Real-world use of remdesivir for the treatment of patients admitted to Italian hospitals with COVID-19: the nationwide retrospective FADOI-RECOVER study

BACKGROUND

Remdesivir is widely used for treatment of SARS-CoV-2 pneumonia. The aim of this study was to evaluate the characteristics of patients with moderate-to-severe COVID-19 treated with remdesivir, and their outcomes during hospitalization.

METHODS

This retrospective observational multicenter study included consecutive patients, hospitalized for moderate-to-severe COVID-19 (September 2020-September 2021), who were treated with remdesivir.

RESULTS

One thousand four patients were enrolled, all with onset of symptoms occurring less than 10 days before starting remdesivir; 17% of patients had 4 or more concomitant diseases. Remdesivir was well tolerated, adverse drug reactions (ADRs) being reported in 2.3% of patients. In-hospital death occurred in 80 patients (8.0%). The median timing of the first remdesivir dose was 5 days after symptom onset. The following endpoints did not differ according to the time span from the onset of symptoms to the first dose: length of hospitalization, in-hospital death, composite outcome (in-hospital death and/or endotracheal intubation). Advanced age, number of comorbidities ≥ 4, and severity of respiratory failure at admission were associated with poor in-hospital outcomes.

CONCLUSION

In a real-world setting, remdesivir proved to be a safe and well-tolerated treatment for moderate-to-severe COVID-19. In patients receiving remdesivir less than 3 or 5 days from the onset of SARS-CoV-2 symptoms, mortality and the need for mechanical ventilation did not differ from the rest of the sample.

Intra- and Extra-Hospitalization Monitoring of Vital Signs-Two Sides of the Same Coin: Perspectives from LIMS and Greenline-HT Study Operators

BACKGROUND

In recent years, due to the epidemiological transition, the burden of very complex patients in hospital wards has increased. Telemedicine usage appears to be a potential high-impact factor in helping with patient management, allowing hospital personnel to assess conditions in out-of-hospital scenarios.

METHODS

To investigate the management of chronic patients during both hospitalization for disease and discharge, randomized studies (LIMS and Greenline-HT) are ongoing in the Internal Medicine Unit at ASL Roma 6 Castelli Hospital. The study endpoints are clinical outcomes (from a patient's perspective). In this perspective paper, the main findings of these studies, from the operators' point of view, are reported. Operator opinions were collected from structured and unstructured surveys conducted among the staff involved, and their main themes are reported in a narrative manner.

RESULTS

Telemonitoring appears to be linked to a reduction in side-events and side-effects, which represent some of most commons risk factors for re-hospitalization and for delayed discharge during hospitalization. The main perceived advantages are increased patient safety and the quick response in case of emergency. The main disadvantages are believed to be related to low patient compliance and an infrastructural lack of optimization.

CONCLUSIONS

The evidence of wireless monitoring studies, combined with the analysis of activity data, suggests the need for a model of patient management that envisages an increase in the territory of structures capable of offering patients subacute care (the possibility of antibiotic treatments, blood transfusions, infusion support, and pain therapy) for the timely management of chronic patients in the terminal phase, for which treatment in acute wards must be guaranteed only for a limited time for the management of the acute phase of their diseases.

LDL-cholesterol control in the primary prevention of cardiovascular diseases: An expert opinion for clinicians and health professionals

AIMS

Although adequate clinical management of patients with hypercholesterolemia without a history of known cardiovascular disease is essential for prevention, these subjects are often disregarded. Furthermore, the scientific literature on primary cardiovascular prevention is not as rich as that on secondary prevention; finally, physicians often lack adequate tools for the effective management of subjects in primary prevention and have to face some unsolved relevant issues. This document aims to discuss and review the evidence available on this topic and provide practical guidance.

DATA SYNTHESIS

Available algorithms and risk charts represent the main tool for the assessment of cardiovascular risk in patients in primary prevention. The accuracy of such an estimate can be substantially improved considering the potential contribution of some additional risk factors (C-reactive protein, lipoprotein(a), family history of cardiovascular disease) and conditions (environmental pollution, sleep quality, socioeconomic status, educational level) whose impact on the cardiovascular risk has been better understood in recent years. The availability of non-invasive procedures to evaluate subclinical atherosclerosis may help to identify subjects needing an earlier intervention. Unveiling the presence of these conditions will improve cardiovascular risk estimation, granting a more appropriate intervention.

CONCLUSIONS

The accurate assessment of cardiovascular risk in subjects in primary prevention with the use of algorithms and risk charts together with the evaluation of additional factors will allow physicians to approach each patient with personalized strategies, which should translate into an increased adherence to therapy and, as a consequence, a reduced cardiovascular risk.

Low birth weight, nephron number and chronic kidney disease

Chronic kidney diseases have a significant impact on morbidity and mortality worldwide. Low birth weight, fetal growth restriction and prematurity are indicators of fetal growth and development disorders associated with a congenital reduction in nephron number, which predisposes to an increased risk for chronic kidney disease. On an individual basis, a small nephron number at birth is not always enough to determine the onset of chronic kidney disease, but it decreases the ability of the kidneys to resist any insults to renal tissue that may occur later in life, such as exposure to nephrotoxic drugs or episodes of acute kidney injury. The high incidence of low birth weight and preterm birth globally suggests that, at the population level, the impact of alterations in fetal development on the subsequent onset of chronic kidney disease could be significant. The implementation of strategies aimed at reducing the incidence of prematurity, fetal growth restriction, as well as other conditions that lead to low birth weight and a reduced nephron number at birth, provides an opportunity to prevent the development of chronic kidney disease in adulthood. For these purposes the coordinated intervention of several specialists, including obstetricians, gynecologists, neonatologists, nephrologists, and family doctors, is necessary. Such strategies can be particularly useful in resource-poor countries, which are simultaneously burdened by maternal, fetal and child malnutrition; poor health; epidemics caused by communicable diseases; and little access to screening and primary care.

