Ascending aorta dilatation is associated to hard cardiovascular events, follow-up from multicentric ARGO-Perspective project

Aortic root dilatation has been proposed as hypertension-mediated organ damage (HMOD). Nevertheless, the role of the aortic root dilatation as a possible additional HMOD is still unclear since studies conducted so far are quite heterogeneous regarding the type of population analyzed, the aortic tract considered, and the type of outcomes accounted for. The aim of the present study is to assess whether the presence of aortic dilatation is associated with strong cardiovascular (CV) events (MACE: heart failure, CV death, stroke, acute coronary syndrome, myocardial revascularization) in a population of patients affected by essential hypertension. Four hundred forty-five hypertensive patients from six Italian hospitals were recruited as part of ARGO-SIIA study1. For all centers, follow-up was obtained by re-contacting all patients by telephone and through the hospital's computer system. Aortic dilatation (AAD) was defined through absolute sex-specific thresholds as in previous studies (41 mm for males, 36 mm for females). Median follow-up was 60 months. AAD was found to be associated with the occurrence of MACE (HR = 4.07 [1.81-9.17], p < 0.001). This result was confirmed after correction for main demographic characteristics such as age, sex and BSA (HR = 2.91 [1.18-7.17], p = 0.020). At penalized Cox regression, age, left atrial dilatation, left ventricular hypertrophy and AAD were identified as best predictor of MACEs and AAD resulted a significant predictor of MACEs even after correction for these confounders (HR = 2.43 [1.02-5.78], p = 0.045). The presence of AAD was found to be associated with an increased risk of MACE independently of for major confounders, including established HMODs. AAD ascending aorta dilatation, LAe left atrial enlargement, LVH left ventricular hypertrophy, MACEs major adverse cardiovascular events, SIIA Società Italiana dell'Ipertensione Arteriosa (Italian Society for Arterial Hypertension).

The multifaceted spectrum of liver cirrhosis in older hospitalised patients: analysis of the REPOSI registry

BACKGROUND

Knowledge on the main clinical and prognostic characteristics of older multimorbid subjects with liver cirrhosis (LC) admitted to acute medical wards is scarce.

OBJECTIVES

To estimate the prevalence of LC among older patients admitted to acute medical wards and to assess the main clinical characteristics of LC along with its association with major clinical outcomes and to explore the possibility that well-distinguished phenotypic profiles of LC have classificatory and prognostic properties.

METHODS

A cohort of 6,193 older subjects hospitalised between 2010 and 2018 and included in the REPOSI registry was analysed.

RESULTS

LC was diagnosed in 315 patients (5%). LC was associated with rehospitalisation (age-sex adjusted hazard ratio, [aHR] 1.44; 95% CI, 1.10-1.88) and with mortality after discharge, independently of all confounders (multiple aHR, 2.1; 95% CI, 1.37-3.22), but not with in-hospital mortality and incident disability. Three main clinical phenotypes of LC patients were recognised: relatively fit subjects (FIT, N = 150), subjects characterised by poor social support (PSS, N = 89) and, finally, subjects with disability and multimorbidity (D&M, N = 76). PSS subjects had an increased incident disability (35% vs 13%, P < 0.05) compared to FIT. D&M patients had a higher mortality (in-hospital: 12% vs 3%/1%, P < 0.01; post-discharge: 41% vs 12%/15%, P < 0.01) and less rehospitalisation (10% vs 32%/34%, P < 0.01) compared to PSS and FIT.

CONCLUSIONS

LC has a relatively low prevalence in older hospitalised subjects but, when present, accounts for worse post-discharge outcomes. Phenotypic analysis unravelled the heterogeneity of LC older population and the association of selected phenotypes with different clinical and prognostic features.

Safety implications of combining ACE inhibitors with thiazides for the treatment of hypertensive patients

INTRODUCTION

ACE-inhibitors (ACEI) and diuretics are the typical first-line antihypertensive drugs with complementary mechanisms of action. The present paper is summarizing the evidence supporting the efficacy of their combination in a broad range of hypertensive patients.

AREAS COVERED

This source of data is different trials investigating the use of ACEI and diuretics in different populations of patients. The available evidence supports some advantage for thiazide-type compounds (chlortalidone-CHT and indapamide-IND) in the prevention of major CV complications. In terms of safety, hydrochlorothiazide (HCTZ) and indapamide are associated with a lesser rate of hypokalemia and abnormalities of metabolic profile (glucose control, uric acid levels, serum potassium levels). As far as the results of clinical trials, the most relevant studies are involving the combination of benazepril or perindopril with HCTZ (benazepril) or IND (Perindopril) respectively. All these studies have resulted in a favorable clinical outcome. In terms of safety profile, the combination of ACEi and diuretic is safe and comparable with that of ACEi and calcium channel blockers with no differences in the rate of major adverse events (cough or angioedema) and a lower rate of ankle edema.

EXPERT OPINION

The combination of ACEi and diuretic is safe and well-tolerated and should be considered among the first-line treatments in most of the patients with hypertension.

