Isolated Aortitis Presenting with an Annoying Persistent Cough: A Case Report

Objectives: To report a case of idiopathic aortitis presenting with chronic cough. Materials and Methods: the Authors describe the case of a 72-year-old man with dry cough, worsening fatigue, weight loss and elevated systemic inflammatory markers. Results: A PET-CT scan showed diffuse thickening of the thoracic aorta and confirmed the diagnosis of aortitis. Systemic corticosteroid therapy was initiated and complete remission was achieved in six months. Conclusion: Persistent dry cough of unknown origin, especially when associated with systemic inflammation, demands a thorough differential diagnosis and should not be underrated

Serum Albumin Is Inversely Associated With Portal Vein Thrombosis in Cirrhosis

We analyzed whether serum albumin is independently associated with portal vein thrombosis (PVT) in liver cirrhosis (LC) and if a biologic plausibility exists. This study was divided into three parts. In part 1 (retrospective analysis), 753 consecutive patients with LC with ultrasound-detected PVT were retrospectively analyzed. In part 2, 112 patients with LC and 56 matched controls were entered in the cross-sectional study. In part 3, 5 patients with cirrhosis were entered in the in vivo study and 4 healthy subjects (HSs) were entered in the in vitro study to explore if albumin may affect platelet activation by modulating oxidative stress. In the 753 patients with LC, the prevalence of PVT was 16.7%; logistic analysis showed that only age (odds ratio [OR], 1.024; P = 0.012) and serum albumin (OR, -0.422; P = 0.0001) significantly predicted patients with PVT. Analyzing the 112 patients with LC and controls, soluble clusters of differentiation (CD)40-ligand (P = 0.0238), soluble Nox2-derived peptide (sNox2-dp; P < 0.0001), and urinary excretion of isoprostanes (P = 0.0078) were higher in patients with LC. In LC, albumin was correlated with sCD4OL (Spearman's rank correlation coefficient [r(s)], -0.33; P < 0.001), sNox2-dp (r(s), -0.57; P < 0.0001), and urinary excretion of isoprostanes (r(s), -0.48; P < 0.0001) levels. The in vivo study showed a progressive decrease in platelet aggregation, sNox2-dp, and urinary 8-iso prostaglandin F2 alpha-III formation 2 hours and 3 days after albumin infusion. Finally, platelet aggregation, sNox2-dp, and isoprostane formation significantly decreased in platelets from HSs incubated with scalar concentrations of albumin. Conclusion: Low serum albumin in LC is associated with PVT, suggesting that albumin could be a modulator of the hemostatic system through interference with mechanisms regulating platelet activation

Beta-Blocker Use in Older Hospitalized Patients Affected by Heart Failure and Chronic Obstructive Pulmonary Disease: An Italian Survey From the REPOSI Register

Beta (β)-blockers (BB) are useful in reducing morbidity and mortality in patients with heart failure (HF) and concomitant chronic obstructive pulmonary disease (COPD). Nevertheless, the use of BBs could induce bronchoconstriction due to β2-blockade. For this reason, both the ESC and GOLD guidelines strongly suggest the use of selective β1-BB in patients with HF and COPD. However, low adherence to guidelines was observed in multiple clinical settings. The aim of the study was to investigate the BBs use in older patients affected by HF and COPD, recorded in the REPOSI register. Of 942 patients affected by HF, 47.1% were treated with BBs. The use of BBs was significantly lower in patients with HF and COPD than in patients affected by HF alone, both at admission and at discharge (admission, 36.9% vs. 51.3%; discharge, 38.0% vs. 51.7%). In addition, no further BB users were found at discharge. The probability to being treated with a BB was significantly lower in patients with HF also affected by COPD (adj. OR, 95% CI: 0.50, 0.37-0.67), while the diagnosis of COPD was not associated with the choice of selective β1-BB (adj. OR, 95% CI: 1.33, 0.76-2.34). Despite clear recommendations by clinical guidelines, a significant underuse of BBs was also observed after hospital discharge. In COPD affected patients, physicians unreasonably reject BBs use, rather than choosing a β1-BB. The expected improvement of the BB prescriptions after hospitalization was not observed. A multidisciplinary approach among hospital physicians, general practitioners, and pharmacologists should be carried out for better drug management and adherence to guideline recommendations

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

The “Diabetes Comorbidome”: A Different Way for Health Professionals to Approach the Comorbidity Burden of Diabetes