Anemia and iron in internal medicine: an Italian survey and a review on iron intravenous therapy in medical patients

In Italy, Internal Medicine Units hospitalize approximately 1,300,000 patients, often elderly and comorbid. The prevalent diagnoses are respiratory diseases, heart failure, or pneumonia. As a matter of fact, anemia is probably underestimated in the compilation of the official discharge forms (SDO) according to ICD-9 diagnostic codes. We promoted a survey among the Members the Italian Scientific Society of Internal Medicine (FADOI) with the aim to investigate the prevalence of anemia and iron deficiency, over than certain aspects related to the therapeutic management of patients with anemia. Furthermore, we performed a review summarizing current evidence for iron intravenous therapy in these patients. According to the survey, anemia is present in around half of the patients hospitalized in Internal Medicine, and about a quarter of them shows iron metabolism alterations. In the evaluation of iron metabolism, the dosage of ferritin is the most requested exam, whereas transferrin saturation is less considered. By focusing on some categories of patients, the awareness of the usefulness of intravenous iron therapy in patients with heart failure seems to be sufficiently common (76% of physicians), while it seems lower (60%) in the management of patients with chronic kidney disease (CKD) and anemia. Finally, more than 75% of the physicians answered that, in their hospital, there are few outpatients’ offices or diagnostic pathways dedicated to patients with anemia. Anemia due to absolute or functional iron deficiency is particularly prevalent in Internal Medicine inpatients. For this reason, an accurate evaluation of iron profile and an adequate iron therapy is mandatory in these patients. Recent studies show that, in patients with heart failure, intravenous iron therapy is an effective way of improving patients’ health, regardless of the presence of anemia. Similarly, iron therapy results fundamental to optimize erythropoiesis-stimulating agent efficacy in patients with chronic renal failure. In the next future, other therapeutic aspects of intravenous iron therapy will be probably clarified by several interesting ongoing studies focused on these patients.

Progetto FADOI “EUCLIDE”. Clinica, comunicazione, telemedicina e governance: le esperienze da COVID-19 per il futuro della Medicina Interna

IntroduzioneDario Manfellotto, Francesco Dentali, Andrea Fontanella Materiali e MetodiDario Manfellotto, Francesco Dentali, Andrea Fontanella Gestione clinica del paziente complesso con patologie cardiovascolari e comorbilitàGiuseppe Campagna, Claudia Ferrigno, Franco Mastroianni Gestione clinica del paziente complesso con diabete e comorbilitàAda Maffettone, Ernesto De Menis, Maria Serena Fiore Cura e comunicazione: l’esperienza nella pandemia e le prospettive futureLuigi Magnani, Lara Bellardita, Salvatore Lenti Gestione a distanza del paziente complesso: la medicina digitaleFilippo Pieralli, Flavio Tangianu, Maria Gabriella Coppola Governance per la Medicina InternaAndrea Montagnani, Roberta Re, Ilario Stefani Considerazioni conclusiveDario Manfellotto, Francesco Dentali, Andrea Fontanella

Intentional Rounding versus Standard of Care for Patients Hospitalised in Internal Medicine Wards: Results from a Cluster-Randomised Nation-Based Study

The aim of the study was to explore the effects of Intentional Rounding, a regular-based proactive patient monitoring, on falls and pressure ulcers in internal medicine units. This is a cluster-randomised controlled study, where units were assigned (1:1) to Intentional Rounding (intervention group) or Standard of Care (control group). The primary outcome was the cumulative incidence of falls and new pressure ulcers. These events were considered separately as secondary endpoints, together with the number of bell calls and the evaluation of patient satisfaction. Primary analyses were carried out on the modified intention-to-treat population (hospitalisation of at least 10 days). Recruitment occurred between October 2019 and March 2020, at which time the study was prematurely closed due to the COVID-19 pandemic. Enrolment totalled 1822 patients at 26 sites; 779 patients were included in the modified intention-to-treat analysis. The intervention group had a lower risk of falls (adjusted incidence rate ratio 0.14; 95% confidence interval, 0.02–0.78; p = 0.03). There were no statistical differences in new pressure ulcers or the cumulative incidence of both adverse events. Mean bell calls for each patient were 15.4 ± 24.1 in the intervention group and 13.7 ± 20.5 in the control group (p = 0.38). Additionally, patient satisfaction in the intervention group was almost at the maximum level. Our study supports the usefulness of Intentional Rounding in a complex and vulnerable population such as that hospitalised in internal medicine units.

Hospitalization and mortality for acute exacerbation of asthma: an Italian population-based study

Asthma is an ever-increasing disease with a highly variable prevalence among different ethnic groups. Information on hospital admission for acute exacerbation of asthma in adult patients and data regarding short-term prognosis of these patients are limited. We, thus, performed an epidemiological study on hospital admission for asthma acute exacerbation in Italy using hospital discharge database records derived from all Italian hospitals. Patients > 15 years old were identified using clinical Modification (ICD-9-CM) codes. Information on baseline characteristics, vital status at discharge, duration of hospitalization, and up to five secondary discharge diagnoses was collected. Comorbidity was evaluated using the Charlson comorbidity index (CCI). During the observation period (2013-2014), 20,056 patients with asthma acute exacerbation were hospitalized. Median length of hospitalization was 7.9 days (interquartile range 4-10) and mean in-hospital mortality was 0.8%. In-hospital mortality and length of hospitalization varied among different regions (from 0 to 2.9% and from 6.5 to 8.9 days, respectively). Old age, invasive and non-invasive mechanical ventilation, and CCI resulted as significantly associated with higher in-hospital mortality. Our study results, on a large sample of patients, confirm that hospitalization for asthma acute exacerbation is not uncommon among Italian current population. Older age, high CCI, and use of ventilator support were associated with a higher mortality rate. These findings should be analyzed to set up appropriate health care policies on patients with asthma.

Abstract book of the XXVII Congresso Nazionale della Società Scientifica FADOI, 21-23 maggio 2022

Abstract book of the XXVII Congresso Nazionale della Società Scientifica FADOI, 21-23 maggio 2022.

Stratification of the risk of developing severe or lethal Covid-19 using a new score from a large Italian population: a population-based cohort study

OBJECTIVES

To develop a population-based risk stratification model (COVID-19 Vulnerability Score) for predicting severe/fatal clinical manifestations of SARS-CoV-2 infection, using the multiple source information provided by the healthcare utilisation databases of the Italian National Health Service.

DESIGN

Retrospective observational cohort study.

SETTING

Population-based study using the healthcare utilisation database from five Italian regions.

PARTICIPANTS

Beneficiaries of the National Health Service, aged 18-79 years, who had the residentship in the five participating regions. Residents in a nursing home were not included. The model was built from the 7 655 502 residents of Lombardy region.

MAIN OUTCOME MEASURE

The score included gender, age and 29 conditions/diseases selected from a list of 61 conditions which independently predicted the primary outcome, that is, severe (intensive care unit admission) or fatal manifestation of COVID-19 experienced during the first epidemic wave (until June 2020). The score performance was validated by applying the model to several validation sets, that is, Lombardy population (second epidemic wave), and the other four Italian regions (entire 2020) for a total of about 15.4 million individuals and 7031 outcomes. Predictive performance was assessed by discrimination (areas under the receiver operating characteristic curve) and calibration (plot of observed vs predicted outcomes).

