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Background: Sepsis and septic shock(SS) are often managed ininternal medicine departments. A validated tool for prognosis isSOFA score. Troponin(TnI) I has been proposed as a marker ofworse prognosis for SS in some studies: we aimed to evaluate ifTnI could predict in-hospital death independently of SOFA score.Patients and Methods: in the period 2015-2017 we enrolled allthe consecutive patients admitted for SS in two Internal Medicinedepartments with expertise in critical care medicine. For each pa-tient we evaluated, at the admission: (1) SOFA score (2) TnI level(3) sex, age, PCR and procalcitonin(PCT) (4) length of in-hospitalstay. The main outcome was defined as in-hospital death for SS.We chose the best cutoff value for TnI and in-hospital death withROC curve analysis, adopting Youden index. Then we prepared aCox proportional Hazard model adopting (a) length of stay (b) inhospital death, as predictors (c) SOFA score (d) TnI and sex, agePCT and PCT as covariates.Results: 390 subjects (age:79,6±11,4;males:49,2%) with 144(36,9%) deaths. The optimal cutoff value for TnI was >0.315ng/ml.Cox proportional hazards model showed (1) one-unit increase ofSOFA score was associated to an increased risk of in-hospital death(HR:1.208;95%CI:1.134-1.287), (2) TnI predicted in-hospital deathindependently of SOFA score (HR:1.925;95%CI:1.278-2.902), evencorrecting for age, sex, PCR and PCT.Discussion: TnI can predict in-hospital death among patients af-fected by SS independently of SOFA score, age, sex, PCR and PCT.

Background: Polypharmacy and multimorbidity affect the prog-nosis in several acute pathologies. We aimed to evaluate ifpolypharmacy at the admission could affect AHF prognosis in acohort of elderly patients.Materials and Methods:We enrolled AHF patients, investigatingage, sex, in-hospital mortality, polypharmacy (defined as the con-temporary use of 5 or more medications) and presence of comor-bidities. We then prepared a logistic regression containing age, sexand all the comorbidities as predictors and in-hospital mortalityas outcome. We then added polypharmacy in a second model. Weobtained two ROC curves predicting in-hospital mortality for AHFand compared them.Results:Mean age was 82.56 (±8,92), females representing53.7% of the sample. In-hospital mortality was 13%. The firstmodel, containing 16 comorbidities, age and sex as predictors,showed excellent predictive value (AUC: 0.931; 95% CI: 0.864-0.971; p

ST, donna, aa 67, in passato buone condizioni; sindrome ansioso-depressiva in tp con triciclico, dislipidemia, familiarità per cardio-patia ischemica. Maggio ‘14: giunge al PS di Osimo per dispneaingravescente da 1 settimana, cardiopalmo, ortopnea. BNP: 818.Versamento pleurico bilaterale.Diagnosi:Scompenso cardiaco”de novo”. Ricovero in Medicina In-terna-Osimo. ECG: IVSx,FC:162 bpm, QRS:130 msec. Eco: FE 22%,Vsx dilatato; E/A>2, insuff. mitralica severa su base funzionale. Co-ronaro: non lesioni stenosanti. Iniziata terapia+ivabradina 7,5 mgx2.Dimissione 11a giornata stabile. E/A < 1, regressione severità insuffmitr, scomparsa versamento pleurico all’eco-torace. Triciclico so-speso (possibile causa precipitante). Controllo 24° g:FE 34%. Fineagosto: switch ramiprilvalsartan per tosse stizzosa, poi scomparsa.BNP:196. Ottobre: FE>55%. Luglio ‘15: marcata astenia. Hb:9,7(13 al ricovero); creat:1,27 (prima: 0,67) VFG:33 ml/min. SOF.Ipotesi diagnostica: Anemia secondaria a progressivo deteriora-mento della funzione renale, esitata in IRC, a possibile eziologia ia-trogenasospesi furosemide/spironolattone,ridotto Tareg a 80 mgx2.Feb ‘16: buone condizioni (no astenia), creat:1,1; Hb:12 (instaurataterapia marziale). FE:63%. Ridotto pantoprazolo a 20 mg/die allaluce delle ultime evidenze (associazione con IRC). Mantenuti Biso-prolo 2,5 mg e Ivabradina 7,5x2. Rivalutata questa settimana,buonecondizioni, mantenuto Valsartan 40 ½ 1 cp. Caso esemplificativodi gestione dello scompenso cardiaco in ambiente internistico,c hedimostra la necessità di follow-up ambulatoriale seriato, con parti-colare attenzione alle comorbilità del paziente.

Background: High serum uric acid(SUA) levels are associated tocardiovascular diseases and death. We evaluated the role of SUA insepsis.Methods:in 2015 we enrolled all septic patients admitted to our de-partment. Age, sex, hypertension, diabetes,cancer, CHF, COPD, smoking,blood gas analysis, SUA, days of hospitalization, death or UTI transferand SOFA were collected. Relationships were explored with bivariatecorrelation. Continuous variables were compared with t-test, dichoto-mous with chi-squared test. Univariate model was used to control for covariates. Analysis was performed with SPSS 13.0 for Windows.Results: 71 patients (M: 49,3%), mean age 76,8 (±15,4) years wereenrolled. Hypertension affected 72,9%, diabetes 28,2%, cancer 25,4%,CHF 43,7%, COPD 12,7% of subjects. Mean SUA was 6,49 (±0,41)mg/dL, mean SOFA 4,34 (±0,24), admission lasted 11,65 (±0,68)days. Death or UTI transfer happened in 32,4%. SUA was associatedto SOFA (p

Uomo, 57 anni, giungeva al PS di Osimo il 2/4/2013 per dispnea in-gravescente, FA ad risposta ventricolare >48h. Anamnesi: dispnea da1 mese in terapia con antibiotici(bronchite?) senza beneficio, febbreda alcuni giorni. Si documentava MO F(disfunz. renale, cardiaca, respi-ratoria, coagulativa), indici di flogosi; disfunz. Vsx severa (FE: 20%) etrombo apicale (diametro 3 cm), addensamenti polmonari multipli all’rxtorace Nel sospetto di una sepsi severa+MOF e grave compromissionemiocardica con trombosi apicale del vsx (miocardite subacuta? SCAN-STEMI?), veniva stabilizzato e trasferito presso il Lancisi di Ancona (cen-tro Hub). 24 ore dopo sviluppava ictus cardioembolico concompromissione della fonesi+VII nervo cranico sx. Alla TC toraco-ad-dome:polmonite lobo medio dx+trombosi massiva auricola sx. Coro-narografia: non stenosi significative. Trasferito il 17/5 per riabilitazionecardiologica. Maggio 2015: ricovero presso la nostra UO per scom-penso cardiaco. Tentata in passato terapia con rivaroxaban e warfarin,interrotta per epatotossicità (↑bilirubina+AST/ALT). Manteneva EBPM.Stabilizzato con terapia diuretica e dimesso in buone condizioni, conpresa in carico in ambulatorio di follow-up scompenso. Oltre a titola-zione di ACEI+betabloccante, si introduceva Dabigatran (razionale:clearance renale 80%): non effetti avversi nel tempo. Gen 2016. Tera-pia on-top, FE Vsx: 25%, con FA permanente. Posto in lista per posi-zionamento ICD (QRS

