bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical applicability of D-dimer assay in the diagnosis of pulmonary embolism reduces with aging
Authors: Masotti Luca , Landini Giancarlo , Antonelli Fabio , Venturini Elio , Cappelli Roberto , Rottoli Paola
Published: June 2016

Despite modern algorithms have been proposed for diagnosis of pulmonary embolism (PE), it remains understimed and often missed in clinical practice, especially in elderly patients, resulting in high morbidity and mortality when early and correctly untreated. One of the main controversial issue is represented by the role and applicability of D-dimer in the diagnostic work up of geriatric patients. Most recent guidelines in young-adult patients suggest to perform D-dimer assay by ELISA or immunoturbidimetric methods only in non high pre-test clinical probability (PTP) patients; in these patients negative D-dimer can safely rule out the diagnosis of PE. This strategy is safe also in elderly patients; however the percentage of patients with non high PTP and negative D-dimer reduces progressively with age, making difficult its clinical applicability. The Authors, starting from two case reports, up date the diagnostic management of PE underling the limitations of D-dimer assay in elderly patients.
A case of inflammatory ascites
Authors: Biolato Marco , Gabrieli Maria Letizia , Gallo Antonella , Miele Luca , Riccardi Laura , Montalto Massimo , Gasbarrini Giovanni , Grieco Antonio
Published: June 2016

Even ascites appears mainly as sign of portal hypertension in patiens with liver cirrhosis, in some case depends on a different lying condition such as right congestive heart failure, peritoneal carcinomatosis or tuberculosis. In these cases, paracentesis represents the key tool for diagnosis. We report a case of cardiac ascites in a 71-years-old woman who developed in four-month an abdominal distension. Preliminary exams showed exudative ascites related to portal hypertension, a pelvic mass with caseous apparence, and inflammatory status ad an elevation of CA-125. Successive evaluation exluded peritoneal carcinomatosis or tuberculosis, underlyng a tricuspidal regurgitation. The literature on ascites has also been reviewed.
An alcohol-acid resistant backache
Authors: El-Hamad Issa , Scarcella Carmelo , Pezzoli Maria Chiara , Bergamaschi Viviana
Published: June 2016

We reported the case of a Pakistani young man, illegally residing in Italy, complaining for chronic backache. X-ray was negative, while the blood test revealed neutrophilic leukocytosis and an increase in inflammation markers. Tuberculin skin test was negative. He worsened despite of repeated cycles of analgesic therapy and fluoroquinolones. After 4 months a nuclear magnetic resonance suggested tubercular (TB) spondylitis whose etiology was confirmed by ex-juvantibus criteria. It is important to take TB in account when facing an immigrant suffering from backache, coming from a highly endemic area.
Management of patients with amyotrophic lateral sclerosis
Authors: Calvo Andrea , Ghiglione Paolo , Chiò Adriano
Published: June 2016

Amyotrophic lateral sclerosis (ALS) is a progressive, fatal, neurodegenerative disease caused by the degeneration of motor neurons. We report a case of a 45-years-old patient with ALS to underline difficulties and challenges in ALS management. Even though ALS remains fatal, several advances have been made in improving the consequences of this disease: symptomatic treatments have an important role in controlling sialorrhea, bronchial secretions, pseudobulbar emotional lability, cramps, spasticity, depression and anxiety, insomnia and pain. An adequate management of ALS should be multidisciplinar, involving not only the neurologist, but also family physicians and many other specialists, such as pulmonologist, rehabilitation medicine physician, speech therapist, dietitian and psychologist. The multidisciplinary approach should be aimed at relieving specific problems associated with the disability of single patients and improving their quality of life.
A case of drug abuse
Authors: Pacini Matteo
Published: June 2016

Methadone maintenance is one of the well-known harm reduction strategies for public health intervention in heroin addiction. The significance of methadone treatment in preventing needle sharing, which in turn reduces the risk of HIV and HCV transmission among injectors, has been demonstrated. Methadone maintenance is also considered gathering site where heroin addicts can effectively acquire knowledge on harm reduction and drug rehabilitation. We report a case of a 34-years-old patient with a history of heroin abuse. Therapy with methadone was essential for an adequate management of the case. The article describe difficulties and complexities of heroin abuse management and the therapeutic role of methadone.
The health care for diabetic persons in Italy: the QUADRI survey
Authors: Maggini Marina , Aprile Valerio , Baldissera Sandro , D’Argenzio Angelo , Lopresti Salvatore , Mingozzi Oscar , Scondotto Salvo , Binkin Nancy , Giusti Angela , Perra Alberto , Caffari Bruno
Published: June 2016

To obtain regional and national data on the quality of diabetes care within the Italian National Health Service, a national survey among persons with diabetes was conducted in 2004. A sample of 3,426 diabetic patients (age 18-64 years) were interviewed using a standardized questionnaire. The population was middle-aged (median age 57 years), had a low educational level, and was followed primarily in public diabetes centres. A total of 54% reported having hypertension but 14% were not on treatment; for hypercholesterolemia, the corresponding figures were 44% and 26%. Of the 72% who were overweight or obese, 51% were trying to lose weight; 26% currently smoked. Only 66% of patients had undergone haemoglobin A1c testing in the past four months (among the 67% who had ever heard of test); 30% suffered from microvascular or macrovascular complications. Only 5% received all eight main tests recommended by the guidelines within the specified intervals. Our study demonstrates that diabetic patients receive less than optimal care, they are engaged in unhealthy behaviours and received inadequate treatment for comorbidities, and that the translation of guidelines into clinical practice was unsatisfactory. These data have been used to formulate national and regional policy regarding integrated case management to improve the quality of diabetes care.
Differential diagnosis of infections in a patient with Chronic Obstructive Pulmonary Disease
Authors: Ghiringhelli Paolo
Published: June 2016

