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Coronavirus disease 2019 (COVID-19) has dramatically changed our lives. In the past months, hospitals were saturated of patients; therefore, it is still important to have simple and standardized prognostic factors and to evaluate the efficacy and safety of medications commonly used for COVID-19. We aimed to collect data of the patients hospitalized in Internal Medicine and Geriatrics Wards at the University Hospital (Policlinico) ‘P. Giaccone’ in Palermo, Italy (COMEPA, COVID-19 Medicina Policlinico Palermo), with the main purpose of finding prognostic tools that can be easily used in clinical practice in order to identify patients hospitalized for/with COVID-19 at higher risk of negative outcomes, such as mortality, transfer to Intensive Care Unit (ICU) and institutionalization, as well as evaluating the efficacy/safety of medications commonly used for COVID-19. For reaching these aims, the medical records of approximately 600 patients will be recorded, having data on several parameters and including as outcomes mortality, ICU placement, institutionalization. With the COMEPA study, we therefore plan to update current literature, giving new data on prognostic factors and on the efficacy/safety of some medications used for COVID-19.

Contrast-enhanced ultrasonography (CEUS) is increasingly being performed in Italy and Europe, particularly in the field of hepato-gastroenterology. Initially, it was mainly carried out to characterize focal hepatic lesions, but, since then, numerous studies have demonstrated its efficacy in the differential diagnosis of focal pancreatic pathologies (D’Onofrio et al. in Expert Rev Med Devices 7(2):257–273, 2010; Vidili et al. in J Ultrasound 22(1):41–51, 2019). The purpose of this paper is to provide Italian Medical Doctors with recommendations and thereby practical guidelines on the management of these patients. The present paper reports the final conclusions reached by the SIUMB guideline commission. This paper addresses particularly percutaneous ultrasound (US) examination (transabdominal US) and is drawn up specifically for publication.

A) Valutare le modificazioni ecografiche (US) dei linfonodi (LN) dell’ilo epatico in pazienti con epatopatia cronica (EC) correlata al virus dell’epatite C (HCV) e Sustained Virological Responders (SVR) alla terapia con i Direct-Acting Antivirals (DAAs); B) rilevare i fattori predittivi correlati con la scomparsa di LN. Abbiamo studiato 177 pazienti, trattati con DAAs, arruolati consecutivamente tra il Gennaio 2015 e il Dicembre 2016, con un follow-up dell’SVR di 24 mesi (SVR24) a Dicembre 2018; erano esclusi i pazienti con storia o insorgenza di epatocarcinoma nel follow-up. I LN erano definiti ingranditi (LN+) se il diametro maggiore era >1 cm. Al baseline (BL) registravamo: età, sesso, BMI, markers HBV, HCV e genotipo, uso di alcol; valutavamo al BL, a 12 mesi (SVR12) e a 24 mesi: test di funzione epatica, HCV-RNA, liver stiffness (Fibroscan), diametri US di vena porta e milza. La prevalenza di LN+ al BL era 49.8%, il diametro 2.1±0.6 cm, in LN+ vs LN- le transaminasi erano più elevate (P

