Parlapiano C

Cortisol circadian rhythm and 24-hour Holter arterial pressure in OSAS patients.

Obstructive sleep apnea syndrome (OSAS) is a syndrome in which the principal symptom is apnea during sleep. Hypoxia in OSAS is a stress condition, which when prolonged in time, could alter hypothalamo-hypophysial-suprarenal control and the cortisol cicadian rhythm. We studied 28 patients with OSAS (30–60 years old), 20 female and 8 male. We calculated the OSAS class according to the Simmons classification. Twenty of the 28 patients maintained unmodified cortisol circadian rhythms, while 8 had cortisol levels more elevated in late and nocturnal hours. Holter monitoring showed arterial hypertension in 8 of the 28 patients (the same patients with cortisol circadian rhythm alteration). Our data seem to indicate that when the OSAS patients lack cortisol circadian rhythm they are having arterial hypertension.

The relationship between glycated hemoglobin and polymorphonuclear leukocyte leukotriene B4 release in people with diabetes mellitus

In order to evaluate polymorphonuclear leukocyte (PMN) activity in diabetes mellitus, leukotriene B4 (LTB4) levels were measured in sixty patients, 31 affected with Type 1 diabetes mellitus and 29 affected with Type 2 diabetes mellitus. The LTB4 levels (12.1+/-0.2 pg/100 microl) in diabetic patients were higher compared to those of the control group (7.9+/-0.1 pg/100 microl) (P < 0.001), and remained significantly higher (P < 0.001) (12.8+/-0.2 pg/100 microl) than in the control group (11.0+/-0.2 pg/100 microl) after stimulation with calcium ionophore. A significant and positive correlation between glycated hemoglobin and LTB4 was demonstrated (P < 0.001, r = 0.80). This study demonstrates that in diabetic patients there is a PMN activation and that this activation is correlated to glycated hemoglobin level.

ET-1 Plasma Levels During Cold Stress Test in Sclerodermic Patients

Endothelial cell injury in blood vessels of small arteries and capillaries is considered the primary event in the pathogenesis of systemic sclerosis (SSc). Because endothelin-1 (ET-1) is mainly released in the site of endothelial cell damage, thereby inducing a potent vasoconstriction, it was our intention to study ET-1 release in a group of SSc patients during a cold pressor test (CPT). Twelve SSc patients and a control group of 10 healthy subjects underwent CPT. Blood samples for ET-1 assay were collected at 90 and 180 seconds of exposure to cold stress. Heart rate and blood pressure were recorded at the same intervals. A capillaroscopic examination was performed in both groups before and after CPT. We observed significantly higher levels of plasma ET-1 in SSc patients compared with those of the control group at baseline (P=0.007) and at 90 (P=0.006) and 180 seconds (P=0.03) of CPT. During the test, the capillaroscopic examination showed a dramatic worsening of the vascular picture that was parallel to the increase in ET-1 plasma levels. This suggests that higher ET-1 plasma levels can have a part in the acute vascular reac tivity of SSc patients undergoing CPT.

Dopamine receptor subtypes in the human coronary vessels of healthy subjects

Objective: Dopamine D1–D5 receptors subtypes were studied in human coronary vessels of healthy subjects to assess their localization and their expression. Methods: Samples of intraparenchymal and extraparenchymal branches of human coronary arteries and veins were harvested from four normal native hearts explanted from four young brain dead heart donors in case of orthoptic transplant, not carried out for technical reasons. In all the samples morphological, biochemical, immunochemical, and morphometrical studies were performed including quantitative analysis of images and evaluation of data. Results: Microanatomical section showed healthy coronary vessels, which expressed all dopamine receptors (from D1 to D5) with a different pattern of distribution between the different layers, in the intra and in the extraparenchymal branches.D1 and D5 (with a prevalence D1 over D5) were distributed in the adventitia and to a lesser extent in the outer media but they were absent in arterioles, capillaries and venules. Endothelial and the middle layer showed D2, D3 and D4 receptors, with a greater expression of D2. Immunoblot analysis of dopamine monoclonal antibodies and dopamine receptors showed a different migration band for each receptor: D1 (45 KDa); D2 (43 KDa); D3 (42 kDa); D4 (40–42 KDa); D5 (38–40 KDa) Conclusion: These findings demonstrate the presence of all dopamine receptor subtypes in the wall of human coronary vessels of healthy subjects. Dopamine D1 and D2 receptor subtypes are the most expressed, suggesting their prominent role in the coronary vasoactivity.

