bluuebunny/crossref_metadata_2025 huggingface dataset:
Sulodexide. Prophylactic and therapy response to endothelial dysfunction
Authors: Masotti Luca
Published: June 2016

Endothelial dysfunction plays the key role in the development of cardiovascular system disorders. Sulodexide, decreasing oxidative stress and stabilizing endothelial cells, has protective properties on endothelial dysfunction. The article describes the role of sulodexide both in prophylaxis and therapy of venous and arterial diseases, underlining its clinical efficacy as demonstrated in clinical trials. Besides, the article describes its role in the management of some other diseases, like diabetic nephropathy, diabetic foot, tinnitus, or hemorrhoids.
Treatment with nilotinib after cytogenetic relapse at 12 months in a patient in chronic phase with sub-optimal response to imatinib
Authors: Breccia Massimo
Published: June 2016

We report a case of patient with chronic myeloid leukemia who started imatinib at standard dose and obtained a sub-optimal response at 6 months. Considering the patient as a possible “late responder”, we decided not to change the imatinib dose, but, at 12 months, we did not achieve a complete cytogenetic response. At that time, we decided to switch to a second-generation tyrosine kinase inhibitor (TKI), nilotinib 800 mg/day, obtaining soon a major molecular response. Recently, the retrospective application of European LeukemiaNet guidelines in large cohorts of patients suggested that patients whose response to imatinib is sub-optimal at 6 months showed significantly worse survival. Therefore we can hypothesise that this kind of patients could be eligible for an early switch to second-generation TKI.
Nilotinib therapy after resistance and intolerance to imatinib in CML patient with trisomy of the chromosome 8
Authors: Russo Rossi Antonella
Published: June 2016

In this article is presented the case of a 30-year-old woman with chronic myeloid leukaemia (CML) treated with imatinib for 15 months, and then with nilotinib as second-line therapy. Two episodes of grade 3 neutropenia, the detection of the trisomy of chromosome 8 and the failed achievement of a major molecular response (MMolR) in 15 months led to the switch to nilotinib. With nilotinib the patient obtained the lack of the genetic anomaly in 3 months and a complete molecular response (CMolR) in 6 months, all confirmed at 9 months. No haematologic or extra-haematologic adverse events were detected with this second-line agent.
A ruptured gastrointestinal stromal tumour of the small intestine: a case report
Authors: Lolli Ivan , Diotaiuti Sergio , Russo Silvana , Campanella Giovanna A. , Giampaolo Nicola , Leandro Gioacchino , Defilippis Vincenzo
Published: June 2016

The management of Gastrointestinal Stromal Tumours (GISTs) has evolved rapidly since imatinib was introduced. Surgery remains the first-line treatment for localised, primary GIST, but the risk for local or metastatic relapse of disease is very high. Prognostic assessment is a critical part of developing a treatment strategy. Perforation or rupture of a GIST to the abdominal cavity has a very high risk for recurrence. We described the case of a 51-year-old man with a haemoperitoneum caused by a ruptured primary GIST of the small intestine. After complete surgical resection, imatinib given for two years as adjuvant therapy achieved no disease progression after prolonged follow-up.
Adjuvant therapy with imatinib mesilate in a patient with intermediate risk GIST
Authors: Aprile Giuseppe
Published: June 2016

The presented case regards a 63-year-old male patient who underwent radical surgery for an intermediate risk gastrointestinal stromal tumor (GIST) and thereafter was treated with imatinib mesilate at a daily dose of 400 mg for one year. Adjuvant therapy for primary GIST has proven benefit in extending relapse free survival in randomised controlled phase III trials; the advantage in overall survival, however, is yet to be proved. Defined risk factors for recurrence are based on GIST size, location, and mitotic rate provide useful guidelines for selecting patients for adjuvant therapy considerations. Nevertheless, it is currently unclear how to select those patients who would benefit the most, which is the optimal dose and treatment duration, and, importantly, if the use of adjuvant imatinib could enhance the chance of cure. The case report will be used as a paradigmatic springboard for further discussion.
Congenital syphilis in a two-month-old infant
Authors: Serranti Daniele , Buonsenso Danilo , Valentini Piero
Published: June 2016

This report describes a rare case of congenital syphilis in a two-month-old Romanian infant. Diagnosis was possible when the baby showed decrease in the left upper limb movements and a papular rash. Her father had been infected and transmitted the infection to the mother, who had two non-treponemal serological tests during pregnancy, both with negative results. Congenital syphilis was confirmed by serological tests and the newborn was successfully treated. A global overview on diagnosis and treatment of children with suspected congenital syphilis is presented.
A case of pulmonary hyperinflation in chronic heart failure: role of diuretic therapy and cardiorespiratory rehabilitation
Authors: Di Gioia Claudio , De Simone Giuseppe , Di Sorbo Antonio , Borzillo Gabriele , D’Addio Giovanni , Ciarimboli Alessandro , Meoli Ilernando , Romano Massimo , Bianco Andrea
Published: June 2016

