A case of chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially fatal complication of pulmonary embolism (PE). Organized thrombus in the pulmonary artery causes a chronic obstruction, leading to a vascular system remodeling, an increase of pulmonary vascular resistance and a chronic pulmonary hypertension. Epidemiology is mostly unknown due to the difficult diagnostic process that often leads to a late diagnosis: findings of persistent pulmonary hypertension (PH), despite correct treatment of PE, lead to the diagnostic suspect. The first choice treatment is pulmonary endarterectomy (PEA) associated with lifelong anticoagulant therapy with vitamin K antagonist. We present the case of a 53-year-old male affected by dyspnea for months, admitted to a sub-intensive care unit for intermediate low-risk PE; echocardiography showed signs of PH persisting after anticoagulant therapy; after 2 months of specific treatment the diagnosis of CTEPH was confirmed and the patient was successfully treated with PEA

Rapidly fatal West Nile virus meningoencephalitis in an immunocompetent patient: a case report

Abstract Background West Nile virus (WNV) is a Flaviviridae most often transmitted by mosquitos. Clinical manifestations vary from no symptoms to neuroinvasive disease. Mortality is rare, but patients with neuroinvasive disease have a fatality rate of 4-14%. Diagnosis is made on epidemiological, clinical and serological criteria. Treatment is based on symptomatic and support therapy. WNV neuroinvasive disease seems associated to advancing age and diabetes, but poor prognosis risk factors are still not clearly recognized. During 2017-2018 10 patients affected by WNV infection were admitted to our Hospital (Policlinico of Modena): 3 patients had a rapid fatal outcome and 3 needed intensive care transfer. We report the most representative case. Case Report A 81-yr-old man from Emilia-Romagna was admitted to our unit with a 6 days history of fever (>38℃), fatigue, nausea, vomiting, hiccough and mild cognitive impairment treated with amoxicillin. Past medical history: type 2 diabetes mellitus, arterial hypertension, permanent pacemaker for type 3 atrioventricular block. Referred exposure to farm animals. No recent travels abroad. Chest x-ray showed a retrocardiac opacity, so empiric levofloxacin was started for suspected community acquired pneumonia. After two days the patient began lethargic with a Glasgow Come Score < 8. Neuroinvasive WNV disease was confirmed by electroencephalogram and rachicentesis. Before serologic results acyclovir and dexamethasone were initiated without benefit and patient diedon the fifth day after admission. Conclusions Risk factors for poor prognosis related to WNV Infection are still not clearly identified. Our patient underwent unexpected rapid clinical deterioration before invasive treatment could positively affect prognosis. This underlines the importance of clinical alert to WNV infections during transmission season in endemic areas and the necessity of more data on fatal WNV cases to define criteria to promptly recognize high-risk patients. Keywords encephalitis; meningoencephalitis; neuroinvasive disease; West Nile virus; fatal meningoencephalitis

Renal infarction as an uncommon cause of abdominal pain. A case report

Renal infarction is a rare cause of abdominal pain whose diagnosis is often misunderstood or severely delayed. The difficulty in identifying this time-dependent condition greatly limits the possibilities of therapeutic intervention and determines the loss of renal parenchyma that could have been saved with prompt diagnosis. It is, therefore, essential to include renal infarction in the differential diagnosis in case of abdominal pain and to identify this pathology beforehand. We present a case of a 65-yearold male with atrial fibrillation in therapy with Edoxaban who was admitted to the hospital for acute onset of widespread abdominal pain with nausea, vomit, and a worsening of renal function according to the laboratory tests. An abdominal computed tomography with contrast confirmed the presence of a bilateral renal infarction. The patient developed chronic kidney disease and was discharged on anticoagulant therapy. The aim of this paper is, therefore, to increase physician awareness towards this condition, the best opportunity to diagnose early renal infarction and to establish acute and long-term therapy

Predicting Local Failure after Partial Prostate Re-Irradiation Using a Dosiomic-Based Machine Learning Model

The aim of this study is to predict local failure after partial prostate re-irradiation for the treatment of isolated locally recurrent prostate cancer by using a machine learning classifier based on radiomic features from pre-treatment computed tomography (CT), positron-emission tomography (PET) and biological effective dose distribution (BED) of the radiotherapy plan. The analysis was conducted on a monocentric dataset of 43 patients with evidence of isolated intraprostatic recurrence of prostate cancer after primary external beam radiotherapy. All patients received partial prostate re-irradiation delivered by volumetric modulated arc therapy. The gross tumor volume (GTV) of each patient was manually contoured from planning CT, choline-PET and dose maps. An ensemble machine learning pipeline including unbalanced data correction and feature selection was trained using the radiomic and dosiomic features as input for predicting occurrence of local failure. The model performance was assessed using sensitivity, specificity, accuracy and area under receiver operating characteristic curves of the score function in 10-fold cross validation repeated 100 times. Local failure was observed in 13 patients (30%), with a median time to recurrence of 36.7 months (range = 6.1–102.4 months). A four variables ensemble machine learning model resulted in accuracy of 0.62 and AUC 0.65. According to our results, a dosiomic machine learning classifier can predict local failure after partial prostate re-irradiation

