Mesothelioma Risk Among Maritime Workers According to Job Title: Data From the Italian Mesothelioma Register (ReNaM)

The study describes the 466 cases of malignant mesotheliomas (MM) collected by the National Mesothelioma Register (ReNaM) in Italy in the period 1993-2018 relating to subjects with exclusive asbestos exposure in merchant or military navy. The cases among maritime workers represent 1.8% of the total cases with defined exposure registred in the ReNaM, of which 212 cases (45.4%) among merchant maritime workers and 254 cases (54.5%) among navy. The distribution by site of mesothelioma showed 453 (97.2%) MM cases of the pleura, 11 (2.3%) of the peritoneum and 2 (0.4%) of the tunica vaginalis of the testis. With regard to occupational exposure, it was classified as certain in 318 (68.2%) cases, probable in 69 (14.8%) cases and possible in 79 (16.9%) cases. Among the 23 classified jobs, the highest percentages of certain exposures are among naval engineers, motor mechanics, machine captains and sailors. Machine crew accounted for 49.3% of the cases, deck crew for 27.6%. All cases began exposure on board between 1926 and 1988. Seamen were exposed to asbestos while at sea by virtue of living onboard ships and from continual release of asbestos fibers due to the motion of a vessel. Epidemiological surveillance through the ReNaM has allowed us to verify among cases in the maritime, navy and merchant marine sectors, that in the past, subjects were exposed regardless of the ship's department where have provided service therefore all these cases must be considered as occupational diseases.

Mesothelioma Risk among Construction Workers According to Job Title: Data from the Italian Mesothelioma Register

BACKGROUND

An increased risk of mesothelioma has been reported in various countries for construction workers. The Italian National Mesothelioma Registry, from 1993 to 2018, reported exposure exclusively in the construction sector in 2310 cases. We describe the characteristics of these cases according to job title.

METHODS

We converted into 18 groups the original jobs (N=338) as reported by ISTAT codes ('ATECO 91'). The exposure level was attributed at certain, probable and possible in accordance with the qualitative classification of exposure as reported in the Registry guidelines. Descriptive analysis by jobs highlights the total number of subjects for each single job and certain exposure, in descending order, insulator, plumbing, carpenter, mechanic, bricklayer, electrician, machine operator, plasterer, building contractor, painter and labourer.

RESULTS

The cases grow for plumbing in the incidence periods 1993-2018, while, as expected, it decreases for insulator. Within each period considered the most numerous cases are always among bricklayers and labourers, these data confirm the prevalence of non-specialised "interchangeable" jobs in Italian construction sector in the past.

CONCLUSIONS

Despite the 1992 ban, the construction sector still presents an occupational health prevention challenge, circumstances of exposure to asbestos may still occur due to incomplete compliance with prevention and protection measures.

Effect of chronic aerobic exercise on cutaneous microcirculatory flow response to insulin iontophoresis and to ischemia in elderly males

The aim of this study was to assess whether chronic aerobic exercise can favourably influence the vascular activity of insulin in elderly subjects. We measured in arbitrary units (A. U.) the cutaneous blood flow basally and in response to iontophoresis of insulin, by the means of a Laser Doppler flowmeter, on the right arm of 10 elderly athletes (10 males, aged 65 +/- 6 years) and of 10 sex- and age-matched sedentary subjects. The cutaneous blood flow response to ischemia was also explored in the right leg of the same subjects by means of the same instrument. No significant differences in cutaneous arm and leg blood flow were observed basally between athletes and sedentary subjects (7.25 +/- 2.65 A. U. versus 6.35 +/- 4.04 A. U. and 9.74 +/- 5.11 A. U. versus 9.41 +/- 6.40 A. U., respectively). Cathodal iontophoresis (six poulses of 0.1 mA each for 20 s, with 40-s interval between stimulations) of regular insulin (0.1 ml Humulin R 100 IU/ml diluted 1/10 with 0.9 % saline) induced a significant increase of cutaneous blood flow in both groups (p < 0.01 in athletes, p < 0.01 in sedentary subjects). However the maximal cutaneous blood flow response to insulin was higher in athletes than in sedentary subjects (24.69 +/- 13.34 A. U. versus 14.33 +/- 7.73 A. U., respectively, p < 0.05) as well as the curve of the net blood flux response to insulin iontophoresis (% change from baseline in response to insulin minus % change from baseline in response to saline iontophoresis) (p < 0.001 ANOVA for repeated measures). After ischemia there was a significant increase of leg cutaneous blood flow in both groups (p < 0.001 in athletes and in sedentary subjects) with higher blood flow response in athletes than in sedentary subjects (38.18 +/- 17.08 A. U. versus 26.01 +/- 6.39 A. U., respectively, p < 0.05). The time reached from the release of ischemia to peak-flow was significantly longer in sedentary subjects than in athletes (43.5 +/- 28.5 s versus 20.0 +/- 9.3 s, p < 0.05, respectively). These results suggest that chronic aerobic exercise increases insulin vasodilatory activity and improves endothelial function in elderly subjects.

Lifelong physical training prevents the age-related impairment of heart rate variability and exercise capacity in elderly people

AIM

Aging is associated with a reduction on heart rate variability (HRV) and working capacity. Aim of this study was to evaluate in a group of elite master athletes the effect of a lifelong history of endurance running on HRV and exercise working capacity.

METHODS

Twenty athletes (males, age 68.5+/-4.5 years) who practiced endurance running for at least 40 years, and 20 age-sex-matched control subjects with sedentary lifestyle were studied. All the participants underwent a maximal stepwise electrocardiogram (ECG) on effort (work-rate increments of 25 Watts every 2 min) and a 24-hour ECG monitoring.

