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Since the COVID-19 outbreak, Italy has been one of the most affected countries in Europe and the second for number of deaths. In this commentary, we discuss some lessons that we learned as healthcare providers working in a large public hospital during the pandemic, with a special focus on the importance of infection containment and early diagnosis, the role of swab, serological tests, home isolation and individual protection devices, and the available therapies and management indications to better face a possible new outbreak in the near future. These comments should stimulate a more diffused, efficient and efficacious management of COVID-19 patients, also reducing the number of accesses to hospital emergency departments and the related spread of the infection.

Cardiac involvement has been studied quite extensively in patients affected by inflammatory bowel disease but, as of now, there is no data regarding QT alterations which are well known to be linked to the risk of dangerous arrhythmias. In this study, QT parameters were digitally measured on standard 12-lead ECG in a population of 20 patients affected by inflammatory bowel disease (IBD), with no prior (recent or old) history of cardiac disease and no evidence of electrolyte imbalance. Eighteen healthy subjects formed the control group. The results obtained using non-parametric statistics (Wilcoxon-Mann-Whitney test) showed that heart rate corrected QT interval (QTc) and QTc dispersion (QTc d) values were both significantly higher in IBD patients than in the control group. QTc rank sum values in patients affected by inflammatory bowel disease were 469 versus 311 in healthy subjects (Z = 1.939, p = 0.0263). QTc d rank sum values were 460 in IBD patients versus 320 in controls (Z = 1.686 with p = 0.0459). Regardless of the cause of these QT alterations, it appears evident that accurate monitoring of QT parameters is required in these patients who often experience electrolyte disturbances and who may, in some cases, be undergoing treatment with potentially cardiotoxic drugs such as infliximab.

In Western countries, thyrotoxic periodic paralysis (TPP) is a rare condition with only sporadic cases described so far. Here, we describe a 29-year-old Italian man who presented with leg weakness and hypokalaemia. Treatment with intravenous potassium resulted in a rapid resolution of symptoms. TPP as the underlying cause was suggested by suppressed thyroid-stimulating hormone (TSH), elevated free T3 and free T4, and the presence of TSH-receptor antibodies (TRAB). Genetic analysis showed no mutations in the candidate exons of calcium ( CACN1AS), potassium ( KCNE3) and sodium ( SCN4A) channel genes. However, we identified the presence of two single nucleotide polymorphisms (SNPs), 1491C > T and 1551 T > C, in exon 11 of the CACN1AS gene. Although the 1491C > T SNP is not apparently involved in the pathogenesis of the disease, the 1551 T > C SNP has been associated with TPP in Asians and reported in only one case in European Caucasians. Further investigations are needed to clarify whether such polymorphisms have a role in the disease pathogenesis in Caucasians.

The present case-control study provides evidence that the correlation between mitral valve prolapse and the clinical observation of low blood pressure persists throughout a 24-hour period as documented by ambulatory blood pressure monitoring. Moreover, the blood pressure circadian rhythm, even though preserved, seems to follow a different course over the 24-hour period in subjects with mitral valve prolapse.

