[Torsione di punta indotta dalla cocaina: un caso clinico.] / A cocaine induced torsade de points: a case report.

Riassunto. La torsione di punta (TdP) è una tachicardia ventricolare polimorfica con una caratteristica torsione sinusoidale del complesso QRS attorno alla linea di base. Si differenzia da altre forme di tachicardia ventricolare per le sue caratteristiche morfologiche, per il meccanismo sottostante e le modalità di terapia. È associato alla sindrome del QT lungo e ha molti meccanismi precipitanti, fattori eziologici e opzioni di trattamento. Questo articolo presenta un caso di TdP che è stato caratterizzato da molteplici fattori e ha richiesto molte modalità di trattamento. Inoltre, vengono discussi i potenziali meccanismi e le modalità terapeutiche della TdP.

COVID-19: the critical balance between appropriate governmental restrictions and expected economic, psychological and social consequences in Italy. Are we going in the right direction?

Since the declaration of COVID-19 pandemic infection by the World Health Organization, many governmental restrictions have been differently applied in the involved countries in order to contain the spread of the infection; Italy applied severe restrictive, public measures actually confining the entire population to an almost complete lockdown for several weeks; the restrictive quarantine can be considered controversial when excessively prolonged over time, due to many possible economic, psychologic and social consequences with a remarkable impact on the population. In this article we analyze possible collateral damages related to the prolonged quarantine.

Management of severe Falciparum malaria on a mission: A case report.

A sailor for forty-two years, in military service on the Italian aircraft carrier, while on a mission in sub-Saharan Africa, came to a physician due to fatigue with a fever, flu-like illness and headache for 6 days. The temperature was 38.8°C, BP 80/145 mmHg and RR 30/min. The oxygen saturation was 88%, while the patient was breathing room air. Laboratory findings showed that WBC count and platelet counts were greatly reduced. Blood smears were positive for Plasmodium falciparum malaria with more than 10 parasites per field. It began immediately antimalarial treatment. After 24 hours the patient showed a 50% reduction in parasitemia but continued to have tachypnoea, dyspnea and hypoxemia. A chest TC scan was then performed that revealed a right basal alveolar consolidation with bilateral pleural effusion. The patient was ultimately diagnosed with pneumonia and malaria (overlap syndrome). The patient began antibiotic and steroid therapy. After two days the fever was gone away and the clinical condition of the patient was greatly improved. The clinical overlap between pneumonia and malaria has important implications for case management strategies and their treatment should be integrated into community case management activities.

A new risk assessment model for the stratification of the thromboembolism risk in medical patients: the TEVere Score.

BACKGROUND: In hospitalized medical patients, the venous thromboembolism (VTE) risk is notable. Nevertheless, the available assessment model (TPF) is generally underused. In this work, we propose an ex novo risk assessment model based on the elaboration of the clinical data exhibited by the VET patients. Differently from previous studies, the proposed approach does not exploit pre-established models, resulting in a more valid and easy-to-use score. METHODS: We performed a double case-control observational study. For each case of VTE, we enrolled two consecutive patients without VTE of equal sex and age group (18-50, 50-55, 55-60, 60-65, 65-70, 70-75, 75-80, >80 years). The study involved both the EM and the IM Departments of 23 hospitals and universities in Lazio and Umbria (Italy). RESULTS: We analyzed the data of 1215 patients, 409 with VTE (50% - deep venous thrombosis [DVT], 9.9% - pulmonary embolism [PE], 40.1% - PE+DVT) and 806 case-control. 365 patients (30%) were in charge to the EM department, while 850 patients (70%) to the IM one. The VET risk factors with more statistical significance (P<0.01) are: previous VTE, active cancer, known thrombophilic condition, immobilization, chronic venous insufficiency, hyperhomocysteinemia, central venous catheter, recent hospitalization. Obesity, recent surgery, family history of VTE, hormone therapy and treatment with drugs that stimulate hematopoiesis are resulted at intermediate statistical significance (P<0.05 but >0.01). A multiple logistic regression was used with robust standard errors and forward selection of the candidate variables using the Bayesian information criterion. A new score is developed, the "TEVere Score", which shows a higher specificity and sensitivity (respectively 43.3 and 87.5, with accuracy 72.1) compared with the Padua, the Kuscer and the Chopard Score. TEVere Score also exhibits a greater predictive validity for thromboembolism risk (AUROC 0.7266; 95% CI: 0.71 to 0.73) than the Kuscer Score (AUROC 0.6891; 95% CI: 0.67 to 0.70) (P=0.0093). CONCLUSIONS: The TEVere Score has proven to exhibit a higher accuracy than the other scores commonly used in clinical practice to stratify the thromboembolism risk.