RESULTS

All the time domain measures of HRV and the LF and HF powers were significantly higher in elderly athletes than in sedentary subjects (P<0.001), while the LF/HF ratio was comparable between the 2 groups. Athletes exhibited significantly higher workload than controls (1610+/-489 vs 687+/-236 W, P<0.0001). Both the groups achieved, at maximum workload, similar heart rate (142+/-10 vs 138+/-18 bpm, ns), systolic blood pressure (226+/-18 vs 220+/-16 mmHg, ns), and rate-pressure product (32,596+/-2952 vs 30,838+/-3675, ns). Maximum work-rate attained in athletes was 225 W. By contrast, none of the controls reached a work-rate higher than 150 W. In the whole group we also showed a positive correlation between the time domain HRV parameter SDNN and maximum workload (r=0.58, P<0.001).

CONCLUSION

Long-term endurance training induces in elderly subjects an increased HRV and a higher exercise working capacity, which are well-established predictors of cardiovascular and overall mortality.

Effect of nebivolol on QT dispersion in hypertensive patients with left ventricular hypertrophy

Hypertensive patients with left ventricular hypertrophy (LVH) have increased QT dispersion, which is considered an early indicator of end-organ damage and a non-invasive marker of risk for clinically important ventricular arrhythmias and cardiac mortality. The purpose of this study was to examine the effect of nebivolol antihypertensive therapy on QT dispersion in hypertensive subjects. Twenty-five subjects (15 men and 10 women, mean age 53.6 +/- 4.5 years) with essential arterial hypertension and mild-to-moderate LVH (blood pressure: 147.2 +/- 6.2/90.6 +/- 3.8 mmHg; left ventricular mass indexed: 149.1 +/- 10.7 g/m(2)) were compared with 25 age-matched healthy control subjects. All the participants underwent a complete clinical examination, including electrocardiogram for QT interval measurements. The QT dispersion was defined as the difference between the longest and the shortest QT interval occurring in the 12-lead electrocardiogram. The QT dispersion was corrected (QTc) with Bazett's formula. Hypertensive subjects were treated with 5 mg daily of nebivolol. The ECG and echocardiogram were repeated after four weeks of treatment. At baseline, hypertensive patients showed QT dispersion (56.9 +/- 6.4 vs. 31.7 +/- 8.4 ms, P < 0.001) and QTc dispersion (58.3 +/- 6.2 vs. 33.2 +/- 7.8 ms, P < 0.001) significantly higher than control subjects. Four-week nebivolol treatment reduced blood pressure from 147.2 +/- 6.2/90.6 +/- 3.6 mmHg to 136.3 +/- 3.1/83.3 +/- 2.5 mmHg (P < 0.0001), and resting heart rate from 75.3 +/- 4.7 to 64.2 +/- 3.0 bpm (P < 0.001), without significant change in left ventricular mass (LVMi: 149.1 +/- 10.7 vs. 151.4 +/- 9.8 g/m(2), ns). Nebivolol-based treatment improved QT dispersion (56.9 +/- 6.4 vs. 40.5 +/- 5.8 ms, P < 0.001) and QTc dispersion (58.3 +/- 6.2 vs. 42.2 +/- 5.6 ms, P < 0.001), which remained higher than in control subjects (P < 0.001 in both cases). The reduction of QT dispersion did not correlate with arterial BP reduction. In conclusion, nebivolol reduced increased QT dispersion in hypertensive subjects after four weeks. This effect, occurred without any change in LVM, did not seem to be related to the blood pressure lowering and could contribute to reduce arrhythmias as well as sudden cardiac death in at-risk hypertensive patients.

Ultrasonic backscatter of the carotid wall in young and older athletes

OBJECTIVES

The aim of this study was to evaluate the effects of habitual exercise on the age-related changes of carotid wall composition defining its acoustic reflectivity by the quantitative approach of integrated backscatter (IBS) analysis.

DESIGN

Cross-sectional study.

SETTING

University Hospital.

SUBJECTS

Fifty-four competitive long-distance runners (males, age range 22-72 years) and 50 healthy sedentary controls.

MAIN OUTCOME MEASURES

All the subjects underwent both 2-D conventional ultrasonography and IBS analysis. IBS values were sampled from a region of interest (ROI) placed within five consecutive regions of the common carotid intima-media, and then corrected (C-IBS) for the IBS value of the adventitia.

RESULTS

Athletes showed a lower C-IBS (-27.07 +/- 2.9 dB vs. -24.57 +/- 4 dB, P < 0.0001) and a smaller intima-media thickness (IMT: 0.64 +/- 0.16 mm vs. 0.78 +/- 0.21 mm, P < 0.001) respect to sedentary controls. By selecting the lowest (<30 years of age) and the highest (>60 years of age) tertile of age, we assess the influence of age on IMT and IBS. Sedentary older individuals exhibited an IMT higher respect to young controls and to the both trained subgroups (P < 0.0001). C-IBS was lower in both subgroups of athletes, independently of age, and lower in sedentary young people respect to sedentary older subgroup (P < 0.0001). Endurance chronic exercise blunted the difference of C-IBS observed between young and older sedentary individuals. Moreover, C-IBS was positively related to age (r = 0.77, P < 0.0001) and IMT (r = 0.52, P < 0.0001).

CONCLUSIONS

The age-related changes of the arterial wall are attenuated by physical training. These modifications can be quantitatively discriminated by ultrasonic backscatter method.

Ultrasonic tissue characterization of the myocardium in anorexia nervosa

AIM

To determine the systodiastolic variations in the integrated backscatter (IBS) signal of the myocardium in patients with anorexia nervosa.

METHODS

25 young women (aged 22.4 +/- 4.3 y) with overt anorexia nervosa, compared with 25 age-matched thin and 25 age-matched control women with body mass index >20 kg m(-2), underwent either conventional two-dimensional echocardiography or analysis of IBS cyclic variations.