RESULTS

We observed a clear positive trend towards increasing outcome incidence as the score increased. The areas under the receiver operating characteristic curve of the COVID-19 Vulnerability Score ranged from 0.85 to 0.88, which compared favourably with the areas of generic scores such as the Charlson Comorbidity Score (0.60). A remarkable performance of the score on the calibration of observed and predicted outcome probability was also observed.

CONCLUSIONS

A score based on data used for public health management accurately predicted the occurrence of severe/fatal manifestations of COVID-19. Use of this score may help health decision-makers to more accurately identify high-risk citizens who need early preventive or treatment interventions.

Position Paper FADOI – SIGG

Il presente documento è stato redatto nell’ambito del progetto di sensibilizzazione sul tema di Fondazione Onda.

Abstract Book of the XXVI Congresso Nazionale della Società Scientifica FADOI, 2-4 ottobre 2021

Abstract Book of the XXVI Congresso Nazionale della Società Scientifica FADOI, 2-4 ottobre 2021.

Renal function and clinical outcome of patients with cancer-associated venous thromboembolism randomized to receive apixaban or dalteparin. Results from the Caravaggio trial

The effect of renal impairment (RI) on risk of bleeding and recurrent thrombosis in cancer patients treated with direct oral anticoagulants for venous thromboembolism (VTE) is undefined. We run a prespecified analysis of the randomized Caravaggio study to evaluate the role of RI as risk factor for bleeding or recurrence in patients treated with dalteparin or apixaban for cancer-associated VTE. RI was graded as moderate (creatinine clearance between 30-59 ml/minute; 275 patients) and mild (between 60-89 ml/minute; 444 patients). In 1142 patients included in this analysis, the incidence of major bleeding was similar in patients with moderate vs. no or mild RI (HR 1.06, 95% CI 0.53-2.11), with no difference in the relative safety of apixaban and dalteparin. Recurrent VTE was not different in moderate vs. no or mild RI (HR 0 .67, 95% CI 0.38-1.20); in moderate RI, apixaban reduced recurrent VTE compared to dalteparin (HR 0.27, 95% CI 0.08-0.96; P for interaction 0.1085). At multivariate analysis, no association was found between variation of renal function over time and major bleeding or recurrent VTE. Advanced or metastatic cancer was the only independent predictor of major bleeding (HR 2.84, 95% CI 1.20-6.71), with no effect of treatment with apixaban or dalteparin. In our study in cancer patients treated with apixaban or dalteparin, moderate RI was not associated with major bleeding or recurrent VTE. In patients with moderate renal failure, the safety profile of apixaban was confirmed with the potential for improved efficacy in comparison to dalteparin.

Hospitalization and mortality for acute exacerbation of chronic obstructive pulmonary disease (COPD): an Italian population-based study

OBJECTIVE

Patients with acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) have a significant mortality and morbidity. Previous studies have identified a number of independent prognostic factors. However, information on hospital admission databases is limited and data regarding short-term prognosis of these patients in Italian hospitals are lacking. Thus, we performed an epidemiological study on hospital admission for COPD acute exacerbation in Italy.

PATIENTS AND METHODS

Patients were identified using clinical Modification (ICD-9-CM) codes. Information was collected on baseline characteristics, vital status at discharge, duration of hospitalization, and up to five secondary discharge diagnoses. Comorbidity was evaluated using the Charlson comorbidity index (CCI).

RESULTS

During the observation period (2013-2014), 170,684 patients with COPD acute exacerbation were hospitalized. Mean length of hospitalization (LOH) was 9.95±8.69 days and mean in-hospital mortality was 5.30%. These data correspond to the 4.1% of all hospitalizations and to the 2.8% of all the days of hospitalization in Italy during the study period. In-hospital mortality and LOH varied among different regions (from 3.13 to 7.59% and from 8.22 to 11.28 days respectively). Old age, male gender, low discharge volume, previous hospitalization for COPD exacerbation and CCI resulted as significantly associated with higher in-hospital mortality.

CONCLUSIONS

Hospitalization for COPD exacerbation is extremely frequent even in contemporary Italian population. COPD exacerbation is clinically demanding with a not negligible short-term mortality rate and a mean LOH approaching 10 days. These latter findings were quite variable in different regions but should be further analyzed to set up appropriate health-care policies on COPD patients.

Not-for-profit observational study to evaluate the quality and safety of care in <em>outliers</em> hospitalized with medical diseases - Study Protocol of Safety Issues and SurvIval For Medical Outliers (SISIFO study)

The progressive cutting of hospital beds in some health systems, together with the increased needs related to the aging population, has led to the phenomenon of patients hospitalized outside the appropriate ward (outliers). This is particularly relevant in the context of Internal Medicine. Despite its relevance in daily clinical practice, available evidence for the potential impact of this phenomenon is limited. The aim of this study is to evaluate the effects of this situation on patients’ outcomes and possibly identify organizational and managerial aspects related to the presence of outliers. The multicenter, observational, prospective Study Protocol of Safety Issues and SurvIval For Medical Outliers (SISIFO) was promoted by the Italian Federation of Associations of Hospital Doctors on Internal Medicine (FADOI). The primary study endpoint is the evaluation of in-hospital mortality in outliers versus controls. A sample size of 2400 patients has been estimated by assuming a mortality rate of 12% and 8% in outliers and controls, respectively. By virtue of the multicentric dimension, the expected number of patients, and the controlled design, the FADOI-SISIFO study might provide interesting and useful findings to better manage the phenomenon of outliers.

Lessons learned from COVID-19 for clinical research operations in Italy: what have we learned and what can we apply in the future?

The coronavirus disease 2019 (COVID-19) pandemic has stressed the importance of health research as never before. In the specific domain of clinical research, the effort to rapidly find responses to health challenges and therapeutic hypotheses has highlighted the need for efficient, timely, ethically correct research. The guidelines published by the Agenzia Italiana del Farmaco have shown that some useful changes are feasible: simple and rapid methods have been implemented to conduct clinical research in the emergency conditions of the pandemic, maintaining high levels of quality. In this perspective, four Italian scientific associations operating in clinical research have worked together to evaluate which measures, among the ones implemented during the pandemic, have been particularly significant and potentially effective under normal conditions or in case of emergencies, and that therefore will be useful in the future as well.