Results From a Large, Multicenter, Retrospective Analysis On Radium223 Use in Metastatic Castration-resistant Prostate Cancer (mCRPC) in the Triveneto Italian Region

Radium 223 was introduced for metastatic castration-resistant prostate cancer based on the results of a randomized controlled trial showing risk reduction for death and skeletal events. Our aim was to evaluate the outcome of patients receiving radium 223 in a real-world setting

Sequencing radium 223 and other life-prolonging agents in castration-resistant prostate cancer patients

Background: Radium 223 (RA223) is currently administered as part of a therapeutic sequence with the other life-prolonging agents (LPAs) for metastatic castration-resistant prostate cancer (mCRPC). Patients & methods: We retrospectively reviewed the clinical records of patients who had received at least three LPAs including RA223. Results: Median overall survival (OS) from the start of first-line treatment was 39.8months, with the patients who completed all six planned courses of RA223 having a longer OS than those who did not (53.2 vs 29.5months; p<0.0001). Conclusions: Our study confirms the activity of RA223 regardless of the treatment line in which it is administered and suggests that patient selection plays a central role in maximizing this activity

Sequencing life-prolonging agents in castration-resistant prostate cancer patients: comparison of sequences with and without radium 223

Background: The retrospective studies that have so far described the outcomes of the sequential use of life-prolonging agents (LPAs) did not include metastatic castration-resistant prostate cancer (mCRPC) patients who received radium 223 (RA223) as part of their treatment. Consequently, it is not known whether including RA223 in the therapeutic sequence has an impact on cumulative survival. The aim of this study was to evaluate this impact by comparing the cumulative overall survival (OS) in two series of mCRPC patients sequentially treated with two or three LPAs after first-line docetaxel (DOC), including RA223 and not.Materials and Methods: The authors retrospectively reviewed the records of mCRPC patients with bone involvement alone who received two or three LPAs (including RA223) after first-line DOC. The control group was a contemporary series of mCRPC patients with bone involvement alone treated with sequences of two or three LPAs other than RA223 after first-line DOC.Results: Median cumulative OS was 40.6 months in the RA223 group of 78 patients and 36.2 months in the non-RA223 group of 186 patients (p = 0.08). OS outcomes were significantly influenced by the number of treatment lines, and baseline Eastern Cooperative Oncology Group performance status (PS) and prostate-specific antigen levels.Conclusions: To the best of the authors' knowledge, this is the first study designed to evaluate the impact of introducing RA223 in the treatment sequences for mCRPC patients, and the results show that its use does not negatively affect cumulative OS

Interim positron emission tomography response-adapted therapy in advanced-stage hodgkin lymphoma: Final results of the phase II part of the HD0801 study

Purpose The clinical impact of positron emission tomography (PET) evaluation performed early during firstline therapy in patients with advanced-stage Hodgkin lymphoma, in terms of providing a rationale to shift patients who respond poorly onto a more intensive regimen (PET response-adapted therapy), remains to be confirmed. Patients and Methods The phase II part of the multicenter HD0801 study involved 519 patients with advanced-stage de novo Hodgkin lymphoma who received an initial treatment with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) and who underwent an early ifosfamide-containing salvage treatment followed by stem-cell transplantation if they showed a positive PET evaluation after two cycles of chemotherapy (PET2). The primary end point was 2-year progression-free survival calculated for both PET2-negative patients (who completed a full six cycles of ABVD treatment) and PET2-positive patients. Overall survival was a secondary end point. Results In all, 103 of the 512 evaluable patients were PET2 positive. Among them, 81 received the scheduled salvage regimen with transplantation, 15 remained on ABVD (physician's decision, mostly because of minimally positive PET2), five received an alternative treatment, and two were excluded because of diagnostic error. On intention-to-treat analysis, the 2-year progression-free survival was 76% for PET2-positive patients (regardless of the salvage treatment they received) and 81% for PET2- negative patients. Conclusion Patients with advanced-stage Hodgkin lymphoma for whom treatment was at high risk of failing appear to benefit from early treatment intensification with autologous transplantation, as indicated by the possibility of successful salvage treatment in more than 70% of PET2-positive patients through obtaining the same 2-year progression-free survival as the PET2-negative subgroup