RESULTS

Compared with thin and control subjects, anorectic patients showed reduced left ventricular mass (LVM: 82.9 +/- 17.1 vs 119.9 +/- 13.8 and vs 126.12 +/- 16.4 g, p < 0.0001; LVM indexed 21.4 +/- 3.3 vs 29.4 +/- 2.5 and vs 31.2 +/- 3.1 g m(-2.7), p < 0.0001), and IBS cyclic variations (septum: -0.49 +/- 2.18 vs 6.86 +/- 1.3 and vs 6.61 +/- 1.74 dB p < 0.0001; posterior wall: 2.77 +/- 2.12 vs 7.15 +/- 2.12 and vs 7.48 +/- 2.23 dB, p < 0.01).

CONCLUSION

Anorexia nervosa is associated with a significant reduction in the cyclic variation in IBS, which is also related to left ventricular hypotrophy. Ultrasonic tissue characterization could give an objective approach for the detection of myocardial structural properties and represent a preclinical index of myocardial dysfunction in anorexia nervosa.

QT dispersion in elderly athletes with left ventricular hypertrophy

The purpose of this study was to examine the QT dispersion in elderly endurance athletes with left ventricular (LV) hypertrophy. Sixteen athletes (males, mean age 67.6 +/- 4.5 years) with mild to moderate LV hypertrophy, were compared with 16 age-matched hypertensive patients with similar degree of LV hypertrophy and 16 age-matched healthy sedentary controls. All the participants underwent echocardiogram and 12-lead electrocardiogram. QT dispersion was defined as the difference between maximum and minimum QT intervals in the different leads. QT dispersion was corrected (QTc) for heart rate according to Bazett's formula. The results showed in athletes and hypertensive patients comparable LV mass (258.2 +/- 14.2 vs. 262.4 +/- 16.8 g, ns), which was significantly higher than that of controls (p < 0.001). Trained subjects had QT dispersion (38.6 +/- 10.2 ms) and QTc dispersion (39.4 +/- 11.3 ms) significantly lower than hypertensive patients (QT dispersion: 68.4 +/- 11.4 ms; QTc dispersion: 72.2 +/- 8.4, p < 0.001) and comparable with controls (QT dispersion: 44.3 +/- 8.4 ms; QTc dispersion: 46.2 +/- 6.2 ms, ns). In conclusion, in elderly athletes training-induced myocardial hypertrophy was characterized by a QT dispersion significantly lower than hypertensive myocardial hypertrophy. This could provide a simple and inexpensive screening method for differentiating physiologic from pathologic myocardial hypertrophy in elderly subjects.

Spontaneous regression and recurrence of primary low-grade B-cell gastric lymphoma on the gastric stump 15 and 20 years after gastroresection

The recurrence of primary gastric lymphoma (PGL) on the gastric stump after gastroresection is rare. We describe the case of an 84-year-old man who had recurrences 15 and 20 years after a Billroth I gastrectomy. The concordance of the three gastric biopsies showing a low grade B-cell lymphocytic lymphoma of the mucosa-associated tissue, demonstrated the recurrence of the disease. The patient has serological evidence of Helicobacter pylori infection but the eradication therapy had no effect on the evolution of the disease. The case suggests that PGL is really a particular entity in the non-Hodgkin's lymphoma group, characterized by a long spontaneous natural history, with long lasting spontaneous remissions and recurrences.

New hematological indices in the healthy elderly

BACKGROUND

Recently, new indices related to erythrocytes and platelet counts have been provided by hematological analysers. The purpose of the study is to investigate these new parameters in the elderly to define their normal values and to compare them with the range provided by the manufacturer.

METHODS

EXPERIMENTAL DESIGN

a comparative study.

SETTING

general community, geriatric and internal medicine ambulatories.

PATIENTS

sixty healthy free-living elderly (cut-off: 65 years) and 66 healthy young-adults, as a control group.

MEASURES

we measured the common and the new hematological parameters by H.1 Bayer technology. The new hematological parameters are red diameter width-RDW, hemoglobin distribution width-HDW, mean platelet volume-MPV, platelet diameter width-PDW, platelet hematocrit-Pct. We then compared the values of our population with the Bayer range.

RESULTS

The confidence interval width of the new indices define very faster limits than the Bayer range. Statistical differences were significant only in male groups: young-adults (Y) versus elderly (E) with higher values in Y than E in RBC p=0.002, in Platelet count p=0.050 and in MPV p=0.026; and higher values in E in MCV p=0.008, MCH p=0.006 and PDW p=0.004.

CONCLUSIONS

In the literature a wide range of common hematological parameters are reported in the elderly, while the new hematological values have not been discussed till now. Our results may contribute to define the laboratory limits of the new hematological values in the healthy elderly.

Blood reduced glutathione (GSH) concentrations in healthy and ill subjects

BACKGROUND

Recently blood reduced glutathione (GSH), an important cellular antioxidant, has been proposed as an indicator of health, particularly in the elderly. To date, a gold standard unit for the expression of GSH concentrations is not known. The aim of the study is to define the most sensitive laboratory expression of GSH.

METHODS

EXPERIMENTAL DESIGN

a comparative study among some laboratory expressions of GSH.

SETTING

Geriatric and Internal Medicine Units; General Community.

PATIENTS AND PARTICIPANTS

forty-eight inpatients from Geriatric and Internal Medicine Units and 82 healthy subjects recruited among medical students and residents, people from preventive medicine services and from local senior centres. EXCLUSION CRITERIA FOR HEALTHY SUBJECTS: use of drugs in the year prior to the study.

INTERVENTIONS

neither treatment nor interventions.

MEASURES

the laboratory expression of GSH, compared in this study, were mg/dl, packed cell volume (PCV), mg/1010 RBC, mM/gHb.

