus,studies has diferents results.The aim of this study was to compare some motor caracteristics of the were examined into the General Hospital of Gumenissa , (82 men and 118 women, 57-78 yearsesophageal body between type 2 diabetics patients and healthy individuals. Material and Methods: old) and 100 healthy people ( 42 men and 58 women, at the same age) as reference group. InA stationary esophageal manometry with 6 channels catheter has been made in 14 adults type 2 both cases, HbA1c and ferritin levels were evaluated in plasma, while other causes of high ferritindiabetics(11 males and 3 females) of mean age 54,8 years old (45-72), and 16 non diabetics he- levels were excluded. We used ADAMS HA-8160 and ACESS). RESULTS: Patients with Diabetesalthy, 11 males and 5 females of mean age 60,2 years old(31-81). Results: In the diabetic group Mellitus type II had statistically significant higher levels of ferritin comparing to the reference groupthe waves registed was: 83,9% peristaltics, 4,4% simultaneas, 9% non transmited and 3,2% re- ( 104.92±83.8, vs. 75.8±47) p<0.05 CONCLUSIONS: Patients with Diabetes Mellitus type II, hadtrograds. However in the healthy group the regist was:86,2% peristaltics, 3,8% simultaneas, 14,9% significantly higher ferritin levels comparing to healthy population, a fact that argues in favor of he-non transmited and 0,56% retrograds. The percentage of diabetics patients with anormal waves mochromatosis having increased impact in Diabetes Mellitus. Small increases of Fe has been sup-up normal was: 7,1% with simultaneas, 14,3% with non transmited and 42% with retrograds waves. ported to contribute into the production of free radicals of Oxygen and thus to the insulin resistance.Between the non diabetics it was:0% with simultaneas, 18,7 % with non transmited and 18% with Possibly, in the future the reduction of iron stores could be an additional factor contributing in Dia-retrograds waves. Conclusion: The anormal esophageal waves were more frequents in diabetic betes Mellitus prevention.pacients than in healthy individuals. Particularly, the retrograd waves was significatively more fre-quent in type 2 diabetics patients.7. METABOLIC SYNDROME PER SE SIGNIFICANTLY INCREASES TARGET ORGANDAMAGE IN SUBJECTS WITHOUT OVERT CARDIOVASCULAR RISK FACTORSDavide Grassi, Cristina Lippi, Stefano Necozione, Monica Michetti, Azzurra D’Aurelio,Luisa Petrazzi, Lorella Polidoro, Giuliana Properzi, Giovambattista Desideri, Claudio FerriObjectives: Metabolic syndrome (MS) often associated with hypertension markedly increases car-diovascular risk. Target organ damage (TOD) is more common in hypertensives with than withoutMS. Whether MS per se, without overt cardiovascular risk (OCVR) is associated with an increasedexpression of TOD is yet controversial. The current study investigated the prevalence of TOD insubjects with MS but no OCVR. Methods: MS was defined according to ATP III criteria. Conside-ring presence or absence of hypertension as OCVR, we divided the patients in two groups (I= MS+ hypertension and II= MS without OCVR), an healthy group was considered for control. Each par-ticipant was submitted to echocardiography, carotid ultrasonography, 24 h urine collection andblood pressure (BP) measures. Results: 158 subjects (26.8%) had MS. 41.1% of these were withoutOCVR. Group I presented with higher BP levels than group II (p<.05). Prevalence of microalbu-minuria and increased IMT (83.8 vs 75.3% and 21.5 vs 18.4%, respectively) was not statistically dif-ferent, while prevalence of LVH (29.0 vs 6.1%, respectively), was significantly higher (p <.001) in Irespect to II group. Compared to II and control groups, group I showed higher albuminuria, LVMIand IMT (p<.05). Group II showed higher albuminuria respect to controls (35.7±10.7 vs 20.7±5.3mg/24h, respectively, p<.05). Insulin resistance was significantly (p<.05) higher in I and II respectto control group. In the population studied, multivariate analysis indicated impaired fasting glu-cose as independent risk factor for microalbuminuria, obesity for impaired IMT and high diastolicBP levels for microalbuminuria and LVH. Conclusion: Our study suggested that: 1) MS per seleads to TOD and combined hypertension entails additional CVR in this population; 2) Presenceof TOD should be researched in apparently healthy subjects presenting with MS; 3) Lifestyle chan-ges and/or combined drug therapy should be eventually considered in all subjects with MS. 68
  • 72. Oral Communications Saturday, May 10, 2008 CLINICAL CASES
  • 73. 1. CUTANEOUS, ARTICULAR, PULMONARY AND GASTROINTESTINAL 2. SPONTANEOUS CHOLESTEROL CHRYSTAL EMBOLIZATION. REPORT OF TWOSARCOIDOSIS – UNUSUAL FORM OF SYSTEMIC PRESENTATION CASES AND REVISION OF LITERATUREAndrea Mateus; Arlindo Guimas; João Correia; Abilio Reis; Nelson Rocha Hernán Michelángelo, Bernardo Martinez, Christian Gallo, Wexler MarceloSarcoidosis is a systemic disease of unknown etiology. The diagnosis is based on suggestive clini- Renal and systemic atheroemboli usually affect older patients with diffuse erosive atherosclerosis.cal and radiological findings and by the presence of noncaseating granulomas at sites of disease Cholesterol crystal embolization occurs when portions of an atherosclerotic plaque break off andinvolvement. Many atypical presentations of Sarcoidosis have been described. Distintion between embolize distally, resulting in partial or total occlusion of multiple small arteries (or glomerular ar-Sarcoidosis and Tuberculosis is not easy because of the many clinical and histological features they terioles), leading to tissue or organ ischemia. Cholesterol Crystals Embolization is not a very frequentshare. We present a case of a woman, 52 years old, with Pulmonary Tuberculosis in the past, who entity that happens in people with atheromatous disease of spontaneous for or after the realiza-present with one year of arthritis of the right hip associated with painful and relapsing cutaneous tion of vascular manipulation (angiographic, angioplasty procedures, cardiovascular surgery) orlesions of the legs. This lesions where tought to be those of erythema nodosum. Secondary cau- more rarely with the treatment with oral anticoagulants and after trombolytic therapy. The clinicalses of erythema nodosum where excluded. One month before admission in our institution, the pa- presentation is according to the arterial affected territory and so from diagnosed cases in autopsycient presented with violet papules in the forearms, fatigue and fever. Skin biopsy shows reports to florid clinic forms exist. The more frequent are the cutaneus manifestations with appa-noncaseating granulomas. She was admitted after sixteen days of antituberculosous therapy be- rition of livedo reticularis and purple toes that could go accompanied of necrosis of lower limbs,cause of persistent fever, atypical abdominal pain and acute arthritis of the right knee. We assumed consecutive from the renal manifestations and the gastrointestinal trac one. The diagnosis is basedthe diagnosis of systemic sarcoidosis based on the previous skin biopsy, poliarthritis, alveolitis on the biopsy of organ affected lessons to level of arterioles, that revealed characteristic choleste-CD4+/CD8+ and mesenteric panniculitis. Excelent improvement with corticosteroid therapy. rol clefts, above all the cutaneus biopsy, muscular and in any case renal. There is no specific the- rapy for renal atheroembolic disease. General issues related to the medical and surgical therapy of atheroembolic disease are discussed in detail separately. Although there is no proven effective me- dical therapy, all such patients should be aggressively treated for secondary prevention of cardio- vascular disease. These modalities include aspirin, statins, blood pressure control, cessation of smoking, and, in patients with diabetes, glycemic control. We present two cases of true spontane- ous cholesterol embolization causing acute renal failure. There was no history of vascular proce- dural interventions or thrombolytic therapy prior to her presentation, but the patients did have a history of difficult hypercholesterolemia and atherosclerosis. This cases highlights the importance of remembering cholesterol embolization as a potential cause of acute renal failure despite no ap- parent precipitant, especially with the presence of unexplained eosinophilia.3. CLOPIDOGREL AND LIVER FAILURE 4. FIBROUS DYSPLASIA ASSOCIATED OR NOT TO MAC CUNE ALBRIGHTPatrícia Howell Monteiro, Luís dos Santos Pinheiro, Lourdes Alvoeiro, Margarida Lucas, SYNDROMERui M.M. Victorino Hamouda M; Ben Fredj F; Toumi S; Mrad B; Mhiri H; Laouani Kechrid CINTRODUCTION: Clopidogrel (CPG) is associated with a low occurrence of adverse side effects, Introduction: Fibrous dysplasia (FD) has been estimated to contribute to 2,5 % of bone disease andbut growing evidence suggests that it may cause hepatic injury. CASE DESCRIPTION: We de- 7% of bone tumors. Endocrine abnormalities are present in 3% of patients in the Mac Cune Al-scribe the case of an 80-year-old woman admitted with congestive heart failure (HF). The patient bright. The disease can be monostotic or polystotic .We report 3 cases of fibrous dysplasia with onehad previous history of hypertension, diabetes, HF and myocardial infarction. She was medicated case of Mac Cune Albright. Observations: There were three patients: a 62 year old man and 42with glibenclamide, furosemide, isossorbide dinitrate, acetylsalicylic acid and sinvastatin for several year and 62 year old two women. The consultation motive was bone pain in 2 first cases with po-years and in the previous month with CPG. Physical exam showed mild jaundice, inspiratory rales lystotic form and fortuity discovery in the third cases with monostotic form. Radiographics showedand lower limbs oedema. Laboratory evaluation revealed gamaglutamiltranspeptidase (gGT):166 a lucent lesion in rib and sclerotic lesion in skull bone. A bone scan showed increased uptake ofUI/L; alkaline phosphatase (AP):137 UI/L; total bilirubin (BIL):1,7 mg/dL; AST/ALT:110/190 UI/L; both sites. Biologic findings showed elevation of serum alkaline phosphatases in the first case andlactic dehydrogenase (LDH):707 UI/L and INR of 1,2. Abdominal ultrasound was normal. Despite biologic hypothyroidism in the second case. The biopsy was realised to the two women’s and re-significant clinical improvement with optimization of heart failure therapy, the patient developed fused by the man .Bisphosphanates was indicated in the two cases with polystotic form, but it wasliver failure (INR: 1,6), with additional elevation of AST/ALT (388/656 UI/L), BIL (3,5 mg/dL), LDH given only to the second case which stabilisation of her clinical state. Discussion: The polystotic(1455 UI/L), AP (139 UI/L) and gGT (209 UI/L). Infectious, obstructive, autoimmune and neopla- form of FD can be associated to the Mac Cune Albright syndrome and associate endocrine ab-sic causes were excluded. Hepatotoxicity associated with CPG was considered the most probable normalities and spots to the bone disease wish was the case of the second patient. The bispho-cause. After discontinuation of CPG liver enzymes normalized in 29 days. DISCUSSION: The dia- sphonates has a clinical and radiographic improvement with thickening of the cortices and fillinggnosis of CPG associated hepatitis was supported by the close temporal relationship between the- of the osteolytic lesions. Malignant transformation is possible, especially suspected in front of atro-rapy initiation and onset of liver injury, exclusion of alternative causes and liver function cious pain and cortical breaks .None of the three patients did degenerate. Conclusion: The diagnosisnormalization after drug discontinuation. The Clinical Diagnostic Scale for the diagnosis of drug- of FD was established by clinical, radiographic findings and histological.The surveillance is basedinduced hepatitis by Maria VAJ and Victorino RMM was applied and yielded a score of 15 (pro- on radiographics and tumor markers to detect a malignancy transformation. This association withbable). There are only 6 cases of CPG hepatotocixity described in the literature. Facing the Mac Cune Albright syndrome is rare but must be systematically researched.increasing use of CPG, namely in new clinical indications, it is mandatory to reinforce the surveil-lance and awareness of possible adverse side effects, such as hepatotoxicity. 70
  • 74. 5. COLONIC CARCINOMA DISCLOSED BY ENDOCARDITIS CAUSED BY 6. DECOMPRESSION SICKNESS IN A SEA-HEDGEHOG DIVERENTEROCOCCUS GALLINARUM Giovita A Piccillo, Aurelio Pantò, L Manfrè, Enrico GM Mondati, Riccardo Polosa, Luca Miele,FJ Cabrera Aguilar, D Gerona Serrano, B Pinilla Llorente, M Gómez Antúnez, A Torres Do Rego, Giovanni GasbarriniA Muiño Miguez INTRODUCTION Decompression sickness, physiological disorder caused by rapid decrease in at-INTRODUCTION: Physicians are aware of the association between Streptococcus bovis infection mospheric pressure, resulting in presence of nitrogen bubbles into the body tissues. It is also knownand colorectal malignancy. However, many are unaware that bacteremia and/or endocarditis from as caisson disease and represents the hazard of persons who work under greatly increased atmo-other organisms may be related to colonic carcinoma. This report describes a patient in whom the spheric pressure below the surface of the earth when their return to normal atmospheric pressurefinding of an Enterococcus gallinarum endocarditis stimulated investigation which resulted in the is made too quickly. At high atmospheric pressure the respiratory gases are compressed and lar-diagnosis and surgical treatment of an adenocarcinoma of the colon. CASE DESCRIPTION: A 81- ger amounts are dissolved in the tissues. During ascent from depths greater than 30 ft (9.1m),year-old man was admitted for several hours of shaking chills and fever. He also presented since these gases escape as the external pressure decreases. The decrease in air pressure releases gastwo moths feces with the presence of fresh blood. Upon physical examination, he was seen to be bubbles that block the small veins and arteries and collect in the tissues, cutting off the oxigen andin regular general condition and febrile (40 ºC). The cardiac beats were rhythmic and had normal causing nausea, vomiting, dizziness, pain in the joints and abdomen, paralysis, and other neurolo-sounds. No masses or enlarged viscera were palpated. The hemoglobin measurement was 11.3 g%. gical symptoms. There may be shock, total collapse, and, if treatment is not prompt, death. De-Radiography of the thorax revealed an increase in the cardiac area. The electrocardiogram showed compression illness from breath-hold diving is quite rare but can occur. It is usually seen in diverssupraventricular extrasystoles. Transoesophageal echocardiography demonstrated mitral vegeta- who are making many deep dives in a short period of time with little surface interval. Taravana (totion. E gallinarum was isolated from three blood cultures. The patient was treated with ceftrioaxone fall crazily) syndrome, first described by Cross in 1958, is a diving condition seen in working Tua-and ampicillin To investigate the presence of intestinal hemorrhage, colonoscopy was performed, motu Island natives diving in the Takatopo Lagoon (French Polynesia). It represents a decompres-which showed a vegetative and infiltrative lesion in the left flexure. Histopathological examination sion illness in divers. The symptomatology is characterized by vertigo, nausea and lethargy, paralysisrevealed adenocarcinoma. Colectomy was performed one moth later. DISCUSSION AND CON- and death. The treatment consists on recompression. CASE REPORT A male 38-year-old subjectCLUSIONS: Enterococci, most often E. faecalis, cause 5 to 20% of cases of infective endocarditis. was admitted to our Department because of nausea, vertigo, paresthesias of left emibody and le-According to a MEDLINE search, this is the the third report of endocarditis due to E gallinarum thargy. He was been diving during the morning as apneist, making almost 30 immersions at 30and the first associated with colonic carcinoma. Several studies reported intestinal colonization by meters of deepth with very short interval of surface in search of sea-hedgehogs. At history, motherE. gallinarum in both hospitalized individuals and nonhospitalized healthy individuals. The low pre- and father affected with hypertension, appendicectomy at the age of ten years The patient appea-valence of motile enterococcal endocarditis may be due to the difficulties in identifying these spe- red pale and suffering, polypnoic, extremely anxious, with nausea, vomiting, dizzness and pare-cies. This case demonstrates the role of E gallinarum as a cause of native valve endocarditis and a sthesias of left arm and leg. Normal BP (130/80 mmHg), EKG, HR (90 b/m), T 37°C, SaO2 97%.very uncommon presentation for colorectal malignancy. Respiratory clinical evaluation revealed normal vesicular breathing. Neurological evaluation no sho- wed left body impairment, but confirmed the presence of paresthesias. Laboratory data no poin- ted out alterations except for moderate anaemia (RBC 3.780.000/mmc, Hgb 12.4 g/dl, Hct 30.6%, MCV 80.9 fl), slight increase of LDH (786 U/L).There was no evidence of C and S proteins defi- ciency and negative resulted antiphospholipid antibodies, lupic anticoagulant Chest-X-ray, imme- diately executed, no pointed out abnormalities as well as chest-CT, apart for slight emphysema signs. Brain magnetic resonance detected few right little hyperintense lesions On the grounds of these findings, we suspected a case of Taravana syndrome and submitted our patient to prompt recompression. The patient at last of hyperbaric session (180 min) appeared ameliorated with re- solution of his symptomatology. DISCUSSION Taravana syndrome is a rare and very often mi- sdiagnosed diving disturb with good prognosis in most cases. It seems be due to nitrogen load of the blood. Of particular relevance to the sport dive is what happens to the snorkelling breath-hold diver who repeatedly dives during the surface interval between sub dives. Very little nitrogen is tran- sferred from the alveoli to the blood during one breath-hold dive. But repeated dives alter the off- gassing process as well as taking on more gas and would completely change the dive profiles. Free diving on-loads N2, to a small degree, more or less depending upon the depth and time at depth of the dives and this time should be taken into consideration when calculating residual nitrogen. Snorkelers between scuba dives should stay on the surface. The gold standard of therapy is re- compression and it should be started as soon as possible to beseech the rare but possible death of these patients.7. HIP FRACTURE IN A YOUNG PATIENT WITH CHRONIC RENAL DISEASECristina Tanaseanu, Monica Popescu, Isabela Tiglea, Alina Dumitrascu, T. IrimiaBackground Bone disease develops relatively early in chronic renal failure. The high turnover va-riants – secondary hyperparatiroidism (SHP) and a combined disorder – are still the most frequent.Low turnover disorders include osteomalacia (OM) and adynamic bone disease. Case discussion:we present a case of a 28-years old woman with multiple pregnancies , without significant medi-cal history, who presents clinical symptoms compatible with a recent hip fractures. On physicalexamination patient presented kyphosis, hypostaturality, finger abnormalities. Of laboratory rele-vance there were: low grade anemia with feature of microangyopathic anemia, elevated alkalinephosphatase , moderately increased serum creatinine level ( 3,4 mg/dl) , nephrotic syndrome, pho-sphorus 5,7 mg/dl , low calcium 4 mg/dl, increased PTH level , low 1,25(OH)2D3. Ultrasoundexamination revealed small hyperechoic kidneys with disorganized structure, compatible with chro-nic glomerulonephritis. Thyroid CT : thyroid and parathyroid structures in normal upper limits. Im-munological tests for SLE were negative. Radiographs: demineralization with subperiosteal erosionsand terminal resorbtion in the phalanges, pepper pot appearance on lateral radiographs of theskull and femoral neck fracture , kyphoscoliosis. Clinical, laboratory and radiological data are fea-ture of long-standing hyperparathyroidism in a patients with silent glomerulonephritis and possi-ble previous vitamin D deficiency due to multiple pregnancies and a reduced alimentary intake.Conclusion : Renal osteodystrophy develops at the early stages of chronic renal failure covering alarge spectrum of abnormalities. . Increased PTH secretion is associated in most cases with diffusehyperplasia of parathyroid tissue. Vitamin D deficiency is one of major pathogenic factors for renalosteodystrophy via secondary hyperparatiroidism and osteomalacia via hypocalcaemia. 71