(1) Background: The disease burden related to diabetes is increasing greatly, particularly in older subjects. A more comprehensive approach towards the assessment and management of diabetes’ comorbidities is necessary. The aim of this study was to implement our previous data identifying and representing the prevalence of the comorbidities, their association with mortality, and the strength of their relationship in hospitalized elderly patients with diabetes, developing, at the same time, a new graphic representation model of the comorbidome called “Diabetes Comorbidome”. (2) Methods: Data were collected from the RePoSi register. Comorbidities, socio-demographic data, severity and comorbidity indexes (Cumulative Illness rating Scale CIRS-SI and CIRS-CI), and functional status (Barthel Index), were recorded. Mortality rates were assessed in hospital and 3 and 12 months after discharge. (3) Results: Of the 4714 hospitalized elderly patients, 1378 had diabetes. The comorbidities distribution showed that arterial hypertension (57.1%), ischemic heart disease (31.4%), chronic renal failure (28.8%), atrial fibrillation (25.6%), and COPD (22.7%), were the more frequent in subjects with diabetes. The graphic comorbidome showed that the strongest predictors of death at in hospital and at the 3-month follow-up were dementia and cancer. At the 1-year follow-up, cancer was the first comorbidity independently associated with mortality. (4) Conclusions: The “Diabetes Comorbidome” represents the perfect instrument for determining the prevalence of comorbidities and the strength of their relationship with risk of death, as well as the need for an effective treatment for improving clinical outcomes

Antidiabetic Drug Prescription Pattern in Hospitalized Older Patients with Diabetes

Objective: To describe the prescription pattern of antidiabetic and cardiovascular drugs in a cohort of hospitalized older patients with diabetes. Methods: Patients with diabetes aged 65 years or older hospitalized in internal medicine and/or geriatric wards throughout Italy and enrolled in the REPOSI (REgistro POliterapuie SIMI—Società Italiana di Medicina Interna) registry from 2010 to 2019 and discharged alive were included. Results: Among 1703 patients with diabetes, 1433 (84.2%) were on treatment with at least one antidiabetic drug at hospital admission, mainly prescribed as monotherapy with insulin (28.3%) or metformin (19.2%). The proportion of treated patients decreased at discharge (N = 1309, 76.9%), with a significant reduction over time. Among those prescribed, the proportion of those with insulin alone increased over time (p = 0.0066), while the proportion of those prescribed sulfonylureas decreased (p < 0.0001). Among patients receiving antidiabetic therapy at discharge, 1063 (81.2%) were also prescribed cardiovascular drugs, mainly with an antihypertensive drug alone or in combination (N = 777, 73.1%). Conclusion: The management of older patients with diabetes in a hospital setting is often sub-optimal, as shown by the increasing trend in insulin at discharge, even if an overall improvement has been highlighted by the prevalent decrease in sulfonylureas prescription

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

Bedside ultrasound in an internal medicine department. Why?

A 74-year-old woman was admitted to the emergency department of her local hospital for fever and vomiting occurred three days before. There was no dyspnoea, but the patient was experiencing left shoulder pain with radiation to her left arm. Her past medical history included the endoscopic excision of a rectal polyp followed by transanal endoscopic microsurgery. Her labs showed neutrophilic leukocytosis (WBC 24000/mcl) and mild hypokalaemia; BNP levels were 428 pg/ml and blood troponin was 4,31 ng/ml. ECG changes such as ST-segment deviation or T-wave inversion were not observed: the patient was thus admitted to the internal medicine department with the diagnosis of Acute Coronary Syndrome. On her first day of hospital stay, the patients body temperature reached 38,5\ub0C, inflammatory markers were elevated (RCP >25 mg/dl), while serial blood samples showed decreasing troponin levels and stenocardic pain was absent. However, the patient was experiencing pain in her right upper quadrant, where a mass of taut-elastic consistency could be palpated and Murphys sign was clearly positive; the abdomen was soft, but tender. The cardiothoracic examination was within normal limits, even though a chest X-ray revealed a consolidation at the superior right pulmonary lobe; the cardiac silhouette was not enlarged. A bedside abdominal ultrasound was performed, showing gallbladder hydrops and a double railway appearance of the gallbladders walls as an evidence of acute cholecystitis; luminal biliary sludge and intrahepatic bile duct dilatation were documented too. In order to check the hypothesis of Acute Coronary Syndrome, the patient underwent a thoracic ultrasound, which excluded signs of hypokinesia; EF, cardiac chambers size and diastolic function (assessed with Tissue Doppler Imaging) were within normal limits; there was no pleural effusion. At the ECG monitoring, ST-segment, T-waves and ventricular repolarization appeared normal. In the case of a suspected myocardial dysfunction supported by a severe sepsis, a broad-spectrum antibiotic therapy was set. The requested confirmatory diagnosis of acute cholecystitis (imaging ultrasound) was assessed by the radiologist on call (public holiday) by means of a further abdominal ultrasound and the surgical consult suggested the need for an urgent cholecystectomy. The patient was thus admitted to the surgery department and immediately underwent surgery for cholecystectomy. The macro- and microscopic histology report confirmed the diagnosis of acute gangrenous cholecystitis. This is an exemplary case to illustrate the utility of bedside ultrasound in internal medicine: in this specific contest, the whole diagnostic process took place in an internal medicine department on a public holiday and bedside ultrasound proved to be a valuable help in rebutting the first hypothesis (Acute Coronary Syndrome), confirming the most likely scenario of sepsis with myocardial dysfunction and early hepatic dysfunction (total bilirubin: 1,82 mg/dl, coagulation, renal function and SpO2 within normal limits; SOFA SCORE: 1) as a consequence of acute gangrenous cholecystitis