RESULTS

We noted statistically significant differences only if GSH was calculated as mg/1010 RBC; higher values were found in healthy subjects than in inpatients, apart from age. This modality of expression is minimally affected by haematological parameters; the low sensibility of the other modalities may be due to variations of MCV and Hb. Instead, the ratio GSH mg/1010 RBC expresses the true GSH concentrations inside each erythrocyte. This modality of expression is minimally affected by haematological parameters; the low sensibility of the other modalities may be due to variations of MCV and Hb.

Blood zinc, copper and magnesium in aging. A study in healthy home-living elderly

BACKGROUND

Blood concentrations of copper, zinc and magnesium were determined in healthy elderly to assess whether aging interferes with mineral and micronutrient status.

METHODS

EXPERIMENTAL DESIGN

case series.

SETTING

Internal Medicine and Geriatrics ambulatories in a University Hospital in Pisa, a city of Central Italy.

PARTICIPANTS

143 healthy outpatients of both sexes, who underwent a cardiological examination.

INTERVENTION

no treatment and intervention were performed.

MEASURES

copper (Cu), zinc (Zn) and magnesium--both intraerythrocytic (iMg) and extracellular (eMg)--were measured.

RESULTS

The concentrations of Cu and eMg were found significantly higher in the elderly: Cu 117.5 +/- 17.0 micrograms/dl in the elderly vs 102.5 +/- 19.6 micrograms/dl in the younger (p < 0.001); eMg 1.8 +/- 0.2 in the elderly vs 1.7 +/- 0.2 mEq/l in the younger (p < 0.05). On the other hand, the levels of Zn and iMg did not differ in the two groups: Zn 113.3 +/- 14.9 micrograms/dl in the elderly vs 118.0 +/- 17.3 micrograms/dl in the younger, p = n.s.; iMg 4.3 +/- 0.4 mEq/l in the elderly vs 4.2 +/- 0.4 mEq/l in the younger, p = n.s. No correlation was found between age and single elements.

CONCLUSIONS

These results suggest that the healthy free-living elderly have an adequate mineral intake. Nutrient supplements may by useful in the elderly with chronic diseases, comorbidities, and polypharmacy to prevent further age dysfunctions.

Congenital hypopituitarism in a 48-year old adult. Natural course, hormonal study and MRI evidence

A case of Congenital Hypopituitarism (CH) in an untreated 48 yr-old-man is reported. The hormonal studies demonstrated a panhypopituitarism and MR imaging revealed absence of pituitary stalk, small anterior pituitary remnant on the sella floor and ectopic neurohypophysis at the tuber cinereum. The pattern of hormonal responsiveness suggests that CH encompasses findings typical of primary anterior pituitary disease and those of hypothalamic dysfunction.

Takayasu's arteritis on steroid therapy. Seven years follow-up

The authors report a 7 year follow-up of Takayasu's arteritis (TA) type III, group 1, in a young Italian woman. At diagnosis, at the age of 25, the echotomographic and angiographic studies showed narrow subclavian arteries, narrow abdominal aorta (diameter of 0.6-0.8 cm) below the renal arteries, stenotic left common carotid and renal arteries, and occluded upper mesenteric artery. With steroid therapy, (prednisone 50 mg/day per os), the erythrocyte sedimentation rate (ESR) normalized within 12 days. With a maintenance dosage of 7.5 mg/day per os, the patient achieved remission as documented by the absence of symptoms, the persistent normalization of ESR, and the improving of the diameter of the abdominal aorta (1.3-1.4 cm). On steroid therapy, the patient had a normal pregnancy and delivered a healthy baby girl. The disease has been stable for seven years. Recently, diabetes mellitus occurred and it has been treated with insulin therapy. The rising of ESR after tapering of steroid therapy (prednisone 5 mg per os on alternate days) suggests an alternative treatment with a cytotoxic agent.

Congenital hypopituitarism in a 48-year old adult. Natural course, hormonal study and MRI evidence

A case of Congenital Hypopituitarism (CH) in an untreated 48 yr-old-man is reported. The hormonal studies demonstrated a panhypopituitarism and MR imaging revealed absence of pituitary stalk, small anterior pituitary remnant on the sella floor and ectopic neurohypophysis at the tuber cinereum. The pattern of hormonal responsiveness suggests that CH encompasses findings typical of primary anterior pituitary disease and those of hypothalamic dysfunction.

[Occult stromal tumour of the small intestine: a cause of chronic intestinal blood loss in a 70 year-old woman]

The case of a 70 year-old woman with a chronic gastrointestinal blood loss due to a stromal tumor located in the middle third of the small intestine is reported. The peculiarities of the case are the characteristic immunohistochemistry of the neoplasm and, particularly, the mimetic clinical presentation, a kind of ''phantom tumor'' confirmed only with celiotomy and surgical excision.

[Why regular physical activity favors longevity]

Regular physical exercise is useful at all ages. In the elderly, even a gentle exercise programme consisting of walking, bicycling, playing golf if performed constantly increases longevity by preventing the onset of the main diseases or alleviating the handicaps they may have caused. Cardiovascular diseases, which represent the main cause of death in the elderly, and osteoporosis, a disabling disease potentially capable of shortening life expectancy, benefit from physical exercise which if performed regularly well before the start of old age may help to prevent them. Over the past few years there has been growing evidence of the concrete protection offered against neoplasia and even the ageing process itself.

Tortuosity, kinking, and coiling of the carotid artery: expression of atherosclerosis or aging?