Persistent dyspnoea during daily activities is commonly observed in patient with chronic heart failure (CHF) despite optimised pharmacological therapy. In CHF patients diuretics are essential for symptomatic treatment when fluid overloads with consequent pulmonary congestion or peripheral oedema. Appropriate use of diuretics is key element versus other drugs used for the success of the treatment of HF. Conversely, the inappropriate use of high doses of diuretics can cause adverse effects as electrolyte and fluid depletion, hypotension and hyperazotemia. Dyspnoea and fatigue, in patients with stable HF, are not related only to fluid overload and/or fluid retention but likely other mechanisms are linked to symptoms increase. These patients at the end of a rehabilitative treatment take less diuretic doses than during the period before the rehabilitative treatment, so reducing the principal adverse effects and improving the symptoms. In these patients in absence of venous congestion but in presence of an increase of symptoms augmenting diuretic drugs is not useful: it is very useful, instead, to undergo these patients a rehabilitative treatment because other mechanisms are linked to symptoms increase. In fact, in our report the predominant mechanism determining the increase in dyspnoea is likely related to an increase in physiological dead space.
Premature cardiovascular disease: evaluation and management of risk factors
Authors: Bosio Angelo , Cerrato Flavio , Pascale Claudio
Published: June 2016

We describe the case of a 50 year-old man admitted to the hospital for a cardiovascular event. The patient had multiple cardiovascular risk factors that should be evaluated and treated before the acute event, sparing the need for a coronary artery bypass surgery and the hospitalisation. Cardiovascular disease is the leading cause of death in the world, due to coronary heart disease and stroke. This case report reminds us the importance of cardiovascular prevention, analysing the main risk scores and showing that the risk assessment of this patient could have lead to an earlier diagnosis of familial dyslipidemia, to an earlier therapy, and thus to a lowering in the risk of a cardiovascular event.
A case of serious bleeding
Authors: Ricca Irene , Coggiola Marisa , Destefanis Silvia , Pascale Claudio
Published: June 2016

Acquired haemophilia A (AHA) is a rare disorder with a high mortality rate. It occurs due to autoantibodies against coagulation factor VIII (FVIII) which neutralise its procoagulant function resulting in severe bleeding. This disease may be associated with autoimmune diseases, malignancies, infections or medications and occurs most commonly in the elderly. Diagnosis is based on the isolated prolongation of aPTT which does not normalise after the addition of normal plasma along with reduced FVIII levels. Treatment involves eradication of antibodies and maintaining effective haemostasis during bleeding. We report a case of a 76-year-old patient with a history of haemorrhage with severe anaemia. The article describes difficulties and complexities of clinical and therapeutic management of the patient.
Usefulness of electrocardiography in the differential diagnosis of dyspnoea
Authors: Cerrato Flavio , Bosio Angelo , Pascale Claudio
Published: June 2016

We report a case of a 88-year-old female, admitted to the hospital with tachycardia, chest pain and dyspnoea. ECG revelead a recent new-onset atrial fibrillation. A pharmacological cardioversion with amiodarone was performed, and restoration of sinus rhythm was obtained. Sotalol for rhythm control was administered. On the eighth day after the admission, she presented with severe dyspnoea and hypotension. An ECG revelead torsade de pointes, associated with prolonged QT interval. Several factors are involved in determining dyspnoea. ECG, although not specific, is an important instrument that supports clinicians in assessment of dyspnoea.
An unusual case of cat scratch disease
Authors: Perazzolo Laura , Marengo Claudio , Quario Manuela
Published: June 2016

A 53-year-old man arrives in emergency room for fever, asthenia and weight loss. Few days before the visit, he was treated with amoxicillin/clavulanic acid for a hard and not much sore submandibular swelling, with no result. Both ultrasound and CT showed the presence of colliquative multiple nodes, as well as multiple areas of hypoechoic nodules in the liver and spleen, granulomas related to pathognomonics of the hepatosplenic form of disease. In spite of a silent medical history and the lack of exposure to animal or insects, he resulted positive to IgM anti-Bartonella, and the diagnosis of cat scratch disease was confirmed by biopsy. We decided to treat with an association of ertapenem 1g/day and teicoplanin 600 mg/day for 3 weeks, and thus we obtained the recovery. The case report is of particular interest because of the lack of guidelines, the unusual manifestation of the disease and the singular associations of drugs administered.
A “mysterious” intrabdominal mass with infectious origin, in a patient with HIV infection under control. A “delayed diagnosis” allows to enlarge our knowledge, by assessing a rare disease
Authors: Sabbatani Sergio , Manfredi Roberto , Fabbrizio Benedetta , Caira Antonio , Trapani Fabio Filippo , Fasulo Giovanni , Viale Pierluigi
Published: June 2016

A probable case report of an abdominal botryomycosis has been hypothesized in a patient with a stable HIV infection under an effective antiretroviral therapy. Hyperpyrexia, abdominal pain and tenderness, and a thickening of small intestinal walls associated with multiple mesenteric adenopathies and a peritoneal involvement, prompted an ultrasonography-guided fine needle biopsy, and later a laparoscopy-laparotomy which excluded a neoplastic or lymphoproliferative disorders, showing only abundant fibrotic and necrotic-steatonecrotic tissue, with sparse multinuclear giant cells type Langhans. The prompt response to surgical intervention and a treatment with i.v. meropenem alone might be referred to a concurrent gram-negative infection of abdominal origin, until a late culture of an atypical Mycobacterium came to our attention over one month after the end of hospitalization. An updated literature search is presented and discussed, in relationship with the observed, extremely infrequent case reports of botryomycosis in different clinical settings.
Acute exacerbation of asthma: a case report
Authors: Urso Domenico Lorenzo
Published: June 2016

