Stroke in patients with tuberculous meningitis in a low TB endemic country: an increasing medical emergency?

Stroke due to brain vascular disease is a serious complication of tuberculous meningitis (TBM). This study evaluated the frequency, clinical characteristics, risk factors and outcomes of patients with TBM complicated by stroke admitted to the Infectious Disease Clinic, University of Perugia Hospital, Italy from 1971 to 2010. Over four decades, 419 patients were admitted with tuberculosis, of these 30 (7.1%) were diagnosed with TBM: 20 definite, one probable and nine possible. Twenty-six were evaluable for stroke and six (23%) had stroke. The latter six had advanced stages of meningitis, two tested HIV positive, three HIV negative and in one HIV was not performed. Of seven patients without stroke tested for HIV, only one resulted positive. No differences were found regarding CSF cell count, sugar, protein, microscopy or growth of Mycobacterium tuberculosis among patients with or without stroke. The overall survival rate at discharge was 83% in patients with stroke and 95% in those without stroke. It was found that stroke can be frequent among patients with TBM and the presence of HIV infection might be associated with a higher rate of stroke. Further research is needed on these findings, especially in low TB endemic countries.

Morbid obesity and hypertension: The role of perirenal fat.

Accumulation of fat in renal sinus and hilum is associated with hypertension development. We evaluated the relationship between perirenal fat and hypertension in a population of morbidly obese patients and the potential variations after sleeve-gastrectomy. Two hundred and eighty-four morbidly obese patients were included in the study, and 126 underwent sleeve-gastrectomy. At baseline and 10-12 months after surgery, we evaluated anthropometric parameters, blood pressure, glycometabolic, and lipidic assessment, and performed an ultrasonographic evaluation of visceral fat area and perirenal fat thickness. The perirenal fat thickness in hypertensive obese was higher than in nonhypertensive (13.6 ± 4.8 vs 11.6 ± 4.1, P = 0.001). It showed a significant direct correlation with age, waist circumference, BMI, systolic blood pressure (SBP), insulinemia, HOMA-IR, glycated hemoglobin, and creatinine. The independent predictors (R2  = 0.129) of SBP were perirenal fat thickness (ß = 0.160, P = 0.022) and age (ß = 0.175, P = 0.011). After surgery, perirenal fat thickness significantly decreased (from 13 ± 4 to 9 ± 4 mm, P <0.001). In the 89 hypertensive obese patients who underwent sleeve-gastrectomy, we observed a significant decrease in antihypertensive medications needed. Sixteen patients suspended therapy. The perirenal fat thickness in obese patients could be a valuable tool to define the risk of developing hypertension, providing the clinician with an additional parameter to define those who need a more aggressive treatment and could benefit most from bariatric surgery.

Facing Morbid Obesity: How to Approach It.

Obesity is a major public health problem, with a prevalence of 10% to 20% in Western Europe. Morbid obesity, characterized by body mass index >40 kg/m(2), showed an increased prevalence in the last 30 years. Obesity is associated with reduced economic and social opportunities, reduced quality of life, and is a determinant of several "intermediate risk factors," leading to an increased mortality and a loss in life expectancy. The rising prevalence of morbid obesity increased the demand for bariatric surgery, also called "metabolic surgery": after these interventions, there is a decrease in metabolic comorbidities, cardiovascular (CV) risk, and total mortality. In this review, we update the evaluation of morbid obese patients from the physical examination to the metabolic, CV and respiratory assessments in order to correctly stratify the CV risk and provide the best treatment. To obtain these achievements, multidisciplinary work has to be carried out with a team involving several experts with different skills.