Echocardiographic changes in anorexia nervosa: a pathophysiological adaptation or a disease?

Anorexia Nervosa is one of the most common form of eating disorders. Cardiac involvement occurs in approximately 80% of patients. Few reports focused on the association between body weight fluctuations and echocardiographic abnormalities, considering linear measurements. We describe echocardiographic and clinical features among male and female patients with anorexia nervosa and the effect of weight gain on these parameters. We performed a single center, retrospective study of patients followed at a dedicated multidisciplinary Unit. The study population consisted of 81 patients, mean age 25 ± 11 years, 94% female. Median body mass index was 14.4 kg/m² (25th-75th percentile 12.7-15.6 kg/m²). Patients with body mass index below the median value had more often pericardial effusion, smaller left ventricular mass and left ventricular end-diastolic volume and thinner interventricular septum. However, when indexed to body surface area, left ventricular mass and volumes were within the normal range in 90% of population. Patients with pericardial effusion showed mitral valve abnormalities and lower values of white blood cells and platelets, although within normal limits. Presence of pericardial effusion was not related to inflammatory parameters or low plasma protein levels. In 39 patients who displayed weight gain during a median follow-up of 189 days (25th-75th percentile 47-471), increased left ventricular mass, interventricular septum thickness, white blood cells and platelet count and decreased pericardial effusion were observed. Patients with anorexia nervosa have a specific echocardiographic pattern which seems to be proportional to the body size, suggesting a pathophysiological adaptation to the lack of substrates.

Sacubitril/Valsartan in heart failure with reduced ejection fraction: clinical and echocardiographic insights from a real world population

Background

Following the PARADIGM trial, some studies have identified cardiac remodeling as major background for hard end point benefits of Sacubitril/Valsartan (S/V), but few adopted a well described definition in the literature.

Purpose

We aimed at a comprehensive evaluation of the effects of S/V on echo-derived measures of cardiac remodeling along with clinical and laboratory data over a medium-term follow-up pointing to a real-world HFrEF population.

Methods

This is a prospective observational study of HFrEF patients on optimal medical therapy (OMT) initiated with S/V at Heart Failure Clinic of our institute (January 2017-January 2020). In 62 HFrEF, echocardiographic, laboratory and clinical data were collected at baseline and over 10 (Q1-Q3 8–13) months after S/V initiation. Mean age was 68±12 years, 79% men. Left ventricular reverse remodeling (LVRR) was defined as: 1) an absolute increase in LVEF ≥10 points or a LVEF ≥50% at follow-up and 2) a relative decrease in indexed left ventricular end-diastolic diameter of at least 10% or an indexed left ventricular end-diastolic diameter ≤33 mm/m2.

Results

Compared to baseline, S/V promoted a significant improvement of LV ejection fraction (LVEF, from 30% to 37%; p<0,0001) with an absolute median increase in LVEF of 8 points. Parallel significant reductions in left ventricular and atrial volumes, lower mitral regurgitation degree and a better diastolic dysfunction along with clinical improvement (NYHA class and NT-proBNP values) were observed at follow up. sPAP (systolic Pulmonary Arterial Pressure) was significantly decreased at follow-up evaluation (37 mmHg vs 31 mmHg p=0,005) (Table 1). Overall, LVRR as defined above was observed in 30% of patients. Younger age (64 vs 74 years, p=0,007), a shorter duration of the disease (7 vs 23 months, p=0,009), and non ischaemic etiology (79% vs 33% p=0,003), along with a smaller baseline LAESVi (Left Atrial End Systolic Volume, 41 vs 48 ml/m2 p=0,012) were more common in patients with LVRR. sPAP and Right Ventricular (RV) function estimated by tricuspid annular plane systolic excursion (TAPSE) were significantly better in LVRR patients along with TAPSE/sPAP ratio (Table 2).

Conclusions

Our data point to a remarkable medium-term reverse remodeling effect by S/V in HFrEF. Findings reinforce the concept that the main benefits of S/V on hard end-points are mediated by its cardiac-related effects. Both a left and right reverse remodeling occur in HFrEF patients who start S/V in the most adaptable phase of the disease supporting an early administration.

Funding Acknowledgement

Type of funding sources: None.

Phenotyping the right heart according to left ventricular geometry patterns in severe HFrEF

Background

Right ventricular (RV) failure significantly impact on heart failure with reduced ejection fraction (HFrEF) prognosis. How and whether specific functional and geometrical phenotypes of the RV function adapt and combined with left ventricular (LV) geometry is unknown.

Purpose

To test the RV function across LV geometrical patterns looking at respective prognostic roles.

Methods

We retrospectively examined a population of patients homogenously diagnosed with chronic HFrEF (defined as LV ejection fraction (EF) less than 35%) and treated with optimal therapy (OT) and all implanted with ICD for primary prevention of sudden cardiac death. Patients were categorized by echocardiography according to remodeling pattern based on left ventricular mass index and relative wall thickness into four groups: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH) and eccentric hypertrophy (EH). RV parameters were: tricuspid annulus plane systolic excursion (TAPSE), TAPSE/pulmonary artery pressures (PAPs), RV basal diameter and fractional area change (FAC). Outcome variable was all-cause mortality, assessed with multivariable Cox proportional hazard (PH) models.

Results

Among 193 patients (age 66±11 years, 81% men, 74% with ischemic etiology of HF and EF 28±5%) 21% had NG, 3% had CR, 8% had CH, and 68% had EH. Distribution of RV echo parameters across LV remodeling groups is shown in table 1. Over a median follow-up time of 4 (1.9 – 6.1) years, 65 deaths occurred. In multivariable Cox PH models adjusted for age, LVEF, ischemic etiology and LV geometry, TAPSE, TAPSE/PAPs, RV basal diameter and FAC strongly and independently predicted the outcome variable [HR 0.92 (95% C.I. 0.86–0.98), HR 0.08 (95% C.I. 0.01–0.57), HR 1.87 (95% C.I. 1.29–2.71), HR 0.97 (95% C.I. 0.95–1.00), respectively all p-value <0.05].