  • 75. Oral Communications Saturday, May 10, 2008CARDIOVASCULAR DISEASE
  • 76. 1. GENETIC POLYMORPHISMS THAT INFLUENCE LONG TERM RISK OF 2. INTERLEUKIN 6 PLASMA LEVELS PREDICT WITH HIGH SENSITIVITY ANDMAJOR ADVERSE CARDIAC EVENTS AFTER PERCUTANEOUS CORONARY SPECIFICITY CORONARY STENOSIS DETECTED BY CORONARY ANGIOGRAPHYINTERVENTION Alberto Notarbartolo, Davide Noto, Santina Cottone, Vincenzo Pernice,, Salvatore Amato,M.I. Mendonça, A.I. Freitas, A. Pereira, A.C. Sousa, P. Faria, S. Gomes, N. Santos, B. Silva, Floriana Di Bella, Emanuela Fertitta, Giovanni Cerasola, Maurizio Rocco AvernaM. Serrão, S. Freitas, I. Ornelas, A. Brehm, A. Cardoso Background: new biomarkers able to measure the coronary atherosclerotic burden have been in-Introduction: In spite of drug eluted stents, double anti-platelet aggregation and statin therapy, the vestigated in recent years. The aim of the study is: a) to measure plasma levels of four biomar-occurrence of precocious restenosis and late major adverse coronary events (MACE) remains si- kers: C reactive protein (CRP), soluble intercellular adhesion molecule-1 (sICAM-1), interleukin 6gnificant. Artery morphology, medical therapy or the presence of risk factors, cannot totally ex- (IL-6), 8-isosprostane (8-ISO), in a series of patients undergoing coronary angiography; b) to as-plain those complications. Genetic background namely through the expression of several sess the power of the biomarkers to predict critical coronary stenosis detected by angiography. Me-polymorphic genes that codify for endothelium proliferation and/or platelet aggregation, can con- thods: among 438 subjects undergoing coronary angiography 160 patients with 0,1,2,3 criticaltribute to explain MACE (death, non fatal acute myocardial infarction, unstable angina, and late vessels have been selected and biomarkers plasma levels have been measured in plasma sam-revascularisation), after percutaneous coronary intervention (PCI). Aims: To study which rennin an- ples obtained before the procedure. The best resulting biomarker has been then assayed in 120giotensin axis polymorphisms, influence the emergence of MACE, after PCI. Methods and Po- patients with critical stenosis and 120 unmatched patients without stenosis. Results: The four bio-pulation: Prospective observational study of 189 consecutive patients (54.9&#61617;10 years) with markers plasma levels increased with the number of diseased vessels. All biomarkers were goodsymptomatic coronary artery disease who underwent successful coronary stent implantation from predictors of critical stenosis in 160 patients (ROC areas; CRP=0.880, IL-6=0.936, sICAM-1=0.907,November 2001 and December 2003, with a medium follow up 3.8±1.5 years. Long term clini- 8-ISO=0.873). IL-6, the best predictor, was confirmed in an extended sample of 240 subjectscal outcome was prospectively evaluated and the rates of MACE (death, non fatal acute myocar- (ROC area=0.959) with a threshold of 3.6 ng/L showing a 100% sensitivity (120/120) and a 90%dial infarction, unstable angina, and late revascularisation) were obtained. The environmental, specificity (108/120). Conclusions: IL-6, sICAM-1, CRP and 8-ISO are predictive of CAD. IL-6 pre-clinical and biochemical variables, were studied as well as ACE (I/D), ACE 8 A2350G, Angioten- dicts critical coronary stenosis with the highest sensitivity and specificity.sinogen AGT T174M and M235T, ATIR A1166C, Paraoxonase 1 (PON1) L55M; Q192R, and IIIaGlycoprotein (PLA1/PLA2) polymorphism. The frequency of MACE was analysed and the groupswith and without MACE, were compared by Chi square test and Student T test. Through a logi-stic regression (Cox’s multivariate analysis), we studied which variables were, in a significant andindependent way, associated with the emergence of MACE. The frequency with which MACE oc-curred during the follow up period in the carriers of ACE I/D polymorphism, was evaluated bythe Kaplan Meier test. Results: 71(38.6%) of the patients with a median age of 56,2±9,2 years,presented MACE. Of these, 9 (10%) were lost to follow-up. Pulse wave velocity (VOP), p=0.003);Leucocytes, p<0. 0001; Lipoprotein (a) p=0.055, Fibrinogen, p=0.010, Angiotensinogen AGTT174M (p=0.033) and ECA I/D (p=0.047) polymorphisms, were significantly and independentlyassociated with the late occurrence of MACE. D allele homozygote had a lower percentage ofMACE (death, non fatal acute myocardial infarction). Conclusion: ACE II, ID and AGT MM ge-notype patients, presented more MACE after PCI, in a significant way. In the DD genotype pa-tients, a careful secondary prevention with ACE inhibitors and &#946; blocker’s can be justified.Eventually in certain genetic polymorphisms less responsive to medical therapy with &#946; bloc-kers or ACE inhibitors, like II or ID genotypes, the possibility of surgical revascularization, with thepurpose of reducing mortality and major adverse events, can be admitted.3. RELATIONSHIP OF SOLUBLE CD40 LIGAND TO VASCULAR ENDOTHELIAL 4. GENDER DIFFERENCES IN CARDIAC STRUCTURE AND FUNCTION INGROWTH FACTOR, ANGIOPOIETINS AND TISSUE FACTOR IN ATRIAL NORMOTENSIVE DIABETIC PATIENTSFIBRILLATION: A LINK BETWEEN PLATELET ACTIVATION, ANGIOGENESIS M. Picca, F. Agozzino, GC PelosiAND THROMBOSIS?Anirban Choudhury, Jeetesh Patel, Gregory Lip Introduction: Diabetes mellitus increases the incidence of myocardial infarction, claudicatio and stroke more in women than in men. Left ventricular hypertrophy is a powerful independent riskBackground: The precise pathophysiological processes underlying the prothrombotic or hyper- factor for cardiovascular morbidity and mortality among hypertensive patients. Data regardingcoagulable state in atrial fibrillation (AF) remain uncertain. We hypothesized a relationship between relationship between diabetes and left ventricular hypertrophy are inconclusive whereas recent stu-abnormal platelet activation, angiogenic factors and coagulation, thereby contributing to increa- dies suggest an increased prevalence of left ventricular hypertrophy in hypertensive women withsed thrombogenecity. Methods: Plasma levels of soluble CD40L (sCD40L, an index of platelet ac- type 2 diabetes mellitus. Objective: The aim of this study was to assess the presence of gendertivation) and tissue factor (TF, an index of coagulation), as well as the angiogenic factors, vascular differences in left ventricular geometry and function in normotensive patients (pts) with type 2 dia-endothelial growth factor (VEGF), angiopoietin-1 (Ang-1) and angiopoietin-2 (Ang-2), were mea- betes mellitus. Materials and methods: Fourthy-eight consecutive pts(26 males, 22 females, meansured by enzyme-linked immunosorbant assay (ELISA) in 59 chronic AF patients. Data were com- age 60.5±11.9 years) with type 2 diabetes mellitus and normal systo(S)-diastolic (D) blood pres-pared to 40 age- and sex-matched healthy controls in sinus rhythm. Results: AF patients had sure (BP) in the absence of specific anti-hypertensive therapies were enrolled. All pts underwentsignificantly higher levels of sCD40L (p=0.038), VEGF (p=0.023) and Ang-2 (p<0.001) but not to clinical examination and laboratory investigations with the dosage of microalbuminuria (Mi) andAng-1 (p=0.363) compared to controls. Tough AF patients not on warfarin had significantly higher plasma (Pl) levels of creatinine (Cr), glucose(Gl) and glycosylated haemoglobin (Gh). The pre-levels of TF than the controls (p=0.043), in the entire cohort of AF patients (compared to controls) sence of Mi was defined as an albumin excretion rate >or=30 mg/24h. An echocardiographic andthis failed to achieve statistical significance (p=0.077) in view of overlap between the two groups. Doppler study was performed to determine left ventricular mass index (LVMI), relative wall thick-This might be due to the significantly lower levels of TF amongst AF patients on warfarin than ness (RWT), the ratio between the observed value of midwall fractional shortening (mFS) and thatthose not anti-coagulated (p=0.042). Amongst AF patients, sCD40L levels correlated strongly with predicted on the basis of the circumferential end-systolic stress, and the ratio between the peaklevels of VEGF (Spearman, r=0.919, p<0.001) and Ang-2 (r=0.546, p=0.002). VEGF levels were early and atrial transmitral flow velocities (E/A). Results: Males (n=26) Females (n=22) Age (years)significantly correlated with Ang-2 (r=0.490, p<0.001) and TF (r=0.298, p=0.044). In multivariate 59.1±10.0* 61.6±12.0 BMI (Kg/m2) 26.6±2.3* 27.2±2.3 SBP (mmHg) 123±8* 125±13 DBPregression analysis, sCD40L levels were independently associated with VEGF (p=0.003) and Ang- (mmHg) 78±5* 80±6 Pts with Mi 7/26* 9/22 Pl Cr(mg/dl) 1.00±0.13* 0.93±0.26 Pl Gl(mg/dl)2 (p=0.005). Conclusions: Plasma levels of sCD40L are elevated in patients with AF and related 125±9* 126±10 Gh (%) 6.3±0.9* 6.4±1.1 LVMI (g/m2.7) 39.2±8.5* 38.8±8.8 RWT 0.38±0.03*to VEGF, Ang-2 and TF. This interaction between platelets, angiogenic markers and TF may play 0.39±0.05 Predicted mFS (%)104±8* 106±10 E/A 0.84±0.21** 0.66±0.20 *not significant com-a role in the generation of the prothrombotic state associated with AF. pared with Females **p<0.02 compared with Females Conclusions: according to our data, gen- der is not associated with significant differences in left ventricular geometry and systolic function in normotensive type 2 diabetic pts; the greater prognostic impact of diabetes mellitus observed in women could be independent from these features. The specific role of left ventricular diastolic dysfunction remains to be assessed. 73
  • 77. 5. THE ASSOCIATIVE THERAPY SIMVASTATIN+EZETIMIBE IS USEFUL TO 6. DETERMINANTS OF PLATELET ACTIVATION IN HEART FAILUREACHIEVE THERAPEUTIC GOAL IN MODERATE-HIGH RISK PATIENTS Francesca Santilli, Stefania Basili, Stefano Lattanzio, Adele Cavoni, Giuseppe Guizzardi,Vitaliano Spagnuolo, Gaetano Mauro, Maria Ferraro Lucrezia De Feudis, Giancarlo Traisci, Giovanni Ciabattoni, Giovanni Davì, Carlo PatronoIn the ACC/AHA Task Force on Practice Guidelines are pointed out the importance to get lower Introduction: Thromboembolism is a critical and relatively common complication of chronic heartLDL levels respects the values achieved in the normal clinical practice. Similar to the hypertension, failure (HF). Methods: We performed a cross-sectional study in 84 HF patients [33 M; 81±8 yr;the fixed associative therapy could be useful to reach the therapeutic goal in hyperlipidaemic sub- 49 in I-II, 35 in III-IV New York Heart Association (NYHA) class] and 42 controls, using urinaryjects. In fact, associative therapy lowers cholesterol reducing the biosynthestis (statins) end lowe- (U) 8-iso-prostaglandin (PG) F2alpha and 11-dehydro-thromboxane (TX) B2 as non-invasive in-ring the absorption [ezetimibe (E)]. Moreover, the fixed associative therapy improves the therapy dexes of oxidative stress and platelet activation, respectively, B-type natriuretic peptide (BNP) ascompliance because patient get just a pill daily. Actually, the only available fixed associative the- a biomarker of cardiac function, plasma asymmetric dimethylarginine (ADMA) as an index of en-rapy is formed by simvastatin (S) ed E (Inegy®, Vytorin®). In our office, we evaluated the achie- dothelial dysfunction, C-reactive protein (CRP) and sCD40 ligand (sCD40L) as markers of in-ving of therapeutic goal (LDL <100 mg/dl) in moderate-high risk hyperlipidaemic patients using flammation. Results: Forty-two HF patients not on aspirin treatment had significantly higherS+E 40+10 mg fixed therapy once a day. Moreover, we evaluated the difference of the principal U-11-dehydro-TXB2 excretion [Median (IQR): 1488(824-2130) vs 440(313-611) pg/mg cr], 8-iso-lipidic parameters after the beginning of the therapy. Forty moderate-high risk hyperlipidaemic pa- PGF2alpha [528(430-702) vs. 304(228-364) pg/mg cr], BNP [363(196-659) vs 78(56-98)tients were enrolled (18 male; 22 female). The medium age was 53.4±11.1 years. All the data are pg/mL], ADMA (1.6±0.5 vs 0.5±0.2 micromol/L), CRP [1.74(0.98-2.7) vs 0.5(0.4-0.7) mg/L] andavailable for 38 of the 40 patients. After three months the beginning of the fixed therapy, 32 pa- sCD40L levels [1342(653-2320) vs 432(322-840) pg/mL] (all p<0.0001) than controls. Forty-tients (78.9 %) have reached the given therapeutic goal. The levels of cholesterol decreased of two HF patients on low-dose aspirin showed significantly lower 11-dehydro-TXB2 [343(227-455)45.09% (from 275±41.1 to 151±32.2 mg/dl). The levels of HDL raised of 4% (from 49±8.65 to pg/mg cr, p<0.007] and sCD40L levels [820(535-1160) pg/mL, p<0.02] than HF patients not on50±8.9 mg/dl). The levels of trglycerides decreased of 30.5% (from 199±91.8 to 139±82 mg/dl). aspirin. Patients in NYHA classes III-IV showed higher U-11-dehydro-TXB2 excretion than pa-Overall, the levels of LDL decreased of 59.72% (from 185.995±41.66 to 74.91±31.01 mg/dl). The tients in I-II classes, independently of aspirin treatment (p<0.05). In the 42 HF patients not onfixed hypolipidaemic therapy with S+E is useful to achieve the therapeutic goal in moderate-high aspirin, U-11-dehydro-TXB2 was correlated with BNP (Rs=0.59), 8-iso-PGF2alpha (Rho=0.58),risk patients. and CD40L (Rs=0.61) (all p<0.0001). Multiple regression analysis revealed that higher BNP levels (Beta Coefficient=0.74), no aspirin therapy (-0.41), and higher sCD40L levels (0.32) (all p<0.0001), independently predicted the excretion rate of 11-dehydro-TXB2 in the 84 pts. Conclusions: Per- sistent platelet activation characterizes patients with heart failure.This phenomenon is related to di- sease severity and is largely suppressable by low-dose aspirin.7. PREVALENCE OF CORONARY ARTERY DISEASE AND PLAQUE MORPHOLOGYASSESSED BY MULTI-SLICE COMPUTED TOMOGRAPHY CORONARYANGIOGRAPHY IN ASYMPTOMATIC PATIENTS WITH VERY HIGHCARDIOVASCULAR RISKR. Nasti, M.L. Mangoni, R.R. Auriemma, S. Esposito, L. Picardi, O. Carbonara, A. Ascione,F. Zibella, R. DUrso, R. Torella, F.C. SassoCardiovascular complications, including coronary artery disease (CAD), are the leading causes ofmorbidity and mortality in individuals with type 2 diabetes mellitus. The 10-year mortality in pa-tients with known CAD and diabetes exceeds 70%. Diabetic nephropathy allows us to identify agroup of patients at very high cardio-renal risk. Recently, multi-slice computed tomography(MSCT) has been proposed as an alternative imaging technique for the evaluation of patientswith known or suspected CAD. MSCT allows anatomic, non-invasive imaging of the coronary ar-teries, including detection of coronary atherosclerosis by assessing the coronary artery calciumburden (calcium scoring) and performing non-invasive angiography. This technique has the ca-pacity to detect CAD at an early stage. The recent 64-slice MSCT showed high sensitivity and spe-cificity for the detection of significant (&#8805;50% luminal narrowing) stenosis, and thistechnique has been validated. We have enrolled 18 patients (mean age 61+8) following these in-clusion criteria: type 2 diabetes, microalbuminuria (AER >30 <300 mg/24h), macroalbuminuria(AER>300 mg/24h), severe diabetic retinopathy, stress and rest single photon emission compu-ter tomography test negative for inducible myocardial ischemia, age >40 years. Patients were stu-died with 64 slice TC. Cardio-MSCT showed following results: nine patients (50%) showobstructive plaques, 5 patients (27,7%) had calcified and mixed non obstructive plaques (<50%),three patients (16,6%) did not show any coronary plaques. Nine patients with obstructive plaquesperformed an invasive coronary angiography. MSCT detected a high prevalence of CAD in asym-ptomatic patients with type 2 diabetes with diabetic nephropathy, without history of coronaryheart disease, and negative for inducible ischemia to traditional screening. In conclusion MSCTresults useful for early diagnosis of coronary heart disease in patient with type 2 diabetes and dia-betic nephropathy. 74