Asthma is a chronic inflammatory disease of the airways with a worldwide prevalence ranging from 1% to 18%. We report the case of a 43-year-old man with acute asthma exacerbation admitted to Emergency Department. All patients with asthma are at risk of having exacerbations characterised by worsening symptoms, airflow obstruction, and an increased requirement for rescue bronchodilators. Patients should be evaluated and triaged quickly to assess the presence of exacerbations and the need for urgent intervention. The goals of treatment may be summarised as maintenance of adequate oxygen saturation with supplemental oxygen, relief of airway obstruction with repetitive administration of rapid-acting inhaled bronchodilators, and treatment of airway inflammation with systemic corticosteroids.
From mother to daughter. Psychic disease: genetic or environmental influence?
Authors: Infrasca Roberto
Published: June 2016

The problem of genetic versus environmental influences in psychiatric disorders is widely discussed in biomedical literature, but remains still controversial. Familiarity has been observed in some disesase, such as obsessive-compulsive disorder and panic attack disorder. In this study we analyse three generations of women, for a total of 4 women (a mother, her two daughters, and a granddaughter) followed by our Psychiatric Department for depressive and anxiety disorders. The aim of the study was to assess wheather there are similarities among the clinical status of the four women, and verify the relationship among those disorders. The Minnesota Multiphasic Personality Inventory (MMPI) was administered to all the patients and the scores obtained were compared. We found out that the many aspects and psychological traits were present in all the four women. These similarities suggest the presence of a dynamic trans-generational transmission.
Rapid and sustained molecular response to nilotinib in a patient with sub-optimal response to imatinib
Authors: Annunziata Mario
Published: June 2016

We describe here the case of a 40-years-old woman diagnosed as having chronic phase chronic myeloid leukemia and treated with standard dose of imatinib; the patient obtained the complete cytogenetic remission in 7 months, but she failed to achieve major molecular response (MMolR) after more than18 months of imatinib therapy. Sub-optimal response, defined according European LeukemiaNet guidelines, persisted despite of increasing imatinib dose to 600 mg daily. No BCR-ABL mutations were detected. Three months after switching to nilotinib 800 mg bid, the patient obtained MMolR. She experienced any toxicities due to nilotinib. We speculate about use of nilotinib in patients classified as sub-optimal at 18 months from imatinib.
Pharmacological treatment of tics in Gilles de la Tourette Syndrome
Authors: Cavanna Andrea E. , Nani Andrea
Published: June 2016

Tourette syndrome is a neurodevelopmental disorder characterised by the chronic presence of multiple motor tics (e.g. eye blinking, shoulder shrugging, etc.) and at least one vocal/phonic tic (e.g. grunting or sniffing). The clinical picture of patients with Tourette syndrome is often complicated by tic-related behavioural problems and associated psychopathology. The pathophysiology of Tourette syndrome is poorly understood, however converging evidence from neuroimaging studies suggests abnormalities within the fronto-striatal pathways. The pharmacological management of the tic symptoms focuses on the dopaminergic and noradrenergic pathways and aims to improve the health-related quality of life of patients.
Risk factors for young ischemic stroke and the enigma of trombophilic polymorphisms: a case report
Authors: Iurato Linda , Ventruto Marialuisa , Police Maria Adalgisa , Morella Alessandro , Fortunato Alfonso , Musto Lanfranco , Fiori Patrizia , Ferrante Mario Nicola Vittorio , Monaco Antonio
Published: June 2016

We report the case of a 48-year-old female patient with stroke family history that was admitted in our ward with suspected ischemic stroke diagnosis. The diagnostic process is described in detail, paying attention in particular to anamnestic data and to genetic polymorphisms related to higher risk for inherited thrombophilia. At the end, the diagnosis indicates red infarct in a migraine patient with cerebrovascular and cardiovascular risk factors of undetermined aetiology according to TOAST criteria. Some of the known thrombophilic polymorphisms were found in the patient: however not all the mentioned thrombophilic markers are universally recognized as predisposing factors for arterial ischemic stroke.
Who should be screened for secondary causes of hypertension?
Authors: Semplicini Andrea , Sandonà Chiara , Stella Federica , Grandi Tommaso
Published: June 2016

The case of a 34-year-old patient with uncontrolled hypertension is described in this article, together with the diagnostic path followed in order to make the diagnosis, that finally reveals an arteriovenous fistula due to an old kidney biopsy. Uncontrolled or resistant hypertension may be caused by unrecognized secondary hypertension: we revise the clinical and laboratory criteria for selecting hypertensive patients in whom to look for secondary hypertension through the most appropriate diagnostic work up. A synthesis of the main causes of secondary hypertension is also provided in the discussion.
Imatinib dose optimisation following the disease progression in a patient with metastatic GIST
Authors: Parodi Mariangela , Boitano Monica , Canobbio Luciano
Published: June 2016