Conclusion

In a homogeneously defined population of severe HFrEF outpatients receiving OT, the majority showed EH remodeling pattern, which did not predict the primary outcome. LV geometry did not further stratify patients in this high risk group. Conversely, RV dysfunction proved to be a strong predictor of mortality, independently of age, LV function and etiology of HF, regardless LV morphology.

Funding Acknowledgement

Type of funding sources: None.

Consequences on the right ventricular to pulmonary circulation coupling of COVID-19 infection

Background

Right Ventricular (RV) dysfunction and pulmonary hypertension (PH) are two very likely acute and long term targets of COVID-19 pneumonia, with a potential prognostic implications.

Purpose

To determine the COVID-19 pneumonia effects on the right ventricular to pulmonary circulation coupling through bedside echocardiography and extend its implications to prognostic assessment.

Methods

Single-centre study including consecutive subjects hospitalized for COVID-19 pneumonia who underwent a clinical indicated echocardiogram between March 2020 and December 2020. Extensive analysis of cardiac function was performed offline by an operator blinded to clinical data, laboratory findings and CT scans.

Results

133 patients were enrolled (mean age 69±12 years, 57% men), 38% of whom already had cardiac disease in their medical history. In-hospital mortality was 26% (35 pts), during a mean hospital stay of 26±16 days. Non survivors had higher pulmonary artery systolic pressure (PASP) and worse RV function, assessed with both standard parameters (i.e. TAPSE) and with the novel speckle tracking analysis by RV-Global Longitudinal Strain (RV-GLS) and RV-Free Wall Longitudinal Strain (RV-FWLS). The combination of these two variables in TAPSE/PASP ratio allows assessment of RV to pulmonary circulation (Pc) coupling and was strongly associated with in-hospital death (HR 0.73, 95% CI 0.59–0.89, p=0.003) and patients with TAPSE/PASP<0.57 mm/mmHg had a more than 4-fold increased risk of in-hospital death (HR 4.8, 95% CI 1.7–13.1, p=0.003). In patients where speckle tracking analysis was feasible, we examined RV-GLS/PASP and RV-FWLS/PASP and found that it was associated with in-hospital mortality. The best cut-offs for predicting in-hospital mortality was 0.51 for RV-GLS/PASP (94% sensitivity and 59% specificity) and 0.49 for RV-free wall LS (87% sensitivity and 70% specificity). At the multivariable analysis RV to Pc remained associated with in-hospital death after adjustments for age, PaO2/FiO2, LVEF, and severity of lung involvement at the CT.

Conclusions

Either PH and RV dysfunction predict in-hospital mortality in patients with COVID-19 pneumonia. The assessment of RV to Pc coupling, however, better describes the adaptive RV response to increased PASP and gives additional prognostic information in a population with a relevant prevalence of comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Echocardographic changes in anorexia nervosa: a pathophysiological adaptation or a disease?

Funding Acknowledgements

Type of funding sources: None.

Background

Anorexia nervosa (AN) is one of the most common form of eating disorders and it is a severe and potentially fatal disease with high rates of morbidity and mortality especially in the population aged 15-25 years. Cardiac involvement occurs in approximately 80% of patients with AN. Cardiovascular complications include changes in the autonomic regulation (increased vagal tone, bradycardia, orthostatic hypotension, syncope), arrhythmias, congestive heart failure and sudden death. Few reports have described, in small series, a variety of echocardiographic abnormalities including decreased cardiac mass, mitral valve prolapse, pericardial effusion and reduced left ventricular (LV) dimensions. No previous studies, however, examined if there is a change in these abnormalities with weight fluctuations. 

Purpose

To describe echocardiographic findings among male and female patients with AN and to examine the effect of weight gain on clinical and echocardiographic parameters.

Methods

We performed a single center, retrospective, study of  patients diagnosed with AN using the diagnostic and statistical manual of mental disorders, fifth edition (DSM-5). Clinical, laboratory and ECG-graphic data were obtained by reviewing each patient’s medical records. Echocardiographic parameters were measured off-line.

Results

The study population consisted of 81 patients, mean age 24.5 ± 11.6 years, 92.6% females. 75% showed an extreme AN degree. Mean body mass index (BMI) was 15.2 ± 2.1 kg/m2. Mean heart rate was 57.2 ± 12.7 beats per minute. Some patients showed right bundle branch block (7.4%) or prolonged QT interval (14.8%). Patients with BMI below the mean value had more often pericardial effusion, smaller LV mass and LV end-diastolic volume and thinner interventricular septum (all p < 0.05). However, when index to BSA, LV mass and volumes were within normal range in the 90% of the population. They also showed mitral valve abnormalities and low values of white blood cells and platelets. The presence of pericardial effusion was not related to inflammatory parameters or protein deficiency. For 39 patients echocardiographic exams at the highest and the lowest weight were available. With weight gain, there was an improvement in LV mass, interventricular septum thickness, pericardial effusion and an increase in white blood cells and platelet count.

Conclusions

Our study showed that patients with AN have a specific echocardiographic pattern which seems to be proportional to the body size, suggesting a pathophysiological adaptation to the lack of substrates, hypothesis confirmed by the regression with weight gain. It is possible that pericardic effusion fills the gap left by mass loss.

How to manage thromboembolic risk in patient with SARS-CoV-2-related disease in the Emergency Department: A case report of cardiogenic shock due to massive pulmonary embolism

BACKGROUND

Although the most known feature of SARS-CoV-2 associated infection is a mild to severe pneumonia, increasing evidence suggests the existence of an infection-associated risk of both arterial and venous thromboembolism (VTE), but the exact magnitude of this phenomenon is still unknown.Given that, it is important for the Emergency Physician to remember that a SARS-CoV-2 associated respiratory failure can be caused not only by the pulmonary parenchymal inflammation that characterizes the pneumonia, but also by an associated pulmonary thromboembolism.

CASE REPORT

A healthy 73-years old woman admitted to the ED for dyspnea, fever and thoracic pain. Cardiac ultrasound, electrocardiogram and clinical findings suggested a diagnosis of cardiogenic obstructive shock due to acute pulmonary embolism, successfully treated with thrombolysis. A CT angiography confirmed the pulmonary embolism (EP) diagnosis and showed bilateral pneumonia, caused by SARS-CoV-2 infection.