We describe a case of a 65-years-old patient with Chronic Obstructive Pulmonary Disease (COPD), receiving oxygen therapy and resistant to antibiotic therapy. He was admitted with high fever, productive cough, marked leukocytosis, and chest X-ray findings of infiltration and fluid levels within lung cysts. A differential diagnosis was essential to start an adequate treatment and avoid the rapid worsening of patients respiratory status. In patients with chronic pulmonary diseases under immunotherapy, micotic infections should be considered. Aspergillus fumigatus was cultured from bronchial washing fluid and we diagnosed chronic necrotizing pulmonary aspergillosis (CNPA). Oral itraconazole was started and his symptoms and laboratory data markedly improved.
Differential diagnosis of small bowel occlusions
Authors: Ghiringhelli Paolo
Published: June 2016

Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome, is a common autosomal dominant syndrome characterized by early age at onset, and microsatellite instability (MSI). Patients with Lynch syndrome have a markedly increased risk of colorectal cancer. We report a case of a 28-year-old male with Lynch syndrome; the case allows to describe clinical manifestations and diagnostic criteria of this syndrome, and to underline the importance of genetics in the diagnosis of this disease.
Multidisciplinary study: DCD method applied to patients with eating disorders
Authors: Conese Marina , Abbruzzese Maria Teresa Laura , Massiah Grace , De Cavi Piero Oberto
Published: June 2016

Eating disorders are quite common in clinical practice and can include out-of-control behaviours and thoughts that powerfully reinforce unhealthy eating patterns. They include anorexia nervosa and bulimia nervosa and Binge Eating Disorder. We conducted a trial on 102 patients (89 females and 13 males) to investigate the efficacy of “DCD method” (appropriate dietary education associated to New-Electrosculpture) on patients with obesity and eating disorders. The study underlines the efficacy of “DCD method”, especially when supported by behavioural therapy, in obese and overweight patients.
Efficacy and safety of darunavir and etravirine in a patient with retroviruses and multiple virologic failure
Authors: Bernardini Claudia , Rosso Raffaella
Published: June 2016

Drug resistance to antiretroviral regimen is a challenging problem in HIV-infected patients. We describe a case of a 45-year-old Caucasian male that, after failure of several successive antiretroviral regimens, has been successfully treated with a combination of darunavir, a protease inhibitor, and etravirine, a non-nucleoside reverse transcriptase inhibitor. This case report underlines the difficulties of everyday management of HIV-infected patients and the importance of an early identification of resistances and the individualization of the therapy
A case of cystic fibrosis
Authors: Monti Maria Alice , Falcier Elisa , Zanardelli Maddalena , Pizzamiglio Giovanna
Published: June 2016

As the expected survival improves for patients with cystic fibrosis (CF), there is a growing population of adults with this disease. We describe a case of a 33-year-old woman with CF presenting with recurrent pancreatitis, malnutrition, borderline sweat test and respiratory diseases. The case report underlines the importance of diagnosis and management of CF in adults, and the important role played by the Family Physician in developing an adult care program.
Severe invasive methicillin-resistant S. aureus (USA300 clone) infection in an Italian adolescent
Authors: Valentini Piero , Angelone Donatella , Crea Francesca , Pantosti Annalisa
Published: June 2016

This report describes an uncommon presentation of invasive community-acquired methicillin-resistant S. aureus (CA-MRSA) infection in an immunocompetent adolescent without any other risk factor, characterized by septicaemia, meningitis, necrotising pneumonia and deep venous thrombosis (DVT). Successful treatment was performed with linezolid, rifampicin and low-molecular-weight heparin (LMWH). MRSA molecular typing revealed the presence of Panton-Valentine leukocidin (PVL) gene, and a genetic background identical to USA300 clone, an emerging aggressive CA-MRSA strain in USA and Europe.
Successful treatment with rituximab of refractory immune thrombocytopenic purpura
Authors: Tirotta Daniela , Durante Vittorio
Published: June 2016

Idiopathic thrombocytopenic purpura (ITP) is a disorder characterized by accelerated destruction of platelets. About 25 to 30% of patients with ITP are resistant to standard treatment. Recent reports suggest that rituximab may be useful in treating chronic refractory ITP. We report a case of a 72-year-old woman with ITP resistant to standard treatment with steroids (prednisone 2 mg/kg for 2 weeks, followed by prednisone 1 mg/kg) and intravenous immunoglobulin (0,5 mg/kg for 5 days). An infection by Helicobacter pylori was eradicated; afterwards she was treated with rituximab 375 mg/m2, once weekly for four weeks, resulting in a complete long-lasting response. Rituximab could represent a satisfactory alternative to the splenectomia in the adults with ITP; in our case the remission is complete (stable platelets > 200 x 109 after 8 months), early (before the fourth dose) and sustained (follow-up 18 months).
Nilotinib after resistance to imatinib in CML patients with Wolf-Parkinson White syndrome
Authors: Breccia Massimo
Published: June 2016

