Colonic perforation in a child with Crohn's disease: successful medical treatment rescues from colectomy.

Background. The challenging treatment of penetrating paediatric Crohn's disease (CD) involves pharmacological and surgical approaches. Despite a proved efficacy of anti-TNF agents for treatment of complex fistula, a large number of patients cannot achieve a complete healing and relapse during the followup. Aim. We report a paediatric case with CD and colonic perforation who was successfully treated with medical therapy only, including anti-TNFα. Case Presentation. During a colonoscopy performed on a 9-year-old girl with CD, a perforation occurred in correspondence of a fistula at the colonic splenic flexure. The formation of a collection was then detected (US, enteric-CT), as well as a fistula connecting the colon to the collection. The girl was kept fasting and treated with total parenteral nutrition and antibiotic therapy. Treatment with Infliximab was also started, and after the third dose a US control showed disappearance of the collection and healing of the enteric fistula. Parenteral nutrition was progressively substituted with enteral feeding, and no surgical treatments were needed. Discussion. In pubertal children with penetrating CD, the option of an efficacious medical treatment to avoid a major surgical approach on the bowel is to be aimed for growth improvement. This approach requires a strictly monitored long-term followup

Weekend Effect and in-Hospital Mortality in Elderly Patients with Acute Kidney Injury. A Retrospective Analysis of a National Hospital Database in Italy

Background: The aim of this study was to relate the weekend (WE) effect and acute kidney injury (AKI) in elderly patients by using the Italian National Hospital Database (NHD). Methods: Hospitalizations with AKI of subjects aged >= 65 years from 2000-2015 who were identified by the ICD-9-CM were included. Admissions from Friday to Sunday were considered as WE, while all the other days were weekdays (WD). In-hospital mortality (IHM) was our outcome, and the comorbidity burden was calculated by the modified Elixhauser Index (mEI), based on ICD-9-CM codes. Results: 760,664 hospitalizations were analyzed. Mean age was 80.5 +/- 7.8 years and 52.2% were males. Of the studied patients, 9% underwent dialysis treatment, 24.3% were admitted during WE, and IHM was 27.7%. Deceased patients were more frequently comorbid males, with higher age, treated with dialysis more frequently, and had higher admission during WE. WE hospitalizations were more frequent in males, and in older patients with higher mEI. IHM was independently associated with dialysis-dependent AKI (OR 2.711; 95%CI 2.667-2.755,p< 0.001), WE admission (OR 1.113; 95%CI 1.100-1.126,p< 0.001), and mEI (OR 1.056; 95% CI 1.055-1.057,p< 0.001). Discussion: Italian elderly patients admitted during WE with AKI are exposed to a higher risk of IHM, especially if they need dialysis treatment and have high comorbidity burden

Acute Kidney Injury and In-Hospital Mortality. A Retrospective Analysis of a Nationwide Administrative Database of Elderly Subjects in Italy

Background: The aim of this study was to investigate the association between acute kidney injury (AKI) and in-hospital mortality (IHM) in a large nationwide cohort of elderly subjects in Italy. Methods: We analyzed the hospitalization data of all patients aged >= 65 years, who were discharged with a diagnosis of AKI, which was identified by the presence of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and extracted from the Italian Health Ministry database (January 2000 to December 2015). Data regarding age, gender, dialysis treatment, and comorbidity, including the development of sepsis, were also collected. Results: We evaluated 760,664 hospitalizations, the mean age was 80.5 +/- 7.8 years, males represented 52.2% of the population, and 9% underwent dialysis treatment. IHM was 27.7% (210,661 admissions): Deceased patients were more likely to be older, undergoing dialysis treatment, and to be sicker than the survivors. The population was classified on the basis of tertiles of comorbidity score (the first group 7.48 +/- 1.99, the second 13.67 +/- 2,04, and third 22.12 +/- 4.13). IHM was higher in the third tertile, whilst dialysis-dependent AKI was highest in the first. Dialysis-dependent AKI was associated with an odds ratios (OR) of 2.721; 95% confidence interval (CI) 2.676-2.766; p < 0.001, development of sepsis was associated with an OR of 1.990; 95% CI 1.948-2.033; p < 0.001, the second tertile of comorbidity was associated with an OR of 1.750; 95% CI 1.726-1.774; p < 0.001, and the third tertile of comorbidity was associated with an OR of 2.522; 95% CI 2.486-2.559; p < 0.001. Conclusions: In elderly subjects with AKI discharge codes, IHM is a frequent complication affecting more than a quarter of the investigated population. The increasing burden of comorbidity, dialysis-dependent AKI, and sepsis are the major risk factors