Background:Both chronic kidney disease(CKD) and serum uric acid levels(SUA) were associated to an increased risk of acute ischemic stroke(AIS). This higher risk is mediated by several mechanisms including platelet dysfunction, coagulation disorders, endothelial dysfunction, inflammation, and increased risk of atrial fibrillation(AF).Materials and Methods: We enrolled 294 consecutive patientsadmitted for AIS and collected age, sex, lenght of admission, in-hospital mortality and comorbidities (hypertension, diabetes, chroniccardiopathy, AF, dyslipidemia, active cancer, COPD, CKD anddementia). Survival was performed with Kaplan-Meier and Coxregression (forward stepwise method) analysis with SPSS 13.0.Results: Mean age was 82,37 (±9,19) years. Mean length of stay inIM was 9,87 (±7,14) days. In-hospital mortality was 7,1%.Patientswith SUA >7,0mg/dl had an increased risk of in-hospital mortality atKaplan-Meier’s regression (p

Background: Acute ischemic stroke(AIS) is common among elderlypatients,affecting 6,5% of the population aged 64-85 years,representing the third cause of death among old subjects.Materials and Methods: 294 consecutive patients admitted to ourInternal Medicine Unit (IM) for AIS were enrolled. Age, sex, lenght ofadmission, in-hospital mortality and comorbidities (hypertension,diabetes, chronic cardiopathy,atrial fibrillation(AF), dyslipidemia, activecancer, COPD, chronic kidney disease (CKD) and dementia) werecollected. Trend of days of hospitalization in relation with the numberof comorbidities was evaluated with ANOVA. Statistical analysis wasperformed with SPSS 13.0.Results: Mean age was 82,37(±9,19) years. Mean length of stay inIM was 9,8 7(±7,14) days.In-hospital mortality was 7,1%.Hypertension was present in 54%, diabetes in 18%, dyslipidemia in11,9%, chronic cardiopathy in 36,4%, AF in 18,4%, cancer in 4,1%,COPD in 10,5%, CKD in 21,7% and cognitive deterioration in 13,3%of the sample. 93,4% of the patients had at least one comorbidity,with a median of two concomitant pathologies at the admission in IM.We observed a linear trend in the days of admission proportional tothe increasing number of comorbidities(from 7,35±3,97 days, nocomorbidities to 16,00±12,52 days, ≥4 comorbidities; p

Uomo, 53 aa, fumatore, familiarità per IMA fatale precoce, giunto inPS(02/2014) per cardiopalmo da 1 settimana: riscontro di FA non da-tabile (FC: 150 bpm). All’ingresso in reparto, asintomatico, buone con-dizioni generali, FA persistente. BNP: 420 pg/ml. TSH normale. Colesttot: 254 mg/dl. Ecocardio. FE: 20%, ipocinesia biventricolare, IT e IMsevere; atrio sx moderatamente dilatato. Eco-vea: ateromasia non ste-nosante alla biforcazione della ACI. Ecocardio alla dimissione (7°giorno): sovrapponibile. Dimesso con warfarin (CHA2DS2-VASc:3),amiodarone, e tentativo di CVE dopo 4 settimane, terapia farmacologiaper scompenso cardiaco come da protocollo. Al 33° giorno, ripristinospontaneo del RS. 40° giorno: FE 50%. Normalizzazione funzione dia-stolica Vsx, contrattilità Vdx e volume Asx. Per INR labile, attuato switcha Dabigatran. Per alto rischio di coronaropatia sottostante, eseguito ECGda sforzo, in wash-out da b-bloccante per 72 ore: 24 ore prima, recidivadi FA ad elevata FC. Eseguita CV farmacologica in PS. Al 3° mese di te-rapia, in considerazione dei fattori di rischio, della recidiva di FA e delladisfunzione sistolica del vsx, eseguiva miocardioscintigrafia da sforzo inwash-out da b-bloccante 48 ore prima: deficit di perfusione al settoposteriore+parete posteriore, dilatazione moderata del Vsx e TV soste-nuta dopo sforzo, a risoluzione spontanea. Nuovo ricovero presso la no-stra U.O. per esecuzione di coronarografia: coronarie indenni. Ecocardiodi controllo: FE: 63%. Tuttora condizioni ottimali. Caso esemplificativodi tachicardiomiopatia, forma reversibile di disfunzione del Vsx tachi-cardia-indotta ampiamente sottodiagnosticata.

Background: Sepsis and septic shock(SS) are frequently managedin internal medicine departments(IMD). SOFA score is used to predictprognosis. Troponin I (TnI) has been associated to worse outcomes inseveral infections.Materials and Methods: All subjects admitted to our IMD for SS wereenrolled. Age, sex, lenght of admission, in-hospital mortality,SOFAscore, Troponin I(TnI), procalcitonin(PCT), C-reactive protein(CRP) andcomorbidities(diabetes, cardiovascula r(CV) pathologies,activecancer,chronic kidney disease(CKD), peripheral artery disease (PAD)and chronic obstructive lung disease (COPD)) were collected.SOFA-Twas obtained adding 1 point to SOFA if TnI was>0,05ng/ml. Coxregression analysis was performed using in-hospital mortality as mainoutcome and clinical characteristics as covariates. SOFA and SOFA-Twere used as predictors. Statistic was performed with SPSS.Results: 123 consecutive patients were enrolled, with mean age77,92 (±11,57) years, mean admission 15,23 (±9,62) days, meanTnI 1,64 (±0,483) ng/ml, mean PCT 11,65(±11,57)pg/ml and meanCRP 14,34 (±9,96) mg/dl. In-hospital mortality was 28,7%. Diabeteswas present in 38,0%, CV pathologies in 74,0%, active cancer in37,4%, COPD in 35,8%, CKD in 54,5% and PAD in 11,4% of thesample.Cox regression showed a significantly increased mortality rate(1,215; 95% CI: 1,077-1,371; p=0,002) for SOFA, which was higher(1,333; 95%CI: 1,121-1,585; p=0,001) for SOFA-T.Conclusions:The difference between the two mortality rates showedthat SOFA-T detected an increased 11,4% in the risk of death for SSevery 1-point increase in the score, if compared to SOFA score.