Lo scompenso cardiaco è una sindrome clinica caratterizzata da specifici segni e sintomi causati da anomalie cardiache di tipo strutturale e/o funzionale. La prevalenza dello scompenso cardiaco è di circa 1-2% nella popolazione adulta dei paesi industrializzati, aumenta fin oltre il 10% oltre i 70 anni ed è la maggiore causa di ospedalizzazione oltre che di disabilità. L’approccio ecografico al paziente con scompenso cardiaco è ad oggi pratica comune, sia per la valutazione della funzionalità cardiaca, sia per il monitoraggio dello stato di volemia che per la quantificazione del liquido interstiziale. Dal 2018 è in corso uno studio multicentrico italiano (“ABCDE”) patrocinato dalla SIUMB che ha come centro promotore il reparto di Medicina Generale e Malattie Aterotrombotiche e Degenerative dell’Università di Verona. L’ approccio ecografico proposto comprende le valutazioni di: A: ABI (Ankle Brachial Index), indice caviglia-braccio; B: linee B all’ecografia polmonare; C: CIMT (Carotid Intima Media Thickness), spessore intima-media carotideo; D: Diametro dell’aorta addominale e della vena cava inferiore; E: stima ecocardiografica della frazione di eiezione ventricolare sinistra. Questa presentazione riporta i risultati aggiornati a poco più di un anno dall’avvio dello studio riportando i dati provenienti dal centro promotore (Verona) e dai centri partecipanti. Dai primi risultati dello studio "ABCDE", la metodica ecografica nel paziente con scompenso cardiaco, intesa sia come “bedside” che come approccio ecografico integrato appare essere uno strumento essenziale di valutazione cardiovascolare globale, e di accorciamento della durata della degenza nei reparti medici.

Valutare i cambiamenti della presentazione ecografica (US) degli epatocarcinomi (HCC) diagnosticati presso la nostra UO di Medicina Interna in tre periodi:1993-98, 2003-2008,2013-18. Il Gruppo 1 (G1) (1993-1998) comprendeva 174 HCC, il Gruppo 2 (G2) (2003-08) 96, il Gruppo 3 (G3) (2013-2018) 102. Sono stati registrati età, sesso, markers HBV, HCV, uso di alcol, alfafetoproteina (AFP), test di funzionalità epatica, autoanticorpi, ferritinemia. La diagnosi di HCC in G2 e G3 è stata posta secondo le linee guida EASL, in G1 con istologia o citologia nel 40%, nel resto con multiple tecniche di imaging concordanti (ecografia, TC, TC con lipiodol, angiografia), livelli sierici di AFP>200 ng/ml. La presentazione US veniva classificata secondo Otho in: Singolo, Multipli, Diffusi (Dig. Liv. Dis. 43 (2011) 875–880). Nel gruppo 1: 11.5% dei pazienti risultava in sorveglianza, meno che nel G2 (66%) e nel G3 (76.4%) (p

The present document describes the SIUMB (Italian Society of Ultrasound in Medicine and Biology) guidelines for the use of ultrasound in the management of focal liver disease. The aim of the paper is to provide a clinical practice guideline for Italian physicians who are approaching the ultrasound study of a focal liver lesion. In particular, these guidelines provide simple indications, recommendations and general practice advices for the correct use of contrast-enhanced ultrasound (CEUS) in this scenario. They represent the SIUMB position of the ultrasound role in the diagnostic flow charts of the principal focal liver lesions, and are in agreement with other, previously published national and international guidelines.

Background: Non-alcoholic fatty liver disease (NAFLD) is the most frequent chronic liver disease in Western countries, and in particular in obese patients the prevalence is higher than in general population. It has a large clinical spectrum, ranging from simple steatosis to steatohepatitis (NASH) and cirrhosis. Aim of the study: To evaluate in obese patients who underwent bariatric surgery in the last 3 years: 1) the histological prevalence and severity of liver steatosis (LS) and fibrosis; 2) the reliability of ultrasound (US) in diagnosing steatosis. Patients and methods: We reviewed preoperative liver US and intraoperative liver biopsy results in 57 bariatric surgery patients (age 42 ± 12.0 years, Body Mass Index (BMI) 43.5 ± 7.1), along with their clinical characteristics. Steatosis was diagnosed when more than 5 % of liver parenchyma was involved, the NAFLD activity score (NAS) and grade of fibrosis were determined according to Clinical Research Network system for scoring activity and fibrosis in non-alcoholic fatty liver disease (NASH CRN). US was performed after a 12-hour fast. US diagnosis of LS was evaluated with bright liver echopattern. Results: The prevalence of liver steatosis was 81 % (CI 95 %: 71-90), in patients with LS, the NAS Score was: 0-2 (not NASH) in 11 patients (24%; 13-37); 3-4 (borderline) in 20 patients (43 %; 30-58); ≥ 5 (NASH) in 15 patients, (33 %; CI 95 %: 21-46). Fibrosis was present in 40 patients (87 %; CI 95 %:75-95), bridging fibrosis (F= 3) in 3 patients, cirrhosis in 1 patients. The Sensitivity of US in steatosis diagnosis was 93% (CI 95 %:81-98), Specificity 42% (CI 95 %:9-75), Positive Predictive Value 89.3% (CI 95 %:83-93), Negative Predictive Value 50 % (CI 95 %:13-72), Accuracy 84.9% (CI 95 %:72- 93). Conclusions: In obese patients the prevalence of steatosis was higher than in the general population (82%), NASH and borderline-NASH were present in 24 and 43%, respectively. Finally, severe fibrosis or cirrhosis was present in 3 and 1 patient, respectively (in total 10 %); this low prevalence may be due to the young age of patients, confirming that earlier therapy could be associated with less irreversible liver damage. The US in diagnosing liver steatosis showed a good sensitivity, but insufficient specificity, confirming that in severe obesity the US reliability is low.