CONCLUSION

Considering the high prevalence of thromboembolic events in COVID-19 patients it is mandatory for the emergency physician to systematically evaluate signs of pulmonary thromboembolism, in order to perform the most patient-tailored therapy as soon as possible.

Assessing apathy in multiple sclerosis: Validation of the dimensional apathy scale and comparison with apathy evaluation scale

BACKGROUND

Apathy is a predictor of cognitive decline in the course of multiple sclerosis (MS). Early identification of apathetic patients is relevant in clinical settings.

OBJECTIVE

To assess applicability and psychometric properties of the self-rated version of the Dimensional Apathy Scale (DAS) in a large cohort of patients with MS and to compare its diagnosing accuracy with that of the Apathy Evaluation Scale (AES).

METHODS

One hundred and twenty-four patients underwent clinical interview based on diagnostic criteria for apathy, DAS, AES, and assessment of depression, global cognitive functioning, and non-verbal intelligence.

RESULTS

According to diagnostic criteria, apathy occurred in 33.4% of the patients. The DAS showed high consistency, and good convergent, discriminant and criterion validity. Factor analysis indicated a three-factor structure: executive, behavioural and emotional apathy. Unlike AES, no significant association between DAS score and severity of neurological disability (expressed by EDSS total score) was found, suggesting that the DAS might be less related to levels of disability. Receiver operating characteristics analyses, with clinical diagnostic criteria for apathy as the gold standard, revealed that a DAS score of 28/29 and an AES score of 35/36 were optimal cut-off values for identifying clinically relevant apathy. The two scales had similar diagnostic accuracy in the present sample.

CONCLUSIONS

The DAS is a valid and reliable multidimensional tool to assess apathy in MS, with diagnostic accuracy similar to that of the AES. However, the DAS score appears to be less strongly related to neurological disability.

Anxiety in Multiple Sclerosis: psychometric properties of the State-Trait Anxiety Inventory

OBJECTIVE

The aims of the present study were to examine psychometric properties of the Spielberger State-Trait Anxiety Inventory (STAI-Y-1 and STAI-Y-2, respectively) in a Multiple Sclerosis (MS) population and to identify a cut-off score to detect those MS patients with high level of state and/or trait anxiety who could be more vulnerable to development of depression and/or cognitive defects.

MATERIAL AND METHODS

The STAI-Y-1 and STAI-Y-2 was completed by a group of patients (n = 175) affected by MS and a group of healthy subjects (n = 150) matched for age, educational level, and gender. In MS patients internal consistency, divergent and discriminant validities were evaluated. Construct validity was examined by exploratory factor analysis for each scale.

RESULTS

There was no missing data, no floor or ceiling effects for both scales. The two scales showed high internal consistency, good divergent, and Known-groups validities. To identify high levels of state and trait anxiety in a patient with MS, we proposed three gender specific screening cut-off values (1, 1.5, 2 SD) for the STAI-Y-1 and the STAI-Y-2.

CONCLUSIONS

The findings showed that the STAI-Y-1 and the STAI-Y-2 are a valid tool for clinical use in MS patients and can be useful to measure the severity of anxiety and to identify those patients with high anxiety to introduce them in specific non-pharmacological intervention.

A randomized clinical trial to evaluate the effects of rasagiline on depressive symptoms in non-demented Parkinson's disease patients

BACKGROUND AND PURPOSE

Depressed mood is a common psychiatric problem associated with Parkinson's disease (PD), and studies have suggested a benefit of rasagiline treatment.

METHODS

ACCORDO (see the ) was a 12-week, double-blind, placebo-controlled trial to evaluate the effects of rasagiline 1 mg/day on depressive symptoms and cognition in non-demented PD patients with depressive symptoms. The primary efficacy variable was the change from baseline to week 12 in depressive symptoms measured by the Beck Depression Inventory (BDI-IA) total score. Secondary outcomes included change from baseline to week 12 in cognitive function as assessed by a comprehensive neuropsychological battery; Parkinson's disease quality of life questionnaire (PDQ-39) scores; Apathy Scale scores; and Unified Parkinson's Disease Rating Scale (UPDRS) subscores.

RESULTS

One hundred and twenty-three patients were randomized. At week 12 there was no significant difference between groups for the reduction in total BDI-IA score (primary efficacy variable). However, analysis at week 4 did show a significant difference in favour of rasagiline (marginal means difference ± SE: rasagiline -5.46 ± 0.73 vs. placebo -3.22 ± 0.67; P = 0.026). There were no significant differences between groups on any cognitive test. Rasagiline significantly improved UPDRS Parts I (P = 0.03) and II (P = 0.003) scores versus placebo at week 12. Post hoc analyses showed the statistical superiority of rasagiline versus placebo in the UPDRS Part I depression item (P = 0.04) and PDQ-39 mobility (P = 0.007) and cognition domains (P = 0.026).

CONCLUSIONS

Treatment with rasagiline did not have significant effects versus placebo on depressive symptoms or cognition in PD patients with moderate depressive symptoms. Although limited by lack of correction for multiple comparisons, post hoc analyses signalled some improvement in patient-rated cognitive and depression outcomes.

Cognitive performances and DAT imaging in early Parkinson's disease with mild cognitive impairment: a preliminary study

OBJECTIVES

Mild cognitive impairment (MCI) is a common feature in Parkinson's disease (PD). We performed an exploratory study to investigate dopaminergic nigrostriatal innervation and its cognitive correlates in early untreated PD patients with MCI as compared to cognitively intact patients.

PATIENTS AND METHODS

A consecutive series of 34-de-novo, drug-naïve patients with PD were enrolled. They underwent [123-I] FP-CIT SPECT and comprehensive neuropsychological battery. MCI was identified in 15 of 34 patients with PD.