Background:Concentration of serum uric acid(SUA)has been asso-ciated with several cardiovascular diseases. Recent evidences showthat SUA concentration increases after acute ischemic stroke(AS).Aims: evaluate relationships among SUA, renal function, survival anddays of hospitalization in patients admitted to Internal Medicine De-partments(IMD).Methods:We retrospectively enrolled 651elderly patients affected byAS, in the acute phase. History, cardiovascular risk factors, serum levelsof creatinine and SUA, days of hospitalization and mortality were col-lected for each patient. Risk was evaluated with binary logistic regres-sion, while survival was analyzed with Kaplan-Meier and Cox’sRegression models. Multivariate models accounted for vascular riskfactors, NIHSS at arrival, renal function, age and sex as covariates.Results:Mean days of admission for AS in our IMD was8.20±5.09days. A one-unit increase in SUA levels increased the riskof in-hospital death of 1.43times(95% CI:1.20-1.70; p4.5mg/dlwere associated to longer in-hospital stay and higher mortality at Ka-plan-Meier model (SUA levels≤ 4.5mg/dl:23.1days,95%CI:22.33-23.89;SUA levels>4.5mg/dl:52.9 days,95%CI:39.3-66.4;p

Introduction: Serum calcium concentration has a pivotal role in car-diac function. In literature there aren’t major studies that investigateassociation of serum calcium levels and clinical outcomes in acuteheart failure.Methods:216consecutive patients admitted in our Internal MedicineDepartment were retrospectively enrolled. In-hospital mortality wascollected as binary variables. BNP and days of hospitalization weretreated as continuous data. Serum calcium levels were synthesizedas an ordinal variable ranging from 2 SDfrom the mean.Results:Mean age was 80years (±12,55years), with M:F ratio of 1:1(males 52.7%). BNP levels had a mean of 1149,36ng/ml(±1193,44ng/ml). 13,4% of sample died during the admission. Meandays of hospitalization was of 12,65days (±8,28days). In the binary logistic model, corrected for all the above-mentioned covariates, cal-cium behaved as an independent risk factor. In the complete model,in-hospital mortality risk increased with the increase of serum calciumlevels In particular, every one-class increase in the ordinal variablerepresenting serum calcium levels was associated to a significant riskincrease of in-hospital mortality (OR:0,272; 95%CI:0,107-0,690;p

Introduction:SOFA score predicts prognosis and in-hospital mortalityin septic patients, with a known AUC of 0.90. Troponin I (TnI) is amarker of myocardial injury and can be related to MOF and septic car-diomyopathy. We evaluated if adding TnI to SOFA score resulted in abetter prognostic performance in sepsis.Methods:49 septic patients were enrolled and prospectively followed-up. Outcome was in-hospital mortality, coded as binary. All the chroniccomorbidities and TnI were synthesized in different binary variables.SOFA score was coded as an ordinal variable: PaO2, FiO2, plateletcount, GCS, bilirubin, blood pressure and serum creatinine were thesingle items of the scale. SOFA-T was calculated adding 1 point to SSif TnI level was >0.05ng/ml. ROC curve analysis was performed withSPSS 13.0 for Windows.Results:Mean age was 75,83years(±13,14 years), males were54,8%. 35,7% of the patients died during the hospitalization. Of thesample, 45,4% were affected by diabetes, 73,7% by chronic cardio-vascular disease, 36,8% by cancer, 21,1% by hepatic disease, 52,6%by CKD, 36,8% by COPD, 26,3% by chronic neurologic disorders,15,8% by chronic haematologic pathologies, 31,6% by chronic gas-troenterologic disorders. SOFA had an AUC of 0.904(95%CI:0.718-1.089) in predicting in-hospital mortality. SOFA-T had an AUC of0.923(95%CI:0.768-1.078) for the same outcome. The difference be-tween the two ROC curves was statistically significant(p

Donna, 85 aa, anemizzazione acuta (Hb:5,9g/dl), deterioramento co-gnitivo, incremento della troponina (picco: 13 ng/ml), con parametrivitali normali. In PS trasfuse emazie 2 UI. Al mattino seguente rilievodi anuria dall’ingresso, comparsa di insufficienza respiratoria con ritmobigemino, ipotensione, bradicardia, leucocitosi neutrofila, Hb 7 g/dl,iperK+, creatinina 4,95 mg/dl Monitorizzata h24. Si pone diagnosi disepsi severa con disfunzione multiorgano (renale, cardiaca, polmo-nare, epatica), si inizia fluid resuscitation secondo protocollo di Rivers,terapia antibiotica a largo spettro, dobutamina (ipotensione persi-stente), O2 alto flusso. A seguire, si esegue in reparto: ecocardio-gramma: segno del kissing ventricle, non ipocinesie segmentarieventricolari con PCWP normali; eco vena cava: dilatata; ecotorace:sindrome alveolare alla base dx (confermata all’RX torace il giornoseguente); ecorenale: non segni di idronefrosi. Per il mancato ripristinodella diuresi nonostante terapia diuretica ad alte dosi,trasferita in Ne-frologia-Jesi per emodialisi d’urgenza, riaccolta 4 ore dopo. In 3ae 4agiornata ripete emodialisi con trasfusione (Hb:7,7). Dalla 5agiornataprogressivo miglioramento della cenestesi con progressiva normaliz-zazione dei parametri PCT 1,12>0. In 13agiornata, rilievo di prolun-gamento del QTc (500 msec): sospesa Levofloxacina Alla dimissione:buone condizioni generali, deambulante, creat: 1,89 mg/dl, troponinanegativa. A nostro avviso caso esemplificativo d’integrazione tra diversemetodiche ecografiche e gestione evidence-based di una sindromeclinica complessa ad elevata mortalità (sepsi severa/shock settico).

Introduction:Serum calcium concentration has a pivotal role in car-diac function. Calcium homeostasys may precipitate AHF. It’s likely tohypothesize a correlation between these two items. We tried to inves-tigate biological relationship (like BNP and serum calcium levels) ofthis pathophysiological relationship. In literature there aren’t majorstudies that investigate association of serum calcium levels and BNP.Materials and Methods:216 consecutive patients admitted in ourdepartment were retrospectively enrolled. In-hospital mortality, hyper-tension, diabetes, atrial fibrillation, chronic heart failure, acute coro-nary syndrome, COPD, sepsis, chronic kidney disease and cancer werecollected as binary variables. Serum calcium levels, BNP and days ofhospitalization were treated as continuous data. The relationship be-tween serum calcium levels and BNP at the admission was analyzedwith multiple regression model, choosing the best-fitting trend line.Results:Mean age was 80 years (±12,55 years), with M:F ratio of 1:1(males: 52.7%). BNP levels had a mean of 1149,36 ng/ml (±1193,44ng/ml). Serum calcium levels had a mean of 8,69 mg/dl (±0,58mg/dl). The best-fitting trendline between the two markers turned outto be an exponential relationship (R2=0,975; p

