Angela Luciana Barilli

Preterm infants with video-EEG confirmed seizures:outcome at 30 months of age

OBJECTIVE Our aim was to identify early predictors of poor neurodevelopmental outcome and of subsequent epilepsy in very early preterm and late preterm newborns with neonatal seizures. STUDY DESIGN Fifty-one preterm infants with gestational age (GA) <or=36 weeks were identified among those admitted to the NICU of University Hospital of Parma between January 1999 and December 2003 and prospectively followed-up. They were subdivided in two Groups: early preterm newborns with a GA <or=29 weeks and those with GA between 30 and 36 weeks. Selection criteria included multiple digital-video-EEG confirmed neonatal seizures and a follow-up of at least 30 months. Independent variables considered for analysis included neonatal risk factors, etiology and type of seizures, EEG activity, and cerebral ultrasound scan examinations. RESULTS Ten infants had a favorable outcome, 17 died, and 23 had an adverse outcome. One infant was lost on follow-up. Apgar score at 1 min (O.R.=15.457, 95% CI: 2.236-106.850, p=0.006) and severely abnormal background EEG activity (O.R.=8.298, 95% CI: 1.316-52.301, p=0.024) were independent predictors of abnormal outcome. Nine infants presented post-neonatal epilepsy. Severely abnormal Cerebral Ultrasound scans were predictive of epilepsy (O.R.=13.72, 95% CI: 1.959-96.149, p=0.008). CONCLUSIONS Neonatal seizures in preterm infants are associated to a high rate of mortality and severe morbidity in survivors but no definitive differences between the two groups of preterm infants were found. Risk-factors for development of subsequent epilepsy are strongly related to the underlying brain damage.

Prevalence and significance of hypoalbuminemia in an internal medicine department

BACKGROUND Serum albumin is commonly measured in hospitalized patients. It has habitually been included among the parameters used for nutritional assessment, and recently its use has become even more widespread. Yet, no data are available in the literature about the prevalence and clinical significance of hypoalbuminemia in patients hospitalized in an internal medicine ward. The aim of this study was to investigate the prevalence and clinical significance of hypoalbuminemia in in-hospital internal medicine patients. METHODS We retrospectively evaluated the albumin level of patients admitted to the Department of Internal Medicine and Biomedical Sciences of the University of Parma during the year 2000. We then evaluated sex, age, nutritional status, some laboratory parameters, associated diseases, and length of hospitalization in hypoalbuminemic patients in comparison with a group of patients without hypoalbuminemia. RESULTS Hypoalbuminemics (46.5% of patients) were older, more frequently anemic, and had a higher erythrocyte sedimentation rate (ESR) and longer hospitalization; they were mostly normal weight or overweight. These patients also had chronic liver (18.6% vs. 4.5%), onco-hematological (33.8% vs. 12%), and infectious diseases (13.4% vs. 2.3%) and nephropathies (6.3% vs. 2%) more often than patients without hypoalbuminemia. The presence of onco-hematological diseases was related to anemia (O.R.=5.73; 95% CI: 3.184-10.310), lymphopenia (O.R.=2.76; 95% CI: 1.584-4.801), and hypoalbuminemia (O.R.=2.5; 95% CI: 1.178-5.307). CONCLUSIONS Hypoalbuminemia is very frequent in an internal medicine ward. In this setting, serum albumin is related to the length of hospitalization and to other parameters with a well-known prognostic value (age, hemoglobin) and clinical usefulness (ESR). It may also play a role in the evaluation of the possible association of onco-hematological diseases.

Endothelial dysfunction and cardiovascular risk profile in long-term withdrawing alcoholics.

Background Rates of cardiovascular morbidity and mortality are greater in heavy alcoholics than in either teetotallers or light-to-moderate drinkers. Objective On the assumption that factors leading to atherosclerotic damage remain operative even after long-term alcohol withdrawal, we studied the possible mechanisms of raised cardiovascular risk in former heavy alcoholics. Methods Forty-two apparently disease-free, normotensive alcoholics detoxified for 37.1 ± 31.9 (SD) months, median 24, participated in the study. They were compared with 39 lifetime alcohol-abstaining control subjects, carefully matched for age, sex, body mass index, smoking and dietary habits, physical activity, lipids and fasting glucose. Endothelial function (flow-mediated dilation of brachial artery, high-resolution ultrasound technique), blood pressure, and some parameters of endothelial activation, oxidative stress, vascular inflammation and insulin sensitivity were measured. Results The maximal percentage of flow-mediated dilatation was reduced in detoxified alcoholics (10.1 ± 4.6 versus 14.9 ± 7.4, P < 0.001) who also showed significantly higher blood pressure (systolic 127.5 ± 12.9 versus 118.2 ± 10.7 mmHg, P < 0.001; diastolic 79.4 ± 7.1 versus 74.6 ± 6.4 mmHg, P < 0.01; mean 95.4 ± 8.2 versus 89.1 ± 7.3 mmHg, P < 0.001), uric acid (5.0 ± 1.1 versus 4.4 ± 0.8 mg/dl, P < 0.05), high-sensitivity C-reactive protein (2.1 ± 2.0 versus 1.0 ± 0.9 mg/l, P < 0.01), endothelin-1 (0.38 ± 0.11 versus 0.17 ± 0.10 pg/ml, P < 0.001) and fasting insulin (10.4 ± 4.5 versus 5.6 ± 1.6 μU/ml, P < 0.001) with abnormal homeostasis model assessment index of insulin resistance (2.3 ± 1.1 versus 1.2 ± 0.4, P < 0.001). Conclusion Previous heavy alcoholism, in spite of long-term withdrawal, is associated with endothelial dysfunction and a wide cluster of haemodynamic, vascular and metabolic abnormalities that indicate an unfavourable cardiovascular and metabolic risk profile even in apparently disease-free former alcoholics.

