Early-stage predictors of the acute phase duration in uncomplicated COVID-19 pneumonia.

OBJECTIVE: In this study, we aimed to highlight the common early-stage clinical and laboratory variables independently related to the acute phase duration in patients with uncomplicated coronavirus disease (COVID-19) pneumonia. METHODS: In hospitalized patients, the acute phase disease duration was followed using the Brescia-COVID respiratory severity scale. Noninvasive ventilation was administered based on clinical judgment. Patients requiring oropharyngeal intubation were excluded from the study. For parameters to be measured at the hospital entrance, age, clinical history, National Early Warning Score 2 (a multiparametric score system), partial pressure of oxygen in arterial blood/fraction of inspired oxygen (P/F ratio), C-reactive protein, and blood cell count were selected. RESULTS: In 64 patients, age (direct relationship), P/F, and platelet number (inverse relationship) independently accounted for 43% of the acute phase duration of the disease (P < .001). CONCLUSIONS: For the first time, the present results revealed that the acute phase duration of noncomplicated pneumonia, resulting from severe acute respiratory syndrome coronavirus 2, is independently predicted from a patient's age, as well as based on the hospital entrance values of P/F ratio and peripheral blood platelet count.

Femoral Vein Leiomyosarcoma Mimicking Thrombosis.

BACKGROUND: Leiomyosarcoma represents a diagnostic challenge since it is often misdiagnosed as deep venous thrombosis (DVT). METHODS: A 49-year-old woman with history of DVT and diagnosed with recurrency of thrombosis came to our observation for right thigh pain persistency. RESULTS: Duplex-Ultrasound (US) examination showed an oval mass inside the superficial femoral vein with color spots and blood flow signal in its context. Contrast enhanced computed tomography and magnetic resonance of the lower limbs showed the presence of vascularized lesion into the distal superficial femoral vein. Echo-guided biopsy revealed the presence of high grade leiomyosarcoma. A total body 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography demonstrated a rounded area of pathological increased FDG uptake, at the distal thigh level without metastatic localization. CONCLUSIONS: Our experience demonstrated that a multimodality approach may help to distinguish leiomyosarcoma from a blood clot in doubtful cases.

Ectopic Origin of the Left Anterior Descending Artery from the Proximal Right Coronary Artery: An Imaging Report.

Anomalies of the coronary arteries represent rare congenital disorders, which are characterized by a wide spectrum of clinical manifestations. Usually, they are asymptomatic, but sometimes they cause myocardial ischemia or sudden cardiac death. Here, we describe the case of a patient who suffered from angina. Coronary angiography revealed an ectopic origin of the left anterior descending coronary artery from the proximal trait of the right coronary artery and the left circumflex artery, originating from the left sinus; the whole coronary tree was free of atherosclerosis. To better define the coronary anatomy, we performed computed tomography angiography with a three-dimensional reconstruction. The patient was discharged from the clinic after 48 h under optimal medical treatment.

A Case of Stent Under-Expansion due to Calcified Plaque Treated with Shockwave Lithoplasty.

We report the case of a stent under-expansion due to heavily calcified plaque treated with the shockwave lithoplasty system. A 77-year-old woman underwent coronary angiography, and intravascular ultrasound revealed stent under-expansion due to calcified plaque. Shockwave lithoplasty balloon was used to disrupt calcium deposits around the stent, thereby allowing a correct stent expansion with an excellent angiographic and intravascular ultrasound result.

When Calcium Gets Tough, the Tough Cardiologist Starts to Play .

Coronary calcification is a hard challenge for the interventional cardiologist, as it is associated with incomplete stent expansion and frequently stent failure. In recent years, innovative techniques, such as rotational atherectomy, have been developed to treat coronary calcification. However, these are burdened with an increased procedural risk. We report the case of a 60-year-old Caucasian man treated 1 month before at another center with primary coronary angioplasty and stenting of the ramus intermedius for coronary syndrome. Coronary angiography showed a critical stenosis of the left main coronary artery as well as critical calcified stenosis of the left anterior descending artery and the diagonal branch. Coronary calcification was treated with rotational atherectomy that preceded the angioplasty and stenting. Because of persistence of the symptomatology, coronary angiography was repeated 1 month later and showed a critical calcified restenosis of the ramus intermedius at the site of the previous stenting. Considering the high risk of traditional atherectomy, we performed lithotripsy-enhanced disruption of calcium beyond the stents with the Shockwave Coronary Lithoplasty System. The Shockwave Coronary Lithoplasty System has been introduced recently in order to treat calcified coronary lesions with greater safety. The procedure allows most calcified coronary lesions to be treated with simplicity and safety. This system employs sound waves, similar to those used for treating kidney stones, to crush the calcified lesions. We present the first case described to date in whom this technique was successfully used to treat calcified restenosis in a previous stent.

