[A case of Takotsubo Syndrome complicated by not embolic cerebral]

The Takotsubo syndrome is characterized by transient left ventricular dysfunction with ST segment elevation in all or some leads, T-wave inversion in anterior and inferior leads and elevate cardiac biomarkers (HS troponin), which can mimic an acute coronary syndrome (STEMI) in the absence of obstructive coronary disease. The echocardiography shows transient alterations in the kinetics of the anterior, intermediate and apical segments of the left ventricle which tends to disappear within 4-8 weeks. A particular variant of Takotsubo Syndrome is reported in a 73-year-old man.

Air pollution, vascular disease and thrombosis: linking clinical data and pathogenic mechanisms

The public health burden of air pollution has been increasingly recognized over the last decades. Following the first assessed adverse effects on respiratory diseases and lung cancer, a large body of epidemiologic and clinical studies definitely documented an even stronger association of air pollution exposure with cardiovascular mortality and morbidity, particularly related to atherothrombotic (coronary and cerebrovascular) disease. Particulate matter (PM), mainly that with lower aerodynamic diameter (fine and ultrafine PM), is responsible for the most severe effects, due to its capacity to transport toxic substances deep into the lower airways. These effects have been shown to occur not only after short-term exposure to elevated concentrations of pollutants, but even after long-term relatively low levels of exposure. Vulnerable subjects (elderly persons and those with preexisting cardiopulmonary diseases) show the highest impact. Fewer and conflicting data also suggest an association with venous thromboembolism. Although not completely elucidated, a series of mechanisms have been hypothesized and tested in experimental settings. These phenomena, including vasomotor and cardiac autonomic dysfunction, hemostatic unbalance, oxidative stress and inflammatory response, have been shown to change over time and differently contribute to the short-term and long-term adverse effects of pollution exposure. Beyond environmental health policies, crucial for improving air quality and reducing the impact of such an elusive threat to public health, the recognition and assessment of the individual risk, together with specific advice, should be routinely implemented in the strategies of primary and secondary cardiovascular prevention.

[A prompt diagnosis of Steinert's dystrophy in emergency unit]

Atrial fibrillation is frequently observed in Fist Aid. A rare cause is myotonic dystrophy There are two forms: Steinert's dystrophy caused by a defect of a gene myotoninaprotein kinase and Promm secondary to a defect of a Zinc Finger Protein Gene Clinical manifestations are localized in skeletal and face muscles, vitreous body, sexual glands, endocrine system, smooth muscle, central nervous system and myocardium. Sometimes, in mild and unrecognized forms of this rare disease there are arrhythmias as atrial fibrillation. We report the clinical case of a 52 year-old man, with a suspect diagnosis of Steinert's dystrophy, admitted to the emergency room for a persistent atrial fibrillation. The patient begins oral anticoagulation therapy. The patient perform a transesophageal echocardiogram before the electrical cardioversion with reset to sinus rhythm. In conclusion, with improving the screening methods of patients with primary and secondary myopathies, it has been seen an increase of cases in which a cardiac involvement occurred before or after the onset of the neuromuscular disorders. One of the most frequent alterations is represented by atrial fibrillation, responsible for an increased risk of cerebral embolism, with absolute indication for oral anticoagulation therapy. The myopathy more frequently associated with atrial fibrillation, is myotonic dystrophy, although the risk of cerebral embolism in these patients does not appear to be higher than the general population. The present case report is a spur to perform the diagnosis of Steinert disease in cases admitted to an Emergency Room because of arrhytmias, because of the possibility to perform fast and reliable specific genetic tests. A similar praxis confers to these Units an even more diagnostic clinical role.

