Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study

BACKGROUND: B-lines evaluated by lung ultrasound (LUS) are the sonographic sign of pulmonary congestion, a major predictor of morbidity and mortality in patients with heart failure (HF). Our aim was to assess the prognostic value of B-lines at discharge to predict rehospitalization at 6 months in patients with acute HF (AHF). METHODS: A prospective cohort of 100 patients admitted to a Cardiology Department for dyspnea and/or clinical suspicion of AHF were enrolled (mean age 70 ± 11 years). B-lines were evaluated at admission and before discharge. Subjects were followed-up for 6-months after discharge. RESULTS: Mean B-lines at admission was 48 ± 48 with a statistically significant reduction before discharge (20 ± 23, p 15) (log rank χ(2) 20.5, p 15 before discharge (hazard ratio [HR] 11.74; 95 % confidence interval [CI] 1.30-106.16) was an independent predictor of events at 6 months. CONCLUSIONS: Persistent pulmonary congestion before discharge evaluated by ultrasound strongly predicts rehospitalization for HF at 6-months. Absence or a mild degree of B-lines identify a subgroup at extremely low risk to be readmitted for HF decompensation

Syn-exhumation coupling of oceanic and continental units along the western edge of the alpine corsica: A review

The Alpine Corsica represents a segment of the Alpine collisional belt. In its western edge, it is characterized by the close association of continental units deformed under high-pressure metamorphic conditions (Lower Units) and oceanic units showing a metamorphism ranging from high-pressure (Schistes Lus-trés Complex) to very low-grade conditions (Upper Units). This paper provides a complete review of the relationships between the continental and oceanic units in selected five areas where the stratigraphic features, deformation history, metamorphic P-T path and tectonic setting are available for each unit. The collected data indicate that the oceanic units occur not only at the top of the continental ones, as generally proposed in the literature, but also intercalated within them. Such relationships were achieved at shallow structural level during the late stage of exhumation, when the continental units were tectonically coupled with the oceanic units which were dragged as slices from the orogenic wedge. The coupling probably occurred immediately before the transition from syn-to post-orogenic geodynamic regime that affected the whole Alpine-Apennine collisional system in the early Oligocene. After the coupling, the stack of oceanic and continental units experienced a further exhumation-related deformation before their final exposure at the surface

ps7 144 application of the doris algorithm for the definition of disease remission over a 2 year period in a cohort of italian patients with systemic lupus erythematosus

Objective Systemic Lupus Erythematosus (SLE) is characterised by a fluctuating course.To achieve sustained remission is the goal of maintenance treatment. In 2014, an international Task Force named DORIS proposed four definitions of remission. Aim of this study was to evaluate the performance of the DORIS algorithm in comparison to the remission status as defined by clinical judgement. Methods Monocentric retrospective study. Among all SLE patients followed at the Lupus Clinic between 2014 and 2016, we enrolled patients fulfilling the SLICC 2012 criteria who were visited at least once in 2016 and who had at least 5 biannual medical examinations in the previous 2 years.Remission according to DORIS was defined as a clinical-SLEDAI (cSLEDAI) score equal to zero and Physician Global Assessment (PGA) Results 85SLE patients were enrolled (95% female). 21% of patients were in remission in all the 5 time-points, 23% never got into remission. 55% of patients satisfied DORIS criteria at least in one time-point. Mean duration of DORIS remission was 9 months.In 169 (40%) visits there was a disagreement between DORIS and Clinical definition of Remission: a) in 2% remission according to DORIS but no clinical remission; b) 98% clinical remission but not according to DORIS. The reasons for discordant results were: a) self-management of steroids dosage and precautionary increase of steroids in the suspect of a flare; b) cSLEDAI >0 in 74%,PGA >0.5 in 47%,daily prednisone >5 mg in 18%.The cSLEDAI items that most contributed to the score were urinary and haematological alterations (figure 1).In 30 visits (16 patients) a clinical definition of remission was given despite a daily prednisone dose higher than 5 mg. Conclusion Nearly 40% of the visits displayed a disagreement between 'clinical' and DORIS remission.This may be attributable mainly to a different approach in evaluating patients: longitudinal in clinical remission and cross-sectional by DORIS. As compared to 'clinical' remission, DORIS definition: may fail to recognise patients with a chronic stable steroid treatment at medium dosage, due to persistent low disease activity; is less sensitive because of PGA being used as a dichotomous variable with a low threshold; is likely to be scored different than zero because of urinary and haematological alterations