Here we report a case of a man affected by metastatic GIST since march 2007. His oncologic history began in 2006 when he was submitted to ileal resection and diagnosis of abdominal GIST was made. He was free of disease at radiologic controls until march 2007, when peritoneal nodules were shown. He started imatinib as first line therapy at standard dose of 400 mg/day and he reached a partial response at 6 months according to Response Evaluation Criteria In Solid Tumors (RECIST). After 24 months he performed CT scan that showed progression disease. For this reason he increased imatinib dose to 800 mg/day. Imatinib was safely administered and radiologic analysis performed at 3 and 6 months demonstrated stable disease according to RECIST. The patient is continuing oral therapy with imatinib at 800 mg/day and the disease is still stable.
Appropriate durations of adjuvant imatinib in patients with high-risk gastrointestinal stromal tumor (GIST) the better choice, for the year 2010
Authors: Tozzi Lucia
Published: June 2016

We report a case of a patient with histopathologically diagnosed GIST who had undergone complete tumor resection for primary localized lesion. The patient has received adjuvant imatinib treatment for at least two years. Studies have shown an improvement in RFS with 1 year of adjuvant imatinib, there is no consensus on the appropriate duration of adjuvant. The 2 year RFS rate in ACOSOG Z9000 was 73%, significantly lower than the 1 year RFS rate of 94%. These findings indicate that 1 year of adjuvant is likely to be insufficient, this implies that an extended duration of adjuvant prolongs RFS in patients with high risk of recurrence. The efficacy of re-challenge with imatinib in the subjects who developed recurrence after drug discontinuation indicates that it was probably due to insufficient treatment duration rather than resistence to imatinib. Waiting the results of phase III trial SSGXVIII/AIO about 3 years of treatment with imatinib we conclude that the better choice, for the year 2010, was to treat patient for at least two years.
Efficacy of nilotinib in a young patient with high Sokal risk CML Ph+ in treatment failure after high dose imatinib
Authors: Russo Sabina , Penna Giuseppa , D’Angelo Arianna , Allegra Alessandro , Alonci Andrea , Musolino Caterina
Published: June 2016

This article describes the case of a 44 year old man, at high-risk according to the Sokal Index, after CML Ph+ diagnosis, started imatinib at the standard dose (400 mg/day). Initially he reached optimal response, but at month 12, because of a loss of cytogenetic response, he was documented as a treatment failure. The mutational screening revealed no mutations and the blood level testing (BLT) showed values of ​​lower limits, therefore he increased imatinib to 800 mg/day. This therapeutic choice did not result in the achievement of an optimal response and the imatinib compliance was deteriorated. So, after nearly 12 months of treatment with high dose imatinib, we considered the treatment as a failure, and he switched to nilotinib, at the dose of 800 mg/day. After only 3 months of treatment, he reached complete cytogenetic response (CCyR) and major molecular response (MMolR), which the patient continues to maintain, as documented by the recent evaluation at month 30.
Efficacy of nilotinib in a patient in late chronic phase CML, intolerant to imatinib and resistant to dasatinib
Authors: Usala Emilio
Published: June 2016

We describe the case of a 60-year-old woman who was admitted to our hospital in 1999. A blood test performed for pain in the upper left side of the abdomen had showed leukocytosis. At the admission the patient was apyretic, with no systemic signs. An important splenomegaly was found at physical examination. The results of the bone marrow aspiration (hypercellularity) and the cytogenetic analysis (chromosoma Ph in all metaphasis) allowed us to diagnose CML. The patient’s Sokal score was high (1.252). The patient was treated with hydroxyurea until 2002, when imatinib became available. Then she started imatinib at the dosage of 400 mg/die. Tests performed during the follow up showed a fast haematological response but no cytogenetic response in two years. The patient received imatinib until February 2004, when a psoriasiform-lichenoid dermatosis appeared. Therefore we decided to interrupt the therapy and the skin lesions disappeared. After starting again imatinib, also dermatosis reappeared, so we decided to interrupt imatinib definitively. On July 2007 the patient started dasatinib, a 2nd generation TKI. No adverse events occurred and cytogenetic analysis performed periodically was always positive (no response). She continued on dasatinib until May 2010, when she switched to nilotinib. In seven months a complete cytogenetic response (CCyR) was documented with level reduction of Bcr Abl transcript from 13.0 to 2.0. Currently the patient is still receiving nilotinib, with persistent CCyR.
Arterial hypertension and dyslipidemia in a HIV-positive patient treated with antiretroviral therapy
Authors: Maloberti Alessandro , Villa Paolo , Dozio Dario , Citterio Francesca , Grosso Giorgia , Betelli Mauro , Cesana Francesca , Giannattasio Cristina
Published: June 2016

The introduction of antiretroviral therapy (ART) has substantially modified the clinical history and epidemiology of HIV infection with an important decline in infective causes of death and an increase in non-infective comorbidities particularly in cardiovascular complications. HIV infection has been related to an increased cardiovascular risk due to the presence of three factors: classic cardiovascular risk factors (shared with the general population), HIV infection itself (indirectly due to the inflammation and directly due to viral molecule) and ART-related chronic metabolic alterations. We describe a peculiar case of metabolic alteration in an HIV infected patient on ART with particular attention to the diagnosis and therapeutic aspects. Giving the higher cardiovascular risk of this specific population it is advisable that the clinician performs a frequent re-assessment of risk factors and cardiovascular organ damage. An early detection of metabolic alteration must lead to an aggressive specific therapy; this must be done by taking care of the HIV-infected subject fragility and the interactions with ART.
Persistent middle ear effusion presumably biofilm-related in a paediatric patient with common variable immunodeficiency
Authors: Torretta Sara , Pignataro Lorenzo
Published: June 2016