Intraethmoidal encephalomeningocele presenting with spontaneous cerebrospinal fluid rhinorrhea in an elderly man. Case report

The case of a 63-year-old patient with spontaneous cerebrospinal fluid rhinorrhea from a intraethmoidal encephalomeningocele is presented. The patient was asymptomatic until the old age. The preoperative coronal CT-scan and the preoperative and postoperative MRI are shown. The rarity of this onset in an elderly man and the surgical indications of this disease are debated.

Intramedullary cervical cavernoma. Case report

A rare case of intramedullary cervical cavernoma with complete neuroradiological examination is described. The Authors debate about clinical course, radiological examination and surgical indications.

Dysphagia due to anterior cervical osteophyte. Case report

A case of 61-year-old man with a 2-year history of progressive difficulty in swallowing solid foods is presented. CT-scan and barium swallow test demonstrated an anterior osteophyte at C6. Resection of the osteophyte resolved the dysphagia. The rarity in the neurosurgical literature, the pathogenesis and the management of this condition are discussed.

An in vivo model of somatic cell gene therapy for human severe combined immunodeficiency

Deficiency of adenosine deaminase (ADA) results in severe combined immunodeficiency (SCID), a candidate genetic disorder for somatic cell gene therapy. Peripheral blood lymphocytes from patients affected by ADA- SCID were transduced with a retroviral vector for human ADA and injected into immunodeficient mice. Long-term survival of vector-transduced human cells was demonstrated in recipient animals. Expression of vector-derived ADA restored immune functions, as indicated by the presence in reconstituted animals of human immunoglobulin and antigen-specific T cells. Retroviral vector gene transfer, therefore, is necessary and sufficient for development of specific immune functions in vivo and has therapeutic potential to correct this lethal immunodeficiency.

[Cerebral vasospasm. Clinical and experimental aspects]

A large number of experimental data suggest a possible biochemical hypothesis for the trigger stimulus of cerebral vasospasm after subarachnoid hemorrhage (SAH). Among several classes of possible spasmogens, arachidonic acid metabolites may play a primary role. Authors have measured with radioimmunoassay technique (R.I.A.) the levels of four arachidonate metabolites (PGD2, TxB2, 6-keto-PGF1 alpha and i-LTC4) in lumbar and cisternal cerebrospinal fluid (CSF) of patients admitted with diagnosis of aneurysmal SAH. In all cases a significant activation of arachidonate metabolism is found, if compared to control cases. Patients with demonstrated vasospasm have significantly higher CSF levels of PGD2 and i-LTC4. Cisternal CSF levels of four metabolites are significantly higher than lumbar CSF levels. This suggests the correlation between subarachnoidal clot extension and the risk for vasospasm. Authors also present an experimental animal model of SAH, which is reliable from a pathological standpoint. This model could be therefore used in the study of neurochemical and neuropharmacological aspects of SAH.

[Comparison of clinical examination, electromyography, myelography, computerized tomography and surgical findings in lumbar disc hernias]

The authors report 152 cases of patients with suspected herniated lumbar disk, operated on by traditional surgical approach. Thirteen of 152 patients underwent exploratory surgery at two vertebral spaces as a result of their neuroradiological examinations. All patients were examined clinically before of instrumental devices. CT-scan was performed on 113 patients, 62 underwent myelography and 36 electromyography. The authors verified reliability of clinical and instrumental devices on the basis of surgical results. Clinical examination was reliable in 83% of cases, electromyography in 78%, myelography in 83% and CT-scan in 87%. The percentage of false positive was 11% for the clinical examination, 9% for CT-scan, 8% for myelography and 11% for electromyography. The percentage of false negative was 6% for the clinical examination, 4% for CT-scan, 9% for myelography, and 11% for electromyography. The authors conclude that the CT-scan is the most reliable method of examination. This is even truer when dealing with extreme lateral disk herniation.

Mitral valve prolapse and transitory cerebral ischemia. Report on 8 cases

Non-complicated mitral valve prolapse (MVP) may cause transitory ischemic attacks (TIA) of a probable micro-embolic nature, especially in young people. This study presents 119 cases of TIA, 41 occurring in patients under 45 years of age. All of the 119 patients were given a brain CT scan and associated risk factors such as dislipidemia, diabetes, arterial hypertension, polycythemia were corrected. In addition, 115 patients underwent an angiography. The 41 patients under 45 were given an echocardiogram. The 8 patients who were found to have mitral valve prolapse were submitted to a 24-hour continuous monitoring of the ECG (Holter test) and only 4 patients were given an angiography. On the basis of the results obtained the Authors propose: (1) to use CT scan and electrocardiograms to study youthful patients who have had one or more events of TIA, (2) not to give them an angiography if they suffer from MVP, (3) to conduct the Holter test on these patients and, (4) to establish a therapy using blood-platelet anti-aggregants. The use of anti-coagulants is debatable, even in cases with recurring events.