Vertical Banded Gastroplasty Modifies Plasma Ghrelin Secretion In Obese Patients

BACKGROUND

Restrictive bariatric surgery causes weight loss through substantial decline of appetite with satiety after meals. Reduction of plasma ghrelin levels after Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding could contribute to these effects, although contradictory results have been reported. The only restrictive operation still not yet investigated is vertical banded gastroplasty (VBG). We studied the effects of VBG on basal plasma ghrelin levels and meal-mediated inhibition.

METHODS

12 morbidly obese patients, 11 female and 1 male, were studied before and after VBG, when the BMI fell by 20%. The control group consisted of 6 lean volunteers. Active ghrelin was determined by RIA after overnight fasting and after the administration of a liquid meal.

RESULTS

Obese patients preoperatively had significantly lower basal plasma ghrelin levels than lean volunteers, and the meal did not inhibit ghrelin secretion. After VBG and 20% BMI loss, basal plasma ghrelin levels increased and the reduction caused by a meal recovered.

CONCLUSIONS

Weight loss caused by VBG is associated with higher plasma ghrelin levels in obese patients. The operation restores the normal adaptation of the A- cells of the stomach to a meal.

Long term follow up of children with myocarditis treated by immunosuppression and of children with dilated cardiomyopathy

OBJECTIVE

To describe the treatment and long term outcome after immunosuppressive treatment of children with myocarditis.

METHODS AND RESULTS

114 patients with newly diagnosed dilated cardiomyopathy were divided into three groups, according to the histological pattern: group A, acute myocarditis; group B, borderline myocarditis; and group C, non-inflammatory cardiomyopathy. Groups A and B were treated with cyclosporine and prednisone in addition to conventional treatment. Survivors of the whole cohort were analysed for 13 year transplant-free survival and assessed for left ventricular function. Event-free survival at 13 years was 97 (3)% for group A, 70 (8)% for group B, and 32 (7)% for group C (p < 0.0001). It was 96 (4)% at one year and 83 (5)% at 13 years for the cumulated myocarditis group (A and B). Cardiac function recovered completely in 79% of survivors in group A, 64% in group B, and 36% in group C. The rate of complete recovery in the cumulated group (A and B) was 70%.

CONCLUSIONS

The high long term survival rate of this cohort of children with myocarditis is probably due to the effect of short term immunosuppression. This result differs from previously published series of conventionally treated children, whose survival probability at one year was about 60%.

Prevalence of hypovitaminosis D in elderly women in Italy: clinical consequences and risk factors

In order to evaluate the prevalence, risk factors, and clinical consequences of hypovitaminosis D in elderly Italian women a multicenter study of 43 osteoporosis centers from all regions of Italy was carried out. Study population included 700 women aged 60-80 years in whom blood was taken for 25-hydroxyvitamin D (25OHD) and parathyroid hormone (PTH) measurements. All subjects were also questioned to assess the prevalence of several risk factors for hypovitaminosis D, osteoporotic fractures and activities of daily living (ADL). Values of 25OHD lower than 5 ng/ml were found in 27% of the women and lower than 12 ng/ml in 76%. 25OHD and PTH levels were negatively correlated ( r=-0.38, after logarithmic transformation of both variables). 25OHD levels significantly declined with advancing age and number of pregnancies and were positively correlated with educational level (years spent at school), dairy calcium intake, and days spent on holiday by the sea. In a multivariate model including all these variables, the only one that remained significant was the level of education. The lowest age-adjusted 25OH D levels were found in smokers or in women living in central Italy as compared with those living in northern or southern Italy. The mean (+/-SD) age-adjusted 25OH D values were significantly lower in women who sustained a hip fracture (7.1+/-2.2 versus 11.0+/-9.9). Women with low 25OHD levels (<12 ng/ml) had worse scores for ADL and mobility ADL (move outdoors, use stairs, walk at least 400 m, carry a heavy object). Vitamin D deficiency is extremely common among elderly Italian women. Women with lower educational level, living in central Italy, smokers or with lower intake of dairy products are at greater risk. Hypovitaminosis D is associated with worsening of the ability to perform activities of daily living and higher hip fracture prevalence. This finding should lead to an urgent population-based strategy to remedy this condition.