Sodium Sensitivity of Blood Pressure in Long-Term Detoxified Alcoholics

To investigate whether sodium sensitivity of blood pressure participates in the relationship of arterial hypertension to chronic alcohol consumption, 30 alcoholics detoxified from 6 to 12 months and 30 teetotaler controls underwent a dietary sodium manipulation study. They received a daily 55 mmol sodium diet for 7 days, followed by a 260 mmol sodium diet for 7 days. Changes in 24-hour urinary sodium excretion between the end of each period were similar in alcoholics and controls (202+/-16 SEM mmol and 227+/-11, respectively). Plasma renin activity in alcoholics was lower than in controls at both low (2.4+/-0.4 ng angiotensin I/mLxh(-1) versus 3. 7+/-0.2, P<0.003) and high sodium intake (0.47+/-0.10 versus 0. 82+/-0.10, P<0.05), with smaller variations in alcoholics (-1.9+/-0. 3 versus -2.9+/-0.2, P<0.009). In alcoholics, alteration in sodium intake was followed by greater changes in both systolic and mean blood pressure (ambulatory blood pressure monitoring), which rose by 10.6+/-2.2 mm Hg and 7.3+/-1.5 versus 4.7+/-1.4 and 3.9+/-1.0 in controls, respectively (P<0.03 for systolic and P<0.05 for mean blood pressure). The ratio of changes in mean blood pressure to those in 24-hour urinary sodium excretion was higher in alcoholics (0.044+/- 0.011 mm Hgxmmol(-1) versus 0.018+/-0.0041, P<0.005). Our data show that in detoxified alcoholics, there is an abnormal response of both blood pressure and plasma renin activity to variations in salt intake similar to that in sodium-sensitive arterial hypertension. The precise relationship between the sodium sensitivity of blood pressure in detoxified alcoholics and the long-term influence of alcohol on blood pressure remains to be elucidated.

Is Steroid Therapy Needed in the Treatment of Destructive Thyrotoxicosis Induced by α-Interferon in Chronic Hepatitis C?

Objective: Treatment with interferon (IFN) of patients affected by chronic hepatitis C (CH-C) may produce alterations in thyroid function, such as hypothyroidism, Graves’-like hyperthyroidism and destructive thyrotoxicosis (DT). IFN-induced DT is characterized by suppressed serum TSH levels, normal or elevated FT4 and FT3 concentrations, with the presence or absence of thyroid peroxidase antibodies and antithyroglobulin antibodies, the absence of thyroid receptor antibodies and radioactive iodine uptake suppressed or <5%. Design: IFN-induced DT is a mild clinical disease, because thyroid-destructive processes last for a short time and involve a small portion of the gland. At present, the therapeutic approach in DT suggests IFN withdrawal and 1–2 months of methylprednisolone treatment. Methods: In consideration of possible untoward side effects of steroid treatment in patients with CH-C, we studied two groups of patients with CH-C who developed DT after treatments with various preparations of recombinant IFN (with or without ribavirin). Patients sequentially entered the study during a 4-year period, at the time of DT diagnosis, when IFN therapy was discontinued. The first 12 subjects (group A) were treated with 8–16 mg/day methylprednisolone for 30–40 days after IFN withdrawal; in the following 15 patients (group B), IFN withdrawal was not followed by any additional treatment. All patients underwent clinical and laboratory controls of thyroid function at 1, 2, 3 and 6 months after DT diagnosis. Results: The results showed restoration of euthyroidism in both group A and group B patients at 6 months after DT diagnosis, regardless of steroid treatment. Conclusions: The simple withdrawal of IFN therapy in patients with CH-C, who had developed DT, appears to be effective in the treatment of the thyroid disease. This therapeutic approach should be preferred in order to avoid possible undesired side effects of steroid therapy in patients with CH-C.

