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Pastori D, Menichelli D, Romiti GF, Speziale AP, Pignatelli P, Basili S, Violi F, Cangemi R. Prediction of new-onset atrial fibrillation with the C 2HEST score in patients admitted with community-acquired pneumonia. Infection 2024; 52:1539-1546. [PMID: 38700657 PMCID: PMC11289234 DOI: 10.1007/s15010-024-02286-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/24/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE Patients hospitalized for community-acquired pneumonia (CAP) may have a higher risk of new-onset atrial fibrillation (NOAF). The C2HEST score was developed to evaluate the NOAF risk in the general population. Data on the value of the C2HEST score in acute patients admitted with CAP are lacking. We want to establish the predictive value of C2HEST score for NOAF in patients with CAP. METHODS Patients with CAP enrolled in the SIXTUS cohort were enrolled. C2HEST score was calculated at baseline. In-hospital NOAF was recorded. Receiver-operating Characteristic (ROC) curve and multivariable Cox proportional hazard regression analysis were performed. RESULTS We enrolled 473 patients (36% women, mean age 70.6 ± 16.5 years), and 54 NOAF occurred. Patients with NOAF were elderly, more frequently affected by hypertension, heart failure, previous stroke/transient ischemic attack, peripheral artery disease and hyperthyroidism. NOAF patients had also higher CURB-65, PSI class and CHA2DS2-VASc score. The C-index of C2HEST score for NOAF was 0.747 (95% confidence interval [95%CI] 0.705-0.786), higher compared to CURB-65 (0.611, 95%CI 0.566-0.655, p = 0.0016), PSI (0.665, 95%CI 0.621-0.708, p = 0.0199) and CHA2DS2-VASc score (0.696, 95%CI 0.652-0.737, p = 0.0762). The best combination of sensitivity (67%) and specificity (70%) was observed with a C2HEST score ≥ 4. This result was confirmed by the multivariable Cox analysis (Hazard Ratio [HR] for C2HEST score ≥ 4 was 10.7, 95%CI 2.0-57.9; p = 0.006), independently from the severity of pneumonia. CONCLUSION The C2HEST score was a useful predictive tool to identify patients at higher risk for NOAF during hospitalization for CAP. CLINICAL TRIAL REGISTRATION www. CLINICALTRIALS gov (NCT01773863).
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Affiliation(s)
- Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
| | - Danilo Menichelli
- Department of General Surgery, Surgical Specialties and Organ Transplantation "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Angela Pia Speziale
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Cangemi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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Rijk MH, Platteel TN, Geersing GJ, Hollander M, Dalmolen BLGP, Little P, Rutten FH, van Smeden M, Venekamp RP. Predicting adverse outcomes in adults with a community-acquired lower respiratory tract infection: a protocol for the development and validation of two prediction models for (i) all-cause hospitalisation and mortality and (ii) cardiovascular outcomes. Diagn Progn Res 2023; 7:23. [PMID: 38057921 DOI: 10.1186/s41512-023-00161-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/10/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Community-acquired lower respiratory tract infections (LRTI) are common in primary care and patients at particular risk of adverse outcomes, e.g., hospitalisation and mortality, are challenging to identify. LRTIs are also linked to an increased incidence of cardiovascular diseases (CVD) following the initial infection, whereas concurrent CVD might negatively impact overall prognosis in LRTI patients. Accurate risk prediction of adverse outcomes in LRTI patients, while considering the interplay with CVD, can aid general practitioners (GP) in the clinical decision-making process, and may allow for early detection of deterioration. This paper therefore presents the design of the development and external validation of two models for predicting individual risk of all-cause hospitalisation or mortality (model 1) and short-term incidence of CVD (model 2) in adults presenting to primary care with LRTI. METHODS Both models will be developed using linked routine electronic health records (EHR) data from Dutch primary and secondary care, and the mortality registry. Adults aged ≥ 40 years with a GP-diagnosis of LRTI between 2016 and 2019 are eligible for inclusion. Relevant patient demographics, medical history, medication use, presenting signs and symptoms, and vital and laboratory measurements will be considered as candidate predictors. Outcomes of interest include 30-day all-cause hospitalisation or mortality (model 1) and 90-day CVD (model 2). Multivariable elastic net regression techniques will be used for model development. During the modelling process, the incremental predictive value of CVD for hospitalisation or all-cause mortality (model 1) will also be assessed. The models will be validated through internal-external cross-validation and external validation in an equivalent cohort of primary care LRTI patients. DISCUSSION Implementation of currently available prediction models for primary care LRTI patients is hampered by limited assessment of model performance. While considering the role of CVD in LRTI prognosis, we aim to develop and externally validate two models that predict clinically relevant outcomes to aid GPs in clinical decision-making. Challenges that we anticipate include the possibility of low event rates and common problems related to the use of EHR data, such as candidate predictor measurement and missingness, how best to retrieve information from free text fields, and potential misclassification of outcome events.