Immune monitoring of glucocorticoid therapy

There is a clear medical need to improve the GC therapy because of the individually variable responsiveness to GC. Recently, several well-standardised cell-based assays focussing on monocyte functions (flowcytometric measurement of HLA-DR expression, semiautomatic measurement of ex vivo TNF release capacity) have been introduced into the clinical laboratory. These techniques allow for both the detection immunosuppression and the monitoring of therapeutic efficacy. The measurement of efficacy might be further improved by applying the novel technology of gene expression profiling that is ready for introducing into the diagnostics.

Short-term intravenous therapy with Neridronate in Paget's disease

AIMS

To describe the effects of two consecutive intravenous infusions of aminohexane bisphosphonate (Neridronate) in patients with active Paget's disease of bone.

METHODS

The study population included 83 patients, aged 41 to 85 years, randomized to 4 cumulative doses of Neridronate (25, 50, 100, 200 mg) given over 2 days, with a follow up of 180 days. The baseline serum alkaline phosphatase activity was at least 10% above the upper limit of the laboratory range. The response to treatment was assessed by changes in the serum total alkaline phosphatase (primary end point of the study), bone alkaline phosphatase and N-telopeptide urinary excretion.

RESULTS

All Neridronate doses significantly suppressed the biochemical indices of disease activity. The nadir of total alkaline phosphatase levels ranged from -16 % to -57.5% of pretreatment values in the four groups, with a dose-response relationship that was apparent even between the two highest doses. The proportion of patients still maintaining a partial response (decreases in serum total alkaline phosphatase >25%) at the 6 month follow-up was also related to the dose: 98%, 67%, 57%, 21% in the patients given 200, 100, 50, 25 mg respectively. The proportion of responders in terms of bone alkaline phosphatase and N-telopeptide excretion changes was similar. Bone pain attributed to Paget's disease was significantly reduced. A typical acute phase reaction (fever and/or arthromyalgia) occurred in 16 out of 83 patients.

CONCLUSIONS

We conclude that all of the Neridronate doses tested here were well tolerated and effective in decreasing, in a dose-related manner the bone turnover parameters of Paget's disease. The highest dose (200 mg) resulted in the normalization of the markers of disease activity in more than 60% of the patients.

Long-term effects of spinal cord stimulation on myocardial ischemia and heart rate variability: results of a 48-hour ambulatory electrocardiographic monitoring

BACKGROUND

Spinal cord stimulation (SCS) has analgesic properties and may be used to treat pain in patients with therapeutically refractory angina who are unsuitable for myocardial revascularization. Some studies have also demonstrated an anti-ischemic effect. The aim of this study was to evaluate the long-term persistence of the effects of SCS on myocardial ischemia and on heart rate variability.

METHODS

Fifteen patients (9 males, 6 females, mean age 76 +/- 8 years, range 58-90 years) with severe refractory angina pectoris (Canadian class III-IV), on optimal pharmacological therapy, unsuitable for myocardial revascularization and treated with SCS for a mean follow-up of 39 +/- 27 months (range 9-92 months) were studied. Eleven patients had had a previous myocardial infarction and 5 a coronary artery bypass graft. The mean ejection fraction was 54 +/- 7% (range 36-65%). All patients underwent 48-hour ambulatory ECG monitoring and were randomly assigned to 24 hours without SCS (off period) and 24 hours with SCS (on period). The primary endpoints were: number of ischemic episodes, total duration of ischemic episodes (min), and total ischemic burden (mV*min).

RESULTS

The heart rate was not statistically different during the off and on SCS periods (median 64 and 67 b/min respectively). The number of ischemic episodes decreased from a median of 6 (range 0-29) during the off period to 3 (range 0-24) during the on period (p < 0.05). The total duration of ischemic episodes decreased from a median of 29 min (range 0- 186 min) during the off period to 16 min (range 0-123 min) during the on period (p < 0.05). The total ischemic burden decreased from a median of 2.5 mV*min (range 0-19.5 mV*min) during the off period to 0.8 mV*min (range 0-13 mV*min) during the on period (p = NS). The heart rate variability parameters were similar during the on and off periods.

CONCLUSIONS

SCS exerts long-term anti-ischemic effects.

Permanent junctional reciprocating tachycardia in infants and children: effectiveness of medical and non-medical treatment

BACKGROUND

The aim of this study was to identify, in children affected by permanent junctional reciprocating tachycardia (PJRT), the effective treatment.

