Clinical Evaluation of Adrenal Incidentaloma: The Experience of a Referral Center.

The number of adrenal incidentaloma (AI) cases has increased in the last few years due to the widespread use of imaging diagnostics. Management requires evaluation of the malignant nature and hormonal activity. The aim of the present study is to assess possible clinical abnormalities in 132 AI patients both at baseline and during follow-up (mean 48.6 ± 12.5 months). In all patients, demographic, anthropometric data, biochemical, metabolic and hormonal data, and 24-h ambulatory blood pressure monitoring were assessed. Mild autonomous cortisol secretions (MACS) were diagnosed in patients without signs and symptoms of overt Cushing's syndrome and post dexamethasone (DXM) plasma cortisol concentration > 50 nmol/L (>1.8 µg/dL). Patients with overnight DXM-1 mg test positive showed higher values of diastolic blood pressure, glycemia and uric acid levels compared to patients with negative DXM test at baseline. During follow-up, the potential development of MACS in patients with nonfunctional AI showed a prevalence of 29%, though the cardiovascular and metabolic alterations were less pronounced compared to those diagnosed with MACS at baseline. Therefore, follow-ups with AI patients are useful for observing changes in clinical features.

Clinical impact of transient lymphopenia.

Transient or persistent immunosuppression is a known risk factor for morbidity and mortality in critically ill patients. Aim of the present study is to evaluate the lymphopenia in patients admitted to the Emergency Unit of AOU Policlinico Umberto I, to investigate its prevalence at admission and the persistence during hospitalization until discharge. Possible correlations were evaluated between lymphopenia, diagnosis of admission, comorbidities and chronic treatments. In this study, 240 patients (142 men; 98 female; mean age 75.1 ± 15.1) were enrolled. Patients were divided into two groups according to the lymphocytes count at hospital admission, namely "Group A" with lymphopenia and "Group B" with values in the normal range. Moreover, the patients in group A were distinguished in relation to the regression or persistence of the lymphopenia assessed at the time of hospital discharge (Group A1: persistence; Group A2: normalization). Prevalence of lymphopenia at admission was 57%; Group A showed higher mean age and percentage of patients over 65 years of age; and none differences were observed regarding gender. Prevalence of lymphopenia at admission was 57%; Group A showed higher mean age and percentage of patients over 65 years of age; no differences were observed regarding gender. All subsets of the lymphocytes (CD4+, CD8+, NK) were equally reduced. Persistent lymphopenia was found in 19% of patients. Lymphopenia should be valued at the time of hospital admission as a factor influencing the prognosis, the management and the treatment of these patients.

Relevance of obesity-related organ damage and metabolic syndrome classification in cardiovascular and renal risk stratification in patients with essential hypertension.

Introduction: Hypertension is a relevant cardiovascular comorbidity. Adipose tissue represents a metabolically active tissue involved in the regulation of blood pressure and metabolic alterations. In recent decades, several classifications for the metabolic syndrome (MS) have been proposed. Recently, a new syndrome called the "Cardiovascular-kidney-metabolic" (CKM) syndrome was identified, to determine patients at high cardiovascular and metabolic risk. The aim of the study was to compare different classifications in a large population of hypertensive patients. Materials and methods: Between September 2022 and August 2023, we consecutively enrolled 772 hypertensive patients (407 men; 365 women; mean age 52.2 ± 15.1 years), evaluating anthropometric, biochemical, and instrumental parameters (transthoracic echocardiogram, carotid echo-Doppler, 24-h ambulatory blood pressure monitoring, fundus oculi). Results: Using different classifications we found MS prevalence: Adult Treatment Panel III (ATP-III) 28.8%, International Diabetes Federation (IDF) 31.5%, CKM 40.7%. CKM Classes 3 and 4 showed higher body mass index and waist circumference compared with other groups. Compared with ATP-III and IDF, CKM Class 4 showed higher 24-h systolic blood pressure, lower percentage of controlled hypertension, increased interventricular septum and posterior wall, reduced ejection fraction, and greater prevalence of hypertensive arterial retinal damage. Discussion: Visceral obesity and MS are frequent conditions with healthy impact, becoming an important trigger for the development of cardiovascular and metabolic complications. The different MS classifications allow the early identification of patients at high risk of cardiometabolic complications. The new CKM syndrome proves useful to identify individuals at high risk for CKM morbidity and mortality.

