Volume 57 (2019): Edizione 2 (June 2019)

Introduction. The severity of liver fibrosis can be assessed noninvasively today by liver stiffness measurements. Vibration-controlled transient elastography, shear wave elastography or magnetic resonance elastography are techniques increasingly used for this purpose.

Methods. This article presents the recent advances in the use of new techniques for liver fibrosis assessment in chronic hepatitis C: the correlation between liver stiffness values and liver fibrosis estimated by liver biopsies, the prognosis role of liver stiffness values, their usefulness in monitoring the treatment response, in assessing the severity of portal hypertension and in estimating the presence of esophageal varices. Scientific articles from January 2017 to January 2018 were searched in PubMed and PubMed Central databases, using the terms “liver stiffness” and “hepatitis C”.

Results. The median liver stiffness values measured with different techniques are not identical, so that FibroScan thresholds cannot be used on any other elastographic machine. The higher the liver’s stiffness measurement, the higher the liver-related events in patients with chronic hepatitis C. A liver stiffness measurement over 17 kPa could be an independent predictor for the presence of esophageal varices as well as a spleen with a longitudinal span ≥ 15 cm for patients with a value of liver stiffness < 17 kPa. A progressive and persistent decrease in liver stiffness is dependent on sustained virological response achievement. The lack of liver stiffness decrease has been associated with relapsers and a low value of liver stiffness at baseline.

Conclusion. Liver stiffness provides clues about the severity and evolution of liver disease.

Atrial fibrillation (AF), as the most common cardiac arrhythmia worldwide, is associated with increased mortality and morbidity. Successful therapeutic strategies have been introduced so far, but they are associated with significant costs. Therefore, identification of modifiable risk factors of AF and the development of appropriate preventive strategies may play a substantial role in promoting community health and reducing health care system costs. Modifiable cardiovascular risk factors including obesity, hypertension, diabetes mellitus, obstructive sleep apnea, alcohol consumption, smoking, and sedentary lifestyles have been proposed as possible contributors to the development and progression of AF. In this review, we discuss the role of modifiable risk factors in the development and management of AF and the evidence for the underlying mechanism for each of the potential risk factor.

Background. In the last years an uprising interest for a relatively unknown entity, eosinophilic ascites (EA), has been recorded.

Our aim is to investigate the potential causes of EA development, as well as clinical, laboratory, endoscopic and radiologic features, management and outcome in these patients.

Methods. The following research was performed on PubMed (MEDLINE) database using the medical subject headings [Mesh] terms “Ascites” AND “Eosinophils”.

Results. A total of 284 results, dating from 1962 onwards, were found and abstracts were examined. 131 papers were excluded and the remaining 153 publications, consisting in case reports and series of cases, were analyzed.

From 171 patients with EA, 127 subjects (74%) had EGE, 17 (10%) parasitic and fungal infections, 11(7%) Hypereosinophilic syndrome and 16 patients (9%) less common diseases (eosinophilic pancreatitis, chronic eosinophilic leukemia, myelofibrosis, T-cell lymphoma, Churg Strauss Syndrome, Systemic lupus erythematosus, Familial paroxysmal polyserositis and Ménétrier’s disease). High eosinophil blood count and IgE levels as well as gastrointestinal symptoms are frequent. The diagnosis is based on ascitic fluid analysis, imaging and endoscopic biopsies. Therapy with corticosteroids results in resolution of eosinophilic ascites in almost all patients.

Conclusion. In most cases, in the absence of allergy, parasitic infections, malignancy, hematological disorders, peritoneal tuberculosis, inflammatory bowel disease or autoimmune disease, EA develops as a manifestation of eosinophilic gastroenteritis.

Introduction. Diabetes Control and Complications Trial has established the importance of glycemic control in reducing the progression of retinopathy, nephropathy, and neuropathy in type 1 diabetics. There is little literature linking the frequency of glycemic monitoring with glycated hemoglobin A (HbA1c) in type 2 diabetics. The objectives were to assess the influence of glycemic self-monitoring on HbA1c in three groups of patients with type 2 diabetes (with insulin, with oral antidiabetics and with combination therapy).

Methods. The glucometer capillary surveys of 117 patients were counted in the 30 days prior to the visit to the Integrated Diabetes Unit at Centro Hospitalar Tondela-Viseu. In the three groups considered, sociodemographic characteristics (age, gender, area of residence, household and schooling) were evaluated and compared.