Non invasive evaluation of left ventricular performance in 294 diabetic patients without clinical heart disease

SummaryThe authors studied the modification of systolic time intervals (STI), pre-ejection period (PEP) and left ventricular ejection time (LVETc), before and after isometric exercise, in 294 diabetic patients without clinical evidence of cardiomyopathy and in good metabolic control compared to 132 normal subjects. The study was aimed at detecting preclinical alterations of left ventricular function. Diabetic patients considered together did not show any difference in STI in basal conditions or after isometric exercise compared to normal subjects. When diabetic patients were divided into sub-groups according to their treatment, the insulin-treated diabetics showed modification of STI after isometric exercise, which indicated an alteration of left ventricular function. Also subjects treated with oral hypoglycemic agents showed similar but less evident changes. In diabetic patients on diet only and in those with duration of diabetes of 6 months or less, STI was identical to that of normal subjects. These data do not explain the pathogenesis of myocardial involvement, although they are in accordance with studies which have laid emphasis on the alteration of compliance of the diabetic heart.

Simultaneous Dual Fast and Slow Pathway Conduction upon Induction of Typical Atrioventricular Nodal Reentrant Tachycardia: Electrophysiologic Characteristics in a Series of Patients

Introduction: Simultaneous dual atrioventricular nodal conduction (SDNC) through slow (SP) and fast pathway (FP) is a rare phenomenon observed upon the induction of atrioventricular nodal reciprocating tachycardia (AVNRT). The aim of this study is to report the electrophysiological features of patients showing typical AVNRT induced through SDNC.

Impaired renal haemodynamic response to L-arginine in essential hypertension : role of buffering anion and tubuloglomerular feedback

Objective To investigate whether changes in tubuloglomerular feedback (TGF) dependent upon the tubular effects of buffering anions affect the renal haemodynamic response to L-arginine in healthy (control) individuals and patients with essential hypertension. Methods Mean arterial pressure (MAP), glomerular filtration rate (GFR), renal blood flow (RBF) and fractional excretion of sodium (FENa), chloride (FECl) and lithium (FELi) were measured in 10 control individuals and 10 hypertensive patients during two 3-h infusions of 0.012 mmol/kg per min L-arginine buffered with either HCl or citric acid. Results FELi, FECl and FENa increased (P < 0.001) comparably in controls and hypertensive individuals with arginine–HCl and decreased with arginine–citrate (P < 0.001). MAP was unchanged in controls with arginine–HCl and decreased by 3% with arginine–citrate (P < 0.001), and decreased in hypertensive individuals with both arginine–HCl and arginine–citrate (by 3 and 7%, respectively; P < 0.001). GFR increased with arginine–citrate in controls and hypertensive individuals (by 6.1 and 5.4%, respectively; P < 0.001), but did not change with arginine–HCl in controls and declined by 4.6% in hypertensive individuals (P < 0.05). RBF increased equally after arginine–citrate in controls and hypertensive individuals (by 34 and 33%, respectively; P < 0.001); it also increased after arginine–HCl (22 and 13%, respectively; P < 0.001), but less than after arginine–citrate (P < 0.001), and 41% less in hypertensive individuals than in controls (P < 0.001). Discussion Because arginine–HCl, unlike arginine–citrate, inhibits tubular reabsorption and elicits much less renal vasodilatation than does arginine–citrate, renal haemodynamics in response to L-arginine are modulated by changes in reabsorption and TGF according to the tubular effects of the attendant anion. As renal vasodilatation in hypertensive individuals was reduced only with arginine–HCl, which activates TGF, the blunted vasodilatation of the hypertensive kidney in response to arginine–HCl reflects an exaggerated response to an activated TGF.

Multivariate Analysis of the Variables Affecting Left Ventricular Filling in Normal Subjects

Pulsed Doppler measurements of left ventricular filling (LVF), two-dimensional and M-mode echocardiograms were performed in 189 healthy subjects, in order to evaluate factors influencing LVF Doppler indexes in normal subjects. LVF Doppler indexes (peak E, peak A, peak E/peak A, deceleration rate of peak E (ED) were related by univariate and multivariate analyses with the following parameters: age, sex, heart rate, systolic and diastolic blood pressure, aortic root and left atrial dimensions, left ventricular mass index, left ventricular shortening fraction. The stepwise analysis showed that age by itself explained up to 18% of peak E variance, 50% of peak A variance, 61% of peak E/peak A variance and 25% of ED variance. The other variables entered into the regression, slightly improved the predictive power (less than 10%). In conclusion, age is the major independent factor affecting LVF in normal subjects, although other variables show significant correlation also after age adjustment.