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Rossella Siligato,1,2 Guido Gembillo,2,3 Alfredo De Giorgi,4 Alessio Di Maria,1 Laura Maria Scichilone,1 Matteo Capone,1,5 Francesca Maria Vinci,1,5 Simone Nicoletti,1 Marta Bondanelli,5 Cristina Malaventura,5 Alda Storari,1,5 Domenico Santoro,3 Sara Dionisi,6 Fabio Fabbian1,5 1Nephrology Unit, University Hospital of Ferrara, Ferrara, Italy; 2Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina, Italy; 3Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy; 4Internal Medicine, University Hospital of Ferrara, Ferrara, Italy; 5Department of Medical Sciences, University of Ferrara, Ferrara, Italy; 6Nursing, Technical and Rehabilitation, Department DATeR Azienda Unità Sanitaria Locale Di Bologna, Bologna, ItalyCorrespondence: Fabio Fabbian, Department of Medical Sciences, via Luigi Borsari, 46, Ferrara, Italy, I-44124, Tel +39 0532 239385, Email f.fabbian@ospfe.itPurpose: Social determinants of health have been related with kidney diseases and their outcomes. Financial toxicity (FT) refers to the negative impact of health care costs on clinical conditions. This scoping review aimed to evaluate the literature linking FT with renal diseases.Patients and Methods: We Included all studies analyzing FT and renal disease recorded in PubMed, Embase and Google Scholar between 2013 and 2023. The research question was formulated with reference to the acronym PCC (Problem, Concept and Contest). For each included study, we considered the study design, the population and main results from different populations with distinct renal conditions and the results were summarized in four tables.Results: Socioeconomic deprivation was the main cause of FT, and the majority of studies on the relationship between FT and chronic kidney disease (CKD) were conducted in the USA (4 studies evaluated the pediatric population and 6 studies included adults). Three studies reported the impact of FT on nephrolithiasis, and 3 studies analyzed the link between FT and renal tumors. The methods used for detecting FT differed and were based on consultations, questionnaires, expenditures and database records analysis. The COmprehensive Score for financial Toxicity (COST) questionnaire was used in 7 studies (43%), and the prevalence of FT was reported to be high in children and adults.Conclusion: Although the quality of the selected study is limited, due to different populations investigated and heterogeneity in detecting FT, the latter seems to be a frequent finding in people with renal disease. Health care professionals should recognize socioeconomic deprivation as the major cause of FT. Detecting FT could help in prioritizing patient-centered care in populations with renal diseases through the development of strategies aimed at improving care for people with kidney diseases.Plain Language Summary: Social determinants of health, especially poverty, social environmental stressors and psychological factors, are increasingly recognized as significant determinants of kidney diseases and their outcomes. Financial toxicity (FT) refers to the negative impact of health care costs on clinical conditions. The relationship between FT and renal disease is not completely understood. With this scoping review, we evaluated all published papers between 2013 and 2023 on this item. We analyzed 16 studies and found that FT is common in pediatric and adult CKD patients and in patients with nephrolithiasis and renal tumors. For patients with kidney disease, FT represents a significant burden, both through the direct costs of disease management and treatment and through indirect costs such as the loss of income due to missed work and expenses for transportation and accommodations near outpatient clinics. Finally, it should be noted that in different countries, it is difficult for people with kidney disease to obtain health insurance coverage. Health care professionals need to improve their knowledge about the relationship between FT and renal disease; there is a paucity of data regarding the effects of FT on different outcomes, although this nonmedical risk factor can negatively influence kidney health and quality of life. Further studies involving different professionals able to consider environmental, physical and emotional risk factors are needed. Keywords: financial toxicity, financial burden, financial hardship, renal disease, chronic kidney disease

Aims Vasovagal syncope (VVS) is often preceded by prodromal symptoms. The haemodynamic changes occurring during the prodrome have not been systematically investigated. The aim of the present study was to investigate the behaviour of blood pressure (BP), heart rate (HR) and sympathetic activity at the beginning of the prodrome in patients with tilt-induced VVS. Methods and Results Sixty-three patients with VVS underwent tilt testing. BP and HR were measured and blood samples for plasma catecholamine determination were obtained during the test. Conclusion These results demonstrate that in patients with tilt-induced VVS, BP is consistently decreased at the beginning of prodromal symptoms because of the withdrawal of sympathetic activity, and HR is often reduced, probably because of increased vagal activity. We may infer that similar haemodynamic features also occur during spontaneous VVS. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved. [ABSTRACT FROM PUBLISHER]