RESULTS

The two groups did not show any statistically significant difference in age, sex, disease duration, education, lateralization, and H&Y and Hospital Anxiety and Depression Scale scores. Logistic regression analysis showed that UPDRS-III was weakly associated with MCI (P = 0.034). Partial correlation analysis controlling for UPDRS-III and age suggested that in PD patients with MCI reduced V3″ values in the more affected caudate were correlated with reduced performances in frontal assessment battery, Trail Making Test: part B minus Part A and copy task of the Rey-Osterrieth complex figure test. Reduced V3″ values in the more and less affected putamen were significantly related with reduced performance in frontal assessment battery and in copy task of Rey-Osterrieth complex figure test, respectively. No correlation was found between neuropsychological scores and DAT availability in PD patients without MCI.

CONCLUSIONS

Although preliminary, our results suggest that striatal dopamine depletion may contribute to some cognitive deficit in early never treated PD patients with MCI.

Increased bilirubin levels in de novo Parkinson's disease

BACKGROUND AND PURPOSE

Oxidative stress is a central pathogenic mechanism of Parkinson's disease (PD), and the heme oxygenase (HO) bilirubin pathway is one of the main mammalian antioxidative defences. Indeed, there is growing evidence of HO-bilirubin upregulation from early phases of PD. Our aim was to investigate bilirubin as a possible biomarker of PD diagnosis and progression.

METHODS

A cross-sectional case-control study was performed to evaluate differences in bilirubin levels between newly diagnosed, drug-naïve PD subjects and controls. Afterwards, PD subjects were included in a 2-year longitudinal study to evaluate disease progression in relation to baseline bilirubin levels.

RESULTS

Seventy-five de novo PD subjects were selected and matched with 75 controls by propensity score. Analysis of variance showed higher bilirubin levels in PD patients compared with controls (P < 0.001). Linear regression analysis failed to show a relationship between bilirubin and Unified Parkinson's Disease Rating Scale (UPDRS) part III (P = 0.283) at baseline evaluation. At 2-year follow-up, indirect relationships between bilirubin levels and UPDRS part III (P = 0.028) and between bilirubin levels and levodopa-equivalent daily dosage (P = 0.012) were found.

CONCLUSIONS

Parkinson's disease subjects showed higher levels of bilirubin compared with controls. Bilirubin increase might be due to HO overexpression as a compensatory response to oxidative stress occurring from early stages of PD.

Migraine and cranial autonomic symptoms in children and adolescents: a clinical study

The frequency of cranial autonomic symptoms in children affected by primary headaches is uncertain. The aim of our study was to estimate the frequency of symptoms in pediatric headaches and correlate it with main migraine characteristics. A questionnaire investigating the presence of cranial autonomic symptoms was administered to all children with primary headache for 2 years. A total of 230 children with primary headache (105 males, 125 females) were included. Two hundred two children were affected by migraine and 28 (12.2%) by other primary headaches. Cranial autonomic symptoms were significantly complained by migraineurs (55% vs. 17.8%) (P < .001) and by children with higher frequency of migraine attacks (odds ratio = 2.6, confidence interval = 1.4-4.7, P = .001). Our findings show that cranial autonomic symptoms are rather common during pediatric migraine attacks. The association between cranial autonomic symptoms and higher frequency of attacks might suggest the role of the trigeminal-autonomic reflex in migraine pathophysiology.

Relationship between apathy and cognitive dysfunctions in de novo untreated Parkinson's disease: a prospective longitudinal study

BACKGROUND AND PURPOSE

Apathy may be either a symptom of major depression or a behavioral disturbance occurring in concomitance with depression or alone in Parkinson's disease (PD). The aim of the present study was to determine the progression of cognitive impairment in drug-naïve untreated PD patients with or without clinically significant apathy.

METHODS

Sixty-two PD patients with a disease duration <2 years and without history of present or past therapy with pro-dopaminergic agents were included and underwent the Apathy Evaluation Scale (S-AES), a clinical interview based on diagnostic criteria for apathy and a comprehensive neuropsychological battery to assess memory, frontal functions and visuospatial functions. Two years after the first assessment, all patients were re-evaluated on the S-AES, a clinical interview and neuropsychological tests.

RESULTS

According to the cut-off value of the S-AES and diagnostic criteria for apathy, eight patients experienced apathy at both baseline and follow-up (A+A+), nine patients had apathy only at follow-up (A-A+), 37 patients never experienced apathy (A-A-) and eight patients showed apathy at the baseline only (A+A-). Cognitive performance significantly declined in all four groups. At both baseline and follow-up A+A+ performed worse than A-A- on visuospatial and frontal tests; A-A+ had lower scores than A-A- on the interference task of the Stroop test (IT-ST). Regression analysis showed that poor performance on the IT-ST at baseline was the only independent predictor of onset of apathy at follow-up.

CONCLUSIONS

The results indicated a relationship between apathy and dysexecutive syndrome in early PD. Reduced scores on the IT-ST may predict development of apathy in PD patients.

Control of post-hemorrhoidectomy symptoms and wound healing by Triclosan: a randomized, double-blind, controlled trial

AIM

Milligan-Morgan hemorrhoidectomy (MM) is still the most common treatment for grades III and IV hemorrhoids despite prolonged post-operative anal pain and wound healing. This multicenter, double blind, randomized, controlled trial was designed to assess the safety and the efficacy of anal wound cleansing with Triclosan (Proctocid®) in the control of symptoms and healing time after MM.

METHODS

A total of 113 patients with grades III and IV hemorrhoids, undergoing open hemorroidectomy by diathermy or Ligasure vessel sealing device, were randomly assigned to Triclosan or sodium hypochlorite solution. All patients received analgesics and a fiber-rich diet after hemorrhoidectomy. Postoperative anal pain, bleeding and/or secretion and itch were assessed 7, 14 and 21 days after hemorrhoidectomy by a Visual Analogue Scale (VAS) and the day of complete re-epithelialization of anal wounds was recorded.

RESULTS

Fifty-five patients were randomized for Triclosan treatment and 58 for the control drug. The two groups were comparable for demographics, severity of hemorrhoids and technique used for the hemorrhoidectomy. The comparison of days to get complete anal wound healing shows a trend of significance (P=0.05) for the Triclosan group. Bleeding and/or secretion, anal pain and itch were significantly better (P=0.003; P<0.0001 and P=0.01, respectively).

