Twenty-four hour Holter ECG in normocalcemic and hypercalcemic patients with hyperparathyroidism.

PURPOSE: To investigate the occurrence of arrhythmias in patients with normocalcemic (NC) primary hyperparathyroidism (PHPT) compared to both hypercalcemic PHPT patients and control subjects by means of 24-h Holter ECG. METHODS: Thirteen NCPHPT postmenopausal patients were enrolled and age-matched with 13 hypercalcemic PHPT patients and 13 controls. Every subject underwent basal ECG, 24-h Holter ECG and mineral metabolism biochemical evaluation. RESULTS: PHPT patients had higher mean serum calcium levels compared to both NCPHPT and controls; there was no difference in mean serum calcium levels between NCPHPT and controls. Both NCPHPT and PHPT patients had significantly higher mean PTH levels compared with controls. There were no differences in ECG parameters between the three groups, except for QTc interval. PHPT patients had normal QTc interval values, but significantly shorter mean values compared with those of controls and NCPHPT patients. During 24-h Holter ECG recording, 100% of PHPT patients had supraventricular premature beats (SVPBs), compared to 46% of NCPHPT (p = 0.005) and to 53% of controls (p = 0.01). PHPT patients experienced ventricular premature beats (VPBs) (69.2%) vs 15% of NCPHPT patients (p = 0.01) and 23% of controls (p = 0.04). There was no difference between NCPHPT and controls subjects concerning occurrence of both VPBs and SVPBs. CONCLUSIONS: NCPHPT patients did not experience an increased occurrence of arrhythmias compared to controls, while PHPT patients showed an increased occurrence compared to both controls and NCPHPT. Our findings are most probably related to the short QTc interval caused by hypercalcemia observed in PHPT patients, but not in NCPHPT.

Study of the link between hemotopoietic and skeletal systems in patients attending a referral center for osteoporosis.

PURPOSE: To investigate the link between hematopoietic and skeletal tissues in patients with fragility fractures. METHODS: We retrospectively analyzed the medical records of women older than 40 years who attended the Bone Disease Unit of "Sapienza" University of Rome for their first visit for osteoporosis from January 2020 to June 2022. RESULTS: Fragility fractures were found in 61.8% of the sample. In particular, vertebral fractures in 35.5%, femoral fractures in 6.3%, Colles fractures in 16.5% and non-vertebral non-hip in 42.5%. Fractured patients were significantly older compared to non-fractured, had lower mean values of lumbar spine (p = 0.01), and femoral neck BMD (p = 0.007). A red blood cell distribution width (RDW) value higher than 15% was observed four times more in those with fractures compared to non-fractured patients (8.9% vs 2%, p = 0.01) and was associated with vertebral fracture after adjusting for age, BMI, menopause, nutritional status, smoking, osteoporosis and anemia (OR = 4.1, 95% CI 1.6-11.4, p = 0.003). Hematocrit was negatively associated with hip fracture also adjusting for age, BMI, menopause, nutritional status, smoking, osteoporosis (p = 0.025). CONCLUSION: Our study demonstrates that RDW values were significantly associated with vertebral fracture and hematocrit with hip fracture. Since both parameters are included in the initial evaluation of patients with suspected bone fragility, our results should push doctors to look at these values with no incremental cost for national health services.

Lumbar spine bone mineral density and trabecular bone score-adjusted FRAX, but not FRAX without bone mineral density, identify subclinical carotid atherosclerosis.