Blood viscosity but not shear stress associates with delayed flow-mediated dilation.

PURPOSE: Flow-mediated dilation (FMD) is a complex mechanism involving several mediators, and different hemodynamic forces. Temporally distinct FMD patterns can be elicited by ischemic stimulus. Some subjects dilate early after cuff release, while others dilate later or do not dilate at all. Aim of the present research was to verify if hemorheological and hemodynamic factors might influence different FMD pattern. METHODS: 148 free-living subjects were studied. FMD was measured at 50 s, 2 min and 3 min. Blood viscosity was measured and shear stress calculated. Shear stress stimulus was quantified as the area under the curve after ischemia (SSAUC) over the first 40-s post-occlusion. RESULTS: Based on the timing or absence of arterial dilation, 82 subjects were classified as Early dilators, 37 as Late dilators and 29 as No dilators. Peak FMD was 7.9 ± 4.3 % in Early dilators, and 9.1 ± 5.7 in Late dilators (p = NS). SSAUC was not significantly different among three groups, while blood viscosity was significantly higher in Late FMD subjects. Regression analyses showed the independent predictive role of age and blood viscosity on FMD patterns, and the lack of any association between FMD pattern and the magnitude of SS. CONCLUSIONS: The present study demonstrates that age and blood viscosity but not the magnitude of SS explain the different timing of the dilatory response to ischemia.

Delayed flow-mediated vasodilation and carotid atherosclerosis.

BACKGROUND: In a previous study, we identified temporally distinct postischaemic flow-mediated dilation (FMD) patterns comparing the standard clinical measurement time of 50s postcuff release with measurement at 2 min. The comparison revealed a cohort with the highest FMD at 50s (Early FMD), another cohort with the highest FMD at 2 min (Late FMD) and a third cohort with no FMD (Absent FMD). The aim of this study was to examine whether these temporally distinct FMD patterns associated with different degrees of carotid atherosclerosis. MATERIALS AND METHODS: One hundred and twenty-four free-living white subjects, participating in a cardio-vascular disease prevention campaign, were enrolled. FMD was measured at 50s, 2 min and 3 min after forearm ischaemia. The intima-media thickness (IMT) of the common carotid artery was measured, and the artery was evaluated for the presence and number of carotid plaques. RESULTS: Fifty-seven subjects had Early FMD, 34 had Late FMD and 33 had Absent FMD. The three groups were comparable for age, sex and cardiovascular risk factors. The number of plaques in the carotid arteries, and IMT, increased progressively from Early, to Late, and to Absent FMD (P < 0·03), indicating that the FMD pattern is an independent predictive variable for IMT and carotid atherosclerosis. CONCLUSIONS: The present study demonstrates that temporal patterns associated with the degree of atherosclerosis of the carotid arteries. Patients with delayed vasodilation (Late FMD) had a higher degree of atherosclerosis than those with early vasodilation (Early FMD), and subjects with no postischaemic vasodilation (Absent FMD) had the most atherosclerosis.

Common carotid and brachial artery hemodynamic alterations in periodontal disease.

AIM: In patients affected by periodontal disease, hypertension and systemic inflammation might cause an arterial hemodynamic derangement; this, in turn, can act as a mediator of the atherogenic process often seen in these patients. This study aimed at a comprehensive hemodynamic evaluation in periodontal patients. METHODS: Fourty-eight subjects participating to a cardiovascular prevention programme were enrolled. Periodontitis, classical risk factors for atherosclerosis, and shear and tensile forces in both carotid and brachial arteries were evaluated. Calculated periodontal indexes were plaque, gingival and pocket deep (PD) indexes. Simple and multiple regression analyses were performed. Afterwards, 30 of them with normal PD index were compared with 30 carefully - matched patients with periodontitis. RESULTS: Brachial and carotid parietal tension were significantly associated with periodontal indexes, especially PD-Sum, in both simple (r = 0.42, p < 0.001 for carotid artery and r = 0.36, p < 0.02 for brachial artery) and multiple regression analyses. Shear stress gave similar results. In case-control analysis, shear stress was lower by 15% and 30%, respectively, in carotid and brachial artery in patients with high PD; common carotid parietal tension was higher. Arterial stiffness resulted not associated with periodontitis. CONCLUSIONS: Periodontal disease is associated to a complex atherosclerotic prone hemodynamic derangement, particularly in large elastic arteries.