Relationship between electrocardiographic findings and cardiac magnetic resonance phenotypes in arrhythmogenic cardiomyopathy

Background-\u2014The new designation of arrhythmogenic cardiomyopathy defines a broader spectrum of disease phenotypes, which include right dominant, biventricular, and left dominant variants. We evaluated the relationship between electrocardiographic findings and contrast-enhanced cardiac magnetic resonance phenotypes in arrhythmogenic cardiomyopathy. Methods and Results-\u2014We studied a consecutive cohort of patients with a definite diagnosis of arrhythmogenic cardiomyopathy, according to 2010 International Task Force criteria, who underwent electrocardiography and contrast-enhanced cardiac magnetic resonance. Both depolarization and repolarization electrocardiographic abnormalities were correlated with the severity of dilatation/dysfunction, either global or regional, of both ventricles and the presence and regional distribution of late gadolinium enhancement. The study population included 79 patients (60% men). There was a statistically significant relationship between the presence and extent of T-wave inversion across a 12-lead ECG and increasing values of median right ventricular (RV) end-diastolic volume (P55 ms in the right precordial leads (V1-V3) was associated with higher RV volume (P=0.014) and lower RV ejection fraction (P=0.053). Low QRS voltages in limb leads predicted the presence (P=0.004) and amount (P<0.001) of left ventricular late gadolinium enhancement. Conclusions-\u2014The study results indicated that electrocardiographic abnormalities predict the arrhythmogenic cardiomyopathy phenotype in terms of severity of RV disease and left ventricular involvement, which are among the most important determinants of the disease outcome

Morphofunctional abnormalities of mitral annulus and arrhythmic mitral valve prolapse

Background\u2014Arrhythmic mitral valve prolapse (MVP) is characterized by myxomatous leaflets and left ventricular (LV) fibrosis of papillary muscles and inferobasal wall. We searched for morphofunctional abnormalities of the mitral valve that could explain a regional mechanical myocardial stretch. Methods and Results\u2014Thirty-six (27 female patients; median age: 44 years) arrhythmic MVP patients with LV late gadolinium enhancement on cardiac magnetic resonance and no or trivial mitral regurgitation, and 16 (6 female patients; median age: 40 years) MVP patients without LV late gadolinium enhancement were investigated by morphofunctional cardiac magnetic resonance. Mitral annulus disjunction (median: 4.8 versus 1.8 mm; P1.5 (22 [61%] versus 4 [25%]; P=0.016) were higher in MVP patients with late gadolinium enhancement than in those without. A linear correlation was found between mitral annulus disjunction and curling (R=0.85). A higher prevalence of auscultatory midsystolic click (26 [72%] versus 6 [38%]; P=0.018) was also noted. Histology of the mitral annulus showed a longer mitral annulus disjunction in 50 sudden death patients with MVP and LV fibrosis than in 20 patients without MVP (median: 3 versus 1.5 mm; P<0.001). Conclusions\u2014Mitral annulus disjunction is a constant feature of arrhythmic MVP with LV fibrosis. The excessive mobility of the leaflets caused by posterior systolic curling accounts for a mechanical stretch of the inferobasal wall and papillary muscles, eventually leading to myocardial hypertrophy and scarring. These mitral annulus abnormalities, together with auscultatory midsystolic click, may identify MVP patients who would need arrhythmic risk stratification

