[Ten questions on cardiac magnetic resonance in patients with heart failure: from etiological diagnosis to prognostic stratification]. / Dieci quesiti in tema di risonanza magnetica cardiaca nel paziente con scompenso cardiaco: dalla diagnosi eziologica alla stratificazione prognostica.

Cardiac magnetic resonance (CMR) imaging has progressively become part of the imaging methods recommended in patients with heart failure. CMR represents the gold standard for assessing volumes, function, biventricular kinetics and providing tissue characterization through scans with and without contrast medium. In patients with heart failure with reduced ejection fraction (HFrEF) and ischemic dilated cardiomyopathy, CMR allows to search for viability, accurately estimate volumes and ejection fraction. It can assess scar extent for predicting response to cardiac resynchronization therapy and for establishing an indication for implanting a defibrillator in borderline cases. In patients with HFrEF and non-ischemic dilated cardiomyopathy, CMR helps to identify specific etiological subgroups and to estimate the arrhythmic risk beyond ejection fraction. In patients with heart failure with preserved ejection fraction, CMR offers the possibility of diagnosing specific phenotypes, including sarcomeric hypertrophic cardiomyopathy, amyloidosis or Fabry disease, and adds prognostic information. Both clinical and scientific interest in this imaging method is constantly expanding; the clinicians dealing with heart failure cannot fail to know the technique, the indications and all the potential that CMR can offer.

Prostate Cancer Biochemical Recurrence Resulted Negative on [68Ga]Ga-PSMA-11 but Positive on [18F]Fluoromethylcholine PET/CT.

For prostate cancer (PCa) biochemical recurrence (BCR), the primarily suggested imaging technique by the European Association of Urology (EAU) guidelines is prostate-specific membrane antigen (PSMA) positron emission tomography/computer tomography (PET/CT). Indeed, the increased detection rate of PSMA PET/CT for early BCR has led to a fast and wide acceptance of this novel technology. However, PCa is a very heterogeneous disease, not always easily assessable with the highly specific PSMA PET with around 10% of cases occuring without PSMA expression. In this paper, we present the case of a patient with PCa BCR that resulted negative on [68Ga]Ga-PSMA-11 PET/CT, but positive on [18F]Fluoromethylcholine (Choline) PET/CT.

Temporal trends in characteristics, treatment, and outcomes of heart failure in octogenarians over two decades.

INTRODUCTION AND OBJECTIVES: Octogenarians represent the most rapidly expanding population segment in Europe. The prevalence of heart failure (HF) in this group exceeds 10%. We assessed changes in clinical characteristics, therapy, and 1-year outcomes over 2 decades in chronic HF outpatients aged ≥ 80 years enrolled in a nationwide cardiology registry. METHODS: We included 2520 octogenarians with baseline echocardiographic ejection fraction measurements and available 1-year follow-up, who were recruited at 138 HF outpatient clinics (21% of national hospitals with cardiology units), across 3 enrolment periods (1999-2005, 2006-2011, 2012-2018). RESULTS: At recruitment, over the 3 study periods, there was an increase in age, body mass index, ejection fraction, the prevalence of obesity, diabetes, dyslipidemia, pre-existing hypertension, and atrial fibrillation history. The proportion of patients with preserved ejection fraction rose from 19.4% to 32.7% (P for trend <.0001). Markers of advanced disease became less prevalent. Prescription of beta-blockers and mineralocorticoid receptor antagonists increased over time. During the 1-year follow-up, 308 patients died (12.2%) and 360 (14.3%) were admitted for cardiovascular causes; overall, 591 (23.5%) met the combined primary endpoint of all-cause mortality or cardiovascular hospitalization. On adjusted multivariable analysis, enrolment in 2006 to 2011 (HR, 0.70; 95%CI, 0.55-0.90; P=.004) and 2012 to 2018 (HR, 0.61; 95%CI, 0.47-0.79; P=.0002) carried a lower risk of the primary outcome than recruitment in 1999 to 2005. CONCLUSIONS: Among octogenarians, over 2 decades, risk factor prevalence increased, management strategies improved, and survival remained stable, but the proportion hospitalized for cardiovascular causes declined. Despite increasing clinical complexity, in cardiology settings the burden of hospitalizations in the oldest old with chronic HF is declining.

Improving the diagnostic approach to celiac disease: Experience from a regional network.