Background: behavioural and psychological symptoms of dementia (BPSD) are typical characteristics of cognitive impairment, present in every phases of illness. They represent a very relevant aspect of patients’ management and produce a significant stress for caregivers. In Alzheimer disease (AD), the most common form of dementia, BPSD are frequent. There are several studies about different characteristics of BPSD, but unexpectedly we do not have data about gender differences. Aim of this study was to evaluate possible differences of typology and frequency of BPSD between genders. Methods: we enrolled 200 consecutive patients (M/F: 100/100) referring to our Neurologic Clinic for suspected cognitive impairment and whom we performed a first diagnosis of AD according to NINCDS-ADRDA criteria. Each patient’s caregiver was submitted to a Neuropsychiatric Inventory scale (NPI) to assess the presence of BPSD in the AD affected subject. Chi-squared test was used first to evaluate differences in frequency distribution of each BPSD. We applied a multivariate balanced model analyzing all NPIs variables. Statistical analysis was performed with SPSS13.0 for Windows systems. Results: in this sample, 185 (92,5%) subjects showed BPSD at disease onset. The most prevalent symptom in the whole sample was apathy (40%), followed by depression (26,3%), irritability (20,6%) and anxiety (17,5%). When we divided our sample between the two genders, we observed that aggressiveness and irritability were significantly more present among men (p=0.042;p=0.040), while depression was more relevant in women (p=0.036). Conclusions: BPSD are a very problematic aspect in the management of AD patients. Every item is useful for a better comprehension of this problem: for example, a more specific BPSD differentiation between genders could help the neurologists to manage specific situations and to reduce caregivers’ stress.

Background and Aims:Acute coronary syndromes(ACS),in particularNSTEMI,are frequent among elderly patients admitted to internal andemergency medicine. Increased intima-media-thickness(IMT)andcarotid stenosis have been associated to a more severe coronary ar-tery disease in stable patients.Less is known of their value in ACS.Onthe contrary, Troponin I(TnI) levels have been related to infarct size andprognosis in this subset of patients. Methods:We enrolled 192 consecutive patients admitted to our de-partment with a definite diagnosis of NSTEMI. Each patient was in-vestigated evaluating sex, age, risk factors, chronic renal failure,presence of atrial fibrillation and troponin levels. Carotid ultrasoundwas performed within 24 hours from the admission, evaluating IMT orcarotid plaques. We performed a multivariate analysis to assess if IMTor carotid plaque could be associated to increased TnI levels at theadmission, correcting for risk factors, chronic renal failure, age, sexand creatinin clearance. Results:Increased IMT and the presence of a carotid plaque of anyseverity were independently related to increased TnI levels at admis-sion. The presence of a pathological IMT or a carotid plaque were as-sociated to a mean increase of TnI of 9.31 ng/ml (p

Background: The intensive proliferation of guidelines and stratification scores for thromboembolic and hemorrhagic risk, such as CHA2DS2-VASC and HAS-BLED, focuses its interest on the proper management of oral anticoagulant therapy (OAT). In clinical practice, narrow therapeutic index of warfarin can be achieved through three cornerstones: (1) reliable laboratory (2) good medical expertise in OAT (3) Patients Compliance. In our Internal Medicine Department (IMD) atrial fibrillation (AF) is among the top 5 DRG by frequency. Driven by this reality, we prepared specific evidence-based protocols and pathways for AF management. Optimal OAT for 4 weeks is required before attempting sinus rhythm restoration, in order to reduce cardioembolic risk related to cardioversion (CV). Current guidelines confirm inverse relationship between time taken to proceed with CV and success of SR restoration. Many procedures still delay because at time of CV, patients (pts) were not in range. We can improve outcomes aiming at stable INR in the 5 weeks before the CV. A strict follow-up of these pts may reduce variations which lead to significant delays in CV. Our department routinely follows pts requiring OAT in preparation for CV. Aims: evaluate the effect of Patient Care Management by our IMD, from diagnosis to CV, especially on the stability of INR values in the 5 weeks preliminary to Electric Countershock (ECV), as indicator of a better outcome, in pts followed by our unit for AF. Methods: We followed 121 pts affected by persistent AF, who underwent ECV. 52 were excluded for AF recurrence, the other 60 were referred to our surveillance center for OAT before ECV. All pts were treated with the same pharmacologic protocol, including 4 weeks of therapy with oral anticoagulants, class III antiarrhythmic, angiotensin receptor blocker (irbesartan) and statin. After 4 weeks, pts underwent to ECV with standard protocol (first shock: 150 J, second shock: 200 J, third shock: 200 J). INR variations in this population of pts were evaluated. Multivariate GLM for repeated measures and Cronbach’s reliability analysis were performed with SPSS 13.0 for Windows systems. Results: The mean value of PT/INR in the 5 reading performed before ECV remained between 2.5 and 3.0 with a 95 %CI between 2.4 and 3.0 in each of the 5 measurements. The multivariate evaluation of intra-subject variation was not significant in the 5 measurements (p[0.05). This observation remained statistically non-significant also in direct comparison of the mean of single measurements, demonstrating a substantial homogeneity of the mean values of PT/INR. The internal reliability of the data was assessed using Cronbach’s test (alpha: 0.72), which confirmed the high intrasurvey validity of the INR in pts followed in our center (Figure 1). Conclusions: OAT management resulted highly reliable in our center: PT/INR controls remained substantially stable in the controls prior to ECV. We observed no major thrombotic nor hemorrhagic adverse events nor major complications in the selected sample. Most of pts are in range the day of ECV after 4 weeks of anticoagulation.With an efficient laboratory and a reliable center, as an IMD, it is possible to keep the dose of warfarin within the therapeutic range, optimizing resources. Undertaking this office, our IMD increases success chances of the procedure. However, the dark horse of pts, who must be reliable. It seems reasonable to argue that attending a reference center, compliance to OAT could be increase.