METHODS

Seventeen children (9 males, 8 females, mean age 59 +/- 62 months, median 24) affected by PJRT were referred to our Institute between the years 1987 and 2000.

RESULTS

Pharmacological therapy was successfully used in 14 patients: flecainide and propranolol in 5 of them, amiodarone alone in 5 and associated with propranolol in 2, propafenone alone in 1 and in association with sotalol in 1. These drugs were given for a mean period of 54.5 +/- 49.8 months with resolution of the cardiomyopathy in 7/7 patients. Treatment had been continued for 3-6 months and there were no side effects. Nine patients were treated with radiofrequency transcatheter ablation, after 78 +/- 53.5 months of medical treatment, at a mean age of 150 +/- 16 months. The shortest endocardial ventriculo-atrial (VA) interval during tachycardia was recorded in all cases at the coronary sinus ostium (mean value of local VA-surface RP' interval -38 ms, range -24/-55 ms). Successful ablation of the anomalous pathway was obtained at this site in all patients (mean watts delivered 26 +/- 3 W, mean T degrees 64 +/- 5 degrees C). During the follow-up period (mean 21 +/- 17 months) 2 patients with recurrences of PJRT underwent a second successful procedure.

CONCLUSIONS

PJRT in pediatric patients can be successfully treated with antiarrhythmic drugs, this may allow delay of the highly effective radiofrequency ablation treatment until the children have reached an adequate growth.

Amiodarone-induced torsade de pointes in a child with dilated cardiomyopathy

Amiodarone has a high incidence of side effects, but few pro-arrhythmic effects. We report a case of amiodarone-induced torsade de pointes in a child aged 10 years. The patient had severe dilated cardiomyopathy, and even though he was treated with low oral doses of amiodarone, without dosage increments and electrolyte imbalance, he developed torsade de pointes at nights, after T-wave modification and increases of the corrected QT interval (QTc, 20%), QT dispersion (QTd, 175%) and QTcd (116%). The arrhythmic events were preceded by sinus bradycardia at Holter monitoring. Amiodarone therapy was discontinued. Intravenous magnesium administration was not effective in the suppression of torsade de pointes. High-rate atrial pacing prevented recurrences of the arrhythmias and reduced the QTc interval by 20%, QTd by 50%, and QTcd by 70%; QTd and QTcd returned below normal limits. This case underscores the need of careful electrocardiographic monitoring during amiodarone therapy.

Vasopressin and thirst in patients with posterior pituitary ectopia and hypopituitarism

OBJECTIVE

Partial diabetes insipidus has been documented in patients with congenital hypopituitarism and posterior pituitary ectopia, some cases being clinically silent except for enuresis. The objective of our study was to evaluate vasopressin (AVP) secretion and thirst appreciation in hypopituitary patients with posterior pituitary ectopia.

PATIENTS

Twelve males and three females, aged between 13 and 38 years (median 19 years). Eleven had multiple pituitary deficiencies, adequately replaced at the time of the study, and four were only growth hormone deficient. None of the patients suffered from polyuria, polydipsia or nocturnal enuresis. We tested the patients with a 5% NaCl infusion. Five patients with abnormal vasopressin production were also tested with nitroprusside, which affects baroceptor vasopressin secretion.

RESULTS

We found that only two out of 12 patients had normal AVP secretion. Thirst assessment showed severe hypodipsia in one patient, hyperdipsia in three out of 15 and more subtle abnormalities in two out of 15 patients. Concordance was found between osmotically and baroceptor-stimulated vasopressin.

CONCLUSIONS

Patients with posterior pituitary ectopia showed a high prevalence of subclinical subnormal vasopressin response to the osmolar stimulus and moreover an impairment of thirst appreciation. Our data on nonosmotically stimulated AVP release suggest the existence of a damage in the hypothalamic vasopressin secreting centres.

Intravenous clodronate in the treatment of reflex sympathetic dystrophy syndrome. A randomized, double blind, placebo controlled study

OBJECTIVE

To evaluate the efficacy of intravenous (i.v.) clodronate in patients with reflex sympathetic dystrophy syndrome (RSDS) and to assess the urinary excretion of type I collagen crosslinked N-telopeptide (NTx) before and after the treatment.