Thyrotoxic periodic paralysis in an Italian man: clinical manifestation and genetic analysis:

Abstract In Western countries, thyrotoxic periodic paralysis (TPP) is a rare condition with only sporadic cases described so far. Here, we describe a 29-year-old Italian man who presented with leg weakness and hypokalaemia. Treatment with intravenous potassium resulted in a rapid resolution of symptoms. TPP as the underlying cause was suggested by suppressed thyroid-stimulating hormone (TSH), elevated free T3 and free T4, and the presence of TSH-receptor antibodies (TRAB). Genetic analysis showed no mutations in the candidate exons of calcium (CACN1AS), potassium (KCNE3) and sodium (SCN4A) channel genes. However, we identified the presence of two single nucleotide polymorphisms (SNPs), 1491C > T and 1551 T > C, in exon 11 of the CACN1AS gene. Although the 1491C > T SNP is not apparently involved in the pathogenesis of the disease, the 1551 T > C SNP has been associated with TPP in Asians and reported in only one case in European Caucasians. Further investigations are needed to clarify whether such polymorphisms have a role in the disease pathogenesis in Caucasians.

Are elevated levels of soluble ICAM-1 a marker of chronic graft disease in heart transplant recipients?

Positivity for circulating intercellular adhesion molecule-1 (ICAM-1) in heart transplant recipients has been claimed to predict the development of coronary artery disease and risk of graft failure. Soluble ICAM-1 were evaluated in 32 heart transplant recipients. Five of these patients, who had undergone transplantation several years before, were positive for soluble ICAM-1 but did not present any clinical sign of graft rejection. Furthermore, although heart graft coronary disease was diagnosed in 15 of the 32 patients, they did not show significantly higher titres of soluble ICAM-1 compared to the remaining patients. These findings suggest that major caution is necessary when considering ICAM-1 positivity as a marker of graft disease.

PLASMA ATRIAL NATRIURETIC HORMONE IN HYPERTHYROIDISM

In 22 hyperthyroid patients, atrial natriuretic hormone (ANH) levels (71.91 +/- 21.03 pg/ml), measured during a 3-h-Holter, were found to be significantly higher (p < 0.001) than those in 20 age-matched normal subjects (37.22 +/- 8.73 pg/ml). We have demonstrated that the presence of tachiarrhythmias does not influence ANH release. The positive and significant correlation of FT3 with both ANH and heart rate confirms the hypothesis of a direct action of thyroid hormones on ANH release.

Increased plasma concentration of atrial natriuretic hormone in myotonic dystrophy.

Atrial natriuretic hormone (ANH) concentrations were measured in 16 patients affected with myotonic dystrophy (MyD) undergoing 24-hour Holter ECG and in 15 age-matched normal subjects. Although the MyD patients did not show overt left ventricular function impairment, their plasma ANH levels were found to be higher (183.76 ± 113.25 pg/ml) compared to those of the control subjects (39.73 ± 9.95 pg/ml, p < 0.001). Nine patients with arrhythmias and some echocardiographic alterations formed subgroup A. Seven patients without cardiac alterations formed subgroup B. No significant difference in ANH emerged between the two subgroups. This evidence suggests that high plasma ANH levels in MyD cannot always be related to overt or latent heart failure and to arrhythmias.

