Antonio Perciaccante

Circadian rhythm of the autonomic nervous system in insulin resistant subjects with normoglycemia, impaired fasting glycemia, impaired glucose tolerance, type 2 diabetes mellitus.

BackgroundIn type 2 diabetes mellitus both insulin resistance and hyperglycemia are considered responsible for autonomic dysfunction. The relation between the autonomic activity, impaired fasting glycemia and impaired glucose tolerance is, however, unclear. The purpose of this study was to evaluate and compare the circadian autonomic activity expressed as heart rate variability (HRV) measured by 24-hours ECG recording in insulin resistant subjects (IR) with characteristics as follow: IR subjects with normal oral glucose tolerance test results, IR subjects with impaired fasting glucose, IR subjects with impaired glucose tolerance and subjects with type 2 diabetes mellitus.MethodsEighty Caucasian insulin resistant subjects (IR) and twenty five control subjects were recruited for the study. IR subjects were divided into four groups according to the outcoming results of oral glucose tests (OGTTs): IR subjects with normal glucose regulation (NGR), IR subjects with impaired fasting glycemia (IFG), IR subjects with impaired glucose tolerance (IGT) and subjects with type 2 diabetes mellitus (DM). Autonomic nervous activity was studied by 24-hours ECG recording. Heart rate variability analysis was performed in time and frequency domains: SDNN, RMS-SD, low frequency (LF) and high frequency (HF) were calculated.ResultsThe total SDNN showed statistically significant reduction in all four groups with insulin resistant subjects (IR) when compared to the control group (p <0,001). During night LF normalized units (n.u.) were found to be higher in all four groups including IR subjects than in the control group (all p < 0,001) and subjects with normal glucose regulation (NGR), with impaired fasting glycemia (IFG) and with impaired glucose tolerance (IGT) were found to have higher LF n.u. than those in the type 2 diabetes mellitus group. The linear regression model demonstrated direct association between LF values and the homeostasis model assessment-index (HOMA-I), in the insulin resistant group (r = 0,715, p <0,0001).ConclusionThe results of our study suggest that insulin resistance might cause global autonomic dysfunction which increases along with worsening glucose metabolic impairment. The analysis of sympathetic and parasympathetic components and the sympathovagal balance demonstrated an association between insulin resistance and sympathetic over-activity, especially during night. The results indicated that the sympathetic over-activity is directly correlated to the grade of insulin resistance calculated according to the HOMA-I. Since increased sympathetic activity is related to major cardiovascular accidents, early diagnosis of all insulin resistant patients should be contemplated.

Circadian rhythm of autonomic activity in non diabetic offsprings of type 2 diabetic patients.

The aim of the present study was to evaluate, by heart rate variability (HRV) with 24-hours ECG Holter (HRV), the circadian autonomic activity in offspring of type 2 diabetic subjects and the relation with insulin-resistance. METHODS: 50 Caucasian offsprings of type 2 diabetic subjects were divided in two groups: insulin-resistant offsprings (IR) and non insulin-resistant offsprings (NIR). Autonomic nervous activity was studied by HRV. Time domain and spectral analysis (low frequency, LF, and high frequency, HF, provide markers of sympathetic and parasympathetic modulation when assessed in normalized units) were evaluated. RESULTS. Time domain showed a reduction of total SDNN in IR (p < 0.001) and NIR (p 0.047) versus controls. Spectral analysis showed a total and night LF higher in IR and NIR than in control group (all p < 0.001). CONCLUSION. In frequency domain, the analysis of sympathetic (LF) and parasympathetic (HF) component evidenced an association between the offspring of type 2 diabetic subjects and a sympathetic overactivity. A global reduction and alteration of circadian rhythm of autonomic activity are present in offspring of type 2 diabetic patients with and without insulin resistance. The data of our study suggested that an autonomic impairment is associated with the familiarity for type 2 diabetes independently to insulin resistance and that an impairment of autonomic system activity could precede the insulin resistance.