Bacterial biofilms play a role in upper respiratory tract diseases, including acute and chronic middle ear diseases, and are involved in chronic infections and resistance to antibiotic treatment. In particular, the nasopharynx and the surrounding tissues act as important reservoirs of resistant bacterial biofilms, which have been detected in biopsies taken from adenoid and/or middle ear mucosa of children with chronic middle ear effusion. Here we describe the management of a child with congenital immunodeficiency and a chronic middle ear effusion, resistant to traditional medical treatment and presumably due to nasopharyngeal colonization by bacterial biofilms, which has been successfully treated by means of medicated nasal douches delivering antibiotic and a biofilm-destroying compound.
A primitive neuroendocrine liver tumour?
Authors: Cevenini Monica , Guidetti Elena , Galassi Eleonora , Ferrata Martina , Tomassetti Paola , Corinaldesi Roberto
Published: June 2016

The aim of the present report is to present a possible primitive case of a neuroendocrine tumour (NET) of the liver. During a routine ultrasound examination, a 51-year-old woman was diagnosed with a lesion in the second segment of the liver, suggestive of a metastasis. A well differentiated neuroendocrine carcinoma (G2, Ki67 = 4.4%) was identified by liver biopsy, positive for chromogranin, synaptophysin and neuron specific enolase. An additional extensive examination aimed at finding the primitive lesion was unsuccessful and PET with 68Gallium revealed a single liver lesion. A left lobectomy was performed, but 15 months later a second liver lesion with the same characteristics as the previous one was observed and was surgically treated, followed by therapy with octreotide LAR 30 mg. A four-year follow-up did not show evidence of a different primitive NET: therefore, while it is improbable that a metastatic G2 primitive tumour would not have presented in the 4-year period, a diagnosis of primitive NET of the liver was made. The paper gives the opportunity of describing an unusual case of a primitive liver neuroendocrine tumour and of presenting the successful treatment of both surgery and cytoreductive pharmacological therapy.
Epilepsy in elderly patients: focus on treatment
Authors: Amidei Annalisa , Righini Isabella , Petrucci Loredana , Guida Melania , Iudice Alfonso
Published: June 2016

Epilepsy is a disorder widely distributed across all age groups, although its incidence and prevalence favours elderly patients. In this population the development of epilepsy is mainlyrelated to other brain disorders that facilitate the occurrence of late seizures, mostly of focal onset. Apart from the difficulties faced in current practice with the appropriate diagnosis of the epileptic nature of the episodes, old subjects require an individualised drug treatment, tailored on their characteristics, such as comorbidity, polytherapy, age-associated biological impairment and compliance. Among the various antiepileptic drugs available for the treatment of epilepsy, rational selection and combination of drugs should drive both initiation and maintenance of the treatment. Choice of antiepileptic drugs should first focus on avoidance of adverse effects and potential drug interactions. The pharmacological control of seizures is usually favourable at this age, with a good prognosis. However, alternative therapeutic options should be considered as soon as drug-response is unsatisfactory.
Sarcoidosis presenting with splenomegaly and abdominal pain: a case report
Authors: Faini Clara , Manetti Natalia , Bucciero Francesca , Razzolini Giulia , Marsico Maria , Biagini Maria Rosa , Milani Stefano
Published: June 2016

Sarcoidosis is a multisystemic disease of unknown aetiology characterized by proliferation of noncaseating granulomas at disease sites. It commonly affects young and middle-age adults and frequently presents with pulmonary infiltration, bilateral hilar lymphadenopathy, ocular and skin lesions. The liver, spleen, lymph nodes, salivary glands, heart, nervous system, muscles, bones, and other organs may also be involved. A diagnosis of the disorder usually requires the demonstration of typical lesions in more than one organ system and exclusion of other disorder known to cause granulomatous inflammation. We present the case of a young woman with abdominal pain and weight loss. The finding of splenomegaly by abdominal ultrasound and the presence of hypercalciuria, hypercalcemia and mild renal impairment led us to include sarcoidosis in the differential diagnosis. The final diagnosis was established by demonstration of involvement of lymph nodes and lung parenchyma on CT scan, and typical histology in bioptic specimens collected from bronchial mucosa.
Massive pleural effusion in a young woman
Authors: Ghiringhelli Paolo , Cattaneo Roberto , Tiso Angelo , Cesaro Claudia
Published: June 2016

Pleural effusion is a clinical manifestation shared by several underlying pathologies. The differential diagnosis is based on the clinical history, the physical examination, the analysis of the pleural fluid, and the laboratory data (mainly blood tests). There are cases, such as the patient described, where TC is not enough, and unusual imaging techniques are required for the study of pleural effusion, i.e. magnetic resonance cholangiography, cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP).This case analyses a 42-year-old female patient who arrived with progressive dyspnoea, chest pain, cough, a history of alcohol abuse, and a recent episode of acute pancreatitis. The physical examination revealed signs of right-sided pleural effusion. These features, together with laboratory data, made it possible to pose the diagnosis of pancreaticopleural fistula, to treat it, and to obtain a complete healing in a two-month period.
Multidisciplinary management of non small cell lung cancer (NSCLC) in stage III: clinical case description. Recommendations and state of the art
Authors: Carnio Simona , Courthod Giulia , Rapetti Simonetta Grazia , Vavalà Tiziana , Giaj Levra Matteo , Capelletto Enrica , Novello Silvia
Published: June 2016