BACKGROUND: Celiac disease (CD) is still underestimated. To close this diagnostic gap, the Health Sicilian Authorities have constituted the "Sicilian Network for CD". AIMS: A) To verify the quality of the current diagnostic approach using the data sheet of the Network. B) To evaluate the clinical, serologic and histologic data of new diagnoses in the context of the Network METHODS: We retrospectively evaluated the data collection forms of 369 patients with CD from three Centers within the Sicilian Network. All the Centers used a standard data collection form. RESULTS: A non-classical CD presentation was more frequent than the classical one, anemia being the most frequent symptom (50%). An IBS-like presentation was found in one third of the cases. A diagnostic delay of about 9 years following the onset of symptoms was observed. Almost half of the patients had not undergone multiple duodenal biopsies; unrecommended CD serology assays were prescribed in 59.9% of the cases. CONCLUSIONS: The regional data sheets allowed an assessment of the diagnostic delay. We recorded a frequent use of unrecommended tests prescribed before referring patients to the regional Centers. Updating the education of physicians regarding CD is necessary to avoid unwarranted health expenditure.

Utility of Blood Flow/Resistance Index Ratio (Qx) as a Marker of Stenosis and Future Thrombotic Events in Native Arteriovenous Fistulas.

Objective: The resistance index (RI) and the blood flow volume (Qa) are the most used Doppler ultrasound (DUS) parameters to identify the presence of stenosis in arteriovenous fistula (AVF). However, the reliability of these indexes is now matter of concern, particularly in predicting subsequent thrombosis. In this study, we aimed at testing the diagnostic capacity of the Qa/RI ratio (Qx) for the early identification of AVF stenosis and for thrombosis risk stratification. Methods: From a multicentre source population of 336 HD patients, we identified 119 patients presenting at least one "alarm sign" for clinical suspicious of stenosis. Patients were therefore categorized by DUS as stenotic (n = 60) or not-stenotic (n = 59) and prospectively followed. Qa, RI, and QX, together with various clinical and laboratory parameters, were recorded. Results: Qa and Qx were significantly higher while RI was significantly lower in non-stenotic vs. stenotic patients (p < 0.001 for each comparison). At ROC analyses, Qx had the best discriminatory power in identifying the presence of stenosis as compared to Qa and RI (AUCs 0.976 vs. 0.953 and 0.804; p = 0.037 and p < 0.0001, respectively). During follow-up, we registered 30 thrombotic events with an incidence rate of 12.65 (95% CI 8.54-18.06) per 100 patients/year. In Cox-regression proportional hazard models, Qx showed a better capacity to predict thrombosis occurrence as compared to Qa (difference between c-indexes: 0.012; 95% CI 0.004-0.01). Conclusions: In chronic haemodialysis patients, Qx might represent a more reliable and valid indicator for the early identification of stenotic AVFs and for predicting the risk of following thrombosis.

Iron Infusion and Induced Hypophosphatemia: The Role of Fibroblast Growth Factor-23.

The mechanism of action of fibroblast growth factor-23 (FGF23) is becoming increasingly clearer as a result of studies that have defined its structure and pleiotropic effects. Furthermore, data are emerging on the effects exerted on this hormone by iron administration. Ten main iron formulations are recognized (with clear differences in composition and possible reactions of intolerance and anaphylaxis), which are indicated for iron deficiency anemia, including nephropathic subjects, as suggested by medical guidelines. With some types of iron formulation (especially iron carboxymaltose) a particular side effect has been observed: hypophosphatemia, mediated by FGF23. This review aims to draw attention to this correlation and the contradiction represented by the presence of both positive and negative modulation by FGF23, with the effects induced by its increase even after long-term treatment with iron formulation. However, more evidence is needed to understand the reasons for this differential stimulation.

[Diagnosis of Biliary Hamartomatosis in Kidney Transplant Recipient affected by ADPKD].

Biliary hamartomas (BH) are rare benign lesions of the liver characterized by a dilation of a variable number of small biliary ducts, usually surrounded by abundant fibrotic tissue. These malformations are due to an aberrant remodelling of the ductal plate, that is the embryonic structure generating the normal biliary tree. BH are usually asymptomatic, but in rare cases they can be associated with jaundice, heartburn and fever. Evidences for a sharing of similar pathological pathways between BH and adult dominant polycystic kidney disease (ADPKD) are widely reported. These similarities induce an increased neoplastic risk transformation in both conditions. This risk is even greater in immunosuppressed patients. The diagnosis of BH by imaging is not easy, especially in the context of ADPKD. We present a clinical case of a 54-year-old kidney transplant recipient affected by ADPKD in which BH, previously undetected, was for the first time suspected on routine ultrasound scan and confirmed with MRI 4 years after renal transplantation. Demodulation of proliferative signals induced by immunosuppressive therapy, and particularly by calcineurin inhibitors, could cause an enlargement of AB and increase the risk of neoplastic transformation. Our case-report suggests a close imaging follow-up may be needed in ADPKD patients with BH, especially if transplanted. High sensitivity techniques, such as CEUS and MRI, should be preferred to conventional ultrasound.

[A cause of acute renal dysfunction: a giant bladder diverticulum].