Results. There was no statistically significant association between HbA1c and the frequency of capillary glucose in any of the groups. In the evaluation of sociodemographic data, contrary to what was expected, the area of residence and schooling did not influence the value of HbA1c.

Conclusion. These results question the role of glycemic monitoring in the metabolic control of type 2 diabetics, highlighting the need to implement therapeutic education programs so that these patients can adequately intervene in the therapeutic adjustment as a function of the information obtained by capillary glycemia.

Introduction. It is known that hyperlipidemia reduces hearing functions. In this study, we aimed to study the effect of antihyperlipidemic drugs on hearing functions and tinnitus.

Methods. Eighty-four patients aged 18 to 84, who were diagnosed with hyperlipidemia and started treatment with the statin group (atorvastatin 20 mg and 40 mg, rosuvastatin 10 mg and 20 mg, and simvastatin 20 mg) of antihyperlipidemic drugs, were included in this study. All patients underwent pure-tone audiometry before starting treatment with antihyperlipidemic drugs. Patients with tinnitus were evaluated by Tinnitus Severity Index and Visual Analogue Scale. In the 6th month of therapy, otologic examination, pure-tone audiometry and tinnitus evaluation of the patients were repeated.

Results. No significant difference was found in the pure-tone averages of the patients before and after statin use (p > 0.05). However, it was found in the audiometry that, after statin use, all drugs caused to statistically significant decrease in the hearing thresholds at 6000 Hertz (p < 0.05). Also, a strong increase was found in the Speech Discrimination percentages after treatment in patients using rosuvastatin 10 mg (p = 0.022). A significant decrease was found in the tinnitus frequency, duration, severity and degree of annoyance in patients using rosuvastatin 10 mg and 20 mg (p < 0.05).

Conclusion. Statin group of drugs can have a positive effect on the hearing functions and subjective tinnitus. In particular, it is seen that rosuvastatin group of statins has a more notable effect on tinnitus. It was considered that further studies with larger patient groups are needed.

Introduction. Circulating autoantibodies against phospholipase A2 receptor (anti-PLA2R) are recognized as key elements in the pathogenesis of idiopathic membranous nephropathy. In current clinical practice, they are increasingly gaining attention as novel tools for diagnosis and disease monitoring. We investigated the diagnostic and prognostic utility of anti-PLA2R antibody measurements in Greek patients with biopsy-proven membranous nephropathy.

Methods. Anti-PLA2R levels were measured in serum samples from 33 patients at diagnosis using ELISA and were associated with treatment outcome. Moreover, serial anti-PLA2R measurements were performed in 15 patients under different clinical conditions and level alterations were correlated with disease activity.

Results. Positive anti-PLA2R antibodies at diagnosis were found in 16 of 33 patients (48.5%). Anti-PLA2R levels were independently associated with the achievement of complete remission of nephrotic syndrome after immunosuppressive treatment compared to partial remission (p = 0.02, R² = 0.265, 95%CI -0.019 to -0.0003). Higher detectable antibody levels at diagnosis were correlated with higher proteinuria levels (r = 0.813, p = 0.0001, 95%CI 0.532 to 0.933) and lower eGFR at the end of follow-up (r = -0.634, p = 0.0083, 95%CI -0.86 to -0.202). Serial antibody measurements during follow-up showed that anti-PLA2R titers were significantly reduced at the end of treatment after complete remission was achieved, remained low under sustained clinical remission, and increased during relapse.

Conclusions. Our findings confirm the usefulness of anti-PLA2R measurements in the diagnosis of idiopathic membranous nephropathy. Low levels of anti-PLA2R antibodies at diagnosis are predictive of complete remission of nephrotic syndrome following immunosuppressive treatment. Serial anti-PLA2R measurements correlate well with clinical status throughout the follow-up period and could be used routinely for monitoring of disease activity and treatment planning.

Background. Endoscopic retrograde cholangiopancreatography has evolved significantly in recent years. The increase in complexity and range of applications has not been adequately reflected in an improvement of training methods for ERCP, with many endoscopists failing to meet required performance standards during their training period and limited available data on their performance immediately after completing training. We aimed to analyze the performance of an independent operator from a developing country after the completion of formal training with regard to procedure and patient-related outcomes.