  • 78. Oral Communications Saturday, May 10, 2008EMERGENCY MEDICINE
  • 79. 1. CLINICAL CHARACTERISATION AND CORRELATES OF ANEMIA IN A COHORT 2. OPTIMIZING RESUSCITATION DECISIONS IN A UK DISTRICT GENERALOF ELDERLY PATIENTS WITH ACUTE CARDIOGENIC PULMONARY OEDEMA HOSPITAL - AN AUDIT OF CURRENT PRACTICEGiovanna Graziadei, Christian Folli, Valeria Savojardo, Annamaria Brambilla, Ciro Canetta, P.S.A de Silva, A.N. de SilvaRoberto Cosentini, Angelo Rovellini and Valter Monzani Preference: Poster presentation Introduction: For many patients receiving care in hospital, the li-Aims. The clinical characteristics of anemia are poorly known in acute cardiogenic pulmonary oe- kelihood of cardiorespiratory arrest (CPR) is small so very often no clinical decision is made in ad-dema (ACPE). Moreover, the cut-off points of hemoglobin (Hb) concentration for diagnosis of vance of such an event. However, as healthcare professionals we have an important role in helpinganemia are frequently discordant. We aimed to characterise anemia in patients with ACPE by sick patients to reach a clear decision about their wishes in respect of CPR . This should be re-using the World Health Organization (WHO) criteria for diagnosis of anemia and to compare garded as a marker of good practice in any healthcare setting and the BMA (British Medical As-anemia status, as diagnosed according to the WHO criteria, to anemia status as diagnosed by re- sociation) and NICE (National Institute of Health and Clinical Excellence) have recommended thatstrictive criteria (Hb concentrations <12 gramms in men and <11 gramms in females). Methods this be an area of audit. Delay and inadequate documentation of a patient’s resuscitation statusand results. We evaluated 200 patients with ACPE. 37% had anemia according to the WHO cri- can lead to inappropriate arrest calls being made. It is important that whenever possible, every op-teria. Anemic patients were older, had higher serum creatinine, I-Troponin and C-reactive protein, portunity be given for patients to make an informed decision about their resuscitation status. Cur-and lower total and LDL-cholesterol, blood iron, plasma albumin, arterial pCO2, and diastolic rent recommended local practice is that all patients should have a valid resuscitation decisionblood pressure than non-anemic patients. Anemic females had higher LVEF than males. On mul- made within 24 hours of hospital admission. If the decision is not for resuscitation then this deci-tivariate analysis, higher serum creatinine and lower serum total cholesterol were independent sion is to be documented in a clear, concise manner. It should be immediately visible in the pa-predictors of anemia in females, and higher serum creatinine, lower serum iron and LVEF in males. tient’s notes. There should be documentation whether this has been discussed withPatients with more severe anemia received CPAP- and nitrate treatment less frequently than non- patient/relatives/carer. Reasons not for resuscitation should be clearly stated. For this purpose,anemic patients. In males, anemia was prevalently normocytic, while 20% of anemic females had each patient’s admission booklet has a resuscitation decision proforma in a conspicuous place. Me-microcytic iron-deficiency anemia. By diagnostic restrictive criteria for anemia, the prevalence of thodology: Retrospective case note review of 30 deceased patients during a 2 month period. Theanemia decreased from 36 to 19.5 %. In females microcytic forms increased from 20 to 33%, admitting complaint, early warning score, recording of DNR (Do Not Resuscitate) decision and itswhile in males anemia remained predominantly normocytic. The susceptibility to CPAP treatment timing was recorded. The level of seniority in DNR decision making, discussion of resuscitatationdecreased from 72.2 to 61.5% of cases. Conclusion. Renal failure is a powerful predictor of ane- with patient, family or carer, documentation of reasons not for/or for resuscitation, time of deathmia, but the cause of anemia in ACPE is multifactorial, including inflammation status and malnu- after admission and incidence of prolonged CPR was recorded. Results: Total number of cases re-trition. Important clinical differences among gender are present in the anemic pattern, suggesting viewed was 30, 73.3% from the medical directorate. Average age 73.2 years. Age range 33-94.that sex-specific targets should be applied. Finally, the cut-off values of Hb concentration influence Underlying diagnosis pneumonia (6), carcinoma (9), CVA (3), sepsis (3), renal failure (2), IHD (1),the clinical features of the anemic population. bowel infarction (1), ALD(1), upper GI bleed (1) dementia (1), myelofibrosis (1), fracture neck of femur (1). Decisions were made not for CPR in 28/30 (93.3%). 39% had decision made within 24 hours and 46.6% within 48 hours. 75% (21) had decision made within 1 week. Duration of decision making varied from within 24 hours to 53 days. 39.3% (11) of DNR decision were made by a consultant and reindorsed in a further 7 (25%). 50% (14) were made by registrars and the rest by F2’s. 50% of F2 & 45% of registrar DNR decisions were discussed with a senior collea- gue. 1 DNR decision was reversed by a senior. Resuscitation discussed with patient 3 (10%). Di- scussed with relative 13 (43.3%) Discussed with carer 2 (6%). Total not discussed 14 (46.6%). Reason not for resuscitation documented in 20/28 (71.4%). Not for resuscitation documented on relevant proforma in 26 (86.6%). None of the patients were subjected to inappropriate CPR. 20% died within 24hrs and 23% within 48hrs. Conclusion: Timing of resuscitation decision making re- mains highly variable. The audit highlights how despite leading to >85% documentation of DNR decisions, a resuscitation decision making proforma in admission booklets does still not lead to ma- king earlier decisions regarding CPR status in a busy district general hospital or increase discus- sions with patient/family regarding the above. Further emphasis and training is necessary to ensure that all aspects of this sensitive issue including documentation are consistently addressed.3. ACUTE INTERNAL MEDICINE - DONT FORGET THE BASICS! 4. REPRODUCIBILITY OF A TRIAGE TOOL FOR ACUTE ADMISSIONSJ Gallagher, Z Memon, CS Mobed Farrah Bakr, Abhijit Chakrobathi, Christian P SubbeIntroduction: Junior doctors are often the first to assess and institute treatment in critically ill pa- Introduction: The Simple Clinical Score (SCS) has been shown in a previous study [1] to accura-tients. This study attempted to determine the level of knowledge about basic aspects of acute tely stratify patients into high and low risk of death up to 30 days after admission to hospital. Thecare among a group trainee doctors and to assess if attendance at life support courses influenced aim of this study was to assess the reproducibility of the SCS. Design: Prospective cohort studythis knowledge. Method: A questionnaire was distributed to trainees. The questions determined Methods: Over a period of three days 88 acute medical admissions were recruited. Variablesadvanced life support courses attended in the previous 2 years and questions regarding common (age, vital signs, mental status, functional capacity, prior illnesses, ECG findings) were collectedaspects of acute care. Results: 45 questionnaires were returned. 1 respondent did not identify from the admissions notes. Data was collected by two members of staff independently. An algo-their grade and was excluded from the analysis. 62.5% - 87.5% of respondents had attended a rithm for discharge from hospital and admission to critical was tested at the same time. Results:basic life support or advanced life support course in the previous 2 years. 40.5% of doctors cor- The assessors agreed on the score for each patient in 60% of cases, with differences by 1 pointrectly identified the correct purpose of a reservoir bag on an oxygen mask, 10.5% correctly iden- in 7%, 2 points in 28%, 3 points in 1% and 4 points in 3%. The differences in total score weretified the percentage of people surviving to discharge following in-hospital cardiac arrest 62% statistically different (Wilcoxon signed-rank Test, p< 0.049). The 3 variables whose scores by thecorrectly identified factors affecting pulse oximetry 60.1% correctly identified a normal capillary two assessors were statistically different (Wilcoxon signed-rank < 0.05) were altered mental sta-refill time 29.8% correctly identified the normal minimum urine output 39.9% correctly identified tus (p-value 0.046), presence of an abnormal ECG (p-value 0.007) and functional capacity (p-valuewhen a patient required intubation to protect their airway. Results were further analyzed based 0.005). In 91% of cases the assessors agreed on the decision to discharge and in 94% of admis-on the grade of doctor. Conclusion: Our study demonstrates that a significant number of doctors sions agreed on the decision to send the patient to critical care. Discussion: Overall reproducibi-have deficiencies in their knowledge of basic principles of acute care. This is despite the majority lity of results was satisfactorily. Assessment of the three variables with poor reproducibility mighthaving attended life support courses recently. This may influence patient management and fur- be improvable by training. An interpretation of the ECG by a software algorithm would assure ather education in these areas is required. more uniform interpretation. Importantly agreement of assessor on scores for discharge and ad- mission to critical care was good. The Simple Clinical Score could be a useful tool in the triage of patients admitted to Acute Medical Admissions Units to shorten length of stay in low risk patients and improve safe care of high risk patients. [1] Kellett, J et al. Q J Med 2006:99:771-81. 76
  • 80. 5. ACUTE INTOXICATIONS IN THE DISTRICT GENERAL HOSPITAL EMERGENCY 6. OUTCOMES OF IN-HOSPITAL ADULT CARDIOPULMONARY ARRESTDEPARTMENT DURING A 6 YEAR PERIOD Haris M, Agarwal S, Safdar A, Attar MN, Williams JGJardim M., Silva A.S., Granito S., Freitas J.M., Gaspar J., Silva S., Brazão M.L., Chaves A.,Freitas D., Vieira R., Nóbrega J. A. Aims: To evaluate the clinical characteristics and outcomes of in-hospital adult patients who had cardiopulmonary arrest and received cardiopulmonary resuscitation (CPR). Methods: Retrospec-Objectives: To determine the incidence of acute intoxications in Madeira Islands. Material and tive, observational study of 133 consecutive patients, experiencing 143 episodes of in-hospital car-Methods: The clinical charts of 1400 patients admitted to the emergency department in Madeira diopulmonary arrest over a 24-month period. Primary end-points include return of spontaneouswith the diagnosis of acute intoxication were consulted, from 2001 to 2006. The following para- circulation (ROSC), survival to hospital discharge, 30-day survival and 1-year survival. Results: 133meters were considered: area of residence, season, poison, mortality, age and sex distribution, patients with a mean age 70 (range 24-92) years; female: male 72(54%): 61(46%). 133(93%) epi-number of events and intent. Discussion and Conclusion: 1400 patients were admitted in the sodes were cardiopulmonary arrests whereas 10(7%) were primary respiratory arrests. 98 episo-emergency department from 2001 to 2006 due to acute poisoning. 50.2% were female and des were witnessed, 27 unwitnessed and no record was available for 18 episodes. On initial49,8% male. The incidence was higher in 13 to 20 years and 21 to 30 years age group, with most assessment, majority (73%) of the patients had non-shockable rhythm. The mean number of CPRevents occurring during spring. Most patients originated from the areas with the highest popu- cycles were 3 (median 3, range 1-12). 65(45%) patients were intubated during CPR. 49(34%) pa-lation density. Most were suicide attempts recurring to analgesics and psychiatric drugs. Alcohol tients received defibrillation, 112(78%) had adrenaline, 80(60%) had atropine, 13(9%) had amio-and pesticides were the most common substance used when not recurring to drugs. 81% of pa- darone and 1 received sodium bicarbonate. 14 patients underwent postmortem following failedtients were discharged and 6% admitted to the medical ward for further treatment and investi- CPR. 53(37%) patients were successfully resuscitated, of which 27(51%) were discharged from thegations. Mortality was approximately 3%. The authors underline the high percentage of alcoholic hospital. 30-day survival following cardiopulmonary resuscitation was 20% and 1-year survivalintoxications, in a community with a high incidence of alcohol abuse. Furthermore, although there was 13%. It was noted that in patients with primary respiratory arrest, successful resuscitation wasis a relatively low mortality, the morbidity related to this phenomenon is high which will require achieved in 90% cases, and 1-year survival was 60%. Conclusions: Inspite of effective advancedthe close monitoring and guidance from health professionals and the Portuguese health system. life support training and early identification of critically ill patients, the overall outcome followingKey Words: Suicide, poisons, organophosphorous poisoning. in-hospital cardiorespiratory arrest remains poor.7. FACTORS PREDICTING SURVIVAL FOLLOWING IN-HOSPITALCARDIORESPIRATORY ARRESTHaris M, Agarwal S, Safdar A, Attar MN, Williams JGBackground: Both short term and long term survival of patients following in-hospital cardiopul-monary arrest has been poor, although there is evidence suggesting some improvement in sur-vival over recent years. This is attributed to intensive life support training and early identificationof critically ill patient. Aims: To evaluate the factors predicting short term and long term survivalfollowing cardiorespiratory arrest. Methods: Retrospective, observational study of all cardiore-spiratory arrests over a 2-year period in a district general hospital setting. Data was retrievedfrom cardiac arrest data collection form based on Utstein template. Case notes were also revie-wed. Results and conclusion: Of the 143 cardiopulmonary arrests, 133(93%) episodes were car-diorespiratory arrests whereas only 10(7%) were primary respiratory arrests. Successfulresuscitation was achieved in 37%. 1-month survival following cardiopulmonary resuscitationwas 20% and 1-year survival was 13%. Non-shockable rhythm at arrest and need for adrena-line and atropine during CPR were associated with poor outcomes (P<0.05). Intubation duringCPR was associated with poor outcomes at 1-month (P=0.02) and 1-year (P=0.05). Witnessed ar-rests had favourable immediate outcome (P=0.01). The median number of CPR cycles in thesurvival group was 1, compared to 3 in the non-survival group. There was no statistically signi-ficant difference in survival with increasing age. Primary respiratory arrest was associated with bet-ter outcome with 1-year survival of 60%. 77
  • 81. Oral Communications Saturday, May 10, 2008 CLINICAL CASES
  • 82. 1. SUCCESSFUL CONTROL OF BLEEDING WITH RECOMBINANT ACTIVATED 2. AN ATYPICAL CASE OF TYPICAL CHEST PAINFACTOR VII (FVIIA) AFTER CARDIAC RE-TRANSPLANTATION IN A PATIENT Francesco Casella, Ilaria Bossi, Giuseppina Pisano, Nicola Montano,ON AGGRESSIVE ANTIPLATELET TREATMENTRosina Albisinni, Ciro Maiello, Nicola Galdieri, Enrico Ragone, Hypothyroidism may present with symptoms and electrocardiographic abnormalities suggestiveEmanuele Durante-Mangoni, Riccardo Utili of ischemic heart disease. We describe the case of 68 years old woman who presented to emer- gency department for a 2-weeks history of chest pain on exertion. The electrocardiogram (ECG)Introduction: Bleeding complications after cardiac surgery are an important cause of morbidity and showed sinus bradycardia ( 48 bpm ) and inverted T-waves in anterolateral chest leads. A coro-mortality. Standard management of post-operative bleeding includes transfusion of blood products nary computed tomography angiogram was performed showing normal coronary arteries. La-and surgical re-intervention which in turn increases costs and morbidity. Control of post-operative boratory investigations revealed a severe hypothyroidism with strongly positive thyroidbleeding is thus crucial in modern patient care. Case report: A 48-yr old woman underwent heart autoantibodies. A therapy with levothyroxine was started which led to remission of chest paintransplantation for dilated cardiomyopathy. She had common cardiovascular risk factors as well and a regression of T-wave inversion on electrocardiogram. An association of angina pectoris andas inherited thrombophilia (heterozigosity for prothrombin G20210A mutation and homozigosity hypothyroidism had already been reported by Toft et al., who observed that approximately 3%for MTHFR C677T with hyperhomocysteinemia). After transplant, she was put on statin and aspi- of patients with longstanding hypothyroidism suffer from chest pain. This association was thoughtrin (100 mg/d). However, due to vascular graft disease, in addition to percutaneous coronary in- to be mediated through hyperlipidemia which may predispose to coronary artery disease As intervention, she received aspirin (100 mg) in combination with clopidogrel (75 mg/d). Despite this our case, there are reports presenting hypothyroid patients who had chest pain and abnormal elec-treatment, her graft coronary disease worsened rapidly, and cardiac decompensation developed. trocardiographic findings, but normal coronary angiograms. The most common ECG changesUrgent cardiac re-transplantation was then needed in this patient on double anti-platelet regi- observed were sinus bradycardia, prolonged QT interval or inverted T waves. In several cases ofmen, which was followed by a significant post-operative bleeding, blood loss reaching 3500 mL hypothyroidism even elevations of cardiac troponin and evidence of actual myocardial damage byover a 6-h period. Despite infusion of >4000 mL of blood products (packed red blood cells, fresh- cardiac magnetic resonance imaging (MRI) have