Pericarditis mimicking Brugada syndrome.

INTRODUCTION: Brugada syndrome (BrS) is a genetic heart disorder due to alteration of the ion channels function that causes an impaired in the cardiac conduction system. It is characterized by an abnormal electrocardiogram pattern and may be complicated by malignant ventricular arrhythmias. Pericarditis is an inflammation of the pericardium and 90% of isolated cases of acute pericarditis are idiopathic or viral. Acute pericarditis may appears with chest pain, fever, pericardial friction rub, and cardiac tamponade. Moreover, widespread ST segment changes occur due to involvement of the underlying epicardium. CASE REPORT: A 27-year-old man was admitted to the Emergency Department of the …. Hospital due to fatigue and chest discomfort. Laboratory findings showed that WBC count and C-reactive protein were increased. Echocardiographic finding was normal. The patient was admitted with a diagnosis of pericarditis. Electrocardiogram (ECG) showed a "saddle back"-type ST elevation in leads V2, recognised as type 2 Brugada pattern. The ECG normalized within a few days after the beginning of anti-inflammatory therapy and the follow-up was uneventful. Based on findings in our patient and data from literature, we hypothesize that the patient developed a Brugada ECG pattern due the pericarditis. CONCLUSIONS: Our case report shows that the pericarditis may mimic BrS. Moreover, it is important to underline that a Brugada ECG pattern should only be considered as a sign of electrical heart disease but detailed diagnostic tests are anyway needed.

[Venous thromboembolism in critically ill patients: analysis of the main age-related risk factors and definition of specific scores.] / Il tromboembolismo venoso nei pazienti critici: studio dei principali fattori di rischio correlati all'età e proposta di punteggi specifici.

INTRODUCTION: Venous thromboembolism (VTE) is the third most common cardiovascular illness after acute coronary syndrome and stroke and and the most common preventable cause of hospital-related death. Several studies have demonstrated a significant reduction of fatal pulmonary embolism attributed to the introduction of thromboprophylactic measures and changes in hospital practices. However, the influence of some demographical variables, especially age, has largely been under appreciated. METHODS: Using the date of the TEVere study, we have studied 187 patients with VTE and 350 case-control, and we proceeded to analyze the major risk factors for venous thromboembolism, separately for three age groups (≤60 years, 60-75 years, >75 years). Patients came from the departments of internal medicine and emergency medicine for 21 hospitals. In this subgroup, we have examined the main risk factors for the individual classes of age and have proposed, through a logistic regression analysis, 3 different types of scores, specific for each age class. We then compared the individual scores obtained with the Kucher's score. RESULTS: It was found that in the class of patients with a lower age of 60, the main risk factors found to be estrogen-progestagen treatment (p=0.004) and family history of VTE (p=0.047), while in older patients (>75 years) the main risk factors were immobilization (p=0.005) and chronic venous insufficiency (p=0.001). In common for the three classes the presence of an evolutionary malignancy and previous episodes of VTE. Through the ROC curve analysis, it was found that the results for the three proposed scores improved sensitivity compared to Kucher's score. However our results showed that the only score of the intermediate class showed a statistically significant difference for prediction of the thromboembolic risk (p=0.0264 (AUROC 0.7946; 95% CI, 0.75 to 0.80, AUROC 0.7042; 95% CI, 0.68. to 0.72). DISCUSSION: Our study emphasizes the importance of carrying a correct stratification, which also consider the patient's age and therefore the concomitant pathologies. In fact, although the age of the patient cannot be considered as the only criterion to start the thromboprophylaxis, as highlighted in literature, you need to consider each individual patient, with its own peculiarities. CONCLUSION: This study showed the difficulty in identifying the key risk factors that are responsible for thromboembolic disease and has emerged the opportunity to be evaluated by larger studies, the use of specific scores by age groups.