Pulmonary embolism post-Covid-19 infection: physiopathological mechanisms and vascular damage biomarkers.

Covid-19 infection is characterized by several acute complications, as well long-term sequelae, mostly sustained by endothelial dysfunction; several studies show that complications as pulmonary embolism (PE) are described both in the acute phase and after negativization. Aim of research was to evaluate anthropometric, bio-humoral, instrumental parameters in a group of patients affected by PE after recent Covid-19 infection compared to PE patients without previous Covid-19 infection. We enrolled 72 consecutive patients (35M, 37F) with acute PE, distinguished in relation to previous acute Covid-19 infection: 54 pts without previous acute Covid-19 infection and 18 pts with previous Covid-19 infection within negativity at least 2 months before PE diagnosis; 44 healthy subjects (21M, 23F) were recruited as control group. Patients who had previously developed Covid-19 needed hospitalization in high percentage (84%); this group showed significantly higher prevalence of diabetes mellitus than Covid-19-free PE patients, reduced serum levels of C-reactive protein, sST2 and PESI score. In post-Covid-19 PE group, we observed higher mean IMPROVE risk score, whereas in Covid-19-free group lower P/F ratio, higher radiological severity, and worse PESI score and severity index. Covid-19 infection affects not just the lung parenchyma but also other organs; endothelial damage plays pivotal role in long-term alterations; in high thrombotic risk group (recent hospitalization due to acute Covid-19 infection), we have described thrombotic complications characterized by persistent prothrombotic state after recovery, highlighted by well-known markers as PCR and D-Dimer as well as novel vascular marker (sST2).

Assessment of sST2 Behaviors to Evaluate Severity/Clinical Impact of Acute Pulmonary Embolism.

Pulmonary embolism (PE) is a potentially life-threatening disorder. Beyond its usefulness in the prognostic stratification of heart failure, sST2 can represent a biomarker with high utility in several acute conditions. Our study was aimed to investigate whether sST2 can be used as a clinical marker of severity and prognostic outcome in acute PE. We enrolled 72 patients with documented PE and 38 healthy subjects; we measured the plasma concentrations of sST2 to evaluate the prognostic and severity performance of different levels of sST2 according to its association with the pulmonary embolism severity index (PESI) score and several parameters of respiratory function. PE patients had significantly higher levels of sST2 compared with healthy subjects (87.74 ± 17.1 vs. 17.1 ± 0.4 ng/mL, p < 0.001); we found higher PESI scores and serum lactate values in the group of patients with sST2 > 35 ng/mL compared with patients with sST2 < 35 ng/mL (138.7 ± 14.9 vs. 103.7 ± 15.1 and 2.43 ± 0.69 vs. 1.025 ± 0.05 mmol/L, respectively; p < 0.05). Patients with sST2 > 35 ng/mL showed higher radiological severity of PE compared with patients with sST2 < 35 ng/mL. Moreover, sST2 was the strongest parameter with a discriminative capacity for the development of acute respiratory failure and a PESI score >106 with respect to C reactive protein (CRP), creatinine, d-dimer, and serum lactate. We clearly demonstrated that sST2 significantly increased in PE and that its elevation was associated with disease severity. Therefore, sST2 may be used as a clinical marker in the evaluation of PE severity. However, further studies with larger patient populations are required to confirm these findings.