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Affiliation(s)
- Merijn H Rijk
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Tamara N Platteel
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Geert-Jan Geersing
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Monika Hollander
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Paul Little
- Primary Care Research Center, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, United Kingdom
| | - Frans H Rutten
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Maarten van Smeden
- Department of Epidemiology & Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Roderick P Venekamp
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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3
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Ali AS, Sheikh D, Chandler TR, Furmanek S, Huang J, Ramirez JA, Arnold F, Cavallazzi R. Cardiovascular Complications Are the Primary Drivers of Mortality in Hospitalized Patients With SARS-CoV-2 Community-Acquired Pneumonia. Chest 2023; 163:1051-1060. [PMID: 36410493 PMCID: PMC9674393 DOI: 10.1016/j.chest.2022.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/10/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Hospitalized patients with SARS-CoV-2 community-acquired pneumonia (CAP) and associated comorbidities are at increased risk of cardiovascular complications. The magnitude of effect of cardiovascular complications and the role of prior comorbidities on clinical outcomes are not well defined. RESEARCH QUESTION What is the impact of cardiovascular complications on mortality in hospitalized patients with SARS-CoV-2 CAP? What is the impact of comorbidities and other risk factors on the risk of developing cardiovascular complications and mortality in these patients? STUDY DESIGN AND METHODS This cohort study included 1,645 hospitalized patients with SARS-CoV-2 CAP. Cardiovascular complications were evaluated. The clinical course during hospitalization was described by using a multistate model with four states: (1) hospitalized with no cardiovascular complications; (2) hospitalized with cardiovascular complications; (3) discharged alive; (4) and dead. Cox proportional hazards regression was used to analyze the impact of prior comorbid conditions on transitions between these states. Hazard ratios (HRs) and 95% CIs are reported. RESULTS Cardiovascular complications occurred in 18% of patients hospitalized with SARS-CoV-2 CAP. The mortality rate in this group was 45% vs 13% in patients without cardiovascular complications. Male subjects (HR, 1.32; 95% CI, 1.03-1.68), older adults (HR, 1.34; 95% CI, 1.03-1.75), and patients with congestive heart failure (HR, 1.59; 95% CI, 1.18-2.15), coronary artery disease (HR, 1.34; 95% CI, 1.00-1.79), atrial fibrillation (HR, 1.43; 95% CI, 1.06-1.95), direct admissions to the ICU (HR, 1.77; 95% CI, 1.36-2.32), and Pao2/Fio2 < 200 (HR, 1.46; 95% CI, 1.11-1.92) were more likely to develop cardiovascular complications following hospitalization for SARS-CoV-2 CAP; however, these factors are not associated with increased risk of death following a cardiovascular complication. INTERPRETATION Prior comorbidities, older age, male sex, severity of illness, and hypoxemia are associated with increased risk of cardiovascular complications. Once patients develop cardiovascular complications, the risk of death is extremely high. Cardiovascular complications are the primary drivers of mortality in hospitalized patients with SARS-CoV-2 CAP.
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Affiliation(s)
- Ahmed Shebl Ali
- Division of Infectious Diseases, University of Louisville, Louisville, KY
| | - Daniya Sheikh
- Division of Infectious Diseases, University of Louisville, Louisville, KY.