We report a case of a young man affected by Wolf-Parkinson White syndrome, who was diagnosed as having chronic myeloid leukemia. He started imatinib at standard dose of 400 mg/day and he reached a partial cytogenetic response at 6 months, a sub-optimal response according to European LeukemiaNet criteria of 2006. For this reason he increased imatinib dose to 600 mg/day, but after 3 months he suddenly lost his hematologic response. Cytogenetic analysis performed at this time showed a cytogenetic relapse and acquisition of an additional cytogenetic abnormality (trisomy 8). Considering the patient as a failure at this time, he switched to second-generation tyrosine kinase inhibitor, nilotinib at the dose of 800 mg/day. He reached complete cytogenetic remission after 3 months and nilotinib was safely administered without further QTc prolongation.
Imatinib resistance: diagnostic and therapeutic choices
Authors: De Muro Marianna , Olimpieri Odoardo Maria , Greco Rosa , Altomare Lidia
Published: June 2016

We report a case of a 42-year-old woman with t(9;22) positive chronic myeloid leukemia (CML) who developed a sub-optimal response to therapy with imatinib mesylate due to M351T mutation and low plasma level of imatinib. Dose increase of imatinib resulted in toxicity. She obtained a complete molecular response to therapy with nilotinib, without adverse events.
Current problems in the first-line treatment of metastatic breast cancer: focus on the role of docetaxel
Authors: Montemurro Filippo
Published: June 2016

Metastatic breast cancer is a very heterogeneous disease, both from a clinical and a biological point of view. Despite being still incurable, the expanding therapeutic repertoire has determined a progressive increase in median survival. We describe the clinical course of a 67-year-old woman with a locally advanced, hormone-receptor positive breast cancer with synchronous liver metastases. Single-agent docetaxel at the dose of 100 mg/m2 for 8 cycles determined a pathological complete remission in the breast and a near complete remission of liver metastases. After more than 4 years from diagnosis, the patient is alive and without signs of tumour progression. Based on this clinical case, we discuss management issues like the choice of the initial treatment, the use of monochemotherapy vs polychemotherapy, the worth of surgery of the primary tumour in patients with stage IV disease, and the issue of maintenance endocrine therapy. Furthermore, we reviewed the pivotal role of docetaxel in the management of advanced breast cancer. Whether monochemotherapy or polychemotherapy is felt to be an adequate choice in the clinical practice, docetaxel qualifies as one of the most active and manageable agents. Single agent activity ranging from 20-48% in terms of response rate has been reported in several clinical trials in patients treated in various clinical settings. Docetaxel-based combinations with other cytotoxic agents have become established in the first line treatment both in patients with anthracycline-resistant and anthracycline-sensitive metastatic breast cancer. Finally, docetaxel has been shown to be an optimal companion drug for biologically targeted agents like trastuzumab or bevacizumab, resulting in further treatment options.
Resistant hypertension in atherosclerotic renovascular disease
Authors: Bosio Angelo , Cerrato Flavio , Pascale Claudio
Published: June 2016

Resistant hypertension requires careful evaluation for cause assessment. In this report we present a case of renovascular hypertension due to atherosclerotic renal artery stenosis, with particular regard for diagnostic options and therapeutic strategies (medical therapy versus endovascular angioplasty). This case underlines the importance of an adequate evaluation of the patient’s characteristics (i.e age and comorbidities) in order to choose the right strategy.
A complicated case of pulmonary embolism in a patient with renal failure
Authors: Pomero Fulvio , Brignone Chiara , Gollè Giovanni , Silvestri Alberto , Migliore Elena , Bracco Christian , Serraino Cristina , Castagna Elisabetta , Severini Sara , Fenoglio Luigi M.
Published: June 2016

We describe a case of pulmonary embolism with instable hemodynamics in a patient with renal failure; the case is complicated by heparin-induced thrombocytopenia (HIT). Renal failure has a high prevalence in hospitalized patients and is a restriction on administration of low molecular weight heparins (LMWH) and fondaparinux. HIT is a potentially life-threatening complication, therefore a precocious diagnosis is essential. Therapy consists in the immediate stop of heparin’s administration and in the administration of non-heparin antithrombotic drugs.
Oesophageal stenosis due to heterotopy of gastric mucosa: a rare case of dysphagia in paediatric age
Authors: Marseglia Antonio , Pastore Maria , D’Altilia Mario Rocco , Pellegrino Michele , Sacco Michele
Published: June 2016

We describe the case of a three-year-old child who presents recurrent vomiting, dysphagia for solids, and weight deficit. Besides the poor general clinical conditions, the kid presents also retrosternal pyrosis. The laboratory tests show the presence of sideropenic anaemia, but it is possible to make a diagnosis only after endoscopy of the superior gastrointestinal tract, which reveals a chronic inflammation due to heterotopy of gastric mucosa. In the suspect of this kind of disease, this test should always be performed, and, if the proton pump inhibitors (PPIs) aren’t effective enough, the Savary-Gilliard® dilators provide a safe and effective therapeutic solution.
Sulodexide. Pharmacokinetics, pharmacodynamics, and mechanism of action
Authors: Masotti Luca
Published: June 2016

