Hypertensive disorders during pregnancy and 3 years after delivery in women with gestational hyperglycemia.

AIMS: Women with gestational hyperglycemia commonly experience hypertensive disorders during pregnancy. More information is needed about how hypertension develops in these patients over time. We investigated the prevalence of hypertension during and 3 years after pregnancy in Caucasian women with gestational hyperglycemia. We also investigated metabolic syndrome presence, glucose tolerance status, insulin sensitivity and insulin secretion levels in the follow-up period. METHODS: In a prospective longitudinal study with a 3-year follow-up, we assessed hypertension status and clinical-related characteristics of 103 consecutive women with gestational hyperglycemia sub-grouped according to their hypertensive status during and after pregnancy. RESULTS: Overall, 29 (28.1%) women had hypertension during pregnancy (24 gestational hypertension; 4 chronic hypertension; 1 preeclampsia). At follow-up 16 (15.5%) women were diagnosed as having hypertension (11 with hypertension in pregnancy; 5 with a normotensive pregnancy). Women with hypertension after pregnancy had higher BMI, metabolic syndrome rate and worse insulin resistance indexes than normotensive women. Weight increase at follow-up (OR 1.17, 95% CI 1.00-1.35) and hypertension in pregnancy (OR 6.72, 95% CI 1.17-38.64) were associated with hypertension after pregnancy. CONCLUSIONS: Women with gestational hyperglycemia should undergo regular monitoring during and after pregnancy to detect metabolic and clinical impairments and to prevent cardiovascular harm.

Hypercalcaemia in systemic lupus erythematosus.

Hypercalcaemia is found in more than 90% of the cases of primitive hyperparathyroidism and malignancies. Rarely, D hypervitaminosis, sarcoidosis, other granulomatous diseases, some drugs, and endocrine diseases may be responsible. Nine patients with systemic lupus erythematosus (SLE) and hypercalcaemia, without evidence of primary hyperparathyroidism, have been previously described. Here we report the 10th patient with SLE and hypercalcaemia, along with a brief review of the literature.

Eating disorders and diabetic ketoacidosis in a pregnant woman with type 1 diabetes: a case report.

OBJECTIVE: To describe a case of diabetic ketoacidosis (DKA) in a pregnant woman with type 1 diabetes (T1DM) and disordered eating behaviour treated with a continuous subcutaneous insulin infusion, and to discuss some aspects of the monitoring and management of DKA in pregnancy and whether a pump is the safest therapeutic choice in the presence of some eating disorders. CASE REPORT: This 26-year-old Caucasian woman affected by T1DM was hospitalised during the last weeks of her fourth pregnancy because of DKA due to disordered eating. She was treated with a fluid infusion, intravenous insulin, and her electrolyte imbalance was carefully corrected. An elective cesarean section was performed after the correction of DKA in the 34th week (+6 days) of gestation. CONCLUSIONS: We suggest that pregnancy in T1DM women with eating disorders may not be rare. The prevention, early recognition and aggressive management of DKA can minimise the possible complications, and is mandatory for the safety of the fetus and mother.

Antitissue transglutaminase antibodies in acute coronary syndrome: an alert signal of myocardial tissue lesion?

BACKGROUND AND AIM: Antitransglutaminase, previously considered identical to antiendomysial in coeliac sprue (CS), have been reported in end-stage heart failure. To clarify the above-mentioned data, we evaluated these antibodies in a cohort of cardiological patients with respect to troponin I, creatine kinase (CK), MB fraction creatine kinase (CK-MB mass) and myoglobin. METHODS: Forty-one patients with acute coronary syndrome (ACS), 39 with dilated cardiomyopathy (DCM), 45 with CS and 58 blood donors (BDs) were evaluated. Antitransglutaminase and antiendomysial antibodies were tested in serum of the patients being studied. RESULTS: High-positive antitransglutaminase values were found in CS, whilst low-positive values were also found in ACS and DCM. In patients at the second ACS, antibody levels were higher than in those at the first cardiac event. In patients with infarct Q, antitransglutaminase were higher than those in infarct non-Q, in which antibody levels were higher than those in unstable angina. A correlation between antitransglutaminase and troponin I, CK, CK-MB mass and myoglobin was found. Finally, antibody levels rose to reach a peak at 30 days from the cardiac event, whereas after further 150 days, approached the values of BDs. Antiendomysial were detectable only in CS. CONCLUSIONS: Data highlight that antitransglutaminase can occur in cardiological patients, and that these antibodies are related to the severity/extent of the myocardial tissue lesion. This feature suggests a loss of specificity for antitransglutaminase in CS. Furthermore, the possibility of employing these antibodies in the long-term follow-up of ACS, could become an object of interesting discussion.