Lung cancer is the leading cause of cancer death in industrialized countries with progressive increase of its mortality rate. Non Small Cell Lung Cancer (NSCLC ) is approximately 80-85% of all lung cancers, being adenocarcinoma and squamous cell carcinoma the most common histologies. The majority of the patients with stage III clinical stage, presents a mediastinal lymph node involvement described with computed tomography (TC) and/or positron emission tomography (PET). The current approach to patients with NSCLC is multidisciplinary, especially for those staged as potentially operable, both for staging and for a correct definition of best treatment strategy. Updated international and national Guidelines and recommendations can provide valuable support to the clinician.The case described concerns the accidental detection of a tumour in the lung in a 58-year-old man with arterial hypertension controlled with ACE inhibitors. The treatments agreed after a multidisciplinary approach are cisplatin and docetaxel, the surgical resection, and the radiotherapy. After three months the patient has neither metastasis nor relapse.
Emergency Plasmapheresis in a case of ThromboticThrombocytopenic Purpura (TTP)
Authors: Pioli Di Marco Mariaserena , Guercini Francesco , Busti Chiara , Minelli Olivia
Published: June 2016

An 84 year-old female was admitted to our Department of Vascular Internal Medicine after a sudden onset of weakness on her right side and aphasia along with signs of myocardial ischemia from Electrocardiogram (EKG). Clinical and blood exams led to a suspicion of Moschcowitz syndrome, which was reinforced by the presence of numerous schistocytes on a peripheral blood smear.Due to a rapid deterioration of vital signs as well as alertness, the patient underwent an emergency transfusion and plasmapheresis treatment as recommended by American Society of Apheresis (ASFA) guidelines: one plasma volume was replaced with fresh frozen plasma (FFP) every 24 hours, for the first eight days, in order to reach at least a level of 150,000 platelets/mm3 over three consecutive days accompanied by a decrease in LDH until to 670 UI/l.After this therapy, the clinical picture significantly improved with a complete recovery of consciousness and the disappearance of neurological defects.Examinations to determine the etiology made us hypothesize a secondary status of thrombotic thrombocytopenic purpura due to an autoimmune disorder compatible with Sjogren’s syndrome. The patient was discharged and prescribed prednisone.Currently the patient is in good clinical condition and continues the therapy with prednisone (5 mg/die).
Reversible MRI abnormalities in mesial temporal lobe epilepsy: a case report
Authors: Pizzanelli Chiara , Caciagli Lorenzo , Bartolami Veronica , Giorgi Filippo Sean , Pesaresi Ilaria , Guida Melania , Bonuccelli Ubaldo
Published: June 2016

The question regarding  the existence of abnormalities in the neuroimaging exams immediately after status epilecticus or epileptic seizures, but showing complete reversibility after a proper antiepileptic therapy, has long been debated. The first reports attempting to demonstrate their existence date back to the 1980s, and relied upon computed tomography as the imaging method of choice. After the introduction of MRI, a more appropriate characterization of these abnormalities was obtained along with the description of their most frequent features: (a) T2 signal hyperintensity in the white matter and, occasionally, (b) reduced apparent diffusion coefficient (ADC) and increased signal in DWI sequences.The MRI abnormalities induced by epileptic activity pose a broad differential diagnosis including infections, inflammatory autoimmune encephalopathies, neoplasms. It remains a diagnosis of exclusion and requires proper diagnostic iter in order to reduce the risk of misdiagnosis and unnecessary intervention.In this case report, a thorough presentation will be outlined about MRI alterations in the left mesial temporal lobe, which resulted completely reversible after a proper antiepileptic therapy.
Pregnancy in epileptic patients: comparison between well-established therapeutic strategies and opportunities coming from new drugs
Authors: Pizzo Francesca , Dilaghi Arianna , Romoli Anna Maria , Pradella Silvia , La Licata Andrea , Chiocchetti Barbara , Pistelli Alessandra , Paganini Marco
Published: June 2016

Treating women affected by epilepsy during pregnancy is challenging.  Clinicians have to consider both the teratogenic effects of Antiepileptic Drugs (AEDs) and the risk of seizure recurrence. Pharmacokinetic changes during pregnancy are rapid and conspicuous so that the serum concentration of drugs can be modified and the effectiveness of AEDs cannot be guaranteed. The aim of this study is to evaluate the risk of Major Congenital Malformation (MCM) associated with AEDs treatment during the first trimester of pregnancy. We collected data from 338 patients who contacted the Teratology Information Services of XXX University Hospital and we found that only the variable monotherapy vs politherapy had statistical significance for MCM. More studies are needed to assess the efficacy and safety of newer AEDs.
Budget impact analysis of use of aliskiren in hypertension on the Italian Health Care System
Authors: Zaniolo Orietta , Pradelli Lorenzo
Published: June 2016