Autologous bone marrow cell therapy for peripheral arterial disease

Inadequate blood supply to tissues caused by obstruction of arterioles and/or capillaries results in ischemic injuries – these injuries can range from mild (eg, leg ischemia) to severe conditions (eg, myocardial infarction, stroke). Surgical and/or endovascular procedures provide cutting-edge treatment for patients with vascular disorders; however, a high percentage of patients are currently not treatable, owing to high operative risk or unfavorable vascular involvement. Therapeutic angiogenesis has recently emerged as a promising new therapy, promoting the formation of new blood vessels by the introduction of bone marrow–derived stem and progenitor cells. These cells participate in the development of new blood vessels, the enlargement of existing blood vessels, and sprouting new capillaries from existing blood vessels, providing evidence of the therapeutic utility of these cells in ischemic tissues. In this review, the authors describe peripheral arterial disease, an ischemic condition affecting the lower extremities, summarizing different aspects of vascular regeneration and discussing which and how stem cells restore the blood flow. The authors also present an overview of encouraging results from early-phase clinical trials using stem cells to treat peripheral arterial disease. The authors believe that additional research initiatives should be undertaken to better identify the nature of stem cells and that an intensive cooperation between laboratory and clinical investigators is needed to optimize the design of cell therapy trials and to maximize their scientific rigor. Only this will allow the results of these investigations to develop best clinical practices. Additionally, although a number of stem cell therapies exist, many treatments are performed outside international and national regulations and many clinical trials have been not registered on databases such as ClinicalTrials.gov or EudraCT. Therefore, more rigorous clinical trials are required to confirm the first hopeful results and to address the challenging issues.

Cancers in patients with hemophilia: a retrospective study from the Italian Association of Hemophilia Centers

BACKGROUND

The increased life expectancy of the hemophilia population, primarily as a result of advances in factor replacement therapy, has enabled hemophiliacs to reach an older age. Consequently, age-related diseases, such as cardiovascular disorders and cancers, are being increasingly recognized in such patients. However, only few data are available on such co-morbidities, their management and impact on the primary bleeding disorders.

OBJECTIVES

With the aim of investigating several still unclear issues regarding cancers in hemophilia patients, we conducted, on behalf the Italian Association of Hemophilia Centers (AICE), a study on cancers among Italian hemophiliacs.

PATIENTS

Data pertaining to 122 hemophiliacs with 127 cancers between 1980 and 2010 were retrospectively collected in 21 centers of the AICE which chose to participate.

RESULTS

Sixty-nine percent of cancers were recorded during the decade 2001–2010. Eighty-three percent of patients were infected with hepatitis C virus (HCV) and 22% of them were also co-infected with human immunodeficiency virus (HIV). Forty-three percent of cancers were HCV-related, whereas 9%were HIV related. Virus-related cancers were more frequent and non-virus-related cancers less frequent in patients with severe hemophilia than in those with mild/moderate forms (P = 0.0004). The non-virus-related standardized mortality ratio (SMR) was 0.3. Hemorrhagic complications occurred more frequently in patients undergoing chemotherapy (14%) or radiotherapy (19%).

CONCLUSIONS

The results of the present study confirm that cancers have become a new challenge for physicians working in hemophilia centers and underline the need for prospective trials to better assess the epidemiology and to optimize the management of hemophiliacs with cancer.

Coronary artery disease, cerebral non-fatal ischemic stroke in retinal vein occlusion: an 8-yr follow-up