Acute Hypotension and Chest Pain as the Presentation of a Post-Myocardial Infarction Acute Pericarditis (Dressler's Syndrome)

We report a case of a 53-year old man admitted because of fever (38.5°C) and atypical chest pain. He also complained of epigastric pain spread to left hypochondrium and exacerbated by breathing. In his past medical history, Hodgkin's lymphoma, gastric MALToma (oncologic follow-up only), hypothyroidism, and hypertension are recorded. Fifteen days prior actual hospital admission, the patient underwent angioplasty with stenting due to a ST elevation myocardial infarction. Moreover, he was enrolled in the experimental clinical double-blind trial GEMINI-ACS [1], designed to compare the safety of rivaroxaban vs aspirin in addition to either clopidogrel or ticagrelor. Thus, his complete therapy included also ticagrelor, bisoprolol, perindopril, levothyroxine, pantoprazole, and atorvastatin. At the time of admission chest X-ray showed bilateral pleural effusion. Blood chemistry panel showed moderate anemia, increase of inflammatory indexes, in particular fibrinogen 1057 mg/dl (normal range 150-400 mg/dl), C-reactive-protein 17.6 mg/dl (normal range <0.5 mg/dl), serum ferritin 650 ng/ml (normal range 11-306 ng/ml), while serum pro-calcitonin was normal. Electrocardiography and cardiac troponin I were not suggestive of further heart ischemic damage. Two days later, the patient showed hypotension, exacerbation of chest pain, as well as a rapid drop hemoglobin values. A thoracicabdominal CT (figure 1) was performed, showing peri-hepatic and pericardial effusions associated with hyper-reflectivity of pericardial leaflets. After a precautionary discontinuation of the experimental drugs, acetylsalicylic acid and clopidogrel were only given, together with antibiotics, diuretics and steroids. Clinical conditions slowly improved, blood pressure levels raised, together with hemoglobin values, and inflammatory parameters decreased. The patient was discharged in good clinical conditions, with the conclusive discharge diagnosis of Dressler syndrome (DS) related to angioplasty and stenting procedure for acute myocardial infarction

Nonischemic left ventricular scar as a substrate of life-threatening ventricular arrhythmias and sudden cardiac death in competitive athletes

Background\u2014The clinical profile and arrhythmic outcome of competitive athletes with isolated nonischemic left ventricular (LV) scar as evidenced by contrast-enhanced cardiac magnetic resonance remain to be elucidated. Methods and Results\u2014We compared 35 athletes (80% men, age: 14\u201348 years) with ventricular arrhythmias and isolated LV subepicardial/midmyocardial late gadolinium enhancement (LGE) on contrast-enhanced cardiac magnetic resonance (group A) with 38 athletes with ventricular arrhythmias and no LGE (group B) and 40 healthy control athletes (group C). A stria LGE pattern with subepicardial/midmyocardial distribution, mostly involving the lateral LV wall, was found in 27 (77%) of group A versus 0 controls (group C; P<0.001), whereas a spotty pattern of LGE localized at the junction of the right ventricle to the septum was respectively observed in 11 (31%) versus 10 (25%; P=0.52). All athletes with stria pattern showed ventricular arrhythmias with a predominant right bundle branch block morphology, 13 of 27 (48%) showed ECG repolarization abnormalities, and 5 of 27 (19%) showed echocardiographic hypokinesis of the lateral LV wall. The majority of athletes with no or spotty LGE pattern had ventricular arrhythmias with a predominant left bundle branch block morphology and no ECG or echocardiographic abnormalities. During a follow-up of 38\ub125 months, 6 of 27 (22%) athletes with stria pattern experienced malignant arrhythmic events such as appropriate implantable cardiac defibrillator shock (n=4), sustained ventricular tachycardia (n=1), or sudden death (n=1), compared with none of athletes with no or LGE spotty pattern and controls. Conclusions\u2014Isolated nonischemic LV LGE with a stria pattern may be associated with life-threatening arrhythmias and sudden death in the athlete. Because of its subepicardial/midmyocardial location, LV scar is often not detected by echocardiography