been described. In view of these findings, ourfrozen plasma, platelet concentrates), she developed haemorrhagic shock. A 70 &#956;g/kg hypothesis is that chest pain, ECG changes and cardiac troponin elevation described in hypothy-bolus of recombinant activated factor VII (rFVIIa) was then infused, with an immediate, dramatic roid patients with normal coronary angiogram, may reflect actual diffuse myocardial injury. Sincereduction of blood losses to 50 mL/h: within 12 hrs the patient recovered her circulatory ad re- hypothyroidism was shown to be a possible etiology in subjects with symptoms suggestive ofspiratory function. She is now doing well, with a normal cardiac function and no further throm- ischemic heart disease and normal coronary angiograms, a thyroid hormone deficiency should al-botic complications. Discussion: This is the first reported case of successful bleeding control with ways be considered in this setting.rFVIIa after emergency cardiac re-transplantation in a patient undergoing aggressive anti-platelettreatment. Activated rFVIIa appears thus promising in critical care settings where severe post-ope-rative bleeding occurs due to treatment with anticoagulant or antiplatelet drugs.3. MENTAL NERVE NEUROPATHY: REPORT OF TWO CASES 4. UN UNUSUAL CASE OF EPIDURAL ABSCESS OF THE THORACIC SPINE INMR. Atienza, R. García-Contreras, JM. Varela, I. Martín-Garrido, S. Gutierrez-Rivero, A DIABETIC WOMANFJ. Medrano, E. Calderón. M.A. Di Sarli, S.PappagalloBackground: Mental nerve neuropathy (MNN) is characterised by hypoaesthesia or paresthesia Una signora di 61 anni si presentava al P.S. accusando intenso dolore in regione dorsale e alof the chin and lower lip, that is, the region nerved by the mental nerve. This is rare seemingly fianco sinistro (sn). In data 23.05.07 era comparsa dolorabilità in regione dorsale e lombare, in-harmless symptom but is frequently associated with cancer. Its frequency is difficult to know be- terpretata dal MMG come colica renale e trattata con FANS, senza remissione della sintomato-cause only a few small series or isolated cases are reported, and also, because this symptom is not logia. Alla visita in P.S., in data 25.05.07 , veniva riscontrata dolorabilità alla base dell’emitoracevery diagnosed. This syndrome can precede the diagnosis of malignancy or appear at the time sinistro alla digitopressione e Giordano sinistro positivo. Fu sottoposta a Rx torace (negativo) e aof tumour progression or recurrence. When it appears, it is the harbinger of a worst prognosis. ECT addome (microlitiasi caliceale sinistra e ispessimento ansa intestinale in emiaddome sinistro).The mechanism whereby MNN occurs in relation to distant neoplasia remain unknown althought Gli esami ematochimici eseguiti evidenziavano solo un aumento del fibrinogeno, con Globuliseveral hypotheses have been proposed: compression of the mental or the inferior alveolar nerve bianchi 10.000. La paziente, trattata con FANS ed antispastici con attenuazione della sintomato-by metastases to the mandibule or intracranial involment of the mandibular nerve by metastases logia, fu dimessa con terapia antidolorifica. Si ripresenta al PS, in data 27.05.07, con dolorabilitàat the base of the skull; leptomeningeal seeding, neoplastic perineural infiltration of the mental alla percussione delle apofisi spinose dorso lombari e lungo i muscoli paravertebrali. E’apiretica ,nerve and lymphatic or haematogenous spread to the central nervous system. The neoplasms non presenta segni di deficit motori e sensitivi agli arti o deficit atassici in atto, l’addome è tratta-more frequently associated with MNN are breast cancer and lymphoproliferative diseases al- bile con lieve dolorabilità alla palpazione profonda in fossa iliaca sn. Viene sottoposta a Rx direttathough are reported related to lung cancer, colon and rectum cancer, ovarian carcinoma, prostate addome (negativo), ad esami ematochimici che evidenziano leucocitosi (GB 13000) ed aumentocancer. We have not found any case of gastric carcinoma in reviewed literarature. Case 1 Case 2 del fibrinogeno rispetto al precedente controllo. La terapia antidolororifica con FANS non dà nes-SEX Female Male AGE Sixty six Sixty six NEOPLASM Gastric Prostate adenocarcinoma adeno- sun risultato, per cui si somministrano oppiacei con lieve beneficio. Data la sofferenza e lo scarsocarcinoma STATUS MNN precedes Progressive diagnosis of disease MECHANISM Bone meta- miglioramento con gli oppiacei, si decide di tenere in regime di Osservazione la paziente pressostases Bone metastases in base of skull NEUROLOGICAL Paralysis of FINDINGS sixth nerve No una U.O.C. di degenza. La paziente, durante il ricovero viene sottoposta a TC torace, data la sin-SURVIVAL Three months Two months Comments: In the first case, MNN was associated with ga- tomatologia refrattaria alla terapia analgesica, nel sospetto di Embolia Polmonare o di Disseca-stric adenocarcinoma, which is a type of neoplasm not described in the literature and preceded zione Aortica, con risultato negativo. Allo stesso esame TC vengono segnalate alcune minuscoleto the diagnosis of disease. However, the second case is related to prostate cancer which is more bolle aeree all’interno del canale vertebrale, posteriormente al midollo dorsale alto, riferibili infrequently reported. In both cases the appareance of the mental nerve neuropathy was a sign of prima istanza a degenerazione vacuolare gassosa di un’articolazione interapofisaria. La visita Neu-bad prognosis. rologica, eseguita il 30.05.07, rileva una viva dolorabilità alla percussione delle apofisi spinose nella metà superiore del rachide dorsale, senza irradiazione radicolare e senza nessun segno di interessamento del midollo spinale ( assenza di deficit motori e sensitivi nei 4 arti). In data 01.06.07, data la persistenza della sintomatologia nonostante la terapia con oppiacei, viene richiesto un nuovo controllo neurologico che evidenzia la comparsa di ipopallestesia negli arti inferiori e atas- sia nella stazione eretta, senza segni di tipo cerebellare. Viene quindi eseguita RMN d’urgenza per una migliore definizione dei reperti segnalati dalla TC precedente. La RMN evidenzia la pre- senza di bolle aeree all’interno del canale vertebrale all’altezza di D1-D6, posteriormente e postero- lateralmente a sn, che depongono per lesione epidurale. Viene quindi trasferita in Neurochirurgia a Firenze, dove una RMN successiva del rachide dorsale, in data 02.06.07, evidenzia la presenza di raccolta fluida, verosimilmente flogistica, a sede epidurale posteriore D1-D9, improntata la dura posteriormente e improntato anche il midollo a sede D2-D5, sottile raccolta localizzata anche a livello epidurale anteriore C7-D1. Viene sottoposta d’urgenza a Laminectomia segmentale di D2 allargata verso l’alto e verso il basso che conduce ad una raccolta purulenta che si svuota spon- taneamente. L’esame colturale evidenzia una infezione da Streptococco gruppo B. Viene quindi sottoposta a terapia antibiotica specifica con netto miglioramento del quadro clinico e senza segni apparenti di deficit neurologici. L’ ascesso epidurale spinale risulta in Letteratura un evento raro. L’incidenza si aggira tra 0,2 – 2,8 casi per 10.000 ammissioni ospedaliere all’anno, con un picco tra 60 e 70 anni d’età. Molti pazienti hanno uno o più fattori predisponenti ( diabete, IRC, al- coolismo, infezioni HIV, trauma spinale, chirurgia spinale, procedure invasive a livello spinale a scopo diagnostico, terapeutico o posizionamento di stimolatori, iniezione di farmaci ev, infezioni, 79
  • 83. ecc.). I germi maggiormente implicati sono lo stafilococco aureo (nei 2/3 dei casi), lo S. Epider- 5. A CASE OF ACUTE HEPATITISmidis, lo Pseudomonas aeruginosa, ecc. La presentazione clinica è subdola e aspecifica, con do- Fiorentini Alessandra, Tofi Cristina, Salatino Bambina, Ronchini Ugo, Cricco Luigilore toracico o addominale che può avere più significati, particolarmente in pazienti con altrepatologie di base che possono ritardare la diagnosi, con il rischio di paralisi irreversibili o morte. A case of acute hepatitis we prefer to present abstract as an oral communication A 83 year-oldIl dolore posteriore è presente nei ¾ dei pazienti, la febbre in quasi la metà ed il deficit neurolo- man with medical history of ischaemic heart disease, mesenteric artery stenosis treated with per-gico in un 1/3 dei casi (disfunzione vescicale o rettale, plegia, radicolopatia/paresi). Questi sono i cutaneous transluminal angioplasty and stent placement, implantation a bi-atrial-ventricular per-tre più comuni sintomi di presentazione. La puntura lombare non è necessaria per il rischio di dis- manent pacemaker due to atrial fibrillation associated to sinus bradycardia, was admitted withseminare l’infezione a livello dello spazio subaracnoideo con conseguente meningite. Harvin et improvise new onset of shortness of breath. At the time of admission he was in mild congestivecoll. sostengono che il meccanismo patogenetico dell’ascesso epidurale spinale sia riconducibile cardiac failure, with a mildly raised jugular venour pressure at 3 cm but no other evidence of oe-all’ipossia determinata dalla compressione del midollo e al danneggiamento vascolare.E’ più fre- dema, ascites, or hepatomegaly. His electrocardiogram showed atrial fibrillation with rapid ventri-quente dove c’è uno spazio epidurale largo e ricco di grassi, come la porzione posteriore delle ver- cular response (130 beats/min). He was started on intravenous amiodarone. The results of initialtebre soprattutto a livello toraco-lombare. La diagnosi si fonda sul sospetto e la clinica di laboratory investigations were normal. Six hours after having started parenteral amiodarone, hepresentazione ( la combinazione di dolore resistente alla terapia analgesica vicino alle apofisi spi- developed biochemical alterations indicative of severe hepatic cytolysis associated with impair-nose delle vertebre con associata iperpiressia che precede in genere il deficit neurologico) e la dia- ment of the synthetic capacity. He became oliguric with increases in creatinine and urea. Theregnostica differenziale. L’esame GOLD STANDARD è la RMN, che permette di identificare il livello was a neutrophil leukocytosis. A toxic hepatitis was suspected and the amiodarone was stopped.e la estensione della lesione. La decompressione chirurgica rimane il trattamento principale degli The chimical and haematological abnormalities returned to normal in twenty days. Amiodaroneasccesi epidurali spinali in combinazione al trattamento antibiotico pre e postoperatorio specifico. was re-introduced orally on day ten without any further evidence of hepatotoxicity. Hepatotoxi-Commento finale: L’ascesso epidurale spinale è una patologia rara che si manifesta con una sin- city is the most frequent one during long-term oral therapy. Acute liver damage after intravenoustomatologia alquanto subdola e aspecifica, ma che necessita di una diagnosi e trattamento pre- amiodarone, possibly induced by the solubilizer polysorbate 80, an organic surfactant added tococe prima che insorgano manifestazioni neurologiche che possano comportare la paralisi, the intravenous infusion, is rare but potentially harmful. Similar reactions have been described withosteomielite o l’exitus (Strohecker and Grobovschek 1986: “The problem with spina epidural ab- polysorbate 80 in association with the E-ferol syndrome in infants. Oral maintenance therapyscesses is not treatment, but early diagnosis – before massive neurological symptoms occur”). Ad with amiodarone is possible, even in patients who developed liver disease during intravenous loa-un Follow up, in data 18.06.07, la paziente riferiva di aver ripreso a deambulare, e di aver ridotto ding. Although this particular adverse reaction of intravenous amiodarone is rare, it remains im-la terapia antidolorifica; l’esame neurologico risultava del tutto negativo. Il caso clinico viene de- portant because of the popularity of amiodarone for the treatment of severe life threateningscritto non solo per la rarità della patologia, ma anche per l’evenienza della stessa patologia in una cardiac arrythmias.popolazione anziana che presenta notevoli fattori di rischio in rapporto all’età. Si sottolinea inol-tre come con l’approccio multidisciplinare si ottiene un ottimo outcome di questo tipo di patolo-gia. Bibliografia: Rabih O. Darouiche, M.D. Spinal Epidural Abscess. N. Engl. J. Med. 2006;355:2012-20 E.Reihsaus, H. Waldbaur, W. Seeling. Spinal epidural abscess: a meta-analysis of 915patients. Neurosurg Rev (2000) 232:175-204. Deardre Chao, M.D., M.S. and Anil Nanda,M.D.Spinal Epidural Abscess: A Diagnostic Challenge. Am Fam Physician. 2002;65:1341-1346.www.aafp.org/afp www.nejm.org David M. Kaufman, M.D., Jerry G.Kaplan, M.D. and Nathan Lit-man, M.D. Infectious agents in spinal epidural abscesses. Neurology 1980; 30:844 S. Grewal, G.Hocking and J.A.W. Wildsmith. Epidural abscesses: British Journal of Anaesthesia 2006- 96(3):292-302. A.R.Mackenzie, R.B.S.Laing, C.C.Smith, G.F.Kaar, F.W. Smith. Spinal epidural abscess: theimportance of early diagnosis and treatment. J.Neurol Neurosurg Psychiatry 1998;65:209-212. Pa-trick A, Tessman, M.D.; David C. Preston, M.D. Spinal epidural abscess in an afebrile patient. ArchNeurol. 2004; 61(4):590-591.6. PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY IN CHRONIC 7. CPAP FOR CHRONIC HEART FAILURE: A CASE REPORTLYMPHOCYTIC LEUKEMIA. A CASE REPORT Federico Lari, Germano Pilati, Gianpaolo Bragagni, Nicola DiBattistaIolanda Margherita Giannico, Elisa Pellegrini, Dante Romagnoli, Amedeo Lonardo,Paola Loria, Nicola Carulli Background: Chronic Heart Failure (CHF) represent worldwide a clinical condition with high so- cial, economical and epidemiological impact, and is increasing in prevalence. Even if new phar-Introduction. Progressive multifocal leukoencephalopathy (PML) is a demyelinating disorder resul- macological and non-pharmacological approach have been used for treatment in last years,ting from JC virus (JCV) infection of the oligodendrocytes. It affects immunocompromised indivi- mortality remain high in general population and quality of life of these patients is poor. The as-duals, especially HIV-positive, or patients with lymphoproliferative disorders and immunosuppressed sociation between CHF and sleep disorders is frequent but still undervalued: sleep apnoeas in CHFby chemiotherapy. The clinical presentation of PML is usually characterised by a progressive de- cause negative effects on cardiovascular system and then an aggravation of prognosis. OSA (Ob-cline of cognitive function associated with neurological focal, motor and visual deficits. We report structive Sleep Apnoea) seems to be a cause of CHF by increasing sympathetic activity and pro-a case of PML in a chronic lymphocytic leukemia (CLL) patient treated with fludarabine. Case re- moting hypertension whereas CSA (Central Sleep Apneas, often associated to Periodic Breathing)port. A 66-year-old man affected by B-cell type CLL developed progressive neurological signs six is probably a consequence of heart disease with chronic lung congestion. CPAP (Continuous Po-months after one cycle of oral fludarabine. He developed hyposthenia of the right arm. Based on sitive Airway Pressure) is commonly used to treat sleep apnoeas in patients without cardiac in-CT scanning, ischemic stroke was initially diagnosed and treatment with ASA was started. Five volvement and is also used in first line treatment of acute cardiogenic pulmonary oedema thanksmonths later, the patient’s neurological complain rapidly worsened with progression to right-side to its hemodynamic and ventilatory effects (reduction of pre and after load, alveolar recruitment,hemyplegia, afasia and paresis of the left upper limb. Magnetic resonance imaging showed mul- increase of functional residual capacity). The addition of nightly CPAP to standard aggressive me-tiple and bilateral subcortical lesions of the white matter, compatible with infectious disease. JCV dical therapy in Patients with CHF and sleep apnoeas reduce the number of apnoeas, reduceDNA was detected in cerebrospinal fluid of the patient by polymerase chain reaction analysis. blood pressure, respiratory and cardiac rate, activation of sympathetic nervous system, left ventri-Seven months after the onset of neurological symptoms, the patient died of acute respiratory in- cular volume, hospitalization rate; besides increase left ventricular ejection fraction, oxygenation,sufficiency. Discussion. Except for reconstitution of the immune system with HAART for HIV/AIDS quality of life, tolerance to exercise and seems to reduce mortality in patients with an higher ap-and removal of immunosuppressive drugs in rheumatic disease or organ transplantation, there is noeas suppression. This suggest to investigate sleep apnoeas in patients with CHF and considerno effective treatment for PML and prognosis is thus poor. Although PML may have been rather to treat them with CPAP. Further studies need to be developed to confirm the use of CPAP in pa-rare in the past, it is becoming much more prevalent now, especially in the contest of AIDS. PML tients with CHF without sleep disorders. The Case: a 50 years old man with type 2 diabetes andshould be suspected whenever immunosuppressed patients develop otherwise inexplicable neu- severe dilated cardiomyopathy with systolic dysfunction (ejection fraction of left ventricle 20%),rological symptoms and further diagnostic examinations (cerebrospinal fluid samplings, magne- NYHA class IV, was admitted in our Hospital for many times in the last years for symptoms rela-tic resonance imaging) should be performed. ted to his chronic congestive cardiac failure. Each time were present dyspnoea at rest with or- thopnoea, distal oedema, hepatomegaly, congestion and enlarged cardiac shadow at chest radiogram. Electrocardiogram reported sinus rhythm with Left bundle branch block, always ne- gative cardiac enzymes, arterial blood gases showed a trend to respiratory alkalosis with sub- stantially normal PaO2 value also breathing ambient air. Each admission resulted in a long hospitalisation, with only little improvements due to standard medical treatment including inotropic agents, high doses of diuretics, nitrates, beta blockers, ace inhibitors, oxygen. It seemed to be an end stage heart failure with perhaps a chance of transplantation. During the last admission we ob- served that the Patients developed a periodic breathing with various episodes of nightly and daily central apnoea. In addition to standard aggressive medical therapy we decided to treat the Patient with CPAP 7.5 cmH2O and low FiO2 (28%), with a Venturi-Like Generator Flow (Whisper Flow &#8211; Caradine) and a facial mask: the Patient performed 10-12 hours/day of CPAP treatment divided into 3-4 cycles of 3-4 hours each, nightly and daily. Since the first day of treatment he re- ported a significant improvement in sensation of dyspnoea, after few days of treatment the re- spiratory pattern sowed a decrease of apnoeas and the Patient was able to arise and perform personal care (NYHA class III); after 15 days of treatment oedema was lowered, a chest radiogram showed reduction of congestion, echocardiography demonstrated an improvement of ejection fraction of left ventricle (33%). In this Patient a long term treatment with nightly electric nasal CPAP at home may be useful in order to improve quality of life and decrease hospitalisation. 80