Forty-five consecutive subjects (26M, 19F; mean age 54 ± 14 yrs) with a diagnosed retinal vein occlusion (RVO), were followed-up for 8 yrs. As many as 145 sex-age- and blood pressure-matched individuals (78M, 67F; mean age 54.4 ± 13.5 yrs), that did not experience any vascular event, served as controls. At the time of the RVO, controls and subjects did not differ as to hypercholesterolemia, hypertrigliceridemia, diabetes mellitus, smoking habits, inherited/acquired thrombophilia. At the follow-up completion, they differed as to statin consumption (p = 0.016). During the 8-yrs follow-up, in the control population, 11 out of 145 (7.6%) subjects had experienced a major vascular event (8 coronary artery disease; 3 cerebral non-fatal ischemic stroke). In contrast, of the 45 subjects with a history of RVO, as many as 10 (22.2%) had experienced a major vascular event: 4 coronary artery disease; 4 cerebral non-fatal ischemic stroke; 2 cardiovascular + cerebrovascular event (p = 0.012). A prolonged antiplatelet treatment, prior to the major vascular event, was found in 5/45 cases (11.1%) vs 23/145 (15.9%) controls (p = 0.63). In contrast, a long-lasting administration of anti-hypertensive drugs, to achieve a control of blood pressure, was found in 83.4% of controls and only in 46.7% of cases (p < 0.0001). In conclusion, in a 8-yr follow-up, coronary artery disease and/or non-fatal ischemic stroke were more common in subjects with a history of RVO than in a large setting of subjects comparable for cardiovascular risk factors. These data also argue for RVO as a vascular disease in which aggressive anti-hypertensive therapy to prevent stroke and/or myocardial infarction is needed.

[An unusual cause of chest pain in]

Myocarditis seems to be mostly caused by a viral infection or more rarely by a pharmacological hypersensitivity or by radiations exposure. Nevertheless, it is not so easy to know the ethiopathogenesis of the myocarditis, because mostly it is impossible to determine the infectious agent that causes the pathology even if it is isolated. The diagnosis could often remain uncertain, so a suspect of myocarditis has to be opportunely confirmed by specific serological and diagnostic investigations, in order to avoid the appearance of a dilated cardiomyopathy which is one of its principal sequences.

[A single effective way to reduce post-thyroidectomy discomfort: a clinical trial]

AIM

Nausea, with or without vomiting (postoperative nausea and vomiting, PONV), occurs up to 60-76% after thyroidectomy and other head and neck surgeries. Due to the fact that patients typically have only mild-to-moderate pain after thyroid or parathyroid surgery, PONV might be the main source of discomfort, and it may be perceived as the most unpleasant aspect of postoperative recovery. This study aims to assess the effects of a preoperative single dose of 8 mg dexamethasone on the nausea, vomiting, pain, and subjective vocal function after thyroidectomy in patients undergoing surgery for benign disease.

METHODS

Seventy patients operated on for thyroidectomy were randomized in two groups: Group A, 8 mg/2 mL of dexamethasone administered in 100 mL of physiologic saline given intravenously (i.v.) 20 minutes before the induction of anesthesia; group B, 2 mL NaCl 0.9% in 100 mL of physiologic saline. Postoperative therapy has been standardized. PONV have been evaluated with a scale of 4, degrees (0-3), pain by a Visual Analog Scale (0-100) and subjective vocal function by a Visual Analog Scale (0-100) at 8, 24, 32 and 48 hours after surgery.

RESULTS

The severity of nausea was less in patients of group A (P=0.0001); Dexamethasone patients reported significantly less pain (P=0.008); no differences were noted about the subjective voice analysis (P=0.693). No steroid-related complications occurred.

CONCLUSION

Dexamethasone 8 mg i.v. is a safe and effective method to reduce PONV and pain after thyroid resection and we advise its routine use.

Cinacalcet hydrochloride in combination with alendronate normalizes hypercalcemia and improves bone mineral density in patients with primary hyperparathyroidism

Cinacalcet is effective in controlling the biochemical abnormalities in patients with primary hyperparathyroidism (PHPT) but it seems to be less effective on bone mineral density (BMD). In the same patients, bisphosphonates are reported to be effective on bone resorption but less effective on calcium and PTH excess. In this study, the efficacy of cinacalcet in combination with alendronate has been retrospectively evaluated in patients with PHPT. Twenty-three patients with PHPT who had not been operated were retrospectively investigated. Cinacalcet was evaluated in combination with alendronate in 10 of the 23 patients, and in monotherapy in 13 other patients. Serum calcium, phosphorus and PTH, 24 h urine calcium and phosphorus as well as BMD, evaluated by DXA and expressed as T-score, were measured before and after treatment. In all patients serum calcium and phosphorus and urinary calcium excretion were effectively and stably controlled and PTH was significantly decreased after treatment. There was no difference in the rate of serum calcium and PTH decrease between subjects treated with cinacalcet plus alendronate and those treated with cinacalcet alone. T-score increased by 9.6% at lumbar spine and 3.9% at femur level in the cinacalcet plus alendronate subgroup and was unchanged in the cinacalcet subgroup (P < 0.01). In patients with PHPT, the biochemical abnormalities are rapidly improved by cinacalcet regardless from the administration in monotherapy or in combination with alendronate. BMD is significantly improved in patients receiving cinacalcet plus alendronate and stable in those receiving cinacalcet in monotherapy.