Cardiovascular (CV) disease management and prevention has been the leading cost driver in health care expenditures of industrialized Countries for many years, and this trend is not expected to change in the next future. Although drugs used for the treatment of arterial hypertension and heart failure account for three fourths of the total Italian pharmaceutical expenditures in this disease area, population studies indicate that only about half of all hypertensive patients are treated for this condition, and that, among treated individuals, only a minority achieves a satisfactory and stable blood pressure control. A complementary observation is that drug expenditures, as high as they seem to be, actually account for only about a fourth of the total direct cost of CV illness, as they are exceeded by costs of hospitalizations required for the acute management of the clinical events that should be, at least partially, prevented by the same cardiovascular drugs. An often pointed out corollary to these findings is that an increase in the rate of controlled hypertension in the population, although surely linked to a further increase in pharmaceutical expenditures, carries the potential to reduce overall health care costs for the management of CV patients. As far as drug treatment is concerned, there seem to be three applicable strategies capable of increasing blood pressure control rates, i.e. interventions directed toward the increase of the treated population, interventions aimed at improving compliance, and the introduction of innovative drugs to cover unmet needs. Aliskiren is the first agent of the new direct renin inhibitors drug class, and has been recently approved in Italy under strict reimbursement restrictions. In this paper, the Authors present a budget impact analysis in the perspective of the National Health Service, conducted by estimating eligible populations according to reimbursement limitations, calculating differential costs by patient subgroups and possible strategies (addition to vs substitution of ACE-Is or ARBs), and finally by applying expected market shares to the identified population. The low forecast market penetration (0.2% and 0.6% of eligible patients, in the first and second year, respectively) drives the results: the treatment of 3,274-9,821 patients induces a yearly increase of 1.5 to 4.5 million € with aliskiren added to ACE-Is or ARBs, and of 917,000 to 2,751,000 € in the substitution scenario.
Budget impact analysis of the use of rituximab in the treatment of rheumatoid arthritis in Italy
Authors: Benucci Maurizio , Iannazzo Sergio , Sabadini Luciano
Published: June 2016

Objective: a Budget Impact analysis was performed to evaluate cost implications for the Italian National Health Service (NHS) of the introduction of rituximab (RTX) in the treatment of rheumatoid arthritis (RA). Methods: RA patients eligible to treatment with a second-line biologic DMARD (Disease Modifying Antirheumatic Drugs) were identified and quantified and available strategies for their management were explored. Costs associated with the different alternatives were estimated, and the impact on the NHS budget was estimated using a cohort simulation based on a Markov chain with a time horizon of 5 years and 1-year cycles. Seven alternative strategies were analyzed, each of them starting after the failure of a first anti-TNFα: 1) the use of a second and a third anti-TNFα; 2) the use of a second anti-TNFα followed by RTX; 3) the use of a second anti-TNFα followed by abatacept (ABAT); 4) the use of RTX as a second biological line, followed by an anti-TNFα; 5) the use of ABAT as a second biological line, followed by an anti-TNFα; 6) the use of RTX as a second biological line, followed by ABAT; 7) the use of ABAT as a second biological line, followed by RTX. Only direct medical costs were considered: drug acquisition, administration, incidental premedication and monitoring exams. Results: Italian patients eligible to second biological line therapies (RA patients refractory or intolerant to at least one anti-TNFα therapy) were estimated in about 650 per year. The adoption of RTX as a second line therapy produced a substantial saving in total costs (-33% at the fifth year) with respect to the strategy with RTX as third line and the one with only anti-TNFα (the last two resulting substantially cost-equivalent). The number of patients in active treatment (biologic DMARD) per unit cost resulted of about 8.1 patient-years/100,000 € with the strategy based only on anti-TNFα and increased of 10% with RTX as a third line. The strategy of RTX as a second line provided a further 41% increase (with respect to RTX as a third line). Conclusions: the introduction of RTX in the treatment of Italian RA patients represents a valuable new therapeutic option for this population especially if anticipated after a first anti-TNFα failure; it can also induce a reduction in health resources consumption for the NHS.
Costs of diabetes in Italy
Authors: Zaniolo Orietta
Published: June 2016

Among chronic diseases, diabetes is one of the most impacting on healthcare expenditures. This impact is expected to continue growing over time, because of increasing prevalence and earlier diagnosis, with subsequent longer duration of the disease. A review of the main Italian cost of illness studies has been conducted, with a focus on papers addressing the cost structure of diabetes care and those exploring the resources determining the expenditure difference between diabetic and non-diabetic patients. According to different sources, in Italy the yearly average direct cost for diabetes management ranges from € 2,340 to 2,990 per patient. Drugs account for 22-34% of this burden, while 52-60% is due to hospitalization. Of the pharmaceutical expenditure, only 10-11% is related to oral hypoglycemic drugs. Complications account for a large share of diabetes costs: vascular complications induce a 70-100% cost increase. Several studies compared health care expenditures for diabetic patients with those for matched control patients without diabetes. These studies point out that diabetic patients have higher health costs due to an increase in the prevalence of use of health care resources and/or an increase in their prescribed amount. As expected, this gap is mainly due to the treatment of diabetes complications, as opposed to routine disease management; furthermore, some evidence showed that cost increases related to diabetes diagnosis are also caused by drugs, hospitalizations and specialist consultations required for managing disorders traditionally considered not related to diabetes. Consistently with international literature data, our review suggests that the improvement of therapy adherence, together with the adoption of strategies specifically prescribed in order to prevent or delay complications, may be able to ameliorate long term clinical and quality of life outcomes, with a marginal increment of health expenditures.
Economic evaluation of temsirolimus on the basis of the results of the ARCC (Advanced Renal-Cell Carcinoma) study
Authors: De Portu Simona , Carteni Giacomo , Belisari Andrea
Published: June 2016