METHODS

Thirty-two patients with RSDS were randomized to receive either i.v. clodronate 300 mg daily for 10 consecutive days or placebo. Forty days later, the placebo treated patients received the clodronate treatment. Outcome measures included as a primary endpoint the visual analog scale of pain (VAS, range 0-100); secondary endpoints were a clinical global assessment (CGA, range 0-3) and an efficacy verbal score (EVS, range 0-3). Clinical and biochemical assessments were performed before the treatment, 40 (T40), 90 (T90), and 180 (T180) days later.

RESULTS

At T40 the 15 patients randomized to clodronate treatment showed significant decreases of VAS and CGA (p = 0.002, p = 0.001, respectively). Compared with the placebo group (17 patients), significant differences were found in all clinical variables (VAS: p = 0.001; CGA: p = 0.001; EVS: p<0.0001). A further clinical improvement was observed throughout the study. Pooling the results of all 32 patients after clodronate treatment, at T180 the overall percentage decrease of VAS was 93.2+/-15.6%, with 30 patients significantly improved or asymptomatic. Significant inverse correlations between baseline NTx values and decreases of VAS were found at T90 (p = 0.03) and T180 (p = 0.01). No adverse events related to treatment occurred.

CONCLUSION

A 10 day i.v. clodronate course is better than placebo and effective in the treatment of RSDS. NTx seems to be a predictive factor for clodronate efficacy.

Non-invasive ventilatory approach to treatment of acute respiratory failure in neuromuscular disorders. A comparison with endotracheal intubation

OBJECTIVE

Prospectively to investigate the efficacy of non-invasive positive pressure ventilation (NPPV) combined with cricothyroid "mini-tracheostomy" (CM) as a first-line intervention in patients with acute respiratory failure (ARF) of neuromuscular origin, in comparison with positive pressure ventilation (PPV) via endotracheal intubation (ETI).

DESIGN

Prospective analysis of the short-term outcomes of 14 non-consecutive patients suffering from ARF of neuromuscular origin who were administered NPPV and comparison with the outcomes of 14 matched historical control patients receiving conventional mechanical ventilation (MV) via ETI.

SETTING

Adult five-bedded respiratory intensive care unit in a university hospital.

PATIENTS AND INTERVENTIONS

Fourteen neuromyopathic patients who developed hypercapnic ARF and were submitted to NPPV (group A) and fourteen matched historical control patients, who were administered PPV via ETI (group B). Seven subjects receiving NPPV also underwent CM.

OUTCOME MEASURES

Mortality during ICU stay and treatment failure were evaluated; treatment failure was defined as death or the need for ETI for the NPPV group and as death or the inability to wean from MV for the control group. Length of stay in the ICU and time to improvement, defined as the time required for a significant relief of dyspnea and neurologic impairment and for correction of arterial blood gases, were also compared.

RESULTS

Intra-hospital mortality and treatment failure were lower in the NPPV group than in the conventional PPV via ETI group (2 vs 8 cases and 4 vs 11 cases, respectively). In addition, the duration of ICU stay for subjects who underwent NPPV was shorter than for patients who were intubated (13.6 +/- 9.7 vs 47.1 +/- 51.9 days). "Mini-tracheostomy" was well tolerated and no significant side effects were encountered. Two patient were excluded from the study because they showed a severe inability to swallow and needed to be intubated to protect the upper airway from the risk of aspiration.

CONCLUSIONS

Non-invasive positive pressure ventilation in combination with CM may be considered as a safer and more effective alternative to ETI in the treatment of patients with neuromuscular disorders (NMD) who develop ARF and require MV; nevertheless, patient selection remains important, since a significant proportion of neuromyopathic patients might have to be excluded from NPPV because of severe risk of aspiration.

[The effectiveness of foot reflexotherapy on chronic pain associated with a herniated disk]

Foot reflexology is both a diagnostic technique and therapy. It is an alternative therapy which is considered useful in pain management. Its effectiveness as a therapy has been studied at the Mestre hospital where a clinical study has been undertaken to determine the effectiveness of reflexology in the reduction of pain. A group of 40 persons suffering almost exclusively from a lumbar-sacral disc hernia received three treatments of reflexology massage for a week. The results found that 25 persons (62.5%) reported a reduction in pain, (rating at 0.75 on a scale of 0-4). These results however did not take into consideration the relationship between the effectiveness of foot reflexology and variables such as the persons physicality (Body Mass Index), or their psychological or social status.