We describe the case of a previously 77-year-old man who accessed in our Nephrology Unit for acute kidney injury (AKI) on chronic kidney disease (CKD), gastric discomfort and vague urinary symptoms with apparently preserved diuresis and suspected "ascites". Physical examination confirmed the presence of abdominal effusion, even though ultrasound abdominal examination revealed the presence of a giant diverticular urinary bladder with bilateral hydronephrosis. We discuss the diagnostic and therapeutic approach of these rare complications by briefly reviewing the technical aspects and the possible consequences.

[Case of sialadenitis by iodinated contrast medium in a dialysis patient].

BACKGROUND: Sialadenitis by iodinated contrast medium (i.c.m) oriodine mumps (IM) is a rare and late benign manifestation that occurs independently of intravenous or endoarterial administration modality. If renal function is normal, i.c.m. does not reach salivary glands concentrations able to induce sialadenitis. However, a critical glomerular filtration reduction may lead to salivary ducts edema and glandular swelling after i.c.m. injection. We report a rare case report of IM in a patient on chronic hemodialysis. METHODS: A 72-year-old woman affected by chronic kidney disease on chronic hemodialysis, underwent to endoscopic removal of a rectal cancer. For disease staging, a total body TC with i.c.m. was performed. The following morning, patient showed a soft and aching bilateral paroditidis swelling. Salivary glands ultrasound was diagnostic for sialadenitis. The patient was rapidly treated with betamethasone following by a 240 minutes post-dilution online hemodiafiltration session. RESULTS: Within the next 24h, a complete remission of IM was obtained. CONCLUSION: In our patient, a compensatory hyperactivity of the sodium / iodine symporter (NIS) on salivary gland cells may have played a crucial role in IM induction. An high efficiency hemodialysis session within the few following hours after i.c.m injection is a fundamental tool in patients on renal replacement treatment to prevent IM that is an epiphenomenon of i.c.m. accumulation.

Eosinophilic myocarditis in a patient with idiopathic hypereosinophilic syndrome: insights into mechanisms of myocardial cell death.

Idiopathic hypereosinophilic syndrome (HES) consists of a prolonged state of eosinophilia of unknown origin with organ involvement. We describe the case of a patient who developed fatal eosinophilic myocarditis. A 23-year-old woman with an 8-month history of eosinophilia presented with symptoms of myocarditis. Histological evaluation of an endomyocardial biopsy specimen revealed marked endomyocardial eosinophilic infiltration with eosinophil-rich granulomas and areas of myocyte necrosis. A terminal deoxynucleotidil transferase assay revealed apoptosis in several cardiomyocytes and vascular cells, mainly in the myocardial areas with higher eosinophil density. Evaluation of an endomyocardial biopsy specimen obtained after steroid therapy demonstrated that the eosinophils had disappeared, but there was marked myocardiosclerosis and scattered apoptotic cells. The patient slowly developed heart failure and died of sudden arrhythmic death. HES can cause severe myocarditis with extensive myocyte loss, probably due to both necrosis and apoptosis. Myocardial fibrosis may occur despite treatment, and patients may be at risk for fatal arrhythmias.

Partial left ventriculectomy (Batista's Procedure) case report: 40 months follow-up.

OBJECTIVE: Partial left ventriculectomy (PLV) (also known as Batista's Procedure) is a surgical procedure for treatment of dilated cardiomyopathy when cardiac transplant is contraindicated. Mitral valve replacement is needed because of mitral regurgitation as a consequence of annulus enlargement and papillary muscle resection. Bleeding and arrythmias are the main complications. METHODS: We considered for this operation a 60-year-old male patient. He suffered from valvular dilating cardiomyopathy as a consequence of mitral and aortic valve regurgitation. Furthermore, a severe peripheral vascular disease treated with aortic-bifemoral prosthesis contraindicated heart transplantation. He needed frequent hospital admissions for pulmonary edema and his quality of life was very poor. Batista's procedure was performed in March 1998, successfully. Mitral and aortic valves were replaced by use of mechanical prosthesis. The postoperative period was characterized by early weaning from ventilator and drugs; atrial fibrillation, reversed by Amiodaron; a little bilateral pleural effusion; and pacemaker implantation following advanced heart conduction block. No bleeding episodes were observed. In March 2001 the progression of the vascular disease forced the patient to undergo to a femoro-femoral bypass and endoarterectomy of the right branch of the vascular prothesis. The patient tolerated the procedure very well. He had no complications during the postoperative period with early weaning from ventilator and drugs. RESULTS: At the end of the procedure ejection fraction raised from 15% to 30%. Echocardiographic data demonstrated a slow but progressive improvement of the cardiac diameters and volumes with a preserved left ventricular function. CONCLUSION: Even if a larger number of cases and longer follow-up are necessary, our report demonstrated that Batista's procedure should be considered as a surgical alternative to heart transplantation, in well-selected patients with absolute contraindication to heart transplantation and left ventricular assist device implantation.