The etiology of carotid abnormalities is both congenital than acquired. The aim of this study was to clarify the role of aging and atherosclerosis in the acquired cases, and the role of these abnormalities in hemodynamic alterations and neurologic symptoms. Over a 1-year period the authors studied all the subjects undergoing carotid examination by continuous-wave and color-coded Doppler sonography at an Angiology Unit. They evaluated neurologic symptoms; risk factors for atherosclerosis; number, sites, and kinds of carotid abnormalities; atherosclerotic lesions; stenosis; hemodynamic alterations of the carotid; and other localizations of atherosclerotic diseases. There were 469 subjects: 272 (58%) with abnormalities (group 1) and 197 (42%) without abnormalities (group 2). The total number of abnormalities was 479 (104 tortuosities, 262 kinkings, and 113 coilings). The abnormalities were more prevalent in the elderly (P<0.001) and in women (P<0.001). In group 1 they found significant prevalences of hyperlipemia (P<0.001), hypertension (P<0.01), chronic cigarette smoking (P<0.01), and ischemic heart disease (P<0.05). Carotid atherosclerotic lesions were more prevalent in group 1 than in group 2 (P<0.001); among the patients with atherosclerotic carotid lesions, those in group 1 were older than those in group 2 (P<0.001). Tortuosity seemed to be associated with fewer hemodynamic alterations. The authors conclude that atherosclerosis, hypertension, and aging may play an important role in producing carotid abnormalities. The aging seemed more important than atherosclerosis. Only a prospective study of patients with carotid abnormalities and no atherosclerotic lesion will clarify the role of hemodynamics and neurologic symptomatology.

[Fever of unknown origin in the elderly of the 90's]

MATERIALS AND METHODS

Eighteen elderly patients (mean age 76.3 +/- 6.9 years) with fever of unknown origin (FUO) are studied sequentially and prospectively from January 1994 to December 1996. The classic Petersdori's criteria of FUO are no more valid for the elderly. The fever of more than 3-4 weeks duration is the only criterion to be considered, the fever is frequently under 38.5 degrees C and the elderly patient is often studied for more than 1 week outside the hospital.

RESULTS

The most frequent underlying conditions were: malignancies in particular haematological diseases, followed by multisystem diseases and infections, tuberculosis "in primis".

CONCLUSIONS

Selected investigations directed to the most frequent underlying conditions of FUO in the aged individuals overcome the financial cost and the patient discomfort of the tests since an identified curable disease can improve the life expectancy and quality.

[Cardiac myxoma in the elderly. Clinical study]

Cardiac mixoma in the elderly. A clinical study. The clinical features of 13 cardiac myxomas surgically resected are presented. The mean age at presentation was 68 years. Ten were in the left atrium, 5 near the fossa ovalis, 3 at the base of the atrial septum, 1 at the inferior wall and 1 on the anterior leaflet of mitral valve, 3 were in the right atrium, 1 of these was accompanied with a myxoma at the apex of left ventricle. The ECG and the chest X-ray were normal in 9 and in 8 patients, respectively. In 3 patients, the diagnosis was occasionally made by routine 2-dimensional echocardiography. 5 patients presented with fever of unknown origin, arthralgias, weakness, weight loss. None had intracardiac or extracardiac recurrence in the 73 months follow-up. The presentation with constitutional symptoms only like fever of UO, may mimic collagen and neoplastic diseases, vasculitis, lymphomas: the 2-dimensional echocardiography is mandatory to esclude a cardiac myxoma in the elderly.

Age-related modifications in the regulation of the hypothalamic-pituitary-thyroid axis

We studied the hypothalamic-pituitary-thyroid function in two groups of healthy elderly subjects: group A (n = 23, age range 65-80 years), and group B (n = 11, age range 81-92 years), and in 32 controls, aged 20-60. A TRH test for TSH and prolactin was performed in all subjects, while the TSH circadian modulation was evaluated in elderly subjects only. Group B showed significantly lower fT3 and TSH, and higher fT4 levels with respect to controls (fT3: 4.4 +/- 0.2 vs. 5.2 +/- 0.2 pmol/l, p < 0.05; fT4: 13.1 +/- 0.9 vs. 11.4 +/- 0.4 pmol/l, p < 0.05; TSH: 1.07 +/- 0.21 vs. 1.46 +/- 0.13 mIU/l, p < 0.05). Morning TSH showed an inverse correlation with age (r = -0.42; p < 0.02) among the 34 elderly subjects, but not among controls. Evidence for TSH circadian modulation was found only in group A (nighttime TSH: 1.60 +/- 0.17, vs. daytime: 1.25 +/- 0.13 mIU/l, p < 0.001). The TRH-stimulated TSH peak was reduced among all elderly subjects with respect to controls (A: 6.26 +/- 0.64 mIU/l, p = 0.01; B: 5.02 +/- 0.58 mIU/l, p < 0.01). The maximal PRL response was also blunted (A: 25.7 +/- 2.6 micrograms/l, B: 27.7 +/- 5.2 micrograms/l, p < 0.0005). In conclusion, a resetting of the pituitary threshold of the TSH feedback suppression, along with complex alterations in peripheral thyroid hormone levels, may progressively develop in older people, becoming apparent only with extreme senescence. Moreover, the TSH nocturnal surge may be lost with increasing age, thus providing evidence also for hypothalamic dysfunction.

[5-Aminosalicylic acid in the prevention of recurrences of Crohn's disease]

AIM OF STUDY

To evaluate the efficacy of 5-aminosalicylic acid (5-ASA) in preventing recurrences of Crohn's disease.

PATIENTS AND METHODS

Between January 1988 and December 1989 a total of 60 patients (37 men, 23 women, mean age 34.8 years) were selected in whom the diagnosis of Crohn's disease had been known for at least 2 years. A further criterion for inclusion was remission for at least one year in patients who had been operated or for one month in the nonoperated ones. Furthermore, the latter must have had at least one recurrence during the last year. They were in turn assigned to be treated with 5-ASA (2.4 g daily by mouth) or not treated (control). The activity and localization of Crohn's disease were defined according to the "Crohn's disease activity index" (CDAI) and the "laboratory index" (LI), as well as by endoscopy and (or) radiology. The patients were examined every 6 months for 4 years. A recurrence was diagnosed if the CDAI was more than 150 or had increased to at least 60 points above the initial value and the LI was above 100.

