Nicolò Gueli

Exercise training and music therapy in elderly with depressive syndrome: A pilot study

OBJECTIVE Recent studies have thrown doubt on the true effectiveness of anti-depressants in light and moderate depression. The aim of this study is to evaluate the impact of physical training and music therapy on a sample group of subjects affected by light to moderate depression versus subjects treated with pharmacological therapy only. DESIGN AND SETTING Randomized controlled study. Patients were randomized into two groups. Subjects in the pharmacotherapy group received a therapy with antidepressant drugs; the exercise/music therapy group was assigned to receive physical exercise training combined with listening to music. The effects of interventions were assessed by differences in changes in mood state between the two groups. MAIN OUTCOME MEASURES Medically eligible patients were screened with the Hamilton Anxiety Scale and with the Geriatric Depression Scale. We used plasmatic cytokine dosage as a stress marker. RESULTS We recruited 24 subjects (mean age: 75.5 ± 7.4, 11 M/13 F). In the pharmacotherapy group there was a significant improvement in anxiety only (p<0.05) at 6-months. In the exercise/music therapy was a reduction in anxiety and in depression at 3-months and at 6-months (p<0.05). We noted an average reduction of the level of TNF-a from 57.67 (± 39.37) pg/ml to 35.80 (± 26.18) pg/ml. CONCLUSIONS Our training may potentially play a role in the treatment of subjects with mild to moderate depression. Further research should be carried out to obtain more evidence on effects of physical training and music therapy in depressed subjects.

Vitamin D: drug of the future. A new therapeutic approach

Besides increasing calcium absorption in the bowel and promoting the normal formation and mineralization of bone, vitamin D exerts relevant pleiotropic effects in different tissues. Serum levels of vitamin D show correlation with the risk of infections, cardiovascular diseases, cancer and autoimmune disorders. The possible therapeutic role of vitamin D in different kind of diseases: inflammatory, immunologic, infectious and neoplastic ones, explains the growing interest in this vitamin due to its pleiotropic effects, and makes it a candidate to become a potential drug in the next future.

Montelukast therapy and psychological distress in chronic obstructive pulmonary disease (COPD): a preliminary report.

Chronic obstructive pulmonary disease (COPD) is an alteration in which ventilatory function, exercise capacity and health status of patients progressively decline and it is characterized by an increase of inflammatory cytokines such as TNF-α, LTB4, IL-8, etc. In this study we considered twenty patients (15 males and 5 females; mean age: 72.8 ± 6.3) with stable COPD. All patients were performed evaluation of psychological stress at enrollment and were treated with leukotriene receptor antagonists (montelukast tablets) 10mg/day for 12 months. After 12 months we observed a significant decrease of serum levels of LTB4, IL-8 and also a decrease of the number of outpatient clinic visits, of the number of hospitalizations and of the duration of hospitalization.

Myocardial Cytoprotection by Trimetazidine Against Anthracycline-Induced Cardiotoxicity in Anticancer Chemotherapy

The ability of trimetazidine (2,3,4, trimethoxybenzylpiperazine dihydrochloride, TMZ) to protect the myocardium against anthracycline (ANT)-induced cardiotoxicity during chemotherapy has been evaluated in female patients with breast cancer. A clinical trial was conducted in 61 patients subdivided into three groups: group 1 (n = 15, G1) treated with standard ANT protocol and cardioprotection by dexrazoxane (DEX) plus TMZ (60 mg, daily dose); group 2 (n = 22, G2) treated with ANT and cardioprotection by TMZ only; and group 3 (n = 24, G3) scheduled to receive ANT therapy and DEX. All the patients submitted to an echocardiographic evaluation of diastolic function (E wave velocity, A wave velocity, isovolumetric relaxation time [IVRT], deceleration time [DT]) at enrollment (TO), at T1 time, at T2 time, and at T3 time. After a 12- month follow-up period, the patients showed a good conservation of diastolic function both in G1 and G2 groups. No statistically significant difference was observed in E wave and A wave velocity and E/A ratio after ANT treatment. TMZ produced a cardioprotective effect, compa rable to DEX protection, against subacute and chronic subclinical cardiotoxicity with no signif icant changes in diastolic function after 1 year of follow-up.

