Roberto Ranieri

Prevalence of erectile dysfunction in thyroid disorders : comparison with control subjects and with obese and diabetic patients

Diagnosis of erectile dysfunction (ED) requires anamnestic investigation, being rarely spontaneously declared by patients. ED occurs frequently in diabetes mellitus, and anecdotal evidence suggests that ED occurs in obesity and in hypothyroidism. The aim of this study was to evaluate the prevalence of ED in patients affected by thyroid disorders (hypothyroidism and hyperthyroidism), in comparison with control subjects and with patients at risk for ED, such as patients with obesity and with type II diabetes mellitus, and the role of age. Spontaneous deposition and International Index of Erectile Dysfunction (IIEF)-5 questionnaire were considered for control subjects and for all patients. Spontaneous deposition of ED occurred for three diabetic patients, never for obese patients, thyroid patients and controls, confirming the value of IIEF-5 in detecting ED. ED was more frequent in obese subjects (42%), and in patients affected by thyroid diseases (59%), than in controls (30%), although less frequent than in type II diabetes mellitus (81%). Both below and above the age of 50 years, ED score was worse in thyroid patients than in control subjects, while ED was more frequent in obese patients than in control subjects only below the age of 50 years.

Gastric Bezoars after Adjustable Gastric Banding

Background: Gastric bezoars may develop in the proximal pouch after gastric restriction. Methods: Of 299 patients who underwent laparoscopic adjustable gastric banding (LAGB), 4 developed gastric bezoars at different intervals after surgery (24 days, 8 months, 18 months, and 6 years). Results: Symptoms of high dysphagia and vomiting occurred in all 4 patients. Removal of the bezoars via endoscopy was uneventful, and all patients have maintained their gastric band. Patients were emphasized to avoid rapid intake of high-residue cellulose foods, and to ach i eve complete mastication. N o bezoar has recurred in these patients at 7 to 75 months further follow-up. Conclusion: Gastric bezoar should be considered after LAGB if the patient complains of persistent high fullness and vomiting.

Subclinical hypothyroidism in a patient affected by advanced AIDS and visceral leishmaniasis

Hypothyroidism has been shown to occur in HIV disease. Thyroid function of patients affected by AIDS and leishmaniasis is unknown. Here we report the case of an AIDS advanced patient developing hypothyroidism during leishmaniasis. The thyroid disorder might have been caused by infiltration of the gland by Leishmania. An additive impact of HIV in thyroid function impairment is suggested.

Insulin resistance affects early virologic response in HIV-infected subjects treated for hepatitis C infection.

To the Editor: The use of highly active antiretroviral therapy (HAART) has been associated with an increased frequency of insulin resistance (IR) and of its clinical correlates, such as glucose intolerance and type-2 diabetes. A direct role of protease inhibitors (PIs) has been proposed; however, traditional risk factors for IR other than HIV infection and HAART use may also predict glucose intolerance or type-2 diabetes in HIVinfected population. In the general population, a correlation between hepatitis C virus (HCV) infection and IR has been demonstrated; the possible mechanisms at the basis of this finding seem to be increased tumor necrosis factor (TNF) production, together with the enhancement of suppressor cytokines (SOC-3), both blocking PI3K and Akt phosphorylation. In HIVnegative patients with chronic HCV receiving pegylated interferon plus ribavirin, IR, as measured by the hemostatic model of assessment (HOMA) index, has been related to the 6-month virologic response. In addition, subjects with a sustained virologic response had lower HOMA values compared with others. Whether IR represents a marker of difficult-to-cure subjects or whether it acts through a pathogenic mechanism by blocking the antiviral activity of interferon is unknown. HCV infection is often a comorbidity in HIV-infected subjects, especially if they are intravenous drug abusers. It has often been associated with IR and hyperglycemia in HIVinfected patients receiving HAART. At the moment, few data are available on the role of IR in influencing the virologic response to anti-HCV treatment in the HIV-infected population. The aim of this study is to evaluate the correlation between IR and early virologic response (EVR) in HIV/HCVcoinfected subjects receiving pegylated interferon plus ribavirin. We included in this study 29 consecutive HIV-infected subjects followed at our clinic who started an antiHCV treatment with pegylated interferon a-2a plus ribavirin (at a dosage of 1000 to 1200 mg according to body weight) in January 2006. The following variables were collected at baseline (time of starting anti-HCV treatment): gender, age, race, body mass index (BMI), platelet count, aspartate aminotransferase (AST), alanine aminotransferase (ALT), serum glucose, insulin, total cholesterol, triglycerides, CD4 cell count, HIV RNA level, HCV RNA level, HCV genotype, and use of HAART (defined as use of