Sulodexide is a highly purified preparation containing glycosaminoglycans composed from heparin-like and dermatan fractions. It is similar to unfractionated heparin, but it shows a prolonged half-life, a higher bioavability and a reduced effect on bleeding parameters. This article describes the mechanism of action of sulodexide and its pharmacokinetic and pharmacodynamic parameters, listing the most important pharmacologic studies published.
Chronic myeloid leukemia: successful therapy with nilotinib in a young patient with high Sokal risk and in sub-optimal response with imatinib
Authors: Palmieri Fausto
Published: June 2016

Here we describe a case of a young patient with chronic myeloid leukemia, at high-risk according to the Sokal index, who started imatinib at standard dose and obtained a sub-optimal response at 12 months. This condition was not automatically an indication to change therapy, but considering the patient as suboptimal, we decided to switch to a second-generation tyrosine kinase inhibitor (TKI), nilotinib 800 mg/die, obtaining soon a complete cytogenetic response (CCYR), thereafter a major molecular response (MMolR). Delayed achievement of cytogenetic and molecular is associated with increased risk of progression among patients with chronic myeloid leukemia in early chronic phase receiving imatinib therapy. Therefore we can hypothesise that this kind of patient could be elegible for an early switch to second-generation TKI.
Nilotinib after imatinib failure
Authors: Pezzullo Luca
Published: June 2016

We here report a case of a woman who was diagnosed as having chronic myeloid leukemia. She started imatinib at standard dose of 400mg/day and she reached a poor haematological response after 30 days of treatment. For good compliance treatment we increased the dose of imatinib at 600 mg/day. after 3 months the patient has not achieved hematologic remission and imatinib compliance has deteriorated. Considering the patient as a failure and intolerant at this time, he switched to second-generation tyrosine kinase inhibitor, nilotinib at the dose of 800 mg/day. She reached complete cytogenetic remission after 3 months and nilotinib and regressed the side effects of imatinib.
Acute heart failure after Caesaerean section: peri-partum or tako-tsubo cardiomiopathy?
Authors: Citro Rodolfo , Giudice Roberta , Mirra Marco , Paolillo Rosa , Paolillo Chiara , Baldi Cesare , Bossone Eduardo
Published: June 2016

A young woman undergoes Caesarean section at the 39th week of pregnancy: shortly after she develops acute cardiorespiratory failure. The electrocardiography shows sinus tachycardia and right bundle branch block. The ventriculography confirms the decrease of the pump function and the mid-ventricular ballooning of the left ventricle; the differential diagnosis is between peri-partum cardiomyopathy and stress induced tako-tsubo cardiomyopathy: the sudden onset, the results of the ventriculography and the complete recovery after 11 days of treatment for acute heart failure led the diagnosis towards tako-tsubo cardiomyopathy.
Possible genetic implications in the response to cardiac resynchronisation therapy in a patient affected by heart failure
Authors: Pezzali Natalia , Metra Marco , Dei Cas Livio
Published: June 2016

This report presents a case of a patient with idiopathic dilated cardiomyopathy and severe left ventricular systolic dysfunction who underwent cardiac resynchronisation therapy (CRT). During the follow-up a progressive increase in left ventricular ejection fraction was observed, as well as clinical improvement. No cardiovascular events occurred during the follow-up, except for appropriate Implantable Cardioverter Defibrillator (ICD) bursts for fast ventricular tachycardia. Genotyping for adrenoceptor gene polymorphisms detected that the patient was Glu27Glu homozygous carrier. There’s a large interindividual variability in response to CRT. Despite attempts to identify factors having an impact on this therapy, only QRS duration is accepted according to guidelines. Beta-adrenoceptors polymorphisms, modulating sympathetic drive in heart failure and left ventricular remodelling, may have a role in identifying patients with a better response to CRT, in order to target and individualise the patients’ treatment.
Hopkins’ syndrome
Authors: Longo Maria Roberta , Falsaperla Raffaele , Romano Catia , Passaniti Eleonora , Pavone Piero
Published: June 2016

Hopkins’ syndrome is a rare disease that affects the anterior horn of the spinal cord after an acute episode of asthma in children with atopic disease. A viral infection or immunological suppression in atopic subjects might be the cause of occurrence of this syndrome, although the mechanism due to the etiopathogenesis of the disease still remains unknown.In general, this disease is manifested by a few days to a few weeks after an acute asthma attack, with flaccid paralysis of one or more limbs and in some cases residual muscle atrophy. The response to corticosteroid therapy is good and rare the possibility of recurrence.
The subacute onset of a bilateral interstitial pneumonia
Authors: Re Roberta
Published: June 2016

We report the case of a patient who presents subacute onset of interstitial pneumonia with rapidly progressive respiratory failure, sepsis and acute thrombotic complication. The diagnosis of the underlying pathology, the HIV infection, is made at the fifth day of hospitalisation, while the BAL allows also the detection of Pneumocistis jiroveci and CMV. Here we discuss the importance of an early diagnosis and the management of antibiotic and antithrombotic therapy in this kind of patients.
Systemic amyloidosis and pneumatosis of bladder wall
Authors: Delsignore Erica , Bellan Luciano , Bertoncelli Maria Cristina , Cantone Roberto , Francese Margherita , Olivetto Luigi , Varese Annamaria , Migliora Paola , Patrucco Giovanna , Vigone Riccardo
Published: June 2016

