Pulmonary embolism with minimal D-dimer increase - disagreement between clinic and laboratory: case report.

Pulmonary embolism is still currently considered a very insidious disease and if not diagnosed and treated rapidly is lethal in almost 10 percent of all cases. Clinical and patient history data are essential for the diagnosis and evaluation of the clinical risk of pulmonary embolism. Pulmonary embolism, particularly during minor episodes, was primarily identified by abnormalities in D-dimer concentration during laboratory testing. Indeed, an increase in D-dimer plasma levels was consequently identified as a valid diagnostic element for pulmonary embolism and therefore, in the absence of D-dimer abnormalities, a tendency to exclude such diagnosis exists. This case report describes the importance of carrying out level II diagnostic investigations which may be particularly valid in patients with a minimal rise in D-dimer levels and a clinical suspicion of a pulmonary embolism. This method allows for a quick diagnosis with early therapeutic measures which improve survival rates during the acute and critical phase.

Bicarbonate transport along the loop of Henle. II. Effects of acid-base, dietary, and neurohumoral determinants.

The loop of Henle contributes to renal acidification by reabsorbing about 15% of filtered bicarbonate. To study the effects on loop of Henle bicarbonate transport (JHCO3) of acid-base disturbances and of several factors known to modulate sodium transport, these in vivo microperfusion studies were carried out in rats during: (a) acute and chronic metabolic acidosis, (b) acute and chronic (hypokalemic) metabolic alkalosis, (c) a control sodium diet, (d) a high-sodium diet, (e) angiotensin II (AII) intravenous infusion, (f) simultaneously intravenous infusion of both AII and the AT1 receptor antagonist DuP 753, (g) acute ipsilateral mechanicochemical renal denervation. Acute and chronic metabolic acidosis increased JHCO3; acute metabolic alkalosis significantly reduced JHCO3, whereas chronic hypokalemic alkalosis did not alter JHCO3. Bicarbonate transport increased in animals on a high-sodium intake and following AII administration, and the latter was inhibited by the AII (AT1) receptor antagonist DuP 753; acute renal denervation lowered bicarbonate transport. These data indicate that bicarbonate reabsorption along the loop of Henle in vivo is closely linked to systemic acid-base status and to several factors known to modulate sodium transport.

Parathyroidectomy has a beneficial effect on experimental cisplatin nephrotoxicity.

It has recently been suggested that selective parathyroidectomy modifies drug-induced acute renal failure. In the present study, we tested whether parathyroid hormone (PTH) could play a role in the pathogenesis of cisplatin (CP) nephrotoxicity. Parathyroidectomized rats (PTX) with normal blood calcium, were injected with two different doses of CP (group Ia: 10 mg/kg and group Ib: 6 mg/kg) and their renal functions were evaluated after 72 hours (group 1 a) and 120 h (group 1 b), respectively. All animals exhibited a milder course of acute renal failure when compared to sham-PTX CP treated rats, with lower serum creatinines (SCr) (group Ia: 1.99 +/- 0.14 vs 2.91 +/- 0.56 mg/dl, p less than 0.05) (group Ib: 1.45 +/- 0.08 vs 1.80 +/- 0.09 mg/dl, p less than 0.05) and blood urea (BUN) (group Ia: 76 +/- 5 vs 115 +/- 19 mg/dl, p less than 0.05) (group Ib: 70 +/- 9 vs 88 +/- 10 mg/dl p less than 0.05). Furthermore, the i.p. administration of PTH (50 I.U. twice daily for 9 days) to normal rats treated with CP (6 mg/kg) aggravated the CP-induced ARF as compared to vehicle injected animals (SCr 2.23 +/- 0.16 vs 1.63 +/- 0.19 mg/dl, p less than 0.05 and BUN 153 +/- 22 vs 97 +/- 20 mg/dl, p less than 0.05). Treatment with the calcium channel blocker verapamil (4 mg/kg) nine days before and three days after CP (4 mg/kg) administration, had no significant effect on cisplatin nephrotoxicity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the accuracy of calcaneus bone tissue findings by a contact ultrasound system. Comparison with the most used absorptiometry methods]. / Valutazione della validità dei rilievi sul tessuto osseo calcaneare di un sistema a ultrasuoni a contatto. Confronto con le più diffuse metodiche assorbimetriche.