Ultrasound imaging and central venous pressure in spontaneously breathing patients: a comparison of ultrasound-based measures of internal jugular vein and inferior vena cava.

BACKGROUND: Ultrasound evaluation of inferior vena cava and internal jugular vein dia-meters predicts the intravascular volume status in critical patients. The aim of the present study was to determine which ultrasound-derived index is most strongly associated with central venous pressure (CVP). Furthermore, we determined the utility of selected variables in predicting low volume status (CVP < 8 mmHg). METHODS: All patients underwent a transthoracic echocardiogram, vascular ultrasound examination, invasive central venous pressure, and intra-abdominal pressure determination. The following indexes were calculated: inferior vena cava diameter, internal jugular vein maximum diameter, collapsibility index, and internal jugular vein ratio. RESULTS: 41 spontaneously breathing patients were recruited. Central venous pressure significantly correlated with inferior vena cava diameter ( r = 0.35, P = 0.02), internal jugular vein ratio ( r = 0.35, P = 0.03), and internal jugular vein maximum diameter ( r = 0.58, P < 0.001). The inferior vena cava collapsibility index did not show any association. The areas under the receiver operating characteristic curves to discriminate a low central venous pressure (< 8 mmHg) were the following: internal jugular vein diameter 0.80 (95% CI: 0.63-0.90); inferior vena cava diameter 0.66 (95% CI: 0.49-0.80); and internal jugular vein ratio 0.68 (95% CI: 0.51-0.82). CONCLUSIONS: The internal jugular vein diameter, the internal jugular vein ratio, and the inferior vena cava diameter showed a significant correlation with central venous pressure. In particular, the internal jugular vein diameter showed good accuracy in predicting a low central venous pressure.

Hyperuricemia in Psoriatic Arthritis: Epidemiology, Pathophysiology, and Clinical Implications.

Psoriatic arthritis (PsA) represents the articular component of the systemic psoriatic disease and the extra-cutaneous disorder most frequently found in patients with psoriasis. Besides the articular involvement, PsA is associated with several metabolic abnormalities such as insulin resistance, hypertension, diabetes and hyperuricemia. Uric acid is the final product of purine metabolism and the etiological substrate of gout. Accumulating evidence highlights the emerging role of hyperuricemia as a major cardiovascular risk factor. Moreover, different studies evaluated the interplay between hyperuricemia and psoriatic disease, suggesting that individuals affected by psoriasis or PsA might present higher serum levels of uric acid and that hyperuricemia might affect severity of clinical manifestations and degree of inflammation in PsA patients. In this review, we focus on the bidirectional relationship between uric acid and PsA, analyzing how uric acid may be involved in the pathogenesis of psoriasis/PsA and how clinical manifestations of PsA and inflammatory mediators are affected by uric acid concentrations. Finally, the effects of anti-rheumatic drugs on uric acid levels and the potential benefit of urate-lowering therapies on psoriasis and PsA were summarized.

Is SARS-CoV-2 infection an emerging risk factor for splanchnic venous thrombosis?

OBJECTIVE: Thrombosis represents one of the most feared complications of the COronaVIrus Disease-2019 (COVID-19). Although pulmonary embolism and deep venous thrombosis are the most described complications, some investigations reported thrombotic localization also in the splanchnic venous district. METHODS: We describe the case of a patient with SARS-CoV-2 infection presenting with abdominal pain and diagnosed with portal vein thrombosis. In addition, we shortly review available literature supporting the possible role of COVID-19 as leading cause of splanchnic venous thrombosis. RESULTS: After in-depth diagnostic workup, we excluded the commonest causes of portal thrombosis and concluded that SARS-CoV-2 infection represented the main explanation of this finding. CONCLUSIONS: Our study warns the clinicians to maintain a high index of suspicion for thrombosis in patients diagnosed with SARS-CoV-2 infection manifesting gastrointestinal symptoms. An appropriate diagnostic work-up could allow to obtain an early diagnosis and consequently improve the clinical outcome of patients.

Higher heparin dosages reduce thromboembolic complications in patients with COVID-19 pneumonia.