CONCLUSION

Triclosan solution for the treatment of post-hemorrhoidectomy wounds is safe and improves the control of post-operative symptoms and wound healing time compared to sodium hypochlorite.

Subthreshold depression and subjective cognitive complaints in Parkinson's disease

BACKGROUND AND PURPOSE

Subthreshold depression (SubD) is characterized by clinically relevant depressive symptoms not meeting criteria for major depression. The possible association of SubD with subjective cognitive complaints and/or objective cognitive impairments was investigated in a sample of consecutive, non-demented Parkinson's disease (PD) outpatients.

METHODS

Amongst 115 patients, SubD was identified in 30 patients, major depression in 33; 36 patients were classified as non-depressed. Enrolled patients were administered tests and questionnaires validated in PD for assessing objective and subjective cognitive dysfunctions.

RESULTS

On objective cognitive measures SubD patients did not differ from non-depressed patients, whereas depressed patients achieved significantly lower scores than the other two groups. SubD and depressed patients reported more cognitive complaints than non-depressed patients.

CONCLUSIONS

SubD is a non-motor aspect of PD that is not related to objective cognitive deficits but is associated with subjective cognitive complaints, thus impacting on patients' well-being.

Regional gray matter atrophy in patients with Parkinson disease and freezing of gait

BACKGROUND AND PURPOSE

FOG is a troublesome symptom of PD. Despite growing evidence suggesting that FOG in PD may be associated with cognitive dysfunction, the relationship between regional brain atrophy and FOG has been poorly investigated.

MATERIALS AND METHODS

Optimized VBM was applied to 3T brain MR images of 24 patients with PD and 12 HC. Patients were classified as either FOG- or FOG+ (n = 12) based on their responses to a validated FOG Questionnaire and clinical observation. All patients with PD also underwent a detailed neuropsychological evaluation.

RESULTS

The VBM analysis in patients with FOG+ showed a reduced GM volume in the left cuneus, precuneus, lingual gyrus, and posterior cingulate cortex compared with both patients with FOG- and HC. We did not detect any significant change of GM volume when comparing HC versus all patients with PD (FOG- and FOG+). FOG clinical severity was significantly correlated with GM loss in posterior cortical regions. Finally, patients with FOG+ scored lower on tests of frontal lobe function.

CONCLUSIONS

Our findings provide the first evidence that the development of FOG in patients with PD is associated with posterior GM atrophy, which may play a role in the complex pathophysiology of this disabling symptom.

Pain sensitivity and modulation in primary insomnia

Sleep of good quantity and quality is considered a biologically important resource necessary to maintain homeostasis of pain-regulatory processes. To assess the role of chronic sleep disturbances in pain processing, we conducted laboratory pain testing in subjects with primary insomnia. Seventeen participants with primary insomnia (mean ± SEM 22.6 ± 0.9 yrs, 11 women) were individually matched with 17 healthy participants. All participants wore an actigraph device over a 2-week period and completed daily sleep and pain diaries. Laboratory pain testing was conducted in a controlled environment and included (1) warmth detection threshold testing, (2) pain sensitivity testing (threshold detection for heat and pressure pain), and (3) tests to access pain modulatory mechanisms (pain facilitation and inhibition). Primary insomnia subjects reported experiencing spontaneous pain on twice as many days as healthy controls during the at-home recording phase (p < 0.05). During laboratory testing, primary insomnia subjects had lower pain thresholds than healthy controls (p < 0.05 for heat pain detection threshold, p < 0.08 for pressure pain detection threshold). Unexpectedly, pain facilitation, as assessed with temporal summation of pain responses, was reduced in primary insomnia compared to healthy controls (p < 0.05). Pain inhibition, as assessed with the diffuse noxious inhibitory control paradigm (DNIC), was attenuated in insomnia subjects when compared to controls (p < 0.05). Based on these findings, we propose that pain-inhibitory circuits in patients with insomnia are in a state of constant activation to compensate for ongoing subclinical pain. This constant activation ultimately may result in a ceiling effect of pain-inhibitory efforts, as indicated by the inability of the system to adequately function during challenge.

Mild cognitive impairment in drug-naive patients with PD is associated with cerebral hypometabolism

OBJECTIVE

To characterize brain metabolic changes associated with mild cognitive impairment (MCI) in drug-naive patients with Parkinson disease (PD) using (18)F-fluorodeoxyglucose (FDG) and PET (FDG-PET).

METHODS

This cross-sectional study included newly diagnosed patients with PD with MCI in single or multiple domain (PD-MCI; n =12) and without MCI (PD-nMCI; n =12), and healthy controls (n =12). The groups were matched for age. Moreover, the patient groups were matched for motor disability. All subjects underwent a FDG-PET study. Cerebral regional relative metabolic maps were compared in PD-MCI, PD-nMCI, and controls using regions of interest analysis (ROIs) and voxel-based analysis with statistical parametric mapping.

RESULTS

ROIs and voxel-based analyses revealed significant relative hypometabolism in the prefrontal, superior/inferior parietal, and associative occipital cortices as well as in the striatum in patients with PD-MCI relative to controls (p < 0.05) and to a lesser extent in patients with PD-nMCI. In contrast, patients with PD-nMCI did not show significant metabolic changes as compared to controls.

CONCLUSION

MCI in patients with PD is associated with cortical hypometabolism since the earliest stage, independent of therapy or motor disability. The early involvement of posterior cortical region, a pattern shared by advanced stages of PD-MCI and PD with dementia, could represent an early marker of dementia. The relevance of this pattern in predicting prodromal dementia has to be evaluated in longitudinal studies.

Mild cognitive impairment in Parkinson disease: a multicenter pooled analysis

BACKGROUND

In studies of mild cognitive impairment (MCI) in Parkinson disease (PD), patients without dementia have reported variable prevalences and profiles of MCI, likely to be due to methodologic differences between the studies.

OBJECTIVE

The objective of this study was to determine frequency and the profile of MCI in a large, multicenter cohort of well-defined patients with PD using a standardized analytic method and a common definition of MCI.