The objective of this study on patients with suspected Acute Coronary Disease (ACS) was to verify with the risk stratification any differences between patients in which the AHA/ACC guidelines were not systematically applied and the same patients in which, retrospectively, the AHA/ACC guidelines were adhered to.Retrospective examination was carried out in our Emergency Department at Rome Policlinico Umberto I on 206 patients (age range 21-88, median age 56.6 +/- 18.9 years) (54.3% males) with symptoms compatible with ACS. All the patients underwent "triage" using code green or code yellow and were sub-divided into 7 subgroups based on degree of risk for death or non-fatal myocardial infarction (MI) at 30 days, (labelled A to G, with A representing highest risk and G the least at-risk) in accordance with the ACC/AHA guidelines. Each patient was then examined for: fi nal outcome, admittance and discharge from hospital, refusal of admittance, death.Of the 206 patients, 48 were judged improperly (23.3%) Of these, 13 were assigned code green rather than code yellow and 11 were assigned code yellow instead of code green. By risk stratification in accordance with the AHA/ACC guidelines, 128 patients (62.1%) belonging to subgroups A,B,C and D should have required hospitalization. Seventy eight patients belonging to subgroups E,F and G should have been sent for observation at the Chest Pain Unit (CPU), 54 from this group would have been potentially discharged after 6-12 hours of negative clinical observation. Actually, hospitalization was requested for 132 patients (64%) of whom 78 accepted, 50 declined and 4 were deceased before admission; 74 patients (35.9%) were discharged after brief observation. Risk stratification for 30 day mortality or non fatal MI emphasizes that 8 of the patients hospitalized should have been treated at the CPU (unwarranted hospitalization). Twenty four of the 50 patients who declined hospitalization should have benefited by brief observation at the Chest pain Unit. Twenty eight of the 78 patients examined in the Emergency Department and later discharged should have been hospitalized (wrong discharge).This study, even if limited by time restriction, provides enough evidence in support of the effectiveness of the ACC/AHA guidelines to determine subgroups and to correctly determine groups according to level of risk, thus limiting unwarranted hospitalizations and wrong discharges.

Obstructive sleep apnea syndrome (OSAS) is a syndrome in which the principal symptom is apnea during sleep. Hypoxia in OSAS is a stress condition, which when prolonged in time, could alter hypothalamo-hypophysial-suprarenal control and the cortisol cicadian rhythm. We studied 28 patients with OSAS (30-60 years old), 20 female and 8 male. We calculated the OSAS class according to the Simmons classification. Twenty of the 28 patients maintained unmodified cortisol circadian rhythms, while 8 had cortisol levels more elevated in late and nocturnal hours. Holter monitoring showed arterial hypertension in 8 of the 28 patients (the same patients with cortisol circadian rhythm alteration). Our data seem to indicate that when the OSAS patients lack cortisol circadian rhythm they are having arterial hypertension.

Many endoscopists sometimes prefer to perform endoscopies without anaesthetic support, using only benzodiazepines. Endogenous opioid peptides are believed to play an important role in the modulation of pain within the endogenous analgesic system. A group of 40 patients undergoing diagnostic and therapeutic Endoscopic Retrograde Cholangiography and Pancreatography (ERCP) was recruited. Patients were divided into 2 groups according to Visual Analog Scale: pain 1-5 (Group A) and pain 6-10 (Group B). The beta-endorphin baseline values were significantly different between patients of Group A and Group B. Our data show that patients with levels of beta-endorphin over 8 pmol/L were less sensitive to pain, so that they become candidates for a traditional utilization of the benzodiazepines. However in the patients with beta-end levels less of 8 pmol/L should be suitable an anaesthetic as propofol because strong pain might provoke neurohumoral reflexes, cardiovascular alterations, and even a heart attack.

Met-enkephalin plasma levels were evaluated in 20 cardioischemic diabetic patients. All the patients had ECG ischemic signs. Ten patients with diabetic autonomic neuropathy, experienced no pain during myocarial ischemia. Met-enkephalin levels in the diabetic patients with silent myiocardial ischemia were significantly lower compared to those in the symptomatic patients. This demonstrates that the absence of myocardial ischemic pain in neuropathic diabetic patients is not accounted for by met-enkephalin action.

Among extra-hepatic manifestations of hepatitis C virus (HCV) infection particular interest is focused on some dermatological diseases such as: leukocytoclastic vasculitis, oral lichen planus, pruritus-urticaria, psoriasis. Aim of this paper is to analyze these typical dermatoses in a population of patients with HCV infection and describe the characteristic clinical pictures. These clinical pictures confirm the importance of liver examination in presence of skin diseases not related to other pathogenetic mechanisms.