Background and Aims: In recent years an increasing number of studies on Non-Celiac Gluten/Wheat Sensitivity (NCG/WS) have been published but no markers of this condition have as yet been found. Although the NCG/WS clinical presentation often overlaps with IBS, no previous study evacuate colon or rectal histology in NCG/WS patients. Patients and Methods: We performed a prospective study on 78 patients (66 females, 12 males, mean age 36. 4 years) diagnosed with NCG/WS by double-blind wheat challenge, presenting at two tertiary care centers in Italy from January 2015 through September 2016. Data were also collected from 55 control patients either with celiac disease (CD) or with self-reported NCG/WS who tested negative at the wheat challenge. Duodenal immunohistochemistry studies were performed to evaluate the number of intra-epithelial CD3+ lymphocytes (IEL), lamina propria CD45+ immunocytes, CD3+, CD4+ and CD8+ lymphocytes, mast cells, eosinophils, and presence and size of lymphoid nodules. Identical studies were performed on the rectal mucosa of NCWS patients and of self-reported NCG/WS with a negative wheat challenge. Results: In the duodenum, NCG/WS patients showed a significantly higher number of CD3+ IEL, lamina propria (LP) CD4S+ immunocytes and eosinophils than self-reported NCG/WS with a negative wheat challenge. NCG/WS patients with dyspepsia had a higher number of LP eosinophils than those not reporting upper digestive tract symptoms. In the rectal mucosa, NCG/WS patients showed enlarged lymphoid follicles more frequently than self-reported NCG/WS subjects with a negative wheat challenge, and a higher number of CD3+ intra-epithelial lymphocytes and LP CD45+ and eosinophils than control patients. The CD controls had the highest number of immunocytes (CD3+, CD45-P, eosinophils) of the 3 groups studied, both in the duodenum and in the rectum. Conclusions: Both the duodenal and rectal mucosa are inflammed in NCG/WS patients and eosinophils are increased in these districts. NCG/WS could be considered an inflammatory condition of the entire intestinal tract, mainly involving the rectum, and eosinophil infiltration a key candidate player in the pathogenesis of NCG/WS. The study was supported by the Italian Foundation for Celiac Disease (FC) Grant for Project 013/2014.

Background:Among the endpoints of antiviral therapy with DAAs in HCV related liver cirrhosis (LC-HCV) in addition to the eradication of the virus there are the regression of fibrosis and of portal hypertension. For this reason we evaluated in LC-HCV patients and sustained virological response (SVR) to DAAs therapy the behavior of the AST to Platelet Ratio Index (APRI) (indirect marker of fibrosis) and of two ultrasound (US) signs of portal hypertension: caliber of the portal vein (cPV ) and longitudinal diameter of the spleen (LDS) Methods:132 patients with LC-HCV at baseline (BL), at three months (PostT3) and 12 months (PostT12) after the end of therapy, performed liver function tests and platelet count, US at BL, at PostT3 and at PostT12 and the liver stiffness (LS) measurement with Fibroscan at BL. The diagnosis of LC was histological in 12% of patients, in 88% was done by LS, US and endoscopy. Genotype 1b was present in 79% of the patients. When we performed the statistical analysis, 90 patients included in the study were at PostT12. We used the t-Student test for paired data, the Spearman's rho and the chi-square test when appropriated. Results: cPV at BL was significantly higher than at postT3 (P