Background: Acute Heart Failure (AHF) is a frequent condition associated to poor prognosis among elderly patients admitted to Internal Medicine departments (IMDs). Length of hospitalization is associated to higher mortality among medical patients. Increased brain natriuretic peptide (BNP) levels have been associated, in this subset, to a raised mortality and morbidity. Aims: to evaluate whether BNP levels at admission could be associated to longer hospitalizations and survival time in the subset of patients who die of AHF. Methods: we enrolled 400 consecutive patients admitted to our IMD with a clinical diagnosis ofAHF.BNPwas evaluated in all patients at the admission. Subjects were stratified in four categories: BNP less than 100 pg/ml (group 1), 101–500 pg/ml (group 2), 501–1500 pg/ml (group 3) and BNP higher than 1501 pg/ml (group 4). Each patient underwent to a complete diagnosticworkup. PatientswithBNP levels less than 100 pg/ ml or a final diagnosis other than AHF were excluded. Kaplan–Meier model with log-rank test was used to assess the differences. Statistical analysis was performed with SPSS 13 package for Windows systems. Results: 293 patients were suitable for final analysis. Mean age was 80 ± 9.85 years, males representing 58 % of the sample. Among patients who were successfully dismissed, group 4 had a significantly longer hospitalization time (16.6 days, 95 %CI: 13.7–19.5) than patients in group 3 (13.1 days, 95 %CI:11.7–14.6) or group 2 (12.3 days, 95 % CI: 10.6–13.9) (p\0.05, all ties, Figure 1).Among patientswho died of AHF, subjects in group 2 had a significantly longer survival time (mean: 46.0 days, SE 3.71) than patients in group 3 (mean: 36.7 days, SE 2.51) or group 4 (mean: 22.9 days, SE 1.88) (p\0.05, all ties, Figure 2). Conclusions: BNP is useful for diagnosis and prognostic stratification in patients with AHF. If confirmed in larger cohorts, it could also be used to predict longer hospitalizations among specific subsets of patients. Among elderly patients admitted into IMD who will die of AHF, higher BNP levels are independently associated to a faster progression of the pathology and death. BNP levels at the admission of patients should be considered as a powerful tool that can help the physicians not only in diagnosis but also in the prognostic stratification

Background: Electric cardioversion (ECV) is a common procedure to restore a sinus rhythm (SR) from an abnormal cardiac pulse. It is widely used as elective procedure to treat atrial fibrillation (AF) or flutter without signs of haemodynamic impairment, while its use in emergency is indicated in all the ventricular or supraventricular tachyarrhythmias with signs of severe haemodynamic impairment or cardiogenic shock. In our Internal Medicine Department (IMD), AF represents the fifth DRG in order of frequency. For this reason, we currently follow patients affected by AF waiting for an ECV with well-defined, evidence-based protocols. However, despite optimal medical therapy, we still frequently observe a failure to maintain SR in a high percentage of patients. For this reason, we retrospectively analyzed 121 patients admitted to our IMD for elective ECV, analyzing SR stability at 30 days after DC shock as our main outcome. Aims: To evaluate retrospectively an association between the number of shocks and the SR stability at 30 days after a successful ECV procedure. To our knowledge, there are no studies that enlightened the relationship between the number of DC shocks required to restore SR at the first electric cardioversion and SR maintenance at 30 days. Methods: We enrolled 121 consecutive patients admitted in our ED in the year 2010–2011 for an AF episode. We excluded 9 patients who underwent to ECV (all with SR restoration) within 48 h from the event. We excluded 52 patients who underwent to ECV for an AF relapse. 60 patients were suitable for analysis and were treated with the same pharmacologic protocol including 4 weeks of therapy with oral anticoagulants, a class III antiarrhythmic, an angiotensin-receptor blocker (irbesartan) and statins. After 4 weeks, patients underwent to ECV with standard protocol (first shock: 150J, second shock: 200J, third shock: 200J). We evaluated age, sex and comorbidities (cardiopathy, hypertension, diabetes mellitus, cerebrovascular or vascular pathology), drug therapy, the number of shocks required to restore SR and SR maintenance at 30 days. Statistical analysis, accounting for sex, age, therapies and comorbidities, was performed with a multinomial logistic regression model with SPSS 13.0 for Windows systems. Results: SR remained stable at 30 days in 48 patients; 12 patients had an AF relapse at 30 days. Adjusting for age, sex and comorbidities, we found that the number of shocks given during the ECV procedure was independently correlated with maintenance of SR at 30 days: subjects achieving SR restoration after the first shock had an OR of 14.083 (95 %IC: 3.708–53.496, p\0.05) of SR maintenance at 30 days in respect to patients who achieved SR after 2 or more shocks (Figure 1). Discussion: AF is the most common malignant arrhythmia observed in an IMD. Its mortality and morbidity is mainly related to internistic pathologies, such as cardioembolic stroke. In a recent work, our group observed how internistic comorbidities (hypertension, diabetes mellitus, chronic heart failure and stroke, coronaric and peripheral atherosclerotic pathology), age and sex, synthesized in the CHA2DS2- VASc variable, can predict the success of ECV at 24 h, probably indicating an electrical and mechanical remodeling of the atrium. This current work adds another piece to the puzzle of clinical prediction of ECV success in AF, enlightening the concept that refractoriness to DC shock could represent itself a marker of atrial electrical/ mechanical remodeling and warn the clinician on the high likelihood of short-term treatment failure in this subset of patients. Larger cohorts and multi-centric studies are required to validate this observation.

Background: Preliminary studies have reported cognitive dysfunction in unilateral asymptomatic carotid stenosis (ACS). Impaired cerebral hemodynamic status measured by cerebrovascular reactivity has been associated with cognitive dysfunction in unilateral ACS. Aims: (1) To evaluate cognitive performance in bilateral ACS compared to unilateral ACS and healthy subjects and (2) to explore the relationship between cognitive performance and cerebral hemodynamic status in bilateral ACS. Methods: Asymptomatic patients with ultrasound evidence of bilateral or unilateral ACS (60 %-99 % diameter reduction) were prospectively collected. Healthy subjects (HS) comparable for demographics and vascular risk profile served as controls. A neuropsychological investigation included phonemic and categorical Verbal Fluency (VF) tests to explore the left hemisphere and Colored Progressive Matrices (CPM), and Complex Figure Test Copy (CFTC) tests to explore the right hemisphere. Cerebrovascular reactivity (CVR) to hypercapnia using the transcranial Doppler (TCD) based breath-holding index (BHI) test was performed in each subject. Impaired CVR was defined as a BHI\0.69. Generalized linear multivariate and univariate models were employed to evaluate the mean difference on left and right cognitive test abilities in bilateral ACS patients with left and right preserved or impaired CVR. Vascular risk factors, education years, mini-mental status examination (MMSE), and current medications were included as covariates. Results: 333 consecutive subjects were included: 126 bilateral ACS; 73/75 left/right unilateral ACS; 56 HS; mean age: 70 ± 3.78 years; males: 65 %; education years: 10.3 ± 3.7; MMSE score: 26.7 ± 1.27. Bilateral and unilateral ACS patients showed significantly lower scores in all cognitive tests compared to HS (p\0.05). In the multivariate analysis, among bilateral ACS an impaired CVR in the right side was associated with a significantly reduced CPM score: from an estimated mean of 32.6 [95 % Confidence Interval (CI): 29.8–35.4) to 23.0 (95 % CI: 20.2–25.8) and the CFTC score from 34.7 (95 % CI: 32.0–37.4) to 26.0 (95 % CI: 23.3–28.7). Similarly, an impaired CVR on the left side was associated with a reduced phonemic VF score: 13.5 (95 % CI: 11.2–15.8) to 7.5 (95 % CI: 5.4–9.7) and categorical VF score from 21.1 (95 % CI: 18.1–24.1) to 12.3 (95 % CI: 9.5–15.1). All comparisons were statistically significant (p\0.05). Conclusions: Patients with unilateral or bilateral ACS are more likely to suffer cognitive dysfunction compared to healthy controls. Impaired CVR predicts the development of cognitive dysfunction in bilateral ACS. A non-invasive assessment of CVR using the TCDbased BHI test may contribute to a more comprehensive risk stratification in these patients.