The correlation among QTc interval, hyperglycaemia and the impaired autonomic activity

BACKGROUND The QT interval reflects the duration of the intracellular action potential. Little is known on the interval QT duration in non diabetic insulin-resistant subjects. OBJECTIVE The aims of the current study were to evaluate the QTc interval in three groups of non diabetic insulin-resistant subjects and the possible correlation between QTc and the autonomic nervous systems activity. DESIGN 90 subjects were divided in subjects with impaired fasting glycaemia (IFG) and, by the results of OGTT, according to the criteria of ADA, in subjects with normal glucose regulation (NGR) and impaired glucose tolerance (IGT). Insulin resistance was evaluated by the homeostasis model assessment-index (HOMA-I). Heart rate variability and Qtc were calculated. RESULTS QTc interval is correlated with SDNN, LF n.u. and LF/HF. CONCLUSION We have observed that the QTc interval is prolonged in insulin-resistant subjects with associated impaired glucose metabolism, while no difference was reported between insulin-resistant and non insulin-resistant subjects with normal glucose regulation. We hypothesize that hyperglycaemia could play a major role than hyperinsulinemia on the QTc prolongation.

Boy with cortical visual impairment and unilateral hemiparesis in Jeff Huntington's “Slip” (2011)

Face recognition is strongly associated with the human face and face perception is an important part in identifying health qualities of a person and is an integral part of so called spot diagnosis in clinical neurology. Neurology depends in part on observation, description and interpretation of visual information. Similar skills are required in visual art. Here we report a case of eye cortical visual impairment (CVI) and unilateral facial weakness in a boy depicted by the painter Jeff Huntington (2011). The corollary of this is that art serves medical clinical exercise. Art interpretation helps neurology students to apply the same skills they will use in clinical experience and to develop their observational and interpretive skills in non-clinical settings. Furthermore, the development of an increased awareness of emotional and character expression in the human face may facilitate successful doctor-patient relationships.

Franz Kafka: An emblematic case of co-occurrence of sleep and psychiatryc disorders

Medical literature robustly supports a close link between sleep disorders and psychiatric disorders. Recently, the co-occurrence of sleep dysfunctions and psychotic experiences (particularly insomnia with paranoia) has been reported, although the causal relationship is still unclear [1]. Moreover, Reeve et al. [2] have observed as insomnia, nightmares and circadian phase delay are associated with an increased occurrence of subsyndromal psychiatric symptoms in young people. In this paper, we report an emblematic case of co-occurrence of sleep and psychiatric disorders in one of the most influential writers of the 20th century: Franz Kafka (Prague, 1883-Kierling, 1924). He was affected by tuberculosis, but, as reported by Felisati et al. [3], mental more than physical diseases have influenced his life and literary work. The main information on Kafka′ s health emerge from the large collection of private correspondence and diaries that were published after the writer′s death. From “Diaries” [4] and “Letters to Milena” [5] emerge: an insecure, frail, anxious and depressed personality, a distorted and unstable self-image, a gloomy relationship with his family, friends and loved women, a man living a state of alienation from the outside world and having a self-destructive tendencies. According with 5th edition of Diagnostic and Statistical Manual for Mental Disorders (DSM-V) [6], these impairments in self and interpersonal functioning and the presence of pathological personality traits (as emotional lability, anxiousness and depressivity) suggest that Kafka could have suffered from a borderline personality disorder with co-occurring anxiety and depression. Moreover, from “Letters to Milena” clearly emerges that the writer suffered from insomnia. Kafka wrote: “ I have had increasing insomnia” and “ my health is good, just that I don′t sleep well”[5]. The write knew the sleep′s importance and he lived his insomnia as a guilt: “sleep is the most innocent creature there is and sleepless man the most guilty” [5]. It is difficult to classify Kafka′s insomnia. We suggest that the causes have to be searched in his lifestyle and in his mental disorders. The writer deliberately did most of his intellectual work at night. This choice depends primarily on Kafka′s persuasion that writing in a sleep-deprived state provides access to otherwise inaccessible thoughts. From “Diaries” seems to emerge his fear of falling asleep: “my insomnia only conceals a great fear of death. Perhaps I am afraid that the soul, which in sleep leaves me, will not be able to return” [4]. This tendency to worry excessively about sleep, the hyper arousal and the anxiety suggest

Dante Alighieri: poet of the syncope.