RESULTS

29 recurrences were noted, 72.4% within the first 2 years. 15 recurrences (46.9%) were in the treated patients and 14 (58.3%) among the untreated controls. The Kaplan-Meier curve (statistical comparison of the probability of recurrence) showed no significant difference between the two groups (P = 0.23): the recurrence rate was the same in the two groups, among the patients with or without previous operation and for different primary localizations. There were no notable side effects.

CONCLUSION

Treatment with 5-ASA was not found to influence the likelihood of recurrence. Age, duration of the disease, primary localization and previous operation were not prognostic factors.

[Malignant peritoneal mesothelioma: its relation to asbestos]

Chronic exposure to asbestos can induce malignant peritoneal mesothelioma (PMM) without pulmonary or pleural involvement (PIMM). The localization to the peritoneum depends on the different susceptibility of the two mesotheliums and, perhaps, on the length of asbestos fibers which can facilitate their direct translocation.

[Vitamin E in the aged]

Aging is a multifactorial process still incompletely known. The role of oxidative damage to cell membranes, as an important phase of the process, is underlined by the recent literature. We emphasize the value of vitamin E as an antioxidant agent supplied by suitable diets in middle age and by cheap tablets in the aged.

[Aging of the aorta: a morphological study]

Aim of this study was to evaluate the aging of aorta with respect to atherosclerotic modifications: abdominal aorta echotomography is the preferred approach for this study. In 354 elderly patients, 65 and over, we have evaluated the diameter and the course of the aorta, the presence of atherosclerotic plaques in the aorta and iliac vessels, and the presence of aneurysms. Two kinds of findings could be identified by echotomography: age-related physiologic modifications, represented essentially by an increase of the aortic diameter; pathologic changes, characteristic for atherosclerosis, of which aneurysms are the most dangerous complications.

[Falls and fractures in the elderly. Causes and consequences]

OBJECTIVE

To evaluate the causes of non-pathologic traumatic fractures in the elderly and their consequences on quality of life.

DESIGN

A prospective trial.

FOLLOW-UP

12 months for the inpatients and 3 months for the outpatients.

SETTING

Basal assessment in orthopaedic hospital; follow-up in geriatric unit.

PATIENTS

Both inpatients and outpatients, 65 years and over, both sexes, both living in a nursing home and in their own home, admitted to an orthopaedic hospital because of a fall, with diagnosis of a subsequent fracture. Criteria of exclusion: patients with pathologic fracture. 121 patients were enrolled, 108 had a complete follow-up.

SURVEYS

Health and functional status prior to the fracture, causes and concomitant causes of the fall, site of the fracture, complications and functional disabilities.

RESULTS

The most frequent cause of fracture is an accidental fall, especially in younger elderly, other causes being acute cardiovascular and neurological diseases. Fractures occur more frequently in females. The most serious injuries affect frailer subjects, with advanced age, neurologic and multiple chronic diseases. Fracture of femur is the most frequent fracture and it has the highest risk complications, functional disabilities and death.

CONCLUSIONS

Because of the high frequency of accidental falls, the authors emphasize the necessity of primary prevention, especially the removal of architectural barriers both at home and in public environment.

[Male impotence in old age]

Normal aging does not induce impotence, but only modifies the physiology of the erection which, however, allows good sexual intercourse. Impotence, found in 55.0% of the over 75 men, is due to organic or psychogenic causes: above all, penile arterial insufficiency and the collateral effects of drugs for the diseases which often affect the elderly, are the main factors.

Takayasu's arteritis: low corticosteroid dosage and pregnancy--a case report

The authors describe a case of Takayasu's arteritis in a twenty-five-year-old Italian woman, characterized by nonspecific symptoms (weakness, arthralgias, fever) and elevated erythrocyte sedimentation rate early onset of these symptoms at the age of about twenty-three years early diagnosis, only eighteen months after the onset of symptomatology absence of progression of the disease under corticosteroid therapy with a follow-up of three years uneventful pregnancy ending in cesarean section and birth of a baby without maternal and neonatal complications.

The use of recombinant interferon alfa-2b in elderly patients with anti-HCV-positive chronic active hepatitis

OBJECTIVE

To compare efficacy and tolerance of recombinant interferon alfa-2b in the treatment of anti-HCV-positive chronic active hepatitis (CAH) in subjects aged 65 years and above with those less than 65.

DESIGN

A randomized controlled trial.

SETTING

Outpatients in two hospitals.

PATIENTS

65 consecutive outpatients with anti-HCV-positive CAH for 1 to 30 years, having basal aminotransferase levels at least twice the normal value. Those 65 and over were randomized to an interferon group (A, n = 22) or a no-treatment group (B, n = 22). All those under 65 received interferon (group C, n = 21).

INTERVENTION

Interferon at a dose of 3 mU 3 times a week for a 6-month period. A normalization of serum aminotransferase levels was considered a positive response to therapy.

RESULTS

Response to therapy was positive in 62% of the treated elderly compared to 57% of the adults (P = 0.85). The two groups of responders showed a common highly significant reduction of aminotransferase (P < 0.001). Side effects were similar in elderly and young. Two untreated elderly showed spontaneous normalization of aminotransferase.

CONCLUSION

Interferon in anti-HCV-positive CAH is useful in the elderly, allowing normalization of aminotransferase, improvement of the histology and remission of the disease in 62% of the cases. Side effects seem to be independent of age. Further studies are required to assess both duration of remission and usefulness of cyclic therapy in previous responders.