Introduction: We present the case of a 72 year-old woman admitted with a diagnosis of diverticulitis in April 2012 to our surgical department for severe diarrhea. An abdominal CT scan confirmed a diverticular disease of the sigmoid colon with multiple protrusions, inflammatory imbibition of perivisceral fat and mesenteric lymphadenopathies. Later the patient developed vomiting, weakness with postural instability, and cachexia with weight loss of 9 kg. For the progressive worsening of her clinical conditions she was transferred to our Internal Medicine Department, in the critical care area. History: The patient was affected by systemic hypertension and chronic kidney disease (CKD) with moderate secondary normochromic anemia. She was submitted 13 years before to left nephrectomy for renal carcinoma and, 12 years before, to hemicolectomy for ascending colon cancer. She was taking angiotensin receptor blockers (ARBs), allopurinol, statins, D vitamin and subcutaneous erythropoietin. She wasn’t currently taking any proton-pump inhibitor (PPIs). Laboratory: At the admission to our department, we observed a neutrophilic leukocytosis, mild normochromic anemia, renal failure, increased indices of inflammation and hyperuricemia; liver and thyroid function were normal. Urinary electrolytes were at the lower limit. Vidal–Wright reaction, ruling out Salmonellosis and Brucellosis, was negative as well as a stool cultures, occult fecal blood and the research of parasites and C. difficile toxins. However, the presence of a faecal calprotectin[300 and the presence of persistent diarrhea and increased ESR and CRP raised the suspicion of an inflammatory bowel disease, having excluded a celiac disorder. Following Procedures: Colonscopic examination with biopsies showed only signs of inflammation in preanastomotic area due to edema, and chronic nonspecific signs of inflammation at the biopsy. After the colonoscopy, the patient presented stupor, and tonic–clonic seizure with fever. An electrolyte imbalance was suspected as a possible cause of this complication: severe hypomagnesemia (0.4 mg/ dl), hypocalcemia (5.9 mg/dl) and hypokalemia (2.9 mEq/l) were found. The immediate administration of intravenous MgSO4 (4 g e.v. in 24 h) and liquids allowed the complete resolution of neurological symptoms. We also observed a normalization of diarrhea and electrolytes in the following days. Therefore, the diarrhea has assumed a dual role: as cause and effect of an electrolyte imbalance. The patient was discharged in good general conditions with calcium and magnesium oral supplements. Conclusions: This case highlights an often underestimated, often misleading clinical entity, such as electrolyte imbalances. On this subject there is very little in the literature. Electrolyte homeostasis is integrated and the normalization of a parameter can not be obtained without the infusion of another electrolyte. In our case, hypomagnesemia and hypocalcemia. Acute hypomagnesaemia the less frequent imbalance, often diagnosed with delay (magnesium is not routinely evaluated). In addition, it rarely occurs as an undeferrable urgency or with a definite clinical picture, as in this case; symptoms are often non-specific and common to many other diseases. Chronic hypomagnesemia is closely related with hypocalcemia, which is caused by impaired parathyroid hormone (PTH) secretion or the refractoriness of bone and renal tubules to PTH. The dominant mechanism of acuteonset, hypomagnesemia-induced hypocalcemia is currently unclear [1]. Another cause of hypomagnesemia is the adverse effects of longterm proton pump inhibitor therapy, but our patient was not taking PPIs [2]. The guidelines, algorithms, protocols, show us the way forward, and are a good ‘‘cookbooks’’, but remember that the patient is always in need of a thinking chef.

background Increased brain natriuretic peptide(BNP) levels have been related to several conditions, such as acute heart failure(AHF), pulmo-nary embolism(PE) and acute coronary syndromes(ACS). Particularlyamong elderly patients, a longer hospitalization is related to higher morbidity and mortality. Aim of this study is to evaluate the relationship between BNP levels and length of in-hospital stay.Methods We retrospectively evaluated 500 consecutive patients admit-ted to our Internal Medicine Department. BNP was evaluated at admis-sion in all the patients. Each patient underwent a complete diagnosticworkup. We evaluated the curve-fit correlation between BNP levels and days of hospitalization using SPSS 13.0 for windows systems.results Mean age was 80±9.85 years, males representing 58% of the sample.AHF represented 74.9%, ACS 13.5%, PE 11.6% of the sam-ple. We found that BNP levels and days of hospitalization were better described by a logarithmic regression model (R2: 0.674, p < 0.0001)conclusion Among elderly patients admitted in an Internal Medicine department, higher BNP levels are associated to longer hospitalizations independently to the pathology. This relationship is better described by a logarithmic regression model. Larger cohorts are required to validate this observation.