Empirical antibiotic therapy (ABT) of lower respiratory tract infections (LRTI) in the elderly: Application of artificial neural network (ANN). Preliminary results

LRTI are among the most common diseases in developed countries, including chronic obstructive pulmonary disease (COPD), one of the most frequent conditions. Their treatment in general practice is often unsuccessful and this increases hospital admissions. We know, bacterial infections in the elderly show a higher morbidity and mortality, either for more severe symptoms, than in younger adults, or because the causing agent often remains unknown. The need for a quick initiation of ABT often requires to chose on empirical grounds. To date there are no official guidelines for empirical ABT of COPD exacerbations, but only heterogeneous and often conflicting recommendations exist. The aim of our study was to identify a tool to guide the choice of the most effective empirical ABT when symptoms are acute and bacteriological tests cannot be performed. We used an ANN to study 117 patients aged between 55 and 97 years (mean 81.5 ± 8.7 years) (± S.D.), admitted with a diagnosis of pneumonia, COPD exacerbation or pneumonia with respiratory failure. We registered symptoms at onset and some individual variables such as age, sex, risk factors, comorbidity, current drug therapies. Then the ANN was applied to choose ABT in 20 patients versus 20 subjects whose therapy was chosen by the physicians, comparing these groups for therapys efficacy, mean durations of therapy and hospitalization (H). In the learning phase, the ANN could predict the resolution index 99.05% of the time (i.e., 104 times) with a ± S.D. = 0.23. After the training, during the test phase, the network predicted the resolution index 91.67% of the time (i.e., 11 times) with a ± S.D. = 0.54, thus proving the validity of the relations identified during the learning phase. Preliminary results of the application of our tool, show the ANN allowed us to greatly reduce the duration of the ABT and subsequently of the H. Based on preliminary results, we assume that the use of ANN can make a valuable contribution in the choice of empirical ABT in the course of acute lung diseases in elderly.

A case of systemic lupus erythematosus (SLE) and myasthenia gravis (MG)

T tosus (SLE) and myasthenia gravis (MG) is well recognized (1). Both must be considered immune diseases, although rarely presenting in acute form at the same time (2). MG usually reveals itself before SLE, whose onset, on the contrary, is rather late and often follows thymectomy. In fact, the clinical features of MG usually appear during the periods of quiescent SLE obtained after steroidal treatment. We report the case of a 53-year-old

Hypovitaminosis D: Which oral supplement therapy?

Objectivesthe possible therapeutic role of vitamin D in different kind of diseases explains the growing interest in this vitamin due to its pleiotropic effects. This short report shows preliminary results of prevalence of hypovitaminosis D in a group of patients and proposes a oral supplement therapy effective in correcting hypovitaminosis in a short time, without side effects.Methods243 patients (aged 26–93; 67 males) were enrolled at this study. We evaluated plasma levels of 25-hydroxyvitamin D [25(OH)D] with the following cut-off values: < 10ng/ml or <0–25 nmol/L (deficient), 10–30 ng/ml or 25–75nmol/L 30–50 (insufficient) and > 30 ng/ml or > 50 nmol/L (normal). The first 73 patients with hypovitaminosis D received at baseline 25,000 IU (Cholecalciferol) per os twice a month (Tp.A). The next patients (Tp.B) at baseline received a loading dose of 50,000 IU once a week for 8 weeks, followed by a maintenance dose of 25,000 IU twice a month.Resultshypovitaminosis D is a widespread condition (i.e. 82.3%) not only in elderly (75.6% of 75 patients aged <65 yrs and 86.5% of 168 subjects aged >65 yrs). Preliminary results at 6 months show that Tp.B is more effective in correcting hypovitaminosis D (baseline 14.4 ± 5.3 ng/ml; 24 wk 43.3 ± 14.7 ng/ml; p<0.0001).Conclusionhypovitaminosis D is an important public health problem. We believe it is important to quickly achieve normal Vit. D plasma values in order to produce pleiotropic effects.