A 72-year-old woman was admitted to our Department for syncopes, diarrhoea, and weight loss. We suspected the diagnosis of systemic amyloidosis after the detection of macroglossia and periorbital purpura, despite the biopsy of the previous year, that resulted negative for amyloid substance. We confirmed the diagnosis after the histological evidence of deposits of amyloid in bone marrow and the clinical evidence of pneumatosis of bladder wall. Chemotherapy improved only temporarily clinical condition.
Efficacy of nilotinib in a patient relapse after 9 years of imatinib treatment and in stable complete cytogenetic response
Authors: Defina Marzia
Published: June 2016

We report a case of a patient with chronic myeloid leukemia in chronic phase who was treated with interferon-alpha plus low dose of cytarabine for 5 years, achieving a partial cytogenetic response. In 2000, he started imatinib at 400 mg/day obtaining rapidly a complete cytogenetic response (CCyR) (after 6 months of treatment) and a “near” major molecular response (MMolR) with BCR-ABL transcript level waving from 0.13 to 0.15% (BCR-ABL/ABL%) during molecular follow-up performed in the subsequent 6 years. To further improve his molecular response, we associated to TKI an immune target therapy with a BCR-ABL derived peptide vaccine developed by us, obtaining a MMolR, confirmed during the following 12 months from the beginning of the vaccinations. Surprisingly, at 9 years from starting imatinib, we documented the loss of MMolR and CCyR. Clonal evolution, kinase domain mutations and reduced drug intake were excluded, thus the patient switched to nilotinb at 400 mg/BID: after 3 months of treatment he achieved CCyR and MMolR and after 6 months we documented also a complete molecular response (CMolR).
Complete Molecular Response due to nilotinib as III line treatment in a patient with CML and F317L point mutation of the Bcr-Abl kinase domain
Authors: Iovine Maria , Monaco Giuseppe , Troiano Mario , Abbadessa Antonio
Published: June 2016

In 1997, a forty-three years old woman was diagnosed with CML and treated with alfa-Interferon, achieving complete haematological response (CHR). Three years later, patient was switched to hydroxiurea due to thyroid toxicity. For logistic reasons, therapy with imatinib 400 mg/die was initiated only in 2003, obtaining complete cytogenetic response (CCyR) and suboptimal molecular response in twelve months. CCyR and CHR were then lost three years later. Doubling imatinib dose to 800 mg/die gave no positive results. Mutational analysis performed in September 2007 showed F317L point mutation of the Bcr-Abl kinase domain. In October 2007 dasatinib was started and in April 2008 CCyR was reached with suboptimal molecular response. In March 2009 Bcr-Abl transcript progressively increased, and in August 2009 cytogenetic analysis showed loss of CCyR. Therapy with nilotinib 800 mg/die was started, and in October 2009 the patient obtained complete molecular response (CMR). Bcr-Abl kinase-domain point mutations, acquired during first line therapy, are a common cause of resistance to tyrosine kinase inhibitors. While several Bcr-Abl mutations have been identified, involvement of codon 317 has been reported in the literature following treatment with imatinib and dasatinib.
Nilotinib is effective and well tollerate in patients with multiple comorbidities
Authors: Fava Carmen , Fizzotti Marco , Saglio Giuseppe , Rege-Cambrin Giovanna
Published: June 2016

A 62 year old lady was accidentally diagnosed of chronic myeloid leukemia, chronic phase, low Sokal risk, during analysis to investigate a monoclonal gammopathy. The patient had many comorbidities, including ischemic heart disease, lung disease and chronic renal insufficiency. She was obese and had a metabolic syndrome with glucose intolerance and hyperlypidemia. She started imatinib, 400 mg daily. Unfortunately she couldn’t tolerate the therapy, developing within one month many side effects that we were only able to manage with drug interruption. The side effects reappeared when the drug was restarted even at a lower level, so we decided to change imatinib with nilotinib. Cardiologic side effects are rare with both drugs although cardiologic monitoring is recommended for these patients. Whereas imatinib is known to reduce glucose level in small settings of patients with type II diabetes, several cases of hyperglycemia developed under treatment with nilotinib. Our patient didn’t show any cross-intolerance between imatinib and nilotinib, tolerated nilotinib very well and didn’t show any increase in glucose levels, with no need of starting therapy for hyperglycemia. Furthermore she achieved very rapidly a complete cytogenetic response with major molecular remission. This case show how nilotinib is effective and tolerable also in patients with many serious comorbidities.
Psychological aspects in the management of patients with essential hypertension
Authors: Genesia Maria Luisa , Rabbia Franco , Testa Elisa , Totaro Silvia , Berra Elena , Covella Michele , Fulcheri Chiara , Bruno Giulia , Veglio Franco
Published: June 2016

The hypertensive patient is the most stable phenotype in psychosomatic medicine. Hypertensive patients represent a vulnerable population that deserves special attention from health care providers and systems, and psychosomatic medicine may be an important tool in the management of high blood pressure. Depression, anxiety disorders and personality features are often associated with elevated blood pressure (BP) and they may have a role in the development of mild high-renin essential hypertension. Besides, “white coat” hypertension and “masked” hypertension demonstrate how clinic blood pressure could be strongly related to trait anxiety. Hypertension is largely asymptomatic, and patients often have little understanding of the importance of achieving BP control. Medication adverse effects may become an important factor in poor adherence to the treatment and the antidepressant use increases the risk of hypertension. So, the challenge in the management of hypertensive patients is the adherence to non-pharmacological and behavioural treatments for hypertension.
The importance of communication in the diagnosis of multiple sclerosis
Authors: Tsantes Elena , Senesi Caterina , Curti Erica , Granella Franco
Published: June 2016