Social support and psychological distress in primary care attenders. Ferrara SIMG Group

BACKGROUND

Growing evidence has been collected about the high prevalence of psychological distress in primary care. The role of psychosocial variables, namely the role of support from the patients' interpersonal ties, has not been extensively explored.

METHODS

The study investigated the relationship between perceived social support, as evaluated by the Multidimensional Scale of Perceived Social Support, and psychological distress, as measured by the Brief Symptom Inventory, in 1,341 primary care attenders.

RESULTS

In comparison with highly supported patients, lowly supported subjects showed higher scores on distress dimensions (e.g. depression, anxiety, phobia) and a higher prevalence of psychological morbidity ('caseness' = 37.3 vs. 11%).

CONCLUSION

The findings suggest that, in the setting of primary care, the GPs' assessment of their patients' social support system may be useful in identifying those more vulnerable to psychological stress.

Altered bone metabolism in inflammatory bowel disease: there is a difference between Crohn's disease and ulcerative colitis

OBJECTIVES

The aims of this study were to assess bone metabolism in inflammatory bowel disease (IBD) patients and to evaluate potential differences between Crohn's disease (CD) and ulcerative colitis (UC) with respect to the mechanisms underlying bone loss in this group of diseases.

DESIGN AND SETTING

This was a cross-sectional study which started in 1992. Patients were randomly selected for invitation to participate and were examined during the years 1992-95 in one research clinic in Milan.

SUBJECTS AND METHODS

Fifty-one patients suffering from CD (30 women and 21 men, mean age 38.7 +/- 13.2 years) and 40 with UC (15 women and 25 men, mean age 34.4. +/- 12.5 years) entered the study. Thirty healthy subjects were selected as sex- and age-matched controls (C). Spine and femoral neck bone mineral density (expressed as T score), calciotropic hormones (parathyroid hormone, PTH; 25-hydroxycholecalciferol, 25(OH)D3; 1,25-hydroxycholecalciferol, 1, 25(OH)D3) and biochemical markers of bone turnover (ostecalcin, OC; total alkaline phosphatase, ALP; type I collagen C-terminal telopeptide, ICTP) were evaluated.

RESULTS

Spine and femur T scores were similar in the two groups (spine: CD = -1.49 +/- 1.46; UC = -1. 67 +/- 1.13; femur: CD = -1.80 +/- 1.36; UC = -1.60 +/- 1.03). Based upon the WHO guidelines, only 8% of CD patients and 15% of UC patients had a normal bone mineral density (BMD), 55% (CD) and 67% (UC) were osteopenic, and 37% (CD) and 18% (UC) were osteoporotic. The distribution amongst the three different diagnostic groups was not significantly different between CD and UC groups (P = 0.11). PTH and 25(OH)D3 concentrations were not significantly different between CD and UC patients and controls, whilst 1,25(OH)D3 concentrations were significantly lower in both CD and UC patients compared with controls (P < 0.05). Bone turnover was increased in UC but not in CD patients, as shown by significantly increased concentrations in UC patients of both OC (CD = 7.77 +/- 5.06, UC = 10.03 +/- 6.24, C = 6. 58 +/- 2.87, P < 0.05 vs. C) and ICTP (CD = 5.74 +/- 3.94, UC = 10.2 +/- 8.47, C = 3.48 +/- 0.95, P < 0.05 vs. CD and C). In a stepwise regression that included age, sex, disease duration and cumulative prednisolone dose as independent variables, the femur T score was significantly inversely related to disease duration (r2 = 0.125, F = 6.06) in CD patients. In UC patients, the spine T score was inversely related to age (r2 = 0.107, F = 5.49) and significantly related to sex (more negative in males: r2 = 0.3, F = 16.1); the femur T score was significantly related to sex (more negative in males) and inversely related to the cumulative prednisolone dose (r2 = 0.283, F = 7.3).

CONCLUSIONS

These data show that IBD patients have a diffuse osteopenia, the degree of which is not different in CD and UC; however, bone turnover is significantly higher in UC. Finally, osteopenia is related to disease duration in CD, whilst it is related to the male sex and glucocorticoid treatment in UC.