METHODS

A total of 1,346 patients with PD from 8 different cohorts were included. Standardized analysis of verbal memory, visuospatial, and attentional/executive abilities was performed. Subjects were classified as having MCI if their age- and education-corrected z score on one or more cognitive domains was at least 1.5 standard deviations below the mean of either control subjects or normative data.

RESULTS

A total of 25.8% of subjects (95% confidence interval [CI] 23.5-28.2) were classified as having MCI. Memory impairment was most common (13.3%; 11.6-15.3), followed by visuospatial (11.0%; 9.4-13.0) and attention/executive ability impairment (10.1%; 8.6-11.9). Regarding cognitive profiles, 11.3% (9.7-13.1) were classified as nonamnestic single-domain MCI, 8.9% (7.0-9.9) as amnestic single-domain, 4.8% (3.8-6.1) as amnestic multiple-domain, and 1.3% (0.9-2.1) as nonamnestic multiple-domain MCI. Having MCI was associated with older age at assessment and at disease onset, male gender, depression, more severe motor symptoms, and advanced disease stage.

CONCLUSIONS

MCI is common in patients with PD without dementia, affecting a range of cognitive domains, including memory, visual-spatial, and attention/executive abilities. Future studies of patients with PD with MCI need to determine risk factors for ongoing cognitive decline and assess interventions at a predementia stage.

[Thyroid ectopia: problems in diagnosis and therapy]

The Authors report the cases of ectopic thyroid (n=22) observed among the thyroid pathologies that underwent surgical approach in the last 20 years (n=2670), to discuss their clinic characteristics other than the diagnostic and therapeutic approaches. Sometimes asymptomatic or emerged after thyroidectomy, the ectopic thyroid may generate functional troubles or, most frequently, local compression that require surgical approach that, in the opinion of these authors, is ever indicated also for asymptomatic forms. Based on author's experience, also if statistically rare, it is not possible to neglect the neoplastic degeneration, elapsed in two out of 22 cases analyzed.

Anhedonia and cognitive impairment in Parkinson's disease: Italian validation of the Snaith-Hamilton Pleasure Scale and its application in the clinical routine practice during the PRIAMO study

OBJECTIVE

To assess the psychometric properties of the Italian version of the Snaith-Hamilton Pleasure Scale (SHAPS) and to study the relationship between anhedonia, depression and cognitive impairment in patients with Parkinson's disease (PD).

METHODS

The SHAPS (14 items) was translated into Italian and pre-tested in a pilot study. Two items evaluating physical anhedonia related to sexual issues were added. The Italian version of SHAPS was validated in 274 consecutive PD patients, divided into patients with major depression according to DSM-IV criteria (dPD) and patients without depression (nPD), and in healthy subjects. To test the feasibility of the instrument and to determine whether clinical data affect anhedonia, we also administered SHAPS to 1307 patients with different types of parkinsonism.

RESULTS

The Italian SHAPS proved to be easy to understand as regards the question and answer modes. Intraclass coefficient for test-retest reliability was 0.65 for the total score. KR index was 0.61. ANOVA of the SHAPS total score revealed that scores were higher in dPD patients than in healthy controls and nPD (p<0.05). In the 1307 patients with various types of parkinsonism, the SHAPS data showed that anhedonia was related to age, type of parkinsonism, apathy, depression and cognitive impairment. Anhedonia was correlated with frontal dysfunctions in supranuclear palsy and PD patients (r=-0.682 and -0.264 respectively, p<0.05).

CONCLUSION

The Italian version of the SHAPS is a reliable tool with which to assess anhedonia in patients with PD and other forms of parkinsonism.

Blind Traumas of the Scrotum: Three Case Reports

The blind traumas of the scrotum are an uncommon event; references, iconography and descriptions of the clinical development of scrotal syndromes are poor. The scrotum and the didimal or funicular structures are often involved in different conditions. The authors are reporting on three interesting cases (for patients’ age, mechanism of traumatism and anatomic damage), gathered from a series of 12 cases of blind traumas of the scrotum, observed during 2 years (2005–2006). They include the iconography related to each single case, and emphasize the uncertain role of ultrasonography with color Doppler for a correct diagnosis.

The clinical evolution and the long-term damage to gonad functionality are presented.

Cetirizine, a second-generation H1 antagonist, modulates Rantes and MCP-1 levels in allergic rhinitis

Chemokines and their receptors are involved in several allergic diseases. We measured RANTES and MCP-1 levels in sera of allergic rhinitis patients, and also we evaluated the effect of cetrizine, a second-generation H1 antagonist, on these chemoattractant proteins. 15 subjects were studied (10 males and 5 females; mean age: 26.7 years). They were suffering from perennial or seasonal allergic rhinitis induced by Dermatophagoides pteronyssinus (8 patients) or by grasses (7 patients). RANTES and MCP-1 serum levels were detected with an enzyme immunoassay before and after two weeks of treatment with 10 mg of cetirizine daily, and again after two weeks of washout. Baseline serum levels of RANTES and MCP-1 chemokines were significantly higher (p &lt; 0.02 and p = 0.007, respectively) in allergic patients than in the healthy control group. Cetirizine resulted in a significant decrease in RANTES (p &lt; 0.02) and MCP-1 (p = 0.003) versus baseline values. There is an increase in RANTES and MCP-1 in allergic rhinitis, which is counteracted by cetirizine.

Serum Tryptase in Allergic Rhinitis: Effect of Cetirizine Treatment

Activated mast cells release a large range of potent mediators of allergic inflammation, including proteases. The tryptase serum levels were evaluated in 13 subjects suffering from allergic perennial rhinitis. Moreover, the effects of cetirizine treatment on serum tryptase were studied using the UniCap™ tryptase fluoroenzymeimmunoassay.

In allergic patients the serum tryptase values (M±SD: 6.1 ± 2.4 μg/L) were significantly (p < 0.02) higher than the values detected in controls (3.0 ± 1.2 μg/L). In allergic rhinitis, after antihistamine treatment, tryptase values (4.4 ± 1.8 μg/L) decreased significantly (p < 0.001). After two weeks from the cetirizine stop, the tryptase levels increased again (5.5 ± 2.6 μg/l).