Acute disseminated encephalomyelitis in an elderly patient

Sirs, The autoimmune encephalomyelitis is a heterogenous group of inflammatory disorders of the central nervous system caused by an immune-mediated damage against myelin antigens [1]. Cerebrospinal fluid (CSF) studies frequently show an inflammatory profile with an increased number of immunoglobulins and oligoclonal bands [2]. Treatments with highdose corticosteroids are currently widely accepted as first-line therapy [3]. In January 2016, a 68-year-old woman was admitted to our hospital. The patient’s medical records showed hypertensive cardiopathy, mild cognitive impairment, and recurrent otitis with previous tympanoplasty of the right ear. The sudden worsening of cognitive status with treatment-resistant behavioral symptoms (after treatment failures with two different antipsychotic drugs, quetiapine, and risperidone), in particular agitation and motor disturbance, made it necessary to hospitalize the patient, who appeared to be suffering from delirium and psychomotor agitation: the language was repetitive, poor, and shouted; she moved all her extremities spontaneously but she was unable to follow the commands of the physician and to respond adequately to nociceptive stimuli (Glasgow Coma Score—GCS—11/15). Neurological signs and neck stiffness were absent. Reflexes were not valuable due to the great motor agitation. Blood chemistry analysis showed an increase in the count of white blood cells (WBC) (13,180 cells/mcL, n.v. 4500 to 10,000 cells/mcL, percent neutrophils 90%, v.n. 40.9–68.1%), and hypoalbuminemia (35.0 g/L, n.v. 40.2–47.6 g/L) with hypotransferrin (2.12 g/L, n.v. 2.5–3.8 g/L); the inflammatory markers were normal (CRP 4600 μg/l, n.v. <5000 μg/l, VES 30 mm/h, n.v. 0–35 mm/h). Urine drug screen showed no significant abnormalities. The brain CT showed diffuse atrophy and vascular chronic damage. The electroencephalogram revealed a diffused slow wave, especially over the fronttemporal convexities. The blood pressure profile was normal. The persistence of behavioral symptoms along with psychomotor agitation and impairment of speech prompted us to perform a magnetic resonance imaging (MRI) with gadolinium that showed the presence of disseminated asymmetric lesions involving the gray white matter junction and the central white matter; diffuse cytotoxic and vasogenic edema similar to an acute/subacute damage was also reported. There was no gadolinium enhancement. Gradient echo sequence did not show amyloid deposits (Fig. 1). The neuroradiological evidence and the medical history (previous recurrent otitis) were suggestive for ADEM. A lumbar puncture showed a clear aspect of the cerebrospinal fluid (CSF); the glucose content was 93mg/dl (v.n. 50– 80 mg/dl), a protein content of 36 mg/dl (v.n. 15–45 mg/ dl) and negative cell content were also reported. There were no CSF oligoclonal bands. Link index was negative. No barrier damage was observed by comparing liquoral albumin with serum albumin. The screening for infectious agents (herpes simplex virus type 1 and 2, human immunodeficiency virus, Epstein-Barr virus, Cytomegalovirus) was negative. Autoantibody serum screen was all negative but autoantibody liquoral screen * Walter Verrusio walter.verrusio@uniroma1.it

Acute and recurring pericarditis: a singular case of overlap syndrome with autoimmune diseases

tests showed a mild hypochromic hyposideremic anemia (Hb 11 g/dL, n.v. 12.2–15.3 g/dL; MCHC 31.4 g/dL, n.v. 32–36 g/dL; serum iron 5.2 μmol/L, n.v. 11–32 μmol/L) and an increase of inflammatory markers (ESR 96 mm/h; n.v. 0–35 mm/h, CRP 63,200 μg/L; n.v. <6000 μg/L). Echocardiography showed EF 50%, with the left ventricle within the limits of size and preserved segmental and global kinesis, and a 2–3 mm circumferential pericardial disconnect. The screening for infectious agents (antistreptolysin O –ASO-titer 111 IU/mL, n.v. <200; blood and urine cultures, serology for Coxsackie, echo, hepatotropic viruses) was negative. Serum autoantibody screen showed: RA test <10 IU/mL (n.v. 15 IU/mL); Waaler–Rose negative; slightly positive rheumatoid factor (16 IU/mL, n.v. 0–14 IU/mL); low positive antinuclear antibodies (ANA) with Ab anti-native DNA negative; anti-CCP (cyclic citrullinated peptide), anti-Sjögren’s syndrome-related antigen A (Anti-SSA) and anti-Sjögren’s syndrome type B (Anti-SSB) antibodies negatives. Determination of immunoglobulins was normal and we found a negative panel for anti-myeloperoxidase (MPO), anti-proteinase 3(PR3), antineutrophil cytoplasmic antibodies (ANCA), cryoglobulins and lupus anticoagulant (LAC) antibodies. The cardiac MR showed: a pericardial membrane edema thickened at the level of the lateral wall of the left ventricle of all planes and the anterior wall of the left ventricle and lower basal planes; an enhancement of pericardial membranes associated with focal areas of infarction in the distribution of the subpericardial enhancement at the level of the anterior, lateral and inferior walls of the left ventricle after gadolinium; a small share of pericardial effusion. Other investigations conducted were: X-rays of esophagus with barium and capillaroscopy (both normal); radiographs and US of hands, wrists, elbows, knees and ankles that showed slight edema to the metacarpal–phalangeal Autoimmune disorders are responsible for a substantial amount of disability and morbidity. Most of the identified autoantibodies are shared among multiple autoimmune diseases. The pattern of these antibodies’ association with autoimmune phenotypes varies, suggesting that certain subgroups of autoimmune diseases are likely to share etiological similarities and underlying mechanisms of disease [1]. In this article, we present a clinical case of acute and recurring pericarditis and we propose an overlap phenotype with Sjögren’s syndrome (SS) and rheumatoid arthritis (RA) with interesting implications in clinical management of patient. In February 2016, a 66-year-old woman was admitted to our hospital following the onset of fatigue, chest pain at rest, especially in the supine position, and low-grade fever. Her history showed familiar idiopathic pulmonary fibrosis, gastroesophageal reflux disease and acute pericarditis in the previous year, successfully treated with steroid therapy and aspirin for 30 days. The patient’s physical exam revealed asthenia, pain (VAS 6/10) and mild hypovisus with xerophthalmia. Vital signs persisted within the limits except for Tc 37.8 °C and the objectivity showed diffuse tenderness with pain over the precordium, hands, wrists and retronuchal region. Electrocardiographic examination and the chest X-ray showed no significant alterations. Blood laboratory