| | - Thomas R Chandler
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY
| | - Stephen Furmanek
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY
| | - Forest Arnold
- Division of Infectious Diseases, University of Louisville, Louisville, KY
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville, KY
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Corica B, Tartaglia F, Oliva A, Raparelli V, Cangemi R, Basili S, Lip GYH, Proietti M, Romiti GF. Prevalence of new-onset atrial fibrillation in hospitalized patients with community-acquired pneumonia: a systematic review and meta-analysis. Intern Emerg Med 2023; 18:127-135. [PMID: 36333574 PMCID: PMC9638315 DOI: 10.1007/s11739-022-03135-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
Community-acquired pneumonia (CAP) is a common lower respiratory tract infection, often complicated by cardiovascular events, including cardiac arrhythmias. New-onset atrial fibrillation (newAF) has been associated with increased mortality in CAP patients, especially in those critically ill; however, limited data on the prevalence of newAF in patients with CAP are available. We aim to estimate the pooled prevalence of newAF and its impact on adverse outcomes in patients with CAP, through a systematic review and meta-analysis. MEDLINE and EMBASE were systematically searched from inception to 27 January 2022. All studies reporting the prevalence of newAF in CAP patients were included and all-cause mortality was extracted when available. The pooled prevalence of newAF, 95% Confidence Intervals (CI), and 95% Prediction Intervals (PI) were computed. The inconsistency index (I2) was calculated to measure heterogeneity. Subgroup analyses were also performed. A protocol for this study was registered on PROSPERO (CRD42022307422). Among 7,655 records retrieved, 10 studies were included, with a total of 280,589 CAP patients. Pooled prevalence of newAF in CAP patients was 7.6% (95% CI 6.4-9.0%, 95% PI 4.3-13.1%, I2 = 95%). Subgroup analyses showed no significant differences according to geographical location or study design. Patients with newAF had a higher risk of mortality among the studies included in the systematic review. NewAF is a common complication, occurring in 7.6% of CAP patients, with prediction intervals suggesting an even higher burden. CAP patients who develop newAF during hospitalization may be at higher risk of mortality in both short- and long-term follow-up.
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Affiliation(s)
- Bernadette Corica
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom, Liverpool, UK
| | - Francesco Tartaglia
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza - University of Rome, Rome, Italy
| | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Faculty of Nursing, University of Alberta, Edmonton, Canada
- University Center for Studies On Gender Medicine, University of Ferrara, Ferrara, Italy
| | - Roberto Cangemi
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom, Liverpool, UK.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy.
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom, Liverpool, UK
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Han X, Chen L, Li H, Zhou F, Xing X, Zhang C, Suo L, Wang J, Liu X, Cao B. Prognostic Factors for Cardiovascular Events in Elderly Patients with Community Acquired Pneumonia: Results from the CAP-China Network. Clin Interv Aging 2022; 17:603-614. [PMID: 35497052 PMCID: PMC9047947 DOI: 10.2147/cia.s356925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/18/2022] [Indexed: 02/05/2023] Open
Affiliation(s)
- Xiudi Han
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital Group, Qingdao City, Shandong Province, 266011, People’s Republic of China
| | - Liang Chen
- Department of Infectious Diseases, Nanjing Lishui People’s Hospital, Nanjing City, Jiangsu Province, 211213, People’s Republic of China
| | - Hui Li
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital; Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, 100020, People’s Republic of China
| | - Fei Zhou
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital; Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, 100020, People’s Republic of China
| | - Xiqian Xing
- Department of Respiratory Medicine, Yan’an Hospital Affiliated to Kunming Medical University, Kunming City, Yunnan Province, 652199, People’s Republic of China
| | - Chunxiao Zhang
- Department of Respiratory Medicine, Beijing Huimin Hospital, Beijing, 100054, People’s Republic of China
| | - Lijun Suo
- Department of Pulmonary and Critical Care Medicine, Zibo Municipal Hospital, Zibo City, Shandong Province, 255000, People’s Republic of China
| | - Jinxiang Wang
- Department of Respiratory Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, 101149, People’s Republic of China
| | - Xuedong Liu
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital Group, Qingdao City, Shandong Province, 266011, People’s Republic of China
- Correspondence: Xuedong Liu, Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital Group, Jiaozhou Road, Qingdao City, Shandong Province, 266011, People’s Republic of China, Tel +86-18661678256, Fax +86-532-82789055, Email
| | - Bin Cao
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital; Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, 100020, People’s Republic of China
- Bin Cao, Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-Yang District, Beijing, 100020, People’s Republic of China, Tel +86-13911318339, Fax +86-10-84206264, Email
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6
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Wang BY, Lin FY, Ku MS, Wang YH, Lee KY, Ho SW. CHA2DS2-VASc Score for Major Adverse Cardiovascular Events Stratification in Patients with Pneumonia with and without Atrial Fibrillation. J Clin Med 2021; 10:4093. [PMID: 34575202 PMCID: PMC8466520 DOI: 10.3390/jcm10184093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Recent studies have shown an association between CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category) score and outcome of acute myocardial infarction, stroke, and chest pain. As pneumonia can affect the cardiovascular system, this study aimed to investigate the performance of the CHA2DS2-VASc score for major adverse cardiovascular events (MACEs) risk stratification in patients with pneumonia. METHODS A retrospective population-based cohort study including 61,843 patients with pneumonia. These patients were divided into two cohorts that were stratified based on the presence or absence of underlying atrial fibrillation (AF). We calculated the CHA2DS2-VASc score and incidence density rates of MACEs in each cohort. Cox regression was conducted to calculate hazard ratio of MACEs in pneumonia patients. The diagnostic performance of CHA2DS2-VASc with regard to MACEs was tested using the receiver operator characteristic curve. RESULTS Pneumonia patients with higher CHA2DS2-VASc score were more likely develop MACEs in both the AF and non-AF groups. In the AF group, the areas under the curve (AUC), sensitivity, and specificity were 0.824 (0.7773-0.8708), 0.7, and 0.84 respectively. In the non-AF group, the AUC, sensitivity, and specificity were 0.8185 (0.8152-0.8217), 0.75, and 0.83 respectively. CONCLUSIONS The CHA2DS2-VASc score showed good performance in the prediction of MACE in patients with pneumonia.