The recent improvements in multiple sclerosis therapy have lead to consequent improvements in its prognosis: however, it still remains a chronic and unpredictable disease. The moment of the diagnosis is the starting point of a durable relationship between the physician and the patient, but, most of all, it is often referred to as the most traumatic experience in patients’ life. Patients’ compliance to prescribed therapies, so important in the course of every chronic condition, particularly hangs on the psychological approach used by the doctor in communicating and explaining the diagnosis for the first time, in addition to the patient’s personality. A brief overview on the main types of physicians’ and patients’ behaviours and communications styles is provided in this article.
Meningococcal vaccine evolution
Authors: Bona Gianni , Guidi Carla
Published: June 2016

Neisseria meningitidis is a leading cause of bacterial sepsis and meningitis worldwide. Although polysaccharide and glycoconjugate vaccines have been developed for serogroups A, C, Y and W-135, currently there are no broadly effective vaccines available for the prevention of meningococcal B disease. A general overview of the burden of the disease and the strains prevalence in the world with the focus in particular on the Italian situation is provided in this article, together with the vaccinations developed and under evaluation.
Major molecular response induced by nilotinib as first line treatment in a LMC patient with intermediate Sokal risk
Authors: Sessa Ursula , Celentano Maria , Rocco Stefano , Fabbricini Rossella , Finizio Olimpia , Mettivier Vincenzo
Published: June 2016

Here we describe a case of a man with chronic myeloid leukemia at intermediate risk, according to the Sokal index. After cytoreduction with hydroxyurea, the patient started nilotinib at standard dose (600 mg/day) obtaining a complete haematological response after one month of treatment.After about 3 months the patient presented a complete cytogenetic response and after six months major molecular response (MR3). At nine months of treatment the patient presented a complete molecular response (MR4).
Efficacy and safety of nilotinib as third-line therapy in an elderly patient with CML
Authors: Caocci Giovanni , Atzeni Sandra , Nasa Giorgio La
Published: June 2016

This case report describes a 74 year old male patient with low Sokal risk chronic myeloid leukemia (CML). Treatment was started four years ago with imatinib, 400 mg/day. The patient achieved complete hematologic response but, after 3 months of treatment, developed grade 3 skin toxicity. Imatinib was stopped and the patient was started on dasatinib, achieving complete cytogenetic and molecular response. Two months later, physical examination revealed bilateral gynecomastia. After 2 years of treatment the patient presented with pleural effusion and the drug dose was reduced but, following relapse of CML, therapy was switched to nilotinib, 800 mg/day. Treatment with nilotinib is currently ongoing and is well tolerated by the patient who is again in complete molecular response, with no signs of pleural effusion. Considering the growing availability of new and more potent tyrosine kinase inhibitors (TKI) it is important for the clinician to be aware of the possible inhibitory effects of these molecules against other members of the tyrosine kinase family. Safety of TKI in frail and elderly patients with CML is a fundamental goal. The results achieved in our patient show that nilotinib is safe and effective even when used as third line therapy.
Safety and efficacy of nilotinib after 10 years of interferon
Authors: Russo Filippo
Published: June 2016

Here we describe a case of a woman with chronic myeloid leukemia at high risk, according to the Sokal Index. The patient started interferon alfa-2b (IFN) at standard dose obtaining a major molecular response after about four years of treatment. After about 10 years the patient presented a toxicity from IFN and different comorbidities, so she was switched to nilotinib and achieved a complete molecular response (MR4). This case shows how nilotinib is effective and tolerable also in patients with multiple comorbidities. Keywords: Chronic myeloid leukemia; Optimal response; Nilotinib; Interferon alfa-2b
The use of vasoconstrictors in patients with liver cirrhosis: how, when, why
Authors: Puoti Claudio
Published: June 2016

Portal hypertension (PH) is a severe complication of liver cirrhosis. Patients with PH run the risk of developing gastro-esophageal varices and massive gastrointestinal bleeding, ascites, hepatorenal syndrome, and hepatic encephalopathy. Portal blood flow in its turn increases because of enhanced production of vasodilators, increased eNOS activity and NO release, systemic and splanchnic vasodilation, hyperkinetic circulation, and hyposensitivity to vasoconstrictors. Thus, it is now widely recognized that this hyperkinetic (hyperdynamic) circulation that characterizes liver cirrhosis is the main cause of the complications of the disease. This review is aimed at addressing the role of vasoconstrictor treatment in patients suffering from complications of decompensated cirrhosis, offering practical suggestions for the management of this treatment at bedside. In particular, the management of terlipressin in patients with cirrhosis, its side effects and the efficacy of this vasoconstrictor will be examined.
Main-duct intraductal papillary mucinous neoplasm of the pancreas: a case report
Authors: Manetti Natalia , Faini Clara , Bucciero Francesca , Razzolini Giulia , Marsico Maria , Biagini Maria Rosa , Milani Stefano
Published: June 2016