Uncommon causes of heart failure with reduced ejection fraction in internal medicine: a case report

Case: 67-years-old woman, with familiarity for ischemic cardiopathy, affected by dyslipidaemia and depression treated with antidepressant tricyclic drugs (TCA). Admitted to our ED for dyspnoea, palpitations and orthopnoea. Both clinical and instrumental examinations were suggestive of acute decompensated heart failure (HF): clinically, we objectivated jugular veins turgidity, S3 tone with gallop rhythm, olosystolic murmur at cardiac auscultation, bilateral rales at lung auscultations and peripheral oedema. Blood pressure was 120/80 mmHg with a cardiac frequency of 120 bpm and oxygen saturation of 96% in oxygen (2 l/min). Lung radiography showed left pleural effusion and diffuse interstitial oedema. BNP was 818 pg/ml, ECG showed left bundle branch block. Cardiac ultrasound showed severe left ventricle (LV) dysfunction, with reduced ejection fraction (22%), left chamber dilatation, diffuse LV hypokinesis, increased filling pressures, restrictive pattern, severe functional mitral insufficiency (vena contracta 0.81 cm) and moderate tricuspidalic insufficiency with increased pulmonary pressure (66 mmHg). Lung ultrasound confirmed left pleural effusion and interstitial syndrome. Admitted to our Internal Medicine department with diagnosis of acute HF with reduced ejection fraction (HFrEF), NYHA class IV, AHA class C. She underwent 24-h saturation and ECG monitoring and submitted to high-dose furosemide, spironolactone, low-dose bisoprolol and ivabradine with symptoms recovery. Coronary angiography, performed in the 3rd day, did not show any significant stenosis. In the 7th day echocardiography confirmed the EF (25%), a reduction of filling pressures, disappearance of the restrictive pattern with a residual type 1 diastolic dysfunction and reduction of mitral insufficiency (vena contracta 5.0 mm). At discharge, she was in good general conditions, without evidence of oedema or pleural effusion at lung ultrasound. Blood pressure was 120/50 mmHg, cardiac frequency was 68 bpm, SpO2 96% in room air. We decided to withdraw TCA, following the hypothesis of a potentially causative role of this class of drugs in the pathogenesis of HF. 25 days after discharge we underlined a net improvement of both clinical conditions and EF (34%), with reduction of BNP (466 pg/ml). We then started titrating bisoprolol (from 2.5 to 5 mg/day) and ivabradine (from 5 to 7.5 mg bid), obtaining a cardiac frequency of 55 bpm and started ACE-inhibitor (ramipril, 2.5 mg bid titrated to 5 mg bid). In the next control we observed further clinical improvement, with amelioration of exercise tolerance (NYHA I-II) and a further reduction of BNP (196 pg/ml, 60th day). Ramipril was switched to valsartan for ACE-inhibitors-related cough. At 90th day after discharge, echocardiography underlined a normalization of EF to 55% and the other previously underlined alterations. At 120th day patient was in NYHA class I, AHA class A. After excluding other common causes, we last hypothesized that TCA have been the cause of the observed clinical picture, which completely reversed after drug withdrawal. TCA-related dilated cardiomyopathy is a rare but reversible cause of HFrEF(1), which can improve after medication removal(2) but can often recur after reintroduction of the causative drug(3). This case underlines the importance of an internistic clinical reasoning even when managing a common pathology such as HF. References: (1) Montastruc G, Favreliere S, Sommet A, Pathak A, Lapeyre-Mestre M, Perault-Pochat MC, Montastruc JL; French Association of Regional PharmacoVigilance Centres. Drugs and dilated cardiomyopathies: A case/noncase study in the French PharmacoVigilance Database. Br J Clin Pharmacol. 2010 Mar;69(3):287-94. (2) Mart\ued V, Ballester M, Obrador D, Udina C, Moya C, Pons-Llad\uf3 G. Reversal of dilated cardiomyopathy after chronic tricyclic antidepressant drug withdrawal. Int J Cardiol. 1995 Feb;48(2):192-4. (3) Briec F, Delaire C, Bouhour JB, Trochu JN. Recurrence of dilated cardiomyopathy after re-introduction of a tricyclic antidepressant. Arch Mal Coeur Vaiss. 2006 Oct;99(10):933-5

