Body composition changes after transjugular intrahepatic portosystemic shunt in patients with cirrhosis

AIM:To investigate the effect of transjugular intra-hepatic porto-systemic shunt (TIPS) on malnutrition in portal hypertensive cirrhotic patients.METHODS: Twenty-one patients with liver cirrhosis and clinical indications for TIPS insertion were investigated before and 1, 4, 12, 52 wk after TIPS. For each patient we assayed body composition parameters [dry lean mass, fat mass, total body water (TBW)], routine liver and kidney function tests, and free fatty acids (FFA). Glucose and insulin were measured for the calculation of the homeostasis model assessment insulin resistance (HOMA-IR); liver function was measured by the galactose elimination capacity (GEC); the severity of liver disease was graded by model for end-stage liver disease (MELD).RESULTS: Porto-systemic gradient decreased after TIPS (6.0±2.1 mmHg vs 15.8±4.8 mmHg, P<0.001). Patients were divided in two groups according to initial body mass index. After TIPS, normal weight patients had an increase in dry lean mass (from 10.9±5.9 kg to 12.7±5.6 kg, P=0.031) and TBW (from 34.5±7.6 L to 40.2±10.8 L,P=0.007), as well as insulin (from 88.9±49.2 pmol/L to 164.7±107.0 pmol/L,P=0.009) and HOMA-IR (from 3.36%±2.18% to 6.18%±4.82%,P=0.023). In overweight patients only FFA increased significantly (from 0.59±0.24 mmol/L to 0.93±0.34 mmol/L, P=0.023).CONCLUSION: TIPS procedure is effective in lowering portal pressure in patients with portal hypertension and improves body composition without significant changes in metabolic parameters.

Tako-tsubo cardiomyopaty after femur fracture

We present the case of an 86-year-old woman referred to us from Orthopaedics Division after surgical treatment for femur fracture without personal or family history of ischemic cardiopathy. During hospitalization the patient had stomach-ache and the electrocardiogram demonstrated ST-segment elevation in anterior leads. The coronarography showed haziness, but no critical stenosis;ventricolography revealed apical ballooning of the left ventricle with severe systolic dysfunction. She was treated with dopamine in renal dose, beta-blockers and warfarin. When she was in fairly good condition, she started physiotherapy for endoprosthesis for the femur fracture. Clinicians should consider takotsubo cardiomyopathy in the differential diagnosis of patients presenting with chest pain, especially in women with a recent history of physical stress.

A strange case of cervical pain

A 56-year-old man was admitted to hospital with fever, progressive fatigue, bilateral shoulder pain, paresthesias and stiffness after awakening. Differential diagnosis were several diseases such as rheumatoid arthritis, fibromyalgia and infectious spondylitis. Routine laboratory assays showed mild anemia and increased markers of inflammation. The worsening of clinical conditions led to performing a Computerized Tomography and a Cervical Magnetic Resonance Imaging which demonstrated an epidural liquid area in both left and anterior section of the spinal canal. Due to the high suspicious of tuberculosis we started a therapy with isoniazid, rifampicin, pyrazinamide and cyprofloxacin, even if the results of culture was negative for any kind of bacteria. This case-report underlines the difficulties of a correct diagnosis in a common symptom as back pain is.

A strange case of normocytic anemia

This case-report underlines the difficulties of a correct diagnosis in a complex vitamin malnutrition that is seldom suspected in patients living in developed Countries with a good social and economic situation. A 79-year-old woman was admitted to hospital with progressive fatigue, dyspnea till orthopnea, pallor and lumbar pain. On physical examination the patient was awake, conscious and pale with severe dyspnea and the laboratory findings revealed severe anemia normochromic and normocytic;chest radiography shows cardiomegaly. An abdomen echography showed hepatomegaly and an increased gallbladder volume with multiple gallstones and “biliary mud”. The patients received infusion of 4 Units of blood and started terapy for secondary congestive heart failure. The third day the temperature increased till 39°C and the urine of the patient shown clear hematuria;considering the hypothesis of hemolytic anemia was started methylprednisolone EV. Blood analysis was made in order to clarify anemia etiology: low blood levels of Vit B12, hypersideremia and very low Unsatured Iron Binding Capacity. A further investigation revealed that her diet had exclusively consisted of potatoes and fresh cheese since years. We started therapy with VitB12 and Folate and the patient was discharge fourteen days after admission. We feel that the importance of this clinical case lies in the diagnostic investigation for the cause of anemia, often more difficult than generally perceived.

Myocardial infarction in antiphospholipid antibody syndrome

A 52-year-old man was admitted to hospital with chest pain after physical activity. Emergency coronary angiography showed multiple throm-boembolic occlusions in the anterior descen-ding coronary artery and in the right coronary artery. Further testing revealed anticardiolipin and ?2-glicoprotein antibodies (the patient had been diagnosed for ulcerative colitis and poly-myalgia rheumatica). Heparin and nitrate were administered intravenously in addition to oral aspirin and metoprolol. Soon after, the patient referred a withdrawal of chest oppression, and his general clinical condition rapidly stabilised. A follow-up examination was performed 9 months later the discharge: he had resumed most of his activities and sieric concentration of lupus anticoagulant antibodies and anticardiolipin an- tibodies, IgM isotype, were decreased.

Machine learning using the extreme gradient boosting (XGBoost) algorithm predicts 5-day delta of SOFA score at ICU admission in COVID-19 patients

Background:Accurate risk stratification of critically ill patients with coronavirus disease 2019(COVID-19)is essential for optimizing resource allocation,delivering targeted interventions,and maximizing patient survival probability.Machine learning(ML)techniques are attracting increased interest for the development of prediction models as they excel in the analysis of complex signals in data-rich environments such as critical care.Methods:We retrieved data on patients with COVID-19 admitted to an intensive care unit(ICU)between March and October 2020 from the RIsk Stratification in COVID-19 patients in the Intensive Care Unit(RISC-19-ICU)registry.We applied the Extreme Gradient Boosting(XGBoost)algorithm to the data to predict as a binary out-come the increase or decrease in patients’Sequential Organ Failure Assessment(SOFA)score on day 5 after ICU admission.The model was iteratively cross-validated in different subsets of the study cohort.Results:The final study population consisted of 675 patients.The XGBoost model correctly predicted a decrease in SOFA score in 320/385(83%)critically ill COVID-19 patients,and an increase in the score in 210/290(72%)patients.The area under the mean receiver operating characteristic curve for XGBoost was significantly higher than that for the logistic regression model(0.86 vs.0.69,P<0.01[paired t-test with 95%confidence interval]).Conclusions:The XGBoost model predicted the change in SOFA score in critically ill COVID-19 patients admitted to the ICU and can guide clinical decision support systems(CDSSs)aimed at optimizing available resources.