Perception of Thromboembolism Risk: Differences between the Departments of Internal Medicine and Emergency Medicine.

The latest developments in emergency medicine (EM) have introduced new typologies of patients that have not been taken into account in previous studies of venous thromboembolism (VTE) risk. The aim of the current study was to evaluate by comparing the main international risk scores whether different perceptions of VTE risk exist in internal medicine (IM) departments and in EM departments. This cross-sectional observational study involved 23 IM and 10 EM departments of 21 different hospitals. The patient data were collected by physicians who were blinded to the purpose of the study. The data were analyzed using the main international risk scores. We analyzed 742 patients, 222 (30%) hospitalized in EM departments and the remaining 520 (70%) in IM departments. We found that fewer patients at risk for VTE were treated with low-molecular-weight heparin (LMWH) in EM departments than in IM departments. Moreover, there was significant statistical difference in the use of LMWH between IM and EM departments when the Padua score and immobilization criteria were used to assess the risk. The infrequent use of LMWH in EM patients may have several causes. For example, in EM departments, treatment of acute illness often takes higher priority than VTE risk evaluation. Moreover, immobilization criteria cannot be evaluated for all EM patients because of the intrinsic time requirements. For the aforementioned reasons, we believe that a different VTE risk score is required that takes into account the peculiarities of EM, and establishing such a score should be the object of future study.

[Cardiac abnormalities in patients with systemic lupus erythematosus: the role of antiphospholipid antibodies]. / Alterazioni cardiologiche in pazienti affetti da lupus: il ruolo degli anticorpi antifosfolipidi.

BACKGROUND: Systemic lupus erythematosus (SLE) is a chronic inflammatory disease that has protean manifestations and follows a relapsing and remitting course. More than 90% of cases of SLE occur in women, frequently starting at childbearing age. It is characterized by the presence of autoantibodies potentially directed toward every organ or apparatus. Cardiac alterations are frequent in patients affected by SLE and the simultaneous presence of antiphospholipid antibodies (aPL), able to cause arterial thrombosis in any vascular district, is considered a possible risk factor for cardiac damage in SLE patients. The aim of this study is to correlate the main cardiac disorders, estimable through transthoracic echocardiography, in SLE patients as well as the typical autoantibody pattern of the disease. METHODS: Our study included 76 patients: 38 SLE and 38 controls patients. Control patients have been properly selected to be comparable in gender, age and risks factors for cardiovascular disease. We performed autoantibody panel to assess the prevalence of various autoantibodies during SLE development (antinuclear antibody [ANA], double-stranded DNA [dsDNA], extractable nuclear antigen antibodies [ENA], aPL). In the study, the determination of the IgG and IgM isotypes for aPL (cardiolipin, phosphatidylinositol [aPI], phosphatidylserine, phosphatidic acid [aPA], and anti-ß2-glycoprotein I antibodies) were checked. Echocardiography was performed in all patients. RESULTS: In patients affected by SLE, 94.7% was positive to ANA (relative risk 20; 95% confidence interval 4.9-340; p<0.0001) whereas 60.5% was positive for aPL. In patients with SLE, valvular alterations were observed, with a statistically significant correlation between mitral and aortic insufficiency (p=0.01 and p=0.02, respectively). Among aPL-positive patients, 68% (17/25) exhibited at least one hemodynamically significant echocardiographic alteration, vss 3/13 (23%) of patients with negative aPL, with a statistically significant correlation (relative risk 2; 95% confidence interval 1.0-29.8; p=0.01). Among positive-aPL patients, a statistically significant correlation was also observed between mitral insufficiency and aPI-IgG positivity (p=0.01) and, regarding non-valvular alterations, between left atrial enlargement and aPI-IgG positivity (p=0.01) and between left ventricular hypertrophy and aPA-IgG positivity (p=0.03). CONCLUSIONS: The present study confirms that SLE is an important risk factor for the presence of cardiac alterations, especially for valvular damage. Moreover, the presence of aPL antibodies in patients with SLE is significantly associated with an increased risk of heart disease, and some specific cardiac alterations are correlated with the positivity of some subclasses of aPL.