Three distinct entities among non-inflammatory cystic lesions of the pancreas have been defined: intraductal papillary mucinous neoplasm (IPMN), serous cystic neoplasm (SCN) and mucinous cystic neoplasm (MCN). IPMN is characterized by intraductal papillary growth and thick mucus secretion: its incidence has dramatically increased since its initial description. These lesions probably can progress towards invasive carcinoma. IPMNs are symptomatic in most cases: the typical presentation is a recurrent acute pancreatitis, without evident cause, of low or moderate severity. The diagnosis is usually based upon the imaging (CT/cholangio-MRI) demonstrating a pancreatic cystic mass, involving a dilated main duct, eventually associated to some filling defects, or a normal Wirsung duct communicating with the cyst lesion. Surgical treatment is generally indicated for main duct IPMN and branch duct IPMN with suspected malignancy (tumour size ≥ 30 mm, mural nodules, dilated main pancreatic duct, or positive cytology) or prominent symptoms. Herein we present a case of IPMN of the main duct which occurred with abdominal and back pain associated with weight loss. After the diagnosis, she successfully underwent surgery and is now in a follow-up program.
Drug-induced lupus: simvastatin or amiodarone? A case report in elderly
Authors: Turrin Mauro , Martinelli Sergio
Published: June 2016

Reports of systemic lupus erythematosus (SLE) seen during treatment with amiodarone are rare in the literature. SLE or immunological abnormalities induced by treatment with statins are more frequent. In this issue we report a case of a 81-year-old male who, after a 2-year therapy with amiodarone, developed a clinical and serologic picture of drug-induced SLE (DILE). He was admitted for congestive heart failure in mechanical aortic valve prosthesis, permanent atrial fibrillation (anticoagulation with warfarin), hypercholesterolaemia, and hypothyroidism. Amiodarone was started two years earlier for polymorphic ventricular tachycardia, statin and L-thyroxine the following year. At admission he presented pleuro-pericardical effusion detected by CT-scan (also indicative of interstitial lung involvement) and echocardiography. Serological main indicative findings were: elevation of inflammatory markers, ANA (Anti-Nuclear Antibodies) titers = 1:320 (indirect immune-fluorescence – IIF – assay on HEp-2), homogeneous/fine speckled pattern, anti-dsDNA titers = 1:80 (IIF on Crithidia luciliae), negative ENA (Extractable Nuclear Antigens) and antibodies anti-citrulline, rheumatoid factor = 253 KU/l, normal C3-C4, negative HbsAg and anti-HCV, negative anticardiolipin antibodies IgG and IgM, negative anti-beta2GPI IgG and IgM. Amiodarone was discontinued and methylprednisolone was started, since the patient was severely ill. At discharge, after a month, the patient was better and pleuro-pericardical effusion was reduced. Readmitted few weeks later for bradyarithmia and worsening of dyspnoea, pericardial effusion was further reduced but he died for refractory congestive heart failure and pneumonia. Clinical picture (sierositis, neither skin nor kidney involvement), other typical side effects of amiodarone (hypothyroidism and lung interstitial pathology) and serological findings are suggestive of amiodarone-induced SLE.
Efficacy and tolerability of treatment with line II nilotinib in a patient with coronary artery disease
Authors: Roncoroni Elisa , Pioltelli Maria Luisa , Frustaci Anna Maria , Pungolino Ester , Morra Enrica
Published: June 2016

The possible cardiotoxicity of tyrosine kinase inhibitors (TKIs) is a topic of extreme interest because in the clinical practice it is frequent the management of elderly patients, in which are common comorbidities and polypharmacotherapies. Several studies have been conducted to evaluate the cardiotoxicity intrinsic to TKIs, but the results are, however, often discordant between in vitro studies and clinical practice. We present a case report about a male patient with several numerous comorbidities: COPD, diabetes mellitus and coronary artery disease. After the failure of imatinib therapy, the patient has switched in second-line to nilotinib therapy, 400 mg twice a day. The therapy was discussed and arranged with the cardiologists, with strict monitoring of cardiac and metabolic parameters. The therapy with nilotinib has allowed to obtain an optimal response according to the ELN guidelines and, from the sixth month of treatment, a major molecular response was obtained. From the standpoint of cardiologists, the patient has maintained a good compensation, despite the permanence of anginal symptoms, which required repeated therapeutic adjustments. Our case shows that nilotinib may be a well tolerated and effective therapy in a patient suffering from a major heart disease, maintaining a close clinical and cardiologic monitoring.
Efficacy of nilotinib in second line in an elderly patient with CML, suboptimal response and multiple comorbidities
Authors: Tomaselli Carmen
Published: June 2016

In this case report we describe the clinical case of an elderly patient with chronic myeloid leukemia and multiple comorbidities (heart disease, diabetes). Following the diagnosis of CML, in 2005 the patient had started treatment with imatinib 400 mg / day; therapy was well tolerated and never suspended until 2011, when he comes to the attention of our center. After re-evaluation of the disease, the patient is considered "failure" according to the recommendations ELN 2009. For this reason he switched to second generation tyrosine kinase inhibitor, nilotinib. After just 3 months of treatment with nilotinib the patient gets a complete cytogenetic response and a reduction of the transcript BCR/ABL %IS from 0,85 to 0,004. These results are still maintained, without any influence on pre-existing conditions.
Severe obsessive-compulsive disorder (OCD): socio-demographic and clinical features
Authors: Rigardetto Sylvia , Aguglia Andrea , Di Salvo Gabriele , Albert Umberto , Bogetto Filippo , Maina Giuseppe
Published: June 2016