[Ulcerative colitis and thrombocytopenia: a clinical case of fortuitous association?]. / Rettocolite ulcerosa e piastrinopenia: un caso clinico di associazione fortuita?

Ulcerative colitis (UC) is an inflammatory bowel disease of unknown etiology, involving primarily the rectum with major intestinal symptoms. Additionally, UC is often associated with extraintestinal manifestations, especially arthropathies, as well as with some autoimmune disorders. Vice versa, UC is rarely described in association with hematologic abnormalities, such as autoimmune hemolytic anemia and immune thrombocytopenic purpura with antiplatelet antibodies positive. Usually UC precedes the onset of thrombocytopenia by days or years or coincides with it. We report a case of UC and thrombocytopenia with negative anti-platelet antibodies in which an immunosuppressive therapy with corticosteroids obtained significant remission of intestinal symptoms along with a rapid increase of platelet count.

Prognostic significance of atrial fibrillation in thrombolysed and non thrombolysed patients.

AIM: Atrial fibrillation (AF) is considered a frequent complication of acute myocardial infarction (AMI). The aim of this study was to examine the incidence and prognostic significance of AF complicating AMI. METHODS: A total of 848 patients with AMI were examined evaluating: age, sex, coronary risk factors, incidence of AF, prior ischemic events, infarct location, electrocardiogram on admission, thrombolytic therapy, in-hospital complications and mortality. RESULTS: AF was recorded in 84 patients (9.9%). They were older (P<0.0001), less frequently smokers (P<0.007), had higher creatinekinase level (P<0.005) and more advanced heart failure (Killip class >or=2). AF was documented in non-thrombolysed more than in thrombolysed patients (11.2% vs 7.5%). Overall mortality resulted significantly higher in patients with AF (P=0.001); nevertheless it did not result as independent predictor of mortality. Instead, independent predictors of mortality have been Killip class >or= II (P<0.0001), age (P<0.0001) and prior infarction (P<0.002 ). CONCLUSIONS: In our experience, AF cannot be considered an independent predictor of mortality. Contrary, advanced heart failure, either in thrombolysed or not-thrombolysed patients, is an independent predictor of AF and mortality. Nevertheless, AF represents an expression of advanced heart failure, that is worsened by the development of arrhythmia with severe consequences on prognosis.

[Atrial fibrillation and thromboembolic events prevention. State of the art]. / Fibrillazione atriale e profilassi tromboembolica. Stato dell'arte..

Atrial Fibrillation (AF) is a common cardiac arrhythmia and stroke is its most devasting complication. The rate of ischemic stroke among people with AF is approximately six times that of people without AF and varies importantely with coexistent cardiovascular diseases; therefore stratification of AF patients into those at high and low risk of thromboembolism has become a crucial determinant of optimal antithrombotic prophylaxis. Multivaria-te analyses of prospective studies consistently show prior TIA/stroke, diabetes, age, heart failure to be independently predictive of stroke; left ventricular dysfunction is also strongly associated with stroke risk. Several randomized clinical trials demonstrated that treatment with adjusted-dose warfarin reduces the risk of stroke in AF patients by about two thirds. The efficacy of aspirin for prevention of stroke is controversial, but supported by pooled results of 3 placebo-controlled trials yelding a 21% reduction in stroke. The inherent risk of stroke should be considered in selection of AF patients for lifelong anticoagulation. Patients with AF and a recent stroke or TIA or multiple risk factors for stroke are likely to benefit from anticoagulation therapy; at present a target INR 2,5 appears optimal for most patients, although INR closer to 2.0 may be safer for patients at increased risk for bleeding events. The addition of aspirin to low- dose warfarin regimen does not provide any significant benefits and should be avoided. Therapy with aspirin is appropriate for patients who are at low risk of stroke or are unable to receive anticoagulants. AF patients treated with aspirin, should be periodically evaluated for development of high-risk features favoring anticoagulation.

[Cigarette smoking and acute myocardial infarct]. / Fumo di sigaretta e infarto acuto del miocardio.