BACKGROUND: Ultrasound measurements of bone include Broadband Ultrasound Attenuation (BUA) and Speed Of Sound (SOS) through a skeletal segment. These techniques do not expose patients to ionizing radiations. Aim of the present study was to evaluate reproducibility, specificity, sensibility and accuracy of these measurements as compared with those obtained by absorptiometric devices at the distal radius and lumbar spine (L2-L4). METHODS: Mean c.v. for repeated measurements on the same subjects was 2.7% for BUA and 0.9 for SOS. Both BUA and SOS were able to separate young normal from healthy post-menopausal subjects and patients with recent vertebral osteoporotic fractures as well as absorptiometric techniques. RESULTS: All compared methods of bone measurements showed non statistically significant differences for what concerns sensibility, specificity and accuracy. CONCLUSIONS: We conclude by affirming that both BUA and SOS measurements at the os calcis with the contact ultrasound analyzer CUBA may represent safe and available methods for routinary assessment of skeletal health. The contact device allows more rapid measurements than other US devices the use of whom is conditioned by the immersion of the foot in a water bath; furthermore the CUBA system detects BUA and SOS in the mid os calcis: at this level bone density resulted more homogeneous than in other regions of the same bone.

The prevalence of cardiovascular autonomic neuropathy and of retinopathy in relation to the duration of diabetes.

In a study on the prevalence of cardiovascular autonomic neuropathy and retinopathy in a group of 57 diabetic subjects, an increased prevalence of these complications related to the duration of diabetes has been found.

Relationships between obesity and ischaemic heart disease in type II diabetic subjects homozygous for the apoprotein E3 allele.

The purpose of the present study was to evaluate the influence of obesity on ischaemic heart disease frequency in a well-documented type II diabetic population. To eliminate one of the possible sources of variability for plasma lipid concentrations, only subjects showing the apoprotein E phenotype, indicative of homozygosity for the epsilon 3 allele (i.e. an E3/E3 genotype), have been recruited. A larger prevalence of ischaemic heart disease was noticed among obese patients as compared to non-obese or merely overweight subjects according to a higher frequency of hypertension and to higher triglyceride concentrations. These results corroborate the hypothesis of a common pathogenesis of the major cardiovascular risk factors.

On the formation of iron(III) hydroxo acetate complexes.

The formation of hydroxo acetate complexes of iron (III) ion has been studied at 25 degrees C in 3 M (Na)ClO4 ionic medium by measuring with a glass electrode the hydrogen ion concentration in Fe(ClO4)3-HClO4-NaAc mixtures (Ac = acetate ion). The acetate/metal ratio ranged from 0 to 6, the metal concentration varied from 0.005 to 0.06 M, whereas [H+] was stepwise decreased from 0.1 M to initial precipitation of hydroxo-acetates. This occurred, depending on the acetate/metal ratio, in the -log[H+] range 1.85-2.7. The potentiometric data are consistent with the presence of Fe3(OH)3Ac3(3+), Fe2(OH)2(4+), Fe3(OH)4(5+), Fe3(OH)5(4+) and, as minor species, of Fe3(OH)2Ac6+, FeAc2+, FeAc2+, FeOH2+ and Fe(OH)2+. Previously published EMF measurements with redox and glass half-cells were recalculated to refine the stability constants of FeAc2+, FeAc2+ and Fe3(OH)2Ac6+. Formation constants *beta pqr for pFe(3+)+(q-r)H2O + rHAc reversible Fep(OH)(q-r)(Ac)r3p-q + qH+ (in parenthesis the infinite dilution value): log*beta 111 = -1.85 +/- 0.02 (-0.67 +/- 0.15), log*beta 122 = -3.43 +/- 0.02 (-1.45 +/- 0.15); log*beta 363 = -5.66 +/- 0.03 (-2.85 +/- 0.40), log*beta 386 = -8.016 +/- 0.006 (-4.06 +/- 0.15), log*beta 220 = -2.88 +/- 0.02 (-2.84 +/- 0.05), log*beta 340 = -6.14 +/- 0.18 (-6.9 +/- 0.4), log*beta 350 = -8.44 +/- 0.09 (-7.65 +/- 0.15).