  • 84. 8. TWO CASES REPORT OF CHYLOTHORAX DUE TO &#61549;/L).Chest and abdomen-HRCT scanning revealed the presence of walled cysts 2-20LYMPHANGIOLEIOMYOMATOSIS mm in diameter distributed through the lung fields, renal angiomyolipomas and uterine fibroidsGiovita A Piccillo, Aurelio Pantò, Tommaso Nicolosi, Filippo Fraggetta, (leiomyomas). The patient underwent to thoracic duct correction, pleurodesis, chest and lymphEnrico GM Mondati, Riccardo Polosa, Luca Miele, Giovanni Gasbarrini nodes biopsies with evidence of LAM cells and diagnosis of “lymphangioleiomyomatosis”, total pleurectomy, ovariectomy and isterectomy. Twelve months later she was on permant O2 therapy.INTRODUCTION Lymphangioleiomyomatosis (LAM), first described in 1937 by von Stossel, is DISCUSSION LAM is a devastating disease with bad prognosis (death within 10 years froma rare disease of unknown origin affecting women of childbearing age and patients of both sexes onset!). Recently the research has helped to define the genetic and immunohistochemical cha-struck by tuberous sclerosis, characterised by hamartomatous proliferation of smooth muscle in racteristics of LAM cells and surely it will soon lead to more effective treatments (rapamicin, siro-the lungs, mediastinum and abdomen. The reported prevalence of LAM is around one per mil- limus, anti-EGF…), but nowadays, the treatment remains only symptomatic on surgery, hormones,lion, although the true prevalence is likely to be greater. LAM is almost exclusively confined to oxygen, pulmonary transplantation with possible relapses. Early diagnosis it is necessary, condi-women the mean age of onset being 34 years and presentation after the menopause is very unu- tioning a different outcome in these unlikely women.sual. While LAM is a systemic disease, the main manifestations are pulmonary. In the lungs theabnormal proliferation is seen around airways, blood vessels, and lymphatics. It extends into thealveolar interstitium causing cystic change and into pulmonary veins causing lung haemorrhage.Lymph node involvement leads to chylous effusion. Extrapulmonary features include renal an-giomyolipomas and lymphangioleiomyomas. Clinically it is characterised by increasing chest pain,dyspnoea, breathlessness, hemoptysis, chylothorax and pneumothorax. CASE REPORT 1 A 22-year-old female patient was admitted to our Dept for acute dyspnoea, cough and chest pain. Thepatient appeared very pale and suffering, dyspnoic, polypnoic, extremely anxious, with cramps toupper and lower limbs. Normal BP (110/70 mmHg), EKG, HR (90 b/m), T 37°C. At EGA de-crease of pO2 (68 %). Respiratory clinical evaluation revealed hypophonesis in left basal pulmo-nary area coherent with absence of vesicular breathing. Chest-X-ray, immediately executed,pointed out the presence of important left pleural effusion. Thoracentesis revealed milky white fluidin chest cavity which laboratory test confirmed to be chyle (milky white colour, pH alkaline, Rivalta---, proteins 2,5 g/dl, cholesterol 65 mg/dl, triglycerides 110 mg/dl). Laboratory data pointed outmoderate anaemia (RBC 3.780.000/mmc, Hgb 11.4 g/dl, Hct 30.6%, MCV 80.9 fl), increase ofLDH (1.086 U/L) and ACE (40 &#61549;/L); decrease of total proteins 5.6 g/dl and Ca++ 7.6mg/dl. Chest-high resolution computerised tomography (HRCT) scanning showed the presenceof dilated thoracic duct and few thin-walled cysts in mid and lower lungs and abdomen-CT re-vealed the presence of ovarian polycystosis. On the grounds of these findings, we suspected LAMand submitted our patient to thoracic duct correction, pleurodesis, chest and lymph nodes biop-sies with evidence of LAM cells and diagnosed “lymphangioleiomyomatosis”. The patient wastreated on total pleurectomy and lymphadenectomy L1-L5 and oral progesterone. Twelve monthslater she was in good clinical conditions and underwent to ovariectomy. CASE REPORT 2 A 42-year-old female patient was admitted to our Division because of acute dyspnoea, cough and chestpain. At history menarche at fourteen years with regular rhythm and flow; hypertension sincetwo years treated initially on enalapril and later on Calcium antagonists, due to onset of cough,suspecting asthma. Moreover since two years dyspnoea for moderate efforts, cough and brea-thlessness on exertion misdiagnosed for asthma or side effects of ACE inhibitor. abdominal pain,oedema of left leg misdiagnosed for relapsing phlebitis. She appeared very suffering with in-creasing dyspnoea. Normal BP (110/70 mmHg), EKG, HR (90 b/m), T 37°C. At EGA decrease ofpO2 (68 %). Respiratory evaluation pointed out hypophonesis in right and left basal pulmonaryarea with absence of vesicular breathing. Chest-X-ray, urgently executed, showed the presenceof bilateral copious pleural effusion. Thoracentesis and laboratory test revealed it was chylous(milky white colour, pH alkaline, Rivalta ---, proteins 2,8 g/dl, cholesterol 53 mg/dl, triglycerides200 mg/dl). Laboratory data pointed out increase of LDH (1.253 U/L) and ACE (509. A CASE REPORT OF BROKEN HEART SYNDROME 10. PATIENTS ON ORAL ANTICOAGULATION THERAPY - INFORMATION ANDGiovita A Piccillo, Aurelio Pantò, Salvatore A Azzarelli, Riccardo Polosa, KNOWLEDGE REGARDING THEIR THERAPYEnrico GM Mondati, Luca Miele, Giovanni Gasbarrini Gomes, Pedro; Póvoas, Marta; Quintas, Inês; Reis, Vera; Silva, Rui; Sousa, GonçaloINTRODUCTION Broken heart syndrome,also called Apical Ballooning Syndrome (ABS), is a cli- Background: Anticoagulation therapy is a type of treatment where patient knowledge on the the-nical entity characterised by transient abnormal wall motion of the mid and apical segments of the rapy is of particular relevance, since these drugs have a narrow therapeutic window, a regular con-left ventricle resulting in the apical ballooning, absence of significant coronary artery disease and trol, and complex pharmacokinetics. Aims: In our research we tried to understand if patients undernew ST-T electrocardiographic abnormalities more prevalent among women than men (7:1). Ja- oral anticoagulation therapy received and had enough information about this type of medication.panese Authors prefer the term Tako-Tsubo for this cardiomyopathy, due to the resemblance of Methods: We interviewed patients that are monitored in an anticoagulation clinic of a central ho-the end-systolic left ventricular angiogram to an octopus (tako) trap (tsubo). Moreover this pa- spital in Lisbon, and asked them if they had already received, and if they considered they nee-thology is also known as stress cardiomyopathy, since it is often triggered by an emotional or ded further information about anticoagulation. Knowledge evaluation was put to test through 8physical stress (sudden accident, death/funeral of a family member, excessive exercise, quarreling, questions, that encompassed questions such as the drug effect, self-medication and safety issues.excessive alcohol consumption or great excitation). The ABS mimics an acute coronary syndrome Results: We collected information on a sample of 211 patients, with a mean age of about 68 years,with anginal chest pain, ischemic ekg alterations, increase in creatine kinasi (CPK) and/or tropo- the majority of whom had completed the fourth grade or less. Concerning the question if theynin (TPN). CASE REPORT A female 72-year-old woman, without cardiovascular risk factors, was were given information, 161 (76,3%) said that was the case. In another question, 62 (29,4%)admitted to our Department because of persistent anginal pain after the death of her son due to thought they needed further information about the therapy, and from these, 45 singled out thecancer. Her physical examination was unremarkable; BP 145/95 mmHg; HR 60 beats/min; the attending physician has the preferred source. We considered that 77,3% had a fair level of kno-EKG showed 1 mm ST segment elevation in II, III, avF, V3-V6 leads and subsequent electrocar- wledge. From the 8 questions used, the ones dealing with diet and the one about dealing withdiogram showed T wave inversion in the same leads. Chest pain was relieved with sublingual ni- sharp objects were the aspects that people had less information about. The statistical analysistrate, aspirin and heparin. Then, she was transferred to the coronary care unit with a diagnosis of shows a trend regarding time of therapy-to-level of knowledge. There is an association betweensuspected acute coronary syndrome. The angiography, perfomed 4 h after starting chest pain, sho- having received information-to-level of knowledge (p=0,001) and wanting to receive more infor-wed the so called "apical ballooning" during systole, in absence of obstructive coronary artery di- mation-to-level of knowledge (p=0,012). Conclusions: Information is very important in patient ma-sease. Serial blood samples pointed out the so-called “apical ballooning” during systole, in absence nagement. From the patient point of view, the attending physician has to play a key role inof obstructive coronary disease. Serial blood samples revealed a peak of troponin I of 7.3 ng/dl delivering information on coumarinic therapy adequately and periodically, being an issue that(normal<0.4 ng/dl); IgM antibody assay against the following microbes influenza type A (H1N1), should be addressed with these patients.influenza type A (H3N2), influenza type B, parainfluenza type 1, parainfluenza type 2, cytome-galovirus, coxackie type B1, coxackie type A16, echo type 7, adenovirus type 3, Chlamidia pneu-moniae, parotite, Mycoplasma pneumoniae, Borrelia garinii, Borrelia burgdorferi, was negative. Themyocardial contrast echocardiogram performed with written consensus at day 6 showed a largeperfusion defect in the akinetic apical region of the left ventricle. At 1-month follow-up myocar-dial perfusion and wall motion became completely normal. At day 8 the patient was dischargedhome on aspirin and Ace-inhibitor. Three months after she remained asymptomatic. DISCUS-SION Pathophysiologic mechanisms proposed for Broken heart syndrome include multivesselcoronary spasm, microvascular coronary spasm, catecholamine-mediated cardiotoxicity, acutemyocarditis, transient obstruction to LV outflow, and the rupture of a non obstructive plaque fol-lowed by spontaneous thrombolysis. These two pathophysiologic mechanisms microvascular dy-sfunction and catecholamine-mediated myocardial stunning may be correlated since acatecholamine-mediated endothelial injury might be the cause of the microvascular dysfuctionseen in patients with ABS. Fortunately, the fatality rate from stress cardiomyopathy is less than thatof acute myocardial infarction (about 4%). The marked left ventricular dysfunction and the pecu-liar shape usually disappear within several weeks, but it is possible recurrence. 81
  • 85. 11. STAPHYLOCOCCUS AUREUS SEPSIS - WITH AN UNSUAL LOCATION 12. RECURRENT ATRIAL FIBRILATION AS A MANIFESTATION OF FATALAna Vintém de Oliveira, Euridice Espirito Santo, Leuta Araujo, Luísa Morais PULMONARY EMBOLI Zamir D, Reitblat T, Polishchuk IThe authors describe a clinical case of a 39 years old black female patient, presented to the emer-gent departement with abdominal pain, fever and vomits. She had a Known past history of hy- A 52 year-old male was admitted due to palpitations. He was found to have atrial fibrilation at ERpertension. On physical examination the abdomen was painful without signs of peritoneal and was admitted to our department. Actually it was the 4th episode of AF he had in the last 2irritation. Laboratory tests showed leucocitocys (23 800 cells/ml), thrombocytopenia (60 000 months, all were converted with propafenone or amiodorone. The patient had swelling of his Rtcells/ml9, hight c-reactive protein (9,4 mg/dl), BUN=59,6 mg/dl, serum creatinine=3,9 mg/dl, calf and echo-duplex findings were compatible with DVT. Since he had non specific chest pain wi-DHL=1345 U/L. She was admited in the Internal Medicine ward. On abdominal x-ray colonic di- thout dyspnea in the last 2 months, CT-angiography was performed and revealed bilateral pul-latation was expressed and on CT-scan a milled right pleural effusion, ascitic fluid and thickeness monary emboli. Anticoagulation treatment was started and the patient was released a few daysof terminal ileum were presented. Ciprofloxacin and metronidazole were introduced. The patient later. Two days later he was admitted due to recurrent atrial fibrilation, medical conversion failedunder went a colonoscopic examination wich observed colonic ulcerations. The pathologic exa- and electric cardioversion was performed. However the patient had an episode of massive rectalmination of these ulcerations revealed a non caseos necrose and presence of bacterial colonies, bleeding; colonoscopy was normal and we inserted a filter to the inferior vena cava and stoppedbut no granulomae. On fourth hospital day the patient become apiretic, but need transfusional anticoagulation for a few days. Abdominal CT was normal. The patient respiratory condition de-support. On blood cultures a staphylococcus aureus was revealed. She improved and the CT- teriorated and we started anticoagulation again with strict monitoring. However a few days latterscan was repeated and revealed none abdormalities. The patient was discharched and refered to he underwent cardio-pulmonary ressuscitation due to ventricular fibrilation and apnea. He was me-the out patient clinic. Conclusions:The location of S. aureus infection in this region is unsual. It re- chanically ventilated and was treated with Catecholamines (dopamin and noradrenaline), but diedsulted in a systemic infection with favorable outcome. 2 days later. Post mortum operation was done in the National Center of Forensic Medicine due to the request of the family and revealed fresh massive pulmonary emboli as well as metastatic adenocarcinoma with unknown origin and diffuse hilar and mediastinal metastases.13. HIGH PREVALENCE OF METABOLIC DISORDERS IN HEART TRANSPLANT 14. A PATIENT WITH SUPERFICIAL TROMBOPHLEBITIS - HOW SERIOUSLY ISRECIPIENTS HE ILL?Emanuele Durante-Mangoni, Domenico Iossa, Daniela Pinto, Roberta Brugnone, Vacula I, Stvrtinova V, Dukat A.Cristina Caianiello, Rosa Albisinni, Enrico Ragone & Riccardo Utili Superficial thrombophlebitis (ST) is considered as benign disease,easily diagnosed by physicalNew onset metabolic changes have shown to negatively impact patient and graft survival after kid- examination and requiring only simple conservative management. On clinical examination STney transplantation. Fewer data are available in heart transplant recipients. Metabolic changes presents as tender wormlike mass with warm and red overlying skin,without generalized oedemamay be implicated in cardiac allograft vasculopathy and cardiovascular mortality after heart tran- of the limb. The incidence of ST in general population is 3-11%. ST is more often seen in obesesplant. In a cross-sectional cohort study, we evaluated the prevalence of deranged metabolic pa- patients,older then 60yrs,women,smokers,in malignity,autoimmune disease and on varicose veins.rameters in 202 heart transplant recipients seen at our transplant medicine clinic from Nov 07 to However,risk factors for ST are the very same as for DVT. If duplex ultrasonography (DUS) is notJan 08. After an overnight fast, subject underwent blood tests and were subsequently evaluated realised,occult concomitant DVT can be missed. DVT may be caused either by direct extensionby the same two investigators according to standard practice guidelines. Patient mean age was of the thrombus or as a result of mentioned risk factors. In a recent study,associated DVT or pul-55.7+-12 years and 81% were males. The median time from transplant to assessment was 82 monary embolism (PE) was found in 120 (13.8%) of 867 screened patients with ST. Case report:months (IQR 45-122 mo). Hypertension was found in 68% of cases (systolic 21%; diastolic 16%; 65 yrs old patient was presented with worsening dyspnoea and negative chest X ray. A monthboth 63%) and mostly was of first grade. One-sixth of patients was diabetic but more than half earlier,he had ST on great saphenous vein above right knee. He was treated conservatively,DUShad impaired fasting glucose. Hypercholesterolemia was found in 29% of cases despite a large was not performed. On admission patient was dyspnoic,D dimer was highly positive. DUS re-proportion of patients was on statin treatment. A low HDL cholesterol was found in more than vealed ST with extension to the SFJ. However,ileofemoral DVT on left leg was found. CT proved40% of patients. Similar rates of hypertrygliceridemia and hyperuricemia were observed. Thirty PE. He was treated by LMWH followed by warfarin and compression therapy. On 12th day,he waspercent of patients were obese (I degree obesity in 78% of cases). Visceral obesity was highly pre- dismissed with signifficant relieve of symptoms. Optimal treatment of ST remains poorly defined.valent, but mostly among males (44% vs 15% in females). Overall, up to 55% of patients fulfilled There is lack of data about indication for LMWH or UH in ST,the dose of LMWH,whether it hasthe diagnostic criteria for metabolic syndrome. In this large cohort of heart transplant recipients, to be combined with NSAID. There are controversions about efficacy and safety of surgical tre-there was a very high prevalence of metabolic syndrome. While the role of immunosuppressive atment. Conclusion: In case of ST on the trunk of GSV or SSV near SPJ,we recommend DUS asdrugs may partly explain several bio-humoral abnormalities, we found a striking prevalence of obe- a mandatory examination for exclusion of DVT. In limited ST on branches of GSV or SSV, com-sity and visceral obesity in our transplant patients. Efforts should be made to understand the bio- pression therapy,local or oral NSAID should be given. In patients with ST above knee or near thechemical mechanisms underlying bio-humoral changes as well as to drastically reduce obesity by SFJ/SPJ,we recommend LMWH in full therapeutic dose for one week,followed by LMWH in pro-restricting food intake and increasing aerobic exercise in heart transplant recipients. phylactic dose or warfarin. 82