Association between serum uric acid and SOFA score in subjects affected by severe sepsis

Background: Serum uric acid (SUA) is a normal product of purine metabolism in humans. Uric acid crystals have the capacity to adhere to the surface of epithelial cells and induce an acute inflammatory response, characterized by systemic cytokine production, tumor necrosis factor, and the local expression of chemokines, monocyte chemotactic protein and cyclooxygenase 2 in blood vessels. Moreover, literature reports a relationship between SUA and different cardiovascular risk factors, including hypertension, metabolic syndrome, chronic kidney disease (CKD), as well as with coronary artery disease, peripheral artery disease, electrocardiographic alterations, cerebrovascular disease, atrial fibrillation, and all-cause mortality. With this study we aimed to evaluate the role of SUA in severe sepsis and septic shock. Materials and Methods: in the period between 2014 and 2015 we enrolled all the patients admitted to our Internal Medicine department for severe sepsis or septic shock. For each patent, at the admission in our department, we evaluated age, sex, the most common comorbidities (hypertension, diabetes, active cancer, CHF, COPD) and smoking attitude. Blood gas analysis, SUA and troponin were collected at the admission. SOFA score was calculated for each subject. Days of hospitalization, death or UTI/SUTI transfer were collected as measures of outcome. Informed consent was required to participate to the study. All patients were treated according to current guidelines. All the data were synthesized in an electronic database. Pearsons bivariate correlation was used to explore relationships between variables. Continuous variables were compared with t-test, dichotomous and ordinal variables with chi-squared test. A GLM/univariate model was used to confirm the preliminary observations controlling for covariates. Statistics was performed with SPSS 13.0 for Windows systems. Results: We obtained a final sample of 71 patients. Mean age was 76.82(±15.37) years, males representing 49.3%. Hypertension affected 72.9%, diabetes 28.2%, cancer 25.4%, CHF 43.7%, COPD 12.7% of the enrolled patients. Mean SUA was 6.49(±0.41) mg/dl, mean troponin I was 0.30(±0.81) mg/dl. Mean SOFA score was 4.34(±0.241). Mean hospitalization was 11.65(±0.68) days. Death or UTI/SUTI transfer was observed in 32.4% of the patients. SUA levels resulted statistically associated to both SOFA score (p<0.05) and death or UTI/SUTI transfer (p<0.001) at Pearsons bivariate test. Patients who died or were transferred to UTI/SUTI had higher mean SUA levels (7.68±5.07mg/dl) than patients who survived (5.92±2.24mg/dl; p<0.05). We observed an exponential relationship between SUA levels and SOFA score (r2=0.836; p<0.0001). The GLM/Univariate model, performed adopting SOFA score as main outcome, SUA levels as main predictor, age, sex, hypertension, smoking attitude, diabetes, cancer, chronic heart failure and COPD as covariates confirmed that patients with SUA levels 7.0 mg/dl had significantly (p=0.01) higher SOFA scores (5.134±0.718) than patients with SUA levels between 4.0 and 6.9 mg/dl (3.562±0.857) and SUA levels under 4.0 mg/dl (3.402±0.857). Conclusions: Among septic patients, increased SUA levels seem to be associated to increased complexity: in this study subjects with hyperuricemia have higher SOFA scores independently of age, sex and all the considered comorbidities. Increased SUA levels seem also be associated to higher UTI/SUTI transfer or in-hospital death. These observations require larger studies to confirm and clarify the nature of this association