An alarming deterioration of neurological status

This clinical case should make us reflect on the potential dangers of lithium, often too readily prescribed by non expert physicians to elderly, and often poorly compliant, patients. There also needs to be very close monitoring of plasma lithium levels, in addition to paying attention to clinical signs, such as a persistent polyuria or hyperosmolarity, because these could be important early warning signs. It is therefore useful to reiterate that, in case of lithium intoxication with altered neurological status despite improvement blood tests, it is necessary to consider pontine or extra-pontine myelinolysis as a rare but possible complicatio

Bosentan treatment for Raynauds phenomenon and skin fibrosis in patients with Systemic Sclerosis and pulmonary arterial hypertension: an open-label, observational, retrospective study.

Raynaud's phenomenon (RP) and cutaneous fibrosis are the distinctive manifestations of scleroderma, in which Endothelin-1 plays a fundamental pathogenetic role. Bosentan, an Endothelin-1 receptor antagonist used for the treatment of pulmonary arterial hypertension, retards the beginning of new sclerodermic digital ulcers (DU). This open-label, observational, retrospective study verified the effect of Bosentan on RP and skin fibrosis in sclerodermic outpatients affected by pulmonary arterial hypertension without DU. Fourteen subjects (13 women, 1 man; mean age 60 ± 7.5 years; ten with limited and four with diffuse scleroderma) were observed at baseline (T0) and after four (T1), twelve (T2), twenty-four (T3) and forty-eight (T4) weeks during treatment with Bosentan. They were evaluated for daily quantity and duration of RP attacks and skin thickness (using modified Rodnan total skin score, MRSS). Videocapillaroscopic evaluation was performed at TO and T4. Bosentan decreased significantly the number and duration of RP attacks, beginning at T2 (p<0.05). Videocapillaroscopy showed significant improvement of microcirculatory patterns at T4 (p<0.05). MRSS decreased throughout the study, reaching the statistical significance at T3 and T4 (p<0.01) in the whole cohort. The present data suggest that Bosentan is effective in stabilmng the microcirculation involvement and in improving skin fibrosis irrespective of scleroderma patterns

MEDICAL TREATMENT OF CRVO

Purpose: A disorder of fibrinolytic power is a risk factor for both venous and arterial thrombosis. An hypofibrinolytic state has been described as a common feature in Central Retinal Vein Occlusion (CRVO) affected subjects. Aim of our study was to evaluate the efficacy of a thrombotic-risk assessement related therapy either in acute phase treatment or secondary prophylaxis in CRVO affected patients. Methods: Phase A: 60 subjects (28 female, 22 male) were respectively treated with ASA 325 mg/die (19), heparin 12500 to 25000 U/die (16) , and mesoglycan 100 mg/die (25) for one month. Phase B: 35 subjects were treated with ASA 325 mg/die for 6 months and 29 patients with mesoglycan 100 mg/die. The development of new thrombotic events was assessed by fundoscopy at one and six months. Results: In phase A 5/19 (26%) subjects in the ASA, 6/16 (37%) in the heparin and 2/25 (8%) (p< 0.001) in the mesoglycan group experienced a new thrombotic event. In phase B 13/35 (37%) in the ASA and 3/29 (10%) (p< 0.001) in the mesoglycan group showed new thrombotic signs. Conclusions: Our data suggest that a profibrinolytic treatment in thrombotic risk-profile selected subjects is safe and effective for the therapy and prophylaxis of CRVO when compared to other antithrombotic agents

TRANSMITRAL AND PULMONARY VENOUS FLOW STUDY IN ELITE MALE RUNNERS AND YOUNG ADULTS

Background: Even if diastolic function has been assessed in athletes by analysis of transmitral Doppler flow, no one has studied pulmonary venous flow in this population. The aim of this study was to establish if the physiological adaptations following a prolonged physical training could influence the diastolic function in a professional Olympic male runner group. Methods: From February to December 1999 we studied 25 athletes (Group 1) during the period of maximal training compared with 18 age- and sex-matched healthy sedentary subjects (Group 11). We used mono- and bidimensional Echocardiography to assess left ventricular structure and systolic function. The diastolic function was evaluated by Doppler method assessing transmitral and venous pulmonary flow. Results: From the comparison between the two groups, we found great differences in the interventricular septum and the posterior wall thickness; the analysis of the systolic function demonstrated a significant increase in ejection fraction, stroke volume, left ventricular mass, and end diastolic volume in the athletes' population. Fluximetric study showed that ventricular diastolic function is not influenced by hypertrophy: indeed, Doppler evaluation of the transmitral flow showed a bigger velocity of the E wave, similarly, when we assessed pulmonary venous flow, we found faster retrograde Ar wave in group 1. Conclusions: Our data indicate that diastolic function remains normal or improves in some cases after physical training; left ventricular hypertrophy and concentric remodeling do not involve diastolic changes like hypertrophic and hypertensive heart diseases. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved

Thymoma and immunodeficiency

hypogammaglobulinaemia in a small percentage of patients with thymoma.1 GS is a rare, adult-onset, immunodeficiency disease characterised by hypogammaglobulinaemia, low or absent B cells in the peripheral blood and, variably, defects in cell-mediated immunity.2 GS was often considered a subset of common variable immunodeficiency (CVID) with thymoma, whereas nowadays it is regarded as a distinct clinical entity whose pathogenesis is still uncertain.3 A bone marrow defect impairing B cell maturation due to an aggression towards B cell precursors has been suggested,4 and deficiencies in other cell lineages with eosinopenia, pure red cell aplasia or neutropenia are often reported.5 Here we report the case of a male patient who developed recurrent respiratory tract infections for two years before being diagnosed with GS. Case report A 61-year-old male presented in March 1996 with a two-year history of recurrent respiratory infections including otitis, bronchitis, sinusitis and two episodes of pneumonia. Chest X-ray and chest CT scan showed a mediastinal mass, biopsy o

Dyslipidemias and fibrinolysis.

BACKGROUND: The relation between fibrinolysis and cardiovascular disease is an open debate. Fibrinolysis is related to endothelial function and presents many molecular links with platelet and coagulation activity. Furthermore, reduced fibrinolysis has been reported in several dysmetabolic conditions. METHODS: To detect mechanisms linking dyslipidemias and fibrinolysis we evaluated 75 subjects (42 males, 33 females, 20 hypercholesterolemic, 20 hypertriglyceridemic or 20 with mixed hyperlipoproteinemia, 15 with isolated low HDL-cholesterol). Plasminogen activator inhibitor (PAI)-1, tissue-type plasminogen activator activity and plasmin-antiplasmin complexes (PAP) were determined at baseline and after the venous occlusion test. We also measured D-dimer, lipid pattern, soluble E-selectin, platelet surface P-selectin, prothrombin fragments 1 + 2 (F1 + 2), lipoprotein(a), factor VII, von Willebrand factor, plasma insulin, fibrinogen, homocysteine, thrombin activable fibrinolysis inhibitor (TAFI) activity, thrombomodulin, factor XIII, urokinase-type plasminogen activator. RESULTS: Hypertriglyceridemic patients were found to have lower PAP and D-dimer and higher PAI-1 serum levels (baseline and venous occlusion test, p < 0.001 and p < 0.01) compared to hypercholesterolemic and control subjects (p < 0.01, p < 0.001). P-selectin, F1 + 2 and TAFI were significantly increased only in hypercholesterolemic subjects (p < 0.001) and associated with reduced PAP and D-dimer, showing a linear relation with LDL-cholesterol levels (p < 0.01, r = -0.62 and p < 0.01, r = -0.59). PAI-1 activity was not different with respect to controls (baseline p = 0.59, venous occlusion test p = 0.42). Serum levels of von Willebrand factor were significantly increased in hypertriglyceridemic/low HDL subjects compared to hypercholesterolemics (p < 0.01). CONCLUSIONS: Impaired fibrinolysis in subjects with hypertriglyceridemia/low HDL-cholesterol is associated with increased serum levels of PAI-1 whereas enhanced thrombin generation and TAFI hyperactivity are the main findings in hypercholesterolemia. Such data may suggest the opportunity of evaluating several fibrinolytic factors when studied as prognostic factors in diverse dyslipidemias

Different mechanisms of fibrinolysis impairment among dyslipidemic subjects

To determine whether there is a correlation between fibrinolytic activity and dyslipidemia, we performed a study of 72 subjects (20 patients with hypercholesterolemia, 20 with hypertriglycerldemia, 12 with isolated low high-density lipoprotein (HDL)-cholesterol (mean age 47.7 +/- 6.3, body mass index 24.7 +/- 0.4) and 20 healthy controls. Plasminogen activator inhibitor-1 (PAI-1), tissue-plasminogen activator activity and plasmin-antiplasmin complexes (PAP) were detected at baseline and after venous occlusion test. We also measured at baseline lipidic pattern, soluble E and P selectins (sE-sel, sP-sel), prothrombin factor 1+2 (F1 + 2), lipoprotein(a), factor VII, plasma insulin, fibrinogen, homocysteine, and thrombin activable fibrinolysis inhibitor (TAFI) activity Fibrinolysis was significantly reduced In hypertriglyceriderritc patients compared with hypercholesterolemic patients and control subjects (PAP p 0 160 mg/dl) (p <0.007, r = -0.76). Moreover there was no significant difference in PAI-1 activity (at baseline and after venous occlusion test) compared with controls. In conclusion, endothelial dysfunction was the main mechanism of decreased fibrinolysis in subjects with hypertriglyceridemia and low HDL-cholesterol, while enhanced thrombin generation and TAF1 activity were the main determinants In hypercholesteridemia