The results demonstrate that mast cells are constantly activated in perennial allergic rhinitis. The antihistamine treatment is effective in reducing the tryptase release from mast cells, but the mechanism of action of cetirizine is still to understand.

Serum tryptase in allergic rhinitis: effect of cetirizine and fluticasone propionate treatment

PURPOSE

A specific reaction against several kinds of inhalant allergens characterizes allergic rhinitis. Mast cells play a crucial role in the allergic inflammation releasing histamine and other mediators. Tryptase is considered to be a specific marker of mast cell activation. This study was devoted to evaluate the serum tryptase in allergic rhinitis and to evaluate the effect of cetirizine and fluticasone propionate on mast cell activation. 13 subjects, suffering from perennial allergic rhinitis induced by Dermatophagoides pteronyssinus, were studied.

MATERIALS AND METHODS

Tryptase serum levels were detected by the fluoroenzymeimmunoassay (Pharmacia & Upjohn AB, Uppsala, Sweden). Blood samples were taken four times: before starting the study, after two weeks of 10 mg cetirizine treatment once a day, after two weeks of wash-out, and again after 15 days of 100 micrograms intranasal fluticasone propionate therapy twice a day.

RESULTS

In allergic rhinitis, the basal values of serum tryptase (M +/- SD: 6.1 +/- 2.4 micrograms/l) were significantly higher than in controls (M +/- SD: 3.0 +/- 1.2 micrograms/l). After the antihistamine treatment, tryptase values (M +/- SD: 4.4 +/- 1.8 micrograms/l) decreased significantly (p < 0.001). After the stop of antihistamine treatment, tryptase levels increased (M +/- SD: 5.5 +/- 2.6 micrograms/l, p < 0.001). After the topical corticosteroid treatment, tryptase values decreased again significantly (M +/- SD: 4.5 +/- 3.1 micrograms/l, p < 0.04).

CONCLUSIONS

All these data seem to confirm the effective action of cetirizine and fluticasone propionate on tryptase serum levels. While the action of corticosteroid is well known, the action of cetirizine is still to define, considering the recent reports on anti-inflammatory effect of the second generation of H1 receptor antagonists. Further studies are necessary to understand if the pharmacological effect on tryptase is a specific one of cetirizine, or if it is common to other anti-H1 molecules.

Serum tryptase in allergic rhinitis: effect of cetirizine treatment

Activated mast cells release a large range of potent mediators of allergic inflammation, including proteases. The tryptase serum levels were evaluated in 13 subjects suffering from allergic perennial rhinitis. Moreover the effects of cetirizine treatment on serum tryptase were studied using the UniCap&#x2122; tryptase fluoroenzymeimmunoassay. In allergic patients the serum tryptase values (M&#x00B1;SD: 6.1 &#x00B1; 2.4 &#x03BC;g/L) were significantly (p &#x003C; 0.02) higher than the values detected in controls (3.0 &#x00B1; 1.2 &#x03BC;g/L). In allergic rhinitis, after antihistamine treatment, tryptase values (4.4 &#x00B1; 1.8 &#x03BC;g/L) decreased significantly (p &#x003C; 0.001). After two weeks from the cetirizine stop, the tryptase levels increased again (5.5 &#x00B1; 2.6 &#x03BC;g/l). The results demonstrate that mast cells are constantly activated in perennial allergic rhinitis. The antihistamine treatment is effective in reducing the tryptase release from mast cells, but the mechanism of action of cetirizine is still to understand.

Mast cell activation in acquired chronic urticaria-angioedema

Mast cells play a central role in the pathogenesis of many allergic disorders. They can be activated in different ways. The present study was focused to evaluate the role of mast cells in acquired chronic urticaria-angioedema induced by gastroesophageal reflux. Tryptase, an important marker of mast cell activation, was detected with UniCap Tryptase Fluoroenzymeimmunoassay (Pharmacia & Upjohn AB, Uppsala, Sweden). Eight subjects were studied: four males and four females, aged between 29 and 71 years (mean age: 45 yrs.), suffering from acquired chronic urticaria-angioedema. Results were compared with the results of seven healthy control subjects. Moreover, data were compared with those of 13 subjects (10 males and 3 females, mean age: 24.7 years) suffering from allergic rhinitis. In acquired chronic urticaria-angioedema, serum tryptase levels (mean +/- S.D.: 9.6 +/- 4.3 microg/l) were significantly higher (P < 0.007) than those of the controls (mean +/- S.D.: 3.0 +/- 1.2 microg/l) and higher also than in allergic rhinitis (mean +/- S.D.: 6.1 +/- 2.4 microg/l, P < 0.03). The results underline the central role of mast cells in the inflammation of acquired chronic urticaria-angioedema.

An immunofluorescence technique for staining ciliated protozoans: highlighting cytoplasmic microtubular arrays and stages of micronuclear meiosis

Ciliated protozoans represent useful organisms for studying the processes involved in the induction and progression of meiosis. In this short report we describe a technique that has allowed us to examine different meiosis phases during the sexual reproduction of Blepharisma japonicum. In order to visualize the phases of meiosis, sexually reproducing pairs were stained by an enhanced technique of anti-tubuline indirect immunofluorescence. Meiotic micronuclei, particularly those showing metaphase spindles, were clearly highlighted. The technique also heavily decorates the main microtubular cytoplasmic arrays in Blepharisma.

The Epibloc system for the treatment of wrist fractures

The current prospective study was conducted to verify the results obtained in a heterogeneous group of 50 displaced fractures of the wrist treated with the Epibloc system. This method is simple and rapid to use and it does not require plaster. The results obtained are very satisfactory (good and excellent 91.6%) in AO type A2 and A3 fractures and in type C1 fractures (92.8%) and in C2 fractures (88.3%); in fractures with multiple fragments and compromise of the joint surface (C3) the results were not very significant because of the small number of lesions treated (4 cases), but they do not seem to differ very much from what was obtained by other authors when more complicated methods were used. The results were very unsatisfactory in type B fractures (Goyrand); it is our belief that this method is not indicated for lesions such as these, because of the intrinsic difficulty in monitoring dislocation of the volar metaepiphyseal fragment.