Epigenetic profiling of Italian patients identified methylation sites associated with hereditary transthyretin amyloidosis

Hereditary transthyretin (TTR) amyloidosis (hATTR) is a rare life-threatening disorder caused by amyloidogenic coding mutations located in TTR gene. To understand the high phenotypic variability observed among carriers of TTR disease-causing mutations, we conducted an epigenome-wide association study (EWAS) assessing more than 700,000 methylation sites and testing epigenetic difference of TTR coding mutation carriers vs. non-carriers. We observed a significant methylation change at cg09097335 site located in Beta-secretase 2 (BACE2) gene (standardized regression coefficient = -0.60, p = 6.26 × 10-8). This gene is involved in a protein interaction network enriched for biological processes and molecular pathways related to amyloid-beta metabolism (Gene Ontology: 0050435, q = 0.007), amyloid fiber formation (Reactome HSA-977225, q = 0.008), and Alzheimer's disease (KEGG hsa05010, q = 2.2 × 10-4). Additionally, TTR and BACE2 share APP (amyloid-beta precursor protein) as a validated protein interactor. Within TTR gene region, we observed that Val30Met disrupts a methylation site, cg13139646, causing a drastic hypomethylation in carriers of this amyloidogenic mutation (standardized regression coefficient = -2.18, p = 3.34 × 10-11). Cg13139646 showed co-methylation with cg19203115 (Pearson's r2 = 0.32), which showed significant epigenetic differences between symptomatic and asymptomatic carriers of amyloidogenic mutations (standardized regression coefficient = -0.56, p = 8.6 × 10-4). In conclusion, we provide novel insights related to the molecular mechanisms involved in the complex heterogeneity of hATTR, highlighting the role of epigenetic regulation in this rare disorder.

Analysis of the characteristics of patients admitted to Internal Medicine wards for exacerbation of chronic obstructive pulmonary disease, and discharge phase optimization. The SDO-ARCA Project of the Scientific Society FADOI

The purpose of this study was to have a nationwide snapshot of the characteristics of patients hospitalized in Internal Medicine Units (IMUs) for exacerbation of chronic obstructive pulmonary disease (COPD), and to assess applicability and contents of a specific Hospital Discharge Form for the patient with exacerbation of COPD discharged from IMUs. This was a prospective study in 44 IMUs in Italy, enrolling patients hospitalized with a diagnosis of COPD exacerbation. Information concerning clinical characteristics of patients, and treatment for COPD at discharge was collected. Specific documents for monitoring of clinical conditions and adherence to therapies as well as a form including individual indications for clinical controls, instrumental tests, etc. were provided upon discharge. Four hundred and seventy-two patients were enrolled (68% male). According to GOLD classification 2015, patients with classes A to D were 12%, 27%, 31%, and 30%, respectively. Triple therapy was prescribed in 14% of GOLD A and 51% of GOLD D patients. Around 10% of patients for each GOLD class received no specific therapy. The vast majority of patients (85%) received instructions on the correct use of inhalers, and in most cases (85%), the quality of counseling was considered optimal/adequate. Indication for performing chest X-ray, spirometry, or blood gas analysis following discharge was addressed to 29%, 59% and 52.1% of patients, respectively. The follow-up sheet for COPD used in our study was shown as applicable. This highlighted the need for greater awareness and more standardized procedures within IMUs in the post-discharge phase.

Renal function and clinical outcome of patients with cancer-associated venous thromboembolism randomized to receive apixaban or dalteparin. Results from the Caravaggio trial

The effect of renal impairment (RI) on risk of bleeding and recurrent thrombosis in cancer patients treated with direct oral anticoagulants for venous thromboembolism (VTE) is undefined. We run a prespecified analysis of the randomized Caravaggio study to evaluate the role of RI as risk factor for bleeding or recurrence in patients treated with dalteparin or apixaban for cancer-associated VTE. RI was graded as moderate (creatinine clearance between 30-59 ml/minute; 275 patients) and mild (between 60-89 ml/minute; 444 patients). In 1142 patients included in this analysis, the incidence of major bleeding was similar in patients with moderate vs. no or mild RI (HR 1.06, 95% CI 0.53-2.11), with no difference in the relative safety of apixaban and dalteparin. Recurrent VTE was not different in moderate vs. no or mild RI (HR 0 .67, 95% CI 0.38-1.20); in moderate RI, apixaban reduced recurrent VTE compared to dalteparin (HR 0.27, 95% CI 0.08-0.96; P for interaction 0.1085). At multivariate analysis, no association was found between variation of renal function over time and major bleeding or recurrent VTE. Advanced or metastatic cancer was the only independent predictor of major bleeding (HR 2.84, 95% CI 1.20-6.71), with no effect of treatment with apixaban or dalteparin. In our study in cancer patients treated with apixaban or dalteparin, moderate RI was not associated with major bleeding or recurrent VTE. In patients with moderate renal failure, the safety profile of apixaban was confirmed with the potential for improved efficacy in comparison to dalteparin.

Diabetes and CoViD-19: Experience from the frontline of Internal Medicine wards in Italy

Available data suggest that the issue of CoViD-19 is particularly critical in patients with diabetes. In Italy, Internal Medicine (IM) wards have played a pivotal role in contrasting the spread of SARS-Cov2. During this pandemic, FADOI submitted a brief questionnaire to a group of its members acting as Head of IM units. Considering 38 units, 58% of beds dedicated to CoViD patients in CoViD Hospitals were in charge of IM, and globally cared for 6650 patients during a six-week period. Of these patients, 1264 (19%) had diabetes. Mortality rate in CoViD patients with or without diabetes were 20.5% and 14%, respectively (p < 0.001). Our survey seems to confirm that diabetes is a major comorbidity of CoViD-19, but it does not support an increased incidence of CoViD-19 infection in people with diabetes, if compared with the figures of patients with diabetes and hospitalized before the outbreak. On the other side, patients with diabetes appeared at a significantly increased risk of worse outcome. This finding underlines the importance of paying special attention to this patient population and its management.