Seven hundred and fifty years after his birth, we want to celebrate the literary genius and medical knowledge of Durante degli Alighieri, simply known as Dante Alighieri (Florence, 1265-Ravenna, 1321), one of the most important poet of all times. Some papers have been written about his state of health, illness and medical knowledge. It has been hypothesized that Dante suffered from epilepsy, narcolepsy or recurrent syncopes [1, 2]. Two recent interesting papers have described symptoms and signs attributable to cardiovascular and neurological diseases reported in ‘‘Divine Comedy’’ [3, 4]. No other poet wrote about diseases as frequently as Dante. We want to highlight the many syncopal episodes accurately described in his literary masterpieces. Syncope is defined as a transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration and spontaneous complete recovery. In some cases, syncope may be preceded by prodromal symptoms and signs [5]. The classification of syncope is reported in Table 1. Celebre are the syncopal episodes described in Dante’s masterwork the ‘‘Divina Comedia’’ (Divine Comedy), an allegoric poem divided in three canticas (Inferno, Purgatorio and Paradiso), each consisting of 33 cantos [6]. It describes the poet’s journey through Hell, Purgatory and Heaven as an allegory of the soul’s journey toward God. In 3rd Canto of Inferno (Hell), when the poet approaches the river Acheron, and finds Caronte, who ferried the damned spirits to Hell, Dante writes: ‘‘all the dusk champaign trembled so violently, that of that terror the recollection bathes me still in sweat. The land of tears gave forth a blast of wind and fulminated a vermilion light, which overmastered in me every sense, and as a man whom sleep hath seized, I fall’’ [6]. In 5th Canto of Inferno, Dante meets Paolo and Francesca’s souls, and, after listening to their love story, he, deeply moved, says: ‘‘and all the while one spirit uttered this, the other one did weep so, that, for pity, I swooned away as if I had been dying and fall, even as a dead body falls’’ [6]. Both episodes have the features of a syncope: rapid onset, short duration and complete recovery. As already reported, they seem to be vasovagal reflex syncopal episodes [2]. More precisely, as suggested by Dell’Orto et al. [7], the syncope described in 3rd Canto may be considered as an emotional typical vasovagal syncope triggered by Dante’s sweating and standing, and by the central neural mechanism activated by the fear of the earthquake; whereas the episode reported in 5th Canto may be an atypical vasovagal syncope characterized by the absence of & Antonio Perciaccante antonioperciaccante@libero.it

Polycystic Ovary Syndrome: Androgens, Autonomic Nervous System, and Hypertension

To the Editor: We have read with interest the article by MJ Chen et al1 on the relationship between androgen levels and blood pressure in young women with polycystic ovary syndrome (PCOS). The authors have observed that characteristic hyperandrogenemia in young …

The Heart of Frederic Chopin (1810-1849)

We read with interest the paper by Witt et al,1 which details the visual examination of Chopins heart. The organ is described as massively enlarged and completely covered with whitish, massive fibrillary coating.1 Tuberculous (TB) pericarditis coupled with massive enlargement of the right ventricle, possibly due to pulmonary hypertension, was proposed as the most plausible cause of death of the artist.1 The retrospective diagnosis of probable TB pericarditis was made by the authors based on the identification of three small nodules, between several mm up to 1 cm in diameter, of white-glass appearance, two on an upper part of the ventricle one just near the apex (Figure, A).1 However, these nodules were not examined histologically.

The facial paralyses of Jules Verne

Rick Bedlack is an Associate Professor of Medicine/ Neurology at Duke University, Durham, NC, who has walked the runway at Men’s Fashion Week in Paris, played in the World Series of Poker in Las Vegas, and won two major patient advocacy awards (the 2009 AAN Viste Award for Patient Advocate of the Year and the 2013 ALS Association Rasmussen Award for Patient Advocate of the Year). He currently directs the Duke ALS Clinic, and the ALSUntangled and ALS Reversals programmes. He lives in Durham, NC, with his wife Shelly and two mischievous cats.

'There will be blood'. Differences in the pictorial representation of the arterial spurt of blood in Caravaggio and followers.

The theme of the beheading of Holofernes by Judith is one of the most frequently painted biblical scenes [1]. Famous painters such as Mantegna (1431–1506), Michelangelo (1475–1564), Botticelli (1445–1510) and Klimt (1862–1918) depicted the same scene. Nevertheless, only few artists, namely, Caravaggio (1571–1610), Artemisia Gentileschi (1593–1693), Louis Finson (1580–1617) and an unknown artist, whose canvas was recently discovered in Toulouse, painted the actual action of beheading.