Aims The hypotensive reflex responsible for vasovagal syncope appears related to a reduction in sympathetic neural outflow. Several animal studies suggest that serotonin may play a role in the genesis of this reflex, through inhibition of sympathetic activity. However, the role of the serotonergic system is unknown in humans. The purpose of the study was to investigate the role of the serotonergic system in the genesis of vasovagal syncope by means of the level of platelet and plasma serotonin, as well as plasma catecholamines, during tilt-induced syncope. Methods and Results Fifteen patients (age 34±16 years) with vasovagal syncope underwent a head-up tilt test (HUT, 60°, 45 min). If syncope did not develop, 300 μg nitroglycerin was administered sublingually and patients continued to be tilted for a further 20 min. Blood samples were obtained in the supine position, and then after 3, 10, 15, 30, 45, 48 and 65 min of HUT. If syncope developed, blood samples were obtained at the beginning of the prodrome, during syncope and after the recovery of consciousness. Platelet and plasma serotonin and plasma catecholamines were measured using high-pressure liquid chromatography with electrochemical detection. Ten patients developed syncope during the unmedicated HUT and four after nitroglycerin. In these patients plasma adrenaline significantly increased from the last programmed sample before the prodrome to its beginning and showed a further increase during loss of consciousness, whereas plasma noradrenaline did not increase, as an expression of inhibition of sympathetic neural outflow. In the patients experiencing syncope, both platelet and plasma serotonin showed no significant change after tilt-up, at the beginning of prodrome, during syncope and after recovery of consciousness. Conclusion These results do not suggest that the serotonergic system plays a role in the pathophysiology of vasovagal syncope. [ABSTRACT FROM PUBLISHER]

Introduction: Everolimus is a treatment option for patients with pancreatic NETs, while its use in patients with gastrointestinal NETs still remains to be defined. Aim(s): To test the efficacy and side effects of Everolimus in six patients with differentiated NET refractory to other therapies. Materials and methods: Everolimus (10 mg/day; compassionate use) was administered until disease progression or unacceptable toxicity. Three patients had metastases of ileal neuroendocrine carcinoma; one of typical lung carcinoid; one of ovary carcinoid and one of pancreatic insulinoma. Results: Two patients showed stable disease at imaging after six and 12 months of treatment. One patient showed biochemical remission. Two patients discontinued treatment due to adverse events. One patient did not reach the six months followup. Side effects were: stomatitis (2); thrombocytopenia (2); nausea (2); fatigue (2) that in one case determined definitive therapy discontinuation after eight months; skin infected lesions (1) leading to definitive discontinuation after three months of therapy. In one case, Everolimus was discontinued after 17 months for severe tricuspid valve insufficiency. Finally, one patient discontinued therapy after three months for worsening dyspnea. The only patient currently under treatment had no side effects. During therapy, lipid and glucose profile did not show significant alterations. Conclusion: Everolimus induces disease stabilization but may have several side effects which should be monitored. [ABSTRACT FROM AUTHOR]

Introduction: Medical treatment of metastatic insulinoma is debated. Aim(s): To test the efficacy of Everolimus on insulin secretion by liver metastases of a pancreatic insulinoma. Materials and methods: The patient (66 yrs old) was admitted due to hypoglycemic crises. Glucose=35 mg/dl, insulin =94.9 mUI/l, HbA1c= 4.5% and C peptide = 11.1 ng/ml suggested an insulinoma. Abdominal CT showed a 1.5 cm nodule of the head of the pancreas and six metastatic liver nodules. Liver biopsy showed metastases of well-differentiated neuroendocrine carcinoma, G2. The patient underwent a total pancreasectomy with removal of a portion of the gastric wall, spleen, duodenum, gallbladder, right liver lobe. Histology showed a pancreatic well-differentiated neuroendocrine carcinoma, Ki-67= 4%, infiltrating the peri-pancreatic adipose tissue, with metastases to the gastric lymphodes and to the liver. One month after angio-US showed the presence of at least six liver mestastases in the residual left liver, not suitable for radiofrequency ablation. Hypoglycemia recurred, indicating the persistence of insulin production by the metastatic liver in keeping with measurable insulin and C-peptide plasma levels. The patient then started compassionate treatment with Everolimus (10 mg/day). Results: Ten days after the patient became diabetic needing insulin administration. She developed hypertrygliceridemia and hypercholesterolemia, with improvement in liver function and no serious adverse events. Conclusion: Everolimus controls insulin secretion in metastatic insulinoma. [ABSTRACT FROM AUTHOR]