Metodologia clinica oggi nel paziente internistico complesso

Introduzione alla letturaA. Fontanella, P. Gnerre Il metodo clinico classico della tradizione italianaI. Portioli Modelli di ragionamento clinico e strumenti utilizzati nella pratica clinica in ambito internistico ai fini decisionaliP. Gnerre, R. Nardi I difetti del ragionamento clinico come causa di errori diagnosticiM. La Regina, F. Orlandini Metodologia clinica e EBM: vantaggi e limiti nel mondo reale dei pazienti complessi - Il mondo realeT.M. Attardo Metodologia clinica e EBM: vantaggi e limiti nel mondo reale dei pazienti complessi - Trappole e possibili biasM. Cavalleri Significatività statistica e rilevanza clinicaD. Tirotta Dalla medicina personalizzata alla medicina di precisioneG. Gensini, N. Scarpa Una possibile alternativa alle decisioni: il metodo Clinical Multi-criteria Decision Assessment (CMDA)O. Para Il metodo clinico in condizioni di incertezza: errori, vincoli, esperienza, buon senso e le opinioni del pazienteM.L. Cipollini, E. Romboli Meta-cognizione e capacità di decision makingF. Gilioli Complessità, caos e ragionamento clinicoF. Tangianu, S. Corrao, A. Mazzone, P. Gnerre, G. Scanelli, M. Gambacorta, D. Tirotta, A. Fontanella, M. Adamo, R. Nardi Competenza e metodologia in Medicina Interna: quali strumenti di valutazione delle capacità di ragionamento clinico? Prima ParteF. Tangianu, A. Mazzone, G. Pinna, G. Chesi, P. Gnerre, F. Berti, M. Stornello, C. Nozzoli, S. Corrao, M. Silingardi, G. Mathieu, A. Fontanella, D. Borioni, R. Nardi Competenza e metodologia in Medicina Interna: quali strumenti di valutazione delle capacità di ragionamento clinico? Seconda ParteF. Tangianu, A. Mazzone, G. Pinna, G. Chesi, P. Gnerre, F. Berti, M. Stornello, C. Nozzoli, S. Corrao, M. Silingardi, G. Mathieu, A. Fontanella, D. Borioni, R. Nardi La semeiotica medica: presente e futuroF. Cipollini

Aggiornamenti in tema di malattia cerebrovascolare: prevenzione, terapia e riabilitazione

IntroduzioneF. Bandini, P. Gnerre Epidemiologia e classificazioneM. Stornello, E. Sanzaro I fattori di rischioT.M. Attardo Prevenzione primariaS. Spolveri Cause rare di strokeM. Zedde L’attacco ischemico transitorioM. Guarino, S. Belluoccio Ictus ischemico: assistenza in fase acutaF. Di Blasio Trombolisi endovenosaP. Candelaresi, V. Andreone Trombectomia meccanicaP. Candelaresi, G. Leone, V. Andreone, M. Muto, M. Muto Modelli organizzativi nella gestione dell’ictus ischemicoR. Iannacchero, A. Siniscalchi, D. Bosco Emorragia cerebrale intraparenchimale spontaneaM. Masato, A. Bruscagnin Emorragia subaracnoideaL.A.A. Lanterna, M. Pantusa, A. Montalbetti, L. Savarese, P. Gritti, M.L. Colleoni Ictus a possibile doppia genesi. Cardioembolica o aterotrombotica?S. Ascione, P. Ripa, G. Grimaldi Ictus criptogenetico: la ricerca della fibrillazione atriale e del forame ovale pervio. Come e quandoM. Botta Le complicanze in fase acutaC. Di Carmine, G. Francolini, S. Bedetta, L. Mucci, G. Frausini Prevenzione secondaria dell’ictus ischemicoL. Gentile La riabilitazione dell’ictusP. Milia, G. Regesta La riabilitazione post-ictusA. Greco, F.R. Greco Trombosi venosa cerebraleA. Iannuzzi Gestione della disfagia e prevenzione delle complicanzeR. Rapetti, F. Bertoncini, L. Vestito

The 2020 Italian Society of Arterial Hypertension (SIIA) practical guidelines for the management of primary aldosteronism

Background and aim

Considering the amount of novel knowledge generated in the last five years, a team of experienced hypertensionlogists was assembled to furnish updated clinical practice guidelines for the management of primary aldosteronism.

Methods

To identify the most relevant studies, the authors utilized a systematic literature review in international databases by applying the PICO strategy, and then they were required to make use of only those meeting predefined quality criteria. For studies of diagnostic tests, only those that fulfilled the Standards for Reporting of Diagnostic Accuracy recommendations were considered.

Results

Each section was jointly prepared by at least two co-authors, who provided Class of Recommendation and Level of Evidence following the American Heart Association methodology. The guidelines were sponsored by the Italian Society of Arterial Hypertension and underwent two rounds of revision, eventually reexamined by an External Committee. They were presented and thoroughly discussed in two face-to-face meetings with all co-authors and then presented on occasion of the 36th Italian Society of Arterial Hypertension meeting in order to gather further feedbacks by all members. The text amended according to these feedbacks was subjected to a further peer review.

Conclusions

After this process, substantial updated information was generated, which could simplify the diagnosis of primary aldosteronism and assist practicing physicians in optimizing treatment and follow-up of patients with one of the most common curable causes of arterial hypertension.

What Quality and Safety of Care for Patients Admitted to Clinically Inappropriate Wards: a Systematic Review

BACKGROUND

In countries with public health system, hospital bed reductions and increasing social and medical frailty have led to the phenomenon of "outliers" or "outlying hospital in-patients." They are often medical patients who, because of unavailability of beds in their clinically appropriate ward, are admitted wherever unoccupied beds are. The present work is aimed to systematically review literature about quality and safety of care for patients admitted to clinically inappropriate wards.

METHODS

We performed a systematic review of studies investigating outliers, published in peer-reviewed journals with no time restrictions. Search and screening were conducted by two independent researchers (MLR and ER). Studies were considered potentially eligible for this systematic review if aimed to assess the quality and/or the safety of care for patients admitted to clinically inappropriate units. Our search was supplemented by a hand search of references of included studies. Given the heterogeneity of studies, results were analyzed thematically. We used PRISMA guidelines to report our findings.

RESULTS

We collected 17 eligible papers and grouped them into six thematic categories. Despite their methodological limits, the included studies show increased trends in mortality and readmissions among outliers. Quality of care and patient safety are compromised as patients and health professionals declare and risk analysis displays. Reported solutions are often multicomponent, stress early discharge but have not been investigated in the control group.

CONCLUSIONS

Published literature cannot definitely conclude on the quality and safety of care for patients admitted to clinically inappropriate wards. As they may represent a serious threat for quality and safety, and moreover often neglected and under valued, well-designed and powered prospective studies are urgently needed.

I diritti negati agli anziani: quali implicazioni per la salute?