UNLABELLED: Cigarette smoking is commonly considered as a major risk factor for Acute Myocardial Infarction (AMI). Although AMI has a high incidence in smokers, it doesn't seem to correlate with a worse in hospital prognosis. In order to investigate if cigarette smoking does affect the in-hospital prognosis in patients with AMI, 590 consecutive patients (451 males and 139 females; mean age 63.4 years) admitted to the Coronary Care Unit (CCU) with definite AMI have been studied. Patients were divided in two groups: Group A (303 patients, 269 males and 34 females) smokers till AMI and Group B (287 patients, 182 males and 105 females) nonsmokers or smokers till a month before AMI. RESULTS: The mean age of nonsmokers was higher than smokers (68.4 years vs 58.8 years; p < 0.001). In addition they showed more frequently hypertension (48.8% vs 38%; p < 0.001), diabetes (31.3% vs 16.3%; p < 0.001), and healed infarction or angina (45.6% vs 37.5%). Among Group B higher global mortality rate was observed (22.6% vs 7.6%; p < 0.001) either among thrombolysed patients (10.1% vs 4.4%; p < 0.001) either among not thrombolysed (26.9% vs 4.4%; p < 0.001). The grading in age classes confirmed a higher mortality in nonsmokers patients (6.7% vs 4.9% age > or = 40 and < or = 65 years; 32.5% vs 13.3% > 65 years). They also presented more frequently arrhythmias (15.3% vs 12.2%), ischemic complications (25.4% vs 18.7%), and congestive heart failure (46% vs 34.2%). CONCLUSIONS: According to other authors the results of this study confirm a better prognosis in smokers with AMI. Up to authors hypothesis this outcome could be related either to the younger age, a to a different pathogenetic mechanism of coronaric occlusion to raised thrombosis.

[The measurement of CoQ10 in the acute phase of a myocardial infarct]. / Dosaggio del Co Q10 nella fase acuta dell'infarto miocardico.

The authors have studied the behaviour of ubidecorenone (Co Q10) in the acute phase of myocardial infarction in 24 patients, 19 male and 5 female, mean age 56.8 +/- 3.3. Ubidecorenone level was determined on admittance, after 48 hours and on the 7th and 30th days. A significant decrease was observed from the first to the 3rd day (mean values 0.90 +/- 0.18 microgram/ml vs 0.72 +/- 0.22, p less than 0.01). Thereafter a progressive rise was observed, but at the 30th day mean values were still below the basal ones. No significant differences were observed between patients treated with fibrinolytic agents and those not so treated, nor between those in whom reperfusion was obtained and the others. Nor was there a proven correlation with changes in creatinkinase. The behaviour of ubidecorenone may be associated with increased consumption for metabolic needs and increased destruction in scavenger action, and also to a lesser extent to decreased production due to lower food intake.

[The peak of creatine phosphokinase level in the acute phase of myocardial infarction in patients with and without ischemic precedents]. / Il picco della creatinfosfochinasi nella fase acuta dell'infarto miocardico nei pazienti con e senza precedenti ischemici.

Two hundred and one patients admitted to Coronary Care Unit with documented acute myocardial infarction, whose chest pain had occurred within 12 hours of hospital admission non thrombolised, were studied. The peak of creatine kinase (CK) was examined and compared between patients without previous manifestations of myocardial ischemia (group A, 106 patients) and patients with/history angina pector or healed myocardial infarction (group B, 95 patients). The mean peak creatine kinase level in the negative history group was higher (2261 +/- 226 U/L vs 1779 +/- 97 U/L p < 0.001), especially in patients aged less than 65. No significant difference was observed in patients aged more than 64 of the two groups. Patients with a positive history presented more frequently ischemic complications (p < 0.05) while the frequency of hemodynamic disturbances and arrhythmias was not significantly different. Total mortality was similar in the two groups (22.6% vs 21%) and more frequently occurred in older patients with congestive heart failure. The authors form the hypothesis that the higher mean peak creatine level in patients without previous myocardial ischemia is the result of absence of coronary collateral circulation. The presence of collateral vessels permits less extensive myocardial infarction but it does not change the prognosis.

[The "natural" history of ischemic cardiopathy, Incidence of coronary events in the follow-up of 114 ambulatory patients]. / La storia "naturale" della cardiopatia ischemica. Incidenza di eventi coronarici nel follow-up di 114 pazienti ambulatoriali.

In the last decade advances in cardiovascular research improved remarkably our understanding of coronary heart disease. However many important problems are so far unresolved. In the present study we focused on the "natural" history of ischemic heart disease in a group of 114 patients. One hundred-seven patients had recent myocardial infarction, and seven suffered from angina. They were observed for a mean period of five years (one to 168 months). Forty-nine patients (42.9%) had no coronary events; sixty-five had angina, myocardial infarction or both. The myocardial infarction was however rare (five cases). The most frequent presentation of angina was stable and effort angina, which sometimes subsided after a period of presence. The classification of angina was often very difficult in cases of effort angina with very low threshold. No relevant differences were found between patients with and without coronary events according to age, sex, duration of follow-up, location of previous myocardial infarction. A significant difference was found in the prevalence of risk factors only for hypertension, which was more frequent in patients with coronary events. Smokers were more frequent in group without coronary events. In our opinion, the most interesting conclusion is that, almost half of these patients remained completely asymptomatic for a very long period.

[Incidence and prognostic significance of anterior precordial ST segment depression in acute inferior myocardial infarct]. / Incidenza e significato prognostico del sottoslivellamento precordiale del tratto ST nell'infarto inferiore acuto.