Background: Infective endocarditis (IE) is a rare pathology, with an incidence of 3–10 cases/100.000 person-year (1). The incidence didn’t significatively change in the last century: the decrease of postrheumatic valvular heart disease at population level is compensated by an increase in degenerative valvular heart disease as predisposing factor. Moreover, the share of patients with intravascular foreign material is increasing. IE is often diagnosed late. The clinical features are usually atypical. Since the introduction of the Duke criteria, clinical, bacteriological and echocardiographic findings (transthoracic and transoesophageal echocardiography) are being integrated, allowing an earlier definite diagnosis (1). Normochromic normocytic anemia, elevated ESR, neutrophilia, increased immunoglobulins, circulating immune complexes and rheumatoid factor are often present in IE. Many factors affect the outcome of this serious disease, including virulence of the species, patient’s characteristics, comorbidities, delays in diagnosis and treatment, surgical indications, and timing of surgery (2). Endocarditis is frequently characterized by a complicated course. About 50 % of the patients develop heart failure. One third of the patients present with cerebral or peripheral embolization. Embolization predominantly occurs at the beginning, in the first two weeks of antibiotic treatment. Abscess formation occurs more frequently than suspected if diagnosis is lead by ultrasonographic methods. Staphylococcus aureus infection is particularly aggressive in the presence of an artificial valve, often leading to extravalvular extension with abscess formation around the artificial valve. Despite improvements in medical and surgical therapies, IE is associated with poor prognosis and remains a diagnostic and therapeutic challenge. For its systemic involvement, endocarditis is typically an internistic pathology, and must be managed in an Internal Medicine Department (IMD) with critical care competence. Aims: To evaluate incidence, prevalence and clinical manifestations of endocarditis in our IMD. Methods: We retrospectively evaluated all the patients admitted in the critical area of our IMD in the year 2011–2012. We selected all the patients dismissed with a diagnosis of IE and reviewed the clinical, laboratoristic and echocardiographic data. Results: Seven patients were discharged with a definite diagnosis of native-valve IE. The most frequent clinical manifestations were dyspnea (57 %) and fever (43 %); our ED admitted the patients in our IMD with the diagnosis of AHF in 57 % of the cases, fever of unknown origin in 14.3 %, other diagnoses in 28.3 %. Mean ESR at diagnosis was 70 mm/h (SD ± 41 mm/h), CRP was 7.57 ng/ml (SD ± 6.16 ng/ml). Many patients (86 %) presents anemia, neutrophilia and increased hypergammaglobulinaemia. New ECG alterations were observed in 28.6 % of the sample. Only two cases resulted positive for rheumatoid factor. 71 % of the performed coltures resulted negative. Among the positive specimens, the most prevalent species found were Enterococcus spp and Staphylococcus spp (14.3 % of the cases each). Transthoracic echocardiography (TTE) resulted positive in 57 % of the cases, while transesophageal study confirmed the diagnosis in all the cases. No one of the described patients had recent hospitalization, carried a CVC or urinary catheter. In only one case IE was related with colon cancer, in another case the way of infection was related to drug addiction. No patient who was found to be diabetic or seriously immunocompromised. Discussion: IE still represents a complex diagnosis. In our series of patients is not possible to identify a common denominator, which could simplify the diagnostic process. The most frequent data (anemia, neutrophilia, hypergammaglobulinemia) is also the most unspecific. Although current guidelines clearly express how to the diagnose and manage IE, this pathology still remains very hard to diagnose without a correct clinical method and proven experience in cardiac ultrasound. IMD with competence both in echocardiography and critical care can carry the right methodological approach, diagnosing and managing most of the cases.

background Acute heart failure(AHF) is frequently associated to poor prognosis among elderly patients admitted to Internal ad Emergency Medicine departments. Increased brain natriuretic peptide(BNP) levelshave been related to increased mortality in this subset. Aim of this study is to evaluate if among patients who die for AHF, BNP at admis-sion can be associated to the length of hospitalization.Methods We enrolled 400 consecutive patients admitted to our Internal Medicine Department with a clinical diagnosis of AHF. BNP was eva-luated at admission in all the patients, stratified in four categories: patients with BNP less than 100 pg/ml (group 1), BNP 101-500 pg/ml (group 2), BNP 501-1500 pg/ml (group 3) and BNP higher than 1501 pg/ml (group 4). Each patient underwent to a complete diagnostic workup. Patients with BNP levels less than 100 pg/ml or a final diagno-sis other than AHF were excluded. Kaplan-Meier model with log-rank test was used to assess the differences.results 293 patients were suitable for final analysis. Mean age was 80±9.85 years, males representing 58% of the sample. Patients in group 2 had a significantly longer hospitalization (mean: 46.0 days, SE 3.71) than patients in group 3 (mean: 36.7 days, SE 2.51) and group 4 (mean: 22.9 days, SE 1.88) (p

background Primary prevention represents the best treatment for cardiovascular(CV) diseases.Especially among younger patients non-pharmacologic approaches are frequently underused.We started aproject of in-hospital physical activity program for primary prevention among high-risk patients.Aims To evaluate metabolic and vascular derangement among conside-red-healthy overweight subjects before a 3 months-course of in-hospital physical activity.Methods 70 consecutive obese patients with no history of acute vascu-lar events(IMA,stroke/TIA or peripheral artery disease)or other diagno-sed comorbidities were enrolled.Each patient underwent to completemetabolic/cardiovascular evaluation before physical activity.results Baseline characteristics were a mean age of 56.8±8.91 years(M:F 2:1,7),BMI of 34.2±5.69g/m2.CV familiarity was present in 45%,hypertension in 64.3%,smoke in 16.7%.We observed high prevalence of insulin resistance(HOMA Index 7.21±6.44) and hypertriglyceridemia;preclinicalmarkers showed endothelial dysfunction (FMD 7.43±10.4%) and high prevalence of increased IMT(30% of the sample);echocardiography showedan increased left ventricle mass(MVSI 108.2±34.0g/m2);double product at stress testresul-ted within lower limits (25.857±6.023).Framingham risk was 14.8%,with a 13.8% comparative increase.conclusions In this sample of italian obese patients we observed a high prevalence of endothelial dysfunction,insulin-resistance,hypertension with end-organ damage with an increased risk for CAD.Paradoxically,we should apply an aggressive therapy for these “healthy”,high-risk,subjects

Background: Increased brain natriuretic peptide (BNP) levels have been related to several conditions, such as acute heart failure (AHF), pulmonary embolism (PE) and acute coronary syndromes (ACS). Particularly among elderly patients, a longer hospitalization is related to higher morbidity and mortality. The usefulness of BNP as a prognostic factor is amply demonstrated in different subpopulations of both medical and surgical patients. Aims: To evaluate the relationship between BNP levels and length of in-hospital stay in patients with PE, ACS, AHF, septic and cardiogenic shock admitted to our internal medicine department (IMD). Methods: We retrospectively evaluated 500 consecutive patients admitted to our IMD. BNP was evaluated at the admission in all the patients. Each patient underwent a complete diagnostic workup. We evaluated the curve-fit correlation between BNP levels and days of hospitalization using SPSS 13.0 for windows systems. Results: Mean age was 80 ± 9.85 years, males representing 58 % of the sample. AHF represented 74.9 %, ACS 13.5 %, PE 11.6 % of the sample. We found that BNP levels and days of hospitalization were better described by a logarithmic regression model (R2: 0.674, p\0.0001) (Figure 1). Conclusions: Among elderly patients admitted in an IMDs, higher BNP levels are associated to longer hospitalizations independently to the pathology. This relationship is better described by a logarithmic regression model. However, larger cohorts are required to validate this observation.