Perchè gli internisti devono occuparsi dei diritti negati agli anziani?M. Campanini, P. Gnerre, A. Fontanella Diritti negati, abusi, maltrattamenti e neglect nell’anziano: macrofenomeno mondiale sommerso, sostanzialmente misconosciuto o trascuratoP. Calogero, A. Salsi Il diritto al coordinamento delle cure e alla continuità assistenziale nella gestione delle malattie croniche: strumenti disponibili oggi e quali potenzialmente fruibili in futuro?F. Orlandini La mancata pianificazione dei fabbisogni di medici e di specialisti in Italia nel Servizio Sanitario pubblico. Quali conseguenze in rapporto all’invecchiamento della popolazione?D. Montemurro, M. D’Arienzo, C. Rivetti, E. Marcante, F. Ragazzo, P. Di Silverio, A. Rossi, C. Palermo I rischi di un eccesso di cure negli anziani: fare di più non significa fare meglio anche nell’anzianoM. Bobbio Pensionamento: ritirarsi dal lavoro, non dalla vita né da un futuro di buona saluteR. Nardi, D. Borioni, D. Tirotta, F. Berti, G. Pinna¸ S. Ehrlich, G. Pentella, P. Cosma, R. Rapetti, A. Fontanella Gestione della depressione, inevitabile compagna del paziente anzianoE. Pecoraro, S. La Carrubba La sessualità nell’anzianoV. Duretto, G. Pinna Gli ostacoli metodologici nella comunicazione con il paziente anzianoM. Felici, A. Tufi, A. Pulerà, S. Lenti L’importanza della capacità di educare all’autogestione delle malattie croniche (self-management) per prevenire l’aggravamento e i ricoveri ripetuti non programmatiM. La Regina, A. Greco Le cure di fine vita negli anziani: il diritto di morire beneL. Lusiani, C. Santini Il programma delle otto R: utopia o possibile realtà per migliorare l’assistenza agli anziani?F. D’Amore  

How to choose and become a reviewer for a scientific medical journal

Peer review is the process of subjecting an author’s scholarly work, research or ideas to the scrutiny of others who are experts in the same field. The peer review of scientific manuscripts is a cornerstone of modern science and medicine. Some journals have difficulty in finding appropriate reviewers who are able to complete reviews on time avoiding publication delay. We discuss some of the main issues involved during the peer review process. The reviewer has a direct and important impact on the quality of a scientific medical Journal. Editors select reviewers on the basis of their expertise. Reviewers are more likely to accept to review a manuscript when it is relevant to their area of interest. They should respond to ethical principles, excluding any conflict of interest condition. The reviewer has to be professional, constructive, tactful, empathetic and respectful. Structured approaches, quality indicators and step-by-step process check list formats could be useful in obtaining a good review.

Effect of the GSTM1 gene deletion on glycemic variability, sympatho-vagal balance and arterial stiffness in patients with metabolic syndrome, but without diabetes

AIMS

An increased rate of cerebrovascular complications in patients with metabolic syndrome (MetS) has been reported. Previous studies demonstrated an association between glycemic variability (GV) and cerebrovascular reactivity (CRV) in MetS, thus suggesting a putative role of GV on cerebrovascular events. Although the pathophysiological mechanism linking GV to damage is still to be elucidated, evidence suggests oxidative stress plays a crucial role. Since functional variants in glutathione S-transferases (GST) genes modulate the cellular detoxification processes, the aim of this study was to elucidate the involvement of GSTs in MetS and investigating the correlation with GV, arterial stiffness, and sympatho-vagal (SV) balance.

METHODS

A hundred metabolic syndrome patients without diabetes underwent GST gene polymorphism analysis and a sub-sample 36 patients were randomly selected to investigate the correlation between GST gene polymorphisms and GV, and sympatho-vagal (SV) balance and arterial stiffness.

RESULTS

GSTM1 showed a significant association with several GV, arterial stiffness, and SV balance indexes. In particular, the GSTM1 deletion positively correlates with lower values of these indexes when compared to the presence of the gene.

CONCLUSIONS

Therefore, we suggested a global influence of GSTM1 deletion on the GV, arterial stiffness, and SV balance pathways in MetS patients, probably also interacting with AMP-activated protein kinase (AMPK) regulation. Our novel findings indicate GSTM1 could be a risk locus in MetS development and shed light novel scenarios on the role of glucose fluctuations in neurological impairments.

Self-reported hypertension, dyslipidemia and hyperuricemia management by Italian Internal Medicine Units: a national survey of the FADOI Study Group in Cardiovascular Medicine

The aim of this study was to evaluate the management practices of internal medicine clinicians for patients with cardiovascular risk factors, with particular respect to treatment thresholds, medication choices and target goals. A sample of internists - representatives of Internal Medicine Units (IMUs) from all the regions in Italy - were identified by the cardiovascular medicine study group of the Italian Internal Medicine FADOI (Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti) Society and invited to fill out a questionnaire about hypertension, dyslipidemia and hyperuricemia. From the 101 questionnaires collected, it was found that despite large heterogeneity between IMUs in terms of patient management and adherence to guidelines, internists were experts in the management of patients with multiple cardiovascular risk factors and associated comorbidities. We hope that these data prompt the internal medicine community to consider the value of producing shared, real-world guidelines on the management of cardiovascular disease.

Non-coding variants contribute to the clinical heterogeneity of TTR amyloidosis

Coding mutations in TTR gene cause a rare hereditary form of systemic amyloidosis, which has a complex genotype-phenotype correlation. We investigated the role of non-coding variants in regulating TTR gene expression and consequently amyloidosis symptoms. We evaluated the genotype-phenotype correlation considering the clinical information of 129 Italian patients with TTR amyloidosis. Then, we conducted a re-sequencing of TTR gene to investigate how non-coding variants affect TTR expression and, consequently, phenotypic presentation in carriers of amyloidogenic mutations. Polygenic scores for genetically determined TTR expression were constructed using data from our re-sequencing analysis and the GTEx (Genotype-Tissue Expression) project. We confirmed a strong phenotypic heterogeneity across coding mutations causing TTR amyloidosis. Considering the effects of non-coding variants on TTR expression, we identified three patient clusters with specific expression patterns associated with certain phenotypic presentations, including late onset, autonomic neurological involvement, and gastrointestinal symptoms. This study provides novel data regarding the role of non-coding variation and the gene expression profiles in patients affected by TTR amyloidosis, also putting forth an approach that could be used to investigate the mechanisms at the basis of the genotype-phenotype correlation of the disease.