Coronavirus disease 2019 (COVID-19) is a new viral disease complicating with acute thrombophylic conditions, probably also via an inflammatory burden. Anticoagulants are efficacious, but their optimal preventive doses are unknown. The present study was aimed to compare different enoxaparin doses/kg of body weight in the prevention of clot complications in COVID-19 pneumonia. Retrospective data from a cohort of adult patients hospitalized for COVID-19 pneumonia, never underwent to oropharyngeal intubation before admission, were collected in an Internal Medicine environments equipped for non-invasive ventilation. Unfavorable outcomes were considered as: deep venous thrombosis, myocardial infarction, stroke, pulmonary embolism, cardiovascular death. Fourteen clinical thromboembolic events among 42 hospitalized patients were observed. Patients were divided into two group on the basis of median heparin dose (0.5 mg-or 50 IU-for kg). The decision about heparin dosing was patient by patient. Higher enoxaparin therapy (mean 0.62±0.16 mg/kg) showed a better thromboprophylactic action (HR=0.2, p=0.04) with respect to lower doses (mean 0.42±0.06 mg/kg), independently from the clinical presentation of the disease. Therefore, COVID-19 pneumonia might request higher enoxaparin doses to reduce thromboembolic events in hospitalized patients, even if outside intensive care units.

Insulin Signaling in Arthritis.

Inflammatory arthritis is burdened by an increased risk of metabolic disorders. Cytokines and other mediators in inflammatory diseases lead to insulin resistance, diabetes and hyperlipidemia. Accumulating evidence in the field of immunometabolism suggests that the cause-effect relationship between arthritis and metabolic abnormalities might be bidirectional. Indeed, the immune response can be modulated by various factors such as environmental agents, bacterial products and hormones. Insulin is produced by pancreatic cells and regulates glucose, fat metabolism and cell growth. The action of insulin is mediated through the insulin receptor (IR), localized on the cellular membrane of hepatocytes, myocytes and adipocytes but also on the surface of T cells, macrophages, and dendritic cells. In murine models, the absence of IR in T-cells coincided with reduced cytokine production, proliferation, and migration. In macrophages, defective insulin signaling resulted in enhanced glycolysis affecting the responses to pathogens. In this review, we focalize on the bidirectional cause-effect relationship between impaired insulin signaling and arthritis analyzing how insulin signaling may be involved in the aberrant immune response implicated in arthritis and how inflammatory mediators affect insulin signaling. Finally, the effect of glucose-lowering agents on arthritis was summarized.

A Case of Critical Calcified Innominate Artery Stenosis Successfully Treated With the Shockwave Lithoplasty.

PURPOSE: The Shockwave Lithoplasty System represents a novel technology combining a balloon angioplasty catheter with the use of sound waves. Evidences suggest that it is a reliable tool to overcome calcified stenosis in both peripheral and coronary arteries. Here, we describe the case of a patient with calcified innominate artery stenosis successfully treated with the Shockwave Lithoplasty System. CASE REPORT: A 78-year-old woman with hypertension, and dyslipidemia, came to our observation for dizziness. Instrumental examinations showed critical calcified stenosis of the innominate artery. The lesion was successfully treated with the Shockwave Lithoplasty System and subsequent stent apposition. Final angiography demonstrated excellent position of the stent, good wall apposition, and confirmed patency of the right common and right vertebral artery origins. CONCLUSION: Our clinical experience demonstrates that Lithoplasty is safe and effective also for the treatment of supra-aortic vessels.

Intravascular ultrasound-guided shockwave treatment of stents overlapping underexpansion of calcified left anterior descending artery.

Heavily calcified lesions may limit optimal stent deployment resulting in stent underexpansion, thus increasing the risk of restenosis and thrombosis. We describe the case of overlapping stents underexpansion treated with a shockwave intravasuclar lithoplasty system (Shockwave Medical Inc., Santa Clara, CA, USA). A 65-year-old man with angina, underwent coronary angiography and intravascular ultrasound showing restenosis, in a site of overlapping stents, due to calcified tissue. Shockwave lithoplasty balloon was able to break calcified tissue in a site of overlapping stents, allowing subsequent vessel dilation and repeat stent implantation with optimal final stent expansion. Heavily calcified lesions may limit optimal stent deployment resulting in stent underexpansion. Treating stent underexpansion or restenosis due to calcified tissue is a great challenge. Shockwave lithoplasty is effective in breaking calcified tissue also in a site of overlapping stents. The improved plaque compliance allows to repeat stent implantation with optimal final stent expansion.