Introduction Liver transplantation (LT) for hepatocellular carcinoma (HCC) is a satisfactory therapeutic choice in patients with “early HCC” selected according to Milan criteria. However, the risk of HCC recurrence after LT is about 7-20% at five years and molecular markers which can predict recurrence are still lacking. We investigated in HCC samples and LC surrounding tissues the significance of VEGFR-2, HSP90, and GRP78/BiP expression in patients with HCC who underwent LT in a western transplantation center and their possible role as molecular markers of recurrence. Methods 42 patients (35 M, 7 F) with early HCC who underwent LT between 2012 and 2013 were enrolled. The tumor recurrence rate was analyzed after a minimum follow-up of 36 months. Immunohistochemical expression of VEGFR-2, HSP90, and GRP78/BiP in HCC tissues and LC surrounding tissues, was correlated with clinicopathological variables and recurrence-free post-LT survival. At statistical analysis t Student’s or Mann Whitney U test were used where appropriate. To assess which variable measured at baseline was predictive of HCC recurrence, the univariate Cox proportional hazards model (Hr) was fitted to each variable. All variables with a P

FIBROSIS DIAGNOSTIC SCORES VALIDATION IN OBESE PATIENTS WITH NON-ALCOHOLIC LIVER DISEASE

Obiettivi dello studio: Tra gli end point della terapia antivirale con DAAs nella cirrosi HCV (LCHCV) oltre all' eradicazione del virus vi sono: la regressione della fibrosi e dell’ipertensione portale. Abbiamo valutato in pazienti LCHCV e risposta sostenuta (SVR) alla terapia con DAAs il comportamento dell’AST to Platelet Ratio Index (APRI) (marker indiretto di fibrosi) e di due segni ecografici di ipertensione portale: calibro della vena porta (cVP) e diametro longitudinale della milza (DLM). Materiali: 98 pazienti con LCHCV,al Baseline (BL) a fine terapia (FT) e tre mesi (PostT3) e 9 mesi dopo la fine della terapia (PostT9) eseguivano i test di funzionalità epatica e la conta piastrinica, l’ecografia al BL, a PostT3 e a PostT9, la misurazione della liver stiffness (LS) con il Fibroscan al BL. La diagnosi di LC era istologica in 13 pazienti, in 85 con LS, ecografica e endoscopica. Il 79% era genotipo 1b. Al momento dell’analisi 45 erano al PostT9. Statistica: t di Student per dati appaiati, r Pearson, test del chiquadro. Risultati: Il cVP al BL era significativamente più elevato vs PostT3 (P

Background: Phenobarbital is a long-acting barbiturate, responsible for many cases of poisoning, from unintentional overdose or attempted suicide. We report a case of phenobarbital overdose in a patient with history of depression. Patients and Methods: A 60 year old woman was admitted to our Internal Medicine Unit for drowsiness, irritability, difficulties in the maintenance of an upright position, dysphasia and weakness. She was suffering from depression and epilepsy and treated with phenobarbital 150 mg/die. Results: At the admittance, she had high fever and neck stiffness; phenobarbital serum levels were 71.2 mcg/ml (3 times u.n.l.); aminotransferases were 12-17u.n.l. Arterial blood pressure was 80/50 mmHg. An inflammatory meningeal process was excluded by lumbar puncture; a brain and spinal cord CT scan excluded spine bone lesions and ischemic stroke. In the suspect of an overdose, a protocol of urine alkalinization was applied resulting in a reduction of phenobarbital levels below the therapeutic range in about 6 days, with state of consciousness, cognitive and behavioral functions improvement. A rapid normalization in aminotransferases levels was noted and serology for hepatitis viruses (HAV, HBV, CMV, EBV, HSV) resulted negative. Conclusions: In our patient phenobarbital was responsible for stupor, hypotension, hypertonicity and aminotransferases elevation, whereas fever was due to a concomitant pulmonary inflammatory process resolved after antibiotic therapy. Despite the use of these drugs has been progressively reduced, the number overdose reports remains still high