Variables determining clinical complexity in hospitalized Internal Medicine patients: a workload analysis

The clinical complexity of Internal Medicine patients is a daily challenge for clinicians. Although clinical complexity cannot be directly measured, several scores describe the variability of clinical severity and comorbidity. The aim of this study was to analyze staff workload by assessing the nursing and medical complexity of patients admitted to an Internal Medicine ward. We included 40 consecutive inpatients [52.5% females, mean age 71.2 (18.2) years] classified according to the index of clinical complexity (ICC, type A: very high; type B: high; type C: moderate) and the cumulative illness rating scale (CIRS) severity and comorbidity index. Patient outcomes, hospitalization duration, tests performed, number of daily medications and time to perform standard nursing tasks were analysed across groups. Mean duration of hospitalization was 15.6 (10.1) days; in-hospital mortality was 15%. Mean CIRS severity index (SI) was 1.03 (0.31) and median CIRS comorbidity index (CI) was 2 (range 1-5). Significant differences were observed among ICC groups in time spent performing specific tasks [univariate analysis of variance F(2.37)=17.26, P&lt;0.001]. No significant differences were found between the three groups for mean CIRS-SI [F(2.37)=3.033, P=0.060] and median CIRS-CI [Kruskal Wallis test: c²(2)= 1.672, P=0.433]. Clinical complexity and caring complexity were not correlated in our sample of Internal Medicine inpatients. Optimal care of Internal Medicine patients must take into account their complexity in both the medical and nursing aspects.

Population diversity of the genetically determined TTR expression in human tissues and its implications in TTR amyloidosis

BACKGROUND

Transthyretin (TTR) amyloidosis is a hereditary disease with a complex genotype-phenotype correlation. We conducted a literature survey to define the clinical landscape of TTR amyloidosis across populations worldwide. Then, we investigated whether the genetically determined TTR expression differs among human populations, contributing to the differences observed in patients. Polygenic scores for genetically determined TTR expression in 14 clinically relevant tissues were constructed using data from the GTEx (Genotype-Tissue Expression) project and tested in the samples from the 1,000 Genomes Project.

RESULTS

We observed differences among the ancestral groups and, to a lesser extent, among the investigated populations within the ancestry groups. Scandinavian populations differed in their genetically determined TTR expression of skeletal muscle tissue with respect to Southern Europeans (p = 6.79*10^-6). This is in line with epidemiological data related to Swedish and Portuguese TTR Val30Met endemic areas. Familial amyloidotic cardiomyopathy (TTR deposits occur primarily in heart tissues) presents clinical variability among human populations, a finding that agrees with the among-ancestry diversity of genetically determined TTR expression in heart tissues (i.e., Atrial Appendage p = 4.55*10^-28; Left Ventricle p = 6.54*10^-35).

CONCLUSIONS

Genetically determined TTR expression varied across human populations. This might contribute to the genotype-phenotype correlation of TTR amyloidosis.

E-learning in order to improve drug prescription for hospitalized older patients: a cluster-randomized controlled study

AIMS

The aim of the study was to evaluate the effect of an e-learning educational program meant to foster the quality of drug prescription in hospitalized elderly patients.

METHODS

Twenty geriatric and internal medicine wards were randomized to intervention (e-learning educational program) or control (basic geriatric pharmacology notions). Logistic regression analysis was used in order to assess the effect of the intervention on the use of potentially inappropriate medication (PIM, primary outcome) at hospital discharge. Secondary outcomes were a reduced prevalence of at least one potential drug-drug interaction (DDI) and potentially severe DDI at discharge. Mortality rate and incidence of re-hospitalizations were other secondary outcomes assessed at the 12-month follow-up.

RESULTS

A total of 697 patients (347 in the intervention and 350 in the control arms) were enrolled. No difference in the prevalence of PIM at discharge was found between arms (OR 1.29 95%CI 0.87-1.91). We also found no decrease in the prevalence of DDI (OR 0.67 95%CI 0.34-1.28) and potentially severe DDI (OR 0.86 95%CI 0.63-1.15) at discharge, nor in mortality rates and incidence of re-hospitalization at 12-month follow-up.

CONCLUSIONS

This e-learning educational program had no clear effect on the quality of drug prescription and clinical outcomes in hospitalized elderly patients. Given the high prevalence of PIMs and potential DDIs recorded in the frame of this study, other approaches should be developed in order to improve the quality of drug prescription in this population.

The change of hospital internal medicine: a study on patients admitted in internal medicine wards of 8 hospitals of the Lazio area, Italy

The hospital internal medicine (IM) needs to adapt to the socio-demographic changes occurred during the last thirty years: patients currently show an increased overall complexity owing to the increase in the average age of the patients admitted, to more several and severe comorbidities, and a higher concentration in our wards of most severe cases. Our departments have to change in order to pursue a more efficient organization and to offer care to users modulated according to their needs and conditions. The Intensity of Care in Internal Medicine Group of the Federation of Associations of Hospital Doctors on Internal Medicine - Lazio carried out a population-based study in eight Internal Medicine wards of the region with the aim of characterizing the patients there admitted, using the modified early warning score (mEWS), monitoring and evaluating the outcomes of hospitalization. This has allowed us to determine the cut-off of the score indicating a greater statistical probability of a fatal outcome corresponding to 3, contrary to what originally reported by Subbe <em>et al.</em> in 2001. According to our results into the Departments of IM should be provided an area of high care, where monitor and stabilize the patients admitted with a mEWS score ≥3, before transferring them to the wards of lower intensity of care. This organizational model of the high care of medical patients has the benefit of offer the technical and professional assistance appropriate to the level of clinical risk, with more intensive care to more critical stages of illness.

GSTA1 gene variation associated with gestational hypertension and its involvement in pregnancy-related pathogenic conditions

OBJECTIVE(S)

Glutathione S-transferases (GSTs) are the main phase II enzymes involved in the cellular detoxification. Through phase I and phase II detoxification reactions, the cell is able to detoxify endogenous and exogenous toxic compounds. In this study, we focused our attention on the GSTA1*-69C/T gene polymorphism (rs3957357) in order to explore its involvement in the genetic predisposition to gestational hypertension (GH).

STUDY DESIGN

The case-control population consists of 195 subjects. The genotyping of the GSTA1*-69C/T was performed by using an RFLP-PCR technique. We calculated odds ratios (ORs), adjusted for the confounding variables, to estimate the association between GSTA1 and GH.

RESULTS

Significant allelic differences in GSTA1*-69C/T are present between GH women and pregnant women without cardiovascular complications (p<0.05). Specifically, we observed that the dominant genetic model best explains the observed genetic association, according to the Akaike information criterion and the Bayesian information criterion.

CONCLUSION(S)

Our study highlighted a significant association between the GSTA1 gene and the risk of GH in Italian patients. In particular, the -69C/T variant was significantly associated with disease risk. Since previous studies indicated that this GSTA1 polymorphism is associated with different pregnancy-related conditions, our finding supports the notion that GSTA1 may play a key role during pregnancy.