  • 86. Oral Communications Saturday, May 10, 2008 NEPHROLOGY
  • 87. 1. ACUTE CORONARY SYNDROME IN PATIENTS WITH CHRONIC RENAL 2. ANAEMIA MANAGEMENT IN HAEMODIALYSIS PATIENTS WITH AGGRESSIVEFAILURE IRON MANAGEMENT, OUTCOME VS. EXPENDITUREKovács Eniko Dr P K Tatavarthi, Ms J Wallis, Ms A Haralambous, Dr G Cserep, Dr ElzubierIntroduction: In the diagnostic and in the risk stratification there are very important the cardiac Tro- Aim: To review our current practice against standards set by the following guidelines &#61656;ponin I and T, which widely used in the clinic practice in the last years. Theese biomarkers highly National Institute of Clinical Excellence (NICE) guidelines: Anaemia management in patients withspecific and sensitive for myocardium laesions, but not only in classic myocardial infarction, acute chronic kidney disease (CKD)(Sept 06) &#61656; The Renal Association Guidelines – Standardscoronary syndrome /ACS/ are elevated is the serum but in other deseases too, for example in renal and audit measures (August 02) &#61656; European Best Practice Guidelines for managementfailure/ RF/ without cardiac symptoms. The coronary artery disease is highly prevalent in patients of anemia in CKD patients (May 04) Methodology: It was a retrospective review performed in thewith end-stage renale failure./ESRF/ Aim: to investigate the patients with RF and ACS for result, newly established renal unit at our NHS trust during the week June 18th -22nd 2007 involvingmortality, and cardiac markers beneficial for establishing of correct diagnosis Method:retrospec- CKD patients with anaemia who were undergoing dialysis. The haemoglobin (Hb), ferritin andtive, simple calculation Data: 36 patients : ACS with RF, male : 21, female: 15, average-year: 64,4 transferritin saturation (TSAT) for these patients were obtained. The amounts of erythropoietinyears / 50-85 years/ . Final diagnosis: STEMI: 24 / 66,4%/, NSTEMI: 4 /11%/, UAP: 8 / 22%/ (EPO) and iron prescribed were also obtained. Exclusion criteria: &#61656; All inpatients duringResults: Primer introduction complaint: chest pain: 25 / 70%/, dyspnoe. 16 / 44%/, vomit: 9 / the study period &#61656; Patients started on dialysis within the last month and were not known25%/ collapse, Adams-Stokes sy:. 5 / 15%/. Coronarography: 15 patients / PTCA, STENT: 9 pa- to pre-dialysis clinic &#61656; Patient started on EPO within the last 3 months before the studytients, CABG: 1 patient. Half year mortality: average : 33% / 12/36/, STEMI: 46 %, NTEMI: 25 period Results: Out of 79 patients who were receiving haemodialysis, 2 were just started on dia-%,UAP: zero. Dyalized patient’s mortality: 5/16 / Peak biomarkers: in STEMI: Troponin I: 65 ng/ml, lysis and not known to pre-dialysis clinic, 5 were inpatients during the study and 9 were startedCKMB: 85,2 U/L, NSTEMI: Troponin I . 10,5 ng/ml, CKMB: 27 U/L, UAP: Tropnin I: 0,9 ng/ml, on EPO within the last three months. Haemoglobin levels: Out of 63 patients, 87% achieved theCKMB: 23 U/L. Patients with chronic heart failure without cardiac symptoms Troponin I : target Hb set by the NICE (>10.5g/dl) 92% met the target Hb (>10g/dl) with the median value0,22ng/ml. Summary: The mortallity is higher in patients with RF plus ACS. The biomarkers are of 12.1g/dl according to the renal association guidelines. 73% met the European guidelines withgood for diagnosis of coronary artery syndrome in renal failure. the Hb of >11g/dl Iron studies: Out of 72 patients, 4 had a ferritin<200 µg/l, 25 had 200-500µg/l and 43 had >500 µg/l and 19 had TSAT <20%. Only 19% matched the NICE guidelines (ferritin 200-500µg/l and TSAT >20%) 74% patients achieved the targets of Renal Association and Eu- ropean guidelines (ferritin >100µg/l and TSAT>20%. Expenditure: The average amount of EPO used by the renal unit in haemodialysis patients was 7,700 units compared to the national ave- rage of around 9,204 units (December 2006, UK Renal registry). Discussion: Our renal unit has achieved excellent results in meeting the standards set by the different organizations with the mi- nimum expenditure. European guidelines and recent DRIVE & DRIVE II studies discussed the ef- ficacy of iron therapy with upper limit of ferritin 800 and 1200µg/l respectively without reported toxicity. However this should be considered with caution until further investigation. We also did not include other factors affecting Hb and ferritin such as blood transfusion, surgery and inflam- mation. Hence these issues should also be addressed in the future.3. NEPHROTIC SYNDROME AS PRESENTATION OF AMYLOIDOSIS: 4. CHLAMYDIA PSITTACI AND ACUTE RENAL FAILUREA DIAGNOSTIC CHALLENGE WITH UPCOMING THERAPEUTIC OPTIONS Tânia Gaspar, Luís dos Santos Pinheiro, Sofia Jorge, Lurdes Correia, Margarida Lucas,Wabbijn M, Schrama YC, Rietveld AP Rui M.M. VictorinoRecently four patients presented in our hospital with a nephrotic syndrome caused by amyloi- Introduction: Acute tubulointerstitial nephritis (ATN) presents frequently as renal failure (RF). Drugdosis. Two had a classical AA amyloidosis with elevated serum amyloid A (SAA). SAA is a pre- toxicity is the most common cause of ATN, but it can also be a complication of systemic immu-cursor protein and an acute phase reactant produced by a chronic inflammatory disease. One nological diseases or infections. Chlamydia psittaci (CP) infection is common in exotic birds butpatient had rheumatoid arthritis and the other Familial Mediterranean Fever (FMF). The other two much less frequent in humans. Case description: We report the case of 76 year-old woman, ad-patients had an AL amyloidosis caused by monoclonal (light) chain overproduction. A systema- mitted with asthenia, fever, dry cough and itching exanthema during the previous month. Thetic approach was needed to complete the diagnostic work-up. 1: To prove amyloid deposition onset of symptoms occurred 3 weeks after a parrot bite, without immediate complications. Renalhistological evidence is needed: on all patients a kidney biopsy performed with a congo-red and ultrasound was normal. Laboratory tests showed normocytic normocromic anaemia, elevated C-thioflavine staining. 2: Local or systemic? Kidney involvement means systemic amyloidosis by de- reactive protein and acute renal failure (creatinine: 7,5 mg/dL), metabolic acidosis and hyperka-finition. Other localisations must be checked (especially myocardium). 3: Identify the type of lemia. Haemodialysis was initiated, and given the improvement of renal function suspended afteramyloid fibrils: In the cases of AL amyloidosis we used immunohistochemical staining to iden- the fourth session. Treatment with levofloxacin was started empirically for respiratory infection. Po-tify the amyloid protein. In one case we excluded a congenital type of amyloidosis by DNA dia- sitive IgM for CP was detected. Complement fractions (C3 and C4), auto-antibodies and immu-gnostics. 4: Identify the precursor protein in serum: In the two AA amyloidosis cases we (should) noglobulin were negative or within normal range. Renal biopsy revealed moderate interstitialhave measured SAA. For AL amyloidosis free light chain in serum was measured. 5: Assess tis- fibrosis with intense tubulointerstitial inflammatory infiltrate by lymphocytes, plasmocytes and raresue load of amyloidosis: Perform SAP-scan or score loading of abdominal fat (biopsy). For AL neutrophils and marked arteriolar hyalinosis. The diagnosis of CP infection with renal, respiratoryamyloidosis a bone marrow aspiration was performed to determine plasma cell burden. CON- and cutaneous involvement was established. Having completed 21 days of levofloxacin, thereCLUSION Amyloidosis consists of a group of diseases with the precursor protein determining was complete resolution of cutaneous and respiratory symptoms, and progressive improvementthe presentation and prognosis. Each requires a specific treatment. Renal amyloidosis is mostly of renal function (serum creatinine: 2.4 mg/dL). Discussion: Pneumonia is the most frequent cli-caused by AA, AL and seldom hereditary amyloidosis. It presents with a nephrotic syndrome. Ge- nical presentation of CP infection. Renal involvement of CP infection is extremely rare, with onlyneral treatment for nephrotic syndrome includes dietary protein restriction, diuretics, ACE-inhi- few individual cases described, and it can present as acute glomerulonephritis, acute tubular ne-bitors and lipid lowering. For AA amyloidosis adjuvant treatment goal is to suppress infection for crosis or ATN. The present case illustrates the favourable outcome, under levofloxacin therapy, ofexample with TNF&#945;-blockers, proteasome inhibitors or colchicine (in case of FMF). Treat- ATN with severe RF in a patient with acute infection by CP.ment for AL amyloidosis is to eradicate clonal plasma cells like high dexamethasone +/- mel-phalan, or the combination vincristine and doxorubicin. Newer treatment consists of high-dosemelphalan and peripheral blood stem cell transplantation. Alternative therapeutic approachesinclude thalidomide (+/- cyclophosphamide), lenalidomide, iododoxorubicin. In the future morespecific immunotherapy and medicines to dissolve fibril deposition will be used. Despite all theseregimens end-stage renal disease (ESRD) can occur. Most experience with kidney transplanta-tion is in AA Amyloidosis; also successfully in one of our patients. In case of AL amyloidosis,transplantation is only reasonable if disease is limited to kidney and slowly progressive over years(even with ongoing production of light chain). 84
  • 88. 5. SEPTIC SYNDROME IN ANURIC PATIENTS; DO NOT FORGET THE BLADDERWabbijn M, Schrama YC, Rietveld APPatient A is an 80-year-old woman with hypertension, rheumatoid arthritis and non- insuline de-pendent diabetes with chronic renal failure for seven years. At a regular dialysis visit she reportednausea and pain in the lower abdomen. She was known to be anuric, so dysuria was absent. Atphysical examination she was relatively hypotensive (90/50 mm Hg), had a tachycardia of 120bpm, without fever or bladder retention on percussion. Biochemical values showed a CRP of 161mg/l, leucocytes of 11.6 X 109/l with 81% neutrophils. Catheterisation of the bladder revealed justa little amount of urine, no pus, but urine examination revealed more than 35 leucocytes and 3-5 erythrocytes per field. Urine culture was positive for Proteus Mirabilis sensitive for ciprofloxacin.Blood cultures, incorrectly drawn after starting antibiotics, were negative. Work-up diagnosis wasseptic syndrome out of a urinary tract infection in this anuric patient. The patient recovered well.Patient B is a 76-year-old man with insuline dependent diabetes, hypertension and end stagerenal failure. He was known to be anuric. On one of his dialysis sessions he presented with hy-potension (RR 70/40 mm Hg) and tachycardia of 104 bpm. Together with a CRP of 296 mg/l andLeucocytes of 2.8 x 109/l, this indicated a septic syndrome. At physical examination no pulmo-nary-, gastro-intestinal-, shunt- or other infection focus could be found. However, on bladder ca-theterisation, we found a bladder empyema with retention of more than 2 liters. Additionalresearch unmasked a benign prostate hypertrofia (BPH). Treatment was started with intravenousfluids, inotropics, cefuroxime and gentamycine. When blood and pus cultures became positive forSerratia Marcescens treatment was switched to ciprofloxacin orally. The patient recovered quic-kly. An urologist was consulted to treat the BPH. Now, the patient is considered oliguric with anurineproduction of 200 ml/24 hrs. CONCLUSION: In anuric or oliguric dialysis dependent pa-tients with a septic syndrome the urinary tract can still be the culprit! This can be masked by thefact that fever is often a missing link in these patients and urine production is, or seems to be, ab-sent. Be aware that still a cystitis/pyelonephritis can develop in anuric patients and be alert thatpost-renal obstruction (especially in men) can mask/inhibit voiding and therewith dysuria as com-plaint, a monthly urine sediment and/or bladder scan may prevent these phenomena or make anearly focused (culture based) antibiotic treatment possible. 85
  • 89. Poster PresentationsWednesday, May 7, 2008
  • 90. 1. PACEMAKER RELATED ENDOCARDITIS 2. ANAEMIA: A REASON TO SUSPECT ADULT CELIAC DISEASEAlbendín H., Herrero J.A, Vázquez E., Hernández A. F. Almeida, L. Gonçalves , T. Veloso, F. AzevedoObjectives: To evaluate incidence, risk factors, clinical presentation and outcome of pacemaker re- Celiac Disease is an immunologically mediated enteropathy triggered by the intake of gluten pre-lated endocarditis attended in our hospital. Patients and Methods: We studied retrospectively all sent in wheat, barley and rie. It results in a malabsorption syndrome with multiple and variablethe patients who suffered a pacemaker related endocarditis in our hospital between 2001 and clinical manifestations. We present a clinical case report of a 49 year old woman admitted with2007. The diagnosis of pacemaker-related endocarditis was considered according to the Duke progressive fatigue and exhaustion. She had a previous medical history of recurrent miscarriagecriteria. All the patients underwent clinical evaluation, blood cultures, and cardiac ultrasonographic and deep venous thrombosis. On examination she had a marked pallor and undernourishment.studies. Results: Sixteen patients were included. The median age of the patients was 71 years and Laboratory analysis revealed a low haemoglobin level of 4,5 g/dL with Ht: 15,4% and VGM: 64predominated men ( 64%).Main baseline diseases were: hypertension (75%), ischemic myocar- fL; Platelets: 1.412.000/&#61549;L; Fe2+: 6 &#61549;mol/L; Ferritin: 1,5 ng/mL and Transferrin:diopathy (43.75%), diabetes (19%). Ten patients (62.25%) received previously treatment with di- 468 mg/dL. Diagnostic workup included malabsorpsion and blood losses, auto-imunity and coa-cumarinics. Infection appeared in pacemakers with 2 o more leads in nine patients. Pocket infection gulation because of her previous medical history. The patient underwent transfusion of 3 Unitsduring the previous three months anteceded endocarditis in 50% of the patients. Manipulation of EC and sideraemia correction with progressive normalization of haemoglobin and platelets le-of the pacemaker occurred in three cases (19%). The main clinical finding at presentation was fever vels. The diagnosis of Celiac Disease was established on the basis of positive antitissue transglu-with no other obvious source(100%). Transthoracic echocardiography showed vegetations in 50% taminase, antiendomysial and antigliadine antibodies and confirmed by duodenal biopsy showingwhile transesophageal echocardiography was diagnostic in 83%. Blood cultures were positive in villous atrophy, crypt hyperplasia and increased intra-epithelial lymphocytes and plasma cells. She13 cases. Most common pathogens were staphylococci, Coagulasa negative staphylococci in was put on a gluten-free diet and under a regular follow up with dietitian and gastroenterology spe-56.25% and Stapylococcus aureus in 12.5%. One patient suffered a Pseudomonas aeruginosa in- cialist. This clinical case report emphasizes that the clinical expressions of Celiac Disease are highlyfection and in another patient Candida albicans was the causative agent. In all the patients removal variable (including recurrent miscarriage and deep venous thrombosis), subtle or occult and it shouldof the pacemaker and medical treatment was performed. The mortality in our series was 12.5%. aware the medical community to the importance of suspicion in establishing this diagnosis.Conclusions: Pacemaker pocket infection is an important predictor for the developing of pace-maker related endocarditis. A transesophageal echocardiography is warranted when peacemakerendocarditis is suspected. The microorganisms more frequently involved were coagulase-nega-tive staphylococci. Complete removal of electrodes is important to eradicate the infection.3. FIRST SYMPTOM: ASTHENIA 4. MYASTHENIA GRAVIS MIMICKING CEREBROVASCULAR DISEASE IN ANF. Almeida,T. Veloso, R. Félix, F. Azevedo ELDERLY PATIENT H Altemimi, B Hennebry, P Buttery, B KeeganAsthenia is a symptom commonly seen in patients suffering from acute and chronic disorders. Itmay be due to systemic disorders or specific organ involvement of, virtually, all etiologies. It can Background: Within the medical literature stroke-mimickers are well documented, and serve tobe a real challenge to evaluate a patient whose main complain is asthenia. We present a clinical remind us that not all weakness is secondary to cerebrovascular disease; although one of thecase report of a 65 year old woman with a history of asthenia with one year of evolution asso- more common causes of weakness in the elderly is a stroke. Nonetheless, the prevalence of si-ciated with anorexia without weight loss. She had no complains of fever, chills or night sweats and lent cerebrovascular disease amongst the elderly may result in coincidental findings on subse-denied complains of any organ or system. The objective examination showed no alterations. La- quent imaging being inadvertently utilised to support an inaccurate diagnosis. Myasthenia Gravisboratorial evaluation showed