Bilateral perinephric fluid accumulation: an unusual manifestation of pulmonary hypertension--a case report

This is the case report of a forty-seven-year-old man with an ostium secundum atrial septal defect and a very high grade of pulmonary hypertension, associated with a large bilateral perinephric fluid accumulation. The fluid accumulation was remarkably reduced after eleven phlebotomies over a twelve-month period. A pathogenetic relation with the Eisenmenger's syndrome is discussed. No previous report of this association has been found in a survey of the literature.

[Congestive heart failure with frequent hospital readmissions in the elderly]

Ten elderly patients with heart failure and frequent hospital readmission within 12 months before the study, were submitted to clinical radiologic, electrocardiographic and echocardiographic evaluation in order to find the causes of readmission. The most frequent factors were found to be non compliance with drug prescriptions and therapy inadequate for the etiology of the heart failure and the kind of cardiac dysfunction.

[Diabetes mellitus, hypercholesterolemia, and therapeutic prospects with simvastatin. General considerations and personal contribution]

The Authors examine the relationship between diabetes mellitus, lipid metabolism and atherosclerosis with particular emphasis on the role of insulin and on the therapeutic consequences. The results of a study on the efficacy and tolerability of simvastatin in the treatment of hypercholesterolemia in non insulin-dependent diabetic patients are reported. Simvastatin administration induce a significant reduction and increase in total and HDL cholesterol levels respectively contributes to the decrease of triglycerides without interfering with the metabolic control of diabetic condition.

[Hyponatremia, cause of reversible dementia in the elderly]

There are several states of reversible dementias. Among these, electrolyte imbalance--especially hyponatremia--can determine transitory modification of cognitive functions. The purpose of this study is the evaluation of the relationship between cognitive disorders and serum sodium concentrations in the elderly. In a sample of 70 elderly people, the Authors reported a prevalence of hyponatremia in 28 patients (40%); only 4 (5.7% of total population) had impaired cognitive functions or mood disturbances. In the symptomatic patients hyponatremia was severe and had a fast onset; the symptoms disappeared by means a proper and ready treatment. This observation stresses out the importance of routine serum sodium determination in the elderly in coincidence with the sudden onset of a pattern of dementia.

[Longevity in tetralogy of Fallot. The natural history of a 63-year-old man living without surgery]

We report the natural history, the clinical, radiological, echocardiographic and hemodynamic pattern of a living sixty-three year old man with tetralogy of Fallot and cyanosis since birth. We discuss the possible circulatory adaptations which allowed exceptional survival up to the seventh decade: it is the sixth case reported in the literature.

[Clinical evaluation of anemia in the aged]

Of 533 patients over 65 years old (153 males and 380 females), admitted to geriatric units for various medical diseases, 111 (20.8%) were anemic. Among males the prevalence of anemia was 30.1%, among females 17.1%. Three principal causes of anemia were revealed. The most frequent (42.3%) was microcytic, hypochromic anemia, with low levels of serum iron concentrations, related to gastrointestinal diseases (with chronic occult blood loss). 38.7% of anemic elderly people was affected by chronic diseases. In 19.0% a folate (16 case) and iron (5 cases) deficiency was revealed. These results suggest that anemia in the elderly is always pathological; hemoglobin values lower than 12 g/dl should be considered abnormal and investigated.

[Venous thrombosis of the lower limbs and pulmonary embolism after desmopressin: a coincidence or a pathogenetic role?]

The authors describe a case of venous thrombosis of the legs, complicated by pulmonary embolism, in a 71 year-old man, following desmopressin therapy for hypothalamic diabetes insipidus. They suggest a role of desmopressin in stimulating the release of Von Willebrand's factor (VWF) from endothelial cells. VWF facilitates platelet adhesion by forming a bridge between platelet membrane and vascular subendothelium, followed by development of a large thrombus.

[Complete endocardial cushion defect and bone malformations of the hands. Holt-Oram syndrome]

A 44 year old woman with upper limb skeletal malformations and endocardial cushion defect is described. This congenital heart disease was rarely reported in association with Holt-Oram syndrome.

[Sodium and diseases in the aged]

The authors describe serum sodium levels in elderly patients at hospitalization and evaluate the role attributable to drugs, diseases, nutrition and fluid balance. Among 167 patients (average age 75.29 +/- 7.14), 132 (79.04%) had normal sodium balance, 34 (20.36%) were hyponatremic and only 1 (0.60%) was hypernatremic. Patients who had serum sodium levels above 129 mEq/l were asymptomatic. In five cases hyponatremia was acute and severe (less than or equal to 127 mEq/l). Seven patients who had serum sodium levels less than 127 mEq/l presented psychiatric and neurological manifestations, which subsided completely after prompt correction of the electrolyte disorder. The authors suggest that the pathogenesis of hyponatremia in pathological states in the elderly is complex, although iatrogenic causes play a fundamental role.

[Destructive endocarditis caused by Streptococcus sanguis on normal valves after gastroduodenoscopy]

In recent years, epidemiological and clinical patterns in infective endocarditis are changed: mean age of patients, sex, underlying cardiac diseases, source of bacteremia, availability of better diagnostic methods--specially two-dimensional and doppler echocardiography--and surgical options. The Authors report a paradigmatic case of a young man without cardiac disease, who developed a destructive endocarditis complicated by refractory congestive heart failure; the cause was an organism of low pathogenicity, Streptococcus sanguis, that entered the bloodstream after gastroduodenoscopy.

[Effects of a low-fat diet including vegetables on total blood cholesterol levels in the aged]

High total serum cholesterol and low HDL levels are major risk factors for cardiovascular disease before the age of 65. Currently in older populations their role has not yet been defined. In the elderly a low-cholesterol diet is therefore preferable to pharmacological treatment, in view of the absence of collateral effects. In this study 40 elderly patients with hypercholesterolemia were divided at random into two groups. They were respectively fed their usual diet and a legume-supplemented normal caloric diet for 8 weeks. Total serum cholesterol levels significantly decreased in the latter group from the 2nd week onward.