[The overuse of thromboprophylaxis in medical patients: main clinical aspects]. / L'uso eccessivo della tromboprofilassi in pazienti medici: i principali aspetti clinici.

BACKGROUND: Overuse of thromboprophylaxis is not an infrequent behavior in internal medicine. However, differently from underuse, overuse of thromboprophylaxis is rarely taken into account, and only few studies have addressed this issue. The purpose of our study was to try to understand the reasons behind this phenomenon. METHODS: Using data from the TEVERE study, we evaluated 279 patients hospitalized in 21 hospitals of the Lazio Region in Italy. Only patients who were negative to major risk scores as established in the scientific literature were included. We assessed the frequency of thromboprophylaxis in acutely ill medical patients hospitalized in emergency and internal medicine wards, and we performed a comparative analysis for each risk factor among patients who received or not received thromboprophylaxis. RESULTS: Forty-seven patients (16.5%) with negative risk scores were given thromboprophylaxis during hospitalization. On backward stepwise logistic regression analysis, severe infection (odds ratio [OR] 2.31; 95% confidence interval [CI] 1.25-4.35) and chronic venous insufficiency (OR 3.02; 95% CI 1.96-4.67) were found to be the strongest predictors of the use of thromboprophylactic treatment with heparin. The subgroup of patients who did not exhibit risk factors was also analyzed, and age was found to be the main factor in the decision-making process regarding heparin administration in the absence of other risk factors (74.9 ± 11.8 vs 63.7 ± 18.1, p=0.002). CONCLUSIONS: Our findings suggest that thromboprophylaxis is associated with considerable uncertainty, which results in its overuse. Further research is needed to better understand thromboembolic risk factors in hospitalized medical patients.

Correlation between epicardial fat and cigarette smoking: CT imaging in patients with metabolic syndrome.

BACKGROUND: The aim of our study was to assess the relationship between cigarette smoking and epicardial fat in a cohort of patients with metabolic syndrome (MetS) at risk for coronary artery disease. METHODS: We studied, in primary prevention, 54 subjects diagnosed with MetS. According to their smoking habits, the subjects were divided into two groups: smokers and non-smokers. Besides anthropometric characterization and screening laboratory tests, the subjects had a multidetector computerized tomography scan, which allowed epicardial fat quantification and calcium score (CS) evaluation. RESULTS: Compared with non-smokers, smokers showed older age (61.6 ± 1.8 vs 56.8 ± 1.2 yrs; p < 0.05). Also, the smokers displayed increased epicardial fat volume (138 [123; 150] vs 101[79; 130] ml; p < 0.01) as well as higher CS (94 [3; 301.5] vs 0 [0;10.2]; p < 0.001), in comparison with non-smokers. Notably, CS was positively correlated with smoking habit (rs 0.469; p < 0.01), epicardial fat (rs 0.377; p < 0.01), age (rs 0.502; p < 0.001) and uric acid (rs 0.498; p < 0.01). Accordingly, the associations between both CS or epicardial fat and cigarette smoking were still maintained after adjustment for age (r 0.317; p < 0.05; r 0.427; p < 0.01). Finally, multiple regression analysis showed that smoke was the variable that best predicted CS (R(2) 0.131; ß 0.362; p < 0.05) and epicardial fat (R(2) 0.177; ß 0.453; p = 0.01). CONCLUSIONS: Our findings suggest that, in subjects with MetS, cigarette smoking is an independent predictor of increased epicardial fat volume and higher CS.