Atrial pacing (AP) procedure was carried out in 11 cardioischemic patients to reproduce tachycardia-induced myocardial ischemia. Six control subjects underwent the same procedure until the maximum pacing rate was reached. During the procedure, endothelin-1 (ET-1) and plasma lactate levels were measured in the coronary sinus and in the aortic root. In all the patients, atrial pacing provoked electrocardiographic signs and metabolic evidence of myocardial ischemia and a significant decrease (p0.001) in left ventricular ejection fraction. At AP-induced ischemia, coronary sinus (17.31 +/- 4.20 pg/mL) and arterial (9.60 +/- 3.31 pg/mL) ET-1 plasma levels were significantly different (p0.001) in the patients. On the contrary, at maximum pacing rate, no significant difference (p=0.186) emerged between coronary sinus (9.72 +/- 1.09 pg/mL) and arterial (8.95 +/- 0.75 pg/mL) plasma ET-1 levels in the control group. These results suggest that, in cardioischemic patients, tachycardia can induce the coronary endothelium to release significant amounts of ET-1.

Mitral valve prolapse was identified as a separate nosological entity by Barlow in 1963. A characteristic of this cardiac anomaly is blood reflux into the left atrium during the systole owing to the lack of adhesion between valve flaps. The presence of symptoms linked to neuroendocrine dysfunctions or to the autonomic nervous system lead to the onset of the pathology known as mitral valve prolapse syndrome (MVPs). It is usually diagnosed by chance in asymptomatic patients during routine tests. MVPs includes complex alterations to the neurovegetative system and a high clinical incidence of neuropsychiatric symptoms, like anxiety and panic attacks. A neuroendocrine mechanism thought to underlie panic attacks was recently proposed based on a biological model. In general, the cardiovascular anomaly manifested by patients with MVPs could be defined in neuroendocrine-constitutional terms.

Positivity for circulating intercellular adhesion molecule-1 (ICAM-1) in heart transplant recipients has been claimed to predict the development of coronary artery disease and risk of graft failure. Soluble ICAM-1 were evaluated in 32 heart transplant recipients. Five of these patients, who had undergone transplantation several years before, were positive for soluble ICAM-1 but did not present any clinical sign of graft rejection. Furthermore, although heart graft coronary disease was diagnosed in 15 of the 32 patients, they did not show significantly higher titres of soluble ICAM-1 compared to the remaining patients. These findings suggest that major caution is necessary when considering ICAM-1 positivity as a marker of graft disease.

In order to evaluate polymorphonuclear leukocyte (PMN) activity in diabetes mellitus, leukotriene B4 (LTB4) levels were measured in sixty patients, 31 affected with Type 1 diabetes mellitus and 29 affected with Type 2 diabetes mellitus. The LTB4 levels (12.1+/-0.2 pg/100 microl) in diabetic patients were higher compared to those of the control group (7.9+/-0.1 pg/100 microl) (P < 0.001), and remained significantly higher (P < 0.001) (12.8+/-0.2 pg/100 microl) than in the control group (11.0+/-0.2 pg/100 microl) after stimulation with calcium ionophore. A significant and positive correlation between glycated hemoglobin and LTB4 was demonstrated (P < 0.001, r = 0.80). This study demonstrates that in diabetic patients there is a PMN activation and that this activation is correlated to glycated hemoglobin level.

Plasma beta-endorphin levels were studied in the coronary sinus of 8 patients undergoing percutaneous transluminal coronary angioplasty (PTCA). All the patients had ECG ischemic signs and pain during the inflation of the balloon. No significant changes in plasma beta-endorphin levels were observed during PTCA-induced ischemia. Baseline coronary sinus plasma beta-endorphin levels were found to be elevated when compared with peripheral ones which would suggest an accumulation of beta-endorphin in the ischemic heart.

Both anti neutrophil cell antibodies and anti endothelial cell antibodies were found in 7 out of 30 newly-diagnosed type-1 diabetic patients. This confirms the abnormal activation of the immunological system in the early stage of type- 1 diabetes mellitus.