In order to evaluate the incidence and prognostic significance of anterior precordial ST segment depression (decreases ST) in acute inferior myocardial infarction (MI), 158 patients with inferior MI were selected. In 90 patients (56.9%) an anterior decreases ST was associated with inferior lesion wave (group A), and in 68 patients (43.1%) only an ecg pattern of inferior myocardial infarction (group B) was present. No significant statistical differences were observed in mortality (group A 10% vs group B 10.2%), in compliances (group A 54.4% vs group B 47.0%) and in higher peak serum ck-levels (group A 83.3% vs group B 69.1%) in two groups during hospitalization period. In conclusion the anterior decreases ST during inferior MI should not be considered a negative prognostic sign. These favourable results are probably related to stringent criteria for ecg diagnosis of inferior myocardial infarction used and to exclusion of all patients with non contemporary evolution of anterior decreases ST and inferior lesion wave.

[Circadian variations in the onset of acute myocardial infarction]. / Variazione circadiana dell'insorgenza dell'infarto miocardico acuto.

BACKGROUND: Several studies have observed a circadian pattern in the onset of acute myocardial infarction (AMI), with a peak incidence in the morning hours. It has been suggested that different circadian rhythms may exist in various subgroups of patients. METHODS: This study sought to determine whether the circadian incidence of AMI varied by sex, age, cardiovascular risk factors, previous history of ischemic accidents, the site of AMI, and the short-term outcome. These possibilities were examined in a population of 597 consecutive patients with AMI, admitted to the coronary care unit. 548 patients have been included in the study, 442 men (80.6%) and 106 women (19.4 %); mean age 64.5 years. RESULTS: A peak incidence of AMI was found between 06.01 a.m. and 12.00 a.m. (32.4%; p<0.0002). This peak was present in patients 65 years old (33.2%; p<0.005), in men (32.5%; p<0.0002) but not in women, in smokers (32.1%; p<0.0005) and in those that did not smoke (33.0%; p<0.04), in patients with hypercholesterolemia (34.9%; p<0.006 ) and without hypercholesterolemia (31.1%; p<0.03). A circadian rhythm was absent in diabetics, hypertensives and in patients with a history of previous cardiovascular events. Regarding the site of AMI, inferior AMI showed an increased incidence between 06.01 a.m. and 12.00 a.m. (36.2%; p<0.002), while the circadian distribution of anterior AMI, as well as non-Q wave AMI, did not show this incidence. Finally, higher mortality was reported in patients with an AMI onset at night (22.3%). CONCLUSIONS: These results give further clues in understanding the external and inner factors acting in the morning hours as triggers for AMI.

[The cardiological evaluation in patients undergoing to Day Surgery: when is indicated]. / La consulenza cardiologica nei pazienti da sottoporre ad intervento chirurgico in regime di Day Surgery: quando è indicate.

AIM: Guidelines established preoperative cardiac management of the patient undergoing non-cardiac surgery in hospitalization. Regarding the patients undergoing the surgery in DS, the management is not defined. Aim of this study was to evaluate the appropriateness of the cardiological consultation requested by the patients undergoing surgery with this method. MATERIALS AND METHODS: We examined the request of cardiological evaluation for patient admitted to DS of Sant'Andrea Hospital in Rome. We have considered: age, sex, clinic history, simpthomatology, electrocardiogram, cardiovascular objectivity, hemodynamic stability, comorbidity, therapy, type of the surgery, the motivation of the request. RESULTS: Of 2350 patients, 495 patients (21%) have been undergone the preoperative cardiologic consultation. The request was resulted as unnecessary for 432 (87.2%) patients, appropriate for 63 (12.7%): 4 that had the ischemic heart disease without knowing this, 6 with severe hypertension; 2 with mitral valve prolapse and valvular regurgitation; 34 with congestive heart failure; 6 with the alterations in EKG : 3 with "Brugada pattern"; 1 with Pace Maker (PMK) that had to be reprogrammed before the operation; 3 under dual antiplatelet therapy; 7 that were taking the oral anticoagulant therapy. Cardiac complications occurred just in one case with patient suffering dilated cardiomyopathy, diabetes and hypertension; during the cataract surgery was presented the abrupt increase of blood pressure and left ventricular failure. CONCLUSIONS: Preoperative cardiologic evaluation results as useless in most patients. However, in some particular situations had allowed the diagnosis of heart disease for the patients who did not know to have it.

Renal limited Wegener's granulomatosis.

Differential diagnosis in patients presenting with fever of unknown origin (FUO) is often difficult because infectious diseases, neoplasms, infective endocarditis or systemic autoimmune diseases may all be responsible for the condition. Furthermore, vasculitis may generate typical, atypical or limited syndromes depending on the extent of vascular involvement. Here, we report the case of a 73-year-old man with FUO and renal failure due to a rare variant of Wegener's granulomatosis, limited to the kidneys.