background Primary prevention with non-pharmacologic approaches represents an intriguing option for cardiovascular(CV) diseases tre-atment. In 2008 we started a project to evaluate if a 3-months in-ho-spital course of physical activity can improve metabolic and vascular parameters among otherwise healthy obese subjects.Methods We enrolled 70 obese patients (age 56.8±8.91 years,M:F 2:1,7,BMI 34.2±5.69 kg/m2) without previous vascular events. CV fa-miliarity was present in 45%, hypertension in 64.3%, smoke in 16.7%.Each patient underwent to a complete CV and metabolic evaluation be-fore physical activity. After a 3-months training subjects were reassessed.T-test for repeated measures was used to analyze differences.results At baseline sample showed insulin resistance, hypertriglyceri-demia, endothelial dysfunction, increased IMT, and increase in leftventricle(LV) mass; double product at treadmill resulted within lower limits. Framingham risk was 14.8%, with a 13.8% comparative increase.At 3 months we observed a significant reduction of weight (96.5±18.9-87.8±13.2kg),BMI(34.2±5.69-28.9±9.03kg/m2),IMT(0.95±0.14-0.76±0.08mm),left ventricle(LV) mass(108.2±34.0-76.36±28.73g/m2),HOMA index(7.21±6.44-2.76±2.14); FMD(7.43±10.4-23.7±13.6%) and double product increased (254.6±60.7-286.5±49.8).conclusion In-hospital controlled physical activity reduced body weight and BMI, the extent of preclinical atherosclerosis and dysmetabolic markers, suggesting that lifestyle changes are as important as drugs inprimary prevention.

background Acute heart failure(AHF)is a frequent condition associated to high mortality and morbility among elderly patients admitted to In-ternal ad Emergency Medicine departments. Length of hospitalization is associated to higher mortality among medical patients. Increased brain natriuretic peptide(BNP) levels have been associated,in AHF patients,to increased mortality and morbidity. Our aim is to evaluate if BNP levels can be associated to longer hospitalizations in this subset.Methods We enrolled 400 consecutive patients admitted to our Internal Medicine Department with a clinical diagnosis of AHF. BNP was evaluatedin all the patients,who were stratified in four categories: patients with BNP less than 100pg/ml (group 1),101-500pg/ml (group 2),501-1500pg/ml (group 3) and BNP higher than 1501pg/ml (group 4). Each patient un-derwent to a complete diagnostic workup. Patients with BNP levels less than 100 pg/ml or a final diagnosis other than AHF were excluded. Ka-plan-Meier model with log-rank test was used to assess the differences.results 293 patients were suitable for final analysis.Mean age was 80±9.85 years,males represented 58% of the sample. Among patients who were successfully dismissed,group 4 had a significantly longer ho-spitalization (16.6 days,95%CI:13.7-19.5)than patients in group 3(13.1 days,95%CI:11.7-14.6) and group 2(12.3 days,95%CI: 10.6-13.9)(p

Purpose It is not known if in low-risk populations a drug-induced bor-derline-QTc (bQTc, males: 440-500ms, females: 460-500ms) predicts adverse outcomes. We assessed clinical impact, prevalence and risk factors for bQTc in a sample of schizophrenic outpatients taking at least 1 antipsychotic in 24 months.Methods All the schizophrenic outpatients followed by our ward were evaluated (history,electrolytes, ECG). Subjects with possible LQT-syn-drome, use of other QT-elonging drugs, ECG alterations or dyselectroly-temias were excluded. 193 consecutive patients were selected and re-assessed at 9-24 months. Risk factors and hazard were evaluated with logistic regression, Kaplan-Meier and Cox models.Results No deaths, syncope or QTc>500ms were registered. 18% of the sample had a bQTc at the admission. Incomplete RBBB (iRBBB) [OR=3.14; 95%CI:1.473-6.694, p3 drugs [OR=1.87; 95%CI:1.045-3.346, p3 drugs [time-to-bQTc: 20.6 vs. 13.2 months, p

Alzheimer’s Disease (AD) is the most common form of progressive dementia among internistic patients. Many hypotheses have been postulated for AD pathogenesis, and there is a growing but conflicting evidence about a vascular theory (1,3). Recently, we found a significant correlation between extracranial carotid atherosclerosis, intracranial vascular reactivity and mini-mental state examination (MMSE) impairment over a 12-months observation in a cohort of 442 AD patients (2). Aims: Aim of this study was to evaluate the correlation between intracranial vascular reactivity index (breath-holding index, BHI), extracranial carotid atherosclerotic involvement and classical cardiovascular risk factors, as demographic characteristics, smoking, hypertension, diabetes and dyslipidemia in a cohort of patients affected by clinically defined AD. Patients and Methods: We enrolled 745 consecutive patients followed by the dementia ward of our University Hospital (A.O.U. Ospedali Riuniti, Ancona). Each patient underwent a standardized interview about clinical history, neuropsycological evaluation, extracranial echo-color Doppler ultrasound and transcranial doppler (TCD), testing BHI for each side. We synthesized each classical risk factor and sex into a dichotomous variable; the number of risk factors affecting a single patient were collected into an ordinal variable (ranging from 0 risk factors to 4 risk factors); extracranial echo-color Doppler result was expressed into an ordinal variable, ranging from ‘‘no stenosis’’ to ‘‘bilateral haemodynamic stenosis’’. Only hemodynamically significant ([60% of the internal carotid lumen) stenoses were considered. MMSE scores, corrected for age and sex, were collected as continuous variables. Breath-holding index, calculated by dividing the percent increase in mean flow velocity occurring during breath-holding by the length of time (in seconds) subjects hold their breath after a normal inspiration, was synthesized both as a dichotomous variable (\0.69, pathologic, [0.69, normal) (3) and as an ordinal variable (normal, monolateral pathologic and bilateral pathologic). Statistical analysis was conducted with two ordinal regression models, one considering BHI as dichotomous, the other considering BHI as ordinal. Both models included the classical risk factors, the synthetic variable for the number of risk factors and the ordinal variable for extracranial echo-color Doppler results. Results have been weighted by MMSE, age and sex. Ordinal regression was calculated with SPSS 13.0 for Windows systems. Probability of each event was calculated as 1/[1 + (ea-bx)], being a the level threshold and bx the factor level. Results: The probability of a normal BHI in AD patients decreased proportionally with the increase of the number of vascular risk factors, from 95% in patients with no risk factor to 21% of patients with four risk factors (Fig. 1, p\0.05). Extracranial echo-color Doppler ultrasound could also predict a pathological BHI: the probability of a normal BHI decreased from 73% among patients without hemodynamically significant stenosis to 21% in patients with bilateral stenosis (Fig. 2, p\0.05). Each vascular risk factor was also associated with an increase of the risk of developing a pathological (monolateral or bilateral) BHI (p\0.05). Discussion: AD is a complex disease, and its pathogenesis, still uncleared, could be related to microvascular alterations in a favourable genetic background. Hypertension, diabetes, smoking and dyslipidemia have already been associated to AD and its progression (1). Both BHI and extracranial vessels involvement can predict a worse outcome at 12 months in MMSE, independently from specific treatment and risk factors presence (2). BHI is a suitable index for cerebral hemodynamics status, and its alteration could express the final pathway of vascular derangement in AD. Classical risk factors and extracranial haemodynamic impairment could act on intracranial circulation initiating and maintaining the cascade of events responsible of AD progression.