A potentiometric study on oxalate and citrate complexes of tin(II).

The formation of oxalate and citrate complexes of the Sn2+ ion in 1 M Na(ClO4) at 25 degrees C was investigated in the -log[H+] range 2 to 5 by potentiometric titrations using glass and tin amalgam electrodes. The tin concentration was varied from 0.5 to 5 mM and the concentration of the ligands from 1 to 40 mM. The experimental data have been explained by the formation of the oxalato complexes SnC2O4(aq) and Sn(C2O4)2(2-) and of the citrate complexes (C3H5O7(3-) = citrate ion) SnC3H5O7-, SnHC3H5O7(aq), SnH2C3H5O7+ and Sn(OH)C3H5O7(2-). The equilibrium constants were refined by the computer program SUPERQUAD. The final values of the constants on the medium scale and in the infinite dilution reference state are given in Table 2.

Screening for frailty in elderly emergency department patients by using the Identification of Seniors At Risk (ISAR).

OBJECTIVES: Frail older adults are at an increased risk for adverse outcomes after an Emergency Department (ED) visit. Comprehensive geriatric assessment (CGA) has been proposed to screen for frailty in the ED, but it is difficult to carry out. We tested whether a CGA-based approach using the Identification of Seniors At Risk (ISAR) screening tool was associated with the brief deficit accumulation index (DAI) of frailty. DESIGN: Prospective observational study. SETTING: Two urban EDs in Italy. PARTICIPANTS: A cohort of 200 elderly (≥65 years) ED patients. MEASUREMENTS: Identifiers, triage, clinical and social data along with the administration of ISAR. CGA was performed using: Charlson Index, Short Portable Mental Status Questionnaire and Katz's ADL. Follow-up data at 30 and 180 days included: mortality, ED revisit, hospital admission, and functional decline. Frailty was defined according to a brief DAI. Logistic regression evaluated the consistency of the frailty definition; ROC curves evaluated ISAR ability in identifying frailty. RESULTS: Frailty was present in 117 (58.5%) subjects and predicted ED revisit and frequent ED return, hospitalization and 6-month mortality. ISAR had an AUC of 0.92 (95%CI 0.88-0.96, p<0.0001) in identifying frail elders in the ED and using a cut-off of 2 showed 94% sensitivity and 63% specificity. CONCLUSION: ISAR is a useful screening tool for frailty and identifies elderly patients at risk of adverse outcomes after an ED visit. ISAR can also be used to select high-risk patients more likely to benefit from a geriatric approach or intervention, independently of admission or discharge.

The elderly in the emergency department: a critical review of problems and solutions.

The elderly are an ever increasing population in overcrowded emergency departments (EDs) in many countries. They have multiple health problems and consume more time and resources than younger patients. They are more frequently admitted and experience adverse outcomes after they are discharged from the ED. These frail patients could require specific skills, instruments and organisational models of emergency care in order to look after their complex needs. As such, several approaches have been tried and tested to improve emergency care for them. This article analyses the epidemiological load and problems faced when confronted with elder ED patients. We critically review organisational models, clinical approaches and methodologies in order to reduce ED physicians' difficulties and to improve quality of care and outcomes for elder patients. Triage, clinical assessment and discharge are identified as critical moments during an emergency care process, and interesting and useful instruments are proposed as possible solutions.

Umbilical cord blood rheology in relation to maternal disease and fetal hypoxia.

Erythrocyte aggregation was studied in 60 samples of cord blood taken at delivery from neonates whose mothers suffered from hypertension or diabetes in pregnancy or from neonates who showed hypoxia during labor. Erythrocyte aggregation significantly increased in the cord blood of neonates who suffered from hypoxia during labor, and in neonates from hypertensive and diabetic mothers. The effects of maternal disease or intrapartum hypoxia may therefore stimulate fetal erythropoiesis and cause major changes in cord blood rheology.