Calcitonin gene-related peptide (CGRP) is a 37 amino acid peptide displaying about 50% homology with amylin which is secreted from the pancreatic islets of Langerhans. The main form, the beta-CGRP, is produced by the enteric nervous system and perivascular nerves of the vasa-vasorum. It represents one of the most powerful vasodilator yet discovered but its role is not yet completely clarified. High levels of this peptide have been shown in patients affected with thyroid medullary carcinoma, phaemocromocytoma and lung carcinoma. Recently circulating levels of CGRP have been found in normal subjects. Endothelin-1 (ET-1), a potent vasoconstrictor peptide, isolated from porcine endothelial cells, is an important regulator of the vascular tone acting in physiological antagonism with atrial natriuretic hormone (ANH). With this study we intended to investigate the presence of any correlation between CGRP and ET-1 in normal subjects.For the study we considered 20 normal subjects (11 males and 9 females) aged 23 to 50.Plasma levels of CGRP and ET-1 were measured by radioimmunological Kit.A positive and significant correlation between calcitonin gene-related peptide and endothelin-1 was found.Our results confirms that CGRP and ET-1 have opposing actions on vessels and that they can act together in haemodinamic regulation.

Atrial natriuretic hormone (ANH) concentrations were measured in 16 patients affected with myotonic dystrophy (MyD) undergoing 24-hour Holter ECG and in 15 age-matched normal subjects. Although the MyD patients did not show overt left ventricular function impairment, their plasma ANH levels were found to be higher (183.76 ± 113.25 pg/ml) compared to those of the control subjects (39.73 ± 9.95 pg/ml, p < 0.001). Nine patients with arrhythmias and some echocardiographic alterations formed subgroup A. Seven patients without cardiac alterations formed subgroup B. No significant difference in ANH emerged between the two subgroups. This evidence suggests that high plasma ANH levels in MyD cannot always be related to overt or latent heart failure and to arrhythmias.

In 22 hyperthyroid patients, atrial natriuretic hormone (ANH) levels (71.91 +/- 21.03 pg/ml), measured during a 3-h-Holter, were found to be significantly higher (p0.001) than those in 20 age-matched normal subjects (37.22 +/- 8.73 pg/ml). We have demonstrated that the presence of tachiarrhythmias does not influence ANH release. The positive and significant correlation of FT3 with both ANH and heart rate confirms the hypothesis of a direct action of thyroid hormones on ANH release.

Endothelial cell injury in blood vessels of small arteries and capillaries is considered the primary event in the pathogenesis of systemic sclerosis (SSc). Because endothelin-1 (ET-1) is mainly released in the site of endothelial cell damage, thereby inducing a potent vasoconstriction, it was our intention to study ET-1 release in a group of SSc patients during a cold pressor test (CPT). Twelve SSc patients and a control group of 10 healthy subjects underwent CPT. Blood samples for ET-1 assay were collected at 90 and 180 seconds of exposure to cold stress. Heart rate and blood pressure were recorded at the same intervals. A capillaroscopic examination was performed in both groups before and after CPT. We observed significantly higher levels of plasma ET-1 in SSc patients compared with those of the control group at baseline (P=0.007) and at 90 (P=0.006) and 180 seconds (P=0.03) of CPT. During the test, the capillaroscopic examination showed a dramatic worsening of the vascular picture that was parallel to the increase in ET-1 plasma levels. This suggests that higher ET-1 plasma levels can have a part in the acute vascular reac tivity of SSc patients undergoing CPT.

According to cirrhotic patient's hyperkinetic circulatory state and to different pathophysiologic moments of kidney and liver failure, it is suggested that in cirrhosis a vasoactive balance is changed to more active vasodilatation. Also calcitonin gene-related peptide (CGRP) is likely involved in this change.

It is well known that the endothelial cells represent one of the most active and versatile elements in the human organism. In fact apart from being the lining of the vessel wall they exert both antithrombotic and prothrombotic functions. Endothelial cells regulate the vasomotor tone and also have a part in the different immunological and inflammatory process. All these functions are possible because the endothelial cells produce many receptors on their surface. This paper is a review of the latest data on different roles played and substances produced by endothelial cells.