a hemogram, renal, hepatic and thyroid functions in a normal range is a potentially serious, but very treatable neuromuscular disease caused by autoantibodies di-with negative sedimentation rate and C-reactive protein. The immunoelectrophoresis revealed a rected against the acetylcholine receptor on the postsynaptic membrane of the neuromuscular jun-polyclonal gammapathy. Auto-immunity was negative. She underwent chest X-Ray, mammogra- ction. Although commoner in the younger population as a whole, up to 20% of cases occur inphy and breast US as well as upper gastrointestinal endoscopy and toracoabdominopelvic CT patients over the age of 70. Literature review reveals several case reports of patients with mya-scan that had no alterations. For six years she was clinical, laboratorial and imagiologically re-eva- sthenia gravis initially misdiagnosed as having suffered a stroke. Case Report: We describe a 79-luated. On the sixth year, the patient started to develop xerostomy and xerophtalmy with in- year old gentleman with a history of ischaemic heart disease who presented four weeks after ancreased asthenia, chills and night sweats. On the observation she had tumefaction of both apparent sudden onset of slurring of speech, followed by swallowing difficulties. Subsequent MRIsubmaxilar glands (SMG). At this time the sedimentation rate was 85 mm and the auto-immu- investigation demonstrated lacunar infarcts in the left external capsule and left caudate nucleusnity was positive for ANAs and anti-Ro antibodies. Ultrasound of the SMG showed nodular for- regions, which resulted in his being treated and investigated further for cerebrovascular disease.mations, bilaterally and left solid laterocervical formations. Fine needle biopsy had lymphoid cells With little improvement during his admission, a throwaway comment prior to his initial dischargewith clonal reordenation for IgH gene. The scintigraphy was compatible with a Sjögren Syndrome. prompted anti-acetylcholine antibody testing, which consequently returned suggesting a diagno-Submaxilar biopsy confirmed the presence of a diffuse infiltration by lymphoid cells with immune sis of myasthenia gravis. Later in-depth review of his history and symptoms was most revealing,histochemical behaviour of B-Lymphoma MALT. Patient underwent excision of the SMG, waiting and he responded well to treatment. Conclusion: Our case highlights the importance of reco-decision of radio and/or chemotherapy. This clinical case shows how important it is to re-evaluate gnising that symptoms of weakness in the elderly may be confounded by silent cerebrovascularand to suspect of serious and severe diseases associated with asthenia. disease, and under such circumstances, an open mind should be maintained. 87
  • 91. 5. SR3PE SYNDROME- ASSOCIATED CRYOGLOBULINEMIA ESSENTIAL MIXED 6. APPARENTLY UNTREATABLE HYPERTENSIONH. Álvarez Díaz, S. Pintos, E. Solla, S. Sánchez, T. Caínzos, P. Sesma. A.R. Alves, R. André, A. Chipepo, H. Gruner, A. Ferreira, M. Ventura, V. RiscadoIntroduction: The classic Remitting Seronegative Symmetrical Synovitis with Pitting Edema (RS3PE) syn- Renal vascular disease, most prevalent in patients over 60 years of age, can cause persistent hy-drome appears as the association of pitting edema, arthritis and severe extensor tenosynovitis of the pertension, renal failure or both. Nowadays, with the increase in age of the population, we musthands with negative rheumatoid factor. It has been associated with inflammatory rheumatic diseases consider, more than ever, generalized atherosclerotic disease, namely of the renal arteries, in pa-(lupus, ankylosing spondylitis, Sjögren, polymyositis, polyarteritis nodosa, temporal arteritis, sarcoidosis) and tients with difficult to treat hypertension and other risk factors for cardiovascular disease. The au-it may represent a paraneoplastic syndrome (gastric, endometrial, pancreatic, prostatic, ovarian, lymphoma thors present a 57 year old woman with hypercholesterolemia, central type obesity, type 2 diabetesor multiple myeloma). It shares common criteria with rheumatoid arthritis and polymyalgia rheumatica, and severe, longstanding hypertension (10 years), resistant to therapy with ACEI, ARA, b-blockers,but its clinical picture and evolution are distinctive. Case presentation: A 79 year-old-caucasian woman diuretics and calcium channel blockers. She presented to the emergency department with a BPwas admitted to the hospital because abrupt onset of severe swelling of both hands associated with me- 250/110mmHg, palpitations and severe headache. The clinical exam did not reveal any relevanttacarpophalangeal (MCPs) and proximal interphalangeal (IPs) joint pains, sparing all the rest of joints. alteration such as renal bruits. In the diagnostic approach to secondary hypertension, we exclu-There were no other complaints or constitutional symptons, including morning stiffness or shoulder and ded drugs which could cause hypertension, Cushing Syndrome, primary aldosteronism, thyroidpelvic girdle pain. Past medical history included: obesity, hypertension, diabetes mellitus, dyslipidaemia, and parathyroid pathology, pheocromocytoma, coarctation of the aorta and sleep apneia as wellhigh uric acid levels without previous arthritis bout, chronic hepatitis C without portal hypertension, chro- as disease of the renal parenchyma. She underwent abdominal angio-CT which revealed 70% ste-nic heart failure, chronic atrial fibrillation, psoriasis and generalised arthrosis. She had had a purpura epi- nosis of the right renal artery, and was subsequently submitted to elective angioplasty of the rightsode in lower both extremities in the setting of overdosed anticoagulant treatment , thirteen years before. renal artery performed successfully with no complications. Follow up revealed a greatly improvedExamination revealed pitting edema of the dorsum of both hands with swollen and painful MCPs and hypertensive profile with only 1 antihypertensive drug. It is necessary to consider the possibilityproximal IPs joints, as well as limited active mobilisation. Onycholysis without sausage fingers appearance of renal artery stenosis in cases of severe, persistent and drug resistant hypertension; it can be dia-neither axial involvement were observed. Hepatomegaly on abdominal palpation and no edema in lower gnosed by non-invasive exams and treated promptly with angioplasty. In this manner, most com-both extremities were noted. There were no other remarkable findings in physical examination. The ery- plications of long-lasting hypertension, such as end-organ damage and cardiovascular events canthrocyte sedimentation rate was 112 mm in the first hour and C reactive protein was 102.8 mg/l. Renal be avoided.and thyroid function tests were normal. There was a moderate increase in gamma-glutamyltransferase,aspartate and alanine aminotransferase. Rheumatoid factor, tumor markers, beta2-microglobulin, ACE,ANA and ANCA were negative. Electrophoresis did not showed monoclonal peak or Bence Jones pro-tein in the urine. Cryoglobulins were positive. Radiography of the hands and wrists showed soft tissueedema and osteopenia, without bone erosions. Tuberculin skin testing was reactive. Chest X-ray showedcardiomegaly without pulmonary infiltrates. RS3PE syndrome was considered. Hydroxichloroquine 400mg per day, was started and inflammatory signs improved. However, despite the deleterious effects ofsteroids (increased hepatotoxicity risk related to isoniazid in the setting of positive tuberculin skin test andC chronic hepatitis, increased infectious diseases and metabolic decompensation in the setting of diabe-tes mellitus, and increased bone loss in the setting of osteoporosis), low dose prednisone (15mg per day)plus calcium and vitamin D supplements needed to be added to achieve complete remission of pain, sy-novitis and edema. After four weeks on combined treatment (hydroxichloroquine 200 mg per day plusprednisone 15mg per day), inflammatory signs have disappeared but small limitation of the wrists andfingers still persists. Discussion: RS3PE is a definite subset of the seronegative symmetrical polyarthritis,male and old age predominance, associated with pitting edema of the hands, with dramatic response tosteroids. This syndrome may be part of a autoimmune rheumatic disease. Our patient was a female andshe had C chronic hepatitis and positive serum cryoglobulins. Rethinking purpura episode in her clinicalhistory, cryoglobulinemia essential mixed should be considered and therefore should be kept in mind asa condition related to RS3PE. To our knowledge, this is the first reported case. Conclusions: In our opi-nion, cryoglobulinemia essential mixed should be considered in patients with RS3PE syndrome, in thesetting of C chronic hepatitis, in addition to other conditions included in a broad differential diagnosis. Re-ferences: 1- Dudler J, Gerster J and So A. Polyarthritis and pitting oedema. Ann Rheum Dis 1999; 58:142-147. 2- Schaeverbeke T, Fatout E, Marcé S et al. Remitting seronegative symmetrical synovitis withpitting oedema: disease or syndrome? Ann Rheum Dis 1995; 54: 681-684.7. A RARE CAUSE OF STROKE 8. THE VALUE OF THE BONE MARROW ASPIRATE AND BIOPSY IN ANA.R. Alves, R. André, A. Chipepo, H. Gruner, A. Ferreira, M. Ventura, V. Riscado INTERNAL MEDICINE DEPARTMENT François Alves, Ana Baptista, Gina Guerreiro, Helena Brito, Idálio MendonçaA 55 year old man was admitted with sudden onset of right side hemiparesis and loss of con-sciousness. Anamnesis disclosed symptoms suggesting TIAs in the past 2 years. He was a heavy Bone marrow evaluation is an important and effective way of diagnosing and evaluating primarysmoker, had hypertrygliceridemia and hypertension. Physical examination on admission confirmed hematologic and metastatic neoplasms as well as nonhematologic disorders. Complete evaluationthe neurological deficits (4/5) but was otherwise unremarkable, BP 162/92mmHg, HR 90bpm. of bone marrow samples should include a brief patient history, pertinent laboratory data, peri-EKG showed sinus rhythm and lab tests revealed no significant alteration. Cranial CT demon- pheral blood films, bone marrow aspirate smears and sections, and biopsy imprints and sections.strated ischemic stroke of the left middle cerebral artery and lacunar lesions. Further investigations Biopsies are superior for the assessment of the bone marrow architecture, the vascularisation, theof causes of stroke were performed. As such, autoimmune profile, AT III, proteins c, s, homocy- cellularity, the localisation and the extent of infiltrates and the degree of fibrosis. As is the case withsteine, thyroid function tests, viral serologies were normal. Doppler ultrasound of the vertebral and aspirates, examination of a biopsy alone is usually sufficient for a correct diagnosis. However, acarotid arteries showed no significant lesion. TT and TE Echocardiograms revealed masses of both combination of both techniques makes possible an optimal assessment of the nature and extentmitral valve leaflets, confirmed as papillary fibroelastoma with cardiac MRI. The patient was di- of the disease process in the often very serious haematological conditions. In order to review thesmissed with oral anticoagulation and is awaiting cardiothoracic evaluation. Papillary fibroelasto- histological characteristics and the presence of valuable findings for diagnostic purposes, we re-mas are the most common primary tumors of the heart and although they are benign and can trospectively studied the patients who had undergone initial bone marrow aspirate and biopsy inoften be asymptomatic, they can also have potential life threatening complications such as sud- our internal medicine department between 2003 and 2007.den death, stroke, and myocardial infarction. All patients should be anticoagulated and conside-red for surgical resection of the tumor (even asymptomatic patients due to the high risk ofembolization) since their complete excision remains the only means of avoiding a recurrence ofembolization. The cases reported in literature reveal successful interventions, mostly with preser-vation of the native valve and its leaflets, as well as an uneventful clinical course. 88
  • 92. 9. SYSTEMATIC LUPUS ERYTHEMATOSUS: EXPERIENCE OF AN INTERNAL 10. A RARE MANIFESTATION OF MILIARY TUBERCULOSIS: CUTANEOUSMEDICINE DEPARTMENT INVOLVEMENT BY HAEMATOGENOUS SPREADFrançois Alves, Gina Guerreiro, Ana Baptista, Anabela Malho, Helena Brito, Augusta Pereira, Gregório T, Belo A, Cardoso MT, Granja JMIdálio Mendonça Mycobacterium tuberculosis infection is a widely distributed disorder worldwide. Although theSystemic lupus erythematosus (SLE) is an autoimmune disease that can affect various parts of the most commonly involved organ is the lung, this agent has the capability of infecting nearly everybody, including the skin, joints, heart, lungs, blood, kidneys and brain. The primary feature of SLE body tissue or organ. Skin involvement by this bacillus can occur threw direct inoculation , hae-is inflammation and it is characterized by pain, heat, redness, swelling and loss of function, either matogenous spread, lymphatic spread or extension from a nearby infective focus. The haemato-on the inside or on the outside of the body. Systemic lupus erythematosus appear with a wide genous spread of Mycobacterium tuberculosis configures the basis of the clinical syndrome ofspectrum of clinical manifestations, characterized by the production of auto-antibodies to com- miliary tuberculosis. Amongst the published series of miliary tuberculosis, skin ranks as one of theponents of the cell nucleus. Treatments include various immunosuppressive regimens, and newer least frequently involved organs and as such constitutes a rare form of manifestation of this di-biological therapies show promising results. The prognosis of SLE has changed dramatically in the sease. We report the case of a 77 year old patient admitted to our department because of pro-last few decades and it is now possible to have SLE and remain active and involved with life, fa- longed fever. The patient was being treated with low dose corticosteroids because of a lumbar painmily, and work. We retrospectively evaluated the prevalence, clinical manifestation, treatment stra- ever since 10 years ago and the physical examination showed enlarged, non-painfull lymph nodestegies and outcome of the 78 patients with SLE that are followed at our department. in the axilla and cervical region. The chest x-ray was apparently normal but the thoraco-abdomi- nal CT scan showed parenquimal lung changes suggestive of an endobronchial spreading infec- tive process. A fine needle biopsy of the enlarged ganglions was performed and acid fast bacilli were detected. Corticotherapy was stopped, quadruple tuberculostatic therapy was started and a bronchofibroscopy was performed, which allowed detection of Mycobacterium tuberculosis by cul- tural and PCR methods. The patient evolved with defervescence and hematogenous spread of the infection to the skin, causing the formation of a tuberculous abcess on the right hand which sub- sequently fistulized. Fistulization also occoured over the enlarged lymph nodes. With this work, documented with illustrative pictures we intend to present, we aim to share this atypical form of presentation of miliary tuberculosis and remind the clinicians the serious menace Mycobacterium tuberculosis still constitutes worldwide.11. CORRELATION BETWEEN ENDOTHELIAL MARKERS IN DIABETIC PATIENTS 12. HEREDITARY HEMOCHROMATOSIS - A CASE REPORTWITH HEART FAILURE Arduan J; Cabrita C; Fonseca P; Santos Silva PMariana Anton, Constanta Antipa, Minerva Muraru, I. Bruckner Introduction: Hereditary Hemochromatosis is an autosomal recessive iron over-load disorder as-Heart failure (HF) can be evaluated by several plasmatic factors of endothelial dysfunction. In athe- sociated with mutation of the HFE gene that cause an increase intestinal iron absorption, perhapsrogensis these factors can become etiological and prognostic markers, especially for the hyper- via an interaction with the transferrin receptor. The clinical manifestations of this disorder are re-tensive diabetic patient. Endothelin1 (ET1) by vasoconstriction, von Willebrand Factor (vWF) a lated to excessive iron deposition in tissues, especially the liver, heart, pancreas and pituitary. Caseprothrombotic factor and adiponectin as a metabolic factor make possible sketching of the en- description: The authors report the case of a 57-year-old woman referred by primary care physi-dothelial profile of the HF patient. Adiponectin, an insulin-sensitizing adipocitokine, may affect cians for a persistent elevated serum ferritine in routine laboratory findings (serum ferritine:pathogenic factors of cardiac failure (inflammation, hypertrophy and fibrosis) and may be corre- 1050ng/ml); the patient was admitted to the Internal Medicine Department to confirm and studylated with other markers of endothelial dysfunction. The aim of this study is to establish in diabetic this laboratory findings. The clinical manifestations included fatigue, weakness, arthralgies, loss ofpatient with HF a correlation between the adiponectin level and endothelial dysfunction. Materials líbido, alopecia and skin hiperpigmentation in the last two years; the laboratory findings confir-and method: 60 diabetic hypertensive patients (mean age 61±9, sex ratio 1:1.5) all presenting dy- med elevation of serum ferritine (1050 ng/ml) and transferrin saturation >45% with normal liverslipidaemia and cardiac failure in different NYHA stages, were investigated for endothelial dy- enzymes. According with the clinical data the most plausible diagnosis was Hereditary Hemo-sfunction markers. The patients were equally divided according to the history of their coronary chromatosis. A genetic test was made that confirmed our clinical suspicion: Primary Hereditary He-arterial disease. In the first group patients without ancient myocardial infarction (MI), while in the mochromatosis (HFE-associated hereditary hemochromatosis type 1: C282Y Homozygosity). Thesecond group patients with MI in antecedents were investigated. ET-1 and adiponectin plasma- patient was treated with therapeutic phlebotomy in outpatient hospital, dietary limitations and thetic levels were determined by ELISA and vWF was determined by immunological quantification. screening of family members was done. On 7 months’ follow-up after discharge the level of serumResults: In the group of patients without MI the vWF and ET1 values were increased in 63.3% ferritine is <50ng/ml and showed no recurrence of symptoms. Discussion: Hereditary Hemo-respectively 33.3% subjects while adiponectin levels were decreased in 60% subjects. In the group chromatosis (HH) is one of the few genetic disorders in which phenotypic manifestations (organII, the vWF and ET1 values were 70.3%, 43.3% and adiponectin levels were lower in 73.3% pa- damage) are delayed to adult life. However, sensitive and specific phenotypic and genotypic te-tients. An important correlation between vWF and adiponectin levels is noted in the group II pa- sting now allows diagnosis of HH while it is still a disorder of iron metabolism and before it re-tients (60% concordance). Regarding the other markers, the concordance was under 38%. sults in end-organ damage.Conclusions In diabetic hypertensive patients with HF we noted an inverse correlation betweenplasmatic levels of vWF and adiponectin. In diabetic patients adiponectin might be an indepen-dent predictor factor for cardiac disease prognostic. 89