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Affiliation(s)
- Bo-Yuan Wang
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan; (B.-Y.W.); (K.-Y.L.)
- Department of Emergency Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Fei-Yi Lin
- Department of Nursing, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
- Department of Nursing, Chung Shan Medical University, Taichung 402, Taiwan
| | - Min-Sho Ku
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
| | - Kun-Yu Lee
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan; (B.-Y.W.); (K.-Y.L.)
- Department of Emergency Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Sai-Wai Ho
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan; (B.-Y.W.); (K.-Y.L.)
- Department of Emergency Medicine, Chung Shan Medical University, Taichung 402, Taiwan
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Pieralli F, Vannucchi V, Nozzoli C, Augello G, Dentali F, De Marzi G, Uomo G, Risaliti F, Morbidoni L, Mazzone A, Santini C, Tirotta D, Corradi F, Gerloni R, Gnerre P, Gussoni G, Valerio A, Campanini M, Manfellotto D, Fontanella A. Correction to: Acute cardiovascular events in patients with community acquired pneumonia: results from the observational prospective FADOI-ICECAP study. BMC Infect Dis 2021; 21:195. [PMID: 33607965 PMCID: PMC7893753 DOI: 10.1186/s12879-021-05891-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Filippo Pieralli
- Intermediate Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Vieri Vannucchi
- Internal Medicine, Hospital "Santa Maria Nuova" Florence, Florence, Italy
| | - Carlo Nozzoli
- Intermediate Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | | | - Francesco Dentali
- Internal Medicine, Hospital of Luino, ASST-Sette Laghi, and University of Insubria, Varese, Italy
| | - Giulia De Marzi
- Intermediate Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Generoso Uomo
- Medical Department, Internal Medicine, Hospital "Cardarelli",Pieralli et al. BMC Infectious Diseases (2021) 21:116 Page 11 of 12, Naples, Italy
| | | | - Laura Morbidoni
- Internal Medicine, Hospital "Civile" of Senigallia, Ancona, Italy
| | - Antonino Mazzone
- Medical Department, Internal Medicine, Hospital "Civile" of Legnano, Milan, Italy
| | - Claudio Santini
- Medical Department, Internal Medicine, Hospital "Vannini", Rome, Italy
| | | | - Francesco Corradi
- Medical Department, Internal Medicine 2, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Riccardo Gerloni
- Internal Medicine, "Ospedali Riuniti di Trieste", Trieste, Italy
| | - Paola Gnerre
- Internal Medicine, "San Paolo" Hospital, Savona, Italy
| | - Gualberto Gussoni
- Research Department, FADOI Foundation, Piazzale Cadorna, 15, 20123, Milan, Italy
| | - Antonella Valerio
- Research Department, FADOI Foundation, Piazzale Cadorna, 15, 20123, Milan, Italy.
| | - Mauro Campanini
- Department of Internal Medicine, Hospital "Maggiore della Carità", Novara, Italy
| | - Dario Manfellotto
- Department of Internal Medicine, Ospedale Fatebenefratelli-AFaR, Isola Tiberina, Rome, Italy
| | - Andrea Fontanella
- Medical Department, Hospital "Buon Consiglio-Fatebenefratelli", Naples, Italy
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