Familial temporal lobe epilepsy with psychic auras associated with a novel LGI1 mutation

BACKGROUND

Autosomal dominant lateral temporal epilepsy (ADLTE) is characterized by focal seizures with auditory features or aphasia. Mutations in the LGI1 gene have been reported in up to 50% of ADLTE pedigrees. We report a family with temporal lobe epilepsy characterized by psychic symptoms associated with a novel LGI1 mutation.

METHODS

All participants were personally interviewed and underwent neurologic examination and video-EEG recordings. LGI1 exons were sequenced by standard methods. Mutant cDNA was transfected into human embryonic kidney 293 cells; both cell lysates and media were analyzed by Western blot. In silico modeling of the Lgi1 protein EPTP domain was carried out using the structure of WD repeat protein and manually refined.

RESULTS

Three affected family members were ascertained, 2 of whom had temporal epilepsy with psychic symptoms (déjà vu, fear) but no auditory or aphasic phenomena, while the third had complex partial seizures without any aura. In all patients, we found a novel LGI1 mutation, Arg407Cys, which did not hamper protein secretion in vitro. Mapping of the mutation on a 3-dimensional protein model showed that this mutation does not induce large structural rearrangements but could destabilize interactions of Lgi1 with target proteins.

CONCLUSIONS

The Arg407Cys is the first mutation with no effect on Lgi1 protein secretion. The uncommon, isolated psychic symptoms associated with it suggests that ADLTE encompasses a wider range of auras of temporal origin than hitherto reported.

[High digoxin serum levels in an elderly patient for the endogenous digoxin-like immunoreactive substances. A case report]

Digoxin is typically prescribed in the treatment of heart failure. Its limited therapeutic range requires systematic monitoring of plasmatic concentration through immunoreactive tests. Laboratory results, however, can be altered by the presence of digoxin-like immunoreactive factors (DLIF) which are released in all clinical conditions involving volemic expansion.

CASE REPORT

An 86-year-old woman arrived in emergency with severe dyspnoea, atrial flutter and a medical history of ischemic cardiopathy. The patient was treated with ACE inhibitor, furosemide, spironolactone and digoxin. The first lab test for digoxin showed levels of digoxin of 7.05 ng/ml. Although the patient did not show any clinical evidence of digital intoxication nor was she treated with drugs which might interfere with digoxin kinetics and even if she had markers of renal function within clinical limits, digoxin was suspended and a treatment was initiated with 0.9% NaCl solution and furosemide. The second lab test showed levels of digoxin of 8.38 ng/ml. A possible interference of DLIF with immunoreactive tests was therefore assumed.

MATERIALS AND METHODS

The patient's serum was ultrafiltered and centrifugated to remove possible DLIF; subsequently, the measurement of digoxin levels was repeated. As a result, the digoxin level decreased to 0.25 ng/ml.

CONCLUSIONS

DLIF increase in several diseases, including heart failure, end-stage renal disease, pre-eclampsy and acromegaly. High digoxin levels in a patient who does not show any symptoms of digital intoxication should lead to suspect the presence of these factors and to preventively determine DLIF in serum so as not to incur the risk of suspending an important treatment like digoxin in heart failure.