  • 93. 13. FEVER IN HIV PATIENT 14. CUSHING´S SYNDROME SECONDARY TO NEUROCARCINOID TUMORArduan J; Cabrita C; Fonseca P; Santos Silva P Armiñanzas C, Peña A, Villegas J, Vega T and Pérez del Molino A.Introduction: Disseminated Mycobacterium avium complex (MAC) infection had been reported CASE DESCRIPTION A 62-year-old man, smoker of 20 paq-year until 2003, diagnosed of dia-rarely prior AIDS epidemy. This infection became one of the most important opportunistic infec- betes mellitus type 2, dislypemia, appendectomy (1984), hypernephroma on rigth kidney with ne-tions associated with the AIDS in many parts of the World. After early 1996 when potent HIV pro- frectomy (2004). The patient presented to our hospital at October 2007 with a 2-month historytease inhibitor drugs became widely available, the incidence of new cases of disseminated MAC of abdominal pain and gastroesophagic reflux symptoms, which did not response to treatmentinfection decreased by more then 80%. Case report: The authors present a case report of a 23- with omeprazol. Physical examination was normal. • Analytical study: hyperamilasemia • Abdo-year-old man, ex-IDU, admitted to an Internal Medicine Department with a clinical, radiologic minal Ecography: multiple liver lesions (confirmed by TC-scan). • Fine-needle Aspiration Punctionand laboratory findings compatible with pulmonary tuberculosis. Acid-fast bacilli was found on in liver: Neuroendocrine carcinoma • Gastroscopy: duodenal bulb ulcer. • Colonoscopy: no fin-smear of sputum. Coinfection HIV1 (C3)/HCV were diagnosed. Tuberculostatic therapy was star- dings. The patient had a follow-up visit by Internal Medicine: • Tumor markers: high CEA and Cated with radiological but not clinical improvement. Diagnosis was questionated 1 month later, 19.9 levels. • Neuroendocrine markers (5-HIAA, gastrine, cromogranin, CYFRA 21-1, Neuron-due of persistent fever, anemia and increase of alkaline phosphatase and gamma-glutamyl tran- Specific Enolase, pancreatic polypeptide): positive. • Calcitonine: increased levels. • Gammagraphyspeptidase. MAC diagnosis was made by bone biopsy. MAC should be suspected in AIDS patient with octreotide-In111: mediastinum, left pulmonary hili, right thyroid lobe and retroperitoneal cap-who exhibit all of the following signs and symptoms: CD4 T cells levels &#8804; 50/ml, fever >30 tation. • Gammagraphy with MIBG-I123: no captation The patient was admited again to the ho-days in 3 months and altereted laboratory values (hematocrit<30% and albumin<3gr/dl). spital in January 2008 because of hyperosmolar diabetic descompensation, atrial fibrillation and hypokaliemia. He appeared icteric, with leg edemas and no other findings on physical examina- tion. • Analytical study: hypokaliemia, hypomagnesemia, hypocalcemia, hypoalbuminemia. During the following week, the patient presented bad glycemic and potassium blood levels control, and three severe tetany crisis. Nugent-test was diagnostic to ectopic Cushing syndrome. Hypercorti- solism was treated with ketoconazole and octreotide. Palliative treatment with etoposide and car- boplatin was also initiated. A day later, the patient presented fever and productive cough: • Analytical study: severe anemia, lymphopenia and thrombocytopenia. • Chest radiography: basal and upper infiltrates in right lung. Considering a nosocomial pneumonia on a immunodepressed patient, treatment with piperazillin-tazobactam and levofloxacine was iniciated immediately. Ne- vertheless, the patient died in less than 24 hours. Multiple nodules on liver, lungs and mediasti- num were found in macroscopic autopsy. Microscopic autopsy confirmed well-differentiated neuroendocrine tumor. DISCUSSION The ectopic corticotropin (ACTH) syndrome refers to ex- cess ACTH production outside of the pituitary, producing Cushing’s syndrome. The most com- mon causes of this disorder are small-cell carcinomas, carcinoid tumors and islet cell tumors. The optimal therapy of the ectopic ACTH syndrome is surgical excision of the tumor, whenever me- tatases are not present. In patients with metastases limited to the liver, metastases resection, cryoa- blation or liver transplantation may result in cure. If tumor is not resectable, chemotherapy and/or radiotherapy may be helpful. Hypercortisolism may pose a more immediate threat. Cortisol syn- thesis should be reduced by an adrenal enzyme inhibitor (ketoconazole, aminoglutethimide,…). Octreotide, a long-acting analogue of somatostatin, also rapidly reduces ectopic ACTH secretion by some nonpituitary tumors. The prognosis is dictated by the nature of the tumor and the se- verity of the hypercortisolism. Most patients with overt metastases at the time of presentation die of the cancer within one year, although patients with indolent tumors may survive for over a de- cade. Patients with small-cell lung cancer, medullary thyroid cancer, and gastrinoma have a par- ticularly poor prognosis.15. NORMAL URINARY EXCRETION OF 5-HIAHH AND SOMATOSTATIN 16. BILATERAL PULMONARY EMBOLISM IN A YOUNG BOY WITHRECEPTOR NEGATIVE IN A METASTASIC CARCINOID TUMOR OF UNKNOWN THROMBOCYTOPENIA AND EOSINOPHILIAORIGEN: A CHALLENGING DIAGNOSIS FOR THE PHISICIANS Arnáiz García A, Latorre M, García Palomo JD, Arnáiz García J, Salesa R, Perez Montes R,Arnáiz García A, Cruz Vicente JM, Nuñez Viejo M, Valero C, González Macías J. Gutiérrez Cuadra M, Lamelas R, Berrazueta JR, Fariñas MCIntroduction:Carcinoid tumors account for less than 1% of all malignancies.The majority arise in Introduction:The antiphospholipid syndrome (APS) is an acquired prothrombotic syndrome cha-the gastrointestinal system.A significant percentage of these tumors present as metastatic disease racterized by venous or arterial thromboses and pregnancy morbidity.It can present as primaryof unknown primary site. The diagnosis of these tumors is often made late and the protean sym- APS without any discernable underlying disease,or in association with autoimmune disease,in-ptoms are easy to overlook.Case:A woman of 67 year-old with antecedents of appendectomy fections and cancer,among others.Case:A 16year-old Guinean boy without history of prior disea-was admited to our hospital with a picture of episodic flushing involving the face and neck,asso- ses was admitted to the hospital because of acute dizziness, precordial pain and syncope whileciated with a burning sensation and epigastric pain.Laboratory findings showed a discrete ane- he was playing football.Laboratory findings showed thrombocytopenia and eosinophilia.Othermia,dissociated cholestasis and increased concentrations of chromogranin A and gastrin.Rest of chemical parameters were within a normal range. S. stercolaris and S. haematobium were isola-chemical parameters,including hypothalamic-pituitary hormonal function,glucagon,C ted in stool cultures.ECG was normal.Echocardiography showed signs of acute pulmonary hy-peptide,PTH,vitamin D metabolites and vasoactive intestinal polypeptide were normal.Urinary ex- pertension.A spiral-CT and V/Q scan were done and confirmed a suspected bilateral pulmonarycretion of 5-HIAA(u5-HIAA),catecholamines and serotonine were normal.CT-scan demonstrated embolism.Doppler-US of lower extremities showed deep venous thrombosis in left superficialmultiple liver metastases.A echocardiography,a complete endoscopic study,an octreoscan and vein.The hypercoagulation study showed deficiency of C and S proteins and moderate high titers18FDG-PET-scan were made, and were also completely normal.Finally a biopsia of one of the me- of IgM and IgG anticardiolipin(aCL) and ß2-glycoprotein-I. Lupus anticoagulant activity was alsotastases was perfomed and confirmed the diagnosis of carcinoid tumor.Symptomatic and long- positive.Otherwise the patient had not criteria for lupus.With the diagnosis of primary APS andterm treatment with lanreotide was administred with good clinical response.The patient died 2 parasitic infection,first treatment with heparin and then with permanent acenocumarol was ad-years after admission.Discussion:Metastatic carcinoid tumors are occasionally found at metastatic ministered. Praziquantel during 3 days and albendazole during 6 days were also given.Nowadayssites without an obvious primary.In this situation,metastases almost always involve the liver,and cli- the patient remains asymptomatic without no new thrombotic events or relapse of intestinal in-nical syndromes from the production of bioactive substances may be apparent.In some patients,the fection.Discussion:APS has been reported in bacterial,viral and in a few cases of parasitic infec-primary sites are subsequently found in the intestine or the pancreas.No references in the litera- tions.These cases are usually IgM aCL,which may occasionally result in thrombotic events.Little isture about the combination of normal u5-HIAA,somastotatin receptor negative tumor and a com- known about the mechanism of the parasitic infection to produce an hypercoagulabity status andpletely normal imaging study with PET-scan,CT-scan and endoscopic studies have been a secondary APS. In this case,a combination of two possible mechanisms of hypercoagulabi-found.Further researches in this way are needed to get an early diagnosis and improve the pro- lity:primary APS with underlying haematologic disorder and a parasitic infection by S. stercolarisgnosis of these patients. and S. haematobium could be the cause. 90
  • 94. 17. ACUTE ABDOMEN SECONDARY TO FOREIGN BODY INGESTION: 18. DRAMATIC GANGRENOUS NECROSIS AND MYOCARDITIS AS AA CHALLENGING DIAGNOSIS FOR CLINICIANS AND RADIOLOGISTS CONSECUENCE OF MENINGOCOCCAL DISEASEArnáiz García AM, Gonzalez Sanchez FJ, Arnaiz García J, Piedra Velasco T, Pintado R, Izquierdo J, Arnáiz García A, Gutierrez Diez F, Gutierrez Cuadra M, Arnáiz García E, García Palomo JD,Pellón R. González Macías J, Fariñas C.Introduction: Only 1% of involuntary and generally unconsciously ingested foreign bodies per- Introduction: N. meningitidis is the leading cause of bacterial meningitis in children and youngforate the bowel, and constitutes abdominal emergencies whose diagnosis represents a challenge. adults in eastern countries, and the second cause of community-acquired adult bacterial menin-We report all the cases of foreign bodies ingestion from January to December of 2007. We found gitis. The clinical manifestations of meningococcal disease can be varied, ranging from transientthree proven cases of bowel perforation by ingested foreign bodies (fish bone, metallic foreign fever and bacteremia to fulminant disease with death ensuing within hours of the onset of clini-body and fruit bone) and two cases of obstruction caused by chicken and rabbit bone.The dia- cal symptoms. Case: A woman of 74 year-old with a previous history of diabetes, hypercholeste-gnosis was suggested by CT scan and the final diagnosis was confirmed by surgery. Results: All rolemia and viral meningitis six years ago, was admitted to our hospital presenting fever, vomitingspatients had diffuse (two cases) or more localized abdominal pain in the hypogastric area (one and abdominal pain focused in epigastric area. The physical examination revealed hypotension,case), in the epigastric area (one case) or in the left iliac fossa (one case). Rebound was present in elevated pulse rate and cyanotic poorly perfused extremities. Laboratory findings showed leuko-all cases. Laboratory tests showed in all patients elevation of the white cell count from 12,000 to cytosis with left shift, moderate renal insuffiency and data of disseminated intravascular coagula-32,000 and C reactive protein >10 mg at the time of admission. All patients were unconscious of tion (DIC) in the blood coagulation study. Arterial blood gas analysis demonstrated acidosis andhaving ingested a foreign body. Only the retrospective alimentary inquiry revealed the consum- hypoxia. Rx thorax showed pulmonary edema. Echocardiography revealed a severe disfunctionption of fish, rabbit, chicken and parsimmon fruit bone in four cases, and the ingestion of a screw of left ventricule, without data of endocarditis. With the diagnosis of septic shock, an empiric the-in a psychiatric patient the days before perforation. Subocclusion or occlusion symptoms were pre- rapy with piperacilin-tazobactam and linezolid was incorporated to the inotropic threatment. Bloodsent at admission in two cases. Plain radiographs were taken in all patients. Aewll patients were cultures and lumbar puncture were done. Fever was increased and in few hours appeared datainvestigated by CT scan, and this examination was the first immediately required after plain ra- of cutaneous haemorrhages and necrosis in fingers of both hands and feet. N. meningitidis wasdiographs. Conclusions: Acute abdomen due to foreign bodies ingestion is a challenging dia- isolated from blood and cerebrospinal fluid cultures. Treatment was modified and cefotaxime wasgnosis for clinicians and radiologists. It should always be invocated in cases of elderly, psychiatric started with remission of signs of sepsis and a quickly improvement of general status. Howeveror patients with a history of drug abuse. The definite diagnosis is based on the demonstration of the gangrenous necrosis needed of amputation of the proximal interphalangeal articulations ofthe responsible foreign body that is optimally achieved by CT scan thanks to its possibilities of mul- both hands and transmetatarseal resection of feet. Discussion: Purpura fulminans is a severe com-tiplanar reconstructions. The security of a very specific and precise diagnosis allows a prompt and plication of meningococcal disease, occurring in 15-25% of those with meningococcemia. It isappropriate management of these patients. characterized by the acute onset of cutaneous hemorrhage and necrosis secondary to vascular thrombosis and DIC. Gangrenous necrosis can follow into the subcutaneous tissue, bone and muscle. The keys to prevent this complication is the early intervention with antimicrobials and support of vascular perfusion. Sometimes, deep necrosis of limbs or digits may call for amputa- tion. Myocarditis appears in more than 50% of the postmortem esmination of patients who die of meningococcal disease.Treatment of myocardial failure can improve the myocardial manife- stations associated with meningococcal meningitis, including heart failure and signs of poor peri- pheral perfusion, like in this case.19. PARADOXICAL RENAL EMBOLISM IN PATIENT WITH HYPERCOAGULABILITY 20. POSTERIOR REVERSIBLE LEUKOENCEPHALOPATHY SYNDROMEDISORDERS ASSOCIATED WITH FAMILIAL MEDITERRANEAN FEVERR.Serrano Morales, M.Arsuaga Vicente, N.Carrasco Antón Kadriye Aydin, Mine Durusu Tanriover, Engin Tezcan, Unal YasavulIntroduction: The two major causes of renal embolic disease are thromboemboli and atheroem- Case presentation A 19-year-old girl with FMF was admitted to our hospital with anuria, hypervolemia and dy-boli which are mostly originated in the heart or aorta and rarely the cause of these renal embo- spnea. She was diagnosed to have nephrotic syndrome and renal amyloidosis due to FMF when she was 15 yearslisms is paradoxical embolism (PE) through a patent foramen ovale (PFO). The most important old. She was put on colchine treatment after when she was lost to follow up for 4 years. On admission she waspotential clinical manifestation due to PE is ischemic stroke and less commonly systemic emboli- on an irregular colchicine treatment and chronic renal disease had already developed. The physical examinationzation, such as renal infarction. Case description: We present the case of a 43-year-old female with revealed 2+ pretibial edema, mild periorbital edema, and rare ronchi secondary to hypervolemia. She had noa medical history of spontaneous abortion in 1994 which cause wasn´t clear and the taking of oral history of bronchial asthma or allergy. Abnormal laboratory findings on admission were as follows: Hemoglobincontraceptives during the last 12 years. She was admitted for abdominal pain irradiated to left flank 7 g/dl, leukocyte 21700/mm3, serum blood urea nitrogen 96 mg/dl, creatinine 16.2 mg/dl, calcium 7.5 mg/dl,and left iliac fossa with nausea and vomiting, remaining stable and without fever. The blood ana- phosphorus 16.2 mg/dl, uric acid 11.2 mg/dl, albumin 1.6 mg/dl. Immediate hemodialysis was done. Althoughlysis showed slight leucocytosis with high LDH levels. A CT renal angiography was performed sho- two cycles of hemodialysis was performed and the patient was put on 10 mg of amlodipin and intravenous ni-wing extense left renal infarction. After local fibrinolysis was done and partial revascularization troglycerin treatment, the blood pressure elevated 150/100 mmHg most of the time. On the seventh day of herwas reached, the radioisotope renogram detected a lowered glomerular filtration rate of 28% for admission, the patient had a generalized tonic clonic seizure when her blood pressure was 170/100 mmHg andthe left kidney. Transthoracic echocardiogram was normal; however, transesophageal echocar-