Management of HCV infection in the penitentiary setting in the direct-acting antivirals era: practical recommendations from an expert panel

2 nucleoside reverse transcriptase inhibitors with any PI or nonnucleoside reverse transcriptase inhibitors). Serum insulin levels were measured by electrochemiluminescence immunoassay using an autoanalyser (Elecsys 1010/2010; Elecsys Modular Analytics E170; Roche, Basel, Switzerland). HIV-RNA load was assessed using the reverse transcriptase (RT) polymerase chain reaction (PCR), with a detection limit <60 copies/mL (Arthus Qiagen, Heiden, Germany). Qualitative PCR analysis for HCV was performed by nested PCR (Amplicor Roche, Basel, Switzerland; detection limit <15 IU/L). HCV genotyping was performed using a line-probe assay (INNOLiPA HCV II; Immunogenetics, Belgium). IR was calculated through the HOMA equation: fasting insulin (mIU/L) 3 fasting glucose (mmol/L)/22.5. IR was defined as a HOMAvalue >3.8, according to other studies on white populations with low risk for diabetes. EVR was defined as HCV RNA level <15 IU/mL after 3 months of anti-HCV treatment; additionally, we evaluated the rapid virologic response (RVR), defined as HCV RNA level <15 IU/L after 1 month of anti-HCV treatment. Differences between variables were calculated using the x and Student t tests when appropriate. Table 1 shows the demographics and clinical characteristics of the subjects included in our study according to the HOMA values at baseline. All the patients were white. Ten subjects (34.5%) had a HOMA index >3.8, and 19 (65.5%) had values #3.8. No statistically significant differences were observed in the 2 groups according to the variables considered. After 3 months of anti-HCV treatment, median AST and ALT levels decreased in both groups. In subjects with IR at baseline, median AST and ALT levels decreased from 109 (interquartile range [IQR]: 60 to 141) IU/ L to 54 (IQR: 42 to 65) IU/L (P < 0.01) and from 105 (IQR: 76 to 124) IU/L to 53 (IQR: 45 to 88) IU/L (P < 0.01), whereas in subjects without IR, AST and ALT levels decreased from 108 (IQR: 61 to 147) IU/L to 37 (IQR: 30 to 50) IU/L (P < 0.01) and from 101 (IQR: 68 to 109) IU/L to 33 (IQR: 27 to 48) IU/L (P < 0.01), respectively. RVR was achieved in 8 (42.1%) of 19 subjects without IR and in 0 of 10 with IR at baseline (P < 0.001); EVR was observed in 16 (84.2%) of 19 subjects without IR and in 0 of 10 with IR (P < 0.001). The 3 subjects who did not achieve EVR had genotype 1a, 3a, and 4c/4d, respectively. HCV infection and HAART are conditions associated with a higher probability of developing IR. Such a condition is a known predictor of reduced sustained virologic response to anti-HCV treatment in HCV-infected subjects. Conversely, the achievement of RVR and EVR is a strong predictor of recovery from HCV infection; therefore, subjects who do not achieve this endpoint may be discontinued from anti-HCV treatment because of a low probability of sustained virologic response. In the present study, including only HIV/HCV-coinfected subjects, we found that subjects without IR at baseline are more likely to reach RVR and EVR than the others. Also, in subjects with genotype 3, which is known to respond better to anti-HCV treatments, the presence of IR does not allow for the achievement of RVR or EVR. These results, obtained on a limited number of subjects, suggest that IR should always be evaluated before starting anti-HCV treatment. Therefore, the correction of IR, and the consequent recovery of insulin sensitivity, could improve RVR and EVR in the HIV/ HCV-coinfected population treated with pegylated interferon and ribavirin, and

Treatment with direct-acting antivirals in a multicenter cohort of HCV-infected inmates in Italy