Aim: the aim of the study is to evaluate the socio-demographic and clinical features with prognostic value in predicting evolution in severe OCD.Materials and methods: patients with a main diagnosis of OCD were recruited according to DSM-IV criteria. Socio-demographic and clinical features were assessed by mean of a semi-structured interview and clinical rating scales (Y-BOCS, HAM-A, HAM-D and SCID-II). Two subgroups were compared according to the severity of symptoms (severe vs mild-moderate).Results: the total sample was made up of 450 OCD subjects aged 34.5±12.1, with a mean age of onset 22.3±9.1; 215 subjects (47.8%) were females. Patients with severe OCD (Y-BOCS ≥ 32) showed a more insidious onset and a more chronic course compared to patients with mild-moderate symptoms. Other predictors of increased OCD severity were washing and hoarding compulsions. Lastly, the severity of the obsessive-compulsive condition was higher when it was associated either with mood disorders or with Axis II disorders (particularly Cluster A).Discussion: our study shows a correlation between severe OCD and severity predictors such as functional impairment and mood disorders. Furthermore washing and hoarding symptoms, lifetime comorbity with mood disorders and Cluster A personality disorders seem to predict OCD severity.
Budget impact analysis of the use of lapatinib in the treatment of breast cancer in Italy
Authors: Bamfi Francesco , Basso Federica , Aglietta Massimo , Bengala Carmelo , Lorusso Vito , Pronzato Paolo , Cavallo Maria Caterina , Zaniolo Orietta , Iannazzo Sergio
Published: June 2016

Objective: to estimate the impact of lapatinib utilization within the Italian National Health Service (NHS) resources consumption. Lapatinib is an oral inhibitor of kinase protein, approved as dual therapy with capecitabine for the treatment of metastatic breast cancer patients with HER2 overexpression who experience disease progression despite trastuzumab treatment. Methods: the analysis is based on a model, which structure can be summarized as follows: a) national cancer registries-based estimate of the yearly number of HER2+ breast cancer patients who develop metastatic disease in Italy; b) literature-based identification of the rate of patients eligible to receive lapatinib; c) identification of the current therapeutic strategy-mix; d) costing of the alternatives, and e) calculation of budget impact. Direct NHS costs (drug acquisition and administration, and monitoring for 8 cycles of 21 days) are estimated based on current Italian prices and tariffs. Results: the annual number of patients eligible for lapatinib-based therapy can vary from 1,676 to 2,172, according to the expected extent of the trastuzumab use as adjuvant therapy. The current strategy-mix beyond progression is based on drugs used in the clinical practice, with a portion of patients continuing trastuzumab. Pharmaceutical cost of lapatinib results higher than the average cost of the current pattern of treatments. This cost increase would be partially offset by the reduction of laboratory tests and hospital personnel work for the oral administration of lapatinib, as compared to intravenous strategies. Furthermore, a risk sharing agreement has been adopted by NHS and manufacturer, according to which the NHS pays only for responding patients. As a consequence, lapatinib-based therapy would increase yearly NHS expenditure by about 3.8-4.9 millions of euro. Conclusions: lapatinib is the only treatment option specifically indicated for the management of HER2+, metastatic breast cancer in patients who received prior treatments including trastuzumab and is estimated to induce a low budget impact for the Italian NHS.
The clinical and economic value of the dipeptide alanyl-glutamine in total parenteral nutrition of critically ill patients treated in intensive care units in Italy
Authors: Muscaritoli Maurizio , Pradelli Lorenzo , Zaniolo Orietta , Iannazzo Sergio , Eandi Mario
Published: June 2016

Introduction: the supplementation of alanyl-glutamine dipeptide in critically ill patients necessitating total parenteral nutrition (TPN) improves clinical outcomes, reducing mortality, infection rate, and shortening ICU hospital lengths of stay (LOS), as compared to standard TPN regimens. Here we present a pharmacoeconomic evaluation of alanyl-glutamine dipeptide in critically ill patients admitted to Italian Intensive Care Units (ICUs). Methods: a Discrete Event Simulation model that incorporates outcomes rates from 200 Italian ICUs for over 60,000 patients, alanyl-glutamine dipeptide efficacy data synthesized by means of a Bayesian Random-Effects meta-analysis, and national cost data has been developed to evaluated the alternatives from the point of view of the hospital. Simulated clinical outcomes are death and infection rates in ICU, death rate in general ward, and hospital LOSs. One-way and probabilistic sensitivity analyses are performed by varying all uncertain parameter values in a plausible range. Results: alanyl-glutamine dipeptide results more effective and less costly than standard TPN: reduced mortality rate (23.55% ± 15.2% vs 34.50% ± 2.06%), infection rate (15.91% ± 3.95% vs 18.97% ± 3.94%), and hospital LOS (25.47 ± 0.26 vs 26.00 ± 0.27 days) come at a lower total cost per patient (23,922 ± 3,249 vs 24,145 ± 3,361 Euro). Treatment cost is completely offset by savings on ICU and antibiotic costs. The cost/effectiveness acceptability curve indicates an estimated 78% probability of alanyl-glutamine dipeptide resulting dominant and a 90% probability of resulting cost/effective for a willingness to pay up to 1,500 Euro for one patient death avoided. Conclusions: alanyl-glutamine dipeptide is expected to improve clinical outcomes and to do so with a concurrent saving for the hospital.