Atrioventricular block associated with Crohn's relapsing colitis in a 12‐year‐old child

To the Editor: Inflammatory bowel diseases (IBDs) are associated with extraintestinal manifestations. Many systems or organs, i.e., eye, skin, liver, bone, and joints are frequently involved in IBD, but cardiac involvement is considered rare. Myopericarditis, worsening of congestive heart failure, sinusal symptomatic bradycardia, and heart block have been described in IBD patients as side effects of infliximab (chimeric monoclonal antibody to tumor necrosis factor-a). Cardiac conduction disturbances associated with IBD, in the absence of infliximab treatment, have been described in only a few case reports regarding adult patients with ulcerative colitis. Cardiac conduction system disturbance in children with Crohn’s disease (CD), not treated with infliximab, have not been reported yet. We describe the case of a 12-year-old child with CD involving the terminal ileum. There was no past history of cardiac disease and no evidence of myocardial ischemia or recent viral infection. The patient was treated with nutritional therapy (Modulen) and with azathioprine, but he was not treated with any anti-TNFa drugs. CD had been in remission for 6 months when the child developed bloody diarrhea without any systemic symptoms. He was hospitalized for relapse of CD. Colonoscopy showed active pancolitis. Laboratory data showed hemoglobin 11.8 mg/dL, white cells 9340 (neutrophils 79.4%), erythrocyte sedimentation rate (ESR) (31 mm/h), and D-dimer (782 mg/dL). Serology for cytomegalovirus, Epstein–Barr virus, and Mantoux test were negative. Fecal exam was positive for Clostridium difficile and antiSaccharomyces cerevisiae antibodies (ASCA) were high (160; normal value < 14). ECG showed first-degree atrioventricular block which was absent in previous electrocardiogram (ECG) (Fig. 1) and it was confirmed by 24-hour ECG monitoring. To assess autonomic system balance, heart rate variability (HRV), by short computed ECG monitoring (10 minutes), was recorded. Low LF/HF ratio (0.36), which is a sign of increased parasympathetic tone, was shown. Treatment with intravenous methylprednisone for 2 days was started. After 48 hours the bloody diarrhea cleared. Subsequently, oral therapy was carried out for several weeks. The azathioprine therapy was later replaced with methotrexate 20 mg/week intramuscularly, salazopyrin 2 cp 3 times a day, and folic acid. Metronidazole for C. difficile infection was also administered. On 3-month follow-up both outpatient review of bowel habits and colonoscopy were normal. Hematochemical parameters returned to normal range (hemoglobin 12.4 mg/dL, white cell 5000, ESR 8 mm/h). The LF/HF ratio returned to normal values (1.48). Monitoring ECG for 5 hours confirmed the persistence of atrioventricular block (PR mean 0.21 sec; normal value for age: 0.09–0.18 sec). To today, atrioventricular block is still present. We describe the case of a child with first-degree atrioventricular block associated with CD. This heart block, absent in previous ECG, appeared during the relapse of colitis and did not disappear at termination of relapse and is still present after 12 months. The excess of vagal activity, observed during relapse of disease, seems not have been implicated in the origin of atrioventricular block because of its persistence after vagal reequilibrium. Atrioventricular block in CD has been associated with infliximab therapy, but our patient had not been treated with this drug. Azathioprine and aminosalycilates seem to play a role in the etiology of pericarditis, but not in cardiac conduction disturbances. In conclusion, in our case both autonomic imbalance and drug therapy do not seem to be implicated in atrioventricular block, so it might be that the inflammatory state of relapsing colitis has caused damage to the cardiac conduction system cells. Microvascular endothelial dysfunction has been found in IBD patients. We speculate that some ischemic microdamage in the cardiac conduction system of our FIGURE 1. ECG recorded in Lead II before (A) and during (B) relapse of CD. ECG in B shows atrioventricular block.

Clinical Features of Subjects with Mitral Valve Prolapse: A Study with 24-Hour Ambulatory Blood Pressure Monitoring

The present case-control study provides evidence that the correlation between mitral valve prolapse and the clinical observation of low blood pressure persists throughout a 24-hour period as documented by ambulatory blood pressure monitoring. Moreover, the blood pressure circadian rhythm, even though preserved, seems to follow a different course over the 24-hour period in subjects with mitral valve prolapse.