Lung ultrasound: a new tool for the cardiologist

For many years the lung has been considered off-limits for ultrasound. However, it has been recently shown that lung ultrasound (LUS) may represent a useful tool for the evaluation of many pulmonary conditions in cardiovascular disease. The main application of LUS for the cardiologist is the assessment of B-lines. B-lines are reverberation artifacts, originating from water-thickened pulmonary interlobular septa. Multiple B-lines are present in pulmonary congestion, and may help in the detection, semiquantification and monitoring of extravascular lung water, in the differential diagnosis of dyspnea, and in the prognostic stratification of chronic heart failure and acute coronary syndromes

Nucleosynthesis Calculations for the Ejecta of Neutron Star Coalescences

We present the results of fully dynamical r-process network calculations for the ejecta of neutron star mergers (NSMs). The late stages of the inspiral and the final violent coalescence of a neutron star binary have been calculated in detail using a 3D hydrodynamics code (Newtonian gravity plus backreaction forces emerging from the emission of gravitational waves) and a realistic nuclear equation of state. The found trajectories for the ejecta serve as input for dynamical r-process calculations where all relevant nuclear reactions (including beta-decays depositing nuclear energy in the expanding material) are followed. We find that all the ejected material undergoes r-process. For an initial Ye close to 0.1 the abundance distributions reproduce very accurately the solar r-process pattern for nuclei with A above 130. For lighter nuclei strongly underabundant (as compared to solar) distributions are encountered. We show that this behaviour is consistent with the latest observations of very old, metal-poor stars, despite simplistic arguments that have recently been raised against the possibility of NSM as possible sources of Galactic r-process material.Comment: 5 pages, 2 figures, proceedings of Nuclei in the Cosmos 2000, to be published in Nucl. Phys. A; minor correctio

Macrophage activation syndrome in adult systemic lupus erythematosus: report of seven adult cases from a single Italian rheumatology center.

The aim was to describe the macrophage activation syndrome (MAS), a life-threatening syndrome characterized by excessive immune activation that can be triggered by conditions affecting immune homeostasis, in a cohort of adult Italian patients with systemic lupus erythematosus (SLE). This was a monocentric retrospective evaluation. The utility of the H-score, developed to estimate the individual risk of having reactive MAS in adult patients, was assessed. Among 511 patients with SLE, 7 cases (1.4%) of MAS (all females) were identified and their medical records reviewed. In all cases, MAS was simultaneous to the onset of SLE. All patients had fever, lymphadenopathy, hematological involvement, and high titer of anti-dsDNA antibodies. Workup for infections and malignancies was negative. In all cases, the H-score was higher than the cut-off suggested for the classification of reactive MAS. All cases required hospital admission, and 2 patients were admitted to the intensive care unit. Most patients were treated successfully with high doses of corticosteroids and with immunosuppressive drugs, whereas the full therapeutic regimen developed for primary hemophagocytic lymphohistiocytosis HLH was used only in one case. No death from MAS was observed. MAS is a rare and severe disorder that complicated the onset of SLE in our cohort. The H-score may be useful in the classification of these patients

[Ultrasound lung comets: new echographic sign of lung interstitial fibrosis in systemic sclerosis].

Objective: Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are common complications of systemic sclerosis (SSc). Echocardiography evaluates PAH, and chest sonography detects even mild ILC as ultrasound lung comets (ULC), i.e. multiple comet-tails fanning out from the lung surface and originating from subpleural interlobular septa thickened by fibrosis. Aim: to assess ILaD and PAH by integrated cardiac and chest ultrasound in SSc. Methods: We enrolled 30 consecutive SSc patients (age= 54±13 years, 23 females) in the Rheumatology Clinic of Pisa University. In all, we assessed systolic pulmonary arterial pressure (SPAP), from maximal velocity of tricuspid regurgitation flow, and ULC score with chest sonography (summing the number of ULC from each scanning space of anterior and posterior right and left chest, from second to fifth intercostal space). All patients underwent plasma assay for anti-topoisomerase antibodies (anti-Scl70), and antiicentromere associated with development of pulmonary involvement. Twenty-eight patients also underwent high resolution computed tomography, HRCT (from 0= no fibrosis to 3= honey combing). Results: ULC number - but not SPAP - was correlated to HRCT fibrosis and presence Scl-70 antibodies. ULC number was similar in localized or diffuse forms (16±20 vs 21±19, p=ns) and was unrelated to SPAP (r=0.216, p=ns). Conclusions: Chest sonography assessment and ULC allow a complete, simple, radiation-free characterization of interstitial lung involvement in SSc - all in one setting and with the same instrument, same transducer and the same sonographer. In particular, ULC number is associated with HRCT evidence of lung fibrosis and presence of Scl-70 antibodies

A Snapshot on the On-Label and Off-Label Use of the Interleukin-1 Inhibitors in Italy among Rheumatologists and Pediatric Rheumatologists: A Nationwide Multi-Center Retrospective Observational Study.