[The syncope in Emergency Department: usual management vs guidelines]

INTRODUCTION

The syncope is a common cause of admission to Emergency Departments, representing around 1-3% of all admissions to the service. However, elderly age and important comorbidities often hinder a definite etiologic diagnosis, with increasing requests for diagnostic tests and longer periods of hospitalization.

MATERIALS AND METHODS

We analyzed the management of 1,204 patients admitted to our Emergency Department for transient loss of consciousness in the period between 1 June 2009 and 1 June 2010, evaluating the following parameters: average age, gender, triage color code at admittance, performed diagnostic tests, diagnosis at discharge from ED and destination ward. We also studied a subgroup of 93 patients admitted to emergency medicine units evaluating their OESIL score at admittance, comorbidities, performed diagnostic tests and diagnosis at discharge from the ward.

RESULTS

In the Emergency Department, 45% of patients were discharged with a diagnosis of syncope of unknown origin; in 21% of patients syncope was excluded; 19% of patients received a diagnosis of cardiogenic syncope; 11% were diagnosed with a presyncope; 3% with orthostatic hypotension and 1% with vasovagal syncope. In emergency medicine units, 51% of patients were discharged with a diagnosis of cardiogenic syncope, 11% were diagnosed with vasovagal syncope, 11% with presyncope, 11% with TIA, 8% with loss of consciousness non-syncope and 8% with syncope of unknown origin.

CONCLUSIONS

Management of patients with syncope, elderly people with important comorbidities in particular, is still a serious problem for the emergency physician. The creation of specialized units for the management of syncope, the so-called syncope units, through the implementation of a shared diagnostic and therapeutic protocol, aims at reducing inappropriate hospitalization and average length of stay.

[The use of cardiac markers bed test in acute coronary syndrome in emergency department]

AIMS

The evaluation of the patient with chest pain in the emergency department is one of the most common situations that the doctor has to face. The diagnostic procedure supposes an observation period of at least 6-12 hours, a well organized medical facilities and the identification of all SCA cases to reduce inappropriate admission.

MATERIALS AND METHODS

In our study we have estimated the utility of the marker assay that is associated to the use of risk scores (TIMI and GRACE risk score) to obtain indication about the most appropriate assistance level. In particular, we used the assay of necrosis markers to highlight the damage along with the assay of natriuretic peptides for their role in the diagnosis and in the monitoring of the patients with cardiac damage.

RESULTS

Also PCR has an important role such as marker of plaque stability and of inflammation. These markers associated to the necrosis markers could give important clinical information of independent nature.

DISCUSSION

The sensibility of laboratory markers, without important necrosis, is low and it is not possible to exclude in a few time a SCA There is now an alternative strategy: a precocious risk stratification. Using clinical criteria it is possible to do a first evaluation of the probability of SCA and the complications.

In vitro and in vivo studies of boron neutron capture therapy: boron uptake/washout and cell death

Boron neutron capture therapy (BNCT) is a binary radiotherapy based on thermal-neutron irradiation of cells enriched with (10)B, which produces α particles and (7)Li ions of short range and high biological effectiveness. The selective uptake of boron by tumor cells is a crucial issue for BNCT, and studies of boron uptake and washout associated with cell survival studies can be of great help in developing clinical applications. In this work, boron uptake and washout were characterized both in vitro for the DHDK12TRb (DHD) rat colon carcinoma cell line and in vivo using rats bearing liver metastases from DHD cells. Despite a remarkable uptake, a large boron release was observed after removal of the boron-enriched medium from in vitro cell cultures. However, analysis of boron washout after rat liver perfusion in vivo did not show a significant boron release, suggesting that organ perfusion does not limit the therapeutic effectiveness of the treatment. The survival of boron-loaded cells exposed to thermal neutrons was also assessed; the results indicated that the removal of extracellular boron does not limit treatment effectiveness if adequate amounts of boron are delivered and if the cells are kept at low temperature. Cell survival was also investigated theoretically using a mechanistic model/Monte Carlo code originally developed for radiation-induced chromosome aberrations and extended here to cell death; good agreement between simulation outcomes and experimental data was obtained.