Introduction: metastatic renal cell carcinoma (mRCC) is highly resistant to chemotherapeutics, rendering limited antitumor effect. Temsirolimus, a specific inhibitor of the mammalian target of rapamycin kinase, may benefit patients with this disease. The Global ARCC Trial (Temsirolimus, Interferon Alfa, or Both for Advanced Renal-Cell Carcinoma) compared temsirolimus alone or temsirolimus plus interferon alfa with interferon alfa alone in mRCC. It has demonstrated that, as compared with interferon alfa, temsirolimus improved overall survival among patients with metastatic renal-cell carcinoma and a poor prognosis while the addition of temsirolimus to interferon did not improve survival. Aim: the objective of our study was to investigate the pharmacoeconomic impact in the Italian context of temsirolimus vs interferon alfa in patients with metastatic renal-cell carcinoma and a poor prognosis. Methods: economic evaluation is based on clinical outcome data from the ARCC trial and was carried out conducting a cost/effectiveness analysis, comparing economic and clinical consequences of temsirolimus (25 mg weekly) vs interferon alfa (18 MU 3 times weekly) in the perspective of the Italian National Health Service. Direct medical costs included in the analysis were drug costs, costs associated with the management of treatment-related serious adverse events (grade 3 and 4), cost related to progression and best supportive care. Effects were measured in terms of overall survival. A sensitivity analysis was performed. Results: the cost of temsirolimus or interferon alfa therapy amounted to approximately € 14,000 and € 2,000 patient respectively. The cost of hospitalization related to drug toxicity was about € 1,500 for temsirolimus and € 2,100 for interferon alfa. Temsirolimus shows an incremental cost per patient per month saved of € 3,767. Sensitivity analysis demonstrates that cost consequences parameters are sensitive to fluctuation. Discussion: this study is the first economic evaluation of ARCC trial based on the Italian context. This evaluation found that temsirolimus therapy in patients with metastatic renal-cell carcinoma and a poor prognosis is cost-effective.
Prevalence in the Italian regions of pain in patients with diabetic peripheral neuropathy (NDP) and the current costs of drug treatment for principals with specific indication
Authors: Guidi Luca
Published: June 2016

The present analysis estimates the prevalence of pain in patients affected by peripheral diabetic neuropathy referring to Italian and English data published recently and the cost of pharmacological treatments related to specifically indicated drugs. 16% of diabetic patients in Italy is affected by pain symptoms during PDN (peripheral diabetic neuropathy). The corresponding prevalence is 425,168 cases annually. A little number of these patients is actually treated with specifically indicated drugs (duloxetine, pregabalin and gabapentin), anyway the increase of share of duloxetine treatments would take to significant savings due to its lower costs among the specifically indicated pharmacological options.
Ankylosing spondylitis and psoriatic arthritis: clinical and economic consequences of the use of etanercept
Authors: Sacchi Viola , Zaniolo Orietta , Olivieri Ignazio
Published: June 2016

Spondyloarthritis (SpA) is the name for a family of inflammatory rheumatic disease that can affect the spine and joints, ligaments and tendons. Spondyloarthritis disease include ankylosing spondylitis, reactive arthritis, psoriatic arthritis, the spondylitis associated with the inflammatory bowel diseases and the undifferentiated spondyloarthritis. The most common treatments prescribed for spondyloarthritis are nonsteroidal anti-inflammatory drugs (NSAIDs) given in combination with disease-modifying antirheumatic drugs (DMARDs). Due to a recently suggested role of the tumour necrosis factor (TNFa) in the pathogenesis of SpA, new therapies specifically blocking TNFa have been investigated. Anti-TNF medications currently available on the Italian market are etanercept, infliximab and adalimumab. The aim of the present work was to furnish a clinical and pharmaco-economical profile of etanercept in treatment of psoriatic arthritis and ankylosing spondylitis based on a review of the published literature. Economical evaluations performed in several countries indicate that total treatment costs are lower with etanercept and adalimumab as compared to infliximab, mainly because of differences in the route of administration. Etanercept appears to be cost effective for the treatment of psoriatic arthritis and ankylosing spondylitis especially considering improved health related quality of life and lower medical costs due to superior efficacy of treatment.
Ipertensione arteriosa polmonare: stima della casistica italiana e considerazioni sull’impatto sul budget dell’introduzione di tadalafil
Authors: Guidi Luca , Mignini Mariano Alejandro
Published: June 2016

This contribution is an attempt to estimate a range of Pulmonary Arterial Hypertension (PAH) prevalence in Italy using international literature and Italian drug market sales data and to evaluate the budget impact of the introduction of tadalafil among the actual drugs with specific indication for this pathology. The final epidemiological figure obtained shows a wide range of prevalence of PAH in Italy (900-3,000 cases). The introduction of tadalafil as PAH treatment should not cause a cost increase for the pharmaceutical budget considering that this new therapy will occupy essentially the patient segment actually treated with sildenafil and that it reduces, in a significant number of patients, the daily cost of PAH therapy through a stable, fixed dose, administration.