Right bundle branch and hypothyroidism in an elderly woman: a complex interaction in the risk of syncope.

The bundle branch block (BBB), in particular the isolated right bundle branch block (RBBB), is an EKG instrumental abnormality frequently found in the general population. When the RBBB is instead associated with a left anterior fascicular block (EAS), the resulting bifascicular block is less frequent and potentially evolving towards complete atrioventricular block (AV block). The alternating bundle branch block (ABBB) is a unidirectional block, usually frequency-dependent. Its pathogenesis (inflammatory or ischaemic or autoimmune disease) is still debated and usually attributed to a prolongation of refractory periods within the atrioventricular node. We know that hypothyroidism occurs more with aging and a possible association between subclinical hypothyroidism and cardiovascular disease (CVD) has been reported [1]. Thyroid hormones are potent modulators of cardiac function, although their action on cardiac conduction itself and their arrhythmogenic effects (proarrhythmic and antiarrhythmic effects) are to be further investigated. Assuming that the auto-immune thyroid disease could trigger the onset of atrioventricular conduction abnormalities, we report the case of a patient presenting syncope associated with hypothyroidism and bifascicular block with ABBB. In December 2012, a 67-year-old woman was admitted to our hospital presenting with overweight, dyslipidemia and recurrent syncope. Her history showed two syncopal events over a 1-year period: at the last syncopal episode she was admitted in hospital and discharged after a quiet 24-h stay. The patient did not have any history of cardiovascular disease or diabetes. A new syncopal episode (she suddenly lost consciousness while she was watching TV) made it necessary to hospitalize the patient, who appeared to be in general good conditions (Glasgow Coma Score 15/15). She denied palpitations or chest discomfort, dyspnea, vertigo, nausea or vomiting. She was taking simvastatin 20 mg at bedtime. The patient’s physical/neurological exam revealed no abnormal findings. Electrocardiographic examination revealed RBBB with EAS. Examination was negative for postural hypotension. The multidimensional geriatric evaluation showed a low risk of falls at the Tinetti’s balance assessment tool in patient without cognitive or mood disturbances: Mini Mental State Examination 27/30; Geriatric Depression Scale 2/15; Activities Of Daily Living 6/6; Instrumental Activities of Daily Living 8/8; Tinetti’s scale 24/28. Blood chemistry analysis showed: free thyroxine (fT4) 1.08 ng/dL (nv 1.0–1.8), thyroid stimulating hormone (TSH) 8.1 lIU/mL (nv 0.27–4.20); increase of inflammatory markers (ESR 41 mm/h; nv 0–35 mm/h, CRP 6600 lg/l; nv \5000 lg/l) and creatine kinase (CK 248 U/L; nv 20–180). We performed several tests to determine the origin of syncope. Echocardiography, carotid Doppler ultrasound, EEG, Tilt test and carotid sinus massage showed no significant alterations. Holter EKG recording displayed a sinus rhythm with a cardiac frequency oscillating in a range between 51 and 112 beats/min, average heart rate 71 beats/min, presence of ectopic ventricular beats and sporadic (7) single supraventricular ectopic beats & W. Verrusio walter.verrusio@uniroma1.it