BackgroundThe prevalence of HCV infection is higher among prisoners than in the general population. The introduction of HCV direct-acting antivirals (DAA) holds the potential to improve clinical outcomes also in inmates. However, treatment of hepatitis C in inmates has to face several clinical and logistical issues which are peculiar of prison environment. Recommendations on the management of HCV infection specific for the penitentiary setting in the DAA era remain scant. The Italian Society for Penitentiary Medicine and Healthcare has, therefore, issued these recommendations, to provide clinicians with a guide for the comprehensive management of HCV infection in the restriction setting, taking into account its peculiar characteristics.ResultsDedicated diagnostic and treatment procedures should be established in each prison. In particular, the use of DAAs appears crucial to provide patients with an effective therapeutic option, able to overcome the limitations of IFN-based regimens with a short period of treatment. DAA treatment should be initiated as soon as possible in all eligible subjects with the aim to cure the patient, as well as to limit the transmission of HCV infection both inside the penitentiary system and to the free community, once the inmates ends his/her release. Importantly, efforts should be made to open a discussion with regulatory bodies, to define specific regulations aimed to guarantee wide access to effective therapies of all eligible patients, to optimize the management of and the adherence to the HCV treatment, and to ensure the therapeutic continuity after discharge from prison.

Hospital admissions for HIV-infected prisoners in Italy

BACKGROUND People who are incarcerated have a significantly higher prevalence of HCV infection than the general population. Given their high-risk behavior, they represent a reservoir of HCV infection for the whole community. METHODS We evaluated all HCV-infected people who were incarcerated in 25 Italian prisons starting direct-acting antivirals (DAAs) treatment between May 2015 and October 2016. We collected information on demographic characteristics, liver disease, HCV-related aspects, anti-HCV treatment, HIV or HBV co-infection. RESULTS We enrolled 142 incarcerated people treated with DAAs. They were mostly Italians (93.7%) and males (98.6%). Median age was 50 years and 108/142 (76.1%) were cirrhotic patients. Prevalent genotypes were 1a (35.9%) and 3 (35.9%). Two patients were HBV co-infected, twenty-one patients (14.8%) were HIV co-infected and almost all (95.2%) received antiretroviral therapy. 118/142 (83.1%) DAAs-based regimens included sofosbuvir. Treatment completion rate was 94.4%. There were eight (5.6%) discontinuations, one (0.7%) due to an adverse reaction, one due to death (0.7%) and six (5.6%) due to release from prison. SVR12 was achieved in 90.8%. Four patients relapsed but no breakthrough occurred. CONCLUSIONS Our study shows that in Italian penitentiary settings DAAs treatment is feasible and effective. This intervention is crucial for reducing HCV circulation with possible benefits to the general population.

Sudden Cardiac Death in a Young HIV-Positive Man on Effective Antiretroviral Therapy

Purpose The purpose of this paper is to give a description of the clinical conditions and patient demographics of inpatient admissions of human immunodeficiency virus (HIV)-infected inmates in three hospital wards that provide hospital care for inmates in Italy. Design/methodology/approach This is a retrospective review of hospital medical admissions of patients living with HIV from January 1 to December 31, 2014, in three Italian referral centers for hospitalization of inmates. Findings A total of 85 admissions for 85 different HIV-infected inmates occurred in 2014 in the three centers participating to the study. Most patients (54.1 percent) were co-infected with hepatitis C. Discharge diagnosis largely varied ranging from common HIV-related co-morbidities to completely independent diagnosis. The most commonly observed discharge diagnoses were chronic hepatitis C, liver cirrhosis, opiate dependence and thrombocytopenia. Originality/value Discharge diagnosis between HIV-infected inmates and HIV-infected patients in freedom are strikingly and significantly different. A large number of hospitalized HIV-infected inmates were affected by chronic viral hepatitis and liver cirrhosis; this is probably a direct consequence of the high prevalence of HCV and/or HBV co-infections in the inmate population in Italy. In addition, a significantly lower proportion of cancer diagnosis was observed among inmates; this is possibly justified by the fact that in our Italian settings when HIV infection is at advanced stages or if cancer treatment is started those affected are released from prison and can continue their diagnostic and treatment follow-up in freedom.

White blood cells in obesity and diabetes : effects of weight loss and normalization of glucose metabolism

We describe the case of a young HIV-positive man on effective HAART with excellent viro-immunological control who presented a massive cardiac infarction. Despite the presence of clinical risk factors for cardiovascular disease, the patient had normal arterial carotid IMT values, known to be strong predictors of atherosclerosis and stroke. Interestingly, parameters of T-cell activation (CD8+CD38+) were shown to increase just before the onset of myocardial infarction. As T-cell activation is known to mediate atherosclerosis, the authors suggest that surrogate immunologic markers should be identified to better assess cardiovascular risk in the setting of HIV infection.