Gitelman disease associated with growth hormone deficiency, disturbances in vasopressin secretion and empty sella: a new hereditary renal tubular-pituitary syndrome?

Gitelman disease was diagnosed in two unrelated children with hypokalemic metabolic alkalosis and growth failure (a boy and a girl aged 7 mo and 9.5 y, respectively, at clinical presentation) on the basis of mutations detected in the gene encoding the thiazide-sensitive NaCl cotransporter of the distal convoluted tubule. GH deficiency was demonstrated by specific diagnostic tests in both children. Hypertonic saline infusion tests showed a partial vasopressin deficiency in the girl and delayed secretion of this hormone in the boy. Magnetic resonance imaging revealed an empty sella in both cases. Up to now, hypomagnesemia and hypocalciuria have been considered obligatory criteria for the diagnosis of Gitelman disease; however, our two patients had hypomagnesemia and hypocalciuria in less than half the determinations. GH replacement treatment was associated with a good clinical response in both children. It appears that these cases represent a new phenotype, not previously described in Gitelman disease, and that the entity may be considered a new complex hereditary renal tubular-pituitary syndrome.

Elite system: recording of condylar movements using a modified computerized technique

BACKGROUND

The aim was to develop a method to measure condylar movements using a computerized system. The Elite system is a computerized device for the graphic recording of mandibular movements by processing images of marks recorded with two video cameras. The Elite system has traditionally been used to measure mandibular movements; it was modified to record condylar movements as well.

METHODS

The position of the markers was altered to enable 3-D recording not only of mandibular movements but also of condylar movements. New software was developed. Ten subjects (young adults; good complete dentition; no temporo-mandibular disorders; no orthodontic treatment) underwent recording with traditional and then with modified Elite system. The subjects were asked to perform the following movements: maximum opening and closing; protrusive and retrusive movements; border movements on the frontal plane. The sequence of movements was repeated three times on three different days. Data processing was effected using the Spline-smoothing method.

RESULTS

The modified Elite system technique records condylar movements with extreme reliability, reproducibility and the resulting graphics are comparable.

CONCLUSIONS

This method provides the chance to obtain more information about condylar movements in healthy subjects with good dentition, but also in patients with joint dysfunction.

Tachycardias in children originating in the right ventricular outflow tract: lack of clinical features predicting the presence and severity of the histopathological substrate

The aim was to determine whether the clinical features of tachycardias originating from the right ventricular outflow tract in children with an apparently normal heart could predict the presence and the severity of the histopathological substrate. Thirteen children (median age 6 years; range 6 months-12 years) with tachycardia originating from the right ventricular outflow tract of apparently normal hearts, were assessed by echocardiography, heart catheterization with angiography, endomyocardial biopsy (13 patients) and magnetic resonance imaging (MRI) (nine patients). Tachycardia was symptomatic in six and sustained in nine. Endomyocardial biopsy and MRI revealed acute myocarditis in five patients (38%), fatty infiltration of the right ventricle in two (15%), and minor histologic abnormalities in three (23%). Myocarditis was diagnosed in three of nine patients with sustained ventricular tachycardia, as opposed to two of four with non-sustained tachycardia (p = NS); in three of six symptomatic versus two of seven asymptomatic patients (p = NS); and in two of eight patients in whom ventricular tachycardia was induced during exercise testing as opposed to one of three in which it was not inducible (p = NS). A histopathological substrate was found in six of nine patients with sustained ventricular tachycardia, and in all four with non-sustained tachycardia (p = NS); in five of six patients with symptoms versus five of seven asymptomatic patients (p = NS); and in five of eight with inducible ventricular tachycardia during exercise testing versus all three in whom it was not inducible (p = NS). The mean rate of tachycardia was 184+/-39 beats min(-1) in patients with myocarditis, as opposed to 171+/-48 in patients without myocarditis (p = NS); and 163+/-33 in patients with a histopathological substrate compared with 210+/-65 in patients without a histopathological substrate (p = NS). It is concluded that a histopathological substrate is present in the greater majority of children affected by the so-called right ventricular outflow tract tachycardia, but that the clinical features of the tachycardia do not predict the presence and the severity of this histopathological substrate.