Background: The anti-aggregant therapy with aspirin and inhibitor of P2Y12 platelets receptor for ADP, such as ticagrelor, can be used to prevent atherothrombotic events in patients with coronaric acute syndrome. Statins are also recommended in these patients even if the safety profile is burdened by the risk of drug interaction (CYP 3A4 inhibition by ticagrelor). Here, we report a case of acute rabdomiolysis and hepatotoxicity in a woman with a recent myocardial infarction treated with ticagrelor 90 mg twice daily, aspirin 100 mg daily, atorvastatina 40 mg once daily. Methods: We report a case of 68 old Caucasian woman with a diagnosis of myocardial infarction and coronary percutaneous stenting treated with ticagrelor and statins, complaining since the first month after discharging of general illness, asthenia, nausea, myalgia, itching and epistaxis. For the accentuation of these symptoms, in the following month she was admitted to our Division of Internal Medicine. Results: At admission, laboratory showed an eleveted value of CPK (100 upper normal limits), eleveted cytolytic and cholestatic values (AST/ALT 45-30 u.n.l, ggt 10 u.n.l, AP 2 u.n.l, bilirubin tot/ 4, 8 mg/dl), creatinine clearance was 37, 3 mL/min/1, 73 m2. No history of alcohol or drug abuse was reported; non-organ specific autoantibody (ANA, SMA, LKM) and viral serology (HAV, HBV, HCV, CMV, HSV) were negative. According consensus criteria for Drug Induced Liver Injury (DILI) patient was diagnosed as suffering from a hepatocellular liver injury. RUCAM score was calculated as 11 (highly probable). Assuming an episode of interaction due to ticagrelor and atorvatastin, we withdrawn immediately atorvastatin and continued ticagrelor with ASA. There was a clinical and biochemical improvement, with decrease of creatinkinase and aminotransferases till normal values within 15 days. Intravenous fluids and albumin were administered to avoid acute kidney failure. Discussion and Conclusions: Drug-drug interaction between ticagrelor and atorvastatin caused certainly the development of muscle and liver injuries. Physician should be informed of the possibility that the ticagrelor/statin association even useful to prevent atherothrombotic events in patients with coronaric acute syndrome could be cause muscle, liver and kidney injuries

Portal vein thrombosis may occur in cirrhosis; nevertheless, its prevalence, and predictors are still elusive. To investigate this issue, the Italian Society of Internal Medicine undertook the “Portal vein thrombosis Relevance On Liver cirrhosis: Italian Venous thrombotic Events Registry” (PRO-LIVER). This prospective multicenter study includes consecutive cirrhotic patients undergoing Doppler ultrasound examination of the portal area to evaluate the prevalence and incidence of portal vein thrombosis over a 2-year scheduled follow-up. Seven hundred and fifty-three (68% men; 64±12years) patients were included in the present analysis. Fifty percent of the cases were cirrhotic outpatients. Viral (44%) etiology was predominant. Around half of the patients had a mild-severity disease according to the Child–Pugh score; hepatocellular carcinoma was present in 20%. The prevalence of ultrasound-detected portal vein thrombosis was 17% (n=126); it was asymptomatic in 43% of the cases. Notably, more than half of the portal vein thrombosis patients (n=81) were not treated with anticoagulant therapy. Logistic step-forward multivariate analysis demonstrated that previous portal vein thrombosis (p&nbsp