ST-elevation Myocardial Infarction Due to Stent Underexpansion Managed with Coronary Lithoplasty.

BACKGROUND: Coronary calcified lesions may limit optimal stent deployment resulting in stent underexpansion, increasing the risk of thrombosis. The Shockwave Lithoplasty System, a new technology combining a balloon angioplasty catheter with the use of sound waves, it is able to break calcium deposits without affecting vascular soft tissue. CASE PRESENTATION: An 80-year-old Caucasian man with ST elevation myocardial infarction underwent emergent coronary angiography showing complete intrastent thrombosis at the proximal trait of LAD. After thrombus removal, it was evident that stent under-expansion at its proximal edge was caused by vascular calcification. Coronary shockwave lithoplasty was chosen to treat this lesion. After calcium deposits disruption we were able to obtain complete stent expansion. CONCLUSION: Our case demonstrates the usefulness and safety of the lithoplasty system in the context of ST elevation myocardial infarction.

Acute coronary stent thrombosis: A case of type 3 Kounis syndrome.

Kounis syndrome refers to an acute coronary syndrome, consequent to an allergic reaction. It results from mast cell degranulation with subsequent release of numerous inflammatory mediators, leading to coronary vasospasm, atheromatous plaque rupture, or stent thrombosis. Here, we describe the case of a 47-year-old Caucasian man with acute stent thrombosis, as a consequence of allergic reaction to contrast media. .

Hepatic Steatosis Index Is Associated with Type 1 Diabetes Complications.

INTRODUCTION: Non-alcoholic fatty liver disease (NAFLD) is associated with an increased risk of complications in type 1 diabetes (T1DM) patients. To date, several biochemical indexes of NAFLD have been developed. Among these, hepatic steatosis index (HSI) strongly relates with the results of magnetic resonance. AIM: The aim of the present study was to evaluate the possible association between HSI and complications in T1DM. METHODS: Medical records of patients with T1DM were evaluated. Macro- and micro-vascular complications were evaluated by a combination of instrumental (ECG, carotid artery echo-Doppler, fundus examination, vibration threshold at biothesiometry) and laboratory examination. HSI was calculated based on gender, body mass index and transaminases level. RESULTS: Of the 124 patients evaluated, 71 were free of complications and 53 had at least one complication. The prevalence of diabetes complications was: 27% for retinopathy, 15% for carotid atherosclerosis, 16% for neuropathy. HSI was directly correlated with age, disease duration, triglycerides, total daily insulin and inversely with HDL and eGFR. In logistic regression analysis, HSI was independently associated with diabetic complications. CONCLUSION: These findings show that HSI is independently associated with the presence of complications in subjects with T1DM. This can be of clinical utility, allowing a better diagnostic classification of the patient and possibly guiding the therapeutic choice.

Ultrasonographic and Clinical Assessment of Peripheral Enthesitis in Patients with Psoriatic Arthritis, Psoriasis, and Fibromyalgia Syndrome: The ULISSE Study.

OBJECTIVE: The purpose of the ULISSE study was to evaluate the prevalence of clinical and ultrasonographic (US) entheseal involvement in patients with psoriatic arthritis (PsA), psoriasis, and fibromyalgia syndrome (FMS). METHODS: In this cross-sectional multicenter study, patients with PsA and psoriasis (not taking systemic therapy) and FMS underwent a clinical evaluation of the entheses, and a B-mode and power Doppler examination of 6 pairs of entheses. RESULTS: The study analyzed 140 patients with PsA, 51 with psoriasis, and 51 with FMS. Clinical and US examinations were performed in 1960 and 1680 entheses in the PsA group, and 714 and 612 entheses both in the psoriasis group and in the FMS group. In both per-patient and per-enthesis evaluation, the frequency of entheseal tenderness was higher in patients with FMS (92% of the patients and 46% of the entheses, compared with 66%/23% in the PsA group and 59%/18% in the psoriasis group). With US examination, signs of entheseal involvement were more frequent in both the per-patient and per-enthesis evaluation in PsA and psoriasis (about 90% of patients in both the PsA and psoriasis groups and 75% of patients in the FMS group had at least 1 site affected, and 54%, 41%, and 27% of the pairs of entheses in, respectively, PsA, psoriasis, and FMS patients showed at least 1 enthesis involved). CONCLUSION: The ULISSE study indicated that enthesitis is a common feature in patients with PsA, those with psoriasis, and in those with FMS if only clinical examination is used. US entheseal assessment showed findings more consistent with the 3 disorders.