Background: Interleukin (IL)-1 inhibitors have been suggested as possible therapeutic options in a large number of old and new clinical entities characterized by an IL-1 driven pathogenesis. Objectives: To perform a nationwide snapshot of the on-label and off-label use of anakinra (ANA) and canakinumab (CAN) for different conditions both in children and adults. Methods: We retrospectively collected demographic, clinical, and therapeutic data from both adult and pediatric patients treated with IL-1 inhibitors from January 2008 to July 2016. Results: Five hundred and twenty-six treatment courses given to 475 patients (195 males, 280 females; 111 children and 364 adults) were evaluated. ANA was administered in 421 (80.04%) courses, CAN in 105 (19.96%). Sixty-two (32.1%) patients had been treated with both agents. IL-1 inhibitors were employed in 38 different indications (37 with ANA, 16 with CAN). Off-label use was more frequent for ANA than CAN (p < 0.0001). ANA was employed as first-line biologic approach in 323 (76.7%) cases, while CAN in 37 cases (35.2%). IL-1 inhibitors were associated with corticosteroids in 285 (54.18%) courses and disease modifying anti-rheumatic drugs (DMARDs) in 156 (29.65%). ANA dosage ranged from 30 to 200 mg/day (or 1.0-2.0 mg/kg/day) among adults and 2-4 mg/kg/day among children; regarding CAN, the most frequently used posologies were 150mg every 8 weeks, 150mg every 4 weeks and 150mg every 6 weeks. The frequency of failure was higher among patients treated with ANA at a dosage of 100 mg/day than those treated with 2 mg/kg/day (p = 0.03). Seventy-six patients (14.4%) reported an adverse event (AE) and 10 (1.9%) a severe AE. AEs occurred more frequently after the age of 65 compared to both children and patients aged between 16 and 65 (p = 0.003 and p = 0.03, respectively). Conclusions: IL-1 inhibitors are mostly used off-label, especially ANA, during adulthood. The high frequency of good clinical responses suggests that IL-1 inhibitors are used with awareness of pathogenetic mechanisms; adult healthcare physicians generally employ standard dosages, while pediatricians are more prone in using a weight-based posology. Dose adjustments and switching between different agents showed to be effective treatment strategies. Our data confirm the good safety profile of IL-1 inhibitors

Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome

<p>Abstract</p> <p>Background</p> <p>Differential diagnosis between acute cardiogenic pulmonary edema (APE) and acute lung injury/acute respiratory distress syndrome (ALI/ARDS) may often be difficult. We evaluated the ability of chest sonography in the identification of characteristic pleuropulmonary signs useful in the diagnosis of ALI/ARDS and APE.</p> <p>Methods</p> <p>Chest sonography was performed on admission to the intensive care unit in 58 consecutive patients affected by ALI/ARDS or by acute pulmonary edema (APE).</p> <p>Results</p> <p>Ultrasound examination was focalised on finding in the two groups the presence of: 1) alveolar-interstitial syndrome (AIS) 2) pleural lines abnormalities 3) absence or reduction of "gliding" sign 4) "spared areas" 5) consolidations 6) pleural effusion 7) "lung pulse".</p> <p>AIS was found in 100% of patients with ALI/ARDS and in 100% of patients with APE (p = ns). Pleural line abnormalities were observed in 100% of patients with ALI/ARDS and in 25% of patients with APE (p < 0.0001). Absence or reduction of the 'gliding sign' was observed in 100% of patients with ALI/ARDS and in 0% of patients with APE. 'Spared areas' were observed in 100% of patients with ALI/ARDS and in 0% of patients with APE (p < 0.0001). Consolidations were present in 83.3% of patients with ALI/ARDS in 0% of patients with APE (p < 0.0001). A pleural effusion was present in 66.6% of patients with ALI/ARDS and in 95% of patients with APE (p < 0.004). 'Lung pulse' was observed in 50% of patients with ALI/ARDS and in 0% of patients with APE (p < 0.0001).</p> <p>All signs, except the presence of AIS, presented a statistically significant difference in presentation between the two syndromes resulting specific for the ultrasonographic characterization of ALI/ARDS.</p> <p>Conclusion</p> <p>Pleuroparenchimal patterns in ALI/ARDS do find a characterization through ultrasonographic lung scan. In the critically ill the ultrasound demonstration of a dyshomogeneous AIS with spared areas, pleural line modifications and lung consolidations is strongly predictive, in an early phase, of non-cardiogenic pulmonary edema.</p