PURPOSE: Osteoporosis and atherosclerosis share common risk factors. Aim of this study was to test if FRAX (which is an algorithm that can identify subjects at risk of fracture), without or with BMD values, also adjusted for trabecular bone score (TBS) was able to identify subclinical atherosclerosis, evaluated by measurement of carotid intima media thickness (cIMT ≥ 0.9 mm) as compared to DXA values. METHODS: Ninety postmenopausal women underwent DXA measurement and cIMT evaluation. For each patient, the FRAX algorithm for major osteoporotic fracture (M) and for hip fracture (H) without BMD was computed, together with FRAX with BMD and TBS-adjusted FRAX. Serum levels of osteoprotegerin, sRANKL, and interleukin-6 were also measured. RESULTS: There were no differences in anthropometric parameters and cardiovascular risk factors between subjects with cIMT ≥ 0.9 mm (35% of subjects, group A) compared to those with cIMT < 0.9 mm (group B). The prevalence of osteoporosis and FRAX BMD, TBS-adjusted FRAX both for M and H were higher in group A compared to group B. The best ROC curves to identify subjects with a cIMT ≥ 0.9 mm were: lumbar spine T-score, with a threshold of - 2.5 SD (area under the curve, AUC 0.64; p = 0.02) with a sensibility of 50% and a specificity of 76%; TBS-adjusted FRAX H with a sensibility of 50% and a specificity of 72% (AUC 0.64; p = 0.01 with a threshold of 3%). Interleukin-6 positively correlated with FRAX BMD H and M. CONCLUSIONS: FRAX without BMD does not identify subclinical carotid atherosclerosis, while lumbar spine T-score and TBS-adjusted FRAX H similarly detected it with higher specificity for T-score.

Vitamin D screening.

At present, there is no need and no sufficient evidence to support universal screening for vitamin D status. There are four categories of subjects in whom there is no requirement for screening, since a number of studies indicate beneficial effects of vitamin D supplementation; these are represented by children and adolescents, pregnant women, patients taking bone active drugs and subjects with documented hypovitaminosis D. In the remaining subjects, the utilization of adequate questionnaires will target with sufficient sensitivity and specificity those with hypovitaminosis D. These must be first supplemented and, at a later time, serum 25(OH)D assay should be requested to confirm attainment of sufficiency, independently of the threshold chosen. This strategy will cut costs deriving from both widespread use of vitamin D assays and vitamin D supplementation.

Initial experience with the inspire MD C-Guard stent in the treatment of carotid artery disease.

OBJECTIVE: One of the main issue concerning the treatment of carotid artery stenosis is about the use of stents which could offer the best navigability through the lesion and the smallest "maximum unprotected circular area", ensuring the lower risk of neurological complication both intraprocedurally and in the long term. Recently, the Inspire MD technology (Tel Aviv, Israel) presented the new stent Inspire MD C-Guard, a bare-metal stent covered by a micron level mesh (MicroNet).We report our experience about the use of this novel stent in the endovascular treatment of carotid artery stenosis, with some technical considerations. METHODS: Data about patients in whom the Inspire MD C-Guard was used for the treatment of carotid artery diseases were retrospectively collected and analyzed. RESULTS: The procedure was completed in all patients without any intraoperative complications. Postoperative course was uneventful in all cases and no complications have been recorded till now. CONCLUSIONS: In our limited experience, the Inspire MD C-Guard has proven to be a safe stent for the treatment of carotid artery diseases. However large studies are needed to better explain strengths and weaknesses of this device.

Treatment options for visceral artery aneurysms: ten year experience.

AIM: Open surgical repair (OSR) and endovascular techniques (ET) are both described in the literature for treating visceral artery aneurysms (VAAs). Aim of this study is to report a two-center experience of patients treated for a VAA using either OSR or ET, analyzing perioperative outcomes. METHODS: Clinical data of 32 VAAs in 32 patients treated between January 2001 and May 2011 were retrospectively reviewed and outcomes analyzed. RESULTS: Eighteen patients were men (56.3%). Median age was 64 years (range 26-79). Sixteen aneurysms were symptomatic: half of them were ruptured causing hemoperitoneum or gastrointestinal bleeding. ET were employed in 19 cases (59%) using covered stents (7 patients), coil embolization (5), plug placement (1), thrombin injection (2) and multiple associated techniques (4). OSR consisted in aneurysmectomy with end to end anastomoses (5 patients) or interposition graft (1), aneurysm ligation (4), splenectomy (2). One patient died during open surgery for hemoperitoneum due to VAA rupture (3%). OSR and ET had similar perioperative complication rates (5.2% vs. 15.3%, P=0.76). OSR had a longer in-hospital stay than ET (8 vs. 4 days, P=0.04). The presence of pancreatitis and alcohol abuse were more frequent in patients who presented with VAAs rupture. Clinical presentation with hemoperitoneum or aneurysm rupture were associated with higher mortality, regardless of the type of treatment. CONCLUSION: Both OSR and ET offered a safe way to treat VAAs in our experience.