Methods. We conducted an observational study of ERCPs performed by a young endoscopist from a referral center. Data about the procedure, cannulation technique (including use of precut), trainee involvement and procedure-related outcomes was retrieved and analyzed from a prospectively maintained database on quality in ERCP (the QUASIE initiative).

Results. Data from 679 consecutive ERCPs conducted or supervised by one endoscopist with < 200 independent procedures prior to the study period were included in the final analysis. Cannulation rates significantly improved over time, from 90% to 96% (p = 0.016). Use of precut techniques changed significantly over time, with an initial increase followed by a subsequent decrease as overall cannulation rates improved. Trainee involvement was significantly associated with prolonged cannulation times (p = 0.003) and use of precut (p = 0.001), but did not impact on technical success or patient safety.

Conclusions. Independent practice of ERCP after the training period is characterized by ongoing changes in technique, especially with regard to cannulation and use of precut, showing significant improvements in performance over time.

Background. Platelet to lymphocyte ratio (PLR) has been demonstrated as a risk and prognostic marker in many of cardiovascular diseases. A relationship between PLR and severity of carotid stenosis has been shown. The aim of our study was to investigate the relationship between PLR and all cause mortality in patients with carotid arterial disease.

Methods. This retrospective study included 146 patients who had been performed selective carotid angiography. Carotid stenosis were graded by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Platelet to lymphocyte ratio was calculated as the ratio of platelets to lymphocytes. The end point of the study was all-cause mortality.

Results. During median follow-up of 16 months (0-65 months) 15 (10.3%) patients suffered all-cause mortality. 50 patients (34.2%) underwent carotid endarterectomy and 69 patients (47.3%) had non-carotid cardiac surgery. 38 patients (26.02%) had cerebrovascular events (stroke/transient ischemic attack) at admission. NASCET grades were not different between survivors and non-survivors. Non-survivors had significantly lower hemoglobin (Hb) levels (12.7 ± 1.6 g/dL vs. 13.7 ± 1.7 g/dL, p = 0.031) and they were older than survivors (74.2 ± 8.4 years vs. 68.6 ± 8.5 years, p = 0.029). Non-survivors had significantly higher PLR values compared with survivors (190.3 ± 85.6 and 126.8 ± 53.8, p = 0.017). In multivariate analysis, only PLR predicted all-cause mortality in patients with carotid artery stenosis.

Conclusion. In our study, higher PLR was associated with increased all-cause mortality.

Introduction. Eosinopenia has been previously investigated as a marker to differentiate infectious from non-infectious diagnoses and as a prognostic marker. Most previous studies were conducted in intensive care unit patients. Our study focuses on the value of eosinopenia in patients admitted to the Internal Medicine department.

Methods. We retrospectively analyzed 271 consecutive patients with infection and 31 patients presenting with fever or inflammatory syndrome and a non-infectious diagnosis. We evaluated and compared the following markers for differentiating infectious from non-infectious diagnoses: eosinophil count [EC], CRP, WBC and neutrophil-to-lymphocyte count ratio [NLCR]. We also evaluated the value of eosinopenia as a monitoring parameter in patients with infections.

Results. Eosinopenia at admission was found in 71% of patients with infection compared to 32% in the non-infection group. EC and NLCR were moderate markers for discriminating infection from non-infection, with an area under the receiver operating characteristic curve of 0.789 and 0.718 respectively. Significant eosinopenia (≤ 10/µL) had a high specificity (90%) for diagnosing infections. High EC at admission (> 400/µL) was rare in the infection group (1.5%), but not uncommon in the non-infection group (25.8%). Persistent eosinopenia was noted in non-survivors, compared to the rapid normalization of EC in survivors.

Conclusions. Among patients presenting with fever and/or high inflammatory markers a low EC is supportive of infection, while a high EC may suggest non-infectious diagnoses. The persistence/ resolution of eosinopenia may be a useful monitoring parameter to predict response to therapy.

Introduction. Changes in thyroid hormone level can affect the cardiovascular system. The aim of this study was to show how the Tpeak -Tend (Tpe) interval, which is a new marker of ventricular arrythmia, is affected in patients who have become euthyroid following Levothyroxine treatment for hypothyroidism, as this has not been examined previously in literature.