The Heat Shock Proteins (HSP) are a special category of proteins synthesized from 2 types of cells, one originating from ordinary organs and the other highly specialized ones from mammals. Their synthesis originates from a reaction of the cells to heat shock and therefore it can be thought of as a defense mechanism activated by the cells to protect themselves from the damage done by heat. HSPs are also qualified as "molecular chaperons" since they are present at the assembling of other proteins and they protect them from any possible anomalous interactions even if they do not take an active part in the final making up of the protein itself. This chaperone role is the base of the hypothesis that HSPs could take part in the processing and presentation of the antigens. Two hypothesis have been formed on the role of HSPs in the immunological process. 1) HSP could be antigens that call for an immediate immunological reaction; 2) HSP could set off a self destructive mechanism brought on by an immunological reaction. From all this it emerges that the immunological reaction to HSP has two angles. One is protective in that it allows the cells to eliminate micro foreign-organisms and the other is harmful due to a badly regulated immunological reaction. In some studies it has been demonstrated that patients with varying autoimmunological disorders as LES and rheumatoid arthritis (AR), have autoantibodies against HSPs. Moreover the HSPs of certain microorganisms induce the formation of autoantibodies in the host and the proliferation of T cells in the synovial fluid in patients with AR.(ABSTRACT TRUNCATED AT 250 WORDS)

The Calcitonin Gene-Related Peptide (CGRP) is a 37 aminoacid peptide displaying about 50% homology with amylin which is secreted from the pancreatic islets of Langerhans. The main form, the beta-CGRP, is produced by the enteric nervous system and perivascular nerves of the vasa vasorum. It represents the most powerful vasodilator yet discovered but its role is not yet completely clarified. Recently it has been implicated in the control of regional blood flow and some authors have hypothesized its role in the development of Non Insulin Dependent Diabetes Mellitus (NIDDM). CGRP and amylin seem to inhibit the release of insulin from beta-cells and to play a role in local paracrine control of insulin secretion. In addition it is also shown to decrease the uptake of glucose by striated muscle. This has led to the suggestion that CGRP might be a circulating hormone implicated in the regulation of peripheral insulin sensitivity. In this review we examine the possible role of CGRP in the development of peripheral insulin resistance and altered insulin secretion which is characteristic of NIDDM.

Pathogenesis of ascites in patients affected by liver cirrhosis is still debated; humoral and haemodynamic factors can play a role. Plasmatic renin activity (PRA), plasmatic aldosterone (PA), atrial natriuretic peptide (ANP) plasma levels, blood Na, K, urea, urinary K and Na were evaluated in 14 patients affected by liver cirrhosis (11 males and 3 females, aged from 38 to 62 years), 8 of them with ascites. The results were compared with those obtained in a control group poised to age and sex to the experimental group. 4 out of 14 patients suffering from ascites unresponsive to medical treatment were submitted to peritoneal venous jugular shunt (PVGS) and blood samples for PRA, PA and ANP were withdrawn immediately before, 4, 8 hours following surgery. The patients affected by liver cirrhosis without ascites showed PRA and PA levels similar to those observed in the control group, while ANP plasma levels were significantly higher (50.6 + 9.6 vs. 39.7 + 9.5 Pg/ml) (p0.02). In patients with ascites ANP, PA and PRA levels were higher than those observed in non ascites patients (ANP = 147.8 + 97.3 vs. 50.6 + 9.6 pg/ml; PA = 20.6 + 2.7 vs 7.8 + 0.8 ng/dl; PRA = 4.48 + 0.5 vs 1.9 + 0.34 ng/ml/h). In patients submitted to PVGS, PA and PRA levels were reduced 4 and 8 hours following the surgery, while ANP levels showed significant increase. A natriuretic and diuretic response has been observed even in the absence of ANP plasma levels variations.(ABSTRACT TRUNCATED AT 250 WORDS)