Time to hospitalisation, CT pulmonary involvement and in-hospital death in COVID-19 patients in an Emergency Medicine Unit.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) are often treated at home given the limited healthcare resources. Many patients may have sudden clinical worsening and may be already compromised at hospitalisation. We investigated the burden of lung involvement according to the time to hospitalisation. METHODS: In this observational cohort study, 55 consecutive COVID-19-related pneumonia patients were admitted to the Emergency Medicine Unit. Groups of lung involvement at computed tomography were classified as follows: 0 (<5%), 1 (5%-25%), 2 (26%-50%), 3 (51%-75%) and 4 (>75%). We also investigated in-hospital death and the predictive value of Yan-XGBoost model and PREDI-CO scores for death. RESULTS: The median age was 74 years and 34 were men. Time to admission increased from 2 days in group 0 to 8.5-9 days in groups 3 and 4. A progressive increase in LDH, CRP and d-dimer was found across groups, while a decrease of lymphocytes paO2 /FiO2 ratio and SpO2 was found. Ten (18.2%) patients died during the in-hospital staying. Patients who died were older, with a trend to lower lymphocytes, a higher d-dimer, creatine phosphokinase and troponin T. The Yan-XGBoost model did not accurately predict in-hospital death with an AUC of 0.57 (95% confidence interval [CI] 0.37-0.76), which improved after the addition of the lung involvement groups (AUC 0.68, 95%CI 0.45-0.90). Conversely, a good predictive value was found for the original PREDI-CO score with an AUC of 0.76 (95% CI 0.58-0.93) which remained similar after the addition of the lung involvement (AUC 0.76, 95% CI 0.57-0.94). CONCLUSION: We found that delayed hospital admission is associated with higher lung involvement. Hence, our data suggest that patients at risk for more severe disease, such as those with high LDH, CRP and d-dimer, should be promptly referred to hospital care.

Cerebral perfusional effects of 1-year rivastigmine treatment in Alzheimer disease: a case report.

It is described the case of a 74-years-old woman with probable Alzheimer Disease who showed good clinical response to rivastigmine associated with relevant improvement of cerebral perfusion after 1 year of treatment. The single-photon emission computed tomography (SPECT) scan showed a significant improvement in cortical uptake of the tracer in temporo-parietal and frontal regions in comparison to the examination performed before the treatment.

Olfactory Dysfunction, Olfactory Bulb Volume and Alzheimer's Disease: Is There a Correlation? A Pilot Study1.

BACKGROUND: Olfactory dysfunction is present since the earliest stage of Alzheimer's disease (AD). In AD patients, the olfactory impairment has been correlated with atrophy of some structures of the olfactory system, but the role of the olfactory bulb remains unclear. OBJECTIVE: The aim of our work is to test if patients suffering from AD exhibit a statistically significant reduction of the average volume of the olfactory bulb (OBV) compared to healthy subjects. METHODS: 78 subjects were enrolled in the study and divided into three groups: 28 healthy elderly (22 females, 6 males, mean age 69.4 ± 9.2), 25 patients with mild cognitive impairment (MCI) amnestic type (14 females, 11 males, mean age 74.5 ± 7.5), and 25 mild AD patients (14 females, 11 males, mean age 73.7 ± 6.8). Every subject underwent an MRI study of the olfactory bulb and an olfactory assessment with the Sniffin' Stick Extended Test. RESULTS: The statistical analysis showed no correlation between the OBV and MCI or AD. Moreover, olfactory function and OBV were not correlated in any of the three groups. CONCLUSION: The reduction of OBV does not seem to represent an index of neuronal damage in the earliest stages of AD.

[Physical and psychological stress in a group of Italian caregivers: a new medical emergency? A pilot study]. / Stress psicofisici in un gruppo di operatori sanitari italiani; nuova emergenza medica? Uno studio pilota.

INTRODUCTION: this study aimed to evaluate physical and psychological stress in a group of italian caregivers. METHODS: 20 subjects were enrolled in the study and divided into 2 groups: 10 healthy controls and 10 caregivers. Every subject underwent an cognitive, clinical and instrumental assessment. RESULTS: the statistical analysis showed an increased presence of pathological alterations in caregivers group such as decreased ejection fraction, cognitive impairment and depressed mood. CONCLUSIONS: the study shows the figure of a elderly caregiver, predominantly women, who spend many hours in patient care. The caregiver-type takes about four drugs a day and is not involved in screening programs offered by the health service for his age group. Results a high risk of social isolation, emotional fragility and an increased risk of cardiovascular events and cognitive impairment.