Materials and Methods. This, cross-sectional study included a total of 119 females aged 18-45 years, separated into 3 groups as hypothyroid, euthyroid and control groups. For evaluation of the QTc and Tpe intervals, examination on precordial V5 lead was made of all the ECGs taken routinely on presentation of the patients.

Results. The Tpe and QTc intervals of the hypothyroid group were determined to be significantly prolonged compared to those of the euthyroid and control groups (p < 0.001) and the values of the euthyroid and control groups were similar. A positive correlation was determined between TSH levels and Tpe and QTc intervals. Tpe interval AUC = 0.801 (%95 CI: 0.719 – 0.884) was higher than that of QTc AUC = 0.689 (%95 CI: 0.591 – 0.786).

Conclusions. The Tpe duration was evaluated in respect of the risk of arrythmia in hypothyroid patients. In patients who had become euthyroid, the Tpe interval was found to be similar to that of healthy individuals and was more predictive than QTc. In the light of these findings it can be recommended that measurement of the Tpe interval should be preferred to QTc as a marker of the arrythmogenic effect in hypothyroid patients.

Quality of care in medicine is not necessarily proportional to quantity of care and excess is often useless or even more, potentially detrimental to our patients. Adhering to the European Federation of Internal Medicine’s initiative, the Romanian Society of Internal Medicine (SRMI) launched the Choosing Wisely in Internal Medicine Campaign, aiming to cut down diagnostic procedures or therapeutics overused in our country. A Working Group was formed and from 200 published recommendations from previous international campaigns, 36 were voted as most important. These were submitted for voting to the members of the SRMI and posted on a social media platform. After the two voting rounds, the top six recommendations were established.

These were:

1. Stop medicines when no further benefit is achieved or the potential harms outweigh the potential benefits for the individual patient.

2. Don’t use antibiotics in patients with recent C. difficile without convincing evidence of need.

3. Don’t regularly prescribe bed rest and inactivity following injury and/or illness unless there is scientific evidence that harm will result from activity. Promote early mobilization.

4. Don’t initiate an antibiotic without an identified indication and a predetermined length of treatment or review date.

5. Don’t prescribe opioids for treatment of chronic or acute pain for sensitive jobs such as operating motor vehicles, forklifts, cranes or other heavy equipment.

6. Transfuse red cells for anemia only if the hemoglobin concentration is less than 7 g/dL or if the patient is hemodynamically unstable or has significant cardiovascular or respiratory comorbidity. Don’t transfuse more units of blood than absolutely necessary.

Background. Shared decision making (SDM) is becoming more and more important for the patient-physician interaction. There has not been a study in Romania evaluating patients’ point of view in the SDM process yet. Therefore, the present study aims to evaluate the psychometric parameters of the translated Romanian version of SDM-Q-9.

Material and methods. A multicentric cross-sectional study was performed comprising eight recruitment centers. The sample consisted of in- and outpatients who referred to Hospital Units for treatment for atrial fibrillation or collagen diseases. Furthermore, patients who were members of Autoimmune Disease Patient Society were able to participate via an online survey. All participants completed the Romanian translated SDM-Q-9.

Results. Altogether, 665 questionnaires were filled in within the hospital setting (n = 324; 48.7%) and online (n = 341; 51.3%). The Romanian version had good internal consistency (Cronbach α coefficient of 0.96.) Corrected item correlations were good ranging from 0.64 to 0.89 with low corrected item correlations for item 1 and item 7. PCA found a one-factorial solution (similar with previous reports) but the first item had the lowest loading.

Conclusion. SDM-Q-9 is a useful tool for evaluation and improvement in health care that was validated in Romania and can be used in clinical setting in this country.

Thrombotic Thrombocytopenic Purpura (TTP) is a thrombotic microangiopathy syndrome resulting from decrease or absence of “a disintegrin and metalloproteinase with a thrombospondin type 1 motif member 13” (ADAMTS13). TTP has been characterized by the classical pentad of thrombocytopenia, hemolysis, fever, renal injury and neurological deficits, yet the patient may present with any atypical symptom related to microthrombi formation in the microcirculation. Here we present a rare case of a young patient with retrosternal chest pain and myocardial injury as the first manifestation of TTP.