Hepatitis C virus: a high risk factor for a second primary malignancy besides hepatocellular carcinoma. Fact or fiction?

PURPOSE

Second primary malignancies occur more and more often. But the hepatocellular carcinoma (HCC) linked to a second primary cancer is not frequent.

MATERIALS AND METHODS

A retrospective study focused on a second primary cancer was performed in 37 patients with HCC, aged between 46 and 81 years, 27 males and 10 females.

RESULTS

5 out of them (13.5%), 3 males and 2 females, developed a second primary neoplasm before or after HCC. In 3 cases the second malignancy was a carcinoma of the kidney, of the breast, and the prostate. The fourth patient had a Hodgkin's lymphoma before HCC. The last and most unlucky case, besides HCC, had a basal cell carcinoma, a colorectal cancer, and a bladder carcinoma. The common data of these 5 patients were the presence of anti-HCV antibodies and the positivity of the HCV RNA polymerase reaction. One patient was also HBV positive.

CONCLUSION

Considering that a large number of virus has been found linked to human cancers, our results brought us to hypothesize that HCV could have played an important role not only in the development of HCC but of the second primary malignancy too. This is likely favoured by constitutional or acquired biological and molecular alterations. Tumor suppressor genes alterations have been reported to be frequently linked to cancers of kidney and breast, of colorectal and skin, of prostate, and lymphoemopoietic tissue. Now just these organs are involved in our patients in addition to the liver. Our results, if confirmed, are of a relevant interest, considering that world-wide HCC is constantly increasing for the spreading of the virus risk-factors.

A five-day course of dirithromycin in the treatment of acute exacerbation of severe chronic obstructive pulmonary disease

Since dirithromycin persists at high concentrations in the lung for at least 3 days following the last dose of a 5-day course, we evaluated the clinical efficacy and tolerance of a 5-day course of dirithromycin in 20 patients with acute exacerbation of severe chronic obstructive pulmonary disease, treated with a total dose of 2.5 g dirithromycin (500 mg once-daily for 5 days) in an open, non-comparative study. Patients were assessed before therapy and after 5 (last administration), 10 (post-therapy) and 20 (late post-therapy) days. Pathogen elimination or presumed elimination was seen in 18/20 patients at the post-therapy visit and at the late post-therapy visit, but two Haemophilus influenzae out 5 were isolated in sputum after 10 days and only one after 20 days (Pseudomonas aeruginosa was the other pathogen). Dirithromycin was well-tolerated and only 2 patients reported mild gastrointestinal pain. This study shows that a 5-day dirithromycin therapy provides a convenient and efficient dosage regimen in acute exacerbation of chronic bronchitis. Notwithstanding its poor in vitro activity against H. influenzae, dirithromycin was fairly active against this microorganism in vivo.

Salmeterol and formoterol in partially reversible severe chronic obstructive pulmonary disease: a dose-response study

When testing the response to beta 2-agonist drugs in severe chronic obstructive pulmonary disease (COPD), a dose-response assessment should be undertaken. This study compares the time course of inhaled salmeterol (25, 50 and 75 micrograms) and formoterol (12, 24 and 36 micrograms) at different doses in a group of 12 patients with partially reversible, but severe COPD (FEV1 of 12-32% of predicted values after beta 2-agonist drugs had been withheld for 24 h). All doses of salmeterol and formoterol induced a significant (P < 0.01) spirometric improvement over the 12-h monitoring period, when compared to the spirometric improvement after placebo, but while formoterol induced a dose-dependent increase of the FVC, FEV1 and FEF50, this was not the case for salmeterol. In fact, 75 micrograms salmeterol did not produce a further improvement of these parameters. Mean peak bronchodilation, expressed as the increase in FEV1 over baseline values, occurred 2 h after inhalation of the three doses of salmeterol, and 1 h after inhalation of the three doses of formoterol. A comparison of 50 micrograms salmeterol with 12 micrograms or 24 micrograms formoterol (clinically recommended doses), showed that improvement of FEV1 after salmeterol was statistically (P < 0.05) higher than that after the two doses of formoterol, although the mean peak bronchodilations were similar. This was because salmeterol has a longer duration of action than formoterol. These data demonstrate that salmeterol is equally effective as, but longer-acting than, formoterol at clinically recommended doses in patients suffering from COPD, with severe airway obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary penetration of ceftazidime

For an antibiotic to be effective in lower respiratory tract infections, it should be available in adequate concentrations in respiratory tissues and fluids. Cephalosporins usually achieve modest concentrations in the respiratory tract. In this study we have determined the pulmonary penetration of intramuscularly administered ceftazidime (a single dose of 1 g). Levels of ceftazidime in bronchial secretions (BS), bronchial mucosa (BM), epithelial lining fluid (ELF), and serum (S) were measured by microbiological assay in 25 patients suffering from acute exacerbation of chronic bronchitis who were divided into 5 groups of 5 subjects according to sampling time (1, 2, 4, 8 and 12 hours after the administration of the antibiotic). The peak S level was high (39.89 +/- 10.42 micrograms/ml at 1 hour) and mean S concentrations decreased slowly and were still detectable at 12 hours (1.07 +/- 0.45 microgram/ml). In all other samples, mean concentrations were in excess of the ceftazidime minimum inhibitory concentrations (MICs) for many relevant respiratory pathogens (Haemophilus influenzae 0.15 microgram/ml; Moraxella catarrhalis 0.06 micrograms/ml; Streptococcus pneumoniae 0.15 micrograms/ml; Klebsiella pneumoniae 0.4 microgram/ml). Concentrations in BM (7.05 +/- 2.38, 8.14 +/- 2.23, 6.40 +/- 1.63, 4.06 +/- 0.99 and 0.45 +/- 0.27 microgram/g) were higher than that in BS (6.87 +/- 1.96, 6.54 +/- 1.84, 3.52 +/- 1.23, 1.56 +/- 0.92 and 0.23 +/- 0.19 microgram/ml).(ABSTRACT TRUNCATED AT 250 WORDS)