Nifedipine treatment in preeclampsia reverts the increased erythrocyte aggregation to normal.

OBJECTIVES: Our objectives were to assess erythrocyte aggregation in hypertensive pregnancy and to evaluate the effect of the antihypertensive treatment on it. STUDY DESIGN: The mean entity of erythrocyte aggregation was determined by an automatic aggregometer in 57 pregnant women: 20 normotensive, seven chronically hypertensive, 10 chronically hypertensive with superimposed preeclampsia, and 20 with preeclampsia. Ten of the latter were subsequently treated by 40 mg/day oral nifedipine; the other 10 by 400 mg/day oral labetalol, to keep diastolic blood pressure < 90 mm Hg. Also, patients with superimposed preeclampsia were treated with 40 mg/day oral nifedipine. RESULTS: Erythrocyte aggregation was increased in all the hypertensive pregnant patients compared with the normotensive pregnant controls, regardless of both the onset (chronic or pregnancy-induced) of hypertension and the status of plasma macromolecules. Antihypertensive treatment with labetalol significantly reduced the aggregability of erythrocytes, whereas treatment with nifedipine reverted it to normal. CONCLUSIONS: Increased erythrocyte aggregation may be due to either conformational changes of the membrane occurring during hypertension or a redistribution of the ionic charges on the two surfaces of the membrane. The effect of nifedipine by restoring the ionic charges may be due to this latter event.

The effect of acute metabolic alkalosis on bicarbonate transport along the loop of Henle. The role of active transport processes and passive paracellular backflux.

The loop of Henle (LOH) reabsorbs approximately 15% of filtered HCO3- via a luminal Na(+)-H+ exchanger and H+ATPase. During acute metabolic alkalosis (AMA) induced by i.v. HCO3- infusion, we have observed previously inhibition of LOH net HCO3- reabsorption (JHCO3-), which contributes to urinary elimination of the HCO3- load and correction of the systemic alkalosis. To determine whether the activities of the Na(+)-H+ exchanger and/or H(+)-ATPase are reduced during AMA, two inhibitors believed to be sufficiently specific for each transporter were delivered by in vivo LOH microperfusion during AMA. AMA reduced LOH JHCO3- from 205.0 +/- 10.8 to 96.2 +/- 11.8 pmol.min-1 (P < 0.001). Luminal perfusion with bafilomycin A1 (10(-4) mol.l-1) caused a further reduction in JHCO3- by 83% and ethylisopropylamiloride (EIPA; 5.10(-4) mol.l-1) completely abolished net HCO3- reabsorption. The combination of bafilomycin A1 and EIPA in the luminal perfusate was additive, resulting in net HCO3- secretion (-66.6 +/- 20.8 pmol.min-1; P < 0.001) and abolished net fluid reabsorption (from 5.0 +/- 0.6 during AMA to 0.2 +/- 1.1 nl.min-1; P < 0.001). To establish whether HCO3- secretion via luminal stilbene-sensitive transport mechanism participates in LOH adaptation to AMA, we added diisothiocyanato-2,2'-stilbenedisulphonate (DIDS; 10(-4) mol.l-1) to the perfusate. No effect was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of thyroid hormones on heart and kidney functions.

Thyroid hormones affect the functions of several organs including the heart and kidney. Using isolated left papillary muscles we have investigated the action of thyroid hormones on the mechanical and electrical properties of the heart. We found that pure hypothyroidism causes a depression in contractile and electrical parameters, but we noticed that superimposed hypoparathyroidism accounts for the marked prolongation in contractile kinetics and action potential duration. At kidney level we have shown that thyroid hormones affect proximal tubular sodium transport and this effect is only partially mediated by the action of thyroid hormones on Na-K-ATPase activity. Using the micropuncture technique, we hypothesized that the early effect of thyroid hormone action is on the potassium permeability of proximal tubular cell membrane. This latter effect would explain the increase in isotonic fluid reabsorption through an increase in the driving force for sodium. Finally, hypothyroid patients have a decrease in glomerular filtration rate and renal plasma flow that are completely reversed by thyroxine administration. On the other hand, hyperthyroid subjects exhibit a significant increase in both parameters.