Olfactory deficit and hippocampal volume loss for early diagnosis of Alzheimer disease: a pilot study.

BACKGROUND: The aim of this pilot study was to verify the role of olfactory test and volumetric magnetic resonance imaging measure of hippocampus to predict conversion from mild cognitive impairment to Alzheimer disease (AD). MATERIALS AND METHODS: Eighteen patients with amnesic mild cognitive impairment, broadly defined, were followed at 12 months. Hypothesized baseline predictors for follow-up conversion to AD were olfactory deficit and hippocampal volumes loss. RESULTS: In the 1-year follow-up, 5 patients converted to AD. The 2 clinical predictors olfactory test and hippocampal volume loss showed the same sensitivity of 92.3% but the olfactory test showed a higher specificity than the hippocampal volume loss (75% vs. 60%). CONCLUSIONS: Our findings suggest the potential utility of olfactory test and hippocampal volume loss for early detection of AD.

Depressive symptoms in older people with metabolic syndrome: is there a relationship with inflammation?

OBJECTIVE: To investigate if there is a higher prevalence of depressive symptoms in older people with metabolic syndrome (MetS) compared with those without and whether dedpressive symptoms are independently associated to MetS and its single components and to the inflammatory markers. METHODS: Physical parameters, standard blood analytes, high sensitivity C-reactive protein (hsCRP) and erythrocyte sedimentation rate (ESR) were assessed. Fifteen-item Geriatric Depression Scale and mini mental state examination (MMSE) were administered. RESULTS: One hundred thirty-three subjects were enrolled. MetS patients (57) exhibited higher prevalence of depressive symptoms (p < 0.0001), worse cognitive function (p < 0.0001), and higher levels of ESR and hsCRP were higher (p < 0.0001). The univariate analysis showed a linear strong correlation of depressive symptoms (p < 0.0001) with the MMSE score (r = -0.422), body mass index (r = 0.414), MetS (r = 0.582), number of MetS components (r = 0.663), fasting blood glucose (r = 0.565), ESR (r = 0.565), hsCRP (r = 0.745), central obesity (r = 0.269; p = 0.002), and high-density lipoprotein cholesterol (r = -0.241; p = 0.005). However, the multivariate analysis showed that only age (B = -0.093; p = 0.032), MetS (B = 1.446; p = 0.025), fasting blood glucose (B = 0.039; p = 0.005), and hsCRP (B = 7.649; p < 0.0001) were independently associated with depressive symptoms. CONCLUSIONS: MetS and inflammation are independently associated with depressive symptoms in older people. Inflammation may explain cognitive decline too. Further investigations are needed to better understand the direction of these associations and to determine whether these can be reversible.

[Predictors of liver fibrosis in patients with non-alcoholic fatty liver disease. The role of metabolic syndrome, insulin-resistance and inflammation]. / Predittori di fibrosi epatica in pazienti con steatosi epatica non-alcolica. Il ruolo della sindrome metabolica, dell'insulino-resistenza e dell'infiammazione.

INTRODUCTION: NAFLD (non-alcoholic fatty liver disease) reaches an high prevalence in the general population, and it is closely related to metabolic syndrome (MetS). The entity of metabolic abnormalities and the chronic inflammation seem to play a main role in the development of liver fibrosis. The aim of our study is to determine whether subjects with NAFLD and MetS have higher liver fibrosis degree when compared with NAFLD subjects without MetS, and to investigate the relations between fibrosis, MetS and its single components and inflammation. MATERIALS AND METHODS: We considered 24 patients with NAFLD. Those who had viral- and alcohol- related liver disease were excluded. MetS was diagnosed according to NCEP ATP III criteria; inflammatory status was determined through C-reactive protein (PCR) assay. The peripheral insulin-resistance was assessed by calculating HOMA ir. Liver fibrosis was measured by transient elastography (Fibroscan®). RESULTS: Subjects with MetS had higher HOMA ir, PCR and Fibroscan® score (log value: 0.92±0.24 KPa vs 0.73±0.2 KPa; p=0.047). The linear correlation analysis showed that Fibroscan® score was related to MetS, number of MetS components, waist circumference, HOMA ir and PCR. However the multivariate regression analysis showed that only HOMA ir (B=0.077; 95%CI: -0.002- 0.157; p=0.05) and PCR (B=0.152; 95% CI: 0.006 - 0.299; p=0.006) were independent predictors of higher Fibroscan® score. CONCLUSION: MetS is associated to higher liver fibrosis degree in subjects with NAFLD. The insulin-resistance and inflammation seem to be the main determinants.