The syndrome X is a clinical disease characterised by anginous pain with the absence of significant and angiographically visible stenosis of the coronary tree. D. P. M., a 61-year-old woman suffering from biliary lithiasis, underwent cholecystectomy. During the immediate postoperative period, the patient showed difficulty in regaining consciousness and there were electrocardiographic signs of extensive anterior ischemia; prior to the operation only a 1st degree atrio-ventricular block and a positive history of occasional precordial pain had been reported. On the 2nd postoperative day the patient complained of violent retrosternal pain irradiated to the left shoulder. Given that the signs of ischemia had regressed, various instrumental tests were performed: echocardiogram, cycloergometric test, dipyridamole test, cold pressure test, Holter's dynamic ECG, all of which were within the normal; moreover, selective coronarography did not reveal significant stenosis of the coronary tree. The patient was therefore diagnosed as suffering from syndrome X. In the light of the present case, the authors conclusion may be summarised as follows: the diagnosis of syndrome X, which is by definition not easy, may sometimes become critical, as in the present case, since rapid intervention would have enabled prophylactic therapy to be performed to combat surgical stress.

Met-enkephalin (Met-enk) has been demonstrated to modulate myocardial-ischemia mechanisms via the opioid receptors, but no studies are now available on Met-enk levels in the coronary circulation. In this experience Met-enk levels were evaluated in aortic root and in coronary sinus at baseline (T0), during PTCA induced transient ischemia (T1) and during reperfusion (T2). No significant differences were found at any time. Thus, it appears that there is no Met-enk extraction from the coronary circulation during provoked myocardial ischemia and no Met-enk release from the ischemic heart.

The decrease in active hormones that characterizes chronic adrenal insufficiency results in hypovolemia. In some patients, residual adrenal function, mineralocorticoid therapy, and concomitant heart or liver failure, or both, can paradoxically provoke edema. The case report that follows describes a patient with iatrogenically induced anasarca resulting from the unhappy confluence of usually appropriate therapy and coexisting medical conditions.

After examining the most recent findings on the physiopathology of the renin-angiotensin system, techniques are analysed for the determination of renin activity (PRA). These are still inadequate and imprecise, notwithstanding radioimmunological techniques and stress is laid on the importance of their standardisation. Analysis of the various forms of arterial hypertension shows that PRA measurement has clinical value only: 1) in nephrovascular hypertension; 2) in primary hyper-reninism; 3) in primary hypercorticosuprarenalism; 4) to back up an indication for bilateral nephrectomy in terminal nephropathies with uncontrollable pressure value. At the present time, however, it would appear that PRA does not have any clinical utility for the study of essential hypertension.

The first therapeutic response to cirrhotic ascites should be a salt-free diet and bed rest. Only if this fails should anti-aldosterones, furosemide or mannitol be adopted. After an examination of the reasons for using any of these drugs, either alone or in association, it is emphasised that thiazide should never be used to treat cirrhotic ascites. Its use has been common practice for years on the basis of apparently convincing empirical evidence. Finally it is pointed out that any treatment should be approached with caution with more emphasis on the patient than on the ascites itself.

The authors treated acute flare-ups of chronic bronchitis with a combination of sulfadiazine (SDZ) and trimethoprim (TMP) (cotrimazine). They treated thirty patients for a week, with daily dosages of 900 mg SDZ and 300 mg TMP, in an open trial in comparison with ampicillin 2 g daily. The result of treatment (course and duration of the acute episode, fever, cough, dyspnoea, sputum amount and description, chest sounds, ESR, and WBC count), tested by suitable statistical methods, showed that cotrimazine had excellent therapeutic activity and was readily tolerated; over-all results compared closely with those obtained with ampicillin. In their concluding remarks the authors state that in addition to being effective in the morbid condition selected for trial, cotrimazine offers some advantages over similar combinations of TMP and other sulfonamides, both because of the intrinsic physicochemical and pharmacological properties of SDZ and because of its lower dosage in this combination.

A study on bioelectromagnetic effects induced by the use of TACS phones, evidencing a variation of the natural response of the auditory system is presented. This study was performed applying a method based on the registration of the evoked otoacoustic emissions (transient and distortion products). The experimental results show that modulated electromagnetic fields modify the distortion products in about all the examined subjects.