Explorative genetic association study of GSTT2B copy number variant in complex disease risks

BACKGROUND

Glutathione S-transferases (GSTs) are the main phase II enzymes involved in cellular detoxification. Through phase I and phase II detoxification reactions, the cell is able to detoxify endogenous and exogenous toxic compounds.

AIMS

This study focused attention on the GSTT2B copy number variant (CNV) in order to explore its involvement in the genetic pre-disposition to asthma, Alzheimer's disease (AD), allergic rhinitis (AR), essential hypertension (EH), hypothyroidism and recurrent miscarriage (RM).

METHODS

The study population consists of 1225 individuals divided into six case-control groups. The genotyping of the GSTT2B CNV was performed by using a duplex-PCR. Odds Ratios (ORs) were calculated, adjusting for the confounding variables, to estimate the association between GSTT2B CNV and the disease status.

RESULTS

The χ(2)-test and ORs did not show any association between this genetic marker and pathological phenotypes.

CONCLUSION

The data highlights that GSTT2B CNV is not associated with the investigated complex diseases in Italian patients. However, further investigations are necessary to replicate these findings in larger sample sizes and to explore other health-related phenotypes.

Most recent common ancestor of TTR Val30Met mutation in Italian population and its potential role in genotype-phenotype correlation

INTRODUCTION

Transthyretin (TTR)-related amyloidosis is characterized by autosomal transmission of amyloidogenic mutated TTR. Val30Met is one of the most common amyloidogenic TTR mutations, showing a worldwide distribution with phenotypic heterogeneity among human populations. Multiple founder mutations for Val30Met foci have been hypothesized and the different origins may explain the phenotypic variability. The aim of our study is to determine the origin of Italian Val30Met and to analyze the genetic relationship of other Val30Met foci.

METHODS

We analyzed the origin of Italian Val30Met through 11 microsatellite markers around the TTR gene in 29 patients and 34 healthy controls.

RESULTS

Our genetic analysis showed an estimated age of origin of 34-36 generations ago for the Italian Val30Met. Comparing Italian Val30Met haplotypes with those from Sweden and Portugal highlights relevant differences that seem to be consistent with an independent origin of Italian Val30Met mutation. This genetic evidence agrees with the disease phenotypic variation in these populations.

DISCUSSION AND CONCLUSIONS

Italian Val30Met mutation should have originated before the Portuguese and Swedish Val30Met ones (which arose through independent mutational events). This indicates a genetic diversity in the surrounding regions of three different Val30Met mutations, supporting the hypothesis that TTR non-coding regions may contribute to phenotypic heterogeneity.

GSTA1*-69C/T and GSTO2*N142D as asthma- and allergy-related risk factors in Italian adult patients

1. Asthma and allergies are characterized by variable and subjective symptoms influenced by many genes, molecular mechanisms and environmental factors. The presence of inflammation and oxidative stress in the airways are important biochemical features of asthma and respiratory allergies. Glutathione S-transferase (GSTs) enzymes play an important role in cellular protection against inflammation, and functional genetic polymorphisms in GST genes show a significant association with asthma and allergy risk. Specifically, our previous study on asthmatic children highlighted GSTA1 and GSTO2 as novel susceptibility loci for asthma. 2. In the present study we focused our attention on GSTA1*-69C/T (rs3957357) and GSTO2*N142D (rs156697) polymorphisms to confirm our previous results in an independent adult study population and to clarify whether GSTA1 and GSTO2 gene polymorphisms are involved in a non-discriminative pathway towards asthma and respiratory allergy. 3. To accomplish this, we recruited 103 patients with respiratory allergies, 199 patients with asthma and 200 healthy controls. Genomic DNA extracted from buccal cells was screened for GSTA1*-69C/T and GSTO2*N142D single nucleotide polymorphisms. 4. The GSTA1*-69T and GSTO2*D142 variants are both associated with a significantly increased risk of asthma, whereas only GSTA1*-69C/T is significantly associated with allergies. These outcomes confirm the involvement of GSTO2 loci in asthma and suggest that GSTA1 is a common risk factor for asthma and allergies.

In silico analysis of TTR gene (coding and non-coding regions, and interactive network) and its implications in transthyretin-related amyloidosis

INTRODUCTION

Transthyretin (TTR)-related amyloidosis is a life-threatening disease. Currently, several questions about the pathogenic mechanisms of TTR-related amyloidosis remain unanswered.

METHODS

We have investigated various TTR-related issues using different in silico approaches.

RESULTS

Using an amino acid similarity-based analysis, we have indicated the most relevant TTR secondary structures in determining mutation impact. Our amyloidogenic propensity analysis of TTR missense substitutions has highlighted a similar pattern for wild-type and mutated TTR amino β acid sequences. However, some mutations present differences with respect to the general distribution. We have identified non-coding variants in cis-regulatory elements of the TTR gene, and our analysis on V122I-related haplotypes has indicated differences in non-coding regulatory variants, suggesting differences among V122I carriers. The analysis of methylation status indicated CpG sites that may affect TTR expression. Finally, our interactive network analysis revealed functional partners of TTR that may play a modifier role in the pathogenesis of TTR-related amyloidosis.

DISCUSSION AND CONCLUSION

Our data provided new insights into the pathogenesis of TTR-related amyloidosis that, if they were to be confirmed through experimental investigations, could significantly improve our understanding of the disease.

Human pharmacogenomic variation of antihypertensive drugs: from population genetics to personalized medicine

Aim: To investigate the human pharmacogenetic variation related to antihypertensive drugs, providing a survey of functional interpopulation differences in hypertension pharmacogenes. Materials & methods: The study was divided into two stages. In the first stage, we analyzed 1249 variants located in 57 hypertension pharmacogenes. This first-stage analysis confirmed that geographic origin strongly affects hypertension pharmacogenomic variation and that 31 pharmacogenes are geographically differentiated. In the second stage, we focused our attention on the ethnic-differentiated pharmacogenes, investigating 55,521 genetic variants. In silico analyses were performed to predict the effect of genetic variation. Results: Our analyses indicated functional interpopulation differences, suggesting insight into the mechanisms of antihypertensive drug response. Moreover, our data suggested that rare variants mainly determine the functionality of genes related to antihypertensive drugs. Conclusion: Our study provided important knowledge about the genetics of the antihypertensive drug response, suggesting that next-generation sequencing technologies may develop reliable pharmacogenetic tests for antihypertensive drugs.

Original submitted 19 September 2013; Revision submitted 14 November 2013