[Dilated cardiomyopathy and visceral anomalies in myotonic dystrophy]

In dystrophia myotonica clinical evidence of cardiac involvement usually appears several years after the onset of neuromuscular symptoms. In more than 90% of cases there is damage to the specialized cardiac tissues and in about 7% of cases there are alterations to the myocardium. We report a case characterized by early and spread deterioration of the pump function developing into refractory congestive heart failure. The contemporary involvement of the smooth muscle of gallbladder and colon confirms the hypothesis that dystrophia myotonica is a pan-muscle disease.

[Echocardiographic parameters and systolic times in arterial hypertension in the elderly]

In 40 subjects, 15 mean age 70.7 +/- 5.6 with systolic-diastolic hypertension, 15 mean age 75.5 +/- 6.8 years with systolic hypertension and 10 mean age 73.6 +/- 5.1 normotensive control group we have analyzed with M-mode 2D echocardiography and echophonocardiography the following parameters: diastolic--EDD--and systolic diameter--SD--of left ventricle, diastolic thickness of septum--SSD--and posterior wall--SPPD--of left ventricle, left ventricular ejection fraction--EF--(Theicholtr. formula), radius posterior wall thickness--R/SPPD--, left ventricular mass--LVM--(Devereux' formula), and systolic time intervals (Q-A2, LVET, PEP and PEP/LVET). The differences between groups are: systolic-diastolic hypertensive patients have increased EDD, SPPD and LVM, reduction of EF and increased PEP/LVET ratio in comparison with B and C groups; systolic hypertension doesn't increase EDD; SSD and PEP/LVET increase, while the EF remains within normal limits. In the healthy aged subjects SSD, SPPD and LVM are normal.

[Recurrent lymphoblastic crises sensitive to vincristine in a case of chronic myeloid leukemia]

Approximately one year after the onset of chronic myeloid leukemia, a 66-year-old patient had multiple recurrent blast crises with the morphological, cytochemical, and immunological features of lymphoblasts. The lymphoblastic eruptions proved always highly sensitive to small doses of vincristine only (1.5 mg), which at variable intervals, of at first 3 months and later 20 days, brought about the immediate disappearance of blast cells from the peripheral circulation as well as from bone marrow blood. Some variable clinical aspects of the case during the crises are described; the crises recurred until the patient's sudden death due to cardiac causes.

Cardiovascular adjustments induced by training evaluated during semisupine isotonic exercise and recovery period: an echocardiographic study

Two groups of subjects were examined: trained athletes (group A) and a sedentary control group (group B). The subjects performed submaximal bicycle exercise in the semisupine position to evaluate the differences between the two groups with regard to cardiovascular response during exercise and recovery and to point out all the changes due to training. During the first part of exercise, cardiac output increased contemporary with heart rate and myocardial contractility as shown by the trend of the ejection fraction, higher in group A, under the same level of total vascular peripheral resistances. Later there was an increase of cardiac output for a further increase of heart rate and cardiac inotropism due to the homeometric mechanism. During recovery the heart rate and peripheral vascular resistance reduction led to an increase of venous return which set up the Frank-Starling mechanism via an increase of left ventricular dimensions. These adjustments were more efficient in group A. During exercise and recovery the heart rate-pressure product was constantly lower in group A with a significant difference to group B. Therefore, trained athletes' myocardium is more efficient than that of the sedentary group because it performs an external work load with a lower oxygen consumption.

Serum and urinary enzyme activities in renal artery embolism

Renal artery embolism is not a rare occurrence, especially in patients with valvular heart disease, but the early diagnosis of this condition is infrequently accomplished. We report the clinical and laboratory data of 2 patients with valvular heart disease who presented with unilateral renal artery embolization. The usefulness of the determination of serum and urinary enzymes and renal function tests is discussed. We propose that these parameters support an earlier and more accurate diagnosis of renal artery embolism.

[Correlation between electrocardiographic and echocardiographic findings in chronic aortic insufficiency]

Echocardiographic indices of left ventricular volume and mass and electrocardiographic indices of left ventricular hypertrophy have evaluated in 25 patients with chronic aortic regurgitation and in 10 normal subjects. When the patients with aortic regurgitation were subdivided in three groups with increasing evidence of left ventricular hypertrophy, the echocardiographic measures of left ventricular dimension and mass were also found to be increased, with statistically significant differences between patients and controls and among the three groups of patients as well. A specially constructed cumulative electrocardiographic index of left ventricular hypertrophy (Sokolow and Lyon's index plus Lewis' index plus strain pattern) is correlated with the left ventricular end-diastolic diameter (r = 0.65; P less than 0.001), cross-sectional area (r = 0.65; p less than 0.001) and mass (r = 0.75; p less than 0.001) better than the isolated electrocardiographic indexes.

Marrow aplasia following colchicine treatment for gouty arthritis

A 69-year-old man was given 8 mg of colchicine intravenously to treat an acute attack of gout. A maintenance dose of 2 mg/day of oral colchicine was then used to prevent recurrence. Three months later, the patient developed thrombocytopenia, followed by leukopenia and then by anemia at three and four months distance, respectively. The patient had shown no signs of acute toxicity with intravenous colchicine, but liver enzymes were raised after two months of oral treatment. The sequential involvement of the three blood precursor lines, in the order to their physiological half-lives, suggests direct toxicity, rather than idiosyncrasy, due to slow accumulation of the drug within target cells. The prophylactic use of colchicine, especially in the elderly, is questioned.

Unusual Takayasu's arteritis: case report

Takayasu's disease, a condition with unusual clinical symptoms and peculiar radiologic manifestations is described. The clinical and physiopathological implications are discussed together with a literary review.