Treatment of significant carotid artery stenosis in 1824 patients.

AIM: We report our experience of thirteen years of treatment of significant carotid artery stenosis. METHODS: Data of all consecutive patients who came to our Division for a significant carotid artery stenosis from January 1999 to January 2012 were collected about patients' demographic, cardiovascular risk factors, neurological symptoms and treatment (carotid endarterectomy, carotid artery stenting or best medical therapy). Retrospective review was performed and the occurrence of death, major cerebrovascular events (major stroke, minor stroke) and myocardial infarction (MI) were recorded both at 30-day and at long-term. Analysis was performed among groups by means of JMP 5.1(®). RESULTS: Of 1824 patients who were admitted to our Department for a significant carotid stenosis, 582 were unsuitable for surgery and underwent carotid artery stenting (CAS, Group A). Three hundred and seventy-three of them were symptomatic (64.1%). Carotid endarterectomy (CEA) was performed in 1030 patients (Group B), 741 (71.9%) of them were symptomatic. The remaining patients (Group C) were treated using best medical therapy (BMT). At 30-day CEA compared to CAS and BMT was associated with higher risk of MI (2.1% vs. 0.2%, and 0.4% respectively, P<0.05), most of all in asymptomatic patients. CEA had a higher risk of cranial nerve injuries than CAS (3.3% vs. 0%, P<0.001). Both risk of death and major neurological complications were similar among the three groups in both symptomatic and asymptomatic patients. At long-term, risk of stroke after CEA was similar to that after CAS, both for symptomatic and asymptomatic patients, while risk of 1-year stroke in Group C was higher than in Group A (P<0.001) and in Group B (P<0.001), for both symptomatic and asymptomatic patients. Risk of long-term MI was similar among the three groups. Mortality at long term in symptomatic patients was higher after CAS than after CEA (P=0.001). Also long-term mortality in Group C was higher than in Group A and B (both P<0.001) but only for asymptomatic patients. A procedure that lasted for more than 60 minutes, patients who had no prior Magnetic Resonance Angiography (MRA) or Computed Tomographic Angiography (CTA) study of the aortic arch were independent risk factors for major neurological complications after CAS. Symptomatic patients were likely to have more major neurological complications in the long term if they were treated with BMT only. CONCLUSION: In our experience, CAS offered a valid alternative for both symptomatic and asymptomatic patients who were poor candidates for CEA, with results that compared favourably to those of CEA both at 30-day and at long-term. Patients who couldn't be operated on neither with CAS nor with CEA had a lower risk of MI at 30-day but a higher risk of stroke during the first year, especially if they had previously experienced neurological symptoms.

Ulnar artery aneurysm: case report and review of the literature.

AIM: We report a case of ulnar and palmar arch artery aneurysm in a 77 years old man without history of any occupational or recreational trauma, vasculitis, infections or congenital anatomic abnormalities. We also performed a computed search of literature in PUBMED using the keywords "ulnar artery aneurysm" and "palmar arch aneurysm". CASE REPORT: A 77 years old male patient was admitted to hospital with a pulsing mass at distal right ulnar artery and deep palmar arch; at ultrasound and CT examination a saccular aneurysm of 35 millimeters at right ulnar artery and a 15 millimeters dilatation at deep palmar arch were detected. He was asymptomatic for distal embolization and pain. In local anesthesia ulnar artery and deep palmar arch dilatations were resected. Reconstruction of vessels was performed through an end-to-end microvascular repair. Histological examination confirmed the absence of vasculitis and collagenopaties. In postoperative period there were no clinical signs of peripheral ischemia, Allen's test and ultrasound examination were normal. At follow-up of six months, the patient was still asymptomatic with a normal Allen test, no signs of distal digital ischemia and patency of treated vessel with normal flow at duplex ultrasound. CONCLUSION: True spontaneous aneurysms of ulnar artery and palmar arch are rare and can be successfully treated with resection and microvascular reconstruction.