[Geriatric telecare, a new model of assistance: a pilot study]. / Teleassistenza geriatrica continua. Nuovo modello di supporto all'anziano fragile: progetto pilota.

Aim of this pilot study was to evaluate the feasibility and explore the patients' acceptance of the -telecare model. The objective of this trial was to investigate the effects of a telecare system on elderly management at home. In a 24-months prospective study we enrolled all patients aged >65 years at risk of disability. During the two years of observation, each patient contact the TELECARE system. Telephone contact was followed by specific intervention and administration of a questionnaire evaluation. Over the 24 months we recorded 90,000 calls and 13,000 elderly were included in the telecare project. We analyzed the calls and the measures adopted. Our findings provide evidence of improved quality of life through clinical management at home from a telecare system. The use of this system had high adherence and was feasible for elderly patients and their family.

Screening cognition in the elderly with metabolic syndrome.

BACKGROUND: Metabolic syndrome reaches its highest prevalence in the elderly, and evidence suggests that metabolic syndrome could be an independent risk factor for cognitive impairment. The aims of this study were to detect whether patients with metabolic syndrome have lower cognition and to investigate whether there is a relationship with cognition and single metabolic syndrome components. METHODS: We assessed fasting blood glucose (FBG), high-density lipoprotein cholesterol (HDL-C), triglycerides, high-sensitivity C-reactive protein (hsCRP), and anthropometric measurements. Metabolic syndrome was diagnosed according to National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. The population sample was divided into two groups according to the presence of metabolic syndrome. Cognitive function was investigated through the Mini-Mental State Examination (MMSE). RESULTS: We enrolled 159 elderly subjects (mean age, 69.8±4.8 years). Seventy had metabolic syndrome. Metabolic syndrome subjects had higher hsCRP values (P<0.0001) and lower MMSE scores (P<0.0001) than those without metabolic syndrome. MMSE scores were significantly correlated with body mass index (BMI), hsCRP, metabolic syndrome, the number of metabolic syndrome components, and each of them. However, at multivariate regression analysis, only fasting blood glucose [FBG; B=-0.046; 95% confidence interval (CI) -0.066 to -0.028; P<0.0001] and the number of metabolic syndrome components (B=-0.317; 95% CI -0.572 to -0.010; P=0.042) were found to be independent predictors of lower MMSE scores. CONCLUSION: We found that subjects with metabolic syndrome have lower MMSE scores than those without, even without symptomatic cognitive impairment, and that the number of metabolic abnormalities is independently associated to lower MMSE scores. We suggest that these patients should always undergo cognitive screening to prevent more severe outcomes.

[Vascular depression in the elderly. Does inflammation play a role?]. / La depressione vascolare nell'anziano. Quale ruolo per l'infiammazione?

Vascular depression in the elderly. Does inflammation play a role?Depression is the most common comorbidity in the elderly, and it is a major determinant of disability. The late-onset depression in highly associated to cardiovascular disease. Depressive symptoms may follow vascular brain damage, especially when mood regulating areas are affected. However depression is strongly associated to vascular disease even when there is no manifest brain damage. Recently great attention has been given to chronic inflammation, both related to depression and vascular disease. Both experimental and clinical evidence shows that a rise in the concentrations of proinflammatory cytokines and glucocorticoids in depressed patients is associated with defect in serotonergic function. Chronic inflammation may underlie many forms of depression associated with vascular disease and metabolic syndrome. The importance of the inflammation hypothesis of depression lies is that psychotropic drugs may have central anti-inflammatory action, and that new generation of central anti-inflammatory drugs may be useful in depression treatment.